scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa december 2018, vol. 10, no. 4 issn 2078 5127 african journal of health professions education 96 december 2012, vol. 4, no. 2 ajhpe abstract context and setting the south african pharmacy council (sapc) registered a new bpharm qualification with the south african qualifications authority (saqa) in march 2009. all pharmacy schools/faculties in south africa have to re-align their curricula and implement no later than 2013. why the idea was necessary the process of curriculum review and re-alignment typically involves four phases: • document analysis • discussions and negotiations within and across disciplines • implementation • monitoring and evaluation of the re-aligned curriculum. reviewing a curriculum also provides a space to analyse it critically in relation to the vision, mission, policies and procedures, educational theory, pedagogy and hegemony. aspects of bernstein’s pedagogic device are useful to determine the way in which knowledge is classified and framed (referred to as the pedagogic code) and how this pedagogic code is enacted within pedagogic practice. therefore, we embarked on a critical review of our curriculum while re-aligning it with the new registered qualification. what was done the study involved analysis of various documents: the newly registered qualification, sapc documents, our current and past curricula, reports following previous curriculum reviews, and others. various stakeholders were consulted. this was followed by discussions within and across the four divisions. notes were taken during these discussions, transcribed and circulated to members of the group discussions for verification. once verified, nvivo8 qualitative data software was used to code and categorise the data. an iterative process was followed: as themes and categories emerged they were used for further discussions, until we agreed on issues. bernstein’s theory of vertical and horizontal discourses and his work on classification and framing provided a theoretical framework. ethical approval for the study was granted by the faculty of pharmacy’s ethics committee. results and impact the research revealed strengths and weaknesses within our curriculum – in terms of content, teaching and learning, assessment and evaluation processes. we will build on the strengths and address the weaknesses. bernstein’s pedagogic device suggests that our curriculum is mostly a collection code which is strongly classified (c+) and framed (f+) with some integrated code which is weakly classified (c-) and framed (f-). there is debate about shifting towards a more integrated code. the research also suggests that we need to have stronger sequencing between the ‘knowledge code’ and the ‘knower code’. there are power relations at play with regard to what constitutes legitimate knowledge and practice. there is also some tension within and across disciplines with regard to the extent of control of the curriculum by the disciplines, by certain agents, and by certain practices. currently, the disciplines, the agents, and the practices within the four disciplines determine what counts as legitimate knowledge. using aspects of bernstein’s pedagogic device to review and re-align the pharmacy curriculum was a useful process. it highlighted the relationships and power relations at play between the different agents and components of the curriculum. ajhpe 2012;4(2):96. doi:10.7196/ajhpe.103 using aspects of bernstein’s pedagogic device to review and re-align the pharmacy curriculum at rhodes university c oltmann division of pharmacy practice, faculty of pharmacy, rhodes university c oltmann, phd corresponding author: c oltmann (c.oltmann@ru.ac.za) march 2020, vol. 12, no. 1 ajhpe 4 short communication the problem despite health research capacity growth in lowand middle-income countries (lmics), the evidence for effective capacity-building strategies is lacking.[1] most studies describe efforts to strengthen research agendas and design, while authorship and writing competencies are overlooked. however, universities in africa can play a powerful role in addressing these challenges. master’s theses of postgraduate medical residents in kenya must be written in english; yet the students come from diverse language backgrounds without formal undergraduate writing instruction. together with widely adopted courses in research methods, attention has to be given to postgraduate writing skill development to facilitate publication on a competitive global scale. the approach we are not aware of a curriculum where the unique writing skill needs of novice health researchers from lmics are described. our novel academic writing curriculum uses the six-step approach:[2] (i) problem identification and general needs assessment; (ii) needs assessment of targeted learners; (iii) goals and objectives; (iv) educational strategies; (v) implementation; and (vi) evalu ation and feedback. a general needs assessment was completed through an exhaustive literature search, while specific needs were informed by senior residents. objectives of the curriculum were: (i) to strengthen knowledge and skills in academic writing; and (ii) to develop residents’ confidence regarding writing and authorship. educational strategies included collaborative learning, formative feedback, online programmed learning and reflection. the 45-hour seminar was piloted, revised and then implemented among 5 first-year family medicine residents at kabarak university, kenya. for all 5 residents english was a second or third language. live sessions focused on referencing skills and paragraph construction, introduction, methods, results, analysis and discussion (imrad) components, analysis and synthesis of articles, revising, editing and manuscript submission. online activities targeted fundamental english writing skills and residents’ reflections on writing. formative written and oral feedback on writing assignments was integrated throughout the seminar. curriculum evaluation explored knowledge, skills and attitudinal domains. on the first and last days, residents completed a 90-minute writing exercise to synthesise 2 articles on antibiotic stewardship. the scoring rubric was shaped and piloted by 3 expert reviewers to strengthen inter-rater reliability. ten-point confidence scales were embedded in reflective writing assignments on: (i) ability to avoid plagiarism (before and after the seminar); and (ii) confidence in writing/being an author (before and after the seminar). ethical approval was obtained from kabarak university. the outcome residents demonstrated improved academic writing skills after the 45-hour seminar. preand post-seminar group writing score means were 24/70 (34%) and 40.3/70 (57%), respectively. despite meaningful gains, this revealed the need for longitudinal writing skill development across the entire programme. in the attitudinal domain, residents expressed greater confidence in avoiding plagiarism and being an author (table 1). we suggest that the active learning methodologies and formative feedback were instrumental in the reported increase in self-efficacy.[3] our experience highlights the value of institutional collaboration in this effort, as most residency programmes have cohorts of ˂10 students. both intraand interinstitutional collaboration can allow broader curriculum implementation and evaluation among other postgraduate programmes, including the impact on african first-author publications. declaration. none. acknowledgements. thanks to dr gundula bosch, faculty, health professions programme at johns hopkins university, baltimore, md, usa, who assisted with the study design. author contributions. so: literature search/review, study design, ethics review submission, data collection, first draft of manuscript; dmbb: data collection, statistical analysis, review of figures, revision of manuscript; vap: data collection, review of figures, revision of manuscript; gmw: data collection, review of figures, revision of manuscript; mba: study design, review of figures, revision of manuscript. funding. none. conflicts of interest. none. 1. franzen sr, chandler c, lang t. health research capacity development in low and middle income countries: reality or rhetoric? a systematic meta-narrative review of the qualitative literature. bmj open 2017;7(1):e012332. https://doi.org/10.1136/bmjopen-2016-012332 2. kern de, thomas pa, hughes mt. curriculum development for medical education: a six-step approach. 2nd ed. baltimore, md: jhu press, 2009. 3. kolb ay, kolb da. learning styles and learning spaces: enhancing experiential learning in higher education. acad manage learn educ 2005;4(2):192-212. https://doi.org/10.5465/amle.2005.17268566 accepted 3 december 2019. afr j health professions educ 2020;12(1):4. https://doi.org/10.7196/ajhpe.2020.v12i1.1258 calling all authors: writing skills for family medicine residents in kenya s onguka,1 md; d m basnight-brown,2 phd; v a pallo,3 phd; g m wechuli,1 mmed-fm; m b adam,4 md 1 department of family medicine, school of medicine and health sciences, kabarak university, kenya 2 department of psychology, school of social sciences, united states international university africa, nairobi, kenya 3 department of focused inquiry, university college, virginia commonwealth university, richmond, va, usa 4 newborn community health project, aic kijabe hospital; and institute of healthcare management, strathmore business school, nairobi, kenya corresponding author: s onguka (educoord.fammed@kabarak.ac.ke) this open-access article is distributed under creative commons licence cc-by-nc 4.0. table 1. residents’ 10-point confidence scale responses avoiding plagiarism being an author resident before after before after a 1 8 3 8 b 1 8 5 8 c 0 7 2 6 d 1 7 2 6 e 1 8 3 7 https://doi.org/10.1136/bmjopen-2016-012332 https://doi.org/10.5465/amle.2005.17268566 june 2020, vol. 12, no. 2 september 2019, vol. 11, no. 3 ajhpe 75 short communication the problem lecturers in health science education programmes wear many hats. their undergraduate training prepares them to deliver healthcare services as clinicians. they may enter academia as clinical educators and then advance to become classroom-based teachers. it is frequently assumed that they are equipped to fulfil the role of teacher. this was certainly the route that i followed. as a digital immigrant, my standard teaching tools were lectures supported by text-laden powerpoint presentations. the realisation dawned that this approach was failing to meet the expectations of digital-age students – it not only favoured student passivity, but was also a missed opportunity to demonstrate responsible use of technology for communicating information to colleagues and clients in the workplace. the communication skill set is an entry-level competency for dietitians[1] who must apply this extensively in the development of information, education and communication tools for the purpose of health promotion and patient education. a keenness to improve e-learning confidence and competence led to registration for a cape higher education consortium (chec) course titled ‘design for learning with technology’. inadvertently, this was also my first and rather overwhelming introduction to the language of pedagogy. the approach the chec blended-learning course consisted of contact sessions facilitated by experts in instructional design, augmented by small-group work in the virtual space. careful consideration of e-tool affordances and the alignment of these to learning outcomes are a key principle for designers of blended or online modules.[2] the brief for the course assessment was to explore the affordances of a range of e-learning tools that could address an identified learning and teaching challenge – i chose to focus on the low student participation rate in the classroom. while ambivalent of my own understanding of the concept of affordances at the offset, i hit the google play store with the enthusiasm of one who had won an all-expenses-paid shopping spree. having downloaded one of each educational application that seemed vaguely appealing, i spent countless hours exploring and brainstorming e-tools that could improve exploring the affordances of e-learning technologies for dietetics education and training j wilkenson, mph, bsc (dietetics) department of dietetics and nutrition, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: j wilkenson (jwilkenson@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. table 1. affordances of a sample of e-tools for the dietetics educator selected e-learning tool application for lecturers/teachers application for students concept maps (coggle, mindmeister, lucidchart) allows use of text, images, videos, audiorecordings and hyperlinks allows easy navigation between different media from a single screen may be presented as a slide show, focusing on areas of interest by various navigation techniques makes explicit the links between concepts addressed under a particular content area may be accessed by students may be shared with co-teachers for collaborative editing may be used as a method of studying students can be taught to build their own maps to ‘see’ links between theoretical content of different modules in the curriculum (e.g. medical bioscience and nutrition science) supports concrete learning as opposed to rote learning infographic software (piktochart, canva, lucidchart) uses a combination of minimal text, images and charts to present ideas may be used to summarise key points of a chapter popular for presenting information to patients/clients can support information sharing when language barrier exists students can be taught to design patient information, education and communication materials using templates provided animation software (powtoon) allows for creating a story board using theoretical content (e.g. clinical signs of micronutrient deficiencies) allows for selection of images, text and audio to showcase content video-file can be shared with students for accessibility and repeatability to create information, education and communication materials to create presentations for submission for online assessments screen-casting software (screencasto-matic) can record a computer screen display along with narration to demonstrate a particular action (e.g. how to navigate data sets or create formulas in excel (microsoft, usa)) created files can be downloaded and shared with students as reference sources students can create screen casts to demonstrate mastery of particular skills 76 september 2019, vol. 11, no. 3 ajhpe short communication student engagement/participation. through this exploration, i discovered powtoon for animation, lucidchart for organograms/graphics, coggle and mindmeister for mind map-styled presentations. outcomes recognising the potential of these e-tools has certainly stimulated my creativity as a teacher/instructional designer. while by no means an exhaustive account of available tools, the affordances of a sample of e-tools with particular relevance to dietetics and nutrition training are presented in table 1. introducing new media for class presentations has been an impetus for improved student participation. traditional, text-laden powerpoint presentations have been revitalised with animations and graphics; lucidchart assists students to link the different concepts, thereby aiding their organisation of ideas, which in turn supports deeper learning. short, humorous animations are used to package messages which, when efficiently designed, can circumvent language barriers. even though the language of pedagogy was intimidating to me – a clinician-turned-teacher – chec course facilitators created a supportive environment that allowed participants to be fully engaged learners. furthermore, technology infusion has had a positive impact on the students in my class, and participation in the course ignited a desire in me to expand professional development in the area of learning and teaching. declaration. none. acknowledgements. convenors of the cape higher education consortium’s ‘design for learning with technology’ short course, 2016. author contributions. sole author. funding. none. conflicts of interest. none. 1. health professions council of south africa. professional board for dietetics and nutrition. the scope and competencies of the new dietitian-nutritionist in the well-being of the south african population with associated assessment criteria for entry-level dietitian-nutritionist. pretoria: hpcsa, 2017. 2. bower m. affordance analysis – matching learning tasks with learning technologies. educ media int 2008;45:3-15. https://doi.org/10.1080/09523980701847115 accepted 1 july 2019. afr j health professions educ 2019;11(3):75-76. https://doi.org/10.7196/ajhpe.2019.v11i3.1192 november 2020, vol. 12, no. 4 ajhpe 165 guest editorial the year of the nurse and midwife will dominate the academic discourse for years to come. there was no better way to celebrate and elevate the status of nursing and midwifery globally than a true demonstration of the work of nurses and midwives during the covid-19 pandemic. in addition, the first ever state of the world’s nursing report was released this year, highlighting milestones in the nursing profession and also the glaring challenges in nursing, nursing education and health systems in general.[1] as we look into the future, i reflect on some of the imminent issues facing nursing and midwifery education on the african continent. the contribution to nursing theory by nurses from africa is still debatable. a link between nursing theory and the formation of professional identity has been established.[2] a well-formed professional identity enhances the contribution of nurses to healthcare, and challenges the dominant norms of nurses being ‘hand-maidens’ who act on instructions from other health professionals. basing nursing education on contextually developed nursing models and theory supports the formation of an appropriate professional identity among graduating nurses and midwives. it is crucial for the future of nursing education in africa that models and theories related to nursing are developed from, and also reflect realities on, the african continent. the world health organization (who) has promulgated interprofessional education as fundamental for the development of collaborative practiceready health professionals.[3] interprofessional education enhances students’ awareness of other health professionals’ roles, and improves communication and teamwork.[4] face-to-face institution-based interprofessional education initiatives have since been reported in africa, involving nursing students in university-based programmes. the literature is silent on interprofessional education opportunities for nursing students in non-university-based programmes, regardless of them being the largest number of nursing students on the continent. with the rise of online and electronic approaches to learning and teaching, virtual interprofessional education may be an alternative. such education may provide an opportunity to include students from various settings, e.g. nursing students in non-universitybased programmes. there are renewed calls for the adoption and implementation of competency-based nursing education across all regions.[1] several reports from the continent have highlighted structural challenges related to the adoption of competency-based education.[5] nursing education institutions seem to have limited support from stakeholders for any meaningful curriculum change. the lack of support for these institutions may potentially negatively influence the quality of nursing education, thus doing more harm than the intended good. nurse educators are vital in the development of future nurses. in africa, in addition to the perpetual shortage of nurse educators, the majority of them are not involved in research and academic scholarship. furthermore, emerging nurse educators grapple with research methodology, resulting in poor-quality research, with limited application beyond a specific context. ultimately, this situation restricts any meaningful contribution to nursing science by nurse educators from the african continent. this special focus issue on nursing and midwifery education in africa reflects the collaboration among nurses and non-nursing professionals from different institutions within a country and across africa. these examples of collaboration and network-building outline some of the ways to overcome parochial concerns and embrace the context of our practice. champion n nyoni guest editor: special focus issue on nursing and midwifery education, school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa nyonic@ufs.ac.za 1. world health organization. state of the world’s nursing report 2020: investing in education, jobs and leadership. geneva: who, 2020. 2. trede f, macklin r, bridges d. professional identity development: a review of the higher education literature. stud high educ 2012;37(3):365-384. https://doi.org/10.1080/03075079.2010.521237 3. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. 4. botma y, labuschagne m. students’ perceptions of interprofessional education and collaborative practice: analysis of freehand drawings. j interprof care 2019;33(3):321-327. https://doi.org/10.1080/13561820.2019.16 05981 5. nyoni cn, botma y. implementing a competency-based midwifery programme in lesotho: a gap analysis. nurse educ pract 2019;34:72-78. https://doi.org/10.1016/j.nepr.2018.11.005 afr j health professions educ 2020;12(4):165. https://doi.org/10.7196/ajhpe.2020.v12i4.1456 collaboration: a potential solution to imminent issues facing nursing and midwifery education in africa? this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1080/03075079.2010.521237 https://doi.org/10.1080/13561820.2019.1605981 https://doi.org/10.1080/13561820.2019.1605981 https://doi.org/10.1016/j.nepr.2018.11.005 june 2020, vol. 12, no. 2 ajhpe 52 short communication problem the traditional approach to developing practical skills in physiotherapy education presents several challenges. because of larger class sizes, it is difficult for all students to see clearly what is being demonstrated, and because of limited staff numbers, lecturers cannot necessarily spend enough time with students to observe and correct their techniques.[1] this study aimed to explore an alternative means of instruction that is emerging as an area of interest in physiotherapy education. video-based learning is increasingly being used in programmes with high levels of practical content to free up time in the classroom for lecturers to help students to problem solve instead. video-based learning allows students to learn a practical technique using only online resources for instruction and demonstration components. the project received ethical clearance from the university of the western cape research committee (ref. no. hs/16/5/7). approach a total of 41 students chose to participate in the study. they were randomly divided into the video-based learning group (n=21) and the face-to-face group (n=20). both groups learnt the static and dynamic patellar apprehension tests in a session of 20 minutes, working in groups of 3 5 students. the face-to-face group observed the lecturer demonstrate the technique and then practised in groups. the video-based learning group watched both techniques by video, which was supplemented with images and text descriptions on a single web page. these students also practised in groups, but there were no lecturers present to clarify any questions they might have had at the time. two weeks later, both groups of students were tested using an objective structured practical examination (ospe). the lecturer designed the ospe and the researchers marked the students’ performance of both techniques. as the study was voluntary, students could choose whether to take the ospe. while all 21 students in the video-based group took the test, only 9 of the 20 in the face-to-face group were assessed. outcome the study found that the abovementioned two practical techniques could be taught using only a video-based teaching session, as 76% (n=16/21) of the students in the video-based group passed the ospe, compared with 55% (n=5/9) of those in the face-to-face group. the average grades of the video-based learning group (67%) were similar to those of the face-to-face learning group (63%). we acknowledge that using performance scores in the assessment is a poor indicator of the success of the intervention and that these findings should be interpreted with caution. however, the aim of this short communication is not to produce generalisable findings, but rather to describe a novel intervention in physiotherapy education that might serve as a foundation for more rigorous feasibility studies. in a face-to-face teaching session, much of the time may be spent on the mechanics of the practical technique, meaning that there may be limited time to engage with the types of questions that emerge after practice and that improve students’ understanding and application of the technique.[2] this small pilot study suggests that some practical physiotherapy techniques might be taught using only video-based learning, including techniques that are relatively simple to describe and model. using video-based approaches might help lecturers free up additional time in class for discussion, increased engagement and problem solving around more advanced techniques. declaration. the claims made in this article represent the perspectives of the authors and not of the institution and employer. acknowledgements. the authors would like to acknowledge the contributions of the following undergraduate students: c van der merwe, a austin, c austin, l alberts and a karsten, who conducted the research and analysed the data. author contributions. mr conceptualised the study and prepared the proposal for ethical approval; bs prepared the first draft of the manuscript and assisted with the revision of the manuscript; and both authors were involved with the preparation of the manuscript and gave final approval for submission. funding. none. conflicts of interest. none. 1. george a, blaauw d, green-thompson l, et al. comparison of video demonstrations and bedside tutorials for teaching paediatric clinical skills to large groups of medical students in resource-constrained settings. int j educational technol high educ 2019;16(34):1-16. https://doi.org/10.1186/s41239-019-0164-z 2. janse van rensburg es. effective online teaching and learning practices for undergraduate health sciences students: an integrative review. int j afr nurs sci 2018;9:73-90. https://doi.org/10.1016/j.ijans.2018.08.004 accepted 19 november 2019. afr j health professions educ 2020;12(2):52. https://doi.org/10.7196/ajhpe.2020.v12i2.1271 using video to learn practical techniques in physiotherapy education m rowe, phd, msc, bsc (physiotherapy); b sauls, msc, bsc (physiotherapy) department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: m rowe (mrowe@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1186/s41239-019-0164-z https://doi.org/10.1016/j.ijans.2018.08.004 october 2020, vol. 12, no. 3 ajhpe 97 short communication the problem despite concerted efforts through policy reforms, research training and mentorship programmes, nursing research capacity remains low.[1] a major reform in south africa is the integration of nursing education with the ministry of higher education and training, requiring nurse educators to obtain higher degrees.[2] a revision of the south african nursing council (sanc) requirements for registration as a nurse educator includes, among other competencies, the ability to conduct research.[3] the management of a university of technology, where the intervention described here took place, displays a willingness to support researchers. a major constraint, however, is material support related to time available for research due to large teaching loads and remote locations of satellite campuses of the institution. the constrained resource environment also hampers different forms of collaboration necessary for nurse educators’ research-capacity development, such as academic, novice-expert, multisite and interprofessional collaboration. the approach the authors launched an experiential and collaborative research-capacity development programme in 2018 (ongoing) that includes nurse educators at the university’s central campus in cape town and four satellite campuses in western cape province. with a participatory action research approach, the programme participants were not only part of the intervention, but also of the research process, i.e. they were learning in action. this short communication reports on the first two 1-day cycles of the pilot programme at the main campus, where a face-to-face style was followed. ten participants were divided into 3 small groups. in the first cycle, participants produced drawings of their research experience and research pathway, while the second cycle concentrated on a collaborative data analysis session with a remix of the original team members. the outcome we learnt that the programme had a positive effect on various levels. on an interpersonal level, the reflective notes indicated that the participants enjoyed the participatory nature of the intervention and particularly the sharing and discussion of ideas, learning of multiple opinions and interpretations of the data analysis. on an intrapersonal level, this led to self-reflection regarding some participants’ assumptions of research and potential biases. participants also appreciated that they often shared similar experiences, such as a fear of conducting research. on other occasions, however, they were not on the same page, e.g. during the data analysis. they appreciated spending dedicated time with colleagues, while learning simultaneously. some found the programme relaxing and fun, while others were continually thinking about the work that was waiting to be done. most found the data collection through drawings interesting – they would apply it to their future research. some found the team data analysis intimidating, as they had to think, interpret and discuss at the same time. in reflection on this research, we realised that not everybody enjoys teamwork. one participant, however, noted that the team approach was a success in this programme. we are also of the opinion that this programme offering can be improved by including remote campuses in similar, but virtual exercises. declaration. none. acknowledgements. we thank the institution for permission to conduct the research, as well as the participants for their engagement. author contributions. both authors were involved in data collection and writing of the report. funding. none. conflicts of interest. none. 1. chen q, tang s, castro ar. research capacity in nursing: a concept analysis based on a scoping review. bmj open 2019;9(11). https://doi.org/10.1136/bmjopen-2019-032356 2. national department of health. national policy on nursing education and training. pretoria: ndoh, 2019. 3. south african nursing council. exit level outcomes ‒ postgraduate diploma in nursing education. pretoria: sanc, 2019. accepted 6 july 2020. afr j health professions educ 2020;12(3):97. https://doi.org/10.7196/ajhpe.2020.v12i3.1370 developing nurse educators’ research capacity in a resource-constrained environment j e maritz,1 dcur; k jooste,2 phd 1 department of health studies, school of social sciences, university of south africa, pretoria, south africa 2 department of nursing sciences, faculty of health and wellness, cape peninsula university of technology, cape town, south africa corresponding author: j e maritz (maritje@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1136/bmjopen-2019-032356 mailto:maritje@unisa.ac.za ajhpe african journal of health professions education october 2020, vol. 12, no. 3 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 from the editor 93 thank you from the guest editors on behalf of the african journal of health professions education c n nyoni, l wolvaardt guest editorial 94 nursing and midwifery students will be left behind c n nyoni short communication 95 group work in a nursing curriculum: a teaching strategy to enhance student engagement e mukurunge, l badlangana, c n nyoni 96 tutorials to support learning: experiences of nursing students in a competency-based nursing programme e mukurunge, m shawa, t nyoni, p mutimbe, r mahomaile, k mokhele, b masava 97 developing nurse educators’ research capacity in a resource-constrained environment j e maritz, k jooste research 98 nursing students’ perceptions and experiences of concept mapping as a learning tool in a human physiology course v nuuyoma, s k fillipus 103 demystifying sexual connotations: a model for facilitating the teaching of intimate care to nursing students in south africa s shakwane, s mokoboto-zwane 109 the contribution of nursing preceptors to the future nursing workforce l hugo, y botma 114 improving postgraduate nursing research output: a south african nursing science perspective p c chukwuere, l a sehularo, m e manyedi, m m ojong-alasia 119 a broken triangle: students’ perceptions regarding the learning of nursing administration in a low-resource setting b masava, l n badlangana, c n nyoni 124 the influence of context on the teaching and learning of undergraduate nursing students: a scoping review r meyer, s c van schalkwyk, e archer ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe ajhpe african journal of health professions education october 2020, vol. 12, no. 3 editorial boardeditor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 130 a review of geriatric care training in the undergraduate nursing and medical curricula at the university of kwazulu-natal, south africa k naidoo, f waggie, j m van wyk 134 effect of a teaching programme on knowledge of postoperative pain management among nurses at lagos university teaching hospital, nigeria m o olawale, o olorunfemi, o m oyewole, r a salawu 140 factors contributing to poor performance of student nurses in anatomy and physiology x l mhlongo, t e masango 144 predicting effect of emotional-social intelligence on academic achievement of nursing students a alenezi, m s moustafa saleh, r a gawad elkalashy 149 liberalisation of education in cameroon: the liberating-paralysing impact on nursing education m n maboh 154 competencies for structured professional development of neonatal nurses in south africa c maree, m scheepers, e s janse van rensburg cpd questionnaire 96 october 2020, vol. 12, no. 3 ajhpe short communication why was the idea necessary (problem)? nursing education institutions (neis) in lesotho have adopted competencybased education in undergraduate nursing programmes.[1] in preparation for class, nursing students are expected to engage with learning material. this material includes research articles, specific textbook sections, best practice guidelines and videos, which are sources of essential foundational knowledge. during class, educators co-construct knowledge with students by applying foundational knowledge to specific scenarios. foundational knowledge influences nursing students’ critical thinking and reasoning, which are essential in nursing care. the educators in this setting have expressed concern regarding first-year nursing students’ lack of preparedness for class activities, attributing it to students’ lack of self-directedness. [1] one of the neis introduced tutorials as a strategy to improve nursing students’ engagement with the learning material. the authors describe the experiences of first-year nursing students regarding the tutorial sessions. what was tried (approach)? alumni with experience of the same curriculum model were employed as tutors to co-ordinate the tutorial sessions. these tutorials were presented in 1-hour group or individualised sessions, focusing on students’ selfidentified learning needs. the group tutorial sessions were integrated into the mainstream timetable, while individual appointments were made at the discretion of the students and recommendation of the nurse educators. data were collected from first-year nursing students (n=30) through qualitative narrative reports. the participants were asked to describe their experiences of the tutorial sessions at their nei. the collected data were thematically analysed. ethical approval was granted by the ministry of health, lesotho (ref. no. 68-2018) and all participants gave informed consent. what were the lessons learnt (outcomes)? using level 1 of kirkpatrick’s model,[2,3] results revealed that tutorials are a less formal support strategy where interactive and friendly games were used to make learning interesting for nursing students. participants indicated that individualised attention and small-group discussions were approaches to learning that clarified concepts. engagement with activities during tutorials led to participants discovering their own learning styles, which enhanced their understanding of concepts. participants generally expressed the need for more time allocation to tutorial sessions to maximise the benefits. nurse educators expressed an improvement in nursing students’ participation following their engagement in tutorials. conclusions first-year nursing students may struggle to adjust to the learning strategies in nursing education. therefore, neis should establish support strategies for students to enhance learning. tutorials have the potential to improve the learning experience of nursing students. to maximise benefits from tutorial sessions, neis should incorporate games and small-group discussions and allow for individual consultations with tutors, as well as allocating enough time for tutorial sessions. declaration. none. acknowledgements. the authors acknowledge dr c n nyoni (university of the free state) for his expert input and for critically reading this manuscript, ms m nkaki (paray school of nursing) and mrs t dyamdeki (paray school of nursing) for their contribution in the conceptualisation of the project. paray school of nursing is acknowledged for providing the platform to develop the project. author contributions. all authors contributed to the conceptualisation, design and execution of this study. all authors equally contributed to the writing of the article. funding. none. conflicts of interest. none. 1. nyoni cn, botma y. implementing a competency-based midwifery programme in lesotho: a gap analysis. nurse educ pract 2019;34:72-78. https://doi.org/10.1016/j.nepr.2018.11.005 2. heydari mr, taghva f, amini m, delavari s. using kirkpatrick’s model to measure the effect of a new teaching and learning methods workshop for health care staff. bmc res notes 2019;12(1). https://doi.org/10.1186/ s13104-019-4421-y 3. akinyode bf, khan th. step by step approach for qualitative data analysis. int j built environ sustain 2018;5(3):163-174. https://doi.org/10.11113/ijbes.v5.n3.267 accepted 13 july 2020. afr j health professions educ 2020;12(3):96. https://doi.org/10.7196/ajhpe.2020.v12i3.1383 tutorials to support learning: experiences of nursing students in a competency-based nursing programme e mukurunge, mnsg; m shawa, mph; t nyoni, diploma in midwifery; p mutimbe, diploma in midwifery; r mahomaile, diploma in midwifery; k mokhele, diploma in midwifery; b masava, mphil paray school of nursing, thaba tseka, lesotho corresponding author: e mukurunge (evamukurunge@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1016/j.nepr.2018.11.005 https://doi.org/10.1186/s13104-019-4421-y https://doi.org/10.1186/s13104-019-4421-y https://doi.org/10.11113/ijbes.v5.n3.267 2 march 2020, vol. 12, no. 1 ajhpe editorial i listen to my footsteps beat like a drum on the sidewalk in the early autumn mist of a cape town sunrise. i have a small window of opportunity to reflect on the arrival of coronavirus disease 2019 (covid-19) on the shores of our continent. yes, finally covid-19 has arrived in africa. what will happen on this vast landmass plagued by so many other scourges of poverty and inequality? how will this virus impact on the lives of those fighting off the ravages of hiv, tuberculosis (tb), malaria, hepatitis b and so many other pathogens that wage their wars, largely in silence? putting this virus in perspective is a healthy way of staying well. helpful data recently released into the vast ocean of social media [mis]information provide a useful anchor for a sane conversation with the ordinary person on the street.[1] while the public are being bombarded with endless downloads of media hype and rapidly multiplying myths, we, as health professions educators, are mandated to stay abreast of developments and provide a clear and simple synthesis of available facts. currently the ‘take home’ messages about the illness are clear: the majority of infections are mild, most people recover, the elderly are at increased risk of an adverse outcome, and preexisting cardiovascular, pulmonary or cancer-related comorbidity increases the risk of an adverse outcome.[2] from an epidemiological perspective, it is critical to be reminded that the virus is not, as it is being called, ‘deadly’ when compared with serious lifethreatening viral infections that have much higher mortality rates, e.g. avian flu, ebola, mers or smallpox, to name just a few the world has encountered in recent times.[1] second, we are still learning about the infectivity of the virus, but it is not in the league of notorious childhood ‘killer’ viruses such as measles and chickenpox.[1] it is also clear that case fatality rates are country dependent.[1] what is more important perhaps, is that this epidemic provides us with an opportunity to remind the world about the ongoing daily global loss of life due to our ‘old friends’ – the giants of the developing world: tb, hiv, malaria and hepatitis b. collectively, these four infections account for >8 000 deaths a day.[1] this daily loss of humanity towers over covid-19 that has averaged ˂300 deaths a day to date.[1] the plight of those who have so little and stand to lose so much remains largely unheard, particularly on the african continent. as health professions educators, we need to raise awareness of this reality whenever we sit in conversations that ruminate about an infection that will never reach the pandemic proportions of the not-so-novel infections we battle on a daily basis. looking ahead, what do we need to ponder? the interaction between covid-19 and our pre-existing untamed healthcare crises, would be my answer. how will this respiratory pathogen engage with communities struggling with tb and hiv co-infection? we have no idea about this potential looming public healthcare crisis and only time will tell. once covid-19 finds its way into high-risk communities by a process of local transmission to non-travellers, we will need to rethink our strategy. in the southern hemisphere, we are also entering the annual winter influenza season, during which about 11 000 south africans perish each year.[3] many of us recall the impact of the swine flu epidemic on the south african healthcare system that was hardly coping with the colliding epidemics of tb, hiv and annual influenza. will we see a similar story unfold again this year? so, what can we do to protect africa’s most vulnerable communities who may carry the greatest risk of an adverse outcome? fortunately, as is so often the case with big health scares, the public health measures are simple and need to be widely disseminated. we urgently need to go viral with real information. the message needs to be displayed infographically, which makes it clear and simple – as recently demonstrated by the johns hopkins center for systems science and engineering.[4] just the essential facts are required: good, regular handwashing, don’t cough or sneeze on anyone, stay home if you are ill and stay away from others who are ill. just these four measures will keep the vast majority of healthy people safe. the challenge is to get this message into public spaces in local languages. digital dissemination in english will miss the majority of high-risk communities. ironically, this viral campaign needs to be in print – displayed in shopping centres, train stations, bus stations, taxi ranks, schools, and on lampposts and street corners, where access is easy and free. 24/7. prof. vanessa burch editor: african journal of health professions education vcburch.65@gmail.com 1. coronavirus datapack. https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographicdatapack/ (accessed 13 march 2020). 2. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet 2020;(epub ahead of print). https://doi.org/10.1016/s01406736(20)30566-3 3. tempia s, moyes j, cohen al, et al. health and economic burden of influenza-associated illness in south africa, 2013 2015. influenza other respir virus 2019;13(5):484-495. https://doi.org/10.1111/irv.12650 4. coronavirus at a glance: infographic. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/ coronavirus-facts-infographic (accessed 13 march 2020). afr j health professions educ 2020;12(1):2. doi:10.7196/ajhpe.2020.v12i1.1342 going viral in a digital world this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/ https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/ https://doi.org/10.1016/s0140-6736(20)30566-3 https://doi.org/10.1016/s0140-6736(20)30566-3 https://doi.org/10.1111/irv.12650 https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-facts-infographic https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-facts-infographic a maximum of 3 ceus will be awarded per correctly completed test. november 2020, vol. 12, no. 4 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) cpd questionnaire november 2020 exploring internal quality assurance for nursing education in the state university of zanzibar, tanzania: a preliminary needs analysis 1. which of the following statements are true regarding the results of the study (more than one answer is correct): a. all nurse educators understood the meaning of the term ‘internal quality assurance’. b. all the students indicated that they understood the meaning of ‘internal quality assurance’. c. the majority of nurse educators had a positive perception of the existing methods for evaluating the effectiveness of teaching. d. less than half of the students indicated that there is no existing process to monitor teaching and learning. facilitators and challenges experienced by first-year nursing students at the university of fort hare, south africa, when conducting home visits 2. the challenges raised by students in this study include (more than one answer is correct): a. insufficient orientation. b. unrealistic expectations by the community. c. insufficient consultation skills. d. unfriendly, unwilling community members. supportive framework for teaching practice of student nurse educators: an open distance electronic learning (odel) context 3. the link between theory and practice is often skewed in favour of practice. (true/false) a competence assessment tool that links thinking operations with knowledge types 4. the authors classified the items under the following themes (more than one answer is correct): a. critical thinking. b. clinical judgement and clinical reasoning. c. behaviour. d. metacognition. f. competence. mentors’ and student nurses’ experiences of the clinical competence assessment tool 5. the students had the following challenges with regard to the assessment tool (more than one answer is correct): a. assessment is subjective. b. no clear assessment guidelines. c. some procedures in the tool are not performed in hospital. d. no guidelines for feedback. e. unclear instructions for students. practice guidelines for peer support among educators during a curriculum innovation 6. the priority areas for the peer support guidelines include (more than one answer is correct): a. attributes of reviewers. b. peer support strategies. c. content needs. d. monitoring and evaluation of the peer support strategy. converging professional nurses’ perceptions and community service nurses’ experiences regarding clinical competence during community service placement 7. for this study, competence is defined as community service nurses’ ‘capacity of individuals to perform the given task’. (true/false) please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. cpd questionnaire november 2020, vol. 12, no. 4 ajhpe the emergence of a clinical skills laboratory and its impact on clinical learning: undergraduate nursing students’ perspective in limpopo province, south africa 8. which statements regarding this study are true (more than one answer is correct): a. students regarded the emergence of the skills laboratory as a positive establishment in the department. b. a limitation of the study is the small sample size. c. simulated skills were viewed as a way of eliminating fear and anxiety. d. a strength of the study is the triangulation of data. evaluating the outcomes of a faculty capacity development programme on nurse educators in sub-saharan africa 9. the four themes that emerged from the study include: a. professional benefit. b. personal benefit. c. student benefit. d. health system benefit. e. institutional/community benefit. stakeholders’ community-engaged teaching and learning (cetl) experiences at three universities in south africa 10. the following are sub-themes of cetl principles (more than one answer is correct): a. reflection. b. shift in mind-set. c. authentic learning. d. reciprocity. the use of an online learning management system by postgraduate nursing students at a selected higher educational institution in kwazulu-natal, south africa 11. the results of the study revealed (more than one answer is correct): a. more than half of respondents have access to a computer at home. b. more than two-thirds of respondents had prior exposure to online learning platforms before enrolling on the course. c. less than half of respondents felt comfortable using moodle. d. english proficiency was not associated with accessibility to computers. nurse educators’ views on implementation and use of high-fidelity simulation in nursing programmes 12. content analysis was performed using which approach (only one answer is correct): a. braun and clarke? b. hsieh and shannon? c. creswell? d. long and johnson? male students’ motivations to choose nursing as a career 13. the intrinsic motivating factors included (more than one answer is correct): a. desire to help people. b. always wanting to be a nurse. c. wanting a stable career. d. wanting to make a difference in society. promoting patient autonomy: perspectives of occupational therapists and nurses 14. trustworthiness was maintained by ensuring an audit trail of processes and decisions taken. (true/false) a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) november 2020 abstracts 24 august 2010, vol. 2, no. 1 ajhpe influence of confidence and experience on the competency of junior medical students in performing basic procedural skills adele de villiers, elize archer correspondence to: adele de villiers (adeledev@sun.ac.za) context and setting studies, mostly done with final-year medical students and doctors, show that the confidence level with which a clinical skill is performed is not a reliable benchmark of actual clinical competence. this inaccurate selfevaluation of proficiency has far-reaching implications, e.g. the inability to identify learning deficiencies and consequently to manage learning – both essential components of self-directed learning programmes. why the idea was necessary the purpose of this study in comparing self-reported competence and actual competence was threefold, i.e. to discover students’ perceptions concerning their competence of specific procedural skills; to establish what the actual competence level of junior medical students were with regard to these skills; and to raise student awareness of the value of accurate self-evaluation. what was done third-year medical students at the faculty of health sciences, stellenbosch university, attended a training session in the clinical skills centre (csc) at the beginning of a year. supervised by clinical tutors, they practised three basic procedural skills on part-task trainers/bench-top manikins, i.e. commencing an intravenous infusion; performing simple wound closure (suturing); and administering an intramuscular injection. during the remainder of the year, they returned in smaller groups in their family medicine rotation for formative assessment of these skills, using an osce. before performing the clinical procedures, students had to rate their perceived competence. clinical tutors then used checklists to rate actual student competence when performing these three skills. evaluation of results and impact in accordance with similar studies, there was poor correlation between selfreported and actual competence regarding the performance of procedural skills. there were, however, significant correlations between self-reported competence and clinical experience (r=0.49, p=0.00) as well as between experience and actual competence (r=0.36, p=0.00). it seems that junior students lack the necessary critical self-assessment skills to accurately evaluate their performance of certain basic procedural skills. however, frequently performing these skills in the clinical setting (or elsewhere) increased both self-reported and actual competence in these students. before this study, junior medical students had limited formal clinical skills teaching in the csc and, because of the already overloaded curriculum, were not assessed with regard to such skills. as a result, the onus rested on the student to gain these and other, often ill-defined, skills in the clinical setting. since the completion of this study, a logbook system has been introduced to encourage students to make the most of the opportunities in the clinical setting to practise the skills taught in the csc. furthermore, a core clinical skills curriculum was compiled, indicating which skills should be taught in simulation and which in the clinical setting, as well as the competency levels (based on miller’s framework for clinical assessment) at which these skills should be performed. from 2011 students will be subjected to a summative osce to assess their clinical skills competency. cracking the nut of service learning in nursing hester julie correspondence to: hester julie (hesjulie@gmail.com) context and setting higher education institutions (heis) worldwide are being held more accountable for the effectiveness and relevance of their educational programmes and are being challenged to ‘reinsert the public good into higher education’. these reasons have contributed to the development of the service learning movement globally. in south africa service learning became entrenched in hei policy documents less than a decade ago. although there are national policy guidelines for community engagement and service learning as a particular type of community engagement, the implementation of service learning has occurred sporadically as heis are struggling with the many changes at all societal levels. purpose while the school of nursing at the university of the western cape is cognizant of this national policy imperative as stipulated in the guidelines of the higher education quality committee, how these statements will be operationalised within the undergraduate nursing programme has not been addressed. the question that therefore needs to be asked is what teaching staff perceive to be the enablers and challenges for institutionalising service learning in the programme by exploring the perceptions of those involved in teaching on the programme. what was done an exploratory, descriptive, contextual design was used. participants, who included academics (n=18) and clinical supervisors (n=18) employed at the school of nursing, completed a selfadministered, structured questionnaire, adapted from furco’s self-assessment rubric for the institutionalisation of service learning in higher education. results of results and impact the preliminary results reported here are part of a wider investigation into the implementation of service learning in selected modules in the undergraduate nursing programme. the findings reveal that the school of nursing has to engage in critical mass building activities because none of the respondents was aware of the higher education quality committee’s assessment criteria for service learning. approximately 9% indicated awareness that the institution has an official definition of service learning that is used consistently to operationalise most aspects of service learning on campus. however, the majority (91%) reported on the absence of a campus-wide definition of service learning, the inconsistent use of service learning to describe a variety of experiential and service activisouthern african faimer regional institute (safri) poster day, cape town, march 2011 and sa association of health educationalists (saahe) conference, johannesburg, july 2010 24 june 2011, vol. 3, no. 1 ajhpe 25 august 2010, vol. 2, no. 1 ajhpe abstracts 25 june 2011, vol. 3, no. 1 ajhpe ties, or that they were unsure. respondents indicated that institutional and departmental involvement in service learning for academics, students and community participation was minimal. although three respondents attended training sessions, all indicated that they would either like to receive information about the national service learning policy guidelines, or attend training sessions on service learning. conclusion it can therefore be concluded that the academics and clinical supervisors are willing to participate in activities to overcome the challenges identified. it is therefore recommended that a tailor-made training programme be designed to address the needs of the school of nursing in order to institutionalise service learning in the undergraduate nursing programme. integrating primary health care principles in clinical teaching melanie alperstein correspondence to: melanie alperstein (melanie.alperstein@uct.ac.za) context and setting primary health care (phc) was adopted as a lead theme for curriculum transformation by the health sciences faculty of the university of cape town in 1994. however, integration of phc in clinical teaching remains limited at the secondary and tertiary levels of care. prior to embarking on this project, recent experience and data from the department of medicine suggest that clinicians at all levels of the health care system can apply these principles in clinical teaching if they are familiar with them. the established clinician education course (cec) provided an ideal opportunity to modify a module to focus on teaching the phc principles as relevant to clinical teaching. why the idea was necessary different strategies to integrate the phc principles in all clinical teaching are necessary for holistic individual and community health care. the cec was chosen as one approach to provide clinicians with an approach, and the skills and knowledge needed to impart to students the importance and application of the principles of phc in clinical care. what was done a module of the cec was re-designed and introduced in 2010. an indepth qualitative study was conducted with 8/15 (53%) of the participants who completed the module. participants completed a preand post-module questionnaire on their knowledge of phc and their perceptions of integrating phc principles in their own clinical practice and teaching. this was followed by observation of their clinical teaching and an in-depth semi-structured interview. the data related to preand postmodule knowledge of phc were analysed using basic tools of discourse analysis. the rest of the data from the questionnaires, in-depth interviews and observations were triangulated and analysed according to the impact of the course on different levels using freeth et al.’s modification of kirkpatrick’s model for evaluation of educational outcomes at different levels. results and impact participants’ post-module knowledge shifted from disorganised, point form, concrete examples to a more coherent understanding of phc and the phc principles. seven participants, 3 each from family medicine and speech therapy and audiology and one from psychiatry, claimed to already be using the phc principles in their clinical teaching prior to the course. this was corroborated by observation of their clinical teaching and/or further explanation in the semi-structured interview. the aspect that all identified as needing further attention, and where greater insight was gained, related to equity of care and violation of human rights within the health care system. the last participant from a tertiary speciality was finding it more difficult to incorporate the phc principles. all eight had identified areas of action for individual and organisational change in the future. ‘…it’s about changing the country and i’m saying to them can we make a difference to healing the nation. so they’ll be laughing about it because it is lofty ideals, but phc is about that, it is about lofty ideals. it’s about healing the nation.’ introducing case-based learning in decentralised nursing programme sindi mthembu correspondence to: sindi mthembu (mthembus1@ukzn.ac.za) background/context the approach to teaching and learning in rural decentralised settings has predominantly been didactic. to introduce a more student-centred approach, a case-based learning programme focussing on primary health care (phc) was undertaken. aim/purpose this project aimed to facilitate the introduction and implementation of case-based teaching and learning approach in a decentralised phc programme at the school of nursing. method/what was done an exploratory descriptive needs assessment survey was administered to 65 phc programme facilitators. the survey canvassed their perceptions on case-based learning and their ability to construct cases and facilitate case-based teaching in the classroom. it also explored their resource(s) constraints. results and discussion the participants were positive towards case-based learning approach. however, they acknowledged limitations in their skills to design cases and facilitate teaching sessions. they also identified a lack of resources which would hinder the successful implementation of the programme. two capacity development programmes were conducted to facilitate the construction of cases and enhancing facilitators with the skills to facilitate case-based classrooms culminating with drafts of a case study booklet and facilitators’ manual. a mobile suitcase library was introduced with all the necessary resources for the phc programme. conclusion/take home message this project will help the school to produce a different kind of graduate who will be in possession of transferable core skills. effective mechanisms for close monitoring of students’ learning and early identification of students with problems will be enhanced. continuous support is needed for facilitators to gain confidence in cased-based teaching. 12 april 2021, vol. 13, no. 1 ajhpe short communication fundamental to interprofessional education (ipe) is the assertion that if health professional students learn together from the outset and throughout their academic studies and training, they will be better prepared to work collaboratively and effectively within an interprofessional team when qualified.[1] in spite of the focus on the conceptualisation of ipe,[2,3] student engagement and collaboration were in need of attention. this was evident in the clinical setting, as students continued working in their discipline-specific silos when practising. the clinical setting was therefore identified as a platform in need of ipe-focused activities to facilitate and encourage students from different health professions to engage and collaborate with each other while completing their clinical rotations. what was tried? (approach) students received weekly on-site supervision from discipline-specific supervisors while on clinical rotations. during this time, the focus was purely on patient assessment and intervention from a discipline-specific standpoint. in addition, ipe-focused activity sessions were introduced for university of the western cape (uwc) health science students present at the same clinical site (i.e.  hospital, community health centre, clinic) simultaneously. this overlap was identified by uwc ipe co-ordinators, based on the clinical rotation rosters provided to them by the various departments. participating disciplines included physiotherapy, occupational therapy, dietetics, social work and pharmacy. weekly 1-hour sessions comprised the ipe and collaborative practice (ipecp) programme for the duration of the respective students’ clinical rotations – each session comprising ~8 12 students. students brought along their case reports and shared these with each other as a means of obtaining additional information and input from other health disciplines. the ipecp planning framework was used to guide this process, where all aspects of a patient’s treatment plan and intervention were explored. this framework is a combination of the comprehensive primary health care and the international classification of functioning, disability and health (icf) frameworks (fig. 1). students were encouraged to discuss their most challenging patients and gain input from the various disciplines present to develop holistic and collaborative treatment and intervention plans. as patient cases were unpacked, students began to develop a deeper understanding of the extent of the roles that various health professionals play, and the necessity of working within a team to treat and care for a patient comprehensively. what lessons were learnt? (outcomes) the success at the forefront of this programme was the positive and constructive manner in which students engaged in an interprofessional space. prior to the ipecp programme, the majority of students had never spoken to each other or interacted, but merely passed each other in creating a space for interprofessional engagement in a clinical setting l jaffer, ma, ba hons, ba; l africa, msc, bsc; f waggie, phd, msc, bsc interprofessional education unit, faculty of community and health sciences, university of the western cape, bellville campus, cape town, south africa corresponding author: l jaffer (ljaffer@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. client/patient/ vulnerable group/ health issue (brie�y describe the issue and develop a priority list that must be addressed by the team) aim of the intervention objectives: how will these be achieved what: plan activities for each objective who: team and their role how: appropriate intervention when: logistics, e.g. date, time rehabilitative curative promotive preventive impairment (changes in body structure) _____________________________ ______________________________________________________________ activity (level of capacity in standard environment) ___________________ ______________________________________________________________ participation restriction (level of performance in usual environment) ______________________________________________________________ environmental factors (household/transport/work environment/ dependants/children) and personal factors (age/sex/medical history/ lifestyle/habits) _________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ priority list _____________________________________________________ ______________________________________________________________ fig. 1. interprofessional education collaborative practice planning framework. april 2021, vol. 13, no. 1 ajhpe 13 short communication hallways and common spaces. students reported that the ipecp programme had been the impetus behind a newfound confidence to approach not only fellow uwc students in the clinical setting, but also senior medical staff, physicians, specialists and others. the ipecp programme had significantly improved their understanding of the roles of other health professionals and their function within a team. declaration. none. acknowledgements. none. author contributions. all authors contributed equally to the article. funding. none. conflicts of interest. none. 1. reeves s, zwarenstein m, goldman j, et al. interprofessional education: effects on professional practice and health care outcomes. cochrane database syst rev 2008;(1). https://doi.org/10.1002/14651858.cd002213.pub2 2. barr h. toward a theoretical framework for interprofessional education. j interprof care 2013;27(1):4-9. https:// doi.org/10.3109/13561820.2012.698328 3. frantz jm, rhoda aj. implementing interprofessional education and practice: lessons from a resourceconstrained university. j interprof care 2017;31(2):180-183. https://doi.org/10.1080/13561820.2016.12 61097 accepted 13 march 2020. afr j health professions educ 2021;13(1):12-13. https://doi.org/10.7196/ajhpe.2021.v13i1.1316 https://doi.org/10.1002/14651858.cd002213.pub2 https://doi.org/10.3109/13561820.2012.698328 https://doi.org/10.3109/13561820.2012.698328 https://doi.org/10.1080/13561820.2016.1261097 https://doi.org/10.1080/13561820.2016.1261097 december 2018, vol. 10, no. 4 ajhpe 191 editorial training and assessing healthcare professionals boils down to one simple question, ‘can they be trusted to provide safe, effective and efficient healthcare?’ how this question is answered is of major interest to the public and healthcare funders who are, respectively, the recipients and ‘sponsors’ of the care to be provided. unfortunately, the wealth of data reporting on the morbidity and mortality associated with medical errors attests to the failure of health professions education programmes to achieve this mandate. how can the situation be remedied? processes for ensuring the competence of graduating healthcare professionals have been a major focus of attention throughout the history of medicine. learning the ‘art and craft’ of medicine 400 years ago was achieved largely through an apprenticeship model. in the early 1900s, flexner revolutionised this ‘cottage industry’ approach to clinical training by introducing a rigorous scientific approach to medical training programmes in the usa.[1] this trend was widely adopted and training programmes with a strong scientific foundation became the norm. over the next century health professions educators wrestled with the design of curricula, which evolved from organand system-based approaches to problem-based learning,[2] and more recently outcome-based[3] and competency-based education.[4] all these iterations of training reflect an earnest ongoing attempt to bridge the gap between theory and practice.[5] competency frameworks for guiding the training of healthcare professionals marked the start of a trend to more specifically define the desired capabilities of healthcare graduates.[4] a major challenge of these frameworks is their practicability in the clinical setting.[6] while they serve as comprehensive descriptions of desired graduate abilities, there remains a gap between competencies described in frameworks and clinicians who can be trusted to deliver safe, effective and efficient patient care. how then can clinical training be reconceptualised to focus on the essential responsibilities and activities of clinicians and their ability to perform them independently? strategies to address this issue have given rise to the development of workplace-based assessment (wba)[7] and the concept of ‘entrustable professional activities’ (epas).[8] these endeavours contribute to improving the likelihood that graduating healthcare professionals will ‘do the job properly’. the idea of assessing the performance of trainees in the workplace began to take shape about 30 years ago. while it has taken time to gain momentum, it is now increasingly being implemented in clinical training, especially postgraduate programmes. the literature highlights the many challenges associated with wba and potential strategies for dealing with current limitations.[9,10] despite ongoing scepticism and resistance from both trainees and educators, it is unlikely that wba will be abandoned in an era where public expectations and demands for safer clinical practice are not negotiable. what about epas? these are tasks or responsibilities that supervising clinicians entrust trainees to execute, unsupervised, once they have demonstrated adequate competence.[8] epas need to be discrete measureable units of work that can be observed and a judgement passed by supervising practitioners on the level of entrustment that trainees can be afforded. the literature warns that epas need to be sufficiently specific and well defined to form a recognisable unit of work, but not dissected into disarticulated lists of actions.[6] it is recommended that postgraduate specialty programmes should focus on 20 30 epas.[11] essentially, epas bridge the gap between the desired abilities of graduates described in competency frameworks and the actual professional activities they undertake in clinical practice.[11] unlike competencies that are generic across a range of clinical specialities, e.g. the canmeds framework, epas have discipline-specific nuances and include both process and content perspectives. for example, managing a patient with severe pregnancyinduced hypertension is a content-orientated obstetric epa, while counselling a patient about end-of-life decisions is a process-orientated epa. while the concept was described more than a decade ago, the actualisation of epas in clinical training programmes is taking time to gain ground. there are descriptions of epa-based training programmes in a range of disciplines, including internal medicine,[12,13] family medicine[14] and psychiatry.[15] however, more work is needed before epas become mainstream practice in health professions education. a key feature of using epas to describe the development of competence in the workplace is that they are assessed using entrustment scales. these scales allow supervising clinicians to ‘make assessments based on narrative descriptors that reflect real-world judgements, drawing attention to the trainee’s readiness for independent practice rather than his/her deficiencies’.[16] it follows logically that assessors are required to explain to trainees why unsupervised practice of an epa is not yet possible, and what further action is needed to achieve independent practice. the scales typically include five points: ‘observation only’; ‘perform under direct supervision’; ‘perform with readily available supervision’; ‘perform unsupervised with oversight’; and ‘provide supervision to more junior colleagues’.[6,11] these scales obviate the need to translate observed behaviour into numerical scores with abstract descriptors that do not resonate with the lived experience of clinicians who supervise trainees, e.g. ‘the trainee performs at the expected level of competence’.[16] these types of descriptors do not provide a clear definition of competence and are known to produce widely varying ratings with poor consistency. once trainees no longer require supervision, they receive a ‘statement of awarded responsibility’ (star).[5] training is complete once a star has been awarded for each epa in the training programme. ultimately this approach to assessment – the glass is half full rather than half empty – may foster a more positive attitude towards wba. so, how can these advances support the endeavours of health professions educators who wrestle with the challenge of declaring trainees safe to undertake independent clinical practice? first, consideration needs to be given to articulating curricula as a set of essential epas with a clear description of the requisite knowledge, skills and attributes to perform each activity. guidelines for undertaking this process have been published.[17,18] second, it seems that assessment in the workplace could be reconceptualised as a process of progressive entrustment, culminating in unsupervised independent practice of predetermined epas. this perspective would clarify the frequently misunderstood purpose of wba and simplify the rating processes currently used.[16] furthermore, feedback – the achilles heel of formative assessment – is an integral part of epa can they be trusted? this open-access article is distributed under creative commons licence cc-by-nc 4.0. 192 december 2018, vol. 10, no. 4 ajhpe editorial assessment processes because clinicians are obliged to provide trainees with reasons why they cannot yet perform an activity without supervision.[19] to make progress in our endeavours to train healthcare professionals who can be trusted to deliver safe, effective and efficient healthcare, broader uptake of new methods for describing and assessing competence in the workplace is needed. as was recently written, ‘be an advocate for a new view of certification and licencing’.[19] vanessa burch honorary professor, department of medicine, faculty of health sciences, university of cape town, south africa vcburch.65@gmail.com 1. cooke m, irby dm, sullivan w, ludmerer km. american medical education 100 years after the flexner report. n engl j med 2006;355(13):1339-1344. https://doi.org/10.1056/nejmra055445 2. barrows hs. problem‐based learning in medicine and beyond: a brief overview. new direct teach learn 1996;1996(68):3-12. https://doi.org/10.1002/tl.37219966804 3. harden rm. outcome-based education: the future is today. med teach 2007;29(7):625-629. https://doi. org/10.1080/01421590701729930 4. frank jr, snell ls, cate ot, et al. competency-based medical education: theory to practice. med teach 2010;32(8):638-645. https://doi.org/10.3109/0142159x.2010.501190 5. ten cate o, scheele f. competency-based postgraduate training: can we bridge the gap between theory and clinical practice? acad med 2007;82(6):542-547. https://doi.org/10.1097/acm.0b013e31805559c7 6. ten cate o. nuts and bolts of entrustable professional activities. j grad med educ 2013;5(1):157-158. https://doi. org/10.4300/jgme-d-12-00380.1 7. norcini j, burch v. workplace-based assessment as an educational tool: amee guide no. 31. med teach 2007;29(9):855-871. https://doi.org/10.1080/01421590701775453 8. ten cate o. entrustability of professional activities and competency‐based training. med educ 2005;39(12):1176-1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x 9. govaerts m, van der vleuten cp. validity in work‐based assessment: expanding our horizons. med educ 2013;47(12):1164-1174. https://doi.org/10.1111/medu.12289 10. academy of medical royal colleges. improving assessment: further guidance and recommendations. aomrc: london, 2016. 11. ten cate o. am last page: what entrustable professional activities add to a competency-based curriculum. acad med 2014;89(4):691. https://doi.org/10.1097/acm.0000000000000161 12. hauer ke, kohlwes j, cornett p, et al. identifying entrustable professional activities in internal medicine training. j grad med educ 2013;5(1):54-59. https://doi.org/10.4300/jgme-d-12-00060.1 13. caverzagie kj, cooney tg, hemmer pa, berkowitz l. the development of entrustable professional activities for internal medicine residency training: a report from the education redesign committee of the alliance for academic internal medicine. acad med 2015;90(4):479-484. https://doi.org/10.1097/acm.0000000000000564 14. shaughnessy af, sparks j, cohen-osher m, goodell kh, sawin gl, gravel jr j. entrustable professional activities in family medicine. j grad med educ 2013;5(1):112-118. https://doi.org/10.4300/jgme-d-12-00034.1 15. boyce p, spratt c, davies m, mcevoy p. using entrustable professional activities to guide curriculum development in psychiatry training. bmc med educ 2011;11(1):96. https://doi.org/10.1186/1472-6920-11-96 16. rekman j, gofton w, dudek n, gofton t, hamstra sj. entrustability scales: outlining their usefulness for competency-based clinical assessment. acad med 2016;91(2):186-190. https://doi.org/10.1097/acm. 0000000000001045 17. peters h, holzhausen y, boscardin c, ten cate o, chen hc. twelve tips for the implementation of epas for assessment and entrustment decisions. med teach 2017;39(8):802-807. https://doi.org/10.1080/014215 9x.2017.1331031 18. ten cate o, chen hc, hoff rg, peters h, bok h, van der schaaf m. curriculum development for the workplace using entrustable professional activities (epas): amee guide no. 99. med teach 2015;37(11):983-1002. https:// doi.org/10.3109/0142159x.2015.1060308 19. ten cate ot. entrustment as assessment: recognizing the ability, the right, and the duty to act. j grad med educ 2016;8(2):261-262. https://doi.org/10.4300/jgme-d-16-00097.1 afr j health professions educ 2018;10(4):191-192. doi:10.7196/ajhpe.2018.v10i4.1173 https://doi.org/10.1080/01421590701729930 https://doi.org/10.1080/01421590701729930 https://doi.org/10.4300/jgme-d-12-00380.1 https://doi.org/10.4300/jgme-d-12-00380.1 https://doi.org/10.1097/acm.-0000000000001045 https://doi.org/10.1097/acm.-0000000000001045 https://doi.org/10.1080/0142159x.2017.1331031 https://doi.org/10.1080/0142159x.2017.1331031 https://doi.org/10.3109/0142159x.2015.1060308 https://doi.org/10.3109/0142159x.2015.1060308 december 2018, vol. 10, no. 4 ajhpe 235 research pharmacotherapeutics as defined by the merriam-webster medical dictionary is ‘the study of the therapeutic uses and effects of drugs in disease states’.[1] it is an essential component of the undergraduate pharmacy curriculum worldwide, and often encompasses drug therapy and several other aspects of patient care. with the move towards greater pharmacist involvement in patient care, the new-generation pharmacist needs to have an above-average clinical knowledge of various medications and disease states.[2] the doctor of pharmacy (pharmd) degree was recently approved as the minimum requirement for registration as a pharmacist in nigeria. therefore, evaluating student perceptions of teaching methods and course content within the previous bachelor of pharmacy (bpharm) curriculum would help us to develop an improved pharmacy education experience for future students. this article describes a project aimed at exploring the perceptions and views of undergraduate pharmacy students at ahmadu bello university, zaria, nigeria, on the course content and structure, as well as methods of delivery of a pharmacotherapeutic course. methods setting the study was conducted among fourthand fifth-year undergraduate students, faculty of pharmaceutical sciences, ahmadu bello university. ethical approval (ref. no. abucuhsr/2016/ug/004) and permission to perform the study were obtained from the research ethics committee of the university. pharmacotherapeutics 1 (phcp 403) is a fourth-year 3-credit unit course (45 contact hours) taught during the first semester of every academic session by permanent academic staff of the department of clinical pharmacy and pharmacy practice. the major objective of the course is to educate students on the pharmacotherapeutic management of common diseases that affect the cardiovascular, respiratory, renal and haematological systems and to provide an overview of nutritional disorders. the course has several prerequisite modules, including anatomy, physiology, pharmacology and pathology, and students are required to pass information technology before enrolling in the final-year course of pharmacy clinical ward rounds. study design a sequential mixed-methods approach was used to collect data in two phases – from april to august 2016. during the first phase, a pretested anonymous questionnaire containing openand closed-ended questions was distributed to all 201 students who enrolled for the course at the end of the 2015/2016 academic session. the questionnaire contained three sections: part 1 collected general demographic information on the student population, including estimated attendance at lectures and student perceptions of whether course objectives had been fulfilled; part 2 contained 9 statements that were used to evaluate course delivery (using a likert scale) by each of the 5 lecturers who taught the course; and part 3 comprised 3 open-ended questions that explored the most enjoyable parts and difficulties encountered, as well as ideas on how best to improve the course. after analysis of student responses to the open-ended questions in the first phase, two focus group discussions (fgds), each lasting ~1 hour, were audio-recorded with 16 randomly selected students (8 participants per focus group). the purpose of these fgds was to aid better understanding background. pharmacotherapeutics is an essential component of undergraduate pharmacy curricula worldwide. therefore, improving the content and teaching of pharmacotherapeutic courses will better equip young pharmacists for their future careers. objectives. to assess the perception and views of fourthand fifth-year pharmacy students at ahmadu bello university, zaria, nigeria, on the content and structure, as well as methods of lecture delivery of a pharmacotherapeutics course. methods. this was a sequential mixed-methods study. during the first phase, a pretested questionnaire containing both openand closed-ended questions was distributed to all 201 students who enrolled for the course during the 2015/2016 academic session. after analyses of questionnaire responses, two focus group discussions (fgds) were held with 16 randomly selected students (8 participants per group). results. over half of respondents (54%) had enrolled for the course more than once. analyses of qualitative data from both questionnaires and fgds yielded three themes: poor student awareness, relevance, and shortcomings in course structure and delivery. the most common complaints of students revolved around the bulkiness of the course and non-interactive teaching methods used by course lecturers. their enjoyment of certain parts of the course was linked to a perceived relevance of some disease conditions over others. conclusion. there is a need to improve the course structure and teaching of pharmacotherapeutics at the institution, as well as student participation in their own learning. afr j health professions educ 2018;10(4):235-237. doi:10.7196/ajhpe.2018.v10i4.1092 teaching pharmacotherapeutics to pharmacy students at a nigerian university: student perspectives s n abdu-aguye,1 mclinpharm; h yusuf,2 msc clin pharm; h u ma’aji,1 mpharm; h m rabiu,1 bpharm 1 department of clinical pharmacy and pharmacy practice, faculty of pharmaceutical sciences, ahmadu bello university, zaria, nigeria 2 department of clinical pharmacy and pharmacy administration, faculty of pharmacy, university of maiduguri, borno, nigeria corresponding author: s n abdu-aguye (sn.abduaguye@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:sn.abduaguye@gmail.com 236 december 2018, vol. 10, no. 4 ajhpe research of the qualitative data generated from the questionnaires; therefore, the questions asked were formulated from questionnaire responses. selection of participants and moderation of the fgds were carried out by a lecturer from another university to ensure that students could express themselves freely without any fear of victimisation. fgd participants all signed informed consent forms. data analysis data collected from the closed-ended questions in the survey instrument were coded and entered into microsoft excel 2013 (microsoft corp., usa) to generate descriptive statistics. data from the open-ended questions and transcribed fgds were analysed using qualitative content analysis. relevant statements were identified from student responses and grouped together based on similarities to generate themes. two of the main investigators performed the thematic analyses; the themes were verified by a third researcher. representative quotes were used to highlight pertinent statements. results of the 201 questionnaires administered, 190 responses were obtained, giving a 94.5% response rate. background characteristics of study respondents are described in table 1. over half of the surveyed respondents had enrolled for the course at least once before. ninety-three percent claimed to have attended at least half of the lectures for the course, while only 11.3% admitted to ever seeking further clarification from a course lecturer. students’ perceptions of lecturers’ teaching style fig. 1 represents study participants’ responses (using a likert scale) towards the statement, ‘lecturer x encouraged student participation during his/her lectures’. on average, just more than half of respondents agreed that all course lecturers encouraged student participation during their lectures. however, this statement had a notable neutral category, with between 16% and ~25% of responses for all 5 lecturers falling into this category. qualitative data theme 1: poor student awareness students appeared to be poorly aware regarding several topics, from their initial motivation for studying pharmacy, to how to answer test/ examination questions, which seemed to be the main focus of many of the respondents. furthermore, a number of students did not seem to see themselves as stakeholders/responsible for their learning, instead believing that their learning was the sole responsibility of lecturers and other external factors: ‘… like me, i always sit at the back. sometimes they will just be discussing, you can’t hear from the back. actually, i don’t like sitting in front. but if they [the lecturers] increase their confidence, then they will be audible enough.’ (fifth-year student) theme 2: relevance all students agreed that the course was important and that lower-level prerequisite courses were needed if a clear understanding of the course was to be obtained; however, some of them felt that the prerequisite course content could be streamlined to better equip students with a good foundation for phcp 403: ‘all these courses, physiology, anatomy and pathology, are relevant, but we are not studying them appropriately, that is why even in this phcp 403 we are having lapses.’ (fifth-year student) their enjoyment of certain sections of the course was linked to their perceived relevance of some disease conditions over others: ‘cardiovascular diseases (cvds) are very common in our normal lives because of the high prevalence of cvds within our society. thus, it is easier to comprehend cvd topics than other diseases because you will be constantly hearing things about the diseases and the risk factors.’ (fourth-year student) table 1. respondents' background information, lecture attendance and engagement with course lecturers variable n (%) attempted course 1 2 ≥3 87 (45.8) 69 (36.3) 34 (17.9) estimate of attendance at lectures ˂50 50 75 >75 13 (6.8) 62 (32.6) 115 (60.6) ‘did you ever meet any of the course lecturers for further clarification on any aspect of the course outside the classroom?’ yes no 21* (11.3) 166 (88.7) *values in this cell do not total 190 because of missing responses. responses, % le ct u re r 5 4 3 2 1 0 25 50 75 100 strongly agree agree neutral disagree strongly disagree fig. 1. responses to the statement ‘lecturer x encouraged student participation during his/her lectures’. december 2018, vol. 10, no. 4 ajhpe 237 research theme 3: shortcomings in course content and delivery most students stated that the major problem with the course was its ‘bulkiness’, which, together with inadequate time to study (because of other courses), led to confusion – a major cause of student failure. another complaint was the absence of a ‘practical aspect’, making it very easy to forget material learnt in class. however, opinions varied on the nature that this 'practical aspect' should take. some felt that clinical ward rotations would be helpful, while others suggested that linking classroom lectures with real-life scenarios would be beneficial. while most students reported that the course lecturers were generally good teachers, several still felt that there was room for improvement. perceptions of lecturer-student relationships, however, were particularly poor, with several students complaining about poor approachability or excessive strictness of the course lecturers: ‘some lecturers when they enter class they behave “no nonsense” … normally for good communication between students and lecturers there should be interaction, like asking questions so that the students would be carried along. however, if a lecturer behaves “no nonsense”, i can have questions to ask in class but i will reserve them … .’ (fourth-year student) discussion this was the first study in our faculty at ahmadu bello university, and possibly in pharmacy schools in nigeria, which attempted to obtain feedback from students to improve the quality of the learning process. pharmacotherapeutics is a particularly focal course in the undergraduate pharmacy curriculum, and special attention needs to be paid to improve the quality of its teaching. the abovementioned prerequisite modules to this course include anatomy, physiology, biochemistry and pathology, all of which are offered during the second and third undergraduate years. these courses are given in other faculties, offered simultaneously to students of these faculties, and are taught by external lecturers who often do not fully understand the specific needs of our students. this can lead to student dissatisfaction with course content, high failure rates and a loss of actual benefit from this learning, as suggested from the results of this study. postma and bronkhorst[3] reported a similar level of dissatisfaction on the part of dental students sharing basic science courses with medical students at a south african (sa) university. learning requires active involvement of students and lecturers. both groups are important stakeholders – students in influencing the teaching environment for lecturers, and lecturers in the learning process for students.[4] however, educational experiences are often only as effective as students’ engagement with them.[5] consequently, understanding the thought processes of students is very important if academics are to optimise student learning experiences. several students in our study seemed to view learning as an event that ‘happened’ to them, rather than one that requires active participation. this finding was in contrast to roman et al.’s[4] study, who discovered that, on average, third-year students in the faculty of health sciences at an sa university perceived themselves to be agents of their own learning. further work needs to done in this area, especially within the nigerian setting, to assess (and change if necessary) the level of preparedness of students entering higher-education institutions. while students generally perceived teaching by course lecturers to be adequate, a recurring complaint was with regard to the non-interactive nature of the teaching methods employed. important to consider is the changing nature of students over the years. as oblinger[6] stated, ‘the aging infrastructure and the lecture tradition of colleges and universities may not meet the expectations of the new generation of students raised on the internet and interactive games’. while our lecturers definitely need to improve their classroom demeanour and communication with students, adopting relatively new teaching techniques may also be useful. studies have shown benefits in using techniques such as problem-based learning and educational games in teaching pharmacotherapeutics,[7-9] although these methods may not be suitable for all topics. other methods (e.g. team-based learning) shift some of the onus of learning onto the students,[10,11] and are thus doubly advantageous. conclusion there is a definite need to improve on the course structure and content, as well as methods used in teaching the course at our institution. these results will be used to comprehensively modify several parts of the course and improve student participation in the learning process. declaration. none. acknowledgements. the authors acknowledge the support of the department of clinical pharmacy and pharmacy practice, ahmadu bello university, zaria, nigeria, for providing the materials to print the questionnaires used in this work. author contributions. sna-a and hy designed the study, participated in data collection, and analysed and drafted the article. hmr collected the data and hum analysed the data and reviewed and approved the final draft of the article. funding. none. conflicts of interest. none. 1. merriam-webster medical dictionary – pharmacotherapeutics. 2017. https://www.merriam-webster.com/medical/pharmacotherapeutics (accessed 24 july 2017). 2. werlissandra m de s, alessandra rm, angelo ra, divaldo p de lj, wellington b da s. teaching in pharmaceutical care: a systematic review. afr j pharm pharmacol 2015:9(10):333-346. https://doi. org/10.5897/ajpp2014.4181 3. postma tc, bronkhorst l. second-year dental students’ perceptions about a joint basic science curriculum. afr j health professions educ 2015;7(2):199-201. https://doi.org/10.7196/ajhpe.409 4. roman nv, titus s, dison a. relationship between student preparedness, learning experiences and agency: perspectives from a south african university. afr j health professions educ 2016;8(1):30-32. https://doi.org/10.7196/ajhpe.2016.v8i1.490 5. richards j, sweet l, billett s. preparing medical students as agentic learners through enhancing student engagement in clinical education. asia-pacific j coop educ 2013;14(4):251-263. 6. oblinger d. gen-xers and millennials: understanding the new students. educause review 2003;38(1):44. 7. toklu hz. problem based pharmacotherapy teaching for pharmacy students and pharmacists. curr drug deliv 2013;10(1):67-70. https:// doi.org/10.2174/1567201811310010012 8. cheng jwm, alafris a, kirschenbaum hl, kalis mm, brown me. problem-based learning versus traditional lecturing in pharmacy students’ short-term examination performance. pharm educ 2003;3(2):117-125. https://doi.org/10.1080/1560221031000151282 9. barclay sm, jeffres mn, bhakta r. educational card games to teach pharmacotherapeutics in an advanced pharmacy practice experience. am j pharm educ 2011;75(2):33. https://doi.org/10.5688/ajpe75233 10. hopman s, popovich ng. a student-initiated, integrated pharmacotherapeutics learner-centered course. inov pharm 2015;6(1):1-9. 11. johnson jf, bell e, bottenberg m, et al. a multiyear analysis of teambased learning in a pharmacotherapeutics course. am j pharm educ 2015;78(7):142. https://doi.org/10.5688/ajpe787142 accepted 24 april 2018. https://doi.org/10.5897/ajpp2014.4181 https://doi.org/10.5897/ajpp2014.4181 https://doi.org/10.7196/ajhpe.409 https://doi.org/10.7196/ajhpe.2016.v8i1.490 https://doi.org/10.2174/1567201811310010012 https://doi.org/10.2174/1567201811310010012 https://doi.org/10.1080/1560221031000151282 https://doi.org/10.5688/ajpe75233 https://doi.org/10.5688/ajpe787142 june 2019, vol. 11, no. 2 ajhpe 38 short research report knowledge translation (kt) in the scientific literature is a relatively new term, first proposed by the canadian institutes of health research (cihr).[1] it describes an issue that has been around for decades. kt is a complex multistep process that is focused on associating the ‘know-do gap’ between knowledge production and its implementation.[2] in other words, it is considered an active process that facilitates the introduction of evidence into practice to reduce the gap between research and clinical practice. graham et al.[2] proposed a knowledge-to-action framework with three sections, i.e.: (i) understanding and defining kt; (ii) determining how knowledge is created and used; and (iii) exploring how knowledge is shared. in the past decade, there has been a surge in the body of evidence regarding kt, with extensive agreement on the importance of transferring knowledge into action. in a scoping review, kt strategies that achieve beneficial outcomes were found to be unknown,[3] with limited empirical research on how to undertake integrated kt.[4] notwithstanding kt being an important competency for occupational therapy (ot),[5] kt strategies that influence professional practice behaviours in rehabilitation disciplines remain largely unknown.[6] with the increasing role of inter-professional primary healthcare teams, the scope of rehabilitation practice is expanding and should include kt, which represents knowledge brokerage. however, the amalgamation of kt activities has not yet been fully explored, despite the articulated need for kt strategies to be adopted in rehabilitation practice.[6] both contextual and individual factors may influence how knowledge is translated into practice, thereby adding this variation to the understanding of kt practices. varied kt approaches may therefore be needed for different rehabilitation disciplines owing to different gaps in evidence and practice,[6] noting that a one-size-fits-all approach might not necessarily be possible, even in similar settings. this study was therefore positioned to elicit current practices (in terms of creation and application of knowledge) and strategies used by student practitioners to identify the know-do gap[2] for the development of relevant kt initiatives. methods this pilot study involved an exploration of ot students’ experiences in accessing, implementing and applying current knowledge in their clinical practice as students. in an explorative approach, a self-administered openended questionnaire was distributed to all final-year ot students (n=24) enrolled at the university of kwazulu-natal (ukzn), durban, sa, in 2016. the final sample comprised 17 students. the sections of the knowledgeto-action framework of graham et al.[2] guided the survey development and a priori codes were included in the analysis. data were analysed with a hybrid inductive-deductive reasoning approach to thematic analysis. quality was ensured by adherence to principles that maintained the truth value of the research, so that constructions by the authors credibly reflect the views of the study participants by the presence of an audit trail and by reflexivity, as well as use of strategies such as member checking and peer debriefing. the authors acknowledge that use of focus group discussions background. while the body of evidence regarding knowledge translation (kt) has surged in the past decade, quality information remains largely unknown, especially in occupational therapy (ot). evidence-based practice within the profession is therefore potentially threatened, necessitating that students are adequately trained and able to translate research into practice when entering the profession. objective. to explore how ot student practitioners create and translate knowledge in their clinical practice settings. methods. an open-ended questionnaire was administered to all final-year ot students (n=24) enrolled at the university of kwazulu-natal, durban, south africa, in 2016, with a response rate of 71% (n=17). data were analysed thematically using an inductive-deductive approach. results. strategies used by students in knowledge creation included inquiry through discussions with peers and interactions with stakeholders (lecturers, mentors and clinicians); synthesis by hands-on practice and in the application of knowledge in research projects; and use of knowledge tools (e.g. electronic searches for literature, presentations and seminars) and social media (e.g. instant messages, videos and blogs). kt was enacted by educational meetings for peer development – both student and clinician driven, educational materials and dissemination channels, such as workshops, presentations and in developing communities. conclusions. this study identified context-specific kt processes and strategies used by ot students. strategies were simple and accessible within their contexts, and were mainly related to gaining insights geared towards specific ot practice. these findings may assist educators in developing opportunities for students that may enhance their creation and translation of knowledge into practice as clinicians. afr j health professions educ 2019;11(2):38-40. doi:10.7196/ajhpe.2019.v11i2.1123 making sense of knowing: knowledge creation and translation in student occupational therapy practitioners p govender,1 bot, mot, phd; k mostert,2 bsc physiotherapy, mphyst, mba, phd 1 discipline of occupational therapy, school of health sciences, university of kwazulu-natal (westville campus), durban, south africa 2 department of physiotherapy, faculty of health sciences, university of pretoria, south africa corresponding author: p govender (naidoopg@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 39 june 2019, vol. 11, no. 2 ajhpe short research report might have elicited a deeper exposition on student practices; however, a limitation was the timing of the data collection, which occurred during student unrest; hence, it was not possible to access students in groups. ethical approval approval from the ukzn human and social sciences ethics committee (ref. no. hss/1213/016) was granted, together with gatekeeper permission from the registrar of the institution. participation was voluntary, informed consent was obtained and participants could withdraw without prejudice. results and discussion a response rate of 71% (n=17) was achieved. the mean age of students was 22.9 years, with 94% female respondents. with regard to kt, the body of scholarship exploring definitions, conceptual and theoretical frameworks, and applications of kt has increased fundamentally over the past decade. it was therefore not surprising that students were generally able to articulate their understanding of the concept as it related to research: ‘my understanding of research utilisation is retrieving research regarding different topics within their practice to drive their intervention and keep up with latest trends.’ (participant 2) ‘… making use of resources of knowledge, especially those that are evidence-based … .’ (participant 6) ‘… process of understanding and integrating research in our professions.’ (participant 7) ‘research allows for updating and improving information to inform practice. therefore, if research is not utilised, the therapist’s knowledge may be limited and outdated.’ (participant 8) ‘making sense of information or research being utilised and translating this knowledge into practice.’ (participant 14) ‘… taking information you have gathered and putting it into practice.’ (participant 15) strategies used by students in this study are highlighted in fig. 1. knowledge creation was possible by means of knowledge inquiry, synthesis and using knowledge tools (fig. 1). the process of inquiry allowed for synthesis and aggregation of existing knowledge. these opportunities were cited as valuable to synthesise ots’ knowledge of discipline-specific aspects during fieldwork or service-learning placements, where they felt learning occurred and application of theory into practice aided their understanding of core content: ‘experience and feedback from others who are more knowledgeable on topics help to identify gaps within one’s own knowledge.’ (participant 1) ‘decisions are made based on experiences within practice … .’ (participant 1) knowledge tools used in knowledge creation included electronic searches for literature, presentations and seminars and use of social media, such as instant messages, videos and blogs (fig. 1): ‘internet access is important, as it is often shared via email, blogs, whatsapp and google drive(s). knowledge is also shared by lending books.’ (participant 1) ‘we currently have a google drive account for our class and we add information and articles that can help one another. we also have a whatsapp group where we constantly share information, such as pictures or links to articles.’ (participant 14) enactment of kt is also described in fig. 1. it included educational meetings for peer development, both student and clinician driven, educational materials and dissemination channels, such as workshops and presentations, and development of communities of practice. these strategies enabled students to examine knowledge and challenge each other, correct misunderstandings, learn and relearn, as well as provide the opportunity for sharing and pooling of knowledge and resources: ‘organise regular meetings and discuss the topic – communication is vital and so is each member’s contribution.’ (participant 7) ‘through peer study groups and explanations.’ (participant 8) ‘sharing information via email or social media, and presenting research through case studies and presentations.’ (participant 14) in terms of the creation of knowledge, salter and kothari[7] postulated that knowledge used in practice is collaboratively constructed, drawing on information from a variety of sources, as seen in the findings of this study. moreover, these findings are aligned with those of wimpenny,[8] who argues that differing forms of knowledge required by healthcare practitioners need not be mutually exclusive, but should rather integrate a range of knowledge in a broader context that reflects the contribution and translation of professional craft knowledge alongside other intellectual constructs. the findings are further supported by those of jones et al.,[6] whose study knowledge translation educational opportunities for peer development small-group discussions – mutual learning groups studentand clinician-driven journal clubs hands-on demonstrations educational materials/dissemination channels posters, pamphlets workshops presentations to peers developing communities of practice collaboration with other student practitioners and clinicians with similar interests knowledge creation knowledge inquiry peers as a source of information interactions with stakeholders (lecturers, mentors, clinicians) knowledge synthesis hands-on practice – experiential learning fieldwork or service learning placements applying kt to research projects knowledge tools literature (electronic searches) presentations and seminars social media (e.g. blogs, instant messages) videos knowledge creation knowledge translation fig. 1. knowledge creation and translation strategies employed by student practitioners in this study (n=17). (kt = knowledge translation.) june 2019, vol. 11, no. 2 ajhpe 40 short research report supports professional education as a common intervention in addition to educational meetings and materials. in the ot and physiotherapy literature, professional interventions, such as clinical guidelines, were also described as a further source of evidence.[6] conclusions this study forms part of a larger study that aims to investigate kt priorities for rehabilitation in the local context of kwazulu-natal province. the findings of this study assisted in identifying context-specific processes and strategies used specifically by ot students in kt. students seemed to have a general understanding of kt and initiated strategies that are simple and accessible, most of which related to gaining insight in specific intervention in ot practice. interestingly, students revealed a sense of sharing, which demonstrated student-initiated altruistic strategies that would inevitably assist students from disadvantaged backgrounds who may be reticent to reveal their deficits regarding kt. this study contributed essential insights into rehabilitation student practitioners’ efforts at implementing knowledge, and would inform endeavours to assist in more effective kt application in the clinical context. while these findings might assist academics in developing opportunities for student practitioners to enhance their creation and translation of knowledge into practice as clinicians, potential barriers to the implementation of such strategies also require further exploration so that the most appropriate ones are selected for this context. declaration. none. acknowledgements. the authors acknowledge the sub-saharan africa-faimer regional institute (safri) for their support of this project by a fellowship granted to the first author. author contributions. pg: conceptualised the study, completed data collection and drafted the manuscript; km supervised the study and served as critical reader. funding. none. conflicts of interest. none. 1. canadian institutes for health research. guide to knowledge translation planning at cihr: integrated and endof-grant approaches. 2015. http://www.cihr-irsc.gc.ca/e/45321.html (accessed 27 june 2018). 2. graham id, logan j, harrison mb, et al. lost in knowledge translation: time for a map? j cont educ health professions 2006;26(1):13-24. https://doi.org/10.1002/chp.47  3. gagliardi ar, berta w, kothari a, et al. integrated knowledge translation (ikt) in health care: a scoping review. implement sci 2016;11(1):38-50. https://doi.org/10.1186/s13012-016-0399-1 4. gagliardi ar, dobrow mj. identifying the conditions needed for integrated knowledge translation (ikt) in health care organizations: qualitative interviews with researchers and research users. bmc health serv res 2016;16(1):256-284. https://doi.org/10.1186/s12913-016-1533-0  5. bennett s, laver k, clemson l. progressing knowledge translation in occupational therapy. austr occupational ther j 2018;65(2):156-160. https://doi.org/10.1111/1440-1630.12473  6. jones ca, roop sc, pohar sl, et al. translating knowledge in rehabilitation: systematic review.  physical ther 2015;95(4):663-677. https://doi.org/10.2522/ptj.20130512 7. salter kl, kothari a. knowledge ‘translation’ as social learning: negotiating the uptake of research-based knowledge in practice. bmc med educ 2016;16(1):76-85. https://doi.org/10.1186/s12909-016-0585-5  8. wimpenny k. using participatory action research to support knowledge translation in practice settings. int j pract learn health soc care 2016;19;1(1):3-14. accepted 4 december 2018. https://doi.org/10.1002/chp.47 https://doi.org/10.1186/s13012-016-0399-1 https://doi.org/10.1186/s12913-016-1533-0 https://doi.org/10.1111/1440-1630.12473 https://doi.org/10.2522/ptj.20130512 https://doi.org/10.1186/s12909-016-0585-5 september 2019, vol. 11, no. 3 ajhpe 71 correspondence to the editor: i read, with great interest, the article by breedt and labuschagne, entitled ‘preparation of nursing students for operating room exposure: a south african perspective’.[1] although an interesting paper, it is a pity that the authors have elected to refer twice to learning retention figures by edgar dale: ‘in dale’s cone of experience, people generally remember between 30% and 50% of what they see and hear.’; and ‘dale postulated that learners remember only 20% of what they hear in a lecture, opposed to 80 90% if they simulate a real experience or perform a task.’[2] unfortunately, the authors are incorrect. while dale did produce a cone of experience, he did not mention these figures, or any figures similar to these, either in the text cited above or in any other text. the authors should have examined the text they are citing so that they could verify this information. if the authors would like more information with regard to the incorrect and inappropriate usage of edgar dale’s cone of experience in medical education literature, then they may wish to refer to my more detailed paper on the topic.[3] ken masters medical education and informatics department, college of medicine and health sciences, sultan qaboos university, oman itmeded@gmail.com 1. breedt s, labuschagne mj. preparation of nursing students for operating room exposure: a south african perspective. afr j health professions educ 2019;11(1):22-26. https://doi.org/10.7196/ajhpe.2019.v11i1.1072 2. dale e. audiovisual methods in teaching. 3rd ed. new york, ny: dryden press, 1969. 3. masters k. edgar dale’s pyramid of learning in medical education: a literature review. med teach 2013;35(11):e1584-e1593. https://doi.org/10.3109/0142159x.2013.800636 afr j health professions educ 2019;11(3):71. https://doi.org/10.7196/ajhpe.2019.v11i3.1215 this open-access article is distributed under creative commons licence cc-by-nc 4.0. preparation of nursing students for operating room exposure: a south african perspective https://doi.org/10.7196/ajhpe.2019.v11i1.1072 https://doi.org/10.3109/0142159x.2013.800636 march 2020, vol. 12, no. 1 ajhpe 5 short communication why was the idea necessary? the recent emphasis on globalisation in healthcare education includes the importance of internationalisation as an approach for providing students with international and intercultural competence.[1] however, the challenge of sending large groups of students on exchange programmes has driven the rise of internationalisation at home (iah) programmes, where all students are given international learning opportunities.[2] this article elaborates on how iah provided international learning opportunities to 104 physiotherapy students in norway and south africa (sa). the article also highlights how the project influenced students’ understanding of the local context in clinical practice and rehabilitation. what was tried? in 2017, we piloted an iah project that included all physiotherapy students in the second-year cohort at oslo metropolitan university in norway and the university of the western cape in cape town, sa. the project included online and face-to-face components, where students completed an assignment and then received feedback and guidance from peers in the other institution. the assignment was informed by principles of photovoice methodology,[3] where students took photos of their local communities with the aim of contextualising healthcare and patient experiences of health and rehabilitation services. these photos were discussed in class and then combined with personal reflections that emphasised how students’ thinking regarding clinical practice and rehabilitation was influenced by their local context. students were also expected to integrate relevant academic literature with their personal narratives to better understand their reflections. the assignment was mandatory for all students as part of their course. we found that most students were eager to participate and enjoyed the assignment, with high levels of activity throughout. the initial drafts of the assignment were shared on google drive so that students from both universities could provide one another with guidance and critical input in the form of questions. this feedback was then reviewed by lecturers, who provided additional comments where necessary. students were able to make changes to their assignments using the peer feedback before submitting the final version. all students participated in a face-toface seminar, where lecturers in each university guided a discussion on how local health contexts influenced clinical practice and health systems more generally. finally, we conducted a focus group discussion with 4 students from the norwegian cohort, during which they elaborated further on the themes from the seminar. the sa students chose not to participate in the focus group interview because the interviews took place during the students’ examination period. what were the lessons learnt? when students gave each other feedback, they not only learnt about other health contexts but also gained insight into their taken-for-granted assumptions regarding their own health system. they were able to identify some of the social and cultural influences on healthcare and rehabilitation, as well as specific aspects of their own culture that were previously underappreciated. this pilot study demonstrates a process for implementing low-cost iah projects, where students in very different health, social and cultural contexts can be introduced to internationalisation concepts within the existing curriculum. such programmes may have important implications for countries that are interested in developing internationalisation components in the curriculum, but cannot afford to send large groups of students on exchange programmes. the availability of free online environments that facilitate student interaction, in combination with common learning resources, means that internationalisation can be achieved without expensive and environmentally harmful travel. declaration. none. acknowledgements. the authors extend their appreciation and gratitude to the student participants. author contributions. td-m and mr collaboratively designed the project. all three authors participated in writing up the article. funding. none. conflicts of interest. none. 1. deardorff dk, arasaratnam-smith la, eds. intercultural competence in higher education: international approaches, assessment and application. abingdon, uk: routledge, 2017. 2. ryan j, ed. cross-cultural teaching and learning for home and international students: internationalisation of pedagogy and curriculum in higher education. abingdon, uk: routledge, 2012. 3. sutton-brown ca. photovoice: a methodological guide. photography culture 2014;7(2):169-185. https://doi.org/10. 2752/175145214x13999922103165 accepted 6 november 2019. afr j health professions educ 2020;12(1):5. https://doi.org/10.7196/ajhpe.2020.v12i1.1260 using internationalisation at home to provide international learning to all physiotherapy students t dahl-michelsen,1 bsc physiotherapy, msc health sciences, phd; k s groven,1 bsc physiotherapy, msc health sciences, phd; m rowe,2 bsc physiotherapy, msc physiotherapy, phd 1 department of physiotherapy, faculty of health sciences, oslomet-oslo metropolitan university, norway 2 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: t dahl-michelsen (tonedami@oslomet.no) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.2752/175145214x13999922103165 https://doi.org/10.2752/175145214x13999922103165 mailto:tonedami@oslomet.no november 2020, vol. 12, no. 4 ajhpe 227 from the editor covid-19 was declared a global pandemic in march 2020, resulting in various strategies aimed at reducing transmission. consequently, planned learning and teaching activities were disrupted – and in some cases halted – in many higher education institutions in africa. educators, administrators and students integrated innovations to their practice and/or research in health professions education during the covid-19 pandemic. ajhpe calls for manuscripts for a special focus issue on ‘innovations in health professions education during the covid-19 era’. we are interested in the descriptions of innovations to educational practice and/ or educational research in health professions education during the covid-19 era. authors can submit their manuscripts as a short report or a full paper. ‘why i will never go back to my old practice’: short report guidelines the purpose of this section is for authors to reflect on innovations to their educational practice and/or research during the covid-19 era. the report should be up to 1 500 words and need not have ethics clearance. the following guidelines should be followed for short reports for this special focus issue: recommended headings • why was the idea necessary (what was the problem)? • what was tried (intervention)? • lessons learnt • what will i keep in my practice? • what will i not do? • evidence of innovation (qr code) all short reports for this special focus issue will be expected to be submitted with a qr code that links to a 3-minute video that reflects the evidence of the innovation being reported. authors are asked to show evidence of their innovation in the form of, e.g. videos, artefacts, collages. for tips on how to make a video and qr code, follow the link or scan the qr code: click the link: https://drive.google.com/file/d/1xckzgom70hqdvz9ed0zzmdfpcqdjyo nc/view?usp= sharing scan the qr code: full manuscripts/research manuscripts submitted as full research papers should have ethics clearance from an accredited institution, ethics body or ethics committee. the manuscripts should be a maximum of 3 000 words, excluding abstract and bibliography. research articles should typically describe the background, methods, results and conclusion of an original research study that is aligned to the theme of the special focus issue. the article should contain the following headings: • structured abstract • introduction • methods • results • discussion • conclusion guidelines for research articles and the submission process: www.ajhpe.org.za important dates the first closing date for the submission of manuscripts: 14 february 2021. publication of the special focus issue: august 2021. afr j health professions educ 2020;12(4):227. https://doi.org/10.7196/ajhpe.2020.v12i4.1458 ajhpe special focus issue – call for papers: innovations in health professions education during the covid-19 era guest edited by: dr champion n nyoni (university of the free state), dr werner cordier (university of pretoria) and dr liz wolvaardt (university of pretoria) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://drive.google.com/file/d/1xckzgom70hqdvz9ed0zzmdfpcqdjyonc/view?usp= sharing https://drive.google.com/file/d/1xckzgom70hqdvz9ed0zzmdfpcqdjyonc/view?usp= sharing http://www.ajhpe.org.za/ march 2019, vol. 11, no. 1 ajhpe 12 research south africans live in a society predisposed to high levels of contact and violent crime. drivers of crime include poverty, unemployment and illegal immigration, and a gini coefficient that is currently among the highest in the world. a gini coefficient is a measure of inequality of income distribution or inequality of wealth distribution. these factors contribute to a situation where, on average, 51 people are murdered in south africa (sa) every day.[1] this is ~5 times the global average. mortality due to interpersonal violence is 46%, compared with a global average of 10%.[2] regrettably, the situation does not seem to be improving, with an increase in the incidence of assault with intent to cause grievous bodily harm, common assault, robbery with aggravating circumstances and car hijacking.[1] emergency medical services (ems) personnel are commonly required to respond to incidents where they assist victims of crime and violence. in some instances, when ambulance crews arrive, the police are not yet on the scene and the situation remains volatile. operating in such potentially hostile environments places paramedics and paramedic students at increased risk of becoming victims of crime and violence. this is by no means just an sa phenomenon. a recent australian study found that 88% of their ems personnel were exposed to violence while at work. verbal abuse was the most prevalent (82%), followed by intimidation (55%), physical abuse (38%), sexual harassment (17%) and sexual abuse (4%).[3,4] a similar study on the prevalence of violence in the swedish prehospital setting found that 66% of ems personnel experienced threats and/or violence while at work.[5] a study was also performed on the exposure of iranian ems staff to workplace violence, which found that 75% experienced at least one form of such violence. verbal abuse was the most prevalent (71%), followed by physical abuse (38%).[6] holgate[7] reported that in sa, physical abuse is commonly encountered by ems personnel as a result of their interactions with patients and bystanders. holgate’s study showed that of the ems staff surveyed, 66% reported having experienced assault while on duty.[7] aside from interactions with patients and bystanders, another source of potential abuse is violent behaviour by criminals. it is thought that ems personnel are seen as ‘soft targets’, as they are usually unarmed, travel into high-crime areas and often enter these areas after dark. criminals target ems staff to gain access to items such as valuable medical equipment, drugs, cell phones and electronic tablets. unfortunately, there are no national statistics on the incidence of sa ems personnel as victims of crime while on duty. furthermore, there is no national system for ems personnel to report crime, violence and abuse directed at them while on duty. this is concerning, given that during 10 months in 2016 western cape province recorded ≥40 incidents of physical violence against their ems personnel.[8] the abovementioned literature supports the view that, due to the nature of their duties, ems personnel – locally and internationally – commonly encounter situations where the environment may be considered unsafe or hostile. it is evident that there is an increase in workplace violence background. south africans experience high levels of contact crime, including assault, robbery and hijacking. emergency medical services (ems) are frequently called to the scene of such incidents. their presence in these potentially hostile environments increases the risk of south african (sa) paramedics and paramedic students becoming victims of crime and violence. a 2015 study showed that ~66% of sa ems staff reported being assaulted while on duty. during a 10-month period in 2016, western cape province recorded >40 incidents of physical violence against their ems personnel. questions are being asked about how well prepared ems staff are to operate in potentially hostile environments. objectives. to explore emergency medical care (emc) students’ experiences of violence and crime and their views on the need for hostile environment awareness training (heat) as part of their undergraduate degree programmes. methods. a self-designed, non-validated, cross-sectional online survey questionnaire was used to document the experiences, views and opinions of 113 under graduate emc students from 4 sa universities. the questionnaire consisted of 24 closed-ended questions with pre-set likert scale options focusing on documenting participants’ experiences, views and opinions regarding hostile environments and the need for heat. results. a high percentage of participants (92%) indicated feeling unsafe while engaging in clinical learning shifts; 63% specified that they had personally witnessed violence against ems crews, and 32% indicated that they had been assaulted while on duty. unsurprisingly, 81% of the respondents felt that there is a need for inclusion of heat in the undergraduate curriculum. conclusions. participation in clinical learning shifts in the current sa prehospital ems environment increases the risk of exposure to potentially hostile environments. consequently, students feel unsafe and support the inclusion of heat as part of their undergraduate degree programmes. afr j health professions educ 2019;11(1):12-15. doi:10.7196/ajhpe.2019.v11i1.1054 students’ views on the need for hostile environment awareness training for south african emergency medical care students c vincent-lambert,1 nd aet, nhd pse, nhd fst, btech emc, mtech ed, phd hpe; r westwood,2 bhs emc 1 department of emergency medical care, faculty of health sciences, university of johannesburg, doornfontein campus, south africa 2 department of emergency medical care and podiatry, faculty of health sciences, university of johannesburg, doornfontein campus, south africa corresponding author: c vincent-lambert (clambert@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 13 march 2019, vol. 11, no. 1 ajhpe research experienced by sa ems personnel. crime, violence and unsafe working conditions are clearly undesirable. one of the negative consequences is the loss of skilled staff when qualified ems personnel leave sa to practise abroad, where working and living conditions are believed to be safer.[9] in response to the abovementioned concerns, certain law enforcement agencies and ems providers offer hostile environment awareness training (heat) programmes for their staff.[10] these heat programmes focus on developing one’s ability to assess situations, recognise specific risk factors, and where possible avoid these risks. however, despite the existence of such programmes, the literature is limited regarding their real value and benefit in the higher education context. throughout their 4-year degree, emergency medical care (emc) students are registered for clinical practice modules. these modules require students to work a predetermined number of prehospital shifts under the guidance of a clinical supervisor. the aim of these clinical shifts is to ensure that students gain exposure to the real-world emc environment. during clinical learning shifts, students are designated to ambulances and response vehicles, attending to incidents that provide an opportunity to assess and treat patients in the real prehospital environment.[11] the exposure and experience obtained through clinical practice are important to provide students with the necessary clinical skills set to competently manage a broad spectrum of emergency situations and patients.[11] although anecdotal reports from emc students include frequently experiencing and/or witnessing verbal and physical abuse against them and other ems personnel during clinical learning shifts, we could not find literature quantifying or describing such experiences. with this in mind, we undertook this study, which aimed to formally explore and document experiences, views and opinions of sa emc students regarding their exposure to hostile environments and the need for inclusion of heat as part of their undergraduate degree programmes. methods this was a descriptive, quantitative, cross-sectional and exploratory study.[12] a self-designed, non-validated, online survey questionnaire was used to document views and opinions of emc students from 4 sa universities regarding their experiences of hostility during clinical learning and the need for heat. at the time of the study, there were 402 potential participants across 4 institutions who were invited to participate; we received 113 responses, giving a final response rate of 28%. the questionnaire comprised closed questions in the form of statements to which the participants were required to indicate their level of agreement, using a likert scale. the responses to each of the questions were tallied by using frequency data analysis.[13] these data were captured on a microsoft excel (microsoft, usa) spreadsheet and analysed using simple statistics, allowing the creation of tables that summarised responses.[13] ethical approval ethical approval for the study was given by the faculty of health sciences academic ethics committee, university of johannesburg (ref. no. rec-0147-2017). in light of the research design, it was not necessary to identify individual students, patients, educators or supervising practitioners. results demographics of the 113 respondents who participated in the survey, 55.75% (n=63) were male and 44.25% (n=50) were female. the majority (68.14%; n=77) were white and 18 26 years of age. the spread of respondents by year of study was fairly even, with 21% in year 1, 26% in year 2, 33% in year 3 and 20% in the final year of study. experiences of violence against emergency medical services personnel table 1 provides the participants’ responses regarding their experiences of acts of violence towards them or other ems personnel during clinical learning shifts. table 2 summarises their views regarding personal safety and the perceived need for and value of heat. discussion our study aimed to provide insight into sa undergraduate emc students with regard to hostile environments that they experienced during their prehospital clinical learning shifts and their perceived need for heat. the results are discussed under three main headings, i.e. demographics, experiences of violence and the need for heat. demographics the black african population of sa is estimated to be ~80.7% of the general population. our sample was not demographically representative, as the majority (68.14%) of our respondents were white, while only 31.86% were of other races. the reason remains unclear, as the invitation to participate was sent to all students from all races. possible reasons for this finding might include the racial profile of emc students from the 4 universities not reflecting that of the general population, and/or that all students did not share an equal interest in the study and/or all students did not have equal table 1. responses regarding violence witnessed or experienced during clinical learning shifts statement yes, n (%) no, n (%) there are times when i have felt unsafe while working during a prehospital shift 104 (92.04) 9 (7.96) i have been verbally assaulted (e.g. sworn at, ridiculed, threatened) by a patient or bystander 89 (78.76) 24 (21.24) i have been physically manhandled (e.g. pushed, pulled, assaulted) while working during a prehospital shift 36 (31.86) 77 (68.14) i have been threatened by a patient or bystander 67 (59.29) 46 (40.71) i have been threatened with a weapon (e.g. gun, knife, baton) while working during a prehospital shift 26 (23.01) 87 (76.99) i have witnessed violence against ems personnel while working during a prehospital shift 71 (62.83) 42 (37.17) i have been on the scene where a firearm has been discharged (including saps) 38 (33.63) 75 (66.37) i am aware of a fellow student who was involved in a vehicle hijacking or attempted vehicle hijacking 85 (75.22) 28 (24.78) ems = emergency medical services; saps = south african police service. march 2019, vol. 11, no. 1 ajhpe 14 research access to the internet to complete the online questionnaire. from a gender and age perspective, these distributions were more aligned with the norms expected for higher education in sa. the extent to which our results might have differed had our sample been different with regard to race, is currently unclear and is acknowledged as a potential limitation. given sa’s ethnic and cultural diversity, it would be valuable if future studies could explore whether or not perceptions and experiences of emc students with regard to crime and hostile environments differ according to gender and race. violence against emergency medical services personnel and students exposure of paramedics to physical violence globally appears to vary considerably – from 2.9% to 79.5%.[3-6,9,14] our literature review found few published studies that specifically dealt with the incidence of violence against ems students. of our 113 respondents, 78.76% reported being verbally abused (sworn at, ridiculed or threatened) either by a patient or bystander. this rate is more than three times higher than that cited in an australian study, which found that 21.2% of their participants had been verbally assaulted during their clinical practice shifts.[4] in the australian study, with 133 respondents (paramedic students), only 1% had experienced assault during prehospital clinical practice shifts. this percentage is much lower than that in our study, where 32% of participants indicated that they had personal experience of assault. assault in the context of our study included being pushed, shoved, hit or manhandled. unsurprisingly, considering this, and as 83% had personally witnessed violence against ems personnel, nearly all of our participants (92.04%) indicated that they felt unsafe during their clinical practice prehospital shifts.[4] a possible reason put forward in the australian study for the low incidence of assault against their paramedic students was that their participants were not required to work at night, when it is thought that the majority of violence against ems personnel takes place. in our study, 84.96% of participants considered themselves to be at higher risk of violence owing to the hours that they work. most violent crimes in sa occur at night.[2] limiting sa paramedic students’ exposure to night shifts might not be desirable, as these shifts are seen to be rich learning environments and many of the serious trauma cases linked to assault and motor vehicle collisions occur after dark. furthermore, on qualifying, graduates are required to work at night, and limiting exposure to night shifts during their undergraduate training could leave students unprepared for the real working environment. the undesirable consequences of working in hostile environments and the resultant concerns regarding physical security are numerous; school leavers consequently do not choose to study emc, as it is seen as ‘dangerous’. crime affects all citizens of a country – not only members of ems. therefore, is it true that one’s chances of being hijacked, assaulted or involved in a hostile environment are greater if ne is studying emc? it would appear that both the literature and the results of this study lend support to this notion, with 94.69% of respondents indicating that they feel at higher risk of crime and violence compared with other students. reasons might be linked to the areas where emc students are sent to work and irregular shift hours. concerns regarding hijacking came across strongly, with 83.19% of participants indicating that they consider themselves to be at higher risk of vehicle hijacking, mainly due to the hours they work and distances they have to travel to shift work. data from the sa police service (saps) indicate that from march 2015 to april 2016 there were 14 602 reported cases of vehicle hijackings in sa.[1] this roughly equates to 40 vehicles being hijacked daily. the majority of these hijackings take place at night, which is when the majority of violent crimes occur.[2] local data suggest that increased travel times, distances travelled and travelling at night, all of which are expected of sa emc students, might increase the probability of being hijacked. further studies are needed to empirically demonstrate if this is indeed the case and also to quantify the increased risk. hostile environment awareness training there are specific heat programmes in many regions of the world for law enforcement, ems and security and related personnel.[10] these courses table 2. participants’ views regarding personal safety and perceived need for and value of heat statements responses, n (%) strongly agree agree neutral disagree strongly disagree there are circumstances where i feel that i am at a higher risk of violence compared with a ‘normal student’, i.e. a student in a mainstream academic programme 72 (63.72) 35 (30.97) 6 (5.31) 0 0 i often consider myself to be at a higher risk of violence owing to the irregular shift hours that i work 44 (38.94) 52 (46.02) 12 (10.62) 3 (2.65) 2 (1.77) i often consider myself to be at a higher risk of vehicle hijacking owing to the hours i work and distances i travel to work shift hours 54 (47.79) 40 (35.4) 11 (9.73) 6 (5.31) 2 (1.77) i believe that adequate training and heat (as described in the information letter) could mitigate risks, thereby creating a safer working environment 53 (46.9) 46 (40.71) 9 (7.96) 3 (2.65) 2 (1.77) i would feel safer knowing that i had specific training on how to handle a hostile environment, should it arise 58 (51.33) 43 (38.05) 9 (7.96) 2 (1.77) 1 (0.88) i believe that violence against ems personnel may be avoided if they have adequate training, e.g. heat 31 (27.43) 49 (43.36) 14 (12.39) 11 (9.73) 8 (7.08) i feel that there is a need for the inclusion of heat in the emc curriculum 49 (43.36) 43 (38.05) 15 (13.27) 4 (3.54) 2 (1.77) heat = hostile environment awareness training; ems = emergency medical services; emc = emergency medical care. 15 march 2019, vol. 11, no. 1 ajhpe research focus on developing one’s ability to assess situations, recognise specific risk factors, and where possible avoid these risks. in sa, er24 (a private ambulance service) offers a similar course, i.e. emergency medical support in hostile environments (emshe). it is designed to address concerns related to violent crimes committed against their ems personnel. the aim of emshe is to teach staff various skills, such as identifying hostile environments, how to deal with dangerous situations and how to mitigate the risks involved.[10,15] we could not find literature on emc students’ perceptions of the need for heat. there is also debate regarding the value of heat. in our study, 87.61% of respondents felt that heat would be valuable and might mitigate the risks associated with operating in a hostile environment. also of interest to the researcher, was that 89.38% of respondents indicated that they would feel safer knowing that they had specific training on how to handle hostile environments. in summary, citizens of any country are exposed to varying levels of violence and crime by virtue of socioeconomic factors that influence where they live and work. the extent to which sa higher education students are to a greater or lesser degree vulnerable compared with the general population is a source of ongoing debate. nonetheless, the mobility, age and timing of related social interactions of a typical sa higher education student are such that they have more exposure to crime and violence than the school-going population. sa higher education institutions consequently allocate significant resources towards endeavours that seek to provide safe learning and living environments on their campuses. the extent to which this responsibility covers safety for their students engaging in off-campus experiential learning placements is unclear. additional studies need to be conducted to establish and quantify the risk profile, including the cost and feasibility of institutional initiatives and measures that seek to limit such risks. conclusion this exploratory study delivers evidence suggesting that participation in clinical learning shifts in the current sa prehospital ems environment comes with a significant risk of exposure to potentially hostile environments. consequently, emc students feel unsafe and support the inclusion of heat as part of their undergraduate degree programmes. consideration needs to be given to include heat in the first year of study, before students are placed according to a roster for prehospital clinical learning shifts. further studies are recommended that better quantify the incidence of violence toward emc students and the impact of heat on their ability to manage such situations. study limitations there are a number of limitations to our study. these include that the racial profile of respondents did not accurately represent that of the general population of the country. furthermore, while we provided our participants with an overview of heat, we did not provide them with a detailed curriculum or suggestions about how it may be implemented in their emc programmes. we did not focus on comparisons of responses per participating institution. we acknowledged that, as participating universities were in different provinces and cities, it is possible that responses might have differed per institution. we therefore recommend that further studies are conducted with larger stratified samples to determine the extent to which race and geography impacts on emc students’ perceptions and experiences of hostile environments and the perceived need for heat. declaration. none. acknowledgements. we acknowledge the participants for giving up their valuable time to complete the survey. author contributions. cv-l wrote the article and supervised the research on which the manuscript is based; rw gathered and analysed the data for this study. funding. none. conflicts of interest. none. 1. south african police service. crime statistics 2015 2016. 2016. http://www.crimestatssa.com/ (accessed 20 march 2017). 2. seedat m, van niekerk a, jewkes r, suffla s, ratele k. violence and injuries in south africa: prioritising an agenda for prevention. lancet 2009;374(9694):1011-1022. https://doi.org/10.1016/s0140-6736(09)60948-x 3. boyle m, koritsas s, coles j, stanley j. a pilot study of workplace violence towards paramedics. emerg med j 2007;24(11):760-763. https://doi.org/10.1136/emj.2007.046789 4. boyle m, mckenna l. paramedic student exposure to workplace violence during clinical placements – a crosssectional study. nurse educ pract 2017;22:93-97. https://doi.org/10.1016/j.nepr.2017.01.001 5. petzall k, tällberg j, lundin t, ove suserud b. threats and violence in the swedish pre-hospital emergency care. int emerg nurs 2011;19(1):5-11. https://doi.org/10.1016/j.ienj.2010.01.004 6. rahmani a, hassankhani h, mills j, dadashzadeh a. exposure of iranian emergency medical technicians to workplace violence: a cross-sectional analysis. emerg med australas 2012;24(1):105-110. https://doi.org/ 10.1111/ j. 1742-6723.2011 7. holgate r. the opinion of emergency medical service personnel regarding safety in pre-hospital emergency care practice. johannesburg: university of the witwatersrand, 2015. 8. etheridge j. the hell paramedics go through to keep you alive. http://www.news24.com/southafrica/news/thehell-paramedics-go-through-to-keep-you-alive-20160914?isapp=true (accessed 21 march 2017). 9. govender k, grainger l, naidoo r, macdonald r. the pending loss of advanced life support paramedics in south africa. afr j emerg med 2012;2(2):59-66. https://doi.org/10.1016/j.afjem.2011.11.001 10. kanyane r. er24 condemns attacks on personnel. taung daily news. 2016. https://taungdailynews.wordpress. com/2016/09/22/er24-condemns-attacks-on-personnel/ (accessed 21 march 2017). 11. stein c. faculty of health sciences department of emergency medical care: learning guide for clinical practice. 8th ed. johannesburg: university of johannesburg, 2017:1-18. http://www.uj.ac.za/en/faculties/health/ departments/emc/pages/default.aspx (accessed 3 march 2017). 12. mccusker k, gunaydin s. research using qualitative, quantitative or mixed methods and choice based on the research. perfusion 2015;30(7):537-542. https://doi.org/10.1177/026765911455911 13. garrett n. textbooks for responsible data analysis in excel. j educ bus 2015;90(4):169-174. https://doi.org/10.1 080/08832323.2015.1007908 14. wongtongkam n. an exploration of violence against paramedics, burnout and post-traumatic symptoms in two australian ambulance services. int j emerg serv 2017;6(2):134-146. https://doi.org/10.1108/ijes-03-2017-0014 15. thusi l. ems personnel under attack. southern courier. 2016. http://southerncourier.co.za/107991/emspersonnel-under-attack/ (accessed 20 march 2017). accepted 3 september 2018. http://www.crimestatssa.com/ https://doi.org/10.1016/s0140-6736(09)60948-x https://dx.doi.org/10.1136%2femj.2007.046789 https://doi.org/-10.1111/j.1742-6723.2011 https://doi.org/-10.1111/j.1742-6723.2011 http://www.news24.com/southafrica/news/the-hell-paramedics-go-through-to-keep-you-alive-20160914?isapp=true http://www.news24.com/southafrica/news/the-hell-paramedics-go-through-to-keep-you-alive-20160914?isapp=true https://taungdailynews.wordpress.com/2016/09/22/er24-condemns-attacks-on-personnel/ https://taungdailynews.wordpress.com/2016/09/22/er24-condemns-attacks-on-personnel/ http://www.uj.ac.za/en/faculties/health/departments/emc/pages/default.aspx http://www.uj.ac.za/en/faculties/health/departments/emc/pages/default.aspx https://doi.org/10.1080/08832323.2015.1007908 https://doi.org/10.1080/08832323.2015.1007908 http://southerncourier.co.za/107991/ems-personnel-under-attack/ http://southerncourier.co.za/107991/ems-personnel-under-attack/ december 2018, vol. 10, no. 4 ajhpe 194 research the communicator role and other professional competencies for medical students have been emphasised internationally and in south africa (sa) as important for healthcare outcomes.[1] while various sa medical schools have adopted aspects of international guidelines for undergraduate health professions curricula,[2,3] there is still limited research on the use of guidelines in the national or regional sa context. internationally, there has been growing consensus on principles for inclusion in communication teaching in undergraduate programmes. these principles include attention to faculty development, fostering personal and professional growth, emphasising a patient-centred approach, consistency between communication skills teaching and clinical teaching, implementing a coherent framework and reliable assessments and evaluation of programmes.[4-6] experts in european countries have developed a health professions core communication curriculum (hpccc) to standardise undergraduate health professions education.[7] the core objectives focus on: • communication with patients • intraand interpersonal communication to foster and develop selfreflection and professionalism • communication in healthcare teams. recent research in communication, while acknowledging the importance of core objectives, has questioned the validity of international guidelines in different sociocultural contexts. attempts were made to reach consensus on which core principles to include in curricula to ensure their relevance and appropriateness to each context.[8-10] for example, in indonesia, claramita and susilo[9] reported on the strong hierarchical and communal culture that influences the doctor-patient interaction and choices relating to the health of individuals. in that context they recommended the use of a simplified guideline, i.e. the ‘greet-invite and discuss’ guide to communication to accommodate the cultural characteristics of southeast asian patients.[10] de leonardo et al.[8] similarly recommended that consensus be reached on communication training among spanish and portuguese speakers. the development of consensus statements has therefore become necessary owing to regional and cultural practices and language, and the effects of trying to deliver efficient care within overburdened healthcare systems that are often under severe consultation time constraints.[10] it is argued that tailored guidelines for communication that consider the specific contexts of the patients and their caregivers are more user friendly and thus more likely to be adopted in everyday use. educating students to function effectively in the multilingual and multicultural sa healthcare context is challenging. in kwazulu-natal (kzn) province, 77.8% of patients are isizulu speaking.[11] the students in this context, even those from different language and cultural backgrounds, are expected to become competent in addressing the needs of patients. in health professions education, recommendations have been made for transformation of education to strengthen connections between the education and health systems[12] and for an increased emphasis on interprofessional and collaborative practice.[13] the practical implementation, however, has been challenging, given the increased student intakes and resource limitations. in the current programme, medical students are taught isizulu in a first-year module, and a patient-centred approach to communication in the disciplines of family and behavioural medicine and in the context of clinical skills.[14] the core background. the teaching of communication is an essential component of health professions curricula internationally and in south africa (sa) for its benefits to healthcare. the teaching, however, remains concentrated in certain disciplines, resulting in an incoherent approach. sa medical schools have incorporated international guidelines into their curricula, but limited research is available on the suitability of amended guidelines for local use. research in different sociocultural contexts has shown benefits in redefining guidelines for suitability for local contexts. objective. to explore suggestions of participants for improving communication teaching and learning in the kwazulu-natal (kzn) healthcare context. methods. participants, including medical students, urbanand rural-based clinical educators, and department of health employees, were purposively sampled. focus group discussions and semi-structured interviews were conducted. the data were analysed for emergent themes to make recommendations for improved teaching. results. recommendations to improve communication teaching and learning at institutional level included developing isizulu language and intercultural communication and other aspects of the curriculum. at an individual level, emphasis should be placed on patient-centred care and appropriate professional behaviours, as the ‘hidden curriculum’ was a noticeable and powerful influence. conclusion. teaching and modelling good communication in clinical skills and clinical teaching should be integrated and complementary. students require a good grounding in communicating in isizulu and improved cultural competence. a unified approach that is reached by consensus and tailored to the kzn context is recommended. afr j health professions educ 2018;10(4):194-198. doi:10.7196/ajhpe.2018.v10i4.1000 improving communication in the south african healthcare context m g matthews, mb chb, doh, mph; j m van wyk, bsc ed, bed, med, phd clinical and professional practice, school of clinical medicine, nelson r mandela school of medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: m g matthews (matthewsm@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 195 december 2018, vol. 10, no. 4 ajhpe research competencies (including the communicator role) are introduced in the first year, and practical sessions with simulated patients continue throughout the second and third years. the importance of communication (and of language and culture in communication) is revisited in the rural health rotation in the final year. however, the manner in which students communicate with patients and other health professionals in practice is frequently modelled on behaviours observed in the clinical disciplines,[15] a phenomenon generally referred to as the ‘hidden curriculum’.[16] students find it challenging to use a patient-centred approach in busy clinical environments, where the emphasis is on biomedical priorities. this study was therefore conducted to explore the suggestions of participants (local students and staff of the university of kzn and the department of health (doh)) to improve communication teaching and learning and the quality of care and health outcomes of patients. methods an exploratory, qualitative case study was conducted at the medical school, using focus group discussions (fgds) and semi-structured interviews (ssis), in 2015 2016. the study population consisted of students, educators and participants from the doh. participants were selected purposively to represent the educational and service platforms. for the student group, a final-year student was requested to assemble a diverse group of peers. for the educator groups, an invitation was sent to discipline heads and year or module co-ordinators with knowledge of curriculum content. for doh participants, staff from hospitals where students complete in-service learning were invited to participate. the final study sample consisted of: • final-year students (fgd 1, n=5). • educators from the schools that teach in the medical programme, viz. school of clinical medicine (fgd 2, n=9) and the schools of nursing and public health and laboratory medicine and medical sciences (fgd 3, n=7). the total in the educator group was therefore 16. • three doh participants comprised a rural family practitioner (ssi 1), a rural hospital manager (ssi 2), and a doh hospital-based researcher (ssi 3). the participants in the three groups were diverse in gender, language and religious and cultural beliefs (table 1). participants were informed of the study, and written individual consent and permission for audio-recording were obtained. participants were assured of anonymity. fgds and ssis were conducted by the researcher, with an assistant to take notes in the groups. a set of questions was used to initiate the discussions and elicit participants’ suggestions. students had completed their final-year examinations and were aware that there could be no negative consequences related to any expressed views. the duration of the fgds was 60 90 minutes, and that of the ssis 35 45 minutes. audio-recorded data were transcribed and checked for accuracy by the researchers. data were analysed by two researchers (a clinician and an educator) for themes related to the study objective, using a social constructionist approach. the themes were reviewed and refined into the main themes at institutional and individual level.[17] trustworthiness was established through several methods to ensure rigour,[18] including triangulation of the data for multiple perspectives, and the use of various sources (fgds and ssis). additional methods included summarising content and true member checking, and keeping records of the data analysis process as evidence of how the data were generated. data were reported anonymously, stating only the first language (l1) of the participant. gatekeeper permission and ethical approval (ref. no. hss1633/014) were obtained from the humanities and social sciences ethics committee, university of kzn. results and discussion this study explored suggestions of participants to improve undergraduate communication teaching and learning. the main themes identified to improve communication teaching on educational and service platforms related to suggestions for implementation at the institutional or individual level (table 2). table 1. demographic data of participants variable medical students, n=5 educators, n=16 department of health, n=3 gender female 2 10 3 male 3 6 first language english 3 14 2 isizulu 1 2 isixhosa 1 sesotho 1 religion christianity 4 8 3 hinduism 1 6 islam 2 academic rank associate professor* n/a 1 n/a senior lecturer* n/a 9 n/a lecturer n/a 5 n/a principal programme officer† n/a 1 n/a n/a = not applicable. *associate professor and senior lecturer were also discipline heads. †in charge of academic administration of the programme. december 2018, vol. 10, no. 4 ajhpe 196 research these have been discussed below and linked to recommendations to improve the teaching of communication. at institutional level, the themes primarily emphasised the necessity for isizulu language development and matters related to cultural competence and curriculum development. confirming the findings of previous sa studies,[19,20] a major concern of participants was related to challenges of language barriers between doctors or health professions students and patients. in spite of concerns from some participants regarding professional mobility within the country, participants in all the groups recommended that isizulu language teaching be improved. they verbalised that current initiatives are inadequate to enable students to communicate effectively with their isizulu-speaking patients: ‘i think isizulu is central in this province where we have a high percentage of people whose first language is isizulu.’ (fgd 3, no. 2, l1 english) the second theme at institutional level related to a greater understanding of cultural diversity and developing cultural competence of students. training in cultural competence has assumed great importance and has been linked to better health outcomes and improved quality of care:[21,22] ‘i think there is one area we don’t foreground adequately and that is cross-cultural communication.’ (fgd 3, no. 6, l1 english) ‘maybe the clinical picture is not making sense, especially in children, with enemas and the like. ask the question this way, “when did you last see the traditional healer?” instead of saying, “did you go to a traditional healer?”’ (ssi 2, l1 sesotho) concern was expressed not only with regard to isizulu culture, but also to other cultures; for example, an educator asked: ‘[regarding] the students that come from rural areas here, how much support do we give them to engage with indian culture or muslim culture? for them it is as much of a cultural divide and we do not give any language or tools on how to ask the question or how to engage, to understand rituals.’ (fgd 3, no. 6, l1 english) relating to these two themes, participants advocated strongly for isizulu to be developed as a clinical competency, with greater emphasis on understanding cultural influences in health: ‘learning zulu is extremely valuable.’ (ssi 1, l1 english) ‘we have to adapt to any environment and to any cultural setting.’ (fgd 2, no. 7, l1 english) for students to achieve language and cultural competence, suggestions were made to include isizulu teaching and assessments in a vertical manner throughout the curriculum: ‘maybe every second year have an exam (in isizulu).’ (fgd 1, no. 3, l1 english) suggestions for improving cultural competence included: ‘you can teach general principles on … different cultures and that you need to be aware of it.’ (fgd 1, no. 1, l1 english) ‘where they call cultural-based people [e.g. sangoma,* nyanga*] to come and interact with the actual doctors at the hospital … and have some discussions around this.’ (fgd 1, no. 4, l1 isixhosa) [*traditional healers in isizulu culture] mention was made of the introduction of interpreters and cultural brokers, but this would seem an unlikely eventuality given the prevailing economic limitations in health, thus strengthening the imperative for improving students’ familiarity with the appropriate terms for common culture-bound syndromes and traditional medicines.[23] the third theme at institutional level related to curriculum development, including the use of a standard approach to communication, and teamwork table 2. results: main themes at institutional and individual levels, and recommendations for improving communication teaching level themes and recommendations institutional isizulu language development implement institutional language policy by expanding on the stand-alone isizulu module in communication training, and by assessing communication competence in isizulu in the clinical years cultural competence improved cultural knowledge, and include training and assessment in intercultural communication curriculum development improve links between the medical school and department of health and increase exposures of students to experiential learning in different contexts use existing hpcsa core competencies framework for all professions in the college of health sciences to develop a standardised approach to communication in healthcare emphasise role-modelling of good communication by all clinical educators include interprofessional education and collaborative practice in teaching communication to undergraduates conduct research aimed at a local consensus and guidelines for communication teaching individual patient-centred approach to care (taught in preclinical phase) support a patient-centred approach in clinical disciplines through the use of local guidelines for communication teaching behaviours encourage continuous self-improvement with regard to behaviours and communication process through critical self-reflection when communicating with patients hpcsa = health professions council of south africa. 197 december 2018, vol. 10, no. 4 ajhpe research by health professionals on the educational and service platforms, as recommended in most international guidelines:[4,7] ‘people talk a lot about the hidden curriculum. maybe we should be asking how is that communicated and what does it communicate and then what strategy should be put in place to address, in a more overt way, those particular issues?’ (fgd 3, no. 4, l1 english) ‘the medical student or doctor needs to feel part of a team and not necessarily above everyone else in the healthcare arena … i think that might be an issue of arrogance, and not relating to everybody as team members.’ (ssi 3, l1 english) ‘… we have nurses who help us interpret … and clinical associates.’ (ssi 2, l1 sesotho) ‘if you have a problem that you want to solve, you know you have to be interacting with the people and communicating … we need a social worker … a dietician … and somebody who is going to the community to trace that patient.’ (fgd 2, no. 9, l1 isizulu) educators and students confirmed the importance of role-modelling. they mentioned that communication skills were not being reinforced in the clinical setting owing to challenges related to the burden of disease: ‘whereas we can’t focus on communication as our number one priority is hiv.’ (fgd1, no. 4, l1 isixhosa) students described negative role-modelling, especially at a higher level of care in an urban context: ‘i think that changing the mindset [of the institution] … i know it’s difficult … i think just to reiterate the importance of all this [communication] to them, because they become our role models.’ (fgd 1, no. 3, l1 english) participants from the specialist disciplines confirmed the practice of negative role-modelling: ‘although we expect students to be able to communicate … i am not sure it is the formal way in which we role play because that is absent in our teaching.’ (fgd 2, no. 1, l1 english) ‘generally speaking, our teaching and our doing are different.’ (fgd 3, no. 8, l1 english) only one student described a positive role-modelling experience at a rural teaching site, which highlights the importance of the learning environment[16] and of role models[24] as influential factors in health professions training: ‘that was a common theme [understanding the patient’s perspective] throughout the rural hospital in that most of the doctors i worked with were very positive influences and very positive role models.’ (fgd 1, no. 3, l1 english) the themes identified at individual level were the use of a patient-centred approach and the demonstration of appropriate behaviours. students’ comments suggested that they were motivated to use the patient-centred approach: ‘i always ask the patients, “how do you feel about it?” even though you don’t really tell the consultant because they don’t really want to know but you do still wonder and you still ask the patient’s opinion because you think it’s a scary situation. they don’t know what’s going on and the sad thing is that the majority of the time the patients know very little about their condition, because on the ward round nobody says anything to the patient, except, “are you okay?”’ (fgd 1, no. 5, l1 isizulu) however, evidence from students and educators suggested limited adoption of the patient-centred approach in practice, with a clinical educator stating: ‘if you look at the doctors, we get the information and we can put it together, but we still don’t understand where the patient comes from and what he is feeling.’ (fgd 2, no. 8, l1 english) this supports the findings of a previous study at this institution,[15] which showed limited adoption of a patient-centred approach in a major clinical discipline. these observations re-emphasise the need for constant attention to be paid to the powerful influence on students’ learning of the hidden curriculum.[16] participants discussed undesirable behaviours of health professionals, and made recommendations for behaviours that demonstrated respect and empathy for patients: ‘like sisters [nurses] aren’t sensitive about patients’ issues, but i find myself, always if i’m going to ask a sensitive question … i’m consciously aware of the fact that this is a sensitive issue.’ (fgd 1, no. 5, l1 isizulu) ‘respect is the word. if we can teach our students respect, you can teach them so much else, even communication and empathy.’ (fgd 2, no. 1, l1 english) ‘communication goes beyond the words and beyond the clinical diagnosis. so for the medical schools to create a sense of empathy between the health practitioner and the patient, and a sense of connectedness between the health practitioner and the patient, i would think that you would do that, not by didactic teaching, but by giving the students more experiential learning in the field, where they can see, first hand, how patients may live, but that has to go hand-in-hand with clinical excellence.’ (ssi 3, l1 english) these findings support global initiatives to enhance core values and communication in healthcare, as embraced in the international charter for human values in healthcare.[25] this charter articulates the role of skilled communication in enacting these values, with an emphasis on compassion and respect, and commitment to ethical practice, excellence and justice. recommendations the findings of this study support the implementation of the institutional language policy, as students require a good grounding in communicating in isizulu. this could be achieved by expanding on the stand-alone isizulu module, and by integrating teaching and assessment of communication competence in isizulu in the clinical years. students’ cultural knowledge and skills in intercultural communication should be included in student evaluations. other recommendations are to further improve links between the medical school and the doh and provide more experiential learning in a clinical context. an interprofessional approach to teaching communication across colleges of health sciences would be beneficial to promote consistency between communication skills and clinical teaching. good role-modelling of communication and professional behaviours by clinical educators in urban and rural contexts is essential and could be included in performance indicators of staff. december 2018, vol. 10, no. 4 ajhpe 198 research the findings support the use of a patient-centred approach in communication that considers the needs of individual patients and respects differences, whether related to gender, age, language, culture, religion or other beliefs. many of the recommendations closely reflect the philosophical principles included in objectives on patient perspectives and health beliefs in the hpccc:[7] • ‘considers the somatic, mental, social, gender, cultural, ethical and spiritual elements … and perceives divergences between own values and norms and the patient’s.’ • ‘responds to the patient’s health beliefs and theories of illness and contrasts and integrates these into own theories as a health care professional.’ the inference, then, is that problems with transferring good communication skills in the kzn clinical environment relate less to policies and principles than to praxis. it is therefore suggested that consensus be reached on the use of an explicit patient-centred approach, which could be operationalised in an interprofessional manner to assist in countering the effects of the hidden curriculum. this should be culturally appropriate, fit for purpose and usable across disciplines. in addition to curriculum development, it is anticipated that professional staff development would also be needed. both students and staff should use critical self-reflection when communicating with patients. continuous self-development in intraand interpersonal communication[7] is important, especially given the negative behaviours, as described in the study. study limitations as a case study with a limited number of participants in one medical school, the findings are not generalisable, although some of the recommendations may be applicable in other regions of sa with similar contexts. the findings should generate discussion and add to the body of knowledge on teaching communication to sa medical students and other health professionals. conclusion language and culture are important in sa healthcare, and it is imperative that attempts to revise curricula and improve communication in the sa context include both intercultural communication and provision for language needs of patients. in addition to efforts at institutional level, emphasis must also be placed on core professional competencies for students, and on developing the necessary reflexivity for them to practise successfully in the multilingual and multicultural society of sa. further research in the sa context is warranted for consensus on communication teaching and learning. research should include students themselves – to promote learner-centredness; representatives of health professionals – to improve collaboration and for standardisation; and community members – for course designers to understand patients’ challenges and priority needs for communication in healthcare. declaration. none. acknowledgements. the authors wish to acknowledge the dean of teaching and learning and the research office for assistance and funding, and participants in the study for their contributions. author contributions. both authors are responsible for the content and writing of the article. funding. funding for the study was provided by the research office of the university of kwazulu-natal, durban, sa. conflicts of interest. none. 1. stewart m, brown jb, donner a, et al. the impact of patient-centered care on outcomes. j fam pract 2000;49(9):796-804. 2. diab p, matthews m, gokool r. medical students’ views on the use of video technology in the teaching of isizulu communication, language skills and cultural competence. afr j health prof educ 2016;8(1):11-14. https://doi. org/10.7196/ajhpe.2016.v8i1.402 3. de villiers mr, van heusden m. a comparison of clinical communication skills between two groups of final-year medical students with different levels of communication skills training. sa fam pract 2007;49(7):16. https://doi. org/10.1080/20786204.2007.10873591 4. makoul g, schofield t. communication teaching and assessment in medical education: an international consensus statement. patient educ couns 1999;37(2):191-195. https://doi.org/10.1016/s0738-3991(99)00023-3 5. von fragstein m, silverman j, cushing a, et al. uk consensus statement on the content of communication curricula in undergraduate medical education. med educ 2008;42(11):1100-1107. https://doi.org/10.1111/j.1365-2923.2008.03137 6. bachmann c, abramovitch h, barbu cg, et al. a european consensus on learning objectives for a core communication curriculum in health care professions. patient educ couns 2013;93(1):18-26. https://doi.org/10.1016/j.pec.2012.10.016 7. health professionals core communication curriculum (hpccc). objectives for undergraduate education in health care professions. 2014. http://www.each.eu/wp-content/uploads/2014/07/hpccc_website-teach.pdf (accessed 2 november 2018). 8. de leonardo cg, ruiz-moral r, caballero f, et al. a latin american, portuguese and spanish consensus on a core communication curriculum for undergraduate medical education. bmc med educ 2016;16(99):1-16. https://doi. org/10.1186/s12909-016-0610-8 9. claramita m, susilo ap. improving communication skills in the southeast asian health care context. perspect med educ 2014;3(6):474-479. https://doi.org/10.1007/s40037-014-0121-4 10. claramita m, susilo ap, kharismayekti m, et al. introducing a partnership doctor-patient communication guide for teachers in the culturally hierarchical context of indonesia. educ health 2013;26(3):147-155. https://doi. org/10.4103/1357-6283.125989 11. statistics south africa. south african census. 2011. http://www.statssa.gov.za/census/census_2011/census_products/ census_2011_census_in_brief.pdf (acccessed 11 june 2018). 12. frenk j, chen l, bhutta c, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi. org/10.1111/j.1365-2923.2008.03137 13. interprofessional education collaborative. core competencies for interprofessional collaborative practice: report of an expert panel. 2011. https://www.aacom.org/docs/default-source/insideome/ccrpt05-10-11.pdf?sfvrsn=77937f97_2 (accessed 10 september 2018). 14. kurtz s, silverman j, draper j. teaching and learning communication skills in medicine. 2nd ed. oxford: radcliffe publishing, 2005. 15. ntando e. application of communication skills in an authentic clinical setting: assessing the communication competency of sixth year medical students during history taking. mmedsci thesis. durban: university of kwazulunatal, 2017. 16. hafferty fw. beyond curriculum reform: confronting medicine’s hidden curriculum. acad med 1998;73(4):403-407. https://doi.org/10.1097/00001888-199804000-00013 17. braun v, clarke v. using thematic analysis in psychology. qual res psych 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 18. creswell j. qualitative inquiry and research design: choosing among five approaches. 3rd ed. thousand oaks, ca: sage publications, 2015. 19. levin m. language as a barrier to care for xhosa-speaking patients at a south african paediatric teaching hospital. s afr med j 2006;96(10):1076-1079. 20. schlemmer a, mash b. the effects of a language barrier in a south african district hospital. s afr med j 2006;96(10):1084-1087. 21. betancourt j, green a. linking cultural competence training to improved health outcomes: perspectives from the field. acad med 2010;85(4):583-585. https://doi.org/10.1097/acm.obo13e3181d2b2f3 22. levin m. language and cultural competency training in south africa: effects on quality of care and health care worker satisfaction. afr j health professions educ 2011;3(1):11-14. https://doi.org/10.7196/ajhpe.96 23. ellis c. communicating with the african patient. scottsville: ukzn press, 2004. 24. boelen c. the five-star doctor: an asset to health care reform? geneva: world health organization, 1993. 25. rider ea, kurtz s, slade d, et al. the international charter for human values in healthcare: an interprofessional global collaboration to enhance values and communication in healthcare. patient educ couns 2014;96(3):273-280. https://doi.org/10.1016/j.pec.2014.06.017 accepted 23 april 2018. https://doi.org/10.7196/ajhpe.2016.v8i1.402 https://doi.org/10.7196/ajhpe.2016.v8i1.402 https://doi.org/10.1080/20786204.2007.10873591 https://doi.org/10.1080/20786204.2007.10873591 https://doi.org/10.1016/s0738-3991(99)00023-3 https://doi.org/10.1186/s12909-016-0610-8 https://doi.org/10.1186/s12909-016-0610-8 https://doi.org/10.4103/1357-6283.125989 https://doi.org/10.4103/1357-6283.125989 http://www.statssa.gov.za/census/census_2011/census_products/census_2011_census_in_brief.pdf http://www.statssa.gov.za/census/census_2011/census_products/census_2011_census_in_brief.pdf https://doi.org/10.1111/j.1365-2923.2008.03137 https://doi.org/10.1111/j.1365-2923.2008.03137 https://www.aacom.org/docs/default-source/insideome/ccrpt05-10-11.pdf?sfvrsn=77937f97_2 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa ajhpe african journal of health professions education june 2019, vol. 11, no. 2 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape marietjie van rooyen university of pretoria elizabeth wolvaardt university of pretoria general manager dr manivasan thandrayen executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani email: publishing@hmpg.co.za issn 2078-5127 editorial 34 leading when it matters v c burch short research report 35 final-year medical students’ ratings of service-learning activities during an integrated primary care block n mapukata, m g mlambo, r dube 38 making sense of knowing: knowledge creation and translation in student occupational therapy practitioners p govender, k mostert research 41 a critical reflection by participants on microteaching as a learning experience for newly appointed health professions educators c a kridiotis, c van wyk 47 practise what you teach: lessons learnt by newly appointed lecturers in medical education c van wyk, m m nel, g j van zyl 53 understanding faculty development as capacity development: a case study from south africa j frantz, a rhoda, d b murdoch-eaton, j sandars, m marshall, v c burch 57 the selection and inclusion of students as research participants in undergraduate medical student projects at the school of medicine, university of the free state, bloemfontein, south africa, 2002 2017: an ethical perspective g joubert, w j steinberg, l j van der merwe 63 advocacy: are we teaching it? b gaede, p pillay cpd questionnaire march 2020, vol. 12, no. 1 ajhpe 17 research student persistence can be defined as the continuation of students’ enrolment and progression towards the completion of a qualification.[1] globally, there are a growing number of postgraduate students.[2] with the increased number of postgraduate enrolments, attrition from such programmes is estimated at 40 50% in most countries worldwide.[3] high postgraduate student attrition has a huge impact on national resources and robs the labour market of highly skilled personnel, resulting in loss of financial investments and knowledge.[1,4] student persistence to completion in undergraduate and postgraduate studies is vital for academic institutions, society and the economy.[4] higher-education institutions are awarded funds based on the number of undergraduates and postgraduates that they produce.[4] the impact of non-completion on undergraduate and postgraduate programmes results in decreased funding and affects resource allocation.[5] furthermore, the effect of student persistence at the societal and economic level can be observed in the production of a highly skilled workforce that is able to generate advanced and creative ideas to improve the economy and society.[6] student persistence to completion in postgraduate programmes is associated with factors related to students and academic institutions.[1,3] student-related factors comprise age, time management, time from last degree, learning approaches and social connections, such as peer, family and employer.[7] factors related to academic institutions include: mode of study, i.e. whether students are enrolled full-time or part-time, faculty support and academic integration.[1,7] in south africa (sa), 10 universities offer master of public health (mph) programmes. mph students come from diverse professional backgrounds and are primarily part-time students who reside off campus.[8] most programmes are characterised by high attrition rates and prolonged time to completion.[9] the throughput for mph programmes in sa ranged from 25% to 60% between 2009 and 2014.[9] the throughput for the university of kwazulu-natal, durban, sa for the cohort of students who enrolled between 2009 and 2011 and graduated between 2012 and 2014 was 25%. although a number of students leave mph programmes prematurely, the context for these students may not differ from that of students who persist to completion. the aim of this study was to gain a deeper understanding of the phenomenon of persistence to completion in an mph programme. methods a constructivist approach was adopted to understand the phenomenon of student persistence to completion among mph graduates. a case study design was implemented. face-to-face in-depth interviews were conducted with mph graduates from the university of kwazulu-natal. purposive sampling was implemented by recruiting participants who were available at the time of data collection. ten interviews were conducted until saturation was reached. saturation refers to when no new information or themes are observed in the data. the in-depth interviews, following the general interview-guide approach, were conducted between august 2015 and october 2015. the interview schedule was developed based on the aims and objectives of the study. the interview guide consisted of 10 open-ended questions and prompts were used. all the interviews were conducted in english. each interview was audio recorded and transcribed verbatim. background. student persistence can be defined as the continuation of student enrolment and progression towards the completion of a qualification. despite the increased number of postgraduate enrolments, attrition from postgraduate programmes is estimated at 40 50% in most countries globally. the throughput for master of public health (mph) programmes in south africa (sa) ranged from 25% to 60% between 2009 and 2014. mph students study primarily part-time and reside off campus. objective. to explore the phenomenon of persistence to completion in an mph programme in sa. methods. a constructivist approach was adopted to understand the phenomenon of student persistence among mph graduates. data were collected through face-to-face in-depth interviews with graduates who completed the mph degree between 2006 and 2014. interviews were conducted from august 2015 to the end of october 2015. each interview was audio recorded and transcribed verbatim. a thematic analysis was implemented. results. the findings indicated that personal, social, work and academic characteristics influenced student persistence to completion. career advancement, the status that comes with an mph qualification and being a first-generation postgraduate student provide internal and external motivations that have an impact on student persistence. an interplay between self-efficacy and social capital positively influences student persistence to completion. conclusion. student persistence to completion is influenced by multifaceted factors. motivation, self-efficacy and social capital play a vital role in fostering persistence among part-time mature postgraduate students. afr j health professions educ 2020;12(1):17-21. https://doi.org/10.7196/ajhpe.2020.v12i1.1183 exploring student persistence to completion in a master of public health programme in south africa t dlungwane, phd; a voce, phd discipline of public health medicine, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: t dlungwane (dlungwane@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:dlungwane@ukzn.ac.za 18 march 2020, vol. 12, no. 1 ajhpe research the completeness and quality of the transcripts were verified using the observational notes taken during the interviews. the transcriptions were done by a professional transcriber and verified by the authors. the researcher (td) read the written transcript of each participant’s interview numerous times to gain a full understanding of the phenomenon and then to identify codes. a thematic analysis was implemented. emergent themes and subthemes were derived through the coding process. finally, a conceptual description of student persistence to successful completion of an mph degree was developed. credibility through triangulation of data was achieved through individual in-depth interviews, field notes during the interviews and a self-administered questionnaire. dependability of the collected data was ensured through an audit trail. to ensure confirmability, the principal researcher (td) and supervisor (av) served as peer reviewers of the individual in-depth interviews. the interview schedule was developed in line with the objectives of the study. the interview guide consisted of 10 questions and prompts were used where necessary. ethical approval ethical approval was granted by the university of kwazulu-natal human and social sciences research ethics committee (ref. no. hss/0561/014d) and permission to conduct the study was granted by the university registrar. mph graduates who agreed to participate in the study signed informed consent forms. these forms were filed separately to ensure anonymity. participation was voluntary and participants were informed that they could withdraw without prejudice. the transcripts were labelled with unique numbers to ensure confidentiality. results study participants were from diverse professional backgrounds, i.e. medicine, nursing, environmental health, social science, dentistry and rehabilitation therapy. of the 10 participants, 5 took more than the maximum permissible period for part-time studies (table 1). significant themes generated from the analysis of participant responses are organised and presented based on their relevance to student persistence to completion: (i) challenges that required overcoming; (ii) reasons for persistence; and (iii) coping mechanisms (table 2). challenges that required overcoming study participants had a variety of experiences during their journey as mph students. challenges were experienced in the following domains: personal, family obligations and academic. personal challenges numerous personal life challenges, coupled with difficulties of being absent from higher education for an extended time, were identified as obstacles during the mph journey: ‘it was personally difficult and traumatic. i was getting divorced and getting relocated and meeting with attorneys. but it did not hinder me from actually finishing the degree. i was not going to quit – irrespective of what.’ (r1) ‘it was difficult, going back to studying after 6 years after completing undergraduate. during undergraduate studies i had time to myself and when i was not at university i was studying and now i have other responsibilities.’ (r2) family obligations family obligations and employment demands exerted additional pressure on participants. furthermore, these pressures were compounded by geographical distances, particularly where participants’ work locations were at a distance from the family, and where both home and work locations were at a distance from the university: ‘my employer wanted me wholeheartedly and committed, but at the same time i had this pressure [studies] and family commitments. i had to be in three different places. my family is in [pieter] maritzburg, [i] work in stanger, and my supervisor [is] in durban. that compounded the problem.’ (r8) ‘it was difficult and i am working at provincial level, i do a lot of travelling. my family needed me as well. my wife was pregnant twice when i was a student and they [my family] also wanted my full attention.’ (r6) academic challenges curriculum demands, dissertation challenges and institutional factors were highlighted as key academic challenges that needed to be overcome. curriculum demands and dissertation challenges difficulty in adjusting to curriculum demands and unfamiliarity with the writing style expected of mph students were highlighted: table 1. demographics of research participants participant commencement of mph studies, age (years) gender professional background time to completion, years r1 32 female occupational therapist 6 r2 24 female physiotherapist 4 r3 26 female environmental officer 7 r4 30 female nurse 6 r5 36 female medical officer 5 r6 38 male physiotherapist 7 r7 28 female environmental officer 3 r8 35 male environmental officer 7 r9 25 male medical officer 3 r10 33 female dentist 8 mph = master of public health. march 2020, vol. 12, no. 1 ajhpe 19 research ‘i had never before written long pieces of prose where you had to develop an argument. in medical school you have very concrete things that you have to describe or regurgitate in an exam. so it [studying in the mph] was much more difficult and much more challenging.’ (r5) entering the dissertation phase was a challenging experience, particularly the transition from the familiar structure of coursework to working independently on the research project: ‘the period when we did our modules was really nice. but when it came to the research project, that is where it started going down. writing the research proposal was difficult; and i will send a draft and think i am finished and then the feedback comes back – have to start all over again, it was discouraging.’ (r3) institutional factors the inherently difficult, and often protracted, process of developing a research proposal and conducting and writing up the research were exacerbated by lengthened administrative procedures, such as delays in obtaining a supervisor and attaining ethical approval, which left students feeling helpless: ‘it was frustrating. a programme that you are supposed to complete within 2 years, took me 7 years. we had few supervisors to supervise research projects for the postgraduates. the first supervisor that i was given was not interested in the area of my research study and couldn’t take me through until i had a second supervisor.’ (r6) reasons for persistence reasons for persisting to completion were influenced by professionally and personally motivated factors. professionally motivated factors professionally motivated reasons for persistence to completion included career changes and advancement, and expected increased marketability, credibility, and compensation: ‘i felt that i needed to improve my knowledge and skills in public health management. a hospital manager or a senior manager in the department of health should have an mph. by having such a degree you can become credible in what you do.’ (r9) the promise of greater remuneration was reported to have motivated persistence to completion: ‘the financial factors, because when you get an mph qualification you expect to get jobs that can pay you better than what you are currently getting or receiving in terms of salary.’ (r6) for participants, obtaining an mph qualification was expected to open up career opportunities and further academic possibilities, including the pursuing of a phd: ‘mph opens other doors like doing a phd and other options in terms of career development.’ (r6) personally motivated factors being part of the first generation to attain a postgraduate qualification, and setting a new standard for the next generation, provided strong motivation to complete the mph. completing the degree was further contextualised within previous educational frustrations, and the need to redirect aspirations. furthermore, commitment to others as well as expectations from family, employer and supervisors, motivated students to complete their degree: ‘but also there was a slight ambition at the personal level to say at least to be the first one in the family to get [a] master’s and to inspire my children.’ (r8) coping mechanisms coping strategies at the personal level, such as committing to personal sacrifice and employing time-management strategies, were adopted to manage the pressures incurred by studying. in addition, self-efficacy, faculty support and social capital were identified as factors that influenced persistence to completion. personal sacrifice committing to new academic priorities required personal sacrifice, e.g. sacrificing sleep, leisure time, family time and weekend time. the commitment to personal sacrifice was a strategy used to cope with the multiple demands on their time: ‘there were times where i would sit up all night finishing an assignment until five o’clock in the morning and then get ready for work and go to work. and most times it [studying] would take up my whole weekend.’ (r2) time management the importance of organising activities and managing time was emphasised as a key coping strategy. this involved keeping calendars, making schedules, writing timelines and developing plans and goals. all these were factors identified by respondents with their persistence to completion: ‘i am very good with time-management skills. one of my children was born during the time i was studying for my master’s, and i had to develop plans and realistic goals to manage.’ (r7) self-efficacy in spite of challenges experienced, study participants described how tenacity, self-belief and determination to complete their degree influenced persistence to completion. most mentioned being ‘goal orientated’, ‘committed’, ‘determined’, ‘self-motivated’, ‘disciplined’, and ‘hard working’. table 2. themes and subthemes emanating from participants’ comments main themes subthemes challenges that required overcoming personal challenges family obligations academic challenges reasons for persistence professionally motivated factors personally motivated factors coping mechanisms personal sacrifice time management self-efficacy faculty support social capital interaction between selfefficacy and social capital 20 march 2020, vol. 12, no. 1 ajhpe research for many, it was simply refusing to quit: ‘if i start something, i want to finish it.’ (r9) ‘... i have always believed in starting something and finishing it. i knew when i started that i needed an mph, although there were times in my mind i had ideas of quitting.’ (r4) faculty support support from administrative and academic staff was identified as a positive experience that facilitated persistence to completion: ‘they [administrative staff ] were excellent. that really made a big difference because we had to be attending lectures, and then you are also getting time off work. so you cannot take any extra time off to do the basics like registration functions.’ (r2) ‘they [academic staff ] were very helpful with everything that i needed help with. [they were] very friendly, very accommodating. there was [an] open-door policy.’ (r9) social capital an array of informal and formal support systems was identified as essential for student persistence to completion. having constructive employer and peer support helped students persevere and not quit in spite of the challenges: ‘i had support from my employer in terms of finance and time off. i also felt [a sense of ] camaraderie with the group – working together also helped and we were able to support each other a lot.’ (r5) ‘there was a group from the same area; we kept motivating each other throughout the degree. and the support that i received from my family, employer and supervisors kept me going.’ (r3) interaction between self-efficacy and social capital regardless of the challenges experienced, students were determined to finish their degree. the interplay between self-efficacy and social capital enabled them to deal with challenges they encountered as students in the mph programme: ‘even though it was challenging with 3 small children [and a] fulltime job. i cannot start something and then not finish it. my husband supported me throughout. we supported each other – my peers. it became more like a family interaction [with peers] and academic staff were supportive. the department was accessible on weekends for group discussions.’ (r7) ‘there were those moments where i felt like just forget it and quit. the support and encouragement that i was getting from my supervisor, colleagues and family kept me going; i am somebody that will start something and will not leave it until i get it.’ (r2) discussion the high student attrition from mph programmes prompted this study of exploring persistence to completion. although a number of students drop out from mph programmes, those with equally conflicting obligations have managed to complete the programme. this study sought to understand the experiences of students who have completed the mph programme and to describe the phenomenon of persistence to completion. the participants reported that they had to overcome a number of setbacks, spanning the personal, social, work and academic domains. the transition occurs when students complete the coursework and have to embark on a research project. the setbacks identified by participants are not unique to sa students. the factors influencing postgraduate student persistence to completion globally include: academic, financial, social and peer support.[1,3] the challenges imposed by geographical location and distances may indeed be unique in the sa context. internal migration for employment purposes is a recognised phenomenon in sa and has historical antecedents.[10] part of the legacy of apartheid is the spatial mismatch between where people live and where they work.[11] working away from one’s family is a widespread phenomenon in sa. if one includes the learning environment together with a different geographical location, it adds to the challenges associated with postgraduate studies. the challenge imposed by a limited number of staff who are able to supervise master’s-level students in sa has been highlighted previously.[1] the poor supervision capacity is further exacerbated by a low number of academic staff with doctoral degrees.[12] the lack of sa academics with doctoral degrees is a major constraint regarding supervision capacity in most institutions.[12,13] a number of initiatives are currently in place to increase the proportion of academic staff with doctorates.[14] the paucity of academic staff with doctoral degrees is common in most developing countries.[12] in the midst of the contextual challenges, the reasons foregrounded by the participants as contributing to their persistence in the mph programme were professionally and personally motivated. the mph degree is perceived as a qualification facilitating career progression, higher levels of remuneration and entry into leadership positions in the health sector. this is consistent with the findings from a study of 6 mph programmes in lowand middle-income countries, where graduates’ leadership positions changed and their remuneration increased after completing an mph degree.[15] being the first-generation postgraduate degree holder in the family was cited as a reason for persistence to completion. postgraduate studies are viewed as a platform to push against previous thresholds of personal achievement to motivate the generations that follow.[1,3,16] furthermore, expectations from family, employer and supervisor encouraged persistence to completion. strategies to cope with the demands of part-time studies included personal sacrifice and time-management skills. coping mechanisms adopted by mature part-time students differ from those used by full-time students.[17] this is because of the nature of responsibilities and commitments of most mature part-time students. mph students who left the programme during the first semester reported difficulty with part-time study, which was attributed to poor time management and failure to balance work and academic obligations.[9] this implies that the curriculum in part-time programmes needs to incorporate student-development activities, such as time and stress management.[9] this study has shown that participants’ belief in their ability to complete their degree, referred to as self-efficacy, is essential to enhance perseverance despite the hurdles and setbacks. self-efficacy is vital in ensuring persistence to completion among students who are at risk of dropping out.[18] students who are self-motivated often see the world through a different lens, viewing experiences from a positive perspective, thus enabling them to stay motivated in spite of setbacks. internal drive and willpower reaffirm the motivation to complete the degree regardless of the obstacles.[19] march 2020, vol. 12, no. 1 ajhpe 21 research the study participants cited that a supportive learning environment, where faculty treat them with respect and are sensitive to their needs as part-time students, contributed to their persistence to completion. moreover, the quality of relationships that students established with peers and employers kept them motivated throughout their studies. supportive relationships are considered important social ties and have been positively linked with student persistence to completion.[20] healthy social networks and connections are crucial to student resilience and persistence, irrespective of challenging circumstances.[20,21] conceptual framework: student persistence to completion based on a synthesis of the findings, we propose a conceptual framework explaining student persistence to completion among mature parttime mph students. the framework views persistence as a longitudinal process in which personal, social and work characteristics influence motivation to persist (fig. 1). motivation is influenced by academic and social/work environments. finally, a benefit analysis occurs where the benefit of obtaining the qualification outweighs the thought of dropping out. the benefits include career advancement, financial incentives and being a role model to future generations. based on a discussion of the findings, a conceptual framework for understanding student persistence to completion for mature parttime students is proposed (fig. 1). study limitations this was a study of a single mph programme and results may be transferrable to mph programmes with mature part-time students. the study lays the foundation for a further study of a similar nature that compares mph graduates from different settings to detect comparable or different patterns. further research needs to be conducted to test the hypothesis proposed in the framework. conclusions student persistence to completion is influenced by multifaceted factors. persistence to completion is the outcome of a dynamic relationship between personal, social and work characteristics that influence student motivation, which in turn influences and is influenced by academic, social and work environments. the process ultimately leads to a cost-benefit analysis where the benefit of persisting to completion outweighs the challenges that had to be overcome. declaration. none. acknowledgements. the authors would like to thank the mph graduates for participating in the study. the contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the university of kwazulu-natal and the us government. authors contributions. td was primarily responsible for the draft of the manuscript; td and av contributed substantially to the intellectual content and finalisation of the manuscript; and all authors read and approved the final manuscript. funding. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). conflicts of interest. none. 1. koen c. postgraduate student retention and success: a south african case study. cape town: university of the western cape, 2007. 2. the association of universities and colleges of canada: trends in higher education. 2011. http://www.cais.ca (accessed 10 february 2016). 3. herman c. obstacles to success – doctoral student attrition in south africa. perspect educ 2011;29(3):40-52. 4. department of education. national plan for higher education. 2001. http://www.education.gov.za (accessed 24 february 2015). 5. scott g, shah m, grebennikov l, singh h. improving student retention: a university of western sydney case study. j inst res 2008;4(1):9-23. 6. pruitt-logan as. leaving the ivory tower: the causes and consequences of departure from doctoral study. rev higher educ 2003;26(4):537-538. https://doi.org/10.1353/rhe.2003.0032 7. chikoko v. first year master of education (med) students’ experiences of part-time study: a south african case study. s afr j high educ 2010;24(1):32-47. https://doi.org/10.4314/sajhe.v24i1.63427 8. dlungwane t, voce a, searle r, stevens f. master of public health programmes in south africa: issues and challenges. public health rev 2017;38(5). https://doi.org/10.1186/s40985-017-0052-9 9. dlungwane t, voce a, searle r,wassermann j. understanding student early departure in a master of public health (mph) programme in south africa. afr j health professions educ 2017;9(3):111-115. https:// doi.org/10.7196/ajhpe.2017.v9i3.793 10. fauvelle-aymar c. migration and employment in south africa: an econometric analysis of domestic and international migrants (qlfs (q3) 2012). johannesburg: african centre for migration and society, university of the witwatersrand, 2014. 11. posel d. households and labour migration in post-apartheid south africa. j studies economics econometrics 2010;34(3):129-141. 12. cloete n, mouton j, sheppard d. doctoral education in south africa. cape town: african minds, 2015. 13. badat s. the challenges of transformation in higher education and training institutions in south africa. johannesburg: development bank of southern africa, 2010:8. 14. national planning commission. national development plan: vision 2030. 2011. http//www.gov.za (accessed 29 july 2016). 15. zwanikken p, huong n, ying x, et al. outcome and impact of master of public health programs across six countries: education for change. human resource health 2014;12(1):40. https://doi.org/10.1186/14784491-12-40 16. adams sg. exploring first generation african american graduate students: motivating factors for pursuing a doctoral degree. 2011. http://scholarworks.uark.edu/etd/179 (accessed 2 january 2020). 17. walters s, koetsier j. working adults learning in south african higher education. perspect educ 2006;24(3):97-108. 18. cassidy s. resilience building in students: the role of academic self-efficacy. frontiers psychol 2015;6:1781. https://doi.org/10.3389/fpsyg.2015.01781 19. taylor h, reyes h. self-efficacy and resilience in baccalaureate nursing students. int j nursing educ scholar 2012;9(1):1-13. https://doi. org/10.1515/1548-923x.2218 20. gasman mpr. it takes a village to raise a child: the role of social capital in promoting academic success or african american men at a black college. j colleg student develop 2008;49(1):52-70. https://doi. org/10.1353/csd.2008.0002 21. world health organization. a conceptual framework for action on the social determinants of health. geneva: who, 2010. accepted 1 august 2019. personal • time management • personal sacri�ce • self-e�cacy social • family • peers work • employer • colleagues motivation • extrinsic • inspirational academic environment • curriculum • administrative procedures • academic support • administrative support social/work environment • employer support • colleague support • family support bene�t analysis • career advancement • financial incentives • social standing completion persistence fig. 1. proposed conceptual framework for understanding student persistence. http://www.cais.ca http://www.education.gov.za https://doi.org/10.1353/rhe.2003.0032 https://doi.org/10.4314/sajhe.v24i1.63427 https://doi.org/10.1186/s40985-017-0052-9 https://doi.org/10.7196/ajhpe.2017.v9i3.793 https://doi.org/10.7196/ajhpe.2017.v9i3.793 http://www.gov.za https://doi.org/10.1186/1478-4491-12-40 https://doi.org/10.1186/1478-4491-12-40 http://scholarworks.uark.edu/etd/179 https://doi.org/10.3389/fpsyg.2015.01781 https://doi.org/10.1515/1548-923x.2218 https://doi.org/10.1515/1548-923x.2218 https://doi.org/10.1353/csd.2008.0002 https://doi.org/10.1353/csd.2008.0002 november 2020, vol. 12, no. 4 ajhpe 220 research since the mid-19th century, nursing has traditionally been a femaledominated profession, with a small number of males entering it.[1] men in nursing are challenged by barriers such as stereotyping, sexism and socialisation issues.[2] those men who enter the nursing field may have initially been drawn to the clinical setting, but these challenges often cause them to respond by working in high-tech, low-touch specialty areas and administration.[3] some countries have instituted equity targets that include recruiting more male nurses to meet clients’ preferences. despite societal needs for quality healthcare, research notes that males account for only ~11% of the nursing population globally, and 9.1% in south africa (sa).[4] recruiting more males into the profession is one way of addressing the demand for more nurses, simultaneously meeting the need to diversify the nursing profession.[5,6] successful recruitment strategies should take into account the motivation of potential nursing incumbents. men who choose to enter the nursing profession are either intrinsically or extrinsically motivated. intrinsic motivation is an incentive to engage in a specific activity because pleasure is derived directly from the activity.[7] the intrinsic motivating factors for most men choosing nursing range from altruistic desires to a sense of achievement and self-validation.[8-10] in contrast, extrinsic motivation is inspired by an external incentive to engage in a specific activity.[7] some of the extrinsic motivating factors for men choosing nursing as a career include salary, employment security, flexibility in terms of working hours and returning to the workforce, travel opportunities and the influence of family and friends.[8-11] although males remain a minority within this female-dominated profession, a university in the western cape province, sa, reported an increased enrolment of males in the nursing programme. the 20% male enrolment for the undergraduate nursing programme is higher than figures reported globally and elsewhere in sa.[4] the university was interested in uncovering the factors motivating male students to enrol in the undergraduate nursing programme, in order to improve the recruitment of males. the objectives of this study were therefore to: (i) identify the factors that motivated male students to choose nursing; and (ii) determine the association between demographic characteristics and motivating factors. methods this descriptive cross-sectional study was conducted among male students registered for the undergraduate nursing programme (n=218) at a residential university in the western cape. this setting was chosen because this school offers a 4-year bachelor of nursing (b nursing) programme and a 5-year extended programme offering an additional foundation year, which prepares students to join the mainstream 4-year programme in their second year of study. a total of 920 female students and 218 male students were enrolled in the b nursing programme in 2018. the researchers used stratified random sampling, as the population was divided into subgroups according to year levels of study.[12] the entire male student population (218) from both undergraduate programmes was included.[13] instrument respondents were asked to complete a questionnaire consisting of two sections, one on demographic characteristics and the other on their motivations for choosing nursing. the demographic section included information about their age, gender, level of nursing, province of origin, year of matriculation, prior nursing experience, marital status and number of child dependents. background. men comprise approximately 11% of the nursing population globally, and 9.1% of the south african (sa) nursing workforce. nursing workforce shortages require strategies for recruiting new nurses, including more males. a university in the western cape province, sa, reported an increased enrolment of males to the nursing programme, and wished to understand the factors motivating this, in order to improve the recruitment of males. objective. to determine factors that motivated male students to choose nursing as a career, and to determine any association with demographic characteristics. methods. data were collected from a stratified sample of 218 male undergraduate nursing students at a residential university in the western cape, using a structured questionnaire to determine their demographic profile and extrinsic and intrinsic motivating factors behind their choice of field of study. results. most respondents were single black males aged 18 25 years, with no dependents, who originated from the eastern cape province of sa. the majority started their nursing studies when aged 20 24 years, and had no prior healthcare or nursing experience. the highest scoring intrinsic motivating factors were wanting to make a difference in society and a desire to help people. the highest scoring extrinsic motivating factor was wanting a stable career, while the lowest scoring extrinsic motivating factor was flexible work hours in nursing. when considering extrinsic motivations, having dependents/children was significantly associated with potential salary and other monetary benefits as well as career mobility. conclusion. men choose nursing as a career for both altruistic motivations as well as monetary benefits. these motivations should be used to attract more men into the nursing profession. afr j health professions educ 2020;12(4):220-223. https://doi.org/10.7196/ajhpe.2020.v12i4.1371 male students’ motivations to choose nursing as a career i noordien, m nursing; j hoffman, mcur; h julie, phd school of nursing, faculty of community and health science, university of the western cape, cape town, south africa corresponding author: h julie (hjulie@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 221 november 2020, vol. 12, no. 4 ajhpe research the section on their motivations for choosing nursing as a path of study consisted of 15 questions. intrinsic motivation was assessed using 5 items asking about different personal and internal motivations for choosing nursing, for example: ‘i have a desire to help people’ and ‘i want to make a difference in society’. extrinsic motivation was determined using 10 items, for example: ‘my parents encouraged me to do nursing’, ‘nursing has flexible working hours’ and ‘potential salary and other monetary benefits’. all items were scored on a 5-point likert scale ranging from 0 = strongly disagree to 4 = strongly agree. items were used as individual responses, and no scale total was calculated owing to the varying nature of the intrinsic and extrinsic motivators covered. the questionnaire was assessed for face validity by nurse academics who were responsible for teaching and selection of undergraduate students and offering the b nursing programme. data analysis spss version 26 (ibm corp., usa) was used to analyse the data. responses to each motivator were converted into a percentage of total agreement for each item, where a response of ‘strongly disagree’ (0) equated to 0% agreement with the motivator, and a response of ‘strongly agree’ (4) equated to 100% agreement with the motivator. the average percentage agreement for each motivator was determined for the sample using this method, in order to determine the primary motivators. pearson’s correlation testing was performed to determine the association between the demographic factors of age, level of study and number of children, and the motivational factors. a one-way analysis of variance was used to determine if there were differences in motivation between groups. ethical considerations the ethical principles of informed consent, respect for autonomy, confidentiality, anonymity and beneficence were adhered to in this study. ethical clearance was given by the human sciences research ethics committee of the university of the western cape (ref. no. hs18/2/2) and permission was obtained from the head of the school of nursing prior to data collection. results a response rate of 65.5% (n=143/218) was obtained. of these, 12 (8%) male students were enrolled in the foundation year and 92% (n=131) in the b  nursing programme at the following levels: 1st year = 25% (n=35); 2nd year = 27% (n=39); 3rd year = 20% (n=29); and 4th year = 20% (n=28). the main findings relating to the demographic profile of the male students indicated that 77% (n=110) were classified as black, with 84% (n=120) aged 18 25 years. the majority (95.8%; n=137) were single and most (79.7%; n=114) had no children. the majority (83%; n=119) of these male students came from either the eastern cape province (44%; n=63) or the western cape (39%; n=56). the origins of the remainder were spread across the other provinces of sa. table 1 gives an overview of the main findings on the year in which the students matriculated, age when they first considered nursing as a profession and age upon entering the nursing programme. a slight majority (53%; n=76) had been studying prior to starting the nursing programme, while most (88%; n=126) had no prior healthcare or nursing experience. motivations for choosing nursing table 2 summarises the intrinsic motivating factors for choosing the nursing profession in this sample, according to the percentage of agreement with various statements. the intrinsic motivator with the highest level of agreement (91.61%) was wanting to make a difference in society, followed closely by the desire to help people (89.86%). the intrinsic motivator with the lowest level of agreement (55.77%) was having always wanted to be a nurse. levels of agreement with extrinsic motivating factors are displayed in table 3. the highest level of agreement on extrinsic motivating factors was on wanting a stable career (88.81%) and a variety of career paths available (86.71%). factors with the lowest levels of agreement in this sample were flexible work hours in nursing (40.91%) and nursing as a second option for studies (38.64%). association between demographic profile and motivation no significant associations were found between demographic factors and intrinsic motivations for choosing nursing. when considering extrinsic motivations, it was found that having dependents/children was significantly associated with potential salary and other monetary benefits (r=0.18, p<0.01) and upward career mobility (r=0.22, p<0.01). discussion the findings reveal that the majority of respondents matriculated between 2013 and 2014. this could be attributed to the introduction of the 5-year extended programme in 2013. according to the council of higher education,[15] the intention of the extended programme is to enable underprepared but talented students to achieve academic success in higher education. the majority of the respondents (n=85; 60%) first considered nursing as a career between the ages of 18 and 25 years (mean 19 years). this corresponds to the results of a study by stanley et al.[16] that indicated that in comparison with female students (82.8%), only 47.8% of male respondents had considered nursing as a career before the age of 20 years. the study also revealed that the majority of respondents (n=71; 50%) started their nursing careers between the ages of 20 and 24 years. stanley et al.[16] found that the majority of their female respondents (71.3%) started their nursing careers before the age of 20 years. the study indicated that the motivation of ‘wanting to make a difference in society’ was identified as topmost for overall motivation (intrinsic and extrinsic), as well as being the most important intrinsic motivator (91.6% agreement). similar results were reported in a study by haigh,[9] where 73% of the male nursing students in western australia chose the same intrinsic table 1. year matriculated, age when considered and starting nursing (n=143) demographic variable category f (%) mean year of matriculation 2008 2013 39 (27) 2014 2017 93 (65) age when nursing was first considered as profession (years) 10 17 50 (35) 19 18 25 85 (60) age when nursing training started (years) 15 19 56 (39) 21 20 24 71 (50) 25 29 12 (8) november 2020, vol. 12, no. 4 ajhpe 222 research motivation factor. the ‘desire to help people’ was ranked second highest intrinsic motivator for the male student nurses, with 89.8% agreement. this confirms the findings of similar quantitative studies;[11] the study by haigh[9] reported that 84.1% of male nursing students in western australia stated that a desire to help people was their main reason for choosing nursing as a career. the ‘variety of career paths’ was identified as the second most important motivation (extrinsic) factor, with 86.7% agreement. haigh[9] reported similar findings, stating that 71.4% of the males in the study selected variety of career pathing as the second reason for choosing nursing. twomey and meadus[10] reported that males found nursing to be very versatile, and indicated this as their fourth-most important reason for choosing nursing as a career. ‘variety and challenges of the work’ was ranked as the third highest motivation (intrinsic), with 80% agreement. male nurses in canada indicated nursing as a ‘challenging and responsible profession’ as their third motivation, according to twomey and meadus.[10] ‘being able to travel overseas’ was ranked third for extrinsic motivation, with 81% agreement. this finding is similar to that reported by twomey and meadus,[10] but much higher than the 60.3% reported by haigh.[9] conclusion most of the respondents were single black males aged 18 25 years, with no dependents, who came from the eastern cape. the majority started their nursing studies between the ages of 20 and 24 years, and had no prior healthcare or nursing experience. the intrinsic motivating factors with the highest level of agreement indicated by the respondents in this study were wanting to make a difference in society as well as a desire to help people. the motivating factor with the lowest level of agreement was having always wanted to be a nurse. the extrinsic motivating factors with the highest level of agreement indicated by the respondents were wanting a stable career, and the variety of career paths available. the extrinsic motivating factors with the lowest level of agreement were the flexible working hours of nursing, and nursing as a second option for study. no significant associations were found between demographic factors and intrinsic motivations for choosing nursing. regarding extrinsic motivations, significant associations were found between having children/dependents and potential salary and other monetary benefits as well as upward career mobility. we recommend that schools of nursing should collaborate with highschool guidance and career counsellors during recruitment drives. this strategy will ensure that potential nursing students are given accurate information about the nursing profession and undergraduate nursing entry requirements. declaration. this article was based on a study done by in in partial fulfilment of her master’s thesis at uwc. acknowledgements. the authors acknowledge leverne gething for providing editorial support, and emma wagener for support with statistics. author contributions. in, jch and hj conceptualised and designed the study; in co-ordinated the data collection; in, jch and hj participated in the data analysis and manuscript organisation; and in, jh and hj wrote and approved the final and revised manuscript for this publication. funding. we express gratitude towards national research foundation for funding provide throughout preparation of this publication. conflicts of interest. none. 1. meadus rj, twomey jc. men student nurses: the nursing education experience. nurs forum 2011;46(4):269-279. https://doi.org/10.1111/j.1744-6198.2011.00239.x 2. chinkhata mm, langley g. experiences of male student nurse midwives in malawi during undergraduate education. ann global health 2018;84(1):83-90. https://doi.org/10.29024/aogh.18 table 2. level of agreement with intrinsic motivators intrinsic motivating factor minimum (%) maximum (%) mean (%) sd want to make a difference in society 0.00 100.00 91.61 13.58 desire to help people 0.00 100.00 89.86 16.58 variety and challenges of the work 0.00 100.00 80.07 20.03 want to be a role model in my family as nurse 0.00 100.00 79.72 26.53 always wanted to be a nurse 0.00 100.00 55.77 27.94 sd = standard deviation. table 3. level of agreement with extrinsic motivating factors extrinsic motivating factor minimum (%) maximum (%) mean (%) sd want a stable career 0.00 100.00 88.81 18.92 a variety of career paths available 0.00 100.00 86.71 16.47 the ability to travel overseas 0.00 100.00 80.94 25.17 nursing as a stepping stone to other careers 0.00 100.00 77.80 26.05 upward career mobility 0.00 100.00 77.10 20.45 potential salary and other monetary benefits 0.00 100.00 67.13 29.88 a family member/friend is a nurse 0.00 100.00 58.57 43.62 encouragement from parents to do nursing 0.00 100.00 50.52 34.91 flexible hours of nursing 0.00 100.00 40.91 32.58 did not meet the requirements for first choice of study 0.00 100.00 38.64 39.66 sd = standard deviation. https://doi.org/10.1111/j.1744-6198.2011.00239.x https://doi.org/10.29024/aogh.18 223 november 2020, vol. 12, no. 4 ajhpe research 3. macwilliams br, schmidt b, bleich mr. men in nursing. understanding the challenges men face working in this predominantly female profession. am j nurs 2013;113(1):38-44. 4. world health organization. state of the world’s nursing report 2020. geneva: who, 2020. https://www.who. int/publications/i/item/nursing-report-2020 (accessed 17 april 2020). 5. bartfay wj, bartfay e, clow ka, wu t. attitudes and perceptions towards men in nursing education. ijahsp 2010;8(2):1-7. https://ijahsp.nova.edu (accessed 28 october 2018). 6. feng d, zhao w, shen s, chen j, li l. the influence of perceived prejudice on willingness to be a nurse via the mediating effect of satisfaction with major: a cross-sectional study among chinese male nursing students. nurse educ today 2016;42:69-72. https://doi.org/10.1016/j.nedt.2016.04.012 7. american psychological association. apa dictionary of psychology. https://dictionary.apa.org/intrinsicmotivation (accessed 17 june 2017). 8. o’connor t. men choosing nursing: negotiating a masculine identity in a feminine world. j men’s studies 2015;23(2):194-211. https://doi.org/10.1177%2f1060826515582519 9. haigh m. men in nursing: a quantitative study from the perspective of west australian nursing students. phd thesis. perth: university of western australia, 2015. 10. twomey jc, meadus rj. men in atlantic canada. career choice, barriers, and satisfaction. j men’s studies 2016;24(1):78-88. https://doi.org/10.1177/1060826515624414 11. kronenfeld jj. systems of health-care delivery: sociological issues linked to health reform and roles of patients and providers. in: kronenfeld j, ed. access to care and factors that impact access, patients as partners in care and changing roles of health providers. bingley: emerald group, 2011:3-17. https://doi.org/10.1108/s02754959(2011)0000029003 12. brink h, van der walt c, van rensburg g. fundamentals of research methodology for healthcare professionals. 2nd ed. cape town: juta, 2006. 13. de vos as. research at grass roots: for the social sciences and human services professions. 3rd ed. pretoria: van schaik, 2005. 14. kirk jr, o’lynn ce, ponton mk. perceptions of gender-based barriers for men in an online nursing completion program compared to traditional on-campus nursing programs. j online learning and teaching 2013;4(9)481-488. 15. council on higher education. a proposal for undergraduate curriculum reform in south africa: the case for a flexible curriculum structure. report of the task team on undergraduate curriculum structure. pretoria: che, 2013. 16. stanley d, beament t, falconer d, et al. the male of the species: a profile of men in nursing. j adv nurs 2016;72(5):1155-1168. https://doi.org/10.1111/jan.12905 accepted 24 august 2020. https://www.who.int/publications/i/item/nursing-report-2020 https://www.who.int/publications/i/item/nursing-report-2020 https://ijahsp.nova.edu https://doi.org/10.1016/j.nedt.2016.04.012 https://dictionary.apa.org/intrinsic-motivation https://dictionary.apa.org/intrinsic-motivation https://doi.org/10.1177%2f1060826515582519 https://doi.org/10.1177/1060826515624414 https://doi.org/10.1108/s0275-4959(2011)0000029003 https://doi.org/10.1108/s0275-4959(2011)0000029003 https://doi.org/10.1111/jan.12905 a maximum of 3 ceus will be awarded per correctly completed test. december 2018, vol. 10, no. 4 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/029/01/2018 (clinical) cpd questionnaire december 2018 true (a) or false (b): improving communication in the south african healthcare context 1. recommendations to improve communication teaching at institutional level included developing the isixhosa language. 2. the authors propose that students’ cultural knowledge and skills in intercultural communication should be included in student evaluations. student-informed directives for clinical communication skills training in undergraduate healthcare programmes: perspectives from a south african university 3. barriers, such as culture and language, are found to restrict the communication-related performance of healthcare students in the clinical environment. 4. all participants felt that language differences negatively influenced the effectiveness of their treatments. knowledge and attitudes of undergraduate medical students with regard to medical research at a south african university 5. the medical students sampled in this study generally had negative attitudes towards research. 6. the literature suggests that there has been a steady decline in the number of physician-scientists worldwide. continuing professional development opinions and challenges experienced by radiographers in kwazulu-natal province, south africa 7. the majority of participants considered continuing professional development (cpd) to be unimportant. 8. cpd funding is a major challenge for healthcare professionals worldwide. mandatory continuing education for psychologists: practitioners’ views 9. half of the sample of participants opposed the idea of mandatory cpd. 10. the three key role-players in the cpd system identified by mulvey include the individual practitioner, the employer and the professional body. a pre-post study of behavioural determinants and practice change in ugandan clinical officers 11. ‘provider behaviour’ is one of five domains of behaviour change that are the building blocks of global health. 12. environmental determinants were the only change from preto postcourse that was statistically significantly associated with a change in use of the airway, breathing, circulation, disability, exposure (abcde) approach to treat acutely ill patients. learning styles of physiotherapy students and teaching styles of their lecturers in undergraduate gross anatomy education 13. several students in this study seemed to view learning as an event that ‘happened’ to them, rather than one that requires active participation. 14. students generally perceived teaching by course lecturers to be inadequate. teaching pharmacotherapeutics to pharmacy students at a nigerian university: student perspectives 15. grasha and yangarber-hicks summed up a learning style as ‘a student’s consistent way of responding and using stimuli in the context of learning’. 16. gender has been shown to influence learning style preference. june 2020, vol. 12, no. 2 ajhpe 86 research the complex nature of current healthcare, which aims to cure and prevent disease and also to promote health, requires effective collaboration between various healthcare professionals.[1] however, interprofessional collaboration is not self-evident and is fraught with problems, such as ineffective communication, poor interprofessional relationships, lack of trust between team members and an underestimation of other health professionals’ roles.[2] these factors impede the effective involvement of all team members in collaborative decision-making regarding patient care and the implementation of healthcare services.[1] to partially address this problem, the world health organization (who) recommended the introduction of interprofessional education (ipe), which helps future healthcare professionals to prepare for their collaborative role in the healthcare system.[3] ipe offers students from different health professions the opportunity to learn with, from and about each other’s profession and has been recognised as a means to safely promote and develop collaborative skills that students would require in their profession.[1] research revealed that health professionals who were trained to collaborate as a team in an ipe setting during their student years, were far more likely to be effective collaborators in their future professional clinical setting.[4] ipe has been shown to eliminate segmented education between healthcare professionals, and therefore overlooks hierarchies, misperceptions and miscommunications.[5] furthermore, ‘the aging society, the increase in chronic illnesses and patients in need of complex care, and rapidly evolving scientific knowledge have necessitated interprofessional collaborations for optimal patient care’.[6] however, a 2010 lancet report states that current healthcare students are not being adequately prepared for interprofessional collaboration owing to the profession-specific nature characterising most health professions education and socialisation.[7] keshtkaran et al.[8] reported that healthcare students had positive attitudes towards teamwork and collaboration. fallatah et al.[9] revealed that medical students and graduates valued ipe and thought that its implementation in their education would improve patient care and healthcare-provider satisfaction. furthermore, others[5,10] reported that most healthcare students have positive attitudes towards ipe at the undergraduate levels of their professional programme. casual conversations with physiotherapy students in their clinical year regarding clinical rotations and attachments in two hospitals in ghana, revealed that most healthcare professionals do not possess sufficient knowledge of the role of members of other health professions in the treatment or management of patients. although similar studies were carried out in other countries and among other health professionals, there seems to be a dearth of information with regard to this topic for allied health professions at a university in ghana. findings from this study generated baseline information about ipe for the allied health professions’ training programmes, such as effective collaboration with other healthcare professionals to improve patient care or management and recovery. ultimately, it could serve as a basis for reviewing the curricula to background. interprofessional education (ipe) is an important academic approach for preparing healthcare students to provide patient care in a collaborative team environment, which improves patient care outcomes and increases patient satisfaction. ipe has been shown to eliminate segmented education between healthcare professionals, and thus renounces hierarchies, misperceptions and miscommunications. objectives. to determine the readiness of allied health students towards ipe. methods. this was a cross-sectional study that involved 299 secondto fourth-year allied health students recruited from various departments at the university of ghana, accra, ghana. the readiness for interprofessional learning scale was used to obtain data regarding readiness of allied health students towards ipe. data obtained were analysed using spss version 22 (ibm corp., usa). differences between groups based on the levels and programmes of study, respectively, were determined using one-way analysis of variance (anova). results. the majority of participants (n=155; 67.7%) had previous experience in the health environment. the overall response of allied health students’ readiness towards ipe was high. this readiness did not differ between the different levels of study (p=0.985) and the various programmes of study (p=0.726). conclusion. the study revealed that allied health students value teamwork and collaboration and appear ready for participation in ipe activities. formatively planning ipe activities may be helpful in developing multidisciplinary teamwork. afr j health professions educ 2020;12(2):86-89. https://doi.org/10.7196/ajhpe.2020.v12i2.1243 readiness of allied health students towards interprofessional education at a university in ghana j quartey,1 phd; j dankwah,2 bsc; s kwakye,3 bsc; k acheampong,4 bsc 1 department of physiotherapy, school of biomedical and allied health sciences, college of health sciences, university of ghana, accra, ghana 2 department of physiotherapy, korle-bu teaching hospital, accra, ghana 3 west africa football academy, sogakope, ghana 4 department of physiotherapy, komfo anokye teaching hospital, kumasi, ghana corresponding author: j quartey (neeayree@googlemail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 87 june 2020, vol. 12, no. 2 ajhpe research promote ipe. hence, there was a need to conduct this study among allied health students in the specific university in ghana. methods this was a cross-sectional study performed at the school of biomedical and allied health sciences, university of ghana, accra, ghana. the study involved secondto fourth-year allied health students from physiotherapy, dental laboratory science, dietetics, occupational therapy, diagnostic radiography/radiotherapy and medical laboratory science. the yamane[12] formula, n=n/(1+ne2), was used to determine the sample size, while the convenient sampling method was used to recruit respondents for the study; n with an error margin, e = allowable error of 5%, and n=population (students, n=534). therefore, n=534/(1+534(0.05)2)=534/(2.335)=228.7. this was rounded off to 229. the parsell and bligh[13] modified version of the readiness for interprofessional learning scale (ripls) (appendix 1 (http://www.ajhpe. org.za/public/files/1243.doc)) was used to measure the readiness towards ipe.[11] the validity and reliability of the questionnaire were confirmed with an alpha coefficient (cronbach’s alpha) of 0.81 and hence an internal consistency of 0.90.[13] a data-capturing form was used to obtain the demographic details of the respondents. the ripls is scored on a 5-point likert scale, as follows: strongly agree = 5, agree = 4, neutral = 3, disagree = 2, and strongly disagree = 1. domain 1 focuses on the aspects of teamwork and collaboration (items 1 9); domain 2 focuses on negative professional identity towards other professions (items 10 12); domain 3 focuses on positive professional identity (items 13 16); and domain 4 focuses on the roles and responsibilities of professionals (items 17 19).[13] the research was explained to respondents; those who agreed to participate signed a consent form. copies of the questionnaire and datacapturing form were administered to students in their lecture halls. the questionnaire, which takes 10 15 minutes to complete, was retrieved from the respondents on the same day. data were collected within 4 weeks (middle of february middle of march 2019) during semester 2 of the 2017/2018 academic year. the data obtained were entered into a database and analysed using spss version 22.0 (ibm corp., usa). the demographic data of the respondents were analysed and described in terms of frequencies and percentages. one-way analysis of variance (anova) was performed to determine significant associations between groups based on level or year of study, and groups based on different healthcare disciplines, with regard to the readiness of allied health students towards ipe at the university of ghana. a p-value of <0.05 was interpreted as significant. ethical approval ethical approval was obtained from the ethics and protocol review committee of the school of biomedical and allied health sciences, university of ghana (ref. no. sbahs-ph./10513879/sa/2017-2018). results a total of 229 respondents from 6 allied health professions took part in the study. students were almost equally spread across the three year levels; 119 (52%) were males, 71 (31%) were second-year students and the majority (n=155; 67.7%) had previous experience in the health environment (table  1). thirty-eight (16.6%) of the respondents were physiotherapy students, and 81 (35.4%) were medical laboratory science students (table 1). table 2 provides information about responses to statements regarding teamwork and collaboration, negative and positive professional identity and roles and responsibilities in ipe. the item ‘patients would ultimately benefit if healthcare students work together’ under the domain ‘teamwork and collaboration’, obtained the highest response (n=165; 72.1%). students were also generally affirmative regarding positive professional identity (table 2). the item ‘shared learning before and after qualification will help me become a better team worker’, under the domain ‘positive professional identity’, also obtained the highest response (54.1%). under the domains ‘roles and responsibilities’ and ‘negative professional identity towards other professions’, students understood their roles and found that learning with other undergraduate healthcare students was necessary. the difference between the level of study and readiness of allied health students towards ipe at a university in ghana was not statistically significant (table 3). the difference between and among the various programmes of study and readiness of allied health students towards ipe was also not statistically significant (table 4). discussion this study revealed that the overall response of allied health students’ readiness towards ipe is high. this result corroborates the findings of lairamore et al.,[10] who showed that most healthcare students have a positive readiness towards ipe at the undergraduate levels of their professional programme. this may be due to problems that students encountered during their clinical rotations and placements. addressing problems of teamwork and collaboration, professional identity and roles and responsibilities would be more beneficial to students. the study also revealed details of the teamwork and collaboration domain, i.e. that most students agreed with the significance of teamwork and collaboration with other healthcare professionals. the highest-rated item under the domain was ‘patients would ultimately benefit if healthcare table 1. sociodemographic profile of respondents sociodemographic profile n (%) year of study 2 71 (31.0) 3 73 (31.9) 4 85 (37.1) total 229 (100) programme of study physiotherapy 38 (16.6) dietetics 28 (12.2) diagnostic radiography/radiotherapy 50 (21.8) medical laboratory science 81 (35.4) occupational therapy 15 (6.6) dental laboratory science 17 (7.4) total 229 (100) gender male 119 (52.0) female 110 (48.0) total 229 (100) previous experience in the health environment yes 155 (67.7) no 74 (32.3) total 229 (100) june 2020, vol. 12, no. 2 ajhpe 88 research students work together’. this reveals that allied health students are willing to work in an effective collaborative manner to improve patient outcomes, which is similar to the findings of keshtkaran et al.,[8] who reported that students showed readiness towards teamwork and collaboration. students generally value sharing of experiences with other healthcare disciplines, as observed in the second domain (positive professional identity). the highest-rated item under the domain was ‘shared learning before and after qualification will help me become a better team worker’. students believe that ipe will facilitate their team-working skills and, thus, improve health outcomes. the third domain, ‘negative professional identity towards other professions’, which received low responses, indicates that students value collaborative learning with other health professions students. this highlights students’ need for shared learning, which would improve communication skills among health professions students and prevent conflicts. the fourth domain, ‘roles and responsibilities’, shows that students understood their roles as healthcare professionals. this may be due to the well-structured tuition in the various disciplines. however, students had divergent responses to the item ‘i have to acquire much more knowledge and skill than other students in my own faculty’, possibly because of individual differences they might have towards acquiring knowledge and skills. the results showed that there was no difference between level of study and readiness or between the various allied health students towards ipe at the university of ghana. therefore, although students are at different levels of study, they have an equal understanding of the benefits of ipe if it is available to them. this is at variance with table 2. readiness of allied health students toward interprofessional education (n=229) response strongly disagree, % disagree, % undecided, % agree, % strongly agree, % teamwork and collaboration learning with other students will make me a more effective member of a healthcare team 2.6 3.5 5.7 34.9 53.3 patients would ultimately benefit if healthcare students work together 3.5 1.3 1.7 21.4 72.1 shared learning with other healthcare students will increase my ability to understand clinical problems 3.1 1.7 4.8 32.3 58.1 communication skills should be learnt with other healthcare students 3.1 0.4 4.4 36.2 55.9 team-working skills are vital for all healthcare students to learn 3.1 0.4 2.6 24.0 51.5 shared learning will help me to understand my own professional limitations 3.1 1.7 7.9 35.8 51.5 learning between healthcare students before qualification would improve working relationships after qualification 3.1 1.7 7.4 36.7 51.1 shared learning will help me think positively about other healthcare professionals 2.2 2.2 2.2 41.0 46.7 for small-group learning to work, students need to respect and trust each other 3.1 4.4 0.4 30.1 62.0 negative professional identity towards other professions i don’t want to waste time learning with other healthcare students 55.5 3.9 1.7 33.2 5.7 it is not necessary for undergraduate healthcare students to learn together 59.0 2.2 2.6 32.3 3.9 clinical problem solving can only be learnt effectively with students from my own school 45.9 7.0 2.6 32.8 11.8 positive professional identity shared learning with other healthcare professionals will help me to communicate better with patients and other professionals 3.5 2.2 4.8 43.2 46.3 i would welcome the opportunity to work on small-group projects with other healthcare students 3.5 3.1 6.1 46.3 41.0 i would welcome the opportunity to share some generic lectures, tutorials or workshops with other healthcare students 2.2 0.4 6.1 41.9 49.3 shared learning will help me clarify the nature of patients’ or clients’ problems 2.2 2.6 11.4 41.5 42.4 shared learning before and after qualification will help me to become a better team worker 1.7 2.2 3.5 38.4 54.1 roles and responsibilities of professionals i am not sure what my professional role will be 50.7 29.3 11.4 5.7 3.1 i have to acquire much more knowledge and skill than other students in my own faculty 15.7 19.2 24.9 24.5 15.7 table 3. differences between and within levels of study and readiness of allied health students towards interprofessional education source df ss ms f p-value between groups 2 0.02 0.01 0.02 0.985 within groups 226 149.40 0.66 total 228 149.42 ss = sum of squares; ms = mean square. table 4. differences between and within programmes and readiness of allied health students towards interprofessional education source df ss ms f p-value between groups 5 1.87 0.38 0.57 0.726 within groups 223 147.54 0.66 total 228 149.42 ss = sum of squares; ms = mean square. 89 june 2020, vol. 12, no. 2 ajhpe research the findings of olenick et al.,[5] who reported a significant difference in the perception of ipe between the higher levels of education (medical residents and interns), who had a higher perception of ipe, and the lower levels (medical and nursing students). the difference shown in that study might be the result of residents and interns having obtained some level of experience of healthcare services and having learnt about interprofessional work, unlike medical and nursing students. the results showed that there was no difference between programme of study and readiness and also not for the various allied health students towards ipe at the university of ghana. although students were in different allied health disciplines, they seem to have understood what it meant to work together as healthcare professionals to improve patient care or management and delivery. this might be due to their experiences during clinical placements and rotations. this is also at variance with the outcomes of keshtkaran et al.,[8] who reported significant differences among disciplines. the difference found in that study might be due to medical students feeling superior to the nurses and, therefore, not experiencing the need to work with them. conclusions allied health students seem to be ready for participation in ipe activities. formatively planning ipe activities might assist in developing multidisciplinary teamwork, which has implications for restructuring the allied health professions curriculum to promote ipe, which could be helpful for the clinical learning of allied health students. declaration. none. acknowledgements. special thanks go to the 2017/2018 allied health professions students of the school of biomedical and allied health sciences  for their participation, and to the management of the school for their support. author contributions. jq and jd contributed to the study design, and collected and analysed the data. sk and ka assisted with data collection, and sourced and reviewed the relevant literature. jq, jd, sk and ka wrote and reviewed the manuscript for important intellectual content, revised the draft version and approved the final version for submission. funding. none. conflicts of interest. none. 1. lestari e, stalmeijer re, widyandana d, scherpbier a. understanding students’ readiness for interprofessional learning in an asian context: a mixed-methods study. bmc med educ 2016;16(1):179. https://doi.org/10.1186/ s12909-016-0704-3 2. besner j. is interprofessional practice rhetoric or reality? canad nurse 2008;104(3):48-48. https://doi. org/10.1002/9780470690352.ch3 3. world health organization. framework for action on interprofessional education collaborative practice. geneva: who, 2010. https://doi.org/10.3109/13561821003676325 4. jacobsen f, lindqvist s. a two-week stay in an interprofessional training unit changes students’ attitudes to health professionals. j interprofes care 2009;23(3):242-250. https://doi.org/10.1080/13561820902739858 5. olenick m, allen lr, smego ra jr. interprofessional education: a concept analysis. adv med educ pract 2010;1:75. https://doi.org/10.2147/amep.s13207 6. thistlethwaite j. interprofessional education: a review of context, learning and the research agenda. med educ 2012;46(1):58-70. https://doi.org/10.1111/j.1365-2923.2011.04143.x 7. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 8. keshtkaran z, sharif f, rambod m. students’ readiness for and perception of inter-professional learning: a crosssectional study. nurse educ today 2014;34(6):991-998.https://doi.org/10.1016/j.nedt.2013.12.008 9. fallatah hi, jabbad r, fallatah hk. interprofessional education as a need: the perception of medical, nursing students and graduates of medical college at king abdulaziz university. creative educ 2015;6(2):248. https:// doi.org/10.4236/ce.2015.62023 10. lairamore c, george-paschal l, mccullough k, grantham m, head da. case-based interprofessional education forum increases health students’ perceptions of collaboration. med sci educ 2013;23(3):472-481. https://doi. org/10.1007/bf03341670 11. coster s, norman i, murrells t, et al. interprofessional attitudes amongst undergraduate students in the health professions: a longitudinal questionnaire survey. int j nurs studies 2008;45(11):1667-1681. https://doi. org/10.1016/j.ijnurstu.2008.02.008 12. yamane t. statistics: an introductory analysis. 2nd ed. new york: harper and row, 1967. https://doi. org/10.1177/001316446402400434 13. parsell g, bligh j. the development of a questionnaire to assess the readiness of health care students for interprofessional learning (ripls). med educ 1999;33(2):95-100.https://doi.org/10.1046/j.13652923.1999.00298.x accepted 10 december 2019. https://doi.org/10.1186/s12909-016-0704-3 https://doi.org/10.1186/s12909-016-0704-3 https://doi.org/10.1002/9780470690352.ch3 https://doi.org/10.1002/9780470690352.ch3 https://doi.org/10.3109/13561821003676325 https://doi.org/10.1080/13561820902739858 https://doi.org/10.2147/amep.s13207 https://doi.org/10.1111/j.1365-2923.2011.04143.x https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/j.nedt.2013.12.008 https://doi.org/10.4236/ce.2015.62023 https://doi.org/10.4236/ce.2015.62023 https://doi.org/10.1007/bf03341670 https://doi.org/10.1007/bf03341670 https://doi.org/10.1016/j.ijnurstu.2008.02.008 https://doi.org/10.1016/j.ijnurstu.2008.02.008 https://doi.org/10.1177/001316446402400434 https://doi.org/10.1177/001316446402400434 https://doi.org/10.1046/j.1365-2923.1999.00298.x https://doi.org/10.1046/j.1365-2923.1999.00298.x november 2020, vol. 12, no. 4 ajhpe 166 short research report there is growing interest in quality assurance (qa) as an important process in higher education programmes to promote appropriate outcomes and graduate competence.[1] in health professions education (hpe) it has been accepted that the use of an internal quality assurance (iqa) system is an important contributor to the social accountability of an institution. it is regarded as the responsibility of the relevant institutional governance structures to ensure that such systems are in place to guarantee professional competence and community protection.[2] there are indications that the implementation of qa systems in higher education is relatively slow in parts of africa.[3] a recent study in nigeria suggests that the presence of improved medical education capacity in an institution may contribute to the quality of teaching and thus facilitate qa practices.[4] the revised standards of proficiency for nursing and midwifery education and practice in tanzania emphasise the importance of qa for all elements of the academic programme and professional practice.[5] currently, there is no comprehensive iqa system in place for education in the department of general nursing and midwifery, school of health and medical sciences, state university of zanzibar (suza), tanzania. there is therefore no effective mechanism for monitoring and evaluating teaching and learning in the department. furthermore, there have recently been complaints from the local community regarding the quality of the graduating nurses. it is therefore opportune to investigate the current status of qa in the teaching and learning of nursing students at suza before making recommendations for the implementation of a comprehensive system. the objectives of this study were to determine the following in the department of general nursing and midwifery: • the awareness of iqa in higher education among nurse educators and students • the extent to which the department monitors the quality of learning and teaching in the nursing programme • the extent to which the department evaluates the quality of education in the nursing programme. methods the study design was exploratory and involved nurse educators and third-year student nurses from suza. qualitative data were collected from participants through individual interviews. a convenience, nonprobability method was used to recruit 6 nurse educators as participants in the study, who constituted all available nurse educators at the time. a purposive convenience sampling method was used to recruit third-year nursing students as study participants. the sample comprised 20 students of a class of 82. data were collected through structured and semi-structured interviews, which were audio recorded. the data collection procedure was carried out by one of the researchers (mb) and an assistant. before the interview, the participants received detailed information regarding the title background. a quality assurance (qa) process is acknowledged as important to ensure good higher education outcomes and graduate competence. complaints about the quality of recent nursing graduates in the department of general nursing and midwifery at the state university of zanzibar (suza), tanzania, suggested that current qa concepts and processes may be inadequate and should be investigated prior to making recommendations for improvements. objectives. to explore the awareness of qa in higher education among nurse educators and students at suza, and the extent to which the department of general nursing and midwifery currently monitors and evaluates teaching and learning. methods. six nursing educators and 20 third-year nursing students were interviewed regarding their understanding of the concept of internal quality assurance (iqa) and procedures and their awareness of the internal processes that are currently in place in the department. results. all the nurse educators had heard of iqa, but only 2 (33%) had detailed knowledge of the processes involved. none of the students knew what iqa entails. most of the educators identified the monitoring of test scores and pass rates as part of an evaluation process. they were also aware of course evaluations by students, but believed these to be untrustworthy. the students did not understand that course evaluations were part of iqa and did not recognise the potential value of these evaluations. there was an understanding by 35% of students of continuous assessment to monitor individual progress, and 20% identified occasional meetings with the head of department to provide feedback on the course. conclusions. a comprehensive programme of education around qa is suggested for educators and students of nursing at suza as a first step in the introduction of a well-planned and supported iqa process. afr j health professions educ 2020;12(4):166-168. https://doi.org/10.7196/ajhpe.2020.v12i4.1385 exploring internal quality assurance for nursing education in the state university of zanzibar, tanzania: a preliminary needs analysis m bilal,1 bsc nursing, mhpe; d manning,2 bsc hons, phd, med 1 department of general nursing and midwifery, school of health and medical sciences, state university of zanzibar, tanzania 2 office of the dean, faculty of health sciences, university of pretoria, south africa corresponding author: d manning (dianne.manning@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 167 november 2020, vol. 12, no. 4 ajhpe short research report and purpose of the study. their rights as participants were also explained and they signed informed consent forms. during the interviews each participant was asked if they were aware of iqa in higher education, and to provide examples of their experiences of how the department of general nursing and midwifery monitors and evaluates the learning and teaching processes. the participants’ narrative responses were taped, transcribed, translated from kiswahili into english and summarised. the narrative data were analysed using content analysis and reported in terms of frequencies, percentages and narrative responses. ethical approval permission to conduct the study was obtained from the research committee of zanzibar (ref. no. ompr/m.95/c.6/2/vol.xv111/29). confidentiality with regard to the individual responses given to the study participants was assured and maintained throughout the study. results awareness of internal quality assurance in higher education the 6 (100%) nurse educators indicated that they understood the meaning of the term ‘internal quality assurance’ or ‘iqa’ in higher education. only 2 (33%) claimed to have an understanding of the actual processes involved in iqa. a typical response was: ‘i understand what quality assurance is and its procedures,’ but without elaborating in detail. one respondent explained the purpose of iqa as ‘quality assurance ensures that teaching and learning activities are taking place according to the curriculum’. an example of a response from those with less knowledge was: ‘i know the meaning of quality assurance but i don’t have knowledge on the processes.’ in contrast, none of the students indicated that they understood the meaning of iqa or knew anything about the processes of an iqa system in higher education. a typical response was: ‘i have no idea what quality assurance in education means.’ extent to which the department of general nursing and midwifery monitors the quality of teaching and learning among the nurse educators, 5 (83%) reported that student performance and pass rates were existing methods of monitoring the quality of the teaching and learning process in the department. only 1 nurse educator indicated that she did not know of any method in place for monitoring teaching and learning. all 6 of the nurse educators agreed that the effectiveness of teaching and the quality of learning processes were currently evaluated through the completion of evaluation forms that are distributed to students at the end of semester examinations. however, the results also indicate that the majority of nurse educators had a negative perception of the existing evaluation method. they believed it to be subjective and lacking in transparency, as it focuses mainly on identifying weaknesses among the nurse educators. there was a greater diversity among the responses from the students: 7 (35%) revealed the use of continuous assessment to monitor progress and 5 (20%) reported on the use of meetings with heads of department as a means of providing feedback on the course: ‘we occasionally have meetings with the heads of department and school administration asking about the attendance and quality of lecturers in all courses at the end of semester exams.’ the majority of student nurses confirmed that they had completed the evaluation forms, but that they had not received feedback and were therefore unaware of the purpose and value of such evaluations. eight (40%) students indicated that there is no existing process to monitor teaching and learning. discussion the low level of understanding by student nurses and educators regarding the meaning and purpose of iqa is of concern and clearly indicative that it is not a priority that is known, embraced and valued by the various stakeholders in the school. the students’ lack of interest and understanding in the purpose of programme evaluations and the educators’ distrust of the system are also evidence that an intervention is required. this suggests that there would be value in the reconceptualisation and design of an effective process so that teachers and students feel that they have ownership of and trust in the process and understand the potential benefits. the full basket of available iqa tools could be explored for the introduction of effective strategies. khamis and scully[3] identified the importance of institutions developing and owning their iqa frameworks. a neutral structure or education unit is of great benefit, although it was recognised that the establishment of such a unit was challenged by a number of factors, including finance, bureaucracy, resistance, sustainability and leadership.[4] of these, the most important for successful implementation of an iqa system is possibly effective leadership. a recent german study[6] showed that support from top executive and interinstitutional co-operation may enhance the perceptions of effectiveness of qa processes. furthermore, improvement is more likely if iqa systems are systematic and structural and embedded in institutional practice.[7] conclusions further engagement with students, nurse educators and faculty management should be pursued as a key step in educating stakeholders on qa and developing an iqa system that can make an important contribution to effective teaching and improved graduate outcomes. as this may not be an isolated finding in the region, other local institutions should be approached and encouraged to investigate the extent to which they have an iqa system that is well understood and is effective. there may be valuable opportunities for sharing information and collaborating on development and implementation of effective iqa processes and systems in other nursing schools in tanzania and further afield. declaration. none. acknowledgements. participation of students and faculty of the department of general nursing and midwifery, school of health and medical sciences, state university of zanzibar (suza) is gratefully acknowledged. author contributions. mb conceptualised the original study, which was refined with assistance from dm. mb collected and analysed the data. mb and dm contributed to the final manuscript. funding. mb was supported during the development and execution of this study by a fellowship of the sub-saharan-africa faimer regional institute (safri), with funding provided by the foundation for advancement of international medical education and research (faimer). conflicts of interest. none. 1. ansah f. a strategic quality assurance framework in an african higher education context. qual high educ 2015;21(2):132-150. https://doi.org/10.1080/13538322.2015.1084720 2. woollard rf. caring for a common future: medical schools’ social accountability. med educ 2006;40(4):301-313. https://doi.org/10.1111/j.1365-2929.2006.02416.x https://doi.org/10.1080/13538322.2015.1084720 https://doi.org/10.1111/j.1365-2929.2006.02416.x november 2020, vol. 12, no. 4 ajhpe 168 short research report 3. khamis k, scully s. questioning the efficacy of quality assurance frameworks for teaching and learning: a case study from east africa. qual high educ 2020;26(1):3-13. https://doi.org/10.1080/13538322.2020.1728836 4. adefuye ao, adeola ha, bezuidenhout j. medical education units: a necessity for quality assurance in health professions education in nigeria. afr j health professions educ 2018;10(1):5-9. https://doi.org/10.7196/ ajhpe.2018.v10i1.966 5. tanzania nursing and midwifery council. standards of proficiency for nursing and midwifery education and practice in tanzania emphasizes the importance of quality assurance for all elements of the academic programme and professional practice. 2014. https://tnmc.go.tz/data/download/revised%20standards%20of%20 proficiency%20for%20nursing%20and%20midwifery%20education%20and%20practice%20in%20tanzania. pdf (accessed 17 may 2020). 6. seyfried m, pohlenz p. assessing quality assurance in higher education: quality managers’ perceptions of effectiveness. eur j high educ 2018;8(3):258-271. https://doi.org/10.1080/21568235.2018.1474777 7. dolmans dhjm, wolfhagen hap, scherpbier ajja. from quality assurance to total quality management: how can quality assurance result in continuous improvement in health professions education? educ health 2003;16(2):210-217. https://doi.org/10.1080/1357628031000116899 accepted 9 september 2020. https://doi.org/10.1080/13538322.2020.1728836 https://doi.org/10.7196/ajhpe.2018.v10i1.966 https://doi.org/10.7196/ajhpe.2018.v10i1.966 https://tnmc.go.tz/data/download/revised standards of proficiency for nursing and midwifery education and practice in tanzania.pdf https://tnmc.go.tz/data/download/revised standards of proficiency for nursing and midwifery education and practice in tanzania.pdf https://tnmc.go.tz/data/download/revised standards of proficiency for nursing and midwifery education and practice in tanzania.pdf https://doi.org/10.1080/21568235.2018.1474777 https://doi.org/10.1080/1357628031000116899 march 2020, vol. 12, no. 1 ajhpe 6 short research report topping[1] defines peer-assisted learning (pal) as ‘the development of knowledge and skill through active help and support among status equals or matched companions’. pal is often used in the clinical learning environment, where a student works with a fellow student under direct supervision of an appropriately qualified clinician. it is perceived to be a beneficial process and has been described among paramedic, midwifery and nursing students.[2] the educational philosophy of pal includes mutually beneficial learning activities. the concept of pal aims to improve the learning environment through social interaction of students.[2,3] pal partnerships usually comprise two equal partners who both benefit from the experience. consequently, delegation of tasks, decision-making and conflict resolution should be a joint effort without predetermined authority from either partner.[3,4] pal partners should ideally be from similar social groups and should be equal in as many aspects as possible.[1] the peer who provides assistance should not be a professional teacher or expert and it is critical that both parties benefit from the pal experience.[1,2,4-6] pal is perceived to unmask areas of uncertainty, leading to better understanding and deeper learning.[4,5] the peer learner benefits from increased self-confidence and a noted increased motivation to learn, resulting in better performance during examination.[3,6] pal has been shown to improve academic results in clinical examinations and to increase confidence levels in participating students.[4] some areas relevant to the prehospital domain where pal has been particularly effective are clinical skills acquisition, problem-solving, clinical reasoning, critical thinking, professional responsibility and teamwork.[3] a literature search revealed a paucity of literature related to pal in the sa prehospital context. it is necessary to determine opinions and experiences of healthcare professionals related to pal to inform future practice. the objective of this study was to explore the perspectives of sa prehospital emergency care personnel regarding pal. methods study design a cross-sectional, purposive design made use of an online questionnaire to gather data from qualified prehospital emergency care personnel. the sa prehospital emergency care profession is a multi-tiered structure that includes both formal (national qualifications framework (nqf) aligned) and informal (non-nqf aligned) qualifications. this study focused specifically on health professions council of sa (hpcsa)-registered personnel broadly classified as advanced life-support providers. they were on the emergency care technician (ect), paramedic (ant) or emergency care practitioner (ecp) registers of the hpcsa, respectively. the ect register included personnel with a 2-year diploma qualification, and the ant register those with a 3-year national diploma or those who had followed a 9-month critical care assistant course. the ecp register included personnel with either a bachelor’s degree in technology or a bachelor’s degree in health sciences. the decision to use only advanced life-support providers was due to the longer periods of time that they spent in the pal clinical domain during their studies. we elected to use only qualified staff, as they would have had sufficient experience to contextualise pal related background. clinical learning is an important component of health professions training. peer-assisted learning (pal) involves students who work in the clinical learning domain, often with their peers. there is a paucity of literature related to pal in the south african (sa) context. objectives. to explore the perspectives of sa prehospital emergency care personnel regarding pal. methods. a cross-sectional design used a purpose-designed online survey to gather data from qualified prehospital emergency care personnel. participation was invited by emailing persons registered on a privately managed database. the questionnaire was available for 2 months after the initial email had been sent. the questionnaire used likert-type scales to measure participant perceptions of specific aspects related to pal. an open-ended question gathered data on participant perceptions of pal. results. participants recognised pal as a contributor to improved theoretical and practical academic performance, increased confidence, better debriefing and creating a platform for future relationships, both professionally and socially. most participants reported a positive relationship with their pal partners. the presence of a pal partner made participants more comfortable during hostile or unsafe situations. conclusions. pal was positively viewed by participants and the environment created by pal was perceived to enhance learning, debriefing and confidence and to improve theoretical and practical assessment results. we recommend that students are included in the pal partner allocation process. further research should include pal in a larger spread of health professions in the african setting. afr j health professions educ 2020;12(1):6-8. https://doi.org/10.7196/ajhpe.2020.v12i1.5 peer-assisted learning in the prehospital educational setting in south africa l gevers, btech, emc; a makkink, nd msrv, nd emc, btech emc, pdte department of emergency medical care, faculty of health sciences, university of johannesburg, doornfontein campus, johannesburg, south africa corresponding author: a makkink (amakkink@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 7 march 2020, vol. 12, no. 1 ajhpe short research report to their clinical practice. the questionnaire was kept open for 2 months. during this period, 3 reminder emails were sent to persons on the mailing list. after 2 months, the questionnaire was closed and access was no longer possible. instrument data were collected from 50 prehospital emergency care personnel using a purpose-designed questionnaire comprising 18 likert-type questions and a final open-ended question that related to choice of pal partner. likert-type questions used a 3or 4-point scale and were used to measure participant levels of agreement with statements related to pal. the questions aimed to explore participant perceptions of the effect of pal on their academic results and confidence, as well as on clinical debriefing and certain aspects of the clinical environment. further questioning related to participants’ general perceptions of pal and aspects that had the potential to improve pal. an open-ended question allowed participants to express their opinions related to pal in their own words. the online version of the questionnaire was hosted on the sogosurvey (sogosurvey inc, usa; www.sogosurvey.com) online platform. we addressed aspects related to reliability and validity by considering and wording each question in relation to the identified literature. validity was addressed by subjecting the questionnaire to scrutiny by two academic committees. as an additional measure, potential participants were given the opportunity to contact lg. potential participants were invited by email using a privately managed, confidential database of advanced life-support providers that comprised 436 advanced lifesupport personnel whose contact details were not made available to us. the email included an introductory information brief stipulating voluntariness, anonymity of participation and a link to the survey. data were not available that linked numbers of active personnel to numbers of personnel registered in each hpcsa registration category, and could, therefore, not be used to determine a recommended sample size. data were imported into an excel 2016 (version 16) (microsoft, usa) spreadsheet and standard calculations were used to determine frequencies. the responses to the open-ended question were read and reread by both lg and am and analysed using thematic analysis for emerging themes. ethical approval ethical approval for the study was obtained from the university of johannesburg’s faculty of health sciences research ethics committee (ref. no. rec-01-166-2016). results participants submitted 50 questionnaires using the online platform. we were unable to confirm delivery of emails and could therefore not calculate table 1. participant perceptions of peer-assisted learning strongly disagree, % (n) disagree, % (n) agree, % (n) strongly agree, % (n) total, % (n) effect of pal on academic results and confidence pal improved my theoretical assessment performance 2 (1) 18 (9) 58 (29) 22 (11) 100 (50) pal improved my practical assessment performance 2 (1) 26 (13) 52 (26) 20 (10) 100 (50) pal promotes academic discussions and practical learning 4 (2) 22 (11) 52 (26) 22 (11) 100 (50) pal increased my confidence 4 (2) 18 (9) 60 (30) 18 (9) 100 (50) pal gave me more confidence in delegating tasks 8 (4) 10 (5) 64 (32) 18 (9) 100 (50) effect of pal on debriefing and practice i was generally more assertive than my practical partner 4 (2) 30 (15) 42 (21) 24 (12) 100 (50) i found it easy to assume the role of submissive partner when my partner was in charge of a call 10 (5) 26 (13) 54 (27) 10 (5) 100 (50) i found it more comfortable discussing calls and debriefing with my practical partner, as we had the same level of knowledge and competency 2 (1) 22 (11) 36 (18) 40 (20) 100 (50) a practical partner’s presence made me feel more comfortable during potentially hostile and unsafe situations 4 (2) 22 (11) 52 (26) 22 (11) 100 (50) general perceptions pal was a positive experience 2 (1) 10 (5) 58 (29) 30 (15) 100 (50) pal is generally beneficial during clinical training 2 (1) 8 (4) 62 (31) 28 (14) 100 (50) i would advise any student to have a practical partner 2 (1) 14 (7) 58 (29) 26 (13) 100 (50) having a practical partner made clinical practice shifts more enjoyable 2 (1) 8 (4) 50 (25) 40 (20) 100 (50) i had a good relationship with my practical partner 2 (1) 6 (3) 44 (22) 48 (24) 100 (50) pal allows for future professional relationships and even friendships 0 (0) 6 (3) 52 (26) 42 (21) 100 (50) it is best for practical partners to be allocated by the institution 22 (11) 44 (22) 28 (14) 6 (3) 100 (50) very easy, % (n) easy, % (n) difficult, % (n) very difficult, % (n) total, % (n) the transition from working with a practical partner to working alone once qualified 33 (16) 31 (15) 35 (17) 2 (1) 100 (49)* pal = peer-assisted learning. *no response (2%; n=1). march 2020, vol. 12, no. 1 ajhpe 8 short research report a response rate. there were 27 ecp, 17 ant and 4 ect participants who completed the demographics section; 41 (85%) were males and 7 (15%) females. the median age was 32 years and the median working experience was 5 years. partner characteristics most participants (68%; n=34) did not have any gender preference, 28% (n=14) indicated that they preferred a male pal partner and 4% (n=2) preferred a female pal partner. both participants (100%) who preferred a female partner were men and of the 14 who preferred a male partner, 2 (14%) were females and 12 (86%) males. seventy percent (n=35) indicated that they had no preference with regard to the age of their pal partner, 18% (n=9) preferred same-age partners, 8% (n=4) preferred older partners and 4% (n=2) preferred younger partners. results of responses related to the effects of pal on academic results and confidence, debriefing and practice, and general perceptions of pal are depicted in table 1. open-ended responses forty participants (80%) provided answers to the open-ended question. the dominant emerging theme related to topping’s[1] description of pal was as follows: ‘people from similar social groupings who are not professional teachers help each other to learn and learn themselves by teaching.’ ‘someone who is not afraid to speak up and challenge you to become better at your skills.’ ‘a partner must be able to point out your weaknesses and assist in strengthening [them].’ ‘choose someone on the same level. for [example] if you are using taxis choose [someone] who uses taxis.’ ‘someone you have a decent relationship with where trust is either already built or would be easy to [get].’ discussion equality is a critical element of pal.[1,4,5] participants did not indicate a preference for gender or age of pal partners, implying that the perception of equality between pal partners may be independent of age and gender. equality forms the basis of a trust relationship and most participants indicated that they trusted their pal partner. there was general consensus that pal partners should be self-chosen, which linked directly to the similarity and trust characteristics identified as requisites by participants. the perception that pal partners improved the feeling of safety during hostile or unsafe situations reinforced the value of having a pal partner who can be trusted. improved academic performance, cognitive development and psychomotor skills have been linked to pal.[3,7] participants in this study confirmed that pal improved theoretical and practical assessment results. participants indicated that pal was generally a positive and enjoyable experience, which made clinical learning more pleasant, and that it was a potential source of future professional relationships and friendships. this is congruent with mclelland et al.,[4] who showed that the pal environment should facilitate an effective setting for learning and professional development. participants in the current study indicated that pal improved their assertiveness, self-confidence and professional development. they also indicated that they were able to assume a more submissive role when they were not in charge. this too is an important characteristic in the emergency situation, where not everyone can be in charge. these characteristics are associated with a reflection on positive growth and development that pal seeks to encourage.[3] pal directly contributes to improved communication and professional development.[4] debriefing is an important mechanism in professional development, and pal has shown potential to create a safe space in which there may be an improved willingness to share information and for reflection.[2,7] fellow students have been shown to exhibit great sensitivity and empathy with regard to providing feedback to their peers.[8] the participants in this study echoed the view by indicating that they were more comfortable discussing cases and debriefing with their pal partners than they were with other practitioners, suggesting that pal partners may serve as an important source of debriefing. this could include feelings and emotions that are uncomfortable to discuss with their clinical supervisor. conclusions pal was viewed positively by participants. the environment created by pal was perceived to enhance learning, debriefing and confidence and to improve theoretical and practical assessment results. we recommend that students are included in the pal partner allocation process. further research should include pal in a larger spread of health professions in the african setting. declaration. none. acknowledgements. we would like to acknowledge the participants in this study. author contributions. lg and am were responsible for conceptualisation of the study and compilation of the questionnaire. lg co-ordinated data collection, supervised by am. lg and am analysed the data, and drafted and revised the manuscript. funding. none. conflicts of interest. none 1. topping kj. the effectiveness of peer tutoring in further and higher education: a typology and review of the literature. high educ 1996;32(3):321-45. 2. williams b, reddy p. does peer-assisted learning improve academic performance? a scoping review. nurse educ today 2016;42:23-29. https://doi.org/10.1016/j.nedt.2016.03.024 3. williams b, fellows h, eastwood k, wallis j. peer teaching experiences of final year paramedic students: 2011 2012. j peer learn 2014;7(7):81-91. 4. mclelland g, mckenna l, french j. crossing professional barriers with peer-assisted learning: undergraduate midwifery students teaching undergraduate paramedic students. nurse educ today 2013;33:724-728. https://doi. org/10.1016/j.nedt.2012.10.016 5. williams b, mckenna l, french j, dousek s. measurement properties of a peer-teaching scale for nursing education. nurs heal sci 2013;15(3):368-373. https://doi.org/10.1111/nhs.12040 6. williams b, olaussen a, peterson el. peer-assisted teaching: an interventional study. nurse educ pract 2015;15(4):293-298. https://doi.org/10.1016/j.nepr.2015.03.008 7. goldsmith m, stewart l, ferguson l. peer learning partnership: an innovative strategy to enhance skill acquisition in nursing students. nurse educ today 2006;26(2):123-130. https://doi.org/10.1016/j.nedt.2005.08.001 8. asghar a. reciprocal peer coaching and its use as a formative assessment strategy for first-year students. assess eval high educ 2010;35(4):403-417. https://doi.org/10.1080/02602930902862834 accepted 3 october 2019. https://doi.org/10.1016/j.nedt.2016.03.024 https://doi.org/10.1016/j.nedt.2012.10.016 https://doi.org/10.1016/j.nedt.2012.10.016 https://doi.org/10.1111/nhs.12040 https://doi.org/10.1016/j.nepr.2015.03.008 https://doi.org/10.1016/j.nedt.2005.08.001 https://doi.org/10.1080/02602930902862834 june 2019, vol. 11, no. 2 ajhpe 63 research being a health advocate has been identified by the health professions council of south africa (hpcsa) as one of the outcome competencies for the undergraduate medical curriculum.[1] this echoes similar calls throughout the world for health professionals to have a role in health advocacy.[2-4] advocacy and activism it is not new to view healthcare professionals – doctors in particular – as advocates. in the late 1800s rudolf virchow, the father of social medicine, famously said that the physician is the ‘natural advocate for the poor’.[5] in the sa context, there is also a strong tradition of healthcare practitioners being advocates and activists, such as steve biko and neil agget, who both died in custody during the apartheid regime for their stand against injustice. a number of health professions bodies and the medical school at the university of kwazulu-natal (ukzn) have a long history of anti-apartheid activism[9] and count many activists among their alumni, such as dr biko mentioned above. the politics of resistance to apartheid among students and faculty from many health professions programmes profoundly shaped the higher education terrain beyond universities. in the late 1990s, the treatment action campaign (tac) started to organise itself in response to the poor handling of the hiv pandemic in southern africa. this profoundly altered healthcare advocacy and activism, where communities and those affected by the failures of the state were at the forefront of fighting for the fulfilment of the constitutional right to healthcare provision.[6] it has been argued that the advocacy role of tac in response to the state’s failure to provide free antiretroviral treatment to all who need it in sa, was critical in the change in policies that ultimately led to significant decreased mortality.[7] in the process, tac also challenged the paternalistic attitude of many healthcare professionals as the custodians of knowledge and who, with notable exceptions, were not inclined to engage in such advocacy.[6,8] the recent groundswell of student activism demanding a critical reappraisal and decolonisation of higher education as part of the #rhodesmustfall and #feesmustfall movements, are reshaping the sphere of higher education.[11,12] therefore, advocacy per se is not a foreign concept for staff and students at universities in sa. advocacy and health advocacy in health professions education there has been limited discourse regarding advocacy.[4] the dearth of literature – locally and internationally – shows that little is being done and, with exceptions, only few institutions seem to have included advocacy as part of a transformative curricular imperative in the undergraduate curriculum. in most health professions programmes, background. health advocacy has been identified as a key outcome competency in the undergraduate curriculum for a number of health professions by the health professions council of south africa (hpcsa) and the university of kwazulu-natal (ukzn), durban, sa. despite health advocacy and activism playing a strong role in the student body and civil society, there has been only limited engagement with the manner in which to teach health advocacy in the health professions literature. objectives. to assess how the faculty in health professions programmes at ukzn understood health advocacy and how it was covered in the curriculum. methods. focus group discussions were held with faculty from undergraduate health professions programmes at the university regarding how health advocacy was understood and how it was being integrated into the current curriculum. a thematic analysis was performed on the transcripts of the focus groups. results. a range of ways in which health advocacy was understood became apparent in the focus groups, with a few disciplines indicating that they do not cover health advocacy explicitly in the curriculum. three main focus areas of health advocacy training were identified: for the profession (particularly in the smaller health professions groups); for services within the health system; and for patients or communities. the main points of departure for health advocacy were ethics and human rights and to a much lesser degree social justice. there was generally limited experience of how health advocacy could be taught as a skill and little consensus between the participating disciplines regarding the scope and content of health advocacy training. advocacy itself was also seen as potentially risky, which could undermine the relationship between the university and the service platform. similarly, the potential risk to whistle-blowers and the institutional culture in universities and public sector services were also seen as limitations. conclusions. ample opportunities were identified for the potential teaching of health advocacy in complex professional and public sector interactions. dual loyalty was seen to be a key dilemma for how to approach advocacy as part of work-based learning, and linked to considerable risk to the institution, educators and students. the current review offers an exciting opportunity to define more clearly what the outcome competencies of health advocacy are, particularly in the context of transformative health professions education – and how these can be operationalised in the overall curriculum. afr j health professions educ 2019;11(2):63-67. doi:10.7196/ajhpe.2019.v11i2.1042 advocacy: are we teaching it? b gaede,1 mb bch, mmed (fam med), phd; p pillay,2 mb bch, msc 1 department of family medicine, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 rural health advocacy project, university of the witwatersrand, johannesburg, south africa corresponding author: b gaede (gaedeb@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 64 june 2019, vol. 11, no. 2 ajhpe research much of health advocacy is subsumed in a limited way by health promotion or ethics, with references to a human rights framework or health rights.[4,13,14] however, advocacy as a competency seems to have received much less attention.[4] there appears to be tension regarding whether the emphasis is on health in health advocacy. yet, the post-apartheid discourse of higher education envisages a more engaged, appropriate graduate emerging out of higher education, who is able to transform society. it requires a move from instrumentalist education (giving skills and knowledge) to a more critical engagement with students who demonstrate agency for the improvement of patients, communities, the healthcare system – and for the country.[10] it is an opportune moment to explore teaching advocacy as part of health advocacy – and to foreground not only the issues around privilege and inequity that are raised, but also contextualise advocacy in itself as a skill and competency in health professions education. at ukzn, a competency framework was adopted that included health advocacy for all health professions programmes at the university. the purpose of the research, therefore, was to explore how the faculty understood advocacy in health professions education and how it was evident as an outcome competency of health advocacy (as required by the hpcsa[1]) for health professions education. its objectives were to: (i) describe the conceptualisation of health advocacy in health professions education at ukzn; (ii) explore how health advocacy was being taught in health professions education at ukzn; and (iii) identify opportunities for teaching health advocacy in health professions programmes at ukzn. methods this exploratory study in phenomenological tradition used qualitative methods to gather data on the manner in which advocacy was understood and taught in health professions education at ukzn. data were gathered through focus group discussions. all faculty involved in undergraduate health professions education programmes offered at ukzn were invited to participate in the discussions to ensure broad representivity in terms of experience, professional discipline and background. the participating faculty included lecturers, module co-ordinators and programme co-ordinators from the programmes involved. following a rigorous discussion regarding participation and anonymity, everyone who responded to the invitation to the study participated, and there were no withdrawals. the seven focus groups were constituted around the following undergraduate professional degrees offered (listed alphabetically): • nursing (n=9) • medicine (n=7) • occupational therapy (n=7) • optometry (n=3) • pharmacy (n=3) • physiotherapy (n=5) • speech and language pathology (n=3). informed consent was obtained from all participants before the focus group discussions. these discussions lasted between 33 minutes and 1 hour and 21 minutes and comprised between 3 and 9 participants. box 1 outlines the questions that guided the discussions. ethical approval the study was part of a larger study to explore the current status of a number of competencies, as well as transformation in the curriculum, for which ethical approval was obtained from the ukzn humanities and social sciences research ethics committee (ref. no. hss/0208/013). as mentioned, in the engagement with participants, considerable discussion took place regarding participation and anonymity. based on this, we do not report on discipline-specific findings. analysis the focus group discussions were audio-recorded and transcribed. an inductive analytical strategy was employed, using a pragmatic approach.[15] after re-reading and familiarisation with the material, a manual coding process was followed with codes, categories and themes that were independently identified by the 2 researchers. through an iterative process, the themes were then compared, reordered and reviewed until consensus was reached regarding the codes, nodes and themes. positionality of the researchers the focus group discussions were conducted by both authors – bg as an insider who has been active in health professions education practice and research at ukzn, and pp as an external researcher with a particular interest in health advocacy and the introduction of advocacy into the undergraduate curriculum of health professions education. study limitations because of logistical reasons, not all health professions programmes and module co-ordinators were represented as part of the data collection. the data presented therefore need to be appraised with this limitation in mind. also, while all faculty was invited, a number of faculty with a heavy service load and who were based in remote settings, were much less likely to participate owing to service delivery pressures and distances to travel. the study also only explored perceptions of educators and the espoused curriculum, rather than reviewing the formal curriculum, the taught curriculum or the hidden curriculum. participation was voluntary and it box 1. guide for focus group discussion the following elements of advocacy were discussed in the focus groups: • how would you define the concept of advocacy in health professions education? • how do you teach health advocacy as a competency? • what context do you teach that prepares students for gaining the competency? • what content is taught? • how would you ensure a critical reflection as an enabling competency? • how would assess that students know and apply this knowledge? • how is the content of course material validated and by whom? • what is the value placed on advocacy as a skill by you and the university? • is it linked with the reputation of the university? • what protection is afforded to those who do speak out against patient rights violations? • is there a license to innovate going forward? june 2019, vol. 11, no. 2 ajhpe 65 research is likely that motivated and engaged staff participated in the discussions. furthermore, the study was cross-sectional – not longitudinal – and therefore changes or implementation of intentions over time have not been reviewed. our positionality introduces a desirability bias, given the focus of the study and the known interest that both researchers have in advocacy in health professions education. results from the outset of the focus group discussions, participants indicated that they had a limited understanding of the concept of advocacy per se, but a broad definition of ‘championing a just cause’ (fg4, fg7) was central to how advocacy was seen. health advocacy was loosely associated with health promotion and, while seen to be desirable and important, participants noted that out of the competency framework that the university had adopted, health advocacy as a field was relatively poorly described and advocacy as a competency in particular was not well understood: ‘i must be honest, we have not really thought about it.’ (fg1) participants described their approach to health advocacy largely structured around what one would advocate for – and out of the data 3 particular focus areas of advocacy emerged: • advocacy for the profession • advocacy for a particular service (within the health system) • advocacy for individual patients or communities. one participant also indicated the need to advocate for students, particularly students in need. the construct of the 3 (or 4) areas to focus the advocacy on was a strong node emerging from the analysis. yet, among the professions, there was considerable variability in which the abovementioned components were identified or foregrounded: ‘we are a cinderella discipline – we are new and small and someone needs to stand up for us.’ (fg3) ‘[a]nd in this context we have to advocate for the expansion of [child health] services.’ (fg7) ‘we have no voice in the university … .’ (fg2) advocacy was understood as giving a voice to someone who does not have the status or capacity to speak out for themselves. the sense of being relatively small and not such a well-established profession as the larger professions further underscored the perceived need and voicelessness of being advocates for their profession. it also reflected on the privileging of medicine in the university and among health professions from focus groups other than medicine: ‘we know, even if we do advocate for ourselves, we will not be listened to.’ (fg5) in this focus group in particular (fg5), the sense of not having a voice related to a sense of powerlessness within their profession and recognition by other disciplines: ‘a lot of the time the students comment on their inability to advocate because they are in a position of no power.’ (fg5) ‘i don’t think we produce a graduate who has the courage and inner power to take on advocacy.’ (fg5) advocacy was seen to be very difficult to teach because the profession was not valued and felt undermined. in the focus group, this was contextualised within the university structures and in the broader healthcare system. it clearly influenced the way the role of a health advocate would be taught within that particular programme. the participants pointed to their unfamiliarity and limited understanding of both the context and content in teaching advocacy and health advocacy. the context of social inequities, such as the high rate of poverty or the rural or urban differences in sa, was strongly referenced among the participants, yet broadly positioned within professional frameworks, e.g. disabi lity, occupation, the healthcare system and human rights. the idea of social justice was implied and not central to how health advocacy was conceptualised. between the health professions, however, there was considerable variability: ‘in the community-based block, the students need to confront the issues of social justice as part of how we teach primary healthcare.’ (fg5) ‘there is a theory regarding access to occupation being necessary for well-being and meaning and there are concepts of justice and deprivation how the lack of occupation is understood … and that is being taught.’ (fg7) in terms of curricular content of health advocacy, the participants viewed health promotion, ethics and rights-based approaches as covering health advocacy topics. besides the requirements for curriculum accreditation by professional boards, there was also limited external validation of the content (e.g. by community boards, input from pressure groups or peer review). furthermore, generally the participants were unsure regarding how advocacy as a skill could be taught. critical reflection was a key skill that was identified in health professions education, even if its use was very limited, specifically in relation to teaching advocacy. there were exceptions: in the undergraduate programme of a particular discipline extensive integration of advocacy and health advocacy concepts across modules and years of study was evident. while not explicitly named as an outcome competency (and therefore reflecting on curricular design), the discipline had developed both content and processes to impart skills in advocacy linked to explicit health issues. yet, even in this profession, it was unclear how advocacy as a skill could be assessed: ‘the way we work, [advocacy] has to be in everything that we teach. how can the students cope out there, if they are not prepared to take up the issues while they are at varsity?’ (fg7) ‘when we assess the student, the advocacy has to be there, it has to be evident in their presentation, as this is the key purpose of this module.’ (fg7) this approach was strongly contrasted to the perceived standing advocacy had within the university and that advocacy among staff and students was not linked to the institution’s reputation. despite priding itself for having prominent figures in advocacy and politics, this was not perceived as ‘valued’: ‘advocacy is not valued. there is some lip-service in the strategic plan, but it is clear what is important for the university. we are rewarded for research output, that’s it – and not for community engagement and specifically not for advocacy.’ (fg3) 66 june 2019, vol. 11, no. 2 ajhpe research advocacy and whistle-blowing was similarly seen as not important and, quite the opposite, being risky for students and staff. there was considerable concern regarding a sense of vulnerability when speaking out – both within the university and in the context of clinical teaching sites that were accessed on the service delivery platform. confidentiality and possible victimisation were cited as major barriers to speaking out. whistle-blowing and advocacy around poor services at the clinical teaching sites were seen to threaten the relationship between the university and the service platform: if a student reported abuse or poor services at a particular clinical teaching site, university faculty were concerned that the availability of the service platform would be withdrawn: ‘there are certain sites that we know where there are some serious problems particularly with work ethic … but if you are caught in between getting complaints about this site and what do you do? they can just turn around and say that they will not take any more students.’ (fg7) it points to a fragile relationship to the services platform that is currently maintained by personal relationships and goodwill: ‘i think, if advocacy is important, we will need to give it a whole lot more thought. how do we teach it and what are we expecting the students to know and do at the end, how do we assess it and how do we know that it has been taught well.’ (fg2) box 2 gives a summary of the key findings. discussion the exploration of health advocacy in the curriculum of health professions education needs to be placed in the context of current discourses that shape future directions, including social accountability of medical schools,[16] community-based education[17] and inter-professional education and collaborative practice. in particular, the move towards transformative learning[10,18] is critical in the manner in which health advocacy is approached and developed further in the curriculum of the health professions. the data point to both informative and formative elements in how health advocacy is currently being conceptualised. advocacy as a competency is to a much smaller degree part of transformative health professions education. whether the focus of transformative learning is primarily internal and a personal engagement,[19] or social action and focused on social justice in freire’s tradition,[20] these approaches assume a higher degree of agency than a traditional curriculum aims for.[21] yet, the results indicate that health advocacy is underpinned by limited theory, content and context, and, with a few exceptions, there is limited detailed understanding of advocacy as a skill. the limitations are evident in scope and depth to support the development of the healthcare professional as a change agent or global citizen, as described in the literature.[21,22] however, data confirm that there are ample opportunities to focus on health advocacy, which are not fully utilised. the significant amount of critical reflection and service-teaching engagements in authentic settings is already evident in the curriculum, which can create a context for possible engagement with health advocacy. in this context, it would be possible to advance health advocacy as a therapeutic tool. as an example, as a medical student is expected to expertly diagnose (as part of the therapeutic process), the student would also be expected to competently raise concerns regarding access to care to ensure that a patient is optimally treated (as part of the therapeutic process). the participants very seldom viewed privilege and inequity as problems – the focus on the need to advocate and advance the profession outweighed engaging with the lived realities of marginalised groups. graduating from university with a professional degree places the student in a privileged position in society, but this did not surface as a point of engagement around advocacy and the promotion of social justice. are we providing skills and capacity to engage with this privileging in a constructive and socially accountable manner? this may be an important avenue to engage in the discourse around decolonising the curriculum, as mentioned above.[11] a concerning finding reveals the fragile nature of the relationship building between communities, service providers and health professionals. advocating for patients was perceived to potentially threaten relationships between service platform and placement of students; consequently, a higher level of inappropriate behaviour by service staff was tolerated and not reported. it became clear that dual loyalty is one of the most difficult dilemmas. the perception that whistle-blowers are not adequately protected and that within the university and the department of health there was not a strong tradition of speaking out, further deepens the dilemma. understanding the tools and legislation to use when advocating (e.g. the public service act[23]), is the key to know how to navigate the dual loyalty. therefore, a concern arising around teaching health advocacy related to how authentic the environmental context could make any formal teaching of advocacy as a skill. if it is perceived (and the perception re-enforced by the faculty) to be difficult to speak out within the organisation, any teaching of advocacy would be perceived to be either superficial lip-service to the idea or subversive and risky. the new hpcsa competency framework[1] offers an opportunity to innovatively link transformative health professions education to being a health advocate that focuses on social injustice. universities can create health professionals who are able to have an impact on the health outcomes of patients and communities and produce health advocates as change agents. it can have an additional advantage, i.e. helping to bridge the gap between disciplines if they can conceptualise a common understanding of it. the lack of alignment of the university’s reputation to advocacy for social justice is an important part of the context that needs to be considered in box 2. key findings • considerable variability between health professions with regard to understanding, teaching and assessing key concepts and characterisation of advocacy • three key themes emerged of how advocacy was understood • for the profession • for patients and communities • for the health system overall • educators feel poorly equipped or capacitated but nevertheless request capacity development for teaching advocacy • the university’s value for social justice is not well communicated and connected to advocacy training • advocacy was perceived to potentially threaten the relationship between service platform and placement of students • there was little perceived protection for those who do speak out (students and educators) june 2019, vol. 11, no. 2 ajhpe 67 research curriculum design. accompanying research focus led by the university with an equal focus on social justice (as they are not antagonistic or mutually exclusive) would be a helpful signal to staff and students. yet, the culture of the university cannot be divorced from those who teach and those who learn. in this context, the fear of speaking out or whistle-blowing and a sense of ‘voicelessness’ among the professions are of deep concern, as it shapes the hidden curriculum around agency and advocacy in profound ways. it is critical for it to be addressed in line with organisational accountability and transformation. conclusions with some exceptions, being a health advocate has not been well defined in terms of skills and outcomes in the curriculum of health professions education programmes at ukzn. this review offers an exciting opportunity to define more clearly what the outcome competencies of health advocacy are, particularly in the context of transformative health professions education, and how these can be operationalised in the overall curriculum. this would align the university in a profound way with its mission of relevance and social accountability. declaration. none. acknowledgements. the authors would like to acknowledge prof. sabiha essack for her leadership in the overall competencies project and the rural health advocacy project for their support and focus on health advocacy in particular. author contributions. bg and pp jointly participated in collection and analysis of data, and drafting and finalising the manuscript. funding. the research was in part financially supported by the rural health advocacy project. conflicts of interest. none. 1. health professions council of south africa. core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2014. 2. royal college of physicians and surgeons of canada. canmeds physician competency framework. 2005. http://www.ub.edu/medicina_unitateducaciomedica/documentos/canmeds.pdf (accessed 7 may 2019). 3. gruen r. evidence-based advocacy: the public roles of health care professionals. med j austr 2008;188(12):684685. https://doi.org/10.5694/j.1326-5377.2008.tb01843.x 4. mu l, shroff f, dharamsi s. inspiring health advocacy in family medicine: a qualitative study. educ health 2011;24(1):534. 5. anderson m. what is social medicine? social med portal 2008. http://www.socialmedicine.org/2008/03/23/ about/what-is-social-medicine/ (accessed 12 march 2019). 6. hassim a, heywood m, berger n, eds. health and democracy: a guide to human rights, health law and policy in post-apartheid south africa. cape town: siber ink, 2008. 7. nunn a, dickman s, natrass n, cornwall a, gruskin s. the impacts of aids movements on the policy responses to hiv/aids in brazil and south africa: a comparative analysis. glob publ health 2012;7(10):1031-1044. https://doi.org/10.1080/17441692.2012.736681 8. rural health advocacy project. voice – a health care provider’s guide to reporting healthcare challenges: principles, tools and strategies. 2014. http://www.rhap.org.za/voice-project-manual/ (accessed 12 march 2019). 9. noble v. a school of struggle: durban’s medical school and the education of black doctors in south africa. durban: university of kwazulu-natal press, 2013. 10. waghid y. the public role of the university reconsidered. perspect educ 2008;26(1):19-24. 11. pillay m, kathard h. decolonizing health professionals’ education: audiology and speech therapy in south africa. afr j rhet 2015;7(1):193-227. 12. jansen j. as by fire – the end of the south african university. tafelberg: cape town, 2017. 13. mann jm, gostin l, gruskin s, brennan t, lazzarini z, fineberg hv. health and human rights. health hum rights 1994;1(1):6-23. 14. london l. what is a human rights-based approach to health and does it matter? health hum rights 2008;10(1):65-80. https://doi.org/10.2307/20460088 15. saldana j. the coding manual for qualitative researchers. los angeles: sage, 2015. 16. woolard rf. caring for a common future: medical schools’ social accountability. med educ 2006;40(4):301-313. https://doi.org/10.1111/j.1365-2929.2006.02416.x 17. worley p. integrity: the key to quality in community-based medical education? educ health 2002;15(2):129-138. https://doi.org/10.1080/13576280210133053 18. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. https://doi.org/10.1016/s01406736 (10)61854-5 19. mezirow j. transformative learning: theory and practice. new direct adult contin educ 1997;74:5-12. https:// doi.org/10.1002/ace.7401 20. freire p. pedagogy of the oppressed. new york: continuum, 1996. 21. hanson l. global citizenship, global health and the internationalization of curriculum: a study of transformative potential. j stud int educ 2010;14(1):70-88. https://doi.org/10.1177%2f1028315308323207 22. freudenberg n. public health advocacy to change corporate practices: implication for health education practice and research. health educ behav 2005;32(3):298-319. https://doi.org/10.1177%2f1090198105275044 23. republic of south africa. the public service act no. 103 of 1994. accepted 7 march 2019. http://www.ub.edu/medicina_unitateducaciomedica/documentos/canmeds.pdf http://www.socialmedicine.org/2008/03/23/about/what-is-social-medicine/ http://www.socialmedicine.org/2008/03/23/about/what-is-social-medicine/ https://doi.org/10.1111/j.1365-2929.2006.02416.x https://doi.org/10.1080/13576280210133053 https://doi.org/10.1016/s0140-6736--(10)61854-5 https://doi.org/10.1016/s0140-6736--(10)61854-5 https://doi.org/10.1002/ace.7401 https://doi.org/10.1002/ace.7401 september 2019, vol. 11, no. 3 ajhpe 83 research assessment helps to determine the impact of the educational experience on students’ learning. clinical assessment decisions are informed by the practice of assessors who typically have no formal training in assessment.[1] formal training in the theory and practice of education, including assessment, remains a rarity among the routine requirements for appointment to a clinical or academic position that typically includes teaching and assessment responsibilities in undergraduate or postgraduate medical degree programmes.[2,3] the requisite knowledge and skills are largely acquired on the job.[4,5] an unavoidable feature of this education model is that levels of knowledge and expertise among medical educators responsible for conducting assessment processes vary widely.[6,7] gaining insight into clinicians’ assessment expertise and practices is therefore essential to understand the decisions made about students’ competencies. notwithstanding the steady expansion of knowledge regarding assessment methods and best practices, little attention is devoted to educators who are responsible for assessment activities in medical training programmes. those involved in assessment not only develop and engage in assessment processes, influencing the quality of data available for decision-making, but also use those data to make strategic decisions about performance, i.e. pass/ fail decisions. given this responsibility, it seems reasonable to assume that medical educators should have pertinent knowledge and skills to inform their assessment practices. while the published literature provides assessors with a plethora of information regarding specific assessment methods, such as the observed structured clinical examination (osce) or multiple-choice questions (mcqs),[8-10] few empirical studies provide guidance on the competencies required of assessors in medical education.[11,12] clinician educators (ces) involved in medical education assessment are often university-employed academic staff with academic and clinical teaching responsibilities, as well as clinical staff who have a joint health service and university appointment (referred to as joint appointments). in our context, this latter group has a dual role as clinicians (70% of the time) and educators/researchers (30% of the time). these clinical staff work in a range of healthcare settings such as hospitals, community health centres and primary healthcare clinics. assessment responsibility devolves to and rests with both academic and clinician educators. an unavoidable feature of this model is the variable levels of expertise and involvement in assessment processes. these variations among clinicians and academics with their varying levels of involvement and challenging workloads are compounded by competing interests, personal experiences and beliefs about assessment, all of which influence assessment practices.[13] background. medical students in their clinical years are assessed by clinician educators (ces) with different levels of involvement and responsibilities in the assessment process. objective. to obtain a better understanding from ces of their involvement in assessment activities in the clinical years of a medical degree programme, their self-reported knowledge of assessment and methods of learning about assessment. this study also explored the potential association between involvement in assessment activities, self-reported knowledge of assessment and employment profile. methods. an online cross-sectional survey was conducted among ces involved in assessment of an undergraduate medical programme (years 4 6) at a south african university. results. fifty-four ces were contacted and 30 responses (56%) were received. assessment responsibilities included design of assessment instruments, participation in assessment activities and quality assurance of assessments. the top five assessment activities that ces were involved in were conducting objective structured practical examinations (ospes)/objective structured clinical examinations  (osces), designing multiple-choice questions, being a clinical examiner, conducting portfolio-based oral examinations and marking written assessments. ces (≥80%) reported having some knowledge of formative and summative assessment, and of validity and reliability. fewer ces reported knowledge of constructive alignment, standard setting, item analysis and blueprinting. ces acquired knowledge of assessment predominantly through informal methods such as practical experience and informal discussion rather than through formal education processes such as attending courses. conclusions. ces participated extensively in assessment, but their knowledge with regard to assessment concepts varied. afr j health professions educ 2019;11(3):83-87. https://doi.org/10.7196/ajhpe.2019.v11i3.1129 involvement, self-reported knowledge and ways in which clinicians learn about assessment in the clinical years of a medical curriculum l pienaar,1 bsc (physiotherapy), msc (physiotherapy); l wolvaardt,2 bcur, mph, phd; f cilliers,1 mb chb, hons bsc (med sc) (med biochem), mphil (higher education), phd; v burch,3 mb chb, mmed, phd, fcp (sa), frcp (london) 1 department of health sciences education, faculty of health sciences, university of cape town, south africa 2 school of health systems and public health, faculty of health sciences, university of pretoria, south africa 3 department of medicine, faculty of health sciences, university of cape town, south africa corresponding author: l pienaar (lunelle.pienaar@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 84 september 2019, vol. 11, no. 3 ajhpe research while there have been calls for a more formalised approach to developing the competence of medical educators with regard to assessment,[12,14] there are few formal descriptions of the competencies required,[7,15,16] the levels of knowledge[6,7] or where or how medical educators gain the knowledge required to meet these obligations.[17,18] furthermore, expectations and involvement may vary at both departmental and institutional levels. therefore, a one-size-fits-all faculty development programme for assessment would be predicated on the flawed belief that educators (university academic and hospital-based clinician) assessing students have equivalent roles, responsibilities and expertise in assessment. the purpose of this study was therefore to obtain a better understanding from ces of their involvement in assessment activities in the clinical years of a medical degree programme, and their self-reported knowledge and methods of learning about assessment. the study also explored the potential association between involvement in assessment activities, self-reported knowledge of assessment and employment profile (university academic or hospital-based clinician). methods study design a cross-sectional observational study of all clinicians teaching in years 4 6 of a 6-year programme at a south african (sa) medical school was conducted using a self-designed questionnaire. a cross-sectional design was chosen, as it is a cost-efficient method to collect data at a point in time about clinician educators’ knowledge of and involvement in assessment.[19] participants participants included medically trained staff employed by either the university or a university-affiliated teaching hospital. those involved for ˂ 1 year within the university or the healthcare system were excluded, as they were deemed to have had inadequate exposure to assessment processes. survey instrument a questionnaire was developed based on a review of the literature and feedback from interviews held with 4 clinicians with an educational background and/or qualification. the questionnaire captured the demographic details of participants, their responsibilities in assessment processes, self-reported knowledge of assessment concepts using a 3-point scale categorised as ‘i can explain this to somebody’, ‘i have heard about it’ or ‘i have never heard of it’, and ways in which ces learnt about assessment. the questionnaire was piloted with 2 ces who were not participants in the study. study procedure the study was conducted as an anonymous online questionnaire using surveymonkey software (surveymonkey, usa). the questionnaire was accompanied by an introductory explanatory email, and the initial invitation was followed by 2 further calls for participation by the year and course convenors, who are responsible for the organisation of assessment activities at the institution. analysis respondents were allocated an alpha-numeric code prior to the data being exported to an excel (microsoft, usa) spreadsheet. a global ‘knowledge score’ was generated during analysis. participants who recorded a positive response (‘i can explain this to somebody’ and/or ‘i have heard about it’) to ≥5 of the 8 terms used to assess knowledge were considered to be ‘assessment aware’. descriptive and inferential statistical analysis was performed using stata 13.1 (statacorp, usa). all responses were used in the analysis, and where answers were omitted these were recorded as missing values. associations between categorical variables were determined using fisher’s exact test. a p-value of ˂0.05 was considered statistically significant. ethical approval the study was approved by the university of cape town’s faculty of health sciences ethics committee (ref. no. hrec ref: 201/2014). consent was obtained from all participants and participation was voluntary. results work profile of clinician educators of the 54 ces invited to participate in the study, 30 completed the survey (56% response rate). most of the ces were medical doctors (83%; n=25) with a postgraduate qualification (93%; n=28) and >5 years of teaching experience (77%; n=23) (table 1). a similar proportion of staff were university employed (50%; n=15) or joint appointments (43%; n=13) (table 1). of those who completed the survey (n=30), a small number did not indicate their employment status (7%; n=2); these values were recorded as being missing (table 1). more than half of the participants (57%; n=17) devoted up to 40% of their weekly working time to educational activities at their place of employment, and 57% (n=17) were also external examiners at other sa medical schools. furthermore, almost half participated in national specialist licensing examinations conducted by the colleges of medicine of sa (47%; n=14). while participants contributed to assessment events across the clinical years of the programme (years 4 6), almost all (83%; n=25) were involved in the assessment of final-year medical students (year 6). involvement of clinical educators in assessment activities ces were involved across a range of assessment activities; the median number of activities was 7 (range 2 13). approximately half were involved in design activities, more than half in conducting examinations and fewer than half in quality-assurance activities (table 2). the top 5 assessment activities that ces were involved in were conducting objective structured practical examinations (ospes)/osces (90%; n=27), designing mcqs (70%; n=21), being a clinical examiner (70%; n=21), conducting portfoliobased oral examinations (67%; n=20) and marking written assessments (67%; n=20). of note, half were involved in administrative tasks related to assessment activities. clinician educators’ self-reported understanding of assessment terminology respondents’ self-reported understanding of 8 terms frequently used in the assessment literature is shown in table 3. more than half of the respondents considered themselves as either being able to explain the term or having heard about all of the terms. specifically, ≥80% were conversant with formative assessment, summative assessment, validity and reliability. fewer september 2019, vol. 11, no. 3 ajhpe 85 research respondents considered themselves knowing concepts describing quality assurance of assessment practices, specifically item analysis, standard setting, blueprinting and constructive alignment. ways clinician educators learnt about assessment ces learnt about assessment in a number of ways (median 7 (range 2 10)). table 4 shows that ces were more likely to have learnt of assessment through table 1. work profile of clinician educators profile profile details respondents, n (%) teaching experience, years (n=29) (missing (n=1; 3%)) 1 5 6 (20 ) 6 10 14 (47) >10 9 (30) first qualification (n=30) medical doctor 25 (83) other healthcare professional* 5 (17) postgraduate qualification (n=30) yes† 28 (93) no 2 (7) employment profile (n=28) (missing (n= 2; 7%)) university 15 (50) full-time 11 (37) part-time (20 25 h/wk) 4 (13) clinical staff with joint appointment 13 (43) time spent on educational activities per week, % (n=30) ˂20 12 (40) 20 39 5 (17) 40 59 5 (17) 60 79 2 (7) 80 100 6 (19) year of study with assessment responsibilities (n=30) 4 15 (50) 5 16 (53) 6 25 (83) external examiner (n=30) undergraduate and/or postgraduate 17 (57) national postgraduate licensing examinations 14 (47) *epidemiologist, pharmacist, professional nurse, scientist, social worker. †only 1 was education related, the remaining 27 were all clinical qualifications, of which a fellowship of the colleges of medicine of south africa was the most commonly reported (n=17). table 2. participation of clinician educators in assessment activities assessment activities participating, n (%) not participating, n (%) missing, n (%) design of assessment instruments mcqs 21 (70) 9 (30) 0 (0) osces 14 (47) 16 (53) 0 (0) rubrics 12 (40) 15 (50) 3 (10) saqs 7 (23) 23 (77) 0 (0) participation in assessment activities conducting osces/ospes 27 (90) 1 (3) 2 (7) clinical examiner (patient presentations) 21 (70) 9 (30) 0 (0) portfolio-based oral examinations 20 (67) 10 (33) 0 (0) marking written assessments (saqs, projects, case reports) 20 (67) 10 (33) 0 (0) examination administration (arranging timetables, venues, rosters) 15 (50) 12 (40) 3 (10) oral examinations 12 (40) 18 (60) 0 (0) projects 7 (23) 23 (77) 0 (0) quality-assurance of assessment reviewing questions 16 (53) 11 (37) 3 (10) standard setting 11 (37) 16 (53) 3 (10%) blueprinting 10 (33) 16 (53) 4 (14) examiner training 7 (23) 20 (67) 3 (10) mcqs = multiple-choice questions; osces = objective structured clinical examinations; saqs = short-answer questions; ospes = objective structured practical examinations. 86 september 2019, vol. 11, no. 3 ajhpe research workplace-based learning, such as practical experience and peer-learning activities, e.g. informal discussions and departmental meetings. internetbased learning and formal courses on assessment were less common methods of learning. relationship between being assessment aware, employment profile and assessment activities seventy percent of ces were regarded as assessment aware on the basis of self-reported knowledge of ≥5 assessment terms used in this study. there was no statistically significant association between being assessment aware and employment profile (p=0.555). similarly, no statistically significant relationship was demonstrated between being assessment aware and involvement in assessment activities listed in table 2. discussion this study provided a better understanding of ces' involvement in assessment activities in the clinical years of a sa medical degree programme, self-reported knowledge of assessment and most common methods of learning about assessment. to date, these topics, which are critical to designing bespoke faculty development initiatives for this niche group of health professions educators, have not been widely discussed in the assessment literature.[20,21] almost half of respondents were jointly appointed staff in fulltime clinical practice. this is consistent with reports in the literature, which highlight that health service employees make a significant contribution to medical education, particularly in resource-constrained settings.[22] despite their significant health service commitments, the respondents were an experienced group of assessors, with involvement at local, inter-institutional and national level. they engaged in a broad range of assessment activities, predominantly focusing on grading processes, i.e. development of assessment instruments and appraisal of student performance. a much smaller proportion of ces were involved in quality-assurance activities, including blueprinting, standard setting and examiner training, a shortcoming that needs to be addressed when identified.[23] this pattern of involvement may reflect a bias of clinical expertise rather than educational expertise, which appears to be a key determinant when inviting examiners to participate in clinically related examinations. it is worth noting that half of ces were involved in administration tasks related to assessment events. this is of particular concern because the competing interests of education, research and patient care already limit the amount of time ces can devote to assessment activities or the pursuit of knowledge regarding assessment.[24] addressing this inefficient use of ces' time should be a priority if better quality-assessment practice is to be achieved. respondents (≥80%) reported that they were aware of (could explain or had heard of ) formative and summative assessment and the principles of validity and reliability. a third or more of respondents with assessment responsibilities had never heard of item analysis, standard setting, blueprinting or constructive alignment. this finding is in keeping with the limited practice of blueprinting and standard setting. of note, though, is that there was no statistically significant difference between the appointment of staff (academic v. clinical) and being assessment aware (based on self-reported knowledge of ≥5 of the 8 assessment terms). this finding is somewhat unexpected because academic appointees, with a primary responsibility for teaching and assessment, may be expected to be more knowledgeable than clinical staff, who are primarily responsible for providing a clinical service. the latter have limited time to participate in faculty development initiatives that may advance their knowledge of assessment. this has previously been shown to be true of clinicians who provide teaching in clinical service settings.[25] table 3. self-reported knowledge of clinician educators knowledge terms i can explain it to somebody, n (%) i have heard about it, n (%) i have never heard about it, n (%) missing, n (%) type of assessment formative assessment 21 (70) 7 (23) 1 (3) 1 (3) summative assessment 20 (67) 8 (27) 1 (3) 1 (3) principles of assessment validity 19 (63) 5 (17) 4 (13) 2 (7) reliability 19 (63) 5 (17) 4 (13) 2 (7) quality of assessment item analysis 8 (27) 11 (37) 8 (27) 3 (10) standard setting 6 (20) 13 (43) 9 (30) 2 (7) blueprinting 10 (33) 6 (20) 12 (40) 2 (7) constructive alignment 6 (20) 10 (33) 12 (40) 2 (7) table 4. ways in which clinician educators learnt about assessment learning method respondents, n (%) workplace-based learning practical experience 28 (93) peer learning informal discussion 28 (93) departmental meeting 24 (80) conference attendance 18 (60) self-directed learning internet 16 (53) structured learning activity workshops on assessment 19 (63) courses on assessment 10 (33) september 2019, vol. 11, no. 3 ajhpe 87 research the dominant mode of learning was practical experience in the workplace, with limited use of structured learning activities such as workshops and assessment courses. the two most common ways in which respondents reported learning, practical experience and informal discussions may provide limited opportunities for gaining experience in quality assurancerelated activities. the prevailing belief that assessment is predominantly a process of measuring knowledge may contribute to this situation.[25,26] this belief is of concern, because it has been suggested that those teaching in the clinical years of medical training programmes not only require knowledge of medicine, patients and context, but also of education to enhance their teaching and assessment practices.[27] the key findings of this study provide some useful information that could contribute to faculty development initiatives aimed at addressing the assessment-related knowledge gaps of ces. in keeping with the preference for learning-by-doing, it would make sense to offer faculty development activities that involve ces in authentic planning, design and qualityassurance processes within their working environment rather than in a traditional workshop setting.[28] the timing of these activities and their duration are key to accommodating busy clinical and academic schedules, e.g. snippets slotted into existing departmental meetings or at the end of the working day.[29] ideally, a short course of customised modules dealing with specific topics would enable ces to focus and develop expertise in targeted areas of assessment in which they usually participate. this type of faculty development programme would promote distributed expertise within a team of ces rather than a few assessors with broad expertise who are limited by time constraints and therefore unable to meet all the assessment demands of a clinical programme. freeing up educators from performing examination administration would be one approach to making capacity available for their broader involvement. study limitations this study has a number of limitations. first, the small sample size limits the generalisability of the findings. a larger sample size involving multiple institutions is required to thoroughly explore the potential association between variables. second, self-reported knowledge is widely recognised to be of limited value and further studies using objective measures of knowledge would be more meaningful. conclusions this study confirms that clinicians play a role in the assessment of medical students and the need for involvement and training of both universityemployed and health service-employed staff with regard to assessmentrelated quality-assurance processes. faculty development initiatives should be customised to target the predominant assessment knowledge gaps of ces, while taking workloads into account. furthermore, such initiatives should focus on a learning-by-doing approach using authentic assessment material rather than traditional generic assessment workshops, where the focus is on knowledge acquisition rather than knowledge application. finally, there is a need to understand why ces do not attend formal courses on assessment. although this study was conducted at one institution, it may be relevant to other institutions in resource-constrained settings that face the challenge of engaging a mixed group of educators around the current body of knowledge of assessment so that changes in practice can keep up with the exponential growth in assessment knowledge. declaration. none. acknowledgements. the authors thank the sub-saharan africa-faimer regional institute (safri) programme from which this research project emanated. author contributions. all authors contributed to the article. lp and lw developed the protocol; lp collected the data and wrote the first draft of the manuscript; lp, lw, vb and fc contributed to the analysis, interpretation of the data and writing of the article; and lp and lw made the final editorial adjustments to the manuscript. funding. none. conflicts of interest. none. 1. van der vleuten cpm, schuwirth lwt. assessing professional competence: from methods to programmes. med educ 2005;39(3):309-317. https://doi.org/10.1111/j.1365-2929.2005.02094.x 2. mclean m. rewarding teaching excellence. can we measure teaching ‘excellence’? who should be the judge? med teach 2001;23(1):6-11. 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competencies for medical educators. acad med 2011;86(10):1211-1220. https://doi.org/10.1097/acm.0b013e31822c5b9a  13. postareff l, virtanen v, katajavuori n, lindblom-ylänne s. academics’ conceptions of assessment and their assessment practices. stud educ eval 2012;38(3):84-92. https://doi.org/10.1016/j.stueduc.2012.06.003  14. holmboe es, ward ds, reznick rk, et al. faculty development in assessment: the missing link in competencybased medical education. acad med 2011;86(4):460-467. https://doi.org/10.1097/acm.0b013e31820cb2a7  15. st-onge c, chamberland m, lévesque a, varpio l. the role of the assessor: exploring the clinical supervisor’s skill set. clin teach 2014;11(3):209-213. https://doi.org/10.1111/tct.12126  16. sherbino j, frank jr, snell l. defining the key roles and competencies of the clinician-educator of the 21st century: a national mixed-methods study. acad med 2014;89(5):783-789. https://doi.org/10.1097/ acm.0000000000000217  17. mcleod p, steinert y, chalk c, et al. which pedagogical principles should clinical teachers know? teachers and education experts disagree disagreement on important pedagogical principles. med teach 2009;31(4):e117-e124. https://doi.org/10.1080/01421590802335900  18. cruess sr, cruess rl, steinert y. role modelling – making the most of a powerful teaching strategy. bmj 2008;336(7646):718-721. https://doi.org/10.1136/bmj.39503.757847.be  19. cohen l, manion l, morrison k. research methods in education. 8th ed. new york: taylor and francis, 2017. 20. downing sm, yudkowsky r. assessment in health professions education. new york: routledge, 2009. 21. govaerts mj. competence in assessment: beyond cognition. med educ 2016;50(5):502-504. https://doi. org/10.1111/medu.13000  22. mullan f, frehywot s, omaswa f, et al. medical schools in sub-saharan africa. lancet 2011;377(9771):1113-1121. https://doi.org/10.1016/s0140-736(10)61961-7  23. tekian a, norcini jj. faculty development in assessment: what the faculty need to know and do. assessing competence in professional performance across disciplines and professions. switzerland: springer, 2016:355-374. 24. darosa da, skeff k, friedland ja, et al. barriers to effective teaching. acad med 2011;86(4):453-459. https://doi. org/10.1097/acm.0b013e31820defbe  25. gunzenhauser m. high-stakes testing and the default philosophy of education. theory pract 2003;42(1):51-58. https://doi.org/10.1353/tip.2003.0007  26. medland e. assessment in higher education: drivers, barriers and directions for change in the uk. assess eval high educ 2016;41(1):81-96. https://doi.org/10.1080/02602938.2014.982072  27. irby dm. excellence in clinical teaching: knowledge transformation and development required. med educ 2014;48(8):776-784. https://doi.org/10.1111/medu.12507  28. kogan jr, conforti ln, bernabeo e, iobst w, holmboe e. how faculty members experience workplacebased assessment rater training: a qualitative study. med educ 2015;49(7):692-708. https://doi.org/10.1111/ medu.12733  29. bar-on me, konopasek l. snippets: an innovative method for efficient, effective faculty development. j grad med educ 2014;6(2):207-210. https://doi.org/10.4300/jgme-d-13-00362.1 accepted 4 april 2019. https://doi.org/10.1111/j.1365-2929.2005.02094.x https://doi.org/10.1080/01421590123039 https://doi.org/10.1001/jama.294.9.1101 https://doi.org/10.1111/j.1525-1497.2004.30334.x https://doi.org/10.1136/bmj.326.7389.591 https://doi.org/10.1080/01421590310001643154 https://doi.org/10.1111/j.1365-2929.2005.02370.x https://doi.org/10.1111/j.1365-2929.2005.02370.x https://doi.org/10.1080/01421590802402247 https://doi.org/10.1007/s10459-007-9068-0 https://doi.org/10.1007/s10459-007-9068-0 https://doi.org/10.1097/00001888-200302000-00021 https://doi.org/10.1097/00001888-200302000-00021 https://doi.org/10.1186/1472-6920-13-123 https://doi.org/10.1097/acm.0b013e31822c5b9a https://doi.org/10.1016/j.stueduc.2012.06.003 https://doi.org/10.1097/acm.0b013e31820cb2a7 https://doi.org/10.1111/tct.12126 https://doi.org/10.1097/acm.0000000000000217 https://doi.org/10.1097/acm.0000000000000217 https://doi.org/10.1080/01421590802335900 https://doi.org/10.1136/bmj.39503.757847.be https://doi.org/10.1111/medu.13000 https://doi.org/10.1111/medu.13000 https://doi.org/10.1016/s0140-736(10)61961-7 https://doi.org/10.1097/acm.0b013e31820defbe https://doi.org/10.1097/acm.0b013e31820defbe https://doi.org/10.1353/tip.2003.0007 https://doi.org/10.1080/02602938.2014.982072 https://doi.org/10.1111/medu.12507 https://doi.org/10.1111/medu.12733 https://doi.org/10.1111/medu.12733 https://doi.org/10.4300/jgme-d-13-00362.1 december 2019, vol. 11, no. 4 ajhpe 129 research a chest radiograph is the most common investigation in many ugandan hospitals. this could be attributed to the many tropical infections, high prevalence of hiv infection and hiv/aids, as well as associated comorbidities such as tuberculosis (tb), malignancy and pneumonia. a chest radiograph has also been reported to be one of the most common radiological investigations in other parts of the world.[1,2] furthermore, chest radiographs constitute >20% of all radiological investigations in imaging departments.[2-5] the interpretation of chest x-ray images has long been the domain of radiologists, although radiographers are now increasingly taking on this role.[6] while radiologists are medical doctors with postgraduate training in radiology, radiographers are not trained in clinical medicine, and had traditionally been trained to operate equipment to produce images. therefore, equipped with adequate medical knowledge, radiologists – not radiographers – usually have been the ones to interpret chest radiographs. however, it has also been reported that, globally, there are few radiologists compared with the number of patients who require radiological reports.[2] this is exacerbated in low-income countries, where radiologists are concentrated in tertiary hospitals in urban areas.[2] therefore, most of the rural and remote areas have only radiographers.[7] for example, in 2014 there were 220 radio logists in nigeria to serve a population of >150 million.[1] in uganda, a sub-saharan african country where this study was conducted, there are just >40 radiologists to serve a population of ~40 million.[8] this has left many hospitals, especially in rural areas, with only radiographers, who therefore become very crucial regarding the provision of expert opinions on some of the x-ray images.[9] against this background, the training of radiographers at degree level in uganda currently involves the basic interpretation of radiographs. the curriculum for radiography training in uganda has some components of x-ray film interpretation of the chest, abdomen, limbs, head and neck. the expected outcome is that graduate radiographers should be able to offer an informed opinion on radiographs in the absence of a radiologist. despite these efforts, however, no study has been conducted in uganda to assess the diagnostic accuracy of radiographers in interpreting radiographs. in our study, the chest radiograph was specifically chosen to determine the diagnostic accuracy of graduate radiographers, as it is the most common radiographic investigation requested in the radiology department for ~100 patients daily. methods study design and setting this was a retrospective cross-sectional study conducted in uganda, a lowincome country in sub-saharan africa. the study involved reviewing chest radiographs by radiographers who had a degree qualification. they had to analyse a set of given chest radiographs and write a probable final diagnosis. the radiographs used in the study were obtained from mulago hospital, uganda’s national referral hospital and teaching hospital for makerere university’s college of health sciences in kampala. sample size purposive sampling was used to select participants. a targeted group, i.e. graduate radiographers, was invited to participate in the study. all eligible radiographers who had a degree qualification were invited by e-mail and/or telephone. their contact details were obtained from records of the allied health professions council, a body that regulates radiography practice background. radiographers are increasingly being called on to take on new roles, such as x-ray film interpretation in imaging departments. in uganda, where this study was conducted, there are just >40 radiologists in a population of ~40 million. in many hospitals, especially in rural areas, clinicians often rely on radiographers to obtain an opinion to assist with proper patient management. therefore, ugandan radiographers are being trained in basic radiographic interpretation to address the shortage of radiologists. objective. to determine the diagnostic accuracy of graduate radiographers in interpreting chest radiographs. methods. this was a cross-sectional retrospective study involving 57 graduate radiographers who were provided with 53 randomly selected chest radiographs to interpret. the validation of a radiographer’s interpretation of a radiograph was aided by the opinion of two senior radiologists. spss version 25 software (ibm corp, usa) was used to analyse the findings and the radiographer’s performance was assessed using the receiver operating characteristic (roc). the mean abnormality location sensitivity, overall radiographer sensitivity, specificity and false-positive rates were calculated. results. the radiographers’ diagnostic accuracy was high. the abnormality location sensitivity was 88.7%, overall sensitivity 76.6%, specificity 79.7% and false-positive rate 20.1%. conclusion. the study demonstrated that radiographers, if trained, can accurately report on chest radiographs to an acceptable standard. afr j health professions educ 2019;11(4):129-132. https://doi.org/10.7196/ajhpe.2019.v11i4.1079 diagnostic accuracy of chest radiograph interpretation by graduate radiographers in uganda a g mubuuke, phd; f businge, msc; e kiguli-malwadde, mmed (radiology) department of radiology, school of medicine, college of health sciences, makerere university, kampala, uganda corresponding author: a g mubuuke (gmubuuke@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:gmubuuke@gmail.com 130 december 2019, vol. 11, no. 4 ajhpe research in uganda. the degree-level radiographers are trained in plain x-ray image interpretation. the diploma-level radiographers were excluded because they are not trained in such interpretation. the invitation was sent to 70 targeted radiographers, of whom 57 who agreed to participate had a degree in diagnostic radiography and had received training in x-ray pattern recognition. sociodemographic data on gender and years of practice since their degree training were also obtained. selection of chest radiographs the radiographs were randomly selected – 53 postero-anterior (pa) chest radiographs were used in the study. these were of patients 10 72 years of age, with a mean age of 35.1 years. of these radiographs, 24 were of female and 29 of male patients. interpretation of chest radiographs by radiologists two independent radiologists initially interpreted the chest radiographs and thus validated the cases selected. these interpretations were also used to compare the radiographers’ findings. the final diagnosis of each chest radiograph was required from the radiologists. they interpreted the radiographs independently at different times before the radiographers interpreted them. using two radiologists was meant to increase the validity of the interpretation, which was used as a reference standard when assessing the radiographers’ performance. of the 53 pa chest radiographs that the radiologists interpreted, 50 reflected the same final opinion, which produced a reference standard that was later used to assess the performance of radiographers. of the 50 cases, 22 were reported as normal by the radiologists, while 28 were reported as abnormal. the latter cases were compiled, and assisted in assessing the performance of the radiographers (table 1). only 3 chest radiograph interpretations by the radiologists differed. these were not included in the final list to be given to the radiographers for interpretation. interpretation of chest radiographs by radiographers after interpretation by the two radiologists, the 50 chest radiographs that reflected a common interpretation (reference standard) were given to the radiographers to interpret. to standardise the interpretation environment for all 57 radiographers, the same viewer and room were used by the radiologists and radiographers in the radiology department. it was impossible to have all 57 radiographers in one room at the same time. therefore, interpretation of the chest radiographs was done at different times until all 57 radiographers had seen the same radiographs. only one radiographer would be in the room at any one time to prevent possible influencing of each other if there were more than one in the room. the radiographers were requested to analyse the radiographs and write a final diagnostic opinion, as was the case with the radiologists. the radiographers were requested to write down the features seen on the chest x-ray images and provide the most likely diagnosis according to the features described. the researcher (agm) considered this final diagnostic opinion (the conclusion) for analysis. the radiographers were not given any indication of how many radiographs were normal or abnormal or of the two radiologists’ conclusions. they were blinded from the radiologists’ findings. it was not possible to trace the clinical notes on the request forms from the records; therefore, the radiographers did not receive the request forms and clinical information. each radiographer was given chest radiographs at random and no specific time frame was fixed for interpreting a radiograph. they first had to state whether the radiograph was normal or abnormal; for those judged as abnormal, each radiographer was requested to provide an opinion of the final possible diagnosis. the reporting by each radiographer did not happen simultaneously for all 50 radiographs owing to time constraints, but was staggered over 1 year to suit the radiographers, as they were employed. data analysis findings were analysed using spss version 25 (ibm corp, usa). the performance of each radiographer was assessed using the receiver operating characteristic (roc) analysis. roc analysis is a statistical tool used to relate sensitivity and specificity of the diagnostic ability of a tool or group of people – in this case, the radiographers compared with the radiologists to provide an accurate evaluation of the diagnostic accuracy. it has previously been used in a related study.[2] roc analysis enabled us to assess parameters, such as correct location of an abnormality on the chest radiograph. sensitivity and specificity of radiographers to diagnose an abnormality were also calculated. sensitivity refers to true positive rates (i.e. presence of an abnormality correctly diagnosed by the radiographers). specificity refers to true negative rates (i.e. absence of an abnormality correctly diagnosed by the radiographers). the performance of all the radiographers was represented by the mean. ethical approval permission to conduct the study, including review of chest x-ray films, was obtained from mulago hospital research ethics committee (ref. no. rec 109-2019), as well as from the records officer to access the radiographs. the patients’ names and the numbers on the selected chest radiographs were removed before interpretation by the radiographers. consent was also obtained from the study participants. results demographic information of the radiographers of the 57 radiographers who attempted to interpret the 50 chest radiographs, 6 did not complete the work and opted out. the remaining 51 completed the task. the 6 radiographers who opted out were eliminated from the final analysis of findings. therefore, there was a total of 2 550 independent reports by radiographers. the age range of the radiographers was between 22 and 40 years. the years since the radiographers’ qualification ranged table 1. abnormal pathological conditions on radiographs, as reported by radiologists abnormality n tuberculosis 5 pleural effusion 4 pneumonia 4 pulmonary oedema 3 atelectasis 3 chronic obstructive pulmonary disease 3 primary lung cancer 2 lung metastases 2 pneumothorax 1 cardiac failure 1 december 2019, vol. 11, no. 4 ajhpe 131 research from 1 to 5. all radiographers involved in this study were employed and have been actively reporting chest radiographs (30 were males and 27 were females). the range of pathological conditions as interpreted by the two radiologists is summarised in table 1. accuracy of radiographers’ interpretation of chest radiographs the radiographers’ sensitivity of correctly locating an abnormality on the chest radiographs ranged from 80.2% (95% confidence interval (ci) 0.654 0.866) to 100% (95% ci 0.886 1.000) (mean 88.7%; 95% ci 0.785 0.978). the sensitivity of locating abnormalities (i.e. location sensitivity) was done to ensure that the final diagnosis was based on the radiographic features observed. overall, from this study it can be inferred that the radiographers’ final diagnoses were based on observed radiographic patterns rather than on assumptions. the roc for radiographer diagnostic performance demonstrated that overall sensitivity ranged from 62.8% (95% ci 0.520 0.792) to 100% (95% ci 0.920 1.000) (mean 76.6%). the overall specificity of radiographer performance ranged from 63.8% (95% ci 0.479 0.800) to 95.5% (95% ci 0.927 1.000) (mean 79.7%). the overall mean falsepositive rate for radiographer reporting was 20.1%. the abnormalities on the chest radiographs that appeared to have been reliably and correctly pointed out by the radiographers included tuberculosis, pneumonia, lung metastases and pleural effusion. the abnormalities that were commonly missed or misinterpreted included pulmonary oedema, atelectasis and cardiac failure. discussion this study suggests that the radiographers made a final diagnosis based on observed chest radiographic patterns rather than on assumptions. therefore, with the necessary training in radiographic interpretation during undergraduate studies, radiographers are capable of an expert opinion on some chest radiographs, which can aid prompt patient management. the radiographers involved in this study had been trained in basic radiographic interpretation, which probably explains why they were able to interpret the chest x-rays films provided. with few radiologists against the ever-increasing patient load, role extension for radiographers to interpret and report on chest radiographs is becoming urgent.[9,10] analysing findings from this study, it can be concluded that trained radiographers can correctly and consistently locate some abnormal disease patterns on chest radiographs, especially those included in this study, and can also reliably report or offer an expert opinion on some of the chest x-ray images to a satisfactory extent. the radiographers’ sensitivity of locating the abnormality (i.e. location sensitivity) was high (88.7%). the overall sensitivity regarding the number of chest radiographs with a correctly identified condition was high (76.6%), while overall radiographer specificity regarding the number of chest radiographs without pathology correctly identified was also high (79.7%). furthermore, this study recorded a fairly low final false-positive rate (20.1%) (i.e. number of normal chest radiographs reported as indicating pathology). therefore, the diagnostic accuracy of radiographers correctly reporting on chest films was remarkably high. the false-positive rate could possibly have been lower, but some key factors might explain the 20.1%. for example, the quality of radiographs interpreted was a factor. the chest radiographs given to the radiographers were retrieved from storage, where conditions might not have been optimal, thus affecting the overall diagnostic quality of the films. for example, the image might have faded or mixed with dust or even become scratched. the radiographers also possibly had limited experience, as they had been been practising for relatively fewer years than the two radiologists. it can be argued that with time and experience, the false-positive rate could be reduced considerably, which might also apply to the radiologists. moreover, the radiographers might have felt as if they were being tested in an examination-like context and thus felt pressurised to identify some form of pathology, even when it was not present on the radiographs. the radiographers were not provided with clinical information relating to the radiographs. although there is no guarantee that availability of clinical information would have significantly improved their performance, it is highly likely that it would have reduced the false-positive rate observed. some of the abnormalities that were misinterpreted, such as pulmonary oedema and cardiac failure, have also been reported in the literature as potentially difficult.[10] a chest radiograph is very challenging to interpret, even for experienced radiologists. for example, variability of interpretation by qualified radiologists has also been observed elsewhere.[11] overall, findings from this study showing a relatively high diagnostic accuracy for radiographer interpretation of x-ray images are comparable with those of a study done in nigeria that reported a sensitivity of 76.9%, specificity of 79.8% and false-positive rate of 20.2%.[2] the findings are also comparable with those of a study in south africa (80% sensitivity),[12] and with studies done in the developed world.[13] this therefore indicates that with training, radiographers can correctly report on x-ray images with a diagnostic accuracy comparable with that of radiologists.[13] the study thus provides evidence that radiographers can accurately interpret some chest radiographs, which can be very useful, especially in areas where there are no radiologists. the radiographers were graduates and had received training in basic chest radiographic interpretation. this possibly explains their ability to interpret some of the radiographs. it is therefore suggested that radiographers should be trained in x-ray film interpretation during their undergraduate studies so that they are able to contribute to the role extension. this should subsequently ease the workload of the radiologists and ensure that patients, especially in rural areas, receive the much-needed service immediately, until an advanced opinion from a radiologist is sought. to ensure quality, the trained radiographers should be encouraged to always consult when in doubt. standardisation of their reporting can be explored by professional regulatory bodies. study limitations only chest radiographs were used to assess the diagnostic accuracy of radiographers. this does not imply that findings would be the same for other body systems outside a chest cavity, a potential limitation of the study. further research as this study focused on the interpretation of chest radiographs and not any other body systems, many more empirical studies are needed to look at the accuracy of radiographer reporting of such systems. 132 december 2019, vol. 11, no. 4 ajhpe research conclusions findings from this study have demonstrated that the majority of graduate radiographers with the required training in chest x-ray film interpretation can accurately interpret and report on some specific chest radiographs, such as those included in this study – almost to the same level as radiologists. with the scarcity of radiologists, especially in low-income countries, there is a need to focus the training of radiographers at degree level and beyond in radiographic interpretation skills involving some body systems. it is, however, important to define the necessary competencies, required standards and scope of reporting for trained radiographers in this role extension. declaration. none. acknowledgements. special thanks to the radiographers and radiologists who participated in the study. author contributions. agm: developed and conceptualised the idea, developed the protocol, collected the data, participated in the analysis and drafted the initial manuscript; fb: refined the idea, participated in data collection and proofread the final manuscript; ekm: refined the concept, participated in the design and proofread the final manuscript. funding. this work was supported by grant number d43tw010132, office of the director, national institutes of health, national institute of dental and craniofacial research (nidcr), national institute of neurological disorders and stroke (ninds), national heart, lung, and blood institute (nhlbi), fogarty international center (fic), and national institute on minority health and health disparities (nimhd). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the supporting offices. conflicts of interest. none. 1. neep mj, steffens t, owen r, mcphail sm. a survey of radiographers’ confidence and self-perceived accuracy in frontline image interpretation and their continuing educational preferences. j med rad sci 2014;61(2):69-77. https://doi.org/10.1002/jmrs.48 2. ekpo eu, egbe no, akpan be. radiographers’ performance in chest x-ray interpretation: the nigerian experience. br j radiol 2015;88(1051):20150023. https://doi.org/10.1259/bjr.20150023 3. ekpo eu, hoban ac, mcentee mf. optimisation of direct digital chest radiography using cu filtration. radiography 2014;20(4):346-350. https://doi.org/10.1016/j.radi.2014.07.001 4. piper k, cox s, paterson a, et al. chest reporting by radiographers: findings of an accredited postgraduate programme. radiography 2014;20(2):94-99. https://doi.org/10.1016/j.radi.2014.01.003 5. hayashi h, ashizawa k, uetani m, et al. detectability of peripheral lung cancer on chest radiographs: effect of the size, location and extent of ground-glass opacity. br j radiol 2009;82(976):272-278. https://doi.org/10.1259/ bjr/22411514 6. brealey s, scally a, hahn s, thomas n, godfrey c, crane s. accuracy of radiographers red dot or triage of accident and emergency radiographs in clinical practice: a systematic review. clin radiol 2006;61(7):604-615. https://doi.org/10.1016/j.crad.2006.01.015 7. soh bp, lee w, kench pl, et al. assessing reader performance in radiology, an imperfect science: lessons from breast screening. clin radiol 2012;67(7):623-628. https://doi.org/10.1016/j.crad.2012.02.007 8. kiguli-malwadde e, mubuuke ag, businge f, nakatudde r, bule s. evaluation of ultrasound training in the problem-based learning radiography curriculum at makerere university, uganda. radiography 2010;16(4):314-320. https://doi.org/10.1016/j.radi.2010.05.003 9. lee cs, nagy pg, weaver sj, newman-toker de. cognitive and system factors contributing to diagnostic errors in radiology. ajr am j roentgenol 2013;201(3):611-617. https://doi.org/10.2214/ajr.12.10375 10. monu ju, hewlett v, ostlere s. international skeletal society outreach in sub-saharan west africa. skeletal radiol 2011;40(3):251-254. https://doi.org/10.1007/s00256-010-1084-0 11. samei e, flynn mj, eylerwr. detection of subtle lung nodules: relative influence of quantum and anatomic noise on chest radiographs. radiology 1999;213(3):727-734. https://doi.org/10.1148/radiology.213.3.r99dc19727 12. williams i. reporting trauma and emergency plain film radiographs: radiologists’ support for role extension of south african radiographers. s afr radiographer 2009;47(1):15-18. 13. brealey s, scally a, hahn s, thomas n, godfrey c, coomarasamy a. accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis. clin radiol 2005;60(2):232-241. https://doi.org/10.1016/j. crad.2004.07.012 accepted 1 july 2019. https://doi.org/10.1002/jmrs.48 https://doi.org/10.1259/bjr.20150023 https://doi.org/10.1016/j.radi.2014.07.001 https://doi.org/10.1016/j.radi.2014.01.003 https://doi.org/10.1259/bjr/22411514 https://doi.org/10.1259/bjr/22411514 https://doi.org/10.1016/j.crad.2006.01.015 https://doi.org/10.1016/j.crad.2012.02.007 https://doi.org/10.1016/j.radi.2010.05.003 https://doi.org/10.2214/ajr.12.10375 https://doi.org/10.1007/s00256-010-1084-0 https://doi.org/10.1148/radiology.213.3.r99dc19727 https://doi.org/10.1016/j.crad.2004.07.012 https://doi.org/10.1016/j.crad.2004.07.012 october 2020, vol. 12, no. 3 ajhpe 119 research nursing education institutions (neis) must ensure that their pre-registration students reflect nursing administration-related competencies at graduation.[1-3] such competencies include the ability to effectively and efficiently manage human resources,[4,5] reason through complex situations,[6] distribute clinical resources, monitor and evaluate healthcare[3] and communicate effectively.[7] these competencies are pertinent in low-resource settings, which are characterised by critical human resource shortages, lack of staff mentorship programmes and limited resources for on-the-job training in nursing administration, compounded by a greater need for quality healthcare provision.[8] numerous neis in africa, guided by regulatory requirements, have included nursing administration-specific learning outcomes in their preregistration programmes.[2,9,10] this inclusion has necessitated the teaching and assessment of elements of nursing administration at pre-registration level, with the anticipation that graduates from such programmes will effectively manage healthcare units, such as primary healthcare clinics and hospital units.[11] however, the complex clinical environment compromises the quality of teaching, learning and assessment of nursing learning outcomes in sub-saharan africa.[8,9] the majority of the neis in africa offer nursing education through vocational programmes long after the call by the world health organization (who) to transform health professions education to be competency driven.[8,12,13] such vocational programmes are presented through teacher-centred, rigid, content-based curricula that are underpinned by behaviourism. nursing students in typical vocational programmes have a limited amount of class time, but extensive placement in the clinical environment. the latter would be advantageous for students to gain real-life experiences, but poor planning limits the value of the clinical placement to enhance students’ nursing administration clinical experience. the staff in the clinical environment perceive nursing students as supernumerary staff, who are expected to shadow professional nurses in practice and even relieve them of their professional duties.[14,15] consequently, newly graduated nurses struggle background. nursing education institutions (neis) must ensure that their graduates are competent in nursing administration. the adoption of nursing administration-related learning outcomes in pre-registration nursing programmes in africa has created a platform for the teaching and assessment of nursing administration. challenges aligned with low-resource neis, such as rigid content-based vocational programmes, limit the value and utility of the teaching of nursing administration, resulting in graduates who are not able to manage healthcare units effectively. therefore, this study explored students’ experiences of a nursing administration module with the hope that alignment of the outcomes, content and assessments would be pivotal in the module review to improve nurses’ efficiency in managing health units. objectives. to describe student nurses’ perceptions regarding the alignment of learning outcomes, content and assessment of a nursing administration module in an nei in a low-resource setting. methods. a sequential mixed methods design was executed in three phases. data were collected through documents, self-administered questionnaires and focus group discussions with students enrolled in a 3-year pre-registration programme at an nei in a low-resource setting. the gathered documents were enumerated and mapped against the specific elements of a curriculum as described by harden and dent. the quantitative data were analysed through descriptive statistics, focusing on frequencies. the data generated from the focus groups were transcribed verbatim, and thematic analysis through an inductive reasoning approach was used. results. the study revealed a non-alignment among learning outcomes, content and assessment of the administration module, causing students to struggle in meeting the expected learning outcomes of the module. in as much as the curriculum documents specified the learning outcomes, the classroom teaching seemed only to be aligned with the described curriculum. in addition to other challenges, the contextual characteristics of the related clinical environment did not support application of what was learnt in the classroom. the assessment practices mirrored the expectations of the curriculum, but were not aligned with contextual realities. conclusion. nursing students struggle to meet expected learning outcomes related to nursing administration due to the non-alignment among learning outcomes, content and assessment of the module. neis in low-resource settings must radically transform their pre-registration nursing curricula to incorporate contemporary issues and clinical contextual realities to enhance the utility of nursing administration learning outcomes. afr j health professions educ 2020;12(3):119-123. https://doi.org/10.7196/ajhpe.2020.v12i3.1352 a broken triangle: students’ perceptions regarding the learning of nursing administration in a low-resource setting b masava,1 bsc hons nursing science, mphil hpe; l n badlangana,2 bs, ms, phd; c n nyoni,3 bsc hons nursing science, msocsc (nursing), mhpe, phd 1 paray school of nursing, thaba-tseka, lesotho 2 department of biomedical sciences, faculty of medicine, university of botswana, gaborone, botswana 3 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: b masava (belovedmas@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 120 october 2020, vol. 12, no. 3 ajhpe research to adapt to the nursing administration requirements of the real-world environment, which compromises the quality of health services.[16] the transition of neis from a vocational to a professional educational programme requires a shift in instructional design and teaching of nursing modules, including nursing administration. neis in low-resource settings need practical guidance to improve the quality of teaching and learning of nursing administration. we argue that insight in the alignment of the learning outcomes, content and assessment of nursing administration education would inform the design of pre-registration nursing administration programmes. the triangle thus refers to the alignment between learning outcomes, content and assessments. this article reports on an evaluation of aspects of a pre-registration nursing administration module in a lowresource setting in africa. objective the objective of this study was to evaluate and describe the alignment of learning outcomes, content and assessment of a nursing administration module in an nei in a low-resource setting. methods underpinned by pragmatism, this study was executed through sequential mixed methods at an nei in a low-resource setting in africa. the nei included in this study offered a 3-year pre-registration nursing programme guided by a national nursing curriculum that includes a nursing administration module. this module was presented in two sequential components, i.e. a classroom-based theoretical component and a hospitalbased practical component, as directed by the national nursing curriculum. the study population comprised final-year nursing students who had completed both components of the nursing administration module. all 40 nursing students were invited and included in the study. data were collected in three sequential phases. the initial phase involved the collection of all available documents related to the learning outcomes, content and assessment of the nursing administration module. the authors requested permission from the institution’s gatekeepers to use the selected documents for study. the collected documents were de-identified, coded, duplicated and categorised. the second phase was the quantitative strand of the study, where data were collected from the nursing students through self-administered questionnaires. selected participants gave written consent to participate in the study survey and focus group discussions. the questionnaire was generated by the researchers from reviewing the literature, and explored the nursing students’ experiences of the components of the nursing administration module. the third phase was informed by the outcome of the data analysis of the preceding phases and was executed through four focus group discussions with the same population. the first author, who is experienced in conducting interviews and worked at the setting, conducted the focus group discussions with the aid of a research assistant. the discussions were digitally recorded and field notes were collected. the collected data were analysed using approaches appropriate for each phase. the documents collected were enumerated and mapped against a curriculum model.[17] the quantitative data were analysed through descriptive statistics, focusing on frequencies. the results of the quantitative analysis informed the development of questions for the focus group discussions. the data generated from the focus groups were transcribed verbatim, and thematic analysis through inductive reasoning was applied, guided by principles of qualitative data analysis by creswell.[18] the rigour of the study was enhanced by the application of the trustworthiness framework.[19,20] first, the study explicitly explained how the authors collected and analysed data, thereby establishing auditability. second, the third author verified the data coding and conclusions drawn from thematic analysis. third, the investigators’ interpretations were checked against those of the readily available participants. fourth, the authors triangulated the data collection methods to validate and corroborate findings obtained during the study.[21] ethical approval ethical approval was granted by the national research ethics committee of the ministry of health, lesotho (ref. no. id08-2017), and the management of the paray school of nursing approved the study. the belmont report ethics framework of 1979 was applied throughout the design and execution of this study.[22] results the results of this study are presented in the three phases in which the study was executed. phase 1: document analysis the initial phase was an analysis of documents used in the implementation of the nursing administration module. the gathered documents were enumerated and mapped against the specific elements of a curriculum, as described by harden et al.[17] the results of document analysis are presented in table 1. phase 2: quantitative survey the quantitative survey was structured under three main sections, i.e. learning outcome, content and assessment. thirty-six of the 40 participants responded to this survey. fourteen (39%) participants highlighted that the teaching and learning activities were not adequate in preparing them for the real-world setting. the majority (n=23; 65%) stated that they felt incompetent to integrate the content learnt in the classroom into practice during work-integrated learning. most of the participants (n=28; 77%) valued the teaching and learning activities for assessment (fig. 1), while 31 (86%) stated that there were differences between real-world nursing administration and written assessments (fig. 2). phase 3: results of focus group discussions three themes emerged from the focus group discussions: cognitive support during learning; alignment of assessment with reality; and achieving learning outcomes (table 2). theme 1: cognitive support during learning the participants described various experiences related to cognitive support in the classroom and the clinical environment as they learnt nursing administration. in the classroom setting, the participants indicated that nurse educators taught nursing administration through lectures supported by powerpoint (microsoft, usa) presentations. the presented content supported their thinking and understanding regarding nursing administration. however, examples in the prescribed textbooks were october 2020, vol. 12, no. 3 ajhpe 121 research focused on foreign or non-native examples, which made it very difficult for the participants to relate to. there were no locally written textbooks for the module and the nurse educators could not translate such examples for the local context. during the classroom activities, there was limited student-tostudent interaction, as the educators lectured didactically: ‘the educators focus on teaching through the slides, at times they read to you the slides as they are written. we just sit there and take notes, as they may not be willing to share those slides.’ (fg2, s2) challenges seemed to arise when students were expected to apply principles of nursing administration in practice. professional nurses in the wards are expected to supervise students as they apply their classroom learning in the clinical setting. however, the professional nurses in the clinical environment had developed routine approaches to administering nursing units, which were not aligned with what the students were taught in the classroom. compounding this situation, was the unavailability of nurse educators in the clinical environment to support students as they translated their knowledge. nurse educators only appeared in the clinical environment for assessments: ‘the nurses in the wards have no idea about management principles, they have routines and expect us to also follow that routine. the problem is that the routine is not what we have been taught and the teachers are never there to help us or even defend us. we only see them [nurse educators] on the date of the final assessment.’ (fg1, s4) theme 2: alignment of assessment with reality the students’ attainment of the learning outcomes was measured through two distinct approaches, i.e. written tests and examinations, and directly observed long case examinations. the written tests and examinations focused on the content taught in class, and the participants described such assessments as fair. however, they indicated that the written tests and assessments were not aligned with the reality in the clinical environment or best practices of nursing administration: table 1. document analysis document learning outcomes content assessment comments curriculum • • • content-based curriculum, behaviourism, approved by local regulator lesson plans • • designed by nurse educators, based on curriculum learning outcomes and outline powerpoint presentations • • • designed based on lesson plan, with examples and formative assessment features test and examinations • • • aligned with learning outcomes and powerpoint presentations clinical placement plan • • students are placed in non-specialised units for 6 weeks for nursing administration assessment tool • • checklist in place, aligned with content in curriculum module reports • • • reflected average student performance in the clinical environment with above-average performance in written tests • = content identified and analysed on collected documents. strongly disagree disagree somehow agree agree strongly agree 0 0 22 44 33 participants, % fig. 1. participants’ responses regarding the value of teaching and learning activities on clinical assessment. 63 strongly agree agree somehow agree disagree strongly disagree pa rt ic ip an ts , % 2 0 12 23 fig. 2. participants’ responses regarding the alignment between module content and assessments. table 2. codes and theme development during qualitative analysis theme codes cognitive support during learning teaching and learning methods learning resources student engagement routine clinical practices alignment of assessment with reality assessment methods validity of assessment tools collaboration related to assessment supervision of students achieving learning outcomes applying principles of nursing administration barriers to achievement of learning outcomes professional nurses’ role in achievement of learning outcomes 122 october 2020, vol. 12, no. 3 ajhpe research ‘… i mean the tests are fair, it’s just the stuff we learnt in class. you cram and regurgitate it and you are fine, but you know you will never see half of that anywhere in this country. but you do that to please the teacher and pass.’ (fg3, s5) challenges related to clinical assessment seemed to emanate from assessment tools that were not informed or inspired by the clinical environment or best practices in nursing administration. the participants conveyed that the assessors seemed to be following a much earlier standard checklist that was not flexible to accommodate the contextual realities of the clinical setting. according to the participants, this checklist contributed to their perceived poor performance in their clinical assessment in nursing administration: ‘i would have passed management [nursing administration] with high marks, but they assess us with an old checklist, which does not adapt to what is happening in the clinical area. the clinical areas in this place are very different from what the checklist is asking us to do.’ (fg1, s2) the students further explained that there was limited collaboration and poor co-ordination between the clinical nursing staff and neis. the students expressed the opinion that there seemed to be poor communication and they often felt lost in the clinical environment when asked to engage in activities not aligned with the stated learning objectives. even then there was minimal supervision regarding these objectives in the clinical setting: ‘our teachers … they just give you a schedule of which ward you will go to and a couple of objectives and that’s it. the nurses have no time for those objectives and they will send you throughout the hospital. by the time of the assessment, you have no idea what you are doing.’ (fg4, s1) theme 3: achieving learning outcomes the learning outcomes of the nursing administration module expected students to be able to apply the principles and theories of nursing administration in the management of a healthcare unit. the participants revealed several barriers that influenced their attainment of the intended learning outcomes. these barriers were compounded by organisational culture and traditions, which were described as norms or routines. such routines were not aligned with best practices and challenged the participants in achieving their learning outcomes: ‘we wonder at times if those nurses were trained through the same programme. we always seem to speak a different language when it comes to management and they are stuck in their ways even when it doesn’t work.’ (fg2, s4) the learning outcomes attained during the clinical practices were informed by what the professional nurse expected from the students in the clinical setting; these outcomes were not necessarily aligned with the curriculum requirements. the participants verbalised that these nurses viewed them as an additional pair of hands and not necessarily as students. discussion this study describes the alignment of learning outcomes, teaching strategies, content and assessment associated with a nursing administration module at a resource-limited nei. the learning outcomes, content, teaching strategies, especially the learning environment and assessments, need to be coherent to enhance learning among students.[23,24] the metaphor of a broken triangle reflects a summary of the outcome of this study, as elements of the design and implementation of the nursing administration module were not aligned and therefore compromised student learning.[25] the learning outcomes are aimed at producing a nurse who is able to manage a healthcare unit effectively. the assessment processes in the classroom and clinical environments are aimed at assisting nurse educators in determining if the students meet the learning outcomes.[26,27] in this study, it is clear that assessment practices are aligned with the expectations of the described curriculum, but are not sensitive to context. assessment methods and the content of assessment tools need to be aligned with the evolving context.[27] this alignment can be done through the continual renewal of assessment methods and their tools based on best practices and context.[26] the classroom teaching activities were aligned with the described curriculum and enacted as described by the curriculum. the study revealed challenges associated with the authenticity of the content being taught and the examples used to support learning.[28,29] authenticity allows students to learn from real-life examples and allows such examples to influence their understanding of concepts.[30] the nature of the curriculum model was not flexible enough to accommodate the contextual realities for the students, thereby reducing the meaning of learning in this module. neis are recommended to transform their curriculum models to embrace competencyand problem-based contextual curricula that allow for flexibility and alignment with contextual realities.[31] students in the clinical environment struggle to apply theoretical approaches to nursing administration owing to several factors. the pervasive shortage of qualified nurse educators and clinical nurses in africa affects their availability for students during clinical practice.[8] revolutionary approaches, such as a robust preceptorship,[32,33] need to be adopted by all neis to enhance students’ supervision and mentoring during nursing administration placements. various preceptorship models have been developed for nurses in africa[32,34,35] and the operationalisation of such models needs to be underpinned by relevant contexts driven by excellence in nursing practice. the preceptors supporting the students should be qualified professionals who must undergo training[32,36] on how to support students and be engaged with best practices in nursing administration. conclusions the international council of nurses[2] has put great emphasis on the need for training of nursing administration competencies in pre-registration programmes. in africa, nurses comprise the bulk of the healthcare delivery system[8] and are often expected to manage health centres and primary healthcare clinics. yet, nursing students, the future of such a system, are struggling to meet expected learning outcomes related to nursing administration owing to the non-alignment of learning outcomes, content and assessment of the related module. neis are therefore expected to fortify their efforts through sound evidence-based programmes in the training of nurses to be able to function independently in administration roles. to achieve this, neis in low-resource settings must radically transform their pre-registration nursing curricula to incorporate contemporary issues and clinical contextual realities to enhance the utility of nursing administration learning outcomes. the neis in africa should also adopt problem-based contextually relevant curricula to enable the inclusion of locally relevant examples that mirror the respective clinical environments. adoption of preceptorship models by neis to capacitate nursing staff in october 2020, vol. 12, no. 3 ajhpe 123 research mentoring and supporting students during clinical learning and engagement of organic assessment methods applied in authentic environments is paramount to enhance the credibility of assessment outcomes. this study was conducted in one nei in a low-resource country, but bvumbwe and mtshali[8] explain that most of the neis in sub-saharan africa face similar challenges and seem to be using similar curriculum models. further research in this area should consider challenging the relevance of nursing administration learning outcomes within the remit of universal health coverage. declaration. none. acknowledgements. we are grateful to the key informants for the valuable insights provided. we thank mr f muzeya for helping to conduct the focus group discussions. many thanks to dr a g mubuuke, dr n mannathoko and prof. m rowe for their helpful comments on this paper. lastly, we say thank you to the subsaharan africa-faimer regional institute (safri) family for their support and encouragement during this journey. author contributions. bm and lnb designed the study. bm collected data and undertook the preliminary analysis and interpretation, which were subsequently reviewed by lnb and cnn. cnn greatly contributed to refining the conceptualisation, critical revision of important scientific content and drafting of the manuscript. all authors read and approved the final article. funding. none. conflicts of interest. none. 1. brown ra, crookes pa. what level of competency do experienced nurses expect from a newly graduated registered nurse? results of an australian modified delphi study. bmc nurs 2016;15(45):1-8. https://doi. org/10.1186/s12912-016-0166-2 2. international council of nurses (icn). nursing care continuum framework and competencies. 2008. https:// siga-fsia.ch/files/user_upload/08_icn_framework_for_the_nurse_specialist.pdf (accessed 28 february 2020). 3. wangensteen s, johansson is, nordström g. the first year as a graduate nurse: an 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https://doi.org/10.1016/j.sbspro.2014.07.702 https://doi.org/10.4102/curationis.v36i1.106 https://doi.org/10.1016/j.ijans.2018.11.006 https://doi.org/10.1016/j.ijans.2018.11.006 https://doi.org/10.1016/j.ijans.2019.04.004 18 april 2021, vol. 13, no. 1 ajhpe article the current covid-19 pandemic, which is expected to continue far into 2021, has severely disrupted the undergraduate bedside learning and teaching programme in the department of paediatrics at the chris hani baragwanath academic hospital (chbah) in south africa. chbah is the largest academic hospital affiliated with the university of the witwatersrand, in johannesburg. traditional bedside learning ceased when south african (sa) universities were closed at the beginning of the lockdown in march 2020, leading to a mass swing to emergency remote learning (erl). while online teaching can augment clinical training, it cannot replace bedside clinical skill training. as the lockdown restrictions have eased, students have gradually returned to the hospital in limited numbers to resume clinical training. however, the clinical learning environment is far from ideal,[1,2] and students are not acquiring the expected clinical competencies. the impact of the pandemic on clinical training at chbah is similar to that experienced elsewhere (table 1). in addition, in our situation, clinicianeducators are anxious and want to minimise the time spent in high-risk clinical areas. the use of personal protective equipment (ppe), coupled with brief clinical examinations, has severely limited direct interactions with patients. there is also uncertainty about, among other things, the impact of a second wave of the pandemic, when students fully return to the clinical learning environment, and how to deal with students who contract covid-19 and miss large parts of their clinical rotations. chiel et al. explicitly stated that ‘the central tenet of medical education [referring to bedside learning and teaching] must be re-examined’ and that ‘it is hard to ignore that question of whether trainee education is worth pursuing amid a pandemic.’[3] the impact of the pandemic on medical education will endure. in our situation, the lack of comprehensive clinical training immediately affects medical students in the final 3 years of study (years 4 6 of the 6-year mb bch degree). assuming a best-case scenario where bedside clinical training ‘normalises’ in the future, these undergraduate students will need additional undergraduate training. affected final (6th)-year students will require additional training during their internship year. while acknowledging hardships caused by the pandemic, the clinical competencies of these students and graduates (through no fault of their own) will be substandard.[2] without additional training, these deficiencies will persist. the pandemic has affected bedside clinical training in various ways. when severe restrictions (or levels of lockdown) were in place, bedside clinical training ceased completely. bedside training did not return to normal when restrictions were eased because clinician-educators continued to work at the pandemic coalface and adherence to covid-19 safety protocols took precedence over bedside training. this consequence meant that students did not fully re-enter the clinical workspace: students took turns to stay at home and attend hospitals and clinics for limited bedside training. prior to the covid-19 pandemic, at our university, medical students learned about basic sciences in their first year, and mainly anatomy and physiology in their second year. the third and fourth years were probably best described as students undertaking ‘integrated body system learning’ with associated minor clinical skills training. in their last 2 years of training, students undertook discipline-based, 5to 6-week block rotations with an emphasis on bedside clinical training, with some lecture-based learning. these clinical blocks were offered either in a single year (for some disciplines) or in both clinical years (for others). final assessments were undertaken at the end of each clinical block and were characterised by theoretical and clinical (mainly objective structured clinical examination (osce)) components. the curriculum specified core topics that students should learn during their clinical rotations; blended learning was not the 2020 covid-19 pandemic has severely disrupted paediatric undergraduate bedside clinical training. facing an uncertain future, we need to be able to adapt to the variable effects of the pandemic on bedside training. during severe conditions, no bedside training is possible, while limited bedside training is possible during less severe conditions. we propose a learning and teaching model for undergraduate paediatric clinical training during and beyond the covid-19 pandemic to facilitate bedside clinical training in order to maximise students’ acquisition of clinical competencies. afr j health professions educ 2021;13(1):18-22. https://doi.org/10.7196/ajhpe.2021.v13i1.1447 a blended learning and teaching model to improve bedside undergraduate paediatric clinical training during and beyond the covid-19 pandemic s g lala,1,2 mb bch, mmed, fcpaed, phd; a z george,3 bsc, bsc hons, phd; d wooldridge,4 ma; g wissing,4 phd; s naidoo,4 bfa; a giovanelli,4 bfa; j king,4 ba; m mabeba,4 bfa, pgce; z dangor,1 mb bch, mmed, fcpaed, phd 1 paediatric education and research ladder, department of paediatrics and child health, faculty of health sciences, university of the witwatersrand and chris hani baragwanath academic hospital, johannesburg, south africa 2 perinatal hiv research unit, faculty of health sciences, university of the witwatersrand and chris hani baragwanath academic hospital, johannesburg, south africa 3 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 4 centre for learning, teaching and development, university of the witwatersrand, johannesburg, south africa corresponding author: s g lala (sanjay.lala@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. april 2021, vol. 13, no. 1 ajhpe 19 article a major feature of the current curriculum and the curriculum was not specifically designed to promote self-directed learning. the pandemic has forced clinician-educators to re-examine and re-imagine existing training methods, especially for students in their final 2 years of study, which have a strong emphasis on bedside clinical training. the introduction of online learning and teaching platforms (albeit imposed by the swing to emergency remote teaching (ert)[4]) has made clinicianeducators aware of blended learning systems that could improve the quality of bedside clinical training in resource-limited settings. the potential advantages that blended learning systems offer are very likely to extend beyond the post-covid-19 period. how, then, do we move forward? we propose a blended learning model for continuing the instruction of fifthand sixth-year undergraduate bedside clinical training during the different stages of the pandemic. most clinician-educators could face three stages of severity of the pandemic (or variations thereof ) when considering if and how bedside training should occur. the first stage describes the period when no bedside training is possible, the second describes a situation where limited bedside training is possible, and the third envisages a return to pre-pandemic training. considering that the duration of the pandemic is uncertain (as evidenced by the often worse second wave of infections in the usa and europe) and that our pre-pandemic bedside teaching conditions were far from ideal,[2] we propose that a blended learning programme be used to continue undergraduate bedside training during and beyond the covid-19 pandemic. during the development of our clinical training model, we accepted the following conditions, choices and assumptions about clinical training during and beyond the pandemic: • we should accept that the quality of clinical training (i.e. the acquisition of clinical competencies and reasoning) will be sub-optimal while safety protocols such as physical distancing are required. • we should not defer difficult choices that lead to a ‘toxic combination of inaction and paralysis.’[5] table 1. the impact of covid-19 on undergraduate bedside clinical training (modified after chiel et al.)[3] and potential solutions limited direct interaction with patients: • clinical encounters with inpatients and outpatients are reduced; parents/ caregivers have restricted access to inpatient wards. • continuity relationships –where one gets to know a patient – are disrupted. improving interactions with patients: • patient encounters need to be focused, brief and effective. patient interactions should be maintained telephonically or electronically for continuity of care. • opportunities need to be identified to facilitate patient, learner and clinician-educator safety in the clinical workspace. reduced colleague/multidisciplinary team interaction: • ‘grand ward rounds’ – where colleagues and students interact around a patient’s bedside – are absent. • live interactions at academic meetings (such as journal clubs and case presentations) have ceased. improving colleague/multidisciplinary team interaction: • professional interactions may continue online/electronically. suspension of bedside clinical training: • cancelled clinic visits and decreased inpatient volumes, postponed elective admissions or procedures, and dramatic changes in staffing protocols limit the number of training opportunities and the number of students who can be taught in the hospital. • the move to online learning and teaching platforms raises several problems such as data access and costs, and clinician-educator and readiness. resuming bedside clinical training using blended learning: • expert clinician-educators should demonstrate bedside clinical skills in online courses. specific clinical skills (selected based on their diagnostic relevance and level of difficulty) should initially be demonstrated. preference should be given to material that promotes self-directed learning. next, to develop specified clinical competencies, learners should be given directed instruction on how to integrate physical findings to make a diagnosis. • high data costs need to be addressed at a co-ordinated institutional, government and service provider level. • faculty development is required for the production of effective online learning materials. • reform existing curricula.[8] insufficient bedside time to develop effective assessment skills: • students (who will soon become interns) who spend minimal time in clinical environments cannot perform efficient and tailored physical examinations, and are therefore unable to make accurate clinical assessments. maximising bedside time to develop effective assessment skills: • new forms of learning materials and online programmes need to be created; for example, blended learning programmes that facilitate the achievement of clinical competence. • faculty development focusing on clinician-educators demonstrating fundamental skills at the bedside is needed; these skills should enable interns to diagnose common and/or life-threatening illnesses. • clinician-educators should adopt effective learning approaches when bedside training time is limited. this includes the facilitation of pattern recognition by the student instead of the slower traditional socratic methods.[9] • assessment tools and examinations (including ward-based assessments) need to be redesigned for blended learning curricula. • students need to learn how to triage effectively during a global pandemic and to develop and strengthen health systems during the pandemic. 20 april 2021, vol. 13, no. 1 ajhpe article • we should design adaptable training programmes that can buffer the uncertainties created by the changing levels of pandemic severity on the learning space and environment. • we need to incorporate innovative, technologically supported methods to enhance blended learning approaches.[6] clinicianeducators need to work out which clinical skills and competencies are best learnt online and which are best learnt at the bedside. our covid-19 blended learning model (fig. 1) shows the different clinical training options that are available during different stages of severity of the pandemic and in the post-pandemic period. four distinct but sequential training options are available during this period: (i) online learning only; (ii) the learning of specific clinical skills at the bedside; (iii) learners receiving directed instruction – at the bedside with clinicianeducators – on how to integrate physical findings to make a diagnosis, and thus acquiring specific and desired clinical competencies; and (iv) the return to full bedside learning. an example of how the model would be used for undergraduate students to acquire clinical competence in the paediatric respiratory examination is presented as an example in box 1. stage 1: severe pandemic as we and other clinician-educators have witnessed,[1,3] bedside clinical training was not possible during the most severe stage of the pandemic. the only available option was online learning, which necessitated an urgent move to what is termed erl. the term ‘erl’ (or sometimes ert – emergency remote teaching) is distinguished from ‘online learning’ because of the lack of time for adequate planning and design,[6] highlighting an urgent need to develop effective online training materials to facilitate student engagement. these resources will be useful both in the post-covid-19 era and if we were to return to severe pandemic conditions in the future. stage 2: moderate-severity pandemic conditions in this scenario, our current situation (as of november 2020) is that students have partially returned to the clinical workspace. clinical training consists of erl and bedside learning. only a certain number of students are allowed into wards at specified times, to maintain physical distancing. the time spent examining children is brief so that all students have an opportunity to examine children. given the limited time at the bedside, online learning is essential to augment clinical training. inspection skills can be effectively learnt online because well-designed materials can excellently demonstrate physical signs. for example, auscultation skills can be taught with greater effectiveness online, compared with bedside learning, using modern electronic stethoscopes that can record and digitise normal and abnormal lung and heart sounds. the shared listening experience of digital recordings, together with the opportunity for immediate feedback, facilitates deliberate practice.[7] palpation and percussion techniques can be demonstrated to students by expert clinicians through short videos, and students can practise these skills among themselves with reference to multimedia resources developed for that purpose. the use of online materials to introduce these examination techniques will allow students and educators to focus on the revision of inspection skills and the mastery of specific examination techniques at the bedside. stage 3: mild-severity pandemic or postpandemic conditions as students and clinician-educators have greater access to clinical workspaces, we should determine how best to design online learning and blend it with bedside clinical training. this situation provides an ideal opportunity to review what we teach and how we teach. we need to consider what has worked during the pandemic thus far, and how best to support clinicianeducators in this time of flux. the educational crisis caused by the pandemic has brought what we teach and how we teach into sharp relief. although we lamented the lack of complete bedside clinical training during the pandemic, we rarely appreciated its value before the pandemic.[2] there is no alternative to learning bedside clinical skills because there are many limitations of technological diagnostic tests. however, we need to define what clinical skills – ranked according to the amount of practice needed to achieve competence – are best taught at the bedside when there is limited time for an examination. less severe pandemic severity more severe (no bedside training) stages of pandemic severity severe pandemic: no bedside training moderate pandemic severity: limited bedside training mild/post-pandemic severity: 'normal' bedside training full bedside training integration of clinical and cognitive skills speci�c clinical skills online learning ert online learning fig.  1. a blended learning and teaching model for undergraduate paediatric clinical training during and beyond the covid-19 pandemic. the figure depicts the changing severity (pink, yellow and green blocks) of a hypothetical covid-19 pandemic (dark blue line) and the variable bedside learning options that are available to students and educators during these times. online learning (red band shown below the broken red line) is the only option available when students are not allowed in the clinical workspace during severe pandemic conditions. with an easing of pandemic severity, other options become available. if bedside learning is possible but severely limited, specific clinical skills should be learnt (blue band). if bedside training time increases, students can learn to integrate multiple clinical skills to develop specified clinical competencies (yellow band). when learning is unrestricted, full bedside learning becomes possible, but online learning options should be retained to complement bedside clinical training. (ert = emergency remote teaching.) april 2021, vol. 13, no. 1 ajhpe 21 article the mastery of clinical skills is not a homogeneous process; some skills are more easily learnt than others. for example, gaining competency in eliciting pedal oedema and detecting scleral jaundice is more straightforward than acquiring mastery in eliciting deep tendon reflexes in children. other clinical skills are challenging to learn and of limited value in undergraduate training: the detection of moderate ascites using the ‘shifting dullness’ technique and the accurate characterisation of cardiac murmurs are very difficult to learn during undergraduate paediatric rotations. the value of these clinical skills needs re-appraisal when the use of ultrasonography and echocardiography is required. therefore, we must define an updated list of essential bedside paediatric clinical skills for undergraduate students. however, the power of clinical examination in making accurate diagnoses must be made clear: students should be strongly encouraged to continuously learn and update their bedside examination techniques throughout their careers. as students become competent in mastering the techniques of specified clinical skills, the interpretation of these clinical signs with deductive reasoning will facilitate clinical diagnosis. to achieve this competency, clinician-educators need to develop teaching and illness scripts that facilitate learning. reflecting on the role of erl during the pandemic, effective online materials must be created, using educational, information technology, media, and contentand clinical-domain experts. although the financial and temporal investment costs for creating these programmes are significant, the box 1. learning clinical skills to acquire competence in the paediatric respiratory examination online learning: online programmes serve as the bridge between the textbook and the bedside, and prepare students for bedside practice of clinical skills before they enter the clinical environment. students will view clinical videos of expert clinicians demonstrating examination techniques and sequences that are relevant to children. specific techniques that facilitate paediatric examination will be demonstrated to novice students. these techniques include reassuring students that it is acceptable to examine the child on the mother’s lap, not to undress the child while ensuring that the examination is thorough and complete, and to avoid ‘adult-style’ examination techniques that upset children – for example, palpating the trachea, assessing chest wall expansion in infants and young children, and percussing before auscultating the chest. programmes should contain clinical recordings (anonymised photographs and videos) of children of various ages with normal breathing patterns and those who demonstrate the abnormal clinical signs associated with respiratory distress (tachypnoea, central cyanosis, alar flaring, head bobbing, opisthotonic posturing, interand sub-costal retractions, chest wall indrawing, hyperinflation, etc.). students can view videos to learn inspection skills; with time, videos can be used to test inspection skills by shortening the viewing time (as an example of purposeful and deliberate practice). the correct percussion techniques, which are often performed incorrectly by doctors, can be demonstrated by expert clinicians; more than one percussion technique can be demonstrated so that students appreciate that clinical skills can be learnt using different approaches. adaptations for challenging clinical scenarios – for example, the percussion of a young infant’s chest – can be demonstrated. digital stethoscopes can record auscultatory sounds (reflecting both the normal physiological state and those present in various illnesses, including sounds indicating upper airway obstruction such as stridor and steator). in this instance, where the student and teacher are both simultaneously listening to identical auscultatory sounds, online learning is better than bedside learning at providing feedback to the student. for 5th-year medical students, online programmes can focus on examination techniques, with the demonstration of both normal and abnormal physical signs. for 6th(or final-) year students, online programmes can focus on clinical diagnosis and management. for both years, material from online programmes can be used to conduct formative and summative assessments. during the level 5 covid-19 lockdown (i.e. severe restrictions), clinical skill acquisition can only be taught using online programmes. clinical skills: focus on specific clinical skill acquisition at the bedside, using purposeful and deliberate practice. clinician-educators should prepare for these lessons in advance, focus on clinical skill practice by the student, and refrain from delivering didactic lectures at the bedside. scripts that facilitate learning of clinical skills and clinical reasoning must be developed. example 1: practice percussion techniques on children of all ages and sizes. teach the student to examine effectively and timeously – for example, two taps with the plexor finger on the pleximeter finger to determine the percussion note accurately. in the first instance, learn what a normal resonant note sounds like, and then extend one’s practice to focus on hyper-resonant and impaired resonance notes. differentiating dullness from stony dullness will come with practice and experience, and remains difficult in young infants. example 2: teach auscultatory skills in a structured and sequential manner. novice students are overwhelmed by the plethora of abnormal physical signs present in ill, hospitalised children. they struggle with the interpretation of abnormal signs because they are unsure about physical signs present in the normal physiological state. we favour using a phased approach and check that students are competent at each stage before moving on to the next. for lung auscultation, we begin by assessment of the nature and intensity of breath sounds, followed by detection of any added abnormal sounds. we teach students to differentiate crackles from wheezes first (and teach timing and further specification of these sounds later). we explain that mastery of uncommon and rare sounds (such as bronchial breathing and pleural rubs) comes with practice and experience. integration of clinical and cognitive skills: once competence in specified clinical skills training is achieved, the student is taught to integrate clinical signs to make a diagnosis or formulate a differential diagnosis. relevant complementary clinical skills are taught – for example, screening for features that suggest right heart failure complicating the respiratory disease. for 5th-year medical students, the focus is on the acquisition of specific clinical skills until acceptable competence is reached. final-year students must be able to elicit physical signs, make a diagnosis (or formulate a differential diagnosis), and discuss management principles of common and life-threatening respiratory illnesses. again, for both years, formative and summative assessments should be conducted during the student’s clinical rotation block. during lockdown levels 3 to 4 (i.e. moderate restrictions), specific clinical skill acquisition should be taught to novice medical students entering the clinical workspace, while more senior medical students should be taught to rapidly diagnose common, acute or life-threatening respiratory illnesses in children. further learning of chronic or non-life-threatening conditions can occur using blended learning programmes. full bedside learning: in the final phase, every student (5th or 6th) should have time and opportunity to complete self-directed detailed examinations and further practice and refine clinical skills. 22 april 2021, vol. 13, no. 1 ajhpe article technology can be efficiently scaled up for use by other clinical departments, and online programmes can be co-created and shared with other national and international departments to reduce costs. although we have focused on undergraduate students in the present discussion, we need to think about the adverse effects of the pandemic on our current interns too. current interns have received limited clinical training during their paediatric rotations, and additional training would be required to ensure that these doctors have the desired clinical competency levels if they choose to undergo further training in paediatrics. these doctors can use the same online teaching resources to complement their clinical training. our experiences at chbah have influenced the development of our model. but we believe that learning and teaching conditions, as well as the effect of the covid-19 pandemic on clinical training, are similar in many other national and international resource-limited settings. we hope that our proposed blended learning model will benefit educators and students in other settings and that it is used and refined beyond the current pandemic period. at our university, the priority would be to update but shorten our current paediatric undergraduate curriculum using a pedagogic content knowledge framework.[8] much content can be effectively delivered using online platforms so that the valuable time available for bedside training is used effectively. ideally, by mid-2021, we should have created a blended learning programme that facilitates the learning of bedside clinical skills, and developed scripts for learning clinical skills and clinical reasoning. to be clear, our model needs scrutiny and validation and may require modification; but, in these uncertain times, we cannot continue on the current path for much longer and fulfil our mandate to train and graduate competent doctors. declaration. none. acknowledgements. none. author contributions. sgl wrote the first draft. all authors contributed to the development of the blending learning model, read and approved the final draft. funding. this work is based, in part, on preparations for creation of a paediatric physical examination skills (ppes) online instructional programme or massive open online course (mooc). the ppes mooc is part of the open-access paediatric technology assisted learning (open petal) project, funded by the discovery fund (ref. no. 039042). the project is managed through malamulele onward npc. conflicts of interest. none. 1. le roux c, stinson k, dawood f, van vuuren nj, dramowski a. south african medical students’ perspectives on covid-19 and clinical training. wits j clin med 2020;2(3):227-230. https://doi.org/10.18772/26180197.2020. v2n3a9 2. george a, dangor z, lala sg. lamenting the changes in clinical bedside paediatric teaching at chris hani baragwanath academic hospital: more resources are needed to train effective doctors. s afr med j 2020;110(5):347. https://doi.org/10.7196/samj.2020.v110i5.14678 3. chiel l, winthrop z, winn as. the covid-19 pandemic and pediatric graduate medical education. pediatrics 2020;146(2):e20201057. https://doi.org/10.1542/peds.2020-1057 4. affouneh s, salha s, khlaif zn. designing quality e-learning environments for emergency remote teaching in coronavirus crisis. interdiscip j virtual learn med sci 2020;11(2):1-3. 5. sneader k, singhal s. beyond coronavirus: the path to the next normal. mckinsey and company. https:// www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/beyond-coronavirus-the-pathto-the-next-normal (accessed 30 september 2020). 6. mccutcheon k, lohan m, traynor m, et al. a systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. j adv nurs 2015;71(2):255-270. https://doi.org/10.1111/jan.12509 7. marcus ch, newman lr, winn as, et al. teach and repeat: deliberate practice for teaching. clin teach 2020;17:1-7. https://doi.org/10.1111/tct.13205 8. george a, dangor z, lala sg. south african undergraduate paediatric clinical training: a call to action. s afr j child health 2020;14(1):2-3. https://doi.org/10.7196/sajch.2020.v14i1.1755 9. black cc. experiential teaching paradigms: adapting the medical education literature to academic pathology practice. acad pathol 2019;6:2374289519892553. https://doi.org/10.1177/2374289519892553 accepted 11 january 2021. https://doi.org/10.18772/26180197.2020.v2n3a9 https://doi.org/10.18772/26180197.2020.v2n3a9 https://doi.org/10.7196/samj.2020.v110i5.14678 https://doi.org/10.1542/peds.2020-1057 https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/beyond-coronavirus-the-path-to-the-next-normal https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/beyond-coronavirus-the-path-to-the-next-normal https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/beyond-coronavirus-the-path-to-the-next-normal https://doi.org/10.1111/jan.12509 https://doi.org/10.1111/tct.13205 https://doi.org/10.7196/sajch.2020.v14i1.1755 https://doi.org/10.1177/2374289519892553 34 june 2019, vol. 11, no. 2 ajhpe editorial i was recently involved in the resuscitation of a patient who collapsed while i was doing a post-intake ward round in a busy public hospital in cape town. without a big fanfare, the nursing staff had started basic cardiopulmonary resuscitation (cpr) and we were alerted to the need for medical assistance. taking a whole ward round of students to a resuscitation event was not part of my plan for the morning, but it presented a unique opportunity for learning. not only for the nursing staff, the students and the junior doctors, but also for me. after we had worked together for about 45 minutes, i had a moment to count the number of faces around me. in total there were 6 nurses, 10 medical students, an intern, a registrar and me. what struck me was the ‘quietness’ of a busy resuscitation engaging the attention of almost 20 people. while everyone was busy doing something useful, it was hard to work out who was ‘in charge’. indeed, afterwards i had to think long and hard about who was issuing most of the instructions and how the entire process was being co-ordinated. it just seemed to ‘work’ without the need for harsh tones of voice, stern words, abrupt instructions or any form of communication that was not appreciative. during the debriefing session after we had concluded our resuscitation work, i asked everyone to reflect on the event. what i had noticed, had not gone unnoticed by those present. the nursing staff were the first to comment on the quality of the communication and the manner in which their fears were allayed by the appreciation showed by everyone for the work that was being done. this theme was again echoed by the students and the junior clinical staff. it was only later in the evening that i had an opportunity to reflect on the power of appreciation and its role in leadership. derived from the philosophy[1] and practice of appreciative inquiry,[2] appreciative leadership has been defined by drs diana whitney and james ludema as ‘the capacity to discover, magnify and connect that which is good and healthy, in people and the world around them, in such a way that deepens relatedness, inspires transformation and mobilises positive social innovation’.[3] essentially, this approach to leadership is characterised by five elements. by providing a brief description of each of these elements it will become apparent that the resuscitation was a spontaneous embodiment of the basic tenets of appreciative leadership. inclusion refers to the engagement of all stakeholders, i.e. the entire organisation, in the process. this requires finding a useful role for everyone – a role that plays to the strengths and passions of all present. inquiry is a shift in the agenda from ‘telling to asking’. indeed, most of the resuscitation was framed as a series of questions focusing on the status of the patient and her response to our treatment. these questions generated more questions about the next most appropriate response, guided by cpr best practice guidelines, and a conversation between staff about the way forward. this dialogue reflected the dynamic nature of the situation we were faced with and the possibilities for learning ‘in the moment’. illumination is a process of creating an ‘alignment of people’s strengths’ so as to make their ‘weaknesses irrelevant’.[4] inspiration creates hope about and for the future. in the face of a very challenging situation, junior staff were learning from the successes of others present and were inspired to ‘do it right and get it right’. students spoke of the opportunity to do real chest compressions and how they were encouraged by the cardiac output achieved when it was done correctly. and then there is integrity, the last spoke of the wheel. this refers specifically to ‘relational integrity’ and the need to create a ‘world that works for all’.[5] it is a process of balancing the needs of everyone and recognising their contribution to the work being done, i.e. being appreciated for doing one’s best. so why write an editorial about an unsuccessful resuscitation? i’ve chosen to write about it because the entire process resonated so well with the critical elements of leadership that we neglect to teach our students. the event reminded me that we don’t spend enough time explicitly teaching our students to lead and we often fail to lead when circumstances seem insurmountable in the harsh realities of clinical practice. so how then will they learn? surely the time has come to embed the elements of this positive approach to leadership in the training of healthcare professionals? prof. vanessa burch editor: african journal of health professions education vcburch.65@gmail.com 1. cooperrider dl, srivastva s. appreciative management and leadership: the power of positive thought and action in organizations. san francisco: jossey-bass, 1990. 2. whitney d, trosten-bloom a. the power of appreciative inquiry: a practical guide to positive change. oakland: berrett-koehler publishers, 2002. 3. whitney d, ludema j. appreciative leadership development program. participant workbook. lexington: corporation for positive change, 2006. 4. cooperrider dl. foreword. in: schiller m, mah holland b, riley d. appreciative leaders: in the eye of the beholder. ohio: taos institute, 2001. 5. whitney d. leading by design: the five elements of appreciative leadership as design criteria. https://www. taosinstitute.net/websites/taos/files/content/5692967/whitney_leading_by_design.pdf (accessed 10 june 2019). afr j health professions educ 2019;11(2):34. doi:10.7196/ajhpe.2019.v11i2.1232 this open-access article is distributed under creative commons licence cc-by-nc 4.0. leading when it matters https://www.taosinstitute.net/websites/taos/files/content/5692967/whitney_leading_by_design.pdf https://www.taosinstitute.net/websites/taos/files/content/5692967/whitney_leading_by_design.pdf june 2020, vol. 12, no. 2 ajhpe 62 research burnout is common among healthcare practitioners and medical students. between 15% and 20% of physicians experience mental health problems in their working lifetime.[1,2] approximately 63.4% of medical students were vulnerable to burnout, with half of these having chronic burnout.[3] medical students are at risk of burnout owing to various demands placed on them, including academic workload, emotional and physical challenges, and meeting the standards required of healthcare professionals from public and governance structures.[4-6] burnout, defined as emotional exhaustion, depersonalisation and a sense of low personal accomplishment[7] may predict dropout and suicide ideation among medical students. depression and suicidal ideation have been reported as 27.2% and 11.1%, respectively.[8] the prevalence of burnout ranges between 18% and 82%.[9,10] understanding burnout and its related factors is essential to protect students during training,[3] and should be addressed timeously to prevent depression and dropout.[11] academic performance may be impeded by increasing levels of distress,[12] and students’ ability to function effectively as future healthcare workers must be ensured.[13] personal characteristics, the learning environment and perceptions regarding support play a role in protecting against or facilitating recovery from burnout.[3] as future healthcare professionals entering the workforce, medical students should be monitored for threats to their wellbeing, including burnout, and institutions should focus on strategies to relieve burnout and its effects to ensure effective performance.[14] the aim of this study was to investigate burnout among undergraduate students at a south african (sa) medical school, and the influence of factors such as demographic profile, perceived stressors and support on their levels of burnout. methods this study formed part of a larger research project on resilience in undergraduate medical students. for the purpose of this article, quantitative data regarding burnout and associated factors were collected by means of a standardised, validated questionnaire that also obtained demographic data and information related to resilience. the target population included all students in the undergraduate medical programme at an sa university, who were invited to participate in a questionnaire survey. all undergraduate students who were registered in the 5-year mb chb programme, from first to final year, were eligible to participate. a pilot study on 5 students in the undergraduate nutrition and dietetics programme determined whether the time taken to complete the questionnaire was sufficient, and it identified any logistical issues related to completion of the questionnaire. the data from the pilot study were not included for analysis. the questionnaires were distributed to all undergraduate medical students during classroom contact sessions. students were informed that their participation was voluntary and anonymous. the questionnaire included variables such as demographic data (age, gender, race, year of study), information regarding recent major stressful life events, levels of support, perceptions of the learning environment, perceptions regarding resilience and academic performance, and the copenhagen burnout inventory (cbi).[15] the cbi measures three areas of burnout: personal, work related and patient related. it consists of 19 items rated on a 5-point likert scale. in the cbi, ‘personal burnout is “the degree of physical and psychological fatigue and exhaustion experienced by the person”, workbackground. medical students are at risk of burnout owing to various challenges. objectives. to investigate burnout and associated factors among undergraduate students at a south african medical school. methods. in this cross-sectional study, findings of the copenhagen burnout inventory (cbi), demographic data and information related to resilience were collected by means of an anonymous self-administered questionnaire. associations between burnout subscales and various factors were determined. results. five-hundred students (preclinical, n=270; clinical, n=230) completed the questionnaire. cbi mean scores for preclinical and clinical students were 17.9 and 17.4 (personal), 22.3 and 21.9 (work related) and 24.8 (patient related; clinical students only), respectively. high scores on the subscale reflect low levels of burnout in related areas. male students and students with high self-reported resilience and low stress had significantly lower burnout levels. white preclinical students had lower levels of personal and work-related burnout, and black clinical students had less patient-related burnout. conclusions. high mean scores in all three burnout subscales indicated low burnout levels among students. academic and personal stress, as well as perceived poor support from institutional structures, were associated with significantly higher personal and work-related burnout, but not patient-related burnout in clinical students. afr j health professions educ 2020;12(2):62-67. https://doi.org/10.7196/ajhpe.2020.v12i2.1172 burnout and associated factors in undergraduate medical students at a south african university l j van der merwe,1 mb chb, mmedsc, da (sa), phd (hpe); a botha,2 phd (counselling psychology); g joubert,3 ba, msc 1 undergraduate medical programme management, school of clinical medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of psychology, faculty of humanities, university of the free state, bloemfontein, south africa 3 department of biostatistics, school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: l j van der merwe (merwelj@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 63 june 2020, vol. 12, no. 2 ajhpe research related burnout refers to “the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work”, and patient(client-) related burnout refers to “the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work with clients”.’[15] the possible range for the score on the 6 items on personal burnout is 6 30, with 6 indicating high and 30 low burnout. the 7 items on the work-related burnout subscale can yield scores between 7 and 35, with 7 indicating high and 35 low burnout. on the patient-related subscale, a range of 6 30 can be scored on the 6 items, with 6 indicating high and 30 low burnout.[15] therefore, the higher the score obtained on a subscale, the less likely the student is to experience burnout in that particular area. a total score of 95 indicates low burnout, while a score of 19 indicates high burnout. in this study, preclinical students did not complete the patient-related burnout subscale. therefore, the scores in each of the three subscales were described separately, and a total score was not determined. the alpha coefficients for the various subscales were between 0.85 and 0.87 for a us adult sample.[15] in addition to anonymous completion of the questionnaire, data were managed with strict confidentiality. statistical analysis of quantitative data was performed using sas software (sas institute, usa). descriptive statistics and reliability coefficients were calculated, and the associations between burnout, demographic and other factors affecting resilience were determined. ethical approval approval to conduct the study was obtained from the health sciences research ethics committee of the faculty of health sciences, university of the free state, bloemfontein, sa (ref. no. hsrec 63/2017). permission to include the students in the research was granted by the relevant university authorities. results the sample population comprised 696 students. a total of 500 students completed the questionnaires and were divided into preclinical (n=270; response rate 79.2%; year 1 and 2; mean age 20 years) and clinical (n=230; response rate 62.0%; year 3, 4 and 5; mean age 22.6 years) groups. preclinical students had not yet been exposed to patients in the clinical training environment, and could therefore not comment on patient-related burnout. the participants included 61.9% female students in the preclinical and 56.5% in the clinical groups. only 20.5% of preclinical and 17.3% of clinical students reported that they were firstgeneration students (defined in this study as students whose parents had never been enrolled in post-school higher education). table 1 shows the cbi scores measured in personal and work-related burnout areas for both the preclinical and clinical groups, and patientrelated burnout for the clinical group. the mean scores for preclinical and clinical students were similar in both personal and work-related burnout areas. both groups had high scores in the personal and work-related subscales, indicating low burnout. clinical students demonstrated high scores in the patient-related subscale, with a mean score of 24.8. the reliability coefficients were calculated for preclinical students in the personal (0.84) and work-related (0.81) subscales, and for clinical students in the personal (0.88), work-related (0.85) and patientrelated (0.82) subscales. in table 2, self-reported resilience and factors related to burnout are shown, and table 3 (http://www.ajhpe.org.za/public/files/1172.doc) summarises the associations between burnout subscales and related factors. in both the preclinical and clinical groups, first-generation students did not show significantly higher levels of burnout than those who were not first generation. the term ‘first-generation student’ originated in the usa. in sa, heymann and carolissen[16] indicated that first-generation status is one of many factors that may influence students’ experiences in higher education. in both groups, significantly higher scores were obtained by male students on the subscales for personal burnout. in the clinical group, male students also had significantly higher scores on the work-related subscale. female students in the clinical group had a slightly higher score on the patientrelated subscale, but this was not statistically significant. students (n=500) self-reported ethnicity as black (n=151), coloured (n=41), white (n=262), indian (n=36), asian (n=5) and other (n=4). one student did not indicate ethnicity. for the purpose of this article, black and white students were included in the analysis to determine the possible associations with burnout, as meaningful conclusions could not be drawn with small numbers of students from other ethnic groups. black students in the preclinical group had significantly lower scores (indicating higher burnout) on both personal and work-related subscales. in the clinical group, black students had significantly higher scores than white students on the patient-related subscale. the slightly lower subscale scores among black students, which related to personal and work-related burnout, did not differ significantly from the white students’ scores. in both groups, self-reported high resilience and no/minor levels of stress were associated with significantly less personal and work-related burnout, as well as lower patient-related burnout in clinical students. the majority of students experienced academic stress, which was associated with significantly more burnout in personal and work-related subscales, but not among clinical students in the patient-related subscale. students reported their academic performance to be above or the same as the class average, and low percentages of students had previously or were currently repeating an academic year. personal stress was also associated with significantly more burnout on the personal and work-related subscales for both student groups. in contrast, clinical students who reported personal stress had less patient-related burnout, although this was not statistically significant. financial stress was not associated with significantly higher burnout, and there were too few other stressors reported to allow for the assessment of an association between other stressors and burnout. the majority of students (preclinical, 97.7%; clinical, 93.8%) did report some stressors, but only clinical students had significantly more personal and work-related burnout than students who reported no stressors. relationship break-up in the preceding 12 months was reported by more preclinical than clinical students and was associated with slightly lower table 1. copenhagen burnout inventory scores on burnout areas for preclinical and clinical undergraduate medical students burnout area preclinical (n=270), mean (sd) clinical (n=230), mean (sd) personal (possible range 6 30) 17.9 (4.5) 17.4 (4.7) work related (possible range 7 35) 22.3 (5.3) 21.9 (5.2) patient related (possible range 6 30) not done 24.8 (3.7) sd = standard deviation. june 2020, vol. 12, no. 2 ajhpe 64 research scores on burnout subscales. no clear association between parents’ divorce or major illness/health events and burnout could be made owing to the low number of students who reported these stressors. major illness in a family member in the preceding 12 months was not associated with significantly more burnout, although clinical students did score slightly lower on the personal burnout subscale when reporting this stressor. preclinical students who reported death of a close friend or family member scored significantly lower on the work-related but not on the personal burnout subscale. preclinical students who reported no major life events in the preceding 12 months also had significantly higher work-related burnout subscale scores. most of the preclinical (66.5%) and clinical (76.1%) students indicated satisfaction with support received from family. the level of satisfaction was not associated with burnout subscale scores. most students reported satisfaction with support received from friends and peers. those who were either neutral or somewhat to very dissatisfied with such support, did have slightly lower burnout scores, although these were not statistically significant. although preclinical students were mostly neutral or satisfied with support received from school of medicine academic staff, those who reported dissatisfaction scored significantly lower on personal and workrelated subscales. clinical students were more dissatisfied with support from the school of medicine; this was associated with significantly lower scores on personal burnout subscales, and a tendency to lower work-related, but not patient-related subscale scores. preclinical students who were somewhat to very dissatisfied with support received from the faculty of health sciences (administrative) staff scored significantly lower on personal and work-related subscales. although similar patterns were seen among clinical students, these were not statistically significant, and there were no clear associations with patientrelated burnout. although most students were neutral or dissatisfied with support from institutional student affairs staff, there were no significant associations with personal and work-related subscale scores. overall, preclinical students were more satisfied than clinical students with the support they received from the university environment, while clinical students were more satisfied than preclinical students with the support they received from family and friends. associations between students’ perceptions of the learning environment at the school of medicine and the three burnout subscales were also determined. many (40.9%) preclinical students agreed that the learning table 2. self-reported resilience and factors related to burnout of preclinical and clinical undergraduate medical students preclinical, n (%)* clinical, n (%)* p-value self-reported level of resilience, n 269 225 high 227 (84.4) 206 (91.6) 0.02† low 42 (15.6) 19 (8.4) current degree of stress, n 269 230 none/minor 96 (35.7) 61 (26.6) 0.02† mild 137 (50.9) 121 (52.6) severe/devastating 36 (13.4) 48 (20.9) major stressors, n‡ 265 226 academic stress 231 (87.2) 194 (85.8) 0.67 personal stress 131 (49.4) 119 (52.9) 0.45 financial stress 92 (34.7) 70 (31.0) 0.38 other 13 (4.9) 6 (2.7) 2.0 none 6 (2.3) 14 (6.2) 0.03† academic performance, n 266 229 same as class average 121 (45.5) 104 (45.4) 1.0 above class average 120 (45.1) 103 (45.0) below class average 25 (9.4) 22 (9.6) repeat academic year, n 270 230 current 41 (15.2) 4 (1.7) <0.01† previous 53 (19.6) 41 (17.8) 0.61 major life events, n‡ 264 226 relationship break-up 102 (38.6) 50 (22.1) <0.01† parents’ divorce 7 (2.7) 7 (3.1) 0.77 major illness/health event 30 (11.4) 18 (8.0) 0.21 major illness in family member 58 (22.1) 69 (30.5) 0.03† death of close friend/family member 73 (27.7) 69 (30.5) 0.48 other 19 (7.2) 18 (8.0) 0.75 none 94 (35.6) 85 (37.6) 0.65 *unless otherwise indicated. †statistically significant difference. ‡more than one option could be selected. 65 june 2020, vol. 12, no. 2 ajhpe research environment in the school of medicine was collaborative rather than competitive, while 32.6% of clinical students agreed with this perception. a clear pattern was noted, i.e. that students who disagreed with the statement that the learning environment was collaborative rather than competitive, also scored lower on all the relevant subscales. in both groups, students’ perceptions of a competitive rather than collaborative learning environment were therefore associated with higher burnout. the majority of preclinical (82.6%) and clinical (67.0%) students agreed that student education was a high priority for the staff in the school of medicine. in both groups, scores on the burnout subscales indicated low levels of burnout. students who perceived that holistic support was available to them in the school of medicine (preclinical, 57.3%; clinical, 42.3%) also scored significantly higher on the relevant subscales. of the preclinical and clinical students, 64.4% and 56.1%, respectively, were satisfied with the learning environment. there were significant differences in burnout subscales (personal and work-related) of preclinical and clinical students, with higher scores obtained by students who were satisfied with the learning environment. a similar pattern was observed for patient-related burnout scores among clinical students. overall, clinical students were less satisfied with the learning environment in the school of medicine compared with preclinical students. discussion eckleberry-hunt et al.[17] cautioned against a pathology-based approach to burnout research, opposed to an approach that emphasises resilience within a positive psychological context. therefore, a cut-off score has not been used in this study to determine whether students had burnout, but their scores on the three subscales (personal, work related and patient related) have been reported throughout. demographic factors, including gender and ethnicity, may place students at greater risk of burnout and affect their resilience.[3,18-20] however, cultural and contextual factors related to resilience in sa youth have not yet been researched extensively.[21] davenport[11] cited the findings of a meta-analysis, which reported a higher prevalence of burnout in middle eastern countries, possibly related to the impact of ongoing conflict, and in north america, where more studies are done in this field than in europe. this meta-analysis did not report on studies conducted specifically in africa.[11] in the current study, male students had significantly lower burnout in both personal and work-related subscales, similar to studies in other populations.[19,20] female students in the clinical group had slightly higher scores in patient-related subscales, indicating lower burnout in this area. gender as a protective factor preventing burnout should be taken into consideration when planning interventions. black students in the preclinical group scored significantly lower on personal and work-related burnout subscales. this was not the case for clinical students, where black students scored significantly higher on patient-related subscales. it could be argued that black students in the early years of study are more susceptible to burnout, but that the clinical environment may protect them against it. although very few participants in this study were first-generation students, this was not associated with higher burnout, indicating that students without relatives who had previous experience of tertiary education, are not more vulnerable to burnout. however, black students from historically disadvantaged backgrounds may be predisposed to burnout in the early years of study, which may impact on their risk of depression or dropout. overall, >80% of preclinical and clinical students perceived themselves as having high resilience. this was associated with significantly higher scores on all the burnout subscales, demonstrating self-awareness in both student groups. this finding was contrary to that in a study in pakistani medical students who demonstrated a lack of awareness, which predisposed them to higher burnout, leading to the promotion of self-awareness strategies when attempting to prevent burnout.[20] the perceived high resilience and low burnout seen in this group of undergraduate medical students are worth noting in the context of the 5-year curriculum offered by the institution, which may be alleged to place greater time pressure on students. as individual and environmental factors influence resilience and burnout, this study provides valuable insight into the learning environment in medical school, which may contribute to protecting students from burnout and foster positive care.[17] medical studies are associated with various stressors.[22] in this study, most students reported some stressors that were associated with generally lower scores on the burnout subscales, indicating more burnout. approximately one-third of both preclinical and clinical students who reported no or minor levels of stress, had higher subscale scores in all three burnout areas. academic stress is inextricably linked to medical training[3,20] and >80% of students in this study reported such stress. it was also associated with significantly lower scores on the personal and work-related burnout subscales in preclinical and clinical students. however, the majority of students reported that their academic performance was above or the same as the class average, revealing that academic stress and related burnout did not impact on academic performance of students in this programme, as has been described previously.[22] more than 90% of all students in this study perceived their academic performance to be the same as or above the class average. a small percentage of students had previously failed (preclinical, 19.6%; clinical, 17.8%) or were currently repeating (preclinical, 15.2%; clinical, 1.74%) the academic year. these findings warrant further research to accurately explore the association between perceived academic stress and recorded academic performance. more preclinical than clinical students reported that they were currently repeating the academic year, indicating that students’ academic progress may improve with increasing seniority. approximately half of the students reported personal stress, which was associated with significantly lower scores on personal and workrelated burnout subscales. in contrast, despite 56.3% of clinical students reporting personal stress, their burnout scores were higher on the patientrelated subscale. this finding may indicate that students increasingly develop resilience and effective coping strategies as they mature into their professional identity – a positive prospect for the future physician workforce. further investigation into the factors that promote resilience in spite of personal stress is warranted, as resilience is regarded as a predictor of wellbeing that may buffer against stress.[23] financial stress was reported by approximately one-third of students, although it was not associated with significantly lower burnout subscale scores. this finding was unexpected in light of the current discourse related to government funding of higher education in sa[24] and the literature pointing to debt as a significant stressor in higher education.[3] further research in this regard is recommended. major life events may contribute to stress in student populations.[3] therefore, this study determined the prevalence of relationship break-up, parents’ divorce, major illness or health events, major illness in a family member and death of a close family member or friend as major life events june 2020, vol. 12, no. 2 ajhpe 66 research in the preceding 12 months. while slightly lower scores on the burnout subscales were observed, students reporting any of these major life events did not have significantly more burnout. the exception was the death of a close family member or friend, which was associated with significantly lower scores in work-related burnout among the preclinical students. in this study, major life events probably did not predispose students towards burnout, as reported by dyrbye et al.,[3] further emphasising the reported high resilience in this study population. social support and autonomy are associated with wellbeing and resilience.[25-27] in this study, the majority of preclinical and clinical students were satisfied with the support received from family, friends and peers, and no significant differences were observed in burnout subscales among students who were not satisfied with the support received from these sources. preclinical students reported more satisfaction with school of medicine academic staff and faculty of health sciences support staff than clinical students, and increased levels of satisfaction were associated with significantly lower burnout. however, patient-related burnout among clinical students was not significantly higher in those who reported dissatisfaction with support received from faculty of health sciences support staff. these findings suggest the need for increased emphasis on medical school support strategies that are visible and accessible to students across the preclinical and clinical years of study. most students reported that they were not satisfied with the support received from institutional student affairs staff, which was also associated with slightly higher burnout in both student groups. the fact that medical students in this programme are somewhat isolated from the general campus environment in terms of academic calendar and geographical training areas, may contribute to their less favourable perception of institutional support. it did not significantly contribute to burnout and was therefore negligible. the competitive nature of medical school is a known cause of stress among students.[28] generally, 30 40% of students in this study perceived the learning environment in the school of medicine to be collaborative rather than competitive. students who perceived the environment as competitive had significantly higher burnout. the majority of participants in this study agreed that students’ education was a high priority for academic staff, and >40% of students felt that holistic support was available. these factors were associated with lower burnout in all three subscales. more than half of all students indicated satisfaction with the learning environment, which was also associated with lower burnout in all the subscales. preclinical students were generally more satisfied with the learning environment than clinical students. this finding could be attributed to preclinical training being mainly limited to the university environment, where lecture facilities, practical training spaces and resources such as staff and equipment are maintained by the institution. however, clinical training takes place in hospitals and clinics outside institutional authority where under-staffing, lack of resources and increased service delivery and patient loads may place greater demands on students rotating in these areas, as well as on academic staff responsible for student training and patient care. the effect of adverse working environments on staff wellbeing has been highlighted in the uk.[29] the findings from this study underline the need to promote wellbeing and resilience among medical students who are trained in a challenging environment, as resulting mental health problems may be associated with poor patient care.[13] study limitations the study was conducted during the second semester (july november) of an academic year over a period of 2 months. differences in burnout scores could be seen during periods of increased academic pressure, e.g. assessment. it would therefore be valuable to repeat the burnout inventory at a different time of the year. the results reported in this paper should not be viewed in isolation, because a single, once-off measure of burnout may not accurately reflect all the nuances impacting on student wellbeing. the additional information obtained regarding coping styles and resilience from the larger study, which falls beyond the scope of this paper, will contribute to a more balanced and comprehensive view of this student population. conclusions in this cross-sectional study on preclinical and clinical undergraduate medical students in a 5-year mb chb programme, high scores on personal and work-related subscales and patient-related subscales for clinical students, using the cbi, revealed a low level of burnout. male students and students who self-reported high levels of resilience and low levels of stress had significantly lower burnout, as indicated by higher scores on the personal and work-related subscales of the burnout inventory, while white preclinical students had lower personal and work-related burnout and black clinical students had lower patient-related burnout. preclinical students who perceived a high level of holistic institutional staff support, and who reported a collaborative rather than competitive learning environment that prioritises student education and academic development, had significantly lower personal and work-related burnout. both preclinical and clinical students who were satisfied with the learning environment had significantly lower burnout in both personal and workrelated subscales. major life events, perceived support from family, friends and peers, as well as being a first-generation student, did not significantly impact on burnout scores. few students reported financial stressors and other major life events such as relationship break-up, parents’ divorce or major illness (self/family). these events were not associated with higher burnout, with the only exception being the death of a close family member or friend in the preceding 12 months reported by preclinical students, which led to lower scores on the personal and work-related subscales, indicating higher burnout. this study confirms that medical students are at risk of burnout owing to academic and other stressors, and that the learning environment in medical school should focus on promoting resilience and wellbeing. recommendations the authors recommend that academic stressors should be addressed and support provided to cope with these and other stressors, including personal losses, and stressors such as the death of or disease in close family members and friends. efforts should be increased to ensure student satisfaction with the learning environment, especially among clinical students who are exposed to the public healthcare training environment external to the tertiary institution. the impact of adverse training or working conditions should be investigated further, as the wellbeing of current and future healthcare professionals may be at risk. appropriate support for vulnerable students, such as preclinical female and black students, should be investigated and 67 june 2020, vol. 12, no. 2 ajhpe research implemented, and current strategies in the existing teaching and learning environment should be enhanced to optimise student wellbeing. declaration. none. acknowledgements. dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. author contributions. all authors contributed equally to the manuscript. funding. partial funding was obtained from the research directorate, university of the free state. conflicts of interest. none. 1. boisaubin ev, levine re. identifying and assisting the impaired physician. am j med sci 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https://doi.org/10.4102/sajs.v106i7/8.252 22. kötter t, wagner j, brüheim l, voltmer e. perceived medical school stress of undergraduate medical students predicts academic performance: an observational study. bmc med educ 2017;17(1):256. https://doi. org/10.1186/s12909-017-1091-0 23. shi m, wang x, bian y, wang l. the mediating role of resilience in the relationship between stress and life satisfaction among chinese medical students: a cross-sectional study. bmc med educ 2015;15:16. https://doi. org/10.1186/s12909-015-0297-2 24. van rensburg d, fengu m. zuma’s fee-free higher education chaos. city press, 27 january 2018. https://www. news24.com/southafrica/news/zumas-fee-free-chaos-20180107-2 (accessed 23 august 2018). 25. botha a, van den berg h. trauma exposure and life satisfaction among at-risk black south african adolescents. j psychol afr 2016;26(6):500-507. https://doi.org/10.1080/14330237.2016.1250422 26. prince-embury s. resiliency scales for children and adolescents. a profile of personal strengths. san antonio: harcourt assessment inc., 2006. 27. rutter m. resilience, competence and coping. child abuse negl 2007;31(3):205-209. https://doi.org/10.1016/j. chiabu.2007.02.001 28. dyrbye ln, thomas mr, shanafelt td. medical student distress: causes, consequences, and proposed solutions. mayo clin proc 2005;80(12):1613-1622. https://doi.org/10.4065/80.12.1613 29. sull a, harland n, moore a. resilience of health-care workers in the uk; a cross-sectional survey. j occup med toxicol 2015;10(1):20. https://doi.org/10.1186/s12995-015-0061-x accepted 9 december 2019. https://doi.org/10.1097/00000441-200107000-00006 https://doi.org/10.1097/acm.0b013e318281696b https://doi.org/10.1111/j.1365-2923.2010.03754.x https://doi.org/10.1111/j.1365-2923.2010.03754.x https://doi.org/10.1097/00001888-200604000-00009 https://doi.org/10.1097/00001888-200604000-00009 https://doi.org/10.1111/j.1365-2923.2011.04188.x https://doi.org/10.5502/ijw.v3i1.4 https://doi.org/10.1007/s40037-016-0313-1 https://doi.org/10.1001/jama.2016.17324 https://doi.org/10.1001/jama.2016.17324 https://doi.org/10.4103/1947-2714.177299 https://doi.org/10.1111/tct.12014 https://www.medscape.com/viewarticle/893466_print https://www.medscape.com/viewarticle/893466_print https://doi.org/10.1186/s12909-016-0565-9 https://doi.org/10.1186/s12909-016-0565-9 https://doi.org/10.1111/medu.12934 https://doi.org/10.1016/j.mayocp.2017.09.008 https://doi.org/10.1080/02678370500297720 https://doi.org/10.1097/acm.0000000000001890 https://doi.org/10.1001/archinte.167.19.2103 https://doi.org/10.7759/cureus.390 https://doi.org/10.4102/sajs.v106i7/8.252 https://doi.org/10.1186/s12909-017-1091-0 https://doi.org/10.1186/s12909-017-1091-0 https://doi.org/10.1186/s12909-015-0297-2 https://doi.org/10.1186/s12909-015-0297-2 https://www.news24.com/southafrica/news/zumas-fee-free-chaos-20180107-2 https://www.news24.com/southafrica/news/zumas-fee-free-chaos-20180107-2 https://doi.org/10.1080/14330237.2016.1250422 https://doi.org/10.1016/j.chiabu.2007.02.001 https://doi.org/10.1016/j.chiabu.2007.02.001 https://doi.org/10.4065/80.12.1613 https://doi.org/10.1186/s12995-015-0061-x september 2019, vol. 11, no. 3 ajhpe 72 forum universities, and in particular the research they produce, are central role players in the knowledge economy of the 21st century.[1] in south africa (sa), one of the core tenets of the national plan for higher education is the production of master’s and doctoral graduates.[2] postgraduate supervision, therefore, is an essential function of university educators.[3] apart from overseeing research projects, teaching the research craft, being a role model and providing a supportive relationship to students,[4] supervisors also need to be informed, open and responsive to current debates on global and national platforms. this opinion paper addresses the imperatives of decolonisation and cognitive justice that were emphasised by the rhodes-must-fall movement at the university of cape town, sa, in 2015. while these concepts are sometimes interpreted as a call for the total repudiation of existing knowledge from western origins – an interpretation that is generally unacceptable to the scientific and health domains – this paper draws on the writings of philosophers such as mbembe, visvanathan and others to provide interpretations that are different and (at least to some) more realistic. based on these interpretations, i offer my opinion regarding the current status of research in the health sciences and raise some concerns about two major current and emerging influences that might be in conflict with the calls for decolonisation and cognitive justice. the readings of mbembe,[5] ndofirepi and cross,[6] visvanathan[7] and augusto[8] paint a picture of the prevailing situation in many countries, where a large part of the population still feels ensnared by the notion that whiteness is everywhere and that everything (worthwhile) originates/originated from it. this perception of marginalisation flows from the de-valuing of nonwestern populations’ cultural richness and their unique knowledges that are often denied formal recognition[7] on academic platforms. in essence, these authors communicate that the call for decolonisation is not about the disregard of existing knowledge, but a call for knowledge equity, i.e. for recognition from knowledge-production factories, such as universities, that cultures other than western are also capable of producing valuable knowledge, and that knowledge produced by western cultures cannot be implemented without regard for the differing cultural contexts worldwide. visvanathan[7] uses the term cognitive justice for what he explains as the ideal situation of knowledge democracy in contrast to the current situation of knowledge apartheid, referring to the notion that only scientifically produced knowledge is true and that prescientific knowledge, produced by people without scientific backgrounds, is inferior. a second component playing into the concept of knowledge apartheid, relates to the methods of disseminating knowledge that are often inaccessible to some groups, typically those living far away from metropolitan areas, which in essence deprive them of further development. with reference to the abovementioned brief definitions of decolonisation and cognitive justice, postgraduate supervisors need to consider and incorporate appropriate approaches to work towards achieving these ideal situations. apart from firstly having to engage in critical self-reflection to clarify their personal standpoints, they also have to consider the kind of research they and their students become involved with. in the health sciences, possibilities for decolonised research are limited with regard to purely anatomical and physiological factors, but if one considers the world health organization’s definition of health, i.e. ‘… a state of complete physical, mental and social well-being …’,[9] opportunities for decolonised approaches are ample. this would include culture-sensitive ethical approaches and methodologies tailored to adhere to the western-originated belmont report principles of autonomy, beneficence and justice,[10] but contextualised to the specific cultural or tribal groups’ settings. in this regard, the san code of research ethics[11] is a ground-breaking document with fundamental but simplistic guidelines. in terms of specific topics, one would consider phenomenological studies[12] with research populations consisting of cultural groups other than westernised white groups. such studies seem to be ample in the health sciences domain and one can but say that at least we are moving in the right direction. in contrast to the seemingly positive direction of postgraduate research in terms of research topics and methodologies, the same cannot be said of the methods used to distribute knowledge produced through research, as these are still mostly done through conference proceedings and publications in peer-reviewed journals, which are mostly inaccessible to groups living in remote areas. these methods very often deny research participants the opportunity to become knowledgeable with regard to the effect of their participation in research and it confirms the claim of knowledge apartheid and inequitable treatment. much rethinking and new initiatives are necessary in this field. one approach may be to incorporate into research proposals suitable methods of information sharing with cultural and tribal groups before and after data collection in an effort to educate and recognise their contribution to new knowledge. the dissemination of research-produced knowledge is, however, closely related to, and thus influenced by, the financial needs of universities. whereas universities seem to gain autonomy when state subsidies decrease, they indeed replace their dependence on financial support to paying students, external funders[12] and state institutions such as the department of higher education and training in sa.[13] these entities play a strong dictating role in terms of the research that has to be done to receive funding and the ways of dissemination that are worthy of subsidies. research output, and by implication dissemination thereof through mostly westernised methods, plays a further critical role in terms of universities’ positions decolonisation and cognitive justice imperatives in health sciencesrelated research supervision a louw, brad, brad hons, mtech, dtech department of medical imaging and radiation sciences, faculty of health sciences, university of johannesburg, south africa corresponding author: a louw (amandal@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 73 september 2019, vol. 11, no. 3 ajhpe forum on international ranking platforms, which in turn influence student registrations and funding opportunities. in my opinion, the knowledge dissemination component of decolonisation and cognitive justice should be central to postgraduate research and supervision change discussions. however, this component forms an additional and important source of the income that universities need to stay competitive in the global knowledge industry. further escalation of this dilemma is the emergence of the fourth industrial revolution and the notion that it might widen the divide between skilled and unskilled populations.[14] by implication, the unskilled populations’ access to knowledge disseminated via highly technical channels may be even further compromised, and with it the strive towards knowledge democracy. the following two questions therefore need to be intensely contemplated and deliberated upon, considering the possible conflicts between the calls for decolonisation on the one hand, and financial support and progress in line with the challenges of the fourth industrial revolution on the other hand: • is the ideal to provide not only content, but also social and cultural context, possible (and considered worthwhile) in the knowledge economy milieu where global first-world institutions such as the world bank and european union play strong dictating roles regarding important and negligible knowledge[7,12] and national institutions such as the department of higher education and training[13] control knowledge-disseminating subsidies? • are universities’ support of the fourth industrial revolution and the ideology of knowledge democracy indeed able to merge and run in unison to achieve the calls of augusto,[8] visvanathan,[7] ndofirepi and cross,[6] mbembe[5] and others for a new epistemology where old knowledge and epistemologies stand and function alongside new and diverse ones? if seen against the current background of robust competition among universities for high international rankings, external funding and students, supervisors wanting to align their supervision and knowledge dissemination practices in accordance with the calls for decolonisation and cognitive justice may have a long and uphill road ahead of them. declaration. none. acknowledgements. the author wishes to thank the university of johannesburg postgraduate school for creating a thought-provoking environment conducive to the enrichment of personal perspectives. author contributions. sole author. funding. none. conflicts of interest. none. 1. altbach pg. advancing the national and global knowledge economy: the role of research universities in developing countries. studies higher educ 2013;38(3):316-330. https://doi.org/10.1080/03075079.2013.773222 2. department of education. national plan for higher education. pretoria: doe, 2001. http://www.dhet.gov.za/ hed%20policies/national%20plan%20on%20higher%20education.pdf (accessed 25 november 2018). 3. van rensburg gh, mayers p, roets k. supervision of post-graduate students in higher education. trends nurs 2016;3(1). https://doi.org/10.14804/3-1-55 4. de gruchy jw, holness l. the emerging researcher. nurturing passion, developing skills, producing output. cape town: juta, 2007. 5. mbembe a. decolonizing knowledge and the question of the archive. 2015. https://wiser.wits.ac.za/system/ files/achille%20mbembe%20-%20decolonizing%20knowledge%20and%20the%20question%20of%20the%20 archive.pdf (accessed 8 august 2019). 6. ndofirepi ap, cross m. transforming epistemologies in the postcolonial african university? the challenge of the politics of knowledge. j educ learn 2014;8(4)291-298. 7. visvanathan s. the search for cognitive justice. 2009. http://www.india-seminar.com/2009/597/597_shiv_visvanathan. htm (accessed 15 november 2018). 8. augusto g. transforming knowledge, changing knowledge relations, and epistemic openness in the university in africa. soc dynam 2007;33(1):199-205. https://doi.org/10.1080/02533950708628749 9. international health conference. constitution of the world health organisation. 1946. http://apps.who.int/gb/ bd/pdf/bd47/en/constitution-en.pdf ?ua=1 (accessed 8 august 2019). 10. the belmont report. basic ethical principles and their application. https://youtu.be/m6akiihofn4 (accessed 12 november 2018). 11. south african san institute. san code of research ethics. 2017. http://trust-project.eu/wp-content/ uploads/2017/03/san-code-of-research-ethics-booklet-final.pdf (accessed 8 august 2019). 12. weiler hn. the new politics of higher education. j educ plan admin 2011;25(3):205-221. 13. department of higher education and training. list of approved south african journals (january 2018). https:// www.vut-research.ac.za/wp-content/uploads/2018/02/dhet-accredited-journal-lists-for-publications-to-bemade-in-2018.pdf (accessed 8 august 2019). 14. peters ma. technological unemployment: educating for the fourth industrial revolution. educ philos theory 2017;49(1):1-6. https://doi.org/10.1080/00131857.2016.1177412 accepted 4 april 2019. afr j health professions educ 2019;11(3):72-73. https://doi.org/10.7196/ajhpe.2019. v11i3.1179 https://doi.org/10.1080/03075079.2013.773222 http://www.dhet.gov.za/hed%20policies/national%20plan%20on%20higher%20education.pdf http://www.dhet.gov.za/hed%20policies/national%20plan%20on%20higher%20education.pdf https://doi.org/10.14804/3-1-55 https://wiser.wits.ac.za/system/files/achille mbembe decolonizing knowledge and the question of the archive.pdf https://wiser.wits.ac.za/system/files/achille mbembe decolonizing knowledge and the question of the archive.pdf https://wiser.wits.ac.za/system/files/achille mbembe decolonizing knowledge and the question of the archive.pdf http://www.india-seminar.com/2009/597/597_shiv_visvanathan.htm http://www.india-seminar.com/2009/597/597_shiv_visvanathan.htm https://doi.org/10.1080/02533950708628749 http://apps.who.int/gb/bd/pdf/bd47/en/constitution-en.pdf?ua=1 http://apps.who.int/gb/bd/pdf/bd47/en/constitution-en.pdf?ua=1 https://youtu.be/m6akiihofn4 https://youtu.be/m6akiihofn4 https://youtu.be/m6akiihofn4 http://trust-project.eu/wp-content/uploads/2017/03/san-code-of-research-ethics-booklet-final.pdf http://trust-project.eu/wp-content/uploads/2017/03/san-code-of-research-ethics-booklet-final.pdf https://www.vut-research.ac.za/wp-content/uploads/2018/02/dhet-accredited-journal-lists-for-publications-to-be-made-in-2018.pdf https://www.vut-research.ac.za/wp-content/uploads/2018/02/dhet-accredited-journal-lists-for-publications-to-be-made-in-2018.pdf https://www.vut-research.ac.za/wp-content/uploads/2018/02/dhet-accredited-journal-lists-for-publications-to-be-made-in-2018.pdf https://doi.org/10.1080/00131857.2016.1177412 june 2019, vol. 11, no. 2 ajhpe 41 research newly appointed health professions educators in the faculty of health sciences (fohs), university of the free state (ufs), bloemfontein, south africa, are given the opportunity to participate in an orientation programme. the programme is specifically designed for educators in the health professions, in line with international trends,[1] and serves to inform educators of their specialised role in training students in the fohs. changes in health and higher education legislation in 1997[2,3] influenced the role of the medical educator, required new approaches to medical education and proposed that the educator should be both developed and empowered.[4] while it is acknowledged that some newly appointed academic staff members might have teaching experience and/or have had prior educational training,[5] research conducted at the ufs centre for teaching and learning[6] indicated that a critical developmental area identified by educators was ‘the ability to engage with students’ in lectures. the introduction of a microteaching activity on the final day of the orientation programme was considered to be a suitable developmental tool. microteaching activities are regarded as providing an environment for teachers to improve their teaching skills and giving them the opportunity to reflect on feedback.[7] background the 2014 course for the newly appointed lecturers’ orientation programme at the fohs was redesigned in consultation with an expert educationalist. the curriculum development cycle as described by kern et al.[8] was used as a guide to identify the topics and flow of the course. the course was presented in 6 blocks: (i) introduction to the fohs and role as a lecturer; (ii) curriculum design and development; (iii) teaching and learning – study material; (iv) teaching and learning – presentation of study material; (v) assessment and evaluation; and (vi) master lecturer. key areas in health professions education, such as community-based education and service learning, were also addressed. after each year’s orientation programme, improvements that can be made are identified and tailored for the following year’s course. since 2014, the orientation programme has also included a microteaching activity for participants, with the aim of developing teaching practices and enhancing student-lecturer engagement. critical reflection by the newly appointed educators was encouraged. the research conducted in this study sought to reflect the views of participants who had been included in the new microteaching activity. this research was based on a german study by roos et al.,[9] who assessed the effectiveness of a 5-day education programme offered to staff members in the medical faculty, using an adopted framework of the kirkpatrick model. peer and expert evaluation of participant behaviour during microteaching and participant self-evaluations were recorded.[9] health professions educators are generally selected and employed based on their qualifications and field of expertise, and not necessarily on their educational experience or abilities.[5] to prepare health professionals for their new role as health sciences educators, academic staff development and continued professional development opportunities are available in faculties of health sciences at tertiary institutions. as highlighted by singh,[7] new models of microteaching are aimed at educators who are already in service, and include peer evaluation with positive reinforcement. for the final day of the orientation programme, educators were assigned the task of preparing a short lecture, which was presented as a microteaching activity to their peers and a panel of expert educators. the session was video-taped so that participants had the opportunity to self-reflect on their presentation at a later stage. this self-evaluation was combined with peer background. a microteaching experience was introduced into an orientation programme for newly appointed health professions educators. objective. to ascertain whether the participants experienced improved confidence in their lecturing ability after the microteaching experience. methods. the activity was evaluated by other participants and experts in education by means of a rubric. it was also video-taped to allow for future self-evaluation. participants’ reflections were documented by means of a qualitative questionnaire, with specific criteria designed by the division health sciences education, university of the free state, bloemfontein, south africa. results. newly appointed educators reflected that the prospect of participating in the microteaching activity initially made them feel apprehensive in terms of ‘being evaluated’. once they had completed the activity, they reported that it had been very useful to obtain feedback from peers and expert educators. collegial relationships in this cohort were strengthened by learning from peers. conclusions. health professions educators found that being evaluated in microteaching was valuable, as they subsequently felt more confident as lecturers and also more competent to implement newly acquired teaching skills. afr j health professions educ 2019;11(2):41-46. doi:10.7196/ajhpe.2019.v11i2.1103 a critical reflection by participants on microteaching as a learning experience for newly appointed health professions educators c a kridiotis, m (health professions education), btech diagnostic radiography; c van wyk, phd (health professions education), msc (med) genetic counselling division health sciences education, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c van wyk (vanwykc2@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 42 june 2019, vol. 11, no. 2 ajhpe research feedback, as well as expert educator feedback. i’anson et al.[10] reported that they ‘identify microteaching as an important stimulus to reflection’, and that participation in microteaching activities could enable participants to become aware of previously internalised attitudes and assumptions about learning. they described the value of a microteaching episode as a triangulation: a personal review of a video tape of the lecture, as well as peer and tutor comment, and considered that this ‘is a significant aspect in scaffolding the development of the process of reflection’.[10] the authors commented that revisiting a microteaching episode through the eyes of a tutor, peers and self, ‘is potentially a powerful event’, and the process of ‘making thoughts about practice explicit, provides a tool that can be used to develop reflective capability’.[10] apart from the lecturing aspect, the emotions experienced by participants engaged in the microteaching experience were also determined. it is not uncommon for participants to experience apprehension ahead of a microteaching activity. bell[11] reported that while microteaching might be perceived as purposeful, it could also be linked to ‘performance’. participants reported that they experienced discomfort, and that the presence of peers could complicate the interaction.[11] a perceived obstacle that new staff members face, may include gaining acceptance from colleagues,[12] or overcoming isolation and anxiety regarding their new position.[13] this perceived need – to connect with colleagues and develop collegial relationships sooner[12,13] – might be achieved through the orientation programme for newly appointed educators and reinforced through positive peer evaluation of a microteaching activity. according to donnelly and fitzmaurice,[14] advantages of microteaching include opportunities for manageable outcomes, supervision, self-evaluation and feedback, and notably ‘immediate guidance in areas of demonstrated shortcomings or in previously identified problem areas by the participant themselves, so that the locus of control in the session always remains with them’. learning that develops from microteaching experiences has been reported as having an impact on individual teaching practice, influencing how participants approach future course development and delivery. participants also viewed potential collaboration with colleagues positively.[14] when designing an instrument to be used in the evaluation of a microteaching activity, very clear directives must be considered to inform peer evaluators on the attributes they should seek to evaluate. not only participant presentation skills, but also actual teaching skills and methods, should form an important part of the assessment of the microteaching presentation of each participant. subramaniam[15] stressed that the theoryto-practice attributes need to be emphasised by course instructors, and the analytical framework, which sets goals for the microteaching activity, also needs to integrate theories of teaching. in a study by vander kloet and chugh,[16] elements of effective teaching were quantified, and the frequency of occurrence of each element could be calculated during a microteaching activity. these elements included the demonstration of material, preparation and involvement of the learner, as well as a review and summary of the material. a qualitative analysis of themes to be considered in what constitutes ‘good teaching’ includes speech patterns, eye contact, mannerisms and gestures.[16] kuswandono[17] reported on the implementation of reflective practice during microteaching activities by asking participants guided questions that included the following: ‘(i) what was the most important thing you learned during the class?; (ii) what was something you already knew or had learned but it was reinforced?; (iii) write down questions or queries you have concerning the topic(s); (iv) what worked well for you in class?; and (v) what did not work well for you in class?’ the role of the expert educationalist in providing comments and group reflection is central to the learning experience.[17] elements of this reflective approach are also used in current research in the fohs, ufs. kamboj et al.[18] indicated that microteaching activities were beneficial, as immediate and supportive feedback was provided, while presentation and interpersonal skills were improved. skills included learning to sustain student motivation, explaining clearly, asking questions effectively and learning to manage students effectively.[18] the current research was aligned with the abovementioned international findings, and specific themes that were identified included ‘positive aspects’ and ‘improvement suggestions’. methods over a 3-year period, 55 newly appointed and/or inexperienced academics completed the course for newly appointed lecturers in the fohs, ufs. a total of 35 newly appointed health professions educators participated in a microteaching activity, which was introduced as part of an orientation programme. the number of participants in the microteaching activity were 11 in 2014, 10 in 2015, and 14 in 2016. the activity was purposefully undertaken at the end of the 3-day orientation programme, after the educators had been exposed to topics such as teaching and learning methods, education concepts and terminology, simulation in teaching and guidelines on assessment and feedback. as part of the microteaching experience, each participant prepared a 10 15-minute teaching session, which was video-taped and presented to their peers and 4 expert educators. each participant had to evaluate the microteaching activity of the other participants. a rubric was used as the evaluation instrument, which had been developed with the personal expertise of health professions educationalists and resources in the fohs.[19] the rubric focused on desirable conduct when presenting a lecture. participants’ reflections were documented through their responses to 3 open-ended questions, with specific criteria designed by the division health sciences education, fohs, ufs. the open-ended items were: ‘(i) i liked your lecture because … ; (ii) you can improve your lecture by … ; and (iii) additional information or needs to be addressed.’ the second part of the study was qualitative and made use of a questionnaire that focused on the participants’ reflections on their emotions before and after the microteaching activity. they were also asked to reflect on and describe aspects and outcomes of what they had learnt from observing others and from feedback. ethical approval informed consent was obtained from participants to use all collected data for research and publication purposes. the data were edited, categorised and summarised by both researchers, and attention was paid to identify common themes in the responses. ethical approval to conduct the study was obtained from the ethics committee, fohs, ufs (ref. no. ecufs 213/2013). results thirty-five newly appointed academics participated in the microteaching session that was evaluated by, on average, 4 expert educationalists on the last day of the course. june 2019, vol. 11, no. 2 ajhpe 43 research from the open-ended section of the evaluation rubric two themes were derived: (i) positive aspects; and (ii) improvement suggestions. table 1 presents the categories identified in the first theme – positive aspects – and includes some of the written responses from the expert educators’ evaluations, including ‘good construction and a systematic approach to the lecture was observed’. when a lecturer directed questions to the audience, it was noted that the lecturer gave ‘consideration for cognitive levels of students’ and allowed enough time for participants to answer. the same 14 categories were identified in the analysis of the peer evaluations. among the responses in each of the categories, 7 elicited the most comments. in the order from most to least commented on, the category ‘presentation emotion’ ranked highest. peers seemed to be impressed by the confidence, enthusiasm and passion with which their colleagues presented their particular teaching sessions. the next category most commonly commented on was ‘session content’, with peer evaluators indicating that they found it interesting and informative. furthermore, peer evaluations revealed observations that their colleagues ‘used relevant examples’, ‘engaged their audience’, ‘demonstrated excellent topic knowledge’, ‘used several (different) presentation skills well (e.g. voice projection)’, and ‘came across as being well-prepared’ for the session. the self-evaluations showed that the lecturers perceived themselves ‘to be topic experts’ and ‘to enjoy presenting the information’. in terms of self-critique regarding their presentation and teaching skills, they were of the opinion that there was room for improvement. table 2 presents categories in the second theme – improvement suggestions – as identified from the analysis of the expert educators’ evaluations. the educators provided practical feedback on improvement of presentation skills, use of technology, teaching practices and didactic skills. similar categories were identified from the peer evaluations of the second theme, i.e. improvement suggestions. of note was that peers made many more comments about the first theme (positive aspects) of their colleagues’ teaching sessions than about how the sessions could be improved. the majority of improvement suggestions from peers related to engagement, time management and presentation skills. in the category ‘use of examples’, 8 different peer evaluators requested that the presenters should consider audience familiarity with terminology used, especially in medical and scientific fields. the participants’ observation that lecturers should ensure that complex terms and concepts be adequately explained, and that time table 1. theme 1: positive aspects, and 14 categories of responses from experts’ feedback on the microteaching activity categories responses from experts preparedness the practical component of the presentation was very well prepared clear introduction the brief overview to put the content of this lecture into context was good topic knowledge the lecturer’s knowledge base on the topic was well used in lectures session content good use of content … practical application – real life session structure the lecture was well structured and prepared good construction and systematic presentation of the lecture were observed use of examples the practical examples used during the lecture were valuable the practical examples used contributed to the clinical aspects of health professions teaching the lecturer conveyed the essential information by using clinical items and medical models (e.g. a stethoscope) the mind maps used in the session clearly outlined the important concepts presentation skills a good presentation style was used, even incorporating some humour the lecturer maintained good eye contact, and demonstrated clear voice projection teaching practices and skills the lecturer was skilful, presented sensitive information professionally and expertly while using contextual and relevant examples … very useful to use actual instruments and integrate a practical component into the theoretical session use of activities the use of the prepared class activity added value to the session it was useful to allow the students to practise with equipment during the practical component of the session use of questions questioning skills were used expertly by the lecturer the questions were asked in a way that showed consideration for cognitive levels; a variety of question types were asked; enough time was offered for students to respond student answers were repeated; therefore, the class could hear the answer incorrect answers were dealt with in a professional manner and students were guided towards the correct answer student engagement the lecturer immediately involved the students by stimulating discussions and asking questions throughout the session presentation platforms there was a good balance between the use of slides and clinical examples the slides were clear and legible, with appropriate use of font size and colour the lecturer made use of multiple presentation platforms … could move effortlessly between the white board, slides and clinical examples use of technology the lecturer used technology seamlessly … he was well prepared and tested the technology in the venue before the presentation several videos were incorporated into the presentation, making the session more visual by showing the clinical procedure in practice … students could relate to it and it was clear that they enjoyed the material presentation emotions it was clear that the lecturer was not only knowledgeable, but also passionate about the content presented the session was presented with enthusiasm, which also contributed to engage the audience 44 june 2019, vol. 11, no. 2 ajhpe research should be made available to discuss terms and concepts, could improve future student engagement in the fohs in a practical manner. on completion of the newly appointed lecturers’ orientation programme, the daily reflection activities, as completed by participants, were qualitatively analysed by the researchers. the main findings of the reflection activity are presented in table 3. the results show that participants initially experienced ‘a sense of apprehension’ at the thought of participating in the microteaching activity in terms of ‘being evaluated’. on completion of the activity, participants reported that receiving evaluation and feedback from peers and expert educationalists had been very useful. they also indicated having gained useful skills from evaluating other participants’ teaching sessions. the novice educators reported that they had benefited from applying newly learnt knowledge and putting newly learnt skills into practice. lastly, collegial relationships in this cohort were strengthened through the experience of the 3-day course. discussion the participants clearly invested time in the preparation of the microteaching activity, and different styles of teaching, presentation and use of technology were observed by peers and expert educationalists who evaluated the activity. the peer and expert educator feedback was an important reflective exercise, which participants indicated was beneficial to them and could lead to changes in their own teaching and presentation styles. an important question that one of the participants considered was whether one would ‘perform’ any differently when lecturing to a larger group of students. this could be an area for further research, examining the usefulness of providing peer and expert educator observation and feedback to newly appointed educators in real-life lecturing scenarios, with larger audience groups. the microteaching activity was not a stand-alone activity, but was preceded by a comprehensive orientation programme, which aimed to develop didactic skills and teaching practices, as well as enhancing student-lecturer engagement, which was appreciated by participants. as the orientation programme was presented by a number of expert educators, each with their own unique style, various teaching strategies and skills were embedded in the programme. these strategies could be reflected on by participants ahead of their preparation of the microteaching activity. one participant commented on the benefit of ‘putting theory in practice’ and that seeing colleagues experience similar challenges was a valuable experience. expert educators indicated that participants appeared to have benefited from the orientation programme, presentation skills, technologies and innovative table 2. theme 2: improvement suggestions, and 12 categories of responses from experts’ feedback on the microteaching activity categories responses from experts introduction phase start with a clear introduction and present clear outcomes for the lecture presentation skills be aware of your movements – avoid swaying left to right present the educational content in a more academic manner consider voice projection in a larger venue be careful not to turn and look back at your slides too often voice projection could improve and should be practised do not read the information presented from the slides speak slower – do not rush through the information engagement be more interactive – get students involved use of examples using examples from practice is very important and useful – but make sure these are carefully selected and address the required learning outcomes … in addition, make sure the examples are appropriate presentation platforms consider colours used on slides and font size – one should be able to read the text easily from the back of the class when using a picture of a figure or table, make sure that it displays clearly when using a white board and explaining concepts by writing on the board, look back at your audience once in a while and engage them throughout test technology test sound of video before; it might be very loud test technology prior to use, such as the sound of a video, an internet link or an application … always have a back-up plan should the technology or equipment fail to work keep to time when preparing for your teaching session, plan a timeframe and pace your lecture … crosscheck the number of slides and the amount of time per slide do not rush over important points, be flexible or plan for extra time to address the concepts questioning technique allocate time for students to indicate whether they know the answer, before providing the answer use questions to check that students understood complex terms and/or new information provided use questions (where applicable) throughout the lecture, not only at the very end when time has expired formulate questions ahead of time (when preparing for the lecture) make eye contact refrain from reading the slides while not looking at the audience look at the entire audience, not only those in the front row summarise conclude the lecture in a more structured manner and refer back to the session outcomes compose emotions take a breath and relax – you are doing a good job no matter how stressed you feel, the students should not be aware of it if you are nervous, take care that this does not to come across to students as being opinionated and judgemental use of fillers avoid use of fillers such as ‘umm, okay and ah’ between words june 2019, vol. 11, no. 2 ajhpe 45 research table 3. participants’ reflections after completion of the microteaching activity themes categories participants’ responses emotions pre-activity emotions a feeling of scepticism about presenting in front of colleagues a feeling of being stressed, negative and anxious to present in front of colleagues an initial feeling that the microteaching activity ‘was a silly idea’, but it was actually a rewarding and good experience post-activity experience the principle behind the presentations made me realise which areas i had to work on to improve my lecturing skills the microteaching session was very constructive and valuable a productive day, with practical teaching sessions and evaluations. the question must be asked: would one ‘perform’ differently in front of a class of 80 students? i learnt a good deal in a short period of time it was good to see the different techniques, styles and approaches to giving a lecture the practical sessions were excellent, with variety and creativity shown by presenters i enjoyed the interactive participation, lecturers showed passion and empathy, and participants were successfully engaged learning learning from others i learnt from my peers/colleagues; i would like to continue to collaborate watching others gave me ideas on how to improve my lecturing style it was meaningful; i learnt by watching others present their lectures it was helpful to get tips and ideas from watching how other academics present their lectures and which methods they use to engage their students i learnt from peers and identified different ways to teach, which i will use to enhance my own approach to lecturing i learnt a lot from other presenters regarding the methods of conducting a lecture an opportunity to witness other lecturers in action, to learn and pick up pointers on how i could adjust and modify my own lectures to keep students interested learning from feedback getting constructive criticism from colleagues was enlightening feedback was very good and i can apply it to improve my lecturing skills feedback and criticism made me understand my own shortcomings in the end, it was very good to get feedback from colleagues and the expert panel for future personal improvement what stood out the most for me were the comments from the audience; my perception was that people have preferences of how they do things and would prefer to see similar approaches from other presenters i welcomed the comments and advice of my peers and the evaluation panel aspects learnt i learnt about various ways of presenting a lecture, different styles and approaches it helped me to identify the most important information for the students it was good to see the different styles and approaches to facilitate lectures; it gave me confidence to attempt different ways, while still obtaining the optimal outcomes i learnt how to be confident i saw examples of using technology successfully i learnt to appreciate the different methods of teaching that colleagues used; i will certainly attempt some of their techniques in the future i learnt a lot about different ways to engage students learning outcome it was good to experience putting theory into practice and see that colleagues experience similar challenges. i was also encouraged to hear that it takes time to successfully engage in all the roles of a lecturer the master-lecturer session was very valuable as a learning experience, a reflection on what we learnt the past 2.5 days and a summary of the important aspects of teaching and learning i will be able to use these techniques to facilitate teaching and learning in my academic/clinical department it was worth attending the sessions; they were very practical and innovative it was helpful to see in action what we have learnt, as well as to take note of other factors, which one might do subconsciously a great deal of knowledge was gained by exposure to microteaching; everyone had a different way of teaching and implementing the work we have done the microteaching activity was the best way to end the course. it was good to consolidate everything in a practical way. it will be easy to recall and apply these skills when giving lectures in the future the opportunity to present and critique other colleagues was very helpful in implementing newly acquired presentation skills excellent reflection of the last 3 days, well demonstrated by the presentations i learnt a lot and grew personally and professionally i am filled with new inspiration to teach students, and i am now more content than ever with my decision to pursue an academic career i will be a better lecturer by applying the knowledge i gained – how to channel the knowledge, communicate, collaborate, support and adapt to new methods of teaching and learning it was interesting to evaluate various lecturing skills; i definitely learnt ways to improve my own lecturing skills i noted a number of different ways to teach, and gained useful information to apply to my new role as teacher and facilitator 46 june 2019, vol. 11, no. 2 ajhpe research teaching platforms that they had observed during the previous 2 days of the orientation course. the ‘improvement suggestions’ documented for feedback were similar to findings reported by kamboj et al.,[18] which indicated that the supportive feedback provided after microteaching activities was beneficial. microteaching activities, when aimed at in-service educators and where peer evaluation with positive reinforcement was used, could lead to ‘a perceptible change in the attitude’ of participants, as described by singh.[7] the newly appointed educators in the current study were already in service and interacting with their students, and could also reflect on these experiences with their peer group. when analysing peer evaluations, few comments were made on ‘how the sessions could be improved’ compared with the feedback from expert evaluators. this was an expected finding, considering that peer evaluators were also newly appointed colleagues, with varied levels of teaching knowledge and experience. the second part of the study, which used the qualitative questionnaire, focused on participants’ reflections on their emotions before and after the microteaching activity (table 3). they were also asked to describe aspects and outcomes, reflecting on what they had learnt from observing others and from feedback provided. the reflections of participants highlighted a positive learning experience and improved confidence, similar to the findings of donnelly and fitzmaurice.[14] pre-activity emotions were negative in some cases, but reflections on post-activity emotions showed that participants found the microteaching activity to be a constructive exercise. participants’ comments included that they had observed ‘different ways to engage students’ and that the activity had served to consolidate new skills that had been learnt – in a practical way. the learning experience of participants in the microteaching activity, where expert educators, peers and participant lecturers observed and reflected, was shown to be meaningful. overall, participants found that the orientation programme, which included a microteaching activity, helped them to connect with colleagues and develop collegial relationships in a short space of time. conclusions in the fohs, ufs, health professions educators who participated in an orientation programme for newly appointed members of staff, found that a microteaching activity added value to their learning experience. self-, peer and expert educator evaluation provided valuable feedback, and developed their reflective capabilities regarding their perceptions of teaching, learning and student engagement. the health professions educators reported that they subsequently felt more confident in their lecturing abilities, became aware of their shortcomings and felt competent to practise newly acquired skills. a microteaching activity embedded into a staff development activity was found to empower health professionals in their role as educators. declaration. this article is linked to research for cvw’s phd, using the same ethics number. acknowledgements. dr daleen struwig, medical writer/editor, fohs, ufs, for technical and editorial preparation of the manuscript. author contributions. both authors were involved in the conceptualisation, analysis and interpretation of the research; cak took the lead in writing the article. funding. none. conflicts of interest. none. 1. steinert y. faculty development in the health professions – a focus on research and practice. dordrecht: springer science, 2014. 2. council on higher education. education white paper 3: a programme for the transformation of higher education. 1997. http://www.che.ac.za/media_and_publications/legislation/education-white-paper-3-programmetransformation-higher-education (accessed 23 january 2018). 3. national department of health. white paper for the transformation of the health system in south africa. 1997. http://www.gov.za/sites/www.gov.za/files/17910_gen667_0.pdf (accessed 23 january 2018). 4. nel cpg. a framework for achieving excellence as a clinical educator in the school of medicine, university of the free state. phd thesis. bloemfontein: university of the free state, 2007. 5. mclean m, cilliers f, van wyk j. faculty development: yesterday, today and tomorrow. med teach 2008;30(6):555-584. https://doi.org/10.1080/01421590802109834 6. centre for teaching and learning, university of the free state. annual teaching and learning report 2014: moving the needle towards success. 2014. https://www.ufs.ac.za/ctl/home-page/general/ctl-annual-reports (accessed 23 january 2018). 7. singh t. microteaching revisited. natl med j india 2011;24(6):363-364. 8. kern de, thomas pa, hughes mt. curriculum development for medical education: a six-step approach. baltimore, md: john hopkins university press, 2009. 9. roos m, kadmon m, kirschfink m, et al. developing medical educators – a mixed method evaluation of a teaching education program. med educ online 2014;19(1). https://doi.org/10.3402/meo.v19.23868 10. i’anson j, rodrigues s, wilson g. mirrors, reflections and refractions: the contribution of microteaching to reflective practice. eur j teach educ 2003;26(2):189-199. https://doi.org/10.1080/0261976032000088729 11. bell nd. microteaching: what is it that is going on here? linguist educ 2007;18(1):24-40. https://doi. org/10.1016/j.linged.2007.04.002 12. boice r. the new faculty member. san francisco, ca: jossey-bass, 1992. 13. menges rj. faculty in new jobs: a guide to settling in, becoming established, and building institutional support. san francisco, ca: jossey-bass, 1999. 14. donnelly r, fitzmaurice m. towards productive reflective practice in microteaching. innov educ train int 2011;48(3):335-346. https://doi.org/10.1080/14703297.2011.593709 15. subramaniam k. creating a microteaching evaluation form: the needed evaluation criteria. education 2006;126(4):666-677. 16. vander kloet ma, chugh bp. an interdisciplinary analysis of microteaching evaluation forms: how peer feedback forms shape what constitutes ‘good teaching’. educ res eval 2012;18(6):597-612. https://doi.org/10.1 080/13803611.2012.704171 17. kuswandono p. university mentors’ views on reflective practice in microteaching: building trust and genuine feedback. reflect pract 2014;15(6):701-717. https://doi.org/10.1080/14623943.2014.944127 18. kamboj m, kamboj p, george j, jha uk. microteaching in dental education. j dent educ 2010;74(11):1243-1244. 19. bezuidenhout j, nel m, nel p. a single robust strategy to evaluate and improve lectures. mededworld 2013;2(1):1-13. accepted 18 september 2018. http://www.che.ac.za/media_and_publications/legislation/education-white-paper-3-programme-transformation-higher-education http://www.che.ac.za/media_and_publications/legislation/education-white-paper-3-programme-transformation-higher-education http://www.gov.za/sites/www.gov.za/files/17910_gen667_0.pdf https://doi.org/10.1080/01421590802109834 https://www.ufs.ac.za/ctl/home-page/general/ctl-annual-reports https://doi.org/10.3402/meo.v19.23868 https://doi.org/10.1080/0261976032000088729 https://doi.org/10.1016/j.linged.2007.04.002 https://doi.org/10.1016/j.linged.2007.04.002 https://doi.org/10.1080/14703297.2011.593709 https://doi.org/10.1080/13803611.2012.704171 https://doi.org/10.1080/13803611.2012.704171 https://doi.org/10.1080/14623943.2014.944127 november 2020, vol. 12, no. 4 ajhpe 169 short research report universities have a social responsibility towards society through consultation with communities and by providing a service to individuals, families and groups in geographical areas surrounding the university. health science faculties, therefore, endeavour to reach excellence in this regard. a requirement of the south african nursing council (sanc) is communitybased education, including negotiation of entry into a community, assessing a community’s needs and strengths, and providing services, such as consultation in clients’ home environments. a strategy by which to enhance community engagement and primary healthcare is to obtain a clear picture of the health-related strengths and needs of families in a specific community during home visits.[1] home visits act as an opportunity for students to compile a family health profile and to increase cultural sensitivity, with a simultaneous positive impact on healthcare delivery.[2] students can practise skills in an environment where they obtain regular feedback and gain exposure to authentic client contexts. service-learning modules, therefore, require substantial interactions outside the classroom to maintain student engagement.[3] the development of trusting relationships, listening to families’ stories and learning about old age take place during home visits.[4] students reported that they gained confidence and self-esteem.[4] nlg observed that at the institution of higher education where she was involved, first-year students seemed reluctant to interact with the community, which was evident from frequent apologies not to carry out home visits, by remaining in the bus that transported them to the community, and from disappearing into the community. therefore, the study aimed to explore and describe facilitators and challenges of student nurses who have to learn how to compile a healthrelated family profile and provide basic health education, as well as conduct an effective and efficient visit to a client’s home as part of the curriculum at a particular institution of higher education in south africa (sa). methods the community served by the department of nursing science, university of fort hare (ufh), was the setting for the research. all first-year students were expected to compile a health profile (using household survey forms) of families during a home visit, which included completing a health screening questionnaire. this was an explorative, descriptive and qualitative study. twenty-four nursing students were purposively selected from the 2017 and 2018 first-year cohorts who did home visits in the same community. students were recruited from both genders, according to level of seniority (entered university straight from matric or from another course) and different performance levels (grades). they were divided into 4 heterogeneous focus groups (n=6 per group). the discussions were conducted by lecturers, who had bachelor degrees and experience in conducting such discussions. the opening question at the discussion was: ‘what were your experiences during the home visits?’ follow-up questions were: ‘what made it easier for you to learn during the home visits?’ and ‘what challenges did you experience?’ more probing questions were asked based on the discussion. ethical approval the discussions were recorded after participants gave written informed consent (university research ethics committee; ref. no. rec-100118-54). background. to be socially responsible, tertiary education institutions collaborate with local communities. community engagement is a teaching and learning strategy that enhances the learning experiences of students while interacting with community members. assessing a family at home is a curriculum task that strengthens a primary healthcare approach to nursing education. objectives. to explore and describe facilitators and challenges experienced by first-year nursing students regarding family assessment during home visits. methods. an explorative, descriptive, qualitative research approach was used. four focus group discussions with 6 participants in each group were conducted with purposively selected first-year nursing students. data were analysed according to tesch’s method. results. participants (n=24) were allocated to the focus group discussions. facilitators of learning included relevant community and home settings, which provided diversity in learning opportunities. challenges included absence of a formal orientation to the learning opportunity, language barriers and lack of basic apparatus. conclusion. participants reported facilitators and challenges of family health assessment and health education. the first step should be to build on the facilitators and address the challenges in an action research project. afr j health professions educ 2020;12(4):169-171. https://doi.org/10.7196/ajhpe.2020.v12i4.1390 facilitators and challenges experienced by first-year nursing students at the university of fort hare, south africa, when conducting home visits n l gosangaye,1 ba nursing science; k mostert,2 mba, phd 1 department of nursing science, faculty of health sciences, university of fort hare, east london, south africa 2 department of physiotherapy, faculty of health sciences, university of pretoria, south africa corresponding author: n l gosangaye (ngosangaye@ufh.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:ngosangaye@ufh.ac.za 170 november 2020, vol. 12, no. 4 ajhpe short research report subsequently nlg transcribed the interviews, while both authors independently coded, categorised and identified themes.[5] after each round of analysis, they negotiated consensus. results the ages of the 24 participants ranged from 19 to 23 years, with the majority being female (70%) (table 1). compiling a family profile and providing basic health education were facilitated and enriched by the nature of the community and households that the lecturers selected for home visits. these settings provided an opportunity for participants to learn about diverse conditions and health needs, contextual factors and determinants of health, culture and primary healthcare. students visited the community in pairs, which added to better learning. a few factors posed challenges to participants to reach the learning objectives of a home visit, i.e.: insufficient orientation regarding possible challenges that they would encounter; the household survey form being in english (which many of the clients did not understand); insufficient knowledge of common conditions; insufficient consultation skills; lack of basic equipment (e.g. a glucometer); the lecturer often not being available to assist; unrealistic expectations by community members (e.g. receiving groceries); adults and the elderly resisting being questioned and educated by young students; and students doing short once-off visits, which limited the building of rapport with clients. discussion this study explored and described facilitators and challenges of first-year nursing students at an sa university to complete the learning outcomes of a healthrelated household questionnaire and basic health education during home visits. facilitators of learning the selected settings offered an opportunity for participants to reach the learning outcomes. applying basic knowledge about common diseases, table 1. themes and categories supported by verbatim quotes (one per category) themes categories student quotes facilitators of learning the community and households offered opportunities to learn about: different conditions and health needs ‘we were able to advise clients on the importance of attending child health clinic, basic hygiene, contraceptive methods, prenatal visits, adherence to treatment.’ different contextual factors and social determinants of health ‘we were able to appreciate importance of communication, to understand the influence of contextual factors on health, e.g. overcrowding and understaffed clinics.’ different cultures ‘we were able to appreciate and learn about effect of cultural factors, e.g. access to healthcare via traditional healers and suspicion of clinics.’ opportunities for primary healthcare activities ‘we identified extensive need for health education.’ the arrangement of the task as an activity in a pair or group ‘this was advantageous because we were able to help and support one another when confronted with a problem.’ challenges to learning insufficient orientation about possible challenges ‘we must be orientated about possible challenges that we will encounter during home visits.’ language barriers ‘household survey form is written in english. it would be better if survey form is written in the vernacular language for clients to understand the question that was asked during home visits. household survey form should be written in a language that is best suitable for all people in the community.’ lack of basic knowledge of common conditions, e.g. tuberculosis and diabetes ‘we were often confronted with situations where the clients were expecting us to be knowledgeable about disease, e.g. tuberculosis, diabetes. as we were allocated to visit homes early during first semester, we were not yet knowledgeable about certain conditions.’ lack of consultation skills ‘as first year during first semester we were not taught about how to conduct consultations.’ lack of basic equipment, e.g. glucometer ‘we sometimes did not have the necessary equipment, e.g. a glucometer.’ lecturer often not available to assist with consultation ‘we were often confronted with challenges that we could not handle.’ unrealistic and non-nursing-related community expectations, e.g. for groceries ‘we were not fully orientated about challenges we would meet when doing home visits.’ ‘it was a very traumatic experience. i felt guilty because i could not help that woman.’ resistance by adults and the elderly to adhere to education provided by health education offered by young students ‘the facilitator was not always available to company us. as a result the elderly resisted interventions offered by young students.’ once-off visits ‘home visits were few. as a result the opportunity to build necessary rapport was not adequate.’ november 2020, vol. 12, no. 4 ajhpe 171 short research report determinants of health, culture and primary healthcare enhanced the success of reaching these outcomes. this knowledge is fundamental to the practice of home visits during training.[6] consolidating knowledge about these factors in the early stage of the educational programme is important.[1,7] challenges to learning participants were challenged, as they did not receive sufficient orientation for community work. this prevented the building of relationships of trust with community members, commitment to community work and management of activities, even more so when community members were not involved in the orientation.[8] it is self-explanatory that a language barrier between clients and participants and lack of consultation skills would challenge completing the household survey and health education.[9,10] in contrast to short-term services as part of service learning,[11] the participants in the current study did not receive basic equipment, which limited their assessment of clients in terms of blood pressure and blood glucose levels. student learning suffers in the absence of a supervisor. clinical facilitators and lecturers are competent regarding the holistic assessment of patients’ physical status and of planning, co-ordinating, implementing and evaluating patient-centred evidence-based care and rehabilitation, which they can share with students.[12,13] furthermore, unrealistic expectations by community members also hampered participant learning.[1] students were not accompanied by an older person on the home visits. as the students were mostly younger than the family members, this posed a challenge when completing the household survey and health education owing to a strong hierarchy in xhosa households, whereby younger adults have to be respectful of older members, as in other collective cultures.[4] once-off visits inadequate exposure because of the absence of follow-up visits was a hindrance to learning. without a follow-up visit less trust was built between participants and clients. this inadequate arrangement did not allow for the bonding of the student and the family, which in turn hampered the humanisation of care based on a trusting relationship.[2,6] compared with studies that can be used for benchmarking,[1,2] working in pairs or groups was not a strategy in the curriculum of the current study. study limitations a limitation of the study was that the lecturers conducted the interviews, leading to an unbalanced power relationship between them and the participants. however, more challenges than facilitators were reported, suggesting that honest participation was not inhibited. conclusion although home visits can provide a valuable learning opportunity at the nursing department at ufh, student participants reported both facilitators and challenges regarding how to carry out a family health assessment and health education. the next step would be to build on the facilitators and address the challenges in an action research project. declaration. none. acknowledgements. the authors are sincerely grateful to dr m mammen, lecturer, and mrs nb qomfo, clinical facilitator, department of nursing science, ufh, who acted as critical academic friends during the proposal development, and mrs sm mnwana, who assisted with conducting the focus group discussions. we also thank the students who participated in the focus group discussions. author contributions. nlg posed the research question, collected and analysed the data and wrote the first draft of the manuscript. km guided the development of the proposal, oversaw the data collection, analysed the data and critically read and improved the manuscript. funding. the sub-saharan african faimer regional institute (safri) and the department of nursing science, faculty of health sciences, ufh, funded this study. conflicts of interest. none. 1. zomorodi m, odom t, askew nc, leonard cr, sanders ka, thompson d. hotspotting. nurs educ 2018;43(5):247-250. https://doi.org/10.1097/nne.0000000000000523 2. uwitonze a. an exploration of nursing students’ experiences of a community-based health promotion and illness prevention programme in a selected school of nursing in kwazulu-natal. phd thesis. durban: university of kwazulu-natal, 2017. 3. ngui ks, voon ml, lee mh. integrating community engagement with management education. educ train 2017;59(6):579-589. https://doi.org/10.1108/et-04-2016-0078 4. walton j, blossom h. the experience of nursing students visiting older adults living in rural communities. j prof nurs 2013;29(4):240-251. https://doi.org/10.1016/j.profnurs.2019.05.010 8 5. creswell j. research design: qualitative, quantitative, and mixed methods approaches. thousand oaks, ca: sage, 2018. 6. borges fr, avelino ccv, da costa lcs, lourenço ds, de sá md, goyatá slt. teaching about home visits to university students. revista da rede de enfermagem do nordeste 2017;18(1):129-138. https://doi. org/10.15253/2175-6783.2017000100018 7. iwasaki r, hirai k, kageyama t, et al. supporting elder persons in rural japanese communities through preventive home visits by nursing students: a qualitative descriptive analysis of students’ reports. public health nurs 2019;36(4):557-563. https://doi.org/10.1111/phn.12596 8. tanabe s, yanagisawa s, waqa‐ledua s, tukana m. identifying characteristic features of community orientation among community health nurses in fiji. nursing open 2019;6:1113-1123. https://doi.org/10.1002/nop2.305 9. czop assaf l, lussier ko. dream camp: drawing on community cultural wealth capital to make sense of career dreams. language culture curriculum 2020;33(1):84-99. https://doi.org/10.1080/07908318.2019.1569020 10. hwang wj, kim ja. development and evaluation of a home-visit simulation scenario for elderly people with diabetes mellitus who live alone. j comm health nurs 2020;37(2):89-102. https://doi.org/10.1080/07370016.2 020.1736399 11. o’handley h, erlinger a. recommendations for planning short-term nursing student mission trips. j profes nurs 2019;35(4):329-334. https://doi.org/10.1016/j.profnurs.2019.01.006 12. vaartio‐rajalin h, näsman y, fagerström l. nurses’ activities and time management during home healthcare visits. scand j caring sci 2019. https://doi.org/10.1111/scs.12813 13. moffatt fw, white fm, sheffer c. a simulated postpartum home visiting program with undergraduate nursing students, faculty, and actors. j obstet gynecol neonat nurs 2017;46(3):s16. accepted 15 september 2020. https://doi.org/10.1097/nne.0000000000000523 https://doi.org/10.1108/et-04-2016-0078 https://doi.org/10.1016/j.profnurs.2019.05.010 8 https://doi.org/10.15253/2175-6783.2017000100018 https://doi.org/10.15253/2175-6783.2017000100018 https://doi.org/10.1111/phn.12596 https://doi.org/10.1002/nop2.305 https://doi.org/10.1080/07908318.2019.1569020 https://doi.org/10.1080/07370016.2020.1736399 https://doi.org/10.1080/07370016.2020.1736399 https://doi.org/10.1016/j.profnurs.2019.01.006 https://doi.org/10.1111/scs.12813 a maximum of 3 ceus will be awarded per correctly completed test. september 2019, vol. 11, no. 3 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/011/01/2019 (clinical) cpd questionnaire september 2019 exploring practising pharmacy graduates’ views on improving the effectiveness of pharmacy education at the university of the western cape, south africa 1. which of the following is true? (multiple items may be selected.) respondents in this study suggested that broader exposure to a range of pharmacy and healthcare sectors during undergraduate education should be combined with generic skills development, such as: a. interpersonal skills. b. leadership. c. entrepreneurship. d. management. e. skills to promote public health. improving the knowledge of clinical forensic medicine among medical graduates: perspectives of community-service doctors 2. choose the correct answer. the authors report that a lack of rigorous training and poor performance standards contribute to healthcare providers’ inept: a. handling of medicolegal evidence. b. collecting of medicolegal evidence. c. processing of medicolegal evidence. d. all of the above. e. b and c above. involvement, self-reported knowledge and ways in which clinicians learn about assessment in the clinical years of a medical curriculum 3. place the top three assessment activities in which clinical educators are involved in order as per the results of this study: a. ospes/osces, designing mcqs, being a clinical examiner. b. designing mcqs, being a clinical examiner, ospes/osces. c. ospes/osces, designing mcqs, marking written assessments. d. ospes/osces, marking written assignments, designing mcqs. communication skills and their association with self-reported academic performances of nigerian pharmacy students 4. true or false? reticence is conceptualised as ‘an individual’s level of fear or anxiety associated with either real or anticipated communication with another person or persons’. a framework for implementing and sustaining a curricular innovation in a higher education midwifery programme 5. updated rules and regulations for the midwifery programme are an output of which of the following: a. standard of the curriculum. b. standard of the midwifery faculty. c. assessment standard. d. standard of organisation and administration. areas of good practice and areas for improvement in work-integrated learning for radiography training in south africa 6. which is the correct answer/s? project-based learning and workplace learning involve: a. theoretical learning focused on what the student needs to know to be able to function sufficiently in the workplace. b. a method in which real-world problems are used to promote student learning. c. an approach where students acquire deeper knowledge through active exploration of real-world challenges and problems. d. none of the above. ajhpe african journal of health professions education march 2020, vol. 12, no. 1 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editor paula van der bijl production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 editorial 2 going viral in a digital world v burch guest editorial 3 nursing education in africa: year of the nurse and midwife c n nyoni short communication 4 calling all authors: writing skills for family medicine residents in kenya s onguka, d m basnight-brown, v a pallo, g m wechuli, m b adam 5 using internationalisation at home to provide international learning to all physiotherapy students t dahl-michelsen, k s groven, m rowe short research report 6 peer-assisted learning in the prehospital educational setting in south africa l gevers, a makkink 9 occupational therapy: the process in acute psychiatry z syed research 12 perceptions of changes made to a clinical skills curriculum in a medical programme in south africa: a mixed methods study s r pattinson, p mcinerney 17 exploring student persistence to completion in a master of public health programme in south africa t dlungwane, a voce 22 social determinants of health in emergency care: an analysis of student reflections on servicelearning projects s g d harrison, j scheepers, l d christopher, n naidoo 27 assessment consolidates undergraduate students’ learning of community-based education i moodley, s singh 36 occupational therapists’ views on core competencies that graduates need to work in the field of neurology in a south african context l jacobs-nzuzi khuabi, j bester 41 exploring barriers that nurses experience to enrolment for a postgraduate nursing qualification at a higher education institution in south africa m o mbombi, t m mothiba cpd questionnaire december 2019, vol. 11, no. 4 ajhpe 149 research according to the recent literature, multimedia teaching is more effective than conventional teaching.[1] studies demonstrated that video-based surgical skills training improves knowledge retention, understanding, acquisition of surgical skills and satisfaction levels compared with conventional teaching.[2-5] video-based teaching reduces the amount of verbal input needed during surgical skills illustration and also reduces learning time.[5] training of surgical procedures requires teaching modalities that are elaborate and easy to understand. the teaching modality should relay details of the procedure in a way that closely resembles real-life scenarios anatomically, such as motion graphics in the form of 3d animation.[1,6] the animation of surgical procedures can be available to students through learning management systems (lms) such as moodle to create a learnerdriven teaching platform. moodle, with its resources and activities (e.g. quizzes, surveys, assignments, chats, gradebooks and back-end databases), would make surgical training, continuous assessment and student feedback more effective. the end product of such a design is a multimedia virtual classroom of surgical procedure illustrations delivered to the student via moodle. when such a resource has been developed and produced, it can be used over years without wear and tear. it is my (mjm) opinion that lowand middle-income countries need to harness the power of organised, multimedia virtual classrooms in medical training, which may appeal to the current generation of medical students.[1] this research proposes that surgical skills illustrations using 3d animation on a moodle platform could improve students’ understanding and satisfaction levels. background of undergraduate surgical rotations the newly established faculty of medicine, university of botswana, graduated its first cohort of undergraduate medical students in 2014. the medical undergraduate programme (mb bs) comprises 5 years of training divided into two phases. phase i consists of the premedical sciences, followed by phase ii – the clinical phase. phase i covers the first 2 years of training, while phase ii covers the last 3 years. surgical specialty rotations occur during phase ii. students rotate through general surgery during the third year (surgery i) and fifth year (surgery iii) of training. the curriculum includes the teaching of practical surgical skills; this is where the challenges lie. we use plain models (those with limited anatomical detail) and text presentations as our teaching aids for surgical skills teaching. we currently do not have procedure-customised models to illustrate the principles and details of each procedure. these models are expensive to acquire and maintain. if acquired, they ultimately need to be replaced owing to wear and tear during demonstrations. the use of lectures and plain models without anatomical detail to teach practical surgical skills is referred to as traditional teaching methods in this article. the abovementioned challenges prompted the researchers to propose 3d animation illustrations as an option worth exploring. none of the departments in the faculty of medicine uses 3d animation as a teaching method. the aim of the study was to compare 3d animation with traditional teaching; the latter uses lectures and plain models as teaching tools. background. teaching undergraduate surgical skills using plain models without detailed anatomy and text presentations lacks detail, and there is a need to explore other teaching methods. objective. to establish whether there is a difference in the satisfaction level and understanding between students taught using 3d animation v. traditional methods. methods. this was a randomised comparative study conducted over 1 year.  participants were thirdand fifth-year undergraduate medical students who provided informed consent. they were randomly assigned to the 3d animation and traditional teaching groups. the animated procedures, the preand post-tests and the survey were hosted on moodle. the difference between preand post-test scores is termed the impact score. the independent samples t-test was used to determine the significance of the difference in the impact scores of the two groups. results. forty-five fifth-year students participated in 3 skills illustrations and 45 third-year students participated in 2 skills illustrations, giving a total of 225 data points. 3d animation teaching is associated with better understanding than traditional teaching (t(223)=6.701; p<0.001) (experimental group, mean 3.11; control group, mean 1.51). traditional teaching was given a median rating of 5 (good) and a mode of 4 (average) v. a median and a mode of 8 (excellent) for 3d animation teaching on a scale of 1 10 (worst superb). however, the combination of the two teaching methods was given a mode and a median of 10 (superb). all students recommended the adoption of 3d animation.  conclusion. students have a better understanding and higher satisfaction levels when taught using 3d animation. afr j health professions educ 2019;11(4):149-152. https://doi.org/10.7196/ajhpe.2019.v11i4.1189 the role of moodle-based surgical skills illustrations using 3d animation in undergraduate training m j motsumi, fcs (sa), mmed (gen surg); a g bedada, md; g ayane, md department of surgery, faculty of medicine, university of botswana, gaborone, botswana corresponding author: m j motsumi (josephmotsumi@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 150 december 2019, vol. 11, no. 4 ajhpe research methods this was a 1-year (may 2017 june 2018), randomised comparative study conducted in the department of surgery, faculty of medicine, university of botswana. students were briefed regarding the study when they started their rotation at the department, and those who were interested registered with the moderators in their own time and not during the briefing session. participants (thirdand fifth-year students) voluntarily consented to participate. those who did not participate attended the routinely scheduled traditional teaching sessions of surgical skills according to the curriculum. five surgical skills procedures, 2 from the thirdyear and 3 from the fifth-year curriculum, were animated. for the production of illustrative videos, we used 3d animation software (3ds max, usa) to create surgical skills animation, and an adobe creative cloud package for postproduction processing for animation. these videos were hosted on a moodle platform of the university network and access was controlled via logging in. the students are familiar with the use of moodle. on arrival of students at the computer laboratories, they were randomly assigned to group a (traditional teaching group) and group b (3d animation teaching group). a simple randomisation method involving computergenerated random numbers was used to assign participants. the traditional method involved the teaching of surgical skills using lectures and demonstrations on plain models, while the 3d animation group watched illustrative videos produced from 3d animation of surgical skills. each of the groups was in a separate computer-laboratory section where they completed a standard multiple-choice pretest quiz. each group had a session moderator. after the pretest, the 3d animation group watched a video illustration of a surgical skill that lasted 8 minutes, followed by a standard multiple-choice post-test hosted on moodle. after completing the post-test, group b joined group a for the routinely scheduled traditional teaching session, which all students had to attend according to the curriculum. after this session, group a completed a 10-minute standard posttest, while group b waited. up to this point, each group had done a pretest, an intervention (3d animation teaching or traditional teaching) and a post-test. after completing the posttest, group a was given the opportunity to watch the 3d animation video; therefore, both groups experienced the two teaching methods. students then completed an online survey in the form of a feedback questionnaire to assess their level of satisfaction. the preand posttest assessments were summative and did not contribute towards their surgical rotation marks. summative assessments evaluate student learning, knowledge, proficiency or success at the conclusion of an instructional period. in contrast, formative assessments occur throughout the instructional period, and seek to improve student achievement of learning objectives through approaches that can support specific student needs. the procedure animations, the preand post-tests and the survey questionnaire were hosted on moodle, and results were captured on the back-end database. the researcher fulfilled the administrator role on moodle and was able to grant or deny access to study materials. the tests, videos and survey questionnaires were made available only to attendees by the administrator during the illustration sessions. intercostal drain insertion, suprapubic catheter insertion and central venous access were animated for fifth-year medical students, and urethral catheterisation and nasogastric tube insertion were animated for third-year students. each procedural training occurred at a scheduled date, with the sequence of randomisation, pretest, intervention, posttest and survey repeated for each procedure (fig. 1). statistics for both study groups, the difference between the post-test and pretest scores – the impact score – was determined. the independent samples t-test was used to determine the significance of the difference between the impact scores of the two groups. descriptive statistics were used to describe feedback from the students. spss version 25 (ibm corp, usa) was used for data analysis. timeline post-test, 10 min traditional teaching session, 60 90 min group a post-test, 10 min group a pretest, 10 min randomisation to study groups group b pretest, 10 min watch a video animation of the skill, 8 min (groups a and b join together for routine traditional teaching) opinion survey questionnaire completion on moodle group b group a watch a video animation of the skill 1 2 3 4 5 6 7 8 step fig. 1. diagrammatic representation of study design. (a = traditional teaching group; b = 3d animation teaching group.) december 2019, vol. 11, no. 4 ajhpe 151 research ethical approval the study received ethical approval from the university of botswana institutional review board (ref. no. ubr/res/irb/bio/017). informed consent was obtained from the participants. results forty-five third-year medical students participated in two procedure illustrations, giving 90 data points (45 × 2), while 45 fifth-year medical students participated in three procedure illustrations, yielding 135 data points (45 × 3). the total data points at the end of the study were 225, with 113 from the animation group and 112 from the traditional teaching group. this implies that there were 113 impact scores in group b and 112 impact scores in group a. the preand post-tests were marked out of 10. the mean impact scores in groups b and a were 3.1 and 1.5, respectively (table 1). levene’s test for equality of variance confirmed that the two study groups were similar and homogenous enough to have the means of the impact scores compared meaningfully (table 2). to determine whether the difference in the mean impact scores of the two study groups was significant, we used the independent samples t-test. we found that the animation group had a significantly higher impact score than the traditional teaching group (t(223)=6.701; p<0.001) (experimental group, mean 3.11; control group, mean 1.51) (table 2). this implies that students taught using 3d animation have a better understanding than those taught using traditional teaching methods. at the end of each session a survey was conducted to obtain feedback from the participants, as well as to determine their satisfaction levels with the two teaching modalities. students were asked to rate 3d animation and traditional teaching methods on a likert scale of 1 10 (worst superb). students gave the traditional teaching method a median rating of 5 (good) and a mode of 4 (average) v. a median and a mode of 8 (excellent) for the 3d animation teaching method. however, students gave the combination of the two teaching methods a median and a mode of 10 (superb) (fig. 2). at the end of each surgical skills illustration session, students were asked to choose the best method of teaching: traditional teaching alone, animation teaching alone, or a combination of the two teaching methods. no student chose traditional teaching alone, 5.3% chose the 3d animation method alone, and 94.7% chose the combination of the two teaching modalities. at the end of each surgical skills illustration session, students were asked to choose their recommendation level for the adoption of 3d animation teaching from the following options: not recommend, not sure, recommended and highly recommended. no student chose not recommend or not sure. students recommended the adoption of the 3d animation teaching method (6.7%), while a much higher percentage highly recommended its adoption (93.3%). discussion motion graphics in the form of 3d animation with its visual cues draw more attention and are a good teaching tool with a potential role in surgical skills training.[1,6-13] the literature suggests that there is significant knowledge gain, shorter learning time, and higher satisfaction levels when students are taught using 3d animation v. traditional methods.[1,6,8-10] this is consistent with the findings in our study in which the improvement in the test score (impact score) was statistically significant in the 3d animation group compared with the traditional teaching group (p<0.001). the aspect of shorter learning time was also evident in our study, in which the longest animation video was 8 minutes compared with the traditional teaching method, which reached a maximum of 90 minutes. 3d animation has also been used to enhance and annotate real surgical videos via postproduction processing.[13] hence, the 3d animation annotation technique defines another dimension of its use in surgical skills training. studies have shown a difference in comprehension levels of candidates who receive 3d animation teaching v. traditional teaching.[14,15] the design of some of these studies may not explain the impact of the teaching methods too well, as they did not have preand post-tests to measure an intervention-attributable impact score.[16] the inclusion of preand post-tests in the study design seeks to isolate the existing baseline knowledge before intervention from the acquired new knowledge after intervention. our study design sought to eliminate this confounding factor by using an impact score as a measure of understanding. one study, however, found no statistically significant difference in test scores after accounting for baseline/pretest scores (p=0.33).[15] this study compared traditional methods with 3d computer models in the instruction of hepatobiliary anatomy. the higher satisfaction level with the 3d animation teaching method was also expressed in other studies.[16-19] in one study, the difference in students’ understanding in either of the groups was not statistically significant; however, students nonetheless expressed higher satisfaction levels with 3d animation teaching methods.[15] this may suggest that students preferred 3d animation for other reasons and not necessarily because it improves their level of understanding. in our study, students were also asked to choose the best teaching method from three options: traditional teaching alone, 3d animation alone or a combination of the two teaching methods. students chose the combination of the two as their preferred teaching method, followed by 3d animation teaching rather than traditional teaching, suggesting that there is something they would want to retain from the traditional teaching method. unfortunately, in our survey design we did not ask students to give table 1. descriptive statistics of the impact score for the two study groups group statistics group n mean (sd) impact scores 3d animation 113 3.11 (1.86) traditional teaching 112 1.52 (1.69) sd = standard deviation. table 2. independent samples t-test of impact scores for the two groups levene’s test for equality of variances t-test for equality of means f sig t df sig (2-tailed) mean difference impact scores equal variances assumed 0.77 0.38 6.70 223.00 0.00 1.59 equal variances not assumed 6.70 221.40 0.00 1.59 152 december 2019, vol. 11, no. 4 ajhpe research reasons for their choices. these findings suggest that 3d animation should augment and not replace traditional teaching methods – a finding reflected in a number of studies.[16,17,19] other studies, which measured knowledge retention and improvement in skills development, found no statistically significant differences between students taught using either of the two teaching methods,[18] while some studies came to the opposite conclusion.[19] study limitations the authors acknowledge the possibility of crosscontamination during the 90 minutes of traditional teaching of students. the same standard tests were used for both groups; hence the concern. we tried to minimise this by having moderators present during the sessions. the summative nature of the test may not have allowed the assessment of all aspects of learning. a formative assessment method is suggested in future studies. conclusion students have a better level of understanding and satisfaction when taught using 3d animation than with the traditional method. however, students considered a combination of the two modalities to be the best way of teaching. to inform how the augmentation of the two teaching modalities should be structured for a higher efficacy, a further study would be required to establish why students unanimously preferred a combination of the teaching methods. the cost-effectiveness assessment and ultimately validation of this teaching tool are milestones to be achieved. 3d anima tion is a viable and effective teaching tool, which appeals to learners. when learning resources using 3d animation are hosted on platforms such as moodle, their access is extended beyond the formal classroom. this has the potential to alleviate the shortage of faculty in lowand middle-income countries. we recommend the adoption of 3d animation as a teach ing tool in medical education. declaration. none. acknowledgements. none. author contributions. mjm conceived the idea, prepared the 3d animations and videos, reviewed the literature and wrote the manuscript; ab and gs reviewed the proposal and the manuscript. funding. none. conflicts of interest. none. 1. ahmet a, gamze k, rustem m, sezen ka. is video-based education an effective method in surgical education? a systematic review. j surg educ 2018;75(5):1150-1158. https://doi.org/10.1016/j.jsurg. 2018. 01.014 2. farquharson al, cresswell ac, beard jd, chan p. randomized trial of the effect of video feedback on the acquisition of surgical skills. br j surg 2013;100(11):1448-1153. https://doi.org/10.1002/bjs.9237 3. van det mj, meijerink wj, hoff c, middel lj, koopal sa, pierie jp. the learning effect of intraoperative video-enhanced surgical procedure training. surg endosc 2011;25(7):2261-2267. https://doi.org/10.1007/ s00464-010-1545-5 4. autry am, knight s, lester f, et al. teaching surgical skills using video internet communication in a resource-limited setting. obstet gynecol 2013;122(1):127-131. https://doi.org/10.1097/aog. 0b013e3182964b8c 5. crawshaw bp, steele sr, lee ec, et al. failing to prepare is preparing to fail: a single-blinded, randomized controlled trial to determine the impact of a preoperative instructional video on the ability of residents to perform laparoscopic right colectomy. dis colon rectum 2016;59(1):28-34. https://doi.org/10.1097/dcr.0000000000000503 6. clements dn, broadhurst h, clarke sp, et al. the effectiveness of 3d animations to enhance understanding of cranial cruciate ligament rupture. j vet med educ 2013;40(1):29-34. https://doi.org/10.3138/ jvme.0512.037r 7. qualter j, fana m, deluccia n, colen k, scharf c, hazen a. visualizing treatment options for breast reconstructive surgery. stud health technol inform 2009;142(1):262-264. https://doi. org/10.3233/978-1-58603-964-6-262 8. marsh kr, giffin bf, lowrie dj, jr. medical student retention of embryonic development: impact of the dimensions added by multimedia tutorials. anat sci educ 2008;1(6):252-257. https://doi. org/10.1002/ase.56 9. lim mw, burt g, rutter sv. use of three-dimensional animation for regional anaesthesia teaching: application to interscalene brachial plexus blockade. br j anaesth 2005;94(3):372-377. https://doi.org/ 10.1093/bja/aei060 10. mehrabi a, glückstein c, benner a, hashemi b, herfarth c, kallinowski f. a new way for surgical education – development and evaluation of a computer-based training module. comput biol med 2000;30(2):97-109. 11. guttmann gd. animating functional anatomy for the web. anat rec 2000;261(2):57-63. https://doi.org/10.1002/(sici)10970185(20000415)261: 2<57:: aid-ar5>3. 0.co;2-r 12. fung a, kelly p, tait g, greig pd, mcgilvray id. creating an animation-enhanced video library of hepato-pancreato-biliary and transplantation surgical procedures. j vis commun med 2016;39(1-2):27-32. https://doi.org/10.1080/17453054.2016.1182474 13. sundsten jw, kastella kg, conley dm. videodisc animation of 3d computer reconstructions of the human brain. j biocommun 1991;18(2):45-49. 14. mata ca, ota lh, suzuki i, telles a, miotto a, leão le. web-based versus traditional lecture: are they equally effective as a flexible bronchoscopy teaching method? interact cardiovasc thorac surg 2012;14(1):38-40. https://doi.org/10.1093/icvts/ivr030 15. keedy aw, durack jc, sandhu p, chen em, o’sullivan ps, breiman rs. comparison of traditional methods with 3d computer models in the instruction of hepatobiliary anatomy. anat sci educ 2011;4(2):84-91. https://doi.org/10.1002/ase.212 16. prinz a, bolz m, findl o. advantage of three-dimensional animated teaching over traditional surgical videos for teaching ophthalmic surgery: a randomised study. br j ophthalmol 2005;89(11):1495-1499. https://doi.org/10.1136/bjo.2005.075077 17. kobayashi m, nakajima t, mori a, tanaka d, fujino t, chiyokura h. three-dimensional computer graphics for surgical procedure learning: web three-dimensional application for cleft lip repair. cleft palate craniofac j 2006;43(3):266-271. https://doi.org/10.1597/04009.1 18. nousiainen m, brydges r, backstein d, dubrowski a. comparison of expert instruction and computer-based video training in teaching fundamental surgical skills to medical students. surgery 2008;143(4):539-544. https://doi.org/10.1016/j.surg.2007.10.022 19. glittenberg c, binder s. using 3d computer simulations to enhance ophthalmic training. ophthalmic physiol opt 2006;26(1):40-49. https://doi.org/10.1111/j.1475-1313.2005.00358.x accepted 24 july 2019. 70 60 50 40 30 20 10 0 traditional teaching alone 3d animation teaching alone combination of the two teaching methods worst worse bad average good best excellent superb fr eq u en cy , % 63.56 22.67 2.67 20.00 33.33 3.56 0.22 13.33 3.56 4.44 20.44 16.44 1.78 9.78 29.78 0.00 0.44 34.67 0.00 0.00 7.56 0.00 0.00 1.78 0.000.000.00 0.000.000.00 ranking of teaching methods below average very good fig. 2. medical students’ rating of the teaching methods. https://doi.org/10.1016/j.jsurg.­2018.­01.014 https://doi.org/10.1016/j.jsurg.­2018.­01.014 https://doi.org/10.1002/bjs.9237 https://doi.org/10.1007/s00464-010-1545-5 https://doi.org/10.1007/s00464-010-1545-5 https://doi.org/10.1097/aog.­0b013e3182964b8c https://doi.org/10.1097/aog.­0b013e3182964b8c https://doi.org/10.1097/dcr.0000000000000503 https://doi.org/10.3138/jvme.0512.037r https://doi.org/10.3138/jvme.0512.037r https://doi.org/10.3233/978-1-58603-964-6-262 https://doi.org/10.3233/978-1-58603-964-6-262 https://doi.org/10.1002/ase.56 https://doi.org/10.1002/ase.56 https://doi.org/­10.1093/bja/aei060 https://doi.org/­10.1093/bja/aei060 https://doi.org/10.1002/(sici)1097-0185(20000415)261:2%3c57::aid-ar5%3e3.0.co;2-r https://doi.org/10.1002/(sici)1097-0185(20000415)261:2%3c57::aid-ar5%3e3.0.co;2-r https://doi.org/10.1080/17453054.2016.1182474 https://doi.org/10.1093/icvts/ivr030 https://doi.org/10.1002/ase.212 https://doi.org/10.1136/bjo.2005.075077 https://doi.org/10.1597/04-009.1 https://doi.org/10.1597/04-009.1 https://doi.org/10.1016/j.surg.2007.10.022 https://doi.org/10.1111/j.1475-1313.2005.00358.x 52 april 2021, vol. 13, no. 1 ajhpe research research training has been identified as the foundation for all programmes in the health science professions.[1] undergraduate exposure is associated with improved scholarship[2] – a key competency that is promoted by the health professions council of south africa (hpcsa).[3] familiarity with doing or using research fosters analytical thinking and develops skills for informed decision-making in patient service delivery and care.[4] although not all rehabilitation students may become primary researchers, all practitioners will need to evaluate, interpret and use research for evidence-based practice (ebp).[5] previous studies investigating research competencies for undergraduates predominantly focused on the medical and nursing professions.[6-8] however, certain competencies may be more relevant to rehabilitation.[9,10] rehabilitation students should be equipped with knowledge, skills, attitudes and tasks that are relevant to the current clinical context and professional research needs. for example, knowledge of pretrial studies or alternative designs to traditional randomised controlled trials (e.g.  practice-based evidence trials[10] and health services research[11]) may be particularly important for rehabilitation research.[10] although not synonymous, ebp and research are closely related concepts.[4] educators in rehabilitation are increasingly restructuring research curricula towards ebp.[12,13] research training may be used to cover ebp, and vice versa.[1,14] the sicily statement on ebp provides a five-step framework to use when developing curricula: (i) research question formulation; (ii) searching for best evidence; (iii)  critically evaluating the evidence; (iv) applying the evidence to clinical practice; and (v) monitoring performance.[15] however, an investigation of existing physiotherapy coursework and ebp coverage[14] indicated that some research competencies are poorly defined in the learning outcomes, while others are not addressed at all. a standardised set of minimum core research competencies needs to be defined more explicitly to benchmark standards for research methods (rm) training in the undergraduate rehabilitation curriculum. recently, 86 ebp competencies were identified in a systematic review involving health professionals, regardless of the discipline or level of training.[16] the findings were generalised to all health professions, leaving it to educators to ‘advance competencies depending on the needs and desires of learners’.[16] no similar reviews exist that focus on research competencies or rehabilitation. this review aimed to provide a comprehensive overview of the existing literature regarding core research competencies that may be required by rehabilitation undergraduates. as a secondary outcome, a list of recommendations regarding the implementation of such competencies was compiled. methods a scoping review was conducted according to the methodological framework developed by arksey and o’malley[17] and refined by levac et al.[18] the six-step process includes: (i) identifying a research question; (ii) identifying relevant studies using an effective search strategy; (iii)  selecting studies fulfilling inclusion criteria; (iv) charting the data involving numeric and background. research training is important for all health science professions and interlinks with evidence-based practice (ebp). previous studies that investigated research competencies for undergraduates predominantly focused on medical and nursing professions. however, specific competencies may be more relevant to certain professions than others. a set of minimum core research competencies has not been defined for research methods (rm) training in the undergraduate rehabilitation curriculum. objectives. to review available evidence and identify a set of research competencies for undergraduate rehabilitation students. method. a scoping review was done of studies published between january 2009 and december 2018. five databases were searched (november december 2018). articles were included if they contained statements referring to knowledge, skills, attitudes and tasks related to research or researchrelated ebp for rehabilitation undergraduates. competencies were categorised into 6 research domains using thematic analysis. results. forty-five competencies were identified from research-related statements in 26 studies. no studies explicitly investigated the most important research competencies for rehabilitation. research competencies were often derived directly from the ebp framework (n=19 studies), resulting in poor representation of competencies related to conducting research. overall, domains related to research methodology and inquiry were best represented, while soft skills, dissemination, professional attitudes and ethics were poorly represented. conclusion. we identified a set of research competencies that may be important for rehabilitation undergraduates. it remains unclear which of these should be prioritised in the rehabilitation curriculum. however, this preliminary set may guide future consensus statements and allow educators to identify and address gaps in current curricula. afr j health professions educ 2021;13(1):52-58. https://doi.org/10.7196/ajhpe.2021.v13i1.1229 research competencies for undergraduate rehabilitation students: a scoping review m y charumbira, 2nd-year m physiotherapy student; k berner, phd (physiotherapy); q a louw, phd (physiotherapy) division of physiotherapy, department of health and rehabilitation sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m y charumbira (yvonne.kamuti@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. april 2021, vol. 13, no. 1 ajhpe 53 research thematic analysis; (v) collating, summarising and reporting results; and, optionally (vi)  consulting with key stakeholders. reporting followed the prisma extension for scoping reviews checklist (supplementary table  1 (http://ajhpe. org.za/public/files/1229-table.pdf )).[19] search strategy a comprehensive search of published research reports was conducted (november decem ber 2018) in 5 compu terised databases (pubmed, sciencedirect, africa-wide information (ebsco), scopus and cinahl (ebsco)). database-specific search strategies were developed, including medical subject headings and boolean operators. a date limit (january  2009 december 2018) was applied to access up-to-date evidence. the search was repeated in march 2019 and reference lists of articles that were identified in the primary search were explored. table 1 lists the main search terms. consensus was reached to include the term ‘evidence-based practice’, considering the potential overlap in coursework. eligibility criteria articles were eligible if they contained statements regarding research-related knowledge, skills, tasks or attitudes (i.e.  competencies[16]) required by undergraduate students in the rehabilitation health professions of physiotherapy, occupational therapy and speech and language therapy. articles that included these professions were considered, regardless of whether other medical or allied health professionals were included. publications were excluded if the sample included postgraduate students or qualified rehabilitation health professionals. only studies written in english or available in translation were eligible for inclusion. data charting a data extraction sheet was developed in excel (microsoft corp., usa) and studies were grouped by design. extracted data included first author, publication year, country, sample health profession and characteristics, aim and main construct addressed in study (ebp v. rm), statements relating to research competencies, and recommendations regarding research competency training or evaluation. extracted data were discussed by all reviewers for consistency and consensus. as this was a scoping review, risk of bias was not assessed. data analysis competency-related statements retrieved from all study designs were combined. overlapping or duplicate statements were collated to produce a comprehensive list of unique statements. thematic analysis was done using categories previously identified in the literature. we identified 6  categories using a combination of research domains described by the research competencies framework (rcf)[20] and the research competencies scale.[21] analysis and grouping of competencies were discussed between the authors to reach consensus. the findings from the included studies were presented narratively. results search results the initial search yielded 1 374 hits, of which 1 211 articles were excluded because titles clearly did not conform to the objective of this review or were duplicates. subsequently, we screened 106 abstracts, of which 57 did not include rehabilitation undergraduate students and were therefore excluded. two more articles were retrieved via pearling; hence 59 full texts were obtained for review. of these, 26 proved eligible for analysis (fig. 1). study characteristics studies were mostly from high-income countries (n=20; 76.9%). more than half (n=16; 61.5%) were published in the past 5 years. no studies included a description of research competencies among their objectives, although competencies were included in the article content. ten studies (34.5%) reflected research or research-related ebp competencies in physiotherapy,[12-14,22-28] 2 (7.7%) in occupational therapy[29,30] and 2 (7.7%) in  speech and language therapy.[31,32] seven studies (26.9%) reported on mixed rehabilitation professions,[29,33-38] while 5 (19.2%) were on unspeci fied allied health professions.[1,39-42] eight studies (30.8%) were surveys, with students being the most frequently surveyed population in 6 of these. self-reported questionnaires were used to establish, e.g.  students’ perceptions of their research or ebp competency levels in a rehabilitation undergraduate programme. in one of the studies[14] academic staff were surveyed to ascertain which competencies are covered in their curricula and which competencies are deemed appropriate at undergraduate or postgraduate level of learning. another study appraised student projects, part of which ascertained evidence of students’ fulfilment of listed research competencies.[23] three pretestpost-test studies (11.5%) evaluated students’ knowledge, skills and attitudes toward ebp after exposure to ebp or rm training courses.[1,26,33] records identi�ed through database searching (n=1 374) • pubmed (n=352) • scopus (n=127) • africa-wide (n=26) • google scholar (n=759) • sciencedirect (n=72) • cinahl (n=28) records screened (n=163) full-text articles assessed for eligibility (n=57) 2 articles added via pearling (n=59) articles included in review (n=26) full-text articles excluded (n=33) studies did not report on any core research competencies studies were rehabilitation postgraduate students or quali�ed rehabilitation professionals excluded articles (n=106) exclusion based on abstract. articles were duplicates or did not include rehabilitation undergraduate students excluded articles (n=1 211) exclusion based on title obviously not conforming to the objective of this review (n=759) and duplicates (n=452) fig. 1. prisma flowchart showing selection of studies for inclusion in review. http://ajhpe.org.za/public/files/1229-table.pdf http://ajhpe.org.za/public/files/1229-table.pdf 54 april 2021, vol. 13, no. 1 ajhpe research four studies (15.4%) described curriculum development.[12,29,36,39] research competencies were identified from the learning outcomes of these curricula. other designs included qualitative studies (n=2; 7.6%), mixed-method studies (n=4; 15.4%), systematic reviews (n=2), a scoping review (n=1), a narrative review (n=1) and an opinion paper (n=1). most studies (n=19; 73.1%) had ebp as main construct (6  surveys,[14,25,28,30,32,38] 4  reviews,[34,40,42,43] 3 mixed-method studies,[24,27,37] 3 studies describing curriculum development[29,36,39] 2 pretest-post-test studies[26,33] and 1 qualitative study[31]). four studies (15.4%; 2 surveys,[23,41] 1 qualitative[35] and 1 opinion paper[22]) had rm as main construct, with direct reference to research competencies. the remaining 3 studies (pretest-post-test,[1] mixed methods,[13] curriculum development[12]) addressed both ebp and rm as main constructs. appendix a (http:// ajhpe.org.za/public/files/1229-a.pdf ) presents study characteristics according to design, including research-related statements (listed according to corresponding item numbers from the research competencies (table 2)). competencies we initially identified 58 research competencies after synthesis of the research competency-related statements from all 26 studies. this initial set was reviewed for duplication, overlap and clarity, leaving 45 competencies. all 6 research domains were represented: research methodology/ processes (n=20); research inquiry/literature review (n=14); soft skills (n=5); dissemination (n=3); professional attitudes (n=2); and ethics (n=1) (table  2). fig.  2 shows overlap between competencies (grouped into the 6 domains) derived from studies with ebp, rm or both as main constructs (appendix a). competencies from articles with ebp as main construct seven of the 45 identified competencies were not alluded to in any of the ebp-focused studies. although these studies commonly referred to ‘ebp competencies’ rather than ‘research competencies’, research-related competencies were evident as part of the ebp framework. researchrelated competencies were mostly derived from the first three steps of the ebp framework, i.e.  research question formulation, searching for best evidence available (both related to the domain of research inquiry/literature review) and critical evidence evaluation (domain of research methodology/ processes). consequently, these were the 3 most commonly cited research competencies overall (table  2). consistent with the ebp context, all but one[40] of the 19 studies with ebp as main construct emphasised the need for students to learn to identify articles that are creditable evidence sources. bozzolan et  al.[24] reported students’ satisfaction with journal clubs as a medium for learning critical appraisal skills. however, in 2 studies, lecturers felt that critical appraisal skills should be taught at postgraduate level, with curricular time constraints[37] and students’ inability to grasp the concepts at undergraduate level[14] cited as reasons. another study[40] acknowledged that learning biostatistics in an ebp context is different from learning to do original research, but that it is nonetheless important, as students learn to be proficient research consumers. seventeen competencies were described exclusively in the ebp-focused studies, with most of these (n=8; 47.1% (fig. 2)) falling under the research inquiry/literature review domain. none of these studies cited research skills, which involve generating new research, such as biostatistics application, data collection, identifying graduate funding and publishing. three studies (15.8%) cited competencies spanning across at least 4 of the 6 research domains considered in this review. seven studies (26.9%) addressed the development of information literacy skills interlinked with ebp. these articles focused on accessing and retrieving information efficiently and effectively. many authors (n=12; 63.2%) mentioned knowledge of research designs, without explicitly stating which designs needed to be taught. one study[14] cited that students need only be equipped with knowledge of ‘commonly used’ designs, whereas no studies indicated which are the most commonly used designs in rehabilitation science. 70 60 50 40 30 20 10 0 epb rm combined research inquiry/literature review (a) research methodology/ processes (b) dissemination (c) soft skills (d) professional ethics (e) attitudes (f) fig. 2. radar chart showing overlap between competencies identified from studies, with main constructs of evidence-based practice (ebp), research methodology (rm) or both (combined). (see table 2 for corresponding domains.) table 1. search terms key areas # keywords rehabilitation students 1 students, allied health 2 students, rehabilitation 3 students, physiotherapy or physical therapy 4 students, occupational therapy 5 student, speech and language therapy or student, speech and language pathology 6 #1 or #2 or #3 or #4 or #5 learning outcomes 7 education, health, undergraduates 8 teaching or training 9 curriculum 10 #7 or #8 or #9 research 11 research competencies 12 research skills 13 core competencies 14 #11 or #12 or #13 evidence-based practice 15 evidence-based practice combined terms 16 #6 and #10 and #14 17 #6 and #10 and #15 http://ajhpe.org.za/public/files/1229-a.pdf http://ajhpe.org.za/public/files/1229-a.pdf april 2021, vol. 13, no. 1 ajhpe 55 research competencies from articles involving rm as main construct although 21 of the 45 identified competencies were not mentioned in any of the 4 studies with rm as main construct, the competencies that were addressed spanned across all 6 research domains. two of the 4 studies (50%) cited competencies spanning at least 4 of the 6 research domains. one study[41] had the highest number of research competencies listed in a single article (n=13; appendix a). the domain of research methodology/processes was covered most extensively among studies with rm as main construct table 2. research competencies for undergraduate rehabilitation students domain research competency-related items studies, n research inquiry/ literature review (a) a1. enquiring mind/curiosity 2 a2. exploring general information sources to increase familiarity with topic 1 a3. recognising gaps in the literature 5 a4. formulating a structured answerable question using pico format 22 a5. identifying key concepts and terms that describe information need 1 a6. successfully searching for and locating relevant literature 19 a7. searching for literature when off campus 1 a8. knowledge of evidence sources and types, including their strengths and weaknesses 4 a9. choosing an appropriate database 6 a10. constructing a systematic and comprehensive search strategy that reflects the purpose of the study 10 a11. applying a search strategy: narrowing a search, use of keywords, boolean, truncation, search filters and mesh 6 a12. managing references/software 2 a13. strategies to obtain full texts of relevant articles 1 a14. reading and understanding scientific articles, including research terminology 4 research methodology/ processes (b) b15. knowledge of research design (differentiating and defining) 13 b16. knowing strength and weaknesses of each study design 2 b17. understanding hierarchy of levels of evidence 5 b18. knowing the best type of design to answer question (matching) 6 b19. critical appraisal of different study designs using cat 23 b20. basic knowledge of biostatistics 5 b21. evaluating statistical tests and principles 1 b22. reporting statistics 1 b23. sample size determination 3 b24. data collection skills 2 b25. data analysis skills 4 b26. using data analysis techniques consistent with research question/hypotheses 2 b27. using statistical software package 1 b28. interpretation/synthesis of findings 5 b29. implications for future research and practice for each discipline 2 b30. interpreting the certainty in evidence and strength of recommendation in healthcare 1 other research processes b31. writing a grant application 2 b32. identifying graduate funding 1 b33. identifying mentors 1 b34. knowing the authorship process 1 dissemination (c) c35. scientific writing: understanding rules for citations, referencing, writing style, formatting, plagiarism 2 c36. publishing research 3 c37. oral presentation 1 soft skills (d) d38. communication skills 4 d39. independent and critical thinking skills 6 d40. problem-solving skills 2 d41. team-working skills/working in groups 3 d42. reflective skills 2 professional ethics (e) e43. addressing ethical and legal issues 6 attitudes (f) f44. evidence-based practice essential to clinical work 3 f45. learning by doing 2 pico = patient/population, intervention, comparison and outcomes; mesh = medical subject headings; cat = critical appraisal tools. 56 april 2021, vol. 13, no. 1 ajhpe research (fig.  2), with competencies particular to this group of studies including biostatistics and epidemiology, evaluating statistical tests and principles,[13] using statistical software packages,[41] and using data-analysis techniques consistent with research questions.[41] within this category, only 1 study highlighted the specific processes that students need to become familiar with to carry out research, such as seeking project funding and knowing the authorship process.[41] research inquiry/literature review was the second-best represented domain; the ability to search and retrieve literature even when off campus[35] was specifically mentioned. publishing research (dissemination domain) was reported as providing a scholarly contribution to the scientific body of knowledge and giving students motivation for doing research.[22] problem-solving (soft skills domain) was cited by 2 studies.[22,41] recommendations for research/ebp competency training or evaluation recommendations pertaining to competency training or evaluation could be grouped into 5 categories: (i) collaboration; (ii) teaching methods/curriculum design; (iii)  supervision; (iv) assessment; and (v) translation of research evidence. recommendations from systematic reviews were the constructing of curricula into manageable sessions;[42] assessing prior knowledge to identify table 3. recommendations for development of research competencies area recommendations regarding strategies to develop research/ebp competencies in undergraduates study design collaboration utilise librarians’ expertise in joint teaching of il skills in rehabilitation curricula[25,29,31,33,36] survey qualitative describing curriculum development support collaborative learning, which helps students develop social networking skills[43] review use journal clubs as a means of collaborative learning and invite students from other disciplines[24] mixed methods teaching methods/ curriculum design ensure effective coverage of all competencies via curriculum mapping in terms of content, timing and type of training[28,36] survey describing curriculum development prioritise areas of research by identifying those that are heavily subscribed to in past student projects[23] survey assess prior knowledge to identify what needs to be taught[40,43] review construct curricula into manageable sessions[42] review include explicit learning outcomes related to ebp/research in module guides and evaluate curricula on a regular basis[37] mixed methods repeat ebp concepts throughout curricula to allow for consolidation and application of knowledge[27-29,37] survey mixed methods describing curriculum development include teaching methods such as didactic lectures, computer practice sessions, journal clubs and group work[14,31,37,40,42,43] survey qualitative mixed methods review incorporate instruction modes, such as audio-visuals and online teaching[33,35] pretest-post-test qualitative supervision upskill faculty members adequately to consolidate their ability to supervise students in research and ebp[14] survey regularly evaluate quality of teaching instruction using validated assessment tools[39] describing curriculum development give regular constructive feedback to encourage reflection skills[24] mixed methods assessment use formal assessment as a stimulus for learning[26,37] pretest-post-test mixed methods incorporate assessment methods, such as poster presentations, research project/thesis, peer review, tests and assignments[14,37,43] survey mixed methods review translation of research evidence evidence synthesis in the form of systematic reviews and meta-analyses is a time-efficient and sustainable way of increasing undergraduate physiotherapy publication outputs[12] describing curriculum development early exposure to ebp training facilitates development of skills and knowledge, which students can build during their remaining years[24,29] mixed methods describing curriculum development encourage publishing of manuscripts/research projects[22] review implement ebp in rehabilitation education by incorporating it into the clinical setting[13] mixed methods ebp = evidence-based practice; il = information literacy. april 2021, vol. 13, no. 1 ajhpe 57 research what needs to be taught;[40] and including teaching methods such as didactic lectures, computer practice sessions, journal clubs and group work;[40,42] other recommendations were from various designs (table 3). discussion we derived 45 core competencies that rehabilitation undergraduates may require to be effective research consumers or conductors. to our knowledge, this is the first review to focus on rehabilitation professions. these competencies may serve as a starting point for developing research training curricula, after considering opinions of students, curriculum experts and rehabilitation clinicians. the identified competencies are largely similar to those reported for nursing and medical undergraduates.[6-8,44] most competencies fell within 2 research domains: inquiry/literature review and methodology/ processes. the most commonly cited competency was critical evidence appraisal, followed by research question formulation, searching, retrieving literature efficiently and effectively, and knowledge of research designs. these are considered important foundational skills in the continuum of undergraduate research training in healthcare education[4] and mostly relate to being informed research consumers. however, competencies lacked considerable detail in their description, making it difficult to clearly assess their relevance specifically to rehabilitation. for example, despite research design knowledge being among the most commonly occurring competencies, no studies explicitly indicated which designs should be taught to rehabilitation students. only teaching the ‘most common’ designs may not be the best approach in rehabilitation research, given the trend towards innovative alternatives (which balance internal and external validity) to traditional effectiveness research.[45] other domains (dissemination, soft skills, ethics and professional attitudes) and even specific competencies within the abovementioned 2 domains (e.g. reading and understanding scientific articles, skills related to statistics, interpreting evidence certainty) were less represented. this does not imply that these competencies are less important; indeed, some of these were identified as areas in need of specific attention in rehabilitation. for example, 2 surveys[14,27] revealed that rehabilitation undergraduates specifically lacked confidence in statistics, reading scientific journals and understanding the relevance of ebp. similar concerns have been raised among medical undergraduates[46] and practising rehabilitation clinicians.[47] it has been suggested that applying a scientist-practitioner model (where clinicians have sound research training) to rehabilitation education may overcome the disconnect between academic research/ebp knowledge and actual clinical practice.[5] such disconnect may result from training that is mostly focused on the first 3 domains of ebp.[1] the order or count of the competencies listed in this review therefore does not reflect their relative importance or teaching sequence. rather, the distribution reflects that the ebp framework may often overtake research training (fig.  2) as a separate but related entity, with many research-related competencies derived exclusively from this framework. although research and ebp processes inform each other, the concepts differ in important areas.[48,49] exclusively relying on the ebp framework to identify a set of research-specific competencies is not sufficient and results in omittance of potentially important skills, such as those required for generating and publishing new research. inconsistencies were noted regarding the teaching sequence of some competencies. in one study,[37] lecturers indicated that formal critical appraisal should only be taught at postgraduate level owing to full undergraduate curricula. however, in another study,[13] students reported not being confident in appraising literature and requiring more training. the timing of introducing various competencies requires careful consideration and input of different stakeholders. a multi-tiered research competency model that progresses along a continuum of underand postgraduate training has been proposed in the medical sciences.[4] while there is great merit in such an approach, the specific competencies (and their sequence) defining each tier need to be tailored to rehabilitation undergraduates. for example, whereas research publication was listed under the most advanced (postgraduate) tier of training in medical education,[4] introduction of this skill may be needed earlier for rehabilitation students, given the rising focus on publishing undergraduate rehabilitation articles.[12] core research competencies need to be taught and evaluated using valid methods. unfortunately, there is a paucity of evidence regarding effective instructional methods in ebp, including research orientation and skills development.[1,40] although not a primary aim of our review, we extrapolated a list of recommendations regarding the development of research-related competencies, which may be subjected to input from educators and students in future. teaching and assessment methods need careful and contextualised consideration and may need to be tailored to suit each competency. for example, group work, while fostering positive qualities such as respect and encouraging (interdisciplinary) teamwork,[24,50] has also been reported by rehabilitation students as a potential barrier to acquiring individual skills.[27] in this case, educators need to identify effective methods of developing and assessing individual competencies that have been taught in a group setting and the competencies that may not be appropriate for this method. such considerations and linkages to specific competencies should be applied to each recommendation. the absence of methodological quality appraisal limits the strength of this review to recommend the identified competency set as the ‘gold standard’ for undergraduate rehabilitation research training. much of the evidence came from self-reported surveys, which are prone to recall and response biases, and cross-sectional studies (level iii evidence). however, we provided a comprehensive map of the current state of information and demonstrated a scarcity of high-level evidence, along with insufficient detail, regarding research competencies for rehabilitation students. this provides grounds for future high-quality research and preliminary material for further investigation among stakeholders. the next steps towards forming a general framework for effective curriculum mapping involve following up on this preliminary evidence using a delphi survey or stakeholder consensus forum to prioritise and gain consensus on the most essential research competencies.[16] this will also inform decisionmaking regarding the optimal timing and depth of content of each research competency. in addition to a clear articulation of each research competency in the outcomes of research curricula, effective methods of instruction and evaluation need to be outlined and linked with relevant competencies. conclusions this scoping review identified knowledge, skills and attributes that may be important for rehabilitation undergraduates to attain throughout their research training. it remains unclear which of these should be prioritised within the rehabilitation curriculum, or how to time their introduction along the continuum of training. however, this set offers 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combining a review of curriculum documents and input from recent graduates. afr j health professions educ 2015;7(1):98-104. https://doi.org/10.7196/ajhpe.501 47. dannapfel p, peolsson a, nilsen p. what supports physiotherapists’ use of research in clinical practice? a qualitative study in sweden. implement sci 2013;8:31. https://doi.org/10.1186%2f1748-5908-8-31 48. sackett dl, rosenberg wm, gray ja, haynes rb, richardson ws. evidence-based medicine: what it is and what it isn’t. bmj 1996;312(7023):71-72. https://doi.org/10.7196/ajhpe.501 49. brown j, libberton p. principles of professional studies in nursing. london: palgrave macmillan, 2007. 50. bridge p, carmichael ma, callender j, et  al. internationalising research methods teaching of undergraduate health professionals. j med imaging radiat sci 2018;49(1):97-105. https://doi.org/10.1016%2fj.jmir.2017.11.003 accepted 9 march 2020. https://doi.org/10.1186%2fs12909-016-0567-7 https://doi.org/10.1007%2fbf03341783 https://doi.org/10.1007%2fbf03341777 https://doi.org/10.1016%2fj.colegn.2013.04.004 https://doi.org/10.1016%2fj.colegn.2013.04.004 https://doi.org/10.1080%2f01421590500271530 https://doi.org/10.1080%2f01421590500271530 https://doi.org/10.5014%2fajot.2011.000828 https://doi.org/10.1097%2fphm.0000000000000700 https://doi.org/10.2522%2fptj.20150033 https://doi.org/10.7196%2fajhpe.516 https://doi.org/10.7196%2fajhpe.516 https://doi.org/10.7196%2fajhpe.2016.v8i2.580 https://doi.org/10.1186%2f1472-6920-13-154 https://doi.org/10.1186/1472-6920-5-1 https://doi.org/10.1001%2fjamanetworkopen.2018.0281 https://doi.org/10.1080/1364557032000119616 https://doi.org/10.1186%2f1748-5908-5-69 https://doi.org/10.7326%2fm18-0850 https://www.fgdp.org.uk/sites/fgdp.org.uk/files/docs/in-practice/research/research competencies.pdf https://www.fgdp.org.uk/sites/fgdp.org.uk/files/docs/in-practice/research/research competencies.pdf https://doi.org/10.1177%2f0748175615625749 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https://doi.org/10.1007%2fs10459-016-9702-9 https://doi.org/10.1187%2fcbe.09-08-0057 https://doi.org/10.3163%2f1536-5050.104.3.004 https://doi.org/10.3163%2f1536-5050.104.3.004 https://doi.org/10.1007%2fs10459-010-9251-6 https://doi.org/10.7196/ajhpe.511 https://doi.org/10.1186%2fs13104-015-1741-4 https://doi.org/10.1186%2fs13104-015-1741-4 https://doi.org/10.7196/ajhpe.501 https://doi.org/10.1186%2f1748-5908-8-31 https://doi.org/10.7196/ajhpe.501 https://doi.org/10.1016%2fj.jmir.2017.11.003 december 2019, vol. 11, no. 4 ajhpe 114 research while student enrolment has grown in the south african (sa) higher education system, the undergraduate throughput rate has been abysmal. only 30% of students who entered for the first time in 2000 had graduated in 2004.[1] consequently, the literature has largely focused on the negative discourse of understanding the hindrance of student success in higher education. this article, however, takes a positive discourse viewpoint in understanding student success in the bachelor of emergency medical care (bemc) degree in sa. the bemc degree is a 4-year paramedic programme undertaken at 4 higher education institutions in sa, i.e. cape peninsula university of technology, durban university of technology, nelson mandela university and university of johannesburg. the bemc provides a foundation in medical sciences, including human anatomy, physiology, pathology and pharmacology, while application to clinical practice becomes more detailed and extensive from the second to the fourth year. from the onset of the programme, students are introduced to key aspects of life support – the theoretical and practical training aspects. the bemc also includes medical rescue, which is physically demanding and requires students to be physically prepared and able to swim, as they do rescue in the sea, in rivers and/or in dams. a bemc student may register as an emergency care practitioner (ecp) with the professional board for emergency care (pbec), health professions council of south africa, upon completion of the degree. they practise independently, needing no permission or supervision for the various interventions they perform. the ecp registration is currently the highest registration category with the pbec. given the dearth of ecps in sa, it may prove useful to understand how bemc students succeed to increase ecp numbers in the country. we used deci and ryan’s self-determination theory to explore students’ motivation to succeed in the bemc programme.[2] self-determination theory suggests that motivation is a two-dimensional concept comprising intrinsic and extrinsic motivation.[3] intrinsic motivation is defined as being moved by something because it is inherently interesting or satisfying.[4] vansteenkiste et al.[5] state that intrinsic motivation represents the ideal type of motivation because it is fully autonomous and has also been associated with: (i) adaptive metacognitive strategies such as planning and time management; (ii) increased will and determination; (iii) greater intention to persist; and (iv) greater effective perseverance. intrinsic motivation has also been found to produce positive academic outcomes and to promote a greater conceptual understanding of the learning material than may otherwise have been the case.[6] however, self-determination theory also suggests that higher levels of motivation do not necessarily yield more positive outcomes, as there are other factors that may affect outcomes.[7] for example, a student who is intrinsically motivated may also be unable to concentrate in class due to personal circumstances, thus resulting in poor academic performance. organismic integration theory is a sub-theory of self-determination theory that details different forms of extrinsic motivation. extrinsic motivation is defined as performing an activity to attain some reward or separable outcome.[8] amotivation refers to the lack of intention to act owing to feelings of incompetence, not valuing the activity or not believing background. while student enrolment has increased in the south african (sa) higher education system, the undergraduate throughput rate has been abysmal. consequently, the literature has largely focused on the negative discourse of understanding the hindrance of student success in higher education. objectives. to take a positive discourse viewpoint of understanding student success in the bachelor of emergency medical care (bemc) degree in sa. the paper uses deci and ryan’s self-determination theory to explore students’ motivation to succeed in attaining the bemc degree in sa. methods. participants were bemc students recruited from 4 universities. thirdand fourth-year students who had not repeated a module/subject while studying for the bemc degree were purposively sampled and invited to join the focus group discussions. these groups were conducted at the respective institutions during the participants’ free time. the audio recordings were transcribed to produce a written text of the focus group discussions. thematic analysis was used to analyse the data with the aid of nvivo 11 (microsoft, usa). results. the thematic analysis yielded two themes, i.e. intrinsic and extrinsic motivation. some students were intrinsically motivated to complete the degree in the minimum time. it is more likely that students’ intrinsic motivation increased with continued success in the programme and that it also satisfied their feeling of competence. some students succeeded owing to extrinsic motivational factors – to prove some people wrong or because of the financial implications of failure. conclusion. the emergency care departments need to assist students to maintain motivation, which may satisfy their feelings of autonomy and competence. addressing students’ motivation may allow for more continued success in the academic programme. afr j health professions educ 2019;11(4):114-117. https://doi.org/10.7196/ajhpe.2019.v11i4.6 a self-determination theory perspective on student success in attaining an emergency care degree s sobuwa,1 phd; b lord,2 phd 1 department of emergency medical care and rescue, faculty of health sciences, durban university of technology, south africa 2 department of community emergency health and paramedic practice, monash university, melbourne, australia corresponding author: s sobuwa (simpiwesobuwa@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 115 december 2019, vol. 11, no. 4 ajhpe research the activity will result in a possible outcome.[8,9] the least form of extrinsic motivation is external regulation, in which people’s behaviour is controlled by external demand. therefore, people behave in a certain way to avoid a threatened punishment or to obtain a tangible reward.[10] for example, students may do their homework not because it is the right thing to do but to avoid punishment at school or at home. introjected regulation refers to people who perform acts as a result of pressure to avoid guilt or to ensure pride or ego-enhancement. for example, a student may study hard to achieve higher marks than his/her colleagues in class to attain pride. the aim of this study was to explore students’ motivation to succeed in the bemc programme using the self-determination theory. methods a qualitative approach was used. bemc students from each of the 4 univer sities were recruited to participate in the study. thirdand fourth-year students who had not repeated a module/subject while studying for the bemc degree were purposively sampled and invited to join the focus group discussions. the researchers felt that these students would be best placed to provide answers to the research aim. the first author conducted a total of 7 focus group discussions at the respective institutions during the participants’ free time. the class captains were responsible for co-ordinating the times and meeting venues, as the researchers did not have the participants’ contact details, which would have contravened the protection of personal information (popi) act, 2013. the class representatives’ contact details had been provided by the lecturing staff after consent from the former. the study information had been disseminated to the participants by the class representatives via the lecturing staff. however, the study information was also provided at the beginning of the focus group discussions, which were audio recorded and lasted between 30 and 60 minutes. all focus group discussions were conducted in english. the audio recordings were transcribed to produce a written text of the focus group discussions. we listened to the recordings and read through the transcripts to ensure accuracy of the latter and to familiarise ourselves with the dataset. accordingly, the transcripts were not returned to the participants to ensure accuracy, as we had verified the accuracy. the data were analysed using thematic analysis. we developed initial codes using nvivo 11 (microsoft, usa) after immersing ourselves in the data, and organised the data into meaningful groups. we then sorted the codes into different themes. themes were reviewed and refined until we were satisfied that these captured the essence of the data. ethical approval participation was voluntary and participants could withdraw at any time. permission to collect data was granted by the respective institutions, while ethical approval was granted by the university of cape town human research ethics committee (ref. no. hrec: 815/2015). results and discussion theme 1: intrinsic motivation the thematic analysis that was applied yielded two themes, i.e. intrinsic and extrinsic motivation. theme 1 considers how the students’ intrinsic motivation enabled success in the bemc programme. the students commented as follows (all names are fictional): ‘well, i started in first year with the goal to complete this course in 4 years, and i think setting yourself a goal does give you a bit of a goal to achieve. so, you’re very driven, you’re very motivated to achieve that goal, you don’t want to slip up anywhere. so, yes, that’s the reason why i have possibly come to fourth year in one go, and haven’t repeated a year because i did set that goal right at the beginning, right when i was accepted.’ (abel) ‘i think on that one also, the mind-set thing, and also people who are internally motivated and you need to do this because, when i started here, swimming was, you know – i mean, it’s a black thing. but it was, i mean, if i was thrown into a pool or whatever, i wasn’t going to drown, i will do that. but i’m telling you, for me to prepare and get to do it in the times. i’m telling you, i used to do that thing in, like 12 minutes, and when i’m done, like i’m out, you know. having to learn those tricks about breathing out when you are in there; you know, when you’re breathing out the bubbles are disturbing [laughter]. no, i’m telling you. but, looking back today, i go in there and i’ve got a goal of doing it in 4 minutes, 30 seconds or something, you look at it and you think, yes, it has to be motivation. you know what you want and you’re going to work hard and do whatever it takes to get through.’ (todani) it was clear that both these students had been intrinsically motivated to achieve their goals – completing the course in the minimum time. these findings are consistent with those in the literature.[11-13] intrinsic motivation means doing something because it is inherently satisfying and this, in turn, results in high-quality learning and innovation.[8] biggs and tang[14] argue that intrinsic motivation results in high-quality learning because of the resulting deep approaches to learning. self-determination theory suggests that, the more autonomous the motivation, the better the outcome.[4] in other words, the use of intentional agency leads to a better academic outcome than may otherwise have been the case. the desire to succeed was evident in the commitment of todani, who initially swam 200 m in 12 min, but 3 years later, was aiming for a time of 4 min 30 s, which was less than the required 6 min. in addition, intrinsic motivation is likely to increase with continued success in an activity. this was borne out in the case of todani, whose swimming time was improving and who had passed successfully.[14] swimming is part of the bemc programme requirements for aquatic rescue. students have to swim 200 m in ˂6 min to be eligible for entry into the aquatic rescue modules. the cognitive evaluation theory is considered a sub-theory of the selfdetermination theory and suggests that feelings of competence may enhance intrinsic motivation, as these feelings satisfy a basic psychological need, i.e. competence.[8] however, the cognitive evaluation theory further argues that feelings of competence involve another basic psychological need, i.e. a sense of autonomy, to enhance intrinsic motivation.[8] lecturers who enjoy their subject and perceive great value in it are likely to inspire their students to become more curious to seek the same worth.[14] this was illustrated by a student who stated that: ‘i nearly failed chemistry in high school and, then, first-year chemistry came and i achieved marks in the nineties. the lecturer had the ability to teach so well and her passion shines through, and that also motivates you to acquire the same passion, like, basically, draw from their strength to go on and actually excel.’ (athalia) december 2019, vol. 11, no. 4 ajhpe 116 research in the education context, intrinsic motivation may result in improved study techniques and intensive studying, which may lead to improved academic performance.[4] selecting the correct study course also enhances intrinsic motivation, as these students are more likely to succeed than those who made an incorrect study choice.[15] a particular programme may be appealing at first, but it may become tedious owing to a mismatch between the student’s perceived expectations and reality, which may result in failure to progress. it is therefore important to provide accurate information to prospective students so that they can provide informed consent to enrol in the paramedic degree. theme 2: extrinsic motivation some students used extrinsic factors as motivation to succeed in the bemc programme: ‘ems (emergency medical services) is a bit of a man’s world and, as a female and being quite feminine, i enjoy my femininity, it can be quite difficult. but it was a challenge and i have really enjoyed it … it is equal rights and, as a paramedic, females can also be paramedics. and you have to acknowledge that men have different strengths to women. i don’t think it was something to prove but, maybe, to myself, but not to anyone else. it was a challenge.’ (marie) ‘i have a learning disability and in high school i had a scribe, as well as a writer on the computer and the papers were read to me, and i got extra time for my papers. but, in high school a lot of, especially pupils, said to me that i would never get tertiary education because i am not clever enough. so, proving everybody else wrong is my kind of own ego boost and just showing everybody else that i am clever enough, that i have the means to get where we are right now.’ (annika) as mentioned above, there are various types of extrinsic motivation. one can conclude from the abovementioned quotes that these participants exhibited the second type of extrinsic motivation, i.e. introjected regulation. this refers to performing an activity to avoid guilt or to produce egoenhancement or pride.[8] marie’s motivating factor was her stance against gender bias in the masculinised emergency care profession. this emerged in her assertion that ‘it is equal rights and, as a paramedic, females can also be paramedics’. therefore, she was using her gender bias stance to motivate her to succeed academically in the bemc programme. annika was dyslexic and had used her learning disability as a motivator to demonstrate that she was capable of obtaining a tertiary qualification, despite her critics. in his book, david and goliath, gladwell[16] argues that being dyslexic may be an advantage and that what may appear to give ‘giants’ their perceived strength, may be their greatest weakness. gladwell uses the story of david boies, one of the most famous trial lawyers in the world, to illustrate his point. boies compensated for his dyslexia by developing the ability to be an effective listener, which made him a good lawyer. it is therefore plausible that annika had also compensated for her dyslexia by developing abilities she had not realised she possessed. both annika and marie passed the bemc programme in the minimum period. some students indicated that they used their financial circumstances as a motivating factor to apply themselves academically: ‘you think of the finances, the strains of it, so we still have siblings that the money is going towards too. so, if you fail, then that just adds to the actual burden on your parents, especially if you are being raised by a single parent, and that salary won’t sustain every single child in the household.’ (parsons) ‘another thing i wanted to add to this was that the financial implications too, if you are looking at the younger students, they are being paid for. whereas us, the more mature guys, it is coming straight from our pockets so we know that there is no way i’m going to repeat a year. my family is going to suffer with me sitting up late and studying, the course is going to be more. there are a whole lot of implications for me if i fail.’ (seth) repeating a year was not an option for some of the students, as it would have meant they had to spend an extra year studying, thus leading to increased costs for their families, some of whom were single-parent families. some of the students were from disadvantaged backgrounds and education was seen as way of improving their socioeconomic situation. these findings are similar to those in the literature, which highlight that students achieved academic success despite their poor background.[11,13] some of the students in this study indicated that they had to sacrifice time away from family and friends to achieve academic success and that repeating a year would have meant more time away from them. some had a sponsorship or a bursary that would have lapsed if they failed. this was illustrated by the following student’s response: ‘my goal was more external. i’m fully sponsored to study, and my sponsor said to me, “if you don’t complete it in 4 years, i can’t help you; there’s nothing i can do”.’ (elon) another student added to this discussion: ‘you know, you’re not satisfied with knowing the bare minimum. i’m going to be having people’s lives in my hands, but i want to know just enough to potentially save their life.’ (sarai) some students, such as sarai, demonstrated the characteristics of regulation through identification – a more autonomous form of extrinsic motivation. in terms of regulation through identification, the individual has identified the personal value of an activity and accepts the activity as his/her own.[8] in other words, sarai had identified the value of applying herself academically, as she would be performing potentially life-saving interventions that may have adverse outcomes if carried out incorrectly. conclusions this study explored students’ motivation to succeed by obtaining an emergency care degree using the self-determination theory. the twodimensional concepts of self-determination theory, i.e. intrinsic and extrinsic motivation, emerged as themes in this study. some students were intrinsically motivated to complete the degree in the minimum time. it is more likely that the students’ intrinsic motivation increased with continued success during the programme and also satisfied their feelings of competence. some students succeeded in obtaining the bemc degree owing to extrinsic motivational factors to either prove some people wrong or because of the financial implications of failing. the emergency care departments need to assist students to maintain motivation, which may satisfy their feelings of autonomy and competence. addressing students’ motivation may allow for more continued success in the academic programme. 117 december 2019, vol. 11, no. 4 ajhpe research declaration. none. acknowledgements. the authors wish to acknowledge the respective emergency medical care departments for their unwavering support for this study. we also acknowledge stevan bruijns for his valuable contribution to the study. author contributions. ss conceptualised the study, collected the data and drafted the manuscript, while bl was responsible for critical revision of the manuscript. both authors approved the final version. funding. this work is based on research supported in part by the national research foundation of south africa for the thuthuka and sabbatical grants, unique grant numbers 99322 and 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gladwell m. david and goliath: underdogs, misfits, and the art of battling giants. new york: little, brown and company, 2013. accepted 1 july 2019. https://www.che.ac.za/media_and_publications/higher-education-monitor/higher-education-monitor-6-case-improving-teaching https://www.che.ac.za/media_and_publications/higher-education-monitor/higher-education-monitor-6-case-improving-teaching https://doi.org/10.1146annurev.psych.53.100901.135153 https://doi.org/10.1146annurev.psych.53.100901.135153 https://doi.org/10.1007/s10459-012-9354-3 https://doi.org/10.1037/a0015083 https://doi.org/10.1007/s11218-013-9245-3 https://doi.org/10.1207/s15327965pli1104_01 https://doi.org/10.1006/ceps.1999.1020 https://doi.org/10.1111/j.1467-6494.1995.tb00501.x https://doi.org/10.1177/008124630503500311 https://doi.org/10.20853/28-4-393 june 2020, vol. 12, no. 2 ajhpe 81 research challenging contexts place a greater onus on child psychiatric nurses who work in communities. in south africa (sa), many children suffer from mental health disorders due to high levels of violence and family problems in their communities.[1,2] a rise in violent conflicts at schools coincides with the themes of emotional and behavioural dysfunction of children, and the need for mental health resources at schools and in communities.[1] there is a dearth of specialised healthcare professionals, such as nurses, occupational therapists and social workers, to meet the enormous mental healthcare needs of children and adolescents.[1,2] challenges in this context require thoughtful curriculum development. one such response is illustrated by the postgraduate diploma in child psychiatric nursing that was developed by a university in response to the mental health needs of children in sa.[3] a family-centred focus in the programme underscores both theory and practice.[3] therefore, a servicelearning and community-engagement approach is integrated in the child psychiatric nursing curriculum by means of frequent outreach programmes to the community. community engagement is an integral and core part of higher education and health education in sa, and it rests upon four pillars (fig. 1). community service is a core function of the study university and educators pursue it by ensuring that they build sustainable partnerships to co-ordinate collaborative partnerships with different stakeholders.[4] annually, child psychiatric nursing students join the specialised child unit for community engagement programmes at the free state psychiatric complex, bloemfontein, which is an outreach to rural communities. students work collaboratively in a multidisciplinary team in different rural towns to attain experiential learning. partnerships benefit all involved stakeholders.[5] the goal of the programme is to expose students and to empower them to respond to the realities of the social and human dynamics in their communities.[4] background. children, families and communities are affected by mental health challenges caused by high levels of violence and domestic upheaval in south african (sa) communities. there are too few specialised healthcare professionals, e.g. nurses, psychologists, occupational therapists and social workers, to meet the enormous mental healthcare needs of children and adolescents in the country. because of the unique challenges people face in this context, professionals need to be trained in all aspects of child psychiatric nursing. one important way to provide this training could be a servicelearning strategy. in this approach, nursing students are taught how to engage and educate communities by means of community-outreach programmes that form part of the curriculum. the purpose of this article is to report on nursing students’ experiences during their community-engagement outreach programmes in the challenging sa healthcare context. objectives. to explore and describe students’ community-based learning experiences during outreach programmes. method. a qualitative methodological approach used structured reflection reports of 47 students over 3 years as data. participants’ responses were thematically analysed by content. results. nursing students experienced community-learning engagement as thought provoking. they were able to practise their professional development within a collaborative environment, which built self-confidence and stimulated critical thinking. they indicated that the experience made them aware of the needs of the community and enabled them to share reciprocal knowledge. it helped them to integrate theory with practice, develop responsible citizenship and enhance professional development. conclusion. evidence from a challenging context supports the use of service learning as an ideal approach to develop students’ professionalism, ethical responsibility and personal growth to become responsible citizens who can engage with mental health users in the community. afr j health professions educ 2020;12(2):81-85. https://doi.org/10.7196/ajhpe.2020.v12i2.1214 the benefits of experiential learning during a service-learning engagement in child psychiatric nursing education a c jacobs, msocsc (nursing) school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a c jacobs (jacobsac@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. community engagement research community-service learning (credit bearing) partnerships community service/volunteers connecting head, hands and heart fig. 1. community engagement as part of professional learning.[4] 82 june 2020, vol. 12, no. 2 ajhpe research students were exposed to a community only after the basics of theoretical and practical components were covered during studentcentred learning activities. first, the training school employs standardised patient simulation as a student-centred learning strategy to bridge the theory-practice gap.[6] students are expected to have a presence in the community throughout the year and to reflect on their experiences regularly in reflective assignments. this premise links to a discipline-based model for communityengagement teaching.[7,8] nursing educators need to recognise the importance of a supportive academic and clinical environment for specialised healthcare professionals, to encourage engagement and active participation and to prepare students to solve real-life problems.[9] the community service-learning strategy improves students’ skills, while students support and guide children, parents and families of children with mental health problems. the strategy also helps students to engage in their own professional and personal development. the goals of the service-learning placement is to stimulate thought, guide, clarify and encourage scholarship, inspire dialogue and model and facilitate collaborative discussion with members of multidisciplinary and multiperspective-thinking teams.[5,9] constructivist teachers motivate students to assess how an activity assists them in gaining understanding. knowledge leads to further cognitive development and meaning as a result of experiences.[10] regular guided critical reflection is a rigorous and necessary component of any experiential learning activity and an effective tool for use in assessment. it assists and deepens students’ understanding of key theoretical and practical applications and their professional roles in the community. reflective writing is particularly beneficial and fundamental to improving critical thinking skills of students.[9,11] the educator facilitates this learning by including reflective writing assignments in the curriculum to help students strengthen their critical thinking and reflective skills. students must move beyond the surface of learning or observing, and engage with the content on a higher level.[12] student reflections are guided by theoretical literature for understanding, analysis of actions taken and evaluation of the results of issues at hand.[11,12] de swardt et al.[11] specify that guided reflection raises the awareness of students of the level of their own competencies. it is the responsibility of educators to investigate their practice to ensure that service-learning projects are aligned to educational objectives, that they provide quality training and apply new ideas in their programmes.[9] a deeper exploration of students’ perspectives enables the educator to remain relevant in the application of service learning to child psychiatric nursing education and, in the process, to make applicable recommendations to other academic programmes that could benefit from the results achieved. this research is the result of the documented reflection reports of students of their involvement in and learning during the 1-year child psychiatric nursing programme. this article, therefore, deals with an investigation into students’ perceptions of their community-based learning during outreach programmes. methods a qualitative, explorative and descriptive research design was used to explore and describe the perceptions of students enrolled on the child psychiatric nursing programme regarding their learning during community-engagement place ment.[13] the research technique comprised an instrument for guided reflection. a structured reflection report was given to students to hand in after every exposure to community-based experiential learning. population and sampling the study population comprised all 47 students registered for the post-basic child psychiatric nursing programme from 2015 to 2017. a purposive sampling technique was used and all 47 nursing students’ reflection reports regarding the outreach experience were used.[14] data collection and analysis data were gathered directly after each outreach experience by means of reflection reports from each child psychiatric nursing student, whose responses were thematically analysed by content.[13] ethical principles the ethical requirements prescribed by the health sciences research ethics committee, university of the free state, bloemfontein (ref. no. hsrec137/2016) were adhered to, as were the ethical principles of beneficence, respect for human dignity and justice.[14] results and discussion four main themes emerged during data analysis, which revealed that the students essentially work through a process. first, they engage in community learning through the integration of theory into practice. students identify the needs of the community, but also engage as scholars by improving their professional development and advancing into responsible citizens. these four major themes were extrapolated with several subthemes (fig. 2). the major themes are important elements of the experiential servicesubthemes under theme 1 • di�erent learning experience • hands-on learning • conducive learning environment • knowledge construction • enjoyable/self-evaluation • thought provoking • integration of theory and learning • critical thinking • intrapersonal re�ection on action subthemes under theme 4 • social responsibility • advocacy • activist scholarship • ethical responsibility • service to people • doing something of value • responsible citizen • lifelong learners subthemes under theme 3 • professional collaboration practice • engage scholarship • skills development • self-awareness • strength and weakness • real-life experiences • self-con�dence • reciprocal knowledge sharing • autonomous • professional growth subthemes under theme 2 • vulnerable children • poverty • under-resourced community • financial constraints • ethical dilemmas • reciprocal knowledge sharing • empowerment • scarcity of mental health resources • di�erent culturescommunitylearning engagement identify the needs of the community practise responsible citizenship professional development fig. 2. the experiential learning process in service-learning engagement. june 2020, vol. 12, no. 2 ajhpe 83 research learning process of the students. a discussion of this study’s most important findings by theme follows. theme 1: community-learning engagement the students experienced the community-learning engagement as a different, enjoyable learning experience, and as a learning environment conducive to integrating theory and practice. through their intrapersonal reflection on action they indicated it as a ‘positive way of learning’ (p26) and that they ‘enjoyed the time i have spent’ (p18). in the process, they were stimulated to think critically and they described service learning as thought provoking. service learning helps students to foster higher levels of thinking, builds problem-solving skills and enhances the application of learning to real-world settings.[15] janse van rensburg[16] and adegbola[9] recommended service-learning engagement for students to integrate theory and practice (knowledge, skills and attitudes) in various fields. the students described outreach community-learning engagement as follows: ‘whoever came up with the outreach idea has really done justice to the children by taking the services to them, though the interval between outreaches are longer, but at least the people know that there is help.’ (p8) ‘outreach has practical opportunities to prepare students for the public as they are exposed to different situations.’ (p35) furthermore, intrapersonal reflection on action provided by students assisted the nurse educator to assess the preparation of nurses for their roles in the clinical setting. a student reported that: ‘it was a good learning environment and free from any intimidation. i was able to measure the little knowledge i have about first interview assessment, diagnosis and intervention.’ (p30) structuring the curriculum to provide learning experiences that prepare students to meet the healthcare needs of communities is the work of academic faculties.[15] the following responses could help educators: ‘beginning, i was still clueless.’ (p11) ‘i realised that one does not read as much.’ (p11) ‘i enjoyed outreach more as i got exposed to different environments with different kinds of children who presented with different problems.’ (p16) students acknowledged that community engagement was an important assignment for students to learn. students valued hands-on learning: ‘it gives an opportunity to link theory to practice and apply learning in community context.’ (p34) outreach to a community-learning environment exposed students to different learning experiences that relate to all the facets of their training. theme 2: needs of the community students experienced that valuable mental health services are rendered in the community: ‘outreach was about empowering patients, parents, and professionals with necessary skills to manage mental ill-health and parenting through workshops’ (p2) that could empower the people to take responsibility for their own mental healthcare. through their encounters, students developed a better understanding of and empathy for the needs of children and the community. face-to-face learning experiences enhanced the nursing students’ sense of connection with the community, which fostered a sense of belonging.[17,18] students were confronted with reality in the community, as explained by one student in a reflection: ‘i have always thought that people that used the phrase “you cannot save them all” or “you cannot save the world” were excusing themselves for doing more than what they currently are doing. but, i learned that one could do as much as resources will allow, and i had to learn to appreciate and be thankful for the little that i had done for those families in the short time i had with them.’ (p2) students developed an appreciation of the nature of the community by being involved in the outreach programme.[15] one student said: ‘i have learned a lot from the outreach and most importantly i was touched by the challenges the children are facing in that community, especially alcohol abuse of the parents. i have learned that when you engage families in the care of their child, they feel like partners and we get a positive result.’ (p26) the students experienced different cultural values[19] and learnt to respect the wishes of community members and how the students could make a difference: ‘at home the child was labelled as a naughty, stubborn child – family seemed not accepting her condition. i did manage to give them parental guidance.’ (p38) ‘the community was different. in one family two or three are mentally ill or the child is abused or raped. i asked myself what [is] wrong with this community.’ (p39) they recognise that not all situations could be treated in the same way: ‘particular intervention or initiative might not apply for every community.’ (p2) the students identified community needs and experienced ethical dilemmas: ‘i was quite challenged by the economic situation which was disrupting my function as a mental health professional – and could see the consequences thereof: some would not even come back due to lack of financing transport back and forth to the hospital.’ (p2) it was not always easy for the students, as they experienced some challenges: ‘far distance – we were leaving early in the morning. we had good welcoming smiles.’ (p28) however, they experienced it as worthwhile to endure: ‘this made me feel proud of myself as i felt i was doing something of value for patients.’ (p7) the students learnt to act on the challenges and needs of the community, which stimulated them to do more for a better outcome for the user of the mental health service. theme 3: professional development working in a team with other healthcare providers helped students to deliver better care to the people. one shared that it was a ‘good learning place for students and the team members are always ready to guide the students’. (p4) students need to participate as members of an interdisciplinary team and 84 june 2020, vol. 12, no. 2 ajhpe research to collaborate with members of a selected community to identify mental health-related issues and concerns.[15] the experiences of others during community engagement – specifically hearing from their peers how the children responded – and the types of questions their peers asked, helped students to develop professionally. overall, learning effectiveness is improved when individuals are highly skilled in engaging, collecting, interpreting and utilising data from multiple sources to assist in improving the health of a community.[15,18] the reciprocity of knowledge sharing was recognised, as the students shared the benefits of their participation in service learning with their team members and became engaged scholars, which contributed to their professional development. moreover, reflection reports helped them to do intraand interpersonal reflection actively. self-awareness helped the students to grow professionally and personally.[20] the students demonstrated respect and self-awareness while participating as members of a multidisciplinary team, and could contribute a nursing perspective. furthermore, the ‘opportunity to work independently’ (p11) helped students to become more confident: ‘i found the transition initially different and confronting, but by reviewing my knowledge and skills i was able to recognise that i already passed a great deal of knowledge and skills that were required for the different units, which bolstered my confidence and allowed me to focus on some issues that i had not had the opportunity to develop prior to this practical experience, thereby further developing myself as a registered nurse working in a mental unit.’ (p2) other students reported: ‘i felt overwhelmed of having completed an assessment with the help of the other professional nurses.’ (p19) ‘useful method for the student to learn and it promotes self-awareness, self-evaluation and self-confidence.’ (p32) the experience made students aware of their strengths and weaknesses: ‘i could not manage the group i started.’ (p14) ‘focus on these areas to develop them and turn them into strengths.’ (p21) several students valued the opportunity to learn and practise in a reciprocal knowledge-sharing environment, to identify gaps in their knowledge and skills. one student reported: ‘i feel we learn more when we are at the outreach than at the clinic, because there we have more one on one consultation with our mentor and we are able to identify our weaknesses and find ways to work around them and find our strong points and enhance on them.’ (p47) it seems that the community engagement helped students to become autonomous. one shared that: ‘outreach gave more experience on almost every aspect of my training and now i feel like i can make it out there as a child psychiatric nurse.’ (p17) community engagement also prepared the students, as one mentioned: ‘i have learned a lot of things that i did not know about my job that these outreach programmes opened my eyes.’ (p6) osman and peterson[21] believe that students, through their experience, construct their own understanding of the world around them, and then they will learn. service learning provides a rich context for students to learn through real-life experiences, and to develop academically, socially and as civic participants in a democracy. critical thinking is stimulated in various ways during this community-engagement experience. theme 4: practising responsible citizenship even though students developed professionally, they were required to make responsible decisions beyond their scope of practice and, thus, the experience touched on their social responsibilities as citizens of sa. in the communities, students were confronted with challenging issues, such as ethical dilemmas, inadequate human resources and financial and logistical problems. one student wrote: ‘i felt that their right to confidentiality was being violated.’ (p2) another student expressed that they needed to empower the community: ‘professional nurses – it is also their role to empower others with their knowledge and skills.’ (p33) these realisations helped the students to develop their activist scholarship, and to deliver service to the people.[22] most students reported finding the hands-on education that service learning provides valuable: ‘i can say that i can be able to go back to my institution with the knowledge that i have gained at these outreach programmes and incorporate it to bring about change.’ (p8) one student summarised the experience: ‘community outreach services should bring specialised healthcare services next to the home of the clients. it is to make healthcare services equally accessible to all sa citizens irrespective of colour, economic status and whether it is in rural areas or townships.’ (p23) from these responses it is evident that nursing students are serious about their development as advanced child psychiatric nurses, and that they will advocate for their patients’ rights and become involved citizens. discussion the results indicate that students experienced how important communityservice learning is. students could link theory to practice, apply learning in a specific community context and address specific needs of the community in a holistic manner. nurse educators can increase the students’ effectiveness by including service-learning concepts and actual field experience in academic education. through experiential learning education, students discovered relationships among ideas, rather than passively receiving information.[23] reciprocal learning takes place for students and community members. the students engaged in critical thought and discussion about the construction of knowledge.[15,21] mayne and glascoff [15] claim, ‘it is an effective way for educators to prepare nurses for their roles in healthcare for the 21th century’. nursing students learnt about all the important components of child mental health, and they could identify what bronfenbrenner’s ecological systems theory[24] means by the explanation that a child is exposed to and influenced by many systems. because children are part of families, communities and society, they cannot be treated in isolation. the students worked in the midst of all these systems. they experienced the needs of the community and, more specifically, the family. june 2020, vol. 12, no. 2 ajhpe 85 research during their outreach sessions, nursing students could compare their performance and learn from one another, as well as from professional team members, e.g. social workers, psychiatrists, psychologists and occupational therapists. a good working relationship among members of the multidisciplinary team and provision of support on personal and professional levels are important for improving the professional development of students.[18] nurse educators should continue exploring reciprocity learning opportunities such as these, where students can develop self-awareness and critical thinking, which promote the development of professional competence, and where they learn to value and respect the authenticity of others. based on the students’ comments, they learnt the value of intercultural communication, advanced therapeutic relationships cross-culturally, improved their language skills and collaborated with community liaisons.[19] focused intercultural and collaborative partnerships have the potential to prepare students to become more comfortable with caring for healthcare users who differ from them, and to encourage students to be leaders in meeting the healthcare needs of a global and multicultural society. conclusions learning is best conceived as a process, not in terms of outcomes. this experiential learning process in service-learning engagement (fig. 2) will improve learning in higher education, because it draws out students’ beliefs and ideas about the subject, so that they can examine, test and integrate new, more refined ideas. they can move back and forth between feeling and thinking. this type of learning involves the integrated functioning of the whole person, who thinks, feels, perceives and behaves. in this study, learning happened from synergetic transactions between the student and the community and, in the process, social knowledge was created and recreated in the personal knowledge of the student. this experiential learning process could slot into any curriculum, and can expose and empower students in relation to the realities of the social and human dynamics in communities. evidence supports the use of community learning to develop students’ professionalism, ethical responsibility and personal growth – in that way they become responsible citizens. they realise how important it is to become community-service volunteers in their careers and being sa citizens. in the process, they practise responsible citizenship. service learning provides rich opportunities for child psychiatric nursing students and is very relevant to nursing education. the mental health of children and families in communities is very important for the future of any country; therefore, healthcare professionals must be trained to address any mental challenges that may occur. training institutions need to support the inclusion of service learning in the curriculum to train student nurses to be competent professionals, who are socially accountable. future studies should include the perceptions of community partners and mental health users in the community about this type of learning and service. declaration. none. acknowledgements. i wish to thank the child psychiatric nursing students; sr ester mabizela, instigator of outreach programmes, free state psychiatric complex child unit personnel; free state communities; school of nursing and the university of the free state for their personal, professional and logistical 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albertyn, r. knowledge as enablement. engagement between higher education and the third sector in south africa. bloemfontein: sun media, 2014:66. 23. stewart t, wubbena zc. a systematic review of service-learning in medical education: 1998 2012. teach learn med 2015;27(2):115-122. https://doi.org/10.1080/10401334.2015.1011647 24. berk le. child development. 5th ed. boston: allyn and bacon, 2000:23-38. accepted 6 december 2019. https://doi.org/10.7196/samj.2018.v108i3.12904 https://doi.org/10.1016/s2214-109x(18)30303-6 https://doi.org/10.1016/s2214-109x(18)30303-6 http://apps.ufs.ac.za/dl/yearbooks/317_yearbook_eng.pdf http://www.ufs.ac.za/supportservices/departments/community-engagement-home https://doi.org/10.7196/ajhpe.2017.v9i3.806 https://doi.org/10.7196/ajhpe.2017.v9i3.806 https://cft.vanderbilt.edu/guides-sub-pages/teaching-through-community-engagement/ https://cft.vanderbilt.edu/guides-sub-pages/teaching-through-community-engagement/ https://doi.org/10.9790/7388-05616670 https://doi.org/10.1097/acm.obo13e31823b55fa https://doi.org/10.1097/acm.obo13e31823b55fa https://doi.org/10.3928/01484834-20190103-08 https://doi.org/10.1080/07370016.2010.515461 https://doi.org/10.1080/07370016.2010.515461 https://doi.org/10.1080/10401334.2015.1011647 ajhpe african journal of health professions education november 2020, vol. 12, no. 4 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 guest editorial 165 collaboration: a potential solution to imminent issues facing nursing and midwifery education in africa? c n nyoni short research report 166 exploring internal quality assurance for nursing education in the state university of zanzibar, tanzania: a preliminary needs analysis m bilal, d manning 169 facilitators and challenges experienced by first-year nursing students at the university of fort hare, south africa, when conducting home visits n l gosangaye, k mostert 172 supportive framework for teaching practice of student nurse educators: an open distance electronic learning (odel) context t e masango research 175 a competence assessment tool that links thinking operations with knowledge types y botma, n janse van rensburg, j raubenheimer 179 mentors’ and student nurses’ experiences of the clinical competence assessment tool m sserumaga, a g mubuuke, j nakigudde, i g munabi, r b opoka, s kiguli 186 practice guidelines for peer support among educators during a curriculum innovation m shawa, y botma 191 converging professional nurses’ perceptions and community service nurses’ experiences regarding clinical competence during community service placement k l matlhaba, a j pienaar, l a sehularo 197 the emergence of a clinical skills laboratory and its impact on clinical learning: undergraduate nursing students’ perspective in limpopo province, south africa t m mothiba, m a bopape, m o mbombi 201 evaluating the outcomes of a faculty capacity development programme on nurse educators in sub-saharan africa j m van wyk, j e wolvaardt, c n nyoni ajhpe african journal of health professions education november 2020, vol. 12, no. 4 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 206 stakeholders’ community-engaged teaching and learning experiences at three universities in south africa f muzeya, h julie 211 the use of an online learning management system by postgraduate nursing students at a selected higher educational institution in kwazulu-natal, south africa l i buthelezi, j m van wyk 215 nurse educators’ views on implementation and use of high-fidelity simulation in nursing programmes e powell, b scrooby, a van graan 220 male students’ motivations to choose nursing as a career i noordien, j hoffman, h julie 224 promoting patient autonomy: perspectives of occupational therapists and nurses p govender, d naidoo from the editor 227 ajhpe special focus issue – call for papers: innovations in health professions education during the covid-19 era c n nyoni, w cordier, l wolvaardt cpd questionnaire a maximum of 3 ceus will be awarded per correctly completed test. june 2020, vol. 12, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) cpd questionnaire june 2020 postgraduate medical specialty training for botswana: a successful innovative partnership with south africa 1. the following challenges were encountered in the first years of speciality training: a. one of the postgraduate programmes collapsed. b. university of botswana mmed students had left most of the training programmes. c. most programmes decided to decrease or not have yearly intakes. d. medical registration with the health professions council of south africa (hpcsa) was lengthier than expected. content analysis of the south african mmed mini-dissertation 2. which of the following statements are true: a. the vast majority of studies were qualitative. b. non-compliant and unconfirmed ethical clearance declined dramatically from pre-2011 to 2011 2014. c. the majority of mmed dissertations were in monograph format. d. more than half of the quantitative studies used statistics to compare variables or test hypotheses. burnout and associated factors in undergraduate medical students at a south african university 3. between 15% and 20% of physicians experience mental health problems in their working lifetime. true or false? enhancement of plastic surgery training by including simulation in education and training programmes 4. the american college of surgeons introduces simulation in training and education for general surgery in three phases: a. phase 1 – skills, phase 2 – procedures, phase 3 – competencies in teamwork. b. phase 1 – procedures, phase 2 – skills, phase 3 – competencies in teamwork. c. phase 1 – competencies in teamwork, phase 2 – skills, phase 3 – procedures. d. phase 1 – competencies in teamwork, phase 2 – procedures, phase 3 – skills. simulation as an educational strategy to deliver interprofessional education 5. scott et al. identified clinical outcomes for the interprofessional team, as well as competencies, such as: a. communication, teamwork and professionalism. b. communication, professionalism and collaboration. c. communication, teamwork and leadership. d. teamwork, leadership and professionalism. the benefits of experiential learning during a service-learning engagement in child psychiatric nursing education 6. which of the following statements related to developing students’ reflective skills are true: a. critical reflection deepens students’ understanding of their professional roles in the community. b. reflective writing is fundamental to improving critical thinking skills of students. c. experiential learning raises the awareness of students’ level of their own competencies. d. experiential learning allows them to move beyond the surface of learning or observing, and engage with the content on a higher level. readiness of allied health students towards interprofessional education at a university in ghana 7. the results of this study showed that: a. there is a significant difference between readiness and programme of study. b. students generally value sharing of experiences with other healthcare disciplines. c. there is a relatively high level of readiness towards interprofessional education. d. students struggled with understanding their roles within the team. editorial 191 can they be trusted? v burch research 194 improving communication in the south african healthcare context m g matthews, j m van wyk 199 student-informed directives for clinical communication skills training in undergraduate healthcare programmes: perspectives from a south african university e c janse van vuuren, m nel 205 knowledge and attitudes of undergraduate medical students with regard to medical research at a south african university a o adefolalu, n j mogosetsi, n m mnguni 210 continuing professional development opinions and challenges experienced by radiographers in kwazulu-natal province, south africa k naidoo, s naidoo 215 mandatory continuing education for psychologists: practitioners’ views a l pillay, a zank 220 a pre-post study of behavioural determinants and practice change in ugandan clinical officers l m t byrne-davis, m j jackson, r mccarthy, h slattery, g yuill, a stevens, g j byrne, h parry, s ramsden, h muwonge, m johnston, c j armitage, s cook, s whiting, j gray, j hart 228 learning styles of physiotherapy students and teaching styles of their lecturers in undergraduate gross anatomy education d a shead, r roos, b olivier, a o ihunwo 235 teaching pharmacotherapeutics to pharmacy students at a nigerian university: student perspectives s n abdu-aguye, h yusuf, h u ma’aji, h m rabiu cpd questionnaire ajhpe african journal of health professions education december 2018, vol. 10, no. 4 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria elizabeth wolvaardt university of pretoria hmpg acting ceo dr manivasan thandrayen executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens senior designer clinton griffin chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m mbokota, dr g wolvaardt issn 2078-5127 file:///volumes/hmpg%20production/in%20progress/ajhpe%20december%202018/word%20docs/javascript:if(intformhaschanged == 0)%7bpopupreviewerinfoemdetails(740, 509,'ajhpe', 0)%7delse%7bpopupreviewerinfoemdetails(740, 509,'ajhpe', 1)%7d mailto:nomsa.mogosetsi@smu.ac.za mailto:nokufa.mnguni@smu.ac.za 94 october 2020, vol. 12, no. 3 ajhpe guest editorial nurses and midwives are being celebrated worldwide as heroes. frontline nurses and midwives are being credited for their tireless efforts in managing the covid-19 pandemic, including the associated positive health outcomes. however, this pandemic has exposed the continued marginalisation of nursing and midwifery students throughout africa. according to the world economic forum (2020), higher education institutions in africa struggled to adapt their planned academic activities to disruptions associated with the covid-19 pandemic. at the beginning of the pandemic, the majority of these institutions suspended their academic activities, while only a handful resorted to emergency remote teaching as a strategy for continued academic activities. in some countries, higher education institutions received additional support from governments to buffer expenses associated with remote learning and teaching. computers, zero-rated online access, and students receiving data from their institutions are examples of support rendered to students to enable access to learning materials in remote locations. in south africa, this support was aimed at ‘not leaving any student behind’ and salvaging the academic year through continued learning in higher education institutions. unfortunately, nursing and midwifery students in africa will be left behind because their training predominantly occurs in hospital-based nursing education institutions governed by the ministries of health.[1] this situation is a result of the complex historical legacies aligned with the establishment of nursing education in africa. these nursing education institutions are hospital departments and not recognised as part of higher education. they compete with other hospital departments for the finite hospital budget, and in crises similar to the covid-19 pandemic, they are not prioritised. consequently, at the beginning of the pandemic, planned academic activities for nursing and midwifery students in africa were suspended. the clinical platform could not admit these students owing to limitations in personal protective equipment. furthermore, while at home, the students did not receive any additional resources or support for continued learning. with the general improvement in health outcomes and continued easing of covid-19-related restrictions in most african countries, higher education institutions are working towards the reopening of academic activities. these institutions are expected to ensure the safety of students and staff by meeting stricter regulations related to physical distancing, sanitisation, health screening and personal protective equipment. governments are working directly with these institutions by supporting risk-adjusted strategies and resource allocation. nursing education institutions will fail to meet stricter covid-19-related regulations, as budgets within ministries of health prioritise patient care. the clinical platform is not ready for students, furthering their plight in meeting regulatory requirements. nursing and midwifery students will continue being at home and not being engaged in any form of learning, unlike their counterparts in higher education. the consequences of leaving nursing and midwifery students behind will have a ripple effect on the already fragile healthcare system. covid-19-related experiences have exhumed discussions around the governance of nursing education in africa. questions on the appropriateness of health ministries governing nursing education have been discussed in the literature, with various authors already calling for the migration of the governance of nursing education to higher education.[2,3] armstrong and rispel,[4] in their argument for the professionalisation of nursing, reflect on the need for nursing and midwifery qualifications to be on par with other higher education qualifications, articulating through similar qualification frameworks. consequently, nursing education institutions will be expected to meet quality-assurance standards set for all higher education institutions, while their students may benefit from all risk-adjusted strategies aimed at continued learning in crises. however, migrating the governance of nursing and midwifery education to higher education may have crippling consequences for the healthcare system, which are related to budgets and human resources, as students are often perceived as part of the staff.[5] this delicate situation needs renewed discussion among all nursing education stakeholders, aimed at a sustainable solution that prioritises learning and the end of the continued marginalisation of nursing and midwifery students. at the beginning of 2020, we called for manuscripts for the special focus issue on nursing and midwifery education in africa. this call received an overwhelming response from authors across the continent, presenting work done in undergraduate, postgraduate and continuing education for nurses and midwives. the african journal of health professions education has dedicated the last two issues of this volume to the special focus issue. champion n nyoni guest editor: special focus issue on nursing and midwifery education, school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa nyonic@ufs.ac.za 1. blaauw d, ditlopo p, rispel lc. nursing education reform in south africa – lessons from a policy analysis study. glob health action 2014;7(1):26401. https://doi.org/10.3402/gha.v7.26401 2. rispel l, schneider h. professionalization of south african nursing: who benefits? int j health serv 1991;21(1):109-126. https://doi.org/10.2190/guhd-gwfq-ywjj-eykh 3. botma y. implications of accreditation criteria when transforming a traditional nursing curriculum to a competency-based curriculum. int j africa nurs sci 2014;1:23-28. https://doi.org/10.1016/j.ijans.2014.06.002 4. armstrong sj, rispel lc. social accountability and nursing education in south africa. glob health action 2015;8(1):27879. https://doi.org/10.3402/gha.v8.27879 5. bvumbwe t, mtshali n. nursing education challenges and solutions in sub saharan africa: an integrative review. bmc nurs 2018;17(1):3. https://doi.org/10.1186/s12912-018-0272-4 afr j health professions educ 2020;12(3):94. https://doi.org/10.7196/ajhpe.2020.v12i3.1441 nursing and midwifery students will be left behind this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.3402/gha.v7.26401 https://doi.org/10.2190/guhd-gwfq-ywjj-eykh https://doi.org/10.1016/j.ijans.2014.06.002 https://doi.org/10.3402/gha.v8.27879 https://doi.org/10.1186/s12912-018-0272-4 november 2020, vol. 12, no. 4 ajhpe 191 research the transition from student status to newly qualified nurse can be stressful because of the adjustments to a new role, which requires a combination of knowledge and skills.[1] the stress is due to the notion of being inadequately prepared, lack of confidence and feelings of incompetence.[2] to overcome this, many countries have resorted to the introduction and implementation of methods to improve clinical capabilities of new graduate nurses. in south africa (sa), the national department of health introduced compulsory community service for health professionals in 1998.[3] the primary objective of community service is to enhance quality healthcare access for south africans, especially in previously under-resourced areas. young professionals are afforded opportunities, through this process, to develop their skills, establish behaviour patterns and critical thinking and acquire knowledge that assists with their professional development.[3] in 2007, the nursing bill was promulgated into the nursing act (act no. 33 of 2005) and, as a result, community service for nurses was effected.[4] the directive stipulates that nurses must complete a mandatory 12-month period of community service after successful completion of the 4-year nursing degree or nursing diploma training (r425) prior to their registration as professional nurses (pns) (general, psychiatric and community) and midwives.[5] since the implementation of mandatory community service, numerous researchers have established that community service nurses (csns) lack competence in some areas, including basic nursing care, leadership and unit management, teamwork and collaboration, and communication skills, yet there is currently no tool that informs the evaluation of these basic competences. this knowledge gap prompted us to carry out a study of this nature in north west province (nwp), sa. this article forms part of the original study, which aimed to develop a tool to evaluate clinical competence of csns in nwp. therefore, the objective was to report the convergence of the results of the experiences of csns and the perceptions of pns with regard to the clinical competence of the former during their community service placements. definition of competence competence during the florence nightingale era was associated with the qualities of the character and skills of a nurse.[6,7] competence is seen as ‘the capacity of individuals to perform the given task’.[7] the south african nursing council (sanc) defines competence as the ‘ability of a practitioner to integrate the professional attributes including, but not limited to, knowledge, skills, judgement, values and beliefs, required to perform as a professional nurse in all situations and practice settings’.[5] therefore, for this study, competence is defined as csns’ ‘ability to function under the legal prescripts, which includes the application of knowledge, psychomotor skills background. transitioning from a student to the role of a newly qualified nurse can be difficult when not well prepared. the expectation is that newly qualified nurses should reflect competency across a wide range of skills. to acquire and improve the necessary skills, many countries opted to introduce and implement strategies to prepare nurses for their professional roles. in south africa (sa), the newly qualified nurse is required to perform an obligatory 12 months’ community service as mandated by the regulation promulgated by the minister of health. objective. to report the convergence results of the perceptions of professional nurses and the experiences of community service nurses (csns) regarding clinical competence of the latter during placement in north west province (nwp), sa. method. the study followed a qualitative, explorative, descriptive and contextual design. it employed the world café data-collection method, including 21 purposively sampled participants. benner’s levels of competence scale was used to rate the competence of csns. pienaar’s four steps of qualitative thematic analysis were adapted to analyse data. results. three main themes emerged, i.e. ethos and professional practice; unit management, governance and leadership; and contextual clinical and technical competence. conclusion. the world café method allowed for real conversations around mutual topics of interest, and rich data collected is a true reflection of the participants’ perceptions and experiences. these results contributed to the development of a clinical competence evaluation tool for csns in nwp. afr j health professions educ 2020;12(4):191-196. https://doi.org/10.7196/ajhpe.2020. v12i4.1401 converging professional nurses’ perceptions and community service nurses’ experiences regarding clinical competence during community service placement k l matlhaba,1,2 phd; a j pienaar,3 phd; l a sehularo,1 phd 1 school of nursing science, faculty of health sciences, north-west university, mahikeng campus, south africa 2 department of health studies, college of human sciences, university of south africa, pretoria, south africa 3 department of psychology, school of health sciences, university of venda, thohoyandou, south africa; and department of graduate studies and research, shifa college of nursing, shifa tameer-e-millat university, islamabad, pakistan corresponding author: k l matlhaba (matlhkl@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://en.wikipedia.org/wiki/thohoyandou 192 november 2020, vol. 12, no. 4 ajhpe research and ability to adequately manage the demands that clinical nursing require’.[5] methods research design this study used a qualitative, exploratory, descrip tive and contextual research design by employing the world café method to gain a greater compre hension of pns’ perceptions and csns’ experiences regarding clinical competence for the duration of their placement. research setting two tertiary hospitals in the two different regions of nwp were selected. these hospitals were deemed appropriate, as the csns were in the second semester of their placement. population and sampling the study employed a non-probability purposive sampling technique to determine participants subjectively, based on a considered population representation.[8] purposive samples consist of characteristics based on a particular quality that will benefit the study. in this study, 12 pns and 9 csns attended the world café.[8] data collection process the world café method was selected for data collection. it was developed as a brainstorming tool with the aim of creating concepts and explanations of a particular topic.[9] according to brown and isaacs, the world café method is a ‘synchronous network of conversations for leading collaborative dialogue, where knowledge is shared; and possibilities for action in groups of all sizes around questions that matter is created’.[10] this method was deemed appropriate for the study, as a volume of rich data could be assimilated within a limited period, which prompted ideas and comments from pns and csns on specific topics in the form of questions asked. in applying the world café principle, an open room was arranged in a manner similar to a café set-up. four tables with 3 4 participants per table convened during data collection, with paper and coloured markers provided to answer the questions. the participants rotated across all the tables. one participant remained at the table to welcome the new group, facilitate their discussions, add to their ideas and capture the responses on the provided paper. refreshments were served during the process to capture the essence of a café. the process lasted between 15 and 20 minutes, and the following questions were posed during the data-collection process to prompt the world café discussions: • which competencies are needed for csns to be regarded as competent practitioners? • which competencies are achieved during community service placement? (use rating scale a and motivate (fig. 1).) each table had a participant who was the host. at the close of each round, the host remained at that table, while the other participants moved to the next table. the host greeted the new group and shared information from the previous group, allowing the new group to familiarise themselves with the written ideas and add new ideas. this process continued until each group of participants had rotated around all the tables and answered all the questions. after the rotation, a final discussion session took place where all the participants reflected on the overall process, and explained and confirmed their results and written ideas. fig. 1 depicts the scale used by participants to rate the csns’ levels of competence for the different competencies mentioned during the first round as they were answering the second question. each group was asked to rate their perceived level of competence since the commencement of their community service, using benner’s 5 levels of competence.[11] data analysis data from the world café discussions were analysed by the second author and research assistants, following pienaar’s 4 steps (adapted) of qualitative thematic analysis:[12] • data collection and analysis occurred with basic concepts being derived from the written quotes, which were analysed to identify similar concepts. • concepts that emerged were categorised and those that were similar or related were linked together. • the ratings and motivations were clustered together as additional information that emerged during the process of data collection. • the pattern was built from themes with ratings and motivations – each theme forming a common background. the first and third authors held a consensus discussion to confirm the final themes. trustworthiness the following criteria for trustworthiness ensured credibility, dependability, confirmability and transferability:[13] • during data collection, credibility was con firmed in the final discussion, which gave parti cipants the opportunity to review the collected data and provide feedback to each other. furthermore, the entire process was recorded. credibility was achieved by interrogation of data by listening to the recordings and reading the transcripts more than once. the researchers immersed themselves in the details to get a sense of the data – co-coding before categorising data into themes and sub-themes. • dependability was ensured by the second author as a co-coder. both researchers analysed novice needs close supervision, instructions and monitoring advanced beginner ability to achieve some goals using one's own judgement, but supervision needed for overall task competent ability to achieve most tasks using one's own judgement pro�cient ability to take full responsibility and accountability for one's own work and assist others expert ability to take responsibility for going the extra mile, going beyond existing standards and creating one's own interpretations fig. 1. figure adapted from benner’s levels of competence.[12] november 2020, vol. 12, no. 4 ajhpe 193 research data individually, compared the results and agreed to the final themes and sub-themes. the results could not be generalised, but the research process, particularly data collection, is discussed in detail so that any alternative application of this research in a similar context will be possible. • to ensure confirmability, data were interpreted, whereby themes and sub-themes were supported by quotations to reflect the views of the participants. confirmability was ensured when the data obtained and the link between the interpretation of results and actual events was supported by discussion of the results, recommendations and conclusions. • to confirm transferability, data were presented in a descriptive manner so that other researchers could compare data if necessary. furthermore, the study employed purposive sampling based on the participants’ knowledge of the phenomenon and a context deemed appropriate for the study. ethical approval the scientific committee of the school of nursing science (sons) and the faculty of agriculture, science and technology health science ethics committee (fast-hsec) of north-west university gave ethical approval for this study (ref. no. nwu-00230-18-a9). the north west department of health (nwdoh) and the two selected hospitals in nwp granted approval for the study. informed consent was obtained before commencement of the process, after an explanation of what was expected from the participants. participants were advised that involvement was voluntary and that they had the right to opt out of the interviews at any stage without providing an explanation and without incurring any penalties, after which they gave their informed consent. results four themes emerged from the data analysis. fig. 2 illustrates the convergence of results. tables 1 and 2 represent the first 3 themes that emerged and the levels of competence of pns and csns. theme 1: ethos and professional practice the international council of nurses (icn) adopted the first international code of ethics for nurses in 1953. since then, other nursing and midwifery regulatory bodies followed and adopted these codes of ethics.[15] the code of ethics is the ‘cornerstone of ethical decision-making and aimed to inform nursing practitioners and the public of the following ethical and moral principles applicable to nursing practitioners in the performance of their duties’.[16] an ‘effective ethical code for nursing practice must provide guidance on managing ethical problems that arise at the societal level, the organisational level, and the clinical level’.[17] therefore, the ethical code summarises ethical behaviour for the nursing profession and guides decision-making when barriers that prevent fulfilment of their professional obligations are encountered.[18] in this study, participants reported that ethos and practice form the basis of the nursing profession, which were in support of those of a study in iran.[19] their qualitative study revealed that the majority of nurses highlighted professional ethics and accountability as important characteristics that provided the basis for the ethical context in healthcare settings.[19] therefore, it is important that csns uphold the ethical and professional conduct of the nursing profession. however, the results revealed that csns from both hospitals had little knowledge of ethical or professional conduct. this was supported by pns, who stated that csns do not uphold the ethical and professional conduct of the nursing profession, particularly with regard to nursing etiquette. results from the literature on interpersonal and communication skills revealed that newly qualified nurses are unable to communicate effectively with multidisciplinary team members.[20] in this study, participants mentioned that csns face challenges when they should communicate with multidisciplinary team members or when answering the telephone. the outcome of this study also concurred with the results of a study conducted in the usa,[21] which revealed that many challenging experiences with regard to team-member communication were described by new graduate nurses. in this study, csns revealed that they had limited knowledge of ethics, which was a concern, as this could also affect their responsibilities with regard to patient advocacy. according to tomaschewski-barlem et al.,[22] the nurse-patient relationship, effective communication and recognition of patients’ needs are essential for effective advocacy practice. they further maintain that the establishment of a proper relationship with patients enables nurses to understand more broadly the patients’ real needs and become more efficacious when defending the desires and interests of their patients. when considering the upholding of values and principles, including batho pele principles and the patient rights charter, the results of this study were in contrast to those of an iranian study conducted on nurses and student nurses’ awareness of patients’ rights,[23] which reported that participants were knowledgeable and aware of these rights. our study showed that csns lacked knowledge or application of ethical and professional conduct. fig. 2. convergence of the results.[14] (pns = professional nurses; csns = community service nurses.) experience of csns perceptions of pns convergence results 194 november 2020, vol. 12, no. 4 ajhpe research theme 2: unit management, governance and leadership participants reported that some csns had the ability to manage the unit with minimal supervision. however, the majority of pns disagreed, as some csns mentioned that they had never been in a situation where they led or managed a unit, and therefore were not confident regarding their leadership skills. these results concurred with an sa study, where csns where unable to manage conflicts, and expressed reluctance to take the lead, particularly with delegation of duties and other managerial responsibilities.[24] theme 3: contextual clinical and technical competence the study by walker et al.[25] established that new graduate nurses work in challenging healthcare environments with unfamiliar technologies, work shift hours, heavy patient loads, and have to deal with patient safety issues. in this study, participants reported that contextual clinical and technical competence was not satisfactory; this competence was dependent on the time spent in specifically allocated units. it was also reported that some csns need supervision on basic procedures, such as management of a patient receiving a blood transfusion and delegation of duties, and that there is a lack of adequate exposure during their training. study limitations the researchers acknowledge that this qualitative research is limited to only two nwp hospitals in sa and that the results cannot be generalised. however, the study delivers important information and confirmation that can be considered by csns and pns, as well as other stakeholders, including hospital management and the nwdoh, for measures to improve clinical competence of csns during their community service placements. recommendations • there is a dire need to improve the ethical and professional conduct table 1. competence levels of community service nurses (rating scale a and motivation), group a[14] csn pn themes sub-themes competence level rating motivation competence level rating motivation ethos and professional practice ethics in nursing 2 – advanced beginner ‘i don’t have much exposure with regard to ethics’ novice ‘they do not uphold to the professional and ethical conducts of nursing. they are resistant to adhere to uniform, no telephone etiquette’ unit management, governance and leadership unit administration 3 – competent ‘i had day-to-day exposure of the wards and what is expected to run the ward’ 2 – advanced beginner ‘application of different management skills and personnel management and communication skills’ governance and leadership 3 – competent ‘i am able to take leadership and assist junior students and personnel who are not well’ 2 – advanced beginner ‘do not take responsibility. they cannot lead’ contextual, clinical and technical competence medical/surgical nursing 3 – competent ‘i have knowledge as i worked there during my studies and i can carry out tasks and run the unit’ 3 competent ‘they [csns] are competent but still need minimal supervision’ midwifery nursing 2 – advanced beginner ‘i am able to apply maternity guidelines to manage patients’ 1 – novice ‘some still need intense supervision’ psychiatric/mental health nursing 2 – advanced beginner ‘i had little time at the unit, but with knowledge of practical, i can achieve some goals’ 1 – novice ‘they cannot be rated as competent because there is no psychiatric unit, patients are admitted for observation, so the exposure for learning is limited’ operating theatre 1 – novice ‘i have never worked there’ 1 – novice ‘their exposure is limited in their training and the area is highly specialised with a lot of risks’ csn = community service nurse; pn= professional nurse. november 2020, vol. 12, no. 4 ajhpe 195 research of csns. strategies include in-service training and staff workshops on topics related to ethical and professional practice to be incorporated into teaching at each unit to which csns are allocated. this should be reinforced on rotation of csns to new units. • orientation and induction programmes must provide relevant information and focus on ensuring overall competence in the specific unit to which a csn is assigned. • supervision and mentorship programmes at different units are recommended. • the allocation and rotation period for csns must be carried out in a manner that includes the majority of the disciplines, which will assist csns with exposure opportunities. • providing csns with opportunities to take charge of the unit through the delegation of management duties will boost their confidence in unit management and leadership. conclusion it was deemed necessary to report convergence of the results because of similarities identified in the outcomes of the world café discussions on the perceptions of pns and csns regarding clinical competence during community service placement. utilisation of the world café method allowed for real conversations on mutual topics of interest, and the rich data collected is an accurate expression of the participants’ perceptions and experiences. these results contributed to the development of a tool to evaluate clinical competence of csns in nwp. declaration. none. acknowledgements. the researchers acknowledge the research assistants for their assistance with data collection and the participants for taking part in this study. author contributions. klm was responsible for finalisation of data analysis and writing of the manuscript. las was responsible for conceptualisation and proofreading of the manuscript. ajp finalised the data collection, analysed the collected data and made conceptual contributions to the manuscript. funding. the health and welfare sector education and training authority (hwseta) and north-west university, mahikeng campus, provided financial support to conduct the main study. conflicts of interest. none. 1. edwards d, hawker c, carrier j, rees c. a systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse. int j nurs stud 2015;52(7):1254 -1268. https:// doi.org/10.1016/j.ijnurstu.2015.03.007 2. fernandez r, sheppard-law s, curtis s, bancroft j, smith w. exploring the experiences of neophyte nurse mentors: a qualitative study. nurse educ pract 2018;29:76-81. https://doi.org/10.1016/j.nepr.2017.11.011 3. national department of health. health on community service by health professionals. 2006. https://www.gov.za/ health-community-service-health-professionals (accessed 15 may 2020). 4. south african nursing council. regulations: community service regulation no. r765 of 2007. 5. national department of health. nursing act, 2005 (act no. 33 of 2005). government gazette no. 34852. 2011. 6. adu-gyamfi s, edward b. nursing in ghana: a search for florence nightingale in an african city. int scholar res notices 2016;2016:1-14. https://doi.org/10.1155/2016/9754845 7. wilkinson ca. competency assessment tools for registered nurses: an integrative review. j cont educ nurs 2013;44(1):31-37. https://doi.org/10.3928/00220124-20121101-53 8. polit df, beck ct. nursing research: generating and assessing evidence for nursing practice. 10th ed. london: lippincott williams and wilkins, 2017. 9. van wyngaarden a, leech r, coetzee im. assessing the value of action research: using world café to explore the professional journey of nurse educators. s afr j higher educ 2018;6:519-531. https://doi.org/10.20853/326-2974.32 10. froneman k, du plessis e, koen m. effective educator-student relationships in nursing education to strengthen nursing students’ resilience. curationis 2016;39(1):a1595. https://doi.org/10.4102/curationis.v39i1.1595 table 2. competence levels of community service nurses (rating scale a and motivation), group b[14] csn pn themes sub-themes competence level rating motivation competence level rating motivation ethos and professional practice ethics in nursing 2 – advanced beginner ‘not really clued up much on ethical principles in nursing’ 2 – advanced beginner ‘their behaviour must still improve’ unit management, governance and leadership unit administration 2 – advanced beginner ‘have not had much chance to run a unit, but i have been trained on how to’ 3 – competent ‘ability to manage the ward under indirect supervision’ governance and leadership 1 – novice ‘never came across a situation where i have to lead people’ 1 – novice ‘not enough exposure to lead in the unit’ contextual, clinical and technical competence medical/surgical nursing 3 – competent ‘i’ve worked in this unit most of my training, i can handle them pretty well by myself ’ 3 – competent ‘with multiple conditions, some appear less often than others; they [csns] are competent’ midwifery nursing 3 – competent ‘i can manage a pregnant woman from antenatal care to puerperium’ 2 – advanced beginner ‘due to limited exposure, supervision is still necessary in the working environment’ psychiatric/mental health nursing 2 – advanced beginner ‘i still need supervision on almost everything i am doing’ 2 – advanced beginner ‘certain situations they [csns] have not come across. so supervision is really needed’ operating theatre 2 – advanced beginner ‘i did not have enough clinical exposure’ 2 – advanced beginner ‘they do not get to be allocated in theatre unit for enough hours’ csn = community service nurse; pn= professional nurse. https://doi.org/10.1016/j.ijnurstu.2015.03.007 https://doi.org/10.1016/j.ijnurstu.2015.03.007 https://doi.org/10.1016/j.nepr.2017.11.011 https://www.gov.za/health-community-service-health-professionals https://www.gov.za/health-community-service-health-professionals https://doi.org/10.1155/2016/9754845 https://doi.org/10.3928/00220124-20121101-53 https://doi.org/10.20853/32-6-2974.32 https://doi.org/10.20853/32-6-2974.32 https://doi.org/10.4102/curationis.v39i1.1595 196 november 2020, vol. 12, no. 4 ajhpe research 11. benner p. from novice to expert: excellence and power in clinical nursing practice. new jersey: prenticehall, 1984. 12. pienaar aj. learning and asserting an african indigenous health research framework. in: ngulube p, ed. handbook of research on theoretical perspectives on indigenous knowledge systems in developing countries. pennsylvania: igi global, 2017:85-99. 13. creswell jw, creswell jd. research design: qualitative, quantitative and mixed methods approaches. 5th ed. los angeles, sage, 2018. 14. matlhaba kl. development of an evaluation tool for clinical competence of community service nurses in north west province, south africa. phd thesis. mahikeng: north-west university, 2019. 15. international council of nurses. the icn code of ethics for nurses. 2012. ethics.iit.edu/ecodes/sites/default/ files/international%20council%20of%20nurses%20code%20of%20ethics%20for%20nurses.pdf (accessed 15 may 2020). 16. south african nursing council. code of ethics for nursing practitioners in south africa. 2013. https://www. sanc.co.za/pdf/learner%20docs/sanc%20code%20of%20ethics%20for%20nursing%20in%20south%20 africa.pdf (accessed 15 may 2020). 17. epstein b, turner m. the nursing code of ethics: its value, its history. online j issues nurs 2015;20(2). https:// doi.org/10.3912/ojin.vol20no02man04 18. zahedi f, sanjari m, aala m, et al. the code of ethics for nurses. iran j public health 2013;42(suppl 1):1-8. 19. dehghani a, mosalanejad l, dehghan-nayeri n. factors affecting professional ethics in nursing practice in iran: a qualitative study. bmc med ethics 2015;16(61):1-7. https://doi.org/10.1186/s12910-015-0048-2 20. phillips c, esterman a, kenny a. the theory of organizational socialisation and its potential for improving transition experiences for new graduate nurses. nurse educ today 2015;35(1):118e-124e. https://doi. org/10.1016/j.nedt.2014.07.011 21. ortiz j. new graduate nurses’ experiences about lack of professional confidence. nurse educ pract 2016;19:19-24. https://doi.org/10.1016/j.nepr.2016.04.001 22. tomaschewski-barlem jg, lunardi vl, barlem eld, et al. patient advocacy in nursing: barriers, facilitators and potential implications. texto contexto-enfermagem 2017;26(3):e0100014. https://doi.org/10.1590/01040707201700010001 23. heidari a, ahmadpour z, ghareh boughlou z. patients’ and nurses’ awareness of patients rights: a comparative study. health spiritual med ethics 2014;1(1):2-8. 24. ndaba bj, nkosi zz. lived experiences of newly qualified professional nurses on community service in midwifery section. afr j phys health educ recreat dance 2015;21(4-10):1150-1160. 25. walker a, earl c, costa b, cuddihy l. graduate nurses’ transition and integration into the workplace: a qualitative comparison of graduate nurses’ and nurse unit managers’ perspectives. nurse educ today 2013;33(3):291-296. https://doi.org/10.1016/j.nedt.2012.06.005 accepted 7 september 2020. http://ethics.iit.edu/ecodes/sites/default/files/international%20council%20of%20nurses%20code%20of%20ethics%20for%20nurses.pdf http://ethics.iit.edu/ecodes/sites/default/files/international%20council%20of%20nurses%20code%20of%20ethics%20for%20nurses.pdf https://www.sanc.co.za/pdf/learner%20docs/sanc%20code%20of%20ethics%20for%20nursing%20in%20south%20africa.pdf https://www.sanc.co.za/pdf/learner%20docs/sanc%20code%20of%20ethics%20for%20nursing%20in%20south%20africa.pdf https://www.sanc.co.za/pdf/learner%20docs/sanc%20code%20of%20ethics%20for%20nursing%20in%20south%20africa.pdf https://doi.org/10.3912/ojin.vol20no02man04 https://doi.org/10.3912/ojin.vol20no02man04 https://doi.org/10.1186/s12910-015-0048-2 https://doi.org/10.1016/j.nedt.2014.07.011 https://doi.org/10.1016/j.nedt.2014.07.011 https://doi.org/10.1016/j.nepr.2016.04.001 https://doi.org/10.1590/0104-0707201700010001 https://doi.org/10.1590/0104-0707201700010001 https://doi.org/10.1016/j.nedt.2012.06.005 march 2019, vol. 11, no. 1 ajhpe 6 research this article provides an understanding of the different perspectives of medical students on patients and their health problems during authentic early experiences (aees) in local south african (sa) communities. in the medical education literature, aee refers to medical students having first contact with people in the clinical or social context, enhancing students’ learning regarding health, illness or disease, and the role of the health professional.[1,2] it includes making meaning from direct experience that is beneficial to the student through guided reflection and analysis.[3,4] over the years, aee has become popular in medical education because of the insight that early experience can have a formative influence, fostering a more socially responsive career choice in later years.[5] furthermore, it has been suggested that early patient contact increases students’ motivation for studying the theoretical background of medicine, and offers opportunities for learning communication skills and how to establish a good doctorpatient relationship.[2,6] many public health and healthcare education programmes currently embody experiential learning through problem-based learning strategies and methods of ‘active learning’. the literature also reports on how students learn in authentic contexts through their service learning.[7] what students learn from aee contexts, such as being exposed to healthcare in local communities, and whether this is what we expect them to learn, is less clear. it is important to know about such learning in the light of current discussions on medical education reforms, where concerns are raised about students’ lack of compassion, responsibility and social responsibility and whether they are sufficiently prepared to become responsible professionals.[8-12] authentic early clinical experience is known to foster more socially responsive attitudes in students. the selectives programme at the university of kwazulu-natal (ukzn), durban, sa (data used in this article) comprises the community-orientated primary care (copc) approach to impart a population perspective to medical students, using public health knowledge and skills. assignments require that students reflect on health and illness and not only on the patient’s disease. in copc, the student starts with the patient and is guided to consider how social determinants impact on the patient’s illness, but also to consider a population perspective on their disease and related ‘upstream’ factors. supported by the analysis of reflections on the meaning of disease and illness, we explored medical students’ learning in the community by examining their reflection on and meaning given to their interactions with patients. we studied the perspectives through which undergraduate sa medical students observe, describe and learn about patients, their community and their daily life. our assumption was that students’ observations and descriptions of these patients, their social context and its meaning are related to their ‘worldview’.[13-15] worldview, translated from the german weltanschauung, literally means the perception of the world. in our case, it indicates the perspective from which students typically view health, illness and disease questions, and their responses.[15-18] our interest in this topic was triggered by the observation that, typically, the biomedical perspective, or positivist worldview, in healthcare is the leading paradigm in how medical curricula are shaped, and therefore also in how students implicitly or explicitly are socialised into the profession of background. many healthcare education programmes embody methods of ‘active learning’ in authentic contexts. what students learn from authentic early experiences when exposed to healthcare in local communities is less clear. objectives. we explored medical students’ learning in south african communities by analysing their reflection on and meaning given to interactions with patients. methods. a directed content analysis was done on a sample of 58 students’ reflection reports with regard to the meaning of disease. four different perspectives were coded, and labelled as positivist, compassionate, moralist and spiritualist. results. students documented their greater understanding of their patients’ circumstances and their compassion and respect for patients and their diseases. overall, the positivist biomedical perspective was observed, followed by the compassionate perspective. in their reflections, students expressed combined perspectives, i.e. the positivist perspective together with one or more of the others. moralist and spiritualist perspectives were also observed in the data. the students indicated the benefits they had experienced, i.e. by visiting a patient in his/her home environment, they were able to construct and contextualise the patients’ lives more holistically. conclusions. raising medical students’ awareness of the realities of seeing patients in primary health clinics, district hospitals and at home, may contribute to their understanding of the meaning of disease and illness and their ability to better serve communities in need. afr j health professions educ 2019;11(1):6-11. doi:10.7196/ajhpe.2019.v11i1.1014 medical students’ reflections on the meaning of disease and illness in south african communities f c j stevens,1 phd; s naidoo,2 md, phd; m taylor,2 phd; s knight,2 md 1 department of educational development and research, faculty of health, medicine and life sciences, maastricht university, the netherlands 2 department of public health medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: f c j stevens (fred.stevens@maastrichtuniversity.nl) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 7 march 2019, vol. 11, no. 1 ajhpe research medicine.[9,19-22] we were curious whether from the students’ descriptions of interactions with the patient, and their deeper understanding of the experiences of the patient, other views could be assessed, enriching the positivist perspective. our study was guided by the following two research questions: • what perspectives do undergraduate medical students use in their observations and reports of patients in authentic local contexts? • what meaning do students give to their observations and patient interviews in authentic local contexts? methods study design this study used a qualitative, phenomenology-orientated research design by means of content analysis. source of the data the data source was medical students’ reflections on the meaning of disease, data available from undergraduates taking part in the selectives programme at the medical school of ukzn.[23] the programme was developed a few years ago in accordance with the mission of the university. academics from the public health discipline at ukzn developed a programme to address national and international education imperatives to ensure that medical students become socially accountable graduates, with a strong population perspective.[23,24] through years 2, 3 and 4 of their medical studies, students participate in primary and public health activities and subsequently are in contact with the local communities where they originate. based on the copc approach, students link clinical activities with public health, identify a community-based research question, and undertake a small study that informs a community diagnosis, culminating in a health-promotion intervention.[23] extraction of the data the students’ reflections on the meaning of disease were completed as part of an assessed component of the programme. they identified a patient with a chronic disease, who they were required to visit twice annually for 3 years. after describing the patient’s disease, their family, and social and environmental circumstances, they reflected on their experience of the patient’s illness and how this related to their own understanding of health and disease as a medical practitioner. coding and data analysis while we acknowledge the social constructivist viewpoint that individuals develop different meanings directed towards objects, persons or things,[13,14,25] we applied a directed qualitative content analysis to the phenomena.[26] the main strength of this approach is that it enabled us to support and/ or extend existing theory, while at the same time protecting us better against the fallacy of naive inductivism.[27] in the most common qualitative data analysis, categories for coding are directly derived from the text. in the directed approach, this is done differently, as the analysis starts from theoretical concepts or categories as guidance for the coding.[26] the reflections were analysed for the students’ worldviews, while maintaining independence of those of the researchers. the process that followed ensured that each reflection was read by more than one researcher and after some discussion by the researchers, consensus regarding the students’ perspectives was obtained. informed by an extensive narrative review[28] of the sociological and anthropological literature on doctor-patient interactions, conceptualisations of the sick role, and exploratory reading of the students’ reflection documents, we explored four perspectives for our coding. these were originally developed by philipsen[15] in a study on norms and values in healthcare, and labelled as positivist, compassionate, moralist and spiritualist perspectives. these four perspectives are explained and discussed in more detail in the results section. the authors of this article, one medical sociologist/educationalist experienced in qualitative methodologies, and three public health experts, were involved in the directed content analysis, and discussed and substantiated the four perspectives and the key features. each independently first analysed the students’ reflections on the meaning of disease in the light of the four perspectives. among the challenges in a directed qualitative content analysis are neutrality, confirmability and trustworthiness, in particular as 3 of the 4 researchers were also assessors on the selectives programme.[26] to increase trustworthiness, a second round was held in which the 4 reviewers (in pairs) discussed their procedures and findings and compared observations, key quotes and classifications.[28] then, in a third round, all 4 researchers met to come to the final conclusions and discuss findings and uncertainties in assigning perspectives to quotes. for example, during the analysis, in some cases it proved to be challenging to make the distinction between the student’s and the patient’s meaning of disease, as will be discussed in more detail below. the variety and different student perspectives of the reflections provided the basis for this article. the reflections were analysed for the students’ worldviews, while maintaining independence of those of the researchers. each reflection was read by more than one researcher and a consensus position was obtained after some discussion. ethical approval the biomedical research ethics committee of ukzn approved the ongoing evaluation and analysis of the undergraduate medical programme (ref. no. ukzn-brec 201/04). participants in 2015, 256 medical students participated in the selectives one programme. sixty percent of these students were female and just over 60% came from rural or township disadvantaged areas. of the student population, 70% are black african, 22% indian, 5% mixed race and 3% white. at the time of our investigation, half of these students had completed the selectives programme and submitted a document where they reflected on the meaning of disease as one of the requirements of the programme. our sample (n=58) was taken from these documents. efforts were made to avoid selection or demographic bias by randomly selecting these 58 cases (using random numbers) from the available documents. the 58 reflections were from students who represented the demographics of the class. results perspectives on disease, health and illness four perspectives guided our content analysis of students’ reflections on the meaning of disease, labelled as positivist, compassionate, moralist and spiritualist perspectives. we describe these below, substantiating each with literature and quotes from students’ documents. march 2019, vol. 11, no. 1 ajhpe 8 research the positivist perspective in the positivist perspective, the world is seen as an objective reality exterior to ourselves. the positivist distinguishes the objective from the subjective social reality, making use of science to produce true knowledge.[28] only empirical data, evidence, objectivity and rational considerations can shape this true knowledge. it includes how we look at healthcare issues and often also at medical education. applied to health and healthcare, it means that there is a preference for a biomedical definition of health and illness, as well as a disposition to look for causes and outcomes in the objective reality, outside ourselves. in this view, connotations with and meanings and perceptions of illness play a minor role. the positivist student/physician will possibly be interested in the ‘disease’, the particular ‘case’ to be observed and how the case should be diagnosed and treated. a detached concern and ‘face-work’ (creating a self, presenting to others, i.e. a medical professional presented to the patient) typify the interactions of the health professional with the patient.[29-31] evidence-based medicine is a typical product of the positivist (or scientific) perspective. one of the students highlighted the patient’s concerns about people’s perceptions of the disease and the possible side-effects of the treatment: ‘the patient was very worried about people’s perceptions of his disease. he mentioned that gout and arthritis are often associated with very old people and he was afraid that he would “be old before his time”. the patient had not been on chronic medicines before this diagnosis and thus he felt afraid that it would affect his ability to function optimally during the workday because of side-effects such as drowsiness. he did not experience any drowsiness but he did have bouts of diarrhoea. this affected the patient because he would not go to work for the first few days of starting his treatment. further into his treatment, however, he believed that the arthritis medication might have been causing him to be constipated.’ another student’s reflections were a typical example of detached concern regarding a patient with chronic disease: ‘the experience of being a chronic patient takes time to get used to, but does normalise as part of the daily routine. families are affected by a chronic disease, as time has to be taken off work to attend to the patient. i realised the importance of addressing parents’ fears and concerns, as this impacts how the disease affects the child’s daily life.’ the compassionate perspective in the compassionate perspective, the subjective constructivist reality prevails. it means the ill person and his/her narrative of how s/he perceives the illness are of primary importance to the observer. a compassionate practitioner/student is primarily focused on the ill person within his/ her subjective environment. accepting illness, learning how to live with one’s incapacities and sharing subjective experiences with others are observations within this perspective. for the patient, the compassionate perspective means being accepted and having the privilege to receive understanding, empathy and compassion from others. one observation is that the compassionate perspective is an essential undercurrent, vital to the sovereignty of the positivist worldview, where patients are dealt with as cases and projects. therefore, students described engaging in a logical effort focused on treatment and care of well-defined, circumscribed health problems.[15,31] one student described it as follows: ‘my feelings toward my patient grew, and the more i listened and empathised, the more i felt for her and understood her. i felt concern for her and her family, knowing that it would be difficult to cope with her health problem. i felt the need to help them. the way that my patient expressed her feelings to me, directly allowed me to empathise with her and to see things from her perspective.’ combined with a positivist perspective, a student reported: ‘p…’s life has been changed by living with hiv and she saw a need to create new life goals and adjust older ones. she expected it to alter only her daily routine with only having to add some medication during the day, but it did more than that. she was able to identify the good and the not so good adjustments that she would have to make; that’s her life now and she has accepted and even embraced this new aspect to it.’ the moralist perspective seen from the perspective of the moralist, illness and disease are caused by carelessness, irresponsible behaviour, and/or indulgence.[32,33] therefore, people should act responsibly and be restrained and self-controlled to be well, happy and whole. the implicit assumption of this perspective would be that a man or woman who lives a morally impeccable life will be healthy, whole and complete (as long as they are secured from ill-fate).[34] upcoming health problems, therefore, should be defied by behaving even more responsibly, restrained and self-controlled. applied to health and illness, two main features stand out. first, illnesses are caused by all kinds of external factors, only to be influenced by sensible, responsible behaviour.[32] secondly, wallowing in physical and mental suffering does not suit the self-controlled person. only the ultimate aim is important, i.e. health, wellbeing, wholesomeness, purity and harmony. moral judgement by the health practitioner is the habitual undertone in such interactions with patients.[35,36] for example, blaming the patient for being obese, stigmatisation by healthcare workers for being hiv-infected, or being reluctant to treat a patient who smokes or drinks, fits into the moralist worldview.[35] accordingly, the student’s description of the patient will include a moral undertone. one student reported: ‘this [hypertension] is the most prevalent disease that we observed in our community and we have devised a list of possible psychosocial determinants for the prevalence of this disease. the inhabitants live mostly sedentary lifestyles, which are coupled with unhealthy diets consisting of excessive salt, fats and sugar products, a lack of exercise and the normal stresses of life that all serve to exacerbate the progression of the disease. lack of education serves as a very important factor, as most of the inhabitants have a lack of knowledge when it comes to such diseases, what causes them, and how to reduce their effects once diagnosed. most of the adults chalk it down to old age when they start getting symptoms of hypertension, and thus get diagnosed in the later stages of the disease, and even then, they underestimate its effects and fail to follow most of the doctor’s/healthcarer’s professional advice.’ another student reported: ‘x has issues coping with his condition. he now has behavioural problems and that has led to him smoking and being a very violent individual. he has coping issues and believes that someone might be responsible for his condition.’ 9 march 2019, vol. 11, no. 1 ajhpe research in the combination of the positivist and moralist perspectives, a student reported on the effect that being hospitalised had on the patient’s understanding of the need for lifestyle changes: ‘ma x initially did not think much of her diagnosis – nor did the family, until she ended up in hospital for a few days. only then did she see the importance of changing her lifestyle and … appreciating the extent and seriousness; the outcome has been favourable thus far. when she started feeling sick prior to her diagnosis, she went to an inyanga (zulu herbalist), who told her she had been bewitched by one of her husband’s many mistresses. she believed this and was given herbs that did not help.’ a student described: ‘for more than 30 years that patient has been having seizures, but she did not seek medical attention until 4 years ago … she told me that she went to see a traditional healer, who told her that the ancestors were angry and hungry and that’s why she had recurrent and progressively worse seizures. she believed him, a ritual was performed, but nothing changed her seizures … my main task was to educate her … on the adverse effect of alcohol on seizures, the effect of missing a dose of medication, and discontinuing the drug without the advice of a doctor … .’ the spiritualist perspective in the spiritualist perspective, the human being is seen as a permanent traveller, usually with a religious belief.[15] illness is one of the discomforts of travelling that needs to be accepted as is. accordingly, in the spiritualist view it is not about the disease (positivist perspective), not about the ill person and his narrative (compassionate perspective), and also not about individual efforts needed to become healthy again (moralist perspective). in the spiritualist perspective, man is always en route – his body does not belong to himself.[15] for religious people, praying provides strength to be a righteous person, but for many, even for those in a rapidly secularising world, it is important to note that the view that a person is not in control of his/her own life, is perhaps much more persistent than some might think.[37,38] for many people, their view on health and illness is grounded in their religion.[38] they consider themselves as stewards of their own body, which ultimately belongs to god, nature, or some other physical or non-physical object. as one student described it: ‘mrs d’s diseases have impacted her life tremendously. apart from her physical symptoms, she has had to adjust her daily schedule and activities, which has affected her emotionally. mrs d copes with the stress and difficulties of her illnesses in a variety of ways. she seeks relief in her hobbies. she finds strength and encouragement in her faith. lastly, she relies on her husband for support, care, love and assistance. the contributions from each of these aspects of her life allow her to manage her health.’ another student’s view is as follows: ‘jane has gone from strength to strength and now leads a life that is almost like the one she led before her diagnosis. her perception on lupus has now changed, as she sees it as one of life’s obstacles and something that god has placed in her destiny to make her the person he wants her to be. her outlook remains positive and she believes that as long as she has faith in god and herself, she can lead a happy life. the main lesson that i took from these visits is that one has to explore to fully grasp the meaning of a disease, and by listening to a patient intently and practising empathy, you are able to heal them not only clinically but psychologically too.’ the following is a student’s explanation: ‘mr m understands that he will have to take medication and modify his lifestyle for the rest of his life to achieve optimal control of his blood pressure. mr m has accepted and is at peace with the present and looks forward to seeing his children achieve independence; then he can die knowing that he has lived a wonderful life.’ in combination with a positivist worldview, one student reported: ‘i noted that she still believes that her ancestors are causing her condition … as a result of her belief she thinks it important that she supplements her western medication provided at the clinic with traditional remedies, such as isinemfu, to achieve optimal control of her condition. she wants to be empowered with knowledge of hypertension … i advised her to buy an automated blood pressure machine … and she can check her blood pressure as often as she wants.’ by visiting patients in their home environment, students were able to construct and contextualise their patients’ lives more holistically. a summary and overview of the different perspectives and their key features are presented in table 1. in most reflections, students expressed combined perspectives, commonly the positivist/biomedical perspective – together with one or more of the others. overall, however, the positivist perspective was frequently observed in students’ reflections. moralist and spiritualist perspectives were also presented in the data, more often than not combined with one or more of the other perspectives. there was general agreement among the reviewers that students articulated a positivist perspective, clearly ahead of the other three perspectives. as indicated in the abovementioned results, students documented their increased understanding of their patients’ circumstances. there was also evidence of their compassion and respect for their patients and their diseases. discussion and conclusions to explore medical students’ learning about health and illness in the community, the analysis in this article was guided by the question of which perspectives undergraduate medical students used in their observations and reports of patients in authentic local contexts. students conducted their selective programmes in their home settings, and were often faced with the reality of living conditions in disadvantaged circumstances. we discuss our findings with regard to two topics: (i) credibility of the four perspectives; and (ii) students’ perspectives relating to authentic learning. credibility of the four perspectives students at the nelson r mandela school of medicine, durban, sa, come from a wide range of educational, geographical, cultural and religious backgrounds. we do not pretend that the four perspectives are the only possible ones to classify students’ perspectives in a meaningful way. for transparency and dependability, it was significant, however, to see how well the perspectives, constructed in a different society and different time frame, were represented by the four different categories, relating to how current sa medical students regard their patients’ illness and disease. in their reflections, many students documented their own shift in greater march 2019, vol. 11, no. 1 ajhpe 10 research understanding of their patients’ circumstances, and their compassion and respect for many of their patients for the manner in which the latter handled their chronic diseases. seeing the reality of a patient in their household circumstances is different from seeing a patient in a clinic or hospital, which may be the reason for the increased compassion. the four perspectives were not mutually exclusive. we found many combinations, in particular a combination of the positivist and compassionate perspectives. this is an important finding, as it is what we usually prefer to see in our (future) doctors – a healthy balance between objective, clinical observation and compassion, and being emotionally restrained and neutral, but certainly not cold and distant.[39] also interesting was that some of the students expressed a moralist and positivist view regarding their patients. the moralist perspective has always been a fertile ground for the development of disciplines such as public health, social medicine and health promotion. these disciplines exist by virtue of the contrasting merits of people being imprudent v. wise, indulgent v. sober, and responsible v. irresponsible. at the individual level, however, moral judgements may compromise trust relationships.[40,41] in the light of all the evidence that unhealthy lifestyles contribute to many diseases, the pairing of a positivist and moralist worldview, and how this may affect the doctor-patient interaction, is interesting to explore further. the patients’ religious beliefs were another important component of students’ views and, interestingly, many of them identified with some of the patients’ belief systems. because students were from the same cultural background as their patients, they were often able to communicate well with them and to use their own access to local information for the benefit of their patients. it is important to note that during data analysis we were not aware of any medical students who considered attendance at traditional healers to be beneficial. however, this conclusion could be influenced by the medical school’s strong positivist, biomedical approach, leading to socially desirable answers. it would be another interesting topic to develop further. students’ perspectives relating to authentic learning students focused on the patient’s clinical features. many students appeared to be keeping their distance, relating a detached concern. interestingly, students related to the compassionate perspective, as they combined this approach, a development in authentic learning that suggests their potential as future health practitioners identifying with their patients. with the current call for more compassion in healthcare, this is an important finding, and future longitudinal research should build on this.[9] from the viewpoint of experiential learning, the benefits that they experienced through community exposure by visiting patients in their home environments, offered an opportunity to construct and contextualise the patients’ lives more holistically. by visiting the same patient during 2 conse cutive years, they were also able to gain a better understanding of how the patient was coping with chronic disease/s. although the analysis provided sufficient applicability and credibility of the four perspectives, evidently the positivist perspective was the most common and easiest to recognise in students, followed by the compassionate perspective. however, the moralist and spiritualist perspectives were helpful additions to these common ones, as we know little about these and how they affect experiential learning regarding the doctor-patient relationship. further exploration and fine-tuning would be needed for students to gain the maximum benefits of this experience of their aees. study limitations firstly, students evaluated the data or information presented to them, whether the information was directly observed or told through the eyes of the patient, while the data could be rooted on, e.g. the symptomatology of the body, the clinical history of the patient, or the social and cultural beliefs of the patient. their experiences therefore remained at the descriptive level, even when they seemed to express an open-mindedness about patients’ situations and explanations. in the light of this, although at times we struggled to distinguish between students’ and patients’ perspectives on the meaning of disease, our data definitely point to experiential learning; nussbaum[42] describes this as the ‘narrative imagination’: ‘the ability to think what it might be like to be in the shoes of a person different from oneself, to be an intelligent reader of that person’s story, and to understand the emotions and wishes and desires that someone so placed might have.’ secondly, the analyses were done with data collected at one point in time. therefore, we were not able to unambiguously assess the students’ change in perspectives and meaning-giving through the years, except when reported table 1. student perspectives on the meaning of disease and illness perspectives positivist compassionate moralist spiritualist key viewpoint objective reality subjective reality social reality supernatural reality key interest focus on clinical features of the patient emphasis on narrative and experiences of the patient description from the perspective of the professional worker/healer moralist undertone emphasis on disease and distress as facts of life description of acceptance of disease and/or resignation by the patient student’s identification difficulties identifying oneself with the patient strong identification with the patient identification with the patient to some extent identification with the patient – to some extent distance student keeps distance, consciously or unconsciously detached concern; the encounter is ritual/clinical distance nearly absent distance is consciously maintained (neutral); the encounter is mainly ritual some distance is maintained ideal patient outcome curing stable situation; alleviation from suffering being; alleviation from suffering becoming a meaningful life 11 march 2019, vol. 11, no. 1 ajhpe research retrospectively by the students in their reflections. only longitudinal data can reveal whether or not the positivist view is tempered by a deeper understanding of the experiences of the patient. however, if through their aees with patients in the community, the students have grown in their narrative imagination, then this would be an additional promising outcome of the programme. thirdly, as mentioned in the discussion, initially the four perspectives were constructs of a particular society. this viewpoint may question their universal value. adding to their credibility, our findings proved to be consistent in relation to the context in which they were generated (dependability). therefore, we continuously analysed and re-examined the data to test whether the four perspectives would hold, which proved to be the case. related to that, a limitation of our methodological approach in using a directed qualitative content analysis was that it might be less open to generating (new) categories or themes on the meaning of disease in an inductive way, a concern to researchers who believe that qualitative data should only be analysed in such a way. while we are aware of this critique, we discovered that starting from a theoretical framework and then testing whether a limited number of assumptions fit the data, challenged us to discuss our theoretical assumptions and, as mentioned, also might have protected us better against the critique of naive inductivism. in this process, we also searched for evidence that could challenge our perspectives and findings, and documented the steps taken in the entire procedure. fourthly, assignments were not written voluntarily and might have been susceptible to social desirability and bias. however, we believe we could avoid this possible bias in our data analysis by focusing not only on ‘what’ students reported, but also on ‘how’ they did this. for example, on the ‘what’, there were clear differences in content, some of them extensively describing ‘disease’ characteristics, others focusing more on the illness experience and/ or the social consequences (sickness). further research to test and substantiate our categories and the longitudinal impact of our findings will, however, be required. declaration. none. acknowledgements. none. author contributions. fcjs developed the research question, sk was responsible for data collection, and all authors participated in data analysis and writing of the manuscript. funding. none. conflicts of interest. none. 1. littlewood s, ypinazar v, margolis sa, scherpbier a, spencer j, dornan t. early practical experience and the social responsiveness of clinical education: systematic review. bmj 2005;331(7513):387-391. https://doi. org/10.1136/bmj.331.7513.387 2. yardley s, brosnan c, richardson j, hays r. authentic early experience in medical education: a socio-cultural analysis identifying important variables in learning interactions within workplaces. adv health sci educ 2013;18(5):873-891. 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van wyk jm, mahomed s. teaching research: a programme to develop research capacity in undergraduate medical students at the university of kwazulu-natal, south africa. bmc med educ 2016;16:61-69. https://doi.org/10.1186/s12909-016-0567-7 24. kwizera en, iputo je. addressing social responsibility in medical education: the african way. med teach 2011;33(8):649-653. https://doi.org/10.3109/0142159x.2011.590247 25. good bj, good m-jd. the meaning of symptoms: a cultural hermeneutic model for clinical practice. in: eisenberg l, kleinman a, eds. the relevance of social science for medicine. dordrecht: springer, 1981:165-196. 26. hsieh h-f, shannon se. three approaches to qualitative content analysis. qualitat health res 2005;15(9):1277-1288. https://doi.org/10.1177/1049732305276687 27. silverman d. doing qualitative research: a practical handbook. thousand oaks, ca: sage, 2013. 28. bryman a. social research methods. oxford: oxford university press, 2008. 29. fox r, lief h. the psychological basis of medical practice. new york, ny: harper and row, 1963:12-35. 30. goffman e. on face-work: an analysis of ritual elements in social interaction. psychiatry 1955;18(3):213-231. 31. goffman e. interaction ritual: essays on face-to-face behavior. new york: doubleday anchor, 1967. 32. crawford r. health as a meaningful social practice. health 2006;10(4):401-420. https://doi.org/10.1177/ 10497 32305276687 33. jallinoja p, absetz p, kuronen r, et al. the dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses. scand j primary health care 2007;25(4):244-249. https://doi. org/10.1080/02813430701691778 34. brown rch. moral responsibility for (un)healthy behaviour. j med ethics 2013;39(11):695-698. https://doi. org/10.1136/medethics-2012-100774 35. murrell vs. the failure of medical education to develop moral reasoning in medical students. int j med educ 2014;5:219-225. https://doi.org/10.5116/ijme.547c.e2d1 36. hill te. how clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. philosophy ethics human med 2010;5:11-25. https://doi.org/10.1186/1747-5341-5-11 37. hill pc, pargament ki. advances in the conceptualization and measurement of religion and spirituality: implications for physical and mental health research. am psychol 2003;58(1):64-74. https://doi.org/10.1037/0003066x.58.1.64 38. miller wr, thoresen ce. spirituality, religion, and health: an emerging research field. am psychol 2003;58(1):24-35. https://doi.org/10.1037/0003-066x.58.1.24 39. stevens fcj, goulbourne j. cultural competence in medical education. in: cockerham wc, dingwall r, quah sr, eds. the wiley blackwell encyclopedia of health, illness, behavior, and society. oxford: wiley blackwell, 2014:13351339. 40. cruess rl, cruess sr. professional trust. in: cockerham wc, dingwall r, quah sr, eds. the wiley blackwell encyclopedia of health, illness, behavior, and society. oxford: wiley blackwell, 2014:1900-1902. 41. mechanic d. in my chosen doctor i trust. bmj 2004;329(7480):1418-1419. https://doi.org/10.1136/bmj.329.7480. 1418 42. nussbaum mc. cultivating humanity. a classical defence of reform in liberal education. cambridge, ma: harvard university press, 1998:10-11. accepted 11 june 2018. https://doi.org/10.1136/bmj.331.7513.387 https://doi.org/10.1136/bmj.331.7513.387 https://doi.org/10.1177%2f105382599902200206 https://doi.org/10.1177%2f014107680509800302 https://doi.org/10.1046/j.1365-2923.2003.01431.x https://doi.org/10.1016/j.amepre.2008.06.012 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1111/medu.12961 https://doi.org/10.1111/medu.12961 https://doi.org/10.1111/medu.12806 https://doi.org/10.1111/medu.12974 https://doi.org/10.1111/medu.12974 https://doi.org/10.1080/00380237.1997.10570691 https://doi.org/10.1186/s12909-016-0567-7 https://doi.org/10.3109/0142159x.2011.590247 https://doi.org/10.1177%2f1049732305276687 https://doi.org/10.11772f1049732305276687 https://doi.org/10.11772f1049732305276687 https://doi.org/10.1080/02813430701691778 https://doi.org/10.1080/02813430701691778 https://doi.org/10.1136/medethics-2012-100774 https://doi.org/10.1136/medethics-2012-100774 https://dx.doi.org/10.5116%2fijme.547c.e2d1 https://doi.org/10.1186/1747-5341-5-11 https://doi.org/10.1037/0003-066x.58.1.64 https://doi.org/10.1037/0003-066x.58.1.64 https://doi.org/10.1136/bmj.329.7480.1418 https://doi.org/10.1136/bmj.329.7480.1418 a maximum of 3 ceus will be awarded per correctly completed test. march 2020, vol. 12, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) cpd questionnaire march 2020 peer-assisted learning (pal) in the prehospital educational setting in south africa (sa) 1. in the prehospital domain, pal has been effective in the following areas: a. problem-solving. b. critical thinking. c. assessments. d. teamwork. e. communication. 1. a, b, d 2. a, b, c, d 3. b, c, d, e 4. a, b, d, e occupational therapy: the process in acute psychiatry 2. the occupational therapy process in an acute psychiatric setting was described in terms of: a. assessment. b. goal setting. c. intervention. d. discharge planning. e. post-discharge monitoring. 1. all 2. a, b, c, d 3. a, b, d 4. a, b, d, e 5. a, c, d perceptions of changes made to a clinical skills curriculum in a medical programme in sa: a mixed methods study 3. the key aspects of successful clinical skills training identified in the literature include: a. clear outcomes. b. structured sessions. c. regular feedback. d. debriefing. 1. a, b 2. a, b, c 3. b, c 4. a, c, d 5. all exploring student persistence to completion in a master of public health programme in sa 4. student-related factors relating to completion of postgraduate completion include: a. age. b. social connections. c. socioeconomic status. d. time management. e. travelling distance. 1. all 2. a, b, c 3. a, b, d 4. b, c, d 5. b, c, d, e social determinants of health in emergency care: an analysis of student reflections on service-learning projects (slps) 5. the meso-level themes identified in this study include: a. the impact of student learning on the individual. b. health promotion and disease prevention. c. impact of slps on communities. d. availability of community-based resources. e. challenges of working in communities. 1. a, b, c, e 2. all 3. b, c, d 4. a, c, d, e 5. c, d, e assessment consolidates undergraduate students’ learning of communitybased education 6. assessment in community-based education should include the following: a. test knowledge. b. technical skills. c. clinical reasoning. d. professionalism. e. reflection. 1. b, c, d, e 2. a, c, d, e 3. all 4. a, b, d 5. b, c, d continued ... cpd questionnaire march 2020, vol. 12, no. 1 ajhpe a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) march 2020 occupational therapists’ views on core competencies that graduates need to work in the field of neurology in a sa context 7. whose theory on transformative learning was the conceptual framework underpinning this research? a. mezirow’s theory. b. frenk’s theory. c. taylor’s theory. d. percy’s theory. exploring barriers that nurses experience to enrolment for a postgraduate nursing qualification at a higher education institution in sa 8. the inconsistencies in enrolment and throughput for postgraduate nursing qualifications are said to be due to the poor adjustment of health practitioners in academic institutions. (true or false?) 12 april 2021, vol. 13, no. 1 ajhpe forum definition of feedback feedback may be defined as a process of providing information to learners or where learners actively seek to find out more about the similarities and differences between their performance and the target performance to generate an improvement in work.[1,2] brief history of feedback earlier literature around feedback provides a historical departure point for this paper. nearly four decades ago, ende[2] described feedback as a unidirectional process, situated within hierarchical structures. he provided best-practice guidelines, e.g. feedback should be timeous, focused on common goals and specific. such older publications now draw critique for their reductionist nature.[2] more recently, publications moved away from  this prescription of ‘rules’ for feedback. instead, recent  reports  suggest that  feedback is a complex, bidirectional, sociocultural process.[1,3] evolving ideas on feedback moving forward, recent work suggests a subtle shift away from fixed feedback guidelines.[3-5] feedback is one of the major influences on learning, but those effects can be either positive or negative.[3,4] the literature suggests that feedback does not inevitably lead to improved learning outcomes.[3,4] for example, the student’s beliefs and mindset influence the way that feedback is processed.[3,4] while praise may confirm a learner’s positive self-beliefs, it may not necessarily improve learning outcomes.[3,4] this introduces the idea of the disutility of praise, i.e.  praise is not necessarily useful as a tool for effective feedback practice.[3,4] furthermore, hattie and timperley posit that feedback ‘involves  both the giving and receiving (by teachers and/or by students)’, which sets the foundation for the recent literature that frames feedback as a dialogical discourse.[4] current issues: feedback for modern medical education bidirectional dialogue recently, there has been a paradigmatic shift in the conceptualisation of feedback. this is characterised by the move away from unidirectional feedback towards a bidirectional model. here the learner has greater engagement in the feedback conversation, and is empowered in the co-construction of a plan for performance improvement.[1,3,5] there seems to be a move away from a top-down feedback monologue towards a student-directed shared dialogue.[1,3,5] however, bidirectional dialogue does not always imply a flattening of hierarchy or dissolution of sociocultural context.[5] one would be remiss to assume that all learners would be equally empowered in these feedback relationships.[3,5] role of the learner the recent literature centralises the learner in the feedback process.[3,5] ramani et al.[3] argue that learners may be more empowered if they actively participate and engage in feedback dialogue. while this may indeed be the case, it should be noted that whether a learner actively engages in the feedback conversation may depend on individual learner beliefs, motivation and behaviours.[3] role of the teacher the older literature tends to delineate feedback as a function of content and method of delivery.[2] historically, the provider of feedback was an expert or senior colleague of the student.[2] much of the newer literature maintains this status quo, but begins to challenge the assumption that students value all expert opinion equally.[3] students may adopt feedback given by one expert, and reject feedback from another, based on their perceptions of the observer.[3] this is termed observer ‘credibility’ and has drawn much attention in the literature as a key determinant of effective feedback.[3] feedback has been purported as a key determinant of effective learning. in this article, we examine the evolving conceptualisation of feedback. we focus on feedback practices between teacher and student, while acknowledging that feedback can also occur between various other role players. we begin with an overview of the historical understanding of feedback, using broader education literature where relevant, and comparing and contrasting it with more recent publications in the field. this is followed by a brief discussion of some of the key issues in providing feedback in the setting of modern medical education. we argue that tensions in the literature may be better understood if varying feedback practices are to be accepted as part of a wider spectrum of practices. afr j health professions educ 2021;13(1):12-13. https://doi.org/10.7196/ajhpe.2021.v13i1.1414 feedback as a spectrum: the evolving conceptualisation of feedback for learning l govender,1,2 pg dip (hpe), mb chb; e archer,1 phd (hpe), mphil (he), bcur hons (critical care), bsocsc (nursing) 1 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 division of anatomical pathology, department of pathology, faculty of health sciences, university of cape town, south africa corresponding author: l govender (lynelle.govender@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. april 2021, vol. 13, no. 1 ajhpe 13 forum feedback culture while it is helpful to closely examine the direct role players within a feedback interaction (student and teacher), it is necessary to consider the wider context. workplace culture is key in terms of the hierarchical structures that dominate the clinical and educational landscape.[5] while the structures may make it clear to the student who the expert is, these may not necessarily support feedback as a dialogical discourse held within safe psychological spaces.[5] the literature thus suggests that institutions and workplaces have a role to play in mitigating the effects of hierarchy by fostering the development of a feedback culture.[5] this is a complex task, which involves, e.g. setting clear guidelines around the expectations of feedback and supporting bidirectional feedback in the workplace.[5] finally, it must be noted that while we have presented the role of the student, teacher and institution under separate sub-headings, these role players are deeply intertwined during the feedback process.[3,5] concluding remarks the understanding of ‘feedback for learning’ has undergone numerous reconceptualisations over the past few decades. feedback was initially understood to be a fixed process that could be easily translated from one scenario to the next, while the newer models appear to take cognisance of individual factors. for example, student motivation, teacher credibility and institutional culture may all influence feedback practices and uptake. finally, it would seem as if feedback has been framed as a binary. the older literature views feedback as a list of recommendations that experts are to use when providing feedback to students. the newer literature models feedback as a ‘dialogue’, which firmly values the student’s role in the process. we argue that this may be a false dichotomy. modern feedback practices do not have to be either unidirectional or dialogical. instead, we propose that feedback be considered as a ‘spectrum of practices’. expert-driven feedback may be useful in some clinical settings, while learner-centred dialogue may be more suitable in others. indeed, the conceptualisation of feedback as a ‘spectrum’ may better suit the widely varying contextual and individual factors that are seen in the global setting of health professions education. declaration. none. acknowledgements. none. author contributions. both authors complied with the international committee of medical journal editors’ rules of authorship and were part of conceptualising, formulating and editing the article. although the initial draft was prepared by the first author, subsequent work on the manuscript included essential inputs from both authors. funding. none. conflicts of interest. none. 1. boud d. feedback: ensuring that it leads to enhanced learning. clin teach 2015;12:3-7. https://doi.org/10.1111/ tct.12345 2. ende j. feedback in clinical medical education. jama 1983;250(6):777-781. https://doi.org/10.1001/ jama.1983.03340060055026 3. ramani s, könings kd, ginsburg s, van der vleuten cp. meaningful feedback through a sociocultural lens. med teach 2019;41(12):1342-1352. https://doi.org/10.1080/0142159x.2019.1656804 4. hattie j, timperley h. the power of feedback. rev educ res 2007;77(1):81-112. https://doi. org/10.3102/003465430298487 5. ramani s, post se, könings k, mann k, katz jt, van der vleuten c. ‘it’s just not the culture’: a qualitative study exploring residents’ perceptions of the impact of institutional culture on feedback. teach learn med 2017;29(2):153-161. https://doi.org/10.1080/10401334.2016.1244014 accepted 5 november 2020. https://doi.org/10.1111/tct.12345 https://doi.org/10.1111/tct.12345 https://doi.org/10.1001/jama.1983.03340060055026 https://doi.org/10.1001/jama.1983.03340060055026 https://doi.org/10.1080/0142159x.2019.1656804 https://doi.org/10.3102/003465430298487 https://doi.org/10.3102/003465430298487 https://doi.org/10.1080/10401334.2016.1244014 a maximum of 3 ceus will be awarded per correctly completed test. june 2019, vol. 11, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/011/01/2019 (clinical) cpd questionnaire june 2019 final-year medical students’ ratings of service-learning activities during an integrated primary care block 1. the results of this study showed that students placed in rural sites enjoyed the following service-learning activities more than students placed in urban sites: a. counselling sessions b. well-baby clinic activities c. labour ward management d. a and b e. b and c. making sense of knowing: knowledge creation and translation in student occupational therapy practitioners 2. the knowledge-to-action framework proposed by graham includes: a. understanding and defining knowledge translation b. determining how knowledge is created and used c. exploring how knowledge is shared d. all of the above e. b and c. a critical reflection by participants on microteaching as a learning experience for newly appointed health professions educators 3. in designing the course content and flow, the researchers were guided by the curriculum development cycle of: a. kuswandono b. kern c. donnelly and fitzmaurice d. bell. practise what you teach: lessons learnt by newly appointed lecturers in medical education 4. based on a study of new faculty in north american medical schools, specific best practices for presenting faculty development services were identified. (true or false) understanding faculty development as capacity development: a case study from south africa 5. in this article, the authors clarify that capacity building: a. includes equipping an individual, institution, region or country with the attitudes, values and behaviours needed to bring about change and progress b. highlights the collective process of interactions in a wider system to address problems and bring about transformational change within a specific context c. serves as a means to an end d. a only e. all of the above f. b only. the selection and inclusion of students as research participants in undergraduate medical student projects at the school of medicine, university of the free state, bloemfontein, south africa, 2002 2017: an ethical perspective 6. students were directly involved as research participants in 93% of the student projects. (true or false) advocacy: are we teaching it? 7. the key themes of how advocacy is understood, which emerged from this study, include: a. for the profession b. for patients and communities c. for the health system overall d. a and b e. b and c f. all of the above. march 2020, vol. 12, no. 1 ajhpe 9 short research report the role of the occupational therapist in the acute psychiatric setting includes individual and group assessment and intervention, discharge planning and community reintegration.[1] however, there is a lack of understanding around specific types of assessment and interventions commonly used in this setting, where the occupational therapist does not have the opportunity to predict a predetermined programme that mirrors the traditional occupational therapy process.[2] the occupational therapist and the students should have flexibility in practice.[3] there is a lack of research into the students’ understanding of the occupational therapy process in the acute psychiatric context. methods this study explored third-year occupational therapy students’ experiences in the acute psychiatric setting. a qualitative approach was used, which allowed participants to share their subjective perspectives.[4] the setting comprised two acute admission wards at a tertiary psychiatric hospital in western cape province, south africa. the study population was a thirdyear occupational therapy class at an institute for higher learning in the western cape. participants were selected using purposive sampling, based on their placement in the acute psychiatric fieldwork setting. a sample size of 4 viable participants was identified.[5] data collection focus group discussions and semi-structured interviews with each of the 4 participants were used for data gathering. students’ electronic-format reflective journals were collected as a third form of data. students were asked about the enablers and limitations with the implementation of the occupational therapy process in the setting. data analysis the 4 interviews and focus group discussions were digitally recorded and transcribed verbatim. data were analysed using inductive, thematic analysis, which complemented the research study.[4] electronic journals were used by the researcher to collate information gained from the semistructured interviews and focus group discussions. trustworthiness was ensured using the principles of transferability, credibility and confirmability.[4] purposive sampling ensured transferability. data triangulation illustrated the application of credibility. conformability was guaranteed by means of an audit trail. reflexivity was considered because of the role of the researcher as a fieldwork supervisor at the same institution where the participants were completing their course.[4] the researcher was not allocated the role of fieldwork supervisor of the participants during this period. ethical approval ethical approval was obtained from stellenbosch university’s health research ethics committee (ref. no. s14/03/059). informed consent was obtained from the participants.[6] results students identified the phenomenon of rapid discharge of clients as one of the main institutional obstacles affecting the implementation of the occupational therapy process. furthermore, students reported that clients background. the role of the occupational therapist in the acute psychiatric setting includes individual and group assessment and intervention, discharge planning and community reintegration. however, there is a lack of understanding around specific types of assessment and interventions commonly used in this setting, as well as a lack of research into students’ understanding of the occupational therapy process in the acute psychiatric context. objective. to explore undergraduate occupational therapy students’ experiences of the implementation of the occupational therapy process in the acute psychiatric setting. methods. a qualitative approach was used. the setting included two acute psychiatric wards in western cape province, south africa. data sources were: a focus group, semi-structured interviews with each of the 4 participants and students’ weekly reflective journals. thematic analysis of all 3 data sources was employed. results. students identified the institutional barrier of rapid discharge of clients as one of the main barriers influencing the implementation of the occupational therapy process. discharge from the acute psychiatric wards occurred before comprehensive intervention, which influenced how they understood implementation of the occupational therapy process. four subthemes were identified: assessment, goal setting, intervention and discharge. conclusion. priority assessment methods and interventions were identified that are seen as unique to the occupational therapy profession. this study contributes towards the body of evidence in understanding students’ experiences of implementing the occupational therapy process in the acute psychiatric setting. afr j health professions educ 2020;12(1):9-11. https://doi.org/10.7196/ajhpe.2020.v12i1.1185 occupational therapy: the process in acute psychiatry z syed, bsc ot, mot, pg dip addiction care division of occupational therapy, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa corresponding author: z syed (zari.syed@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 10 march 2020, vol. 12, no. 1 ajhpe short research report seemed to be discharged before comprehensive intervention, which initially hindered how they understood the implementation of the occupational therapy process. four subthemes were identified: assessment, goal setting, intervention and discharge. assessment students reported that the high turnover rate resulted in restrictive time frames, where they needed to adapt their process to maximise engagement with clients. the challenge identified by students in relation to the restricted time frames appeared to modify their skills of assessing clients in a short period of time. therefore, students reasoned that the use of group sessions was a means of adapted assessment that was efficient to observe the behaviours of clients. adapted, individual assessments were also carried out with methods such as functional observation, interviews and activity clocks: ‘i had to adapt the assessment, and chose to discuss the relevant issue.’ (peter, journal 2) goal setting the institutional barrier of a high turnover of clients appeared to be difficult for students to manage when learning about the importance of specific, measurable, appropriate, realistic and time-sensitive (smart) goal setting as part of the occupational therapy process. students further reported having to be creative and think very concretely when planning goals. they also observed that, because of the short-term nature of the acute setting, clients’ discharge was fast tracked. consequently, the practice of goal-setting skills seemed to be difficult to implement: ‘psychiatry, the biggest difficulty i’ve had at the moment is having to write up goals on a client and then going the next day and finding out the client has been discharged.’ (david, interview) intervention students identified interventions, including reality orientation and psychoeducation, which were found to be most appropriate to address deficits. providing reality-orientation intervention to clients who seemed to be experiencing psychotic symptoms tends to be considered a part of occupational therapy. psychoeducation is one of the occupational therapy interventions that appeared to be provided to clients in the setting. students reported that psychoeducation included educating clients about their conditions, and the impact on their occupational functioning was seen to be instrumental in maintaining clients’ health. accordingly, students highlighted that the improvement of clients’ functional performance in activities such as self-care was a focus of intervention in relation to occupation: ‘it’s [intervention] very much focused on functional performance and how we can put them back into their premorbid condition.’ (julia, interview) discharge acceleration of clients’ discharge a few days after admission was perceived as one of the institutional barriers identified by students. the high pace of the ward process led to the therapeutic process being more fast tracked than anticipated. this seemed to make the students feel frustrated by the reality of the healthcare system: ‘the frustration of high turnover is quite a challenging experience of the acute psychiatry block.’ (david, interview) discussion a short admission period appears to be a global phenomenon.[2] accordingly, occupational therapists and students need to evolve to meet the demands of such strains on mental healthcare. the institutional barrier of the high turnover in the wards was one of the key aspects that influenced students’ learning regarding the role of occupational therapy in this setting. the initial stage of assessment appeared to be restricted owing to the uncertain, impending daily discharge of clients. institutional expectations regarding the types of assessment techniques students could practise were discussed. the literature indicated that the use of formal assessment tools in this setting tends to be tricky.[2] students acknowledged that the use of standardised assessments was not the norm. assessment of function is the main priority in the short space of time assigned.[2] students reported that they adapted assessment methods and made use of more functional, activity-based assessments to gain information regarding the clients’ occupational performance. being aware of the limited time frames during which clients were in the setting, allowed students to consider goals that had a measure to determine the degree of achievement. the involvement of clients in the therapeutic process suggests a client-centred approach.[7] students indicated that within the limited time frames, goals needed to be set with clients to identify priority occupation needs where functional deficit was evident. providing clients with a forum in which to engage about their goals creates the opportunity for them to analyse their strengths and limitations. this leads to more goal-directed activities during the intervention phase.[7] students highlighted addressing occupational functional deficit as a focus in their quest to understand intervention in this setting. reality orientation, psychoeducation and facilitation of functional self-care were identified as important interventions.[2,8] students reported that intervention with clients in areas of occupation such as self-care was a primary role of the occupational therapist. they also have the scope to enable a client to engage in functional self-care that is essential to improve performance.[2] psychoeducation is stressed in the literature as an effective intervention in this setting. one of the roles of the occupational therapist is to facilitate clients’ understanding of their illness.[8] students reported that educating clients regarding their diagnosis was significant in improving health maintenance as an occupation. reality orientation appeared to be an enabler that facilitated clients having continuous awareness of person, place and time, which are important in the management of psychosis.[2] therefore, the students felt that reality orientation was another integral part of intervention with clients that was unique to occupational therapy, which led to the improvement of deficits in other areas of occupation. discharge planning was highlighted as a priority in the occupational therapy process in the acute psychiatric setting.[1] students were able to consider the community occupational therapist as a valuable resource in the intervention process regarding clients. this may mean that there is a need for collaboration between those in the acute psychiatric setting and community occupational therapists.[1] conclusion the occupational therapy process in an acute psychiatric setting was delineated to assessment, goal setting, intervention and discharge planning. priority assessment methods and interventions were identified that are seen as unique to the occupational therapy profession. it is recommended that march 2020, vol. 12, no. 1 ajhpe 11 short research report mental health coursework should include a stronger focus on the role of the occupational therapist in the acute psychiatric context. use of the identified and adapted assessment and intervention techniques is also suggested. further research with regard to student experiences in acute psychiatric settings and their experience of adapting to institutional barriers would enhance student experiences of service delivery. declaration. this article is based on a study done by zs in partial fulfilment of her master’s degree in occupational therapy. acknowledgements. the author would like to acknowledge the participating students for their contribution. thanks is extended to the department of occupational therapy at the institute of higher learning where the study was conducted for their permission to work with the students. author contributions. mrs nicola vermeulen and ms juanita bester assisted in supervising the author during the research study from which this article originated. funding. none. conflicts of interest. none. 1. lloyd c, williams pl. occupational therapy in the modern adult acute mental health setting: a review of current practice. int j ther rehabil 2010;17(9):483-493. https://doi.org/10.12968/ijtr.2010.17.9.78038 2. shorten c, crouch r. acute psychiatry and the dynamic short term intervention of the occupational therapist. in: crouch r, alers v. occupational therapy in psychiatry and mental health. nj, usa: john wiley, 2014:115-123. 3. bryant w, cordingley k, sims k, et al. collaborative research exploring mental health service user perspectives on acute inpatient occupational therapy. br j occ ther 2016;79(10):607-613. https://doi. org/10.1177/0308022616650899 4. creswell jw. designing a qualitative study. in: creswell jw. qualitative inquiry and research design: choosing among five approaches. thousand oaks, ca: sage, 2006:42-68. 5. sandelowski m. sample size in qualitative research. res nurs health 1995;18(2):179-183. https://doi.org/10.1002/ nur.4770180211 6. world medical association. world medical association declaration of helsinki: ethical principles for medical research involving human subjects. jama 2013;310(20):2191-2194. https://doi.org/10.1001/jama.2013.281053 7. robinson am, avallone j. occupational therapy in acute inpatient psychiatry: an activities health approach. am j occ ther 1990;44(9):809-814. https://doi.org/10.5014/ajot.44.9.809 8. eaton p. psychoeducation in acute mental health settings: is there a role for occupational therapists? br j occ ther 2002;65(7):321-326. https://doi.org/10.1177/030802260206500704 accepted 4 september 2019. https://doi.org/10.12968/ijtr.2010.17.9.78038 https://doi.org/10.1177/0308022616650899 https://doi.org/10.1177/0308022616650899 https://doi.org/10.1002/nur.4770180211 https://doi.org/10.1002/nur.4770180211 https://doi.org/10.1001/jama.2013.281053 https://doi.org/10.5014/ajot.44.9.809 https://doi.org/10.1177/030802260206500704 march 2019, vol. 11, no. 1 ajhpe 3 short research report the literature indicates that there is a shortage of medical practitioners in rural underserved areas of south africa (sa). of sa’s 49 million residents, ~46% are served by only 12% of our doctors, mostly in the public sector.[1] reasons that have contributed to this include doctors who emigrate, as well as lack of recruitment of doctors for rural placement after qualification.[1] in response to this phenomenon, the training of undergraduate medical students to practise in rural communities was defined as an educational priority.[2] medical education in sa is entering ‘exciting times’.[2] educational institutions in australia, canada, the usa and sa are addressing the need for training of practitioners in rural areas by providing students with opportunities for exposure to rural health experiences.[2] the division of family medicine, faculty of health sciences, university of cape town (uct), sa, implemented a voluntary, rural clerkship in the west coast district of vredenburg in 2011. in 2014, there was a decline in student recruitment numbers. therefore, to ensure sustainability of the rural rotation, the family medicine clerkship was adapted. since january 2015, all final-year students rotating through family medicine complete a 1-week mandatory rotation in the rural district hospital and community clinic in vredenburg. they return to the urban setting to complete the remaining 3 weeks, based at community health clinics. the aim was to expose all students to clinical activities in a rural setting to sensitise and develop an interest in rural medicine as a career. this is based on a study by critchley et al.,[3] which confirmed that 70% of students who completed a course in rural health showed an interest in rural health practice. it may be argued that 1 week is not sufficient to enable students to benefit from the rural experience. however, there is some support in the literature for this innovation. in a qualitative study by adams et al.[4] at an australian medical school, a rural placement was defined as a minimum of 1 week in a rural location, which was associated with the current area of study. the aim of this research project was to explore the expectations and experiences of final-year medical students regarding the rural rotation for family medicine, and to identify factors that may influence uct students to practise in a rural setting after graduation. background. during recent years, a shortage of medical practitioners has been reported in rural underserved areas of south africa (sa). the division of family medicine, faculty of health sciences, university of cape town (uct), sa, implemented a voluntary 4-week rural rotation in vredenburg, west coast district, in 2011 in response to the need for rural training to be included in the medical curriculum. the reason for the decline in the number of students making use of this opportunity, is unknown; therefore, a compulsory 1-week rural rotation, as part of the final-year 4-week clerkship, was implemented in 2015. the rationale for this intervention was to ensure a sustainable rural learning environment and to highlight the need to explore students’ expectations and experiences with regard to the rural rotation. objectives. to explore the expectations and experiences of 6th-year medical students regarding the family medicine rural rotation, and to identify factors that may influence return to a rural setting after graduation. methods. a qualitative study design was used. sixth-year medical students (n=31) participated in the pre-rural focus group discussions (fgds), and 28 in the post-rural fdgs. a content analysis method was used to identify key themes. results. key themes for student expectations included programme content, clinical experiences, language barriers and physical environment. themes for student experiences related to environment and resources, programme content and clinical experience, language barriers and logistics. positive experiences included good mentorship, autonomy to perform procedures and improved preparedness for internship. negative experiences included inadequate clinical exposure and time allocation. most students expressed an intention to enter rural practice; reasons included effective teamwork and making a difference. conclusions. student expectations of the rural rotation varied from feelings of apprehension about language barriers to programme content and clinical experience. however, the majority were excited about the potential clinical exposure in a rural setting. positive experiences related to student expectations being met and working independently while supervised by good mentors. based on these findings, it can be concluded that all medical students, irrespective of geographical background, should be exposed to rural medicine in the undergraduate curriculum. afr j health professions educ 2019;11(1):3-5. doi:10.7196/ajhpe.2019.v11i1.1071 expectations and experiences of final-year medical students regarding family medicine rural rotations: influence on intention to practise in a rural setting n beckett,1 mb chb, bsc, bsc hons med sc, pgdipfm; r delport,2 bsc (nursing), bcur hons (intensive care nursing), msc (medical physiology), phd (chemical pathology), med (computer-assisted education) 1 division of family medicine, school of public health and family medicine, faculty of health sciences, university of cape town, south africa 2 health sciences skills laboratory, faculty of health sciences, university of pretoria, south africa corresponding author: n beckett (nazlie.beckett@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 4 march 2019, vol. 11, no. 1 ajhpe short research report this research is relevant, as students are the key role-players who will be ambassadors to promote the rural programme, and the study findings inform future logistical planning of the family medicine programme to ensure a sustainable rural learning environment. methods final-year medical students at the faculty of health sciences, uct, were invited to participate in this study during their family medicine rotation. informed consent was obtained, and students were notified that the primary investigator (pi) conducting the research is also the course convenor. a convenience sampling method was used. seventy-one students in their family medicine rotation from july to october 2015 were eligible, and all students who gave consent were included (n=31). data were collected during focus group discussions (fgds), which were conducted by the pi at the faculty of health sciences. each participant was allocated a specific code, which was linked to the responses. fgds were conducted before and after rural rotations. three probing questions were asked: ‘what are your thoughts/expectations about the rural rotation for family medicine?’, which was used to initiate discussion during the pre-rural fgds, and ‘what were your experiences regarding the rural rotation?’ and ‘based on your experience, would you consider returning to a rural setting after you qualify and why?’, which were used for the post-rural discussions. the pi recorded the fgds and a moderator took notes. transcribed data were available to participants for member checking. data pertaining to the expectations and experiences of the students were captured on an excel spreadsheet. data were grouped into common categories and allocated a specific code. a content analysis method was used to identify key themes, and data were analysed until saturation was reached. data from the second probing question used in the post-rural fgds were transcribed verbatim and analysed to identify factors that may influence return to a rural ractice. demographic data were obtained from uct’s undergraduate student office, which were recorded in categories to identify age, sex and area of origin of the participants. these data were used during the analysis of results pertaining to intent to return to rural practice. each quote used in this article is referenced to the participant. ethical approval ethical approval was obtained from the human research ethics committee at uct (ref. no. hrec 336/2015). permission for student participation was received from the student affairs office. results thirty-one students participated in the fgds conducted before the rural rotation and 28 students in the post-rural fgds. three students were lost to follow-up in the post-rural discussions owing to logistical reasons. the participants’ ages ranged from 22 to 33 years. the majority were female (n=21), and participants were from western cape province (n=16), kwazulunatal province (n=6), gauteng province (n=2), limpopo province (n=2), mpumalanga province (n=2), white river (n=1) and north west province (n=2). main themes related to student expectations programme content and clinical experience a few of the students expected it to be a new and varied experience and felt apprehensive about resources, but were keen to implement clinical knowledge into practice: ‘i am looking forward to seeing a new population with a range of conditions compared to urban patients.’ (5.10) ‘exposure to a smaller environment with more generalised illness, with limited resources. being sparing with ordering of investigations.’ (3.1) language barriers, feelings and emotions and physical environment some students were concerned about language barriers, and emotions ranged from excitement to apprehension, while others had no specific expectations but were willing to adapt: ‘i am worried about the language because i do not speak afrikaans.’ (4.1) ‘i don’t expect it to be “really rural” where you go into the community … not like kzn.’ (2.1) themes related to student experiences themes identified for experiences were closely linked to student expectations and related to environment and resources, programme content and clinical experience, language barriers and logistics. programme content and clinical experience students found the participation rewarding and gained good clinical experience regarding the rural health system and referral patterns. others found the experience frustrating because of lack of patients during quiet casualty calls and limited time in vredenburg: ‘if we had better exposure for longer … we would have a better opportunity to work in a team. it would have been better to go for 2 weeks, with more clinical time immersed in outpatient clinics.’ (1.2) language barriers and logistics students experienced issues with transport and found the language barrier to be challenging: ‘transport was a problem; it should be clear that the vehicle is for everyone.’ (2.2) ‘there was a huge language barrier … patients speak only afrikaans and notes are written in afrikaans.’ (4.9) rural setting based on students’ experiences, a probing question was asked to assess intention to return to a rural setting. most of the students (67%) expressed an intention to return to such a setting to practise (table 1): ‘i would still go back to a rural setting … i liked the hospital and treating patients in a community setting. i liked the autonomy and the confidence it gave me. i would be able to focus on my own interests.’ (3.2) the remaining students (33%) indicated that they would not consider returning to rural medicine because of personal reasons, such as children’s schooling and intention to specialise: ‘no! i will never work in a rural area … i have a family life. i want to specialise … there is no place for a physician in a district hospital. i feel you get pressurised to go rural … it is a personal choice.’ (3.8) discussion students had varied expectations regarding the rural rotation. some had spoken to peers, which influenced their perceptions positively, whereas others were anxious because of language issues and the unknown environment. student experiences were closely linked to their expectations. march 2019, vol. 11, no. 1 ajhpe 5 short research report most students had a positive experience and appreciated the autonomy to work independently, but with good support and mentoring. those who had a negative view based their opinions on their experiences in the casualty department , as there were too few patients. the majority of students (67%) expressed intent to return to a rural setting after graduation, based on their rural experience. this is supported by evidence from a study conducted by critchley et al.,[3] which confirmed that 70% of students who completed a course on rural health, showed an interest in rural health practice. some of the student recommendations were implemented in 2016, while other suggestions might be considered in future. this would ensure a sustainable rural learning environment that addresses student needs. study limitations a limitation of this study was that it was conducted on one cohort of students. as krahe et al.[5] suggested, more research should be done to gain a better understanding of student perceptions and identification of factors that encourage rural recruitment of students to ensure sustainability of the rural rotation. it would be necessary to repeat this study with future groups of students to determine if the study findings regarding intent to return to a rural setting after graduation are supported. a future study would follow up this cohort of students to determine if intent was put into practice. conclusion the objective of this study was to explore the expectations and experiences of final-year medical students regarding the rural rotation, and whether the experience influenced their intention to return to a rural setting after graduation. based on the study findings, it can be concluded that all medical students, irrespective of their geographical background, should be exposed to rural medicine in the undergraduate curriculum. declaration. none. acknowledgements. the authors would like to thank the 6th-year family medicine students for their co-operation. author contributions. nb and rd designed the study; nb collected and analysed the data; nb and rd wrote the draft report; and nb reviewed the final draft for publication. funding. none. conflicts of interest. the first author is the convenor of the family medicine undergraduate programme. 1. burch v, reid s. fit for purpose? the appropriate education of health professionals in south africa. s afr med j 2011;101(1):25-26. 2. van schalkwyk sc, bezuidenhout j, conradie hh, et al. ‘going rural’: driving change through a rural education innovation. rural remote health 2014;14:1493. 3. critchley jc, de witt j, khan ma, liaw st. a required rural health module increases students’ interest in rural health careers. rural remote health 2007;7:688. 4. adams me, dollard j, hollins j, petkov j. development of a questionnaire measuring student attitudes to working and living in rural areas. rural remote health 2005;5:32-37. 5. krahe lm, mccoll ar, pallant jf, cunningham ce, de witt de. a multi-university study of which factors medical students consider when deciding to attend a rural clinical school in australia. rural remote health 2010;10:1477. accepted 23 august 2018. table 1. reasons for intention to return to a rural setting reason participants, % effective teamwork 42 making a difference 21 safe working environment 11 autonomous practice 11 continuity of care 10 manageable doctor-patient ratio 5 ajhpe african journal of health professions education april 2021, vol. 13, no. 1 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 forum 4 navigating covid-19: preparing medical students in a time of pandemic n jacob, f cilliers, k begg, l green-thompsonr 6 feedback as a spectrum: the evolving conceptualisation of feedback for learning l govender, e archer 8 the strategic development and strengthening of the profession of biokinetics b k grobler, t j ellapen, y paul, g l strydom short communication 10 drill: an innovative programme to develop health research leadership in kwazulu-natal, south africa f suleman, d wassenaar, n nadesanreddy, p brysiewicz 12 creating a space for interprofessional engagement in a clinical setting l jaffer, l africa, f waggie article 14 legal and ethical requirements for developing a medical mooc: lessons learnt from the paediatric physical examination skills mooc a george, d wooldridge, j king, a g giovanelli, s g naidoo, m a mabeba, s morar, s g lala, z dango 18 a blended learning and teaching model to improve bedside undergraduate paediatric clinical training during and beyond the covid-19 pandemic s g lala, a z george, d wooldridge, g wissing, s naidoo, a giovanelli, j king, m mabeba, z dangor short research report 23 facilitators of and barriers to clinical supervision of speech-language pathology students in south africa: a pilot study a mupawose, s adams, s moonsamy research 29 simulation in plastic surgery: features and uses that lead to effective learning c p g nel, g j van zyl, m j labuschagne 36 significance of relationships in the cognitive apprenticeship of medical specialty training a a khine, n hartman ajhpe african journal of health professions education april 2021, vol. 13, no. 1 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state elizabeth wolvaardt university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 41 cognitive load theory in simulations to facilitate critical thinking in radiography students a louw 47 factors influencing radiography lecturers’ perceptions and understanding of reflective practice in a newly implemented curriculum h thomas, m volschenk 52 research competencies for undergraduate rehabilitation students: a scoping review m y charumbira, k berner, q a louw 59 learner engagement as social justice practice in undergraduate emergency care education: an exploration of expectations, impediments and enablers for academic success n naidoo, r matthews 65 a capability approach analysis of student perspectives of a medical consultation quality-improvement process j m louw, t s marcus, j f m hugo 72 validation of a questionnaire evaluating the effect of a preparatory year on qualifying students for studying at health professions education faculties m al-rabia, l al shawwa, e gouda, a aldarmahi, h asfour, h atwa 77 development of a baseline assessment tool to establish students’ foundational knowledge of life sciences at entry to university l pienaar, r prince, a abrahams 83 how well do we teach the primary healthcare approach? a case study of health sciences course documents, educators and students at the university of cape town faculty of health sciences j irlam, m i datay, s reid, m alperstein, n hartman, m namane, s singh, f walters cpd questionnaire mailto:matthewsr@cput.ac.za june 2019, vol. 11, no. 2 ajhpe 35 short research report south africa (sa), like most other developing countries, has a shortage of doctors, especially in rural and underserved communities, where most of the population’s healthcare needs are required.[1] service learning (sl) is well embedded in the curricula of higher education institutions in sa, as universities must support transformation initiatives and address social ills of the past.[2] sl as a form of experiential learning is a link between the university and the community.[3] therefore, a sl curriculum creates an interrelationship between family and community health and different levels of care.[4] through sl, students are most likely to engage in reflective practice when they encounter real patients with health problems.[5] furthermore, the decentralised training sites where sl activities (slas) are practised offer opportunities for medical students to rekindle their altruistic commitment.[3] academic sl is a common practice at sa universities.[6] at the university of the witwatersrand (wits), johannesburg, sa, sl is a form of community engagement whereby health science students participate in a range of activities that enhance academic sl and also facilitate purposeful civic engagement. after such exposure, students are required to submit a reflective journal in the form of a portfolio or logbook, where the community attachment includes a clinical component for which students must meet the goals for formative assessment.[7] it is against this background that the wits centre for rural health introduced the integrated primary care (ipc) block as a 6-week placement for final-year medical students in primary healthcare (phc) facilities, incorporating reciprocity as a central theme to sl.[7] this study aimed to assess the situated learning experiences of final-year medical students, based on their ratings of the educational value and enjoyment of the 27 slas that form part of the ipc block. methods this descriptive cross-sectional study was conducted among final-year medical students who completed their ipc block in 1 academic year (n=245). data were collected at phc sites where final-year students were placed to gain practical experience of slas. the 7 rural sites and 9 underserved urban sites, which were used interchangeably, included clinics, community healthcare centres and level i or ii hospitals in rural or urban underserved communities.[7] data were collected using logbook entries submitted at the end of the 6-week cycle for each of the 7 rotations. the focus of this study was limited to the two sections in the logbook where students were asked to rate the value of an sla as a learning experience, as well as enjoyment of an sla. students rated the sla values (1 = no value and 5 = great value) and enjoyment (1 = no enjoyment and 5 = great enjoyment) on a 5-point likert scale. data were captured and analysed descriptively using spss version 25 (ibm corp., usa). we used cross-tabulations to assess whether being in a rural/urban site led to significant value and enjoyment of an sla. associations were considered to be significant at p<0.05. ethical approval approval for this study was obtained from the wits human research ethics committee (ref. no. hrec m1311162) as part of the ongoing evaluation of background. service learning (sl) has as its pedagogy the ability to link medical education to the community through the identification of healthcare needs for citizens residing in rural and urban underserved communities. integrated primary care (ipc) is a clinical block through which final-year medical students manage common presenting problems in context and engage the community in a reciprocal manner. objective. to assess the educational value and enjoyment of the 27 sl activities (slas) undertaken by final-year medical students as part of the ipc block. methods. a cross-sectional descriptive study was conducted among final-year medical students (n=245), focusing on logbook activities during 1 academic year. results. students reported positively on the educational value of the majority of the 17 clinical slas, but only 3 activities were ranked the same for enjoyment and educational value. for non-clinical activities, only 2 of 10 were matched for educational and enjoyment value. there was no significant difference in the rating of educational value and enjoyment between rural and urban underserved sites. conclusions. the study provided insight into clinical and non-clinical slas that accumulate value for students when they are based in primary healthcare settings. the lack of enjoyment on reflective activities is a concern that should be explored through a qualitative review of slas. afr j health professions educ 2019;11(2):35-37. doi:10.7196/ajhpe.2019.v11i2.906 final-year medical students’ ratings of service-learning activities during an integrated primary care block n mapukata,1,2 msc (health care management), msc (med); m g mlambo,1,3 phd; r dube,1 mb bch 1 department of family medicine and primary care, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 school of public health and family medicine, faculty of health sciences, university of cape town, south africa 3 college of law, institute for dispute resolution in africa (idra), university of south africa, pretoria, south africa corresponding author: m g mlambo (motlatso.mlambo@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 36 june 2019, vol. 11, no. 2 ajhpe short research report the ipc block. the sections that form part of this study were not marked as part of the formative assessment of the student. results the results are described according to clinical and non-clinical activities. the activities that included less patient contact were classified as non-clinical slas, whereas those with more patient contact were classified as clinical slas. clinical service-learning activities clinical activities that were given the highest educational value were antenatal consultations (91.0%), undifferentiated patient consultations (91.0%) and well-baby clinic visits (90.4%). the same slas that rated highly for educational value were also rated highly for enjoyment. these were consultation of well-baby clinics (90.7%), undifferentiated patients (83.1%) and antenatal consultations (82.3%). a moderate positive and significant correlation between value and enjoyment were found with regard to all clinical slas. non-clinical service-learning activities the role of other health professionals was highly valued (79.0%) and enjoyed (77.3%). interestingly, the school health education (76.7%) and significant event analysis (68.4%) were rated equally for both value and enjoyment of sl. although the health facility audit was valued at 63.5%, it was less enjoyed (43%). teleconferences and weekly reflection meetings were less valued and less enjoyed. a moderate positive and significant correlation between value and enjoyment was found regarding all the non-clinical slas, except for school health education. service-learning value and enjoyment by site the comparison of sl value and enjoyment by site is reported in table 1. in terms of value rating, significant differences were found between urban and rural sites for some slas. only teleconferences (p=0.021) and triage (p=0.017) were statistically significant. in terms of enjoyment rating, significant differences were found between urban and rural sites for some slas. only teleconferences (p<0.001), school health education (p<0.001), observed consultations (p=0.028) and reflective stories (p=0.047) were statistically significant. discussion this study assessed students’ educational value and enjoyment of clinical and non-clinical slas. the results revealed the highest rating for both value and enjoyment for the clinical slas that involved direct contact with table 1. service-learning value and enjoyment in urban v. rural sites sla educational value by site enjoyment by site urban, % rural, % p-value urban, % rural, % p-value antenatal consultations 92.0 88.5 0.435 82.8 80.3 0.699 calls 87.5 85.2 0.662 69.0 69.4 1.000 chronic consultations 85.0 83.1 0.683 66.1 71.2 0.523 consultation of undifferentiated patients 90.3 91.5 1.000 84.7 77.6 0.230 counselling sessions 82.5 90.2 0.216 67.8 70.0 0.872 weekly reflection meetings (nc) 37.1 47.2 0.200 58.3 47.1 0.308 labour ward management 79.7 80.4 1.000 58.3 47.1 0.194 observed consultations 87.3 96.5 0.074 57.0 73.7 0.028* pmtct 84.1 80.4 0.525 66.2 62.7 0.735 reflective stories (nc) 42.4 45.8 0.640 43.0 60.4 0.047* tb/hiv management 88.3 86.4 0.817 73.5 72.4 0.865 teleconferences (nc) 38.8 56.9 0.021* 23.1 52.5 0.001** well-baby clinic activities 88.7 94.9 0.164 90.4 91.2 1.000 anaesthesia 70.2 71.7 0.871 55.6 59.3 0.650 family planning consultations 75.9 72.9 0.727 71.0 69.5 0.869 health facility audit (nc) 62.2 66.1 0.641 43.2 40.7 0.762 home visit (nc) 74.0 78.0 0.603 73.4 72.4 0.860 imci consultations 77.8 79.3 1.000 71.3 73.7 0.865 medico-legal 74.8 79.7 0.593 42.6 37.9 0.641 mental health patient consultations 61.2 66.7 0.534 40.2 53.3 0.095 mini-cex 76.6 75.0 0.860 47.4 61.7 0.071 quality improvement project (nc) 69.0 75.9 0.404 53.2 62.1 0.285 referral 55.5 59.6 0.643 43.9 47.4 0.757 role of other health professional (nc) 78.4 80.0 0.856 77.8 76.7 0.858 school health education (nc) 76.7 75.9 1.000 100 100 0.001** significant event analysis (nc) 67.7 69.5 0.871 40.5 33.9 0.436 triage 52.2 75.4 0.017* 46.8 56.1 0.279 sla = service-learning activity; nc = non-clinical; pmtct = prevention of mother-to-child transmission; tb = tuberculosis; imci = integrated management of childhood illness; cex = clinical evaluation exercise. significant at *p<0.05, **p<0.01. june 2019, vol. 11, no. 2 ajhpe 37 short research report patients, such as antenatal consultation, consultation of undifferentiated patients and well-baby clinic visits. the high rating of slas and positive significant correlation regarding both value and enjoyment reflect students’ satisfaction with exposure to primary care patients as part of their learning experience. studies indicate that students tend to accord deep feelings of personal satisfaction and higher educational value to activities where they have direct patient contact.[6,8] in a study by nyangairi et al.,[7] students seemed to enjoy exposure to some common illnesses that they were exposed to during a primary care rotation. in this study, students seemed to value most of the learning activities if they enjoyed them. this is in accordance with findings reported by wilson et al.,[9] as their students’ perceived enjoyment when the activity was considered to be of high value, with the exception of non-clinical activities. in our study, the majority of non-clinical activities were assigned a moderate educational value, except for reflective stories, weekly reflection meetings and teleconferences, which received the lowest ratings. reasons for these low ratings could be technical problems associated with teleconferencing, such as loss of connection or poor connection during a session.[10] an unexpected finding was the poor ranking of weekly reflections and reflective stories as student-directed non-clinical slas. in keeping with a study by van hell et al.,[8] reflections were not highly valued by our students. muir[11] attributed this to students requiring much more guidance about how to reflect, and failure to introduce reflective practice earlier in the curriculum. overall, students’ experiences were not influenced by site allocation – either urban based and underserved or rural for the majority of slas, except for triage, where students in rural sites seemed to derive more educational value than their urban counterparts. nyangairi et al.[7] alluded to the phc context being valued much more than the location of the setting, as students focused on potential attributes, such as providing holistic care to the patient. our students expressed value and enjoyment of home visits, school health projects and time spent with other healthcare professionals as non-clinical slas, which is supported by leung et al.[4] as one of the benefits of the sl curriculum, they cite exposure to relationships between the community and health facility, as well as different levels of healthcare. the attachment of value to health-promotion activities reported in our study was linked to the opportunity for medical students to engage learners in the choices they make for their future healthcare.[6] compared with experiences at other universities, where the educational value of slas in decentralised training platforms is largely reported from a clinical perspective with either a limited attachment period or limited activities,[9] the 27 slas may be too many for students and may also be influenced by the setting. conclusions this study provided insight into clinical and non-clinical slas that accumulate value for students when they are based at phc settings. students managed to achieve reciprocal learning through the school health project. they did not enjoy reflecting on their experiences, which is a concern that should be explored through a qualitative review of slas. declaration. none. acknowledgements. our gratitude is extended to the research interns who assisted with the data capturing and to prof. ian couper for his input during the conceptual phase of the study. author contributions. all three authors were involved in the preparation of the initial draft and also contributed to the final draft. funding. none. conflicts of interest. none. 1. couper i, de villiers m, sondzaba n. human resources: district hospitals. in: ijumba p, barron p, eds. south african health review. durban: health systems trust, 2005. 2. higher education quality committee south africa. a good practice guide and self-evaluation instruments for managing the quality of service-learning. pretoria: council on higher education, 2007. 3. diab p, mcneill pd, ross aj. review of final-year medical students’ rural attachment at district hospitals in kwazulu-natal: student perspectives. s afr fam pract 2014;56(1):57-62. https://doi.org/10.1080/20786204.20 14.10844584 4. leung k-k, liu w-j, wang w-d, chen c-y. factors affecting students’ evaluation in a community servicelearning program. adv health sci educ 2006;12(4):475-490. https://doi.org/10.1007/s10459-006-9019-1 5. keselyak n, simmer-beck m, bray k, gadbury-amyot c. evaluation of an academic service-learning course on special needs patients for dental hygiene students: a qualitative study. j dent educ 2007;71(3):378-379. 6. srinivas sc, wrench ww. evaluation of a service-learning elective as an approach to enhancing the pharmacist’s role in health promotion in south africa. afr j health professions educ 2012;4(2):107-111. https://doi. org/10.7196/ajhpe.108 7. nyangairi b, couper id, sondzaba no. exposure to primary healthcare for medical students: experiences of final-year medical students. s afr fam pract 2010;52(5):467-470. https://doi.org/10.1080/20786204.2010.1087 4027 8. van hell ea, kuks jbm, cohen-schotanus j. time spent on clerkship activities by students in relation to their perceptions of learning environment quality. med educ 2009;43(7):674-679. https://doi.org/10.1111/j.13652923.2009.03393.x 9. wilson nw, bouhuijs pa, conradie hh, reuter h, van heerden bb, marais bj. perceived educational value and enjoyment of a rural clinical rotation for medical students. rural remote health 2008;8(999). 10. lamba p. teleconferencing in medical education: a useful tool. australas med j 2011;4(8):442-447. https://doi. org/10.4066/amj.2011.823 11. muir f. the understanding and experience of students, tutors and educators regarding reflection in medical education: a qualitative study. int j med educ 2010;1:61-67. https://doi.org/10.5116/ijme.4c65.0a0a accepted 23 august 2018. https://doi.org/10.1080/20786204.2014.10844584 https://doi.org/10.1080/20786204.2014.10844584 https://doi.org/10.7196/ajhpe.108 https://doi.org/10.7196/ajhpe.108 https://doi.org/10.1080/20786204.2010.10874027 https://doi.org/10.1080/20786204.2010.10874027 https://doi.org/10.1111/j.1365-2923.2009.03393.x https://doi.org/10.1111/j.1365-2923.2009.03393.x https://doi.org/10.4066/amj.2011.823 https://doi.org/10.4066/amj.2011.823 march 2020, vol. 12, no. 1 ajhpe 41 research many academically orientated people aspire to achieve postgraduate qualifications. higher-education institutions (heis) provide an opportunity for students to advance their academic careers and to achieve the desired professional development. this article addresses only two opportunities (honours and master’s degree qualifications) for professional development in nursing as a discipline of the healthcare system. these two qualifications have proven to be beneficial in clinical nursing education and the practice stream, healthcare leadership and administration, as well as the education stream.[1] depending on the nursing stream, a professional nurse can enrol in postgraduate courses for different reasons, including promotion, improving health and technology, personal enrichment and career development.[2,3] however, this does not seem to be the case for nurse clinical practitioners at a tertiary hospital in limpopo province, south africa (sa). this institution of higher learning has continuously indicated a concern regarding the low enrolment of professional nurses for postgraduate studies. in this context, a postgraduate qualification, therefore, refers to an honours and a master’s degree in sa higher institutions. master’s qualifications enhance the educative, research and administrative roles of the professional nurse.[1] therefore, suggesting that having more clinically trained professional nurses with a master’s qualification provides an opportunity for sustaining the nursing profession and improving the healthcare institution.[4] a nursing practitioner with a master’s qualification enhances a patient’s safety needs in hospital.[1] furthermore, interest in a postgraduate qualification is motivated by possible opportunities, such as business opportunities, and research and collaboration with academics and professionals in the same field of practice or the same discipline.[3,5] therefore, increasing the enrolment of professional nurses becomes important for both clinical and academic institutions (especially considering the growing number of academics who are due to retire). however, this objective seems to be impossible owing to various barriers. nevertheless, for professional nurses to take advantage of the benefits of a clinical master’s degree in nursing, one needs to eliminate the barriers to enrolling for this postgraduate qualification. smith et al.[2] identified a lack of time to study, lack of finances, workload, programme limitations and family commitments as barriers to part-time study for a clinical master’s degree in physiotherapy in canada. in kenya,[6] barriers for professional nurses who undertake postgraduate courses are the cost of the course, family commitments, course workload and lack of remuneration directly after obtaining the postgraduate degree. in contrast, a study in the usa indicated that there is an increase in nurses enrolling for an advanced nursing qualification, e.g. master’s and doctoral degrees.[7] the authors further outlined that family, finances, support from employers, the complicated application process of the education institutions and age (>38 years) were perceived by other professional nurses as barriers to enrolling for a postgraduate nursing qualification.[7] while employment and education institutions are barriers to enrolling for an advanced degree (master’s) in nursing, especially when there is little or no collaboration between institutions, these contribute to the shortages of nurses in faculties of health sciences.[8] in sa, despite the reported rise in enrolment for postgraduate studies,[9] the nursing profession continues to experience inconsistencies in enrolment and throughput for postgraduate nursing qualifications, particularly master’s and doctoral degrees.[10] these inconsistencies are due to the background. professional nurses with a master’s degree have shown competence in improving quality and continuous care, including palliative care, mental health, post-transplant care and central venous care. however, nursing departments at south african (sa) universities experience challenges, such as fewer students in postgraduate courses, including master’s studies. objective. to explore and describe the barriers that nurses experience regarding enrolment for postgraduate qualifications. methods. a qualitative explorative-descriptive approach was used to examine experiences of nurses regarding enrolment for postgraduate studies at a tertiary hospital in limpopo province, sa. purposive sampling was used to select professional nurses at this tertiary hospital. data were collected using a semi-structured interview, which was analysed by tesch’s open coding of data analysis. results. it was found that professional nurses’ lack of information regarding postgraduate studies and lack of funding were barriers to enrolment, as well as not being satisfied with the current educational status and not seeing the purpose of obtaining a master’s degree. conclusion. the study findings highlight a need for workshops in limpopo hospitals, especially regarding how to enrol and the importance of enrolling for postgraduate qualifications. afr j health professions educ 2020;12(1):41-45. https://doi.org/10.7196/ajhpe.2020.v12i1.1126 exploring barriers that nurses experience to enrolment for a post graduate nursing qualification at a higher education institution in south africa m o mbombi,1 mcur; t m mothiba,2 phd 1 department of nursing science, school of health care sciences, faculty of health sciences, university of limpopo, polokwane, south africa 2 executive dean's office, faculty of health sciences, university of limpopo, polokwane, south africa corresponding author: m o mbombi (masenyani.mbombi@ul.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 42 march 2020, vol. 12, no. 1 ajhpe research poor adjustment of health practitioners in academic institutions.[11] it would seem as though there are more professional nurses with master’s degrees in academic institutions than in the clinical environment. there has also been concern regarding professional nurses not enrolling for master’s studies.[12] this concern raises questions regarding the barriers to enrolment of professional nurses for master’s studies at higher institutions. the growing health complexity in the province necessitates exploring the barriers experienced by professional nurses, as it is necessary to increase the number of policymakers, academic authors, nurse educators and administrators. therefore, the objective of this study was to explore and describe barriers experienced by professional nurses regarding enrolment for postgraduate nursing studies. the study findings are anticipated to create an awareness in sa schools of nursing, the sa nursing council (sanc) and the department of health (doh) regarding recognition of master’s qualifications in the clinical setting as an important requirement for the improvement of healthcare institutions. methods a qualitative research approach was used to explore barriers that nurses experience to enrolment for a postgraduate nursing qualification at heis. explorative and descriptive research designs were applied to achieve the research aim. population and sampling the population comprised all professional nurses who were working in nursing care units at a tertiary hospital. the study sample consisted of 20 professional nurses, using a non-probability purposive homogeneous sampling method. only professional nurses who could enrol for postgraduate studies at a tertiary institution were selected to participate in the study. study site the study was conducted at a tertiary hospital in capricorn district of limpopo province. this hospital caters for all patients transferred from clinics and primary and secondary hospitals in the province. the hospital has many professional nurses who qualify to register for postgraduate studies. data collection a semi-structured interview guide was used for data collection. quality of data was ensured by the listening skills of the participants describing the barriers they experience when they want to enrol for postgraduate studies, and also probing professional nurses for in-depth data regarding the barriers. reflective skills were used to summarise, obtain clarity and further stimulate professional nurses to describe in detail the barriers to enrolment.[13] for example: ‘you said you fail to enrol in a master’s programme due to the workload. could you kindly elaborate further?’ the authors showed interest in the participants by using responses, such as ‘ooh’ and ‘okay’, to interact. interviews lasted 35 45 minutes and data were saturated in 13 professional nurses. a digital audiotape was used to capture all interviews, which were conducted in a quiet cubicle in the hospital – free from noise and disturbances. data collection was completed in 30 days in 2016. measures to ensure trustworthiness four criteria of trustworthiness were adhered to in the study to ensure accuracy and the true value of the study findings.[14] the researcher (mom) used a purposive sampling method to enhance transferability and select professional nurses to participate in the study. independent coding of the results was done by the second author to enhance dependability. confirmability was ensured by writing field notes and using a voice recorder during semi-structured one-on-one interviews – the voice recordings were preserved for further auditing by external auditors. credibility was obtained by prolonged engagement, during which the researcher interviewed participants; data collection was completed in a month. data analysis tesch’s open coding method, as described by creswell,[15] was used to analyse data. data were condensed into discrete parts, closely examined and compared for similarities and differences. questions were asked about experiences as reflected in the data. three themes emerged from the study findings: employment-related barriers, hei-related barriers and personal barriers. ethical approval ethical approval was obtained from the turfloop research ethics committee (ref. no. trec/185/2016). permission to conduct the study at a tertiary hospital in limpopo was granted by the limpopo department of health. professional nurses gave informed consent and voluntarily signed the consent form before participation in the interview sessions. to ensure confidentiality, we stored the audiotaped interview records where only authorised personnel could obtain access. professional nurses were allocated code numbers to ensure anonymity. the employer permitted professional nurses to be part of the study, which assured their safety while participating in the study. all professional nurses were treated equally. the nurses could recuse themselves from the interview sessions without coercion to continue. there were no financial benefits for participants, and nurses were assured that participation bore no psychological and socioeconomic risks. results and discussion demographic data of professional nurses table 1 summarises the demographic data of professional nurses who participated in the study. the results of the study are summarised in table 2. table 1. demographic data of professional nurses demographic variables population, n (%) qualifications basic nursing degree (honours) 13 (65) postgraduate diploma 7 (35) gender male 6 (30) female 14 (70) working experience, years 2 5 3 (15) 6 9 7 (35) 10 13 6 (30) ≥14 4 (20) total 20 march 2020, vol. 12, no. 1 ajhpe 43 research theme 1: employment-related barriers the findings revealed various factors that hinder professional nurses from enrolling for postgraduate studies at heis: work-related factors, such as workload and shortage of staff; and personal factors, such as lack of passion for studying for a postgraduate degree. lack of support by management was also indicated as a factor hindering professional self-development for professional nurses to upgrade their skills for career development and personal growth. the subthemes are discussed below. financial gain after obtaining a master’s degree professional nurses verbalised that there is no financial gain after obtaining a postgraduate qualification, and therefore felt that continuing education at the postgraduate level is a waste of time. they consequently felt discouraged to enrol for postgraduate studies: ‘… why should i use my family money to study for a degree that will not benefit me financially … .’ (participant 8) ‘there are no financial benefits after getting the degree … don’t see a need to enrol for such a course.’ (participant 14) similarly, it was found that lack of direct remuneration is a barrier to enrolling for a postgraduate qualification in australia.[16] lack of remuneration discourages nurses from enrolling in postgraduate courses, as there are no prospects of career advancement, such as increased financial benefits, after obtaining a postgraduate degree.[17] work overload v. staff shortage the workload that results from staff shortages in nursing care units was indicated as a reason for professional nurses not to enrol for postgraduate studies – they did not have enough time because they were exhausted: ‘when will you study … the ward is always full and all those patients are expecting that you take care of them.’ (participant 2) ‘the unit is always full of patients … at times only one professional nurse has to run the whole unit along with two staff nurses. at the end of the day you become so exhausted, and thinking of enrolling for the postgraduate course is a dream that one will never achieve.’ (participant 5) smith et al.[2] indicated that insufficient rest time affects one’s health, which may result in discontinuation of postgraduate studies. according to fang et al.,[16] a person with a heavy workload and family responsibilities might struggle to find time to study. lack of recognition of academic achievement by management the findings revealed that the doh attaches no value to a postgraduate qualification, such as a master’s degree in nursing. the department does not increase one’s salary level on completion of the degree. participants also indicated that the sanc sees no value in nurses studying towards a master’s degree, which can be demotivating: ‘why should i get a master’s … our doh does not value the qualification … they won’t increase your salary. therefore, it will be a waste of time for me to study towards the achievement of that qualification.’ (participant 4) ‘the sanc does not recognise the qualification because it is not registering it in their system. they do not even make recommendations that the course should be given by nurse managers as in other countries as i have heard.’ (participant 12) the findings are consistent with those of hoffman and julie,[11] who indicated that career progression is an intrinsic motivator for a person to enrol in a master’s programme at the university of the western cape. poor financial compensation and a non-competitive salary are barriers to studying towards a postgraduate nursing degree. theme 2: barriers relating to higher-education institutions professional nurses described barriers that relate to heis as those regarding enrolment in postgraduate nursing studies. lack of information on postgraduate studies professional nurses indicated that there was a lack of information on postgraduate studies, especially regarding the master’s degree in nursing: ‘i do not know what they want for one to register for a master’s degree.’ (participant 7) ‘i only have a diploma, not a degree; they will not allow me even if i want to register it.’ (participant 13) a lack of course information on websites and the complicated application process of education institutions could become barriers to enrolment in postgraduate studies.[17] most professionals want to pursue postgraduate courses, but lack information about admission criteria.[6] requirements for postgraduate courses viewed as difficult to achieve professional nurses indicated that it was not easy to enter master’s studies, as most of them did not qualify when considering admission requirements: ‘… they want 60 marks average from the basic degree and that is the problem, because we do not have in my case my performance – in the final year it was not satisfactory in the basic degree that i have obtained.’ (participant 14) ‘… eish, my final-year results of my former degree are not good and if you table 2. results of the study themes subthemes 1. employment-related barriers • financial gain after obtaining a master’s degree • workload v. shortage of staff • lack of recognition of academic achievement by management 2. barriers relating to higher-education institutions • lack of information regarding the degree • requirements for postgraduate courses viewed as difficult to achieve 3. personal barriers • lack of finances v. family responsibilities • lack of study passion v. satisfaction with current job status 44 march 2020, vol. 12, no. 1 ajhpe research want to enrol for a master’s degree you should have obtained your junior degree at least with 60% and above ... .’ (participant 10) smith et al.[2] support the findings by stating that barriers to enrolment in postgraduate studies are institutional and personal – institutional refers to policies and practices that make it difficult for a person to access courses at tertiary institutions. dam[17] agrees with smith et al.’s[2] findings by highlighting that higher-institution entry requirements block access to a postgraduate course. matsolo et al.[18] confirmed that poor entry-level marks became a barrier to postgraduate studies, which was confirmed by lakati et al.[6] theme 3: personal barriers professional nurses described personal barriers to enrolling in postgraduate nursing studies. lack of finances v. family responsibilities some professional nurses indicated that lack of financial support, such as insufficient scholarships and bursaries, was a barrier to enrolling in postgraduate courses, while others highlighted that their families’ financial responsibilities were the reason for not enrolling in postgraduate degrees at heis. this view was supported by the following participants: ‘i cannot use my family money for my personal studies while there is a dire need in the family to use such money. for example, i have to provide for the basic needs of my family members, which require finances.’ (participant 6) ‘if there can be a lot of scholarships and bursaries to assist us to enrol for the postgraduate course, then i can take that option and register because it will not put any strain on my family finances.’ (participant 12) some authors[2,8] support the findings that an advanced degree may be financially costly and, as such, lack of finances becomes a barrier to enrolling in the postgraduate course. however, matsolo et al.[18] indicated that financial instability has an impact on racial enrolment in most academic institutions, as some students of specific races are restricted by lack of finances to enrol in courses at universities. others[16,19] indicated that overwhelming responsibilities, including spouse, parental and employers’ roles, are barriers that confront postgraduate students. in support of the findings, challenges have been highlighted, e.g. having to support children and families as a part-time female student.[20,21] these challenges resulted in an imbalance between personal life (family), employment and students’ responsibilities, which became a burden. lack of study passion v. satisfaction with current job status some professional nurses who qualify to enrol in postgraduate courses at heis indicated lack of interest to further their studies, mainly because they were satisfied with their current educational status and employment, and therefore see no need to do so: ‘study master’s to do what … am still happy with my position in the hospital and my current academic achievement.’ (participant 9) ‘enrol master’s for what reason; i do not like research … and there will be no changes in my job title after obtaining that master’s.’ (participant 5) in support of the findings, bani-khaleb and diab[22] indicated that personal interest in learning was a factor that influenced jordanian students’ choice of enrolling at university to study further. other findings show that in gauteng province, sa, 77% of blacks are satisfied with their current educational status, and therefore do not see the need to further their studies. matsolo et al.[18] concur with the findings by stating that lack of commitment seems to be another factor hindering students from furthering their studies. lin[19] indicated that personal attitudes and self-perceptions with regard to continuing education are blamed for hindering people’s personal development. recommendations the study findings recommend a support programme by the doh and the sanc related to continuing education, especially for professional nurses to enrol in postgraduate courses that lead to upscaling of their skills to provide quality care to patients. the support should include awarding study leave for time off from work during enrolment as a postgraduate student. furthermore, there should be an increase in financial scholarships and bursaries by the doh and universities/department of higher education and training to support professional nurses with financial problems and family responsibilities, but who nonetheless pursue postgraduate studies. universities should be aggressive in raising awareness of programmes through roadshows to ensure that professional nurses are knowledgeable regarding the postgraduate qualification. workshops should be conducted to educate nurses, remind the sanc and inform the doh regarding the benefits of postgraduate studies related to patient care. authorities such as the doh and the sanc should indicate that postgraduate studies, e.g. a master’s degree, are a prerequisite for leadership positions, and that all those who qualify for master’s studies should be promoted. lastly, there should be collaboration between academic institutions and employers regarding academic programmes that could have an impact on nursing care. conclusion employment and institutional and personal factors were described as barriers experienced by professional nurses to enrolling for postgraduate studies. those who are interested to pursue postgraduate studies, including a master’s degree, fail to enrol owing to various factors in the employment area, coupled with family responsibilities. lack of support and lack of recognition of postgraduate qualifications by authorities, such as government leadership and the sanc, are major barriers to enrolment of professional nurses in postgraduate nursing studies. declaration. none. acknowledgements. the authors would like to acknowledge all nurses who participated in the study to make it a success. we further acknowledge the efforts of final-year nursing students of the university of limpopo, who assisted in the data collection. author contributions. mom: assisted in the initial conceptualisation and the finalisation of the manuscript. tmm: assisted in the second draft and refinement of the manuscript for publication. funding. none. conflicts of interest. none. 1. oermann mh, lynn mr, agg ca. faculty opening shortage and mentoring in the associate degree nursing program. j teach learn nurs 2015;10:107-111. https://doi.org/10.1016/j.teln.2015.03.001 http://dx.doi.org/10.1016%2fj.teln.2015.03.001 march 2020, vol. 12, no. 1 ajhpe 45 research 2. smith an, boyd ld, rogers cm, le jeune rc. self-perceptions of value, barriers, and motivations for graduate education among dental hygienists. j dent educ 2016;80(9):1033-1040. 3. cotterill-walker sm. where is the evidence that master’s level nursing education makes a difference to patient care? j nurse educ today 2010;32:57-64. https://doi.org/10.1016/j.nedt.2011.02.001 4. matthias ad. making the case for differentiation of registered nurse practice: historical perspective meets contemporary efforts. j nurs educ prac 2015;5(4):108-114. https://doi.org/10.5430/jnep.v5n4p108 5. fourie-malherbe m, albertyn r, bitzer e. postgraduate supervision: future foci for the knowledge society. stellenbosch: african sun media, 2016. 6. lakati a, ngatia p, mbindyo c, mukami d, oywer e. barriers to enrolment into a professional upgrading program for enrolled nurses in kenya. pan afr med j 2012;13(1):1-11. 7. kovner ct, brewer c, katigbak c, djukic m, fatehi f. charting the course for nurses’ achievement of higher education levels. j prof nurs 2012;28(6):333-343. https://doi.org/10.1016/j.profnurs.2012.04.021 8. cathro h. pursuing graduate studies in nursing education: driving and restraining forces. j issues nurs 2011;16(3):7. https://doi.org/10.3912/ojin 9. academy of science of south africa. consensus report on phd study. pretoria: assaf, 2010. 10. council on higher education. vital statistics of public higher education. pretoria: che, 2015. 11. hoffman jc, julie h. the academic transitional experiences of master’s students at the university of western cape. curationis 2012;35(1):1-8. https://doi.org/10.4102/curationis.v35i1.33 12. department of nursing science. 2012 2015 report. polokwane: university of limpopo, 2015. 13. brink h, van rensburg g, van der walt c. fundamentals of research methodology for health care professionals. 3rd ed. cape town: juta, 2012. 14. babbie e, mouton j. the practice of social research. cape town: oxford university press, 2009. 15. creswell jw. qualitative inquiry and research design: choosing among five approaches. 2nd ed. thousand oaks, ca: sage, 2014. 16. fang d, bednash gd, arietti r. identifying barriers and facilitators to nurse faculty careers for phd nursing students. j prof nurs 2016;32(3):193-201. https:/doi.org/10.1016/j.profnurs.2015.10.001 17. dam sa. what matters most? factors influencing choice of a student affairs master’s program. master's thesis. lincoln: university of nebraska, 2014. http://digitalcommons.unl.edu/cehsedaddiss/176 (accessed 6 march 2020). 18. matsolo mp, ningpuanyeh wc, susuman as. factors affecting enrolment rate of students in higher education. j asian afr stud 2018;53(1):63-80. https://doi.org/10.1177/0021909616657369 19. lin x. barriers and challenges of female adult students enrolled in higher education: a literature review. high educ stud 2016;6(2):119-126. https://doi.org/10.5539/hes.v6n2p119 20. council of australian postgraduate association. postgraduate reports. melbourne: capa, 2011. 21. fowler gc. students’ progression to post-graduate studies: an exploratory study on demographic attributes among psychology honours students at the university of cape town. cape town: uct, 2013. 22. turki aa, bani-khaled d. factors that influence jordanian efl students’ choice of a university. arab world english j 2014;5(1):247-259. accepted 4 september 2019. https://doi.org/10.1016/j.nedt.2011.02.001 https://doi.org/10.5430/jnep.v5n4p108 https://www.ncbi.nlm.nih.gov/pubmed/?term=kovner ct%5bauthor%5d&cauthor=true&cauthor_uid=23158196 https://www.ncbi.nlm.nih.gov/pubmed/?term=brewer c%5bauthor%5d&cauthor=true&cauthor_uid=23158196 https://www.ncbi.nlm.nih.gov/pubmed/?term=katigbak c%5bauthor%5d&cauthor=true&cauthor_uid=23158196 https://www.ncbi.nlm.nih.gov/pubmed/?term=djukic m%5bauthor%5d&cauthor=true&cauthor_uid=23158196 https://www.ncbi.nlm.nih.gov/pubmed/?term=fatehi f%5bauthor%5d&cauthor=true&cauthor_uid=23158196 https://doi.org/10.1016/j.profnurs.2012.04.021 https://doi.org/10.3912/ojin https://doi.org/10.4102/curationis.v35i1.33 https://doi.org/10.1016/j.profnurs.2015.10.001 http://digitalcommons.unl.edu/cehsedaddiss/176 https://doi.org/10.1177%2f0021909616657369 https://doi.org/10.5539/hes.v6n2p119 36 april 2021, vol. 13, no. 1 ajhpe research the approach to education for medical specialties has universally been postulated as cognitive apprenticeship training to develop novices into experts. this model requires mediation by a mentor, with participation in the community of practice (cop) and learning through situated contexts, each of which places importance on meaningful engagement and a close relationship between the educator and the student.[1-4] the study was set in the context of formal postgraduate students who were training in one of the medical specialty programmes in pathology from 2006 to 2012, offered at 6 medical universities across south africa (sa). the training programme was 4 6 years and students wrote the national exit examination managed by the colleges of medicine of south africa (cmsa). the students, also referred to as registrars, are employed by the service provider as trainees while enrolled with academic departments, and learn from consultants in the same department, who are experts in the field. with cognitive apprenticeship training in this discipline, consultants are the trainers who facilitate registrars’ cognitive development through personal mentoring, using situated learning opportunities and encouraging them to participate in the departmental cop, which is referred to as legitimate peripheral participation.[5] this requires mediating one’s development in the zone where the registrar moves from the previous or current knowledge and capability to another level, closer to the expertise in the discipline mediated by the mentor. far more learning opportunities are provided through informal discussions with peers and consultants when discussing real-life problems occurring during daily service and practice than in a formal setting. learning and development can only be realised in such situations if there is an active engagement between the parties. the need to engage and interact closely places relationships at the centre of the training programme. in some medical specialties, the number of students and consultants is very limited. with the recent dawn of transformation, increased numbers of black students entered medical specialties where most of the consultants were whites and indians. given the landscape of historical divisions with inequalities in sa, developing relationships of learning parties in this context can be challenging. objectives we set out to explore how former postgraduate students conceived the racial and sociocultural diversity in their learning environment; and if, and how, these influenced their relationships with their consultants and peers, and ultimately their learning. henceforth, registrars are referred to as participants. background. the cognitive apprenticeship model is universally recommended for medical specialty training and has been introduced in some clinical disciplines by consultant specialists through the personal coaching of students and participation in the community of practice. in post-apartheid south africa (sa), transformative initiatives gave rise to significant numbers of students from disadvantaged backgrounds in higher education that led to  racial and sociocultural diversity among students and their consultants. most notably, this occurred in medical specialties, where the number of  students  is much smaller than in undergraduate medicine. this stimulated interest in how this landscape may influence the cognitive apprenticeship model. objectives. to explore how former students of a medical specialty discipline conceived the nature of racial and sociocultural diversity in their learning environment and if/how this influenced their relationships with peers and consultants. methods. a qualitative enquiry was conducted with 9 formal postgraduate students (registrars) from 6 universities in sa. data collection was through in-depth individual interviews with open, semi-structured questions. data were analysed, recognising sub-themes and themes, and interpretation was done in a social constructionist approach of epistemology, where the participants and researcher co-construct the concepts. results. participants conceived the sociocultural diversity as personal differences and related their experience of not receiving one-on-one mediation or mentoring to a lack of relationship with the consultants, which was believed to be underpinned by sociocultural differences. power-plays in departmental culture also inhibited the legitimate access and participation of postgraduate registrars in the community of practice, inhibiting their growth of professional expertise. conclusions. cognitive apprenticeship in medical specialty training has specific challenges in the context where postgraduate students and consultants are from societies previously divided by inequalities. common acknowledgement was that learning in collaboration begins with learning to know each other and by forming relationships. students faced challenges seeking professional mentorship, which was conceived as a principal contributing factor in their failure to learn. afr j health professions educ 2021;13(1):36-40. https://doi.org/10.7196/ajhpe.2021.v13i1.1114 significance of relationships in the cognitive apprenticeship of medical specialty training a a khine,1 mmed (chemical pathology), mphil (health sciences education); n hartman,2 phd 1 division of chemical pathology, department of pathology, faculty of medicine and health sciences, national health laboratory service, stellenbosch university, cape town, south africa 2 department of health sciences education, faculty of health sciences, university of cape town, south africa corresponding author: a a khine (ayeaye.khine@nhls.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. april 2021, vol. 13, no. 1 ajhpe 37 research methods the study employed a qualitative enquiry to attempt to unpack the participants’ conceptions around racial and sociocultural diversity of the relevant medical specialty in their learning environment; and if, and how, this influenced the relationships among learning parties. racial profile of participants the sample consisted of postgraduate registrars who were formally in the training programme between 2006 and 2012 at 6 universities in sa. there was a total of 12 registrars, of whom 9 agreed to participate. five of the 9 left the specialty programme unqualified and 4 left as qualified specialists. the researcher’s own department was excluded for ethical purposes. of the 5 who left the programme unqualified, 3 were black south africans, 1 was an sa indian, and the other was an indian childhood immigrant to sa. in the group that qualified, 3 were sa blacks and 1 was an sa indian. gender is not described, as participants used pseudonyms across gender for anonymity. in both groups, participants were trained in their respective departments by consultants who were in the majority white (afrikaans or  english speaking) and sa indians, with 1 sa black consultant and 1 foreign consultant. data collection and analysis participants were interviewed by the researcher/author individually and discretely after obtaining informed consent, agreeing on using self-selected pseudonyms and gender, and keeping the identity of the university of study hidden. participants agreed to disclose their racial identity, as it was crucial information for the purposes of the study. the interviews for each participant were conducted at their chosen place and time, using a standard tool that was approved by the departmental technical committee (department of health sciences education, university of cape town) and the ethics committee. it consisted of semi-structured, open-ended questions that probed the landscape of the learning environment and relationships, with impact on the training and learning (the questions are available from the corresponding author on request). interviews were audio-recorded by the researcher, transcribed by the professional transcriber and coded by the researcher, using deductive and inductive approaches based on the method of thematic analysis.[6] data were interpreted using a social constructionist approach. this method of epistemology was used to build knowledge from the concepts co-constructed by the students as peers through social interactions during their training; co-constructed with the researcher during the interviews; and co-constructed by an independent analyst during analysis. an inductive coding approach provided systematic coverage of data, which was expected, based on the research questions and interview questions, and the deductive approach checked the data that emerged from interviews that were not initially expected. using both at the same time ensured that all data had been covered. together with the social constructionist epistemology, the trustworthiness of the data and interpretations were improved, as the latter affords multiple layers of perspectives with iterative processes of seeking consensus. the researcher was inevitably invested in this study, being one of the trainers in the discipline for many years, but her bias was reduced or controlled by self-awareness and reflexivity throughout the process of planning, interviews, data coding, analysis and interpretation.[7] individual participants received the transcript of their interviews and coding to ensure that their messages were captured correctly and important contributions were not missed in the coding. this is referred to as member checking and improved trustworthiness of the data. an independent co-analyst was employed for reviewing codes, patterns and interpretations. data interpretation was also strengthened by comparing contributions from the participants from contrasting groups (the group that left the programme owing to failures and the group that qualified). ethical approval ethical approval for this study was obtained from the human research ethics committee, faculty of health sciences, university of cape town (ref. no. hrec ref 656/2016). results the interview questions probed into participants’ history of learning (schooling and undergraduate study) as a foreground to the most recent postgraduate study in the relevant medical specialty, as well as family background and their concepts of sociocultural diversity. the participants, from lowto middlesocioeconomic family backgrounds, had lived through the country’s apartheid system. parents of all participants reportedly wished for their children to overcome inequalities and succeed in higher education. some studied at single-race school; others had to adjust at multiracial schools and developed the skill of cross-cultural relationships. nonetheless, they all enjoyed their schooling and fared well in matric. however, most struggled with a language barrier during undergraduate medical studies and faced challenges with social and cultural diversities, which they interpreted as differences. as sa blacks and indians, they experienced being underrated by white consultants during undergraduate medical training, which they felt became more pronounced during postgraduate training owing to fewer students and working closer with consultants. in the following sections, participants are cited (two groups), where their contributions are quoted: the group that qualified and the group that left the training programme unqualified. relationships in the learning environment the relationship between the participants and their consultants was conceived as multiple layers: as student and mentor, student and supervisor in research projects, junior and senior members in the cop, and work colleagues in the same department. most participants reported being treated differently by consultants because of their race, and sociocultural and economic status. the striking phenomenon is that all participants, including those who successfully qualified, experienced these differences; they had relationship issues with consultants; and they constructed that their learning was negatively affected, although 4 managed to navigate these difficulties and succeed. participants expressed the need to be recognised as professionals, given that they were already qualified doctors with some practice experience. this  perception came from the conjecture by their consultants that they were not academically prepared or smart enough to be successful in the course, as a participant reflected: ‘…  we’re labelled as useless people and people who can’t learn anything, so, it broke down our relationships in that respect.’ there was a disjointed expectation between consultants and registrars across both groups. the consultants believed that at a postgraduate level a registrar should self-study and initiate enquiry or ask if they needed assistance. however, the participants felt that they needed consultants to initiate regular supervision and professional mentoring, as highlighted by a participant from the qualified group: ‘it is also important to be guided because the consultants have the experience and they’ve got 38 april 2021, vol. 13, no. 1 ajhpe research knowledge that you’re still trying to find out, so they would be able to guide you better.’ another qualified participant mentioned: ‘the former peers were assuming that there’s continuous learning. they thought there would be continuous contact with a consultant. they realised there wasn’t much contact, it was self-learning, and they left the programme.’ a lack of contact sessions or mediation from consultants led to participants constructing that the consultants had no interest in their learning process, as one participant recalled: ‘…  there’s no consultant that sat with you and looked at results with you, and said, look at this, look at this. one consultant did it initially, but it faded away. it was very brief, and it was rather interrogating. i want to show you that you’re not doing it properly type of attitude. so, it was a very interrogating approach.’ the differences in opinion and expectations created tensions, disconnection with consultants and unhappiness of participants, which persisted throughout the 4 6 years of their training (in the group that left). they felt that they could not solve this disconnection owing to a lack of relationships. a participant in this group highlighted that: ‘we had no relationships, and that was identified as a shortcoming in our training.’ the lack of or strained relationships were also due to restricted contact time with consultants who focused on their own professional growth or agendas, as mentioned by participants. furthermore, participants from both groups felt that initiating contact or approaching consultants was difficult, citing feelings of discomfort that made the interactions with consultants from across cultures challenging. both groups experienced apparent power play within their respective departments among the consultants or between the consultant and the head of department (hod). this contributed to difficulties experienced by the registrars in approaching one consultant over the other, as a participant who left the programme identified: ‘… there was no coherence in the department amongst the [head of department] hod and consultants, it was more like personalities and power struggles.’ interestingly, despite sharing these challenges, participants in the qualified group worked out ways to approach and engage with at least one consultant, either in their department or from the private sector. they also managed to form relationships with peers and consultants from other universities in the same field. this showed that relationships were formed more easily when dealing with consultants from another institution, as there was no history of tension or grudges or preformed ideas against each other. one of the qualified participants advised, ‘…  if somebody feels that it’s not their responsibility to teach you, that’s how they feel about it. there’s nothing they’re going to do. you have to find a way around.’ this participant had worked out that the culture of the department could be navigated. he or she tapped into a consultant’s expertise by initiating enquiry and bringing problems identified during daily service provision to the consultant, with possible solutions. another qualified participant had a different experience, whereby he or she was personally mentored by the hod and had regular formative assessments early on in the training. this participant conceived that the success in forming a relationship with the hod was due to his or her upbringing rooted in showing respect to elders and co-operating with their suggestions. another qualified participant, having been unsuccessful in many attempts, recollected how he or she was noticed by the consultant from the private sector, who was also the external examiner at an exit examination. the consultant examiner noticed the participant’s good behaviour and potential during the examination and offered private mentoring. the participant believed it was his or her obedience and non-confrontational attitude that won the heart of the consultant. at the next exit examination, the participant passed and qualified, and went on to join the mentor in a private business. curriculum, training programme and behavioural factors apart from the conceptions around relationships, there was other important information that emerged from the data, such as lack of awareness regarding the scope, depth and outcomes of the curriculum during the time of training. lack of awareness was not only applicable to registrars, but also to consultants, as the blueprint of the curriculum was only completely mapped out in 2013 for this discipline, and for many other medical specialties it may still be pending. from the contributions, it was noted that the formal training programme at the various departments was highly variable and not all departmental programmes were aligned to what was required for registrars to know before sitting the exit examination. personal mentoring, mediation and participation in the cop, as suggested and mapped out in the cognitive apprenticeship model, did not exist, according to the participants. participants reported a scarcity of opportunities for informal interactions and learning in situatedness that had prevented their development. one participant, an ethnic african-language speaker and second-language english speaker, believed that this was due to a language barrier, with consultants and peers speaking afrikaans during informal discussions: ‘i  now was exposed in an afrikaans environment …  although english was there, it was predominantly afrikaans. i was thrown completely out of my culture. well, mainly it was through the language used during formal or informal learning sessions. language sort of over-ruled or dominated us by exclusion so we were already disadvantaged. the rest is taken after the fact that now we were lost in their discussion. so, we appeared as if we did not know anything – then we became outsiders or less well prepared.’ another participant related: ‘it was a huge shocker. not necessarily because it was a different language, but the fact was the expectation was that i had to know afrikaans for me to learn medicine.’ a participant reported being too slow in answering the consultant’s questions after having to translate into her home language, which made her feel uncomfortable to join discussions: ‘i  talked slowly as i had to translate english to vernacular and back there again and my white peers would answer the questions much faster as it was their mother tongue.’ such incidences hampered participants’ access to situated learning and participation in the cop. as participants from the qualified group provided their recommendations, self-directed learning (sdl) was one of the contributory factors in their success, but with the caution that they needed considerable guidance from the consultants. their construction of sdl was to find alternative ways to reach out and tap into the expertise of at least one consultant who was knowledgeable and skilful in practice. two participants in the qualified group took the initiative in identifying problems and finding solutions, and approached a consultant for further discussion, as one of them expressed: ‘…  you need the consultants to guide you but most of the effort has to come from you, so that at least when you approach them [consultants] with your case, you know that from your side you’ve done your part. i think it would be embarrassing to ask them and you don’t know anything in the background, so better gather the information.’ furthermore, there were behavioural expectations from the consultants, i.e.  submissiveness and obedience, reported by both groups. however, registrars in the group that left felt that they should have maintained being assertive, whereas those in the group that qualified believed in adjusting to april 2021, vol. 13, no. 1 ajhpe 39 research what was expected by the consultants – at least for a period of the training. participants in both groups believed that these demands were underpinned by power and control issues from the consultants, which strained the relationships. the findings highlight that the feelings of sociocultural differences, assumptions rooted in these differences, choice of language use, especially in the informal discussions, disjointed expectations, as well as behaviour diversity, are intricately related to strained relationships and ultimately to loss of learning opportunities. discussion the social domain of the cognitive apprenticeship model plays a pivotal role in social and cultural engagement between the registrar and consultant for facilitating learning and development into professions.[1] this promotes internalisation of the discipline-specific culture and skills to a level closer towards expertise, thus preparing registrars for the expected outcomes. in this model, coaching by the expert is related strongly to the mediation in the  zone of proximal development by vygotsky,[8] which requires the mentor to know and understand the weaknesses and strengths of the novice registrar to grow in their potential. learning in situated contexts can only occur if students participate in the problem-solving processes and contributions in the cop. through participation and mediation, the cultures of the discipline and attitude of the profession are transferred. responding to the difficulties expressed, qualified participants had relied heavily on sdl and peer learning, given the scarcity of opportunities to learn from their senior consultants. realising that they needed a consultant to guide them with sdl, they managed to navigate the power-plays in their departmental culture and initiate engagement with at least one consultant who was impressed with their persistence. this experience agrees with the notion of sdl that recently emerged as requiring guidance from more knowledgeable others in a facilitative environment, as shown in the recent literature, where one of the articles is a meta-analysis review.[5,9,10] qualified participants had realised that it is possible to adjust to what is expected of them, at least for the period of their training, to be accepted by the cop to improve their chances of success. in the eyes of participants who left the programme unsuccessfully, the lack of day-to-day supervision and coaching by not having a mentoring relationship led to their failure to progress in their studies. cruess et al.[2] claim that the attributes  of the trainer as an effective role model are  compassion, honesty and integrity. equally important is an ability to maintain interpersonal relationships, showing enthusiasm for practice and teaching,  and an unwavering effort to  thrive for excellence. the authors cautioned that institutions tend to accept situations where clinical staff members are overworked, which leads to insufficient time for coaching and mentoring. a lack of institutional support for such activities also contributes to students and clinical teachers failing to form relationships. vygotsky’s[8] concept of mediation focuses on the sociocognitive process of conceptual development, although there is no emphasis on the personal differences between mentor and mentee. another theorist, bandura,[11] stressed the importance of a continuous interaction between people in the learning environment, their behaviours and personal factors, as well as their cognition. he referred to this interactive environment as a reciprocal causation model highlighting their effects on one another. lave and wenger[12,13] explain the effects of power relations within the cop and how these impact on participation and contributions. registrars and consultants work together as colleagues on a daily basis, and their social interactions constitute learning in situatedness and problem solving that are critical for professional development, culture and attitudes of the profession, and the road map towards expertise of the discipline. lack of understanding, encouragement or mediation can lead to feelings of alienation. bezuidenhout et  al.,[3] in their sa study, reported alienation and lack of engagement perceived by novice registrars in a postgraduate education programme. the authors constructed that the source of feeling alienated could be due to the lack of relationships that students expected to experience, but did not get an opportunity to develop. relationships have emerged as being significant in the development of participants in this study. this relates to the theory of the human development concept that mental capacity and a sense of self-confidence develop due to the continuous process of communication and relationship formation.[14] relationships are vehicles for learning to develop cognitively, provide opportunities for student and teacher to engage by sharing conversations and experiences, and understanding each other’s cultural identities, which may allow both parties to navigate training and learning in the complex social environment.[15] bradbury[16] stressed that the mentor should understand and respect the level of development of the novice, evaluate their beliefs regarding learning, recognise the significance of their prior learning and contribution as a source of knowledge, and use the expertise of self and student in developing new ideas. this reflects reciprocity and interdependence in their relationship. findings in this study, together with the literature, show the importance of co-operative learning that equips both consultant and registrar for work-place collaboration, fostering relationships and cultivating initiatives in enquiry in medical specialties. reflecting on these theories illuminates how, in this study, the lack of relationships influenced learning negatively, while it also assisted in explaining how the few participants that were mentored, secured their learning and succeeded through their relationships with their mentors. reflections at the protocol stage and during data collection, race was used as a major construct, as it is in sa’s higher education arena. it was therefore relevant to be included in this study. however, data revealed that there were other factors that influenced relationships, such as personalities. this was more apparent during discussions with participants from the qualified group, who constructed race as not being a sole factor for the lack of relationships. thus, the study was framed as a doubled-research approach: firstly, the study problem with a strong racial construct, and then it considered interpretations towards deracialising, rather than the mid-stream method described by muzzin and mickleborough.[17] study limitations nine of 12 participants were registered during 2006 2012 for the discipline of pathology in sa. although the sample size may seem small, it comprised 75% participation as purposeful sampling. the study excluded consultants of the same departments to protect identities of participants, and therefore could not triangulate the data from their perspectives. a  further study is recommended to interview the consultants. moreover, the findings may only be relevant for the abovementioned training period, as the curriculum was established in 2013 and in some departments training programmes might have been updated. as it has been a number 40 april 2021, vol. 13, no. 1 ajhpe research of years since the study was conducted and much progress has been made in terms of decolonising the curriculum, as well as improving racial relationships, it is hoped that current students are not experiencing the dynamics described in this article. conclusion in the context of post-apartheid transformation in sa, students in medical specialties from a previously disadvantaged background may perceive that divisions are still apparent in their training. when students immerse in an environment where they perceive they are treated differently, relationships can be threatened. lack of relationships with mentors can have a negative impact on learning and professional development, as the opportunities for cognitive apprenticeship are lost. providing workshops with activities towards cross-cultural immersion should be part of training for consultants and registrars to foster relationships. a mentor should be identified for each registrar at the time of joining the programme. the  number of registrars per mentor consultant should be established by  the health professions council of sa and the employer, and they should be aware of the importance of relationships in medical specialty training to ensure the success of all trainees. declaration. none. acknowledgements. we thank the study participants for their valuable contributions. author contributions. aak collected and analysed the data and drafted the manuscript and nh made inputs. funding. none. conflicts of interest. none. 1. collins a. cognitive apprenticeship. in: sawyer rk, ed. the cambridge handbook of the learning sciences. cambridge: cambridge university press, 2006:47-60. 2. cruess sr, cruess rl, steinert y. role modelling: making the most of a powerful teaching strategy. bmj 2008;336:718-721. https://doi.org/10.1136/bmj.39503.757847.be 3. bezuidenhout j, cilliers f, van heusden m, wasserman e, burch v. alienation and engagement in postgraduate training at a south african medical school. med teach 2011;33(3):e145-e153. https://doi.org/10.3109/014215 9x.2011.543198 4. genzen jr, krasowski md. resident training in clinical chemistry. clin lab med 2007;27(2):343-358. https://doi. org/10.1016/j.cll.2007.03.007 5. couper i, town c. self-directed learning in educating health professionals: a scoping review of the literature. teaching advancement at university (tau) fellowships programme. 2016. http://heltasa.org.za/wp-content/ uploads/2016/10/tau-project-report-rev-ian-couper-final.pdf (accessed 24 november 2020). 6. braun v, clarke v. thematic analysis. in: cooper h, ed. the apa handbook of research methods in psychology, vol. 2. research designs. washington, dc: american psychological association, 2012:57-91. 7. lincoln y, guba e. ethics: the failure of positivist science. rev high educ 1989;12(3):221-240. https://doi. org/10.1353/rhe.1989.0017 8. vygotsky ls. interaction between learning and development. in: mind and society. cambridge, ma: harvard university press, 1978:79-91. 9. knowles ms. self-directed learning: a guide for learners and teachers. new york: association press, 1975. 10. bok hg, teunissen pw, favier rp, et al. programmatic assessment of competency-based workplace learning: when theory meets practice. bmc med educ 2013;13:1-10. https://doi.org/10.1186/1472-6920-13-123 11. bandura a. social cognitive theory. in: vasta r, ed. annals of child development. vol. 6. greenwich, ct: jai press, 1989:1-60. 12. lave j, wenger e. situated learning: legitimate peripheral participation. in: pea r, brown js, eds. learning in doing. cambridge, ma: cambridge university press, 1991:95. https://doi.org/10.1017/cbo9780511815355 13. wenger e. communities of practice and social learning systems: the career of a concept. in: blackmore c, ed. social learning systems and communities of practice. berlin: springer verlag and milton keynes: open university, 2010. 14. fogel a. developing through relationships. chicago: university of chicago press, 1993. 15. goodman s. the importance of teaching through relationships. 2015. https://www.edutopia.org/blog/importanceteaching-through-relationships-stacey-goodman (accessed 24 november 2020). 16. bradbury lu. educative mentoring: promoting reform-based science teaching through mentoring relationships. sci educ 2010;94(6):54-71. https://doi.org/10.1002/sce.20393 17. muzzin l, mickleborough t. what does ‘race’ have to do with medical education research? med educ 2013;47:760-767. https://doi.org/10.1111/medu.12186 accepted 16 january 2020. https://doi.org/10.1136/bmj.39503.757847.be https://doi.org/10.3109/0142159x.2011.543198 https://doi.org/10.3109/0142159x.2011.543198 https://doi.org/10.1016/j.cll.2007.03.007 https://doi.org/10.1016/j.cll.2007.03.007 http://heltasa.org.za/wp-content/uploads/2016/10/tau-project-report-rev-ian-couper-final.pdf http://heltasa.org.za/wp-content/uploads/2016/10/tau-project-report-rev-ian-couper-final.pdf https://doi.org/10.1353/rhe.1989.0017 https://doi.org/10.1353/rhe.1989.0017 https://doi.org/10.1186/1472-6920-13-123 https://doi.org/10.1017/cbo9780511815355 https://www.edutopia.org/blog/importance-teaching-through-relationships-stacey-goodman https://www.edutopia.org/blog/importance-teaching-through-relationships-stacey-goodman https://doi.org/10.1002/sce.20393 https://doi.org/10.1111/medu.12186 december 2018, vol. 10, no. 4 ajhpe 205 research medical research as a component of undergraduate medical training is a very crucial aspect that has the potential of developing certain skills in students. these skills would serve as a means of improving the standard of healthcare that the students deliver after graduation by means of the generation of new scientific findings and introduction of good clinical practice.[1,2] clinicians who are engaged in research in the field of medicine are often referred to as physician-scientists.[3] the literature suggests that there has been a steady decline in the number of physician-scientists worldwide, who are very difficult to replace. some of the reasons for this decline have been attributed to the absence of good training programmes, unattractive careers in clinical research, and inadequate exposure to research at an early stage of the medical curriculum.[3-5] the need for more physicianscientists has resulted in the rapid expansion of medical research-related courses at several medical schools. this trend should expose undergraduate medical students to medical research-related courses at an early stage in their medical education, with emphasis on acquisition of skills, knowledge and attitudes rather than factual learning. all these would lead to students developing the habit and skills of active inquiry, which are inculcated for life.[4,6,7] furthermore, various studies have shown that medical students who were enthusiastic about medical research during training developed an interest in research after graduation. these doctors most likely fill the void of physician-scientists in the future.[2,4.8] courses in evidence-based medicine, which are crucial in clinical practice, have also been introduced into the medical curriculum, together with epidemiology, research methods and journal article critique at some south african (sa) universities.[9-11] these courses have been shown to improve students’ competencies at undergraduate level.[9-11] according to the literature, there is sufficient evidence that medical curricula in sa medical schools have been through significant renewal in the past decade.[7,9-12] some of the outcomes include the early exposure of students to medical research as part of the modernisation of the undergraduate medical curriculum.[7] there is a strong indication that the quality of doctors would be highly influenced by this renewed curriculum.[7,13] despite all the recent innovation regarding medical curricula in sa, a review of the literature showed very little information on the knowledge and attitudes of medical students in sub-saharan africa towards medical research. therefore, this study was designed to describe the knowledge and attitudes of a sample of undergraduate medical students at a sa university with regard to medical research. methods study design and setting this was a descriptive, cross-sectional observational study conducted among medical students at sefako makgatho health sciences university (smu), pretoria, sa, one of eight public-funded medical schools in sa that provides training to medical, dental and other allied healthcare professionals.[14] the university offers a 6-year undergraduate medical programme that has adopted the innovative case-based learning (cbl) background. the early introduction of medical students to medical research-related courses is one of the innovative solutions devised by medical schools to address the dearth of physician-scientists. objective. to describe the knowledge and attitudes of medical students towards medical research at a medical school where research and measurement skills are taught from the first year of study. methods. a validated, pretested self-administered questionnaire was employed in a cross-sectional study to collect data from 228 thirdand fourthyear medical students at sefako makgatho health sciences university (smu), pretoria, south africa in april 2017. knowledge of medical research was assessed with a 15-item questionnaire, and attitude towards research was measured with a 10-item scale. the data were analysed with epi info (centers for disease control and prevention, usa) and findings are presented as means, percentages, proportions and tables. the χ2 test was used to assess association among the variables, with p<0.05 considered significant. results. the mean age of the 228 participants was 22.7 (standard deviation 2.55) years, with ages ranging between 19 and 36 years; 66.2% were female. although only a few (22%) had prior research experience and less than half (36%) were confident to interpret medical research, the mean score on research knowledge was 73% and a positive attitude towards research was demonstrated. statistical significance was found between having previous research experience and ability to interpret medical research (χ2=12.8; p=0.01), and between age and having previous research experience (χ2=35.7; p=0.01). conclusion. the findings revealed a good knowledge and positive attitude to medical research among the students. all these outcomes are the result of early exposure to medical research. more research-based courses are recommended for medical students, without overloading the medical curriculum. afr j health professions educ 2018;10(4):205-209. doi:10.7196/ajhpe.2018.v10i4.1022 knowledge and attitudes of undergraduate medical students with regard to medical research at a south african university a o adefolalu, mb chb, mph, phd; n j mogosetsi, bsc hons, mb chb, dip hiv man (sa), mmed (fam med), fcfp (sa), pgdip (hpe); n m mnguni, mb chb, doh practice of medicine unit, school of medicine, sefako makgatho health sciences university, pretoria, south africa corresponding author: a o adefolalu (adegoke.adefolalu@smu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 206 december 2018, vol. 10, no. 4 ajhpe research approach in the teaching and learning of undergraduate medical students. the cbl approach as an educational strategy adopted at smu stresses that students develop lifelong self-directed learning skills, construct an extensive and flexible knowledge base and effective problem-solving skills. various aspects of research and measurement skills are taught from the first to the sixth year of study. this gives the students the opportunity of being exposed to courses in research methods, referencing styles, epidemiology, evidencebased medicine and clinical audits and how to critique scientific journal articles. the introduction of these skills is in line with new trends in medical education worldwide as a response to the abovementioned decline in the number of physician-scientists.[3,5,7] sampling the researchers sampled the thirdand fourth-year students owing to their accessibility and attributes; they had already been exposed to some of the research and measurement skills in their previous years of study. nonprobability sampling was deemed feasible because the firstand second-year students were being taught courses on which the study questionnaires were based and were therefore not suitable. the fifthand sixth-year students were in their clinical rotations in different training settings; therefore, it would have been difficult to do a cross-sectional study involving them. at the time of the research there were ~500 medical students in both the third and fourth years of study. convenience sampling was used for an equal number of participants from both classes; the data were not contaminated. the prevalence of adequate knowledge was estimated at 50% or 0.5, with an absolute error of 0.05. a total of 218 students were required based on finite correction. a ~5% non-response rate was added, making the final sample 230 students. data collection a self-administered closed-ended questionnaire was designed after a thorough literature review. it had been pre-tested in 10 medical students in their fifth year of study, who were not part of the final participants selected for the study, and subsequently amended for both clarity and content validity. the fifth year was used for this purpose, because convenience sampling was to be used during data collection and the researchers did not want to contaminate the data. it would have been difficult to exclude thirdor fourth-year students during data collection. the questionnaire contained information with regard to knowledge and attitude of medical students towards medical research. data collection was done in mid-april 2017 during lectures, when the majority were in attendance. questionnaires (n=115) were handed out at each class, i.e. a total of 230. these were distributed to all consenting students who were present at class lectures; no randomisation was done. the researchers handed out 115 questionnaires to students, which they returned after completion. ethical approval ethical approval was obtained from the smu research and ethics committee (ref. no. smurec/m/186/2016) and all the participants gave signed, written informed consent before participating in the study. study variables demographical data, such as age, gender and prior research experience, were collected. knowledge of medical research was measured using a 15-item multiple-choice questionnaire. each question had 5 options and 1 correct answer (a e). the attitude towards research was assessed with a 10-item scale with 3 options, i.e. ‘yes’, ‘no’ or ‘undecided’. examples of questions are as follows: ‘do you feel confident in interpreting a medical research article?’; and ‘do you think that medical research ethics is relevant and important?’ statistical analysis all the returned questionnaires, except 2, were completed, which were returned almost blank, with the respondents completing only the demographic data. these 2 questionnaires were excluded from the rest and a total of 228 questionnaires were collated, captured and analysed. the collected data were cleaned, checked for errors and captured onto an excel spreadsheet initially. the data were subsequently analysed using epi info (centers for disease control and prevention, usa). descriptive statistics were done, and data were presented using frequencies, means, standard deviations, proportions and percentages, as appropriate. the assessed students’ knowledge of medical research was analysed and compared across age, gender, prior research experience and ability to interpret a journal article. the χ2 test was used to assess the association among the variables and a critical p=0.05 was regarded as statistically significant. results the mean age of the 228 participants was 22.7 (standard deviation (sd) 2.55) years, mode was 20 years and median was 22 (range 19 36) years. as shown in table 1, in terms of gender distribution, 77 (33.8%) were male and 151 (66.2%) were female. table 2 indicates the response of medical students to knowledge of medical research. the mean score on the 15-item questionnaire that assessed research knowledge was 73%, while the expected average score for each question was 70%. therefore, if the participants’ mean score was >70% in any of the 15 questions, it is described as having good knowledge of that question. the result indicates that participants performed well in 10 of the 15 questions (i.e. scored >70%). they performed poorly in the question regarding the best study design that allows for causality; the correct answer was a randomised controlled trial (˂10% of participants answered the question correctly). the other question where the participants did not do well was to differentiate various types of observational studies – ˂50% answered this correctly. table 3 depicts the students’ responses to their attitudes toward medical research. in most cases the majority agreed that the inclusion of research article critique skills in the medical curriculum is important (91%); evidence-based medicine is relevant and important (91%); and medical research ethics is relevant and important (94%). table 1. characteristics of participants (n=228) characteristics participants age (years), mean (sd) 22.7 (2.55) sex, n (%) male female 77 (33.8) 151 (66.2) previous research experience, n (%) yes no 50 (22) 178 (78) ability to interpret research, n (%) yes no 81 (36) 147 (64) sd = standard deviation. december 2018, vol. 10, no. 4 ajhpe 207 research the mean scores on research knowledge of the thirdand fourth-year medical students were compared; there was no statistically significant difference (p>0.05). the average score on research knowledge was 73.4% and 72.6% (p>0.05) for thirdand fourth-year students, respectively. table 4 shows the segregation of participants with a positive attitude towards medical research. there were no major differences between the thirdand fourth-year students across the questions that assessed their attitudes towards research, except in the area of research exposure, where 54% of fourth-year students and 46% of third-year students had previous experience. the χ2 test of association was applied to some of the variables to establish whether there is an association between them, but there was no statistically significant association between age and ability to interpret medical research (χ2=10.6; p=0.10), between gender and ability to interpret medical research (χ2=2.9; p=0.24), between gender and having previous research experience (χ2=1.71; p=0.42) and between having previous research experience and table 2. participants’ knowledge scores of medical research (n=228) knowledge correctly answered, n (%) the focus of epidemiological studies is on … ? 224 (98.0) sampling in research reflects … ? 211 (92.5) the following are types of observational studies, except … ? 111 (48.7) the ability of a screening test to correctly identify individuals who don’t have the disease is called … ? 125 (54.8) in the hierarchy of evidence, what method gives the most reliable evidence? 204 (89.5) the constraints or problems faced by researchers in the study are known as … ? 208 (91.0) we do literature review in research to know … ? 149 (65.4) the most frequently occurring observation in a data set is … ? 186 (81.6) in medical research articles, an abstract is … ? 165 (72.4) outline of a scientific report include the following, except … ? 167 (73.3) the study design is most useful in investigating causality between exposure and outcome 19 (8.3) prevalence of a disease refers to … ? 180 (79.0) which one of the following is used to reduce bias in a study … ? 209 (91.7) the confidence interval is … ? 138 (60.5) which one of the following is not an acceptable ethical standard in medical research? 180 (79.0) table 3. participants’ responses with regard to attitude towards medical research (n=228) responses yes, n (%) no, n (%) undecided, n (%) do you feel confident in interpreting a medical research article? 81 (35.5) 80 (35.1) 67 (29.4) do you think that the epidemiology block is relevant and important? 182 (79.8) 30 (13.2) 16 (7.0) do you think that the epidemiology block is appropriately placed in first year? 134 (58.8) 76 (31.6) 22 (9.6) do you think that medical research article critique is relevant and important? 207 (90.8) 11 (4.8) 10 (4.4) do you think that the research article critique block is appropriately placed in second year? 165 (72.4) 45 (19.7) 18 (7.9) do you think evidence-based medicine is relevant and important? 207 (90.8) 10 (4.4) 11 (4.8) do you think that evidence-based medicine is appropriately placed in third year? 173 (75.9) 29 (12.7) 26 (11.4) do you think that medical research ethics is relevant and important? 214 (93.9) 4 (1.8) 10 (4.4) do you think undergraduate students should undertake research activity? 138 (60.5) 51 (22.4) 39 (17.1) do you have previous exposure to research, except at undergraduate level at medical school? 50 (21.9) 175 (76.8) 3 (1.3) table 4. comparison of attitude towards medical research between thirdand fourth-year students answer: yes attitude third year, n (%) fourth year, n (%) do you feel confident in interpreting a medical research article? (n=81) 42 (52) 39 (48) do you think that the epidemiology block is relevant and important? (n=182) 90 (49) 92 (51) do you think that the epidemiology block is appropriately placed in first year? (n=134) 70 (52) 64 (48) do you think that medical research article critique is relevant and important? (n=207) 100 (48) 107 (52) do you think that the research article critique block is appropriately placed in second year? (n=165) 85 (52) 80 (48) do you think that evidencebased medicine is relevant and important? (n=207) 100 (48) 107 (52) do you think that evidence-based medicine is appropriately placed in third year? (n=173) 86 (50) 87 (50) do you think that medical research ethics is relevant and important? (n=214) 103 (48) 111 (52) do you think undergraduate students should undertake research activity? (n=138) 69 (50) 69 (50) do you have previous exposure to research, except at undergraduate level at medical school? (n=50) 23 (46) 27 (54) 208 december 2018, vol. 10, no. 4 ajhpe research belief in the importance of medical research (χ2=2.8; p=0.58). using the χ2 test, a statistical significance was found between having previous research experience and ability to interpret medical research (χ2=12.8; p=0.01) and between age and having previous research experience (χ2=35.7; p=0.01). discussion this study showed that the participants had a good knowledge of medical research, which differs greatly from similar studies among pakistani and croatian medical students, where the mean score on medical research knowledge was poor.[4,15] however, the medical students in both studies showed a positive attitude towards medical research.[4,15] in another sa study, the majority of medical students also demonstrated a positive attitude towards medical research, and almost the same proportion of these participants and those in the current study had similar research experience.[6] one would have expected the fourth-year students to have a higher average score than those in their third year, but the current study revealed otherwise. the reason could be that the third-year students might have found it easier to recall the answers to some of the questions on research knowledge than those in the fourth year. the questions on medical research were based on medical research-based courses, which are offered in the first and second year of study at smu. having previous research experience was found to be associated with the ability to interpret medical research; this is highly suggestive of the assertion that students who had prior research experience are better placed to understand the concepts of medical research than others. the association between age and having previous research experience points to older students being likely to have had previous research experience. as mentioned above, there is growing concern globally among clinical scientists about the dearth of physician-scientists, who are saddled with the responsibility of generating new clinical knowledge that we use in the practice of medicine through cutting-edge research.[3,7] the consequences for clinical practice would be lack of quality research, which is necessary for the delivery of evidence-based medical care.[5,7] fortunately, a good number of medical schools have already responded to this with the early introduction of research courses into their medical curriculum, together with encouragement of student participation in research activities during their medical training.[7,9-11] all of this is done to foster favourable attitudes towards medical research among students.[3,6,7,9-11] anecdotal evidence suggests that this innovation has improved knowledge and attitudes of students regarding medical research significantly, as shown in the current study.[9-11] furthermore, earlier studies that attempted to determine the level of knowledge and attitudes of medical students towards research revealed that students who have been involved in research activities performed academically well during their postgraduate studies.[4,7,13] therefore, medical research forms an important aspect of undergraduate medical education that is highly relevant to any doctor who seeks to practise medicine, where there is an ever-increasing body of information in the field of medicine globally.[3,7] having a good grasp of scientific methodology is vital to future doctors, who have to understand the principles of scientific research, develop skills necessary to collect data, and analyse and subsequently disseminate knowledge in a form of a research article in a peer-reviewed journal.[7,8,11,16] furthermore, the vast amount of available information in various medical disciplines implies that these future doctors need to be able to evaluate and critique medical research articles to apply best evidence in their clinical practice, as informed by research.[7,13] as shown in our study, medical students have a positive attitude towards research, but very few are able to confidently interpret a research article at this stage. they were in third and fourth year at the time of the study – their performance will possibly improve as they proceed to fifth and sixth year. therefore, their good knowledge and positive attitude are most likely a consequence of their early exposure to research-related courses. conclusion although very few of the students had research experience before entering medical school and a minority were fully confident of interpreting scientific journal articles, the majority agreed that undergraduate medical students should be involved in research activities. the research and measurement skills taught at an early stage of medical training are aimed at developing critical thinking and reasoning skills.[3,7] it also enables them to develop a positive attitude towards medical research from a very early stage of their career, with the hope that some would become physician-scientists after graduation.[3,7] in view of the abovementioned reasons, it is therefore important to inculcate critical thinking and a positive attitude towards research into medical students at an early stage in their training by a variety of research and measurement courses.[3,7,10,13] epidemiology, public health, health systems, research methods, evidencebased medicine and journal article critique are some of the research and measurement courses being offered at some of sa universities.[7,9,10-12] it is highly recommended that these form part of the undergraduate medical curriculum at all medical schools. future studies into research and measurement skills knowledge among medical students are also needed, which should use a larger multicentred design and consider a longitudinal study that will measure variables over time. study limitations our study was limited by its cross-sectional design. causation is difficult to establish in cross-sectional studies, and a longitudinal study could have allowed for the assessment of students’ knowledge and attitudes over time. recall or memory bias is a problem when outcomes being measured require that subjects recall past events. often a person recalls positive events more easily than negative ones. this limitation was minimised by affording the participants enough time to recall information required to complete the questionnaires. the study was conducted in only one medical school; the findings should therefore be interpreted with caution in terms of generalising these to other medical schools. declaration. none. acknowledgements. the authors would like to thank all medical students who participated in the research, as well as the management of sefako makgatho health sciences university that granted permission to conduct the study. the authors gratefully acknowledge the contribution of devon hough (medical student, smu) for capturing the data. author contributions. aoa and njm: study conception and design; njm and nmm: data collection; aoa: data analysis, data interpretation and drafting of the initial manuscript; and njm and nmm: review and revision of the manuscript for important intellectual content. all three authors reviewed and agreed on the final version of the article before submission. funding. none. conflicts of interest. none. december 2018, vol. 10, no. 4 ajhpe 209 research 1. hmelo-silver ce. problem-based learning: what and how do students learn? educ psychol rev 2004;16(3):235-266. https://doi.org/10.1023/b:edpr.0000034022.16470.f3 2. prideaux d. curriculum development in medical education: from acronyms to dynamism. teach teach educ 2007;23:294-302. https://doi.org/10.1016/j.tate.2006.12.017 3. mayosi bm, dhai a, folb p, et al. consensus report on revitalising clinical research in south africa: a study on clinical research and related training. pretoria: academy of science of south africa, 2009. http://www.assaf. co.za/wp-content/uploads/2009/09/assaf-clinical-report-2009.pdf (accessed 10 february 2018). 4. khan h, khawaja m, waheed a, et al. knowledge and attitudes about health research among a group of pakistani medical students. bmc med educ 2006;6:54. https://doi.org/10.1186/1472-6920-6-54 5. neilson eg. the role of medical school admissions committees in the decline of physician-scientists. j clin invest 2003;111(6):765-767. https://doi.org/10.1172/jci200318116 6. nel d, burman rj, hoffman r, randera-rees s. the attitudes of medical students to research. s afr med j 2014;104(1):32-36. https://doi.org/10.7196/samj.7058 7. seggie jl. mb chb curriculum modernisation in south africa – growing doctors for africa. afr j health professions educ 2010;2(1):8-14. 8. pugsley l, mccrories p. improving medical education: improving patient care. teach teach educ 2007;23(3):314322. https://doi.org/10.1016/j.tate.2006.12.023 9. burger m, louw qa. integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: reflections on a new approach. afr j health professions educ 2014;6(2 suppl 1):198-202. https://doi.org/10.7196/ajhpe.516 10. knight se, van wyk jm, mahomed s. teaching research: a programme to develop research capacity in undergraduate medical students at the university of kwazulu-natal, south africa. bmc med educ 2016;16:61. https://doi.org/10.1186/s12909-016-0567-7 11. dudley ld, young tn, rowher ac, et al. fit for purpose? a review of a medical curriculum and its contribution to strengthening health systems in south africa. afr j health professions educ 2015;7(1 suppl 1):81-85. https:// doi.org/10.7196/ajhpe.512 12. reid s. the ‘medical humanities’ in health sciences education in south africa. s afr med j 2014;104(2):109-110. https://doi.org/10.7196/samj.7928 13. van der merwe lj, van zyl g j, st clair gibson a, et al. south african medical schools: current state of selection criteria and medical students’ demographic profile. s afr med j 2016;106(1):76-81. https://doi.org/10.7196/ samj.2016.v106i1.9913 14. health professions council of south africa. medical and dental education and training. http://www.hpcsa.co.za/ pbmedicaldental/education (accessed 15 february 2018). 15. vodopivec i, vujaklija a, hrabak m, et al. knowledge about and attitude towards science of first year medical students. croat med j 2002;43:58-62. 16. noorelahi mm, soubhanneyaz aa, kasim ka. perceptions, barriers, and practices of medical research among students at taibah college of medicine, madinah, saudi arabia. adv med educ pract 2015;6:479-485. https:// doi.org/10.2147/amep.s83978 accepted 27 march 2018. https://doi.org/10.1023/b:edpr.0000034022.16470.f3 https://doi.org/10.1016/j.tate.2006.12.017 http://www.assaf.co.za/wp-content/uploads/2009/09/assaf-clinical-report-2009.pdf http://www.assaf.co.za/wp-content/uploads/2009/09/assaf-clinical-report-2009.pdf https://doi.org/10.1186/1472-6920-6-54 https://doi.org/10.1172/jci200318116 https://doi.org/10.1016/j.tate.2006.12.023 https://doi.org/10.7196/ajhpe.516 https://doi.org/10.1186/s12909-016-0567-7 https://doi.org/10.7196/ajhpe.512 https://doi.org/10.7196/ajhpe.512 https://doi.org/10.7196/samj.7928 https://doi.org/10.7196/samj.2016.v106i1.9913 https://doi.org/10.7196/samj.2016.v106i1.9913 http://www.hpcsa.co.za/pbmedicaldental/education http://www.hpcsa.co.za/pbmedicaldental/education https://doi.org/10.2147/amep.s83978 https://doi.org/10.2147/amep.s83978 december 2018, vol. 10, no. 4 ajhpe 210 research dr margaret chan, director-general of the world health organization (who), is in support of activities associated with the ‘transforming and scaling up of health professionals’ education and training’.[1] globally, there is a health workforce crisis in terms of human resource shortages, as well as an imbalance in the skills mix.[1] this imbalance is not only applicable to students and graduates, but also to employed radiography professionals.[2] enhancing or improving the skills mix has to be a lifelong learning practice for employed radiographers because they need to stay informed of the current changes in the health services environment.[3] one of the ways in which this can be achieved is for individuals to engage in continuing professional development (cpd) activities.[4] ‘the south african health professions act, 1974 (act no. 56 of 1974) (as amended) endorses cpd as the means for maintaining and updating professional competence, to ensure that the public interest is always promoted and protected, as well as ensuring the best possible health care service to the community.’[5] the health professions council of south africa (hpcsa) cpd guidelines[5] highlights that cpd activities must be pertinent to the health priorities of the country and focus on the emerging health needs of the population. therefore, the hpcsa implemented a cpd programme to ensure consistent and continuous commitment to lifelong learning by all health professionals. during the course of 1 year a total of 30 continuing education units (ceus) must be accumulated, 5 of which must be related to ethics, human rights and medical law. the hpcsa conducts random mandatory audits to ensure compliance with the cpd programme. it has been noted, however, that >50% of radiographers and clinical technologists (rcts) who were audited from july 2009 to january 2013 were considered non-compliant (appendix*). non-compliance is the failure of a healthcare professional to meet their annual cpd requirements.[5] non-compliance is of great concern, as it may result in a radiographer enduring penalties or even being suspended from the hpcsa register. radiographers who are non-compliant may experience challenges. there needs to be an understanding of these perceived challenges encountered by healthcare professionals to have effective educational and training programmes that support professional development.[6-10] the most common challenges that have been identified in the literature include, but are not limited to, lack of cpd awareness, funding, time, employer support and increased family commitments. reasons for non-compliance among radiographers in kwazulu-natal (kzn) province, sa, are unknown and the literature on cpd compliance by radiographers in sa is scarce. the aim of this study was to identify the opinions and challenges related to cpd compliance by radiographers working in kzn and to ascertain their suggestions for improvement to cpd practices for recommendations to the hpcsa. methods this research followed a quantitative, descriptive and cross-sectional research design. background. continuing professional development (cpd) was introduced as a method to ensure that healthcare professionals continuously update their knowledge and skills. in south africa (sa), cpd has been adopted as a mandatory requirement by the health professions council of sa (hpcsa) for all registered healthcare professionals. however, despite cpd being mandatory, a number of healthcare professionals nationally are still non-compliant. hence, research was conducted to determine the reasons for non-compliance. objective. to identify the opinions and challenges related to cpd compliance by radiographers working in kwazulu-natal (kzn) province, sa. methods. a positivist paradigm and cross-sectional research design were used. the methodology was quantitative and the measuring instrument was a survey questionnaire. the majority of questions were closed-ended and a few were open-ended. the latter questions allowed participants to make suggestions and give opinions freely. radiographers from all four disciplines in radiography, working in kzn, were included in this study. quantitative data were analysed using spss version 23.0 (ibm corp., usa). open-ended questions were assessed qualitatively by means of coding and thematic analysis. results. this study revealed that the two most common challenges experienced by kzn radiographers were lack of time and the inability to attend cpd activities owing to shift work. the majority of participants acknowledged the importance of cpd; however, most indicated engagement with cpd only because of mandatory requirements by the hpcsa. this could imply a need to review the effectiveness of the current cpd processes. conclusion. in a profession such as radiography, which is constantly evolving and progressing, the need for cpd is indisputable. it is evident from the findings of this study that kzn radiographers acknowledge the importance and value of cpd in their profession. however, they experience a number of challenges that negatively affect their cpd participation. these challenges need to be addressed to ensure that the aim of cpd is achieved. afr j health professions educ 2018;10(4):210-214. doi:10.7196/ajhpe.2018.v10i4.1001 continuing professional development opinions and challenges experienced by radiographers in kwazulu-natal province, south africa k naidoo,1 mhsc: radiography, btech: radiography (d), ndip: radiography (d); s naidoo,2 masc (mrt), btech: radiography (nm) 1 department of medical imaging and radiation sciences, faculty of health sciences, university of johannesburg, south africa 2 department of dental science, faculty of health sciences, durban university of technology, south africa corresponding author: k naidoo (kathleenn@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 211 december 2018, vol. 10, no. 4 ajhpe research population and sampling the hpcsa online register, which is available to the public, was used to identify the participants. only radiographers who worked in kzn were invited to participate. at the time of the study, there were ~1 200 kzn radiographers registered with the hpcsa. the entire population was sampled, using the total population sampling technique to ensure a maximum return rate. the statistically acceptable sample size as calculated by a statistician was 292 radiographers. only 146 of the 292 questionnaires were returned. this provided a response rate of 50%. data collection the data collection instrument comprised an online questionnaire. closed-ended questions were used to answer the constructs on ‘radiographers’ opinions of cpd’ and ‘radiographers’ cpd challenges experienced’. open-ended questions were used to gain insight into the participants’ suggestions for overcoming the identified cpd challenges. surveymonkey was selected as the online platform of choice. the privacy policy of the online survey website indicates that all data and email addresses are kept securely.[11] validity of the study was ensured, as the researcher developed the questionnaire design and structure after an extensive literature review of previous studies.[12] the questionnaire was piloted by 14 radiography professionals, who were excluded from the main study. the aim of the pilot study was to ensure content validity. recommendations were considered and minor amendments were made to the main questionnaire before final distribution. data collection was conducted from may to july 2015 in kzn. an invitation to participate in the study was sent to kzn radiographers, who were contacted directly, via email, in their personal capacity. data analysis quantitative data were analysed by means of descriptive statistics to determine the frequency and means of data. the quantitative data collected from the questionnaire responses were analysed using spss version 23.0 (ibm corp., usa). to compare sets of data that are in the form of frequencies, χ2 tests were used.[12] to determine whether the scoring patterns per statement were significantly different per option, a χ2 test was done. this is represented by p-values. if p˂0.05, it implies that the distributions were not similar. reliability testing was conducted using cronbach’s alpha coefficient test. the pilot study and the main study were analysed using cronbach’s alpha. each construct achieved a value >0.600, which indicated a high degree of acceptable, consistent scoring for the various relevant sections of the research. the qualitative data were reviewed to develop themes based on the overall understanding of the data. summaries were created based on participants’ answers and similar concepts were combined.[13] once themes were identified, the data were reviewed for supporting verbatim quotes. ethical approval ethical approval for the study (ref. no. rec 12/15) was obtained from the institutional research ethics committee at the durban university of technology (dut). study participation was voluntary and participants could withdraw from the study at any time. consent for the study was obtained electronically, as the participant followed the web link to complete the questionnaire. results from 292 questionnaires, 146 (50%) were comple ted and available for analysis. fig. 1 illustrates the construct on radiographers’ opinions of cpd. the majority of respondents (74.66%; p=0.000) agreed that cpd is important and improves knowledge (90.42%; p=0.000). interestingly, more than half of the respondents disagreed with the statement that cpd is not costly to the practitioner (p=0.000). more than half of the respondents (76.71%; p=0.000) engaged in cpd only because it is a requirement of the hpcsa. it is important to note that the majority of respondents agreed that cpd should be linked to both developmental and professional needs (p=0.000) (fig. 2). furthermore, most respondents agreed that cpd should be provided by in-house training (p=0.000) and that it should be conducted during working hours (p=0.000). respondents were hesitant towards compulsory cpd, with only 45.8% of respondents agreeing on this (p=0.001). table 1 depicts the extent to which various factors affected cpd participation. the construct on ‘radiographers’ cpd challenges experienced’ revealed two major factors that affected cpd participation to a great extent, i.e. lack of time is important improves the e�ectiveness of service delivery improves professional competence improves quality of patient care improves your knowledge improves your clinical skills decreases patient waiting time by having more skilled employees improves professional/clinical practice/standards aids in advanced technology learning bene�ts the individual bene�ts the employer bene�ts the patient should be delivered by radiographers working in the hospital/clinical environment is not costly to the practitioner is an investment to the employer is an investment to the practitioner is not a waste of time has to be completed because it is a requirement for the hpcsa 74.66 12.33 62.33 20.55 68.49 16.44 57.53 21.23 90.41 4.11 70.55 15.07 34.25 32.88 68.49 16.44 80.14 8.90 76.03 12.33 58.22 21.92 64.38 17.12 54.79 13.01 19.86 57.53 54.79 22.60 58.90 21.23 63.01 20.55 76.71 9.59 0 10 20 30 40 50 60 70 80 90 100 responses, n agree disagree fig. 1. responses with regard to opinions on continuing professional development. (hpcsa = health professions council of south africa.) december 2018, vol. 10, no. 4 ajhpe 212 research (46.5%) and inability to attend cpd activities due to shift work (47.2%). another significant factor affecting cpd participation was the lack of employer support in terms of funding (34.9%), time (36.3%) and motivation (21.9%). the factors that least affected cpd participation were lack of understanding of what is required (54.1%) and inaccessibility to technological facilities (47.9%). the responses to accessibility of resources are shown in table 2. the majority of respondents (91.1%) had access to the internet (p=0.000), but more than half (58.9%) did not have access to funding to attend cpd workshops or seminars (p=0.031). results from the open-ended questions are given here. participants were asked for suggestions to overcome their identified cpd challenges. most agreed that support should be provided for cpd engagement (p=0.000). the majority (84.14%) agreed that study leave should be provided to attend seminars, workshops and conferences (p=0.000). respondents were also in agreement that employers should have formal policies to support cpd financially (94.48%; p=0.000) and cpd update courses should be made available (94.48%; p=0.000). suggestions to address the challenges related to cpd compliance included the following: • provision of funding should be allocated. • provision of time should be allocated. • there should be an increased accessibility to cpd activities. • there should be an increase in employer involvement. • improved locations for cpd activities should be addressed. • there should be an increased awareness of cpd. • the hpcsa’s involvement with practitioners should be increased. most of the respondents considered the provision of funding to be a method to overcome cpd challenges, while others considered increased accessibility of cpd activities to be a means of overcoming some of the challenges. respondents were also requested to provide suggestions with regard to ways to improve the cpd auditing process. the common themes that emerged were as follows: • systematic audit method • improvement of hpcsa’s communication • extended time for ceus • increase in audit awareness. some participants expressed negative feelings towards cpd audits and suggested ‘the doing away of audits’. the majority of participants expressed the need for an online system for uploading certificates directly to the hpcsa website for regular monitoring whenever the need arises. discussion there was a clear indication by participants that cpd is important and beneficial for improving an individual’s knowledge. there were similar findings among radiographers in sudan, europe and australia.[3,9,14,15] despite the recognised importance of cpd by the participants in this study, they also indicated that they took part in cpd activities owing to mandatory hpcsa requirements. unfortunately, this is an indicator of a ‘tick-box’ mentality that was identified in international studies, whereby individuals undertake cpd to fulfil regulatory obligations.[16,17] this mentality defeats the purpose of cpd and compulsory optional and conducted when you wish to do so only evidence based delivered by experts in the higher-education sector provided through in-house training linked to developmental needs aligned with professional needs conducted during the week, monday to friday, 08h00 16h00 conducted during weekend and after-hours 45.89 33.56 47.26 34.25 39.73 13.70 49.32 17.81 73.29 6.85 89.04 1.37 90.41 3.42 56.85 14.38 23.97 51.37 0 20 40 60 80 100 responses, % agree disagree fig. 2. responses with regard to opinions on continuing professional development implementation. table 1. responses to the extent to which factors have affected participation in cpd activities responses not at all, % least extent, % some extent, % great extent, % lack of time 8.2 3.4 41.8 46.6 lack of funding and financial support for cpd 13.0 13.7 37.0 36.3 lack of employer/management support in terms of funding 17.1 17.8 30.1 34.9 lack of employer/management support in terms of motivation 26.7 19.9 31.5 21.9 lack of employer/management support in terms of allocating time for cpd 16.4 17.1 30.1 36.3 inability to participate in cpd activities because of shortage of staff 11.6 19.9 28.1 40.4 unable to attend cpd activities because of shift work 18.5 11.0 23.3 47.3 lack of understanding of what is required 54.1 27.4 13.0 5.5 inaccessibility of technological facilities 47.9 26.7 15.1 10.3 commitments outside work limit time for participation 12.3 24.7 33.6 29.5 difficulty keeping own records up to date 41.8 26.0 18.5 13.7 no help from hpcsa when required 32.2 24.7 18.5 24.7 cpd = continuing professional development; hpcsa = health professions council of south africa. 213 december 2018, vol. 10, no. 4 ajhpe research has no value with regard to professional or individual development. therefore, there are ongoing debates on the effectiveness of mandatory cpd.[14,15] some international authors recommend that cpd be based on outcomes rather than the number of hours or points attained.[18] while these findings are based on a smaller professional sample, further investigations into whether other professionals display similar attitudes could be valuable for review of the current cpd system. the two main contributors that affected cpd participation in this study were a lack of time and the inability to attend cpd activities due to shift work. another significant factor that is closely related to these two factors was a lack of support from employers in terms of the provision of funding, time and motivation. similar findings were illustrated in radiography research studies in sudan, namibia and the uk.[3,4,19] however, participants from the uk were unable to suggest strategies to overcome the challenge of limited time, but did indicate a need for ‘protected’, dedicated time to engage in cpd activities.[4] the impact of shift work on cpd activities is a critical factor. however, finding a balance between work commitments and time to engage in cpd activities is necessary. in namibia, radiographers indicated that they preferred cpd involvement during their leisure time. this was in contrast to findings from kzn radiographers, who preferred cpd to be conducted during the week (between 08h00 and 16h00). a significant number of participants in this study agreed that employers should have formal policies to support the financial implications of cpd. the namibian radiographers displayed comparable findings for a need for management support funding of cpd activities.[19] globally, cpd funding continues to be a major challenge for healthcare professionals. similarly, in this study more than half of the participants did not have access to funds for cpd engagement. this, however, seems to be a greater challenge among public-sector employees than those in the private sector. since the introduction of mandatory cpd in australia, the government has provided staff with financial support and leave to participate in cpd activities.[20] because of mandatory cpd in sa, it could be recommended that the government consider incorporating methods to assist with the financial implications of cpd. as many individuals considered lack of time as a challenge when required to participate in cpd activities, engaging in reflective practice is highly recommended in literature.[9] education is regarded as ongoing and cannot be a once-off experience. therefore, individuals need to have a deep, meaningful approach to learning, which can be achieved through reflective practice.[21] work-based learning is encouraged and was noted to be very beneficial, as it provided more flexibility for the professional.[9] this reduces the need to take time off from work to attend cpd activities.[9] work-based learning is a method that radiography employers could consider to assist radiographers in achieving cpd goals. the literature also illustrates that there is a lack of time for the recording and evidence-keeping of cpd activities.[10] this challenge has been overcome by many professional councils and institutes implementing an online cpd recording system for their members.[22-24] the sa institute of chartered accountants (saica) and the pharmaceutical society of northern ireland provide their members with two options for the recording of cpd engagement – paper-based and online. however, both societies clearly state that their preferred method is the online facility.[23,24] the online database provides members with convenient and easy safe-keeping of all cpd activities – thus reducing the time required for manual recording. similarly, the participants of this study suggested having an online cpd recording system as a strategy to improve the cpd auditing process. this method of cpd recording is a suggestion for the hpcsa to consider and could prove valuable to improving cpd audits. conclusion in a profession such as radiography, which is constantly evolving and progressing, the need for cpd is indisputable. it is evident from the findings of this study that kzn radiographers acknowledge the importance and value of cpd within the profession of radiography. however, they do experience a number of challenges that affect their cpd participation. they also find themselves in an environment that does not fully support their professional development. these identified challenges, if not addressed, may negatively affect cpd participation and the efficiency of service delivery. *the appendix is available from the corresponding author on request. declaration. none. acknowledgements. the authors would like to thank all participants for their contribution to this study. author contributions. both authors contributed equally to the article. funding. financial assistance was received from the faculty of health sciences at the university of johannesburg. conflicts of interest. none. 1. world health organization. guidelines. transforming and scaling up health professionals’ education and training. 2013. http://apps.who.int/iris/bitstream/10665/93635/1/9789241506502_eng.pdf (accessed 5 november 2018). 2. wareing a, buissink c, harper d, et al. continuing professional development (cpd) in radiography: a collaborative european meta-ethnography literature review. radiography 2017;23:s58-s63. https://doi.org/ 10.1016/j.radi.2017.05.016 3. elshami w, elamrdi a, alyafie s, abuzaid m. int j med res health sci 2016;5(1):68-73. https://doi.org/10.5958/23195886.2016.00015.1 4. stevens bj, wade d. improving continuing professional development opportunities for radiographers: a single centre evaluation. radiography 2017;23(2):112-116. https://doi.org/10.1016/j.radi.2016.12.001 5. health professions council of south africa. continuing professional development guidelines for the health care professionals. 2017. http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/cpd/cpd_guidelines_ sept_2017.pdf (accessed 5 november 2018). 6. ikenwilo d, skatun d. perceived need and barriers to continuing professional development among doctors. health pol 2014;117(2):195-202. https://doi.org/10.1016/j.healthpol.2014.04.006 7. mizuno-lewis s, kono k, lewis dr, et al. barriers to continuing education and continuing professional development among occupational health nurses in japan. workplace health safety 2014;62(5):198-205. https:// doi.org/10.3928/21650799-20140422-03 8. gawugah jnk, jadva-patel h, jackson mt. the uptake of continuing professional development (cpd) by ghanaian radiographers. radiography 2011;17(4):332-344. https://doi.org/10.1016/j.radi.2011.07.002 9. gibbs v. an investigation into the challenges facing the future provision of continuing professional development for allied health professionals in a changing healthcare environment. radiography 2011;17(2):152-157. https:// doi.org/10.1016/j.radi.2011.01.005 10. henwood sm, flinton dm. 5 years on: have attitudes towards continuing professional development in radiography changed? radiography 2012;18(3):179-183. https://doi.org/10.1016/j.radi.2012.04.001 11. surveymonkey. privacy policy. 2013. https://www.surveymonkey.com/mp/policy/privacy-policy/ (accessed 10 octo ber 2018). 12. brink h, van der walt c, van rensburg g. fundamentals of research methodology for healthcare professionals. 3rd ed. cape town: juta, 2012. 13. holloway i, wheeler s. qualitative research in nursing and healthcare. 3rd ed. west sussex, uk: wileyblackwell, 2010. 14. sholer h, tonkin s, lau kf, law c, rahman r, halkett gkb. continuing professional development: western australian radiographers’ opinions and attitudes. radiographer 2011;58(2):19-24. https://doi.org/10.1002/j.2051-3909.2011.tb00146.x table 2. responses to accessibility of resources responses frequency (%) internet 133 (91.1) peer-reviewed journals 93 (63.7) opportunities to undertake cpd activities 114 (78.1) transport to attend cpd activities 100 (68.5) funds to attend cpd workshops/seminars 60 (41.1) cpd = continuing professional development. http://apps.who.int/iris/bitstream/10665/93635/1/9789241506502_eng.pdf https://doi.org/-10.1016/j.radi.2017.05.016 https://doi.org/-10.1016/j.radi.2017.05.016 https://doi.org/10.5958/2319-5886.2016.00015.1 https://doi.org/10.5958/2319-5886.2016.00015.1 http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/cpd/cpd_guidelines_sept_2017.pdf http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/cpd/cpd_guidelines_sept_2017.pdf https://doi.org/10.3928/21650799-20140422-03 https://doi.org/10.3928/21650799-20140422-03 https://doi.org/10.1016/j.radi.2011.01.005 https://doi.org/10.1016/j.radi.2011.01.005 https://www.surveymonkey.com/mp/policy/privacy-policy/ https://doi.org/10.1002/j.2051-3909.2011.tb00146.x december 2018, vol. 10, no. 4 ajhpe 214 research 15. castillo j, caruana cj. maltese radiographers’ attitudes towards continuing professional development: an initial study using concept maps. j med imaging radiat sci 2014;45(1):37-46. https://doi.org/10.1016/j.jmir.2013.09.003 16. mathers n, mitchell c, hunn a. a study to assess the impact of continuing professional development (cpd) on doctors’ performance and patient/service outcomes for the gmc. 2012. https://www.dcnz.org.nz/assets/ mathers-et-al-2013.pdf (accessed 5 november 2018). 17. nsemo ad, john me, etifit re, mgbekem ma, oyira ej. clinical nurses’ perception of continuing professional education as a tool for quality service delivery in public hospitals calabar, cross river state, nigeria. nurse educ prac 2013;13(4):328-334. https://doi.org/10.1016/j.nepr.2013.04.005 18. schafheutle ei, hassell k, noyce pr. ensuring continuing fitness to practice in the pharmacy workforce: understanding the challenges of revalidation. res soc admin pharm 2013;9(2):199-214. https://doi.org/10.1016/ j.sapharm.2012.08.007 19. uarije c, daniels er, kalondo l, amkongo m, damases-kasi c, nabasenja c. radiographers’ attitudes towards continuous professional development (cpd) at state hospitals in windhoek, namibia. s afr radiographer 2017;55(1):18-22. 20. summers a. continuing professional development in australia: barriers and support. j cont educ nurs 2015;46(8):337-339. https://doi.org/10.3928/00220124-20150721-11 21. govranos m, newton jm. exploring ward nurses’ perceptions of continuing education in clinical settings. nurse educ today 2014;21(8):607-615. 22. general pharmaceutical council. 2016. http://www.uptodate.org.uk/home/welcome.shtml (accessed 5 november 2018). 23. south african institute for chartered accountants. 2012. https://www.saica.co.za/news/mediakit/publications/ electronicnewsletters/learningandopportunities18september2012/cpd/tabid/2702/language/en-us/default. aspx (accessed 5 november 2018). 24. pharmaceutical society of northern ireland. 2016. http://cpd.psni.org.uk/manual/unit3/index.asp (accessed 5 november 2018). accepted 23 april 2018. https://www.dcnz.org.nz/assets/mathers-et-al-2013.pdf https://www.dcnz.org.nz/assets/mathers-et-al-2013.pdf https://doi.org/10.1016/--j.sapharm.2012.08.007 https://doi.org/10.1016/--j.sapharm.2012.08.007 http://www.uptodate.org.uk/home/welcome.shtml https://www.saica.co.za/news/mediakit/publications/electronicnewsletters/learningandopportunities18september2012/cpd/tabid/2702/language/en-us/default.aspx https://www.saica.co.za/news/mediakit/publications/electronicnewsletters/learningandopportunities18september2012/cpd/tabid/2702/language/en-us/default.aspx https://www.saica.co.za/news/mediakit/publications/electronicnewsletters/learningandopportunities18september2012/cpd/tabid/2702/language/en-us/default.aspx http://cpd.psni.org.uk/manual/unit3/index.asp december 2019, vol. 11, no. 4 ajhpe 110 short communication why was the idea necessary (problem)? because of the south african political dispensation, lack of equitable distribution of services severely impacts on access to quality health services in low socioeconomic communities. these communities are widely known to be underdeveloped, and to date, health services in various areas are in high demand owing to the burden of disease.[1] consequently, there is tremendous strain on the clinical platform that hinders effective collaboration, which is imperative when addressing complex health needs.[1] therefore, innovative learning activities to enhance health and social science students’ knowledge, skills, attitudes and values have been incorporated into the curriculum of an interprofessional health and social education course. interprofessional education (ipe) occurs when students from two or more backgrounds learn about, from and with each other to enable effective collaboration and improve health outcomes.[2] what was tried (approach)? social accountability and cultural competencies are important components to consider when developing an ipe environment that appropriately services the current clinical platform. as part of an ipe module, seven community organisations were invited into the classroom to provide insight into prevalent health and social issues. through storytelling, as a narrative pedagogy, community representatives shared their experiences regarding the structure of their communities and the role community organisations play in addressing health and social challenges. in this way, a class of 737 inter ­ professional students were exposed to vulnerable communities through the lens of community members’ knowledge of the local context. concerns related to care for the elderly and the frail, substance abuse, domestic and gender­based violence, and orphaned children were raised in their stories. thus, students were able to collaboratively determine possible causes of these social issues and provide organisations with recommendations to address the effects on the community. what lessons were learnt (outcome)? this approach was beneficial to all three stakeholders, i.e. the academic institution, the student and the community. academia acknowledges the importance of community­engaged learning and teaching to inform pedagogical activities when considering the effects of health and social issues on community wellness.[3] by bringing the community into the classroom, there is an opportunity to co­create the curriculum with students and community members. the quality of teaching is thus improved, as local and indigenous knowledge systems (ikss) are embedded in the curriculum design of health professions education. ikss go a long way in developing knowledge and skills relating to social accountability and cultural acceptance of students engaged in interprofessional practices in health science curricula.[4] community members hold implicit knowledge that they unintentionally impart to students, who have the potential to foster humility, social sensitivity, social responsiveness, communication and cultural awareness.[4] in this manner, students could develop and enhance their interpersonal skills, self­confidence and cultural competencies. this co­creation ensures that interventions developed by students are based on evidence from complex challenges in communities. furthermore, activities such as these may develop capacity and agency for community members, as they are provided with a platform to share their experiences and practices in a university setting. declaration. none. acknowledgements. none. author contribution. both authors contributed equally to the article. funding. none. conflicts of interest. none. 1. pillay­van wyk v, msemburi w, laubscher r, et al. mortality trends and differentials in south africa from 1997 to 2012: second national burden of disease study. lancet glob health 2017;4(9):e642­e653. https://doi. org/10.1016/s2214109x(16)30113­9 2. education collaborative expert panel. core competencies for interprofessional collaborative practice: report of an expert panel. washington, dc: interprofessional education collaborative, 2011. 3. maistry m. community engagement, service learning and student social responsibility: implications for social work education at south african universities. a case study of the university of fort hare. social work 2012;48(2). 4. rankoana sa, nel k, mothibi k, mothiba tm, mamogobo p, setwaba m. the use of indigenous knowledge in primary health care: a case study of makanye community in limpopo province, south africa. afr j phys health educ recreat dance 2015;2(suppl 1):272­278. accepted 4 september 2019. afr j health professions educ 2019;11(4):110. https://doi.org/10.7196/ajhpe.2019.v11i4.1238 co-creating an interprofessional education curriculum using local and indigenous knowledge l kock-africa, msc; s titus, phd interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: s titus (sititus@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1016/s2214109x(16)30113-9 https://doi.org/10.1016/s2214109x(16)30113-9 14 april 2021, vol. 13, no. 1 ajhpe article the growing interest in integrating massive open online courses (moocs) into medical education[1-3] is likely to increase during the current covid-19 pandemic because of safety concerns for medical students being taught around the bedside. moocs typically consist of any combination of videos, images, slide presentations, assignments, computer-graded quizzes, and discussion forums.[4,5] originally designed to provide learning opportunities for students who might not otherwise have access to higher education,[6] moocs are increasingly being developed for use in combination with face-to-face teaching (blended instruction[7]), which is the preferred way of integrating technology-enhanced learning into medical education.[8,9] the paediatric physical examination skills (ppes) mooc is part of the open-access paediatric technology assisted learning (open petal) project funded by the discovery fund since 2018. this project, undertaken at the chris hani baragwanath academic hospital (chbah), was conceived as a teaching and learning resource to supplement face-to-face bedside paediatric teaching. the ultimate aim is to improve child health outcomes in resource-limited settings. the mooc was conceptualised as a means of addressing the clinical teaching burden at chbah, the largest of four teaching hospitals affiliated with the university of the witwatersrand (wits). the problems encountered in clinical teaching at chbah, including large student groups at the bedside[10] and a lack of teaching resources,[11] are likely to be present in other resource-limited settings. of the 34 paediatric-related courses hosted on the mooc platforms edx, coursera, udemy and futurelearn, none of them as of december 2019 teaches paediatric physical examination skills. in our ppes mooc, the issue of legal and ethical consent became a critical consideration because the mooc would include recordings (photographs and videos) of ill children to demonstrate pathology. it is worth noting that any reproduction of a child’s image, irrespective of the presence or absence of illness, requires ethical consent. we were unable to find any open source or university-approved consent form that documents legal or ethical consent for medical moocs. the project team (two paediatricians from chbah, an educational expert, and the mooc development team from the university’s centre for learning, teaching & development) therefore conducted a series of workshops with a representative from the university’s legal office, which led to the development of a consent form that meets the legal and ethical requirements in our setting (appendix 1: http://ajhpe.org.za/public/files/1412-1.pdf ). the lessons we learnt during the preparatory phase and the operational considerations essential to comply with the required legal and ethical considerations may be valuable to other educators who are planning to create medical moocs. we have summarised these lessons in fig. 1. lessons for developing a legally and ethically compliant consent form for the use of recordings of children in an online training course while there are guidelines for obtaining informed consent and ethics clearance from an ethics board for paediatric research,[12] there is none for teaching purposes. a consent form for the use of recordings of children by health professionals in an online training course (consent form) should meet the following criteria for legal and ethical compliance. clearly define what the requested consent is for in terms of the south african national health act of 2003,[13] a patient is required to provide informed consent for all medical treatment. accordingly, the consent form requests permission for the use of recordings by health professionals for teaching and learning purposes, including in the mooc and iterations thereof. acknowledging that varied recording methodologies may present different burdens to the child and that obtaining a satisfactory image massive open online courses (moocs) are increasingly being integrated into medical education. the production of a mooc demonstrating physical examinations of children raised the issue of legal and ethical consent for the use of images and video-recordings of children. the present article shares the valuable lessons we learned around the legal and ethical consent required, and the operational issues that will be essential to comply with these legal and ethical considerations. this information may be valuable to other educators, especially those in similar resource-constrained settings,who are planning to create medical moocs. afr j health professions educ 2021;13(1)14-17. https://doi.org/10.7196/ajhpe.2021.v13i1.1412 legal and ethical requirements for developing a medical mooc: lessons learnt from the paediatric physical examination skills mooc a george,1 phd; d wooldridge,2 ba; j king,2 ba; a g giovanelli,2 bfa; s g naidoo,2 bfa; m a mabeba,2 bfa; s morar,3 ba; s g lala,4,5 phd; z dangor,4 phd 1 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 centre for learning, teaching and development, university of the witwatersrand, johannesburg, south africa 3 legal services, university of the witwatersrand, johannesburg, south africa 4 paediatric education and research ladder, department of paediatrics and child health, chris hani baragwanath academic hospital, johannesburg, south africa 5 perinatal hiv research unit, chris hani baragwanath academic hospital, johannesburg, south africa corresponding author: a george (ann.george@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://ajhpe.org.za/public/files/1412-1.pdf april 2021, vol. 13, no. 1 ajhpe 15 article may require several attempts, the consent form requests permission for more than one photograph or recording, where necessary, on the understanding that every effort will be made to minimise the duration of photographing and recording and the discomfort to the patient. specify who needs to provide consent many children in the areas served by the chbah (and elsewhere in south africa) are cared for by extended family members or family friends who may not be the child’s legal guardian or have any recognised legal relationship to the child.[14] section 32 of the children’s act no. 38 of 2005[15] allows a person who cares for a child voluntarily without formal parental responsibilities, to consent to medical (but not surgical) examination and treatment on that child’s behalf. a caregiver can thus provide consent for the use of the recordings in the mooc. the consent form provides for a parent, legal guardian, or caregiver [the consentor(s)] to consent to clinical recordings of ‘my child/my dependent/my ward’ [authors’ emphasis]. there are no clear guidelines relating to a minor consenting to have their photograph taken or to be video-recorded, and whether such consent is legally binding. snyman[16] recommends obtaining consent from children as young as 7 years of age to record their image. in clinical research, children aged 7 18 years are required to assent to participate in research studies.[12] in line with these requirements, the consent form allows children aged 7 18 years to write their names or sign assent, where possible. protection of confidentiality as required by the health professions council of south africa,[17] in accordance with the promotion of access to information act of 2000,[18] the national health act of 2003[13] and the protection of personal information act of 2013,[19] the consent form includes several clauses aimed at protecting the child’s confidentiality. the consent form states that all reasonable precautions will be taken to preserve the child’s anonymity and privacy. these precautions include removing facial features (wherever possible) and other distinguishing features from recordings or disguising them using pixelation. the consent form also includes a line drawing of a human body (as used by snyman[16]), where the consentor(s) can indicate which features should be hidden in the edited footage (appen dix 1: http://ajhpe.org.za/public/files/1412-1.pdf). the consent form further states that all recordings will be stored on an off-line drive at a secure site. the dissemination or duplication of digital images is difficult to prevent. as pointed out by marshall,[20] ‘privacy, anonymity, and confidentiality on the internet are increasingly fraught with challenges.’ it is therefore vital that informed consent acknowledges that all reasonable precautions will be taken to preserve anonymity and privacy. give the consentor(s) and the child the right to review the recordings the consent form allows consenters to be present during the recording. the consentor(s) and/ or children will be able to view the raw and edited footage, on request. requests to view the recordings will be facilitated, since consenters and children in resource-limited settings may not have access to the internet or be digitally literate. make provision for the withdrawing of consent children and consenters may request that recordings are deleted from the mooc at any stage. a register matching recordings to individuals will be kept so that recordings can be removed if consent is withdrawn. the register will be securely stored in a site separate from the secure storage of the clinical recordings. include permission from the hospital/ health facility we obtained blanket written permission from the chief executive officer (ceo) of the hospital for the project. this information is disclosed in the consent form. obtain all required signatures the consent form must be signed by the consentor(s), the child, the doctor(s), a translator (if used) and an independent witness. anticipating that some consenters may not be literate, the consent form provides for consenters to use their thumbprint if they are not able to sign. operational issues in addition to developing a legally and ethically compliant consent form, the following operational issues are required to fulfil the legal and ethical obligations. determine who is responsible for obtaining consent the doctors leading the project will obtain informed consent, and no recording will happen prior to obtaining consent. footage that does not contain a legible version of the signed consent form as the first photograph or 10 seconds of any video, will be deleted. including the signed consent form in the footage will: (i) facilitate matching names to images during the editing process, so that metadata can be added that will allow the correct footage to be located if consent guidelines for using clinical recordings of children in online training courses a. development of the consent form: legal and ethical considerations • clearly de�ne what the requested consent is for • specify who needs to provide consent • protection of con�dentiality • give consentor(s) and children the right to review the recordings • make provision for the withdrawing of consent • include permission from the hospital/ health facility • obtain all required signatures b. operational issues • determine who is responsible for obtaining consent • obtain video-release forms from the hospital and educators • maintain the con�dentiality of recordings • prepare extensively for all recordings • uphold intellectual property rights and copyright • promote the protection of data • monitor the compliance of the use of digital images fig.1. guidelines for the using clinical recordings of children in online training courses. 16 april 2021, vol. 13, no. 1 ajhpe article is withdrawn; and (ii) serve as a check for videographers that they are allowed to continue filming. obtain video-release forms from the hospital/health facility and educators educators are required to consent to their appearance (photographs and videos) being used in the mooc. this form is available as appendix 2 (http://ajhpe.org.za/public/files/1412-2.pdf ). the hospital or health facility needs to sign a video-release form for material recorded on the hospital premises. in our case, the blanket permission we obtained from the hospital includes permission to release the videos. maintain the confidentiality of recordings all recordings will take place in a private space at the hospital to maintain patient confidentiality and minimise disruptions to clinical services rendered in resource-limited settings. all non-clinical personnel present during recordings must ‘understand and agree to adhere to medical standards of privacy and confidentiality,’[21] as enshrined in south african legislation. these medical standards pertain to not divulging patient information and safe record-keeping of patient information. clinical images will be recorded in a non-intrusive and discreet manner, and framing shots will exclude the child’s identifying features. every precaution will be taken to avoid sharing edited footage online. prepare extensively for all recordings cognisant of the need to minimise the burden placed on children, all recordings will be extensively planned. additionally, the training of clinical personnel in video-recording techniques will facilitate efficient recording. all members of our team were trained by a videographer to understand better the techniques to be used. uphold intellectual property rights and copyright the applicable policies of an institution govern ownership of material created within an institution. such material must be protected from unauthorised usage and appropriately acknowledged when used outside the institution. the ppes mooc will be released under the terms of creative commons licence attribution – non-commercial-sharealike 4.0 (cc by-nc-sa 4.0).[22] the south african copyright act[23] provides that copyright in recorded material vests in the creator. for example, at wits niversity, staff and students are bound by the provisions of the university’s intellectual property policy,[24] in terms of which the university owns all intellectual property developed or originated by staff and students in the course and scope of their employment or studies. all consultants employed on the project to record photographs or videos will be required to assign the copyright in all recordings made on the hospital premises to the university. promote the protection of data all secure digital (sd) cards from digital cameras must be returned to a locked facility at chbah or the university immediately after a recording session. recordings will be stored on an external drive that will be kept in a secured facility at the university. recordings may not be retained by a staff member, or saved, backed up or transferred online. editing of recordings will occur in private, secured workspaces. monitor the compliance of the use of digital images there needs to be an appropriate institutional mechanism in place for dealing with ethical or legal complaints arising from the use of digital images in online courses. for example, the integrity of the project could be reviewed by an independently appointed quality control team. conclusion we believe that the production of medical moocs and online courses will accelerate in response to the training of undergraduate and postgraduate students during the covid-19 pandemic. numerous legal and ethical challenges were encountered during the planning of our medical mooc, especially as it involves children. we embarked on an unfamiliar process to resolve these concerns, and we hope that the lessons we learned prove helpful to other educators intending to produce medical moocs. some of the lessons we have shared may need to be re-evaluated if any additional legal or ethical concerns arise. during the current pandemic, appropriate measures (including the use of personal protective equipment and social distancing) will be taken to ensure the safety of children, their parents/ guardians/caretakers, doctors and filming crew. acknowledgements. none. author contributions. ag wrote the first draft. all authors read and approved the final draft. funding. the ppes mooc is part of the open-access paediatric technology assisted learning (open petal) project funded by the discovery fund (ref: 039042). the project is managed through malamulele onward npc. conflicts of interest. none. 1. o’doherty d, dromey m, lougheed j, hannigan a, last j, mcgrath d. barriers and solutions to online learning in medical education – an integrative review. bmc med educ 2018;18(1):1-11. https://doi.org/10.1186/s12909018-1240-0 2. hendriks ra, de jong pgm, admiraal wf, reinders mej. instructional design quality in medical massive open online courses for integration into campus education. med teach 2020;42(2):156-163. https://doi.org/10.1080 /0142159x.2019.1665634 3. de jong pgm, pickering jd, hendriks ra, swinnerton bj, goshtasbpour f, reinders mej. twelve tips for integrating massive open online course content into classroom teaching. med teach 2020;42(4):393-397. https:// doi.org/10.1080/0142159x.2019.1571569 4. hoy mb. moocs 101: an introduction to massive open online courses. med ref serv q 2014;33(1):85-91. https://doi.org/10.1080/02763869.2014.866490 5. kurt s. the case of turkish university students and moocs. am j distance educ 2019;33(2):120-131. https:// doi.org/10.1080/08923647.2019.1582284 6. mcaleavy t, gorgen k. overview of emerging country-level response to providing educational continuity under covid-19: best practice in pedagogy for remote teaching. 2020. https://edtechhub.org/wp-content/ uploads/2020/04/summary-research-best-practice-pedagogy-remote-teaching.pdf (accessed 1 june 2020). 7. dziuban c, graham cr, moskal pd, norberg a, sicilia n. blended learning: the new normal and emerging technologies. int j educ technol high educ 2018;15(1):1-16. 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are needed to train effective doctors. s afr med j 2020;110(5):347. https://doi.org/10.7196/samj.2020.v110i5.14678 12. world health organization: research ethics review committee. informed assent form template for children/ minors. 2020. https://www.who.int/ethics/review-committee/informed_consent/en/ (accessed 3 may 2020). 13. republic of south africa. national health act no. 61 of 2003. government gazette no. 26595:869.23 july 2004. https://www.gov.za/sites/default/files/gcis_document/201409/a61-03.pdf (accessed 3 may 2020). 14. buchner-eveleigh m, vogel f. section 71 of the national health act: a call for a review of the consent requirement for child participation in health research. jure 2015;48(2):280-292. https://doi.org/10.17159/22257160/2015/v48n2a2 15. the republic of south africa. children’s act no. 38 of 2005. government gazette no. 28944:610. 19 june 2006. https://www.gov.za/sites/default/files/gcis_document/201409/a38-053.pdf (accessed 10 march 2020). 16. snyman p. who allowed the speaker to use my patient’s photo? s afr j child health 2012;6(4):102-105. https:// doi.org/10.7196/sajch.457 17. health professions council of south africa. ethical guidelines for good practice in the health care professions. pretoria: hpcsa, 2016. https://www.hpcsa.co.za/uploads/professional_practice/ethics_booklet.pdf (accessed 10 march 2020). http://ajhpe.org.za/public/files/1412-2.pdf https://doi.org/10.1186/s12909-018-1240-0 https://doi.org/10.1186/s12909-018-1240-0 https://doi.org/10.1080/0142159x.2019.1665634 https://doi.org/10.1080/0142159x.2019.1665634 https://doi.org/10.1080/0142159x.2019.1571569 https://doi.org/10.1080/0142159x.2019.1571569 https://doi.org/10.1080/02763869.2014.866490 https://doi.org/10.1080/08923647.2019.1582284 https://doi.org/10.1080/08923647.2019.1582284 https://edtechhub.org/wp-content/uploads/2020/04/summary-research-best-practice-pedagogy-remote-teaching.pdf https://edtechhub.org/wp-content/uploads/2020/04/summary-research-best-practice-pedagogy-remote-teaching.pdf https://doi.org/10.1186/s41239-017-0087-5 https://doi.org/10.2471/blt.08.051599 https://www.who.int/hrh/documents/elearning_hwf/en/ https://doi.org/10.1186/s41239-019-0164-z https://doi.org/10.7196/samj.2020.v110i5.14678 https://www.who.int/ethics/review-committee/informed_consent/en/ https://www.gov.za/sites/default/files/gcis_document/201409/a61-03.pdf https://doi.org/10.17159/2225-7160/2015/v48n2a2 https://doi.org/10.17159/2225-7160/2015/v48n2a2 https://www.gov.za/sites/default/files/gcis_document/201409/a38-053.pdf https://doi.org/10.7196/sajch.457 https://doi.org/10.7196/sajch.457 https://www.hpcsa.co.za/uploads/professional_practice/ethics_booklet.pdf april 2021, vol. 13, no. 1 ajhpe 17 article 18. republic of south africa. promotion of access to information act, 2000. government gazette no. 20852:95. 3 february 2000. https://www.gov.za/sites/default/files/gcis_document/201409/a2-000.pdf (accessed 10 march 2020). 19. republic of south africa. protection of personal information, act 4 of 2013. government gazette no. 37067. 26 novem ber 2013. http://www.gov.za/sites/www.gov.za/files/37067_26-11_act4of2013protectionofpersonalinfor_correct. pdf (accessed 10 march 2020). 20. marshall s. exploring the ethical implications of moocs. distance educ 2014;35(2):250-262. https://doi.org/10.1080 /01587919.2014.917706 21. american medical association. audio or visual recording patients for education in health care. https://www.amaassn.org/delivering-care/ethics/audio-or-visual-recording-patients-education-health-care (accessed 3 june 2020). 22. creative commons. https://creativecommons.org/ (accessed 10 august 2020). 23. republic of south africa. copyright act, act no. 98 of 1978. government gazette no. 6092; 30 june 1978. https://www.gov.za/sites/default/files/gcis_document/201504/act-98-1978.pdf (accessed 1 december 2019). 24. university of the witwatersrand. intellectual property policy c2012/228. 2012. johannesburg: university of the witwatersrand, 2012. accepted 6 september 2020. https://www.gov.za/sites/default/files/gcis_document/201409/a2-000.pdf http://www.gov.za/sites/www.gov.za/files/37067_26-11_act4of2013protectionofpersonalinfor_correct.pdf http://www.gov.za/sites/www.gov.za/files/37067_26-11_act4of2013protectionofpersonalinfor_correct.pdf https://doi.org/10.1080/01587919.2014.917706 https://doi.org/10.1080/01587919.2014.917706 https://www.ama-assn.org/delivering-care/ethics/audio-or-visual-recording-patients-education-health-care https://www.ama-assn.org/delivering-care/ethics/audio-or-visual-recording-patients-education-health-care https://creativecommons.org/ https://www.gov.za/sites/default/files/gcis_document/201504/act-98-1978.pdf september 2019, vol. 11, no. 3 ajhpe 101 research the changing nature of work and the capacity of educational institutions to prepare students for the changing work environment have been of concern to many governments. consequently, linking on-campus learning with learning in industry has received increased attention.[1] it is also applicable to healthcare education programmes, such as radiography, biomedical and clinical technology, nursing and other allied health professions, where conversion from analogue to digital requires student-centred curricula underpinned by clinical practice outcomes.[2] to address this challenge, the higher education qualifications framework (heqf)[3] in south africa (sa) mandates all new qualifications to integrate theory and practice through incorporation of work-integrated learning (wil) as a structured part of the curriculum. the wil component of a programme should be properly structured, assessed and supervised, and should integrate university and workplace learning.[3] in the wil context, integration means that students take what they have learnt at university into the workplace. conversely, what they have learnt in the workplace is taken into the next phase of learning when returning to university.[4] aside from workplace learning (wpl), wil should preferably be facilitated using a variety of learning modes, e.g. work-directed theoretical learning (wdtl) – theoretical learning focused on what the student needs to know to be able to function sufficiently in the workplace;[5] problem/scenario-based learning (pbl/sbl) – a method in which real-world problems are used to promote student learning; project-based learning and workplace learning (pjbl) – an approach where students acquire deeper knowledge through active exploration of real-world challenges and problems, to stimulate the integration of concepts and higher order cognitive learning (deep learning) to construct understanding.[1,5-8] deep learners aim to understand the meaning behind the concept and interact with information by creating appropriate arguments and examples related to the topic.[9] ideally, the different learning modes should be used interchangeably in the delivery of wil, while activities to accommodate these learning modes can occur in various environments (e.g. simulation laboratories, interactive discussion groups and forums, virtual and e-learning, the workplace). exposing students to a combination of learning modes and environments has proved to promote deep learning and the development of soft skills, such as communication, confidence and assertiveness, time management, critical thinking, computer literacy, emotional intelligence, empathy and the ability to work in a team.[10] proficiency in these skills ensures that students are better equipped to function in the real world of work. soft skills that promote employability are the qualities that an employer requires for success in the workplace. to deliver competent healthcare professionals, these skills should be developed as part of students’ university training.[10] despite many positive aspects identified in the current delivery of wil, the authors recognised some challenges regarding the curriculum design and facilitation, assessment and monitoring of wil. these shortcomings in the training of healthcare students may produce graduates lacking the skills and competencies required for employment as professionals. consequently, the following research question directed this study: ‘what are the areas of good practice and areas for improvement in the current delivery of wil in radiography training in sa?’ in the absence of a structured programme for wil in radiography training in sa, the aim of the study was to develop a background. work-integrated learning (wil) forms an essential part of many learning programmes to equip students with the required knowledge and a complete set of skills to be successful in the world of work. however, all aspects (teaching/learning, assessment and monitoring) of wil have to be implemented appropriately to ensure quality learning for students to construct meaning from their learning. objective. to conduct an enquiry regarding the current practices for wil in radiography training. methods. using a questionnaire, a quantitative survey was conducted among selected university lecturers, workplace learning co-ordinators and finalyear radiography students at 7 south african universities. results. the results revealed the following areas of good practice: inclusion of activities to stimulate deep learning, development of soft skills, good management/co-ordination of wil and existing good lines of communication. improvement measures for identified areas include: use of different learning modes, increased use of electronic teaching media, involvement of workplace supervisors in the development of outcomes and learning material, quality supervision and adequate preparation of students prior to placement. conclusions. this study recommends the inclusion of wil as part of the curriculum in healthcare programmes to assist students with the continuous development of new disciplinary knowledge and application of the acquired skills in the work environment. afr j health professions educ 2019;11(3):101-106. https://doi.org/10.7196/ajhpe.2019.v11i3.1043 areas of good practice and areas for improvement in work-integrated learning for radiography training in south africa j du plessis,1 phd; j bezuidenhout,2 phd 1 department of clinical sciences, faculty of health and environmental sciences, central university of technology, bloemfontein, south africa 2 division health professions education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: j du plessis (duplesj@cut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:duplesj@cut.ac.za 102 september 2019, vol. 11, no. 3 ajhpe research wil education and training programme for radiography by focusing on the requirements of the heqf.[3] the main objective was to conduct an enquiry with regard to the current practices for wil in radiography training. the developed programme was shared with the wil co-ordinators at all participating sa universities for implementation in their programmes. we report only on the areas of good practice and areas for improvement derived from a multifaceted enquiry with regard to the current status of wil in radiography training at universities in sa.[8,11-17] curriculum developers across all healthcare programmes can benefit from relevant information provided by this research to rectify possible shortcomings in the wil component of their training. methods research design and data collection data for this cross-sectional, descriptive study were collected by means of a quantitative questionnaire survey. the questionnaire was developed by the researcher, who was guided by a questionnaire used for a benchmarking project on wil conducted by the university of tasmania (utas), australia.[16] with reference to curriculum design, teaching/learning, assessment and monitoring of wil, the researcher developed the questions to specifically enquire about the delivery of wil in radiography training at participating institutions. the questionnaire consisted mainly of 27 closed questions and allowed opportunity for open-ended comments. the same questionnaire was distributed to purposively selected lecturers, wil co-ordinators and final-year students (who had been exposed to the thematic areas longer than other students) at all 7 sa universities offering radiography training. questions were rated from level 1 to 3, where level 1 indicated that effective strategies for the thematic areas were implemented successfully across the programme, and level 3 indicated that effective strategies for the thematic areas were not implemented successfully across the programme. level 2 indicated existing strategies as useful, but with some limitations towards the sound implementation of these strategies.[16] to augment the information, participants had the opportunity to provide comments. sampling and statistical analysis the empirical phase of the study consisted of the administration of an electronic questionnaire to lecturers (n=14/32; 44% response rate) and wil co-ordinators (n=22/44; 50% response rate), and a hard-copy questionnaire to final-year radiography students who had been exposed to wil for a 3-year period (n=146/146; 100% response rate). the questionnaire was designed to obtain the views of all role players in the current training and delivery of wil in radiography training at 7 sa universities. purposive sampling was used to select lecturers and supervisors, and random sampling was used for students by selecting every second student from the class list.[17] the quantitative data were analysed by a statistician (e.g. frequencies, standard deviations, significance) and then organised, summarised and presented as descriptive statistics.[18] qualitative data from the open-ended comments were organised in themes that mirrored the concepts covered in the questionnaire. ethical approval the ethics committee of the faculty of health sciences, university of the free state, bloemfontein, sa, approved the protocol (ref. no. ecufs nr 106/2012). additional approval was granted by the heads of department at the 7 universities. to ensure anonymity, the questionnaires were coded using a number system. validity was enhanced by the questionnaire being piloted on 4 lecturers, 4 super visors and 4 final-year radiography students. their recommendations were applied before distribution of the final questionnaire. results areas of good practice when comparing the activities of lecturers to stimulate deep learning in the wil environment, the results showed that lecturers’ and students’ feedback indicated similarity on only 3 actions (fig. 1), including individual work (lecturers 62%; students 54%), group work (lecturers 61%; students 64%), and sharing responses (lecturers 63%; students 67%). for the other actions to stimulate deep learning, a difference in opinion between the lecturers and students was observed, from 12% (asking questions – lecturers 93%; students 81%) to 21% (issuing a challenge and allowing constructive critique – lecturers 82%; students 61%). there was also a difference between lecturers and students regarding the posing of a problem to stimulate deep learning (lecturers 82%; students 76%). there was a strong correlation between the lecturers’ and students’ results regarding the use of actions to stimulate deep learning (r=0.664), indicating that most of the lecturers and students reported positively about the use of actions to stimulate deep learning in their programmes. the development of soft skills was also identified as an area of good practice in the current delivery of wil. most lecturers (96%) confirmed the development of soft skills in the facilitation and assessment of wil at their respective institutions. ninety-four percent of students indicated that soft skills were important for a healthcare professional to work effectively. students reported the attainment of soft skills in their wil programmes as follows: professional and ethical behaviour (88%), communication (with patients, peers and managers) (91%), critical thinking/problem-solving (86%), integration of theoretical knowledge and practical skills (84%), teamwork (84%) and use of technology (85%) (fig. 2). eighty-two percent of students confirmed that they were assessed on the attainment of soft skills in the wil component of their programmes. when asked whether the employer created sufficient opportunities to develop skills and abilities in the workplace, 82% of students answered positively. pa rt ic ip an ts , % 100 80 60 40 20 0 lecturers (n=32) students (n=146) as k q ue sti on s po se a p rob lem iss ue a c ha lle ng e ind ivi du al w ork gr ou p w ork sh are re sp on ses all ow co ns tru cti ve cri tiq ue 61 93 81 82 76 82 61 62 54 61 64 63 67 82 fig. 1. comparison of actions to stimulate active/deep learning. september 2019, vol. 11, no. 3 ajhpe 103 research wpl supervisors were certain about who was responsible for the general management of wil at their institutions (fig. 3). they confirmed that the management and co-ordination of wil are primarily controlled by the learning programme at the university (55%) in collaboration with the wpl supervisor in clinical practice (55%). the management and co-ordination of the wil practices of students through the wil central office at the 7 participating universities was 23%, while the role of the faculty was 9%. there were adequately established lines of communication between all the universities and their clinical sites, although a variety of communication systems was used. the results in fig. 4 show that email correspondence is the preferred line of communication between the co-ordinator/s at the university and the wpl supervisors at the clinical institutions (86%). advisory committee meetings were indicated as the second most used mode of communication regarding wil-related and wpl-related matters (77%), followed by standing committee meetings (41%). some universities indicated wil committee meetings as the line of communication between the involved parties (23%). another 23% indicated that other avenues were followed for communication between the different parties. areas for improvement certain areas for improvement were identified in the current application of wil at participating universities, including the use of different learning modes for the facilitation of wil. as shown in fig. 5, wpl is the preferred learning mode of all lecturers in the participating programmes (100%). wdtl was used by 71% of the lecturers. learning modes such as pbl/ sbl, which are perfectly suitable for teaching in the wil environment, were indicated as being used by 50% and 57%, respectively. only 43% of lecturers indicated the use of pjbl to facilitate the learning process in wil. an area showing a huge discrepancy in the responses of lecturers and students was the use of different types of electronic teaching media (fig. 6) to facilitate learning when using the different learning modes of wil. according to participating lecturers, powerpoint was the medium mostly pa rt ic ip an ts , % 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 pr of es sio na l a nd et hi ca l b eh av io ur co m m un ica tio n cr iti ca l t hi nk in g/ pr ob le m -so lvi ng in te gr at io n of kn ow le dg e s kil ls te am w or k us e o f t ec hn ol og y im po rta nc e o f ge ne ric sk ills as se ss m en t o f ge ne ric sk ills op po rtu ni tie s t o d ev el op g en er ic sk ills 88 91 86 84 84 85 94 82 82 fig. 2. students’ perceptions of the attainment of graduate attributes (soft skills) (n=146) . faculty programme co-ordinator other pa rt ic ip an ts , % 100 80 60 40 20 0 wil central o�ce 14 23 9 55 55 fig. 3. responsible entity (n=44). (wil = work-integrated learning.) otheradvisory committee meetings standing committee meetings wil committee meetings email correspondence pa rt ic ip an ts , % 100 80 60 40 20 0 77 41 23 86 23 fig. 4. lines of communication (n=44). (wil = work-integrated learning.) wdtl pbl sbl pjbl wpl pa rt ic ip an ts , % 100 80 60 40 20 0 71 50 57 43 100 fig. 5. types of curricular modalities/learning modes used at participating institutions (n=32). (wdtl = work-directed theoretical learning; pbl = problem-based learning; sbl = scenario-based learning; pjbl = project-based learning; wpl = workplace learning.) 104 september 2019, vol. 11, no. 3 ajhpe research used when teaching wil (100%), followed by video (74%), the internet and blackboard (67%), and skype (56%). the correlation between responses from students compared with those of lecturers was observed only for the use of powerpoint (students 94%; lecturers 100%). students indicated the use of video in teaching of wil (45%), as well as the internet (46%), blackboard (52%) and skype (34%). other areas of concern included the involvement of wpl supervisors in the development of learning outcomes and learning material for the wil component, as 50% of the wpl supervisors were positive regarding involvement, 27% indicated no involvement and 23% indicted some involvement (fig. 7). the visitation of students by lecturers while placed for wpl seems to be a considerable challenge across all participating learning programmes. it was worrisome that 32% of the participating wpl supervisors indicated that the wpl students were never visited by university lecturers (fig. 7). only 45% of the wpl supervisors indicated frequent visits, while the remaining 23% reported limited visits. the frequency of visitation only once a year by a university lecturer/wil co-ordinator was indicated by 23% of students. the frequencies of biannual and quarterly visits were both rated at 9%, while monthly and weekly visits were rated at 18% and 14%, respectively (fig. 7). the lack of training of supervisors and preparation of students prior to placement for wpl in clinical practice were regarded as a concern regarding the success of wil. only 41% of the wpl supervisors indicated that they had received appropriate training from their institutions for their supervisory role. however, a substantial number of wpl supervisors indicated some training (32%) and no training (27%) (fig. 8). related to the preparation of students before placement for wpl in clinical practice (fig. 8), the supervisors indicated in favour of such pre-placement training (76%). the remaining 26% indicated no pre-placement training programme (5%) and limited pre-preparation training (19%). discussion alignment of the outcomes with the level descriptors and exit-level outcomes for a qualification, as proposed by the south african qualifications authority (saqa),[19] is imperative for successful teaching and learning in any programme. therefore, the alignment of the learning outcomes for wil with teaching/learning activities and assessment strategies is essential to the quality of learning. lecturers and supervisors should embrace activities to stimulate deep learning, especially when working in the wil components of their programmes. deep learning is stimulated when working under the guidance of an experienced professional. such assistance can stimulate critical thinking to help graduates/students link different concepts and thus develop a graduate who can function as an admirable professional in the workplace.[20,21] a key purpose of wil is to provide graduates with a comprehensive set of soft skills preferred by potential employers, as indicated previously.[4] therefore, the incorporation of soft skills in the wil curriculum of healthcare programmes should be encouraged. similarly, the attainment of soft skills should be included in the assessment of wil, whether assessed at the university or while the student is doing wpl. the wil environment is ideal for assessing whether students have attained soft skills, and whether they are video pa rt ic ip an ts , % 100 80 60 40 20 0 lecturers (n=32) students (n=146) powerpoint presentations internet blackboard skype 100 94 67 67 74 52 56 45 34 46 fig. 6. comparison of electronic teaching media used for work-integrated learning. frequent 45% participation in development of wil learning material visitation to monitor student progress visitation frequency weekly 14% monthly 18% quarterly 9% biannually 9% annually 23% other 27% yes 50% no 27% to some extent 23% none 32% limited 23% fig. 7. involvement and visitation. (wil = work-integrated learning.) yes 41% yes 76% no 27% no 5% to some extent 32% to some extent 19% appropriate training preparation programme fig. 8. training of workplace learning supervisors and preparation of students before placement. september 2019, vol. 11, no. 3 ajhpe 105 research able to apply them across a number of activities to ensure preparedness for clinical placement. the management of wil in a learning programme cannot be prescribed and may vary widely between programmes. however, the success of a wil programme depends on the meaningful interaction of all the role players (students, universities and industry).[22] it is therefore not important who the manager of the wil component of the programme is, as long as collaborative action occurs between the wil central office, learning programme, wil co-ordinator/s, wpl supervisors in clinical practice and students. similarly, good communication is an important aspect in ascertaining collaboration among role players, who need to communicate expectations about outcomes, assessment practices and monitoring. the avenues for communication between the different role players for wil can also not be prescribed. it is important, however, that proper and timely communication occurs between the role players to ensure quality of learning in the wil environment. the results confirmed that wpl is still the preferred learning mode for training of healthcare professionals in the wil environment. also noteworthy is that a large percentage of the lecturers (71%) used wdtl when teaching wil. conversely, pbl/sbl and pjbl were indicated across the spectrum of participating lecturers as being average (i.e. 43 57%). for many health professions in sa, the popular use of wpl can be explained by these professions having had a professional body which, in the past, had prescribed a certain number of hours that students had to be placed in clinical practice as a prerequisite to obtain the qualification. this learning mode was compulsory. nevertheless, the importance of pbl/sbl and pjbl in the wil environment to stimulate the integration of theoretical knowledge with workplace skills development cannot be overemphasised. these learning modes are ideally suited to facilitate wil, focusing on reallife problems and stimulating students to form the necessary links between what has been learnt in the classroom and what happens in the workplace.[23] the different learning modes should be selected carefully to fit the purpose and level of students’ learning.[7] facilitators must empower themselves to use electronic teaching media in an era where laptops, data projectors and internet connection have become part of everyday life. this is even more relevant in the healthcare professions, such as radiography, where online libraries and other electronic teaching tools are readily available. students value lecturers’ use of digital resources, which, alongside other forms of teaching support, steer them through the potentially overwhelming volume of work they have to master.[24] even though frequent visitation by a lecturer cannot be prescribed, it stimulates a culture of trust among all role players in the wil environment. frequent visitation by lecturers/wil co-ordinators while doing wpl contributes to the success of the latter (personal communication with: (i) mr henri jacobs, director, work-integrated learning and skills development, central university of technology, bloemfontein, 12 october 2013; and (ii) dr marius wessels, head, cooperative education unit, university of johannesburg, 11 march 2012). if frequent visitation is not possible, clear guidelines for monitoring and assessment must be available to wpl supervisors. it is even more important to train wpl supervisors correctly. the importance of supervision during wpl cannot be overemphasised, especially when policies and regulations regarding professional practice and human rights govern patient-related actions and activities. students’ wpl experience is an extension of the learning process. therefore, supervisors should provide opportunities to bridge the two experiences and receive training for their important role of supervising students towards attaining a complicated set of skills.[25] in most health professions programmes, it has become increasingly important that programme developers consider the development of soft skills during a preparation programme prior to placement of students in clinical practice. an increasingly demanding work environment requires that students have skills pertaining to professionalism, communication, the ability to work in groups, critical thinking and problem-solving.[26] therefore, at many universities, the inclusion of a core curriculum is now compulsory in an effort to address the acquisition of soft skills. we recommend that firstyear students be kept at university for some time before placement for wpl to develop these soft skills. conclusions and recommendations we believe that the inclusion of wil as part of the curriculum in many healthcare programmes will assist students to interchange continuously between disciplinary knowledge and the application of skills in the clinical environment. the delivery of quality wil programmes is seen as an excellent tool to equip students with the employment qualities needed in a growing and increasingly demanding economy. at the conceptual level, it became clear that for education and training programmes to influence the quality of graduates for work in the health sector, new wil curricula will have to be designed with a vision to align the teaching/learning, assessment and monitoring of the programme. the newly developed programme for wil is currently being implemented and evaluated continuously to improve its delivery in radiography training in sa. after comparing the results of the study with the challenges identified in the introduction, we recommend the following towards improvement of wil practices in health programmes: the teaching and learning of wil in all health programmes should be planned and structured to incorporate different learning modes and environments such as skills and computer laboratories, not only the workplace. the visitation of students by a university lecturer while they are engaged in wpl should receive urgent attention. planning in conjunction with the available support structures at the university should be done to ensure that all students are visited as often as possible while they are engaged in wpl. the developers of health professions programmes should give urgent attention to the training of wpl supervisors to ensure quality delivery of wil. in this regard, we suggest the delivery of a structured course with continuing professional development units to encourage wpl supervisors to empower themselves for supervision and mentoring of students in clinical practice. study limitations the main limitation of the study was that the student sample was limited to final-year radiography students; therefore, the perceptions of students regarding current wil practices in the first and second years of study were excluded. declaration. the article is based on research conducted by jdp in partial fulfilment of her phd thesis in health professions education. acknowledgements. dr daleen struwig, medical writer and editor, faculty of health sciences, university of the free state, bloemfontein, for technical and editorial preparation of the manuscript. 106 september 2019, vol. 11, no. 3 ajhpe research author contributions. jdp: identified the research topic, conceptualised the study design, formulated the research aims and objectives, performed the collection and interpretation of the data and drafted the initial version of the article; jb: supervised the study and assisted with writing of the article; both authors approved the final version of the article. funding. none. conflicts of interest. none. 1. wingrove d, turner m. where there is a wil there is a way: using a critical reflective approach to enhance work readiness. asia pac j coop educ 2015;16(3):211-222. 2. engel-hills pc. an integrated approach to curriculum. s afr radiographer 2005;43(2):24-27. 3. council on higher education. work-integrated learning: good practice guide. pretoria: che, 2011. 4. coll rk, eames c, paku l, et al. an exploration of the pedagogies employed to integrate knowledge in workintegrated learning in new zealand higher education institutions. https://researchcommons.waikato.ac.nz/ handle/10289/5554 (accessed 6 august 2019). 5. du plessis jge. a work-integrated learning education and training programme for radiography in south africa. phd thesis. bloemfontein: university of the free state, 2015. http://scholar.ufs.ac.za:8080/xmlui/bitstream/ handle/11660/1064/duplessisjge.pdf?sequence=1 (accessed 6 august 2019). 6. petersen s. principles of curriculum reform. university of the free state: division health sciences education, 2013. 7. howard p, jorgensen d. project-based learning and professional practice: enhancing cooperative education. j coop educ 2006;40(2):1-11. 8. martin a, hughes h. how to make the most of work-integrated learning: a guide for students, lecturers and supervisors. albany, new zealand: massey university press, 2009. 9. lublin j. deep, surface and strategic approaches to learning. belfield: centre for teaching and learning, university college dublin, 2003. 10. bowden t, drysdale m. work-integrated learning in the 21st century: global perspective on the future. bingley, uk: emerald publishing, 2009. 11. choy s, delahaye b.  partnerships between universities and workplaces: some challenges for work-integrated learning. stud contin educ 2011;33(2):157-172. https://doi.org/10.1080/0158037x.2010.546079 12. mclennan b, keating s. work-integrated learning (wil) in australian universities: the challenges of mainstreaming wil. altc nagcas national symposium 19 june 2008, melbourne, australia. http://citeseerx.ist. psu.edu/viewdoc/download?doi=10.1.1.530.4443&rep=rep1&type=pdf (accessed 7 june 2018). 13. copper l, orrell j, bowden m. work-integrated learning: a guide to effective practice. london: routledge, 2012. 14. govender cm, qit m. work-integrated learning benefits for student career prospects – mixed mode analysis. s afr j high educ 2017;31(5):49-64. https://doi.org/10.20853/31-5-609 15. lewis m, hotlzhausen n, taylor s. the dilemma of work-integrated learning (wil) in south african higher education – the case of town and regional planning at the university of johannesburg. http://journals.ufs.ac.za/ index.php/trp/article/view/428 (accessed 6 august 2019). 16. university of tasmania (utas), faculty of business. work-integrated learning benchmarking project. http://acen. edu.au/docs/utas-wil-benchmarking-project-synopsis-questionnaire.pdf (accessed 4 december 2017). 17. bowling a. research methods in health: investigating health and health services. 2nd ed. london: open university press, 2002. 18. yan f, robert m, li y. statistical methods and common problems in medical or biomedical science research. int j physiol pathophysiol pharmacol 2017;9(5):157-163. 19. south african qualifications authority. registered qualifications. pretoria: saqa, 2013. 20. stirling a, banwell j, macpherson e, heron a. a practical guide for work-integrated learning effective practices to enhance the educational quality of structured work experiences offered through colleges and universities. higher education quality control of ontario. 2016. https://www.vu.edu.au/sites/default/files/cclt/pdfs/heqco-practicalguide-wil.pdf (accessed 7 june 2018). 21. atherton js. learning and teaching: deep and surface learning. https://www.researchgate.net/ publication/246664388_learning_and_teaching_deep_and_surface_learning (accessed 4 december 2017). 22. forbes be. assessment strategies for work-integrated learning at higher education institutions. 2004. cctprojects. co.za/wbeproject/documents/wil/forbes-paper.pdf (accessed 4 december 2017). 23. gallagher sa. problem-based learning: where did it come from, what does it do, and where is it going? j educ gifted 1997;20(4):332-362. https://doi.org/10.1177/016235329702000402 24. white d, manton m. open educational resources: the value of re-use in higher education. oxford: university of oxford, 2011. 25. true m. starting and maintaining a quality internship program. https://www2.virginia.edu/career/intern/ startinganinternship.pdf (accessed 4 december 2017). 26. fleming j, zinn c, ferkins l. bridging the gap: competencies students should focus on during their cooperative experience to enhance employability. e-proceedings of the asia pacific cooperative education conference, 30 september 3 october 2008, sydney, australia. acen.edu.au/resources/2008-conference-proceedings/ (accessed 4 december 2017). accepted 7 march 2019. https://researchcommons.waikato.ac.nz/handle/10289/5554 https://researchcommons.waikato.ac.nz/handle/10289/5554 http://scholar.ufs.ac.za:8080/xmlui/bitstream/handle/11660/1064/duplessisjge.pdf?sequence=1 http://scholar.ufs.ac.za:8080/xmlui/bitstream/handle/11660/1064/duplessisjge.pdf?sequence=1 https://doi.org/10.1080/0158037x.2010.546079 http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.530.4443&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.530.4443&rep=rep1&type=pdf https://doi.org/10.20853/31-5-609 http://journals.ufs.ac.za/index.php/trp/article/view/428 http://journals.ufs.ac.za/index.php/trp/article/view/428 http://acen.edu.au/docs/utas-wil-benchmarking-project-synopsis-questionnaire.pdf http://acen.edu.au/docs/utas-wil-benchmarking-project-synopsis-questionnaire.pdf https://www.vu.edu.au/sites/default/files/cclt/pdfs/heqco-practical-guide-wil.pdf https://www.vu.edu.au/sites/default/files/cclt/pdfs/heqco-practical-guide-wil.pdf https://www.researchgate.net/publication/246664388_learning_and_teaching_deep_and_surface_learning https://www.researchgate.net/publication/246664388_learning_and_teaching_deep_and_surface_learning http://cctprojects.co.za/wbeproject/documents/wil/forbes-paper.pdf http://cctprojects.co.za/wbeproject/documents/wil/forbes-paper.pdf https://doi.org/10.1177/016235329702000402 https://www2.virginia.edu/career/intern/startinganinternship.pdf https://www2.virginia.edu/career/intern/startinganinternship.pdf http://acen.edu.au/resources/2008-conference-proceedings/ june 2020, vol. 12, no. 2 ajhpe 50 short communication why was the idea necessary? digital x-ray imaging systems have a wide, dynamic exposure latitude that allows almost 500 times the exposure necessary to produce optimal diagnostic images.[1,2] consequentially, patients may receive more exposure to ionising radiation than necessary to produce an image of optimal diagnostic quality. a recent study showed that ~54% of radiographers understood and used indicators of exposure in digital x-ray imaging systems.[3] with just more than half of radiographers understanding and using indicators of exposure in digital x-ray imaging systems, enhancing radiographers’ understanding of exposure technique factors (kilovoltage peak (kvp), milliampere and the exposure time (mas)) in digital x-ray imaging systems is needed to curtail unnecessary exposure to ionising radiation. ethical approval for the study was obtained from the faculty of health sciences research ethics committee, university of johannesburg (ref. no. rec-234-2019). what was tried? a structured tutorial demonstrating the effect of mas on image quality in digital x-ray imaging systems was tried. four radiographs were taken of a hand phantom, using a constant kvp, focal film distance (ffd), focal spot size, 4-sided collimation and the same computed radiography (cr) (a type of digital x-ray imaging system) cassette. only the mas changed for each exposure (exposure refers to each time the radiograph is taken and the phantom hand is ‘exposed’ to ionising radiation) (fig. 1a-d). before the tutorial, students needed to predict the image quality for each exposure. after the tutorial, students compared their predicted outcomes with the actual outcomes. dose area products (daps), exposure indicators (eis) and image quality for each exposure without any image post-processing were tabulated. students then evaluated and reported the effect of mas. the resultant images and exposure technique factors are indicated in fig. 1. the effect of mas on image quality in digital x-ray imaging systems was observed. it was noticeable that at higher than standard optimum mas, the image quality was preserved (acceptable mas for a posteroanterior (pa) projection of a hand for the x-ray unit used in the tutorial was 2.5 mas (fig. 1b)). however, with higher mas, there was a congruent increase in the dose to the phantom (dap). students predicted that for the exposure technique factors used in fig. 1c and fig. 1d, they would not be able to observe an image, but acceptable images were obtained. students predicted a contrary outcome, despite learning the theory of the wide dynamic exposure latitude of digital x-ray imaging systems and seeing images similar to those in fig. 1 in the literature. therefore, using a blended teaching approach provided an opportunity for students to experiment with varied mas to enhance their understanding of the effect of mas on image quality in digital x-ray imaging systems. declaration. none. acknowledgements. thank you to the students who voluntarily participated in the tutorials. author contributions. sole author. funding. none. conflicts of interest. the author lectures the students who participated in the tutorial. 1. moore qt, don s, goske mj, et al. image gently: using exposure indicators to improve pediatric digital radiography. radiol technol 2012;84(1):93-99. 2. don s, whiting br, rutz lj, apgar bk. new exposure indicators for digital radiography simplified for radiologists and technologists. am j radiol 2012;199(6):1337-1341. https://doi.org/10.2214/ajr.12.8678 3. lewis s, pieterse t, lawrence h. evaluating the use of detector dose indicators in digital x-ray imaging systems. radiography (lond) 2019;25(3):e58-e62. https://doi.org/10.1016/j.radi.2019.01.003 accepted 28 january 2020. afr j health professions educ 2020;12(2):50. https://doi.org/10.7196/ajhpe.2020.v12i2.1261 exposure technique factors in digital x-ray imaging systems: demonstrating the effect of mas s lewis, mtech: radiography department of medical imaging and radiation sciences, faculty of health sciences, university of johannesburg, south africa corresponding author: s lewis (shantell@uj.ac.za ) this open-access article is distributed under creative commons licence cc-by-nc 4.0. a b c d fig. 1. images from the demonstration: (a) 45 kvp/0.5 mas. (b) 45 kvp/2.5 mas. (c) 45 kvp/200 mas. (d) 45 kvp/400 mas. https://doi.org/10.2214/ajr.12.8678 https://doi.org/10.1016/j.radi.2019.01.003 march 2019, vol. 11, no. 1 ajhpe 27 research a challenge in curriculum designing and refining is to ensure that objectives for knowledge, skills and attitudes are clear, structured within the learning opportunities of modules, and aligned with assessment formats, outcomes, competencies and content taxonomies. curriculum mapping entails a process of matching learning outcomes with elements of the curriculum[1] and provides the required visual representation of these various curriculum components, attributes and relationships.[2] the challenge of alignment can therefore be met by mapping on an electronic platform, which provides for the systematic organisation and linking of various curriculum elements into a database.[3-5] harden[3] describes curriculum mapping as a blueprint that provides a multidimensional overview of four interrelated key areas: content (learning objectives), learning outcomes, learning opportunities (events contributing to outcomes) and the related assessment. viewing the map through these four ‘windows’ reveals what has to be learnt, how it can be learnt and how it must be assessed. curriculum mapping visually represents key elements of a programme that contributes to student learning.[1] a relational curriculum database as described above makes the curriculum transparent owing to the online accessibility and search ability. it allows users to browse through the information in different ways[6] to view aligned content by using descriptors in various hierarchies of the outcomes, competencies and content taxonomies as keywords to filter data. the power of the map clearly lies in the links between curriculum elements[7] on which these searches are based. the transparency of the curriculum map enables the visibility of students’ prior exposure to particular content and planning of the level and breadth of new learning.[3] viewing the learning spiral by filtering the progression in terms of breadth, depth, utility and proficiency, as reflected in learning objectives,[4] clarifies students’ and educators’ understanding of where students are going and the steps they need to take to get there.[4,8] revision of a curriculum is facilitated through multiple searching and reporting features of a curriculum map. educators are enabled to check for redundancies, inconsistencies, misalignments and weaknesses.[9] this includes reviewing whether the content is congruent with expected learning outcomes,[3,5,6] considering the availability of teachers and suitable patients,[5] identifying learning objectives that are not covered or overlap with other content domains and detecting inconsistencies between objectives and assessment.[10] the map provides for a review of assessment methods,[9] and by correcting inconsistencies and possible mismatches between teaching and assessment, valid examinations can be constructed.[3] viewing the scope of these patterns and relationships, complexity and cohesion of the curriculum[11] are important for the purposes of curriculum management, analysis and reporting.[7,12,13] a web-based curriculum platform facilitates constant evaluation, updating and improving of curricula in real time, driving improvements to learning and teaching practices,[14] and is seen as an essential tool to background. a web-based curriculum is made transparent by providing multidimensional overviews of content (learning objectives) aligned with learning outcomes and frameworks, opportunities and assessment formats. a south african university embarked on the mapping of its curricula on the web-based learning opportunities, objectives and outcome platform (looop). objectives. to reflect on the customisation of looop and training of lecturers, and to determine lecturers’ perceptions of the usability and value of looop.  methods. the project manager reflected on the initiating processes, and a survey determined the lecturers’ perceptions of the usability and value of curriculum mapping, using a 4-point likert scale questionnaire. the convenience sample comprised the first 30 lecturers who had uploaded their curriculum content and consented to partake in this ethics-approved study. descriptive statistics portray the percentages of agreement on the positive statements of the questionnaire. results. challenges related to slow staff buy-in and development were experienced. required modifications to looop were promptly dealt with. the majority of participants agreed on the usability (≥89%), as well as structure and transparency (≥87%) of looop. mapping is expected to enhance curriculum revision (≥95%) and communication (≥96%), viewing the curriculum scope, complexity and cohesion (97%), as well as abstracting data for management analysis and reporting (100%). conclusions. the lecturers agreed on the usability and values of curriculum mapping, which indicates that online mapping is sufficiently beneficial to justify the time and resources invested. mapping should be a product of collaborative participation and planned as a long-term commitment, which can also be used to research the impact of mapping on student learning. afr j health professions educ 2019;11(1):27-31. doi:10.7196/ajhpe.2019.v11i1.1073 initiating curriculum mapping on the web-based, interactive learning opportunities, objectives and outcome platform (looop) i treadwell,1 mcur, dcur; o ahlers,2 md, phd; g c botha,3 ma, mphil hse 1 looop project manager, sefako makgatho health sciences university, pretoria, south africa 2 looop project, department of anaesthesiology, charité – universitätsmedizin berlin, germany 3 practice of medicine, sefako makgatho health sciences university, pretoria, south africa corresponding author: i treadwell (ina.treadwell@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 28 march 2019, vol. 11, no. 1 ajhpe research operationalise and review a curriculum.[5,6] according to harden,[3] ‘no good curriculum can afford to be without one’. the use of a multidimensional curriculum map has therefore become increasingly necessary to model, track and report on curricula.[13] a south african (sa) university embarked on a project to map their curricula online. a web-based platform for curriculum mapping, known as the learning opportunities, objectives and outcome platform (looop), as described by balzer et al.,[5] was acquired by joining the non-commercial, international looop network. looop was designed by a team of academics and information technology programmers from charité – universitätsmedizin berlin, germany, who have been using, updating and researching the system and its concepts since 2004. objectives the aim of this article is to report: • reflections of the project manager on the process of adapting looop and initiating lecturers’ mapping of curriculum content • lecturers’ perceptions of the usability of looop, as well as the experienced and expected values of curriculum mapping. methods a mixed methods design was used in this study. the project manager reflected on the adaptations made to customise looop and on the training of lecturers during the initial period of mapping the curriculum content. the research design to determine lecturers’ perspectives was explorative and descriptive, with a quantitative approach embedded in a survey as methodology. the population comprised lecturers (n=175) who had received training and assistance between october 2015 and may 2016. lecturer training was done throughout by the same person (the project manager) to enhance consistency and reduce bias. after the training, these lecturers had to complete the mapping on their own. the convenience sample comprised the first 30 lecturers who had completed uploading of their curriculum content by may 2016 and consented to partake in this ethics-approved study. a tested, self-constructed 4-point likert scale questionnaire was used to determine the participants’ perceptions of the use of and experienced and expected values of curriculum mapping. the content validity of the questionnaire was assured by basing the questions on the literature and having the three researchers validate the appropriateness of the items. qualitative data were obtained from the comment section in the questionnaire. descriptive statistics were used to portray the percentage of agreement on the positive statements of the questionnaire. ‘agree’ in the text refers to the combination of ‘agree’ and ‘strongly agree’ in the graphs, unless otherwise indicated. results reflections on adapting looop and initiating lecturers’ uploading of curriculum content our institution acquired looop in 2015. a full-time academic with qualifications in healthcare sciences and education volunteered to be contracted as project manager. she was trained and supported in the use of looop by the charité team (project manager as well as programmers). initially, the process of mapping had a bottom-up approach, and a lack of managerial impetus was experienced. management supported the looop project financially, but did not become involved. adaptation looop was adapted to address the needs of the institution and the requests throughout this process were promptly dealt with by support from the looop team at charité. the following outcome and competency frameworks have been added: • core competencies in the seven roles of medical and dental practitioners, as adapted from canmeds by the health professions council of sa.[15] • the medical subject headings (mesh) index catalogue,[16] with subject headings as descriptors, is used as a catalogue of core diseases. mesh provides hierarchically organised terminology for the indexing of biomedical information, ranging from very broad headings to more specific terms. the 13-level hierarchy was condensed to 3 levels,[7] which include descriptors of the core diseases identified at the institution. • level descriptors for the sa national qualifications framework.[17] • exit-level outcomes for the various courses offered at the institution. initiating the uploading of curriculum content demonstrations of the functionalities of looop were given to academic departments and to relevant committees, and lecturers were invited to upload their curriculum elements. the process of populating looop started in 2015 by uploading modules in the undergraduate medical programme. module outcomes and assessment formats were added during the uploading phase. the project manager trained the lecturers individually and in small groups. mapping of educational objectives to domains, levels in taxonomies and active verbs was facilitated by online support of looop. objectives copied from existing study guides were reviewed during the process and often changed to improve on construction or the required level of a domain taxonomy. contextual relationships were then created by aligning these objectives with outcomes, competencies and frameworks, as listed above, as well as assessment formats. being a volunteer as well as a full-time academic resulted in slow progress in the population of looop. the manager’s limited time to train lecturers was exacerbated by slow staff buy-in, participation and development. the uploading of objectives was done from existing study guides, but for some of the modules the objectives had to be formulated and the level of domain had to be explained, which proved to be time-consuming. the attitude of reluctance observed among lecturers in many cases changed to enthusiasm when they realised the value of a curriculum map, as reflected in their comments reported in the questionnaire. lecturers’ perceptions of the usability and value of curriculum mapping fig. 1 reflects lecturers’ perceptions of the usability and ease of curriculum mapping in general and the linking of objectives to domains, outcomes, frameworks and assessment formats. there was ≥89% agreement of participants on the usability statements. almost all participants agreed on the ease of linking of objectives, with the exception of 20%, who found the linking to mesh problematic. no respondent disagreed strongly with the statements. the agreement on positive value statements of looop as experienced by respondents is reported in fig. 2. almost all respondents valued looop in general, the structure and alignment of curriculum elements in particular, and the search ability very highly. march 2019, vol. 11, no. 1 ajhpe 29 research lecturers’ expected values of looop once all the modules of a curriculum had been populated are reflected in fig. 3. respondents (≥97%) had very high expectations of looop being transparent and familiar, and facilitating an integrated approach once the uploading of all curriculum content had been completed. the visibility of students’ prior learning was expected to be useful in planning the level and breadth of new learning, sequencing, and monitoring vertical and horizontal integration (96%). respondents indicated that revision of the curriculum should also be enhanced (≥95%). communicating curriculum and assessment matters to students was expected to be very valuable (≥96%). the majority of respondents agreed that the visibility of the curriculum scope, complexity and cohesion (97%), as well as abstracting of data (100%), are very beneficial for management analysis and reporting purposes. no respondent disagreed strongly with the statements. the respondents commented positively on the mapping of their curriculum content on looop: ‘this process forced me to re-evaluate my study guide, which was necessary.’ ‘it [the guide] is easily updateable.’ ‘… happy to have an electronic, transparent guide for easy use by lecturer and student.’ ‘it saves the cost of printing the curriculum guide every year.’ ‘i love the fact that i can now see what my students will learn in other subjects. this helps me to focus more on the important areas of my course.’ ‘a good tool which i think will benefit the students and lecturers to have a good idea how learning topics fit in the whole curriculum.’ ‘looop helped me to re-evaluate and restructure my course content in a more holistic and systematic way.’ ‘excellent tool to prepare for accreditation visits.’ ‘opening up exciting possibilities to get data easier for the purpose of educational research.’ discussion adaptation of looop and initiating the uploading of curriculum content all modifications to looop were made promptly to address the needs at the institution. this is important, as studies on curriculum mapping inform that mapping is an ongoing process that requires continual upgrading and maintenance.[6,14] according to hale,[18] a map should never be considered complete and done with. the lack of dedicated time and personnel for curriculum mapping at our institution concurs with the literature, which states that the greatest concerns regarding the construction and maintenance of electronic platforms for curriculum mapping focus on the demand for time and human resources.[5,6,13,19] slow staff buy-in, participation and development were experienced, which are similar to the findings of watson et al.[14] and willet.[6] studies indicate that working with busy academic staff to review a curriculum is complex, time-consuming and often unpredictable.[20] reluctance in some cases, especially of clinical staff, could possibly be ascribed not only to busy schedules, and understandably priority of patient care, but also to lack of an education background or understanding. lecturers are challenged to map the contextual relationships in the curriculum for which they are responsible.[7] hale[18] also reported moments of frustration, that some lecturers learn faster than others and that some need more support, while others may refuse to participate actively. however, the uploading of objectives from existing study guides often resulted in revision thereof, which could be seen as a quality assurance process. a lack of managerial impetus was probably due to student unrest and the transition to a new university that took precedence. hale[18] emphasises that curriculum mapping is not a ‘spectator sport’; there must be continual support from administrators, where educators have to learn or expand their understanding of curriculum design. appropriate leadership and ongoing educational support are needed to overcome inertia among educators when matters of curricula are raised, which is common in universities.[12] the need for transformational leadership must be emphasised, as it embraces teaching, coaching, mentoring, facilitating, inspiring, influencing and bringing about effective change.[21] usability of curriculum mapping and experienced and expected values the ease of linking to and navigating in looop is promising, as the usability of the interface, according to willet,[6] has been proven to have a great impact on the use and success of the electronic system. it therefore has to be user-friendly and non-threatening.[3] 0 20 40 60 80 100 creating modules/learning events organise curriculum in the structure generate automated learning guides navigate, edit, use online manual 11 43 46 3 20 77 36 64 5 41 54 % objective domains, levels and verbs mesh terms hpcsa competencies/nqf levels exit level and module outcomes assessment formats % 0 20 40 60 80 100 3 52 45 20 37 43 3 38 59 7 43 50 4 48 48 disagree agree strongly agree a. usability b. ease of linking objectives to curriculum elements fig. 1. perceptions of curriculum mapping (n=30). (mesh = medical subject headings; hpcsa = health professions council of south africa; nqf = national qualifications framework.) 30 march 2019, vol. 11, no. 1 ajhpe research the linking of objectives to the mesh framework, however, was the exception. this could probably be due to unfamiliarity with the framework and in some cases the absence of suitable subcategories. the looop team, who added a few subcategory terms to mesh, have addressed this issue. the structure, alignment and filtering of curriculum elements were highly valued, which is encouraging, as it is claimed that mapping facilitates the staff and students’ understanding of planned progression and complex relationships between learning outcomes, opportunities and content. mapping provides for transparency,[4] and by identifying students’ prior learning, educators can focus on building on previous know ledge.[9] the feeling of sustainability and sense of ownership reported by almost all the respondents are promising, as this would result in academic and clinical teaching staff who are involved.[14] the use of looop made the respondents aware of the limitations of a paperbased curriculum, which concurs with harden’s[3] statement that it is impossible to reproduce the different elements of a curriculum and the interrelationships between these elements on a paper version of a map. the respondents’ expectations of a transparant and familiar curriculum should be beneficial for implementing an integrated approach,[3] as well as for integration among disciplines.[9] the visibility of students’ prior learning, as expected through mapping, should facilitate the planning of the level and breadth of new learning,[3] as well as monitoring of vertical and horizontal integration, planning the sequencing of content and avoidance of duplication.[14] the value of mapping for revision purposes became very clear and concurs with hale,[22] who emphasised the importance of taking adequate time to review a map for multiple purposes to gain insights into gaps, absences and redundancies in a curriculum. the communication functionalities as expected correspond to claims in the literature. hale[18] describes a mapping system as a 24/7 communication tool that provides educators and administrators with evidence of the planned and taught curriculum, horizontally and vertically. it also provides educators and students with a shared understanding of what the curriculum seeks to accomplish, i.e. a view of the bigger picture.[23] students can view clear statements of the learning outcomes at each stage, and how these match with learning outcomes, easy access to information for external audit curriculum will be transparent familiarity with the curriculum implementation of integrated approach feasible b. visibility of students' prior exposure planning of level and breadth of new learning planning sequencing monitoring of vertical and horizontal integration c. curriculum review evaluation, updating and improvement in real time identi�cation of learning objectives duplicated or omitted identi�cation of inconsistencies d. communication to students student access to curriculum map electronic and print-based learning guides understanding of what to learn a. in general understanding of assessment format e. management, analysis and reporting visibility of scope, complexity and cohesion abstracting data for management analysis and reporting 3 21 76 31 69 3 24 73 4 36 60 3 34 62 3 34 62 34 66 5 23 72 37 63 3 28 69 3 28 69 3 17 79 3 3 93 3 24 72 31 69 10 90 0 0 0 0 0 0 10 20 30 40 50 60 70 80 90 100 % disagree agree strongly agree fig. 3. perceptions of the value of looop, as expected (n=30). (looop = learning opportunities, objectives and outcome platform.) a. structure and alignment of curriculum enhanced objective formulation improved organisation of curriculum clari�ed congruency with outcomes identi�ed inconsistencies enhanced planning of progressions b. ability to search and browse filtering objectives per outcomes and frameworks c. in general limitations of paper-based curriculum apparent feeling of sustainability and ownership strongly disagree disagree agree strongly agree 0 10 20 30 40 50 60 70 80 90 100 3 20 77 25 75 50 50 3 7 38 52 13 60 27 3 7 38 52 50 50 3 20 77 % fig. 2. perceptions of the value of looop, as experienced (n=30). (looop = learning opportunities, objectives and outcome platform.) march 2019, vol. 11, no. 1 ajhpe 31 research learning experiences and assessments in an electronic or print-based study guide.[24] due to easy access to required curricular information, the respondents had very high expectations of looop in terms of management, analysis, reporting and accreditation processes. showing relationships between the elements provides a visual analytical tool and makes evident the need for strategy decisions, which in turn can lead to improvements.[3] the use of curriculum mapping as preparation for accreditation has been described by perlin[25] as a transformational experience in curriculum quality for faculty. the comments of participants on the usability and values of looop were extremely positive. not only did they experience the structuring and alignment of curriculum elements and the search ability as very valuable, but also the expected transparency and communication functionalities needed for familiarity with the curriculum that will enable integration review, informed management and reporting. conclusion and recommendations in light of the high level of agreement of lecturers on the usability and values that they experienced with and expected of curriculum mapping, it can be concluded, in concurrence with willet,[6] to be sufficiently beneficial to justify the time and resources invested. the value of mapping in terms of alignment of curriculum elements, transparency, filtering of objectives, communication, management and reporting has been thoroughly acknowledged. except for the appointment of a project manager with a healthcare and educational back ground, lecturers from key areas in a faculty need to be identified and allowed protected time to function as members of a leadership team. it is recommended that such a team should consist of a member from top management, the project manager and committed lecturers representing departments, or schools should be formed to drive a curriculum mapping initiative and to research the impact of mapping on student learning. mapping should be a product of collaborative participation in an organisation’s ongoing curriculum, as education is not a static environment. it is designed to become a component of an educational system’s infrastructure[18] and should be planned as a longterm commitment, ensuring that the map is sustained and used in ways expected by lecturers, who spent time and effort to revise and upload their curricula. declaration. none. acknowledgements. none. author contributions. it: conceptualisation, design, analysis and interpretation of data, drafting of important scientific content and approval of the version to be published; oa: design, analysis and interpretation of data, critical revision of important scientific content and approval of the version to be published; gcb: design, analysis and interpretation of data, critical revision of important scientific content and approval of the version to be published. funding. none. conflicts of interest. none. 1. pierce g. curriculum mapping. 2015. https://www.bu.edu/provost/files/2015/04/4.8.15-ceit-teaching-talkassessment-curriculum-mapping-powerpoint.pdf (accessed 13 november 2018). 2. komenda l, karolyi m, vaitsis c, spachos d, woodham, l. a pilot medical curriculum analysis and visualization according to medbiquitous standards. 30th eee international symposium on computer-based medical systems ieee cbms 2017, thessaloniki, greece, 22 24 june 2017. http://cbms2017.org/slot/pilot-medical-curriculumanalysis-and-visualization-according-medbiquitous-standards (accessed 12 november 2018). 3. harden rm. amee guide no. 21. curriculum mapping: a tool for transparent and authentic teaching and learning. med teach 2001;23(2):123-137. https://doi.org/10.1080/01421590120036547 4. harden rm. learning outcomes as a tool to assess progression. med teach 2007;29(7):678-682. https://doi. org/10.1080/01421590701729955 5. balzer f, 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editor/userfiles/downloads/medical_dental/mdb%20core%20competencies%20-%20english%20-%20 final%202014.pdf (accessed 12 november 2018). 16. us national library of medicine. medical subject headings. 2017. https://www.nlm.nih.gov/mesh/ (accessed 17 july 2017). 17. south african qualifications authority (saqa). level descriptors for the south african national qualifications framework. 2012. http://www.saqa.org.za/docs/misc/2012/level_descriptors.pdf (accessed 19 june 2017). 18. hale ja. a guide to curriculum mapping: planning, implementing, and sustaining the process. thousand oaks, ca: corwin press, 2008. 19. davis mh, harden rm. planning and implementing an undergraduate medical curriculum: the lessons learnt. med teach 2003;25(6):596-608. https://doi.org/10.1080/0142159032000144383 20. oliver b, jones s, ferns s, tucker, b. mapping curricula: ensuring work-ready graduates by mapping course learning outcomes and higher order thinking skills. ant evaluation and assessment conference, brisbane, australia, 29 30 november 2007. http://c2010.curtin.edu.au/local/docs/paper3.pdf (accessed 12 november 2018). 21. hale ja, dunlap rf. an educational leader’s guide to curriculum mapping: creating and sustaining collaborative cultures. 2010. https://us.corwin.com/en-us/nam/book/educational-leaders-guide-curriculum-mapping (accessed 17 july 2017). 22. hale ja. curriculum decisions. curriculum mapping basics. http://curriculumdecisions.com/curriculum-mapping (accessed 12 november 2018). 23. carney e. curriculum mapping: a quick guide for programs. 2015. https://atl.wsu.edu/documents/2015/03/ curriculum-mapping.pdf (accessed 15 july 2017). 24. dent ja, harden r. a practical guide for medical teachers. 4th ed. london: churchill livingston, 2013. 25. perlin ms. curriculum mapping for program evaluation and cahme accreditation. j health admin educ 2011;28(1):33-53. accepted 17 july 2018. https://www.bu.edu/provost/files/2015/04/4.8.15-ceit-teaching-talk-assessment-curriculum-mapping-powerpoint.pdf https://www.bu.edu/provost/files/2015/04/4.8.15-ceit-teaching-talk-assessment-curriculum-mapping-powerpoint.pdf http://cbms2017.org/slot/pilot-medical-curriculum-analysis-and-visualization-according-medbiquitous-standards http://cbms2017.org/slot/pilot-medical-curriculum-analysis-and-visualization-according-medbiquitous-standards https://doi.org/10.1080/01421590701729955 https://doi.org/10.1080/01421590701729955 http://https//doi.org/10.1111/j.1365-2923.2008.03093.x http://https//doi.org/10.1111/j.1365-2923.2008.03093.x http://www.educationworld.com/a_curr/virtualwkshp/curriculum_mapping.shtml http://www.educationworld.com/a_curr/virtualwkshp/curriculum_mapping.shtml http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/medical_dental/mdb%20core%20competencies%20-%20english%20-%20final%202014.pdf http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/medical_dental/mdb%20core%20competencies%20-%20english%20-%20final%202014.pdf http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/medical_dental/mdb%20core%20competencies%20-%20english%20-%20final%202014.pdf http://www.saqa.org.za/docs/misc/2012/level_descriptors.pdf https://us.corwin.com/en-us/nam/book/educational-leaders-guide-curriculum-mapping https://atl.wsu.edu/documents/2015/03/curriculum-mapping.pdf https://atl.wsu.edu/documents/2015/03/curriculum-mapping.pdf a maximum of 3 ceus will be awarded per correctly completed test. october 2020, vol. 12, no. 3 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) cpd questionnaire october 2020 nursing students’ perceptions and experiences of concept mapping as a learning tool in a human physiology course 1. participants in this study felt that concept mapping: a. promoted group work. b. facilitated a deep learning approach. c. improved their assimilation of knowledge. d. a and b. e. all of the above. demystifying sexual connotations: a model for facilitating the teaching of intimate care to nursing students in south africa (sa) 2. the main concept in this study was defined using the following steps: a. the dictionary definition, subject definition and exemplary case. b. the subject definition, dictionary definition and exemplary case. c. the dictionary definition, exemplary case and subject definition. d. the exemplary case, dictionary definition and subject definition. the contribution of nursing preceptors to the future nursing workforce 3. the first three steps of mey and dietrich comprise: a. contextualisation, description and coding. b. contextualisation, description and segmentation. c. description, segmentation and coding. d. description, coding and interpretation. improving postgraduate nursing research output: an sa nursing science perspective 4. difficulties in exposing student nurses to research include: a. excessive workload. b. poor time management. c. poor programme management. d. a and b. e. all of the above. a broken triangle: students’ perceptions regarding the learning of nursing administration in a low-resource setting 5. the main themes emerging from this study are: a. cognitive support during learning. b. alignment of assessment with reality. c. validity of assessment tools. d. achieving learning outcomes. e. all of the above. the influence of context on the teaching and learning of undergraduate nursing students: a scoping review 6. in this study, organisational climate and organisational culture were regarded as interchangeable. a review of geriatric care training in the undergraduate nursing and medical curricula at the university of kwazulu-natal, sa 7. nursing students in this study had clinical exposure to the following settings: a. community. b. primary care. c. residential facilities. d. hospitals. e. a, b, c and d. f. all of the above. effect of a teaching programme on knowledge of postoperative pain management among nurses at lagos university teaching hospital, nigeria 8. the results of this study showed that there was: a. no improvement in knowledge in the experimental group after the intervention. b. a relationship between the teaching programme and the knowledge of postoperative pain management. c. a relationship between the teaching programme and the knowledge of pain assessment. d. all of the above. factors contributing to poor performance of student nurses in anatomy and physiology 9. the findings of this study revealed that student failure in anatomy and physiology is related to: a. poor teaching strategies. b. short study periods. c. language barriers. d. workload. predicting effect of emotional-social intelligence (esi) on academic achievement of nursing students 10. some of the reasons provided for the satisfactory esi levels of more than two-thirds of the participants were: a. extracurricular activities. b. cultural influences. c. increased attention to emotional domains in teaching. d. summer courses. cpd questionnaire october 2020, vol. 12, no. 3 ajhpe liberalisation of education in cameroon: the liberating-paralysing impact on nursing education 11. in this study, the theme of advancement included the following subcategories: a. increased access. b. policy controversies. c. status recognition. d. personal prejudices. competencies for structured professional development of neonatal nurses in sa 12. the competency framework for the professional development of different categories of nurses in neonatal practice was based on benner’s five stages of development. a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/006/01/2020 (clinical) october 2020 april 2021, vol. 13, no. 1 ajhpe 59 research given the extent of socioeconomic change worldwide, students may need to approach their education at different entry levels or stages of life experience. the nature of diversity this presents requires higher education institutions (heis) to understand the educational aspirations, aims, resources and realities of their students. understanding this diversity, sets the stage for a student-centred response to retention and persistence,[1] where students remain the critical actors in their own education. diversity in heis has increased,[2] partially owing to the widening of access to heis and a grass-roots demand for the realisation of constitutional rights.[3] in a south african (sa) study on the gap between students’ expectations and experience, it emerged that the intensity of such a gap can negatively affect the goal of achieving access and success among learners from diverse backgrounds.[4] on the assumption that all learners may experience varying levels of under-preparedness at some time, the identification of educational approaches that lessen the negative impact of under-preparedness on learning[5] is a worthwhile endeavour for all. notwithstanding social gains (e.g. youth solidarity in an emerging constitutional democracy), hei disruptions and consequent ‘underpreparedness’ resulting from recent student protests (2015 2017) during the ‘fees-must-fall’ and ‘decolonisation of curriculum’ campaign, may have been seen as acceptable or unacceptable struggle opportunity-costs. on the basis of disengaged students being vulnerable, and that students affected by protest disruption are particularly vulnerable, learner engagement has a value proposition that may be promotive of social justice before, during and after any disruption of hei activity. understanding and responding to pervasive and entrenched protest-related issues, approaches such as neoliberalism, colonialism, toxic masculinity and heteronormativity become more probable and palpable when learners are engaged and social justice orientated. the sa prehospital emergency care (ec) system is in transition towards professionalisation.[6] in their ‘mitigation triad for [ec] scope of practice and professional relevance’, naidoo et  al.[7] suggest the consideration of public, practitioner and patient interests. however, practitioner status is contingent upon student enrolment, making it appropriate to document the expectations and experiences of ec learners, as they may be affected by diversity, issues of access and academic epistemology. the programme design process includes the consideration of who the learner is.[8] however, an implementation bias towards who the learner will be may prevail. the aim of this article is to explore learner expectations of, impediments to and enablers for success in undergraduate ec education at an sa university. ‘access and success cannot be achieved without understanding learners’ university expectations and experiences, as these are critical factors that are integrated with retention and success.’[4] background. it is uncertain how descriptions of learner experiences and expectations can influence learner engagement in prehospital emergency care education in south africa (sa). improved access to higher education may imply a greater diversity of life experiences and academic needs. however, neither this diversity nor the consequent disengagement-engagement differential has been documented for the emergency care student body in sa. objectives. to explore the expectations of, impediments to and enablers for success in undergraduate emergency care education. methods. a concurrent (embedded) mixed-methods design was employed. through a prospective online survey, 115 of 249 emergency care learners who were registered in 2014 2018 were sampled. qualitative responses were thematically analysed from a process of mind mapping and dyadic contrasting of codes. results. three propositions emerged: (i) the paradox of programme motivation and subject hindrance suggests that participants were intrinsically and extrinsically motivated for programme completion, but experienced hindrances at the subject level; (ii) there was a perception of insufficient academic interaction and engagement; and (iii) while there were divergent experiences and expectations, coercive contexts for premature attrition in emergency care education prevail. conclusions. sacrifices made by respondents to overcome challenges were identified as a profound loss of time, money and relationships. extrinsic factors affecting learner success included competing demands, institutional structure/processes, teaching quality and online teaching and learning. a learner-centred approach is therefore posited, given expression through learner engagement. if engagement is to become a meaningful social justice practice, then monoculture ideation in emergency care education must be challenged. afr j health professions educ 2021;13(1):59-64. https://doi.org/10.7196/ajhpe.2021.v13i1.1223 learner engagement as social justice practice in undergraduate emergency care education: an exploration of expectations, impediments and enablers for academic success n naidoo,1,2 ndipaec, btech emc, hd ed, mph, phd (forensic med); r matthews,1 ndipemc, btech emc, pgdiphetl, mphil (emergency med) 1 department of emergency medical sciences, faculty of health and wellness sciences, cape peninsula university of technology, cape town, south africa 2 paramedicine, school of health sciences, western sydney university, sydney, australia corresponding author: n naidoo (n.naidoo2@westernsydney.edu.au) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 60 april 2021, vol. 13, no. 1 ajhpe research this article explores the diversity of characteristics and self-appraised academic needs of undergraduate ec learners. the characteristics of ec learners have not been explicitly described in sa, posing challenges for student selection, curriculum design, teaching, learning and assessment, as it is unclear what ec learners’ needs and preferences are. the research questions are therefore: • what are the expectations and experiences of past and present learners of the ec programme? • what are their self-reported enablers of and impediments to success with regard to successful completion of the degree? in a progressive educational dispensation, where learner objectification is counter-productive to social transformation, a standardised programme cannot imply standardised learners/learning, whatever the extent of exclusivity. as graduates conform to the same practice standards in clinical scope, the inherent risk for educators is to impose inflexible pedagogy in pursuit of a singular practitioner identity. however, monoculture ideation in a so-called rainbow nation[9] is indeed paradoxical and prejudicial. furthermore, given that lecturers’ experiences and approaches are not standardised and that typologies of knowledge require diversity in pedagogic practice, the promotion of a monoculture of practice by ec educators (through narrow selection, un-evidenced yet stoic standard setting, inflexible programmes and assessments, and singular approaches to delivery) may contribute to the ‘thingification’ of human beings.[10] new students should not be forced to adopt the teaching culture of the organisation.[11] to avoid an assimilationist approach (fostered by teacher centredness), a learner-centred approach is posited, which gives expression to critical pedagogy through academic interaction and learner engagement. methods in the context of state or institutional interest in improved success, previous interviews with knowledge brokers at six sa universities (2012 2016)[12] led to the development of taxonomy of social justice practices. the taxonomy included ‘epistemological access; values-oriented curriculum; critical pedagogies and professionalism; learner engagement and belonging; critical enquiry and communities of practice; ethical leadership and strategic embedding of practice’.[12] in this study, we take learner engagement to denote the quality of effort that students devote to educationally purposeful activities that directly contribute to the desired outcomes.[13] in so doing, it may promote a sense of belonging and mitigate the risk of alienation, particularly inherent in undergraduate education. a concurrent (embedded) mixed-methods (qual + quan) design, through a critical pragmatist lens,[14,15] was employed to provide descriptions of the ec learner demographic, related experience and programme expectations. lamkin and saleh,[16] in the encyclopedia of curriculum studies, hold that for critical pragmatists, the curriculum is the vehicle to bring about the desired social changes for the advancement of society. the terms ‘student’ and ‘learner’ are used interchangeably on the assumption of risk of polarisation associated with their philosophical inferences, such as the didactic-dialectic denotation of the former or the neoliberal connotation of the latter. ethical approval ethical clearance for the study was granted by the fundani centre for higher education development, cape peninsula university of technology (cput) (ref. no. 017/18). the entire population of ec students had an opportunity to self-administer the electronic questionnaire at their convenience, with unfair exclusion obviated by the use of the existing learner management system. there was a possibility of non-response bias if students who responded differed from those who did not respond in terms of their characteristics and opinions. non-response is an inevitable feature of ethical survey research, in which invited participants exercise autonomy by being free to decline the invitation to participate. informed consent and voluntary participation prevailed. responses were anonymised and researchers were aware of the risk of group harm to the extent that the programme and departmental heads were requested to independently appraise manuscripts for risk of harm. the questionnaire contained open-ended, closed-ended and likert scale questions that explored demographic characteristics, personal circumstances and educational preferences. demographic, registration and learner progression data were obtained from the higher education management information system (hemis). all registered learners in the ec degree programme at one of four sa hei during 2014 2018 were purposely sampled, including recent graduates and early/premature cases of attrition. the early-attrition group included students who were academically excluded (involuntarily) on the basis of repeated failure to complete, as well as those who self-deregistered (considered voluntary, although coercive contexts may have underpinned the decision). this study was aimed at providing direct, primary evidence of student diversity in terms of age groups, self-identified ethnicity, cultural affiliation, social background, prior educational experience, academic potential and university expectations. these elements, among others, are thought to be indicative of student diversity,[4,17] and prominent findings are reported here. using google forms, the link was distributed to 167 registered learners: 19  most recent graduates and 63 former learners (of the early-attrition group); the eligible population was 249. we received 115 voluntary responses from current students/graduates (12 graduates plus 103 respondents with learner registration during the reporting period; response rate 61.8%) and 11 responses from the early-attrition group (response rate 17.4%). overall, the response rate was 50.6%. quantitative and qualitative responses were exported to a microsoft excel (microsoft corp., usa) spreadsheet with unique coding and grouped into an early-attrition sub-group and a group consisting of current learners/graduates. quantitative data were analysed using r statistical software.[18] qualitative responses were categorised using freemind 0.1 open-source mind-mapping software. thematic analysis, using a qualitative description approach,[19] was aided by dyadic contrasting of the attrition and non-attrition groups and of merged and emergent propositions. the dyadic technique of congruity achieves consonance by excluding, defining and contrasting one part of the dissonant dichotomy with the other.[20] results in the interest of describing diversity in this study sample, demographic, registration and learner progression hemis data proved useful. the mean ages at first registration for the population of interest and of the sample were 22.66 years and 25.17 years, respectively. the sample was representative of the population in terms of age, self-reported race and gender. language diversity among respondents included english (n=53; 46.1%), afrikaans (n=31; 27%) and isixhosa (n=22; 19.1%). setswana, isizulu, sepedi, shona and siswati totalled 8.2%. notwithstanding the marital status (only 10 (8.7%) april 2021, vol. 13, no. 1 ajhpe 61 research students were married), 14 (12.2%) were the primary caregivers for children and 21 (18.3%) supported other dependents. noteworthy too is that 16.5% (n=19) indicated that they were breadwinners. three propositions emerged (table  1): (i)  the paradox of programme motivation and subject hindrance suggests that participants were intrinsically and extrinsically motivated for programme completion, but challenges at the subject level created cognitive dissonance; (ii)  there was a perception of insufficient academic interaction and engagement (not necessarily from the early-attrition group); (iii)  there were divergent (majority positive and minority negative) experiences and (met/unmet) expectations, but coercive contexts for premature attrition in ec prevail. theme 1: the paradox of programme motivation and subject hindrance motivation for the programme manifested in self-reported achievement expectations (sub-theme 1.1). most respondents (n=88; 76.5%) cited practitioner competency and proficiency as an achievement expectation, as practitioner eligibility is a prerequisite for employability. the value proposition of the programme included professional status, while the enabling of further study/knowledge was a self-achievement goal. professional standing is valued in a context where ec education is in transition from a short-course system to one that is aligned to a national qualifications framework. most (n=76; 66.1%) respondents did not start with the programme immediately after high school and, of those, many had some healthcare and non-healthcare-related work experience. some participants had other credentials and/or professional registration. qualification attainment was a proximal goal for most participants and a small minority (n=4) cited resilience and agency as academic endpoints. a dichotomy of academic and non-academic challenges emerged. the former involved a heavy workload and competing interests (n=26), poor time management (n=25), insufficient support or poor resources (n=15). the majority of non-academic challenges were financial constraints (n=35), poor time management (n=12) and travel time/distance (n=10). medical rescue was the only subject considered to be both an academic (n=7) and non-academic barrier to success (sub-theme 1.2.) in terms of unplanned expenses. one participant’s view was: ‘i expected [the] bemc [bachelor of emergency medical care] course to be purely medical and i believe the rescue aspect of the course is a complete waste of resources and money. it is the most expensive, yet after completion of the course we are all registered as ecps [emergency care practitioners] not rescue personnel.  in future the university can at least consider making the rescue modules optional for those who are keen.’ notwithstanding all students undergoing exposure to many compulsory rescue applications, spanning the built, wilderness and aquatic environments, medical rescue, as a subject, was portrayed by a minority as a ‘futile’ endeavour. theme 2: the perception of insufficient academic interaction and engagement academic interaction (sub-theme 2.1) may be deficient to the extent that learner autonomy is sacrificed and the threshold/tolerance for enduring ‘suffering’ is increased. academic interaction and engagement were considered a non-academic and academic challenge by students and graduates. incoherent/poor academic planning/interactions were seen as challenges to study completion. staff-learner and learner-learner interactions were regarded as inadequate for addressing the risk of marginalisation of learners, and in the extreme, perceived as harmful. academic challenges (sub-theme 2.1) included study load (most commonly), capacity and perception of content relevance. however, load is relative to competing interests and/or poor time management. insufficiency of resources or lack of support compounds workload dilemmas. an indication of no academic challenge by a few participants may reflect insufficient experience or a need that has been met. infrequent findings in relation to academic challenges included the medical rescue burden (n=7), financial constraints (n=6), poor internet access at their place of residence (n=40; 34.8%) and experiences of racism (n=2) (without qualifying who the alleged perpetrators were). the proposition that emerged is that academic interaction may serve as an intervention toward programme completion. participants cited that support structures or measures (as academic interactions) were needed for study completion. lack of financial and family support completed the majority response to academic challenges (sub-themes 2.1, 2.2). the proposition that emerged is that academic challenges for the attrition group included the promotion/interconnection of resilience, agency and identity (sub-theme 2.2). respondents held the belief that psychological and emotional wellness were mutually exclusive (which may serve to undermine coping strategies). moreover, current academic interactions were seen as inadequate to address learner marginalisation. expectations were met or exceeded for 75 participants. while the majority of learners applied resilience to attain success, a small minority considered the programme insurmountable by design. theme 3: divergent experiences and expectations, and coercive contexts for premature attrition response analysis of the early-attrition group indicated a perceived lack of support/intervention measures that created a coercive context for premature departure (sub-theme 3.1). the presence of divergent (positive/ negative) experiences, in the same programme, among the attrition participants suggests that neither is protective of premature programme exit or retention. some respondents were ambivalent about programme challenges or ‘enjoyment’. a minority of early-attrition respondents were either ambivalent or demonstrated a denial of responsibility and a desire for conditional readmission. table 1. themes and sub-themes theme sub-theme theme 1: the paradox of programme motivation and subject hindrance 1.1: learner motivation for the programme 1.2: medical rescue is considered as an academic and non-academic challenge for the attrition sub-group theme 2: the perception of insufficient academic interaction and engagement 2.1: academic interaction, challenges and support 2.2: academic interaction and engagement are considered academic and non-academic challenges theme 3: divergent experiences and expectations, and coercive contexts for premature attrition 3.1: lack of support measures 3.2: experiences and expectations were diverse 62 april 2021, vol. 13, no. 1 ajhpe research there were diverse and divergent experiences/expectations (sub-theme 3.2). the majority perspective suggested that expectations had been met or exceeded. participant experiences indicated that the programme was acceptable, enjoyable or unacceptably challenging. the lack of enablers by some respondents may suggest the presence of learnt hopelessness. expectations included met expectations, maligned expectations or exceeded expectations, as demonstrated below: ‘this course was not what i expected at all. in the sense that how it was advertised. the politics, power struggles, lecturer-learner relations, administration, expectations etc. even [if ] i knew the truth i still would have studied this degree, [it’s] just the advertisement does not wholly describe this course truthfully. ‘the answer to the latter is no. i have become cynical about the health system and specifically ems as i believe it is not curative or of a problemsolving nature. it has changed me as a person and i struggle to relate to normal humans. my spirituality and sense of [humour] have been affected in a way that is not relatively optimal to who and what i would like to be. my experiences thus far have included highs and lows. my perspective on life has changed, but ironically, it has been skewed away from a pro-life persuasion. issues with colleagues and academics and finances are a given and are not worth mentioning. ‘the medical aspects yes, but not the rescue component of the course. the course is indeed similar to medicine and it has met my expectations. learning new skills and acquiring new medical knowledge every year, has always been my best experience. [t]his equips and empowers me as person …  i do see myself continuing and [graduating] despite my financial situation. the only thing [i] am worried about is the rescue component of this course because it does not quite equip and empower me in the same manner as the medical component of this course. ‘yes, the course has exceeded my expectations with regard to depth of content, the expectations on us as future practitioners, as well as the phenomenal opportunities afforded us during clinical practice. rescue (all its components) has been both a surprising delight as well as an incredibly frustrating challenge. it has most certainly been worthwhile, and i fully intend to complete the degree.’ the sacrifices of the early-attrition group were motivated by the pursuit of personal wellness and family needs, sometimes presented as reciprocal sacrifices. for 56 (48.7%) respondents, they were the first member of their family to access higher education, which nuances the reciprocal obligations. the most frequent non-academic challenge was reported to be of a financial nature. financial constraints were self-identified as ‘causal’ of the premature departure and non-academic challenges (worsened by competing financial demands and work responsibilities). not surprisingly, a reported 48.7% of respondents (n=56) had work commitments while studying, while 57.4% (n=66) of participants had their living costs funded by family or bursaries, and 33.9% (n=39) were self-funded, 10 (8.7%) were unable to cover their living costs. some (n=14) respondents reported that there were no academic challenges or were ambivalent. the second most frequent non-academic challenge was time management (n=25) and related to procrastination and work burden. additionally, long distances and unreliable public transport re-affirmed the education-as-struggle perspective. furthermore, physical fitness was associated with sacrifices in terms of time and effort. the sacrifices can be understood against the finding that 39.1% (n=45) did not spend any time on hobbies or sport activities. a further 38.3% of respondents spent <5 hours per week on hobbies or sports. most support measures that were required related to the need for academic interaction. academic, personal or emotional factors had an interacting and compounding (rather than mediating) dynamic. the desired enabler for success among the earlyattrition group was considered to be staff-learner interaction. the majority view among the attrition group was that health and wellbeing needs were confounders to academic success. discussion theme 1: the paradox of programme motivation and subject hindrance the findings reaffirm that factors related to learner engagement/ disengagement are indeed multifactorial.[21] upon entry to higher education, there is a motivational shift. heis require a greater level of intrinsic motivation (encouraged by a feeling that success is related to one’s own effort), as much of the time is self-organised and much of the work is done without overt reward.[22] the perceived futility of rescue, albeit a minority finding, may imply a disproportionate success-to-effort ratio. many of the other potential attrition factors, such as poverty, were initiated long before entering the hei and are not disputed in the literature. these deep-rooted factors include: academic under-preparedness, low commitment to persist, academic boredom, difficulties managing the transition to university, uncertainties about long-term goals, irrelevance of the university curriculum, social isolation, mismatch between student expectation and early experiences and finance.[22] the study findings centred on the latter four. zepke and leach[23] synthesised 93 studies from 10 countries to develop a learner-engagement conceptual frame that consists of four perspectives: learner motivation; transactions between teachers and learners; institutional support; and engagement for active citizenship. this frame provides contextual resonance with our findings. it proposes learner engagement opportunities,[23] all of which had direct and indirect expression in the study responses. such learner opportunities include enhancing self-belief; enabling autonomous work; enjoying learning relationships with others; and feeling confident regarding ability. for teachers, opportunities include the recognition of their centrality to engagement; the creation of active/collaborative learning; and the fostering of learning relationships. teachers can also create challenging/ enriching educational experiences for learners that extend their academic abilities. they can ensure that institutional cultures are welcoming to learners from diverse backgrounds; promote investment in a variety of support services; adapt to changing expectations; enable active citizenship; and enable social and cultural capital. the abovementioned opportunities summarise the value proposition for learner engagement. theme 2: the perception of insufficient academic interaction and engagement notwithstanding the large majority of this study sample describing the programme as worthwhile, partial control over learning processes may develop confidence and commitment to become learning agents (that is requisite of learner engagement). another requirement for engagement is to cultivate intrinsic motivation, which fosters self-determination. ‘findings acknowledge that active learning in groups, peer relationships, and social skills are important in engaging learners.’[23] when learners are reflecting, questioning, conjecturing, evaluating and making connections between ideas, they are engaged.[23] however, to become engaged, learners must first april 2021, vol. 13, no. 1 ajhpe 63 research feel accepted and affirmed, and have a sense of belonging at an institution. some group activities, such as group work and peer assessment, however, are not benign. in an sa case study of racial and gender problematics, a ‘growing measure of discontent with the process of assessing peer contributions to group tasks emerged, including actual and perceived racial and gender stereotyping, and related rejection-sensitivity’.[24] nonetheless, some innovations to improve learner engagement include the adoption of teaching roles, such as peer assessment/tutoring/mentoring.[25] there are many approaches to dealing with aberrant behaviour that include political incorrectness or disengagement.[26] support services are perceived as part of the institutional culture, and learners are likely to engage when the culture values and supports their efforts to learn. early attrition may arise from the institution’s behaviour or a lack of congruence between individual students and institutional structures, personnel and procedures.[22] the focus on the student experience is a strategy to value subjectivity. the inherent risk of student-institution value malalignment, is that the pursuit of knowledge is undermined.[27] we do not imply the stigmatisation of non-traditional learners by differing approaches, but rather that learners are sufficiently motivated to attend university, prepare before attending and participate in class. we therefore posit that a learner-engagement orientation is desired to promote learner success. theme 3: divergent experiences and expectations, and coercive contexts for premature attrition there is a need to enable learners to develop their social and cultural capital. this kind of capital, however, derives from a sense of belonging. what is needed is a democratic critical conception of engagement as participatory and dialectic, leading beyond the more proximal academic success to success as an active citizen. transformative learning effects of university courses may be seen in the integration of academic learning with practical experience, as is the case in ec. the student can act as a catalyst for this emancipatory perspective, promote ‘transformative and sustainable learning experiences for all involved, not just the student, and contribute meaningfully to civil society – and are particularly pertinent to placements with organisations working for social change’.[28] the learning-throughparticipation approach[29] refers to the experiential learning contexts, where ec learners practise within an ec organisation. such civil society, public or private placements are located at the grass-roots level of communities and provide for a contextualisation of skills, knowledge and attitudes within sociopolitical realities and economic inequity, among other social determinants of health.[30] the roots of the non-academic challenges appear to lie in the absence of privilege. in the systematic synthesis of 32 papers, ‘…  student disengagement was conceptualised as a combination of behavioural, emotional and cognitive domains influenced by intrinsic (psychological factors, low motivation, inadequate preparation for higher education, and unmet or unrealistic expectations) or extrinsic (competing demands, institutional structure and processes, teaching quality and online teaching and learning) factors’.[21] this study emphasised such extrinsic factors: sacrifices made by respondents to overcome challenges include loss of time, money and relationships (the latter two being dominant). however, sacrifices were counterbalanced by coping mechanisms (in the form of coping-orientated sacrifices). statements referring to the programme experience, such as ‘…  it  has changed me as a person and i struggle to relate to normal humans ...’, make compelling argument for institutions to facilitate student skills to foster healthy and supportive relationships and to cope with any inevitable loss of relationships that inevitably invokes a sense of loss and bereavement. as student roles are changing, students, in this study and elsewhere, face a multitude of social and personal issues that intrude into the educational setting and influence persistence and retention.[1] the undertaking of paid work was found to contribute, rather counter-productively, to university attrition in the uk.[22] the financial challenge extends beyond the cost of study to the preceding state of poverty from which students come, lack of financial support from/for family and insufficient income (if any) during the study period. regarding the behavioural economics of attrition in education, factors that are negatively related to student success include a full/part-time off-campus job, hours spent watching television and hours spent commuting to campus.[31] study limitations the study did not measure the competence of educators, their awareness of diversity, and their sensitivity to learner differences, and how they make use of these demographic differences in teaching and learning.[1] future research into a customer focus among this population should ascertain the participants’ learning styles[32] and the programme readiness to satisfy these. in the final analysis, the duty to provide meaningful educative opportunity is overwhelmingly in the hands of the educator,[26] but the learning potential depends on the extent of learner engagement,[33] which is limited somewhat by the abovementioned factors. both educator and learner concepts of current and future professional identity may be given expression through these educative opportunities. conclusion the study makes a knowledge contribution to learner-engagement needs in ec education. it provides useful baseline data on experiences/expectations for intervention development. learner engagement has the potential to provide a deliberate reflective space in which they engage with their unpleasant and pleasant experiences. through learner engagement, the promotion of voice for marginalised groups is upheld. the main contribution is a point of reflection for academics/programme designers and support for learner engagement as a social justice practice. the implications for further research include value mechanisms for subjectivity. finally, ec education should demonstrate a deliberate intention to promote  resilience, support recovery and enable identity creation by the self. it should apply learner engagement as a theory and method of academic interaction that links curriculum to assessment and fosters coherence, promotes agency and redresses learnt helplessness. learner engagement simultaneously redefines the role of lecturer and learner and will likely promote a shared responsibility for academic success. a reduction in negative experiences and coercive contexts and promotion of positive experiences may mitigate early attrition. furthermore, mentoring, tutoring and constructive alignment within and between subjects are supported. student sacrifices should be acknowledged by educators, who should work painstakingly to mitigate the profound learner losses of time, money or relationships. declaration. none. acknowledgements. roxanne maritz (bsc life sciences, bemc, memc) is acknowledged for her contribution to data handling. 64 april 2021, vol. 13, no. 1 ajhpe research author contributions. nn and rm conceptualised the study, developed the data collection instrument and conducted the analysis. nn led the initial manuscript draft. nn and rm approved the final manuscript. funding. this work was supported by the fundani centre for higher education development, cput, through the research and innovation fund for teaching and learning (riftal).  conflicts of interest. none. 1. dumbrigue c, moxley d, najor-durack a. keeping students in higher education: successful strategies and practices for retention. abingdon-on-thames: taylor and francis group, 2001:1-8. https://doi.org/10.4324/9780203062401 2. council on higher education. vital stats: public higher education, 2016. pretoria: che, 2018. 3. south african history. student protests in a democratic south africa. 2019. https://www.sahistory.org.za/article/ student-protests-democratic-south-africa (accessed 1 april 2019). 4. pather s, dorasamy n. the mismatch between first-year students’ expectations and experience alongside university access and success: a south african university case study. j student affairs africa 2018;6(1):49-64. https://doi. org/10.24085/jsaa.v6i1.3065 5. brüssow sm, wilkinson ac. engaged learning: a pathway to better teaching. s afr j high educ 2010;4(3):374-391. https://doi.org/10.4314/sajhe.v24i3.63444 6. sobuwa s, christopher ld. emergency care education in south africa: past, present and future. australas j paramed 2019;16. https://doi.org/10.33151/ajp.16.647 7. naidoo n, zalgaonker m, christopher ld. pre-hospital phlebotomy and point of care testing: relevance and implications for professional emergency care practice. med technol j s afr 2013;27(2):33. https://doi. org/10.10520/ejc150433 8. kern de. overview: a six step approach to curriculum development. in: thomas pa, kern de, hughs mt, chen by, eds. curriculum development for medical education. a six step approach. baltimore: johns hopkins university press, 2016:7. 9. george d. let us revisit the idea of a rainbow nation. news24, 25 march 2018. https://www.news24.com/ columnists/guestcolumn/let-us-revisit-the-idea-of-a-rainbow-nation-20180323 (accessed 2 april 2019). 10. martin b. ethical marxism: the categorical imperative of liberation. illinois: open court publishing, 2008:423. 11. meier c, hartell c. handling cultural diversity in education in south africa. sa-educ j 2009;6(2):180-192. 12. wisker g, masika r. creating a positive environment for widening participation: a taxonomy for socially just higher education policy and practice. high educ rev 2017;49(2):56-84. 13. hu s, kuh gd. being (dis) engaged in educationally purposeful activities: the influences of student and institutional characteristics. res high educ 2002;43(5):555-575. https://doi.org/10.1023/a:1020114231387 14. onwuegbuzie aj, collins km. a typology of mixed methods sampling designs in social science research. qual rep 2007;12(2):281-316. 15. denzin nk, lincoln ys, eds. sage handbook of qualitative research. 5th ed. thousand oaks, ca: sage, 2018. 16. lamkin ml, saleh a. critical pragmatism. in: kridel c, ed. encyclopedia of curriculum studies. thousand oaks, ca: sage, 2010. 17. leach l. exploring discipline differences in student engagement in one institution. high educ res develop 2010;35(4):772-786. 18. r core team. r: a language and environment for statistical computing. 2018. https://www.r-project.org/ (accessed 25 march 2019). 19. sandelowski m. what’s in a name? qualitative description revisited. res nurs health 2010;33:77-84. https://doi. org/10.1002/nur.20362 20. shoham s. society and the absurd: a sociology of conflictual encounters. brighton: sussex academic press, 2006. 21. chipchase l, davidson m, blackstock f, et al. conceptualising and measuring student disengagement in higher education: a synthesis of the literature. int j high educ 2017;6(2):31-42. https://doi.org/10.5430/ijhe.v6n2p31 22. cook t, rushton bs. how to recruit and retain higher education students: a handbook of good practice. abingdon-on-thames: taylor and francis group, 2010. 23. zepke n, leach l. improving student engagement: ten proposals for action. active learn high educ 2010;11(3):167-177. https://doi.org/10.1177/1469787410379680 24. thondhlana g, belluigi dz. students’ reception of peer assessment of group-work contributions: problematics in terms of race and gender emerging from a south african case study. assess eval high educ 2017;42(7):1118-1131. 25. duran fb. considering the role of tutoring in student engagement: reflections from a south african university. j student affairs africa 2017;5(2):1-15. https://doi.org/10.24085/jsaa.v5i2.2699 (accessed 30 march 2019). 26. mccrorie p. teaching and leading small groups. in: swanwick t, ed. understanding medical education: evidence, theory and practice. 2nd ed. oxford: john wiley, 2014:123-137. 27. mieschbuehle r. beyond ‘student experience’. in: hayes d, ed. beyond mcdonaldization: visions of higher education. abingdon-on-thames: taylor and francis group, 2017. 28. sakinofsky p, amigo m, janks a. green sprouts: transformative learning in learning through participation (ltp). educ res soc change 2018;7(2):132-145. https://doi.org/10.17159/2221-4070/2018/v7i2a9 29. mackaway ja, winchester-seeto t, coulson d, et  al. practical and pedagogical aspects of learning through participation: the ltp assessment design framework. j univ teach learn pract 2011;8(3). 30. commission on social determinants of health.  closing the gap in a generation: health equity through action on the social determinants of health. geneva: world health organization, 2008. 31. shireman rm, price jm. prepare for class, attend, and participate! incentives and student success in college. in: castleman bl, schwartz s, baum s. decision making for student success: behavioral insights to improve college access and persistence. abingdon-on-thames: taylor and francis group, 2015. 32. vonderembse ma. crisis in higher education: a customer-focused, resource management resolution. abingdon-on-thames: taylor and francis group, 2018. 33. ivala e, joseph k. student levels of engagement in learning: a case study of cape peninsula university of technology (cput). perspect educ 2013;31(2):123-134. accepted 27 may 2020. https://doi.org/10.4324/9780203062401 https://www.sahistory.org.za/article/student-protests-democratic-south-africa https://www.sahistory.org.za/article/student-protests-democratic-south-africa https://doi.org/10.24085/jsaa.v6i1.3065 https://doi.org/10.24085/jsaa.v6i1.3065 https://doi.org/10.4314/sajhe.v24i3.63444 https://doi.org/10.33151/ajp.16.647 https://doi.org/10.10520/ejc150433 https://doi.org/10.10520/ejc150433 https://www.news24.com/columnists/guestcolumn/let-us-revisit-the-idea-of-a-rainbow-nation-20180323 https://www.news24.com/columnists/guestcolumn/let-us-revisit-the-idea-of-a-rainbow-nation-20180323 https://doi.org/10.1023/a https://www.r-project.org/ https://doi.org/10.1002/nur.20362 https://doi.org/10.1002/nur.20362 https://doi.org/10.5430/ijhe.v6n2p31 https://doi.org/10.1177/1469787410379680 https://doi.org/10.24085/jsaa.v5i2.2699 https://doi.org/10.17159/2221-4070/2018/v7i2a9 june 2021, vol. 13, no. 2 ajhpe 94 short reportshort communication problem the novel covid-19 pandemic is an important inflection point for humanity, with future outcomes being shaped daily by our collective actions across the globe. compulsory lockdowns have meant that universities had to close their doors, causing widespread disruption across the highereducation landscape. although different local circumstances call for different responses, healthcare educators worldwide face unprecedented changes and can learn from one another moving forward. in this short communication, we reflect on our experiences, challenges and potential opportunities as pharmacy educators in south africa (sa) and the usa. in sa, the most popular option for continued education amid the pandemic involved moving curricula onto online platforms. as in many low and middle-income countries (lmics), sa faces significant challenges in technological readiness and availability of critical resources to immediately offer this pedagogy in a way that does not marginalise any students. educators in the usa were also tasked with rapidly transitioning faceto-face pedagogical approaches to online learning experiences. although online platforms and video-conferencing software were commonly in place before the covid-19 pandemic, many instructors lacked experience with these technologies and were forced to quickly adopt unfamiliar teaching modalities. common challenges that have emerged include maintaining pedagogical quality and rigour for students with diverse learning needs, ensuring effective teaching and student engagement, developing reasonable assessment methods of practical skills, and continuing experiential education without compromising student safety or learning outcomes. approach early during the covid-19 pandemic, we facilitated a group discussion between our two faculties to share our approaches to common challenges faced with distance education. from both institutions it was clear that, while recorded lecture formats transmit information, these leave little opportunity for active learning or critical thinking. furthermore, students were struggling to adapt to online learning for a number of reasons. as instructors, the most helpful strategies that we implemented included creating a predictable course structure, allowing options for asynchronous course participation when live participation is not necessary, reaching out to struggling students, making time to solicit their input, and making clear when and how we are available for communication. by creating predictable structure, we can focus our communications on course material  rather than  logistics. we found tools such as poll everywhere, kahoot! and zoom polls to be key to increasing student engagement by distance. we acknowledge that students also require training and support for online delivery, something that was difficult to achieve in the abrupt move to online teaching. when considering teaching and learning, attention to ensuring the integrity of the assessment and therefore legitimacy of the qualification is also warranted. for all involved, transitioning assessments online demands creativity and patience, and training in online assessments would be beneficial for students and instructors. we explored methods, including lockdown browsers and live proctoring via zoom, to promote integrity of remote assessments. at this point, it is difficult to further elaborate on the success of adopted strategies, as research into this is ongoing. beyond the classroom, a greater challenge for many institutions has been how to continue experiential education, as many hospitals and pharmacies close their doors to pharmacy students and other health sciences students. these challenges raise the question of whether phone or video encounters can provide the necessary direct patient-care experience and interprofessional interaction to prepare practice-ready pharmacists. during patient telehealth encounters, for example, students may miss the opportunity to learn from non-verbal communication and make physical assessments that provide important information about a patient’s health and  disposition. despite limitations, it was envisioned that students engaging in care have the chance to overcome communication barriers and learn skills to thrive in a post-covid-19 world remotely, which may embrace telehealth more readily. other skills, such as patient work-up and documentation, can easily be practised if remote medical record access is available. in line with keeping people safe, social distancing has become a civilised norm across the world. compulsory lockdowns have meant that universities closed their doors to students and staff, thus causing widespread disruption across the higher-education landscape. pharmacy education is no exception. as pharmacy educators from institutions in different countries, with an existing partnership, we have identified common challenges between our different educational environments and have benefited from sharing possible solutions. afr j health professions educ 2021;13(2):94-95. https://doi.org/10.7196/ajhpe.2021.v13i2.1445 teaching in the time of covid-19: shared perspectives from south africa and the usa v bangalee,1 bpharm, mpharm, phd; o garza,2 phd, mba; f oosthuizen,1 bpharm, msc, phd; v perumal-pillay,1 bsc hons, bpharm, mmedsci, phd; h rotundo,2 bs, pharmd, bcacp, cdces 1 discipline of pharmaceutical sciences, school of health sciences, university of kwazulu-natal, durban, south africa 2 university of louisiana monroe, college of pharmacy ‒ new orleans campus, usa corresponding author: f oosthuizen (oosthuizenf@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 95 june 2021, vol. 13, no. 2 ajhpe short reportshort communication outcome in the midst of tragedy, challenges and disruptions posed by the coronavirus, if we are attentive, we may find ways to improve teaching of the world’s future pharmacists through the lens of this pandemic. through the impact of the coronavirus we can teach our students the critical importance of managing chronic diseases, such as diabetes and heart failure. as the pandemic highlights shortcomings of our healthcare systems, we can point to ways that pharmacists improve care, fill gaps and make a difference in patients’ lives. declaration. none. acknowledgements. drs v bangalee and v perumal-pillay are university of kwazulu-natal (ukzn) developing research innovation, localisation and leadership in south africa (drill) fellows. drill is a national institutes of health (nih) grant (d43tw010131) awarded to ukzn in 2015 to support a research training and induction programme for early career academics. author contributions. all authors contributed to conceptualisation of the article. hr and vb wrote the manuscript. all authors contributed to editing of the document. fo prepared the manuscript for submission. the content is solely the responsibility of the authors and does not necessarily represent the official views of drill and the nih. funding. none. conflicts of interest. none. accepted 12 january 2021. 140 october 2020, vol. 12, no. 3 ajhpe research professional nurse training in south africa (sa) takes place within public nursing colleges, which are spread over the nine provinces. there are 14 such public nursing colleges in sa, with 34 sub-campuses. professional nurse training is offered in terms of regulation r425 of the nursing act no. 50 of 1978, leading to registration as a nurse (general, psychiatry and community) or midwife. anatomy and physiology (a&p) is a core subject taught in the first year of training.[1] the expectation is that on completion of education and training, students should have good observational, analysis and problem-solving skills, since modern nursing requires awareness of interactions between anatomical and physiological systems in pathological processes.[2] a background in a&p for the 4-year comprehensive basic nursing course is part of strict entry requirements for nursing students. life sciences entail basic terminology that is used in human anatomy and physiology, and therefore form part of the admission requirements for the 4-year comprehensive basic nursing course. without passes in life sciences, nursing colleges in sa do not admit applicants, regardless of their grade 12 score, to ensure that all students have at least a foundation in a&p.[3] the entry requirements for nurse training at the public nursing colleges in sa also include a grade 12 certificate with a minimum score of 25. admission requirements in australia are similar to those in the colleges under study, as mathematics, science and english are the prerequisite subjects for admission.[4] in ghana, english, mathematics, science and some age restrictions are basic requirements for admission. unlike in sa, applicants must be between the ages of 18 and 35 years. this means that applicants under or over the stipulated age categories are excluded from the applications even if they meet the other requirements for admission.[5] however, as reflected in a study conducted by mcvicar et al.,[2] regardless of strict entry requirements, the performance of student nurses in biological subjects is poor, and this is a global phenomenon. in the uk, first-year nursing students struggle with the biological subjects. a&p as a biological science subject creates a solid foundation for nursing because it provides a simple approach to describing the body’s systems. understanding of basic medical and surgical conditions is based on the application of knowledge gained in these subjects.[6] statement of the research problem a&p is a core subject in nursing curriculum; it provides necessary knowledge of the structure and function of the human body. the knowledge gained from a&p provides the foundation for all nursing subjects: for instance, a student cannot learn how to assist a mother during birth without knowledge of the anatomy of the pelvis. the biological sciences entail human a&p, and this is a core subject in nurse training. in australia, students who opted for nursing as a career but did not do natural or life sciences in secondary school performed poorly in a&p.[7] analysis of results at the college campuses under study in a&p from 2014 to 2017 indicated that the performance of student nurses in a&p fluctuated. the pass rates during the period between 2014 and 2017 fluctuated between 54% and 70%. the researchers wanted to identify the factors contributing to the unsustainable performance of student nurses in a&p, in order to develop measures to ensure that performance improves to close to 100%, as envisioned by the college, and is sustained at that level. at present, despite having a secondary school background in a&p, students struggle with the subject.[8] the implications of this problem for students are that the students will not be able to master nursing and midwifery as subjects, since a&p is background. student nurses in south africa view anatomy and physiology (a&p) as the most complex subject in the nursing curriculum. objective. to describe the factors contributing toward inconsistent and fluctuating performance among student nurses doing a&p as a subject. methods. the study adopted a quantitative descriptive design. census sampling was used to draw a sample size of 114 respondents. a structured self-administered questionnaire with close-ended questions was used to collect data from the six nursing campuses under study. raw data were captured using excel spreadsheets, and descriptive and inferential statistics were used to analyse data. results. the key findings were: (i) poor teaching strategies contributed to subject failure; (ii) lack of after-class sessions had an impact on failure; (iii) a shorter study period for examinations contributed to failure; and (iv) a language barrier also played an important role in students’ failure in a&p. conclusion. student nurses struggle with and find a&p in nursing programmes challenging and anxiety-provoking. nurse educators need to come up with innovative teaching strategies that will ensure an integrative approach to link theory to practice and to link sciences throughout curricula. support programmes are needed to help students enhance performance in a&p. the examination schedules should be adjusted so that student nurses have enough time to study, and nurse educators should engage students in active learning. afr j health professions educ 2020;12(3):140-143. https://doi.org/10.7196/ajhpe.2020.v12i3.1357 factors contributing to poor performance of student nurses in anatomy and physiology x l mhlongo, mcur (nursing education); t e masango, phd (nursing education) charles johnson memorial nursing campus, nqutu, south africa corresponding author: t e masango (masante@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 141 research essential to understanding the physiology and pathophysiology of a patient’s condition, and the related treatment. they will not be able to provide safe nursing care without success in this module (for example, the names and locations of injection sites are covered in the module). to the best of our knowledge, there is currently no literature in sa on factors contributing to the failure of student nurses in a&p. therefore the present article aims to describe the factors contributing toward inconsistent and fluctuating performance among student nurses in a&p. methods a quantitative, descriptive research design was used in the study to explain and describe factors contributing to the failure of students in a&p. the system of education and training in kwazulu-natal province is unified, meaning that there is one college with 10 campuses spread over the province. the study was conducted in the kwazulu-natal college of nursing, which has 10 nursing campuses. the researchers selected 6 campuses purposively because they contained those second-year student nurses who had completed and passed a&p. the selected campuses were identified as locations a f, to maintain anonymity. the inclusion criteria were all second-year student nurses on the selected campuses. first-year student nurses were excluded from the study because they were still studying a&p, and thirdand fourth-years were excluded because some campuses did not include such levels. there were 170 second-year student nurses who met the inclusion criteria. census sampling was used to select the respondents. student nurses who met the inclusion criteria but did not consent to participate in the study were excluded, thus voluntary participation in the study was ensured. a sample of 114 second-year student nurses was selected and enrolled in the study. the number of respondents from each of the campuses were: campus a, 21 respondents; campus b, 10; campus c, 24; campus d, 20; campus e, 23; and campus f, 16. the respondents who were selected received questionnaires and consent forms as part of the data collection process. the self-administered structured questionnaire was used to collect data. the questionnaire was developed following a review of the literature. the questionnaire consisted of four sections. in section 1, respondents’ demographic information was gathered; section 2 covered respondents’ academic performance; section 3 examined respondents’ attitudes towards a&p; and section 4 examined their general perceptions of a&p, comprising 18 items, from simple responses to rating scales to graded 5-point likertscale options with ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ or ‘strongly disagree’ as optional answers to provided statements. a pre-test was conducted with five respondents, and thereafter, data collection started on 11 april 2018, continuing until 4 may 2018. the process of data collection took place on the six nursing campuses under study. it took place during respondents’ lunch time, during a free period or after school. this was to prevent disturbance during teaching and learning. on arrival at each campus, respondents were gathered in one large classroom. the purpose of the study was fully explained to the respondents by the researchers, and they were given consent forms to sign to indicate their voluntary participation. completion of the questionnaire was scheduled to take 20 30 minutes, although some questionnaires were answered in 10 15 minutes. two sealed boxes, one for consent forms and the other one for questionnaires, were provided to the respondents, so that the signed consent forms could not be linked to the questionnaires, to ensure anonymity. data analysis the completed questionnaires were collected, and all items were coded appropriately and entered into an excel spreadsheet (microsoft, usa). the items were then cross-checked for accuracy. coded data were transferred to spss (ibm corp., usa) version 24. demographic data were presented in frequencies and percentages. a reliability test was conducted to statistically determine the level to which the selected set of items measured a single latent construct. cronbach’s α coefficient was computed to statistically assess the degree to which similar responses could be obtained from participants should the same set of questions be asked several times under similar settings to the same group of respondents. data management a password-protected laptop was used to store all data that were electronically captured. all data in the form of hard copies were stored in a researcher’s locked cabinet. ethical consideration ethical clearance to conduct the study was obtained from health studies research and ethics committee of the university of sa (ref. no. hshdc/786/2017) and from the national health research database board (ref. no. kz_201803_012) of sa. permission was granted by the principal of the kwazulu-natal college of nursing and also by the principals of the six campuses under study. results the respondents’ demographic profiles showed that: 70% (n=80) were females; 46% (n=53) were aged 20 24 years old and 27% (n=31) were 25 29 years old; 74% (n=84) were black african and 19% (n=22) were indian; and 58% (n=66) had completed matriculation (grade 12) after 2008 and 42% (n=48) completed before 2008. regarding the schools attended in matriculation (grade 12), 40% (n=46) had attended rural schools, 30% (n=34) suburban schools and 29% (n=33) township schools (table 1). a structural equation model of overall academic performance v. general perceptions showed that only ‘2 hours for the subject examination’ exhibited a positive effect on students’ performance in a&p, although statistically, the 2-hour examination had an insignificant effect on students’ overall academic performance (z-statistic=1.13; p>0.05). although statistically insignificant, all the remaining items were generally perceived to contribute to high failure rates of student nurses in a&p. cronbach’s α coefficient value (α=0.700) for the finally selected 18 items satisfied the minimum acceptable threshold of 0.700 scale reliability score. the result therefore reveals that items measured a single-dimensional latent construct (table 2). discussion the present study determined the factors that contributed to student failure in a&p, which were: poor teaching strategies; lack of after-class sessions; shorter study period for examinations; and a language barrier. these factors are in line with results from previous studies. the majority of respondents (43%) reported that poor teaching strategies of nurse educators were viewed as not being effective in producing good results in a&p. according to pinehas et al.,[8] in a study conducted in oshana, namibia, participants found that poor teaching strategies, poor student-teacher relationships, and communication 142 october 2020, vol. 12, no. 3 ajhpe research barriers affect academic performance. in a study conducted in the eastern cape province, sa, tom et al.[9] suggested that nurse educators should fully assist students as part of their educational strategy to help students to understand a&p. this shows that a good relationship between the educator and students improves student learning outcomes. the majority of respondents (39.5%) reported that lack of after-class sessions for those students who did not understand the content contributed to failure. this is similar to the study conducted by tom et al.,[9] which found that students’ performance improved when students participated in after-class sessions on academic concepts and general academic and writing skills, and were provided with feedback on assignments. in their study, tshotsho et al.[10] reported that students gave positive feedback, and described individual class sessions as one of the most useful aspects of the programme. learning centres that teach students who speak english as a second language (esl) skills such as grammar, vocabulary and pronunciation have been found to be useful. in their study, pinehas et al.[8] found that students, especially those considered slow learners, needed more support from their nurse educators to understand what they had been taught. shorter study periods before examination were viewed by the majority of respondents in the present study (44.7%) as a contributory factor to failure. similarly, alos et al.[5] reported that among other factors, constrained study time and limited time in examinations contributed to student failure. alos et al.[5] further showed that demographic and cognitive factors had different effects on student performance in different disciplines. the study also showed that five main factors contributed to student failure, namely personal conditions, study habits, shorter study and examination times, shorter breaks and home aspects, such as the language commonly used. the system of limited study days, combined with a short, overloaded exam schedule negatively impacted student performance. pinehas et al.[8] revealed that nursing students reported that the examination schedule impacted their performance badly, especially if there was a short break during the examination and one or more modules were written in a day or in a row. additionally, many respondents (48%) reported that the language barrier contributed to failure of student nurses in a&p. students are not taught in their vernacular, and all text books are written in the english language. according to langtree et al.,[11] esl students have difficulties with the english language in the first semester of study, which affects the study of new and complex terms, which in turn negatively affects first-year nursing students and leads to high failure rates.[11] students’ home languages therefore have an influence on their performance at first-year level. an evaluation of a blended learning approach in an a&p module for nursing students revealed that participants encountered difficulties in using new and complex terms and concepts.[12] for this reason, students reported that a&p was the most difficult subject in nursing programmes. on the contrary, however, manson[13] reported that participants with higher matric scores in isizulu performed well academically in several nursing subjects compared with speakers of english or other languages. recommendations the recommendations below are drawn from comments by the respondents, and from the literature, and may be utilised by nurse educators to facilitate effective teaching of a&p: • use of the following should be considered: presentations by peers (peer group teaching), poems, songs, storytelling and visuals; a skills laboratory for visualisation of models; anatomy quizzes and puzzles. • examination schedules should be adjusted so that student nurses have enough time to study. table 1. respondents’ demographic profile (n=114) characteristic n (%) gender male 34 (30) female 80 (70) race white 2 (2) indian 22 (19) coloured 6 (5) black african 84 (74) age, years 15 19 10 (9 ) 20 24 53 (46) 25 29 31 (27) 30 34 17 (15) ≥35 3 (3) period matric completed before or during 2008 48 (42) after 2008 66 (58) school type attended during matric (grade 12) rural 46 (40) township 33 (29) suburban 34 (30) finishing/bridging school 1 (1) table 2. structural equation model of overall academic performance v. general perceptions items (n=114)* structural overall academic performance coefficient robust se z p>ιzι 95% ci 2 hours for the subject examination 0.096 0.085 1.13 0.257 –0.070 0.264 teaching strategies –0.062 0.108 –0.58 0.564 –0.276 0.150 1-day study in between exams –0.068 0.077 –0.89 0.371 –0.219 0.082 home language –0.005 0.081 –0.07 0.942 –0.165 0.153 no after-class sessions provided 0.020 0.085 –0.24 0.808 –0.187 0.146 construct 2.347 0.459 5.11 0.000 1.446 3.248 overall academic performance 0.818 0.084 0.668 1.000 se = standard error; ci = confidence interval. *estimation method = ml. log likelihood =–487.277. october 2020, vol. 12, no. 3 ajhpe 143 research • support programmes are needed to enhance performance in a&p. • future research should be conducted on factors contributing to the failure of student nurses in a&p; studies should include other provinces and universities. study limitations the present research was conducted only at those six campuses of a public nursing college that had second-year nursing students. a sample size of 114 student nurses was obtained. consequently, the findings cannot be generalised to other nursing colleges, nursing education institutions or provinces. the questionnaire was closeended and did not allow respondents to state their views. conclusion the results showed that home language significantly affected students’ overall academic performance in a&p at a public nursing college. conversely, students’ overall academic performance in a&p was constrained by: poor teaching strategies; lack of after-class sessions; shorter study period for examinations; and the language barrier. declaration. this article was based on a study done by xlm in fulfilment of his ma in nursing science. acknowledgements. the authors are grateful to all their co-workers for their support and guidance during the writing of this article. author contributions. xlm: identified the research topic, conceptualised the study design, formulated the research aim and objectives, performed the collection and interpretation of data and drafted a version of the article. tem: supervised the study and assisted with writing of the article. both authors approved the final version of the manuscript. funding. none. conflicts of interest. none. 1. montayre j, sparks t. important yet unnecessary: nursing students’ perceptions of anatomy and physiology laboratory sessions. teach learn nurs 2017;12(3):216-219. https://doi.org/10.1016/j.teln.2017.03.009 2. mcvicar a, andrew s, kemble r. the bioscience problem for nursing students: an integrative review of published evaluations of year 1 bioscience, and proposed directions for curriculum development. nurs educ today 2015;35(3):500-509. https://doi.org/10.1016/j.nedt.2014.11.003 3. department of health studies, kwazulu-natal college of nursing. curriculum: diploma in nursing (general, community and psychiatry) and midwifery. pietermaritzburg: government printer, 2010b. 4. ralph n, rogers c. entry requirements in nursing: results from a national survey of nurse academics on entry requirements in australian bachelor of nursing programs. https://doi.org/10.1016/j. colegn.2018.06.005 5. alos sb, caranto al, david jjt. factors affecting the academic performance of the student nurses of bsu. intern j nurs sci 2015;5(2):60-65. https://doi.org/10.5923/j.nursing.20150502.04 6. ross aw, wilson ag. anatomy and physiology in health and illness. 12th edition. edinburgh: elsevier, 2015. 7. cox jl, crane cj. shifting the focus: increasing engagement and improving performance of nursing students in bioscience subjects using face-to-face workshops to reduce anxiety. inter j innov sci math educ 2014;22(7):11-22. 8. pinehas ln, mulenga e, amadhila j. factors that hinder the academic performance of the nursing students who registered as first year in 2010 at the university of namibia (unam), oshakati campus in oshana, namibia. j nurs educ prac 2017;7(8):63-71. https://doi.org/10.5430/jnep.v7n8p63 9. tom f, coetzee i, heyns t. factors influencing academic performance in biological sciences among students in a nursing education institution in the eastern cape province of south africa: an appreciative inquiry approach. afri j phys health edu recreation dance 2014(suppl 3):s102-s115. 10. tshotsho b, mumbembe l, cekiso m. language challenges facing students from the democratic republic of congo in a university in south africa. inter j educ sci 2015;8(3):597-604. https://doi.org/10.1080/09751122.2 015.11890281 11. langtree em, razak a, haffejee f. the effect of speaking english as a second language on the study of anatomy and physiology in the nursing programme. s afr j higher educ 2018;32(1):129-139. https://doi.org/10.20853/321-793 12. white s, sykes a. evaluation of a blended learning approach used in an anatomy and physiology module for pre-registration health care students. paper presented at the fourth international conference on mobile, hybrid, and on-line learning held on january 30, 2012 to february 4, 2012 in valencia. london: university of huddersfield, 2012. 13. manson ta. the relationship between matriculation english results and academic performance in nursing students at the kwazulu-natal college of nursing. durban: durban university of technology, 2014. accepted 19 june 2020. https://doi.org/10.1016/j.teln.2017.03.009 https://doi.org/10.1016/j.nedt.2014.11.003 https://doi.org/10.1016/j.colegn.2018.06.005 https://doi.org/10.1016/j.colegn.2018.06.005 https://doi.org/10.5923/j.nursing.20150502.04 https://doi.org/10.5430/jnep.v7n8p63 https://doi.org/10.1080/09751122.2015.11890281 https://doi.org/10.1080/09751122.2015.11890281 https://doi.org/10.20853/32-1-793 https://doi.org/10.20853/32-1-793 december 2019, vol. 11, no. 4 ajhpe 139 research laboratory medicine is part of the total process of healthcare.[1] biomedical technologists are an essential part of the interprofessional healthcare approach. they perform routine and complex laboratory tests, which guide clinicians in diagnosing diseases and treating patients. the role of biomedical technologists is changing at an unprecedented pace – from being mere providers of test results to becoming partners in healthcare.[2] in south africa (sa), the national diploma in biomedical technology is a 3-year university undergraduate qualification. an additional 1-year mandatory internship training at an accredited medical laboratory is a prerequisite to write the national board examination and for registration with the health professions council of south africa (hpcsa) as a qualified practitioner. the south african national blood service (sanbs) is an accredited training institution providing internship training in the discipline of blood transfusion. biomedical technologists need to have knowledge of a diverse group of medical specialties, as well as leadership skills and professional attributes that will enable them to function successfully in interdepartmental multidisciplinary healthcare teams[3] – all aimed at quality patient care. baingana et al.[4] explain that patients entrust their health to healthcare workers, who are expected to have a high degree of professionalism. professionalism is an integral part of clinical practice in allied health and medical fields[5] and must be reinforced in health practitioners.[6] educational curricula are usually explicit in defining knowledge and skills development. contrary to this, professionalism has traditionally been part of the hidden or informal curriculum and known to be ‘caught rather than taught’.[4] the literature currently points to the growing threat of professional values and work standards being compromised in the medical and health science fields.[4,7,8] consequently, the need for improving instruction on professionalism in medical education[9] is widely supported. one of the authors (vr), who is a health science educator at the sanbs, found that several students demonstrated poor professional behaviours during their internship training, which often persist as they progress into their careers. failure to follow instructions, error rates, poor compliance to laboratory work standards and counselling of the interns by their superiors bear testimony to the identified poor attitudes, behaviour and work standards. the broad aim of the study was to determine the interns’ understanding of professionalism and to explore the need for structured teaching of professionalism. gaining insight into the interns’ perceptions was used as a needs analysis to upscale and strengthen the internship curriculum by including teaching of professionalism, as indicated by the study. as very little knowledge is available on the teaching of professionalism in the field of biomedical technology, the study also aimed to unpack what professionalism entails and how it should be taught. background. biomedical technologists are key role players in the diagnosis of disease and serve as consultants for the appropriate use of medical laboratory services, making them essential partners in interprofessional healthcare. the blood transfusion biomedical technology national internship curriculum strongly emphasises knowledge and laboratory skills development. very little has been published on research regarding biomedical technology interns’ knowledge, understanding and development of professionalism, which prompted this study. objectives. to determine intern blood transfusion biomedical technologists’ understanding of professionalism and to explore potential strategies for effective teaching of professionalism for improved practice. methods. a mixed-methods research design was used, consisting of a curriculum analysis, followed by a questionnaire in the quantitative phase of the study and focus group interviews in the qualitative phase. a statistical analysis of qualitative data indicated a trend in the perceptions of interns, while the qualitative data were thematically coded and analysed. results. professionalism had different meanings for different individuals, but a strong focus on ethical conduct evolved. professionalism in education was not only a deficiency in the internship curriculum, but was also absent in the various university undergraduate biomedical technology curricula. the need for structured teaching of professionalism was strongly supported by the interns and their educators. a host of active and interactive approaches to the teaching of professionalism was suggested to achieve the goal of elevating the role of biomedical technologists in the interprofessional healthcare approach. conclusions. professionalism needs to be purposely taught to ensure a consistent understanding and to inform practice. reviewing and upscaling of the internship and the university undergraduate biomedical technology curricula are needed to include explicit teaching of professionalism. afr j health professions educ 2019;11(4):139-144. https://doi.org/10.7196/ajhpe.2019.v11i4.1101 the imperative of teaching professionalism to biomedical technologists v rambiritch,1 btech biomedical technology, pgdip hpe, mphil hpe; a smith-tolken,2 ba socsc, mphil, phd 1 learning and development, south african national blood service, johannesburg, south africa 2 department of sociology and social anthropology, faculty of arts and social sciences, stellenbosch university, cape town, south africa corresponding author: a smith-tolken (asmi@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 140 december 2019, vol. 11, no. 4 ajhpe research methods a mixed-methods design guided the study, consisting of a curriculum analysis, a questionnaire and focus group discussions. the questionnaire provided quantitative data using likert-scale answers. it aimed at identifying trends related to how and where the respondents placed themselves in terms of understanding professionalism and their perspectives regarding the need for professionalism education. the focus group discussions that followed generated qualitative data regarding perceptions on what and how professionalism should be taught. the researcher (vr), who facilitated the focus group discussions, was not involved with teaching of the interns at the time of the study to ensure that respondents were not coerced into participation. each participant completed and signed a consent form before participation. the sampling was purposive and included the interns and educators involved with internship training at the sanbs. all 54 interns enrolled in the sanbs internship programme across sa at the time of the study were invited to complete the questionnaire and participate in the focus group discussions. all 8 sanbs educators were invited to participate in a separate focus group discussion. fifty interns completed the questionnaire, providing a response rate of 92.59%. a total of 28 interns and 4 educators (n=32) participated in 5 focus group discussions. the interns had completed their undergraduate biomedical technology studies at different universities in sa. the quantitative data were statistically analysed, coded and categorised into themes. the qualitative data were coded through thematic analysis and categorised into themes. both sets of data were compared through triangulation to develop the overall findings, which culminated into four main emerging themes that are presented in the findings in this article. blood transfusion biomedical technology internship programme – curriculum analysis curriculum defines the learning during a course or programme[10] in terms of knowledge, skills and attitudes. curriculum analysis provides an opportunity to evaluate the efficiency of a curriculum with regard to its content, appropriateness and instruction. the national internship curriculum was analysed according to an adapted version of harden’s 10 questions for curriculum analysis[11] and is presented in table 1. ethical approval ethical approval for the study was attained from the sanbs (ref. no. 2014/21) and stellenbosch university medicine and health sciences research ethics committee (ref. no. s15/04/069). results table 2 shows the strengths and weaknesses of the internship curriculum by using the framework presented in table 1 as a lens. the curriculum analysis showed adequate focus on technical knowledge and routine laboratory skills development. however, it was deficient in guiding the development of professional values, and also lacked guidelines for leadership development and mentorship models to guide and support students. table 1. curriculum analysis framework applied to the blood transfusion biomedical technology curriculum no. question 1 what is the purpose of the internship programme? 2 are the learning outcomes relevant and appropriate to the broad programme? 3 is the content adequate, relevant and is there enough time to ensure learning? 4 are the theoretical and practical learning areas of the programme appropriately integrated? 5 what teaching strategies are applied to achieve outcomes and are they effective? 6 are there opportunities for structured teaching of professionalism, humanistic and ethical values? 7 are assessment methods fit for purpose in measuring outcomes? 8 do the educators have the knowledge, skills and resources to deliver the programme? 9 are there systems in place for guidance and support of learners? 10 is the curriculum adequately evaluated? table 2. strengths and weaknesses of the internship curriculum strengths weaknesses • the internship programme has a meaningful purpose that relates to the overall broad biomedical technology programme, with strong technical and scientific focus • the learning outcomes are clear, specific and achievable within the duration of the programme • resources needed for the development of routine practical laboratory skills are appropriate and adequate • practical learning follows theoretical learning, which provides good integration of learning • assessment methods for knowledge and practical assessments are fit for purpose and appropriately matched to learning outcomes • opportunities for learner support and feedback are in place • the educators have the knowledge and skills to guide and support learning • overload of theoretical content in preparation for the national board examination, with little focus on fieldwork experience • inadequate opportunities for development of non-routine/ specialised practical laboratory skills • inadequate opportunities for critical analysis of laboratory procedures and case study interpretations • lack of selfand peer assessment • the same stakeholders routinely evaluate the curriculum • absence of outcomes related to development of student leadership and of professional and humanistic values • absence of dedicated mentorship models december 2019, vol. 11, no. 4 ajhpe 141 research a host of basic themes emerged from analysis of the quantitative and qualitative data. the basic themes were categorised into subthemes that evolved into 4 main themes. a breakdown of the basic themes, subthemes and main themes is presented in fig. 1. graphs containing the quantitative data indicate the preferences of respondents, while the qualitative data are discussed with direct quotes from respondents in the focus group discussions. in the findings, fg refers to the focus group and is used to link direct quotes from the respondents to the respective focus group 1. meaning of professionalism personal ethics role ethics work ethics part of oneself morals and values self-respect institutional role attire understanding one's role technical competence work standards altruism work passion con�dentiality punctuality respect teamwork consideration consistency communication positive attributes negative attitudes that lead to poor professionalism favouritism nepotism gossip plagiarism professionalism work environment 3. in�uences on professionalism development conscious awareness millennial generation need teaching informs practice inadequate curriculum high school tertiary education workplace – internship explicit expectations lectures role plays poe workshops newsfeeds role models mentorship evaluation and re�ection 2. attributes of professionalism home environment life experiences tertiary education primary/secondary education 4. teaching professionalism rationale when to teach how to teach fig. 1. basic themes, subthemes and main themes. (poe = portfolio of evidence.) 142 december 2019, vol. 11, no. 4 ajhpe research discussions. focus groups 1 4 included intern participants, while focus group 5 included educator participants. the quotes given below substantiate the statements that precede them regarding what is perceived as professional behaviour and identity. theme 1: meaning of professionalism the meaning of professionalism was equated with ethical behaviour and linked to professional role and identity. some of the respondents perceived professionalism as relating to one’s inherent morals and values, which form part of one’s identity as a person: ‘i also see professionalism as some sort of natural instinct … our morals, your own values, your common sense as to what is right and wrong.’ (fg1) attire symbolises professionalism and contributes to one’s professional role and identity, which serve to entrench public trust and faith in health professionals: ‘once you wear that uniform you must, you must show you are here to save a life, people must have faith in you and when people see us, they must have faith in us.’ (fg2) technical competence is imperative to save lives by performing highstandard transfusion testing and providing safe, compatible blood for transfusion to patients: ‘professionalism would be to acknowledge that i am competent in what i’m doing. i have the skills and knowledge behind it.’ (fg1) ethical conduct manifested from understanding one’s role and purpose within the profession. a sound understanding of that role encouraged ethical behaviour. perceiving their role as essential in healthcare determines the way in which work ethics are maintained. the questionnaire responses showed that 100% of the respondents agreed that they had an essential role in healthcare. the focus groups, however, revealed that the interns and their educators felt that some biomedical technologists lacked an understanding of professionalism and the importance of their role in healthcare, which affected their attitudes and work standards: ‘from their behaviour, i think some have an understanding of professionalism, but not everybody. i don’t think they know where they fit in healthcare.’ (fg5) one of the roles of biomedical technologists is to advise other healthcare professionals with regard to laboratory testing and appropriate use of blood aimed at preventing blood wastage and reducing healthcare costs. collaboration with doctors and providing them with guidance were sometimes challenging. subsequently, professionalism meant more than being a biomedical technologist; it was about taking on a leadership and advisory role, despite such challenges: ‘… some of them [the doctors] feel like you don’t know what you are doing. then when you tell them the right thing they respect you.’ (fg3) negligence is perceived as a classic demonstration of poor work ethics that compromises work standards, with the potential to cause harm to patients. the interns indicated that some practitioners have a poor attitude and little fear of making errors, which could influence the wellbeing of patients: ‘they don’t follow the sop [standing operating procedure]. anything can happen to the patient … that’s unprofessional.’ (fg4) this theme concluded that professionalism had different meanings for different respondents, and was reflected in three distinct domains of personal ethics, role ethics and work ethics. theme 2: attributes of professionalism the respondents also described specific attributes that encourage positive professional development, and negative attitudes that hamper professionalism. the essential positive attributes of professionalism included altruism, work passion, commitment, dedication, confidentiality, punctuality, respect, teamwork, consistency, being considerate and good communication skills: ‘i would say commitment and dedication; it goes with your passion for work.’ (fg3) the inverse of the abovementioned positive attributes constituted unprofessional behaviour; such behaviours impacted negatively on the work environment. negative behaviours described by participants included nepotism, favouritism, plagiarism and gossip: ‘you create a bad environment when you end up having people who gossip about each other.’ (fg4) overall, the interns showed good awareness of the required professional attributes and inappropriate negative attitudes. theme 3: influence on development of professionalism fig. 2 shows that several factors influenced the interns’ understanding of professionalism. the work environment, however, emerged as the most dominant determinant. the interns ascribed their exposure to both positive and negative behaviours in the workplace. negative attributes demonstrated by colleagues had a negative influence on the conduct of some interns, while good role modelling by some practitioners contributed positively to the professional development of other interns: fig. 2. influences on the understanding of professionalism (n=50). work environment 40 30 20 10 0 in te rn s, n 8 5 18 21 33 home environment primary/ secondary school tertiary education life experiences december 2019, vol. 11, no. 4 ajhpe 143 research ‘the way they carried themselves, the commitment that they had for their work … this is what i’m here for. now they showed professionalism.’ (fg4) in addition to the attitudes and behaviours of workplace colleagues influencing the interns, intrinsic factors such as their upbringing, morals, values, selfreflection and reflection on workplace activities also contributed to their development of professionalism: ‘… your upbringing, your morals, your own values, your common sense as to what differs to what, your resistance to stay true to what you believe in.’ (fg1) theme 4: teaching professionalism the questionnaire responses indicated that 40% of the respondents had been exposed to some education on professionalism development. however, 82% indicated the need for formal teaching of professionalism. exploring the rationale for teaching professionalism, the interns and educators responded differently. interns indicated that professionalism should be taught to instil conscious awareness of appropriate behaviours and conduct; it must be taught for it to be applied. the educators felt that professional values were not inherent in millennials; hence the need to teach these: ‘… the old school people they came with those values. they didn’t have to be taught, it was part of them naturally.’ (fg5) the educators’ perceptions of millennials were interpreted as bias because no substantial evidence was provided to support their views. the literature points to professionalism deteriorating globally,[7] but there is no scientific evidence to categorise millennials as a particular group lacking professionalism. the educators’ feedback on the imbalances that existed in the internship curriculum offered a useful perspective. they pointed out the dominant focus on technical knowledge and practical skills development, with inadequate opportunities for the development of humanistic values and people skills: ‘… also the focus of the training is knowledge and skills.’ (fg5) ‘they have the knowledge and skills but they can’t communicate properly.’ (fg5) there was agreement among interns that professionalism education should be included in the life-orientation curriculum for secondary school education. it should also be taught during tertiary education to ensure readiness for the world of work. teaching professionalism should start early in the biomedical undergraduate programme and not on an exit level of the study programme or at the time of work-integrated and internship learning, as currently: ‘don’t wait for that experiential training, because that is not going to work. they need to know from the beginning.’ (fg3) probing the ‘how’ of teaching professionalism revealed an extensive list of teaching methods, including activities that could be used, supported by a quote from the respondents in the focus groups. table 3 presents a list of teaching approaches that emerged from the focus groups. discussion and recommendations professionalism had different meanings for different individuals – no consistent definition emerged. ethical behaviour, however, stood out as a strong indicator of professionalism. a previous study reported similar interpretations of professionalism where definitions differed within and between various health professional groups, thus making professionalism conceptually unclear.[12] although no one common meaning of professionalism emerged, one common thread linking the domains of understanding surfaced in the study. the need to do what is right for the patient formed the central core upon which professionalism was defined – where doing what is right for the patient requires an appropriate make-up of behaviours that contribute to saving lives. when a person joins the healthcare profession, they should have a clear concept of their professional identity and their roles and responsibilities, and bring with them certain non-negotiable ‘must-have’ attributes, such as altruism and work passion. the essential positive attributes of professionalism described by the interns closely resemble the required attributes for health practitioners described in the literature.[4,9,12] role models in the work environment presented with positive and negative influences, having a dual impact on the professional development of some of the interns. baingana et al.[4] explain that students’ participation in unprofessional conduct is linked to witnessing unprofessional conduct, with an enhanced likelihood of them viewing these behaviours as acceptable and thus creating a cycle that entrenches unprofessional conduct. what students hear in the classroom does not make the most durable impression; what they see and hear in everyday practice of those in the profession etches their attitudes and hardens their perceptions about the real expectations of the profession.[9] the work environment is therefore a powerful stage, not only for technical expertise development, but also for professional development. professionalism education was absent in the university biomedical technology undergraduate curricula. the need for structured teaching of professionalism through the formal curriculum surfaced as a strong imperative. ongoing education was called for as a means to create conscious awareness of professionalism and its associated attributes. what may seem common sense for some is not common sense for all; hence the need to teach professionalism. swick[13] advocates a normative definition of professionalism – one that is simple, yet comprehensive, and that allows for consistent understanding of professionalism. a possible definition that the researchers saw emerging from the meanings provided was: ‘professionalism is a combination of values and attitudes that inform behaviours and interactions that serve as the foundation for good ethical practices as a duty to patients and to society.’ such a definition can serve as a consistent and robust thread linking teaching and learning at all the phases of studying for a profession. defining the role of biomedical technologists, and how they fit in the collaborative interprofessional healthcare approach through interprofessional education, is strongly recommended in future research. educational partnerships with medical and health science faculties to allow biomedical technology students to collaborate and learn with other health professional disciplines during their study, should become a commitment on the part of their future employers. opportunities for students and interns to have some monitored exposure to patients during their study will allow better conceptualisation of their healthcare roles. it will support the development of their professional identity and improve understanding of how their attitudes, behaviours and work practices affect patients. leadership development and explicit teaching of professionalism should be incorporated into the curricula for the bachelor of health science (bhsc) degree, which soon replaces the national diploma in biomedical technology. the various stakeholders involved in the education of biomedical technologists at all levels of study, as well as university-led advisory boards and education committees, need to partner in the curricula reform process. the approaches to teaching professionalism suggested in this study should be analysed, tailored and integrated into the 144 december 2019, vol. 11, no. 4 ajhpe research curricula as a continuum of ongoing learning. ‘development of professionalism is a continuum and a realization that proper standards of professional behaviour have to sustain for a lifetime.’[4] once-off teaching of professionalism is therefore not a solution. opportunities for reflection on learning experiences, which contribute to deep learning, should be incorporated in curricula.[14] capacity building for educators, those in leadership roles and those who serve as role models, as means to provide readiness to embrace and deliver the outcomes of the redefined curricula, emerged as a need. a value proposition of this study is that a national competency framework model similar to the canadian medical education directives for specialists (canmeds) model[15] be developed to serve as a blueprint guiding the development of knowledge, skills, behaviours and leadership of biomedical technologists in sa and elsewhere. conclusions curriculum is essential in directing the teaching and learning of professionalism. a once-off evaluation of the curriculum, however, is not the solution; ongoing review is needed to support meaningful learning directed towards the development of well-rounded future health professionals. declaration. the research was a requirement for vr’s mphil hpe degree, but the publication was not a requirement for the degree. acknowledgements. the authors thank the intern and educator study respondents at the south african national blood service for their participation in the study. author contributions. as was vr’s study leader. the authors contributed equally to the writing of the article. funding. none. conflicts of interest. none. 1. plebani m. the clinical importance of laboratory reasoning. clin chim acta 1999;280(1-2):35-45. 2. plebani m. charting the course of medical laboratories in a changing environment. clin chim acta 2002;319(2):87-100. 3. panteghini m. the future of laboratory medicine: understanding the new pressures. clin biochem 2004;25(4):207-215. 4. baingana rk, nakasujja n, galukande m, omona k, mafigiri dk, sewankambo nk. learning health professionalism at makerere university: an exploratory study amongst undergraduate students. bmc med educ 2010;10:76. https://doi.org/10.1186/1472-6920-10-76 5. tsoumas lt, pelletier d. integrating professional behaviour across a professional allied health curriculum. j allied health 2007;36(4):e313-e325. 6. wear d, castellani b. development of professionalism: curriculum matters. acad med 2000;75(6):602-611. 7. cruess rl, creuss sr. teaching professionalism: general principles. med teach 2006;28(3):205-208. https://doi. org/10.1080/01421590600643653 8. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an independent world. lancet 2010;376(9756):1923-1956. https://doi.org/10.1016/s01406736(10)61854-5 9. cohen jj. professionalism in medical education, an american perspective: from evidence to accountability. med educ 2006;40(7):607-617. https://doi.org/10.1111/j.1365-2929.2006.02512.x 10. mckimm j. curriculum design and development. 2003. www.faculty.londondeanery.ac.uk/ curriculumdesignanddevelopment (accessed 5 september 2016). 11. harden rm. ten questions to ask when planning a course or curriculum. med educ 1986;20:356-365. 12. burford b, morrow g, rothwell c, carter m, illing j. professionalism education should reflect reality: findings from three health professions. med educ 2014;48(4):361-374. https://doi.org/10.1111/medu.12368 13. swick hm. toward a normative definition of medical professionalism. acad med 2000;75(6):612-616. 14. haggis t. constructing images of ourselves? a critical investigation into ‘approaches to learning’ research in higher education. brit educ res j 2003;29(1):89-104. https://doi.org/10.1080/0141192032000057401 15. frank jr. the canmeds 2005 physician competency framework. better standards. better physicians. better care. ottawa: royal college of physicians and surgeons of canada, 2005. accepted 1 july 2019. table 3. teaching approaches that emerged from the focus groups method activities quotes from respondents lectures presentations fg1: ‘lectures are a good start.’ group discussion providing clarity on work responsibilities and professional obligations fg2: ‘… knowing what is expected of them.’ role play active practice learning through scenario setting fg1: ‘… given scenarios and act out how they would conduct themselves professionally and that way they can be corrected as to what is the right way to act professional in different situations.’ portfolio documenting experiences and observations associated with good and poor professionalism bad experiences can create tension fg4: ‘i’ve collected all my evidence. what happens to these bad experiences? it’s a bad idea because everyone will be on edge in the lab now.’ educator-facilitated workshop sharing learning experiences defining appropriate and inappropriate behaviour fg2: ‘we can have workshops just to tell people what is expected of them and we can talk about what affects us in the workplace … someone can actually change their attitude.’ news feed acknowledging or congratulating practitioners for their good professional deeds could inspire others to follow suit fg3: ‘oh, well done for going the extra mile on this, this, and this and it will be circulated.’ mentoring appointing mentors to novice practitioners mentors support, educate and guide fg4: ‘… have mentors, they have a lot of influence in shaping you to being your best.’ peer-assisted learning and reflection seniors complete questionnaires evaluating the interns’ professional conduct interns reflect on their own attitudes and behaviours and complete a similar self-evaluation questionnaire fg5: ‘… a questionnaire where the supervisor will reflect and report on the student attributes and the student will reflect and report.’ online cpd platform case study analysis fg5: ‘yes cpd. it should not just be information on professionalism; case studies could be used. i think that will be more effective and meaningful.’ exposure to real-life situations field trips to hospitals – interacting with patients and other healthcare professionals fg5: ‘take them on a session where they can go to a hospital and see patients that are on chronic transfusion programmes … it will create an emotion and emotion will become a lifelong commitment.’ cpd = continuing professional development. https://doi.org/10.1186/1472-6920-10-76 https://doi.org/10.1080/01421590600643653 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1111/j.1365-2929.2006.02512.x http://www.faculty.londondeanery.ac.uk/curriculumdesignanddevelopment http://www.faculty.londondeanery.ac.uk/curriculumdesignanddevelopment https://doi.org/10.1111/medu.12368 https://doi.org/10.1080/0141192032000057401 98 october 2020, vol. 12, no. 3 ajhpe research concept mapping refers to a strategy where concepts are organised conceptually in the form of graphical networks,[1] providing a pictorial view of the knowledge presented. in concept mapping, concepts are displayed in boxes or circles that are joined by phrases or words that describe the association between the ideas.[2] the strategy aims to develop students’ cognitive structures by establishing linkages and relationships between bodies of knowledge and linking theory to practice.[3,4] by means of concept mapping, students develop critical thinking and judgement skills.[5] concept maps are underpinned by the assimilation theory of meaningful learning created by the psychologist david ausubel in 1963.[6] in addition to ausubel’s theory, concept mapping is also based on the constructivist teaching and learning approach. since its introduction, concept mapping has been effectively practised in disciplines such as mathematics, chemistry, education and policy studies.[2] according to vodovozov and raud,[7] concept mapping may be used as a teaching, learning and assessment tool. moreover, it is suitable for use as a research tool,[8] as a curriculum-development tool, as well as a reflection tool.[5] in nursing education, concept mapping is a useful tool, assisting students to plan patient care, and clinical educators may use it to teach clinical nursing.[9] when used as a learning tool, concept mapping improves learning outcomes and helps to clarify learning objectives.[7] in a study conducted in egypt, 68.3% of nursing students agreed that concept mapping helped them to understand concepts, while 71.7% agreed that their performance improved with the use of concept maps.[10] in the literature, other benefits of concept mapping are an improvement of students’ cognitive abilities and the ability to develop clinically competent nurses.[11] furthermore, concept mapping is also suitable for use as a tool for self-evaluation. despite the benefits and positive effects of using concept mapping as a learning tool, it is rarely used by nursing students at one of the public universities in namibia. human physiology is perceived as one of the challenging courses in the undergraduate nursing degree programme offered at one of the public universities in namibia. this could be due to the large volume of content that is integrative and encompasses difficult concepts. it is one of the courses that is most often failed at second-year level of training, as evidenced by the high number of students who write supplementary examinations, as well as those who register for tutorial classes in the summer and winter terms. human physiology is offered as a semester course, with written examinations at the end of each semester. the teaching of human physiology is done using interactive lectures, group discussions, online discussion platforms and assignments. students mostly learn human physiology by memorising the content, discussion with peers, making notes from textbooks and online resources. the second-year nursing students at a rural campus in north-east namibia were introduced to concept mapping as a learning tool for human physiology in the 2018 academic year. concept mapping is used as a background. nursing students perceive human physiology as one of the most challenging courses, and it is also the course most often failed. to address this perceived challenge, a university campus introduced concept mapping to facilitate learning among nursing students in the human physiology course. despite evidence of its use in other disciplines and educational contexts, it is not known how nursing students perceive and experience its use when learning human physiology. objective. to explore and describe the perceptions and experiences of nursing students’ use of concept mapping as a learning tool in a human physiology course. methods. a qualitative descriptive study was conducted at a university campus in namibia. data were obtained through three focus group discussions with 18 second-year nursing students in the bachelor of nursing science (clinical) honours programme, who were conveniently sampled. transcriptions from the discussions were analysed following tesch’s 8-step coding process. ethical approval and permission to conduct the study were granted by the campus research ethics committee in the school of nursing, university of namibia. results. four themes emerged from the analysis: concept mapping facilitates deep learning; concept mapping as a group activity; effects of concept mapping on students’ academic performance; and implications of concept mapping for learning resources. conclusion. nursing students had positive experiences and perceptions of concept mapping as a learning tool for human physiology. however, students felt that this learning tool is time consuming and requires many learning resources. considering its benefits for learning, it is recommended that concept mapping be used as it promotes deep learning, which in turn leads to in-depth knowledge of human physiology. nevertheless, students should be guided on time-management strategies and learning resource options available in resource-constrained settings. afr j health professions educ 2020;12(3):98-102. https://doi.org/10.7196/ajhpe.2020.v12i3.1330 nursing students’ perceptions and experiences of concept mapping as a learning tool in a human physiology course v nuuyoma, mphil hpe, phd nursing education; s k fillipus, bnsc school of nursing, faculty of health sciences, university of namibia, rundu, namibia corresponding author: v nuuyoma (vistolina.nuuyoma@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 99 research self-directed learning activity after the lecturer has introduced content in didactic classes. students submit concept maps in the lecture hall during the human physiology class, usually after completing a particular body system. this is generally submitted as individual work or a group activity. the lecturer evaluates the concept maps and gives feedback using criteria designed according to the content of each body system; therefore, concept maps serve as a tool for formative feedback. the idea of including new learning approaches in nursing is to foster long-term and meaningful learning in students;[11] thus, concept mapping was deemed a suitable option. given the novelty of concept mapping to nursing students at the public university, the researcher was not aware of how they perceived and experienced its use as a learning tool. therefore, this article describes the perceptions and experiences of nursing students in the use of concept mapping as a learning tool in a course on human physiology. methods this qualitative descriptive study was conducted from october to november 2019 at one of the public university campuses in namibia. the study population consisted of second-year nursing students registered in an undergraduate programme. this population group was included because they used concept mapping as a learning tool in a human physiology course. participants were conveniently selected to participate in the study and data were obtained from focus group discussions conducted by the principal researcher. the principal researcher was a final-year student in the bachelor of nursing science (clinical) honours programme, while the co-researcher, who supervised the research project, is a lecturer in the school of nursing. both researchers maintained reflexivity by using reflective notes. reflexivity means that the researcher reflects on their own biases, values and assumptions and writes about them openly in their research.[12] the principal researcher possesses good communication and group facilitation skills[13] and was therefore able to listen, paraphrase, clarify questions and summarise content during the group discussions. a focus group interview guide was used during the discussion, consisting of the following questions: what is your experience with the use of concept mapping as a learning tool in the human physiology course? how do you perceive concept mapping as a learning tool in the human physiology course? all second-year students were informed of the study and the researcher confirmed the willingness and availability of the potential participants. they were also informed of their right to withdraw from the study at any point; no coercion or form of threat was used to recruit participants. furthermore, written informed consent was obtained from all participants prior to participation in the study. written consent to audio recording was also obtained from each participant prior to the focus group discussions. data saturation was reached after three discussions, each consisting of 6 partici pants. the focus group discussions took place on campus and lasted between 49 and 55 minutes. all discussions were audio recorded and then the researchers transcribed the data. data were analysed manually following tesch’s 8-step coding process.[14] the coding process started with the researchers reading through all transcriptions to get a sense of the whole and then writing down ideas that came to mind. thoughts were written down in the margins, followed by making a list of all topics in the margins and clustering similar topics together. the researchers then found the most descriptive wording for the topics and categorised them, forming themes. the rigour of this study was assured by means of whittemore et al.’s[15] framework. this framework encompasses four primary criteria that are crucial to all qualitative inquiry, including integrity, authenticity, credibility and criticality. the researchers engaged in self-reflection, self-scrutiny and documentation of all steps during the study to ensure integrity. authenticity was ensured through verbatim transcription of all data from focus group discussions, and credibility was ensured through peer debriefing, member checking and collection of data until saturation was reached. peer debriefing was necessary to explore aspects of the study that might otherwise have remained hidden in the researchers’ minds,[16] and was done by meeting with the senior researcher, who is experienced in qualitative research. during the meeting, the two researchers presented all steps taken during the study and how themes were developed. member checking involves checking data, themes and conclusions with participants. this was carried out by one researcher during data collection, as well as after the data were analysed. the purpose was to confirm whether the researchers’ interpretations of the findings and conclusions represented what was said by participants.[16] the researchers ensured criticality by engaging in critical thinking throughout all stages of the study. the pre-test of the focus group discussion guide was done with 4 second-year nursing students, who did not participate in the main study; however, the transcriptions of the pre-test were analysed and also form part of the study findings. the project supervisor listened to the audio recording of the pilot study to check the interviewing skills used, and improvements were proposed. ethical approval ethical approval and permission to conduct the study were granted by the campus research ethics committee in the school of nursing at the university of namibia (ref. no. sf/09/2019). results eighteen participants took part in the study. they were aged between 18 and 25 years, including 11 females and 7 males. four themes emerged from the data analysis: concept mapping facilitates a deep learning approach; concept mapping as a group activity; perceived effects of concept mapping on students’ academic performance; and perceived implications of concept mapping on learning resources. findings are presented in table 1. theme 1: concept mapping facilitates a deep learning approach students stated that concept mapping made it easier to create linkages between related concepts that are used to explain physiological processes and also to group related concepts together. they further mentioned that concept mapping helped them to engage deeply with the course content because it provokes curiosity to explore physiological processes. table 1. themes for perceptions and experiences of nursing students of the use of concept mapping as a learning tool in human physiology • concept mapping facilitates a deep learning approach • concept mapping as a group activity • perceived effects of concept mapping on students’ academic performance • perceived implications of concept mapping on learning resources 100 october 2020, vol. 12, no. 3 ajhpe research consequently, students tend to read more to understand and are greatly motivated: ‘for me, concept mapping is a nice tool to use, because in the first place you put things together and then you create a link on how the terms are related, so in that way it is much easier for one to understand processes rather than looking for them like how the step is presented in the book.’ (fgd2 p1) ‘ after starting to use concept map, i become curious to study physiology because you just want to study more chapters.’ (fgd3 p6) participants indicated that concept mapping assisted them to focus on the most important course content, which acted as the foundation for understanding other content. consequently, students developed a broader view of the content and an ability to identify what is important for understanding other physiological processes: ‘i find it easy to identify what is important, what i mean is … you know there are some topics that we have to understand before moving to the next topic. some topics are more like introductory to complicated ones.’ (fgd1 p5) participants furthermore indicated that concept mapping improved their assimilation of knowledge, which means that they are able to link new information to their pre-existing knowledge, therefore making it easy to understand new information in the course. moreover, students indicated that concept mapping made revision of their work stress free, as they could easily locate information in the textbooks and notes: ‘my perception is that concept mapping helps me understand new information through linking to what i learnt in the past. for example, what i did with endocrine system, i first start mapping anatomical concepts i learn in first year then i embedded new physiology concepts.’ (fgd3 p4) ‘with concept maps, i know exactly where to get information when i am looking for something to learn.’ (fgd2 p4) theme 2: concept mapping as a group activity this study revealed that concept mapping promotes group work. the participants reported that by using concept mapping, communication in the group improved, making individual contributions to the group helpful to others. with concept mapping, students had an opportunity to identify areas that need future collaboration in terms of forming smaller study groups to discuss further course content. some participants felt that concept mapping could assist them to identify topics that needed scaffolding from their peers or teachers: ‘actually we did concept mapping in groups, it was easy to communicate. we bring together our different understanding and it was possible to help each other.’ (fgd1 p3) ‘first we discuss concepts in a group, if there’s something we do not understand as a group we ask for assistance from a colleague or our lecturer.’ (fgd2 p4) theme 3: perceived effects of concept mapping on students’ academic performance students indicated that human physiology is a complex course and consists of a large volume of content; therefore, they tend to learn using a surface approach. when students memorised, they were not able to link and apply information. however, by using concept maps, participants were optimistic that their performance would improve because they thought their understanding had improved. improvement of academic performance was not only hoped for in human physiology, but also in other courses, as concept mapping is also suitable for application to other courses: ‘i use to memorise a lot but when i am taking a test, i can’t even remember what i learn, with concept maps, i just have to jot down main concepts and then to explain a certain process, this really help me pass.’ (fgd3 p4) other participants added: ‘it [concept mapping] is really helping because we are now able to relate physiology to other modules and even clinical practice, that way it improves my overall performance, i’m positive and have high hope to excel in the coming exams.’ (fgd3 p2) ‘it’s good that we are introduced to this method, we can also make use of it in other subjects which are problematic, it really help us to do better, oh this nursing school is just too much.’ (fgd1 p3) theme 4: perceived implications of concept mapping on learning resources for learning to take place, students should interact with different resources, such as hard copies of textbooks, e-books, journal articles and online resources as blogs. in the current study, participants reported that concept mapping required them to gather more information from different resources to construct their maps: ‘for one to come up with a concept map, you need to consult as many titles as possible, especially me i like to write in my own understanding so using one book is not enough.’ (fgd3 p3) time is another resource that is required by individuals to perform any activity, i.e. students also need time for learning activities. in this study, constructing concept maps was perceived to be time consuming; this is because a student first needs to read up on a topic, think about it and reflect on it. making links and defining concepts also need time and, especially if the learning resource is not clear, a student may be obliged to consult other resources, which also requires a lot of time: ‘concept mapping is not that easy, it really needs one to have time but we are very busy. all i can say is that it’s really time consuming because we try to understand and put information in our own perspectives.’ (fgp2 p5) ‘it [concept mapping] requires more time, like you have to come up with everything and you branch it and sometimes it is so hard to come up with one idea when you are working in a group like people think differently.’ (fgp3 p6) owing to the limited number of textbooks in the public and university libraries, students seek information from online sources such as google scholar, youtube videos and other accessible learning websites. students found this to be a burden because of poor internet connections and the high cost of connectivity. students perceived that they needed access to the internet to search for online information to deepen their understanding before constructing concept maps: ‘i would say it is more challenging when it comes to access to internet, we need to look for information from online resources and it is costly.’ (fgd3 p5) october 2020, vol. 12, no. 3 ajhpe 101 research ‘you have to search, you have to get more material and so on, and sometimes the content is too much and needs more time to review … . we went to the library searching from different books but we didn’t really get enough but we also googled.’ (fgd1 p3) discussion this study revealed that nursing students perceive concept mapping as a facilitator of deep learning. in deep learning, students are actively involved, curious, determined and seek for meanings.[17] it is important for students to engage in deep learning in human physiology, as class contact is short compared with the content that has to be covered. deep learning in foundational subjects such as human physiology may improve students’ ability to think critically and reason clinically. according to cárnio,[18] nursing is a profession that uses a comprehensive knowledge area and, therefore, cannot be practised without a knowledge of the basic sciences, as students may not reason without such basic knowledge. additionally, the successful application of human physiology to clinical practice and other courses helps students to relate knowledge to diseases and different health conditions.[18] students are required to have a deeper understanding of human physiology and be knowledgeable regarding the physiological processes. therefore, basic science courses, including human physiology, are designed to enhance nursing students’ academic success and are important for safe practice throughout their career as nurses.[19] the finding that concept mapping promotes deep learning correlates with that of khrais and saleh,[11] who reported that concept mapping transforms passive students into active ones. the findings of the current study demonstrate that the students are aware of prerequisite and important information that they have to understand before proceeding to more advanced content. similarly, daley et al.[20] reported that with application of concept mapping as a learning tool, students were able to focus on clinically important materials. in the undergraduate nursing degree programme, students are engaged in group activities for the purpose of assessment or as a learning activity. for learning purposes, they identify a peer to work with and meet on a regular basis to discuss academic work, which also includes using concept mapping. this study reveals that concept mapping is also undertaken as a group activity. as a result, it can promote collaborative learning through constructive interaction between students and it also helps them to identify areas that need more elaboration by their lecturers. concept mapping is an interactive activity and creations made by students may differ,[21] thus encouraging students to share information with one another. this promotes students’ active participation and learning in the process. the findings of the current study are in accordance with those of campbell,[22] who indicated that students tend to compare their maps and take note of how their connections are similar to or differ from those of their peers. furthermore, concept maps may afford students an opportunity to share their thinking and understanding on a particular topic.[22] the current study reveals that concept mapping may help to build teams. abd el-hay et al.[10] reported that 55% of their participants agreed that they become friendly with their group members when they use concept maps. despite the integrative nature of the content and difficult concepts in human physiology, students perceived that concept mapping would contribute positively to their academic performance. when using concept mapping, there is no need to study human physiology using memorisation.[23] in addition, it is possible to display causal relationships,[23] which are commonly used to show how physiological processes occur and how body systems are integrated. although concept mapping was introduced to this group of students for learning physiology, participants indicated that it may improve overall performance in other courses and assist in the application of theory in practice. similarly, harrison and gibbons[24] indicated that nursing students perceive concept mapping as a helpful tool to organise theoretical knowledge and promote ease of correlation with practical components. the undergraduate nursing degree curriculum stipulates the human physiology course as a prerequisite for general nursing, midwifery and pharmacology at third-year level. students are also expected to integrate human physiology with daily clinical practice. as shown in this study, the use of concept mapping makes it easy to apply human physiology to other courses, including clinical practice, irrespective of the students’ settings. this study was conducted at a campus located in a resourceconstrained setting. therefore, the problems of limited internet access and lack of learning resources, such as textbooks, as indicated by the study participants, are not limited to this nursing programme or this campus, but may apply to all resource-constrained settings. other than learning materials, participants perceived that concept mapping is time consuming. creating concept maps entails creativity, reflection and insight,[24] which indicates that it takes time to construct concept maps, and at the same time one needs to prepare thoroughly by consulting different materials. it is recommended that students be guided on time-management strategies, as well as the learning resource options available in a resource-constrained setting. there is a need for libraries to put forward an effective strategy to ensure that the minimal resources available are accessible to all students for learning purposes. as human physiology is considered a difficult course that is associated with poor performance, it is recommended that concept mapping be fully integrated into learning activities, given its perceived positive effect on learning. as a way forward, the researchers propose that students should construct concept maps at the end of each session and revise them regularly as new understandings and perspectives on the subject content develop. conclusions future research should consider exploring the use of concept mapping as a teaching and assessment tool in nursing degree programmes and other health science programmes. there is also a need to study the relationship between concept mapping and students’ academic performance, as well as exploring how concept mapping can be used for learning to manage different conditions in clinical settings. data collection for this study was done a few weeks before the second-semester examinations. this is considered to be a limitation because it was challenging to agree upon the focus group discussion schedule with the students. deep knowledge of human physiology is important, as it provides the foundational knowledge needed by students to apply critical thinking and clinical reasoning. nursing students experienced and perceived concept mapping as a tool that supports deep learning and teamwork and improves academic performance. however, more time is required to construct concept maps, as they require various learning resources that have to be consulted. the researchers recommend that nursing students should be supported to extend the use of concept maps to other courses, as this may improve their learning experiences despite the lack of learning resources. 102 october 2020, vol. 12, no. 3 ajhpe research declaration. the research for this study was done in partial fulfilment of the requirement for skf’s bachelor of nursing science (clinical) honours degree at the university of namibia. acknowledgements. the authors would like to acknowledge the campus library staff, who assisted during the literature search process. author contributions. all authors were involved in the conceptualisation, data collection and analysis, literature review and writing of the manuscript. funding. none. conflicts of interest. none. 1. yang hh. beliefs and concept mapping on webquest development. in: handbook of research on instructional systems and technology. london: igi global, 2008:272-286. 2. gerdeman jl, lux k, jacko j. using concept mapping to build clinical judgment skills. nurse educ pract 2013;13(1):11-17. https://doi.org/10.1016/j.nepr.2012.05.009 3. daley bj, durning sj, torre dm. using concept maps to create meaningful learning in medical education. mededpublish 2016;5(1):1-29. https://doi.org/10.15694/mep.2016.000019 4. kaddoura m, vandyke o, cheng b, shea-foisy k. impact of concept mapping on the development of clinical judgment skills in nursing students. teach learn nurs 2016;11(3):101-107. https://doi.org/10.1016/j. teln.2016.02.001 5. rahnama f, mardani-hamooleh m. iranian nursing students’ perceptions regarding use of concept mapping: a content analysis. res dev med educ 2017;6(1):45-50. https://doi.org/10.15171/rdme.2017.008 6. wei w, yue k-b. integrating concept mapping into information systems education for meaningful learning and assessment. inf syst educ j 2017;15(6):4-16. 7. vodovozov v, raud z. concept maps for teaching, learning, and assessment in electronics. educ res int 2015;2015:1-9. https://doi.org/10.1155/2015/849678 8. conceição sco, samuel a, yelich biniecki sm. using concept mapping as a tool for conducting research: an analysis of three approaches. cogent soc sci 2017;3(1). https://doi.org/10.1080/23311886.2017.1404753 9. chabeli m. concept-mapping as a teaching method to facilitate critical thinking in nursing education: a review of the literature. heal sa gesondheid 2010;15(1):1-7. https://doi.org/10.4102/hsag.v15i1.432 10. abd el-hay sa, el mezayen se, ahmed re. effect of concept mapping on problem solving skills, competence in clinical setting and knowledge among undergraduate nursing students. j nurs educ pract 2018;8(8):34. https:// doi.org/10.5430/jnep.v8n8p34 11. khrais h, saleh a. the outcomes of integrating concept mapping in nursing education: an integrative review. open j nurs 2017;7(11):1335-1347. https://doi.org/10.4236/ojn.2017.711096 12. creswell j. qualitative inquiry and research design: choosing among five approaches. 3rd ed. los angeles: sage, 2013:1-448. 13. botma y, greeff m, mulaudzi fm, wright s. research in health sciences. cape town: heinemann, 2010. 14. creswell j. research design: qualitative, quantitative and mixed methods approaches. 4th ed. london: sage, 2014:1-273. 15. whittemore r, chase s, mandle l. validity in qualitative research. qual res 2001;2(4):522-537. https://doi.org/ 10.1177%2f104973201129119299 16. polit d, beck c. nursing research: generating and assessing evidence for nursing practice. 10th ed. philadelphia: wolters kluwer, 2017:1-784. 17. bran c. strategies for developing a deep approach of learning in higher education. j plus educ 2014;11(2):130-140. 18. cárnio ec. basic sciences and nursing. rev lat am enfermagem 2011;19(5):1061-1062. https://doi.org/10.1590/ s0104-11692011000500001 19. cetindag a, taskin yilmaz f, vicil s, basli m, ahmet arslan s. views of nursing students on basic medical sciences courses. educ res med sci 2018;7(1):1-6. https://doi.org/10.5812/erms.80220 20. daley bj, morgan s, black sb. concept maps in nursing education: a historical literature review and research directions. j nurs educ 2016;55(11):631-639. https://doi.org/10.3928/01484834-20161011-05 21. guy r, byrne b, dobos m. stop think: a simple approach to encourage the self-assessment of learning. adv physiol educ 2017;41(1):130-136. https://doi.org/10.1152/advan.00174.2016 22. campbell lo. concept mapping: an ‘instagram’ of students’ thinking. soc stud 2016;107(2):74-80. https://doi. org/10.1080/00377996.2015.1124377 23. henige k. use of concept mapping in an undergraduate introductory exercise physiology course. adv physiol educ 2012;36(3):197-206. https://doi.org/10.1152/advan.00001.2012 24. harrison s, gibbons c. nursing student perceptions of concept maps: from theory to practice. nurs educ perspect 2013;34(6):395-399. https://doi.org/10.5480/10-465 accepted 16 june 2020. https://doi.org/10.1016/j.nepr.2012.05.009 https://doi.org/10.15694/mep.2016.000019 https://doi.org/10.1016/j.teln.2016.02.001 https://doi.org/10.1016/j.teln.2016.02.001 https://doi.org/10.15171/rdme.2017.008 https://doi.org/10.1155/2015/849678 https://doi.org/10.1080/23311886.2017.1404753 https://doi.org/10.4102/hsag.v15i1.432 https://doi.org/10.5430/jnep.v8n8p34 https://doi.org/10.5430/jnep.v8n8p34 https://doi.org/10.4236/ojn.2017.711096 https://doi.org/10.1177%2f104973201129119299 https://doi.org/10.1177%2f104973201129119299 https://doi.org/10.1590/s0104-11692011000500001 https://doi.org/10.1590/s0104-11692011000500001 https://doi.org/10.5812/erms.80220 https://doi.org/10.3928/01484834-20161011-05 https://doi.org/10.1152/advan.00174.2016 https://doi.org/10.1080/00377996.2015.1124377 https://doi.org/10.1080/00377996.2015.1124377 https://doi.org/10.1152/advan.00001.2012 https://doi.org/10.5480/10-465 november 2020, vol. 12, no. 4 ajhpe 175 research healthcare in africa faces a substantial human resource crisis nested in poverty, a high burden of disease and emerging epidemics and pandemics.[1,2] there is consensus in the literature that not only more nurses are needed but that they should be competent.[2] globally, as in africa, there is an educational shift from content-based curricula to competency-based education. however, people differ with regard to the interpretation of competency-based education.[3] a competent nurse is someone who is ‘able to integrate knowledge from all disciplines to identify the problem, understand the theory related to the problem, as well as the appropriate response, treatment and care of the patient … in real-life’.[4] nurses should be reflective of their practice to think about their thinking processes and develop metacognition.[5] reflective practitioners become lifelong learners. nurses demonstrate competence in critical thinking, clinical reasoning, clinical judgement and metacognition through assessing patients, diagnosing, and implementing optimal care plans.[6] fig. 1 shows the conceptual representation of the association between the thinking process and knowledge levels based on botma and klopper’s thinking model.[5] according to this model, a person should have foundational and procedural knowledge to be able to think critically, resulting in noticing or identifying a problem.[7-9] clinical reasoning would therefore flow from critical thinking when clinical data of a patient are collected and evaluated in a specific context to make a diagnosis,[9] i.e. conditional knowledge.[10] conditional knowledge portrays insight into the patient's condition and associated circumstances.[11] critical thinking and clinical reasoning are in turn building blocks for clinical judgement, i.e. when a nurse formulates a decision about interventions.[5,7] nurses demonstrate functional knowledge when they decide about treatment options that will be advantageous for a patient.[12] clinical judgement and the demonstration of functional knowledge indicate the level of understanding of a specific situation and whether the response is appropriate.[10,12] metacognition involves the assessment of thought processes, referred to as ‘thinking about thinking’.[13] during metacognition, nurses analyse their personal clinical performance to identify weaknesses in the reasoning process, and to plan and monitor actions for improvement.[13,14] metacognitive knowledge is constructed through the process of critical reflection and is referred to as ‘new knowledge built on previous knowledge’.[13] it can be argued that a nurse is competent when they can demonstrate all four knowledge levels and associated thinking operations in different contexts. botma and klopper’s thinking model[5] suggests that, without adequate foundational knowledge, clinical reasoning and clinical judgement may be compromised. it is, therefore, the responsibility of nursing education institutions to train competent nurses who are ‘ready to run’ and are competent on all four levels when they have completed their training. however, there is no single definitive tool for assessing the competence of nurses.[6] becoming competent is a process, and nursing students therefore need support throughout their training as the content and complexity of learning opportunities increase.[6] the developed competency assessment instrument may allow nurse educators to shed light on the thinking operations and levels of knowledge that a student has mastered and what needs to be developed. this background. although there is a need for a greater number of nurses to meet the demands for universal health coverage, these trained nurses should also be competent. however, assessment of nurses’ competence remains a challenge, as the available instruments do not focus on identifying the knowledge level that is lacking. objectives. to report on the development and reliability of an instrument that can be used to assess undergraduate student nurses’ competence. methods. a methodological research design was used. the authors extracted items from existing competence assessment instruments, inductively analysed the items and categorised them into themes. the extracted items were used to draft a new instrument. review by an expert panel strengthened the content and face validity of the instrument. twenty assessors used the developed assessment instrument to assess 15 student nurses’ competence via video footage. results. the cronbach alpha coefficient of 0.90 and intraclass correlation coefficient of 0.85 indicate that the instrument is reliable and comparable with other instruments that assess competence. conclusions. nurse educators can use the developed instrument to assess the competence of a student and identify the type of knowledge that is lacking. the student, in collaboration with the educator, can then plan specific remedial action. afr j health professions educ 2020;12(4):175-178. https://doi.org/10.7196/ajhpe.2020.v12i4.1350 a competence assessment tool that links thinking operations with knowledge types y botma,1 phd, rn, rm, fansa; n janse van rensburg,1 master of nursing, rn, rm, operating theatre nurse; j raubenheimer,2 phd (research psychology) 1 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa 2 discipline of pharmacology, school of medical sciences, faculty of medicine and health, university of sydney, australia corresponding author: y botma (botmay@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 176 november 2020, vol. 12, no. 4 ajhpe research article reports on the development and reliability of such an instrument that can be used to assess undergraduate student nurses’ competence and development throughout their training. methods a quantitative methodological research approach was used. the design defined the construct or behaviour to be measured, identifying competence assessment tools, inductively analysing items from identified assessment tools, formulating items, developing instructions for users and assessors, and testing the reliability and validity of the instrument.[15] development of the assessment instrument with the assistance of a librarian, the authors identified 16 publications (from 2000 to 2017) of instruments that assessed competence in health sciences. only 9 of the 16 instruments had comparable definitions of competence and were used for item extraction. the authors inductively analysed and classified the extracted items under the following themes: • critical thinking (noticing) • clinical reasoning (interpreting) • clinical judgement (responding) • attitude • communication • metacognition. the identified themes correspond with the types of decision-making, as described by marques[16] and botma and klopper’s thinking model.[5] elimination of vague items and arranging items in a logical sequence contributed to the refinement of the draft instrument. the authors used a 5-point likert scale that was weighted as follows: 0 = not done (student does not demonstrate any aspect of expected behaviour) 1 = incompetent (student demonstrates some aspects of expected behaviour haphazardly) 2 = competent (student demonstrates most of the aspects of expected behaviour orderly) 3 = exceptionally competent (student demonstrates all of the aspects of expected behaviour orderly and consistently) na = not applicable (no opportunity to demon strate expected behaviour during simulated patient scenario). botma and van rensburg’s competence assessment tool is available as an appendix (http://ajhpe. org.za/public/files/1350.doc) to this article. an expert panel consisting of 7 nurse educators in the field of transfer of learning and nurse competence, and who were knowledgeable regarding instrument construction, evaluated the draft instrument for face and content validity. the agreement regarding the abovementioned 6 categories and individual items contributed to the content validity of the draft instrument, as the expert panel evaluated each item against the following criteria: (i) applicable to the category; (ii) measurable; (iii) unambiguously phrased; and (iv) understandable. fig. 2 gives the content validity index per domain. four domains have the ideal value of 1 and the lowest value is 0.85, which exceeds the cut-off value of 0.83.[17] a pilot study was done after the instrument had been validated, during which 7 assessors evaluated archived video footage of students interacting with standardised patients. the assessment instrument was regarded as easy to use, but the quality of the sound and visibility of the footage were poor. additional cameras, audio-recording machines and positioning of the standardised patient improved the quality of the video footage for the real study. population and sample two groups, i.e. assessors and students, participated in the study. the student population consisted of 60 second-year undergraduate student nurses, who participated in the compulsory standardised patient simulation activities. these simulation activities are compulsory for edu cational purposes, but the students could withdraw the footage that captured their interactions for the purposes of research. the biostatistician used simple random sampling to select 15 students who consented to participate in the study. the inclusion criteria for the 20 purposefully selected assessors, who all agreed to participate in the study, were that they should be educators or registered nurses who are interested in the facilitation of clinical learning, transfer of learning, clinical judgement or primary healthcare. data collection the second author trained all the assessors and provided opportunities for them to practise using the instrument. each assessor received a demographic sheet, 15 copies of the assessment instrument, simulation footage of students and patient records written by each student. assessors completed the instrument at their convenience for all 15 students while they watched the footage of the interaction between a student and a standardised patient. each assessor couriered the package back to the first author at the cost of the author. simulation activities are routine and compulsory learning experiences for under graduate student nurses after they have completed a learning unit at the relevant school. all simulated learning experiences are routinely captured, because the facilitators use the footage during debriefing. for this research, each student engaged with an aged standardised patient at a primary healthcare clinic. the patient’s main complaint was earache and loss of appetite. students had to assess the patient, link the assessment findings with theory by stating the differential diagnoses, and make a final diagnosis through a process of elimination. they then had to use the adult primary healthcare guidelines to decide, in collaboration with the patient, on the best acceptable treatment option. after they recorded the treatment, the students had to reflect on their performance and state how they would improve their performance in similar circumstances. data analysis the second author coded and captured the data on an excel spreadsheet (microsoft corp., usa). reflection meta cognition clinical judgment functional knowledge clinical reasoning conditional knowledge critical thinking foundational & procedural knowledge figure 1. model of thinking operations and associated knowledge levels (adapted from botma and klopper’s thinking model)(5) foundational and procedural knowledge re�ection clinical judgement clinical reasoning critical thinking metacognition functional knowledge conditional knowledge fig. 1. model of thinking operations and associated knowledge levels (adapted from botma and klopper’s thinking model[5]). http://ajhpe.org.za/public/files/1350.doc http://ajhpe.org.za/public/files/1350.doc november 2020, vol. 12, no. 4 ajhpe 177 research a biostatistician used sas/stat software, version 12.3, sas system for windows (sas, usa), to analyse the data. cronbach’s alpha coefficient test determined the internal consistency of the developed instrument, and the intraclass correlation coefficient test measured the inter-rater reliability of the respondents who used the instrument. ethical approval the health sciences research ethics committee (hsrec), university of the free state, approved the research (ref. no. ecufs nr 49/2014), and all the relevant authorities granted permission to conduct the study. all participants gave informed consent. results most assessors (80%) were degree qualified – 30% of the 80% had a master’s degree and 5% of the 80% had a doctoral degree. all the assessors were registered as professional nurses for >5 years and therefore had good foundational knowledge of nursing as a science. the majority (80%) had a postgraduate qualification in nursing education that covers assessment of students, among other topics. furthermore, all the assessors had received additional training on the assessment of students, either through assessment-specific courses or through mentor/preceptor training programmes before this study. reliability the internal consistency of the final assessment instrument, as measured by the cronbach alpha coefficient, tested 0.90. the intraclass correlation coefficient value measuring the inter-rater reliability tested 0.85. discussion immonen et al.[18] concluded that assessors should use reliable and valid assessment instruments and that the need to develop consistent and systematic approaches in assessment continues. clear assessment criteria alleviate the stress that clinical learning facilitators experience during assessment.[18] the developed assessment instrument has a high internal consistency, with a cronbach alpha value of 0.90, and is comparable with other instruments that measure competence. for example, juntasopeepun et al.[19] found that the internal consistency of the nurse competence scale varied between 0.85 and 0.88 for the 6 factors. the intraclass correlation coefficient value of 0.85 is remarkable, considering that 20 assessors participated, while most inter-rater studies report on 2 3 assessors. fig. 2 shows that the content validity index per domain is high; thus, the assessment tool is reliable and valid. an advantage of the developed tool is that it is structured according to the thinking process and knowledge levels. the assessor was able to identify the level where the students struggled and could plan remedial activities with the student. for example, the students lack foundational knowledge when they are unable to link the theory to the assessment findings of a patient and could not identify deviations from the norm. furthermore, using the developed instrument throughout the training programme may ensure that the thinking operations become automated knowledge. conclusions the internal consistency of the developed instrument and inter-rater reliability are comparable with the lasater clinical judgement rubric, the competency inventory for nursing students and the nurse competence scale. the developed instrument is unique because it is set according to the knowledge levels and associated thinking operations. furthermore, the assessor could identify the type of knowledge that is lacking to achieve competence and guide the student in rectifying the identified gap. study limitations the small student sample and the homogeneity of the sample are limitations of the study. the simulated environment and the use of video footage also influenced the results, because the assessors could not validate their observations with the students. assessors can clarify what students mean and position themselves to optimise observation in clinical practice. the psychometric properties of the instrument should be tested through an exploratory and confirmatory factor analysis. other health sciences student populations could be included in further studies, as the thinking operations are generic for all students in the health sciences. the instrument should also be tested in the clinical learning environment, as it could be used for integrated assessments. declaration. none. acknowledgements. the authors acknowledge the effort and time of the 20 assessors and the contributions of the critical reader and language editor. author contributions. njvr did the fieldwork and drafted the manuscript. jr wrote the methods and results sections, while yb edited the manuscript for submission to the journal. funding. the authors acknowledge the financial assistance of the national research foundation (nrf). conflicts of interest. none. attitude 0.85 communication 1 responding/ clinical judgement 1 re�ection/ metacognition 0.86 noticing/critical thinking 1 interpretation/ clinical reasoning 1 1 0.95 0.90 0.85 0.80 0.75 fig. 2. content validity index per domain. 178 november 2020, vol. 12, no. 4 ajhpe research 1. asamani ja, akogun ob, nyoni j, ahmat a, nabyonga-orem j, tumusiime p. towards a regional strategy for resolving the human resources for health challenges in africa. bmj glob health 2019;4(suppl 9):e001533. https:// doi.org/10.1136/bmjgh-2019-001533 2. agyepong i, sewankambo n, binagwaho a, piot p. the path to longer and healthier lives for all africans by 2030: the lancet commission on the future of health in sub-saharan africa. lancet 2017;390(10114):2803-2859. https://doi.org/10.1016/s0140-6736(17)31509-x 3. fernandez n, dory v, chaput m, charlin b, boucher a. varying conceptions of competence: an analysis of how health sciences educators define competence. med educ 2012;46:357-365. https://doi.org/10.1111/j.13652923.2011.04183.x 4. nursing education stakeholders (nes) group. a proposed model for clinical nursing education and training in south africa. trends nursing 2012;1(1):49-58. 5. botma y, klopper h. thinking. in: bruce j, klopper h, eds. teaching and learning the practice of nursing. 6th ed. pretoria: pearson, 2017:189-210. 6. lourenqo t, gamara p, abreu fiigueiredo r. the relevance of critical thinking for the selection of the appropriate nursing diagnosis. ec nurs healthcare 2020;2(2):1-3. 7. bruce j, klopper h, eds. teaching and learning the practice of nursing. 7th ed. pretoria: pearson, 2017. 8. tanner ca. thinking like a nurse: a research-based model of clinical judgment in nursing. j nurs educ 2006;45(6):204-211. https://doi.org/10.3928/01484834-20060601-04 9. de carvalho ec, oliveira-kumakura ar de s, morais scrv. clinical reasoning in nursing: teaching strategies and assessment tools. rev bras enferm 2017;70(3):662-668. https://doi.org/10.1590/0034-7167-2016-0509 10. biggs j, tang c. teaching for quality learning at university. 4th ed. berkshire: mcgraw-hill education, 2011. 11. botma y, van rensburg gh, coetzee im, heyns t. a conceptual framework for educational design at modular level to promote transfer of learning. innov educ teach int 2013:1-11. https://doi.org/10.1080/14703297.20 13.866051 12. sedgwick mg, grigg l, dersch s. deepening the quality of clinical reasoning and decision-making in rural hospital nursing practice. rural remote health 2014;14(3):1-12. 13. frith cd. the role of metacognition in human social interactions. philos trans r soc lond b biol sci 2012;367(1599):2213-2223. https://doi.org/10.1098%2frstb.2012.0123 14. lasater k. clinical judgment development: using simulation to create an assessment rubric. j nurs educ 2007;46(11):496-503. https://doi.org/10.3928/01484834-20071101-04 15. lobiondo-wood g, haber j. nursing research. methods and critical appraisal for evidence-based practice. 7th ed. st. louis: mosby-elsevier, 2010. 16. marques m de fm. decision making from the perspective of nursing students. rev bras enferm 2019;72(4):1102-1108. https://doi.org/10.1590/0034-7167-2018-0311 17. pollit d, beck c. nursing research: generating and assessing evidence for nursing practice. 10th ed. philadelphia: wolters kluwer, 2017. 18. immonen k, oikarainen a, tomietto m, et al. assessment of nursing students’ competence in clinical practice: a systematic review of reviews. int j nurs stud 2019;100:103414. https://doi.org/10.1016/j. ijnurstu.2019.103414 19. juntasopeepun p, turale s, kawabata h, thientong h, uesugi y, matsuo h. psychometric evaluation of the nurse competence scale: a cross-sectional study. nurs health sci 2019;21(4):487-493. https://doi.org/10.1111/ nhs.12627 accepted 30 july 2020. https://doi.org/10.1136/bmjgh-2019-001533 https://doi.org/10.1016/s0140-6736(17)31509-x https://doi.org/10.1111/j.1365-2923.2011.04183.x https://doi.org/10.1111/j.1365-2923.2011.04183.x https://doi.org/10.3928/01484834-20060601-04 https://doi.org/10.1590/0034-7167-2016-0509 https://doi.org/10.1080/14703297.2013.866051 https://doi.org/10.1080/14703297.2013.866051 https://doi.org/10.1098%2frstb.2012.0123 https://doi.org/10.3928/01484834-20071101-04 https://doi.org/10.1590/0034-7167-2018-0311 https://doi.org/10.1016/j.ijnurstu.2019.103414 https://doi.org/10.1016/j.ijnurstu.2019.103414 https://doi.org/10.1111/nhs.12627 https://doi.org/10.1111/nhs.12627 september 2019, vol. 11, no. 3 ajhpe 74 short communication why was this idea necessary (problem)? the use of digital games to mitigate some of the challenges of engagement and active participation has been successful in some countries.[1] while games are equated with fun, they should also be designed to provide learning opportunities that allow students to reflect, construct knowledge and test hypotheses. however, the design of digital games remains a challenge within course design, and has remained under-explored in historically disadvantaged institutions in south africa (sa). what was tried (approach)? using design-based research, a qualitative pilot study was conducted as part of the design and implementation of an interactive learning environment, using a self-developed sport psychology trivia/quiz digital game in a health science discipline in sa. the game was designed to be played in groups of five players on each team, with the purpose of facilitating cross-cultural learning. players formed two small groups and played three head-to-head rounds to determine whether the beta version of the digital game would be a beneficial tool to mediate crosscultural engagement before implementation in a large classroom. the digital game was designed so that content from other cognate health science disciplines could be embedded in the database of the game. it could be played on a laptop or a mobile device such as an ipad or an android-enabled smartphone or tablet. the beta version of the game requires teams to answer as many questions as possible correctly within 30 seconds. for each game round, there is a group leader who controls the game and reads the questions. his/her group members assist in answering the questions. groups that answer the most questions correctly, score the highest points. each gaming session lasts 7 minutes, after which a new leader is selected until each member has had a leadership opportunity. five players who tested the game participated in a focus group discussion. what lessons were learnt (outcome)? there are at least two major lessons to consider when developing games in health sciences education, i.e. game design and group dynamics. game design takes into account time and academic challenge, i.e. games should be designed with degrees of difficulty so that students are able to improve their competence with subject matter embedded in the digital game. lack of time resulted in anxiety and therefore time allocation had to be adjusted in the final game. group dynamics takes into account that groups should be randomised to avoid the formation of cliques. this, coupled with small groups of not more than five players per team, allows for better productivity, interaction, integration and group cohesion. these are integral design features to be embedded in a digital game for learning to ensure interaction, engagement and co-construction of knowledge in a fun and meaningful way. this innovation offered new insight into the development of a digital game to facilitate engagement in the health sciences, and it is a novel way to support a current blended learning environment. declaration. the article was based on a study done by st in partial fulfilment of her phd thesis. acknowledgements. ethical approval for this study was obtained from the university of cape town doctoral degrees board (ref. no. c0098). author contributions. both authors contributed equally to the article. funding. the study was supported by the deputy vice-chancellor (academic), university of the western cape, and the national research foundation, south africa. conflicts of interest. none. 1. giannakas f, kambourakis g, papasalouros a, gritzalis s. a critical review of 13 years of mobile game-based learning. educ technol res develop 2018;66(2):341-384. https://doi.org/10.1007/s11423-017-9552-z accepted 1 july 2019. afr j health professions educ 2019;11(3):74. https://doi.org/10.7196/ajhpe.2019.v11i3.1190 design of digital games in health sciences education s titus,1 phd; d ng’ambi,2 phd 1 interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town, south africa 2 school of education, university of cape town, south africa corresponding author: s titus (sititus@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:sititus@uwc.ac.za ajhpe african journal of health professions education june 2020, vol. 12, no. 2 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editor paula van der bijl production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 short communication 50 exposure technique factors in digital x-ray imaging systems: demonstrating the effect of mas s lewis 51 the use of appreciative inquiry as an interview technique in radiography research k naidoo 52 using video to learn practical techniques in physiotherapy education m rowe, b sauls short research report 53 postgraduate medical specialty training for botswana: a successful innovative partnership with south africa m cox, j masunge, o nkomazana research 56 content analysis of the south african mmed mini-dissertation e s grossman 62 burnout and associated factors in undergraduate medical students at a south african university l j van der merwe, a botha, g joubert 68 enhancement of plastic surgery training by including simulation in education and training programmes c p g nel, g j van zyl, m j labuschagne 74 simulation as an educational strategy to deliver interprofessional education r van wyk, m j labuschagne, g joubert 81 the benefits of experiential learning during a service-learning engagement in child psychiatric nursing education a c jacobs 86 readiness of allied health students towards interprofessional education at a university in ghana j quartey, j dankwah, s kwakye, k acheampong cpd questionnaire september 2019, vol. 11, no. 3 ajhpe 96 research higher education institutions (heis) responsible for training midwives need to transform their education programmes to align with the changing educational landscape.[1,2] such transformations should focus on the development of competent midwives who have a positive influence on maternal and neonatal mortality indicators, driven by a cutting-edge curriculum. the curriculum is seen as a multi-layered phenomenon encompassing the espoused curriculum, the enacted curriculum and the experienced curriculum.[3] changes in the needs of society influence heis to innovate their espoused curriculum[4,5] through the introduction of new learning outcomes, new teaching and assessment methods and even different pedagogical values.[6] failure to promote the implementation of such curricular innovations may result in curricular drift, which woods[5] describes as the difference between the espoused curriculum and the enacted curriculum. the outcome of curriculum drift may be dire, because envisaged outcomes in the espoused curriculum, such as the development of competent midwives, may not be realised. the context of the study reported in this article was a competency-based curriculum (cbc) for a 1-year midwifery programme, developed and implemented for the first time in 2014 in the kingdom of lesotho. the adoption of a cbc was aimed at producing midwives who have a positive influence on the perennially high maternal and neonatal mortality indicators. the maternal mortality ratio in lesotho is 487 deaths per 100 000 live births, which is above the global average of 216 deaths per 100 000 live births.[2] the cbc replaced a teacher-centred content-driven hospital-based curriculum, which had been in place for many years. the new curriculum was underpinned by constructivism as a learning theory[7] and fused with other educational principles, such as scaffolding,[8] authenticity and constructive alignment.[9] it was also aligned with the national policy of primary healthcare, which is the pregnant woman’s first point of contact with healthcare services. implementing the cbc resulted in a need for a different set of administrative, teaching and learning skills from primary stakeholders. these skills included the development of student-centred learning material, new assessment approaches, integration of evidencebased practice, simulation-based education and placement of students in the community. however, within 2 years of a nationwide implementation, the authors became aware of disparities in the enactment of the cbc in and among the nursing education institutions (neis), which threatened the sustainability of the entire competency-based midwifery programme. these disparities included the adoption of previous teaching approaches and assessment practices not aligned with the new curriculum, and students verbalising a lack of support during learning. these were evidenced in minutes of meetings, interaction with primary stakeholders and results of programme accreditation from the council on higher education (che) in lesotho. stakeholders in the neis reflected on the lack of a framework for implementing the new curriculum as a contributing factor to the disparities in enactment of the cbc. background. a competency-based curriculum was adopted for a 1-year post-basic midwifery programme in a small african country with a high maternal and neonatal mortality ratio. two years after nation-wide implementation, disparities in the enactment of the curriculum were observed within and across the nursing education institutions (neis). such disparities were attributed to lack of a framework in implementing the new curriculum, which jeopardised sustainability of the entire competency-based midwifery programme. a framework for implementing and sustaining a curricular innovation in a higher education midwifery programme was developed. objective. to develop and validate a framework for implementing and sustaining a curricular innovation in a higher education midwifery programme. methods. a multiple-methods research design was used to develop the framework, guided by the theory-of-change logic model. this design was executed in three sequential but interrelated phases, inclusive of an integrative review, a gap analysis of the implementation of the programme and a frameworkdevelopment process. primary implementers from all neis in the setting validated the developed framework through discussion and consensus. results. a framework for implementing and sustaining a curricular innovation in a midwifery programme was developed. it reflects an integration of evidence obtained from research and expertise from primary implementers of the curriculum. conclusions. designing a strategy for higher education institutions (heis) for implementing and sustaining curricular innovations should be based on an interplay of empirical evidence and contextual realities. heis should identify challenges related to curriculum implementation, and recommend tailor-made approaches that are based on evidence. primary implementers of the curriculum are fundamental in enhancing the validity and feasibility of such a strategy within their setting. afr j health professions educ 2019;11(3):96-100. https://doi.org/10.7196/ajhpe.2019.v11i3.1153 a framework for implementing and sustaining a curricular innovation in a higher education midwifery programme c n nyoni, bsc hons nursing science, msoc sc nursing, phd; y botma, phd school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c n nyoni (nyonic@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 97 september 2019, vol. 11, no. 3 ajhpe research through multiple-methods research executed in three phases, we developed a framework for implementing and sustaining a curricular innovation for the midwifery programme in lesotho. this article presents the framework as validated by primary implementers from neis in lesotho. we argue that insights into the development of a sustainable strategy for implementing and sustaining a curricular innovation could guide higher education midwifery programme renewal for more effective education. methods the framework was developed through a multiple-methods approach underpinned by the theory-of-change logic model.[10] three separate but interrelated studies were performed in the development of this framework. the initial study synthesised strategies used to sustain curricular innovations in higher education between 1996 and 2016 through an integrative review. the findings of this phase have been reported by nyoni and botma.[11] the second study described the implementation of the competencybased midwifery programme in lesotho. primary stakeholders engaged in the implementation of the cbc, i.e. students (n=48), educators (n=11) and administrators (n=16) from all neis (n=5), were included in the study. data were collected through individual interviews and focus group discussions. in addition to the narrative data, documents used in the programme were also captured. data were analysed through both inductive and deductive reasoning against the international confederation of midwives (icm) global standards for midwifery education.[1] the study revealed the needs of primary stakeholders in relation to implementing the cbc in their institutions[12] and factors influencing the implementation of the cbc in their midwifery programme.[13] the third and final study was articulated in two sequential strands. the first strand involved researchers using the theory-of-change logic model to integrate the results of the first two studies to develop a framework. the second strand was a validation exercise of the developed framework by primary implementers (n=13) of the cbc in midwifery from all the neis in lesotho. these primary implementers of the curriculum were invited to a 1-day validation session led by the first author. during the session, the purpose of the study was presented, including approaches to validating the framework. the primary implementers discussed the framework, based on its specific headings, in small groups. each group presented the outcomes of their discussion, which were either confirmed or rejected by the entire group. consensus was reached based on feasibility and reasoning. ethical approval ethical approval for the study was granted by the health sciences research ethics committee of the university of the free state (ref. no. hsrec 22/2017) and the institutional research and ethics committee of the ministry of health in lesotho (ref. no. id 25/2017). the framework for ethical educational research by burgess and cilliers[14] underpinned the development and execution of the current study. the neis granted the researchers access to their institutions, and all individuals engaged in this study provided informed consent. theoretical underpinning of the framework logic models allow for the development of programmes, in this case a framework that links its intentions or objectives with the intended outputs, outcomes and foreseeable impact, inclusive of relevant processes.[10] the w k kellogg foundation explains that logic models allow for a visual presentation of how a particular programme or framework would work to reach its intended outcomes. there are various types of logic models, but this study was nested in the theory-of-change logic model. it allowed the researchers to articulate clearly the problems related to implementing the cbc in the midwifery programme in lesotho, describe the scope of needs and assets of the community of stakeholders implementing the cbc, and acknowledge the factors that may influence implementation of the proposed framework. the model also allowed for the investigation of best practices as plausible solutions to the identified problems, including a statement of assumptions regarding why the selected strategies could work. the intended outcome of the framework is also described. methodological integrity the validation exercise with the primary implementers of the cbc from all neis in lesotho enhanced the credibility of the framework, while the integration of evidence from the literature strengthened its content validity. the nature of this developmental process was embedded in contextually based challenges, which limit the transferability of such a framework to any other setting, although an audit trail of the development of the framework may support other heis implementing a cbc in midwifery in sustaining their curriculum-change process. findings this study resulted in the development of a framework for implementing and sustaining a curricular innovation in a midwifery programme in lesotho (fig. 1). the description of the framework includes the problem or issue, community needs and assets, strategies, influencing factors, assumptions and desired results. the problem or issue the validation exercise confirmed that neis struggled with implementing the curricular innovation of the cbc, which threatened the sustainability of the entire competency-based midwifery programme.[13] accreditation results from a local higher education regulatory body affirmed this finding, as only one programme from one nei was fully accredited. community needs and assets the primary implementers validated the suggested community needs and were able to add other assets available in their neis. the community needs and assets are presented in accordance with the icm global standards for midwifery education:[1] organisation and administration; midwifery faculty; student body; the curriculum, including teaching and learning; resources; and assessment. with regard to organisation and administration, primary implementers validated the need for independence of institutions from hospital boards, full accreditation of their programmes by the che, leadership in their programmes, and strengthening and redesigning of their partnerships with stakeholders who have a direct influence on the midwifery programme, such as government. the primary implementers acknowledged that the funding from government, availability of education partners, accreditation standards and support from the che were assets within the neis. on the standard of midwifery faculty, the primary implementers agreed that, at the time of this research, there was a need for development of all september 2019, vol. 11, no. 3 ajhpe 98 research educators in the programme in relation to implementing a cbc. the need for mentoring of educators, support in clinical facilitation and adequate human resources were also supported by the primary implementers. they further acknowledged the presence of educators with expertise in the cbc, who could support others. performance-appraisal policies were also realised as an asset, while some institutions had full-time clinical instructors for midwifery students, which would support the implementation of the cbc when mentored. students are expected to manifest curriculum goals at the end of their education. primary implementers acknowledged the need for student orientation programmes into the cbc, student support, including strategies to motivate them to study midwifery, and enhancing the quality of midwifery training. the primary implementers reflected that institutions had prospectuses and were guaranteed of students every year. with regard to the standard of the curriculum, which included teaching and learning, primary implementers validated the need for improved classroom facilitation, improved clinical facilitation, and programme planning to align with the cbc. an approved cbc and platform for neis to meet and discuss the curriculum were reflected as assets. the infrastructure for curriculum implementation and aligment of the clinical teaching resources to the cbc were validated by the implementers as needs with regard to the standard of resources and infrastructure. the primary implementers acknowledged support from the nursing education partnership initiative (nepi), which supported all neis with simulation laboratories and human birth simulators. the primary implementers also reflected that they had clinical platforms for training students; however, few institutions had any memoranda of understanding (mous) regarding such platforms. mous detail expected interactions between clinical platforms and neis, and can be tailor made to support the implementation of the cbc. the assessment of learner competence in these neis lacked oversight, as there were no such policies in place. the primary stakeholders explained that the presence of a co-ordinating office for summative assessments, including assessment blueprints, was an asset within these neis. strategies the primary stakeholders validated all strategies synthesised from the integrative review.[11] these strategies were presented against the specific standards, as stipulated in the icm global standards for midwifery education[1] based on the needs and assets of neis. according to the integrative review and validation of primary stakeholders, the implementation of these strategies was intended to reflect interaction between students, educators and administrators in the neis in lesotho. influencing factors influencing factors determine the utility of the framework, which were validated by the primary stakeholders informed by the second study.[13] fig. 1. a framework for implementing and sustaining a curricular innovation in a midwifery programme in lesotho. (cbmp = competency-based midwifery programme; cbe = competency-based education; icm = international confederation of midwives; che = council on higher education; mous = memoranda of understanding; cpd = continuing professional development.) transforming policies, politics and laws strategic approaches collaborative planning on implementation ongoing programme evaluation communities of practice mentoring interacting with like-minded colleagues tailor-made faculty development tangible educational support communities of practice quality assurance through monitoring recognition through incentives tailor-made preceptor programme tangible support transformation of policies, politics and laws communication with current and prospective students academic support, including explaining the reason for the change transformation of policies, politics and laws co-responsibilities through direct involvement co-responsibilities through direct involvement ongoing evaluation collaboration in the development of teaching and learning material review of curricular enactment ongoing consultation changing organisational culture through dissemination of positive practice collaborative planning quality assurance by institution and governing body collaborative planning ongoing programme evaluation against curriculum and standards transformation of policies, politics and laws strategies national culture; age of the implementers; experience in the content curriculum; attitude towards change and cbmp; self-directedness of all stakeholders involved; accountability throughout the programme; motivation of all stakeholders; leadership; national collaborative e�orts a framework for implementing and sustaining a curricular innovation in a midwifery programme in lesotho assumptions political will funding cbe is better than previous curriculum problem/issue implementing and sustaining a curricular innovation in a midwifery programme in lesotho co-ordinating o�ce for assessment assessment blueprints assessment policy independence che accreditation leadership partnerships funding from government available partners accreditation standards che trains institutions midwifery faculty organisation and administration faculty development monitoring support in clinical facilitation adequate human resources educators trained to facilitate cbmp performance-appraisal policies clinical instructors student body orientation to cbmp student support motivation to study midwifery quality midwifery training prospectus student numbers curriculum, including teaching and learning improved classroom facilitation improved clinical facilitation planning aligned to cbmp approved national curriculum intercollege co-ordination resources, facilities and services infrastructure for curriculum implementation alignment of clinical resources with cbmp simulation laboratories placement sites mous with placement sites assessment oversight of all assessments policies related to assessments influencing factors community needs/assets icm standard needs assets outcomes independent council and board; institutional strategic plan; certi�cate of programme accreditation; longer duration of programme leaders; mous with all partners; success plan for leadership tailor-made cpd programme for educators; support groups/ community of practice; training programme on competency-based education; module evaluation; human resource plan prospectus and orientation programme; policy on optional midwifery; incentives for midwifery training; student support system; quality assurance system clinical teaching strategy; quality teaching and learning material; programme implementation plans minimum infrastructure standards; minimum standards per level of healthcare facility monitoring and evaluation strategy; assessment policy; updated rules and regulations outputs autonomous institutions; che accreditation; stability in leadership; bene�cial partnerships educators able to implement and sustain cbmp; e�ective monitoring and evaluation by teaching sta�; e�ective clinical accompaniment of students; number of well-trained facilitators; number of quali�ed human resources informed students; high student throughput; self-directed learners; positive attitude towards midwifery; improved quality of training engaged students; positive learning experience; well-planned programme infrastructure that meets the minimum standards for cbmp implementation; health facilities that meet minimum standards quality assessments; enactment of policy; standard examinations impact reduction in maternal mortality ratio; improved family-centred care desired results 99 september 2019, vol. 11, no. 3 ajhpe research these factors comprised the culture and age of the implementers, their experience in the previous content-driven curriculum, and their attitude towards change. the level of self-directedness of all the stakeholders engaged with the programme, including accountability for and of the programme, had to influence the implementation of the framework.[13] leadership style was also included as an influencing factor. assumptions the assumptions in this framework were based on descriptions by the authors and primary stakeholders. these assumptions are the political will, funding and belief that the cbc is better than the previous curriculum. desired results the desired results reflect what was anticipated after implementing the framework. these were presented as three main criteria, i.e. outputs, outcomes and impact. the results were informed by the intentions of the cbc, including the needs of the neis in lesotho in relation to the competency-based midwifery programme as validated by the primary implementers. outputs are the direct products of activities of this framework, presented under each specific standard and aligned with the needs and assets of the neis. with regard to the standard of organisation and administration, the outputs are: independent councils and boards, institutional strategic plans, accreditation certificates, longer terms for the position of head of the midwifery programme, mous with all partners and succession plans for leadership. in terms of the standard of midwifery faculty, the outputs are: tailor-made continuing professional development (cpd) programmes for educators, a training programme on competency-based education for educators, module evaluation and a human resource plan. outputs with regard to the student body are: a comprehensive prospectus and orientation programme for students, a policy on optional midwifery, incentives for midwifery training, a student support system and a quality-assurance system. outputs with regard to the standard of the curriculum are: a clinical teaching strategy, quality teaching and learning material and programme implementation plans. infrastructure-related outputs are minimum criteria and standards for educational institutions and healthcare facilities. for the assessment standard, outputs are: updated rules and regulations for the midwifery programme, including a monitoring and evaluation strategy for assessments. outcomes included specific changes in the primary stakeholder’s behaviour, knowledge, skills, status and level of functioning after interventions prescribed by the framework. from this framework, the desired outcomes were autonomous institutions with stable leadership and beneficial partnerships with all nei stakeholders. other desired outcomes were educators who are able to implement a competency-based midwifery programme. consequently, students would be better informed regarding the programme and have a positive attitude towards midwifery as a discipline. curriculum outcomes include a positive learning experience and quality assessments. the desired impact of implementing this framework will be experienced in the long term, aligned with the reduction of maternal and neonatal mortality by family-centred care. discussion a variety of factors influence the sustainability of curricular innovations in professional programmes in higher education. the curriculum is the fulcrum of professional programmes, and curriculum innovation directly influences all other aspects of the programme. failure to adjust the various interrelated aspects of a professional programme during the implementation of curricular innovation may contribute to disparities in curricular enactment, setting the stage for curricular drift.[5] frameworks based on contextual realities have a significant influence on supporting heis in adjusting programme-related aspects for sustained curricular innovations as opposed to frameworks imported from external settings. implementing a curriculum is largely influenced by contextual factors, which should be paramount in designing strategies used in sustaining professional programmes.[15] such strategies should be grounded in the experiences and expertise of primary implementers, who are able to relive contextual realities through designing feasible solutions. in this study, primary implementers provided valuable insight into validating components of a framework based on contextual realities around the implementation of a cbc in lesotho. bottom-up approaches to developing and validating frameworks for sustaining curricular innovations in programmes such as midwifery improve acceptance, further increasing the utility of such a framework.[16] it is essential that frameworks designed to improve curricular innovation implementation within higher education be grounded in the espoused curricular goals and the standards used in establishing a professional programme. such approaches allow for heis to respond to their original reason for curricular change, at the same time avoiding superficial evaluations, where curricular innovations may be branded as failure. in the current setting, the cbc document and the icm global standards for midwifery education[1] underpinned the inquiry and design of the framework for implementing and sustaining curricular innovation in the midwifery programme. conclusions a variety of factors influence heis to introduce curricular innovations in professional programmes, such as midwifery. the implementation of such curricular innovations needs to be supported by contemporary frameworks based on contextual realities and experiences of primary implementers. these primary implementers provided expert opinion based on their experiences and realities within their context. involving primary implementers in the development of such frameworks increases acceptance and buy-in. further research in this field should evaluate the effect of implementing such contextually designed frameworks on primary implementers and population outcomes. declaration. this article is based on a study done by cnn in partial fulfilment of his phd thesis. acknowledgements. the authors acknowledge dr r albertyn for critical reviewing of the manuscript and ms j viljoen for language editing of the article. the heads of nursing education institutions in lesotho are acknowledged for their role in allowing their educators, students and other administrators to be part of the study. author contributions. cnn: designed the study, collected and analysed the data and drafted the manuscript; yb: designed the study, analysed the data and drafted the manuscript. funding. none. conflicts of interest. none. september 2019, vol. 11, no. 3 ajhpe 100 research 1. international confederation of midwives (icm). the global standards for midwifery education. 2014. http:// www.internationalmidwives.org/what-we-do/education-coredocuments/global-standards-education (accessed 16 june 2017). 2. united nations population fund. state of the world’s midwifery. 2014. http://www.unfpa.org (accessed 3 july 2019). 3. prideaux d. curriculum design. bmj 2003;326(7383):268-270. https://doi.org/10.1136/bmj.326.7383.268 4. wilson ea, rudy d, elam c, pfeifle a, straus r. preventing curriculum drift: sustaining change and building upon innovation. ann behav sci med educ 2012;18(2):23-26. https://doi.org/10.1007/bf03355202 5. woods a. exploring unplanned curriculum drift. j nurs educ 2015;54(11):641-644. https://doi. org/10.3928/01484834-20151016-05 6. markee n. managing curricular innovation. cambridge: cambridge university press, 1997. 7. amineh rj, asl h. review of constructivism and social constructivism. j soc sci lit lang 2015;1(1):9-16. 8. brunner j. vygotsky: a historical and conceptual perpective. in: weitsch v. culture, communication and cognition: vygotskyan perspective. cambridge: cambridge university press, 1985. 9. biggs j. enhancing teaching through constructive alignment. high educ1996;32(3):347-364. https://doi. org/10.1007/bf00138871 10. w k kellogg foundation. logic model development guide, 2004. https://www.wkkf.org:443/resource-directory/ resource/2006/02/wk-kellogg-foundation-logic-model-development-guide (accessed 1 november 2016). 11. nyoni cn, botma y. strategies to sustain curricular innovations in higher education: an integrative review. proceedings of the 2017 south african association of health educationalist conference, 26 28 june 2017, potchefstroom, south africa. 12. nyoni cn, botma y. implementing a competency-based midwifery programme in lesotho: a gap analysis. nurse educ pract 2019;34:72-78. https://doi.org/10.1016/j.nepr.2018.11.005 13. nyoni cn, botma y. sustaining a newly implemented competency based-midwifery programme in lesotho: emerging issues. midwifery 2018;59:115-117. https://doi.org/10.1016/j.midw.2018.01.015 14. burgess t, cilliers f. a framework for ethical educational research: principles and application. 2016. http://www. healthedu.uct.ac.za (accessed 16 june 2017). 15. reis s. curriculum reform: why? what? how? and how will we know it works? isr j health policy res 2018;7(1):30. https://doi.org/10.1186/s13584-018-0221-4 16. collins se, clifasefi sl, stanton j, et al. community-based participatory research (cbpr): towards equitable involvement of community in psychology research. am psychol 2018;73(7):884-898. https://doi.org/10.1037/ amp0000167 accepted 1 july 2019. http://www.internationalmidwives.org/what-we-do/education-coredocuments/global-standards-education http://www.internationalmidwives.org/what-we-do/education-coredocuments/global-standards-education http://www.unfpa.org https://doi.org/10.1136/bmj.326.7383.268 https://doi.org/10.1007/bf03355202 https://doi.org/10.3928/01484834-20151016-05 https://doi.org/10.3928/01484834-20151016-05 https://doi.org/10.1007/bf00138871 https://doi.org/10.1007/bf00138871 https://www.wkkf.org:443/resource-directory/resource/2006/02/wk-kellogg-foundation-logic-model-development-guide https://www.wkkf.org:443/resource-directory/resource/2006/02/wk-kellogg-foundation-logic-model-development-guide https://doi.org/10.1016/j.nepr.2018.11.005 https://doi.org/10.1016/j.midw.2018.01.015 http://www.healthedu.uct.ac.za http://www.healthedu.uct.ac.za https://doi.org/10.1186/s13584-018-0221-4 https://doi.org/10.1037/amp0000167 https://doi.org/10.1037/amp0000167 october 2020, vol. 12, no. 3 ajhpe 109 research nurses have much more to offer than merely being the handmaidens of doctors and performing psychomotor skills, especially in countries that aim for universal health coverage (uhc) and those with healthcare disparities.[1] threats to uhc include unfit-for-purpose human resources, insufficient numbers and inequitable distribution of healthcare workers.[2] as an example, we refer to the study by freer,[3] who reported that in 2017, 12% of doctors worked in rural areas of south africa (sa), where 46% of the population were living. while sub-saharan africa carries 25% of the world’s disease burden, only 3% of the global health workforce resides there.[4] therefore, the needs-based projection by scheffler et al.[5] shows that low and middle-income countries will have a shortage of 6 million healthcare professionals by 2030. asamani et al.[2] therefore warn that there is little hope of meeting the human resources need because governments are unable to pay the wage bill. the education of healthcare professionals should focus on meeting the needs of the health system and communities[6] and not only on increasing the number of nurses being trained. the importance of this focus should be on quality rather than quantity of nurses, as noted by drennan and ross.[7] although more healthcare professionals – especially nurses – are required, more relevant training through intraand interprofessional collaboration, education and continuous professional development is needed to maximise the capacities and potentials of nurses and mid wives.[8] relevant training relates to curriculum relevance, a person-centred approach and continuous skills development.[9,10] hence, innovations in health professions education are urgently needed to develop an adequate and skilled health workforce.[11] in addition to other educational approaches, rwanda emphasises simulationbased and clinical education, thereby intending to promote critical thinking and clinical reasoning skills of nursing students.[4] preceptors are ideal to promote critical thinking and clinical reasoning in students. in 2011, the national department of health accepted a clinical teaching model in which nursing education institutions (neis) employ preceptors to accompany nursing students during their clinical placements.[12] the named strategies aim to improve the quality of nursing education, as well as that of the nursing workforce. however, the authors could not find literature on preceptors’ perceptions of their contribution to the development of the future nursing workforce. in this article, we report on a study that explored preceptors’ views of their contribution to the development of the nursing workforce. methods the researchers used a qualitative, visual, narrative inquiry design[13] to explore participating preceptors’ views on their contribution to developing the future nursing workforce. through an interpretive stance, the researchers gained insight into the reality as perceived by preceptors within their specific context. population the first author presented the preceptor-training programme at two neis. census sampling allowed all preceptors at both neis to participate in the study. thirty-eight preceptors attended the training programme, and the images that the preceptors created collectively in groups comprised one deliverable of the programme. background. apart from a global need for more nurse practitioners, there is also a need for nurse practitioners who are competent and confident to address the needs of their communities. furthermore, the future nursing and midwifery workforce needs to have effective interprofessional collaboration skills and a person-centred approach. a clinical model, accepted by the national department of health in 2011, places preceptors at the centre of clinical education to assist in the improvement thereof and to develop much-needed attributes in nursing students. no research has been conducted to explore the way in which preceptors see their contribution to developing the future nursing workforce. objective. to explore preceptors’ views of their contribution to the development of the future nursing workforce. method. a qualitative, visual, narrative inquiry design was used. following a 3-day preceptor-training workshop, 38 preceptors from two nursing education institutions collectively participated in creating images of their views on their contribution to developing the future nursing workforce. the first 6 steps in the visual analysis were used to analyse the images. results. six categories originated from the images, i.e. skill set, stakeholders, diverse students, transformative learning, relationships and practice. conclusion. preceptors are more than handmaidens of the educational system. they may contribute significantly to the development of the nurse and midwife workforce, as they promote competence, people-centredness and interprofessional collaboration, which are strategies proposed by the world health organization for reaching universal health coverage. afr j health professions educ 2020;12(3):109-113. https://doi.org/10.7196/ajhpe.2020.v12i3.1372 the contribution of nursing preceptors to the future nursing workforce l hugo, rn, rm, phd; y botma, rn, rm, phd school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: l hugo (hugol1@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 110 october 2020, vol. 12, no. 3 ajhpe research data collection at the end of the 3-day preceptor-training programme, participants created an image on the collective views of their contribution in developing the future nursing workforce of 2030. among the two neis, 8 images were developed, but 3 were not submitted by participants, leaving the researchers with 5 images for analysis. data analysis following mey and dietrich,[14] the first 6 steps in the visual analysis in combination with an adapted image-analysis worksheet created by the us national library of medicine[15] were used to analyse the images. the worksheet guided the researchers in describing the images by focusing on details regarding people, actions, objectives, symbols and questions, which captured the first 3 steps of mey and dietrich,[14] i.e. contextualisation, description and segmentation. steps 4 and 5 of mey and dietrich[14] comprise memo writing, coding and interpretation. these steps correspond with the coding of the worksheet as missing information and the main messages portrayed by the images. ethical approval the health sciences research ethics committee and research sites approved the study (ref. no. ecufs 134/2013b). all the preceptor-training attendees gave written informed consent that the first author may use all deliverables for research. results in line with the first 3 steps of mey and dietrich,[14] a brief description of each image is provided, followed by the coding and interpretation. fig. 1 reflects the upper body of a woman with two red bows in her hair, a green band around her neck and an inverted red triangle in the lower third of her thorax. she has prominent shoulders on which is written, ‘carry all the burden’ and ‘willing horse’. her heart is a passion for teaching, with an electrocardiogram (ecg) rhythm strip. both arms are stakeholders. her senses characterise the preceptor as a good listener and observer; her mouth tells no lies and is decisive. other characteristics flow over her right shoulder. the triangles in the corners state copy time 10, 100 and 1 000. her legs are a vehicle for clinical teaching and transformation. the stick figure in the bottom left-hand corner of fig. 2 wears a hat with the sa flag, and holds 3 torches shining towards student education, practice and management. the lines between the stick figure and education, practice and management are linear and star studded. a sketch of a tie appears next to management. the students – depicted as multicoloured dots with various expressions – are in the middle of a practice circle. there are also question marks in the circle. a spiral forms the link between the stick figure and the students. education is portrayed in an elliptical form with a graduation cap, and crosses practice to meet the students in the middle of the practice circle. fig. 3 is a tree with branches and leaves in the upper third of the page. the branches represent thoughts, while the leaves depict characteristics of the preceptor. stakeholders are captured in the trunk. a green ribbon is wrapped around the trunk and is fastened with a red heart, with the words ‘art of preceptorship’. ‘building the future’ is written in the soil. beneath the soil are the roots, depicting ethics, standards, foundational knowledge, communication pathway, clinical and theoretical expertise, recruitment process, role models and mentors. the preceptor and facilitation techniques are shown as raindrops. paper figures with different facial expressions and coloured dots fill the bottom half of fig. 4. stars on the images may indicate the level of study, as they vary from 1 to 4. centred in the top half is a paper image similar to the one in the bottom half. this figure holds on to two chains overarching fig. 1. the upper body of a woman. fig. 2. shining a light. october 2020, vol. 12, no. 3 ajhpe 111 research the images in the bottom half of the representation. the surrounding words portray tasks such as communication and facilitation. in the top left-hand corner is a different image (manager) who holds a whip. above the manager are the words ‘i am the boss’. in fig. 5 there are 2 females – on opposite sides of the page. the lefthand one is more prominent and colourful than the one on the right, which represents a student. the preceptor, on the left, has a halo with the words, ‘role model’ and ‘looking up to’. the words surrounding the preceptor indicate her tasks, such as ‘manage’, ‘evaluate’ and ‘collaborate’ with ‘unit managers’, ‘fellow preceptors’ and ‘multidisciplinary team’. preceptor characteristics, such as ‘friendliness’, ‘compassion’, ‘acknowledging success’ and ‘advocate’ are associated with the large mouth. the preceptor also gives positive reinforcement. there is no link between the preceptor and the student, but rather a great distance. the researchers noticed information missing on the images, which they had expected to find in the context of preceptorship. only fig. 2 portrays the clinical context where preceptors primarily work. students with whom preceptors engage are absent from figs 1 and 3. figs 4 and 5 lack stakeholders involved in students’ clinical learning. the coded messages were then grouped into 5 categories. table 1 shows the categories, i.e. skill set, stakeholders, diverse students, transformative learning, relationships and practice. the numbers indicate figs 1 5, which portray the information. the categories mentioned are discussed in the following section, with theoretical links to indicate rationale and guide neis in terms of important elements for inclusion in future training programmes. discussion preceptors are the lynchpin between the educational system and health system, as they liaise with stakeholders involved in students’ clinical learning (figs 1 and 2).[16,17] stakeholders include but are not limited to placement co-ordinators, educators, programme directors, unit managers, nurse practitioners, students and patients.[18] figs 1, 3, 4 and 5 illustrate the importance of a specific skill set that preceptors should have. for example, negotiation skills are pivotal for collaboration with the stakeholders to arrange learning opportunities for students.[19,20] they thereby contribute to a positive clinical learning environment where students can integrate theory into practice. four of the 5 images highlight the skill set of preceptors, which enables them to facilitate the development of students’ critical thinking, clinical reasoning and problem-solving skills – contributing to students becoming competent, autonomous practitioners.[20,21] crisp and watkins[1] concur that nurses should move away from being mere handmaidens who practise fig. 3. the tree. fig. 4. holding hands. fig. 5. the preceptor and the student. 112 october 2020, vol. 12, no. 3 ajhpe research psychomotor skills, and instead refocus on integration of knowledge, psychomotor skills and people-centred behaviour to achieve uhc. fig. 3 shows specific techniques, such as snapps (summarising, narrowing, analysing, probing, planning and selecting), isbar (introduction, situation, background, assessment and recommendation) and i pass the baton (introduction, patient, assessment, situation, safety concerns, background, actions, timing, ownership and next) as ways to facilitate students’ learning.[17,20] effective facilitation develops self-directedness in students, resulting in lifelong learners. lifelong learning is a critical characteristic for practitioners to be able to cope with emerging technology and scientific healthcare knowledge.[22] student learning occurs primarily in practice, which is often a challenging and unpredictable environment, as illustrated by means of question marks (fig. 2). it is noticeable that only 1 of the 5 images includes the clinical context. challenges refer to a poor human-resourced environment, together with a lack of consumables, such as medicinal drugs, and inadequate or malfunctioning equipment, which may have a negative influence on developing a competent workforce for 2030.[11] the support preceptors provide to students is, therefore, essential to promote students’ clinical learning.[17] students often experience clinical practice as stressful and unfriendly.[20,23] preceptors should therefore provide emotional support in practice.[17] building interpersonal relationships with students is essential to provide emotional support, depicted in fig. 4 as the preceptor protecting students. students who experience support from preceptors may be able to manage challenging situations in practice.[17] additionally, interpersonal relationships with stakeholders contribute to a positive clinical learning environment.[18] stakeholders in the clinical environment include other healthcare professionals, as interprofessional collaboration during clinical learning is essential to abolish the biomedical model and promote a biopsychosocial approach to healthcare.[24] fig. 5 portrays collaboration with the teams, emphasising the unit manager, fellow preceptors and the multidisciplinary team. however, according to preceptors, managers are perceived as autocratic (fig. 4), endangering the establishment of personal relationships with others. other stakeholders are absent (figs 4 and 5). preceptors’ relationships with stakeholders are essential for students to flourish in the clinical learning environment. interpersonal relationships are embedded in person-centredness, embracing the diversity of students and healthcare consumers. figs 2 and 4 show the diversity of students by way of different colour stickers, varying facial expressions, and the number of stars illustrating the educational level of students. person-centred preceptors consider students’ personalities, learning styles, motivation, cultural backgrounds, different educational levels and circumstances during the facilitation of learning.[25] subsequently, students will be motivated to transfer their learning and improve their nursing care practices. traditionally, preceptorship focused on demonstrating psychomotor skills and assessments.[17] this left limited space for relationship building with students, and might have been the reason for the power distance (fig. 5). also noticeable is that students are absent from figs 1 and 3. conclusions preceptors created images on how they perceived their contribution to the future nursing workforce of 2030. five images were analysed according to mey and dietrich’s[14] 6 steps. preceptors need a specific skill set to develop competence in students. from the images, participating preceptors became aware that they should move away from psychomotor skills training and assessment and focus on facilitating the integration of knowledge, skills and behaviour, thereby developing a competent nursing workforce. images portrayed that stakeholders in the educational and health system should work together to create a positive clinical learning environment for students to transfer their learning into practice and become competent. preceptors view their liaising role with the educational and health system as essential for stakeholder collaboration. interprofessional collaboration could be role-modelled by preceptors through the facilitation of clinical learning across healthcare professions. several images portrayed the importance of relationships, taking into consideration the diversity of students and person centredness in practice. the authors’ interpretation of the preceptors’ views regarding their contribution to the workforce for uhc is to develop table 1. categories for messages from figs 1 5 category main message per image skill set preceptors need a specific skill set, e.g. being skilful, knowledgeable, a good listener, a communicator, observant, compassionate, a collaborator with stakeholders, a facilitator, a role model, a mediator and an assessor (figs 1, 3, 4 and 5) facilitation techniques are specific to the development of thinking operations (fig. 3) stakeholders the preceptor stands central to the stakeholders (fig. 1) preceptor as a link between education, student, practice and practice management (fig. 2) preceptors comprise the essential element (rain) that allows the fundamental requirements, through the governance of stakeholders, to be absorbed and to feed the branches and leaves to portray a healthy nursing workforce (fig. 3) diverse students the diverse student population in practice (figs 2 and 4) clinical learning the preceptor is the vehicle for clinical learning (fig. 1) the preceptor recognises that students are at different levels and adapts facilitation accordingly, as illustrated by the spiral between facilitator and students in practice (fig. 2) relationships an autocratic relationship exists between the manager and the preceptor, while the preceptor embraces the students (fig. 2) there is a power distance between the preceptor and the student, as shown in the space between them and the difference in size (fig. 5) practice the size of practice may indicate the importance of student development towards competence, and also the context of their place of work (fig. 2) october 2020, vol. 12, no. 3 ajhpe 113 research students’ clinical competence, and cultivate stakeholder collaboration, person-centredness and interprofessional collaboration. a limitation is that the interpretation is based on the authors’ perspective and theoretical explanations for insight into refining the training programme. readers might view images from a different perspective and therefore generalisations cannot be made. although a small study, the findings may be transferable to similar preceptor programmes. a larger study is needed to verify the findings of this study. preceptors are more than mere handmaidens of the educational system. they may contribute significantly to the development of the nursing and midwifery workforce, as they emphasise competence, people-centredness and interprofessional collaboration – strategies proposed by the world health organization for reaching uhc. recommendations future studies could investigate the effect of preceptors on workforce development. preceptors should be trained to contribute to the development of a competent nursing workforce. declaration. none. acknowledgements. we acknowledge the participating preceptors at the two nursing education institutions. author contributions. the authors contributed equally to the article. funding. the research was funded by the plume fundisa/nrf grant (2015/001). conflicts of interest. none. 1. crisp n, watkins m. the triple impact of nursing. int j nurs stud 2018;78:a3-a4. https://doi.org/10.1016/j. ijnurstu.2017.05.001 2. asamani ja, akogun ob, nyoni j, ahmat a, nabyonga-orem j, tumusiime p. towards a regional strategy for resolving the human resources for health challenges in africa. bmj glob health 2019;4(suppl 9):e001533. https:// doi.org/10.1136/bmjgh-2019-001533 3. freer j. sustainable development goals and the human resources crisis. int health 2017;9(1):1-2. https://doi. org/10.1093/inthealth/ihw042 4. uwizeye g, mukamana d, relf m, et al. building nursing and midwifery capacity through rwanda’s human resources for health program. j trans nurs 2018;29(2):192-201. https://doi.org/10.1177/1043659617705436 5. scheffler rm, campbell j, cometto g, et al. forecasting imbalances in the global health labour market and devising policy responses. hum resource health 2018;16(1):1-11. https://doi.org/10.1186/s12960-017-0264-6 6. da silva fm, gutierrez jfg. transforming health professions education to advance toward universal health. int am j med health 2018;1:1-3. https://doi.org/10.31005/iajmh.v1i1.45 7. drennan vm, ross f. global nurse shortages: the facts, the impact and action for change. br med bull 2019;130(1):25-37. https://doi.org/10.1093/bmb/ldz014 8. nkowane a, ferguson s. the world health organization launches the 2016 2020 global strategic directions for strengthening nursing and midwifery. nurs econ 2016;34(4):206-208. https://doi.org/10.1213/ ane.0000000000003438 9. mamede mv. nursing and midwifery workforce and the new sustainable development goals (2016 2030). rev rene 2018;18(6):710-711. https://doi.org/10.15253/2175-6783.2017000600001 10. van vliet k, roodbol p, chorus a, ossebaard h. education for future health care: a radical shift in perception, learning and action. int j healthcare 2017;4(1):1-4. https://doi.org/10.5430/ijh.v4n1p1 11. agyepong i, sewankambo n, binagwaho a, et al. the path to longer and healthier lives for all africans by 2030: the lancet commission on the future of health in sub-saharan africa. lancet 2017;390(10114):2803-2859. https://doi.org/10.1016/s0140-6736(17)31509-x 12. nursing education stakeholders. a proposed model for clinical nursing education and training in south africa. pretoria: forum of university nursing deans in south africa (fundisa), 2012:49-58. 13. given l, ed. the sage encyclopedia of qualitative research methods, vol. 1-2, 2008. https://books.google.com/ books?id=y_0naqaamaaj&pgis=1 (accessed 23 march 2020). 14. mey g, dietrich m. from text to image: shaping a visual grounded theory methodology. historic soc res 2018;42(4):280-300. https://doi.org/10.17169/fqs-17.2.2535 15. united states national library of medicine. image analysis worksheet. http://www.nlm.nih.gov/picturesofnursing (accessed 1 april 2020). 16. botma y, hurter s, kotze r. responsibilities of nursing schools with regard to peer mentoring. nurs educ today 2012:33(8):808-813. https://doi.org/10.1016/j.nedt.2012.02.021 17. hugo l. development and implementation of a training programme for preceptors: a realist evaluation. phd thesis. bloemfontein: university of the free state, 2018. https://scholar.ufs.ac.za/handle/11660/9879 (accessed 23 march 2020). 18. du plessis j. stakeholders’ viewpoints on work-integrated learning practices in radiography training in south africa: towards improvement of practice. radiography 2019;25(1):16-23. https://doi.org/10.1016/j. radi.2018.06.011 19. berntsen k, bjørk it, brynildsen g. nursing students’ clinical learning environment in norwegian nursing homes: lack of innovative teaching and learning strategies. open j nurs 2017;7(8):949-961. https://doi. org/10.4236/ojn.2017.78070 20. trede f, sutton k, bernoth m. conceptualisations and perceptions of the nurse preceptor’s role: a scoping review. nurs educ today 2016;36:268-274. https://doi.org/10.1016/j.nedt.2015.07.032 21. tanner ca. thinking like a nurse: a research-based model of clinical judgment in nursing. j nurs educ 2006;45(6):204-211. https://doi.org/10.3928/01484834-20060601-04 22. al moteri mo. self-directed and lifelong learning: a framework for improving nursing students’ learning skills in the clinical context. int j nurs educ scholar 2019;16(1):1-10. https://doi.org/10.1515/ijnes-2018-0079 23. msiska g, smith p, fawcett t. the ‘lifeworld’ of malawian undergraduate student nurses: the challenge of learning in resource poor clinical settings. int j afr nurs sci 2014;1:35-42. https://doi.org/10.1016/j.ijans.2014.06.003 24. gray a, vawda y. south african health review 2014/15. durban: health systems trust, 2015. https://doi. org/10.1007/s13398-014-0173-7.2 25. donovan p, darcy dp. learning transfer: the views of practitioners in ireland. int j train dev 2011;15(2):121-139. https://doi.org/10.1111/j.1468-2419.2011.00374.x accepted 24 june 2020. https://doi.org/10.1016/j.ijnurstu.2017.05.001 https://doi.org/10.1016/j.ijnurstu.2017.05.001 https://doi.org/10.1136/bmjgh-2019-001533 https://doi.org/10.1136/bmjgh-2019-001533 https://doi.org/10.1093/inthealth/ihw042 https://doi.org/10.1093/inthealth/ihw042 https://doi.org/10.1177/1043659617705436 https://doi.org/10.1186/s12960-017-0264-6 https://doi.org/10.31005/iajmh.v1i1.45 https://doi.org/10.1093/bmb/ldz014 https://doi.org/10.1213/ane.0000000000003438 https://doi.org/10.1213/ane.0000000000003438 https://doi.org/10.15253/2175-6783.2017000600001 https://doi.org/10.5430/ijh.v4n1p1 https://doi.org/10.1016/s0140-6736(17)31509-x https://books.google.com/books?id=y_0naqaamaaj&pgis=1 https://books.google.com/books?id=y_0naqaamaaj&pgis=1 https://doi.org/10.17169/fqs-17.2.2535 http://www.nlm.nih.gov/picturesofnursing https://doi.org/10.1016/j.nedt.2012.02.021 https://scholar.ufs.ac.za/handle/11660/9879 https://doi.org/10.1016/j.radi.2018.06.011 https://doi.org/10.1016/j.radi.2018.06.011 https://doi.org/10.4236/ojn.2017.78070 https://doi.org/10.4236/ojn.2017.78070 https://doi.org/10.1016/j.nedt.2015.07.032 https://doi.org/10.3928/01484834-20060601-04 https://doi.org/10.1515/ijnes-2018-0079 https://doi.org/10.1016/j.ijans.2014.06.003 https://doi.org/10.1007/s13398-014-0173-7.2 https://doi.org/10.1007/s13398-014-0173-7.2 https://doi.org/10.1111/j.1468-2419.2011.00374.x march 2020, vol. 12, no. 1 134 october 2020, vol. 12, no. 3 ajhpe research postoperative pain is a common, predictable and expected experience following surgery, and if not adequately managed leads to delayed postoperative recovery, poor prognosis, increased mortality and morbidity and increased risk for pain becoming chronic.[1] this can lead to a decline in the patient’s functionality and productivity, and consequently have a negative effect on their quality of life.[2] the relief of pain has been and remains one of the major campaigns in the health sector, but regardless of this, studies continue to reveal poor and ineffective postoperative pain management by healthcare providers.[3] this problem has been identified in underdeveloped, developing and developed countries: it is a global challenge. the institute of medicine in 2010 described quality in healthcare as ‘the degree of healthcare provided to patient populations sufficient to improve their desired health outcomes’.[4] they identified six basic steps to high-quality healthcare: care must be effective; safe and reliable; patient-centred; efficient; timely; and equitable. adequate pain management has consequently been described as: conducting a detailed clinical assessment of pain, periodically reassessing the patient’s responses to pain treatment, and developing a modality of care that is safe, involves the patient and his or her family members and is culturally consistent and developmentally appropriate.[5] quality pain management training is important in ensuring effective patient care, and this can be achieved by empowering nurses with adequate knowledge and skills needed for the provision of quality postoperative pain management.[6] the drive to improve postoperative pain management has been in place for some time, but nurses continue to experience challenges in this area of practice.[7] accreditation of healthcare organisations in 2000 specifically demands pain assessment and documentation, staff education in pain management and competency assessments, adequate pain control to allow functional rehabilitation, and education of patients and families on pain and symptom management.[7,8] the fact, however, remains that most professions have neglected the concept of pain in their curriculum at undergraduate level and even during clinical practice.[9] the reported undermanaged postoperative pain in different studies has affected institutions adversely, and contributes to decreased patient satisfaction and longer impaired mobility and hospital stay, increased morbidity and mortality and, consequently, poorer quality of life.[10-12] poor management of postoperative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. it is therefore important that all patients undergoing surgery should receive adequate pain management. however, evidence suggests this is not currently the case: between 10% and 50% of patients develop complications related to background. postoperative pain management is a way of reducing or eliminating pain and discomfort with minimum side-effects after surgery. pain is a predictable and expected experience following surgery, and if not well controlled poses a major risk to the patient. research shows that most patients suffer complications associated with postoperative pain. it is therefore important to develop approaches on how to improve knowledge of postoperative pain management among nurses. objective. to determine the effectiveness of a teaching programme on the knowledge of postoperative pain management among nurses in the adult surgical ward of lagos university teaching hospital, nigeria. methods. a quasi-experimental research design was conducted, and an accidental sampling technique used to select a total of 60 nurses. probability sampling was used to divide this group into two (control n=30, experimental group n=30). data were collected using a modified structured questionnaire, the ‘knowledge and attitudes survey regarding pain’ tool. ethical clearance was obtained from the hospital before the administration of the questionnaire. data obtained were coded and analysed using statistical package for social sciences version 21.0 statistical software, at p=0.05 level of significance. results. the pre-intervention mean (standard deviation) score on knowledge of postoperative pain management among participants in the control group was 1.05 (0.60) and 1.06 (0.63) in the experimental group, with a mean difference of 0.01. following intervention, there was a rise in mean score on knowledge of postoperative pain management among the nurses in the experimental group to 1.62 (0.97), while participants in the control group had 1.05 (0.62), with a mean difference of 0.57. there were significant statistical differences between the preand post-intervention mean score of participants’ knowledge of postoperative pain management (t=3.68, p=0.00). conclusion. the teaching programme was effective in improving participants’ knowledge of postoperative pain management. therefore continued education on postoperative pain management is recommended for nurses who are involved in the care of postoperative patients. afr j health professions educ 2020;12(3):134-139. https://doi.org/10.7196/ajhpe.2020.v12i3.1343 effect of a teaching programme on knowledge of postoperative pain management among nurses at lagos university teaching hospital, nigeria m o olawale,1 rn, msc; o olorunfemi,2 rn, msc; o m oyewole,1 rn, msc; r a salawu,3 rn, phd 1 department of medical surgical nursing, school of post basic nursing, lagos university teaching hospital, idi-araba, lagos state, nigeria 2 department of medical surgical nursing, school of nursing, university of benin teaching hospital, benin edo state, nigeria 3 department of medical surgical nursing, school of nursing sciences, babcock university, illisha remo ogun state, nigeria corresponding author: o olorunfemi (olaolorunfemi@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 135 research poor management of postoperative pain, even in developed countries.[13] inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. consequently, this study aimed to determine the effectiveness of a teaching programme on the knowledge of postoperative pain management among nurses in the adult surgical ward of the lagos university teaching hospital. materials and methods the present study had a quasi-experimental design, and was conducted among nurses. the sample size was calculated using leslie kish’s formula, where n0 = sample size, p = the estimated proportion of an attribute, q  =  1–p, margin of error = 0.05, with a confidence level of 95%. accidental sampling was used to select a sample size of 60, and probability sampling was further used to divide the sample size into two equal parts (control and experimental group). the setting was lagos university teaching hospital, (luth) situated in idi-araba, mushin local government area, nigeria. the target population was nurses working in luth. the inclusion criteria were as follows: nurses who were willing to participate in the study, and who consented after carefully going through the detailed procedure of bioethical principles in conducting research studies on human participants. excluded were any nurses who had <5 years’ working experience, and those working in the recovery room at the time of the research, to avoid distractions from taking care of the critical ill patients in their care. a modified structured questionnaire called the knowledge and attitudes survey regarding pain tool (kaspt) was used to evaluate the effect of a teaching programme on the knowledge of postoperative pain management among nurses. the data-gathering tools were the demographic characteristic questionnaire, a questionnaire on the knowledge of pain assessment, knowledge of pain management and knowledge on the route and method of postoperative drug administration. the kaspt is a global standardised tool that was designed and reported by alqahtani et al.[14] in 2019. the psychometric properties of the questionnaire were checked by an expert in the field using face and content validity criteria, and the reliability of the instrument was established through a pretest method by administering 15 questionnaires to nurses with the same inclusion criteria among nurses in the federal medical centre, ebute-meta, lagos. cronbach’s α coefficient was used to test reliability. the value obtained was 0.8, which indicated high reliability of the instrument. there were three phases in this study. phase 1 was mobilisation. in this phase, the researchers met with the director of the nursing service, the head of the department and staff nurses in the adult surgical ward in luth to explain the purpose of the study and its benefits. the purpose of this was also to seek co-operation for the success of the study. the researchers and research assistants visited the ward on monday to friday in the mobilisation week of the study to observe how the staff managed postoperative pain, and gaps were identified that were used to modify the training programme (see appendix: www.http://ajhpe.org.za/public/ files/1343.pdf ). interested participants were selected for the study after seeking their consent. questionnaires were administered as a pretest to both control and experimental groups. the results from this phase were also used to modify the training programme. experimental and control participants were followed up via phone calls (at least a call per week for the period of the training) and text messages, reminding them to come for the training. phase  2 consisted of class-based training about postoperative pain management, and was developed and presented over 3 weeks in a seminar room. in the first week of the training, 10, 5, 4, 6 and 5 participants were available on different weekdays, respectively, based on their shifts. throughout the training programme, the researchers used teaching aids. weeks 2 and 3 of follow-up produced good results. during phase 3, after the application of the training programme for the experimental group, a post-test was conducted, using the same questionnaire as for the pre-test for experimental and control groups. data obtained were coded and analysed using statistical package for social sciences (spss) version 21.00 statistical software (ibm corp., usa). variables and research questions were analysed using descriptive statistics and independent t-tests for inferential statistics. ethical considerations ethical approval for this study was obtained from two institutional ethical committees where the study took place, with approval ref. no. buhrec576/16 on 30 november 2016 from babcock university, and ref. no. adm/dcst/ hrec/app1398 from luth on 5 january 2017. the interviewer explained the importance of the study and what the participants and others stood to benefit from it. therefore, informed consent was obtained from the participants before the study commenced. participation in the study was voluntary, and participants had the right to withdraw from the study at any stage. results table 1 shows that 33.3% of the respondents in the control group were between the ages of 31 and 40 and 41 and 50 years, while 16.7% were between 21 and 30 and 51 years and above, with mean ages of 42.5 and 40.0, respectively. all respondents (100%) were female. with regard to their educational status, 56.7% were registered nurses and midwives (rn/ rm), 40% were bachelor degree holders while 3.3% had master’s degrees. concerning their professional status, 23.3% were classed nurse officer 2 (noii) and senior nurse officer (sno), while 13.3% were nurse officer 1 (noi), principal nurse officer (pno), acting chief nurse officer (acno) and chief nursing officer (cno). forty percent of respondents had <5 years’ working experience, 23.3% had 6 10 years’ experience, 6.7% had 11 15 years, 13.3% had 16 20 years and 16.7% had 20 years’ experience. in the experimental group, 36.7% of respondents were between ages 21 and 30, 30% were between 31 and 40, while 16.7% were between 41 and 50 and 51 and 60 years. a total of 96.7% were female, and 3.3% male. with regard to their educational status, 30% were rn, 46.7% were rn/rm and 23.7% had a bsc degree. concerning their professional status, 30% were noii, 36.7% were noi, 10% were sno and 23% were cno. fifty percent of the respondents had >5 years’ working experience, 13.3% had 6 10 years’ experience, 3.3% had 11 15 years, and 33.3% had 20 years’ experience. table 2 shows that all respondents (100%) knew that reassessment of pain after medication helps to evaluate the effectiveness of the pain medication. in the experimental group, only 13.3% knew that patients can sleep in spite of severe pain, 50% knew that analgesics should be given round the clock on a fixed schedule and 40% knew that transcutaneous electrical nerve stimulation (tens) can be used as an adjunct to other postoperative pain treatments. in the control group, 96.7% agreed that reassessment of pain after medication helps to evaluate the effectiveness of the medication, 10% knew that patients can sleep in spite of severe pain, only 30% knew that analgesics should be given round the clock on a fixed schedule and 46.7% agreed that tens could be used as an adjunct to other postoperative pain treatments. overall, there was no difference in knowledge mean (standard deviation (sd)) scores www.http://ajhpe.org.za/public/files/1343.pdf www.http://ajhpe.org.za/public/files/1343.pdf 136 october 2020, vol. 12, no. 3 ajhpe research between the two groups before intervention: 1.06  (0.63) and 1.05 (0.60), respectively. table 3 shows the post-intervention knowledge level of nurses in both groups after the teaching programme. responses to questions on knowledge about postoperative pain assessment and management after the intervention showed that there was improvement in knowledge in the experimental group: the majority (70%) knew that patients can sleep in spite of severe pain, compared with 13.3% pre intervention; 86.7% knew that analgesics should be given round the clock on a fixed schedule, while 90% knew that tens can be used as an adjunct to other postoperative pain treatments. in the control group, there was no significant improvement in knowledge: 10% agreed that patients can sleep in spite of severe pain pre and post intervention, 36.7% knew that analgesics should be given round the clock on a fixed schedule while 50% knew that tens can be used as an adjunct to other postoperative pain treatments. in table 4, the p-value of 0.00 reveals that there was a significant difference between the knowledge of the control and experimental groups after the intervention. discussion knowledge plays a major role in decision-making, because to be well informed in nursing practice is to be knowledgeable about different skills required to enhance the recovery of patient.[15] the findings from this study revealed overall fair knowledge about postoperative pain management among the nurses. in 2019, tinaikar and anuradha[16] carried out a crosssectional study on nursing staff working in a tertiary hospital attached to krims, india, for a period of 2 months. an adapted version of the knowledge and attitudes survey regarding pain (kasrp) instrument was used to test the knowledge of nurses, and found that 64% nurses had adequate knowledge on postoperative pain management, but suggested that the knowledge level need to be improved upon.[16] in the same year, a study[17] was carried out on nurses’ knowledge regarding postoperative pain management in a hospital in peshawar, pakistan. the study included nurses working at the bedside in postoperative units of the hospital. a selfdeveloped questionnaire was used for data collection. the χ2 test was used to analyse the data, and it was found that the level of knowledge could be divided into poor, average, good and excellent categories. percentage scores in these categories were: poor (0%); average (6.7%); good (71.7%); and excellent (21.7%).[17] these two studies are in agreement with the fact that there is overall fairly good knowledge among nurses about postoperative pain management, but an ideal situation is yet to be achieved. in addition, the present study showed that there was a relationship between the teaching programme and the knowledge of pain assessment. this is in agreement with the results of keshk et al.[18] in 2018, who carried out a study on the effectiveness of an educational programme regarding nursing on acquiring advanced skills among internship nursing students, and found that there was a statistically significant level of knowledge among the internship nursing students regarding steps in nursing assessment after the educational programme implementation, compared with an unsatisfactory level before the implementation of the educational programme.[18] the present study also showed that there was a relationship between the teaching programme and the knowledge of postoperative pain management. this is in agreement with a study on the role of patient education in postoperative pain management.[19] the authors found that postoperative pain continues to be a significant issue in healthcare, with a considerable proportion of patients experiencing severe pain after surgery and finding pain management at home challenging. there are several barriers to effective pain management involving both patients and healthcare professionals, and the authors concluded that patient education is a useful way to overcome many of these barriers involved in postoperative pain management.[18] in 2019 a study was carried out in a government hospital in the united arab emirates between february and april 2019 on the effect of a nursing in-service education programme on nurses’ knowledge and attitudes towards pain management. the sample of this study consisted of 200 participants selected randomly, who were exposed to a pre-test and posttest before and after receiving the pain management programme, and the findings on the experimental group revealed that the mean (sd) score on the kasrp increased after the intervention from 61.36 (11.60) to 69.94 (7.74), with a mean difference of 8.58, while in the control group the mean score slightly decreased following the test (60.99 (1.53)) compared with the pre-test (61.00 (11.60)), with a mean difference of 0.01. the in-service education pain management programme therefore proved to be effective.[20] this present study also revealed that there was a relationship between the teaching programme and the knowledge of route and other skills required for the administration of postoperative pain drugs. this substantiates a study[21] carried out on 150 undergraduate medical students of gandhi medical college, india, for a period of 3 months, which found that of 136 students, 93.4% had seen intramuscular (im) or intravenous (iv) table 1. sociodemographic characteristics of respondents in each group variable experimental (n=30), n (%) control (n=30), n (%) age, years 21 30 11 (36.7) 5 (16.7) 31 40 9 (30.0) 10 (33.3) 41 50 5 (16.7) 10 (33.3) 51 60 5 (16.7) 5 (16.7) mean 40.0 42.5 gender male 1 (3.3) 0 female 29 (96.7) 30 (100.0) education rn 9 (30.0) 0 rn/rm 14 (46.7) 17 (56.7) bachelor’s degree 7 (23.3) 12 (40.0) master’s degree 0 1 (3.3) professional status noii 9 (30.0) 7 (23.3) noi 11 (36.7) 4 (13.3) sno 3 (10.0) 7 (23.3) pno 0 4 (13.3) acno 0 4 (13.3) cno 7 (23.3) 4 (13.3) work experience, years 5 <6 15 (50.0) 12 (40.0) 6 10 4 (13.3) 7 (23.3) 11 15 1 (3.3) 2 (6.7) 16 20 0 4 (13.3) ≥20 10 (33.3) 5 (16.7) rn = registered nurse; rn/rm= registered nurse and midwife; noii = nurse officer 2; noi = nurse officer 1; sno = senior nurse officer; pno = principal nurse officer; acno = acting chief nursing officer; cno = chief nursing officer. october 2020, vol. 12, no. 3 ajhpe 137 research table 2. pre-intervention knowledge level of nurses in each group item experimental (n=30), n (%) mean (sd) control (n=30), n (%) mean (sd) a. knowledge of pain assessment before intervention ever heard of multimodal analgesia? 6 (20.00) 0.4 (0.23) 9 (30.00) 0.6 (0.35) received training on postoperative pain assessment and management? 10 (33.30) 0.7 (0.39) 9 (30.00) 0.6 (0.35) reassessment of pain after medication helps to evaluate the effectiveness of pain medication 30 (100.00) 2.0 (1.17) 29 (96.70) 1.9 (1.13) postoperative pain assessments should be done as often as vital signs are taken 27 (90.00) 1.8 (1.05) 26 (86.70) 1.7 (0.99) pain assessment scales include: numeric rating scale 25 (83.30) 1.7 (0.97) 9 (30.00) 0.6 (0.35) visual analogue scale 14 (46.70) 0.9 (0.55) 14 (46.70) 0.9 (0.55) wong baker faces scale 9 (30.00) 0.6 (0.35) 6 (20.00) 0.4 (0.23) verbal rating scale 20 (66.70) 1.3 (0.78) 17 (56.70) 1.1 (0.66) mcgill pain questionnaire 11 (36.70) 0.7 (0.43) 6 (20.00) 0.4 (0.23) a numerical rating scale 5 (16.70) 0.3 (0.19) 5 (16.7) 0.3 (0.19) the most accurate judge of the intensity of pain is the patient 25 (83.30) 1.7 (0.97) 23 (76.7) 1.5 (0.89) b. knowledge of pain management before intervention patients should be individually assessed to determine cultural influences on pain 26 (86.70) 1.7 (1.01) 24 (80) 1.6 (0.94) in applying the principles of pain treatment, the client must be believed about perceptions of own pain 29 (96.70) 1.9 (0.60) 28 (93.3) 1.9 (1.09) patients who can be distracted from pain usually do not have severe pain 12 (40.00) 0.8 (0.47) 19 (63.3) 0.6 (0.37) patients may sleep in spite of severe pain 4 (13.30) 0.3 (0.16) 3 (10.00) 0.2 (0.11) giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real 5 (16.70) 0.3 (0.17) 7 (23.30) 0.5 (0.27) patients should be encouraged to endure as much pain as possible before using an opioid 18 (60.00) 1.2 (0.70) 15 (50.00) 1.0 (0.58) patients’ spiritual beliefs may lead them to think pain and suffering are necessary 9 (30.00) 0.6 (0.35) 18 (60.00) 1.2 (0.70) assessment of patient’s pain postoperatively is best done by: asking the patient to trace the area of pain 17 (56.70) 1.1 (0.66) 15 (50.00) 1.0 (0.58) asking the patient to describe how (s)he feels the pain 24 (80.00) 1.6 (0.94) 30 (100.00) 2.0 (1.17) checking patient’s pulse 15 (50.00) 1.0 (0.59) 16 (53.30) 1.1 (0.62) checking blood pressure 16 (53.30) 1.0 (0.62) 16 (53.30) 1.0 (0.62) using an objective pain-assessment tool 23 (76.70) 1.5 (0.89) 16 (53.30) 1.1 (0.62) the goal of giving narcotic analgesics during the first 48 hours postoperatively is to: relieve pain completely 4 (13.30) 0.3 (0.16) 4 (13.30) 0.3 (0.16) relieve as much pain as possible 26 (86.70) 1.7 (1.01) 26 (86.7) 1.7 (1.01) c. knowledge on route and other skills required for the administration of postoperative pain drug before intervention intravenous 19 (63.30) 1.3 (0.74) 27 (90.00) 1.8 (1.05) intramuscular 11 (36.70) 0.7 (0.43) 3 (10.00) 0.2 (0.12) around the clock on a fixed schedule 15 (50.00) 1.0 (0.58 9 (30.00) 0.6 (0.35) only when the patient asks for it 3 (10.00) 0.2 (0.12) 3 (10.00) 0.2 (0.12) only when the nurse determines that the patient has moderate or greater discomfort 2 (6.70) 0.1 (0.08) 1 (3.30) 0.1 (0.04) only as ordered by the surgery resident 10 (33.30) 0.7 (0.39) 17 (56.70) 1.1 (0.66) combining analgesics that work by different mechanisms (e.g. combining an nsaid with an opioid) may result in better pain control with fewer side-effects than using a single analgesic agent 27 (90.00) 1.8 (1.05) 19 (63.30) 1.3 (0.74) oral route is preferred for administration of daily analgesics (if all body systems are functional) 27 (90.00) 1.8 (1.05) 14 (46.70) 0.9 (0.55) unrelieved pain has harmful effects on patient’s respiratory function and activity level 22 (73.30) 1.5 (0.86) 23 (76.70) 1.5 (0.90) tens can be used as an adjunct to other postoperative pain treatments 12 (40.00) 0.8 (0.47) 14 (46.70) 0.9 (0.55) postoperative pain management starts from the pre-operative phase 24 (80.00) 1.6 (0.94) 22 (73.30) 1.5 (0.86) deep breathing causes relaxation and thus relieves pain 28 (93.30) 1.9 (1.09) 27 (90.00) 1.8 (1.05) positioning is effective in the management of postoperative pain 23 (76.70) 1.5 (0.90) 25 (83.30) 1.7 (0.97 distraction (e.g. music) is not an effective measure in the management of postoperative pain 9 (30.00) 0.6 (0.35) 17 (56.70) 1.1 (0.66) non-pharmacological measures of pain management can replace pharmacological measures 14 (46.70) 0.9 (0.55) 17 (56.7) 1.1 (0.66) ground mean 1.06 (0.63) 1.05 (0.60) sd = standard deviation; nsaid = non-steroidal anti-inflammatory drug; tens = transcutaneous electrical nerve stimulation. 138 october 2020, vol. 12, no. 3 ajhpe research table 3. post-intervention knowledge level of nurses in each group experimental (n=30), n (%) mean (sd) control (n=30), n (%) mean (sd) a. knowledge of pain assessment after intervention ever heard of multimodal analgesia? 29 (96.70) 1.9 (1.13) 9 (30.00) 0.6 (0.32 received training on postoperative pain assessment and management? 26 (86.70) 1.7 (0.99) 10 (33.30) 0.7 (0.39) reassessment of pain after medication helps to evaluate the effectiveness of pain medication 30 (100.0) 2.0 (1.17) 28 (93.30) 1.9 (1.09) postoperative pain assessments should be done as often as vital signs are taken 30 (100.0) 2.0 (1.17) 26 (86.70) 1.7 (0.99) pain assessment scales include: numeric rating scale 30 (100.0) 2.0 (1.17) 10 (33.30) 0.7 (0.39) visual analogue scale 25 (83.30) 1.7 (0.97) 15 (50.00) 1.0 (0.59) wong baker faces scale 23 (76.70) 1.5 (0.89) 6 (20.00) 0.4 (0.23) verbal rating scale 21 (70.00) 1.4 (0.81) 18 (60.00) 1.2 (0.70) mcgill pain questionnaire 14 (46.70) 0.9 (0.55) 7 (23.30) 0.4 (0.27) a numerical rating scale 17 (56.7) 1.1 (0.66) 5 (16.70) 0.3 (0.19) the most accurate judge of the intensity of pain is the patient 30 (100.0) 2.0 (1.17) 24 (80.00) 1.6 (0.94) b. knowledge of pain management after intervention patients should be individually assessed to determine cultural influences on pain 30 (100.0) 2.0 (1.17) 25 (83.30) 1.7 (0.97) in applying the principles of pain treatment, the client must be believed about perceptions of own pain 30 (100.0) 2.0 (1.17) 28 (93.30) 1.9 (1.09) patients who can be distracted from pain usually do not have severe pain 26 (86.70) 1.7 (0.99) 21 (70.00) 1.4 (0.81) patients may sleep in spite of severe pain 21 (70.00) 1.4 (0.81) 5 (16.70) 0.3 (0.19) giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real 25 (83.30) 1.7 (0.97) 8 (26.70) 0.5 (0.31) patients should be encouraged to endure as much pain as possible before using an opioid 27 (90.00) 1.5 (1.05) 14 (46.70) 0.9 (0.55) patients’ spiritual beliefs may lead them to think pain and suffering are necessary 15 (50.00) 1.0 (0.59) 18 (60.00) 1.2 (0.70) assessment of patient’s pain postoperatively is best done by: asking the patient to trace the area of pain 21 (70.00) 1.4 (0.81) 15 (50.00) 1.0 (0.59) asking the patient to describe how (s)he feels the pain 30 (100.0) 2.0 (1.17) 30 (100.0) 2.0 (1.17) checking patient’s pulse 21 (70.00) 1.4 (0.81) 17 (56.7) 1.1 (0.66) checking blood pressure 18 (60.00) 1.2 (0.70) 16 (53.30) 1.0 (0.62) using an objective pain-assessment tool 26 (86.70) 1.7 (0.99) 17 (56.7) 1.1 (0.66) the goal of giving narcotic analgesics during the first 48 hours postoperatively is to: relieve pain completely 21 (70.00) 1.4 (0.81) 5 (16.70) 0.3 (0.19) relieve as much pain as possible 29 (96.67) 1.9 (1.13) 25 (83.33) 1.7 (0.97) c. knowledge on route and other skills required for the administration of postoperative pain drug after intervention intravenous 29 (96.67) 1.9 (1.13) 27 (90.00) 1.5 (1.05) intramuscular 30 (100.0) 2.0 (1.17) 6 (20.00) 0.4 (0.23) around the clock on a fixed schedule 26 (86.70) 1.7 (0.99) 10 (33.30) 0.7 (0.39) only when the patient asks for it 16 (53.30) 1.0 (0.62) 7 (23.30) 0.4 (0.27) only when the nurse determines that the patient has moderate or greater discomfort 18 (60.00) 1.2 (0.70) 5 (16.70) 0.3 (0.19) only as ordered by the surgery resident rather than using a single analgesic agent 27 (90.00) 1.5 (1.05) 20 (66.70) 1.3 (0.78) oral route is preferred for administration of daily analgesics (if all body systems are functional) 30 (100.0) 2.0 (1.17) 15 (50.00) 1.0 (0.59) unrelieved pain has harmful effects on patient’s respiratory function and activity level 30 (100.0) 2.0 (1.17) 15 (50.00) 1.0 (0.59) tens can be used as an adjunct to other postoperative pain treatments 27 (90.00) 1.5 (1.05) 21 (70.00) 1.4 (0.81) postoperative pain management starts from the pre-operative phase 29 (96.67) 1.9 (1.13) 26 (86.70) 1.7 (0.99) deep breathing causes relaxation and thus relieves pain 27 (90.00) 1.5 (1.05) 17 (56.7) 17 (56.7) positioning is effective in the management of postoperative pain 26 (86.70) 1.7 (0.99) 18 (60.00) 1.2 (0.70) distraction (e.g. music) is not an effective measure in the management of postoperative pain 29 (96.67) 1.9 (1.13) 18 (60.00) 1.2 (0.70) non-pharmacological measures of pain management can replace pharmacological 11 (36.70) 0.7 (0.43) 17 (56.7) 17 (56.7) ground mean 1.6 (0.97) 1.05 (0.62) sd = standard deviation; tens = transcutaneous electrical nerve stimulation. october 2020, vol. 12, no. 3 ajhpe 139 research administration, but only 29.4% and 16.9% had ever administered im and iv injections, respectively. a significant increase in knowledge regarding im and iv administration technique was observed following interventional training of the participants.[21] finally, some limitations were encountered in the course of the study despite the research objective having been met. gathering all the nurses into a single session for the training programme was difficult because of their different shifts, hence the participants were trained in several different sessions, which may have affected the results. conclusion the results of this study reveal that there is a fair knowledge level among nurses in the areas of postoperative pain, and pharmacological and nonpharmacological measures of pain management. the results also showed that a teaching programme was useful in improving nurses’ knowledge of postoperative pain management, which may further improve the practice of pain management, and patients’ satisfaction levels. the findings of this study, therefore, create an impetus for continued education of nurses taking care of patients after surgery. declaration. the present article was derived from the result of thesis no. buhrec608/16 that was approved by the research ethics committee of babcock university, illishan-remo, ogun state, nigeria. acknowledgements. the researchers would like to thank the nurses who participated in the study from luth, despite their tight schedules. author contributions. all authors contributed equally to the research. funding. none. conflicts of interest. none. 1. feldheiser a, aziz o, baldini g, et al. enhanced recovery after surgery (eras) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. acta anaesthesiol scand 2016;60(3):289-334. https://doi. org/10.1111/aas.12651 2. younossi zm, stepanova m, afdhal n, et al. improvement of health-related quality of life and work productivity in chronic hepatitis c patients with early and advanced fibrosis treated with ledipasvir and sofosbuvir. j hepatol 2015;63(2):337-345. https://doi.org/10.1016/j.jhep.2015.03.014 3. rawal n. current issues in postoperative pain management. eur j anaesthesiol 2016;33(3):160-171. https://doi. org/10.1097/eja.0000000000000366 4. nass sj, beaupin lk, demark-wahnefried w, et al. identifying and addressing the needs of adolescents and young adults with cancer: summary of an institute of medicine workshop. oncologist 2015;20(2):186. https://doi. org/10.1634/theoncologist.2014-0265 5. scarborough bm, smith cb. optimal pain management for patients with cancer in the modern era. ca cancer j clin 2018;68(3):182-196. https://doi.org/10.3322%2fcaac.21453 6. menlah a, garti i, amoo sa, atakro ca, amponsah c, agyare df. knowledge, attitudes, and practices of postoperative pain management by nurses in selected district hospitals in ghana. sage open nurs 2018;4(2018). https://doi.org/10.1177/2377960818790383 7. meissner w, coluzzi f, fletcher d, et al. improving the management of postoperative acute pain: priorities for change. curr med res opin 2015;31(11):2131-2143. https://doi.org/10.1185/03007995.2015.1092122 8. hui d, bruera e. integrating palliative care into the trajectory of cancer care. nat rev clin oncol 2016;13(3):159. https://doi.org/10.1038%2fnrclinonc.2015.201 9. knaul fm, farmer pe, krakauer el, et al. alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage: the lancet commission report. lancet 2018;391(10128):1391-1454. https://doi.org/10.1016/s0140-6736(17)32513-8 10. cullom c, weed jt. anesthetic and analgesic management for outpatient knee arthroplasty. curr pain headache rep 2017;21(5):23. https://doi.org/10.1007/s11916-017-0623-y 11. bird jm, owen rg, d’sa s, et al. guidelines for the diagnosis and management of multiple myeloma 2011. br j haematol 2011;154(1):32-75. https://doi.org/10.1111/j.1365-2141.2011.08573.x 12. allen j, hutchinson am, brown r, livingston pm. quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. bmc health serv res 2014;14(1):346. https://doi. org/10.1186/1472-6963-14-346 13. meissner w, coluzzi f, fletcher d, et al. improving the management of postoperative acute pain: priorities for change. curr med res opin 2015;31(11):2131-2143. https://doi.org/10.1185/03007995.2015.1092122 14. alqahtani m, jones lk. quantitative study of oncology nurses’ knowledge and attitudes towards pain management in saudi arabian hospitals. eur j oncol nurs 2015;19(1):44-49. https://doi.org/10.1016/j.ejon.2014.07.013 15. osian ea, afemikhe ja, olorunfemi o, eweka a. knowledge and perception of assisted reproductive technology among women attending the university of benin teaching hospital, benin city, nigeria, 2018. j nurs midwifery sci 2019;6:125-130. https://doi.org/10.4103/jnms.jnms_15_19 16. tinaikar a, anuradha g. knowledge of postoperative pain management among nurses in a tertiary hospital uttara kannada, karnataka. inter j surg 2019;3(4):445-447. https://doi.org/10.33545/surgery.2019.v3.i4h.282 17. zeb a, farhana j, marym u, bi nb. nurses’ knowledge regarding postoperative pain management. j healthcare commun 2019;4(1):1654. https://doi.org/10.4172/2472-1654.100151 18. keshk li, qalawa sa, ibrahim na. effectiveness of an educational programme regarding nursing process on acquiring advanced skills among internship nursing students. inter j nurs 2018;5(2):32-44. https://doi. org/10.15640/ijn.v5n2a4 19. ingadóttir b, zoëga s. role of patient education in postoperative pain management. nurs stand 2017;32(2). https:// doi.org/10.7748/ns.2017.e10939 20. salim na, joshua r, abubaker na, chehab f, jose a. effect of a nursing in-service education programme on nurses’ knowledge and attitudes towards pain management in a governmental hospital in the united arab emirates: experimental random assignment study. dubai med j 2019;2(4):146-152. https://doi.org/10.1159/000503560 21. bhatia p, sawlani h, tarachandani r. a study to assess and develop injection administration skill in medical undergraduates of gmc, bhopal. inter j comm med public health 2019;6(1):390. https://doi.org/10.18203/23946040.ijcmph20185278 accepted 24 june 2020. table 4. t-test analysis for the effectiveness of the teaching programme on knowledge of postoperative pain management among nurses in the experimental group knowledge n (%) minimum maximum mean (sd) t p-value* pre-test 6 12 10.04 (1.99) poor 3 (10.0) average 19 (63.3) good 8 (26.7) post-test 9 16 11.83 (1.77) poor average 8 (26.7) good 22 (73.3) 3.68 0.00 *p<0.05. sd = standard deviation. https://doi.org/10.1111/aas.12651 https://doi.org/10.1111/aas.12651 https://doi.org/10.1016/j.jhep.2015.03.014 https://doi.org/10.1097/eja.0000000000000366 https://doi.org/10.1097/eja.0000000000000366 https://doi.org/10.1634/theoncologist.2014-0265 https://doi.org/10.1634/theoncologist.2014-0265 https://doi.org/10.3322%2fcaac.21453 https://doi.org/10.1177/2377960818790383 https://doi.org/10.1185/03007995.2015.1092122 https://doi.org/10.1038%2fnrclinonc.2015.201 https://doi.org/10.1016/s0140-6736(17)32513-8 https://doi.org/10.1007/s11916-017-0623-y https://doi.org/10.1111/j.1365-2141.2011.08573.x https://doi.org/10.1186/1472-6963-14-346 https://doi.org/10.1186/1472-6963-14-346 https://doi.org/10.1185/03007995.2015.1092122 https://doi.org/10.1016/j.ejon.2014.07.013 https://doi.org/10.4103/jnms.jnms_15_19 https://doi.org/10.33545/surgery.2019.v3.i4h.282 https://doi.org/10.4172/2472-1654.100151 https://doi.org/10.15640/ijn.v5n2a4 https://doi.org/10.15640/ijn.v5n2a4 https://doi.org/10.7748/ns.2017.e10939 https://doi.org/10.7748/ns.2017.e10939 https://doi.org/10.1159/000503560 https://doi.org/10.18203/2394-6040.ijcmph20185278 https://doi.org/10.18203/2394-6040.ijcmph20185278 june 2021, vol. 13, no. 2 ajhpe 99 research accreditation visits are ‘high stake’ processes that have a tendency to place additional pressure and workload on a faculty. for accreditation, medical and dental schools need to provide evidence that their graduates are trained according to the requirements of the accreditation bodies and are therefore able to service the needs of patients. in preparation for these accreditation processes, guidelines are provided for the schools by the accreditation bodies to ensure transparency and fairness. the medical and dental professions board of the health professions council of south africa (hpcsa), in collaboration with training institutions and the south african committee of medical and dental deans, adapted the core competency framework of the canadian medical education directives for specialists (canmeds) to inform medical and dental curricula in south africa (sa).[1] this adapted version of the canmeds framework is the competency framework of the african medical education directives for specialists (afrimeds) (fig.  1). the afrimeds framework guides the accreditation process of all medical and dental schools in sa.[2] because of the adoption of the afrimeds competency framework by the hpcsa, all dental schools in sa are required to incorporate and implement the core competencies described by afrimeds in undergraduate curricula. each dental school has autonomy in the strategies for implementation of these core competencies in its undergraduate dental curriculum. a self‑evaluation questionnaire is used in the accreditation process of the undergraduate curriculum to elicit information about the implementation and translation of the afrimeds core competencies. from a previous undergraduate dental accreditation process at the university of the western cape (uwc), sa, it was found that the  core competencies were not clearly or consistently described and the implementation thereof was not evident. furthermore, the translation of the afrimeds core competencies throughout the undergraduate dental curriculum was not explicit. consequently, the completion of the self‑evaluation questionnaire was challenging, background. in response to the adoption of the african medical education directives for specialists (afrimeds) competency framework by the health professions council of south africa, all dental schools in the country were required to incorporate and implement the core competencies described in afrimeds in the undergraduate curricula. objectives. to describe curriculum mapping as a tool to demonstrate the alignment of an undergraduate dental curriculum with a competency framework, such as afrimeds, in preparation for accreditation and curriculum review. methods. all the module descriptors (n=59) from the first to fifth year of study were included, and outcomes were mapped against the afrimeds competency framework. the presence of afrimeds core competencies (healthcare practitioner, communicator, collaborator, health advocate, leader and manager, scholar, professional) were located (if present) within the module learning outcomes. afrimeds core competencies were quantified and illustrated in the form of a curriculum map. results. healthcare practitioner, health advocate and communicator were present across all 5 years of the undergraduate dental curriculum, while healthcare practitioner was present in 46 modules, health advocate in 8 modules and communicator in 13 modules. competencies related to collaborator were present in the first, third and fifth year in 7 modules. leader and manager competencies were present in the fifth year in 1 module. professional competencies were present in the second and fifth year in 3 modules. competencies related to scholar were present in the first, third, fourth and fifth year in 8 modules. conclusions. from the results, it was highlighted that all afrimeds competencies were present in the university of the western cape (uwc) dental programme. curriculum mapping identified gaps in or areas of development for the afrimeds competencies in the uwc dental curriculum. curriculum mapping can be recommended as a valuable tool for curriculum development. afr j health professions educ 2021;13(2):99‑104. https://doi.org/10.7196/ajhpe.2021.v13i2.1257 curriculum mapping: a tool to align competencies in a dental curriculum r maart,1 bchd, mphil; r z adam,2 phd; j frantz,3 phd 1 department of prosthetic dentistry, faculty of dentistry, university of the western cape, cape town, south africa 2 department of restorative dentistry, faculty of dentistry, university of the western cape, cape town, south africa 3 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: r maart (rmaart@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. step 2 designed curriculum uwc dental curriculum step 3 communicated curriculum module outcomes step 1 intended curriculum afrimeds core competencies fig. 1. modified conceptual framework for curriculum mapping. (uwc = university of the western cape; afrimeds = african medical education directives for specialists.) https://doi.org/10.7196/ajhpe.2021.v13i2.1257 100 june 2021, vol. 13, no. 2 ajhpe research thus highlighting the need for the development of clear guidelines regarding the implementation and translation of afrimeds core competencies in the undergraduate curriculum. globally, schools have been increasingly obliged to maintain a curriculum map as part of their ongoing accreditation reporting.[3] national competency‑based frameworks and consented outcomes serve as curricular guidelines in medical and healthcare education.[4] harden[5] introduced the concept of curriculum mapping and asserted that ‘the real genius of mapping is to give a broad picture of the taught curriculum’ or ‘authentic picture’.[3] mapping makes the curriculum more transparent to all the stakeholders (teachers, students, curriculum developers, managers, professionals and the public). it is a powerful tool for managing the curriculum[5] and is widely advocated in the generic skills literature.[6] the use of the term ‘mapping’ reflects the process of connecting two or more data sets related to a curriculum, such as established content and the canmeds competencies.[7] another vital function is that a map displays clear routes of learning that focus on work readiness. mapping guides university teachers in integrating teaching content with occupational competence.[3] in addition, a curriculum map demonstrates the links between learning out‑ comes and  learning opportunities and the links between the components of elements (e.g. between different learning outcomes).[3] mapping can also be used as a method of operationalising outcome‑based education and can play a role in determining whether the curriculum meets specific standards, i.e. whether the school’s curriculum is congruent with the expected learning outcomes.[3] curriculum mapping can be used to identify gaps in a curriculum.[8] web‑based curriculum mapping is a feasible approach, as it enables alignment of complex, student‑ centred competencies with course‑specific, well‑ defined behavioural objectives.[9] although curriculum mapping has become a common activity, particularly at medical schools in the usa and  canada, there has been little standardisation or commonality of function and purposes for these maps. implementation in the technology platforms used and the data sets drawn upon reflects local institutional needs and technological resources.[7] various methods for curriculum mapping exist.[10] for example, in a generic skills mapping study, data were gathered using document analysis.[10] in another study, data for the curriculum  maps  were acquired through a review of course syllabi and interviews with course instructors.[8] in a study by willett,[11] medical schools in canada and the uk were asked to indicate which outcome frameworks were included in their curriculum maps. as a consequence of this study, it seemed possible to consider the use of curriculum mapping in the current research. to date, no published literature exists regarding dental schools’ in‑practice implementation and translation of the afrimeds core competency framework within the sa context. this article aimed to describe curriculum mapping as a tool to demonstrate the alignment of an undergraduate dental curriculum with a competency framework, such as that of afrimeds, in preparation for accreditation and curriculum review. methods a case study was used as the strategy of inquiry. this type of design enables researchers to gain an in‑depth understanding of the situation and provides meaning for those involved.[12] according to darke et  al.,[13] single cases allow researchers to investigate phenomena in depth to provide rich description and understanding. curriculum mapping was used in the current study to review the undergraduate dental curriculum. although various electronic curriculum mapping systems are available, the researcher did not have access to them. therefore, the curriculum mapping process was followed manually. veltri et  al.[14] developed a conceptual frame‑ work for curriculum mapping that was based on a ‘learning outcomes model’. this conceptual mapping framework was designed to include 5 different conceptions of the curriculum: intended, designed, communicated, enacted and assessed.[14] definitions of the 5 conceptions are as follows: • an intended curriculum comprises articulated statements of intended programme‑level outcomes. • a designed curriculum is reflected through degree plans and course sequences. • a communicated curriculum consists of course‑ level outcomes and the specific teaching and learning activities listed in the course syllabi. • an enacted curriculum refers to classroom pedagogies and the content, scope and depth of the material delivered by the instructor in the classroom. • an assessed curriculum consists of the type and content of specific assessment tasks assigned to the students in a given course.[14] for this study, the conceptual model of veltri et al.[14] was modified to align with the needs of the uwc dental school (fig. 1): • step 1: afrimeds core competencies (intended programme outcomes) • step 2: designed curriculum (uwc dental curriculum; displayed as modules) • step 3: communicated curriculum (module learning outcomes). the 2018 uwc dental calendar was used to evaluate the alignment of the undergraduate dental curriculum with the afrimeds core competency framework (intended programme outcomes). there are 59 modules (designed curriculum) from the first year of study to the final year (fifth  year). all the module learning outcomes (communicated curriculum) in the module descriptors (n=59) were mapped against the afrimeds competency framework. in this research, the curriculum map was displayed in the form of tables, and competencies were colour‑ coded to ensure a simple and transparent result: • step 1 involved mapping the afrimeds core competencies: healthcare practitioner (hcp), communicator, collaborator, health advocate, leader and manager, scholar and professional (tables 1 and 2). • step 2 involved mapping all the undergraduate dental modules (tables 1 and 2). • step 3 involved locating the presence of the competencies relating to the afrimeds core competencies in the module‑learning outcomes of each module. related core competencies present within a module‑learning outcome were quantified as numeric values (tables 1 and 2). these data provided an understanding of the curriculum context relative to the afrimeds competencies. peer debriefing as a validity strategy was used. a debriefing strategy involving an interpretation beyond the researcher and invested in another person adds validity to an account.[15] to ensure validity and reliability in the current study, the data were shared with a colleague who is a module co‑ordinator at the dental school and a colleague from a different health science background. comments from june 2021, vol. 13, no. 2 ajhpe 101 research table 1. presence of afrimeds roles in modules in the year of study modules, n year of study healthcare professional communicator collaborator leader and manager scholar professional health advocate 1 (n=9) 3 5 2 0 3 0 2 2 (n=11) 10 1 0 0 0 1 2 3 (n=14 ) 13 3 1 0 2 0 2 4 (n= 13) 11 1 0 0 2 0 1 5 (n=12) 9 3 4 1 1 2 1 afrimeds = african medical education directives for specialists. table 2. curriculum map ‒ presence of afrimeds roles in the undergraduate dental curriculum year of study module (n=59) healthcare professional communicator collaborator leader and manager scholar professional health advocate 1 (n=9) primary healthcare     x   x   x chemistry for dentistry   x x   x     life sciences x             physics for dentistry         x     clinical dentistry 1 x x          x human biology x             intro to xhosa   x           intro to afrikaans   x           academic literacy   x           2 (n=11) preclinical periodontic techniques x             interdisciplinary health promotion             x basics of dental materials x             human biology x             oral biology x             basis of disease process x             non‑invasive restorative techniques x             radiographic techniques 200 x             radiation physics x             prosthetics techniques x             clinical dentistry ii x x       x x 3 (n=14) principles of medicine and general surgery x x           systemic pathology x             dental pharmacology x             medical microbiology for dentistry x             invasive restorative techniques x             basic orthodontics iii x             measuring health and disease   x x   x   x social sciences and dentistry x       x   x oral medicine and periodontology i x             maxillofacial and oral surgery i x             conservative dentistry i x             dental materials x             dental prosthetics i x             radiographic techniques x x           ...continued 102 june 2021, vol. 13, no. 2 ajhpe research the colleague (peer) in the faculty were addressed and incorporated into the reported results. in addition to the insight and knowledge of this colleague regarding the content of the curriculum, this process facilitated reflection for the researcher. in deductive content analysis, the organisational phase involves categorisation matrix development, whereby all the data are reviewed for content and coded for correspondence with the identified categories.[16] the curriculum map processes that are described in steps 1 ‑ 3 comprised the matrix development procedure. trustworthiness and authenticity as criteria have been proposed for assessing qualitative studies.[17] study respondent validation as a trustworthiness criterion is the process whereby the researcher provides the participants of the study with an account of the findings.[17] findings of the generated curriculum map were shared with module co‑ordinators during focus group interviews to ensure respondent validation. the use of quotations is necessary to indicate the trustworthiness of the results; quotations show connections between the data and the results and provide richness of data.[16] quotes from the module outcomes extracted from the dental calendar, 2018, were included in the results of the current study. ethical approval ethical approval was obtained from the biomedical research committee, uwc (ref. no. bm19/1/27). results the results are presented in three sections. firstly, if present, the quantified competencies relating to the afrimeds roles in a module in the year of study are displayed in table  1. the modules in each year of study (first column) and the presence of the roles (marked with ‘x’) are displayed in table  2. secondly, examples of the module outcomes (academic calendar, 2018) relating to the competencies and/or roles are described. lastly, the results that describe the alignment of the afrimeds framework to the undergraduate dental curriculum of uwc are demonstrated. healthcare practitioner competencies relating to hcps were present in the undergraduate dental curriculum in all 5 years: • first year: ‘identify and describe the tissues of the periodontium, recognise and describe oral tissues in health and disease’ – cld100. • second year: ‘explain the physicochemical principles that underlie the properties of dental materials’ – bdm. • third year: ‘describe the causative agent, reservoir, mode of transmission, signs and symptoms, pathogenesis, treatment and basic laboratory diagnosis of the major oral infections and infectious diseases of the body systems’ – medical microbiology for dentistry. table 2. (continued) curriculum map ‒ presence of afrimeds roles in the undergraduate dental curriculum year of study module (n=59) healthcare professional communicator collaborator leader and manager scholar professional health advocate 4 (n=13) dental research         x     prevention         x   x oral medicine and periodontology ii x             anaesthesiology and sedation x             maxillofacial and oral surgery ii x             conservative dentistry ii x             endodontics x             diagnostics and radiology x             paediatric dentistry techniques x x           orthodontics i x             prosthetic dentistry ii x             advanced dental materials x             oral pathology x             5 (n=12) health systems         x   x ethics           x   advanced restorative techniques x             advanced removable prosthetics x             paediatric dentistry v x             clinical orthodontics x             conservative dentistry iii x             maxillofacial and oral surgery iii x   x         oral medicine and periodontology iii x x           implants x   x         practice management   x x x   x   clinical dentistry v x x x         afrimeds = african medical education directives for specialists. june 2021, vol. 13, no. 2 ajhpe 103 research • fourth year: ‘plan and manage extensive posterior restorations’ – conservative dentistry 11. • fifth year: ‘integrate the principles of behaviour management and apply them to the comprehensive management of the child’ – paediatric dentistry v. communicator competencies relating to communicator were present in all 5 years: • first year: ‘explain the meaning of and generate academic text in oral health’ – academic literacy. • second year: ‘discuss and apply various communication skills to effectively converse with a patient’ – cld200. • third year: ‘explain to the patient the radiographic views to be done as well as the reason for taking them’ – radiographic techniques. • fourth year: ‘communicate with the paediatric patient and the parent/caregiver as well as other health professionals’ – paediatric dentistry techniques. • fifth year: ‘communicate with the patient to elicit all pertinent information adhering to ethical code of practice at all times’ – oral medicine and periodontology iii. collaborator competencies relating to collaborator were present in the first, third and fifth years: • first year: ‘work productively in co‑operative learning groups’ – chemistry. • third year: ‘work in a cross‑disciplinary group using effective time management’ – measuring health and disease. • fifth year: ‘apply a multidisciplinary approach to patient management’ – maxillofacial and oral surgery. leader and manager competencies relating to leader and manager were present in the fifth year only: • fifth year: ‘apply the key principles of managing a successful dental practice’ – practice management. scholar competencies relating to scholar were present in the first, third, fourth and fifth years: • first year: ‘begin to develop life‑long learning capabilities and to see chemistry as [a] discipline in a wider context’ – chemistry. • third year: ‘assess the quality and relevance of data used to describe community health and illness’ – measuring health and disease. • fourth year: ‘define a research problem, and describe the related aims and objectives’ – dental research. • fifth year: ‘critically evaluate some aspect of health care delivery’ – health systems. professional competencies relating to the role of a professional were present in the second and fifth years: • second year: ‘describe the role of the oral health team in south africa’ – cld200. • fifth year: ‘describe key ethical, moral and social principles underlying the notion of human rights’ – ethics. health advocate competencies relating to the role of health advocate were present throughout the undergraduate dental curriculum: • first year: ‘discuss the concepts of health, development and primary health care’ – hdp. • second year: ‘explain the main approaches to health promotion’ – hdp. • third year: ‘describe the community in relation to a variety of epidemiological indicators to measure the occurrence of health‑ related states in populations’ – measuring health and disease. • fourth year: ‘explain philosophical issues in prevention and health promotion’ – prevention. • fifth year: ‘recognise the main structural features of different health systems’ – health systems. alignment of afrimeds to the undergraduate dental curriculum from the results of the curriculum mapping (tables 1 and 2), the alignment of the uwc dental curriculum to afrimeds was demonstrated.  it is clear  that all the roles indicated by afrimeds were included in the curriculum (fig.  2).  this dental curriculum focused mostly on the healthcare  professional (54% of curriculum), which is expected in a health professions training  context. inclusion of the other competencies was demonstrated to be much less. communicator (15%) appeared to have an acceptable presence in the curriculum. however, collaborator, leader and manager, scholar, health advocate and professional roles were  not  very  prominent, demonstrating a presence of <10% in the curriculum. discussion this article describes how curriculum mapping could be used to demonstrate the alignment of an undergraduate dental curriculum with the afrimeds  competency framework in preparation for accreditation and curriculum review. this research also developed a modified conceptual framework for curriculum mapping that may be relevant to other undergraduate dental programmes. studies have used the curriculum map to reveal curricular elements such as cultural competency that are difficult to recognise in a curriculum because the language of the learning objectives may not be sufficiently explicit even though the intended expectations of those objectives address the topic.[18] the afrimeds competencies were recognised in the uwc dental curriculum. healthcare professional communicator collaborator leader and manager scholar professional health advocate 9% 4% 9% 1% 8% 15% 54% fig.  2. alignment of afrimeds with the uwc dental curriculum. (afrimeds = african medical education directives for specialists; uwc = university of the western cape.) 104 june 2021, vol. 13, no. 2 ajhpe research all the core competencies relating to the 7 roles, hcp, communication, collaborator, scholar, health advocate, professional, leader and manager, were present. in a study by michael et  al.,[19] the value of curriculum mapping as strategies for: (i)  horizontal and vertical integration of geriatric‑specific content in nurse practitioner curricula; and (ii) evaluation, improvement and curricula in health professional academic programmes, were described. competencies relating to hcps were horizontally and vertically integrated within the uwc dental curriculum. it appears that the curriculum concentrates on the theory and clinical skills required to become a dental practitioner. this was more evident in the third, fourth and fifth years. although communication was integrated vertically (within modules over the different years), the horizontal integration (within modules of the same year) is an area of development and should be considered during the curriculum review process. similarly, scholar, health advocate and collaborator competencies (outcomes) were included vertically in all 5 years, but were not integrated horizontally. professional and leader and manager competencies were highlighted as roles that need to be developed both horizontally and vertically within the uwc curriculum. professional competencies were only included in the second and final years. as suggested by harden and stamper,[20] a spiral curriculum implies the vertical and horizontal integration of themes/ competencies (as in this research) across and between disciplines and modules. if the example of communication competencies is used in this dental curriculum, it would suggest that these competencies should be taught from the first to the fifth year and within each year in different modules. medical schools today are gradually departing from the traditional curricula to more integrated programmes,[18] and therefore the suggested integration of competencies into the uwc dental curriculum would ensure that this curriculum is relevant and current. in addition to the research relating to the afrimed competencies in the undergraduate dental curriculum, the use of a curriculum map to describe these competencies was implemented in this research. furthermore, as there is no literature available that focuses on this subject, this research contributes to the current literature by describing the implementation and translation of the afrimeds core competency framework by the uwc dental school. the study also illustrated the possibility of considering the use of a curriculum map as a tool for dental schools’ accreditation purposes. for faculties involved in the preparation for accreditation, this tool would enable authentic visualisation of the entire curriculum. the presentation and simplification of the illustrated curriculum map could assist faculties in their preparations for accreditation in a non‑threatening and structured manner. the unique modified conceptual model used in this research to outline the methods employed could be translated to similar settings. according to the literature, various methods for curriculum mapping exist,[10] depending on institutional or other needs. although the intention of using a curriculum map was for accreditation purposes, the added benefit of identification of gaps or overlap in the undergraduate curriculum was highlighted. conclusion curriculum mapping is recommended as a valuable tool to navigate curriculum renewal or to be used as a starting point for curriculum development. the results of curriculum mapping in this study identified gaps or areas of development for the afrimeds competencies in the uwc dental curriculum. alignment to curricula using other competency frameworks, such as the framework of canmeds, should be possible, as curriculum mapping is a reliable and valid tool. moreover, the process of curriculum mapping identifies content overlapping and omissions. curriculum mapping is also recommended as a valuable tool to guide or to prepare for accreditation visits. it has the ability to display the ‘big picture’ or the authentic picture,[2] and the illustration of a curriculum map makes this possible. for faculties that are not comfortable with curriculum development, curriculum mapping allows for transparency of the curriculum. declaration. the research for this study was done in partial fulfilment of the requirements for rm’s phd degree at the university of the western cape. acknowledgements. none. author contributions. rm contributed 50%, ra 25% and jf 25% to the manuscript. funding. none. conflicts of interest. none. 1. medical and dental professions board of the health professions council of south africa. core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2017:1‑14. 2. van heerden b. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2013;103(1):21‑22. https://doi.org/10.7196/samj.6463  3. wang cl. mapping or tracing? rethinking curriculum mapping in higher education. stud high educ 2015;40(9):1550‑1559. https://doi.org/10.1080/03075079.2014.899343 4. fritze o, lammerding‑koeppel m, boeker m, et al. boosting competence‑orientation in undergraduate medical education – a web‑based tool linking curricular mapping and visual analytics. med teach 2019;41(4):422‑432. https://doi.org/10.1080/0142159x.2018.1487047 5. harden rm. amee guide no. 21. curriculum mapping: a tool for transparent and authentic teaching and learning. med teach 2001;23(2):123‑137. https://doi.org/10.1080/01421590120036547 6. sumsion j, goodfellow j. identifying generic skills through curriculum mapping: a critical evaluation. high educ res dev 2004;23(3):329‑346. https://doi.org/10.1080/0729436042000235436 7. ellaway rh, albright s, smothers v, cameron t, willett t. curriculum inventory: modeling, sharing and comparing medical education programs. med teach 2014;36(3):208‑215. https://doi.org/10.3109/014215 9x.2014.874552 8. rawle f, bowen t, murck b, hong r. curriculum mapping across the disciplines: differences, approaches, and strategies. collect essays learn teach 2017;10:75‑88. 9. balzer f, hautz we, spies c, et  al. development and alignment of undergraduate medical curricula in a web‑based, dynamic learning opportunities, objectives and outcome platform (looop). med teach 2016;38(4):369377. https://doi.org/10.3109/0142159x.2015.1035054 10. robley w, whittle s, murdoch‐eaton d. mapping generic skills curricula: a recommended methodology. j furth high educ 2005;29(3):221‑231. 11. willett tg. current status of curriculum mapping in canada and the uk. med educ 2008;42(8):786‑793. https:// doi.org/10.1111/j.1365‑2923.2008.03093.x 12. merriam s. qualitative research and case study applications in education. revised and expanded from ‘case study research in education’. san francisco, ca: jossey‑bass, 1998. 13. darke p, shanks g, broadbent m. successfully completing case study research: combining rigour, relevance and pragmatism. inform syst j 1998;8(4):273‑289. https://doi.org/10.1046/j.1365‑2575.1998.00040.x 14. veltri nf, webb hw, matveev ag, zapatero eg. curriculum mapping as a tool for continuous improvement of is curriculum. j inf syst educ 2011;22(1):31‑42. 15. creswell j. research design: qualitative, quantitative and mixed methods approaches. 3rd ed. thousand oaks, ca: sage, 2009. 16. elo s, kääriäinen m, kanste o, pölkki t, utriainen k, kyngäs h. qualitative content analysis. sage open 2014;4(1). https://doi.org/10.1177/2158244014522633 17. bryman a. social research methods. 4th ed. new york, ny: oxford university press, 2012. 18. al‑eyd g, achike f, agarwal m, et  al. curriculum mapping as a tool to facilitate curriculum development: a new school of medicine experience. bmc med educ 2018;18(1):185. https://doi.org/10.1186/s12909‑018‑1289‑9 19. michael m, wilson c, jester dj, et al. application of curriculum mapping concepts to integrate multidisciplinary competencies in the care of older adults in graduate nurse practitioner curricula. j prof nurs 2019;35(3):228‑239. https://doi.org/10.1016/j.profnurs.2019.01.007 20. harden rm, stamper n. what is a spiral curriculum? med teach 1999;21(2):141‑143. https://doi. org/10.1080/01421599979752 accepted 8 june 2020. https://doi.org/10.7196/samj.6463 https://doi.org/10.1080/03075079.2014.899343 https://doi.org/10.1080/0142159x.2018.1487047 https://doi.org/10.1080/01421590120036547 https://doi.org/10.1080/0729436042000235436 https://doi.org/10.3109/0142159x.2014.874552 https://doi.org/10.3109/0142159x.2014.874552 https://doi.org/10.3109/0142159x.2015.1035054 https://doi.org/10.1111/j.1365-2923.2008.03093.x https://doi.org/10.1111/j.1365-2923.2008.03093.x https://doi.org/10.1046/j.1365-2575.1998.00040.x https://doi.org/10.1177/2158244014522633 https://doi.org/10.1186/s12909-018-1289-9 https://doi.org/10.1016/j.profnurs.2019.01.007 https://doi.org/10.1080/01421599979752 https://doi.org/10.1080/01421599979752 april 2021, vol. 13, no. 1 ajhpe 47 research the last decade has seen a growing emphasis on reflective practice as a graduate outcome of health professions education (hpe) programmes across the globe.[1-4] reflective practice for professionals was popularised by schön,[5] who introduced the concepts of reflection in action and reflection on action in the late 1980s. reflection in action refers to a reflective process during an activity, which helps a person to modify their approach, if needed, to achieve desired results. reflection on action is aimed at revisiting and reflecting on a particular experience with a view to learning how to improve and grow from the experience. critical reflection is therefore regarded as an essential component of ongoing personal and professional learning, as it supports both students and professionals in critically analysing and directing their progression toward learning outcomes and required practice standards. [6] when the first bachelor of science (bsc) radiography programme in south africa (sa) commenced in 2014, it incorporated a focus on reflective practice as a graduate outcome that was not apparent in the former qualification, the national diploma in radiography.[7] both the health professions council of sa and the sa qualifications authority require that students develop reflective practice as a graduate attribute in the new programme.[7] however, no guidelines or competency framework is provided. as a result, lecturers on this programme are required to facilitate new forms of learning, which may prove challenging in some instances. although it is often assumed that lecturers themselves are reflective practitioners, and thus skilled in integrating reflective practice into learning and teaching, many lecturers may not possess the necessary experience or skills in practising and teaching in this manner.[8,9] this is a critical aspect to consider, as lecturers’ experience of reflective practice may impact significantly on learners’ experiences and the subsequent development of their reflective skills.[9] from the literature, it is evident that in order to engage appropriately with reflective practice, educators need to develop a comprehensive understanding of the concept, its underpinning assumptions and, similarly, its value.[4,8,10] however, studies that have explored the understanding and level of training of those who facilitated the learning of reflective skills report that between 23% and 55% had received no training, and required support to develop this higher-order cognitive skill.[3,8] moreover, in a study that explored registered nurses’ experiences of mentoring undergraduate nursing students in a rural context, participants indicated that their own limited knowledge of reflective practice posed a barrier to facilitating the development of reflective learning skills in their students.[9] coulson and harvey[11] found that facilitators of reflective practice may first need to develop their own reflective capacity before being able to teach the practice to their students. the authors propose a scaffolding framework aimed at supporting the progressive development of reflective capacity in both teachers and students. scaffolding goals include learning to reflect, and practising reflection for action, reflection in action and reflection on action in various contexts.[11] background. reflective practice has become an integral component of the new bachelor of science (bsc) radiography programme in south africa (sa). as a result, lecturers on the programme are required to facilitate reflective learning, and are assumed to be skilled in this. however, relevant literature indicates that health professions educators may not necessarily possess the requisite competence or experience in facilitating reflective learning. moreover, there is a paucity in the literature on lecturers’ perceptions and understanding of reflective practice in the context of undergraduate radiography curricula, particularly in sub-saharan africa. objective. to gain insight into bsc radiography lecturers’ perceptions and understanding of reflective practice at a selected university of technology in sa. methods. this was a qualitative exploratory study in which individual semi-structured interviews were conducted with lecturers teaching on the new bsc  radiography programme. the purposively selected sample consisted of 11 participants. interviews were audio-recorded, transcribed and thematically analysed. results. analysis of the data revealed three themes, namely diverse understandings of reflective practice among lecturers, factors influencing optimal facilitation of reflective learning and strategies to improve reflective practice. conclusion. the findings of this study indicated that lecturers felt unprepared to facilitate reflective practice in the new bsc radiography curriculum. the need for faculty development initiatives, such as an introduction to reflective tools and educational strategies to support lecturers in facilitating reflective practice, was highlighted. furthermore, it was found that if objectives were clearly outlined and facilitator guides available, a desired reflective practice could be established. afr j health professions educ 2021;13(1):47-51. https://doi.org/10.7196/ajhpe.2021. v13i1.1249 factors influencing radiography lecturers’ perceptions and understanding of reflective practice in a newly implemented curriculum h thomas, mphil, hpe; m volschenk, mphil, hpe centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: h thomas (thomashe@cput.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 48 april 2021, vol. 13, no. 1 ajhpe research although well established internationally,[2,4] the concepts of reflection and reflective practice have received little attention in radiography education in the sub-saharan african context. available literature focuses on the use of reflective tools for radiography students in which their reflective writing skills are assessed through guided reflective writing.[2] there is, however, a paucity in the literature on radiography lecturers’ engagement with reflective practice, and their perceptions and understanding thereof in the context of undergraduate radiography education. this study aimed to explore radiography lecturers’ perceptions and understanding of reflective practice in the context of the new bsc radiography programme at a selected university of technology in sa, with a view to inform future curriculum design and faculty development initiatives. methods research design in this study, an exploratory descriptive design was used to explore and develop  a meaningful interpretation of how lecturers’ perceptions and  understanding of reflective practice influenced its facilitation in their specific teaching context.[12] study participants the study population consisted of 14 lecturers teaching on the radiography programme. lecturers who taught on both the clinical and academic curriculum of the new bsc radiography programme were eligible to participate in the study. a study sample of 11 participants (n=11) was purposively selected. two lecturers did not respond to the invitation to participate, while another only taught on the academic curriculum, and was therefore excluded from the study. the 11 eligible lecturers who responded to the invitation were all selected, given the diverse qualities they would bring to the study. this allowed the researchers to explore whether aspects such as years of teaching experience, being a junior v. a senior lecturer and having a master’s degree v. a btech qualification had any influence on participants’ perceptions and understanding of reflective practice in the context of the new bsc radiography curriculum. data generation qualitative data were generated by means of semi-structured, individual, faceto-face interviews, which were conducted by the principal investigator. this approach allowed for considerable flexibility in scope and depth, enabling the researchers to gain a deep, holistic understanding of the participants’ viewpoints within their settings.[12] the interview schedule was guided by the study objectives and informed by the literature on previous studies that explored the perceptions and understanding of educators facilitating reflective practice in the health professions context. interview questions explored participants’ own experiences with, and understanding of, reflective practice, as well as their experiences with implementing reflective practice in the new bsc radiography curriculum. interviews were audio-recorded with the  written consent of participants, and transcribed verbatim by an independent transcriber. data analysis data were thematically analysed using braun and clarke’s[13] six phases  of thematic analysis, which include familiarising oneself with the data, generating initial codes, searching for themes, reviewing themes, refining and naming themes and producing a report. the transcripts were initially read and re-read by the principal investigator in order to familiarise herself with the data and identify initial codes. after initial coding, common meanings were recognised, and themes were identified. codes and themes were reviewed and refined in collaboration with the co-investigators. the themes were developed inductively. quality assurance shenton’s[14] strategies for ensuring trustworthiness in qualitative research were followed, to ensure rigour. the quality criteria that were addressed included credibility, transferability, dependability and confirmability.[14] a step-by-step approach to the data analysis process, the researcher’s reflective notes and appendices are available to demonstrate transparency. additionally, the transcriptions were returned to participants for member checking in order to ensure that a shared meaning of the data was obtained.[12] since the principal investigator was part of the teaching team on the new bsc radiography programme, and conducted all interviews, it was essential to remain cognisant of her own preconceptions and biases, as well as the potential influence she might have on data generation and analysis. reflexivity was enhanced through keeping a research journal and maintaining open dialogue and discussion with the co-investigators during data generation and analysis. ethical considerations ethical approval was obtained from the stellenbosch university health research ethics committee (ref. no. s17/03/063) as well as from the research ethics committee of cape peninsula university of technology (ref. no. 2017/h19). participation in the study was voluntary, and informed consent was obtained from each participant prior to interview commencement. anonymity was ensured by assigning a unique number to participants. data were stored on a password-protected computer. results the qualitative data analysis provided valuable insight into lecturers’ perceptions and understanding of reflective practice in the context of the new bsc radiography curriculum. three themes, namely diverse understandings of reflective practice among lecturers, factors influencing optimal facilitation of reflective learning and strategies to improve reflective practice, were identified. all participants were lecturers at the selected university of technology, and were involved in a faculty development programme or held a formal qualification in teaching in higher education. the data and interpretative comments were organised into three overarching themes, as follows. theme 1: diverse understandings of reflective practice among lecturers lecturers’ responses revealed diverse understandings of the concept of reflective practice. this influenced their personal engagement with it. some of the junior lecturers indicated that they were exposed to reflective practice during their own training, either as radiographers or lecturers. as a result, their engagement with reflective practice seemed to have an outward focus on issues relating to student interaction and learning, as well as the identification of problem areas in learning: ‘after having given the class, i would think about the student participation, whether or not i was happy with that and if i felt the student participation was what i expected.’ (participant 1) april 2021, vol. 13, no. 1 ajhpe 49 research ‘once you’ve done with your teaching, you think to yourself, have they understood what you’ve done and the evidence is when they do an assignment.’ (participant 3) the more senior lecturers, on the other hand, reported that they had little prior exposure to reflective practice in their own training. during engagement with reflective practice, they seemed to adopt an inward focus, assessing their own teaching methods and analysing their teaching practices: ‘what i’ve done was it good or bad and how can i improve it?’ (participant 7) one lecturer indicated that (s)he did not understand the concept of reflective practice: ‘i don’t really understand reflective practice …  i can just maybe think that it is reflecting on stuff that you know or things that you have learnt.’ (participant 6) theme 2: factors influencing optimal facilitation of reflective learning this theme highlighted lecturers’ perceptions of factors that may influence the facilitation of reflective learning in students. one lecturer considered self-exploration with reflective practice as a key enabler to the effective facilitation of reflective learning in students: ‘i don’t think i would have been so comfortable to teach it to students or to invite students on this journey if i didn’t read about it and if i didn’t try it out.’ (participant 2) poor student engagement with reflective learning was viewed by many participants as a negative influence on the effective implementation of reflective practice in the new curriculum: ‘they [students] are not used to that kind of learning. it’s not something that they get introduced to early on, and by the time they get to fourth year, they’re like …  we got by without this new learning method.’ (participant 1) large groups posed a significant challenge to the optimal facilitation of reflective practice: ‘the other challenge … the numbers … when you are dealing with a large number of students it becomes a little bit challenging.’ (participant 8) furthermore, lecturers expressed frustration with the limited time allocated for the facilitation of reflective learning in the curriculum: ‘i think time is the biggest obstacle because on the timetable you get sessions with the students and you have that as contact time to deliver content.’ (participant 2) in addition, the fact that reflective practice was not overtly taught and assessed in the new curriculum was viewed by many lecturers as a hindrance to the facilitation of reflective practice: ‘reflection needs to be made explicit … it must find a place in whether it’s a learner guide …  whether it’s a lesson plan that we give to the students, it must be mentioned by name’. (participant 2) ‘if there is nothing attached to it, a mark or a requirement then some of them are just doing it for the sake of completing it.’ (participant 10) theme 3: strategies to improve reflective practice this theme emphasises lecturers’ need to be introduced to reflective tools and to be supported with the integration of reflective practice in the new curriculum. a few lecturers alluded to the need for clear guidelines on the implementation of reflective practice in the new curriculum: ‘as a department, we must decide sort of a policy on reflective practice or reflection.’ (participant 9) lecturers reported that they found it challenging to familiarise themselves with the disciplinary content of the new curriculum while simultaneously having to learn how to facilitate the development of reflective skills: ‘first of all okay, in a new setting, you have to try and get a grasp of what needs to be in the curriculum first, and this is a new programme. so i think we are still trying to grasp content at the moment.’ (participant 4) although the majority of lecturers were mindful of reflective tools, several acknowledged that they would benefit from further exploration of such tools in order to better support students: ‘i think there is a need for a programme to be in place for us to make us aware of reflective practice because you want them [students] also prepared for life-long learning and how to implement [that] within our teaching’ (participant 3) ‘first of all i think faculty can assist in maybe running workshops on reflective practice.’ (participant 10) discussion to the authors’ knowledge, this is the first study to be conducted in the sa context since reflective practice was introduced as an exit-level outcome of the new bsc radiography qualification. the study highlighted a number of factors that may impact on the successful integration of reflective practice in the new curriculum. participant responses indicated that most lecturers found it challenging to conceptualise reflection within the context of radiography. this may have a direct impact on student learning and the extent to which reflective practice is embedded in students’ understanding. difficulty in conceptualising reflective practice appears to be a universal problem,[8,9] which resonates well with this study’s findings and suggests the need for a conceptual framework in which the grounding of beliefs, understanding, values and consequences for reflective practice[15] within the radiography context is clearly defined. the development of such a framework may, in turn, lead to a more structured and unified understanding of reflective practice. responses revealed a link between lecturers’ personal reflective approaches and the ways in which they facilitated reflective learning. those who regularly engaged in reflection and embarked on self-exploration into reflective tools were generally more mindful of engaging students in structured reflective approaches. the majority of experienced lecturers were unfamiliar with the use of structured reflective tools, and infrequently incorporated these into teaching and learning activities. this could be explained by the fact that most junior lecturers were exposed to reflective practice during either their radiography or postgraduate studies, while senior lecturers did not receive the same exposure during any of their studies. our findings suggest that the facilitation of reflective learning calls for personal exploration and commitment on the part of the lecturer, especially since reflective practice is often considered a complex concept. 50 april 2021, vol. 13, no. 1 ajhpe research indeed, race[10] emphasises the need for lecturers to be skilled in reflective practice in order to effectively facilitate the reflective learning process. the introduction of coulson and harvey’s[11] scaffolded framework into the radiography education context could add value, as it makes provision for the scaffolding of both lecturers’ and students’ reflective competence in workplace-based curricula. lecturers could greatly benefit from the opportunity to identify their own proximal zone of reflective development as a starting point in developing a more critical reflective approach to teaching and learning.[11] this is important because the outcomes of the reflective learner may be critically influenced by the lecturer’s reflective competence. participant responses revealed diverse understandings of the concept of reflective practice as it relates to the new curriculum. the finding that reflective practice was not overtly taught and assessed in the curriculum highlights the need for clear and detailed curriculum guidelines on its facilitation. a study by braine[8] correspondingly identified the issue that reflection was not made explicit in the curriculum and, as such, appeared to be disconnected from learning. frank et al.[16] propose a clearly defined curriculum purpose, with measurable outcomes, to avoid possible misperceptions in educational programmes. without clear objectives, facilitator guides and detailed teaching and assessment strategies, it may prove challenging to facilitate the desired type of learning. furthermore, the finding that students were less likely to engage with reflective practice if marks were not allocated for such learning activities not only speaks to the fact that assessment drives learning, but also emphasises the importance of constructive alignment between learning outcomes, teaching and learning activities and assessment.[17] the context in which learning takes place has a major impact on learning outcomes. some lecturers felt that radiography, as a profession, lends itself naturally to reflection owing to the large component of workintegrated learning in the curriculum. however, they were confronted with overwhelming contextual challenges when facilitating reflective learning, including large classes and poor student engagement. they concluded that additional time should be allocated for reflective learning to promote optimal student engagement. others felt that reflective learning was too time-consuming, and that learners needed convincing to engage with this kind of learning. these challenges are consistent with those found in the literature,[17] and the lecturers in the present study voiced the need to be introduced to strategies that will allow them to nurture reflective learning in large groups, and to manage time more efficiently. as a result of research and educator development programmes, lecturers were cognisant of tools that encourage reflection. interestingly, the more junior lecturers were most comfortable using reflective tools, as they had been exposed to them during their radiography training or other postgraduate studies. the data, however, shed little insight into the way lecturers use these tools. structured questionnaires and portfolios in the final year of study were the only clear facilitative methods that could be identified from the data. findlay et  al.[2] advocate structured reflection as an effective method to encourage reflection in radiography. however, structured questionnaires could potentially be restrictive in nature for those who want to reflect critically. lecturers, therefore, need to further explore tools that encourage critical reflection. participants further emphasised the need for faculty to participate in, and collaborate on, strategies that support the integration of reflection with discipline-specific content. although most lecturers agreed that reflection was an integrated part of workplace learning, most of them found it challenging to integrate the theory and practice of reflection in the workplace. braine’s[8] findings echoed this, in that facilitators required guidance in innovative approaches to incorporating reflection into learning. participants unanimously concluded that guidance, or the lack thereof, ultimately holds implications for the teaching and assessment of reflective practice. it became clear that a need for faculty development existed within the context of the new curriculum. study limitations a limitation of the study is that it only considers the view of the radiography lecturers at a single institution. students’ reflective competence, as embedded via the new curriculum, was not addressed. however, the findings of the study provided insight into how reflective practice was interpreted and facilitated by lecturers in the new curriculum, which could assist other institutions that are also in the process of re-curriculation. conclusion this study has highlighted the need for faculty development initiatives in which lecturers are introduced to reflective tools and educational strategies to support the facilitation of reflective practice in the new bsc radiography curriculum at a selected university of technology. clearly outlined objectives and facilitator guides could establish a desired reflective practice culture. furthermore, lecturers demonstrated varied understanding of reflective practice within radiography, which points to the need for a shared understanding of the concept. the successful facilitation of reflective practice was furthermore influenced by many barriers, which may ultimately impact on the successful attainment of graduate outcomes. there is a need for further research to determine the extent to which graduates of this programme have developed reflective competence. declaration. ht conducted the study in partial fulfilment of a master’s degree in health professions education from stellenbosch university. acknowledgements. this work would not have been possible without the participation of the radiography lecturers at the study site, and the authors gratefully acknowledge their valuable contributions. we would also like to thank the management at the study site for their support and permission to conduct the study. we gratefully acknowledge dr lakshini mcnamee’s contribution as co-investigator. we also extend our thanks to mrs i meyer for her contribution towards the final editing of the manuscript. author contributions. ht conducted the study in partial fulfilment of a master’s degree in health professions education from stellenbosch university. she collected and analysed the data and subsequently prepared the manuscript. mv acted as primary research supervisor, assisted with verifying the data analysis, and commented and contributed to various sections of the manuscript. both authors reviewed and approved the final article. funding. none. conflicts of interest. none. 1. sandars j. the use of reflection in medical education: amee guide no. 44. med teach 2009;31(8):685-695. https://doi.org/10.1080/01421590903050374 2. findlay n, dempsey se, warren-forward hm. development and validation of reflective inventories: assisting radiation therapists with reflective practice. j radiother pract 2011;10(1):3-12. https://doi.org/10.1017/ s1460396910000142 3. ward a, gracey j. reflective practice in physiotherapy curricula: a survey of uk university-based professional practice coordinators. med teach 2006;28(1):e32-39. https://doi.org/10.1080/01421590600568512 https://doi.org/10.1080/01421590903050374 https://doi.org/10.1017/s1460396910000142 https://doi.org/10.1017/s1460396910000142 https://doi.org/10.1080/01421590600568512 april 2021, vol. 13, no. 1 ajhpe 51 research 4. brackenridge sa. perceptions of reflective practice among recent australian radiation therapy graduates. radiogr 2007;54(2):18-23. https://doi.org/10.1002/j.2051-3909.2007.tb00068.x 5. schön da. educating the reflective practitioner: toward a new design for teaching and learning in the professions. san francisco: jossey-bass, 1987. 6. black pe, plowright d. a multi‐dimensional model of reflective learning for professional development. reflectpract 2010;11(2):245-258. https://doi.org/10.1080/14623941003665810 7. south african qualifications authority. registered qualification: bachelors of radiography. pretoria: saqa, 2013. http://regqs.saqa.org.za/viewqualification.php?id=66949 (accessed 15 august 2019). 8. braine me. exploring new nurse teachers’ perception and understanding of reflection : an exploratory study. nurse educ pract 2009;9(4):262-270. https://doi.org/10.1016/j.nepr.2008.08.008 9. atkins s, williams a. registered nurses’ experiences of mentoring undergraduate nursing students. j adv nurs 1995;21:1006-1015. https://doi.org/10.1046/j.1365-2648.1995.21051006.x 10. race p. evidencing reflection: putting the ‘w’ into reflection. escalate, 2006. http://escalate.ac.uk/resources/ reflection/03.html (accessed 15 august 2019). 11. coulson d, harvey m. scaffolding student reflection for experience-based learning: a framework. teaching higher educ 2013;18(4):401-413. https://doi.org/10.1080/13562517.2012.752726 12. maree k. first steps in research. pretoria: van schaik, 2007. 13. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 14. shenton ak. strategies for ensuring trustworthiness in qualitative research projects. educ inf 2004;22(2):63-75. 15. barrie, sc. a conceptual framework for the teaching and learning of generic graduate attributes. studies higher educ 2007;32(4):439-458. https://doi.org/10.1080/03075070701476100 16. frank jr, mungroo r, ahmad y, et  al. toward a definition of competency-based education in medicine: a systematic review of published definitions. med teach 2010;32:631-637. https://doi.org/10.3109/014215 9x.2010.500898 17. biggs jb. teaching for quality learning at university: what the student does. london: mcgraw-hill education (uk), 2011. 18. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. adv heal sci educ 2009;14(4):595-621. https://doi.org/10.1007/s10459-007-9090-2 accepted 24 april 2020. https://doi.org/10.1002/j.2051-3909.2007.tb00068.x https://doi.org/10.1080/14623941003665810 http://regqs.saqa.org.za/viewqualification.php?id=66949 https://doi.org/10.1016/j.nepr.2008.08.008 https://doi.org/10.1046/j.1365-2648.1995.21051006.x http://escalate.ac.uk/resources/reflection/03.html http://escalate.ac.uk/resources/reflection/03.html https://doi.org/10.1080/13562517.2012.752726 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1080/03075070701476100 https://doi.org/10.3109/0142159x.2010.500898 https://doi.org/10.3109/0142159x.2010.500898 https://doi.org/10.1007/s10459-007-9090-2 article 10 july 2012, vol. 4, no. 1 ajhpe introduction in medical training an intern or houseman is a professional who has almost completed training as a doctor and is working in an accredited facility under supervision within the limits of a well-defined scope. the purpose of medical internship is to equip trainees with the knowledge and practical skills of medical practice in order for them to become independent, competent and safe medical professionals having obligations to patients, health systems and communities.1 medical internship was introduced in south africa in 1950 by the south african medical and dental council (samdc) and has been regulated and administered by the health professions council of south africa (hpcsa) from 1997.2 in the early years, training took place in specialised and subspecialised departments and lasted for 1 year. lack of uniformity in the training programme led to dissimilarities in structure with some interns spending 6 months in medicine and 6 months in surgery without exposure to other domains such as obstetrics and gynaecology or paediatrics.2 this unstructured exposure was identified as a major cause for lack of allround competence among the doctors completing internship. it also failed to address the challenges of turning theory into practice that every newly qualified doctor has to face, with the consequence that the junior doctor may be left with dangerous skills and knowledge gaps that negatively affect professional capabilities.3 concerns about the structure, relevance and quality of such training were raised by the medical fraternity. the traditional training focused on specialised fragmented training for the most part with issues such as context, community, culture and ethics, together with strategies in primary health care and public health being poorly addressed.4 equally important was the misunderstanding regarding skills and competencies of doctors that were generally taken as referring to clinical skills, or ‘technical skills’ such as diagnosis and management, surgical and other procedural activities.5 issues such as team work, ethics, confidence, professionalism and communication, which are important in the delivery of quality medical service, were not given adequate attention. the deficiency in a number of individuals and hospital teams significantly hampered the provision of the medical services as a whole.5 this led the hpcsa to change the duration of medical internship from 1 to 2 years. the programme was implemented in phases in 2005 for graduates of some universities and then implemented for all universities from 2007.17 the availability of resources as well as quality of supervision in training facilities also plays a significant role in the competence levels of interns. lack of equipment and medicines hamper the training and acquisition of skills to junior doctors.5 supervisors who are approachable, available, and up-to-date with relevant and practical teaching (such as interactive bedside teaching) enhance the confidence and competence of trainees.6 background. medical internship that entails training as a doctor and working in an accredited facility under supervision within the limits of a well-defined scope prepares the professional for independent, competent, ethical medical practice. in south africa medical internship is managed by the health professions council of south africa and was changed from 1 to 2 years in 2008. mandatory rotations include internal medicine, obstetrics/gynaecology, paediatrics, surgery and family medicine. the researchers investigated the determinants of effective training during internship at an accredited hospital following concerns of incompetence of medical interns at the end of training. method. a qualitative study using individual interviews was done among 7 purposefully selected doctors who had completed internship at rustenburg hospital. thematic analysis was done. results. determinants of effective training in internship were identified as good quality supervisors, effective supervision, adequate opportunity to experiential learning, conducive environment, good support system (hospital management, hospital staff, academic opportunities), personal attributes and reasonable work load. conclusion. the need for accredited training institutions to create conducive training environments based on the identified determinants was identified. ajhpe 2012;4(1):10-14. doi:10.7196/ajhpe.100 determinants of effective medical intern training at a training hospital in north west province, south africa ni ni sein, john tumbo department of family medicine & primary health care, university of limpopo (medunsa campus), pretoria ni ni sein, mb bs, m fam med john tumbo, mbchb, m fam med, mcfp (sa) corresponding author: j m tumbo (tumbo@lantic.net) article 11 july 2012, vol. 4, no. 1 ajhpe having observed deterioration in the competencies of doctors completing internship, the researchers became concerned about the quality of training provided at the hospital to the medical interns. this study was undertaken to establish the determinants of effective training during medical internship as experienced by doctors who completed internship at rustenburg provincial hospital. findings of this study form a useful guide in improving the training of medical interns at accredited institutions of similar nature. methods a descriptive qualitative study using free attitude individual interviews18 was done in 2005 december and 2006 january. the study was done at rustenburg provincial hospital, an accredited intern training secondary level hospital in north west province, south africa. interns undergoing training annually at this hospital rotated for 12 weeks through 4 main disciplines; surgery & orthopaedic, medicine, paediatrics, obstetrics & gynaecology and for 2 weeks in the anaesthesia department. twenty interns who completed 1 year intern training in december 2004 and 2005 at rustenburg provincial hospital were considered as the study population. purposive sampling of seven doctors who continued employment at the hospital as community service doctors or medical officers was done.those who refused to participate in the study, those who studied medicine outside south africa and those who had left rustenburg provincial hospital after internship were excluded. a free attitude individual interview was conducted with each consenting participant. the exploratory question was: ‘what were your experiences on training during your internship in the rustenburg provincial hospital?’ facilitation of the interview was done through reflections, clarification and periodic reflective summaries. the interviews were recorded on audiotapes. verbatim transcription of data and content analysis was done. identified themes were grouped, compared and contrasted. ethical approval to conduct this study was given by the research ethics and publications committee, medunsa campus, university of limpopo; certificate number repc/mp/153/2005. results table 1 lists the themes identified as determinants of effective training of interns. experiential learning enhanced skills acquisition and development experiential learning provided opportunity to develop intuition and improved clinical judgement ‘i learnt a lot. improved clinical judgement and skills made me trust my instincts and to sieve through all my knowledge i have in my brain and see which is better applicable to each patient.’ opportunity to practise affects acquisition of surgical skills ‘… i did above ... yah. i think it is below-knee amputations and stuff, and do few laparotomies , appendectomies um … so in surgery i learn a lot, and i really enjoy surgery. i did minor operations like circumcision, stuff like that. that is really positive for me.’ exposure in accident and emergency enhanced skills ‘casualty, i enjoy the part a lot that it was unselected cases, meaning that the patients were not worked up and so you have to work up yourselves and relate to your own clinical judgement about what is the problem? what is the diagnosis? what investigations you should do, and we see a lot of very interesting cases … resuscitations ... intubations in casualty … um so that’s the things that we are comfortable with …’ exposure to challenges enhances learning ‘you are like the first point of call for most patients before you get to the ward. so you get all the emergency cases, how to treat poison, how to treat snakebites, how to resuscitate patients, you know, and all those things. you don’t get that in the ward because the patient has already been treated in casualty, he is now stabilised … you get that in the ward.’ ‘you need to know these things as doctors’. the environment and context of training is important lack of equipment and space diminishes learning ‘how do you learn where there is no equipment and monitors are not working?’ table 1. themes identified as determinants of effective training of interns themes quotes 1. experiential learning enhances skills acquisition and development ‘i enjoy the part a lot that it was unselected cases, meaning that the patients were not worked up and so you have to work up yourselves and relate to your own clinical judgement about what is the problem? 2. training context and environment influence learning ‘how do you learn where there is no equipment and monitors are not working?’ 3. supervision and support by senior medical practitioners influence the training of medical interns ‘you always had a senior doctor, you were given space to make a decision and the senior doctor supervises what you do’ 4. the attitude of the intern is an important factor in training and learning ‘because working as a doctor in this situation, having a certain degree of responsibility, you are learning a lot more, you are more actively involved.’ ‘this matures you as a doctor, teaches you to take responsibility, and to work under pressure’ 5. training and learning happens best where there is a strong team ‘i like team work and learn from them.’ 6. social factors influence intern training and personal development ‘my personal life is shot to bits. i have no time, most of the time i spend up here working’ 7. workload is an important determinant of learning ‘the heavy workload is something good. at the end, i gained more’ 8. management support is an important factor influencing training ‘there was no one to take, like, the responsibility of interns.’ article 12 july 2012, vol. 4, no. 1 ajhpe poor safety of the work environment increases the risk of occupational injury and affects learning ‘and i wanted to do it in this time when there were no interns, but i was on arv and i was very, very sick. and i was so mad at myself ’ intern learning is negatively affected by the fear of medico-legal consequences of their actions ‘at the beginning they would come out with you but the others, not always, and i feel that could result maybe one of these days in serious medico-legal issues.’ availability of clinical guidelines and protocols enhances learning ‘… they help, like … you know… like in casualty you have a protocol for paraffin ingestion, then you know things to do for that’ limited time during the rotations retards learning ‘i think 2 weeks in anaesthetics is also not quite enough. i think that is also something that can improve’ supervision and support by senior medical practitioners influence the training of medical interns a positive attitude of the supervisor facilitates intern training while a negative attitude impedes training and learning ‘his philosophy is he is not appointed as a training person so he doesn’t really like to show… or to let interns do procedures themselves; if you are not going to stay in the department itself. he says if you change every two months, then just when you’re trained you have to go back and it takes a lot to train somebody … which i felt is, is not ideal.’ unavailability of supervisors/senior doctors affects the morale of interns ‘interns are thrown a bit into the deep end and you know … you need senior people available.’. ‘not just leaving an intern in the ward alone to basically fight and fend for himself and sort out for himself’...’ support and affirmation encouraged interns to explore and learn ‘here i felt like a doctor.’ ‘you were never alone, you always had a senior doctor, you were given space to make a decision and the senior doctor supervises what you do’. ‘he is very, very reassuring even with an appendectomy, though it was the first operation i ever assisted, he showed me how to cut and i did it myself.’ negative behaviour and attitude of senior doctors demoralised interns ‘a lot of the senior doctors would do their ward round and basically disappear. expecting the intern to be … maybe being a slave is a harsh word’ a good role model nurtures the intern ‘i was there with dr x. and she was very nice to be with ... she did a protocol book. she is a role model worth following ...’ trainers with deficient knowledge and skill negatively influence training ‘i think the academic knowledge was maybe not that great or up to date; so i did not learn’ constant support by supervisor enhanced learning ‘he never left me alone so there was never a point when i felt like i don’t know what to do, there’s no one around, you know, so my experience with medicine was fine. i learnt a lot.’ the attitude of the intern is an important factor in training and learning a positive attitude leads to transformation of the intern to a mature professional ‘because working as a doctor in this situation, having a certain degree of responsibility, you are learning a lot more, you are more actively involved.’ ‘this matures you as a doctor, teaches you to take responsibility, and to work under pressure’ the intern’s perception of internship as a fruitful experience enhances learning ‘i’m quite confident in all the specific disciplines and that’s thanks to rph in the way they constructed the intern rotation, that you actually go through every department’. ‘it prepares you for anything you want to do after that.’ intuition improves training and learning ‘i’ve learned also …. something that they don’t teach in medicine, you start getting that gut feeling, something that’s bothering you and you go for it, and many times you’re right’ self-motivation among interns enhances training and learning ‘i always made it a point to try and help where one can, that you get involved, that you get to know the patient, that you get experience in what is happening basically in theatre.’ training and learning happens best where there is a strong team good interpersonal relationship between team members facilitates learning ‘interpersonal relationship with doctors and other members of staff, nurses, i get along with most people … 95% of the people … i like that … i like team work and learn from them.’ learning can happen from any member of the team ‘you will learn more from the sisters than from the other doctors, especially us interns.’ lack of respect is very demoralising ‘you know, you get treated like a piece of … like a chair or something… something dead. you just have to accept it.’ harassment by senior staff belittles interns and interferes negatively with training ‘i think that is a personality problem. i don’t know how to … when it comes to confrontation, i don’t know how to handle it. in the beginning i got like really mad, and now it’s like … with my last serious confrontation i just said nothing. even though the sister was standing there insulting me and insulting me and… uhm’ social factors influence intern training and personal development internship is very intense and affects the social and personal development of the trainees ‘my personal life is shot to bits. my dad thinks i work too much, i have no chance to go anywhere, ha ha, especially in terms of my girlfriend, she doesn’t article 13 july 2012, vol. 4, no. 1 ajhpe want to talk to me, because i have no time; most of the time i spend up here working’. lack of social amenities such as good housing demoralise interns and interfere with training ‘that was a bad experience for me. is this housing fit for human beings?’ workload is an important determinant of learning workload of interns has both positive and negative effects on training. interns decried the effect of heavy workload on their social life and competence. however, reasonable workload was appreciated as it provides an opportunity to learn and gain more experience ‘the heavy workload is something good. at the end, i gained more.’. ‘fortunate that i don’t think it was one of the busiest intern hospitals, so it’s a nice balance.’ management support is an important factor influencing training laxity and indiscipline of managers and senior doctors frustrated the medical interns ‘the head of the department would be there in the morning, but then from 10 or 11 whenever the ward rounds were finished until about 3 o’clock again, you were basically flying solo.’ poor interest by management made interns to feel neglected ‘there’s one thing i don’t like about this facility, and i’ll keep saying it until i go to my grave, … uhm i think we do not take care of our doctors in terms of administration. i think it’s very shameful that a hospital of this standard doesn’t have a tearoom for doctors.’ lack of management responsibility for intern training impedes learning ‘the only problem was there was no one to take, like, the responsibility of interns, like even for other departments.’ discussion this study found that effective training of medical interns is facilitated by factors including an environment that offers learning opportunities, effective supervision, support by management, positive attitude of the interns, teamwork and a positive social atmosphere. intern training will not be possible where the intern does not get the opportunity to learn and practise. such a non-conducive environment has been described in some disciplines in academic hospitals in south africa.2 the regulations of the hpcsa regarding intern training prior to 2007 did not enforce an all-round exposure and proof of competence in a wide variety of domains. several training facilities only rotated interns in two out of the four major domains (medicine, surgery, paediatrics and obstetrics and gynaecology), leaving the rest of all the other domains as optional attachments. this impacted negatively on the skills and competence of interns in the general medical practice that they are exposed to as community service doctors and medical officers in the district health system. several authors have highlighted the inappropriateness of training of interns in academic hospitals for general practice.3 with evolution of hpcsa intern training regulations, interns trained in rustenburg provincial hospital rotated in all major disciplines. respondents expressed their gratitude for this opportunity which prepared them well for the future. the importance of this multidisciplinary exposure during internship prepares the intern for effective medical community practice including rural practice.4 the important role of effective supervision was also highlighted by this study. the respondents shared that they learnt more when the supervisor showed support, guidance, affirmation, was committed and available to train and supervise. multiple studies have reported similar roles and characteristics of supervisors that enhance training and learning of medical interns.3,7-9 this study found that the competence levels of senior doctors are critical for positive learning. it is this competence that interns recognise as an important aspect of role modelling.5 this phenomenon is echoed by other authors who shared the similar view that approachable, available and up-to-date teachers improve their confidence and allow them to extend their existing skills.6 unapproachable, physically and mentally remote teachers are detrimental to confidence of the trainees and inhibit learning. it is also important to note that the supervisor is a role model for the interns. not only are the academic skills of senior doctors who are seen as intern supervisors important but also their behaviour. this study and others found that unethical behaviour of supervisors is a major source of frustration of the trainees and also inhibits learning.10 the training and work environment have strong influence in learning. medical internship can be a physically exhausting and emotionally traumatic experience as found in a study done at the 5 teaching hospitals of the university of witswatersrand that assessed various aspects of internship, including continuing medical education, workload and stress during 1985 and 1986.11 problem areas identified were excessive patient load, sleep deprivation and severe stress. the commonest symptoms of stress were fatigue, irritability and weight loss. in 1985, 53% of interns stated that they could not cope, and in 1986 this increased to 65%. forty eight per cent of 1985 and 69% of 1986 interns lost interest in medicine during the intern year. workload was identified as an important influence to learning. the study highlighted the importance of quality of work compared with quantity of work. the majority of respondents felt that the number of hours they worked was reasonable compared with their counterparts. the reasonable workload gave opportunity to have a balanced life style, and enough recuperating time afterwards. the respondents did not mention the medical errors they made as a result of exhaustion. medical errors have been attributed to long working hours12 and duration of shifts.13 intense work demands, limited control and high degree of work-home interference during internship predispose to burn out.14 the results of the study concluded that the work load in rustenburg provincial hospital is reasonable. the attitude, personality and interpersonal skills of interns are the essential qualities to overcome challenges during internship. coping mechanism depends upon how the intern perceives his/her internship. according to respondents in one report, ‘it all depends on your attitude to your internship. if you make the most of it, you can handle most things.’5. this study identified diversity in the coping styles of interns including, submission, confrontation, reporting to authorities and suppressions. with regard to personality, this study found that the respondents, who had bold personality, took initiative and went the extra mile to learn gained more experience and knowledge than those who are humble, submissive and timid. one respondent expressed her disappointment that she was not confident with caesarean section because she was denied the chance to do one by the senior doctor while the other counterpart believed that one must be keen and bold to learn during internship. article 14 july 2012, vol. 4, no. 1 ajhpe the study highlighted the positive influence of teamwork on intern training. there must be good interpersonal relationship among healthcare workers to work as a team. to build a good interpersonal relationship there must be social interaction. social interaction will assist members to understand each other’s weaknesses and strengths and tolerate each other better. good interpersonal relationship reduces the conflicts at the workplace and intern training provides opportunities to further develop skills in communication and team work as they were equally important in the delivery of quality services.5 the study showed that interpersonal skills are important in overcoming personal challenges, yet there was no formal training on such life skills. this is similar to the situation in ireland where research highlighted that interns received minimal training in personal life skills at the under graduate level.15 a survey done in new south wales also revealed low levels of training in interactional skills both prior to and during the intern year.9 an important work-related factor affecting training of interns is the everincreasing fear of occupational injury and medico-legal hazards. owing to the human immunodeficiency virus (hiv) pandemic in south africa, needle-stick injury and exposure to body fluids are scary and stressful experiences during internship training. the important influence of occupational and medico-legal hazards were demonstrated by 2 out of 7 respondents. the occurrence of such hazards is closely associated with extended work duration that was found to be common during internship.16 conclusion this study found that in order to achieve effective training, good quality supervisors, effective supervision, adequate opportunity to experiential learning, conducive environment, good support system (hospital management, hospital staff, academic opportunities), personal attributes and reasonable workload are essential factors. learning is impeded by poor supervision, inexperienced and indifferent supervisors, lack of opportunity to learn, poor support system, indiscipline, indifferent managers, lack of equipment, poorly organised academic sessions, unreasonable workload and the fear of occupational and medicolegal hazards. this training institution (and similar ones) is lacking in some of the factors conducive to effective training and needs to urgently implement steps to address this shortcoming. references 1. medical and dental professions board, health professions council of south africa, handbook on internship training. guidelines for interns, accredited facilities and health authorities [brochure]. pretoria: hpcsa, 2002. 2. mentjies y. the two year internship training. s afr med j 2003;93(5):336-337. 3. cameron d, blitz j, durrheim d. teaching young docs old tricks was aristotle right? an assessment of the skills training needs and transformation of interns and community service doctors working at a district hospital. s afr med j 2002;92(4):276. 4. mokhobo kp. intern training is the system crippled forever? s afr med j 1998;88(1):54-55. 5. classen l, mannie j, mashaphu j, et al. skills and competencies of interns and community service doctors. national department of health: maternal, child, women’s health and nutrition cluster. task team report. pretoria: doh, 2001. 6. pearson sa, rolfe i, smith t. factors influencing prescribing: an intern’s perspective. med educ 2002;36(8):781-787. 7. mateau tm, wynne g, kaye w, evans tr. resuscitation: experience without feedback increases confidence but not skill. bmj 1990;300:849-850. 8. barnsley l, lyon pm, ralston sj, et al. clinical skills in junior medical officers: a comparison of self reported confidence and observed competence. med educ 2004;38(4):358-367. 9. rouche am, sanson-fisher rw, cockburn j. training experiences immediately after medical school. med educ 1997;31(1):9-16. 10. shojana kg, fletcher ke, saint s. graduate medical education and patient safety: a busy — and occasionally hazardous — intersection. ann intern med 2006;145(8):592-598. 11. touyz rm, kelly a, tollman s, milne fj. an assessment of internship at the teaching hospitals of the university of the witswatersrand. s afr med j 1988;74(4):173-177. 12. ladrigan cp, rothschild jm, cronin jw, et al. effect of reducing intern’s work hours on serious medical errors in intensive care unit. n engl j med 2004; 351(18):1838-1848. 13. barger lk, ayas nt, cade be, et al. impact of extended duration shifts on medical errors, adverse events, and attention failures. plos med. 2006; 3(12):487. 14. thomas nk. resident burn out. j am med assoc 2004;292(23):2880-2889. 15. hannon fb. a national medical education needs assessment of interns and the development of an intern education and training program. med educ 2000;34(4):275-284. 16. ayas nt, barger lk, cade be, et al. extended work duration and the risk of self-reported percutaneous injuries in interns. jama 2006;296(9):1055-1062. 17. prinsloo eam. a two year internship programme for south africa. sa family practice 2005;47(5):3. 18. schurink em. the methodology of unstructured face to face interviewing. in: de vos as, ed. research at grass roots: a primer for the caring professions. pretoria: van schaik, 2001. june 2021, vol. 13, no. 2 ajhpe 140 research the backbone of a caring nurse is compassion, when nurses have feelings of empathy for the suffering of others and understand patients’ personal feelings or experiences without being judgemental.[1] as a result, nursing is particularly stressful,[2-4] as nurses not only cope with their personal stress but also with secondary forms of stress due to the nature of their interaction with patients and their families. nursing students may be more vulnerable to the harmful effects of secondary stress, as they are developing the skills necessary to fulfil their professional roles effectively.[5] they are also faced with academic stressors,[5-11] such as practical training  in environments characterised by high patient loads, insufficient resources and long working hours;[12] lack of professional knowledge and skills;[5] and unclear roles and responsibilities.[8,10] while nursing education fosters empathy and compassion in the student nurse to prepare them for their professional role of caring for others,[13] ongoing empathetic and compassionate behaviour and stress pave the way for burnout and compassion fatigue.[12,13] burnout is a combination of negative behavioural, attitudinal and physical changes in response to work-related stress.[14] burnout or compassion fatigue among nursing students may result in students failing to acquire the knowledge and skills  needed to care for their patients. this situation has a domino effect on  the quality of care, which could expose patients to healthcare-related risks.[15] with this in mind, this article describes the emotional wellbeing of undergraduate and postgraduate nursing students at a university in south africa (sa). wellbeing was defined by levels of emotional exhaustion, personal accomplishment, compassion satisfaction, compassion fatigue and perceived stress. more specifically, the objectives of the study were to: • describe levels of emotional exhaustion, personal accomplishment, compassion fatigue, compassion satisfaction and perceived stress experienced by nursing students • compare levels of emotional exhaustion, personal accomplishment, compassion satisfaction, compassion fatigue and perceived stress of undergraduate and postgraduate nursing students • determine the influence of compassion fatigue, perceived stress and disengaged coping on emotional exhaustion of undergraduate and postgraduate nursing students. methods design and sample a cross-sectional descriptive survey was undertaken at a purposively selected  sa university. there was a total of 685 registered under graduate (n=333) and postgraduate (n=352) nursing students at the university. four hundred  and seventy-one questionnaires (258 undergraduate and 213 postgraduate) were returned (68.8% response rate), of which 27 were discarded owing to extensive missing data, leaving a total  of  444  completed  questionnaires (252  undergraduate and 192 postgraduate). background. nursing students face dual stress from a combination of academic and clinical demands, which may affect their emotional wellbeing. poor emotional wellbeing may prevent them from gaining the necessary knowledge and skills to care for patients. objectives. to describe and compare levels of emotional exhaustion, personal accomplishment, compassion satisfaction, compassion fatigue and perceived stress of undergraduate and postgraduate nursing students, and to determine the influence of compassion fatigue, perceived stress and disengaged coping on emotional exhaustion. methods. this study was a cross-sectional descriptive survey at a purposively selected south african university. there were 685 students, of whom 471 (68.8%) completed the questionnaire, which comprised a biographical section, as well as standardised and validated scales. results. the respondents obtained a moderate score for perceived stress and were at average risk for emotional exhaustion and compassion fatigue. there were statistically significant differences between undergraduates and postgraduates on all scales, with undergraduates faring the worst. stress from assignments and workload, lack of professional knowledge and skills, teachers and nursing staff and compassion fatigue made a statistically significant contribution to the prediction of emotional exhaustion in undergraduates. compassion fatigue and stress from assignments and workload made a statistically significant contribution to the prediction of emotional exhaustion in postgraduates. conclusion. nursing students had moderate stress scores and were at average risk for emotional exhaustion and compassion fatigue, with undergraduate students faring the worst. schools of nursing should prioritise the emotional wellbeing of their students, particularly that of undergraduates. afr j health professions educ 2021;13(2):140-144. https://doi.org/10.7196/ajhpe.2021.v13i2.1300 factors associated with emotional exhaustion in undergraduate and postgraduate nursing students m engelbrecht,1 phd; m wilke,2 phd 1 centre for health systems research & development, faculty of the humanities, university of the free state, bloemfontein, south africa 2 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m engelbrecht (engelmc@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1300 mailto:engelmc@ufs.ac.za 141 june 2021, vol. 13, no. 2 ajhpe research data collection at the start of each class, students received an envelope with an information leaflet, consent form and questionnaire. the class co-ordinator allowed time for students who wished to participate in the study to complete the questionnaire. completed questionnaires and consent forms were returned in a sealed envelope. measures the first section of the questionnaire collected demographic and background information (e.g. sex, age, marital status, dependants, home language, place of residence, payment of university fees and year of study). the second section comprised the following standardised and validated scales: • the maslach burnout inventory, which assesses three dimensions of burnout, i.e. emotional exhaustion, depersonalisation and personal accomplishment.[14] reliability and validity were found acceptable for  sa nurses.[4] scoring for this scale is as follows: emotional exhaustion – low  score ≤18, average score 19 26, high score ≥27; depersonalisation – low score ≤5, average score 6 9, high score ≥10; and personal  accomplishment – low score ≥40, average score 39 40, high score ≤33.[14] • the professional quality of life (proqol) scale measures compassion fatigue, burnout and compassion satisfaction.[16] sa studies with nurses report good levels of internal consistency for two sub-scales, i.e.  compassion satisfaction and compassion fatigue.[17] for all scales, a low-risk cut-off score was set at a total sum of ≤22, between 23 and 41 for average risk, and ≥42 for high risk.[16] • the perceived stress scale measures stress from taking care of patients; teachers and nursing staff; assignments and workload; peers and daily life; lack of professional knowledge and skills; and clinical environment.[18] cronbach’s α of 0.87 was reported for the total scale among filipino nursing students.[5] the following cut-off points have been suggested: 2.67  4.00 for high levels of perceived stress; 1.34 2.66 for moderate levels of perceived stress; and 0 1.33 for low levels of perceived stress.[5,18] • the coping strategies inventory short form measures engaged and disengaged coping styles.[19,20] data analysis data were double captured, cleaned and analysed in spss version 25 (ibm corp., usa). descriptive statistics were generated yielding frequency counts and percentages for categorical variables, and means and standard deviations (sds) for continuous variables. composite scores were calculated for all sub-scales. cronbach’s α was used to test the internal consistency of the scales and sub-scales. the independent sample t-test was used to determine if there was a difference between undergraduate and postgraduate students on the mean scores for emotional exhaustion, personal accomplishment, compassion satisfaction, compassion fatigue, perceived stress and coping strategies. standard multiple regression was performed to predict emotional exhaustion for undergraduate and postgraduate nursing students from compassion fatigue, perceived stress and disengaged coping. ethical approval before data collection early in october 2018, ethical clearance was obtained from the ethics committee, faculty of economic and management sciences, university of the free state, bloemfontein (ref.  no.  ufs-hsd2017/1097). the various scales were purchased/accessed in line with their copyright agreements. results reliability analysis an α value of 0.7 is considered a sufficient measure of reliability.[21] therefore, scales with alpha <0.7 were eliminated from further analyses (table 1). biographical characteristics the majority of respondents were female (88.5%) and the average ages of undergraduates and postgraduates were 21.8 years and 37.1 years, respectively. two-thirds of postgraduates (67%) were married or in a longterm relationship compared with 30.9% of undergraduates. while most postgraduate students lived at home with family (61.8%), undergraduates mostly stayed in student houses off campus (37.7%) or at home (24.6%). two-thirds of postgraduates paid for their own studies (67.7%), while undergraduates reported having bursaries (44.6%) or their parents paid for their studies (37.8%) (table 2). perceived stress overall, nursing students obtained a moderate score on the perceived stress scale (mean (sd) 1.48 (0.61)). there was a statistically significant difference between undergraduates (1.72 (0.53)) who fell in the ‘moderate’ category, and postgraduates (1.15 (0.55)) who fell in the ‘low’ stress category (95% confidence interval (ci) 0.47 0.68; t(442)=11.094; p=0.000). a closer look revealed significant differences between undergraduate and postgraduate students on all sub-scales. more specifically, undergraduates had moderate scores on all sub-scales while postgraduates had low scores on stress from taking care of patients (0.87 (0.56)), lack of professional knowledge and skills (0.66 (0.76)), the environment (1.16 (0.78)) and teachers and nursing staff (1.06 (0.73)) (table 3). table 1. reliability of the scales scales items, n cronbach’s α maslach burnout inventory 22 emotional exhaustion 9 0.86 depersonalisation 5 0.55 personal accomplishment 8 0.76 professional quality of life 30 compassion satisfaction 10 0.85 burnout 10 0.63 compassion fatigue 10 0.75 perceived stress scale 29 0.93 stress from taking care of patients 8 0.80 stress from assignments and workload 5 0.85 stress from lack of professional knowledge and skills 3 0.92 stress from the environment 3 0.67 stress from peers and daily life 4 0.71 stress from teachers and nursing staff 6 0.81 coping strategies (short form) 16 engaged coping 8 0.76 disengaged coping 8 0.70 june 2021, vol. 13, no. 2 ajhpe 142 research burnout the student nurses scored an average of 24.83 (11.62) (range 0 - 54) on the emotional exhaustion sub-scale, indicating an average risk for burnout. there was a statistically significant difference in the mean emotional exhaustion scores between undergraduates (26.01 (10.87)) and postgraduates (23.28 (12.38)) (95% ci 0.56 4.91; t(442)=2.471; p=0.016). the mean scores  for undergraduates suggest that they were close to a high risk for emotional exhaustion, where scoring guidelines indicate that ≥27 is a high score.[14] at the other end of the spectrum, student nurses had a high score on personal accomplishment (26.35; 6.42; range 0 48). there was a statistically significant difference between undergraduates and postgraduates on feelings of personal accomplishment (95% ci ‒2.80 - ‒0.40; t(442)=‒2.623; p=0.009). postgraduates had a higher mean score on personal accomplishment (27.26 (6.53)) than undergraduates (25.66 (6.26)) (table 3). compassion fatigue and satisfaction an average of 24.03 (6.14) was scored on the compassion fatigue subscale, an indication of average levels. undergraduates scored higher on compassion fatigue (25.19 (5.8)) than postgraduates (22.51 (6.26)). this statistically significant difference (95% ci 1.56 3.82; t(442)=4.674; p=0.000) places undergraduates at an average risk and postgraduates at a low risk for compassion fatigue. average levels of compassion satisfaction were recorded (40.16 (6.34)), with a statistically significant difference between undergraduates (39.59; 6.67) and postgraduates (40.91 (5.81)) (95% ci ‒2.51 – ‒1.35; t(442)=‒2.189) (table 3). engaged coping the students had an overall mean score of 27.55 (5.12) for engaged coping. there was a statistically significant difference between postgraduates (28.66 (5.14)), who scored higher than undergraduates (26.71 (4.95)) (95% ci ‒2.90 – ‒1.00); t(424)=‒4.043; p=0.000). the mean score for disengaged coping was 23.44 (5.24), and differed significantly for undergraduates (24.83 (5.24)) and postgraduates (21.62 (5.21)) (95% ci 2.27 4.16); t(242)=6.716; p=0.000) (table 3). table 2. biographical information total (n=444), n (%) undergraduate (n=252), n (%) postgraduate (n=192), n (%) sex male 51 (11.5) 18 (7.1) 33 (17.2) female 393 (88.5) 234 (92.9) 159 (82.8) married/in a long-term relationship* 203 (46.5) 77 (30.9) 126 (67.0) place of residence† at home with family 180 (40.6) 62 (24.6) 118 (61.8) student house off campus 127 (28.7) 95 (37.7) 32 (16.8) rent accommodation off campus 75 (16.9) 36 (14.3) 39 (20.4) residence on campus 61 (13.8) 59 (23.4) 2 (1.0) payment of university fees‡ bursary 154 (35.2) 111 (44.6) 43 (22.8) self-funded 135 (30.8) 7 (2.8) 128 (67.7) parents pay 94 (21.5) 94 (37.8) student loan 55 (12.6) 37 (14.9) 18 (9.5) *n=440; n=188 (postgraduate). †n=443; n=191 (postgraduate). ‡n=438; n=249 (undergraduate); n=189 (postgraduate). table 3. descriptive statistics scales total, mean (sd) undergraduate, mean (sd) postgraduate, mean (sd) p-value maslach burnout inventory emotional exhaustion 24.83 (11.62) 26.01 (10.87) 23.28 (12.38) 0.016 personal accomplishment 26.35 (6.42) 25.66 (6.26) 27.26 (6.53) 0.009 professional quality of life compassion satisfaction 40.16 (6.34) 39.59 (6.67) 40.91 (5.81) 0.260 compassion fatigue 24.03 (6.14) 25.19 (5.80) 22.51 (6.26) 0.000 perceived stress scale 1.48 (0.61) 1.72 (0.53) 1.15 (0.55) 0.000 stress from taking care of patients 1.14 (0.62) 1.35 (0.58) 0.87 (0.56) 0.000 stress from assignments and workload 2.23 (0.96) 2.54 (0.87) 1.82 (0.90) 0.000 stress from lack of professional knowledge and skills 1.06 (0.86) 1.37 (0.80) 0.66 (0.76) 0.000 stress from the environment 1.36 (0.76) 1.52 (0.71) 1.16 (0.78) 0.000 stress from peers and daily life 1.71 (0.86) 1.98 (0.79) 1.36 (0.83) 0.000 stress from teachers and nursing staff 1.39 (0.78) 1.65 (0.72) 1.06 (0.73) 0.000 coping strategies (short form) engaged coping 27.55 (5.12) 26.71 (4.95) 28.66 (5.14) 0.000 disengaged coping 23.44 (5.24) 24.83 (4.83) 21.62 (5.21) 0.000 143 june 2021, vol. 13, no. 2 ajhpe research prediction of emotional exhaustion multiple regressions were run to predict emotional exhaustion in undergraduate and postgraduate nursing students from stress from taking care of patients; assignments and workload; lack of professional knowledge and skills; the environment; peers and daily life; teachers and nursing staff; as well as compassion fatigue and disengaged coping (tables 4 and 5). the assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality residuals were met. for undergraduate nursing students (table  4), these variables were statistically significant in predicting emotional exhaustion (f(9.243)=1.517; p=0.000; adjusted r2=0.358). compassion fatigue (t=5.587; p=0.000), stress  from assignments and workload (t=6.020; p=0.000), stress from lack of professional knowledge and skills (t=‒2.837; p=0.005) and stress from teachers and nursing staff (t=2.531; p=0.012) made a statistically significant unique contribution to the prediction of emotional exhaustion. stress from assignments and workload (β=0.412) was the highest predictor of emotional exhaustion, followed by compassion fatigue (β=0.314) and stress from teachers and nursing staff (β=0.159). for postgraduate nursing students, these variables were statistically significant in predicting emotional exhaustion (f(8.183)=9.954; p=0.000; adjusted r2=0.273) (table  5). compassion fatigue (t=4.470; p=0.000) and stress from assignments and workload (t=3.289; p=0.001) made a statistically significant unique contribution to the prediction of emotional exhaustion. compassion fatigue (β=0.310) was the highest predictor of emotional exhaustion, followed by stress from assignments and workload (β=0.249). discussion university students in general,[8,22] and nursing students in particular,[5-11] experience numerous stressors during their academic life, which affect their emotional wellbeing. this is the first cross-sectional study investigating and comparing the emotional wellbeing of undergraduate and postgraduate nursing students in sa. overall, we found that nursing students had moderate stress scores and were at average risk for emotional exhaustion and compassion fatigue. more specifically, undergraduate students had higher levels of perceived stress, compassion fatigue and emotional exhaustion than postgraduate students. in his research, labrague[5] found that senior nursing students have less stress than junior students. a possible explanation is that, as students obtain more experience, they perceive less stress. it is, however, important to keep in mind that academic and occupational stress is inevitable, even necessary at times, but it should not need to lead to dysfunction. this can be avoided if preventive stress management and enhanced wellbeing strategies are in place. in this regard, the scores on perceived stress, compassion fatigue and emotional exhaustion suggest that nursing students may not have appropriate stress management strategies. more specifically, undergraduates, with higher scores on emotional exhaustion, compassion fatigue and perceived stress, also scored higher on disengaged coping, a negative strategy that sees the individual not sharing their feelings with others, avoiding thoughts about situations and not initiating behaviours that could change the situation. however, postgraduate students, who had lower levels of emotional exhaustion, compassion fatigue and perceived stress, scored higher on engaged coping, which is a positive strategy that sees the individual engage in active and ongoing negotiation with the stressful event.[19] while research suggests that coping mechanisms have a great influence on the occurrence of burnout,[23] we did not find a significant association  between type of coping strategy and emotional exhaustion in undergraduate or postgraduate students. further research is necessary to inform strategies to prevent burnout in nursing students. significant predictors of emotional exhaustion among undergraduates were increased levels of compassion fatigue and stress from assignments and workload, as well as teachers and nursing staff. the finding that a decrease in stress from lack of professional knowledge and skills led to an increase in emotional exhaustion requires further research for clarification. emotional exhaustion in postgraduates was significantly predicted by compassion table 4. standard multiple regression analysis related to the prediction of emotional exhaustion in undergraduate nursing students independent variables b standard error β t p-value compassion fatigue 0.588 0.105 0.314 5.587 0.000 stress from taking care of patients ‒0.616 1.261 ‒0.033 ‒0.488 0.626 stress from assignments/workload 5.130 0.852 0.412 6.020 0.000 stress from lack of professional knowledge/skills ‒2.398 0.845 ‒0.177 ‒2.837 0.005 stress from the environment 0.104 0.918 0.007 0.114 0.910 stress from peers and daily life ‒1.040 0.982 ‒0.075 ‒1.059 0.291 stress from teachers and nursing staff 2.576 1.018 0.171 2.531 0.012 disengaged coping ‒0.055 0.127 ‒0.024 ‒0.433 0.666 table 5. standard multiple regression analysis related to the prediction of emotional exhaustion in postgraduate nursing students independent variables b standard error β t p-value compassion fatigue 0.656 0.147 0.331 4.470 0.000 stress from taking care of patients ‒2.500 1.853 ‒0.114 ‒1.349 0.179 stress from assignments/workload 3.514 1.069 0.257 3.289 0.001 stress from lack of professional knowledge/skills ‒1.337 1.288 ‒0.082 ‒1.038 0.301 stress from the environment 0.478 1.257 0.030 0.380 0.704 stress from peers and daily life 1.689 1.246 0.113 1.355 0.177 stress from teachers and nursing staff 0.930 1.433 0.055 0.649 0.517 disengaged coping 0.119 0.163 0.050 0.773 0.465 june 2021, vol. 13, no. 2 ajhpe 144 research fatigue and stress from assignments and workload. according to rudman and gustavsson,[24] increased levels of emotional exhaustion experienced during nurse education could have a sustained effect on an individual’s health when entering professional working life. following this line of reasoning, if studies are academically and practically (i.e. clinical training) demanding, it is also more likely that considerable resources will be needed to assist students to cope with the situation and recover from energy loss. therefore, it is recommended that nursing educators take cognisance of the need to introduce effective and preventive measures to manage burnout – already at the outset of nursing education. in this regard, demir et  al.[25] found that a peer mentoring intervention, where fourth-year nursing students mentored first-year nursing students, improved the ability of those in their first year to cope with stress. in line with this, and based on our findings, nursing schools should consider using postgraduate students, who seem to be doing better emotionally and who cope better with stress and emotional exhaustion. clinical peer mentorship programmes are already in place at nursing schools and have been found to benefit mentors and mentees,[26,27] and could be extended to include aspects of emotional wellbeing. this reciprocal relationship would then also benefit postgraduate students, who despite being at lower risk for emotional exhaustion still experienced this to a degree. study limitations the study was conducted at one university among a convenience sample of undergraduate and postgraduate nursing students. we did, however, reach 68.8% of the total group of nursing students at the university. nonetheless, the results  cannot be generalised to other university settings. our questionnaires were self-administered and, as with most self-reported measures, some level of response bias is likely. it could be helpful to supplement survey data with  other data sources. finally, we collected our data towards the end of the year, which could also have influenced the findings, as exams were approaching. conclusion overall, we found that nursing students had moderate stress scores and were at average risk for emotional exhaustion and compassion fatigue. there were  significant differences between undergraduate and postgraduate students in terms of perceived stress, emotional exhaustion and compassion  fatigue. it is evident that nursing schools should include a component focusing on the emotional wellbeing of their students, particularly undergraduate students. in this regard, peer mentorship of undergraduates by postgraduates should be considered. further research is required to investigate the link between coping strategies and burnout, as this will be key to informing the type of assistance that should be available for nursing students. declaration. none. acknowledgements. none. author contributions. me and mw designed the study and research instruments. me analysed the data and prepared the manuscript. mw gave inputs on the manuscript. both authors approved the final version for submission. funding. university of the free state (interdisciplinary grant). conflicts of interest. none. 1. williams j, stickley t. empathy and nurse education. nurse educ today 2010;30(8):752-755. https://doi. org/10.1016/j.nedt.2010.01.018 2. dlamini bc, visser m. challenges in nursing: the psychological needs of rural area nurses in mpumalanga. remed open access 2017;2:1068. 3. khamisa n, oldenburg b, peltzer k, ilic d. work related stress, burnout, job satisfaction and general health of nurses. int j environ res public health 2015;12(1):652-666. https://doi.org/10.3390/ijerph120100652 4. van der colff jj, rothmann s. occupational stress of professional nurses in south africa. j psychol afr 2014;24(4):375-384. https://doi.org/10.1080/14330237.2014.980626 5. labrague lj. stress, stressors, and stress responses of student nurses in a government 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inventory short-form (csi-sf) in the jackson heart study cohort. int j environ res public health 2007;4(4):289-295. https://doi.org/10.3390/ijerph200704040004 21. taber ks. the use of cronbach’s alpha when developing and reporting research instruments in science education. res sci educ 2018;48:1273. https://doi.org/10.1007/s11165-016-9602-2 22. leppink ew, odlaug bl, lust k, christenson g, grant je. the young and the stressed: stress, impulse control, and health in college students. j nerv ment dis 2016;204(12):931-938. https://doi.org/10.1097/ nmd.0000000000000586 23. cumbe vfj, pala an, palha ajp, et al. burnout syndrome and coping strategies in portuguese oncology health care providers. arch clin psychiatry 2017;44(5):122-126. https://doi.org/10.1590/0101-60830000000135 24. rudman a, gustavsson jp. burnout during nursing education predicts lower occupational preparedness and future clinical performance: a longitudinal study. int j nurs stud 2012;49(8):988-1001. https://doi.org/10.1016/j. ijnurstu.2012.03.010 25. demir s, demir sg, bulut h, hisar f. effect of mentoring program on ways of coping with stress and locus of control for nursing students. asian nurs j 2014;8(4):254-260. https://doi.org/10.1016/j.anr.2014.10.004 26. mlaba zp, emmamally w. describing the perceptions of student nurses regarding barriers and benefits of a peermentorship programme in a clinical setting in kwazulu-natal. health sa gesondheid 2019;24:a1118. https:// doi.org/10.4102/hsag.v24i0.1118 27. joubert a, de villiers j. the learning experiences of mentees and mentors in a nursing school’s mentoring programme. curationis 2015;38(1):1145. https://doi.org/10.4102/curationis.v38i1.1145 accepted 29 july 2020. https://doi.org/10.1016/j.nedt.2010.01.018 https://doi.org/10.1016/j.nedt.2010.01.018 https://doi.org/10.3390/ijerph120100652 https://doi.org/10.1080/14330237.2014.980626 https://doi.org/10.5455/annalsmedres.2018.06.108 https://doi.org/10.7196%2fajhpe.2018.v10i2.993 https://doi.org/10.7196%2fajhpe.2018.v10i2.993 https://doi.org/10.1016/j.nedt.2017.09.008 https://doi.org/10.1016/j.nepr.2016.11.002 https://doi.org/10.1016/j.ijnurstu.2016.08.010 https://doi.org/10.1080/14330237.2012.10820554 https://doi.org/10.4102/curationis.v40i1.1784 https://doi.org/10.1186/1472-6955-13-9 http://www.compassionfatigue.org/pages/proqolmanualoct05.pdf https://doi.org/10.1016/j.ijans.2018.03.004 https://doi.org/10.1016/j.ijans.2018.03.004 https://doi.org/10.1016/s0020-7489(01)00016-5 https://doi.org/10.1016/s0020-7489(01)00016-5 https://doi.org/10.3390/ijerph200704040004 https://doi.org/10.1007/s11165-016-9602-2 https://doi.org/10.1097/nmd.0000000000000586 https://doi.org/10.1097/nmd.0000000000000586 https://doi.org/10.1590/0101-60830000000135 https://doi.org/10.1016/j.ijnurstu.2012.03.010 https://doi.org/10.1016/j.ijnurstu.2012.03.010 https://doi.org/10.1016/j.anr.2014.10.004 https://doi.org/10.4102/hsag.v24i0.1118 https://doi.org/10.4102/hsag.v24i0.1118 https://doi.org/10.4102/curationis.v38i1.1145 november 2020, vol. 12, no. 4 ajhpe 197 research skills laboratory training for nurses is an educational intervention that assists nursing students to become experts in performing clinical skills in a clinical context – it enhances their critical thinking when they provide patient care. clinical laboratory sessions or simulations are conceptualised as a concentrated, individualised effort to improve the performance of a specific skill.[1] simulation is the reproduction approach of the essential features of a real-life situation and provides students with a learning opportunity regarding clinical and decision-making skills.[2] however, the approach can be categorised as low-fidelity and high-fidelity simulations.[3] although nurse educators strive to mirror real situations in their skills laboratories using low-fidelity simulation, they often find that nursing students do not have the imaginative attitude necessary to visualise a dummy model as a real patient. consequently, students frequently experience difficulty in making the transition from skills laboratory learning to real-patient situations in the clinical area. to facilitate this transition, nursing education institutions now use computerised simulation of high-fidelity medical simulations to facilitate clinical learning under the correct conditions, i.e. simulation-based nursing education.[4] notably, first-level students in all healthcare professions, including nursing, do not have training for handling patients before they start their university programmes. therefore, clinical laboratory sessions are a suitable way to teach nursing students how to deal with real-life situations.[5] imran et al.[6] maintain that it is important for students to acquire clinical skills in the skills laboratory, thus making such sessions the best option to assist health professional students to acquire clinical skills before being exposed to real-life settings.[6] these sessions serve to improve clinical acumen and understanding, as well as to enhance the competency of their clinical skills in healthcare settings. skills laboratory sessions also assist students to be efficient and effective when they are placed in hospital settings, as they can provide quality care to patients, based on the orientation acquired from the sessions.[5] however, students’ effectiveness in the given sessions depends on the role played by clinical lecturers. the duties of clinical skills laboratory lecturers include planning and organising of teaching sessions, designing a learning programme and evaluating programmes to ascertain that the objectives have been met. clinical skills laboratory lecturers are also expected to develop study materials, including study guides for skills training, to demonstrate clinical skills to students and to assess students regarding these skills, to measure their performance and to keep records as required.[7-9] lӧfmark et al.[10] point out that students gained greater independence through clinical learning. nursing education institutions have to design and implement clinical learning activities that provide students with opportunities to develop their practical skills and, at the same time, to incorporate patient safety principles.[11,12] the clinical skills laboratory of the department of nursing science, university of limpopo, south africa (sa) was established in 2010 to provide a conducive learning area for undergraduate nursing students, using demonstrations, simulations and role modelling. furthermore, the skills laboratory provides voluntary practice sessions across all background. skills laboratory training is used as a teaching strategy to assist nursing students in developing clinical skills. this educational intervention assists nursing students to develop expertise in clinical skills to ensure the safe care of patients. since the establishment of a new skills laboratory, the department of nursing science, university of limpopo, south africa has not evaluated the impact of the laboratory on the clinical learning of nursing students. objective. to explore and describe the impact of clinical skills laboratory sessions on undergraduate students in the department. methods. qualitative, descriptive research explored the impact of skills laboratory sessions on undergraduate students. purposive sampling was used to select participants for the study. unstructured one-on-one interview sessions were conducted and 12 students were interviewed until data saturation was reached. thematic content was used for data analysis. results. three themes emerged: the impact of skills laboratory sessions on undergraduate nursing students; the existing benefits of skills laboratory learning sessions; and the importance v. insignificance of laboratory skills lecturers in clinical teaching. conclusion. the study revealed that the clinical skills laboratory has a positive, diverse impact on the clinical learning of nursing students. the sessions should be integrated into the curriculum, as they aid in translating theory into practice. nursing institutions must have a clinical skills laboratory, as they prepare student nurses for learning in a clinical area. afr j health professions educ 2020;12(4):197-200. https://doi.org/10.7196/ajhpe.2020.v12i4.1375 the emergence of a clinical skills laboratory and its impact on clinical learning: undergraduate nursing students’ perspective in limpopo province, south africa t m mothiba, phd; m a bopape, mcur; m o mbombi, bnurs, mcur department of nursing science, faculty of health sciences, university of limpopo, polokwane, south africa corresponding author: m o mbombi (masenyani.mbombi@ul.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 198 november 2020, vol. 12, no. 4 ajhpe research modules of the nursing programme – general nursing science, community nursing science, psychiatric nursing science and midwifery. for example, simulation lessons for nursing students might include insertion of an intravenous line or indwelling urinary catheter on a manikin or a demonstration of a vaginal delivery of a newborn. furthermore, the effective simulations of all modules are achieved by dividing nursing students into groups of 5 6, which are spread across the 10 cubicles of the skills laboratory and closely monitored by 2 nurse educators. the skills laboratory gained its momentum for effective clinical skills learning when the department purchased low-fidelity manikins in 2014. since its establishment, the department has not evaluated the impact of the new skills laboratory on clinical learning among nursing students, while the department continues to use low-fidelity simulations for clinical demonstrations. viewed from this perspective, the study was undertaken to explore and describe the impact of clinical skills laboratory sessions on undergraduate students in the department of nursing science at the university of limpopo. methods qualitative, descriptive research was used, as this approach examines human experience from the viewpoint of research participants. qualitative research enabled the authors to interpret and improve their understanding of the impact of skills laboratory sessions on undergraduate students, as the latter gave descriptions of the questions that the authors asked through the exploratory design.[13,14] population and sampling the study was conducted among students registered for the bachelor of nursing science degree with the department of nursing science at the university of limpopo for the academic year 2017. purposive sampling was used, based on the judgement of the researchers, to select participants who would represent the student population for the interview sessions.[13] authors employed purposive sampling to select thirdand fourth-level nursing students with good attendance in the skills laboratory. these students were selected because of their clinical exposure level, i.e. whether they were exposed to clinical learning with/without a skills lab in the department of nursing science. data collection unstructured one-on-one interview sessions were conducted with 12 students. during these sessions, the main question asked was: ‘can you kindly describe the impacts of skills laboratory sessions that are conducted for you as a student nurse?’ field notes were written and a voice recorder was used to capture all interview sessions.[14,15] data analysis tesch’s open-code qualitative data technique was applied for data analysis, following the steps outlined by creswell.[16] the data were organised, transcribed verbatim and coded. categories, themes and sub-themes were generated. measures to ensure trustworthiness trustworthiness was ensured by adhering to credibility, confirmability, dependability and transferability. these measures confirm the value of the study and substantiate the researchers’ honesty, truthfulness and loyalty to the participants during the research process. credibility was ensured by interviewing the students and recording all the interview sessions until data saturation. confirmability was ensured by submission of transcribed data to the independent coder for analysis, and a discussion session was set for the researchers and the independent coder to reach an agreement on codes that were found independently. dependability was ensured by the writing of field notes and the use of a voice recorder to capture all interview sessions. transferability was established by describing the research methods followed throughout the study.[17] ethical approval ethical approval was obtained from the university of limpopo turfloop research ethics committee (ref. no. trec/186/2016). permission to conduct the study was obtained from the department of nursing science, faculty of health sciences, university of limpopo. informed consent was obtained from all participants before the interview sessions. participants were made aware of their right to autonomy, confidentiality, anonymity and privacy. data will be kept in a password-encrypted computer document for a period of 5 years. results and discussion the findings of the study are summarised in table 1. the themes and subthemes reflect the impact of skills laboratory sessions on undergraduate nursing students of the university of limpopo. theme 1: description of diverse learning opportunities and the skills laboratory the nursing students reported that the skills laboratory provides diverse learning opportunities regarding clinically related contents. the students table 1. themes and sub-themes that reflect the impact of skills laboratory sessions on undergraduate nursing students, university of limpopo, south africa themes sub-themes 1. description of diverse learning opportunities on the skills laboratory 1.1 skills laboratory sessions aid in translating theory into practice 1.2 acquisition of knowledge related to medical equipment used in the clinical area 1.3 a conducive area to learn more about clinical skills 2. benefits of skills laboratory learning sessions 2.1 skills laboratory sessions described as an orientation to clinical contents 2.2 skills viewed as a way of eliminating fear and anxiety 3. description of the clinical lecturers’ role in the skills laboratory 3.1 clinical lecturers viewed as important in clinical teaching 3.2 dissatisfaction regarding clinical lecturers who provide clinical teaching during students’ rest time november 2020, vol. 12, no. 4 ajhpe 199 research had different views on skills laboratory sessions and the facilitators, which are interpreted according to the following three sub-themes. sub-theme 1.1: skills laboratory sessions aid in translating theory into practice the findings reveal that during skills laboratory sessions the students can translate theory into practice. this was supported by one of the participants: ‘what is being taught in class is sometimes not easy to understand because it is just something that is written in the book, but when we attend skills laboratory sessions we can understand how the theory is being translated into practice.’ another participant with the same view stated: ‘when something is demonstrated practically [it] is easier to understand than having a theory in mind that you cannot be able to apply it anywhere.’ the use of clinical simulation in nursing education provides many opportunities for students to learn and apply the theoretical principles of nursing care in a safe environment.[18] sub-theme 1.2: acquisition of knowledge related to medical equipment used in the clinical area the findings demonstrate that the skills laboratory sessions provide an opportunity for students to acquire knowledge related to the equipment used in the clinical area. the participants clarified as follows: ‘the skills laboratory sessions expose us to some of the equipment that is utilised in the hospital area, such as needles, syringes, suturing pack, urinary catheter, bedpan, body mass scale, apparatus for urinalysis, etc.’ a participant stated: ‘when we go to the practical area things become easy as we are already familiar with the equipment that is in used in the hospital.’ simulation offers many advantages to nursing education, e.g. the clinical setting can be realistically simulated, and there is no threat to patient safety, as during simulation the correct equipment is used so that demonstrations of practical skills can be well presented.[19] sub-theme 1.3: a conducive area to learn more about clinical skills the majority of participants indicated that the skills laboratory improves their clinical knowledge, as it provides a conducive area for them to learn about clinical contents. the skills laboratory impacts positively on their learning, because it assists in executing clinical tasks: ‘being taught a skill in the skills laboratory helps me to improve the level of knowledge i have acquired and makes the clinical area a place that i can be able to carry out my duties diligently.’ another participant indicated that: ‘it prepares us because we have done the procedures in the laboratory sessions and so when we go to the practice setting we know what to expect and what to do.’ findings show that using simulations is perceived to be a valuable method of learning, which should positively impact the clinical effectiveness of nursing students approaching the transition to registered nurses.[18,19] theme 2: benefits of skills in laboratory learning sessions the findings indicate that skills laboratory sessions have several benefits for students. sub-theme 2.1: skills laboratory sessions described as an orientation to clinical skills skills laboratory sessions are viewed as part of the clinical skills orientation of students to empower them to perform the required skills competently in a clinical setting. this was confirmed by a participant: ‘the skills laboratory sessions orientate us to certain skills that are done in the hospital, such as bed making, taking vital signs, suturing, and many other things, and these sessions assist us so that when we arrive in the hospital we perform those skills as expected.’ another participant maintained: ‘the skills laboratory sessions are very helpful because it orientates us to the clinical skills that are being performed at the hospital and prevents us from being completely blank and helpless; it therefore reduces frustration when we are allocated in the hospital wards.’ a participant shared the same view: ‘the skill laboratory sessions make us competent because the clinical skills are repeatedly demonstrated and as students we are then assessed on those skills to ensure our competency before applying the skills in real-life situations.’ simulation has become more integrated into nursing education in the past 20 years. it is fully integrated into the development of clinical skills for student nurses so that they can be competent when practising. the benefits of skills laboratory sessions, such as simulations, have been discussed by other authors, and are a significant process for the clinical learning of students.[19,20] sub-theme 2.2: simulated skills viewed as a way of eliminating fear and anxiety the attendance of clinical skills laboratory sessions assists students to dispel fear and anxiety when they are required to perform procedures on real patients in nursing care units. one student confirmed: ‘being trained beforehand about the things that we are going to experience during our practical allocation in hospital, eliminates anxiety and makes us be prepared for that particular event or skill in the hospital. the laboratory skills sessions help us overcome fear.’ the findings are congruent with the those of other authors.[2,20-23] for example, becker et al.[23] indicated that a potential strategy to minimise anxiety and fear in the clinical setting is by preparation of undergraduate nursing students during their laboratory skills training. the students are trained to portray an illness or a scenario while interacting with other students to create a realistic, low-risk learning experience.[21] 200 november 2020, vol. 12, no. 4 ajhpe research theme 3: description of the clinical lecturers’ role in the skills laboratory the role of clinical lecturers in the clinical skills laboratory is to assist students in mastering such skills. when these students are placed in hospital wards, they will not experience problems or make mistakes while taking care of patients. sub-theme 3.1: clinical lecturers viewed as important in clinical teaching confidence is a necessity that students cannot obtain on their own regarding the competent performing of clinical skills. students state that clinical lecturers are important initiators of the confidence they desire in their learning. the following excerpts support these results: ‘with the demonstration of the skills by clinical laboratory lecturers, we know what to do at the clinical area. it is easier to do clinical skills because they were demonstrated before. like when you are busy doing it in the clinical areas you will recall what the lectures have said and done.’ a participant outlined the importance of clinical lecturers: ‘every time i do skills in the practical area, i feel confident because i know what to do and for me, this emerged from the fact that the clinical lecturers were there to create this confidence by demonstrating through simulation the skills.’ the findings are congruent with those of other authors.[20,21,24] for example, porter et al.[24] indicate that self-confidence is a key component of effective clinical performance and is instilled by laboratory lecturers. confident students are more likely to be effective and competent nurses. clinical exposure plays an important role in students’ skills acquisition so that they can succeed in the clinical area.[20] sub-theme 3.2: dissatisfaction regarding clinical lecturers who provide clinical teaching during students’ rest time nursing students were unhappy with clinical lecturers who assume the clinical teaching role during students’ rest time. one of the participants maintained: ‘skills laboratory sessions consume our time, as sometimes some of them call us during the weekend for clinical lectures. that is our time to catch up with our studies and also to rest for the following week so that we can be effective. weekends are meant for us to study and rest.’ in contrast, the study conducted by porter et al.[24] indicates that students are willing and prepared to be placed in the skills laboratory for clinical learning, which results in building the confidence necessary to perform in healthcare settings. study limitations some of the participants were uneasy about giving their honest opinion, as the interview sessions were recorded and might have influenced the findings of the study. also, given the nature of the study, only a small sample was included. there was no triangulation of data. quantitative research is warranted to examine the impact of clinical skills laboratory sessions on undergraduate nursing students, involving a larger sample and students in other sa universities. conclusion this study indicates that students received the emergence of the skills laboratory as a positive establishment in the department of nursing science, which enabled them to gain different clinical learning experiences. clinical skills laboratory sessions should be integrated into the curriculum, as these aid in translating theory into practice. the sessions orientate students regarding clinical skills, eliminate fears of clinical practice, familiarise them with equipment used in clinical practice, and enhance the confidence of learner nurses. nursing institutions must incorporate clinical skills laboratory sessions because they prepare student nurses for learning in a practical setting. declaration. none. acknowledgements. we acknowledge all learner nurses who participated in this study to make it a success. we also acknowledge the efforts of final-year nursing students of the university of limpopo, who assisted in data collection. author contributions. mom assisted in the initial conceptualisation and the finalisation of the manuscript. tmm assisted in the second draft and refinement of the manuscript. mab assisted with writing the methodology and finalisation of the manuscript for publication. funding. none. conflicts of interest. none. 1. ericsson ka. deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. acad med 2004;79(10 suppl):s70-s81. https://doi.org/10.1097/00001888-200410001-00022 2. kim j, park j, shin s. effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis. bmc med educ 2016;16:152. https://doi.org/10.1186/s12909-016-0672-7 3. medley cf. using simulation technology for undergraduate nursing education. j nurs educ 2005;44(1):31-40. 4. 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https://doi.org/10.3928/01484834-20060401-03 https://doi.org/10.2147%2famep.s42157 10 april 2021, vol. 13, no. 1 ajhpe short communication early-career academics, apart from formal training in the conduct of research at undergraduate and graduate levels, develop individual research capacity principally ‘on the job’.[1-3] research leadership capacity entails research leadership skills development, supervision and mentorship, multidisciplinary team collaborations, grant-writing skills, research career pathing, publication in high-impact journals and dissemination of important research projects and outcomes to policymakers and other stakeholders. developing research innovation, localisation and leadership (drill) programme the drill programme at the university of kwazulu-natal (ukzn), durban, south africa, nurtures a selected talented group of early-career researchers (drill fellows) and is a move towards active, focused development of research leadership capacity and research. in this regard, the shift has been from a more unstructured (laissez-faire) to an increasingly structured and managed (contractual and directed) mode of research supervision and mentorship. the key objectives are: • to capacitate, train and produce, after 5 years, at least 20 research leaders in health, including early-career academics at ukzn and selected personnel from the kzn department of health (doh) • to build the eligibility and increase the likelihood of retention of these trained scientists at ukzn and the kzn doh as a pool of highly skilled researchers on an accelerated research leadership trajectory • to develop skills of mentorship and supervision in these drill fellows to identify, inspire, train and support emerging research talent and build thematic communities of practice. outcomes the drill programme is currently active. an empirical evaluation will be conducted and published at the end of the grant period. two multidisciplinary cohorts of 10 fellows were enrolled in the programme in october 2016 and 2017, respectively. the high visibility and perceived impact of the programme resulted in a surplus of interested and appropriate candidates. we managed to enrol an unplanned third cohort (5 fellows) in 2019, which was made possible owing to unexpected exchange rate  improvements in our financial resources. more females have been enrolled (table 1). research leadership development of these fellows is provided in the form of technical, scientific and research ethics competence, a dedicated, drill: an innovative programme to develop health research leadership in kwazulu-natal, south africa f suleman,1 bpharm, mpharm, phd; d wassenaar,2 ba hons, ma (clin psych), phd; n nadesanreddy,3 mb chb, fcphm, mmed (public health medicine); p brysiewicz,4 bsocsc, ba, mcur, phd 1 discipline of pharmaceutical sciences, college of health sciences, westville campus, university of kwazulu-natal, durban, south africa 2 discipline of psychology, school of applied human sciences, university of kwazulu-natal, durban, south africa 3 developing research, innovation, localisation and leadership (drill) programme, college of health sciences, university of kwazulu-natal, durban, south africa 4 discipline of nursing, school of nursing and public health, university of kwazulu-natal, durban, south africa corresponding author: f suleman (sulemanf@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. table 1. demographic profile of drill fellows by cohort demographic variable total, n cohort 1, n cohort 2, n cohort 3, n gender male 7 3 3 1 female 18 7 7 4 race/ethnic group* black 11 5 3 3 white 2 1 1 0 indian 9 2 6 1 coloured 3 2 0 1 place of employment ukzn (academic) 20 10 5 5 kzn doh (clinical) 5 0 5 0 stage of research phd 10 1 6 3 post-doc 15 9 4 2 age, years <40 14 4 6 4 ≥40 11 6 4 1 scientific track health professions education 5 2 2 1 health systems strengthening 7 3 3 1 hiv/aids 6 3 3 0 mental health 5 2 1 2 health research ethics 2 0 1 1 discipline physiotherapist 3 2 1 0 optometrist 3 1 2 0 pharmacist 2 1 1 0 nurse 3 1 2 0 medical specialist 4 1 3 0 physiologist 2 2 0 0 neuroscientist 2 2 0 0 anatomist 2 0 1 1 psychologist 2 0 0 2 audiologist 1 0 0 1 sports scientist 1 0 0 1 drill = developing research innovation, localisation and leadership; ukzn = university of kwazulu-natal; doh = department of health. *described as per south african census data variables. april 2021, vol. 13, no. 1 ajhpe 11 short communication well-resourced and supportive environment, and systematic supervision and mentoring from established locally based research leaders. drill fellows are required to maintain a research portfolio comprising 6 components: an individual development plan (to document activities for reporting back to our funder); a reflective journal (to allow for deliberation on their career path, goals and reflective practice); research competencies (skills and competencies acquired); health communication and social media engagement (communicating research to the lay media); a teaching portfolio; and preparation for formal rating by our national research council. writing and communication skills are also integral, especially the production of articles in high-impact publications. conclusions although empirical data are currently being collected for future analysis and publication, we believe that drill is a unique, comprehensive research leadership programme that will help our institution and the region to maintain its national and international standing as a leader in high-impact evidence-based solutions to pressing regional health problems. declaration. none. acknowledgements. the authors acknowledge support from prof. j burns, initial principal investigator of drill, prof. m moshabela and dr s ramlall, members of the drill leadership team and the kzn doh. author contributions. all authors contributed to: (i)  conception and design of the programme; (ii) drafting or critical revision of the article for intellectual content; and (iii) approval of the version to be published. funding. the drill project is supported by the fogarty international center (fic), national institutes of health (nih) common fund, office of strategic coordination, office of the director (od/osc/cf/nih), office of aids research, office of the director (oar/nih), national institute of mental health (nimh/nih) of the national institutes of health under award number d43tw010131 (under the scientific areas of hiv/aids, mental health, health professions education, health research ethics and health systems research). the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. conflicts of interest. none. 1. lalloo u, bobat ra, pillay s, et  al. a strategy for developing future academic leaders for south africa in a resource-constrained environment. acad med 2014;89(8). https://doi.org/10.1097/acm0000000000000354 2. uthman ga, wiysonge cs, ota mo, et al. increasing the value of health research in the who african region beyond 2015 – reflecting on the past, celebrating the present and building the future: a bibliometric analysis. bmj open 2015;5:e006340. https://doi.org/10.1136/bmjopen-2014-006340 3. chu km, jayaraman s, kyamanywa p, et  al. building research capacity in africa: equity and global health collaborations. plos med 2014;11(3):e1001612. https://doi.org/10.1371/journal.pmed.1001612 accepted 27 july 2020. afr j health professions educ 2021;13(1):10-11. https://doi.org/10.7196/ajhpe.2021. v13i1.1422 https://doi.org/10.1097/acm0000000000000354 https://doi.org/10.1136/bmjopen-2014-006340 https://doi.org/10.1371/journal.pmed.1001612 june 2020, vol. 12, no. 2 ajhpe 68 research simulation is in widespread use for professional health education; however, by itself, it is not a guarantee that adequate learning will occur. simulation has  to be integrated with the outcomes of the curriculum, applicable simulation modalities have to be used, the learning environment must be conducive to education and training, and the features and uses of simulation have to be optimally and correctly incorporated into the training programme.[1] to revolutionise medical education, an increased efficiency of education by standardising the curriculum, an individualisation of education and a shift from time-based training to competency-based training are essential.[2] residents (registrars/specialists in training) may receive little guidance in terms of the knowledge, competencies, skills and attitudes that they are expected to acquire during residency. surgical training in the 21st century is characterised by an increasingly objective, standardised approach using equipment such as simulators to optimise patient safety, surgical care and hospital resources, and to minimise errors.[3] the driving forces behind this are developments in medical error statistics, evidence-based medicine and fewer attending hours. through increased accuracy, simulation can improve results and lower risk and procedure cost because of fewer procedures and less operating room time.[3] the accreditation council for graduate medical education (acgme) and the american board of medical specialties (abms) identify six core competencies for residents: patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism and systems-based practice.[4] a joint initiative of the acgme and abms, the plastic surgery milestone project, compiled descriptors and targets for residents’ performance, based on the abovementioned core competencies. these descriptors and targets (outcomes) are categorised at five training levels, starting at level 1, where the resident demonstrates the mastering of milestones expected of an incoming resident, moving up to level 5, where the resident has advanced beyond performance targets set for residency and can graduate.[5] simulation represents a safe and standardised postgraduate training method, and provides a yardstick for gauging residents’ ability to perform certain procedures, surgery and teamwork in a clinical setting.[4] the american college of surgeons (acs) introduces simulation in training and education for general surgery in three phases, i.e. skills training, procedure training and team training. plastic surgery should follow this simulation initiative with modifications appropriate to the specialty.[4] phase 1, skills, is included in the residents’ general surgery training, but phase 2, procedures, focuses on the development of procedures specific to plastic surgery. for phase 3, competencies in teamwork, the competencies for plastic surgery resemble those for general surgery and include team-training simulators to improve communication in emergency departments, clinics, operating rooms and hospital wards.[4] background. this research investigated the possibility of integrating simulation in plastic surgery residency training. the problem addressed was the lack of knowledge about using simulation as a teaching method to enhance the training of plastic surgeons. there was a lack of empirical evidence regarding learning outcomes that could be mastered by simulation-based education and training and their specific cognitive levels. objectives. to identify and describe: (i) learning outcomes for plastic surgery education and training for which simulation might be an important (essential and useful) training method; and (ii) simulation modalities, linked to specific cognitive levels, to establish the influence of simulation on plastic surgery education and training. the objectives entail determining the importance of simulation in plastic surgery training and identifying simulation modalities most suited to attain specific outcomes. methods. data were collected by means of a delphi survey to obtain consensus from an expert panel comprising 9 plastic surgeons, supplemented by semi-structured interviews conducted with 8 national and international role players in simulation and postgraduate education. results. learning outcomes, levels of training, possible simulation modalities, cognitive levels and descriptive verbs and phrases were described, as these pertain to learning. participants agreed that simulation in medical education can be used to enhance postgraduate plastic surgery training, with special reference to specific outcomes and cognitive levels. participants made recommendations for the planning and support of the implementation, aimed at ensuring the quality of training. conclusion. the objectives set were achieved and the results of the study serve as encouragement and guidance in the striving for the enhancement of postgraduate plastic surgery education and training, and in other medical disciplines. afr j health professions educ 2020;12(2):68-73. https://doi.org/10.7196/ajhpe.2020.v12i2.1182 enhancement of plastic surgery training by including simulation in education and training programmes c p g nel,1 mb chb, mhpe, fc plast surg (sa), mmed (plastic surgery), phd; g j van zyl,2 mb chb, mfammed, phd; m j labuschagne,3 mb chb, mmed (ophthalmology), phd 1 department of plastic and reconstructive surgery, faculty of health sciences, university of the free state, bloemfontein, south africa 2 faculty of health sciences, university of the free state, bloemfontein, south africa 3 school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c p g nel (nelcpg@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 69 june 2020, vol. 12, no. 2 ajhpe research in many plastic surgery programmes it is problematic to balance clinical, hands-on education and training with the didactic programme.[6] work and duty-hour restrictions add another layer of complexity to surgical education. the rate-limiting step in learning is not the transmission of information from the teacher to the learner, but the processing of the information by the learner.[6] educational technology offers unique tools to help learners acquire and process the information needed to become masters in their surgical specialty.[6] to understand the concepts of learning effectiveness and learning at different cognitive levels or domains of competence, necessitates examining learning theories and making these applicable to plastic surgery. according to kolb’s learning cycle,[7] learners must have a concrete experience on which to reflect. through their reflection, students are able to formulate abstract concepts and make appropriate generalisations, after which they solidify their understanding by testing the implications of their knowledge in new situations. this provides them with an objective experience, and the cycle continues. learners with different learning preferences will have strengths in different quadrants of kolb’s cycle.[7] to build knowledge and understanding, learners need to understand the ‘context of an unknown learning situation’.[7] this can be achieved through a process called instructional scaffolding,[8] during which sufficient support is provided to promote learning when concepts and skills are introduced to students. this support may include resources such as a list of intended learning outcomes when they enter the programme or a new clinical environment.[7] learning outcomes should be formulated using bloom’s taxonomy, designating the levels of cognition, i.e. knowledge, understanding, application, analysis, synthesis and evaluation.[8,9] anderson’s adapted version of this taxonomy uses verbs to describe the six levels of cognition (levels 1 6), i.e. remember, understand, apply, analyse, evaluate and create.[8] subsequently, in medical education, scales were developed to indicate competence, the most frequently encountered being miller’s pyramid,[9,10] which builds up from knowledge of (knows how), to competence in performance and independent action (shows how). this pyramid can be used as a guide for planning and assessing student learning, especially the mastery of skills.[10] a relationship is recognised between miller’s pyramid for developing skills and competence and the type of simulator most appropriate for each level, as well as the degree of simulator fidelity and the nature of skills that can be developed with each type of simulator.[11] a comparison between bloom’s taxonomy and miller’s pyramid can also be drawn.[12] bloom’s levels of remembering and understanding equal miller’s knowledge, while application boils down to know how and show how (competence), and analysing, evaluating and creating can be equalised with miller’s doing and integrating into practice (independent action).[13] simulation can be applied to developing and demonstrating higher-order levels of thinking, which approximate the levels of thinking required in clinical practice.[12] with the development of simulator technology providing greater degrees of fidelity, simulators can be employed as precision instruments in the measurement of performance in the clinical setting. simulation makes it possible to assess the development from the ‘knows how’ to the ‘shows how’ category in miller’s framework.[14] simulators are valid instruments for use in assessment, on condition that the simulator type has sufficient fidelity to elicit the expected competencies and performance level, and students have had previous exposure to the simulators during training.[11,12] aims and objectives the aim of the larger study was to identify and describe: (i) learning outcomes for plastic surgery education and training for which simulation might offer an important (essential and useful) training method; and (ii)  simulation modalities, linked to specific cognitive levels, to establish the influence of simulation on plastic surgery education and training as far as knowledge, skills, clinical competence and professional conduct are concerned. the objectives discussed in this article are those set to: (i)  determine the importance of simulation in plastic surgery training; (ii)  identify simulation modalities most suited to attain specific outcomes; and (iii) determine whether simulation can enhance student learning at different cognitive levels. methods a descriptive research design was followed, and a qualitative and quantitative approach was regarded best suited to attain the objectives.[13] the methods used to attain the objectives mentioned above, were: (i) a delphi survey; and (ii) semi-structured interviews. these two data collection methods are discussed separately. delphi survey data collection data were collected using a survey questionnaire, which consisted of three parts: part 1 (questions regarding the importance of simulation as a method) comprised items in two main categories, i.e. medical knowledge and patient care, with 18 sections in total, divided into five education and training levels totalling 453 learning outcomes. these learning outcomes for the delphi survey were developed (adapted) from the literature[6] and categorised in training levels used as point of departure in compiling the delphi questionnaire.[6] the participants (panel members) had to indicate the importance of simulation as an education and training method for each of the outcomes by indicating whether simulation was an essential method, a useful method or not applicable/important in training a plastic surgeon as far as a specific outcome was concerned. in part 2 of the questionnaire (simulation modalities), the participants had to give their opinions on each learning outcome and indicate which type of simulation modality (low-tech simulation or high-tech simulation) would be best suited for achieving a learning outcome. in part 3 of the questionnaire (cognitive levels), the participants had to indicate which level of learning should be addressed by simulation to achieve the specific outcome. sample nine experts in plastic surgery and clinical simulation were selected purposively according to a set of criteria (approved by the evaluation and ethics committee, faculty of health sciences, university of the free state (ufs), bloemfontein, south africa (sa)). the main criteria were expertise and experience in the field of the study.[14] the selected experts who agreed to participate in the delphi process were qualified plastic surgeons – knowledgeable about medical education, serve as policymakers, leaders and managers in postgraduate education and are of high national and international academic and scientific standing. the aim of the delphi process was to reach a level of consensus among participants on the statements in the questionnaire. for this study 66.7% (n=6/9) of participants was regarded as consensus.[13,15] june 2020, vol. 12, no. 2 ajhpe 70 research data analysis the researcher analysed the data. responses were entered into a computer spreadsheet for the calculation of consensus or stability. the results were reported separately, listing the experts’ comments on simulation as a method to train plastic surgeons, the uses and applicability of simulation modalities, as well as the levels of cognition that might be addressed by simulation. reliability and trustworthiness reliability was ensured by making use of a pilot study, determining strict criteria in sample selection, and by using a carefully constructed delphi questionnaire based on a detailed literature study. the pilot study entailed pretesting of the delphi questionnaire by a plastic surgeon, a medical education specialist and a clinician; no changes were recommended. reliability was ensured by carefully constructed and tested delphi questionnaires and interview guides. trustworthiness of the qualitative study was ensured by subjecting the research protocol to the evaluation and ethics committee, faculty of health sciences, ufs, by conducting an in-depth literature study and by providing a thorough description of the research project, as well as written feedback to the participants. semi-structured interviews data collection interviews were conducted to obtain an in-depth, comprehensive overview of the contribution of simulation to postgraduate plastic surgery education and training. an interview guide, developed by the first author (cpgn) on the basis of a literature review, was used. the questions used in the interview guide were as follows (with the objectives to which they are linked in brackets): • can simulation be used to enhance student learning at different cognitive levels? (objective (i): to determine whether simulation can enhance student learning at different cognitive levels.) • which types of simulation or simulation modalities might lead to effective learning? (objective (ii): to identify simulation modalities most suited to attain specific outcomes.) • any recommendation(s) you would like to make when considering including simulation in specialist training? (both the aim and the objectives.) questions 1 4, 7 11 and 13 are not included here, because the data are not directly applicable to the objectives of this article. the findings reported regarding questions 3, 4 and 7 were dealt with in an article, ‘simulation in plastic surgery: features and uses that lead to effective learning’.[14] sample professionals with experience in simulation and postgraduate education were requested to participate in the semi-structured interviews. participants, selected according to a set of criteria, were directors of simulation units, heads of clinical medical departments, programme directors of medical and nursing programmes, education management specialists, researchers and representatives from the simulation industry. the sample size was determined by the point of data saturation, i.e. when no new information was offered. written consent was obtained from the participants. data collection the first author (cpgn) conducted individual interviews based on a single interview guide with 8 participants. all interviews were audio-recorded, transcribed by the interviewer and checked by an individual who was not part of the study. field notes taken during the interviews contributed to the data. data analysis data were analysed using the grounded theory approach that requires continued comparison of data, following the data analysis steps of coding, categorisation and theory generation.[16] theory building occurred by finding patterns in the data, which continued until saturation of data was reached.[17] reliability and trustworthiness reliability was ensured by making use of explorative studies, determining strict criteria for sampling, using the carefully constructed interview guide, as well as an interview process that was audio-taped, transcribed and carefully described. trustworthiness of the interviewing process was ensured by involving voluntary interviewees with a clear understanding of what the interviewer expected from them, and using open-ended questions, as well as transcribing of and verifying the accuracy of data. scientific record-keeping ensured dependability. ethical approval ethical approval to conduct the research was obtained from health sciences research ethics committee, ufs (ref. no. ecufs 122/2015). results data collected by means of parts 1 3 of the delphi questionnaire survey and questions 5, 6 and 12 of the semi-structured interviews are reported. data on simulation modalities and cognitive levels are summarised and qualitative perspectives are shared on how simulation can be used to enhance student learning at different cognitive levels, as well as on the types of simulation modalities that may lead to effective learning. recommendations made by the interviewees are discussed with a view to possibly including simulation in specialist training. delphi survey (parts 1 3) after completing round 2 of the delphi process, sufficient consensus (92.05%) was achieved and the process came to an end. participants indicated that they would not be changing their answers in a third round. the results are summarised in table 1. consensus was reached on 45.92%, i.e. 208 of the 453 learning outcomes (descriptors in the form of statements), indicating that simulation as a method of training for plastic surgeons was important. consensus was table 1. results after two rounds of the delphi survey results learning outcomes, n consensus, n (%) simulation is important 453 208 (45.92) simulation is not applicable/not important 453 209 (46.14) undecided (stability) 453 36 (7.95) 71 june 2020, vol. 12, no. 2 ajhpe research reached on 209 (46.14%) statements, indicating that simulation was not applicable/not important as a method of training. consensus could not be reached on 36 (7.95%) statements, but stability was reached. the results of the 18 sections of the delphi questionnaire were summarised. each section dealt with the learning outcomes categorised on five education and training levels indicated as l1 5. the first statements related to medical knowledge, while the statements in the second part (in italics) related to patient care. the participants in the delphi survey indicated where simulation might play a role of importance and be of value as one of the training methods in the specialist training of plastic surgeons. the delphi participants indicated which type of simulation modality, i.e. low-tech and/or high tech, could be applied, and the cognitive level that would be addressed by the simulation. the different descriptive phrases/verbs that were used to formulate these specific learning outcomes at the five education and training levels, and the proposed simulation modality and cognitive levels at which learning will take place, are described. this was done to serve as an example and to provide an overview of the data that had been gathered during the delphi process. the section on surgical care (section 1), which consisted of the main categories, i.e. medical knowledge and patient care, resulted in 14 learning outcomes (covering five training levels) indicated by the delphi panel as outcomes for which simulation can be used as a training method. the schematic overview includes descriptive verbs (underlined in the delphi questionnaire), simulation modalities and cognitive levels (fig. 1). statements on medical knowledge are in ordinary print and statements on patient care are in italics. it is important to understand that by changing the action verb in an outcome or by formulating a simulation scenario at a higher cognitive level, learning that may occur will be at a higher cognitive level and will influence the effectiveness of learning. the discussion on section 1, i.e. surgical care, serves as an example (fig. 1). simulation was indicated as a possible method for training plastic surgeons at different cognitive levels related to the training level, using lowand/or high-tech simulation modalities and simulated patients. the  underlined verbs/action words (fig. 1) give an indication of the cognitive level at which learning most probably will take place. the other sections that were addressed (in the sequence in which they appeared in the delphi questionnaire) are wound care, tissue transfer, congenital anomalies, head and neck, maxillofacial trauma, facial aesthetics, non-cancer breast surgery, breast reconstruction, reconstruction of trunk and perineum, upper-extremity trauma, non-trauma hand, cosmetic trunk and lower extremity, lower extremity, system-based practice, practicebased learning and improvement, professionalism and interpersonal and communication skills. twenty learning outcomes indicated by the participants to be attained through simulation were in the sections on system-based practice (including patient safety, resource allocation and practice); six of the 20 were in the domain of patient safety. the section on practice-based learning and improvement, including investigate, evaluate and assimilate, t5 t4 t3 t2 t1 t1 5 training level develops/implements simulation for the teaching and evaluation of surgical skills teaches/supervises other learners involved in patient management demonstrates an understanding of the management of complicated multisystemic surgical pathophysiological processes anticipates potential problems and devises management plans manages a surgical firm manages, under supervision, a surgical patient afflicted by multisystemic disorders independently manages multiple surgical consultations and patients identifies exceptions and offers solutions conducts, with assistance, surgical consultations performs routine procedures independently recognises patterns and prioritises management, offering a solution demonstrates an understanding of the principles utilised to ensure surgical safety examines surgical patients while using algorithms like advanced trauma life support & advanced cardiac life support performs basic techniques in the management of a surgical patient independently experts indicated that simulation might be important as one of the methods to train registrars to attain outcomes (descriptive verbs underlined) learning outcomes low-tech and high-tech simulation modalities could be used at all six levels from remembering and knowledge to highest cognitive level of creating and evaluation lowand high-tech simulation modalities could be used to attain outcomes, which were at cognitive levels 1 3, but to anticipate potential problems would also require a higher cognitive level of analysis lowand high-tech simulation modalities could be used in the management of a surgical patient at lower cognitive levels of remembering and understanding; independently manage multiple surgical consultations and patients at level of remembering, understanding and applying; identify exceptions and o�er solutions using lowand high-tech simulation modalities, cognitive levels 1 3 low-tech simulation modalities and standardised patients could be used to conduct consultations, recognise patterns and prioritise management-offering solutions; performing routine procedures low-tech and high-tech modalities to be used, indicated as outcomes at cognitive levels of remembering, understanding, applying and analysing low-tech simulation modalities could be used to attain outcomes, indicated as outcomes at lower cognitive levels, remembering, understanding and applying simulation modalities to attain outcomes at cognitive levels (indicated in bold) simulation modalities and cognitive levels fig. 1. schematic overview where simulation can be applied to obtain learning outcomes in surgical care. june 2020, vol. 12, no. 2 ajhpe 72 research entailed five learning outcomes, while research and training had four learning outcomes. in the section on professionalism (ethics and values, and personal accountability), the participants in the delphi survey indicated three learning outcomes that may be attained by simulation; these were in the domain of personal accountability. in the interpersonal and communication skills section, participants indicated two learning outcomes that may be attained through simulation. although the participants indicated fewer outcomes to be attained by means of simulation in the domain of the softer skills, it must be emphasised that they were of the opinion that simulation was applicable at the higher cognitive levels, mostly cognitive level 6, i.e. evaluate and create. semi-structured interviews the enhancement of student learning through simulation at different cognitive levels, and the types of simulation modalities that may lead to effective learning, were addressed by the first two questions to the interviewees. simulation provides the opportunity to learn at different cognitive levels, e.g. remembering information (during preparation, understanding and applying, using low-fidelity simulators); analysing and evaluation (using high-fidelity simulators); and developing and formulating new concepts and ideas. using interprofessional teams in multipurpose, complex scenarios, with real-world experiences, can ensure learning at different cognitive levels. simulated patients play an important role in the training of registrars in a safe environment. the curriculum outcomes must be aligned with the objectives of simulation; however, using both lowand high-tech modalities while training and experiencing the holistic scenario will emphasise integration, group work and the multidisciplinary approach. recommendations (made by the interviewees when considering including simulation in specialist training – the third question) were focused on curriculum and training initiatives, aspects that should be in place, and suggestions on planning and support aimed at ensuring the quality of training. the emphasis should be on employing persons knowledgeable in curriculum and simulation development. data gathered by means of the semi-structured interviews were triangulated with data gathered through parts 1 3 of the questionnaire survey, and by means of the literature review, to identify aspects for compiling a framework to serve as a directive when considering the inclusion of simulation as one of the methods to train plastic surgeons. discussion this discussion of learning outcomes, levels of training, possible simulation modalities, cognitive levels and descriptive verbs and phrases pertaining to learning, paved the way for investigating the role of simulation in medical education. recommendations for considering the inclusion of simulation in specialist training were offered. of the proposed learning outcomes for plastic surgery training, the participants in the delphi survey reached consensus that 45.92% of the proposed learning outcomes for such training could be supported by including simulation as an instructional method in the postgraduate education and training programme. the participants thought that simulation should be implemented progressively at all five training levels during the training years. in the earlier years of training, students should concentrate more on remembering and understanding concepts, followed by the mastering and application of skills, demanding analysis, evaluation and creating (synthesis) in the later years of training as proposed in the literature.[10] the delphi participants expressed the opinion that simulation is an important method for training students in medical knowledge, skills, competencies and patient care; however, they did not favour simulation as a teaching method for the ‘softer skills’, e.g. team training, patient safety, interpersonal and communication skills, professionalism, ethics, values and personal accountability, although the literature suggests that soft skills also be trained through simulation.[18,19] delphi participants emphasised the importance of these skills being trained at higher cognitive levels to reach maximum competency and proficiency in professional conduct. with regard to the type of simulators used, the participants agreed that the simulation type should be in line with the objectives/stated outcomes of the scenarios: scenarios involving higher cognitive levels would demand learning with the use of high-tech simulators and simulated patients. simulation provides opportunities for learning that involve different cognitive levels. it is important to identify the competence/expertise/ proficiency that is required at each training level and for the qualified professional, as also pointed out in the literature.[11,12] when introducing simulation in specialist training, the following is recommended: • develop an integrated, structured education and training system, including theoretical lectures, simulation sessions and clinical work on real patients – striving to find a balance between the different components. • align the simulation plan with the curriculum according to a scientific and co-ordinated process and guidelines. • develop a training course for trainers before implementing simulation in the plastic surgery programme. • research the role of simulation in assessment carefully before implementation. • evaluate the workplace environment on a continuous basis and carefully consider feedback received from role players. from the results of this study, and supported by the literature,[2-5,11-14,20,21] a clear reasoning process built the argument favouring the implementation of simulation in postgraduate plastic surgery education and training programmes. the study results clearly indicate that certain processes must be in place and steps should be taken to ensure that adequate learning will occur, and that simulation outcomes are integrated with the objectives and outcomes of the curriculum in an environment that is conducive to learning. it is evident from the research that simulation in plastic surgery education and training programmes will enhance effective learning, but further research is needed for ultimate success.[13,22] conclusion aspects worthy of further investigation with a view to integrating simulation successfully in postgraduate plastic surgery education and training programmes include considerations and challenges for effective and efficient implementation of appropriate simulation modes. another aspect that needs to be investigated more profoundly is the use of simulation for assessment in medical education and training. recommendations for compiling guidelines for the implementation of simulation as part of postgraduate plastic surgery education and training programmes must be compiled to serve as a directive. 73 june 2020, vol. 12, no. 2 ajhpe research therefore, having determined that simulation does make a contribution to plastic surgery education and training, and having identified outcomes that can be attained best by using specific (identified) simulation modes, we trust that the objectives achieved through this study will serve as encouragement and guidance in the striving for the enhancement of postgraduate plastic surgery education and training, and in other medical disciplines. declaration. none. acknowledgements. the authors gratefully acknowledge the assistance received from: (i) the participants in the study, who were willing to take part in the pilot testing and quality control of the delphi questionnaires, and the role players in the explorative study conducting the exploratory interviews; (ii)  the delphi panel and interviewees involved in the research for their valuable contributions and their time in completing the questionnaires and participating in individual semi-structured interviews; (iii) prof. g joubert, head, department of biostatistics, faculty of health sciences, ufs, for her advice during the early stages of the research, protocol development and quality assurance of the study; and (iv) dr h bezuidenhout, ufs, for support regarding the scientific formulation and language editing of the manuscript, as well as editing of the references. author contributions. cpgn designed the study, compiled the protocol, collected data and performed the analysis, interpreted data and wrote the manuscript; gjvz and mjl were promotors of the study, reviewed the protocol and manuscript and contributed substantially to the conceptualisation, design, analysis and interpretation of data and scientific content. all authors approved the final version of the manuscript. funding. this research was partially funded by a grant from the health and welfare sector education training authority (hwseta). conflicts of interest. none. 1. issenberg sb, mcgaghie wc, petrusa er, et al. features and uses of high-fidelity medical simulations that lead to effective learning. med teach 2005;27(1):10-28. https://doi.org/10.1080/01421590500046924 2. satava r. emerging trends that herald the future of surgical simulation. surg clin north am 2010;90(3):623-633, https://doi.org/10.1016/j.suc.2010.02.002 3. rosen jm, long sa, mcgrath dm, greer se. simulation in plastic surgery training and education: the path forward. plast reconstr surg 2009;123(2):729-738. https://doi.org/10.1097/prs.0b013e3181958ec4 4. mittal mk, duman kr, edelson pk, et al. successful implementation of the american college of surgeons/ association of program directors in surgery, surgical skills curriculum via a 4-week consecutive simulation rotation. soc simul health 2012;7(3):147-154. https://doi.org/10.1097/sih.0b013e31824120c6 5. american board of medical specialists and accreditation council for graduate medical education. the plastic surgery milestone project. a joint initiative. 2013. j grad med educ 2014;6(1s1):225-242. https://doi. org/10.4300/jgme-06-01s1-24 6. neumeister mw. technology and education: the future of plastic surgery training. plast reconstr surg glob open 2016;4(6):e777. https://doi.org/10.1097/gox.0000000000000780 7. bloom bs, engelhart md, furst ej, hill wh, kratwohl dr. taxonomy of educational objectives: the classification of educational goals. handbook i, cognitive domain. new york: longmans green, 1956. 8. taylor dcm, hamdy h. adult learning theories: implications for learning and teaching in medical education: amee guide no. 83. med teach 2013;35:e1571-e1576. https://doi.org/10.3109/0142159x.2013.828153 9. atherthon js. learning and teaching bloom’s taxonomy. 2011. https://www.economicsnetwork.ac.uk/archive/ atherton_learning/bloomtax (accessed 15 may 2020). 10. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9):s63-s67. 11. alinier gp. a typology of educationally focused medical simulation tools. med teach 2007;29(8):e243-e250. https://doi.org/10.1080/01421590701551185 12. labuschagne mj. clinical simulation to enhance undergraduate medical education and training at the university of the free state. phd thesis. bloemfontein: university of the free state, 2012:1-282. 13. nel cpg. simulation in postgraduate plastic surgery education and training. phd thesis. bloemfontein: university of the free state, 2019:11-13. 14. nel cpg, van zyl gj, labuschagne mj. simulation in plastic surgery: features and uses that lead to effective learning. afr j health professions educ 2020 (accepted). 15. dajani js, sincoff mz, talley wk. stability and agreement criteria for the termination of delphi studies. technol forecast social change 1979;13(1):83-90. https://doi.org/10.1016/0040-1625(79)90007-6 16. byrne m. grounded theory as a qualitative research methodology – brief article. aorn j 2001;73(6):1155-1156. https://doi.org/10.1016/s0001-2092(06)61841-3 17. labuschagne mj, nel mm, nel ppc, van zyl gj. recommendations for the establishment of a clinical simulation unit to train south african medical students. afr j health professions educ 2014;l6(2):2-6. https://doi. org/10.7196/ajhpe.534 18. arbogast p, rosen j. simulation in plastic surgery training: past, present and future. intechopen 2012:235-256. https://doi.org/10.5772/28550 19. scalese rj. energising medical education through simulation: powering minds, not just machines. proceedings of the 6th asia pacific medical education conference (apmec), 19 22 february 2009, singapore. singapore: apmec, 2009. 20. cregan p, watterson l. high stakes assessment using simulation: an australian experience. stud health technol inform 2005;111:99-104. 21. nel cpg, labuschagne mj, van zyl gj. why is research needed on simulation to enhance plastic surgery education and training? int j cross-disciplinary subjects educ 2018;9(1):3301-3308. 22. nel cpg, labuschagne mj, van zyl gj. simulation in plastic surgery: a research agenda to improve teaching, learning and clinical expertise/professional competence. proceedings of the ireland international conference of education (iice), 25 28 april 2016. dublin: iice, 2016:56-62. accepted 14 november 2019. https://doi.org/10.1080/01421590500046924 https://doi.org/10.1016/j.suc.2010.02.002 https://doi.org/10.1097/prs.0b013e3181958ec4 https://doi.org/10.1097/sih.0b013e31824120c6 https://doi.org/10.4300/jgme-06-01s1-24 https://doi.org/10.4300/jgme-06-01s1-24 https://doi.org/10.1097/gox.0000000000000780 https://doi.org/10.3109/0142159x.2013.828153 https://www.economicsnetwork.ac.uk/archive/atherton_learning/bloomtax https://www.economicsnetwork.ac.uk/archive/atherton_learning/bloomtax https://doi.org/10.1080/01421590701551185 https://doi.org/10.1016/0040-1625(79)90007-6 https://doi.org/10.1016/s0001-2092(06)61841-3 https://doi.org/10.7196/ajhpe.534 https://doi.org/10.7196/ajhpe.534 https://doi.org/10.5772/28550 a maximum of 3 ceus will be awarded per correctly completed test. april 2021, vol. 13, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire april 2021 facilitators of and barriers to clinical supervision of speech-language pathology students in south africa: a pilot study 1. clinical educators must understand (more than one answer may be correct): a. the needs of the student. b. the context. c. the university’s initiatives and policies. d. b and c only. e. a and b only. simulation in plastic surgery: features and uses that lead to effective learning 2. the researchers identified simulation as having the following influences on student learning (more than one answer may be correct): a. motivation to make a difference. b. importance of preparation. c. deliberate practice. d. level of competence. significance of relationships in the cognitive apprenticeship of medical specialty training 3. some of the feedback received by respondents in this study include (more than one answer may be correct): a. lack of day-to-day supervision and coaching by not having a mentoring relationship led to students' failure to progress in their studies. b. sufficient opportunities for informal interactions and learning in situatedness. c. self-directed learning was one of the contributory factors in their success. d. initiating contact or approaching consultants was easy to do. cognitive load theory (clt) in simulations to facilitate critical thinking in radiography students 4. which of the following statements on clt is false (only one answer is correct): a. clt aims to facilitate the development of simulations that consider the cognitive interplay between working memory and long-term memory to optimise learning. b. clt is based on the principle that a person’s working memory has a limited capacity when dealing with novel information. c. students’ total working cognitive load consists of the sum of the intrinsic cognitive load and the extraneous cognitive load. d. only when both intrinsic load and extraneous load components exceed working memory capacity, will learning be impaired. factors influencing radiography lecturers’ perceptions and understanding of reflective practice in a newly implemented curriculum 5. participants in this study highlighted the following (more than one answer may be correct): a. that they had sufficient exposure to reflective practice in their own training. b. large groups posed a challenge to the optimal facilitation of reflective practice. c. reflective practice is overtly taught and assessed in the new curriculum. d. there is a need for faculty to participate in, and collaborate on, strategies that support the integration of reflection with discipline-specific content. research competencies for undergraduate rehabilitation students: a scoping review 6. the sicily statement on evidence-based practice provides a five-step framework to use when developing curricula, which follows this order (only one answer is correct): please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. cpd questionnaire april 2021, vol. 13, no. 1 ajhpe a. searching for best evidence, critically evaluating the evidence, research question formulation, applying the evidence to clinical practice, monitoring performance. b. research formulation, searching for best evidence, applying the evidence to clinical practice, critically evaluating the evidence, monitoring performance. c. research question formulation, searching for best evidence, critically evaluating the evidence, applying the evidence to clinical practice, monitoring performance. d. searching for best evidence, applying the evidence to clinical practice, critically evaluating the evidence, monitoring performance. learner engagement as social justice practice in undergraduate emergency care education: an exploration of expectations, impediments and enablers for academic success 7. this study found that the extrinsic factors affecting learner success included (more than one answer may be correct): a. competing demands. b. institutional structure/processes. c. teaching quality. d. online teaching and learning. a capability approach analysis of student perspectives of a medical consultation quality-improvement process 8. the four dimensions of learners of sources of human capacity and competence according to marcus, are (only one answer is correct): a. physical and mental abilities, sense of others, sense of self, knowledge and beliefs. b. sense of self, sense of others, social relationships, knowledge and beliefs. c. sense of self, interpersonal relationships, physical and mental abilities, knowledge and beliefs. d. social relationships, sense of self, knowledge and beliefs, physical and mental abilities. validation of a questionnaire evaluating the effect of a preparatory year on qualifying students for studying at health professions education faculties 9. the results of this study reveal that students have perceived teaching, teachers and assessment positively. (true/false) development of a baseline assessment tool to establish students’ foundational knowledge of life sciences at entry to university 10. which of the following statements are true (more than one answer may be correct): a. the test had a higher reliability for the medical students than for the occupational therapy and physiotherapy students. b. medical students entered university with a slightly higher final school grade for life sciences than physiotherapy and occupational therapy students. c. the baseline assessment scores of the medical students were slightly lower than those of the occupational therapy and physiotherapy students. d. the medical students scored significantly higher in both cognitive categories of blooms taxonomy than occupational therapy and physiotherapy students. how well do we teach the primary healthcare approach? a case study of health sciences course documents, educators and students at the university of cape town faculty of health sciences 11. there was a fair degree of convergence overall between students’ and educators’ perceptions of facilitating factors for primary healthcare. (true/false) a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) april 2021 210 september 2021, vol. 13, no. 3 ajhpe short report why was the idea necessary? the occupational therapy (ot) programme at the university of the western cape endeavours to develop graduate competencies for critical practice that recognises how conditions of people’s lives affect occupational participation.[1] the curriculum tenet of community development at the fourth-year level of study contributes to this development. the key focus of community development is to confront structural oppression within a specific community context.[2] accordingly, freire’s[3] critical pedagogy is adopted to assist students to question and challenge beliefs and practices that dominate in communities. given that fieldwork allows students to immerse themselves in communities, students become critically aware of various social injustices prevalent in those communities. in building connections, students learn to work with communities to plan, implement and support relevant actions to promote health and well-being in the community at large. however, the rapid transition to online learning necessitated by the covid-19 pandemic meant a shift to alternative forms of teaching outside the historical format. what was tried? adopting a co-operative inquiry approach,[4] lecturers and supervisors utilised continuous joint reflections on teaching practice as a shared space to re-think learning and teaching practices. while students could not be physically present in the community, to guard their safety as well as that of community members, they were still expected to meet core competencies and attributes of being critically conscious. online learning had to achieve what authentic and experiential learning would have. the challenge was to find ways of collaborating with communities and to create an enriching fieldwork learning experience within a virtual learning environment. cultivating a nurturing and enabling online learning environment and ensuring that students had a choice regarding when and how they engage in learning was imperative in being responsive to the call for decolonising health professions curricula.[5] while the university endeavoured to support students with data and devices, we were nonetheless aware of the difficulties students would experience. some of the challenges that shifting to online learning posed include access to devices, data and connectivity. lecturers and fieldwork supervisors needed to heed students’ home contexts and psycho-emotional readiness in dealing with the changes forced upon them by the pandemic. an adapted online community fieldwork module was devised and presented on the university of the western cape online learning management system ikamva. sund’s[6] suggestions for moving teaching online in the face of the covid-19 crisis were useful in guiding a re-thinking of learning and teaching practices. adopting a community of inquiry process, he premises that online learning occurs through three interconnected elements. the first element is social presence that concerns students’ ability to identify and communicate with the learning community. for example, students joined small (tutorial) groups that were co-ordinated by their supervisors. tutorials took place on ikamva, zoom or google meet, and enabled students to interact with their peers, with interactions often continuing in student groups on whatsapp after the completion of the tutorial. the second element, cognitive presence, concerns students’ ability to develop knowledge and understanding of theoretical constructs, and apply this to a specific context. students engaged with literature in the form of dedicated readings, formal input, breakaway group discussions and individual reflections. scheduled discussion forums and class meetings on ikamva, google meet and/or zoom at dedicated times further facilitated knowledge and application through lecturerand student-led inputs, as well as through the submission of group tasks, individual essays and reflective journals. the third element of teaching presence encompasses both the overall design of the educational experience and the facilitation of learning, highlighting the role of lecturers and supervisors. table 1 provides an overview of the different learning and teaching strategies employed in relation to the different elements. two focus communities were selected, one urban and one rural. each student worked with one of these communities as an online practice setting. students could access previous project reports in the course resources folder on ikamva. further information on their respective communities was to be accessed via the internet, e.g. youtube. over a 6-week period, students engaged in a process that commenced with community entry and analysis, through to intervention planning and implementation. case scenarios were integrated into various tasks done in small tutorial groups or larger class meetings. these often resulted in vibrant discussions that continued among student groups outside online lectures. a key dimension of the curriculum was collaboration with community stakeholders, who played a significant role in providing contextual information in order for students to compile community profiles. it was important that communities’ voices were heard in order for the students to work with them in planning relevant interventions. community members were invited to engage with the students on the virtual platforms in the form of dialogues, meetings, consultations and workshops. these activities were digitally recorded for the purpose of student video presentations, and learning portfolios were shared with supervisors, who provided feedback and facilitated critical analysis and evaluation of the community strategies, approaches and principles demonstrated. for formative assessment purposes, students compiled digital graphic presentations and home videos in which they demonstrated interventions and specific skills by involving community members online as well as members of their households in role-plays and simulated activities while moving fieldwork online: innovations in an occupational therapy curriculum l hess-april, bsc (ot), mph, phd; m alexander, bsc (ot); s stirrup, bsc (ot); a b khan, bsc (ot) occupational therapy department, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: l hess-april (lhess@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:lhess@uwc.ac.za september 2021, vol. 13, no. 3 ajhpe 211 short report observing covid-19 protocols. students further chose the option of live online skills demonstrations on ikamva and/or google meet as an alternative to sit-down exams for summative assessments. detailed guidelines were effective, as students appeared to engage in the examination sessions with minimal anxiety. students presented the community process they followed with related evidence, demonstrated their skills through a compilation of the aforementioned home video clips, evaluated their own personal transformation and growth throughout the fieldwork module and engaged in discussions with examiners. the lessons learnt the covid-19 pandemic provided an opportunity for lecturers to be creative concerning transferring learning materials online, and to increase their understanding of challenges that students experience regarding learning. students who would generally not speak up in a class environment became more engaged as they received individual attention during one-to-one online meetings with supervisors. uploading content such as videos, articles and presentations, as well as using platforms such as ikamva, are excellent ways to make content accessible. however, the key to online learning is utilising platforms in such a way that it is possible for students to engage fully. lecturers and supervisors are responsible for creating opportunities for learning and interaction that stimulate exploration and thinking, while student-directed learning is reinforced in turn. similarly, adaptability in how supervisors facilitate learning, as well as in understanding how students learn, are necessary skills for online learning to be successful. in evaluating the module, students shared incidents of transformation and personal growth. they highlighted a process of personal development within the learning area of cultural competence even though the experience was online. they acknowledged that critical questions posed by supervisors exposed systemic injustices and personal privileges and preconceived ideas that they were unaware of, such as making assumptions about communities based on stereotypical views. this is evidence of how the online module, not unlike previous fieldwork experiences within communities, contributed to the development of graduate attributes. one of the overarching lessons learnt through this process is that despite certain constraints, the transition to online learning and teaching was generally a positive experience for students and lecturers. the reciprocal relationship between supervisor and student was maintained. it must, however, be noted that community members reported that online learning did not allow for the relationship between the community and community developer (the student) to reach previous levels of depth, owing to limitations on the time spent with community members. the experience emphasised the importance of institutional support. lecturers and supervisors were careful to provide students with not just the necessary support to assist in coping with the demands of remote learning, but also the emotional demands of the covid-19 pandemic. ways in which lecturers demonstrated support was through being flexible regarding deadlines and forms of submission, and extending time allowed for completion of tasks and assignments. this, together with adopting innovative ways of teaching, however, proved to be more demanding than previously in terms of time and increased pressure on lecturers, also highlighting their need for support. nonetheless, learning outcomes were achieved, in that examinations proved students to be generally competent in the knowledge and skills required to engage in community development practice. what will we keep in our practice? a variety of tools that catered to students’ different learning styles was utilised within the online learning approach. the flexibility that accompanied the approach made room for renewed approachability by lecturers and supervisors, which allowed for optimal learning. going forward, a blended learning approach will be adopted, where students’ physical fieldwork learning experiences in communities will be complemented with online learning as an integral part of practice education and service learning. while the programme successfully moved to online learning and teaching, there were certain challenges related to connectivity and data-related constraints that caused some students to be inactive for some of the online learning activities. should students continue to experience connectivity difficulties, printed material and provision of flash drives with learning content are one way in which this constraint will be addressed. in sustaining institutional support, the university should continue to explore ways in which support provided to students during the covid pandemic and beyond could be provided to students on an ongoing basis in order to ensure that online learning is accessible to all students. declaration. none. acknowledgements. we wish to thank the students and community members who participated in the online fieldwork module. author contributions. lh-a lead the writing of the various drafts of the report, and edited and finalised the manuscript. all authors assisted with its conceptualisation and contributed to the final manuscript. funding. none. conflicts of interest. none. table 1. elements of online learning* online learning elements learning and teaching strategies social presence tutorial groups class meetings class whatsapp group breakaway groups discussion forums cognitive presence literature/readings formal input and narrated powerpoint slides participation of community stakeholders online case scenarios group tasks guided community process graphic presentations home videos individual essays journal reflections teaching presence clear expectations student-directed learning reciprocal learning access to resources video recordings of learning activities *see qr code for video link. 212 september 2021, vol. 13, no. 3 ajhpe evidence of innovation 1. hammell kw, iwama mk. well-being and occupational rights: an imperative for critical occupational therapy. scand j occup ther 2012;19(5):385-394. https://doi.org/10.3109/11038128.2011.611821 2. ife j. human rights from below: achieving rights through community development. port melbourne: cambridge university press, 2010. 3. freire p. pedagogy of the oppressed. london: penguin, 1990. 4. heron j. co-operative inquiry: research into the human condition. london: sage, 1996. 5. ramugondo e. healing work: intersections for decoloniality. world fed occup ther bull 2018;74(2):83-91. https://doi.org/10.1080/14473828.2018.1523981 6. sund kj. suggestions for moving teaching rapidly online in the face of the corona crisis. working paper. roskilde university, 2020. https://rucforsk.ruc.dk/ws/portalfiles/portal/67024853/moving_teaching_online. pdf (accessed 8 february 2021). accepted 15 june 2021. afr j health professions educ 2021;13(3):210-212. https://doi.org/10.7196/ajhpe.2021.v13i3.1485 short report https://doi.org/10.3109/11038128.2011.611821 https://doi.org/10.1080/14473828.2018.1523981 https://doi.org/10.1080/14473828.2018.1523981 https://rucforsk.ruc.dk/ws/portalfiles/portal/67024853/moving_teaching_online.pdf https://rucforsk.ruc.dk/ws/portalfiles/portal/67024853/moving_teaching_online.pdf https://rucforsk.ruc.dk/ws/portalfiles/portal/67024853/moving_teaching_online.pdf https://doi.org/10.7196/ajhpe.2021.v13i3.1485 a maximum of 3 ceus will be awarded per correctly completed test. december 2019, vol. 11, no. 4 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/011/01/2019 (clinical) cpd questionnaire december 2019 a self-determination theory perspective on student success in attaining an emergency care degree 1. intrinsic motivation has been associated with: a. adaptive metacognitive strategies. b. increased will and determination. c. greater intention to persist. d. greater effective perseverance. e. all of the above. f. a, b and d. views of emergency medical care students on the value of simulation for achievement of clinical competence 2. in this study, simulation was more valued than clinical learning shifts for patient assessment. true or false? south african health practitioners’ patterns of cpd practices – implications for maintenance of licensure 3. using patient/client-satisfaction surveys was found to be useful for which percentage of respondents: a. 56.8%. b. 29.9%. c. 40.2%. d. 17.3%. diagnostic accuracy of chest radiograph interpretation by graduate radiographers in uganda 4. the abnormalities on the chest radiographs that appeared to have been correctly pointed out by the radiographers included: a. tuberculosis, pneumonia, lung metastases and pleural effusion. b. tuberculosis, pleural effusion, pneumonia, atelectasis. c. tuberculosis, pleural effusion, pneumonia, lung metastases. d. tuberculosis, primary lung cancer, pneumonia, atelectasis. teaching communication as a core competency in health professions edu cation: an exploratory case study in a college of health sciences, south africa 5. this study explored the teaching, learning and assessment of communication as a core competency with academic staff in five health professional programmes in the college of health sciences. true or false? the imperative of teaching professionalism to biomedical technologists 6. the authors used the following tool to analyse the south african national blood service internship curriculum: a. hecat (health education curriculum analysis tool). b. harden’s 10 questions. c. core curriculum analysis matrix. d. the prisms strategy. factors influencing bachelor of nursing science students’ attitude towards clinical exposure 7. the following factors have been found to influence nursing students’ attitudes towards clinical exposure: a. mentorship. b. good relationships with nurses. c. overcrowded clinical facilities. d. clinical supervision. e. all of the above. f. a, b and d. the role of moodle-based surgical skills illustrations using 3d animation in undergraduate training 8. research has shown that compared with conventional teaching, videobased surgical skills training improves: a. knowledge retention. b. acquisition of surgical skills. c. satisfaction levels. d. b and c. e. all of the above. june 2021, vol. 13, no. 2 ajhpe 110 research learning clinical medicine in the medical practice workplace is considered to be one of the most effective ways for students and lecturers to translate medical theory learnt in the classroom into clinical practice. the clinical workplace plays an important role in preparing students for future practice as physicians.[1] advances in medical education have led to the establishment of skills laboratories as places for learning clinical skills using simulation-based medical education. however, realpatient encounters create authenticity in learning, because complaints are articulated better and physical signs are shown, with deeper and broader insight by real patients.[2] contemporary medical practice has evolved over time, with changes in health system expectations and clinical practice requirements, such as patient numbers and demographics and expectations of patients and employers.[3] while these changes are particularly obvious in developed countries, the advent of health-related technologies and increased litigation means this trend is rapidly catching up in developing countries, including africa. all these changes have implications for training medical students to provide quality healthcare services on graduation. concerns have been raised by employers, lecturers and regulators of medical graduates in uganda and elsewhere that graduate competencies and population health needs are mismatched.[4,5] for example, the uganda medical and dental practitioners council (umdpc) report of 2017/2018 describes cases of professional incompetence and unprofessionalism as some of the common offences handled by its ethics and disciplinary committee.[5] these offences may be an indication that the changes in health professions education have not kept pace with healthcare delivery expectations. work and learning are interdependent, and understanding the perceptions and experiences of learners regarding the workplace as a learning environment may be an initial step in identifying the factors responsible for the mismatch between medical education and health system expectations.[6] studies assessing student perceptions of the learning environment using the dundee ready educational environment measure (dreem) questionnaire have been done in nigeria, south africa (sa), turkey, australia and the uk. the questionnaire comprises 50 items, divided into five separate domains that can be analysed individually.[7-10] no such study has ever been done in uganda, thus creating an information gap and a need to evaluate the learning environment with a view to optimising learning in the workplace. undergraduate medical students at makerere university college of health sciences (makchs), kampala, uganda, have placements at the background. one of the most effective ways of translating medical theory into clinical practice is through workplace learning, because practice is learnt by practising. undergraduate medical students at makerere university college of health sciences, kampala, uganda, have workplace rotations at mulago national referral and teaching hospital (mnrth), kampala, for the purpose of learning clinical medicine. objectives. to explore undergraduate medical students’ perceptions and experiences regarding the suitability of mnrth as a learning environment to produce competent health professionals who are ready to meet the demands of contemporary medical practice, research and training. methods. this was a cross-sectional study with a mixed-methods approach. students’ perceptions and experiences were assessed using the dundee ready educational environment measure (dreem), as well as focus group discussions (fgds). data from dreem were analysed as frequencies and means of scores of perceptions of the learning environment. fgd data were analysed using thematic analysis. results. the majority of students perceived the learning environment as having more positives than negatives. among the positive aspects were unrestricted access to large numbers of patients and a wide case mix. negative aspects included overcrowding due to too many students, and inadequate workplace affordances. conclusions. the large numbers of patients, unrestricted access to patients and the wide case mix created authentic learning opportunities for students – they were exposed to a range of conditions that they are likely to encounter often once they qualify. the areas of concern identified in the study need to be addressed to optimise learning at the workplace for undergraduate medical students. afr j health professions educ 2021;13(2):110-117. https://doi.org/10.7196/ajhpe.2021.v13i2.1191 the workplace as a learning environment: perceptions and experiences of undergraduate medical students at a contemporary medical training university in uganda mike nantamu kagawa,1 mb chb, mmed (obstet gynaecol), phd; sarah kiguli,2 mb chb, mmed (paediatrics and child health), mhpe; wilhelm johannes steinberg,3 mb bch, dtm&h, dph, dip obst (sa), mfammed, fcfp (sa); mpho p jama,4 bcur, pgdch, mhe, phd 1 department of obstetrics and gynaecology, makerere university college of health sciences, kampala, uganda 2 department of paediatrics and child health, makerere university college of health sciences, kampala, uganda 3 department of family medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 4 division student learning and development, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m n kagawa (kagawanm@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1191 111 june 2021, vol. 13, no. 2 ajhpe research workplace in mulago national referral and teaching hospital (mnrth) for the purpose of learning clinical medicine as they progress from novices to proficient clinicians. the purpose of the study was to explore undergraduate medical students’ perceptions and experiences regarding the suitability of mnrth as a learning environment that can produce competent health professionals who are ready to meet the demands of contemporary medical practice, research and training. methods this was a cross-sectional study design with a mixed-methods approach. setting mnrth has a bed capacity of 1 500 and is about 1.8 km (19 minutes’ walk) from the main campus of makchs. mnrth is the makchs teaching hospital for all clinical specialties (surgery (general surgery, orthopaedics, cardiothoracic surgery, neurosurgery), obstetrics and gynaecology, internal medicine, paediatrics and child health, ophthalmology, anaesthesia and critical care, and ear, nose and throat), save psychiatry, for which training takes place in butabika hospital, a specialised hospital ~9 km from mnrth. undergraduate medical students at makchs study for 5 years before graduation, and start their comprehensive clinical placements at the workplace in the fourth year. during these placements, groups of 30 40 students are allocated to each clinical specialty in mnrth for workplace learning. clinical placement in each speciality lasts 5 weeks during their fourth year, and 7 weeks during their fifth year. lecturers of undergraduates include all specialist doctors (with at least a master’s degrees) from mnrth and makchs (fig. 1). prior to their comprehensive clinical placements, undergraduates are introduced to workplace learning during clinical exposure – from the first year. this is an observership, which is intended to assist students from an early stage of their medical training, so that they learn how to relate knowledge of the basic sciences to clinical conditions in the workplace. participants all the study participants were undergraduate medical students (mb chb) in their fourth and fifth years of study (n=258). questionnaires were sent to 216 students who were rotating at mnrth at the time of the study (42 medical students were excluded because they were in butabika for their psychiatry placement); 170 completed questionnaires were returned and analysed. data collection quantitative data were collected using an adapted dreem questionnaire. dreem is a validated tool with 50 items for assessing an education environment, and has been tested for reliability and validity – though not in uganda.[11] the adaptation focused mainly on language and context, e.g.  teacher became lecturer, class became ward, and ‘this year’ became ‘this  course’, so as to improve participants’ understanding. the items in dreem are scored using a likert scale, offering the following options: strongly agree (s)  – 4, agree (a)  – 3, uncertain (u)  – 2, disagree (d)  – 1, strongly disagree (sd)  – 0. nine of the 50 items shown in italics (4, 8, 9, 17, 25, 35, 39, 48 and  50) (table  1) are negative statements and are scored as strongly agree (s) – 0, agree (a) – 1, uncertain (u) – 2, disagree (d) – 3, strongly disagree (sd) – 4. participants for dreem were selected by consecutive sampling. qualitative data were collected using a focus group discussion (fgd) guide with questions that were formulated from the literature and items in the dreem tool that received the lowest scores, with additional questions being formulated as the fgds progressed. the guide included questions on matters such as preparations prior to clinical placement, learner expectations and if they were met, positive and negative learning experiences in the workplace, learning opportunities and challenges and use of spare moments in the workplace. the fgds were conducted by the principal investigator, who was assisted by an fgd expert. the purpose of the fgds was to explain and corroborate the findings from dreem.[12] participants for the fgds were selected by purposive sampling; they could thus be comfortable with each other and be motivated to engage freely in the discussion and generate data based on the synergy of group interaction. students in the fourth year were placed in separate groups from those in the fifth year. each fgd comprised 8 10 medical students and lasted from 45 minutes to 1 hour. efforts were made to ensure an equal number of male and female participants in each focus group. the fgds were conducted shortly after dreem had been completed, and students who had completed the dreem questionnaire were eligible to participate in fgds; they could, therefore, provide insights into the reasons underlying their dreem responses. after obtaining consent, the discussions were recorded using an audio recorder. additional notes were taken to record non-verbal interactions and to document the impact of group dynamics and exchanges of views. data analysis analysis of dreem was done using spss version 23 (ibm corp., usa), to determine the overall score and the scores for the five separate domains. scores were interpreted according to the guidelines by mcaleer and roff.[7] the five domains are perceptions of learning (pol), perceptions of teachers (pot), academic self-perceptions (asp), perceptions of atmosphere (poa) and social self-perceptions (ssp). in addition, mean scores for individual items in dreem were determined to pinpoint specific strengths and makchs mnrth professor senior consultant associate professor consultant senior lecturer medical o�cer special grade (registrar) lecturer assistant lecturer fig. 1. hierarchy of teaching staff for undergraduates at makerere university college of health sciences (makchs) and mulago national referral and teaching hospital (mnrth). june 2021, vol. 13, no. 2 ajhpe 112 research weaknesses in the learning environment. items with mean scores of ≥3 indicated really positive points, between 2 and 3 were aspects that could be enhanced, and ≤2 were items that needed closer examination, as these indicated real problem areas. data analysis from the students’ fgds was done using atlas.ti software version 7 (atlas.ti, germany) according to the seven stages of the framework method.[13,14] audio recordings of the fgds were transcribed into text, listened to and read several times as a way of becoming immersed table 1. dundee ready education environment measure (dreem) domain item perception of learning (12 items/maximum score 48) i am encouraged to participate during clinical learning sessions the clinical teaching is often stimulating the teaching is interactive between teacher and student the teaching helps me to develop my skills the teaching is well focused the teaching helps me to develop my confidence the clinic time is put to good use the teaching over-emphasises factual learning i’m clear about the course learning objectives the teaching encourages me to participate lifelong learning is emphasised over short-term learning the teaching is too teacher controlled perception of teachers (11 items/maximum score 44) the lecturers are knowledgeable the lecturers promote a patient-centred approach to consulting the lecturers ridicule (make fun of ) the students the lecturers are authoritarian the lecturers have good communication skills with patients the lecturers are good at providing feedback to students the lecturers provide constructive criticism the lecturers give good demonstrations the lecturers get angry during teaching sessions the lecturers are well prepared for their classes the students appear to irritate the lecturers academic self-perception (8 items/maximum score 32) learning strategies that worked for me before clinical placements still work for me now i am confident about my passing this course i feel i am being well prepared for my profession the preclinical teaching was good preparation for this year’s clinical clerkship work i’m able to practise all i need on the ward i have learnt a lot about empathy in my profession my problem-solving skills are being well developed here much of what i have to learn seems relevant to a career in healthcare perception of atmosphere (12 items/maximum score 48) the atmosphere is relaxed during ward teaching the course is well timetabled cheating is a problem at makerere university college of health sciences the atmosphere is relaxed during theatre practice there are opportunities for me to develop interpersonal skills i feel socially comfortable on the ward the ward atmosphere allows for return demonstration i find the ward experience disappointing i’m able to concentrate on my skills well the enjoyment outweighs the stress of the work on the ward the atmosphere motivates me as a student i feel able to ask the questions i want social self-perception (7 items/maximum score 28) there is a good support system for students on the ward: nurses, doctors and other staff i am too tired to enjoy the ward work i am rarely bored during this placement i have good friends on the ward the places of convenience on the ward are good i seldom feel lonely in the medical school the meals at galloway hostel are pleasant http://atlas.ti http://atlas.ti 113 june 2021, vol. 13, no. 2 ajhpe research in the data; then the data were exported to atlas.ti for analysis. using an inductive approach, quotes were identified and open coding was done by 2 individuals, who later jointly developed a list of codes. these were used to code the rest of the transcripts, and the codes were then arranged into families that constitute the themes. the themes, which were developed deductively and inductively, are based on the fgd guide, as well as discoveries of unexpected perceptions and experiences of the students. the themes were used to describe and shed light on the attributes of the workplace as a learning environment. ethical approval before commencing with data collection, permission was obtained from the ethical committees of makchs (ref.  no.  2015-125), mnrth (ref.  no.  mrec 868), the uganda national council for science and technology (ref.  no.  ss 3935), and the university of the free state (ref.  no.  ecufs 174/2015). participation in the study was voluntary, as the consent forms approved by the institutional review board stated. anonymity of the study participants was ensured by using numbers instead of names on the dreem questionnaire, while participants in the fdgs were assigned and referred to by letters – not by their real names. the fgds were conducted in one of the offices on campus to ensure visual and auditory privacy. confidentiality was ensured by storing the completed dreem questionnaires in a locked drawer that was accessible to only the researcher and his team, while the audio recordings and transcripts were stored as password-protected files on a password-protected laptop belonging to the researcher. results quantitative results completed questionnaires were returned by 170 students; 82 in the fourth year and 88 in the fifth year (table 2), giving a response rate of 78%, which is similar to that of other studies.[8,9] overall perception of the learning environment of the 170 respondents, 12 (7.1%) perceived the learning environment as excellent, 127 (75%) perceived it as having more positives than negatives, 27 (16%) reported that there were many problems, while 3 (1.8%) rated it as very poor (fig. 2). results of the domain sub-analysis are presented as percentages for the whole study population (table  3), while mean scores for individual items are presented in table 4. a total of 114 students (67%) had more positive pol, while 15 (8.8%) viewed teaching negatively (table  2). five of 12 items in this domain had mean scores >3.0, 6 items had means from 2.0 to 3.0, and 1 item scored <2 (table  3). one hundred and eight students (63.9%) perceived the lecturers (pot) as moving in the right direction, while 33 (19.5%) indicated that the lecturers were in need of further training (table  2). mean scores for this domain show only 1 item with a score >3.0 (table 3). for asp, 59 students (34.7%) were confident of performing well, while 85 (50%) reported a positive perception (fig.  2). the mean scores for individual items indicate that, generally, students had a positive asp, with 4 of the 8 items having mean scores >3.0 (table  3). regarding poa, 106 students (62.4%) had a positive attitude, while 49 (28.8%) perceived the atmosphere as having many issues that needed attention (table 2). the mean scores indicate none of the items scoring >3.0, while 3 had scores <2.0 (table 3). in the domain of ssp, 79 students (46.5%) perceived the learning environment as not a nice place, while 74 (43.5%) reported that it was not too bad (table 2). all items in this domain had mean scores <3.0 (table  3), reflecting a social environment with issues. qualitative results three themes emerged from the results of the fgds, i.e. learning opportunities, overcrowding and workplace affordances. learning opportunities according to the students’ perceptions, there were good learning opportunities at the workplace, because of large number of patients, unrestricted access to the patients and a wide case mix. there were also challenges, as illustrated by the following quotes: ‘for mulago as a teaching hospital, the patients are there with all sorts of diseases, so we get the exposure which is a bonus and they want you to attend to them so you can never say you don’t have a patient.’ – fifth year ‘about the working environment here, am very positive about it that there is opportunity to learn, because in mulago, which is a national referral hospital, we get all kinds of patients and conditions, so there is a very big opportunity to learn.’ – fourth year ‘i expected to gain practical skills in addition to enriching my knowledge but i have not yet realised all my expectations, ok, i have gained knowledge, but mostly the practical aspect is a bit lacking, it is still limited.’ – fifth year ‘i know problem-based learning is supposed to be more self-driven; we do  80% of the reading and they give us a little of the 10% but then very poor more positives than negatives 1.8 75.1 7.1 16 many problems excellent fig. 2. overall perceptions of the learning environment. table 2. participant demographics year of study male, n female, n total, n fourth 58 24 82 fifth 64 24 88 total 122 48 170 http://atlas.ti june 2021, vol. 13, no. 2 ajhpe 114 research even this 10% they are not giving it; we have to hustle to get the clinical teaching.’ – fourth year overcrowding the students reported that the wards as learning spaces were overcrowded by students, as illustrated in the following quotes: ‘now, for me, those clinicals, first of all we were so many, you had to be extremely vigorous as you fight to view and you have to stand. i think i wasn’t so aggressive and i reached a point when i would just sit. when people are done, i just ask someone, “what did they say?” and you find one person heard half-way, another one heard another version and another one also heard another version.’ – fourth year ‘you find that there are so many of us; senior house officers, fifth years, and you the fourth years; you are the underdog, you are the lowest in the food chain, and you sometimes have to stand somewhere far from the patient’s bed because the whole place is packed, they are doing something and you can’t see and you learn nothing.’ – fourth year workplace affordances workplace affordances are situational factors that invite and support learner participation, and participants had this to say: ‘there are some [lecturers] who trash what you say, you know introducing something and then someone tells, “that is very wrong! ooh my god you are so stupid, our generation of doctors was better, you want to kill our patients!”’ – fifth year ‘i think some of these doctors have been employed because they excelled in school. someone can excel academically but when they don’t know how to teach, when they don’t have the heart to teach so i think it is better for us to have somebody who can teach us whether they are excellent or not, than somebody who is so excellent but can’t teach.’ – fourth year ‘i think the first thing they should do is to first reorient the lecturers, the doctors or workers, on their duties besides seeing patients, they should be taught how to teach. they should train them every year like in seminars.’ – fifth year other contributors to workplace affordances, such as nurses, paramedics and laboratory personnel, were also not supportive, as illustrated by the following quotes: ‘i think there is a problem with the nurses and yet there is a lot we can also learn from them. i realise that there is this attitude they have about medical students; i think they are not aware. if you ask for any help, they don’t want to help. they tend to keep away everything you are supposed to use on the ward; the gauze, the vacutainers, the gloves, so you sort of have to beg all the time and yet they have this attitude that won’t encourage you to go on.’ – fifth year ‘yes, because some of them are really very unfriendly, they are already biased, like i went to some clinic and the nurse said, “these medical students want to behave as if they are doctors.” it is really our first day there and we do not know what to do, so how can we behave like doctors? then i tried asking another one and she put me off and told me to wait for our doctors to teach us. so, for example, i might come and maybe there are no doctors, does that mean i cannot be taught? so, your day is gone, so it is not nice at all.’ – fourth year discussion overall, the majority of the participants (75.1%) viewed the learning environment as having more positives than negatives (fig. 1). this finding is comparable with results obtained by studies with regard to the education environment of medical training schools in sa and canada.[8,15] the results of the fdgs validated the positive assessment found by dreem among the positive attributes of the workplace at mnrth, i.e. unrestricted access to patients, large patient numbers and wide case mix. these attributes should apply to any learning environment if the goal is an authentic learning experience where students gain knowledge, skills and the right attitudes while experiencing professional practice first-hand during their transition from a student identity to that of a clinical practitioner.[16] there were factors at the workplace that appeared to serve as barriers to learning. among these factors that limited student participation in learning activities were overcrowding and inadequate workplace affordances. participation in activities at the workplace is central to the acquisition of competence, as clinical medicine is learnt by practising, and an environment with adequate workplace affordances motivates students to participate in the activities according to their ability.[17] innovative solutions to address overcrowding in the workplace, such as using satellite learning environments, are, therefore, required to provide sufficient opportunities for all students to participate in workplace activities.[18] in the absence of supported participation in patient care, acquisition of the necessary competence can be compromised, leading to students experiencing selfperceptions of academic inadequacy, which consequently lead to poor learning outcomes.[17] perceptions of learning the students generally had positive pol at the workplace, and teaching was highly regarded (table  2). similar findings are reported by a study done in india.[19] the large number of patients available, a wide case mix and students having easy access to patients are important for competence table 3. dundee ready educational environment measure (dreem) scores by domain domain perceptions of learning (%) perceptions of teachers (%) academic self-perceptions (%) perceptions of atmosphere (%) social self-perceptions (%) learner perception very poor (0.6) abysmal (0.6) feeling of total failure (5.3) a terrible environment (3.5) miserable (8.8) teaching viewed negatively (8.8) in need of training (19.5) many negative aspects (10.0) too many issues (28.8) not a nice place (46.5) a more positive perception (67.1) moving in the right direction (63.9) feeling more on a positive side (50.0) a more positive attitude (62.4) not too bad (43.5) teaching highly thought of (23.5) model lecturers (16.0) confident (34.7) a good feeling overall (5.3) very good socially (1.2) 115 june 2021, vol. 13, no. 2 ajhpe research development, as the students are exposed to real-life experiences during workplace learning. further analysis shows that 5 items in this domain had mean scores of ≥3.0, indicating really positive points. six items, however, had mean scores between 2.0 and 3.0, implying areas that need close review table 4. mean scores of individual items in dundee ready educational environment measure (dreem) domain item mean perceptions of learning (12 items/maximum score 48) i am encouraged to participate during clinical learning sessions 3.28 the clinical teaching is often stimulating 3.07 the teaching is interactive between teacher and student 3.09 the teaching helps me to develop my skills 3.03 the teaching is well focused 2.77 the teaching helps me to develop my confidence 3.15 the clinic time is put to good use 2.53 the teaching over-emphasises factual learning* 1.33 i’m clear about the course learning objectives 2.63 the teaching encourages me to participate 2.99 lifelong learning is emphasised over short-term learning 2.94 the teaching is too teacher controlled* 2.19 perceptions of teachers (11 items/maximum score 44) the lecturers are knowledgeable 3.39 the lecturers promote a patient-centred approach to consulting 2.73 the lecturers ridicule (make fun of ) the students* 2.12 the lecturers are authoritarian* 1.80 the lecturers have good communication skills with patients 2.97 the lecturers are good at providing feedback to students 2.24 the lecturers provide constructive criticism 2.80 the lecturers give good demonstrations 2.83 the lecturers get angry during teaching sessions* 2.15 the lecturers are well prepared for their classes 2.54 the students appear to irritate the lecturers* 2.30 academic self-perceptions (8 items/maximum score 32) learning strategies that worked for me before clinical placements still work for me now 2.00 i am confident about my passing this course 3.20 i feel i am being well prepared for my profession 3.14 the preclinical teaching was good preparation for this year’s clinical clerkship work 2.67 i’m able to practise all i need on the ward 2.26 i have learnt a lot about empathy in my profession 2.83 my problem-solving skills are being well developed here 3.05 much of what i have to learn seems relevant to a career in healthcare 3.26 perceptions of atmosphere (12 items/maximum score 48) the atmosphere is relaxed during ward teaching 1.96 the course is well timetabled 1.91 cheating is a problem at makerere university college of health sciences* 2.25 the atmosphere is relaxed during theatre practice 2.20 there are opportunities for me to develop interpersonal skills 2.95 i feel socially comfortable on the ward 2.58 the ward atmosphere allows for return demonstration 2.38 i find the ward experience disappointing* 2.83 i’m able to concentrate on my skills well 2.48 the enjoyment outweighs the stress of the work on the ward 1.64 the atmosphere motivates me as a student 2.34 i feel able to ask the questions i want 2.85 social self-perceptions (7 items/maximum score 28) there is a good support system for students on the ward: nurses, doctors and other staff 2.11 i am too tired to enjoy the ward work* 2.29 i am rarely bored during this placement 2.21 i have good friends on the ward 2.93 the places of convenience on the ward are good 1.00 i seldom feel lonely in the medical school 2.27 the meals at galloway hostel are pleasant 0.38 *negative statements for which the likert scale score was reversed. june 2021, vol. 13, no. 2 ajhpe 116 research (table  3), and that students prefer a more focused approach to clinical teaching, better utilisation of clinic time, clearer learning objectives and greater participation during workplace learning. perceptions of teachers while lecturers were mainly perceived as moving in the right direction and being knowledgeable, some were perceived as being in need of further training in clinical teaching (table  2). this opinion was validated by the participants during the fgds, when they said, ‘the lecturers needed to be taught how to teach’. many physicians are experts in their fields, but their communication-related attitudes and abilities are lacking, which can have a negative impact on students’ competence development.[20] among the attributes clinical lecturers are expected to have, such as interpersonal skills, ability to teach, professional skills and administrative skills, ability to teach was ranked highly by the medical students in one study.[21] beyond content expertise, clinical lecturers should, therefore, have an all-round capability to diagnose patients based on the clinical findings, in addition to ‘diagnosing’ students by observing their skills, attitudes and knowledge expressed during the teacher-student encounter.[22] clinical lecturers, therefore, need to be empowered to perform these tasks better, which could be achieved through focused faculty-development sessions. academic self-perceptions a cumulative percentage (85%) of students expressed a positive asp, implying that the majority were hopeful of performing well, as the workplace at mnrth was supportive of undergraduate learning (table  2). the medical school is essentially a community of high achievers, and asp can be affected by actual individual achievement, or by comparison with peers. asp reflects how students perceive themselves as fitting into the context of the learning environment,[23] which plays a very important role in ensuring the highest possible academic achievement and student satisfaction. when students perceive that the strategies they have used before suit them within the context of the learning environment, it gives them a sense of assurance in their ability to perform, they become more confident and they are encouraged to perform to their highest potential.[19] the small percentage (10%) of participants who perceived the workplace as having many negative aspects, and the 5% who reported feelings of total failure, represent a group of students whose expectations were not met during workplace learning; the attribute with the lowest mean score in this domain related to opportunities to practise at the workplace. students with negative perceptions of the learning environment are likely to associate this environment with poor learning outcomes.[17] similar findings are reported in an indian study, whose authors recommend that future studies should explore the reasons behind the scores during fgds.[19] to improve competence development during workplace learning, supported participation should be prioritised. there should be greater appreciation of content and situations in which content could be applied than of mere knowledge acquisition, which may be required mainly for passing tests.[20,24] perceptions of atmosphere while most participants had positive perceptions of the learning atmosphere, close to one-third (29%) perceived the atmosphere as having several issues that need changing (table 2). all the items in this domain had mean scores of <3.0, indicating a need to enhance the atmosphere. three items that scored <2.0 indicate real problem areas that require closer scrutiny (table 3). the participants identified a tense atmosphere during ward teaching, improper timetabling, and too much stress caused  by work as areas that needed attention. education stakeholders should, therefore, view the learning atmosphere as an ecosystem that is composed of lecturers, patients and students to contextualise the importance of the complex interaction between these entities for cognitive, behavioural and psychomotor applications during competence development.[23] social self-perceptions the social climate in a teaching institution has important implications for  the learning experience.[19] the ssp domain produced results that were quite different from those of the other domains, with an almost equal number of students perceiving the learning environment as ‘not too bad’ (43.5%) and as ‘not a nice place’ (46.5%). at the extremes, a greater percentage of participants perceived the learning environment as ‘miserable socially’ (8.8%) than those who judged it to be ‘very good socially’ (1.2%). similar results were reported by studies in nigeria and sa.[7,8] all items in this domain had mean scores <3.0, which is worrying, because these scores  reflect a learning environment  with major issues (table  3). this domain returned items with the lowest mean scores throughout dreem, e.g. places of convenience scored 1, and meals 0.38. this reflects problem areas that need to be examined closely, because these are basic needs on maslow’s hierarchy of needs.[25] meals are an important part of the social environment, and unpleasant meals can be a source of stress and lead to poor academic performance. studies have demonstrated that, although brain maturation occurs early in life, certain functions continue to  develop  into adulthood, and nutrition can play a role in the development of abstract thinking and problem-solving skills.[26] there is, therefore, a need to create a learning environment in which social amenities are available and  interaction is promoted through good social networks among students and faculty. doing so will minimise work stress and promote learning. study limitations a limitation of this study was that only the perceptions of students were explored, excluding faculty involved in clinical teaching of undergraduates at this medical school. however, this limitation is mitigated by the use of validated data collection tools and triangulation with quantitative and qualitative methods, which provided corroboration of findings. conclusions overall, the majority of students perceived the learning environment as having more positives than negatives, which created authentic learning opportunities based on the availability of patients, a wide case mix, unrestricted access to patients and knowledgeable lecturers. the areas of concern included overcrowding and inadequate workplace affordances, improper approaches to clinical teaching, with few opportunities for supported participation, probably due to lecturers’ inadequate clinical teaching skills, and a stressful learning atmosphere with inadequate social support networks. recommendations effective workplace learning at mnrth requires that the positive attributes pointed out in this study are enhanced, while the negatives are addressed. 117 june 2021, vol. 13, no. 2 ajhpe research while lecturers were expected to provide background knowledge, for which they were rated highly, the transition from a student identity to that of a clinical practitioner requires that students are provided with opportunities by the lecturers for supported participation in clinical activities at the workplace. it therefore becomes imperative that educational stakeholders focus efforts on improving workplace learning by addressing factors that encourage students to appreciate content and situations in which it may be applied – more than gaining knowledge for the purpose of passing an examination. areas of further research because of the complexity of workplace learning, further research is needed to determine the perceptions of other stakeholders, such as lecturers and administrators, and possibly patients. armed with information from all these stakeholders, any suggestions for improvement could be subjected to a delphi study to generate recommendations for improving the workplace as a learning environment using an all-inclusive approach. declaration. none. acknowledgements. we would like to acknowledge the students who agreed to participate in the study, and the research assistants who assisted with data collection. author contributions. mnk contributed to the conceptualisation of the idea, the design of the study, data collection and analysis, and manuscript writing; sk contributed to conceptualisation and concretisation of the idea, the design of the study and manuscript writing; hs contributed to conceptualisation and concretisation of the research idea, the design of the study and manuscript writing; and mpj contributed to the conceptualisation and concretisation of the research idea, the design of the study and writing the manuscript. funding. most of the funding for this work was from personal savings. additional funding was obtained from two sources: (i) nurture (grant number d43tw010132) to attend some courses pertinent to this work; supported by the office of the director national institutes of health (od), national institute of dental and craniofacial research (nidcr), national institute of neurological disorders and stroke (ninds), national heart, lung, and blood institute (nhlbi), fogarty international center (fic), national institute on minority health and health disparities (nimhd); and (ii)  fogarty international center of the national institutes of health, us department of state’s office of the us global aids coordinator and health diplomacy (s/gac), and the president’s emergency plan for aids relief (pepfar) (award number 1r25tw011213) for ajhpe page fees. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. conflicts of interest. none. 1. sajjad m, mahboob u. improving workplace-based learning for undergraduate medical students. pak j med sci 2015;31(5):1-3. https://doi.org/10.12669/pjms.315.7687 2. akaike m, fukutomi m, nagamune m, et  al. simulation-based medical education in clinical skills laboratory. j med invest 2012;59(1-2):28-35. https://doi.org/10.2152/jmi.59.28 3. weinberger s. the medical educator in the 21st century: a personal perspective. transact am clin climatolog assoc 2009;120:239-248. 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 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(2002). part 3: a practical guide to using the dundee ready education environment measure (dreem). in: genn jm, ed. amee education guide no. 23, curriculum, environment, climate, quality and change in medical education: a unifying perspective. dundee, uk: association of medical education in europe, 2002. 8. schoeman s, raphuting r, sebakeng p, et al. assessment of the education environment of senior medical students at the university of the free state, bloemfontein, south africa. afr j health professions educ 2014;6(2):143-149. https://doi.org/10.7196/ajhpe.397 9. tontuş ho. dreem; dreams of the educational environment as its effect on education result of 11 medical faculties of turkey. j exp clin med 2010;27:104-108. https://doi.org/10.5835/jecm.omu.27.03.002 10. vaughan b, carter a, macfarlane c, et  al. the dreem, part 1: measurement of the educational environment in an osteopathy teaching program. bmc med educ 2014;14(1):1-11. https://doi.org/10.1186/1472-6920-14-99 11. koohpayehzadeh j, hashemi a, solatani arabshahi k, et al. assessing validity and reliability of dundee ready educational environment measure (dreem) in iran. med j islam repub iran 2014;28:60. 12. östlund u, kidd l, wengstöm y, et  al. combining qualitative and quantitative research within mixed method research designs: a methodological review. int j nurs stud 2011;48(3):369-383. https://doi.org/10.1016/j. ijnurstu.2010.10.005 13. gale nk, heath g, cameron e, et al. using the framework method for the analysis of qualitative data in multidisciplinary health research. bmc med res methodol 2013;13:117. https://doi.org/10.1186/1471-2288-13-117 14. woods m, paulus t, atkins dp, et  al. advancing qualitative research using qualitative data analysis software (qdas)? reviewing potential versus practice in published studies using atlas.ti and nvivo, 1994 2013. soc sci computer rev 2015;34(5):597-617. https://doi.org/10.1177/0894439315596311 15. veerapen k, mcaleer s. students’ perception of the learning environment in a distributed medical programme. med educ 2010;15(1):5168-5177. https://doi.org/10.3402/meo.v15i0.5168 16. magnier k, wang r, dale vhm, et al. enhancing clinical learning in the workplace: a qualitative study. vet rec 2011;169:682. https://doi.org/10.1136/vr.100297 17. chen hc, ten cate o, o’sullivan p, et al. students’ goal orientations, perceptions of early clinical experiences and learning outcomes. med educ 2016;50(2):203-213. https://doi.org/10.1111/medu.12885 18. kibore mw, daniels ja, child mj, et  al. kenyan medical student and consultant experiences in a pilot decentralised training program at the university of nairobi. educ health (abingdon) 2014;27(2):170-176. https://doi.org/10.4103/1357-6283.143778 19. pai pg, menezes v, srikanth, et  al. medical students’ perception of their educational environment in western maharashtra in medical college using dreem scale. j clin diagn res 2014;8(1):103-107. https://doi. org/10.7860/jcdr/2014/5559.3944 20. pimmer c, pachler n, genewein u. contextual dynamics in clinical workplaces: learning from doctor-doctor consultations. med educ 2013;47(5):463-475. https://doi.org/10.1111/medu.12130 21. kiani q, umar s, iqbal m. what do medical students expect in a teacher? clin teach 2014;11(3):203-208. https:// doi.org/10.1111/tct.12109 22. salam a, siraj hh, mohamad n, et al. bedside teaching in undergraduate medical education: issues, strategies, and new models for better preparation of new generation doctors. iran j med sci 2011;36(1):1-6. 23. patel rs, tarrant c, bonas s, et  al. medical students’ personal experience of high-stakes failure: case studies using interpretative phenomenological analysis. bmc med educ 2015;15(86). https://doi.org/10.1186/s12909015-0371-9 24. barab sa, roth w-m. curriculum-based ecosystems: supporting knowing from an ecological perspective. educ res 2006;35(5):3-13. https://doi.org/10.3102/0013189x035005003 25. kenrick dt, griskevicius v, neuberg sl, et al. renovating the pyramid of needs: contemporary extensions built upon ancient foundations. perspect psychol sci 2010;5(3):292-314. https://doi.org/10.1177/1745691610369469 26. correa-burrows p, burrows r, blanco e, et al. nutritional quality of diet and academic performance in chilean students. bull world health organ 2016;94(3):185-192. https://doi.org/10.2471/blt.15.161315 accepted 29 july 2020. https://doi.org/10.12669/pjms.315.7687 https://doi.org/10.2152/jmi.59.28 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://www.umdpc.com/resources/brochures/annual report fy 2016-2017.pdf https://www.umdpc.com/resources/brochures/annual report fy 2016-2017.pdf https://doi.org/10.7196/ajhpe.397 https://doi.org/10.5835/jecm.omu.27.03.002 https://doi.org/10.1186/1472-6920-14-99 https://doi.org/10.1016/j.ijnurstu.2010.10.005 https://doi.org/10.1016/j.ijnurstu.2010.10.005 https://doi.org/10.1186/1471-2288-13-117 http://atlas.ti https://doi.org/10.1177/0894439315596311 https://doi.org/10.3402/meo.v15i0.5168 https://doi.org/10.1136/vr.100297 https://doi.org/10.1111/medu.12885 https://doi.org/10.4103/1357-6283.143778 https://doi.org/10.7860/jcdr/2014/5559.3944 https://doi.org/10.7860/jcdr/2014/5559.3944 https://doi.org/10.1111/medu.12130 https://doi.org/10.1111/tct.12109 https://doi.org/10.1111/tct.12109 https://doi.org/10.1186/s12909-015-0371-9 https://doi.org/10.1186/s12909-015-0371-9 https://doi.org/10.3102/0013189x035005003 https://doi.org/10.1177/1745691610369469 https://doi.org/10.2471/blt.15.161315 october 2020, vol. 12, no. 3 ajhpe 95 short communication why was the idea necessary (problem)? health professions education institutions across the globe are adopting competency-based education (cbe) models. [1] inherent in cbe is learner centredness, which emphasises the contribution of learners to the learning process. nursing education institutions (neis) in lesotho adopted cbe for all undergraduate nursing programmes, inspired by the government’s need for improved quality of learning that aligns with global trends in health professions education.[2] nurse educators from neis who adopted cbe use group work as a dominant teaching strategy to enhance learner centredness. group work, when appropriately applied, is associated with enhanced teamwork, motivation and deep learning.[3] nursing students in neis in lesotho asynchronously prepare for class activities through engaging with specified learning resources, such as study guides and workbooks. nurse educators moderate learning in class and randomly assign students to small groups. the use of random allocation is deliberate to prepare them for the authentic clinical environment, where there is no autonomy in choosing team members. as a result, differences in learning styles, personalities and experiences were not taken into account. each group collectively solves a specific problem, applying knowledge learnt during the asynchronous time. however, educators observed poor engagement, dominance by some students and general disparities in the performance among the groups. therefore, in view of these challenges, we explored how the students experienced group work. what was tried (approach)? student nurses’ (n=30) experiences of group work were explored through qualitative research. these student nurses were enrolled in a competencybased nursing programme and had experienced group work in different modules, which were facilitated by various nurse educators. data were collected by a research assistant, who facilitated two focus group discussions using a semi-structured interview guide. data were analysed using creswell’s method of thematic analysis.[4] ethical approval was granted by the ministry of health, lesotho (ref. no. 68-2018) and all participants gave informed consent. what were the lessons learnt (outcomes)? participants thought that their diverse personalities influenced the functionalities of groups. in the initial stages of group work, time was spent on understanding the personalities of the group members, leaving little time to meet the specified learning outcomes. the establishment of leadership seemed to enhance group cohesion and minimised conflicts. however, participants expressed the need for a structured group conflict-resolution strategy. participants expected nurse educators to frequently reward the best performing groups as a means of motivating all groups to perform better. conclusions nursing programmes are being modified to provide quality learning experiences for students. group work has the potential to improve the learning experience of nursing students in cbe. nonetheless, factors that negatively affect group work need to be addressed to maximise the benefits. therefore, nurse educators need to apply innovative approaches to motivate collaboration in the groups, such as game-based learning, and establish appropriate strategies to ensure leadership and conflict resolution. declaration. none. acknowledgements. the authors acknowledge dr m gonzaga (makerere university, uganda), dr n mannathoko (university of botswana) and dr w cordier (university of pretoria) for their expert inputs and for critically reading this manuscript. the subsaharan africa-faimer regional institute (safri) is acknowledged for providing the platform for incubating and developing this project. author contributions. all authors contributed to the conceptualisation, design and execution of this study. all authors equally contributed to the writing of the article. funding. none. conflicts of interest. none. 1. ross s, hauer ke, van melle e. outcomes are what matter: competency-based medical education gets us to our goal. mededpublish 2018;12:7. https://doi.org/10.15694/mep.2018.0000085.1 2. nyoni cn, botma y. sustaining a newly implemented competence-based midwifery programme in lesotho: emerging issues. midwifery 2018;59:115-117. https://doi.org/10.1016/j.midw.2018.01.015 3. ladley d, wilkinson i, young l. the impact of individual versus group rewards on work group performance and cooperation: a computational social science approach. j business res 2015;68(11):2412. https://doi.org/10.1016/j. jbusres.2015.02.020 4. creswell jw. research design: qualitative, quantitative and mixed methods approaches. 3rd ed. singapore: sage, 2009. accepted 29 june 2020. afr j health professions educ 2020;12(3):95. https://doi.org/10.7196/ajhpe.2020.v12i3.1358 group work in a nursing curriculum: a teaching strategy to enhance student engagement e mukurunge,1 mnsg; l badlangana,2 phd; c n nyoni,3 phd 1 paray school of nursing, thaba tseka, lesotho 2 department of biomedical sciences, faculty of medicine, university of botswana, gaborone, botswana 3 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: e mukurunge (evamukurunge@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.15694/mep.2018.0000085.1 https://doi.org/10.1016/j.midw.2018.01.015 https://doi.org/10.1016/j.jbusres.2015.02.020 https://doi.org/10.1016/j.jbusres.2015.02.020 june 2020, vol. 12, no. 2 ajhpe 53 short research report botswana is a southern african middle-income country of 2.2 million people, with a stable economic and political profile.[1] the first medical school in the country, at the university of botswana (ub), was opened in august 2009 and, courageously, 5 months later in january 2010, postgraduate medical specialisation programmes were launched. this establishment of local postgraduate specialisation programmes was seen as imperative for ub medical graduates’ career paths, encouraging continuing medical employment in botswana and thus providing local medical specialist graduates to reduce the significant country-wide shortages.[2] methods while establishing the ub medical school, botswana’s health system was recognised as not yet able to ensure complete and high-quality in-country training for all postgraduate specialty programmes. ub staff engaged in extensive benchmarking exercises for high-quality and locally relevant specialist training programmes by examining curriculums, duration of training, models of governance and relationships with health services and government departments. programmes in the uk, canada, usa, australia, east africa and south africa (sa) (largest regional neighbour) were reviewed. this benchmarking exercise highlighted sa’s programme as the most appropriate owing to internationally recognised medical education standards, comparable disease profiles and cultural similarities. sa’s master of medicine (mmed) programmes are well established postgraduate training programmes with clinical, academic and research requirements over a 4-year curriculum. sa doctors who wish to specialise join these programmes, enrol in sa academic institutions as postgraduate students and work as residents in clinical rotations at the major teaching hospitals. educational and clinical progress are measured by performance in the first (primary) and final (fellowship) specialty written and oral examinations run by the relevant medical specialty college in conjunction with the colleges of medicine of sa (cmsa). many sub-saharan countries and individual medical practitioners utilise sa for full postgraduate medical education, but ub suggested a novel hybrid partnership, where doctors from botswana enrolled in the ub mmed programme and performed the cmsa’s relevant medical speciality training in both countries consecutively. the following specialties introduced this hybrid arrangement: anaesthesia, emergency medicine, internal medicine, pathology and paediatrics. the departments of family medicine and public health had well-established relationships with sa medical institutions and greater numbers of local faculty, and therefore elected to deliver their entire programmes in botswana, with academic assistance from sa. the clinical and public health training platforms in the country were considered adequate for successful training. the five ub specialty training programmes that decided to adapt and use the sa 4-year specialty curriculums, including the cmsa examinations and a research dissertation to fit ub regulations, required their programmes to be endorsed by the ub medical faculty and ub senate. representation was made at various sa academic medical institutions through the cmsa to allow ub mmed students to initiate training in botswana and then continue training in sa in accredited centres. ub mmed students would work, study and pass their primary cmsa examinations in botswana over the first 2 years and then move to sa, background. sub-saharan africa has a significant shortage of healthcare providers, and educational collaborations are recommended as one of the crucial steps to increase the medical workforce. objectives. to describe a successful innovative postgraduate medical specialisation programme involving two neighbouring african countries, botswana and south africa (sa). methods. after lengthy consultative processes, a postgraduate training programme was approved between the university of botswana and the colleges of medicine of sa (cmsa). this programme utilised a 4-year master of medicine (mmed) curriculum for consecutive training and examinations in both countries. extensive collaborations with government and regulatory bodies in both countries were required to facilitate the programme. results. despite initial diverse challenges, the two countries continue to support the partnership, with 40 local doctors having graduated as medical specialists since 2014, and additional mmed programmes in development for botswana. conclusions. the university of botswana and cmsa partnership model is a novel and sustainable cross-border collaboration with significant benefits for both health systems and individual trainees. it is possible to have a successful and high-quality specialisation programme without all the resources in place by being innovative and leveraging external partnerships and collaborations. this partnership hopes to encourage other developing countries to explore similar associations. afr j health professions educ 2020;12(2):53-55. https://doi.org/10.7196/ajhpe.2020.v12i2.1221 postgraduate medical specialty training for botswana: a successful innovative partnership with south africa m cox,1,2 bmed, facem, miph; j masunge,2 mb chb, dch (sa), fcpaed (sa); o nkomazana,2 mb chb, fcopth (sa), msc, phd 1 faculty of medicine and school of public health, university of sydney, australia 2 faculty of medicine, sir ketumile masire teaching hospital, university of botswana, gaborone, botswana corresponding author: m cox (megan.cox@sydney.edu.au) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 54 june 2020, vol. 12, no. 2 ajhpe short research report functioning as supernumerary doctors, but receiving the same clinical and academic supervision as their sa counterparts. this pathway is demonstrated in fig. 1. working in sa allowed mmed students to receive exposure and training for 18 24 months in many areas not yet available in botswana, depending on the specialty, and sit for the cmsa fellowship examination. all mmed programmes were open to botswana citizens, as well as to noncitizens, on a full-time basis. applicants were required to have completed medical training at a recognised medical school and have been in active clinical practice for at least 2 years, with financial sponsorship arranged before enrolment and confirmation of selection. doctors who successfully completed all ub mmed academic, clinical and research requirements qualified for the mmed degree from ub and specialist registration with the botswana health professions council, but would not be registered as a specialist by the health professions council of sa (hpcsa). this arrangement hoped to encourage the growth of specialist clinical practice in botswana. a large recruitment process by ub employed local and expatriate medical staff for the new medical school curriculum and work in newly developed teaching hospitals in botswana.[3] recruitment was slow, and some specialties staff proved extremely difficult to recruit or retain; therefore, timing of postgraduate programmes planned and initiated at ub occurred in relation to the availability of recruited staff.[4] internal medicine and paediatrics were the first to start in january 2010, followed by anaesthesia, family medicine, public health and emergency medicine the following year. anatomical pathology was the last programme to be introduced in january 2013. ub mmed students’ enrolment and graduation numbers are shown in table 1. results significant challenges occurred early in the first 2 years. in 2012, various logistical, human resource and financial challenges at ub led to uncertainty in both the undergraduate and postgraduate programmes. by 2013, one of the postgraduate programmes collapsed and ub mmed students had left many of the training programmes.[4] the departure of significant numbers of senior ub clinicians left overwhelming academic and clinical workloads for those remaining; most programmes decided to decrease or not have yearly intakes. medical registration with the hpcsa was lengthier than expected, and ub mmed students were delayed longer than expected for official sa student visas. the botswana ministry of health sponsored most ub mmed students. on starting supernumerary training in sa, the students found their salaries reduced owing to a botswana government policy. the temporary loss of young hospital-based trainee specialists led to an increased burden on the botswana health system, and trainees moving to sa left behind their young families, adding to personal and economic burdens. the four hybrid programmes based on the 4-year sa curriculum required extensions by an additional 1 2 years owing to all these challenges. a breakthrough occurred in 2014, when the ub medical school celebrated the graduation of the country’s first 33 locally trained doctors and the first ub paediatric mmed student successfully completed the cmsa fellowship examination while training in cape town. more ub mmed students completed sa fellowship examinations in internal medicine and paediatrics the following year. these high-profile successes spurred on the mmed students and their supervisors, leading to graduations every year since. to date, 40 specialists have graduated with an mmed degree from ub, 20  of them using this novel hybrid programme that has led to many ongoing benefits. benefits to botswana the ub medical school adopted a teaching health system whereby ub medical students and academic staff are present in numerous health centres in botswana, in this way increasing healthcare providers and improving healthcare at all levels.[3] ub mmed students work, train and table 1. university of botswana mmed students’ enrolment and graduation ub mmed programme students enrolled in training (2010 2018), n students who graduated (2014 2018), n internal medicine 33 6 paediatrics 39 12 emergency medicine 9 3 anatomical pathology 10 0 anaesthesia* 6 5 family medicine† 32 10 public health† 17 4 total 146 40 ub = university of botswana; mmed = master of medicine. * the anaesthesia programme was suspended in 2013 and all students relocated to south africa for the entire duration of training. †family medicine and public health programmes were conducted in botswana only. doctor accepted at ub as mmed student and enrols in relevant medical specialty programme at ub and cmsa research doctor passes the �rst cmsa specialty examination while working in botswana doctor moves to sa in third year and works in the relevant medical specialty programme in sa teaching institution doctor passes �nal cmsa specialty examination in sa and receives the relevant fellowship quali�cation doctor returns to botswana, completes research component and graduates from ub with an mmed doctor recognised as a medical specialist in botswana with an mmed (ub) and fellowship (cmsa) fig. 1. proposed hybrid pathway for ub/cmsa specialist training collaboration. (ub = university of botswana; mmed = master of medicine; cmsa = colleges of medicine of south africa; sa = south africa.) june 2020, vol. 12, no. 2 ajhpe 55 short research report teach in this system, showcasing a locally based postgraduate programme for the many ub medical students who, in keeping with international trends, express an intent to specialise after graduation.[5] for ub mmed students in sa, ongoing clinical supervision from sa specialists provided objective assessments of their clinical and academic progress for ub faculty. sa  medical specialists also provided mentorship in educational support to ub medical faculty programmes through frequent curriculum and programme reviews. relevant ub faculty were invited to assist with official cmsa examinations, improving their examination and academic development skills. progress is being made to match the duration of the ub mmed students’ curriculum with the sa 4-year curriculum. the research requirement was a major hurdle regarding the 4-year completion, as identified by ub faculty. ub faculty have been mentored in research principles, have been involved in local research partnerships and have established clearer guidelines and pathways for mmed research dissertations to be achieved earlier in the curriculum. leveraging on the successes and experiences of these existing mmed programmes, new ub postgraduate specialist medical programmes in psychiatry, surgery and obstetrics and gynaecology are being developed and hope to be ready in 2020. the increasing numbers of ub-trained specialists have not only improved the health system capacity but also increased the ability to train postgraduate specialists in botswana. this progress envisages ub shortening some of the sa rotations and eventually fully localising some of the mmed programmes. evaluations of all ub mmed programmes and postgraduation career pathways are planned. benefits to south africa ub mmed students and those from other countries live, train and work in sa on a supernumerary arrangement. they provide essential and muchneeded service at health institutions at no cost to the sa economy, and also participate in healthcare education to students and junior doctors at these institutions. this educational collaboration demonstrates that the sa medical education system accommodates variable levels of training residents, from those who do their entire training in sa, to those who spend a limited time in sa, such as the students in the hybrid arrangement with the ub mmed programme. the fact that the sa medical education system continues to complete this successfully over many years, indicates that they have significant expertise in various training needs. the adoption of the sa curriculum in botswana raises the profile of sa medical specialisation programmes and promotes their healthcare system regionally and internationally. conclusions the successful graduation of 40 local medical specialists since 2014, demonstrates that it is possible to have a successful and high-quality medical specialisation programme, without all the resources in place, by being innovative and leveraging external partnerships and local collaborations. frequent consultations with government health and finance departments, medical specialist colleges and registration bodies in botswana and sa were crucial for this productive health education and training partnership. the success of this novel hybrid specialisation programme and the benefits to both countries should encourage further networking and research between them, as well as inspire academic medical institutions in other developing countries to consider implementing similar partnerships. declaration. none. acknowledgements. the authors would like to acknowledge the assistance of the many staff from the botswana ministry of health and university of botswana, who were pivotal to the success of this partnership. author contributions. mc and jm wrote the article; all three authors edited the article and approved the final version. funding. none. conflicts of interest. none. 1. world health organization. who country statistics – botswana. geneva: who, 2019. 2. nkomazana o, peersman w, willcox m, mash r, phaladze n. human resources for health in botswana: the results of in-country database and reports analysis. afr j prim health care fam med 2014;6(1):e1-e8. https://doi.org/10.4102/phcfm.v6i1.716 3. mokone gg, kebaetse m, wright j, et al. establishing a new medical school: botswana’s experience. acad med 2014;89(80):s83-s87. https://doi.org/10.1097/acm.0000000000000329 4. kebaetse m, mokone gg, badlangana l, mazhani l. academic staff recruitment and retention challenges at the university of botswana medical school. s afr med j 2016;106(7):730-734. https://doi.org/10.7196/samj.2016. v106i7.10482 5. rukewe a, abebe wa, fatiregun aa, kgantshang m. specialty preferences among medical students in botswana. bmc res notes 2017;10(1):195. https://doi.org/10.1186/s13104-017-2523-y accepted 17 october 2019. https://doi.org/10.4102/phcfm.v6i1.716 https://doi.org/10.1097/acm.0000000000000329 https://doi.org/10.7196/samj.2016.v106i7.10482 https://doi.org/10.7196/samj.2016.v106i7.10482 https://doi.org/10.1186/s13104-017-2523-y november 2020, vol. 12, no. 4 ajhpe 186 research curriculum transformation in higher education institutions contributes to enhancing the quality of graduates and prepares them to address emerging socioeconomic and health challenges in different communities.[1,2] the successful execution of a transformed curriculum depends on the capability of the faculty as the drivers of curriculum implementation.[3] however, transforming the curriculum from one learning theory to another that is underpinned by different principles and pedagogical approaches can challenge the educators’ existing skill set. ill-equipped faculty may struggle to implement the curriculum as intended, thereby necessitating support strategies to enhance their abilities to appropriately enact the transformed curriculum. therefore, educational institutions embarking on curriculum transformation need to proactively formulate clear strategies for relevant ongoing faculty development to support the change process.[4] however, planning and undertaking formal faculty development and capacitybuilding interventions in lowand middle-income countries (lmics) may be deterred by limited resources. therefore, lmics embarking on curriculum transformation may benefit from affordable support strategies such as peer support. evidence shows that peer support can sustain and improve the outcomes of an innovation.[5-7] peers can support one another through encouragement and by providing emotional support and information to improve knowledge and skills. such support activities and exemplar behaviour may increase peers’ self-efficacy and enhance the implementation of the change process. bandura[8] highlights vicarious experience and verbal persuasion as some of the means by which peers can support one another. peer support activities could be compromised by the absence of a structured approach. the researchers argue that guidelines for peer support can give direction and enhance the interactions of peers during the change process, as with curriculum innovation. this article describes the guidelines for peer support developed for educators engaged in curriculum change in nursing education in lesotho, a low-income country in southern africa. the context of this study is the implementation of curriculum innovation in the midwifery programme in lesotho. in 2014, nursing education institutions in lesotho implemented the first competency-based curriculum (cbc) in the 1-year midwifery programme. the transformed curriculum required a new skill set among nurse educators, who were at different levels of readiness. however, the institutions had no deliberate plan for ongoing support or faculty development. naturally, the early adopters of the new curriculum provided unstructured support to their peers. although the unstructured peer support during the midwifery cbc was successful, there were some limitations, such as lack of administrative commitment, lack of accountability and lack of monitoring and evaluation (m&e).[9] methods the practice guidelines were developed through a qualitative research design using multiple data collection methods, guided by the world health organization (who) handbook for guideline development as a framework.[10,11] the guideline development process entailed three separate phases, each addressing a specific objective(s) through interrelated studies (fig. 1). the study conducted in phase i synthesised existing peer support strategies background. curriculum transformation in nursing education addresses changing healthcare needs of communities. however, without ongoing support of educators, the fidelity of curriculum enactment could be compromised. nursing education institutions in lesotho implemented a competencybased curriculum that required novel pedagogical approaches. new facilitation approaches can challenge implementers, as was observed during the implementation of a new curriculum for the midwifery programme in lesotho. without ongoing faculty development and support, the educators resorted to supporting one another. however, the sustainability and effectiveness of the unstructured peer support could be compromised; hence the need to develop guidelines to enhance peer support among educators during curriculum innovation. objective. to develop and validate guidelines to enhance peer support among educators during curriculum innovation. methods. a qualitative research design with multiple data collection methods was conducted, guided by the world health organization handbook for guideline development as the framework. three interrelated phases, inclusive of an integrative review, an exploratory qualitative study, guideline development and validation, were conducted. external reviewers validated the developed guidelines by means of a delphi survey. results. five priority areas were identified for the practice guidelines, i.e. attributes of peer supporters, peer support strategies, content/support needs, outcomes of peer support, and monitoring and evaluation of the peer support strategy. recommendations were formulated for each priority area. conclusion. these practice guidelines provide relevant recommendations that can enhance peer support among educators in nursing education programmes during curriculum innovation. the recommendations serve as a blueprint and provide direction for the structured peer support engagements. afr j health professions educ 2020;12(4):186-190. https://doi.org/10.7196/ajhpe.2020.v12i4.1388 practice guidelines for peer support among educators during a curriculum innovation m shawa, bsc nursing, mph; y botma, phd school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m shawa (mirriamshawa06@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 187 november 2020, vol. 12, no. 4 ajhpe research that enhanced the implementation of an innovation or new programme among professionals between 2000 and 2016 through an integrative review. the details and findings of the integrative review have been reported elsewhere.[11] phase ii entailed a qualitative study that described the experiences of midwife educators regarding peer support during the implementation of a new curriculum in lesotho. data were collected from 12 midwife educators through unstructured interviews, which were recorded, transcribed verbatim and analysed inductively. the details and findings of this study are reported elsewhere.[12] the third and final phase involved triangulation of evidence from the studies of the two preceding phases, followed by development and validation of the guidelines for peer support. in line with the who handbook for guideline development,[11] the researcher established a task team consisting of a methodology expert and curriculum specialist, a faculty development expert knowledgeable regarding peer support and the researcher. based on the triangulated evidence from the studies of the preceding two phases, the task team identified, discussed and agreed on priority areas and recommendations through consensus. secret voting was used to reach a decision whenever there was a disagreement. five priority areas and seven recommendations were formulated and evaluated against the quality assessment framework described in the handbook for guideline development.[11] validation of the guidelines was conducted by a panel of external reviewers through a delphi survey. a detailed description of the development process and the guidelines are presented in the supplementary material (http://ajhpe.org.za/public/files/1388.pdf ). rigour of the guideline development process validation by an expert panel contributed to the rigour of the development of the guidelines. the task team purposefully identified 16 experts in nursing education and mentorship from africa and asia, based on their qualifications, expertise and experience. nine reviewers accepted the invitation to participate in the delphi survey. the expert panel used the 23-item appraisal of guideline for research and evaluation (agree ii) tool to evaluate the guidelines through a two-cycle delphi survey.[13,14] the agree ii tool addresses 6 domains: • scope and purpose • stakeholder involvement • rigour of development • clarity and presentation • applicability • editorial independence. the response rates during rounds i and ii of the delphi survey were 89% and 75%, respectively. hasson and mckenna,[14] citing sumsion, suggest that a response rate of 70% is rigorous for a delphi survey. the responses from the expert reviewers were analysed using the proportions of agreement for each of the items on the agree ii tool. the task team made amendments and consolidated the recommendations based on the analyses of both rounds of the delphi survey. fig. 2 summarises the guideline validation process. ethical approval ethical approval was obtained from the health sciences research ethics committee, university of the free state (ref. no. hsrec 28/2017) and the lesotho ministry of health research and ethics committee (ref. no. phase i research objectives phase ii research objectives triangulation of �ndings from phases i and ii develop guidelines to enhance peer support among nurse educators during curricular innovation using the who handbook[11] validate the developed guidelines through a delphi survey describe the existing peer support strategies that enhance implementation of an innovation through an integrative review describe the experiences of nurse educators regarding peer support during implementation of the midwifery cbc curriculum, using an exploratory qualitative study phase iii research objectives fig. 1. methodological process for guideline development. (cbc = competencybased curriculum; who = world health organization.) fig. 2. summary of the guideline validation process. • population: external reviewers, n=9 • response rate, 89% • items, n=17 (>80% agreement) • items, n=6 (<80% agreement) • population: external reviewers, n=6 • response rate, 75% • >90% agreement round 1 round 2 consolidation http://ajhpe.org.za/public/files/1388.pdf november 2020, vol. 12, no. 4 ajhpe 188 research id 91-2017). all participants in the qualitative study and the delphi survey received detailed information and participated voluntarily. the external reviewers remained anonymous to one another throughout the validation process.[14] results five priority areas and seven recommendations were developed for the peer support guidelines. the priority areas are as follows: priority area 1: attributes of peer supporters this priority area focuses on the qualifications, capabilities and qualities of peer supporters. evidence suggests that peer supporters require a higher qualification and expertise in a specific discipline, such as a master’s or doctoral degree in nursing/health professions education. however, it is unlikely that many educators in lmics have the necessary higher qualifications. therefore, a formal qualification in nursing/health professions education is acceptable for a peer supporter. attributes such as experience, motivation and commitment to peer support are valued and readily accepted among peers. priority area 2: peer support strategies this priority area focuses on the strategies for providing support and the characteristics of an effective support strategy. evidence shows that relevant and tailor-made strategies and platforms have positive outcomes and are acceptable and valued by peers receiving support. strategies include group support approaches and paired techniques. acceptability and feasibility are high when there is institutional commitment to the strategy. priority area 3: content/support needs tailor-made content is valued and acceptable, and has a positive effect on peers. assessment to determine the content or support should be done in collaboration with those who need support. the content should be aligned to the new curriculum implementation needs of individuals. priority area 4: outcomes of peer support the goals and objectives of the peer support strategy should be directed towards sustaining curriculum innovation, improved curriculum implemen tation and promotion of professional and personal growth. the commitment of institutional administrators enhances accountability regarding the outcomes of peer support, promotes success of peer support and ultimately sustains curriculum innovation. priority area 5: monitoring and evaluation of the peer support strategy m&e is an essential component of successful peer support, and enhances and sustains peer support strategies. a peer support strategy should have an m&e mechanism that provides opportunity for feedback and enhances effectiveness of the strategy. table 1 presents a summary of the recommendations. discussion practice guidelines can enhance peer support interactions among implementers of a transformed curriculum, particularly in resourcelimited institutions that cannot afford ongoing faculty development. the lack of ongoing faculty development and support could compromise the fidelity of the implementation of the transformed curriculum and table 1. summary of guideline recommendations on peer support priority area recommendations a1: attributes of peer supporters a1.1: peer supporters should be in possession of a formal qualification in nursing/health professions education, be knowledgeable about the principles guiding the curriculum innovation, experienced in mentoring, motivated and committed to provide support and facilitate the professional growth of the peers level of evidence used: moderate b1: peer support strategies b1.1: peer supporters should consider the needs of the peers related to the implementation of curriculum innovation, such as developing appropriate facilitation materials and using relevant pedagogical and assessment methods. peer supporters should select the most appropriate strategies and platforms to provide support level of evidence used: moderate b1.2: institutional leadership should ensure that the support strategy has clear goals and objectives, explicit systems and mechanisms to enhance and sustain the effective implementation of the strategy during curriculum innovation level of evidence used: moderate c1: content/support needs c1.1: peer supporters should collaborate with the peers/faculty to assess and identify support needs to enable the development of relevant and applicable content that is aligned with the implementation of the new curriculum level of evidence used: moderate d1: outcomes of peer support d1.1: goals and objectives of peer support activities should be aligned with the identified needs and directed towards sustaining the curriculum innovation, capacity building, professional growth, community of practice and scholarship level of evidence used: moderate d1.2: institutions should recognise support strategies as a valued service and commit by allocating resources to meet the departmental/support needs to enhance peer support during a curriculum innovation level of evidence used: moderate e1:m&e of the peer support strategy e1.1: institutional leadership should ensure that there is a mechanism for m&e of peer support strategies used during curriculum innovation level of evidence used: moderate m&e = monitoring and evaluation. 189 november 2020, vol. 12, no. 4 ajhpe research create an environment for curriculum drift.[15] botma[16,17] reiterates that educators who are not familiar with the principles underpinning the new curriculum could facilitate curriculum drift. therefore, without ongoing support for educators during curriculum transformation, curriculum drift is unavoidable. these practice guidelines are contextualised and recommend strategies and processes essential for effective peer support among educators engaged in the enactment of curriculum innovation. various factors, including qualifications, experience and commitment of support providers, influence the effectiveness of peer support strategies.[5,6,18] however, in lmics, such as lesotho, it may not be feasible for most nursing education institutions to have educators with qualifications that are higher than the basic nursing degree. in the absence of highly qualified peer supporters, institutions can utilise knowledgeable and experienced individuals, such as early adopters.[17] institutional leaders also need to develop deliberate faculty plans directed towards building of capacity of potential supporters.[17,19] peer supporters should also possess effective interpersonal and communication skills to facilitate a positive and collegial environment and interactions during support activities.[5,20,21] the content for the peer support strategy should be well planned and relevant to the curriculum implementation needs of peers. klinge[22] agrees with pololi and colleagues that learning occurs naturally when adult students perceive it as relevant to improve their self-efficacy. ensuring relevant content requires collaborative assessment and identification of support needs.[5,23] the designed content should be administered using appropriate strategies, such as workshops, presentations, meetings, supportive peer reviews and hands-on methods. role modelling and encouragement further enhance the self-efficacy of colleagues during the change process.[8] the participants may value and prefer engaging and hands-on strategies that are in line with the challenges they are facing. knowles’ work cited by klinge[22] alludes to the principles of adult learning and emphasises the importance of designing needs-driven support strategies that promote active learning. however, peer support providers in lmics need to be cognisant of limitations associated with some strategies and platforms, such as connectivity, systems failure and the technological abilities of individuals,[20] which might influence the effectiveness and success of the support strategy. outcomes of an effective peer support strategy include sustained curriculum innovation, personal and professional growth and development of a community of practice.[6,7] peer support approaches that promote self-directedness and critical thinking ought to be encouraged. besides these positive outcomes, unintended effects, such as negative emotional reactions, might also be experienced and compromise the effectiveness of the support.[5,18] therefore, establishment of a committee instead of one person working on peer support interventions may create a buffer for the potential emotional strains that individuals may experience.[6,18] some factors that can compromise the effectiveness of a peer support strategy include disconnections in relationships, power differences, unclear mentoring roles and lack of m&e.[5,18,21] however, critical to the attainment of positive outcomes is the commitment of institutional leadership to the strategy of peer support. the guidelines allude to the commitment of institutional leadership, which is essential in creating an environment conducive to successful peer support strategies.[4] such commitment is key to the success of peer support and influences the allocation of resources, accountability and m&e of the strategy.[6,18,21] both the integrative review and the qualitative study highlighted the importance of administrative endorsement.[9,12] although m&e is essential for any effective intervention, these quality assurance mechanisms are sometimes disregarded, leading to delayed identification of challenges and weakness, and subsequently no corrective measures are undertaken.[7,24] m&e can be the mainstay of the support strategy and for sustaining the implementation of curriculum innovation.[7,18] these peer support guidelines can be adapted to different contexts and used among educators in institutions undergoing curriculum transformation in lmics. peer support is one of the affordable approaches that can benefit educators in resource-limited institutions. conclusions the practice guidelines presented in this article are aimed at enhancing peer support engagement among educators in nursing education programmes during curriculum transformation. these contextualised guidelines recommend strategies and processes that address critical aspects of peer support, including attributes of peer supporters, peer support strategies, content/support needs, outcomes of peer support, and monitoring and evaluation of the peer support strategy. the formulated recommendations can serve as a blueprint that gives direction to structured peer support interactions among educators during curriculum innovation in resourcescarce countries. however, these guidelines are not a panacea for all the challenges associated with curricular transformation processes, but form part of the solutions. therefore, the guidelines should be used together with other strategies that enhance fidelity of curriculum implementation. further research is recommended to evaluate the usability and effectiveness of the guidelines in the different institutions that may use them. there is also a need to evaluate the efficacy of the implementation of curriculum reforms funded by the nursing education partnership initiative (nepi) in african countries. declaration. the study was conducted in partial fulfilment of the requirements for ms’s phd degree at the university of the free state, bloemfontein. acknowledgements. the authors acknowledge ms j viljoen and ms e heyns for language and technical editing of the manuscript, respectively. the external reviewers are acknowledged for their role in validating the developed practice guidelines. author contributions. ms and yb conceptualised the study design, ms collected and analysed the data. ms and yb triangulated evidence, developed and consolidated the peer support practice guidelines. ms drafted the manuscript and yb provided critical guidance throughout the process and approved the final manuscript. funding. none. conflicts of interest. none. 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 2. niehaus e, williams l. faculty transformation in curriculum transformation: the role of faculty development in campus internationalization. innov high educ 2016;41:59-74. https://doi.org/10.1007/s10755-015-9334-7 3. snyman s. reconceptualising of health professions education in south africa. pretoria: assaf, 2018. 4. galea s, fried lp, walker jr, rudenstine s, glover jw, begg md. developing the new columbia core curriculum: a case study in managing radical curriculum change. am j public health 2015;105(suppl 1):s17-s21. https://doi. org/10.2105/ajph.2014.302470 5. bryant al, aizer brody a, perez a, et al. development and implementation of a peer mentoring program for early career gerontological faculty. j nurs scholar 2015;47(3):258-266. https://doi.org/10.1111%2fjnu.12135 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1007/s10755-015-9334-7 https://doi.org/10.2105/ajph.2014.302470 https://doi.org/10.2105/ajph.2014.302470 https://doi.org/10.1111%2fjnu.12135 november 2020, vol. 12, no. 4 ajhpe 190 research 6. fleming gm, simmons jh, xu m, et al. a facilitated peer mentoring program for junior faculty to promote professional development and peer networking. acad med 2015;90(6):819-826. https://doi.org/10.1097/ acm.0000000000000705 7. magers tl. an ebp mentor and unit-based ebp team: a strategy for successful implementation of a practice change to reduce catheter-associated urinary tract infections. worldviews evidence-based nurs 2014;11(5):341-343. https://doi.org/10.1111/wvn.12056 8. bandura a. human agency in social cognitive theory. am psychol 1989;44(9):1175-1184. https://doi. org/10.1037/0003-066x.44.9.1175 9. shawa m, botma y. peer support strategies that enhance implementation of an innovation among professionals: an integrative review. bloemfontein: university of the free state, 2020. 10. harrell mc, bradley m. data collection methods: semi structured interviews and focus groups. geograph anal 2009;31:1-147. 11. world health organization. handbook for guideline development. 2nd ed. geneva: who, 2014:1-179. 12. shawa m, botma y. peer support during implementation of a new curriculum: experiences of nurse educators. bloemfontein: university of the free state, 2020. 13. agree next steps consortium. the agree ii instrument. 2017. http://www.agreetrust.org (accessed 18 novem ber 2018). 14. hasson f, mckenna hp. research guidelines for the delphi survey technique. j adv nurs 2000;32(4):1008-1015. https://doi.org/10.1046/j.1365-2648.2000.t01-1-01567.x 15. burgess t, cilliers f. a framework for ethical educational research: principles and application. 2017. www. healthedu.uct.ac.za/framework (accessed 16 june 2017). 16. botma y. implications of accreditation criteria when transforming a traditional nursing curriculum to a competency-based curriculum. int j africa nurs sci 2014;1(12):23-28. https://doi.org/10.1016/j.ijans.2014.06.002 17. botma y. how a monster became a princess: curriculum development. s afr j high educ 2014;28(6):1876-1893. https://doi.org/10.20853/28-6-431 18. sexton jm, lord ja, brenner cj, curry ce, shyn si, cowley ds. peer mentoring process for psychiatry curriculum revision: lessons learned from the ‘mod squad’. acad psychiat 2016;40(3):436-440. https://doi. org/10.1007/s40596-014-0274-9 19. brownie sm, docherty c, al-yateem n, gadallah mh, rossiter r. developing a national competencybased curriculum for technical nurses in egypt. east mediterr heal j 2018;24(9):922-932. https://doi. org/10.26719/2018.24.9.922 20. bang e. hybrid-mentoring programs for beginning elementary science teachers. int j educ math sci technol 2013;1(1):1-15. https://doi.org/10.18404/ijemst.97208 21. bennett s, paina l, ssengooba f, waswa d, m’imunya jm. mentorship in african health research training programs: an exploratory study of fogarty international center programs in kenya and uganda. educ heal chang learn pract 2013;26(3):183-187. https://doi.org/10.4103/1357-6283.126001 22. klinge cm. a conceptual framework for mentoring in a learning organization. adult learn 2015;26(4):160-166. https://doi.org/10.1177%2f1045159515594154 23. bennett s, santy j. a window on our teaching practice: enhancing individual online teaching quality though online peer observation and support. a uk case study. nurse educ pract 2009;9(6):403-406. https://doi. org/10.1016/j.nepr.2009.01.019 24. chukwu cl, mezieobi di, uguwanyi be, okpoebo cc. monitoring and evaluation on effective delivery of social studies for improved academic performance. rev eur stud 2019;11(1):175. https://doi.org/10.5539/res.v11n1p175 accepted 17 august 2020. https://doi.org/10.1097/acm.0000000000000705 https://doi.org/10.1097/acm.0000000000000705 https://doi.org/10.1111/wvn.12056 https://doi.org/10.1037/0003-066x.44.9.1175 https://doi.org/10.1037/0003-066x.44.9.1175 http://www.agreetrust.org https://doi.org/10.1046/j.1365-2648.2000.t01-1-01567.x http://www.healthedu.uct.ac.za/framework http://www.healthedu.uct.ac.za/framework https://doi.org/10.1016/j.ijans.2014.06.002 https://doi.org/10.20853/28-6-431 https://doi.org/10.1007/s40596-014-0274-9 https://doi.org/10.1007/s40596-014-0274-9 https://doi.org/10.26719/2018.24.9.922 https://doi.org/10.26719/2018.24.9.922 https://doi.org/10.18404/ijemst.97208 https://doi.org/10.4103/1357-6283.126001 https://doi.org/10.1177%2f1045159515594154 https://doi.org/10.1016/j.nepr.2009.01.019 https://doi.org/10.1016/j.nepr.2009.01.019 https://doi.org/10.5539/res.v11n1p175 june 2020, vol. 12, no. 2 ajhpe 51 short communication why was the idea necessary? the use of appreciative inquiry (ai) formed the basis of the interview questions for a study that focused on exploring and understanding the concept of caring among first-year radiography students to develop a model to teach caring. the aim was that the participants should collaborate by sharing their understandings, without it merely being a session for complaining. when participants are asked questions in a positive manner, they are more willing to engage and share their stories. ai is a method of focusing on the positive in any situation to create innovative ideas that bring about more meaningful, deeper and sustainable change.[1,2] while the use of ai is increasing, i have not found any research using this tool among diagnostic radiography students. what was tried? the 4-d model of ai, i.e. discovery, dream, design and destiny (fig. 1), has been used extensively in ai research; it was also used to structure the questions in the focus group interviews in this study. questions in these interviews were asked in a positive manner to promote storytelling that provided narrative-rich communication. firstly, participants were asked to share stories where they discovered a time or times when they expressed or experienced caring. it also made them focus on a time that caring meant the most to them. the following question was posed to participants: ‘tell me what caring means to you as a student radiographer.’ secondly, participants were asked to share stories where they were given the opportunity to dream about the ideal caring professional. the following question was asked: ‘describe how you see yourself in the future as a caring radiographer.’ next, participants were asked to design and create the qualities and attributes required by them to become the ideal caring professional. the question asked was: ‘what do you think you will need to be a caring radiographer?’ lastly, there was the destiny phase, where participants were asked to develop innovative ways to achieve the required qualities and attributes of a caring professional. the question was: ‘tell me creative/innovative ways in which we can achieve this caring.’ what were the lessons learnt? ai is an effective interview tool, as it allowed for collaboration and teamwork. using this technique, participants were very eager and willing to share their experiences. this method also promoted a very comfortable environment for storytelling among participants. rich and informative data were collected. the use of ai in radiography research has proved to be valuable. ai is an innovative method that allows healthcare professionals to explore the potential of change by moving the focus away from the problems at hand. declaration. none. acknowledgements. the author thanks all participants for their valuable contribution to the study. author contributions. sole author. funding. the researcher would like to thank the health and welfare sector education and training authority  (hwseta) for providing funding for this study (postgraduate research bursaries 2017 2018). conflicts of interest. none. 1. cooperrider d. what is appreciative inquiry? 2012. http://www.davidcooperrider.com/ai-process/ (accessed 4 march 2020). 2. richer mc, ritchie j, marchionni c. ‘if we can't do more, let's do it differently!’ using appreciative inquiry to promote innovative ideas for better health care work environments. j nurs manage 2009;17(8):947-955. https:// doi.org/10.1111/j.1365-2834.2009.01022.x accepted 19 november 2019. afr j health professions educ 2020;12(2):51. https://doi.org/10.7196/ajhpe.2020.v12i2.1269 the use of appreciative inquiry as an interview technique in radiography research k naidoo, dtech: radiography department of medical imaging and therapeutic sciences, faculty of health and wellness science, cape peninsula university of technology, cape town, south africa corresponding author: k naidoo (naidooka@cput.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. dream 'what might be' discovery 'the best of what is' positive core destiny 'how to empower, learn and improvise' design 'what should be – the ideal' fig. 1. the 4-d model of appreciative inquiry.[1] http://www.davidcooperrider.com/ai-process/ https://doi.org/10.1111/j.1365-2834.2009.01022.x https://doi.org/10.1111/j.1365-2834.2009.01022.x june 2021, vol. 13, no. 2 ajhpe 105 research traditional lecture methods, where the lecturer teaches for the full duration of class, result in students being passive learners owing to limited student engagement.[1] these students mostly memorise module content[2] and accept all course content without questioning or distinguishing underlying principles or patterns.[3] the passive nature of the lecture-centred class provides a lower level of knowledge retention and cognition for students.[4] the lecture method encourages surface learning, as defined by marton and säljö,[5] where students only remember facts they think they would be asked during assessments to receive a passing grade. in contrast to passive learning, active learning strategies allow students to engage more actively with course content, which promotes students’ learning experiences.[6] currently, exit-level competencies for health professionals have moved from knowing information to solving complex problems,[7] which require collaboration and integration of information. to achieve this, students need not only understand, but have to interact critically with course content to relate ideas to previous knowledge and experiences.[3,5] this method results in deeper learning, where holistic insight into course content and the ability to integrate information take place through use of analytical skills and cross-referencing. however, deep learning depends on the student’s level of engagement with course content.[8] it is therefore important that health professions education incorporate strategies that foster deep learning. the purpose of team-based learning (tbl) is to deepen students’ learning.[9] this structured, student-centred, active learning strategy[10] includes three phases to deepen students’ learning of course content. prior to class, students have to study the selected assigned reading to understand basic concepts and ideas relevant to the scheduled class. the assigned reading may include textbooks, scientific articles or lecture notes.[11,12] at the beginning of the class, students’ preparation is assessed through individual readiness assurance tests (irat) and team readiness assurance tests (trat), focusing on foundational concepts. the purpose of this phase is to assess whether students have a sound understanding of basic and fundamental concepts required for the next phase.[13] lastly, the remaining class time is allocated to the application of course concepts in exercises designed to deepen the students’ understanding of course content.[10] these applicationfocused team exercises foster participatory discussions to solve the problem, which promote collaboration and critical thinking.[14] in a previous study on the effect of tbl on students’ learning, elliot[15] found that students in tbl showed a greater engagement and involvement in their learning compared with their involvement in the traditional lecture. she also acknowledged that students gained knowledge from their peers, similar to the working environment, where it will be expected of them to work and collaborate with each other to solve patient problems. in another study, faculty members from several us colleges and schools of pharmacy revealed that they perceive tbl as an educational strategy that not only fosters student learning and engagement in course content, but also supports the achievement of educational outcomes.[11] huitt et al.[16] reported on the academic benefits of tbl on students’ performance, as it led to improved application of content and an increase in their problem-solving abilities. although several studies included questions to determine students’ understanding of course content when tbl was implemented, no study was found that included a comprehensive investigation into whether students’ achievement of learning outcomes had improved, as well as their understanding of course content and knowledge retention, compared with background. the benefit of deep learning compared with surface learning is the ability to retrieve, apply and integrate previously learnt knowledge rather than simply memorising course content most likely to be evaluated during assessments. team-based learning (tbl) is an educational strategy that echoes the purpose of deeper learning. objectives. to identify whether tbl as a teaching strategy increases pharmacy students’ understanding of theoretical work. method. fourth-year pharmacy students completed a questionnaire consisting of biographical data (gender, age and ethnicity) and 16 questions on their  understanding of course content. a total of 183 students (91.5%) participated after giving informed consent that their data may be included in the study. results. the results indicated that, due to the implementation of tbl in the course, students perceived that they learnt more and made more effort, experienced increased understanding of content, perceived higher knowledge retention, performed better during assessments in the module where tbl was implemented and felt that course outcomes were achieved more easily. conclusion. tbl as a teaching strategy could potentially promote deeper learning of course content. afr j health professions educ 2021;13(2):105-109. https://doi.org/10.7196/ajhpe.2021.v13i2.878 promoting deeper learning in pharmacy education using team-based learning m j eksteen,1,2 phd (hpe); g m reitsma,2 phd; e fourie,3 phd 1 division health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 centre for health professional education, faculty of health sciences, north-west university, potchefstroom, south africa 3 statistical consultation services, north-west university, potchefstroom, south africa corresponding author: m j eksteen (mariet.eksteen@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.878 mailto:mariet.eksteen@gmail.com 106 june 2021, vol. 13, no. 2 ajhpe research traditional lecture methods. in this study, we investigated whether tbl as a teaching strategy increased pharmacy students’ understanding of theoretical work (curriculum), thus promoting deeper learning. method target and sample population the target population consisted of all fourth-year pharmacy students (n=200) enrolled in a pharmacy practice course, where tbl was introduced for the first time. although all students in the target population were invited to participate in this research, not all students agreed to participate. the final sample size consisted of 183 (91.5%) students. pearson’s χ2 test was used to determine if the sample represented the target in terms of age, gender and ethnic group. the p-values >0.05 (0.67, 0.91 and 0.79, respectively) indicate no statistically significant association. therefore, the sample population represented the target population in terms of biographical data (table 1). research instrument a questionnaire was developed based on existing information acquired through an intensive literature study on tbl in undergraduate health professions education. the questionnaire consisted of biographical data, such as age, gender and ethnic group, as well as 16 questions related to students’ understanding of theoretical work. students had to indicate their level of agreement with the statements on a likert scale of 1 4, where 1 indicated ‘strongly disagree’ and 4 ‘strongly agree’. as the questionnaire was developed for this purpose, it was piloted through an exploratory investigation to assure validity before utilisation in the main investigation.[17] cognitive interviews with students who were not part of the study population were conducted one-on-one between the student and the researcher. the main difference between conducting a cognitive interview and other forms of interviews is that the former is used to gather information about the functioning of the research instrument rather than the collection of data. secondly, cognitive interviews are more flexible and rely heavily on probe questions rather than verbatim administration of a standardised instrument.[18] the purpose was to determine whether these students: (i)  could understand the questions; (ii)  were familiar with the terminology used in the questions; (iii) could answer the questions; and (iv) had any advice or suggestions on restructuring or rephrasing of the questions, as suggested by wills.[18] content validity was ensured through the use of experts in health professions education and pharmacy, who reviewed the questionnaire and gave their opinions on some aspects: (i)  clarity of the questions; (ii)  time needed to complete the questionnaire; (iii)  presence of bias in questions; and (iv)  suggestions and/or recommendations. finally, the questionnaire was reviewed by a statistician for face validity. the recommendations were included to improve the quality of the questionnaire. ethical approval and data collection all students in the target population were invited to participate in the study and received a leaflet containing information regarding its purpose, researchers, procedures, benefits, risks/discomforts, cost/remuneration, access to data, inquiries, funding, ethical approval and feedback on the findings. participation was voluntary and students were under no obligation to participate. those who were willing to participate completed an informed consent form. it was explained to students that, should they decide to withdraw from the study at any point, even if they did agree to participate initially, it would not affect them or their course marks in any way. all data were collected anonymously; therefore, it was not possible to trace the questionnaire back to the student. ethical approval was granted by the ethics committee of the faculty of health sciences at the university of the free state (ref. no. ecufs 107/2015) and the health research ethics committee of the faculty of health sciences at north-west university (ref.  no.  nwu-0018215-s1) prior to commencement of the study. data were collected during a scheduled class in the particular course. questionnaires were completed and collected separately from the informed consent forms to adhere to anonymity. the quantitative data were analysed using spss version 23 (ibm corp., usa) to determine descriptive statistics, such as percentage, mean and standard deviation (sd), exploratory factor analysis (efa), cronbach’s α, spearman’s rho correlation coefficients, as well as independent sample t-tests with cohen’s d-value. results the results of the questionnaire are presented in table  2. for each of the 16 questions, the percentages for each response option are indicated, as well as the mean and sd. an efa indicated that the first 5 questions could be grouped together to form a factor regarding how students learnt through their own understanding. the factor loadings of the questions ranged between 0.375 and 0.942. cronbach’s α of 0.800 confirmed internal reliability. the 3 questions set out below formed a factor describing how students learnt from others. factor loadings ranged between 0.316 and 0.690. although cronbach’s α was lower than the guideline value of 0.7 (α=0.529), ≥0.5 is also sufficient for the early stages of research;[19] however, interpretation should be done with caution. the third factor included the last 8 questions on learning through tbl and/or teams and had factor loadings between 0.275 and 0.569. cronbach’s α of 0.761 indicated internal reliability for this factor. questions indicated with an asterisk were formulated in a negative trend. learning through own understanding the results indicated that students’ understanding of module content increased with the practical application thereof in a team (q1*, mean 1.79 (sd 0.684)) and through teaching their team members (q2, 3.12 (0.640)). students indicated that problem-solving in a team was an effective way to practise what was learnt (q3, 3.32 (0.653)). the majority of students claimed to perform better in assessments where tbl was used than with traditional table 1. biographical data of target and sample population in terms of gender, age and ethnic groups biographical data target population (n=200), n (%) sample population (n=183), n (%) gender* male 41 (20.5) 34 (18.6) female 159 (79.5) 147 (80.3) age (on 31 december 2016), years* ≤22 130 (65.0) 117 (63.9) >22 70 (35.0) 65 (35.3) ethnic group white 183 (91.5) 166 (90.7) other 17 (8.5) 17 (8.3) *two questionnaires did not specify gender and one questionnaire did not indicate age. june 2021, vol. 13, no. 2 ajhpe 107 research lecture methods (q4, 3.07 (0.805)). students used feedback regarding team performances to improve their learning and to help the team be more effective (q5, 2.85 (0.733)). learning from others learning from mistakes helped students to remember information better (q6*, 1.85 (0.790)). students also learnt new knowledge from fellow team members (q7*, 1.59 (0.779)). assessments were in line with the learning outcomes set for the course (q8*, 1.44 (0.570)). learning through tbl and/or teams tbl promoted students’ achievement of the learning outcomes of the course (q9*, 1.67 (0.673)). learning outcomes were achieved more easily (q10, 3.31 (0.671)) and content was remembered better over a long period (q14, 3.13 (0.737)). working in teams helped students to learn better (q11, 3.12 (0.798)), learn more (q12, 3.07 (0.819)) and understand course content better (q13, 3.17 (0.720)) than they would have if they learnt on their own. however, students were convinced that a traditional lecture should be presented before a tbl session (q15, 3.09 (0.881)). tbl did increase students’ interest in the course (q16*, 2.18 (0.842)). correlation between factors and age spearman’s rho did not indicate practically or statistically significant correlations between age and learning through own understanding (r=0.004; p=0.955), learning from others (r=0.141; p=0.057) and learning though tbl and/or teams (r=0.149; p=0.045). table 2. results of the team-based learning questionnaire percentage quote reference student reference strongly disagree, 1 disagree, 2 agree, 3 strongly agree, 4 mean (sd) learning through own understanding 1* my understanding of the course content did not increase with the practical application of it in a team 33.3 56.8 6.60 2.70 1.79 (0.684) 2 teaching my team members confirmed my own understanding of difficult concepts 2.2 8.2 63.4 24.6 3.12 (0.640) 3 solving problems in a team is an effective way to practise what i have learnt 2.2 3.8 54.1 39.9 3.32 (0.653) 4 i performed better in assessments where team-based learning was used to cover the material than on assessments where only traditional lectures were used 4.4 15.8 48.1 31.7 3.07 (0.805) 5 we used feedback regarding team performances to help the team to improve the effectiveness 4.4 22.4 57.4 15.8 2.85 (0.733) learning from others 6* learning from mistakes while working in a team did not help me to remember information better 35.5 48.6 11.5 4.4 1.85 (0.790) 7* i did not learn any new knowledge from fellow team members 54.1 36.1 4.9 4.4 1.59 (0.779) 8* assessments for this course were not in line with the learning outcomes 59.6 36.1 3.8 0 1.44 (0.570) learning through team-based learning and/or teams 9* team-based learning did not promote my achievement of the learning outcomes 42.1 50.8 4.9 2.2 1.67 (0.673) 10 learning outcomes set in this module were achieved easier due to the team-based learning approach 1.1 4.9 55.7 38.3 3.31 (0.671) 11 teams helped me learn course content better compared with studying alone 4.9 11.5 49.7 33.3 3.12 (0.798) 12 teamwork helped me to learn more than i would have learnt on my own 4.9 15.3 47.5 32.2 3.07 (0.819) 13 team participation helped me to understand course content better than i would have understood it on my own 2.7 10.4 53.6 33.3 3.17 (0.720) 14 team-based learning helped me to remember the content better over a long period 2.7 13.1 52.5 31.7 3.13 (0.737) 15 it is necessary to have a traditional lecture before a teambased learning session on the same course content 5.5 18.0 38.3 38.3 3.09 (0.881) 16* team-based learning did not increase my interest in the course 20.8 47.5 24.6 7.1 2.18 (0.842) sd = standard deviation. *questions formulated in a negative trend. 108 june 2021, vol. 13, no. 2 ajhpe research correlation between factors spearman’s rho indicated statistically significant correlations between learning through own understanding and learning from others (r=‒0.418; p=0.0001), learning through own understanding and learning through tbl and/or teams (r= 0.702; p=0.0001) and learning from others and learning through tbl and/or teams (r=‒0.472; p=0.0001). independent t-tests between factors and gender or ethnicity independent t-tests with cohen’s d-value indicated no practically or statistically significant differences between female and male students (d<0.18) or between white and other ethnic groups (black african, asian, coloured, indian and korean) (d<0.08) for any of the factors. the mann-whitney test for differences between two independent groups on a continuous measure also indicated no practically or statistically significant differences between two ethnic groups for any factor (d<0.02; p>0.781). discussion the purpose of this study was to identify whether tbl as a teaching strategy in an undergraduate pharmacy curriculum increased students’ understanding of the theoretical work presented during the course. the study formed part of a larger research project to develop guidelines for the implementation of tbl in undergraduate pharmacy education in south africa (sa). as this was the first time that tbl was implemented in pharmacy education at the university of the free state, bloemfontein, sa, there are no other data for comparison of the findings. learning through own understanding students indicated that their understanding of course content was increased owing to its practical application. deeper learning in tbl was achieved  during the application exercise, according to their experience, where students were required to apply course concepts to solve significant problems they are most likely to face in practice.[9] these exercises enhanced learning by forcing students to re-examine and, where needed, modify their assumptions and/or interpretations of their pre-class preparation. students also acknowledged that teaching their team members confirmed their own understanding of difficult concepts. students indicated that solving  problems in a team was an effective way to practise what they had learnt. in assessments where students are required to reproduce knowledge, students indicated that they performed better in tests on material learnt through tbl than by traditional lecture methods. this was an easy comparison for students to make, as they were exposed to tbl in one course and still continued with traditional lecture methods in the other four courses, all running simultaneously during the semester. this finding is in line with those in other studies, which found that students performed better in examinations when tbl was used.[16] students agreed that feedback regarding team performances helped the team be more effective. immediate feedback is considered one of four essential elements in tbl. feedback is provided to students after the trat and the team application exercise so that students can correct any misunderstandings immediately. learning from others students indicated that they learnt new knowledge from fellow team members ‒ either from other students’ more detailed study or from courserelated life experiences. students found that knowledge retention was also reinforced by learning from mistakes while working in a team. as mentioned above, feedback on the trat and the application exercise was provided directly afterwards, providing the opportunity for students to correct misunderstandings and misconceptions immediately. students perceived assessments to be fair, as they were in line with the learning outcomes of the course. this finding is important to acknowledge, as better grades due to tbl may be perceived by critics as easier assessments. the difference is that, instead of covering theory in class and then exposing students to application in the assessment, application exercises in tbl are part of in-class activities. learning through tbl and/or teams students indicated that tbl not only promoted the achievement of learning outcomes set in the course, but also made it easier to achieve those outcomes. when designing a tbl course, the first set of decisions is to identify the instructional goals and learning outcomes. these are needed to determine the assigned reading that is necessary for students to prepare sufficiently for the tbl session.[9] several studies concluded that the setting of learning objectives is the single most important aspect of helping students to do the assigned reading for their preparation.[12,16] students indicated that teams and teamwork helped them to learn more and to learn course content better that they would have learnt on their own. due to the lively discussions used in tbl during the trat, as well as the application exercises, students engage with course content while answering questions.[7] it is expected of students to actively participate in sharing opinions and even make good, logical arguments to persuade others of their viewpoint. they indicated that team participation helped them to understand module content better than if they had been studying on their own. students experienced that teams are able to accomplish more than the sum of individual members’ contributions, the greatest difference between ‘groups’ and ‘teams’.[20] during learning, information stored in short-term memory decays very rapidly, e.g. when cramming before examinations. to be able to use information in the future, it should be transferred to long-term memory and be retrievable when needed.[21] students indicated that tbl helped them to remember course content better over a long period. we also found that, due to the increased awareness of the application of course content from the application exercises, it could have increased students’ interest in the course. tbl moved the lecturing of theoretical concepts out of the classroom to pre-class preparations to use scheduled class time for the application of knowledge. however, almost 80% of students felt that it is necessary to have a traditional lecture before a tbl session on the same course content. this view could be due to the feeling of uncertainty, as students have to rely on their own preparation, and indicates that they would like to clarify some uncertainties before individual tests. there were significant correlations between the three factors, indicating that when you learn through own understanding, you will most probably be able to learn from others and through tbl and/or the team. conclusion this study investigated whether fourth-year pharmacy students experienced an increased understanding of theoretical work during the course. it is clear that, according to these students, tbl helped them to learn more than they would have learnt on their own, increased their understanding of course june 2021, vol. 13, no. 2 ajhpe 109 research concepts, enhanced their knowledge retention, improved their individual performance during assessments and enabled easier achievement of course outcomes. from these students’ experiences, tbl could provide pharmacy education the opportunity to deepen students’ learning by integrating and applying course content during real-life case studies. it would be interesting to investigate the effect of tbl on other pharmacy curricula in africa. future studies could also test retention over a longer period of time to confirm deeper learning. declaration. the research for this study was done in partial fulfilment of the requirements for mje’s phd degree at the university of the free state (awarded in 2017). acknowledgements. the authors gratefully acknowledge the assistance received from the participants and role-players in the overall phd study. author contributions. mje designed the study, wrote the protocol, collected data and performed the analysis, interpreted data and wrote the manuscript. gmr was the supervisor of the study, reviewed the protocol and manuscript and contributed substantially to the conceptualisation, design, analysis and interpretation of data and scientific content. ef performed all the statistical analyses. all authors approved the final version of the manuscript. funding. this research was partially funded by a grant from the health and welfare sector education training authority (hwseta). conflicts of interest. none. 1. clark mc, nguyen ht, bray c, levine re. team-based learning in an undergraduate nursing course. j nurs educ 2008;47(3):111-117. https://doi.org/10.3928/01484834-20080301-02 2. altintas l, altintas o, caglar y. modified use of team-based learning in an ophthalmology course for fifth-year medical students. adv physiol educ 2014;38:46-48. https://doi.org/10.1152/advan.00129.2013 3. entwistle nj, ramsden p. understanding student learning. london: croom helm, 1983. 4. deslauriers l, schelew e, wieman c. improved learning in a large-enrolment physics class. science 2011;332(6031):862-864. https://doi.org/10.1126/science.1201783 5. marton e, säljö r. on qualitative differences in learning: outcome as a function of learners’ conception of task. brit j educ psychol 1976;46:115-127. https://doi.org/10.1111/j.2044-8279.1976.tb02304.x 6. hutchings p, huber mt, ciccone a. the scholarship of teaching and learning reconsidered. institutional integration and impact. san francisco: jossey-bass, 2011. 7. sibley j, parmelee dx. knowledge is no longer enough: enhancing professional education with team-based learning. in: michaelson lk, sweet m, parmelee dx, eds. team-based learning: small group learning’s next big step. san francisco: jossey-bass, 2008:41-54. 8. ramsden p. the context of learning in academic departments. in: marton f, hounsell d, entwistle n, eds. the experience of learning. edinburgh: scottish academic press, 1997:198-216. 9. michaelsen lk, sweet m. fundamental principles and practices of team-based learning. in: michaelsen lk, parmelee dx, mcmahon kk, levine re, eds. team-based learning for health professions education: a guide to using small groups for improving learning. virginia: stylus, 2008:9-34. 10. mennenga ha, smyer t. a model for easily incorporating team-based learning into nursing education. inter j nurs educ schol 2010;7(1). https://doi.org/10.2202/1548-923x.1924 11. allen re, copeland j, franks as, et al. team-based learning in us colleges and schools of pharmacy. am j pharm educ 2013;77(6):115. https://doi.org/10.5688/ajpe776115 2013 12. inuwa im. perceptions and attitudes of first-year medical students on a modified team-based learning (tbl) strategy in anatomy. sultan qaboos university med j 2012;12(3):336-343. 13. michaelsen lk. getting started with team-based learning. in: michaelsen lk, knight ab, fink ld, eds. team-based learning: a transformative use of small groups in college teaching. virginia: stylus, 2004:27-50. 14. hawkins d. rationale and methods for developing team-based learning education. in: hawkings d. a team-based learning guide for faculty in the health professions. bloomington, in: authorhouse, 2014:1-10. 15. elliot s. using a modified team-based learning approach to teach nursing students about communicable diseases control and community health nursing. j nurs educ 2014;53(1):651-653. https://doi.org/10.3928/0148483420141027-01 16. huitt tw, killins a, brooks ws. team-based learning in the gross anatomy laboratory improves academic performance and students’ attitudes towards teamwork. anat sci educ 2014;8(2):95-103. https://doi.org/10.1002/ ase.1460 17. delport csl, roestenburg wjh. quantitative data-collection methods: questionnaires, checklists, structured observation and structured interview schedules. in: de vos as, strydom h, fouché cb, delport csl, eds. research at grass roots: for the social sciences and human service professions. 4th ed. pretoria: van schaik, 2011:171-205. 18. wills gb. cognitive interviewing: a tool for improving questionnaire design. thousand oaks: sage, 2005:5-6; 35-54. 19. field a. discovering statistics using ibm spss statistics. 4th ed. london: sage, 2014. 20. michaelsen lk, sweet m. creating effective team assignments. in: michaelsen lk, parmelee dx, mcmahon kk, levine re, eds. team-based learning for health professions education: a guide to using small groups or improving learning. virginia: stylus, 2008:35-59. 21. bruning rh, schraw gj, ronning rr. cognitive psychology and instruction. 2nd ed. englewood cliffs, nj: prentice hall, 1994. accepted 29 july 2020. https://doi.org/10.3928/01484834-20080301-02 https://doi.org/10.1152/advan.00129.2013 https://doi.org/10.1126/science.1201783 https://doi.org/10.1111/j.2044-8279.1976.tb02304.x https://doi.org/10.2202/1548-923x.1924 https://doi.org/10.5688/ajpe776115 https://doi.org/10.3928/01484834-20141027-01 https://doi.org/10.3928/01484834-20141027-01 https://doi.org/10.1002/ase.1460 https://doi.org/10.1002/ase.1460 a maximum of 3 ceus will be awarded per correctly completed test. march 2019, vol. 11, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/011/01/2019 (clinical) cpd questionnaire march 2019 expectations and experiences of final-year medical students regarding family medicine rural rotations: influence on intention to practise in a rural setting 1. one of the main reasons provided by respondents as to why they would return to a rural setting included: a. making a difference b. continuity of care c. safe working environment d. financial motivation. medical students’ reflections on the meaning of disease and illness in south african communities 2. which one of the following was not one of the four perspectives that guided the content analysis of students’ reflections on the meaning of disease: a. ethical b. compassionate c. moralist d. spiritualist. 3. research does not support that early patient contact increases students’ motivation for studying the theoretical background of medicine. (true or false) students’ views on the need for hostile environment awareness training for south african emergency medical care students 4. drivers of crime in south africa, as cited in this article, include poverty, unemployment, a gini coefficient that is currently among the highest in the world, as well as one of the following: a. inadequate social services b. homelessness c. drug abuse d. illegal immigration. 5. of the 113 respondents in this study, which percentage reported being verbally abused (sworn at, ridiculed or threatened) either by a patient or bystander: a. 86.54% b. 78.76% c. 62.34%. physiotherapists’ perception of a community-based primary healthcare clinical education approach to undergraduate learning 6. recommendations by respondents of this study included academic incentives. (true or false) 7. one of the barriers to decentralised clinical training identified in this study was: a. poor academic support b. transport challenges c. attitudinal barriers d. perceived burden on the health system. preparation of nursing students for operating room exposure: a south african perspective 8. which category was not identified as part of the proposed preparation programme: a. documentation b. maintaining of sterility c. equipment use d. safety training. initiating curriculum mapping on the web-based, interactive learning opportunities, objectives and outcome platform (looop) 9. curriculum mapping enables educators to check for redundancies, inconsistencies, weaknesses, as well as one of the following: a. strengths b. misalignments c. opportunities. 10. which framework, as adapted by the health professions council of south africa, was added to the looop project: a. canmeds b. tomorrow’s doctors c. accreditation council for graduate medical education d. the dutch blueprint for medical education. june 2019, vol. 11, no. 2 ajhpe 57 research the national department of health (ndoh) makes the following statement regarding the importance of scientific integrity in research projects in its document ethics in health research: principles, processes and structures:[1] ‘the study’s design and methodology are vital for research integrity, regardless of the discipline. sound design and methodology are likely to result in reliable and valid data and outcomes that address the research objectives. poor design and inappropriate methods may expose participants to unnecessary risk of harm and burden with little or no compensating benefit in the form of useful knowledge gained.’ an important methodological aspect of any research project is the selection of appropriate participants. the ndoh document states the following in this regard:[1] ‘… recruitment, selection, exclusion and inclusion of participants for research must be just and fair, based on sound scientific and ethical principles. persons should not be excluded unreasonably or unfairly on the basis of any of the prohibited grounds for discrimination: race, age, sex, sexual orientation, disability, education, religious belief, pregnancy, marital status, ethnic or social origin, conscience, belief or language (s 8 of the constitution). similarly, persons should not be unfairly targeted for research merely on the basis of one or other of these grounds.’ at a workshop titled ‘ethics in educational research’, hosted by the south african association of health educationalists (saahe) in bloemfontein on 16 september 2016, concern was raised regarding the selection of students as research participants, in particular by student researchers. it was suggested that the choice or use of students as research participants could be based on convenience only, rather than on sound scientific or ethical principles. this may be seen as unfairly targeting student populations who are potentially vulnerable in the context of educational research, especially in terms of giving valid informed consent.[2,3] the term ‘over-researched populations’ has often been used in the literature for populations that are recruited for many research projects owing to their geographical location (conveniently close to the researchers), willingness to participate or specific disease profile. by targeting student populations for research participation, such populations could become over-researched. koen,[4] however, concluded that ‘using the term [overbackground. university of the free state (ufs), bloemfontein, south africa undergraduate medical students perform a research project as part of their training. these projects frequently include students as participants. this could be seen as targeting convenient populations who are potentially vulnerable, raising ethical concerns. objectives. to review the selection and inclusion of students as research participants in undergraduate medical student projects at the school of medicine, ufs, 2002 2017, to assess ethical conduct. methods. for this descriptive study all undergraduate medical student projects from 2002 to 2017 were screened for the inclusion of any type of student as participant (458 projects). information was obtained from research protocols and final reports. results. fifty-seven student projects (12.4%; range 0% (2002) 26.9% (2017)) included students as participants. participants were mainly undergraduate medical students (50.9% of the 57 projects) or undergraduate residence students (24.6%). in 86.7% of projects with participating medical students, there was evidence of literature or subject motivation for this choice, compared with 42.9% of projects that included undergraduate residence students. recruitment was mostly done in class (43.4%) by student researchers (84.9%). no incentives for participation were offered (90.6%). participation generally followed directly after recruitment (58.5%). in 63.2% of projects, anonymous questionnaires were used. conclusions. the percentage of undergraduate medical student projects that included students as participants increased during the study period, and may necessitate some form of scheduling of researchers’ contact with students. the selection and inclusion of students as research participants appear to be ethically acceptable, with the possible exception of undergraduate residence students. afr j health professions educ 2019;11(2):57-62. doi:10.7196/ajhpe.2019.v11i2.1081 the selection and inclusion of students as research participants in undergraduate medical student projects at the school of medicine, university of the free state, bloemfontein, south africa, 2002 2017: an ethical perspective g joubert,1 ba, msc; w j steinberg,2 mb bch, dtm&h, dph, dip obst (sa), mfammed, fcfp (sa); l j van der merwe,3 mb chb, mmedsc (chir), da (sa), phd (hpe) 1 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of family medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 3 undergraduate programme management, school of clinical medicine, university of the free state, bloemfontein, south africa corresponding author: g joubert (gnbsgj@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:gnbsgj@ufs.ac.za 58 june 2019, vol. 11, no. 2 ajhpe research researched] may lead to an obscured understanding of real or perceived ethical transgressions, making it difficult to intervene to address the underlying concerns’. for the purpose of this article, we refer to student populations as being targeted more frequently. during the saahe workshop discussion, concerns were also raised regarding practical issues, such as scheduling of researchers’ contact with students as participants, as participation in research projects during classroom contact sessions may affect academic time. at the school of medicine, university of the free state (ufs), bloemfontein, south africa (sa), undergraduate medical students plan, execute and report on a research project as part of their training (research modules: epidemiology, biostatistics and special study module). this is done in small groups under the guidance of a clinical or laboratory study leader after students have received structured training in protocol writing, research ethics and research methodology. it is their first exposure to research, and research outcomes might not be publishable, often due to sample-size constraints. however, sound methodology remains essential, and therefore protocols are required to be approved by the health sciences research ethics committee (hsrec) and appropriate authorities. nonetheless, the concerns raised during the saahe workshop discussion regarding the possible targeting of medical student peers or ufs residence students as convenient and accessible target populations for student researchers need to be considered. such targeting could be inappropriate, as the topic under investigation may be unrelated to medical students (or health sciences students or any student) as study participants. furthermore, data collection for these projects usually occurs from july to november. the timing and frequency of data collection may place an additional burden on students in an already full and demanding academic programme. currently, there are no data regarding the extent to which students are approached for participation in research projects at the school of medicine, ufs. therefore, as a first step to gain some relevant data, we did an audit of the practices regarding the selection of students as research participants from 2001, when student research projects were introduced into the undergraduate medical programme. by obtaining such information, we could ascertain whether students were exposed to or even encouraged to follow unethical practices in selection of participants during this first experience of the research process. we would also be able to advise staff involved in training and guiding medical students through the research process, as well as the school of medicine and faculty of health sciences and ufs management regarding research involving students. these findings could assist in developing appropriate guidelines regarding the inclusion of students in research projects in our setting, as has been done in other institutions.[5,6] objectives the aim of the study was to review the selection and inclusion of students as research participants in undergraduate medical student projects at the school of medicine, ufs, to assess the ethical conduct with regard to participant selection. for this purpose, the following data were obtained: • number and percentage of projects that included students as participants, and trends over time • a description of students selected, including their academic study year, gender, and other inclusion or exclusion criteria • motivations for the selection of students as participants • participant recruitment procedures, location of participation, data collection procedure followed, type of measuring instruments used and timing of research participation in academic year • nature of consent obtained, use and nature of incentives to encourage participation and response rates achieved. methods this descriptive study included all undergraduate medical student projects in the research modules from 2002 to 2017. an initial screening regarding the inclusion of any type of student as a participant was done by the first author, based on the project oral presentation programmes. further information regarding the projects that included student participants was obtained by scrutiny of the research protocols and reports (documents that are archived by the first author as co-module leader of the research modules). information was noted on data forms, which were compiled based on the objectives of the study. in addition to the research projects that formed part of the undergraduate medical research modules, all other protocols submitted to the hsrec, ufs from 2014 to 2017 were screened for inclusion of student participants. this screening was done by the first author (a member of the hsrec) using the agendas and minutes of hsrec meetings. a pilot study of student projects of 2002 and 2012 was done, and data from these projects were included in the main study. information from the data forms was analysed by the first author in terms of frequencies and percentages. no names of students (as research participants or researchers), study leaders or departments were noted or reported on. all information was dealt with confidentially, and only summary information was reported. no information (e.g. exact study topic) was divulged that could lead to the identification of a specific project or student research group. ethical approval the protocol for this study was approved by the hsrec, ufs (ref. no. hsrec 155/2016), the head of the school of medicine, the dean of the faculty of health sciences, the dean of student affairs, and the vice-rector research, ufs. results of the 458 undergraduate medical student projects performed from 2002 to 2017, 57 (12.4%) included students as participants. this percentage ranged from 0% (2002) to 26.9% (2017) (fig. 1). table 1 outlines details of participants included in these 57 projects. in 4 (7.0%) projects, student records only were used. the student participants were mainly undergraduate medical students (50.9% of the 57 projects), or students staying in ufs residences (24.6%). both genders were included in most studies (82.5%). some studies had additional inclusion criteria (24.6%), but few stated exclusion criteria (5.3%). sampling was frequently done in residence students (78.6%), but seldom in undergraduate medical students (13.3%). in >85% of projects that included undergraduate medical students as participants, there was evidence of literature or subject motivation for this choice. such evidence was present in fewer than half of the projects that included ufs undergraduate residence students as participants. table 2 outlines recruitment procedures. recruitment was mostly done in class or during an academic contact session (43.4%) by the student researchers june 2019, vol. 11, no. 2 ajhpe 59 research (84.9%), and no incentives for participation were offered (90.6%). in 43.3% of projects involving students directly, the project study leader was a lecturer of the student participants, but in only 1 of these did the lecturer take part in the recruitment of participants (registrars in the specific case). participation generally followed directly after recruitment (58.5%). table 3 summarises details of the measuring instruments used. in 61.4% of the projects, only questionnaires were used, which were mainly anonymous (76.6%). only 4 projects made use of interviews – 3 were structured and 1 was semistructured. the latter was the only qualitative study performed with student participants. fourteen projects (24.6%) included medical students in other year groups than participants in the pilot study, and 9 projects (15.8%) included students from other schools in the faculty in the pilot study. because of the structure of the module, data collection was planned to be performed during specific months in the second half of the year. however, of the 35 projects for which information regarding data collection was provided in the reports, data collection took place later than the dates stated in the protocol in 20 (57.1%) projects. as the following quote from a 2006 report shows, some students leave data collection very late: ‘the day the questionnaires were handed out to the final-year medical students was their last academic session of the year and the questionnaire could only be handed out at the end of the 3-hour session. the students showed much reluctance to filling out the questionnaires. many were also in a hurry and anxious about their then approaching exams; this could have affected the way they answered the questions.’ this study had a response rate of 52.3% of the 128 potential participants. for projects with undergraduate medical students as participants, response rates were usually >75% (except for fifth-year students, who frequently had lower or even poor response rates). for projects with undergraduate residence students as participants, response rates were usually <50%. table 4 summarises projects with student participants submitted to the hsrec from 2014 to 2017, other than those by undergraduate medical student groups. students were included as participants in 24 (8%) of the submissions in 2017 and 13 (4%) in 2015, mainly from the school for allied health professions. discussion research projects performed by undergraduate medical students often include students as participants. results from this study showed a rise in the percentage of undergraduate medical student projects at ufs that included students as participants, with the three highest percentages occurring from 2014 to 2017. this increase was also seen in general research project applications reviewed by the hsrec, ufs. approval by review boards is one method of ensuring ethical research practices. institutional review boards (irbs) have varying approaches to the evaluation of protocols and the risks involved in research with students as participants.[8] for an interventional educational trial, for example, only 1 of the 7 irbs that had to evaluate the protocol required full review, 4 followed an expedited process, and 2 indicated that the protocol required no irb approval.[8] all projects at the faculty of health sciences, ufs undergo full review by the hsrec, i.e. scrutiny by 2 review ers and discussion by the full committee. no exceptions are made, regardless of the type of project (e.g. record review v. intervention) or the level of the applicants (undergraduate student v. post-doctorate researcher). all projects have to adhere to all requirements and procedures of the hsrec, such as submission of amendments, progress and final reports. all projects also have to be approved by the relevant institutional authorities, such as university authorities in the case of student participants. the hsrec requires detailed information documents for all projects other than record reviews, outlining, in particular, the voluntary nature of participation and that participants can withdraw at any time without prejudice. although ufs requires full review of all protocols, other changes have occurred over the period included in this study. in the past, written informed consent was required for the completion of anonymous questionnaires, whereas more recently the hsrec considers completion of the anonymous questionnaire as consent (this needs to be indicated to the participant on the questionnaire). results from our study showed that in these undergraduate medical student projects using students as research participants, anonymity is frequently ensured, incentives are not abused to encourage participation and consent procedures are followed as stipulated by the appropriate ethics committee. easy access to convenient populations may lead to populations being targeted for inclusion in research projects. research topics making use of student participants should be relevant and well motivated. results from this study demonstrated that literatureor subject-based motivation for the choice of student participants was apparent in 75% of the projects. more than 85% of projects that included undergraduate medical students as participants had a literature or subject motivation for this choice. furthermore, student researchers are in their second year of study when they perform their projects, which is not the most frequently selected year group to participate. the suspicion that medical students may choose other medical students as participants based on fig. 1. percentage of undergraduate medical student projects that included students as participants, annually, 2002 2017. 0.0 5.9 3.2 17.1 12.9 14.3 8.8 6.9 7.1 15.2 6.1 12.0 17.9 21.9 14.8 26.9 0.0 5.0 10.0 15.0 20.0 25.0 30.0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 year pr o je ct s, % 60 june 2019, vol. 11, no. 2 ajhpe research convenience only, therefore currently does not seem to have merit. however, the possibility might exist that research topics are preferentially selected, for which medical students are an appropriate population. the selection of topics in such a way could be considered methodologically unsound[9] and ethically unfair.[7] walsh[7] pointed out that in medical education research, many more projects are done on easily accessible medical student populations than on less accessible groups doing continuing professional development. certain groups (and thereby topics) are unfairly not included in the research. in projects with ufs undergraduate residence students as participants, more than half had no motivation for including residence students. the literature used in these projects usually referred to university students, not specifically residence students. only 2 projects targeted all undergraduates; one used a complex cluster sampling of class venues, the other a methodologically less sound use of volunteers at different sites on campus. student researchers clearly use (often on the advice of the study or module leader) residence students as a proxy for all undergraduate students owing to the convenience of being able to approach these students fairly table 1. details of the type of student participants included in projects (n=57) student participants n (%) type of participation students directly involved as participants 53 (93.0) student records only used 4 (7.0) study includes only ufs students yes 42 (73.7) types of ufs students included any undergraduate student 2 (3.8) residence undergraduate students 14 (24.6) faculty of health sciences undergraduate students 1 (1.8) school of medicine undergraduate students 29 (50.9) school of medicine registrars 6 (10.5) school of medicine undergraduates and registrars 1 (1.8) residence students 1 (1.8) any student 2 (3.5) hostel league rugby players 1 (1.8) study year of students included ufs undergraduate residence students (n=14) any year 10 (71.4) first year 4 (28.6) medical students (n=29)* first year 13 (44.8) second year 12 (41.4) third year 13 (44.8) fourth year 9 (31.0) fifth year 16 (55.2) gender male 2 (3.5) female 8 (14.0) male plus female 47 (82.5) further inclusion criteria specified for the selected student population 14 (24.6) further exclusion criteria specified for the selected student population 3 (5.3) type of student 43 (75.4) undergraduate medical students (n=30) 26 (86.7) ufs undergraduate residence students (n=14) 6 (42.9) study year (n=38) 29 (76.3) gender (n=10) 10 (100.0) sampling done within the selected student population yes 22 (38.6) undergraduate medical students (n=30) 4 (13.3) undergraduate residence students (n=14) 11 (78.6) type of sampling (n=20) volunteers 5 (25.0) convenience 3 (15.0) some form of random sampling 12 (60.0) ufs = university of the free state. *six projects included all year groups, 16 projects included 1 specific year group, the remaining 8 included combinations, e.g. 1 and 5; 4 and 5; 1, 3 and 5. table 2. details of recruitment procedures (n=53) recruitment procedures n (%) place of recruitment class only 23 (43.4) class plus other venues 3 (5.7) departmental meeting 2 (3.8) residence house meeting 10 (18.9) residence house meeting plus letter delivered to residence room 1 (1.9) not clear 1 (1.9) not stated 5 (9.4) team practice 1 (1.9) questionnaire delivered to room 1 (1.9) clinical rotation groups 1 (1.9) specially arranged meeting 2 (3.8) department 2 (3.8) various public venues on campus 1 (1.9) who does participant recruitment? student researchers only 45 (84.9) student researchers (for students) and study leader (for registrars) 1 (1.9) student researchers and class/group leaders 2 (3.8) student researchers or residence primarius 1 (1.9) residence committee member 1 (1.9) not clear 1 (1.9) not stated 2 (3.8) incentive offered for participation yes (sweets, raffle for movie tickets) 3 (5.7) not stated 2 (3.8) no 48 (90.6) participation follows immediately after recruitment no 14 (26.4) unclear 4 (7.5) yes 31 (58.5) yes, plus some later opportunity/involvement 4 (7.5) informed consent implicit (anonymous questionnaire) 27 (50.9) unclear 1 (1.9) written 25 (46.2) june 2019, vol. 11, no. 2 ajhpe 61 research easily. this is therefore a group that in our context can be considered as being inappropriately targeted. recruitment of students as research participants may expose them to coercion. guidelines for student participation at other institutions,[5,6] and concerns raised regarding medical students being a vulnerable group,[7] are mainly aimed at projects in which staff members (as figures of authority) are the researchers. it is encouraging that student researchers do the recruitment themselves; there is no evidence of abuse of authority by, for example, the study leader doing the recruitment, which could lead to coercion and possible non-voluntary participation. participating in research projects may place a burden on students who have limited time and who experience severe academic pressure. the timing and duration of participation should therefore be considered when ‘scheduling’ of researchers’ access to students is to be done via, for example, the programme director’s office in the case of medical students as participants. our results showed that recruitment often takes place in class, with participation mostly following directly after recruitment. the impact of this on academic time might be a hidden risk, which cannot be considered to be a minimal ethical risk.[7] we estimate that participation in student questionnaire surveys takes 30 45 minutes, covering the introduction of the project to potential participants and the completion and handing in of the questionnaires. relevant authorities may need to consider putting specific guidelines in place as part of protocol review processes. the ufs school for allied health professions has decided that research on student participants in the school may no longer be done during class time (personal communication – executive committee, school for allied health professions, october 2017). from a practical point, note that data collection often does not occur at the time stipulated in the protocol, which complicates potential scheduling. class attendance is compulsory in the faculty of health sciences, ufs. it is therefore not surprising that projects with undergraduate medical student participants generally did not make use of any sampling, and generally had good response rates. during the clinical years of training (years 4 and 5), all academic and training activities take place in 5 rotation groups, and students seldom have sessions together as an entire year group. accessing these clinical students is more cumbersome, and response rates are therefore lower in projects that include clinical students as research participants. despite fifth-year medical students being less easily accessible, this year group is selected for the largest percentage of projects, thus indicating that convenience only is not the motivating factor in the selection of participants. projects with undergraduate residence students generally used some form of sampling and had lower response rates – clearly linked to size and ease of access to the populations. study limitations the results of this study were affected by data not being available in reports (e.g. actual time of data collection) or data not being accessible for a few projects owing to missing records or termination of projects because of students leaving the programme. data collection did not include information regarding research topics or risk assessment specifically and could be expanded in future studies. for other projects with student participants reviewed by the hsrec, ufs, from 2014 to 2017, only the agendas and minutes of meetings were available as source documents. these documents contained limited detail regarding the projects, and the appropriateness of students as participants could not be ascertained. the brief results about these projects were primarily given to provide some broader context. recommendations ongoing vigilance regarding the appropriateness of students as research participants is required. only by constant scrutiny of one’s practices in this regard can ethical conduct be ensured. a checklist of items such as appropriate motivation for selection of the specific type of participant and avoidance of coercion or undue influence (in this case by lecturers as authority figures) would be of value to these projects specifically and all projects in general. a more comprehensive exploration of risk assessment for students as research participants would provide valuable information for review boards table 3. details of measuring instrument used measuring instrument n (%) measuring instrument (n=57) data form only 4 (7.0) data form plus measurements 2 (3.5) interview 2 (3.5) interview plus measurements 2 (3.5) questionnaire only 35 (61.4) questionnaire plus measurements 12 (21.0) if questionnaire (n=47) anonymous 36 (76.6) table 4. other projects with student participants reviewed by the health sciences research ethics committee, university of the free state, 2014 2017 type of student participant 2014, n 2015, n 2016, n 2017, n medical students 2 0 2 5 registrars 1 1 1 2 nursing students 3 2 4 1 school for allied health professions students 5 4 6 5 entire faculty of health sciences 1 2 4 3 residence students 2 1 1 0 any university of the free state student 0 1 0 2 a specific sport 1 1 0 4 a specific limitation 0 1 1 1 a specific subject 0 0 1 1 total submissions, n (%) 15 (4) 13 (4) 20 (7) 24 (8) 62 june 2019, vol. 11, no. 2 ajhpe research and educational authorities in determining guidelines for inclusion of students as research participants. further studies could be done on student perceptions regarding willingness to participate and vulnerability experienced as research participants, the impact of time demands on their participation, as well as their opinions on the value of the contribution to research. conclusions there is an increase in the use of students as participants in undergraduate medical student research projects at the school of medicine, ufs, and therefore this practice needs attention. while the choice of undergraduate medical students as participants is generally well motivated, it appears that residence students may be targeted mainly for convenience. anonymity is frequently ensured, and incentives are seldom offered for participation. recruitment takes place mainly by student researchers during classroom contact sessions, with participation following directly. using students as research participants appears to be ethically justified, but some guidelines on the protection of academic time may be necessary. further research regarding risk assessment and student perceptions of their experiences as research participants will be valuable. declaration. none. acknowledgements. the researchers thank ms t mulder, medical editor, school of medicine, ufs, for technical and editorial preparation of the manuscript. author contributions. gj conceived the idea, drafted the initial protocol, collected and analysed the data and wrote the first draft of the manuscript. wjs and ljvdm contributed to writing of the protocol, interpretation of the data and writing of the manuscript. funding. none. conflicts of interest. none. 1. national department of health. ethics in health research: principles, processes and structures. 2nd ed. pretoria: ndoh, 2015. 2. wendler d, grady c. what should research participants understand to understand they are participants in research? bioethics 2008;22(4):203-208. https://doi.org/10.1111/j.1467-8519.2008.00632.x 3. ridley rt. assuring ethical treatment of students as research participants. j nurs educ 2009;48(10):537-541. https://doi.org/10.3928/01484834-20090610-08 4. koen jl. the ‘over-researched community’: an exploration of stakeholder perceptions and ethical analysis. ma thesis. durban: university of kwazulu-natal, 2010. http://researchspace.ukzn.ac.za/bitstream/ handle/10413/5163/koen_jennifer_leigh_2010.pdf ?sequence=1&isallowed=y (accessed 21 september 2016). 5. johns hopkins university. policy concerning the recruitment and enrolment of students in research involving human subjects. baltimore, md: johns hopkins university, 2005. 6. university of colorado boulder. students as research subjects: how to avoid undue influence and coercion. boulder, co: university of colorado boulder, 2017. 7. walsh k. medical education research: is participation fair? perspect med educ 2014;3(5):379-382. https://doi. org/10.1007/s40037-014-0120-5 8. sarpel u, hopkins ma, more f, et al. medical students as human subjects in educational research. med educ online 2013;18:1-6. https://doi.org/10.3402/meo.v18i0.19524 9. joubert g, katzenellenbogen jm. planning a research project. in: ehrlich r, joubert g. epidemiology. a research manual for south africa. 3rd ed. cape town: oxford university press, 2014:50-57. accepted 4 december 2018. https://doi.org/10.1111/j.1467-8519.2008.00632.x https://doi.org/10.3928/01484834-20090610-08 http://researchspace.ukzn.ac.za/bitstream/handle/10413/5163/koen_jennifer_leigh_2010.pdf?sequence=1&isallowed=y http://researchspace.ukzn.ac.za/bitstream/handle/10413/5163/koen_jennifer_leigh_2010.pdf?sequence=1&isallowed=y https://doi.org/10.1007/s40037-014-0120-5 https://doi.org/10.1007/s40037-014-0120-5 https://doi.org/10.3402/meo.v18i0.19524 december 2019, vol. 11, no. 4 ajhpe 118 research this article focuses on describing the perspectives of a sample of south african (sa) emergency care practitioner (ecp) students regarding the value of simulation v. four other learning methods in preparing them for clinical practice. in the context of our study, simulation refers to the creation of learning experiences through the use of actors, manikins, training aids and related equipment to simulate an authentic patient-practitioner interaction. incident or scene management refers to the management of resources and application of management strategies to deal with the patient and the environment. a ‘case’ in the context of this study refers to a particular patient – real or simulated. in sa, prehospital emergency care is provided by a number of private and public emergency medical services. each service employs staff with different levels of education, training and associated scope of practice. historically, emergency care training ranged from only a few weeks (for basic ambulance attendants) to months and years for paramedics. sa advanced life-support paramedics enjoy an extensive scope of practice that allows them to independently manage the majority of patients they encounter. however, there remains a subset of critically ill or injured patients who require interventions that fall outside the paramedic scope of practice. in many other countries, such patients would be attended to by emergency service doctors. in sa, a shortage of doctors to fulfil this role prompted government to follow a different path, which saw the emergence of the ecp. ecps are healthcare professionals who function as prehospital acute care clinicians and medical rescue specialists.[1]  ecps practise independently, predominantly within the preand inhospital emergency and critical care transport environments. to become an ecp, one needs to complete a 4-year (national qualifications framework (nqf) level 8) professional degree in emergency medical care (emc). ecp graduates register as independent practitioners with the health professions council of south africa (hpcsa). the university of johannesburg (uj) is 1 of 4 institutions nationally that offer the bachelor degree in emc.[2] these institutions use simulation for teaching, learning and assessment. simulation in health science education is not new and was first described in the 17th century in france, where rudimentary manikins were used for simulating the process of birth.[3,4] technology has progressed considerably, with modern human patient simulators now being able to closely replicate the anatomy of real patients, including the performance of a range of physiological actions such as blinking, breathing, bleeding, vomiting, sweating and even convulsing. many simulators, including those used at uj, are equipped with computer-feedback systems that allow for the recording and analysis of a number of clinical procedures and interventions. uj, along with most national and international providers of emergency care education and training, makes extensive use of task trainers and models together with advanced life-support manikins for clinical teaching, learning and assessment. at uj, these are housed in a purpose-built simulation laboratory that services a number of departments in the faculty. our application of simulation in the academic unit is based on an educational philosophy of constructivism, where we see emc students as active participants in the learning process, with lecturers taking on the role of facilitators of learning. clinical learning usually begins with the mastery background. simulation is a commonly used method for clinical learning and assessment in the health sciences. however, despite technological advancements, we are unable to perfectly simulate the appearance and behaviour of real patients, including the stressors, distractions and surroundings commonly encountered in the authentic clinical environment. in south africa, simulations are used extensively in the education and training of emergency care practitioners (ecps). objective. to investigate and describe the views of ecp students regarding the value of simulation v. four other learning methods in preparing them for real-world practice. methods. ecp students (n=79) completed a purposefully designed questionnaire. a likert scale was used to obtain participants’ views on how well simulation ranks compared with theoretical lectures, tutorials, inhospital and prehospital work in preparing them for clinical practice. results. participants valued simulation as an educational tool. simulation was ranked as the best method for teaching clinical assessments and procedures and came second only to the real clinical environment for teaching clinical decision-making. simulation was ranked third, after theoretical classes and prehospital shifts, with regard to learning to take a history and identify life-threatening conditions. conclusions. ecp students view simulation as a valuable learning method to manage incidents, conduct clinical assessments, perform procedures and make clinical decisions. simulation, however, has limitations and was seen as less suited for teaching history-taking and identification of life-threatening conditions. further research is needed to determine the ideal blend of simulation with other pedagogies in the education of ecp students. afr j health professions educ 2019;11(4):118-122. https://doi.org/10.7196/ajhpe.2019.v11i4.1041 views of emergency medical care students on the value of simulation for achievement of clinical competence c vincent-lambert, nd aet, nhd pse, nhd fst, btech emc, mtech ed, phd, hpe; c n douglas, btech emc department of emergency medical care, faculty of health sciences, university of johannesburg, doornfontein campus, johannesburg, south africa corresponding author: c vincent-lambert (clambert@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 119 december 2019, vol. 11, no. 4 ajhpe research of individual clinical procedures and associated psychomotor skills linked to set tasks such as measurement of vital signs, suturing, airway interventions and intravenous cannulation. we view mastery of these individual skills as essential building blocks and a prerequisite for engaging in a simulated patient interaction. the individual procedural skills are taught and assessed by objective structured clinical examinations (osces). during a simulation learning experience, students are expected to perform one or more osces in the appropriate context, setting and sequence. as simulation requires active student participation, simulation has become entrenched in the framework of our curriculum as a learning method that is used by all our educators involved in clinical learning. ecp students are also exposed to a number of other diverse learning experiences, ranging from conventional theoretical lectures and tutorials to inhospital clinical work. in addition to these, great emphasis continues to be placed on the attendance of rostered prehospital clinical learning shifts. during these shifts students have the opportunity to work and learn in an authentic prehospital emergency care environment under the guidance of a supervising clinician (usually a qualified ecp), where ecp students are expected to apply their knowledge and skills that were taught and practised via simulation. despite the longstanding use of simulation, there is limited literature describing perspectives of ecp students on the value of simulation for learning, or the perceived link between clinical practice and procedures taught via simulation, and their performance in the real world. we chose to explore the views of emc students on the value of simulation for achievement of selected core competencies required to function as an ecp in the prehospital emergency medical service environment. we feel this study delivers new insights into how ecp students rank and/or value simulation compared with other commonly encountered learning experiences. methods a prospective, quantitative, descriptive design was chosen for our study.[5] we chose this design because there was no pre-existing dataset available to analyse that spoke sufficiently to our aim and objective. data were therefore gathered by means of a self-designed, non-validated questionnaire, which consisted of 17 closed-ended questions. questions 1 3 focused on gathering selected demographic information that described the participants. this data set included year of study, age and gender. questions 4 9 required participants to rank different learning methods (including simulation) from best to worst for the achievement of defined core competencies. the latter were selected pragmatically by the researchers, who felt that these reflected important exit-level learning outcomes from the qualification. the final 8 questions provided statements relating to practices and procedures taught in the simulated learning environment and their application in the authentic clinical environment. a likert response scale was used to obtain participant degree of agreement or disagreement with each statement. the questionnaire was piloted with 4 students before being used in the study. the participants in the pilot group indicated that the questions were clear; consequently no adjustments were made. the participants from the pilot group were excluded from the study population. participants were ecp students from years 1 4 enrolled for the emc degree programme at uj. at the time of the study, all participants would have had prior exposure to simulations and would have worked in both the pre and inhospital clinical learning environments. there were ~120 students in the degree programme at the time of data gathering; of these, 81 agreed to participate. two of the questionnaires were found to be incomplete and had to be excluded. seventy-nine completed questionnaires were thus available for analysis. data were analysed descriptively by tallying the responses to each question, allowing for calculation of percentage and frequency of selected options. data were captured onto an excel spreadsheet, allowing for generation of charts and tables summarising responses. ethical approval ethical approval for the study was granted by the faculty of health sciences research ethics committee, uj (ref. no. rec-01-104-2017). participation in the study was voluntary and individual students, educators and supervising practitioners remained anonymous. results in presenting the results, we attempted to follow the logic and flow similar to those of the questionnaire. table 1 shows how participants ranked simulation as a learning method against four other selected learning methods for achievement of six identified core competencies. tables 2 9 provide a summary of responses to statements made regarding simulation learning. a brief narrative at the end of each table draws attention to selected core findings/areas of interest. these are dealt with in greater depth in the discussion. table 1 shows that, overall, the participants ranked simulation highly in terms of its educational value. simulation was ranked as the best method for learning clinical assessments and procedures and came second only to the real clinical environment for learning clinical decision-making. simulation, however, was seen to be less effective in preparing students to take a medical history and identify life-threatening conditions. responses to statements on simulation practices the statements, together with tables summarising the responses, are given here. table 1. ranking of simulation compared with other selected learning methods for achievement of core competencies learning method core competency best 2nd best 3rd best 4th best worst incident management prehospital shifts simulation theoretical lectures inhospital shifts tutorials history-taking theoretical lectures prehospital shifts simulation inhospital shifts tutorials clinical assessment simulation prehospital shifts inhospital shifts theoretical lectures tutorials identification of life-threatening emergencies theoretical lectures prehospital shifts simulation inhospital shifts tutorials performance of clinical procedures simulation prehospital shifts inhospital shifts theoretical lectures tutorials clinical decision-making prehospital shifts simulation inhospital shifts theoretical lectures tutorials december 2019, vol. 11, no. 4 ajhpe 120 research statement 1: ‘when i practise simulations in the simulation laboratory, the main reason i do so is to improve the way in which i manage real patients.’ participants’ responses are summarised in table 2. the majority of participants agreed with the statement, indicating that the main reason they practise simulation is to improve the way in which they manage real patients in the real clinical environment. statement 2: ‘the way in which i am taught to manage a patient in the simulation laboratory is the same way as i am expected to manage a similar case when i work in the hospital or in the prehospital environment.’ participants’ responses are summarised in table 3. the participants agreed that the way in which they are taught to manage a patient in the simulated environment is the same as they are expected to manage a patient in the inhospital and prehospital environment. statement 3: ‘the way in which i am taught to use equipment in the simulation laboratory is the same way as i am expected to use it inhospital and in the prehospital environment.’ participants’ responses are summarised in table 4. the majority of participants agreed that they use equipment the same way in the real clinical environment as they do in the simulation laboratory. statement 4: ‘the way in which i am taught to perform specific skills in the simulation laboratory is the same as the way these skills are performed in the hospital or prehospital environment.’ participants’ responses are summarised in table 5.there was agreement by 45/79 (58%) participants that the way in which they perform skills is the same in the simulated environment as in the real clinical environment. interestingly, 42% of the participants did not feel that the way skills are taught in the simulation environment is the same as the way they are performed in the real world. statement 5: ‘the way in which the simulation environment and manikins are prepared accurately represents the real clinical environment.’ participants’ responses are summarised in table 6. despite the institution having invested in expensive ‘high-end’ manikins and related simulation technologies, only 33% of participants felt the simulation environment and manikins realistically represent the real clinical environment. statement 6: ‘it is better to first practise clinical procedures and patient management in a simulated environment before being expected to perform these in the real clinical setting.’ participants’ responses are summarised in table 7. the majority of participants (57%) strongly agreed that it is better to first practise a clinical procedure and patient management in a simulated environment before being expected to perform these in a real clinical setting. statement 7: ‘the amount of time spent practising in the simulation environment is sufficient to prepare me for engaging in the real clinical environment.’ participants’ responses are summarised in table 8. only 38% of participants felt that the time they spent practising in the simulated environment was sufficient to prepare them for the real clinical environment. we noted that the second-year participants contributed to the majority of the population who disagreed with the statement. statement 8: ‘when i practise simulations in the simulation laboratory, the main reason i do so is to improve my performance in a simulation assessment.’ participants’ responses are summarised in table 9. only 9% of students disagreed with the abovementioned statement. this outcome linked with table 2. responses to statement 1 (n=79) response n (%) strongly disagree 1 (1) disagree 6 (8) neutral 9 (11) agree 29 (37) strongly agree 34 (43) table 3. responses to statement 2 (n=79) response n (%) strongly disagree 1 (1) disagree 15 (19) neutral 15 (19) agree 30 (38) strongly agree 18 (23) table 4. responses to statement 3 (n=79) response n (%) strongly disagree 1 (1) disagree 4 (5) neutral 10 (13) agree 33 (42) strongly agree 31 (39) table 5. responses to statement 4 (n=79) response n (%) strongly disagree 0 (0) disagree 17 (21) neutral 17 (21) agree 26 (34) strongly agree 19 (24) table 6. responses to statement 5 (n=79) response n (%) strongly disagree 5 (6) disagree 28 (36) neutral 20 (25) agree 24 (30) strongly agree 2 (3) table 7. responses to statement 6 (n=79) response n (%) strongly disagree 2 (2) disagree 3 (4) neutral 3 (4) agree 26 (33) strongly agree 45 (57) 121 december 2019, vol. 11, no. 4 ajhpe research responses indicating that the main reason for practising in the simulation environment was to improve actual patient management. discussion the literature shows that simulation-based learning is a mode of instruction widely used by emergency care educators locally and abroad as a way of improving confidence with regard to the performance of clinical skills in stressful situations.[6] in sa, simulations are used extensively in the education and training of ecps. our study explored the perspectives of a group of ecp students regarding the value of simulation v. four other learning methods in preparing them for real-world practice. table 1 shows that simulation was highly ranked by ecp students as a method of learning to perform clinical assessments and procedures. this finding may be linked to emergency care interventions and procedures being infrequently performed and many being invasive. consequently, emergency care educators tend to rely heavily on practising emergency procedures such as intubation, establishing a surgical airway and defibrillation on models and manikins in a simulated environment. however, simulation was more valued than clinical learning shifts for patient assessment. this outcome was unexpected, as one would have thought that the best way to learn patient assessment skills would be to practise on live patients. reasons for this finding are not clear, but may point to limitations and/or negative experiences encountered by our participants in the authentic clinical learning environment rather than the strength of simulation as a tool to achieve this outcome. further research to explore the possible reasons for this finding are therefore recommended. our participants’ views that the prehospital environment was best for learning how to manage a scene may have been linked to recognised limitations of current simulation technologies. at the time of this study, our simulation facilities were such that we were not able to fully replicate the prehospital environment in terms of noise, on-scene hazards and distractions, such as the presence of patients’ family members and bystanders. despite these limitations, the literature supports the idea that simulations can remain an accepted way of teaching students how to deal with stressful environments in a controlled setting.[7] a potential solution to making simulation a better tool for learning to manage an emergency scene may be to increase the level of fidelity when creating prehospital emergency care simulations. our participants saw simulations as a beneficial learning method to teach clinical decision-making skills. clinical decision-making is a complex process that involves the gathering and interpreting of data from multiple sources to make a decision on clinical interventions, treatment plans and/or immediate courses of action.[8,9] in our context, we see clinical decision-making as a critical exit-level learning outcome of the bachelor degree qualification and a critical cornerstone of independent prehospital emergency care practice. this study supports the value of simulation as a tool for the learning and assessing of clinical decision-making for ecp students. the study also explored students’ experiences of the links between the way they are taught and their experience in the simulation laboratory and what they encountered in the real world. the respective frequencies for agreement (tables 2 4) were 61%, 81% and 81%, respectively, indicating that the majority agreed that the way they are taught to perform certain skills in the simulation laboratory is similar to how these skills are expected to be performed in the prehospital or inhospital environment. conversely, the students disagreed that our simulated environments and manikins accurately present the real-world setting. as mentioned above, this is a wellrecognised limitation of simulation-based learning.[9,10] conclusions although the results of this study show that ecp students value simulation as a learning method, they seem to agree with educators that clinical competence cannot be achieved through simulation alone. clinical placements, prehospital caseload and work in the authentic environment remain highly valued learning experiences.[11] study limitations there are certain limitations relating to the scope and design of this study. firstly, we acknowledge that our study was purely exploratory and descriptive. we did not probe in-depth exact reasons for the views expressed by our participants. further research needs to be conducted to explore in greater depth ecp students’ experiences of simulation as a pedagogical tool. this may further assist educators to determine the optimum blend of learning experiences and how simulation is expressed in the curriculum. secondly, certain of our response options contained what may be considered ‘neutral’ responses/ statements. should similar surveys be considered, we would advocate omitting this option. finally, while the study delivered some interesting findings, our participants were from a single university and thus the views and options expressed may differ between institutions and across disciplines. declaration. none. acknowledgements. we wish to thank the participants for giving their valuable time to participate in the study. author contributions. cvl supervised the research and wrote the article; cnd gathered the raw data and wrote the report on which the article is based. funding. none. conflicts of interest. none. 1. vincent-lambert c, bezuidenhout j, van vuuren mj. are further education opportunities for emergency care technicians needed and do they exist? afr j health professions educ 2014;6(1):6-9. https://doi.org/10.7196/ajhpe.285 2. department of emergency medical care. university of johannesburg. 2017. https://www.uj.ac.za/faculties/ health/emergency-medical-care/pages/default.aspx (accessed 20 august 2017). table 8. responses to statement 7 (n=79) response n (%) strongly disagree 8 (10) disagree 16 (20) neutral 25 (32) agree 21 (27) strongly agree 9 (11) table 9. responses to statement 8 (n=79) response n (%) strongly disagree 0 (0) disagree 7 (9) neutral 8 (10) agree 28 (35) strongly agree 36 (46) http://dx.doi.org/10.7196%2fajhpe.285 https://www.uj.ac.za/faculties/health/emergency-medical-care/pages/default.aspx https://www.uj.ac.za/faculties/health/emergency-medical-care/pages/default.aspx december 2019, vol. 11, no. 4 ajhpe 122 research 3. mack p. understanding simulation based learning. in: understanding simulation based learning. 1st ed. singapore: sgh-life support training centre, 2009:1-2. 4. mcgaghie wc, issenberg sb, petrusa er, scalese rj. a critical review of simulation-based medical education research: 2003 2009. med educ 2010;(44):50-63. https://doi.org/10.1111/j.1365-2923.2009.03547.x 5. williams c. research methods. j bus econ res 2007;5(3):65-72. https://doi.org/10.19030/jber.v5i3.2532 6. omer t. nursing students’ perceptions of satisfaction and self-confidence with clinical simulation experience. j educ pract 2016;7(5):131-138. 7. kaddoura ma. new graduate nurses’ perceptions of the effects of clinical simulation on their critical thinking, learning, and confidence. j contin educ nurs 2010;41(11):506-516. https://doi.org/10.3928/00220124-20100701-02 8. tiffen j, corbridge sj, slimmer l. enhancing clinical decision making: development of a contiguous definition and conceptual framework. j prof nurs 2014;30(5):399-405. https://doi.org/10.1016/j.profnurs.2014.01.006 9. vincent-lambert c, bogossian f, eds. a guide for the assessment of clinical competence using simulation. 1st ed. johannebsurg: universitas 21 health sciences group, 2017. 10. perkins gd. simulation in resuscitation training. resuscitation 2007;73(2):171-324. https://doi.org/10.1016/j. resuscitation.2007.01.005 11. ruessler m, weinlich m, muller m, byhahn c, marzin i, walcher f. simulation training improves medical emergency management. 2012. http://www.medscape.com/viewarticle/764050 (accessed 20 august 2017). accepted 1 july 2019. https://doi.org/10.1111/j.1365-2923.2009.03547.x https://doi.org/10.19030/jber.v5i3.2532 https://doi.org/10.3928/00220124-20100701-02 https://doi.org/10.1016/j.profnurs.2014.01.006 https://doi.org/10.1016/j.resuscitation.2007.01.005 https://doi.org/10.1016/j.resuscitation.2007.01.005 http://www.medscape.com/viewarticle/764050 ajhpe african journal of health professions education june 2021, vol. 13, no. 2 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: units 9&10 lonsdale building, gardener way, pinelands, 7430. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town wernercordier univsersity of pretoria rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university champion nyoni university of the free state anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors paula van der bijl kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 short communication 94 teaching in the time of covid-19: shared perspectives from south africa and the usa v bangalee, o garza, f oosthuizen, v perumal-pillay, h rotundo short research report 96 exploring experiences of using a case study as a teaching strategy to learn about spirituality in occupational therapy education t g mthembu, a rhoda research 99 curriculum mapping: a tool to align competencies in a dental curriculum r maart, r adam, j frantz 105 promoting deeper learning in pharmacy education using team-based learning m j eksteen, g m reitsma, e fourie 110 the workplace as a learning environment: perceptions and experiences of undergraduate medical students at a contemporary medical training university in uganda m n kagawa, s kiguli, w j steinberg, m p jama 118 do we assess what we set out to teach in obstetrics: an action research study s adam, i lubbe, m van rooyen 123 late-night simulation: opinions of fourthand fifth-year medical students at the university of the free state, bloemfontein, south africa c theron, t-l van zyl, a joubert, b kleynhans, p van der walt, m g hattingh, g joubert 129 evaluating palliative care training in the oncology registrar programme in south africa r krause, j parkes, d anderson, n hartman, l gwyther 135 medical students using the technique of 55-word stories to reflect on a 6-week rotation during the integrated primary care block a dreyer, m g mlambo, n o mapukata-sondzaba 141 factors associated with emotional exhaustion in undergraduate and postgraduate nursing students m engelbrecht, m wilke 146 improving south african medical curricula related to traditional health systems c lawrence, j bollinger, k a stewart, m moshabela cpd questionnaire september 2021, vol. 13, no. 3 ajhpe 201 research why was the idea necessary? the covid-19 pandemic placed educators in unique circumstances, not only due to their disciplineand student-specific considerations, but also their personal and professional milieu. given a series of sudden additional academic, managerial and research responsibilities, transitions of the first author’s pharmacology learning opportunities to an online setting required consideration of educational scholarship, resources and a tumultuous daily schedule. although hybrid learning was already incorporated into the modules using preparatory, engagement and consolidation features, an overarching concern was passive, complacent and complicit learning, given the transition of the (primarily) physical space of learning to that of digital and onlineonly learning. furthermore, pharmacology is perceived as difficult, content heavy and suffering from a demotivating learning environment,[1,2] which has also been observed by the authors. hybridand blended-learning improved this perception, but the sudden and all-encompassing transition of programmes was seen as a trigger to increase anxiety and decrease learning amenability among the students. what was tried? with the assistance of the second author, low-maintenance, resourceoptimal and effective platforms for student engagement and active learning were planned using the learning management system. traditionally, sessions were primarily didactic, with less student involvement, contextualisation or authenticity. to stimulate engagement and active learning, an underlying framework of scenario-based learning[3] and socioconstructivism[4] was used to: (i) ensure contextualisation of the basic sciences within a clinical environment; (ii) provide a level of authenticity to the context of the learning opportunity; (iii) foster communication, collaboration and peerworking attitudes; and (iv) stimulate critical thinking. for undergraduate pharmacology modules and an honours course that the first author is involved with, resources comprised, at minimum, expansive lecture notes, a narrated presentation, a preparatory exercise and a consolidation activity featuring reflective feedback. three modalities are discussed: (i) interactive narrated presentations; (ii) collaborative blogs; and (iii) collaborative wikis. research ethics committee approval (ref. no. 345/2020) was obtained for student feedback collected throughout the modules as likert scales and open-text fields (which were thematically analysed). for undergraduate modules (3 modules; n=55 248 students), to deviate from standard narrated presentations, 2 active elements were included: (i) hyperlink-mediated scenario-based critical and formative questions; and (ii) reflective feedback. interspaced in the presentation were embedded questions structured as clinical scenarios that required students to either deduce the next logical step in a case and/or apply concepts they had just encountered. students would answer, and then be redirected to either a correct or incorrect slide containing immediate reflective feedback. this created a teachable moment without requiring direct lecturer intervention by providing information on why it was correct (with a hyperlink to the next section) or incorrect (with a hyperlink to return to the question). where multiple answers were correct, students could return to the question to seek the other correct answers. each reflective feedback slide contained a meme (either as a gif (graphics interchange format) or image), which allowed for a little visual humour alongside the information provided. for the honours course (n=22 students), the writing an article and pharmacokinetics learning opportunities were modified into socioconstructivist activities, with teams of 4 5 students. for writing an article, teams were provided with guidelines to writing and 3 published articles of varying quality and scope, as well as instructions to provide short reflective notes on: (i) positive aspects; (ii) negative aspects; (iii) a general opinion on each article; and (iv) how it compares with their research protocols. students needed to compile these into a blog, which after a set deadline, was unblinded to the other teams for their purview. thereafter, a synchronous consolidation session was held to discuss trends and offer additional insights on factors possibly missed. for pharmacokinetics, each team was given a pharmacokinetic concept (absorption, distribution, metabolism or excretion) and tasked to construct a clinical scenario, where a self-selected patient factor would modulate downstream effects of the pharmacokinetic parameter for a drug. these 4 scenarios were unblinded to the other teams and discussed during the online session. to consolidate and formatively assess learning, teams were provided with a final activity, where a lecturer-created clinical scenario incorporating pharmacokinetic parameters unique to a certain drug, disease or patient context needed to be discussed using a wiki. what lessons were learnt? personally, the transition was an ideal time to shift modalities to something new; however, other responsibilities complicated dedicating focus on teaching strategies. using easily accessible resources and scholarship of teaching and learning, innovative timeand resource-efficient sessions could be created that allowed for active student engagement and greater application of their knowledge. such a strategy was more beneficial for attaining graduate competencies and facilitating higher-order thinking, and helped to prepare students for online, open-book assessments. students’ structured feedback regarding the modalities was overtly positive. interactive narrated presentations were enjoyed, with students speaking towards its ability ‘to make students understand and apply knowledge (it’s not just about recalling information)’; that it ‘makes learning it fun’; and that they ‘love the fact that he includes memes and gifs in his presentation … makes learning so much fun and easy to understand’. the effort was also noted: ‘it must’ve taken a long time to compile and it teaching pharmacology online: not just another narration w cordier,1 phd; i (j c) lubbe,2 phd 1 department of pharmacology, school of medicine, faculty of health sciences, university of pretoria, south africa 2 department for education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: w cordier (werner.cordier@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:werner.cordier@up.ac.za 202 september 2021, vol. 13, no. 3 ajhpe research really just made my day!’ based on the feedback, the presentation style is enjoyable and fosters a sense of learning. as pharmacology is often noted as difficult and content overloaded, any activity to help lift students’ spirits and motivate them to learn is a positive. using humour as a vehicle for delivering feedback also helps soften the blow to incorrect answers, or allows for some laughter during the learning process, while embedding new knowledge to memor y. the size of narrated presentations was greater than desired (30 80 mb) owing to images (inclusive of powerpointand externally mediated compression), which may perturb their use to some. writing an article and pharmacokinetics sessions were ranked positively (out of 5.00) in terms of enjoyment (4.29) and knowledge construction by self (4.57), and via collaboration (4.00). although the socioconstructivist elements were noted positively, the enjoyment of collaboration itself was ranked lower (3.71), supported by ‘collaboration is very difficult online. some people don’t participate and others can’t do the work and communicate with the group simultaneously.’ the modality is feasible; however, collaboration (whether face-to-face or virtual) remains a contentious topic for students, given the workload distribution, possibility of conflict and perception of ‘weak links in the learning chain’. although both the blog and wiki allowed for synchronous working, students tended to discuss all matters outside of the platform, and then present a consolidated report instead. this appears to be a factor of: (i) inexperience with using the formats; and (ii) belief that it will be slower to complete. a mental note worth making is that, although students use the learning management system for certain activities, they may not be knowledgeable enough to understand all of its unique properties, especially if it is their first opportunity to use certain features. both modalities, however, showcased learning outcomes that were reached for both topics. students were able to differentiate strong and weak elements of all 3 papers, and were introspective regarding where their protocols fell short, which would serve them well during their manuscript writing. furthermore, students could apply pharmacokinetic knowledge in the construction of their own clinical scenarios, and discuss pertinent considerations during provided case reports, highlighting development of metacognitive and critical thinking skills. what will i keep in my practice? all 3 modalities worked well and can be easily adjusted to a hybrid learning approach once a new sense of normality resumes. the scenario-based learning will be strengthened to afford students branched opportunities based on their choices, instead of a linear path. for example, incorrect selection could, instead of being stopping points, lead to subsequent questions to showcase clinical repercussions of their selections (such as adverse effects and interactions that may occur). introduction of a longitudinal reflective journal can be used during students’ writing journey to facilitate meta-reflective practice and improved scholarly discourse. what will i not do? three concerns were observed during reflection. although the interactive narrated presentations have broad potential, extensive imagery (regardless of compression) could increase data cost, making it less enticing for those with limited access to the necessary infrastructure. alternative, or at the very least, clear need for it will be important to assess. more in-depth instructions are needed for blogs and wikis, as the assumption of prior exposure and knowledge about its purpose was incorrect. collaboration was noted as positive, but had typical frustrations, which could be overcome by having an orientation to such peer work and/or the introduction of roles for each member of the team. conclusion the scenario-based and socioconstructivist learning modalities showcased maintaining of educational scholarship in an online environment, while keeping design minimal to accommodate facilitator responsibilities. the principles used are easily transferrable to other disciplines, with appropriate adjustments. teaching during the covid-19 pandemic is challenging for many reasons; however, with careful design and some creativity, it can breathe some life into any session to make it more engaging, rewarding and didactically sound. declaration. none. acknowledgements. the authors would like to acknowledge the support of the sub-saharan africa regional institute of the foundation for the advancement of international medical education and research (safri) for soundboarding during the design phase. author contributions. wc designed all learning opportunities and drafted the manuscript, with input from il on educational design, scholarship of teaching and learning, and the manuscript. funding. none. conflicts of interest. none. evidence of innovation 1. andersen ea, moralejo l. using the delphi process to attain expert consensus on bioscience concepts, topics, and skills in undergraduate nursing curricula. j nurs educ pract 2015;6(1):67-75. https://doi.org/10.5430/jnep. v6n1p67 2. ahsan m, mallick a. use of prelecture assignment to enhance learning in pharmacology lectures for the 2nd year medical students. indian j pharmacol 2016;48(7):s65-s68. https://doi.org/10.4103%2f0253-7613.193326 3. koulas i, billis a, kousouri n, et al. design and evaluation of mobile scenario based learning in the self-management of chronic pain. health informatics j 2021;27(1):1-14. https://doi.org/10.1177%2f1460458220977575 4. vygotsky l. mind in society: the development of higher psychological processes. cambridge: harvard university press, 1978. accepted 11 may 2021. afr j health professions educ 2021;13(3):201-202. https://doi.org/10.7196/ajhpe.2021.v13i3.1502 https://doi.org/10.5430/jnep.v6n1p67 https://doi.org/10.5430/jnep.v6n1p67 https://doi.org/10.4103%2f0253-7613.193326 https://doi.org/10.1177%2f1460458220977575 https://doi.org/10.7196/ajhpe.2021.v13i3.1502 june 2019, vol. 11, no. 2 ajhpe 47 research the staff of an institution is said to be its most valuable asset and resource.[1] therefore, it is reasonable to expect higher-education institutions to support their staff . faculty development initiatives offer staff members the opportunity to gradually obtain the necessary educational competencies in teaching, scholarship and service, which they need to function efficiently and effectively in their roles and responsibilities as educators.[2,3] over the years, numerous studies using both quantitative and qualitative methodologies have characterised and described the orientation, support and development of new staff members in academia. a few key authors in the field, primarily in the usa, include boice,[4] boyd,[5] carney et al.,[6] chauvin et al.[7] and rice et al.[8] the focus of research on new staff development varies, from preparing (including orientating) them to get off to a good start[4,7,8] and supporting them, with a specific focus on addressing their experience of stress caused by the demands of rapid adaptation to their new roles and/or experiences related to conflicting professional responsibilities,[8,9] to how to be socialised in academia.[2] many orientation initiatives include a focus on mentor-mentee relationships to support and develop newly appointed academics.[10] research on continued improvement of orientation initiatives is also available, as are studies considering new staff members’ reflections on, perceptions of and attitudes towards orientation activities,[2] and how to improve faculty development services offered to newly appointed academics.[6,11] faculty developers at medical schools in south africa (sa) can make use of existing models and practices to develop and implement faculty development programmes and services;[12] however, it is critical to explore the potentially unique needs of their own academic staff and tailor faculty development initiatives accordingly. in a study of new faculty in north american medical schools,[7] the researchers examined new faculty orientation, and concluded that there were no conclusive ‘best practices’ for presenting faculty development services. however, factors that appeared to support satisfactory orientation of new staff across the medical schools included setting explicit learning outcomes; easily accessible information resources; multiple sessions distributed over time; opportunities to build collegial relationships; programme evaluation, with a focus on processes and overall impact; and explicit faculty commitment and support. furthermore, the literature shows that ongoing training experiences offered over a period of time, or scaffolded learning opportunities, are more effective than once-off offerings.[3] the training can be centralised (to include all disciplines in a faculty or university) or decentralised (to have the same disciplines together). all of these factors are regarded to be important and should be considered when planning for and presenting orientation initiatives to newcomers to medical education. in addition to learning needs and the abovementioned factors, faculty developers should consider the specific target population. newly appointed academics in medical education generally possess professional or health sciences degrees in various disciplines (making them content or discipline experts); they do not always possess the required pedagogic and andragogic competencies to teach effectively in a contemporary medical education setting. even for candidates with prior teaching experience, one should examine whether their experience is sufficient in light of the rapid changes background. this article reports on research conducted on the orientation, support and continued development of lecturers in medical education, which took place at a south african (sa) university. objectives. to provide insights that are relevant for faculty developers and senior leadership, and evidence for reconsidering approaches to faculty development initiatives for newly appointed lecturers. methods. new lecturers’ experiences of a well-established orientation course were explored qualitatively using focus group interviews. participants’ responses were transcribed and analysed thematically. results. on entering the programme, participants generally reported having no or little prior teaching experience. participants’ experiences revealed that an orientation structure is context sensitive and a centralised approach strengthened collegial relationships, but that decentralisation could be considered in medical education orientation. we found that education instruction that allows for active engagement between instructors and peers elicited positive responses. furthermore, our approach to orientation cultivated a sense of accountability in new staff members to continue their participation in faculty development. conclusions. the findings suggest that successful and up-to-date orientation initiatives are indispensable. however, more research should be done in our context and we recommend collaborating with other sa universities in future research endeavours. afr j health professions educ 2019;11(2):47-52. doi:10.7196/ajhpe.2019.v11i2.1115 practise what you teach: lessons learnt by newly appointed lecturers in medical education c van wyk,1 phd (health professions education), msc (med) genetic counselling; m m nel,1 phd (tertiary education management), bed, phd (anatomy); g j van zyl,2 mb chb, mfammed, postgrad dipl health administration, postgrad dipl community health, mba, phd (health professions education) 1 division health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c van wyk (vanwykc2@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 48 june 2019, vol. 11, no. 2 ajhpe research in higher education, including medical education, which have brought about multiple opportunities and challenges for academic staff. teaching-learning concepts have changed, from traditional ways of teaching to more authentic approaches, which advocate for learner-centredness, active learning, higherorder thinking and skills and competency-driven educational principles. the use of technology in education has also increased and the platform grows daily, with new concepts and approaches for improving engagement with the current generation of students and contributing to their learning experiences in medical education.[13] orientation and support initiatives should be aimed at newly appointed academics, who are adult learners, to avoid stagnation; instead, they should be flexible and regularly updated with regard to a specific target population and the continuously changing higher-education environment. for example, faculty developers at ben-gurion university of the negev, israel, draw upon the prior knowledge and experience of newly appointed staff by using facilitated inter-professional small-group activities. in this innovative approach to orientating new staff, a series of interactive activities involve all participants to guide and support learning and create opportunities for course facilitators to consolidate knowledge on a particular subject and add additional and new knowledge or clarify misconceptions.[14] this perspective raises the question of whether approaches to new academic staff orientation that are more engaging are more effective at helping them learn than the long-established model of transmitting information through presentations and lecture-based models. sa authors kridiotis and van wyk[15] included a peerand educationist-evaluated microteaching experience in an orientation programme. the engagement between the group of newly appointed academic staff members (peers) and educationists through evaluating the microteaching sessions and presenting verbal feedback in the larger group led to reflections, stating that the activity was valuable, as the group subsequently felt more confident as lecturers and more competent to implement newly acquired teaching skills. our contribution to the literature on new academic staff orientation is, therefore, based on findings from research conducted on the orientation, support and continued development of newly appointed academics in medical education. we focus on an sa university, where the division health sciences education of the faculty of health sciences had established an educational development course aimed at newly appointed academics. over time, however, there were variations in the course duration, topics covered and presentation styles and teaching-learning methods used by the course presenters. furthermore, centralised training has always been offered to newly appointed academic staff members in the faculty of health sciences, including academic staff members from all disciplines and professions who were appointed on all academic levels in the health sciences. questions regarding the overall effectiveness of the programme led to a qualitative enquiry into newly appointed academics’ experiences after successfully completing the course. the enquiry was initiated with the primary intent of stimulating improvements to our programme, but also to share the findings that might have broader application to other faculty development programmes for newly appointed academics in medical education. background to the course for newly appointed lecturers a course for newly appointed lecturers has been offered in the faculty of health sciences, university of the free state, bloemfontein, sa since 1992. the foundation of this course has always been soundly grounded in offering staff members basic knowledge and skills required to teach and assess student learning in medical education. the course has always been centralised, i.e. one course was offered to all newly appointed academic staff members in the faculty of health sciences, regardless of their discipline or type of appointment. attendance was voluntary and senior staff were allowed to participate in the course to refresh their knowledge and skills. this course ran intermittently, usually twice a year, and was spread over 2 3 days, covering 20 hours of training. from 2011 to 2013, the course was presented once a year and extended over 1 3 days (2 days in 2011, 1 day in 2012 and 3 days in 2013). both the 2011 and 2013 courses were delivered in a venue in the faculty buildings, while the 2011 course was offered at an off-campus venue. the course was funded by the division health sciences education (funding obtained from the faculty of health sciences). for these 3 years, the planning, co-ordination and facilitation of the course were managed by an academic staff member qualified in the field of health professions education. the individual sessions were presented by senior staff members, of whom many also hold degrees in health professions education. educational topics in the 2011 and 2012 programmes included the roles of the lecturer, introduction to teaching-learning, with a focus on specific educational methods (e.g. lecturing, group work, community-based education, service learning, e-learning and use of technology), assessment, student support and, to a limited extent, personal and professional development topics (e.g. time management, self-knowledge and performance management). in the 2013 course, consideration was given to including some factors recommended by chauvin et al.[7] this was approached as follows: (i) ‘explicit faculty commitment and support’ was ensured by including the dean of the faculty in the course, giving a word of welcome and a presentation on the faculty and university structures; (ii) ‘opportunities to build collegial relationships’ was elicited by demonstrating simulation and a training method – the course participants simulated patients in role-plays, coupled with discussions and debriefing activities; it included an interactive microteaching activity, which was found to be successful in this setting;[15] and (iii) distributing to each participant a resource file containing copies of all the powerpoint presentations, additional notes, articles or other interesting sources and information regarding faculty development services, thereby ensuring ‘easily accessible information resources’. over the 3-year period, the course evaluation focused only on identifying participant satisfaction and no further research was done in this setting. this led to our research enquiry, i.e. to establish which experiences of newly appointed academic staff members followed their participation in the 3-day orientation course. the research formed part of a phd study conducted between 2014 and 2016. methods research design a phenomenological research design was used, in which focus group interviews were conducted to describe the lived experiences of course participants as they relate to a centralised course for newly appointed lecturers at the faculty of health sciences. ethical approval ethical approval to conduct the study was obtained from the health sciences research ethics committee, university of the free state (ref. no. ecufs 213/2013). june 2019, vol. 11, no. 2 ajhpe 49 research participants academic staff members, from junior lecturer to professor, who were employed permanently or on contract and had completed the faculty of health sciences course for newly appointed lecturers during 2011, 2012 or 2013, were included in the study. the potential sample comprised 45 eligible academics, of whom 42 worked at the university at the time of this study – between 2014 and 2015. there was a 43% response rate (participants, n=18). some reasons for non-participation included busy schedules, being short staffed in clinics and academic departments, and being unavailable owing to attendance of conferences. data collection eligible academic staff members were personally invited by email and/or telephonically to participate in the study. the focus group interviews were conducted in a neutral location, i.e. a conference room in the faculty’s skills and simulation unit. an independent observer managed the logistical aspects on the day of the interviews, which included obtaining consent. an independent, experienced focus group interviewer facilitated the groups. the principal investigator, who was a course presenter, was not present during the interviews, thereby allowing participants to speak freely about their experience of having completed the course. four focus group interviews were conducted, each group being representative of participants who had completed the 2011, 2012 and 2013 courses. each interview lasted 45 60 minutes. two topics were discussed in the focus groups. the first focused on participants’ experiences of the faculty-specific course for newly appointed lecturers: ‘what were your experiences of the newly appointed lecturers’ course that you attended in the faculty of health sciences?’ the second topic involved a closer look at the course content and educational development needs. two questions with some probes were used: (i) ‘as a newly appointed lecturer, what educational needs should have been addressed in the newly appointed lecturers’ course (consider what you required, as a newly appointed lecturer, to successfully do your job)?’; and (ii) ‘what topics that were included in the newly appointed lecturers’ course that you completed, should have been offered in more depth?’ the questions to the focus group were self-compiled, guided by the specific research objective, to describe the experiences of newly appointed academic staff members after their participation in the course. video and audio recordings were used for the transcription process. the videos enabled the researcher, group participants and a co-coder to revisit the interviews to gain a better sense of group interactions and non-verbal communication. this contributed to the trustworthiness of the transcribed (e.g. the video was consulted to transcribe sections where the voice recording was inaudible), analysed and interpreted data. the transcriptions were done by the principal investigator and validated by the facilitator, independent observer and several focus group interview participants. data analysis data management and analysis were done in a systematic and sequential manner, following a 5-phase continuum of analysis process, as described by rabiee:[16] (i)  becoming familiar with the raw data by re-reading the transcripts; (ii) identifying a draft thematic framework by focusing on what was said and the topics discussed in each group, and deriving a theoretical concept from this; (iii) indexing, by referring back to the raw data, noting and highlighting quotes related to the thematic framework; (iv) charting (lifting out) the quotes into a single microsoft word document; and (v) mapping or ordering the data under the specific focus areas, themes and categories as identified. the analysis was co-coded by the focus group interview facilitator. results and discussion key findings that pertain to the participants’ overall experiences of the course and the lessons learnt are described under the following subheadings: overall experience; orientation structure; active learning practices; and value of faculty professional development throughout one’s career. participant responses extracted from the research data are presented verbatim (where applicable). we also refer to the literature on new faculty development that supports or diverges from our findings. overall experience the overall experiences of attendees completing this course were positive, and include both content and social-emotional outcomes. first, the group, as newly appointed academics, reported that they generally had no or very little teaching experience, and that they initially lacked knowledge of important medical education concepts, including educational terminology: ‘yes look, a person must just always remember this is the first time that we step into this higher education, like the lingo that we use that we are completely inexperienced in.’ (d1.28) ‘they talk about (educational) terminology where you had [before the course] no frame of reference where that terminology fits in.’ (h2.85) participants reported the purpose of the course as clarifying expectations that the faculty had regarding their academic roles. furthermore, the participants experienced the purpose of the course as providing a solid base of knowledge with regard to teaching and learning as they started their teaching careers: ‘the orientation session … gave me a better idea of what the faculty thoughts are around being a lecturer and where the faculty wants to move in terms of the training of students.’ (e1.4) ‘this course helps you to give you that necessary background to move from the clinical set-up to the lecture hall.’ (g2.11) ‘because i don’t come from an educational background and i know nothing about the theories of education; they inform you about all these theories and methods … it is there where you bring your practical or your content [referring to discipline knowledge], and now you must fuse it with the educational methods.’ (h2.28) researchers such as gale[17] observed that many newly appointed academics enter the academic environment with knowledge of the academic realm, gained on the ‘other side of the fence’, having been students themselves. gale[17] suggests that this experience provides a very limited view of the actual role of academics. our research shows that this shortcoming was addressed in our orientation initiative by including it as an explicit course outcome, a factor supporting satisfaction in orientation programmes[7] under the topic ‘the roles of the lecturer’. earlier research that investigated the experiences of novice and junior faculty members commonly reported that new staff members need to gain acceptance from their colleagues and that junior faculty ‘cannot flourish 50 june 2019, vol. 11, no. 2 ajhpe research in isolation’. [4] extended perceived thoughts of ‘feeling like a small fish in a big pond’[5] and feeling isolated[4] and anxious[9] may hinder the timely incorporation of a new staff member into a team of colleagues. in our approach to orientate newly appointed staff members, such academics revealed a twofold socially orientated benefit of the initiative. participants expressed appreciation for the opportunity to meet other newly appointed academics. this gave them a sense of belonging and of feeling less isolated. they also valued meeting more experienced academics and having the opportunity to learn from them: ‘it is nice to meet all the new staff and see that we have the same fears and uncertainties.’ (l3.10) ‘we are isolated, we don’t know anybody else, so it was nice for me to meet other people in other disciplines.’ (g2.63) ‘it is nice to also [learn] from the different departments how they experience their challenges for giving lectures or how to handle a clinical case.’ (f2.29) ‘i found it very interesting to learn from the more experienced colleagues … and you can get some tips from them.’ (g2.63) orientation structure we agree with chauvin et al.[7] that there seems to be no single ‘golden standard’ for the most efficient and effective way to orientate, support and develop newly appointed academics in medical education. we discovered that structure is possibly highly context sensitive. for example, in our setting, we found that a centralised approach to the orientation initiative supported its effectiveness. our results showed that the benefit of our service being centralised was that it provided an opportunity for new staff members, as a uniform group, to meet peers and feel less isolated. in our case, this is critically important, because our faculty comprises 5 schools, some housed in separate buildings on campus, and some individual departments of schools housed off campus in government hospitals: ‘we are not even one faculty here, one building, we sit at oranje hospital, so this makes it more difficult in terms of just the logistics and so it helps significantly if, at least, you just know when you come here to whom you must go, who you must see.’ (r4.63) ‘we are isolated, we don’t know anybody else, so it was nice for me to meet other people in other disciplines.’ (g2.63) ‘it was nice to meet other new lecturers … just to get to know other people in the faculty.’ (m3.9) this centralised approach led to observations of strengthened collegial relationships among academics who completed the course together. jarvis[18] considers collegiality to be one of the most important aspects of faculty career development. strengthened collegial relationships were also observed in a study conducted by pololi and frankel,[19] who investigated centralised faculty development initiatives at their institution. our study furthermore found that professional friendships formed, and we observed colleagues from different disciplines in health sciences working together. for example, participants reported that they referred patients between and across disciplines and professions, taught students from different professions simultaneously, and created research collaborations as a result of their interactions in our orientation course. sorcinelli[20] reiterated the important role that faculty development programmes can play in encouraging staff involvement in engagements between disciplines. a decentralised faculty development approach may not guarantee the benefit of such engagement. despite the efficacy of a centralised approach, our study found that there could be benefits to decentralising a certain aspect of the orientation. this might include focused sessions or learning communities that respond to different appointment types and practices in the various disciplines in health sciences: ‘certain things work differently at the school of nursing than at medicine.’ (o4.56) ‘i think there is also a difference between the clinical guys that work in the wards and hospitals with the students and lecturers in the classroom. it boils down to different methods of presentation and assessment … apply more specifically to the different disciplines and then also to the different settings within specific fields.’ (b1.29) with this in mind, there is scope for school and departmental faculty development initiatives aimed at the newly appointed academic. for new academics to contribute confidently and competently as scholars within their specific departments, jawitz[21] recommended that new academic staff members engage with communities of practice within their specific departments. this will help new academics to acquire the necessary knowledge and skills – ‘know how’ of educational practices and approaches in a specific department. such initiatives should be focused on particular learning requirements of the individual school or department, and should consider prior learning and experiences.[14] a review of staff development models in the health sciences by lancaster et al.,[22] highlighted the benefit of a faculty learning community, i.e. it offers continuing educational development opportunities on a platform where pedagogical practices are shared between colleagues. this is an area for improvement, which this study identified for our specific orientation programme. active learning practices another focus of the discussions was the approach taken to presenting the orientation course. traditionally, the course for newly appointed lecturers in the faculty of health sciences followed a teacher-centred approach. this involved the educationalist identifying a series of topics and then presenting these to medical educators, mainly through a traditional educational method, e.g. using a lecture with slides or hosting a teacher-centred panel discussion. in the past, this approach would have been regarded as the most appropriate, and it was even considered as successful. however, in a changing higher-education environment that emphasises engaged learning for students, the question is whether this is still the best approach to faculty learning – our answer is that it is not. constructive criticism from a participant in one of the focus group interviews presented food for thought for the course co-ordinator and presenters. the participant noted the following: ‘i always feel a bit odd when people tell me about the means for adult education [how to teach in a higher education setting] … and they do that in a format of a 45-minute formal lecture of pop one slide, pop one slide, pop one slide, and this is how you should teach, next pop another slide … the context does not match the methodology of how it is presented, you know, and i remember within another context, a guy, the instructor, i really enjoyed it [referring to the instructor’s presentation], because as he was telling you what you needed to do, he was actually doing it with the group, so then it became authentic.’ (c1.34) june 2019, vol. 11, no. 2 ajhpe 51 research from this response we learnt that it is not useful only to tell an audience about a specific teaching technique or method, but that our adult learners want to obtain new knowledge and skills through demonstrations that allow for active engagement with the instructor and other students. for example, during our course, there was a bedside teaching session that was demonstrated in our simulation and skills unit that elicited positive responses, such as the following: ‘we experienced bedside teaching in the simulation unit where we, all the participants, were around the bed. they had an sp [simulated patient] in the bed and a doctor demonstrated how to teach at a patient’s bedside using the participants as students.’ (g2.25) in this session and similar ones we experienced that this approach, which was more practical and hands-on, inspired our newly appointed academics to make use of the teaching-learning strategies and methods that were demonstrated. over the past 5 years, the presentation style of this course has evolved to become more learner-centred, and presenters have revised sessions to create more of a workshop format, comprising a theoretical followed by a practical component that involves the learners. we started using a similar approach to that described by benor[14] at ben gurion university of the negev. the key is to make use of all the knowledge and expertise of medical education faculty, as well as of staff of the greater faculty, to scaffold learning. in accordance with the proverb that states, tell me, and i forget, show me, and i remember, involve me, and i understand, we made a further improvement to our course by offering participants the opportunity to apply their newly acquired knowledge and skills in practice. this was done by incorporating a peerand educationist-evaluated and video-recorded microteaching activity on the final day of the course. microteaching is a simulated teaching exercise during which participants present a teaching session to an audience that represents students; this activity is useful, as the audience provides instant feedback to the lecturer.[23] reflections of our course participants indicated that they found the experience enjoy able.[15] furthermore, their opinion of the activity was that it offered definite benefits through learning from others and obtaining constructive feedback: ‘after the course, they sent us the responses of the evaluation forms [of the microteaching session] – there was a lot of qualitative quotes. it was really an experience, now, afterwards, to go through that again, it’s like feedback you can learn from, from how others experienced it [referring to their teaching session presented to the peers and educationists] and how they saw it.’ (i3.173) value of faculty professional development throughout one’s career newly appointed academics agreed that, having attended our course, they realised the value of participating in faculty development. there was strong agreement that academics should be accountable for their own continued learning, especially in relation to the roles and responsibilities of a teacher. examples of participants’ responses are the following: ‘something that i just realised is that the onus rests much more on myself. yes, orientation is one thing, but that one is made more aware that it’s not just a once off, you must make time … perhaps emphasise more the fact that this is not only just the beginning, please remain involved [the participant referred to continuing to participate in faculty development opportunities offered in the faculty]’. (n4.83) ‘yes, i actually agree, because for me it is really worth it and the quality of the training that the faculty presents is good … it is a responsibility from yourself also to know what is available and to have a programme [faculty development programme], and then to make time.’ (p4.83) coaldrake and stedman[24] refer to the need for greater accountability and quality teaching in higher education, which can only be achieved through the upkeep and improvement of educational competencies. it was, therefore, beneficial to follow up this discussion in our study. we believe that our orientation initiatives fostered a sense of responsibility to continue with training that contributed to a positive attitude towards faculty development. regarding continuing development and support for senior staff, there were discussions in the focus groups about either including senior staff as course participants in orientation initiatives for newly appointed academics or have separate, focused refresher initiatives for such a cohort. this suggestion relates to new and innovative educational practices for the health professions and technology to enhance teaching practices that become available regularly. therefore, academics in the health professions should have the opportunity to continuously update, not only their content knowledge, but also their pedagogical knowledge and skills: ‘new things come out, things that they are not even aware of – so i think it will be very valuable if they could have a refresher course for senior lecturers, or for people who have been there for very long.’ (a1.77-79) ‘so, maybe we can do a new lecturers’ course for old lecturers, it’s just to keep everybody updated.’ (g2.106) ‘it should be mandatory, like a first-aid course that you have to renew, so it should be mandatory that you go every so many years.’ (h2.108) our findings showed that a senior colleague with 10 years’ teaching experience who completed our orientation course, reported doing so to refresh and update his educational competencies. he described his experience as follows: ‘i enjoyed it, even doing it 10 years after i started as a lecturer, i think that it is really valuable and, even after 10 years, i learnt a lot.’ (g2.106) this comment suggests that even an experienced academic can find an orientation course to be a valuable learning opportunity. another benefit we found with the participation of more experienced or senior staff (someone who had worked as a medical educator for a while) in the orientation course was that they had a better understanding of the functioning of the institution and related differently to some of the information provided; they even played a mentor/coaching role in the group. we learnt that orientation initiatives should not have restrictions on who may participate. when senior faculty members participate in the course, there is great benefit in bringing along their self-learnt experience acquired over time in teaching; at the same time they will be able to update their knowledge and skills regarding any new teaching methods and modern technologies. one of our limitations regarding the topic of professional development throughout a career is that the role of mentoring in the successful orientation of new staff was not explicitly probed during the focus group interviews or discussed by the participants. this could be because a formal mentoring programme is not yet fully established in our faculty development services. there are, however, mentor-mentee relationships in some departments of the faculty of health sciences. our study found that new staff members regarded exposure to peers and senior colleagues as 52 june 2019, vol. 11, no. 2 ajhpe research important, and they valued learning from all their colleagues involved in the orientation programme. we recommend that our faculty development service encourages the adoption of a mutual mentoring model for new faculty members. with this type of mentoring model, the mentee will have multiple self-identified mentors, who can offer support in all their roles and responsibilities in academia.[25] this will ensure continued support and development for newly appointed academics, even after they have completed a formal orientation programme. conclusions the findings of our research leave little doubt that the orientation course was a success, and it will continue to be refined and improved. we also learnt several important lessons from our study, which we share as considerations for other such faculty development endeavours. first, our centralised faculty development approach offered a number of benefits to the group of newly appointed academics. these included opportunities for supportive peer interaction, collaborations, building and strengthening collegial relationships, and also learning from experienced senior colleagues. attention should also be given to specific education-related learning requirements and practices of individual schools and departments, where there is space for decentralisation of several aspects of orientation. one evidence-based approach to addressing these requirements is to establish communities of practice within schools and departments in the faculty of health sciences. another evidence-based approach includes the adoption of a mutual mentoring initiative for newly appointed academic staff members. second, we learnt that, for a faculty development initiative to be effective, staff should gain insight into how to effectively make use of innovative, learner-centred teaching-learning strategies, such as simulation, which is one form of experiential learning. in this way, staff can experience the reality of a scenario and gather meaning from it, instead of passively listening to a lecture or panel discussion. furthermore, by including microteaching in an orientation programme, participants will be more confident and better equipped, and have the opportunity to engage with the learning material and use it in a constructive and supportive learning environment. finally, faculty developers should foster a culture of accountability towards continued faculty professional development throughout a career – the importance of this accountability should be instilled in academic staff early in their career. this could be fostered by an orientation programme aimed at newly appointed academic staff members. moving forward, we recommend continued research regarding our programme by focusing on its contributions and strengths. some areas of research could include measuring knowledge and skills of participants before and after the orientation, or comparing a measurement of the effects of the orientation with the performance management of academic staff members who complete the orientation and those who do not. evidence should be used to improve the programme and to contribute to the body of knowledge. we, therefore, conclude by advising continued research in the field, especially in the context of medical education at sa universities. we also recommend collaboration among faculty developers at different sa universities. declaration. none. acknowledgements. thanks is due to the academic staff members who participated in the study and to dr mary deane sorcinelli of the university of massachusetts, amherst, usa, for reading the article and offering insightful comments. author contributions. cvw: principal investigator of the research and reponsible for writing the article; mmn and gjvz: contributed as research promotors, as well as to the conceptualisation and completion of the article. funding. health and welfare sector education and training authority (hwseta); office of the dean, faculty of health sciences, university of the free state (ufs) for funding to benchmark the research at conferences; and staff doctoral study support funding, postgraduate school, ufs. conflicts of interest. none. 1. educba. why are employees the most valuable intangible assets? educba business blog tutorials. https:// www.educba.com/employee-most-valuableintangible-assets/ (accessed 15 october 2018). 2. puri a, graves d, lowenstein a, hsu l. new faculty’s perceptions of faculty development initiatives at small teaching institutions. isrn educ 2012:1-9. https://doi.org/10.5402/2012/726270 3. steinert y. faculty development in the health professions. a focus on research and practice. dordrecht: springer, 2014:1-446. 4. boice r. the new faculty member. 1st ed. san francisco, ca: jossey-bass, 1992:336. 5. boyd p. academic induction for professional educators: supporting the workplace learning of newly appointed lecturers in teacher and nurse education. int j acad develop 2014:15(2):155-165. https://doi. org/10.1080/13601441003738368 6. carney ae, bacig kz, helms rm. new faculty orientation at the university of minnesota, twin cities, usa. conference paper. what works conference, paris, france, 3 4 september 2007. www.academic.umn.edu/ newfaculty/france07.pdf (accessed november 2018). 7. chauvin sw, anderson w, mylona e, greenberg r, yang t. new faculty orientation in north american medical schools. teach learn med 2013;25(3):185-190. https://doi.org/10.1080/10401334.2013.797345 8. rice re, sorcinelli md, austin ae. heading new voices: academic careers for a new generation. washington, dc: american association for higher education, 2000. https://www.umb.edu/editor_uploads/images/ofd/ good_practice_supporting_early_career_fac__sorcinelli.pdf (accessed 15 january 2019). 9. menges rj. faculty in new jobs: a guide to settling in, becomming established, and building institutional support. san francisco, ca: jossey-bass, 1999:368. 10. beane-katner l. anchoring a mentoring network in a new faculty development program. ment tutor 2014;22(2):91-103. https://doi.org/10.1080/13611267.2014.902558 11. boyden km. development of new faculty in higher education. j prof nurse 2000;16(2):104-111. https://doi.org/ 10.1016/s8755-7223(00)80023-x 12. mclean m, cilliers f, van wyk jm. amee educational guide 36. faculty development: yesterday, today and tomorrow. med teach 2008;30:555-584. https://doi.org/10.1080/01421590802109834 13. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 14. benor de. faculty development, teacher training and teacher accreditation in medical education: twenty years from now. med teach 2000;22(5):503-512. https://doi.org/10.1080/01421590050110795 15. kridiotis c, van wyk c. a critical reflection by participants on microteaching as a learning experience for newly appointed health professions educators. afr j health professions educ 2019;11(2):41-46. https://doi.org/10.7196/ ajhpe.2019.v11i2.1103 16. rabiee f. focus group interviews and data analysis. proc nutri soc 2004;63:655-660. https://doi.org/10.1079/ pns2004399 17. gale h. the reluctant academic: early-career academics in a teaching-orientated university. int j acad develop 2011;16(3):215-227. https://doi.org/10.1080/1360144x.2011.596705 18. jarvis d. junior faculty development. a handbook. new york: modern language association of america, 1991:128. 19. pololi lh, frankel rm. humanising medical education through faculty development: linking self-awareness and teaching skills. med educ 2005;39:154-162. https://doi.org/10.1111/j.1365-2929.2004.02065.x 20. sorcinelli md. faculty development: the challenge going forward. peer review ass am college univer 2007;9(4):4-8. 21. jawitz j. new academics negotiating communities of practice: learning to swim with the big fish. teach high educ 2007;12(2):185-197. https://doi.org/10.1080/13562510701191943 22. lancaster jw, stein sm, maclean lg, et al. faculty development program models to advance teaching and learning within health science programs. am j pharm educ 2014;78(5):99. https://doi.org/10.5688/ajpe78599 23. donnelly r, fitzmaurice m. towards productive reflective practice in microteaching. innov educ train intern 2011;48(3):335-346. 24. coaldrake p, stedman l. on the brink: australia’s universities confronting their future. st. lucia: university of queenstown press, 1998. 25. yun jh, baldi b, sorcinelli md. mutual mentoring for early-career and underrepresented faculty: model, research, and practice. innov high educ 2016;41(5):441-451. https://doi.org/10.107/s10755-016-9359-6 accepted 4 december 2018. https://www.educba.com/employee-most-valuableintangible-assets/ https://www.educba.com/employee-most-valuableintangible-assets/ https://doi.org/10.1080/13601441003738368 https://doi.org/10.1080/13601441003738368 http://www.academic.umn.edu/newfaculty/france07.pdf http://www.academic.umn.edu/newfaculty/france07.pdf https://doi.org/10.1080/10401334.2013.797345 https://www.umb.edu/editor_uploads/images/ofd/good_practice_supporting_early_career_fac__sorcinelli.pdf https://www.umb.edu/editor_uploads/images/ofd/good_practice_supporting_early_career_fac__sorcinelli.pdf https://doi.org/10.1016/s8755-7223(00)80023-x https://doi.org/10.1016/s8755-7223(00)80023-x https://doi.org/10.1080/01421590802109834 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1080/01421590050110795 https://doi.org/10.7196/ajhpe.2019.v11i2.1103 https://doi.org/10.7196/ajhpe.2019.v11i2.1103 https://doi.org/10.1079/pns2004399 https://doi.org/10.1079/pns2004399 https://doi.org/10.1080/1360144x.2011.596705 https://doi.org/10.1111/j.1365-2929.2004.02065.x https://doi.org/10.1080/13562510701191943 https://doi.org/10.5688/ajpe78599 https://doi.org/10.107/s10755-016-9359-6 154 october 2020, vol. 12, no. 3 ajhpe research competent nursing staff in the neonatal intensive care unit (nicu) can make the difference between life and death for sick and premature babies. unique challenges exist in neonatal practice owing to a high-risk period of adaptation in the days after birth, whether the context is resource limited or equipped with the newest technology. globally, in 2016, 2.7 million babies died in their first month of life, and an additional 2.6 million were stillborn.[1] fifteen million babies (1 in 10 live births) are born prematurely every year, one million of whom die due to complications of prematurity.[2] neonatal mortality is a serious problem worldwide. newborn infants who need special care are prone to suffer injury, with long-term morbidity or even death. neonatal outcomes can only be optimised and sustained if the nurses who are responsible for the care have the necessary knowledge and skills.[3] it is, however, important to clarify exactly what the specific knowledge, skills and attributes (competencies) should be. the working group of the council of international neonatal nurses[4] has stated that ‘neonatal nursing is a highly specialised field. to meet the complex needs of neonates and their families, there must be uniform qualifications and competencies to support standard knowledge and clinical performance.’ in the south african (sa) context, nurses play a key role in neonatal practice, but they have various levels of competency as they are trained via different programmes with different levels of knowledge, skills and attributes. the sa nursing council (sanc) has not recognised neonatal nursing as an individual specialised qualification since 2012,[5] which results in a lack of training opportunities that focus on caring for ill and prematurely born infants, and specialised nicu care. shift leaders play a crucial role in the management of the nicu and ensuring a high quality of care by neonatal nurses who have updated knowledge, skills and attributes. in the current situation in sa, the competency framework for professional development of nurses in neonatal practice can be used as an alternative to formal neonatal training, which may improve quality of care. the shift leader can utilise this competency framework for supervision and performance management, while professional, enrolled and auxiliary nurses can use it as a guide for practice. a competency framework refers to standardised and integrated knowledge, skills and attributes, offering a structured description of competencies with the purpose of facilitating an understanding of the requirements of staff in a specific context. in the context of this study, the focus is on nurse specialists/ shift leaders, professional nurses and enrolled and auxiliary nurses in a variety of sa neonatal practice settings.[6] several neonatal competency frameworks have been developed over time.[7-11] in developed countries, neonatal competencies seem to have comparable domains such as using research and evidence, leadership and professional development, communication, and legal and ethical considerations.[7,9-11] none of these could be applied directly to the sa context, since neonatal care takes place in a variety of settings. these settings include the public and private sector and rural and urban settings. neonatal care is provided by different categories of nurses, as neonatal nursing is background. the unpredictability of any illness at birth, and recovery from such an illness after birth, create challenges for nurses involved in neonatal care, and require competent nurses in the period following birth in both resource-limited and technologically advanced contexts. neonatal nursing emerged worldwide as a nursing specialty over the last five decades to meet these challenges through in-depth knowledge of healthy, preterm and ill neonates. there is a high demand for neonatal nurses to lower neonatal mortality and morbidity, negative media exposure and litigation. objectives. to reflect on a competency framework for nurses in neonatal practice to enhance professional development that is context specific. methods. a competency framework for nurses involved in neonatal practice was developed and validated through nominal group techniques, literature control and delphi techniques. results. although nurse training is done at tertiary education institutions, there is a gap in ensuring consistencies in clinical performance and professional development from novice to expert, especially in a field such as neonatal care. professional development can enhance the standard of neonatal care, especially if linked to competencies that are specific to the neonatal context. conclusion. a competency framework has an important role to play in equipping nurses in neonatal practice with the knowledge and skills required to reduce the persistent neonatal mortality and morbidity rates in south africa. afr j health professions educ 2020;12(3):154-160. https://doi.org/10.7196/ajhpe.2020.v12i3.1364 competencies for structured professional development of neonatal nurses in south africa c maree,1 bcur, ba cur, mcur, phd, pgche; m scheepers,2 bcur, mcur, phd; e s janse van rensburg,3 bcur, mcur, dcur 1 department of nursing science, faculty of health sciences, university of pretoria, south africa 2 life college of learning, life healthcare, illovo, johannesburg, south africa 3 department of health studies, school of social sciences, college of human sciences, university of south africa, pretoria, south africa corresponding author: c maree (carin.maree@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 155 research no longer acknowledged as an individual specialised qualification by the sanc, but only as a component of midwifery and child nursing.[12] the categories of nurses in neonatal practice are neonatal nurse specialists (trained between 2000 and 2012), nurses specialised in midwifery, critical care of child nursing, professional nurses acting as shift leaders (senior/ experienced professional nurses who take responsibility for decisions in neonatal practice) and professional nurses and enrolled nurses with a range of experience in neonatal care. every category of nurses, enrolled or registered, has a scope of practice in sa.[13] all nurses are bound to apply their specific knowledge and skills to provide safe, competent and ethical care, [14] but there has not previously been a clear framework to inform what competencies each category of nurses should have in neonatal practice. the competency framework developed in this study was, therefore, an attempt to clarify the needed competencies based on the generic competency framework of the sanc[15] that could be applied for professional development in neonatal practice. professional development can be defined as ‘the continuous process of acquiring new knowledge and skills that relate to one’s profession, job responsibilities, or work environment’.[16] the competency framework for the professional development of different categories of nurses in neonatal practice was based on benner’s[17] five stages of development to move from a novice to becoming an expert. each individual nurse begins as a novice within his/her respective category when exposed to neonatal practice for the first time, and has the potential to move through the different levels towards expertise at his/her own pace, but not all will master all the levels. novice nurses are those beginners who have no experience of the situations in which they are supposed to perform. rules are taught and applied generally in order to assist them with their performance. as they gain experience, they become advanced beginner nurses who can demonstrate marginally acceptable performance in real situations by applying formulated principles based on their experiences.[17] competent nurses develop when they observe their own actions in terms of the long-range goals they are consciously aware of, and formulate a plan based on abstract and analytical considerations of a problem. however, they do not have enough experience to recognise a situation in terms of an overall picture, or understand which aspects are most important. they become proficient nurses when they are able to observe or perceive a situation as a whole and not only in a separated part, and can identify when the normal does not realise and decide on appropriate actions. they become expert nurses when they have an immense background of knowledge and experience and can intuitively grasp a situation. they no longer rely on analysis to obtain an understanding of a situation before appropriate action is taken, and they work from a profound comprehension of the whole situation.[17] the higher the level of professional development of nurses, the higher the expectation is that they will be able to deliver high-quality competent care to a specialised group of patients in the nicu within their specific range of responsibilities. only proficient and expert professional nurses should be responsible for shift leading. the focus of this study was therefore to provide a framework for structuring professional development to achieve competency in the different categories of nurses involved in neonatal care. this article, however, only reports on the competency framework for nurse specialists/shift leaders in neonatal practice, while the others are available on request. methods a multi-method research design that applies two or more research methods in one project[18] was used in the study in the form of consensus research. the types of consensus research methods included the nominal group technique, the delphi method[19] and a literature review in three phases. ethical approval was obtained by the university of pretorial faculty of health sciences’ ethics committee (ref. no. 93/2012). phase 1 in phase 1, consensus was reached on the competencies and their priorities needed by nurses in neonatal nursing practice. seven nominal group discussions were held in sa in gauteng, north west and mpumalanga provinces with registered nurses working in nicus of private and public hospitals, 5 facilitated in the private sector and 2 in a public hospital setting. the number of participants varied between 4 and 7 members per nominal group, with a total of 32 participants to address the competencies of neonatal nurses. phase 2 during phase 2, a literature review was conducted on existing neonatal competency frameworks, and those included were the royal college of nursing (uk),[7] rwandan competency framework,[8] scottish neonatal nurses’ group,[9] australian college of neonatal nurses[10] and the panlondon band 5 competency document.[11] through a process of inductive and deductive reasoning, the competencies were formulated as an abridged list of competencies and verified by seven neonatal nursing experts through the delphi technique. phase 3 in phase 3, competency frameworks for professional development of nurses in neonatal practice were further unpacked based on the findings from phase 2, and aligned with the sanc’s competency framework[15] to make them applicable for the sa context. the competencies were verified with a literature control, and interpreted within benner’s levels from novice to expert,[20] so that the framework can be used for professional development in nursing practice. the competency framework of the neonatal specialists/ shift leaders was formulated first, and thereafter adjusted for the enrolled nurses and auxiliary nurses based on their respective scopes of practice. the competency frameworks were validated by an expert panel consisting of six experts in the field of neonatal nursing in the sa context, using the delphi technique. results neonatal nurses serve a unique and vulnerable population for which they need specific competencies. the competencies are divided according to professional, ethical and legal practice; care provision and care management; and personal development and quality of care to be aligned with the sanc competency framework.[15] the competencies for the neonatal specialists/shift leaders as derived during the different phases of this study are illustrated in tables 1, 2 and 3, and should be interpreted within benner’s framework[17,20] (last columns of tables) for self-evaluation or for performance management purposes. 156 october 2020, vol. 12, no. 3 ajhpe research professional, ethical and legal practice in the sanc competency framework,[15] accountability and the responsibility for one’s own judgement, outcomes of care and continued competence according to legislation is noted, and ethical practice is described in terms of the nurses’ code of conduct, ethical decision-making, advocacy and professional integrity. the related competencies in neonatal nursing practice are captured in table 1. neonatal specialists/shift leaders should be able to display professional autonomy, accountability and responsibility within their scope of practice.[13] they need to practise reflectively and in an evidence-based manner, while they act as a role model and leader in neonatal practice.[21] they are also expected to function as part of, or to co-ordinate, an interprofessional healthcare team in the nicu to the benefit of patients and families.[22] a crucial requirement for neonatal specialists/shift leaders is adherence to ethical principles, bioethical decision-making in practice, and facilitation of ethical awareness.[23] they have the responsibility to protect human rights and to advocate for neonates and their families[24] and facilitate sensitivity to cultural, religious, language, professional and technological diversity in neonatal care.[25] in terms of legal practice, they need to ensure compliance with relevant acts, regulations, policies, guidelines, protocols and algorithms.[13,21,23] care provision and care management care provision and care management refers to the underpinning of the provision of care including health promotion, assessment, diagnosis, planning and implementation, evaluation, recording and information management, and therapeutic communication and relationships.[10] the related competencies for neonatal specialists/shift leaders are captured in table 2. in terms of health promotion, neonatal nurse specialists/shift leaders should be able to create awareness, and provide care and health education. they need to understand the continuum of care and the need to advocate for improved family planning, maternal health, antenatal and intrapartum care in order to improve neonatal outcomes.[26] this implies the application of the essential care of every baby[27] guidelines for neonates with common illnesses, prevention of disability of very preterm and critically ill neonates, hygiene and infection prevention,[29] developmental care (including skin-toskin care),[28] exclusive breastfeeding[31] and immunisation.[32] the core of their responsibilities lies with assessment, diagnosis, planning and implementation of care of preterm, very preterm, ill and critically ill neonates. to be competent, they need to have specific prior knowledge, be able to assess, diagnose, plan and implement neonatal care, be skillful in resuscitation and transport of neonates and demonstrate technical competence in the nicu.[33-37] the prior knowledge that they should possess should enable competency in neonatal care related to: the principles and application of the nursing process in neonatal practice, and creating a safe, secure and therapeutic environment for these neonates; fetal and neonatal development, anatomy, physiology, pathophysiology and genetic disorders affecting neonates; the principles and application of neonatal pharmacology and medication management; and the principles and application of developmental care, including the ‘golden hour’, skin-to-skin care, kangaroo care and facilitation of bonding and attachment.[33-37] they should be able to assess and diagnose conditions related to the different systems of any neonate using history taking, physical assessment, vital data assessment and diagnostic investigations,[33-37] including but not limited to aspects mentioned in table 2. they are required to conduct basic and advanced resuscitation of neonates.[35] neonatal nurse specialists/shift leaders are expected to plan and implement care of the preterm, very preterm, ill and critically ill neonate by means of application of the principles of essential care of small babies,[35] advanced medical and surgical neonatal nursing care, palliative care and medication management. the application is related to the respiratory, cardiovascular, neurological, endocrine, musculoskeletal, genitourinary, gastrointestinal, haematological and integumentary systems, eyes, ears, pain and complex multi-organ disorders.[33-37] related aspects to each of these are included in but not limited to those indicated in table 2. they should be skilful in transport of the preterm, very preterm, ill and critically ill neonates (including skin-to-skin transport) internally in institutions, or by means of ambulance or being airlifted.[38] furthermore, table 1. competencies of neonatal nurse specialists/shift leaders related to professional, ethical and legal practice benner’s levels of professional development (to be completed by user) competency novice advanced beginner proficient competent expert a1: professional practice display professional autonomy, accountability and responsibility within scope of practice[13] practise reflectively and in evidence-based manner[21] act as a role model and leader[21] function as part of, or co-ordinate, an interprofessional healthcare team[22] a2: ethical practice adhere to ethical principles and bioethical decision-making in practice, and facilitate ethical awareness e.g. through presenting workshops[23] protect human rights and advocate for neonates and their families[24] facilitate sensitivity to cultural, religious, language, professional and technological diversity in neonatal care[25] a3: legal practice ensure compliance with relevant acts, regulations, policies, guidelines, protocols and algorithms[13,21,23] october 2020, vol. 12, no. 3 ajhpe 157 research ta bl e 2. c om pe te nc ie s of n eo na ta l n ur se s pe ci al is ts /s hi ft le ad er s re la te d to c ar e pr ov is io n an d ca re m an ag em en t ( to b e co m pl et ed b y us er ) b en ne r’s le ve ls o f pr of es si on al d ev el op m en t c om pe te nc y novice advanced beginner proficient competent expert b 1: h ea lth p ro m ot io n c re at e aw ar en es s, p ro vi de c ar e an d he al th e du ca tio n, a nd im pl em en t t he fo llo w in g: [2 3, 26 -3 2] • un de rs ta nd in g of th e co nt in uu m o f c ar e an d th e ne ed to a dv oc at e fo r im pr ov ed fa m ily p la nn in g, m at er na l h ea lth , a nt en at al a nd in tr ap ar tu m c ar e in o rd er to im pr ov e ne on at al o ut co m es • es se nt ia l c ar e of e ve ry b ab y fo r ne on at es w ith c om m on il ln es se s • pr ev en tio n of d is ab ili ty o f v er y pr et er m a nd c ri tic al ly il l n eo na te s • hy gi en e an d in fe ct io n pr ev en tio n • de ve lo pm en ta l c ar e (i nc lu di ng s ki nto -s ki n ca re ) • ex cl us iv e br ea st fe ed in g • im m un is at io n b 2: a ss es sm en t, di ag no si s, p la nn in g an d im pl em en ta tio n po ss es s th e fo llo w in g pr io r kn ow le dg e to e na bl e co m pe te nc y in n eo na ta l c ar e: [3 337 ] • pr in ci pl es a nd a pp lic at io n of th e nu rs in g pr oc es s i n ne on at al p ra ct ic e, a nd c re at in g a sa fe , s ec ur e an d th er ap eu tic e nv iro nm en t f or p re te rm , v er y pr et er m , i ll an d cr iti ca lly il l n eo na te s • fe ta l a nd n eo na ta l d ev el op m en t, an at om y, ph ys io lo gy , p at ho ph ys io lo gy a nd g en et ic d is or de rs o f a p re te rm , v er y pr et er m , i ll an d cr iti ca lly il l n eo na te o f a t l ea st th e fo llo w in g sy st em s: re sp ir at or y; c ar di ov as cu la r; ne ur ol og ic al ; e nd oc ri ne ; m us cu lo sk el et al ; g en ito ur in ar y; g as tr oi nt es tin al ; h ae m at ol og ic al ; i nt eg um en ta ry ; e ye s; ea rs • pr in ci pl es a nd a pp lic at io n of n eo na ta l p ha rm ac ol og y an d m ed ic at io n m an ag em en t • pr in ci pl es a nd a pp lic at io n of d ev el op m en ta l c ar e (in cl ud in g th e ‘go ld en h ou r’, sk in -t osk in c ar e, k an ga ro o ca re a nd fa ci lit at io n of b on di ng a nd a tta ch m en t) a ss es s a nd d ia gn os e th e di ffe re nt sy st em s o f a p re te rm , v er y pr et er m , i ll an d cr iti ca lly il l n eo na te a s r el at ed to : h is to ry ta ki ng (f am ily h is to ry , p re gn an cy , b ir th , p os tn at al ); ph ys ic al as se ss m en t ( in sp ec tio n, p al pa tio n, a us cu lta tio n an d pe rc us si on ; r ef le xe s, ge st at io na l a ge a ss es sm en t) ; v ita l d at a (a pg a r a t b ir th , t em pe ra tu re , r es pi ra tio n, h ea rt ra te a nd p at te rn , o xy ge n sa tu ra tio n an d ca rb on d io xi de m on ito ri ng , b lo od p re ss ur e, b lo od g lu co se , p ai n as se ss m en t) ; d ia gn os tic in ve st ig at io ns (a ci dba se b al an ce , f lu id a nd e le ct ro ly te b al an ce , h ae m at ol og ic al in ve st ig at io ns , e le ct ro ca rd io gr ap hy , a m pl itu de -in te gr at ed e le ct ro en ce ph al og ra ph y, ra di og ra ph ic in ve st ig at io ns , e ye sc re en in g, h ea ri ng a ss es sm en t, dr ug le ve ls an d m or e) c on du ct b as ic a nd a dv an ce d re su sc ita tio n of n eo na te s. pl an a nd im pl em en t c ar e of th e pr et er m , v er y pr et er m , i ll an d cr iti ca lly il l n eo na te ( in cl ud in g, b ut n ot li m ite d to e ss en tia l c ar e of s m al l b ab ie s (e c sb ), ad va nc ed m ed ic al a nd su rg ic al n eo na ta l n ur si ng c ar e, p al lia tiv e ca re a nd m ed ic at io n m an ag em en t) r el at ed to th e fo llo w in g sy st em s: • re sp ir at or y sy st em , i nc lu di ng p re ve nt io n of o lfa ct or y ov er st im ul at io n, m an ag em en t o f s tr uc tu ra l a nd a cq ui re d re sp ir at or y de fe ct s ( e. g. su rf ac ta nt th er ap y, no nin va siv e ve nt ila tio n, in tu ba tio n an d in va siv e ve nt ila tio n an d os ci lla tio n, c ar e of u nd er w at er d ra in ag e) • ca rd io va sc ul ar sy st em , i nc lu di ng b lo od p re ss ur e m ai nt en an ce a nd m an ag em en t o f c on du ct io n di so rd er s a nd st ru ct ur al c ar di ac d ef ec ts • ne ur ol og ic al , e nd oc ri ne a nd m us cu lo sk el et al sy st em , i nc lu di ng d ev el op m en ta l c ar e, m an ag em en t o f b ir th c om pl ic at io ns , i nt ra cr an ia l h ae m or rh ag e, st ru ct ur al a nd c on du ct io n de fe ct s an d en do cr in e di so rd er s, po st op er at iv e ca re , a nd in iti at io n an d m ai nt en an ce o f t he ra pe ut ic c oo lin g • pa in m an ag em en t, in cl ud in g no nph ar m ac eu tic al a nd p ha rm ac eu tic al • ge ni to ur in ar y sy st em , f lu id a nd e le ct ro ly te h om eo st as is an d m an ag em en t o f g en ita l a nd re na l d ef ec ts (i nc lu di ng c at he te ri sa tio n, o bt ai ni ng a nd m ai nt ai ni ng v as cu la r a cc es s) • ga st ro in te st in al sy st em , i nc lu di ng b lo od g lu co se h om eo st as is, fe ed in g, n ut rit io n an d el im in at io n, m et ab ol ic h om eo st as is, a nd m an ag em en t o f m et ab ol ic d is or de rs , s tr uc tu ra l d ef ec ts (c on ge ni ta l a nd a cq ui re d) o f t he m ou th , t hr oa t, st om ac h, li ve r, in te st in es a nd a nu s • ha em at ol og ic al sy st em m an ag em en t o f b lo od d is or de rs o f r ed b lo od c el ls an d pl at el et s, an d di so rd er s r el at ed to im m un ity a nd c om m un ic ab le d is ea se s • in te gu m en ta ry sy st em , i nc lu di ng p ro te ct io n of p re m at ur e sk in in te gr ity , t he rm or eg ul at io n, im pl em en ta tio n of sk in -t osk in c ar e an d m an ag em en t o f p re te rm , c on ge ni ta l a nd a cq ui re d sk in d is or de rs • ey es , i nc lu di ng p re ve nt io n of b lin dn es s a nd m an ag em en t o f e ye d is or de rs • ea rs , i nc lu di ng p re ve nt io n of h ea ri ng lo ss a nd v es tib ul ar d ist ur ba nc es , m an ag em en t o f s tr uc tu ra l a nd a cq ui re d ea r d ef ec ts a nd h ea ri ng lo ss • co m pl ex m ul tior ga n di so rd er s c on ti nu ed .. . 158 october 2020, vol. 12, no. 3 ajhpe research they are expected to have technical competence in the nicu, and give input into the development of specifications, and evaluation of equipment and consumables.[39] the expected competence of neonatal nurse specialists/shift leaders stretches further to evaluation, recording and information management, as they must be able to develop, obtain, maintain, store and audit nursing care documents and digital information, records of investigations and treatment, personal information, administrative processes and human resource and systems management.[40] they also should maintain therapeutic communication and relationships, as they need to take the lead with implementation of family-centred/family-integrated neonatal care, alternative and transcultural care, as well as interprofessional teamwork.[41] personal development and quality of care lifelong learning enhances personal development. neonatal specialists/shift leaders should adopt the culture of continuous learning to ensure that their competencies are updated and relevant.[46] specialised knowledge and skills is a requirement to ensure safe caring practices for neonates.[42-44] the quality of care as reflected in neonatal mortality and morbidity can be enhanced by the design and implementation of quality improvement processes. evidence-based practice ensures that research is translated into practice to enhance the quality of neonatal care.[43,44] the management of human and material resources and staff development forms additional aspects of quality improvement, as indicated in table 3. the competencies for the neonatal nurse/ shift leader are addressed in the discussion of the results, and indicated in tables 1 3. the competencies for professional, enrolled and auxiliary nurses were derived from these, and adjusted according to their respective scopes of practice.[46] the detailed competency frameworks for these categories are available on request. discussion neonates are vulnerable at birth and during the days following birth.[47,48] some neonates need to be hospitalised owing to illness and/or prematurity, and they need competent staff to take care of them.[23] unfortunately, inadequate care of these neonates and a lack of competent neonatal nurses pose a risk to quality and competent care for neonates.[47] one option to improve the competency of staff working in neonatal practice is to focus on the professional development and performance management of individuals. the purpose of this study was to develop a competency framework that could be used as a tool to structure professional development and performance management of the different categories of nurse working in neonatal practice. professional development implies advancement from one level to the next, from novice to expert,[17,20] to meet the expected competencies. it is furthermore vital that nurses work within their scope of practice to ensure competent and quality care.[47] in the sa context, the scope of practice of the different categories of nurse is prescribed by the sanc.[46] with the expected competencies recognised, individual plans can be developed for professional development, and nurses can be acknowledged by suitable rewards and recognition, or merely by acknowledgement in work performance reviews. the potential value thereof is described by half[49] as a win for the entire team. one can increase the collective knowledge of the team by investing in the staff; as they become more effective, they become more confident and happier, and their job satisfaction also increases. the company becomes more appealing as an employer of choice, which, in turn, strengthens the staff retention strategy.[49] the specific competencies needed in the nicu that can be strengthened through a competency framework and professional development include those related to professional, ethical and legal practice to enhance accountability and responsibility.[13,21-25] competencies should be established for the provision of care of preterm, very preterm, ill and critically ill neonates. competencies are based on health promotion, assessment, diagnosing, planning, implementation, evaluation, recording and information management, therapeutic communication and interprofessional teamwork.[23,26-41] personal and professional development and performance management might contribute to lifelong learning, which, in turn, is expected to lead to continuous improvement of competency and work satisfaction.[49] furthermore, using a competency framework for professional development and performance management is expected to limit or reduce instances of injury to neonatal patients, and improve the outcomes for neonates and their families.[50] the competency framework enhances practice by providing clear guidance on what ta bl e 2. (c on ti nu ed ) c om pe te nc ie s of n eo na ta l n ur se s pe ci al is ts /s hi ft le ad er s re la te d to c ar e pr ov is io n an d ca re m an ag em en t b en ne r’s le ve ls o f pr of es si on al d ev el op m en t c om pe te nc y novice advanced beginner proficient competent expert tr an sp or t p re te rm , v er y pr et er m , i ll an d cr iti ca lly il l n eo na te s (i nc lu di ng s ki nto -s ki n tr an sp or t) in te rn al ly in in st itu tio n, o r by m ea ns o f a m bu la nc e or b ei ng a ir lif te d[ 38 ] d em on st ra te te ch ni ca l c om pe te nc e an d gi ve in pu t i nt o th e de ve lo pm en t o f s pe ci fic at io ns a nd e va lu at io n of e qu ip m en t a nd c on su m ab le s[3 9] b 3: e va lu at io n, r ec or di ng a nd in fo rm at io n m an ag em en t d ev el op o r ob ta in , m ai nt ai n, s to re a nd a ud it nu rs in g ca re d oc um en ts a nd d ig ita l i nf or m at io n, r ec or ds o f i nv es tig at io ns a nd tr ea tm en t, pe rs on al in fo rm at io n, a dm in is tr at iv e pr oc es se s an d hu m an r es ou rc e an d sy st em s m an ag em en t[4 0] b 4: t he ra pe ut ic c om m un ic at io n an d re la tio ns hi ps ta ke th e le ad w ith im pl em en ta tio n of fa m ily -c en tr ed /f am ily -i nt eg ra te d ne on at al c ar e, a lte rn at iv e an d tr an sc ul tu ra l c ar e, a nd in te rp ro fe ss io na l t ea m w or k[ 41 ] october 2020, vol. 12, no. 3 ajhpe 159 research is expected of the nurse in neonatal practice. education can be improved through professional development and in-service training of neonatal nurses according to the expected competencies. it is recommended that additional research be conducted on the implementation of the competency framework and the effect thereof on neonatal mortality and morbidity, and its contribution to the third sustainable development goal.[26] study limitations the competency framework is developed for the sa context, but needs to be exposed to more participants for input before it can be generalised and adapted for other countries. conclusion in order to deal with the vulnerability of neonates in the days following birth, the inadequate care of these neonates and the lack of competent neonatal nurses, a competency framework was developed. the competency framework is an attempt to assist with the challenges that pose a risk to quality and competent care of neonates, and provides a guide for training, supervision, delegation and performance management in the nicu. declaration. this study was completed as a requirement for a phd qualification. acknowledgments. the authors would like to thank santrust for the funding received for the phd study. author contributions. planning of the document: ms with input from cm and ejvr. data collection and analysis: ms under supervision of cm and ejvr. manuscript writing: ms, cm and ejvr. critical revisions for important intellectual content: ms, cm and ejvr. funding. this research received a funding grant from santrust. conflicts of 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practice 2014;14(5):504-511. https://doi.org/10.1016/j. nepr.2014.07.001 22. kenner c, reinarz s. interprofessional teamwork and neonatal patient safety: a nursing perspective. neo rev 2013;14(10)e480-e482. https://doi.org/10.1542/neo.14-10-e480 23. pattinson rc. safety versus accessibility in maternal and perinatal care. s afr med j 2015;105(4):261-265. https:// doi.org/10.7196/samj.9182 24. spence k. ethical advocacy based on caring: a model for neonatal and paediatric nurses. j paediatrics child health 2011;47:642-645. https://doi.org/10.1111/j.1440-1754.2011.02178.x 25. callister l. culturally competent care of women and newborns: knowledge, attitude, and skills. j obstet gynecol neonatal nursing 2006;30(2):209-215. https://doi.org/10.1111/j.1552-6909.2001.tb01537.x 26. world health organization. world health statistics 2018. monitoring health for the sdgs, sustainable development goals. geneva: who, 2018. 27. esamai f, lockyer j, bose c, et al. evaluation of an educational program for essential newborn care in resourcelimited settings: essential care for every baby. bmc pediatrics 2015;15(1):1–11. https://doi.org/10.1186/s12887015-0382-z 28. burke s. systematic review of developmental care interventions in the neonatal intensive care unit since 2006. j child health care 2018;22(2):269-286. https://doi.org/10.1177/1367493517753085 29. sharma g, zaka n, hailegebriel t. infection prevention control at neonatal intensive care units. unicef, 2018. https://www.healthynewbornnetwork.org/resource/infection-prevention-and-control-at-nicu/ (accessed 8 novem ber 2019). 30. baley j. committee on fetus and newborn. skin-to-skin care for term and preterm infants in the neonatal icu – from the american academy of pediatrics: clinical report. pediatrics 2015;136(3):596-599. 31. kramer ms, kakuma r. optimal duration of exclusive breastfeeding. cochrane database of systematic reviews 2012;8. https://doi.org/10.1002/14651858.cd003517.pub2 32. world health organization. immunization. https://www.who.int/topics/immunization/en/ (accessed 8 november 2019). 33. gardner sl, carter bs, hines me, et al., (editors). merenstein and gardner’s handbook of neonatal intensive care. 8th ed. st. louis, missouri: elsevier, 2016. 34. verklan mt, walden m, eds. core curriculum for neonatal intensive care nursing. 5th ed. pennsylvania: wb saunders, 2015. table 3. competencies of neonatal nurse specialists/shift leaders related to personal development and quality of care benner’s levels of professional development (to be completed by user) competency novice advanced beginner proficient competent expert c1: quality improvement assess, plan, implement and evaluate quality improvement processes and initiatives to address neonatal mortality and morbidity[42] translate research findings into practice to contribute to setting standards and development of best practice guidelines and policies[43,44] manage human and material resources, including but not limited to budget, equipment, staffing, environment and service delivery[42] contribute to staff development and nursing practice through education[44] c2: continuing personal development engage in a culture of lifelong learning and continuous professional development and active involvement in a professional association[45] https://doi.org/10.1016/s0140-6736(16)31593-8 https://doi.org/10.1016/s0140-6736(09)61123-5 https://doi.org/10.7196/samj.2017.v108i3b.12804 http://coinnurses.org/wp-content/uploads/2013/06/coinn-pos-paper.pdf http://coinnurses.org/wp-content/uploads/2013/06/coinn-pos-paper.pdf https://www.sanc.co.za/professional_practice.htm https://www.sanc.co.za/professional_practice.htm https://www.rcn.org.uk/professional-development/publications/pub-004641 https://doi.org/10.1186/s12992-017-0252-6 http://www.snng.org.uk/publications/datafiles/career framework for neonatal support workers.pdf http://www.snng.org.uk/publications/datafiles/career framework for neonatal support workers.pdf http://www.acnn.org.au/resources/australian-standards-for-neonatal-nurses/acnn-standards-for-neonatal-nurses-2012.pdf http://www.acnn.org.au/resources/australian-standards-for-neonatal-nurses/acnn-standards-for-neonatal-nurses-2012.pdf http://www.acnn.org.au/resources/australian-standards-for-neonatal-nurses/acnn-standards-for-neonatal-nurses-2012.pdf http://www.londonneonatalnetwork.org.uk/wp-content/uploads/2015/07/pan-london-neonatal-odn-band-5-neonatal-competency-document-2014-15-00000003.pdf http://www.londonneonatalnetwork.org.uk/wp-content/uploads/2015/07/pan-london-neonatal-odn-band-5-neonatal-competency-document-2014-15-00000003.pdf https://www.medbox.org/countries/guidelines-for-maternity-care-in-south-africa/preview https://www.medbox.org/countries/guidelines-for-maternity-care-in-south-africa/preview https://doi.org/10.1186/s12913-016-1683-0 https://doi.org/10.1016/j.nepr.2014.07.001 https://doi.org/10.1016/j.nepr.2014.07.001 https://doi.org/10.1542/neo.14-10-e480 https://doi.org/10.7196/samj.9182 https://doi.org/10.7196/samj.9182 https://doi.org/10.1111/j.1440-1754.2011.02178.x https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1111%2fj.1552-6909.2001.tb01537.x?_sg%5b0%5d=ujnglig86ax_jdxmh0kaflu-jwvcmwp9vqvnrht4iun3pweekjhhqczpxqadf3ckl8dxt6tuwik3yogb3r29flpkdg.d00o-yrnbcm35l7brvkmhcdclpxlsabclg-saiyqbnard892ocn8ux788f07qs0ve0hu1apvyxtd-1cozyjaia https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1111%2fj.1552-6909.2001.tb01537.x?_sg%5b0%5d=ujnglig86ax_jdxmh0kaflu-jwvcmwp9vqvnrht4iun3pweekjhhqczpxqadf3ckl8dxt6tuwik3yogb3r29flpkdg.d00o-yrnbcm35l7brvkmhcdclpxlsabclg-saiyqbnard892ocn8ux788f07qs0ve0hu1apvyxtd-1cozyjaia https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1111%2fj.1552-6909.2001.tb01537.x?_sg%5b0%5d=ujnglig86ax_jdxmh0kaflu-jwvcmwp9vqvnrht4iun3pweekjhhqczpxqadf3ckl8dxt6tuwik3yogb3r29flpkdg.d00o-yrnbcm35l7brvkmhcdclpxlsabclg-saiyqbnard892ocn8ux788f07qs0ve0hu1apvyxtd-1cozyjaia https://doi.org/10.1177/1367493517753085. https://www.healthynewbornnetwork.org/resource/infection-prevention-and-control-at-nicu/ https://doi.org/10.1002/14651858.cd003517.pub2 https://www.who.int/topics/immunization/en/ 160 october 2020, vol. 12, no. 3 ajhpe research 35. american academy of pediatrics. guidelines and policies. https://www.aap.org/en-us/professional-resources/qualityimprovement/pages/guidelines-and-policy-development.aspx (accessed 8 november 2019). 36. cochrane library. cochrane neonatal database. https://neonatal.cochrane.org/ (accessed 8 november 2019). 37. world health organization. infant, newborn. https://www.who.int/infant-newborn/en/ (accessed 8 november 2019). 38. ohning bl, rosenkrantz t. transport of the critically ill newborn. pediatrics: cardiac disease and critical care medicine. medscape, 2019. https://emedicine.medscape.com/article/978606-overview#showall (accessed 8 november 2019). 39. te pas ab. improving neonatal care with technology. front pediatr 2017;5:110. https://doi. org/10.3389%2ffped.2017.00110 40. limpopo initiative for newborn care. norms and standards for essential newborn care, 2016. http://www. lincare.co.za/wp-content/uploads/2016/06/chapter-2-norms-and-standards-for-essential-newborn-care.pdf (accessed 10 november 2018). 41. vetcho s, cooke m, ullman a. family-centred care in dedicated neonatal units: an integrative review of international perspectives. j neonatal nurs 2020;26(2):73-92. https://doi.org/10.1016/j.jnn.2019.09.004 42. pattinson rc, rhoda n. 2012 2013: ninth report on perinatal care in south africa. saving babies. pretoria: tshepesa press, 2014:35 http://www.ppip.co.za/wp-content/uploads/savingbabies-2012-2013.pdf (accessed 10 november 2018). 43. montanholi ll, merighi mab, de jesus mcp. the role of the nurse in the neonatal intensive care unit: between the ideal, the real and the possible. www.eerp.usp.br/rlae 2011:307 (accessed 6 july 2020). 44. petty j. a global view of competency in neonatal care. j neonatal nurs 2014;20:3-10. https://doi.org/10.1016/j. nnn.2013.05.001 45. melnyk bm. editorial: the difference between what is known and what is done is lethal: evidence-based practice is a key solution urgently needed. worldviews evidence-based nurs: sigma theta tau international 2017;14(1):3-4. https://doi.org/10.111/wvn.12194 46. south africa. nursing act no. 33 of 2005. regulations 786: the scope of practice of nurses and midwives. pretoria: government printers, 2013. 47. oestergaard mz, inoue m, yoshida s, et al. neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections and priorities. plos med 2011. https://doi.org/10.1371/ journal.pmed.1001080 (accessed 14 november 2019). 48. eklund w, kenner c. council of international neonatal nurses – global neonatal provider database initiative: results from an implementation focus group. adv neonatal care 2015;15(6):407-415. https://doi.org/10.1097/ anc.0000000000000236 49. half r. professional development training: a win for the entire team. 2017. https://www.roberthalf.com/blog/ management-tips/professional-development-training-a-win-for-the-entire-team (accessed 3 march 2020). 50. united nations. sustainable development knowledge platform. new york: un, 2015. https:// sustainabledevelopment.un.org/partnerships/unsummit2015 (accessed 3 march 2020). accepted 23 july 2020. https://www.aap.org/en-us/professional-resources/quality-improvement/pages/guidelines-and-policy-development.aspx https://www.aap.org/en-us/professional-resources/quality-improvement/pages/guidelines-and-policy-development.aspx https://neonatal.cochrane.org/ https://www.who.int/infant-newborn/en/ http://reference.medscape.com/guide/pediatrics-cardiac http://reference.medscape.com/guide/pediatrics-cardiac https://emedicine.medscape.com/article/978606-overview#showall https://doi.org/10.3389%2ffped.2017.00110 https://doi.org/10.3389%2ffped.2017.00110 http://www.lincare.co.za/wp-content/uploads/2016/06/chapter-2-norms-and-standards-for-essential-newborn-care.pdf http://www.lincare.co.za/wp-content/uploads/2016/06/chapter-2-norms-and-standards-for-essential-newborn-care.pdf https://doi.org/10.1016/j.jnn.2019.09.004 http://www.ppip.co.za/wp-content/uploads/savingbabies-2012-2013.pdf http://www.eerp.usp.br/rlae https://doi.org/10.1016/j.nnn.2013.05.001 https://doi.org/10.1016/j.nnn.2013.05.001 https://doi.org/10.111/wvn.12194 https://doi.org/10.1371/journal.pmed.1001080 https://doi.org/10.1371/journal.pmed.1001080 https://doi.org/10.1097/anc.0000000000000236 https://doi.org/10.1097/anc.0000000000000236 https://www.roberthalf.com/blog/management-tips/professional-development-training-a-win-for-the-entire-team https://www.roberthalf.com/blog/management-tips/professional-development-training-a-win-for-the-entire-team https://sustainabledevelopment.un.org/partnerships/unsummit2015 https://sustainabledevelopment.un.org/partnerships/unsummit2015 november 2020, vol. 12, no. 4 ajhpe 211 research the use of information and communications technology (ict) and e-learning in health professions and nursing education has been thrust into the limelight as the most suitable option for learning in the wake of the global and devastating covid-19 pandemic. apart from the focus on professional-level disciplinary skills, the greater use of learning management systems (lms) for e-learning offers an opportunity to reflect on metacapabilities required of graduates to function effectively as lifelong learners in the social and working environments of the 21st century. these metacapabilities include self-regulation of learning, knowledge construction and synthesis, adaptability, creativity, information management, critical thinking and digital competence.[1] while e-learning is believed to be an attractive option to meet the growing demand for education in countries with teacher shortages,[2] it is equally important that adult users understand the benefits of digital literacy skills[3] and strive to become suitably skilled to use the more flexible learning modalities for lifelong and continued professional education.[4] e-learning refers to the use of technology to advance teaching, learning and assessment.[5] the use of ict for education is widely believed to support social transformation, and it is viewed as a viable option to improve the skill sets of citizens of the country.[5,6] the national plan for higher education in south africa (sa)[7] encourages institutions to develop information societies through technology use and advancements to create new platforms for active learning, and thus improve education. a 2015 study, however, reported that despite the national policies to promote equitable access to ict to previously disadvantaged people,[7] higher education institutions (heis) lacked a common strategy for the rollout of e-learning, and that there were variable use of and access to ict across sa institutions.[5,8] one of the national strategies was the proposal for ict and curriculum departments to form stronger collaborations and synergies to advance the use of e-learning in sa,[9] as reports suggested that heis in sa had no common approach or strategy. the issue of unfamiliarity with technological advances has been described in high-income countries. [10] much less is known about student readiness for digital learning in lowand middle-income countries. all heis are obliged to provide the necessary policy, infrastructure, support and training to facilitate students’ use of learning management systems (lms), of which the one used at the current institution is moodle. it is therefore important that students receive the necessary training and technical support in using moodle for learning to help them experience the benefits of online learning. the technology acceptance model (tam) provides a possible framework to understand the relationship between humans and technology by focusing on the perceived usefulness and perceived ease of use in technology for learning. [11] according to the tam, users’ beliefs influence their attitudes, and resilience towards a new technology and an assessment of their attitude can be used to predict the actual use of the technology. the nursing department at the institution offers a module in communitybased education every alternative thursday in an online format via the platform. the facilitator posts the objectives for the session weekly on the discussion forum. she then encourages students to respond to questions background. the use of information and communications technology (ict) in nursing education is a key strategy following the impact of covid-19 on higher education institutions. it highlights the need for efficient learning management systems and meta-capabilities of graduates. studies have described e-learning at the undergraduate level, while less is known about learning management systems (lms) use among postgraduate nurses. objectives. to explore students’ perceptions of e-learning, their perceived challenges with technology on a compulsory postgraduate nursing module and associations between demographic data and listed challenges. methods. an exploratory quantitative study used a self-administered questionnaire to collect data from all postgraduate students (n=60). data included demographics, language proficiency, prior training, computer access at home, frequency of use, prior exposure to e-learning platforms, attitude to technology, perceived computer self-efficacy, and anxiety and attitude towards computer use for learning. statistical analysis included using frequency distributions, χ2 and pearson’s test to measure and explore associations between challenges and sociodemographic factors. results. the cohort consisted of mainly black (95%) and female (75%) students. they expressed positive views about technology usage. seventy percent reported first-time exposure to the moodle learning management system at the university, and 68.3% had access to a computer. the majority (66.7%) expressed having limited ict skills and difficulty using moodle. statistically significant associations were found between the ability to use moodle and proficiency in english, computer literacy, availability of technical support and access to computers. conclusion. e-learning has the potential to yield positive outcomes for continued professional learning. students should be proficient in english, and require early introduction, training and technical support to use moodle effectively. afr j health professions educ 2020;12(4):211-214. https://doi.org/10.7196/ajhpe.2020.v12i4.1391 the use of an online learning management system by postgraduate nursing students at a selected higher educational institution in kwazulu-natal, south africa l i buthelezi, m nursing education; j m van wyk, phd department of clinical and professional practice, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: j m van wyk (vanwykj2@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 212 november 2020, vol. 12, no. 4 ajhpe research posed during the session. she continues to interact with each student who has responded to the questions, and asks clarifying and follow-up questions until task completion. while this process is communicated to students before they access the course online, and despite training and orientation, students become frustrated with the system. some common complaints are an inability to log onto the lms, difficulty in sending emails, and basic insecurities about the best way to solve their online learning problems. given the changing educational landscape and greater demand for students (including postgraduate (pg) students) to make use of available information technologies, it became necessary to explore students’ engagement with e-learning, and the use of the e-learning platform (moodle) at a selected higher education institution within kwazulu-natal (kzn) province, sa. the specific objectives of the study were to: (i) explore pg nursing students’ perceptions of the use of an e-learning platform (ii) explore pg nursing students’ perceived challenges regarding the use of e-learning platforms (iii) explore demographic factors of pg nursing students that are associated with their use of the e-learning platform. methodology research design an exploratory quantitative study was conducted using a questionnaire [12] to collect the views of pg nursing students about their access to, and familiarity and experiences with, the lms on one campus at a sa hei that offers a nursing qualification in kzn. a purposive convenience sampling strategy was used to invite all eligible pg students (n= 60) to complete a self-reported questionnaire that was only available in english. respondents included all students who were enrolled in a compulsory core module of the master’s of nursing qualification. data collection process ethical approval for the study was obtained from the university of kzn ethics committee (ref. no. hss/1718/016m), and gatekeepers’ permission was obtained from the dean of the school of nursing and public health, and the head of the nursing department. the self-reported questionnaire was modified [13,14] and piloted with 10 final-year undergraduate students to establish the content validity of the questionnaire. the questionnaire explored latent variables of attitude towards technology, perceived computer self-efficacy, computer anxiety and attitude towards using computersupported education. section a of the questionnaire explored mainly demographic data – race, age, gender, home language, lms training, computer access at home, and frequency of use and exposure to e-learning platforms before registering on the module. section b presented a set of 26 statements where respondents had to use a four-item likert scale with 1 representing ‘strongly agree’ and 4 representing ‘strongly disagree’ to indicate their level of agreement with various statements relating to the moodle lms. the first author met with the students and lecturers and negotiated a date for data collection. she then attended the class at a pre-arranged time to explain the purpose of the study, answer questions, assure respondents that their contributions would be anonymous and explain that they could participate or withdraw if they wished to do so. data analysis and presentation spss version 24.0 (ibm corp., usa), was used to organise and analyse the raw quantitative data. descriptive statistics that described one variable at a time were used: mean, unvaried standard deviation, contingency tables, correlation indexes and the frequencies of two or more variables were cross-tabulated. measures of central tendency were used to describe data (mode, mean, median), and the relationships between variables were established using correlational procedures. statistical analysis included using frequency distributions and a χ2 test to measure associations between challenges and sociodemographic factors. pearson’s test was used to explore the nature of associations between sociodemographic variables and challenges regarding the use of e-learning. results descriptive statistics the biographical details of the cohort are reported in table 1. analytical statistics students’ perceptions regarding moodle use in response to the objective that explored students’ perceptions regarding moodle use, students used a likert scale to indicate their level of agreement to each statement (appendix: http://ajhpe.org.za/public/files/1391.pdf ). the results showed that 62.1% (n=36) of participants had undergone training before accessing the moodle platform, while 37.9% (n=22) had not received training. a total of 68.3% (n=41) respondents reported having access to a computer at home, while 31.7% (n=19) did not have home access and therefore used a computer on campus. seventy percent (n=42) of respondents had no prior exposure to online learning platforms before enrolling on the course, as opposed to 30.0% (n=18) who reported prior online learning experience. when asked about their knowledge of using computers, 57 responses were received. twenty-eight percent (n=16) agreed, and 5.3% (n=3) strongly agreed that they had limited computer knowledge. overall score relating to perception of moodle use an overall score of the students’ perception of the use of moodle was calculated on the first 13 items. the responses ranged from 1 = strongly table 1. summary of sociodemographic characteristics characteristic variable n (%) race (n=59) african 56 (94.9) white 2 (3.4 ) coloured 1 (1.7) age group (n=57) 21 30 years 21 (36.8) 31 40 years 20 (35.1) 41 50 years 15 (26.3) 51 60 years 1 (1.8) gender (n=57) male 14 (24.5) female 43 (75.4) proficient in reading english (n=58) yes 56 (96.5) no 2 (3.4) http://ajhpe.org.za/public/files/1391.pdf november 2020, vol. 12, no. 4 ajhpe 213 research disagree, 2 = disagree, 3 = agree, to 4 = strongly agree. a higher score indicated a more positive perception of the use of moodle. the minimum score was 24, and the maximum score was 47. the mean was 37.30, and the standard deviation was 5.148. the median and the mode were 37. overall, an average of 50% of respondents had a score of 37, which indicated a positive perception of the use of moodle. challenges regarding the use of e-learning the findings relating to students’ challenges associated with using the lms were based on 57 responses. a collective 24.5% of the respondents strongly agreed (n=4) and agreed (n=10) to experiencing difficulty with navigating the programme after having been away from moodle for a few days. a total of 58% of respondents agreed (n=21) and strongly agreed (n=11) with the item regarding the need for technical support when being introduced to moodle, while 42% collectively disagreed (n=16) and strongly disagreed (n=8) with the need for technical support to use moodle effectively. three students did not answer this item. the majority of the respondents in this study, 54.5% (n=30), were comfortable using moodle: 32.7 percent (n=18) strongly agreed that they were comfortable, 7.3% (n=4) disagreed, and 5.5% (n=3) strongly disagreed with the statement. in the present study, 38.6% (n=22) of respondents agreed that they felt at ease using moodle, 33.3% (n=19) strongly agreed that this was the case, 22.8% (n=13) disagreed with the statement, and 5.3% (n=3) strongly disagreed. this study also showed that out of 57 respondents, 61.4% (n=35) agreed that the organisation of information on moodle was clear, and 22.8% (n=13) strongly agreed that it was clear, while 14.0% (n=8) disagreed and 1.8% (n=1) strongly disagreed. out of 54 respondents, 57.4% (n=31) disagreed with the statement that they found it difficult to recover after having made errors when using moodle, and 18.5% (n=10) strongly disagreed; 16.7% (n=9) and 7.4% (n=4) agreed. student challenges with moodle use concerning the objective that investigated students’ challenges with moodle use, a pearson χ2 test was used to explore associations between sociodemographic variables and the items related to the challenges regarding the use of e-learning. an association was found between the following: age and making errors (χ2=13.407, df =6, p=0.03); age and finding it difficult to adapt to the culture of learning (χ2=17.675, df=9, p=0.039); proficiency in english and learning to use moodle quickly (χ2=9.420, df=3, p=0.024); access to computers and learning to use moodle quickly (χ2= 9.41; df=3; p=0.024); access to a computer and exploring features of moodle by trial and error (χ2=17.120; df=3; p=0.001); exposure to online learning platforms before registration and the need to remember a lot of information when using moodle (χ2=9.695; df=3; p=0.021). the majority of participants viewed moodle as a flexible lms. the study, however, did find an association with proficiency in english and accessibility to computers. english proficiency was associated with the following challenges: ease of reading; students’ perception that content was well-structured; and ease of moodle use. those who indicated that the lms was user-friendly were also more proficient in english. discussion this study investigated the use of e-learning platforms by pg nursing students, specifically their perceptions of and perceived challenges in engaging on moodle as an lms. as indicated by the demographic and age profile (table 1), the cohort was a representative sample of pg students who typically enrol in the master’s in nursing degree at the institution. while 93.3% of the class indicated that they were proficient in english, it is disconcerting that four students who classified themselves as not proficient enrolled in the programme despite being aware of the requirement for english proficiency. english is the official medium of instruction at the institution. table 2. cross-tabulation of perceived challenges demographic factor perceptions and challenges p-value age if i make an error, i find it difficult to recover from it. 0.03 age i find it difficult to adapt to this culture of learning. 0.039 english proficiency i feel that moodle is easy to use. 0.020 english proficiency i feel i need to use technical support to use moodle. 0.040 english proficiency i feel that moodle is a flexible learning management software. 0.001 english proficiency i feel that moodle has a simple and natural dialogue. 0.037 english proficiency overall, i am satisfied with how easy it is to use moodle. 0.000 english proficiency the information provided on moodle is easy to understand. 0.000 english proficiency while using moodle, it is easy to read characters on the screen. 0.005 english proficiency i feel that the organisation of information in moodle is clear. 0.000 english proficiency i learned to use moodle quickly. 0.024 duration of training i feel that the organisation of information in moodle is clear. 0.043 accessibility of a computer i feel i need to use technical support to use moodle. 0.018 accessibility of a computer i feel that moodle is a flexible learning management software. 0.008 accessibility of a computer i learned to use moodle quickly. 0.024 accessibility of a computer i can explore features of moodle by trial and error. 0.001 accessibility of a computer the information provided on moodle is easy to understand. 0.025 exposure to online learning platforms before registration when using moodle, i need to remember a lot of information. 0.021 214 november 2020, vol. 12, no. 4 ajhpe research many students agreed with the statement that they found the use of moodle relatively easy. while lwoga[8] recommends the need for technical support for students who experience difficulty with online learning, chipps et al.’s[15] study strongly recommended that technical support be provided to all students, including those who re-entered a hei after having been part of the workforce for many years. they argued that students from the latter categories were more used to traditional methods of teaching and in greater need of support. only 7% of the current cohort reported this as a challenge. in this cohort, students received training and technical support in the use of moodle at the start and during the online course. the department of information communication technology provided technical support, and staff from the library provided training to access databases and online journals. we did, however, find a significant association between students’ perception of ease of use and their proficiency in english. although most of the students experienced moodle as a good lms, the results indicate a significant association between age and familiarity with technology. this finding means that older students generally faced greater challenges in accessing and using the moodle platform to support their learning. it is possible that older students lacked a proper understanding of the value of moodle as the lms. the limited use of the lms was likely to support those learners who were intimidated by the online learning format. that older students are ‘digital strangers’ has been confirmed by various authors,[15-17] whose findings also report the need for technical support for students less familiar with ict. this study also found some associations to highlight. these include accessibility of a computer and learning to use moodle quickly, general accessibility of a computer and exploration of features in moodle by trial and error. secondly, associations were found between exposure to online learning platforms before registration and the perception that one needs to remember a lot of information when using moodle. thirdly, this study found an association between student age and making errors, age and difficulty in adapting to the culture of learning, as well as proficiency in english and learning to use moodle quickly. these results relating to age as a barrier are similar to studies that reported age and lack of knowledge as barriers to the successful use of technology. [18] study limitations this questionnaire was administered only to students in one module of a master’s programme at one institution; therefore, the results are not generalisable to other modules or institutions. a mixed methodology study would have enhanced the findings and provided richer insight and exploration into issues that had been highlighted in the survey. however, the findings will contribute to greater insight into challenges and possible solutions for pg students who return to study after a prolonged period away from heis. conclusion the study produced information that can help to promote a healthy culture of use of e-learning in heis. the knowledge can be used to inform curriculum development to integrate ict into the teaching and learning process at pg level and to assist pg nursing students to access the online platform for specific reasons such as continued professional development. declaration. none. acknowledgements. the authors would like to acknowledge the pg nursing students who participated in this project. we extend our appreciation to dr b tlou for statistical assistance, and dr a smith from the department of nursing and public health and dr b keke from the school of life sciences for their support and guidance during the design phase. author contributions. lb contributed to the conception, design, development and execution while jv assisted in manuscript preparation. funding. none. conflicts of interest. none. 1. plomp t. educational design research: an introduction to educational design research. in: plomp t, nieveen n, eds. an introduction to educational design research. enschede: netherlands institute for curriculum development 2013:9-36. 2. united nations educational, scientific and cultural organization institute for statistics. teachers and educational quality: monitoring global needs for 2015. paris: unesco ifs, 2006. http://uis.unesco.org/sites/default/files/ documents/teachers-and-educational-quality-monitoring-global-needs-for-2015-en_0.pdf (accessed 7 june 2020). 3. schreurs ka, quan-haase a, martin k. problematizing the digital literacy paradox in the context of older adults’ ict use: aging, media discourse, and self-determination. canadian j communication 2017;42(2). https://doi. org/10.22230/cjc.2017v42n2a3130 4. bichsel j. the state of e-learning in higher education: an eye toward growth and increased access. educause, 2013. https://library.educause.edu/~/media/files/library/2013/6/ers1304.pdf?la=en (accessed 30 september 2020). 5. bagarukayo e. social media use to transfer knowledge into practice and aid interaction in higher education. int j educ dev using ict 2018;14(2):211-232. https://www.learntechlib.org/p/184689/article_184689.pdf (accessed 30 september 2020). 6. jaffer sd, ng’ambi l, czerniewicz l. the role of icts in higher education in south africa: one strategy for addressing teaching and learning challenges. int j educ dev using ict 2007;3(4):131-142. https://www.learntechlib. org/p/42220/article_42220.pdf (accessed 20 may 2020). 7. bagarukayo e, kalema b. evaluation of elearning usage in south african universities: a critical review. int j educ dev using ict 2015;11(2):168-183. https://www.learntechlib.org/p/151848/article_151848.pdf. (accessed 30 september 2020). 8. lwoga et. critical success factors for adoption of web-based learning management systems in tanzania. int j educ dev using ict 2014;10(1):4-21. https://www.learntechlib.org/p/147447/article_147447.pdf (accessed 30 september 2020). 9. lwoga et. integrating web 2.0 into an academic library in tanzania. electronic library 2014;32(2):183-202. http:// www.academia.edu/download/36781072/final_electronic_lib_archiving.pdf (accessed 30 september 2020). 10. bridgstock r. educating for digital futures: what the learning strategies of digital media professionals can teach higher education. inno educ teach int 2016;53(3):306-315. https://doi.org/10.1080/14703297.2014.956779 11. al-busaidi ka, al-shihi h. instructors’ acceptance of learning management systems: a theoretical framework. communications of the ibima 2010. 2010(2010):1-10. http://ibimapublishing.com/articles/ cibima/2010/862128/862128.pdf (accessed 30 september 2020). 12. polit df, beck ct. nursing research: generating and assessing evidence for nursing practice. philadelphia: lippincott williams & wilkins, 2008. 13. celik v, yesilyurt e. attitudes to technology, perceived computers self-efficacy and computer anxiety as predictors of computers of computer supported education. computers edu 2013;60(1);148-158. https://doi.org/10.1016/j. compedu.2012.06.008 14. daneshmandnia a. a usability study of moodle. proceedings of the spring 2013 mid-atlantic section conference of the american society of engineering education. https://www.asee.org/papers-and-publications/papers/sectionproceedings/middle-atlantic/asee-middle-atlantic-spring-2013-proceedings.pdf (accessed 12 november 2020). 15. chipps j, kerr j, brysiewicz p, walters f. a survey of university students’ perceptions of learning management systems in a low-resource setting using a technology acceptance model. computers informatics nursing 2015;33(2):71-77. https://journals.lww.com/cinjournal/fulltext/2015/02000/a_survey_of_university_students__ perceptions_of.6.aspx (accessed 30 september 2020). 16. czerniewicz l, brown c. the habitus of digital ‘strangers’ in higher education. br j educ tech 2013;44(1):44-53. https://doi.org/10.1111/j.1467-8535.2012.01281.x 17. queiros d, de villiers m. online learning in a south african higher education institution: determining the right connections for the student. int rev res open distributed learning 2016;17(5):165-185. https:// www.erudit.org/en/journals/irrodl/1900-v1-n1-irrodl04876/1064710ar.pdf (accessed 30 september 2020). 18. porter ce, donthu n. using the technology acceptance model to explain how attitudes determine internet usage: the role of perceived access barriers and demographics. j business res 2006;59(9):999-1007. http://www.academia. edu/download/52477167/using_technology_acceptance (accessed 30 september 2020). accepted 27 july 2020. http://uis.unesco.org/sites/default/files/documents/teachers-and-educational-quality-monitoring-global-needs-for-2015-en_0.pdf http://uis.unesco.org/sites/default/files/documents/teachers-and-educational-quality-monitoring-global-needs-for-2015-en_0.pdf https://doi.org/10.22230/cjc.2017v42n2a3130 https://doi.org/10.22230/cjc.2017v42n2a3130 https://library.educause.edu/~/media/files/library/2013/6/ers1304.pdf?la=en https://www.learntechlib.org/p/184689/article_184689.pdf https://www.learntechlib.org/p/42220/article_42220.pdf https://www.learntechlib.org/p/42220/article_42220.pdf https://www.learntechlib.org/p/151848/article_151848.pdf. https://www.learntechlib.org/p/147447/article_147447.pdf http://www.academia.edu/download/36781072/final_electronic_lib_archiving.pdf http://www.academia.edu/download/36781072/final_electronic_lib_archiving.pdf https://doi.org/10.1080/14703297.2014.956779 http://ibimapublishing.com/articles/cibima/2010/862128/862128.pdf http://ibimapublishing.com/articles/cibima/2010/862128/862128.pdf https://doi.org/10.1016/j.compedu.2012.06.008 https://doi.org/10.1016/j.compedu.2012.06.008 https://www.asee.org/papers-and-publications/papers/section-proceedings/middle-atlantic/asee-middle-atlantic-spring-2013-proceedings.pdf https://www.asee.org/papers-and-publications/papers/section-proceedings/middle-atlantic/asee-middle-atlantic-spring-2013-proceedings.pdf https://journals.lww.com/cinjournal/fulltext/2015/02000/a_survey_of_university_students__perceptions_of.6.aspx https://journals.lww.com/cinjournal/fulltext/2015/02000/a_survey_of_university_students__perceptions_of.6.aspx https://doi.org/10.1111/j.1467-8535.2012.01281.x https://www.erudit.org/en/journals/irrodl/1900-v1-n1-irrodl04876/1064710ar.pdf https://www.erudit.org/en/journals/irrodl/1900-v1-n1-irrodl04876/1064710ar.pdf http://www.academia.edu/download/52477167/using_technology_acceptance http://www.academia.edu/download/52477167/using_technology_acceptance march 2020, vol. 12, no. 1 ajhpe 36 research the south african (sa) population is burdened by a prevalence of neurological conditions, such as congenital, acquired and progressive disorders.[1] given the effect of neurological conditions on a person’s quality of life, these form a sizeable proportion of an occupational therapist’s workload in school and healthcare settings.[2] the assessment and treatment of persons with neurological conditions are included in undergraduate occupational therapy courses to prepare students with the necessary competencies to work in this field. there are regular changes in the practice of neurology, given constant research developments in the domains of neurological assessment and treatment. service provision is often characterised by limited resources, short and intermittent therapeutic input and a high therapist-client ratio.[3] therapists have alluded to the existence of possible gaps in the core knowledge and skills of the students they supervise in the clinical field. this highlighted the need for revision of the neurology curriculum at a university in western cape province, sa. the current curriculum at this university is structured in such a way that students are taught physiology, anatomy and assessment of neurological components in their second year of study. the treatment of neurological conditions is taught in the classroom and in clinical settings throughout the third and final years of the academic programme. the relevance and need for a curriculum to be responsive to the needs of the community have been highlighted by frenk et al.[4] these authors highlighted that the health professional of the 21st century requires additional tools to be a competent practitioner. they stressed that traditional training focused on the first two levels of learning, i.e. informative (learning of facts and skills) and formative (elements required to become a professional). they argue that students, however, also need to be exposed to transformative learning to ensure that the population’s health needs are met, inequities are minimised and deficiencies in health systems are addressed. frenk et al.’s[4] theory on transformative learning was the conceptual framework underpinning this research. within this framework, students need to become agents of change through their experiences of teaching and learning at a university. to ensure that learning is transformative, it is essential that the undergraduate occupational therapy neurology curriculum is relevant and responsive. the relevance and responsiveness may therefore be facilitated through the use of a collaborative approach to curriculum design.[5-8] such an approach between clinicians and academic staff is essential to ensure that the knowledge, skills and attitudes that are taught, mirror what graduates need to provide, i.e. comprehensive, effective and efficient service within a given community.[7] studies using a collaborative approach to develop curricula have been conducted in various fields of occupational therapy, e.g. paediatrics,[9,10] adult physical dysfunction[11] and gerontology.[12] a review of the literature has demonstrated that collaborative curriculum design in the field of neurology is limited and studies were either conducted in high-resource countries or focused on a single diagnosis in neurology, such as a cerebrovascular accident.[5-7,13] a study that explored the core skills and knowledge that an occupational therapy-specific undergraduate neurology curriculum should foster to enable graduates to provide interventions across all age groups and background. the burden of neurologically related conditions in south africa (sa) necessitates that undergraduate occupational therapy education and training provide students with core competencies to deliver comprehensive, effective client-centred interventions. given developments in the practice of neurology and changes in policy, funding and infrastructure, it is essential that training remains relevant and responsive to the needs of individuals and their context. occupational therapists should be in touch with the local context and its challenges and consider the practicalities of the suggested interventions. objectives. to explore occupational therapists’ perspectives on the knowledge, skills and attitudes that graduates need to work in the field of neurology. methods. an explorative qualitative study consisting of semi-structured interviews was conducted with 10 occupational therapists in western cape province, sa. data were analysed using inductive analysis. results. four themes emerged from the findings, including foundational knowledge and skills, intraand interpersonal attitudes, suggestions to consider when revising a neurology curriculum and resource constraints. conclusions. this study highlighted that, in addition to neurology-specific skills, graduates also require core generic knowledge, skills and attitudes that address the evolving needs of society. these competencies are further necessary to allow graduates to work within the constraints of the health and educational systems. afr j health professions educ 2020;12(1):36-40. https://doi.org/10.7196/ajhpe.2020.v12i1.1021 occupational therapists’ views on core competencies that graduates need to work in the field of neurology in a south african context l jacobs-nzuzi khuabi, phd (ot), mph (health economics), bsc (ot); j bester, b ot, bsc hons (epidemiology and biostatistics), m phil (higher education), pg dip (program monitoring and evaluation) division of occupational therapy, department of health and rehabilitation sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: l jacobs-nzuzi khuabi (leeann@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 37 march 2020, vol. 12, no. 1 ajhpe research with regard to neurological conditions was conducted by mccluskey[6] in australia. this qualitative study included the views of occupational therapists on the core neurology content of a new occupational therapy course. four main themes were identified that illustrated the knowledge and skills needed for practising in the field of neurology: (i) integrated foundation studies (neuroanatomy and neurophysiology) as prerequisites; (ii) the art of a thorough assessment; (iii) treatment approaches in neurology; and (iv) building confidence in clinical settings, as neurology was perceived as a difficult area of practice for students. we report on one component of a larger collaborative study that focuses on the development of a relevant and responsive occupational therapy undergraduate neurology curriculum in the sa context. this larger study is two pronged and focuses on evidence-based practice and the views of a number of critical stakeholders, i.e. final-year occupational therapy students, and qualified occupational therapists and experts (i.e. academics and clinical educators). we also report on the views of qualified occupational therapists in terms of core knowledge, skills and attitudes needed by graduates, which should be included in the undergraduate occupational therapy curriculum, as well as factors that should be considered when revising the curriculum. methods an explorative qualitative research study was conducted.[14] the study population consisted of 10 occupational therapists working in the field of neurology in the western cape. therapists who treat adults and/or children with neurological conditions were included. purposive sampling was used. the selection criteria included occupational therapists who were registered with the health professions council of south africa (hpcsa) and practising in the western cape. therapists had to have worked in the field of neurology for at least 3 years, as according to hodgetts et al.,[8] occupational therapists appeared to need 6 months 2 years of clinical practice in a specific field to feel clinically competent. data were collected by means of a 60-minute face-to-face semi-structured interview per participant. an interview guide was used, the questions were based on the literature and were guided by the objectives of the study. the interview guide consisted of two sections: (i) gathering of demographic information (personal and work characteristics) of the research participants; and (ii) gathering of qualitative data with 5 open-ended questions: • what core knowledge would you suggest newly qualified therapists should have to work in the field of neurology? • what core skills would you suggest newly qualified therapists should have to work in the field of neurology? • what core attitudes would you suggest newly qualified therapists should have to work in the field of neurology? • are there any factors that should be considered when revising the neurology curriculum? • in your opinion, what is the influence of resource constraints in practice and what should be considered when teaching students in the undergraduate curriculum? data saturation was reached after interviews had been conducted;[14] the interviews were also audio recorded and transcribed verbatim. burnard’s[15] framework for inductive data analysis was used, as well as a system of open coding with peer checking throughout. similar codes were collapsed into categories; from these, overarching themes emerged. lincoln and guba’s[16] model of trustworthiness for qualitative research was used to ensure rigour. credibility was obtained by participants’ views, ensuring a good understanding of current neurology practice. investigator triangulation was used to ensure dependability, whereby the research supervisor became the second investigator to analyse the data. transferability was ensured by thick descriptions of procedures for data collection and analysis. ethical approval ethical approval was obtained from the health research ethics committee of stellenbosch university (ref. no. n14/09/118). participants were contacted telephonically to explain the purpose of the study and to determine their willingness to participate in the research. written consent was obtained on the day of the interview before it commenced. results the demographic profile of the participants is depicted in table 1. from the data analysis, four major themes emerged: (i) foundation knowledge and skills; (ii) intraand interpersonal attitudes; (iii) suggestions to consider when revising a neurology curriculum; and (iv) resource constraints (table 2). discussion for the purpose of the discussion, knowledge and skills were combined, as the data did not differentiate between assessment knowledge and skills or treatment knowledge and skills. participants stated that a solid foundation in generic knowledge may assist in students’ understanding of the effect of underlying pathology on an individual’s performance. these views are similar to those of occupational therapists in the australian study.[6] assessment is an integral component of the occupational therapy process, which was reiterated by the participants. they highlighted that knowledge and skills of assessment need to extend beyond those of assessment for sensorimotor function, and encompass cognition, social functioning and context of the person. assessment of the person in context provides for a more holistic understanding of the client and facilitates client-centred practice. participants also advocated for a more functional approach to assessment, for which good observational and activity analysis skills are crucial. relevant treatment depends on core knowledge and skills of various treatment modalities. in addition, students need to develop clinical reasoning skills for an appropriate choice of treatment modality(ies) to address the needs of the patient. participants emphasised the skill to integrate treatment modalities into functional activity. this integration is supported by the literature, which recognises the role of engagement and practice in functional tasks in neurological recovery from central nervous system dysfunction.[17-19] participants expressed the view that even though neurology-related knowledge and skills are essential, there are also key intrapersonal attitudes that need to be developed in graduates. this finding is different from that in other studies,[5,6] where the focus of education and training was predominantly on knowledge and skills. according to barnett,[20] knowledge and skills are essential in developing competence, but training needs to extend to the fostering of graduates’ attitudes, such as those that exhibit reflective and ethical practice. a common thread in this study and other march 2020, vol. 12, no. 1 ajhpe 38 research studies was the need to improve students’ confidence to work in the complex field of neurology.[5,6] the findings also emphasise the importance of interpersonal attitudes that necessitate cognisance of the roles of other team members and the ability to communicate intervention plans to all involved. this was confirmed by caldwell et al.,[21] where they highlighted the importance of effective communication and a good understanding of the roles of other team members as prerequisites for working as part of an effective team. resource constraints in practice settings and community contexts require that education and training equip students with innovative skills and the ability to identify ways of using existing resources to assist patients to attain their goals. students further require training to enable them to advocate for patients to have access to resources embodied in the bill of rights of the sa constitution. a few suggestions emerged regarding factors to be considered when revising a neurology curriculum. participants highlighted the importance of creating opportunities for more hands-on skills. they also alluded to the need for increased collaboration between clinicians and lecturers to narrow the gap between academic teaching and the practice setting. these findings concur with the perspectives of final-year occupational therapy students regarding suggestions that could be included in the revision of an undergraduate occupational neurology curriculum.[22] study limitations limitations of this study include the lack of variation in the sample in terms of the geographical work setting. the recruitment of additional participants who work in rural settings may have allowed increased insight into additional competencies that graduates require when working in such settings, as well as to inform further factors that should be considered when revising a neurology curriculum. conclusions the study explored occupational therapists’ perspectives of the knowledge, skills and attitudes that graduates need to work in the field of neurology. findings reflect that there are various resource constraints and subsequent changes in the clinical platform in the western cape that have a direct impact on the training of students. findings further highlighted that to practise in the field of neurology, new graduates require core knowledge, skills (both neurology specific and generic) and attitudes that address the evolving needs of society and allow them to work within the constraints of the health and educational systems. educators involved in revising undergraduate occupational therapy neurology curricula are urged to consider that preparing new graduates for practice in the 21st century necessitates that education and training encompass: • opportunities for interprofessional teamwork, which would facilitate an increased awareness of their own roles and those of other professions to deliver holistic care • a focus on an integrated teaching approach to facilitate optimal integration between neurology-specific content and generic principles of occupational therapy practice • a closer alignment between the outcomes of the undergraduate neurology curriculum and the core competencies that will enable graduates to be competent practitioners • the inclusion of evidence-based practice in teaching in conjunction with nurturing students’ critical appraisal skills to ensure that they are able to select interventions that are most relevant and responsive to their patients’ needs and contexts • emphasis on a functional approach to assessment and treatment • opportunities for students to cultivate their innovative skills so that they are able to work with the existing resources that are readily available within their patients’ contexts. table 1. demographic profile of participants participant gender clinical experience, years geographical work location work setting caseload 1 female >11 rural acute-care hospital mixed* 2 male >11 urban outpatient and community-based rehabilitation institute mixed* 3 female 5 10 urban acute-care hospital mixed* 4 female >11 urban acute-care hospital subacute or rehabilitation institute outpatient and community-based rehabilitation institute old-age home mixed* 5 female >11 urban/rural acute-care hospital mixed* 6 female >11 urban special needs school mixed* 7 female 5 10 urban outpatient and community-based rehabilitation institute mixed* 8 female >11 urban acute-care hospital outpatient and community-based rehabilitation institute neurological 9 female >11 urban subacute or rehabilitation institute neurological 10 female 3 4 urban acute-care hospital neurological *general rehabilitation of neurological and other diagnoses, e.g. orthopaedic conditions. 39 march 2020, vol. 12, no. 1 ajhpe research table 2. themes: foundation knowledge and skills, intraand interpersonal attitudes, suggestions to consider when revising a neurology curriculum and resource constraints theme category quotation foundation knowledge and skills this encompasses the core generic knowledge of neuroanatomy, physiology and pathology, including core knowledge pertaining to occupational therapy-specific neurological assessment and treatment foundational generic knowledge participants shared the opinion that core generic knowledge is important for newly qualified therapists to have a good understanding of neurological conditions in terms of the clinical picture, aetiology and prognostic factors ‘… so long as they have a good knowledge of how hemiplegia presents … then they should also have an understanding of what is muscular dystrophy, what is multiple sclerosis, parkinson’s disease, guillain-barré … one really needs to have a good understanding of the symptoms … a good knowledge of the pathology… and how that leads to the type of picture that the client presents.’ (participant 9) neurological assessment the scope of the neurological assessment should cover a broad spectrum, ranging over assessing and interpreting components of the postural response mechanisms, cognition, perception, standardised testing and functions ‘the core skills that they should have … is a good grasp of assessment, and i’m talking of neurological assessments and physical assessments … also cognitive assessments … and psychological … i would say social assessment of their circumstances … .’ (participant 9) ‘… some input on home visits, assessment in the home, assessment of ergonomics, assessment of your … type of assistive devices … .’ (participant 2) ‘it doesn’t help that you can test but not understand the interpretation of what you have … because you must know what to do with the information.’ (participant 5) neurological treatment treatment includes knowledge and skills of therapeutic modalities, activity analysis, applying a functional approach, selecting appropriate assistive devices and educating patients and their carers ‘so you learn about weight bearing and tapping and all of those things … you get the words and maybe the definition and you get shown how to do it on a healthy person, but, it doesn’t necessarily mean that the student then has the ability to decide what of this is important for the specific patient … that’s why i think knowledge is not necessarily the problem, but the application is.’ (participant 1) ‘so they get so much into the preparation and ndt [neurodevelopmental treatment] and stuff, which they don’t actually translate into functional activity. when i’m talking about functional activity, i’m not talking about something the student or the ot [occupational therapist] thinks will be nice. it’s what the client believes in and finds meaning for and what is relevant specific to them.’ (participant 9) ‘activity analysis … and good observational skills, the students take an activity and think it’s a nice activity, but this isn’t correct thinking because they need to look at what the child’s functional problem is, what you want to improve. then you have to go and look for an activity that contains those components or whatever you want to enhance.’ (participant 6) intraand interpersonal attitudes this alludes to the importance of personal and interpersonal characteristics that are necessary to work in the field of neurology personal attitudes several attitudes were indicated as important for working in the diverse field of neurology, i.e. honesty, compassion, empathy, confidence and being non-judgemental ‘attitudes, one has to be honest with people as well, it’s not always easy to deal with people who are unrealistic about their expectations and their recovery so you have to be willing to make time to help people go through that process of gaining insight, accepting the disability, accepting the loss and the change.’ (participant 2) ‘you mustn’t be scared to touch a patient … you must just have a bit of self-confidence that you have already felt it … .’ (participant 7) interpersonal attitudes these should be fostered during education and training to equip graduates to work with other team members and patients, their family and/or carers, including the ability to build good interpersonal relationships, be adaptable when working with different personality types, different developmental stages and different levels of education ‘… it’s almost i would say 85% of the time you have both people; the carer and the patient … and not to maybe forget about the carer – treat the carer as well. so be mindful who is around this individual.’ (participant 8) ‘i think there has to be a clear understanding of all the different disciplines’ roles to be able to work in a team. (participant 2) continued ... march 2020, vol. 12, no. 1 ajhpe 40 research declaration. none. acknowledgements. we acknowledge the participants and the honours research group (2014), division of occupational therapy, department of health and rehabilitation sciences, faculty of medicine and health sciences, stellenbosch university: alett-marie burger, arauna van der merwe, esmaré theron, helena langenhoven, jessica ramsay and simoné van tonder. author contributions. both authors conceptualised the idea for the research. lj-nk supervised the data collection. both authors were involved in the analysis of the data and contributed to the write-up of this article. funding. fund for innovation research learning and teaching (firlt). conflicts of interest. none. 1. south african health review. 2017. durban: health systems trust, 2017. http:// www.hst.org.za/media/pages/hstsouth-african-health-review-2017.aspx (accessed 22 november 2018). 2. world federation of occupational therapists. definition and function of occupational therapy. 2017. http://www. traffic.libsyn.com›fot_definitions_2017_updated_june_2017aspx (accessed 11 april 2017). 3. hassan s, visagie s, mji g. the achievement of community integration and productive activity outcomes by cva survivors in the western cape metro health district. s afr j occ ther 2012;42(1):11-15. https://doi. org/10.4102%2fsajp.v67i2.39 4. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 5. freeme j, casteleijn d. a proposal for an undergraduate stroke rehabilitation curriculum appropriate for south africa. s afr j occ ther 2014;44(1):68-74. 6. mccluskey a. collaborative curriculum development: clinicians’ views on the neurology content of a new occupational therapy course. austr occ ther j 2000;47(1):1-10. https://doi:org/10.1046/j.1440-1630.2000.00200.x 7. hanekom sd, unger m, cilliers f. deriving criteria by which to determine core curriculum content: a high engagement process. afr j health professions educ 2014;6(2):181-184. https://doi.org/10.7196%2fajhpe.496 8. hodgetts s, hollis v, triska o, dennis s, madill h, taylor e. occupational therapy students’ and graduates’ satisfaction with professional education and preparedness for practice. can j occ ther 2007;74(3):148-160. https:// doi.org/10.1177/000841740707400303 9. dewire a, white d, kanny e, glass r. education and training of occupational therapists for neonatal intensive care units. am j occ ther 1996;50:486-503. https://doi.org/10.5014/ajot.50.7.486 10. brown gt, brown a, roever c. paediatric occupational therapy university programme curricula in the united kingdom. br j occ ther 2005;68(10):457-466. https://doi.org/10.1177/030802260506801004 11. nelson ce, cash sh, bauer df. adult physical dysfunction content in professional curricula. am j occ ther 1990;44(12):1079-1087. https://doi.org/10.5014/ajot.44.12.1079 12. strasburg dm, gingher mc. a review of entry level education in gerontology. am j occ ther 1986;40:557-560. https://doi.org/10.5014/ajot.40.8.557 13. schriner m, thome j. rehabilitation of the upper extremity after stroke: current practice as a guide for curriculum. open j occ ther 2014;2(1):1-14. https://doi.org/10.15453/2168-6408.1056 14. merriam sb, tisdell e. qualitative research. a guide for design and implementation. san francisco: wiley and sons, 2016. 15. burnard p. a method of analysing interview transcripts in qualitative research. nurse educ today 1991;11(6):461-466. https://doi.org/10.1016/0260-6917(91)90009-y 16. lincoln ys, guba eg. paradigmatic controversies, contradictions and emerging confluences. in: denzin nk, lincoln ys, eds. the sage handbook of qualitative research. 4th ed. thousand oaks, ca: sage publications, 2011:97-128. 17. dobkin b. activity-dependent learning contributes to motor recovery. ann neurol 1998;44:158-160. https://doi. org/10.1002/ana.410440204 18. carr jh, shepherd r. neurological rehabilitation: optimizing motor performance. oxford: butterworth-heine mann, 2010. 19. thielman gt, dean cm, gentile am. rehabilitation of reaching after stroke: task centred training vs progressive resistive exercise. arch phys med rehab 2004;85:1613-1618. https://doi.org/10.1016/j.apmr.2004.01.028 20. barnett r. the limits of competence: knowledge, higher education and society. in: hagerdorn r. tools for practice in occupational therapy. a structured approach to core skills and processes. london: harcourt, 2000:49-56. 21. caldwell k, atwal a, copp g, brett-richards m, coleman k. preparing for practice: how well are practitioners prepared for teamwork. br j nurs 2006;15(22):1250-1254. https://doi.org/10.12968/bjon.2006.15.22.22565 22. jacobs-nzuzi khuabi l, bester j, gatley-dewing k, et al. occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology. afr j health professions educ 2017;9(1):39-43. https://doi.org/10.7196/ajhpe.2017.v9i1.722 accepted 5 september 2019. table 2. (continued) themes: foundation knowledge and skills, intraand interpersonal attitudes, suggestions to consider when revising a neurology curriculum and resource constraints theme category quotation suggestions to consider when revising a neurology curriculum this reflects possible suggestions on the scope of content and instructional methods to optimise integration between theory and practice integration and application of practical skills the majority of participants stated that students require the opportunity to practise more hands-on skills to apply what has been learnt in the classroom ‘… you cannot get insight into the patient and the treatment techniques if you are not seeing them demonstrated, if you are not getting a little bit of practice; practice on a fellow student is not always appropriate. you cannot get a sense of what the muscle tone is like… .’ (participant 2) ‘the ideal, i would say, is that you are shown, but then to physically feel it for yourself.’ (participant 5) collaborative teaching approach this should involve experienced lecturers, clinicians and experts in neurology from other disciplines ‘external people, the people who work in the field and … have a passion for it, that have worked with students, i think they must be contacted … there aren’t a lot of people who are ndt [neurodevelopmental treatment] trainers … but there are physiotherapists and i don’t think people should be reluctant to use them.’ (participant 1) resource constraints this encompasses the limited/ unavailable resources in different practice settings or contexts, which impact on student education and training practice settings these are under-resourced in terms of staff, resulting in a high workload, which causes constraints in terms of time available to teach and support students ‘obviously we have big workloads … i can’t watch my students do their sessions because i actually don’t have time … if we’re lucky once a week, or once every second week, i get to do that, and then i’m basically not seeing my patients that i should see. so it’s time that is the biggest resource constraint.’ (participant 3) community context there are a number of resource constraints in the communities where patients live (i.e. lack of social support, economic and accessible community facilities), which have an influence on patients’ goal setting ‘… a safe environment, money to get access to things they need, the resources to get down the stairs from a fourth-floor flat, because it’s human resources, because they need family and strong people to help them get down the stairs, they need access to resources like libraries and sport facilities in the community; those are not there, so their goal setting is always limited.’ (participant 2) http://www.hst.org.za/media/pages/hst-south-african-health-review-2017.aspx http://www.hst.org.za/media/pages/hst-south-african-health-review-2017.aspx http://www. traffic.libsyn.com›fot_definitions_2017_updated_june_2017aspx http://www. traffic.libsyn.com›fot_definitions_2017_updated_june_2017aspx https://doi.org/10.4102%2fsajp.v67i2.39 https://doi.org/10.4102%2fsajp.v67i2.39 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.7196%2fajhpe.496 https://doi.org/10.1177/000841740707400303 https://doi.org/10.1177/000841740707400303 https://doi.org/10.5014/ajot.50.7.486 https://doi.org/10.1177/030802260506801004 https://doi.org/10.5014/ajot.44.12.1079 https://doi.org/10.5014/ajot.40.8.557 https://doi.org/10.15453/2168-6408.1056 https://doi.org/10.1016/0260-6917(91)90009-y https://doi.org/10.1002/ana.410440204 https://doi.org/10.1002/ana.410440204 https://doi.org/10.1016/j.apmr.2004.01.028 https://doi.org/10.12968/bjon.2006.15.22.22565 https://doi.org/10.7196/ajhpe.2017.v9i1.722 march 2019, vol. 11, no. 1 ajhpe 22 research the nursing student entering the operating room (or) for the first time often finds it an intimidating environment. misconceptions and misunderstandings frequently result in a negative experience, leading to the inability to optimise the learning opportunity. the or could be perceived by many nurses’ standards as a demanding, hostile, overwhelming, high-paced and high-stress working environment, and even more so by a student nurse who is a novice in the or.[1] nursing students often do not know what is expected of them or how to do the work.[2,3] global and local shortages of or nurses[4-7] put student nurses under even more pressure. furthermore, or personnel expect students to function as experienced members of the or team, while students might have the perception of being useless and feeling out of place.[3,5] currently, in the south african (sa) context, student nurses are being placed in the or even though they have very limited theoretical teaching or practical training for this work.[8] several international studies[5,9,10] where preparation programmes were implemented prior to or placement, described positive outcomes and a positive impact on learning in the or. recruitment and retention of or nursing staff are additional benefits of preparation programmes.[5,9,10] meyer[3] and van der merwe[8] found that students need an improved preparation programme before being placed in the or. the participants in these studies were of the opinion that the development of such a programme would enhance student nurses’ learning during placement and their overall perception of the or.[3,8] in sa, or placement is mandated by the sa nursing council (sanc).[11] most of the students are placed in the or with limited preparation, contributing to compromise student nurses’ learning during clinical placement.[8] george et al.[7] reported that in 2009, ~18.0% of registered nurses were sedentary, 65% of nurses who were trained between 1997 and 2005 did not appear on the sanc register, and 76% of registered professional nurses were facing retirement within the next decade. this situation may result in a group of young and inexperienced registered nurses, who do not have the support and guidance of a large cluster of experienced registered nurses to become established in their new roles as registered nurses. the current international and local shortages of qualified registered nurses put increased pressure on student nurses, contributing to anxiety and even fear of the situation in the or.[4] with regard to the or as a learning environment, meyer[3] and van der merwe[8] stated that for learning in the or to be effective, students have to feel that they are being supported, encouraged and included as part of the team. for student nurses to cope with the complex or environment and participate as team members, they need to be prepared sufficiently.[12] educational approaches to this type of preparation have been described extensively and include strategies and methods such as demonstrations, working in small groups, simulation, practical assessment and feedback.[13,14] research that focuses on the preparation of student nurses for their first rotation in the or is limited, both internationally and in sa. the findings of this study could contribute towards the improvement and/or development of a student nurse’s preparation programme for or rotation. a programme resulting from the findings could have a positive impact on sa students’ or rotation in terms of learning and general experience, similar to the international examples mentioned by gregory et al.[9] and hope et al.[10] this study was conducted at an academic training hospital in sa to obtain the views of nursing students and permanent or staff, who were directly involved with and affected by student nurses’ placement in the background. limited time for training and preparation of student nurses in a busy operating room (or) could be attributed to a shortage of qualified or nurses in south africa. objective. to determine the participants’ perceptions of the content and modes of delivery of an improved preparation programme for nursing students to enhance learning in the or. methods. a qualitative research approach, which included nominal group discussions with students and or staff, was used for data collection. results. the need for an improved preparation programme was confirmed. the programme should address documentation, equipment, maintaining sterility, orientation, swab and instrument control, and or preparation. suggested modes of delivery include practical demonstrations in small groups, flip-the-classroom approach and simulation. conclusion. adequate preparation has a direct impact on students’ learning in and their impression of the or, which could result in more students selecting or nursing as a career path. afr j health professions educ 2019;11(1):22-26. doi:10.7196/ajhpe.2019.v11i1.1072 preparation of nursing students for operating room exposure: a south african perspective s breedt,1 dip general nursing, psychiatric nursing and midwifery, dip operating room science, dip nursing management, dip nursing education, b advanced nursing, m hpe; m j labuschagne,2 mb chb, mmed (opht), phd 1 division health sciences education, faculty of health sciences, university of the free state, bloemfontein, south africa 2 clinical simulation and skills unit, school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m j labuschagne (labuschagnemj@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 23 march 2019, vol. 11, no. 1 ajhpe research or, the current or preparation programme and how it could be improved to better prepare the student nurse for or placement. furthermore, their opinions with regard to the best modes of delivery of such a programme were determined. based on the results of the study, the principal researcher intended to develop a preparation programme that would prepare the nursing student before or placement. the matters that needed to be addressed were: (i) what an or preparation programme should consist of regarding its content; and (ii) the optimal method of delivery of such a programme. methods a descriptive qualitative study design was employed, with the intention to explore the content and delivery methods of an or programme.[15] the investigation focused on the practical problems encountered by participants during their training, who all shared the unique experience of being novices in the or, and to acquire practical solutions.[16] the nominal group technique (ngt) has been proven to be a feasible and reliable method for the production and prioritisation of responses relating to a specific phenomenon enquiry,[17,18] and was used as data collection method for this study. the ngt process included the following steps: preparation (design, room and meeting preparation), silent idea generation, recording of the ideas, discussion of the ideas, preliminary voting, discussion of preliminary voting and final voting.[19] setting and sample the setting was an academic hospital, affiliated to the university of the free state, bloemfontein, sa, where undergraduate and postgraduate students from various disciplines are trained. the study included only one institution, but future studies might include more institutions, even private hospitals. purposive sampling was done so that participants could objectively contribute to this specific phenomenon.[17] the inclusion criteria for the sample of the following two groups were: (i) group 1 – undergraduate nursing students (n=8) with no prior or exposure, who very recently completed their or rotation; and (ii) group 2 – permanently employed personnel (n=5), including registered/scrub nurses, anaesthetic nurses and floor/circulating nurses, working in ors where students had completed their clinical placement. as all participants were able to express themselves in english, it was the language used to conduct the ngt discussions, even though the participants spoke different languages. data collection and measures the research was carried out in 2016 in a quiet room in the or complex of the academic hospital while participants were on duty on saturdays, because that day is not extremely busy and participants are in the or complex should an emergency occur. the ngt discussions were conducted under the supervision of an experienced facilitator, with the researcher as an observer in the room. both were unknown to the students. two questions were posed to the two nominal groups: ‘what should an operating room preparation programme consist of ?’ and ‘what would be the most optimal way to present the programme?’ data were collected from the two group discussions; both indicated what would be valuable skills for a novice or student nurse to acquire, and the most effective methods to teach the students these skills. data were documented as accurately and comprehensively as possible to ensure that the findings of the study were dependable. the rigour of this qualitative study was ensured by it having truth-valued, applicable, consistent, neutral and authentic data and results. the reliability of qualitative data is to a considerable extent determined by the methodological competence, sensitivity and integrity of the researcher,[20] which in turn contributes to its trustworthiness and credibility. this study invites the reader into the phenomenon being researched by enabling them to develop an intensified understanding of the issues being addressed.[17] ethical approval the ethics committee of the faculty of health sciences at the university of the free state granted institutional approval to conduct the study (ref. no. ecufs 202/2015). permission was also obtained from the university and hospital authorities. before the ngt discussions started, all participants were informed that participation was voluntary and would not in any way impose on or affect their human rights. they were made aware that they had the right to stop participating at any point without any form of penalty or discrimination. all participants had to give written informed consent to participate in the nominal group discussions. data analysis ideas and theories regarding the phenomenon were developed by the participants during the ngt process. participants had to rank their chosen statements, which were placed in order of the most important to least important. the most important statement was scored with a 6 and the least important with a 1. the top 6 votes were indicated, and votes with their rankings were recorded. the researcher was involved with the data collection observer during the process,[17] resulting in simultaneous collection and analysis of data. the data were captured by transcribing the participants’ ideas verbatim. the text was then interpreted by the researcher to find similarities and identify categories/themes.[17,21] the categories that were identified during the ngt were used when compiling the description of the content and modes of delivery of the preparation programme.[17] results with regard to a proposed preparation programme, the top 6 statements of both groups were combined and categorised according to their similarity. the categories that were identified and ranked are listed in table 1. the main categories were documentation (29%), maintaining of sterility (19%), equipment use (19%), or preparation (15%), swab and instrument control (10%) and orientation (8%). both ngt groups identified these categories, which were in line with the needs of student nurses and or personnel in a functioning, busy or. both groups listed methods that they felt were best suited for presenting a preparation programme. suggested modes of delivery included practical demonstrations and simulation, visual learning, practical group sessions, preplacement preparation and formal lectures with written tests. the suggestions were tabulated, categorised and prioritised according to group consensus (table 2). in the student group, simulation, demonstrations and videos were considered the best modes of delivery for the preparation programme compared with those of the or staff, who put more emphasis on lectures and booklets. this could be ascribed to the generation gap between the two groups. demonstration and simulation, however, were top of the list in both groups. march 2019, vol. 11, no. 1 ajhpe 24 research discussion content of a preparation programme from a medico-legal perspective, documentation in the or is of vital importance to safeguard patients and healthcare personnel.[22,23] competence with or documentation is a skill that takes time to accomplish, and the staff indicated that they needed student nurses to be reasonably skilled in the completion of intraoperative documentation. they also felt that they did not have adequate time to teach student nurses during procedures, which is one of the main areas where student involvement increased their stress levels and workload. participants listed maintaining sterility as one of the areas that the student nurse should be well acquainted with. the problem that had been raised was that students were mostly ‘unaware’ that they were contaminating a sterile field, adding pressure on or personnel, which often culminated in permanent staff becoming anxious and agitated. the fear of doing something incorrectly and being unsure of what was expected, caused student nurses to become anxious; they would often withdraw and not participate. currently, the students’ programme includes a theoretical lecture, demonstrations and practical training and assessment pertaining to basic general aseptic principles. however, this programme is inadequate, as table 1. combined findings for the top 6 statements regarding question 1: ‘what should the content of an or preparation programme consist of?’ category statement group votes, n final ranking documentation learnt how to use and complete intraoperative documentation and or registers 1 37 1 receiving a patient in the or 1 18 2 receiving a patient in the or – consent and what questions to ask 2 12 maintaining of sterility how to correctly open sterile packs 1 17 5a identification of sterile and non-sterile areas in the operating room 2 11 8a pouring of solution into sterile containers 2 6 10 preparation of a sterile trolley 2 9 9 equipment use how to use the suction unit 1 11 8b use of the suction unit 2 0 how to use the diathermy machine 1 17 5b application of diathermy plate 2 8 9 knowing how the tourniquet works – use, hazards, application time limits, how it looks 2 0 14a how and where the or lights are turned on and how to operate the ear, nose and throat headlight 1 0 14b how the or beds functions 1 4 12 how to use operating room doors – how and when too open and close 2 5 11a use and hazards of the bear hugger 2 0 12 or preparation preparing the or before each patient 2 16 6 preparing the or bed before each patient 2 13 7 collecting of the refrigerated drugs and preparing intravenous infusions for assisting with anaesthesia 2 2 13 basic procedural routine to be explained to know what to do and when 1 0 14d patient privacy in the or – no over-exposure, cover patients 2 5 11b swab and instrument control counting of swabs and instruments: want to be able to differentiate between different swabs and instruments– the names and what each looks like 1 24 3 orientation student to know how to introduce themselves – name, what type and year student, what they want to learn 2 18 4 placement to one discipline a week – to be orientated and instructed in one discipline at a time 1 0 14c or = operating room. table 2. methods proposed for the presentation of an or preparation programme for student nurses, and combined ranking of the two groups students permanent or personnel combined ranking demonstrations and simulation simulation presentation and demonstration demonstration and simulation videos preand post-clinical placement lecture with pictures and a booklet to recheck information visual learning aids lectures and powerpoint presentations formal lectures and a test during rotation formal lectures with assessment practice sessions in small groups formal lectures practical small-group sessions preparation programme before rotations simulation with outcomes preplacement preparation or = operating room. 25 march 2019, vol. 11, no. 1 ajhpe research students are not competent to comply with the sterility principles applicable to the or. when equipment in the or fails, it can lead to a catastrophe.[24] the term equipment was used as an overarching concept that enveloped numerous statements by participants. all participants were of the opinion that student nurses should be able to use some of the basic equipment in the or. the inability to correctly manage basic or equipment could lead to misuse of or damage to it, which might result in malfunction and/or harm to the patient. student nurses thought that they were perceived as being ‘dumb’ or ‘stupid’ or ‘not interested’ when following or participating in the procedure while they were unsure of what equipment was being referred to or how to make the required adjustments. or preparation was mentioned by both groups. on the one hand, students did not feel sure of what or personnel expected. on the other hand, the personnel thought that students did not want to participate in routine work in the or. students felt that they had to do what registered nurses do; however, the role of the student in the or should be made clear in advance. to become an excellent or nurse, one should be able to be an excellent student nurse. swab and instrument control was an area of concern for student nurses. they mostly felt unable to differentiate between the various swabs and instruments, and therefore were apprehensive of being responsible for a miscount that could have a negative impact on the staff or patient. participants in the personnel group felt that during the orientation of students, the latter should be made more aware of the importance of correct and thorough introduction to the specific or staff they had been allocated to. this would ensure that students are allocated correctly to reach their specific clinical goals, as students from various healthcare professions receive their training in the hospital or complex. mode of delivery of a preparation programme in reply to the second question regarding the optimal format of transferring the content of an improved preparation programme, different categories were identified by both groups. during the nominal group discussions, the participants suggested modes that are presented in order of highest ranking. simulation and demonstrations was the category that was rated highest in the combined section by both groups, despite permanent staff members having no or little simulation experience. the student participants indicated that simulation was one of the more effective ways to transfer knowledge to clinical practice. simulation gives the student the chance to observe and practise actions, and can be used to train both technical and nontechnical skills, such as communication, teamwork and professionalism. demonstrations of certain procedures, equipment functioning and protocols could be incorporated into simulations with scaffolding from ‘show and tell’ to a simulation where students can perform the procedure or action themselves with feedback through debriefing.[25] most students preferred visual learning and mentioned examples such as videos, powerpoint presentations, pictures and booklets. in dale’s[26] cone of experience, people generally remember between 30% and 50% of what they see and hear. today’s technology-dependent learners prefer visual teaching aids to gather and process new knowledge and to apply it in the clinical situation.[27] formal lectures and written tests were proposed by the permanent or staff, but nursing students did not mention this format. it could probably be ascribed to lectures currently being part of the students’ training and the main frame of reference of the older staff members. contributing to these frames, students are being exposed to newer teaching strategies, such as simulation, to which the older or personnel had little or no exposure. dale[26] postulated that learners remember only 20% of what they hear in a lecture, opposed to 80 90% if they simulate a real experience or perform a task. practical group sessions could assist students in learning, training and practising what they should apply, especially through simulation. students preferred smaller groups for demonstrations, ensuring that all group members have the opportunity to practise their skills. deliberate practice principles of technical skills should be introduced to allow students to master skills. in smaller groups, students tend to support each other, and it would allow the lecturer to observe all group members to identify problems and assist where needed.[28] preplacement preparation prior to the student’s placement is preferred, so that the newly acquired information may be implemented while fresh in the student’s memory. e-learning of theoretical principles can form part of the preplacement preparation before contact time with preceptors or faculty. principles of the flip-the-classroom concept can be introduced to augment the preplacement preparation to enhance the learning experience with empowered and engaging students.[29] a comprehensive and well-prepared programme would benefit the students’ perceptions of the or and have a positive impact on their learning while there. study limitations the study population was linked to one training institution. the specific expectations may not be reproducible in another study with a different unit of analysis in an alternative context. however, the main categorical findings (documentation, swab and instrument control, maintaining of sterility and equipment use) are basic and should correlate with the needs and expectations at other institutions. recommendations education • the findings of the study could contribute to the development of a preparation programme for this institution, institutions in africa and internationally. • the improved programme could be presented at different nursing schools and also for different nursing qualification levels where clinical placement of students in an or is obligatory. • a preparation programme could also include students in other professions who rotate in the or. clinical practice • the programme could be adjusted and implemented in other healthcare settings to prepare nurses and other healthcare professionals with no previous or exposure for placement in the or. future research • a follow-up study should be conducted with a larger sample group, including students from other nursing schools, provinces and countries. conclusion the problem identified was that student nurses rotating in the or for the first time were not adequately prepared for their placement. this study march 2019, vol. 11, no. 1 ajhpe 26 research provided a platform whereby participants had the opportunity to give their opinion on what was needed in a preparation programme that would improve the student nurses’ participation and learning. shortcomings identified were that students needed more preparation prior to placement in the or. specific content that participants felt should be included in a preparation programme included documentation, equipment, maintaining sterility, orientation, swab and instrument control and theatre preparation. all stakeholders were of the opinion that an improved preparation programme was needed, as it would have a direct and positive impact on students’ learning and impression of the or. moreover, it could result in recruiting more students to choose or nursing as a career. this study provides first-hand research into the needs, content and modes of delivery of a preparation programme for student nurses in sa prior to first placement in the or. declaration. this publication was compiled from results of a study by sb for a master’s degree, but was not a prerequisite for the degree. acknowledgements. dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. author contributions. sb designed the study, wrote the protocol, collected the data, performed the analysis, interpreted the findings and wrote the manuscript. mjl reviewed the protocol and manuscript. both authors approved the final version of the manuscript. funding. none. conflicts of interest. none. 1. lyon pma. making the most of learning in the operating or: student strategies and curricular initiatives. med educ 2003;37(8):680-688. https://doi.org/10.1046/j.1365-2923.2003.01583.x 2. brinkman ma. a focused ethnography: experiences of registered nurses transitioning to the operating room. phd dissertation. chester, pa: widener university, 2013. 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creating supportive environments for students. nurs times 2013;109(37):18-20. 13. dent ja, harden rm. a practical guide for medical teachers. 4th ed. london: elsevier, 2013. 14. quinn fm, hughes sj. quinn’s principles and practice of nurse education. 6th ed. andover, hampshire: cencage learning, 2013. 15. de vos as, strydom h, fouché cb, delport csl. research at grass roots: for the social sciences and human service professions. 4th ed. pretoria: van schaik, 2011. 16. nieuwenhuis j. qualitative research designs and data gathering techniques. in: maree k, ed. first steps in research. pretoria: van schaik, 2014:70-79. 17. botma y, greeff m, mulaudzi fm, wright scd. research in health sciences. cape town: pearson, 2010. 18. hiligsmann m, van durme c, geusens p, et al. nominal group technique to select attributes for discrete choice experiments: an example for drug treatment choice in osteoporosis. patient prefer adhere 2013;7:133-139. https://doi.org/10.2147/ppa.s38408 19. university of wisconsin-madison. nominal group technique. https://niatx.net/content/contentpage.aspx?nid=147 (accessed 25 july 2018). 20. patton mq. qualitative evaluation and research methods. 2nd ed. newbury park: sage publications, 1990. 21. van breda ad. steps to analysing multiple-group ngt data. soc work pract-res 2005;17(1):1-14. 22. kohn lt, corrigan jm, donaldson ms. to err is human: building a safer health system. washington, dc: national academies press, 2000. 23. søndergaard sf, lorentzen v, sørensen ee, frederiksen k. the documentation practice of perioperative nurses. a literature review. j clin nurs 2017;26(13-14):1757-1769. https://doi.org/10.1111/jocn.13445 24. degan t. medical equipment malfunctions are a significant cause of operating room errors. 2015. http://cmglaw. com/blog/2015/12/medical-equipment-malfunctions-are (accessed 19 february 2018). 25. lopreiato jo, ed. healthcare simulation dictionary. rockville, md: agency for healthcare research and quality, 2016. 26. dale e. audiovisual methods in teaching. 3rd ed. new york, ny: dryden press, 1969. 27. weiler a. information-seeking behavior in generation y students: motivation, critical thinking, and learning theory. j acad libr 2005;31(1):46-53. https://doi.org/10.1016/j.acalib.2004.09.009 28. allery l. how to use small groups to invigorate your teaching. educ prim care 2012;23(6):446-450. https://doi. org/10.1080/14739879.2012.11494159 29. o’flaherty j, philips c. the use of flipped classrooms in higher education: a scoping review. internet higher educ 2015;25:85-95. https://doi.org/10.1016/j.iheduc.2015.02.002 accepted 23 august 2018. https://doi.org/10.1046/j.1365-2923.2003.01583.x https://search.proquest.com/docview/1420357372?pq-origsite=gscholar https://search.proquest.com/docview/1420357372?pq-origsite=gscholar http://scholar.sun.ac.za/handle/10019.1/95860 https://www.iol.co.za/news/south-africa/poorly-paid-nurses-leave-in-droves-217535 https://www.iol.co.za/news/south-africa/poorly-paid-nurses-leave-in-droves-217535 https://doi.org/10.1016/j.aorn.2014.03.015 https://doi.org/10.7748/nr2008.04.15.3.45.c6456 https://doi.org/10.4102/hsag.v17i1.622 https://doi.org/10.4102/hsag.v17i1.622 https://doi.org/10.1016/j.aorn.2013.10.012 https://doi.org/10.1016/j.nedt.2010.12.011 http://www.sanc.co.za/pdf/qualifications/bachelor’s%20degree%20in%20nursing%20and%20midwifery%202014-07-23.pdf http://www.sanc.co.za/pdf/qualifications/bachelor’s%20degree%20in%20nursing%20and%20midwifery%202014-07-23.pdf http://www.sanc.co.za/pdf/qualifications/bachelor’s%20degree%20in%20nursing%20and%20midwifery%202014-07-23.pdf https://doi.org/10.2147/ppa.s38408 https://niatx.net/content/contentpage.aspx?nid=147 https://doi.org/10.1111/jocn.13445 http://cmglaw.com/blog/2015/12/medical-equipment-malfunctions-are http://cmglaw.com/blog/2015/12/medical-equipment-malfunctions-are https://doi.org/10.1016/j.acalib.2004.09.009 https://doi.org/10.1080/14739879.2012.11494159 https://doi.org/10.1080/14739879.2012.11494159 https://doi.org/10.1016/j.iheduc.2015.02.002 september 2021, vol. 13, no. 3 ajhpe 193 research the advent of the covid-19 pandemic precipitated challenges which most of africa was not ready to deal with, especially within higher education institutions, and severely impacted health professionals’ education (hpe) because of the extensive clinical component involved in hpe. problem before covid-19, a group of four lecturers would travel to the various provinces to facilitate objective structured clinical examinations (osces) for the wound care students of the school of nursing, university of the free state (ufs). the original method of facilitation proved beneficial for students, as they did not have to travel. the lecturers hired a vehicle and were booked into the most cost-effective accommodation, taking into consideration the distance from the venue where the osces were held and the cost of the accommodation. the original method had cost implications for the ufs as all facilitators had to travel and be housed near the venue where the osces would take place. during the covid-19 pandemic, this proved to be problematic as financial constraints, combined with travel restrictions, limited travel opportunities. intervention the problem mentioned above led to the conception and execution of a possible solution, which was to send a technical expert with a valid travel permit to set up and stream the osces to the facilitators at the school of nursing, ufs. the technical expert utilised cameras that had initially been used to stream simulation sessions at the school of nursing. this seemed to be a viable solution as it did not impose additional equipment costs. sending one person instead of four reduced travel and accommodation expenses as well. for the intervention, the technical expert used logitech c910 web cameras (logitech, usa) and a kbport portable streaming tool (a laptop with software aimed at streaming simulation sessions) (kbport, usa). these were connected to a blackboard collaborate session (blackboard collaborate is an online platform used to engage with people anywhere there is an internet connection, similar to zoom or skype). the evaluators could ask questions and evaluate the students remotely, using the link provided. original process the intervention differed widely from the original method of facilitation. the original process made use of two osce stations. students were given an ankle-brachial pressure index (abpi) value at the first station. the abpi value is the ratio of systolic blood pressure, measured at the brachial artery of the ankle and then divided by the highest systolic pressure taken from the arms. the abpi helps determine whether the patient has any underlying peripheral arterial disease.[1] the students had to interpret and apply the correct pressure bandage system for the given abpi, e.g. a fourlayer or short stretch bandage system. at the second station, they had to take patients’ abpi value and interpret it. the students had to rotate between the two stations. the students would wait their turn and move in two at a time, one per station. each station had two facilitators to assess the students. students were given 20 minutes to complete the procedure at each station. new process for the intervention, still referred to as an osce, there was only one station at which students were asked multiple questions. students were instructed to arrive at their appointed times, and were kept separate in a waiting area before participating in the assessment. there was one facilitator on site with the technical expert and two evaluators who dialled in remotely. the onsite facilitator was a wound care expert who was responsible for the region in which the wound care students reside. the osces were conducted at the onsite facilitator's respective wound clinics. the station was sanitised between each student’s arrival, and the technical expert, the onsite facilitator and the students wore surgical masks for the entire duration. the onsite facilitator presented the student with a set of cards from which a card was blindly selected. there were four cards. the first card prompted them to take the patient’s abpi value and interpret it. the second card gave an abpi value of 0.7 mmhg, which prompted the student to select and apply a short stretch bandage system. the third card gave an abpi value of 1.2 mmhg, which was meant to prompt the student to apply a four-layer compression bandage system. the last card had a value of 0.8 mmhg; this could have been interpreted either way because the value is a borderline case, so either modified or full compression was accepted, depending on the ankle circumference of the patient (an ankle circumference of less than 18 cm meant that modified compression must be used). students were given 20 minutes to complete the task assigned to their cards. once the student had completed her task, she was questioned and asked to interpret various aspects of different abpi values. the osces for wound care students are conducted once at the end of the year. the assessment tools and guides remained the same as the previous years' as they were approved tools which were created and moderated to the appropriate standards of the relevant regulating authorities in south africa. reliability of the mark allocation depends on the instruments used. because the tools were not changed for the remote assessment, they were accepted as reliable. validity, on the other hand, lies more with the evaluators than the tools.[2] to promote validity of the final mark, the onsite planning and facilitating remote objective structured clinical examinations (osces) for wound care students in south africa during the covid-19 pandemic b s botha, msc; m mulder, phd school of nursing, university of the free state, bloemfontein, south africa corresponding author: b s botha (bothabs@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:bothabs@ufs.ac.za 194 september 2021, vol. 13, no. 3 ajhpe research facilitator assessed the students together with the two remote evaluators. the trio compared their scores after each student procedure and deliberated on aspects such as tightness of the bandage, which was not available to the remote evaluators. only after comparison and consultation with each other was the final mark assigned, and the student given feedback on the procedure. lessons learnt during these endeavours, various lessons were learnt: • the first and foremost was that it is not easy to adapt to such big challenges, but it is necessary to ensure the continuation of education. • sending one person instead of three or four is a more cost-effective alternative and is viable even during non-covid-19 times. • financial constraints are a major concern; therefore one must use what is available and improvise to avoid unnecessary costs. • one of the major positive aspects was that of cost reduction when compared with the previous method of in-person osces. there were, however, some drawbacks. in some cases, it is not always easy to ensure a stable internet connection, but a backup plan was put into place when the connection failed. this necessitated a switch to mobile devices, which did not yield the same effect as the multiple camera approach. the mobile device also incurred additional costs as mobile data is more expensive than fibre counterparts. for the remote facilitation sessions, the stream rate was set not to exceed 750 megabytes per hour (mbph). • the sites chosen for the sessions had dedicated fibre connections, the first of 20 megabits per second (mbps) and the second 10 mbps, which was adequate to maintain the level of streaming. (to obtain the number of mb per second the mbps should be divided by eight, i.e 20 mbps /8 = 2.5 mbps). during some of the remote sessions, technical issues were experienced, such as a drop in internet connection, which sometimes occurred on both sides. this required immediate intervention from the technical expert. an amount of 2 gigabytes (gb) was available in total for mobile streaming, of which a total of just over 1 gb was used during interventions required to continue the streaming service. if additional data were required, the finance officer at the institution would assist in purchasing it beforehand. • the technical issues encountered put significant stress on the facilitators, the technical expert and the students, as the osce had to pause while the issue was being attended to. the technical expert tried to address problems as fast as possible, while facilitators might get impatient and students might stress even more; these situations were, however, kept to a minimum and students were provided with additional time if a technical glitch occurred. • the experience overall was good according to students and facilitators; however, a face-to-face approach was still preferred by some, as in-person feedback was something that some students wanted. the ideal would have been to have had more than one station and to have students perform procedures at both stations. this, however, was not possible in the covid-19 climate because of restrictions in place. the endeavour did, however, provide very useful insight into what could be used in future. • some aspects can be retained for the future. sending a technical expert to facilitate a virtual osce is much more cost-effective than sending a team of assessors. this did, however, raise the question of whether students are comfortable with this approach or prefer an in-person facilitator. this requires future research to determine the effectiveness of student engagement. conclusion the covid-19 pandemic demonstrated that there are always innovations and methods of teaching and learning waiting to be discovered that we may not previously have thought of, but will assist in future teaching and learning activities. declaration. none. acknowledgements. none. author contributions. equal contributions. funding. none. conflicts of interest. none. evidence of innovation 1. guttormsen k, smith l. what is an ankle brachial pressure index? diabet foot j 2016;19(2):22-28. http://search. ebscohost.com/login.aspx?direct=true&db=ccm&an=116541045&site=ehost-live (accessed 12 january 2021). 2. van der vleuten cpm, schuwirth lwt, scheele f, driessen ew, hodges b. the assessment of professional competence: building blocks for theory development. best pract res clin obstet gynaecol 2010;24(6):703-719. https://doi.org/10.1016/j.bpobgyn.2010.04.001 accepted 11 may 2021. afr j health professions educ 2021;13(3):193-194. https://doi.org/10.7196/ajhpe.2021.v13i3.1507 http://search.ebscohost.com/login.aspx?direct=true&db=ccm&an=116541045&site=ehost-live http://search.ebscohost.com/login.aspx?direct=true&db=ccm&an=116541045&site=ehost-live https://doi.org/10.1016/j.bpobgyn.2010.04.001 https://doi.org/10.7196/ajhpe.2021.v13i3.1507 march 2020, vol. 12, no. 1 ajhpe 12 research in 2015, a review of the university of the witwatersrand, johannesburg, south africa (sa) mb bch curriculum identified that there was too large a gap between the medical school-based teaching in the fourth year of study and the hospital-based teaching in the fifth year, when students begin their clinical clerkships (k mfenyana et al., medical and dental professions board of the health professions council of south africa (hpcsa) accreditation of undergraduate education and training in medicine in the mb bch programme, university of the witwatersrand, 2015 – unpublished; r rispel et al., quinquennial review, university of the witwatersrand, 2015 – unpublished). the reviewers found that there was a theory-practice gap; the students were underprepared for the application of clinical skills in a real clinical setting with patients. this difficult transition from the medical school-based curriculum to the hospital-based curriculum has been identified as an important problem in need of attention in medical education,[1,2] as it results in student emotional distress, stress, burnout[3,4] and unpreparedness that puts patient safety as risk.[5] in an attempt to bridge this gap and remedy this concern, a number of changes were made to the fourth-year clinical skills curriculum for 2017. these changes were based on the latest medical education literature and consultations with staff and students. adjustments to the curriculum included centralising the teaching of clinical skills in a clinical skills unit and standardising the content and objectives of the teaching, which were aligned with the theoretical curriculum. more teachers were employed to improve the tutor-student ratio and allow for small-group learning and increased monitoring and support. the clinical skills sessions were designed to allow for supervised deliberate practice[6] with simulated patients and models in small groups. the sessions included feedback on practice, followed by interactive debriefing. formative assessment was introduced in the form of regular tutor-student assessments and formative objective structured clinical examinations (osces) with feedback. the weighting of the final summative osce was increased to communicate its importance to the students. a clinical methods programme was also introduced to allow for early application of clinical skills in a real-life clinical setting. this was in the form of structured bedside-teaching tutorials, based on clearly defined outcomes, and was facilitated by the clinical departments. the structured tutorials replaced less structured clinical encounters, where learning tended to be opportunistic. the literature on teaching clinical skills recommends the use of simulation to bridge the theory-practice gap, decrease the cognitive load and support this challenging transition.[5,7,8] the key aspects of successful clinical skills training identified in the literature include clear outcomes,[5] standardised and structured sessions,[9,10] deliberate practice,[6] a safe mistake-forgiving environment[1] and regular feedback and debriefing.[1] small-group teaching allows for teamwork and collaboration among students and improved monitoring and supervision from tutors, who can act as role models and mentors and encourage open discourse.[11-13] other evidence in the literature includes systematically assessing clinical skills to drive learning, informative feedback on assessment and elevating the importance of clinical skills in the curriculum.[14,15] ramani[14] recognises the importance of having both simulated clinical skills teaching and hospital-based bedside clinical skills teaching in an integrated curriculum for the successful development of clinical skills. peters and ten cate[16] identify the bedside as a valuable opportunity to integrate and improve skills. background. in 2015, a medical curriculum review at the university of the witwatersrand, johannesburg, south africa, identified too large a gap between the medical school-based teaching in the fourth year of the course and the hospital-based teaching in the fifth year, when students begin their clinical clerkships. a number of changes were made to the curriculum to improve the preparation of students for the expectations of the clinical setting. objectives. to determine students’ perceptions of how well their clinical skills curriculum in the fourth year prepared them for their clinical clerkships in the fifth year. methods. an exploratory mixed methods approach was used. phase i was a narrative qualitative study. the data underwent qualitative analysis and the categories that emerged informed the development of a questionnaire for phase ii. this was a cross-sectional, comparative, quantitative study comparing students taught in the new curriculum (2018; fifth-year students (n=299)) with those taught in the old curriculum (2018; sixth-year students (n=291)). results. the fifthand sixth-year students had response rates of 50% and 34%, respectively. the results showed a perception of improved preparation for clinical clerkship through the changed clinical skills training. the p-value for 14 of the 16 questions was ˂0.05, with a 95% confidence interval, indicating that the difference between the two cohorts was statistically significant. conclusion. the new curriculum has resulted in a significant improvement in students’ perceived preparation for their clinical clerkships. afr j health professions educ 2020;12(1):12-16. https://doi.org/10.7196/ajhpe.2020.v12i1.1220 perceptions of changes made to a clinical skills curriculum in a medical programme in south africa: a mixed methods study s r pattinson,1 mb chb, pgdip hse, mhse; p mcinerney,2 phd 1 unit for undergraduate medical education, school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: s r pattinson (stuart.pattinson@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 13 march 2020, vol. 12, no. 1 ajhpe research while the evidence suggests that changes made to the new curriculum should help with this difficult transition, none of the research identified was conducted in the sa medical education context. the sa context provides unique challenges, including financial constraints, limited resources, a need for generalist, primary care over specialist training and a demand for doctors who can provide care in rural areas and meet the burden of the hiv epidemic.[17] limited human resources, particularly of academic staff who have to meet a high clinical burden and find time for teaching, is a major constraint.[17] our student group is diverse and comes from a wide range of educational backgrounds, including many underprivileged and previously disadvantaged students.[17] it is important to determine what influence these curriculum changes have had on students’ preparation for their clinical years in the current context. one of the ways to evaluate the curriculum change is to explore the students’ perceptions of how well prepared they felt for the clinical setting, based on their experiences in their clinical clerkships. the perceptions of students who were taught under the new and old curricula were compared with regard to the question: have these changes had the desired outcome in the current context and to what extent have the problems identified been resolved? methods an exploratory, sequential mixed methods study design was adopted, with a dominantly quantitative paradigm.[18] this is represented based on creswell’s notation in mixed methods research, as follows: qual → quant → interpretation.[18] as a suitable, validated quantitative tool could not be found, the researchers developed such a tool for the purpose of gathering data regarding the students’ perceptions of their preparation for clinical clerkships by means of the clinical skills curriculum. phase i was a narrative qualitative study. an open-ended question was used to identify the themes, ideas, concerns and perceptions of the students. these were used to inform the development of a tool for the collection of the quantitative data in the second phase of the study, which accurately measured these constructs while exploring the research question. the following question was posed in phase i: what is your perception of the fourth-year clinical skills curriculum’s preparation of you for your clinical rotations in fifth year? systematic sampling was used; every tenth fifthyear and sixth-year student on an alphabetised class list was emailed a link to an online system (research electronic data capture (redcap)). a total of 62 students were sampled (31 from the fifth year and 31 from the sixth year). phase ii was a cross-sectional, comparative, quantitative study. a preliminary questionnaire was developed based on the objectives, a literature review and the researchers’ experiences of teaching in the programme. the qualitative analysis of the narrative data from the open-ended question in phase i informed the modification of the phase ii questionnaire to best reflect the students’ ideas, concerns and expectations. this process included assessing the relevance and value of the questions already included in the questionnaire (13 questions) and 3 additional questions that measured the constructs identified as dominant categories, as described under results, phase i, below. the questionnaire was piloted on the target population of the study (20 students from the fifth year and 20 from the sixth year, using systematic sampling). there were no problems or errors detected with the administration of the questionnaire, understanding of the questions or the collection of data. no changes were made to the data collection tool. in phase ii, the refined questionnaire, consisting of 5-point likert scaletype questions (n=16), was distributed to the entire target populations of the fifth-year (n=299) and sixth-year (n=291) students. the likert scale questions had 5 options (strongly disagree, disagree, neutral/undecided, agree, strongly agree), which were assigned values of 1 5 to allow for numerical data for quantitative analysis. a research database was created using the redcap (version 8.4.5) tool, and the link to the questionnaire was made available online. the link was then emailed to all students in the target populations, except those who had been invited to participate in the pilot study (fifth-year sample population (n=299); sixth-year sample population (n=291)). data were collected for 80 days after distribution of the questionnaire to allow for maximum opportunity for responses within the time constraints of the study. fifth-year students had completed at least one, and at most four, of their clinical rotations at the time of data collection. data were captured anonymously using the redcap tool, and were exported for analysis. ethical approval this research was approved unconditionally by the human research ethics council (hrec), university of witwatersrand (ref. no. m171052). results phase i of the 62 students included in phase i, 28 responded – a response rate of 45%. an inductive and iterative approach was used to identify patterns, similarities and differences in the narrative texts. data were coded into meaningful segments and then into frequent, dominant and significant categories for interpretation into findings and conclusions. three categories emerged from the data. the first was that the students felt underprepared to detect actual pathology in the clinical setting. they indicated that, having learnt skills on healthy simulated patients and models, they struggled to confidently detect and interpret clinical signs and abnormalities, making transfer to the clinical setting difficult. the second category, closely related to the first, was that they felt that they had had insufficient exposure to real patients in their preparation for their clinical clerkships. the third category related to the high student-tutor ratio, which prevented students from getting hands-on experience with a skill and being able to perform the skill with guidance and feedback. all 13 questions of the preliminary, self-developed questionnaire were retained and 3 additional questions that measured the abovementioned constructs were added. phase ii data from the likert scale-type questions were analysed as ordinal, as although the categories have rank order, the distances between them cannot be presumed to be equal.[19] a total of 247 students (n=590) responded to the questionnaire, giving a response rate of 42%, which met the requirements for a 95% confidence level and a confidence interval (ci) of 5 for the total sample. of the respondents, 149 were in their fifth year, giving a response rate of 50% for this class of 299 students. of the sixth-year class (n=291), 98 students responded – a response rate of 34%. while neither of these subsamples met the requirements for a confidence level of 95% and a ci of 5, they were still above the average online response rate of 33%[20] and did meet march 2020, vol. 12, no. 1 ajhpe 14 research the liberal conditions set for an adequate response rate, a 10% sampling error and an 80% confidence level.[20] the response rate with regard to the questionnaire may have been limited by the reliance on responses to emails, the questionnaire being online rather than a face-to-face engagement, survey fatigue and limited time available for data collection.[20] a shapiro-wilk test was performed on each of the closed-ended questions. the test was performed on the data for the two groups combined and for each group independently for each question. the results indicated that the data were not normally distributed, and therefore non-parametric tests would need to be employed. the means, medians and standard deviations (sds) were calculated for every closed-ended question in the questionnaire for each cohort. the means for the fifth-year sample were higher than those for the sixthyear sample for every question. the means for 13 of the 16 questions in the fifth-year sample were >3, indicating a generally more positive view. three questions had means ˂3. the first was their perception of the difficulty of the transition from the fourth year to the fifth year of study. the other 2 questions related to their perception of how the clinical skills curriculum and the hospital-based curriculum, respectively, prepared them for performing procedures. in the sixth-year cohort, 13 of the 16 responses had means ˂3, indicating a more negative view of the curriculum. because the ordinal data were not normally distributed, the nonparametric mann-whitney u-test was used to compare the responses of the two cohorts for each question to test for significance (table 1). the difference between the two groups was statistically significant for 14 of the 16 questions (p<0.05; 95% ci). the only 2 questions that did not have a statistically significant difference were the ‘difficulty in the transition to fifth year from fourth year’ and the ‘ability to transfer skills learnt on manikins to real-life patients’. the mean for both groups for these 2 questions was ˂3, showing that both groups had a more negative perception for these questions. discussion the mean values for each question were consistently higher in the fifth-year sample. this suggests better preparation among fifth-year students for their clinical clerkships. the first statement in the questionnaire was: ‘the clinical skills teaching curriculum in fourth year adequately prepared me for application of clinical skills in the clinical setting in fifth year.’ there was a statistically significant difference between the two groups, showing that the students who were taught under the new curriculum had a perception of markedly improved preparation for the clinical setting. this significant finding speaks directly to the research question. the second statement required the students to respond to: ‘the transition from the fourth year to the fifth year was very difficult.’ the mann-whitney u-test for this question showed no statistically significant difference between the two groups; both perceived the transition as difficult. while the previous statement showed that fifth-year students felt better prepared than sixth-year students, the former still found the table 1. questions asked and responses from two cohorts (mann-whitney u-test) questions y5, mean (sd) y6, mean (sd) p-value y5, n y6, n the clinical skills teaching curriculum in y4 adequately prepared me for application of clinical skills in the clinical setting in y5 3.6 (1.0) 2.8 (1.0) 0.0 149 98 the transition from y4 to y5 was very difficult 2.7 (1.0) 2.6 (1.1) 0.3 149 98 i was equipped in y4 with the skills needed to meet the expectations of students in y5 3.5 (1.0) 2.7 (1.0) 0.0 149 98 i had confidence in performing clinical skills learnt in y4 with real patients in y5 3.5 (1.1) 2.7 (1.1) 0.0 149 98 i was able to transfer skills learnt and practised with simulated patients to real patients 3.7 (0.9) 3.3 (1.1) 0.0 149 98 i was able to transfer skills learnt with simulation on manikins to real patients 3.1 (1.0) 2.9 (1.1) 0.1 149 98 the clinical skills teaching curriculum prepared me to identify real clinical findings in patients with pathology 3.0 (1.0) 2.4 (1.1) 0.0 149 98 the clinical skills teaching curriculum in y4 adequately prepared me for history taking in y5 with real patients in the clinical setting 4.0 (1.0) 3.7 (1.1) 0.0 149 98 the clinical skills teaching curriculum in y4 adequately prepared me for physical examination of real patients in the clinical setting in y5 3.8 (0.9) 3.1 (1.0) 0.0 149 98 the clinical skills teaching curriculum in y4 adequately prepared me for performing clinical procedures in the clinical setting in y5 2.9 (1.1) 2.3 (1.1) 0.0 149 98 the resources available for learning clinical skills were adequate 3.5 (0.9) 2.9 (1.0) 0.0 149 98 the number of clinical lecturers available for teaching clinical skills was adequate for the number of students 3.3 (1.2) 2.5 (1.2) 0.0 149 98 the hospital-based teaching in y4 adequately prepared me for seeing real patients in the clinical setting in y5 3.3 (1.1) 1.9 (1.1) 0.0 149 98 the hospital-based teaching in y4 adequately prepared me for history taking in the clinical setting in y5 3.6 (1.0) 2.4 (1.3) 0.0 149 98 the hospital-based teaching in y4 adequately prepared me for physically examining patients in the clinical setting in y5 3.5 (0.9) 2.1 (1.1) 0.0 149 98 the hospital-based teaching in y4 adequately prepared me for performing clinical procedures in the clinical setting in y5 2.6 (1.1) 1.9 (1.1) 0.0 149 98 p-value (mann-whitney u-test). y = year; sd = standard deviation. 15 march 2020, vol. 12, no. 1 ajhpe research transition challenging. the transition from the medical school setting to the clinical setting will always be challenging; the academic, skill and emotional demands of performing on real patients are high. okuda et al.,[1] as well as eyal and cohen,[2] recognise that students often feel inadequately trained and ill-equipped for the clinical setting. therefore, finding a way to continue to improve the curriculum to reduce this difficulty is critically important. the data showed a significantly better perception among students taught under the new curriculum of how well equipped they were with regard to the skills needed to meet the expectations of the fifth year and how confident they were in performing the clinical skills they learnt in the fourth year. the data showed an improved ability to transfer skills learnt and practised with simulated patients to real patients, but indicated that both cohorts found it difficult to transfer skills learnt on manikins to real patients. it may be that the learning done on manikins too distantly resembled the real-life experience of performing a procedure on a patient, and thus the students struggled to transfer skills.[21] this is an area that needs revision and improvement in the new curriculum. even though there was a notable improvement from the old curriculum in the students’ perceived ability to identify clinical findings in patients with pathology, students taught under the new curriculum were neutral with regard to their ability to detect pathology. remmen et al.[7] recommend that students need a longitudinal, integrated curriculum with increased clinical exposure. de boulay[22] suggests that the best way to learn pathology is in an integrated, interactive curriculum, where students are asked to solve real clinical problems. as the perceived lack of preparedness to detect pathology is a concern for teachers, improvement in the integration of the curriculum and increased clinical experience earlier in the curriculum need to be considered. fifth-year students had a perception of being significantly better prepared to take histories, physically examine patients and perform clinical procedures than those in the sixth year. the mean values for both groups were low regarding the perception of their preparation for the performance of clinical procedures on real patients. this is possibly related to the earlier finding that it is difficult for students to transfer skills from practise on manikins. while examination and history taking are taught using simulated patients in the theoretical setting and on real patients at the bedside, clinical procedures are taught on manikins. moss et al.[23] suggest that doctors underestimate the anxiety of students when having to perform simple practical procedures, indicating that they need better preparation to increase confidence, as well as more support and guidance when they first perform the procedures on real patients. fifth-year students had a significantly more positive view regarding the student-tutor ratio and the resources available for learning clinical skills. this justifies the employment of new tutors to allow for effective smallgroup teaching. likewise, they had a significantly better perception than those in the sixth year of how well the clinical methods curriculum prepared them for their clinical clerkships. this may be attributed to the value of wellstructured bedside teaching methods with clear objectives that are aligned with the curriculum.[24] conclusion the new curriculum has resulted in a significant improvement of the students’ perceived preparation for their clinical clerkships compared with those taught under the old curriculum. the new clinical skills curriculum has had a positive effect on, and has begun to address, the concerns raised by the curriculum review committee. improvements need to be made to further reduce the difficulty of the transition to the clinical setting, advance the detection of pathology and make more effective use of manikins for preparing students for the performance of clinical procedures. several recommendations for practice can be identified from the results of the research. the changes led to a perceived improvement in preparation among the students being taught under the new curriculum. these changes need to be reinforced and strengthened, particularly through faculty development in learning about and applying these teaching and learning strategies. there needs to be an effort to find more ways to make the transition from the theoretical setting to the clinical setting less difficult. the amount of time spent in the real-life clinical setting and on the practical, clinical aspects of the curriculum needs to be increased and needs to start earlier in the curriculum. the students’ learning opportunities should more closely resemble the real-life clinical setting to better prepare them for the expectations and demands. this applies to the use of manikins, which, in addition, needs more time for deliberate practice and feedback. the changes made to the curriculum have resulted in students’ perception of improved preparation, but further research is needed to determine if these changes have advanced the achievement of curricular outcomes in the clinical setting and improved patient outcomes, as well as having a positive effect on reducing students’ emotional distress, stress and burnout. study limitations as they were in the second year of their clinical clerkships at the time of data collection, the perceptions of sixth-year students of how well prepared they were when they started their clerkships may have been affected by how much time had passed and the experiences they had had in the clinical setting since then. this may have limited the comparison between the 2 years. because of the timing of the research, the fifth-year students had only completed 1, 2, 3 or 4 of their clinical rotations and had to evaluate their perceptions of their preparedness for their clinical clerkship based only on those rotations. declaration. this research was done in partial fulfilment of srp’s postgraduate degree (master in health sciences education). acknowledgements. colleagues from the unit for undergraduate medical education at the university of the witwatersrand medical school for their advice, support and assistance during the conduct of the study. author contributions. srp: conception of research question, collection and analysis of data for a higher degree; pm: supervised and contributed towards development of the study and analysis of the findings. funding. none. conflicts of interest. the researcher (srp) is a clinical lecturer at the university of the witwatersrand medical school, teaching clinical skills to the thirdand fourth-year students in the revised clinical skills curriculum. the data were gathered in the fifth and sixth years of study, during which time he had no part in the facilitation, teaching or assessment of the students, nor will he have for the remainder of their studies. 1. okuda y, bryson eo, demaria s jr, et al. the utility of simulation in medical education: what is the evidence? mt sinai j med 2009;76(4):330-343. https://doi.org/10.1002/msj.20127 2. eyal l, cohen r. preparation for clinical practice: a survey of medical students’ and graduates’ perceptions of the effectiveness of their medical school curriculum. med teach 2006;28(6):162-170. https://doi. org/10.1080/01421590600776578 https://doi.org/10.1002/msj.20127 https://doi.org/10.1080/01421590600776578 https://doi.org/10.1080/01421590600776578 march 2020, vol. 12, no. 1 ajhpe 16 research 3. schiller jh, stansfield rb, belmonte dc, et al. medical students’ use of different coping strategies and relationship with academic performance in preclinical and clinical years. teach learn med 2018;30(1):15-21. https://doi.org/ 10.1080/10401334.2017.1347046 4. dendle c, baulch j, pellicano r, et al. medical student psychological distress and academic performance. med teach 2018;40(12):1257-1263. https://doi.org/10.1080/0142159x.2018.1427222 5. cleland j, patey r, thomas i, walker k, o’connor p, russ s. supporting transitions in medical career pathways: the role of simulation based education. adv simul 2016;1(14):1-9. https://doi.org/10.1186/s41077-016-0015-0 6. duvivier rj, van dalen j, muijtjens am, moulaert vrmp, van der vleuten cpm, scherpbier ajja. the role of deliberate practice in the acquisition of clinical skills. bmc med educ 2011;11(101):1-7. https://doi. org/10.1186/1472-6920-11-101 7. remmen r, scherpbier a, van der vleuten c, et al. effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools. med educ 2001;35(2):121-128. https://doi.org/10.1111/ j.1365-2923.2001.00835.x 8. teteris e, fraser k, wright b, mclaughlin k. does training learners on simulators benefit real patients? adv health sci educ 2012;17(1):137-144. https://doi.org/10.1007/s10459-011-9304-5 9. remmen r, derese a, scherpbier ajja, et al. can medical schools rely on clerkships to train students in basic clinical skills? med educ 1999;33(8):600-605. https://doi.org/10.1046/j.1365-2923.1999.00467.x 10. remmen r, scherpbier ajja, derese a, et al. unsatisfactory basic skills performance by students in traditional medical curricula. med teach 1998;20(6):579-582. https://doi.org/10.1080/01421599880328 11. zeng r, xiang l, zeng j, zou c. applying team-based learning of diagnostics for undergraduate students: assessing teaching effectiveness by a randomized controlled trial study. adv med educ 2017;8(1):211-218. https://doi.org/10.2147/amep.s127626 12. jacques d. abc of learning and teaching in medicine – teaching small groups. bmj 2003;326(7387):492–494. https://doi.org/10.1136/bmj.326.7387.492 13. middendorf j, pace d. a model for helping students learn disciplinary ways of thinking. new direct teach learn 2004;2004(98):1-12. https://doi.org/10.1002/tl.142 14. ramani s. twelve tips for excellent physical examination teaching. med teach 2008;30(9-10):851-856. https:// doi.org/10.1080/01421590802206747 15. leppink j, duvuvier r. twelve tips for medical curriculum design from a cognitive load theory perspective. med teach 2016;38(7):669-674. https://doi.org/10.3109/0142159x.2015.1132829 16. peters m, ten cate o. bedside teaching in medical education: a literature review. med educ 2014;3(2):76-88. https://doi.org/10.1007/s40037-013-0083-y 17. kent a, de villiers mr. medical education in south africa – exciting times. med teach 2007;29(9-10):906-909. https://doi.org/10.1080/01421590701832122 18. creswell jw, creswell jd. research design. 5th ed. los angeles: sage, 2018. 19. norman g. likert scales, levels of measurement and the ‘laws’ of statistics. adv health sci educ 2010;15(5):625-632. https://doi.org/10.1007/s10459-010-9222-y 20. nulty dd. the adequacy of response rates to online and paper surveys: what can be done? assess eval high educ 2008;33(3):301-314. https://doi.org/10.1080/02602930701293231 21. herrmann-werner a, nikendei c, keifenheim k, bosse hm, lund f, wagner r. ‘best practice’ skills lab training vs. a ‘see one, do one’ approach in undergraduate medical education: an rct on students’ long-term ability to perform procedural clinical skills. plos one 2013;8(9):e76354. https://doi.org/10.1371/journal.pone.0076354 22. du boulay c. learning pathology: why? how? when? j clin pathol 1997;50(8):623-624. https://doi.org/10.1136/ jcp.50.8.623 23. moss ha, derman pb, clement rc. medical student perspective: working toward specific and actionable clinical clerkship feedback. med teach 2012;34(8):665-667. https://doi.org/10.3109/0142159x.2012.687849 24. ramani s. twelve tips to improve bedside teaching. med teach 2003;25(2):112-115. https://doi.org/10.1080/01 42159031000092463 accepted 11 october 2019. https://doi.org/10.1080/10401334.2017.1347046 https://doi.org/10.1080/10401334.2017.1347046 https://doi.org/10.1186/1472-6920-11-101 https://doi.org/10.1186/1472-6920-11-101 https://doi.org/10.1111/j.1365-2923.2001.00835.x https://doi.org/10.1111/j.1365-2923.2001.00835.x https://doi.org/10.2147/amep.s127626 https://doi.org/10.1136/bmj.326.7387.492 https://doi.org/10.1080/01421590701832122 https://doi.org/10.1371/journal.pone.0076354 https://doi.org/10.1136/jcp.50.8.623 https://doi.org/10.1136/jcp.50.8.623 https://doi.org/10.1080/0142159031000092463 https://doi.org/10.1080/0142159031000092463 march 2019, vol. 11, no. 1 ajhpe 16 research the dynamic transitions in healthcare systems globally necessitate the training of healthcare professionals who are responsive to the needs of the community that they serve to ensure quality and relevance of care.[1] undergraduate clinical education is therefore critical for the development of socially competent graduates who are equipped with technical skills and insight to function purposefully within these changing social and health contexts.[2] students’ clinical competence, proficiency and aptitude are core to their clinical education and training, which should be rooted in a competency-based undergraduate programme.[3-5] in south africa (sa), the gaping disparity in health provision between the over-accessed public health facilities and well-resourced private healthcare settings prompted government to introduce the national health insurance (nhi), with the incorporation of the primary healthcare (phc) approach.[6,7] nhi is a government funding model that ensures disenfranchised communities access to quality healthcare. through nhi, phc has proposed re-engineering focused on prevention of diseases, promotion of health and ensuring availability of rehabilitative services at community level. phc is a strategy to ensure that healthcare services are available in resource-scarce communities, but the uptake in healthcare systems nationally remains poor.[8] innovative approaches of actualising the implementation of the ideal phc model are necessary to influence the disparity in public v. private healthcare in sa.[8] perpetuating the vision for nhi, the university of kwazulu-natal (ukzn) college of health sciences (chs), in collaboration with the kwazulunatal (kzn) department of health (doh), embarked on the roll-out of community-based training within a phc (cbtphc) approach.[9] ukzn adopted this approach to equip health science students with the necessary skills to serve communities in dire need of healthcare. for the purpose of this article, we refer to this method of training as decentralised clinical training (dct). this study focused on the discipline of physiotherapy within the chs at ukzn, which offers a 4-year undergraduate degree programme with a professional qualification (bachelor degree). there is a greater theoretical bias in years 1 and 2, with a deliberate shift to clinical training and competency development in years 3 and 4 of study. intake varies between 50 students in year 1 and up to 55 students in the final year, depending on the throughput of students during the programme. for 2017, final-year students were introduced to the dct framework in which they were placed at urban, rural and peri-urban sites in kzn province, where they were predominantly under the care and supervision of physiotherapy clinicians at the respective settings. the facilities provided them with clinical exposure to neurological, cardiopulmonary and neuromusculoskeletal conditions and communitybased rehabilitation. each physiotherapy student spent 5 weeks at 4 of the clinical sites, 2 of 6 newly introduced settings that were rural/peri-urban and 2 urban facilities that were used prior to the new cbtphc approach. before background. south african health systems are challenged by numerous stressors, such as a lack of resources, staff shortages and overburdened public sector demands. this necessitates appropriately equipped and trained healthcare professionals to meet the demands of this system. community-based primary healthcare (phc) clinical education is an approach towards preparing health science students to meet these demands. clinical education is the cornerstone of undergraduate training. physiotherapists are among the healthcare professionals who require undergraduate training that drives competence for independent practice. objective. to explore the perceptions and experiences of physiotherapists as clinical supervisors within a physiotherapy undergraduate programme that adopted a community-based phc approach to clinical training. methods. an explorative qualitative approach was used, with semi-structured interviews with 10 purposively selected physiotherapists supervising students on the newly introduced platform. data were transcribed and analysed using content analysis. results. seven themes emerged from the data, which relate to curriculum redress, organisational factors, stakeholder dynamics, barriers and enablers to decentralised clinical training, perceived preparedness for practice and recommendations. conclusions. as the need for an increasing number of health professionals is realised, more innovative methods for clinical education of undergraduate health science students are required. community-based phc training for physiotherapy students is one such approach and was generally perceived as a valuable framework to incorporate competencies required for practice as future independent practitioners. furthermore, improved communication between students, clinicians and academic staff was seen as a recommendation to influence clinical education. afr j health professions educ 2019;11(1):16-21. doi:10.7196/ajhpe.2019.v11i1.1046 physiotherapists’ perception of a community-based primary healthcare clinical education approach to undergraduate learning s blose,1 mphysio, bphysio; n c t chemane,1 mphysio, bphysio; v chetty,1 phd (health sciences), mphysio, bphysio; p govender,2 phd (health sciences), mot, bot; s maddocks,1 mphysio, bphysio 1 department of physiotherapy, school of health sciences, university of kwazulu-natal, durban, south africa 2 department of occupational therapy, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: v chetty (chettyve@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 17 march 2019, vol. 11, no. 1 ajhpe research the commencement of dct, participating physiotherapists were invited to attend preclinical supervision workshops at the university. the workshops aimed to equip the physiotherapist employed at the healthcare facilities on the dct platform with teaching and learning competences, as well as supervisory skills to influence learning outcomes for undergraduate students. mostert-wentzel et al.,[3] in their study of the status of undergraduate community-based and public health physiotherapy education in sa, found that while community physiotherapy curricula address the health profile of the population and priorities in the health system to different degrees, gaps in preparing physiotherapy students for the needs of the sa population were highlighted. dct as a vehicle could possibly respond to this need, as it allows for preparation of health science students via training at these decentralised clinical facilities that are primarily based in rural or peri-urban communities and are in keeping with the phc approach. implementation of dct, however, requires careful consideration of a number of factors, such as clinical site organisational structure, student attitudes, clinician attitudes and exploration of curriculum implications. a current flaw in the roll-out of dct in the chs at ukzn is the lack of a working clinical training model to facilitate such a novel approach. in this article, we report the findings of a study that explored the perceptions of physiotherapists as clinical supervisors in the novel dct programme in the study context. the understanding of participating physiotherapists’ perceptions aids in the development of an integrated model of clinical training by valuable insight into their role and recommendations for teaching and learning. this study forms part of a larger study that is geared towards the development of a model for physiotherapy clinical education, which will feed into an overall model for health professions education within dct platforms for the chs at ukzn.[10] methods a qualitative study approach[11,12] was employed to explore the perceptions of physiotherapists supervising undergraduate physiotherapy students in a dct approach. ten physiotherapy clinical supervisors employed by the doh in public sector facilities across peri-urban and rural settings on the dct platform were purposively selected. only qualified physiotherapists, currently registered with the health professions council of south africa (hpcsa) for 2017 2018 and actively involved in clinical supervision of students, were included in the study. the use of qualitative research allowed for in-depth exploration of the perceptions and experiences of these physiotherapists as clinical supervisors to inform the future planning and review of the novel clinical training approach within this setting. study setting the study was done in kzn, sa, on 6 clinical training platforms, i.e. murchison hospital (rural), port shepstone hospital (peri-urban), g j crookes hospital (peri-urban), newcastle hospital (peri-urban), madadeni hospital (rural) and ngwelezane hospital (rural). the facilities provided exposure to neurological, cardiopulmonary and neuromusculoskeletal conditions and community-based rehabilitation. students were exposed to traditional institutional care, as well as outreach and phc facilities. ethical approval ethical approval was granted by the humanities and social sciences research ethics committee of ukzn (ref. no. hss/0727/017) and the doh (ref. no. kz_201805-007). all participants were recruited on a voluntary basis and informed of their right to withdraw from the study at any time. they also gave informed consent. anonymity was ensured by allocating pseudonyms to clinical supervisors when reflecting quotes.[13] data collection following ethical approval, 10 individual semi-structured interviews were conducted with physiotherapists at the end of the year. a flexible interview guide was developed with open-ended questions encompassing work experience and exposure to student training, and involvement and role of therapists in the implementation of dct were explored. all interviews were conducted in english. initial questions were followed up with probing and clarification to gain full understanding of comments and responses during the interview. interviews lasted from ~45 minutes to 1 hour and were audiorecorded with field notes by the principal author. a moderator was present at each interview, together with the principal author.[14] data analysis the recorded data were transcribed verbatim and verified for accuracy against the audio-recordings by the principal author and moderator. transcriptions were forwarded to participants as a strategy for member checking to ensure that opinions were accurately captured in the analysis. data were read and re-read for familiarisation to obtain an in-depth understanding of the content. the principal author and moderator performed separate data coding to enhance trustworthiness of the findings. thematic analysis was used to identify emerging themes and subthemes. similarities and differences in the coding were disputed until consensus was reached.[11,15,16] results the demographic profile of participants is presented in table 1. the results of the study are premised on the 7 overarching themes, highlighted in table 2. discussion the theme of curriculum redress includes the following subthemes: theory into practice, phc integration and community-based rehabilitation strategy. the participants believed that the undergraduate physiotherapy curriculum required review, and issues remained with regard to integration of theory into clinical practice. a recent study in the same context revealed that physiotherapy students were of the opinion that there were curriculum disparities in terms of content and fluidity, which were believed to be integral to transformation of classroom teaching to practice.[3] recent studies in similar contexts also reflect the need for healthcare professional programmes to be dynamic and move towards the needs of healthcare systems.[17-19] the integration of community-based approaches to teaching is crucial in preparing socially and culturally competent physiotherapy students to offer the relevant care.[20,21] the participants in this study believed that this approach allowed students to gain insight into communities, enabling a better understanding of those in their care.[18,20] however, alignment of the curriculum to community needs remains key to physiotherapy students being adequately prepared for clinical practice. [3,17,18,22,23] organisational factors this was a resounding theme and included poor infrastructure and lack of resources and equipment as subthemes. inadequate infrastructure remains march 2019, vol. 11, no. 1 ajhpe 18 research table 1. demographic characteristics of physiotherapists participant pseudonym age, years gender race clinical experience, years clinical super vision experience, years tertiary institute context type of facility andrew 50 male black african 20 18 university of zambia peri-urban tertiary/regional hospital palesa 43 female black african 17 1 university of kwazulu-natal peri-urban specialised hospital priya 36 female indian 14 13 university of kwazulu-natal peri-urban district hospital thandi 36 female black african 13 8 university of kwazulu-natal peri-urban regional hospital gugu 37 female black african 11 10 university of kwazulu-natal peri-urban regional hospital thembeka 30 female black african 8 4 university of kwazulu-natal rural district hospital gloria 30 female black african 8 3 university of kwazulu-natal peri-urban tertiary/regional hospital tanya 28 female mixed 7 3 stellenbosch university rural regional hospital rithesh 26 male indian 3 7/12 university of kwazulu-natal rural regional hospital yolisa 24 female black african 2 7/12 university of cape town rural district hospital table 2. summary of themes and subthemes with verbatim quotes theme 1: curriculum redress theory into practice ‘i think i matured in a certain way and also learnt to remove textbook thinking, because the university trains us in such a way that we think in a textbook style; even with patients – we want them to come in textbook style.’ (priya) ‘the second group, i thought that they were lacking theoretical knowledge and i had to sit down with them and give them tutorials; and it didn’t feel like it was sort of a refresher, it was like the first time they ever heard about such things.’ (tanya) phc integration ‘you trained in urban facilities and graduated there, then you come to a rural hospital where it is something different altogether.’ (rithesh) community-based rehabilitation strategy ‘we have two or three students allocated in the community, which is good because there is a lot they can do for the community. we take them on home visits and to clinics, and one group trained the healthcare team as a community project; they should be taught about this (theory modules) – community caregivers.’ (priya) theme 2: organisational factors poor infrastructure ‘the department has occupational therapy, speech and audiology here and we don’t have space.’ (palesa) ‘we felt that our department is very small and we are in a district hospital.’ (thembeka) lack of resources and equipment ‘we don’t have all the equipment but the university has been extra supporting in providing us with equipment (referring to tens machines, ultrasound and hot packs) that we can use in the department.’ (yolisa) we didn’t have the heat packs, ultrasound and infrared, so the university provided that.’ (gloria) we wanted ice and hot packs and they did give them to us. the electrode-cover things – they did give them to us.’ (palesa) ‘the driver had a problem with taking students to the clinic and on home visits.’ (thembeka) ‘time is a problem … tutorials in the afternoon, but sometimes there are many patients.’ (rithesh) ‘i was a bit resistant, very resistant, thinking about staffing we had, our manager was leaving us in that year. i was busy with my masters, which took a lot of time and was a heavy load; i didn’t know how we were going to cope.’ (thandi) theme 3: stakeholder dynamics effective leadership roles ‘i did speak to my staff about it (manager). i am fortunate that i don’t have staff that are resistant to having students here.’ (priya) ‘we had to sit down and discuss it (manager to staff ). we all agreed that we were willing to help out.’ (andrew) collaboration between academics and clinical supervisors ‘if lecturers can be involved more, at least once a week or month, they can pop in once or twice before the exams. they must not just come when it’s an exam.’ (palesa) ‘i wish in january or february when they attend lectures we can be there so we can learn. because there are many challenges. we are always not sure if you are giving them the right thing. i think it is me who is feeling inferior.’ (gloria) partnership between student and clinician ‘students are not the same, some are willing to learn and some need to be pushed .we worry about if we give them enough supervision. it is our duty to guide them and mentor. we took a stand as a department that we will support dct, but they need to want to learn’. (palesa) continued ... 19 march 2019, vol. 11, no. 1 ajhpe research an organisational limitation in sa healthcare systems.[8,20,24-27] evidence from other studies concurs with findings in this article in terms of transport and equipment limitations that remain a barrier to optimal care in rural and peri-urban healthcare facilities.[3,24,25] rural health facilities are understaffed and there is a continuous exodus of clinicians into private sector or urban-based facilities.[19,28-30] stiller et al.,[31] in a 2004 study, postulate that healthcare staff juggle high patient demands and administrative duties, which contend with participation in clinical education. however, de villiers et al.,[26,27] in recent studies in sa, reported that approaches such as decentralised clinical training can address such incongruences in table 2. (continued) summary of themes and subthemes with verbatim quotes theme 3: stakeholder dynamics community-service therapists and students ‘the community-service therapists were giving more patients to the students in the ward … they would fight … they were sort of bullying the first group.’ (yolisa) theme 4: barriers to decentralised clinical training communication and technology issues ‘i know that some constraints that the students brought to us is that they didn’t have access to materials, in terms of getting a modem or data.’ (rithesh) student attitudinal barriers ‘they didn’t want to learn as well. even if you give them a patient, opd patient, they change their facial expression. they were lazy, the first group was bad, even their feedback at the end of the block.’ (gloria) ‘they were not happy, the students were not communicating with us as clinical supervisors.’ (thembeka) theme 5: enablers to decentralised clinical training rural v. urban clinical education ‘they have exposure to rural facilities, comparative to the facilities in the city. they see a different environment, a different setting that will prepare them for when they become professionals and they are qualified, instead of being thrown in at the deep end of rural lifestyle or a rural setting.’ (rithesh) personal growth ‘i feel that i’ve grown since the first group. in the first group it was quite daunting for me because they would ask questions and i really had to think about it. but now i feel that i am confident, i can answer their questions to the best of my ability.’ (tanya) ‘the students help stimulate staff. the stimulation is that as clinical supervisors we are always kept on our toes because we have to be ready when students ask questions and stuff.’ (priya) students preclinical training ‘it’s a block that they have already done in third year and i assume they had more supervision than the first time around.’ (yolisa) student impact ‘students help us a lot and some people wouldn’t want to admit it.’ (rithesh) ‘we have more helping hands in the department.’ (yolisa) theme 6: perceived preparedness for clinical supervision clinical practice experience ‘this is the first time i am working with students. i have no previous experience working with students.’ (yolisa) ‘almost every year we had elective students that i had to supervise. when i was in, we were actively involved in supervising students.’ (priya) ‘clinical supervision is a learning process. it’s a continuous learning process. supervising community-service therapists also helped me this year.’ (gugu) preclinical supervision workshops ‘the workshops they had on campus (referring to preclinical workshops offered by the university).’ (yolisa) ‘i’ve attend some of the meetings and i attended the training (referring to preclinical workshops offered by the university). so, all of us at the department we quite hands-on with the students that come here, although they are here for a more independent block, they are here for the community block; so we really only supervise them when they are on the hospital premises and then they would be working on their projects.’ (gugu) ‘we also attended all the meetings called upon by the university towards when they introduced the training from the start until the end … first meeting that we had to assess and i think to give us what was expected, and while they’re willing to help us in terms of equipment and whatever material that is needed here … we were willing to help in terms of whatever outcomes were set out.’ (andrew) theme 7: recommendations improved collaboration ‘their supervisors and clinical staff need to come together, not only to assess students but to also have patient presentations to improve knowledge.’ (palesa) recruitment of local clinical supervisors ‘the academic staff cannot do much about the fact that there are no part-timers, but one recommendation is that having part-time staff locally will make much difference in the dct; it will actually help students and the academic supervisors because i don’t think they can spread themselves all around.’ (priya) improved information and communication systems ‘if they had an online tutorial that they could do on a daily basis – because they don’t see patients the whole day.’ (tanya) ‘if the university also had set up online access to learning material and lectures; that would help us here to teach.’ (thandi) academic incentives ‘if there could be some form of incentives that can be done, it could be in a form of learning courses, remember we are continuously learning every day… .’ (priya) phc = primary healthcare; tens = transcutaneous electrical nerve stimulators; dct = decentralised clinical training; opd = outpatient department. march 2019, vol. 11, no. 1 ajhpe 20 research healthcare systems. moreover, there is the notion that students who train at rural sites are more likely to accept employment at such sites.[9,27] stakeholder dynamics this theme included effective leadership roles, collaboration between academics and clinical supervisors, the relationship between students and clinicians, as well as community service therapists as subthemes. the role of physiotherapy managers in the clinical education approach is crucial for success of student learning.[27,29] furthermore, communication and ongoing collaboration between students, academics and supervising physiotherapists are imperative in this process.[32] collaborative preparation and planning prior to the commencement of dct is believed to be of importance.[19,28] a study by lo et al.[33] reveals that a working partnership between academic staff and clinicians promotes future collaboration. the partnership between student and supervising therapist is also important and aids in creating a mutual beneficial learning environment for effective training in technical skills, core competencies and ethical and social integration into clinical practice. a concern voiced in this study was the poor partnership at a site between the community service officer (cso) or therapist and students. junior staff, such as csos, viewed as support ‘buddies’ for students, rather than clinical supervisors, have been cited.[29] other studies on the placement of students cite clashes between students and clinicians due to personality conflicts.[28,29] barriers barriers to dct included communication and technological issues, as well as student attitudinal barriers as subthemes. technology and communication access in the dct sites posed barriers to learning, as students were unable to access information.[24] there has been a surge in the use of technology as a method to enhance learning;[34] however, efforts are required towards improving access to optimise this tool in resource-limited settings. in this study, student attitudinal barriers were also believed to inhibit optimal learning.[35] enablers enablers to dct included the subthemes rural v. urban clinical education, personal growth, students’ preclinical training and student impact. physiotherapy supervisors were motivated and found it rewarding to work with students,[28] in addition to personal growth in the supervision process and becoming increasingly confident as time progressed. further personal development included physiotherapists updating their clinical knowledge and skills to be of value to students.[28,29] the preclinical training of students prior to embarking on dct was identified as key in preparation for clinical practice.[18] students were seen as added personnel and other studies corroborate that students can alleviate the high burden of staff and relieve workload pressure.[1] perceived preparedness of physiotherapists within the theme of perceived preparedness of physiotherapists for clinical supervision, clinical practice experience and preclinical supervision workshops were identified as subthemes. most physiotherapists indicated that, despite their clinical practice experience, they initially felt unprepared to supervise students. feelings were attributed to change in the curriculum and teaching pedagogy and lack of personal confidence. similar feelings were expressed by clinicians involved in supervision of occupational therapy students, who felt that they had not been suitably prepared and were anxious about judgement by students.[36] there was a perceived preparedness of physiotherapists who had experience in supervision of students during clinical elective rotations with students from other sa tertiary institutions during their vacation, as well as exposure to communityservice physiotherapists at the respective healthcare facilities. furthermore, a preclinical supervision workshop offered to supervising physiotherapists appeared to offer them respite in their perception of unpreparedness.[29,37] recommendations finally, recommendations identified in this study included improved collaboration, improved information and communication systems, recruitment of local clinical supervisors and academic incentives. physiotherapists emphasised the need for improved communication between academics and clinicians. this was in keeping with findings in other studies, where communication between stakeholders was an enabler to improved clinical education approaches.[19,38] a sa study that explored an undergraduate physiotherapy programme highlighted that communication between academics and clinicians supervising physiotherapy students is a facilitator of clinical education and preparedness for practice.[17] good communication between academic staff and clinicians provides a seamless learning environment for student learning.[38] recruitment of private sector physiotherapists as clinical supervisors was recommended as respite for the overburdened hospital staff who supervise students.[28] campbell et al.[39] reported that a direct relationship must be built with local community members, healthcare services and health professional education institutions.[39] online platforms were also recommended to enhance clinical education, which is aligned to current trends in undergraduate health professions education.[40] a further recommendation included the offering of academic incentives in the form of continuous professional development courses, as well as tuition remission for postgraduate courses. study limitations the study was limited to 6 new dct placement sites for one tertiary institution. moreover, the number of clinical supervisors was limited to those who were directly involved in the supervision of students during the pilot year and represented subjective reports of their experiences. the results should therefore be interpreted with caution and may not be generalisable. conclusion as the need for increasing the number of health professionals to respond to the current health needs of the country is realised, more innovative methods for the clinical education of health science students are required. cbtphc is an option that allows students to be exposed to phc in rural and underserved communities. however, for this platform to become an enabling clinical training environment and to ensure success, the voices of essential stakeholders are necessary. this study sought to explore the perceptions and experiences of physiotherapists as clinical supervisors within the cbtphc programme. the platform of clinical training for physiotherapy students was generally perceived as a valuable framework to incorporate competencies required for community-based phc practice. furthermore, physiotherapists believed that good communication between stakeholders enhances the learning environment and incentives for clinicians, such as academic study fee remissions. such incentives are mutually beneficial, as these will further enhance the knowledge of physiotherapists who supervise 21 march 2019, vol. 11, no. 1 ajhpe research students. further research into the experiences of health science students and academics is key to the development of novel integrated approaches such as cbtphc in clinical training. declaration. the study was in fulfilment of sb’s postgraduate degree in the school of health sciences, university of kwazulu-natal, durban, sa. acknowledgements. the authors acknowledge the physiotherapy clinical supervisors who shared their experiences and insights regarding the study. author contributions. sb: principal investigator and responsible for the coconceptualisation, data collection and write-up; vc, nc, pg and sm: assisted in the conceptualisation and supervision, guided data interpretation and assisted in the critical review of the article. funding. funded under the i-dect project that received support via a college of health sciences, university of kwazulu-natal, competitive grant. conflicts of interest. none. 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 2. allodola vf. the effects of educational models based on experiential learning in medical education: an international literature review. tutor 2014;14(1):23-49. https://doi.org/10.3280/erp2013-002005 3. mostert-wentzel k, frantz jm, van rooijen t. status of undergraduate community-based and public-health physiotherapy education in south africa. s afr j physiother 2013;69(1):26-35. https://doi.org/10.4102/sajp. v69i1.369 4. mostert-wentzel k, frantz j, van rooijen aj. a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. afr j health professions educ 2013;5(1):19-25. https://doi.org/10.7196.203 5. lardinois kl, gosselin d, mccarty d, ollendick k, covington k. a collaborative model of integrated clinical education in physical therapist education: application to the pediatric essential core competency of familycentered care. j phys ther educ 2017;31(2):131-136. 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study. afr j health professions educ 2014;6(1):17-22. https://doi.org/10.7196/ajhpe.219 18. ramklass ss. an investigation into the alignment of a south african physiotherapy curriculum and the expectations of the healthcare system. physiotherapy 2009;95(3):215-222. https://doi.org/10.1016/j.physio. 2009.02.004 19. rodger s, webb g, devitt l, gilbert j, wrightson p, mcmeeken j. clinical education and practice placements in the allied health professions: an international perspective. j allied health 2008;37(1):53-62. 20. ernstzen dv, statham sb, hanekom sd. learning experiences of physiotherapy students during primary healthcare clinical placements. afr j health professions educ 2014;6(2):211-216. https://doi.org/10.7196/ ajhpe.530 21. strohschein j, hagler p, may l. assessing the need for change in clinical education practices. phys ther 2002;82(2):160-172. 22. krause mw, viljoen mj, nel mm, joubert g. development of a framework with specific reference to exit-level outcomes for the education and training of south african undergraduate physiotherapy students. health pol 2006;77(1):37-42. https://doi.org/10.1016/j.healthpol.2005.07.015 23. diab p, flack p. benefits of community-based education to the community in south african health science facilities. afr j prim health care fam med 2013;5(1). https://doi.org/10.4102/phcfm.v5i1.474 24. paliadelis ps, parmenter g, parker v, giles m, higgins i. the challenges confronting clinicians in rural acute care settings: a participatory research project. rural remote health 2012;12(2):2017. 25. muasya mk, dienya tm, wagaiyu eg, nduati r, kiarie jn. capacity of non-tertiary kenyan health facilities selected for decentralised dental training. east afr med j 2016;93(2):55-59. 26. de villiers m, van schalkwyk s, blitz j, et al. decentralised training for medical students: a scoping review. bmc med educ 2017;17(1):196. https://doi.org/10.1186/s12909-017-1050-9 27. de villiers mr, blitz j, couper i, et al. decentralised training for medical students: towards a south african consensus. afr j prim health care fam med 2017;9(1):1-6. https://doi.org/10.4102/phcfm.v9i1.1449 28. moore a, morris j, crouch v, martin m. evaluation of physiotherapy clinical educational models: comparing 1: 1, 2: 1 and 3: 1 placements. physiotherapy 2003;89(8):489-501. https://doi.org/10.1016/s0031-9406(05)60007-7 29. currens ja, bithell cp. clinical education: listening to different perspectives. physiotherapy 2000;86(12):645-653. https://doi.org/10.1016/s0031-9406(05)61302-8 30. crisp n, chen l. global supply of health professionals. new engl j med 2014;370(10):950-957. https://doi. org/10.1056/nejmra1111610 31. stiller k, lynch e, phillips ac, lambert p. clinical education of physiotherapy students in australia: perceptions of current models. austr j physiother 2004;50(4):243-247. https://doi.org/10.1016/s0004-9514(14)60114-8 32. gassner la, wotton k, clare j, hofmeyer a, buckman j. theory meets practice: evaluation of a model of collaboration. academic and clinician partnership in the development and implementation teaching. collegian 1999;6(3):14-21. https://doi.org/10.1016/s1322-7696(08)60337-6 33. lo k, curtis h, keating jl, bearman m. physiotherapy clinical educators’ perceptions of student fitness to practise. bmc med educ 2017;17(1):16. https://doi.org/10.1186/s12909-016-0847-2 34. talib z, van schalkwyk s, couper i, et al. medical education in decentralized settings: how medical students contribute to health care in 10 sub-saharan african countries. acad med 2017;92(12):1723-1732. https://doi. org/10.1097/acm.0000000000002003 35. bolton d. student attitude and online learning: the impact of instructional design factors upon attitudes toward the online learning experience. in: northcote m, gosselin kp. handbook of research on humanizing the distance learning experience. hershey, pa: igi global, 2017:307-333. 36. de witt p, rothberg a, bruce j. clinical education of occupational therapy students: reluctant clinical educators. s afr j occup ther 2015;45(3):28-33. https://doi.org/10.17159/2310-3833/2015/v45n3/a6 37. currens jb, bithell cp. the 2:1 clinical placement model: perceptions of clinical educators and students. physiotherapy 2003;89(4):204-218. https://doi.org/10.1016/s0031-9406(05)60152-6 38. mcmahon s, cusack t, o’donoghue g. barriers and facilitators to providing undergraduate physiotherapy clinical education in the primary care setting: a three-round delphi study. physiotherapy 2014;100(1):14-19. https://doi.org/10.1016/j.physio.2013.04.006 39. campbell lm, ross aj, macgregor rg. the umthombo youth development foundation, south africa: lessons towards community involvement in health professional education. afr j health professions educ 2016;8(1):50-55. https://doi.org/10.7196/ajhpe.2016.v8i1.559 40. rowe m, bozalek v, frantz j. using google drive to facilitate a blended approach to authentic learning. br j educ tech 2013;44(4)594-606. https://doi.org/10.1111/bjet.12063 accepted 12 july 2018. https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.3280/erp2013-002005 https://doi.org/10.4102/sajp.v69i1.369 https://doi.org/10.4102/sajp.v69i1.369 https://doi.org/10.1097/00001416-201731020-00015 https://www.phasa.org.za/wp-content/.../11/pillay-the-implementation-of-phc.pdf https://www.phasa.org.za/wp-content/.../11/pillay-the-implementation-of-phc.pdf http://dx.doi.org/10.7196%2fsamj.2017.v107i1.12008 https://doi.org/10.2196/preprints.7551 http://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-­­­human-subjects/ http://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-­­­human-subjects/ https://doi.org/10.1016/j.nedt.2003.10.001 http://dx.doi.org/10.7196%2fajhpe.219 https://doi.org/10.1016/j.physio.2009.02.004 https://doi.org/10.1016/j.physio.2009.02.004 https://doi.org/10.7196/ajhpe.530 https://doi.org/10.7196/ajhpe.530 https://doi.org/10.1016/j.healthpol.2005.07.015 https://doi.org/10.1186/s12909-017-1050-9 https://doi.org/10.4102/phcfm.v9i1.1449 https://doi.org/10.1016/s0031-9406(05)60007-7 https://doi.org/10.1016/s0031-9406(05)61302-8 https://doi.org/10.1056/nejmra1111610 https://doi.org/10.1056/nejmra1111610 https://doi.org/10.1016/s0004-9514(14)60114-8 https://doi.org/10.1016/s1322-7696(08)60337-6 https://doi.org/10.1097/acm.0000000000002003 https://doi.org/10.1097/acm.0000000000002003 https://doi.org/10.17159/2310-3833/2015/v45n3/a6 https://doi.org/10.1016/s0031-9406(05)60152-6 https://doi.org/10.1016/j.physio.2013.04.006 https://doi.org/10.7196/ajhpe.2016.v8i1.559 https://doi.org/10.1111/bjet.12063 december 2019, vol. 11, no. 4 ajhpe 123 research south africa (sa) was one of the first countries to integrate 12 statutory health professional boards: dental therapy and oral hygiene (doh); dietetics and nutrition (dtb); emergency care (emb); environmental health (eho); medical and dental (mdb); medical technology (mtb); occupational therapy, medical orthotics prosthetics and arts therapy (oct); optometry and dispensing opticians (odo); physiotherapy, podiatry and biokinetics (ppb); psychology (psb); radiography and clinical technology (rct); speech, language and hearing (slh). these boards represent 83 professional categories under one umbrella body, the health professions council of south africa (hpcsa). in 2007, the hpcsa changed the statutory requirement to include continuing professional development (cpd) compliance to remain registered as a health practitioner.[1,2] the intention was to promote ethical and competent practice, which requires continually updating knowledge and skills with an end benefit to the patient/client.[3] the cpd system is one of self-selected continuing education activities to update knowledge and skills. practitioners are required to engage with cpd for at least 30 hours per year (15 hours for certain categories), of which 5 hours must be in the area of ethics, human rights and health law. one hour is equivalent to one continuing education unit (ceu). the range of accredited learning activities includes those at level 1, i.e. once-off activities (e.g. workshops, lectures, seminars, conferences); and level 2, i.e. formal courses/programmes of study with measurable outcomes, and other activities (e.g. learning portfolios and practice audits).[3] practitioners are free to select learning activities and are expected to maintain their records. random audits of practitioners, which require submission of cpd records, are conducted to determine adherence with the requirements. a challenge for the hpcsa is its ability to assess the impact of cpd on practitioners’ competence and performance[4] to assure the public that practitioners are up to date with new knowledge, skills and current trends. internationally, efforts to assess competence and performance, improve quality of care, detect early performance that does not meet the standard and promote professional accountability have seen the introduction of recertification,[5] revalidation[6] and maintenance of licensure (mol).[7] these processes require practitioners to improve practice by implementing an individualised cpd programme that meets the individual’s learning needs, with assessment of performance and/or competence.[6,8] in 2013, the hpcsa initiated the process for mol. the rationale was to move beyond the acquisition of knowledge to include the development of skills and improvement of performance. development of the mol strategy is underway. this study set out to determine practitioners’ perceptions and experiences relating to their engagement with cpd to inform the development of the mol system. methods a cross-sectional prospective survey design was used. participants were required to be health practitioners registered with the hpcsa, and to have email access. practitioners for whom cpd is not a requirement were excluded, i.e.: (i) those in non-clinical practice; (ii) those doing community service; and (iii) undergraduate students. at the time of the survey, there were 182 152 practitioners who were eligible for participation. an electronic questionnaire designed for self-administration and based on a survey of dentists[9] was modified to reflect sa requirements and background. the statutory requirement for continuing professional development (cpd) for all health professionals registered with the health professions council of south africa (hpcsa) has been in place since 2007. the hpcsa intends to implement maintenance of licensure (mol). objectives. to determine practitioners’ perceptions and experiences of engaging with cpd to inform the development of the mol system. methods. a cross-sectional survey of practitioners registered with the hpcsa was conducted. the self-administered 30-item electronic questionnaire covered practitioner demographics and patterns of cpd practice and was completed by 11 307 respondents. results. methods used to determine learning needs included self-assessment (56.8%) and audit of own practice (53.2%). selection of cpd activities was based on interest (80.2%) and expertise (72.8%) and less so on gaps in knowledge (66.1%) and skills (61.8%). the most frequent learning activities were primarily didactic (workshops (58%), lectures (53%) and conferences (51%)). barriers included cost and location of cpd activities, especially for women and rural practitioners (p<0.001). employer support for cpd was associated with adherence (p<0.001). there was strong support (88.7%) for continuing education as a component of mol, but less support (<50%) for other elements, even though practitioners voluntarily engaged with these practices. conclusion. respondents engage in a range of activities that could be incorporated into a mol system. the transition to mol requires development of tools, including objective assessments, guidelines for individualised learning programmes and expanding the range of learning activities. strategies to address barriers to cpd need to be considered. afr j health professions educ 2019;11(4):123-128. https://doi.org/10.7196/ajhpe.2019.v11i4.1088 south african health practitioners’ patterns of cpd practices – implications for maintenance of licensure s a singh,1 phd; t d fish,2 mb chb, mba 1 department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa 2 division of health systems and public health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: s a singh (shajila.singh@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 124 december 2019, vol. 11, no. 4 ajhpe research the range of health professionals registered with the hcpsa. content and face validity were addressed through an iterative process of consulting with selected healthcare practitioners on the registers of different professional boards, members of the hpcsa’s cpd committee, and by pilot testing. the 30-item questionnaire covered practitioner demographics, as well as areas related to the study objectives: (i) patterns of cpd practice (i.e. methods of determining own learning needs, criteria for selection of cpd activities, preferred cpd learning activities); (ii) attitudes towards cpd; (iii) adherence to cpd requirements; (iv) facilitators and barriers to engaging with cpd; (v) perceived impact of cpd; and (vi) implications for mol. the questionnaire primarily comprised closed-ended questions suitable for ease of scoring and analysis in a large survey. open-ended questions allowed for alternative responses. convenience sampling was used. in june and july 2014, practitioners who were registered with the hpcsa were invited to participate in the online survey (surveymonkey, usa) via the communication channels (e.g. websites, short message service (sms) and email) of the hpcsa, professional associations and higher education institutions. participants were given 2 weeks to respond and were sent reminders prior to the end of the data collection period. it was not possible to determine how many practitioners received the invitation to participate in the study. a total of 14 572 questionnaires were received. data management and analysis data cleaning involved removal of 3  257 incom plete questionnaires based on set criteria (<10 of 30 questions answered and 8 duplicates) before exporting to stata version 13.1 (statacorp, usa) for analysis. of the questionnaires included, not all respondents answered every question. statistical analyses were performed using pearson χ2 tests to determine associations between demographics and study variables (barriers, adherence with cpd requirements). a p-value of 0.05 was set for statistical significance. answers to open-ended questions were analysed and no new response categories emerged. ethical approval ethical approval for the study was obtained from the university of cape town faculty of health sciences human research ethics committee (ref. no. uct fhs hrec 190/2013). results results are based on analysis of completed questionnaires by 11 307 respondents, reflecting 6.2% of eligible practitioners. the distribution of respondents was relatively proportional to the registration of practitioners in the various boards, with the highest number of respondents (34%) registered with the mdb (fig. 1). the majority (93.8%; n=10 093) of respondents worked in sa and were primarily from gauteng (37.8%), western cape (22.1%) and kwazulunatal (14.2%) provinces. of the respondents, 73.8% were <50 years of age. most (55.6%) worked in the private sector, with 33.0% in the public service. respondents (79.5%) had a bachelor degree (national qualification frame work (nqf) level 7 or 8) as a minimum qualification. table 1 shows selected demographic characteristics. patterns of cpd practice methods of determining learning needs most respondents (91.31%; n=11 124) reported being able to determine their learning needs. the most frequently reported methods used were self-assessment and audit of own practice (fig. 2). other approaches, while not currently used, were considered potentially useful. pr ac ti ti o n er s, % doh dtb emb eho mdb mtb oct odo ppb psb rct slh 2.6 1.6 37.0 1.9 28.1 5.6 3.2 2.0 4.8 6.8 4.9 1.5 2.41 3.28 2.39 12.13 34.03 5.70 5.87 3.06 8.23 14.88 4.51 3.51 registered (n=180 152) respondents (n=10 691) 40 35 30 25 20 15 10 5 0 fig. 1. distribution of respondents across the various professional boards. (doh = dental therapy and oral hygiene; dtb = dietetics and nutrition; emb = emergency care; eho = environmental health; mdb = medical and dental; mtb = medical technology; oct = occupational therapy, medical orthotics prosthetics and arts therapy; odo = optometry and dispensing opticians; ppb = physiotherapy, podiatry and biokinetics; psb = psychology; rct = radiography and clinical technology; slh = speech, language and hearing.) respondents, % 0 10 20 30 40 50 60 70 80 90 100 self-assessment (n=8 663) audit of own practice (n=8 431) peer feedback (n=8 306) patient/client-satisfaction survey (n=8 203) critical incident reviews (n=7 665) 360-degree appraisal (n=7 450) analysis of video of own practice (n=7 699) 56.8 32.4 10.8 53.2 35.8 11 40.2 18.6 41.2 29.9 51.8 18.3 29.9 47.9 22.2 17.3 52.8 30 8.6 42.2 49.2 use potentially useful not useful fig. 2. methods of determining learning needs. december 2019, vol. 11, no. 4 ajhpe 125 research criteria for selection of cpd topics respondents selected cpd topics based on their areas of interest (80.2%) and expertise (72.8%). fewer respondents selected topics based on lack of expertise (64.6%), knowledge gaps (66.1%) and skills gaps (61.8%), while 43.3% selected topics from a broad range. nature of cpd learning activities workshops, lectures and conferences (level 1 activities) were most frequently selected (fig. 3). clinical audit, publications, postgraduate study and videos with multiple-choice questions (mcqs) were less frequently chosen. self-reported adherence with cpd requirements nationally, 47.6% (n=10 995) of respondents had been selected for a cpd audit (an hpcsa administrative process that randomly selects practitioners and requires them to submit evidence of compliance with cpd requirements) during the previous 3 years, with 97.94% responding and 82% reporting adherence. for those working outside sa, 46% (n=595) were audited by the hpcsa and 92.5% were adherent. generally, there were high levels of reported adherence with cpd requirements. adherence was significantly associated with higher qualifications (χ2 (5, n=10 313) = 212.04; p<0.001), membership of a professional association (χ2 (1, n=9 956) = 198.54; p<0.001) and involvement of the employer (table 2). attitude towards cpd two-thirds (66.1%; n=10 485) of respondents indicated that the number of ceus expected was ‘about right’, while 30.6% felt that this requirement was too high. at least two-thirds (67.5%) indicated that cpd had to be done because it is a statutory requirement, and 12.8% considered cpd to be a waste of time. barriers to engaging with cpd barriers to participating in cpd activities were reported by 55.8% (n=10 093) of respondents. the cost and location of cpd activities, loss of work days and difficulty getting time off work were primary barriers across several professional boards (table 3). cost as a barrier was reported by >50% of respondents in 7 of the 12 professional boards, particularly by females (χ2 (1, n=5 910) = 68.49; p<0.001) and rural respondents (χ2 (1, n=5 890) = 15.05; p<0.001). a total of 575 respondents (5.7%) were unsure of what is expected with regard to cpd. cpd and the workplace the workplace supported cpd by offering learning activities (51.7%; n=9 591) and by allowing time off work to engage with cpd (48.15%; n=11 160). financial support from employers for cpd was more limited (<31%). a quarter of respondents (26.1%; n=11 066) indicated that their employers monitored adherence with cpd requirements. perceived impact of cpd cpd was reported to have improved a broad range of areas (fig. 4). while a high number of respondents (93%) perceived that cpd resulted in an improvement in knowledge, there was a lower percentage of reports (68%) of improvement in performance. implications for maintenance of licensure most respondents across professions (62.8%; range 56.2 76.8%; n=10 615) supported an expanded cpd system for mol, including continuing table 1. demographic characteristics of survey respondents demographic characteristics % urban/rural work location (n=11 129) 83/17 female (n=11 194) 59.9 age, years (n=11 129)   ≤29 20.0 30 39 32.4 40 49 21.4 50 59 15.9 60 65 5.6 >65 4.7 member of a professional association (n=10 718) 83.7 highest qualification obtained (n=11 165) advanced/higher certificate (nqf 5) 10.6 diploma (nqf 6) 9.9 degree (nqf 7/8) 37.4 postgraduate diploma (nqf 8) 10.0 masters/specialist and subspecialist (nqf 9) 28.1 phd (nqf 10) 4.0 nqf = national qualifications framework. r es p o n d en ts , % (n = 10 6 91 ) 57.6 53.3 50.5 37.8 33.4 27.4 27.0 17.7 14.9 14.6 9.0 7.9 60 50 40 30 20 10 0 w or ks ho ps le ct ur es co nf er en ce s in te rn et /e -le ar ni ng h an ds -o n co ur se s jo ur na l c lu bs re ad in gs w ith m cq s le ar ni ng p or tfo lio s pu bl ic at io ns po st gr ad ua te st ud y cl in ic al a ud its vi de os w ith m cq s learning activities fig. 3. nature of continuing professional development learning activities selected. (mcqs = multiple-choice questions.) table 2. employer support for cpd and reported adherence employer support adherence offers cpd activities χ2 (1, n=8 953) = 130.41; p<0.001 financially supports cpd χ2 (1, n=7 787) = 113.21; p<0.001 supports cpd related to practitioners’ interest χ2 (1, n=7 646) = 148.03; p<0.001 allows time off for cpd χ2 (1, n=8 189) = 54.22; p<0.001 monitors adherence χ2 (1, n=8 083) = 65.75; p<0.001 cpd = continuing professional development. 126 december 2019, vol. 11, no. 4 ajhpe research edu cation (88.7%; n=10 193), with less support for those elements that entail assessment of performance and competence (fig. 5). discussion respondents reflected a diverse group of practitioners across professions, age groups and qualifications and were primarily based in sa, females, in urban areas, <50 years of age, in the private sector and members of professional associations. the lower number of rural respondents may reflect the disparity in distribution of practitioners in urban and rural areas.[10] a range of strategies was used to determine learning needs, despite the absence of statutory guidelines, which is an improvement compared with earlier surveys.[11] some methods not currently used were considered to be potentially useful. nevertheless, less than half supported the inclusion of assessments in mol. while this study did not explore the nature of self-assessments (the most popular strategy), subjective self-assessments may not be reliable, as practitioners’ ability to accurately self-assess is limited, with the worst accuracy among those who were the least skilled and the most confident.[12] there is consensus that there should be external assessment to evaluate practitioners’ competence and performance and guide professional development.[12-14] as the hpcsa develops mol, it will be important for its professional boards to support practitioners by developing objective and externally verified tools for assessments. table 3. barriers to participating in cpd across professional boards barriers % doh dtb emb eho mdb mtb ocp odo ppb psb rct slh boards, n (n=10 093) 237 338 1 127 219 3 508 556 615 311 843 1 522 452 365 cost 45.5 51.1 51.2 32.5 56.6 34.9 32.4 74.8 39.9 63.4 53.6 48.5 67.4 location 38.6 46.4 44.4 35.3 40.6 31.6 34.4 61.1 37.6 43.4 39.0 44.0 55.3 loss of workday 29.2 27.9 27.2 19.6 12.3 27.6 15.7 44.1 26.7 39.6 35.2 22.8 43.6 time off work 23.6 19.8 23.1 25.7 22.4 23.5 29.1 25.5 17.4 18.7 21.6 34.5 20.6 insufficient ethics activities 16.4 11.0 29.6 17.9 25.1 15.4 21.4 22.8 13.2 13.6 10.8 21.5 15.1 relevance of activities 14.3 12.2 17.5 8.5 17.8 11.4 11.0 29.6 7.7 16.8 16.2 20.1 18.4 lack of employer support 11.9 13.5 13.3 16.9 35.6 9.7 16.9 13.7 6.4 8.1 8.2 20.4 9.0 obtaining ceus from providers 11.3 8.4 13.9 13.1 20.1 10.5 9.7 19.7 8.0 9.0 9.3 14.2 9.3 hpcsa support 11.2 13.5 12.1 13.6 35.6 9.4 9.4 11.1 8.4 8.1 13.3 12.0 8.2 quality of cpd activities 8.4 11.0 9.2 8.4 14.2 8.0 6.5 9.3 6.1 10.0 10.4 10.2 8.2 maintaining own cpd records 8.4 8.4 14.8 7.4 5.5 8.0 9.4 10.2 10.0 7.8 8.8 8.2 6.3 obtaining attendance records 7.4 6.8 8.3 9.5 9.6 9.0 7.2 6.8 5.8 3.2 5.4 8.6 3.3 unsure of cpd requirements 5.7 5.9 5.3 9.6 11.0 4.6 7.2 4.7 4.5 3.4 6.7 7.1 1.9 cpd = continuing professional development; doh = dental therapy and oral hygiene; dtb = dietetics and nutrition board; emb = emergency care board; eho = environmental health; mdb = medical and dental board; mtb = medical technology board; ocp = occupational therapy, medical orthotics prosthetics and arts therapy; odo = optometry and dispensing opticians; ppb = physiotherapy, podiatry and biokinetics; psb = psychology board; rct = radiography and clinical technology; slh = speech, language and hearing; ceu = continuing education units; hpcsa = health professions council of south africa. respondents, % (n=10 248) 0 10 20 30 40 50 60 70 80 90 100 knowledge ethical practice competence evidence-based practice performance communication record keeping 93.0 89.7 80.3 78.3 68.0 59.3 51.6 fig. 4. areas of practice reported to have improved with continuing professional development. 0 10 20 30 40 50 60 70 80 90 100 respondents, % (n=10 053) continuing education assessment of performance peer review competence test 360-degree feedback annual audit of practice 88.7 41.9 35.2 31.4 28.2 27.2 fig. 5. support for elements of an expanded continuing professional development programme for maintenance of licensure. december 2019, vol. 11, no. 4 ajhpe 127 research most respondents chose cpd activities related to their interest and expertise, with fewer selecting learning activities to address gaps in knowledge, skills and expertise. practitioners often choose to participate in cpd activities within their comfort zone.[15] without guidelines and mechanisms to support the identification and selection of cpd learning activities that are appropriate and relevant to practice, it could be suggested that practitioners try to meet the cpd requirements by selecting learning activities in a manner described as opportunistic, erratic or casual.[16] the impact of cpd activities is limited when undertaken in an ad hoc manner outside of a defined structure of directed learning and contributes little to improving practitioners’ performance or patient/client health outcomes.[17] guidelines on how to develop learning plans that address gaps in knowledge and skills could be beneficial to practitioners in the context of mol. the most frequently chosen learning activities were input-based approaches (i.e. lectures, conferences and workshops), which are regarded as simple and cost effective and provide an easily quantifiable method of measuring individual cpd activity.[17] systematic reviews suggest that these common, primarily didactic learning activities have a limited effect on improving practitioner competence and performance, and no significant effect on patient and health systems outcomes.[17,18] cpd activities, which are interactive, provide opportunities to acquire and practice skills,[19] involve multiple exposures, encourage reflection on practice, and are focused on outcomes, are reported as effective in improving practice and patient health outcomes.[17] respondents generally supported the expected level of engagement with cpd, i.e. the number of ceus expected annually. the finding that cpd had to be done because it is a statutory requirement, suggests that adherence may be related to the need to be compliant. a small but sizeable group (12.8%) considered cpd to be a waste of time, suggesting a perceived lack of the inherent benefits of cpd. in comparison, only 0.4% of uk physicians surveyed indicated that cpd was unnecessary.[15] assisting practitioners to develop individualised cpd programmes that are linked explicitly to improving their professional performance and patient/client health, could result in greater ownership of professional development.[17] cost is a frequently reported barrier to cpd.[20-23] female and rural practitioners experienced cost as a greater challenge. strategies to reduce costs should be explored, e.g. self-study activities[24] aligned with identified learning needs. challenges in accessing cpd activities due to the location in which they are offered, are common,[11,21,22] as was time off from work to attend cpd activities.[21,22,25,26] cpd providers could be encouraged to make their offerings available through a variety of delivery modes, including online initiatives[24] such as webinars and podcasts. mechanisms to address the quality and relevance of learning activities, as well as administrative barriers that practitioners experience, need to be considered. workplace support for cpd in offering or allowing time off for cpd, was significantly associated with self-reported adherence. in sa, where cpd compliance is a statutory requirement for health practitioners, it is of concern that not all employers provide support. it is in the interest of employers and patients/clients that practitioners are up to date regarding professional knowledge and skills.[16,17] employers should be encouraged to support their practitioners’ engagement with cpd. cpd was perceived to improve knowledge more than performance. cpd activities are frequently not designed to promote clinical behaviour change,[27] with delays of 5 50 years in the translation of acquired knowledge into practice.[17,28] it is estimated that 30 40% of patients/clients do not receive care that is informed by best evidence, and 20 50% receive inappropriate care.[17] cpd activities should increasingly be designed to meet the standard for improving practice and health outcomes. there was support for an expanded cpd system for mol to include continuing education activities, with much less support for other essential components of mol, i.e. peer review, audit of practice and multisource feedback. although respondents engage with such practices voluntarily, they are less supportive of these in a mandatory mol environment, which could reflect perceived threats associated with review, assessments and meeting requirements for licensure in a formalised system. as these elements are part of the international components of mol, work needs to be done to familiarise sa healthcare practitioners with requirements to move from the acquisition of knowledge to that of skills and improvement of performance. study limitations convenience sampling introduced bias. the results are based on a small sample of registered practitioners and exclude those without electronic access, leading to coverage bias.[29] selection bias is inherent to such a survey[30] and could explain the high adherence. the results reflect the perceived impact of cpd and not the objectively measured impact. practitioners’ perceptions of whether they support the introduction of mol and its implications were not explored. conclusion respondents to the online survey included 11 307 health practitioners across all 12 hpcsa professional boards, with most being females, in urban areas, <50 years of age, in the private sector and in sa. self-assessment, which has inherent limitations, was the most frequent method used to determine learning needs, with other approaches considered potentially useful. cpd topics were selected based on interest and expertise, with fewer topics related to lack of expertise and knowledge gaps. workshops, lectures and conferences were the most popular cpd learning activities; these are known to have a limited effect on patient and health systems outcomes. self-reported adherence was high and linked to membership of professional associations and involvement of the employer in supporting cpd. employers should be encouraged to support their practitioners’ engagement with cpd. barriers included cost and location of cpd activities, and strategies to address these could include expanding the range of cpd activities to comprise self-study and online activities. in the transition to mol, practitioners would need to be supported in determining their learning needs by devising and making available objective and valid assessment tools of competence and performance, such as 360-degree appraisals, peer review and online assessments of knowledge. guidelines for learning plans should be developed to assist practitioners to tailor their programme of learning to address gaps and meet expected standards. accreditation of cpd activities should require them to be interactive, provide opportunity to acquire and practise skills and be focused on improving performance and 128 december 2019, vol. 11, no. 4 ajhpe research patient outcomes. limitations of the study include the use of convenience sampling that probably led to bias, only the perceived impact of cpd could be described and support for the introduction of mol was not explored. declaration. none. acknowledgements. the authors wish to acknowledge support of the hpcsa in recruiting practitioners for this study; maxwell chirehwa for his assistance with statistical analysis; edelweiss wentzel-viljoen for initial discussions of the results and comments on a draft of the document; and colleagues who participated in the validation of the questionnaire. author contributions. sas and tdf: substantial contribution to the concep tualisation and design of the study, analysis and interpretation of data, write-up of the article, and approval of the version to be published. funding. statistical analysis was funded by stellenbosch university. conflicts of interest. sas was chair and tdf a member of the hpcsa’s cpd committee at the time of the survey. both authors are currently working on a mol framework with the hpcsa. 1. de villiers m. global challenges in continuing professional development: the south african perspective. j cont educ health prof 2008;28(s1):25-26. https://doi.org/10.1002/chp.205 2. van den berg l, de villiers mr. cpd – the learning preferences of general practitioners. s afr fam pract 2003;45(3):10-12. 3. health professions council south africa. continuing professional development. guidelines for the health care professionals. pretoria: hpcsa, 2017. http://www.hpcsa.co.za (accessed 13 december 2017). 4. rethans jj, norcini jj, baron‐maldonado m, et al. the relationship between competence and performance: implications for assessing practice performance. med educ 2002;36(10):901-909. https://doi.org/10.1046/j.13652923.2002.01316.x 5. medical council of new zealand. recertification and continuing professional development booklet. wellington: mcnz, 2017. https://www.mcnz.org.nz (accessed 13 december 2017). 6. general medical council. the good medical practice framework for appraisal and revalidation. london: gmc, 2013. https://www.gmc-uk.org/static/documents/content/the_good_medical_practice_framework_for_ appraisal_and_revalidation_-_dc5707.pdf (accessed 13 december 2017). 7. federation of state medical boards. maintenance of licensure (mol) framework policy. washington: fsmb, 2010. 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systematic review. jama 2006;296(9):1094-1102. https://doi.org/10.1001/jama.296.9.1094 13. chaudhry hj, cain fe, staz ml, talmage la, rhyne ja, thomas jv. the evidence and rationale for maintenance of licensure. j med regul 2013;99:19-26. https://doi.org/10.7326/0003-4819-158-3-201302050-00022 14. eva kw, regehr g. ‘i’ll never play professional football’ and other fallacies of self‐assessment. j cont educ health prof 2008;28(1):14-19. https://doi.org/10.1002/chp.150 15. schostak j, davis m, hanson j, et al. ‘effectiveness of continuing professional development’ project: a summary of findings. med teach 2010;32(7):586-592. 16. ahmed k, wang tt, ashrafian h, layer gt, darzi a, athanasiou t. the effectiveness of continuing medical education for specialist recertification. can urol ass j 2013;7(7-8):266. https://doi.org/10.5489/cuaj.378 17. wallace s, may sa. assessing and enhancing quality through outcomes-based continuing professional development (cpd): a review of current practice. vet rec 2016;179(20):515. https://doi.org/10.1136/vr.103862  18. shibu l, rajab e, eldabi t. the role of social media in continuing professional development of physical therapists: a review of the literature. physiotherapy 2015;101:e1384. https://doi.org/10.1016/j.physio.2015.03.1328 19. 2018 annual meeting of the network: tufh abstract submission form. https://www.tfaforms.com/364076 (accessed 17 december 2017). 20. cook da, price dw, wittich cm, west cp, blachman mj. factors influencing physicians’ selection of continuous professional development activities: a cross-specialty national survey. j contin educ health prof 2017;37(3):154-160. https://doi.org/10.1097/ceh.0000000000000163 21. dent aw, asadpour a, weiland tj, paltridge d. australasian emergency physicians: a learning and educational needs analysis. part one: background and methodology. profile of facem. emerg med australasia 2008;20(1):51-57. https://doi.org/10.1111/j.1742-6723.2007.01036.x 22. kanamu lg, van dyk b, chipeya l, kilaha sn. barriers to continuous professional development participation for radiographers in kenya. afr j contin educ health prof 2017;9(1):17-20. https://doi.org/10.7196/ajhpe.2017. v9i1.605 23. uarije c, daniels er, kalondo l, amkongo m, damases-kasi c, nabasenja c. radiographers’ attitudes towards continuous professional development (cpd) at state hospitals in windhoek, namibia. s afr radiogr 2017;55(1):18-22. 24. lindsay e, wooltorton e, hendry p, williams k, wells g. family physicians’ continuing professional development activities: urgent practices and potential for new options. can med educ j 2016;7(1):e38. 25. ikenwilo d, skåtun d. perceived need and barriers to continuing professional development among doctors. health policy 2014;117(2):195-202. https://doi.org/10.1016/j.healthpol.2014.04.006 26. jiandani mm, bogam r, shah c, prabhu s, taksande b. continuous professional development: faculty views on need, impact and barriers. natl j integr res med 2015;7(2):43-75. 27. légaré f, freitas a, thompson-leduc p, et al. the majority of accredited continuing professional development activities do not target clinical behavior change. acad med 2015;90(2):197-202. https://doi.org/10.1097/acm. 0000000000000543 28. mickan s. using knowledge to action practice change. oxford: centre for evidence-based medicine, 2014. 29. https://www.edrm.net/glossary/coverage-bias (accessed 18 october 2018). 30. olsen r. self-selection bias. in: lavrakas p, ed. encyclopedia of survey research methods. thousand oaks, ca: sage, 2008:809-811. https://doi.org/10.4135/9781412963947.n526 accepted 1 july 2019. https://doi.org/10.1002/chp.205 http://www.hpcsa.co.za https://doi.org/10.1046/j.1365-2923.2002.01316.x https://doi.org/10.1046/j.1365-2923.2002.01316.x https://www.mcnz.org.nz https://www.gmc-uk.org/static/documents/content/the_good_medical_practice_framework_for_appraisal_and_revalidation_-_dc5707.pdf https://www.gmc-uk.org/static/documents/content/the_good_medical_practice_framework_for_appraisal_and_revalidation_-_dc5707.pdf https://www.fsmb.org/ https://www.inpractice.org.nz/guide/welcome.aspx https://www.inpractice.org.nz/guide/welcome.aspx https://doi.org/10.1111/j.1600-0579.2010.00615.x https://doi.org/10.1111/j.1600-0579.2010.00615.x https://doi.org/10.1186/1478-4491-12-26 https://doi.org/10.1001/jama.296.9.1094 https://doi.org/10.7326/0003-4819-158-3-201302050-00022 https://doi.org/10.1002/chp.150 https://doi.org/10.5489/cuaj.378 https://doi.org/10.1136/vr.103862 https://doi.org/10.1016/j.physio.2015.03.1328 https://www.tfaforms.com/364076 https://www.tfaforms.com/364076 https://doi.org/10.1097/ceh.0000000000000163 https://doi.org/10.1111/j.1742-6723.2007.01036.x https://doi.org/10.7196/ajhpe.2017.v9i1.605 https://doi.org/10.7196/ajhpe.2017.v9i1.605 https://doi.org/10.1016/j.healthpol.2014.04.006 https://doi.org/10.1097/acm.­0000000000000543 https://doi.org/10.1097/acm.­0000000000000543 https://www.edrm.net/glossary/coverage-bias https://doi.org/10.4135/9781412963947.n526 december 2019, vol. 11, no. 4 ajhpe 111 short research report mentorship in health sciences education and thus in prehospital emergency medical care should be a nurtured, guided venture led by an experienced mentor. in most instances, mentees from higher education institutions are placed on the clinical platform in emergency medical services, hospitals and clinics, where they are mentored by qualified, registered healthcare practitioners. recent research indicates that there are problems with mentor/mentee relationships in health sciences education. the relationship between mentees and mentors as analysed within an activity system illustrated the difficulties within clinical mentorship. research design and methods a qualitative study was conducted using the cultural historical activity theory (chat) as the interpretive framework to identify, elucidate and exemplify the elements of the clinical mentorship system and thus indicate difficulties and opportunities for change. in performing the chat analysis, the clinical mentorship system was split into various elements: subject, object, tools and signs, rules, division of labour (dol) and community. the subject in this activity system is the mentee, who is guided by the mentor. the object of the system is preparation of mentees for the real world of work. tools and signs are identified as physical material, such as equipment, and non-physical material, such as knowledge of the mentor or community member (any person involved with or invested in the object of the activity system). the subject uses these tools to work on the object. the rules are formal, such as processes governing practice, including the scope of practice as determined by the health professions council of south africa (sa), and informal, such as workplace cultural practices and trust. the dol comprises the different roles and responsibilities of mentee and mentor or community member as they work on a common object of the activity. during the analysis, there was a search for contradictions within and between the elements of the system that impede successful working on the object of the activity. the aim, after identifying the contradictions, was to resolve areas in need of change and development. the participant sample was selected through purposive, convenience sampling that identified student and mentor participants. five students (mentees) and 5 paramedic practitioners (mentors) consented to participate. data were collected through mentees’ reflection on significant learning events and difficulties experienced during work-integrated learning (wil). these were recorded by the mentee in a hand-written diary (provided by the researcher (nl)). each mentee recorded a minimum of two 12-hour shifts, which were analysed and interpreted by the researcher. secondly, focus group interviews were conducted that were guided by elements of chat and concepts and matters of interest identified in the diaries. these interviews were held with both mentors and mentees as separate groups and allowed further exploration to develop in-depth accounts of perceptions and experiences.[1] ethical approval ethical approval was granted by the cape peninsula university of technology, cape town, sa (ref. no. cput/hw-rec 2013/h26) and the provincial department of health, western cape, sa (ref. no. rp 164 /2013). results and discussion the object of the activity system was understood to be mentee preparation for the world of work, but what was identified and actually happened during clinical mentorship was not necessarily conducive to working on this object. for example, the clinical placement of students during the academic term often set up a conflict within the object, as students focused on preparation for academic assessments rather than on clinical work. during clinical work, mentors allowed mentees only to observe rather than practise clinical care. a lack of trust between mentor and mentee (informal rule) was conflicted with and constrained by ‘who does what’ while working on a task (dol). this created difficulties within the dol background. clinical mentorship in health sciences education is a nurtured venture where mentees are guided through practice by their more experienced mentors. however, recent research suggests that there are problems with clinical mentorship. objective. to explore problems in work-integrated learning within the mentor/mentee relationship. methods. the cultural historical activity theory (chat) was used to interpret data gathered from diaries and focus group interviews. results. difficulties identified were poor communication between the university and the mentors at clinical platform sites. the unclear roles and responsibilities of mentees and mentors led to a breakdown of trust. conclusions. better university training and development of mentors would aid in the holistic development of mentors and mentees. afr j health professions educ 2019;11(4):111-113. https://doi.org/10.7196/ajhpe.2019.v11i4.1138 a cultural historical activity theory (chat) analysis of prehospital emergency medical care clinical mentorship to enable learning n liebenberg,1 memc, hdhet; l christopher,2 mtech: emc; j garraway,3 dphil 1 lebone college of emergency care, department of health, gauteng provincial government, pretoria, south africa 2 department of emergency medical sciences, faculty of health and wellness, cape peninsula university of technology, bellville campus, cape town, south africa 3 fundani centre for higher education, cape peninsula university of technology, bellville campus, cape town, south africa corresponding author: n liebenberg (nuraan.jacobs@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 112 december 2019, vol. 11, no. 4 ajhpe short research report element (fig. 1) and constrained mentees’ learning, which was the object of the activity system. a contradiction adding to the constraint of learning was a lack of clear mentorship policy and processes (formal rules) to guide the mentor in the role of working on the object of the activity. therefore, communication between mentor and mentee was hindered, e.g. mentors were not informed of mentees being assigned to them, or what the expected learning outcomes were for the mentees. the mentors’ knowledge and practice (tools for the mentees) were sometimes outdated and not based on current best practice; therefore, the mentee, using best practice to work on the object of learning, was potentially constrained. furthermore, a lack of foundational knowledge of mentees (tools) added to problems for both mentors and mentees working on the object of activity. to resolve the difficulties identified in the clinical mentorship activity system, suggestions are made for improvement and development. where trust was lacking, mentors could work with students in the university skills laboratories to obtain an understanding of what the students are capable of doing. in this way mentors could observe students performing complex procedures competently. stronger mutual participation could also be improved by engagement between students, academics and mentors, perhaps through shared online sites where problems can be discussed. this would serve to improve communication. a manual on teaching/mentoring, and a short course, could be developed for mentors. this could be part of the continuing professional development of mentors, as well as help to improve mentees’ experiences.[3,4] to improve students’ tools during clinical mentorship, the curriculum should aid in bridging the theory-practice gap.[5] students could, for example, do more problem-based work, during which they are specifically expected to challenge what they have learnt, and to adapt and apply knowledge to real-life problems.[6-8] conclusions if the object of the activity system of learning is to become a paramedic, then changes need to be made to the clinical mentoring activity system to realise this object more effectively. this article highlights how changes to tools, rules and dol elements can enhance learning. the key difficulties identified in the social clinical mentorship activity system were poor communication and understanding of the roles and responsibilities of mentee and mentor, both often leading to a breakdown of trust. a better integration of mentors in the university system would improve the development of mentees. declaration. this article is based on a study done by nl in partial fulfilment of her master’s degree in emergency medical care. acknowledgements. we acknowledge support, guidance and encouragement from dr navindhra naidoo. author contributions. nl: conceived the idea, identified the theory and performed the analysis in consultation with and with guidance from jg and lc. analytical methods were verified by jg and lc and both encouraged and supervised the findings of this work. all authors discussed the results and contributed to the final manuscript. funding. none. conflicts of interest. none. 1. cousin g. researching learning in higher education. an introduction to contemporary methods and approaches. new york: routledge, 2009. 2. engeström y. expansive learning at work: toward an activity theoretical reconceptualization. j educ work 2001;14(1):133-156. https://doi.org/10.1080/13639080123238 knowledge resources of mentors and mentees technology mainly the mentee, but sometimes the mentors trust in the professional relationship rules community two-way learning division of labour mentor and mentee attitudes roles and responsibilities object outcome learning to be part of a community of medical professionals learning in real and di�cult situations the purpose of mentoring tools/ resources subject standardised curriculum mentorship procedures cultural in�uences becoming a professional paramedic m ed ia tin g ar te fa ct smediating artefacts mediating artefacts fig. 1. cultural historical activity theory (chat) illustration of contradictions in the clinical mentorship activity system (adapted from engeström[2]). https://doi.org/10.1080/13639080123238 december 2019, vol. 11, no. 4 ajhpe 113 short research report 3. hudson p. forming the mentor-mentee relationship. ment tutor partner learn 2016;24(1):1-14. https://doi.org/ 10.1080/13611267.2016.1163637 4. matthew s, taylor r, ellis r. relationships between students’ experiences of learning in an undergraduate internship programme and new graduates’ experiences of professional practice. high educ 2012;64(4):529-542. 5. gamble j. the relation between knowledge and practice in curriculum and assessment. 2009. https://www. umalusi.org.za/docs/research/2009/jgamble.pdf (accessed 2 august 2019). 6. michau r, roberts s, williams b, boyle m. an investigation of theory-practice gap in undergraduate paramedic education. bmc med educ 2009;9:23. https://doi.org/10.1186/1472-6920-9-23 7. billet s. realising the educational worth of integrating work experiences in higher education. stud high educ 2009;34(7):827-843. https://doi.org/10.1080/03075070802706561 8. mcwhirr s, gordon r. a holistic view of formal mentoring relationships: can activity theory bridge the gap? aberdeen, uk: robert gordon university, 2014:1-2. accepted 1 july 2019. https://doi.org/­10.1080/13611267.2016.1163637 https://doi.org/­10.1080/13611267.2016.1163637 https://www.umalusi.org.za/docs/research/2009/jgamble.pdf https://www.umalusi.org.za/docs/research/2009/jgamble.pdf https://doi.org/10.1186/1472-6920-9-23 https://doi.org/10.1080/03075070802706561 published online ajhpe forum at the university of cape town (uct), academic activities were temporarily suspended on 16 march 2020 in response to the anticipated national covid19 pandemic. health sciences educators were tasked with adapting teaching to an online platform, with an expected return to the clinical platform at a later stage. reasons for suspension of clinical teaching included safety of students, concerns that students may themselves be vectors of transmission, limited learning opportunities on a clinical platform overwhelmed by the outbreak response, and pressured clinical staff who may struggle to balance both teaching demands and service on an overburdened clinical platform.[1,2] the president of south africa had declared a national state of disaster on 15 march, followed by a national lockdown, commencing 27 march. by may 2020, after extensive stakeholder engagements, final-year medical students were invited to return to the clinical platform in order to support learning and timeous graduation by the end of the year. at the time of this invitation, the cape town metro was experiencing an increase in covid-19 case numbers and approaching the peak of the epidemic. on return to campus, a mandatory two-week quarantine period was instituted by uct for all 216 final-year medical students. this quarantine period was identified as an opportunity to prepare students for return to the clinical platform. the challenges of delivering remote learning were ameliorated through the more reliable network provided on the university campus compared with variable home circumstances. as at many universities, the traditional ‘clinical years’ of training at uct include rotations or clinical clerkships through different clinical specialties.[3] this practice is against a backdrop of a more integrated ‘preclinical’ approach that uses medical education strategies such as problembased learning.[4] the well-described divide between pre-clinical and clinical years often results in more discipline-based approaches in the latter years of training.[3,4] learning areas such as public health often lose relevance in the latter years owing to the ‘siloed’ approach to teaching. the covid19 pandemic has forced health professionals and systems to consider the multiple dimensions of planning and resource management, prevention, clinical management, as well as surveillance and tracing of possible contacts. covid-19 has provided an illustrative example of a major public health crisis, exacerbated by existing socioeconomic inequities and affecting all aspects of society, being not limited to any one sector or discipline. as students were being prepared to return to a clinical platform transformed by the pandemic, they reflected similar anxieties prevalent in society towards the risks associated with the pandemic. a clear need was highlighted to prepare students more holistically to function as learning professionals within the conditions of the pandemic. an interdisciplinary and interprofessional team of educators prepared a two-week course to facilitate the re-entry of final-year students into clinical learning contexts. the navigating covid-19 online course was thus conceived, embracing an integrated approach to learning and building on learning from earlier years of study. a key consideration for the course was to include students in the shaping of content areas. the first day of the course focussed on asynchronous student discussion about their fears, anxieties and learning needs. this feedback was used to shape and adapt content areas. given the limited time to prepare the course, content included a combination of existing pandemic resources supplemented by newly developed learning resources in response to student needs. time was dedicated to review resources for specific content areas, as well as consolidation and assessment (table 1). assessment was intentionally limited in order to encourage learning without the additional pressure of formal assessment. core assessments included personal protection equipment (ppe) competency and completion of a covid-19 training module developed for primary healthcare settings.[5] three synchronous activities were scheduled in the form of live webinars. speakers included a healthcare worker recovering from covid-19, hospital managers, faculty leadership, different medical specialists, registrars, interns and final-year students themselves who had volunteered as contact tracers the covid-19 pandemic has resulted in an upheaval in health sciences education.[1] globally, training of medical students on university campuses and clinical platforms was suspended and rapidly transitioned to online learning.[1,2] in some countries, graduation of senior medical students was expedited in order to contribute to a health workforce in crisis.[1,2] the transition to online learning has been particularly challenging in lowand middle-income countries where access to remote learning opportunities is limited for some students and further widens societal inequities.[1] the pandemic, however, also provides an opportunity to re-imagine clinical learning and develop innovative ways to strengthen the clinical training platform and health system. afr j health professions educ 2021;13(1):x-x. https://doi.org/10.7196/ajhpe.2021. v13i1.xx navigating covid-19: preparing medical students in a time of pandemic n jacob,1 mb chb, mmed, fcphm (sa); f cilliers,2 mb chb, honsbsc, mphil, phd; k begg,3 mb chb, dch, dip obs, fcphm (sa); l green-thompson,3 mb bch, da, phd, fca (sa) 1 school of public health and family medicine, faculty of health sciences, university of cape town, south africa 2 department of health sciences education, faculty of health sciences, university of cape town, south africa 3 deanery: faculty of health sciences, university of cape town, south africa corresponding author: nisha jacob (nisha.jacob@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. published online ajhpe forum during the initial pandemic response. the webinars focussed on critical aspects raised by students in earlier engagements: • what happens if i get covid-19? • being a healthcare worker in a time of pandemic • public health and clinical considerations in the management of covid-19. the varied array of speakers prompted active student engagement and further discussion of concerns originally presented on the first day of the course. many of the invited speakers were recent graduates. engagement with these young professionals as teachers appeared to appeal to students as their experiences were more relatable and the traditional power dynamic between educator and learner was attenuated. the largely positive reception of the course prompted adaptation and delivery of the course to a wider student base, not limited to medical students, as well as staff. while the covid-19 pandemic presents many challenges in health sciences education, the navigating covid-19 course has provided a glimpse into the potential of integrated learning in a clinical environment. the integrated approach relies heavily on teamwork and integration among educators themselves and strong support from faculty leadership. as educators, it is important to be flexible in adapting teaching methods and responsive to student needs, to reshape curricula and strengthen known weaknesses. by adopting such approaches to education, we can better support the development of integrated healthcare practitioners who can provide safe patient care, strengthen the health systems that they work in, and advocate for improved health for all of society. acknowledgements. we gratefully acknowledge chivaugn gordon, rachel weiss, gillian ferguson, brigid brennan, nazlie beckett, celeste de vaal, ayanda gcelu, kirsten reichmuth, mariam karjiker, waseela khan, steve reid, graeme meintjes, michal harty, leigh ann richards, shamila manie, petula wicomb, lebogang ramma, tracey naledi, sean burmeister and landon myer. author contributions. nj convened the course and wrote the manuscript. fc co-convened the course and made significant intellectual contributions to the manuscript. kb and lgt provided support and made significant intellectual contributions to course development and manuscript preparation. all authors read and approved the final manuscript. funding. none. conflicts of interest. none. 1. gill d, whitehead c, wondimagegn d. comment: challenges to medical education at a time of physical distancing. lancet 2020;6736(20):10-12. https://doi.org/10.1016/s0140-6736(20)31368-4 2. kachra r, brown a. the new normal: medical education during and beyond the covid-19 pandemic. can med educ j 2020;11(6):4-6. https://doi.org/10.36834%2fcmej.70317 3. norris te, schaad dc, dewitt d, et al. longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in australia, canada, south africa, and the united states. acad med 2009;84(7):902907. https://doi.org/10.1097/acm.0b013e3181a85776 4. wood d. problem based learning. bmj 2003;326:328. https://doi.org/10.1136%2fbmj.326.7384.328 5. practical approach to care kit western cape covid-19 course. 3rd ed. cape town: western cape department of health; 2020. https://ktuonlineschool.datafree.co/courses/pack-western-cape-covid-19-3 (accessed 16 june 2020). accepted 7 december 2020.. table 1. navigating covid-19 course: content areas epidemiology, transmission and pathogenesis of covid-19 impact of covid-19 on the population pandemic management approaches to managing patients during covid-19 across clinical specialties coping mechanisms, including mental health and well-being and coping with loss and grief principles of interprofessional practice personal and team safety and competency in use of personal protective equipment (ppe) https://doi.org/10.1016/s0140-6736(20)31368-4 https://doi.org/10.36834%2fcmej.70317 https://doi.org/10.1097/acm.0b013e3181a85776 https://doi.org/10.1136%2fbmj.326.7384.328 https://ktuonlineschool.datafree.co/courses/pack-western-cape-covid-19-3 april 2021, vol. 13, no. 1 ajhpe 83 research in 1978, the landmark declaration of alma ata on primary healthcare (phc) recognised that a new approach was needed to achieve ‘health for all by the year 2000’.[1] in 1994, the university of cape town (uct) faculty of health sciences (fhs), recognising phc-inspired health policy developments in a democratic south africa (sa), adopted the phc approach as a ‘lead theme’ in its teaching, research and clinical service.[2] the multidisciplinary phc directorate was established in 2003 as a cross-cutting ‘horizontal’ unit to promote the phc approach in the fhs, as well as expanding and managing the decentralised clinical teaching platform for more community-based education (cbe). the concept of social accountability, or the capacity to respond to priority health needs and health system challenges, has gained currency in the past quarter century.[3,4] it emphasises partnerships between health science faculties and key stakeholders in the health sector and communities, and the need for health sciences education to maximise its relevance and impact on people’s health.[5,6] the international training for health equity network (thenet) was founded in 2008 to promote health equity through health workforce education, research and service, based on the principles of social accountability and community engagement. thenet has developed a practical tool with extensive indicators to help health science faculties align their training of health workers with community needs: the framework for socially accountable health workforce education.[7] an academic review of the phc directorate in october 2014 recommended, inter alia, that indicators be developed for monitoring and evaluating the phc lead theme, which shares many principles with those of social accountability, such as equity, community partnerships and advocacy. all the authors of this article have extensive experience in teaching the phc approach in the fhs, and most are members of the phc working group, which was mandated by the fhs deanery in june 2017 to respond to the recommendations of the academic review. the authors therefore formed an action research group to develop a set of indicators and evaluate phc teaching and learning of final-year health and rehabilitation sciences and medical students at selected cbe sites of the fhs. the research group’s objectives for the present study were therefore to identify evidence of selected phc indicators in the documented learning outcomes, activities and assessments of final-year students, to evaluate the alignment of the background. the comprehensive primary healthcare (phc) approach has been a lead theme in the university of cape town faculty of health sciences (fhs) since 1994. a 2014 institutional academic review recommended that indicators be developed for monitoring and evaluating the phc theme. objective. to evaluate phc teaching and learning of final-year health and rehabilitation sciences and medical students at three community-based education (cbe) sites of the faculty, two in cape town and one in a distant and largely rural district. methods. course documents were analysed for evidence and alignment of nine indicators of the phc approach in the documented learning outcomes, activities and assessments of final-year health sciences students. clinical educators and students were interviewed to identify factors that facilitate or impede phc teaching and learning on site. results. final-year health sciences disciplines engage inconsistently with phc principles at the cbe sites. alignment appears to be strongest between learning outcomes and teaching activities, but the available data are insufficient to judge whether there is also strong alignment between outcomes and teaching, and formal graded assessment. phc teaching and learning at the cbe sites are facilitated by good multiprofessional teamwork, educator rolemodelling and good infrastructural and logistical support. language barriers, staff shortages and high workloads are significant and prevalent barriers. conclusion. strong faculty leadership is required to promote the phc lead theme and to achieve better departmental and multiprofessional collaboration in teaching the phc approach. this study provides evidence from well-established cbe sites to inform future work and participatory action research in promoting the phc approach in teaching and learning in the fhs. afr j health professions educ 2021;13(1):83-92. https://doi.org/10.7196/ajhpe.2021.v13i1.1284 how well do we teach the primary healthcare approach? a case study of health sciences course documents, educators and students at the university of cape town faculty of health sciences j irlam,1 bsc, bsc hons (med), msc, mphil; m i datay,1 mb chb, dphil, fcp; s reid,1 bsc (med), mb chb, mfammed, phd; m alperstein,2 bsocsci nursing, pg dip, mphil; n hartman,2 msocsci, phd; m namane,3 mb chb, msc (immunol), mphil (fam med), msc (clin epidemiol); s singh,4 bspht, ma, phd; f walters,4 bspht, msc 1 primary health care directorate, faculty of health sciences, university of cape town, south africa 2 department of health sciences education, faculty of health sciences, university of cape town, south africa 3 division of family medicine, faculty of health sciences, university of cape town, south africa 4 division of communication sciences and disorders, faculty of health sciences, university of cape town, south africa corresponding author: j irlam (james.irlam@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 84 april 2021, vol. 13, no. 1 ajhpe research outcomes, activities and assessments, and to identify factors that facilitate or impede teaching and learning of the phc principles at the cbe sites. congruent with the action research approach, a faculty-wide phc symposium was planned from the outset to present the preliminary study findings to key stakeholders and collectively develop recommendations for promoting the phc approach in the faculty. methods a case study design was employed, examining three cbe sites that were deemed to have good potential for phc teaching and learning by virtue of having permanent and dedicated site co-ordinator staff who were members of the phc directorate: the secondary-level new somerset hospital (nsh) in central cape town (which also has primary-level district functions); the primary-level vanguard community health centre (vchc) in a nearby suburb; and vredenburg district hospital (vdh) in a largely rural district about 140 km north of cape town. the study received ethical clearance from the fhs human research ethics committee (ref. no. hrec 157/2018). case study designs facilitate the exploration of a phenomenon within its context using a variety of data sources, which are converged during data analysis to enhance credibility.[8] the flexibility and rigour of the design makes it useful for developing theory, evaluating programmes and developing interventions in health science educational research.[9] a national delphi panel of experts in socially accountable health sciences education first selected a set of nine phc indicators over two rounds (table 1). five indicators were adapted from the health for all mnemonic developed for students by the phc directorate (fig. 1), and four from the training for health equity network framework for socially accountable health workforce education.[7] the delphi phase of the research is described in an article currently being prepared for publication by the team. course documents were then analysed for evidence of the delphi phase indicators in final-year student learning outcomes, activities and assessments, by two members of the action research team. a family medicine specialist (mn) analysed documents for medical courses, and a speech language therapist educator (fw) analysed documents from the health and rehabilitation sciences, as they are very familiar with the curriculum and have experience in curriculum design and review. data collection sheets were designed to capture whether the indicators were present, absent or not relevant, as well as to record any examples or comments and the documentary source (course manuals, teaching and assessment tools, service-learning documents, the online course management system vula). each indicator had a descriptor to assist consistent understanding of what it represented. all clinical educators with at least a year’s experience at the cbe sites were invited by email to be interviewed individually by either ji or mid, who are experienced senior lecturers and phc tutors in the phc directorate, and eight educators accepted. use was made of a standard interview guide to elicit educators’ understanding of the phc approach, their perceptions of how evident the phc principles were in student learning outcomes on site and what the main facilitators and barriers are to phc teaching and learning (table 2). a table of 18 phc principles was used to check which principles are taught and/or assessed at each site. all final-year students in the fhs with at least 3 weeks’ exposure to one of the cbe sites were invited to focus group discussions via several vula announcements. eighteen students were eligible, nine responded initially, but only two speech language therapy (slt) students and one medical student finally consented to participate. the slt students were interviewed together, and the medical student alone. two authors not involved in finalyear teaching or assessment (nh and ma) used an interview guide and the health for all mnemonic to elicit the students’ understanding of phc, their phc learning experiences on site and their perspectives on facilitators and barriers (table 2). all interviews were audio-recorded with consent, transcribed and anonymised. internal validity and credibility checks were done by summary and confirmation with interviewees during or after the interviews. the key themes were deduced from the transcripts during analysis. results document analysis course documents were requested from all heads of departments and conveners of final-year courses in the fhs. after three emailed requests, documents were received from family medicine, surgery, obstetrics and gynaecology (o&g), paediatrics, physiotherapy (pt) and communication sciences and disorders (csd, including audiology and slt). three disciplines responded that they do not teach on the cbe platform (orthopaedics, psychiatry and pharmacology), one agreed to participate but did not submit documents (rheumatology) and one did not respond (occupational therapy). the key findings are described in tables 3 a and b, which summarise the evidence of selected phc indicators in the documents. table 1. indicators selected by delphi panel for document analysis health for all indicators 1. holistic understanding of healthcare users is emphasised. 2. accessible care is provided to all. 3. health promotion by means of patient education is emphasised. 4. rights of healthcare users are always respected. 5. levels of care and referral provide good continuity of care. thenet indicators (training for health equity network 2016[7]) 6. the education programme, including curriculum content, reflects priority health and social needs of the communities served. 7. the teaching philosophy and practice embodies core values of social accountability (e.g. respect for dignity and rights of learners and patients, social justice). 8. the teaching philosophy and practice are appropriate to learners’ needs and context (e.g. support for dealing with language and cultural diversity in unfamiliar settings). 9. the safety of students in the community is a priority for the faculty. april 2021, vol. 13, no. 1 ajhpe 85 research medical disciplines all four medical disciplines engage to varying extents with the nine phc indicators. in paediatrics, all indicators and corresponding learning outcomes are explicitly stated in the 6th-year course manual, and the principle of human rights is apportioned a quarter of the ward mark. family medicine promotes accessible care by teaching in rural and urban communities, and extending palliative care into patients’ homes. paediatrics is the only medical discipline with documentary evidence of the thenet indicator of social accountability. prioritising the safety of learners is evident in the ‘keep safe’ uct student guide on vula and in general safety awareness posters around campus. specific advice about disease prevention and infection control is only evident in the paediatrics course manual. health and rehabilitation disciplines all five health for all indicators were evident in the pt and csd documents. continuity of care is taught and assessed at all levels of the healthcare system, and csd students do referrals with help from their uct clinical supervisors, since there are no permanent western cape department of health staff to manage the caseload. the international classification of functioning, disability and health (icf), which is the world health organization framework for measuring health and disability at individual and population levels,[10] emphasises a holistic understanding of clients’ needs. there were multiple examples of respect for human rights in references to informed consent, respect for privacy, professional communication and learning key words and phrases in the client’s home language. pt students make services accessible in settings such as factories, childcare centres and patients’ homes, and csd students see both booked and unbooked patients. health promotion is a central principle, so pt and csd students undertake compulsory health promotion projects during their site rotations. most of the four thenet indicators were evident. in addition to the ‘keep safe’ guide and tuberculosis policy on vula, there is profession-specific advice about infection control, such as cleaning audiology equipment and adopting a holistic, biopsychosocial ('whole person') approach to health seekers, healthcare and health provision. being conscious of equity ('fairness') and equality requirements, and emphasising ways to facilitate social justice in healthcare. recognising and responding to the impact of environmental concerns (especially climate change) on health. ensuring universal access to healthcare and provision. ensuring meaningful and reciprocal community and family liaison, engagement, participation and involvement in healthcare. commitment to multidisciplinary team approach to individual and public health. promoting individual and public health by means of information, education, communication, advocacy, mediation and enabling. committing appropriate resources (�nancial, structural, human, etc.) to ensure a�ordable quality healthcare. promoting broad intersectoral collaboration in addressing the social determinants of health. providing healthcare that is framed by and facilitates the realisation of human rights and responsibilities. ensuring that healthcare and provision is acceptable and appropriate for all users. providing healthcare that integrates critically appraised 'best' evidence from the literature with the patient's values and the clinician's experience. ensuring that levels of healthcare are appropriate and that referral processes are e�cient. holistic equity, equality and environment accessibility listening to, and learning from, communities teamwork (multidisciplinary) health promotion funding and resources (a�ordability) other sectors (intersectoral collaboration) rights (human) and responsibilities acceptability and appropriateness literature (evidence-based practice) levels of care and referral primary health care directorate health for all primary healthcare principles fig. 1. health for all mnemonic (primary health care directorate, university of cape town). 86 april 2021, vol. 13, no. 1 ajhpe research safely managing drips and catheters. pt course documents refer explicitly to the needs of communities, and csd students are assessed on their community needs analyses. although social accountability was not made explicit, csd students undertake projects with community partners. interviews with clinical educators educators’ understanding of phc approach table 4 provides illustrative quotes from educator and student interviewees. for a clinical educator in o&g at nsh, the phc approach is evident in the multidisciplinary team that (s)he works alongside (quote 1). an experienced physiotherapy educator at vchc referred to the team being able to recognise all the needs of the patient and to refer appropriately among themselves (quote 2). a qualified speech language therapist and audiologist who had convened csd placements at vdh since 2013 emphasised partnerships with communities and non-governmental organisations, and the need for high-quality care that is evidence-based, cost-effective and respects the rights of patients and healthcare providers. the understanding of phc as a holistic approach to care at all levels, rather than just primary-level care, is not always evident, however (quote 3). an educator at nsh observed that paediatrics registrars have no exposure to the phc approach, and therefore do not explicitly teach it (quote 4). educator perceptions of phc in learning outcomes an experienced specialist physician at nsh who has taught medicine, physiology and pathology for a decade always teaches the multiple determinants of illness and healthcare behaviour, such as non-adherence (quote 5). an o&g educator, who graduated from uct over a decade previously, perceives more evidence of a holistic approach in the three preclinical years than during the clinical rotations at nsh during years 4 6 (quote 6). she expects that students should broaden their approach by fifth year to include health promotion and prevention (quote 7). an educator in slt and audiology at vdh gave health promotion and disease prevention, especially in the form of counselling and educating mothers, as examples of phc. a family physician at vdh believes that their multiprofessional (mp) team provides a holistic community-based service to all patients. students also learn the importance of patient-centred care and making the most of available resources, such as learning to manage disease based on the essential drugs list. an ot educator at vdh spoke about the value of student exposure to community development with community-based ots, specifically in early childhood development centres (quote 8). a pt educator at vchc believes that weekly observation of students’ clinical skills and patient communication, followed by a feedback session, makes students more aware of the importance of respect, empathy and how to make therapy more effective. an experienced slt educator gets her students to consider population health by doing group projects at various community-based sites (quote 9). she viewed the collaboration of pt, audiology, slt and pharmacology students at the vchc student learning centre as an important experience of mp teamwork. educator perceptions of teaching and assessment of phc principles table 5 summarises educators’ perceptions of the teaching and assessment of each of 18 phc principles by site and discipline. the principles that are most often taught and assessed are: person-centred care; a multidisciplinary team approach; community participation; continuity of care; respecting human rights; appropriate care; evidence-based care; and promoting health by means of health education, behaviour change and public advocacy. five principles that are most often taught but not assessed are: promoting equity and social justice; promoting broad intersectoral collaboration; affordable care; accessible care; and acceptable care. principles that are seldom taught are: promoting health by means of policy reform; sustainably funded care; and environmentally sustainable care. table 2. interview questions for clinical educators and students clinical educators 1. there are different understandings of what is meant by the phc approach: a. please briefly describe your understanding of the phc approach. b. can you name any values or principles that characterise this approach? 2. please describe the key student learning outcomes for this site. 3. please describe how you think the student learning outcomes for this site reflect the phc approach and principles that you have described above. 4. please describe any factors that facilitate or inhibit the realisation of the phc approach in teaching and learning at this site: a. facilitating factors b. inhibiting factors 5. please assist us in strengthening our teaching and assessment of the phc approach by indicating which of the statements in the table below apply to learning at this site. review table of 18 phc principles and indicate which are taught/assessed: 6. please motivate your responses. 7. do you have any closing comments about this interview? students 1. what is your understanding of the principles of the phc approach? 2. how did you experience these principles in your learning activities at the cbe sites? please provide examples of your experiences. 3. how were these principles assessed, if at all? for principles not raised: share the mnemonic and ask questions 2 and 3: 4. please describe any facilitators or obstacles to implementation of the phc principles at the sites? 5. what changes, if any, would you like for improved learning about phc at the sites? phc = primary healthcare; cbe = community-based education. april 2021, vol. 13, no. 1 ajhpe 87 research ta bl e 3 a . e vi de nc e of s el ec te d p h c in di ca to rs fr om d oc um en t a na ly si s: t h en et t h en et in di ca to r ev id en t i n co ur se do cu m en ts ? c om m en ts family medicine o&g surgery paediatrics csd (audiology; slt) physiotherapy fa m ily m ed ic in e o & g su rg er y pa ed ia tr ic s c sd p hy si ot he ra py sa fe ty o f s tu de nt s is a pr io ri ty y y y y y y u c t k ee p sa fe g ui de o n v ul a; v c h c h as a c om m itt ee fo r st ud en t sa fe ty u c t k ee p sa fe g ui de o n v ul a u c t k ee p sa fe g ui de ; p re ca ut io ns ag ai ns t i nf ec tio us di se as es a re ta ug ht u c t k ee p sa fe g ui de a nd t b p ol ic y on v ul a; s pe ci fic he al th a nd s af et y gu id el in es c ou rs e m an ua l in cl ud es t b, in fe ct io n co nt ro l, ne ed le st ic k in ju ri es a nd pa tie nt s af et y gu id el in es ( e. g. ca re o f d ri ps a nd ca th et er s) te ac hi ng r ef le ct s th e ne ed s of c om m un iti es se rv ed n n y y y y b ar el y an y te ac hi ng o n vi ol en ce ( a to p ca us e of d is ab ili ty a nd d ea th in v c h c c om m un ity ) n ot e vi de nt in do cu m en ts st ud en ts e xp os ed to c om m on su rg ic al c on di tio ns th at a re m an ag ed at p ri m ar y le ve l 6t hye ar s er vi ce le ar ni ng is a co nt in uu m o f 5t hye ar s tr uc tu re d te ac hi ng , s o a u c t st af f m em be r is es se nt ia lly p re se nt a t 6t hye ar le ve l se ct io n on n ee ds an al ys is in cl ud ed in m ar k sh ee t le ar ni ng o ut co m e is to c on si de r th e ne ed s of th e co m m un ity te ac hi ng is s oc ia lly ac co un ta bl e to co m m un iti es s er ve d n n n y y n pr oj ec ts a dd re ss in g co m m un ity / fa ci lit y ne ed s st op pe d in 2 01 6 to d ed ic at e th e sh or t p la ce m en t to c lin ic al tr ai ni ng a nd s er vi ce le ar ni ng n ot e vi de nt in do cu m en ts fo cu s on di ag no st ic a nd m an ag em en t s ki lls g oo d em ph as is (a lb ei t t he or et ic al ) i n co ur se m at er ia l fo cu s on c on du ct in g co m m un ity p ro je ct s on b lo ck n ot e xp lic it in do cu m en ts te ac hi ng is ap pr op ri at e to le ar ni ng n ee ds o f st ud en ts y n y y y n ot cl ea r r ot at io n st ru ct ur ed to c ap st on e pr io r sp ir al le ar ni ng a nd s up po rt se rv ic e le ar ni ng ; s tu de nt s fo llo w pr ot oc ol s an d po lic ie s us ed a t t he v c h c ; p at ie nt s tu dy r eq ui re d fo r ad dr es si ng s tu de nt s’ ow n qu al ita tiv e an d qu an tit at iv e cl in ic al q ue st io ns n o sp ec ifi c se lfdr iv en e xe rc is es to ad dr es s le ar ni ng n ee ds re ga rd in g di ag no st ic an d m an ag em en t te ch ni ca l s ki lls fo r ob st et ri c co nd iti on s st ud en ts m ay m is s le ct ur es to s pe nd tim e in st ea d in w ar ds o r th ea tr es a t l ea st 6 p at ie nt w ri te -u ps e xp ec te d fo r st ud en t t o ad dr es s ow n le ar ni ng n ee ds w ith s up po rt o f a re gi st ra r le ar ne rs w or k to ge th er a nd c on du ct pe er r ev ie w s on ea ch o th er ’s in pu t t o en su re g ro up u ni ty an d ef fe ct iv e gr ou p w or ki ng s ki lls n ot c le ar w he th er s tu de nt ev al ua tio ns a re ev id en ce o f t hi s pr in ci pl e 88 april 2021, vol. 13, no. 1 ajhpe research ta bl e 3 b . e vi de nc e of s el ec te d p h c in di ca to rs fr om d oc um en t a na ly si s: h ea lt h f o r a ll h ea lt h f o r a ll in di ca to rs ev id en t i n co ur se do cu m en ts ? c om m en ts ( du ra ti on a t c b e si te , w ee ks ) family medicine o&g surgery paediatrics csd (audiology; slt) physiotherapy fa m ily m ed ic in e (3 w v c h c ; 1 w v d h ) o & g (4 w n sh ) su rg er y 3 w n sh pa ed ia tr ic s (6 w n sh ) c sd (6 w c h c ; 6 w v d h ; 1 2 w n sh ) p hy si ot he ra py (5 w n sh ; 5 w v d h ) le ve ls o f c ar e an d re fe rr al pr ov id e go od c on tin ui ty of c ar e y y y y y y st ud en ts r ef er a cc or di ng to e st ab lis he d re fe rr al p at hw ay s of th e he al th s er vi ce s th at p ro m ot e co nt in ui ty o f ca re st ud en ts m an ag e an d re fe r pa tie nt s to s ec on da ry a nd te rt ia ry le ve ls o f ca re r ec og ni se s ac ce ss to re ha bi lit at io n ac ro ss al l l ev el s; in te rv en tio ns sh ou ld b e su st ai na bl e an d ap pr op ri at e gi ve n lim ite d ac ce ss to h ig he r le ve ls o f c ar e h ol is tic u nd er st an di ng of h ea lth ca re u se rs is em ph as is ed y y n y y y t hr ee -s ta ge a ss es sm en ts in fa m ily m ed ic in e an d ho m e vi si ts in p al lia tiv e ca re a re r ou tin e r eg ul ar r ef le ct io n on ex pe ri en ce s in m o u s an d co m m un ity p er in at ol og y le ar ni ng ob je ct iv e re st ri ct ed to k no w in g as so ci at ed m ed ic al co nd iti on s ex pl ic it al ig nm en t e vi de nt be tw ee n ou tc om es , t ea ch in g an d as se ss m en t st ud en ts un de rt ak e ne ed s an d si tu at io n an al ys is u po n en te ri ng co m m un iti es u se o f t he ic f re qu ir ed r ig ht s of h ea lth ca re u se rs ar e al w ay s re sp ec te d y y y y y y c lin ic al e va lu at io n ex er ci se ( m in ic ex ) to ol us ed fo r da ily s tu de nt as se ss m en ts ‘p ro fe ss io na l c on du ct ’ i s br ie fly e xp la in ed ; c au tio ns in ap pr op ri at e us e of s oc ia l m ed ia em ph as is es re sp ec tf ul co m m un ic at io n, pr of es si on al ap pe ar an ce a nd be ds id e et iq ue tt e pr of es si on al c on du ct c ou nt s 25 % o f w ar d as se ss m en t; fh s co de o f c on du ct fo r ele ar ni ng a ct iv iti es a dd re ss ed in pr oj ec t d es ig n an d m an ag em en t co ur se a dd re ss es in fo rm ed c on se nt an d pr of es si on al co m m un ic at io n (e .g . kn ow k ey w or ds in cl ie nt ’s la ng ua ge , d ra pe th e cl ie nt e ff ec tiv el y to re sp ec t p ri va cy ) a cc es si bl e ca re is pr ov id ed to a ll y y y y y y a cc es s is h or iz on ta l (t ri ag e) a nd v er tic al (a pp oi nt m en ts ), bu t n o en ga ge m en t w ith h om e an d co m m un ity -b as ed ca re s er vi ce fr eq ue nt s tu de nt a nd m id w ife c om an ag em en t a t co m m un ity b ir th in g un its r ef er re d an d w al kin p at ie nt s se en pa tie nt s w ith c hr on ic il ln es se s fo llo w ed u p, b ut te ac hi ng ab se nt a t c om m un ity le ve l b oo ke d an d un bo ok ed pa tie nt s se en pa tie nt s se en a t a va ri et y of s ite s (f ac to ri es , c hi ld ca re ce nt re s, o ld a ge h om es , et c. ) h ea lth p ro m ot io n by m ea ns o f p at ie nt ed uc at io n is e m ph as is ed y y n y y y se le ct ed u pt od at e ar tic le s in v ul a re so ur ce s h ea lth p ro m ot io n re qu ir ed fo r m an ag em en t o f m ed ic al pa tie nt s (e .g . a p os t c /s d v t ) n ot e vi de nt in c ou rs e do cu m en ts h ea lth e du ca tio n em ph as is ed th ro ug ho ut ; s el ec te d u pt od at e ar tic le s in v ul a st ud en ts e ng ag e in h ea lth pr om ot io n pr oj ec ts st ud en ts ta ke o n he al th pr om ot io n in iti at iv e of th e di st ri ct a t v d h ph c = p ri m ar y he al th ca re ; c be = c om m un ity -b as ed e du ca tio n; o & g = o bs te tr ic s an d gy na ec ol og y; c sd = c om m un ic at io n sc ie nc es a nd d is or de rs ; s lt = s pe ec h la ng ua ge th er ap y; v c h c = v an gu ar d c om m un ity h ea lth c en tr e; n sh = n ew s om er se t h os pi ta l; v d h = v re de nb ur g d is tr ic t h os pi ta l; m in ic ex = m in i c lin ic al e va lu at io n ex er ci se ; m o u = m id w ife o bs te tr ic u ni t; ic f = in te rn at io na l c la ss ifi ca tio n of f un ct io ni ng , d is ab ili ty a nd h ea lth ; f h s = fa cu lty o f h ea lth s ci en ce s; c /s = c ae sa ri an s ec tio n; d v t = d ee p ve in th ro m bo si s. april 2021, vol. 13, no. 1 ajhpe 89 research table 4. selected quotes from clinical educator and student interviews clinical educators 1. ‘it cannot be done only by the medical doctor. we reach out to multiple areas in our discipline. the social workers are involved, and the physiotherapists are involved and dieticians are involved, and i think to me that is what primary healthcare represents.’ (o&g educator, nsh) 2. ‘the patient should have availability or access to a combination of healthcare professionals to provide the basic services required; the interaction between those professionals should be able to recognise the needs of the patient and be able to refer amongst each other.’ (pt educator, vchc) 3. ‘a lot of people get confused about the primary healthcare approach, confusing it with primary care and thinking this is something that only happens in clinics and at community level.’ (speech language therapist, vchc, nsh, vdh) 4. ‘i was surprised to discover there is a primary health care directorate within uct. you have a great website, and this is good stuff, but i have never heard of this and come across this before and seen the penetration of this through the undergraduate curriculum. the registrars don’t know any of this and they get no exposure to it; and then when we teach as clinicians, we teach clinical work.’ (paediatrics educator, nsh) 5. ‘i always bring in the social and economic factors, religious, traditional factors that influence diseases and especially in our setting with tb and hiv. i remind the students of all the various factors that contribute to non-adherence to medications.’ (general medicine educator, nsh) 6. ‘i think we get this message (the importance of a biopsychosocial approach) across to the students actually quite strongly in the first 3 years. they take a little bit of time to get into it in the clinical years, but it is great if they get it all back at the end and it comes together. you get the students who don’t focus on this at all, but i am sure there are consultants who do the same. and at the end of the day, i think we just need to reinforce that we cannot lose the primary healthcare principles in our everyday practice of medicine.’ (o&g educator, nsh) 7. ‘i think if the student can take an adequate history and do a good examination, obviously problem-related, then they have achieved their goal in third and fourth year. in fifth year, it is much broader and i expect them to piece the puzzle together and make a diagnosis and come up with the management plan and then address all the key issues, including the health promotion and prevention issues.’ (o&g educator, nsh) 8. ‘and within those centres in terms of the learning outcomes there is a lot related to the intention or philosophy of ot, but i think they mimic quite a few of the primary healthcare principles, in that it’s about forming partnerships, building understanding as pivotal to forming a partnership, identifying occupational profiles of the children and their caregivers, which means gaining an understanding of not only what their skills are or their deficits, but how the context, the community, their home, their school, the broader community supports their health and wellbeing.’ (ot educator, vdh) 9. ‘when you are a hospital therapist it is actually a complete package in terms of seeing individual clients and doing group projects. these could be anything from providing information to breastfeeding mothers to explaining to them why it is beneficial to their babies, depending on what needs arise.’ (speech language therapist, vchc, nsh, vdh) 10. ‘they learn how to make low-cost toys for example; they learn about assistive devices; they learn about different options that service users have to access different levels of healthcare. they know about the rights, say for example, of children to access health in the public sector for free beyond a certain age in line with their income.’ (ot educator, vdh) 11. ‘when i examine end-of-block and end-of-year exams and i do a portfolio exam and wrap up with what they learn from their phc approach, they always say something quite glib and trite about intersectoral collaboration; or what this case taught me was this and that, and they say a very smug one-line sentence, which has probably been handed down and cut and pasted from years’ worth of student portfolio cases, and we leave it at that. i don’t teach explicitly phc principles, and i don’t explore their grasp and if they are able to come up with a principle and apply it to their case.’ (paediatrics educator, nsh) 12. ‘i think that is somewhere we can improve, somehow assess them more formally. i would think them seeing a patient and focusing then on primary healthcare would be a nice, practical way of them assessing their knowledge and understanding of primary healthcare.’ (general medicine educator, nsh) 13. ‘clinical exposure is massively important, since students are listening to stories and listening to where people go when they are not in your office; and that helps them to actually understand how to adjust projects.’ (speech language therapist, vchc, nsh, vdh) 14. ‘the intention in sending our final students there is because they gain a lot of the individual and population-based reasoning from them, and they’ve learnt already from community development practice about the value of gaining understanding, initiating, and working in a more developmental model. sites such as vredenburg give students the opportunity in a smaller kind of environment to work together, but also to live together and learn from each other.’ (ot educator, vdh) students 15. ‘so for us we have devices that could help with speaking … but they are not always affordable for all patients, so we need to think okay, what can we implement that will be suitable to the patient, that will be affordable.’ (slt student) 16. ‘we all struggled with the language barrier … for a lot of stroke patients who have aphasia, when you do the therapy that helps them, i don’t know if you know about semantic feature analysis? the words just come out, and it was coming out in his home language, but now because he thought he had to do it in english, he kept shifting back to english and that’s something that upset him, because now it’s affecting his care and it’s just, you don’t realise how much language can affect, especially in the adult setting … then you might just diagnose them wrong, i mean it might come across as he has aphasia, which is not true, it’s just that’s not his first language. so you might just do something wrong.’ (slt student) 17. ‘so we in vredenburg, tuesday afternoons were set out for multidisciplinary team, interdisciplinary, the new word, that term that they use, interdisciplinary team meeting with the med students, the audiologists, physios and the speech therapists … the first scenario that we had was a patient with tb and how you would treat them. and the doctors were like so what were the speech therapists and the audiologists doing here? and they were sitting there and they gave the facts, what medication they would give very briefly … the speech therapist and audiologist came and we had this whole thing about feeding, if the patient is strong enough, if the patient is aspirating and then the audio said about the hearing that’s going to get affected and if they are young and there’s a long space of you not being able to hear, then that would affect the language. so the speech therapist and the audiologist took over that whole session, and we were just talking, and the doctors at the beginning were like but why are you here? and then after hearing all of these things, they were like oh, i didn’t know you deal with feeding, or like oh? so it was such an eye opener for them and it was so nice for us to see that we could actually teach people about what we're doing, because there’s such a small understanding of our job description, which is really nice to be able to advocate.’ (slt student) 18. ‘we need more research and creating more culturally acceptable assessments, or translating assessments.’ (slt student) o&g = obstetrics and gynaecology; nsh = new somerset hospital; pt = physiotherapy; vchc = vanguard community health centre; vdh = vredenburg district hospital; uct = university of cape town; tb = tuberculosis; ot = occupational therapy; phc = primary healthcare; slt = speech language therapy. 90 april 2021, vol. 13, no. 1 ajhpe research an ot educator at vdh believes that students are well assessed by means of written work and practical projects with respect to the affordability, accessibility, appropriateness, acceptability and environmental sustainability of care (quote 10; table 4). paediatrics students have to describe a phc principle in their case report and portfolio examination, although an educator at nsh expressed some doubts about the validity of the assessment (quote 11). another educator at nsh believes that formal assessment of the phc principles should be improved (quote 12). educator perceptions of factors that facilitate or inhibit phc teaching and learning most educators considered facilitating factors to be good mp teamwork, experienced health professionals who demonstrated the phc approach, and the high burden of preventable disease that requires a preventive and health-promoting approach at all levels of care. the vulnerability of patients to diseases of poverty and underdevelopment, and to abuse by health professionals, was cited by some educators as motivating a strong focus on health equity and respect for patient rights. other facilitating factors include well-run facilities, the purpose-built student learning centre at vchc, wellestablished district outreach programmes, good monitoring of outcomes of care and reliable connectivity. engaging with communities in their context is seen by an slt educator to enhance understanding and the design of adaptive projects (quote 13, table 4), a view shared by an ot educator in the rural vdh district, where collaborative learning in a more intimate and supportive environment adds great value to learning (quote 14). the main barriers to phc teaching and learning are lack of space in health facilities, excessive workload, understaffing, lack of critical staff, and inadequate and costly transport. additional barriers were perceived to be a narrow biomedical focus in teaching, student safety in the community, poor referral pathways, inadequate student accommodation, insufficient outreach visits and suboptimal alignment between essential drug lists and tertiary treatment protocols. interviews with final-year students all three students could define and share personal experiences of accessible, appropriate, affordable and holistic care. the slt students also explained the multiprofessional and intersectoral principles of phc. immersion in the district at vdh helped students to appreciate patients in context, to better understand the referral system, and to see the importance of adapting patient management in low-resource and rural settings (quote 15, table 4). role-modelling by experienced clinicians, as well as tutorials and formal discussions, enabled individual patient advocacy. while the two slt students had advocated on behalf of school pupils and undertaken health promotion, this was not part of the medical student’s experience, although he was aware of district health promotion activities. none had experience of broader advocacy such as public health campaigns. continuity of care was evident in family medicine rotations at vdh and vchc, and by students referring to phc principles in their written work. none, however, had specifically discussed phc principles during ward rounds or in practice learning settings. language barriers constrain medical history-taking and slt assessments, and hence the potential extent of patient or client-centredness (quote 16). only the slt students cited application of human rights principles. they described the weekly interdisciplinary team meetings at vdh at some length, ta bl e 5. t ea ch in g an d as se ss m en t o f 1 8 p h c p ri nc ip le s by s it e an d di sc ip lin e ac co rd in g to c lin ic al e du ca to rs site discipline person-centred care multidisciplinary team comm unity participation continuity equitable rights-based intersectoral affordable accessible appropriate acceptable sustainably funded environmentally sustainable evidence-based health education behaviour change public advocacy policy reform n sh pa ed ia tr ic s n t ta t t ta t t t t t n n t ta ta ta n n sh o & g ta ta ta ta t ta t t t t t n n t ta ta ta n n sh in te rn al m ed ic in e ta t ta t t ta t t t n n n n ta ta ta n n v d h sl t a nd a ud io lo gy ta t ta ta ta ta ta ta ta ta ta ta ta ta ta ta ta n v d h fa m ily m ed ic in e ta ta t t t ta t t t ta t t t ta ta ta t n v d h o t ta ta ta ta ta ta ta ta ta ta ta ta ta ta ta t n n v c h c ph ys io th er ap y ta ta n ta n ta n n n ta t t n ta ta t n n v c h c , n sh sl t ta ta ta ta ta ta ta t ta ta ta t n ta ta ta ta t ph c = p ri m ar y he al th ca re ; n sh = n ew s om er se t h os pi ta l; n = n ot ta ug ht o r as se ss ed ; t = ta ug ht ; t a = ta ug ht a nd a ss es se d; o & g = o bs te tr ic s an d gy na ec ol og y; v d h = v re de nb ur g d is tr ic t h os pi ta l; sl t = s pe ec h la ng ua ge th er ap y; o t = o cc up at io na l t he ra py ; v c h c = v an gu ar d c om m un ity h ea lth c en tr e. april 2021, vol. 13, no. 1 ajhpe 91 research where they experienced hierarchy, ‘rank-pulling’ and patronisation, and in practice settings as well (quote 17). they observed the consequences of lack of interdisciplinary referrals due to clinicians’ insufficient understanding of the complementary roles of health professionals. constraints on practising evidence-based care were identified by the slt students, who reported that several assessments needed to be adapted specifically for the sa context (quote 18). although a few phc principles are formally assessed in written work, all three students said that summative assessment of most of the principles was absent. discussion document analysis phc indicators are evident in the documented learning outcomes of finalyear medical students at the sites, but most principles are inconsistently taught within the disciplines reviewed. the ‘spiral of learning’ is particularly evident in o&g and paediatrics, progressing from mostly structured learning in earlier years to service-learning in the final year. final-year teaching in pt and csd is well scaffolded from previous years, and clinical expectations are built on an academic knowledge base. use of the icf may account for relatively good understanding in pt and csd of the contextual factors that influence clinical assessment and management. services are made accessible: family medicine students do home visits for palliative care, pt students treat clients in a variety of workplace settings and slt students see patients who have not been formally referred. the principle of social accountability is not evident, however, in the documents from three of the four medical disciplines. there were no documents that explicitly encourage students to engage with public health issues or with primary care strategies, such as the 90-90-90 strategy[11] and the healthcare 2030 strategy of the provincial department of health.[12] family medicine community projects, discontinued in 2016, cannot be reintroduced because the 4-week block is too short. graded phc-related assessments are generally conducted by supervisors and sometimes by peers, but there are also non-graded assessment activities such as case discussions for formative feedback only. neither the analysed documents nor the educator interviews provided sufficient clarity on which phc principles are formatively assessed and which are assessed for marks. interviews with clinical educators educators’ understanding of the phc principles varied, yet most cited the importance of teamwork for holistic and accessible care at all levels, including health promotion and disease prevention. continual awareness of the comprehensive phc approach as a lead theme of the fhs is evidently needed among all clinical educators, however, so that the preclinical emphasis on the biopsychosocial approach, and opportunities for health education and promotion, are not lost during the clinical rotations. educators’ perceptions of phc principles in student learning outcomes, teaching and assessment reflected a good appreciation of their importance. some excellent examples were shared of mp practice, community participation, respect for patient rights and health promotion, particularly at vdh and vchc. there is, however, a missed opportunity for mp teamwork at vchc with the absence of medical, ot and nursing students from weekly team meetings, which may be due to logistical difficulties arising from insufficient course planning across disciplines. nevertheless, the student learning centre at vchc is generally considered to facilitate phc teaching and learning, as is the supportive peer learning environment at vdh. allowing students of different disciplines to interact and collaborate is evidently very beneficial for all teaching and learning, and should therefore be facilitated wherever possible. interviews with final-year students the medical student appears to have had fewer opportunities to observe, experience and/or practise the phc principles than the slt students. the structure of the final-year curriculum allows medical students only 1 week of immersion at the vdh site, in contrast to 7 weeks for slt students, with no opportunities for health promotion or home visits and only one mp session. nevertheless, that 1 week of immersion was considered valuable for deepening understanding of holistic patient care. it was reported that some phc principles were also taught and role-modelled at vchc. all three students commented on limited formative assessment of the phc principles, and their absence in summative assessment, which does not fully concur with the documents and perceptions of the educators. it may be that educators are not explicit enough about the assessments, or that students are not engaging sufficiently with the descriptors on the marksheets. there is a fair degree of convergence overall between students’ and educators’ perceptions of facilitating factors for phc. the slt students’ description of hierarchy in the weekly team meetings does not concur, however, with the opinion of most educators that role-modelling of good teamwork enables phc teaching and learning. furthermore, educators did not focus as much as students on language barriers to care. other barriers are inadequate understanding of the comprehensive phc approach, too few supervisors at some sites and insufficient time to engage in public health initiatives of the provincial department of health. study limitations there are several limitations to this study. firstly, only three cbe sites were studied, which although broadly representative of diversity across the clinical teaching platform, limits the generalisability of these findings. secondly, the very low response rate among students, which we ascribe to deep trauma in the faculty following the former dean’s recent untimely passing, meant that only one medicine and two slt students with a predominant focus on one cbe site were interviewed. thirdly, not all disciplines were represented in the samples of reviewed documents and educators interviewed. future research should therefore enlarge the sample of sites and disciplines, and strive particularly for many more student responses. it should also include the views of the communities it serves, which is essential if the fhs seeks to be more community-engaged.[13] conclusion this study found that that final-year health sciences disciplines engage inconsistently with the selected phc principles at the cbe sites. alignment appears to be strongest between learning outcomes and teaching activities, particularly in the health and rehabilitation sciences, but there were insufficient data to judge whether there is also strong alignment with formal graded assessment. this finding needs further research and attention in future curriculum planning, as any misalignment introduces a ‘hidden curriculum’, which may signal that the phc principles are of lesser importance than other learning outcomes.[14] 92 april 2021, vol. 13, no. 1 ajhpe research the eight educators and three students who were interviewed perceived that phc teaching and learning is facilitated by good multiprofessional teamwork, educator role-modelling and good infrastructural and logistical support. language barriers and health system issues such as staff shortages and high workloads are prevalent barriers to phc teaching and learning on the cbe platform. we recommend strong faculty leadership to promote the phc lead theme and to achieve better departmental and multiprofessional collaboration in teaching the phc approach. a new dean and two deputy deans in the fhs provide a good opportunity for the phc directorate to strengthen the phc approach under new leadership, with a strong grounding in social accountability. this work should be done in alignment with the fhs strategic plan, as two of its five goals are directly relevant to phc: to develop the decentralised teaching and learning platform for cbe, including a rural campus; and to promote the phc approach in teaching, research, health service partnerships and community engagement. recommendations of the 2018 faculty-wide symposium that are endorsed by the action research group include: providing training and support for all educators in the phc approach; ensuring that phc is explicit in all curriculum documents; integrating social accountability into the key performance areas of academic staff, including heads of department; and regular (5-yearly) reviews of fhs governance with respect to the phc principles. the academy of science of sa (assaf ) report of 2018 (reconceptualising health professions education in sa) also provides practical recommendations on addressing the inequitable national shortages of healthcare professionals, which include prioritising applicants from rural and underserved areas, and strengthening education for practice in such areas.[15] the present study provides important and timely evidence from wellestablished cbe sites in the fhs to inform future work and participatory action research in promoting the phc approach in teaching and learning in the fhs. declaration. none. acknowledgements. fatima le roux, nsh site co-ordinator; all clinical educator and student participants. author contributions. all authors complied with the international committee of medical journal editors’ rules of authorship and were part of formulating and conceptualising the article. the initial draft was prepared by the first author, and subsequent work on the manuscript included inputs from all authors. funding. none. conflicts of interest. none. 1. world health organization. declaration of alma-ata: international conference on primary health care, alma-ata, ussr, 6 12 september 1978. https://www.who.int/publications/almaata_declaration_en.pdf (accessed 23 february 2021). 2. irlam j, keikelame mj, vivian l. integrating the primary health care approach into a medical curriculum: a programme logic model. afr j health professions educ 2009;1(1):8-11. 3. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 4. ritz sa, beatty k, ellaway rh. accounting for social accountability: developing critiques of social accountability within medical education. educ health 2014;27(2):152-157. https://doi.org/10.4103/13576283.143747 5. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43(9):887-894. https://doi.org/10.1111/j.1365-2923.2009.03413.x 6. boelen c. why should social accountability be a benchmark for excellence in medical education? educación médica 2016;17(3):101-105. https://doi.org/10.1016/j.edumed.2016.06.004 7. training for health equity network (thenet). framework for socially accountable health workforce education, ver. 2. thenet, 2016. https://thenetcommunity.org/the-framework/ (accessed 23 february 2021). 8. yin r. case study research: design and methods. thousand oaks, ca: sage publications inc., 2003. 9. baxter p, jack s. qualitative case study methodology: study design and implementation for novice researchers. qual rep 2008;13(4):544-559. 10. world health organization. international classification of functioning, disability and health: icf. geneva: who, 2001. 11. ajayi a, mudefi e, adeniyi o, et al. achieving the first of the joint united nations programme on hiv/aids (unaids) 90-90-90 targets: understanding the influence of hiv risk perceptions, knowing one’s partner’s status and discussion of hiv/sexually transmitted infections with a sexual partner on uptake of hiv testing. int health 2019;11(6);425-431. https://doi.org/10.1093/inthealth/ihz056 12. western cape department of health. healthcare 2030: the road to wellness. cape town: wcdoh, 2014. https://www.westerncape.gov.za/assets/departments/health/healthcare2030_0.pdf (accessed 23  feb ruary 2021). 13. strasser r, worley, p, cristobal f, et al. putting communities in the driver’s seat: the realities of community-engaged medical education. acad med 2015;90(11):1466-1470. https://doi.org/10.1097/ acm.0000000000000765 14. alsubaie ma. hidden curriculum as one of current issue of curriculum. j educ pract 2015;6(33):125-128. 15. academy of science of south africa. reconceptualising health professions education in south africa. pretoria: assaf, 2018. http://research.assaf.org.za/handle/20.500.11911/95 (accessed 23 february 2021). accepted 20 march 2020. https://www.who.int/publications/almaata_declaration_en.pdf https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.4103/1357-6283.143747 https://doi.org/10.4103/1357-6283.143747 https://doi.org/10.1111/j.1365-2923.2009.03413.x https://doi.org/10.1016/j.edumed.2016.06.004 https://thenetcommunity.org/the-framework/ https://doi.org/10.1093/inthealth/ihz056 https://www.westerncape.gov.za/assets/departments/health/healthcare2030_0.pdf https://doi.org/10.1097/acm.0000000000000765 https://doi.org/10.1097/acm.0000000000000765 http://research.assaf.org.za/handle/20.500.11911/95 september 2019, vol. 11, no. 3 ajhpe 77 short research report higher education is increasingly seen as a major engine of economic development, thus implying that there is a need to produce graduates who are able to effectively further the public good.[1] this echoes the sentiments of broader health education reform, whereby a co-ordinated effort between health education and the local healthcare system is required to pool resources towards the realisation of universal health coverage.[2] this would mean that educational outcomes should be systematically tracked to identify indicators that have the greatest impact on society, i.e. return on investment.[1] however, measuring the effectiveness of health education has been limited by historical isolation between health education institutions and health service delivery platforms.[3] furthermore, accreditation requirements of professional councils generally consider evidence of the impact of graduates on the community and on practice outside the scope of educational institutions.[4] a global systematic review of the impact of health professional education showed a general paucity of evidence to support the effectiveness of current educational approaches at a societal level.[5] a key question is: how can health education institutions focus their activities to ensure maximal effectiveness of their educational programmes? a target audience that is often overlooked is practising graduates, whose experience and insight could be useful in monitoring and evaluating educational outcomes to strengthen the healthcare system and benefit society. the purpose of this study was to explore the views of pharmacy graduates of the university of the western cape (uwc) on the effectiveness of pharmacy education in relation to their current and anticipated practice aspirations. the results of this article form the baseline/pilot for a larger longitudinal study on establishing a partnership between the school of pharmacy, uwc, and its graduates to create a continuous dialogue regarding the relevance of the pharmacy curriculum to prepare graduates to address the needs of society, thereby illustrating educational effectiveness. methods this was a cross-sectional exploratory study. an electronic survey was administered to graduates at the school of pharmacy, uwc, through the network of the university’s alumni office. the survey used a structured questionnaire containing closed and open-ended questions to elicit practising pharmacy graduates’ opinions. the target population included practising pharmacists who graduated from uwc and who were involved in the school’s experiential learning programme as a student or a practising pharmacist. exclusion criteria included graduates not from uwc, those who were not practising pharmacists, and those who did not take part in the experiential learning programme as a student or as a practising pharmacist. by means of the alumni office database we made contact with uwc pharmacy graduates by email. they were invited to participate in the study by downloading a link to the questionnaire. the first section of the electronic survey contained the information sheet and a space for background. south african health professional education institutions have a mandate to produce graduates who are able to address priority needs of the healthcare system and larger society. however, evidence of the effective use of public resources by health education institutions is not routinely collected. practising graduates are a target audience who could provide part of this evidence. objectives. to explore the views of university of the western cape (uwc) pharmacy graduates on the effectiveness of pharmacy education in relation to their current and anticipated practice aspirations. methods. a cross-sectional electronic survey was administered to uwc pharmacy graduates through the university’s alumni office network. results. twenty-five graduates responded, of whom 60% were male (average age 38.9 (standard deviation 9.52) years). one of the strongest themes that emerged was the need for exposing pharmacy students from early on in the curriculum to a broad range of pharmacy and healthcare sectors and addressing real issues in these changing and complex environments. graduates stressed the importance of the development of generic skills, such as interpersonal skills, leadership, advocacy and innovative problem-solving, which are necessary to effect positive change through collaborative and equitable approaches. conclusions. the findings are aligned with general trends in health education reform, such as embedding undergraduate training in the healthcare system and development of generic skills. routine and reciprocal communication with graduates might be a valuable resource to monitor and evaluate educational outcomes to strengthen the healthcare system and benefit society. afr j health professions educ 2019;11(3):77-80. https://doi.org/10.7196/ajhpe.2019.v11i3.1065 exploring practising pharmacy graduates’ views on improving the effectiveness of pharmacy education at the university of the western cape, south africa m van huyssteen, phd, msc, bpharm; a bheekie, phd, mpharm, bpharm, bsc school of pharmacy, faculty of natural science, university of the western cape, cape town south africa corresponding author: m van huyssteen (mvanhuyssteen@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:mvanhuyssteen@uwc.ac.za 78 september 2019, vol. 11, no. 3 ajhpe short research report participants to indicate their informed consent. as a means of snowball sampling, the invitation and link were also posted on the uwc alumni facebook page to further recruit graduates. the 3-part questionnaire consisted of: (i) baseline demographics; (ii) details of the participants’ current practice of pharmacy; and (iii) inquiry into their pharmacy education at uwc, which concluded with 3 open-ended questions: • what advice do you have for pharmacy training institutions to make the training more relevant and beneficial for pharmacy practice in south africa (sa)? • how can practising pharmacists engage with pharmacy training institutions to improve the quality of graduates? • when thinking about the future of pharmacy practice, could you recommend changes that would benefit the health system/larger society? quantitative data were analysed using descriptive statistics, and the 2 researchers independently coded and thematically analysed the 3 openended question responses. ethical approval ethical approval for the study was obtained from uwc’s senate research ethics committee (ref. no. 15/6/101). results on 23 may 2016, the questionnaire was first emailed to 398 pharmacy graduates; only 116 of the emails were opened. thereafter, the alumni office updated its database and a second email was forwarded on 14 june 2016 to 744 pharmacy graduates, including the previous 398 cohort (as a reminder). only 185 of these emails were opened. a third reminder was sent out to 744 graduates, of which 149 were opened. from the three attempts, only 25 graduates completed the survey. the average age of all the participants was 38.9 (standard deviation 9.52) years and most were male graduates (60%). the current workplace of most respondents was in sa (n=24; 96%) – 44% were working in western cape province (only 1 respon dent worked outside cape town). further details on demographics are given in appendix a. the thematic analysis is summarised in table 1. the three most promi nent themes regarding graduates’ advice for making the curriculum more relevant and beneficial to pharmacy practice related to explicitly linking pharmacy students and practitioners working in the sa healthcare system, expanding experiential learning for students and education opportunities for graduates. most graduates (n=14) suggested exposing students to a wider range of pharmacy and healthcare sectors during undergraduate education. they also suggested that this broader exposure needed to be combined with generic skills development, such as interpersonal skills, leadership, entrepreneurship, management and skills to promote public health. in conjunction with broader exposure to aspects of the healthcare system, one-third of graduates (n=9) recommended more experiential learning from early on in the curriculum, with learning outcomes integrated across disciplines and different sectors of pharmacy. another less-mentioned theme included postgraduate training relating to continuing professional development (cpd) (n=5) and more specialised postgraduate short courses (n=4). table 1. thematic analysis of the 3 open questions put to respondents 1. what advice do you have for pharmacy training institutions to make pharmacy training more relevant and beneficial for pharmacy practice in south africa? theme 1.1: embedding of pharmacy education in the healthcare system ‘i think institution staff should be directly involved at the practice level to gauge the role of pharmacists and how it’s changing at the realistic level. in this way changes can be incorporated immediately ... i think time is of the essence to adapt [teaching methods and materials] to changing needs and roles.’[8] theme 1.2: expand experiential learning ‘expose students in the very early years of their studies to the various industries … financial management studies or business/entrepreneurship would be beneficial.’[9] theme 1.3: education for graduates ‘[university x] has found its niche in developing the dpharm degree. i wish that uwc could do the same in making it more of a home for postgrad and alumni studies.’[2] 2. how can practising pharmacists engage with pharmacy training institutions to improve the quality of graduates? theme 2.1: value of pharmacists’ engagement in education ‘for the different modules that are offered, if institutions could have a pharmacist from the different sectors of pharmacy coming and sharing their experiences with the learners ... and maybe try to see how the learners can resolve some of those issues if they were to come across them. just to have that kind of interaction between an experienced pharmacist, old and young, with the learners.’[24] theme 2.2: multisectoral engagement ‘to obtain participation and valuable contribution [of graduates] it may be necessary to have regular interaction with pharmacists from different sectors representing different issues. in this way the real issues of various communities become known. this will give training institutions better insights on what needs to be changed and adapted.’[8] 3. when thinking about the future of pharmacy practice, recommend changes that would benefit the health system or larger society theme 3.1: generic skills ‘pharmacists need to take active roles in working and collaborating with other healthcare professionals … healthcare is moving towards electronic or digital processes, thereby implying that pharmacists need to start learning or adjusting to the changing environment.’[19] theme 3.2: equity (universal health coverage) ‘they should lead quality improvement and multidisciplinary teams to strengthen health systems. they should be managing health systems strengthening programmes, which would entail more engagement with partners and at different levels of government … i implore pharmacists to make a difference in rural, resource-limited settings!’[3] september 2019, vol. 11, no. 3 ajhpe 79 short research report in response to the question on how the school and pharmacists could engage to increase the quality of graduates, there was general consensus that practising pharmacists had a valuable contribution to make in terms of student training. some suggested increasing the number of faceto-face lectures and workshops between graduates and students, and electronic communication between the school and graduates. multisectoral involvement was a common suggestion to strengthen these potential collaborative efforts and address issues. lastly, graduates’ opinion of the future of the practice of pharmacy and efforts to advance the profession culminated in the emergence of a common underlying theme relating to the changing healthcare environment and the ability to seize service delivery opportunities borne from these challenges in the healthcare system. the most often-mentioned examples of changes that could improve quality in the profession and strengthen the healthcare system were towards embracing primary healthcare practice, addressing universal health coverage and innovation. discussion this exploratory study attempted to start a dialogue with graduates to guide pharmacy education at uwc towards more effective educational outcomes in the healthcare system and larger society. this discussion focuses on two cross-cutting themes that repeatedly emerged from the 3 open questions posed to the 25 respondents, which centred around embedding the curriculum in the context of the larger healthcare system and focusing on the development of generic competencies of uwc pharmacy students to strengthen the healthcare system. based on the requests from the 25 graduates to include more sectors of pharmacy and health in education, it seemed clear that current pharmacy education at uwc is not well contextualised within the wider healthcare system. this stance is supported by the problem statement of the lancet commission on health education reform that underscored the narrow technical focus of health education without having a broader contextual understanding of health.[2] a pharmacy-graduate study conducted at another sa university noted low skills acquisition in subjects related to activities such as drug use, reviews and screening,[6] which require engagement with the wider healthcare system beyond pharmaceutical services. the call for the development of generic skills, which includes interpersonal skills, teamwork, advocacy, leadership and entrepreneurial skills, seemed to be important to all 25 respondents. this tendency has been noted in higher-education trends in resource-constrained countries, where there is often tension between producing specialists and technical professionals v. strong leaders with generalist knowledge who are creative, adaptable and able to give broad ethical consideration to social advances.[1] a comparative study from 4 developed countries, which mapped the learning outcomes for pharmacy graduates against the international pharmaceutical federation (fip)’s global competency framework, found that the global framework was geared towards producing pharmacists who would be skilled primarily as medicine experts offering patient-centred care, but was lacking in its reference to generic competencies such as (interprofessional) teamwork and leadership attributes.[7] other generic orientations and skills, such as the ability to offer comprehensive primary healthcare services and undertaking advocacy work, have been discussed in wider health education circles.[4] this underscores the constantly changing environment that graduates have to navigate as health needs and systems change over time. study limitations limitations of this study include the small sample size and graduate self-reporting. similarly, other graduate-tracking studies have shown notoriously poor response rates – one of the primary challenges to electronic surveys.[8] conclusions the findings of this study, however limited, aligned with general trends in health education, such as embedding education in the healthcare system and development of generic skills. establishing a routine and reciprocal method of communication with uwc graduates is one way for the school of pharmacy to offer evidence to gauge educational effectiveness. a longitudinal tracking approach might be more effective[4] to secure meaningful engagement between graduates and their educational institution. declaration. none. acknowledgements. pharmacy graduates who participated in the study and the fourth-year pharmacy research student group. author contributions. mvh and ab: conceptualised the research project; mvh: collected the data and performed the first analysis; ab: performed the second analysis; mvh: wrote the first draft; ab: edited the article. funding. national research foundation: community engagement grant (2015 2017). conflicts of interest. none. 1. altbach pg, reisberg l, rumbly le. trends in global higher education: tracking an academic revolution. a report prepared for the unesco 2009 world conference on higher education. paris: united nations educational, scientific and cultural organization, 2009. 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 3. boelen c, woollard rf. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43(9):887-894. https://doi.org/10.3109/0142159x.2011.590248 4. larkins sl, preston r, matte mc, et al. measuring social accountability in health professional education: development and international pilot testing of an evaluation framework. med teach 2013;35(1):32-45. https:// doi.org/10.3109/0142159x.2012.731106 5. reeve c, woolley t, ross sj, et al. the impact of socially-accountable health professional education: a systematic review of the literature. med teach 2017;39(1):67-73. https://doi.org/10.1080/0142159x 6. naidoo p, govender t, hoosen t, et al. identifying perceptions of the university of kwazulu-natal graduates on the relevance and adequacy of the pharmacy curriculum to current pharmacy practice. s afr pharmaceutical j 2009;76(10):36-43. 7. stupans i, atkinson j, mestrovic a, et al. a shared focus: comparing the australian, canadian, united kingdom and united states pharmacy learning outcome frameworks and the global competency framework. pharmacy 2016;4(26). https://doi.org/10.3390/pharmacy4030026 8. mijic d, janovic d. using ict to support alumni data collection in higher education. croatian j educ 2014;16(4):1147-1172. https://doi.org/10.15516/cje.v16i4.613 accepted 4 april 2019. https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.3109/0142159x.2011.590248 https://doi.org/10.3109/0142159x.2012.731106 https://doi.org/10.3109/0142159x.2012.731106 https://doi.org/10.1080/0142159x https://doi.org/10.3390/pharmacy4030026 https://doi.org/10.15516/cje.v16i4.613 80 september 2019, vol. 11, no. 3 ajhpe short research report appendix a. baseline demographics, pharmacy education and current workplace details of respondents (n=25) baseline demographics n (%) gender 25 (100) female 10 (40) male 15 (60) pharmacy education highest qualification 25 (100) bpharm 23 (92) master’s degree 2 (8) year in which bpharm was obtained 25 (100) before 2000 7 (28) 2000 2010 18 (72) current employment province 24 (100) eastern cape 3 (12) gauteng 6 (24) kwazulu-natal 0 (0) limpopo 1 (4) mpumalanga 2 (16) western cape 11 (44) location 24 (100) rural 5 (20) urban 17 (68) rural and urban 2 (16) health sector 24 (100) private 12 (50) public 6 (25) other* 6 (25) level of care 23 (100) primary 11 (48) secondary 5 (22) other† 7 (30) *other workplace health sectors included non-governmental organisations (n=3), across public and private institutions (n=1) and as training consultants (n=2). †other practice descriptions included working across the three levels of care (n=1), in training (n=2), policy research (n=1), pharmaceutical industry (n=2) and providing technical assistance to the national department of health (n=1). november 2020, vol. 12, no. 4 ajhpe 215 research over the past 20 years, there has been a steady growth in the use of simulation as a clinical teaching-learning strategy in nursing education.[1] simulation using high-fidelity manikins is used to teach student nurses skills that are necessary to reduce the frequency and harm attributable to errors in the healthcare setting.[1,2] nurse educators need to use high-fidelity simulation (hfs) to enhance clinical skills development in student nurses due to limited clinical exposure, difficulty in clinical placements and decreasing learning opportunities during work-integrated learning, especially as experienced in the private healthcare environment.[2,3] simulation training encourages the student nurse to use higher-order thinking skills while in a safe environment, to make sense of and to integrate new experience into the schema that they are constructing of ‘how things are’. this simulation environment mimics the real world with real patient problems where students can better integrate theory and practice principles.[4] berragan[3] emphasises that simulation training creates an environment where collaboration and participation take place, while clinical skills are developed and students are prepared for the real world of nursing. successful implementation of hfs depends on the support of nurse educators.[5] paige and morin[6] state that there are only a few studies that have explored nurse educators’ assumptions and beliefs on hfs as teachinglearning strategy, and that nurse educators hold varying beliefs regarding this phenomenon due to their views, perspectives, cultural differences and the availability of resources. in order to fill the gap in the knowledge base in the field of nursing education, the main objective of this research is to explore and describe nurse educators’ views of hfs as an educational approach in the nursing programmes of a south african private higher education institution (saphei). methods a qualitative descriptive research design was used.[7] the population consisted of 33 (n=33) nurse educators at a saphei. a randomised purposive sampling method was used. the inclusion criteria were: head nurse educators and nurse educators permanently employed at one of six learning centres at the saphei (the remaining learning centre where the researcher is employed as the manager was excluded from the study); learning and development facilitators and clinical facilitators permanently employed at the clinical facilities affiliated with the saphei; and participants who took part in the quantitative phase of the research study and each voluntarily consented to take part in an individual semi-structured interview. the researcher selected a representative sample from each of the six learning centres of the saphei. data were collected using individual, semi-structured interviews of approximately 45 minutes each.[8] data saturation was obtained as no new concepts emerged after 19 interviews. the interview guide consisted of two parts, including firstly an introduction that read: ‘as nurse educators, our goal is to improve clinical competence of student nurses through the use of various teaching methods. hfs is one of those teaching methods used to enhance clinical competence.’ the following part included five open-ended questions: (i) what are your views about the implementation of hfs as a teaching method in nursing programmes at your institution?; (ii) what are your expectations of hfs as a teaching method?; (iii) what are your perceptions of hfs as a teaching method to enhance clinical competence of nursing students?; (iv)  what is your opinion about the current practices and use of hfs in your institution?; and (v) what value does hfs add as a teaching method in a nursing programme? background. clinical skills development of student nurses is a concern in nursing education owing to limited clinical exposure and learning opportunities. high-fidelity simulation as a teaching-learning strategy creates an environment where student nurses develop clinical skills through interactive participation. objectives. the aim of this research study was to explore nurse educators’ views of high-fidelity simulation as an educational approach in nursing programmes. methods. a qualitative descriptive design was used. data were collected through individual semi-structured interviews. data saturation occurred within 19 interviews. the population consisted out of 33 (n=33; n=19) nurse educators. direct content analysis was done using hsieh and shannon’s approach. the study was conducted at a south african private higher education institution. results. five main themes were identified. the nurse educators had not been exposed to or had limited experience with high-fidelity simulation. limited resources and/or the lack of nurse educators trained in high-fidelity simulation were identified. the nurse educators agreed that high-fidelity simulation would contribute to the enhancement of clinical skills development and theory and practice integration. conclusion. high-fidelity simulation is not implemented owing to limited equipment or experience in using the equipment optimally. the nurse educators see high-fidelity simulation as a solution and valuable training method where clinical skills are developed before the student nurse is exposed to the private clinical environment. afr j health professions educ 2020;12(4):215-219. https://doi.org/10.7196/ajhpe.2020.v12i4.1411 nurse educators’ views on implementation and use of high-fidelity simulation in nursing programmes e powell, phd, ma cur hons, ba cur, bcur (ed et admin), rn, rm; b scrooby, phd, mcur, rn, rm, ne, nm; a van graan, phd, mcur, rn, rm, ne, nm school of nursing science, faculty of health sciences, north-west university, potchefstroom, south africa corresponding author: b scrooby (belinda.scrooby@nwu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 216 november 2020, vol. 12, no. 4 ajhpe research direct content analysis was done using hsieh and shannon’s[9] approach, identifying five themes. the variables identified during the quantitative phase of the research study were used together with key concepts identified during the qualitative phase of the research as initial coding categories. transcripts were read and all text that on first impression appeared to present identified themes was highlighted. coding of highlighted passages was done using the predetermined codes. data that could not be placed in the predetermined codes were analysed to determine if they represent a new category or subcategory on an existing code. a co-coder was used to determine the accuracy of the research findings. ethical considerations ethical approval for the study was obtained from the university health research ethics committee and the saphei. the north-west university health research ethics committee (ref. no. nwu-00011-18-a1) provided written consent to the researcher to conduct this research. the participants gave written informed consent to participate in this study and could withdraw at any time. interviews were recorded, transcribed and saved on a password-protected external hard drive. confidentiality was maintained by coding of data to ensure anonymity. results the following main themes, themes and sub-themes were identified, as outlined in table 1. main theme 1: experiences using hfs under this main theme, two themes named ‘no or very few experiences’ and ‘use only low-fidelity simulation’ with their respective sub-themes emerged. table 1. main themes identified from the views of nurse educators on implementing and use of hfs in nursing programmes main themes themes sub-themes experiences using hfs no or very few experiences not actively involved in simulation training have very little exposure do not use it at all use only low-fidelity simulation do not have high-fidelity manikins experiences with low-fidelity simulation only comfort using hfs equipment available for simulation do not have equipment only have low-fidelity simulation equipment budget constraints too expensive training received to use hfs not enough training need follow-up training need trained facilitator to assist learning environment simulation creates a safe environment for students to practise students experience less stress patient is safe from inexperienced learners invasive procedures are practised in safe environment before attempting them on a patient scenarios used in simulation must represent the clinical setting realistic clinical setting/scenarios controlled environment with planned outcomes safe time/no interruptions skill development development of psychomotor skills demonstrations of skills not all skills are found at the patient’s beds set goals to improve skills should not replace clinical practice competent before going to patient assess competency more approachable to attempt tasks refresh educator’s skill development of cognitive and affective skills develop clinical reasoning/judgement effective communication share ideas encourage students to interact build student-facilitator report must not replace communication with the patient theory-practice integration theory integrated in practice blended learning understand theory better because it is visual audiovisual stimulation hfs = high-fidelity simulation. november 2020, vol. 12, no. 4 ajhpe 217 research no or very few experiences with hfs sub-themes identified were: ‘not actively involved in simulation training’; ‘have very little exposure’; and ‘do not use it at all’. al-ghareeb and cooper[10] state that hfs as a teaching tool is undervalued and underused. the challenge using hfs is the limited resources and knowledge available on how to use it, as hfs training is demanding technological resources.[11] in supporting the literature, the participants stated: ‘i have limited experience.’ (participant 2; age 59 years; experience 12 years) ‘we do not have the exposure or the means to train on that equipment.’ (participant 4; age 42 years; experience 9 years) ‘i just feel we are underutilising them.’ (participant 18; age 42 years; experience 9 years) use only low-fidelity simulation sub-themes identified were: ‘do not have high-fidelity manikins’; and ‘experiences with low-fidelity simulation only’. low-fidelity simulation creates a semblance of reality by using part-task trainers or static manikins with props and techniques such as role play.[12] lowfidelity simulation is preferred owing to the perception of nurse educators that the implementation of hfs is difficult and requires extensive content to development simulations for the classroom environment.[13] in supporting the literature, the participants stated: ‘we have a manikin in the simlab. it is really basic.’ (participant 4; age 42 years; experience 9 years) ‘we have a low-fidelity doll.’ (participant 10; age 36 years; experience 1 year). ‘i will say low-fidelity in terms of it is only the arm.’ (participant 14; age 46 years; experience 16 years) main theme 2: comfort using hfs under this main theme, two themes named ‘equipment available for simulation’ and ‘training received to use hfs’, with their respective subthemes, emerged. equipment available for simulation sub-themes identified were: ‘do not have equipment’; ‘only have low-fidelity simulation equipment’; ‘budget constraints’; and ‘too expensive’. achieving high-quality simulation experiences requires clear learning objectives to articulate the curriculum, and sufficient high-quality simulation resources, including adequately prepared staff.[14] equipment needed for hfs includes full-bodied manikins with advanced technology and an environment that resembles a particular healthcare setting.[15] it is costly to set up hfs as the equipment and its maintenance is expensive.[16] in supporting the literature, participants stated: ‘if i have larger groups of students, how many educators do you have and how many simulation dolls do you have?’ (participant 7; age 53 years; experience 15 years) ‘we did put it on the budget but it was so expensive to have the right equipment available.’ (participant 12; age 48 years; experience 17 years) ‘there must be enough equipment and it support on the premises because it can happen at any time that the programme has power outage.’ (participant 13; age 62 years; experience 30 years) ‘there is a very big financial layout with putting together a decent simlab.’ (participant 17; age 51 years; experience 8 years) training received to use hfs sub-themes identified were: ‘not enough training’; ‘need follow-up training’; and ‘need trained facilitator to assist’. hfs places demands on the technological ability of nurse educators because it necessitates greater engagement than other passive forms of instruction.[10] to implement hfs as a teaching-learning strategy in a nursing curriculum, nurse educators need to be equipped with the necessary simulation-based teaching skills through workshops and skills training.[15] in supporting the literature, the participants stated: ‘i think one of the things we must look at is upskilling of the educators. i just did not have time to really go and learn how to use the equipment.’ (participant 3; age 41 years; experience 10 years) ‘the educator needs to be well trained.’ (participant 10; age 36 years; experience 1 year) ‘your educators have to be taught how to work with the equipment.’ (participant 13; age 62 years; experience 30 years) main theme 3: learning environment under this main theme, two themes named ‘simulation creates a safe environment for students to practise’ and ‘scenarios used in simulation must represent the clinical setting’, with their respective sub-themes, emerged. simulation creates a safe environment for students to practise sub-themes identified were: ‘student experiences less stress’; ‘patient is safe from inexperienced learners’; and ‘invasive procedures are practised in safe environment before attempting it on a patient’. nurse educators are challenged with providing an engaging and motivating learning environment for clinical nursing education.[17] simulation provides an opportunity for student nurses to acquire experience in a safe environment by allowing them to make mistakes without causing harm to the patient.[18] in supporting the literature, the participants stated: ‘simulation is a safe area for students. it develops their skills before they practise this on a patient.’ (participant 3; age 41 years; experience 10 years) ‘in a sense give safety to the student for her to experiment and just get over her initial fear.’ (participant 7; age 53 years; experience 15 years) ‘a safe environment, where my student can practise without feeling that they are putting a patient at risk. an environment where there is no judgement.’ (participant 11; age 58 years; experience 9 years) scenarios used in simulation must represent the clinical setting sub-themes identified were: ‘realistic clinical setting/scenarios’; ‘controlled environment with planned outcomes’; and ‘safe time/no interruptions’. student nurses gain confidence before providing patient care in clinical practice through repeating practices in a more realistic learning environment.[18] nurse educators should be skilled practitioners in order to integrate simulation appropriately into nursing programmes, and should not merely have knowledge of learning theories and how to integrate simulation into the curriculum, but should also demonstrate practical expertise and expert knowledge of the subject matter.[19] in supporting the literature, the participants stated: 218 november 2020, vol. 12, no. 4 ajhpe research ‘it will enhance the whole learning and training setup … it reflects the real thing.’ (participant 1; age 57 years; experience 6 years) ‘students view simulation as a much more appropriate way of learning skills before going to the actual clinical environment. not all the procedures are available in the clinical environment.’ (participant 3; age 41 years; experience 10 years) ‘the better the simulation environment, the more accurate and competent the results will be for your student. educators to know how to properly facilitate the high-fidelity simulation to ensure that we use it comprehensively to enable the students.’ (participant 9; age 48 years; experience 5 years) main theme 4: skills development under this main theme, two themes named ‘development of psychomotor skills’ and ‘development of cognitive and affective skills’, with their respective sub-themes, emerged. development of psychomotor skills sub-themes identified were: ‘demonstrations of skills’; ‘not all skills are found at the patient’s beds’; ‘set goals to improve skills’; ‘should not replace clinical practice’; ‘competent before going to patient’; ‘assess competency’; ‘more approachable to attempt tasks’; and ‘refresh educator’s skill’. clinical experiences often focus on tasks or skill performance, which is problematic to find owing to a complex healthcare system and difficulty in finding clinical placements for student nurses.[20] therefore hfs has been suggested as an alternative to face-to-face clinical experience. simulation allows student nurses to improve their cognitive, affective and psychomotor skills and make fewer medical errors, thus contributing to the protection of patients.[18] in supporting the literature, the participants stated: ‘they will be hands-on after completion of their training.’ (participant 1; age 57 years; experience 6 years) ‘fill the gap where our students do not have the opportunity to either nurse patients with a particular condition or just because the patients are not being keen on being guinea pigs.’ (participant 2; age 59 years; experience 12 years) development of cognitive and affective skills sub-themes identified were: ‘develop clinical reasoning/judgement’; ‘effective communication’; ‘share ideas’; ‘encourage students to interact’; ‘build studentfacilitator report’; and ‘must not replace communication with the patient’. student nurses are expected to gain knowledge, critical thinking and psychomotor skills that will enable them to make clinical judgements about care and manage complex clinical situations.[10] in supporting the literature, the participants stated: ‘we know [that] by doing, people develop more knowledge or gain more knowledge.’ (participant 6; age 59 years; experience 29 years) ‘set different type of scenarios for a student, so that you can test their knowledge. i think it can also assist in theoretical training, because now you get an enforcement of what you discussed maybe in a theoretical facilitation session.’ (participant 15; age 54 years; experience 13 years) the healthcare needs of a patient must always take priority over the education needs of the student nurse. however, in simulation the student’s needs are placed at the centre of attention.[3] hfs can improve student nurses’ current knowledge, skill performance, clinical judgement and affective skills if they receive the correct support, including: a facilitator in the simulation room; supportive feedback; role modelling of expected performance; an opportunity to repeat their performance; and communication tools.[21] in supporting the literature, the participants stated: ‘it will be difficult for a student to be able to empathise with the patient and reflect on what the patient is feeling when the patient is a manikin.’ (participant 3; age 41 years; experience 10 years) ‘other students feel alienated from this doll and struggle to see it as a human being that can react and they know it’s me speaking. so they constantly ignore the doll and speak to me.’ (participant 7; age 53 years; experience 15 years) main theme 5: theory-practice integration under this main theme, one theme named ‘theory is integrated in practice’ with its respective sub-themes emerged. theory is integrated in practice sub-themes identified were: ‘blended learning’; ‘understand theory better because it is visual’; and ‘audio-visual stimulation’. simulation provides a safe environment where student nurses can experience different learning strategies that will allow them to integrate their knowledge and apply it to real patients.[18] problem-based learning will prepare student nurses for clinical practice by letting them solve problems during their clinical skills training, allowing them to integrate theory into practice.[17] high-fidelity simulation-based learning can facilitate the acquisition of clinical reasoning skills, because the student nurse reflects on her/his actions and discusses alternative actions.[18] the integration of an interactive learning method such as hfs in a nursing programme is important as it results in the development of more qualified and skilled nursing practitioners.[18] in supporting the literature, the participants stated: ‘it will create opportunities for students to develop their clinical skills as well as their critical thinking, clinical judgement. when you create a scenario you are allowing them to make decisions. so part of that decision-making process will end up in clinical judgement.’ (participant 3; age 41 years; experience 10 years) ‘you can combine your theoretical explanation with a practical demonstration. so it assists with theory, theory to the practice.’ (participant 7; age 53 years; experience 15 years) ‘they use all types of learning as they go around. to collaborate all of that together, and having that visual and auditory together with the aesthetic.’ (participant 9; age 48 years; experience 5 years) ‘it will help with the development of clinical judgement. it will help them with decision-making. with problem solving, they have to think, but again i have to give them a proper scenario.’ (participant 10; age 36 years; experience 1 year) ‘i think you can set up simulation scenarios, to see how their theorypractice integration is.’ (participant 15; age 54 years; experience 13 years) ‘it makes a lot more sense when you can actually visually see what the person is talking about. be able to practise and i think more collaborative learning can take place. they can share their experiences a lot more.’ (participant 16; age 44 years; experience 4 years) november 2020, vol. 12, no. 4 ajhpe 219 research discussion nurse educators at the saphei have not been exposed or have limited experience using hfs as a teaching strategy. venkatasalu et al.[22] concur that simulation-based training is not yet widely used, as its effectiveness in nursing schools is not understood. the equipment currently in use in the majority of the clinical settings of the saphei is low-fidelity manikins. the equipment and facility for hfs is not always available or used optimally owing to cost and availability of space to create a simulation environment effective enough to accommodate bigger classes. nurse educators’ lack of training and/or the lack of technological skills are the cause of their ‘fear of the unknown’ and resistance to using hfs. nurse educators expressed the need for technical support from experts, and more available time in their programme to develop and plan simulation scenarios. hfs is seen as a valuable training method in a safe environment where clinical skills are developed before the student nurse is exposed to the clinical environment. it enhances student nurses’ confidence and competence, leading to safe patient care.[18] nurse educators need to be hands-on and knowledgeable about hfs as a teaching method, demonstrating practical expertise and expert knowledge of the subject matter in order to assist student nurses to obtain the necessary psychomotor and cognitive skills in a realistic environment that represents clinical practice. it cannot, however, replace real clinical practice. affective skills should be learned and developed in the clinical setting through interaction with a patient. hfs makes use of teaching-learning methods via which student nurses can enhance their clinical judgement and problem-solving skills by engaging with a dynamic learning environment.[17] it integrates theory into practice through a hands-on approach where student nurses exercise solving patient problems during hfs case studies that empower the student to integrate their theoretical knowledge into clinical practice by solving problems using their reasoning skills as well as reflection on nursing care done. study limitation the research study was conducted at a single saphei, therefore the findings of this study can only be used as guide for other sapheis. recommendations the recommendations for research, education and practice are given below: • develop a practice model to implement hfs in the nursing programmes at a saphei; • hfs as a clinical teaching-learning method should be added to the curriculum of the nursing programmes presented at the saphei; and • nurse educators and student nurses should be trained to use hfs as a clinical teaching-learning method to enhance clinical skills development through theory-practice integration, which will lead to better patient safety. conclusion simulation training encourages the student to think innovatively using higher-order thinking skills to make sense of and enable students to integrate each new experience while in a safe environment. this valuable teaching method can assist student nurses to develop their critical thinking skills, which would become evident in student nurses’ ability to assess, identify and plan nursing action according to the patient’s needs and diagnoses, and assist to immediately identify any abnormality presented in the patient, acting promptly in order to prevent complications by implementing meaningful actions. declaration. none. acknowledgements. we acknowledge financial and material support for language editing and publication fees from our affiliated university. author contributions. the first author collected the data and analysed it as well as wrote a chapter on qualitative data as part of her phd thesis. the first author also wrote this article according to the journal’s guidelines. the second and third authors as the first author’s promotor and co-promotor reviewed and revised the article. the second author submitted the article to the journal. all authors revised the article and the second author finalised it. funding. this project was self-funded. north-west university gave financial support in the form of a postgraduate bursary. conflicts of interest. none. 1. garden al, le fevre dm, waddington hl, weller jm. debriefing after simulation-based non-technical skill training in healthcare: a systematic review of effective practice. anaesth intensive care 2015;43(3):300-308. https://doi.org/10.1177/0310057x1504300303 2. garrett bm, macphee m, jackson c. implementing high-fidelity simulation in canada: reflections on 3 years of practice. nurse educ today 2011;31(2011):671-676. https://doi.org/10.1016/j.nedt.2010.10.028 3. berragan l. simulation: an effective pedagogical approach for nursing? nurse edu today 2011;31(2011):660-663. https://doi.org/10.1016/j.nedt.2011.01.019 4. bambi d, washburn j, perkins r. outcomes of clinical simulation for novice nursing students: communication, confidence, clinical judgment. nursing educ res 2009;30(2):79-82. 5. jones al. faculty members’ comfort levels in utilizing high-fidelity simulation in a bachelor of science nursing programme. phd thesis. vermillion: university of south dakota, 2005. 6. paige jb, morin kh. using q-methodology to reveal nurse educators’ perspectives about simulation design. clinical sim nursing 2015;11(1):11-19. https://doi.org/10.1016/j.ecns.2014.09.010 7. mouton j, marais hc. basic concepts in the methodology of the social sciences. pretoria: human sciences research council, 1996. 8. creswell jw. educational research: planning, conducting and evaluating quantitative and qualitative research. 4th ed. edinburgh: pearson, 2014. 9. hsieh h, shannon se. three approaches to qualitative content analysis. qual health res 2005;15(9):1277-1288. https://doi.org/10.1177%2f1049732305276687 10. al-ghareeb az, cooper sj. barriers and enablers to the use of high-fidelity patient simulation manikins in nurse education: an integrative review. nurse edu today 2016;36(2016):281-286. https://doi.org/10.1016/j. nedt.2015.08.005 11. walker dm, holme f, zelek st, et al. a process evaluation of pronto simulation training for obstetric and neonatal emergency response teams in guatemala. medical edu 2015;15(117):1-8. https://doi.org/10.1186/ s12909-015-0401-7 12. winkelmann zk, eberman le, edler jr, livingston lb, games ke. curation of a simulation experience by the clinical scholar: an educational technique in postprofessional athletic training. athletic train educ j 2018;13(2):185-193. https://doi.org/10.4085/1302185 13. sharpnack pa, madigan ea. using lfs with sophomore nursing students in a baccalaureate nursing program. nurs edu perspect 2012;33(4):264-268. https://doi.org/10.5480/1536-5026-33.4.264 14. forber j, digiacomo m, davidson p, carter b, jackson d. the context, influences and challenges for undergraduate nurse clinical education: continuing the dialogue. nurse edu today 2015;35(2015):1114-1118. https://doi.org/10.1016/j.nedt.2015.07.006 15. welman a, spies c. high-fidelity simulation in nursing education: considerations for meaningful learning. trends nursing 2016;3(1):1-16. https://doi.org/10.14804/3-1-42 16. weller j, cumin d, torrie j, et al. multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in new zealand hospitals. n z med j 2015;128(1418):40-51. 17. koivisto jm, haawisto e, niemi h, hano p, nylund s, multisilta j. design principles for simulation games for learning clinical reasoning: a design-based research approach. nurse edu today 2018;60(2018):114-120. https:// doi.org/10.1016/j.nedt.2017.10.002 18. eyikara e, baykara zg. effect of simulation on the ability of first year nursing students to learn vital signs. nurse edu today 2018;60(2018):101-106. https://doi.org/10.1016/j.nedt.2017.09.023 19. topping a, bøje rb, rekola l, et al. towards identifying nurse educators’ competencies required for simulationbased learning: a systemised rapid review and synthesis. nurse edu today 2015;35(2015):1108-1113. https://doi. org/10.1016/j.nedt.2015.06.003 20. zapko ka, ferranto mlg, blasiman r, shelestak d. evaluating best educational practices, student satisfaction, and self-confidence in simulation: a descriptive study. nurse edu today 2018;60(2018):28-34. https://doi. org/10.1016/j.nedt.2017.09.006 21. erlam g, smythe l, wright-st clair v. action research and millennials: improving pedagogical approaches to encourage critical thinking. nurse edu today 2018;61(2018):140-145. https://doi.org/10.1016/j.nedt.2017.11.023 22. venkatasalu mr, kelleher m, shao ch. reported clinical outcomes of hfs versus classroom-based end-of-life care education. int j palliative nurs 2015;21(4):179-186. accepted 10 september 2020. https://doi.org/10.1177/0310057x1504300303 https://doi.org/10.1016/j.nedt.2010.10.028 https://doi.org/10.1016/j.nedt.2011.01.019 https://doi.org/10.1016/j.ecns.2014.09.010 https://doi.org/10.1177%2f1049732305276687 https://doi.org/10.1016/j.nedt.2015.08.005 https://doi.org/10.1016/j.nedt.2015.08.005 https://doi.org/10.1186/s12909-015-0401-7 https://doi.org/10.1186/s12909-015-0401-7 https://doi.org/10.4085/1302185 https://doi.org/10.5480/1536-5026-33.4.264 https://doi.org/10.1016/j.nedt.2015.07.006 https://doi.org/10.14804/3-1-42 https://doi.org/10.1016/j.nedt.2017.10.002 https://doi.org/10.1016/j.nedt.2017.10.002 https://doi.org/10.1016/j.nedt.2017.09.023 https://doi.org/10.1016/j.nedt.2015.06.003 https://doi.org/10.1016/j.nedt.2015.06.003 https://doi.org/10.1016/j.nedt.2017.09.006 https://doi.org/10.1016/j.nedt.2017.09.006 https://doi.org/10.1016/j.nedt.2017.11.023 december 2018, vol. 10, no. 4 ajhpe 215 research continuing education has long been recognised as a critical feature of upskilling and keeping health practitioners abreast of the latest developments in their field. the value of such post-qualification education for improved patient care forms the main thrust that drives continuing education initiatives. historically, however, this was regarded as a voluntary form of self-development. while compulsory continuing education regulations for health professionals, including psychologists, have been in place in some countries for many years, regulatory developments in the south african (sa) context have occurred mainly in the past two decades, with some professions, e.g. nursing, yet to implement such regulations. a study of nurses showed that 39.4% were against such regulation.[1] the term continuing professional development (cpd) has been coined to refer to the regulated continuing education system in the country, and the current article uses the terms cpd and continuing education interchangeably. for psychologists to maintain their licence and registration with the health professions council of south africa (hpcsa), they need to accumulate 30 cpd points each year, with at least 5 points in the area of ethics, human rights or medical law.[2] one cpd point is earned for each hour of an accredited learning activity, and cpd activities can include workshops, conferences, symposia, journal clubs and other similar professional activities. the rationale for mandatory continuing education lies in the necessity for healthcare practitioners to keep abreast of developments in their field to provide optimal, evidence-informed, patient care.[3] in addition to traditional formats of continuing education, online learning systems provide a further option for practitioners. while most young people are adept at (and even prefer) digital technology, this does not translate straightforwardly to online learning. a recent irish study of diagnostic radiographers revealed that about half of their participants were not very confident using online learning systems.[4] mulvey[5] identified three key role-players in the cpd system, i.e. the individual practitioner, the employer and the professional body. such a conceptualisation is useful because it acknowledges the critical role of each in ensuring the ultimate goal of best practice and optimal patient care. the practitioner and the employer have direct responsibility towards patient care, while the professional body has the task of safeguarding the public by regulating health professionals’ behaviour, ethical practice and adherence to appropriate standards of healthcare. however, cpd compliance can be costly in terms of time and money, with implications for the practitioner and in some cases for the employer. grehan et al.[4] found that funding, time and location were significant barriers to cpd compliance. notwithstanding the cost-bearers of continuing education, there has been concern about costeffectiveness issues relating to cpd activities.[6] while there has been concern about the extent to which collecting cpd points results in improved practitioner skills or improved service,[5] the findings have been varied. although it is difficult to directly attribute patient outcomes to continuing education initiatives, there is evidence that professional education influences changes in practice and enhances background. with the system of mandatory continuing professional development (cpd) for psychologists in its second decade in south africa (sa), research into practitioners’ views of and experiences with the system is almost non-existent. the current research is necessary to help to inform future developments in this subject area. objectives. to understand psychologists’ experiences with the mandatory continuing education system, including their attitudes, means of accessing cpd, barriers and perceived improvements in knowledge and skills. methods. a survey approach was used to ascertain feedback from clinical, counselling and educational psychologists in kwazulu-natal province, sa. questions addressed means of accessing cpd activities, relevance to practitioners, whether continuing education needs were being met, topics that should be covered, perceived impact of cpd on practice, cost implications and experiences of being audited by the health professions council of sa (hpcsa). descriptive statistics were computed to analyse emerging trends. results. a total of 204 completed practitioner responses (response rate 28.2%) were received, of whom 55.4% agreed with the mandatory cpd policy, 91.7% noted that they would pursue continuing education even if not compulsory, and 84.3% stated that their continuing education needs were being met. about three-quarters of the participants felt that cpd costs were excessive, 70.1% self-funded their cpd, and 46.8% reported being audited by the hpcsa, of whom 49% had not met the requirements. conclusion. despite the finding that close to half of the sample opposed the idea of mandatory cpd, the expressed willingness to engage in continuing education is a positive sign. cost as the major barrier will need to be examined as one of the factors that could enhance cpd compliance. afr j health professions educ 2018;10(4):215-219. doi:10.7196/ajhpe.2018.v10i4.1049 mandatory continuing education for psychologists: practitioners’ views a l pillay, phd; a zank, ma department of behavioural medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: a l pillay (anthony.pillay@kznhealth.gov.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 216 december 2018, vol. 10, no. 4 ajhpe research practitioner competencies and confidence.[7] such growth and development are essential, and balmer[8] describes how the ‘level of competence for each professional changes over time from the completion of the initial academic degree as a novice and to the level of an expert later in their career when intuitive implementation of skills is evident’. it is also noted that continuing education formats and outcome measurements may need scrutiny, with attendance and time-based measures not being regarded as sole requirements. a focus on the competencies achieved could be a more meaningful approach.[8] similarly, boud and hager[9] suggested that cpd may be better served if it is located within practice theory. they argued against the current trends of having professionals participate in training programmes that are independent of their practice contexts. situation-specific and relevant training makes sense, especially for middleand lower-income countries, where practice contexts can be vastly different to cpd classrooms. similarly, a study of malaysian general medical practitioners (gps) noted favourable self-reports of cpd, even considering it an investment with potential for good return, but also felt that locally initiated programmes would be more relevant to their practices.[10] a recent african study of cpd for medical and nursing professionals in tanzania, malawi and sa also recommended that programmes should reflect the disease contexts of the communities served and that workplace mentorship was preferable to classroom-based teaching.[11] against this background, the authors, who are cpd providers, deemed it necessary to engage practitioners in exploratory research to gauge their views on various cpd matters. the objectives of this study were to understand practising psychologists’ experiences of complying with cpd requirements, their views on its professional relevance, the means by which they access continuing education, accessibility of programmes, issues relating to cost, their views on who the providers should be, as well as participants’ experiences of the auditing system. to the authors’ knowledge, these issues have not been evaluated to any significant degree among psychologists in sa. a previous sa study looked at cpd among mental health practitioners as a group, with only partial focus on psychologists.[12] methods participants clinical, counselling and educational psychologists in kwazulu-natal (kzn) province, who were registered as such with the hpcsa, were approached regarding participation. these three categories of psychologists were identified for the study, as they are psychology professionals who are in practice in healthcare and educational settings – unlike the other two categories in the country (industrial/organisational and research). while an ideal approach would have included all of the psychologists registered in these categories throughout sa, the complexity of such a task, including lack of electronic access to all (as the hpcsa does not store email addresses of all practitioners), made such an endeavour beyond the scope of this work, and not necessarily as meaningful and productive. moreover, given that kzn is one of the two largest provinces in the country, comprising almost one-fifth of the national population,[13] there is reason to believe that findings from a study in this province will be reasonably representative of the national situation. furthermore, as the authors provide regular cpd programmes in kzn, they have relatively good access to email databases for psychologists in the three registration categories in the province, thus improving the likelihood of a desirable response rate. at the time of the investigation there were 722 licensed practitioners in the three categories in kzn (clinical: n=326, counselling: n=232, educational: n=164) (hpcsa – personal communication, 14 july 2016). instrument the authors developed a questionnaire, as there were no established instruments. the questions were devised to address the issues they were interested in, and were based on their experiences with the provision of cpd programmes provincially and nationally, as well as collegial feedback regarding cpd involvement and compliance. apart from basic demographics, the instrument tapped participant views, attitudes and experiences of the cpd system in the following areas: work and practice context; means of accessing cpd activities; relevance of the cpd system to practitioners; whether continuing education needs were being met; topics that should be covered; perceived impact of cpd on practice; cost implications of cpd; and experiences of being audited by the hpcsa. procedure an online survey approach was used. the population of clinical, counselling and educational psychologists in kzn was accessed through the use of multiple data sources that included the various professional association databases, as well as the authors’ own databases of cpd-registered participants throughout the province. an invitation to participate was emailed to psychologists registered on the databases, providing the url link to access the study, should they choose to do so. the link opened to the introductory page, which described the study, its purpose, estimated completion time, as well as voluntary participation details. the sample comprised all those who agreed to participate in the survey and provided complete responses. anonymity was ensured with the online programme used. ethical approval the study received ethical approval from the university of kzn humanities and social sciences research ethics committee (ref. no. hss/1757/015). the introductory information on the online administration system made it clear that participation was voluntary and that the participants could withdraw at any stage. data analysis data were analysed using spss 25 (ibm corp., usa) to examine emerging trends. descriptive statistics were computed to identify variables of significance. results a total of 204 completed responses were received; all were included in the study. this constituted a response rate of 28.2%, which may be somewhat lower than desired, but is understandable given the tendency among practitioners to ignore research participation requests either through electronic or postal mail. women comprised the majority (n=176; 86.3%) of the participants, while the age range was 29 72 (mean 40.44, standard deviation (sd) 7.09) years. duration of practice ranged from 1 to 41 (mean 11, sd 6.3) years. although the professional registration categories of the participants appeared relatively evenly distributed, with 71 (34.8%) counselling psychologists, 65 (31.9%) clinical psychologists and 64 (31.4%) educational psychologists, the proportional representation was skewed. the december 2018, vol. 10, no. 4 ajhpe 217 research category response rates were as follows: 39.0% educational psychologists, 30.6% counselling psychologists and 19.9% clinical psychologists. although the overall response rate was lower than ideal, earlier professional psychology research has documented similar rates of survey response.[14,15] table 1 shows the participants’ primary place of employment. of those working in government departments, health (51.0%) and education (41.2%) were the predominant contexts. table 2 reflects the means used by participants in accessing cpd activities. more than half of the participants (n=115; 56.4%) reported having problems accessing cpd activities. the types (areas) of problems experienced are reflected in table 3. while 113 (55.4%) of the sample agreed with the policy of mandatory cpd, 89 (43.6%) believed that cpd should not be mandatory. however, the overwhelming majority of participants (n=187; 91.7%) stated that they would undertake professional development activities even if cpd was not compulsory. in a similar vein, 172 (84.3%) of the sample noted that their continuing education needs were currently being met. table 4 shows the areas where participants reported that their knowledge and skills have improved. participants’ responses regarding who they believed should provide cpd activities are listed in table 5. participants’ views on the extent to which current cpd activities address specific aspects are reflected in table 6. regarding the funding of cpd activities, 143 (70.1%) of participants reported self-funding their continuing education, while about one-quarter (n=53; 26.0%) indicated joint funding by themselves and their employers. most participants (n=156; 76.5%) felt that the cost of cpd was excessive, while 40 (19.6%) considered the activities reasonably priced. close to half of the participants (n=95; 46.8%) reported that they had been audited by the hpcsa regarding their cpd compliance, and 49% of those had not met the requirements immediately. responding to the question of providing cpd activities, 164 (80.4%) stated that they do not provide or initiate such activities, with 28 (13.7%) stating that they do. of the latter, most (n=17; 63.0%) found the application process for cpd accreditation easy to follow and 20 (83.3%) noted that their applications were processed in a timely manner. nearly all of the cpd providers in the sample (n=21; 91.3%) had not had their events audited. table 7 reflects the broad areas of psychology that participants requested as cpd programmes of choice for future programmes. table 8 presents the gender effects on selected variables. significantly more men than women reported being audited and agreed with mandatory cpd, but considering sample gender distribution these interaction effects should not be over-stated. being in full-time private practice had no influence on participants’ experiencing problems in accessing cpd (χ2 0.152; p=0.697), agreement with mandatory cpd policy (χ2 0.005; p=0.945), willingness to undertake cpd regardless of legislation (χ2 0.786; p=0.375) or whether they were audited (χ2 0.082; p=0.775). however, significantly more participants in table 1. primary place of employment employment n (%) private practice 75 (36.8) university and private practice 50 (24.5) government department 30 (14.7) government and private practice 19 (9.3) private practice and other 15 (7.4) university 7 (3.4) other 6 (6.0) missing 2 (1.0) total 204 (100) table 2. means of accessing cpd activities access to cpd n (%) workshops 184 (90.6) symposia or conferences 155 (77.3) journal clubs/professional groups 142 (70.0) online activities 45 (22.2) other 5 (2.5) cpd = continuing professional development. table 3. problems experienced in accessing cpd activities problems n (%) physical accessibility 45 (22.2) time to attend 105 (51.7) availability/awareness 2 (1.0) cost 115 (56.7) topics covered not of interest 40 (19.7) other 0 (0.0) cpd = continuing professional development. table 4. knowledge and skills improvement because of cpd areas of improvement improved, n (%) not improved, n (%) practical skills 158 (77.5) 45 (22.1) theoretical knowledge 152 (74.5) 51 (25.0) ethics, legal or human rights knowledge 180 (88.2) 23 (11.3) cpd = continuing professional development. table 5. preferred cpd providers preferred provider n (%) university 198 (97.5) professional association 144 (70.9) interest group 57 (28.1) employing organisation 43 (21.2) other 8 (3.9) cpd = continuing professional development. table 6. adequacy of cpd activities in addressing specific areas activity adequately addressed, n (%) not adequately addressed, n (%) basic knowledge 154 (75.5) 48 (23.5) updating latest professional developments 168 (82.4) 33 (16.2) refresher courses 169 (82.8) 31 (15.2) specialised techniques 126 (61.9) 73 (35.8) cpd = continuing professional development. 218 december 2018, vol. 10, no. 4 ajhpe research full-time private practice viewed cpd costs as excessive than those who were not in full-time private practice (χ2 5.853; p=0.016, cramer’s v 0.173). more participants who reported that their continuing education needs were currently met were not in full-time private practice, although this finding fell slightly short of significance (χ2 3.500; p=0.061). discussion the substantially higher proportion of responses from educational and counselling psychologists than clinical psychologists is interesting. among the reasons might be the heightened concern among educational and counselling psychologists in recent years regarding professional training and scope of practice issues. these matters have dominated the discipline of psychology and led to court action and pressure on the hpcsa to address the scope of practice legislation. the preponderance of women in the sample is in keeping with the gender distribution trends in psychology locally and internationally, with some referring to this development as the ‘feminisation of psychology’.[16] the means of accessing continuing education reveals interesting trends. clearly, the majority of participants preferred group-based learning contexts with peers, and >90% favoured workshops, suggesting the need for skills acquisition that workshops generally deliver. this is similar to the transnational african study findings that show a preference for workplacebased mentoring, which also emphasised practical skills development as opposed to theory uptake.[11] it is encouraging to note that 70% of participants were involved in journal clubs or professional groups, which are generally self-selected peer-groupings for practitioners who desire collegial interaction and support, as opposed to insular ways of working and learning. the finding that less than one-quarter of participants used online offerings is slightly unexpected, considering the relatively young sample and the plethora of marketing of online cpd programmes. however, the finding seems to align with that of grehan et al.,[4] who noted that about half of their sample was not sufficiently confident with online learning systems. the finding that over half of participants experienced problems accessing cpd activities, with cost and time being the major barriers, is of concern. while similar to the finding of grehan et al.,[4] in ireland, the related matter of cost-effectiveness[6] is one that needs ongoing monitoring and evaluation, especially considering the prolific marketing of cpd activities nationally. close to half the sample believed that cpd should not be mandatory, which is a slightly higher proportion than that found in an earlier sa study of nurses.[1] this very possibly reflects the preference for autonomous decision-making in continuing education, because >90% of the current sample conceded that they would undertake continuing education even if it was not mandatory. the positive reports by about three-quarters of the participants regarding perceived improvement in their knowledge, should be viewed against the very prominent view (close to half the sample) that cpd should not be compulsory, suggesting that perhaps mandatory cpd has been fruitful. this is consistent with the finding of abdul samad et al.[10] regarding general practitioner reports on the positive benefits of mandatory cpd. the more substantive improvement reported in knowledge of ethics, law and human rights must be viewed in a positive light, given sa’s not-sodistant history of serious human rights abuses, as well as the relatively recent uncovering of us psychologists’ complicity in torture and human rights violations at guantanamo bay.[17,18] participants’ preference for universities and professional associations as the main providers of cpd programmes is not surprising, considering that the former are the purveyors of academic and scientific knowledge and the primary source of participants’ basic professional education, while the latter are charged with professional growth and development of the discipline. participants were generally satisfied with the adequacy of cpd activities addressing most areas, but were relatively less impressed with the extent to which specialised techniques were covered. the greater quest for knowledge in specialised areas speaks to the fact that practitioners completed their basic training (with an average of 11 years in practice), but now require more training on techniques that are novel, sophisticated or innovative. perceptions regarding the cost of cpd activities may be relative to income and overall economic status of the participants. nevertheless, it is important to note that cost issues are significant variables that have been linked as barriers to continuing education initiatives and compliance,[4,11] especially as >70% of participants in the current study were self-funding their cpd. table 7. desired cpd topics for future programmes topics n (%) therapy 84 (41.4) ethics 29 (14.3) forensics 29 (14.3) specific disorders 26 (12.8) assessment 24(11.8) neuropsychology 16 (7.9) corporate-related work 10 (4.9) theories 9 (4.4) career/vocational counselling 8 (3.9) pharmacotherapy 6 (3.0) research 5 (2.5) culture 2 (1.0) other 11 (5.4) cpd = continuing professional development. table 8. gender effects on selected variables variables χ2 df p-value cramer’s v problems accessing cpd 3.33 1 0.068 0.128 agreement with mandatory cpd 4.26 1 0.039 0.146 would undertake cpd regardless of legislation 0.00 1 0.991 0.001 continuing education needs currently met 0.51 1 0.475 0.051 have been audited by hpcsa 11.65 1 0.001 0.241 views of cost of cpd activities 0.097 1 0.756 0.022 cpd = continuing professional development; hpcsa = health professions council of south africa. december 2018, vol. 10, no. 4 ajhpe 219 research the finding that significantly more participants in full-time private practice viewed cpd costs as excessive than those who were not in full-time private practice, could be viewed in the context of overall costs to such individuals, rather than simply cost of the cpd activity, as these practitioners lose income through closure of their practice if the activity takes place during the workday. the report by almost half the participants that their cpd compliance had been audited by the hpcsa is indicative of the regulatory body’s seriousness about continuing education. it is, however, concerning that about half of those selected for random audits had not met the cpd points requirement. the hpcsa does note, however, that practitioners who are found non-compliant are given a further 6 months to remedy their situation.[2] that ~13% of participants were themselves cpd providers is encouraging, and the relative ease that most report in the accrediting of their activities is an indication that the system functions better than it did several years previously, when the regulator had temporarily abandoned cpd owing to difficulties in managing the system. conclusion the findings of this study of psychologists’ experiences with the cpd system suggest an overall positive sentiment, barring cost and funding issues. the general consensus towards undertaking cpd activities, even if it was not mandatory, coupled with the self-identified improvements in theoretical, practical and ethics-related knowledge and skills, augurs well for the profession. the preference for peer-group learning formats is also encouraging. it is, therefore, recommended that cpd programmes include more specialised techniques, using more group-training formats, and pay more serious attention to cost reduction in such offerings. the latter can be better facilitated when arranged by universities and professional associations, which also address participant preferences noted in this study. declaration. none. acknowledgements. none. author contributions. the authors contributed jointly to conceptualising, executing and reporting on the research. funding. none. conflicts of interest. none. 1. davids jm. continuing professional development in nursing. mphil thesis. cape town: stellenbosch university, 2006. 2. health professions council of south africa. cpd overview. 2017. http://www.hpcsa.co.za/cpd (accessed 14 december 2017). 3. balmer jt, bellande bj, addleton rl, et al. the relevance of the alliance for cme competencies for planning, organizing, and sustaining an interorganizational educational collaborative. j contin educ health prof 2011;31(suppl 1):s67-s75. https://doi.org/10.1002/chp.20150 4. grehan j, butler m-l, last j, et al. the introduction of mandatory cpd for newly state registered diagnostic radiographers: an irish perspective. radiography 2018;24(2):115-121. https://doi.org/10.1016/j.radi.2017.09.007 5. mulvey r. how to be a good professional: existentialist continuing professional development (cpd). br j guid counc 2013;41(3):267-276. https://doi.org/10.1080/03069885.2013.773961 6. brown ca, belfield cr, field sj. cost effectiveness of continuing professional development in health care: a critical review of the evidence. bmj 2002;324(7338):652-655. https://doi.org/10.1136/bmj.324.7338.652 7. fletcher m. continuing education for healthcare professionals: time to prove its worth. prim care respir j 2007;16(3):188-190. https://doi.org/10.3132/pcrj.2007.00041 8. balmer jt. the transformation of continuing medical education (cme) in the united states. adv med educ pract 2013;4:171-182. https://doi.org/10.2147/amep.s35087 9. boud d, hager p. re-thinking continuing professional development through changing metaphors and location in professional practices. stud cont educ sciences 2012;34(1):17-30. https://doi.org/10.1080/0158037x.2011.608656 10. abdul samad n, md zain a, osman r, et al. malaysian private general practitioners’ views and experiences on continuous professional development. malays fam physician 2014;9(2):34-40. 11. feldacker c, pintye j, jacob s, et al. continuing professional development for medical, nursing, and midwifery cadres in malawi, tanzania and south africa. plos one 2017;12(10):e0186074. https://doi.org/10.1371/journal. pone.0186074 12. pillay al, tooke l, zank a. continuing education needs and related variables among mental health professionals in south africa. j psychol africa 2013;23(4):643-646. https://doi.org/10.1080/14330237.2013.10820681 13. statistics south africa. mid-year population estimates 2017. pretoria: statssa, 2017. 14. brosig cl, hilliard me, williams a, et al. society of pediatric psychology workforce survey. j pediatr psychol 2017;42(4):355-363. https://doi.org/10.1093/jpepsy/jsx051 15. pillay al, kritzinger am. the dissertation as a component in the training of clinical psychologists. s afr j psychol 2007;37(3):638-655. 16. skinner k, louw j. the feminization of psychology: data from south africa. int j psychol 2009;44(2):81-92. https:// doi.org/10.1080/00207590701436736 17. hoffman dh, carter dj, viglucci lopez cr, et al. report to the special committee of the board of directors of the american psychological association: independent review relating to apa ethics guidelines, national security interrogations, and torture. chicago, il: sidley austin llp, 2015. 18. pillay al. psychology, ethics, human rights, and national security. s afr j psychol 2015;45(4):424-429. https://doi. org/10.1177/0081246315611045 accepted 26 april 2018. http://www.hpcsa.co.za/cpd https://www.radiographyonline.com/issue/s1078-8174(18)x0002-9 https://doi.org/10.1016/j.radi.2017.09.007 https://doi.org/10.1080/03069885.2013.773961 https://doi.org/10.1136/bmj.324.7338.652 https://doi.org/10.2147/amep.s35087 https://doi.org/10.1080/0158037x.2011.608656 https://doi.org/10.1371/journal.pone.0186074 https://doi.org/10.1371/journal.pone.0186074 https://doi.org/10.1093/jpepsy/jsx051 https://doi.org/10.1080/00207590701436736 https://doi.org/10.1080/00207590701436736 https://doi.org/10.1177/0081246315611045 https://doi.org/10.1177/0081246315611045 114 october 2020, vol. 12, no. 3 ajhpe research nursing research exposes professional nurses to a wealth of knowledge and experience, which could entail using the emerging experiences to understand how to interact appropriately in the new world, expand one’s horizon of thinking and one’s approach to problem-solving.[1] nursing research explores the preparedness of professional nurses to leadership positions, further education, appropriate measures to improve teaching and learning and professional growth.[2,3] nursing research programmes produce experts on whom south african (sa) healthcare institutions are dependent for the promotion of quality healthcare services, and expansion of preventive strategies and healthcare policies.[4] furthermore, nursing research strengthens evidence-based healthcare practices for the effective functioning of healthcare institutions.[5] it also leads to increased career opportunities for professional nurses and to master’s and doctoral degrees in a chosen research area.[6] conducting nursing research demands organisation, diligence, following systematic patterns of enquiry, looking for answers, validating existing research knowledge and generating new evidence-based knowledge.[7,8] in sa, there is a dire need for more throughput of postgraduate research graduates. nursing is not an exception, owing to the low level of completion among those who enrol for the programme.[9] the researchers in this study conducted an unsystematic narrative literature review from computerised databases, synthesising their findings to foster an understanding of how to improve postgraduate nursing research throughput in sa. objectives the purpose of this unsystematic narrative literature review was to explore the relevant literature obtained from a computerised database that focused on improving postgraduate nursing research throughput in sa to synthesise ideas and draw conclusions. methods an unsystematic narrative literature review, also known as a narrative review, was done in this study,[10] and is distinct in its approach, as it enables periodic synthesis of the existing literature and drawing of conclusions.[11,12] adopting an unsystematic narrative literature review enabled the researchers to review the relevant literature from a computerised database search and to synthesise findings to foster measures for improving postgraduate research throughput in nursing science in sa. a literature search was conducted in three databases, i.e. google scholar, sciencedirect and sabinet online, with regard to articles not beyond 2009, using the following keywords: ‘improving’, ‘nursing research’, ‘output’ and ‘postgraduate research’. owing to paucity of the literature in this regard, the researchers carefully reviewed and synthesised the findings of the available literature, thereby drawing possible solutions and conclusions for the study. brief overview of postgraduate nursing research nurses with master’s and doctoral degrees are leaders in healthcare and education globally. graduates with these qualifications are necessary for managerial and other leadership positions in healthcare/research and higher education institutions.[13] postgraduate research in nursing prepares nurses for delivering cost-effective healthcare services and evidence-based nursing care, enhancing critical thinking and improved solving of healthcare problems.[14] those with master’s and doctoral degrees contribute to improving human resource shortages in the health professions.[15] excellent background. postgraduate nursing research programmes prepare professional nurses for receiving master’s or doctoral degrees, foster growth of the profession and strengthen the nation’s health sectors through development and implementation of innovative approaches for better nursing care. enrolment in and completion of postgraduate nursing research programmes follow rigorous processes, involving the student, supervisor(s) and university. objectives. to review the relevant literature obtained from a computerised database search that focused on improving postgraduate nursing research throughput in south africa (sa) to synthesise ideas and draw conclusions regarding the topic being discussed. methods. an unsystematic, narrative literature review approach was adopted for a computerised database search. results. the study revealed that postgraduate nursing research throughput could be improved through enrolment of a greater number of master’s and doctoral students across sa universities, and adequate provision of structures for accessing information, e.g. the latest technologies. the study also revealed the need for adequate support of supervisors with the necessary resources and continuous training of more supervisors in innovative methods for appropriate development of the requisite skills to strengthen research supervision. conclusion. there is a dire need to promote postgraduate nursing researchers owing to the importance of professional growth, development of new knowledge and university funding. afr j health professions educ 2020;12(3):114-118. https://doi.org/10.7196/ajhpe.2020.v12i3.1337 improving postgraduate nursing research output: a south african nursing science perspective p c chukwuere, msc; l a sehularo, phd; m e manyedi, phd; m m ojong-alasia, msc school of nursing science, faculty of health sciences, north-west university, potchefstroom, south africa corresponding author: p c chukwuere (chibuikeprecious45@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 115 research master’s or doctoral research contributes to the academic or professional field and most importantly fulfils the requirement for awarding a degree.[16,17] exposing student nurses to a good research background during undergraduate projects enhances their understanding of research and could benefit them during postgraduate research programmes. however, in most cases, schools find it difficult to expose their students to this information because of factors such as poor programme management, excessive student workload and poor time management, which translate into lack of adequate background knowledge of research. most professional nurses who also enrol for postgraduate research programmes struggle to balance work and academia. maintaining a balance between work and study, coupled with indifferences in perceptions regarding the need for postgraduate nursing research programmes, could lead to difficulties with enrolment and completion of a master’s or doctorate in nursing science.[6] furthermore, multiple nursing roles and the brain drain are also among the factors discouraging professional nurses from enrolling and completing postgraduate research programmes.[14-18] most of those enrolling for postgraduate research programmes are faced with numerous difficulties and commitments, which affect their productivity in the programme.[19] postgraduate nursing research in south africa completion of postgraduate research remains a vital concern for institutions of higher education in sa and worldwide.[18-20] in sa, there has been an insufficient number of master’s and doctoral graduates across disciplines, including nursing science.[21,22] sa has a <20% throughput rate of doctoral nursing graduates per year, which poses a challenge to postgraduate nursing research.[23] therefore, the high postgraduate dropout negatively affects universities’ economic resources and deprives them of master’s and doctoral graduates for the growing labour market, especially in the nursing profession.[24,25] this dropout rate affects all disciplines in sa, which is detrimental to economic growth. universities are key drivers of innovation and change through research efforts of master’s and doctoral students.[9] from 2000 to 2006, at the college of health sciences, university of kwazulu-natal, durban, sa, master’s and doctoral nursing programmes had a completion rate of 11% and 10%, respectively, with an average dropout rate of 56%, especially for master’s programmes.[26] the low throughput rate of postgraduate research students at sa universities is problematic,[9] as there is a discrepancy between the high number of enrolments in postgraduate programmes, including nursing, and the completion rate. therefore, the increase in students dropping out from their respective postgraduate nursing research programmes leads to discouragement among supervisors, low academic growth for supervisors and professional growth for nurses, while remuneration and university prestige are jeopardised. nurses constitute a vital part of the sa workforce, which necessitates completion of master’s and doctoral degrees to assist in placing the profession at a highly ranked professional position globally and to enhance the delivery of quality healthcare services for all users of such care. however, enrolling for and completing a postgraduate research programme in nursing are challenging for the school management, supervisors and students. many prospective postgraduate research students across all disciplines perceive research as insurmountable, which also applies to nurses. an adequate understanding of the underlying principles and their application leads to an easier ride.[27] hence, the need for understanding the principles and starting correctly is imperative. research is a complex term used to denote any type of investigation geared towards finding a solution(s) to an existing problem and generating new knowledge through rigorous processes.[28] postgraduate research programmes are crucial to investigate new phenomena that lead to discoveries, knowledge creation and possibly solutions and strategies across the socioeconomic and political landscape.[9] such programmes in all disciplines contribute greatly to the development of a nation and institutions of higher learning.[29] universities as key drivers in postgraduate nursing research programmes universities are key role players in knowledge development and dissemination through utilisation of the collaborative functions of students and their supervisors – thus equipping students for the future.[26] globally, there is a high demand across universities for more postgraduate students – also in sa – especially with regard to nursing science.[27] postgraduate research programmes have proven to be an important source of income to universities through publications (during the course of the study and on completion of the research project) and also helps in marketing of their brand globally.[30] postgraduate research constitutes a huge source of funds to university management,[2,6] and universities also develop competent researchers, enabling the expansion of skills. hence, the slow completion of postgraduate research programmes (master’s and doctorates) across all disciplines, with nursing not being an exception, is a serious concern to universities.[31] they suffer with regard to subsidies when a student fails to complete a postgraduate research programme in the appropriate time; therefore, throughput rates are important to higher institutions of learning.[32] universities face challenges regarding student demands and changes in government policies.[33] studies have shown that sa has a shortage of competent supervisors, especially in health science faculties, including nursing science. recently, there has been an increase in the intake of postgraduate students in universities across sa, but the limited number of competent supervisors increases the workload, thereby undermining their productivity and generally leading to a low output of master’s and doctoral graduates.[34] the slow rate of completion of postgraduate research programmes by nurses deprives the universities of the various financial subsidies.[23] supervisors as important role players in postgraduate nursing research postgraduate supervision is an interactive process, contributing to quality dissertations and theses.[32] such supervision is also important in fostering improvement in the quality of care and for successful completion of master’s and doctoral programmes.[35] supervisors play a pivotal role in influencing the academic progress of postgraduate research nursing students. they use the combination of projection technique and personality profile to enable students to understand what is necessary to enhance their chances of completing their studies.[32] standard postgraduate research supervision is a vital requirement for successful completion of a postgraduate programme.[36] undertaking postgraduate research supervision is an enormous, but rewarding challenge. such supervision is performed in the university setting, with the university shouldering the overall support and development of the supervisor for adequate output.[38] postgraduate nursing research supervision is important for producing quality researchers.[35] through postgraduate supervision roles, nursing supervisors manage and guide the research progress of their supervisees 116 october 2020, vol. 12, no. 3 ajhpe research at different levels of study. supervisors are rewarded for contributing to the graduation of students by either being promoted in their various positions, general institutional obligations, self-actualisation, expansion of research horizons and professorship awards. hence, postgraduate nursing research supervision is considered a crucial aspect of facilitating postgraduate graduation. such supervision poses a huge challenge to supervisors because of the heavy workload or lack of adequate experience, which directly affects the throughput of students. many postgraduate nursing research supervisors lack the quality time to allow them to participate in training programmes for mentorship, which will contribute to their development.[23] to that effect, advancement in scholarly development among nursing research supervisors is undermined owing to lack of time. interestingly, in sa, only five academic nurses have reached the national research foundation rating.[37] furthermore, the slow rate of throughput of postgraduate students could be as a result of the inexperience of supervisors. because of lack of competent supervisors, inexperienced ones have to supervise student researchers without proper mentorship, which directly reflects on the disappointing results.[23] discussion starting and completing a master’s or doctoral programme in nursing is a tricky journey, underpinned by taking the right steps at the right time. the preparedness of a prospective postgraduate nursing research student is a vital determining factor towards enrolment and completion of the degree programme.[38] a nurse who appreciates the need for undertaking master’s or doctoral studies should take appropriate steps towards becoming acquainted with the embedded processes and challenges that follow. therefore, combining daily practice with a master’s or doctoral programme is never an easy journey. envisaging the end at the beginning strengthens the mind towards the challenges ahead and, importantly, towards adhering to the step-by-step processes involved.[39] therefore, the researchers in this study are of the view that a determined and focused individual always completes an undertaking. it is imperative to understand that as a postgraduate nursing student, especially at doctoral level, you are almost alone on the research journey, and you need to take the correct decisions throughout. importantly, the writing of postgraduate nursing research can be challenging and time consuming, which demands skills for intellectual conceptual abilities and constructive thinking. research across all disciplines follows structured, systematic, replicable and universally accepted formats that are purposely designed for solving of ambiguous problems within a specific area.[9] postgraduate research nursing students should have a personal target, decide on the direction they want to go and discuss it with their supervisor to attain a distinct consensus to work effectively. such students should endeavour to understand that finalising and passing a good dissertation or thesis entail engaging with their supervisor and completing fundamental tasks, including: • deciding on the field of research (conceptualisation of research ideas) • choosing a topic • choosing a supervisor • discussing the research area or interest • starting with writing (drafting a preliminary proposal). a nurse who embarks on postgraduate research studies at a university should try to make clear-cut decisions on the area of research, consider the financial implications and job and family commitments, which may directly or indirectly affect their studies.[40] however, the student can try to make contact with the school for a supervisor who shares their research interests. supervisors, who are generally more knowledgeable in specific research areas, are expected to guide the student in decision-making. the research supervision processes should lead to knowledge creation and expertise in a chosen field of research.[26] therefore, it is essential for a prospective nurse researcher to consider an area of interest, conceptualise a research idea and discuss it with the supervisor. the choice of research area of interest, identifying and constructing research topics, developing clear research questions, producing a good proposal and conducting the study are challenging to students.[41] master’s or doctoral research processes can be rigorous, frustrating, depressive, monotonous or even daunting, but selecting an area of interest could help in navigating research-associated difficulties. furthermore, a well-written research proposal enables easy navigation through the research ethical review committee, approval, conducting of the study and subsequent writing of the research findings.[41] the choice of a supervisor can be challenging. at some universities, the management helps in assigning supervisors to master’s students, while the student has the choice of accepting to work with the assigned supervisor or make their own choice. however, this is more challenging to doctoral students, as they have the responsibility of contacting the university and selecting a supervisor(s) for their research. to that effect, the appropriate choice of a supervisor enhances the professional relationship between the student and the supervisor. for instance, when the supervisor has the same area of interest as the student, it leads to mutual understanding and professionalism. students are expected to communicate well with their supervisors to foster appropriate working conditions. communication is a vital component of nursing research supervision; hence, the student should prioritise communicating with their supervisor for timely completion of the study.[6] interestingly, the chosen topic for nursing research represents the umbrella for the entire study. the topic/title should be concise, comprehensive and contain few words.[42,43] research topics should demonstrate professional importance, be original, researchable, feasible and of interest to the nurse researcher.[6] the topic should be presented to the prospective supervisor for validation, and there should be consensus regarding the topic. this will enable the student and the prospective supervisor to start on the same page and to work together well. preliminary research to obtain information on the chosen topic enables the researcher or student to conceptualise valid research ideas. preliminary research also enables the student to determine if there is enough supporting literature, or an excess of literature, which might indicate that the topic is over researched. the preliminary research might also guide a nurse in selecting a topic without a preconceptualised research topic. possible solutions considering the individual and societal benefits of master’s and doctoral degrees in the sa nursing profession, it is imperative to acknowledge the possible solutions for improvement. sa postgraduate nursing research throughput could be improved by enhancing the method of enrolment, and more support for addressing students’ personal and academic-related ordeals to promote completion and graduation rate.[13] postgraduate nursing research students need emotional support from their supervisors, which october 2020, vol. 12, no. 3 ajhpe 117 research helps to encourage them regarding effective output.[32] adequate provision of structures for accessing information, such as the latest technology and library facilities, enables postgraduate nursing research students to obtain educational material for their studies.[33] supervisors have an important role in developing appropriate research capacity and competence among students. hence, they should be properly supported with the appropriate resources and information for more research throughput.[34] furthermore, sa institutions should endeavour to encourage postgraduate research students to align their research with the current economic, educational, health and social challenges and adequate decisionmaking.[34] monitoring and reporting of student progress to the appropriate authority are imperative for timely completion of the study. consequently, the research environment and available support systems are integral components for completing postgraduate nursing research programmes. these environments primarily refer to the study context, which facilitates adequate data collection. universities should prioritise the studies of their students and assist them where necessary.[27] postgraduate nursing research programmes are vital to society; therefore, students need to be adequately supported by institutional authorities, taking cognisance of the areas of the curriculum to enhance their success in their various roles after graduation. these might include teachers, research consultants, managers, mentorship and research scholarship.[44] those with master’s and doctoral degrees are considered to have more advanced knowledge, and supervisors are therefore expected to have a high level of expertise in their respective fields. owing to the increase in demands and intake of postgraduate nursing research students in the various higher institutions in sa and the limited number of supervisors, there is a need for continuous training of more supervisors and innovative methods for appropriate development of adequate skills, which will promote research supervision.[45] furthermore, improving postgraduate nursing research supervision should be contractual and evenly distributed among students, supervisors and the university; each role players can thus prioritise their various roles for timely completion of the study.[35] supervisors should understand their central roles in the completion of a postgraduate degree, taking cognisance of the complex nature of mentoring a student.[40] hence, relational orientation leadership is vital for postgraduate nursing supervision, as it encourages supporting, developing, supervising, recognising and empowering students.[35] it is a complex process that requires competency, multiple skills and knowledge. supervisors should continually improve their skills to enhance their abilities in guiding the students properly. furthermore, postgraduate nursing research supervisors require a good knowledge of methodology, and facilitation and management skills for adequate research output.[26] exposing postgraduate nursing research students to research training, computer skills acquisition, information searches and stress management will help to improve throughput.[19] conclusions postgraduate nursing programmes help to prepare nurses for the provision of evidence-based practices and to advance the nursing profession through research. sa has a low throughput of postgraduate nursing graduates, specifically of master’s and doctoral degrees, as a result of numerous factors, as portrayed in the study. hence, there is a dire need for adequate throughput of postgraduate nursing graduates, specifically at master’s and doctoral level. to explore the topic of discussion, the study adopted an unsystematic, narrative literature review method, which enabled the researchers to cover distinct subheadings, including a brief overview of postgraduate nursing research in sa, universities as key drivers of postgraduate nursing research programmes, supervisors as important role players, as well as a discussion and conclusion. the literature was reviewed and synthesised in line with the topic of discussion. findings revealed that postgraduate nursing research throughput could be improved through provision of more support for postgraduate nursing research students to enable them to address personal and school-related challenges. there should be provision of adequate structures, such as library facilities, encouragement of students to be innovative in their research areas and continuous training of supervisors to enable them to be grounded in their respective research areas. recommendations • this study strongly recommends the supervision of postgraduate nursing research students by more than one supervisor. this will encourage expertise and prevent disruption should the supervisor be dismissed, incapacitated or pass away. • nurse researchers should be ethically sound; hence, faculty management or ethical bodies should endeavour to find common ground in maintaining ethical standards to minimise unnecessary delays. declaration. none. acknowledgements. the authors would love to acknowledge almighty god for his grace to complete this study. author contributions. all authors contributed equally to the manuscript. funding. 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some of the challenges facing postgraduate nursing education in south africa. nurse educ today 2011;31:253–258. https://doi.org/10.1016/j.nedt.2010.11.007 https://doi.org/10.7553/77-2-60 https://doi.org/10.1097/nnr.0000000000000069 https://doi.org/10.1097/nnr.0000000000000069 https://doi.org/10.5172/conu.2011.273 https://doi.org/10.5172/conu.2011.273 https://www.preprints.org/manuscript/201812.0305/v1 https://www.preprints.org/manuscript/201812.0305/v1 https://doi.org/10.1136/eb-2018-102895 https://doi.org/10.1186/s41073-016-0019-2 https://doi.org/10.1186/s41073-016-0019-2 https://doi.org/10.1179/2047480615z.000000000329 https://doi.org/10.1179/2047480615z.000000000329 https://doi.org/10.4102%2fhsag.v23i0.1107 https://doi.org/10.1111/j.1466-7657.2008.00683.x https://doi.org/10.1016/j.nedt.2016.03.010 https://doi.org/10.1080/03075079.2011.651448 https://doi.org/10.1016/j.nedt.2010.11.007 118 october 2020, vol. 12, no. 3 ajhpe research 19. motseke m. reason for the slow completion of 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staff in a nigerian research institute. front res metrics analyt 2018;25(3):26. 30. botma y, roets l. ways to improve research outputs of nurse academics in sub-saharan africa. j new gen sci 2013;11(1):31-41. 31. mcculloch a, thomas l. widening participation to doctoral education and research degrees: a research agenda for an emerging policy issue.  high educ res develop 2013;32(2):214-227. https://doi.org/10.1080/07294360.2 012.662630 32. grobler h. a supervision tool to guide postgraduate students during research supervision. res soc work pract 2015;27(2):246-263. https://doi.org/10.25159/2415-5829/366 33. roets l, botma y. cyclic efforts to improve completion rates of master’s degree student in nursing. curationis 2012;35(1):1-7. https://doi.org/10.4102/curationis.v35i1.111 34. chikte ume, chabilall ja. exploration of supervisor and student experiences during master’s studies in health science. s afr j higher educ 2016;30(1):57-79. https://doi.org/10.20853/30-1-559 35. severinsson e. research supervision: supervision style, research-related tasks, importance and quality – part 1. j nurs manage 2012;20:215-223. 36. mafora p, lessing a. the voice of external examiner in masters dissertations. s afr j high educ 2014;28(4):1295-1314. 37. national research foundation. list of nrf rated researchers. 2015. http://www.nrf.ac.za/sites/default/files/ documents/list%20of%20nrf%20researchers%20with%20a%20valid%20rating_28%20feb%202015_web.pdf (accessed 11 march 2019). 38. roets l, botha d, van vuuren l. the research supervisors expertise or postgraduate student preparedness: which is the real concern. afr j nurs midwifery 2017;19(2):1-10. https://doi.org/10.25159/2520-5293/3740 39. couper i, mash b. african primary care research: writing a research report. afr j prim health care fam med 2014;6(1):1-5. https://doi.org/10.4102%2fphcfm.v6i1.639 40. ismail a, abiddin nz, hassan a. improving the development of postgraduates’ research and supervision. int educ stud 2011;4(1):78-89. 41. rout c, aldous c. how to write a research protocol. s afr j anaesth analg 2016;22(4):101-107. 42. hofstee e. constructing a good dissertation. a practical guide to finishing a master’s, mba or phd on schedule. 2018. www.exactica.co.za (accessed 31 august 2020). 43. chukwuere je, chukwuere pc. guide for postgraduate student research and publication: a step-by-step approach. in: dervin f, ed. handbook of research on connecting research methods for information science research. helsinki: timely knowledge, 2020:529-550. 44. dreifuerst kt, mcnelis am, weaver mt, broome me, draucker cb, fedko as. exploring the pursuit of doctoral education by nurses seeking or intending to stay in faculty roles.  j prof nurs 2016;32(3):202-212. https://doi. org/10.1016/j.profnurs.2016.01.014 45. naidoo jr, mthembu s. an exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a south african university. afr j health professions educ 2015;7(2):216-219. https://doi.org/10.7196/ajhpe.443 accepted 13 july 2020. https://doi.org/10.1111/j.1365-2834.2011.01342.x https://doi.org/10.1111/j.1365-2834.2011.01342.x http://www.aacn.nche.edu/media-relations/fact/nursing-faculty-shortage https://doi.org/10.4102%2fcurationis.v38i1.1441 https://doi.org/10.7196/ajhpe.2017.v9i3.793 https://doi.org/10.7196/ajhpe.2017.v9i3.793 http://www.asocsa.org/news_articles/sharondell_universityworldnews_ south africa-decline-in-phd-numbers-a-major-problem-22august2010.pdf http://www.asocsa.org/news_articles/sharondell_universityworldnews_ south africa-decline-in-phd-numbers-a-major-problem-22august2010.pdf http://www.asocsa.org/news_articles/sharondell_universityworldnews_ south africa-decline-in-phd-numbers-a-major-problem-22august2010.pdf https://doi.org/10.7196/ajhpe.2016.v8i2.294 https://doi.org/10.4102/sajp.v74i1.445 https://doi.org/10.1080/07294360.2012.662630 https://doi.org/10.1080/07294360.2012.662630 https://doi.org/10.25159/2415-5829/366 https://doi.org/10.4102/curationis.v35i1.111 https://doi.org/10.20853/30-1-559 http://www.nrf.ac.za/sites/default/files/documents/list of nrf researchers with a valid rating_28 feb 2015_web.pdf http://www.nrf.ac.za/sites/default/files/documents/list of nrf researchers with a valid rating_28 feb 2015_web.pdf https://doi.org/10.25159/2520-5293/3740 https://doi.org/10.4102%2fphcfm.v6i1.639 http://www.exactica.co.za https://doi.org/10.1016/j.profnurs.2016.01.014 https://doi.org/10.1016/j.profnurs.2016.01.014 https://doi.org/10.7196/ajhpe.443 december 2018, vol. 10, no. 4 ajhpe 199 research clinical communication skills (ccs) are core to the successful practice of healthcare professionals, as good ccs are directly linked to positive patient health outcomes and satisfaction of patients with their care.[1] in the past, it was thought that ccs cannot be taught, but the literature indicates that it can indeed be taught and developed by specific, focused teaching and learning activities.[1] rotthoff et al.[2] point out that clinical experience does not automatically improve ccs and that the training thereof is essential and should be ongoing.[2] attentive consideration of relevant ccs training is therefore essential if adequately trained healthcare professionals are to be delivered. various aspects are included under the domain of ccs, such as empathy, listening skills,[3] ability to convey information and give constructive feedback, body language and documenting health information.[4] the literature describes a wide variety of methods that are used to teach and enhance ccs in healthcare students, including theory-based, practicebased and clinical-based methods. however, parry and brown[5] found that theoretical instruction is still the major method for ccs training, which results in limited translation into the clinical setting. junod perron et al.[6] warn that a longitudinal decrease of ccs could occur if skills are not practised constantly. wouda and van de wiel[7] suggest that ccs training should be a continuous ‘mainstream activity’ to develop students’ ccs to an expert level. strategies for training of ccs in healthcare programmes include role-play, video playback, audio-visual aids (such as videos), simulated/standardised patients, clinical training, peer evaluation and group discussions/activities.[1] thoughtful integration of a variety of methods can create a balance between theoretical, practical and clinical strategies, which should be carefully selected, planned and integrated in healthcare training programmes, if the desired outcomes for ccs are to be attained. the assessment and feedback strategies associated with the use of each of the ccs training activities should also be planned carefully to enhance learning. lanning et al.[8] regard a combination of peer, self, student instructor (tutor) and lecturer (academic) assessments and/or feedback strategies to be potentially appropriate to achieve the desired outcomes. in addition to the attainment of the basic ccs mentioned, many barriers, such as culture and language, further restrict the communication-related performance of healthcare students within the clinical environment. schyve,[9] for example, alludes to patient populations worldwide becoming more multicultural and multilingual – a phenomenon that complicates communication further. the importance of unceasing changes in the healthcare environment, and the impact thereof on healthcare delivery (and training), is highlighted by the ongoing debate regarding cultural and language competence and their influence on communication (and ccs training) within the healthcare setting.[10] background. clinical communication skills (ccs) are fundamental to good-quality healthcare and health outcomes, but remain problematic for healthcare students – in particular in the multilingual, multicultural south african context. as ccs can be taught, the importance of ccs training in healthcare programmes, as the basis of clinical practice, is well known. objectives. to suggest practical, student-informed directives for ccs training, we explored current challenges of undergraduate healthcare students and their ccs training. methods. the research was conducted in two phases. a mixed-methods approach was followed in phase 1, including a questionnaire survey (n=38) and semi-structured interviews (n=19), among third-year physiotherapy students. a quantitative questionnaire survey was conducted in phase 2 among final-year allied healthcare students (n=105). results. results from phase 1 indicated that students found it difficult to communicate with other members of the healthcare team (64%) and with patients’ families (82%). students indicated that language barriers influenced their treatment of patients negatively. in phase 2 of the research, only 43% of students indicated previous exposure to ccs training, and they supported the inclusion of specific ccs training methods throughout their undergraduate education. conclusions. ccs training directives, which are specifically focused on patient, family, interdisciplinary and written communication and enhancement of the student voice in the training, are suggested for inclusion in undergraduate healthcare programmes. afr j health professions educ 2018;10(4):199-204. doi:10.7196/ajhpe.2018.v10i4.1009 student-informed directives for clinical communication skills training in undergraduate healthcare programmes: perspectives from a south african university e c janse van vuuren,1 phd; m nel,2 mmedsc 1 department of physiotherapy, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: e c janse van vuuren (jansevanvuurenec@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:jansevanvuurenec@ufs.ac.za 200 december 2018, vol. 10, no. 4 ajhpe research the first author, a physiotherapy lecturer at a south african (sa) university for >15 years, recognised continuing challenges associated with ccs among physiotherapy students during their clinical training. scrutiny of previous research into ccs training appeared to be focused predominantly on the educator voice and the testing of different ccs training methods, portraying a rather limited reference to the student voice. this apparent shortcoming in the literature, as well as the authors’ concerns relating to the performance of their students, served as an impetus for undertaking this study. this article should therefore be regarded as a contribution to the ccs knowledge base by providing a student perspective on ccs training by exploring their experiences, expectations and possible suggestions for more effective ccs training at undergraduate levels. methods the research was conducted in two independent phases. the first phase consisted of an explanatory, sequential, mixed-methods approach, as described by creswell.[11] in this phase, results from an initial questionnaire survey served as the basis for the development of an interview schedule for the qualitative section of the phase. a descriptive, quantitative study was undertaken in the second phase of the research. the questionnaires used in both phases of the study were self-compiled and informed by the relevant literature. these were made available in both instructional languages (i.e. english and afrikaans) at the university of the free state (ufs), bloemfontein, sa, at the time of the research. backtranslation was used to ensure comparability of the english and afrikaans questionnaires. to enhance the validity, both questionnaires were compiled from the relevant literature and reviewed by experts in the field of physiotherapy and physiotherapy education to ensure appropriateness and perspective reflection. reliability was addressed by means of pilot studies conducted for both phases of the study, during which participants could provide feedback on the questionnaires tested. details of the pilot studies are included in table 1. trustworthiness, for the qualitative section of the study, was enhanced by the verbatim transcription of recorded interviews by an independent transcriber, which ensured truth value of the data, as the data could be revisited. ethical approval participation in both phases was voluntary. the two phases of the study were approved separately by the ethics committee of the faculty of health sciences, ufs (ecufs ref. no. 78/2011 and ecufs ref. no. 79/2012, respectively). valuable results obtained during phase 1 initiated the planning and implementation of phase 2, which necessitated separate ethical approval. phase 1 the questionnaire consisted of 70 open-ended and closed-ended questions that focused mainly on communication with patients, their families and members of the interdisciplinary team, and written communication. a description of the content focus of the questionnaire is included in fig. 1. all third-year physiotherapy students at ufs who had engaged in clinical practice for the first table 1. details on pilot studies for phases 1 and 2 of the study details phase 1 phase 2 questionaire survey, n=10 semi-structured interviews, n=4 questionnaire survey, n=5 sample randomly selected fourth-year physiotherapy students (i.e. not part of the study population) randomly selected from study population (i.e. third-year physiotherapy students) randomly selected from study population to represent all departments included in phase 2 changes made after pilot study no changes made to the questionnaire no changes made to the semi-structured interview schedule only grammatical corrections made to the questionnaire data from pilot study included in study data no yes yes figure 1: content focus of the questionnaire and semi-structured interview schedule for phase 1 of the study phase 1 of the study questionnaire survey semi-structured interviews communication with patients interdisciplinary communication written communication communication with patients’ families communication with patients’ families interdisciplinary communication written communication language barriers and the influence thereof on treatment execution quality proficiency in additional languages and the influence thereof on treatment execution quality effective motivation/ encouragement/ support of patients in an environment with language barriers language barriers and the influence thereof on explaining the patients’ condition to the family explaining to the patients’ family their role in contributing to the treatment/ recovery/ support of the patient preparation for ward rounds and the associated protocol to optimally benefit patient outcomes, interdisciplinary communication and goal-setting understanding of interdisciplinary communication (verbal nonverbal) through a variety of communication forms (as appropriate for different members of the interdisciplinary team and different clinical settings) use of information in patient files to effectively communicate with other members of the interdisciplinary team and support interdisciplinary goal-setting explored possible reasons for the identified ineffectiveness in motivating patients explored possible reasons for the identified ineffectiveness in communication with the patients’ families explored possible reasons for why interdisciplinary communication was identified as problematic and focused on: interdisciplinary breakdown in communication between specific professions lack of interdisciplinary communication via verbal forms (interdisciplinary communication mostly happened through written forms) effectiveness of interdisciplinary communication during ward rounds explored possibilities of how written communication (as a key form of communication) could be enhanced to support patient outcomes and interdisciplinary communication goal-setting fig. 1. content focus of the questionnaire and semi-structured interview schedule for phase 1 of the study. (ccs = clinical communication skills.) december 2018, vol. 10, no. 4 ajhpe 201 research time that year were included in the study sample (n=38). physiotherapy students were included in phase 1 of the study as a convenience sample from the same department as the first author. however, because of the value of data collected during this phase, the study was extended to all allied healthcare students in phase 2. quantitative data for phase 1 were collected by the researchers during a single, pre-set session. completed questionnaires were placed in a sealed box at the exit of the venue to ensure anonymity. the authors acknowledge that this is a relatively small number of students, but results are used to provide an indication of trends and not for generalisation. descriptive statistics were calculated for the quantitative data, i.e. frequencies and percentages for categorical data and medians and percentiles for continuous data, while responses from the open-ended questions were coded and reported on descriptively. based on the data from the questionnaire survey, a semi-structured interview schedule was developed to gain a greater in-depth view of the perceptions of these students with regard to their ccs. it included questions related to communication with specific members of the interdisciplinary healthcare team, patients’ families, unco-operative patients, as well as communication during ward rounds and via patient files (fig. 1). the interviews ended with a broader question, exploring students’ perceptions of their own ccs (including strengths and weaknesses). nineteen participants were purposefully selected for the interview from the group who had completed the questionnaire. participants were selected according to predetermined criteria (i.e. age, instructional language and gender) in an effort to represent variation in the study sample. the researchers conducted the interview in a single, pre-set session to limit contamination of results. the qualitative data from the semi-structured interviews comprised verbatim transcriptions of the voice recordings. the researchers used inductive coding[12] to analyse the transcribed data, which were read repeatedly, and descriptive codes were assigned to data bits. these codes were continuously refined and revised as relevant data were put together. the researchers then read through the codes, identifying recurrent themes, which became the categories. lastly, these categories were combined with quanti tative data to formulate the training directives for ccs training presented in this article. there was a high level of agreement between the emergent categories and the focus of the questionnaires (i.e. language barriers, family communication, interdisciplinary communication and written communication). interestingly, patient communi cation did not emerge as a specific category in the qualitative section of the study, possibly as participants were mostly satisfied with their communication skills with patients (table 2). phase 2 phase 2 of the research made use of a descriptive, quantitative study to determine the theoretical, practical and clinical methods for ccs training employed by allied healthcare training programmes. students could rate and reflect on their experience of ccs training, as well as the strategies to be introduced in their respective training programmes to enhance their ccs training. fig. 2 displays a description of the content focus of the questionnaire. phase 2 included 105 final-year allied health care students (from the departments of physiotherapy, occupational therapy, optometry, dietetics and nutrition). the questionnaire was completed in a computer laboratory during a single, pre-set session per department (and within 1 week for all departments to limit contamination). as students might not have been familiar with all the training methods referred to in the questionnaire, preloaded videos and a glossary explaining each of the methods were made available during the administration of the questionnaire. the preloaded videos were available on each of the computers in the computer laboratory for participants to access during completion of the questionnaire, as table 2. confidence in communication with patients in the clinical setting (n=35) communication yes, % no, % in general, do you find it easy to communicate with your patients? 79 21 do you feel you could effectively explain your treatment to your patient in layman’s terms? 77 23 could you correct your patients if they were carrying out a technique incorrectly? 94 6 could you effectively motivate your patients if they were struggling with their condition or feeling depressed? 74 26 if the patient did not understand the implications or prognosis of his condition, could you assist him with these aspects? 80 20 figure 2: content focus of the questionnaire for phase 2 of the study phase 2 of the study q ue st io nn ai re s ur ve y evaluation of current ccs training clinical scenario testing evaluation of own ccs skills and suggestions for training directives methods exposed to during undergraduate training programmes timing of exposure to these different methods during undergraduate training a variety of clinical scenarios were sketched were participants had to indicate which ccs training method they think could enhance their ccs in order to handle the situation appropriately in the clinical setting use of information in patient files to effectively communicate with other members of the interdisciplinary team and support interdisciplinary goal-setting fig. 2. content focus of the questionnaire for phase 2 of the study. (ccs = clinical communication skills.) 202 december 2018, vol. 10, no. 4 ajhpe research needed. completed questionnaires were placed in a sealed box at the exit of the venue to ensure anonymity. descriptive statistics were calculated, i.e. frequencies and percentages for categorical data and medians and ranges for continuous data (as the distribution of age was skew). results and discussion demographic data indicate that 35 physiotherapy students participated in phase 1 of the study, giving a response rate of 92% (n=38). the median age of the participants was 21 (range 20 31) years, and 65.7% (n=35) were women. for phase 2, the study population included 105 allied healthcare students, of whom 67 participated in the questionnaire survey (response rate 63.8%). the median age of the participants was 22 (range 21 27) years and the majority of participants (85%) were women. all departments training allied healthcare students were represented (table 3). even though comprehensive data were gathered during the two phases of the study, results in the remainder of the discussion reflect only on key aspects and patterns of meaning that were identified, and which were used to derive a number of practical directives for ccs training in the specific context. students’ perspectives on clinical communication skills within the clinical setting (phase 1) quantitative data with regard to communication with patients showed overall confidence among participants (table 2). despite these positive findings, all participants (n=35) indicated that language differences sometimes negatively influenced the effectiveness of their treatments, which can be expected in a multilingual country such as sa. this conclusion was confirmed by several interview responses in the category language barriers, e.g. that ‘sometimes they [patients] don’t understand you because they speak another language and you don’t always get the message through to them’ [translated]. this corresponds to results of a study by bischoff and denhaerynck,[13] which found that language barriers often diminish health outcomes. it has been suggested that instruction in the basics of an additional language to healthcare professionals and students could improve quality of care, patient satisfaction, and level of communication between patients and healthcare professionals, as well as decrease misunderstandings and frustration.[14] in support of this suggestion, 97% of participants in phase 1 indicated that basic education in an additional language would benefit their patient interactions; it is included as part of the ccs training directives (fig. 3). communication with patients’ families was found to be problematic by 82% of participants (n=35), mostly because family members were not present when treatment was administered. this finding was confirmed by the interviews and responses were included in the category family communication, such as: ‘i think it is difficult to communicate with the family in the set-up in which we work, which is mainly in the mornings and not during visiting hours’ [translated]. wolff [15] and ahmann and dokken[16] refer to the importance of involving patients’ families in their care to improve the partnership between healthcare professionals and the family, and quality of healthcare provided. communication with the families of patients is therefore specifically included in the ccs training directives (fig. 3). communication within the interdisciplinary healthcare team was another key area of concern for 64% of survey participants (n=35). reasons included a lack of understanding of the roles of other healthcare professionals in the healthcare team and communication breakdown, mostly due to time or availability constraints. these results were supported by qualitative interview responses in the category interdisciplinary communication, such as ‘they don’t really know the clinical presentation of the patients and how it influences us’, and ‘often you phone them and then they are busy, hurried and you feel in the way’ [translated]. weller et al.[17] as well as nancarrow et al.[18] identified understanding the roles within the interdisciplinary team and specific communication strategies as key components of effective interdisciplinary communication and teamwork. this forms the basis of ccs training table 3. departmental representation of study population and study sample for phase 2 of the study study population or sample physiotherapy occupational therapy dietetics and nutrition optometry study population, n 30 35 14 18 study sample, n (response rate, %) 30 (100) 16 (45.7) 7 (50) 14 (77.8) figure 3: ccs training directives for undergraduate healthcare programmes in te rd is ci pl in ar y co m m un ic at io n w ri tt en co m m un ic at io n l ac k of s tu de nt vo ic e in c c s ensure that ccs training is as healthcare students still find it difficult to function effectively in the clinical setup training in one additional language only provides a partial solution, as languages are linked to regions and learning a single additional language does not necessarily provide a comprehensive solution for the south african context. consider the provide throughout undergraduate healthcare training, , thereby including families in the healthcare management process through methods such as short-report writing, video/voice calls and video/voice messaging healthcare students are often discouraged by ineffective interdisciplinary communication, referral and interaction. therefore, as part of ccs training, the importance of interdisciplinary referral and communication structures provide students with , by be aware that students often experience written communication within the clinical environment as highly ineffective, even though they might recognise the importance thereof. it is therefore important to (such as patient files) as an official communication method during clinical years, and simulations (in written, theory-based format) during years, also within an interdisciplinary education setup identify and subsequently address students’ needs and problems by , especially in the clinical years. if problems with ccs are noticed, ccs training can be supplemented by techniques such as simulations or video playback the further by the regular use of questionnaires and/or group interviews (as in this study) 1st key area of concern : difficulties communic ating with patien ts and their families li nked to the south afric an multiling ual and multicu ltural conte xt 2nd key area of c oncern: interdisc iplinary commun ication linked to limited in terdiscip linary knowled ge and re ferral, as well a s commu nication breakdow ns 3rd key are a of concer n: written co mmunicati on linked to lim ited informa tion in and utilis ation of pat ient files 4th key are a of concer n: lack of the student vo ice in determinin g ccs need s and training l inked to lim ited literature on student perspective s on ccs n eeds and training figure 3: ccs training directives for undergraduate healthcare programmes in te rd is ci pl in ar y co m m un ic at io n w ri tt en co m m un ic at io n l ac k of s tu de nt vo ic e in c c s ensure that ccs training is as healthcare students still find it difficult to function effectively in the clinical setup training in one additional language only provides a partial solution, as languages are linked to regions and learning a single additional language does not necessarily provide a comprehensive solution for the south african context. consider the provide throughout undergraduate healthcare training, , thereby including families in the healthcare management process through methods such as short-report writing, video/voice calls and video/voice messaging healthcare students are often discouraged by ineffective interdisciplinary communication, referral and interaction. therefore, as part of ccs training, the importance of interdisciplinary referral and communication structures provide students with , by be aware that students often experience written communication within the clinical environment as highly ineffective, even though they might recognise the importance thereof. it is therefore important to (such as patient files) as an official communication method during clinical years, and simulations (in written, theory-based format) during years, also within an interdisciplinary education setup identify and subsequently address students’ needs and problems by , especially in the clinical years. if problems with ccs are noticed, ccs training can be supplemented by techniques such as simulations or video playback the further by the regular use of questionnaires and/or group interviews (as in this study) fig. 3. ccs training directives for undergraduate healthcare programmes. (ccs = clinical communication skills.) december 2018, vol. 10, no. 4 ajhpe 203 research directives related to interdisciplinary communication (fig. 3). nevertheless, the participants mostly had a positive perception of communication with professionals from their own discipline. the majority of participants (65 92% in different clinical settings; n=35) indicated that they discussed treatment plans with qualified healthcare professionals. the qualitative responses, included in the category for interdisciplinary communication, reflected the same message and included responses such as: ‘i really felt i could talk to each one of them and ask questions’ [translated] and ‘the best part was that they were prepared to teach us’ [translated]. some participants held other views, however, and stated that ‘there were a few qualified physiotherapists that were not very friendly. they left us in the deep end.’ powell and toms[19] emphasised the importance of good communication platforms and qualified personnel to serve as role models to healthcare students in training, as it creates an effective learning environment. written communication was seen as another problematic area in this study, as only 34.3% of respondents (n=35) stated that patient files contained sufficient information. only 40% (n=35) indicated that their notes were used by other members of the interdisciplinary healthcare team, even though the majority of participants indicated that most of the communication within the interdisciplinary team was based on notes in patient files (57 80% in different clinical settings). the interviews supported these results, included in the category of written communication, by responses, such as: ‘i feel it [patient files] is a good way to communicate but then everybody has to write on the same page’ [translated]. according to pullen and loudon,[20] effective patient record-keeping is very important for effective interdisciplinary communication, but records are often poorly maintained and not prioritised by members of the healthcare team. written communication forms an important component of ccs training directives (fig. 3). students’ perspectives on current clinical communication skills training (phase 2) less than half of the participants (43.3%) indicated that they had been exposed to any methods to improve their ccs during their current training programmes (table 4). participants who indicated previous exposure to ccs training reported that ~29% of the training opportunities were theory based, 19% practice based and 52% clinically based. theoretical training opportunities included lectures, written notes, e-presentations (computer based) and readers on basic communication and communication skills, communication via different media formats, importance of effective communication practices, psychology of empathy and non-verbal communication, as well as applicable sesotho [local language] words and phrases. practical training opportunities included peer role-play and practice opportunities with peers, demonstrations and group discussions. lastly, the clinical techniques included real-life communication with patients, their families and other members of the healthcare team, and clinical attendances, such as ward rounds and non-verbal communication via medical records, using the services of an interpreter and community-based learning. simulated patients, peer role-play and video playback have been identified as practical methods to improve ccs in undergraduate healthcare students. table 4 gives an indication of the participants’ knowledge, current use and anticipated value for implementing these methods. participants with previous exposure to the abovementioned practical methods of ccs training indicated that simulated patients and video playback were used during their third year of study, while peer role-play was used in both the second and third years of study. most of the participants (82.8%; n=67) thought that using these methods benefited them personally, and indicated that specific ccs training methods could also benefit other students if included in their undergraduate training programmes (table 5). participants (n=67) were mostly in favour of peer role-play (87%) and simulated patients (80%) being implemented in their undergraduate training programme in the year(s) preceding clinical engagement with patients, while video playback (78%) was preferred during the first year of clinical engagement (as an opportunity to reflect on their own ccs during real-life clinical encounters). these methods are specifically included in the ccs training directives proposed in this article (fig. 3). student-informed clinical communication skills training directives the integration of key findings from both phases of this study – emphasising the student voice in an sa context – informed the formulation of a number of practical ccs training directives for undergraduate healthcare programmes (fig. 3). fig. 3 firstly presents the problems students experienced with ccs, as mentioned during phase 1 of the study. these involved four main areas, i.e. patient and patient family communication, interdisciplinary communication, written communication and absence of the student voice in ccs training. to address the abovementioned problems effectively, either in isolation or in different combinations, training directives included in fig. 3 build on results from phase 2, and include suggestions for training methods that could be incorporated in undergraduate healthcare programmes to teach ccs. the value of the research, therefore, lies on practical and theoretical levels, and provides a unique student perspective. a concern noticed from the student perspective, is the participants’ lack of understanding or acknowledgement of ccs training included in their undergraduate training table 4. knowledge, current use and anticipated value of simulated patients, peer role-play and video playback as methods to improve clinical communication skills in undergraduate healthcare programmes (n=67) training method knowledge of the method,% current use of the method, % anticipated value of implementing the method to improve different aspects of clinical communication skills written communication, % non-verbal communication, % verbal communication with patients, % verbal communication with patients’ families, % interdisciplinary communication, % simulated patients 32.8 32.8 46.9 77.3 95.5 68.2 59.1 peer role-play 56.7 50.8 33.9 66.1 93.2 67.8 67.8 video playback 55.2 30.3 24.2 83.3 92.4 75.8 74.2 204 december 2018, vol. 10, no. 4 ajhpe research programmes (table 5). questions could be raised regarding curriculum design and emphasis on ccs in the curriculum, or the possible lack of students’ understanding of ccs. to address these concerns, the directives, as provided in this article, can serve as a guide to healthcare educators on aspects such as curriculum design and inclusion of teaching and learning activities and assessment tasks specifically related to ccs. adaptations to the use of simulation, peer role-play and video playback for enhancing the practical training of the necessary ccs, specifically, and the importance thereof for enhancing inadequate ccs identified in the clinical setting, are important study contributions (fig. 3). another key directive proposed as a result of this study, is teaching students healthcare phrases in several languages, instead of training in a single additional language, owing to the limitations posed by a single language in a wide geographical area (fig. 3). conclusion as a result of student perspectives gained, this article proposes ccs training directives for the sa multilingual and multicultural environment, which could be considered for implementation in similar contexts, or customised for other contexts. the findings and proposed directives can also inform debate on aspects of ccs training in sa, with its particular problems and challenges. the directives lend themselves to further research and extension to include other problem areas in verbal and written ccs of healthcare students, as well as aspects directly influencing each of the problem areas. additional research could provide evidence for the inclusion of another domain, i.e. non-verbal ccs and its related facets. the proposed directives emphasise the sentiment of rotthoff et al.[2] that clinical experience does not automatically improve ccs, and training in ccs is therefore essential and should be ongoing. attentive consideration of relevant ccs training is thus essential for delivery of adequately trained healthcare professionals. declaration. none. acknowledgements. e colyn, de v koster, y marx, n mienie, j oosthuizen, f de klerk, c engelbrecht, m janse van rensburg, l opperman and z prinsloo collected data in 2012 and 2013 as part of their undergraduate research projects. h nel was the co-supervisor of the undergraduate research project conducted in 2013. k bodenstein provided valuable advice during the writing of the article. author contributions. ecjvv wrote the article with the assistance and advice of mn. mn analysed the quantitative data and ecjvv the qualitative data. both authors made significant contributions to all phases of the article, including the conceptualisation, drafting, revision and submission. funding. none. conflicts of interest. none. 1. jarvis r, snadden d, ker j. clinical communication. in: dent j, harden rm, eds. a practical guide for medical teachers. london: elsevier, 2009:265-273. 2. rotthoff t, baehring t, david d, et al. the value of training in communication skills for continuing medical education. patient educ couns 2011;84(2):170-175. https://doi.org/10.1016/j.pec.2010.07.034 3. henry s, fuhrel-forbis a, rogers m, eggly s. association between nonverbal communication during clinical interactions and outcomes: a systematic review and meta-analysis. patient educ couns 2012;86(3):297-315. https:// doi.org/10.1016/j.pec.2011.07.006 4. joseph c, frantz jm, hendricks c, smith m. evaluation of a new clinical performance assessment tool: a reliability study. s afr j physiother 2012;68(3):15-19. https://doi.org/10.4102/sajp.v68i3.19 5. parry rh, brown k. teaching and learning communication skills in physiotherapy: what is done and how should it be done? physiotherapy 2009;95(4):294-301. https://doi.org/10.1016/j.physio.2009.05.003 6. junod perron n, sommer j, louis-simonet m, nendaz m. teaching communication skills: beyond wishful thinking. swiss med wkly 2015;145:w14064. https://doi.org/10.4414/smw.2015.14064 7. wouda jc, van de wiel hbm. the communication competency of medical students, residents and consultants. patient educ couns 2012;86(1):57-62. https://doi.org/10.1016/j.pec.2011.03.011 8. lanning sk, brickhouse th, gunsolley jc, ranson sl, willett rm. communication skills instruction: an analysis of self, peer-group, student instructors and faculty assessment. patient educ couns 2011;83(2):145-151. https://doi. org/10.1016/j.pec.2010.06.024 9. schyve pm. language differences as a barrier to quality and safety in health care: the joint commission perspective. j gen intern med 2007;22(suppl 2):360-361. https://doi.org/10.1007/s11606-007-0365-3 10. burch v. cultural competence or speaking the patient’s language? bmc health serv res 2010;8(1):3. https://doi. org/10.7196/ajhpe.2016.v8i1.802 11. creswell jw. a concise introduction to mixed methods research. los angeles: sage, 2015. 12. nieuwenhuis j. analysing qualitative data. in: maree k, ed. first steps in research. pretoria: van schaik, 2016:103-131. 13. bischoff a, denhaerynck k. what do language barriers cost? an exploratory study among asylum seekers in switzerland. bmc health serv res 2010;10(1):248. https://doi.org/10.1186/1472-6963-10-248 14. levin me. language and cultural competency training in south africa: effects on quality of care and health care worker satisfaction. afr j health professions educ 2011;3(1):11-14. 15. wolff jl. family matters in health care delivery. jama 2012;308(15):1529-1530. https://doi.org/10.1001/ jama.2012.13366 16. ahmann e, dokken d. strategies for encouraging patient/family member partnerships with the health care team. fam matters 2012;38(4):232. 17. weller j, boyd m, cumin d. teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. postgrad med j 2014;90(1061):149-154. 18. nancarrow sa, booth a, ariss s, smith t, enderby p, roots a. ten principles of good interdisciplinary team work. hum resour health 2013;11(1):19. https://doi.org/10.1186/1478-4491-11-19 19. powell s, toms j. passing away: an exploratory study into physiotherapy students’ experiences of patient death whilst on clinical placement. int j pract-based learn health soc care 2014;2(1):108-121. https://doi.org/10.11120/ pblh.2014.00026 20. pullen i, loudon j. improving standards in clinical record-keeping. adv psychiatr treat 2006;12(4):280-286. https://doi.org/10.1192/apt.12.4.280 accepted 5 march 2018. table 5. previous exposure to methods to improve clinical communication skills per undergraduate healthcare programme department yes, n (%) no, n (%) physiotherapy (n=30) 11 (36.7) 19 (63.3) occupational therapy (n=16) 11 (68.8) 5 (31.2) dietetics and nutrition (n=7) 5 (71.4) 2 (28.6) optometry (n=14) 2 (14.3) 12 (85.7) https://doi.org/10.1016/j.pec.2011.07.006 https://doi.org/10.1016/j.pec.2011.07.006 https://doi.org/10.1016/j.pec.2010.06.024 https://doi.org/10.1016/j.pec.2010.06.024 https://doi.org/10.7196/ajhpe.2016.v8i1.802 https://doi.org/10.7196/ajhpe.2016.v8i1.802 https://doi.org/10.1001/jama.2012.13366 https://doi.org/10.1001/jama.2012.13366 https://doi.org/10.11120/pblh.2014.00026 https://doi.org/10.11120/pblh.2014.00026 april 2021, vol. 13, no. 1 ajhpe 29 research evidence of the role of simulation in medical education has emphasised the use of simulation technology over the past number of decades in an effort to increase learner knowledge, to provide students with controlled and safe practice opportunities, and to shape the acquisition of doctors’ clinical skills.[1-3] simulation is becoming an integral part of medical education at all levels,[1-3] as medical education, for various reasons, has fast become subject to radical and innovative changes. many major shifts in medical education methods are due to changes in the delivery of healthcare. according to issenberg et  al.,[3] in the usa, for example, the pressures of managed care shape the form and frequency of hospitalisation, ‘resulting in higher percentages of acutely ill patients and shorter in-patient stays’. medical students, therefore, have fewer opportunities to assess patients with a wide variety of diseases and physical findings, while reductions in physician remuneration due to shrinking financial resources constrain the educational time that doctors in training receive.[4] consequently, at all educational levels, doctors find it increasingly difficult to keep abreast of skills and topics they need to practise successfully.[4] issenberg et al.[3] identify 5 factors that contribute to the increased use of simulations in medical education, i.e. lack of clinical teaching opportunities and therefore less patient material due to changes in healthcare delivery; new technologies for diagnosis and management; assessing professional competence; medical errors, patient safety and team training; and the role of deliberate practice.[4] surgical training in the 21st century is characterised by an increasingly objective, standardised approach using equipment, such as simulators, to optimise patient safety, surgical care and hospital resources, and minimise errors.[5] the driving forces behind these factors are developments in medical error statistics, evidence-based medicine and fewer attending hours. through increased accuracy, simulation can improve results and lower risk and procedure costs because of fewer procedures and less operating room time.[5] simulation during training allows students ample opportunity to hone their skills and competencies in safe, no-risk circumstances. insufficient and inefficient clinical teaching has stressed the need for strategies to improve clinical education, including the use of simulation.[5] simulation-based medical education is an educational method that makes use of simulation to bridge the gap between theory and practice.[6] regarding medical simulation, the word simulation means ‘imitation of the operation of a real-world process or system over time’.[7] over the past 30 years, new technologies in medicine have revolutionised patient diagnosis and care. examples are the development of flexible sigmoidoscopy and bronchoscopy, and minimally invasive surgery, including laparoscopy, and robotics for orthopaedics, urology background. increased competition for surgical exposure and practice, smaller teaching platforms and shorter training times have an impact on the quality of training and competence of plastic surgery registrars. demands for accountability and minimising patient risks are the driving forces for incorporating simulation in healthcare education. we addressed the problem of whether the features and uses of simulation would enhance postgraduate plastic surgery education and training and ensure more effective learning. objective. to identify and describe: (i)  how simulation impacts on student learning; therefore, how the effectiveness of learning may be enhanced in postgraduate and/or plastic surgery education and training; and (ii)  which features and uses of simulation have the potential to enhance learning in plastic surgery. methods. a descriptive design was used for the study. data were collected by means of semi-structured interviews with 8 national and international role players in simulation. results. the results indicated a positive outcome of simulation, as it provides, e.g. a non-threatening environment for learning and improves clinical competency, ensuring an increase in patient safety. the features and uses of simulation render it an excellent method to enhance learning effectiveness at different cognitive levels and to fulfil a specific role in integrated and holistic training, while providing opportunities to practise specific skills. the lack of clinical opportunities can be addressed, and more clinical exposure and practice will result in fewer medical errors. conclusion. simulation-based education in postgraduate plastic surgery education and training proved to be an effective teaching-learning method, which provides solutions to current deficiencies, hindrances and gaps in health professions education. the research question was answered and the use of simulation is recommended to enhance plastic surgery education and training and promote safe patient care. afr j health professions educ 2021;13(1):29-35. https://doi.org/10.7196/ajhpe.2021.v13i1.1181 simulation in plastic surgery: features and uses that lead to effective learning c p g nel,1 mb chb, mhpe, fc plast surg (sa), mmed (plastic surgery), phd; g j van zyl,2 mb chb, mfammed, phd; m j labuschagne,3 mb chb, mmed (ophthalmology), phd 1 department of plastic surgery, faculty of health sciences, university of the free state, bloemfontein, south africa 2 faculty of health sciences, university of the free state, bloemfontein, south africa 3 school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c p g nel (drcnel@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 30 april 2021, vol. 13, no. 1 ajhpe research and cardiology. the  benefits of these innovations include reduced postoperative pain and suffering, shorter hospitalisation and earlier resumption of normal activities, as well as significant cost savings.[8] these newer techniques, however, demand psychomotor and perceptual skills that differ from traditional approaches, and these innovative methods may be associated with a higher complication rate than traditional practices.[9] haluck et  al.[10] maintain that these ‘newer technologies have created an obstacle to traditional teaching that included hands-on experience. for example, endoscopy requires guiding one’s manoeuvres in a three-dimensional environment by watching a two-dimensional screen, requiring the operator to compensate for the loss of binocular depth cue with other depth cues.’ one of the corollaries to these new techniques was the introduction of simulation technology in the training and assessment of students. research indicates that training programme directors emphasised that virtual reality and computer-based simulations have become indispensable technological tools in clinical education.[10] the accreditation council for graduate medical education (acgme) in the usa, in an endeavour to ensure and improve the quality of graduate clinical medical education and to attain a higher level of effectiveness, listed 6 domains of clinical medical competence.[8] postgraduate programmes should provide educational experiences, which ensure that graduates demonstrate competence in acgme project outcomes, i.e.  patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and system-based practice.[11] these are the educational experiences that benefit most from simulation in the light of a lack of patients and clinical exposure. miller[12] proposed a framework (miller’s pyramid), which argues that a medical learner’s clinical skills should be assessed at four levels: (i)  knows (knowledge) – recall of facts, principles and theories; (ii)  knows how (competence) – ability to solve problems and describe procedures; (iii) shows how (performance) – demonstration of skills in a controlled setting; and (iv) does (action) – behaviour in real practice.[4] simulation technology is increasingly being used in each domain of competence to assess the first three of miller’s levels of learning because of its ability to  programme and select learning-specific findings, conditions and scenarios to provide standardised experiences to all examinees and to include outcome measures that yield reliable data.[13] the research question was whether the features and uses of simulation would enhance plastic surgery education and training and ensure more effective learning. methods the research included data collected by means of semi-structured interviews and a delphi process. this article focuses on outcomes of the interviews. an article dealing with the delphi part of the study has been published in ajhpe.[14] elements of grounded theory came into play to describe features and uses of simulation, and to relate why simulation lends itself perfectly to be included in educational programmes. grounded theory (inductive approach) was used to develop recommendations to promote learning in postgraduate plastic surgery education and training, as a grounded theory deals with discovering, developing and verifying by means of systematic data collection and data analysis pertaining to a phenomenon.[15] the study focused on the opinions and perspectives of medical and healthcare professionals regarding the features and uses of simulation, and whether and how simulation as an education and training method might influence student learning. the study was aimed at developing recommendations to enhance the effectiveness of learning in postgraduate  plastic surgery education and training by employing simulation as one of the methods used. semi-structured interviews semi-structured individual interviews were used to explore key national and international role players’ opinions and perceptions on simulationbased medical education, aimed at investigating and establishing clarification on simulation in postgraduate plastic surgery education and training. the features and uses of simulation that might prove effective in postgraduate plastic surgery were thus determined. the researcher conducted the interviews because he is a skilled interviewer and was familiar with the topic; he knew how to phrase the questions, as he was aware of the frame of reference of the interviewees and the goals of the study. it was also important to concentrate on the responses and monitor the coverage of the topic – which would have been impossible for another interviewer.[16] an interview guide (table  1), developed by the author on the basis of a literature review, was used. occasionally, table 1. guide for semi-structured interviews with national and international role players question 1. what experience with/exposure to simulation in the field of health education have you had in general? briefly describe your experience with/exposure to simulation in terms of the type of simulation, your role, duration of involvement. 2. are you currently involved in simulation and/or postgraduate education and training? in what context are you involved? 3. does/can simulation influence student learning in postgraduate education and training? in what regard? 4. how can effectiveness of learning be enhanced in postgraduate and/or plastic surgery education and training (in the areas of knowledge, skills, clinical competence, professional conduct)? 5. can simulation be used to enhance student learning at different cognitive levels? (will the student only use simulation to remember knowledge/or understand/or apply/or analyse/or evaluate/or create new concepts and ideas?) 6. which types of simulation or simulation modalities might lead to effective learning? 7. which features and applications of simulation in postgraduate or plastic surgery education and training will lead to more effective learning? 8. does simulation have: (i)  a contribution to make to postgraduate education; (ii) a role to play in postgraduate education; or (iii) a specific value to add to postgraduate education? 9. what would your main consideration be if you decided to include simulation in your teaching and training programme? 10. if you have to guide a team of experts tasked to develop a curriculum with simulation as one of the training/learning methods, which important guidelines would you put forward? 11. do you wish to make any recommendations that may be used in compiling guidelines on simulation for postgraduate plastic surgery? 12. are there any recommendation(s) you would like to make when considering including simulation in specialist training? 13. will you please share: (i)  some of the lessons learnt regarding the implementation of simulation in a curriculum; and (ii)  the biggest challenge in implementing simulation in training? april 2021, vol. 13, no. 1 ajhpe 31 research additional questions arose during the semi-structured interviews; the data thus collected were included in the research. data on questions 3, 4 and 7 of the interview guide are reported in this article. unit of analysis national and international role players in simulation and postgraduate education were requested to participate in the semi-structured interviews. eight participants were invited to participate, all of whom accepted the invitation. four interviewees were from the usa, canada and the uk and 4 from south africa (sa). they were directors of simulation units, clinical heads of clinical medical departments, programme directors of medical and nursing programmes, and education management specialists, researchers and representatives from the simulation industry. written consent was obtained from all participants. data collection and analysis the author conducted individual interviews with 8 participants, based on an interview guide. the interviews were audio-recorded, transcribed and checked by an independent person who was not part of the study. field notes taken during the interviews contributed to the data. the data were analysed using the grounded theory approach, which requires continuous comparison of data, following the data analysis steps of coding, categorisation and theory generation.[17] theory building occurred by finding patterns in the data, which continued until saturation of data was reached.[18] as more data were collected and re-reviewed, codes were grouped into concepts, and then into categories. these categories formed the basis for new theory, and were compared with data collected during the literature study. data saturation was reached when no more ideas came to the fore. reliability and trustworthiness reliability was ensured by making use of an explorative study (with 2  individuals who were involved, had a sound knowledge of simulation and complied with the selection criteria), determining strict criteria for sampling, using the carefully constructed interview guide, as well as an interview process that was audio-taped and carefully described.[19] trustworthiness of the interviewing process was ensured by involving voluntary interviewees with a clear understanding of what the interviewer expected from them, and  using open-ended questions, as well as the transcription and verification of data. scientific record keeping ensured dependability.[19] ethical approval ethical approval to conduct the research was obtained from the ethics committee of the faculty of health sciences, university of the free state, bloemfontein, sa (ref. no. ecufs 122/2015). results data collected by means of questions 3, 4 and 7 of the semi-structured interviews are reported in this article. data were analysed, findings were summarised and qualitative perspectives are shared on the influence of simulation on student learning (table 2) and how the effectiveness of learning can be enhanced (table  3). the features and uses of simulation that may enhance learning in postgraduate education and training served as basis for a number of recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training (table 4). quotes from table 2. influence of simulation on student learning in postgraduate education and training 1. simulation as a learning strategy simulation influences student learning in different ways: • simulation is a very specific learning and education strategy that can be described as a holistic process that ensures meaningful learning • ‘to be effective it needs to be an important component in the curriculum.’ (s1) • ‘effectiveness can only be enhanced if there is proper integration.’ (s1) • simulation is based on an adult learning strategy, as it is built on adult learning principles that can be combined in different ways • ‘different people learn in different ways.’ (c3) • simulation can replace other educational strategies, e.g. theoretical lectures, by bringing simulated case engagement into the normal learning strategy • ‘simulation will trigger more excitement.’ (d1) • ‘students will be more focused and remember more.’ (d1) • ‘it gives students the opportunity to learn hands-on.’ (c1) 2. motivation to make a difference simulation of rare clinical cases or life-threatening, important scenarios is motivational: • ‘… students can be motivated to make a difference in a patient’s life.’ (c1) 3. importance of preparation theoretical grounding and preparation will influence student learning: • ‘students may attend a lecture, e-learning programme, read articles, do a self-test before visiting the simulation lab, which ensures that learning is more meaningful, and promotes deep learning and commitment.’ (d1) identify own shortcomings, evaluate own level of competence against own tempo: • ‘students must be prepared when they come to the simulation lab.’ (d2) 4. learn by repetition practising non-technical and technical skills will influence student learning: • ‘giving students the opportunity to practise in the simulation lab so that they are more competent when performing certain procedures on a patient.’ (c1, d1) 5. group simulations simulation scenarios that include different health professionals will foster and enhance learning: • ‘debriefing provides students the opportunity not only to identify their own shortcomings, but also those of the individual group members and of the group as a whole.’ (c1) learn to work in groups and that communication among them is of great importance: • ‘you have to have small-group engagement.’ (s1) 6. level of competence the aim of simulation is to attain and sustain a certain level of competence or expertise: • ensure that the health professional/student maintains the same level of competence after the initial mastering of the procedure • ‘attaining some sort of competence level quicker before going to the patient.’ (c2) • ‘competent = bare minimum (knows/knows how).’ (c2) • ‘proficient = level of skill above minimum (shows/does).’ (c2) • ‘as you practise a skill more, you become proficient = on your way to mastering.’ (c2) 32 april 2021, vol. 13, no. 1 ajhpe research table 3. enhancing the effectiveness of learning in postgraduate and/or plastic surgery education and training by introducing simulation 1. non-threatening environment a non-threatening environment enhances the effectiveness of learning: • enhancement of learning • ‘students can practise with less stress.’ (d1, d2) • ‘you learn in an environment where you are allowed to make mistakes.’ (d1) • ‘to get learners to think about their actions, to analyse, taking ownership of own learning, reflective learning.’ (d2) • ‘they learn in a completely safe, non-threatening environment.’ (d2) • patient safety • ‘first learn through simulation, then on real patient.’ (d1) • ‘steep learning curve before practising on real patient.’ (d1) • ‘give them a plan according to which they can work when in a real situation.’ (d2) • ‘it allows them to practise more on the simulator ‒ so there are fewer medical errors when working with real patients.’ (d2) advantage of using simulation in training: • ‘operation time less; complications fewer; costs lower – big advantage to train postgraduate students/registrars.’ (d1) 2. soft medical skills training of soft skills through simulation enhances the effectiveness of learning: • interpersonal communication, interprofessional communication, patient communication, health communication etc. to be included in simulation training • ‘some people may think these are not technical skills (as in afrimed/canmed) so these are not assessed.’ (d1) • ‘colleges to include soft skills in evaluation.’ (d1) • ‘powerful tool to develop clinical reasoning.’ (s1) • ‘clinical reasoning will happen in a complex space.’ (s1) • ‘different reasoning in rural situations.’ (s1) 3. deliberate practice deliberate practice enhances the effectiveness of learning: • bench models may be used to practise psychomotor skills by repetition or deliberate practice of specific procedures until students feel safe • ‘to make deliberate practice more successful, students may use a tick-sheet to test themselves.’ (c2) • ‘to make deliberate practice more successful, the student must be accompanied by consultant/educator.’ (d1) • ‘student must know what he/she is doing correctly.’ (d1) • ‘there must be scheduled times for practice, as well as for feedback.’ (d1) • ‘registrars are adult learners and identify skills that need more practice.’ (d1) 4. feedback feedback enhances the effectiveness of learning: • constructive feedback • ‘can be according to a debriefing manner: first focus on the positive, then focus on things which he/she should do in another way without negative critique.’ (d1) • ‘give feedback directly after simulation/time slot; in writing or on video.’ (d1) • ‘feedback to be planned, structured according to a template or may be more personal.’ (d1) • ‘for non-technical skills use the debriefing method – look at what was good; discuss what can be different.’ (d1) • ‘for technical skills – use a tick-sheet; it will allow for more constructive feedback and certain skills can be revisited.’ (d1) • ‘give feedback to students so that they can correct themselves.’ • feedback and assessment with a view to enhancing the effectiveness of learning • ‘formative feedback will help students to prepare for assessment and examination; then they will have time to correct their mistakes.’ (d1) • ‘timely feedback before assessment can help the student to lower stress levels.’ (d1) • ‘feedback on quality of operations can offer opinion where the registrar is safe; by using easy scenarios evaluate whether the registrar executes the technique in a good/proper way and/or quick enough – this is a good learning opportunity.’ (c1) • ‘students to be observed on a continuing basis.’ (c2) • ‘student can be observed during a skill performance.’ (c2) 5. debriefing debriefing enhances the effectiveness of learning: • the process of debriefing gives more insight • ‘debriefing is another way to learn.’ (c1) • ‘it is the debriefing aspect that affects learning.’ (d2) • ‘do not use debriefing as a teaching opportunity, let learners think how they can improve.’ (d2) • ‘observation of skills, then debriefing after that, improves practical skills.’ (c2) continued ... april 2021, vol. 13, no. 1 ajhpe 33 research interviewees’ responses are indicated in inverted commas, followed by a code number assigned to each of the participants. simulation influences student learning (table  2), as it substitutes other learning strategies; it supports adult learning principles, as it requires students to prepare, placing a responsibility on them as adult learners; it  provides self-confidence and skills, motivating students to confront life-threating situations, making a difference to a patient’s life; it provides the opportunity to learn by repetition, to work individually or in groups; it fosters communication; and it ensures that the student attains and sustains a specific level of competency. interviewees’ opinions on how simulation can enhance the effectiveness of learning are indicated in table 3 and emphasise the role of simulation as a non-threatening learning method that enhances the effectiveness of learning. students can practise with less stress in a completely safe environment before working with real patients; this highlights the advantages of training using simulation. simulation also enhances the effectiveness of learning by fostering interpersonal, interprofessional patient communication, communication regarding health and reasoning skills. through deliberate, as well as repetitive practice, learning is enhanced (table 3). the debriefing aspect offers another way of learning and allows students to decide on selfimprovement. authentic scenarios help students to learn more effectively than when using paper cases. the assessment opportunities of simulation improve student learning. recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training are offered in table 4. to apply the unique features and uses of simulation in a correct manner influences the effectiveness of learning in a positive way. discussion the third and fourth semi-structured interview questions addressed the effect of simulation on student learning and how learning may be enhanced by simulation as a learning method in postgraduate and/or plastic surgery education and training. the opinion was that simulation does enhance the effectiveness of learning as far as the mastery of knowledge, skills, clinical competence and professional conduct is concerned. the findings of data gathered during the semi-structured interviews were compared with perspectives gained from the literature review. key outcomes of this research were the identification of the features and uses of simulation, and how simulation might be applied to enhance the effectiveness of learning in plastic surgery. as specific features and uses of simulation influence learning positively, these should be maximised in plastic surgery education. the results of the study provided ample evidence that simulation improves teaching and learning in medical (surgical) postgraduate education, as is evident from the following research. according to issenberg et al.,[4] ‘traditional medical training has focused on individual learning to care for individual patients. medical education has neglected the importance of teamwork and the need to develop safe systems. the knowledge, skills and attitudes needed for safe practice are not normally acquired, nor are they required, as part of medical education.’ simulation is an appropriate method for team training ‒ a prerequisite for interprofessional healthcare required of modern medical education. simulation offers the possibility of a cyclic learning dimension structure, i.e. a safe, purposefully planned learning environment, including variations of learning strategies/methods and the opportunity to select material offering different applicable learning opportunities, and ensuring a unique learning experience where the learning can be evaluated by the registrar or feedback/debriefing can be done by a consultant to achieve competence,  or  to re-plan and/or deliberately practise specific, identified learning units. deliberate practice, not just time and experience in clinical settings, is key to the development of medical clinical competence.[4] deliberate practice involves ‘(a) repetitive performance of intended cognitive and psychomotor skills in a focused domain, coupled with (b) rigorous skills assessment that provides learners with (c) specific, informative feedback, table 3. (continued) enhancing the effectiveness of learning in postgraduate and/or plastic surgery education and training by introducing simulation 6. realism or fidelity realism of fidelity enhances the effectiveness of learning: • the degree of realism of a scenario or patient influences the effectiveness of learning: ‘in the beginning, students do not believe in the simulation scenario; later you can observe the “overcoming of disbelief ” – the suspension of disbelief – they think it is a real patient: that leads to more effective learning than using a paper case.’ (d2) 7. repetitive practice repetitive practice enhances the effectiveness of learning: • for learning to take place, a medical or practical situation is necessary • ‘you have to practise on a continuous basis – do it repeatedly over the time span of a month or year.’ (c1, d1) • ‘it must become a natural action – you learn by repeating – repeat soon after the first practice; 1 week; after weeks; months.’ (c1) 8. training platform the training platform enhances the effectiveness of learning: • as training platforms may become smaller in certain disciplines, simulation offers opportunities for learning • ‘platform varies from rural situation to complex.’ (s1) 9. assessment assessment enhances the effectiveness of learning: • evaluation of clinical skills in summative assessment of registrars plays a role in effective learning • ‘in the field of specialists, assessment should include well-defined objectives and competencies.’ (c2) • ‘assess levels for competence.’ (c2) • ‘assessment to be reliable and statistically sound; use tick-sheet.’ (c2) • ‘use simulated patients for clinical examinations.’ (s2) 34 april 2021, vol. 13, no. 1 ajhpe research that results in increasingly (d) better skills performance in a controlled setting’.[4] simulation is the ideal way to ensure deliberate practice, regardless of whether patient material is available or not. research emphasises the importance of repetition for clinical skills acquisition and maintenance,[20] and research evidence clearly shows that high-fidelity medical simulations facilitate learning.[4] simulation-based education allows students to practise and acquire patient care skills in a controlled and safe learning environment. feedback to students, the opportunity for deliberate and repetitive practice, multiple learning strategies, individualised learning within a controlled environment, and the opportunity for hands-on experience foster students’ self-confidence and play a cardinal role in mastering educational outcomes.[8] to revolutionise medical education, an increased efficiency of education by standardising the curriculum, an individualisation of education and a shift from time-based training to competency-based training are essential.[21] residents (registrars/specialists in training) may receive little guidance in terms of the knowledge, competencies, skills and attitudes that they are expected to acquire during residency. surgical training in the 21st century is characterised by an increasingly objective, standardised approach using equipment such as simulators to optimise patient safety, surgical care and hospital resources, and to minimise errors.[5] the driving forces behind this are developments in medical error statistics, evidence-based medicine and fewer attending hours. through increased accuracy, simulation can improve results and also lower risk and procedure cost because of fewer procedures and less operating room time.[5] simulation can play an important role in postgraduate education; however, it cannot totally substitute education involving real patients in genuine settings. table 4. recommendations to enhance the effectiveness of learning in postgraduate plastic surgery education and training by applying the unique features and uses of simulation environment the provision of a controlled non-threatening environment to registrars will unlock the opportunity to learn more effectively: • simulation has the ability to create a safe environment, enabling registrars to detect problems and patient care errors in a non-threatening way of learning, fostering reasoning skills and thought processes; learning takes place where it is acceptable to make mistakes and causes less stress • the simulation environment is open to accommodate a process that can change from a unito a multipurpose process where learning can be based on a single objective or on multiple objectives; learning could span different cognitive levels and include variations from superficial to deep learning • a simulation scenario may be changed or adapted to a more complex scenario, where learning could take place at a entirely different level of competence and applicability curriculum the integration of simulation in the curriculum of a postgraduate plastic surgery training programme will offer registrars the opportunity to learn more effectively: • simulation should be integrated in the curriculum and training schedule and be directed by guidelines for teaching through simulation; the role of simulation should be clearly stated in curriculum documents and how it will form part of the registrars’ performance management • teaching and learning strategies should be aligned with educational goals and learning outcomes and should be adaptable to the learning situation • simulation offers the opportunity for large-group training by developing scenarios for multiprofessional teams, where individual and group learning can take place with an opportunity for debriefing and constructive feedback; individualised learning according to the registrars’ learning needs set to specific standards should be offered clinical teaching and learning simulation should offer registrars opportunities for clinical learning to be more effective: • registrars’ engagement in deliberate practice should take place according to set learning outcomes based on real clinical problems in simulated settings; the realism of clinical problems and the hands-on experience should help them to master clinical outcomes and to transfer knowledge, skills and competencies to real clinical settings • learning outcomes will enhance the effectiveness of learning and processes must be in place to ensure they are met • smaller learning units can give registrars the opportunity to master learning outcomes at their own pace, ensuring intrinsic motivation and fostering deep learning • effective learning is enhanced when registrars practise clinical skills across a wide range of difficulty levels; scenarios set on different levels of difficulty ensure that learning takes place at different cognitive levels • by offering registrars the opportunity to engage in repetitive practice in a safe environment will give them the challenge to correct and hone their clinical skills and competencies feedback registrars should approach simulation opportunities in a different way when accompanied by consultants, who give feedback; they will experience scenarios as a direct learning opportunity; problems can be corrected immediately – they should see it as teaching them purposefully and deliberately: • feedback should be planned, formally scheduled and be an integral part of the training programme • feedback should be built into simulations, or presented at scheduled times, on video or electronic media • registrars should use the opportunity of feedback to correct themselves by taking notice of feedback on accuracy and timing • constructive feedback should drive decisions as far as preparation for final assessment technology technology should be seen as offering endless possibilities to enhance learning for registrars: • technical skills, non-technical skills and the softer skills can be explored for learning at different levels by adding or changing scenarios • sharing facilities between institutions will be beneficial, as registrars can see or use a whole spectrum of simulations; standardisation of outcomes is possible, as well as opportunities for quality learning and learning of new skills april 2021, vol. 13, no. 1 ajhpe 35 research conclusion from the findings of this research, it is clear that simulation can be introduced as a teaching method and a learning opportunity for residents to improve plastic surgery education and training. to ensure success, however, clear recommendations on how simulation can enhance effective learning, and a description of the role and value of simulation based on scientific research, should be available. this requires the development of guidelines for teaching through simulation as part of training programmes for evidence-based plastic surgery education/practice. research is required to enhance the role of simulation in plastic surgery training,[22,23] and this study made a contribution in that regard by identifying why and how simulation can improve the effectiveness of postgraduate and/ or plastic surgery teaching and learning. ‘simulation has the potential to play an integral role in developing better and safer health care services for patients worldwide, avoiding risk and providing real-life opportunity for students to hone their skills.’[22,23] the features and uses of simulation discussed here will contribute to and lay the foundation for more effective learning in plastic surgery education and training in the future. the novel contribution made by this study entails the compilation of the advantages simulation holds for medical education, with special reference to postgraduate plastic surgery education, and the detail in which this teaching-learning method is expounded. declaration. the research for this study was done in partial fulfilment of the requirements for cpgn’s phd degree at the university of the free state. acknowledgements. the authors gratefully acknowledge the assistance received from the participants in the overall phd study, who were willing to take part in the pilot testing and quality control of the delphi questionnaires. we also acknowledge the role players who participated in the explorative study that conducted the interviews, and specifically the interviewees involved in the research reported in this article, for their valuable contributions and their time in participating in individual semi-structured interviews. we thank prof. g joubert, head: department of biostatistics, faculty of health sciences, university of the free state, for her advice during the early stages of the research, and for the protocol development and quality assurance of the study; and dr  m  j  bezuidenhout, university of the free state, for support with regard to the scientific formulation and language editing of the publication, as well as editing of the references. author contributions. cpgn designed the study, wrote the protocol, collected data and performed the analysis, interpreted data and wrote the manuscript. gjvz and mjl were supervisors of the study, reviewed the protocol and manuscript and contributed substantially to the conceptualisation, design, analysis and interpretation of data and scientific content. all authors approved the final version of the manuscript. funding. this research was partially funded by a grant from the health and welfare sector education training authority (hwseta). conflicts of interests. none. 1. fincher rme, lewis la. simulation used to teach clinical skills. in: norman cpm, van der vleuten cpm, newble dj, eds. international handbook of research in medical education, part 1. dordrecht, the netherlands: kluwer academic publishers, 2002:91-95. 2. gaba d. human work environment and simulators. in: miller rd, ed. anaesthesia. 5th ed. philadelphia: churchill livingstone, 2000:236. 3. issenberg sb, mcgraghie wc, hart ir, et al. simulation technology for health care professional skills training and assessment. jama1999;282(9):861-866. https://doi.org/10.1001/jama.282.9.861 4. issenberg sb, mcgaghie wc, petrusa er, et al. features and uses of high-fidelity medical simulations that lead to effective learning. med teach 2005;27(1):10-28. https://doi.org/10.1080/01421590500046924 5. rosen jm, long sa, mcgrath dm, greer se. simulation in plastic surgery training and education: the path forward. plast reconstruct surg 2009;123(2):729-738. https://doi.org/10.1097/prs.0b013e3181958ec4 6. akaike m, fukotomi m, nagamune m, et al. simulation-based medical education in a clinical skills laboratory. j med invest 2012;59(1-2):28-35. https://doi.org/10.2152/jmi.59.28 7. banks j, carson js, nelson bl, nicol dm. introduction to simulation. in: banks j, carson js, nelson bl, nicol dm. discrete event simulation. upper saddle river: pearson education inc., 2009:21. 8. issenberg sb, mcgaghie wc, petrusa er, et  al. features and uses of high-fidelity medical simulations that lead to effective learning: a beme systematic review. beme guide no. 4. best evidence medical education. dundee, scotland: association for medical education europe (amee), 2004. 9. deziel dj, millikan kw, economo sg, doolas a, ko st, airan mc. complications of laparoscopic cholecystectomy: a national survey of 4 292 hospitals and an analysis of 77 604 cases. am j surg 1993;165(1):9-14. https://doi.org/10.1016/s0002-9610(05)80397-6 10. haluck rs, marshall rl, krummel tm, melkonian mg. are surgery training programs ready for virtual reality? a survey of program directors in general surgery. j am coll surg 2001;193(6):660-665. https://doi. org/10.1016/s1072-7515(01)01066-3 11. accreditation council for graduate medical education (acgme). outcomes project. http:/www.acgme.org (accessed 26 june 2016). 12. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9 suppl):s63-s67. https://doi.org/10.1097/00001888-199009000-00045 13. issenberg sb, mcgaghie wc, gordon dl, et  al. effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice. teach learn med 2002;14(4):223-228. https://doi.org/10.1207/s15328015tlm1404_4 14. nel cpg, van zyl gj, labuschagne mj. enhancement of plastic surgery training by including simulation in education and training. afr j health professions educ 2020;12(2):68-73. https://doi.org/10.7196/ajhpe.2020. v12i2.1182 15. fouché cb. research strategies. in: de vos as, strydom h, fouché cb, delport csl, eds. research at grass roots: for the social sciences and human service professions. 2nd ed. pretoria: van schaik, 2002:270-277. 16. greeff m. information collection: interviewing. in: de vos as, ed. research at grassroots. 2nd ed. pretoria: van schaik, 2002:291-320. 17. byrne m. grounded theory as a qualitative research methodology. aorn j 2001;73(6):1155-1156. https://doi. org/10.1016/s0001-2092(06)61841-3 18. labuschagne mj, nel mm, nel ppc, van zyl gj. recommendations for the establishment of a clinical simulation unit to train south african medical students. afr j health professions educ 2014;6(2):2-6. https:// doi.org/10.7196/ajhpe.345 19. nel cpg. simulation in postgraduate plastic surgery education and training. phd thesis. bloemfontein: university of the free state, 2019:42-43. 20. ericsson ka. deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. acad med 2004;79(10 suppl.):s70-s81. https://doi.org/10.1097/00001888-200410001-00022 21. satava rm. emerging trends that herald the future of surgical simulation. surg clin north am 2010;90(3):623-633. https://doi.org/10.1016/j.suc.2010.02.002 22. nel cpg, labuschagne mj, van zyl gj. simulation in plastic surgery: a research agenda to improve teaching, learning and clinical expertise/professional competence. ireland international conference on education, dublin, ireland, 25 28 april 2016. http://terezaventura.net/iice-2016%20proceedings.pdf (accessed 4 novem ber 2020). 23. nel cpg, labuschagne mj, van zyl gj. why is research needed on simulation to enhance plastic surgery education and training? int j cross discpl subject educ 2018;1(1):3301-3308. accepted 16 january 2020. https://doi.org/10.1001/jama.282.9.861 https://doi.org/10.1080/01421590500046924 https://doi.org/10.1097/prs.0b013e3181958ec4 https://doi.org/10.2152/jmi.59.28 https://doi.org/10.1016/s0002-9610(05)80397-6 https://doi.org/10.1016/s1072-7515(01)01066-3 https://doi.org/10.1016/s1072-7515(01)01066-3 http://www.acgme.org https://doi.org/10.1097/00001888-199009000-00045 https://doi.org/10.1207/s15328015tlm1404_4 https://doi.org/10.7196/ajhpe.2020.v12i2.1182 https://doi.org/10.7196/ajhpe.2020.v12i2.1182 https://doi.org/10.1016/s0001-2092(06)61841-3 https://doi.org/10.1016/s0001-2092(06)61841-3 https://doi.org/10.7196/ajhpe.345 https://doi.org/10.7196/ajhpe.345 https://doi.org/10.1097/00001888-200410001-00022 https://doi.org/10.1016/j.suc.2010.02.002 http://terezaventura.net/iice-2016%20proceedings.pdf november 2020, vol. 12, no. 4 ajhpe 224 research autonomy is a complex concept, and although universal, varies widely in its meaning and interpretation between different healthcare professions.[1] the basic definition of autonomy is ‘freedom from external control or influence and independence’ and is synonymous with the concepts of ‘selfdetermination’ and ‘freedom’.[2] within the medical realm, autonomy is defined as a personal decision that is void of controlling interferences that prevent meaningful choice,[3] and the agreement to respect another’s right to self-determine a course of action and support independent decisionmaking, thereby highlighting the concept of client-centred care.[4] apart from these definitions, the clinical application of autonomy is not merely allowing patients to make their own decisions, but incorporating respect for the individual’s right to self-determination, and creating the necessary conditions for autonomy.[4] the proposition of autonomy as individualistic has been widely recognised, with a more recent definition of personal autonomy as ‘self-rule free of controlling interferences by others’.[5] relational autonomy, on the other hand, considers autonomy as socially embedded, and with a view that self-determination is both defined and pursued in a social context, which influences the opportunities a patient has to express or develop autonomy.[6] there has been a turn in the last decade towards autonomy in patient care. promoting patient autonomy is required as a collaborative endeavour between the patient, healthcare professionals and families and caregivers of patients.[7] often, clinical practice is standardised with routine care; the patient’s identity disappears,[8] a patient is often considered a passive participant,[9] patients are immobilised in decision-making and the relationship between the nurse and patient is based on the premise that everything is done for the patient, but without the patient.[8] our current discourse demonstrates patient autonomy as essential. hence in this study we sought to explore how nurses and occupational therapists (ots) consider autonomy in their individual and collective practice as healthcare professionals. methods design and sampling within a qualitative explorative approach, nurses and ots from five public hospitals and one private hospital located in kwazulu-natal, south africa, were purposively recruited into the study.[10] the hospitals were selected based on (i) a high patient turnover; (ii) the presence of acute care; and (iii) the provision of physical rehabilitation services and the presence of rehabilitative healthcare providers. in total, the sample comprised 26 participants, 12 occupational therapy participants and 14 nurse participants. data collection data collection methods were dependent on the availability and willingness of recruited participants. ot participants were involved in a triad interview (n=3) and two focus groups (n=5; n=4), while the nursing participants were involved in two individual semi-structured interviews (n=2), a triad interview (n=3), a focus group (n=5) and use of an open-ended background. there has been a turn in the last decade towards autonomy in patient care. promoting patient autonomy is required as a collaborative endeavour between the patient, healthcare professionals and the families and caregivers of patients. our current discourse demonstrates patient autonomy as essential. objective. to explore the concept of autonomy in nurses’ and occupational therapists (ots)’ individual and collective practice as healthcare professionals. methods. the study followed a qualitative explorative approach. fourteen nurses and 12 ots from 6 facilities in kwazulu-natal province of south africa were recruited into the study. following ethical approval, and dependent on the availability of participants, data were collected via focus groups, triad and individual semi-structured interviews and qualitative questionnaires. data were analysed using inductive thematic analysis per profession initially, and then later merged to develop themes. results. two major themes emerged that spoke to the deconstruction of autonomy and deterrents to the promotion of autonomy in clinical practice. an individualistic view of autonomy was embedded within the participants’ understanding of the concept. it included the patient’s right and ability to selfdetermine or direct treatment and various interventions, having appropriate guidance and the relevant information to make decisions, and opportunities to self-determine their course of treatment. patient-related and organisational factors served as barriers to the promotion of autonomy. conclusion. by analysing the experiences of autonomy in practice of these two professions, we may be able to establish new ways of understanding how professional practice can truly become patient-centred and transition from an individualistic understanding of autonomy towards viewing autonomy as relational. afr j health professions educ 2020;12(4):224-226. https://doi.org/10.7196/ajhpe.2020.v12i4.1366 promoting patient autonomy: perspectives of occupational therapists and nurses p govender, phd; d naidoo, phd discipline of occupational therapy, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: p govender (naidoopg@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 225 november 2020, vol. 12, no. 4 ajhpe research qualitative questionnaire (n=4). the inclusion of the interview questions in a questionnaire was implemented in order to accommodate those nursing staff who could not avail themselves for an interview or focus group, but who wanted to provide their perspectives on the topic. selection criteria and demographic profile of participants participants were required to have an active registration with their regulatory bodies, work experience of more than 2 years in an acute physical setting and exposure working with each of the other professions. the mean (standard deviation) age of participants in the study was 34 (9.4 ) years for ots and 39.4 (12.8) years for nurses. the majority of ots held a bachelor’s degree (n=9; 75%), while the majority of nurses had a nursing diploma (n=11; 79%). gender distribution of the sample favoured females; ots (n=12; 100%) and nurses (n=13; 93%), which can be noted as a limitation in the lack of diversity in the sample. data analysis the focus groups and interviews were audio-recorded and transcribed. responses to the open questionnaires were collated. data were analysed inductively via thematic analysis within each professional group, following the first four steps outlined by braun and clarke[11] prior to data being merged at the level of naming and renaming themes (step 5) by patternmatching, thus ensuring source triangulation.[10,11] ethical approval was granted by the school of health sciences, ukzn (ref. no shsec005) and by the health research and knowledge management directorate of the department of health (ref. no. hrkm 126/15), and informed consent was solicited from all voluntary participants. the right to withdraw without prejudice as well as the right to privacy and confidentiality was adhered by use of pseudonyms, de-identified demographics and password-protected files. trustworthiness was maintained by ensuring credibility by peer-briefing (especially during data analysis), investigator and source (nurses and ots) triangulation. for dependability, an audit trail (of processes and decisions taken as well as ensuring bracketing) were used as strategies to maintain rigour in the study.[10] results the coded data resulted in two broad emergent themes that spoke to the deconstruction of patient autonomy and deterrents to the promotion of autonomy. deconstructing patient autonomy a basic understanding of patient autonomy that focused on patient choice and promoting patient independence was observed. the participants’ definitions of autonomy encompassed being more independent with basic activities of daily living (adl), returning to previous roles and offering patients ‘choice’. this can be attributed to the fact that both professions are embedded in patient-centredness, and therefore naturally fostering the promotion of patient autonomy. reference to batho pele principles[12] was also made: ‘to preserve their autonomy we need to make sure they have a right to refuse or accept therapy beforehand.’ emily, ot (ot focus group 2) ‘having a say in what is provided and what own goals are.’ carly, ot (ot focus group 2) ‘sometimes patients give up, [but] once they [find] they can do things for themselves, they begin to gain confidence physically and spiritually.’ (nurse, questionnaire) ‘part of our batho pele principles is to give patients a choice.’ belinda, ot (ot focus group 1) the ots described their position within the multidisciplinary team (mdt) as not always visibly delineated, but conveyed their primary roles in promoting autonomy as translated into ensuring functional independence. the nurses equally expressed this view. nurses were seen to encourage autonomy related to personal management and advocating for the patient as the centre of nursing care: ‘having the ability to just choose for them self and direct where they want to go in their treatment.’ ashley, ot (ot triad interview) ‘with them gaining their independence, we let them do things for themselves, we let them bath themselves if they can or if they can’t we assist them … we are there for them should they need to be pushed a little.’ lindiwe, nurse (nurse focus group) deterrents to promoting patient autonomy barriers to promoting patient autonomy, which were either patientrelated or organisation-related, were reported. family involvement and the self-perception of patients of their situation contributed to a lack of empowerment and independence. the adoption of a ‘sick role’ while in hospital undermined the ability of patients to act more autonomously, or as their skills and abilities would allow. participants postulated that the community perception of a nurse, that is as someone who cares and nurtures, is responsible for the execution of all adl tasks in the best interests of patients. the idea was raised that this community perception prevents nurses from optimally promoting patient autonomy, and patients from actively working towards the attainment of independence. ‘the difficulties are not from the patients themselves, but it’s always related to the relatives,’ zanele, nurse (nurse focus group) ‘they feel because they sick and in the hospital they not allowed to have a say.’ carly, ot (ot focus group 2) ‘when they need to go to the bathroom, even when they can go to the bathroom, they ask for a bed pan just because their relatives are there … when they were using a bed pan here, they will go home and be given nappies and they come back and they have a bigger problem.’ zanele, nurse (nurse focus group) the issues around understaffing and burnout among nurses, patient attitudes and general resource limitations, especially in the public healthcare system, that impede their ability in promotion of autonomy among patients were recognised: ‘they work long hours and there is a high burnout factor.’ uvira, ot (ot focus group 1) ‘patients are constantly calling and demanding and often very rude to them.’ hannah, ot (ot focus group 2) ‘sometimes the patients have attitude with the nurses.’ nokuthula, nurse (nurse focus group) conclusion in this study, we set out to determine how both ots and nurses enacted autonomy in the clinical setting. in any health system, strategies that aim november 2020, vol. 12, no. 4 ajhpe 226 research to humanise and improve the quality of care of patients are paramount, and in keeping with the ethical responsibility of health professionals. with this, the shift towards patient-centred care, as well as the rejection of medical paternalism, have led scholars towards alternative models that emphasise patient autonomy.[13] patient-centredness is a concept embedded in both the occupational therapy and nursing professions, making both professions suitable for a role in the promotion of patient autonomy. nurses are encouraged to value patients’ decisions, listen and advocate,[8] while ots essentially engage patients in occupation, thus enabling participation and promoting autonomy.[14,15] by critical examination in this empirical study, we argue that the individualistic view of autonomy has been embedded within the participants’ understanding of autonomy. this notion of patient autonomy included the patient’s right and ability to self-determine or direct treatment and various interventions, having appropriate guidance and the relevant information to make decisions, and opportunities to self-determine their course of treatment. both professions support the notion that the concept of autonomy is related to independence.[4,14] thus, it is evident that both the occupational therapy and nursing professions have embedded the concept of client-centredness and independence, which contributes towards the promotion of patient autonomy. notwithstanding this, several obstacles were noted in the promotion of autonomy in this study. while the ots spoke of marginal hurdles related to their promotion of autonomy, nurses extensively described barriers experienced. tensions appear to remain among these healthcare professionals, and from the nursing literature, we are acutely aware of how the biomedical model has resulted in the undervaluing of nurses’ contributions toward holistic patient care.[8] largely, nurses have been considered the patient’s advocate owing to the emotional and physical care provided,[16] and as agents of patient safety.[8] while agreeing that autonomy is a product of more than just the individualistic view, this study reiterates the need for consideration of the relational and social components in the process of complex decision-making in autonomy.[6] from this study, it was difficult to extrapolate aspects related to how relational autonomy translated to practice for both professions. the challenge of relational autonomy as a moral and ethico-legal principle and threat to patient choice has been noted in the available literature.[1,6,7,17] future studies should, therefore explicate a more holistic perspective of autonomy, and yield possible strategies that could serve as enablers to the mdt towards authentic patient-centred practice. declaration. none. acknowledgements. the authors acknowledge s cresswell-george, a kaka, n mlaba and t wanless for their contributions to the study. author contributions. pg and dn were responsible for the conceptualisation of the study, data analysis and drafting and critical review of the manuscript. funding. none. conflicts of interest. none. 1. killackey t, peter e, maciver j, mohammed s. advance care planning with chronically ill patients: a relational autonomy approach. nurs ethics 2019;27(2):360-371. https://doi. org/10.1177/ 0969733019848031 2. chalker s, weiner e. the oxford dictionary of english grammar. oxford: oxford university press, 1998. https:// doi.org/10.1093/acref/9780192800879.001.0001 3. pantilat s. autonomy vs beneficence. san francisco: uc san francisco, 2008. http://missinglink.ucsf.edu/lm/ ethics/content%20pages/fast_fact_auton_bene.htm (accessed 29 april 2020). 4. american nurses association. nursing world – autonomy. 2011. http://www.nursingworld.org/ mainmenucategories/anamarketplace/anaperiodicals/ojin/columns/ethics/ethics-and-pain-management. html (accessed 29 april 2020). 5. beauchamp tl. making principlism practical: a commentary on gordon, rauprich and vollman. bioethics 2011;25(6):301-303. https://doi.org/10.1111/j.1467-8519.2011.01908.x 6. sherwin s, winsby m. a relational perspective on autonomy for older adults residing in nursing homes. health expectations 2010;14(2):182-190. https://doi.org/10.1111/j.1369-7625.2010.00638.x 7. jacobs g. patient autonomy in home care: nurses’ relational practices of responsibility. nurs ethics 2018;26(6):1638-1653. https://doi.org/10.1177/0969733018772070 8. molina-mula j, peter e, gallo-estrada j, perelló-campaner c. instrumentalisation of the health system: an examination of the impact on nursing practice and patient autonomy. nurs inq 2017;25(1):e12201. https:// doi.org/10.1111/nin.12201 9. truglio-londrigan m. the patient experience with shared decision-making. j infusion nursing 2015;38(6):407-418. https://doi.org/10.1097/nan.0000000000000136 10. patton mq. qualitative research and evaluation methods: integrating theory and practice. newbury park, ca.: sage, 2014. 11. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 12. south africa. white paper on transformation of the public services. pretoria: government printer, 1995. https:// www.gov.za/sites/default/files/gcis_document/201409/183401.pdf (accessed 11 july 2020). 13. kilbride mk, joffe s. the new age of patient autonomy. jama 2018;320(19):1973. https://doi.org/10.1001/ jama.2018.14382 14. american occupational therapy association. about occupational therapy. 2015. https://www.aota.org/aboutoccupational-therapy.aspx (accessed 29 april 2020). 15. world federation of occupational therapy. defining occupation. https://www.wfot.org/about/aboutoccupational-therapy#:~:text=definition%20%22occupation%22,and%20are%20expected%20to%20do (accessed 11 july 2020). 16. bird aw. enhancing patient well-being: advocacy or negotiation? j med ethics bmj 1994;20(3):152-156. https:// doi.org/10.1136/jme.20.3.152 17. dove es, kelly se, lucivero f, machirori m, dheensa s, prainsack b. beyond individualism: is there a place for relational autonomy in clinical practice and research? clin ethics 2017;12(3):150-165. https://doi. org/10.1177/1477750917704156 accepted 20 august 2020. https://doi.org/10.1177/­­0969733019848031 https://doi.org/10.1177/­­0969733019848031 https://doi.org/10.1093/acref/9780192800879.001.0001 https://doi.org/10.1093/acref/9780192800879.001.0001 http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_auton_bene.htm http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_auton_bene.htm http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/columns/ethics/ethics-and-pain-management.html http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/columns/ethics/ethics-and-pain-management.html http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/columns/ethics/ethics-and-pain-management.html https://doi.org/10.1111/j.1467-8519.2011.01908.x https://doi.org/10.1111/j.1369-7625.2010.00638.x https://doi.org/10.1177/0969733018772070 https://doi.org/10.1111/nin.12201 https://doi.org/10.1111/nin.12201 https://doi.org/10.1097/nan.0000000000000136 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa https://www.gov.za/sites/default/files/gcis_document/201409/183401.pdf https://www.gov.za/sites/default/files/gcis_document/201409/183401.pdf https://doi.org/10.1001/jama.2018.14382 https://doi.org/10.1001/jama.2018.14382 https://www.aota.org/about-occupational-therapy.aspx https://www.aota.org/about-occupational-therapy.aspx https://www.wfot.org/about/about-occupational-therapy# https://www.wfot.org/about/about-occupational-therapy# https://doi.org/10.1136/jme.20.3.152 https://doi.org/10.1136/jme.20.3.152 https://doi.org/10.1177/1477750917704156 https://doi.org/10.1177/1477750917704156 september 2019, vol. 11, no. 3 ajhpe 81 short research report since the beginning of mankind there has been a need for clinical forensic medical services: ‘cain overpowered abel and killed him’ (genesis 4:8, new international version bible). clinical forensic medicine (cfm) applies knowledge from all specialties of medicine for the administration of justice in courts of law,[1,2] thereby acting as a link between medical practice and the law. because all practising physicians, regardless of specialty, are often required to evaluate cfm cases, increasing scrutiny by the judicial system demands that medical graduates/students undergo satisfactory training in cfm and are informed regarding the consequences of their practices, not only on health, but also in the legal, social and economic domains, as the consequences relate to the rights and quality of life of their patients.[3] we previously demonstrated that some community service doctors (csds) lack the required competence to assess and document medicolegal findings relating to rape/sexual assault,[4] inebriated drivers,[5] and common physical assault.[6] these findings revealed a consequential gap in the cognisance and adeptness of medical graduates regarding the practice of clinical forensics, and the necessity for a revised curriculum for cfm to address the inadequacies of undergraduate medical training programmes. we present the perspectives of the abovementioned csds on how knowledge of medical graduates of cfm can be improved. methods this research was designed as a descriptive study that made use of a questionnaire survey to gather qualitative data from 150 csds. instrument data were collected using a structured, self-administered questionnaire distributed electronically to participants via the evasys electronic survey system (electric paper, germany). it comprised open-ended questions that allowed participants to suggest how medical graduates’ knowledge of cfm can be increased. ethical approval this study was approved by the health sciences research ethics committee, faculty of health sciences, university of the free state, bloemfontein, south africa (sa) (ref. no. hsrec 149/2011). data analysis responses to the open questions were read and re-read by the investigators to familiarise themselves with the content. content analysis was done using nvivo 12 software (qsr international pty ltd, australia). thematic analysis formed the cornerstone of the analysis, with emphasis on patterns and emerging themes. results analysis of the comments of the csds revealed three core themes, i.e. training, practical work and exposure. each theme is supported by csds’ responses quoted verbatim. training csds indicated that providing more training opportunities at undergraduate level is key to improving medical graduates’ knowledge of cfm: ‘more undergraduate training and exposure.’ ‘i think there should be more training for an undergraduate on the legal implications for the examiner.’ ‘undergraduates should rotate and be on call with the district physician in medicolegal departments.’ background. teaching and learning of clinical forensic medicine (cfm) in the undergraduate medical curriculum is declining, which results in deficient handling of medicolegal cases by doctors. we previously demonstrated that some community-service doctors (csds) lack the required competence to assess and document medicolegal cases involving rape/sexual assault, inebriated drivers and common physical assault. objective. to obtain the perspectives of csds on how medical graduates’ knowledge of cfm can be improved. methods. this was a descriptive study using a questionnaire survey to gather qualitative data from 150 csds. results. analysis of the comments of the csds revealed three core themes, i.e. training, practical work and exposure. conclusions. south african courts rely heavily on medicolegal evidence for successful prosecution of physical assault, rape/sexual assault or drunk driving cases. the inept handling, collecting and processing of medicolegal evidence by healthcare providers have been attributed to lack of rigorous training and poor performance standards. it is important that healthcare providers are trained and competent, and possess the skills required to collect evidence and document medicolegal findings correctly. afr j health professions educ 2019;11(3):81-82. https://doi.org/10.7196/ajhpe.2019.v11i3.1171 improving the knowledge of clinical forensic medicine among medical graduates: perspectives of community-service doctors l fouché, mb chb, mmed (med forens), fc for path (sa), phd (hpe); j bezuidenhout, ba (ed), med, dtech (ed), pgd (hpe); a o adefuye, mb chb, msc (microbiol), phd (med biochem) division health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a o adefuye (adefuyeao@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 82 september 2019, vol. 11, no. 3 ajhpe short research report one major component of cfm is the detailed assessment/examination, documentation and treatment of patients who report having been physically or sexually assaulted or raped.[4] known as medicolegal examinations, they entail a very detailed history regarding the incident, and a thorough general examination coupled with collection of forensic samples.[4] therefore, csds in this study suggested that training should focus more on aspects of history taking, examination, completing the appropriate form (j88) and documentation, and how to use the required kits to collect forensic evidence: ‘restructuring the medical training to include examining and appropriate history taking and correctly filling in documentation as part of undergraduate education would be a step in the right direction.’ ‘… also training in filling in the documents correctly … .’ ‘training on how to complete j88 forms.’ ‘training with the actual kits.’ practical work according to the csds, theoretical teaching of cfm is inadequate for impacting knowledge. therefore, they advocated that training should be made more practical: ‘one lecture is not enough … theoretical lectures are not sufficient. i think it needs to be shown to students practically.’ ‘combine theoretical knowledge with practical exposure.’ ‘… thus i would suggest more practical exposure be given to students … .’ ‘getting practical experience would help.’ exposure the third core theme was exposure. here, csds suggested that undergraduate students should be exposed to real-life cases, as this would make training more meaningful: ‘proper exposure to cases, especially assault cases; wound examinations with an experienced clinician on a regular basis.’ ‘more practical exposure to different case studies.’ ‘to increase exposure to case studies and increase the time period spent on forensics.’ discussion the training of undergraduate mb chb students in cfm is a prerequisite set by the subcommittee for undergraduate education and training of the medical and dental professions board in sa.[7] however, teaching and learning of cfm in the undergraduate medical curriculum has been declining, which has resulted in deficient handling of medicolegal cases by doctors.[8,9] in this study, csds claim that more teaching/training opportunities are required in the undergraduate medical curriculum to improve medical graduates’ knowledge of cfm. furthermore, csds indicated that training should be made more practical and meaningful by exposing students to real-life cases. this suggestion is very important, as traditional methods of teaching (i.e. didactic lectures with few demonstrations) have resulted in impaired student learning and poor skills acquisition.[10] sa courts rely heavily on medicolegal evidence for successful prosecution of physical assault, rape/sexual assault or drunk-driving cases. the inept handling, collecting and processing of medicolegal evidence by healthcare providers have been attributed to lack of rigorous training and poor performance standards.[11] therefore, it is important that healthcare providers are trained and competent, and possess the skills needed to collect evidence and document medicolegal findings properly. study limitations and future research the csds who participated in this study were graduates of a single medical institution, which could limit the generalisability of this study. further research could investigate the perspectives of other csds (graduates of other medical institutions) to obtain views from a representative population. furthermore, studies can be conducted to develop a curriculum framework for teaching cfm in undergraduate medical education. declaration. none. acknowledgements. the health and welfare sector education and training authority (hwseta). author contributions. lf conceptualised the study and collated the data; jb conceptualised the study and reviewed the manuscript; aoa collated and analysed the data and wrote the manuscript. funding. none. conflicts of interest. none. 1. reddy nks. the essentials of forensic medicine and toxicology. mumbai: jaypee brothers medical publishers, 2014. 2. madea b, saukko p. future in forensic medicine as an academic discipline – focussing on research. forensic sci int 2007;165(2-3):87-91. https://doi.org/10.1016/j.forsciint.2006.05.030 3. magalhães t, dinis-oliveira rj, santos a. teaching forensic medicine in the university of porto. j forensic leg med 2014;25:45-48. https://doi.org/10.1016/j.jflm.2014.04.011 4. fouché l, bezuidenhout j, liebenberg c, adefuye a. medico-legal documentation of rape or sexual assault: are community-service doctors equipped for the task? s afr fam pract 2018;60(1):8-12. https://doi.org/10.1080/20 786190.2017.1348046 5. fouché l, bezuidenhout j, liebenberg c, adefuye a. medico-legal aspects regarding drunk driving: experience and competency in practice of community service doctors. s afr fam pract 2018;60(2):63-69. https://doi.org/1 0.1080/20786190.2017.1386899 6. fouché l, bezuidenhout j, liebenberg c, adefuye a. practice of community-service doctors in the assessment and medico-legal documentation of common physical assault cases. s afr fam pract 2018;60(1):21-25. https:// doi.org/10.1080/20786190.2017.1364014 7. kotzé jm, brits h, botes b. part 1: medico-legal documentation south african police services forms, department of justice forms and patient information. s afr fam pract 2014;56(5):16-22. 8. jones rm. getting to the core of medicine: developing undergraduate forensic medicine and pathology teaching. j forensic leg med 2017;52:245-251. https://doi.org/10.1016/j.jflm.2017.10.006 9. murty o. modular teaching in forensic medicine and toxicology. j forensic med toxicol 2012;29(1):1-17. 10. gupta s, parekh un, ganjiwale jd. student’s perception about innovative teaching learning practices in forensic medicine. j forensic leg med 2017;52:137-142. https://doi.org/10.1016/j.jflm.2017.09.007 11. du mont j, white d. seeking a better world for women and girls. bmj 2011;343:d5712. https://doi.org/10.1136/ bmj.d5712 accepted 7 march 2019. https://doi.org/10.1016/j.forsciint.2006.05.030 https://doi.org/10.1016/j.jflm.2014.04.011 https://doi.org/10.1080/20786190.2017.1348046 https://doi.org/10.1080/20786190.2017.1348046 http://www.tandfonline.com/doi/abs/10.1080/20786190.2017.1386899#.vqcjlpwjhgu http://www.tandfonline.com/doi/abs/10.1080/20786190.2017.1386899#.vqcjlpwjhgu http://www.tandfonline.com/doi/abs/10.1080/20786190.2017.1364014#.vqcjlpwjhgu https://doi.org/10.1016/j.jflm.2017.10.006 https://doi.org/10.1016/j.jflm.2017.09.007 https://doi.org/10.1136/bmj.d5712 https://doi.org/10.1136/bmj.d5712 208 september 2021, vol. 13, no. 3 ajhpe research why was the idea necessary? in the 5-year dentistry curriculum at the university of the western cape, south africa (sa), prosthetic dentistry is presented as modules, starting in the 2nd year and culminating in the final module in the 5th year. students are taught theory, and laboratory and clinical skills of removable (complete or partial) prostheses. thus, acquiring psychomotor, clinical and problem-solving skills are an essential part of dental students’ education and training.[1] for trainee dentists, assessments include providing treatment for ‘real patients’, allowing them to demonstrate how theoretical knowledge of clinical procedures may be integrated with clinical skills in the clinical setting.[1] teaching of clinical skills was completely interrupted during sa’s initial response to the covid-19 pandemic, although theoretical teaching continued on various virtual platforms. educators uploaded clinical cases, and narrated and scaffolded clinical procedures aligned with module outcomes to provide continued training for students, even though the impact in terms of clinical competence was limited. proceeding with assessments to determine competency for maintaining performance standards for graduating students, became an unprecedented challenge under pandemic conditions.[2] with the easing of the country’s lockdown restrictions, the consequent return to campus of final-year dental students and expecting them to continue clinical practice training, called for innovative and novel strategies to determine and address inadequacies in their learning and clinical practice. to this end, the department of prosthetic dentistry adapted the existing teaching and assessment methods, including greater collaboration with all stakeholders. the following are some of the questions educators felt needed to be addressed: • what influence the interruption of clinical practice had on the clinical competence of students • how to ease transitioning students back to clinical practice during the pandemic • how to focus and modify clinical teaching when students return to clinical practice • how to adapt an objectively structured clinical examination (osce) to adhere to covid-19 protocols what was tried? to assess the impact of the interruption of clinical practice, an osce was planned as formative assessment for final-year students on their initial return to campus for face-to-face teaching after the country’s lockdown restrictions were lifted. the purpose of the intended osce was twofold: to evaluate students’ clinical competence and to provide constructive feedback on their preparedness to continue with clinical practice after an extended absence from clinical work. feedback of students’ performance in the osce enabled lecturers to focus their teaching appropriately and as per individual student’s needs. to illustrate the adapted osce, we describe how osces were conducted before and after the pandemic: • presentation of osce prior to covid-19 it was a station-based assessment, where students moved from station to station to complete the questions. the time for questions per station was 10 15 minutes and the organisation was fairly easy, as no other considerations were included. to provide students with extra time and to accommodate the large number of students in class, there were also several question-free stations. osce sessions were conducted on one day, with 2 sessions per day and ~16 questions per osce. educators would prepare 4 sets of each material/question and place these at 4 different areas, which allowed half of the class to be assessed simultaneously. • the adapted osce because of the covid-19 pandemic and the associated risk of infection transmission, this circuit-based test had to be modified. a single osce station was created, which included all questions as planned by the department. the student therefore did not have to move from station to station, thus limiting the spread of infection. for the modified osce, the allocated time for the entire osce was set at 180 minutes. therefore, students were allowed to manage their time, which differed as applied per question. when planning this osce, the department therefore considered and implemented appropriate personal protective equipment (ppe) and surface disinfection precautions necessary during the pandemic. the osce was in an enclosed clinic, which was prepared using the advocated covid-19 disinfection protocols, but most importantly, all clinics were prepared with the instruments and equipment required for each osce question. to  ensure social distancing, groups of students were scheduled individually. the osce was therefore conducted over 4 days, with 22 students divided into 2 separate sessions, hours apart, per day. other covid-19 protocols included ensuring that students were using hand sanitisers and wearing masks and gloves when inspecting, evaluating and completing each procedure set out for the osce. covid-19 protocols were also adhered to when input from educators was required during invigilation of the osce, when marking/evaluating completed procedures and when scripts were completed. sound educational principles, such as reliability, transparency, blueprinting and constructive feedback, underpinned the planning of the osce. questions included clinical procedures, such as taking impressions and preparing procedures on typodont teeth set up on a mannequin on the clinical chair (qr code). the nature of these questions was aligned with the clinical competencies for the final-year level. moreover, the criteria for assessment, as well as having 2 examiners, were carefully planned. a  memorandum for each question and a rubric for clinical procedures were prepared, shared with examiners and adapting an undergraduate dental objectively structured clinical examination (osce) during covid‑19 r maart, bchd, mphil; s khan, bchd, msc, phd; b kathree, bchd; r ahmed, bchd, msc; r mulder, bchd, msc, phd; n layloo, bchd; w asia‑michaels, bchd, mchd department of prosthetic dentistry, faculty of dentistry, university of the western cape, cape town, south africa corresponding author: r maart (rmaart@uwc.ac.za) this open‑access article is distributed under creative commons licence cc‑by‑nc 4.0. mailto:rmaart@uwc.ac.za september 2021, vol. 13, no. 3 ajhpe 209 research followed. the 2 examiners discussed the students’ answers, and consensus was reached for clinical procedures to ensure that appropriate, objective comprehensive feedback was shared with students. to this end, structured feedback sessions were prepared, and where students required remediation, this was also addressed. from the poor results obtained in certain procedures, e.g. the preparation of a postdam for a maxillary denture, a video illustrating this procedure was created and uploaded on the e-learning platform. additional videos demonstrating clinical procedures were uploaded on this platform to assist students to prepare for the transition to clinical practice. most importantly, students received prior briefing on the change in format and the entire scope of the osce. blueprinting of the osce was completed to ensure that appropriate outcomes and bloom’s taxonomy were included and aligned. therefore, for all stages of this osce, kane’s framework of validity, which includes scoring, generalisations, extrapolation and implications, was considered, as it ensures success with such assessments.[3] lesson/s learnt performance of students in the osce provided staff with feedback on clinical competence and preparedness to return to clinical practice, as well as identifying gaps in their teaching. these unprecedented consequences of covid-19 provided a catalyst for changing teaching and assessment strategies, and challenged us to be more collaborative, reflective educators with flexible learning and teaching approaches.[4] more importantly, this assessment, after such a long period of absence from clinical work, gave students reassurance and confidence on their return to clinical activities to manage patients, their learning and themselves during the covid-19 pandemic. a change in the expected assessment plan was also included, as well as structured feedback sessions involving all educators in the department, where they could ask questions and share fears related to working in the pandemic. what will we keep in practice? we shall definitely use the newly adapted format of the osce, including the collaborative practice, planning and evaluation, as it is a more objective manner of assessing students’ clinical competence. moreover, as we are still in the pandemic, and covid-19 may become endemic, we may continue to use this format. as a consequence of the experience of planning the osce, the department continued to plan and conduct osces collaboratively. the inclusion of specific and detailed formative feedback sessions after osces, is a sound educational practice that will continue in our department. what will we not do? an osce must not be planned and prepared without students knowing what it entails and how it impacts on their learning and assessments for the year. we will not make osces high-stakes assessments, as these are good deep-learning opportunities for students and should be used as such. we will not change the inclusion of a group of examiners, and having two  people assess one question, as this approach will ensure the integrity of the osces. following from this experience of arranging the adapted osce and observing the concerns regarding students’ learning and clinical skills, we will not allow students to proceed with clinical practice after an extended period of disruption, without some form of formative assessment and structured feedback. declaration. none. acknowledgements. we acknowledge the assistance and input of the nonacademic staff in the department of prosthetic dentistry during the osce sessions. author contributions. equal contributions. funding. none. conflicts of interest. none. evidence of innovation 1. englander r, cameron t, ballard aj, dodge j, bull j, aschenbrener ca. toward a common taxonomy of competency domains for the health professions and competencies for physicians. acad med 2013;88(8):1088-1094. https://doi.org/10.1097/acm.0b013e31829a3b2b 2. boursicot k, kemp s, ong t, et al. conducting a high-stakes osce in a covid-19 environment. mededpublish 2020. https://doi.org/10.15694/mep.2020.000054.1 3. tavares w, brydges r, myre p, et  al. applying kane’s validity framework to a simulation based assessment of clinical competence. adv health sci educ 2018;23(2):323-338. https://doi.org/10.1007/s10459-017-9800-3 4. almarzooq z, lopes m, kochar a. virtual learning during the covid-19 pandemic: a disruptive technology in graduate medical education. j am coll cardiol 2020;75(20):2635-2638. https://doi.org/10.1016/j.jacc.2020.04.015 accepted 15 june 2021. afr j health professions educ 2021;13(3):208-209. https://doi.org/10.7196/ajhpe.2021.v13i3.1515 https://doi.org/10.1097/acm.0b013e31829a3b2b https://doi.org/10.15694/mep.2020.000054.1 https://doi.org/10.1007/s10459-017-9800-3 https://doi.org/10.1016/j.jacc.2020.04.015 https://doi.org/10.7196/ajhpe.2021.v13i3.1515 186 september 2021, vol. 13, no. 3 ajhpe short report what was the problem? the fourth industrial revolution is upon us, bringing with it modern trends and new imaging equipment and techniques to radiography. while resource-rich institutions have successfully moved from analogue to digital equipment, many institutions in resource-constrained countries still depend on analogue equipment to deliver radiographic services to their communities.[1] radiography relies heavily on analogue and digital machines to create images for diagnostic purposes, and it is important that radiography students are trained in both these aspects to align their skills with the available resources in different healthcare settings.[2] undergraduate radiography students in our department have to attend both work-integrated learning and formal face-to-face contact sessions. in 2020, these students were unable to physically engage with analogue equipment as a result of a shortage of automatic film processors (afps) at clinical training sites, exacerbated by movement restrictions imposed during the covid-19 pandemic. students had to learn about analogue radiography equipment from static textbook images, similar to that shown in fig.  1. not being able to physically engage with afps led to students disconnecting from the learning material and not fully comprehending the dynamic nature of the afp. the afp is a complex piece of equipment that relies on many sequential steps, such as radiographic film moving in and out of the chemical tanks, the temperature and circulation control system and simultaneous replenishment tanks pumping chemicals back into the tanks (fig. 1). a solution to the problem in 2020, covid-19 restrictions led to radiography students not being able to access analogue equipment, resulting in students not being able to visualise the dynamic nature of the afp. to overcome this challenge, the idea arose of creating an online digital animation to explain afp, based on the static image in fig.  1, to illustrate analogue imaging in real time. the  lecturer who taught the second-year  radiographic imaging module, which includes afp concepts, developed a customised animated recording of the physical processes involved in afp to demonstrate the basic processes that the film undergoes.  in  collaboration with the education innovation department, university of pretoria (up), we created basic animations based on general static images found in the radiographic imaging textbooks  using 3d animation software (3d studio  max (autodesk  inc., usa). second-year  radiography  students  enrolled for the radiographic imaging module were requested to do an assignment for formative assessment purposes. students watched the short, animated film, illustrating the process, with extra features enabled, including narration and close-captions. during the formative assessment, students had to disable the extra features, watch the animation again and write an essay explaining the events depicted in the animation. for self-assessment, students re-enabled the narration and caption feature and revised their essays. after engaging with the animation, we invited students to participate in a reflective focus group interview to share their experience of the learning opportunity. lessons learnt from the focus group interview, students’ experiences could be categorised into two major themes, namely, theme 1: the afp animation without narration as an inquiry-based learning tool; and theme 2: the afp animation with narration and captions as a passive learning tool. theme 1: the afp animation without narration as an inquiry-based learning tool in this theme, students mentioned that they preferred the animation without narration. students were intrigued by the animation. ‘i was looking at the video [animation] and i was wondering what was happening. so, watching the video made me want to find out what is happening. visualizing made me want to read more on it.’ another student touched on self-directed learning and taking ownership of the process, when watching the video without narration prompted her to conduct further research in the form of in-depth reading to enhance her understanding of the events illustrated in the animation. ‘i don’t think i would do as much research, because now i understand so much about that automatic processor [animation].’ this self-directed teaching strategy is well aligned with kolb’s model of experiential learning.[3] in this model, students are involved in four aspects, which are: • going through a new experience or gaining a new perspective of an existing experience • interpreting and reflecting on the experience • a learning experience is put into a new context • the learner applies new understanding to reality to test its validity.[3] students were exposed to a new experience in visualising the afp in a dynamic teaching format. students then reflected on the video (animated film) in relation to the theory, enticing them to conduct further research. this exercise led to a learning experience which students could use to  complete their assignment, ultimately testing the validity of their experience. bringing literature to life: a digital animation to teach analogue concepts in radiographic imaging during a pandemic lessons learnt h essop,1 mrad (diag), brad hons; i (j c) lubbe,2 bsoc, msocsci, med, phd; m kekana,3 mtech, phd 1 department of radiography, school of healthcare sciences, university of pretoria, south africa 2 department for education innovation, university of pretoria, south africa 3 department of radiography, school of healthcare sciences, university of pretoria, south africa corresponding author: h essop (hafsa.essop@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:hafsa.essop@up.ac.za september 2021, vol. 13, no. 3 ajhpe 187 short report theme 2: the afp animation with narration and captions as a passive learning tool students’ responses revealed that the functionality and value of the animation was largely influenced by their learning styles, which varied from visual and auditory to written. one student expressed it as follows: ‘it [the animation] made it a lot easier because then you can visualize it, because we don’t use it every day, ever’. learners often create better internal representations of content when watching videos, compared with learning from static images only.[4] although online videos have many benefits, the content is watched as opposed to hands-on experience, and the extent of the benefit will depend on the detail portrayed in the video. contrary to the previous student’s reaction, another student was frustrated by the narrations and captions, saying that ‘the voice was distracting. i am trying to look at the picture and, you know, trying to understand [but] the words kept coming.’ the student expressed frustrations that align with mayer’s ‘redundancy principle’, according to which multiple stimuli should be kept separate to eliminate the extraneous cognitive processing load.[5] in mayer’s ‘cognitive theory of multimedia learning model’, three fundamental principles, derived from cognitive science, must be considered when using animations: (i) the dual channels principle, whereby students have separate visual and auditory processing stations; (ii) the limited capacity principle, when students can only process a limited number of concepts illustrated in the animation; and (iii) the active processing principle, in which there is active engagement with the animation.[5] some students reported that the narrated animation was a valuable passive learning tool, as it provided a visual element to the learning material. however, the high cognitive load may have hindered deep learning. what will i keep in my practice? the animation without narration served as an effective inquiry-based learning tool and we will use it again to teach afp concepts. inquirybased learning gives learners an opportunity to formulate their own explanations from evidence at their disposal and relate it to scientific knowledge and theories.[6] learners can communicate and explain their findings, which translates into deep learning and long-term knowledge retention. the online environment further creates the ideal platform for inquiry-based learning, which has benefits such as students taking ownership of their own learning and inquiry skills. during the covid-19 pandemic, all teaching across the globe dramatically transitioned to online platforms.[7] using the online animation as an inquiry-based learning tool was an appropriate and welcome method of teaching during times of limited physical access to equipment. what will i not do? we will not use the animation with narration and captions as a primary teaching tool for afp, but rather keep it as an additional resource for students should the need arise. the animation with narration showed potential to be an effective visual aid for learning, but had minimal engagement opportunities and thus supported passive learning. many students were distracted by the extra features, which hindered their learning. in future, when developing online multimedia, such as animations, we will not combine multiple methods of delivery such as narration and caption, but rather limit the animation to one form of communication if the animation is to be used as a teaching tool. declaration. none. acknowledgements. the researchers would like to acknowledge ms charissa pick, second-year radiography student, for illustrating the automatic film processor for this short report. author contributions. equal contributions. funding. none. conflicts of interest. none. drying chamber feed tray film thermostat over�ow entrance rollers planetary roller master roller recirculation system guide shoe developer replenisher fixer replenisher replenishment �lter guide shoe fixer tank wash tank squeegee rollers developer tank replenishment pump drain filter filter developer heater wash (water) pump blower receiving bin heat exchange system fig. 1. redrawn illustration of the automatic film processor (afp). 188 september 2021, vol. 13, no. 3 ajhpe short report evidence of innovation 1. campbell s, morton d, grobler a. transitioning from analogue to digital imaging: challenges of south african analogue-trained radiographers. radiography (lond) 2019;25(2):e39-e44. https://doi.org/10.1016/j. radi.2018.10.001 2. jacobs-nzuzi khuabi l, bester j. occupational therapists' views on core competencies that graduates need to work in the field of neurology in a south african context. afr j health professions educ 2020;12(1):36-40. https:// doi.org/10.7196/ajhpe.2020.v12i1.1021 3. kolb da. experiential learning: experience as the source of learning and development. upper saddle river, nj: ft press, 2014. 4. arguel a, jamet e. using video and static pictures to improve learning of procedural contents. comput human behav 2009;25(2):354-359. https://doi.org/10.1016/j.chb.2008.12.014 5. mayer re. using multimedia for e‐learning. j comput assis learn 2017;33(5):403-423. ttps://psycnet.apa.org/ doi/10.1111/jcal.12197 6. khalaf bk. traditional and inquiry-based learning pedagogy: a systematic critical review. int j instruct 2018;11(4):545-564. https://doi.org/10.12973/iji.2018.11434a 7. lestiyanawati r. the strategies and problems faced by indonesian teachers in conducting e-learning during covid-19 outbreak. cllient (culture, literature, linguistics, english teaching) 2020;2(1):71-82. accepted 15 june 2021. afr j health professions educ 2021;13(3):186-188. https://doi.org/10.7196/ajhpe.2021. v13i3.1513 https://doi.org/10.1016/j.radi.2018.10.001 https://doi.org/10.1016/j.radi.2018.10.001 https://doi.org/10.7196/ajhpe.2020.v12i1.1021 https://doi.org/10.7196/ajhpe.2020.v12i1.1021 https://doi.org/10.1016/j.chb.2008.12.014 ttps://psycnet.apa.org/doi/10.1111/jcal.12197 ttps://psycnet.apa.org/doi/10.1111/jcal.12197 https://doi.org/10.12973/iji.2018.11434a april 2021, vol. 13, no. 1 ajhpe 65 research person-centred practice is an ethical imperative[1,2] and an essential competency that has value for patients, clinicians and the health service.[3] at its core is a holistic view of the patient as a person with a unique illness experience, as well as the creation of a therapeutic relationship between patient and clinician.[1] despite various interventions, research shows that person-centredness and its constituent elements decline during the training of medical students.[4-6] to understand this phenomenon, it is necessary to examine the underlying assumptions and effects of training interventions on person-centred practice. this, in turn, requires an understanding of learning and the learner. marcus[7] refers to four dimensions of the learner as sources of human capacity and competency, i.e. physical and mental abilities, knowledge and beliefs, sense of self and identity and social relationships. when there is a disturbance to any, some or all of these dimensions, the person experiences uncertainty. this uncertainty becomes the trigger to several, preferably conscious, cognitive and metacognitive activities that lead to learning. these include reviewing the activities or events that triggered the disruption, finding new information and critically evaluating the new information against the disruption, while taking into account self and identity, relationships and competencies. all this is done to develop an appropriate plan of action. through practice, learners improve or develop new competencies, and develop or deepen their understanding of themselves and others, thereby growing the ability to learn in a continuously iterative learning cycle.[8] the capability approach (fig. 1)[7,9,10] enables learners to develop mastery and move towards self-directed learning over time. it needs to be made consciously visible, scaffolded and guided by mentors and teachers, for all individuals to learn how to use it.[9] in this article, we use the capability approach to assess bachelor of clinical medical practice (bcmp) students’ learning of person-centred consultation skills during a quality-improvement (qi) process on the medical consultation. students with the bcmp degree are qualified to practise as clinical associates in south africa (sa).[11] they spend most of background. research shows that person-centredness declines during medical education. this study examines the underlying assumptions and effects of clinical associate training interventions on person-centred practice. objectives. to understand student experiences of a medical consultation quality-improvement (qi) process in terms of a capability approach to learning and the effects of this process on their person-centredness. methods. in a randomised controlled trial students from 8 clinical learning centres (clcs) participated in a qualitative, medical consultation qi process. qualitative data (focus group discussions and reflective reports) were analysed using a capability approach to the learning framework. results. learning was triggered by disruptions to students’ abilities, knowledge, identity and relationships. through facilitated review-read-reflectre/action scaffolded by feedback and practical assessment tools they learnt new person-centred consultation skills. the qi process functioned as a learning cycle in which students reviewed disruptions, identified areas for improvement and developed improvement plans. through it, awareness of themselves developed more deeply, their relationships with peers and patients grew and they improved their knowledge and consultation skills. conclusions. students demonstrated learning through their understanding of the skills and competencies required for person-centred practice. the study found students to be at different points along the directed/self-directed learning continuum, with most of them developing abilities to learn independently, work in groups, give and receive feedback and apply learning across different contexts. facilitation is particularly important, given the uneven development of the ‘dimensions of a person’ at an individual level. lastly, the capability approach is useful as an analytical framework and as a way of ‘doing learning’. afr j health professions educ 2021;13(1):65-71. https://doi.org/10.7196/ajhpe.2021.v13i1.1224 a capability approach analysis of student perspectives of a medical consultation quality-improvement process j m louw, mb chb, dtm&h, mmed (fammed), phd (fammed); t s marcus, bsc (econ), msc, phd; j f m hugo, mb chb, mfammed department of family medicine, school of medicine, faculty of health sciences, university of pretoria, south africa corresponding author: j m louw (murray.louw@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. fig. 1. the capability approach to learning.[7,9,10] 66 april 2021, vol. 13, no. 1 ajhpe research their 3 years of training doing service learning in a decentralised learning platform at clinical learning centres (clcs). typically, these comprise a district-level public hospital and its surrounding clinics.[12] a local family physician provides oversight and leadership for student learning in each clc, where students have daily contact with patients and conduct consultations under the supervision of qualified health professionals. methods as part of a mixed-methods study, a randomised controlled trial of a qi intervention to learn person-centred practice was conducted with secondand third-year bcmp students.[13] we report on the qualitative data from student reflective reports and focus group (fg) interviews with intervention group students. students learning at 8 of 19 clcs selected for the intervention by clustered randomisation were trained to implement the qi process as follows: • form a team of 2 4 fellow students in the same year group to work together to improve consultation skills. • read and reflect on 2 articles describing the medical consultation.[14,15] • study 4 consultation assessment tools: kalamazoo essential elements communication checklist (adapted) (keecc(a)), consultation peer assessment tool (adapted for students at the university of pretoria), care patient feedback measure and patient enablement instrument. • measure current consultation practice by assessing each other’s consultations with the tools provided. consultations could be video recorded, audio recorded and/or observed in person. give feedback to each other based on the tools, and reflect on patients’ perceptions of their consultations as recorded in the tools. do self-assessment using one or two of the tools. • plan and implement measures to improve their own consultations. • repeat the measurements of their consultation practice. • reflect on changes in their performance and submit a report on the qi process. one clc closed after randomisation, but before commencement of training for the intervention. the 3 affected students were moved individually to 3 other clcs. students at the remaining 10 clcs served as controls. even though intervention group students were repeatedly encouraged to submit reports, only 9 reports were received. data for this analysis (fig. 2) were drawn from these 9 written reflection reports from 17 students in 4 clcs and 10 focus group discussions (fgds) that explored student experiences of the qi process on the medical consultation conducted between 19 octo ber and 23 november 2015. all 62 students in the intervention group were invited (volunteer sampling) to participate in fgs when they were on campus for tests or examinations. each fgd involved 2 12 participants, lasted 7 25 minutes and was conducted by the first author in english, audio recorded and transcribed. the 48 fg participants included students from 7 of the 8 clcs trained for the qi process. no student from clc 8 volunteered to participate in an fgd, and no student participated in more than one fgd. in all fgds, participants were asked: ‘how are you progressing with the quality improvement on the medical consultation?’, and 4 supplementary questions: ‘how useful did you find the feedback that you were giving to one another?’, ‘how useful did you find the feedback from patients?’, ‘how useful did you find reflecting and thinking about your own consultation?’ and ‘how useful were the evaluation tools or rubrics?’ data were interpreted using a capability approach to learning as a framework. for the purposes of this analysis, the physical and mental abilities of the learner were interpreted specifically in terms of consultation skills rather than as general abilities. scaffolding for learning consultation skills included academic readings explaining the processes of the medical consultation, as well as assessment tools detailing the behaviours evaluated in a consultation. guidance of learning included a qi process and advocating for a learning environment that enabled learners to engage meaningfully in the process. it was also facilitated by peer feedback among students to stimulate reflection on their performance as related to assessment tools. feedback was deemed effective when it related to a specific learning context and was directed towards the attainment of specific goals.[16] data were analysed through repeated reading of the reports and transcribed texts, as well as repeated listening to the audio recordings to identify specific insights into learning the consultation skills required for person-centred practice and to relate these to the phases and elements of the capability approach to learning (fig. 1). quotations were coded and catalogued deductively in themes using the atlas.ti (version 7.5) (atlas.ti scientific software development gmbh, germany) computer program. codes and themes were verified through discussions between the first and second authors, with involvement of the third author when there was no agreement. ethical approval the study was granted ethical clearance by the research ethics committees of the mpumalanga provincial government and the faculty of health sciences, university of pretoria (ref. no. 128/2013). results the average age of the 62 students in the intervention group was 23.3 years and 44% were female. describing their competencies prior to undertaking the qi process, students said that by their second year they had a better understanding clcs, n=19 with 2ndand/or 3rd-year bcmp students, n=137 clcs served as controls (no intervention), n=10 (n=75) all students removed from one clc due to lack of accommodationclcs received instruction in the intervention, n=8 (n=62) clcs implemented the intervention, n=5 in one clc some students implemented the intervention and others not clcs did not implement the intervention, n=2 clc 2: participated in fgds 2 and 9 clc 4 and 7: participated in fgds 4, 7 and 10 clc 1, 3 and 5: participated in fgds 1, 3 and 5 and submitted 8 written reports clc 8: students only submitted a written report clc 1 and 6: participated in fgds 6 and 8 fig. 2. study sites, participants and data sources for the quality improvement process intervention. (clcs = clinical learning centres; bcmp = bachelor of clinical medical practice; fgds = focus group discussions.) april 2021, vol. 13, no. 1 ajhpe 67 research of person-centred practice, which prepared them for this qi process (table 1: quote 1:25). they ascribed their skill in involving patients as equals in decision-making to previous training in preparation for an objective structured clinical examination (osce) (table 1: quote 1:28). students reported gaps in their knowledge of pharmacology (table 2: quote 18:16), special investigations and communication skills (table 1: quote 21:4). in one instance, a student continued to externalise responsibility for learning (table 3: quote 5:15). students experienced several disruptions in the qi process that triggered learning, including: being observed by peers (table 3: quote 2:57; table 4: quote 2:59) and/or recorded (table 3: quote 2:16), while conducting a consultation, watching (table 3: quotes 2:25 and 2:27) and listening (table 1: quote 3:5) to recordings of themselves, not knowing enough (table 2: quote 18:16; table 4: quote 19:5) and feeling as though patients regarded them as incompetent (table 3: quote 6:11; table 4: quote 19:5). some were also disrupted by technical and logistical barriers during implementation of the qi process and in 2 clcs by administrative prohibition of recording videos of consultations together. students responded to the disruptions by reviewing their consultations through self-evaluation, using the consultation scoring tools (table 1: quote 8:2), discussing with peers who observed them (table 1: quote 3:14), listening to audio recordings (table 1: quote 3:5) or watching video recordings (table 3: quote 2:27). patient information needs triggered students to read up on pharmacology and investigative studies so that they could manage and explain the information to patients (table 2: quotes 18:8 and 18:16; table 4: quote 19:5). students became self-aware as they observed themselves in video and audio recordings (table 1: quote 2:23; table 3: quotes 2:26 and 2:27), with some responding that starting video recording themselves earlier in the course would have made them more comfortable (table 1: quote 2:17). they reflected on their mannerisms and how they appear to patients (table 3: quote 2:25). they also reflected on the way they interact in the consultation, becoming aware of not allowing patients to elaborate and of being unable to formulate open-ended questions (table 3: quote 2:62). by watching their recordings, some gained an understanding of what it means to reflect (table 3: quote 2:26), while others recognised that they were biased in their selfevaluations (table 3: quote 1:33). through joint reflection on their consultation skills, students developed action plans to find solutions to the disruptions they experienced, such as reading about the subject, discussing issues with one another and others and practising (table 3: quote 15:2; table 2: quote 19:7; table 1: quotes 20:8 and 21:9). for some, their insight into the value of learning with peers extended to planning co-operative learning to grow their all-round competencies beyond the qi process (table 2: quote 19:7). there were two different approaches to the disruption caused by administrative prohibition of video recording their consultations. some students observed one another’s consultations, used the reading material and gave one another feedback during consultations to improve their skills (table 1: quote 6:22). other students stopped the qi process to avoid confrontation with hospital management (table 3: quote 7:6). specific feedback given by peers helped them learn physical examination and other consultation skills, such as not repeating questions and time management (table 1: quotes 3:14, 5:34 and 20:4). they saw the value of diversity of experience and knowledge that came by way of peer learning, even suggesting that partners be rotated to get other opinions (table 1: quote 21:9). the presence of peers was less intimidating and they could implement what they learnt. some felt facilitator feedback was too general or, at times, not given at all. furthermore, the fear of making mistakes hampered their performance in formal assessments observed by an examiner (table 4: quote 5:4). students did not find formal patient feedback helpful. they felt it did not contribute to their learning, because it was consistently positive and nonspecific. students reported that the readings and assessment tools to support their learning were helpful. they especially found that hugo and couper’s[15] juggling analogy helped them grasp key components of the consultation (table 1: quote 8:12) and that the consultation assessment tools helped them identify areas for improvement during self-evaluation (table 1: quote 8:2). some found the english used in the kalamazoo measuring tool difficult to follow and preferred the adapted consultation peer assessment tool. in terms of new and strengthened person-centred practice, students expressed strong person-centred beliefs regarding the medical consultation. for example, they felt it was important to facilitate patients to tell their stories (table 2: quote 2:54) and to focus more on the patient’s ideas and feelings (table 2: quote 2:49). they also believed that making a personal connection with the patient was therapeutic (table 4: quote 6:26). they reported learning valuable person-centred consultation skills, such as listening and building trust to discuss sensitive information (table 1: quote 3:7); being fully focused on the patient to better explore their illness experience (table 4: quote 6:5) and improve treatment adherence (table 4: quote 6:7); eliciting patient expectations (table 3: quote 6:8); adopting a holistic approach to find underlying causes of patients’ worries and complaints (table 1: quotes 6:9 and 3:6) and recognising the importance of negotiation to achieve compliance (table 1: quote 6:6). students considered consultation skills to be a foundation for clinical practice, suggesting that they be learnt prior to clinical skills in the earlier years of the programme. discussion students found the qi process a valuable opportunity to self-evaluate and identify practice areas needing improvement to gain the competencies expected of them as clinicians. our findings show that a self-directed qi process with evaluation tools, peer feedback and reflection on audio and video recordings led students to learning person-centred care. disruptions triggered cognitive and metacognitive processes, which through scaffolding, enabled students to engage in a self-directed cycle of reading, reviewing, reflecting and acting or planning action, impacting on all their dimensions as learners.[9] watching video recordings of themselves conducting a consultation disrupted students’ identity and sense of self. it triggered them to reflect on who they are, how they appear to others, and what they know or do not know. self-awareness created through auto-critique is a recognised essential component for self-directed learning.[17,18] as reported elsewhere, students found being recorded stressful,[17,19] which may explain why many did not video record themselves. as proposed by these students and in other studies,[19] this could be partly alleviated by introducing video recordings of consultations early in the course. this study confirms the importance of motivation and self-efficacy for all learning, especially learning that centres on self-directed activities.[8] the student groups who abandoned the qi process when they were unable or not permitted to video record their consultations failed to learn. through their own agency, the groups who continued the qi process, either without 68 april 2021, vol. 13, no. 1 ajhpe research table 1. quotes related to the physical and mental abilities of learners (consultation skills) quote reference student reference quote related to theme(s) 1:25 fg1, clc1, f, yr2 ‘i think we are better than during our first year … on how to interview a patient and then make that patient the centre of attention.’ learner before 1:28* fg1, clc1, m, yr2 ‘… maybe if it was last semester it was going to be a problem, but for now because we even had like an osce … we know that you must ... not act like a boss whereby you must tell the patient that this is what you must do … it is between [you and] the patient, you discuss and you reach like a certain agreement. so, it was not that bad because we were well trained in that aspect.’ learner before 2:17 fg2, clc2, f, yr3 ‘if we start(ed) this project in the beginning of the year by now … you would have seen stars.’ response 2:23 fg2, clc2, m, yr3 ‘but it is a good thing because after that you do reflect and you start thinking of okay, i should have done this better, i should have done that and you learn actually, you learn a lot.’ response 3:5 fg3, clc3, f, yr3 ‘… we also got to pick up which questions we leave out in consultations and where we sometimes tend to ask the same questions over and over again … recording helped us to pick up on that.’ disruption and response 3:7† fg3, clc3, m, yr3 ‘what i’ve learned is all about firstly, listening … you create a rapport with the patient … because sometimes if you don’t make them feel at ease they won’t give you everything. some of the things they’ll just keep them inside that they don’t want to tell you. but if you make them feel at ease they will tell you. at least they might manage to tell you some things. they might even tell you things: “this one, even my family don’t know”.’ learner after 3:14 fg3, clc3, m, yr3 ‘i took a long consultation whereby i’m repeatedly asking the same question … i go back … and then she [peer] told me … don’t spend more than fifteen minutes or ten minutes, but make sure that you get everything that you need. but it doesn’t mean that … you just hurry up and then you leave some important things out, but make sure that you gathered everything that you needed so that you can go on with your working diagnosis.’ response and facilitation 5:34 fg5, clc3, m, yr3 ‘i think the other thing is the feedback. you get a better feedback from your peers than [from] facilitators. some of them, they are in a rush. sometimes you don’t get feedback at all. they [facilitators] say work on your skills of examination. which one? skills of examination? how? in our peers we just get a clear feedback.’ facilitation 6:6*† fg6, clc6, f, yr3 ‘then on the management, you work together, you negotiate so that the patient can do compliance. using that facilitation and collaboration helped me a lot.’ learner after 6:9* fg6, clc6, f, yr3 ‘you find that the patient may come to you, having a complaint that he is drunk, but the main problem is depression … so, as we dig further, as we approach the patient as a whole, we find different diagnoses.’ learner after 6:22 fg6, clc6, f, yr3 ‘as you’re interviewing the patient, if maybe you forgot something to ask then he can help you then. so that’s how we give feedback.’ facilitation 6:36* fg6, clc6, f, yr3 ‘so, it’s better to understand that if you are not treating a human emotionally, even the adherence is affected. the patient can’t take the pills because the cause, the inner cause which is … maybe depression, is not sorted, your work would be in vain.’ learner after 8:2 fg8, clc1, f, yr3 ‘when we did these questionnaires, like when we evaluated ourselves, it alerted us on where do we lack on and then we have improved on that.’ response and facilitation 8:12 fg8, clc1, m, yr3 ‘… the thing that was most useful, it was reading the article, it tells about the important steps that you need to outline in case of the consultation.’ facilitation 20:4 qi report 6, clc3, 2 × m & f, yr2 ‘the examination still needs to be practiced, the exams of meningitis were not done well and musculoskeletal examination was superficial not according to sequence and active range of motion was not done, it was only passive.’ facilitation 20:8 qi report 6, clc3, 2 × m & f, yr2 ‘… take history on as many patients as possible to improve his consultation skills … try to examine lots of patients to be good.’ response 21:4 qi report 7, clc3, 2 × m & f, yr2 weak points sharing information with a patient displaying sensitivity to the patient recognising patients’ verbal clues supporting patient in coping with the current situation learner before 21:9 qi report 7, clc3, 2 × m & f, yr2 weak points do more consultations together and with a doctor where possible have a doctor to observe most of our consultations try and exchange partners just to get different opinions response and facilitation fg = focus group; clc = clinical learning centre; f = female; yr = year; m = male; osce = objective structured clinical examination; qi = quality improvement. *also relates to the ‘knowledge and beliefs’ dimension of the learner. †also relates to the ‘relationships’ dimension of the learner. april 2021, vol. 13, no. 1 ajhpe 69 research video recording or by overcoming technical and logistical obstacles, were able to develop their critical thinking skills and gain valuable personcentred competencies. as reported by aper et al.,[20] conducting consultations with real patients both inspired and challenged students. being regarded by them as incompetent, not only disrupted students’ relationships with patients but also their sense of self. this has been described elsewhere as part of the process of identity formation, where individuals form their identity by imagining how they appear to and are judged by others.[21] the qi process made students aware of how their own and patients’ lack of confidence in their knowledge and abilities prevented them from inspiring trust in patients. for some, the awareness triggered by this disruption motivated self-development, driving them to re-establish and build themselves as competent healthcare student apprentices. for others, it triggered a defensive reaction that obstructed learning, as it cut to the core of their sense of self, leading them to express reluctance to share decision-making power with patients. this response points to the critical need for facilitation of learning to be an on-going process so that students develop the necessary competencies and skills to help them to retain their sense of self-worth and give them the confidence to collaborate with patients without appearing incompetent. through the qi process, students built and developed relationships with one another as peers. in this study, the principles of good feedback to promote changed practice were followed, i.e. that it be given face to face, be part of a coaching process (qi), contain specifics with examples, be based on observation, comparison (between peers) and a clear standard, as well as supporting positive change.[22] the use of evaluation tools with clearly explained criteria to guide peer feedback ensured that what was said guided practice, even though it came from peers on the same level. students demonstrated the ability to discern useful and unhelpful feedback. as with medical students,[17,23] this study found that clinical associate students preferred peer feedback for its clarity and details and did not report any drawbacks.[24] as in other research, the cognitive and social congruence between peers put students at ease being observed while conducting medical consultations.[25] they felt that peers helped them focus, perform better and learn more than when they did consultations in the presence of a lecturer or examiner. although trained how to give feedback, the study found that student feedback was constrained by limitations in their knowledge of content and their relationships with one another. generally, they gave feedback that related to their understanding of the knowledge and abilities required for the tasks and processes of the consultation, but did not address the issues of identity and relationships that these brought to light. this points to the important role of mentor and lecturer facilitation of learning to ensure that students are guided towards the best available knowledge and provided with deeper levels of feedback. study limitations this study was conducted in a decentralised workplace-based training platform for clinical associate students and the findings may therefore not be generalisable to other teaching models. not all students submitted qi reports. students from one of the intervention clcs did not participate in the fgds. they, however, submitted a joint report congruent with the rest of the data, suggesting that the results are an accurate reflection of their experiences with the qi process. despite repeated engagement with local supervisory structures, their support for the study was insufficient and contributed to variable implementation across clcs. fgds 9 and 10 were of very short duration, largely because these involved only 2 or 3 students who did not implement the intervention. even though table 2. quotes related to learners’ knowledge and beliefs quote reference student reference quote related to theme(s) 2:49 fg2, clc2, m, yr3 ‘most time when you see a patient you just want to go straight to diagnosing what’s wrong. you don’t hear what he feels, what he thinks, his ideas. you just wanna [go]: “oh, he is coughing: tb, pneumonia.” you know, and go straight to treatment without focusing on the patient’s ideas: what he thinks, what he feels. which is also just as important as the clinical part.’ disruption and response 2:54 fg2, clc2, m, yr3 ‘i was asking focused questions. if you have a headache, i’d be saying like: “where is it? can you please point? okay. no, i think it’s this and this.” without allowing the patient to say… to tell me more about the headache.’ disruption 18:8 qi report 4, clc1, 2 × m, yr2 ‘it also helped us because we got to know more of pharmacology as we were explaining to patient(s).’ response 18:16 qi report 4, clc1, 2 × m, yr2 weak points ‘knowing the alternatives of medication, in case other medications are out of stock and the correct doses as well. educating the patient on how to take medication and also the common adverse effects associated with the medication prescribed. explaining to the patient why the medication is given and how it works. emphasising on patient adherence and compliance.’ learner before and disruption 19:7 qi report 5, clc3, 2 × m & f, yr2 ‘… planned meeting up every friday as a group and come up with common conditions that most patients present with to the hospital and discuss the right procedures, examinations and tests to do in each and every condition.’ response fg = focus group; clc = clinical learning centre; m = male; yr = year; qi = quality improvement; f = female. 70 april 2021, vol. 13, no. 1 ajhpe research table 3. quotes related to the sense of self and identity of the learner quote reference student reference quote related to theme(s) 1:33 fg1, clc1, f, yr2 ‘usually you are biased to yourself so you can’t say this was bad.’ response 2:16 fg2, clc2, f, yr3 ‘but as soon as i, like, put the recorder there. i’m like, oh my gosh, i don’t know anything. so that was my problem.’ disruption 2:25 fg2, clc2, m, yr3 ‘when you see yourself on a video, then you actually get a real idea of how you … present yourself to the patient … if you have any funny mannerisms like “uh-huh … uh-huh”.’ disruption 2:26 fg2, clc2, f, yr3 ‘… and that’s when we all understood the part of reflection, and i must say i never understood what reflection was until ... i watched myself and then i’m like, okay, now i need to reflect.’ disruption and response 2:27* fg2, clc2, f, yr3 ‘... if you’re watching the video you can see how you behave when talking to the patient and the kind of questions that you are supposed to ask … so it’s a good reflection.’ response 2:56 fg2, clc2, f, yr3 interviewer: ‘what makes you learn the things you are now saying you are going to do different?’ student: ‘watching ourselves ...’ disruption 2:57† fg2, clc2, f, yr3 ‘... and plus our colleague is in the room. besides us watching ourselves … someone else is watching,’ disruption 2:62* fg2, clc2, f, yr3 ‘one thing i learned about myself as an individual was that i tend to ask a lot of closed questions. i don’t give the patient an opportunity to elaborate on their presenting complaint … it’s kind of hard for me to find open ended questions.’ learner before, disruption and response 5:15 fg5, clc3, f, yr2 ‘i was generally taught to go through full history … so focused history, i don’t know what you are referring to ... how am i supposed to know that?’ learner before 6:11† fg6, clc6, f, yr3 ‘when you ask the patient to involve himself or herself, he feels like you don’t know what you are doing. “why are you asking me this? you don’t know what you are supposed to do”.’ disruption 6:8†* fg6, clc6, f, yr3 ‘in this thing, i’ve learnt that you should ask about the patient expectations. if you don’t meet the patient’s expectations, then you become a bad clinician.’ learner after 7:6 fg7, clc7, f, yr3 ‘someone suggested that i speak to him but i didn’t.’ response 15:2* qi report 1, clc8, 4 × m, yr2 ‘this study research was very helpful. … it gave us the opportunity to prove or rate ourselves on how far we have developed when it comes to clinical practice, and where we need to put more effort and practice more correctly in order to improve, so that we can become quality and professional clinical associates.’ disruption, response and learner after fg = focus group; clc = clinical learning centre; f = female; yr = year; m = male; qi = quality improvement. *also relates to ‘physical and mental abilities’ dimension of the learner. †also relates to the ‘relationships’ dimension of the learner. table 4. quotes related to learners’ sense of relationships quote reference student reference quote related to theme (s) 2:59 fg2, clc2, f, yr3 ‘it’s like even though we were comfortable with each other as soon as they are in a formal setting, friendship goes away and it’s like teacher-student relationship all of the sudden.’ disruption 5:4 fg5, clc3, f, yr2 ‘and you become nervous when you are doing it with your facilitator “cause you’re scared: what if i do something wrong? but if it’s your peer you are chilled, you just do everything the way you learned …”.’ disruption 6:5*† fg6, clc6, f, yr3 ‘ok, on my side, i learnt a lot. on the consultation: it’s not about you as a clinician. it’s about the patient. facilitating the patient, so that the patient can explore all the symptoms.’ learner after 6:7† fg6, clc6, f, yr3 ‘then for a patient, it is easy to comply, as the patient sees that you are interested in him or her and you understand better.’ learner after 6:26 fg6, clc6, f, yr3 ‘and what we’ve learnt from this thing is that some of the patients they don’t need medicine, they need your touch, your smile, your time.’ learner after 19:5 qi report 5, clc3, 2 × m & f, yr2 ‘when it comes to selecting the right tests to perform … and start going back to our books to check what must we do next and we feel like that makes the patient to start doubting us.’ disruption fg = focus group; clc = clinical learning centre; f = female; yr = year; qi = quality improvement; m = male. *also relates to ‘physical and mental abilities’ dimension of the learner. †also relates to ‘knowledge and beliefs’ dimension of the learner. april 2021, vol. 13, no. 1 ajhpe 71 research fgds 7 and 8 had 4 participants each, they were also of short duration. participants in fgd 7 did not implement the intervention, while data generated in fgd 8 were congruent with the rest of the data. these limitations were mitigated by the number of fgds and extent of data generated by the fgds. the researcher’s position as bcmp programme co-ordinator may have prevented students discussing negative attitudes toward the course or patients. even though students did not report personal negative attitudes toward patients, they did critique the consultation skills of other clinicians, as well as the timing of the qi intervention. however, the researcher’s experience as a clinician allowed students to freely share their clinical experiences, which he could understand and empathise with.[26] conclusion students demonstrated the learning achieved in the qi process through their understanding of the skills and competencies required for personcentred practice. using a capability approach to understand the triggers and processes of learning person-centred care, the study revealed that students are at different points along the directed/self-directed learning continuum. while some had yet to internalise their responsibility for learning, most were developing their abilities to learn independently, to work in groups, to give and receive feedback and to apply what they have learnt across different contexts. given the uneven development of the ‘dimensions of a person’ at an individual level, facilitation of learning is particularly important to help students translate disruptions into learning. similarly, the cycle of reviewing, reading, reflecting and acting benefits all students when it is scaffolded through reading and evaluation instruments, as well as by creating deliberate opportunities for feedback. in addition to being a way of ‘doing’ learning, the article also demonstrates the usefulness of the capability approach as a framework to analyse if and how learning happens. based on the quality of learning, it is recommended that a qi process on the medical consultation with video recording be included in the undergraduate curriculum of clinicians. areas for future research include the effects of different tools to guide self-evaluation and peer feedback, the role and place of video recording in the learning cycle, the best methods and processes to support the learning of person-centred practice, and an exploration of the development of students’ ‘review’ competencies over time. declaration. the research for this study was done in partial fulfilment of the requirements for jml’s phd (family medicine) degree at the university of pretoria. acknowledgements. appreciation is expressed to the study participants, to ms d mhlari, ms g moodley, mr k m komana, miss z sithole and ms l i mudau for transcribing the focus group recordings, and to mrs n smit for editing the manuscript. we thank gerhard cruywagen of greenhouse cartoons for designing fig. 1. author contributions. jml: study conceptualisation, design, data collection and analysis; jml, tsm: interpretation framework; jml, tsm and jfmh: discussion and critical review. funding. none. conflicts of interest. none. 1. louw jm, marcus ts, hugo jfm. patientor person-centred practice in medicine? a review of concepts. afr j prim health care fam med 2017;9(1):a1455. https://doi.org/10.4102/phcfm.v9i1.1455 2. entwistle va, watt is. treating patients as persons: a capabilities approach to support delivery of personcentered care. am j bioeth 2013;13(8):29-39. https://doi.org/10.1080/15265161.2013.802060 3. olsson le, jacobsson ue, swedberg k, ekman i. efficacy of person-centred care as an intervention in controlled trials ‒ a systematic review. j clin nurs 2013;22(3-4):456-465. https://doi.org/10.1111/jocn.12039 4. hojat m, vegare mj, maxwell k, et al. the devil is in the third year: a longitudinal study of erosion of empathy in medical school. acad med 2009;84(9):1182-1191. https://doi.org/10.1097/acm.0b013e3181b17e55 5. bombeke k, van roosbroeck s, de winter b, et al. medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships. patient educ couns 2011;84(3):310-318. https://doi.org/10.1016/j.pec.2011.03.007 6. archer e, van heerden bb. undergraduate medical students’ attitudes towards patient-centredness: a longitudinal study. mededpublish 2017;6(3):47. https://doi.org/10.15694/mep.2017.000161 7. marcus ts. copc: a practical guide. 1st ed. pretoria: minuteman press, 2018. 8. sandars j, cleary tj. self-regulation theory: applications to medical education: amee guide no. 58. med teach 2011;33(11):875-886. https://doi.org/10.3109/0142159x.2011.595434 9. hugo j, marcus t. community-orientated primary care: where there is a doctor. in: mash b, ed. handbook of family medicine. 4th ed. cape town: oxford university press southern africa, 2017:334-359. 10. marcus ts, cruywagen g, hugo jfm. 2017. a capability approach to learning. 2017. https://www.youtube.com/ watch?v=uwpr5oauovq&feature=youtu.be 11. bac m, hamm j, van bodegraven p, pater b, louw jm. a new health care profession in rural district hospitals: a case study of the introduction of clinical associates in shongwe hospital. s afr fam pract 2017;1(1):1-4. https:// doi.org/10.4102/safp.v59i1.4654 12. moodley sv, wolvaardt je, louw m, hugo jfm. practice intentions of clinical associate students at the university of pretoria, south africa. rural remote health 2014;14:2381. 13. louw jm, hugo jfm. learning person-centred consultation skills in clinical medicine: a randomised controlled case study. s afr fam pract 2020;62(1):a5109. https://doi.org/10.4102/safp.v62i1.5109 14. fehrsen gs, henbest rj. in search of excellence. expanding the patient-centred clinical method: a three-stage assessment. fam pract 1993;10(1):49-54. https://doi.org/10.1093/fampra/10.1.49 15. hugo j, couper i. the consultation: a juggler’s art. educ primary care 2005;16(5):597-604. 16. hattie j, timperley h. the power of feedback. rev educ res 2007;77(1):81-112. 17. paul s, dawson kp, lanphear jh, cheema my. video recording feedback: a feasible and effective approach to teaching history-taking and physical examination skills in undergraduate paediatric medicine. med educ 1998;32(3):332-336. https://doi.org/10.1046/j.1365-2923.1998.00197.x 18. benbassat j, baumal r. enhancing self-awareness in medical students: an overview of teaching approaches. acad med 2005;80(2):156-161. https://doi.org/10.1097/00001888-200502000-00010 19. ozcakar n, mevsim v, guldal d, et al. is the use of videotape recording superior to verbal feedback alone in the teaching of clinical skills? bmc public health 2009;9(474):5-9. https://doi.org/10.1186/1471-2458-9-474 20. aper l, veldhuijzen w, dornan t, et al. ‘should i prioritise medical problem solving or attentive listening?’: the dilemmas and challenges that medical students experience when learning to conduct consultations. patient educ couns 2015;98(1):77-84. https://doi.org/10.1016/j.pec.2014.09.016 21. cooley ch. human nature and the social order. new york: charles scribner’s sons, 1902. 22. archer j. multisource feedback. excel med educ 2012;1(2):28-30. 23. al-kadri hm, al-kadi mt, van der vleuten cpm. workplace-based assessment and students’ approaches to learning: a qualitative inquiry. med teach 2013;35(suppl 1):s31-s38. https://doi.org/10.3109/014215 9x.2013.765547 24. cushing a, abbott s, lothian d, hall a, westwood om. peer feedback as an aid to learning. what do we want? med teach 2011;33(2):e105-e112. 25. ten cate o, durning s. dimensions and psychology of peer teaching in medical education. med teach 2007;29(6):546-552. https://doi.org/10.3109/0142159x.2011.542522 26. berger r. now i see it, now i don’t: researcher’s position and reflexivity in qualitative research. qual res 2015;15(2):219-234. https://doi.org/10.1177%2f1468794112468475 accepted 18 november 2019. https://doi.org/10.4102/phcfm.v9i1.1455 https://doi.org/10.1080/15265161.2013.802060 https://doi.org/10.1111/jocn.12039 https://doi.org/10.1097/acm.0b013e3181b17e55 https://doi.org/10.1016/j.pec.2011.03.007 https://doi.org/10.15694/mep.2017.000161 https://doi.org/10.3109/0142159x.2011.595434 https://www.youtube.com/watch?v=uwpr5oauovq&feature=youtu.be https://www.youtube.com/watch?v=uwpr5oauovq&feature=youtu.be https://doi.org/10.4102/safp.v59i1.4654 https://doi.org/10.4102/safp.v59i1.4654 https://doi.org/10.4102/safp.v62i1.5109 https://doi.org/10.1093/fampra/10.1.49 https://doi.org/10.1046/j.1365-2923.1998.00197.x https://doi.org/10.1097/00001888-200502000-00010 https://doi.org/10.1186/1471-2458-9-474 https://doi.org/10.1016/j.pec.2014.09.016 https://doi.org/10.3109/0142159x.2013.765547 https://doi.org/10.3109/0142159x.2013.765547 https://doi.org/10.3109/0142159x.2011.542522 https://doi.org/10.1177%2f1468794112468475 march 2020, vol. 12, no. 1 ajhpe 27 research community-based education (cbe) is an empirical learning experience that shifts clinical education from traditional to community settings to provide students with meaningful opportunities for self-development, improving their clinical skills, problem solving and lifelong learning.[1-3] health sciences students are exposed to real-life situations that can contribute to a deeper understanding of social determinants of health and various cultures, improved communication skills and a more positive, compassionate attitude towards patients.[4,5] the university of kwazulu-natal (ukzn), durban, south africa, in its effort to be more community engaged, strives to transform health professionals’ education from a traditional structure to one that is more competency based, which adds value to the communities it serves. the school of health sciences drives this agenda by embracing cbe with similar aims and objectives into current curricula across all disciplines, including audiology, biokinetics, exercise and leisure sciences, dentistry, occupational therapy, optometry, pharmaceutical sciences, physiotherapy and speech language pathology. clinical training in these disciplines usually occurs at campus clinics and designated off-campus academic training sites.[6] however, with cbe being introduced in 2016, part of this clinical training has now shifted to various sites, such as primary and community healthcare centres and decentralised sites, including regional and district hospitals. at the decentralised sites, students have an extended clinical exposure for 2 6 weeks, depending on discipline-specific requirements for clinical training. the university provides support for this type of training by ensuring transport to the sites and accommodation for students. academics prepare students for the decentralised sites by ensuring that they have attained an adequate level of competency in terms of clinical exposure and theoretical knowledge before they depart. clinical staff at decentralised sites are responsible for monitoring and supervising students on a daily basis as an informal part of their work. the main outcomes of cbe are to provide students with clinical skills in primary healthcare and to equip them with graduate competencies (table 1) to be empathic healthcare practitioners, communicators, collaborators, leaders, managers, health advocates, scholars and professionals – able to function effectively in a variety of health and social contexts, as noted in the institution’s business plan.[6] a key component of cbe is reflection on learning, which facilitates the connection between practice and theory, thought and action, and fosters critical thinking.[1,5] from the literature, three main theories explain how learning occurs in a community environment: social constructivism, kolb’s experiential learning theory[7] and the situated theory culture,[8,9] in which students learn through observation, experience and reflection and construct their own understanding. while students are at a distant learning site, academics need to determine if learning does in fact occur, and if cbe has achieved its intended outcomes. therefore, assessment of cbe is important, as it drives learning[10] and inspires students to set higher standards for themselves.[11] the main reasons for assessments in health sciences education are to optimise student capabilities and protect the public against incompetent clinicians.[11] assessments should therefore test knowledge, technical skills, clinical reasoning, professionalism, communication skills and reflection.[11] in an academic setting, assessments are formal and well structured, taking the form of tests and assignments. to background. community-based education (cbe) is an empirical education experience that shifts clinical education from traditional to community settings to provide health sciences students with meaningful learning opportunities. however, assessing the effectiveness of these learning opportunities is a challenge. objectives. to describe the methods used for assessment of cbe by the various disciplines in the school of health sciences, university of kwazulu-natal (ukzn), durban, south africa, and to determine how they were aligned to the anticipated learning outcomes. methods. this qualitative study consisted of a purposively selected sample of 9 academics who participated in audio-taped interviews and focus group discussions, with the data being thematically analysed. ethical approval was obtained from ukzn. results. the disciplines in the school of health sciences used various assessment methods, ranging from simple tests, assignments and case presentations to more complex clinical assessments, blogging and portfolio assessments. multiple methods were required to meet the anticipated learning outcomes of cbe, as a single assessment would not achieve this. conclusion. the study findings indicated that assessment plays an important role in consolidating student learning at cbe sites, with multiple assessment methods being required to achieve graduate competencies in preparation for the workplace. choice of assessment methods must be contextual and fit for purpose to allow for overall student development. afr j health professions educ 2020;12(1):27-35. https://doi.org/10.7196/ajhpe.2020.v12i1.1135 assessment consolidates undergraduate students’ learning of community-based education i moodley, phd; s singh, phd discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: i moodley (moodleyil@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 28 march 2020, vol. 12, no. 1 ajhpe research test knowledge, academics in various disciplines use bloom’s model for written assessments, starting with testing lower-order thinking levels of remembering, understanding and applying, and continuing to higher-order thinking levels of analysing, evaluating and creating (fig. 1).[12] similarly, academics use miller’s model to assess clinical competence, starting with cognition-testing knowledge (knows), competence (knows how), performance (shows how) and action (does) (fig. 2)[13] – conducted within a closed academic clinical training environment. however, development of competence in different contexts may occur at different rates, depending on a student’s ability to adapt to various clinical settings.[11] the question then arises: can the methods used in formal academic settings be applied to test learning that occurs in community-based settings? the literature indicates that there is a trend towards continuous assessment in the form of small formative evaluations throughout the year rather than a single summative one at the end of the year.[14] however, designing assessments in cbe settings may prove challenging for several reasons: the learning environments are not standardised, making it difficult to control,[15] and students are assessed by a number of tutors with varied levels of educational skills.[16] moreover, it can be challenging to assess learning experiences that do not require memorising facts.[17] personal growth and change in attitude towards others with greater needs are also hard to measure. in addition, the principles of assessment must be followed when deciding on which methods to use, i.e. assessments should be valid (measuring what is intended to be measured), reliable (consistency in marks obtained by several examiners), transparent (able to match the learning outcomes) and authentic (student’s original work – no signs of plagiarism). appropriate assessments are therefore required to measure both clinical skills and personal attributes that are truly reflective of the social context of the learning experience. in the literature, clinical supervisors’ observations and impressions of students are the most common assessment method used in community-based settings.[11] however, the perception of most academics is that this method is often criticised as being subjective, especially if there are no clearly articulated standards.[11] multisource assessment, in which a student is assessed by different members in a clinical setting, such as peers, creating evaluating analysing applying understanding remembering fig. 1. revised bloom’s taxonomy (http://www.learnnc.org). does (action) shows how (performance) knows how (competence) knows (knowledge) fig. 2. miller’s pyramid framework for clinical assessment. (adapted from miller.[13]) table 1. graduate competencies for student health professionals at the university of kwazulu-natal, durban, south africa role criteria healthcare practitioner provide optimal, compassionate and culturally sensitive patient care using primary healthcare principles; adapt to working in a community setting; use critical thinking in managing complex care situations communicator communicate with patients from different cultural backgrounds; develop trusting and ethical relationships with patients collaborator participate effectively in an interdisciplinary team; recognise and respect the roles, responsibilities and competencies of other team members leader and manager identify the socioeconomic, demographic, cultural and environmental factors that affect the health of the community; possess skills to understand how the health system operates at different levels health advocate identify the health needs of individual patients, taking their culture into consideration; advocate for patients with particular health needs (including the poor and marginalised members of society) scholar reflect on one’s strengths and limitations of knowledge and skills; enhance professional skills and lifelong learning professional display professional behaviour, commitment, respect, empathy, altruism, beneficence and no maleficence when treating patients source: business plan of the university of kwazulu-natal, 2014.[6] http://www.learnnc.org march 2020, vol. 12, no. 1 ajhpe 29 research nurses and patients, to provide feedback of a student’s work habits, ability to function in a team and patient sensitivity, is another assessment method.[11] self-assessment in the form of portfolios, in which reflections of technical skills and personal development are documented, is also used.[11] disciplines in the school of health sciences conduct cbe individually and collaboratively, with different levels of implementation and assessment. the researcher (im), a lecturer in the discipline of dentistry with >10 years of experience in training dental therapists and oral hygienists and a phd promotor, aims to determine the methods used by other disciplines with the vision of capacity building and learning from fellow colleagues. therefore, the objectives of this study were to describe the assessment methods used in cbe in the school of health sciences at ukzn and to determine how these assessments were aligned to the learning outcomes. methods research design this was a qualitative, descriptive and explorative study. the theoretical orientation is underpinned by the constructivism paradigm. this orientation facilitated the exploration of cbe using various data sources and methods to ensure that the phenomenon was not viewed through a single lens but through multiple lenses to obtain a deeper understanding of it. in constructivism, knowledge is obtained through social construction, mainly through subjective understandings of people’s experiences and their interactions with each other. this study used different qualitative methods, such as interviews and focus group discussions, to obtain information on assessment methods used for cbe, and explored the extent to which each method achieved its learning outcomes. participants a purposive sampling method was used to select the study sample. the academic leader of teaching and learning in the school of health sciences was selected for an interview for expert opinion on the roll-out of cbe in the school. the researcher sent emails to the academic leaders of each of the health sciences disciplines to nominate one academic currently involved with cbe to participate in a focus group discussion. the researcher, who has a professional working relationship with each participant, sent email invitations to the identified academics who agreed to participate in the study. a total of 9 participants (a1 a9), the academic leader and one academic from each discipline agreed to participate and provided written informed consent. the participants comprised 8 women and 1 man, ranking from lecturer to professor and having 5 25 years of experience. an information sheet was given to each participant before data collection, outlining the reason for the study. data collection data were collected using two methods. firstly, a semi-structured, faceto-face interview using mainly open-ended questions was conducted with the school’s academic leader of teaching and learning to gain a better understanding of cbe at managerial level. sample questions included: what is the role of assessment in community-based teaching? who should be involved in the assessment? the interview took place in the office of the academic leader and lasted ~30 minutes. secondly, the researcher facilitated focus group discussions in the relaxed environment of the boardroom in the discipline of dentistry in the presence of a research consultant, who made field notes during the discussions. as all academics were not available simultaneously owing to work commitments, two focus group discussions were conducted separately on different days, each with 4 participants. the researcher, with the assistance of the consultant, developed a set of open-ended questions to guide the focus group discussions, focusing on their current cbe projects, their experiences and the role of assessment. sample questions included: what are your views on assessing community-based training? can you suggest appropriate methods you use in assessing community-based training? the focus group discussions lasted ~65 minutes and the same set of questions was used in both discussions. the interview and focus group discussions were conducted in english and audio recorded, which a research assistant transcribed verbatim, after which the data were cleaned before analysis. the researcher engaged the services of the research consultant to assist with the thematic data-analysis process following the 6-phase process to thematic analysis by braun and clarke[18] to undertake the qualitative data analysis. the researcher and consultant independently read through the transcripts several times to identify familiar patterns. initial coding was undertaken by identifying a segment that could be organised into meaningful categories relating to the objectives. open coding was done manually by writing notes on the transcripts. several codes were linked together in axial coding and the core categories were collated through selective coding. the different codes were then sorted and collated into large overarching themes and subthemes. the researcher and consultant compared the themes that were worked on independently and collated them. the collated extracts were reviewed to check whether they formed a coherent pattern and then refined, discarding certain extracts not falling into themes, until data saturation was reached.[18] furthermore, the researcher conducted a review of the assessment methods, using an inductive analysis process and tabling the results. credibility, a form of internal validity in qualitative research, was established by using varied research methods, i.e. interviews and focus group discussions, to obtain the data. credibility was further established through peer debriefing, which was undertaken by another member of the research team who reviewed the data collection methods and processes, transcripts and data-analysis procedures, and provided guidance to enhance the quality of the research findings.[19] transferability, which relates to external validity, was facilitated by the use of a purposively selected sample, thereby providing a thick description of the context of the enquiry.[20] this aspect was further enhanced by comparing research findings with those in the current literature. dependability, which determines consistency in research findings of the same participants and context, was achieved through the use of member checks. the analysed data were sent to 2 participants from each focus group to evaluate the interpretations made by the researcher and to provide feedback.[20] dependability was further enhanced by the researcher, as well as the research consultant as a co-coder analysing the same data and comparing the results. confirmability was established through quotations of actual dialogue of the respondents. participant confidentiality and anonymity were maintained. ethical approval this study was part of a larger study on cbe conducted in the school of health sciences, ukzn. the larger study explored the intended role of cbe being rolled out in the school, described the perceptions of academics from 30 march 2020, vol. 12, no. 1 ajhpe research the different disciplines on this teaching strategy, explored interprofessional learning opportunities for dental therapy students in public, private and non-governmental organisations and obtained the perceptions of finalyear dental therapy students participating in cbe projects. this study is part of academics’ perceptions of cbe. ethical approval was obtained from the humanities and social sciences research committee, ukzn (ref. no. hss/1060/015d). results based on the responses of the interviews and focus group discussions, two main themes emerged regarding assessment in cbe: the assessment process and the methods of assessment used. furthermore, a review of assessment methods is given and discussed. theme 1: the assessment process under this theme, three subthemes arose: the relevance of assessments in cbe, who should perform the assessment and how assessments should be done. the relevance of assessments in cbe all respondents in this study agreed that assessment was an integral part of cbe to ensure that students remain engaged, as supported by the following quotes: ‘yes, definitely … assessment and education for me goes hand in hand. i cannot split the two.’ (a1) ‘the good thing about assessment is that it gives them an opportunity to reflect on their practice, … , so you can see the learning, the growth and to ensure that this is something they do as a lifelong practice, not just in this module.’ (a2) ‘the assessment actually forces them to understand the different professions that they are working with …when they are out there, you do not know what they are imbibing.’ (a3) ‘assessment plays a very big role and is taken very seriously.’ (a5) ‘there is no student who will take the training seriously if they know that there is no sort of assessment.’ (a7) who should perform the assessment? generally, academics in higher-education institutions are responsible for teaching the course content and ensuring that skills are transferred through assessment. in this study, the academics in the focus groups raised concerns about who should conduct assessments, as the competence of clinical supervisors varied among the programmes, as did the participation of academics at such learning sites: ‘now with the shift towards decentralised training because it is going to be community based, my problem is our students are going to go to these complexes that are further away from us. who is responsible for the assessment? what framework or tools are available? the way we assess right now is a very objective assessment, but are the people who are supervising our students equipped to use that assessment tool?’ (a8) while some respondents believed that both academic staff and clinical supervisors should be equally involved with assessment, given their differing roles in imparting knowledge and skills, others believed that clinical staff could be empowered, through training, to assess students, as illustrated by the following quotes: ‘it will have to be both because you need the academic side of it, as you know about the assessment, you understand it better, how assessment works. the clinical supervisor has not been trained formally in assessment, but from their experience, they can be roped in. they cannot assess a student only, but you need them as well, because they have worked with the student. so … we need to get those people comfortable with assessing this student.’ (a1) ‘can be done if staff at these sites are trained and willing to do it. however, they should be monitored by university staff.’ (a4) ‘yes, the supervisors are there. they [students] get a clinical evaluation mark and that will be what the supervisor gives them over the 6 weeks. there can be certain criteria they follow to allocate marks.’ (a2) however, some participants in the focus group argued that clinical supervisors are reluctant to become actively involved with student supervision and assessment, as highlighted by the following remarks: ‘the other challenge is that there are perceptions from the department of health that this is an outside programme or an outside responsibility that is being imposed on them.’ (a7) ‘… many of the health professionals in the hospital facility are young, as this is a fairly new profession in the public sector. they are still finding their feet. they are in no position to clinically supervise.’ (a6) some participants of the focus group offered solutions to overcome the challenges of supervision and assessments, as suggested by the following quotations: ‘the one solution that we had was train the trainer. we bring all the clinical staff into university, we get a workshop going and then we do programmes with them and then we do sessions at the end where we get them to watch. we were thinking of getting videos and getting them to watch and assess, so there is inter-reliability.’ (a8) ‘i agree that was also a strategy that all those who would be involved in the training should be trained first by the college of health sciences.’ (a7) how assessments should be done senior management of teaching and learning believed that assessment should be formative (ongoing) rather than summative: ‘… there are very interesting ways of looking at assessment … it must be continuous assessment. you cannot have exams on something like this. it is continuous assessment where every step of the way a student is taught something; it is assessed if he knows it. if he does not know it, you go a step back and you teach him.’ (a1) theme 2: methods of assessment from the focus group discussion, it was established that only 1 of the 8 disciplines had very limited participation in cbe, with no assessments being conducted. academics in the other 7 disciplines conducted their assessments using varied methods that included oral, written, clinical, online, peer and multiple modes, as described below. oral assessment the academics from 7 disciplines used some form of oral assessment, which included seminars, case and handover presentations and oral examinations. march 2020, vol. 12, no. 1 ajhpe 31 research • seminars, case and handover presentations the seminars were oral presentations on topics that were well researched and presented, using microsoft powerpoint, to an audience of peers and academics. case presentations on particular patients attended to were also a common method of oral assessment. academics in the school of health sciences used this type of assessment to assess knowledge and communication skills. these assessments are conducted summatively at the end of the block at the clinical site by academics from individual disciplines, while others are assessed as a group by academics from different disciplines, with written documentation to support the oral presentation, as illustrated by the quotes below: ‘the whole team is expected to see 1 patient – then all students across the professions present the case and each student is expected to present from their professional perspective, and they each get a mark for this.’ (a5) ‘handover presentation – where they talk about all the projects and all the clients they have seen, do a verbal presentation and also hand in a written document which is e-filed and stored as an information base for future rotations, and they get a mark for this.’ (a5) ‘case presentations on the patients they have managed to an audience of clinical, academic staff and fellow students at the end of a clinical block at the community site.’ (a8) the academics reflected that the main advantages of case presentations were teamwork and the promotion of interprofessional collaboration: ‘we really grow them in those case presentations because they do it, they plan it collaboratively and they present it collaboratively and they do not necessarily present on the audio part, they may present on the ot [occupational therapy] part. it actually forces them to really understand to give value … .’ (a2) however, they found that in group case presentations, weaker students might go undetected: ‘the disadvantage of what we do at the moment with case presentations, and handovers particularly, is that when they are doing group work, we have very little opportunity to hone in on the weak individual student until the exam, and a student can slide, based on competent group members who do not want their mark to be compromised. so, they will pick up the slacker, they will work harder to make sure this group gets a good mark.’ (a2) • oral examination some disciplines conducted an oral examination, as it enabled assessment of knowledge and communication skills with academics: ‘we also have an individual oral exam that covers a lot of the theory behind their thinking about why they are doing it, what primary healthcare principles are evident in the programme … .’ (a2) written assessments this study showed that disciplines also used written assessments to test knowledge and writing skills, such as assignments, essay writing and portfolios of evidence. • assignments and essay writing some academics reported using assignments as an assessment method, with varying levels of success. assignments test a student’s ability to present a clear, concise summary of evidence of experiential learning: ‘an assignment that is huge, some of them are 50 pages long, is submitted. essays too are used. a set topic is given to them, which asks them to unpack through theory what they are seeing and engaging with and to think things through using a very rich theoretical focus.’ (a5) • portfolio of evidence in this study, academics showed strong support for the use of portfolios as an effective means of assessing cbe, this being a compilation of work over time, and regarded by them as a good overview of a student’s abilities: ‘students need to produce a portfolio of evidence of their experience of what they learnt at these sites, their weaknesses and their strengths.’ (a4) ‘the best, the most efficient way of assessing is a portfolio.’ (a2) ‘a detailed written report of work done and their observations in a workplace.’ (a7) some participants in the focus group argued that a disadvantage of portfolios was the time taken to mark them: ‘the portfolio assessment in itself is a nightmare in terms of managing it with the limited resources we have and the time as staff.’ (a2) clinical assessment this involved assessment of a clinical procedure and logbook entry. • assessment of a clinical procedure three of the 7 disciplines used this assessment, which academics conducted at clinical sites. it entailed direct observation of a student’s interview with a new patient, history taking, diagnosing and treatment planning, which were then presented, as well as performing a clinical procedure on a patient observed by a lecturer, for which a mark was allocated: ‘they get a clinical evaluation mark and that will be what the supervisor awards them over the 6 weeks … there are certain criteria they allocate. this makes up 50% of their clinical assessment mark and is based on what the supervisors are saying on a daily basis when they are out there. the other 50% comes from group work, which is the case presentation.’ (a2) ‘clinical assessment by trained health professionals in hospitals.’ (a6) • logbook entry academics reported also using logbooks to assess cbe, and provide students with a list of clinical procedures or tasks that must be completed and verified by clinical staff by signature that these tasks were adequately performed. it also documents the range of patient care and learning experiences undertaken by students as a means of self-reflection. students also had an opportunity to comment on their own work, with the staff rating them according to level of competency: ‘daily assessments and entry into logbook at the site, which is marked by the clinical supervisors.’ (a4) online assessment the advancement of information and communication technology has expanded the learning environment to allow students to learn anytime and anywhere. academics in the health sciences made use of the university’s e-learning platform to assess their students. they indicated that it provided a communication platform for academics when students are at a decentralised learning site and promoted self-learning, as students reflected on their work progress. 32 march 2020, vol. 12, no. 1 ajhpe research ‘they have got the weekly blog and before they go in … they know in advance what they are going to be doing. they submit a plan at the beginning of the week, which is reviewed and assessed in terms of have they allocated their time to do whatever they are doing and then from the blog we get a better idea of how the week went.’ (a2) ‘… that blog gives them a chance to reflect on their practice, … so you can see the learning, the growth and development and even in the exam they are usually questioned about the blog and also to ensure that this is something they do as a lifelong practice, not just in this module.’ (a3) ‘blogging – they need to blog every week. it is about writing and reflecting and thinking things through using kolb’s learning cycle during the blogs.’ (a5) peer assessment the academics indicated that peer assessment was a useful tool to assess cbe, as it enabled students to evaluate their colleagues, alongside academics, thereby ensuring fairness and consistency of assessment. it also encourages reflection by students as they become more aware of how their work is evaluated: ‘we also have peer assessment on the last day, which is very strong, because when the students get their feedback they pull up their socks. they will say this person does not come for equipment, they just pitch up late on the bus … so they get quite brutal … . they just say it as it is, so it does actually make students reflect also on their performance.’ (a2) the disadvantage raised in this study was that students tend to be biased towards friends: ‘sometimes the students are biased towards their friends with the peer assessments, because the students will inflate the marks.’ (a4) review of assessment methods a review of the assessment methods indicated by the academics in theme 2 was conducted using inductive analysis. each assessment strategy was examined for its strengths and limitations, and how it related to learning outcome and development of graduate competencies. it also showed how each method ranked against the revised bloom’s[12] taxonomy and miller’s[13] framework of clinical competence (table 2). discussion in this study, academics from the school of health sciences considered assessment an important aspect of cbe, inculcating a habit for selfreflection that can contribute to lifelong learning. it serves as a means of determining whether a student can progress to the next level and exit the programme with key professional competencies and relevant technical and non-technical skills in communication, collaboration, scholarship, leadership and advocacy, as outlined in the business plan of the school.[6] this is supported by epstein,[11] who asserts that assessment drives students, motivates and directs future learning to incrementally improve their capabilities from a student to graduate to health professional. in institutions of higher education, academics are responsible for assessments, with the literature indicating a change from single-test methods to multisource assessments.[14] in this study, academics were of the opinion that part of this responsibility should be shared with clinical supervisors at community-based sites. they were also willing to conduct training workshops to empower clinical supervisors. this is supported by doherty,[21] who views the clinical supervisor as a personal mentor and role model who contributes towards improving student clinical and communication skills. according to doherty,[21] clinical supervisors should be actively involved with assessment, but where they are unable to do so, they need to be mentored. ferris and o’flynn[14] assert that students should be given a chance to judge their own work and that of fellow students, as self-reflection and self-assessment ensure active engagement with theory and practice and a deeper learning experience that promotes lifelong learning. in support of this, the literature affirms that formative assessment is the most appropriate way to assess cbe, as it guides future learning, promotes self-reflection and instils values.[11,22] competence is developmental, as students start off as novice learners, only knowing theory, then progress to applying it in clinical situations. by engaging with patients on repetitive rotations, they reflect and learn through trial and error to effectively manage patients in a professional manner.[11] formative assessment therefore aids in the progress of a student from novice to competent professional, with feedback from assessors to guide the learning.[11] it was observed that academics used a variety of methods to assess cbe, ranging from simple tests, assignments and essays, which test lower-order thinking, to complex case presentations, clinical assessments, blogging and portfolio assessments, which test higher-order thinking. table 2 indicates that most of the methods used by academics tested higher-order thinking, according to bloom[12] and miller.[13] this is relevant, as those who participate in cbe programmes are exit-level students who need to meet graduate competencies in preparation for the work environment. most of the methods meet ≥2 of these competencies, but not all, while assessment in the roles of being a leader, manager and advocator is lacking. one of the common methods of assessment used by academics in this study was oral case presentations. green et al.[23] support this type of assessment, as it tests a student’s clinical reasoning, decision-making and organisational skills, and establishes their ability to determine what information is required for a good presentation. more importantly, it is the primary mode of communication between healthcare professionals and facilitates efficient patient care.[23] the added value of case presentations is that they are the most common mode of communication between professionals, and affords students the opportunity to learn and master these while in training.[23] furthermore, oral assessments test students’ knowledge and communication skills, as well as their ability to work with other health professional students, thus contributing towards graduate competencies in the roles of healthcare practitioner, communicator, collaborator, scholar and professional. in terms of bloom’s[12] taxonomy, it tests the understanding of knowledge, while in miller’s[13] model of clinical competence, it tests competence (knows how). in our study, oral examinations were also used to assess cbe. however, it has been criticised in the literature for being unreliable and biased, with inconsistencies in questioning and marking.[24] moreover, students are tested under pressure within a limited time, which could be particularly difficult for students for whom english is their second language. written assessments were also commonly used by academics in this study. this method is supported in the literature, as al-wardy[22] affirms that assignments and essays are good for processing and summarising information, as well as applying it to new situations. however, epstein[11] argues that written assessments have little value if they are not contextual, including clinical scenarios and questioning. written assessments rank march 2020, vol. 12, no. 1 ajhpe 33 research low on bloom’s[12] taxonomy, as they test remembering, which comprises understanding of knowledge, while miller’s[13] framework only tests cognition (knows) and competence (knows how). in terms of graduate competencies, written assessment can contribute to developing the student in the roles of healthcare practitioner and scholar. in this study, some academics believed that a portfolio of evidence was the best method to assess cbe. this is supported in the literature, as it is a collection of students’ work that shows their effort, progress and achievement over time through self-reflection.[24] friedman et al.[25] are of the opinion that portfolios are an authentic way to assess a student’s personal real-world experience of integrating learning of a wide range of personal, academic and professional development. it directs students to develop self-learning and autonomy, transferring responsibility for learning from the teacher to the student. turnbull[26] also finds it to be a reliable, valid and feasible form of assessment. however, al-wardy[22] argues that it is not very practical, because it is difficult for students to compile and time-consuming for academics to mark. many academics in this study used clinical assessment in cbe. in the literature, assessment of a clinical procedure is the most common tool and is ranked high, as it is a valid evaluation of clinical competence.[11] such assessments prepare students with the experience necessary to manage patients on a day-to-day basis.[11] they groom a student to meet graduate competencies of being a caring healthcare professional and cross-culture communicator, as they provide detailed information of student and patient interaction to make a diagnosis and design a treatment plan in the patient’s best interest. this type of assessment also ranks high with bloom’s[12] taxonomy (applying, analysing and creating) and miller’s[13] framework (action/does). however, al-wardy[22] argues that clinical assessment cannot be very reliable, because it lacks standardisation and there is a limited sampling of skills,[2] as students are normally assessed on a single patient and may not perform at their best on that given occasion. in our study, it was found that keeping a logbook of all the clinical procedures at a community-based site is an effective way of assessing cbe. according to blake,[27] keeping a logbook is very useful for focusing a student’s attention in obtaining important objectives within a specific time period. this is a practical way of assessing a student at a decentralised site and directly aligning their graduate competencies as healthcare practitioner, table 2. strengths and limitations of assessment methods outlined in this study assessment method learning outcomes graduate competencies strengths limitations bloom’s[12] taxonomy miller’s[13] taxonomy written assessments, e.g. tests, assignments, essays knowledge, ability to solve problems, primary healthcare principles healthcare practitioner, scholar can assess large content, high reliability may seem artificial – removed from real-life situations, essays are time consuming to mark remembering knows oral assessments, e.g. seminars, case presentations, oral examinations knowledge, clinical reasoning, clinical skills, communication skills, collaborative skills healthcare practitioner, communicator, collaborator, scholar, professional feedback provided by credible experts subjective, time consuming, requires ≥2 examiners to rule out bias, difficult to detect weak student in group presentations understanding knows how portfolio of evidence competence, analytical writing skills, organisational skills, clinical skills, professional development healthcare practitioner, scholar, professional fosters reflections, shows evidence of learning taking place time consuming to compile and mark, low to moderate reliability applying analysis shows how blogging knowledge creation and sharing, communication skills, lifelong learning skills healthcare practitioner, scholar, professional student centred, critical reflection, critical thinking not for summative assessment applying analysis shows how selfand peer assessments, reflective journals teamwork, professionalism, interpersonal relationships, behaviour skills, attitudes, beliefs healthcare practitioner, scholar, professional encourages reflection, promotes lifelong learning, insightful peer assessment can be biased towards friends, undermining, destructive applying analysis shows how performance assessments, e.g. clinical assessments, logbook entries knowledge, clinical reasoning and skills, communication skills, competence, professionalism, adaptability to a work environment, primary healthcare principles healthcare practitioner, communicator, scholar, professional very realistic and accurate way of assessing students’ abilities, valid and authentic, resembles real-life situations subjective, time consuming, inadequate reliability due to lack of standardisation creating does/action 34 march 2020, vol. 12, no. 1 ajhpe research communicator, scholar and professional. however, for logbooks to be effective, al-wardy[22] asserts the use of checklists or rating scales for assessing specific behaviours, actions and attitudes, which will also ensure standardisation of marks allocated by the clinical supervisor and academic. blogging is one of the newer methods used by academics in this study. it is well documented in the literature as providing a rich situated learning environment that encourages knowledge creation, sharing of thoughts and opinions, creativity, interpretation of materials and reflection, which are more often applied than the structured exercises in a classroom setting.[28,29] however, boulos et al.[30] note that blogging does not support learning when used in an unplanned manner. while there may be many advantages to blogging, access to computers and the internet may be a problem for students at ukzn, as there may be limited resources at decentralised community-based sites. blogging has the potential to mould a student into being a good healthcare practitioner, scholar and professional if it is used for knowledge generation and application. when used appropriately, it ranks high in bloom’s[12] taxonomy, as it tests application and analysis of knowledge, while in miller’s[13] framework it tests performance (shows how). another method used was peer assessment. in the literature, peer evaluation demonstrates many strengths and was noted as being effective for assessing skills acquisition and attitudinal learning, such as integrity and respect.[30] students perceived this form of assessment as a non-threatening exercise, being done by fellow colleagues, which offers them an opportunity to compare their own work with the standards achieved by others.[31] while this can contribute to developing reflective practices and deeper learning, some students were sceptical, and questioned the credentials of peers.[14] moreover, this type of assessment is based on trust, and in its absence, this exercise can be undermining and destructive.[14] peer assessment ranks high in bloom’s[12] taxonomy, as it tests the analysis of knowledge, while in miller’s[13] framework, it demonstrates action (does) and develops graduate competencies of the healthcare practitioner, scholar and professional. to avoid bias, race et al.[32] suggest the use of designated criteria, and that a mark be allocated to each item before the assessment process begins. in addition, they contend that the final grade of a student being assessed should be a combined percentage of scores of their peers and the academics. in the deductive analysis of assessments, it was observed that academics in the study considered using multiple methods in designing assessment methods, as a single method is inadequate to assess a range of competencies. furthermore, it was noted that assessment must be fit for purpose, i.e. to test knowledge and its application; use tests, assignments, essays (knows); case presentations to test competence (knows how); portfolios, blogging and peer assessment to test performance (shows how); and clinical assessments and logbooks to test action (does).[13] this is supported by al-wardy,[22] who confers that each assessment has its own strengths and flaws, and that by using a variety of methods, the advantages of one may overcome the disadvantages of the other. implication of findings the findings show that academics in this study consider assessment an important aspect of educational practice in health professionals’ education, particularly in cbe. the study provided useful data regarding assessment methods used in cbe by academics in the school of health sciences, ukzn, and how they can contribute to preparing graduates for the work environment. the findings may be applicable to academics in other universities, where students undertake community-based training. study limitations the study only explored the opinion of one academic in each discipline, and did not take into account their experience with assessing such situations. as cbe in this institution is fairly new for most academics, their opinions may change over time as they modify the content to address perceived limitations of choice and context of assessment methods they may use. recommendations for disciplines that rely on academics to conduct assessments at community sites, this skill needs to be transferred to clinical supervisors who have the competence to undertake the evaluations. this can be done by empowering clinical staff at community-based clinical training platforms by running training workshops or as a continuing professional development (cpd) activity. research needs to be conducted to establish the extent to which students have taken ownership of their learning, and whether the opportunities for self-reflection and peer assessment are useful or could be improved. academics should always take into consideration ethical and moral principles around patient confidentiality when clinical cases are presented in the presence of an audience of peers. more importantly, assessment must relate to the context of the disease prevalence and socioeconomic status of the community setting, so that it can reflect students’ personal, professional and social growth. more innovative assessments are required to establish graduate competencies in the roles of leader, manager and advocate. conclusion the study findings indicated that assessment plays an important role in consolidating student learning at cbe sites, with multiple assessment methods being required to achieve graduate competencies in preparation for the workplace. the choice of assessment methods must be contextual and fit for purpose to allow for overall student development. greater emphasis should be placed on enabling clinical supervisors to perform student assessment at these sites and engaging students with self-reflective assessment practices to promote lifelong learning. declaration. none. acknowledgements. none. author contributions. im was responsible for data collection, data analysis and conceptualisation. ss was responsible for refining the methodology and overseeing the write-up. funding. none. conflicts of interest. none. 1. deogade sc, naitam d. reflective learning in community-based dental education. educ health 2016;29(2):119-123. https://doi.org/10.4103/1357-6283.188752 2. mabuza lh, diab p, reid sj, et al. communities’ views, attitudes and recommendations on community-based education of undergraduate health sciences students in south africa: a qualitative study. afr j prim health care fam med 2013;5(1). https://doi.org/10.4102/phcfm.v5i1.456 3. bean cy. community-based dental education at the ohio state university: the ohio project. j dent educ 2011;75(10):s25-s35. 4. mofidi m, strauss r, pitner ll, et al. dental students’ reflections of their community-based experiences: the use of critical incidents. j dent educ 2003;67(5):515-523. https://doi.org/10:1.1.508.8022 5. holland b. components of successful service-learning programs. int j case method res appl 2006;18(2):120-129. 6. essack s. draft business plan: community based training in primary health care model in school of health science. durban: university of kwazulu-natal, 2014. https://doi.org/10.4103/1357-6283.188752 http://dx.doi.org/10.4102/phcfm.v5i1.456 https://doi.org/10 march 2020, vol. 12, no. 1 ajhpe 35 research 7. kolb ay, kolb da. experiential learning theory: a dynamic, holistic approach to management learning, education and development. london: sage, 1984:1-59. 8. lave j, wenger e. situated learning: legitimate peripheral participation. cambridge, uk: cambridge university press, 1990. 9. kelly l, walters l, rosenthal d. community-based medical education: is success a result of meaningful personal learning experiences? educ health 2014;27(1):47-50. https://doi.org/10.4103/1357-6283.134311 10. wormald bw, schoeman s, somasunderman a, et al. assessment drives learning: an unavoidable truth? anat sci educ 2009;2(5):199-204. 11. epstein rm. assessment in medical education. n engl j med 2007;356(4):387-396. https://doi.org/10.1056/ nejmra054784 12. bloom bs. taxonomy of educational objectives. handbook i: cognitive domain. new york: david mckay, 1956. 13. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9 suppl):s63-s67. https:// doi.org/10.1097/00001888-199009000-00045 14. ferris h, o’flynn d. assessment in medical education: what are we trying to achieve. int j higher educ 2015;4(2):139-144. https://doi.org/10.5430/ijhe.v4n2p139 15. magzoub mema. studies in community-based education: programme implementation and student assessment at the faculty of medicine, university of gezira, sudan. phd thesis. sudan: university of gezira, 1994. 16. kaye dk, muhwezi ww, kasozi an, et al. lessons learnt from comprehensive evaluation of community-based education in uganda: a proposal for an ideal model community-based education for health professional training institute. bmc med educ 2011;11(7):1-9. https://doi.org/10.1186/1472-6920-11-7 17. cameron d. community-based education in a south african context. was socrates right? s afr fam pract 2000;22(2):17-20. 18. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 19. pitney wa, parker j. qualitative research in physical activity and the health professions. auckland, new zealand: human kinetics, 2009. 20. bitsch v. qualitative research: a grounded theory example and evaluation criteria. j agribus 2005;23(1):75-91. https://doi.org/10.22004/ag.econ.59612 21. doherty je. strengthening rural health placements for medical students: lessons for south africa from international experience. s afr med j 2016;106(5):524-527. https://doi.org/10.7196/samj.2016.v106i5.10216 22. al-wardy nm. assessment methods in undergraduate medical education. squ med j 2010;10(2):203-209. 23. green eh, durning sj, decherrie l, et al. expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. j gen intern med 2009;24(3):370-373. https://doi.org/10.1007/s11606-008-0900-x 24. gisselle o, martin-kneip go. becoming a better teacher. med teach 2001;23(6). 25. friedman bdm, davis mh, harden rm, et al. portfolios as a method of student assessment. amee med educ guide 2001;(24). 26. turnbull j. clinical work sampling. j gen intern med 2000;15(8):556-561. https://doi.org/10.1046/j.15251497.2000.06099.x 27. blake k. the daily grind – use of logbooks and portfolios for documenting undergraduates’ activities. j med educ 2001;35(12):1097-1098. https://doi.org/10.1046/j.1365-2923.2001.01085.x 28. yang c, chang ys. assessing the effects of interactive blogging on student attitudes towards peer interaction, learning motivation, and academic achievements. j com assist learn 2012;28(2):126-135. https://doi. org/10.1111/j.1365-2729.2011.00423.x 29. land sm. cognitive requirements for learning with open-ended learning environments. educ technol res develop 2000;48:61-78. https://doi.org/10.1007/bf02319858 30. boulos mn, maramba i, wheeler s. wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. bmc med educ 2006;6(41). https://doi. org/10.1186/1472-6920-6-41 31. van rosenthal gma, jennet pa. comparing peer and faculty evaluations in an internal medicine residency. acad med 1994;69(4):299-303. https://doi.org/10.1097/00001888-199404000-00014 32. race p, brown s, smith b. 500 tips on assessment. 2nd ed. london: routledge, 2005. accepted 8 july 2019. https://doi.org/10.4103/1357-6283.134311 https://doi.org/10.1056/nejmra054784 https://doi.org/10.1056/nejmra054784 https://doi.org/10.1097/00001888-199009000-00045 https://doi.org/10.5430/ijhe.v4n2p139 https://doi.org/10.1186/1472-6920-11-7 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.22004/ag.econ.59612 https://doi.org/10.7196/samj.2016.v106i5.10216 https://doi.org/10.1007/s11606-008-0900-x https://doi.org/10.1046/j.1525-1497.2000.06099.x https://doi.org/10.1046/j.1525-1497.2000.06099.x https://doi.org/10.1046/j.1365-2923.2001.01085.x https://doi.org/10.1111/j.1365-2729.2011.00423.x https://doi.org/10.1111/j.1365-2729.2011.00423.x https://doi.org/10.1007/bf02319858 https://doi.org/10.1186/1472-6920-6-41 https://doi.org/10.1186/1472-6920-6-41 https://doi.org/10.1097/00001888-199404000-00014 174 september 2021, vol. 13, no. 3 ajhpe research why was the idea necessary? the covid‑19 pandemic forced educators to go online in a hurry in 2020 and adapt their teaching and assessment approaches. however, despite the urgency, teaching and assessment still need to remain constructively aligned, enforce learning, and be student centred while simultaneously developing 21st century graduate attributes and critical thinking skills. while interactive and collaborative learning is frequently cited as a good educational practice in the online environment, this learning approach is not without challenges for the student or the facilitator. the approach that students need to work together to learn is supported by piaget, dewey and bruner (quoted by jackman[¹]). they theorised that learning is a social and active process and knowledge is constructed through interaction. medical education is based on interaction with patients, the environment, peers and near‑peers, and facilitators or experts. the isolation associated with lockdown due to covid‑19 disrupted this engagement that is pivotal to medical education and student learning. however, despite the enforced quarantine, all students need to develop the skill set to work, engage and collaborate as global and digital citizens. effective medical care requires healthcare professionals to work in multi‑ and inter‑professional teams. this emphasises the need to provide students with learning opportunities, even in the virtual environment, to work in small but diverse groups. collaborative learning occurs when small groups of students work together and support each other to contextualise and learn. it is not merely students talking to each other, or video‑conferencing, while each does his or her individual task, or helping each other complete the group  assignment. rather, collaborative learning is an approach that gives students an  opportunity to engage and deliberate, develop socialised intelligence, take responsibility for their own learning and thus become critical thinkers.[²,³] team‑based learning promotes active group learning while decreasing facilitator dependence, which was an important consideration, given the added clinical workload that healthcare workers faced due to the covid‑19 pandemic. peer‑evaluation skills are not typically taught to students,[4] but can have a positive impact on student behaviour and attitudes towards group assignments.[5] peer evaluation is also cited as a means of reflective learning as it provides an opportunity to monitor, evaluate and adjust their overall skills.[5] numerous studies provide persuasive evidence that peer‑evaluation scores were comparable to tutor scores or test grades, and should be used as part of the assessment process. peer evaluation reinforces and assesses a multitude of skills, while individual test grades only evaluate students’ knowledge, rather than student involvement, active listening, critical assessment, and interaction.[5,6] what was tried? as part of programmatic assessment,[7] medical students in their third‑year pregnancy and neonatology rotation were divided into 24 groups. groups were assigned rather than formed organically. this approach of group allocation was intended to introduce students to new or alternative peer perspectives. the contextual concern was that south africa is failing to make remarkable improvement in achieving sustainable development goals (sdgs) pertaining to maternal and child health. problems are related to individual, social circumstances and public health issues. therefore, an assignment was drafted to include this challenge and force students to think critically about the implications, current situation and consequences. each group was assigned a three‑part group project.[8] the learning outcome of the first assignment focused on creation of a novel, engaging, creative solution to problems identified in the video, why  did mrs x die?[9] the format of the assignment was open to the students; however, traditional essays and powerpoint presentations were prohibited. the second assignment focused on understanding evidence‑based medicine. groups selected a relevant review from the cochrane database and interrogated the topic further. they then compiled an e‑poster including an interpretation of a meta‑analysis with a 5‑minute narration. the final group assignment was based on peer‑led teaching. each group was assigned a clinical case and questions that incorporated themes covered in the preceding week. the assigned group was tasked with facilitating a dialogue on the online discussion board. groups were required to provide evidence of communication and collaboration. assignment 1 and 2 were peer‑assessed. each group assessed five other groups’ submissions. assessment was based on a three‑point likert scale  rubric developed in consultation with the students, based on three critical factors, namely, identification and expected solutions, novel solutions, and creativity of submission. peer evaluation included a score and  comments. assignment 3 was adjudicated by the facilitators of the course. the assignments were intended to achieve the following: 1. teamwork/collaboration 2. information and communication technologies (ict)‑skill development 3. flexible, creative, critical thinking 4. knowledge application, integration, self‑directed learning 5. visionary leadership 6. fun while learning. breaking the isolation: online group assignments s adam,1 mb chb, fcog (sa), mmed (o&g), cert mat fetal med (sa), pgche, phd (o&g); m coetzee,2 mb chb, fcpaed (sa), mmed (paed), cert neonatology (sa); i (j c) lubbe,3 bsocsc, msocsc, med (post‑grad educ); phd 1 department of obstetrics and gynaecology, school of medicine, faculty of health sciences, university of pretoria, south africa 2 department of paediatrics, school of medicine, faculty of health sciences, university of pretoria, south africa 3 education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: s adam (sumaiya.adam@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:sumaiya.adam@up.ac.za september 2021, vol. 13, no. 3 ajhpe 175 research lessons learnt while all groups accomplished the tasks, it was evident that students are much more task‑focused and able to engage in co‑operative learning where  tasks were divided and completed, rather than embracing true collaborative learning. students voiced their preference to choose their own groups. this was unsurprising as students keenly desire to associate with fellow students of similar drive, stamina and performance. however, as part of the hidden curriculum, they proved that they were able to navigate issues of working with unfamiliar colleagues (a real‑life simulation), dealing with absent or poor‑performing colleagues, team roles and differences of opinion. according to yoon et  al.,[6] the optimal group size is 6 ‑ 8 students. in future assignments this should be taken into consideration to optimise group dynamics. students further proved that despite challenges such as limited data, entry‑level digital devices, and inconsistent electricity supply, they were able to communicate constructively using digital platforms such as blackboard, whatsapp and google docs. these assignments demonstrated that greater involvement of a facilitator is required to foster collaborative learning. in future, role allocation will be done within the groups, including the appointment of a ‘project manager’ who provides regular updates to the facilitator. although the purpose of the activity was outlined, our competitive and result‑driven students did not always see the benefit of the process of engagement and brainstorming with their peers. they focused more on product and less on process; therefore, facilitators should provide clear expectations and examples of how students should collaborate. progress reports, discussion forums and virtual conferences that can be accessed by the facilitator can be considered to encourage and guide collaborative learning.[3,10] groups were more attentive to assignments 1 and 2 which carried a grade rather than assignment 3 which was part of formative assessment, supporting the notion ‘if it is not graded, it will not be done’. groups received a mark rather than individual marks, which may have rewarded underperforming students. in the future, a three‑tier assessment should be considered – self, individual and group. groups can peer‑evaluate their co‑workers, and groups can anonymously evaluate each other according to rubrics, a standardised action to reduce bias. this approach to evaluation may keep students engaged when they are tempted to drift. the rubric should be more focused, especially on preparation for the activity, peer participation, peer contribution overall to the group, and respect and sincerity towards the group.[6] what will i keep in my practice? in the future, the class of 300 will be divided into groups of 5 ‑ 8 students, with role allocation determined at the outset. the need for a facilitator for each group will be explored further; however, resources are limited. the focus will be on self, anonymous individual and group assessments, with further revision of the rubric used. future assignments should compel students to reflect and act on the peer feedback received and incorporate it in a subsequent draft. this process of feedback develops skills of communicating in a professional manner, developing autonomy of feedback, and resilience. we live in diverse communities; hence the effect of culture on peer feedback needs to be explored.[5] to develop the students’ metacognitive skills, reflection during the entire three‑tier process will be included from the onset. what will i not do? we will not revert to individual‑ or facilitator‑assessed assignments. we believe that working with diverse peers contributes to the learning process and therefore will not accede to requests for self‑selected groups. team‑based learning encourages learning and development of transferable skills. while it may be simpler to design and assess individual assignments, students learn valuable transferable skills in communication, navigating logistic challenges, and group dynamics that will serve them well in the authentic workplace. declaration. none. acknowledgements. we would like to thank the students who participated in this study. author contributions. sa, il and mc contributed equally to the conceptualisation, implementation and preparation of the manuscript for this study. funding. none. conflicts of interest. none. evidence of the innovation 1. jackman d. learning theories. https://www.edapp.com/blog/learning‑theories/ (accessed 28 february 2021). 2. laal m, laal m. collaborative learning: what is it? soc behavioural sci 2011; 31: 491‑495. http://www. sciencedirect.com/science/article/pii/s1877042811030217 (accessed 28 february 2021). 3. zygouris‑coe v. proceedings from icite 2012: collaborative learning in an online teacher education course: lessons learned. rhodes, greece. http://www.icicte.ord/proceedings2012/papers?08‑4‑zygouris‑coe.pdf (accessed 28 february 2021). 4. anderson os, el habbal n, bridges d. a peer evaluation training results in high‑quality feedback, as measured over time in nutritional sciences graduate students. adv physiol educ 2020; 44:203‑209. https://doi.org/10.1152/ advan.00114.2019 5. rahadi ra, tampubolo mn, hasanah en. students peer‑evaluation process: a case study in malaysia. int j educ psychology counsel 2018; 3(15):7‑16. 6. yoon hb, park wb, myung sj, moon sh, park jb. validity and reliability assessment of peer evaluation method in team‑based learning classes. korean j med educ 2018; 30(1): 23‑29. https://doi.org/10.3946/kjme.2018.78 7. van der vleuten c. what is programmatic assessment? https://www.ceesvandervleuten.com/publications/ programmatic‑assessment/what‑programmatic‑assessmen (accessed 28 february 2021). 8. adam s. university of pretoria. faculty of health sciences. bbl‑series. 2019. peer evaluation and competency‑ based assessment. https://youtu.be/juloozzomn8 (accessed 18 april 2021). 9. macha. why did mrs x die? retold (produced by world health organization.) 2016. https://www.youtube. com/watch?v=gs7fcvcle1k (accessed 18 april 2021). 10. lowes s. how much 'group' is there in online group work? j asynchronous learn networks 2014;18(1 april). http://jaln.sloanconsortaium.org/index.php/jaln/article/view/373/82 (accessed 28 february 2021). accepted 28 april 2021. afr j health professions educ 2021;13(3):174‑175. https://doi.org/10.7196/ajhpe.2021.v13i3.1518 https://www.edapp.com/blog/learning-theories/ http://www.sciencedirect.com/science/article/pii/s1877042811030217 http://www.sciencedirect.com/science/article/pii/s1877042811030217 http://www.icicte.ord/proceedings2012/papers?08-4-zygouris-coe.pdf https://doi.org/10.1152/advan.00114.2019 https://doi.org/10.1152/advan.00114.2019 https://doi.org/10.3946/kjme.2018.78 https://www.ceesvandervleuten.com/publications/programmatic-assessment/what-programmatic-assessmen https://www.ceesvandervleuten.com/publications/programmatic-assessment/what-programmatic-assessmen https://youtu.be/juloozzomn8 https://www.youtube.com/watch?v=gs7fcvcle1k https://www.youtube.com/watch?v=gs7fcvcle1k http://jaln.sloanconsortaium.org/index.php/jaln/article/view/373/82 https://doi.org/10.7196/ajhpe.2021.v13i3.1518 editorial december 2012, vol. 4, no. 2 ajhpe 107 article introduction as a developing country, south africa (sa) faces numerous challenges in implementing equitable access to healthcare for its population. the ratio of healthcare professionals to the population is reported to be 8 doctors, 41 nurses and 3 pharmacists per 10 000 population,1 which is inadequate to address quality healthcare in terms of treating and managing health problems as well as providing health promotion activities. it is estimated that the disease burden attributed to preventable non-communicable diseases (ncds) in sa is 21% compared with 25% attributed to povertyrelated conditions such as infectious diseases and under-nutrition.2 even though the prevalence of ncds due to lifestyle changes is almost equal to that of infectious diseases, the resource allocation of the current healthcare system continues to focus on eradication of infectious diseases.3 the document on the assessment of the global burden of disease substantiates that ncds are the major cause of mortality worldwide and are expected to increase with time in lowand middle-income countries.4 hence it is imperative that more intensive efforts are undertaken to promote healthy lifestyles5 in developing countries such as sa. there is an urgent need to develop simple health promotion techniques to empower communities with knowledge for the prevention and management of chronic health conditions.6 health promotion involves actively engaging in strategies that will ultimately provide opportunities to the population to be healthy and to make healthy choices.7 conventionally, health promotion has been approached as a classroom teaching experience resulting in limited outcomes for students and little or no benefit to the community. this requires a pragmatic change in approaching health promotion in tertiary institutions that would benefit the students and also address the needs of the community. a structured educational approach would provide opportunities for healthcare professionals, especially future pharmacists, in understanding the challenges and implications of chronic health conditions affecting south africans. it is critical that future pharmacists engage actively in health promotion so that the shift in pharmacy practice from product to patient-focus, which requires that more time be spent talking to and advising patients rather than in dispensing medicines, can be made. although health promotion is considered important, barriers such as lack of time, space, finance, training and perceived conflict between the professional and commercial role of the pharmacist hinder pharmacists’ involvement in health promotion.8 sa has experienced a paradigm shift in its educational policy by implementing outcomes-based education,9 in place of conventional didactic learning. there has been a concerted effort to introduce the concept of evaluation of a service-learning elective as an approach to enhancing the pharmacist’s role in health promotion in south africa s c srinivas, w w wrench faculty of pharmacy, rhodes university, grahamstown s c srinivas, m pharm, phd, pgdhe w w wrench, m pharm corresponding author: s srinivas (s.srinivas@ru.ac.za) background. a service-learning (sl) elective offered to final-year pharmacy students was introduced in 2007. the elective demonstrated a holistic approach to creating opportunities for future pharmacists to understand the current needs and future challenges of the burden of disease in developing countries such as south africa and to foresee their key roles in health promotion. methods. the 2007 sasol national festival of science and technology (scifest) was chosen as the ideal platform to implement this elective. evaluation of the elective was carried out in association with the academic development centre using a web-based software tool known as the adc evaluation assistant (adcea). the adcea consisted of a ‘question bank’ from which the course facilitators selected nine ranked closed questions as well as two open-ended questions. results. scifest participation, in the course of the service-learning elective, was acknowledged by students to have prepared them as responsible citizens to undertake health promotion in the public sector healthcare system. conclusion. students’ experiences of the learning opportunities provided in the scifest elective highlight the strengths of this sl programme. the sl elective provided a unique and relevant opportunity to address the health promotion needs of the south african community and potentially enhance human capacity to deliver health promotion in south africa. ajhpe 2012;4(2):107-111. doi:10.7196/ajhpe.108 108 december 2012, vol. 4, no. 2 ajhpe article service learning (sl) in tertiary education institutions to contribute towards local and national developmental needs.10,11 currently sl is recognised as an important pedagogy in higher education12 which encompasses an instructional method that combines community service with didactic learning. as an instructional practice, sl allows students to be reflective and apply their acquired knowledge in real-life situations.13 many sl activities have been successfully developed for students as a part of their curriculum in healthcare professions such as medicine,14,15 dentistry,13 nursing,16 public health17 and pharmacy.18,19 this paper describes the evaluation of a sl elective for final-year pharmacy students, which was incorporated for the first time in the curriculum of the faculty of pharmacy at rhodes university in grahamstown, south africa. the 2007 sasol national festival of science and technology (scifest) was chosen as the ideal platform to implement this elective. the elective was designed to provide students with the opportunity to prepare for their professional roles as pharmacists in the area of health promotion by raising awareness and providing information on priority health conditions based on local prevalence. obesity, hypertension, diabetes, asthma, epilepsy, tuberculosis and hiv-aids, a combination of five ncds and two infectious diseases were identified for this elective. firstly, students were required to design and develop an interactive computer-based quiz with preand post-intervention questions to assess the knowledge of, and also to educate, attendees regarding the prevention and management of a particular identified health condition.20 this was facilitated by conducting workshops with the help of various experts from the rhodes university computer science department in developing computer-based quizzes. secondly, interactive models were designed to assist in the understanding of the particular health condition. thirdly, a visual aid in the form of a poster described the health condition, highlighting key aspects as well as prevention and management. workshops were organised with the help of experts to facilitate design of posters and interactive models for health promotion. fourthly, information leaflets in both english and isixhosa (the chief local indigenous language) were distributed to all attendees to the exhibit, thereby ensuring further dissemination of information on all the identified health conditions. all activities had to be organised within five weeks, which was the time available between the start of the academic term at rhodes university and the beginning of scifest. a total of 1 529 learners participated in the quizzes and many more visited the exhibit where they interacted with the students. since the elective was newly introduced into the curriculum, it was evaluated by the academic development centre (adc), rhodes university, for the effectiveness of the teaching and learning, based on course feedback from students.21 the students were also required to further reflect on the critical cross-field outcomes (ccfos)22 perceived to have been achieved during the course of this elective, in a written portfolio. this paper provides insight into the students’ evaluation based on their experiences of the new sl pharmacy elective course that addressed health promotion and how it contributed to their learning and development. method the first evaluation of this elective was carried out in association with the adc, which used a web-based software tool known as the adc evaluation assistant (adcea).23 the adcea consists of a ‘question bank’ from which the course facilitators selected nine ranked closed questions as well as two open-ended questions. an adc consultant scrutinised these questions which were given to the 18 participating students. students were required to indicate their response for the ranked closed questions and provide written comments for the two open-ended questions. these responses were captured and analysed by the adc consultant who provided feedback to the facilitators. the second evaluation, designed by the course facilitators, required students to address specific criteria in a reflective portfolio. these criteria were based on the ccfos which are in accordance with the south african qualifications authority (saqa) act22 and institutional policies at rhodes university. in their portfolios, students quoted examples to substantiate on the personal development of the following ccfos during the elective: • ability to identify and solve problems • ability to work in a team • how they organised and managed themselves in a group • how they collected, analysed and evaluated information • how they communicated effectively • how they used science and technology • how they recognised problem solving contexts • how they explored effective learning strategies during scifest • how scifest participation prepared them as a responsible citizen • how scifest prepared them to be culturally and aesthetically sensitive • how scifest provided them with opportunities to explore education and career opportunities • how scifest would influence their future behaviour as a pharmacist • other relevant comments/reflection regarding scifest. results the students’ responses to the nine ranked questions from the adcea provided insight as to how they approached and participated in the elective. the evaluation, based on their ranking, is shown in table 1. regarding interest in the topic and extent of effort, 94% of the students indicated that they either ‘agreed or strongly agreed’ (table 1) with the statement ‘i worked hard preparing for and taking part in scifest as i found the topic interesting’. this statement also correlated with the open-ended responses, where most students answered positively to the question: ‘do you believe that during your preparation for the scifest exhibit you put in as much effort as you were able to in your circumstances?’ the beneficial experience was elicited by one student, who expressed: ‘we put in a lot of effort. but we enjoyed every minute of it and it was great to present our exhibit at scifest because all our hard work paid off and scifest patrons enjoyed chatting to us and interacting with our display’. in response to the second open-ended question, ‘list the ways in which, during the scifest elective, you were given opportunities to take control of your own learning’, varied responses were obtained. the issue of ‘shared responsibility’ between students and facilitators was reflected upon, with some students highlighting it in a positive manner while others highlighting the issue of ‘ownership’ of the elective being more with the facilitators than the students. some students discussed how the guided help and advice of the facilitators allowed for these learning opportunities. a student felt that editorial december 2012, vol. 4, no. 2 ajhpe 109 article ‘the facilitators were open to compromise and they did a lot to help us and make life easier’. another student suggested that ‘more autonomy and a less directed process would be better’. students highlighted that preparation of posters, quizzes and models contributed to their learning opportunities. in addition, planning, time management, creativity and communicating with members of the public were mentioned as additional opportunities for learning. the open-ended responses included comments on how working as part of a group was helpful for this elective. one student articulated: ‘working as a group is beneficial as the workload is equally distributed and becomes manageable’. in response to a related ranked question, students either strongly agreed or agreed to ‘i found that working in a group contributed to my learning’, which was again highlighted by 66% of students who either disagreed or strongly disagreed (table 1) to the statement: ‘i generally prefer to work on my own than in a group’. although 93% of students either agreed or strongly agreed to ‘although working in a group was difficult at times, i think i learnt a lot from the experience’, one student felt hampered by group work. in response to the statement ‘engaging with the course process for scifest gave me a feeling of deep personal satisfaction’, over a third of the students strongly agreed, with an additional 50% agreeing. the reflective writing of all 18 students included examples to illustrate their experience of the ccfos during the sl elective. various examples were quoted to show how the elective helped them identify and solve problems. although they found it to be a challenging course as an introductory elective without any prior experience to learn from, students quoted examples to show how the elective offered them a chance to be ‘creative, original and set the standards’. the ability to work in a team demonstrated insight into their personal social styles24 which they took into consideration when pooling the strengths of each member of the group for a common benefit. students quoted examples of how they took personal responsibilities as well as delegated tasks within the group which involved ‘inherent creativity, shared insight, enthusiasm, motivation, and generating ideas for the team to succeed’ within the given constraints of time. time constraints and the difficulty in managing other course requirements while managing scifest commitments were highlighted by all students. while reflecting on communication, all students highlighted the challenges they faced in communicating with attendees who visited the exhibit, while responding to questions based on popular myths. for example, some attendees thought that hiv is spread by mosquito bites. students had to explain that this was not the case, and found it difficult to convince a few attendees. students also highlighted the effectiveness of their posters on health conditions as useful visual aids, along with interactive models and information leaflets which helped them to communicate effectively with scifest attendees on health promotion. communication within their group as well as with the course facilitators and the interactive use of moodle, an online learning management system at rhodes university, were also quoted as facilitating factors for effective communication. by problem-solving using science and technology, students were able to explore learning strategies. one student articulated how ‘the scifest elective has been fun, competitive, challenging and highly beneficial for the practice of pharmacy and the future profession that lies ahead of me’, while another student stated: ‘i feel that a major benefit of this elective was that it provided an effective means of enabling me to integrate my theory with practice’. students also explained how workshops organised with the help of various experts from the rhodes university computer science department in developing computer-based quizzes and the graphic services unit in designing posters had contributed to enhancing the skills they would need as future pharmacists. table 1. responses of students to ranked questions ranked questions strongly disagree disagree neutral agree strongly agree my aim with this elective is to do as little work as possible in order to pass 7 (38%) 7 (38%) 0 2 (11%) 2 (11%) i did not manage to do any reading or work over and above what was assigned for us by the lecturers 4 (22%) 10 (55%) 1 (5%) 3 (16%) 0 i spent a lot of time searching for extra information for my group’s topic for scifest 0 3 (16%) 1 (5%) 7 (38%) 7 (38%) i found preparing for and taking part in scifest boring, so did the bare minimum work for it 10 (55%) 6 (33%) 0 2 (11%) 0 i worked hard preparing for and taking part in scifest as i found the topic interesting 0 0 1 (5%) 8 (44%) 9 (50%) in this context i found that working in a group contributed to my learning 1 (5%) 1 (5%) 2 (11%) 4 (22%) 10 (55%) i generally prefer to work on my own than in a group 3 (16%) 9 (50%) 0 4 (22%) 2 (11%) although working in a group was difficult at times, i think i learnt a lot from the experience 1 (5%) 0 0 5 (27%) 12 (66%) engaging with the course process for scifest gave me a feeling of deep personal satisfaction 1 (5%) 2 (11%) 0 9 (50%) 6 (33%) 110 december 2012, vol. 4, no. 2 ajhpe article the comments made by students on how scifest participation prepared them as responsible citizens highlight gaps in health promotion in developing countries, especially in the public sector healthcare system, and also showed how they intend to address these gaps. one student articulated: ‘i intend to work in public sector. this corresponds to my belief that access to healthcare is a human right.’ their comments on how scifest prepared them to be culturally and aesthetically sensitive by ‘choosing words carefully so as to avoid making anyone feel uncomfortable’, ‘understanding cultural myths and being sensitive’ and ‘using pictures and languages in quizzes appropriate to all cultural groups’. overall, students were able to articulate why it is important to be open and sensitive to the feelings of other people while fulfilling their roles as future pharmacists. the evidence of how scifest contributed to students exploring opportunities in education and careers in areas of health promotion and patient education was evident based on their reflection on the scope of opportunities in health promotion as well as the extent to which it could prove to be satisfying. their responsibility as future healthcare professionals (hcps) as well as their newfound confidence in interacting with the community or patients was articulated in their reflection. aspects such as ‘opportunity to do things i have never done before’ as well as ‘obligations to impart my knowledge to the community’ were articulated to demonstrate how this elective provided training and opportunities in developing skills and understanding that are required to practise as a pharmacist. discussion sa is currently experiencing a shortage of hcps and this situation leads to inequities in healthcare for the majority of the population who are dependent on public sector healthcare facilities. it is evident from the recent who release4 that health promotion to prevent ncds has to be considered on par with the prevention and treatment of infectious diseases, as they are expected to increase in the future. this situation requires active health promotion through hcps who have been trained using sl concepts. this builds on the concept of transforming higher education in sa by training pharmacists who have experienced active learning by responding to local health needs of the community through sl experiences. sl is an important learning experience and is considered to be the step towards simultaneous learning and teaching for students. sl progresses towards a definitive social change in the form of services provided by the students through their lifelong learning commitment towards community engagement.17 the sl elective was introduced in 2007 with the intention to create reflective practitioners with key skills to address health promotion. activities associated with sl are considered diverse in application and essentially incorporate four elements: preparation, action, evaluation and reflection.25 all four elements were incorporated in designing and implementing this elective for final-year students who are in the process of entering the professional arena. during the preparation and action phase students were exposed to concepts of sl and responding to the community’s health promotion. during evaluation and reflection students provided feedback on how this learning process facilitated in gaining experience to develop critical cross-field outcomes. the elective demonstrates a holistic approach in creating opportunities for future pharmacists in understanding the current needs and future challenges of the burden of disease in developing countries. the guided reflection in the student portfolios, based on experience gained during this activity, results in instilling a sense of civic responsibility with an intention of contributing to health promotion. it also helps in linking service and learning, which is in line with the outcomes of other sl programmes.19,26,27 the students’ experiences of the different learning opportunities provided in scifest highlight the strengths of sl programmes. however, the limited time available for this activity was expressed as a major concern. similar strengths and concerns in a qualitative evaluation study of dental students were reported.13 it is reported that health promotion was introduced into the south african health system in 1990, but research and evaluation in this field have made limited progress. this necessitates immediate action in health promotion education and training.28 initiating this sl elective provided a unique and relevant opportunity to address this need and eventually develop human capacity that is critical in initiating health promotion in south africa. conclusion the outcomes of the evaluation of the sl elective reported here demonstrate the value of such a strategy in sensitising future pharmacists to their key role in health promotion to enable their clients to take greater control over the conditions affecting their health. acknowledgements. the authors would like to gratefully acknowledge dr srinivas patnala for his assistance in developing and editing the earlier drafts of this manuscript. the authors would also like to thank the following members from rhodes university: mrs s abraham, graphic services unit; dr k bradshaw and professor e p wentworth, computer science; mr m mostert, academic development centre; ms p maseko, school of  languages; and mrs k benyon. m k van winkel’s (st andrew’s college, grahamstown) contribution is also kindly acknowledged. the 18 final-year students who completed the scifest elective in 2007 are also acknowledged for their enthusiastic participation. rhodes university is acknowledged for funding this health promotion intervention. conflict of interest: none. references 1. who. health systems resources, world health statistics 2010. http://www.who.int/whosis/whostat/en_ whs10_full.pdf (accessed 18 march 2011). 2. bradshaw d, groenewald p, laubscher r, et al. initial burden of disease estimates for south africa, 2000.s afr med j 2003;93(9):682-688. 3. kruger sh, puoane t, senekal m, van der merwe mt. obesity in south africa: challenges for government and health professionals. public health nutr 2005;8(5):491-500. 4. who. new study presents state of the world’s health. http://www.who.int/mediacentre/news/notes/2008/np11/ en/print.html (accessed 9 march 2011). 5. bourne lt, lambert e, steyn k. where does the black population of south africa stand on the nutrition transition? public health nutr 2002;5(1a):157-162. 6. porter c. ottawa to bangkok: changing health promotion to discourse. health promot int 2007;22(1):72-79. 7. the health promoting schools initiative. http://www.unep.org/training/programmes/instructor%20version/ part_2/activities/interest_groups/public_awareness/strategies/the_health_promoting_schools_initiative.pdf (accessed 9 march 2011). 8. anderson c. health promotion in community pharmacy: the uk situation. patient educ couns 2000;39:285-291. 9. national qualifications framework and curriculum development (2000). http://www.saqa.org.za/structure/nqf/ docs/curriculum_dev.pdf (accessed 18 october 2010). 10. council of higher education. community engagement, 2004. http://www.che.ac.za/documents/d000081/sa_ he_10years_nov2004_chapter7.pdf (accessed 18 october 2010). 11. osman r, castle j. theorising service learning in higher education in south africa. perspectives in education 2006;24(3):63-70. editorial december 2012, vol. 4, no. 2 ajhpe 111 article 12. bringle rg, hatcher ja. reflection in service learning making meaning of experience. educ horiz 1999;77(4):179-185. 13. keselyak nt, simmer-beck m, bray kk, gadbury-amyot cc. evaluation of an academic learning-service course on special needs patients for dental hygiene students: a qualitative study. j dent educ 2007;71(3):378-392. 14. brieger wr. developing service-based teaching in health education for medical students. health educ monogr 1978;6(4):345-358. 15. jones kv, hsu-hage bh. health promotion projects: skill and attitude learning for medical students. medical educ1999;33(8):585-591. 16. reising dl, shea ra, allen pn, laux mm, hensel d, watts pa. using service-learning to develop health promotion and research skills in nursing students. international journal of nursing education scholarship 2008;5(1):29. http://www.bepress.com/ijnes/vol5/iss1/art29 (accessed 18 october 2010). 17. cashman sb, seifer sd. service-learning an integral part of undergraduate public health. am j prev med 2008;35(3):273-278. 18. sauer bl. student-directed learning in a community geriatrics advanced pharmacy practice experience. am j pharm educ 2006;70(3):54. 19. brown b, heaton pc, wall a. a service-learning elective to promote enhanced understanding of civic, cultural and social issues and health disparities in pharmacy. am j pharm educ 2007;71(1):9. 20. srinivas sc, wrench w, karekezi c, radloff s, daya s. obesity: a baseline health promotion intervention of an introductory service-learning course for pharmacy students. health sa gesondheid 2009;14(1). http://www. hsag.co.za/index.php/hsag/article/view/454/434 (accessed 18 october 2010). 21. karekezi cw, wrench w, quinn l, belluigi d, srinivas cs. design, implementation, and preliminary evaluation of an introductory service-learning elective for pharmacy students. education for change. community service learning 2007;11(3):143-156. 22. ministry of health. the higher education qualification framework. pretoria: department of education, 2004. 23. adc evaluation assistant. rhodes university. http://ea.ru.ac.za/ (accessed 18 october 2010). 24. rosario kj. quick identification of social style, aptitudes, and motivation, 2004. http://www.keithrosario.com/ images/newsocialstylesweb.pdf (accessed 18 october 2010). 25. geleta ne, gillam j. an introduction to service learning. in: learning to serve, serving to learn: a view from higher education. salisbury university, 2003. http://www.servicelearning.org/filemanager/download/111/ tecsl%20chap%201.pdf (accessed 18 october 2010). 26. cauley k, canfield a, clasen c, et al. community-campus partnerships for health. service learning: integrating student learning and community service. educ health 2001;14(2):173-181. 27. yoder km. a framework for service-learning in dental education. j dent educ 2006;70(2):115-123. 28. onya h. health promotion in south africa. promot educ 2007;14(4):233-237. 72 april 2021, vol. 13, no. 1 ajhpe research the preparatory year or first-year experience in higher education is dynamic and contextually specific, and consistently aims to meet the needs of students, institutions and the broader society of which they are part.[1] preparatory programmes are considered by some educational systems globally as one of the best practices in higher education.[2] the preparatory year aims to help the student to transition from the high school system of teaching and learning to that of the university, acquaint them with the various academic disciplines and introduce them to the university environment before they decide on their future fields of study.[3] the year also prepares them psychologically for their prospective fields of study in subsequent years.[4] furthermore, it offers intensive training courses to set students on the right track towards their professional careers and enrich their cultural background.[4] one established aim of the preparatory year is to enable new students to explore the academic disciplines at the university, and to familiarise them with the campus environment. as a result, students are well prepared to act as meaningful contributors in their personal and professional lives at university and beyond.[4] although considerable attention is given in the higher education literature to the preparatory year, most universities did not practise this trend seriously.[5] therefore, the aim of the current study was to validate a newly developed instrument that evaluates the effect of the preparatory year on students for studying in health professions education faculties. findings of this study had a great impact on reforming preparatory-year programmes, not only for the health professions but also for the concept in any other similar programmes. this study will direct the attention of saudi arabian medical educators to reform initiatives and to consider implementing changes in the existing structure of preparatory years. methods this was a cross-sectional descriptive study conducted at king abdulaziz university (kau), saudi arabia. the sample comprised male and female secondand third-year students who completed their preparatory year and started studying at the faculty of medicine, faculty of dentistry, faculty of pharmacy, faculty of applied medical sciences and faculty of nursing. sampling was comprehensive – all background. the preparatory year or first-year experience in higher education aims to consistently meet the needs of students, institutions and broader society. it aims to help students transition from high school to university, acquaint them with the various academic disciplines at university and introduce them to the university environment. objectives. to validate a newly developed instrument that evaluates the effect of the preparatory year on preparing students for studying in health professions education faculties. methods. a descriptive cross-sectional study was conducted at king abdulaziz university, saudi arabia, on a comprehensive sample of male and female secondand third-year students who completed their preparatory year and started studying at health professions education faculties. data were collected through a questionnaire newly developed by the authors. descriptive statistics were used and statistical significance was set at p<0.05. results. the study showed high internal consistency of the questionnaire. cronbach’s alpha coefficient value for the total scale was 0.94. among the 5 dimensions of the questionnaire, the students were highly satisfied with ‘university conduct’, but less so with the ‘perception of teachers, teaching and assessment’. conclusion. there was good validity and reliability of the newly developed questionnaire. from a student’s perspective, the preparatory-year programme needs to be revisited. afr j health professions educ 2021;13(1):72-76. https://doi.org/10.7196/ajhpe.2021. v13i1.1273 validation of a questionnaire evaluating the effect of a preparatory year on qualifying students for studying at health professions education faculties mohammed al-rabia,1 md, phd; lana al shawwa,1 phd; enas gouda,2 md, phd; ahmed aldarmahi,3 phd; hani asfour,1 phd; hani atwa,2,4 md, phd 1 faculty of medicine, king abdulaziz university, jeddah, saudi arabia 2 faculty of medicine, suez canal university, ismailia, egypt 3 college of medicine, king saud bin abdulaziz university for health sciences (ksau-hs), ministry of national guard-health affairs (mng-ha), jeddah, saudi arabia 4 college of medicine and medical sciences, arabian gulf university, manama, bahrain corresponding author: h atwa (doctorhani2000@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021. v13i1.1273 april 2021, vol. 13, no. 1 ajhpe 73 research students were invited to participate in the study. of the 717 students in the second and third year who completed their preparatory year, 633 responded and completed the questionnaire (88.3%). instrument a questionnaire was developed to include items that addressed the perception and opinion of students regarding the current status of the preparatory year. the questionnaire was based on a 5-point likert scale and included 32 items evaluating different aspects of the preparatory year from the viewpoint of students. to establish validity and reliability, the questionnaire was piloted on a small sample of students (n=100) (who were not included in the study population) prior to using it on a wide scale. based on piloting, some items were rephrased for clarification. exploratory factor analysis (efa) was performed to identify the number of factors that could explain most of the common variance. reliability of the questionnaire was tested for internal consistency, using cronbach’s alpha. data analysis spss version 22 (ibm corp., usa) was used. descriptive statistics, validation and reliability studies were performed and statistical significance was set at p<0.05. internal consistency for each scale was analysed using cronbach’s alpha. missing data were replaced with means of missing variables. efa was used to test the psychometric proprieties of the questionnaire. principal component analysis with varimax rotation was performed to identify the different factors. the number of factors extracted and used was based on kaiser’s criterion, which considers factors with an eigen value >1.00 as common factors,[6] the scree test criterion to identify the point of inflexion displayed by the scree plot[7] and the cumulative percent of variance. in humanities research, the explained variance is commonly as low as 50 60%.[8] factor solutions retained according to the psychometric criteria were then subjected to analysis in line with the following interpretability criteria:[9] • a given factor contains at least 3 variables with significant loadings, a loading of 0.30 being suggested as the cut-off point. • variables loading on the same factor share the same conceptual meaning. • variables loading on different factors appear to measure different constructs. • the rotated factor pattern demonstrates ‘simple structure’, i.e.: • most variables load relatively high on only one factor and low on the other factors. • most factors have relatively high factor loadings for some variables and low loadings for the remaining ones. ethical approval this study was part of a research project that was approved by the research ethics committee of the faculty of medicine, king abdulaziz university (ref. no. 155-16). results to determine the suitability of the questionnaire, validity and reliability studies were conducted. validity study validation of the questionnaire was done through the following methods. face validity the questionnaire was given to a group of preparatory-year programme experts and also to the medical education department at kau, as well as to an external expert in medical education. they were asked to review the questionnaire from the structural aspect, the different dimensions, and the students’ viewpoints. modifications of some items were done based on their recommendations. for example, some items, which were not set out clearly, could be misunderstood by students and were thus reformulated. construct validity: exploratory factor analysis checking the suitability of data for factor analysis • sample size: n=633 participants, which is adequate for factor analysis. • factorability of the correlation matrix: the correlation matrix revealed statistically significant, moderate correlations among the observed variables used in the analysis. none of the correlation coefficients was large. therefore, there was no need to eliminate any variables at that stage. • kaiser-meyer-olkin (kmo) measure of sampling adequacy and bartlett’s test of sphericity: these revealed that the kmo measure of sampling adequacy was 0.94 (excellent). this value indicates that there were sufficient items predicted by each factor. furthermore, bartlett’s test of sphericity was statistically significant (p<0.001), which indicated that the variables were significantly correlated. therefore, this output indicated the appropriateness of the data for factor analysis. extraction of factors principal component analysis with varimax rotation was performed to identify and interpret the number of factors that could explain most of the common variance and to delete non-reflective or redundant items. results revealed that the 32 items of the questionnaire resulted in 6 factors with an eigenvalue >1.00. the 6 factors that emerged from factor analysis accounted for 62.6% of total variance. the number of factors was also confirmed with the visual inspection of the scree plot that indicated a sudden drop in the scree, beginning with the sixth factor. rotation of factors from the initial 32 items, 2 were removed from the analysis. the rules used for deleting items were the following: • number of items per factor: a factor with <3 items is generally weak and unstable; ≥4 items are desirable and indicate a solid factor. • cross-loadings of items: items that load at ≥0.3 on ≥2 factors. • factor loading <0.30: lower factor loadings demonstrate a lower degree of association between the factor and the item. items 22 and 23 were deleted, as these were only 2 items in 1 factor (weak factor). finally, the questionnaire was composed of 30 items distributed on 5 factors. the factors were named according to the heaviness of 74 april 2021, vol. 13, no. 1 ajhpe research loading of the statements on each factor and also on the idea behind the statements. table 1 shows that the highest contribution was from the college of medicine (25.4%) and the lowest from the college of pharmacy (14.7%). the majority of respondents were females (n=207; 58.8%), whereas overall there were 41.2% respondents. appendix 1 (http://ajhpe.org.za/public/files/1273-a1.pdf ) shows the following: • factor 1 explained 13.696% of the variance in responses, with an eigenvalue of 4.383. seven statements loaded on this factor, with values between 0.565 and 0.771. this factor has been renamed ‘general perception after completing the preparatory year’. • factor 2 explained 13.133% of the variance in responses, with an eigenvalue of 4.203. eight statements loaded on this factor, with values between 0.457 and 0.799. this factor has been renamed ‘perception of teachers, teaching, and assessment’. • factor 3 explained 12.165% of the variance in responses, with an eigenvalue of 3.893. six statements loaded on this factor, with values between 0.479 and 0.761. this factor was renamed ‘university conduct’. • factor 4 explained 9.625% of variance in responses, with an eigenvalue of 3.080. six statements loaded on this factor, with values between 0.445 and 0.770. this factor was renamed ‘administrative and regulatory matters’. • factor 5 explained 7.722% of variance in responses, with an eigenvalue of 2.471. three statements loaded on this factor, with values between 0.593 and 0.765. this factor was renamed ‘facilities and services’. • furthermore, the communalities of the 30 items are presented in table 1. it revealed that the communalities ranged between 0.517 and 0.751, i.e. extracted factors explained most of the variance in the variables being analysed. only one item (item 17) had low communalities (<0.50). correlations between variables (using product moment-to-moment pearson correlation coefficient) the pearson correlation coefficient was calculated between the 5 factors (after factor analysis) and each other, and between each factor and the total score of the questionnaire. appendix 2 (http://ajhpe.org.za/public/ files/1273-a2.pdf ) shows the results of correlation. there is high statistical significance for all correlation values. there were moderate relationships between all the factors of the questionnaire, i.e. each factor is considered independent of the other factors and measures a different aspect of student perception. hence, all the factors show that the tool is valid for measuring students’ perceptions of the preparatory year. also, values for correlation between the first 4 factors and total questionnaire values were high and statistically significant (p<0.01). however, for the factor ‘generally, after completing the preparatory year’, it gave a moderate correlation with the total questionnaire value (0.613). reliability study reliability of the questionnaire was studied by performing cronbach’s alpha for the 5 factors and the total questionnaire. table 2 shows the following results: all cronbach’s alpha values for the factors and the entire questionnaire were high (between 0.744 and 0.942), which indicates the high internal consistency (reliability) of the questionnaire. alpha levels did not increase when items were deleted. perception of students in health professions education faculties of the effect of the preparatory year in qualifying for studying in their faculties table 3 reveals that the students were highly satisfied with factor 3 (university conduct), with a mean of 3.16. however, they were less satisfied with factor 2 (perception of teachers, teaching and assessment), with a mean of 2.59. appendix 3 (http://ajhpe.org.za/public/files/1273-a3.pdf ) shows frequencies and percentages of students’ response for all factors. regarding factor 1 (generally, after completing the preparatory year), around half of the students agreed that after the preparatory year they had confidence in their abilities to research information (51.9%), their thinking table 1. demographic distribution of study sample variable category n (%) college medicine 161 (15.4) dentistry 110 (17.4) pharmacy 112 (14.70 applied medical sciences 152 (24.0) nursing 98 (15.5) total 633 (100) gender male 261 (41.2) female 372 (58.8) total 633 (100) table 2. cronbach’s alpha values for the 5 factors and the total questionnaire factors n (cronbach’s α) factor 1: general perception after completing the preparatory year 7 (0.904) factor 2: perception of teachers, teaching and assessment 8 (0.874) factor 3: university conduct 6 (0.864) factor 4: administrative and regulatory matters 6 (0.793) factor 5: facilities and services 3 (0.744) total: questionnaire 30 (0.942) table 3. means and standard deviations for students’ responses factors items, n mean (sd) factor 1: general perception after completing the preparatory year 7 3.04 (0.76) factor 2: perception of teachers, teaching and assessment 8 2.59 (0.83) factor 3: university conduct 6 3.16 (0.93) factor 4: administrative and regulatory matters 6 3.04 (0.87) factor 5: facilities and services 3 3.07 (0.96) sd = standard deviation. http://ajhpe.org.za/public/files/1273-a1.pdf http://ajhpe.org.za/public/files/1273-a2.pdf http://ajhpe.org.za/public/files/1273-a2.pdf http://ajhpe.org.za/public/files/1273-a3.pdf april 2021, vol. 13, no. 1 ajhpe 75 research skills improved (46.6%), their computer skills became more sophisticated (46.1%) and they could access and use learning resources (53.5%). regarding factor 2 (perception of teachers, teaching and assessment), nearly two-thirds (64.8%) of the students disagreed that the preparatory year provided activities that developed their various personal skills (e.g. social, physical, cultural, creative). more than half disagreed that teachers motivated them to develop their creative and innovative abilities (56.4%), 58.5% stated that the academic counsellor was helpful, and 57.7% described this interaction as adequate and fruitful. with regard to teaching, ~53.4% believed it was interactive rather than that they were spoon-fed. when measuring the ease of communication with their teachers, 40.6% of students stated that it was easy, while around one-quarter (24.5%) were neutral and one-third (34.9%) stated that communication was not easy. means of responses were low, except for ease of communication with teachers, which was slightly higher. regarding factor 3 (university conduct), around half of the study sample agreed that the preparatory year made them self-confident and reinforced their discipline (49.2% and 46.9%, respectively). less than two-thirds agreed that the preparatory year reinforced their sense of responsibility and helped them adapt to the university educational environment (60.6% and 64.3%, respectively). regarding the role of the preparatory year in helping students select their major subjects, more than half of the students (58.5%) did not believe that the preparatory year had an effect. also, more than half (57.2%) did not agree that the preparatory year prepared them for their major subjects. this is evident from the low mean score for their responses (2.41). for factor 4 (administrative and regulatory matters), 45.7% of the students agreed that the assessment tasks were appropriate, 45.7% agreed that adequate awareness sessions were planned for newcomer students, 55.8% believed that student guidebooks were informative, and 49.7% believed that teaching timetables were set out appropriately. when addressing the accessibility of the academic affairs service, 41.4% agreed that it was easily accessible. however, less than one-third (28.9%) agreed that student support services were adequate. finally, regarding factor 5 (facilities and services), about two-thirds (63.5%) of the students agreed on the appropriateness of the facilities, such as library, computers, data displays, smart boards. about half of them (45.6%) agreed on the appropriateness of areas designed for students to rest. more than half disagreed about the suitability of food-purchasing areas for students. discussion this study discusses the validation of a newly developed programme evaluation instrument. the instrument focuses on evaluation of the preparatory year at kau as a novel experience. it was imperative to conduct such a study to search for solutions for problems to effectively prepare students for their new learning experiences as university students – from school to university life. this was a cross-sectional descriptive study. the study sample comprised male and female secondand third-year students who completed their preparatory year and started studying at the faculties of medicine, dentistry, pharmacy, applied medical sciences and nursing. samples were comprehensive. a self-administered questionnaire to evaluate the effect of the preparator y year in preparing students for studying in health professions education faculties was used and the psychometric properties of the instrument were tested. to test the construct validity of the questionnaire, efa was conducted using principal component analysis with varimax rotation. data revealed that the questionnaire was categorised into 5 factors. the current study revealed high internal consistency (reliability) of the questionnaire. cronbach’s alpha coefficient value for the total scale was 0.94. in addition, internal consistency reliability, on its own, shows evidence of construct validity of the questionnaire. a unique addition to the existing literature was development of a new, validated, highly reliable tool for evaluating the effect of preparatory programmes for students for studying in health professions education faculties. therefore, it was difficult to find previous studies for comparison. the current study findings revealed that among the 5 dimensions of the questionnaire, the students were highly satisfied with ‘university conduct’. they agreed that the preparatory year made them self-confident. they also agreed that the preparatory year reinforced their sense of responsibility and helped them adapt to the university educational environment. from the abovementioned results, we can infer directly that the effect of the preparatory year on students in the different aspects of ‘university conduct’ is good. this is similar to the principle on which the preparatory year was originally planned, being the first contact with university life and the transitional stage between that and high school life. however, the previous finding was inconsistent with that in a study by alkathiri,[10] who found dissimilar results in his evaluation of the preparatory year. in the current study students were less satisfied with the ‘perception of teachers, teaching and assessment’, i.e. most of the students disagreed regarding the preparatory year providing activities that developed their various personal skills (e.g. social, physical, cultural, creative). furthermore, students disagreed that teachers motivated them to develop their creative and innovative abilities. students agreed that interaction with the academic counsellor was inadequate. also, they were not very satisfied with the teaching strategies. teaching (including teachers) and assessment are the cornerstone of the preparatory year, where most of the attention should be directed. however, it is clear from the students’ responses that they negatively perceived teaching, teachers and assessment. as stated by alkathiri,[10] it is a major challenge to attract and train qualified teachers for the success of the preparatory year. the current study agrees with the recommendation by zeller[11] and zlotkowski,[12] who argued that universities should strive to attract qualified teachers for the preparatory year, otherwise that year may be continuously questioned, reflecting on the impact on the quality of the outputs and thus possibly affecting reviewing its significance in the future. conclusion and recommendations this study established the validity and reliability of the newly developed questionnaire (preparatory-year programme evaluation survey) after measuring different types of construct validity evidence through efa and reliability analysis. 76 april 2021, vol. 13, no. 1 ajhpe research the study also concluded that from the student perspective, the preparatory year programme needs to be revisited, as students were satisfied with certain facets, such as ‘university conduct’, while less satisfied with other aspects, such as ‘perception of teachers, teaching and assessment’. consequently, research is needed to explore further the reasons behind the ineffectiveness of certain aspects in the preparatory year in its current format. declaration. none. acknowledgements. we thank the students who participated in the study. we also appreciate the endless support of the administration of king abdulaziz university. author contributions. ma-r: developed the idea and original research project, as well as the tool for data collection, wrote the methodology section and entered data. ha and las were supervisors. ha did the statistical analysis, wrote the discussion and edited the manuscript. eg was responsible for doing and interpreting the factor analysis and testing the tool for validity and reliability. aa helped to write the introduction and edited the manuscript. ha was mainly responsible for arranging for data collection and writing of the results. all authors critically reviewed and approved the final draft and were responsible for the content and similarity index of the manuscript. funding. none. conflicts of interest. none. 1. barefoot b, griffin b, koch a. enhancing student success and retention throughout undergraduate education. a national survey. north carolina: john n gardner institute for excellence in undergraduate education, 2012. 2. alexander js, gardner jn. beyond retention: a comprehensive approach to the first college year. about campus. 2009;14(2):18-26. https://doi.org/10.1002/abc.285 3. adelman c. the toolbox revisited: paths to degree completion from high school through college. washington, dc: us department of education, 2006. 4. barefoot bo. current institutional practices in the first college year. in: upcraft ml, gardner jn, barefoot bo, eds. challenging and supporting the first-year student: a handbook for improving the first year of college. san francisco: jossey-bass, 2005. 5. gardner j. seven principles of good practice for student success partnerships. north carolina: john n gardner institute for excellence in undergraduate education, 2013. 6. kaiser hf. the application of electronic computers to factor analysis. educ psychol measure 1960;20(1):141-151. https://doi.org/10.1177%2f001316446002000116 7. cattell rb. the scree test for the number of factors. multivariate behav res 1966;1(2):245-276. https://doi. org/10.1207/s15327906mbr0102_10 8. pett ma, lackey nr, sullivan jj. making sense of factor analysis: the use of factor analysis for instrument development in health care research. thousand oaks, ca: sage, 2003. 9. lee n, saunders j, hooley g. the evolution of ‘classical mythology’ within marketing measure development. eur j marketing 2005;39(3/4):365-385. https://doi.org/10.1108/03090560510581827 10. alkathiri n. preparatory year (first year experience). saudi j higher educ 2014;11:65-70. 11. zeller w. first-year student living environments. in: upcraft ml, gardner jn, barefoot bo, eds. challenging and supporting the first-year student: a handbook for improving the first year of college. san francisco: jossey-bass, 2005. 12. zlotkowski e. service learning and the first-year student. in: upcraft ml, gardner jn, barefoot bo, eds. challenging and supporting the first-year student: a handbook for improving the first year of college. san francisco: jossey-bass, 2005. accepted 2 january 2020. https://doi.org/10.1002/abc.285 https://doi.org/10.1177%2f001316446002000116 https://doi.org/10.1207/s15327906mbr0102_10 https://doi.org/10.1207/s15327906mbr0102_10 https://doi.org/10.1108/03090560510581827 september 2021, vol. 13, no. 3 ajhpe 157 research why was the idea necessary? the covid‑19 pandemic led to the closure of educational institutions across the globe to limit its spread. the loss of contact teaching necessitated the need for development of teaching and learning resources, which could be used where emergency remote teaching (ert) was adopted. with limited time and variable accessibility of students and teachers to educational resources, these resources needed to encapsulate core knowledge and skills, such as the completion of the partogram (a labour management tool) and gravidogram (a pregnancy growth chart). the partogram and gravidogram are essential components of the maternity case record, which is a patient‑held record used for all pregnant women in the public health sector in south africa. these pregnancy and labour monitoring tools allow the early identification and management of problems in pregnancy and labour. the world health organization advocates the use of the partogram in particular, as it has been identified as an effective tool to monitor labour and prevent obstructed labour.[1,2] all students training to be maternity care providers must be confident and skilled in the use of the partogram, as its competent use has been identified as a means to reduce maternal and perinatal mortality.[3,4] what was tried? a means was needed to provide teaching and training on essential tools used in the care of pregnant and labouring women. teaching on the use of these tools was to be offered remotely and solely online to obviate face‑to‑ face teaching. one educator and two final‑year medical students created a website (www.obstetricgrams.co.za) that synthesised both the practical and theoretical components of the maternity case record. the practical components include the standardised partogram and pregnancy growth charts (gravidogram). these virtual charts were coded to be fully interactive on any device with a web browser and internet access that allows cross‑ platform access regardless of the device. users can interact with these virtual charts as they would with a physical chart, i.e. they can plot the examination findings, write patient details and add comments. in addition, they can remove/refactor plotted data, change themes (light/dark mode) for better viewing, and download the completed virtual charts in portable network graphics (png) format. png supports lossless data compression, meaning that saving, opening and resaving an image will not reduce its quality. users can harness this feature to submit their work for assessment, or simply save for later review. the charts are constructed purely from code to minimise their size. the file size is ~250 kilobytes, which reduces the cost of access significantly, in addition to the ‘offline’ use that saving and downloading a chart allow. furthermore, the person who wrote the coding for the resource tested the charts on a wide variety of screen resolutions to ensure usability across all types of devices. the theoretical component consists of the ‘partogram learning hub’ module, which contains summarised and up‑to‑date learning points about labour and the partogram. the resource was compiled using the intrapartum care in south africa 2019 guidelines. the modules are also available to download for offline access in portable document format (pdf). this information is provided via a download function on the actual module. the guidelines used are also available for download via a link embedded in the module. expansions into the near future include additionally making them usable offline as desktop and/or mobile applications. furthermore, users are not required to create an account to access any of the content, i.e. both the charts and theory. users can submit work, report bugs and provide feedback via the ‘contact us’ link in the website. this combination of a free, lightweight, integrated and online/cross‑platform solution allows a hassle‑free learning experience; please access the qr code for the web address and demonstration. in this current age of technology, students should find this approach to teaching both different from how this was taught previously and also generationally appropriate. the lessons learnt expertise and abilities do not always reside with the teacher or their counterparts in the department, faculty or institution. students have a wealth of knowledge and skills that can be harnessed not only to develop online learning materials, but also can provide feedback and critique the materials before use because they are ultimately the end‑users. teacher‑ student collaboration can lead to the development of appropriate and user‑friendly learning resources. teacher humility can open the doors to productive engagements to develop what would work for students in their learning. working together between teachers and students, in developing resources for teaching and learning, can answer the question: ‘this is what you need; how do you want it?’ rather than: ‘this is what they need; this is how i will do it.’ despite the ‘emergency’ in developing the resource, formal evaluation of the resource is still outstanding, and this innovation does present an opportunity for further work to be done. involving a larger group in the testing prior to the launch might have provided more user feedback, but this was not possible owing to the time constraints. developing the resource has made it possible to offer this type of teaching asynchronously, making it as accessible to as many students as possible, because they were not limited to specific times with which to engage with the material; this takes students’ variable accessibility to reliable connectivity into account. what will i keep in my practice? medical students, in particular, spend limited time in the labour ward, and consequently often need to maximise skills via other means. creating a sustainable and easily modifiable teaching and learning resource that is applicable and of use to other disciplines and health science faculties, is an plotting through the pandemic j marcus, mphil, pgdip (adv mid); b nkuna, 6th‑year mb chb student; j andras, 6th‑year mb chb student department of obstetrics and gynaecology, faculty of health sciences, university of cape town, south africa corresponding author: j marcus (jason.marcus@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://www.obstetricgrams.co.za mailto:jason.marcus@uct.ac.za 158 september 2021, vol. 13, no. 3 ajhpe research indisputable way forward. the resource has been made available on social media and the departmental website for any student or teacher at any health science faculty or nursing college to use, for free. engaging with students in developing what best suits their educational needs can occur outside the formal educational milieu, and this should be actively sought. diverse input perspectives promote the inclusivity, accessibility and appropriateness of educational resources, which should be encouraged when developing learning materials for students. formal learning objectives, assessment parameters and related desired outcomes must be complemented by ongoing, detailed student feedback in terms of teaching and learning material production and refinement. furthermore, these resources need to be sustainable in terms of means of use, cost to the provider and user, and ease of editability and maintenance with, at most, minimally interrupted use when the site needs updating and maintenance. the ability to interact with a resource offline, even in part, is an important element of these considerations. what will i not do? ignoring the skill and talent that exist within the student body to contribute to the development of educational resources cannot continue. there appears to be no need to revert to synchronous, face‑to‑face teaching of these core knowledge and skills elements of perinatal care. declaration. none. acknowledgements. none. author contributions. equal contributions. funding. none. conflicts of interest. none. evidence of innovation 1. mathai m. the partograph for the prevention of obstructed labor. clin obstet gynecol 2009;52(2):256‑269. https://doi.org/10.1097/grf.0b013e3181a4f163 2. world health organisztion. who recommendations: intrapartum care for a positive childbirth experience. geneva: who, 2018. 3. dalal ar, purandare ac. the partograph in childbirth: an absolute essentiality or a mere exercise? j obstet gynaecol india 2018;68(1):3‑14. https://doi.org/10.1007/s13224‑017‑1051‑y 4. bazirete o, mbombo n, adejumo o. utilisation of the partogram among nurses and midwives in selected health facilities in the eastern province of rwanda. curationis 2017;40(1):e1‑e9. https://doi.org/10.4102/ curationis.v40i1.1751 accepted 30 april 2021. afr j health professions educ 2021;13(3):157‑158. https://doi.org/10.7196/ajhpe.2021. v13i3.1533 https://doi.org/10.1097/grf.0b013e3181a4f163 https://doi.org/10.1007/s13224-017-1051-y https://doi.org/10.4102/curationis.v40i1.1751 https://doi.org/10.4102/curationis.v40i1.1751 https://doi.org/10.7196/ajhpe.2021.v13i3.1533 https://doi.org/10.7196/ajhpe.2021.v13i3.1533 editorial setting standards in health sciences education – a wake-up call scarpa schoeman e-mail: schoemanfhs@ufs.ac.za standard setting is the process of determining what the minimum requirements are to be deemed knowledgeable or competent to practise.1 as the second decade of the 21st century progresses, we as health sciences educators in africa need to ask ourselves whether we are keeping pace with current international practice. determining the cut score or pass mark of an examination has rightfully been coined the ‘holy grail’ in assessment,2 and it is therefore not surprising that many methods have been described over the past 50 years.3-5 despite the wealth of literature on determining cut scores the ‘most widely used one (i.e. the holistic fixed percentage pass mark) is the least defensible!’2 a holistic fixed percentage pass mark is commonly still used by african institutions for both undergraduate and postgraduate assessments. by convention it is set at 50% in south africa, but ranges vary from 50% to 60% at some european and north american universities.6 why then are the vast majority of medical schools and health sciences faculties in africa still employing a holistic pass mark of 50%? where does this number come from? why is it not 52% or 55% or 45%? what is the scientific rationale for using a score of 50%? unfortunately, the answer to all these questions is the same: we don’t know! thankfully, this is not an african problem alone – the holistic fixed percentage method is still widely used in many universities around the globe. we have been using 50% (or whichever fixed percentage) since memory began. as one author put it, ‘it was pulled from the air’.3 so, why is this tried and trusted method inherently flawed? there are two key reasons: (i) we are unable to explain the rationale for using an empirically derived fixed score to our stakeholders and (ii) the method does not take into account test difficulty. cut scores have profound effects on stakeholders including the student, the university, health professions registration bodies, the department of health and most importantly the patients we serve. setting the pass mark is clearly entrenched in this process of maintaining and setting standards for graduating health professionals. our aim must surely be to strive to eliminate false positives (passing the incompetent) and false negatives (failing the competent)1,3 from our assessment systems. to be able to do this, we need to factor in the issue of test difficulty, among other things. it is logical that no two tests or examinations have the same difficulty. small, minor variances in the level of difficulty are acceptable between papers, but we have all experienced that ‘horribly difficult’ or ‘ridiculously easy’ paper. reasons why major variances in test difficulty occur are plentiful and commonly occur due to a lack of moderation and repeated use of old questions. therefore, any standard setting process used must be able to absorb these variances and adapt the pass mark accordingly.1,7 as previously mentioned there is no gold standard for determining the cut score in all circumstances.1-3,7 however, there is always an appropriate method for your institution, considering the intricate details of your situation and resources.2 in 2010, a new and exciting method for determining the pass mark for written papers was described by cohen-schotanus and van der vleuten from the netherlands.6 they called it the ‘cohen method’ and it offers a fresh perspective and approach to standard setting for written papers, in particular. in this method, the top performing students are used as a point of reference to set the pass mark. essentially the performance of the top 95th percentile of the test scores is used as the benchmark and the pass mark is set as 60 70% of the 95th percentile. this sets the pass mark as a function of the performance of the top candidates who offer a real reflection of the difficulty of the examination. the 95th percentile is used because this top cohort of students is usually stable and performs equally well between different year groups compared with the mean test score which is usually dragged down by poorly performing students. this method, as well as the borderline regression method for osces, will be the topic at the author’s workshop on standard setting at the 2011 saahe conference in potchefstroom. in conclusion, appropriate and transparent standard setting is a critical element of good assessment and educational practice.2,8 we as health sciences educators need to make this issue a top priority and move towards implementing explicable, defensible and stable standard setting methods2 to the benefit all stakeholders in health sciences education. conflict of interests: none scarpa schoeman guest editor 1. cusimano md. standard setting in medical education. acad med 1996;71(10 suppl):s112-120. 2. schuwirth lwt, van der vleuten cpm. how to design a useful test: principles of assessment. in: swanwick t, editor. understanding medical education: evidence, theory, practice. 1st ed. wiley-blackwell, 2010:204-205. 3. barman a. standard setting in student assessment: is a defensible method yet to come? ann acad med singapore 2008;37(11):957-963. 4. downing sm, tekian a, yudkowsky r. procedures for establishing defensible absolute passing scores on performance examinations in health professions education. teaching and learning in medicine 2006;18:50-57. 5. norcini jj. setting standards for educational tests. med educ 2003;37:464-469. 6. cohen-schotanus j, van der vleuten cp. a standard setting method with the best performing students as point of reference: practical and affordable. med teach 2010;32(2):154-160. 7. bandaranayake rc. setting and maintaining standards in multiple choice examinations: amee guide no. 37. med teach 2008;30(9-10):836-845. 8. norcini j, anderson b, bollela v, et al. criteria for good assessment: consensus statement and recommendations from the ottawa 2010 conference. med teach 2011;33(3):206-214. 2 june 2011, vol. 3, no. 1 ajhpe scarpa schoeman guest editor september 2021, vol. 13, no. 3 ajhpe 163 researchshort report why was the idea necessary? the undergraduate medical curriculum at the faculty of health sciences at the university of cape town (uct) has adopted an interdisciplinary, active learning approach, termed supported problem-based learning (spbl). the spbl model retains the hallmarks of a pbl curriculum,[1] which is a selfdirected,[2] collaborative, experiential and constructivist approach to learning.[3,4] however, learning is supported by lectures, tutorials and practical sessions. spbl engages active learning through facilitator-led, face-to-face smallgroup work that addresses contextually relevant paper-based cases, and aims to develop the higher-order cognition and clinical reasoning of pre-clinical students (years 1 3). students engage with each case through an eight-step process that entails interrogating their prior knowledge (i.e.  constructivism), linking important concepts, identifying gaps in their knowledge about the case (i.e. self-directed learning) and addressing these knowledge gaps through engaging with the work independently and within their spbl groups. covid-19-related risks required an urgent transition from face-to-face teaching to emergency remote teaching (ert),[5] which is an entirely online curriculum. this created significant challenges, as many students and staff struggled to work from home owing to increased family responsibilities, unstable internet connectivity and a lack of access to computer devices and data. these challenges prompted uct to issue the following guidelines for course revisions in ert, which incorporated a socially just and equitable approach: • reduced curricula time from 40 to 30 hours per week • a completely online curriculum using low technology and low data costs • asynchronous learning, i.e. information-sharing and peer engagement, which occurred without real-time sessions. furthermore, many students experienced increased anxiety, social isolation and depression owing to the covid-19 crisis. therefore an element of social cohesion had to be included in ert. a critical rationale for maintaining spbl in ert was to render emotional containment through paced online sessions with small-group learning. thus a spbl curriculum was developed to address the pedagogical challenges of ert in a south african setting, namely remote spbl. what was tried? uct’s online collaboration and learning environment, vula, was the primary technology used to drive remote spbl, especially since it was the data was zero-rated by mobile networks as a result of the covid-19 pandemic.[6] each spbl group had a dedicated ‘folder/section’ on the forums tool in vula (see evidence of innovation section), where they could actively engage with one another via asynchronous online discussions by uploading responses to learning objectives, and posting questions. however, some groups acknowledged the need for greater collaboration, and opted for synchronous discussions (i.e. realtime engagement) using various online communication tools, mainly whatsapp. narrated lectures, online tutorials and continuous formative assessments were uploaded onto vula to support student learning. student engagement with spbl cases assisted with the assimilation of complex concepts and knowledge transfer during ert. laptops and data were provided to students who required them. reduced curriculum time during ert, and the limitations of the online tools, led to certain amendments to spbl, such as the exclusion of self-directed learning (sdl) and the interrogation of prior knowledge. the loss of these principles was offset by the flexibility afforded within years 1 3, which is one extended learning cohort, thereby offering opportunities for catching up in the later years of the mb chb programme. a key priority was to ensure that students completed the core learning material. consequently, sdl was excluded, as students were provided with weekly guidelines and lesson plans to assist with time management. collaborative, experiential and contextual learning was maintained, as small-group learning continued to centre around locally relevant paperbased cases. another priority during ert was non-academic student support, and the early identification of students who were struggling academically. facilitator-led group work was maintained to ensure that a network of staff members was in contact with all students. thus the early detection of each student’s barriers to learning was facilitated and relevant support rendered timeously. spbl facilitators received training to guide their groups online and monitor student participation. an effective student referral system was developed between facilitators, students, class representatives and course convenors through consistent communications on whatsapp groups and regular (fortnightly) meetings (fig. 1). following feedback from students, facilitators and class representatives, convenors referred students to appropriate support structures. this would have been impossible if the small-group learning model was abandoned during ert. an innovative, remote supported problem-based learning model in a south african medical curriculum during the covid-19 pandemic j jayakumar,1 phd, pgdip (educat technol); f amien,2 bchd; mchd (commun dentistry); g gunston,3 mb chb, mphil (ed); l pio de paulo,3 ma (psychol res); s crawford-browne,4 msocsci (clinical social work); g doyle,5 msc (inform technol); k bugarith,3 phd 1 department of pathology, faculty of health sciences, university of cape town, south africa 2 division of public health medicine, faculty of health sciences, university of cape town, south africa 3 department of human biology, faculty of health sciences, university of cape town, south africa 4 primary health care directorate, faculty of health sciences, university of cape town, south africa 5 education development unit, department of health sciences education, faculty of health sciences, university of cape town, south africa corresponding author: j jayakumar (jaisubash.jayakumar@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:jaisubash.jayakumar@uct.ac.za 164 september 2021, vol. 13, no. 3 ajhpe short report the lessons learnt what worked remote spbl achieved the aim of providing students with academic and social support while working remotely. students found solidarity, appreciated their peers’ diverse experiences and supported one another during the pandemic. remote spbl offered an effective learning repository for students to share resources, resulting in enriched interactions with the content. moreover, students appreciated the peer-held accountability for spbl sessions, and seeing their peers’ integration of different resources. it  also ensured student inclusion, contributed to their progression and facilitated the successful completion of their courses. remote spbl offered new scope for preparing students for ethical digital communications and online learning, and developed their confidence in using technology. it strengthened the students’ capacity to effectively problem-solve using the technologies of the fourth industrial revolution, enhancing their capacity for online interaction, networking and collaboration. despite the challenges of implementing remote spbl, the core elements of the curriculum and the integration of disciplinary knowledge were maintained. responsiveness to student and facilitator feedback was central to the success of remote spbl, which evolved to be more userfriendly over time. lastly, the asynchronous format required fewer facilitators, negating the need to train new facilitators, and thereby saving on costs. what did not work during remote spbl, some challenges were identified, including the limitations of an asynchronous digital learning platform for effective group interaction and collaborative learning. this resulted in diminished interactions and visual prompts, which impacted students’ conceptual integration and discussion. this, along with limited preparation time, resulted in students’ applying bloom’s lower-order thinking skills of rote learning, rather than higher-order thinking skills[7] that utilise critical thinking and problem-solving. [8] furthermore, time management was a reported problem, as students struggled with the pace of the online curriculum, which impacted their sdl. non-academic commitments presented obstacles to accessing online learning adequately, and varied across gender, class, race and location, for example, caring for elderly relatives, young children and livestock, and trying to work in disruptive environments. what we will keep in our practice upon students’ return to campus, it was anticipated that their access to the internet would improve. where the low-technology approach necessitated asynchronous learning, which negatively impacted collaborative learning, future online spbl models will adopt a blended learning approach utilising appropriate tools and technology. this will enable an amalgamation of synchronous discussions using online communication tools, and asynchronous engagement with the learning materials. tools such as a virtual whiteboard (e.g. padlet) should be considered to enhance small-group communication and teamwork. therefore the implementation of the blended spbl approach is imperative to effectively scaffold students’ learning and facilitate their higher-order thinking skills. before embarking on remote spbl, surveys of student access to the internet, data and devices, and home circumstances, were conducted to inform the need for financial and other forms of support to ensure that no student was excluded or disadvantaged by online learning. such surveys should be updated on an annual basis for efficacious feedback to account for new students and evolving needs. remote spbl promoted group cohesion and social solidarity and provided emotional containment among students at a time of crisis. continuity in group membership and facilitation led to sustained relationships that rendered greater peer support and stability in the learning environment. therefore, spbl groups should remain the same for more than one semester. with the move to blended teaching where distanced teaching is still required, the blended spbl approach will be valuable in tracking student participation, identifying students with anxieties and challenges, providing appropriate academic, social and emotional support and fostering a sense of social solidarity, thereby strengthening collaborative learning. hence we will continue with this approach as we navigate the changing requirements for social distancing. the remote spbl innovation could be adopted in low-resourced educational and healthcare settings, owing to its easy and cost-effective approach that draws on simple web-based learning platforms. virtual collaborative learning through asynchronous peer discussion utilising problembased cases could be included in the training programmes of other healthcare professionals, and in preparing community members for task-shifting (e.g. community health workers or traditional birth attendants). what we will not do core aspects of spbl are constructivism and sdl. therefore, these steps will not be excluded in future, to ensure scaffolding of knowledge and personalised learning. spbl will also not be delivered solely asynchronously at uct as long as adequate resources are available. however, in the event of inadequate resources, the benefit of hindsight has revealed that asynchronous group discussions could be strengthened by structured and active online facilitation, and incorporating interactive tools such as blogs and padlet. we caution against dividing learning objectives among students and assessing their spbl participation, as this will further undermine collaborative learning. declaration. none. acknowledgements. we gratefully acknowledge jawaya shea for the critical feedback on the successes/highlights of online spbl support support academic support non-academic support convenors spbl facilitators students support feedback referral fig. 1. student referral system in the remote supported problem-based learning (spbl) model. september 2021, vol. 13, no. 3 ajhpe 165 researchshort report manuscript. we also gratefully acknowledge cathy de groot, jennifer ramesar, patience zantsi, candice dykes and vuyolwethu siyo for their contribution to the remote spbl model.  author contributions. all authors conceptualised, designed and implemented the remote spbl model. all authors co-wrote and provided intellectual input toward the drafting and critical revision of the manuscript. funding. none. conflicts of interest. none. evidence of innovation 1. wood d. abc of learning and teaching in medicine: problem-based learning. br med j 2003;326:328-330. https://doi.org/10.1136/bmj.326.7384.328 2. knowles m. self-directed learning: a guide for learners and teachers. new york: association press, 1975. 3. vygotsky ls. mind in society: the development of higher psychological processes. cambridge, ma: harvard university press, 1978. 4. dolmans dhjm, de grave w, wolfhagen ihap, van der vleuten cpm. problem‐based learning: future challenges for educational practice and research. med educ 2005(39):732-741. https://doi.org/10.1111/ j.1365-2929.2005.02205.x 5. centre for innovation in learning and teaching. remote teaching. cape town: cilt, 2020. http://www. cilt.uct.ac.za/cilt/remote-teaching (accessed 10 april 2020). 6. mckane, j. here is the full list of zero-rated websites in south africa. mybroadband, 17 june 2020. https://mybroadband.co.za/news/internet/356371-here-is-the-full-list-of-zero-rated-websites-in-southafrica.html (accessed 11 november 2020). 7. hussin wntw, harun j, shukor na. problem-based learning to enhance students’ critical thinking skill via online tools. asian soc sci 2019;15(1):14-20. https://doi.org/15.14.10.5539/ass. v15n1p14 8. anderson lw, krathwohl dr, airasian pw, et al. a taxonomy for learning, teaching, and assessing: a revision of bloom’s taxonomy of educational objectives. abridged edition. new york: longman, 2001. accepted 4 may 2021. afr j health professions educ 2021;13(3):163-165. https://doi.org/10.7196/ajhpe.2021.v13i3.1526 https://doi.org/10.1136/bmj.326.7384.328 https://doi.org/10.1111/j.1365-2929.2005.02205.x https://doi.org/10.1111/j.1365-2929.2005.02205.x http://www.cilt.uct.ac.za/cilt/remote-teaching http://www.cilt.uct.ac.za/cilt/remote-teaching https://mybroadband.co.za/news/internet/356371-here-is-the-full-list-of-zero-rated-websites-in-south-africa.html https://mybroadband.co.za/news/internet/356371-here-is-the-full-list-of-zero-rated-websites-in-south-africa.html https://doi.org/15.14.10.5539/ass https://doi.org/10.7196/ajhpe.2021 june 2021, vol. 13, no. 2 ajhpe 123 research medical students and interns are prone to sleep deprivation due to long and  irregular working hours. several studies have highlighted the effects  of  sleep deprivation on medical doctors.[1-7] some medical doctors displayed a  decline in their performance and mental ability due to the increase in sleep pattern disturbances and deprivation as a result of their work.[3] the current medical internship programme in south africa (sa) consists of a 2-year structured postgraduation period.[1] the interns rotate in various  key medical fields, such as surgical and medical disciplines, working  under supervision to ensure they are competent in the clinical skills  required to be an independent medical practitioner.[1] many of the interns currently working in sa healthcare facilities feel that they are ill-equipped for the responsibility and the workload experienced during their internship.[8] a study conducted on the internship programme in australia found that interns suffer from higher levels of anxiety and depression than the general population.[9] factors influencing increased levels of anxiety and depression include long working hours, conflict with colleagues and a stressful work environment.[9] in the sa healthcare system, it is common practice that medical interns work shifts of ≥30 hours, which have the potential to negatively affect not only the interns’ abilities but also how they interact with their environment.[8] a single night’s sleep deprivation may lead to a significant decrease in a doctor’s ability to complete complex tasks and reduce their problem-solving skills.[10] along with the decline in performance, it was also noted that other issues, such as reduced vigilance, patient aversion, loss of empathy, over-optimistic risk-taking, prolonged post-call recovery and adverse events in the medical field, were triggered by the effects of sleep deprivation resulting from long shifts.[10-12] medical students need to be prepared for the requirements of their profession and long working hours to maintain their cognitive abilities and decision-making to the fullest.[13,14] the performance of students improves when they are confident about their abilities, anxiety is reduced, and they can think more clearly when posed with a problematic situation.[15] the clinical simulation and skills unit at the faculty of health sciences (fohs), university of the free state (ufs), bloemfontein, sa, allows lecturers at the fohs to train medical students on technical and nontechnical aspects required by their profession (personal communication, prof. mj labuschagne, clinical simulation unit, school of clinical medicine, background. sleep deprivation is a problem for medical students and practitioners due to long and late working hours, which may result in a decline in their performance in practising medicine. objectives. to investigate whether educational practices require altering with regard to the time at which simulation classes are presented, or identify any other possible suggestions for improving the preparation of students for shift work in their profession as medical doctors as a potential solution to reduce sleep-deprivation-related adverse outcomes. methods. in this quantitative cross-sectional study, an anonymous questionnaire was distributed to 111 fourth-year and 141 fifth-year medical students at the faculty of health sciences, university of the free state (ufs), bloemfontein, south africa, during the second half of 2018. the researchers interpreted the responses and the department of biostatistics, ufs, analysed the data. results. the majority of the fourth-year (88.6%) and fifth-year (90.4%) student groups responded that late-night simulation classes between 01h00 and 04h00 would not be beneficial to their preparation for shift work. the motivation for negative responses was that it might worsen sleep deprivation due to time constraints in an already demanding course. the fourth-year (61.4%) and fifth-year (80.5%) student groups did not regard simulation as realistic and felt that late-night simulation training sessions would not prepare them better for future shift work. however, both groups believed ‘practice makes perfect’ and, as such, their confidence with procedures would improve as they practise more during simulation. conclusion. the majority of students were negative towards the idea of late-night simulation classes, because of the effect it would have on their already full programme. students are familiar with the effects of sleep deprivation and felt that late-night simulation classes would add pressure to their busy lives and worsen their sleep deprivation. further investigation and practical testing would be required to conclude the impact of late-night simulation classes in preparation for shift work of medical doctors and the resultant effect on clinical performance. afr j health professions educ 2021;13(2):123-128. https://doi.org/10.7196/ajhpe.2021.v13i2.1267 late-night simulation: opinions of fourthand fifth-year medical students at the university of the free state, bloemfontein, south africa c theron,1 medical student; t-l van zyl,1 medical student; a joubert,1 medical student; b kleynhans,1 medical student; p van der walt,1 medical student; m g hattingh,1 bsocsci (nurs), badv (nurs), pg dip labour law, mhpe; g joubert,2 ba, msc 1 clinical simulation and skills unit, school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m hattingh (hattinghmgm@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 124 june 2021, vol. 13, no. 2 ajhpe research ufs, 11 april 2018). simulation-based training can be used by students to practise different procedures and techniques until they feel comfortable and competent.[15] this training improves their self-confidence and makes them better doctors.[15] a study by laack et al.,[16] at an australian medical school, regarding the use of extended immersive live-action simulation training, which included ‘on-call’ night shifts as part of the exercise, was regarded as ‘highly effective’ by the respondents. in a randomised, controlled trial aimed to determine the educational benefits of extended immersive simulation, it was shown that immersive simulation led to an increase in the preparedness of medical students for their role as medical doctors.[17] definition of key terms the researcher’s definition of late-night classes was a class between 01h00 and 04h00. this definition was used, as it was found that after 18 20 hours without sleep, a person’s ability to complete tasks is similar to that of a person suffering from minor alcohol intoxication.[18] total sleep deprivation can be defined as the duration of time that has passed since the end of the preceding period of sleep.[4] total sleep deprivation is referred to as ‘sleep deprivation’ throughout this study. aim this study aimed to determine whether the students deemed late-night simulation-based training as beneficial in preparing them for the clinical phase of their training and their future work as interns and doctors. the study included the following objectives: • to determine the general sleeping patterns and sleep requirements of fourthand fifth-year medical students at the fohs, ufs • to determine the effect that sleep deprivation has on the medical students • to establish whether the medical students feel they are adequately prepared for the long working hours and late-night shifts, and the measures that could be implemented to make them feel better prepared for the demands of the work environment • to determine the influence of clinical simulation classes on the medical students regarding the skills that they acquire, their opinions about being adequately prepared for the workload and long hours, as well as a possible reduction in errors and self-confidence while tired • to establish whether the medical students regard late-night simulation training sessions to possibly be beneficial in preparing them for the long working hours and late-night shifts • to describe any differences between the opinions of male v. female students • to determine how many students have repeated a year in the mb chb undergraduate medical programme at ufs and whether there is a link to other aspects being researched. methods this was a quantitative cross-sectional study. study population the target population comprised mb chb undergraduate medical students  at the fohs, ufs, who were in their fourth and fifth year of studies  in 2018;  in  total 111 and 141 students, respectively. all students were eligible for participation, but those who chose not to participate and any absentees on the day that the questionnaires were distributed, were excluded. data management data were collected via an anonymous, self-administered english questionnaire distributed to all willing respondents in the study population. the researchers were present while the respondents completed the questionnaire to assist with the administration surrounding the completion and intake of questionnaires. the researchers composed the questionnaire, which comprised closedended quantitative questions, with a number of open-ended followup questions to capture the students’ opinions.[19] data collection was completed during the compulsory scheduled class time, which minimised logistical complications and ensured an adequate response rate. pilot study the newly developed questionnaire was pre-tested to evaluate the contentrelated validity and sequencing of the questions. this questionnaire was distributed to 2 fohs lecturers, who were familiar with the topics of the effects of shift work and simulation training, to evaluate the validity of the questionnaire, and 2 fohs fourth-year and 2 fifth-year medical students. additional space was provided on the questionnaire to allow for comments or suggestions by the respondents. the feedback regarding changing of the sequence of the questions and altering the categories of 2 questions was implemented. the data collected from the 6 questionnaires were excluded from the main study. data analysis the quantitative data were entered into an excel version 16 (microsoft corp., usa) document by the researchers as nominal categorical variables.[20] the answers to the open-ended follow-up questions were categorised into similar themes before forming part of the data set. the researchers did the qualitative data analysis. the quantitative data analysis was performed by the department of biostatistics, ufs. results were summarised as frequencies and percentages. the χ2 and fisher exact tests were used to compare the differences between the fourthand fifth-year group responses, as well as the male and female responses in the respective year groups. ethical approval approval for the research project was obtained from the health sciences research ethics committee (hsrec), ufs (ref.  no.  ufshsd2018/0431/3107), the dean of the fohs, dean of student affairs, head of the school of clinical medicine and the vice-rector: research, ufs. the respondents were provided with a short overview of the study on an information document attached to the questionnaire. the following was explained in the information document: purpose of the study; no one would benefit from the study other than the contribution that the results of the study would make to research; time required for respondents to complete the questionnaire; how data were to be protected and stored; and how anonymity would be maintained. respondents were also assured that participation was voluntary and that they could withdraw at any stage during the data collection process without any retribution. consent was implied by the completion of the questionnaire. to ensure anonymity, no identifiable data were collected. june 2021, vol. 13, no. 2 ajhpe 125 research results a total of 71 questionnaires was received from the fourth-year class, of which 1 questionnaire had to be omitted owing to it being largely uncompleted. the response rate for the fourth-year class was 64.8% (n=70/108). a total of 84 questionnaires was received from the fifth-year class, of which 1 questionnaire had to be omitted owing to untrustworthy data entries. the response rate for the fifth-year class was 60.6% (n=83/137). the median age for the fourth-year students was 22 (range 20 27) years, while the median age for the fifth-year students was 23 (21 28) years. almost 60% of the fourth year students were female (58.6%; n=41) compared with just over half of the fifth year students (53.0%; n=44). of the fourth-year respondents, 18.8% (n=13) had to repeat a year of their studies, while 21.7% (n=21) of the fifth-year respondents had to repeat a year. the majority of fourth-year (72.9%) and fifth-year (66.3%) respondents indicated that they needed 7 8 hours’ sleep to feel well rested (table  1). two-thirds of fourth-year (65.7%) and fifth-year students (65.1%) reported that they usually slept 5 7 hours a night during the academic term. a  statistically significantly higher percentage of fourth-year students (89.9%) felt they did not have enough time for sleep, work and study compared with 72.3% of fifth-year students. both groups felt negative about their decision-making in the clinical setting when they were sleep deprived (fourth year ‒ 60.9%; fifth year ‒ 49.4%). the majority of students from both groups (fourth year ‒ 79.7%; fifth year ‒ 86.7%) felt that their sleep deprivation might negatively affect their patient interaction (table  2). based on the open responses given, the main effects mentioned by fourth-year students were negative patient interaction, student becoming irritable and student being less patient, whereas the main  effects mentioned by fifth-year students were negative patient interaction, student  becoming irritable and the consultation and examination being rushed. students felt unprepared (fourth year ‒ 55.1%; fifth year ‒ 44.6%) for the long working hours combined with their studies, but did not feel that a change in the curriculum would prepare them for the hours and study work table 1. sleeping patterns and sleep requirements variable fourth-year students, n (%) fifth-year students, n (%) p-value how many hours of sleep do you need to feel well rested? n=70 n=83 fisher’s 0.1948 1 2 0 0 3 4 2 (2.9) 0 5 6 11 (15.7) 22 (26.5) 7 8 51 (72.9) 55 (66.3) ≥9 6 (8.6) 6 (7.2) how many hours do you normally sleep per night during the academic term? n=70 n=83 fisher’s 0.7848 1 3 0 0 3 5 13 (18.6) 12 (14.5) 5 7 46 (65.7) 54 (65.1) 7 9 11 (15.7) 16 (19.3) ≥9 0 1 (1.2) do you feel you normally have enough time for sleep, work and study? n=69 n=83 χ2 0.0067 yes 7 (10.1) 23 (27.7) no 62 (89.9) 60 (72.3) how is your confidence in decision-making in the clinical setting impacted while sleep deprived? n=69 n=83 χ2 0.2602 positive 6 (8.7) 6 (7.2) negative 42 (60.9) 41 (49.4) neutral 21 (30.4) 36 (43.4) table 2. students’ opinions regarding sleep deprivation and preparedness variable fourth-year students, n (%) fifth-year students, n (%) p-value do you think sleep deprivation may have a negative effect on your patient interaction? n=69 n=83 fisher’s 0.4145 yes 55 (79.7) 72 (86.7) no 10 (14.5) 9 (10.8) unsure 4 (5.8) 2 (2.4) do you feel adequately prepared for the long hours of work and late-night shifts, combined with the amount of study hours required in the clinical phase of your training? n=69 n=83 χ2 0.4792 yes 22 (31.9) 34 (41.0) no 38 (55.1) 37 (44.6) unsure 9 (13.0) 12 (14.5) do you think the curriculum should be adjusted to prepare you for the long hours of work and study of the clinical phase? n=69 n=83 χ2 0.6157 yes 17 (24.6) 17 (20.5) no 44 (63.8) 59 (71.1) unsure 8 (11.6) 7 (8.4) do you think repeating procedures during simulation training assisted you to become skilled in those procedures? n=68 n=83 χ2 0.4860 yes 50 (73.5) 55 (66.3) no 14 (20.6) 19 (22.9) unsure 4 (5.9) 9 (10.8) would more simulation training sessions prepare you better for the workload and long hours of work of the clinical phase? n=70 n=82 χ2 0.0249 yes 17 (24.3) 12 (14.6) no 43 (61.4) 66 (80.5) unsure 10 (14.3) 4 (4.9) do you think more exposure to late-night clinical work will teach you to make fewer errors and be more confident while tired? n=70 n=83 χ2 0.7615 yes 16 (22.9) 17 (20.5) no 48 (68.6) 56 (67.5) unsure 6 (8.6) 10 (12.0) do you think clinical simulation training sessions between 01h00 and 04h00 would be beneficial in preparation for night-shift work? n=70 n=83 fisher’s 0.9206 yes 3 (4.3) 4 (4.8) no 62 (88.6) 75 (90.4) unsure 5 (7.1) 4 (4.8) 126 june 2021, vol. 13, no. 2 ajhpe research during their clinical phase (fourth year ‒ 63.8%; fifth year ‒ 71.1%). the main suggestion in the fifth-year group regarding how their preparedness could be improved, was course adjustment. examples of these were: ‘in the second half of third year, we very suddenly went from 1 2 classes per day that started at 09h00 to being put in hospital daily from 08h00 to 13h00 and classes from 14h00 with after-hours work. it was a dramatic change’; and ‘more sleep and more reasonable daytime schedules and some night simulation training’. the fourth-year group made a wide variety of suggestions, such as: ‘more study time should be allocated instead of only providing 3 days to prep for 3rd and 4th surgery, internal medicine … exams’; and ‘from 3rd to 4th year the amount expected from you is too much’. the main reason the fourth-year group required a curriculum change was that students considered the 5-year course too short: ‘course should be 6 years’; and ‘… make the curriculum 6 years again to give more time to study in the clinical phase’. in both year groups, the main reason why students considered repetition of procedures in simulation helpful was that practice makes perfect, whereas the main reason for disagreeing with this statement was that simulation was not realistic. statistically, more fifth-year students (80.5%) than fourth-year students (61.4%) felt that more simulation training sessions will not prepare them better (p=0.0249). the main reasons for this response in both year groups were that simulation is not realistic and the course is demanding. almost 70% of students from both groups (fourth year ‒ 68.6%; fifth year ‒ 67.5%) did not feel that more exposure to late-night clinical work would result in fewer errors and more confidence, as the students are tired. in both year groups, the main reasons for this response were that it would cause or worsen sleep deprivation, and the course is demanding enough. the majority of fourth-year (88.6%) and fifth-year (90.4%) students did not feel that clinical simulation training between 01h00 and 04h00 would be beneficial in preparation for night-shift work. in both year groups, the main reasons for this response were that sleep is more important, the course is demanding enough, it would cause or worsen sleep deprivation and it is not practical. upon further analysis, no significant associations were found between having failed a year and responses to questions. furthermore, per year group, no significant differences were found between genders. discussion response rate as seen in the results, the response rate for the fourth-year class was 64.8%, while the response rate for the fifth-year class was 60.6%. the questionnaires were distributed during information sessions presented by the mb chb programme management and not during academic sessions. despite these sessions being compulsory, students often did not attend. therefore, the most probable reason for the low response rate could be attributed to low class attendance. this rate, however, is comparable with previous experience. in ufs undergraduate medical student projects on fifth-year medical students, the median response rate was 68%, with response rates ranging from 17% to 85%. only 2 studies in fourth-year student groups have been conducted since 2001, recording response rates of 49% and 82%, respectively (personal communication, prof. g joubert, department of biostatistics, school of biomedical sciences, ufs, 21 january 2019). demographics the gender distribution for the fourthand fifth-year student respondents showed a slight predominance of females, which is similar to the gender distribution of the classes as a whole (fourth year ‒ 57.4% female; fifth year ‒ 49.6% female). the age distribution of the study population was also within the expected range appropriate for the year of study. from this it can be deduced that the response group accurately reflects the total study population. objectives objective 1: to determine the general sleeping patterns and sleep requirements of fourthand fifth-year medical students at the fohs, ufs the recommended sleep duration for young adults is between 7 and 9 hours per night.[21] the majority of both student groups felt that they require between 7 and 8 hours of sleep per night to feel well rested. however, the amount of sleep the students usually obtained was between 5 and 7 hours. therefore, the majority of students in the fourthand fifth-year groups were not getting enough sleep during the academic term and might have experienced varying degrees of sleep deprivation. objective 2: to determine the effect that sleep deprivation has on the medical students the majority of the students in both year groups felt that there was not enough time to balance sleep, work and study. possible reasons for the larger percentage in the fourth year than the fifth year include the differences in course intensity, i.e. fifth-year students are possibly more mature in their decision-making and are more comfortable with their workload and working environment due to more prolonged exposure, which might have allowed them to cope better with their academic load and management of time. the majority of respondents felt that their confidence was negatively affected when they were sleep deprived. despite fewer fifth-year students sharing this sentiment, nearly half of the fifth-year group felt that sleep deprivation had a negative impact on their confidence. this is in line with results reported by parshuram et  al.,[5] who found that sleep deprivation decreased the confidence levels of doctors. the majority of fourthand fifth-year students felt that sleep deprivation had a negative impact on their interaction with patients. the reasons they provided for their answers are in line with research that states that sleep deprivation has multiple effects, including reduced performance and vigilance, patient aversion, loss of empathy, over-optimistic risk-taking, prolonged post-call recovery and adverse events in the medical field.[10-12] objective 3: to establish whether the medical students feel they are adequately prepared for the long working hours and late-night shifts and the measures that could be implemented, in their opinions, to make them feel better prepared for the demands of the work environment more than half of the fourth-year students and just less than half of the fifthyear students did not feel prepared for the time requirements of the clinical phase of their training. the wide variety of open responses related mainly to the lack of available time. the students felt that the 5-year course was very demanding and full, for example: ‘changing the course to 6 years and not cramming everything in just to say we did it.’ june 2021, vol. 13, no. 2 ajhpe 127 research objective 4: to determine the influence of clinical simulation classes on the medical students regarding the skills that they acquire, their opinions on being adequately prepared for the workload and long hours, as well as a possible reduction in errors and self-confidence when tired the recurring opinion of ‘practice makes perfect’ surfaced in the responses listed for both year groups. the students once again confirmed that more simulation-based training would improve their efficiency and make them more comfortable with procedures, but not prepare them better for the workload and hours of the clinical phase. one can therefore deduce, on account of the students’ opinions, that the negative aspects and complications of additional simulation training would outweigh the benefits. objective 5: to establish whether the medical students regard late-night simulation training sessions to possibly be beneficial in preparing them for long working hours and late-night shifts nearly 90% of students of both year groups felt that late-night simulation classes would not be a good idea. it should be emphasised that many of the students who answered ‘no’, listed logistical and other minor technical details, such as student safety and lack of simulation realism, as reasons for their answers. students do not necessarily have a negative outlook on late-night work; however, they feel that more exposure to late-night simulation during their course would not improve or prevent sleep deprivation. if the simulationbased training were to be ‘realistic’ and placed in a time slot that would suit the students, a different overall response to this particular question could be obtained. objectives 6 and 7: to describe any differences between the opinions of male v. female students and determine how many students have repeated a year in the mb chb undergraduate medical programme at ufs, and whether there is a link to other aspects being researched there was no statistically significant difference between the answers given by male and female students. owing to the small number of students who failed, no association between those who failed and any other question asked in the questionnaire could be determined. methodological errors during the pilot study, the suggestion was made that the interval ranges for  the number of hours of sleep that students require and obtain should be  changed from 1-hour to 2-hour intervals. this was altered for only 1 of  the 2 questions, which made a comparison of hours required and obtained difficult. although an adequate response rate was recorded for this study, it could have been improved by possibly distributing the questionnaires during an academic session. the researchers were unaware that 6 cuban-trained students, who had different exposure to the clinical environment and simulation, were included in the study population of the fifth-year students. although the overall effect on the data should be minimal, the impact of their responses on the results cannot be determined, as the questionnaires were anonymous. conclusion the majority of respondents felt that late-night simulation would not assist them. they regarded late-night simulation as an addition to an already demanding course and therefore rejected the idea, not necessarily due to its flaws, but due to the impact it would have on their programme. the students felt that late-night simulation sessions would add extra pressure to their already time-constrained programme. furthermore, it can be concluded that the fourthand fifth-year medical students at the fohs, ufs, are familiar with the effects of sleep deprivation and are exposed to late-night shift work during their rotations. the participants were also aware of the advantages of simulation training and were positive regarding participating in this educational strategy in general. recommendations this topic needs further investigation and practical testing to conclude the impact of late-night simulation classes in preparation for the shift work of medical doctors and the resultant effect on clinical performance. it would be beneficial to perform a similar study on medical interns, as they work regular shifts, experience sleep deprivation regularly and have a better understanding of the clinical environment as a whole. clinical testing of late-night simulation classes on a group of students or interns is planned by the research team as a step towards determining the value of such sessions, rather than relying solely on the opinions of the study population. it could be of value to investigate students’ opinions if the late-night simulation session is not be an additional session, but if it replaces one of the current simulation sessions or a clinical rotation session. other time slots, such as from 10h00 to 02h00, can also be investigated. declaration. none. acknowledgements. we would like to acknowledge dr nc theron for his input and supervision throughout the project, dr n fourie for her input and diligent proofreading, mrs c coetzee, for proofreading and recommendations, and ms t mulder, medical editor, faculty of health sciences, ufs, for technical and editorial preparation of the manuscript. author contributions. ct, t-lvz, aj, bk and pvdw were medical students who conceived the idea, compiled the protocol, performed the data collection and wrote the first draft of the manuscript. mgh was the study leader, who supervised the students through the project process. gj advised with the planning of the study, performed the quantitative analysis and assisted with the write-up of the manuscript. funding. none. conflicts of interest. none. 1. health professions council of south africa. handbook on internship training. pretoria: hpcsa, 2017:4-6. 2. yasin r, muntham d, chirakalwasan n. uncovering the sleep disorders among young doctors. sleep breath 2016;20(4):1137-1144. https://doi.org/10.1007/s11325-016-1380-6 3. de grado j. are you alert and oriented to person, place and time? sleep deprivation in physicians. grad med educ news 2010;15(7):22. 4. wali so, qutah k, abushanab l, basamh r, abushanab j, krayem a. effect of on-call-related sleep deprivation on physicians’ mood and alertness. ann thorac med 2013;8(1):22-27. https://doi.org/10.4103/1817-1737.105715 5. parshuram cs, dhanani s, kirsh ja, cox pn. fellowship training, workload, fatigue and physical stress: a prospective observational study. can med assoc j 2004;170(6):965-970. https://doi.org/10.1503/cmaj.1030442 6. welp a, meier ll, manser t. emotional exhaustion and workload predict clinician-rated and objective patient safety. front psychol 2015;5:1573. https://doi.org/10.3389/fpsyg.2014.01573 7. purim ks, guimarães at, titski ac, leite n. sleep deprivation and drowsiness of medical residents and medical students. rev col bras cir 2016;43(6):438-444. https://doi.org/10.1590/0100-69912016006005 8. bola s, trollip e, parkinson f. the state of south african internships: a national survey against hpcsa guidelines. s afr med j 2015;105(7):535-539. https://doi.org/10.7196/samjnew.7923 9. willcock sm, daly mg, tennant cc, allard bj. burnout and psychiatric morbidity in new medical graduates. med j aust 2004;181(7):357-360. 10. sun nz, gan r, snell l, dolmans d. use of a night float system to comply with resident duty hours restrictions: perceptions of workplace changes and their effects on professionalism. acad med 2016;91(3):401-408. https:// doi.org/10.1097/acm.0000000000000949 11. wen j, cheng y, hu x, yuan p, hao t, shi y. workload, burnout, and medical mistakes among physicians in china: a cross-sectional study. biosci trends 2016;10(1):27-33. https://doi.org/10.5582/bst.2015.01175 12. erasmus n. slaves of the state ‒ medical internship and community service in south africa. s afr med j 2012;102(8):655-658. https://doi.org/10.7196/samj.5987 https://doi.org/10.1007/s11325-016-1380-6 https://doi.org/10.4103/1817-1737.105715 https://doi.org/10.1503/cmaj.1030442 https://doi.org/10.3389/fpsyg.2014.01573 https://doi.org/10.1590/0100-69912016006005 https://doi.org/10.7196/samjnew.7923 https://doi.org/10.1097/acm.0000000000000949 https://doi.org/10.1097/acm.0000000000000949 https://doi.org/10.5582/bst.2015.01175 https://doi.org/10.7196/samj.5987 128 june 2021, vol. 13, no. 2 ajhpe research 13. murray a, pounder r, mather h, black dc. junior doctors’ shifts and sleep deprivation. bmj 2005;330(7505):1404. https://doi.org/10.1136/bmj.330.7505.1404 14. hawkins f, murphy jg, dunn wf. ‘is my doctor impaired, or just sleep deprived?’ chest 2009;136(5):1194-1197. https://doi.org/10.1378/chest.09-1213 15. brown dk. simulation before clinical practise: the clinical advantages. audiol today 2017;29(5):17-23. 16. laack ta, newman js, goyal dg, torsher lc. a 1-week simulated internship course helps prepare medical students for transition to residency. simul healthc 2010;5(3):127-132. https://doi.org/10.1097/ sih.0b013e3181cd0679 17. rogers gd, mcconnell hw, de rooy nj, ellem f, lombard m. a randomised controlled trial of extended immersion in multi-method continuing simulation to prepare senior medical students for practice as junior doctors. bmc med educ 2014;14:1-10. https://doi.org/10.1186/1472-6920-14-90 18. bonnet mh, arand dl. clinical effects of sleep fragmentation versus sleep deprivation. sleep med rev 2003;7(4):297-310. https://doi.org/10.1053/smrv.2001.0245 19. maree k, pietersen j. first steps in research. pretoria: van schaik publishers, 2012. 20. ehrlich r, joubert g. epidemiology: a research manual for south africa. 3rd ed. cape town: oxford university press southern africa, 2014:133. 21. hirshkowitz, m, whiton k, albert sm, et al. national sleep foundation’s sleep time duration recommendations: methodology and results summary. sleep health 2015;1(1):40-43. https://doi.org/10.1016/j.sleh.2014.12.010 accepted 27 may 2020. https://doi.org/10.1136/bmj.330.7505.1404 https://doi.org/10.1378/chest.09-1213 https://doi.org/10.1097/sih.0b013e3181cd0679 https://doi.org/10.1097/sih.0b013e3181cd0679 https://doi.org/10.1186/1472-6920-14-90 https://doi.org/10.1053/smrv.2001.0245 https://doi.org/10.1016/j.sleh.2014.12.010 june 2021, vol. 13, no. 2 ajhpe 135 research in recent years, there has been increasing interest for most medical education programmes to encourage reflection as a required competency. programmes in higher education use student reflections as a measure to evaluate programmatic success.[1] the literature defines reflective learning as a mode of internally enquiring and questioning an issue of concern, caused by an experience.[2] this concern, which relates to the experience, creates and clarifies meaning for the student to learn from, which then translates into changes in their perspective. reflective practice also helps to facilitate insights that might otherwise be missed. there is consensus among  researchers that reflective practice must be demonstrated in observation of professional practice by students; similarly, in the education of students.[3,4] moon[5] lists many reasons for the practice of using journals and reflection as part of learning, such as fostering reflective and creative interaction; increasing active involvement in learning; and personal ownership of learning. she argues that enabling learners to understand their own learning process through reflection can be effective in aiding and reinforcing learning. daudelin[6] suggests that reflection allows the opportunity for students to take a step back from an experience to ponder, carefully and persistently, its meaning to the self through the development of inferences. this would suggest that learning is the creation of meaning from past or current events and can serve as a guide to future behaviour. these two important conditions for learning from experience, i.e. self-reflection and meaning-making, facilitate the formation of insights from past events and the application of these insights to future actions.[6] the graduate entry medical programme (gemp) at the university of the witwatersrand, johannesburg, south africa (sa) was introduced in 2003 as a 4-year training medical programme that complements the traditional approach, leading to the completion of the mb bch degree. through this programme, students are exposed to aspects of community-based healthcare practice, including providing them with clinical skills necessary to function optimally in rural and urban community settings. the integrated primary care (ipc) block is a 6-week preceptorship in either a rural or urban primary healthcare centre, which may take place in a variety of settings, such as a healthcare centre or a clinic or district hospital, based in gauteng or north west province.[3] as part of the ipc block, final-year medical students were asked to write short reflective stories of no more than 55 words on experiences that had the greatest impact at the end of each of week, until week 5 of their 6-weekly placement. to date, students continue to reflect using this tool for the block. fifty-five-word stories make use of creative background. reflection and reflective practice are identified as a core competency for graduates in health professions education. students are expected to be in a position to process experiences in a variety of ways through reflective learning. in doing so, they can explore the understanding of their actions and experiences, and the impact of these on themselves and others. objectives. to draw on 5-weekly reflections by final-year medical students during the integrated primary care block placement. these reflections explore the learning that occurred during the rotation and the change in experiences during this period, and illustrate the use of reflection as a tool to support the development of professional practice. methods. this descriptive qualitative study analysed students’ 55-word reflective stories during a 6-week preceptorship in either a rural or urban primary healthcare centre. the writing technique of short 55-word reflective stories was used to record student experiences. inductive thematic analysis was conducted using maxqda software. this involved identifying the most commonly used words for each week through a word cloud, highlighting each week’s most notable focus for learning to generate themes and sub-themes. results. analysis of 127 logbook entries generated 464 stories on a range of experiences that had a significant impact on learning. students’ reflections in the first 2 weeks were linked to personal experiences and views about the block. in subsequent weeks, reflections focused on the individual responses of students to the learning experiences regarding the curriculum, patient care, ethics, professionalism and the health system. conclusions. the reflections highlighted the key learning experiences of the medical students and illustrated how meaning is constructed from these experiences. the 55-word stories as a reflection tool have potential to support reflection for students, and provide valuable insight into medical students’ learning journey during their clinical training. afr j health professions educ 2021;13(2):135-140. https://doi.org/10.7196/ajhpe.2021.v13i2.1332 medical students using the technique of 55-word stories to reflect on a 6-week rotation during the integrated primary care block a r dreyer,1 ba, adv dip adult ed, mph; m g mlambo,1,2 phd; n o mapukata,3 msc (health care management), msc (med) 1 department of family medicine and primary care, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 department of institutional research and business intelligence, portfolio: strategy, risk and advisory service, university of south africa, pretoria, south africa 3 school of public health and family medicine, faculty of health sciences, university of cape town, south africa corresponding author: a dreyer (abigail.dreyer@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1332 mailto:abigail.dreyer@wits.ac.za 136 june 2021, vol. 13, no. 2 ajhpe research writing elements of prose.[7] the stories consist of 55 words and take on a poetic expression. this creative writing technique was first introduced in 1986 at an independent alternative weekly newspaper in california, usa, as part of a writing competition. a 55-word story challenges one to pack in a lot in just a few words and has a structure, with 4 elements:[7] • the setting is any place where the story is told. it can be the consultation room, the hospital or any space, including your mind. • one or more characters can be the patient, self or even an inanimate object. • conflict involves an event, which could be a fear, fight, conspiracy, reason or even silence. • resolution is a solution that concludes the story, giving the reader a good message or summary. box 1 details how fogarty[7] proposes that a 55-word story should be written. according to fogarty, there is the gain of understanding of key moments for the writers and readers. there is also the gain of the healing arts in the shortness of the pieces, which adds to the impact of writing and reading. objectives this article draws on 5-weekly reflections by final-year medical students during the ipc block placement. the reflections determine the student learning that occurred during the rotation and the change in experiences during this time, and illustrates the use of reflection as a tool to support the development of their professional practice. methods design this descriptive qualitative study analysed 55-word reflective stories by medical students during a 6-week rotation. students had to complete a section in their logbook, which required them to reflect on a weekly basis by  writing 55-word reflective stories, recording their experiences of all learning activities, such as clinical skills. population and data collection we used the data collected during the 2014 academic year as part of the ipc block placement. all final-year medical students participating in the ipc block placement were required to document 55-word reflective stories as part of the logbook. a total of 127 students submitted their reflective weekly stories for 5 weeks of the 6-week block. box 2 shows the instruction as it appears in the logbook. the weekly reflective stories had no specific instruction regarding the details that should be included. data analysis a total of 464 stories that were documented during one academic year (2014)  were thematically coded and analysed using maxqda software version  11 (verbi software, germany). through an interactive inductive reasoning approach, the authors analysed each story to understand whether  the reflective process influenced the learning experience or if it contributed to the development of professional practice of the students. the spelling and grammar of the stories were not subjected to an editing process. a word cloud was generated weekly to identify the most commonly used words in each week as an illustration of the most notable focus for learning. the most prominent words in the word cloud provided the themes  to  group  the stories. stories were then separated based on whether there was a positive or negative tone. all authors completed this process of coding to ensure intercoder reliability. fig. 1 summarises the coding process.  direct quotations from students were used to support the identified themes. ethical approval we received approval for the ongoing evaluation of the ipc block from the wits human research ethics committee (ref. no. m1311162). the section box 1. how to write a 55-word story[7] 1. think of a compelling story based on your experience (as clinician, patient, other?). 2. write down everything you can think of. 3. don’t edit, just write (phrases, words, key chunks of memory). 4. put it away (optional and can be done at any time between #2 and finishing). 5. read over your writing and begin to clarify the idea or storyline that you want to convey. 6. begin editing, sometimes ruthlessly. 7. share your work with others for reactions and feedback. 8. keep editing until you get to 55 words. use your word counter, and also double check manually. a. title doesn’t contribute to word count but shouldn’t be more than 7 words. b. contractions count as single words. c. eliminating articles (the, a, an) can help with word count. 9. if you cannot cut enough words, you probably have material that either would lend itself to a longer essay or become multiple 55-word stories. 10. given the brevity, formatting can make a big difference. experiment with line length, indentations, hanging indents, and other use of white space. box 2. instruction to students as it appears in the logbook reflective stories at the end of each of week, until week 5, write a short reflective story about any experience that made the biggest impact on you in that week. this can be anything about your experiences on the site, clinical experiences, consultations, interactions with staff, home visits, referrals, etc. the story should not be more than 55 words, thus forcing you to focus very clearly on the key issues and to crystallise your experience. (see guide for details and examples.) positive negative facility patient care disease/illness ethics/values health system coding guide word cloud analysis personal studies/course patients peers/mentors community fig. 1. coding process for 55-word stories. june 2021, vol. 13, no. 2 ajhpe 137 research on reflective stories that forms part of this study was not used as part of the overall assessment of students. no biographical details of the students were captured for the study. data analysis was conducted independently of the assessment of the programme. results in total, 5 weekly reflections from 127 students were captured. through consensus, the identified major themes oscillated between personor patientcentred reflections, and influences on students’ reflective practice. the coding process revealed two major shifts that had a positive and negative tone. in week 1, the response rate was 75.6% (n=96). in week 2, there was a notable decline in the response rate at 66.1% (n=84). in the 2 follow-up weeks, the response rate was 74.8% for week 3 (n=95) and 74.8% for week 4 (n=94). during the last week of the reflections (week 5), the response rate was 74% (n=94). we hypothesise that the variation in the number of submitted reflections is attributed to the focus on placement objectives and adjustment of having to meet the demands of a clinical rotation. the maximum effort in week 3 is attributed to an adjustment to the setting, clarity on the objectives of the block and confidence that the placement would prepare students for the examination that is completed at the end of the rotation. positive/negative shifts in reflective stories the positive/negative shifts during the 5 weeks are presented in fig.  2. interestingly, the positive shift illustrated the impact on learning in weeks 2 - 4, when students were clearly focused on their objectives and the learning that is provided in the placement. personal/patient shifts in reflective stories during the 5 weeks, there was a significant shift in the focus on the reflective stories. in week 1, the stories focused more on the personal experiences of adjusting to being in clinical settings outside of the academic training complex. from week 2, the stories were significantly more patient centred. a word cloud was generated by capturing words that suggested patientfocused reflections. initially, students submitted a rather personalised viewpoint in their reflections. a shift became evident as students began to prioritise patients (fig. 3). influences on students’ reflective practice the first dominant theme related to personal reflections had 4 sub-themes, i.e. studies/course, patients, peers/mentors and community. the second dominant theme related to the facility; it had 5 sub-themes, i.e. facility, patient care, disease/illness, ethics/values and health system. the narrative accounts provided by students on their commitment to their chosen profession often focused on personal factors, such as peer companionship and independence. students indicated the importance of peer companionship ‒ especially at the beginning of a block ‒ as a determining factor for looking forward to providing service. the excerpt below shows the initial feelings of a student regarding the block, which later changed when peer companionship was realised: ‘krugersdorp, muldersdrift. sounds foreign. and strange. i got my wits survival kits, so i hope to god i’ll be fine. my initial thoughts on the ipc block. but oh, how wrong i was! actually truly impressed and loving it. our group is really amasing, and it seems like i’m definitely going to enjoy this block.’ ‘infectious smiles filling the waiting area. a pleasant change from grumpy, ill faces that we are usually exposed to. working in the well-baby clinic provided a different sense of satisfaction. providing immunisations and cheerful chatter left me feeling unusually positive, as opposed to the negativity often associated with many of our hospital cases.’ peer companionship appeared to be strikingly important, as it allowed students to appreciate who they were, as they reported similar experiences together: ‘settling in to our new home for 5 weeks. i learn all about my new roommates. sharing where we grew up, went to school and what drives us. understanding the different reasons for studying medicine. looking forward to experiencing the highs and lows together. what a good start to our 3rd block this year.’ a feeling of independence also influenced students’ commitment to the practice of medicine. although challenging at first, students enjoyed managing patients and providing the necessary treatment, while also assuming the role of a doctor. this point is echoed by one of the students: ‘beginning to love this block. every day is an adventure for me filled with great learning experience. i feel like a qualified doctor in my own consultation room dispensing medication and writing sick notes. it is really exciting to be a part of the primary healthcare team.’ as the role of a doctor is assumed, the need to be familiar with the content becomes more evident: r e� ec ti ve s to ri es , n 90 80 70 60 50 40 30 20 10 0 stories week 1 week 2 week 3 week 4 week 5 negative positive fig. 2. positive/negative shifts in reflective stories. r e� ec ti ve s to ri es , n 80 70 60 50 40 30 20 10 0 stories week 1 week 2 week 3 week 4 week 5 personal patients fig. 3. personal/patient shifts in reflective stories. 138 june 2021, vol. 13, no. 2 ajhpe research ‘little girl who knew her abc, came in with red patches on her skin and knee, on history no trauma or injury, but her shins full of red, swollen mystery. what could the diagnosis possibly be? the mystery of her shins  and knee. the next day it all came to me, erythema nodosum possibly.’ ‘you found your feet. previously lost in seas of patients. a pre-programme due to patients. accustoming to discipline, people you’ll never meet. but now you start down a new road. vast oceans with different tides. no one behind whom to hide. the undifferentiated territory is broad. but you use the gate keeper. it’s only you.’ having receptive staff made students appreciate their attachment to the site and, as such, developed their commitment to the profession. students felt that having friendly staff who were willing to offer guidance when needed, greatly assisted their learning. to show appreciation towards the health facility staff, one of the students said: ‘what impacted me the most this week was the friendliness and welcome reception we received from all the staff (nurses and doctors) in both the clinics and hospitals during our calls. each person helped us achieve the most that we could, from every learning experience.’ the interest in medicine was also influenced by academic factors, such as having a significant learning experience, an opportunity to practise skills and an institutional reputation endorsement. a meaningful experience was seen as an important factor for influencing future professional practice. one student narrated how the amount of learning becomes nothing if there is no experience attached to it: ‘i don’t know anything! but you’ve spent 6 years at medical school? so? i don’t know anything! submandibular abscess, communityacquired pneumonia, infertility, urinary retention-acute! so broad! so undefined! it could be anything! i could see anyone! good! you’ve read it before, at least once! but, what’s knowledge without experience? a challenge, of course!’ ‘i can see how this has the potential to be a beautiful and enriching experience. i will try in earnest to make it, even though living here in suboptimal conditions, will prove a considerable challenge. i am sure i can adapt. i will not lie, though, it has already begun to dampen my spirits.’ significant learning experience was also evident with application of knowledge and skills learnt: ‘working in the clinics was initially challenging. the nurses, patients, diseases and problems that i encountered were unique. even though i was equipped with the knowledge, i now needed to apply it in such a way that i had never done before. this was a new skill i had to learn. i needed to adjust.’ ‘my perceptions and reluctance to put effort (with all honesty) into my home visit as planned with sister ellen was perpetually turned upside down in a matter of minutes. seeing the harrowing nature of circumstances people live in first hand gave me a deeper appreciation for my life, and highlights the unfairness we so nearly share. since this day no matter how much i thank my lord, it can never be enough.’ the ability to practise skills learnt also influenced the interest students had in doing the work. the two stories below illustrate reflection on the skill. it appears that both stories relate to circumcision. in the first story, there is an awareness of the role of after-hours calls in creating opportunities for learning though practice under supervision: ‘as part of our weekend call we participated in medical male circumcision services. it was a wonderful learning experience. we were able to perfect our suturing skills. we were fortunate to be taught by a very studentoriented doctor. who afforded us the opportunity to do circumcisions on patients unsupervised.’ in support of learning through practice, the second story illustrates mastery of skill: ‘circumcisions are easy, declared the doctor as he completed one in less than 5 minutes. now it was my turn, with shacking hands i began taking 20 minutes for the first ‘cos i lacked suturing experience. however, as i did more, i became faster ‒ moral: practice makes perfect.’ institutional reputation endorsement by clinical staff was another academic factor that had a positive influence on the medical students’ approach to work. students were resolute in demonstrating a commitment to the profession, as they felt that they had a responsibility to uplift the reputation of their academic institution: ‘i am … from … university! so, you are from … university! you guys have your ducks in a row. this was a common response i got from most of the doctors after introducing myself. it evoked feelings of inadequacy and also activated me to excel so i can live up to the “… university student” title.’ discussion the adoption of 55-word stories as one of the widely accepted journaling tools in family medicine, where reflective practice is just as critical as the practice of medicine itself,[8] was a novel experience for us. as a tool for professional growth and stimulating personal reflection on key training experiences, the combination of fogarty’s[7] approach and a word cloud generator became critical in guiding a process that appropriated the value of 55-word stories. self-reflection encourages students to assume responsibility for their learning experience and also build a rapport between them and the site facilitator as they agree to disagree,[9] which is evident in the interplay of numerous factors influencing our students’ 55-word stories. furthermore, this reflection supports spending quality time with patients, becoming tuned to the patient experiences, and thus adapting to the environment.[10] reflective learning diaries play a role in mediating the limitations faced by medical students, and are an essential component of doctoring that is congruent with the experiences that were reflected by the students.[11,12] we propose that through this process of story-telling, the experiences of our students are validated as they connect with their patients emotionally in the process of providing healthcare.[13] the difficult encounters that students refer to, as well as associated behaviours of feeling anxious, are similar to those reported by shapiro et  al.[14] in such instances, taking a moment to reflect is an opportunity to engage  realistically on the range of clinical encounters as an affirming practice and a critical influence of one’s professional development,[3] while also preparing for future practice.[2,15] the student narratives, while mostly focused on patient encounters, also provide insight to career affirmation that is realised,[10] professional relationships that are established and friendships that are formed at a moment in time. personal factors, such as having peer companionship and independence, influenced the students’ commitment to the practice of medicine. this june 2021, vol. 13, no. 2 ajhpe 139 research peer companionship and independence facilitated learning for students during their ipc block placement. these factors were further facilitated by student placement in small, intimate, clinical settings in groups of 3 4 students.[3] such facilities created opportunities for students to learn from each other,[8] learn together and share tasks.[9] similarly, in other studies, the student reflective accounts further revealed that managing patients holistically empowered them to build confidence and contribute to role identification for themselves as future healthcare providers.[3,6] a study conducted in a similar setting found that students felt more confident through experiential learning.[8] our study found that the students’ dedication and passion for work were highly motivated by site factors, such as having receptive staff and good teachers, who they could look up to as role models.[3,8,10] academic factors were also shown to have an influence on their eagerness to work with patients. additionally, we found that knowledge alone does not translate into experience. through their 55-word reflective stories, experience was seen as an important factor to enable students to practise what they knew.[8] the narrative that the students presented through their reflections is informed by a setting that is different to the mainstream academic training complex with which they are familiar. the uncertainty that comes with managing difficult encounters, their professional skills (which may be inadequate for the setting) or issues related to patient experiences also influence the students’ reflections. conclusions interest in reflection is based on the assumption that its value is linked to helping professionals to learn about and improve their practices.[15] all our students’ stories speak to their professional development. the stories demonstrate a mode of internal inquiry that is consistent with reflective learning. more research is needed to explore how this feedback can be utilised to inform the design and planning of such activities to improve the future placements of students. declaration. none. acknowledgements. the authors would like to extend their appreciation to the co-ordinators of the block, prof. ian couper and dr rainy dube, and to the students who so eagerly engaged in sharing their 55-word stories. acknowledgment and thanks are also due to the research interns, alessandra caldeira, papike makhuba, mmapula adams and sine madlala, for deciphering bad handwriting and capturing with such accuracy. author contributions. ard: conceptualisation, data collection, thematic analysis, literature review, framework development, manuscript writing; mgm: literature review, thematic analysis, manuscript writing, editing; and nom-s: literature review, manuscript writing, editing. funding. none. conflicts of interest. none. 1. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. adv health sci educ 2009;4(4):595-621. https://doi.org/10.1007/s10459-007-9090-2 2. finlay l. reflecting on ‘reflective practice’. 2008. https://oro.open.ac.uk/68945/1/finlay-%282008%29reflecting-on-reflective-practice-pbpl-paper-52.pdf (accessed 1 june 2021). 3. mapukata no, dube r, couper i, mlambo m. factors influencing choice of site for rural clinical placements by final year medical students in a south african university. afr j prim health care fam med 2017;9(1). https://doi.org/10.4102/phcfm.v9i1.1226 4. mcalpine l, weston c. reflection: issues related to improving professors’ teaching and students’ learning. instruct sci 2000;28(5):363-385. https://doi.org/10.1023/a:1026583208230 5. moon ja. reflection in learning and professional development: theory and practice. london: routledge, 1999. 6. daudelin mw. learning from experience through reflection. organ dynamics 1997;24(3):36-48. 7. fogarty ct. fifty-five word stories: ‘small jewels’ for personal reflection and teaching. fam med 2010;42(6):400-402. 8. cameron d, wolvaardt l, van rooyen m, hugo j, blitz j, bergh a-m. medical student participation in community-based experiential learning: reflections from first exposure to making the diagnosis. s afr fam pract 2011;53(4):373-379. https://doi.org/10.1080/20786204.2011.10874117 9. tai jh-m, haines tp, canny bj, molloy ek. a study of medical students’ peer learning on clinical placements: what they have taught themselves to do. j peer learn 2014;7(6):57-80. 10. van rooyen m. using fourth-year medical students’ reflections to propose strategies for primary care physicians, who host students in their practices, to optimise learning opportunities. s afr fam pract 2010;54(6):513-517. https://doi.org/10.1080/20786204.2012.10874285 11. nevalainen mk, mantyranta t, pitkala kh. facing uncertainty as a medical student ‒ a qualitative study of their reflective learning diaries and writings on specific themes during the first clinical year. patient educ counsel 2010;78(2):218-223. https://doi.org/10.1016/j.pec.2009.07.011 12. charon r. narrative medicine: a model for empathy, reflection, profession, and trust. j am med assoc 2001;286(15):1897-1902. https://doi.org/10.1001/jama.286.15.1897 13. shapiro j, bezzubova e, koons r. medical students learn to tell stories about their patients and themselves. ama j ethics 2011;13(7):466-470. 14. shapiro j, rakhra p, wong a. the stories they tell: how third year medical students portray patients, family members, physicians, and themselves in difficult encounters. med teach 2016;38(10):1033-1040. https://doi. org/10.3109/0142159x.2016.1147535 15. schön d. the reflective practitioner. new york: basic books, 1983. accepted 27 august 2020. https://doi.org/10.1007/s10459-007-9090-2 https://oro.open.ac.uk/68945/1/finlay-%282008%29-reflecting-on-reflective-practice-pbpl-paper-52.pdf https://oro.open.ac.uk/68945/1/finlay-%282008%29-reflecting-on-reflective-practice-pbpl-paper-52.pdf https://doi.org/10.4102/phcfm.v9i1.1226 https://doi.org/10.1023/a https://doi.org/10.1080/20786204.2011.10874117 https://doi.org/10.1080/20786204.2012.10874285 https://doi.org/10.1016/j.pec.2009.07.011 https://doi.org/10.1001/jama.286.15.1897 https://doi.org/10.3109/0142159x.2016.1147535 https://doi.org/10.3109/0142159x.2016.1147535 124 october 2020, vol. 12, no. 3 ajhpe research the role that context plays in the teaching and learning space has been well documented, characterised as complex and dynamic, and changing in response to competing international and local demands.[1] this complexity has been recognised in health professions education, with calls for the adaptation of existing curricula that do not adequately equip graduates in the health professions to meet the needs of the communities they serve.[2,3] understanding the context – the surroundings, circumstances, environments and settings within which learning must occur, particularly when seeking to inform such curriculum renewal processes – is therefore important. several years ago, harden[4] argued that an important aspect of curriculum development and renewal is the undertaking of a proper assessment of the learning environment, a dimension of context. the training of healthcare professionals requires that teaching and learning take place across a range of contexts that extend beyond the traditional classroom, and typically include the clinical space. researchers in the field have explored context, arguing that this concept extends beyond the physical environment.[5] its influence has been described as multifaceted, comprising the physical (environmental), semantic (contribution to the learning task) and affective (relating to motivation and responsibility) dimensions.[5] context in health professions education has been described in terms of the setting, the participants and their interactions,[6] while others view it as six core patterns, including the patient, and the physical, practice, educational, institutional and social contexts.[7] in the field of nursing education, research exploring context and its influence on the learning experiences of nursing students has also been conducted. studies have sought to determine the degree to which different entities within the educational context affect the learning experiences of nursing students, including the contribution made by the educator,[8] the type of supervision offered by the manager[9] and the dynamics within the team.[10] work of other authors points to the psychosocial factors, physical resources and organisational culture within the learning contexts as critical elements influencing learning experiences.[11] it is evident that there are multiple factors within the educational context that may influence learning experiences, which ought to be considered. in south africa (sa), nursing education is currently undergoing significant curriculum renewal across its range of undergraduate programmes.[12] therefore, to better understand how the context influences teaching and learning, specifically among undergraduate nursing students, a scoping review was undertaken. methods scoping reviews are useful for reviewing and synthesising the available evidence, as well as identifying the ‘nature and extent’ of research available on a particular topic.[13] this scoping review was guided by the first 5 of 6 stages for review proposed by arksey and o’malley,[13] which include identifying the research question, identifying relevant studies, selecting the studies for inclusion, charting the data, collating, summarising and reporting results, and consultation. the research team determined the purpose and steps of the review and research questions were identified. the agreed aim of this review was to synthesise perspectives from previous studies related to the influence of context on the teaching and learning experience of undergraduate nursing students. to inform this (step 1), one broad question was decided on for the scoping review: how does the context influence the teaching and learning of undergraduate nursing students? background. the role that context plays in the teaching and learning space has been well documented. objectives. to synthesise perspectives from previous studies related to the influence of context on teaching and learning among undergraduate nursing students. methods. this study was guided by the stages for review proposed by arksey and o’malley. six databases were searched, generating 1 164 articles. based on the eligibility criteria, the articles were screened through several processes, resulting in 55 articles being included in the final review. results. five themes were identified, including the organisational space, the nature of interactions in the healthcare team, the role of the nurse manager, the role of the educator and the academic institution-hospital engagement. conclusion. while there are many studies of the role of context in teaching and learning, this review highlights the interconnectedness of the various factors within the learning context, providing a framework that can inform decision-making when seeking to enhance teaching and learning in nursing education. afr j health professions educ 2020;12(3):124-129. https://doi.org/10.7196/ajhpe.2020.v12i3.1373 the influence of context on the teaching and learning of undergraduate nursing students: a scoping review r meyer, rn, rm, mphil health sciences education, ba cur (education and management), dip operating room technique; s c van schalkwyk, phd; e archer, phd centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: r meyer (rhodameyer@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 125 research the search was conducted widely to identify relevant studies (step 2) related to the topic. six databases were included, i.e. cinahl, eric (ebscohost), medline, proquest, google scholar and web of science. the search commenced in may 2018 (step 3), guided by specific inclusion criteria as determined by the research team. data were collected from literature published from january 2008 to june 2018 to capture the more recent work in this area. all study designs were considered, including quantitative, qualitative and mixed methods. this review also considered empirical and secondary studies, e.g. reviews and conceptual articles. finally, only those articles published in english were examined. in consultation with a librarian, a set of search terms was agreed on (box 1). using the prespecified terms and criteria, the initial search yielded a total of 1 164 articles (step 4). after 17 duplicate articles were removed, the title and abstract of the papers were reviewed against the inclusion criteria, resulting in a total of 183 articles. abstracts were rejected for two main reasons: when reference was made to students other than nursing students, and/or when there was no reference to the learning context. the full texts of the selected papers were entered into a database and reviewed by one of the authors, at which point all articles not applicable to undergraduate nursing students were excluded, resulting in a total of 55 articles eligible for full analysis (fig. 1). data were extracted from the included articles and entered into the data extraction sheet in excel (microsoft, usa) (step 5) (box 2) (detailed list – addendum a (http://ajhpe.org.za/public/files/1373.doc)). this analysis was guided by the main question and keywords/ideas (box 3), based on the earlier perspectives of koens et al.,[6] durning et al.[5] and bates and ellaway,[7] which informed the theoretical framework for this study. the first stage of the content analysis involved one of the authors familiarising herself with the content. thereafter, similar concepts were grouped together to generate codes. similar codes were combined to form themes and sub-themes.[14] these codes, sub-themes and themes were then reviewed by the co-authors. to further enhance the trustworthiness of the study, an experienced senior research assistant independently analysed the data. the two analyses were then compared to identify similarities and box 1. terms included in the search • ‘nursing students’ or ‘student nurses’ or ‘undergraduate student nurses’ or ‘student nurses diploma’ or ‘student nurses midwifery’ or ‘baccalaureate nursing students’; and • ‘learning environment’ or ‘context’; and • ‘learning’ or ‘clinical learning’ or ‘facilitation’ or ‘training’ or ‘learning experiences’ or ‘contextual learning’ or ‘education’ in cl u d ed el ig ib ili ty sc re en in g id en ti �c at io n duplicate articles removed, n=17 literature identi�ed through cinahl, n=531 literature identi�ed through eric, n=102 literature identi�ed through medline, n=192 literature identi�ed through web of science, n=80 literature identi�ed through google scholar, n=191 literature identi�ed through proquest, n=68 total, n=1 164 articles kept after abstract screening, n=183 articles included in review, n=55 fig. 1. study identification and selection. box 2. summary of extracted data categories • author and year of publication • location of study (country) • institution (university, public nursing college, private nursing college) • nature of study (qualitative, quantitative, mixed methods) • study population • definition of different teaching roles (clinical facilitator, mentor, preceptor, clinical educator) • contextual factors http://ajhpe.org.za/public/files/1373.doc 126 october 2020, vol. 12, no. 3 ajhpe research discrepancies that were resolved through further discussions and consensus. in addition to the abovementioned steps, an audit trail was kept by clearly documenting steps taken throughout the review.[15] according to arksey and o’malley,[13] consultation with stakeholders regarding the findings of the scoping review is an optional step that could be included. however, this step was not utilised for this review. results of the 55 articles eligible for review, 23 used qualitative study designs, 14 used quantitative study designs, 7 used mixed methodology, 8 were reviews, 1 was presented as a conference paper, 1 was a conceptual paper and 1 was an editorial. the 8 review articles focused on specific aspects of context, e.g. factors affecting the adoption of deep approaches to learning,[16] factors affecting readiness to practice,[17] and the influence of sociocultural factors on perceptions of learning.[18] this review adopted an overarching approach seeking to explore all aspects within the learning context that may have influenced teaching and learning. forty-four articles described empirical studies mostly conducted at universities. however, a small percentage (19%) was conducted at public nursing schools and private nursing schools, representing the traditional range of nursing institutions. studies reported in publications were conducted in 19 countries, with australia, the uk and the usa contributing more than half of the included studies (n=28). thirty-six studies examined the influence of contextual factors on learning from the perspective of students, 1 article from the perspective of the head of the school,[19] 1 from the perspective of educators and students,[20] another from the perspective of supervising nurses and students, and 5 from the perspective of qualified nurses in the ward and students. five themes were identified from this review (table 1), which frame the context within which teaching and learning of undergraduate nurses take place, including the organisational space, the nature of interactions within the healthcare team, the role of the nurse manager/senior nurse, the role of the educator, and the academic institution-hospital engagement. these five themes represent components of context that influence the way teaching and learning experiences were perceived by the various participants in the included studies (addendum a (http://ajhpe.org.za/public/files/1373.doc)). while the findings below are presented according to themes, there is a high degree of integration between them, resulting in some overlap. organisational space the organisational space, i.e. the place where the training of nurses was undertaken, was one of the most dominant themes across the included studies. it comprises three sub-themes, i.e. the physical environment and organisational structures within the institution, the organisational culture, and the organisational climate within the learning environment. physical environment and organisational structures this sub-theme relates to all the structural issues – the ways in which the parts of a system are arranged – that may influence the creation of an environment conducive to learning. physical factors that negatively influenced learning experiences included large class sizes[21] and lack of restrooms, facilities, space, equipment and learning tools.[11,22-25] a specific physical aspect that improved learning experiences was the availability of infrastructure to enable the use of technology in teaching and learning.[26-28] one of the factors related to organisational structures that negatively influenced learning experiences was insufficient staffing in the clinical areas, resulting in higher workloads for the students engaged with workplacebased learning, who were expected to fulfil more tasks than might have been expected of them in more fully staffed environments.[25,29-31] outcomes of these higher patient workloads for students included increased stress,[29,30] emotional and physical burnout[31] and ‘superficial learning’, reducing satisfaction with the learning environment.[25] insufficient staffing and increased stress also influenced the dynamics within the healthcare team and the extent to which educators were able to provide support owing to less time allocated for teaching.[32,33] some studies revealed that students had a positive experience when the context enabled exposure to variable learning opportunities specific to their level of training.[20,34] students also indicated that a longer duration of clinical placement increased their exposure to learning opportunities,[20,32,34,35] while sufficient time for clinical teaching and learning allowed the opportunity to develop clinical skills and consolidate knowledge.[10,32,35] this issue is addressed below. another aspect related to organisational structures was the presence of social hierarchies.[31] these hierarchies, which are based on age, work experience and job titles, seem to have negatively influenced learning experiences, as students indicated that they felt positioned at the bottom of the hierarchy. organisational culture culture is seen to reside in the ideas, norms, values and customs of a particular context.[36] according to some of the included articles, an organisational culture that promotes learning includes aspects such as the organisation’s box 3. keywords/ideas relating to contextual factors • anything related to the physical setting or environment • any factors that contributed to the learning task • any factors relating to the motivation and responsibility of the student • any patient-related factor that influenced learning • participants in the learning environment who may have impacted on students’ learning • any factors related to that of nursing that may have influenced teaching and learning • educational factors that may have influenced teaching and learning • factors related to the educational and healthcare institution that may have influenced learning • factors within the social context that may have influenced teaching and learning table 1. themes and sub-themes organisational space physical environment and organisational structures organisational culture climate of the learning environment the nature of interactions within the healthcare team role of the nurse manager/senior nurse role of the educator academic institution-clinical engagement october 2020, vol. 12, no. 3 ajhpe 127 research perception of nursing education as a valuable entity,[35] leadership styles that promote quality learning experiences,[11] the manager’s positive attitude towards education,[33] and organisational policies that support teaching, learning and supervision.[11,22,37] low levels of organisational support, e.g. not recognising the role of informal teaching as an inherent function of experienced nurses, seemed to be another recurring theme.[11,22,25,32] it was argued that these factors reflected a culture that did not support teaching and learning.[38] denison[39] distinguishes between organisational climate and culture, referring to climate as ‘a situation and its link to thoughts, feelings, and behaviors of organisational members’. flott and linden[11] suggest that organisational culture influences organisational climate, where an organisation that values education has a positive climate and vice versa. therefore, although both concepts are interrelated, they will be discussed separately. climate of the learning environment in the included studies, climate was linked to a sense of belonging within a team, influenced by the nature of interactions. being welcomed by the staff created a positive climate, which contributed to a positive learning environment,[10,40-43] one that specifically supported learning.[10,42,43] factors creating a negative climate included unfriendliness, stress and fatigue among staff.[18,31,33,44] although it might seem that an enabling climate is an essential contributor to the learning environment, one study found that students rated the ward climate less important to learning than the role of the educator.[45] however, this finding was ascribed to students being taught by various members in the healthcare team, and that they were possibly dissatisfied with the lack of a designated educator. this issue will be discussed below (see: role of the educator). the nature of interactions within the healthcare team creating an environment conducive to learning requires support and recognition from fellow senior students, ward staff, senior nurses, medical personnel and managers. support from fellow senior students and peers reduced the feeling of isolation for some students,[18,24,46] while a positive attitude towards learning by other students and staff in the unit (the team) enhanced learning experiences.[20,37,47,48] other positive aspects relating to the healthcare team included being recognised as a team member,[10,37,45,49] receiving acknowledgement from medical personnel,[48] being recognised as autonomous practitioners within the team,[10,36,38,46] experiencing mutual respect, good communication and positive interactions with team members.[10,11,46,50-52] aspects related to this theme that served as barriers included students feeling unwanted by and a hindrance to senior nurses,[10,47] and sensing that other medical personnel and/or their colleagues did not respect them[53] or have confidence in their ability to perform certain skills.[42] role of the nurse manager/senior nurse supervision in health professions education often refers to a wide range of activities. in the context of this review, however, supervision encompasses managing the work performance of the nursing team, including the student, as well as offering clinical teaching.[20,33,54] the included studies revealed that support offered through supervision is perceived as an important component of the context that influences students’ learning experiences.[8,33,34] the ward manager and senior nurses were perceived as central to creating an environment conducive to learning through effective management and supervision in the clinical environ ment.[8,33,37,53] aspects such as availability of the manager to teach,[55] and a positive supervisory relationship between the manager and the student,[18] were perceived as factors that promoted learning. although satisfaction with the amount of exposure students received was influenced by the role of the educator, it was clear that organisational support and the role of the nurse manager/senior nurse invariably influenced the time allocated to formal clinical teaching and learning[33,38,48] as mentioned above (see: physical environment and organisational structures; and organisational culture). a negative aspect highlighted in two of the included studies as an obstacle to effective learning experiences was when the nurse manager or senior nurses were perceived as being unaware of learning objectives, with minimal consideration for encouraging student independence.[33,56] role of the educator this theme focuses on those specifically appointed to the teaching role. the importance of distinguishing between the various role-players involved in the teaching of students in the clinical environment was highlighted.[57-59] although there are different role-players involved in the teaching/supervision of students, most of the studies that refer to this theme did not provide clear definitions or distinguishing features of the roles of mentors, preceptors, clinical facilitators and clinical educators. nevertheless, many articles pointed to the importance of the educator role, as preceptor or mentor in preparing the environment for teaching and learning.[8,10,45] key factors that seemed to have enabled learning included a higher level of educator competence in terms of teaching ability,[44] the allocation of students to a designated educator, as described above (see: climate of the learning environment),[9,33,43,45] frequent contact with educators,[34] and constructive relationships between students and educators.[8,22,43] inevitably, the converse of these situations often tended to negatively influence learning, such as the lack of preparedness for teaching sessions by educators,[48] the allocation of different educators, or the absence of a designated educator during clinical placement.[30] furthermore, a lack of congruence between student and educator expectations,[29] poor mentorship,[44] limited support by educators in achieving learning objectives,[53,60] a lack of feedback[40] and negative attitudes of educators towards students[25] constrained effective learning experiences. academic institution: hospital engagement the nature of nursing education typically implies a relationship between an academic institution and a hospital. although not dominant across the included studies, it was evident that this relationship had an influence on the learning culture in the clinical learning environment. engagement between role-players occurs in different contexts: institutionally, in the clinical space, in the classroom and interpersonally. some of the included studies also revealed that an enabling environment is premised on meaningful engagement between the academic institution and the clinical learning environment.[37,43,61,62] for example, learning experiences were perceived as positive when there was better co-operation between academic and ward staff,[37,43,61,62] as this fostered a more positive climate in which learning could take place.[62] poor co-operation resulted in frustrated students, creating a negative learning experience.[53,61,62] moreover, poor interpersonal 128 october 2020, vol. 12, no. 3 ajhpe research relationships between academic staff and ward staff caused confusion and limited the opportunities for ward staff and nurse managers to assist students in meeting their learning objectives.[61] summary the organisational space seems to have shaped the teaching and learning context by influencing all other contextual influences presented in this review. furthermore, it is evident that the other contextual factors in the included articles have varying degrees of influence on each other, as well as the organisational space. fig. 2 provides a visual perspective of the interrelatedness of the various themes. discussion this review confirms that context is indeed a complex concept,[7] encompassing multiple components that interact with one another in different ways and across different levels. however, this review also offers a framework (fig. 2) to better understand this complexity. it is clear that the way in which context influences teaching and learning is best understood across structural, cultural and interpersonal domains, as discussed below. it is evident that the organisational space has a major influence on the way teaching and learning takes place within a healthcare institution. therefore, those responsible for developing nursing curricula need to be mindful of the challenges and affordances that are available within the organisational space and then plan accordingly. furthermore, this framework posits that the relationship between the academic institution and hospital sets the tone for the way in which the organisational climate and culture are established. this culture and climate permeate the various interactions that a nursing student is exposed to, whether in the clinical domain or in the classroom. a proper assessment of the dynamics within the context through its influence on teaching and learning is therefore essential when seeking to improve teaching, learning and curriculum renewal.[4] findings from this review suggest the presence of multiple sources of teaching, both formal and informal, by various role-players in the clinical environment, affirming the complexity of nursing education. these roleplayers form an integral part of the context, influencing students’ learning experiences in varying degrees.[37,43,61,62] to achieve synergy among the roleplayers, it is necessary to acknowledge the contributions of these individuals, including the academic staff, educators in the clinical environment, the healthcare team and nurse managers. what seems to be absent in this review is the distinct role of the patient as a contextual factor in the learning environment. this is in contrast to what bates and ellaway[7] found in their scoping review, which points to patient characteristics as a recurring theme in their included articles. finally, the role of the student, who is central to the discussion on teaching and learning, did not seem to feature in any of the reviewed articles. if we consider what norman and schmidt[64] said when they claimed that ‘the context includes all features of the environment at the time of learning …’, which is still relevant to current health professions education, then in a clinical learning context, the essential role of the patient and student and its influence on teaching and learning must be considered. there are a number of limitations that must be kept in mind when reading the results of this review. some relevant articles may have been unintentionally excluded owing to the inclusion of only articles published in english, in scientific journals, and from 2008 to 2018. in addition, the quality of the articles included in this review was not formally appraised,[13] as the intention of this scoping review was to provide a description of what was available on the topic. furthermore, while a research assistant provided some sample checking, one of the authors (rm) was predominantly responsible for populating the data extraction sheet. conclusion the learning context as an integral part of teaching, learning and curriculum renewal is currently receiving increased attention. although there have been many studies on the role of context in teaching and learning, this review highlights the interconnectedness of the various factors within the learning context. given the current transitions in nursing education, we argue that further research into the influence of context is needed, especially for those seeking to enhance teaching and learning across all spheres (clinical and classroom). declaration. none. acknowledgements. the authors acknowledge the contribution made by ilse meyer, who conducted an additional data extraction and analysis for comparison. author contributions. rm, scvs, ea: conception and design of the study; rm, scvs, ea: acquisition of data, analysis and interpretation of data; rm: drafting the article; scvs, ea: revising the article critically for important intellectual content; scvs, ea, rm: final approval of the version to be submitted. funding. none. conflicts of interest. none. 1. bitzer e. inquiring the curriculum 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review. j nurs educ 2015;14(8):421-428. https://doi.org/10.3928/0148483420150717-01 55. rebeiro g, edward k, chapman r, evans a. interpersonal relationships between registered nurses and student nurses in the clinical setting – a systematic integrative review. nurse educ today 2015;35(12):1206-1211. https:// doi.org/10.1016/j.nedt.2015.06.012 56. melincavage sm. student nurses’ experiences of anxiety in the clinical setting. nurse educ today 2011;31:785-789. https://doi.org/10.1016/j.nedt.2011.05.007 57. mills je, francis kl, bonner a. mentoring, clinical supervision and preceptoring: clarifying the conceptual definitions for australian rural nurses. a literature review. rural remote health 2005;5(3):410-419. 58. bray l, nettleton p. assessor or mentor? role confusion in professional education. nurse educ today 2007;27:848-855. https://doi.org/10.1016/j.nedt.2006.11.006 59. holland k, lauder w. a review of evidence for the practice learning environment: enhancing the context for nursing and midwifery care in scotland. nurse educ pract 2012;12(1):60-64. https://doi.org/10.1016/j. nepr.2011.05.008 60. salamonson y, everett b, halcomb e, et al. unravelling the complexities of nursing students’ feedback on the clinical learning environment: a mixed methods approach. nurse educ today 2015;35(1):205-211. https://doi. org/10.1016/j.nedt.2014.08.005 61. mabuda bt, potgieter e, alberts uu. student nurses’ experience during clinical practice in the limpopo province. curationis 2008;31(91):19-27. https://doi.org/10.4102/curationis.v31i1.901 62. watt e, pascoe e. an exploration of graduate nurses’ perceptions of their preparedness for practice after undertaking the final year of their bachelor of nursing degree in a university-based clinical school. int j nurs pract 2013;19(1):23-30. https://doi.org/10.1111/ijn.12032 63. houghton ce, casey d, shaw d, murphy k. students’ experiences of implementing clinical skills in the real world of practice. j nurs pract 2012;22(13-14):1961-1969. https://doi.org/10.1111/jocn.12014 64. norman gr, schmidt hg. the psychological basis of problem-based learning: a review of the evidence. acad med 1992;67(9):557-565. https://doi.org/10.1097/00001888-199209000-00002 accepted 24 june 2020. https://doi.org/10.1111/j.1365-2929.2005.02338.x https://doi.org/10.1097/acm.0b013e3181d7427c https://doi.org/10.1097/acm.0b013e3181d7427c https://doi.org/10.1111/medu.13034 https://doi.org/10.1016/j.nedt.2014.01.009 https://doi.org/10.1016/j.nedt.2014.01.009 https://doi.org/10.1016/j.nedt.2013.06.023 https://doi.org/10.1016/j.nedt.2015.11.013 https://doi.org/10.1016/j.nedt.2015.11.013 https://doi.org/10.1111/jan.12861 https://doi.org/10.1080/1364557032000119616 https://doi.org/10.1111/nhs.12048 https://doi.org/10.1097/acm.0b013e31828abf7f https://doi.org/10.1016/j.edurev.2010.06.001 https://doi.org/10.1016/j.profnurs.2017.03.003 https://doi.org/10.1016/j.profnurs.2016.03.006 https://doi.org/10.14804/1-1-24 https://doi.org/10.1016/j.nepr.2012.01.003 https://doi.org/10.3928/01484834-20111017-05 https://doi.org/10.1016/j.nedt.2015.03.015 https://doi.org/10.1016/j.nedt.2015.03.015 https://doi.org/10.4102%2fcurationis.v39i1.1507 https://doi.org/10.1016/j.nepr.2015.12.008 https://doi.org/10.1016/j.nedt.2017.09.008 https://doi.org/10.1111/jan.12509 https://doi.org/10.1016/j.nepr.2009.03.006 https://doi.org/10.1111/j.1365-2648.2010.05453.x https://doi.org/10.1111/inm.12054 https://doi.org/10.1111/inm.12054 https://doi.org/10.1111/jocn.12506 https://doi.org/10.1016/j.nepr.2017.12.003 https://doi.org/10.1016/j.nepr.2015.07.002 https://doi.org/10.1016/j.nepr.2015.07.002 https://doi.org/10.1016/j.nepr.2013.11.005 https://doi.org/10.1016/j.nepr.2013.11.005 https://doi.org/10.15452/cejnm.2016.07.0017 https://doi.org/10.15452/cejnm.2016.07.0017 https://doi.org/10.1016/j.colegn.2015.03.001 https://doi.org/10.1111/j.1365-2923.2011.04059.x https://doi.org/10.1016/j.nedt.2015.02.005 https://doi.org/10.1016/j.nedt.2015.02.005 https://doi.org/10.1016/j.nepr.2013.08.012 https://doi.org/10.1016/j.nepr.2013.08.012 https://doi.org/10.2307/258997 https://doi.org/10.1111/j.1440-172x.2007.00664.x https://doi.org/10.1016/j.nedt.2008.01.003 https://doi.org/10.1016/j.nedt.2015.01.012 https://doi.org/10.1016/j.nedt.2015.01.012 https://doi.org/10.1016/j.nepr.2017.05.002 https://doi.org/10.1016/j.nepr.2017.05.002 https://doi.org/10.1016/j.nepr.2009.05.008 https://doi.org/10.1016/j.nepr.2009.07.003 https://doi.org/10.1111/j.1365-2702.2009.02981.x https://doi.org/10.1111/j.1365-2648.2008.04865.x https://doi.org/10.1111/j.1365-2648.2008.04865.x https://doi.org/10.1016/j.nepr.2016.03.005 https://doi.org/10.1016/j.nedt.2013.02.007 https://doi.org/10.1016/j.nedt.2013.02.007 https://doi.org/10.1016/j.nedt.2016.05.007 https://doi.org/10.1016/j.nedt.2016.05.007 https://doi.org/10.1016/j.nedt.2016.04.011 https://doi.org/10.1016/j.nedt.2016.04.011 https://doi.org/10.1016/j.ienj.2012.09.003 https://doi.org/10.1016/j.nepr.2011.11.004 https://doi.org/10.3928/01484834-20150717-01 https://doi.org/10.3928/01484834-20150717-01 https://doi.org/10.1016/j.nedt.2015.06.012 https://doi.org/10.1016/j.nedt.2015.06.012 https://doi.org/10.1016/j.nedt.2011.05.007 https://doi.org/10.1016/j.nedt.2006.11.006 https://doi.org/10.1016/j.nepr.2011.05.008 https://doi.org/10.1016/j.nepr.2011.05.008 https://doi.org/10.1016/j.nedt.2014.08.005 https://doi.org/10.1016/j.nedt.2014.08.005 https://doi.org/10.4102/curationis.v31i1.901 https://doi.org/10.1111/ijn.12032 https://doi.org/10.1111/jocn.12014 https://doi.org/10.1097/00001888-199209000-00002 a maximum of 3 ceus will be awarded per correctly completed test. december 2021, vol. 13, no. 4 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire december 2021 learn-teach-learn: evaluating a south african near-peer teaching programme 1. the results of the study showed that student learners: a. demonstrated an insignificant improvement in knowledge scores b. demonstrated a significant improvement in both the confidence scores c. agreed that the npt programme was a useful addition to the standard curriculum d. would recommend the programme to other students at developmental level. is blended learning the way forward? students’ perceptions and attitudes at a south african university 2. online teaching and learning has been found to a. lead to better utilisation of content b. improve retention rate c. increase collaboration d. improvement in student attittude. evaluation of assessment marks in the clinical years of an undergraduate medical training programme: where are we and how can we improve? 3. from a theoretical perspective, it is possible to improve the quality of assessment by addressing criteria such as: a. reliability b. validity c. fairness d. standardisation medical students’ perceptions of global health at the university of cape town, south africa: the gap between interest and education 4. the study found that: a. the majority of students reported no formal or informal global health education b. very few expressed interest in incorporating global health into their career. c. most students perceived a lack of role models as a barrier to incorporating global health into their careers d. less than half of the students were aware that the majority of surgical conditions worldwide occur in lmics. the knowledge and attitudes of final-year medical students regarding care of older patients. 5. despite student perceptions of receiving an adequate level of teaching in geriatrics, they displayed a minimal level of knowledge. (true/false) nominal group technique review of the emergency care content of the clinical skills module in the undergraduate medical programme at the university of the free state 6. feedback from students and technical experts included the following suggestions for improvement: a. increase the practical parts of the learning experience b. changes to the resources c. less use of blended learning techniques d. additional financial resources. understanding of clinical reasoning by undergraduate students and clinical educators in health and rehabilitation sciences at a south african university: the implications for teaching practice 7. according to the literature, which of the following about clinical reasoning are considered true: a. failure to develop cr is considered one of the key reasons for students’ lack of confidence and effectiveness in the clinical area b. teaching cr need not be tangible for students to develop and apply in clinical practice c. developing cr is one of the key goals of clinical teaching d. there are clear and specific terminologies, definitions and concepts for cr. please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. cpd questionnaire december 2021, vol. 13, no. 4 ajhpe development of a feedback framework within a mentorship alliance using activity theory 8. the results of the study showed that: a. most students reported positive experiences with feedback received during the mentorship process b. feedback from mentors mostly focused on academic matters c. all students reported knowing the meaning of mentorship d. all students reported having a faculty mentor at one point in time during their studies teaching about disability and food security in the school of health sciences, university of kwazulu-natal, south africa 9. educators had a somewhat good understanding of the link between the different dimensions of food security and disability. (true/false) nursing students’ perceptions regarding feedback from their educators in a selected higher education institution in kwazulu-natal, south africa 10. the definition of student feedback is a response in which information regarding previous performance is used to provide the facilitator’s positive views, suggestions and guidance on students’ work, according to: a. hughes and quinn b. brookhart c. mulliner and tucker d. kohn. a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) december 2021 cpd questionnaire december 2021, vol. 13, no. 4 ajhpe a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) september 2021 industri agriculture budidaya kentang kentang adalah tanaman pangan paling signifikan di planet ini. ini adalah tanaman yang ekonomis dan digambarkan sebagai teman orang miskin. asalnya di amerika selatan. tanaman kentang adalah sumber karbohidrat dan vitamin yang tinggi. ini digunakan sebagai sayuran juga digunakan untuk produksi keripik. ini digunakan untuk berbagai keperluan industri untuk pembuatan pati dan alkohol. tanaman kentang dapat tumbuh pada berbagai jenis tanah, mulai dari tanah lempung berpasir, lempung berlumpur, lempung, dan tanah liat. ini menawarkan hasil terbesar ketika ditanam di bawah lempung berpasir yang dikeringkan dengan baik dan tanah lempung sedang dengan kandungan organik yang kaya. mereka dapat tumbuh di tanah asam. itu tidak dapat tumbuh di bawah tanah yang basah, juga salin, tanah alkalin tidak ideal untuk produksi kentang. media tanam yang dihaluskan dengan baik harus dibuat dengan membajak ladang sekali hingga kedalaman 20-25 cm. ambil dua atau tiga garu setelah prosedur membajak. tanah harus diratakan dengan operasi papan untuk satu sampai dua kali. pertahankan kelembaban yang sesuai di tanah sebelum disemai. untuk penanaman, umumnya digunakan dua metode, 1) metode guludan dan alur 2) teknik bedengan datar. waktu tanam yang tepat waktu tanam yang akurat sangat penting untuk menghasilkan hasil yang baik. periode tanam kentang terbaik adalah ketika suhu maksimum dan minimum berkisar antara 30-32 °c dan 18-20 °c. untuk panen awal musim tanam lengkap dari 25 september sampai 10 oktober. untuk tanaman umur sedang, penyemaian sebaiknya dilakukan pada minggu pertama bulan oktober sampai minggu ketiga bulan oktober. sedangkan untuk panen lama, tanam lengkap mulai minggu ketiga oktober sampai minggu pertama november. untuk musim semi, dua minggu kedua januari adalah waktu tanam yang optimal. jarak tanam untuk penanaman, gunakan jarak 20 cm antar umbi dan 60 cm antar guludan secara manual atau mekanis. jarak tanam bervariasi dengan ukuran umbi. jika diameter umbi bervariasi 2,5-3,5 cm, gunakan jarak tanam 60x15 cm sedangkan jika diameter umbi 5-6 cm, gunakan jarak tanam 60x40 cm. kedalaman bibit gali parit sedalam 6-8 inci dan tanam irisan kentang dengan mata mengarah ke atas. cara menabur bibit untuk menabur, gunakan penanam semi-otomatis atau otomatis yang dioperasikan dengan traktor. gunakan takaran benih 8-10 qtl/hektar untuk umbi ukuran kecil, 10-12 qtl/hektar untuk ukuran sedang dan 12-18qtl/hektar untuk umbi ukuran besar. gunakan benih yang tidak rusak untuk produksi benih berkualitas bebas penyakit. perlakuan benih pilih benih/umbi dari sumber terpercaya. pilih bibit umbi kentang ukuran sedang dengan berat 25-125 gram untuk keperluan perkebunan. untuk keperluan perkebunan, umbi kentang setelah dikeluarkan dari penyimpanan dingin disimpan di lingkungan yang sejuk dan teduh selama satu sampai dua minggu untuk memungkinkan munculnya kecambah. untuk mendapatkan perkecambahan yang seragam, perlakukan umbi dengan asam giberelat@1 gm/10 ltr air selama 1 jam kemudian keringkan di tempat teduh dan simpan di ruangan yang diangin-anginkan selama 10 hari. celupkan irisan umbi dalam larutan 0,5 persen larutan mancozeb (5 gm/ltr air) selama sepuluh menit. ini akan menghindari pembusukan umbi pada tahap awal penanaman. untuk mencegah tanaman membusuk dan penyakit kudis hitam, obati umbi utuh dan cincang dengan larutan merkuri (tafasan) 6 persen @0,25 persen (2,5 gm/ltr air). irigasi tergantung kelembaban tanah hadir di tanah, bidang air segera atau 2-3 hari setelah tanam. irigasi ringan dan sering menghasilkan efek optimal, hindari irigasi banjir karena dapat menyebabkan penyakit busuk. untuk tanah sedang sampai berat, tiga sampai empat irigasi diperlukan namun untuk tanah berpasir, 8-12 irigasi diperlukan. penyiraman kedua harus dilakukan dalam waktu 30-35 hari setelah tanam tergantung pada kelembaban tanah. sisa irigasi harus diberikan sesuai kebutuhan tanah dan kebutuhan tanaman. hentikan irigasi 10-12 hari sebelum panen. panen dehaulming: sangat penting untuk mendapatkan benih bebas virus tetapi juga meningkatkan ukuran dan jumlah umbi. dehaulming melibatkan pemangkasan daun dekat dengan tanah pada waktu atau tanggal tertentu. waktunya bervariasi tergantung pada geografi dan juga pada populasi kutu. di utara dilakukan pada minggu terakhir bulan desember. tanaman siap panen ketika sebagian besar daun menguning-coklat dan jatuh di tanah. panen tanaman 15-20 hari setelah dehaulming pada kelembaban yang tepat di tanah. pemanenan dapat dilakukan dengan penggali kentang yang ditarik traktor atau secara manual dengan bantuan sekop atau khurpi. setelah panen kentang ditaburkan di tanah dan dibiarkan kering di tempat teduh, simpan dalam tumpukan selama 10-15 hari di kanopi untuk penyembuhan kulit. buang umbi yang rusak dan busuk. pasca panen lakukan pemilahan umbi dan buang umbi yang dipotong dan terluka. setelah sortasi dilakukan grading tergantung diameter atau ukuran umbi. ubi besar memiliki permintaan yang penting karena berguna untuk produksi keripik kentang. simpan kentang pada suhu 4° hingga 7°c dan kelembapan relatif. june 2020, vol. 12, no. 2 ajhpe 74 research evolving developments in healthcare and patient populations result in patients with more complex needs, which highlights the need for interprofessional patient-centred collaborative care. it is apparent that no single profession can respond adequately in isolation to such complex needs.[1] the lack of interprofessional collaboration and communication has been cited as a contributing factor in up to 98 000 preventable deaths per year in the usa.[2] other negative consequences with regard to inadequate interprofessional communication are delays in patient care, poor patient outcomes and wasted staff time and resources.[2] although no similar data could be found for south africa (sa), it could be assumed that ineffective communication and teamwork that lead to adverse patient events might be even worse in sa owing to the 11 official languages. members of a healthcare team might have difficulty in expressing themselves in a particular language.[3] interprofessional education (ipe) is very often advised as a corrective measure in such cases.[4] the fragmented sa healthcare systems in the private and public sectors could be strengthened by the inclusion of ipe to improve health outcomes. this will align with the world health organization (who)’s framework for action on ipe and collaborative practice that will enable the future healthcare workforce to apply collaborative practice effectively.[5] ipe could contribute to the way sa healthcare professionals are trained to become agents of change to address the health needs of the sa population.[6,7] to prepare healthcare students for collaborative practice, various educational methods could be used to deliver ipe. one approach that has been suggested comprises three elements, i.e. didactic learning experiences, simulation-based experiences and community-based ipe learning experiences.[8] didactic learning experience is most effective when it takes the form of interprofessional, small-group guided discussions on the concepts of interprofessional practice.[9] simulation-based health education can be defined as a training and feedback method where learners practise tasks and processes in lifelike circumstances using models or virtual reality, with feedback from observers, peers, simulated patients and video cameras to assist improvement of skills.[10] according to botma et al.,[11] the main purpose of interprofessional simulation is an increase in patient safety. it also serves as an education strategy to break down professional barriers. interprofessional simulation sessions have their own unique challenges, such as logistical issues, strain on resources and managing teams with learners from different foundational backgrounds.[12] scott et al.[13] identified clinical outcomes for the interprofessional team and also competencies such as communication, teamwork and professionalism. ipe simulation scenarios should be developed with these specific competencies listed as learning objectives. effective simulation experiences depend on the availability of experts to develop scenarios with interprofessional outcomes in mind,[13] as well as facilitators for effective debriefing and reflection.[3] baker et al.[12] stated that learners find simulation-based interprofessional experiences useful and relevant. community-based learning experiences depend on groups of students from multiple professions working in a setting, such as a clinic in a rural area with a selected community partner.[8] background. various educational methods are available to deliver interprofessional education (ipe) to prepare healthcare students for collaborative practice. one such method is simulation-based health education. objectives. to identify current ipe methods used in undergraduate programmes in the faculty of health sciences at the university of the free state, bloemfontein, south africa, and to determine the opinions of module leaders on using simulation as a particular ipe teaching strategy. methods. a quantitative, cross-sectional descriptive study design was employed. structured interviews were conducted with 47 module leaders of the undergraduate programmes in the faculty of health sciences. these programmes cover 66 modules in the schools for allied health professions (nutrition and dietetics, occupational therapy, physiotherapy and optometry), nursing and medicine. results. at the time of the study, ipe activities were used in 29 (43.9%) of the modules, of which 17 (58.6%) were coincidental. respondents’ opinions on the potential use of simulation to address formalised ipe activities included the challenge of ‘scheduling’ (73.9%) and ‘logistical and high cost issues’ (19.6%). the most prominent advantage that was foreseen (41.3%) was better clarification of roles among the different professions. conclusions. the module leaders had a positive attitude towards simulation and its potential use for ipe, with their major concern being logistical challenges. to improve role clarification, a scenario should be developed to engage students from all the relevant professions. the proposed type of simulation was to use standardised patients in a role-play scenario. the outcomes of these activities should be aligned with the principles of ipe. afr j health professions educ 2020;12(2):74-80. https://doi.org/10.7196/ajhpe.2020.v12i2.1213 simulation as an educational strategy to deliver interprofessional education r van wyk,1 mhpe, bcomm (it); m j labuschagne,1 mb chb, mmed (ophth), phd (hpe); g joubert,2 ba, msc 1 clinical simulation and skills unit, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: r van wyk (vanwykr3@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 75 june 2020, vol. 12, no. 2 ajhpe research in all three of these elements, the clinical outcomes of the interprofessional team should be accompanied by profession-specific competencies, common competencies and ipe competencies. ipe competencies include collaboration, communication, teamwork and professionalism. exposure of students to these elements serves to break down barriers between professions and contributes to clarifying the different roles of each profession in the interprofessional team. the ipe programme of the faculty of health sciences (consisting of the schools of medicine, nursing and allied health professions, the latter comprising the departments of nutrition and dietetics, occupational therapy, physiotherapy and optometry) of the university of the free state (ufs),[9] which was initiated in 2014, incorporated common competencies, profession-specific competencies and interprofessional competencies. these competencies are depicted in fig. 1. after an initial pilot phase, four 2-hour ipe sessions have been presented to all fourth-year health science students from six professions since 2015. the first session provides a theoretical background of and orientation on ipe. the second and third are simulated sessions with a standardised patient and a facilitator (lecturers from various professions) for each group. the simulation takes the form of a hospital setting with the standardised patient playing the role of a stroke patient. the group manages the patient as an interprofessional team, focusing on collaborative practice and interprofessional competencies. after each session, a facilitator debriefs the students. each debriefing session is divided into two parts – the first includes the standardised patient, who gives feedback to the group from a patient’s perspective. the second part of the debriefing excludes the standardised patient. during the fourth session, the groups present an interprofessional care plan for collaborative practice that could be applied to community-based rotations later in their fourth year.[11] the intention of these sessions is to improve students’ conceptual grasp of collaborative practice (principles of collaboration, professionalism, communication and improving healthcare systems)[9] and to prepare them for community-based interprofessional rotations. objective the aim of the study was to determine the opinions of the module leaders in the undergraduate programmes in the faculty of health sciences, ufs, on using simulation as a learning strategy in ipe. methods design a quantitative, cross-sectional descriptive study design was employed. to provide the necessary context, the current approach of undergraduate module leaders across all three schools in the faculty of health sciences with regard to ipe, was determined as part of the study. sampling and participants participants were module leaders in the undergraduate programmes of the school for allied health professions (consisting of the departments of nutrition and dietetics, occupational therapy, physiotherapy and optometry), school of nursing and school of medicine at ufs. a participant could be the module leader of more than one module. data collection structured interviews were conducted by the first author (rvw). the structured interview was divided into four main sections. firstly, demographic data of the module leader were obtained. the second section ascertained whether any ipe activity took place within the module(s) and, if so, in which form. the third section obtained the module leader’s opinion on aspects of simulation-based medical education. in this section, various statements about simulation-based health education were given and participants had to use a 5-point likert scale to indicate their responses. the last section obtained the module leader’s opinion on the possible use of simulation to address ipe needs. principles and characteristics of health simulation as described by ziv[14] were used as a guide in the formulation of questions/statements and options of the interview schedule. pilot study a pilot study was conducted with three of the module leaders, one from each school. these module leaders were selected by simple random sampling from each school, using random.org. after the first pilot interview, a minor adjustment was made to the interview schedule (the question options on formal v. informal ipe were changed to allow the option for both formal and informal). the data from all three pilot interviews were included in the main study. data analysis all quantitative data were coded and summarised on an excel version 14.0 (microsoft, usa) spreadsheet by the first author to ensure confidentiality before it was sent to the department of biostatistics, ufs, for analysis. results were summarised by frequencies and percentages. answers to open-ended questions were noted in writing during the interview. these answers were then coded into themes by the first author and summarised quantitatively. in the presentation of the results, it was indicated whether the denominator consisted of module leaders or modules. ethical approval approval for the study was obtained from the ethics committee of the faculty of health sciences, ufs (ref. no. ecufs 146/2014). permission to common competencies interprofessional competencies profession-speci�c competencies 4th-year health professions student fig. 1. elements of interprofessional education in health professions programmes. june 2020, vol. 12, no. 2 ajhpe 76 research conduct the research was granted by the heads of the three schools involved, the dean of the faculty of health sciences and the ufs vice-rector: research. results fifty-seven module leaders representing 80 modules were approached to participate in the study. interviews were conducted with 47 module leaders (response rate of 82.5%) who covered 66 modules (representing 82.5% of the total number of modules). some module leaders represented more than one module. the school of medicine (16 of 19 disciplines) had a total of 58 modules (46 (79.3%) were represented), the school of nursing 4 of 4 (100%) and the school for allied health professions 16 of 18 (88.9%). the median number of years of experience of teaching undergraduate health professions students was 12 (range 1 43), which was also the median for their number of years of teaching at ufs. the academic years of students represented in the modules ranged from 1 to 5 in the school of medicine, and from 1 to 4 in the school for allied health professions and the school of nursing. the distribution of the modules across the academic years of the undergraduate programmes is shown in table 1. considering the opinions of module leaders on simulation (table 2), the majority (n=38; 80.8%) indicated that simulation should not completely replace bedside training on real patients (clinical work); however, the majority (n=39; 83.0%) indicated that some clinical work could be replaced by simulation sessions. the majority (n=44; 93.7%) of module leaders indicated that simulation sessions could replace some of the traditional classes. more than half of the module leaders were of the opinion that simulation sessions (in general) were not disruptive to the schedule. however, many of them (n=29; 61.7%) indicated that they needed more time in the schedule to add simulation sessions. with the exception of one module leader, the majority (n=46; 97.9%) indicated that simulation sessions and the use of debriefing/reflection increased the students’ understanding of a problem. most of the module leaders indicated that simulation was a safe environment for students (n=46; 97.9%) and patients (n=45; 95.7%). more than two-thirds (n=32; 68.1%) said that simulation would be beneficial to their module(s) and enhance clinical training, and that small-group learning (n=40; 85.1%) would be an effective strategy to employ in their module(s). more than 90% of module leaders were of the opinion that simulation could be used for training of technical and non-technical (professional attributes) skills. the percentage of modules per year during which students are exposed to some form of ipe, is shown in table 3. the largest percentages are during the latter years of the undergraduate programme. in the second year of study, students are only exposed to some form of ipe in 2 of the 15 modules, i.e. 13.3% of second-year modules. in the 29 modules (43.9%) where ipe has been incorporated, 17 (58.6%) coincidentally used ipe activities. in 7 (24.1%) of the 29 modules, formal ipe activities were used, while in 5 (17.2%) of these modules a combination of formal and coincidental ipe activities was employed. formal activities included those where ipe outcomes were assessed, while informal activities were considered as coincidental without outcome measures and assessment. the percentages of ipe activities in the 29 modules are shown in table 4. with regard to time, ipe comprised ≤10% in more than half (58.6%) of these modules. table 1. distribution of modules covered by interviews (n=66) across the undergraduate programmes presented in the faculty of health sciences, university of the free state academic year n (%) 1st year* 15 (22.7) 2nd year* 15 (22.7) 3rd year* 19 (28.8) 4th year* 12 (18.2) 5th year† 5 (7.6) *schools for allied health professions, nursing and medicine. †school of medicine only. table 2. module leaders’ (n=47) opinions on simulation-based health education statement 1 2 3 4 5 strongly disagree, n (%) disagree, n (%) no opinion, n (%) agree, n (%) strongly agree, n (%) all traditional lessons can be substituted by simulation sessions 13 (27.7) 22 (46.8) 4 (8.5) 7 (14.9) 1 (2.1) some traditional lessons can be substituted by simulation sessions 0 (0) 2 (4.3) 1 (2.1) 20 (42.6) 24 (51.1) there is enough time in the schedule to add simulation sessions 11 (23.4) 18 (38.3) 2 (4.3) 12 (25.5) 4 (8.5) a simulation learning environment is safe for students 0 (0) 0 (0) 1 (2.1) 6 (12.8) 40 (85.1) a simulation learning environment is safe for patients 0 (0) 1 (2.1) 1 (2.1) 12 (25.5) 33 (70.2) simulation can be used for assessment 1 (2.1) 1 (2.1) 0 (0) 17 (36.2) 28 (59.6) simulation sessions are non-disruptive to the schedule 5 (10.6) 5 (10.6) 8 (17.0) 17 (36.2) 12 (25.5) small-group training is effective for the module 1 (2.1) 4 (8.5) 2 (4.3) 8 (17.0) 32 (68.1) reflection/debriefing enhances students’ understanding 0 (0) 1 (2.1) 0 (0) 9 (19.1) 37 (78.7) simulation is a ‘nice to have’ and cannot be used for module outcomes 24 (51.1) 8 (17.0) 2 (4.3) 5 (10.6) 8 (17.0) simulation can be used for non-technical skills 1 (2.1) 0 (0) 1 (2.1) 15 (31.9) 30 (63.8) simulation can be used for science/technical skills 0 (0) 0 (0) 1 (2.1) 12 (25.5) 34 (72.3) simulation may lead to deeper understanding of a problem 0 (0) 1 (2.1) 0 (0) 10 (21.3) 36 (76.6) simulation training can replace all practical, real patient management 23 (48.9) 15 (31.9) 3 (6.4) 6 (12.8) 0 (0) simulation training can replace some practical, real patient management 1 (2.1) 5 (10.6) 2 (4.3) 24 (51.1) 15 (31.9) staff are aware of advantages of simulation training 3 (6.4) 7 (14.9) 10 (21.3) 18 (38.3) 9 (19.1) staff are aware of disadvantages of simulation training 2 (4.3) 8 (17.0) 10 (21.3) 18 (38.3) 9 (19.1) 77 june 2020, vol. 12, no. 2 ajhpe research the types of ipe activities used in the 29 modules are summarised in fig. 2, with some modules using more than one type of ipe activity. in 19 (65.5%) of the modules, ward rounds were used to deliver ipe, although the amount of ipe-specific exposure during such rounds was not determined. respondents representing 44 (66.7%) of the 66 modules indicated that they did not consider simulation as a viable learning strategy to address ipe in that specific module. the main reason was that no ipe activities were employed in the module; also, ipe could be regarded as informal and coincidental (table 5). in some cases, more than one reason was given. in the 22 (33.3%) modules where simulation could be considered a viable learning strategy, the types of simulation were mainly role-play (n=17; 77.3%), followed by standardised patients (n=14; 63.6%) (fig. 3). with regard to foreseen disadvantages of using simulation in ipe, 10 of 46  (21.3%) interviewees mentioned that they did not foresee any disadvantages. as shown in table 6, the potential disadvantages most commonly mentioned were the high costs of simulation and logistical challenges (n=9/46; 19.6%). the two main advantages identified by module leaders for using simulation to address ipe were that it would improve role clarification among students of the different professions (n=19/46; 41.3%) and that it would be a safe learning environment for students and patients (n=15/46; 32.6%) (table 6). approximately three-quarters of respondents (n=34/46; 73.9%) indicated that scheduling was the main challenge when considering simulation for ipe, while 10 (21.7%) were concerned about the attitude of the staff and that a paradigm shift would be needed (table 7). discussion in this study, the focus was on simulation as a mode of delivery in ipe. most of the module leaders interviewed were of the opinion that simulation could be a useful strategy to train students in the practice of interprofessional collaborative care. one of the main advantages identified was the improvement of role clarification among professions in a safe learning environment where real patients were not used. simulated scenarios could improve interprofessional teamwork, empathy and respect for other professions. when developing ipe simulation scenarios, students from all the relevant professions should be engaged. the proposed types of simulation could be standardised patients in a role-play scenario, hybrid simulation or high-fidelity team-training simulation.[13] in this study, role-play and simulated patients were considered as the most effective types of simulation. virtual reality simulation was considered by ˂10% of participants. the limited exposure of the module leaders to virtual reality simulation at this institution could explain the response. table 3. modules that include ipe exposure per academic year academic year modules with ipe, n (%) 1st year, n=15 5 (33.3) 2nd year, n=15 2 (13.3) 3rd year, n=19 11 (57.9) 4th and 5th year, n=17 11 (64.7) ipe = interprofessional education. table 4. modules that include ipe (n=29) ipe, % n (%) 0 10 17 (58.6) 11 20 5 (17.2) 21 30 4 (13.8) 31 40 1 (3.4) 41 50 2 (6.9) 51 100 0 (0) ipe = interprofessional education. table 5. reasons for not considering simulation as a viable training tool in modules not incorporating ipe (n=44) reasons n (%) no ipe activities in the module 37 (84.1) ipe is informal and coincidental 6 (13.6) paper cases and group work are adequate 4 (9.0) concept of own profession not yet formed 3 (6.8) only multiprofessional classes 2 (4.5) ipe = interprofessional education. table 6. disadvantages and advantages of using simulation for ipe in health education (n=46) disadvantages n (%) advantages n (%) logistical issues and high costs 9 (19.6) improves role clarification among the different professions 19 (41.3) negative attitudes or unprepared students 8 (17.4) safe learning environment for students and no real patients are used 15 (32.6) balance between the focus on multiple professions 5 (10.9) improves empathy and respect for other professions 9 (19.6) too artificial 4 (8.7) improves students’ training through expanded platform and scenarios 9 (19.6) shallow interactions/not enough critical reasoning 4 (8.7) improves students’ training through exposure to other professions 9 (19.6) conflict within a group leads to negative perceptions 3 (6.5) improves teamwork among professions 8 (17.4) cannot replace real patients completely 2 (4.3) improves professional and inter-team communication 6 (13.0) students might feel exposed among other professions 2 (4.3) improves patient management 4 (8.7) theory might not be learnt 1 (2.2) opportunity for students to reflect 3 (6.5) could lead to compartmentalising of skills 1 (2.2) better preparation for real-world situations and clinical training 3 (6.5) own role/profession must first be defined 1 (2.2) improves students’ non-technical skills 3 (6.5) ‘hidden roles’ difficult to expose with simulation 1 (2.2) assessment could be objective and ongoing 2 (4.3) undergraduate students not exposed to simulation 1 (2.2) fewer staff might be needed for simulation than for cbe 1 (2.2) ipe = interprofessional education; cbe = community-based education. june 2020, vol. 12, no. 2 ajhpe 78 research the outcomes should also specifically be aligned with the principles of ipe. learning opportunities must be carefully aligned with students’ interests, concerns and level of exper tise.[15] this is more challenging with ipe, as there might be great diversity among multidisciplinar y students.[16] simulation provides a safe learning environment for students, which was mentioned by 15 (31.9%) of the participants in this study. the other advantages of simulation as a mode of delivery for ipe were identified as improved role clarification, empathy and respect for other professions and patients, improved learning from, with and about other professions, and improved teamwork among professions.[12] notwithstanding the importance of clinical skills, healthcare professionals must also be equipped with a broader set of non-technical skills.[17] healthcare workers can virtually never work in isolation; therefore, collaboration, communication and professionalism are paramount to successful teamwork and patient care.[18] interprofessional collaborative care does not occur coincidentally; students must deliberately be exposed to ipe, which can promote these skills and develop a healthcare student into an effective team member in a collaborative practice.[19] ipe should be part of the institutional culture.[20] educational methods to deliver ipe, such as didactic learning experiences, community-based learning experiences and simulation experiences, can be employed.[8] interprofessional simulation sessions have unique challenges, such as: • logistical issues, e.g. the challenge to schedule an interprofessional group of students from different professions, departments and rosters. baker et al.[12] argued that logistical challenges were some of the major concerns when implementing ipe into a curriculum, a matter that was echoed by the participants in this study. • resource-intensive challenges, e.g. multiple simulation venues are often needed for sessions. because of the small groups comprising each session, multiple sessions are needed. strain is also placed on staff (of different professions) with regard to their availability as facilitators and to provide technical support.[12] in our study, high costs were a concern mentioned by ~20% of participants. • for effective interprofessional simulation, members of staff need to be trained as facilitators in the principles of ipe and simulation methodology.[21] all facilitators receive intensive training in ipe before the sessions at our institution. • according to baker et al.,[12] students with varied foundational backgrounds may require orientation sessions prior to simulation to clarify technical and ipe concepts. • negativity and bad role modelling might have a negative influence on the attitude of students regarding ipe.[12] in this study, potential disadvantages of using simulation for ipe included negative attitudes and unprepared students. • organisations might not be structured effectively for the high level of collaboration needed between different professions for effective interprofessional simulation.[21] • a culture of non-collaboration would initially need to be addressed in some cases.[21] keeping the advantages and disadvantages of ipe simulation in mind, care should be taken to balance the workload of students to prevent overloading and prompting surface learning.[22] students’ level of prior learning and establishment of a personal professional identity are necessary for successful ipe, and will leverage their existing knowledge to enhance their learning opportunities.[23] 65.5 ward rounds, n=19 24.1 community service, n=7 20.7 clinic work, n=6 17.2 multiprofessional classes, n=5 3.4 simulation (pilot), n=1 3.4 introduction to other professions, n=1 a ct iv it ie s, % (n = 29 ) 100 80 60 40 20 0 fig. 2. different types of interprofessional education activities (n=29). 77.3 role-play, n=17 63.6 standardised patients, n=14 31.8 skills training, n=7 18.2 high�delity scenarios, n=4 9.1 virtual reality, n=2 m o d u le s, % (n = 22 ) 100 80 60 40 20 0 fig. 3. type of simulation considered for interprofessional education in modules where it was regarded as viable (n=22). 79 june 2020, vol. 12, no. 2 ajhpe research successful simulation education has to challenge students, but these challenges should be monitored and adjusted to ensure productive learning. initially, the facilitator should structure the programme, but as students’ confidence increases, these structured approaches may be reduced.[24] repeated, deliberate practice leads to improved performance, and opportunities for regular practice in ipe should be incorporated into training programmes.[25] as with most other skills, repeated practice is vital to embed interprofessional collaboration skills longitudinally into a curriculum. reflection and feedback can lead students to self-evaluate, seeking constant improvement and exploring alternative strategies to a problem. the most effective feedback for ipe is guided, structured feedback (debriefing after simulation),[26] and facilitators should be trained in the debriefing of interprofessional groups. debriefing could be the most difficult part of simulation, but this is where learning occurs.[27] the main purpose of interdisciplinary simulation and debriefing is to increase patients’ safety. it also serves as an education strategy to break down professional barriers.[11] to enhance ipe in the undergraduate programmes at our institution, we propose a three-phase longitudinal approach. these three phases are in line with the elements proposed by bridges et al.[8] and include the use of didactic lessons at initial exposure level, simulated interprofessional experiences at the preclinical level and a community-based education platform during the clinical level (fig. 4). during all three levels, ipe and collaborative practice principles and values should be addressed (fig. 1). this approach would expose students to ipe principles at all levels during their studies. this form of exposure would ensure structured, guided and non-coincidental ipe and transference to the workplace. each phase of training should incorporate an assessment component. when the adapted version of miller’s framework for clinical assessment[28] is considered, this three-phase longitudinal approach addresses all the relevant levels of training. the didactic lessons (initial exposure phase) ensure that students have the relevant knowledge about ipe (‘knows’). the simulation experiences (preclinical) ensure students are competent in the ‘knows how’ and ‘shows how’ aspects of ipe. the community-based interprofessional aspect (clinical) would build on the first two levels and ensure that students are able to ‘show how’ and ‘do’. consequently, all the building blocks are in place for students to develop their sense of professionalism (‘is’). study limitations limitations identified in the study were that interviews were conducted only with module leaders and not all lecturers involved in the presentation of these modules, and the approach to assessment of ipe activities was not explored during the interviews. the understanding of terms such as simulation and ipe was not determined. since the conception of the ipe simulation project in 2013, ipe and simulation have been discussed and addressed with various role-players, including the faculty’s module leaders, on various platforms such as strategic planning meetings. conclusions although there are various challenges, using simulation to enhance ipe is a viable and realistic approach in a number of modules in undergraduate training at our faculty. during simulation debriefing sessions, deliberate emphasis on patient-centred collaborative practice can enhance the principles in students’ minds, enabling them to bridge the gap between theory and practice. this would lead to transference of collaborative practice principles, and improved, more effective, patientcentred management and care. the three-tiered longitudinal approach can help students to experience the principles of collaborative practice and may lead to improvement of a fragmented healthcare system to the advantage of patients and professions. declaration. none. acknowledgements. the module leaders who participated in the study; and dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. author contributions. rvw and mjl conceptualised the study, gj provided methodological input. rvw collected the data and gj analysed the data. rvw drafted the manuscript, which all authors reviewed and edited. funding. none. conflicts of interest. none. 1. barr h. interprofessional education. in: dent ja, harden rm, eds. a practical guide for medical teachers. 3rd ed. edinburgh: churchill livingstone, 2009:187-192. 2. olenick m, allen lr. faculty intent to engage in interprofessional education. j multidiscip healthcare 2013;6:149-161. https://doi.org/10.2147/jmdh.s38499 3. botma y, butler m, coetzee d, hattingh r, labuschagne m, van wyk r. interprofessional education, faculty of health sciences. bloemfontein: university of the free state, 2014. 4. kohn lt, corrigan jm, donaldson ms. to err is human. building a safer health system. washington, dc: national academy press, 2000. 5. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. 6. van heerden b. effectively addressing the health needs of south africa’s population: the role of the health professions education in the 21st century. s afr med j 2012;103(1):21-22. https://doi.org/10.7196/samj.6463 simulation • preclinical didactic • initial exposure community based • clinical healthcare professional healthcare student edu cat ion str ate gy fig. 4. proposed learning continuum for interprofessional education, and the platforms used. table 7. potential challenges of using simulation for ipe in health education (n=46) potential challenges n (%) scheduling challenges 34 (73.9) paradigm shift needed from staff 10 (21.7) staff resources 9 (19.6) physical resources and correct equipment 8 (17.4) difficult to standardise training for multiple professions 8 (17.4) simulation needs to be more realistic 4 (8.7) potential negative attitudes from students 4 (8.7) challenging to apply formal assessment of ipe 1 (2.2) ipe = interprofessional education. https://doi.org/10.2147/jmdh.s38499 https://doi.org/10.7196/samj.6463 june 2020, vol. 12, no. 2 ajhpe 80 research 7. frantz jm, rhoda aj. implementing interprofessional education and practice: lessons from a resource-constrained university. j interprof care 2017;31(2):180-183. https://doi.org/10.1080/13561820.2016.1261097 8. bridges dr, davidson ra, odegard ps, maki iv, tomkowiak j. interprofessional collaboration: three best practice models of interprofessional education. med educ online 2011;16(1):6035. https://doi.org/10.3402/meo.v16i0.6035 9. botma y, labuschagne m. students’ perceptions of interprofessional education and collaborative practice: analysis of freehand drawings. j interprof care 2019;33(3):321-327. https://doi.org/10.1080/13561820.2019.1605981 10. eder-van hook j. building a national agenda for simulation-based education. washington, dc: advanced initiatives in medical simulation, 2004. 11. botma y, brysiewics p, chipps j, mthembu s, phillips m. creating stimulating learning opportunities. cape town: pearson, 2014. 12. baker c, pulling c, mcgraw r, dagnone jd, hopkins-rosseel d, medves j. simulation in interprofessional education for patient-centred collaborative care. j adv nurs 2008;64(4):372-379. https://doi.org/10.1111/j.13652648.2008.04798.x 13. scott hm, perrone j, drozd a. dimensions in paediatric simulation: teamwork and communication. in: gallo k, smith lg, eds. building a culture of patient safety through simulation. an interprofessional learning model. new york: springer, 2015:127-142. 14. ziv a. simulators and simulation-based medical education. in: dent ja, harden rm, eds. a practical guide for medical teachers. 3rd ed. edinburgh: churchill livingstone, 2009:217-222. 15. knowles ms, holton ef, swanson ra. the adult learner: the definitive classic in adult education and human resource development. 8th ed. new york: routledge, 2015. 16. freeth d. interprofessional education. in: swanwick t, ed. understanding medical education: evidence, theory and practice. edinburgh: association for the study of medical education and wiley-blackwell, 2007:53-68. 17. thistlethwaite je. interprofessional education. in: dent ja, harden rm, eds. a practical guide for medical teachers. 4th ed. edinburgh: churchill livingstone, 2013:190-198. 18. chan ak, wood v. preparing tomorrow’s healthcare providers for interprofessional collaborative patient-centred practice today. ubc med j 2010;1(2):22-24. 19. haire b. interprofessional care: a model of collaborative practice. prince edward island: pei health sector counsel, 2010. 20. casimiro l, macdonald cj, thompson tl, stodel ej. grounding theories of w(e)learn: a framework for online interprofessional education. j interprof care 2009;23(4):390-400. https://doi.org/10.1080/13561820902744098 21. robertson j, bandali k. bridging the gap: enhancing interprofessional education using simulation. j interprof care 2008;22(5):499-508. https://doi.org/10.1080/13561820802303656 22. ruiz-gallardo j, castano s, gomez-alday jj, valdes a. assessing student workload in problem based learning: relationships among teaching method, student workload and achievement. a case study in natural sciences. teach teacher educ 2011;27(3):619-627. https://doi.org/10.1016/j.tate.2010.11.001 23. freeth ds, hammick m, reeves s, koppel x, barr h. effective interprofessional education: development, delivery and evaluation. oxford: blackwell publishing, 2005. 24. barr h, koppel i, reeves s, hammick m, freeth d. effective interprofessional education: argument, assumption and evidence. oxford: blackwell publishing, 2005. 25. ericsson k, krampe r, tesch-römer c. the role of deliberate practice in the acquisition of expert performance. psychol rev 1993;100(3):363-406. https://doi.org/10.1037/0033-295x.100.3.363 26. clark pg. reflecting on reflection in interprofessional education: implications for theory and practice. j interprof care 2009;23(3):213-223. https://doi.org/10.1080/13561820902877195 27. østergaard d, dieckmann p. simulation-based medical education. in: dent ja, harden rm, eds. a practical guide for medical teachers. 4th ed. edinburgh: churchill livingstone, 2013:207-214. 28. cruess rl, cruess sr, steinert y. amending miller’s pyramid to include professional identity formation. acad med 2016;91(2):180-185. https://doi.org/10.1097/acm.0000000000000913 accepted 14 october 2019. https://doi.org/10.1080/13561820.2016.1261097 https://doi.org/10.3402/meo.v16i0.6035 https://doi.org/10.1080/13561820.2019.1605981 https://doi.org/10.1111/j.1365-2648.2008.04798.x https://doi.org/10.1111/j.1365-2648.2008.04798.x https://doi.org/10.1080/13561820902744098 https://doi.org/10.1080/13561820802303656 https://doi.org/10.1016/j.tate.2010.11.001 https://doi.org/10.1037/0033-295x.100.3.363 https://doi.org/10.1080/13561820902877195 https://doi.org/10.1097/acm.0000000000000913 november 2020, vol. 12, no. 4 ajhpe 179 research nursing education in uganda has undergone major transformations, from certificate-level training through registration level up to degree level and higher degree level in line with the national health policy of uganda of training more skilled nurses to address the health needs of the population.[1-4] through all these training levels, attainment of clinical competency is key. this study focuses on the clinical training in the registered comprehensive nursing (rcn) programme ‒ a diploma-level programme. clinical training in the rcn programme is guided by the clinical competence assessment tool that should be completed by nursing students after every clinical procedure. thereafter, nurse mentors are expected to evaluate student competence based on records in the clinical competence assessment tool. the clinical competence assessment tool was introduced by the uganda nursing and midwifery council with support from the ministry of education to assist students to keep track of their clinical procedures, to assist nurse mentors in evaluating the progressive performance in clinical competency of student nurses and to provide corrective feedback, if necessary. the tool is in the form of a checklist with procedures that the students are expected to perform during clinical rotations. the nurse mentor observes if the student is able to complete the tasks of a particular procedure. the mentor ticks off each task that is performed correctly, awards a mark and is expected to give some feedback. this is done with all procedures performed by students. the tool resembles a logbook with an assessment checklist. the procedures outlined in the tool are performed on real patients in the wards. however, other aspects of the tool, such as bed making and damp dusting, are sometimes performed outside the clinical ward. the procedures in the tool are spread over 3 years, which is the duration of training for nursing on rcn level. the programme is hospital based. the tool covers most of the nursing procedures expected of a registered comprehensive nurse, such as bed making, patient admission, drug administration, feeding of patients, catheterisation and collecting specimens. a record of having performed these procedures is a requirement for registration with the nursing council. assessment of this clinical competence tool is also a requirement to successfully complete the nursing course. although the tool was meant for formative and summative use, it is currently being used only for summative assessment of a student’s clinical competency. the clinical nurse mentors receive some orientation on the tool background. the assessment tool for registered comprehensive nursing was introduced in nursing education in uganda in 2005 with the main purpose of facilitating nurse mentors to easily assess the clinical competency of student nurses. the tool contributes to the formative and summative assessment of students. despite continued use of the assessment tool over the years, no study has been conducted to explore the perceptions of nurse mentors and students regarding its use. objective. to explore the experiences of nursing students and their mentors regarding the clinical competence assessment tool. methods. a qualitative exploratory study design was used. the study was conducted at masaka school of comprehensive nursing in uganda. the participants included 48 final-year nursing students and 5 nurse/midwifery mentors. purposive sampling was used to select the participants. data were collected using 6 focus group discussions with students and 5 key informant interviews with mentors, and thematic analysis was used to interpret the data. results. from the responses, the participants generally had mixed experiences of the tool and suggestions were put forward for improvement. five major themes emerged from student responses: (i) the orientation process; (ii) using the assessment tool; (iii) strengths of the assessment tool; (iv) challenges with the assessment tool; and (v) suggestions for improvement. the nurse mentors generally corroborated what the students reported, i.e. that the tool had challenges when one assesses student performance and gives feedback. conclusion. the participants reported satisfaction with the design of the assessment tool. however, some challenges were identified regarding its implementation by students and mentors. key among these were the failure to have immediate assessment and feedback to students. findings from the study could offer insights on how the tool could be improved. afr j health professions educ 2020;12(4):179-185. https://doi.org/10.7196/ajhpe.2020.v12i4.1380 mentors’ and student nurses’ experiences of the clinical competence assessment tool m sserumaga,1 bmed educ, mhpe; a g mubuuke,2 phd; j nakigudde,3 phd; i g munabi,4 phd; r b opoka,5 mmed (paediatrics), mhpe; s kiguli,5 mmed (paediatrics), mhpe 1 rakai community school of nursing, masaka, uganda 2 department of radiology, school of medicine, makerere university, kampala, uganda 3 department of psychiatry, school of medicine, makerere university, kampala, uganda 4 department of anatomy, school of biomedical sciences, makerere university, kampala, uganda 5 department of paediatrics, school of medicine, makerere university, kampala, uganda corresponding author: a g mubuuke (gmubuuke@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 180 november 2020, vol. 12, no. 4 ajhpe research before students present it in the hospital. nurses lack some of the key clinical skills, which are drivers behind relooking at this tool. however, despite being in operation for several years, perceptions of students and mentors towards its use have not been previously explored, which necessitated the need for this study. nurses’ attainment of the desired clinical skills is an important part of nursing education. the assessment tool introduced for rcn in uganda was aimed at aggregating the skills acquired by student nurses in various nursing procedures at different levels of learning throughout the 3 years of their training. the tool contains almost all nursing procedures expected to be performed after qualification. it was designed to facilitate the students’ carrying out of procedures under direct supervision of nurse mentors, who then score the students, discuss the assessment outcomes and provide corrective feedback. it was intended to be a mechanism for students to document a portfolio of their progression throughout their clinical rotations, which they then present to the regulatory body for registration. most of the intentions of this assessment tool have been alluded to in literature. various scholars have described an effective assessment tool for nurses. for example, skúladóttir and svavarsdóttir[5] suggested that an assessment tool in nursing education needs to be based on nursing care theories and principles. helminen et al.[6] added that a good assessment tool must have capacity to address the cognitive, psychomotor and affective domains of the learning process. an effective assessment tool must also be able to assess the student’s ability to integrate theory and practical procedures at clinical sites.[7] the tool should provide an effective mechanism of giving constructive feedback to facilitate student learning.[8] the quality, utilisation and perception of the tool have to reflect the quality of the nursing education offered, and of the healthcare services eventually delivered.[9] therefore, the assessment tool for rcn used in uganda has to possess all the qualities of a good assessment tool as outlined in literature. the competent professional nurse should have had acceptable clinical placements, as required by the training institution, and should have been effectively assessed on knowledge, attitudes and skills[10,11] – key aspects that the assessment tool for rcn in uganda targeted. teaching without assessment is incomplete, as they complement each other. training would be regarded as incomplete without effective assessment to judge the nurses’ competence.[12,13] as stated above, the assessment tool has never been reviewed, and some of the drivers calling for its review originate from the poor clinical skills of the students, as well as complaints from students and nurse mentors. to inform a more comprehensive review of the tool, including its validity and reliability, there was a need to generate baseline informative data on how the students and mentors who use this tool perceive it. views obtained from students and mentors can inform future reviews and improvements of the tool. therefore, the purpose of this study was to explore the experiences of student nurses and their mentors regarding the clinical assessment tool currently used for the rcn programme in uganda. it is hoped that baseline information obtained will inform not only continuous improvement of the tool, but also future empirical studies on its validity and reliability. methods research design this was an exploratory qualitative study. this design was found to be the most appropriate, as the intention of the study was to explore the perceptions of nurse mentors and students regarding the practical assessment tool. study setting the study was conducted at masaka school of comprehensive nursing (mscn), masaka, uganda. mscn is a rural-based government-aided nurses’ training school established in 1946 to train nursing aides. it later started training certificate nurses and rcn students in 1992. at the time of this study, mscn has 352 students, of whom 104 were in third-year (final group), with 14 nurse mentors. participants the participants were final-year rcn students and their mentors. some of the nursing students in the rcn programme join directly, while others upgrade from certificate level to rcn diploma level. the mentors are clinical nurse tutors who supervise students during clinical rotations. they were selected purposively, depending on their gender, sponsorship and criteria for entry into the course. sampling from different categories of participants aimed at achieving maximum variation, where heterogeneity was achieved by representation from each category of the targeted participants. data collection data were collected using focus group discussions (fgds) and key informant interviews (kiis). fgds were conducted with final-year nursing students. six fgds of 8 students in each group were conducted. the fgds were guided by semi-structured questions. five kiis were conducted with nurse tutors. the final number of kiis was determined at data saturation point, where responses from the tutors became repetitive. the kiis were conducted in addition to the student fgds to triangulate data and obtain an explanation from the tutors regarding the responses of students about the assessment tool. data for the fgds and kiis were collected by a research assistant with a social science background and expertise in qualitative data collection and transcribing. the research assistant did not have any relationship with the students or mentors. quality control data tools were developed by the researcher. these guides were pretested with second-year students to ensure that they were appropriate for the study and that the questions were clear. unclear question items in the tool were corrected and addressed. during the process of data collection, the interviewer asked questions and the scribe took notes. audio-recording was done to prevent missing any of the data. to ensure adequate rigour, kiis and fgds were used to triangulate the data. there was prolonged engagement with the participants and the developed themes were sent to them to confirm whether their opinions were represented. the researchers ensured reflexivity by bracketing off their own ideas and interpreting information, as reported by the participants. data analysis thematic analysis was used in this study. data were immediately transcribed by the investigator following each interview and fgd. the data, being purely qualitative, were analysed through a process of coding, assisted by software r as a platform (qualitative data analytical software). november 2020, vol. 12, no. 4 ajhpe 181 research ethical approval approval to conduct the study was granted by the school of medicine research and ethics committee, makerere university (ref. no. rec ref 2019-077). administrative clearance to conduct the study was obtained from masaka school of comprehensive nursing. written informed consent was obtained from the participants before they were enrolled in the study. they were also assured of the confidentiality of their responses. raw data were kept securely by a password, which was only accessible by the researchers. results demographics a total of 53 participants were recruited into this study. of these, 90.6% (n=48) were nursing students and the remaining 9.4% (n=5) were nurse tutors, 56.7% (n=30) were females and 43.4% (n=23) were males. all the participants were familiar with the tool that was being used to assess clinical competency. findings from the nursing students from analysis of the qualitative data, 5 key themes emerged from the fgds with the students. all the themes related to the perceptions of student nurses towards the assessment tool. key representative participant quotations have been provided to contextualise each theme. table 1 summarises these themes. theme a: the orientation process one of the major themes from the fgds related to the orientation of students regarding the assessment tool. all the students reported that they were orientated with regard to the assessment tool before using it. however, they expressed concern about the orientation process, as it was not explicit: ‘the orientation was done and we were introduced to the assessment tool. however, the process was not detailed … as we were taken through it, some aspects were not touched, such as how the tool is marked and targeted learning goals … and thus did not get to know what was expected of us … the main focus was put on those areas, which are a bit complicated … .’ (fgd1) another key concern regarding the orientation was that it was conducted late and in a rush, without adequate time for the students to comprehend the tool and get to know how to use it: ‘the orientation process starts late when we have already commenced our clinical training. therefore, the tutors rush through the process … and also they give out these books very late when we have already gone through some procedures unrecorded … .’ (fgd2) from the abovementioned responses, it can be seen that student orientation regarding the assessment tool is done late and they are given limited time to fully comprehend the tool before using it in the clinical areas. from the analysis of the responses, some of the students resorted to consulting their colleagues regarding the use of the tool during clinical procedures, which is a clear indication that the tutors did not orientate the students adequately. the following response resonated through all the fgds: ‘since we were not properly introduced to the tool, the only option was to consult each other … those who had got a better understanding of the tool helped other colleagues.’ (fgd5) participants also felt that the orientation process was conducted when some students were absent. this led to a number of students missing out on this table 1. themes that emerged from the focus group discussions with the nursing students theme key concepts theme a: the orientation process • orientation was done late • students relied on peer support • students missed orientation • students were given limited time to comprehend the tool theme b: using the assessment tool • students panicked in the ward with the assessment tool • some procedures in the tool were not done in the ward • some procedures in the tool seemed to be for doctors • there was no provision for feedback theme c: strengths of the assessment tool • good tool design • wide range of procedures included • easy to fill out for students • reflects variety • clear language • tool can guide students during clinical rotations theme d: challenges with the assessment tool • assessment of the tool is subjective • no provision of feedback to master clinical skills • some procedures reflected on the tool are not performed in the hospital theme e: suggestions for improvement • make assessment of the tool more objective • motivation of nurse tutors • include provision for feedback • orientate students early • provision for student reflection about procedures 182 november 2020, vol. 12, no. 4 ajhpe research important exercise. this is reflected in the following response: ‘… i remember in the first week when we reported to school, they oriented us about the tool, but many students were missing. no more orientation was done and they just gave us the assessment tool weeks later to use during our clinical practice.’ (fgd6). in summary, the students therefore felt that the process of orientating them with regard to the tool was not adequate to fully comprehend it. theme b: using the assessment tool the second theme related to the students’ experiences of using the tool during clinical training. students reported that they became too anxious and panicky to complete the tool. using and filling out the tool became a challenge during clinical procedures, because the nurse tutors (preceptors) were too busy and could not adequately supervise completion of the tool. the following responses reflected these observations: ‘it was a tense moment in the clinical ward to complete the tool because we had not been properly introduced to the tool and yet as finalists, we had to complete the tool … so when it usually comes to the finalists, the students usually panic to sign the assessment tools … .’ (fgd6) ‘the nurse tutors who were supposed to supervise our clinical work were most times too busy to guide us during procedures and also to guide us on how to accurately fill out the tool. this caused a lot of panic among us and yet we needed these tools filled up.’ (fgd3) it was also observed that the assessment tool might not have reflected what was on the ground as far as some procedures were concerned and it contained procedures that were no longer performed; yet, students had to log them into the tool. in addition, there was no time for feedback regarding the procedures performed. these observations can be seen in the following student responses: ‘during ward rotations, using the tool sometimes proved a challenge because it contained nursing procedures that are not done any more or some procedures that are not done by nurses. this was challenging because you could not fill in these procedures and yet the tutors were asking for them.’ (fgd4) ‘lack of feedback from our tutors was a big challenge. the assessment tool had no provision for feedback and the tutors were also busy on the ward and they could not give us feedback as we wanted in time.’ (fgd2) from the abovementioned responses it can be observed that using the tool in the real clinical context seemed to be a challenge to the students owing to a number of factors, such as limited feedback, busy clinical setting and anxiety. theme c: strengths of the assessment tool this theme is about the strengths of the assessment tool from the students’ point of view. despite the weaknesses of the assessment tool, some strengths were reported. key among these were that the tool design and organisation to record most of the procedures performed and the coverage of skills required within the tool seemed to be wide: ‘the assessment tool has a wide variety of nursing clinical procedures that we are supposed to cover and this at least guides us on what we should look out for. this is good and if our mentors were always present for us as the procedures are performed, and after for feedback, this would be a good tool for us.’ (fgd6) ‘most of us think it is a good tool, especially when it comes to the way it is organised with most skills required incorporated within. its content coverage for all competencies including attitudes is good. its design and language used are also easy to use, especially that the wards are always busy and we have to perform procedures as we fill the tool for later assessment.’ (fgd1) from the abovementioned observations, it therefore appears that the design of the tool and nursing skills captured by the tool seem adequate and met the expectations of the students. theme d: challenges regarding the assessment tool despite the observed strengths of the assessment tool, the students also reported some challenges. the key challenges seemed to rotate around the assessment of the procedures and feedback. the following responses reflected this theme: ‘the marking of the recorded nursing procedures has bias because the tool is marked way after procedures were done and recorded and the tutors lack the time to devote to the supervision of the students and mark the tools according to their familiarity.’ (fgd3) ‘in many situations, the tutors on wards are busy and we also get busy, so we just fill in procedures for the sake of completion and these tools are looked at by the tutors weeks after procedures are done or even at the end of the semester. when they start marking, it is hard for them to objectively mark you.’ (fgd6) ‘the issue of feedback needs serious attention. we are not given feedback that can help us in future procedures because tutors look at these tools way after procedures. this immediate feedback that is important is not there since tutors are few. even the tool itself has limited opportunities for tutors to write feedback comments for the students.’ (fgd1) there were also challenges, as the tool included procedures that were not performed in the wards; yet, students were required to fill in the procedures. students reported that there was always inadequate medical equipment and supplies, as well as a limited number of supervisors required for proper administration of the assessment tool: ‘when it comes to the practice, you cannot apply the standards of the book because health centres lack some instruments.’ (fgd2) from the abovementioned responses, it can be demonstrated that the major challenge with the tool seemed to be the subjectivity of assessment, which at times used to happen several weeks after the students had completed the tool. theme e: suggestions for improvement all participants recognised that the tool needed to be improved. this theme gives suggestions of students for improving the tool. the key suggestions that resonated through the fgds related to improving the orientation process so that students are introduced to the tool early, thus improving the assessment of the tool, as well as provision of feedback, motivation of mentors to supervise the completion of the tool during clinical practice, revising the tool to eliminate any outdated procedures november 2020, vol. 12, no. 4 ajhpe 183 research and provision of a mechanism in the tool for students to reflect on their clinical procedures: ‘one way to improve the utilisation of this tool is that we should receive the books the moment we come to start the course … .’ (fgd2) ‘the mentors who are supervising the students need to be motivated in order to ensure that students fill out the tool and they get feedback from them … the mentors seem unmotivated. the feedback for the procedures carried out needs to be given early enough when it is still useful to facilitate our learning. in addition, the marking of the tool needs to be looked into. currently, the marking is subjective as tutors mark our work many weeks after the procedure when a student cannot do much corrective action.’ (fdg3) ‘we need to think about the procedures we do and also give feedback to the tutors. we should include a provision for students’ remarks in the tool so that we can write the situation where we perform the procedure and comment on the score.’ (fgd6) findings: nurse tutors five kiis were conducted with nurse tutors in addition to the fgds with students to gain a better understanding of how the students responded from the perspective of the teachers, who used the assessment tool to evaluate the students’ clinical competency. an exploration of the perceptions of the nurse tutors generated two themes (table 2). theme a: strengths of the assessment tool one of the themes that emerged from the interviews with the nurse tutors was about the strengths of the assessment tool. as with the students, the tutors reported that the tool provides for a wide variety of nursing procedures expected of students, thus making it more suitable to use. the other strength of the tool is its clarity and ability to guide students during clinical rotations. the following tutors' responses captured these strengths: ‘the assessment tool is very important because it was designed with a wide range of clinical procedures, thus giving students an opportunity to capture all procedures participated in.’ (p1) ‘the current assessment tool was designed to enable students to participate in many examinations and record them. it contains all examinations expected of a nurse at registered level to know.’ (p2) ‘the tool is written in clear language, which gives students an opportunity to follow. in addition, every procedure has clear instructions on what to do and document, making it suitable for students to use even in the absence of nurse supervisors.’ (p5) the mentors seemed to agree that the tool has a wide variety of nursing procedures that students are expected to perform and it has clear instructions for students to follow. theme b: challenges regarding the assessment tool another theme highlighted by the nurse tutors related to challenges regarding the assessment tool. all the nurse tutors felt that the tool lacks guidelines on how to objectively assess the students, which often leads to subjective assessment. this was particularly manifested when tutors assessed the records of students several weeks after they had filled in the tool: ‘the assessment of student performance with this tool is still a challenge. many times we are busy and it is difficult to assess students as they fill in the tool. this forces us to look at the tool weeks after students have recorded procedures. unfortunately, it is difficult to remember what exactly they were able to perform, especially when it comes to specific details of the procedure.’ (p3) ‘there is a lot of subjectivity while evaluating student performance using this tool. in addition, the tool has no clear assessment guidelines for us as tutors for both formative use as well as summative use, yet i think the tool is intended for both functions.’ (p4) the tutors also reported that the tool lacks clear guidelines on how to give feedback to students, and some of the procedures in the tool are not done in the hospital; yet, students are required to record them: ‘most of us are not trained in giving feedback and the tool lacks clear guidelines for us to give feedback to students. this combined with the fact that we are few on the ward makes giving feedback to students very difficult.’ (p1) ‘the tool is comprehensive enough; however, there are many procedures included in the tool that are not performed in the hospital. at the same time, some of the procedures are not performed because there are other better procedures. therefore, perhaps the tool needs to be revised to bring it up to date.’ (p4) from these abovementioned responses, therefore, the assessment tool has some challenges, despite various advantages. the challenges pointed out by the nurse mentors correspond to what the students pointed out. key among these are the subjective assessment, as well as limited opportunity to deliver immediate corrective feedback to support learning. discussion the purpose of this study was to explore the experiences of student nurses and their mentors regarding the clinical competence assessment tool. findings demonstrated that the students received orientation regarding the tool. this orientation process assisted them to become familiar with the tool and its requirements. the importance of such an orientation process before implementation of the assessment tool has also been emphasised in studies table 2. themes from key ideas with nurse tutors theme key ideas theme a: strengths of the assessment tool • wide range of nurse procedures • clear instructions for students • clear guides for students on what to do theme b: challenges with the assessment tool • assessment is subjective • no clear assessment guidelines • some procedures in the tool are not done in hospital • no guidelines for feedback 184 november 2020, vol. 12, no. 4 ajhpe research by helminen et al.[6] and baumgartner et al.[12] these scholars reported that mentors and students need to be orientated with regard to any type of assessment the tool before maximum benefit is achieved. orientation will possibly achieve the following: students are given an opportunity to become familiar with tool and what is required of them. any questions that arise can then be addressed before the tool is applied in the clinical setting. however, the findings revealed some drawbacks. the orientation process seemed to have missed addressing some of the student expectations, such as targeted learning goals and outcomes, as well as criteria for scoring student performance. such discrepancies in the orientation process of students and faculty towards the use of the assessment tool can therefore influence its effectiveness. the implication for nursing education is that any assessment method for clinical skills needs to be explained to the students. filling in the assessment tool forms part of the requirement for professional registration, which further strengthens the importance of properly introducing the tool to the students. some of the students missed the orientation session – perhaps because they had not reported to school during the first year. there is a greater need to phase in the orientation sessions to ensure that all students benefit. doing it once during the first year for a tool that is supposed to be used over 3 years, needs attention. the goal of the tool is to ensure that students use it to track their attainment of the desired nursing procedures. therefore, periodic debriefing sessions with the students should be considered. as alluded to in this study, peer-to-peer support in utilisation of the tool is important, especially when senior students guide junior students on how to use it. there are too few nurse mentors compared with students. therefore, the possibility of senior students mentoring junior students in using the assessment tool may be one way of addressing this challenge. in most situations, senior nursing students have probably gone through a similar assessment process using a similar tool. therefore, they can be a great resource in mentoring their junior colleagues on the use of the tool so that students can attain the desired outcomes. this suggestion is in agreement with that in a previous study, which emphasised the benefit of peer mentoring, where senior students assist junior students, thereby empowering them to provide constructive feedback during the learning and mentorship process.[14] it was also noted that there is a need to increase awareness regarding the importance of assessment, particularly when using the tool that has been designed to track and monitor student progress. the assessment of the tool seemed to be rather subjective, as pointed out by students and mentors. this calls for the training of mentors on how to conduct assessment using the tool. although it would have been good for formative assessment, the mentors seemed to have used it for summative purposes, which was subjective. to reliably evaluate the achievement of competency in nursing procedures, there should be an objective way of assessing the tool. for example, use of standardised checklists that specify important aspects is key. in addition, faculty need to be trained on how to assess the tool through participatory and interactive workshops, e.g. mccarty and higgins[15] advised that mentors should be prepared for their complex and demanding roles, especially how they view the assessment tool and how such a tool can be effectively used to facilitate the learning process. part of this preparation can therefore be achieved through training. there was also a challenge with provision of feedback to the students. corrective feedback is paramount, especially when students are learning clinical skills. the assessment tool had no guidelines for delivering feedback to students. it was also observed from the interviews with mentors that they lacked skills on how to provide feedback. one way of addressing this challenge is to include some structured guidelines in the tool on aspects with regard to feedback. leaving it open to mentors creates some gaps, which unfortunately impacts on effective learning. another solution would be to train mentors on how to deliver feedback and what particular aspects to focus on. as observed from this study, some students occasionally became too anxious and panicky in an effort to complete the assessment tool, probably because the tool is later needed for professional registration. students were also possibly anxious because they had not received adequate orientation regarding the tool. this finding requires urgent attention, because assessment is meant to facilitate learning and not to create panic among learners. therefore, nurse mentors and clinical preceptors are potentially needed to guide and mentor the students. it can be argued that it is the responsibility of mentors to facilitate, coach and guide students to perform nursing procedures, create a supportive and motivating learning environment and evaluate the performance of student nurses through the use of the assessment tool. this calls for training of mentors – also on how to guide the students as they implement the tool. such preparation is necessary if valid and reliable decisions are to be made about the students’ competency based on the assessment tool. there are definitely more challenges in using the assessment tool, which involve the clinical setting and the educational process. the same observation has been reported in the literature, i.e. that challenges continue to exist in the clinical setting despite the assessment tool possibly being effective.[16] challenges were observed, such as laziness of students to complete the assessment tool and record procedures, failure to allocate procedures per semester, inclusion of rare and obsolete procedures in the assessment tool, limited time of mentors, who sometimes sign off procedures that have not been performed, and increasing numbers of students in the clinical wards. all these challenges may limit the effective implementation of the assessment tool in the clinical setting. one way of mitigating this could be to have a timetable of student rotations on the wards, to train nurse mentors and to occasionally use senior students to mentor junior students. the study findings therefore concur with those of al-kadri et al.,[14] who observed that mentors can empower students through provision of effective feedback to their peers. if such challenges are not addressed, the implementation of the assessment tool becomes ineffective. for example, from this study it was shown that at times the scores within the assessment tool did not reflect students’ competencies. morgan[7] argued that any effective assessment tool must be able to assess the students’ ability to integrate theory and practical procedures in clinical settings. overall, it has been shown that, although we may design very good assessment tools to evaluate the competency of nurse trainees, such tools may be ineffective if they are not properly organised and if nurse mentors and students are not satisfactorily orientated or trained to use the tool. provision of feedback is crucial. clinical nursing procedures are important for any professional nurse. assessment of mastery of those procedures is perhaps even more crucial. findings from this study open up a debate regarding nursing education and particularly regarding learning and assessment of clinical nursing skills. the question arises whether the tool discussed in this study is best for assessing acquisition of clinical nursing skills and using it as a regulatory framework for registration. with key drawbacks identified, such as unreliable assessment, suboptimal orientation regarding the tool, limited feedback and subjective november 2020, vol. 12, no. 4 ajhpe 185 research assessment, the need to rethink how nurse educators assess clinical skills is important. going forward, using a tool such as a learning portfolio may be more important than including students’ reflections of their learning. this could be combined with other assessments of clinical competency, such as an objective structured clinical examination (osce), which can contribute to requirements for registration rather than solely relying on records logged into a paper tool. therefore, this study highlights some key issues that all nursing institutions need to give some thought as they design effective assessment tools to evaluate clinical and practical competency for nurses, especially when such assessment forms part of the requirements for certification to practise independently. study limitations despite the observed strengths and positive insights that have emerged from this study, there are some limitations. it was carried out in only one nurse training institution, whose context might be quite different from other nursing institutions globally. there could be other contextspecific factors that contributed to study observations. this, coupled with the small number of participants, may limit the generalisability of the findings to many other settings. however, the findings generate important insights regarding assessment of nurse clinical competency, especially when educators design assessment tools. important key issues have been generated in this study. further research there are implications for further research, e.g. this study focused on exploring the perceptions of nurse mentors and students regarding the clinical assessment tool. however, further research is needed to evaluate the reliability and validity of the tool. more empirical studies focusing on this direction in many more settings are therefore encouraged. conclusions the students and mentors generally had positive perceptions towards the assessment tool, and participants appreciated its design. the tool had adequately covered all domains in the curriculum. however, orientation regarding the tool was inadequate and affected its applicability in the clinical environment. it lacked a sufficient structured guide for rating student competency in procedures, thus occasionally making the assessment largely subjective. mentors were not able to mark and sign the tool immediately after a procedure, as required. some procedures were rare and others outdated. however, there were procedures that were frequently performed by students during their placement, but which were not included in the tool. declaration. none. acknowledgements. special thanks go to the students and mentors who participated in this study. author contributions. ms: conceptualised and developed the idea, drafted the protocol, collected data, participated in the analysis and wrote the initial draft; agm: participated in the analysis, refined the methodology, did critical reading and refined the final manuscript; jn: participated in refining the methodology and data analysis; igm: refined the initial manuscript draft and assisted in the analysis; rbo: participated in the analysis and refined the manuscript draft; sk: assisted in refining the methods and proofread the final manuscript. funding. research reported in this publication was supported by the fogarty international center of the national institutes of health (nih), us department of state’s office of the us global aids coordinator and health diplomacy (s/gac), and the president’s emergency plan 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https://doi.org/10.1016/s0260-6917(02)00187-9 16. wade gh, hayes e. education: challenges and opportunities associated with preceptored community health clinical experiences. public health nursing 2010;27(5):459-467. https://doi.org/10.1111/j.15251446.2010.00879.x accepted 13 august 2020. http://moodle.amref.org http://moodle.amref.org http://moodle.amref.org https://doi.org/10.1016/j.nepr.2016.06.008 https://doi.org/10.1016/j.ijnurstu.2015.09.014 https://doi.org/10.1016/j.ijnurstu.2015.09.014 https://doi.org/10.1111/j.1365-2702.2006.01237.x https://doi.org/10.1111/j.1365-2702.2006.01237.x https://doi.org/10.1080/01421590802061613 https://doi.org/10.12968/bjon.2012.21.9.536 https://doi.org/10.12968/bjon.2012.21.9.536 https://doi.org/10.1016/j.nedt.2014.11.022 https://doi.org/10.1016/j.nedt.2014.11.022 https://sigma.nursingrepository.org/handle/10755/616445 https://doi.org/10.5430/jnep.v7n11p111 https://doi.org/10.5430/jnep.v7n11p111 https://doi.org/10.2202/1548-923x.1384 https://doi.org/10.3402/meo.v17i0.11204 https://doi.org/10.3402/meo.v17i0.11204 https://doi.org/10.1016/s0260-6917(02)00187-9 https://doi.org/10.1111/j.1525-1446.2010.00879.x https://doi.org/10.1111/j.1525-1446.2010.00879.x 182 september 2021, vol. 13, no. 3 ajhpe research why was the idea necessary? anatomy forms part of the preclinical curricula of the bachelor of pharmacy (bpharm) and medicine (mb chb) degree programmes at the university of namibia (unam). the focus of this report relates to the challenges and subsequent interventions during the onset of the second semester of 2020. the modules of interest involve the respiratory and cardiovascular systems. these modules are concurrently presented for both degree programmes and include the histology, embryology and gross anatomy of these systems.[1] medical students are required to complete practical laboratory dissections while the pharmacy students are not. owing to the growing pandemic, the namibian government announced a state of emergency on 27 march 2020. this announcement was most inopportune as unam students were on recess the week before the national lockdown was announced and we were caught off guard. institutional attempts to introduce blended learning and formal online learning were not achieved in time before our students went on recess. our students (pharmacy and medicine) were at home and could not return to campus. they were subsequently restricted by whatever educational resources they happened to have taken with them on holiday. many spent their recess at home in a rural setting (off-grid villages) with little infrastructure and without textbooks or laptop computers. the biggest challenges our students faced related to internet connectivity and reliability, and the availability of sufficient data. a google forms survey, distributed during the student recess, confirmed our concerns: 50.8% of students possessed only a mobile phone, while a meagre 4.1% own laptop computers. students’ internet connectivity relied on mobile data (56.6%) and 48.4% stated that they did not have internet at home. these findings correlate with an american report which found that 56% of students from low-income households reported reliable internet access. only 45% stated that their home environment was conducive to remote learning.[2] matters were made worse by a surge of users taxing the learning management system (lms) and the limited server space. practical dissections were not feasible because of travel restrictions and social distancing regulations. we provided links to essential anatomy 3d, kenhub, acland’s anatomy and youtube as a substitute via our lms (moodle) and cloud storage (google drive or g-drive). these resources proved to be ‘too much of a good thing’ and the medical students were subsequently overwhelmed by too many electronic resources that exceeded their internet data availability. furthermore, narrated powerpoint (ppt) lectures proved challenging as a result of the 250 mb data restriction on our lms server and the loss of narrations on mobile devices. the data and file format limitations necessitated a small file size alternative that addressed the educational needs of our students and aligned with the intended learning objectives. here the authors report on a novel and content-specific approach to emergency remote teaching (ert) – i.e. the emergency provision of access to instructional content as opposed to formal online learning (fol), which is carefully planned in advance.[3] what was tried? we developed a feasible alternative to multiple electronic resources that accounted for students’ lack of data in the form of short, to-the-point video tutorials, with an average duration of 3 minutes and a file size of 6 mb. the tutorials focused on cadaveric specimens, histological slides and medical images that could be shared via whatsapp and other messaging services. the videos were deemed ‘just right’ by the lecturers in reference to the aims of the programme, intended learning outcomes, mode of assessment, duration and file size, and can therefore be considered as ‘goldilocks anatomy’. freely available and user-friendly software programmes were selected to capture the video content of annotated images and allow compression of the rendered files. ispring free cam (version 8) (ispring, usa) was used as a desktop recorder and proved invaluable during the process. the programme allows screen capturing with audio recordings of any educational activity on one's desktop. the same can be done with an interactive virtual histology programme running in the background. the software permits customisation of the recording area and editing of the video after recording (trimming and noise removal). the generated videos were typically between 20 and 90 mb in size, but were compressed and converted to mp4 and m4v formats which ranged from 3 to 9 mb. we used handbrake software to compress and encode the video files to the desired format. the file compression reduced the image quality but it was found to be negligible, with no noticeable loss of detail for their intended purpose. we also found that the audio quality was unaltered. the generated video tutorials were uploaded onto moodle and g-drive and emailed to class representatives who then shared the material via whatsapp. lessons learnt the visual nature of anatomy as a subject lends itself to innovative approaches to its delivery. various virtual anatomy and web-based educational systems exist.[4] multimodal approaches, where didactic lectures and practical dissections are supplemented with clinical correlation, medical imaging, models, and teamand problem-based approaches, have gained much interest.[5] while the best pedagogical approach to anatomy continues to be debated,[6] we are faced with the realities of ert where the majority of our students are confronted with resource-limited learning environments. we were completely cognisant in our approach and well aware of the impact of these limitations on students’ learning. anatomy’s visual nature is also its biggest drawback during ert, where online resources require substantial amounts of internet data. narrated ppt lectures can be substituted by video tutorials of smaller file sizes. furthermore, the use of in-house resources such as prosected ‘goldilocks anatomy’ – data-conserving anatomy video tutorials during emergency remote teaching q wessels, msc (clin ed), fhea, phd; a du plessis, mb chb; k van niekerk, mb chb department of anatomy, school of medicine, faculty of health sciences, university of namibia, windhoek, namibia corresponding author: quenton wessels (qwessels@unam.na) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:qwessels@unam.na september 2021, vol. 13, no. 3 ajhpe 183 research specimens, donated medical images and digitised high-definition histology micrographs prevented copyright infringement. these short tutorials allowed for sharing on multiple messaging platforms such as whatsapp. the benefits and convenience of whatsapp as a learning tool are well known.[7] another tendency during ert is compensation on our side, where we as educators try to provide as much information as possible. we subsequently lose sight of the students’ challenges. as lecturers, we sometimes forget that students have other subjects that require additional data use in resourcelimited environments. this is an extremely important consideration when providing students with web-based resources that consume their internet data. ‘less’ in this context is therefore ‘more’. the element of selfdirected learning can be addressed in a similar fashion with the provision of essential reading material as opposed to too many supplementary resources. however, the primary driver must be constructive alignment. a well-structured programme guide with appropriate learning outcomes, specific unit descriptors, and assessment criteria and standards proved to be an indispensable resource during ert. the inclusion of medical images was expected to facilitate learning in context, i.e. the integration with clinical medicine, to some degree.[6] the contextual aspects of remote online learning, such as time, content and server limitations, had to be addressed as far as possible. we have learnt that fol is not feasible in a resource-constrained setting and fol can only work when and where technology permits. this holds true for active and synchronous online instruction. we have also come to appreciate the importance of feedback and explicit and frequent communication with our students. communication can either be synchronous or asynchronous and allows for constant feedback. finally, the ownership of intellectual property (ip) of online teaching content needs to be addressed. to the authors’ knowledge, unam has no clear ip policy that addresses the distribution of the video tutorials generated by the authors. it is therefore important for institutions to stay abreast with the digital learning revolution and implement the appropriate policies. what will i keep in my practice? in practice, the video tutorials serve as a viable alternative to the gold standard of narrated ppt and youtube lectures. they were provided in synchrony with a scheduled timetable. these recordings are versatile and provide an auditory and a physical reference (visual) to anatomical structures. the provision of essential rather than supplementary tutorials, with selected web-based learning resources, affords an even wider learning experience. considering that students mostly use smart phones and that ppt narrations are sometimes corrupted or inaccessible when diverse applications are used, these data-limited, pertinent tutorials provide a bespoke alternative. we will continue to facilitate student-to-student engagement on the lms. collaborative pedagogy through forum discussions proved very useful and helped to clarify difficult concepts. constant engagement encouraged students to contribute towards their own learning. what will i not do? it is important not to overwhelm students with too many electronic resources in the hope that it will supplement what cannot be addressed through virtual lectures or online discussions. it is tempting to direct students to the wonderful array of electronic resources on the internet. many are freely available, but it is important to remember that ‘free’ resources are never free and require internet data, more so in a resource-limited environment. maintaining a balance between the use of an lms and other modalities is essential, and students should not be dependent on only one. declaration. none. acknowledgements. none. author contributions. all authors made a substantial contribution to the conceptualisation, write-up of the article, and approval of the version to be published. funding. none. conflicts of interest. none. evidence of innovation 1. wessels q, vorster w, jacobson c. anatomy education in namibia: balancing facility design and curriculum development. anat sci educ 2012;5(1):41-47. https://doi.org/10.1002/ase.1250 2. kim h, krishnan c, law j, et al. covid-19 and us higher education enrollment: preparing leaders for all, 2020. https://www.mckinsey.com/~/media/mckinsey/industries/public%20and%20social%20sector/ our%20insights/covid%2019%20and%20us%20higher%20education%20enrollment%20preparing%20 leaders%20for%20fall/covid-19-and-us-higher-education-enrollment-preparing-leaders-for-fall_f. pdf ?shouldindex=false (accessed 24 december 2020). 3. hodges c, moore s, lockee b, et al. the difference between emergency remote teaching and online learning. educause review, 2020. https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remoteteaching-and-online-learning#fn10 (accessed 24 december 2020). 4. preim b, saalfeld p. a survey of virtual human anatomy education systems. comput graph 2018;71:132-153. https://doi.org/10.1016/j.cag.2018.01.005 5. johnson eo, charchanti av, troupis tg. modernization of an anatomy class: from conceptualization to implementation. a case for integrated multimodal multidisciplinary teaching. anat sci educ 2012;5(6):354-366. https://doi.org/10.1002/ase.1296 6. drake rl, pawlina w. multimodal education in anatomy: the perfect opportunity. anat sci educ 2014;7(1):1-2. https://doi.org/10.1002/ase.1426 7. gon s, rawekar a. effectivity of e-learning through whatsapp as a teaching learning tool. mvpjms 2017;4(1):19-25. https://doi.org/10.18311/mvpjms.v4i1.8454 accepted 11 february 2021. afr j health professions educ 2021;13(3):182-183. https://doi.org/10.7196/ajhpe.2021.v13i3.1469 https://doi.org/10.1002/ase.1250 https://www.mckinsey.com/~/media/mckinsey/industries/public and social sector/our insights/covid 19 and us higher education enrollment preparing leaders for fall/covid-19-and-us-higher-education-enrollment-preparing-leaders-for-fall_f.pdf?shouldindex=false https://www.mckinsey.com/~/media/mckinsey/industries/public and social sector/our insights/covid 19 and us higher education enrollment preparing leaders for fall/covid-19-and-us-higher-education-enrollment-preparing-leaders-for-fall_f.pdf?shouldindex=false https://www.mckinsey.com/~/media/mckinsey/industries/public and social sector/our insights/covid 19 and us higher education enrollment preparing leaders for fall/covid-19-and-us-higher-education-enrollment-preparing-leaders-for-fall_f.pdf?shouldindex=false https://www.mckinsey.com/~/media/mckinsey/industries/public and social sector/our insights/covid 19 and us higher education enrollment preparing leaders for fall/covid-19-and-us-higher-education-enrollment-preparing-leaders-for-fall_f.pdf?shouldindex=false https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning#fn10 https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning#fn10 https://doi.org/10.1016/j.cag.2018.01.005 https://doi.org/10.1002/ase.1296 https://doi.org/10.1002/ase.1426 https://doi.org/10.18311/mvpjms.v4i1.8454 https://doi.org/10.7196/ajhpe.2021.v13i3.1469 december 2018, vol. 10, no. 4 ajhpe 220 research the importance of behavioural science in advancing health in lowand middle-income countries (lmics) was highlighted in a journal funded by the us agency for international development (global health science and practice).[1] in particular, the authors outlined six domains of behaviour change that were building blocks of global health. one of these domains was ‘provider behaviour’ and included understanding healthcare workers’ capabilities, opportunities and motivations to provide high-quality care. we propose that understanding provider behaviour is most urgent in the areas of healthcare that have been shown to impact greatly on patient mortality and morbidity, e.g. management of the critically ill patient. management of the deteriorating and critically ill patient is a key activity in acute healthcare facilities. firth and ttendo[2] emphasised the need for recognition, assessment and management of the critically ill in uganda and other low-income countries. this need is great because many patients present to hospital in a critical state owing to certain factors, including underlying health issues (e.g. malnutrition); present to hospital at a late stage owing to the time taken to travel to hospital; and seek help at a late stage of an illness because of the need to pay fees. a systematic review of critical care in lmics found that many health professional students had limited training in the assessment and management of acutely ill patients.[3] it is clear, therefore, that there is a need to educate and train staff in the management of acute illness in lmics. there are many courses that teach the recognition and management of acutely ill people. examples are the 1-day acute illness management (aim) background. understanding the drivers of ‘provider behaviour’ has been highlighted as one of the six domains of behaviour change in strengthening healthcare systems. objectives. to assess changes in healthcare provider behaviour, i.e. use of the airway, breathing, circulation, disability, exposure (abcde) approach in acute illness management, after participating in a 1-day course on the assessment and management of acutely ill patients. we aimed to assess whether changes in psychological determinants of the abcde approach were associated with changes in the use of the approach. methods. we used a pre-post design to study self-reported change in behaviour after a 1-day training course from pre-course to follow-up 1 month later. we also measured psychological determinants of behaviour immediately before and after and at 1-month follow-up. we explored if changes in psychological determinants were associated with change in practice 1 month later. results. we found the following: firstly, use of the abcde approach increased at 1 month post-course from a median use of 50 90%. secondly, the increase in the abcde approach was associated with a positive change in only one of the determinants of practice from preto post-course: perception of environmental determinants (r=0.323; p<0.05). finally, there were no other significant associations with practice change or practice at follow-up. conclusions. change in perceptions of availability of resources was associated with increased use of an abcde approach, but evidence was limited owing to the pre-post design. afr j health professions educ 2018;10(4):220-227. doi:10.7196/ajhpe.2018.v10i4.994 a pre-post study of behavioural determinants and practice change in ugandan clinical officers l m t byrne-davis,1 bsc hons, msc, phd, cpsychol, pfhea; m j jackson,2 bsc hons, mb chb, pgcert; r mccarthy,3 rn, rm, msc, pgce, som, phd; h slattery,4 rn, bsc, pgce; g yuill,2 mb chb, frca; a stevens,5 rgn; g j byrne,6 mb chb, md, frcs, mame, ntf; h parry,1 mb chb; s ramsden,7 mb chb, bmedsc, dtm&h; h muwonge,8 mb chb, pgd, ppm, muma; m johnston,9 bsc, phd, cpsychol, cclinpsych; c j armitage,10 ba hons, phd, cpsychol, afbps; s cook,5 rn; s whiting,11 rn, enb100; j gray,12 rn; j hart,1 bsc hons, msc, phd, cpsychol, afbps pfhea 1 division of medical education, university of manchester, uk 2 stockport nhs foundation trust, stepping hill hospital, stockport, uk 3 school of nursing, midwifery, social work and social sciences, university of salford, uk 4 university hospital of south manchester academy, university hospital of south manchester, uk 5 critical care skills institute, manchester, uk 6 health education england, manchester, uk 7 great western hospital, swindon, uk 8 uganda-uk health alliance, kampala, uganda 9 health psychology group, institute of applied health sciences, university of aberdeen, scotland, uk 10 manchester centre for health psychology, university of manchester, uk 11 pennine acute hospitals nhs trust, north manchester general hospital, uk 12 east lancashire hospitals trust, blackburn, uk corresponding author: l m t byrne-davis (lucie.byrne-davis@manchester.ac.uk) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 221 december 2018, vol. 10, no. 4 ajhpe research and its sister course maternal acute illness management (m-aim), which teach an airways, breathing, circulation, disability, exposure (abcde) approach to acute illness recognition and management. aim and m-aim have previously been shown to improve the knowledge of participants immediately after the course.[4,5] further research on these two courses revealed barriers and facilitators to healthcare professionals using their new knowledge and skills in practice.[6] in response to these barriers, the greater manchester critical care skills institute developed aim4africa, a 1-day interactive course, which could increase the implementation of knowledge and skills in practice by addressing barriers and focusing on facilitators. research investigating how healthcare professionals put new knowledge and skills into practice, explores variables, i.e. ‘behavioural determinants’. these variables typically influence whether someone executes a particular behaviour and can be categorised as capability, opportunity and motivation.[7] there are many behavioural determinants in each category. eccles et al.[8] described behavioural determinants that had been associated specifically with changes in provider behaviour. these include both deliberative/reflective processes and automatic or habitual processes,[9] and were constructs in: (i) theory of planned behaviour; (ii) social cognitive theory; (iii) selfregulation model; (iv) learning theory; (v) implementation intentions; (vi) knowledge, attitudes, behaviour; and (vii) stages of change, as specified by the precaution adoption process. innovations in practice are frequently investigated using the promoting action on research implementation in health services (parihs) framework.[10] the constructs in parihs are: (i) impact of having facilitation/support while attempting to change practice; and (ii) perception of the strength of evidence change in practice. moreover, burnout has frequently been shown to be high in healthcare professionals.[11,12] it is not known whether high levels of burnout might negatively impact practice change. many training courses assess whether programmes are effective by measuring behavioural determinants within the category of ‘capability’, e.g. knowledge and skills. however, it is rare for training courses to assess whether programmes are effective by examining changes in behavioural determinants that fall into the categories of opportunity and motivation. therefore, there is little understanding of whether a training course that encourages an abcde approach to acute illness management changes behavioural determinants in the categories of capability, opportunity and motivation. there is also little understanding about whether changes in any of the behavioural determinants are associated with changes in use of the abcde approach. to address these gaps, our study sought to examine the following: • determine if attendance at an acute illness management course tailored to the low-resource setting (aim4africa) would be associated with change of specific behaviour, specifically using an abcde approach to care for acutely ill patients from before the course to 1 month later. this was done by measuring and comparing self-report use of an abcde approach immediately before the course and 1 month later. • explore if aim4africa changed any behavioural determinants regarding the use of an abcde approach from before to immediately after the course by measuring these. • explore associations between changes in behavioural determinants and in the use of an abcde approach by investigating data statistically for associations. • explore associations between behavioural determinants that occur at the point of putting new knowledge and skills into practice (i.e. implementation support, feedback and burnout) and behaviour by exploring the data statistically for association. methods in a pre-post design, we examined self-reported use of an abcde approach by clinical officers in gulu, uganda, prior to the aim4africa course and 1 month later. we measured behavioural determinants before and immediately after the course and at 1 month follow-up. we compared changes in behavioural determinants from preto post-course with changes in the use of an abcde approach pre-course to 1 month follow-up. participants clinical officer students (n=77) in year 3 (final year, 2014 2015) of their course enrolled in aim4africa. these ugandan students train to become licensed, fully qualified medical practitioners. completion rates were 73 of 77 (95%) for pre-course and 70 of 77 (91%) for follow-up (i.e. 93% of the pre-course completers). the participants’ mean age was 24 (standard deviation 2.3; range 21 35) years and 71% were men. measures applied knowledge we assessed applied knowledge by ‘single best answer’ multiple-choice questions (mcqs) with between 4 and 6 response options, authored by the aim steering group. items were divided into two papers and each participant had the same paper preand post-course. participants scored 1 point for each correct answer and a percentage score was calculated for overall knowledge. capability checklist (self-report) measured with a 49-item checklist from the core capabilities in the aim4africa course, participants were asked to indicate if they could perform each task or skill independently (2 points), with some support (1 point), not at all (0 points) or do not know (missing data). scores ranged from 0 to 98. behavioural determinants’ questionnaire and usual behaviour there were 18 behavioural determinants and 46 questions. we assessed usual behaviour by: (i) two questions requiring strength of agreement, with statements about how typical it was for the participant to conduct that behaviour in that context; and (ii) estimates of the number of patients seen in the past month, who they thought might have been acutely unwell and estimates of with how many of these patients they used the abcde approach. we based the style of questions on the research-based education and quality improvement (rebeqi) manual,[15] which outlines methods for creating questions assessing the construct in the theory of planned behaviour. names, numbers of questions and minimum and maximum possible scores of each construct are given in table 1. procedure before the aim4africa course: pre-course the questionnaires were integrated into the course timetable; information emphasised that the evaluation was not a prerequisite to take the course; all learners consented to take part; and participants completed the pre-course measures. december 2018, vol. 10, no. 4 ajhpe 222 research after the aim4africa course: post-course and follow-up on completion of the course, participants completed the pre-course questionnaires again, without questions about usual behaviour. one month later, the researchers attended the 4 local health centres, where participants were placed for 3 days (20 22 students at each facility). questionnaires were administered during breaks in clinical practice. analyses change in use of the abcde approach we compared median behaviour pre-course and at follow-up using the wilcoxon signed-rank test. we calculated a change score for behaviour by subtracting the percentage of acutely ill people for whom participants reported taking an abcde approach pre-course from the percentage at follow-up. use of the abcde approach is advocated for all people suspected to be acutely ill. therefore, we dichotomised the self-reports of behaviour into those using the abcde approach in 100% of people they suspected were about to become acutely ill and those not using the approach 100% of the time. we reported frequencies and percentages of participants always using the abcde apparoach and those not using abcde continuously precourse and at 1 month follow-up. these were compared using the χ2 test to see if frequency of maximal use of the abcde approach had changed. change in behavioural determinants from preto immediately post-course we calculated a change score for each behavioural determinant by subtracting pre-course scores for each construct from immediately post-course scores. we also compared median behavioural determinant scores pre-course and immediately post-course using the wilcoxon signed-rank test. since the scale can be split into agree or disagree (with neutral included in the disagree category, as it is not ‘agreeing’), we also calculated the number and percentage of participants who agreed (i.e. were not neutral or disagreed) with the statements at each time point by calculating an agree/ not agree variable for each behavioural determinant, ≥4.5 being agree and 1 4.4999 being not agree. we used the χ2 test to determine if the number of those agreeing changed from pre-course to post-course. internal consistency reliability of behavioural determinant scales for the constructs with >1 item assessing the construct, cronbach’s alpha analyses were conducted to assess internal consistency reliability. where these showed poor internal consistency (<0.2), we reported the results but did not use the construct in any further inferential analyses. distribution of variables we conducted the shapiro-wilk test of normality on each variable to determine whether to use parametric or non-parametric inferential table 1. constructs, descriptions, number of items and range of possible scores for behavioural determinants and usual behaviour construct description n (range) awareness of need for change being aware that a problem exists and thinking about overcoming it, but without having made a plan or a commitment to take action 1 (1 7) behavioural expectation one’s expectation that one will perform a behaviour 1 (0 10) habit a behaviour or pattern of behaviours that tends to occur unconsciously in response to a situation or context 2 (1 7) burnout a prolonged response to chronic emotional and interpersonal stressors at work and defined by three dimensions of exhaustion, cynicism and inefficacy 3 (1 7) implementation support having specific individuals who facilitate the carrying out of a behaviour 3 (1 7) action control self-regulatory processes; processes that involve initiating, inhibiting, modulating or monitoring a particular behaviour 3 (1 7) general intention motivation or decision to act in a particular goal-directed way 3 (1 7) attitudes to behaviour positive and negative beliefs and feelings towards a behaviour 5 (1 7) outcome expectancies perceived likelihood that one or more outcomes will occur having acted in a particular way 3 (1 7) subjective norms rules and standards that are understood by members of a group, that guide and/or constrain social behaviour without the influence of laws 3 (1 7) self-efficacy self-efficacy is the extent or strength of one’s belief in one’s ability to complete tasks and reach goals 1 (1 7) perceived behavioural control an individual’s perceived ease or difficulty of performing a behaviour 2 (1 7) knows how knowing how to perform a behaviour or achieve a goal 2 (1 7) strength of evidence codified and non-codified sources of knowledge, including research evidence, clinical experience, e.g. professional craft knowledge, patient preferences and experiences and local information, in favour of performing a new behaviour 1 (1 7) action planning a process that links goal-directed responses to situational cues specifying how, where and when to act 3 (1 7) coping planning making a plan of what to do to achieve one’s goals when there are difficulties in executing one’s initial action plan 4 (1 5) feedback response of other people after performing a particular behaviour 3 (1 7) environmental determinants influence of the physical environment and surroundings on behaviour 3 (1 7) self-report behaviour percentage of possible times of behaviour = (number of times you performed the behaviour/number of times appropriate for performance of the behaviour) multiplied by 100 2 (0 100) usual behaviour to what extent one performs a behaviour in a particular situation or context 2 (1 7) 223 december 2018, vol. 10, no. 4 ajhpe research statistics. of the 36 variables measured at preand post-course and followup, 5 were normally distributed. the others were shapiro-wilk 0.184 0.969, df=29 and p<0.05. we therefore continued with presenting median and interquartile ranges as descriptions of the variables and conducted non-parametric inferential statistics. change scores we tested change score variables for normality to determine whether to use parametric or non-parametric inferential statistics, again using shapirowilk. of the 11 change scores calculated, 3 were normally distributed. the test of normality for the others were shapiro-wilk 0.605 0.983, df=54 and p<0.05. we therefore continued with presenting median and interquartile ranges as descriptions of the variables and conducted non-parametric inferential statistics. change in behavioural determinants associated with behaviour change using spearman’s rank test, we correlated all change in behavioural determinants (from preto immediately post-course) with change in behaviour (from pre-course to follow-up) to establish if any behavioural determinant changes during the course were associated with behaviour change from pre-course to follow-up. missing data for constructs with multiple items, where there was one missing data point, medians or means were calculated using the remaining items. where there was more than one missing data point, data from the whole construct were excluded for that participant. ethical approval this project had approval from the lacor institutional review board and ministry of health in uganda. confirmation was given from the university of manchester research ethics committee in the uk that they did not require additional formal approval, as the work would be considered evaluation of training. results change in use of the abcde approach (study aim 1) the median use of the abcde approach was 50% at pre-course and 90% at follow-up; a wilcoxon signed-rank test indicated that this was a statistically significant change (z −3.941; p<0.001). at pre-course, 16 of 66 (24%) participants reported using the abcde approach in 100% of acutely ill patients. at follow-up, it was 34 of 71 (45%). a χ2 test indicated that this increase was not statistically significant (table 2). behavioural determinants internal consistency reliability we assessed internal consistency reliability at the first time of measurement, e.g. pre-course. subjective norms and perceived behavioural control were not considered to be measured reliably enough to be included in further analyses (table 3). stage of change before the course, almost half of participants reported that they had already started using an abcde approach, although this number decreased to only a fifth after the course. those reporting that they had made a decision to use an abcde approach rose from 23% to 62% from preto post-course. this finding perhaps indicates that participants thought that they were using an abcde approach before the course; yet, after attending the course, they realised they were not and then made the decision to try this method (table 4). change in behavioural determinants (study aim 2) pre-course medians tended towards the top of the range for each scale. measures with lower scores were action control (median 4.7) and action planning (median 5.0). burnout had a median of 3.7, but, in this case, a lower score is positive, as it indicates a lower level of burnout. the wilcoxon signed-rank test showed that there were significant increases in scores for capability, knowledge (measured by mcq), general intention, attitudes to behaviour, outcome expectancies and self-efficacy, knows how, strength of the evidence and action planning after the course, with fewer participants with lower scores on these measures (table 3). most of the questions were answered by most of the participants. however, the question about behavioural expectation was answered by 40 of 73 (55%) participants at pre-course, 54 of 77 (70%) at post-course and 68 of 71 (96%) at follow-up. change in behavioural determinants associated with change in use of the abcde approach (study aim 3) change in use of an abcde approach from pre-course to follow-up was statistically significantly correlated with change in perception of environmental determinants from preto post-course (r=0.323; p<0.05). no other change in behavioural determinants from preto post-course was statistically significantly correlated with change in behaviour from precourse to follow-up. association between behaviour (at follow-up) and implementation support, feedback and burnout (study aim 4) spearman’s rank correlations illustrated that there were no statistically significant correlations between implementation support, feedback, burnout and behaviour at follow-up. discussion participation by ugandan clinical officers in an acute illness management programme was statistically significantly associated with an increase in self-reported use of an abcde approach to treat acutely ill patients from pre-course to follow-up 1 month after course completion. multiple behavioural determinants, which were measured at preand post-course, changed. the only changes from preto post-course that were statistically significantly associated with a change in use of the abcde approach from pre-course to follow-up were environmental determinants, e.g. perception of time and resources. this is significant, because there are many theoretical determinants of change,[8] but this study indicates that, in a low-resource environment, the perception of environmental determinants is crucial. it is important to distinguish actual environmental determinants, e.g. having time and resources, from what we assessed in our study, i.e. perceptions of time and resources. it is clear that these were perceptions, as they changed from preto post-course when actual time and resource had not altered. the setting is known to be a low-resource one; therefore, it is possible that december 2018, vol. 10, no. 4 ajhpe 224 research ta bl e 2. n um be r, c ro nb ac h’ s al ph a, m ed ia n an d in te rq ua rt il e ra ng e fo r ea ch b eh av io ur al d et er m in an t a t p re a nd p os tco ur se a nd fo llo w -u p p re -c ou rs e po st -c ou rs e fo llo w -u p c on st ru ct it em s, n (r an ge ) pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th se lfre po rt b eh av io ur (a cu te ly u nw el l p at ie nt s – a b c d e ap pr oa ch ), % 2 (0 1 00 ) 16 ( 24 ) 68 n/ a 50 .0 33 .3 89 .4 34 ( 45 ) 71 n/ a 90 .0 60 .0 10 0. 0 c ap ab ili ty ( ch ec kl is t) , % * 49 (0 1 00 ) 0 73 n/ a 82 .7 78 .6 89 .8 23 ( 32 ) 73 n/ a 98 .0 91 .8 10 0. 0 19 ( 24 ) 65 n/ a 96 .9 93 .0 10 0. 0 k no w le dg e (m c q )* 20 (0 1 00 ) 0 72 n/ a 56 .0 44 .0 64 .8 2 (3 ) 77 n/ a 80 .0 72 .0 86 .0 k no w s ho w †, * 2 (1 7 ) 20 ( 28 ) 73 0. 72 1 6. 0 4. 3 7. 0 67 ( 89 ) 73 -0 .0 11 7. 0 7. 0 7. 0 51 ( 68 ) 71 0. 56 2 7. 0 6. 7 7. 0 u su al b eh av io ur 2 (1 7 ) 44 ( 60 ) 73 0. 68 8 7. 0 6. 0 7. 0 57 ( 76 ) 71 0. 73 8 7. 0 7. 0 7. 0 b eh av io ur al e xp ec ta tio n 1 (0 1 0) 29 ( 71 ) 40 n/ a 10 .0 0 6. 50 10 .0 0 51 ( 94 ) 54 n/ a 10 .0 0 10 .0 0 10 .0 0 54 ( 72 ) 68 n/ a 10 .0 0 9. 25 10 .0 0 n um be r of a cu te ly u nw el l pa tie nt s 1 (0 +) n/ a 73 n/ a 6. 0 3. 0 10 .0 n/ a 71 n/ a 8. 0 5. 0 25 .0 a w ar en es s of n ee d fo r ch an ge 1 (1 7 ) 38 ( 51 ) 73 n/ a 7. 0 4. 0 7. 0 55 ( 73 ) 72 n/ a 7. 0 7. 0 7. 0 35 ( 47 ) 71 n/ a 6. 0 1. 0 7. 0 g en er al in te nt io n* 3 (1 7 ) 38 ( 51 ) 72 0. 32 9 7. 0 6. 0 7. 0 62 ( 83 ) 72 0. 37 4 7. 0 7. 0 7. 0 55 ( 73 ) 71 0. 84 9 7. 0 7. 0 7. 0 a tt itu de s to b eh av io ur * 5 (1 7 ) 20 ( 28 ) 71 0. 37 0 6. 6 5. 8 7. 0 59 ( 79 ) 73 0. 20 9 7. 0 7. 0 7. 0 53 ( 71 ) 71 0. 03 7 7. 0 6. 8 7. 0 o ut co m e ex pe ct an ci es ** 3 (1 7 ) 54 ( 74 ) 73 0. 47 4 7. 0 6. 7 7. 0 69 ( 92 ) 73 0. 51 9 7. 0 7. 0 7. 0 58 ( 77 ) 69 -0 .1 37 7. 0 7. 0 7. 0 su bj ec tiv e no rm s‡ ,§ , ** 3 (1 7 ) 3 (4 ) 71 0. 21 1 5. 0 4. 7 5. 3 11 ( 15 ) 71 0. 08 8 5. 0 5. 0 5. 7 6 (8 ) 71 -0 .5 04 5. 0 4. 7 5. 3 se lfef fic ac y* 1 (1 7 ) 49 ( 53 ) 73 n/ a 7. 0 6. 0 7. 0 70 ( 93 ) 73 n/ a 7 7 7 60 ( 80 ) 71 n/ a 7. 0 7. 0 7. 0 pe rc ei ve d be ha vi ou ra l co nt ro l§ 2 (1 7 ) 6 (8 ) 73 0. 10 9 4. 0 4. 0 5. 0 9 (1 2) 72 -0 .1 49 4. 0 4. 0 4. 5 4 (5 ) 70 -0 .4 23 4. 0 4. 0 4. 5 st re ng th o f e vi de nc e* * 1 (1 -7 ) 50 ( 67 ) 73 n/ a 7. 0 6. 0 7. 0 63 ( 84 ) 73 n/ a 7. 0 7. 0 7. 0 59 ( 79 ) 71 n/ a 7. 0 7. 0 7. 0 h ab it 2 (1 7 ) 25 ( 34 ) 73 0. 55 0 6. 0 4. 0 7. 0 27 ( 36 ) 71 -0 .1 76 4. 5 4. 0 7. 0 en vi ro nm en ta l d et er m in an ts 3 (1 7 ) 4 (5 ) 73 0. 69 0 4. 7 3. 0 5. 7 14 ( 19 ) 71 0. 73 3 5. 0 3. 0 6. 7 8 (1 1) 71 0. 68 8 4. 0 3. 0 5. 3 a ct io n co nt ro l 3 (1 7 ) 7 (6 ) 70 0. 83 3 4. 7 3. 0 6. 0 32 ( 43 ) 71 0. 78 4 6. 7 6. 0 7. 0 c on ti nu ed .. . 225 december 2018, vol. 10, no. 4 ajhpe research people would tend to report lack of resources, time and equipment. this changed over the course of a day, with no change in the actual resources. this could be a methodological limitation in using the method of selfreporting; yet, the internal consistency reliability of the three questions about these environmental determinants changed from moderate to high, at 0.690. in terms of the direction of change, there were changes in both directions. some people reported less availability of resources, while some reported higher availability. aim4africa was specifically modified for low-resource settings and one modification is offering alternatives to goldstandard management techniques, such as high concentrations of oxygen. in terms of behaviour change, techniques offering these alternatives are likely to help the participants form coping plans. a coping plan is one that an individual creates to cope if something happens that makes what they intend to do more difficult.[13,14] in the example of a lack of the goldstandard concentration of oxygen, offering the participant the option of using the highest concentration available, will encourage them to formulate a plan to use the highest concentration available should the gold-standard concentration not be available. the observed change in the participants’ views of the availability of time and resources might, therefore, be related to these features of the course. a positive change in the perceptions of availability of time and resources from the start to the end of the course was associated with an increase in target behaviour from pre-course to followup. therefore, in this case, perceptions of a resource can change, which might be associated with a change in behaviour 1 month later. based on this finding, we recommend that future research examine whether a change in perception of environmental determinants is brought about by other courses, and whether this is related to a change in other types of practice, particularly coping planning behaviour change techniques. it is significant that changes in preto post-behavioural determinants in the category of capability were not associated with change in use of the abcde approach. this finding is important because, as stated above, it is typical for training courses to assess changes in capability (e.g. knowledge) and not to assess changes in the categories of opportunity and motivation. if our finding that perception of opportunity is a key driver of change in practice is replicated in other courses, it would indicate that courses should broaden the way in which they assess course outcomes. we found that it was feasible to create a preand post-course evaluation that assessed multiple behavioural determinants and self-reported behaviour. exploration of the behavioural determinants of practice and their associations with both the techniques used in the courses and the subsequent adoption of new practices would enhance educational practice. an understanding of the ‘active ingredients’ of training courses, how they change the psychology of the trainees and how these relate to change in provider behaviour, would provide further insights into the design of new education tools that aim to change practice and ways of understanding if the tools are effective. study limitations the behavioural measure was self-reported. self-reported measures are useful where observation is not possible but are potentially influenced by forgetting and social desirability. verification of self-reported changes in practice through observation would add to the strength of the evidence. we conducted a pre-post study; therefore, we cannot conclude that the content of the course was responsible for the change in practice. ta bl e 2. (c on ti nu ed ) n um be r, c ro nb ac h’ s al ph a, m ed ia n an d in te rq ua rt il e ra ng e fo r ea ch b eh av io ur al d et er m in an t a t p re a nd p os tco ur se a nd fo llo w -u p p re -c ou rs e po st -c ou rs e fo llo w -u p c on st ru ct it em s, n (r an ge ) pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th pa rt ic ip an ts sc or in g m ax im um , n (% ) n a lp ha m ed ia n 25 th 75 th a ct io n pl an ni ng * 3 (1 7 ) 8 (1 1) 71 0. 90 8 5. 0 3. 3 6. 0 48 ( 64 ) 71 0. 78 8 7. 0 6. 3 7. 0 41 ( 55 ) 71 0. 90 2 7. 0 6. 0 7. 0 c op in g pl an ni ng 4 (1 5 ) 24 ( 33 ) 24 ( 33 ) 72 0. 68 8 4. 25 3. 5 5. 0 15 ( 20 ) 71 0. 79 6 4. 0 3. 5 4. 8 im pl em en ta tio n su pp or t 3 (1 7 ) 7 (1 0) 73 0. 63 4 5. 0 3. 5 6. 0 23 ( 31 ) 71 0. 69 9 6. 0 5. 0 7. 0 fe ed ba ck 3 (1 7 ) 18 ( 24 ) 70 0. 05 5 5. 2 4. 7 7. 0 bu rn ou t¶ 3 (1 7 ) n/ a 72 0. 46 3 3. 7 3. 0 5. 0 n/ a 71 0. 83 8 5. 0 5. 0 5. 0 em pt y ce lls in di ca te th at th e co ns tr uc t w as n ot m ea su re d at th at ti m e po in t. a b c d e = a ir w ay , b re at hi ng , c ir cu la tio n, d is ab ili ty , e xp os ur e; n /a = n ot a pp lic ab le ; m c q s = m ul tip le -c ho ic e qu es tio ns . † ‘k no w s ho w ’ h as s uc h lit tle v ar ia bi lit y po st -c ou rs e, w ith a lm os t a ll pa rt ic ip an ts re po rt in g a sc or e of 7 , t ha t c ro nb ac h’s a lp ha s ho w s po or in te rn al c on si st en cy re lia bi lit y. ‡ i f s n 3 (s oc ia l p re ss ur e) is d el et ed a nd a lp ha r is es to 0 .2 51 p os tco ur se a nd 0 .5 33 p re -c ou rs e, it in di ca te s th at th e co nc ep t o f s oc ia l p re ss ur e do es n ot a lig n w ith e xp ec ta tio ns o f c ol le ag ue s re ga rd in g us e of th e a b c d e ap pr oa ch . t he re fo re , s ub je ct iv e no rm s ar e re po rt ed in th e ta bl e bu t a re n ot u se d in a ny fu rt he r an al ys es . § t he se it em s ca nn ot b e sa id to a ss es s th e sa m e co ns tr uc t a nd a re th er ef or e re po rt ed in th e ta bl e, b ut a re n ot u se d in a ny fu rt he r an al ys es . ¶ i f b ur no ut 1 (e m ot io na lly d ra in ed ) i s de le te d, th e al ph a ri se s to 0 .5 33 a t p re -c ou rs e. *p <0 .0 1, * *p <0 .0 5 (p re t o po st -c ou rs e) , w ilc ox on s ig ne dra nk te st . december 2018, vol. 10, no. 4 ajhpe 226 research we also aimed to explore if any behavioural determinants of the use of an abcde approach changed from before to immediately after the course. although there were significant increases in some behavioural determinants from preto post-course, pre-course medians for many determinants were already high. as with much health professional assessment, it is hard to know if people are answering as they think or how they believe they should think. the participants were reassured at multiple times of their anonymity and the scores did show variability over time and between participants. yet, further exploration of the impact of social or professional desirability on the answering of these types of questions is also warranted. finally, we found that some questions were not effective for this population, i.e. those around perceived behavioural control and subjective norms. in both of these behavioural determinants, the questions showed low internal consistency, indicating that these were not reliable in measuring an underpinning of the latent variable. we based the development of our questions for these constructs on the rebeqi manual; therefore, the types of questions had been used before.[15] measurement of these constructs in ugandan healthcare professionals would, therefore, require further exploration. *supporting data. the data supporting the results of this study are available from the corresponding author on request. declaration. consent to participate: all participants were informed that the pre-, postand follow-up questionnaires were not compulsory to complete; if they chose not to complete them, they were still welcome to fully participate in the training. the mcq assessment is a standard part of the aim courses and therefore all participants were expected to complete this. acknowledgements. this work would not have been possible without the participation of the clinical officers in gulu, uganda. we are very grateful for their time and expertise. the use of aim was supported by the greater manchester critical care skills institute. the university hospital of south manchester academy and the national health service global health exchange supported this work. we are also grateful to the university of manchester for enabling the involvement of its staff in this study. author contributions. design: lbd, ca, mj, gjb, jh; data collection: mjj, rm, hs, as, sc, sw, hp, sr; data analysis and interpretation: lbd, ca, mj, jh, jg, gy, hm; write-up: all authors; and final version approval: all authors. funding. the data for this research were collected as part of a training course delivered by the greater manchester critical care skills institute in gulu, uganda. travel, accommodation and associated costs were funded by the greater manchester critical care skills institute. members of the training team collected data, and their time both in delivering the course and collecting data was unfunded, i.e. voluntary (mjj, rm, hs, as, sc, sw). data collection was supported by other self-funded volunteers (hp, sr). research design, data analysis and write-up were conducted by unfunded volunteers (all authors). there was no formal role for the funding body in the study design, data collection, analysis or write-up. however, authors of the article are active members of the greater manchester critical care skills institute (as, mjj, rm, hs, sc, sw). table 4. medians, interquartile ranges of preto post-course change scores for behavioural determinants and preto follow-up change scores for use of abcde approach and habit change variable n median (iqr) behaviour change pre-course to follow-up 64 18.3 (−2.1 50.0) capability checklist change preto post-course 66 11.2 (6.1 17.6) awareness of need for change preto post-course 72 0.0 (0.0 1.0) behavioural attitudes preto post-course 71 0.4 (0.0 0.8) outcome expectancies preto post-course 73 0.0 (0.0 0.2) self-efficacy preto post-course 73 0.0 (0.0 1.0) strength of the evidence preto post-course 73 0.0 (0.0 0.5) habit pre-course to follow-up 69 0.0 (−1.5 1.0) environmental determinants preto post-course 69 0.0 (−1.7 0.8) action planning preto post-course 69 1.7 (1.0 3.0) action control preto post-course 66 2.0 (0.3 3.7) abcde = airway, breathing, circulation, disability, exposure; iqr = interquartile range. table 3. stage of change of participants at preand post-course and follow-up stage of change pre-course, n (%) post-course, n (%) follow-up, n (%) i have not yet thought about using an abcde approach with patients who might be acutely unwell 4 (5) 1 (1) 1 (1) it has been a while since i have thought about using an abcde approach with patients who might be acutely unwell 8 (11) 1 (1) 0 i have thought about it and decided that i will not use an abcde approach with patients who might be acutely unwell 0 0 0 i have decided that i will use an abcde approach with patients who might be acutely unwell 17 (23) 46 (62) 20 (27) i have already started using an abcde approach with patients who might be acutely unwell 36 (49) 15 (20) 46 (62) i have already done something about managing patients who might be acutely unwell, not using an abcde approach 1 (1) 0 2 (3) not completed (missing) 8 (11) 11 (15) 5 (7) abcde = airway, breathing, circulation, disability, exposure. 227 december 2018, vol. 10, no. 4 ajhpe research conflicts of interest. as was the director of the greater manchester critical care skills institute at the time of data collection and write-up. lbd, mjj, rm, hs, gy, as, gjb, sc, sw and jh are co-editors of the aim4africa course manual, which forms the basis of the training course described in this article. 1. shelton jd. the six domains of behavior change: the missing health system building block. glob heal sci pract 2013;1(2):137-140. https://doi.org/10.9745/ghsp-d-13-00083 2. firth p, ttendo s. intensive care in low-income countries – a critical need. n engl j med 2012;367:1974-1976. https://doi.org/10.1056/nejmp1204957 3. baker t. critical care in low-income countries. trop med int health 2009;14(2):143-148. https://doi.org/10.1111/ j.1365-3156.2008.02202.x 4. mccarthy r, byrne-davis l, hart j, et al. a feasible, acceptable and effective way to teach healthcare workers in lowand middle-income countries: a method to manage acutely ill obstetric women. midwifery 2015;31(1):19-24. https://doi.org/10.1016/j.midw.2014.04.009 5. byrne-davis l, slattery h, whiteside s, et al. efficacy and acceptability of an acute illness management course delivered to staff and students in uganda by staff from the uk. int health 2014;7(5):360-366. https://doi. org/10.1093/inthealth/ihu078 6. byrne-davis lm, byrne gj, jackson mj, et al. understanding implementation of maternal acute illness management education by measuring capability, opportunity and motivation: a mixed methods study in a lowincome country. j nurs educ pract 2015;6(3):59. https://doi.org/10.5430/jnep.v6n3p59 7. michie s, van stralen mm, west r. the behaviour change wheel: a new method for characterising and designing behaviour change interventions. implement sci 2011;6:42. https://doi.org/10.1186/1748-5908-6-42 8. eccles mp, grimshaw jm, maclennan g, et al. explaining clinical behaviors using multiple theoretical models. implement sci 2012;7:99. https://doi.org/10.1186/1748-5908-7-99 9. presseau j, johnston m, heponiemi t, et al. reflective and automatic processes in health care professional behaviour: a dual process model tested across multiple behaviours. ann behav med 2014;48(3):347-358. https:// doi.org/10.1007/s12160-014-9609-8 10. rycroft-malone j, seers k, chandler j, et al. the role of evidence, context, and facilitation in an implementation trial: implications for the development of the parihs framework. implement sci 2013;8:28. https://doi. org/10.1186/1748-5908-8-28 11. bria m, baban a, dumitrascu dl. systematic review of burnout risk factors among european healthcare professionals. cognitie, creier, comportament 2012;16(3):423-452. 12. zachariah r, ford n, philips m, et al. task shifting in hiv/aids: opportunities, challenges and proposed actions for sub-saharan africa. trans r soc trop med hyg 2009;103(6):549-558. https://doi.org/10.1016/j. trstmh.2008.09.019 13. sniehotta ff, schwarzer r, scholz u, schuz b. action planning and coping planning for long-term lifestyle change: theory and assessment. eur j soc psychol 2005;35(4):565-576. https://doi.org/10.1002/ejsp.258 14. sniehotta ff, scholz u, schwarzer r. action plans and coping plans for physical exercise: a longitudinal intervention study in cardiac rehabilitation. br j health psychol 2006;11(1):23-37. https://doi.org/10.1348/ 135910705x43804 15. francis ajj, eccles mp, johnston m, et al. constructive questionnaires based on the theory of planned behaviour: a manual for health services researchers. uk: centre for health services research, university of newcastle, 2004:1-42. accepted 20 june2018. https://doi.org/10.1111/j.1365-3156.2008.02202.x https://doi.org/10.1111/j.1365-3156.2008.02202.x https://doi.org/10.1093/inthealth/ihu078 https://doi.org/10.1093/inthealth/ihu078 https://doi.org/10.1007/s12160-014-9609-8 https://doi.org/10.1007/s12160-014-9609-8 https://doi.org/10.1186/1748-5908-8-28 https://doi.org/10.1186/1748-5908-8-28 https://doi.org/10.1016/j.trstmh.2008.09.019 https://doi.org/10.1016/j.trstmh.2008.09.019 https://doi.org/10.1348/-135910705x43804 https://doi.org/10.1348/-135910705x43804 editorial 2 professionalising health professions education v burch, j norcini short research report 3 expectations and experiences of final-year medical students regarding family medicine rural rotations: influence on intention to practise in a rural setting n beckett, r delport research 6 medical students’ reflections on the meaning of disease and illness in south african communities f c j stevens, s naidoo, m taylor, s knight 12 students’ views on the need for hostile environment awareness training for south african emergency medical care students c vincent-lambert, r westwood 16 physiotherapists’ perception of a community-based primary healthcare clinical education approach to undergraduate learning s blose, n c t chemane, v chetty, p govender, s maddocks 22 preparation of nursing students for operating room exposure: a south african perspective s breedt, m j labuschagne 27 initiating curriculum mapping on the web-based, interactive learning opportunities, objectives and outcome platform (looop) i treadwell, o ahlers, g c botha cpd questionnaire ajhpe african journal of health professions education march 2019, vol. 11, no. 1 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria general manager dr manivasan thandrayen executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani email: publishing@hmpg.co.za issn 2078-5127 june 2021, vol. 13, no. 2 ajhpe 145 research an unexamined education south african (sa) medical curricula on traditional health systems remain a largely unexamined topic, despite millions of south africans using traditional healthcare daily. chitindingu et  al.’s[1] 2014 study outlined the major formal elements of the traditional healing curricula, as described by administrators at each of sa’s eight medical schools. our study aims to answer their call for better understanding of this topic from the perspective of medical students’ experience of the curricula ‒ not that of the administrators. specifically, our study objectives were to determine the hidden curriculum surrounding traditional medicine (tm) in sa medical schools, and how students describe the impact of this hidden curriculum on their perceptions of tm. we define the hidden curriculum as an interpersonal/social concept and a contextual/cultural concept, based on student descriptions of interactions and cultural norms experienced during medical training.[2] finally, we provide recommendations to mitigate the hidden curriculum’s harmful effects, while promoting its more positive aspects. broad efforts at integration globally, the use of tm is widespread.[3] in sa, tm use is increasingly recognised as an essential element of and opportunity to improve the health of the nation.[4-6] traditional health practitioners (thps) have various roles in the healthcare system outside of healing, including spiritual protectors, counsellors and cultural repositories.[5,7] furthermore, thps represent an area of under-utilised potential in the fight against hiv/aids, particularly due to their overwhelming willingness to engage in hiv/aids training and refer patients to biomedical facilities when necessary.[6,8] discouragingly, however, the tension between biomedicine and tm, largely due to historical injustices, gaps in scientific evidence and mistrust, has resulted in a fragmented and inefficient health system.[6,9,10] medical schools provide a prime location to combat these challenges, ideally fostering understanding and integration of the two health systems.[1,11] a recent study in uganda argued that training medical students in the principles of tm was feasible and may improve health outcomes; therefore, integration should not be delayed.[12] curricular reforms health professions education systems in sa, due to their roots in imperialism, colonialism and apartheid, often produce providers who are incompletely equipped to properly care for many patients, specifically the black african population.[13] recognition of this deficit has led to a movement to decolonise the nation’s graduate education system, including medical schools.[13] our research aims to look at how we can progress towards decolonisation via integration of traditional health education in medical schools. although background. increased co-ordination and co-operation between traditional and biomedical health systems in south africa (sa) is a national priority. to improve care, practitioners in both systems must learn to recognise the value of their parallel counterparts, and such lessons should begin in medical school. however, there is little research regarding the way in which sa’s medical students are taught to interact with the traditional medicine (tm) system. objectives. to explore how sa medical students perceive their curriculum as it relates to the traditional health system and to describe their suggestions for improvement. methods. we conducted individual in-depth interviews and focus group discussions with 43 final-year medical students across 3 sa medical schools. we applied thematic analysis to improve our understanding of student-reported experiences with tm in their medical school curricula. results. all 3 medical schools rely heavily on hidden curricula to educate students on the sa traditional health system. these hidden curricula are largely negative and learnt primarily from witnessing faculty-client interactions involving tm use. students across the institutions agree that this problematic deficit in formal teaching contributes to their incompetence in treating patients who use tm. their suggestions for improvement focused largely around 3 themes: (i)  understanding the fundamentals of the traditional health system; (ii)  empathising with patient use of tm; and (iii)  promoting broader structural integration of the two health systems. conclusion. medical students in sa recognise the value of increased exposure to and education surrounding the traditional health system. future curricular interventions should focus on increasing formal teaching of tm, directly addressing the hidden curriculum related to the topic, and instituting policies and initiatives that improve integration of the sa biomedical and traditional healing paradigms on a structural level. afr j health professions educ 2021;13(2):145-149. https://doi.org/10.7196/ajhpe.2021.v13i2.1246 improving south african medical curricula related to traditional health systems c lawrence,1,2 md; j bollinger,3 msc (global health) student; k a stewart,3 phd; m moshabela,1,4 mb chb, mfammed 1 centre for rural health, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 mount sinai hospital, new york city, usa 3 duke university, durham, usa 4 africa health research institute, university of kwa-zulu natal, durban, south africa corresponding author: c lawrence (carlton_lawrence@hms.harvard.edu) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1246 146 june 2021, vol. 13, no. 2 ajhpe research tm is increasingly regarded as a critical element of medical education, much of the recent curricular overhauls has focused on addressing the shortage of medical professionals.[14-16] solutions to the shortage include the introduction of decentralised medical training and integration of an array of healthcare professionals into the medical system.[15,16] using a decentralised approach to medical training increases the number of medical professionals receiving training by promoting education outside of tertiary hospitals.[16-18] this approach serves to strengthen primary healthcare and communitybased education by producing more medical professionals directly trained in community settings.[16-18] these community sites offer key opportunities for student exposure to tm.[19] sa health legislation, such as the traditional health practitioners act 22 of 2007, encouraged the integration of tm into the medical curriculum.[1,20,21] however, these policies have yet to translate into practical integration or large actionable commitments.[5,6] sa is certainly not the first country to struggle with the integration of its various healing systems. in countries around the globe, from thailand and taiwan, to the usa and the uk, efforts to adequately train medical professionals are wide spread.[22-25] ghana, for example, identifies tm experts in the medical curriculum as repositories of indigenous medical knowledge with much to teach health professionals, but sa has no such policy.[26] chitindingu et al.[1] provided important groundwork by evaluating the inadequacies of the formal medical curriculum relating to tm. research also demonstrates that the hidden curriculum is often the major force in shaping physicians’ professional identity.[27] we aim to describe medical student perspectives on tm and the hidden curriculum, coupled with their own suggestions for its integration into medical curricula. medical students offer unique first-hand perspectives of the lived experience of the curriculum and its effects on their views of the  traditional health system. these data are invaluable in uncovering areas for improvement of the student experience to produce better-prepared future health professionals. this article seeks to use these data to provide concrete recommendations for educators and policymakers to further improve medical syncretism, the harmonious integration of various health systems to improve population wellbeing, both within sa and beyond. methods the study methodology follows the consolidated criteria for reporting qualitative research checklist (coreq).[28] research team and reflexivity researchers (cl, bh, nm) interviewed final-year medical students across 3 medical schools in sa: university of kwazulu-natal (ukzn), university of the witwatersrand (wits) and walter sisulu university (wsu). we selected these 3 of 8 medical schools in sa to ensure geographical and demographic diversity. interviews occurred from october 2015 through june 2016. as part of the broader transformation in medical education (time) study facilitated by the centre for rural health (crh) at ukzn, interviewers were trained in administering the specific questionnaire and other qualitative research techniques during formal training sessions. study design researchers interviewed 43 participants for the study, 23 during in-depth key informant interviews and 20 across a total of 5 focus group discussions at each institution (table  1). interviewees were distributed evenly across the 3 sites: 15 participants from wsu (total estimated class population of 120  students), and 14 participants from ukzn and wits each (both with total estimated class populations of 250 students).[29] participants were recruited by convenience sample through email and by word-of-mouth from faculty and current students at the various institutions, with the inclusion criteria being students in their final year at their respective medical schools. students had to speak english, which is largely a requirement for medical school admission – it was not a problem. interviews were conducted at each of the 3 medical schools. the questionnaire, developed in conjunction with the crh, explored students’ perspectives on tm and how current medical school curricula shaped or determined these views. individual interviews (idis) and focus group discussions (fgds) of ~60 minutes were conducted in english, recorded with digital voice recorders and transcribed. the interviewers went through a standardised review of the questionnaire with the principal investigator to ensure that the purpose of each question was clear. after each interview, researchers also wrote field notes to describe their initial impressions, key moments and take-away impressions from the interview. the data were entered into the qualitative research software program nvivo version12 (qsr international, australia). data analysis the framework analysis technique, derived from applied thematic analysis, was applied to the data using the qualitative data software nvivo.[30] deductive analysis focused on the interview guide questions according to provided initial codes. the reviewers (jb and cl) used these codes to induce novel codes, synthesised into themes via the nvivo data tree function. after applying these themes to an initial sample of the data, overlay in themes was compared between reviewers to ensure mutual agreement. ethical approval the researchers obtained signed informed consent from all participants. ethical approval was obtained from duke university (ref. no. d0195) in the usa and from the 3 sa medical schools involved: ukzn (ref. no. be466/15), wits (ref. no. m151191) and wsu (ref. no. 068/15). results current state of the formal curriculum ‘what have you learned in medical school relating to traditional medicine and traditional medicine use?’ (interviewer cl) ‘honestly, i haven’t learned anything.’ (ukzn fgd b) the students across all universities in the study cited a lack of a formal curriculum, defined as the medical curriculum knowingly and explicitly planned by the medical school. although it varied slightly in specifics, the formal curricula across the 3 sites were largely described similarly. table 1. study participants characteristics participants, n (%) data gathering individual interviews (idis) 20 (47) focus group discussions (fgds) 23 (53) university walter sisulu 15 (36) kwazulu-natal 14 (32) witwatersrand 14 (32) june 2021, vol. 13, no. 2 ajhpe 147 research therefore, unless noted, data reported here are aggregated by location. exposures to tm at each school involved a combination of a meeting with or lecture from a traditional healer. this was often remembered as a single lecture, with content that included the importance of tm integration in the biomedical health system and a description of the uses of specific tms. students largely described these encounters as low impact, and many participants failed to recall any formal lecture during their medical school tenure. students at wsu notably described an additional encounter with tm, most likely because they were required to develop and report on a collaborative project with a traditional healer. wsu students enthusiastically endorsed this pedagogical innovation; no students at the other institutions reported on a similar experience. the hidden curriculum of traditional medicine ‘the attitude of doctors – when in that kind of [situation] – is always scorn and distain for the patient that [has] dared see a traditional healer.’ (wits idi 4) ‘the doctors, the nursing staff, everyone. they don’t condone it [traditional medicine].’ (wsu fgd d) ‘had we come to medical school and been taught that every time we treat a patient, [we must] try as much as we can to incorporate traditional medicine in our management … that’s what we’d be doing. but, we came in, and most of what was told to us about traditional medicine was negative.’ (ukzn fgd e) the majority of students reported that the hidden curriculum was largely a negative influence on their views of both tm and the patients who  use the alternative health system. this was the case across institutions. contributions to this negative impression occurred during students’ clinical years. the main factors cited by students were: (i)  open criticism of the practices by their clinic preceptors; (ii) witnessing negative effects of certain tms, specifically in the paediatric population; and (iii)  experiencing exasperation at patients hiding tm use during history-taking. there was one notable positive outlier in the hidden curricula, which was that students felt they developed a more complete and less biased understanding of tm when senior students took time to explain its uses and effects during clinical scenarios. student proposals for curricular improvement participants across the 3 institutions expressed nearly universal motivation for curricular change surrounding traditional healing. students recognise tm as an integral part of patients’ lives and agree that their training creates a largely negative and unhealthy opinion of this alternative healing system. they identified clear deficits and proposed numerous interventions to improve current learning. participant suggestions for improvement focused on 3 themes: (i)  understanding the fundamentals of the traditional health system; (ii)  empathising with patient use of tm; and (iii)  promoting broader structural integration of the two health systems: • fundamentals of traditional health system ‘i would love if from the first day that people come [to medical school] that they actually understand that it [traditional medicine] is not purely about the science. it’s about the spirituality, which no one addresses, [either] of the patient or you yourself.’ (ukzn idi 2) ‘[i’m] not saying whole curriculum now must be all about traditional medicine but … just for us to have a background understanding and when we get to [see] these patients maybe we will understand better where they’re coming from, because it’s easy for us to just judge them.’ (ukzn fgd b) students cited a dearth of factual understanding of the fundamentals of tms, their indications, typical dosing and potential side-effects. although students understand that they are not intended to be practitioners of traditional health systems, they believe increased teaching regarding the foundations of the system will make them better physicians. these foundations include, but are not limited to, specific examples of tms, common indications, methods of use and known side-effects. students recognise that their unfamiliarity with the basics of traditional healing, coupled with their exposure to the hidden curriculum of medical school, creates a largely stigmatising atmosphere for patients using tm and affects patient care. they recognise the harms of these deficits and actively desire curricular remedies. • empathising with patient use of tm ‘i mean there are patients who tell you, “you know what? i have diabetes. i’m not going to take insulin because i have so much faith in my god.” as a doctor, i would come and say, “listen, if you don’t take insulin, you will collapse, and you will die.” but they still refuse, so i think the [best] approach would be for students to be taught to reach an agreement [regarding traditional medicines] as opposed to imposing.’ (wits idi 9) ‘it [tm-use] wasn’t a good thing … the doctor would get the history from the nurses and the nurses would shout at a patient like why didn’t you come to the clinic? why did you have to take this? ... what i’ve seen is never a good response to it [tm-use].’ (ukzn fgd b) the second theme, empathy with patient use, stems from student requests for increased teaching around the reasons why patients use tm, the cultural and religious connection of the practices, and the larger history of the healing paradigm. as reported by the students, their lack of understanding often makes its difficult to interact with tm-using patients in a collaborative fashion and exacerbates stigma and barriers to care. students find it difficult to empathise with these patients and request training to bridge the divide. as opposed to the first theme, which requires more concrete scientific and historical teaching to increase education on tm, this learning centres on how to create a sphere of mutual respect in the patient-doctor relationship. similar to their lack of fundamental tm knowledge, the students are aware of their own stigma and request increased training on this topic to mitigate harmful effects. to address their concerns regarding empathy, participants requested structured learning on how to approach a clinical interaction that involves tm. much of their learning comes from watching preceptors, which students cited as a largely negative experience. participants desired step-wise guidance on the clinical encounter, including, but not limited to, how to take a tm patient’s history and how to best form a therapeutic alliance with patients who practise traditional healing. • structural integration of the healing systems ‘going forward i think … the government needs to incorporate traditional 148 june 2021, vol. 13, no. 2 ajhpe research medicines … but i think [now] it’s just recognizing them, it’s not incorporating them. there’s a difference between the two … it will have to be that traditional medicine is taught in all medical schools in south africa because the government has incorporated it into the health system.’ (ukzn fgd e) finally, students see themselves as operating within a system unfavourable to integration of the two healing paradigms. they highlight that, although the government and medical institutions often express a desire for integration of the traditional and biomedical, this does not occur in practice. according to students, a more top-down integration would promote a culture of patient respect over patient denigration. participants often viewed formal teaching as the main mechanism to improve their understanding of and interaction with the traditional health system. although students described some formal teaching on the topic, they nearly universally described it as inadequate. they request increased emphasis on longitudinal learning opportunities, such as traditional healing lectures series, discussion groups and increased integration with traditional healers and patients using tm. discussion proposed curricular interventions students are keenly aware of their learning environment surrounding the traditional health system. they recognise its strengths and deficits and its impact on their medical practice. they are willing and motivated to improve their understanding, but look to the medical curriculum to guide this goal. the deficit therefore lies not in the desire of the students, but in the current educational milieu of the medical schools. the focus for improvement must lie largely in addressing curricular deficits, particularly those involving hidden curricula.[31] this does not assume ill-will on the part of medical educators, but instead creates a sense of urgency for further practical research into why such gaps exist despite student motivation. we must move beyond statements of the importance of integration of the traditional and biomedical in health professions and into rigorous evaluation of curricular interventions that succeed at this goal. the proposals of the students, organised into the previously outlined 3 themes, provide a foundation from which to start. we propose a threefold strategy to address the students’ concerns, focusing interventions on 3 levels of medical school organisation: institutional, departmental and individual.[32] these interventions focus on: (i)  increasing formal teaching of the traditional health system; (ii)  making the hidden curriculum explicit; and (iii) structural integration of the two medical systems (fig. 1). increasing formal teaching of the traditional health system students view their lack of formal education as fundamental to their problematic understanding of the traditional health system. we therefore propose that sa medical schools make clear their formal support for a dynamic sa health system that supports integration of the biomedical and traditional healing paradigms, not separation of the two.[6] we support course guidelines that review common tms, their typical indications and their historical and cultural importance. teaching sessions should provide students with an opportunity to simulate clinical interactions with patients who use tms and hone student skills in this regard. formal examinations should, at some level, include information on traditional health systems. schools should consider implementing a longitudinal traditional healing component, lecture series, increased interaction with traditional healers and formalised learning from patients who practise tm. making the hidden curriculum explicit interventions must focus heavily on addressing the hidden curriculum, which students state is largely responsible for their negative, inaccurate and incomplete views of tm. the literature is clear that one of the most effective ways to address the hidden curriculum is to make it explicit.[33-38] we propose that institutions incorporate the idea of ‘painful feedback’, where students are presented direct evidence of the hidden curriculum’s known negative effects to facilitate reflection and promote insulation from these effects.[31] our study highlights many of these more harmful elements and thus may be used to promote discussion of the current climate and propose suggestions for change. furthermore, traditional formats of open discussion and written self-reflection protect against negative elements of the hidden curriculum.[39-45] these interventions should occur on multiple levels of organisation, including student-student, student-faculty, faculty-faculty and among learners and patients using tm and practitioners. structural integration of sa health systems there is well-established value in integrating traditional and western health systems to achieve a mutually respectful co-existence.[9,46-48] multiple interviewees made note of this point. medical students will practise what they witness. therefore, medical schools and healthcare institutions should increase their involvement with broader initiatives, government-sponsored or otherwise. this shift must occur across levels of organisation, both within and across medical schools. these institutions should specifically seek to support initiatives that make clear the value of the traditional health system and collaborate between medical institutions on curricular reforms. most of the students’ curricular complaints and suggestions were similar across the 3 sites, thus idea-sharing between institutions will benefit sa students. students have demonstrated their desire for this change, and it is now the responsibility of the medical schools to create an institutional culture that propagates respect through all levels of learning. the shift does not have to occur from the top down, as a response to broad national initiatives or government mandates. medical schools, faculty and students must advocate for the changes they want to see. the agency of the physicians and future physicians in these institutions is not minimal. actively promoting integration and leading, e.g. by publicly demonstrating and calling for mutual respect and recognising value in traditional healing, would push the narrative towards one that bridges the two health systems and deconstruct the larger forces that continue to propogate division. increase formal education longitudinal learning lecture series facilitated patient interactions involving tm make the hidden curriculum explicit 'painful feedback'[31] by students for one another and educators written re�ection and open discussion of experiences involving tm actionable health system integration collaboration between medical institutions vertical integration with government initiatives fig. 1. proposed curricular interventions. (tm = traditional medicine.) june 2021, vol. 13, no. 2 ajhpe 149 research conclusion medical students in sa recognise the value of increased exposure and education to tm. they cite a lack of teaching rather than a lack of student desire as the cause for perceived deficits in knowledge and skills to treat patients using tm. they specifically request teaching regarding the fundamentals of traditional healing, how to empathise with patient use of tm and how to approach such patients during a clinical encounter. we recognise that the solution is not only about changing curricula and student understanding, but about shifting the mindset of faculty. going forward, it will require investment of faculty, medical institutions and government agencies to accomplish these goals. the national government has stated their interest in bettering the relationship between traditional and biomedical health systems, and sa medical schools need to make the same commitment.[1,21] improving tm education in medical school will benefit patients and providers and should be a priority for sa education reform. declaration. none. acknowledgements. we wish to acknowledge members of the transformation in medical education study team, bonnie hughes and neeri moodley, for their help with interviewing participants. we also acknowledge the college of health sciences and us nih medical education partnership initiative (mepi) at the university of kwazulu-natal (http://mepi.ukzn.ac.za/homepage.aspx), the duke global health institute (https://globalhealth.duke.edu/) and the us fulbright fellowship program. this publication contributes to the hidden curriculum theme of transformation in medical education (time). authors contributions. cl, kas and mm made substantial contributions to the conception, design, analysis and drafting of the work. jb made significant contributions to the analysis, interpretation, and drafting of the manuscript. all authors read and approved the final manuscript. funding. the sudy was supported by the us department of state institute of international education fulbright fellowship program and the medical education partnership initiative (mepi) at the university of kwazulu-natal. the study was also supported by the south africa national research foundation (nrf) (grant number 90394) and the us national institute of health (grant number 5r24tw008863). conflicts of interest. none. 1. chitindingu e, george g, gow j. a review of the integration of traditional, complementary and alternative medicine into the curriculum of south african medical schools. bmc med educ 2014;14(40):1-6. https://doi. org/10.1186/1472-6920-14-40 2. lawrence c, mhlaba t, stewart ka, moletsane r, gaede b, moshabela m. the hidden curricula of medical education: a scoping review. acad med 2018;93(4):648-656. https://doi.org/10.1097/acm.0000000000002004 3. nxumalo n, alaba o, harris b, chersich m, goudge j. utilization of traditional healers in south africa and costs to patients: findings 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acad med 1996;71(6):624-642. https://doi.org/10.1097/00001888-199606000-00014 36. martimianakis ma, hafferty fw. exploring the interstitial space between the ideal and the practised: humanism and the hidden curriculum of system reform. med educ 2016;50(3):278-280. https://doi.org/10.1111/medu.12982 37. o’callaghan a. emotional congruence in learning and health encounters in medicine: addressing an aspect of the hidden curriculum. adv health sci educ theory pract 2013;18(2):305-317. https://doi.org/10.1007/s10459012-9353-4 38. wilkinson tj. stereotypes and the hidden curriculum of students. med educ 2016;50(8):802-804. https://doi. org/10.1111/medu.13008 39. baker m, wrubel j, rabow mw. professional development and the informal curriculum in end-of-life care. j cancer educ 2011;26(3):444-450. https://doi.org/10.1007/s13187-011-0199-x 40. bandini j, mitchell c, epstein-peterson zd, et al. student and faculty reflections of the hidden curriculum. am j hosp palliat care 2017;34(1):57-63. https://doi.org/10.1177/1049909115616359 41. chretien k, goldman e, faselis c. the reflective writing class blog: using technology to promote reflection and professional development. j gen intern med 2008;23(12):2066-2070. https://doi.org/10.1007/s11606-008-0796-5 42. gaufberg eh, batalden m, sands r, bell sk. the hidden curriculum: what can we learn from thirdyear medical student narrative reflections? acad med 2010;85(11):1709-1716. https://doi.org/10.1097/ acm.0b013e3181f57899 43. karnieli-miller o, vu tr, frankel rm, et al. which experiences in the hidden curriculum teach students about professionalism? acad med 2011;86(3):369-377. https://doi.org/10.1097/acm.0b013e3182087d15 44. rabow mw, remen rn, parmelee dx, inui ts. professional formation: extending medicine’s lineage of service into the next century. acad med 2010;85(2):310-317. https://doi.org/10.1097/acm.0b013e3181c887f7 45. white cb, perlman rl, fantone jc, kumagai ak. the interpretive project: a creative educational approach to fostering medical students’ reflections and advancing humanistic medicine. reflect pract 2010;11(4):517-527. https://doi.org/10.1080/14623943.2010.505718 46. carrie h, mackey tk, laird sn. integrating traditional indigenous medicine and western biomedicine into health systems: a review of nicaraguan health policies and miskitu health services. int j equity health 2015;14(129):1-7. https://doi.org/10.1186/s12939-015-0260-1 47. kesler do, hopkins lo, torres e, prasad a. assimilating traditional healing into preventive medicine residency curriculum. am j prev med 2015;49(5 suppl 3):s263-s269. https://doi.org/10.1016/j.amepre.2015.07.007 48. krah e, de kruijf j, ragno l. integrating traditional healers into the health care system: challenges and opportunities in rural northern ghana. j commun health 2018;43(1):157-163. https://doi.org/10.1007/s10900017-0398-4 accepted 1 july 2020. http://mepi.ukzn.ac.za/homepage.aspx https://globalhealth.duke.edu/ https://doi.org/10.1186/1472-6920-14-40 https://doi.org/10.1186/1472-6920-14-40 https://doi.org/10.1097/acm.0000000000002004 https://doi.org/10.1057/jphp.2011.26 https://doi.org/10.1057/jphp.2011.26 https://doi.org/10.21767/amj.2016.2725 https://doi.org/10.1186/s12906-016-1293-8 https://doi.org/10.1186/s12906-016-1293-8 https://doi.org/10.1080/16549716.2017.1352210 https://doi.org/10.1080/16549716.2017.1352210 https://doi.org/10.1080/02533950508628708 https://doi.org/10.1080/02533950508628708 https://doi.org/10.1046/j.1525-1497.1998.00168.x https://doi.org/10.1186/s12909-018-1419-4 https://www.ingentaconnect.com/content/sabinet/aarrhetoric/2015/00000007/00000001/art00010 https://doi.org/10.7196/samj.7323 https://doi.org/10.7196/samj.7323 https://doi.org/10.22605/rrh4337 https://doi.org/10.22605/rrh4337 https://doi.org/10.4102/phcfm.v9i1.1449 https://doi.org/10.1186/s12909-017-1050-9 https://doi.org/10.7196/samj.2016.v106i4.10623 https://doi.org/10.2147/jmdh.s189644 https://doi.org/10.1016/0277-9536(94)90127-9 https://doi.org/10.2147/amep.s69761 https://www.hindawi.com/journals/ecam/2012/656812/ https://www.hindawi.com/journals/ecam/2012/656812/ https://doi.org/10.5455/jice.20160421125217 https://doi.org/10.1097/00001888-199804000-00013 https://doi.org/10.1093/intqhc/mzm042 https://doi.org/10.1093/intqhc/mzm042 https://doi.org/10.7196/samj.2016.v106i1.9913 https://doi.org/10.7196/samj.2016.v106i1.9913 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1542/hpeds.2014-0180 https://doi.org/10.1016/j.ajog.2010.04.035 https://doi.org/10.1080/03075079912331379888 https://doi.org/10.3109/0142159x.2015.1073241 https://doi.org/10.3109/0142159x.2015.1073241 https://doi.org/10.1097/00001888-199606000-00014 https://doi.org/10.1111/medu.12982 https://doi.org/10.1007/s10459-012-9353-4 https://doi.org/10.1007/s10459-012-9353-4 https://doi.org/10.1111/medu.13008 https://doi.org/10.1111/medu.13008 https://doi.org/10.1007/s13187-011-0199-x https://doi.org/10.1177/1049909115616359 https://doi.org/10.1007/s11606-008-0796-5 https://doi.org/10.1097/acm.0b013e3181f57899 https://doi.org/10.1097/acm.0b013e3181f57899 https://doi.org/10.1097/acm.0b013e3182087d15 https://doi.org/10.1097/acm.0b013e3181c887f7 https://doi.org/10.1080/14623943.2010.505718 https://doi.org/10.1186/s12939-015-0260-1 https://doi.org/10.1016/j.amepre.2015.07.007 https://doi.org/10.1007/s10900-017-0398-4 https://doi.org/10.1007/s10900-017-0398-4 december 2021, vol. 13, no. 4 ajhpe 215 short report near-peer teaching (npt) is an education modality in which a more senior student provides teaching to junior students within the same curriculum.[1] previous studies have demonstrated the benefits of npt programmes, with student learners (sls)  reporting subjectively improved confidence, knowledge and skills following npt interventions.[2] near-peer tutors (nts) also report benefits from involvement in npt programmes, attributing these to the reinforcement of previously learnt concepts and improved time management, leadership and teaching skills.[3] teaching is a key competency for undergraduate students identified by the medical and dental professions board of the health professions council of south africa (sa).[4] however, opportunities to formally develop teaching skills are rare in undergraduate medical training, despite the expectation for junior doctors, registrars and consultants to ultimately fulfil teaching roles. npt programmes may offer students an opportunity to better prepare for these roles. the literature reveals that the existing data on npt are exclusively sourced from the developed world. sa is a unique educational environment and findings from the developed world should be extrapolated to the sa context with caution. we aimed to study whether npt programmes are effective as an adjunct to traditional undergraduate medical training in sa by evaluating the utility of an npt programme in improving the knowledge and confidence of medical students, for both sls and nts. methods we used a non-randomised, uncontrolled experimental study design to measure the outcomes – ‘knowledge’ and ‘confidence’ – in participants before and after completion of an npt programme. the near-peer teaching programme in 2018, the internal medicine society, a student-run society based at the university of cape town (uct), established an extracurricular npt programme. clinical students (years 4 6) served as nts, while pre-clinical students (years 1 3) received tuition as sls. each tutorial group consisted of 1 nt and 3 or 4 sls. four tutorials, discussing heart failure, pneumonia, liver failure and stroke, were held between march and november 2018. each tutorial consisted of a theoretical discussion and a clinical approach at the patient’s bedside. nts were provided with consultant-approved information sheets to guide the discussion. consent for bedside tutorials was obtained from patients and approval for the programme was granted by groote schuur hospital, cape town, sa. evaluation we invited all participants in the npt programme to enrol as participants in a study of the programme. we obtained consent for all data collected and we preserved anonymity. ethical approval was granted by the human research ethics committee, uct (ref. no. hrec 251/2018). background. near-peer teaching (npt) programmes may benefit both student learners (sls) and near-peer tutors (nts). however, data evaluating npt programmes in developing countries such as south africa are lacking. objectives. to evaluate the efficacy of an npt programme in improving the knowledge and confidence of sls and nts, and to evaluate student perceptions of the npt programme. methods. an npt programme in which clinical year students provided tutorials to pre-clinical year students was developed. participants completed a knowledge-assessing multiple-choice questionnaire (mcq)  and a confidence-assessing questionnaire at commencement and conclusion of the programme. participants also completed an evaluation at the end of the programme. results. for 38 sls, the median mcq score improved from 58.9% at baseline to 78.6% at completion of the programme (p<0.001; d=1.3). the mean overall confidence score improved from 2.6/5 at baseline to 3.6/5 at completion (p<0.001; d=1.3). all sls agreed that the npt programme was a useful addition to the standard curriculum and that they would recommend the programme to other students at developmental level. the effect of the npt programme was less pronounced for the 16 nts, with median mcq scores of 87.5% and 89.3% at baseline and completion of the programme, respectively (p=0.179; d=0.4). the mean overall confidence score improved from 3.8/5 at baseline to 4.2/5 at completion (p=0.004; d=1). ninety-four percent of nts agreed that their role as nts reinforced their existing knowledge. conclusion. npt programmes may improve the knowledge and confidence of sls, while consolidating the knowledge of nts. the ntp programme was well received by medical students. in resource-limited settings, the effectiveness and acceptability of npt make it an attractive adjunct to traditional teaching. afr j health professions educ 2021;13(4):215-217. https://doi.org/10.7196/ajhpe.2021.v13i4.1442 learn-teach-learn: evaluating a south african near-peer teaching programme r spies,1 mb chb; h lee,1 mb chb; i esack,1 mb chb; r hollamby,1 mb chb; c viljoen,2 mmed (int med) 1 department of medicine, faculty of health sciences, university of cape town, south africa 2 division of cardiology, department of medicine, faculty of health sciences, university of cape town, south africa corresponding author: r spies (ruanspies21@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1442 mailto:ruanspies21@gmail.com 216 december 2021, vol. 13, no. 4 ajhpe short report we administered a 28-question multiple choice questionnaire (mcq), approved by consultants from the department of medicine, uct, to nts and sls as a measure of their explicit knowledge at baseline and completion stages of the npt programme. this outcome was labelled ‘knowledge’. explicit knowledge refers to facts that can be readily articulated and stored. it is complementary to tacit knowledge, which refers to intuition and the kind of knowledge that is not easily expressed. we chose to measure knowledge through an mcq, as this allowed for an objective assessment of participant performance and yielded data that were amenable to statistical analysis and comparison, both preand post-intervention. we assessed self-reported confidence through a likert scale, i.e. the overall confidence score, which we developed. this outcome was labelled ‘confidence’. participants responded to questions using a 5-point scale (1 = very unconfident, 2 = unconfident, 3 = neutral, 4 = confident, 5 = very confident). the mean value of the responses was recorded as the overall confidence score. although the scale was not previously validated, it was only used with the aim of comparing scores at the baseline and completion stages of the npt programme. we evaluated participant perceptions upon completion of the programme through the completion of a survey, adapted from a survey previously used by doumouras et al.[5] statistical analysis we used stata 14 (statacorp., usa) to analyse the data. median values were used to measure mcq scores, as these data were non-parametric, while mean values were used to measure overall confidence scores, as these data were parametric. we used the wilcoxon rank-sum test to compare mcq scores between groups, while paired t-tests were used to compare overall confidence scores. we determined effect size through the calculation of cohen’s d. results student learners of the 71 sls in the npt programme, 38 (54%)  participated in the study. sls demonstrated a significant improvement in both the knowledge and confidence scores. the median mcq score was 58.9% at baseline and 78.6% at completion (p<0.001; d=1.3), while the mean overall confidence score rose from 2.6 at baseline to 3.6 at completion (p<0.001; d=1.3) (table 1). all sls agreed that the npt programme was a useful addition to the standard curriculum and that they would recommend the programme to other students at developmental level (supplementary material 5). near-peer tutors of the 21 nts in the npt programme, 16 (76%) participated in the study. there was marginal improvement in knowledge, with median mcq scores of 87.5% at baseline and 89.3% at completion (p=0.17; d=0.4). however, nts demonstrated a significant improvement in overall confidence, with scores of 3.8 and 4.2 at baseline and completion, respectively (p=0.001; d=1) (table 1). ninety-four percent of tutors agreed that their role as nts reinforced their existing knowledge, and 81% of tutors felt that the npt programme would be a useful addition to the standard curriculum (supplementary material 6). discussion student learners upon completion of the npt programme, sls demonstrated a significant improvement in knowledge scores and in the score measuring sl’s confidence in their knowledge. the theoretical advantages of npt are explained by the concepts ‘cognitive congruence’ and ‘social congruence’, which hypothesise that an approximate equivalence in knowledge, skill level and social role enhances the transmission of knowledge between nts and sls.[6] in the traditional educational hierarchy, the gap between the student and teacher’s comprehension of a subject may be so vast that the teacher cannot effectively communicate the subject at a cognitive level, which is optimal for the student’s understanding. nts, who more closely approximate the cognitive levels of those they are teaching, may be better suited to using techniques such as simplification, which may allow for more efficient and effective transfer of information. nts also occupy social roles, which approximate the social role of the sl more closely than that of the traditional teacher, allowing for the exploration of concepts in an environment that is perceived as less threatening than the traditional educational environment.[6] our study is among few that demonstrate improvement in objective measures, such as knowledge scores after an npt programme.[7,8] evaluation of the npt programme was exceptionally positive, with all sls responding that the programme was a useful addition to the standard curriculum and recommending involvement in the programme to someone at developmental level. these findings are in keeping with those from the literature on the perceived usefulness of npt.[2] near-peer tutors our study suggests that serving as an nt may allow for knowledge retention. however, our findings do not suggest that serving as an nt leads to knowledge improvement. improvement in nts’ knowledge may have been masked by the high baseline mcq scores in the cohort, which left little room for improvement. all of the nts in our study volunteered to teach other students, which may have resulted in the selection of a non-representative sample of clinical year students. it is reasonable to postulate that students at the higher end of the academic performance scale may have been more likely to volunteer as tutors, as they may have greater confidence in their knowledge and ability to transfer the knowledge through teaching. furthermore, the mcq consisted of questions at a difficulty level most appropriate for students at completion of their third year of medical school (in a 6-year undergraduate medical training programme). the questions may, therefore, not have been at a difficulty level appropriate for the assessment of clinical year students. the increase in the overall confidence of knowledge may reflect the reinforcement of previously learnt knowledge. the consolidation of prior learning is often cited as one of the perceived benefits of npt programmes.[3] our findings link this subjective perception to more objective measures of knowledge and confidence, and although the magnitude of the effect is difficult to measure, it supports the hypothesis that npts promote the consolidation of tutors’ prior knowledge. study limitations and directions for future work our study was not without limitations. the sample size was small and the study vulnerable to confounding, as sls continued to receive traditional curriculum teaching from faculty during the study period. it is also possible that cognitive maturation over the course of the year may have contributed to increased confidence. the precise strength of this association cannot be determined with the design of this study, and follow-up research should compare sls with randomised control groups. december 2021, vol. 13, no. 4 ajhpe 217 short report recruitment in our study may have resulted in selection bias, as participants were not randomly sampled, but volunteered for the programme. it is difficult to ascertain how this may have led to bias in the study sample. better-performing students may have been more likely to commit extracurricular time to academic-related activities, while worse-performing  students may have sought academic support from the programme. finally, our measures of knowledge and confidence may not have sufficiently addressed all the competencies required for the practice of medicine. future work should consider including objective structured clinical examination (osce)  measures for a more holistic evaluation of competency. conclusion this study is the first description of an npt programme in sa – run for students by students. its findings suggest that npt may result in improved knowledge and confidence in sls, while consolidating the knowledge of nts. it also suggests that both sls and nts perceive benefit from involvement in npt and that medical students are receptive to npt as an educational modality. in a resource-limited setting, the effectiveness and acceptability of npt make it an attractive adjuvant to traditional teaching. declaration. none. acknowledgements. the authors wish to thank the npt programme tutors for their generosity in giving of their time to teach others. we would also like to thank dr richard raine, prof. wendy spearman and dr kathleen bateman for reviewing the information sheets and mcq questions for each tutorial. the authors additionally wish to thank patients at groote schuur hospital, cape town, for the opportunity to learn from them. author contributions. rs and hl conceptualised and designed the study and analysed data. ie and rh co-ordinated the study. cv supervised the study. all authors contributed to reviewing and revising the manuscript. funding. none. conflicts of interest. none. 1. whitman na, fife jd. peer teaching: to teach is to learn twice. asheeric high educ rep no. 4, 1988. 2. jackson ta, evans dj. can medical students teach? a near-peer-led teaching program for year 1 students. adv physiol educ 2012;36(3):192196. https://doi.org/10.1152/advan.00035.2012 3. nelson aj, nelson sv, linn am, raw le, kildea hb, tonkin al. tomorrow’s educators today? implementing near-peer teaching for medical students. med teach 2013;35(2):156-159. https://doi.org/10.310 9/0142159x.2012.737961 4. health professions council of south africa. core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2014. 5. doumouras a, rush r, campbell a, taylor d. peer-assisted bedside teaching rounds. clin teach 2015;12(3):197-202. https://doi.org/10.1111/ tct.12296 6. schmidt hg, moust jh. what makes a tutor effective? a structural equations modelling approach to learning in problem-based curricula. acad med 1995;70(8):708-714. https://doi.org/10.1097/00001888199508000-00015 7. rodrigues j, sengupta a, mitchell a, et  al. the southeast scotland foundation doctor teaching program – is ‘near-peer’ teaching feasible, efficacious and sustainable on a regional scale? med teach 2009;31(2):e51-e57. https://doi.org/10.1080/01421590802520915 8. blank wa, blankenfeld h, vogelmann r, linde k, schneider a. can near-peer medical students effectively teach a new curriculum in physical examination? bmc med educ 2013;13:165. https://doi.org/10.1186/14726920-13-165 accepted 13 november 2020. table 1. mcq and overall confidence scores for student learners and near-peer tutors, at baseline and completion student learners, n=38 near-peer tutors, n=16 between-group difference, p-value mcq score, % (iqr) baseline 58.9 (46.4 68.8) 87.5 (82.1 92.9) <0.001 completion 78.6 (67.9 85.7) 89.3 (86.6 92.9) 0.001 within-group change p-value cohen’s d <0.001 1.3 0.172 0.4 overall confidence score (sd) baseline 2.6 (0.8) 3.8 (0.7)  0.006 completion 3.6 (0.7) 4.2 (0.5) 0.016 within-group change p-value cohen’s d <0.001 1.3 0.001 1 mcq = multiple choice questionnaire; iqr = interquartile range; sd = standard deviation. https://doi.org/10.1152/advan.00035.2012 https://doi.org/10.3109/0142159x.2012.737961 https://doi.org/10.3109/0142159x.2012.737961 https://doi.org/10.1111/tct.12296 https://doi.org/10.1111/tct.12296 https://doi.org/10.1097/00001888-199508000-00015 https://doi.org/10.1097/00001888-199508000-00015 https://doi.org/10.1080/01421590802520915 https://doi.org/10.1186/1472-6920-13-165 https://doi.org/10.1186/1472-6920-13-165 a maximum of 3 ceus will be awarded per correctly completed test. june 2021, vol. 13, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire june 2021 exploring experiences of using a case study as a teaching strategy to learn about spirituality in occupational therapy education 1. the requirements from students for the case study included (more than one answer may be correct): a. students were expected to work alone during their case study. b. students had to summarise literature in their own words. c. students were expected to make recommendations. d. students had to give feedback on their progress. curriculum mapping: a tool to align competencies in a dental curriculum 2. the results of this study showed that not all the afrimeds competencies were present in the university of the western cape dental programme. (true/false) promoting deeper learning in pharmacy education using team-based learning 3. students in this research indicated that (more than one answer may be correct): a. their understanding of course content was increased owing to its practical application. b. solving problems in a team was an effective way to practise what they had learnt. c. they performed better in tests on material learnt through team-based learning than by traditional lecture methods. d. only a and b. the workplace as a learning environment: perceptions and experiences of undergraduate medical students at a contemporary medical training university in uganda 4. the results of this study showed that (more than one answer may be correct): a. a majority of respondents perceived the learning environment as excellent. b. a majority of respondents perceived the learning environment as having more positives than negatives. c. a majority viewed teaching positively. d. half of respondents had positive academic self-perception. do we assess what we set out to teach in obstetrics: an action research study 5. the researchers used anderson’s taxonomy to define the learning outcomes in this study. (true/false) late-night simulation: opinions of fourthand fifth-year medical students at the university of the free state, bloemfontein, south africa 6. the findings of this study revealed that (more than one answer may be correct): a. students felt unprepared for the long working hours combined with their studies. b. the majority of students felt that simulation training between 01h00 and 04h00 would be beneficial in preparation for night-shift work. c. the majority of students felt that sleep deprivation would affect their patient interaction. d. a majority of students felt that more exposure to late-night clinical work will teach them to make fewer errors. evaluating palliative care training in the oncology registrar programme in south africa 7. feedback from the registrars participating in this study include (more than one answer may be correct): a. many of the skills were not mentored to them. b. the workload of the course was heavy and unmanageable. c. academic material, including journal articles, were preferred by registrars. d. communication skills contributed most to registrars’ learning. please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. cpd questionnaire june 2021, vol. 13, no. 2 ajhpe medical students using the technique of 55-word stories to reflect on a 6-week rotation during the integrated primary care block 8. the 55-word story challenge included the following structure (more than one answer may be correct): a. setting. b. characters. c. conflict. d. plot. factors associated with emotional exhaustion in undergraduate and postgraduate nursing students 9. stress from the following made a significant contribution to the prediction of emotional exhaustion (more than one answer may be correct): a. assignments and workloads. b. lack of professional knowledge. c. environment. d. peers. improving south african medical curricula related to traditional health systems 10. this study revealed that medical students in sa do not recognise the value of increased exposure to and education surrounding the traditional health system. (true/false) a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) june 2021 november 2020, vol. 12, no. 4 ajhpe 201 research nurses and midwives contribute ~66% of the health workforce in africa,[1] and are usually the first, and often the only, health professionals to be accessed by members of their communities.[2] the efficient education, successful deployment and ongoing retention of the nursing and midwifery workforce are key strategies to ensure a well-functioning healthcare system aimed at the ultimate goal of universal health coverage.[3,4] however, regional and international indicators reflect a protracted shortage of nurses and midwives in the healthcare system.[5] an estimated additional 5.7 million nurses are required to meet the health needs of the global population by 2030.[1] the need for more nurses correlates with the need to improve the numbers and quality of nurse educators, especially in africa, where there is a substantive need.[6] african literature describes the quantity, quality and competences of nurse educators in nursing education institutions (neis). in particular, seekoe[7] reports the needs of newly appointed nurse educators in south african (sa) universities and colleges regarding teaching, research, community engagement and work ethic. these needs may be similar throughout many african settings and influence the quality of nursing education. consequently, nursing education stakeholders, such as the world health organization (who), have called for greater investments in nursing and midwifery education, strengthening of educational infrastructure and upskilling of nurse educators to ensure increased graduation outputs.[8] the adoption of recognised continuing professional development (cpd) programmes and their relationship with licensure in many african countries have improved opportunities for upskilling of nurse educators.[9] however, evidence suggests that the mainstream cpd programmes for nurses and midwives, including educators, focus on clinical practice and have limited content related to pedagogy, scholarship and leadership.[10] the lack of capacity development programmes that are tailored to the needs of nurse educators, inadequate numbers of qualified nurse educators,[11] and lack of self-directedness among nurse educators in africa[12] compromise the quality of nursing education and consequently the competencies of graduates of nursing programmes. nurse educators need opportunities to engage with pedagogical evidence and design strategies to solve educationrelated challenges in their neis. not only are there relatively few funded programmes to upskill nurse and health educators comprehensively for leadership and academic duties, but there are also few programmes in the sub-saharan african (ssa) region that provide individualised mentoring in educational research to ensure successful project completion. condell and begley[13] define research capacity development as ‘a funded, dynamic intervention operationalised through a range of foci and levels to augment the ability to carry out research or achieve objectives in the field of research over the long-term, with aspects background. the efficient education, deployment and ongoing retention of the nursing and midwifery workforce are key strategies to ensure a wellfunctioning healthcare system. the african region, however, has relatively few funded programmes to develop educational research capacity in novice academics while also addressing their leadership and educational needs. objectives. to evaluate the outcomes of a faculty capacity development programme on nursing and midwifery educators in sub-saharan africa (ssa). this study explored the scope of scholarship outcomes, career trajectories and leadership outcomes. methods. a mixed methods study collected quantitative and qualitative data from nursing and midwifery educators (n=26) who enrolled for the subsaharan africa-faimer regional institute (safri) fellowship between 2009 and 2019. data from project abstracts presented at a local conference and a subsequent electronic survey were included for review and analysis. deductive thematic analysis was used to report the findings. results. most projects (n=24) focused on undergraduate programmes at the home institutions. all the projects were presented at a local conference and 4 projects were published in peer-reviewed journals. the projects impacted on community and curriculum change, led to improvements in teaching and research and various strategies to improve learning and assessment at home institutions. the reported outcomes relating to the career trajectories of 7 fellows indicate that the programme accrued benefits to their institutions and the community, to students and their peers, and that they experienced personal benefits. conclusion. the safri fellowship vision is evident in the projects and subsequent actions of its nursing and midwifery fellows. nurse educators’ engagement with pedagogical evidence and design strategies has culminated in knowledge to solve some of the education-related challenges in their nursing education institutions. afr j health professions educ 2020;12(4):201-205. https://doi.org/10.7196/ajhpe.2020.v12i4.1389 evaluating the outcomes of a faculty capacity development programme on nurse educators in sub-saharan africa j m van wyk,1 phd; j e wolvaardt,2 phd; c n nyoni,3 phd 1 school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 school of health systems and public health, faculty of health sciences, university of pretoria, south africa 3 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: j m van wyk (vanwykj2@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 202 november 2020, vol. 12, no. 4 ajhpe research of social change as an outcome’. a more recent definition by willis et al.[14] captures the complexities for those wishing to evaluate the impact of such interventions by highlighting that ‘purposefully coordinated components of a research development programme could be targeted at multiple levels of a system, that may operate independently and interdependently in the contexts within which the components are implemented’. in terms of measuring the success of capacity development programmes, we therefore embrace cooke’s[15] notion of the futility of applying only traditional outcome measures, such as ‘successful grant applications and publications in peer-reviewed journals’ as indicators of success. the processes and products are indicators of success – recognising novice academics as researchers who often need to create or join suitable institutional environments for research and collaboration after developing the necessary skills and confidence to conduct independent research. this research uses cooke’s framework to guide readers to assess whether: (i) the intervention aided in the development of new skills/confidence; (ii) the intervention was supported through partnerships/networks; (iii) the research was undertaken close to the coalface of the practitioner; (iv) the capacity programme supported or advanced appropriate dissemination of findings; (v) there was any contextual investment in infrastructure; and (vi) the programme contained elements of sustainability and continuity.[15] the safri fellowship programme: a vehicle for capacity development in ssa the sub-saharan africa-faimer regional institute (safri) offers a faculty and research capacity building programme that is delivered via an integrated residential and distance-learning format. the 2-year programme focuses on developing leadership, project management and programme evaluation skills in health professions education while a fellow engages in an educational research project based on a problem identified at their home institution. safri fellows also engage with key principles of health professions education, such as curriculum design, assessment, teaching and learning, while being guided in the design and implementation of an education innovation project.[16] they are furthermore supported to develop appropriate scholarship skills by presenting their findings in the form of a poster presented to the safri community, and presenting orals/posters at a national peer-reviewed conference, as well as being encouraged to submit a research report for publication in a peer-reviewed journal. the programme recently celebrated its 10th anniversary with >180 health professionals from 23 african countries, including nurses and midwives who graduated successfully as fellows.[17] given the 10-year milestone and the relative absence of similar capacity development programmes in the region, this study was conducted to review the outcomes of the safri programme on educational programmes and personal achievements of fellows representing nursing and midwifery. purpose of this study this paper describes the outcomes of a faculty capacity development programme (safri) on nursing and midwifery educators in ssa. the objectives were to: • describe the demography of nurse educators who graduated from the safri fellowship • provide a thematic overview of the types of educational innovation projects conducted by nurse educators who graduated from the safri fellowship • describe the scholarship outcomes of nurse educators who graduated from the safri fellowship • describe the career trajectories and leadership outcomes of nurse educators who graduated from the safri fellowship. methods research design this study was executed through a parallel convergent mixed methods design applying both quantitative and qualitative methods.[18] population and sampling the study population comprised 26 nursing and midwifery educators, practitioners or managers who graduated between 2009 and 2019 from the safri fellowship. all the fellows had to have been engaged with a nursing or midwifery education-related project during the fellowship. census sampling was used to include all the nurses and midwives as participants in this study. all abstracts related to nursing and midwifery education presented at a local conference by the 26 fellows were included for review and analysis. subsequently, all the fellows were contacted by email explaining the purpose of the study and inviting them to complete an electronic survey. data collection data were collected through two parallel methods aligned with the overarching research design. qualitative data were extracted from the abstract booklets of a local conference. the data were collated on a data extraction sheet that focused on the country of origin, research design, focus of the study, issues of contention, summary of the main findings and take-home message.[19] the authors individually extracted data from each abstract and discussed the outcomes thereof. discrepancies were resolved through discussion to reach consensus. the collected data were entered into an excel spreadsheet (microsoft, usa) to facilitate thematic synthesis.[20] a researcher-developed survey that explored the career trajectories, leadership outcomes and postgraduate scholarship outcomes was administered to the participants (n=26) using online surveymonkey software. data analysis data were analysed to address each of the objectives of the study. thematic synthesis according to braun and clarke[20] informed the analysis of the qualitative data. thematic synthesis aligns with the analysis of secondary qualitative data and is executed in three sequential steps. the initial step focused on line-by-line coding of the extracted data. this process was engaged by each of the researchers independently to generate a list of ‘free’ codes emanating from the data. the second step aimed at inductively organising the free codes to generate descriptive themes. in this step, the free codes were grouped based on similarities and alignment to generate the descriptive themes. the final step focused on the development of analytical themes, which were an outcome of contesting and clustering the descriptive codes against the research objectives.[20] ethical approval this study was approved by the human and social sciences research ethics committee of the university of kwazulu-natal (ukzn) (ref. no. hssrec/00001238/2020). the chief executive officer of the safri company november 2020, vol. 12, no. 4 ajhpe 203 research granted permission to access fellowship-related data. all participants included in the study consented to participate. ethical considerations, such as voluntary participation, informed consent, privacy and confidentiality, were taken into account throughout the study. results the data extracted from the abstract books represent the work of 14% of all completed safri projects (n=184). projects conducted by female and male fellows represented 77% (n=20) and 23% (n=6) of the sample, respectively. nineteen of the included studies used qualitative research designs, 4 employed mixed method designs and 3 used quantitative methodologies. the majority of fellows were from lesotho (table 1). four analytical themes (table 2; http://ajhpe.org.za/public/files/1389-2.pdf) were identified in response to the objective that sought to describe the nature and scope of the educational research projects conducted by the nursing/ midwifery fellows during the safri fellowship. most studies (n=24) focused on undergraduate programmes. the analytical themes include: impact on the community; impact on curriculum change; improving teaching and research; and improving learning and assessment. while the analysis of the abstracts provided insight into the shortterm outcomes of the educational projects and the concerns of the nurse educators who completed the safri fellowship, the data from 7 completed questionnaires were analysed to establish longer-term career trajectories and leadership and scholarship outcomes of the nursing and midwifery fellows. this analysis resulted in 4 new themes: • theme 1: professional benefit • theme 2: personal and peer benefit • theme 3: student benefit • theme 4: institutional and community benefit. theme 1: professional benefit the participants reported acquiring an increasing number of educationrelated roles and responsibilities after completion of the fellowship. specific examples were: heading of departments, leading education-related research projects and driving faculty development initiatives: ‘yes, as head of the programme i was responsible for the strategic leadership of a nursing programme, planning and budgeting for teaching and learning for the programme, mentoring junior staff, quality assurance and improvement activities.’ (fellow 3) in their new roles, participants were able to develop curricula and a variety of educational materials for their programmes: ‘during project implementation, i used the competence i acquired on faculty development to develop a curriculum on student performance assessment incorporating construction items, measurement, criterionreferenced pass score, item blueprinting, item analysis, item bank etc. for nursing, midwifery and clinical officer faculty.’ (fellow 1) theme 2: personal and peer benefit the participants noted improved interpersonal relationships and collaboration with other safri fellows from either their home institutions or internationally. some of this collaboration included academic support: ‘reviewing fellows’ data collection tool; participating in fellows’ predefending of proposal; supporting someone to apply for the fellowship; develop academic programmes and design education-related projects.’ (fellow 2) peers also clearly benefited from the activities of the fellows: ‘i have used the knowledge and skill related to research and have conducted research projects with colleagues in the institution. i have been able to use the knowledge and skills related to teaching, learning, and assessments in the faculty development activities for newly recruited faculty in our institution. i conduct refresher workshops on assessment for colleagues prior to summative assessments every semester. the knowledge about the management of self and other has always been handy in the day to day activities and as tips to colleagues.’ (fellow 4) ‘i have been able to use some of the findings from the project in my own mentoring activities with other faculty, both old and new.’ (fellow 6) participants reflected that these collaborations improved their participation in scholarly activities, such a conferences, and reported completing further studies such as master’s or doctoral degrees. theme 3: student benefit students also reportedly benefited by having these safri fellows as educators. the benefits were directly related to their educational projects during the fellowship and the educational programme of the safri fellowship, such as improved support for student learning, authentic teaching approaches and eagerness of students to engage with their clinical environment: ‘the safri project has helped improve the support of students. some aspects of the safri project are embedded in the learning approaches for students. the revised curriculum requires students to engage in co-operative learning as they engaged in group activities. i have been able to develop better learning activities and study guides for students, leading to better learning experiences. there has also been the introduction of other student support strategies such as tutorials at the institutions.’ (fellow 6) the problem-solving skills acquired during the fellowship enabled participants to procure appropriate resources for learning: ‘the students needed equipment for screening of clients during home visits, so we developed a bag with blood pressure machines for checking blood pressure and also glucometers for checking glucose levels. the community members were participating and fully involved especially in changing their lifestyle. now that we have the equipment even the table 1. country where the educational projects were conducted country % (n ) lesotho 31 (8) south africa 27 (7) kenya 15 (4) uganda 15 (4) botswana 4 (1) namibia 4 (1) zambia 4 (1) total 100 (26) http://ajhpe.org.za/public/files/1389-2.pdf 204 november 2020, vol. 12, no. 4 ajhpe research students were motivated and participating fully during home visits.’ (fellow 5) participants shared numerous other examples of how they could apply their educational expertise, such as revision of assessment programmes, integration of objective structured clinical examinations (osces) within the assessment strategy, and simulation-based education. theme 4: institutional and community benefit participants reported broader institutional effect, such as a greater recognition of health professions education and institutional cyclic efforts associated with curriculum change, and more nurses were supported to apply for the safri fellowship: ‘there are institutionalised approaches to cyclical revision and development of curricula in the country. the educational bodies are beginning to recognise the role medical education systems can play in improving outcomes of educational programmes.’ (fellow 1) some reported investment in expanded opportunities for faculty development for all nurses, which is usually led by safri fellows: ‘more faculty development activities for institutional staff and members from other institutions. more research output from the institution other than that related to safri and academic achievements. the institution safri fellows spearheaded curricular reviews and designed assessment of programmes for the two programmes offered at the institution. the institution safri members spearheaded the quality assurance committee and helped the accreditation of all the programmes offered.’ (fellow 6) the effect of the fellowship extended beyond the institution, as one of the nursing departments was formally recognised for excellence in community engagement: ‘the department of nursing was awarded with the vice-chancellor excellence award in community engagement from the university.’ (fellow 5) a second example was where efforts to engage nurses in clinical practice environments to support nursing students while on rotation had been successful: ‘there was more engagement of clinical staff in training of nurses as a result of the results and recommendations from the study. clinical staff members are now more engaged in student placement planning and clinical assessments. moreover, more preceptorship training has been lined up and budgeted for as a result of the study.’ (fellow 3) participants also contributed to the nursing and midwifery community at national levels: ‘membership of important national decision-making bodies.‘ (fellow 2) discussion this study explored the outcomes of the safri capacity development programme on educational research projects and personal achievements of nursing and midwifery safri fellows. the actions of the fellows in both the short and long term confirm the intended outcome of the fellowship with regard to community effect, and reflect cooke’s assertion that each principle can affect the individual, team or organisational level.[15] both the projects and subsequent actions supported the philosophy of meeting key stakeholders’ needs – those of the patient and community being paramount. in some cases, this community focus was rewarded by formal recognition within an institution. formal recognition for community work is an important aspect of ensuring continuity and sustainability of projects, thereby meeting the sixth principle in cooke’s framework.[15] while all the projects originated from an identified problem at the fellows’ home institution (table 2; http://ajhpe.org.za/public/files/1389-2.pdf ), it was rewarding that the projects had an effect at varying levels. some of the projects resulted in policy and practice changes at community level, whereas others were conducted in institutions where curricular changes could best be negotiated. the most rewarding aspect was that all the reported projects satisfied cooke’s criterion of having engaged in research close to the coalface.[15] a noticeable and common remark from the personal and career data indicates the engagement and involvement of fellows in leadership, academic and research activities after completion of the fellowship. this continued engagement included taking the lead in faculty development workshops, presenting their projects at national conferences and mentoring others at their institutions. these activities indicate the personal and professional growth and substantial skill and confidence developed during their engagement with supportive networks – cooke’s second principle.[15] evidence suggests that research skills development ultimately increases research activity[21] and results in positive attitudes towards research collaboration,[22] while a lack of research training is a barrier to doing research.[23] while only 4 fellows in the current cohort reported having reworked their safri projects into publications, all 26 fellows had presented their findings at the national conference – an appropriate platform to disseminate results.[15] the 7 qualitative reports indicated that the fellows continue to engage and collaborate in further educational research. some of this continued research has culminated in formal qualifications, such as master’s and phd degrees. many of the projects and subsequent interventions appear to also have benefited the neis and colleagues. institutional benefit included the formation of local networks that drove improved educational practice of educators, the introduction of a wide range of new teaching and assessment strategies, as well as fellows engaging in faculty development activities. participants were also concerned about ensuring the quality of the teaching and learning and the student experience. the focus of the majority of the projects and subsequent actions has been to improve the curricula and the current teaching and assessment strategies in terms of content, choice of educational material and clinical skills. the formation of home teams suggests that fellows had used the experience gained to build new alliances in their neis, thus ensuring some continuity of their gains. other fellows have identified like-minded junior academics to coach into safri fellowship, thus forming local and sustainable networks. these data reflect several of cooke’s principles at an individual, team and organisational level.[15] the notion of stepping outside of a safety zone may also suggest increased confidence and ability to do research.[15] this may be illustrated at an individual level by the practitioner-researcher taking on managerial roles, supervising others, or tackling new methodologies/approaches in research, or working with other groups of health and research professionals on research projects. this approach is supported by the model of research http://ajhpe.org.za/public/files/1389-2.pdf november 2020, vol. 12, no. 4 ajhpe 205 research capacity building suggested by farmer and weston[24] to indicate one’s progress and participation through to academic leadership. many of the reported faculty development activities were aligned with strengthening the teaching and assessment competence of educators employed by the neis. some of the projects (and subsequent actions) also extended the notion of educator to nurses and midwives in clinical settings. the concept of supporting education competencies of nurses and midwives in the clinical environment is essential, but receives little attention.[25] some of the projects focused on responding to change, and even though this aspect did not emerge in the survey, the covid-19 pandemic has certainly forefronted this need. conclusion the safri fellowship has a specific vision that finds form and structure in the actions of its fellows. this study confirms that the vision has been fulfilled by the projects and subsequent actions of its nursing and midwifery fellows. it is clear that these fellows as nurse educators have used the fellowship opportunity to engage with pedagogical evidence and design strategies, and have applied this knowledge to solve some of the educationrelated challenges in their neis. declaration. none. acknowledgements. the authors would like to acknowledge the safri management for permitting this study and the safri fellows who participated in the study. author contributions. all authors contributed to the conception, design, development and execution of this study. funding. none. conflicts of interest. none. 1. world health organization. state of the world’s nursing 2020: investing in education, jobs and leadership. geneva: who, 2020. 2. nyoni cn, botma y. sustaining a newly implemented competence-based midwifery programme in lesotho: emerging issues. midwifery 2018;59:115-117. https://doi.org/10.1016/j.midw.2018.01.015 3. shalala d, bolton l, bleich m, brennan t, campbell r, devlin l. the future of nursing: leading change, advancing health. washington dc: national academy press, 2011. 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 5. world health organization. global strategy on human resources for health: workforce 2030. geneva: who, 2016. 6. bvumbwe t, mtshali n. nursing education challenges and solutions in sub-saharan africa: an integrative review. bmc nurs 2018;17(1):3. https://doi.org/10.1186/s12912-018-0272-4 7. seekoe e. competence developmental needs of newly appointed nurse educators during the mentoring process. afr j phys health educ recreat dance 2013;19:118-127. 8. campbell j, dussault g, buchan j, et al. a universal truth: no health without a workforce. geneva: who, 2013. 9. hosey kn, kalula a, voss j. establishing an online continuing and professional development library for nurses and midwives in east, central and southern africa. j ass nurse aids care 2016;27(3):297-311. https://doi. org/10.1016/j.jana.2016.01.007 10. feldacker c, pintye j, jacobs s, et al. continuing professional development for medical, nursing and midwifery cadres in malawi, tanzania and south africa: a qualitative evaluation. plos one 2017;12(10):e0186074. 11. asamani ja, amertil np, ismaila h, francis aa, chebere mm, nabyonga-orem j. nurses and midwives demographic shift in ghana – the policy implications of a looming crisis. hum resource health 2019;17(1):1-5. 12. van rensburg gh, botma y. bridging the gap between self-directed learning of nurse educators and effective student support. curationis 2015;38(2):1503. https://doi.org/10.4102/curationis.v38i2.1503 13. condell sl, begley c. capacity building: a concept analysis of the term applied to research. int j nurs pract 2007;13(5):268-275. https://doi.org/10.1111/j.1440-172x.2007.00637.x 14. willis c, riley b, lewis m, stockton l, yessis j. guidance for organisational strategy on knowledge to action from conceptual frameworks and practice. evidence policy 2017;13(2):317-341. 15. cooke j. a framework to evaluate research capacity building in health care. bmc fam pract 2005;6(1):44. 16. frantz jm, bezuidenhout j, burch vc, et al. the impact of an educational faculty development programme for health professionals in sub-saharan africa: an archival study. bmc med educ 2015;15(28):3-9. https://doi. org/10.1186/s12909-015-0320-7 17. sub-saharan africa-faimer regional institute (safri). 10th year anniversary photo book. 2018. https://www. yumpu.com/en/document/view/60848567/10th-year-anniversary-photo-book (accessed 20 august 2020). 18. creswell jw, clark vlp. designing and conducting mixed methods research. thousand oaks, ca: sage, 2017. 19. munn z, tufanaru c, aromataris e. jbi’s systematic reviews: data extraction and synthesis. am j nurs 2014;114(7):49-54. https://doi.org/10.1097/01.naj.0000451683.66447.89 20. braun v, clarke v. reflecting on reflexive thematic analysis. qual res sport exerc health 2019;11(4):589-597. https://doi.org/10.1080/2159676x.2019.1628806 21. schmidt dd, webster e, duncanson k. building research experience: impact of a novice researcher development program for rural health workers. aust j rural health 2019;27(5):392-397. https://doi.org/10.1111/ajr.12520 22. kotecha p, walwyn d, pinto c. deepening research capacity and collaboration across universities in sadc: a southern african universities regional research and development fund. 2011. https://www.academia.edu/ download/53557890/deepening_research_capacity_and_collabor20170617-2773-5scbod.pdf (accessed 20 august 2020). 23. verhoef mj, mulkins a, kania a, findlay-reece b, mior s. identifying the barriers to conducting outcomes research in integrative health care clinic settings – a qualitative study. bmc health serv res 2010;10(1):14. https://doi.org/10.1186/1472-6963-10-14 24. farmer e, weston km. a conceptual model for capacity building in australian primary health care research. aust fam phys 2002;31(12):1139. 25. rebeiro g, evans a, edward k, chapman r. registered nurse buddies: educators by proxy? nurse educ today 2017;55:1-4. https://doi.org/10.1016/j.nedt.2017.04.019 accepted 25 august 2020. https://doi.org/10.1016/j.midw.2018.01.015 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1186%2fs12912-018-0272-4 https://dx.doi.org/10.1016%2fj.jana.2016.01.007 https://doi.org/10.4102/curationis.v38i2.1503 https://doi.org/10.1111/j.1440-172x.2007.00637.x https://doi.org/10.1186/s12909-015-0320-7 https://doi.org/10.1186/s12909-015-0320-7 https://www.yumpu.com/en/document/view/60848567/10th-year-anniversary-photo-book https://www.yumpu.com/en/document/view/60848567/10th-year-anniversary-photo-book https://doi.org/10.1097/01.naj.0000451683.66447.89 https://doi.org/10.1080/2159676x.2019.1628806 https://doi.org/10.1111/ajr.12520 https://www.academia.edu/download/53557890/deepening_research_capacity_and_collabor20170617-2773-5scbod.pdf https://www.academia.edu/download/53557890/deepening_research_capacity_and_collabor20170617-2773-5scbod.pdf https://doi.org/10.1186/1472-6963-10-14 https://doi.org/10.1016/j.nedt.2017.04.019 june 2020, vol. 12, no. 2 ajhpe 56 research the decision by the health professionals council of south africa (hpcsa) to regulate a research component in the form of a mini-dissertation (master of medicine (mmed)) for specialist registration, was accorded a mixed reception when implemented in 2011. while most south african (sa) surgical registrars consider research an important component of their careers,[1] some view the research requirement as an imposition on their clinical training time and were sufficiently incensed to legally challenge the decree.[2] there also appears to be divergent understandings of the purpose of the mmed among the sa specialist trainer cohort.[3-5] the hpcsa ruling, introduced to solve existing problems of variations between training centres, correspondingly addressed a number of researchrelated and clinically meaningful concerns. anaesthetists in the usa warn that the status of their profession is at risk of becoming a trade union if research training is not enhanced.[6] european family physicians fail to see the direct association between research and clinical reality, limiting their ability to practise evidence-based medicine,[7] while psychiatrists at the university of maryland, baltimore, usa, highlight the serious shortage of physician researchers, which impacts the profession at large.[8] it is important, at this point, to understand that sa is not alone in incorporating a research component into the trainee specialist programme. in other parts of the world, similar steps have been taken to integrate research training in specialist curricula, thereby preparing trainees for future challenges. it is unsurprising that they have also encountered comparable sticking points and wrestle with similar conflicting stances.[7,9-15] given the robust discussion about the appropriateness of the mmed in specialty training,[2-5,16] it is surprising that, 9 years after the implementation of the hpcsa decree, the extent and nature of the sa  mmed remain unstudied. it therefore seems an appropriate time to take stock of the mmed by presenting evidence-based information about the current composition of the research output. such information will assist in identifying strengths and deficiencies in the research programme and provide facts for monitoring, reviewing and decision-making on policy,  and programme and project performance of trainee specialist research. should future changes be implemented, evidence such as that provided here can serve as a reference for determining change. finally, details on current mmed mini-dissertations can assist candidates to improve the structure of their dissertations and offer a glimpse of the quality and relevance of institutional research. therefore, the following descriptive study was undertaken to provide basic information on qualifying sa  mmed mini-dissertations sampled between 1996 and 2018. methods this was a record review of sa mmed mini-dissertations downloaded from local (www.netd.ac.za) and global (www.ndltd.org) electronic theses and dissertation websites. university library repositories of the 8 universities that train registrars were similarly searched until each inquiry revealed proportionally more spurious targets than strikes, whereafter the search was discontinued. acceptable evidence of mmed research competency has many permutations. cochrane reviews[17] and reprints of a single published paper in pdf format[18] were encountered, apart from the typical mini-dissertation in monograph or publication-ready format. to obtain a uniform study sample that could provide all the desired data, two inclusion criteria were applied: • the output had to be identified as an mmed and/or include the colleges of medicine of sa (cmsa) specialty discipline. • the mmed had to be in either monograph or publication-ready format. background. there is no baseline information on the south african (sa) mmed mini-dissertation, which became a compulsory (and controversial) research component for specialist registration in 2011. objective. to obtain evidence-based information regarding the current composition of the research output of the mmed mini-dissertation. methods. sa mmed mini-dissertations (n=307) were downloaded from electronic theses and dissertation websites and 8 university repositories that provide specialist training. fourteen variables were noted for each mini-dissertation, the data were entered into an excel (2016) (microsoft, usa) spreadsheet and analysed using descriptive statistics. results. the 307 mini-dissertations, representing 24 of the colleges of medicine of sa, were submitted from 1996 to 2018, mainly in monograph format (76%) and almost equally divided between prospective and retrospective studies. observational studies predominated, with meta-analyses, systematic reviews and randomised controlled trials comprising 5% of the sample. although quantitative investigations dominated (82%), just less than half of these used statistics to test variables. confirmed ethical compliance improved from 41% in pre-2011 dissertations to 83% for dissertations submitted during 2015 2018. conclusions. this study provides descriptive data on the sa mmed mini-dissertation. comparisons indicate that the mmed research component compares favourably with the content and research approach of similar international specialist trainee research outputs. afr j health professions educ 2020;12(2):56-61. https://doi.org/10.7196/ajhpe.2020.v12i2.1227 content analysis of the south african mmed mini-dissertation e s grossman, phd east london and port elizabeth health resource centres, faculty of health sciences, walter sisulu university, eastern cape province, south africa corresponding author: e s grossman (grossmane@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 57 june 2020, vol. 12, no. 2 ajhpe research excluded were single pdf journal papers, cochrane reviews and any other mmed qualifiers that did not fulfil the inclusion criteria. each retrieved mmed was identified for author, title, year of submission, ethical clearance, university and whether the submission was in monograph or publicationready format. the appropriate college in the cmsa (www.cmsa.co.za), indicating the clinical discipline under which the candidate was registered, was noted, as well as study type, design and data analysis. in each case the research approach was ranked as per the hierarchy of evidence and clinical decision-making. finally, the number of study samples or participants, references and mini-dissertation page numbers were recorded. the data were entered into an excel (2016) (microsoft, usa) spreadsheet and analysed using descriptive statistics (mean, standard deviation, range and median). ethical approval ethical approval was obtained from the walter sisulu university, faculty of health sciences, postgraduate education, training, research and ethics unit: human research committee clearance certificate (ref. no. 032/2019). results a total of 307 mmed mini-dissertations comprised the study sample. general university all 8 universities offering specialist training were represented (table 1). the university of pretoria (up) is under-recorded because mmed research outputs are permitted as a single pdf journal publication, which fell outside the selection criteria of the study. clinical discipline there were 24 colleges in the sample (table 1). submission years year of submission ranged from 1996 to 2018, with peak numbers occurring in 2014. mmed submission started rising in 2010 in anticipation of the hpcsa ruling (fig. 1). mmed layout both mmed formats selected for this study had layout variations. the typical monograph followed the broad outline of front matter, introduction, methods, results, discussion and references. some mmeds included an afrikaans translation of the english abstract (a university norm) and in one instance the entire monograph was in afrikaans.[19] publication-ready format mmeds are generally structured to include the original research proposal, a structured literature review and a publication-ready manuscript or published article for a named, peer-reviewed journal. the ‘instructions to authors’ of the journal are incorporated and co-author contribution is stated. most publication-ready mmeds adhered to the abovementioned provisos. in monograph and publication-ready formats, one or more of the following were encountered: approval of a departure from the original protocol; ethical approval document; extensions to the original ethical approval; plagiarism report; copy of the university mini-dissertation guidelines; annual student progress report; confirmation of word count of each section; outline of referencing style used; and, finally, verification by the statistician of statistical analysis undertaken. omissions were the absence of traditional front matter, table of contents, list of figures or tables, abstract and appendix. descriptive findings mmed format the majority of mmeds were in monograph format (n=236), with 71 in publication format (table 2). the first publication-ready mmed sampled table 1. university and college affiliations for mmed minidissertations, n=307 affiliations n (%) university uct 87 (28) wits 69 (22) su 45 (15) ukzn 44 (14) smu* 30 (10) up 14 (5) ufs 11 (4) wsu 7 (2) college† cog 58 (19) cphm 36 (12) cfp 34 (11) ca 29 (9) cpaed 23 (7) cs 17 (5) cp 16 (5) corth 15 (5) cro 14 (5) cpath 11 (4) cpsych 11 (4) cophth 7 (2) corl 7 (2) cneurosurg 6 (2) cplast 4 (1) cforpath 3 (1) cem 3 (1) cderm 2 (1) cneurol 2 (1) cnp 2 (1) cps 2 (1) cmg 1 (0.3) cr 1 (0.3) cu 1 (0.3) uct = university of cape town; wits = university of the witwatersrand; su = stellenbosch university; ukzn = university of kwazulu-natal; smu = sefako makgatho health sciences university; up = university of pretoria; ufs = university of the free state; wsu = walter sisulu university; cog = college of obstetricians and gynaecologists; cphm = college of public health medicine; cfp = college of family physicians; ca = college of anaesthetists; cpaed = college of paediatricians; cs = college of surgeons; cp = college of physicians; corth = college of orthopaedic surgeons; cro = college of radiation oncologists; cpath = college of pathologists; cpsych = college of psychiatrists; cophth = college of ophthalmologists; corl = college of otorhinolaryngologists; cneurosurg = college of neurosurgeons; cplast = college of plastic surgeons; cforpath = college of forensic pathologists; cem = college of emergency medicine; cderm = college of dermatologists; cneurol = college of neurologists; cnp = college of nuclear physicians; cps = college of paediatric surgeons; cmg = college of medical geneticists; cr = college of radiologists; cu = college of urologists. *due to mergers, the numbers reported here are the totals obtained from adding mmed dissertations appearing in medunsa, university of limpopo and smu repositories. †www.cmsa.co.za june 2020, vol. 12, no. 2 ajhpe 58 research was in 2010; from 2014 onwards, this format formed around half of the submitted mini-dissertations for each year (fig. 1). prospective/retrospective studies investigations were almost equally divided between prospective (n=158) and retrospective (n=149) studies (table 2). investigation type the vast majority of studies were quantitative (n=254), with 41 mmed students undertaking qualitative research and 12 using a mixed methods approach (table 2). quantitative data analysis just fewer than half (n=122) of the 254 quantitative studies used statistics to compare variables or test hypotheses, while the other 132 used simple descriptive statistics (table 2). research approach observational studies such as case studies and reports predominated (table  2). research approaches that provide the best evidence-based information, such as meta-analyses, systematic reviews and randomised controlled trials, comprised ~5% of the sample. when broken down by prospective and retrospective approaches (table 3), surveys (28.9%) and cohort studies (20.1%) comprised half of prospective approaches. case studies and reports (70.9%) dominated retrospective research investigations. the category ‘management’ of 25 mini-dissertations, grouped a diverse collection of studies, which included a hospital quality-improvement cycle,[20] the appeals process against the mental health care act[21] and the impact of family physicians in a district health system.[22] ethical compliance a total of 220 mmeds had a confirmed ethical clearance or waiver with dated evidence provided. of the remaining mini-dissertations, 68 mentioned that ethical clearance was obtained, but lacked confirmation; 13 neglected to obtain clearance for research that clearly required ethical approval and 6 undertook investigations for which ethical approval was table 2. content of mmed mini-dissertations, n=307 mini-dissertations n (%) format monograph 236 (77) publication ready 71 (23) studies prospective 159 (52) retrospective 148 (48) research quantitative 254 (83) qualitative 41 (13) mixed methods 12 (4) data analysis for quantitative studies, n=254 descriptive 132 (52) statistical testing of variables 122 (48) research approach ranked as hierarchy of evidence meta-analysis 1 (0.3) systematic review 3 (1) randomised controlled trial 12 (4) cohort 49 (16) case control 17 (5.7) case study and report 121 (39) narrative 17 (5.7) research categories outside hierarchy of evidence survey 46 (15) management 25 (8.1) experiment/laboratory 16 (5.2) pages mean; median (range) sample, n=307 76; 67 (12 260) monograph, n=235 77; 67 (12 260) publication ready, n=72 73; 67 (17 164) references 51; 40 (6 229) sample range, n=307 1 28 563 no size stated 13 table 3. research approach to prospective and retrospective studies for mmed mini-dissertations, n=307 approach prospective (n=159), % retrospective (n=148), % meta-analysis 0.0 0.7 systematic review 0.0 2.0 randomised controlled trial 7.6 0.0 cohort 20.1 11.5 case control 6.3 4.7 case study and report 10.1 70.9 narrative 9.4 1.4 survey 28.9 0.0 management 10.7 5.4 experimental/laboratory 6.9 3.4 d is se rt at io n s, n 0 50 45 40 35 30 25 20 15 10 1996 2001 2006 2010 2014 2018 5 monograph publication ready fig. 1. graph of submission year and mini-dissertation format for the 307 mmed mini-dissertations sampled. the decrease in numbers from 2015 onwards is probably due to the time lag between mini-dissertation completion and website uploading. the first publication-ready mmed was in 2010; this has become an increasingly popular submission format. 59 june 2020, vol. 12, no. 2 ajhpe research unnecessary (fig.  2). non-compliant and unconfirmed ethical clearance declined dramatically from 59% pre-2011 to 19% for 2011 2014, with a further reduction to 17% for 2015 2018. number of pages there was a wide range of page numbers (12 260), with a mean of 75.6 and median of 67. a 4-page difference in mean page numbers occurred between publication-ready and monograph mini-dissertations (table 2). references the number of references listed ranged from 6 to 229, with a mean of 51 and a median of 40 (table 2). mmed study sample/participant size sample sizes ranged from 1, an unusual case study and comprehensive review,[23] to an extensive sample of 28  563 records.[24] thirteen mmeds lacked study sample numbers. sample size figures gave little indication of the records sifted to achieve the final selection. for instance, mopeli[25] retrieved 883 files to obtain the 131 cases investigated. reporting of such informative detail was seldom encountered (table 2). discussion the novelty of this study is that it presents, for the first time, a basic, tangible description of mmeds that have successfully fulfilled national qualifications framework (nqf) 9 requirements for a professional master’s by coursework and mini-dissertation. as such, it provides useful guidelines for registrars, supervisors and thought-leaders as to the size and scope of the degree, although it cannot indicate the quality of the mmed sampled. the literature was explored to contextualise and gain further understanding of the results of this study, thereby positioning the sa mmed in the global trainee specialist arena. zambian mmed programmes report a preponderance of observational studies (94%).[26] elsewhere, 59.8% of general medicine[32] and 76.9% of family medicine[33] studies were reported as descriptive compared with the current 60% of sa mmed qualitative, mixed methods and descriptive quantitative studies. nour-eldien et al.[28] comment favourably on descriptive studies, deeming them to be inexpensive and useful to generate hypotheses for further studies of more rigorous designs. sa mmeds were almost equally prospective/retrospective in nature, which resonates with similar numbers for prospective studies in ophthalmology (57%)[29] and urology (47.5%)[30] dissertations. prospective studies are considered to have higher scientific value than retrospective studies.[30] the latter formed 50% and 76% of paediatric[31] and radiology[32] dissertations, respectively. in the case of radiology, this is considerably higher than the current 48% finding in the current study. the wide range of research fields and approaches encountered is probably due to the 24 colleges represented in the sample. ranking, using levels of evidence, has been a logical way to contrast these diverse research approaches. koca et al.,[33] employing a similar ‘evidence and grades of recommendation’ grouping, found that 75% of orthopaedic theses were case control, case series and retrospective comparative studies, somewhat greater than the 60.9% for equivalent rankings for sa mmeds. ideally, registrar research should be undertaken at the ‘best’ level of an evidence-based study approach. ‘high level’ studies, which comprised 5% of the current sample, are equal to the 5% reported for ‘high quality’ studies (i.e. randomised controlled trials) in family medicine theses.[28] elsewhere, 13% of paediatric residency research theses[31] are reported as being randomised controlled trials, well above the sa mmed finding. according to jaruratanasirikul and khotchasing,[31] forcing trainee specialists to undertake high-level studies is not realistic. these authors further state that high-level studies can be completed by registrars within the specified time constraints, provided that the studies are kept simple, with a small sample size and tailored for the limited amount of resident time that can be devoted to research. prospective studies with ‘higher scientific value’ are further hampered by ethical and financial considerations.[32] the complexity of ethical approval procedures (whether in terms of time or paperwork) is a major research constraint in resident research.[30,34] this has led sansone et al.[35] to opt for institutional review board (irb)exempted research activities in an internal medicine residency training programme, rather than conducting research that requires expedited or full review. the sa mmed has not followed this course, with <2% of studies requiring no ethical clearance. ethical compliance has also steadily increased over the years in accordance with the national health act.[36] with regard to data analysis, 93% of public health theses were quantitative studies[37] compared with 82.7% of dissertations in the current study. the 38.8% of quantitative finnish medical diploma theses using statistics to analyse data,[38] approximate the current finding of 48%. two studies[31,34] enlarge on the difficulties of doing statistically based research in resident research programmes due to lack of expertise and suboptimal information technology infrastructure in hospitals and teaching premises, a situation bedevilling sa mmed training. looming large in the registrar mind when embarking on the research project, are three questions: how many pages must i write? how many references must i have? how large should my study sample be? therefore, data on the number of pages, references and research subjects were collected to provide some perspective on size, however inappropriate this may be. fortunately, it seems that such questions are commonly encountered and the literature is able to provide comparative data. page numbers for the 307 sa uncon�rmed ethics, 22% no ethics required, 2% ethics required, but absent, 4% con�rmed ethics, 71% fig. 2. pie chart of ethical compliance of the 307 mmed mini-dissertations. june 2020, vol. 12, no. 2 ajhpe 60 research mmeds are well aligned with those suggested – just >60 double-spaced pages for a coursework minor thesis[39] and 40 60 double-spaced pages for a mini-dissertation/research report.[40] despite this consensus, page numbers in the current sample varied enormously owing to omissions and inclusions of items, as described in the results section. even in this light, the 12-page monograph encountered in this study appears rather skimpy. the number of references in the 307 mini-dissertations is also within the ranges suggested – 40 100 for a minor coursework master’s[39] and 28 215 for a master’s in the health sciences.[40] mouton[40] is at pains to point out that the number of references depends on the kind of study undertaken and the field or discipline involved, which could go some way to explaining the range of references (n=6 229) encountered in this study. the diversity of studies, research questions and approaches encountered during this investigation makes it inappropriate to suggest a suitable sample or participant size. a power analysis for size and corresponding statistical significance can be calculated, but this does not assist in descriptive studies, when a limited sample is available or when time limitations restrict data gathering. sansone et al.[35] suggested a participant range of 300 400 for legitimate statistical analysis in prospective studies, but warns of logistical problems such as irb approval, data collection and data-entering efficiencies that could disrupt timeframes. thomas[39] goes further and makes some suggestions on sample size and research scope suitable for health science dissertations and theses. his section on a coursework master’s degree is worth quoting in full: ‘it is usual [to] have one empirical study only or perhaps use secondary sources such as documents and/or previously collected data. for example, the study might be a clinical survey of a small group of patients or perhaps a social survey of a larger group of patients. mind you, the results need to be statistically meaningful so there does need to be a decent sample size to avoid adverse examiner comment. in a social survey using an easily administered questionnaire the expectation might be for over 100 participants in the research, depending on the specific power requirements of the analysis to be performed. in a clinical study, perhaps a two-group intervention study with, say, a minimum of a dozen or so participants per group would be a basic expectation. however, if the measures taken contain a lot of error then the power of the design is likely to be inadequate.’ he qualifies with the words, ‘i have based my estimates on quite a few years of close observation of what seems to be acceptable to other thesis examiners’. publication-ready mmeds are a relatively new form of submission and an in-depth investigation into this format can be found elsewhere.[41] therefore, for completeness, only a few comments on this mmed format are given here. the data show that publication-ready mini-dissertation formats are becoming increasingly popular as a research output. this format is favoured by sa faculties of health science to meet university demands for subsidy-generating publications, while at the same time meeting academic obligations of the registrar research component.[42] additionally, time to completion for publication-ready mini-dissertations is significantly faster than for monograph-type dissertations.[43] study limitations mmed mini-dissertations that are unavailable because of university uploading policy or because of delayed uploading could cause a lack of required randomness in the current sample, but it is felt that this has not materially detracted from the study findings. two studies[32,33] have similarly remarked on university libraries that fail to appropriately upload defended theses onto required databases, potentially affecting sampling strategies. the thrust of available literature on mmed-type dissertations is predominantly on dissertation properties linked to publication, not content analysis per se. a  further problem relates to the discipline-specific nature of the published studies that favour research methods best suited to the clinical discipline in question. finally, it is not always clear how data categories have been organised in other publications, e.g. blurring of what is included in ‘study design’ and whether these categories are comparable with those in the current study. conclusion in summary, there is agreement that the research vacuum in specialty training worldwide has been to the detriment of the profession as a whole and that research skills and evidence-based critique are required to enhance patient care and disciplinary professional status. this long-overdue article has provided basic content data on the sa mmed mini-dissertation, confirming the acquisition of a learned research skill as outlined by r hift and c aldous (standardisation of the research component of the master of medicine (mmed) degree. final recommendations. south african committee of medical deans, 2017 – unpublished). comparisons with the international literature indicate that the scope of the sa mmed, measured by the study variables, is roughly on a par with those provided by other global institutions. this study can serve to assist thought leaders in sa on how best to utilise a research component during registrar training, while at the same time honouring specialist practice and enhancing clinical and 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medicine programme. med j zambia 2010;37(2):52-57. 27. balaghafari a, siamian h, kharamin f, rashida ss, ghahrani n. quantitative assessment of theses at mazandaran university of medical sciences years – (1995-2014). acta inform med 2016;24(4):281-285. https:// doi.org/10.5455/aim.2016.24.281-285 28. nour-eldien h, mansour nm, abdulmajeed aa. master’s and doctoral theses in family medicine and their publication output, suez canal university, egypt. j fam med prim care 2015;4(2):162-167. https://doi. org/10.4103/2249-4863.154622 29. bayramlar h, karadag r, gurturk ayk, ocal a, dag y, sari u. publication patterns of ophthalmology residency mini-dissertations in turkey. eur j gen med 2015;12(3):213-216. https://doi.org/10.15197/sabad.1.12.45 30. yüksel m, i̇pekçi t, tunçkıran a. publication patterns and citation analysis of urology mini-dissertations written at medical faculties from turkey between 2008 2011: a cross sectional study. turk j urol 2018;44(4):341-345. https://doi.org/10.5152/tud.2017.32042 31. jaruratanasirikul s, khotchasing w. publication of pediatric residency research theses from prince of songkla university, hat yai, thailand. asian biomed 2015;9(2):231-235. https://doi.org/10.5372/1905-7415.0902.392 32. chassagnon g, dangouloff-ros v, vilgrain v, ronot m. academic productivity of french radiology residents: where do we stand? diagn interv imaging 2016;97:211-218. https://doi.org/10.1016/j.diii.2015.08.001 33. koca k, ekinci s, akpancar s, gemci mh, erşen ő, akyıldız f. an analysis of orthopaedic theses in turkey: evidence levels and publication rates. acta orthop traumatol turcica 2016;50(5):562-566. https://doi. org/10.1016/j.aott.2016.03.001 34. amgad m, man kin tsui m, liptrott sj, shash e. medical student research: an integrated mixed-methods systematic review and meta-analysis. plos one 2015;10(6):e0127470. https://doi.org/10.1371/journal. pone.0127470 35. sansone ra, wiederman mw, sawyer rj. effective research strategies for trainees in internal medicine residency programmes. prim care companion cns disord 2015;17(1):1-8. https://doi.org/10.4088/ pcc.14r01712 36. national department of health. ethics in health research: principles, processes and structures. 2nd ed. pretoria: ndoh, 2015. 37. hollmann m, borrell c, garin o, fernández e, alonso j. factors influencing publication of scientific articles derived from masters theses in public health. int j public health 2015;60(4):495-504. https://doi.org/10.1007/ s00038-015-0664-0 38. niemenin p, sipilä k, takkinen h-a, renko m, risteli l. medical theses as part of the scientific training in basic medical and dental education: experiences from finland. bmc med educ 2007;7(5):1-7. https://doi. org/10.1186/1472-6920-7-51 39. thomas sa. how to write health science papers, mini-dissertations and theses. sydney: churchill livingstone, 2005:29. 40. mouton j. how to succeed in your masters and doctoral studies. pretoria: van schaik, 2001. 41. grossman es. publication rate of 309 mmed dissertations submitted between 1996 and 2017: can registrars fulfil hpcsa form 57 med amendments? s afr med j 2020;110(4):302-307. https://doi.org/10.7196/ samj.2020.v110i4.14339 42. rout c, aldous c, hift r. response to concerns expressed in the journal regarding the hpcsa requirement for registrar (mmed) research. s afr j anaesth analg 2018;24(2):4850. 43. grossman es. how long does it take a registrar to complete the compulsory research project enabling specialist registration? s afr med j 2019;109(4):254-258. https://doi.org/10.7196/samj.2019.v109i4.13377 accepted 4 november 2019. https://doi.org/10.1080/20786190.2017.1364012 https://doi.org/10.1080/20786190.2017.1364012 http://scholar.sun.ac.za/handle/10019.1/52386 http://scholar.sun.ac.za/handle/10019.1/52386 http://scholar.sun.ac.za/handle/10019.1/97214 http://wiredspace.wits.ac.za/handle/10539/18471 http://scholar.sun.ac.za/handle/10019.1/99325 http://scholar.sun.ac.za/handle/10019.1/99325 http://researchspace.ukzn.ac.za/handle/10413/14794 https://open.uct.ac.za/handle/11427/27824 http://wiredspace.wits.ac.za/handle/10539/23297 https://doi.org/10.5455/aim.2016.24.281-285 https://doi.org/10.5455/aim.2016.24.281-285 https://doi.org/10.4103/2249-4863.154622 https://doi.org/10.4103/2249-4863.154622 https://doi.org/10.15197/sabad.1.12.45 https://doi.org/10.5152/tud.2017.32042 https://doi.org/10.5372/1905-7415.0902.392 https://doi.org/10.1016/j.diii.2015.08.001 https://doi.org/10.1016/j.aott.2016.03.001 https://doi.org/10.1016/j.aott.2016.03.001 https://doi.org/10.1371/journal.pone.0127470 https://doi.org/10.1371/journal.pone.0127470 https://doi.org/10.4088/pcc.14r01712 https://doi.org/10.4088/pcc.14r01712 https://doi.org/10.1007/s00038-015-0664-0 https://doi.org/10.1007/s00038-015-0664-0 https://doi.org/10.1186/1472-6920-7-51 https://doi.org/10.1186/1472-6920-7-51 https://doi.org/10.7196/samj.2020.v110i4.14339 https://doi.org/10.7196/samj.2020.v110i4.14339 https://doi.org/10.7196/samj.2019.v109i4.13377 september 2021, vol. 13, no. 3 ajhpe 199 research intervention a desktop-based virtual environment (ve) was developed to address the covid-19-related limitations of the ‘nursing students’ virtual environment’. the original strategy, based on the head-mounted display (hmd), was used to develop the desktop-based virtual reality platform aimed at improving student access to the virtual reality learning experience. students were expected to access this platform either through their personal computers or via mobile phones at remote locations. the authors report on the feasibility of this desktop-based virtual reality platform in the form of the lessons learnt, based on information from a sample of volunteer undergraduate nursing students and the developers of the platform. the student group, comprising 34 undergraduate nursing students in their third or fourth year, were asked to install the platform on their personal computers (or phones), navigate through the platform and provide the developers with feedback based on their experience. adam et al.[1] argue that virtual educational interventions need to be tested for feasibility, especially in lowand middle-income countries, before they can be adapted to mainstream education. information gathered through feasibility testing may be used to enhance the usability of interventions, such as this desktop-based virtual reality platform, further enhancing its utility within the undergraduate nursing programme at the university of the free state. the lessons learnt the covid-19 pandemic re-emphasised the need for innovative teaching strategies for all health professions students, including nursing students, because of the limited opportunities for work-integrated learning. it was thought that a desktop-based virtual reality platform might enhance students’ access to simulation activities from remote locations. based on our modified feasibility test of the desktop-based virtual reality platform on volunteer undergraduate nursing students and the developers of the platform, we learned several lessons from this experience, namely: 1. all students, regardless of their covid-19 status, must be able to access the virtual reality sessions. students exposed to or diagnosed with covid-19 were expected to quarantine or isolate from other students, and risked missing planned simulation activities and work-integrated learning when at home. the desktop-based virtual reality platform afforded students in quarantine or isolation an opportunity to continue learning. in addition, the students continued learning with limited physical contact, thus reducing the chances of spreading covid-19. the current requirements are a personal computer or laptop capable of running low-end gaming applications (4 gb of ram, 1.8 ghz dual core processor with 1 gb storage and an intel hd on-board graphics processor). the long-term goal is to provide an even more accessible platform via a web-based, mobile and desktop application. 2. the virtual clinical learning platform can be re-used. nursing students engaged in an institution-based virtual reality simulation do not have an opportunity to re-engage or re-enact the simulation, owing to logistical limitations and student numbers. the desktop-based virtual reality platform can be re-used and re-engaged at the student’s convenience. 3. a student may develop clinical reasoning skills. inasmuch as the desktopbased virtual reality simulation relates to clinical learning, students may only develop clinical reasoning skills as their decisions on the care of the virtual patient may directly result in a simulated physiological response. however, students will not develop any nursing-related psychomotor skills from this platform, as they use only a conventional mouse and keyboard or a touch screen interface when interacting with the scenario. the nursing students will still need to learn nursing-related psychomotor skills. 4. the rapid development of the platform may result in errors. the abrupt disruption of learning in health science education institutions (hseis) owing to the covid-19 pandemic catalysed the rapid development of teaching and learning resources, including this desktop-based virtual reality platform. the development of such a platform needs meticulous checking and re-checking to avoid errors that may have serious consequences for the entire simulation. such errors may be incorrect psychological indicators, incorrect navigation mechanisms, and noncompatibility with certain devices. during the original testing, such errors were found and addressed before exposing students to the ve. these errors included incorrect lung sounds, incorrect blood gas values and issues with navigation, which caused some users to experience extreme nausea. 5. connectivity is the mainstay of learning through the platform. the literature underscores the value of connectivity as integral to remote teaching and learning.[1] the utility of this desktop-based virtual reality platform hinges on the internet connectivity available to students. the initial download of this platform is through a zero-rated university website; however, future use will require students to use their internet resources, which might limit the utility of the platform. further improvements to this platform need to be directed towards minimal data use. 6. time and support commitment. the initial development of such a system is time-consuming. the original ve took 19 months to design, develop, test and implement. subsequent changes took ~3 months. extensive the reality of virtual reality at a south african university during the covid-19 pandemic b s botha, msc csi; l hugo-van dyk, phd; c n nyoni, phd school of nursing, university of the free state, bloemfontein, south africa corresponding author: b s botha (bothabs@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:bothabs@ufs.ac.za 200 september 2021, vol. 13, no. 3 ajhpe research training is required for lecturers, but not as much for students, as was found in previous research endeavours.[2] a dedicated support person is needed to assist with queries. at this stage, the developer is fulfilling this role, but the ideal solution would be to establish a separate support structure in the future. what will be kept in practice? our intervention, namely the desktop-based virtual reality platform, was necessitated by the abrupt disruption of planned clinical learning activities as a result of the covid-19 pandemic. it is envisaged that after the covid-19 pandemic disruption, all the elements of this platform will be integrated into the mainstream undergraduate nursing programme. while this intervention was designed and tested on some volunteer nursing students, we plan to expand it for all levels in the undergraduate nursing programme. furthermore, this desktop application will also include multiple scenarios for the various student levels, and tools used in the development of this application, such as unity (unity technologies, usa) and visual studio (microsoft, usa) will be integrated into future virtual clinical education environments. what we will not do in the future before the covid-19 pandemic, students had to wait for planned educational sessions for them to experience the virtual clinical learning platform. these planned educational sessions were usually timed, and students did not always explore simulation activities fully or have an opportunity to replay the sessions. based on experience, we have realised that the desktop application could increase student access to the virtual clinical learning environment from their remote locations before planned educational sessions. in future, we will not limit student experience of virtual reality only to planned institution-based simulation sessions but integrate the desktop virtual clinical learning. conclusions the covid-19 pandemic has forced the rapid development and adoption of education-related innovations. a desktop-based virtual reality platform could enhance access to virtual reality by undergraduate nursing students from remote locations. such an education-related innovation may improve the thinking operations of nursing students, resulting in better quality nursing graduates. declaration. none. acknowledgements. none. author contributions. equal contributions. funding. none. conflicts of interest. none. evidence of innovation 1. adam t, mcburnie c, haßler b. rolling out a national virtual learning environment (edtech hub helpdesk response no.22). https://docs.edtechhub.org/lib/kwjrw62j (accessed 18 june 2021). 2. botha bs, de wet l, botma y. usability of a foreign body object scenario in vr for nursing education. 2020 ieee conference on virtual reality and 3d user interfaces, abstracts and workshops (vrw). atlanta, 2020:787-788. http://ieeevr.org/2020 (accessed 18 june 2021). accepted 11 may 2021. afr j health professions educ 2021;13(3):199-200. https://doi.org/10.7196/ajhpe.2021. v13i3.1503 https://docs.edtechhub.org/lib/kwjrw62j http://ieeevr.org/2020 https://doi.org/10.7196/ajhpe.2021 236 december 2021, vol. 13, no. 4 ajhpe research medical graduates in south africa (sa), in almost all disciplines, encounter older adults in their professional lives owing to the rapid ageing of the population.[1] the number of people aged ≥60 years in sa is predicted to double from 7.8% of the total population in 2012 to 14.8% in 2050.[2] this will result in an increased demand for health services that are responsive to the health needs of older adults. studies in sa indicate that older patients receive poor-quality and inadequate medical care at primary care level.[3,4] this situation is partly due to the limited geriatric training and perceived ageist attitudes of health professionals.[3,5] the planned implementation of a national health insurance (nhi) scheme in sa is dependent on primary care providers’ ability to deliver quality health services to all, including elderly patients. however, it is unclear whether medical graduates possess an appropriate level of knowledge and positive attitudes towards caring for older patients. a recent systematic review indicated that medical students have little interest in geriatric medicine.[6] this field of medicine, which focuses on healthcare of the elderly, is a relatively new and neglected area in medical education, and is often perceived as unimportant by medical students.[7] the pensionable age in sa is 60 years, and geriatric medicine is therefore directed at people aged ≥60 years.[8] there is a scarcity of geriatric teaching faculty in sa, often resulting in limited geriatric teaching in the undergraduate (ug)  medical curriculum.[9] lack of exposure to geriatric teaching may contribute to students’ lack of interest in caring for older patients. furthermore, due to a lack of interest, student learning in geriatrics may be poor.[10] apart from the formal curriculum, students’ geriatric knowledge and attitudes towards their elderly patients are influenced by cultural factors, experiences with older adults and the hidden curriculum.[11] meiboom et  al.’s[6] investigation into the hidden curriculum in the netherlands revealed that medical students were influenced by negative attitudes of their role models towards caring for elderly patients. this finding is supported by evidence indicating that students’ attitudes towards the care for older people became increasingly negative as they progressed through medical school.[12] this phenomenon could also be due to students’ exposure to high levels of morbidity and mortality among geriatric patients, resulting in their perceived futility of caring for the aged. while most studies indicate that medical students possess negative attitudes towards the elderly and their care, a study from malawi demonstrated positive attitudes among medical and nursing students.[13] this positive finding may be attributed to cultural factors and exposure to community-based education. in most traditional african societies, the elderly are revered and respected. it is likely that these traditional values and attitudes may persist during ug training if supported by ongoing engagement with the community. given that health professions educators are being increasingly challenged to prepare medical graduates to care for ageing populations, the current study was conducted to explore the knowledge and attitudes of final-year medical students towards caring for the elderly. the information on student geriatric knowledge and attitudes will inform the design of educational interventions targeted at improving student preparedness to care for older patients. background. south african (sa) studies indicate that elderly patients receive poor-quality and inadequate medical care at primary care level. medical schools must be responsive to the needs of the communities they serve. this article reviews medical students’ knowledge of and attitudes towards caring for older patients to identify areas to enhance their learning. objective. to evaluate the knowledge and attitudes of final-year medical students regarding the care of older patients at the university of kwazulu-natal (ukzn), durban, sa. methods. all final-year medical students were invited to complete a self-administered questionnaire that evaluated their geriatric knowledge and attitudes. geriatric knowledge was assessed with a modified palmore’s facts on aging quiz, and the ucla geriatric attitudes scale was used to assess their attitudes. ethical approval was obtained from the ukzn biomedical research ethics committee and data were collected from september to november 2019. results. there was a 79% (n=173)  response rate. the average age of participants was 24 (interquartile range (iqr)  23 24)  years. the mean geriatric knowledge score was 56.8% (standard deviation 10.4). the mean attitude score was 3.67 out of 5, indicating mildly positive attitudes towards caring for older patients. the majority of students expressed difficulties in communicating with older patients. conclusion. the poor knowledge and mildly positive attitudes of students necessitate educational interventions to stimulate student interest in geriatrics and improve learning in this field, including increased attention to communication skills training relevant to the care of older patients. afr j health professions educ 2021;13(4):235-239. https://doi.org/10.7196/ajhpe.2021.v13i4.1331 the knowledge and attitudes of final-year medical students regarding care of older patients k naidoo,1 phd; j van wyk,2 phd 1 department of family medicine, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 discipline of clinical and professional practice, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: k naidoo (naidook7@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1331 mailto:naidook7@ukzn.ac.za december 2021, vol. 13, no. 4 ajhpe 237 research aim our aim was to explore and describe final-year medical students’ knowledge of and attitudes towards the care of elderly people. objectives our objectives were: • to evaluate medical student knowledge of medical care for elderly patients • to evaluate medical student attitudes towards care for elderly patients • to investigate factors influencing student knowledge of and attitudes towards caring for elderly patients. methods this cross-sectional, descriptive study was conducted at the university of kwazulu-natal (ukzn)  between september and november 2019. the ug medical programme spans 6 years and uses a problem-based learning approach. teaching and assessment of geriatric topics are integrated into other modules across most years of the academic programme. the study population comprised all ug medical students registered for the final (6th) year of the medical programme at ukzn (n=219). a research assistant distributed a self-administered questionnaire to all eligible participants at the end of teaching sessions. data collection tools the self-administered questionnaire included questions on demographic characteristics, prior qualifications, exposure to older adults outside the curriculum and assessment of geriatric knowledge and attitudes. the knowledge and attitude assessment instruments have been used globally, with good internal reliability. minor modifications were made to reflect the sa context. the tool was piloted before data collection. students’ geriatric knowledge was assessed using palmore’s facts on aging quiz.[14] this survey consisted of 50 true/false questions to assess factual knowledge on ageing and geriatric care. correct responses scored 1 and incorrect responses 0. the total scores were converted to a percentage. higher scores indicate a greater knowledge of ageing and geriatric care. the university of california at los angeles geriatric attitudes scale (ucla-gas)  is a 14-item survey assessing attitudes towards the aged and has previously been used among medical students.[15] the survey uses likert-scale responses to indicate whether the respondent agrees or disagrees with the statement. data management and analysis data were exported to the statistical software package stata version 15 (statacorp., usa)  for analysis. one outlier was noted and included in the statistical analyses. the latter were performed using analysis of variance (anova) to compare mean student knowledge and attitude scores among variables (age, prior qualifications, exposure to older adults). spearman’s correlation examined the relationship between knowledge and attitude scores. a p-value of 0.05 was set for statistical significance. ethical approval ethical approval was obtained from the ukzn biomedical research ethics committee (ref. no. be479/19)  prior to data collection. participants were  assigned a study number, and no personal identifying data were recorded. results the response rate for the survey was 79% (n=219). nearly 60% (n=103)  of the cohort consisted of female students and the median (interquartile range (iqr)) age was 24 (23 24) years. twentyfour of the respondents (14%)  had a higher education qualification in fields of study that included science, finance and optometry. of all respondents, 38% had some exposure to geriatric patients outside the formal curriculum. geriatric knowledge of medical students the mean score on palmore’s facts on aging quiz was low (56.8% (standard deviation (sd)  10.4). as indicated in table  1, students aged ≥26  years (n=24)  had a significantly higher mean score than younger students. the students’ knowledge scores did not differ significantly by gender or ethnicity. possession of a prior higher education qualification was associated with greater geriatric knowledge. students’ attitudes towards caring for elderly patients the ucla-gas measured attitudes on a scale of 1 5, with the scores reversed on the negatively worded statements. scores >3.5 indicate a mostly positive attitude towards the aged, and a score <3.5 indicates a negative attitude. in this study, participants demonstrated a mean score of 3.67, indicating a slightly positive attitude towards the elderly. cronbach’s α was 0.69. no factors were identified that contributed to positive or negative student attitudes towards caring for the elderly. although students aged ≥26 years were found to hold a more positive attitude than younger students, this finding was not statistically significant. there were also no significant differences in attitudes between table 1. mean geriatric knowledge percentage scores per variable variable n (%) mean (sd) p-value age group, years 0.0004* <23 56 (32.4) 57.6 (9.6) 23 24 74 (42.8) 54.2 (10.4) >24 25 16 (9.2) 54.5 (10.5) 26 34 27 (15.6) 63.9 (9.6) gender 0.47 female 103 (59.5) 57.3 (10.5) male 70 (40.5) 56.1 (10.6) ethnicity 0.05 black 116 (67.0) 55.4 (10.6) coloured 9 (5.2) 60.6 (6.5) indian 43 (24.9) 59.3 (10.6) white 4 (2.3) 64.5 (5.7) not specified 1 (0.6) 56.8 (0)  other qualifications yes 24 (13.9) 62.3 (9.6) 0.01* no 149 (86.1) 56.0 (10.4) sd = standard deviation. *p<0.05. 238 december 2021, vol. 13, no. 4 ajhpe research male and female students, nor between those of different ethnicities (table  2). respondents with prior higher education qualifications held a more positive attitude, but this finding was not statistically significant. there was no association between previous exposure to older patients and student attitudes. student responses to each of the statements were analysed to obtain a deeper understanding of their attitudes towards elderly patients. the numbers of students that agreed, disagreed or were neutral to each statement are summarised in figs 1 and 2. more than 82% (n=142)  of students agreed that it was interesting to listen to the elderly accounting their past experiences. there were 76% (n=132) of students who agreed that elderly patients were pleasant to be with and that they tended to be more appreciative of medical care than younger patients. however, fewer students (53%) reported that they were more sympathetic to older patients than younger ones (53%)  and that it was society’s responsibility to care for the elderly (45%). student responses to negatively worded statements are indicated in fig. 2. more than 79% (n=137)  of students disagreed with the statement that treatment of chronically ill patients is hopeless. almost 70% (n=121)  of students also disagreed with the statement that the elderly do not contribute much to society. however, more students agreed than disagreed that people become more confused as they grow older and that it was laborious to take a medical history from older patients. relationship between geriatric knowledge and attitude (total geriatric attitudes scale (gas) and geriatric knowledge test (gkt) percentage) as depicted in fig.  3, there was no correlation between students’ knowledge scores and their attitude scores regarding the care of older patients. discussion the current literature suggests that limited knowledge and negative attitudes of health professionals result in the neglect and suboptimal care of geriatric patients.[16] health professions educators are challenged to prepare medical graduates who will be able and willing to provide quality medical care for their elderly patients. despite student perceptions of receiving an adequate level of teaching in geriatrics, they displayed a minimal level of knowledge, with a mean (sd) score of 56.84 (10.42)%. this finding is concerning, given the inclusion of geriatric topics in almost all years of the ug medical curriculum. it is possible that the lack of sub-minima in the assessment of geriatric content contributed to students’ poor learning regarding this discipline.[17] it is also uncertain how this knowledge is translated into practice. to address medical students’ relatively little knowledge of ageing, there should be a greater emphasis on teaching and assessment of geriatric learning objectives in the curriculum. given the limited time afforded to geriatric teaching, it is crucial to evaluate the efficacy of educational strategies that can improve student learning in this neglected discipline. it was encouraging to note that most students had positive attitudes towards working with elderly patients. similar findings were noted among students in singapore and malawi.[13,18] however, these results conflict with reports of negative attitudes and behaviours of medical professionals towards their elderly patients.[3] it is possible that, after graduation, student attitudes could be negatively influenced by the organisational culture it is interesting to listen to old people's accounts of their past experiences i pay more attention and have more sympathy towards my elderly patients than towards my younger ones elderly patients tend to be more appreciative of the medical care that i provide than the younger patients it is society's responsibility to provide care for the elderly most people are pleasant to be with agree neutral disagree students, n 0 20 40 60 80 100 120 140 160 132 28 11 78 60 35 132 26 15 92 45 36 142 15 16 fig. 1. geriatric attitudes scale: student responses to positively-worded statements. table 2. associations between student attitudes and demographic characteristics variable n (%) mean (sd) p-value age group, years 0.11 <23 56 (32.4) 51.4 (5.6) 23 24 74 (42.8) 49.9 (6.7) >24 25 16 (9.2) 50.8 (8.5) 26 34 27 (15.6) 53.5 (6.5) gender 0.78 female 103 (59.5) 51.2 (6.4) male 70 (40.5) 50.9 (6.8) ethnicity 0.42 black 116 (67.0) 51.2 (6.8) coloured 9 (5.2) 53.4 (5.0) indian 43 (24.9) 50.7 (6.4) white 4 (2.3) 47.0 (6.7) not specified 1 (0.6) 51.3 (0) other qualifications 0.15 yes 24 (13.9) 52.9 (7.6) no 149 (86.1) 50.8 (6.4) sd = standard deviation. december 2021, vol. 13, no. 4 ajhpe 239 research in health facilities and by the role models they observe in practice. as this study only examined the attitudes of final-year medical students, it could not be determined if student attitudes towards caring for older patients improved or declined over the course of study. further investigation is needed regarding the changes in attitudes at different stages of study and professional practice, and other factors influencing the attitudes of medical professionals towards their elderly patients. an analysis of students’ attitudes indicated that communicating with older patients was a challenge for most students. greater attention is therefore required in communication skills training, especially regarding older adults with sensory and cognitive impairments. furthermore, teaching and assessment of communication skills should be integrated with practical skills to provide a more realistic and comprehensive approach to the care of older adults.[19] communication skills is also a key educational strategy in developing patient-centred practices in students, which is a key element in quality care for older adults.[20,21] studies report that female students and those who had exposure to the elderly outside the prescribed curriculum were more inclined to have positive attitudes towards the elderly.[11] however, this was not the case in our study. it is likely that the students were exposed to the same medical curriculum for 6 years, resulting in equal levels of empathy at exit level. further research is needed to explore the influence of role models and intrinsic factors in students, which could contribute to student attitudes towards caring for older adults. the seemingly better knowledge and attitudes of older students would suggest that intake of mature students into the medical profession could produce graduates better able to provide quality healthcare to elderly patients. older students may also be more likely to choose to work with older patients. of note, our findings showed no association between geriatric knowledge and attitudes towards caring for elderly patients. other studies have also noted the poor relationship between geriatric knowledge and student attitudes.[22] many initiatives in geriatric medical education have been noted to improve student knowledge in geriatrics, but not attitudes.[23] hence, simply increasing the geriatric content in the ug medical curriculum is unlikely to develop empathy in students towards caring for elderly patients. medical educators need to include teaching and assessment approaches that target the attainment of positive attitudinal and behavioural attributes in graduates regarding the care of older adults. the use of critical reflective activities, such as self-reflection journals, would be of particular value, as they assist students to identify and examine their perceptions towards elderly people. the current literature indicates that educational interventions that involved community engagement and mentorship programmes with the healthy community-dwelling elderly lead to agree neutral disagree students, n 0 20 40 60 80 100 120 140 160 in general, old people act too slowly for modern society old people don't contribute their fair share towards paying for their healthcare treatment of chronically ill patients is hopeless old people in general do not contribute much to society taking a medical history from an elderly patient is frequently an ordeal as people become older, they become less organised and more confused healthcare for old people uses too many human and other resources i would rather see younger patients than elderly ones money from chronic care programmes should be re-allocated to hiv/paediatric services 103 33 37 104 47 22 137 22 14 121 32 20 37 47 89 45 33 95 104 39 30 78 60 35 64 51 58 fig. 2. geriatric attitudes scale: student responses to negatively-worded statements. female male gkt, % g a s sc o re , n 0 10 20 30 40 50 60 70 80 90 80 70 60 50 40 30 20 10 0 fig. 3. relationship between student geriatric attitudes scale (gas) and geriatric knowledge test (gkt). 240 december 2021, vol. 13, no. 4 ajhpe research positive attitudinal changes in students.[24] community skills training and interprofessional education are considered  to be of particular importance in preparing health professionals to care for older adults. these educational strategies have been shown to help develop patient-centred competencies in students and improve attitudes towards older patients.[11] short-term clinical placements, as practised in the current curriculum, were shown to wear down student empathy towards elderly patients. this study highlights the need to review and enhance the ug medical curriculum regarding teaching, learning and assessment of geriatric competencies. given the overall poor geriatric knowledge of final-year medical students, there is an evident need for educators to reach consensus  on the minimum competencies required by medical graduates for effective geriatric care. educational interventions are required to stimulate student interest in geriatrics and improve learning in this field. further studies should address the role of curricula in the development of student attitudes, and identify the reasons for the discordance between student attitude and graduate behaviour towards elderly patients. it is also evident that continuing medical education is required to enhance the limited geriatric  knowledge of our graduates, particularly those working with aged patients. study limitations the results of this study have limited generalisability, because the study was carried out at a single academic institution. the questionnaire only provided for binary classification of gender, and did not allow for ethnic classification other than the four groups enrolled at the facility. conclusion sa’s growing elderly population needs good-quality medical care. findings from this study showed that students held mainly positive attitudes towards older patients, but that their knowledge of geriatrics was poor. these findings require an urgent analysis of the ug geriatric curriculum to assist health professions educators to enhance teaching and learning of core geriatric competencies. these could possibly include communication skills training, interprofessional education, greater community engagement and mentorship programmes with healthy community-dwelling elderly. there is also an urgent need to gain consensus on the minimum geriatric care competencies for inclusion in the ug medical curriculum. the poor geriatric knowledge of soon-to-be medical graduates also highlights the importance of continuing medical education in geriatric care for medical professionals who work with aged patients. declaration. the research for this study was done in partial fulfilment of the requirements for kn’s phd degree at the university of kwazulu-natal, durban, south africa. acknowledgements. we thank ms silindile nzimande for assisting with data collection, and ms cathy connolly, biostatistician at ukzn college of health sciences, for input regarding statistical analyses and reporting. author contributions. kn was primarily responsible for the conceptualisation of the study, data collection and drafting of the manuscript. jvw contributed substantially to the finalisation of the manuscript. both authors read and approved the final manuscript. funding. none. conflicts of interest. none. 1. banerjee s. multimorbidity – older adults need health care that can count past one. lancet 2015;385(9968):587589. https://doi.org/10.1016/s0140-6736(14)61596-8 2. united nations population fund. ageing in the twenty-first century: a celebration and a challenge. london: unpf, 2012. 3. kelly g, mrengqwa l, geffen l. ‘they don’t care about us’: older people’s experiences of primary healthcare in cape town, south africa. bmc geriatr 2019;19(1):98. https://doi.org/10.1186/s12877-019-1116-0 4. naidoo k, van wyk j. what the elderly experience and expect from primary care services in kwazulu-natal, south africa. afr j prim health care fam med 2019;11(1):6. https://doi.org/10.4102/phcfm.v11i1.2100 5. kalula sz. the quality of health care for older persons in south africa: is there quality care? esr rev 2011;12(1):22-25. 6. meiboom a, diedrich c, de vries h, et al. the hidden curriculum of the medical care for elderly patients in medical education: a qualitative study. gerontol geriatr educ 2015;36(1):30-44. https://doi.org/10.1080/027 01960.2014.966902 7. kirk h. geriatric medicine and the categorisation of old age; the historical linkage. aging soc 1992;12(4):483497. https://doi.org/10.1017/s0144686x00005286 8. padmadas s, tiemoko r, madise n, et  al. tracking progress towards the madrid international plan of action on ageing (mipaa)  in east and southern africa: milestones and challenges. int j age dev countr 2018;2(2):184-206. 9. frost l, navarro al, lynch m, et al. care of the elderly: survey of teaching in an aging sub-saharan africa. gerontol geriatr educ 2015;36(1):14-29. https://doi.org/10.1080/02701960.2014.925886 10. robbins td, crocker-buque t, forrester-paton c, et  al. geriatrics is rewarding but lacks earning potential and prestige: responses from the national medical student survey of attitudes to and perceptions of geriatric medicine. age ageing 2011;40(3):405-408. https://doi.org/10.1093/ageing/afr034 11. samra r, cox t, gordon al, et  al. factors related to medical students’ and doctors’ attitudes towards older patients: a systematic review. age ageing 2017;46(6):911-919. https://doi.org/10.1093/ageing/afx058 12. de biasio jc, parkas v, soriano rp. longitudinal assessment of medical student attitudes toward older people. med teach 2016;38(8):823-828. https://doi.org/10.3109/0142159x.2015.1112891 13. zverev y. attitude towards older people among malawian medical and nursing students. educ gerontol 2013;39(1):57-66. https://doi.org/10.1080/03601277.2012.660869 14. palmore e. facts on aging: a short quiz. gerontologist 1977;17(4):315-320. https://doi.org/10.1093/ geront/17.4.315 15. reuben db, lee m, davis jr jw, et al. development and validation of a geriatrics attitudes scale for primary care residents. j am geriatr soc 1998;46(11):1425-1430. https://doi.org/10.1111/j.1532-5415.1998.tb06012.x 16. chang e-s, kannoth s, levy s, et al. global reach of ageism on older persons’ health: a systematic review. plos one 2020;15(1):e0220857. https://doi.org/10.1371/journal.pone.0220857 17. cilliers fj, schuwirth lw, adendorff hj, et al. the mechanism of impact of summative assessment on medical students’ learning. adv health sci educ 2010;15(5):695-715. https://doi.org/10.1007%2fs10459-010-9232-9 18. koh gc, merchant ra, lim ws, et al. the knowledge-attitude dissociation in geriatric education: can it be overcome? ann acad med singap 2012;41(9):383-389. https://doi.org/10.1080/03601277.2012.660869 19. silverman j. teaching clinical communication: a mainstream activity or just a minority sport? patient educ couns 2009;76(3):361-367. https://doi.org/10.1016/j.pec.2009.06.011 20. bombeke k, symons l, vermeire e, et  al. patient-centredness from education to practice: the ‘lived’ impact of communication skills training. med teach 2012;34(5):e338-e348. https://doi.org/10.3109/014215 9x.2012.670320 21. de carvalho ia, epping-jordan j, beard jr. integrated care for older people. in: michel j-p, ed. prevention of chronic diseases and age-related disability. heidelberg: springer, 2019:185-195. https://doi.org/10.2471/ blt.16.187617 22. nagoshi mh, tanabe mk, sakai dh, et  al. the impact of curricular changes on the geriatrics knowledge, attitudes and skills of medical students. gerontol geriatr educ 2008;28(3):47-58. https://doi.org/10.1300/ j021v28n03_04 23. samra r, griffiths a, cox t, et al. changes in medical student and doctor attitudes toward older adults after an intervention: a systematic review. j am geriatr soc 2013;61(7):1188-1196. https://doi.org/10.1111/jgs.12312 24. ross l, jennings p, williams b. improving health care student attitudes toward older adults through educational interventions: a systematic review. gerontol geriatr educ 2018;39(2):193-213. https://doi.org/ 10.1080/02701960.2016.1267641 accepted 28 january 2021. https://doi.org/10.1016/s0140-6736(14)61596-8 https://doi.org/10.1186/s12877-019-1116-0 https://doi.org/10.4102/phcfm.v11i1.2100 https://doi.org/10.1080/02701960.2014.966902 https://doi.org/10.1080/02701960.2014.966902 https://doi.org/10.1017/s0144686x00005286 https://doi.org/10.1080/02701960.2014.925886 https://doi.org/10.1093/ageing/afr034 https://doi.org/10.1093/ageing/afx058 https://doi.org/10.3109/0142159x.2015.1112891 https://doi.org/10.1080/03601277.2012.660869 https://doi.org/10.1093/geront/17.4.315 https://doi.org/10.1093/geront/17.4.315 https://doi.org/10.1111/j.1532-5415.1998.tb06012.x https://doi.org/10.1371/journal.pone.0220857 https://doi.org/10.1007%2fs10459-010-9232-9 https://doi.org/10.1080/03601277.2012.660869 https://doi.org/10.1016/j.pec.2009.06.011 https://doi.org/10.3109/0142159x.2012.670320 https://doi.org/10.3109/0142159x.2012.670320 https://doi.org/10.2471/blt.16.187617 https://doi.org/10.2471/blt.16.187617 https://doi.org/10.1300/j021v28n03_04 https://doi.org/10.1300/j021v28n03_04 https://doi.org/10.1111/jgs.12312 https://doi.org/10.1080/02701960.2016.1267641 https://doi.org/10.1080/02701960.2016.1267641 june 2019, vol. 11, no. 2 ajhpe 53 research there is a global shortage and misdistribution of health professionals, which has major consequences for the future quality of healthcare, with an estimated 1 billion individuals not having access to trained healthcare professionals.[1] this is especially true for poorer countries; in sub-saharan africa this crisis is worsened by the inability to retain and maintain the services of such professionals.[2] an effective response to this challenge requires urgent interventions to address the shortage of healthcare professionals.[1] there have been several policy documents that have used the terms capacity building and capacity development to describe these interventions to achieve the increase and growth of healthcare, leading to improvement.[3,4] an essential component of the capacity-building and capacity-development interventions is facultydevelopment programmes.[3,4] in the current literature on faculty development, capacity, capacity building and capacity development have been interchangeably used.[4,5] an understanding of these concepts is essential if they are to meaningfully inform faculty-development programmes. while capacity broadly refers to the increase in skills and knowledge required for individuals and organisations to perform more effectively, morgan[6] proposed that there are fundamental differences between the terms capacity building and capacity development. the former is a broad term that considers equipping an individual, institution, region or country with the attitudes, values and behaviours needed to bring about change and progress.[6] however, this process of increasing capacity often focuses on the individual and ignores the importance of the collective ability of individuals in capacity building.[6] capacity development highlights the collective process of interactions in a wider system to address problems and bring about transformational change within a specific context.[6] capacity building may be viewed as a goal, while capacity development serves as a means to an end.[6] faculty-development programmes focusing on capacity development of healthcare professionals and educators are key to providing initiatives geared towards addressing the shortage of such professionals and improving healthcare.[7] traditional faculty-development programmes largely emphasise the individual development of health professions educators through new teaching skills or assessment techniques, improved planning or implementation of curricula, new ways of thinking about the studentteacher relationship, and an increased commitment to educational scholarship and leadership.[3,8-10] some aspects are often missing from these faculty-development programmes, e.g. those necessary to ensure socially accountable curricula that relate to the need to train faculty in communitybased education, community engagement, equity and aspects of social responsiveness.[3] these traditional programmes place a strong emphasis on the individual educator without simultaneously addressing the development of a wider community of healthcare professionals who can make a meaningful long-term contribution to health professions education (hpe) and healthcare. this wider development is essential if faculty-development background. faculty-development programmes for health professions educators focus on capacity building, which may not recognise the pre-existing skills and knowledge of participants. a shift to capacity development that recognises the individual and collective skills and knowledge of faculty is needed. objectives. to explore the contribution an african faculty-development programme made to the professional and personal development of faculty and teaching in the programme. also, to investigate the contribution the programme made to the wider health professions education community of practice in africa. methods. a qualitative, exploratory design was used, with a convenience sample of 15 faculty members of the sub-saharan africa-foundation for advancement of international medical education and research (faimer) regional institute (safri) faculty development programme. each participant’s safri journey was explored through an in-depth interview, and data were thematically analysed. ethical approval was obtained for the study. results. a model of faculty development for individual and collective capacity development was derived from five emergent themes: (i) personal and professional development; (ii) collaborative practice; (iii) networking; (iv) research and scholarship; and (v) support. conclusions. faculty-development initiatives may result in capacity development, which extends beyond individual participants to include a wider community of practice. this expanded understanding is best articulated by the african term ubuntu (i am because you are). afr j health professions educ 2019;11(2):53-56. doi:10.7196/ajhpe.2019.v11i2.1120 understanding faculty development as capacity development: a case study from south africa j frantz,1 phd; a rhoda,1 phd; d b murdoch-eaton,2 phd; j sandars,3 mb chb, msc, md; m marshall,4 phd med, bmedsci hons; v c burch,5 mb bch, mmed, fcp (sa), phd 1 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 medical education, academic unit of medical education, medical school, university of sheffield, uk 3 medical education, edge hill university, and academic unit of medical education, medical school, university of sheffield, uk 4 learning and teaching, academic unit of medical education, medical school, university of sheffield, uk 5 department of medicine, faculty of health sciences, university of cape town, south africa corresponding author: j frantz (jfrantz@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 54 june 2019, vol. 11, no. 2 ajhpe research programmes are to be socially accountable.[3] therefore, this study aimed to explore the contribution an african faculty-development programme had on the professional and personal development of faculty teaching in the programme and the wider hpe community of practice in africa. methods study design a qualitative exploratory design was used. population and sampling the study population was conveniently sampled from faculty members of the sub-saharan africa-foundation for advancement of international medical education and research (faimer) regional institute (safri) programme who were teaching at the on-site session of the programme. the population was appropriate, as all faculty members had completed the faimer or safri fellowship programme and were actively involved in hpe activities. the final sample consisted of 15 faculty members (79% of possible participants). design of the intervention faimer has expanded the reach of their faculty-development programme by establishing regional institutes in asia (3 in india and 1 in china), latin america (1 in brazil and 1 in chile), and 1 in africa (safri operating from south africa (sa)). the safri fellowship is a longitudinal facultydevelopment programme implemented over 18 months. steinert et al.[11] indicated that longitudinal programmes produce sustainable outcomes, which cover a host of skills that transcend beyond teaching effectiveness to include academic leadership and scholarship. the safri programme includes three residential sessions, a distance-learning component and design and implementation of an education innovation project, which is outlined in detail by frantz et al.[12] study procedure ethical approval was obtained from the university of the western cape and the university of cape town (ref. no. 11/3/15). faculty members were contacted electronically to inform them about the purpose of the study and to invite them to participate. interviews were conducted at a time and location convenient for participants by independent research assistants trained and competent in the collection of qualitative data. interviewers checked that participants understood the purpose and nature of the study and obtained permission to audio-record interviews. each participant’s safri journey was explored through an in-depth interview initiated by two broad questions: ‘how would you describe your personal and professional growth since the fellowship?’ and ‘how have you shared your knowledge and skills gained from the fellowship?’ data analysis we conducted a thematic analysis according to the guidelines proposed by braun and clarke.[13] audio data were transcribed and read by the research team for the development of initial codes. two researchers (mm and dbm-e) analysed and coded all the transcripts. the initial codes were cross-checked by both these researchers for consistency of analysis and then checked by the remaining authors. discrepancies in coding were resolved through discussions, resulting in consensus. the coding frame was then cross-checked by the full research team and further refined until all authors were in agreement. data were organised into themes and managed using microsoft excel version 10 (microsoft, usa). the analysis and emergent conceptual model were developed by mm and dbm-e and refined through reflexive discussion with the research team. the final stage involved testing the conceptual model using the original data and themes to check for theoretical saturation of constructs and trustworthiness. no new themes emerged at this final stage. results demographics of participants the study sample consisted of 15 participants representing a wide range of professions, including nursing, dentistry, medicine and physiotherapy. the majority were south africans at local universities who were training health professionals. they had an average of 15 years of discipline-specific teaching and research experience and 13 years of hpe-specific teaching and research experience. emerging themes five core themes emerged from the data: (i) personal and professional development; (ii) collaborative practice; (iii) networking; (iv) research and scholarship; and (v) support. a conceptual framework was developed from the five core themes, contributing to an overarching theme of the influences of the programme on self and others (fig. 1). developments within self were described as personal or professional capabilities of participants. influences on others referred to the empowerment of participants to contribute in three areas: (i) their local place of employment, i.e. university or health professions school; (ii) the safri community; and (iii) the broader hpe community. personal and professional development personal and professional development of individuals reflected enhanced insight and self-awareness. participants reported an increase in job satisfaction through increased empowerment and confidence: research and scholarship re se ar ch a nd sc ho la rs hi p safri networking collaborative practice support place of employment broader hpe community personal and professional development of self fig. 1. conceptual framework of capacity development in the safri programme. (safri = sub-saharan africa-foundation for advancement of international medical education and research (faimer) regional institute; hpe = health professions education.) june 2019, vol. 11, no. 2 ajhpe 55 research ‘i could be very confrontative … i was introduced to appreciative leadership and i really changed my attitude, which led to better relationships where i worked.’ (participant 5) participants articulated that skills enhancement in leadership and communication resulted in greater credibility, evidenced through promotion and career development: ‘so i think there has been a huge change … i was able to get promotion. i applied and because i had tools how to market my expertise and how to frame it, i was able to successfully have an interview, and even there i think people were amazed to see the transformation in me as a person, how i presented myself during the interview, and i got promotion after 25 years at the institution.’ (participant 15) collaborative practice collaborative practice outcomes were presented by participants at both an individual (self ) and wider (other) level. collaborative practice was articulated through participants’ abilities to contribute to initiatives impacting on others: ‘that’s your growth within that community … as you interact with others their input and their feedback to you enhance your own growth and you grow and develop greater and greater levels of competence until you become somebody who is more of an expert than you were when you entered.’ (participant 4) ‘as a result of the [safri] project some of those students remained with me and i have mentored some of the undergraduate students. one of the students has now launched an online free course for all medical students in sa; that would not have happened if i didn’t mentor him.’ (participant 18) ‘i have decided that i am going to make a difference, so i do a lot of faculty development and my life’s outlook is to develop others. therefore, whether it is a student or whether it’s a fellow staff member, it’s about developing others and that is what i got out … personally and professionally.’ (participant 9) networking networking between programme participants and the safri faculty was identified as providing critical personal support and engagement within a community of practice for both reference and assistance: ‘you know that somebody … will help you and that’s both professional and personal. you can put out a personal request for help, as well as a professional request for help, and it is always non-judgemental, it’s always not competitive, but that is not always the case in an institution or any other countries … .’ (participant 18) ‘… if you have … a critical mass … of people who think alike and can really influence practice in the institutions where they are working. working together and also getting the community of practice going in terms of joint research projects – that’s very valuable.’ (participant 5) research and scholarship educational research and scholarship through active participation in a safri education research project were identified as valuable key outcomes for participants. this influenced individual skills and knowledge development, but also influenced fellows’ engagement in advancing scholarly educational activities within their home institutions: ‘i published my very first article during that first year … basically my phd had been launched. and life also gets in the way, so it did still take longer than i planned, but at least my proposal was finished and in the end i did finish my phd.’ (participant 5) ‘… professionally around the confidence supervising students through their research … having had experienced having a fellow on safri has also given me that confidence around supervising our students, mostly master’s students, who are doing rural health focus back at the office … it has really given me a lot of practice.’ (participant 1) support the term support was used by several participants to express the widely acknowledged value of an individual’s responsibility to use personal learning for the development of others: ‘what we do when we improve things, we also set standards for the other universities. whenever we had our faculty development workshops we opened it to other universities – so in a way we spread the message to the other universities to say, yes, there is something that we need to do in terms of improving our way of doing business.’ (participant 14) ‘… share my experience with the novices … and that is a very nice feeling, but also nice to know that you can help other people. but, as happened this morning, i also learnt from … our first-year fellows certain things that they do and i just realised that it is actually further than … why didn’t i do that? so i am going to implement that in my own research. so contributing is a give-and-take thing, it’s not really from one side.’ (participant 17) discussion the study contributes to our current understanding of faculty development by highlighting that the safri faculty-development programme is a process of active engagement with support and knowledge sharing to build the personal and professional capabilities of individuals and the entire group. this process can be interpreted from a capacity-development perspective, which includes the individual (personal and professional capabilities) and the collective.[6] the essential processes through which individuals are empowered include collaborative practice, networking, research and scholarship, and support. morgan[6] interprets capacity development as a process of engagement within a wider system, including individual and collective action to create public value that positively contributes to the system. therefore, capacity development enabled safri faculty members to enhance their contributions and responsibilities to their local environment, while simultaneously contributing to organisations outside their local environment or resident institutions. this notion of a wider community responsibility is best expressed by the african term ubuntu (i am because you are). ubuntu describes the belief in a universal bond of sharing that acts to connect all of humanity by emphasising the essential elements of empathy, sharing and co-operation in the combined efforts of individuals to address common problems.[14,15] our work is the first study to provide some early insights into the mechanisms by which the safri faculty-development initiative facilitates individual capacity building, while also contributing to capacity development in the broader hpe community of practice in africa. our data identified five key mechanisms – each making a unique contribution to the process: (i) personal and professional development; (ii) collaborative 56 june 2019, vol. 11, no. 2 ajhpe research practice; (iii) networking; (iv) research and scholarship; and (v) support. conceptually, these mechanisms are expressed in the engagement between individuals and their respective communities of practice within safri, their places of employment and the broader hpe community. this is diagrammatically represented in fig. 1. the use of dashed lines in the model is intended to reflect the permeability and capacity for bi-directional exchange within and between the individual and the broader communities of practice. an important feature of the conceptual model is the bi-directional interplay of the process, leading to individual capacity building and collective capacity development. personal growth contributed towards professional development, such as gaining promotion at work, which was likely to further impact on the personal development of the respective individual. ongoing professional growth also had a positive effect on the institutional environment of faculty members, as they contributed through knowledge creation and sharing, teaching and collaborative practices with other individuals, institutions and communities. this process of capacity development, with a shift of focus on the development of others, is essential for sustaining and improving healthcare services and hpe. the world health organization[16] recently endorsed the mandate to intentionally and sustainably address the process of large-scale upskilling of health professions educators to improve hpe, and ultimately the health of communities in africa. further systematic research is needed to gain a more detailed understanding of how the mechanisms for simultaneous capacity building and capacity development identified in this article are affected in educational practice. study limitations although this study has shed light on the capacity development of the hpe faculty, it is not without limitations. the small sample size mandates further work in the broader safri community of practice in africa to explore other mechanisms of bi-directional capacity building (self ) and capacity development (others), which may not have been identified in this study. the researchers also realise that the participants were drawn from a focused intervention, and selection bias holds important implications for the generalisability of the findings. conclusions there is an urgent need, especially in developing-world regions, to offer more faculty development programmes for health professions educators. such initiatives should facilitate personal capacity development and enable capacity building beyond the self to include the broader community of practice. this is especially important in the context of resource constraints, where most educators will never have the opportunity to engage in programmes catering for limited numbers of participants. the findings of this article suggest that faculty-development initiatives that facilitate individual capacity development and collective capacity building promote personal and professional development, collaborative practice, networking, support, and hpe research and scholarship. this conceptual model of faculty development may serve as a useful starting point for further exploring the work that needs to be done. declaration. none. acknowledgements. the authors thank the national research foundation for funding, which made this research project possible. author contributions. all authors contributed to the article. jf drafted the article and all the other authors commented and contributed to various sections. data were initially analysed by dbm and mm and cross-checked by js, ar, jf and vcb. final edits were done by jf and vcb. funding. national research foundation. conflicts of interest. although 3 of the authors are part of the safri programme, data were analysed independently by the other authors and checked by safri participants. 1. crisp n, chen l. global supply of health professionals. n engl j med 2014;370(10):950-957. https://doi.org/10.1056/ nejmra1111610 2. world health organization. scaling up, saving lives: task force for scaling up education and training for health workers, global health workforce alliance. 2008. www.who.int/workforcealliance/documents/global_health_ final_report.pdf (accessed 8 march 2019). 3. couper i, sen gupta t, mcinerney p, larkins s, evans r. transforming and scaling up health professional education and training: policy brief on faculty development. geneva: world health organization, 2013. 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 5. burdick wp, morahan ps, norcini jj. capacity building in medical education and health outcomes in developing countries: the missing link. educ health 2007;20(3):65. 6. morgan p. the idea and practice of systems thinking and their relevance for capacity development. maastricht: european centre for development policy management, 2005. 7. united nations. the united nations development programme. capacity development. new york: un, 2009:1-62. 8. monekosso gl. a brief history of medical education in sub-saharan africa. acad med 2014;89(8):s11-s15. https:// doi.org/10.1097/acm.0000000000000355 9. kamel am. role of faculty development programs in improving teaching and learning. saudi j oral sci 2016;3(2):61. https://doi.org/10.4103/1658-6816.188073 10. steinert y, naismith l, mann k. faculty development initiatives designed to promote leadership in medical education. a beme systematic review: beme guide no. 19. med teach 2012;34(6):483-503.  https://doi.org/10. 3109/0142159x.2012.680937 11. steinert y, mann k, anderson b, et al. a systematic review of faculty development initiatives designed to enhance teaching effectiveness: a 10-year update: beme guide no. 40. med teach 2016;38(8):769-786. https://doi.org/10. 1080/0142159x.2016.118185 12. frantz jm, bezuidenhout j, burch vc, et al. the impact of a faculty development programme for health professions educators in sub-saharan africa: an archival study. bmc med educ 2015;15(1):28. https://doi.org/10.1186/s12909015-0320-7 13. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 14. gade cb. what is ubuntu? different interpretations among south africans of african descent. s afr j philos 2012;31(3):484-503. https://doi.org/10.1080/02580136.2012.10751789 15. murithi t. practical peacemaking wisdom from africa: reflections on ubuntu. j pan afr studies 2006;1(4):25-34. 16. world health organization. transforming and scaling up health professionals’ education and training: who education guidelines. geneva: who, 2013. accepted 7 march 2019. https://doi.org/10.1056/nejmra1111610 https://doi.org/10.1056/nejmra1111610 http://www.who.int/workforcealliance/documents/global_health_final_report.pdf http://www.who.int/workforcealliance/documents/global_health_final_report.pdf https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1097/acm.0000000000000355 https://doi.org/10.1097/acm.0000000000000355 https://doi.org/10.3109/0142159x.2012.680937 https://doi.org/10.3109/0142159x.2012.680937 https://doi.org/10.1080/0142159x.2016.118185 https://doi.org/10.1080/0142159x.2016.118185 https://doi.org/10.1186/s12909-015-0320-7 https://doi.org/10.1186/s12909-015-0320-7 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa 144 october 2020, vol. 12, no. 3 ajhpe research emotional-social intelligence (esi) is known to improve and enhance the learning process, and it is a popular topic of debate in the field of nursing education. emotional intelligence is a concept that has received increased attention in in academic circles. emotional intelligence helps students excel, and it also can help teachers to effect and excel in their profession.[1]  the development of emotional intelligence will increase academic achievement and ensure that new nursing entrants to the profession have the abilities, knowledge and skills to provide efficient and effective nursing care. academic achievement refers to how well students accomplish their tasks and studies.[2] to achieve this, nurse educators must determine the areas that require improvement in relation to esi, and assess the educational needs of nursing students.[3] a previous study reported a significant relationship between emotional intelligence and undergraduate students’ academic achievement at the midwestern university in the usa.[4] similarly, a study from pakistan reported that students with high emotional intelligence showed better academic performance than students with low emotional intelligence.[5] previous research has also confirmed a significant correlation between emotional intelligence and self-efficacy with academic achievement among nigerian university students.[6] furthermore, sünbül and aslan[7] concluded a similar relationship between emotional intelligence and academic achievement among 312 education students in konya, turkey. moreover, there is a significant body of research that suggests esi and other non-traditional measures are just as predictive of academic success as traditional iq tests.[8] even though there is significant evidence to support the influence of emotional intelligence on academic achievement, very few studies have explored this motivational mechanism in nursing students in saudi arabia. hence, this research attempts to shed some light on the relationship between emotional intelligence and academic success among saudi undergraduate nursing students. results of the present study could be used by nursing educators to include the concept of emotional intelligence in their students’ curriculum and classrooms to help them cope better with educational and social pressures. methods the researchers used a descriptive-comparative approach. the respondents in this study were nursing students from the university of shaqra (kingdom of saudi arabia). participants were identified via convenience sampling, and 127 male and female nursing students from year 2 to year 4, enrolled in the academic year 2018 2019 at the colleges of applied medical sciences in shaqra, participated in the study. this research used two tools to collect data: an esi questionnaire, developed by bar-on et al.,[9] and an academic achievement scale. the esi questionnaire was composed of two parts: part one consists of a personal characteristics data sheet, including a code number, age, sex, and parents’ occupation; part two consists of 53 competencies under 5 components specific for undergraduate nursing students: (i) intrapersonal competencies (16 competencies) grouped under 5 subscales: self-esteem, self-awareness, assertiveness, independence and self-actualisation; (ii)  interpersonal competencies (13 competencies) grouped under 3 subscales: empathy, social responsibility and personal relationships; (iii) adaptability (9 competencies) grouped under 3 subscales: reality testing, flexibility and problem-solving; (iv) stress management (8 items) grouped under 2 subscales: stress tolerance, and impulse control. in addition, general mood (7 items) is grouped under 2 subscales: optimism and happiness. background. academic achievement refers to the extent to which a learner, instructor or institution has accomplished their shortor long-term educational goals. there are inconclusive results about the individual factors that successfully predict academic performance. emotional intelligence has been a popular topic in the field of higher educational learning. several research reports have shown that emotional intelligence is one of the factors that successfully predicts students’ academic achievement. objectives. to examine the relationship between emotional-social intelligence (esi) and self-reported academic achievement among nursing students. methods. a descriptive-comparative approach was used. the study was carried out on 127 nursing students from different academic levels. the study used two tools, namely an esi questionnaire and an academic achievement scale. results. the females had statistically significant higher means than the males in their scores on the esi questionnaire (p=0.042) and interpersonal competencies (p=0.003). there were positive correlations between esi score, its five components and students’ self-reported academic achievement. conclusion. the outcome of this study suggests that educational planners and academicians should embrace emotional intelligence-developing courses at college and university levels. afr j health professions educ 2020;12(3):144-148. https://doi.org/10.7196/ajhpe.2020.v12i3.1365 predicting effect of emotional-social intelligence on academic achievement of nursing students a alenezi,1 phd; m s moustafa saleh,1,2 phd; r a gawad elkalashy,1,3 phd 1 department of nursing, college of applied medical science, shaqra university, saudi arabia 2 department of nursing, nursing administration, faculty of nursing, zagazig university, egypt 3 department of nursing, medical surgical nursing, faculty of nursing, menoufia university, egypt corresponding author: a alenezi (atta@su.edu.sa) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 145 research the instrument uses a 5-point likert scale, with item response scores ranging from 1 (not true for me) to 5 (true for me). the total score for each student (265) was calculated and converted into a % score, and was categorised into unsatisfactory if the score was <60% and satisfactory if the score was ≥60%. the researchers tested the reliability of the questionnaire and found that this questionnaire had high internal consistency (cron bach’s α coefficients were 0.980, 0.850, 0.880, 0.840 and 0.870 for intrapersonal competencies, interpersonal competencies, adaptability, stress management and general mood, in that order). in terms of determining the academic achievement of the students, a tool was constructed and developed by researchers based on the review of literature, as per zimmerman and schunk.[10] students indicated their level of agreement using the scale 0 = very little efficacy, 1 = little, 2 = moderate, 3 = a lot and 4 = quite a lot. this scale consisted of 45 self-report statements to capture respondents’ views of their academic achievement. the tool was divided into five main categories as: academic performance; extracurricular activities; student’s interaction; student’s behaviour; and student’s attendance. each category has nine statements, and the scores for each category were summed to give a total score and categorised into lower academic achievement (0 <60), moderate academic achievement (60 - <120) and higher academic achievement (120 180). the higher score means the greater the student’s academic achievement. a high internal consistency was observed by the researchers, through tested cronbach α coefficients to measure the reliability of the tool in this study guided by sun et al.[11] and tavatol and dennis.[12] the reliability of five main categories of academic achievement mentioned before (0.935, 0.860, 0.860, 0.935, 0.900) correspond. a pilot study with 11 randomly selected nursing students (10% of the study sample) was performed to ensure applicability, clarity and feasibility of the instruments. the students took around 15 20 minutes to complete the questionnaire. no modifications were made, and the results of the pilot study were included in the study results. ethical approval (ref. no. e1032) was given by the deanship of scientific research, shaqra university (saudi arabia). the study was conducted at the college of applied medical sciences in shaqra. the students’ participation in the study was voluntary and all participants were assured that their marks would not be affected if they did not participate in the study, and that they could withdraw from the study at any time. statistical design the data collected were computerised, revised, categorised, tabulated, analysed and presented in descriptive and associated statistical form using statistical package for social sciences version 20 (ibm corp., usa). the data were tested by numerical data expressed as mean (standard deviation (sd)). qualitative data were expressed as frequency and percentage. difference between quantitative variables was tested by using the independent t-test and one-way analysis of variance test. the correlations between different numerical variables were tested using pearson’s correlation test. p≤0.05 was considered significant, and highly significant at p≤0.001. results table 1 contains demographic traits of the students, and shows that 66.1% of the participants were male, and the mean (sd) age of participants was 20.7 (2.4), with 57.5% >20 years old. the majority (83.5%) reported a high grade point average score. most of the students’ parents were highly educated (62.2% and 54.3% of the mothers and fathers of the students, respectively, were university graduates). fig. 1 describes categories of esi among participants: it shows that more than two-thirds of the study sample had a satisfactory level for emotional intelligence (66.9%), as compared with 33.1% who had an unsatisfactory level of emotional intelligence. table 2 illustrates that there were significant statistical differences between male and female students regarding their scores on the esi questionnaire and interpersonal competencies score, in favour of females, with a mean difference of 9.52 and 4.65, respectively, and p-values of 0.003 and 0.042, respectively, at a 95% confidence interval. table 1. sociodemographic characteristics of sample (n=127) n (%)characteristic gender 84 (66.1)male 43 (33.9)female age, years 54 (42.5)>20 73 (57.5)≤20 20.73 (2.42)mean (sd) academic level 57 (44.9)year 2 43 (33.9)year 3 27 (21.3)year 4 gpa 12 (9.4)low 9 (7.1)average 106 (83.5)high level of mother’s education 3 (2.4)illiterate 23 (18.1)basic 22 (17.3)intermediate 79 (62.2)higher education level of father’s education 1 (8)illiterate 24 (18.9)basic 33 (26)intermediate 69 (54.3)higher education sd = standard deviation; gpa = grade point average. 66.9% satisfactory unsatisfactory 33.1% fig. 1. distribution of emotional-social intelligence levels among study sample. 146 october 2020, vol. 12, no. 3 ajhpe research fig. 2 describes levels of academic achievement among the study sample, and demonstrates that it was high in 70% of participants, compared with 8.7% of the participants whose academic achievement was low. table 3 explains the difference in academic achievement between male and female students. however, there were no significant differences between the two sexes regarding total mean score of self-reported academic achievement or its dimensions. table 4 reveals the results of analysis of variance tests for the relationship between the level of education of students’ parents and esi questionnaire scores, and shows a significant difference between parents’ education with regard to esi score (p≤0.05). additional results found a low degree of positive correlation between age and esi score (p=0.012 and r=0.223). table 5 shows that there is an association between esi score and academic achievement score. also, all esi questionnaire dimensions (intrapersonal and interpersonal competencies, adaptability, stress management and general mood) separately correlated positively with academic achievement score. table 2. difference in mean score of esi questionnaire between male and female students (n=127) variables male, mean (sd) female, mean (sd) mean difference t-test p-value* mean score of intrapersonal competencies 68.88 (9.16) 70.63 (5.77) 1.75 1.31 0.19 mean score of interpersonal competencies 54.17 (8.32) 58.82 (7.58) 4.65 3.017 0.003* mean score adaptability 36.48 (5.62) 37.97 (5.98) 0.49 1.38 0.17 stress management 43.41 (4.94) 44.30 (8.01) 0.89 0.66 0.51 general mood 30.30 (4.07) 31.06 (3.51) 0.76 1.092 0.28 mean score of esi questionnaire 233.27 (27.07) 242.79 (24.08) 9.52 1.397 0.04* *p≤0.05; 95% confidence interval. esi = emotional-social intelligence; sd = standard deviation. fig. 2. academic achievement levels among study sample. high moderate low 8.7% 70% 21.3% table 3. mean score of subscale and total academic achievement scale by sex (n=127) p-value*t-testmean differencefemale, mean (sd)male, mean (sd)items 0.600.811.8734.51 (6.57)36.38 (6.88)academic performance 0.450.760.6339.76 (7.39)39.13 (4.87)extracurricular activities 0.120.921.0138.22 (8.49)37.21 (6.64)student interaction 0.200.630.7626.83 (6.40)27.59 (6.97)student behavior 0.780.910.3225.95 (6.04)25.63 (7.10)student attendance 0.460.841.79165.27 (27.67)165.94 (19.90)total academic achievement mean score *p≤0.05. sd = standard deviation. table 4. the relationship between level of education of students’ parents and esi questionnaire score anova variables mean (sd) f-value p-value* mother’s educational levels illiterate 227.56 (11.33) 9.40 0.004 basic 232 (15.12) intermediate 231.77 (13.91) higher education 247.33 (12.23) father’s educational levels illiterate 239.48 (14.37) 12.5. 0.001 basic 242.62 (17.52) intermediate 240.12 (16.35) higher education 254.46 (15.21) *p≤0.05. esi = emotional-social intelligence; sd = standard deviation; anova = analysis of variance. table 5. correlation coefficient between the esi score, its dimensions and academic achievement score (n=127) variables p-value* r-value* esi and academic achievement scores 0.00 0.446 intrapersonal competencies and academic achievement scores 0.00 0.440 intrapersonal competencies and academic achievement scores 0.00 0.379 adaptability and academic achievement scores 0.00 0.385 stress management and academic achievement scores 0.007 0.236 general mood score and academic achievement scores 0.00 0.407 *p≤0.01. esi = emotional-social intelligence. october 2020, vol. 12, no. 3 ajhpe 147 research discussion it is believed that the application of the esi concept in nursing education programmes helps students to deal with pressures related to their studies, and also improves their communication skills.[13] earlier studies have indicated an association between esi and academic achievement. the aim of the present study was to examine the association between emotional intelligence and academic achievement in undergraduate nursing students at the college of applied medical sciences, saudi arabia. the results identified an association between esi and the demographic characteristics of participants, and recognised a correlation between academic achievement and level of esi. about two-thirds of the study sample were male, the mean age of the participants was 20.73 years, with most aged >20 years, and the majority of participants’ parents had obtained higher education. the demographic characteristics of participants in this study were different from those in earlier studies among nursing students. jacob and pavithran[14] and fallahzadeh[15] studied the impact of esi in nursing students, the majority of whom were female. the age of participating nursing students in our study was similar to that reported by sinha et al.[16] and moawed et al.[17] with respect to parents’ education, the data in the present study were similar to those in a study by moawed et al.,[17] who carried out a comparative study of emotional intelligence skills of nursing students in riyadh (saudi arabia) and tanta (egypt), and showed that most of the students’ parents in riyadh had high education levels.  the current study revealed that more than two-thirds of participants were of satisfactory esi level (>60% of the total score). this may be due to the presence of more extracurricular activities and summer courses, which enhance and refresh abilities that help students improve their esi. this emotional intelligence level may also be due to increased attention given to the affective and emotional domains during the teaching process. this result was similar to that reported by manjusha et al.18] on emotional intelligence and academic performance among nursing students, where 68.3% of assessed students had a satisfactory emotional intelligence level. the results are also in line with sinha et al.,[20] who reported that 61% of assessed students had normal and high emotional intelligence (46% had normal levels and 15% had high levels). the mean total esi scores of male and female participants were 233.27 and 242.79, respectively, and this difference between male and female participants was statistically significant (p<0.042). the interpersonal competencies score was significantly higher in female students (p=0.003). earlier studies comparing esi scores in male and female students reveal varying results. fallahzadeh[15] reported no statistically significant difference in total esi scores between male and female students. further, he reported that there was no significant difference between male and female students in the mean of all dimensions of esi (p>0.05) except for the difference in mean score of adaptability scale. the findings of this study were supported by saddki et al.[19] and acebes-sánchez,[20] who reported that females had a significantly higher emotional intelligence score than males. about two-thirds of the participants had a high level of self-reported academic achievement in the present study. this is possibly because most participants had a satisfactory emotional intelligence level. our results support an earlier report by manjusha et al.[18] in which 69% of nursing students had good and very good levels of emotional intelligence and academic performance. regarding academic achievement and sex, results of this study showed that there was no significant correlation between the two, which supports the findings of earlier studies. blackman et al.[21] and ugoji[22] showed that there was no significant correlation between sex and academic achievement of students. wan chik et al.[23] indicated that male students have lower academic performance than female students, as measured by grade point average. this may have been due to a difference in the percentage of male and female participants in their study. the pearson correlation test presented a positive correlation between the age of participants and the total score in esi. the findings are in line with carstensen et al.,[24] snowden,[25] suleman et al.,[26] nagar[27] and hamouda and al nagshabandi,[28] who reported the presence of a significant positive relationship between age and esi. this may be due to the fact that older adults are more skilled at regulating their emotions than younger adults, and that particular aspects of emotional intelligence may increase with age. the education of participants’ parents significantly affected participant’s esi scores, with high scores among participants whose parents had a high educational level. the result was similar to haraluretal[29] and pant and singh,[30] who reported significant statistical differences in esi scores based upon parents’ education levels. our study revealed a positive correlation between emotional intelligence and academic achievement. several studies support this result. manjusha  et  al.[18] and kouchakzadeh et al.[31] also support a significant positive relationship between academic performance and emotional intelligence of nursing students. similarly, kumar et al.[32] and suleman et al.[26] confirmed the strong positive relationship between emotional intelligence and academic success. the results of our study are also supported by a comprehensive quantitative review by ranjbar  et  al.[33] for all published studies on emotional intelligence and academic achievement in iranian students, and a systemic review by hanafi and noor.[34] esi can be considered as a predictor for academic achievement level, as students with low emotional intelligence may have low concentration and show aggression in their relations and in dealing with their peers. they may also struggle to communicate their feelings to their colleagues. in contrast, students with higher levels of emotional intelligence are able to manage themselves better and communicate more effectively with their peers and teachers. this can assist them to improve self-motivation and effective communication skills, and help students become more confident learners. the findings of our study contradict earlier reports by shah et al.[35] and gilani et al.[36] that show that academic achievement and esi are negatively correlated. our results are also different from those reported by zirak and ahmadian,[37] which suggest an absence of a significant relationship between total emotional intelligence and academic achievement. our study results also indicated the presence of positive correlations between the five dimensions of the esi questionnaire, including intrapersonal and interpersonal competencies, adaptability, stress management and general mood (r values 0.440, 0.379, 0.385, 0.236 and 0.407, respectively). our results are supported by oyewunmi et al.[38] conclusion our results indicate an association between emotional intelligence and the academic achievement of nursing students. nursing educators should create esi-developing courses that can be taught by experts in the field at college and university level, and workshops on strategies to boost the esi 148 october 2020, vol. 12, no. 3 ajhpe research of learners. emotional intelligence should be part of the educational plan for students, and students should be provided with workshops to boost their esi. this study should be replicated with a larger sample size and in a different setting to further confirm its findings. declaration. none. acknowledgements. none. author contributions. equal contributions. funding. none. conflicts of interest. none. 1. banat byi, rimawi ot. the impact of emotional intelligence on academic achievement: a case study of al-quds university students. int humanities 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2017;24(1):59. https://doi.org/10.21315%2fmjms2017.24.1.7 20. acebes-sánchez j, diez-vega i, esteban-gonzalo s, rodriguez-romo g. physical activity and emotional intelligence among undergraduate students: a correlational study. bmc public health 2019;19(1):1241. https:// doi.org/10.1186/s12889-019-7576-5 21. blackman i, hall m, darmawan i. undergraduate nurse variables that predict academic achievement and clinical competence in nursing. int edu j 2007;8(2):222-236. 22. ugoji fn. the impact of counseling on the academic performance of secondary school students. africa j int discip studies 2008;8(2):67-69. 23. wan chik wz, salamonson y, everett b, et al. gender difference in academic performance of nursing students in a malaysian university college. int nur rev 2012;59(3):387-393. https://doi.org/10.1111/j.1466-7657.2012.00989.x 24. carstensen ll, turan b, scheibe s, et al. emotional experience improves with age: evidence based on over 10 years of experience sampling. psychol aging 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meta-analysis. acta facultatis medicae naissensis 2017;34(1):65-76. https:// doi.org/10.1515/afmnai-2017-0008 34. hanafi z, noorf. relationship between emotional intelligence and academic achievement in emerging adults: a systematic review. int jacad res business social sci 2016;6(6):268-290. https://doi.org/10.6007/ijarbss/v6i6/2197 35. shah cj, sanisara m, mehta hb, vaghela hm. the relationship between emotional intelligence and academic achievement in medical undergraduates. int j res med sci 2014;2(1):59-61. https://doi.org/10.5455/2320-6012. ijrms20140211 36. gilani n, waheed sa, saleem k, shoukat l. do emotions affect academic success in adulthood relationship between postgraduate students’ trait emotional intelligence success. ayer, 2015;2:37-44. 37. zirak m, ahmadian e. relationship between emotional intelligence & academic achievement emphasizing creative thinking. mediterr j social sci 2015;6(5):561-561. https://doi.org/10.5901/mjss.2015.v6n5s2p561 38. oyewunmi ae, osibanjo ao, adeniji aa. emotional intelligence and academic performance of undergraduates: correlations, implications and interventions. mediterr j social sci 2016;7(1):509. https://doi.org/10.5901/ mjss.2016.v7n1p509 accepted 13 july 2020. https://doi.org/10.1108/02621710210430272 https://doi.org/10.1177%2f097133360701900204 https://doi.org/10.1177%2f097133360701900204 https://doi.org/10.21315%2fmjms2017.24.1.7 https://doi.org/10.1186/s12889-019-7576-5 https://doi.org/10.1186/s12889-019-7576-5 https://doi.org/10.1111/j.1466-7657.2012.00989.x https://doi.org/10.1037%2fa0021285 https://doi.org/10.1016/j.nedt.2014.09.004 https://doi.org/10.1371/journal.pone.0219468 https://doi.org/10.18843/ijcms/v8i3/04 https://doi.org/10.11648/j.ajns.20180705.13 https://doi.org/10.4103/njcp.njcp_37_19 https://doi.org/10.29252/ijn.29.102.1 https://doi.org/10.29252/ijn.29.102.1 https://doi.org/10.1515/afmnai-2017-0008 https://doi.org/10.1515/afmnai-2017-0008 https://doi.org/10.6007/ijarbss/v6-i6/2197 https://doi.org/10.6007/ijarbss/v6-i6/2197 https://doi.org/10.5455/2320-6012.ijrms20140211 https://doi.org/10.5455/2320-6012.ijrms20140211 https://doi.org/10.5901/mjss.2015.v6n5s2p561 https://doi.org/10.5901/mjss.2016.v7n1p509 https://doi.org/10.5901/mjss.2016.v7n1p509 december 2021, vol. 13, no. 4 ajhpe 253 research mentorship has been defined as a developmental relationship in which a more  experienced person assists a less experienced person to grow professionally and realise their maximum potential.[1,2] literature emphasising the importance of mentorship in health professions education is fast emerging.[3-6] the common denominator in this literature speaks to the fact that mentorship should be part of the overall student learning experience. in a number of institutions, the closest relationship a student has with a faculty member is through supervision during clinical rotations, practical sessions, tutorials and conduction of a research project.[7,8] however, such supervision is not necessarily mentorship, and students may not accrue the real benefits of mentorship.[8] a mentor is an advisor, coach, counsellor, teacher, listener and facilitator, who pays attention to all facets of the learning process, including cognitive, psychomotor and affective domains of learning. the mentor should view completed tasks within the realm of broader professional growth, positive progression and holistic development of the learner, focusing on not only academic achievements, but also psychosocial accomplishments.[9] any feedback given therefore needs to target all these developmental aspects of the learner/mentee. it is important that faculty (mentor)  and learners (mentees)  recognise that there are natural phases in the mentorship relationship, so that they can think purposefully and communicate effectively on how to maximise the relationship benefit and navigate transitions. the phases have been defined by different names in the mentorship literature.[8-11] however, they eventually converge on a similar meaning. these stages include: (i) initiation phase (creating rapport between mentor and mentee, setting targets); (ii) cultivation phase (maturation, and where mentee engages with mentor to reach set targets, involving performance reviews); (iii)  separation phase (accomplishment of goals, evaluation of targets); and (iv) redefinition phase (moving on and closure, where mentee transitions from novice to expert). through all mentorship phases, provision of feedback by the mentor is crucial.[9-13] feedback is information provided to someone that identifies both strengths and weaknesses, aimed at attaining desired goals.[14] effective background. mentorship is useful in enhancing student learning experiences. the provision of feedback by faculty mentors is a central activity within a fruitful mentorship relationship. therefore, effective feedback delivery by mentors is key to the development of successful mentorship relationships. mentorship is a social interactive relationship between mentors and mentees. therefore, activity theory, a sociocultural theory, has been applied in this study to develop a framework for feedback delivery within the mentorship educational alliance between mentors and mentees. objective. the purpose of the study was to explore experiences of students and faculty mentors regarding feedback in a mentorship relationship, and to develop a feedback delivery framework in a mentorship relationship underpinned by activity theory. methods. this was a mixed-method sequential study conducted at makerere university college of health sciences using both quantitative and qualitative data collection methods. the study involved undergraduate medical students and faculty mentors. data were collected through self-administered questionnaires, focus group discussions and interviews. descriptive statistics were used for quantitative data, while thematic analysis was used for qualitative data. results. most students reported negative experiences with feedback received during the mentorship process. of the total of 150, a significant number of students (n=60)  reported receiving no feedback at all from their mentors. one hundred students reported that feedback received from mentors focused on only weaknesses, and 80 reported that the feedback was not timely. a total of 130 students reported that the feedback sessions were a one-way process, with limited involvement of mentees. the feedback also tended to focus on academics, with limited emphasis on psychosocial contextual aspects that may potentially influence student learning. the focus group discussions with students confirmed most of the quantitative findings. the interviews with faculty mentors led to the emergence of two key themes, namely: (i)  limited understanding of feedback delivery during mentorship; and (ii)  need for feedback guidelines for faculty mentors. based on the findings of the mixed-method study as well as the theory guiding the study, a feedback framework for mentorship interactions has been suggested. conclusion. while students generally reported low satisfaction with feedback received from mentors, faculty suggested the need to have feedback guidelines for mentors to frame their feedback during mentorship interactions. a feedback framework to guide mentorship interactions has therefore been suggested as a result of this study, guided by principles of activity theory. afr j health professions educ 2021;13(4):252-258. https://doi.org/10.7196/ajhpe.2021.v13i4.1291 development of a feedback framework within a mentorship alliance using activity theory a g mubuuke,1 mrad, msc hpe, phd; i g munabi,2 msc, msc hpe, phd; s n mbalinda,3 msc, phd; d kateete,2 msc, phd; r b opoka,1 mmed, msc hpe, phd; r n chalo,3 mph, phd; s kiguli,1 mmed, msc hpe 1 school of medicine, college of health sciences, makerere university, kampala, uganda 2 school of biomedical sciences, college of health sciences, makerere university, kampala, uganda 3 school of health sciences, college of health sciences, makerere university, kampala, uganda corresponding author: a g mubuuke (gmubuuke@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1291 mailto:gmubuuke@gmail.com 254 december 2021, vol. 13, no. 4 ajhpe research feedback has been reported to facilitate the achievement of reflective, selfdirected and life-long learning, and self-judging and self-regulated learning skills.[15] mentoring is an interactive process through which faculty feedback can play a central role towards the acquisition of such skills. at makerere university college of health sciences in uganda, where this study was conducted, students are randomly assigned mentors from their first year, and these are expected to interact with the students and nurture them during their development. the assigned mentors are academic faculty members at the institution. all faculty members are supposed to be mentors, and usually undergo some training in principles of mentorship. the training is usually a 1-day session that may occur once every academic year. since the mentorship training occurs infrequently and is not periodically programmed throughout the year, some mentors have more skills and knowledge than others. some junior mentors learn from more experienced mentors. in addition, students are engaged in an interactive talk on mentorship at the beginning of each academic year with the faculty. therefore, the students may have some knowledge about mentorship. the mentorship relationships have not been previously evaluated at the institution. in addition, there is limited published literature from the sub-saharan african context that positions faculty-student mentorship relationships as a form of interactive educational alliance that involves learning via a community of practice between the faculty mentor, student mentee and learning environment. in this alliance, feedback is a key driver of the mentorship process. in the present study, we also applied principles of activity theory (at), to develop a feedback framework to be used in the mentorship social learning interaction. thus, at provided a lens for the interpretation and synthesis of the findings in this study. at originated from the sociocultural tradition in russian psychology, the key concept of which is the ‘activity’, which is an interaction between individuals (subjects) and the world (object).[16] the fulcrum of this theory is the ‘activity’ a purposeful and transformative interaction between people.  during the interaction, there are rules and roles, and tools to execute the activity and the targeted outcome to be achieved. activity cannot thus be separated from the context in which it occurs. the at framework is illustrated in fig. 1. according to the at framework, any activity is organised into components that include: subjects (individuals being studied who are engaged in the activity, e.g. the mentors and mentees in a mentorship relationship); object (the raw materials or problem areas to which activity is directed, e.g. feedback)  – the object of the activity could be either physical or a construct, and is always oriented towards achieving particular outcomes with the assistance of mediating tools or instruments; and instruments/ tools in the framework, which are mediation artefacts for executing the activity – instruments could be physical or mental artefacts. in a mentorship educational alliance, for example, an instrument for executing feedback delivery could be a feedback guide. all of these are geared towards a purpose to which members in a community of practice direct their activity (e.g.  in a mentorship relationship, the activity of feedback delivery is directed towards addressing any gaps, and thus facilitating effective development of the mentee). thus, it can be argued that the at framework is applicable in a social learning environment such as a mentorship relationship. the relationship between the mentors/mentees and their environment is then considered through the component of community. although at has been applied in various settings, its application as an interpretive lens in mentorship relationships in health sciences education has been less widely reported. thus, the purpose of this study was twofold: (i) to explore students’ and mentors’ experiences of feedback during mentorship relationships; and (ii) to utilise these experiences to develop a framework for feedback delivery during mentorship interactions underpinned by principles of at. methods setting and design this was a mixed-methods sequential study conducted at makerere university college of health sciences between march and july 2019. participants the study involved undergraduate medical students and faculty. only faculty who had previously been mentors were included in the study. for the  quantitative survey, simple random sampling was used to select 300 students. this was done by allocating all students codes, and randomly selecting 300 codes. these were the ones that were used. for the qualitative part of the study, two focus group discussions were conducted with the students, each group consisting of 8 participants. this translated into a total of 16  students who participated in the focus group discussions. convenience sampling was utilised to select participants in the focus groups on a first-come, first-serve basis. only students who had participated in the quantitative survey were eligible to participate in the focus group discussions. in addition, 10  individual interviews were conducted with faculty mentors. the faculty who participated in the individual interviews were selected using purposive convenience sampling. faculty members who were available to give time to the study were selected. data collection quantitative data from students were collected using self-administered electronic questionnaires. the questionnaire captured the demographics of the students, an indication of their previous experience of mentorship and specific items regarding the students’ experiences of feedback from their mentors during their mentorship relationships. the measure of positive experience of feedback received from faculty mentors was the indication of agreement with each item on the questionnaire. an item where students indicated either ‘disagree’ or ‘neutral’ was regarded as negative feedback instruments subject object outcome rules community division of labour fig. 1. activity theory framework.[16] december 2021, vol. 13, no. 4 ajhpe 255 research experience during mentorship. response frequencies were tallied. the questionnaire items were developed from a review of literature on student satisfaction with feedback within mentorship relationships. to provide a measure of face and content validity, the questionnaire was first piloted with 10  students. the major change made to the questionnaire was the wording of items that had technical educational terms such as outcomes that were not familiar to the respondents. such terms were replaced with more basic words. three weekly email reminders were sent to the students to complete the questionnaire. qualitative data were collected using focus group discussions conducted with students, as well as individual interviews conducted with faculty mentors. one of the researchers moderated the discussions and interviews. responses from the focus group discussions and interviews were audio-recorded and later transcribed. questions for the student focus groups and faculty interviews were open-ended and semistructured. the questions were informed by findings from the quantitative survey and synthesis of previous literature. the qualitative aspect was aimed at further exploring the students’ and faculty mentors’ experiences of feedback within the faculty-student mentorship alliance. data analysis quantitative data were analysed using spss version 25 (ibm corp., usa). this involved determining frequencies and percentages of responses to given items, as well as determining whether there were any significant differences in responses across the years of study the students were in. thematic analysis was used for qualitative data using open coding. the coding was conducted manually by one of the researchers following an iterative process,  and it commenced immediately after the first student focus group and first faculty mentor interview. the open coding involved identifying patterns of similar meaning from the participant responses. these were aggregated to form representative themes. findings from the quantitative part of the study informed the questions developed for the qualitative part. ethical considerations approval to conduct this study was granted by the research and ethics committee, school of medicine, makerere university (ref. no. rec ref 2019-007). informed consent was also obtained from each study participant prior to conducting the interviews. confidentiality of participants and their responses were also observed. results results were both quantitative and qualitative in nature. quantitative results a total of 300 questionnaires were sent out to the sampled students electronically. of these 300 sampled students, 72 were in year one, 70 were in  year two, 62 were in year three, 50 were in year four and 46 were in year five. of the 300 questionnaires sent out, 172 were returned, giving a response rate of 57.3%. of the 172 returned questionnaires, 22 were excluded from further analysis because the students only partially completed the questionnaire, as they indicated that they had never previously participated in any mentorship relationship. this left 150  student questionnaires that were included in the final analysis. therefore, the results presented were from the 150  students who fully completed the questionnaire. of the 150  students included in the final analysis, 61.3% (n= 92)  were male and 38.7% (n= 58)  were female. the distribution of students by year of study is summarised in table 1. the students who responded to the survey reflected similar numbers from each year of study. in order to assess student satisfaction with feedback received during their mentorship relationships, the students were asked to indicate whether they agreed with, disagreed with or remained neutral on key items. these findings are summarised in table 2. from table 2, one can see that all students who completed the questionnaire reported knowing the meaning of mentorship, and reported having had a faculty mentor at one point in time during their studies. however, the majority of the students seemed not to fully understand the roles of mentors/mentees. specifically, in relation to feedback during mentorship, the overall trend in findings generally indicates that students infrequently received feedback from mentors, and that the feedback was not very clear and mostly addressed students’ weaknesses. in addition, the feedback from mentors mostly focused on academic matters, with less emphasis on psychosocial aspects of the students’ experiences. more than three-quarters of the students reported that the feedback process was unidirectional and not interactive, with the mentor driving and dominating the process. overall, the findings indicate low student satisfaction and negative experience with the feedback from their mentors. there were no significant differences noted across the different student years of study within the responses. further insight into the meaning of the survey results was carried out using  focus group discussions with students and interviews with faculty mentors. qualitative results two focus groups were conducted with 16 students about feedback from mentors. the students’ experiences of the feedback from mentors are illustrated below. student experiences of mentor feedback the student responses from the focus groups generally reflected what was observed from the survey results. for example, many responses emphasised the observation that feedback from mentors often addressed only weaknesses and not strengths, that feedback was infrequent and that little attention was paid to psychosocial aspects: ‘although the mentors tried sometimes to give us feedback, they often pointed out only bad things … this somehow demotivates us the students … they should also point out what areas am doing well as my mentor.’ ‘my mentor used to point out mostly the negative aspects of what i was not doing well during our mentorship sessions … this was sometimes demotivating … i would have liked to hear more about what i was doing well also.’ ‘mentorship would have been good if only our mentors also stressed those aspects that we the students are actually doing well … only pointing out the not so good things is not enough for us because we also want to know table 1. student distribution by year (n=130) year of study students, n (%) 1 26 (17.3) 2 30 (20.0) 3 31 (20.7) 4 33 (22.0) 5 30 (20.0) 256 december 2021, vol. 13, no. 4 ajhpe research what is going on well both academically and socially … since i believe that is what mentorship is all about.’ the aspect of feedback being infrequent during mentorship interactions can be seen through the following responses: ‘some of our mentors gave feedback about how we were learning. however, they were rare and there was no formula of receiving this feedback. for me i only got feedback only once in the whole semester yet i would like to get such feedback more often.’ ‘i tried to meet my mentor as often as possible; however, this was not possible all the time. therefore, the feedback i used to receive came only once in a while … i think there should be a schedule when we meet our mentors to give us feedback on our progression in medical school.’ ‘i think the frequency of the feedback meetings with our mentors needs to be streamlined. i agree we cannot meet mentors all the time, but some of us rarely got feedback that we desired yet that feedback is supposed to drive us to improve.’ the observation that mentor feedback focused heavily on academic issues is seen in the student responses below: ‘as students, we have many issues affecting our studies. it may not be academic only, but social issues, stress, challenges. however, the mentors given to us most times only talk about academic matters … from what i know of a mentor, even they are supposed to guide us on how to go about some of these social challenges that may affect out studies.’ ‘much as our mentors sometimes tried to give us feedback, however infrequent it was, this feedback the few times it was given to us tended to drill us on our academic progress. i do not remember my mentor for example having a talk about my social life, challenges and how i behaved in the mentorship relationship.’ the aspect of limited interaction between mentor and mentee during the feedback process also resonated through most responses, further emphasising the limited interaction observed in the questionnaire survey. the following response reflects what was observed across most participants: ‘i think our dear mentors should give us time to interact and participate in the feedback process, allowing us to give opinions and views regarding our studies. i think it would be interesting when we actively participate in the feedback process where we exchange ideas and opinions.’ interviews with faculty mentors in order to gain more understanding of the feedback process during mentorship, views were also sought from faculty mentors through individual interviews. two key themes emerged from the faculty responses, namely: (i)  limited understanding of feedback and mentorship; and (ii)  need for feedback guidelines for mentors. limited understanding of feedback delivery during mentorship the faculty interviewed in this study reported that they had limited training in feedback and the mentorship process. this may have influenced the manner in which they directed the feedback process during mentorship. the following responses reflected this observation: ‘feedback seems to be an important activity during mentorship. although we may have some understanding of feedback principles and the mentorship process, probably we need more training on how first of all mentorship means and then how to give feedback during the mentorship process.’ ‘the fact that we as faculty are not trained on how to be mentors and how to give effective feedback most likely contributes to how our students experience the mentorship process. if mentors do not deliver well-balanced feedback, the students are likely to have negative attitude towards the whole process.’ from the responses above, it can be observed that mentors need training on how to drive the mentorship process, and then on how to give effective feedback for students to benefit from the mentorship relationship. table 2. student responses regarding feedback from mentors (n=150) item agree, n (%) neutral, n (%) disagree, n (%) i know the meaning of mentorship 150 (100) 0 0 i clearly understand the benefits of mentorship 100 (66.7) 20 (13.3) 30 (20) i clearly understand the roles of a mentor 80 (53.3) 20 (13.3) 50 (33.3) i clearly understand the roles of a mentee 85 (56.7) 19 (12.7) 46 (30.6) i have ever had a mentor at medical school (if yes, proceed to next questions. if not, do not proceed, stop at this question.) 150 (100) 0 0 i periodically received feedback from my mentor 60 (40) 40 (26.7) 50 (33.3) my mentor always gave me feedback in time 40 (26.7) 30 (20) 80 (53.3) the feedback received from my mentor was clear to me 35 (23.3) 40 (26.7) 75 (50) the feedback received from my mentor specified my strengths 20 (13.3) 30 (20) 100 (66.7) the feedback received from my mentor specified my weaknesses 100 (66.7) 20 (13.3) 30 (20) the feedback received from my mentor gave direction to cover up my gaps 60 (40) 20 (13.3) 70 (46.7) the feedback from my mentor positively facilitated my learning 50 (33.3) 30 (20) 70 (46.7) the mentor gave me feedback about social life besides academic issues 15 (10) 15 (10) 120 (80) feedback from my mentor often helped me psychologically 20 (13.3) 20 (13.3) 110 (73.4) the feedback process was interactive, where my mentor allowed me to give my views/opinions 10 (6.7) 10 (6.7) 130 (86.6) overall, i was satisfied with feedback received from my mentor 40 (26.7) 30 (20) 80 (53.3) i never received any feedback from my mentor 40 (26.7) 50 (33.3) 60 (40) december 2021, vol. 13, no. 4 ajhpe 257 research need for feedback guidelines for faculty mentors the other dominant theme that resonated through the faculty responses related to the need to have guidelines for giving feedback for faculty mentors. this can be seen through the following responses: ‘sometimes we do not know what to concentrate on when giving feedback to our mentored students. there are so many aspects to think about, but how do you prioritise? probably we need some kind of guidance on what to consider when giving feedback to our students that we are mentoring.’ ‘feedback is wide and there are so many aspects to consider depending on situation. as i mentor my students, how should i go about the feedback to give? besides, we are different mentors and we need to give at the feedback that follows similar lines. maybe we need some institutional guidance for feedback delivery during the mentorship interactions.’ the above responses demonstrate the need to have feedback guidelines for faculty mentors to be used during the mentorship interactions with students. discussion the purpose of the present study was to explore student (mentee)  and faculty (mentor)  experiences of feedback delivery during mentorship, and to utilise these experiences to develop a framework for feedback delivery during these interactions. the developed framework is guided by principles of at. the survey conducted with students demonstrated that they had mentors and reported some knowledge about mentorship; however, they were not satisfied with the feedback received from their mentors. from the present study, students demonstrated some knowledge about mentorship, probably owing to the fact that students are given orientation on mentorship at the beginning of every academic year, which may have increased their knowledge. they may have reported low satisfaction with mentor feedback because the feedback did not meet their expectations in terms of supporting their development. from the reported literature, key principles of feedback delivery include timeliness, specificity, a balance between positive and negative feedback, and clarity.[14] from the student experiences reported, most of these aspects were not adequately met by mentors. this can partly be explained by mentor training that was inadequately focused on effective feedback delivery within a mentorship relationship, as evidenced by the responses from the mentors themselves. feedback in mentorship relationships is key, and faculty mentors play a crucial role in this process. therefore, training of mentors on how to effectively deliver feedback is important, an observation that has been previously reported.[12] the limited training in feedback delivery could perhaps also offer an explanation as to why some student mentees never received any feedback at all. however, it should be noted that training alone may not necessarily lead to improved feedback delivery during mentorship. other factors, such as motivation and protected time for mentors, should also be considered. as part of the leaning process, it has been reported that mentors’ feedback to mentees should not focus only on academic progress, but also on other factors that may influence the holistic professional growth and development of the mentee.[9] siddiqui[11] suggests that this may include provision of feedback on psychosocial and contextual experiences that a mentee may be undergoing. in the present study, mentors seemed to place less emphasis on feedback that targeted issues outside the academic progress of the students.  previous studies have also reported similar tendencies among some mentors.[8,10] the reason for this is not clear cut. however, a plausible explanation speaks to the limited importance mentors may attach to sociocontextual and psychological factors that may influence student progress. mentorship interactions do not occur in a vacuum, but are rather situated within a community of learning. this community of learning may have various interacting factors that can influence student growth. addressing these factors through feedback by mentors should therefore not be ignored. the fact that students in this study experienced limited feedback from mentors targeting psychosocial aspects other than academic progress calls for significant attention. this observation may point to the need to have guidelines on feedback delivery for mentors. such guidelines could emphasise key domains that mentors should focus on when framing their feedback. having guidelines for feedback delivery during mentorship interactions was also proposed by the mentors themselves. it has been reported that mentorship should be an interactive process between mentees and mentors, where each person has a defined role to play, with mutually agreed-upon targets to achieve.[3] this active interaction involves dialectical communication in the form of feedback between mentor and mentee, which ultimately differentiates mentorship from supervision.[13] in the present study, we therefore propose a framework that can perhaps improve feedback delivery during mentorship interactions in a community of learning between mentors and mentees. this framework, guided by principles of at, can potentially deepen our understanding of mentorship interactions and how well-framed feedback can play a role in enhancing these mentorship interactions in order to achieve the desired learning outcomes. framework for feedback delivery during mentorship interactions utilising findings from this study, a framework for feedback delivery in a mentorship relationship has been developed. the framework, based on at, is illustrated in fig.  2. this framework moves beyond merely training mentors in feedback delivery, and considers mentorship as a reciprocal process between the mentor and mentee in which each has a role within a community of practice. at is useful in studying human interactions in a social group. mentor and mentee interactions through feedback represent a mediation tool (f) feedback guide mentorship process community (b) mentor and mentee learning environment social factors rules (e) ground rules for mentorship relationship division of labour (c) mentee roles mentor roles tasks object (d) feedback subjects (a) mentor mentee outcome (g) enhanced student learning personal growth fig. 2. feedback delivery framework within a mentorship alliance. 258 december 2021, vol. 13, no. 4 ajhpe research social learning group, and thus principles of at are key in such a community of learning. the fulcrum of this theory is an activity through which human interactions occur. in this study, the activity should be regarded as the feedback delivery process during mentorship interactions. such an activity takes place within a community, organised into components that include: subjects; object; tools; rules; community; division of labour; and outcomes, key elements of at. the components illustrated in the framework are dialectic in nature, interacting with each other within one system to influence the feedback delivery process. therefore, there exist multiple mediating dialectical relationships within a complex integrated mentorship activity system. subjects (a in fig. 2) refer to the players in the mentorship interaction (i.e. the mentor and mentee). the mentor delivers feedback, and the mentee is the recipient of that feedback. the mentor and mentee thus form a team that actively engages with the feedback in an interactive manner. this team subsequently becomes a community of learning with a common understanding of their goals. formation of this social community of learning is another key component of the activity framework (b in fig 2). both mentors and mentees should have specific roles in the mentorship relationship that translate into a division of labour (c in fig.  2)  along with key ground rules that should be followed by both mentor and mentee (e in fig. 2). to contextualise this to the mentorship process, tasks for both mentor and mentee need to be clarified, and feedback should focus on these tasks. in the context of this study, the object (d in fig.  2)  is the feedback itself, which should interactively occur between the mentor and mentee. this feedback plays a key role in the mentorship alliance as it provides the pathway towards achieving the targeted outcome of the mentorship relationship, which is enhanced student learning, and professional and personal growth of the mentee (g in fig.  2). however, according to at, a mediating tool is crucial to drive the feedback process within the mentorship alliance. such a mediating tool can be in the form of a feedback guide (f in fig. 2). the need for a feedback guide also strongly resonated throughout this study. thus, from this study, we propose a feedback guide (mediating tool)  for mentors that can potentially drive mentorship interactions in the desired direction. this feedback guide is crucial within the mentorship activity framework. the feedback delivery guide for mentors: a mediation tool from the at framework the feedback delivery guide is summarised in table 3. this guide is aimed at acting as a mediating tool for mentors during feedback delivery, and at ensuring that mentors frame their feedback to target holistic growth of mentees. the strength of the guide lies in its simplicity and highly structured nature. structuring the guide is likely to achieve two things: (i) it may be acceptable to faculty, and feasible to implement; and (ii) it could be an avenue through which mentees receive feedback across other domains beside academic progress. though structured, the feedback guide should not be viewed as restrictive to mentors. the mentor should be free to deliver feedback on any other aspects (s)he deems necessary for the benefit of the mentee. this study utilised the experiences of students (mentees)  and faculty (mentors) to develop a framework for feedback delivery during mentorship interactions. the framework was further underpinned by principles of at, a sociocultural theory that places mentorship and feedback delivery within the mentorship relationship as an activity between faculty mentors and student mentees. application of at in this context to develop a feedback delivery framework has been infrequently reported in health sciences education, a gap that this study has tried to address. specifically, the emergence of a mediating tool in the form of a feedback guide for faculty mentors may have implications for mentorship practice in health sciences education. therefore, these findings form a basis upon which future studies can be anchored. study limitations this study was conducted in one institution, but social and academic contexts may differ across institutions, and therefore the findings may not be generalisable, a major limitation of the study. in addition, the model/ framework developed did not consider other areas of student support such as peer mentorship/feedback that could be vital, since this was not the focus of the study. this could be an area for further research focusing on peer mentorship. further research the implementation of the feedback guide developed for mentors, and evaluation of its potential impact on the outcomes of mentorship table 3. feedback guide for mentors (mediation tool) feedback domain description academic growth and development mentor should discuss with mentee: • progress in terms of mentee’s academic work • extent of achieving set goals • enablers and barriers towards achieving goals • plan for achieving the set targets psychosocial growth and development mentor should discuss with mentee: • progress in terms of mentee’s psychosocial growth outside academics e.g. networks made, organisations joined, activities involved in, social achievements, motivation to learn strengths and areas to improve mentor should identify to the mentee his/her: • strengths • areas that need improvement nb. mentor should comment on academic strengths and other generic competencies such as time management, communication skills, interpersonal skills, teamwork and collaborative practice, self-regulative skills, reflective skills, self-judgement learning environment mentors should discuss with mentee: • mentee’s experience of the learning environment, with focus on: learning resources; where to seek assistance; how to negotiate through the learning context; how to make the learning experience better challenges mentor should probe and assist mentee to: • identify challenges (both academic and psychosocial, such as stress, depression, emotions, relationship issues, power tensions, conflicts with fellow students and staff etc.) that may hinder academic and social growth of mentee • identify strategies to overcome the challenges • identify resource persons/units in the institution that can assist mentee to address the challenges december 2021, vol. 13, no. 4 ajhpe 259 research interactions, are particularly encouraged. in addition, the at framework developed from the study perhaps needs further interrogation, especially investigating the various factors that interact within the mentorship activity system, such as peer mentorship/feedback, which could potentially provide additional support for students. conclusion the present study explored student and faculty experiences of feedback delivery within a mentorship alliance. students were not satisfied with the feedback, and faculty pointed to the lack of feedback guidelines to use for mentors. an activity framework has been developed to aid more understanding of feedback delivery within the mentorship alliance, and specifically, a feedback guide for mentors has been developed as a mediating tool to potentially improve feedback delivery within the mentorship relationship. declaration. none. acknowledgements. we thank all the participants who took part in this study. author contributions. agm: conceptualised the study and developed the idea, drafted the protocol, collected data, participated in analysis and wrote the initial draft; igm: participated in analysis and refining of the manuscript; snm: participated in data collection and refining of the draft manuscript; dk: refined the initial manuscript draft; rbo: participated in analysis and refining of the manuscript draft; rnc: participated in collecting data and reading the initial draft; sk: refined the initial idea and provided critical input during writing the article, in addition to proofreading the final version. funding. research reported in this publication was supported by the fogarty international centre of the national institutes of health (nih), us department of state’s office of the us global aids co-ordinator and health diplomacy (s/gac), and president’s emergency plan for aids relief (pepfar)  under award number 1r25tw011213. the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. conflicts of interest. none. 1. bhatia a, navjeevan s, dhaliwal u. mentoring for first year medical students: humanising medical education. indian j med ethics 2013;10(2):100-103. https://doi.org/10.20529/ijme.2013.030 2. dalgaty f, guthrie g, walker h, stirling k. the value of mentorship in medical education. clin teach 2017;14(2):124-128. https://doi.org/10.1111/tct.12510 3. faucett ea, mccrary hc, milinic t, hassanzadeh t, roward sg, neumayer la. the role of same-sex mentorship and organisational support in encouraging women to pursue surgery. am j surg 2017;214(4):640-644. https:// doi.org/10.1016/j.amjsurg.2017.07.005 4. fricke ta, lee mgy, brink j, d’udekem y, brizard cp, konstantinov ie. early mentoring of medical students and junior doctors on a path to academic cardiothoracic surgery. ann thor surg 2018;105(1):317-320. https:// doi.org/10.1016/j.athoracsur.2017.08.020 5. kostrubiak de, kwon m, lee j, et al. mentorship in radiology. curr prob diag rad 2017;46(5):385-390. https:// doi.org/10.1067/j.cpradiol.2017.02.008 6. nakanjako d, byakika-kibwika p, kintu k, et al. mentorship needs at academic institutions in resource-limited settings: a survey at makerere university college of health sciences. bmc med educ 2011;11:53. https://doi. org/10.1186/1472-6920-11-53 7. keshavan ms, tandon r. on mentoring and being mentored. asian j psychiatr 2015;16(august):84-86. https:// doi.org/10.1016/j.ajp.2015.08.005 8. meijs l, zusterzeel r, wellens hj, gorgels ap. the maastricht-duke bridge: an era of mentoring in clinical research – a model for mentoring in clinical research. a tribute to dr. galen wagner. j electrocardiol 2017;50(1):16-20. https://doi.org/10.1016/j.jelectrocard.2016.10.009 9. nimmons d, giny s, rosenthal j. medical student mentoring programmes: current insights. adv med educ pract 2019;10: 113-123. https://doi.org/10.2147/amep.s154974 10. schäfer m, pander t, pinilla s, fischer mr, von der borch p, dimitriadis k. a prospective, randomised trial of different matching procedures for structured mentoring programmes in medical education. med teach 2016;38(9):921-929. https://doi.org/10.3109/0142159x.2015.1132834 11. siddiqui s. of mentors, apprenticeship, and role models: a lesson to relearn? med educ online 2014;19(1):25428. https://doi.org/10.3402/meo.v19.25428 12. stenfors-hayes t, kalén s, hult h, dahlgren lo, hindbeck h, ponzer s. being a mentor for undergraduate medical students enhances personal and professional development. med teach 2010;32(2):148-153. https://doi. org/10.3109/01421590903196995 13. singh s, singh n, dhaliwal u. near-peer mentoring to complement faculty mentoring of first-year medical students in india. j educ eval health prof 2014;11:12. https://doi.org/10.3352/jeehp.2014.11.12 14. bowen l, marshall m, murdoch-eaton d. medical student perceptions of feedback and feedback behaviors within the context of the ‘educational alliance’. acad med 2017;92(9):1303-1312. https://doi.org/10.1097/ acm.0000000000001632 15. murdoch-eaton, d, bowen l. feedback mapping – the curricular cornerstone of an educational alliance. med teach 2017;39(5):540-547. https://doi.org/10.1080/0142159x.2017.1297892 16. engestrom y. learning by expanding: an activity-theoretical approach to developmental research. phd thesis. helsinki: orienta-konsultit, 1987. accepted 14 july 2020. https://doi.org/10.20529/ijme.2013.030 https://doi.org/10.1111/tct.12510 https://doi.org/10.1016/j.amjsurg.2017.07.005 https://doi.org/10.1016/j.amjsurg.2017.07.005 https://doi.org/10.1016/j.athoracsur.2017.08.020 https://doi.org/10.1016/j.athoracsur.2017.08.020 https://doi.org/10.1067/j.cpradiol.2017.02.008 https://doi.org/10.1067/j.cpradiol.2017.02.008 https://doi.org/10.1186/1472-6920-11-53 https://doi.org/10.1186/1472-6920-11-53 https://doi.org/10.1016/j.ajp.2015.08.005 https://doi.org/10.1016/j.ajp.2015.08.005 https://doi.org/10.1016/j.jelectrocard.2016.10.009 https://doi.org/10.2147/amep.s154974 https://doi.org/10.3109/0142159x.2015.1132834 https://doi.org/10.3402/meo.v19.25428 https://doi.org/10.3109/01421590903196995 https://doi.org/10.3109/01421590903196995 https://doi.org/10.3352/jeehp.2014.11.12 https://doi.org/10.1097/acm.0000000000001632 https://doi.org/10.1097/acm.0000000000001632 https://doi.org/10.1080/0142159x.2017.1297892 september 2021, vol. 13, no. 3 ajhpe 191 short report why was the idea necessary? (what was the problem?) the pharmacology of antibacterials can be a tricky topic to lecture to students at any level.[1] the cohort that we have is comprised of first-year medical students in their second semester, and teaching antibacterials at this point can be quite a challenge. the students have little exposure to biomedical science modules such as microbiology in their first semester, meaning that they have not yet built adequate foundational knowledge to understand the mechanisms of antibacterial drugs. a proper understanding of antimicrobial mechanisms and resistance is crucial from early on in a medical student’s education, to circumvent gaps in knowledge and lack of confidence observed with prescription of antibiotics.[2] in a large-group class where face-to-face interaction is possible, i perform continuous diagnostic assessment to test prior knowledge and to assess understanding of newly introduced concepts, thereby consolidating acquired knowledge. this is usually done by presenting case studies or by asking short probing questions, which allows for the visual assessment of student comprehension and for provision of ‘on-the-spot’ remediation measures.[3] the loss of face-to-face contact sessions meant the absence of the initial visual diagnostic assessment, and limited the opportunities to consolidate acquired knowledge in real time. in my experience, the initial transition to online learning at the beginning of the pandemic still allowed teaching and learning to continue, with lecturers attempting different ways to maintain interaction. participant reactivity to most activities put forward on the online platform was high and the voluntary learning opportunities were very well utilised. for most modules, the learning management system allowed students to download and listen to narrated lectures. this was followed by, if the lecturer felt the need to do so, a voluntary virtual session during the allocated lecture slots. as the year progressed and these practices became the ‘new norm’, we experienced a decline in student interest and engagement, and observed an ‘online fatigue’. this was echoed across other disciplines and by other lecturers and educators, and the term ‘zoom fatigue’ was coined.[4] the lack of face-to-face contact sessions, compounded by the lack of interest by students to interact, established a need for creative solutions that would motivate students to make use of the voluntary online platforms. what was tried? (intervention) to circumvent the difficulties experienced, saving the starks was born. saving the starks is a case study-based interactive game adapted from a popular television series, game of thrones. in an attempt to create a truly immersive experience, the game was developed using a microsoft powerpoint format with animated triggers and audio files from the soundtrack of game of thrones. this is similar to an interactive television show where the viewer decides the fate of the character in a scenario-branched televised show, such as those found on popular streaming networks like netflix. the game is called saving the starks, as it is centred around a group of characters in the series called the stark family, and the aim of the game is to rescue the family members from bacterial infections using the knowledge acquired during the antibacterials narrated lecture. the game consists of three scenarios. in each scenario, different characters find themselves in a dramatised situation requiring treatment with antibacterials. the player (medical student) is asked a series of multiple-choice questions about the treatment regimen that the character must receive. their decisions will determine the outcome of the stark family member in the scenario. the player must select the correct option, or they will not progress to the next question. answering all the questions correctly will result in success in saving the stark family member in the scenario. players were asked to time themselves and post their times on their learning management systems' discussion board. the player with the fastest completion time was named the winner. students were informed in advance that the game link would be made available to them only during the allocated lecture time, after which they could no longer download and play the game. by doing this, students were encouraged to go through the study notes and watch the narrated lecture beforehand or during the lecture slot to enable them to play the game. this resulted in interaction on the discussion board from more than half of the class during the lecture slot. a  definite increase in student engagement was observed. saving the starks was very well received by the students, based on the overwhelmingly positive response on the discussion board. as evidenced by the video, it can be seen that the students were grateful for the fun activity. the module feedback report highlighted this; for example, one participant said, ‘it’s great to have lecturers who take the time to make classes more fun and interesting’, while others expressed thanks for the effort and the experience. quantitative feedback in the module reports also indicated this, with a high score for the lecturer’s session (9.08 out of 10). these results show that most students rated the learning opportunity as above average, which corroborated the positive responses observed on the discussion board. the lessons learnt gamification is a useful tool to enhance student interest and increase student interaction in a fun and engaging way. it creates formative learning opportunities for students in a way that is non-threatening and promotes ‘graceful failure’, with a promise to try harder next time.[5] the possibilities of its use are widespread, especially in a time when lecturers have to continuously find ways to keep students motivated to use online platforms. creating interest in subject matter is a powerful motivator and can contribute to a more engaged learning experience for students.[6] a lesson learnt from the implementation of this activity is that students are very appreciative of the effort made by their lecturers to relate to them, especially by using popular culture references. this format further engaged them in the content, while stimulating interest in the subject matter, and saving student interaction by saving the starks h parkar, msc (pharmacology) department of pharmacology, faculty of health sciences, university of pretoria, south africa corresponding author: h parkar (hafizaparker@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:hafizaparker@gmail.com 192 september 2021, vol. 13, no. 3 ajhpe short report also encouraged students to open dialogue with their lecturer. many of the comments from students were about the theme of the game, and one student commented that they ‘felt like a doctor in a movie’. the use of popular culture as a teaching tool can aid in stimulating students and developing their excitement about a specific topic. it can also help educators to ground content in a way that is more relatable and accessible to students.[7] what will i keep in my practice? i will continue to use gamification in my lectures as, i believe that it increases student engagement and makes them excited about the content. the competitive aspect creates enthusiasm within the learning environment and among peers.[5] elements such as leader boards allow students to see where they stand in comparison with their peers, which motivates them to try harder.[5] this platform also allows me to engage with my students on a more congenial level, making it more enjoyable for me as the lecturer. things i would do differently an element that was lacking was the provision of feedback for incorrect responses. in subsequent versions, a response system will be included that will enable students to understand why the option they selected was correct/ incorrect. the feedback would allow consolidation of knowledge and real-time remediation. another element was the strength of the questions used in the scenarios. certain questions were contextualised and were true application questions, while others were rote questions or application-type questions without contextualisation. this is an area for improvement in subsequent versions of the game. questions will be modified to highly contextualised application-type questions to improve contextualisation for students. a link to the discussion board at the end of the game would also be included or ideally a system that can be integrated with the online learning system, such as h5p or similar, would be used, to automate the loading of scores at the end of the game, as students may have attempted the game but not posted their time on the discussion board. this will also allow moderation of players and ensure fairness to all students. declaration. none. acknowledgements. i thank prof. werner cordier for his advice, encouragement and guidance, and ms shamiso mlambo for her support and assistance. author contributions. sole author. funding. the office of the deputy-dean: teaching and learning, faculty of health sciences, university of pretoria, funded manuscript processing charges. conflicts of interest. none. evidence of innovation 1. kim dh, lee jh, kim sa. the pharmacology course for preclinical students using team-based learning. korean j med educ 2020;32(1):35. https://doi.org/10.3946/kjme.2020.151 2. efthymiou p, gkentzi d, dimitriou g. knowledge, attitudes and perceptions of medical students on antimicrobial stewardship. antibiotics 2020;9(11):821. https://doi.org/10.3390%2fantibiotics9110821 3. terwase tn, oluwatoyin c. diagnostic assessment: a tool for quality control in education. educ res rev 2014;1(1):17-24. 4. lee j. a neuropsychological exploration of zoom fatigue. psychiatric times 17 november 2020. 5. ćosović m, brkić br. game-based learning in museums cultural heritage applications. information 2020;11(1):22. https://doi.org/10.3390/info11010022 6. harackiewicz jm, smith jl, priniski sj. interest matters: the importance of promoting interest in education. policy insights behav brain sci 2016;3(2):220-227. https://doi.org/10.1177%2f2372732216655542 7. clapton w. pedagogy and pop culture: pop culture as teaching tool and assessment practice. e-international relations, 2015. accepted 11 may 2021. afr j health professions educ 2021;13(3):191-192. https://doi.org/10.7196/ajhpe.2021.v13i3.1508 https://doi.org/10.3946/kjme.2020.151 https://doi.org/10.3390%2fantibiotics9110821 https://doi.org/10.3390/info11010022 https://doi.org/10.1177%2f2372732216655542 https://doi.org/10.7196/ajhpe.2021.v13i3.1508 november 2020, vol. 12, no. 4 ajhpe 206 research community engagement (ce) in higher education is a contested field because of the diverse definitions linked to the concept, as argued in the literature.[1-3] the us committee on institutional cooperation’s committee on community engagement defines it as ‘the partnership of university knowledge and resources with those of the public and private sectors to enrich scholarship, research, and creative activity; enhance curriculum, teaching, and learning; prepare educated, engaged citizens; strengthen democratic values and civic responsibility; address critical societal issues, and contribute to the public good.’[4] the purpose of ce is to magnify the impact that higher education has on students and the community. in south africa (sa), ce is integrated within higher education and forms part of institutional audit standards.[5] the higher education act no. 101 of 1997 mandates for integrated higher education underpinned by research, teaching and ce.[6] an array of interventions aimed at magnifying community-engaged pedagogical practices at sa universities has been implemented. the joint education trust launched the community higher education services partnership that in 1999 brought in initiatives to improve ce at programme, institutional and national level and to conceptualise and implement ce as a core function of higher education in sa.[7] the sa higher education community engagement forum (sahecef), formed in 2009, provides a national forum where 23 universities in sa are represented. higher education standards for nursing education implies approaches that will produce students who are able to impact health at community level. nurses and other healthcare workers are crucial in helping to improve the health and wellbeing of populations, as well as in improving the social determinants of health (sdh) in communities. ce teaching and learning (cetl), including service learning, are approaches that increase students’ competencies in sdh.[8] the state of the world’s nursing 2020 report by the world health organization (who) recommended that health science education, including nurse education, should prepare graduates who can improve the health and wellbeing of people by dealing with the sdh.[9] indeed, schroeder et al.[8] showed in their 2019 study that cetl in the form of service learning increased nursing students’ knowledge and confidence in addressing sdh. in addition, health sciences (including nursing curricula) are being redesigned so that they can answer to the new developments in higher education. these developments include the integration of nursing into higher education, the replacement of the traditional content-based curricula with outcomes-based curricula, and changes in relation to quality assurance standards, including the requirement that institutions and programmes fulfil ce obligations. a number of countries in africa, and indeed worldwide, have engaged in nursing curricula redesign from traditional to outcomes-based curricula that emphasise performance of proficiency and community-based interventions.[10] the who recommended the transformation of health professions, including nursing education, so that it produces graduates who are responsive to the health needs of populations. the development of community-engaged curricula and social accountability in the education of healthcare professionals was one of the recommendations.[11] cetl activities are aimed at improving the impact of health sciences education’s preparation of graduates that will contribute to the overall background. transformation forces in south african (sa) higher education and beyond have called for incorporation of community engagement into higher education. specifically, the sa white paper 3 that informed the higher education act no. 101 of 1997 mandated higher education institutions, including those involved in the training of nurses, to move towards community-engaged teaching and learning (cetl). an array of interventions has been implemented that aim at magnifying community-engaged pedagogical practices in sa universities, including nursing departments. however, this has not been without challenges. objective. to describe stakeholders’ cetl experiences at three sa universities. methods. a phenomenological descriptive qualitative study using focus group discussions and semi-structured interviews was conducted with academics, students and community members at the health sciences departments of three universities that applied cetl approaches. data were analysed through an inductive thematic approach and the outcomes are presented as themes. results. four themes emerged from the data: empowerment; forms of cetl; principles of cetl; and awareness. conclusion. stakeholders in cetl at the health sciences and nursing departments at three universities in sa indicated a rich array of experiences that can be used to leverage a transformative effect in nursing education. appropriate integration of cetl into programme design and development of curricula, and use of explicit cetl methods with intentional outcomes for the students and communities, will go a long way toward achieving transformation in nursing education. afr j health professions educ 2020;12(4):206-210. https://doi.org/10.7196/ajhpe.2020.v12i4.1393 stakeholders’ community-engaged teaching and learning experiences at three universities in south africa f muzeya, mph, bsc nursing; h julie, phd, mph, bcur nursing department of nursing, faculty of community health sciences, university of the western cape, cape town, south africa corresponding author: f muzeya (3718239@myuwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 207 november 2020, vol. 12, no. 4 ajhpe research wellbeing, including the health, of populations. thus ce is a fundamental element for the solution of problems associated with sa higher education and society in general, otherwise inequalities and disparities among hosts of other problems will continue to persist. there is a lack of structural and functional frameworks for the conceptualisation of ce in sa higher education institutions (heis).[2] initiatives on ce by universities in sa have been ad hoc, disjointed and not related to the scholastic endeavour.[12] currently there is no shared and cohesive definition for ce or cetl.[1,4,12] although various sa institutions have attempted to develop contextual definitions, a coherent framework needs to be developed by south africans for sa. this study was part of a larger study that aimed to develop a cetl typology for sa heis, rooted in the transformational agenda as expressed in the education white paper.[12] the review of curricula, including the incorporation of ce among other high-impact practices, is determined by the needs of various stakeholders in higher education, which includes students, educators and community members. faculty, students and community are crucial stakeholders in cetl endeavours and indeed in curricular reforms.[9] the objective of this study was to explore the stakeholders’ (academics/educators, students and community members) experiences of cetl at three sa universities. methods research design a phenomenological descriptive qualitative approach was used to explore the stakeholders’ experiences of cetl at three sa universities.[13-15] the study sought to explore how cetl is conceptualised, and to discern similarities among the stakeholders. population and sampling data were collected from three conveniently sampled universities that are members of the sahecef, with ce programmes as displayed on their websites. the sample for this study comprised academics (n=14), students (n=28), and community members (n=3) from the health sciences faculties of the included universities, who were identified though snowball sampling from recommendations by the board of directors of the sahecef. semistructured interview guides for individual interviews were used to collect data from the academics, students and community members, with 14 semistructured interviews conducted with academics and community members across the three universities. three focus group discussions (fgds) (one per institution) with students were carried out, each of which included 8 10 participants. data collection ethical approval/clearance was obtained from the university of the western cape (ref. no. hs18/10/5), and institutional gatekeeper permission was obtained from the respective universities’ research directorates. access to collect data from each university department/faculty was obtained through the ce offices of two universities and the office of the dean of health sciences for the other university. data were collected through individual semi-structured interviews with academics and community members and fgds with the students, observing ethical principles as guided by burgess and cilliers’ framework.[16] the interview questions for both techniques were generated from the literature[17] and in consultation with an expert in ce in higher education (project supervisor/second author). the first author piloted the data collection at one hei in sa, and the necessary adjustments to interview questions were made. the focus of the interviews sought to explore the experiences of these stakeholders in cetl in their institutions. the interview questions were adjusted per population group. individual appointments were made with each academic included in the study, at their convenience. the interviewed academic assisted the researchers in accessing students and community members within their institution who met the inclusion criteria. all data were recorded, and field notes were taken during the data collection process. data were collected between march and october 2019. the interviews and fgds lasted between 29 and 76 minutes each, with a mean (standard deviation (sd)) of 46.8 (13.1) minutes, and were conducted by the first author. data analysis the information from the interviews and fgds was recorded by the first author and transcribed with the help of a transcriptionist (ma english student). checking of the transcripts and coding was carried out by the first author, and atlas.ti 8 caqdas (atlas.ti, germany) software was used to analyse the transcripts. an inductive approach was used for analysis, which created 41 codes. the transcripts were checked for quotations that implied experiences, and attribute, emotive, value and in vivo coding were used to generate codes.[18] the codes were then organised into 4 themes and 14 sub-themes. assistance of a co-coder was sought, and agreement was reached between the first author and co-coder on the coding that was completed. results description of participants fourteen academics participated in this study, comprising 6 phd holders and 8 master’s degree holders. these academics included nursing, radiography, dental therapy, somatology, biomedical technology and ce professionals. twenty-eight students participated in three fgds, made up of the following groupings: second-year bcur nursing (n=10), second-year diploma in somatology (n=8), and fourth-year bachelor’s degree in radiography (n=10) students. the participants’ ages ranged from 19 to 60 years, with a mean (sd) of 31 (13.5) years. females made up the larger proportion of participants (82.2%, n=39) and males constituted 17.8% (n=8). the academic participants reported having between 2 and 5 years and an average of 3 years of cetl experience. three community members participated in the study, representing community-based organisations that worked with primary and high school students, youth who were school-leavers and a university-based club. themes and sub-themes four themes emerged from the data, each with a number of sub-themes. the four main themes were as follows: empowerment; forms of cetl; cetl principles; and awareness. table 1 lists the themes and sub-themes that emerged, and they are described in more detail in the sections that follow. theme 1: empowerment this theme had the following four sub-themes: projects, authentic learning, resource allocation and engagement, and a shift in mind-set. november 2020, vol. 12, no. 4 ajhpe 208 research sub-theme 1.1: projects. cetl projects that participants experienced and engaged in encompassed those related to health, education, and environment and community development aspects. in relation to health, interviews revealed that students engaged in experiential learning activities that entailed nutrition projects, as well as health education on oral hygiene, hand hygiene, safe sex, waste disposal, road safety and awareness about drug abuse. projects on education included teaching science to primary school students and assisting high school students with homework and with applying for university admission and bursaries. community development endeavours included income-generating projects. this sub-theme is illustrated by the following extract: ‘we have wellness days where we host, like small that we do certain treatments [somatology treatments], maybe three. we host them at the libraries … or at the sports centre. even when it’s career what what … career expo, we also come to school as part of community service.’ (02s (second institution student) fgd2 participant 7) sub-theme 1.2: authentic learning. this study showed that cetl experiences were associated with different types of communities, including schools, informal settlements, townships, parents, teenagers, prisons, old people’s homes, workplaces and the disabled. these included communities that were described as less privileged, rural or with fewer resources, diverse communities and those described in terms of being within a specified radius according to hei policy. this is shown in the following extracts from participants: ‘we go to our homes, schools, old age homes.’ (o2fgd2 participant 6) ‘currently, i would say a largest community that we target are young school children. most of the communities we go and visit are schools, especially our less public schools, and we have targeted a crèche, although i haven’t been, but we teach them how to wash hands and hygiene. so i think school is probably our largest target audience to do the education.’ (o1e2 (educator 2)) sub-theme 1.3: resource allocation and engagement. participants indicated how university resources were used to support cetl activities, including facilities for summits, acquisition of boreholes, mentors from the university and transport. some universities have ce institutes and forums for students, academics and community members to share innovative ideas to support cetl. this is shown in the following extract: ‘most of the things we do at the schools, but the university provides us with facilities for big events, like when we have summits. in summits, the learners engage with the professional, we give out the topic for the day and we have a debate. usually the topic is something that is affecting all of us, like last year it was about free education, so that’s what they were engaging about with the professionals. we had people from the [university name], even the chancellor was there as well. (o1c2 (community member2)) sub-theme 1.4: shift in mind-set. ce effecting change in frame of reference, transformative learning and attainment of graduate attributes emerged as major aspects that participants revealed in relation to students experiencing being empowered by the cetl activities. participants’ accounts showed that cetl activities affected the following on the part of the students: sense of responsibility; change from pessimism to valuing the experience; problemsolving abilities; and appreciation of the culture, norms and values of society, among other things. this is shown in the following excerpt: ‘as future healthcare professionals, we are being trained to be citizens who care, those citizens who do something about the community, meaning that if like when we go to that community and experience things, we have to do something about it.’ (03fgd3 participant 2) theme 2: forms of cetl this theme had four sub-themes, namely service learning, volunteerism, community service and work-integrated learning. these reflected a profile of cetl activities that participants, particularly students and academics, reported having experienced. sub-theme 2.1: service learning. this sub-theme is illustrated by the following excerpt: ‘apart from the working, we also take part in service learning, which is more directly focused on the community and projects in the community.’ (01e6) sub-theme 2.2: community service. another term that is used to describe a form of cetl experienced by the participants is community service: ‘we do community service, it’s part of the curriculum … i think … academic curriculum. we go to homes, schools, old age homes and we do treatments that we usually do here at school and in return we get hours.’ (o2sfgd2 part. 6) sub-theme 2.3: work-integrated learning. this sub-theme is illustrated by the following excerpt: ‘also, we have a take-a-learner-to-work day where people who are working from the organisation do take a few learners with them to work on that take-a-person-to-work day.’ (o1c2) sub-theme 2.4: volunteer activities. one other form of cetl reflected by the interviews with stakeholders included volunteer activity. this is shown in the following extract: ‘we usually encourage the students to come and volunteer with us here.’ (o1c3) theme 3: principles of cetl this theme had four sub-themes, namely the multidisciplinary nature of cetl, reflection, reciprocity and sustainability. another feature was table 1. themes and sub-themes themes sub-theme empowerment projects authentic learning resource allocation and engagement shift in mind-set forms of cetl service learning community service work-integrated learning volunteer cetl principles multidisciplinary nature of cetl reflection reciprocity sustainability awareness community valuing community and cetl cetl = community-engaged teaching and learning. 209 november 2020, vol. 12, no. 4 ajhpe research that a profile of frameworks was used to undergird pedagogical practices, including constructivist, problem-based approaches, using sustainable development goals and the national development plan to guide the cetl activities. this is shown in the excerpts below: ‘they must teach the community something and at the same time they must also learn something from the community.’ (01e3) ‘the students learn how to handle these situations as professionals and then how to work with multidisciplinary teams; if we find out that this is social problem … how to refer to the relevant stakeholders.’ (03e4) theme 4: awareness this theme related to awareness and had two sub-themes, namely awareness of the community, and valuing the community and cetl. sub-theme 4.1: awareness of the community. participants’ interviews identified experiences of an improved awareness of the community in various cultural, political or social aspects. stakeholders had a consciousness of community challenges, appreciation of other cultures, and gained professional socialisation through engagement in cetl activities. this is illustrated in the following excerpt: ‘behaviour-wise i think they now know more about what’s going on out there in the world, not just being confined to the [university] environment. so in terms of behaviour, they’ve become more openminded, i would think.’ (02e2) sub-theme 4.2: valuing the community and cetl. cetl activities taught stakeholders to value the community and to value cetl approaches, as shown in the following quote: ‘from my viewpoint, yes indeed community engagement is important for students, and the community, more especially with the nursing students because in nursing, a nurse is always a nurse anywhere. like in the community, hence it is important to involve the community in the students’ learning, so that they can be able to form the relationship with the community that they serve.’ (03e3) discussion a phenomenological descriptive approach was used to describe similarities of experiences with regard to cetl among stakeholders (students, academics and community members) at the nursing and health science departments of three universities. this exploration yielded themes relating to participants’ experiences of empowerment, forms of cetl, principles of cetl and awareness. the experience of cetl is shown as empowering by the stakeholder accounts in this study. cetl creates authentic learning experiences for students, which enhances their ability to achieve their competencies by the time of graduation. additionally, effects on academics and community participants in cetl encounters are also recorded, and this corroborates the findings of previous studies.[19,20] however, boyle-baise et al.[21] argue that cetl in its ideal form should ‘destabilise inequitable distribution of power, privilege and knowledge’. furthermore, these authors elaborate that service for social justice examines injustice, deepening students’ grasp of equity, and fostering activism. this is not evident from the students’ experiences in this study. the study findings illustrated that cetl activities can be implemented and integrated into curricula in various ways. this is corroborated by the literature, which describes various forms of ce teaching. this includes service learning, which is distinct from community service or volunteerism in that it focuses on the learner in addition to the communities served.[22] a differentiation between service learning and volunteerism is also made by identifying that the former ‘integrates service in the community with intentional learning activities’, while the latter ‘involves all kinds of learning, but most of the learning in volunteerism is not implicit or unintentional’.[22] work-integrated learning is described as an approach to teaching and learning that integrates what students have learned at the hei through workplace experience. the literature shows utilisation of cetl in nursing and health sciences education.[19,20] in relation to principles of cetl, the study indicates the involvement of various stakeholders in cetl activities, which is a requirement if such a pedagogical approach is to be effective. the role of cetl in magnifying student transformation in higher education is shown in this study. this is corroborated by boyle-baise et al.,[21] who argue that deliberately exposing students to cetl activities helped to develop civic commitment, including a sense of social responsibility. participants’ experiences in this study furthermore revealed an improved awareness of the community. indeed, olson and brennan[23] argue that cetl activities lead to what they call development of community and development in community. they describe development of community as a process-motivated emergence of community that represents the ‘coming together of people to discuss and act upon issues […] of greater value than outcome or outcomes’.[23] development of community is biased towards outcomes such as improvement in built and natural environment of an area.[23] these study findings reveal the potential that cetl has in prompting development of community as stakeholders develop awareness in the process of engaging in cetl activities. the optimal realisation of cetl principles is important for the context of sa, if nursing and health sciences education are to realise the transformative agenda as outlined by the white paper on higher education of 1997.[24] conclusion the findings of this study reveal the opportunities that abound for health sciences education and indeed nursing education through utilisation of high-impact approaches such as cetl. the study showed a rich array of strategies that can be used to leverage the transformative effect of teaching and learning in nursing education. appropriate integration of cetl into programme design and development of curricula, and use of explicit cetl methods with intentional outcomes for students and communities, will go a long way to achieving transformation in nursing education. declaration. none. acknowledgements. the authors would like to acknowledge the students, academics and community members from the three universities who participated in this study. furthermore, the authors would like to acknowledge dr c nyoni (school of nursing, university of the free state) for a critique of the manuscript. author contributions. fm (university of the western cape (uwc)) is the doctoral candidate who researched and wrote the article. hj (uwc) is the doctoral supervisor, who provided support especially during the conceptualisation phase, review and write-up of this article. funding. national research foundation. conflicts of interest. none. november 2020, vol. 12, no. 4 ajhpe 210 research 1. driscoll a, sandmann lr. from maverick to mainstream: the scholarship of engagement. j high educ outreach engagem 2016;20(1):83-94. 2. kasworm ce, abdrahim nab. scholarship of engagement and engaged scholars: through the eyes of exemplars. j high educ outreach engagem 2014;18(2):121-148. 3. rawlings-sanaei f, sachs j. transformational learning and community development: early reflections on professional and community engagement at macquarie university. j high educ outreach engagem 2014;18(2):235-260. 4. fitzgerald he, bruns k, sonka st, furco a, swanson l. the centrality of engagement in higher education. j high educ outreach engagem 2016;20(1):223-244. 5. council on higher education. criteria for programme accreditation. pretoria: council on higher education, september 2004, revised june 2012. 6. council on higher education. community engagement in south african higher education, kagisano no. 6. johannesburg: jacana media, 2010. 7. lazarus j, erasmus m, hendricks d, nduna j, slamat j. embedding community engagement in south african higher education. educ citizenship soc justice 2008;3(1):57-83. https://doi.org/10.1177%2f1746197907086719 8. schroeder k, garcia b, phillips rs, lipman th. addressing social determinants of health through community engagement: an undergraduate nursing course. j nurs educ 2019;58(7):423-426. https://doi.org/10.3928/0148483420190614-07 9. world health organization. state of the world’s nursing 2020: investing in education, jobs and leadership. geneva: who, 2020. 10. nyoni cn, botma y. integrative review on sustaining curriculum change in higher education: implications for nursing education in africa. int j afr nurs sci 2020;12:1-8. https://doi.org/10.1016/j.ijans.2020.100208 11. world health organization. transforming and scaling up health professionals’ education and training: world health organization guidelines 2013. geneva: who, 2013. 12. hester j, adejumo oa, frantz jm. cracking the nut of service-learning in nursing at a higher educational institution. curationis 2015;38(1):1-9. https://doi.org/10.4102%2fcurationis.v38i1.117 13. reiners mg. understanding the differences between husserl’s (descriptive) and heidegger’s (interpretive) phenomenological research. j nurs care 2012;01:5. https://www.omicsgroup.org/journals/understanding-thedifferences-husserls-descriptive-and-heideggers-interpretive-phenomenological-research-2167-1168.1000119. php?aid=8614 (accessed 25 july 2020). 14. lopez ka, willis dg. descriptive versus interpretive phenomenology: their contributions to nursing knowledge. qual health res 2004;14(5):726-735. https://doi.org/10.1177/1049732304263638 15. starks h, brown trinidad s. choose your method: a comparison of phenomenology, discourse analysis, and grounded theory. qual health res 2007;17(10):1372-1380. https://doi.org/10.1177%2f1049732307307031 16. burgess t, cilliers f. a framework for ethical educational research: principles and application. cape town: university of cape town educational development unit, 2016. www.healthedu.uct.ac.za/framework-ethicaleducational-research-principles-and-application (accessed 5 august 2018). 17. stellenbosch university. social impact strategic plan. stellenbosch: stellenbosch university, 2016. 18. saldaña j. the coding manual for qualitative researchers. london: sage publications, 2009. 19. tyndall de, kosko da, forbis km, sullivan wb. mutual benefits of a service-learning community-academic partnership. j nurs educ 2020;59(2):93-96. https://doi.org/10.3928/01484834-20200122-07 20. sandberg mt. nursing faculty perceptions of service learning: an integrative review. j nurs educ 2018;57(10):584-589. https://doi.org/10.3928/01484834-20180921-03 21. boyle-baise l, brown r, hsut m-c, et al. learning service or service learning: enabling the civic. int j teach learn high educ 2006;18(1):17-26. 22. van styvendale n, mcdonald j, buhler, s. community service-learning in canada: emerging conversations. engaged sch j community-engaged res teach learn 2018;4(1):i-xiii. 23. olson b, brennan m. from community engagement to community emergence: the holistic program design approach. int j res serv-learn community engagem 2017;5(1). 24. department of higher education and training, south africa. education white paper 3. a programme for higher education transformation. pretoria: dohet, 1997. accepted 24 august 2020. https://doi.org/10.1177%2f1746197907086719 https://doi.org/10.3928/01484834-20190614-07 https://doi.org/10.3928/01484834-20190614-07 https://doi.org/10.1016/j.ijans.2020.100208 https://doi.org/10.4102%2fcurationis.v38i1.117 https://www.omicsgroup.org/journals/understanding-the-differences-husserls-descriptive-and-heideggers-interpretive-phenomenological-research-2167-1168.1000119.php?aid=8614 https://www.omicsgroup.org/journals/understanding-the-differences-husserls-descriptive-and-heideggers-interpretive-phenomenological-research-2167-1168.1000119.php?aid=8614 https://www.omicsgroup.org/journals/understanding-the-differences-husserls-descriptive-and-heideggers-interpretive-phenomenological-research-2167-1168.1000119.php?aid=8614 https://doi.org/10.1177/1049732304263638 https://doi.org/10.1177%2f1049732307307031 http://www.healthedu.uct.ac.za/framework-ethical-educational-research-principles-and-application http://www.healthedu.uct.ac.za/framework-ethical-educational-research-principles-and-application https://doi.org/10.3928/01484834-20200122-07 https://doi.org/10.3928/01484834-20180921-03 a maximum of 3 ceus will be awarded per correctly completed test. march 2022, vol. 14, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire march 2022 module evaluation for emergency remote teaching: an oral hygiene case study during the covid-19 pandemic 1. the results of the study showed that student learners: a. found assessments to be fair in terms of the outcomes b. identified that practical application supported their understanding of the modules most c. felt that school visits did not encourgae an interest in community health d. reported that lecture notes were the most useful resource during lockdown. an innovative educational strategy for learning and teaching clinical skills during the covid-19 pandemic 2. some of the challenges noted by the educators with respect to the bootcamps included: a. unprepared students b. tired students c. overwhelmed students d. disinterested students. undergraduate dental students’ perspectives on teaching and learning during the covid-19 pandemic: results from an online survey conducted at a south african university using a mixed-methods approach 3. the majority of students understood blended learning to be a combination of: a. online lectures, face-to-face contact and self-study b. online lectures and self study c. face-to-face contact and self study d. face-to-face contact, self study and small group sessions. justice as fairness in preparing for emergency remote teaching: a case from botswana 4. the study found that: a. mobile data was the predominant method of internet access b. students were satisfied with the speed of the internet at home c. most students could easily remember their email password d. most students had study material at home. teaching and learning considerations during the covid-19 pandemic: supporting multimodal student learning preferences 5. the study found that: a. most students demonstrated a preference for multimodal learning b. the kinaesthetic learning preference as the most frequently used style c. of students who preferred a unimodal preference, the visual mode was preferred most d. of students who preferred a multimodal preference, the read/write and kinaesthetic modes were preferred most. the effect of the initial months of the covid-19 national lockdown on mmed training activities at the university of the free state, south africa 6. this study showed that the final months of the covid-19 lockdown affected registrars’ mmed research progress more than the initial months did (true/false). please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. december 2021, vol. 13, no. 4 ajhpe 271 research there is global awareness of investment in education to ensure quality teaching.[1] therefore, higher education institutions (heis)  have taken a proactive approach to improve quality teaching by designing principles of  effective, transparent and easy-to-understand feedback related to assessment criteria.[2] according to taras,[3] provision of quality feedback is widely perceived as a key benchmark of effective teaching, as it is vital in meeting students’ expectations. this article describes nursing students’ perceptions of feedback received from educators in selected heis in south africa (sa). student feedback has been defined differently by various scholars. brookhart[4] defines feedback as a response in which information regarding previous performance is used to provide the facilitator’s positive views, suggestions and guidance on students’ work. progressive philosophical views regard quality feedback as a collaborative problem-solving intervention or a strategy rather than a reward for complying with teachers’ expectations or  punitive consequences for failing, which is observed in behavioural theory.[5] therefore, nursing education encompasses the external curriculum programme for which assessment and feedback are mandatory in both classroom and clinical teaching.[6] according to mulliner and tucker,[7] the purpose of feedback is to increase students’ understanding of a learning goal and their own achievement status in relation to the goal, as well as enabling them to bridge the gap between their status and the desired status. hughes and quinn[8] assert that feedback provides scaffolding that may help to guide students through their potential maze of complex feedback by providing signs, clues and a partial learning solution. moreover, brookhart[4] states that feedback involves motivating learners to deconstruct a task to make it more achievable, providing direction, identifying differences between achievements and expectations and reducing risks. furthermore, hughes and quinn[8] suggest that it is crucial that feedback feeds forward, encouraging further learning and helping  students to identify gaps between their actual and desired performance. for  students to benefit fully from the clinical experience, regular feedback is required, which provides student nurses with information on current practice and offers practical advice for improved performance.[9] according to clynes and raftery,[9] the benefits of feedback include  an  increased sense of personal satisfaction, student confidence, motivation, self-esteem and enhanced interpersonal skills. even though principles of feedback may be employed in higher education, students’ experiences might differ; hence their perceptions could be useful on how feedback can be improved.[10] the principles of effective feedback need to be adhered to, as students’ learning processes, progress and understanding will otherwise be diminished. [4] moreover, recent studies of perceptions of feedback explain that students are dissatisfied and do not use feedback owing to timing, clarity, quality and the way in which written feedback is presented.[3,7,10] a study in the background. there is global awareness of investment in higher education to ensure quality learning. provision of quality feedback is perceived as a key benchmark of effective learning and a vital requirement in meeting students’ expectations. nevertheless, increased students’ demands and expectations regarding quality feedback compete with increased pressure on academic resources, which may result in student dissatisfaction. despite the high priority that higher education institutions (heis) place on quality of feedback, insufficient research studies have been conducted of student nurses’ perceptions of such feedback. objectives. to describe nursing students’ perceptions of feedback received from educators in a selected hei. method. a non-experimental, exploratory descriptive design was used to guide the research process. the non-probability convenience sampling method was used, with 75 nursing students as respondents. a descriptive statistics procedure was used to present the findings of the study. results. most respondents (82.7%)  reported that they received understandable, timely, personalised, criteria-referenced, positive clear feedback after assessment. conversely, 17.3% of respondents indicated that they received delayed, non-understandable feedback, as well as unclear and negatively written feedback. the findings of the study suggest that quality feedback mechanisms in the selected hei were used for effective learning and to meet nursing students’ requirements and expectations. conclusion. the findings of the research indicate that nursing students receive quality feedback after assessment. however, there is a need for the hei to develop a clear organisational structure with an operational guideline to aid the feedback process and ensure that all students receive quality feedback, improving their performance and meeting their needs. the feedback process should be made transparent and communicated to educators and students. afr j health professions educ 2021;13(4):270-274. https://doi.org/10.7196/ajhpe.2021.v13i4.1111 nursing students’ perceptions regarding feedback from their educators in a selected higher education institution in kwazulu-natal province, south africa l m rathobei, honours degree in nursing student; m b dube, phd department of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: m b dube (202507610@stu.ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1111 mailto:202507610@stu.ukzn.ac.za 272 december 2021, vol. 13, no. 4 ajhpe research school of built environment, john moores university, liverpool, uk, of undergraduate students (n=194), showed that the majority (95%)  agreed that feedback received too late was useless.[2] the same study revealed that regarding the ideal time frame to receive feedback, 42% of students agreed on 2 3 weeks.[7] however, khowaja et  al.[11] found that in pakistan, ~40% (n=152)  of students perceived delayed feedback, low grades and limited opportunity to clarify feedback as common obstacles related to learning. in tanzania, lack of adequate supervision and feedback were regarded as hindering factors.[12] in sa, a study that evaluated higher education management students’ (n=601) perceptions of teacher feedback, found that 64% rated their perceptions as average, 17.5% as good and 13.2% as weak.[13] however, information on feedback in heis, particularly in kwazulu-natal (kzn) province, remains limited. in this context, the current article seeks to explore nursing students’ perceptions regarding feedback from their educators in a selected hei. methods a quantitative, non-experimental, exploratory descriptive design was used to conduct the research. an exploratory design investigates the full nature of the phenomenon, the way it manifests and other factors in relation to the underlying process.[14] according to grove et al.,[15] a descriptive design may be used for development of theory, identification of problems in current practice, justifying current practice, making judgements or detecting what others in similar situations do. this design was appropriate to obtain information that describes ‘what exists’ with regard to nursing students’ perceptions of feedback, the key question addressed in this study. setting the study was conducted at a selected hei in kzn. the specific school (within the hei) where the research was conducted falls under the college of health sciences and offers various undergraduate programmes, such as the diploma in nursing, the bachelor’s degree in nursing and advanced practice. population and sampling the study population comprised all 84 nursing students registered for the first year of the bachelors’ degree in nursing programme in 2017. the nonprobability convenience sampling method was used to select respondents. according to polit and beck[14] and brink et  al.,[16] when using the non-probability convenience sampling technique, the researcher chooses elements of the study that are available and ready at the right place and the right time during the study period. in the current study, the researcher distributed questionnaires to nursing students who were available and accessible in their theory class for the two weeks that data were collected. seventy-five of 84 nursing students registered for the first year of the bachelor’s degree in nursing science programme in 2017, who completed the questionnaire and were included in the study. data analysis descriptive analysis was used to describe and summarise student nurses’ perceptions of feedback. according to polit and beck,[14] descriptive statistics are sometimes used to directly address research questions in studies that are primarily descriptive and help set the stage for understanding of quantitative research evidence. the questionnaire was developed by a researcher with the assistance of a research supervisor and a statistician, using the literature to guide the development. the five responses on the likert scale were: strongly agree, agree, not sure, disagree and strongly disagree. face validity was established by consulting experts in the field of nursing education, the supervisor and the statistician to provide feedback regarding validity of the questionnaire. to maintain test-retest reliability of the questionnaire, it was pretested in 10 respondents. as no changes were made to the questionnaire, these data were included in the final sample. by means of cronbach’s alpha reliability statistics, validity of the instrument (questionnaire)  was grounded at 0.81 (81.0%), i.e. findings from this study would be reliable. the completed questionnaires were counted and coded to facilitate capturing and auditing of data after collection. the scores of the negative questions in the questionnaire were reversed to accommodate negativity. data were then entered into spss version 24 (ibm corp., usa)  for analysis. descriptive statistics were used to describe and synthesise data, where frequencies, percentages, standard deviations (sds)  and means were reflected. tables and graphs were used to enhance interpretation. the composite score was computed for questions with ranges. ethical considerations grove et  al.[15] asserted that researchers must comply with three ethical principles, i.e. beneficence, respect for human dignity and justice. permission to conduct the study was obtained from the school of nursing and public health, university of kzn, and ethical clearance was received from the research ethics committee of the university of kwazulu-natal (ref. no. hss/1409/017h), where the study was registered and conducted. to respect the rights of respondents, the researcher explained the purpose of  the study, that participation was voluntary and that students may withdraw at any time without fear of negative consequences. the researcher also explained that respondents would experience no harm by participating in the study. after providing the necessary information regarding the study, signed informed consent was obtained from those who voluntarily accepted to participate. the researcher explained to the respondents that the questionnaire would take ~15 minutes to complete and that their anonymity and confidentiality were respected by using codes. their names and student numbers did not appear on the questionnaire. the respondents were treated equally and data were transcribed verbatim. the data were kept in a locked area that only the researcher and supervisor could access. the researcher explained that the findings of the study would be helpful to students, including those who did not participate, as it would aid their transition to higher education. the results of the study may be useful in informing and reviewing the policies of the institution. results questionnaires were handed out to the total population of 84 nursing students, of whom 75 completed and returned their questionnaire. students had varied perceptions regarding quality of feedback (table 1). when exploring quality of feedback after assessment, 20.0% (n=15) of 75 respondents strongly agreed and 37.3% (n=28)  agreed with the statement that ‘feedback mainly tells me how well i am doing in relation to others’, while 5.3% (n=4) strongly disagreed and 29.3% (n=22) disagreed. however, 8.0% (n=6) were not sure about the statement. december 2021, vol. 13, no. 4 ajhpe 273 research regarding ‘feedback shows how to do better next time’, 40.0% (n=30)  of respondents strongly agreed and 42.7% (n=32)  agreed with the statement, 4.0% (n=3)  strongly disagreed and 10.7% (n=8)  disagreed, whereas 2.7% (n=2) indicated that they were not sure. as to ‘feedback helps respondents to understand things better next time’, 41.3% (n=31) strongly agreed and 41.3% (n=31) agreed, 2.7% (n=2) strongly disagreed and 6.7% (n=5) disagreed, while 8.0% (n=6) were not sure about the statement. based on the statement that ‘i can hardly see from the feedback what i need to do to improve my performance’, 22.7% (n=17)  of respondents strongly agreed and 10.7% (n=8) agreed, 8.0% (n=6) strongly disagreed and 42.7% agreed, whereas 16.0% (n=12) stated that they were not sure, with the highest mean score (sd) 3.03 (1.33). regarding ‘once i read the feedback, i understand why i got the marks i received’, 34.7% (n=26)  strongly agreed and 41.3% (n=31)  agreed, 5.3% (n=4)  strongly disagreed and 10.7% (n=8)  disagreed, whereas 8.0% (n=6) stated that they were not sure. with reference to ‘i do not understand some of the feedback that i receive’, 12.0% (n=9)  strongly agreed and 24.0% (n=18)  agreed with the statement, 4.0% (n=3)  strongly disagreed, 38.7% (n=29)  disagreed and 21.3% (n=16) stated that they were not sure. as regards ‘feedback encourages me to improve my performance’, 44.0% (n=3)  strongly agreed and 40.0% (n=30)  agreed, 2.7% (n=2)  strongly disagreed and 8.0% (n=6) disagreed, while 5.3% (n=4) stated that they were not sure, with the lowest mean score 1.85 (1.02). regarding ‘i can easily read the feedback i receive on my assignment’, 26.7% (n=20)  strongly agreed with the statement, 41.3% (n=31)  agreed, 1.3% (n=1)  strongly disagreed and 12.0% (n=9)  disagreed, whereas 18.7% (n=14) stated that they were not sure. based on the statement that ‘feedback received on assignment was too brief to be helpful’, 25.3% (n=19)  strongly agreed, 48.0% (n=36)  agreed, 1.3% (n=1)  strongly disagreed and 10.7% (n=8)  disagreed, whereas 14.7% (n=11) stated that they were not sure. with respect to ‘feedback on an assignment can be useful in a subsequent assignment’, 26.7% (n=20)  strongly agreed and 45.3% (n=34)  agreed, 2.7% (n=2)  strongly disagreed and 5.3% (n=4)  disagreed, while 20.0% (n=15) stated that they were not sure. discussion the study indicates that the majority of respondents perceived that feedback mainly shows them how well they are doing in relation to others, compared with a minority of 34.6% of respondents, who opposed the statement. this may be owing to the previous content-based curriculum, which emphasised students’ comparison of marks rather than their competency. the study results are in line with those of the university of western cape, where the majority of respondents reported that the purpose of feedback was to show them how well they were doing in relation to others.[13] the majority of respondents agreed that feedback shows them how to do better next time, while the minority opposed the statement. this may be owing to educators’ use of principles of effective feedback, such as transparent feedback, easy-to-understand feedback and feedback related to assessment criteria that are imposed by heis. this is in line with hughes and quinn,[8] who asserted that it is crucial that feedback feeds forward, encouraging further learning and progress. moreover, seker and dincer[17] echoed this sentiment in a study at the foreign language school in turkey, to identify students’ perceptions on feedback. the results revealed that students felt that they had been assessed, they were satisfied and had improved. table 1. quality of feedback after assessment in nursing science items strongly agree, n (%) agree, n (%) not sure, n (%) disagree, n (%) strongly disagree, n (%) mean (sd) feedback mainly tells me how well i am doing in relation to others 15 (20) 28 (37.3) 6 (8.0) 22 (29.3) 4 (5.3) 2.63 (1.25) feedback shows how to do better the next time 30 (40.0) 32 (42.7) 2 (2.7) 8 (10.7) 3 (4.0) 1.96 (1.12) feedback helps me to understand things better the next time 31 (41.3) 31 (41.3) 6 (8.0) 5 (6.7) 2 (2.7) 1.88 (0.91) from the feedback, i can hardly see what i need to do to improve my performance 17 (22.7) 8 (10.7) 12 (16.0) 32 (42.7) 6 (8.0) 3.03 (1.33) once i read the feedback, i understand the marks i received 26 (34.7) 31 (41.3) 6 (8.0) 8 (10.7) 4 (5.3) 2.11 (1.16) i do not understand some of the feedback that i receive 9 (12.0) 18 (24.0) 16 (21.3) 29 (38.7) 3 (4.0) 2.99 (1.13) feedback encourages me to improve my performance 33 (44.0) 30 (40.0) 4 (5.3) 6 (8.0) 2 (2.7) 1.85 (1.02) i can easily read the feedback i receive on my assignment 20 (26.7) 31 (41.3) 14 (18.7) 9 (12.0) 1 (1.3) 2.20 (1.01) feedback received on my assignment is too brief to be helpful 19 (25.3) 36 (48.0) 11 (14.7) 8 (10.7) 1 1.3) 2.15 (0.97) feedback on my assignment can be useful in subsequent assignments 20 (26.7) 34 (43.3) 15 (20.0) 4 (5.3) 2 (2.7) 2.12(0.96) sd = standard deviation. 274 december 2021, vol. 13, no. 4 ajhpe research the current study suggests that the majority of respondents agreed that feedback helped them to understand things better subsequently, while the minority disagreed with the statement. this may be owing to the selected hei-qualified nurse educators, who were able to deliver clear, understandable feedback based on the needs of students. this is in keeping with the report by mulliner and tucker,[7] who asserted that the prime aim of feedback was assisting students to understand more regarding their learning purpose. the results of the current study also correspond to those of a study conducted in the school of built environment, liverpool, where the majority of students (72%)  agreed with the concept.[7] however, in the national student survey (nss)  study in 2009, <55% of respondents in the uk agreed that feedback was helpful in clarifying understanding.[3] moreover, taras[3] added that the results of the nss were in marked contrast to the overall course dissatisfaction (>80%). based on whether respondents hardly have an understanding of the feedback of what is needed to improve their performance, the minority of respondents were positive, while the majority opposed the statement. this may be owing to educators providing clear and understandable criteria and guidelines before assessment and when marking and giving feedback. these results concur with those of a study conducted among first-year businessunit students at an australian university, where results revealed that 80 81% of students agreed that feedback helped them to achieve the unit outcomes and satisfaction was between 70% and 79%.[18] the results indicated that once the respondents had read the feedback, they understood their results, because the majority responded positively to the statement. this could be because of educators’ use of clear marking criteria, which are provided to students in advance. nixon et  al.[19] echoed this sentiment in the study conducted at john moores university, liverpool, uk, with second-year students, where the major theme was around marking criteria, with issues such as vagueness, lack of detailed guidance, lack of clarity and unhelpful comments. the results indicated that the respondents understood only some of the feedback that they received, because the majority answered negatively. this is in contrast to the study by pitt and norton,[20] who asserted that some of their students reported that they did not understand all the feedback they received from their lecturers, as they did not understand the language that their lecturers used. for the purpose of whether feedback encouraged respondents to improve their performance, the results suggested that feedback encouraged respondents to improve their performance, because most responded positively. this may be observed in students’ continuous assessment reports and portfolios, which show that respondents improved on their performance. the study results are in keeping with those of the foreign language school in turkey. the results revealed that the majority of students felt that they had been assessed, they were satisfied and had improved.[17] the current study results also correspond to those of a study of firstyear students in business and the humanities, uk, where the majority of students (97%)  believed that they kept feedback in mind for later use.[21] however, this is in contrast to results of a study conducted by crisp,[22] on effects of students’ response to feedback, where findings revealed that there was little evidence of improvement in scores or regarding the reduction of problems. based on whether feedback received on an assignment was too brief to be helpful, most respondents answered positively. this may be because the educators, when giving feedback to students, observed the quality – not the quantity – of feedback, which may also be influenced by the types of feedback, such as verbal, written and email feedback. however, the results are in contrast with those of the nss study, where <55% of respondents agreed that feedback had been detailed and helpful in clarifying understanding.[3] based on whether feedback can be useful in a subsequent assignment, the majority answered positively. this may be assessed in students’ portfolios on a summative report. it is also in line with the study by pitt and norton,[22] who stated that the majority of the students indicated that the feedback they received regarding an assignment helped them in writing the next assignment, as it made them realise their weaknesses. recommendations for improving feedback the provision of quality feedback is widely perceived as a key benchmark of effective teaching and as an important requirement for meeting students’ expectations.[3] however, there is need for heis to develop a clear organisational structure with a policy and an operational guideline, which will aid the process to ensure that all students receive quality feedback to improve their performance and meet their needs. the feedback process should be transparent and communicated to educators and students. conclusion students acknowledged that quality of feedback received after an assessment positively aided the process. however, there is a need to provide feedback that improves performance of students and that meets their needs. recommendation for further research and policies further research is recommended, including four levels of the bachelor’s degree in nursing science, using both qualitative and quantitative research approaches. it is also recommended that feedback policy be developed in heis. declaration. none. acknowledgements. none. author contributions. mb dube supervised lm rathobei’s research. funding. none. conflicts of interest. none. 1. pakkies ne, mtshali ng. students’ views on the block evaluation process: a descriptive analysis. curationis 2016;39(1):1-8. https://doi.org/10.4102%2fcurationis.v39i1.1516 2. thomas l, oliver e. application of feedback principles to marking proformas increases student efficacy, perceived utility of feedback, and likelihood of use. sport exercise psychol rev 2017;13(2):39-47. 3. taras m. excellence in university assessment: learning from award-winning practice. lond rev educ 2015;13(3):59-61. https://doi.org/10.18546/lre.13.3.09 4. brookhart sm. how to give effective feedback to your students. virginia: ostertag, 2017. 5. kohn a. progressive education: why it’s hard to beat, but also hard to find. new york: bank street college of education, 2015. 6. agu gu. factors affecting clinical training of nursing students in selected nursing educational institutions in enugu and ebonyi states of nigeria. phd thesis. nsukka: university of nigeria, 2017. 7. mulliner e, tucker m. feedback on feedback practice: perceptions of students and academics. assess eval high educ 2017;42(2):266-288. https://doi.org/10.1080/02602938.2015.1103365 8. hughes sj, quinn fm. the principles and practice of nurse education. 6th ed. hampshire: nelson thornes, 2013. 9. clynes mp, raftery se. feedback: an essential element of student learning in clinical practice. nurs educ pract 2017;8(6):405-411. https://doi.org/10.1016/j.nepr.2008.02.003 10. carvalho c, santos j, conboy j, martins d. teachers’ feedback: exploring differences in students’ perceptions. proc social behav sci 2014;159:169-173. https://doi.org/10.1016/j.sbspro.2014.12.351 11. khowaja aa, gul rb, lakhani a, rizvi nf, saleem f. practice of written feedback in nursing degree programmes in karachi: the students’ perspective. j coll phys surg pak 2014;24(4):241. https://doi. org/10.5958/j.0974-9357.6.1.001 12. ugwu sn. nursing students’ perceptions of clinical nursing training in selected nursing programmes in enugu state. phd thesis. nigeria: enugu state university, 2016. 13. amuah a. student nurses’ perceptions of written feedback after assessment at a university in the western cape. mcur thesis. cape town: university of the western cape, 2016. https://doi.org/10.4102%2fcurationis.v39i1.1516 https://doi.org/10.18546/lre.13.3.09 https://doi.org/10.1080/02602938.2015.1103365 https://doi.org/10.1016/j.nepr.2008.02.003 https://doi.org/10.1016/j.sbspro.2014.12.351 https://doi.org/10.5958/j.0974-9357.6.1.001 https://doi.org/10.5958/j.0974-9357.6.1.001 december 2021, vol. 13, no. 4 ajhpe 275 research 14. polit f, beck c. nursing research: generating and assessing evidence for evidence-based practice. philadelphia: wolters kluwer health, 2016. 15. grove sk, gray jr, burns n. understanding nursing research: building an evidence-based practice. amsterdam: elsevier health sciences, 2014. 16. brink h, van der walt c, van rensburg g. fundamentals of research methodology for health care professionals. 4th ed. cape town: juta, 2017. 17. seker m, dincer a. an insight to students’ perceptions on teacher feedback in second language writing classes. engl lang teach 2014;7(2):73. https://doi.org/10.5539/elt.v7n2p73 18. vardi i. effectively feeding forward from one written assessment task to the next. assess eval high educ 2013;38(5):599-610. https://doi.org/10.1080/02602938.2012.670197 19. nixon s, brooman s, murphy b, fearon d. clarity, consistency and communication: using enhanced dialogue to create a course-based feedback strategy. assess eval high educ 2017;42(5):812-822. https://doi.org/10.1080/ 02602938.2016.1195333 20. pitt e, norton l. ‘now that’s the feedback i want!’ students’ reactions to feedback on graded work and what they do with it. j assess eval high educ 2017;42:499-516. https://doi.org/10.1080/02602938.2016.1142500 21. li j, de luca r. review of assessment feedback. stud high educ 2014;39(2):378-393. https://doi.org/10.1080/0 3075079.2012.709494 22. crisp br. is it worth the effort? how feedback influences students’ subsequent submission of assessable work. assess eval high educ 2007;32(5):571-581. https://doi.org/10.1080/02602930601116912 accepted 18 august 2020. https://doi.org/10.5539/elt.v7n2p73 https://doi.org/10.1080/02602938.2012.670197 https://doi.org/10.1080/02602938.2016.1195333 https://doi.org/10.1080/02602938.2016.1195333 https://doi.org/10.1080/02602938.2016.1142500 https://doi.org/10.1080/03075079.2012.709494 https://doi.org/10.1080/03075079.2012.709494 https://doi.org/10.1080/02602930601116912 8 april 2021, vol. 13, no. 1 ajhpe forum on 3 november 1982, the former south african (sa) medical and dental council communicated to the committee of the heads of physical education departments at sa universities that biokinetics was officially acknowledged and included as a healthcare profession in the register of medical sciences.[1] subsequently, on 17 october 1987, the sa association of biokinetics was constituted, which was later renamed the biokinetics association of sa (basa).[1] the profession of biokinetics operates within the pathogenic and fortogenic healthcare paradigms, with a scope of profession (sop) that involves improving the health and physical status of individuals through the prescription of structured exercise as derived from clinical assessments.[2,3] the cardinal areas of practice involve final-phase rehabilitation and prevention of non-communicable diseases (ncds), neuromusculoskeletal injuries, physical work capacity assessments and campaigning for health and wellness.[2,3] biokineticists are affiliated with their professional body (basa) and their statutory body (the health professions council of sa (hpcsa)).[4] basa supports the interests of students in training, intern biokineticists and practitioners, while the hpcsa protects the wellbeing of the public and guides the profession accordingly.[1,2] biokineticists operate within the sa private healthcare sector. the three primary areas of strategic development are: (i)  training and education; (ii)  entry into the sa public healthcare system; and (iii) interprofessional healthcare collaboration. training and education currently, there are 12 biokinetics training institutions, of which six offer the traditional educational model (a 3-year undergraduate degree in human movement science (hms) or equivalent, and a subsequent postgraduate specialisation in biokinetics).[5] the other six institutions offer the new model, i.e. a 4-year professional degree. although both models have similar academic content, it is imperative that all 12 institutions offer the 4-year professional degree. this degree is structured solely for the edification of biokinetics, while the traditional hms undergraduate degree allows for specialisation in other subjects through subsequent postgraduate programmes. the professional degree has the advantage that students start their biokinetics internship (work-integrated learning) during their first year of study, affording them more time to hone their clinical expertise. moreover, uniform compliance with the 4-year professional degree structure, similar to the academic requirements of physiotherapy and occupational therapy, reinforces the identity of this young profession.[4,5] training institutions should furthermore continue with evidence-based research, supporting the ethos of the profession (salutogenic effect of exercise). the evidence-based research must be published in a specialised biokinetics journal, similar to other therapeutic journals for the professions of physiotherapy and occupational therapy.[4] the proposed journal must be accredited with the sa department of higher education and training and the institute for scientific information, providing the opportunity for all subscribers to receive continuously updated information relevant to their professional development. the layout of the journal should be analogous to other professional journals, and therefore include original research and review articles, short communications, case studies, letters to the editor, announcements regarding upcoming conferences, as well as employment opportunities.[4] entry into the south african public healthcare system the high prevalence of ncds in sa places a great deal of pressure on the public healthcare system, which needs the support of and would benefit from the expertise of the biokinetics profession.[6] compliance with structured habitual physical activities to help support the healthcare management of coronary heart disease, hypertension, obesity, diabetes mellitus and chronic respiratory diseases is financially cheaper and effective.[6,7] furthermore, the inclusion of biokineticists in the public healthcare sector will provide additional skilled clinicians who are able to collaborate with overworked members of the current healthcare system, thereby lessening the overall workload. one of sa’s national healthcare strategies is to increase the physical activity of its citizens; this can be accomplished by the appointment of biokineticists at public hospitals, clinics and schools. continuous planning for the future of any profession is wise. the profession of biokinetics has made remarkable advances since the 1980s. however, new opportunities for development need to be embarked on. this short commentary explores three such areas: training and education; entry into the south african public healthcare system; and interprofessional healthcare collaboration. the intention is to encourage the biokinetics association of south africa and biokineticists to work together to attain these goals, thereby strengthening the profession. afr j health professions educ 2021;13(1):8-9. https://doi.org/10.7196/ajhpe.2021.v13i1.1287 the strategic development and strengthening of the profession of biokinetics b k grobler,1 bsc biokinetics; t j ellapen,2 phd; y paul,2 phd; g l strydom,1 phd (emeritus professor) 1 school of biokinetics, recreation and sport science, faculty of health sciences, north-west university, potchefstroom, south africa 2 department of sport, rehabilitation and dental sciences, faculty of science, tshwane university of technology, pretoria, south africa corresponding author: b k grobler (groblerkatryn@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. april 2021, vol. 13, no. 1 ajhpe 9 forum interprofessional healthcare collaboration a third area of development is the encouragement of interprofessional healthcare collaboration. respect for the sop of fellow health professionals is firmly established through interprofessional education,[8] which is a strong component of the training curriculum of international medical schools. this structure fosters an understanding and appreciation of the place of each profession within the healthcare paradigm, and aids in minimising the encroachment of the clinical sop.[8] biokineticists are not primary healthcare practitioners (as opposed to general practitioners, medical specialists, nurses and physiotherapists); rather, they are finalphase therapists.[2,3] biokinetics training institutions, basa and the hcpsa need to provide continuous education in this area. furthermore, interprofessional collaboration should be extended with international affiliation to the world confederation for physical therapy, as well as to various clinical exercise physiology, sports and rehabilitation medicine, national athletic training and kinesiotherapy associations, all of which are exercise-therapy professions.[8] basa should pursue international collaboration with exercise therapy professions in the usa, canada, the uk, asia, australia, new zealand, namibia and botswana. conclusion a uniform 4-year professional biokinetics bachelor’s degree will ensure a nationally aligned academic programme, mirroring other healthcare professions. admission into the public healthcare system will provide much-needed professional exercise therapy-based management of ncds and orthopaedic injuries, and strengthen the campaign for enhancing health and wellbeing through habitual exercise. interprofessional collaboration, starting at tertiary institutions, will open the door for interprofessional respect and professionalism and eventually culminate in collaboration. collectively, these strategies will strengthen the profession and improve the health and wellbeing of many south africans. declaration. none. acknowledgements. none. author contributions. bkg and tje conceptualised the idea of the article. bkg, tje, yp and gls drafted the article. bkg served as corresponding author. bkg and tje amended the article as per reviewers’ comments. funding. none. conflicts of interest. none. 1. strydom gl. biokinetics – the development of a health profession from physical education – a historical perspective. s afr j res sport phys educ recreat 2005;27(2):113-128. 2. hall j. scope of professions of physiotherapy, podiatry and biokinetics: overlap identification. physiother podiatr biokinet news 2013:8. 3. strydom gl, wilders cj, moss sj, bruwer e. a conceptual framework of biokinetic procedures and referral system: an integrated protocol for the various health paradigms. afr j phys health educ recreat dance 2009;15(4):641-649. 4. ellapen tj, swanepoel m. the evolution of the profession of biokinetics. s afr j res sport phys educ recreat 2017;39(1):41-49. 5. basa ‒ biokinetics association of south africa: guidelines for biokineticists. 2020. http://www.biokinetics.org. za (accessed 30 january 2020). 6. evans rw, smith t, kay p, et al. the need for biokineticists in the south african public health care system. s afr j sports med 2016;28(3):85-86. https://doi.org/10.17159/2078-516x/2016/v28i3a1310 7. ehrman jk, gordon pm, visich ps, keteyian sj. clinical exercise physiology. 3rd ed. champaign, il: human kinetics, 2013. 8. ellapen tj, strydom gl, swanepoel m, hammill hv, paul y. biokinetics. a south african health profession evolving from phyical education and sport. london: intech, 2018. accepted 13 march 2020. http://www.biokinetics.org.za http://www.biokinetics.org.za https://doi.org/10.17159/2078-516x/2016/v28i3a1310 march 2022, vol. 14, no. 1 ajhpe 13 research the advent of covid‑19 and the subsequent lockdown, both nationally and internationally, has catapulted higher education institutions into emergency remote teaching and learning (ert) and the hitherto unchartered realm of digitisation, for many.[1‑4] the agility with which this move was achieved, in terms of making all modules available online, is notable; however, most academics and students were not ready for this paradigm shift.[1,3] online teaching and learning (t&l) represents a reciprocal relationship between students, academics and the course curriculum, through the use of technology and the internet.[5] thus, successful online t&l involves the integration of content (what needs to be taught), pedagogy (what is the best method to teach it) and technology (what is the most appropriate form used to promote content and pedagogy).[6] a principal challenge facing online t&l is the ability to nurture and maintain student motivation during the process and to improve understanding and retention of course content.[7] students may differ widely in their learning preferences, i.e. the preferred way in which they interact  with academic content, and so this consideration, particularly in the context of covid‑19 and ert, requires academics to critically reflect on their curriculum and pedagogy.[7,8] the visual, aural, read/write and kinaesthetic (vark) model presents a means to determine students’ learning preferences but also highlights the necessity and benefits of carefully planned multimedia presentations to encompass the varying preferences.[7] the creation of multimodal learning environments allows the curriculum to be offered using a combination of the vark sensory modes, thus grasping student attention and improving student motivation to learn.[9] although built primarily on theoretical knowledge, the evolution of the basic medical sciences towards an integrated theoretical and practical approach in t&l has largely been adopted.[10] the practical/hands‑on component enhances active learning through visual and kinaesthetic engagement. it is, however, important that the move towards integrated t&l approaches, warranted by the evolution of discipline‑specific trends, complements the type of students typically accessing health sciences qualifications. furthermore, ert, which has caused a gap in supporting this integrated approach to t&l, requires careful consideration to continue supporting and enhancing ongoing student engagement against the backdrop of student learning preferences. while ert encompasses an unexpected interventional shift of t&l delivery to an online platform, it differs from pre‑arranged online courses designed for virtual delivery.[11‑13] hence, most universities and their staff were unprepared and therefore required immediate academic development (in terms of technological skills) and curriculum transformation to meet the demands of online teaching and delivery.[11‑13] academics were required to adapt their subject content as well as create and implement varying types of t&l strategies.[14] the present study used the learning preference profile of undergraduate students in a health sciences faculty to provide an outline of simple modifications in t&l approaches that have been applied to support the this open-access article is distributed under creative commons licence cc-by-nc 4.0. background. the advent of covid‑19 and the subsequent national lockdown has catapulted higher education institutions into emergency remote teaching (ert). a principal challenge in this shift is the ability to stimulate student interest towards engagement with, and retention of, course content. the creation of teaching and learning (t&l) resources and activities using a combination of the visual, aural, read/write and kinaesthetic (vark) modes is fundamental in ensuring student engagement. objectives. to determine the learning style profiles of undergraduate students and to explore how student learning profiles may be incorporated in t&l approaches during ert. methods. this descriptive study profiles the learning preferences of undergraduate students in a health science faculty using the vark questionnaire. the study further outlines modifications in t&l implemented to support the varied learning preferences during the covid‑19 ert response. results. our findings demonstrate that the majority of our students have a multimodal learning preference, with the kinaesthetic modality being the most preferred. voice‑over powerpoint presentations with transitioning images, and audio files, supported the visual and aural learners through asynchronous engagement. additionally, online discussion forums and applied projects (such as theme park designs) enhanced asynchronous learning by stimulating the visual, read/write and kinaesthetic preferences, respectively. microsoft team sessions with powerpoint presentations supported visual and aural learning preferences through synchronous engagement. conclusions. rethinking traditional t&l approaches towards supporting the diverse student learning preferences is critical in student‑centred t&l amidst the many challenges that ert has precipitated. academics need to be dynamic in their t&l approaches and intuitive in their awareness of how subject content may be modified/enhanced in the ert environment. afr j health professions educ 2022;14(1):13‑16. https://doi.org/10.7196/ajhpe.2022.v14i1.1468 teaching and learning considerations during the covid-19 pandemic: supporting multimodal student learning preferences f ally, phd; j d pillay, phd; n govender, phd department of basic medical sciences, faculty of health sciences, durban university of technology, south africa corresponding author: n govender (nalinip@dut.ac.za) https://doi.org/10.7196/ajhpe.2022.v14i1.1468 mailto:nalinip@dut.ac.za 14 march 2022, vol. 14, no. 1 ajhpe research varied learning preferences of students. in response to ert and equipped with awareness of the learning preferences of the current study cohort, availability of student data/connectivity, and heuristic knowledge of the research team,[15] a number of multimodal teaching materials such as voice‑ over powerpoint, audio podcasts and discussion forums were developed. methodology study design this was a quantitative and descriptive study. it comprises two components: the first profiles the learning preferences of undergraduate students in the department of basic medical sciences, faculty of health sciences, durban university of technology (dut), and the second component provides an outline of t&l modifications that were implemented to support the multimodal learning preferences of the student cohort, during the covid‑19 ert response. study population and recruitment all registered 1st‑ and 2nd‑year undergraduate students were informed of the study during selected t&l sessions of the different courses. written informed consent was obtained from interested students (n=495), who completed the demographic and vark questionnaires during their first week of lectures in 2020. ethical approval was obtained from the institutional research ethics committee (rec 153/16). vark questionnaire learning style preferences data were collected using a downloaded copy of the vark questionnaire version 8.01 (http://www.vark‑learn.com/the‑ vark‑questionnaire/). a subscription site specifically for use of the vark questionnaire was purchased and the copyright permission was held by fleming.[16] the vark questionnaire is a 16‑item, self‑reporting multiple‑ choice questionnaire based on four sensory modalities (visual, aural, read/ write and kinaesthetic) which are used for learning and understanding information.[17] data collection demographic data including age and gender were obtained using a self‑ administered questionnaire. the vark questionnaire was administered to all students who provided informed consent. students were informed that they could choose more than one option per question, a recommendation strongly suggested by fleming and mills, and were not compelled to answer all questions, if external to their experience.[17] completed questionnaires were received and results were captured on the vark website (http://site. vark‑learn.com/subscription‑administration/?access=dut) to determine the overall learning preferences and learning modality status of each participant. all responses were scored and results were generated online for each of the vark categories of the questionnaire. data analysis (vark) all data from the vark subscription website were captured onto excel and the scores were statistically analysed using stata version 15, to determine the percentage of students in each category. data were categorised as either a unimodal category (only one of the vark preferences was dominant) or a multimodal category (dominance of more than one preference). the multimodal category was further categorised into bimodal (demonstrating two preferences); trimodal (demonstrating three preferences); and quadrimodal (demonstrating four preferences). data are presented as graphs, frequencies and percentages. demographics (age, gender, race, etc.) were stratified by unimodal v. multimodal learning modality, to determine the student modality preference. demographic variables were further stratified by each category of learning style (vark) to determine the student’s preferred unimodal learning style. a probability value of p<0.05 was considered statistically significant. modifications considered in t&l approaches using the vark data collected from the current student cohort, modifications in t&l strategies and delivery during ert were implemented. these modifications were tabulated and contrasted with conventional t&l practices (table 1). findings and discussion the impact of gender and age on learning preferences is a topic of active research, with previous studies yielding inconsistent results. a 100% response rate was recorded for the vark questionnaire. while previous studies have yielded varied results in terms of gender and learning preferences, the majority (64%) of both the women and men surveyed in this study displayed a multimodal learning preference. this finding is consistent with the findings of previous studies.[9,18] as expected, 95% (n=470) of the population represents generation z. generation z (born between 1996 and 2010), is the generation following the millennials and is described as having a low attention span with great reliance on technology and a need to engage through multiple learning channels.[19] most of the students profiled displayed a multimodal learning preference (64%, n=317) in contrast to 36% (n=178) who displayed a unimodal learning preference (fig. 1). in addition, unimodal preferences, namely kinaesthetic, was noted in 17% of this cohort (n=84), followed by 7% each for aural and read/write (n=35) and 5% for visual (n=25) (fig. 1). moreover, of the 317 students who demonstrated a multimodal learning preference, 26% (n=82) also preferred two modes of presentation (bimodal), 20% (n=63) preferred three modes (trimodal) and the remaining 54% (n=171) preferred four modes of presentation (quadrimodal) (fig.  2). the most prevalent bimodal combination identified was the aural and kinaesthetic (ak) modes (9%, n=29), followed by visual and kinaesthetic table 1. traditional v. emergency remote teaching (ert) and learning approaches traditional t&l approaches modifications during covid-19 ert powerpoint (v/a) audios via podcasts (a) voice‑over powerpoint (v/a) video powerpoint via zoom (v/a/r) microsoft teams sessions (v/a/r) tutorials with demonstrations/ tutors (k/a) discussion forums via engagement with current covid‑19‑related published articles (v/r) applied projects (theme park designs; v/a/r/k) practical sessions (k/a/v) designing online activities (k/v/r) textbooks* (r) hardcopy notes (r) virtual sessions with powerpoint on key concepts (v/a) primary learning modes are indicated in parentheses. v = visual; a = aural; r = read/write; k = kinaesthetic. *textbook availability during ert was limited for many students as a result of emergency evacuation from residence and bursary‑related issues. http://www.vark-learn.com/the-vark-questionnaire/ http://www.vark-learn.com/the-vark-questionnaire/ http://site.vark-learn.com/subscription-administration/?access=dut http://site.vark-learn.com/subscription-administration/?access=dut march 2022, vol. 14, no. 1 ajhpe 15 research (vk) modes (7%, n=22), read/write and kinaesthetic modes (rk) (5%, n=16), visual and read/write (vr) mode (3%, n=9), visual and aural (va) modes (1%, n=3) and aural and read/write (ar) modes (1%, n=3) (fig. 2). the most prevalent trimodal combination identified was the aural, read/ write and kinaesthetic modes (ark) (8%, n=25) and the visual, aural and kinaesthetic modes (vak) (8%, n=25), followed by the visual, read/ write and kinaesthetic modes (vrk) (3%, n=9) (fig.  2). the least popular trimodal combination was the visual, aural and read/write (var) mode (1%, n=3). we highlight the kinaesthetic learning preference as the most frequently used style, followed by read/write and aural (table  1). an earlier report suggested that embracing t&l strategies that complement one’s learning style may improve learning outcomes, in contrast to those that oppose one’s preferences.[16] interestingly, 64% (n=317) of our total sample were multimodal learners, which is in agreement with various other studies.[18,20‑22] multimodality was highlighted in our study as the most prominent learning preference in the genz subgroup as well as in male and female subgroups. this generation is known to require stimulation through multiple learning channels, hence a more diverse array of t&l strategies in an ert platform will augment successful learning outcomes. traditional t&l delivery incorporates face‑to‑face classroom lectures, with the use of resources such as textbooks, chalkboard, anatomical models, tutorials and practical manuals (atlases and dissection guides) as  well as online repositories through learning managements systems such as moodle.  furthermore, during the face‑to‑face lecture delivery, students deliberately used their smartphones to voice‑record real‑time lectures which  appeased their aural and read/write preferences when accessing outside class  time. given that most students are multimodal learners, it  is  essential that our digitised delivery incorporates multimodal strategies,  focussing on the use of auditory and kinaesthetic styles. despite the limitations associated with online t&l, a recent study suggests that tactile stimuli achieved through  touching and interacting with laptops  and pcs may augment the learning experience of the kinaesthetic learner.[23] it is presumed that auditory learners prefer aural resources to enhance the learning and understanding  of content, following which they are empowered  to  interrogate their understanding and translate to read/ write style. several studies recommend a multimodal delivery to improve student learning.[20,24,25] for example, a study conducted by peter et al.[26] substantiates the integration of digitised learning with vark learning preferences, advocating the use of online resources aligned with learning categories, to improve ongoing student engagement and increase the efficiency of online learning.[26] our observations suggest that traditional t&l strategies support visual and aural learners. during the covid‑19‑induced ert, it was evidently difficult to accommodate all learning preferences, as delivery of resources occurred predominantly through the virtual classroom which primarily supports the aural and read/write learning styles. hence, the ability to adopt strategies that respond to the multimodal learner requires much reflection and consideration. an outline of various strategies/modifications applied during 2020’s ert approach is demonstrated and contrasted with traditional t&l approaches (table  1). the activities also highlight the primary modes of learning supported in each approach in an attempt towards demonstrating simple modifications to traditional t&l that can be made in ensuring that multimodal learning preferences are supported. the implementation of various synchronous and asynchronous online activities during ert shown in table  1, was aimed at maintaining the ongoing engagement of multimodal learners. asynchronous engagement was encouraged through the use of voice‑over powerpoint presentations with transitioning images, and audio files. this mode enables students to visualise and listen to the explanations of the content simultaneously, which supports both the visual and aural learners. moreover, the use of voice‑over powerpoint, for example, had to be designed to ensure that the intensity and pitch of speech was adequate to support student engagement. recorded powerpoint videos and audio files further allowed students to move through lecture presentations at their own pace by pausing and moving forwards and backwards when necessary for self‑reinforcement. in light of the lack of tutorial and practical sessions, the option of integrating relevant study outcomes (e.g. the cardiovascular system) with online discussion forums supported the visual and read/write preferences. additionally, the use of applied projects (such as theme park designs) enhanced student engagement unimodal, 36% multimodal, 64% k, 17% 64% v, 5% a, 7% r, 7% fig. 1. unimodal v. multimodal learning preferences of students. vark, 54% ak, 9% rk, 5% vk, 7% ar, 1% va, 1% vr, 3% ark, 8% vak, 8% var, 1% vrk, 3% fig. 2. distribution of students’ multimodal learning preferences. 16 march 2022, vol. 14, no. 1 ajhpe research by stimulating their vark preferences. the use of weekly microsoft teams sessions with powerpoint on key concepts encouraged synchronous engagement, which subsequently stimulated the visual and aural learning preferences. these sessions also encouraged student engagement by creating a virtual platform and forum questions and discussions in the virtual classroom. strengths of the study the present study is among the first, to our knowledge, that highlights the need for academics to be dynamic in their t&l approaches and intuitive in their awareness of how students may perceive and interact with their subject content in the ert climate. limitations and recommendations this cross‑sectional study was only conducted among first‑ and second‑year students from the faculty of health sciences, consequently restricting us in generalising the data to all students. moreover, it is possible that as students progress into later years, their learning style preferences may change. assessments have also not been highlighted in this study. it is possible that the use of virtual assessments such as mcqs/true/false questions, among kinaesthetic and aural learners, may compromise their overall assessment outcomes as the learning preferences of these learners may differ from these modes. conclusion the shift to the use of the multimodal strategies such as audios via podcasts, voice over powerpoint/zoom videos, microsoft teams and discussion sessions enhanced the learning process. this finding is reflected in student feedback reports, emphasising general student satisfaction with resources provided and their flexibility for asynchronous use. navigating through the unchartered territories of ert therefore requires the academic to creatively improve the quality, delivery and diversity of online resources that promote ongoing student engagement. learning style preferences is a critical consideration in the delivery of online t&l within this context. rethinking traditional t&l approaches towards supporting the diverse student learning preferences is critical in student‑centred t&l amidst the many challenges that ert has precipitated. considering modifications in traditional t&l approaches to ensure that multimodal learning preferences are supported, is therefore warranted. declaration. none. acknowledgements. the authors thank sapna ramdin for her administrative assistance. author contributions. fa: conceptualisation and design of study, data collection, preparation and finalisation of manuscript. jdp: assistance with editing and preparation and finalisation of manuscript. np: conceptualisation and design of study, data collection, data analysis, and preparation and finalisation of manuscript. funding. the authors thank the centre for excellence in learning and teaching (celt), durban university of technology, for their financial assistance. conflicts of interest. none. 1. bao w. covid‐19 and online teaching in higher education: a case study of peking university. hum behav emerg technol 2020;2(2):113‑115. https://doi.org/10.1002%2fhbe2.191 2. goh p‑s, sandars j. a vision of the use of technology in medical education after the covid‑19 pandemic. med ed publish 2020;9:1‑8. https://doi.org/10.3946%2fkjme.2021.197 3. toquero c. challenges and opportunities for higher education amid the covid‑19 pandemic: the philippine context. pedagogical research 2020;5(4):1‑5. https://doi.org/10.29333/pr/7947 4. shehata mh, abouzeid e, wasfy n, abdelaziz a, wells rl, ahmed sa. medical education adaptations post covid‑19 ‑ an egyptian reflection. j med educ curric dev 2020;7:1‑9. https://doi.org/10.1177/2382120520951819 5. barr ba, miller sf. higher education: the online teaching and learning experience. online submission. 2013:1‑ 23. https://files.eric.ed.gov/fulltext/ed543912.pdf (accessed 30 november 2020). 6. aguilar sj. a research‑based approach for evaluating resources for transitioning to teaching online. info learn sci 2020:1‑10. https://doi.org/10.1108/ils‑04‑2020‑0072 7. zhang k, bonk cj. addressing diverse learner preferences and intelligences with emerging technologies: matching models to online opportunities. canadian journal of learning and technology/la revue canadienne de l’apprentissage et de la technologie. 2009;34(2):1‑14 8. becker k, kehoe j, tennent b. impact of personalised learning styles on online delivery and assessment. campus‑ wide info syst 2007;24(2):105‑119. https://doi.org/10.1108/10650740710742718 9. renuga m, vijayalakshmi v. applying vark principles to impart interpersonal skills to the students with multimodal learning styles. life sci j 2013;10(2):55‑60. 10. mcmenamin pg. body painting as a tool in clinical anatomy teaching. anat sci educ 2008;1(4):139‑144. https:// doi.org/10.1002/ase.32 11. mohmmed ao, khidhir ba, nazeer a, vijayan vj. emergency remote teaching during coronavirus pandemic: the current trend and future directive at middle east college oman. innov infrastruct solut 2020;5(3):72‑83. https:// doi.org/10.1007/s41062‑020‑00326‑7 12. durak g, çankaya s. emergency distance education process from the perspectives of academicians. asian j distance educ 2020;15(2):159‑174. 13. whittle c, tiwari s, yan s, williams j. emergency remote teaching environment: a conceptual framework for responsive online teaching in crises. info learn sci 2020;(5/6):311‑319. https://doi.org/10.1108/ils‑04‑2020‑0099 14. ferri f, grifoni p, guzzo t. online learning and emergency remote teaching: opportunities and challenges in emergency situations. societies 2020;10(4):1‑18. https://doi.org/10.3390/soc10040086 15. bailey dr, lee ar. learning from experience in the midst of covid‑19: benefits, challenges, and strategies in online teaching. computer‑assisted language learning. electr j 2020;21(2):178‑198. 16. fleming nd. the case against learning styles: "there is no evidence...’. 1st ed. christchurch: vark learn limited; 2012;3:1‑3. 17. fleming nd, mills c. helping students understand how they learn. the teaching professor 1992;7(4):44‑63. 18. prithishkumar ij, michael s. understanding your student: using the vark model. j postgrad med 2014;60(2):183‑ 186. https://doi.org/10.4103/0022‑3859.132337 19. singh ap, dangmei j. understanding the generation z: the future workforce. south‑asian j multidiscipl stud 2016;3(3):1‑5. 20. samarakoon l, fernando t, rodrigo c, rajapakse s. learning styles and approaches to learning among medical undergraduates and postgraduates. bmc med educ 2013;13(1):1‑6. https://doi.org/10.1186/1472‑6920‑13‑42 21. farkas gj, mazurek e, marone jr. learning style versus time spent studying and career choice: which is associated with success in a combined undergraduate anatomy and physiology course? anat sci educ 2016;9(2):121‑131. https://doi.org/10.1002%2fase.1563 22. martinez eg, tuesca r. learning styles and gross anatomy assessment outcomes at a colombian school of medicine. educ médica 2019;20(2):79‑83. https://doi.org/10.1016/j.edumed.2017.12.012 23. seyal ah, rahman mna. understanding learning styles, attitudes and intentions in using e‑learning system: evidence from brunei. world j educ 2015;5(3):61‑72. https://doi.org/10.5430/wje.v5n3p61 24. parashar r, hulke s, pakhare a. learning styles among first professional northern and central india medical students during digitisation. adv med educ pract 2019;10:1‑5. https://doi.org/10.2147%2famep.s182790 25. choudhary r, dullo p, tandon r. gender differences in learning style preferences of first year medical students. pak j physiol 2011;7(2):42‑45. 26. peter s, bacon e, dastbaz m. learning styles, personalisation and adaptable e‑learning. in: uhomoibhi j, ross m, staples g, editors. 14th international conference on software process improvement research, education and training, inspire 2009. swindon, uk: british computer society; 2009:77‑87. accepted 3 may 2021. https://doi.org/10.1002%2fhbe2.191 https://doi.org/10.3946%2fkjme.2021.197 https://doi.org/10.29333/pr/7947 https://doi.org/10.1177/2382120520951819 https://files.eric.ed.gov/fulltext/ed543912.pdf https://doi.org/10.1108/ils-04-2020-0072 https://doi.org/10.1108/10650740710742718 https://doi.org/10.1002/ase.32 https://doi.org/10.1002/ase.32 https://doi.org/10.1007/s41062-020-00326-7 https://doi.org/10.1007/s41062-020-00326-7 https://doi.org/10.1108/ils-04-2020-0099 https://doi.org/10.3390/soc10040086 https://doi.org/10.4103/0022-3859.132337 https://doi.org/10.1186/1472-6920-13-42 https://doi.org/10.1002%2fase.1563 https://doi.org/10.1016/j.edumed.2017.12.012 https://doi.org/10.5430/wje.v5n3p61 https://doi.org/10.2147%2famep.s182790 june 2022, vol. 14, no. 2 ajhpe 83 research the current healthcare context requires professionals to work collaboratively to provide the best possible care.[1] interprofessional education (ipe) is an approach that facilitates learning from, with and about one another to allow for more effective collaboration in the delivery of safe and high-quality person-centred care.[2-5] the world health organization framework on ipe and collaborative practice[2] suggests that exposure to ipe creates the opportunity to develop skills to join the workforce as collaborative practiceready practitioners. although educators may prepare health professions students to understand the roles of team members to develop their capacity to communicate outside the boundaries of their own profession,[6] offering shared learning opportunities is still a challenge in health education.[7] people with stroke require management by an interprofessional team, owing to the related functional implications and long-term morbidity of this condition.[8,9] mortality due to stroke has decreased, leading to more survivors with disabilities,[10] increasing the burden of care, particularly for poor people in urban and rural settings.[10] this results in a greater demand for community-based stroke rehabilitation,[11] often provided as group-based interventions.[12] these group-based interventions, often called group therapy, may involve a few patients (with similar impairment or levels of disability) who receive an exercise or education class, facilitated by a single therapist.[13] it is therefore plausible that a single therapist may be inclined to provide a more profession-specific intervention, such as a physiotherapist  focusing mainly on lower-limb strengthening or balance re-education.[12] these traditional group-based interventions provide peer support and create the opportunity for patients to interact socially. according to english et  al.,[12] circuit-based interventions involve a more ‘tailored intervention program, focusing on the practice of functional tasks received within a group setting […] and could involve participants physically moving between workstations’. circuit-based interventions allow for targeting of multiple impairments and functional limitations by fewer healthcare professionals, which is ideally suited to resource-constrained environments where one is able to simultaneously address the needs of more patients. circuit-based interventions therefore allow for intensive practice of specific exercises or functional tasks with more than two participants per therapist.[13] the repetitive practice of functional tasks engages patients in tasks graded to suit individual needs, and encompasses group dynamics, including peer support and psychosocial benefits.[13] this approach provides a costand time-efficient alternative for community-based stroke rehabilitation.[14] interprofessional circuit-based therapy, in which different stroke rehabilitation therapists contribute to the structure and facilitation of workstations on the circuit, could be a clinical activity to counter so-called tribalism, in which professions tend to act in isolation.[15] it could also provide opportunities for mutual learning, which is a recognised need to remodel health professions education.[15] however, there is no evidence on the potential value of an interprofessional approach to communitybased stroke intervention on student learning in the clinical training of this open-access article is distributed under creative commons licence cc-by-nc 4.0. background. collaborative approaches in healthcare contexts may provide better care for patients. interprofessional circuit-based group therapy could counter profession-specific tribalism. there is no evidence on interprofessional education (ipe) community-based interventions on student learning in the health professions. objective. to explore undergraduate health sciences students’ experience of being involved in community-based interprofessional circuit-based group therapy. methods. semi-structured interviews were inductively analysed exploring undergraduate health sciences students’ experience of involvement in an ipe community-based stroke intervention. results. a total of 12 final-year students participated, with representation from physiotherapy, occupational therapy and speech therapy. this ipe opportunity beneficially impacted students’ collaborative competencies in knowledge, attitudes, skills and behaviours. this community-based rotation immersed students in a service-delivery environment where patient management was co-ordinated by a multiprofessional rehabilitation team. the integrated stroke circuit group activity aimed to enhance further interconnectedness between student participants. students who were exposed to this clinical activity reported an understanding of (i) patients’ unique contexts; (ii) role development and complementary overlap between health professions; and (iii) the value of joint interventions to both patients and rehabilitation teams in resource-constrained settings. conclusion. these students have been primed in their practice-readiness as healthcare professionals for the 21st century who will promote quality care, and embrace collaborative professional practice and person-centredness. afr j health professions educ 2022;14(2):83-88. https://doi.org/10.7196/ajhpe.2022.v14i2.1341 the lived experience of health sciences students’ participation in an interprofessional community-based stroke class m kloppers,1 m ot; f bardien,2 bsc logopaedics, m audiology; a titus,3 m physio; j bester,1 b ot, mphil he; g inglis-jassiem,3 m physio 1 division of occupational therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 division of speech, language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 division of physiotherapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m kloppers (maatje@sun.ac.za) https://doi.org/10.7196/ajhpe.2022.v14i2.1341 mailto:maatje@sun.ac.za 84 june 2022, vol. 14, no. 2 ajhpe research healthcare professionals. this necessitated exploring the lived experiences of undergraduate health sciences students while planning and executing a community-based interprofessional functional circuit-group activity (ifcga) during a clinical rotation. methods the research was conducted at a community-based rehabilitation centre that offered individual and group rehabilitation services provided by health sciences students, including medical and dietetics students, facilitated by qualified therapists. to facilitate holistic care at this resource-constrained clinical site, an interprofessional approach for clients with stroke was sought by the managing healthcare professional team, which entailed collaborative planning and execution of stroke group classes (e.g. using single stations in a circuit class to address multiple therapeutic goals). this integrated circuit group activity was similar to the circuit class therapy proposed by english et  al.[13] to save time, space and manpower. one of the adaptations included that all group members at a station (6 10 stroke group members) had to engage in activities that contributed toward the collaborative goals as planned by the healthcare professionals. in addition, multiple ‘circuit stations’ were uniquely integrated into a storyline that more closely simulated real-life situations, feeding into an overarching theme for each group class. themes were purposely chosen based on challenges identified by members of the stroke group (e.g. grocery shopping after receiving a social grant). storylines were developed by the healthcare professionals to target multiple impairments and functional disabilities of stroke group members (which were assessed prior to inclusion in the group class). these storylines therefore targeted multiple domain-related goals of the international classification of functioning[16] (body functions and structures, activity and participation) such as independence in physical shopping tasks, plus treating memory deficits by, for example, drafting a shopping list. group members with stroke were encouraged to help each other if or when needed to closely simulate real-life scenarios (e.g. asking fellow shoppers for assistance in a busy store). final-year undergraduate students (speech-language and hearing, and occupational and physiotherapy) who received clinical training at this site were included in the planning and execution of the stroke group classes. the  managing healthcare professionals provided an orientation session to all students where the aims and processes of the functional circuit-group class were explained. the students were allowed to self-select peers from the three different professions to form smaller groups, who were then responsible for the planning and execution of a specific station. due to the disproportionate number of students placed at the clinical site, some of these peer groups had more physiotherapy and/or occupational therapy students. the clinical site’s managing healthcare professionals and academic staff from the three divisions provided support and mentoring to the smaller peer groups during their initial planning session, as well as the final planning session before the stroke group class. during these two sessions, staff facilitated peer groups on aspects such as: (i) alignment between their therapeutic goals and selected activities; (ii) the feasibility, resource requirements and time allocation of each station; and (iii) the flow and cohesion between different stations to contribute to the holistic storyline of the stroke group class. students were encouraged to meet separately as many times as they deemed necessary, whether face-to-face or via email and messages. staff were also available to the smaller peer groups during the interim period for troubleshooting via email and/or cellular phone messages. a final walk-through presentation of the circuit stations was done a few days before the stroke group class, with peer groups describing their activities to each other and the managing staff. although all staff were available for potential contingency management on the day of the stroke group class, the whole activity was independently managed and executed by the students. a descriptive phenomenological design was followed in this study, which allowed for a description of the ‘lived experiences of individuals’.[17] final-year undergraduate students from three health sciences divisions (speech-language and hearing, and occupational and physiotherapy) were purposively sampled. potential participants were approached if they were first-time final-year students and involved in the joint planning and execution of the ifcga (with no prior experience of ifcga). all students who fulfilled the criteria participated in the study. semistructured individual interviews were conducted with the students by an independent experienced interviewer within 3 working days following the ifcga. an interview guide with predetermined openended questions was used to question participants regarding their roles and experiences during the planning and execution phases of the ifcga. the audiorecorded interviews were transcribed verbatim by nonaffiliated individuals. thematic analysis was conducted by the research team to delineate emerging themes. the framework of burnard[18] was used to analyse the transcriptions inductively. ethical and institutional approval was obtained before commencement of the study (ref. no. hrec n18/02/2019). participant information was de-identified during the interview process by not referring to their names on the recording to ensure anonymity. trustworthiness and credibility were addressed by using an independent interviewer and peer examination of the themes by various members of the interprofessional research team. providing relevant information about the research process and context, procedures, research participants and interviewers addressed transferability. clear and comprehensive documentation of the research procedure enables replication of the study, which addressed dependability. research team members familiar with qualitative research addressed confirmability. results twelve students participated (i.e. two physiotherapy, four occupational therapy and six speech, language and hearing therapy students) in the study. all participants were involved in the joint planning and execution of the ifcga during their clinical rotation at the community-based rehabilitation centre. three themes emerged from the data analysis, namely: (i) ipe wheel; (ii) tandem riding; and (iii) rolling effects. each theme and its categories are depicted in figs 1 3. the analogy of a bicycle has been used to illustrate the interconnectedness of themes. theme 1: ipe ‘wheel’ theme 1, outlined in fig.  1, highlights the ipe experiences of students participating in ifcga, and reflects an iterative learning cycle of planning, execution and reflection. this learning cycle pivots around patients, their context and preferences, with momentum provided through facilitation and role-modelling by the ipe rehabilitation team. the three categories of this theme represent the bicycle wheel and its component parts (central ‘axis’, ‘spokes’ and ‘tyre’). the ‘central axis’ category represents person-centredness, where students recognised the patient as a person and developed insight into the value of june 2022, vol. 14, no. 2 ajhpe 85 research person-centred outcomes. the ‘spokes’ represent the experiential learning cycle provided by interactive learning opportunities from planning to execution of the ifcga, where repetition allowed students to make clinical adjustments. the ‘tyre’ category emphasises the teaching approach, rolemodelling and facilitation by the rehabilitation team providing impetus for the students’ learning. table  1 contains verbatim quotations in support of the categories and subcategories of this theme. theme 2: ‘tandem riding’ collaborative teamwork, such as two cyclists working together in tandem to achieve an easier and efficient riding experience, was required (fig.  2). students affirmed their own and others’ professional scope and the value of complementary overlap between professions. integrated planning and execution led to group cohesion, which fostered learned reliance and appreciation for working together. the second theme consists of two categories: (i) scope of practice; and (ii) teamwork and collaboration. the first category encompasses the scope progression experienced during collaborative participation in the ifcga. principles of teamwork such as communication, shared responsibility and collaborative goal-setting in category 2 led to a positive experience of interdependence among students. table  2 contains verbatim quotations in support of the categories and subcategories of theme two. theme 3: ‘rolling effects’ if the ipe wheel (theme 1) and collaborative tandem riding (theme 2) had occurred, the resultant ‘tyre tracks’ allowed for successful ipe interventions for all involved. theme 3 (fig.  3) describes the students’ perception of these effects on various role-players. students valued the positive learning environment created by this ipe activity, which triggered their curiosity to learn and resulted in perceived improvement of their clinical skills. table  3 provides verbatim quotations in support of the category relating to the effects for students. the ‘service delivery’ category highlighted how students valued the realistic simulation, patient challenges and logistical implications. students acknowledged the improved motivation and patient participation in this real-life simulated group activity. table 4 highlights verbatim quotations in support of the category ‘effects on service delivery and patients’. insight into the value of patient-centred functional outcomes central axis spokes tyre theme 1: ipe 'wheel' seeing the patient as a person planning process practical considerations clinical learning opportunities o�ered by the circuit facilitation role-modelling fig. 1. theme 1: interprofessional education ‘wheel’. theme 2: 'tandem riding' bicycle frame: scope of practice bicycle chain: teamwork and collaboration role-release learned reliance creating an 'us' own scope others' scope recognition of complementary overlapping fig. 2. theme 2: ‘tandem riding’. theme 3: 'rolling e�ects’ e�ects for students e�ects on service delivery and patients community reintegration bene�t challenges clinical experience clinical skills space and time fig. 3. theme 3: ‘rolling effects’. 86 june 2022, vol. 14, no. 2 ajhpe research discussion the findings of this study highlighted the experiences of undergraduate physiotherapy, occupational, and speech and language therapy students exposed to an interprofessional clinical learning activity in a community setting. responses reflected a positive impact on self-development and a realised codependency on other team members, including patients, in achieving health outcomes. students recognised patients by no longer viewing them as passive recipients of therapeutic input, but rather autonomous beings who could direct and contribute to their own healthcare management. students’ understanding of their own role expanded when they identified the unique and valuable contribution that their profession could make. the collaborative planning and execution of the stroke group class allowed them to incorporate team goals and to role-release in the absence of another profession. this encouraged thinking beyond their specific professional role.[6] planning and working collaboratively also fostered table 1. quotations in support of categories and subcategories of theme 1: ipe ‘wheel’ category subcategory quote central axis insight into value of person-centred functional outcomes ‘i definitely saw the value in doing intervention in such a way. it’s practical. it’s relevant to them … it’s very real to them, i mean, they have to go to the shop and be able to complete that activity … so, i can definitely saw the value in it for the patients.’ (180 183;12)* seeing patient as a person ‘it was so nice and it was actually rewarding for you to see what your patients can do and especially those who thought they could not do it for example cutting.’ (354 361;1) spokes planning process ‘we used whatsapp to plan … also made a google doc where we all stated our goals … with the planning we just sat and brainstormed … that’s how we started planning – what’s the story, what problems are we going to put in between what they have to solve … just lots of ideas thrown together and then we decided that ok we like this, it will work or that will not work … everybody had his own goals … so we each set our goals according to what we think and then we explained it to each other so that we could all facilitate.’ (84 -113;1) practical considerations ‘… was very limited space to move around for the patients.’ (108;5) ‘the structuring… we could have used our space a bit better. plan … better.’ (189 196;12) clinical learning opportunities offered by the circuit ‘it was the first time we had to plan a … activity that was larger than just with a single individual patient … and, i could really see the value in the team working together and having the functional circuit include all three disciplines.’ (101-106;12) ‘…with the first round is always a bit of a trial run to see how it works. and after that one adapts a little to the patients.’ (91-93;6) tyre facilitation ‘then our supervisors also went to the different places and they asked okay what are you planning and they gave us ideas on how we can make it more functional, difficult and more realistic.’ (45 48;4) role-modelling ‘the way they explained it to us about how we should tackle it also helped a lot. because we got a good overview of what we’re going to do.’ (173 177;2) ipe = interprofessional education. *transcription line start transcription line end; participant number. table 2. quotations in support of the categories and subcategories of theme 2: ‘tandem riding’ category subcategory quote bicycle frame: scope of practice own scope ‘sometimes it … feels like we overlap in a lot of things. and for me it was just like … this is what ots do. so, i think it was nice for me to realise in that moment that we are unique.’ (55 61;3)* others’ scope ‘the misperceptions we had about each other’s professions and that we had the opportunity to break down those preconceived ideas, and to know more about each other’s professions … it also helped us to have more respect for each other’s professions and … there is a place for everyone’s profession and our patients need us all. there is an area that we can all make a difference and even if we work together, there is so much more opportunity to make a bigger difference, which was wonderful for me to see … how well one can work together.’ (391 399;1) recognition of complementary overlapping ‘it’s nice to have sessions with them, instead of separately. where we can just target the same ... similar things.’ (81 83;5) bicycle chain: teamwork and collaboration role-release ‘we learned a lot from each other … how to work with each other … i know we have to stick to your field. but i think it’s an important skill to learn. if you are in a place next year and there is no ot or a speech, you can still give a little bit of that knowledge to the patient.’ (272 283;2) learned reliance ‘it was half, are they going to understand the whole point, are they going to do it right, will your other professions also understand what your goal is, for example the speech therapist will they know that she should not just give the scissors – the patient should actually stretch for it.’ (335 339;1) creating an ‘us’ ‘there was no way that i could have said that i did it all, or the physio did it all. we really did it together.’ (292 293;3) ot = occupational therapist. *transcription line start transcription line end; participant number. june 2022, vol. 14, no. 2 ajhpe 87 research a deeper understanding of others’ roles, which is a core competency for person-centred collaborative practice.[19] these final-year students also approached patient management holistically to reach overarching functional goals, which highlighted how shared learning opportunities led students to not only appreciate their distinctive roles, but also what they could offer to patients.[6] providing interprofessional clinical practice training enhances respect for other professionals, including opportunities to value interprofessional care in delivering effective healthcare.[20] similar positive outcomes to learners’ experience of ipe were reflected in a recent review, which reported enhanced understanding of the roles and responsibilities of other professionals, beneficial changes in perceptions of other professionals and the overall value of working collaboratively.[21] the nature of this clinical activity (ifcga) lends itself to creating a cohesive ‘us’. this cohesiveness stemmed from joint communication, clear expectations of an integrated end-goal, a shared passion for helping others and the requirement of close co-operation with different professions. working together with peers from other professions became a less threatening learning opportunity, and peer-to-peer teaching allowed freedom to approach each other. the students were also able to observe collaboration between clinicians from different professions. students reported feeling more confident in seeking collaboration after this exposure, including when starting their professional careers. the ifcga provided a platform for collaborative learning in an interprofessional environment that fostered the development of effective working relationships with fellow healthcare professionals, as described by guraya and barr.[7] through the collaborative ifcga activity, students identified benefits for service delivery, the patients and themselves. they noted that it reduced the service delivery load while providing care to more people, in less time and with fewer resources. a core assumption of ipe is thus highlighted by the better use of scarce resources through enhanced collaboration between professionals.[3,21] students felt that they were providing more contextually appropriate treatment to achieve residential and community reintegration, thus realising that patients bring a wealth of knowledge and experience to the clinical encounter. this form of role-release to the patient highlighted patient-centredness and how patients became partners in their recovery trajectory. conducting the activity in a group context was also thought to contribute to the socioemotional peer-to-peer support patients needed to foster hope for their recovery.[13,22] realistic simulation of everyday activities allowed students to see how patients engaged with enjoyment, which carried over to the students’ experience. these students recognised the role that facilitators fulfilled in supporting the formulation of goals and ensuring equal participation by interprofessional team members, including students, thus highlighting the value of facilitators in creating a learning environment conducive to collaborative learning experiences.[3] future research it is recognised that the staff who facilitated this ipe activity may have influenced the students’ experience, owing to their commitment and belief in this teaching and learning strategy. the experiences and characteristics of the ipe facilitators could be explored in future studies. conclusion the ifcga clinical opportunity beneficially impacted final-year health professions students’ collaborative competencies in their knowledge, attitudes, skills and behaviours. health sciences students at stellenbosch university are exposed to ipe theory and philosophy in preclinical years that are accompanied by regular contact with various professions during clinical training. students who participated in this study were immersed in a service-delivery environment where patient interventions table 3. quotations in support of the category: effects for student subcategory quote clinical experience ‘it was … a learning experience for us … in theory it works different to how it worked practically.’ (130 132;5)* ‘overall, it was a good experience ... it’s something that i will then take with me in my actual practice one day.’ (200 201;12) clinical skills ‘and some groups had patients who struggled a little bit more so then we adjusted a little for them, gave some more support and so.’ (115 117;6) ‘the first session was so trial and error, because we had the planning and then we did it the way we wanted to do it … it does not work so well. then we made some adjustments again … so we could have given more facilitation to the people who needed it.’ (120 136;7) *transcription line start transcription line end; participant number. table 4. quotations in support of the category: effects on service delivery and patients subcategory quote space and time ‘there is no time to see one patient for 3 hours a day, going to a physio for an hour, an hour to occupational and then an hour to speech therapist, while you can do activities where you can actually find all three professions’ purpose in one activity.’ (167 170;1)* community reintegration ‘at the end of the day it’s all that our therapy is about – to get the person to function in society.’ (67 77;4) benefits ‘if you actually create the opportunity for them … to still say, “i’m here for you to help you,” but just to stand back a little bit that they themselves can see that they are able to do so.’ (132 136;7) ‘i realised it’s amazing how when someone understands where you coming from, how much they’re more likely to listen to you. so, i think the circuit really helped me to see the value of that. like, what that interaction … how much value it can add to that person.’ (193 197;3) challenges ‘because i don’t always think they know why they are doing these things … we want to make it realistic … you don’t tell them why … because we just want to present it in a natural, realistic way.’ (171 175;4) *transcription line start transcription line end; participant number. 88 june 2022, vol. 14, no. 2 ajhpe research are co-ordinated by a multiprofessional rehabilitation team that conducts weekly planning discussions (based on the international classification of functioning[16] framework) and joint home-based therapy visits. within this already rich ipe clinical context, the ifcga was nested to enhance further interconnectedness between students. scaffolding these students’ collaborative competencies has brought them closer to future professional practice. these students have been primed in their practice readiness as healthcare professionals for the 21st century who will embrace teamwork, which promotes quality person-centred care. declaration. none. acknowledgements. the research team wish to thank mrs l kleineibst, physiotherapist at the bishop lavis rehabilitation centre, for her invaluable input in the conceptualisation of the integrated circuit group activity and her dedication to student training on the clinical platform. author contributions. all authors contributed to the conceptualisation of the project and manuscript, data analysis and content development. they all participated in the critical review of the intellectual content, and approved the final version of the manuscript. funding. fund for innovation and research into learning and teaching at stellenbosch university. conflicts of interest. none. 1. takahashi s, brissette s, thorstad k. different roles, same goal: students learn about interprofessional practice in a clinical setting. nurs leadersh 2010;23(1):32-39. https://doi.org/10.12927/cjnl.2010.21727 2. gilbert jhv, yan j, hoffman sj. a who report: framework for action on interprofessional education and collaborative practice. j allied health 2010;39(2):196-197. http://www.who.int/hrh/resources/framework_ action/en/ (accessed 11 february 2019). 3. reeves s, fletcher s, barr h, et al. a beme systematic review of the effects of interprofessional education: beme guide no. 39. med teach 2016;38(7):656-68. https://doi.org/10.3109/0142159x.2016.1173663 4. thistlethwaite j. interprofessional education: a review of context, learning and the research agenda. med educ 2012;58-70. https://doi.org/10.1111/j.1365-2923.2011.04143.x 5. ateah ca, snow w, wener p, et  al. stereotyping as a barrier to collaboration: does interprofessional education make a difference ? nurse educ today 2011;31(2):208-213. https://doi.org/10.1016/j. nedt.2010.06.004 6. konrad sc, browning dm. relational learning and interprofessional practice: transforming health education for the 21st century. work 2012;41:247-251. https://doi.org/10.3233/wor-2012-1295 7. guraya sy, barr h. the effectiveness of interprofessional education in healthcare: a systematic review and metaanalysis. kaohsiung j med sci 2018;34(3):160-165. https://doi.org/10.1016/j.kjms.2017.12.009 8. hilari k. the impact of stroke: are people with aphasia different to those without? disabil rehabil 2011;33(3):211218. https://doi.org/10.3109/09638288.2010.508829 9. kirkevold m. the unfolding illness trajectory of stroke. disabil rehabil 2002;24(17):887-898. https://doi. org/10.1080/09638280210142239 10. mayosi bm, flisher aj, lalloo ug, sitas f, tollman sm, bradshaw d. the burden of non-communicable diseases in south africa. lancet 2009;374:934-947. https://doi.org/10.1016/s0140-6736(09)61087-4 11. wasserman s, de villiers l, bryer a. community-based care of stroke patients in a rural african setting. s afr med j 2009;99(8):579-583. https://doi.org/10.1111/j.1747-4949.2009.00275.x 12. english c, hillier s, stiller k, warden-flood a. circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial. arch physical med rehab 2007;88(8):955-963. 13. english c, hillier s, lynch e. circuit class therapy for improving mobility after stroke. cochrane database syst rev 2017;6:cd007513. https://doi.org/10.1002/14651858.cd007513.pub3 14. wevers l, van der port i, vermue m, mead g, kwakkel g. effects of task-oriented circuit class training on walking competency after stroke. stroke 2009;40:2450-2459. https://doi.org/10.1161/strokeaha.108.541946 15. frenk j, chen l, bhutta za, et al. health professionals for a new century: ttransforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 16. world health organization. towards a common language for functioning, disability and health icf. geneva: who, 2002. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf (accessed 27 september 2017) 17. creswell j, miller d. determining validity in qualitative inquiry. theory pract 2000;39(3):124-130. https://doi. org/10.1207/s15430421tip3903_2 18. burnard p. a method of analysing interview transcripts in qualitative research. nurse educ today 1991;11(6):461466. https://doi.org/10.1016/0260-6917(91)90009-y 19. lait j, suter e, arthur n, deutschlander s. interprofessional mentoring: enhancing students’ clinical learning. nurse educ pract 2011;11(3):211-215. https://doi.org/10.1016/j.nepr.2010.10.005 20. pinto a, lee s, lombardo s, et  al. the impact of structured inter-professional education on health care professional students’ perceptions of collaboration in a clinical setting. physiother can 2012;64(2):145-156. https://doi.org/10.3138/ptc.2010-52 21. reeves s, perrier l, goldman j, freeth d, zwarenstein m. interprofessional education: effects on professional practice and healthcare outcomes (update). cochrane database syst rev 2013;2013(3):cd002213. https://doi. org/10.1002/14651858.cd002213.pub3 22. kloppers m. die uitkomste wat fisies-gestremde kliënte bereik deur hul deelname aan rehabilitasie by ’n gemeenskapsrehabilitasiesentrum in die wes-kaap. moccther thesis, stellenbosch university. stellenbosch, 2012. http://hdl.handle.net/10019.1/71707 accepted 10 february 2021. https://doi.org/10.12927/cjnl.2010.21727 http://www.who.int/hrh/resources/framework_action/en/ http://www.who.int/hrh/resources/framework_action/en/ https://doi.org/10.3109/0142159x.2016.1173663 https://doi.org/10.1111/j.1365-2923.2011.04143.x https://doi.org/10.1016/j.nedt.2010.06.004 https://doi.org/10.1016/j.nedt.2010.06.004 https://doi.org/10.3233/wor-2012-1295 https://doi.org/10.1016/j.kjms.2017.12.009 https://doi.org/10.3109/09638288.2010.508829 https://doi.org/10.1080/09638280210142239 https://doi.org/10.1080/09638280210142239 https://doi.org/10.1016/s0140-6736(09)61087-4 https://doi.org/10.1111/j.1747-4949.2009.00275.x https://doi.org/10.1002/14651858.cd007513.pub3 https://doi.org/10.1161/strokeaha.108.541946 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.1016/0260-6917(91)90009-y https://doi.org/10.1016/j.nepr.2010.10.005 https://doi.org/10.3138/ptc.2010-52 https://doi.org/10.1002/14651858.cd002213.pub3 https://doi.org/10.1002/14651858.cd002213.pub3 http://hdl.handle.net/10019.1/71707 december 2019, vol. 11, no. 4 ajhpe 145 research nurses are important members of the healthcare team and constitute the largest group of healthcare providers globally.[1] nursing as a discipline deals with theory and practice. one of the key components of a nursing programme is the clinical experience component, also known as clinical exposure. it is an important component of the curriculum aimed at actively engaging student nurses in learning and developing essential skills. this usually takes place in clinical learning environments such as hospitals, school clinics, healthcare centres and other healthcare settings used for student learning. studies have shown that in the clinical setting, where theory is put into practice, the focus is on psychomotor activities (e.g. giving a patient a bed bath and medication), whereas cognitive abilities receive more focus in the classroom.[2] effective learning takes place when student nurses apply their classroom learning in the clinical setting – hence the need for clinical exposure. from an educational perspective, in the clinical learning environment setting, skills, knowledge and attitudes are developed, whereas in the theoretical part of the curriculum, these are applied, developed and integrated.[3] clinical experience is important for nursing education in a number of ways, such as preparing student nurses to perform clinical functions in practice, as well as knowing about these functions. the integration of theory and practice enables student nurses to learn effectively, feel confident regarding their skills and become competent in taking care of patients.[3] as part of the academic preparation for the nursing profession, students are required to participate in clinical rotation work in various healthcare settings under the supervision of staff nurses at the facilities and clinical instructors from the educational institution. studies have shown that clinical exposure helps student nurses to participate actively in the healthcare setting, seek solutions to real-life problems, and learn by doing while caring for patients.[4] attitude plays a major role in guiding human behaviour towards achievement of goals, awareness of consequences and effective processing of complex information regarding the learning environment.[5] an important part of working with undergraduate nursing students is therefore building a positive attitude to clinical exposure as a vital component of their training. attitude to clinical exposure can crucially influence nursing skills and competence once the student nurse graduates and cares for hospital patients. this study was aimed at evaluating student nurses’ attitude to clinical exposure and identifying factors that influence their attitude to such exposure at delta state university, abraka, nigeria. methods study area and population delta state university has three campuses, i.e. oleh, asaba and abraka, and seven faculties (law and engineering at oleh campus; agriculture at asaba campus, and art, science, education and the college of health sciences at abraka campus). abraka campus has three sites (i, ii and iii). the college of health sciences is located at site iii and has two faculties: basic medical science and clinical science. the faculty of basic medical science comprises nursing science, anatomy, physiology, pharmacology and medical biochemistry, with a population of about 4 500 students. the total population of nursing science students (2015/2016 session) is shown in table 1. background. clinical exposure is an important component of the nursing curriculum aimed at engaging student nurses in learning and developing essential skills. studies on students’ attitude to clinical exposure have been conducted in nigeria, but none in delta state. objectives. to evaluate student nurses’ attitude to and identify factors that influence their attitude to clinical exposure at delta state university, abraka, nigeria. methods. a descriptive quantitative design was used to elicit information from a sample of 181 individuals: 31 males and 150 females statistically drawn using a stratified sampling technique from a population of 237 at levels 300, 400 and 500 of study. a post hoc test was done to evaluate student nurses’ attitude to clinical exposure at different levels of study. results. results showed that 88% of respondents had a positive attitude towards clinical exposure. post hoc tests indicated that attitude towards clinical exposure among 300and 500-level students was statistically different (p=0.001). factors such as adequate clinical equipment, adequate supervision and guidance from clinical supervisors, behaviour of staff nurses in the ward and readiness to learn were the most frequently reported factors that influenced their attitude to clinical exposure. fisher’s exact test showed no association between these factors and respondents’ attitude to clinical exposure (p=0.369). conclusion. students’ attitude to clinical exposure was positive, with average scores higher among 500-level students. hence, the higher the level of study, the more positive their attitude was towards clinical exposure. intensive preparation of nursing students before clinical training will help to improve their attitude. afr j health professions educ 2019;11(4):145-148. https://doi.org/10.7196/ajhpe.2019.v11i4.1155 factors influencing bachelor of nursing science students’ attitude towards clinical exposure m i ofili,1 phd; b p ncama,1 phd; o d moses-ewhre,2 bnsc 1 school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 2 department of nursing science, college of health sciences, delta state university, abraka, nigeria corresponding author: m i ofili (isiomamary74@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 146 december 2019, vol. 11, no. 4 ajhpe research study design, sampling method and sample size a descriptive quantitative design was used. the department of nursing science was purposively selected. sample size was determined using yamane’s formula for quantitative study: ny = n/(1+ne 2). the population of nursing students in the department was 237 (levels 300 500). a stratified sampling technique was used in selecting the participants at three levels of study (levels 300, 400 and 500). stratified sampling was employed by dividing the entire population of nursing students into different strata/ subgroups: subgroup 1 – level 300, subgroup 2 – level 400 and subgroup 3 – level 500. then, the final subjects were randomly selected proportionally from the different strata. after the stratified sampling technique, which ensured that the three clinical classes of nursing students were represented in the study, a simple random sampling technique was used to select 62 nursing students from year 5; 51 students from year 4; and 68 students from year 3, because of the larger number in that class. a total of 181 students constituted the sample size for this study. the clinical experience was only for students at these levels of study. study procedures a questionnaire was used for data collection. it comprised three sections: sections a and b were self-constructed, while section c was adapted from dlama et al.[6] in their study on perception of nursing students and preceptors regarding factors influencing the clinical performance of nursing students. the instrument from dlama et al.[6] consists of 16 ques tions (related to our work). all the questions were used in the pilot study. in the main work, 13 questions were used after modification. the reasons for modification were to enable the researchers to achieve the study objectives, to exclude questions that were irrelevant and those that had the same responses. the first section consisted of questions regarding the respondents’ sociodemographic data and other background information. the second section evaluated their attitude to clinical exposure, while the last section identified factors influencing their attitude to clinical exposure. the validity of the questionnaire was established by the use of content validity, and participants easily identified the variables described. the content validity was developed based on the analysis of each item for clarity, coverage, consistency and relevance. items that were considered ambiguous were either rephrased or eliminated. the instrument (questionnaire) was pilot tested by administering it to 20 respondents. cronbach’s reliability was computed to ensure internal consistency of the instrument. an alpha value of 0.79 (p<0.05) was obtained, which was an indication of good reliability. the participants gave written informed consent before data collection. the questionnaire was distributed to selected nursing students in their lecture areas, and was collected on the same day – after completion. ethical approval the delta state university research and ethical committee granted ethical approval for this study (ref. no. rec/fbms/delsu/16/22). participants were protected from any forms of harm by giving them information about the nature of the study/research, and participation was voluntary. furthermore, their responses were treated confidentially and they were free to withdraw from the study at any time, without negative or undesirable consequences. a written informed consent form was signed by the participants. anonymity and privacy were maintained by excluding all personal details from the final report and eliminating any cross-references that could link the results of the questionnaire to the participant. no identities were disclosed in journal articles published from the research. confidentiality was also clearly spelled out in the questionnaire. all data files were saved as password-protected documents. data analysis data were processed and analysed using spss version 25 (ibm corp, usa), and summary data were presented using descriptive statistics (frequency distribution and percentages) and inferential statistics. fisher’s exact test was conducted to establish the association between respondents’ attitude to clinical exposure and factors influencing their attitude to clinical exposure. results a summary of the characteristics of the study participants (n=181) is given below. participants were fairly evenly distributed between the three levels of study – from level 300 to level 500, with slightly more (37.5%; n=68) from level 300 and slightly fewer (28.2%; n=51) from level 400. the age range of respondents was between 20 and 38 years, with a mean of 24.64 (2.36) years. with regard to age distribution, 69.1% (n=125) of respondents were in the 23 27-year age bracket, 20.4% (n=37) in the 18 22-year bracket, 8.8% (n=16) in the 28 32-year bracket, and only 3 were ≥33 years of age. there was a majority of female participants (82.9%; n=150), a majority of single participants (88.4%; n=160), and all but 3 were christians (91.7%; n=177). roughly a third of participants (34.8%; n=63) were from the igbo ethnic group. with regard to mode of entry to the university, the majority (82.9%; n=150) of participants gained admission through the university matriculation examination (ume). table 2 presents the frequency distribution of respondents’ attitude to clinical exposure. respondent scores on the attitude-to-clinical-exposure scale were measured at two levels: positive (strongly agree and agree) with a score of ≥4, and negative (strongly disagree, disagree and uncertain), with a score ˂4. of the 181 respondents, 88.4% (n=160) scored >4 (positive) and 11.6% (n=21) scored ˂4 (negative). scores ranged from 1 to 7, with a mean of 4.53 (0.97). on evaluation of attitude towards clinical exposure, 88.4% (n=160) had a positive attitude, while 11.6% (n=21) had a negative attitude. table 1. population of nursing science students (2015/2016) level of study students, n 100 66 200 64 300 82 400 81 500 73 total 366 table 2. frequency distribution of respondents’ attitude to clinical exposure attitude frequency (%) positive 160 (88.4) negative 21 (11.6) total 181 (100) december 2019, vol. 11, no. 4 ajhpe 147 research a one-way analysis of variance (anova) test of student nurses’ attitude to clinical exposure by their levels of study is set out in table 3. seven attitudinal questions were asked and students were given a total score out of 7, which was converted to a percentage. students’ attitude was scored as follows: 1 = positive and 0 = negative. using a one-way anova, average student scores were compared among 300-, 400and 500-level students with the following scores: 78.6%, 87.1% and 92.3%, respectively. these scores were found to be statistically different (p=0.001). because of the statistically significant one-way anova, a post hoc test was conducted to ascertain the differences in their attitude towards clinical exposure at the different levels of study. the test indicated that attitude towards clinical exposure among 300and 500-level students was statistically different (p=0.001). however, attitude towards clinical exposure among 300and 400-level students, as well as 400and 500-level students, was not statistically different (p=0.080 and p=0.410, respectively). table 4 presents the frequency distribution of factors that influenced respondents’ attitude to clinical exposure. respondent scores were measured at two levels: high ≥7, and low ˂7. of the 181 respondents, 93.9% (n=170) scored >7 (high reported factor values) and 6.1% (n=11) scored ˂7 (low reported factor values). scores ranged from 2 to 13, with a mean of 10.56 (2.07). table 5 shows the reported factors influencing respondents’ attitude to clinical exposure. the factors most frequently reported were adequate clinical equipment (94.5%; n=171), adequate supervision and guidance from clinical supervisors (94.5%; n=171), behaviour of practising/staff nurses in the ward (93.9%; n=170), regularity (93.4%; n=169) and readiness to learn (91.7%; n=166). table 6 presents contingency findings showing respondents’ attitude to clinical exposure and the identified factors influencing their attitude to clinical exposure. the null hypothesis showed that there was no association between respondents’ attitude to clinical exposure and identified factors influencing their attitude to clinical exposure. using fisher’s exact test, it was ascertained that there was no association between students’ attitude to clinical exposure and factors influencing their attitude to clinical exposure (p=0.369). discussion most of the respondents were young adults. marital status showed that 88.4% (n=160) were single and 11.6% (n=21) were married. therefore, the majority of respondents were not subject to marital obligations. the majority (n=150) of participants were female, re-emphasising the general belief that the nursing profession continues to be female dominated. an understanding of students’ perception and attitude during clinical exposure and training can assist in the effective evaluation of the strengths and weaknesses of an educational programme, thus promoting curricular development in support of holistic nursing care. previous studies[7-9] found that among student nurses the clinical learning environment is perceived as the most influential context for gaining nursing skills and knowledge. in evaluation of attitude towards clinical exposure, 88.4% (n=160) had a positive attitude and 11.6% (n=21) had a negative attitude. in line with previous research,[10-12] this study also showed that nursing students had a positive attitude towards clinical experience and that clinical practice and available opportunities provided a reflection of the process of becoming a professional nurse. this is contrary to awuah-peasah et al.’s[5] finding that nursing students had a negative attitude towards clinical exposure. this was table 3. one-way analysis of variance (anova) test of student nurses’ attitude to clinical exposure by level of study level of study attitude towards clinical exposure, mean f-test p-value 300 400 500 78.6 87.1 92.3 6.838 0.001 table 4. frequency distribution of factors influencing respondents’ attitude to clinical exposure factor values frequency (%) high values 170 (93.8) low values 11 (6.1) total 181 (100) table 5. distribution of responses to factors influencing attitude to clinical exposure factors high values, n (%) low values, n (%) institutional behaviour of practising/staff nurses in the ward 170 (93.9) 11 (6.1) adequate clinical equipment 171 (94.5) 10 (5.5) duration of clinical time 160 (88.4) 21 (11.6) adequate supervision and guidance from clinical supervisors 171 (94.5) 10 (5.5) feedback from clinical supervisors 148 (81.8) 33 (18.2) integration of theory into practice 162 (89.5) 19 (10.5) selecting staff nurses for their roles 119 (65.7) 62 (34.3) preparing staff nurses for their roles 156 (86.2) 25 (13.8) individual anxiety 143 (79.0) 38 (21.0) readiness to learn 166 (91.7) 15 (8.3) active participation during ward rounds 133 (73.8) 48 (26.5) regularity 169 (93.4) 12 (6.6) respect for staff nurses 154 (85.1) 27 (14.9) 148 december 2019, vol. 11, no. 4 ajhpe research apparently seen in their behaviour during clinical training, which included nursing students reporting late for work, being absent from clinical work without permission, using mobile phones during clinical working hours and lacking commitment to clinical work. a previous study[13] also reported that nursing students had a negative attitude towards clinical exposure. this was seen in their behaviour during clinical postings at hospitals, which included anxiety, feelings of vulnerability, lack of respect and loss of interest. nursing students also identified the following factors as influencing their attitude towards clinical exposure: adequate clinical equipment, adequate supervision and guidance from clinical supervisors, behaviour of practising staff nurses in the ward, duration of clinical time, integration of theory into practice, selecting and preparing staff nurses for their roles, anxiety, regularity and readiness to learn. other important factors that previous studies have identified as influencing nursing students’ attitude to clinical exposure (either positively or negatively) are: preceptorship and mentorship, good relationship with nurses, clinical supervision, professional role acceptance, simulation, peer teaching and learning, high levels of stress and anxiety, poor interpersonal relationships, theory-practice gap, inadequate clinical time, overcrowded clinical facilities, shortage of equipment and staff and lack of feedback.[6,9,14,15] factors at an academic level that have been similarly identified are programme of study, ineffective communication, inadequate preparation and emotional reactions.[16,17] fisher’s exact test indicated no significant association between students’ attitude to clinical exposure and factors influencing their attitude towards clinical exposure, although a high proportion had a positive attitude, with high reported factors affecting their attitude. this could be because of the small sample size. the students’ attitude to clinical exposure was statistically significant (p=0.001), with average scores higher among level-500 students. this implies that a positive attitude to clinical exposure enhances students’ behaviour during clinical training. hence, the higher the level of study, the more positive the attitude towards clinical exposure. intensive preparation of level-300 students for clinical training is important to improve their attitude towards clinical exposure. conclusion our findings indicate that students had a positive attitude towards clinical exposure. the identified factors did not significantly relate to their attitude towards such exposure. however, these factors may have an impact on their learning outcomes, such as bed making, taking vital signs, giving a bed bath, wound dressing, administration of medication and offering bed pans/ urinals. however, adequate clinical supervision and guidance are necessary for an effective clinical practice. declaration. none. acknowledgements. we thank the students of the department of nursing science who consented to participate in the survey. we also thank dr wilbert sibanda for the statistical input. author contributions. mio contributed to the conception of the study, and drafted and revised the manuscript; bpn contributed to the revision of the manuscript; and odm contributed to the conception of the study. all authors read and approved the final manuscript. funding. none. conflicts of interest. none. 1. eta vea, atanga mbs, atashii j, d’cruz g. nurses and challenges faced as clinical educators: a group of nurses in cameroon. pan afr med j 2011;8(2):467. https://doi.org/10.4314/pamj.v8i1.71085 2. ghodsbin f, shafakhah m. facilitating and preventing factors in learning clinical skills from the view points of the third year students of fatemeh school of nursing and midwifery. iran j med educ 2008;7(2):343-352. 3. tiwaken su, caranto lc, david jt. the real world: lived experiences of student nurses during clinical practice. int j nurs sci 2015;5(2):66-75. https://doi.org/10.5923/j.nursing.20150502.05 4. irby dm. effective clinical teaching and learning: clinical teaching and the clinical teacher. j med educ 1986;9(2):35-45. 5. awuah-peasah d, sarfo la, asamoah f. the attitudes of student nurses toward clinical work. int j nurs midwifery 2013;5(2):22-27. https://doi.org/10.5897/ijnm12.017 6. dlama gj, modupe o, umar a. perception of nursing students and preceptors about factors influencing the clinical performance of nursing students. j nurs health sci 2015;4(5):57-69. 7. chan d. development of an innovative tool to assess hospital learning. nurse educ today 2009;21(8):624-631. https://doi.org/10.1054/nedt.2001.0595 8. chuan ol, barnett t. student tutor and staff perception of the clinical learning environment. nurs educ pract 2012;12(8):192-197. https://doi.org/10.1016/j.nepr.2012.01.003 9. sharif f, masoumi s. a qualitative study of nursing student experiences of clinical practice. bmc nurs 2005;4(6):1-7. https://doi.org/10.1186/1472-6955-4-6 10. jack-ide io, amiegheme fe, ongutubor ke. undergraduate nursing students’ mental health and psychiatric clinical experience and their career choice in nursing: perspectives from the niger delta region of nigeria. j ment disord treat 2016;2(2):1-5. https://doi.org/10.4172/2471-271x.1000116 11. papp i, markkanen m, von bonsdorff m. clinical environment as a learning environment: student nurses perceptions concerning clinical learning experiences. nurse educ today 2003;23(4):262-268. 12. papastavrou e, dimitriadou m, tsangari h, andreou c. nursing students’ satisfaction of the clinical learning environment: a research study. bmc nurs 2016;15:44. https://doi.org/10.1186/s12912-016-0164-4 13. elcigil a, sari m. determining problems experienced by student nurses in their work with clinical education in turkey. nurse educ today 2008;7:491-498. https://doi.org/10.5430/jnep.v4n11p82 14. mabuda bt, potgieter e, alberts uu. student nurses’ experiences during clinical practice in the limpopo province. curationis 2008;31(1):19-27. https://doi.org/10.4102/curationis.v38i2.1517 15. rajeswaran l. clinical experiences of nursing students at a selected institute of health sciences in botswana. health sci j 2016;10(6):1-6. https://doi.org/10.21767/1791-809x.1000471 16. buhat-mendoza dg, mendoza jnb, tianela ct, fabella el. correlation of academic and clinical performance of libyan nursing student. j nurs educ pract 2014;4(11):23-24. https://doi.org/10.5430/jnep.v4n11p82 17. jamshidi n, molazem z, sharif f, torabizadeh c, kalyani mn. the challenges of nursing students in the clinical learning environment: a qualitative study. sci world j 2016:1-7. https://doi.org/10.1155/2016/1846178 accepted 1 july 2019. table 6. relationship between identified factors and respondents’ attitude to clinical exposure attitude to clin ical exposure, n (%) factor values positive negative p-value (fisher’s exact test) 0.369 high values 151 (93.8) 11 (6.2) low values 17 (89.5) 2 (10.5) https://doi.org/10.4314/pamj.v8i1.71085 https://doi.org/10.5923/j.nursing.20150502.05 https://doi.org/10.5897/ijnm12.017 https://doi.org/10.1054/nedt.2001.0595 https://doi.org/10.1016/j.nepr.2012.01.003 https://doi.org/10.1186/1472-6955-4-6 https://doi.org/10.4172/2471-271x.1000116 https://doi.org/10.1186/s12912-016-0164-4 https://doi.org/10.5430/jnep.v4n11p82 https://doi.org/10.4102/curationis.v38i2.1517 https://doi.org/10.21767/1791-809x.1000471 https://doi.org/10.5430/jnep.v4n11p82 https://doi.org/10.1155/2016/1846178 november 2020, vol. 12, no. 4 ajhpe 172 short research report nurse educators are not born to be teachers, but becoming effective at teaching requires special knowledge and skills.[1] this competency is achieved by student nurse educators (snes) undergoing teaching practice (tp) sessions to acquire pedagogical skills and learn how to teach. in south africa (sa), preparation of nurse educators is done at universities by departments of nursing science. at the institution concerned in the present study, tp is a component of a bachelor’s degree programme leading to registration as a nurse educator. the degree is offered online, as the university is an open distance electronic learning institution (odel). it is undertaken by students who are at their third-year level of training in a simulated environment for a period of 1 week. simulation workshops are a common feature of student teacher preparation and are done in other countries to teach snes how to teach. in india and iraq, tp is termed a simulation workshop and forms part of sne preparation as an educator.[2] the link between theory and practice is often skewed in favour of theory. the one-week exposure of snes currently practiced at the institution under study is short, to enable them to rapidly acquire the requisite pedagogical skills. objectives the aims of the study were to: • explore the experiences of snes who attend the tp workshop • gather suggestions from participants on improving tp • develop a supportive framework to guide and enhance tp. methods a qualitative, phenomenological research design to gain insight into the depth, richness and complexities inherent in the lived experiences of snes who attend tp workshops was adopted. tp workshops at the institution under study are spread over a period of 3 months, from june to september of each year. data were obtained from two groups: the first group (9 students) attended between 14 and 18 july 2018 and the second group (11 students) between 14 and 18 august 2018. using non-probability purposive sampling, a total of 20 (out of 35) snes participated in the study after signing consent forms. data were obtained from snes using written narratives as proposed by hopwood and paulson.[3] participants were requested to reflect on their experiences and to write them down on the narrative guide that was given to each participant. the guide included two questions: • share your experiences on tp workshops you have attended. • how can the quality of tp workshops be enhanced for maximum acquisition of pedagogical skills? give suggestions. data were analysed using tesch’s (1990) eight steps of the coding process. the researcher read and re-read written narratives, identifying similar ideas and patterns which were coded and grouped together into themes. ethical approval ethical approval was granted by the health studies research and ethics committee (hsrec) of the department of health studies, university of sa, and the college ethics committee (ref. no. hsdc/821/2017). results and discussion participants were requested to indicate their experiences during tp workshops and to suggest solutions for improvements. a mixed bag of background. teaching practice is an integral part of the preparation of student nurse educators. it provides students with an opportunity to translate theory into practice and to gain knowledge and skills to become effective and competent nurse educators. objectives. the study sought to explore experiences of student nurse educators who attended a teaching practice workshop (students attend one session for 5 days at the third-year level of training) and to develop a supportive framework to enhance the acquisition of pedagogical skills. methods. a qualitative, phenomenological research design was used. out of 35 participants who attended the workshop, 20 consented to participate in the study. data were collected through written narratives and analysed using thematic content analysis. a purposive sampling technique was followed. results. most participants reported a number of challenges experienced during teaching practice, which were grouped into six themes, namely: poor orientation, lack of adequate support by supervisors, teaching strategies not aligned with open distance electronic learning, expectation of doing a powerpoint presentation without prior knowledge, use of an outdated study guide, and limited time for teaching practice. conclusion. orientation of students for teaching practice needs to be detailed, accessible online after sessions, and conducted via video classes, podcast, smartboards, etc. before a workshop. support and guidance should be provided through prompt feedback on lesson planning and online classes to teach principles and procedures of lesson presentation. promotion of computer skills and allocation of more time for teaching practice are necessities. afr j health professions educ 2020;12(4):172-174. https://doi.org/10.7196/ajhpe.2020.v12i4.1431 supportive framework for teaching practice of student nurse educators: an open distance electronic learning (odel) context t e masango, phd (nursing education) department of health studies,university of south africa, pretoria, south africa corresponding author: t e masango (masante@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:masante@unisa.ac.za 173 november 2020, vol. 12, no. 4 ajhpe short research report responses were given, of which the negatives outweighed the positives. themes that emerged were: poor orientation, lack of support, use of teaching strategies not aligned with odel, use of technology without preparation, outdated study guide, and a short period of time for tp, leading to poor mastering of teaching skills. for each negative experience, participants were requested to suggest solutions to alleviate the challenges experienced during tp. suggestions included: 1. improved orientation practices findings revealed that orientation was poorly done, making students frustrated, anxious and without any clarity regarding how to prepare for tp and what to expect. participants suggested extending the orientation period to 2 weeks: ‘… there should be more orientation before the workshops to prepare more effectively and efficiently. unsure of certain things like case study – should be clearer – and state it is “problem solving” was misinterpreted.’ (p3) ‘… i was not happy with the online orientation because i was unable to watch it later that day. as an open distance learning, i feel the online presentations should be available anytime for those who were busy during the presentation time to watch it later.’ (p5) poor orientation of snes was also mentioned in a study conducted by summers,[4] where snes reported inadequate preparation and support; this was contrary to the view that good orientation with formal mentor support and clear direction about role expectation are essential in nurse educator preparation. 2. use of transformative teaching strategies participants’ views were divided among those who had resources such as computers and internet access v. those without technological resources. participants suggested teaching strategies that are in line with odel such as video classes, podcast and smartboards; others preferred conventional teaching methods: ‘… as student nurse educators, we must be taught teaching strategies in line with odel, such as podcast, interactive chart forums etc.’ (p15) ‘… teaching methods for rural areas and colleges must also be accommodated. not every student has access to computer or internet access.’ (p20) 3. effective and adequate support poor student support during preparation for the workshop emerged as yet another issue: ‘… little/no guidance with preparation of the lesson plans.’ (p4) a mock demonstration was suggested before the start of the teaching session: ‘… demonstration before practicals to be given to get a chance to learn as we are here to learn.’ (p8) the same findings were reported by musin gafi et al.,[5] where student teachers reported inade quate academic support by facilitators. 4. inclusion of technology lessons in the tp programme some participants indicated they had never used acomputer before and need to be taught basic computer skills including powerpoint: ‘… to have a teaching session on basic computer skill and powerpoint presentation.’ (p17) inclusion of technology in the nursing curriculum is supported by gonen et al.[6] who propound that informatics and technology need to be accommodated within the nursing curriculum, including different types of electronic health record. 5. updating of study guides and extension of workshop period the workshop period was too short to ensure adequate learning; 2 weeks were recommended and that the study guide must be updated: ‘… teaching practice has a lot of work and one week is not enough.’ (p2) ‘... the study guide must match what is expected on the actual practical session. unisa used outdated study guide.’ (p6) most participants indicated that the tp workshop period should be extended to give them enough time to learn teaching skills.the same sentiments were shared by mukumbang and alindekane,[7] who stated that there was an unequal link between theory and practice in the preparation of nurse educators. they viewed this as one of the basic problems in sne preparation. some participants indicated that the mentoring and coaching received was beneficial in their preparation as educators, but the majority felt unsupported by the facilitators. the findings from this study prompted the researcher to develop a teaching practice supportive framework (fig. 1) with the purpose of enhancing tp and improving the acquisition of teaching skills by students. the practice4. college administration (40 hours) • peer group teaching x 5 lessons (2 critiqued by peer and 3 critiqued by lecturer): period = 45 min • exposure to basic computer skills • train on powerpoint preparation and presentation • lesson plan preparation • media preparation • online/college lessons presentations x 5 • clinical demonstrations x 5: 2 clinical lab and 3 practice demonstrations • budgeting • motivation for new equipment • cost containment • quality assurance • personnel appraisal 1. orientation to teaching and learning 2. technology integration 3. acquisition of pedagogical skills fig. 1. supportive framework for teaching practice for student nurse educators. november 2020, vol. 12, no. 4 ajhpe 174 short research report oriented theory by dickoff as cited by justus and nangombe[8] was used to guide the development of the framework, and prescripts of the south african nursing council regulations (r118) were incorporated. conclusion findings from the present study concluded that orientation of students for tp workshops should be detailed; conducted via online platforms such as video classes and podcasts, etc.; and accessible online after sessions for referral purposes during preparation. student support should be strengthened to promote learning of teaching skills, study guides be regularly updated, lessons on computer skills be provided, and duration of the workshop be extended. well-planned and well-executed tp sessions are critical in the preparation of nurse educators. there is a need to develop a supportive framework to improve tp. declaration. the article is based on a study conducted by the researcher during research and development leave. acknowledgements. the researcher thanks students who participated in this study. author contributions. study conduction, and drafting and critical revision of the article, were done by the researcher. funding. none. conflicts of interest. none. 1. lateef am, mhlongo em. factors influencing nursing education and teaching methods in nursing institutions: a case study of south west nigeria. glob j health sci 2019;11(13):13-24. https://doi.org/10.5539/gjhs.v11n13p13 2. garner sl, killingsworth e, bradshaw m, et al. the impact of simulation education on self‐efficacy towards teaching for nurse education. int nurse rev 2018. https://doi.org/10.1111/inr.12455 3. hopwood n, paulson j. bodies in narratives of doctoral students’ learning and experience. stud high educ 2012;37(7):667-681. https://doi.org/10.1080/03075079.2010.537320 4. summers ja. developing competenciesin the novice nurse educator: an integrative review. teach learn nurs 2017;12(4):263-276. https://doi.org/10.1016/j.teln.2017.05.001 5. musingafi mc, mapuranga b, chiwanza k, zebron s. challenges for open and distance learning (odl) students: experiences from students of the zimbabwe open university. j educ pract 2015;6(18):59-66. https://doi. org/10.12691/education-3-10a-3 6. gogen a, sharon d, levi-ari l. intergrating information technology’s competencies into academic nursing education. an academic study. congent educ 2016;4(1):1-9. https://doi.org/10.1080/2331186x.2016.1193109 7. mukumbang fc, alindekane lm. student nurse educators’ construction of teacher identity from a selfevaluation perspective: a quantitative case study. nurse open 2017;4:108-115. https://doi.org/10.1002/nop2.75 8. justus ah, nangombe jp. paradigmatic perspective for a quality improvement training programme for health professionals in the ministry of health and social services in namibia. int j health 2016;4(2):89-95. https://doi. org/10.14419/ijh.v4i2.6164 accepted 5 october 2020. https://doi.org/10.5539/gjhs.v11n13p13 https://doi.org/10.1111/inr.12455 https://doi.org/10.1080/03075079.2010.537320 https://doi.org/10.1016/j.teln.2017.05.001 https://doi.org/10.12691/education-3-10a-3 https://doi.org/10.12691/education-3-10a-3 https://doi.org/10.1080/2331186x.2016.1193109 https://doi.org/10.1002/nop2.75 https://doi.org/10.14419/ijh.v4i2.6164 https://doi.org/10.14419/ijh.v4i2.6164 december 2019, vol. 11, no. 4 ajhpe 133 research the world health organization emphasises that curriculum reform should be geared to population needs and inequalities in health.[1] a seminal report in the lancet[2] called for major reforms in health professional (hp) education, recommending a competency-based approach and the reorientation of health services to meet patient and population needs in the 21st century. contrary to traditional educational practices, which concentrate on what and how learners are taught, competency-based education (cbe) attends to the performance or goal state of instruction[3-5] to ensure that learners can use their learning to communicate well, assess and manage patients effectively, solve problems and make good clinical decisions in practice. as competencies are context dependent, it is important that context-specific health issues are used to ensure that the desired competencies are aligned with population needs. assessment and evaluation of competencies should be conducted in context.[2,3,6,7] of concern is that efforts to counter existing deficiencies in hp education faltered, in part due to the tendency of various professions to act in isolation from, or even in competition with, each other.[2] an interprofessional (ip) approach has been recommended to support student learning and collaboration in future practice.[8,9] the outcomes for a shared patient are improved by reconfiguring activities to be interteam and ip based.[10] teamwork is also important for information sharing and developing new work practices to reduce error in changing contexts.[9] in south africa (sa), communication between hps, and particularly communication with patients, in both the public and private sectors, is affected by population complexity and diversity, and varying backgrounds, languages and literacy levels.[11] ip communication is also influenced by the hierarchical nature of role players in the healthcare system.[11] against this background the health professions council of sa (hpcsa) specified the inclusion of a set of seven core competencies, including communication, in the medical, dental and medical associate undergraduate programmes.[12] this hpcsa framework was based on the royal college of physicians and surgeons of canada core competencies document for postgraduate education (canmeds),[13] ensuring coherence between underand postgraduate education. the college of health sciences (chs) at the university of kwazulu-natal (ukzn), durban, sa, subsequently expanded its application to include all hp programmes in the college[14] (fig. 1) in 2014 to emphasise the importance of these competencies for all hps involved in healthcare. of interest in this study is the role of communicator. with the incontrovertible evidence for the benefits of good communication in healthcare,[15] communication teaching is now an integral part of hp curricula worldwide.[16-18] good communication is important, not only background. competency-based and interprofessional education are increasingly favoured approaches for training health professionals (hps) to meet patient and population needs. the health professions council of south africa (hpcsa) and college of health sciences (chs) at the university of kwazulu-natal, durban, sa, specified a requirement for a core competencies framework to be incorporated into all hp programmes in 2014. objectives. to explore teaching, learning and assessment of communication as a core competency in eight hp programmes in the chs to determine how communication was taught and whether the competencies framework had been adopted successfully. the study is important, as there has been limited research on the teaching of communication as a competency in hp education in sa. methods. the case study comprised educational qualitative research. the chs document was reviewed and purposive sampling was used to select educators from the programmes. focus group discussions were conducted in july and august 2015 with 5 9 participants per group. data were analysed thematically and themes and subthemes described. gatekeeper and ethical permissions were obtained. results. aspects of communication were taught in all programmes. none of the programmes had fully incorporated the chs framework. the medicine programme had incorporated aspects of the framework in teaching, although it did not reflect consistently in all disciplines. teaching was largely profession or discipline specific. important challenges were language barriers and interprofessional communication. conclusions. while the consistent use of the chs core competencies framework may contribute to improving the teaching of communication in the hp programmes, the success of a competency-based approach depends on responsiveness to context. research in local settings is recommended to identify and align competencies and content with patient and community needs. afr j health professions educ 2019;11(4):133-138. https://doi.org/10.7196/ajhpe.2019.v11i4.1098 teaching communication as a core competency in health professions education: an exploratory case study in a college of health sciences, south africa m matthews,1 mb chb, doh, mph, phd; t naidu,2 ba hons, ma (clin psych), pg dip narrative research, phd 1 clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 department of behavioural medicine, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: m matthews (matthewsm@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 134 december 2019, vol. 11, no. 4 ajhpe research in the practitioner-patient context, but also in relating with communities served by the hp team, and in ip communication in the healthcare context.[18] the key and enabling competencies for communication described in the chs framework[14] therefore promote communi cation and the development of ethical relationships with patients (or clients) and their families and communities, as well as with colleagues and other professionals. further key competencies include the ability to accurately synthesise rele vant information, convey explanations and develop a shared plan of care with patients. conveying oral and written information accurately to colleagues and other professionals is also deemed essential.[14] key competencies are listed in appendix 1. professional training in the chs, where the medium of instruction is english, aims to produce primary healthcare providers[19] in a region where patients are predominantly isizulu mother-tongue speakers.[20] in the process of integrating the chs core competencies into professional programmes, there is concern about whether there is appropriate focus on the development of communication skills, and whether clinical educators feel competent to demonstrate these skills and develop them in their students, particularly if the educators have not received formal training in communication. this study explored the teaching, learning and assessment (tla) of communication as a core competency with academic staff in eight hp programmes in the chs (optometry (opt), physiotherapy (physio), pharmacy (pharm), medicine (med), speech-language pathology (slp), dental therapy (dt), audiology (audio), and occupational therapy (ot)). the overall objective was to determine if the chs framework had been adopted and how communication was included in the hp curricula. the specific research objectives were to determine: • whether communication was being taught and assessed as a core competency in the hp programmes • whether the chs core competencies framework had been successfully adopted in teaching communication • the approach to the tla of communication • hp educators’ ideas and concerns about tla of communication • educators’ opinions regarding communication teaching that reflects contextual needs in practice. as there has been limited research on the use of cbe in the communicator role in local hp education, the study was considered important to guide curriculum reform to respond to local health needs. methods study design a qualitative case study design was used.[21] it was an educational study in the interpretivist paradigm to allow for exploration of participants’ views. positionality of the researcher both researchers have been involved in the development and teaching of communication in the medical programme and in qualitative educational research. mm is an experienced medical practitioner working in education, and tn is a clinical psychologist. the study improved our understanding of the topic by including other hp educators, as well as medical educators. setting the study was conducted in the chs of an sa university. study population and sample the study population comprised academic staff who teach undergraduates in eight hp programmes. participants were purposively sampled for their in-depth knowledge of content and approach to the tla of communication in the modules, and invited by the office of the dean of teaching and learning to participate. the final samples included academic leaders (academic heads for the programme or discipline) and year or module co-ordinators, described in more detail in table 1. he al th ad vo ca te co m m un ica to r leader and manager co lla bo ra to r re se ar ch er an d sc ho lar professional healthcare practitioner cu ltu ra l s en sit iv ity r esourcefulness re�ectiveness c reativity re�exivity resilience in te gr ity f le xi bi lit y a cc es si b ili ty practice environment practice environment p ractice en viro n m en tp ra ct ic e en vi ro n m en t fig. 1. the core competencies framework for undergraduate students in the college of health sciences (chs) at the university of kwazulu-natal (developed by the chs teaching and learning task team in collaboration with kwazulu-natal provincial department of health representatives, stakeholders and interested parties (2014)[14]). december 2019, vol. 11, no. 4 ajhpe 135 research data collection a series of academic meetings was held by the dean of teaching and learning and senior academics in the schools that would be involved in research to plan the study and review the chs framework. data were collected during focus group discussions (fgds) in july and august 2015. educators were interviewed in professional groups of 5 9 participants. for logistical reasons, educators in the medical programme were interviewed in two groups. both researchers were present for the fgds – one facilitating the discussion, and the co-facilitator observing and keeping notes. a semistructured set of prompt questions initiated the discussions. reflective questioning related to the topic offered opportunities to explore the knowledge, skills and attitudes of participants.[22] this method allowed the facilitator to maintain a sense of the progress of the dialogue, while taking cues for follow-up questions to explore the responses of participants in greater depth. audio recordings were professionally transcribed, and the researchers checked the transcripts for accuracy against the audio recordings. data analysis data analysis was conducted in five phases (table 2). trustworthiness the study method is described against the consolidated criteria for reporting qualitative research. rigour and robustness of data were ensured in the manner described. firstly, good representation of hp educators by profession was ensured in the samples. duration of the fgds was 45 75 minutes to ensure data saturation in the larger groups. member checking was done during the fgds for participant validation of the content. dependability of the data was achieved through the use of an audit trail during the data collection and analysis process.[23] ethical approval gatekeeper and ethical permission was obtained from the ukzn humanities and social sciences research ethics committee (ref. no. hss/0415/015; 1633/014d). normal ethical guidelines were followed. in terms of basic ethical principles, individual informed written consent was obtained from each study participant after a verbal briefing and sharing an information sheet describing the nature of the study. participation was voluntary and participants were assured of anonymity of their responses. no identifying information was included with the data. as it was an educational study, there was no risk to participants, who were informed that the general benefit of the study would be to improve the teaching and learning of communication in hp education. results with regard to the first objective, educators in all hp programmes indicated that aspects of communication were included in teaching. in response to the second objective, it was found that no hp programme had developed an overarching pedagogical approach to the teaching of communication. only the medicine programme had adopted the chs framework, albeit partially; it did not reflect consistently across all disciplines. educators in all programmes except medicine acknowledged that students would not be able to identify aspects of teaching that pertained to communication as a core competency, as this was not defined in formal learning objectives. the data were explored further to respond to research questions 3 5. the main and subthemes identified are summarised in table 3. general approach to teaching, learning and assessment of communication teaching, learning and assessment approaches and methods in medicine, skills related to communication process and content were taught explicitly in the first 3 (preclinical) years, and during the family table 1. focus group discussions and description of participants health professional programme focus group number participants, n description of participants optometry 1 9 1 al/l, 2 sl, 6 l, 7 f, 2 m physiotherapy 2 9 1 al/l, 1 sl, 1 l, 3 l (part-time), 3 st, 5 f, 4 m pharmacy 3 6 1 prof, 1 al/sl, 2 sl, 2 l, 3 f, 3 m medicine (2 × 8 participants) 4 16 1 al/assoc prof, 1 al/sl, 7 sl, 6 l, 1 ppo, 10 f, 6 m speech-language pathology 5 7 1 al/l, 1 sl, 4 l, 1 st, 7 f dental therapy 6 5 1 sl, 3 l, 1 st, 4 f, 1 m audiology 7 5 1 al/sl, 4 l, 5 f occupational therapy 8 7 1 assoc prof, 4 l, 1 dl, 1 tutor, 5 f, 2 m al = academic leader; l = lecturer; sl = senior lecturer; f = female; m = male; st = senior tutor; prof = professor; assoc prof = associate professor; ppo = principal programme officer; dl = developmental lecturer. table 2. phases in data analysis phase process 1 two researchers independently familiarised themselves with the data 2 each researcher independently coded the data for themes against the college of health sciences core competencies framework 3 one researcher then coded the data on nvivo 10 (qsr international) qualitative data analysis software for these themes 4 themes were refined and subcategorised into meaningful elements related to the purpose of the study, relevant literature and subthemes memos and notes were used to describe patterns in the data 5 themes were reviewed and discussed in an iterative process, then further condensed, combined or excluded, based on consensus between the researchers 136 december 2019, vol. 11, no. 4 ajhpe research medicine modules. the chs framework had been introduced explicitly into teaching from the first year, linked to communication skills training. the other hp programmes included aspects of communication teaching and learning mainly implicitly, but explicitly in some modules. in general, the approach to teaching was module dependent and suited to the professionspecific need and scope of practice. most of the emphasis was on history taking from individual patients. in some programmes, counselling, a shared plan of care and aspects of oral and written communication were taught. there was less emphasis on teaching communication beyond the patient, to involve families, communities and other professionals. teaching methods included didactic teaching, simulation and experiential learning in the clinical setting. assessment in some programmes included qualitative methods such as portfolios or case studies. certain programmes included quantitative assessments in the form of objective structured clinical examinations (osces), or a relatively small mark allocation for communication competence in clinical assessments. importantly, workplace-based assessment[6] of communication as a critical competency for graduating was not identified in any programme. communication skills were mentioned as being important in holistic patient care: ‘initially we were very medical model focused, which meant that we were mostly interested in diagnosis and management, and now we are shifting into a more patient-holistic approach, wherein lies the need for communication skills.’ (fgd4 med) in some cases, communication was seen as a natural ability that did not need to be taught explicitly: ‘it is so much a part of us that we don’t see it, and we assume that students will have it because we have it.’ (fgd8 ot) ‘the assumption is, very often, when they go to the clinic, [the students] will just know how to talk to the child.’ (fgd5 slp) some educators expected students to learn communication experientially by observation as they progressed through the programme: ‘it is like osmosis.’ (fgd1 opt) ‘communication happens along the way, whether right or wrong.’ (fgd1 opt) educators appeared to value profession-specific knowledge over competency in communication, and in two programmes indicated that it was possible to graduate ‘good’ or ‘excellent’ clinicians who were poor communicators: ‘i feel you can be a good [professional] and still lack communication.’ (fgd2 physio) ‘i think we can all attest to the fact that we have produced some excellent clinicians who are bad communicators, you know!’ (fgd1 opt) profession-specific communication teaching professions in which communication was fundamental (e.g. audio and slp) focused on relevant aspects of communication teaching. slp had experience with patients with specific communication challenges, and in ip collaborative practice with audio. in dt, where the nature of interventions might inhibit communication, educators made specific efforts to address communication in teaching. ot included communication teaching in various modules and, with audio, demonstrated strength in their strong relationships with the communities they served. physio described the importance of a collaborative management plan formulated with patients, as adherence to home-exercise prescriptions was crucial to outcomes. nonetheless, most of this teaching was implicit and subsumed within clinical training. contextual lessons on broadening the scope of communication in health professionals’ practice language in communication inability to speak isizulu was a frequent challenge, experienced first-hand by educators and students in clinical and community settings. educators described isizulu taught in the first year as generic content not tailored to a professional clinical context (the exception to this being the isizulu module in the medicine programme). educators commented on the lack of trained interpreters in clinics, and several educators alluded to staff and students relying on other hps or students to assist as interpreters when language or cultural challenges were experienced. all of these factors contributed to poor communication between hps and patients: ‘you can learn zulu but still not be able to communicate with a patient.’ (fgd2 physio) ‘in the public sector [pharmacists] use assistants to do the counselling at the pharmacy and very little communication exists between the pharmacist and the patient. in the wards [pharmacists] use nurses or they simply focus on what is written down and speak to the doctors only and to the nurses, but never to the patient.’ (fgd3 pharm) ‘for [students] it is easier to go to their colleagues in the class and say, “how do i say this, how do i ask that?”’(fgd4 med) table 3. main themes and subthemes main themes subthemes general approach to tla tla approaches and methods profession-specific communication teaching contextual lessons on broadening the scope of communication in hp education language in communication communication beyond the patient with families and communities ip communication and teamwork group reflections on including the chs framework in the curriculum and improving communication teaching use of a consistent framework; increased focus on communication teaching with specific learning objectives; teaching integrated with professional content; staff development; improving ip communication and responding to the language requirement tla = teaching, learning and assessment; hp = health professional; ip = interprofessional; chs = college of health sciences. december 2019, vol. 11, no. 4 ajhpe 137 research some educators voiced concerns about learning a specific indigenous language in a country with 11 official languages, of which 9 were indigenous african languages. educators referred to global migration and professional mobility of professionals around sa: ‘it is going to be a challenge. when you go to pretoria they emphasise tswana and in venda they emphasise venda. there is no way you can teach all the languages. maybe you can create that appetite in students to [learn multiple languages], i don’t know how we can do it … .’ (fgd2 physio) communication beyond the patient with families and communities the importance of the ability to extend communication beyond practitionerpatient communication was acknowledged, but not specifically addressed as a key competency: ‘… there is another communication … and it is the [hp] and the caregivers and parents. you get to a point where the whole family is there while you are treating a patient, so to have a skill to communicate with everyone, including the patient, including the kids … how do you tell them about the patient’s condition?’ (fgd2 physio) interprofessional communication and teamwork ip communication formed an important subtheme: ‘we have shifted from just the doctor-patient relationship … we now have a wider community that students have to be able to communicate with. it is about interprofessional communication.’ (fgd4 med) of concern was that, generally, ip communication was perceived to be inadequate, both in the educational environment and in practice. comments reflected poor oral and written communication, as well as a lack of respect between professionals: ‘… the way we talk to each other … we don’t communicate well.’ (fgd4 med) ‘pharmacists very rarely engage with medical practitioners in writing, except in hospitals, and it is poorly done.’ (fgd3 pharm) ‘… among our colleagues, [other hp] colleagues don’t respect you.’ (fgd4 med) notwithstanding these concerns, only the ot and audio programmes stressed the importance of teaching team dynamics and theory for effective community interventions: ‘… to actually know how to work in teams, team dynamics, and one of the key things is communication.’ (fgd7 audio) group reflections on improving communication teaching the collaborative process in the fgds allowed reflection on the benefits of the use of a common framework in the chs. hps indicated that they would be best qualified to teach communication within their own programmes, integrated with content teaching, which is consistent with international trends.[24] staff development and collaboration with communication experts were suggested. educators agreed that greater focus on communication teaching would emphasise its role in clinical competence, and suggested foregrounding communication early in training, coupled with an explanation of expected exit-level learning outcomes: ‘i think the student will look at communication a little bit differently if we have it upfront. communication as a competency, this is how we are going to teach it … and at the end … you can evaluate it yourself, do you have xyz in your communication competence? … students will look at it differently if we have it explicitly, not interwoven … if we have a document that says, this is how we are going to address it.’ (fgd8 ot) while educators were aware that language concordance and an ip and interdisciplinary approach in the clinical setting[25] had been shown to improve patient outcomes, they nonetheless expressed concern about how the already limited time for teaching would be impacted by the inclusion of language teaching and addressing ip communication in programmes. discussion even though communication was included in hp teaching, the programmes had not successfully adopted the chs framework. the approach to tla was directed mainly at profession-specific needs and not at developing key and enabling competencies, which have been shown to promote effective communication in healthcare contexts.[18] findings showed an overall bias towards a biomedical approach, profession-specific communication strategies and providing individual services for patients, with less emphasis on community-centred care. while the challenges of language barriers and benefits of languageconcordant healthcare have been well documented,[26] this study showed that language challenges had not been resolved. in spite of being specifically articulated in the chs framework,[14] broadening the conceptualisation of communication to include community in the context of hp education lacked emphasis. there was, however, acknowledgement of the need for communication beyond the patient, and for strategies that went beyond curative interventions into the preventive and primary realms of community care. the profession-specific strengths demonstrated in some hp programmes suggested opportunities for collaborative learning in ip practice contexts. ip communication, shown previously to be a challenge in the sa healthcare context,[11] was acknowledged as a stumbling block in practice, but nonetheless had not been explicitly incorporated as a key competency for undergraduate students. communication in the workplace between sa healthcare providers and teams is affected by multiple and complex factors,[11] and the rationale for cbe is to train students to be able to meet such workplace challenges.[3,6] a theoretical perspective affords that educators, in spite of their concerns, had not successfully applied cbe to align their teaching methods with contextual needs. the issues of patientand community-centred communication, language and ip communication in healthcare were closely related in the findings of this sa case study. of concern was that some hps still questioned the feasibility of learning indigenous languages to communicate with patients, stating that such communication was often effected by other hps, called upon to act as language, cultural and health education brokers. this stance, contrary to a competency-based approach, may relegate competency in communication, particularly in indigenous languages, as an unnecessary luxury relative to a biomedical approach. critical questions were asked relating to how communication was taught in the chs, and whether educators felt equipped to train students in communication for their context. the results of this study suggest that current communication training initiatives do not adequately prepare hp students for contextual needs in sa healthcare. 138 december 2019, vol. 11, no. 4 ajhpe research study limitations participants were hp educators only. the data collected were based on the participants’ experiences of communication teaching and clinical practice. findings, while not generalisable, are intended to generate discussion on the teaching of communication using cbe in similar healthcare contexts. conclusions deficiencies in demonstrating and teaching good communication to undergraduates were evident. the main problems were a narrow biomedical emphasis in education and practice; language barriers; and insufficient emphasis on broadening communication teaching to include aspects such as ip communication in the healthcare team. the chs adoption of a cbe approach is intended to respond to local needs, and should be strongly supported in teaching and learning. recommendations include raising awareness, staff development and use of champions in the hp programmes to improve teaching and encourage research in communication in local healthcare contexts. improving communication in education and practice may be addressed partly by educators adopting the chs framework, combined with ip learning, to unify the teaching approach across hp programmes. however, cbe theory suggests that responsiveness to context in curriculum development necessitates the identification of specific competencies by expert consensus in authentic sa healthcare settings to ensure fit-for-purpose graduates. finally, deliverable outcomes in communication in hp programmes should be ensured through evaluation of key and enabling competencies in context, together with workplace-based assessment of hp students. declaration. the publication was included in a phd by publication submitted to the university of kwazulu-natal in 2018. acknowledgements. the authors wish to acknowledge the assistance of the dean (teaching and learning) and thank the staff in the chs for their participation in the study. author contributions. both authors were responsible for the content and writing of the article, and participated in the design and co-ordination of the study. both authors were involved in data collection and analysis. mm wrote the first draft, while both authors contributed to subsequent revisions and approved the final manuscript for submission. funding. funding for the study was provided by the research office and the office of the dean of teaching and learning, chs, ukzn. conflicts of interest. none. 1. world health organization. transforming and scaling up health professions education and training: who guidelines. geneva: who, 2013. 2. frenk j, chen l, bhutta c, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 3. gruppen ld, burkhardt jc, fitzgerald jt, et al. competency-based education: programme design and challenges to implementation. med educ 2012;50(5):532-539. https://doi.org/10.1111/medu.12977 4. frank jr, snell ls, ten cate o, et al. competency-based medical education: theory to practice. med teach 2010;32(8):638-645. https://doi.org/10.3109/0142159x.2010.501190 5. epstein rm, hundert em. defining and assessing professional competence. jama 2002;287(2):226-235. https:// doi.org/10.1001/jama.287.2.226 6. modi jn, gupta p, singh t. competency-based medical education, entrustment and assessment. ind pediatr 2015;52(5):413-420. https://doi.org/10.1007/s13312-015-0647-5 7. singh t, modi j. workplace based assessment: a step to promote competency based training. ind pediatr 2013;50(6):553-559. https://doi.org/10.1007/s13312-013-0164-3 8. world health organization. who framework for action on interprofessional education and collaborative practice. 2010. http://www.who.int/iris/handle/10665/70185 (accessed 19 august 2019). 9. roberts c, kumar k. student learning in interprofessional practice-based environments: what does theory say? bmc med educ 2015;26(15). https://doi.org/10.1186/s12909-015-0492-1 10. bleakley a. advances in medical education 3. patient-centred medicine in transition: the heart of the matter. switzerland: springer international publishing, 2014. 11. etheredge hr, penn c, watermeyer j. interprofessional communication in organ transplantation in gauteng province, south africa. s afr med j 2017;107(7):615-620. https://doi.org/10.7196/samj.2017.v107i7.12355 12. health professions council of south africa. core competencies for undergraduate students in the clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2012. 13. royal college of physicians and surgeons of canada. canmeds physician competencies for postgraduate education. ottawa: royal college of physicians and surgeons of canada, 2005. 14. college of health sciences. core competencies for undergraduate students in the college of health sciences teaching and learning programmes at the university of kwazulu-natal. durban: ukzn, 2014. 15. institute for healthcare communication. impact of communication in healthcare. 2011. http://healthcarecomm. org/about-us/impact-of-communication-in-healthcare/ (accessed 4 april 2018). 16. makoul g. essential elements of communication in medical encounters: the kalamazoo consensus statement. acad med 2001;76(4):390-393. https://doi.org/10.1097/00001888-200104000-00021 17. von fragstein m, silverman j, cushing a, quilligan s, salisbury h, wiskin c. uk consensus statement on the content of communication curricula in undergraduate medical education. med educ 2008;42(11):1100-1107. https://doi.org/10.1111/j.1365-2923.2008.03137.x 18. health professionals core communication curriculum (hpccc). objectives for undergraduate education in health care professions. 2014. http://www.each.eu/wp-content/uploads/2014/07/hpccc_website-teach.pdf (accessed 17 july 2017). 19. botha f, snyman e, mchunu g, et al. university of kwazulu-natal college of health sciences and kwazulu-natal department of health business plan for community based training in a primary health care model. durban: ukzn, 2014. 20. statistics south africa. south african census. 2011. http://www.statssa.gov.za/census/census_2011/census_ products/census_2011_census_in_brief.pdf (accessed 28 november 2017). 21. yin rk. case study research: design and methods. 3rd ed. thousand oaks, ca: sage, 2003. 22. lee g, barnett b. using reflective questioning to promote collaborative dialogue. j staff develop 1994;15(1). 23. tong a, sainsbury p, craig j. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. int j qual health care 2007;19(6):349-357. https://doi.org/10.1093/intqhc/mzm042 24. kurtz s, silverman j, benson j, draper j. marrying content and process in clinical method teaching: enhancing the calgary-cambridge guides. acad med 2003;78(8):802-809. https://doi.org/10.1097/00001888-200308000-00011 25. interprofessional education collaborative expert panel. core competencies for interprofessional collaborative practice: report of an expert panel. washington, dc: interprofessional education collaborative, 2011. 26. ngo-metzger q, sorkin dh, phillips rs, et al. providing high-quality care for limited english proficient patients: the importance of language concordance and interpreter use. j gen int med 2007;22(2):324-330. https://doi. org/10.1007/s11606-007-0340-z accepted 1 july 2019. appendix 1. key competencies for the communicator role described in the university of kwazulu-natal college of health sciences core competencies framework[14] communicator role:[14] as communicators, healthcare professionals effectively facilitate the carer-patient/carer-client relationship and the dynamic exchanges that occur before, during and after interventions key competency 1: develop rapport, trust and ethical therapeutic relationships with patients/clients, families and communities from different cultural backgrounds key competency 2: accurately elicit and synthesise relevant information and perspectives of patients/clients, families, communities, colleagues and other professionals key competency 3: convey relevant information and explanations accurately and effectively to patients/clients, families, communities, colleagues and other professionals, as well as statutory and professional bodies key competency 4: develop a common understanding of issues, problems and plans with patients/clients, families, communities, colleagues and other professionals to develop a shared plan of care/action key competency 5: convey effective and accurate oral and written information about a client encounter core competencies: attitudes, skills and knowledge that students should develop by the time they graduate from an academic programme in the health sciences. these competencies are not subject or discipline specific; rather, they are central qualities necessary to enable students to use effectively the knowledge that they have gained key competencies: any of several generic competencies considered essential for graduates to participate effectively in the workplace https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1111/medu.12977 http://dx.doi.org/10.3109/0142159x.2010.501190 http://dx.doi.org/10.1001/jama.287.2.226 http://dx.doi.org/10.1001/jama.287.2.226 http://dx.doi.org/10.1007/s13312-015-0647-5 http://dx.doi.org/10.1007/s13312-013-0164-3 http://www.who.int/iris/handle/10665/70185 http://dx.doi.org/10.1186/s12909-015-0492-1 http://dx.doi.org/10.7196/samj.2017.v107i7.12355 http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ https://doi.org/10.1097/00001888-200104000-00021 https://doi.org/10.1111/j.1365-2923.2008.03137.x http://www.each.eu/wp-content/uploads/2014/07/hpccc_website-teach.pdf http://www.statssa.gov.za/census/census_2011/census_products/census_2011_census_in_brief.pdf http://www.statssa.gov.za/census/census_2011/census_products/census_2011_census_in_brief.pdf https://doi.org/10.1093/intqhc/mzm042 http://dx.doi.org/10.1097/00001888-200308000-00011 http://dx.doi.org/10.1007/s11606-007-0340-z http://dx.doi.org/10.1007/s11606-007-0340-z june 2022, vol. 14, no. 2 ajhpe 47 forum ever-increasing pressure is being placed on faculty members and students to engage in research and produce publishable outputs.[1] projectivised multisite research provides a possible avenue toward alleviating this pressure, but it is not without potential pitfalls.[2] the purpose of this document is to critically reflect on some of the most pervasive ethical dilemmas faced by postgraduate researchers when engaging in such projects. the stellenbosch institute for advanced studies (stias) hosted a visit by four scholars to engage in a project named ‘using a projectivised approach towards advanced studies in mental health research and developing graduateness among mental health students’. the envisioned outcome of the stias endeavour was to develop one large and comprehensive research project to which numerous postgraduate students could contribute through smaller, independent studies. following lengthy discussions and consultation, a project titled ‘covid-19 as psychological trauma, and managing the consequences’ was conceptualised. in order to attract postgraduate students from various universities to participate in the study, the possible concerns of the relevant institutional review boards (irbs) needed to be considered. these irbs exist within the context of their own membership and policies, but also subscribe to the requirements set by universities for degrees, guidelines from the department of higher education and training and the publication guidelines of peerreviewed journals, all of which relate to the dissemination of the research. the aim of this article is to assist prospective collaborators on multisite research projects to deal with the challenges they may face when dealing with irbs, and to provide them with practical insights that might ease the journey to publication. six prominent ethical dilemmas specific to projectivised research were identified: (i) the first dilemma foreseen with outputs from multiple sites was that stakeholders (university authorities and journal editors) may deem the outputs as not independent or as a strategy to increase the number of outputs. in our planning, we were aware of these concerns, and therefore conceptualised each subproject to contribute independently to a well-defined and evolving body of knowledge. in the write-up, we described all the planned subprojects in detail, and how they independently and cumulatively contribute to the larger project. specifying these subprojects should ensure that reviewers appreciate the gravitas of each subproject, and that they will be assured that fragmentation or dilution does not occur. doing so will also provide reassurance that the employment of the leastpublishable-units[3] approach (salami-publishing) is avoided. (ii) related to the aforementioned is the fact that many universities require students to publish as a prerequisite to graduation.[1] it was therefore important to design the projects in a manner conscious of the authorship requirements set by leading journals.[4] as the student contributors were not involved in the conceptualisation of this research, they needed to be involved in ‘the acquisition, analysis, or interpretation of data’, as this would grant them access to authorship. it will subsequently be required of all student collaborators to be involved in the execution of the study under consideration. furthermore, with multiple sites and contributors involved, it is suggested that all collaborators agree early in the process to accept the guidelines of authorship allocation, as stipulated by the international committee of medical journal editors.[5] students should make sure that the by-line conventions specified in their university policies are considered in these agreements. (iii) another problem associated with projectivised research is that a large part of the conceptualisation, methodology and research ethics is addressed on behalf of the student collaborators. however, it is important for students to attain the required learning outcomes associated with the degrees for which they have enrolled.[6] student collaborators are therefore encouraged to take ownership of their own study and to defend the theoretical and methodological choices made on their behalf.[2] to acquaint the students with the workings of ethics applications, supervisors are to recommend certified online ethics training programmes to students. attaching these certificates should be a prerequisite for the completion of their studies and the awarding of degrees. (iv) related projects (investigating x in areas a and b) may require similar literature reviews, which brings us to the fourth issue, namely plagiarism.[3] although cross-site collaboration is encouraged, students are also advised to conduct literature reviews independently. it is also projectivised multisite research is gaining popularity, but is not without its pitfalls. presented are eight possible challenges that could be encountered, and strategies to manage them. this article presents valuable information to scholars planning projectivised multisite research endeavours. afr j health professions educ 2022;14(2):47-48. https://doi.org/10.7196/ajhpe.2022.v14i2.1444 ethical dilemmas in projectivised multisite research r steyn,1 ma, phd; u subramaney,2 mb chb, phd; e s idemudia,3 msc, phd; j becker,4 mcomm, phd 1 graduate school of business leadership, university of south africa, pretoria, south africa 2 department of psychiatry, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 3 faculty of humanities, north-west university, potchefstroom, south africa 4 department of industrial psychology, faculty of economic and management sciences, university of the western cape, cape town, south africa corresponding author: r steyn (steynr@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1444 mailto:steynr@unisa.ac.za 48 june 2022, vol. 14, no. 2 ajhpe forum recommended that students who work on similar projects (x in areas a and b) should approach the studies from different theoretical perspectives. the unique literature reviews and subsequent tailored discussions of findings will combat plagiarism and, simultaneously, contribute to the richness of the bigger project. (v) data pooling forms an integral part of multisite research projects. ethical concerns on this matter can be dealt with in the consent form[3] by stating that data will be pooled, and also by providing examples of how this will be done. linked to this issue is the quality of the data collected from different sites. this is primarily a technical issue, but will also be of interest to some irbs. to ensure the integrity of the data collected, standardised instruments are prescribed and strict research protocols should be developed to ensure the uniform collection of data. (vi) most of these projects are multidisciplinary, thereby involving different departments within the university. there is always the temptation to submit the application of ethical clearance to a specific irb with a reputation for leniency. students should, however, ensure that the authority of the irb in question is recognised by the department from which they plan to graduate. to facilitate student applications to irbs, a copy of the certificate approving the grand project at a well-established university should be attached. it is envisaged that such a letter will add authority and help to facilitate the approval of these applications. four strategies to assist students in obtaining irb approval for multisite projects were employed. the first involved a broad approach, in which it was demonstrated that the grand project could meaningfully be segmented into a number of smaller, independent studies. the second strategy involved engaging students in their research project, allowing them to take ownership and to defend the prescribed protocols. the third strategy involved the utilisation of standardised procedures, in which all projects follow a predetermined and standardised approach, assuring ethical adherence. the fourth strategy related to foreseeing the most pertinent ethical dilemmas related to multisite research. declaration. none. acknowledgements. the stellenbosch institute for advanced study (stias) hosted the authors during the period in which this text was conceptualised and written. author contributions. all authors contributed equally to the conceptualisation and production of the text. funding. none. conflicts of interest. none. 1. bateman ea, teasell r. publish or perish: research productivity during residency training in physical medicine and rehabilitation. am j phys med rehab 2019;98(12):1142-1146. https://doi.org/10.1097/ phm.0000000000001299 2. steyn r. ethical dilemmas associated with hyper-structured student research projects. s afr j higher educ 2020;34(1):231-248. https://doi.org/10.20853/34-1-3095 3. american psychological association. the publication manual of the american psychological association. 7th edition. washington, dc: apa, 2020. 4. cope discussion document. what constitutes authorship? cope, 2015. http://publicationethics.org/news/whatconstitutes-authorship-new-cope-discussion-document (accessed 10 august 2020). 5. international committee of medical journal editors (icmje). defining the role of authors and contributors. icmje, 2016. http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-ofauthors-and-contributors.html (accessed 26 april 2020). 6. south african qualifications authority. the south african qualifications authority (saqa). level descriptors for the south african national qualification framework. saqa, 2012. http://www.saqa.org.za/docs/misc/2012/ level_descriptors.pdf (accessed 15 august 2020). accepted 1 june 2021. https://doi.org/10.1097/phm.0000000000001299 https://doi.org/10.1097/phm.0000000000001299 https://doi.org/10.20853/34-1-3095 http://publicationethics.org/news/what-constitutes-authorship-new-cope-discussion-document http://publicationethics.org/news/what-constitutes-authorship-new-cope-discussion-document http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html http://www.saqa.org.za/docs/misc/2012/level_descriptors.pdf http://www.saqa.org.za/docs/misc/2012/level_descriptors.pdf march 2022, vol. 14, no. 1 ajhpe 17 research the covid-19 pandemic resulted in the disruption of academic programmes globally, thereby compelling contact universities to adopt a reactionary mode of programme delivery.[1,2] south african (sa) universities were affected similarly with regard to the academic agenda. transitions from contact teaching to an online platform during the entire lockdown period, and transitions to an adjusted clinical/practical programme upon return to contact teaching, were instantaneous. during this period, rapidly developed instructional methodologies replaced the well-planned and well-designed academic programmes used before the crisis,[3] affecting academics and students in higher education in different ways.[4] lecturers required theoretical and technological skills to present online teaching and assessment, and students, as adult learners, needed to become more independent.[4,5] sa, where there is a huge disparity of resources between the rich and the poor, has been quoted as the most unequal country in the world.[6] data from 2002 to 2014 showed that nationwide, more than one-quarter of formal, low-cost dwellings were overcrowded.[7] although food secure in terms of its ability to produce food for the population, 2012 figures indicated that 54% of sa households were food insecure, i.e. 28% were at risk of hunger and 26% experienced hunger.[8] food security was previously expressed as a growing concern among university students in sa.[9] the consequences of the lockdown contributed to reduced access to the affordances of universities, put students at higher risk of food insecurity, led to challenges with communication technology[4] and reduced access to study space. academics of the faculty of dentistry at the university of the western cape (uwc) had to resort to a temporary emergency teaching environment as seen in other parts of the world. [10] the bachelor of oral health (boh) degree at uwc is offered as a full-time contact programme, with learning and teaching taking place in the classroom, preclinical laboratories, dental clinics and various community-based facilities. the focus of the oral hygiene profession is oral health promotion, prevention of oral diseases and delivery of preventive and therapeutic clinical care.[11] core competencies include oral health promotion and a range of clinical procedures, encompassing scaling, polishing, restoration and provision of local anaesthesia (la). in 2020, the academic year commenced with the traditional programme for the first term, ending in march. subsequently, the various levels of lockdown resulted in an adjusted academic programme for the remainder of the year, which included online (synchronous and asynchronous) learning and teaching for the duration of the year. modules with a clinical component required students to return to the clinical platform during the last term. with quality assurance being an integral part of all curricula offered at higher education institutions (heis), two diverse modules of the boh degree that were presented during the covid-19 pandemic were evaluated. to ensure credibility and validity of academic programmes, diverse stakeholders and different sources should inform the evaluation process.[12] modified versions of two evaluation tools, the modified concept-indicator method (cim) and the emergency remote teaching environment (erte), were used to guide this process. although findings are not generalisable to the boh programme, an evaluation of sufficiently diverse modules in the same academic year may provide insight into the benefits and challenges regarding the teaching and learning pedagogy. the results may validate these modules background. the covid-19 pandemic resulted in emergency remote teaching, with limited student contact time. for programmes with strong clinical and community-based requirements, such as the bachelor of oral health, one had to be innovative to meet module outcomes. objectives. to (i) evaluate the curriculum and pedagogy of two diverse modules in the second year; and (ii) explore contextual factors affecting teaching and learning. methods. this evaluation study used a mixed-methods design. the sample comprised lecturers (n=3), clinical teachers (n=2), students (n=29) and documents for analysis. the modified concept-indicator method and the emergency remote teaching environment frameworks guided the data collection process. tools included questionnaires, a focus group discussion and document analysis. quantitative data were presented as frequencies and qualitative data were themed. results. student participation for the ohp213 module was 76% (n=19) and 68% for the los200 module (n=19). all the lecturers (n=3) participated. overall, the content and teaching and learning specialists were satisfied with the modules, but made suggestions for improvement. student experiences highlighted diversity in their learning styles and challenges, while lecturers articulated challenges and emphasised affordances during this period. conclusions. the curricula were generally found to be aligned in terms of outcomes, content and assessment. emergency remote teaching presented affordances from the perspective of students and lecturers, which could be explored further. if online teaching were to be a feature of university education, the affordances highlighted by students and staff may argue for a revised hybrid approach to delivering an oral health programme. however, such a system would require thorough research, with the necessary support built into the university as an ecosystem. afr j health professions educ 2022;14(1):17-25. https://doi.org/10.7196/ajhpe.2022.v14i1.1506 module evaluation for emergency remote teaching: an oral hygiene case study during the covid-19 pandemic m cupido,1 bchd; n gordon,2 dipl oh, mph, dipl adult education; n behardien,1 msc (dent) 1 department of maxillofacial and oral surgery, faculty of dentistry, university of the western cape, cape town, south africa 2 department of oral hygiene, faculty of dentistry, university of the western cape, cape town, south africa corresponding author: m cupido (macupido@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i1.1506 mailto:macupido@uwc.ac.za 18 march 2022, vol. 14, no. 1 ajhpe research in their current form, highlight areas for change and explore affordances presented by emergency remote teaching. the aim of this research was therefore to evaluate two modules presented in the second year of the boh programme within the context of the covid-19 pandemic. the objectives were: (i) to evaluate the module content; and (ii) to explore the learning and teaching experiences of involved stakeholders. methods this research was an evaluation study using a mixed-methods design. two methodological frameworks were used to guide data collection.. [10,13] the overarching tool was the cim framework,[13] with the erte educational framework[10] nested within. the core evaluation concepts emanated from the aim of this project, with aligned indicators from the objectives. relevant key indicators, criteria, methods, tools and data sources were identified (table 1). the selection of the two modules was based on the diversity presented by a clinical (los200) and public health (ohp213) focus. during the pandemic, the home environment was a proxy for the community, while the clinical platform was used to perform la. although both modules were year modules, formal teaching for ohp213 was completed at the end of semester 1, with a final assessment concluded at the end of the academic year. data collection and analysis participants comprised oral hygiene students in their second year of study (ohp213: n=29; los200: n=32), clinical chairside teachers (n=2) and lecturers (n=3) of the two modules. data were generated from: (i) student evaluation of modules; (ii) documents, including assessments such as tests and assignments, learning activities and clinical procedures; (iii) reports of an internal teaching and learning specialist (faculty of dentistry) and external subject specialists (academics from two dental schools in sa); and (iv) lecturer/clinical teacher feedback. a modified version of the faculty module evaluation questionnaire, guided by the literature on the effects of the covid-19 pandemic, was used for students. this questionnaire, using google forms, was self-administered and anonymous and included open-ended and closed-ended questions. the questionnaire comprised 4  sections, which included demographic information and student perceptions and opinions of teaching, learning and assessments within the context of the covid-19 pandemic. students could respond to a range of statements on a 5-point scale, ranging from strongly agree, agree, neutral, disagree to strongly disagree, to elicit their perception of teaching and learning (table 2). in addition, they could identify their access to resources and factors impacting on their learning from a predefined list (figs 1 3). open-ended questions included their challenges, suggestions and reflections. records of teaching, learning and assessment, as well as faculty protocols, were used as data on student performance. the teaching and learning specialist was requested to review these and provide a report on the alignment of modules in terms of outcomes, content, assessment and teaching practice, while the content specialists reported on theoretical and practical content and teaching application relevant to each module. a modified version of the erte framework[10] was used to generate data on lecturers’ perceptions and experiences of their modules. two iterations were done. the three lecturers individually recorded a self-reflection on ‘affordances and challenges’ presented and experienced during this period, which was then shared. these  recordings informed the topics for the focus group discussion and a second iteration facilitated by a colleague acquainted with teaching and learning pedagogy, and allowed for deeper exploration of the themes. quantitative data were described and presented as frequency tables. table 1. data collection guide: modified concept-indicator method key indicators  criteria  methods and tools data source  core concept 1: curriculum and pedagogy course design alignment: outcomes, teaching and learning, assessment content: discipline appropriate, relevance of theory and practicum document analysis lecturer reflections and focus group discussion clinical teacher feedback questionnaires module descriptors teaching and learning and content specialist reports transcripts of lecturer reflections student and clinical teacher evaluations learning and teaching interaction presentation of modules teaching and learning methods document analysis questionnaire lecturer reviews and reflections module guide student evaluations transcripts of lecturer reflections learning material and resources relevance, availability of learning materials and usefulness in achieving module outcomes questionnaire learning material and resources student evaluations discipline-specific expert input competence in practical aspects of modules competence in provision of local anaesthesia competence in application of healthpromotion theory questionnaire lecturer review interviews with clinical staff student assessments and evaluations clinical assessment forms assessment  assessments at appropriate level, validity, reliability and transparency monitoring of student progress questionnaire  document analysis student assessments and evaluations assessment records, faculty moderation policy document core concept 2: contextual factors affecting learning and teaching during covid-19 lecturer response to teaching and learning lecturer experience of online learning and teaching environmental contextual factors lecturer reflection and focus group discussion transcripts of lecturer reflection and focus group discussion student response to teaching and learning student adaptation to the online system of learning and teaching environmental contextual factors questionnaire student evaluation march 2022, vol. 14, no. 1 ajhpe 19 research ethical approval ethical approval was obtained from the biomedical research ethics committee of uwc (ref. no. bm16/5/9). results the results of the evaluation from the four data sources of core concepts 1 and 2 are presented. student response to key indicators of the cim framework nineteen students completed the evaluation for both modules (76% for ohp213 and 68% for los200). core concept 1: curriculum pedagogy students’ views on course design, learning and teaching interaction, learning material and resources, competence in practical aspects of modules and assessments are presented below. the results indicate that fewer students understood the learning outcomes of ohp213 than of los200. furthermore, this difference was mirrored in the preparation of lessons for these modules (table  2). views of course design were further expressed as follows: ‘lecturers can reduce content and stick to what’s really important to know.’ ‘overall, it was a well-planned module and the lecturer was always there to assist.’ students’ experiences of learning and teaching are reported in table  2. the following quotations illustrate varying views: ‘weekly assessments and quizzes helped me a lot with my studies and helped me retain information.’ ‘group assignments are not the best way in which group work can be tested.’ the view of lecturers being approachable and learning being interactive was consistent between the two modules. there was a strong view that assessments were fair in terms of the outcomes and that feedback supported learning. students identified the practical application (school visits during term 1 and administration of la done in term 4) as supporting their understanding of the modules the most. for los200, the preclinical block (100%), administration of la (94.7%), being paired with a dental student (94.7%), lecturer-student feedback (78.9%) and clinical teachers being approachable and providing the necessary support (89.5%) were deemed most effective for learning. guided reflections were elicited as ‘critical incidents,’ as used by tsang.[14] the quotations from their reflections highlighted the main themes, supporting their learning as the behaviour of the clinical teacher, student experiences with patients and consolidating theory with clinical experience: reflection of student experience of their learning was highlighted: ‘despite the pandemic and loss of clinical time, students were able to learn very quickly as the lecturers were hands on and very approachable if something needed more clarification.’ ‘one of my class mates had a needle prick injury [experience]. i was a little nervous [feeling] cause it can happen so quick … learn to always use your mirror [learning] to retract … always prepare my patient to cooperate [do differently].’ in the ohp213 module, most students reported that the school visits supported understanding of the module and encouraged an interest in community health (89.9%). a student reflection, after the first school visit with grade 1 learners, illustrates the value of community-based learning experiences: ‘we had a discussion … “what could happen if we do not brush our teeth?” they all replied, “you will have rotten teeth!” … pointed to a girl who had visible dental caries. she went silent and one could see her discomfort [experience]. i felt shocked about how cruel such young children can be to one another, sad and embarrassed that we as healthcare professionals table 2. student perceptions and experiences of module outcomes and assessment, n=19 ohp213, % los200, % key indicators statements to which students responded agree neutral disagree agree neutral disagree presentation of modules met the outcomes i understood the learning outcomes of the module 63.2 31.6 5.2 79 21 i achieved the learning outcomes of the module  68.4 31.6 73.7 5.3 21 teaching and learning methods supported learning, facilitated an interactive approach and were effective in preparing students for theory and practical i received adequate assistance in this module when i needed it 55.6 38.9 5.6 73.7 5.3 21 lecturers were approachable and supported my learning in this module 83.3 11.1 5.6 94.7 5.3 i found that learning in this module was interactive between lecturer and student  77.8 22.7 73.7 26.3 i generally prepare for lessons as required for this module 61.1 22.2 16.7 73.7 26.3 assessments were appropriate and transparent, assisted with learning and reflected outcomes assessments were fair in terms of module outcomes 72.3 16.7 11 68.5 10.5 20 online practice tests and tasks helped me to prepare for assessments in this module 68.8 31.2 57.9 5.3 36.8 feedback from the assessments supported my learning 72.2 22.2 5.6 63.2 21.2 15.6 20 march 2022, vol. 14, no. 1 ajhpe research placed that little girl in that position [feeling]. in a similar situation, i would ask children to write down in their own words what they think can happen instead of letting them shout it out [do differently], which may result in some learners feeling invalidated [learning].’ there was a marked difference between the two groups in the resources they found supportive of their learning (fig.  1). in los200, activities best supporting understanding were: online practical demonstrations (84.2%), synchronous online lectures (78.9%), role-play (47.4%) and group work (47.4%). in contrast, in ohp213, the activities were: developing a portfolio (61.1%), voice-over powerpoint (microsoft corp., usa) lectures in which the lecturer was visible (55.6%), reflecting on learning (55.5%) and researching professional websites (47.4%). lecture notes were reportedly the most useful resource for both groups. responses of agree and strongly agree were combined and are reported as agreed. responses of disagree and strongly disagree were combined and reported as disagreed. in one of the statements, most of the time was an option instead of neutral. core concept 2: student contextual factors affecting teaching and learning contextual factors that impacted positively and negatively on student learning are presented below. the views of student experiences of their learning environment and the impact on their learning are shown in figs 2 and 3. there were marked differences in the factors impacting positively on learning in the two modules (fig.  2). these were less so in recorded online lectures and time management. there were marked differences in factors impacting negatively on student learning, except poor connectivity, which was common to both. although food was not indicated as impacting negatively, inadequate money for basic necessities was a concern for approximately a third of students. the loss of family income was expressed as a concern for more than a third of students (fig. 3). in the open-ended questions, students were asked to identify the most significant change in their lives during lockdown. these were themed as: (i) personal such as time management, being more productive and organised, compromising on how the day was organised, being more disciplined, self-motivated and adapting to new ways; (ii) the home such as changes such as juggling household duties, not having to travel and being indoors most of the time; and (iii) learning such as adapting to a new norm of studying online, not going to university, not being able to interact with lecturers and peers, being dependent on technology, online assessments and insufficient enough time to go over learning material virtual communication with lecturer easy access to online learning material recorded online lectures i could focus on my studies i became more independent i learnt to manage my time better private space to study financial security family better understood demands of my studies more time with family 0 20 3010 40 50 60 70 80 90 ohp213 los200 89.5 68.8 52.6 62.5 73.7 50 84.2 87.5 42.1 25.0 73.7 56.3 52.6 50 63.2 43.8 5.3 18.8 47.4 37.5 68.4 50 fig. 2. factors identified by students as positive to their learning and development. 0 20 3010 40 50 60 70 80 90 100 ohp213 los200 whatsapp messages journal articles online lectures videos communication via ikamva notes 66.7 78.9 27.8 31.6 55.6 78.9 50.0 84.2 55.6 47.4 66.7 89.5 fig. 1. resources supportive of learning. (ikamva = university of the western cape e-learning platform.) march 2022, vol. 14, no. 1 ajhpe 21 research practical experience: ‘this really increased my stress levels because while i was still regularly studying to get good grades, they [parents] felt that me being home, meant that i had more time to focus on housework.’ document analysis aligned to the cim framework core concept 1: curriculum pedagogy in the ohp213 module, 25 of the 29 registered students (86.2%) completed and passed the module. in the los200 module, 28 of the 32 registered students (87.5%) completed and passed the module. students in both modules discontinued participation at different periods of the lockdown and did not respond to faculty follow-up processes. this amounts to an attrition rate of 13.8% for ohp213 and 12.5% for los200. lecturers’ views were that assessments were aligned to the faculty assessment and moderation protocol. the range of assessments (e.g. tests, case studies) accommodated the differing needs of students. expert response to key indicators of the cim framework core concept 1: curriculum pedagogy the teaching and learning specialist suggested presenting module outcomes as ‘applied integrated competencies’ rather than ‘knowledge, skills and values’. this would allow a more detailed description of learning to be attained and guide the associated teaching, learning and assessment practices. it was advised that when deciding on the type of assessment and the breakdown thereof, in view of adjustments due to lockdownassociated challenges, lecturers should be guided by the question, ‘do the assessment outcomes produce competence at a level expected of the students?’ furthermore, assessments should be flexible enough to encompass the differing needs of students. the content specialist for los200 reported that the module was appropriately covered and relevant. it was suggested that content taught at a preclinical and clinical level be introduced through didactic lectures to scaffold clinical application, that selected topics be presented in greater detail, and where such topics are taught in other modules, these be consolidated in los200. the evidence of varied teaching methods, such as online lectures embedding theoretical knowledge and application in the clinical setting, and a good balance of learning activities aligned with the learning outcomes, was highlighted. a review on the weighting of the clinical component of the module was suggested; however, the reduction of this weighting during the pandemic was deemed acceptable. the content specialist for the ohp213 module indicated that the attributes expected at secondyear level were evident and clearly achieved from the outline of the learning units; relevant theories of oral health promotion were covered and appropriate; and the module content, supported by relevant theory, empowered learners to work in inter-disciplinary health promotion. it was further suggested that lecture presentations (powerpoint (microsoft corp., usa)) were well organised and informative but that there should be a more visual presentation to accommodate diverse learners with differing learning styles. lecturer response to key indicators of the cim framework core concept 1: curriculum pedagogy the views of lecturers were that assessments were aligned to the faculty assessment and moderation protocol. the range of assessments such as online tests, case studies, independent learning tasks and clinical procedures accommodated the differing needs of students. lecturers expressed concern regarding the reliability and validity of online assessment outcomes, considering that these were conducted in an environment in which there was limited control over the process. 0 20 3010 40 50 60 70 80 90 100 ohp213 los200 lectures not uploaded on time poor internet connectivity no internet access at primary residence limited access to data limited access to device family not understanding i need study time lecturers not available no private space to study sharing bursary/loan with family bursary/loan not paid on time insu�cient food for daily needs inadequate money for basic necessities family losing income unable to access online lectures regularly isolated from family/friends intermittent access to data or wifi 42.1 23.5 47.4 47.1 5.3 17.6 36.8 47.1 15.8 11.8 5.3 17.6 10.5 11.8 21.1 41.2 21.1 17.6 15.8 5.9 0 5.9 31.6 41.2 47.4 35.3 26.3 41.2 10.5 41.2 26.3 11.8 fig. 3. factors identified by students as negative to their learning and development. 22 march 2022, vol. 14, no. 1 ajhpe research lecturers indicated that the broad outcomes of modules were met within the current context and that there was alignment between outcomes, teaching and assessment despite the challenges of changing from contact teaching to a hybrid format. in both modules, theoretical and practical components could not be scaffolded as in the ‘traditional’ offering owing to effects of the lockdown. practical aspects were in part presented online for both modules, but for ohp213, the home environment was used as an authentic learning activity for the practical component of the module. in the ohp213 module, an opportunity was created to streamline content to outcomes, but adjustments to module design in terms of learning opportunities and assessment practices may have compromised the learning for some students. the school project (ohp213) was viewed as a ‘real-world perspective’ for students, enabling context-specific application of theory to practice, encouraging an appreciation of social determinants of oral health and understanding the difference between empathy and sympathy, as also evident in a student reflection (as reported above). clinical chairside teachers (los200) considered the online platform to teach application and clinical relevance challenging. they reported that, on return to the clinical platform, the preclinical block course was of great value in preparing students for administering la. although the standard method of teaching at the chairside continued on the return of students to the clinical platform, clinical teachers had to be cognisant of the challenges students experienced regarding the use of personal protective equipment (ppe) in performing injection techniques. core concept 2: contextual factors affecting teaching and learning lecturers reflected on their experiences of programme delivery during the lockdown period. using the erte framework,[10] they specifically reflected on the challenges encountered and affordances gained. the latter appeared to be standard, i.e. collegial support and the learning and use of new technology. the main themes generated during the first iteration of reflection included the emotions experienced by lecturers, lecturers’ concern for students, rapid change in the academic environment, transition to technology, academic programme concerns, information technology (it) issues, assessment concerns and communication challenges. the second iteration included additional themes and a deeper understanding of themes raised in the first iteration (table 3). discussion through systematic curricula evaluation, developers can optimise the curricula to ensure that their goals are met.[15] the cim framework, a comprehensive tool encompassing the perspectives and expertise of all stakeholders, provided table 3. lecturers’ perspective of learning and teaching during the covid-19 pandemic themes illustrative quotations emotions experienced by lecturers anxiety, frustration, concern, fear and being overwhelmed there were many reasons for these emotions, including the unknown, uncertainty, lack of command of technology, retaining the rigour of the academic programme and, in a sense, lack of control of the academic environment ‘what overwhelmed me the most, was having to do everything online instantaneously.’ ‘i think i was anxious about doing online lectures because of my lack of command of technology.’ ‘i was really scared to go online and knowing that there’s so many students sitting somewhere.’ ‘the other challenges that i encountered with this whole online setup was the, the assessments. i found it very frustrating, knowing that, you know, or asking myself: am i really testing the student well enough on this platform?’ ‘[w]hat frustrated me as well, is the fact that our university has a platform that we can utilise but it was not very user-friendly.’ concern for students lecturers expressed a great amount of concern for student wellbeing, both professionally and personally much of the planning and reflection on teaching activities considered the needs and challenges of the students ‘… learn to download video clips, etc. in the format that you could include it into your powerpoints, without it using data for students.’ ‘and also with the challenges that they faced with not having stable connectivity.’ ‘but i don’t think that parents always understood how hard they have to work.’ ‘and then ultimately finding the suitable platform for students that’s convenient for them and easy.’ communication challenges the rapid transition from a contact university to an online institution highlighted the unpreparedness of the educational ecosystem ‘[i]t was difficult for me to speak to an inanimate screen because there was no one there. you couldn’t sense whether there were any questions or uncertainties from a student’s perspective.’ ‘so not being able to see them or see their expressions, whether they were confused or whether they were engaged with the lecture; that was a challenge for me. so i didn’t really know whether the message was going across.’ it-related issues challenges varied from learning new software applications to modifying course content for an online platform, learning new online platforms and managing the university online learning and teaching site managing standard student-related administration, such as the attendance register, which was cumbersome because students entered and left the meeting constantly ‘the technology aspect, which also i found challenging, was having to learn to download video clips, etc. in the format that you could include it into your powerpoints without it using data for students.’ ‘[h]aving to acquire the skills to facilitate discussions or lectures on the various online platforms.’ (continued) march 2022, vol. 14, no. 1 ajhpe 23 research the necessary rigour for this evaluation. the erte framework, although used by primary school teachers,[10] has been found to be of value by the lecturers at the tertiary academic institution where this study was conducted. triangulation of data indicates views being corroborated by different sources. the use of multiple stakeholders and data sources in module evaluations has been shown to provide a useful overview of both modules, highlighting aspects that may need further investigation. although teaching diverse modules, lecturers appeared to have similar concerns regarding the coping mechanisms of students with respect to personal and academic challenges imposed by the pandemic. lecturers being approachable and supportive of student learning, and the interactive nature of the module presentation, as highlighted by students, may be an indication that lecturers acted on these concerns. all students who participated for the entire academic year passed the modules, which is an indication of students’ resilience to cope in adverse conditions. a concern, however, is the attrition of 4 students in a relatively small class. the suggestion by the ohp213 content specialist to increase visual material in lectures is supported by the literature.[16] this may make this resource more useful to students, particularly as they found recorded lectures supportive to learning. the los200 content specialist’s suggestions highlight that professional programmes have different approaches to presenting the oral hygiene clinical scope of practice, e.g. regarding administration of la, with regard to content and clinical teaching thereof. although second-year modules are not subject to external review, the results of this study may make an argument for collegial discussions to inform oral hygiene curricula design across programmes in sa, as done in the usa.[17] presenting outcomes as integrated competencies, as suggested by the teaching and learning specialist, may make learning outcomes more explicit to students. evidence of the inherent differences between the two modules was highlighted in the student evaluation. in ohp213, one aspect of competence in health promotion is developed through community-based activities. table 3. (contined) lecturers’ perspective of learning and teaching during the covid-19 pandemic themes illustrative quotations academic programme concerns lecturers expressed concern in transforming the traditional face-to-face academic programme to an online programme, while retaining its academic rigour ‘transforming the traditional programme to an online one.’ ‘so i didn’t really know whether the message was going across.’ ‘[f]inding ways of assessing that was [sic] authentic but that was [sic] also practical for the students to do, then converting some of my practical aspects of the module into something that would meet the same outcomes. so it’s basically to do with the level of teaching, the type of assessment that was done.’ ‘having to prepare lectures differently to make it [sic] more accessible to students.’ increased workload the sudden change in programme delivery from face-to-face to online resulted in an increased workload for academic staff ‘… and having to rewrite tests and having to redo online assessments. that to me was very challenging and time consuming, knowing that i’m going to have to mark and then i’ll have to set up another test. where normally you would have just set up maybe one test and a sick test, you find yourself doing four or five because of the challenges that they [students] also have wherever they are.’ ‘but then, it was such a problem because then i had to download the recordings from zoom, then put it on whatsapp and put it on the ikamva* site. or sometimes, i found that i couldn’t hear the recordings, so i had to sit and do the lecture over. i actually had to do the lecture over at night so that i could put it on whatsapp. so there was such a lot of administrative work that you almost don’t realise that all the things you had to do to prepare to make sure the lecture was on. and then the recorded lecture ‒ and sometimes they couldn’t hear it.’ learning culture lockdown may be encouraging an environment that is more relaxed, with no measure of urgency in such an environment there are few guidelines or time constraints enforced by an authority figure, which may lend to a more relaxed academic work ethic ‘you don’t know if they get used to this idea of, “i get a recorded lecture”. what kind of culture are [we] going to inculcate in our students in terms of learning? so for me, there was a lot of concern around the students in terms of how they are coping being at home but also how they will learn in the future because you want them to learn in a way that they enjoy studying.’ type of professionals there was concern that the nature of online learning (flexibility) and reduced input of academic professionals within the discipline may lead to behaviour that is not in line with professional etiquette ‘… but also how they will learn in the future because you want them to learn in a way that’s that they enjoy studying, but we can actually take them on a road of listening to a lecture and learning something they don’t really understand. so i think it’s a concern for them, concern for the kind of professionals we’re going to produce and also i think there were times you just got a sense that they were really tired.’ assessment concerns lecturers were concerned that the rapidly developed assessments did not offer adequate rigour in assessing module outcomes the trustworthiness of online assessments was of concern ‘… and creating assessments where you know that the results would be valid, a true indication of the students’ knowledge on the content which was tested.’ ‘the other challenges that i encountered with this whole online setup was the, the assessments. i found it very frustrating, … asking myself: am i really testing the student well enough on this platform … are we really looking at outcomes and then assessing them properly?’ it = information technology. *ikamva is the university of the western cape e-learning platform. 24 march 2022, vol. 14, no. 1 ajhpe research during the pandemic, the home environment was used as a proxy for the community, resulting in additional and more independent learning activities and assessments. in contrast, the nature of the los200 module was such that online demonstrations and video clips could be used to scaffold learning until return to the clinical platform to achieve clinical competence. the different teaching and learning methodologies, coupled with their styles and demands, may explain the varied experiences of students. the duration of los200 compared with ohp213, may also have contributed to the difference in experience of students, as the longer contact period with los200 allowed students to acclimatise to the ‘new norm’ as the academic year progressed. within a context such as erte, curriculum planning should be informed by an understanding of the demands of diverse modules. the global concern for validity and reliability of online assessment has been addressed by some dental schools using it applications, e.g. lockdown browser.[15] such technology, however, may be a challenge for resourcepoor countries. the external review highlights the possible inconsistency of la as a competence between at least two oral hygiene programmes in sa. it may therefore be useful for oral hygiene programmes to institute collegial review platforms, where subject specialists can develop a common framework to meet minimum standards for competence, particularly clinical procedures as implemented in dental hygiene curricula in the usa.[17] emergency remote teaching required heis to offer programmes in a new hybrid format. the evaluation of the modules indicated reasonable success, as seen in completion rates, lecturers’ perceptions of teaching and students’ learning experiences. hodges et  al.[3] caution against using such outcomes as a basis to introduce online teaching as a new norm at contact universities. these authors argue that the lecturer, together with learning and teaching, is but one aspect within a university ecosystem. other aspects of contact, online or distance universities include library services, different levels of student support and lecturers providing additional support such as mentoring.[3] therefore, in considering the affordances presented by erte, such as lecturers learning new skills, students becoming more independent, spending less time on travelling and being able to study at their own pace, one should consider and research the infrastructure needed. factors that may need to be examined regarding an expanded university ecosystem include developing appropriate student support systems, building student agency, ensuring that lecturers are informed of the pedagogy of online teaching and learning, providing lecturers with support to develop and administer online learning and monitoring the entire learning process. feedback from students on components that were helpful to their learning included the design of the course, followed by comfort with technologies, motivation and time management.[15] students’ views highlighted the importance of effective instructional design for online courses. reporting on dental student satisfaction with online learning during the covid-19 pandemic, wang et  al.[1] found that online learning content provided the highest satisfaction, while interaction between teachers and students showed the lowest satisfaction. factors such as network instability, objective teaching assessments, inefficient online teaching ability and platform instability were noted. a number of these aspects appear to be common to our study. in resource-poor contexts, as seemingly is the case in this study, the use of technology without the necessary support may further hinder success. if online teaching is to be a feature of university education, universities should develop creative spaces for students to study. student evaluation systems are routine to the hei environment, but do not necessarily result in changes in lecturer practices.[18] in this study, feedback indicated that students are able to provide meaningful input into factors that affect their learning and contribute to solutions, as also demonstrated by brooman et  al.[19] academics, as reflective practitioners, need to determine how such evaluations should be structured and administered to reflect student voice and agency fully. contact universities’ academic staff with limited experience in the pedagogy or delivery of online learning should upskill themselves rapidly regarding online learning platforms and its demands.[3,4] this view is supported by the stresses and challenges highlighted by lecturers in this study. hodges et  al.[3] liken the experiences to ‘faculty feeling like instructional macgyvers, having to improvise quick solutions in less than ideal circumstances’.[18] although lecturers reported finding innovative means to conduct online teaching (blended learning), these were noted to be stressful owing to concern for student resources and participation and their own anxieties. blended learning is potentially a transformative process, requiring careful, thoughtful and informed design inclusive of, but more than the addition of technology.[20] remedial efforts by universities such as providing devices and data contribute little to help students living in remote areas where electricity supply is inconsistent and network coverage poor.[4] these concerns were reported in this study. contextual factors affecting learning appear to be more extensive than in other studies.[1,15] this is particularly evident in the reported loss of family income and insufficient money for basic necessities during the lockdown period. when appraising extended online teaching and learning, universities should take cognisance of these factors.[20] conclusions the curricula were generally found to be aligned in terms of outcomes, content and assessment. the emergency remote teaching presented affordances from the perspective of students and lecturers, which could be explored further. if online teaching were to be a feature of university education, the affordances highlighted by students and staff may argue for a revised hybrid approach to delivering an oral health programme. however, such a system would require thorough research, with the necessary support being built into the university as an ecosystem. declaration. none. acknowledgements. we acknowledge the contribution of dr i moodley, subject specialist, oral surgery and local anaesthesia (university of kwazulunatal), ms  n sofala, subject specialist, oral health promotion (university of pretoria), dr  s lundie, learning and teaching specialist (uwc) and dr r maart, facilitator (uwc). author contributions. all authors contributed equally to the article. funding. none. conflicts of interest. none. 1. wang k, zhang l, ye l. a nationwide survey of online teaching strategies in dental education in china. j dent educ 2021;85(2):128-134. https://doi.org/10.1002/jdd.12413 2. chang ty, hong g, paganelli c, et  al. innovation of dental education during covid-19 pandemic. j dent sci 2021;16(1):15-20. https://doi.org/10.1016/j.jds.2020.07.011 3. hodges c, moore s, lockee b, trust t, bond a. the difference between emergency remote teaching and online learning. educause rev 2020;27:1-2. 4. hedding dw, greve m, breetzke gd, nel w, van vuuren bj. covid-19 and the academe in south africa: not business as usual. s afr j sci 2020;116(7-8):1-3. https://doi.org/10.17159/sajs.2020/8298 https://doi.org/10.1002/jdd.12413 https://doi.org/10.1016/j.jds.2020.07.011 https://doi.org/10.17159/sajs.2020/8298 march 2022, vol. 14, no. 1 ajhpe 25 research 5. wong tw, gao y, tam wws. anxiety among university students during the sars epidemic in hong kong. stress heal 2007;23(1):31-35. https://doi.org/10.1002/smi.1116 6. greenwood x. south africa is the most unequal country in the world and its poverty is the ‘enduring legacy of apartheid’. the independent, 4 april 2018. https://www.independent.co.uk/news/world/ africa/south-africaunequal-country-poverty-legacy-apartheid-world-bank-a82 88986.html (accessed 7 february 2022). 7. statistics south africa. housing from a human settlement perspective: in depth analysis of the general household survey data, 2002 2014. pretoria: stats sa, 2016. 8. shisana o, labadarios d, rehle t, et  al. south african national health and nutrition examination survey (sanhanes-1). cape town: human sciences research council, 2013. 9. van den berg l, raubenheimer j. food insecurity among students at the university of the free state, south africa. s afr j clin nutr 2015;28(4):160-169. https://doi.org/10.1080/16070658.2015.11734556 10. whittle c, tiwari s, yan s, williams j. emergency remote teaching environment: a conceptual framework for responsive online teaching in crises. inform learn sci 2020;121(5/6):311-319. https://doi.org/10.1108/ils-042020-0099 11. bowen dm, pieren ja. darby and walsh dental hygiene: theory and practice. 5th ed. amsterdam: elsevier, 2019. 12. harris l, driscoll p, lewis m, matthews l, russell c, cumming s. implementing curriculum evaluation: case study of a generic undergraduate degree in health sciences. assess eval high educ 2010;35(4):477-490. https:// doi.org/10.1080/02602930902862883 13. waggie f. development of an evaluation matrix for a community-based interdisciplinary health-promotion course. afr j health professions educ 2015;7(1):58-63. https://doi.org/10.7196/ajhpe.432 14. tsang akl. oral health students as reflective practitioners: changing patterns of student clinical reflections over a period of 12 months. j dent hyg 2012;86(2):120-129. 15. song l, singleton es, hill jr, koh mh. improving online learning: student perceptions of useful and challenging characteristics. high educ 2004;7(1):59-70. https://doi.org/10.1016/j.iheduc.2003.11.003 16. asiry ma. learning styles of dental students. saudi j dent res 2016;7(1):13-17. https://doi.org/10.1016/j. sjdr.2015.02.002 17. mccomas mj, hurlbutt m, fontana m. a survey of cariology education in us dental hygiene programs: the need for a core curriculum framework. j dent educ 2020;84(12):1348-1358. https://doi.org/10.1002/jdd.12348 18. blair e, valdez noel k. improving higher education practice through student evaluation systems: is the student voice being heard? assess eval high educ 2014;39(7):879-894. https://doi.org/10.1080/02602938.2013.875984 19. brooman s, darwent s, pimor a. the student voice in higher education curriculum design: is there value in listening? innov educ teach int 2015;52(6):663-674. https://doi.org/10.1080/14703297.2014.910128 20. mackey j, gilmore f, dabner n, breeze d, buckley p. blended learning for academic resilience in times of disaster or crises. j online learn teach 2012;8(2):35-48. accepted 17 january 2022. https://doi.org/10.1002/smi.1116 https://www.independent.co.uk/news/world/ https://doi.org/10.1080/16070658.2015.11734556 https://doi.org/10.1108/ils-04-2020-0099 https://doi.org/10.1108/ils-04-2020-0099 https://doi.org/10.1080/02602930902862883 https://doi.org/10.1080/02602930902862883 https://doi.org/10.7196/ajhpe.432 https://doi.org/10.1016/j.iheduc.2003.11.003 https://doi.org/10.1016/j.sjdr.2015.02.002 https://doi.org/10.1016/j.sjdr.2015.02.002 https://doi.org/10.1002/jdd.12348 https://doi.org/10.1080/02602938.2013.875984 https://doi.org/10.1080/14703297.2014.910128 september 2019, vol. 11, no. 3 ajhpe 88 research in 2006, the world health organization (who), in collaboration with the international pharmaceutical federation (fip), underpinned the new concept of a 7-star pharmacist. among other attributes, it especially called for pharmacists globally to be communicators. the pharmacist is thus seen as being in ‘an ideal position to provide a link between prescriber and patient and to communicate information on health and medicines to the public’.[1] pharmacists who are skilled communicators have been reported to be more likely to have a greater influence on prescribing than those who communicate less effectively.[2] effective communication skills training is essential in pharmacy education and eventual pharmacy practice, especially during patient and medication counselling. these skills have been shown to improve patient outcomes and satisfaction and also to enhance pharmacists’ status and self-esteem.[3] assertiveness is an effective communication skill important for patient safety and teamwork.[4] this skill has been described as the direct expression of ideas and opinions, while respecting the rights of others in an atmosphere of trust.[4,5] it is said to be the middle state between aggression and passivity and includes skills such as responding appropriately to criticism, being persistent and expressing one’s opinions and feelings appropriately.[6] the literature suggests that there are communication difficulties among pharmacists and pharmacy students.[7-9] these difficulties could interfere with the provision of pharmaceutical care to a patient and crosscommunication with other colleagues in and outside the healthcare team. communication difficulties have been divided into various subtypes, including apprehension, reticence and shyness, and are characterised by some form of communication problem.[8] communication apprehension has been conceptualised as ‘an individual’s level of fear or anxiety associated with either real or anticipated communication with another person or persons’,[10] while reticence, on which this study focuses, is viewed as primarily a problem of repeated ineffectiveness in communication encounters.[11] not much research has been done regarding communication skills ability among pharmacy students; it has focused mainly on communication apprehension. studies in the 1980s, investigating communication apprehension and shyness among a large group of pharmacy students, reported that 1 in 5 students was highly communication apprehensive and over a third were shy.[8] recently, two studies conducted among malaysian pharmacy students focused on communication apprehension, and reported the prevalence of such communication difficulty among its pharmacy students.[9,12] the first study, a comparative survey of communication apprehension among firstand final-year students of a pharmacy school in malaysia, reported a greater prevalence of communication apprehension among first-year students. the study also reported many cases of communication apprehension among females and younger-aged pharmacy students.[12] the second study was conducted a year later, in 2010, among first-year pharmacy students in one school. the findings showed that communication apprehension was significantly high, but there were no differences between male and female students. one in 4 students selfreported communication apprehension.[9] these studies might, however, background. effective communication is an important attribute for practising pharmacists worldwide. however, little is known about the effects of communication skills on pharmacy students’ academic performances in nigerian pharmacy schools. objectives. to identify the distribution of two communication skills, i.e. assertiveness and reticence, among pharmacy students and the association of these skills with the students’ academic performances. methods. seven pharmacy schools were randomly sampled in this study. a validated 18-item questionnaire measuring communication constructs, assertiveness and reticence was distributed to eligible students after ethical approval had been obtained. the questionnaire adopted a 5-point likert scale for responses. demographic details and self-reported academic performances in the most recent pharmacy examinations were also collected. descriptive and regression statistics were reported for the distribution of these communication skills and student factors that influence performances, respectively. results. pharmacy students (n=1 550) were surveyed. students were more assertive (mean 3.40) than reticent (mean 3.30) in their communication. female students were more reticent and less assertive than male students (p≤0.05), but age had no influence on either construct. being highly assertive was associated with higher grade performances in the three courses examined (p≤0.027 for each course). however, for clinical pharmacy, lower reticence scores were associated with better academic performances (p=0.035). regression analysis showed that assertive pharmacy students were less likely to report lower grades in all three courses (p≤0.004) and reticent students were more likely to report lower grades in only clinical pharmacy (p=0.042). conclusions. assertive and reticent communication skills were present among nigerian pharmacy students. being assertive and reticent, as well as students’ gender, age and marital status, were associated with the students’ self-reported academic performances. afr j health professions educ 2019;11(3):88-95. https://doi.org/10.7196/ajhpe.2019.v11i3.1099 communication skills and their association with self-reported academic performances of nigerian pharmacy students c m ubaka, phd; c v ukwe, phd department of clinical pharmacy and pharmacy management, faculty of pharmaceutical sciences, university of nigeria, nsukka, nigeria corresponding author: c m ubaka (pharmubk@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 89 september 2019, vol. 11, no. 3 ajhpe research not reflect the views of african or specifically nigerian students. also, the studies did not include students in other years of pharmacy training and did not focus on possible factors that could be associated with student communication skills. from 2019, pharmacy training in nigerian pharmacy schools is slowly but steadily migrating to the patient-centred doctor of pharmacy programme, and it is important to evaluate students’ communication skills status, as they will engage and communicate more with peers, instructors and patients. such an evaluation is also important in the context of male/female inequality regarding scholarly and productivity expectations, which is believed to be common in the african setting. this inequality could interfere with communication abilities of female pharmacy students, especially with their male counterparts. there is currently no literature on communication skills or communication difficulty among pharmacy students in africa. to the best of our knowledge, there is also no literature on the association between communication skills and academic performance among pharmacy students. therefore, the objectives of this study were as follows: (i) to measure the distribution of communication skills – assertiveness and reticence – among pharmacy students; and (ii) to evaluate the association of assertiveness and reticence with academic performances of pharmacy students in selected pharmacy examinations. methods setting the bachelor of pharmacy degree is the minimum qualification necessary to practise pharmacy in nigeria. pharmacy training in nigeria is regulated by the pharmacists council of nigeria (pcn) and curricular contents and modules are similar across the same years of study in all pharmacy schools. teaching styles might differ slightly among schools and within a school, but training schedules and a time frame are regulated by the pcn in all pharmacy schools. the bachelor of pharmacy programme in nigeria comprises 5 years, including 1 year of pre-pharmacy training. during the next 4 years, often regarded as professional years, students are trained over 5 broad course areas, i.e. pharmacology, pharmaceutics, pharmacognosy, clinical pharmacy and pharmaceutical chemistry. pharmacology, clinical pharmacy and pharmaceutics are studied during all training years from the third to the fifth year, unlike pharmacognosy and chemistry, which are not. in the former courses there is more contact and communication with instructors and preceptors. all pharmacy courses in nigeria are offered over a 2-semester period, each covering 4.5 months of an academic year. communication skills training is introduced in the final year of study before and during clinical rotations of the clinical pharmacy course. design this multicentre study was designed as a cross-sectional survey conducted among university pharmacy students at the end of the second semester of the 2014/2015 academic session. population and sample there are 19 pharmacy schools in nigeria, of which only 12 had received full council accreditation at the time of the study. all pharmacy students from their third to fifth course year formed the study population. only 7 councilaccredited pharmacy schools in the country were selected by a multi-stage sampling technique from 12 accredited schools, employing both cluster and random sampling methods. the country was divided into three clusters, i.e. south south-east, south-west, and north, based on regions having an accredited pharmacy school. the schools were then randomly selected ‘proportionally’ within each cluster to produce 7 schools from the possi ble 11: south south-east (n=3/40); south-west (n=2/4); and north (n=2/3). pharmacy students from these schools who had registered for study and completed the pharmacy professional examinations the previous academic year (i.e. from the third to the fifth year) were eligible to participate and were included in the study (n=2 156). first-year pharmacy students who do not take professional examinations, and second-year pharmacy students who had yet to take their professional examinations, were excluded from the survey. verbal consent was obtained from all participating students. survey instrument the questionnaire used in this study was a modification of a previous questionnaire and validated by lee et al.[16] to assess the effects of assertiveness and reticence on the performance of medical interns in their clerkship specialties. the original questionnaire comprised 12 items (cronbach’s alpha coefficient 0.82) and assessed students’ assertiveness and communication abilities during classes. these items evaluated students’ ease of public speaking, confidence, risk-taking, on-the-spot questioning and networking.[16] it also included 6 items (cronbach’s alpha coefficient 0.74) that assessed reticence (shyness or discomfort) when being questioned by lecturers/instructors.[16] responses to these items were scored on a 5-point likert disagree/agree scale, with a score of 5 assigned to strongly agree and 1 to strongly disagree. five recent pharmacy graduates of the university of nigeria were handed the questionnaires to assess their understanding of the items and provide feedback. some adjustments were made to 6 questionnaire items (3 each in assertiveness and reticence). the adjustments were mainly the change of resident/physician to lecturer in item 12 for assertiveness, and items 1, 5 and 6 for reticence. other adjustments were the rewording of items 2 and 8 for assertiveness to reflect a classroom or laboratory setting. the final questionnaire comprised 18 items (12 assertiveness and 6 reticence). students’ characteristics, such as year of enrolment, age, gender and marital status, were also collected. they were requested to report their performances in percentages or letter grades as applicable in 3 preselected pharmacy examinations, i.e. pharmacology, clinical pharmacy and pharmaceutics. permission to conduct the survey in each school was obtained from the dean or head of the faculty. students were approached immediately after a mandatory class or laboratory session and the survey instrument was administered while they were seated in the class. participation was voluntary and no reward was offered or penalty imposed for participation or nonparticipation, respectively. statistical analysis retrieved questionnaires were collected; all items were coded appropriately, entered into the 2015 microsoft excel (usa) spreadsheet and cross-checked for accuracy. coded data were transferred into spss 20.0 (ibm corp, usa). the schools of pharmacy were de-identified and recorded as a, b, c, d, e, f and g before the analysis. all questionnaire items were first reported as frequencies, percentages and means. mean responses to the reticence and assertiveness scales were summarised as low and high for september 2019, vol. 11, no. 3 ajhpe 90 research mean scores ≤3.0 and >3.0, respectively. differences in mean responses for each of the constructs by students’ demographic variables were conducted by independent student’s t-test and analysis of variance, followed by scheffe post hoc analyses. students’ self-reported performances were then classified as lower grades, representing self-reported scores ˂70%, or between grades b and f and highest grades, representing scores ≥70% or grade a, respectively. this grading system is specific to universities in this country, where grade a is ≥70%, b is 60 69%, c is 50 59%, d is 45 49%, e is 40 44% and f is ˂40%. a χ2 analysis was done for differences in proportional data among the various student subgroups. multivariate logistic regression was conducted to identify factors, i.e. demographic variables and survey constructs, which influence the attainment of lower and highest grades. odds ratios and 95% confidence intervals were reported. an a priori significance level of p<0.05 was used. cronbach’s alpha was the numerical coefficient of reliability reported for the two scales tested. ethical approval ethical approval for this study was received from the university of nigeria teaching hospital research and ethics committee (ref. no. nrec/05/01/2008b-fwa00002458-irb00002323), and permission was sought from each participating pharmacy school. informed consent was obtained from each participating student before administration of the survey instrument. results response rates and respondents’ characteristics of the 2 156 students eligible for the study, 1 550 from third-, fourthand fifth-year classes of 7 schools of pharmacy took part in the survey, giving an overall response rate of 71.9%. furthermore, the individual response rates of the pharmacy schools ranged from 55% to 89%. the majority of students (84.5%) was young, i.e. ˂25 years of age, with females representing 49.5% of all students. there were also more single students in the survey (n=1 407; 90.8%). class distribution showed a nearly equal proportion of pharmacy students for each class; third year (n=458; 29.5%), fourth year (n=594; 38.3%) and fifth year (n=498; 32.1%) (table 1). demographic characteristics and level of assertiveness and reticence pharmacy students’ responses to the assertiveness scale showed a marginally high assertiveness (mean 3.40 (standard deviation (sd) 1.22)) (table 2). nearly half of the students disagreed with two assertiveness items: item 1 – ‘if i don’t know an answer to a question, i still act as though i do’ (39%); and item 2 – ‘i feel comfortable when asked a question in front of the class’ (48%). also, regarding responses to the two assertiveness items measuring confidence in communication, items 3 and 12 had mean values of 3.25 and 3.27, respectively. cronbach’s alpha of the 12-item assertiveness scale was 0.72, indicating good internal consistencies and reliability of the instrument in this setting. responses to the reticence scale (table 3) revealed an average score of 3.03 (1.24). interestingly, for item 6, half (51.5%) of the pharmacy students agreed that they were reticent, preferring not to challenge or question answers/comments from their lecturers. cronbach’s alpha for the 6-item reticence scale was 0.66, also indicating acceptable reliability of the instrument’s construct. students in their fifth year of study showed significantly lower assertiveness than those in the third and fourth years (mean 3.15 v. 3.25 v. 3.26, respectively; p=0.008) (table 4). female students were significantly less assertive (mean 3.18 v. 3.27; p=0.005), but more reticent (mean 3.11 v. 2.99; p=0.003) than their male counterparts. lastly, married students were found to be significantly less reticent than single students (mean 2.88 v. 3.07; p=0.036) (table 4). influence of assertiveness and reticence on pharmacy students’ performances in selected examinations higher assertiveness scores were significantly associated with higher-grade performances in all three selected professional examinations (p<0.05) (table 5). lower reticence scores were associated with higher-grade performances in clinical pharmacy (p=0.035). in all the courses, there were significantly more female than male students with higher grades (p<0.0001). the students who were single reported significantly more highest grades compared with students who were engaged or married (p<0.001). similarly, older pharmacy students scored significantly higher grades in pharmaceutics compared with younger students (44.4% v. 26.6; p<0.0001). after multivariate logistic regression analysis, pharmacy students reporting greater assertiveness were less likely to report lower grades in all three selected professional examinations (p≤0.027, for each course). however, the odds for reporting lower grades in clinical pharmacy courses alone were significantly higher for students who were more reticent (p=0.042). male pharmacy students were more likely to report lower grades table 1. demographic characteristics of pharmacy student participants in a non-grade indicator survey, nigeria characteristics possible participants, n 2 156 valid participants, n 1 550 participation rate, % 71.9 year of study, n (%) third year (second professional) 458 (28.4) fourth year (third professional) 594 (36.8) fifth year (fourth professional) 498 (30.9) age, years (n (%)) 16 25 1 309 (84.5) ≥26 241 (15.5) gender, n (%) female 767 (49.5) male 790 (50.5) marital status, n (%) single 1 407 (90.8) engaged/married 143 (8.2) schools of pharmacy (response rate), n (%) a 273 (73.2) b 100 (75.2) c 457 (89.0) d 232 (68.0) e 149 (55.5) f 166 (57.4) g 173 (78.7) 91 september 2019, vol. 11, no. 3 ajhpe research in two of the pharmacy courses, i.e. pharmacology and clinical pharmacy (p≤0.012, for each course). lastly, older students (p=0.002) or those who were engaged/married (p=0.02) were more likely to report lower grades in the pharmaceutics course. regression results are displayed in table 6. discussion this cross-sectional study represents an initial attempt to investigate two communication variables, i.e. assertiveness and reticence, and their association with academic performance of pharmacy students. results revealed that, even though both communication skills were prevalent among these students, assertiveness rather than reticence significantly influenced their academic performance. reticence, a communication difficulty, is prevalent among students in the schools of pharmacy surveyed. similar studies that focused on other types of communication difficulty reported lower prevalence rates.[8,9,12] berger et al.[8] reported high communication apprehension and shyness in only 19.5% and 34.4% of students, respectively, although shyness as high as 42% was reported in some schools surveyed. in studies conducted among malaysian students, the prevalence of communication apprehension among final-year pharmacy students remained at an average of 24% (i.e. 24.6 23.5%) over 3 years.[9,12] however, a high prevalence of communication apprehension similar to figures obtained in our study was reported among malaysian first-year pharmacy students (45.8% in one of the studies).[12] the high level of reticence among pharmacy students relating to their instructors in the current study should be a cause for concern for the country’s pharmacy practice system, where its pharmacists are trying hard to integrate fully into patient care and counselling. of note are the lower levels of assertiveness and higher levels of reticence among female students than male students; yet, female students had better results in all courses evaluated. this effect of gender on communication abilities has been documented in the pharmacy and medical education literature.[8,12,17] a study in the usa in the 1980s reported a significantly higher communication apprehension among female pharmacy students compared with males.[8] more recently, in a study among firstand finalyear pharmacy students in malaysia, a significantly higher percentage of females showed more communication apprehension.[12] studies assessing communication difficulties in medical education also associated female gender with difficulty in communication. blanch et al.,[17] in 2008, observed table 2. distribution of pharmacy students’ responses to questions on assertiveness* instrument domain/items n strongly disagree disagree undecided agree strongly agree mean (sd) 1. if i don’t know an answer to a question, i still act as though i do 1 501 17.2 22.1 22.0 26.2 12.6 2.95 (1.3) 2. i feel comfortable when asked a question in front of the class 1 514 18.3 29.7 26.6 18.9 6.6 2.66 (1.2) 3. i feel comfortable with my current communication skills 1 507 7.4 21.7 22.6 34.7 13.6 3.25 (1.1) 4. i see a competitive side to pharmacy and it drives me to do well 1 498 4.0 8.1 18.2 43.3 26.4 3.82 (1.3) 5. i feel confident in my potential to be a good pharmacist 1 500 2.5 3.9 10.4 37.1 46.0 4.20 (0.9) 6. i have made sure that important people know who i am 1 504 6.8 15.5 40.3 23.4 14.0 3.24 (1.3) 7. i am a logical and goal-directed speaker when i need to be 1 497 3.6 9.9 27.1 40.5 19.0 3.61 (1.0) 8. i know how to answer a question and use it to my advantage 1 491 2.3 8.7 32.4 40.9 15.7 3.62 (1.4) 9. ‘powerful’ is a word i would use to describe myself 1 494 6.2 15.3 40.9 24.9 12.7 3.22 (1.0) 10. i enjoy taking risks that will advance my career as a student 1 500 5.0 12.6 27.9 35.9 18.7 3.52 (1.0) 11. when i know an answer to a question i am eager to respond 1 505 7.2 18.0 24.9 28.7 21.3 3.38 (1.2) 12. i am confident when interacting with my lecturers and professors 1 467 7.5 17.2 29.9 32.4 13.0 3.27 (1.1) sd = standard deviation. *mean assertiveness score=3.40 (1.22); cronbach’s α for assertiveness domain 0.72. items on the assertiveness scale adapted from lee et al.[16] table 3. distribution of pharmacy students’ responses to questions on reticence* instrument domains/items n strongly disagree disagree undecided agree strongly agree mean (sd) 1. i don’t readily respond to questions from my lecturers because i am uncomfortable speaking out 1 468 16.3 26.5 26.1 21.3 9.8 2.80 (1.2) 2. i am uncomfortable responding to questions because i am not always sure i’m right 1 475 14.1 27.9 27.8 22.4 7.9 2.80 (1.1) 3. i do not always ask questions, because i am afraid people will think my questions are foolish 1 476 22.5 31.9 23.0 14.9 7.7 2.51 (1.2) 4. i speak and participate as much as other students, but i am still seen by others as being quiet/reserved 1 468 12.1 18.9 27.8 27.2 14.0 3.11 (1.2) 5. i am reserved when interacting with my lecturers 1 474 6.4 13.0 25.5 38.5 16.6 3.44 (1.1) 6. out of respect for my lecturers, i prefer not to challenge or question their answers or comments 1 470 7.2 14.9 26.3 28.0 23.5 3.46 (1.2) sd = standard deviation. *mean reticence score=3.03 (1.24); cronbach’s α for reticence domain 0.66. items on the reticence scale adapted from lee et al.[16] september 2019, vol. 11, no. 3 ajhpe 92 research a set of medical interns during a clinical observation examination, and reported higher odds of female students being more reticent or lacking in self-confidence when dealing with real patients or communicating with their instructors. in the african context, females are perceived to be weaker and to have a minor voice and role in general adult communication. in nigeria, for instance, it is unexpected and highly uncommon to see a female child challenge an adult in society or at home over issues that rightly favour them. this might be transferred to their educational training. a female student who is known to be vocal about issues is often labelled ‘talkative’, even when a male student is much more vocal. females are expected by societal perspectives to be nice and warm and not initiate communication or negotiations as often and quickly as males, even when within their rights.[18] this ‘forced respect’ for older adults might have contributed to the lower assertiveness and higher reticent behaviours among female pharmacy students in our study. there have also been reports that gender inequality from an african societal perspective has been influenced by cultural, religious and political marginalisation.[19] religion emphasises the role of the male as the head of the home or any gathering and in politics. for example, in nigeria females are ‘compensated’ with political positions merely to fill a gender quota system. it is noteworthy that this gender-communication observation in our study was found to be different from that in another study that assessed reticence directly as a construct. the study reported that there was no significant difference in the level of assertiveness or reticence based on gender among medical interns.[16] a cause for concern in the current study is the lowest level of assertiveness reported among final-year students compared with those in other years of study. communication skills training is taught from the fourth year of study in most pharmacy schools and it is expected that in the final year most students should have developed assertive communication skills, even in class. these students know they are about to graduate, but would probably rather not confront their instructors even when they feel they are correct, perhaps to avoid lower marks during clerkship rounds. however, we do not know if responses among final-year students might have differed if the assertiveness items were directed towards their communication with patients and not their preceptors/instructors. students reporting lower assertiveness, a sign of communication difficulty, were more likely to report lower grades in all courses. also, students reporting greater reticence were more likely to report poorer grades in clinical pharmacy courses – a result also seen with medical interns and performances in some select clerkship courses.[16] these clinically based courses demand a high interaction time with instructors/preceptors and these students might have expressed their true state of mind of being reticent. in pharmacy practice, reasons for pharmacists’ communication difficulties with other health professionals include a struggle for power, poor communication, lack of trust and an unsatisfactory communication environment.[7] these factors could result in a strained working relationship between key professionals and could negatively affect patient outcomes.[20] however, the literature shows that when pharmacists make suggestions to physicians regarding important changes in a patient’s drug treatment, the recommendations are usually accepted and implemented.[21] pharmacy students lacked confidence, as expressed by low mean values of survey items measuring confidence when communicating. to boost confidence, students and pharmacists must possess knowledge, willingness and belief to provide effective communication.[22] rogers and king,[23] in a recent study, suggested three factors that are possibly responsible for impeding the development of effective table 4. summary of pharmacy students’ responses to assertiveness and reticence by demographic characteristics variable n assertiveness, mean (sd) p-value n reticence, mean (sd) p-value school of pharmacy* <0.0001 <0.0001 a 215 3.41 (0.55) 215 3.01 (0.80) b 101 3.11 (0.64) 100 2.69 (0.76) c 477 2.93 (0.60) 476 3.07 (0.72) d 238 3.47 (0.64) 233 3.12 (0.73) e 155 3.29 (0.49) 156 3.09 (0.71) f 172 3.19 (0.62) 174 3.17 (0.75) g 181 3.49 (0.63) 181 3.02 (0.76) year of study* 0.008 0.682 third 454 3.25 (0.63) 450 3.05 (0.75) fourth 591 3.26 (0.63) 591 3.07 (0.75) fifth 494 3.15 (0.65) 494 3.03 (0.74) age, years 0.456 0.914 ≤25 1 300 3.23 (0.63) 1 297 3.05 (0.74) >25 223 3.19 (0.68) 222 3.04 (0.80) gender 0.005 0.003 female 766 3.18 (0.63) 763 3.11 (0.73) male 740 3.27 (0.64) 738 2.99 (0.77) marital status 0.196 0.027 single 1 397 3.22 (0.63) 1 393 3.07 (0.74) engaged/married 87 3.31 (0.75) 86 2.88 (0.81) sd = standard deviation. *analysis of variance for subgroups >2; others by independent t-test; p<0.05; both instruments were measured on a 5-point likert scale. 93 september 2019, vol. 11, no. 3 ajhpe research communication skills of pharmacy students, including a low perception of self-efficacy, poor outcome expectations during communication and communication anxiety, fear or apprehension. instructors at a pharmacy school in the united arab emirates developed and tested a tool to teach assertive communication skills to pharmacy students to enable them to interact more effectively with physicians and other members of the healthcare team.[24] the study employed simulated case scenarios of interactions between pharmacists and physicians and allowed pharmacy students to explore different communication techniques and improve their assertive communication skills. these suggested strategies can be adopted in any pharmacy school to improve communication efficiencies among its students. communication skills played a significant role in the academic performance of pharmacy students in this study. being assertive was associated with better performances, which could be linked to confidence and interpersonal relationships. it is thought that students who were assertive during classes might have a better interaction with their instructors outside classes or privately. interestingly, reticent students performed poorly in the clinical pharmacy course – a highly interactive course, especially during clinical rotations and patient case defences. marks might not be given to more expressive students, but such confidence exhibited by assertive students might have affected subjective grading during these rotations. lee et al.[16] suggested that medical students who were more assertive regarding their knowledge might have been rewarded with better grades by their instructors. importantly, the association between communication skills measured and performances of pharmacy students might not be causal, as students who scored the highest grades might in future return to being reticent over time. table 5. proportions of demographic characteristics and means (sd) of assertiveness and reticence by course grade performance among pharmacy students course* lower grades highest grades p-value pharmacology age, years (n (%)) 0.131 ≤25 748 (83.3) 150 (16.7) >25 162 (90.0) 18 (10.0) gender, n (%) <0.0001 female 438 (79.6) 112 (20.4) male 461 (89.5) 54 (10.5) marital status, n (%) 0.458 single 823 (84.3) 153 (15.7) engaged/married 60 (85.7) 10 (14.3) assertiveness, mean (sd) 3.21 (0.64) 3.33 (0.65) 0.027 reticence, mean (sd) 3.04 (0.77) 3.07 (0.71) 0.654 clinical pharmacy age, years (n (%)) 0.007 ≤25 660 (79.4) 171 (20.6) >25 149 (87.6) 21 (12.4) gender, n (%) 0.001 female 399 (76.7) 121 (23.3) male 400 (85.1) 70 (14.9) marital status, n (%) 0.475 single 727 (80.2) 179 (19.8) engaged/married 53 (81.5) 12 (18.5) assertiveness, mean (sd) 3.18 (0.63) 3.38 (0.74) <0.0001 reticence, mean (sd) 3.08 (0.75) 2.95 (0.80) 0.035 pharmaceutics age, years (n (%)) <0.0001 ≤25 560 (55.6) 448 (44.4) >25 135 (73.4) 49 (26.6) gender, n (%) 0.036 female 338 (55.6) 270 (44.4) male 348 (60.9) 223 (39.1) marital status, n (%) 0.001 single 619 (57.0) 467 (43.0) engaged/married 55 (76.4) 17 (23.6) assertiveness, mean (sd) 3.12 (0.65) 3.42 (0.58) <0.0001 reticence, mean (sd) 3.09 (0.76) 3.01 (0.7) 0.093 sd = standard deviation. *analysis was conducted using the χ2 test for all categorical data and independent t-test for continuous data (assertiveness and reticence); overall performance (highest grades are scores ≥70% or a grades, depending on the school in the specific professional course; lower grades are scores <70% or b f grades, depending on the school in each professional course). september 2019, vol. 11, no. 3 ajhpe 94 research study limitations and strengths this study had some limitations. academic performances were self-reported and could have an element of bias. verifying these would also have proved difficult, as participation was anonymous. secondly, only schools with council accreditation were sampled. therefore, pharmacy schools yet to receive accreditation might exhibit different levels of assertiveness and reticence. lastly, the instrument used in this study was a modification of a questionnaire used in another setting and a different health profession. therefore, further study of its validity is important to make conclusive statements on its reliability among nigerian pharmacy students. this study also possessed some strengths. it was a multicentre study conducted among students across three senior classes of the pharmacy school, thus providing a result that can generally be applicable to pharmacy training in nigeria. the study instruments showed good reliability and can thus be applied to other schools of pharmacy with similar settings as the surveyed schools. conclusions six of every 10 pharmacy students in this survey were assertive, while nearly half of them expressed reticence when communicating with their instructors. being assertive, single and of a female gender were all associated with higher performances in the selected pharmacy examinations. findings suggest that communication skills training should be commenced early in pharmacy school and sustained throughout training. special focus should be placed on vulnerable groups, such as female students, to further alleviate their communication difficulties. table 6. multivariate logistic regression models predicting lower grades in each professional course regression coefficients course* or 95% ci p-value pharmacology (n=1 013) age, years 0.275 ≤25 1.000 >25 1.375 0.776 2.436 gender <0.0001 female 1.000 male 2.121 1.466 3.069 marital status 0.684 single 1.000 engaged/married 1.164 0.559 2.423 assertiveness 0.668 0.507 0.881 0.004 reticence 0.950 0.757 1.192 0.657 clinical pharmacy (n=943) age, years 0.126 ≤25 1.000 >25 1.504 0.892 2.538 gender 0.012 female 1.000 male 1.547 1.101 2.174 marital status 0.977 single 1.000 engaged/married 1.010 0.509 2.004 assertiveness 0.595 0.457 0.774 <0.0001 reticence 1.254 1.008 1.560 0.042 pharmaceutics (n=1 123) age, years 0.002 ≤25 1.000 >25 1.850 1.262 2.712 gender 0.14 female 1.000 male 1.204 0.941 1.540 marital status 0.02 single 1.000 engaged/married 2.002 1.115 3.596 assertiveness 0.433 0.349 0.537 <0.0001 reticence 1.125 0.953 1.327 0.165 or = odds ratio; ci = confidence interval. *all independent variables entered as a block in each model for each professional course. lower grades were compared with the highest grades (as reference). categories with or = 1.000 are reference values. 95 september 2019, vol. 11, no. 3 ajhpe research declaration. this article was based on a study done by cmu in partial fulfilment of his phd thesis. acknowledgements. the authors are grateful to all students, lecturers and staff of the participating schools of pharmacy. author contributions. cmu and cvu conceptualised and designed the study; cmu co-ordinated the survey data collection; cmu and cvu participated in the data analysis and manuscript organisation; and cmu and cvu wrote and approved the final and revised manuscript. funding. none. conflicts of interest. none. 1. wiedenmayer k, summers rs, mackie ca, et al. developing pharmacy practice: a focus on patient care. geneva: world health organization, 2006. 2. young sf, macleod ak. influencing prescribing through effective communication skills. am j health syst pharm 2005;62(23):2528-2530. https://doi.org/10.2146/ajhp040305 3. morrow n, hargie o. effective communication. in: taylor k, harding g, eds. pharmacy practice. london: taylor and francis, 2005:207-228. 4. tindall wn, beardsley r, kimberlin c. assertiveness, in communication skills in pharmacy practice. baltimore, md: williams and wilkins, 2003. 5. berger ba. assertiveness, in communication skills for pharmacists: building relationships, improving patient care. washington:american psychological association, 2005. 6. rantucci mj. human interactions and counseling skills in pharmacy. in: rantucci mj. pharmacists talking with patients: a guide to patient counseling. baltimore, md: williams and wilkins, 2007. 7. kimberlin c. communications. in: werthiemer a, smith mc, eds. pharmacy practice: social and behavioral aspects. 3rd ed. baltimore, md: williams and wilkins, 1989. 8. berger ba, baldwin hj, mccroskey jc, richmond vp. communication apprehension in pharmacy students: a national study. am j pharm educ1983;47:95-102. 9. sariff a, gillani ws. communication apprehension among malaysian pharmacy students: a pilot study. ind j pharm educ res 2011;45(1):8-14. 10. mccroskey jc. an introduction to rhetorical communication. 8th ed. massachusetts: prentice hall, 2001:269-277. 11. sokoloff ka, phillips gm. a refinement of the concept ‘reticence’. j commun disord 1976;9(4):331-347. 12. khan tm, ejaz ma, azmi s. evaluation of communication apprehension among first year and final year pharmacy undergraduates. j clin diagn res 2009;3(6):1885-1890. 13. sansgiry ss, kawatkar aa, duta ap, bhosle, mj. predictors of academic performance at two universities: the effects of academic progression. am j pharm educ 2004;68(4):103. https://doi.org/10.5688/aj6804103 14. lobb wb, wilkin ne, mccaffrey dj, wilson mc, bentley jp. the predictive utility of nontraditional test scores for first year pharmacy student academic performance. am j pharm educ 2006;70(6):128. https://doi. org/10.5688/aj7006128 15. ubaka cm, sansgiry ss, ukwe cv. cognitive determinants of academic performance in nigerian pharmacy schools. am j pharm educ 2015;79(7):101. https://doi.org/10.5688/ajpe797101 16. lee kb, vaishnavi sn, lau skm, andriole da, jeffe db. ‘making the grade’: noncognitive predictors of medical students’ clinical clerkship grades. j natl med ass 2007;99(10):1138-1150. 17. blanch dc, hall ja, roter dl, frankel rm. medical student gender and issues of confidence. patient educ couns 2008;72(3):374-381. https://doi.org/10.1016/j.pec.2008.05.021 18. bowles hr, babcock l, lai l. societal incentives for gender differences in the propensity to initiate negotiations: sometimes it does hurt to ask. org beh hum dec proc 2007;103:84-103. https://doi.org/10.1016/j.obhdp.2006.09.001 19. bako mj, syed j. women’s marginalization in nigeria and the way forward. hum res dev int 2018;21(5):425-443. https://doi.org/10.1080/13678868.2018.1458567 20. rubin rh, sleath bl. improving pharmacist-physician communication: report of a pilot workshop. am j pharm educ 1997;61:359-364. 21. deady je, lepinski pw, abramowitz pw. measuring the ability of clinical pharmacists to affect drug therapy changes in a family practice clinic using prognostic indicators. hosp pharm 1991;26(2):93-97. 22. anderson-harper hm, berger ba, noel r. pharmacists’ predisposition to communicate, desire to counsel and job satisfaction. am j pharm educ 1992;56(3):252-258. 23. rogers er, king sr. the influence of a patient-counseling course on the communication apprehension, outcome expectations, and self-efficacy of first year pharmacy students. am j pharm educ 2012;76(8):152. https://doi. org/10.5688/ajpe768152 24. hasan s. a tool to teach communication skills to pharmacy students. am j pharm educ 2008;72(3):67. accepted 1 july 2019. https://doi.org/10.2146/ajhp040305 https://doi.org/10.5688/aj6804103 https://doi.org/10.5688/aj7006128 https://doi.org/10.5688/aj7006128 https://doi.org/10.5688/ajpe797101 https://doi.org/10.1016/j.pec.2008.05.021 https://doi.org/10.1016/j.obhdp.­­­2006.09.001 https://doi.org/10.1080/13678868.2018.1458567 https://doi.org/10.5688/ajpe768152 https://doi.org/10.5688/ajpe768152 184 september 2021, vol. 13, no. 3 ajhpe research why was the idea necessary? (what was the problem?) it is not a debatable issue that the covid‑19 pandemic created several challenges in the education sector, and institutions across the world had to employ various interventions to ensure continuation of teaching and learning. at the university of pretoria, one of south africa’s largest contact universities, exclusive online learning was implemented for the remainder of the first semester of 2020. although this was helpful to facilitate learning during strict lockdown, it also came with its own problems. for third‑year undergraduate students in the disciplines of nursing, dietetics, physiotherapy and medical sciences, pre‑existing issues such as failure to apply critical thinking skills in pharmacology were inflated during this period. critical thinking in education is defined as a learning process where students analyse, evaluate, interpret or synthesise information, and apply creative thought to solve a problem.[1] however, for the majority of the abovementioned student cohort, which comprised 252 students, learning scarcely went beyond memorisation and recall of information and facts. a potential cause of this could have been diminished learning skills owing to pressure and anxiety associated with the pandemic as reported in the literature,[2] or a lack of active interaction among the students, where prior to covid‑19, problem‑solving was often conducted as a team effort during contact sessions. a combination of these causes is also likely. based on historical evidence from the pharmacology module, appropriate application of concepts and principles learned has always been a mammoth task for many students, as evidenced by the poor performance during summative assessments, which makes the module infamous at the university of pretoria. this was more prominent in the first semester of 2020, where students struggled to contextualise and work through case report type questions in tests and examinations. as a result, we could infer that the new learning environment was possibly contributing to a lack of higher‑ order thinking, as well as negatively impacting the students’ understanding and application of pharmacological principles and concepts. prior to the covid‑19 pandemic, this challenge was tackled by clarifying any areas of concern and working through practice questions or case‑reports during contact sessions such as lectures, tutorials and one‑on‑one remedial sessions. however, the stringent covid‑19 lockdown regulations meant that contact sessions were rarely conducted and, consequently, alternative online interventions such as game‑based learning, flipped classrooms and case report generation activities, were incorporated in the second semester to improve learning. the case report generation activity was developed and implemented to ensure that students refined and applied their critical thinking skills for successful completion of the pharmacology module, with a clear understanding of key concepts. what was tried? (intervention) to provide a platform for critical thinking development and ascertain that it was taking place, students were tasked to generate case reports for their peers to work on, incorporating pharmacological concepts from the adrenocorticosteroids learning material that had been made available to them. the aim was to stimulate critical thinking by delivering an engaging and highly interactive experience which would compensate for the lack of face‑to‑face interactions, while at the same time avoiding digital dumping of  content on students or using resource‑intensive modalities. asking the students probing questions as they worked through the case reports aided in achieving this goal. to encourage participation, questions from the best case report that indicated higher levels of critical thinking were included in the semester test and exam as an incentive. the assessments that followed case report generation activity indicated that students were able to integrate adrenocorticosteroids with the pathologies mentioned during the semester, and there was evidence of higher‑order thinking, not the usual ‘copy‑paste tendencies’ that had previously been observed. the approach we used is supported by the constructivist framework, which is considered as one of the leading theoretical frameworks of education.[3] constructivism states that learning is a process where learners construct knowledge rather than passively taking in information.[4‑6] to ensure this information is imparted, an active experience has to be created for students to construct their own knowledge.[7] as such, by generating case reports with follow‑up questions, students were able to find information from the lecture material provided, construct realistic clinical scenarios to showcase their knowledge, and make relevant connections in order to apply them appropriately. lessons learnt as the chinese government’s covid‑19 nationwide campaign ‘school’s out but class’s on’ demonstrates, critical thinking can still be stimulated on an online platform even in situations where, in the past, face‑to‑face interactions would have been preferred. based on the students’ participation and engagement, it was apparent that they enjoyed creating the case reports while learning at the same time. the students challenged themselves and took charge of their own work, which was an indication that while the activity stimulated critical thinking, it also developed their independent learning skills. additionally, students were inevitably drawn to interact with and teach each other, which promoted peer‑learning and assessment. this was proof of social constructivism, which is an extension of the constructivist learning approach, where the role of other individuals in the process of constructing knowledge is incorporated.[8] through the case report generation activity, an opportunity was also created for students stimulating students’ critical thinking skills in pharmacology using case report generation s s mlambo, bsc hons, msc department of pharmacology, faculty of health sciences, university of pretoria, south africa corresponding author: shamiso mlambo (shamiso.mlambo@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:shamiso.mlambo@up.ac.za september 2021, vol. 13, no. 3 ajhpe 185 research to ask the lecturer questions, which helped clarify any areas of concern. however, at the other end of the spectrum, a major drawback was that each student had an opportunity to create a case report, and consequently some reports were ignored because of the large pool that was available. therefore, keeping the case reports to a minimum, for instance by conducting them in group settings, would be more effective in future. what will i keep in my practice? the inability to appropriately apply concepts and principles is a constant challenge that is experienced each year by most students who undertake the undergraduate pharmacology module. this is evidence of a lack of critical thinking skills, and it goes without saying that the skills have to be developed as critical thinking and problem solving go hand‑in‑hand, regardless of whether the students find themselves working in a clinical or research setting. the idea of case report generation should therefore be carried forward into the future as it is a learning tool that can be used, among others, to stimulate critical thinking, resulting in improved student performance and appropriate application of knowledge. this is important especially in a clinical scenario as most of the student complement were enrolled for a clinical health profession. what will i not do? as each student had an opportunity to generate a case report, there was an excess of reports, which meant some of them were not attempted by other students. this could potentially discourage the students whose work was ignored, causing non‑participation in future. therefore, to avoid despondency, case reports can be kept to a minimum by dividing students into groups, and each group would provide a case report that the other groups can work on. conclusions the covid‑19 pandemic has isolated most people and forced them to work remotely. this lack of interaction may cause students to feel isolated and overwhelmed, which may give rise to anxiety, dissatisfaction and performance issues. case report generation is an activity that can be conducted online and provide social interaction among students, thus compensating for lack of face‑to‑face interactions. more importantly, this involves an active, student‑centred learning approach where students construct their own knowledge, so that critical thinking skills are developed, ensuring better understanding of principles and concepts. declaration. none. acknowledgements. the author would like to acknowledge prof. werner cordier and ms h parkar of the department of pharmacology, university of pretoria, for their support and assistance. author contributions. sole author. funding. the office of the deputy‑dean: teaching and learning, faculty of health sciences, university of pretoria. conflicts of interest. none. evidence of innovation 1. wallmann hw, hoover dl. research and critical thinking: an important link for exercise science students transitioning to physical therapy. int j exercise sci 2012;5(2):93‑96. 2. pokhrel s, chhetri r. a literature review on impact of covid‑19 pandemic on teaching and learning. higher education for the future 2021;8(1):133‑141. 3. mvududu n, thiel‑burgess j. constructivism in practice: the case for english language learners. int j educ 2012;4(3):108‑118. https://doi.org/10.5296/ije.v4i3.2223 4. amineh rj, asl hd. review of constructivism and social constructivism. j soc sci literat lang 2015;1(1):9‑16. 5. bruner js. toward a theory of instruction. cambridge, ma: harvard university press; 1966. https://doi. org/10.1119/1.2350966 6. applefield jm, huber r, moallem m. constructivism in theory and practice: toward a better understanding. the high school journal 2000;84(2):35‑53. 7. ayaz mf, sekerci h. the effects of the constructivist learning approach on student’s academic achievement: a meta‑analysis study. turkish online journal of educational technology‑tojet 2015;14(4):143‑156. 8. vygotsky ls. thought and language. cambridge, ma: massachusetts institute of technology press, 2012. https:// doi.org/10.1037/11193‑000 accepted 11 may 2021. afr j health professions educ 2021;13(3):184‑185. https://doi.org/10.7196/ajhpe.2021.v13i3.1514 https://doi.org/10.5296/ije.v4i3.2223 https://doi.org/10.1119/1.2350966 https://doi.org/10.1119/1.2350966 https://doi.org/10.1037/11193-000 https://doi.org/10.1037/11193-000 https://doi.org/10.7196/ajhpe.2021.v13i3.1514 september 2021, vol. 13, no. 3 ajhpe 179 researchshort report in response to the national lockdown in south africa due to the covid‑19 pandemic, educational institutions adapted their programmes to meet the challenges of the disruption in teaching and learning. in line with this need, the sub‑saharan african faimer regional institute (safri) was faced with the challenge of exploring innovative ways to continue faculty development workshops. the safri programme focuses on developing african health professions educators as leaders, teachers, scholars and advocates for change at multiple levels, including individual, school and university, and the health professions.[1] the faculty development workshops, which are traditionally face‑to‑face, are placed at the end of the 18‑month fellowship. playing a leadership role in developing and facilitating these workshops provides a meaningful learning experience for the fellows to become active role‑players and change agents in their own institutions and the broader community of practice. participation may foster capacity development in areas such as leadership for educational interventions and support for academic activities. it also provides fellows with authentic opportunities to draw on the theories and exposures that were gained during the fellowship. some of the competencies to plan and implement the faculty development workshops include self and team management, leadership, conflict management and the application of educational skills. why was the idea necessary? in the final learning activity of the safri fellowship, the fellows develop and conduct faculty development workshops incorporating diverse active participation strategies. since the national lockdown disrupted the planned face‑to‑face contact sessions for this faculty development activity, the consequences would have delayed the completion and graduation of the cohort of fellows. therefore, a decision was made to provide an opportunity for the 2019/2020 fellows to complete their fellowship by ‘going virtual’. despite the challenges and turmoil of covid‑19, and the need to adapt rapidly to the online learning environment, the fellows fully embraced this opportunity to learn new skills and prepare virtual workshops that met the desired learning outcomes. what was tried? three virtual workshops of about 90 minutes each were planned and offered on consecutive days: research supervision, integrating technology into teaching and learning, and coaching and mentoring in higher education. the facilitators notified the fellows by email of the transition to virtual workshops, and a zoom platform was made available. training to use the zoom technology was offered, and within each group an ‘expert’ was identified to facilitate training as part of the group preparation. the groups all chose to use an online meeting platform of their own, and thus had greater ownership of hosting and managing the process. each group sent out invitations with the links to the workshops, pre‑reading materials and participation in preparatory online activities as necessary. all participants of the workshops were thus encouraged to be fully engaged both in the pre‑workshop activities, such as uploading of personal videos, and during the actual workshops through completion of online evaluations, participation in quizzes and games and use of audience response system software (see qr code below). breakaway rooms were incorporated with good effect, and the use of applications such as kahoot contributed to keeping participants actively, and in some cases competitively, engaged throughout the 90‑minute sessions. the opportunity for colleagues to use the chat function and contribute during the workshops created a strong sense of sharing and engagement. although the participants could not be together physically as previously anticipated, these workshops truly provided a sense of community. in the summing up at the end of each workshop by one of the facilitators, the message was clear that not only had all participants learnt about the content presented, but important new skills in online teaching and learning and faculty development had been acquired. this feedback, together with the reflections of the faculty who facilitated these workshops, informed the planning of future virtual workshop in safri. in this way the workshops had delivered even more than the planned face‑to‑face version used in the past. for some fellows, the transition to virtual platforms and the use of online tools was a steep learning curve that influenced the intended flow of the workshops. all the groups were led by fellows with experience of and knowledge about the online platforms, who were therefore able to navigate some of the technical challenges during the presentations. since the workshops were collaboratively offered by fellows from across sub‑ saharan africa, a major execution challenge was the digital divide, which hindered some participants’ ability to access the workshops seamlessly. these connectivity‑related issues, poor sound quality from some participants and low bandwidth and lack of internet infrastructure in some regions influenced the delivery of some parts of the workshops. however, this did not detract from the overall community of practice and collegiality among fellows and faculty, which made this a comfortable virtual space that allowed everyone to contribute. ‘going virtual’: innovative online faculty development during covid‑19 r maart,1 bchd, pgdip, pgdip (hm), mphil (higher educ); a rhoda,2 bsc, bsc hons, msc, phd; s titus,3 ba (srm), ma (sres), phd; d manning,4 bsc hons, phd, med 1 department of prosthetic dentistry, faculty of dentistry, university of the western cape, cape town, south africa 2 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 3 interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town, south africa 4 office of the dean, faculty of health sciences, university of pretoria, south africa corresponding author: r maart (rmaart@uwc.ac.za) this open‑access article is distributed under creative commons licence cc‑by‑nc 4.0. mailto:rmaart@uwc.ac.za 180 september 2021, vol. 13, no. 3 ajhpe researchshort report the lessons learnt the need to change rapidly and at fairly short notice to a different teaching medium challenged the fellows, who drew on their resilience and skills in innovation, leadership and teamwork, thus demonstrating the importance of adapting in adversity to develop new insights and skills. the use of different strategies and activities likely supported the learning through a cognitive apprenticeship.[2] the support that fellows and faculty provided to each other through the community of practice was a key factor in the successful outcome of the workshops. a recent study[3] concluded that the safri programme is a capacity‑development process through which participants are empowered through actively engaging in a supportive community of practice, with a strong reliance on the reciprocal interplay between individual and collective capacity development. the on‑site sessions of the programme were heavily reliant on the face‑to‑face interaction and team building that occurred between participants. in the covid‑19 environment it was important that the faculty development workshops created by the fellows for the continued development of themselves, one other and the safri faculty should achieve the same goal, albeit in a purely virtual environment. previous studies on success factors for collaborative online learning have identified the importance of a constructivist and collectivist approach[4] that acts to enhance active engagement.[5] what will i keep in? with the continuation into 2021 of the covid‑19 epidemic and associated lockdown, social distancing and travel restrictions, it will not be possible to resume face‑to‑face teaching. therefore, the faculty development workshops hosted and delivered successfully in 2020 will be repeated in 2021. the responsible fellows will be advised to contact the previous cohort, with whom they are already in a community of practice through the organisational nature of the fellowship, for advice and support in developing their materials. while the future of online learning looks exciting, we will also heed the cautionary advice to seek out tested practices[6] and accommodate the challenge of diversity and equity in access to the technology,[7] particularly in the resource‑constrained african environment where large differences exist in connectivity and bandwidth. furthermore, a review of health professional educational developments in response to covid‑19 has identified that there is a lack of good faculty development studies.[8] the intention of safri is to develop robust research in this area that may provide insight into constructive faculty development activities. declaration. none. acknowledgements. the authors thank all participating fellows and faculty of the safri fellowship programme 2020. at the start of their fellowship, all participants signed a photography, audio and video recording release consent, and informed consent for the use of evaluation data in research. author contributions. rm, ar and dm were the facilitators of the workshop development. st was a participating fellow in all three workshops, played a leadership role in one workshop and created the electronic evidence linked to the qr code. all authors contributed to the final manuscript. funding. the participation of all authors in the safri fellowship programme was supported by funding made available by the foundation for advancement of international medical education and research (faimer). conflicts of interest. none. evidence of innovation 1. frantz jm, bezuidenhout j, burch vc, et  al. the impact of a faculty development programme for health professions educators in sub‑saharan africa: an archival study. bmc med educ 2015;15:28. https://doi. org/10.1186/s12909‑015‑0320‑7 2. eltayar an, eldesoky ni, khalifa h, rashed s. online faculty development using cognitive apprenticeship in response to covid‑19. med educ 2020;54(7):665‑666. https://doi.org/10.1111/medu.14190 3. frantz j, rhoda a, murdoch‑eaton db, sandars j, marshall m, burch vc. understanding faculty development as capacity development: a case study from south africa. afr j health professions educ 2019;11(2):53‑56. https:// doi.org/10.7196/ajhpe.2019.v11i2.1120 4. chan tm, thomas b, lin m. creating, curating, and sharing online faculty development resources: the medical education in cases series experience. acad med 2015;90(6):785‑789. https://doi.org/10.1097/ acm.0000000000000692 5. cook da, steinert y. online learning for faculty development: a review of the literature. med teacher 2013;35(11):930‑937. https://doi.org/10.3109/0142159x.2013.827328 6. zuo l, miller juvé a. transitioning to a new era: future directions for staff development during covid‑19. med educ 2020;55(1):104‑107. https://doi.org/10.1111/medu.14387 7. lubarsky s, thomas a. thinking inside the box: using old tools to solve new problems in virtual learning. med educ 2020;55:108‑110. https://doi.org/10.1111/medu.14388 8. daniel m, gordon m, patricio m, et  al. an update on developments in medical education in response to the covid‑19 pandemic: a beme scoping review: beme guide no. 64 202; med teach 2021;43(3)253‑271. https:// doi.org/10.1080/0142159x.2020.1864310 accepted 15 june 2021. afr j health professions educ 2021;13(3):179‑181. https://doi.org/10.7196/ajhpe.2021.v13i3.1516 https://doi.org/10.1186/s12909-015-0320-7 https://doi.org/10.1186/s12909-015-0320-7 https://doi.org/10.1111/medu.14190 https://doi.org/10.7196/ajhpe.2019.v11i2.1120 https://doi.org/10.7196/ajhpe.2019.v11i2.1120 https://doi.org/10.1097/acm.0000000000000692 https://doi.org/10.1097/acm.0000000000000692 https://doi.org/10.3109/0142159x.2013.827328 https://doi.org/10.1111/medu.14387 https://doi.org/10.1111/medu.14388 https://doi.org/10.1080/0142159x.2020.1864310 https://doi.org/10.1080/0142159x.2020.1864310 https://doi.org/10.7196/ajhpe.2021 72 june 2022, vol. 14, no. 2 ajhpe research health professionals are often required to collaborate with one another in the management of patients and clients. the interactive nature of this type of  work includes the need for interprofessional teamwork, which  has become increasingly relevant in health sciences education (hse).[1,2] following a global shift in hse toward the implementation of explicit  teamwork pedagogies,[3,4] contemporary hse curricula at many universities worldwide now include some type of shared learning programme. shared hse curricula typically bring students from various health professions together, with the  objective of fostering the teamwork skills required for collaborative practice.[5] this is most commonly done under the banner of interprofessional education (ipe),[1] where health professional students learn interactively, rather than in parallel.[6] a need to problematise constructions of teamwork in hse contexts has been identified.[7] few studies have looked at entry-level students’ experiences of interacting with others, or the relationships between students from the various professions.[8] in particular, there is scope to explore the meaning of teamwork from the perspective of first-year health sciences students. at  the  university of cape town (uct), curriculum transformation discourse is topical and challenges the use of ‘traditional epistemologies, theories [and] methodologies’ that exclude students as rightful participants in the change  process.[9] thus, one of the intended outcomes of this study was to offer insight into students’ perceptions and experiences, to potentially inform the future design and delivery of shared learning or ipe courses, effectively involving students in the transformation process currently underway at uct. background at uct’s faculty of health sciences (fhs), a shared learning programme implemented in the first year of study for health sciences students takes the form of two semester-long courses. based on adult education principles, ‘becoming a professional’ (bp) in semester 1 and ‘becoming a health professional’ (bhp) in semester 2 aim to instil overarching skills required to function effectively as a healthcare professional and member of a healthcare team. multiprofessional groups of students studying audiology, medicine, physiotherapy, occupational therapy, and speech and language pathology come together with a facilitator each week for small-group, experiential learning.[10] to introduce working in a healthcare team, learning activities include working in small teams of 5 or 6 to produce two public health themed presentations. at its design and implementation in the early 2000s, bp and bhp were avant-garde amid a temporal context in which academics and clinicians challenged the then new, transformative instalment of ‘medical education’ at uct. ‘[t]he importance of the programmes, especially in the face of the lack of hard evidence of the benefits of interdisciplinary education’ was questioned.[11] at a time when the ipe field was relatively young,[12] bp and bhp were conceptualised and designed within the domain of multiprofessional education (mpe), the historical and conceptual antecedent of ipe.[1,13] with the proviso that bp and bhp were ‘not just another’ rendition of parallel learning associated with mpe, these courses took ‘the first tentative steps towards a radical reconceptualisation of multiprofessional education that values the journey of shared knowledge construction and learning as much as it background. student engagement in curricular transformation is topical at the university of cape town (uct), including in its faculty of health sciences (fhs). teamwork, which is essential to contemporary interprofessional healthcare, is an objective of transformative health sciences education. this study offers a contemporary contribution from the perspective of students to earlier work on shared learning at uct fhs. objectives. there is a paucity of research literature on this study’s target population. therefore, a qualitative design was used to explore first-year health sciences students’ perceptions and experiences of teamwork within an undergraduate shared learning programme. methods. the primary data collection method was focus group discussion. two additional qualitative methods, free-listing and pile-sorting, were used to expand upon data collected in the focus groups. results were analysed thematically. results. the study sample (n=32) included first-year audiology, medical, occupational therapy, physiotherapy, and speech and language pathology students. the findings revealed that although their experiences of teamwork varied, students had a comprehensive perception of what teamwork entailed in their educational context. therefore, the findings were used to generate a heuristic for teamwork learning for undergraduate health sciences students. conclusion. the study positions students to contribute tangibly to the curricular transformation process at their university. students’ perspectives of teamwork may be useful in the future design and delivery of entry-level interprofessional courses aiming to instil teamwork skills. afr j health professions educ 2022;14(2):72-77. https://doi.org/10.7196/ajhpe.2022.v14i2.1423 a journey through interprofessional education: students’ perspectives of teamwork in a transforming curriculum a hendricks,1 mphil health sciences education; n hartman,1 phd health sciences education; l olckers,2 phd public health and family medicine 1 department of health sciences education, faculty of health sciences, university of cape town, south africa 2 school of public health and family medicine, faculty of health sciences, university of cape town, south africa corresponding author: a hendricks (hndabi001@myuct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1423 mailto:hndabi001@myuct.ac.za june 2022, vol. 14, no. 2 ajhpe 73 research does the outcomes’.[11] teamwork learning is a desired outcome of shared learning programmes, and this article reports on first-year students’ perceptions and experiences of teamwork within the context of the second-semester course, bhp. methods the study was approved by the university of cape town faculty of health sciences human research ethics committee (ref. no. 429/2019). research paradigm as teamwork is innately a social activity experienced in relation to others, one of the assumptions underpinning this study was that students’ perspectives of teamwork may be co-constructed. thus, the study was positioned within an interpretivist paradigm in which reality is subjective but also co-constructed.[14] research design a qualitative approach was used to gather preliminary data in this exploratory study. in line with the research questions, sampling was purposive (only registered bhp students at the time of data collection were invited to participate) and convenient (students self-selected to participate). the primary data production method of focus group discussion (fgd), an appropriate method for exploratory research,[15] was used to explore students’ perceptions and experiences of teamwork in bhp. two additional qualitative methods, free-listing and pile-sorting, were used within the fgds to expand the data. a similar format for each fgd was used; however, there was no predetermined agenda to configure the topics for discussion. research questions students’ perspectives were explored in relation to the following research questions: • what were students’ perceptions of what teamwork is? • based on their perceptions of what teamwork is, what were students’ experiences of teamwork within the bhp context? • in light of these perspectives on teamwork, what factors did students consider as facilitators or inhibitors of teamwork? data production two broad questions were asked at the beginning of each fgd to elicit students’ perceptions of what teamwork is. participants were asked to free-list their responses to the questions ‘what is teamwork?’ and ‘what does teamwork require?’ these responses, written on cue cards, became the topics for the ensuing discussions. students were then asked to consider whether they experienced teamwork in their bhp course activities. a pile-sorting exercise was used in the next part of the discussion, as students considered their experiences within bhp in relation to their perceptions of teamwork. their free-listed responses were sorted into two piles, one for aspects they had experienced and the other for those that they had not experienced. the sequence of these additional methods gave students an opportunity to first unpack what they perceived teamwork to be, before discussing whether they had experienced any of the parts of teamwork in bhp. this format effectively enabled participants to generate the topics for and flow of discussion themselves. students were also asked to consider what they thought facilitated and/or inhibited teamwork in bhp. data analysis interpretivism acknowledges that research is a conversation between participants and the researcher, and therefore researcher subjectivity, inherent  to the paradigm, can be seen as a useful resource.[16,17] thus the  method of thematic analysis, which relied on interpretations, was appropriate in this study. a combination of in vivo and process coding was  used in the analysis of the data. deductive thematic analysis was applied  initially using the research questions as broad categories. overarching  themes were then  interpreted inductively from the codes and categories. having been previously applied in hse contexts,[18,19] contact theory was  used as a theoretical framework in the interpretation of findings. contact theory, which originated from the ‘contact hypothesis’, postulates that when individuals from different groups have opportunities to come together under certain conditions, positive outcomes may result. on the contrary, contact between distinct groups could also bring about adverse effects.[20,21] results study sample each of the student groups who participated in bhp were represented in the study sample, as depicted in fig.  1. thus, the results of this study were co-constructed by students from each profession required to enact teamwork in this context. of the five fgds conducted, four included two  or  more professions, while one fgd included only one profession. this was due to the convenient sampling procedure in which students self-selected to participate. where students self-selected to participate but numbers were insufficient for a fgd, one joint and two individual interviews were also conducted. the professional degree programme in which the student groups were registered was the only marker of difference in the study. although demographic diversity in terms of gender, race, ethnicity and socioeconomic factors is pertinent to the context of this south african university,  excluding  these and other diversity markers was a deliberate  delimitation in this study in accordance with its focus on interprofessionality. physiotherapy n=6 speech and language pathology n=2 audiology n=4 medicine n=16 occupational therapy n=4 fig. 1. research participants per health professional degree programme. 74 june 2022, vol. 14, no. 2 ajhpe research study findings and discussion words and phrases written on cue cards at the beginning of the fgds (and interviews) are depicted in the pyramid in fig.  2. data that were replicated often are represented in the top of the pyramid, and the least frequently recorded words at the narrow end. the pertinence of data to the interpretive account during data analysis was not considered solely in terms of frequency, however, as both novel and replicated data were considered in relation to ‘whether it captures something important in relation to the overall research question’.[17] the fgd and interview data were coded, categorised and themed in multiple iterations. the codes and categories were organised into three broad themes: the purpose of teamwork; the persons involved; and the teamwork process (fig. 3). teamwork has purpose students’ perceptions of teamwork included having a sense of purpose, working  towards something deliberate and being motivated in that action.  students experienced this purpose as having to work together on their bhp coursework, particularly two team-based presentation assessments. these presentation assessments were an important reference point for students in reporting their experiences of teamwork. the immediate purpose  of teamwork for students was to answer the presentation  questions, fulfil the rubric and achieve their desired marks. the  presentation assessments represented a common goal because students had the collective  motivation to pass. while their experiences of deliberate action were largely for the purpose of scoring marks, students communicated an understanding that the purpose of the presentations was to learn to work with others, ultimately for future work in interprofessional healthcare teams: ‘when you’re working as part of the team like in a hospital or a clinical setting, it’s not just your marks that are on the line or the fear of … failing … its patients’ lives … that’s on the line.’ since the performance of working together was being assessed, there appeared to be a tension between the purpose of teamwork and students’ motivations for scoring marks. students raised concerns that this tension resulted in ‘fake teamwork’ being enacted during the assessments. however, it would be superficial to ascribe ‘fake teamwork’ to student motivations for high scores alone. as participants noted, their assessors only saw what was presented to them, and were not privy to what was ‘actually … going on’ in the student teams: ‘our facilitator had said “try and link” so … [we] mentioned … “as my colleague so and so has already mentioned” … [everyone laughs] so that it looks like unified and that you did the work together … and we all wore … one colour to show unity … but otherwise, doing the actual work, there was no teamwork at all.’ in bhp, teamwork was overtly assessed by facilitators using a presentation rubric, and indirectly assessed by a peer assessment in which students were required to rate each other’s contributions to the team presentation. although a rubric was used, facilitators were empowered to score teamwork according to their subjective judgements of whether or not the rubric criteria for teamwork were demonstrated. thus in this particular ipe course, the manner in which students were assessed appeared to be an inhibiting factor to teamwork learning. the logic of this particular finding seems to infer that a ‘reverse’ assessment practice may be viable. that is, the summative assessment of teamwork by  facilitators could be allocated a smaller weighting (shifting  assessment power away from facilitators), with a higher weighting allocated to the student-based peer assessment. this more transformative assessment practice not only lends agency to students but may result in greater alignment between the outcome being assessed (teamwork among  students)  and the assessment practice (peer assessment among students). students seemed to recognise this lost opportunity, based on their perception that relationship building is a requirement for teamwork. students noted that relationships take time to build, and that while bhp created opportunities for relationship building, this was not always a priority, suggesting that the purpose of the presentation assessment had not been achieved. ‘[the presentation must be done] for the … course requirements to be met and … to pass the course on a superficial level. but on a deeper level to appreciate a multiprofessional team … and to … build relationships.’ teamwork involves persons the idea that everyone has a particular role in a team was pervasive. students noted that a team is made up of individuals, each having a specific communication, respect, empathy, leadership, equality, participation di�erent roles, working together, delegation, trust, common goals commitment, equal e�ort, compromise, collaboration, consistency, patience, motivation, sharing, people fig.  2. pyramid depicting students’ written responses to the questions ‘what is teamwork?’ and ‘what are the parts of teamwork?’ in a free-listing exercise. process: working together where everyone contributes, and there is trust, relationship building and communication persons: leaders, diverse personas, de�ned roles purpose: meeting course requirements fig. 3. the three ps of teamwork in ‘becoming a health professional’ course. june 2022, vol. 14, no. 2 ajhpe 75 research role. these ‘defined roles’ were constructed in terms of the different tasks required for the team presentations and the delegation of those tasks. students also recognised an inherent diversity within teams. members represented different professions, but also brought their own unique strengths, weaknesses and idiosyncrasies to the team. students perceived team members as having different contributions to make, to add value to the end product. students seemed to appreciate that differences between individual team members must be exploited, and that teams must utilise their inherent diversity: ‘the more versatile the group is, the more inputs … can come from different perspectives. and that’s actually a very … good attribute for a group. as long as you respect those differences you can actually work with them and have a better outcome of whatever it is you’re trying to accomplish.’ although students appreciated that there were differences between the health professions represented in bhp, they noted that professional diversity was not part of the presentation brief. since the interprofessional nature of healthcare teams was not salient in the presentations, students perceived differences between team members as being largely personality based: ‘we did have different … professions in our team, but i don’t really think the … professions … played that big a role in what we did with our presentations … or our teamwork … i think mostly the personalities is what contributed to the differences.’ personality attributes (of both students and facilitators), particularly leadership qualities of students, were perceived to be pertinent to teamworking. the role of leadership was deliberated in each of the fgds. there was a sense that leadership is an inherent part of teamwork and that some people are ‘natural leaders’ who will tend to take on leadership roles: ‘it’s like a natural instinct … somebody always will … rise up to the position and be a little bit more authoritative over the group … it’s a natural thing … somebody will just be a little bit … more assertive than everybody else.’ being able to work within a defined role that matched individual capabilities, interests and one’s introverted or extroverted personality style was considered an important part of teamwork. teamwork is an experiential process unsurprisingly, a range of experiences of teamworking was evident, ranging  along a continuum. on the one end was ‘zero’ teamwork, which  included solo work, where one person reported having worked alone,  and independent work, where each team member worked by themselves: ‘we didn’t work together at all … [and] i ended up doing the whole thing … everyone just read what i wrote … it was really unfair.’ ‘people did like come up with ideas and stuff like that, but since they were not listened to then we decided to like individualise the work … and then the day of the presentation there was no consistency at all.’ on the other end of the continuum were positive experiences of teamworking, where students reported successful interactions: ‘i think this is probably the best group i got to work in … in bhp today we had to … reflect on our group presentation and there wasn’t one negative from anyone … everyone was … laughing and smiling … it was honest.’ ‘we all shared our information … it wasn’t like you’re doing your own thing and then just coming together at the end … we all ran through our presentation parts and then we would … say what’s working, what’s not working.’ students highlighted that teamworking required an element of trust, and that trust was broken down when others did not do their part. students noted the difficulty of being expected to work in teams with others whom they didn’t know very well, making it hard to be trusting: ‘we couldn’t choose who we’d be with … you’re not … with friends where you know you can trust them. you know they always do their work. so, in a situation like that … i don’t have that much trust.’ in terms of team process, communication was a prominent theme in the  data. open communication which showed ‘respect, empathy … for a person … a team member’ was noted as a facilitator of teamwork. communication was identified as the part of teamwork that allowed the other parts to be enacted: a way to achieve the interactivity of working together, to facilitate the exchange of collective resources, to designate each team member’s defined role, to enact leadership and ultimately to achieve a team’s common goal: ‘communication is … the first thing … the most important out of all because … that’s how you can actually do all of these … other things … so communication’s priority.’ realising the study aim this study sought to answer the broad question ‘what is teamwork?’ from the perspective of the students who participated in this study. the  knowledge contribution generated by this study is essentially a synthesis  of how these students operationalised teamwork, through their perceptions and experiences of a shared learning course. this synthesis is presented as a heuristic (fig.  4). themes generated during data analysis became the conceptual components for the development of the heuristic (examples of this analytical step are shown in table 1). by definition, a heuristic is not ‘a fit for all’, rather it is a tool to navigate learning. thus, it offers guidelines for how to do teamwork, and presents discussion points for students to engage with as they negotiate how their teams will function. in light of the present study’s findings, the ‘students teamwork heuristic’ offers ‘an evidence-based tool’ for growing teamworking[22] and a concrete guide for explicit teamwork training[4] for entry-level health sciences students. contributing to curriculum transformation ipe courses present opportunities for students to create unique patterns of interaction rather than maintain prevailing power differentials that may hinder the eventual goal of collaborating in healthcare teams.[8] by engaging with the ‘students’ teamwork heuristic’, a learning tool co-developed by bhp students, students may be empowered to negotiate and forge their own patterns of team interactions. involving students in curriculum development is a hallmark of transformative pedagogies. students were included in the initial design process of bp and bhp, signalling a promise of transformation.[11] an intended outcome of this study was to generate a student-centred contribution to the future design and delivery of bhp, and more broadly, to 76 june 2022, vol. 14, no. 2 ajhpe research involve students in the contemporary curriculum change discourse at uct fhs. thus, this study’s findings present  a further opportunity to trouble outdated power structures of traditional curriculum development, effectively continuing the transformative spirit of  bp and bhp’s initial design vision. conclusion the significance of this study is that it contributes a contextualised operationalisation of teamwork from the perspective of first-year health sciences students, a novel contribution to the interprofessional literature. the heuristic developed as a result of engaging with students in this empirical study places students firmly in a position ‘to play a critical role’ in curriculum transformation at uct fhs.[9] the study findings suggest that bhp begins to build a foundation for the implementation of ipe courses beyond first-year level. as noted more than a decade ago, the vertical integration of ipe, including teamwork training for  collaborative practice throughout subsequent years of undergraduate study, remains a  challenge at uct fhs.[10] as participants in this study noted, building trusting relationships for teamworking takes time, highlighting the  importance as well as the necessity of vertically spiralled ipe programmes within hse. with a focus on teamworking as a building block for future collaborative practice, further research could investigate the  utility value of the ‘students’ teamwork heuristic’ as an ipe learning tool for undergraduate health professional students. table 1. conceptual components of the heuristic with corresponding data extracts and sample codes data extract sample code heuristic component ‘we didn’t work together at all … we set a date for when everyone was supposed to do their bits by, but no one stuck to it … i was the only one who was done … [and] i ended up doing the whole thing … everyone just read what i wrote … it was really unfair.’ ‘we all shared our information with one another. it wasn’t like you’re doing your own thing and then just coming together at the end … we all ran through our presentation parts and then we would … say what’s working, what’s not working. and then we all corrected what we did wrong and kept what we did right.’ working together; integration; communication working together interactively ‘a common objective … in this case [for the presentation] it was gonna contribute 15% towards all our final marks … so … maybe having a common objective whereby it benefits us all in the same way.’ ‘if one person wants to do well and the others just want to like get by or pass, it affects the entire team’s performance.’ purpose of the team; common goal is a success factor; motivation common goals ‘it’s like a natural instinct … somebody always will … rise up to the position and be a little bit more authoritative over the group … it’s a natural thing … somebody will just be a little bit … more assertive than everybody else.’ ‘the first time we had to … discuss what we were gonna do there were a couple of people who were kind of leading the discussion and just making sure that we … stuck to the point. but then the more comfortable we got with each other … that kind of fell away and everybody was just contributing freely and … equally to what we needed to do. and we didn’t need a leader, i guess.’ leaders rise up naturally; some people have leadership qualities that emerge leadership team members work together interactively everyone contributing to a shared workload utilising everyone's skills and talents having an aptitude for teamwork a common purpose communication mutual respect empathy trust team members have common goals a team has a collective pool of resources a team has a natural or elected leader each team member has a de�ned role e�ective teamwork requires: the foundation of teamwork is building relationships with team members through: parts of teamwork fig. 4. ‘students’ teamwork heuristic’. (blue = parts; red = requirements; pink = foundational components.) june 2022, vol. 14, no. 2 ajhpe 77 research the role of assessment specifically in relation to teamwork learning is another area for further study. while this project focused on students’ perspectives, further research with a more inclusive approach (including educator and other stakeholders’ perspectives) may offer a broader view of assessment practice in this context. contact theory was used in a very narrow sense in this study. contact theory is complex, containing a web of interconnected mediators and moderators (how and when contact between different groups can bring about changes in relations between groups) identified in the literature. [23] none of these mediating or moderating factors were considered in this study. linked to this is the delimitation of discounting demographic diversity markers in the study sample. is teamworking just the sum of multiple versions of reality of participants and concomitant analytical outputs, as presented in this interpretivist study? expanding the application of theory may have offered a broader answer. declaration. the study was completed in fulfilment of ah’s master’s dissertation at the university of cape town, supervised by nh and co-supervised by lo. acknowledgements. thanks to the bhp staff who supported this study. special thanks to the bhp students who gave their time to participate in this study. author contributions. article written by ah in collaboration with nh and lo. funding. self-funded. conflicts of interest. none. 1. paradis e, reeves s. key trends in interprofessional research: a macrosociological analysis from 1970 to 2010. j interprof care 2013;27(2):113-122. https://doi.org/10.3109/13561820.2012.719943 2. reeves s, xyrichis a, zwarenstein m. teamwork, collaboration, coordination, and networking: why we need to distinguish between different types of interprofessional practice. j interprof care 2018;32(1). https://doi.org/10.1 080/13561820.2017.1400150 3. frenk j, chen l, bhutta za, et  al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 4. earnest ma, williams j, aagaard em. toward an optimal pedagogy for teamwork. acad med 2017;92(10):1378-1381. https://doi.org/10.1097/acm.0000000000001670 5. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. 6. hammick m, olckers l, campion-smith c. learning in interprofessional teams: amee guide no. 38. med teach 2010;31(1):1-12. https://doi.org/10.1080/01421590802585561 7. reeves s. the need to problematise interprofessional education and practice activities. j interprof care 2010;24(4):333335. https://doi.org/10.3109/13561820.2010.492748 8. engel j, prentice d, taplay k. a power experience: a phenomenological study of interprofessional education. j prof nurs 2016;33(3):204-211. https://doi.org/10.1016/j.profnurs.2016.08.012 9. university of cape town. curriculum change framework. cape town: uct, 2018. 10. olckers l, gibbs t, mayers p, alperstein m, duncan m. early involvement in a multiprofessional course: an integrated approach to the development of personal and interpersonal skills. educ prim care 2006;17(3):249-257. https://doi.or g/10.1080/14739879.2006.11864069 11. mayers p, alperstein m, duncan m, olckers l, gibbs t. not just another multiprofessional course! part 2: nuts and bolts of designing a transformed curriculum for multi-professional learning. med teach 2006;28(2):152-157. https:// doi.org/10.1080/01421590600603137 12. xyrichis a. interprofessional science: an international field of study reaching maturity. london: taylor & francis, 2020. 13. barr h. interprofessional education: today, yesterday and tomorrow: a review. london: higher education academy, health sciences and practice network, 2005. 14. samuel ma. the research wheel. 3rd edition. durban: university of kwazulu-natal school of education, 2017. 15. stalmeijer re, mcnaughton n, van mook wn. using focus groups in medical education research: amee guide no. 91. med teach 2014;36(11):923-939. https://doi.org/10.3109/0142159x.2014.917165 16. henning e, van rensburg w, smit b. finding your way in qualitative research. pretoria: van schaik, 2004. 17. braun v, clarke v. reflecting on reflexive thematic analysis. qual res sport exercise health 2019;11(4):589-597. https://doi.org/10.1080/2159676x.2019.1628806 18. michalec b, giordano c, dallas s, arenson c. a longitudinal mixed-methods study of ipe students’ perceptions of health profession groups: revisiting the contact hypothesis. j interprof educ pract 2017;6:71-79. https://doi. org/10.1016/j.xjep.2016.12.008 19. carpenter j, dickinson c. understanding interprofessional education as an intergroup encounter: the use of contact theory in programme planning. j interprof care 2016;30(1):103-108. https://doi.org/10.3109/13561820.2015.1070134 20. allport g. the nature of prejudice. reading, ma: addison-wesley, 1954. 21. pettigrew tf. intergroup contact theory. ann rev psychol 1998;49(1):65-85. 22. salas e, shuffler ml, thayer al, bedwell wl, lazzara eh. understanding and improving teamwork in organisations: a scientifically based practical guide. hum resource manag 2015;54(4):599-622. https://doi.org/10.1002/hrm.21628 23. dovidio jf, love a, schellhaas fm, hewstone m. reducing intergroup bias through intergroup contact: twenty years of progress and future directions. group proc intergroup relations 2017;20(5):606-620. https://doi. org/10.1177%2f1368430217712052 accepted 16 july 2021. https://doi.org/10.3109/13561820.2012.719943 https://doi.org/10.1080/13561820.2017.1400150 https://doi.org/10.1080/13561820.2017.1400150 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1097/acm.0000000000001670 https://doi.org/10.1080/01421590802585561 https://doi.org/10.3109/13561820.2010.492748 https://doi.org/10.1016/j.profnurs.2016.08.012 https://doi.org/10.1080/14739879.2006.11864069 https://doi.org/10.1080/14739879.2006.11864069 https://doi.org/10.1080/01421590600603137 https://doi.org/10.1080/01421590600603137 https://doi.org/10.3109/0142159x.2014.917165 https://doi.org/10.1080/2159676x.2019.1628806 https://doi.org/10.1016/j.xjep.2016.12.008 https://doi.org/10.1016/j.xjep.2016.12.008 https://doi.org/10.3109/13561820.2015.1070134 https://doi.org/10.1002/hrm.21628 https://doi.org/10.1177%2f1368430217712052 https://doi.org/10.1177%2f1368430217712052 26 december 2009, vol. 1, no. 1 ajhpe cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can checkthe answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/007/01/2011 (clinical) cpd june 2011 cpd 1. true (a) or false (b) – click on the correct answer: most exam pass marks that are set at 50% are largely based on historical practice and tradition rather than validated standard setting methods. 2. what is the name of a new standard setting method used to determine the pass mark of an exam that takes account of student performance? a. hofstee method b. contrasting groups method c. cohen’s method 3. true (a) or false (b) – click on the correct answer: quantitative literacy differs from mathematics in that it is embedded in a specific context, and data analysis and interpretation play a prominent role. 4. true (a) or false (b) – click on the correct answer: university lecturers who are experts in their discipline may not explicit ly recognise the quantitative demands of the discipline. 5. which one of the following statements is true? a. the quantitative literacy demands of first-year medical students often exceed the level achieved by school leavers b. the quantitative literacy needs of first-year medical students is adequate c. there is no need for quantitative literacy skills for first-year medical students 6. which learning strategies may be useful in decentralised learning programmes in rural settings? a. case-based learning b. lectures c. self-directed learning from a prescribed textbook 7. which university adopted a primary health care lead theme for curriculum transformation in 1994? a. university of the free state b. stellenbosch university c. university of cape town 8. which one of the following statements is true? a. service learning is widely practised in south africa b. implementing service learning is challenging in south africa c. a significant part of service learning is classroom-based lectures 9. true (a) or false (b) – click on the correct answer: key phases of learning include the activation of prior experience, demonstration of skills, application of skills and the integration of these skills into real-world activities. 10. what does the term ‘blended learning’ mean? a. a combination of lectures and tutorials b. a combination of lectures and self-directed learning c. a combination of face-to-face teaching and online learning activities 11. which one of the following statements is true? a. blended learning is not significantly limited by information technology in south africa b. blended learning is not suitable for use in south africa c. blended learning may address the overcrowded tertiary learning environment in south africa 12. which one of the following statements is true? a. communication between non language-concordant health care workers (hcw) and patients adversely affects patient and staff satisfaction b. patients do not appreciate attempts of hcw to address them in their preferred language of communication c. improved language skills of hcw cannot be achieved in a short course, e.g. a 10-week course comprising 120-minute sessions 13. how many south african medical schools offer an extra language course for non-indigenous african language speakers? a. 1 b. 3 c. 5 14. are culture-specific models of disease common reasons for misunderstandings in the primary care setting in south africa? a. yes b. no 15. do ‘writing support groups’, ‘writing retreats’ and ‘writing courses’ have an impact on the academic output of departments in south african universities? a. yes b. no 16. true (a) or false (b) – click on the correct answer: the measurement of research output is an important gauge of university productivity and stature in south africa. 17. true (a) or false (b) – click on the correct answer: most medical students are able to use the academic discourse appropriate to their level of training by the time they are final-year students. 18. true (a) or false (b) – click on the correct answer: there is an apparent diversity of discourse use between students of similar academic backgrounds, i.e. students who achieve similar scores in the end-of-year examinations. 19. true (a) or false (b) – click on the correct answer: clinical supervisors who teach health sciences students benefit from short-course education about the principles of adult learning and effective teaching strategies. 20. true (a) or false (b) – click on the correct answer: self-reported confidence levels of medical students’ or junior doctors’ ability to perform basic procedures are a reliable benchmark of actual clinical competence. 26 june 2011, vol. 3, no. 1 ajhpe december 2018, vol. 10, no. 4 ajhpe 228 research anatomical knowledge is essential to the competency of physiotherapists in professional practice.[1] therefore, the way in which physiotherapy students learn gross anatomy has a bearing on their clinical acumen. an abundance of literature on learning style models has been promulgated from the 1960s to date. diverse opinion as to the value of learning style research is apparent. early researchers were positively disposed to the idea of the educational value of knowing learning styles[2-4] and some still uphold that belief.[5] recently, researchers have been more sceptical about the scientific value of enhancing student academic performance and facilitating better teaching methodology in general,[6,7] and in anatomy education in particular.[8] in 1978, claxton and ralston[2] summed up a learning style as ‘a student’s consistent way of responding and using stimuli in the context of learning’. grasha and yangarber-hicks[9] found that some learning styles are more dominant than others and some are only used if sufficient reason and support are given.[10] it was found that the subject to be learnt could influence learning style preference,[11] and health science students showed a preference towards a particular learning style.[9] in 1987, curry[12] described a learning style model depicted by an onionlike structure with four layers. these are from outside to innermost the ‘instructional preference’, ‘social interaction’, ‘information processing style’ and ‘cognitive personality style’ layers. the grasha-riechmann learning style scale (grlss) was placed in the social interaction layer of that model and was aligned with the expectations of teachers and students and their interaction with the learning environment, as is the case in this study.[3,11,12] criteria that guided the choice of the grlss and grasha-riechmann teaching style scale (grtss) tools for data collection in this study were that the former was designed to collect information from university students.[4,13] it exhibits compatibility with the grtss and thus facilitates easy comparisons between the two tools. the grlss has not been specifically negatively critiqued in the literature for its learning style preference stance. this study forms part of a research project investigating various aspects of gross anatomy education for undergraduate physiotherapy students. it sought to identify any learning style preference trend peculiar to physiotherapy students and document the teaching styles of two consecutive cohorts of gross anatomy lecturers. the realisation that there was a paucity of specific pertinent information on these aspects of gross anatomy education necessitated the collection of the study data. it has been shown that age and gender significantly influence student learning style preference.[14] this study aimed to assess how age and gender influence the learning style preferences of two chronologically consecutive student cohorts. all the information collected is factored into the research project and adds to the body of literature pertaining to the ongoing debate on the relevancy of using learning and teaching style measurement tools. methods a descriptive cross-sectional design was used, with purposive sampling. the students invited to participate were second-year physiotherapy students in background. anatomy is essential to prepare physiotherapy students for future clinical practice. student learning styles and lecturer teaching styles may influence learning outcomes. objective. to determine if the learning style of this student population is consistent and compatible with lecturers’ teaching styles for better learning outcomes. methods. a descriptive cross-sectional study was undertaken during 2015 and 2016. the grasha-riechmann learning style scale (grlss) and grashariechmann teaching style scale (grtss) were used to measure learning styles of two consecutive physiotherapy student cohorts and teaching styles of their anatomy lecturers, respectively. results. student samples were small (group 1: n=59 and group 2: n=54), but response rates high (n=39; 66.1% and n=43; 81.5%) in 2015 and 2016, respectively. mean likert scores for grlss indicated that the most popular choice for learning style was the dependent style (mean (standard deviation) 3.81 (0.75)) for group 1 and the independent style (3.68 (0.61)) for group 2. female students preferred the dependent style (group 1: n=12; 30.8% and group 2: n=10; 23.3%) and male students the participant style (group 2: n=6; 14%) of learning. lecturers scored highest in the expert category of teaching styles. compatibility between learning and teaching styles was seen in both years based on comparisons made using teaching style clusters, where the identified grlss and grtss were grouped together and seen to fit into specific cluster categories. conclusion. consistency in learning style choice was observed. a degree of cohesion between student learning styles and their respective lecturers’ teaching styles augured well for good interaction between staff and students. afr j health professions educ 2018;10(4):228-234. doi:10.7196/ajhpe.2018.v10i4.1070 learning styles of physiotherapy students and teaching styles of their lecturers in undergraduate gross anatomy education d a shead,1,2 msc physiotherapy; r roos,1 phd; b olivier,1 phd; a o ihunwo,2 phd 1 department of physiotherapy, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 school of anatomical sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: d a shead (dots@icon.co.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:dots@icon.co.za 229 december 2018, vol. 10, no. 4 ajhpe research the gross anatomy classes of 2015 (student group 1: n=59) and 2016 (student group 2: n=54). the invited gross anatomy lecturers who taught the students were designated as lecturer group 1 (n=5) and lecturer group 2 (n=4). ethical clearance was obtained from the human research ethics committee (ref. no. h15/04/12) of the university of the witwatersrand, johannesburg, south africa. permission was obtained from the university’s dean of student affairs and the head of the department of physiotherapy to administer the survey to the student body. the standardised 60-question version of the grlss[13] was administered to student groups in september 2015 and late august 2016. to maintain confidentiality of participants, the grlss and demographic questionnaires were distributed and collected by the respective class representatives. no identifiers were on the answer sheets. permission was obtained from the head of the school of anatomical sciences prior to distribution of the grtss to the lecturer groups. the standardised 40-question version of the grtss[15] was distributed to and collected from the lecturer groups by the gross anatomy course coordinator for physiotherapy students. the timing of this distribution was aligned with that of the grlss to the student groups. the standardised grlss[4,13] administered to the student groups was evaluated for reliability by baykul et al.;[16] these authors found medium co-efficient scores for the six sub-categories. internal consistency of each subscale was found to be acceptable and suitable for measuring inter active learning styles.[16] the scoring sheet for the grlss includes information on learning style preference norm values according to specified age groups.[4] these norms were formulated using grasha’s[15] own research regarding learning styles, where he defined low, moderate and high ‘cutpoints’. he also defined the same levels for the grtss.[15] the development of teaching style clusters by grasha[15] allowed for the matching of student learning style preferences with teaching style preferences for optimum transfer of knowledge from teacher to student. data pertaining to validity or reliability of the grtss tool administered to the lecturers in the current study could not be found during a literature search. a 5-point likert scale was used to score both scales. the sum of the scores in each category was divided to produce an overall score to one decimal place. mean and standard deviation (sd) calculations were presented to two decimal places. descriptive data analysis was done using spss version 24 (ibm corp., usa). missing data were not replaced and therefore not included in the analysis. the 2015 and 2016 student cohorts’ grlss data analysis results, including descriptive findings, are presented as means (sd), frequencies and percentages (table 1). results of pearson’s correlation coefficient and paired t-tests at p<0.05, comparing group means for differences and correlations between student groups 1 and 2, student group 1 and the grlss norms, and student group 2 and the grlss norms, are presented in table 2. calculations for the age groups 17 21 years and 22 28 years were done separately, as the grlss norms for each age group differed. figs 1 and 2 illustrate comparison of group means for each learning style by age category and their comparison with the associated grlss norms. fig. 3 shows the relationship between gender and student learning style preference for student groups 1 and 2. the grtss rankings for teaching style choices made by both lecturer groups were calculated and tabulated as mean (sd) values (table 3). data analysis was undertaken to establish prevalent teaching styles and cluster categorisation of the two teaching cohorts for comparison with the student learning style preferences identified in each year studied. results participants in 2015, the student group comprised 59 students and 39 (66.1%) completed the grlss. in 2016, the student group consisted of 54 students and 43 (81.5%) completed the grlss. five lecturers taught the students in 2015 and all completed the grtss. in 2016, 4 lecturers taught the students and 3 (75%) participated in the study. table 1 provides information regarding the demographic profile of student participants. the majority were 20 years of age (group 1: n=18; 46.2% and group 2: n=22; 51.2%). in both groups, g ro u p m ea n s (1 7 2 1 ye ar s) 1 3.48 3.68 3.34 2 2.82 2.9 2.18 3 3.69 3.67 3.67 4 3.84 3.66 3.34 5 2.51 2.19 2.76 6 3.51 3.63 3.91 student group 1 student group 2 grlss norms student group 1 student group 2 grlss norms 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 g ro u p m ea n s (2 2 2 8 ye ar s) 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1 3.53 3.67 3.28 2 2.37 3.0 1.96 3 3.13 3.17 3.72 4 3.57 3.83 3.45 5 2.47 2.33 2.68 6 3.67 3.53 4.03 le ar n in g s ty le p re fe re n ce b y g en d er fo r 20 15 a n d 2 01 6 st u d en t co h o rt s, % distribution of learning style female group 1 male group 1 female group 2 male group 2 35 30 25 20 15 10 5 0 1 2 3 4 5 6 fig. 1. comparison of group means for grasha-riechmann learning styles (17 21 years) and grasha-riechmann norms for this age group. (grlss = grasha-riechmann learning style scale; 1 = independent; 2 = avoidant; 3 = collaborative; 4 = dependent; 5 = competitive; 6 = participant.) g ro u p m ea n s (1 7 2 1 ye ar s) 1 3.48 3.68 3.34 2 2.82 2.9 2.18 3 3.69 3.67 3.67 4 3.84 3.66 3.34 5 2.51 2.19 2.76 6 3.51 3.63 3.91 student group 1 student group 2 grlss norms student group 1 student group 2 grlss norms 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 g ro u p m ea n s (2 2 2 8 ye ar s) 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1 3.53 3.67 3.28 2 2.37 3.0 1.96 3 3.13 3.17 3.72 4 3.57 3.83 3.45 5 2.47 2.33 2.68 6 3.67 3.53 4.03 le ar n in g s ty le p re fe re n ce b y g en d er fo r 20 15 a n d 2 01 6 st u d en t co h o rt s, % distribution of learning style female group 1 male group 1 female group 2 male group 2 35 30 25 20 15 10 5 0 1 2 3 4 5 6 fig. 2. comparison of group means for grasha-riechmann learning styles (22 28 years) and grasha-riechmann norms for this age group. (grlss = grasha-riechmann learning style scale; 1 = independent; 2 = avoidant; 3 = collaborative; 4 = dependent; 5 = competitive; 6 = participant.) december 2018, vol. 10, no. 4 ajhpe 230 research the number of female students was greater than that of male students (group 1 females: n=32; 82.1% and males: n=7; 17.9%) (group 2 females: n=33; 76.7% and males: n=10; 23.3%). pre-university education was predominantly private in group 1 (n=24; 61.5%) and governmental in group 2 (n=23; 53.5%). learning style choices of student groups table 1 provides information regarding the learning style of the student participants. overall, the most popular learning style choice for student group 1 was the dependent style (3.81 (0.75)) and for student group 2 the independent style (3.68 (0.61)). a student who chooses the dependent style is said to be passive, and needs structure g ro u p m ea n s (1 7 2 1 ye ar s) 1 3.48 3.68 3.34 2 2.82 2.9 2.18 3 3.69 3.67 3.67 4 3.84 3.66 3.34 5 2.51 2.19 2.76 6 3.51 3.63 3.91 student group 1 student group 2 grlss norms student group 1 student group 2 grlss norms 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 g ro u p m ea n s (2 2 2 8 ye ar s) 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 1 3.53 3.67 3.28 2 2.37 3.0 1.96 3 3.13 3.17 3.72 4 3.57 3.83 3.45 5 2.47 2.33 2.68 6 3.67 3.53 4.03 le ar n in g s ty le p re fe re n ce b y g en d er fo r 20 15 a n d 2 01 6 st u d en t co h o rt s, % distribution of learning style female group 1 male group 1 female group 2 male group 2 35 30 25 20 15 10 5 0 1 2 3 4 5 6 fig. 3. distribution of learning styles (1 6), by gender, for student groups 1 (2015) and 2 (2016); results are inclu sive of age groups (17 21 years and 22 28 years). (1 = independent; 2 = avoidant; 3 = collaborative; 4 = dependent; 5 = competitive; 6 = participant.) table 1. comparison of demographic information for student groups 1 and 2 demographic information group 1 group 2 age (years), n (%) 19 4 (10.2) 10 (23.3) 20 18 (46.2) 22 (51.2) 21 14 (35.9) 8 (18.6) 22 1 (2.6) 1 (2.3) 23 1 (2.6) 1 (2.3) 24 1 (2.6) 1 (2.3) gender, n (%) male 7 (17.9) 10 (23.3) female 32 (82.1) 33 (76.7) type of school, n (%) government 15 (38.5) 23 (53.5) private 24 (61.5) 20 (46.5) learning style preference rankings in descending order, mean (sd) 1. dependent 3.81 (0.75) 1. independent 3.68 (0.61) 2. collaborative 3.65 (0.56) 2. dependent 3.67 (0.86) 3. participant 3.52 (0.53) 3. collaborative 3.63 (0.50) 4. independent 3.49 (0.64) 4. participant 3.63 (0.48) 5. avoidant 2.78 (0.44) 5. avoidant 2.91 (0.42) 6. competitive 2.42 (0.67) 6. competitive 2.20 (0.61) learning style preference by age group in descending order (17 21 years), mean (sd) n=35 1. dependent 3.84 (0.43) n=40 1. independent 3.68 (0.34) 2. collaborative 3.69 (0.45) 2. collaborative 3.67 (0.53) 3. participant 3.51 (0.51) 3. dependent 3.66 (0.46) 4. independent 3.48 (0.41) 4. participant 3.63 (0.57) 5. avoidant 2.82 (0.59) 5. avoidant 2.90 (0.61) 6. competitive 2.51 (0.74) 6. competitive 2.19 (0.71) learning style preference by age group in descending order (22 28 years), mean (sd) n=3 1. participant 3.67 (0.49) n=3 1. dependent 3.83 (0.40) 2. dependent 3.57 (0.25) 2. independent 3.67 (0.47) 3. independent 3.53 (0.31) 3. participant 3.53 (0.38) 4. collaborative 3.13 (0.45) 4. collaborative 3.17 (0.32) 5. competitive 2.47 (0.25) 5. avoidant 3.00 (0.70) 6. avoidant 2.37 (0.59) 6. competitive 2.33 (1.19) sd = standard deviation. 231 december 2018, vol. 10, no. 4 ajhpe research and constant support.[4] a student who chooses the independent style learning option is one who is individualistic, confident and acts alone.[4] the younger age group (17 21 years) results in both cohorts differed little from the overall results. the least-favoured learning style choices overall were avoidant (group 1: 2.78 (0.67) and group 2: 2.91 (0.42)) and competitive (group 1: 2.42 (0.67) and group 2: 2.20 (0.61)). avoidant-style students are unenthusiastic and disinterested.[4] competitive-style students are keen to outshine others, be recognised and be rewarded.[4] the top four ranked learning styles were the same in both years, but their order varied (table 1). comparison of learning style mean score differences and correlations between student groups 1 and 2 and grashariechmann learning style scale norms the group means for all six learning styles were calculated. a comparison of learning style means for groups 1 and 2 and the grlss norms by student age category are set out in figs 1 and 2. there is little parity between the grlss norms and the scores attained in this study, except in the 17 21-year collaborative category. collaborative-style students are keen group participants and enjoy sharing ideas.[4] table 2 illustrates that a statistically significant strong pearson’s correlation was found between the set of learning style means for student groups 1 and 2 (pair 1) in the 17 21-year age group (r=0.95; p<0.003). a significant but weaker correlation between learning style means occurred between student groups in the 22 28-year category (pair 4) (r=0.86; p<0.03). paired t-tests showed that there was no significant difference in overall grlss scores (17 21 years) for group 1 (3.3 (0.52)), group 2 (3.3 (0.62)) at 0.02 (95% confidence interval (ci) −0.19 0.23; t (5)=0.249; p=0.813), or a significant difference in overall grlss scores (22 28 years) for group 1 (3.1 (0.58)), group 2 (3.3 (0.55)) at −0.13 (95% ci −0.44 0.17; t (5)=−1.112; p=0.317). the null hypothesis (ho) put forward was that the grlss choices of physiotherapy students in sequential cohorts would be significantly similar. the overall paired t-test results were in agreement with the h0.the correlation between student group 1 (22 28 years) and the grlss norms was significant (r=0.87; p<0.031). distribution of learning styles by gender fig. 3 illustrates the percentage of students who preferred each learning style by gender, across the two cohorts. it showed that female students had a high preference for the dependent learning style over both years (group 1: n=12; 30.8% and group 2: n=10; 23.3%). male students showed little or no preference for this style. an equal number of female students favoured the participant learning style (group 1: n=8; 20.5% and group 2: n=8; 18.6%) and the majority of male participants (group 2: n=6; 14.0%) also preferred this style. participant-style students complete coursework, take part in activities and work well with others.[4] male and female students in group 1 (n=5; 12.8%) equally favoured the collaborative style, but differences occurred in group 2, as female participants (n=9; 20.9%) and male participants (n=2; 5.0%) preferred it. the independent learning style was popular with female group 1 students (n=5; 12.8%), group 2 students (n=6; 14%) and male group 2 students (n=2; 4.7%). teaching styles of anatomy lecturers the mean age for lecturer group 1 was 33.8 (1.64) years and the ratio of male to female was 3:2. the mean age for lecturer group 2 was 33.7 (0.58) years and the ratio of male to female was 1:2. in 2015, of a total of 5 respondents, 1 lecturer had a phd degree (20%) and 4 lecturers had master’s degrees (80%). in 2016, of a total of 3 respondents, 2 lecturers had phds (66.7%) and 1 lecturer had a master’s degree (33.3%). all lecturer group 2 respondents had previously responded to the grtss in 2015, as they were also teaching the students in 2015. table 3 records the lecturers’ teaching style preferences based on a 5-point likert scale allocation. although mean (sd) scores may be higher in one category than in another, the ratings from low to high are based on a comparison with mean scores found by grasha.[17] a high rating denotes preference for that teaching style by a respondent. more than one teaching style can be rated highly within a group. respondents in both groups scored highest for the expert category, where the teacher offers detailed and expert coverage of the work and challenges students to achieve.[15] grasha[15] described four types of teaching style clusters. scores rated from highest to lowest for the different style categories on either the grlss or the grtss, which determined into which cluster the teacher and student should be placed. table 3 shows that for lecturer group 1 the formal authority-expert and personal models had the highest rating overall. lecturer group 2 showed highest teaching style preferences for the expert-personal model, facilitator and delegator categories. the clusters are as follows: cluster 1: student learning styles – participant-competitive-dependent; teaching styles – formal authorityexpert. cluster 2: learning styles – collaborative-participant-dependent; teaching styles – formal authority-personal model-expert. cluster 3: learning styles – independent-participant-collaborative; teaching styles – expert-facilitator-personal. cluster 4: learning styles – participantcollaborative-independent; teaching styles – expert-delegator-facilitator. in lecturer group 1, 3 respondents (60%) fell into the grasha cluster 2 and 1 respondent (20%) into clusters 1 and 4, respectively. in lecturer group 2, 1 respondent (33.3%) fell into cluster 2 and 2 respondents into cluster 4. table 2. comparison of means for combined grlss score differences and correlations between student groups 1 and 2 and grlss norms group pairs mean difference (sd) 95% ci lower, upper t-value df p-value (2-tailed) correlation p-value pair 1: student groups 1 and 2 (17 21 years) 0.02 (0.20) −0.19, 0.23 0.249 5 0.813 0.954 0.003* pair 2: student group 1 and grlss norms (17 21 years) 0.11 (0.41) −0.32, 0.54 0.651 5 0.544 0.767 0.075 pair 3: student group 2 and grlss norms (17 21 years) −0.09 (0.47) −0.58, 0.40 −0.463 5 0.663 0.721 0.106 pair 4: student groups 1 and 2 (22 28 years) −0.13 (0.29) −0.44, 0.17 −1.112 5 0.317 0.868 0.025** pair 5: student group 1 and grlss norms (22 28 years) 0.07 (0.64) −0.60, 0.74 −0.403 5 0.704 0.865 0.026** pair 6: student group 2 and grlss norms (22 28 years) −0.06 (0.39) −0.47, 0.34 0.263 5 0.803 0.560 0.247 grlss = grasha-riechmann learning style scale; sd = standard deviation ; ci = confidence interval; df = degrees of freedom. *p<0.01, **p<0.05. december 2018, vol. 10, no. 4 ajhpe 232 research using the cluster combinations listed above, it was seen that in 2015, where the top three ranked learning styles chosen were dependent, participant and collaborative, the most appropriate teaching style cluster would be cluster 2. in that year, 60% of faculty subscribed to cluster 2. other lecturers were in clusters 1 and 4 and would be able to relate to 2 of 3 of the most preferred learning styles. in 2016, the top three ranked learning styles were independent, dependent and collaborative. it was apparent that in 2016, 1 of the lecturer participants had ‘accommodated’ from cluster 1 or 2 to cluster 4. this meant that 2 of the lecturers had now aligned themselves with the teaching styles represented in cluster 4 and therefore would facilitate and delegate in their teaching methodology. this would be more in line with the more independently orientated student group 2. discussion in the overall scenario, age influenced student learning style preferences. marked preferential differences were seen between the 17 21-year age cohorts and the related 22 28-year age cohorts. a comparison of the means for the two groups for 2015 and 2016 showed more compatibility between the younger age groups (50%) than the older age groups (17%). life experience and environmental factors may have influenced diversity in older students’ thinking.[18] overall student participants were millennials from generation y, born between 1982 and 2003, which might have played a part in age-related learning style preference. coates[19] describes children of the millennial generation as being mollycoddled by their parents and unable to make decisions or manage conflict. hence, these students possibly lack table 3. teaching style scores of anatomy lecturer, groups 1 and 2 teaching style respondent group group, mean (sd) mean scores of individual respondents rating level expert lecturer, group 1 3.96 (0.47) r1=3.8 r2=4.3 r3=4.2 r4=4.3 r5=3.2 high high high high moderate lecturer, group 2 4.37 (0.40) r1=4.0 r2=4.8 r3=4.3 high high high formal authority lecturer, group 1 3.52 (0.32) r1=3.0 r2=4.0 r3=4.3 r4=2.6 r5=3.7 moderate high high moderate high lecturer, group 2 3.37 (0.76) r1=3.2 r2=4.2 r3=2.7 moderate high moderate personal model lecturer, group 1 3.56 (0.46) r1=3.3 r2=4.3 r3=3.1 r4=3.3 r5=3.6 moderate high moderate moderate high lecturer, group 2 3.70 (0.98) r1=4.0 r2=4.5 r3=2.6 high high low facilitator lecturer, group 1 3.43 (0.53) r1=4.0 r2=3.7 r3=3.2 r4=2.9 r5=2.8 moderate moderate moderate low low lecturer, group 2 3.87 (0.51) r1=4.3 r2=4.0 r3=3.3 high high moderate delegator lecturer, group 1 2.68 (0.39) r1=2.7 r2=3.0 r3=2.5 r4=2.4 r5=2.2 moderate high moderate moderate moderate lecturer, group 2 3.05 (0.07) r1=3.1 r2=3.0 r3=2.1 high high moderate sd = standard deviation; r = respondent. 233 december 2018, vol. 10, no. 4 ajhpe research independence and are more suited to the grasha dependent style category seen to dominate learning style preference in the 2015 student cohort. the 2016 student cohort’s preference for the independent learning style may appear to contradict this assumption, but consideration should be given to the result being marginal, with the dependent style ranked as a close second preference. gender has been shown to influence learning style preference.[20] gender considerations impacted results of this study, with some clear differences between male and female learning style preferences. while both female student cohorts clearly ranked the dependent learning style highly, male students did not. furthermore, the predominantly female nature of both student cohorts skewed the overall learning style preference towards the dependent category, especially in 2015. however, this may not be problematic, as kulac et al.[21] found that female medical students preferring the dependent style scored higher than their male counterparts in examinations. unpopularity of the avoidant and competitive categories was seen across all genders in both cohorts, which could be considered a similarity between gender preferences. using the participant, collaborative and independent learning style markers for guidance, most gender style preference alignment was in the collaborative category in 2015, but in the participant category in 2016. the collaborative category is associated with the desired deep-learning approach that produces better academic results.[20] hence, the prominence of the selection of the collaborative learning style in both female groups and male group 1 may augur well for beneficial outcomes in these groups. it has also been postulated that different learning styles pertain to specific student groups.[10,15] based on the evidence, the learning styles of medically orientated student bodies appear to coalesce and are dissimilar to other student group preferences.[16] this study aimed to assess whether physiotherapy students favoured particular learning styles. it was shown that while the order of preference differed over the 2 years, there was consistency in the first four listed preferences. furthermore, the collaborative category was similarly selected according to mean scores for both years. however, to address the diversity of learning styles possible in student groups, more accurate diagnostics may be achieved from more than one learning style instrument being used in this type of research.[22] the 2015 and 2016 grtss survey results showed characteristic cluster groupings of lecturers’ styles.[15] it can be challenging for faculty to match learning styles of specific student populations to teaching styles to ensure clinical readiness.[23] in 2011, king[24] stated that the teaching/learning process is less effective if there is no cohesion between the teaching style of the teacher and learning style of the student. furthermore, anxiety levels are lowered and the degree of learning and teaching satisfaction is increased when the learning styles of students and the teaching styles of staff are matched appropriately.[12] the results of this study showed a degree of cohesion between the learning styles of 2 student cohorts surveyed in 2015 and 2016 and the respective teaching styles of their lecturers. this is in line with grasha’s[16] suggestion that teachers vary their teaching style to accommodate the multiplicity of student learning styles, as such compatibility would augur well for establishing a sustained learning environment in future.[15] study strengths and limitations with regard to the strengths of the study, although the study samples were small and limited to the same institution, data were collected from two sequential student and staff cohorts. the significantly strong positive correlation of results between samples for the 17 21-year age cohorts and the 22 28-year age cohorts meant the two samples could be pooled, leading to more valid and reliable conclusions being made. there was a high response rate for the student cohorts each year. lecturer groups were small and the response was not favourable in 2016. however, it was apparent that in 2016, 1 respondent who had also participated in 2015 ‘accommodated’ to a different teaching style cluster more in line with student group 2 learning requirements, adding a new dimension to the results. a weakness was that there was paucity of information in the literature for comparison of grlss findings with regard to student groups’ learning styles; therefore, comparisons had to be drawn with studies using other learning style instruments for data collection. this process was akin to matching ‘apples’ with ‘pears’ – an unsatisfactory situation. furthermore, since the data were collected for this study, the movement debating the learning style ‘myth’ has gathered momentum, with researchers noting that moves towards ‘debunking’ such data collection are not necessarily effective, but suggesting that there should be a progression towards evidence-based research in its place.[25] conclusion this study gives insight into the possible learning styles of physiotherapy students as applied to the anatomy scenario. it is therefore useful for faculty involved in gross anatomy education of this student population to consider the outcomes to perhaps adapt their teaching styles to facilitate beneficial outcomes for their students. however, the question remains whether this study is sufficient to evaluate the learning styles of physiotherapy students in anatomy definitively – generally and in particular – in relation to age and gender considerations. a larger longitudinal study may provide answers to this question and give new direction to gross anatomy learning for this student population. however, there is an ongoing debate as to whether continued use of learning style instruments is valid, and although this study did produce some plausible findings, consideration has to be given to conducting the suggested longitudinal research using more verifiable evidence-based research methodology. declaration. this study was undertaken and published as part of the phd degree requirements of the first author. acknowledgements. we wish to acknowledge the willing involvement of the participants. author contributions. all authors were involved in the study design. the first author was responsible for data collection, statistical analysis of the data, writing the drafts and for submission and re-submission of the article. all authors reviewed the drafts before they were submitted or resubmitted for publication. funding. south african society of physiotherapy research foundation (grant no. rc2016/01/03). conflicts of interest. none. 1. shead d, roos r, olivier b, et al. gross anatomy curricula and pedagogical approaches for undergraduate physiotherapy students: a scoping review protocol. jbi database system rev implement rep 2016;14(10):98-104. https://doi.org/10.11124/jbisrir-2016-003164 2. claxton cs, rolston y. learning styles: their impact on teaching and administration. 1st ed. washington, dc: american association for higher education, 1978. 3. cassidy s. learning styles: an overview of theories, models and measures. educ psychol 2004;24(4):419-444. https://doi.org/10.1080/0144341042000228834 4. rollins m. learning style diagnostics: the grasha-riechmann student learning styles scale. 2015. http://www. elearningindustry.com/learning-style/ (accessed 1 march 2017). 5. fleming nd. the case against learning styles: ‘there is no evidence … .’ 2012. http://vark-learn.com/wp-content/ uploads/2014/08/the-case-against-learning-styles.pdf (accessed 27 april 2018). https://doi.org/10.11124/jbisrir-2016-003164 http://www.elearningindustry.com/learning-style/ http://www.elearningindustry.com/learning-style/ http://vark-learn.com/wp-content/uploads/2014/08/the-case-against-learning-styles.pdf http://vark-learn.com/wp-content/uploads/2014/08/the-case-against-learning-styles.pdf december 2018, vol. 10, no. 4 ajhpe 234 research 6. pashler h, mcdaniel ma, rohrer d, bjork r. learning styles: concepts and evidence. psychol sci public interest 2008;9(3):105-119. https://doi.org/10.1111/j.1539-6053.2009.01038.x 7. willingham dt, hughes em, dobolyi dg. the scientific status of learning style theories. teach psychol 2015;42(3):266-271. 8. husmann pr, o’loughlin vd. another nail in the coffin for learning styles? disparities among undergraduate anatomy students’ study strategies, class performance, and reported vark learning styles. anat sci educ 2018;(epub ahead of print). https://doi.org/10.1002/ase.1777 9. grasha af, yangarber-hicks n. integrating teaching styles and learning styles with instructional technology. coll teach 2000;48(1):2-11. https://doi.org/10.1080/87567550009596080 10. kolb da. experiential learning. 1st ed. englewood cliffs, nj: prentice-hall, 1984. 11. spoon jc, schell jw. aligning student learning styles with instructor teaching styles. j industr teach educ 1998:35(2). 12. curry a. an organization of learning styles theory and constructs. am educ res ass 1983:1-25. 13. grasha af, riechmann-hruska s. grasha-riechmann teaching style scale (grtss). 1996. http://www.longleaf. net/teachingstyle.html (accessed 9 october 2018). 14. mohammadi s, mobarhan mg, mohammadi m, ferns gaa. age and gender as determinants of learning style among medical students. br j med med res 2015;7(4):292-298. 15. grasha af. teaching with style: a practical guide to enhancing learning by understanding teaching and learning styles. 2nd ed. san bernadino, ca: alliance, 2002. 16. baykul y, gürsel m, sulak h, et al. a validity and reliability study of grasha-riechmann learning style scale. int j educ pedagog sci 2010;4(3):323-330. 17. alami m, ivaturi p. typical teaching styles among elc lecturers at salalah college of technology, oman. j appl ling lang res 2016;3(7):251-261. 18. smith dm, kolb da. user’s guide for the learning-style inventory. 1st ed. boston, ma: mcber, 1986. 19. coates j. generational learning styles. 1st ed. river falls: lern books, 2007. 20. azarkhordad f, mehdinezhad v. explaining the students’ learning styles based on grasha-riechmann’s student learning styles. j admin manage train 2016;12(6):241-247. 21. kulac e, sezik m, asci h, et al. learning styles, academic achievement, and gender in a medical school setting. j clin anal med 2015;6(5):608-611. https://doi.org/10.4328/jcam.2317 22. hawk tf, shah aj. using learning style instruments to enhance student learning. decis sci j innov educ 2007;5(1):1-19. 23. meehan-andrews ta. teaching mode efficiency and learning preferences of first year nursing students. nurs educ today 2009;29(1):24-32. https://doi.org/10.1016/j.nedt.2008.06.007 24. king a. culture, learning and development: a case study on the ethiopian higher education system. high educ res net j 2011;4:5-13. 25. newton pm, miah m. evidence-based higher education – is the learning styles ‘myth’ important? front psychol 2017;8:444. https://doi.org/10.3389/fpsyg.2017.00444 accepted 31 may 2018. https://doi.org/10.1111%2fj.1539-6053.2009.01038.x https://doi.org/10.1002/ase.1777 https://doi.org/10.1080/87567550009596080 http://www.longleaf.net/teachingstyle.html http://www.longleaf.net/teachingstyle.html https://doi.org/10.4328/jcam.2317 https://doi.org/10.1016/j.nedt.2008.06.007 https://doi.org/10.3389/fpsyg.2017.00444 ajhpe african journal of health professions education sept 2021, vol. 13, no. 3 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state werner cordier university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 editorial 155 we survived w cordier, c n nyoni short research report 157 plotting through the pandemic j marcus, b nkuna, j andras 159 from work-integrated learning to virtual case studies: navigating an alternative to fieldwork in paediatric occupational therapy k van niekerk, k uys, i (j c) lubbe 161 pedagogy to probity h roos, c lubbe 163 an innovative, remote supported problem-based learning model in a south african medical curriculum during the covid-19 pandemic j jayakumar, f amien, g gunston, l de paulo, s crawford-browne, g doyle, k bugarith 167 synchronous online pharmacy skills group work: a breakout room toolbox for teaching v a perumal-pillay, f walters 170 how a global pandemic fuelled an all-time career high in emergency remote teaching at the faculty of health sciences, university of cape town c gordon 172 innovative mentorship: implementation of an online mentorship programme for south african medical internship and junior doctors in kwazulu-natal v s singaram, k l naidoo, n c dlova 174 breaking the isolation: online group assignments s adam, m coetzee, i (j c) lubbe 176 whatsapp as a support strategy for emergency nursing students during the covid‐19 pandemic y botma, t heyns, c filmalter, c nyoni 179 ‘going virtual’: innovative online faculty development during covid‐19 r maart, a rhoda, s titus, d manning 182 'goldilocks anatomy' – data-conserving anatomy video tutorials during emergency remote teaching q wessels, a du plessis, k van niekerk ajhpe african journal of health professions education sept 2021, vol. 13, no. 3 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state werner cordier university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria acting general manager dr vusumuzi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 184 stimulating students’ critical thinking skills in pharmacology using case report generation s s mlambo 186 bringing literature to life: a digital animation to teach analogue concepts in radiographic imaging during a pandemic: lessons learnt h essop, i (j c) lubbe, m kekana 189 a ray of sunshine in the covid‐19 environment, with a virtual sunburst elective a turner, i (j c) lubbe, w ross 191 saving student interaction by saving the starks h parker 193 planning and facilitating remote objective structured clinical examinations (osces) for wound care students in south africa during the covid-19 pandemic b s botha, m mulder 195 anaesthesia skills and simulation training during the covid-19 pandemic r van wyk, e w turton 197 outsmarting covid-19 through rapid 3d printing and flipped learning in fixed prosthodontics a fortuin, j h van den heever, t c postma 199 the reality of virtual reality at a south african university during the covid-19 pandemic b s botha, l hugo-van dyk, c n nyoni 201 teaching pharmacology online: not just another narration w cordier, i (j c) lubbe 203 reflection on remote teaching and learning of a final-year bpharm clinical training module during a pandemic m viljoen, r coetzee, n hoffman, j mccartney, e upton, m van huyssteen 205 learning during a pandemic: evaluating university of cape town first-year health sciences students’ experiences of emergency remote teaching n o mapukata, s k toto 208 adapting an undergraduate dental objectively structured clinical examination (osce) during covid‐19 r maart, s khan, b kathree, r ahmed, r mulder, n layloo, w asia‐michaels 210 moving fieldwork online: innovations in an occupational therapy curriculum l hess-april, m alexander, s stirrup, a b khan cpd questionnaire september 2021, vol. 13, no. 3 ajhpe 170 research during the first wave of the covid‑19 pandemic, health professions students at the university of cape town (uct) were not allowed onto the clinical platform and had to learn asynchronously from home for at least four months. online courses, in order to be successful, require extensive planning, explicit objectives and outcomes, multiple revisions and iterations, and a sound pedagogy underpinning them, among other factors.[1,2] the ‘e’ aspect of e‑learning is used as an appropriate vehicle or tool to fulfil the outcomes and serve the pedagogy in meaningful ways. what we were about to embark on was not a true reflection of what e‑learning is supposed to entail, as we had little (if any) time to plan, align to pedagogy, determine online learning outcomes, create and edit content and evaluate what had been done in a meaningful way – and we had no choice about the vehicle of delivery: this was to be the uct learning management system named vula. the university called this approach ‘emergency remote teaching’ to emphasise that this was not conventional e‑learning. as a medical educationist with an mphil in health professions education, i have a detailed knowledge of what makes a good teaching and learning experience, but so far this had only applied in a face‑to‑face setting. i felt very strongly that i still wanted my students to have a high‑quality, enjoyable experience, despite not being in the room with their teachers. i wanted them to have as interactive an experience as possible, given that we were not able to include synchronous teaching owing to data costs, and i wanted them to have an emotional connection to the content, for ‘if incoming stimuli are to cause synapse firing and strengthening, they must be accompanied by emotional involvement and interest’.[3] i had never designed an online course before, yet our department was now expected to create four emergency remote teaching (ert) courses, essentially overnight, two of which i was directly responsible for. i was reasonably familiar with vula, but i had never built an online module before. the interventions firstly, i did not and could not do it alone; collaboration was essential. i and my team engaged in several training workshops with the uct centre for innovation in learning and teaching (cilt), who provided excellent guidelines as to how a site should be structured. this included creating a clear pathway for students to progress through, so the content was broken up into weeks and days, which students really appreciated. furthermore, i  worked according to the uct student survey, which gave guidelines on the average time that most students could spend doing coursework. i tried to give fewer hours’ work than the guidelines suggested in an attempt to ensure that all students could complete their tasks each day. cilt also advised on maximum file sizes, and they advised that all video content be transcribed. most of the content that i made was in video format, although we did make use of some narrated powerpoint. i had had no idea how to make my own videos – would my phone be adequate, how would i transfer the videos, how would i hold the phone up? a fellow educationist colleague told me that all i needed was a tripod and my phone, and i managed to procure a cheap tripod just before hard lockdown. there was very little to be purchased during hard lockdown, so most props had to be sourced from my own household. examples of what was done during this time include: hand‑stitching a pituitary gland and a thyroid; making an endometrium with hair gel and red glitter; biopsying a potato; making tiny sphygmomanometers for stuffed toys, and making a chicken hand puppet go into labour. self‑assessment quizzes were created for every topic, which had not been done before. my team of undergraduate teachers also stepped up to the challenge of creating content, and i involved volunteer students in content creation, site construction and other logistics. students helped with conceptualising the pathway through which fellow students would progress, helped to design the site, and two students in particular made excellent video content for contraception – the largest topic in our course content. the first course i had to design was for fifth‑year gynaecology students. i learned a lot from this experience, so by the time the third‑year women’s health block came around, i was able to design a better educational experience. during the time we were constructing the third‑ and fifth‑ year modules, the final‑year students returned to the clinical platform. because their clinical exposure was minimal owing to the lack of non‑ covid‑19 patients, we decided to have zoom tutorials with simulated patient scenarios, which could now be synchronous, as students were back on campus. i became a number of different simulated patients for these videos. simulated patient videos and tutorials were later applied to fifth‑year gynaecology students when they too returned to the platform. as someone with a flair for the dramatic, i revelled in the numerous simulated patient scenarios. favourites were zoya lockdownikov (an extremely unsubtle russian spy) and the duchess of covidshire in her sequinned hospital gown, who was always on the phone with various prime ministers and presidents. what was learnt? i was forced to think more deeply about students’ home circumstances than ever before. understanding the home spaces in which students were expected to learn was an eye‑opening and invaluable experience, which had to be incorporated into my course planning. i learnt an extensive amount about technology, including video editing, which i had always felt how a global pandemic fuelled an all-time career high in emergency remote teaching at the faculty of health sciences, university of cape town c gordon, mb chb, mphil (health professions education) department of obstetrics and gynaecology, faculty of health sciences, university of cape town, south africa corresponding author: c gordon (c.gordon@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:c.gordon@uct.ac.za 171 september 2021, vol. 13, no. 3 ajhpe research was beyond my capabilities. i learnt in the truest sense that students really respond positively to authenticity, effort and off‑the‑wall humour – it did not matter that the videos were not perfect, and my drawings were stick figures; in fact, i think students resonated with those little vulnerabilities in my work. they enjoyed the novelty of seeing a teacher in their home environment, with all the interruptions of pets and children. yet again, i could see the importance of collaboration with others, especially with students, in creating content that they themselves had to consume. i also realised that scarcity inspires creativity: whatever was made was done with items already in the house, which forced me to think in a radically different way. i have never enjoyed my work as much as i did during this time, despite the attendant stressors. i also really learnt the value of the flipped classroom approach. students enjoyed consuming material in their time and at their own pace, and we began using face‑to‑face teaching time more productively – instead of teaching facts (which they now receive online), we are cultivating clinical reasoning around‑the‑case scenario videos. how did the students respond? in my eight years as an academic, i have never had such overwhelmingly rave reviews, especially from the third‑year students. this group had to give compulsory feedback as part of their course requirements. i received so many emails of thanks on top of the compulsory feedback. students were enthused; they were inspired; and they had learnt. what will come of this? firstly, i have a revitalised vision of what face‑to‑face teaching time can be used for. from 2021 onwards, we will be using a blended learning approach, where blended learning is defined as: a ‘learning environment that combines face‑to‑face instruction with technology‑mediated instruction’.[4] because of the factors that students enjoyed (which are reflected in the literature),[5] such as flexible and individualised learning, enjoyment, enhanced motivation to learn and increased opportunities for feedback, we will formalise the flipped classroom, where the vast majority of learning time for foundational concepts takes place outside face‑to‑face teaching time, and scheduled face‑to‑face teaching time is built around discussion, application and problem‑solving.[6] in our case, these will be centred on the case scenario videos already developed, to help students consolidate and apply their knowledge. the content will be freely available as open‑access resources on a dedicated web page, which is currently under development. the saying ‘never let a good crisis go to waste’ is attributed to winston churchill. i feel that we would never have reached these innovations and insights in the absence of the intense pressure caused by this global pandemic. the success of our interventions will be leveraged, in my opinion, to better educate future generations of doctors. declaration. none. acknowledgements. i wish to acknowledge my educational team and certain clinical colleagues who joined me for this uncharted experience, as well as the volunteer students for their contributions to our online teaching and learning venture. author contributions. sole author. funding. none. conflicts of interest. none. evidence of innovation 1. govindsamy t. successful implementation of e‑learning: pedagogical considerations. internet high educ 2001;4:287‑299. https://doi.org/10.1016/s1096‑7516(01)00071‑9 2. watson r, fardinpour a. twelve tips for developing and supporting generic online training for health and medical researchers. mededpublish 2017;6(4). https://doi.org/10.15694/mep.2017.000206 3. gravett s. adult learning. pretoria: van schaik, 2010:9. 4. graham c, dziuban c. in: spector m, merrill m, van merriënboer j, driscoll m, editors. handbook of research on educational communications and technology. abingdon: routledge, 2008:270‑274, 270. 5. akçayır g, akçayır m. the flipped classroom: a review of its advantages and challenges. computers educ 2018;126:334‑345. https://doi.org/10.1016/j.compedu.2018.07.021 6. thai n, de wever b, valcke m. the impact of a flipped classroom design on learning performance in higher education: looking for the best ‘blend’ of lectures and guiding questions with feedback. computers educ 2017;107:113‑126. https://doi.org/10.1016/j.compedu.2017.01.003 accepted 5 may 2021. afr j health professions educ 2021;13(3):170‑171. https://doi.org/10.7196/ajhpe.2021.v13i3.1521 https://www.sciencedirect.com/science/journal/10967516 https://doi.org/10.1016/s1096-7516(01)00071-9 https://doi.org/10.15694/mep.2017.000206 https://www.routledgehandbooks.com/author/m. david_merrill https://www.routledgehandbooks.com/author/jeroen_van merri%c3%abnboer https://www.routledgehandbooks.com/author/marcy p._driscoll https://www.routledgehandbooks.com/doi/10.4324/9780203880869 https://www.routledgehandbooks.com/doi/10.4324/9780203880869 https://www.sciencedirect.com/science/article/pii/s0360131518302045#! https://www.sciencedirect.com/science/article/pii/s0360131518302045#! https://doi.org/10.1016/j.compedu.2018.07.021 https://doi.org/10.1016/j.compedu.2017.01.003 https://doi.org/10.7196/ajhpe.2021.v13i3.1521 april 2021, vol. 13, no. 1 ajhpe 23 short research report clinical supervision supports the speech-language pathology student’s application of theory to diagnostic assessment and therapeutic intervention practices. the process of supervision includes the ‘observation, facilitation, acquisition of knowledge and skills, guidance and assessment of any student interaction’.[1] furthermore, clinical supervision plays a vital role in maintaining professional standards in the training of students in undergraduate and postgraduate professional degrees such as medicine, social work, nursing and speech-language pathology (slp).[2,3] according to the american speech and hearing association (asha),[4] the supervisory process is the interaction that takes place between the clinical educator and the student clinician. the success of this interaction may be related to the behaviour of the student clinician, clinical educator, client or the training programme in which the clinical educator and student clinician are involved.[5] therefore, the goal of clinical supervision is to facilitate the professional growth and development of the clinical educator and student clinician to provide optimal service to the client(s). clinical supervision is undergirded by a developmental approach, which requires clinical educators to change their expectations of clinical practice in accordance with the level of clinical preparedness of the student clinician. previous research has indicated that clinical educators’ expectations of students are based on their own prior experience and personal values.[6,7] these expectations result in biases and sources of error when acting as a clinical educator. thus, there is a need to collect behavioural data and information on the student clinicians' and clinical educators’ personal perceptions. obtaining these data and information can positively improve clinical supervision by influencing the development of the clinical curriculum. if the curriculum is improved, then service delivery to linguistically and culturally different clientele is also improved. questions concerning clinical educators’ biases and the differential effects of supervising student clinicians from linguistically and culturally different backgrounds were explored in a study by keeton et  al.[1] the study was conducted in johannesburg, south africa (sa), where 8 clinical educators were interviewed regarding their experiences working with diverse students in underserved contexts. results indicated that clinical educators struggled with  supervising students from linguistically and culturally diverse backgrounds, which affected their assessment of student clinicians. furthermore, the student clinicians’ effectiveness in providing appropriate client intervention was reduced. these findings highlight the need to understand ways in which clinical educators can be supported and the challenges that they experience working with students from linguistically and culturally different backgrounds within underserved and underresourced contexts. furthermore, to evaluate the efficacy of the supervisory process, empirical documentation is needed. in this article, we argue that it is important to identify facilitators and barriers in the supervision process, which will enable the department to improve the clinical curriculum to address the needs of students, clinical educators, and clients at the various sites. clinical educators in speech-language pathology at the university of the witwatersrand, johannesburg clinical educators have an important role in training student clinicians, as well as ensuring that clients receive relevant interventions. to embody both, clinical educators must understand the needs of the student, the context and the university’s initiatives and policies.[8] currently, the university has called for a transformed curriculum that is inclusive of student demographics background. clinical supervision plays a fundamental role in maintaining professional standards when training students of professional degrees at a university undergraduate level. objective. to describe the perceptions of clinical educators regarding the facilitators of and barriers to learning when training undergraduate speechlanguage pathology students in underserved and under-resourced clinical contexts in gauteng, south africa. methods. a qualitative approach, using a focus group discussion, was employed. data were gathered from 8 clinical educators regarding their experiences of supervision of students. themes were identified and analysed using thematic analysis. results. themes generated revealed that there were barriers in supervision due to attitudes of student clinicians, clinical educators’ preparedness and infrastructure at clinical sites. facilitators of the supervisory process were identified as feedback from student clinicians and support given by the department to clinical educators. conclusion. these findings suggested that clinical educators require additional time, support and training to assist them with clinical supervision. as  clinical supervision is fundamental to the speech-language pathology curriculum and student experience, its value should not be underestimated. these findings contribute to the process of transforming the effectiveness of clinical supervision. afr j health professions educ 2021;13(1):23-28. https://doi.org/10.7196/ajhpe.2021.v13i1.1216 facilitators of and barriers to clinical supervision of speech-language pathology students in south africa: a pilot study a mupawose, phd (speech pathology); s adams, ma (speech pathology); s moonsamy, phd (speech pathology) department of speech pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa corresponding author: a mupawose (anniah.mupawose@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 24 april 2021, vol. 13, no. 1 ajhpe short research report and contextually relevant instruction.[1] the pedagogical knowledge and praxis of clinical educators must be in step with the curriculum changes. at the university of the witwatersrand, the slp department relies heavily on clinical educators, who are contracted as sessional staff. this process has often resulted in discrepancies in operation between departmental and clinical level. previous research has highlighted the challenges different health science training programmes have in working with clinical educators, particularly part-time or sessional staff. however, there is limited research on clinical educators facilitating clinical learning with students from diverse backgrounds in underserved contexts. challenges previously reported in the literature include the teaching of students who are culturally and linguistically different from the clinical educators, availability of clinical educators to students, and how feedback is provided.[1,3,5,9-12] it is, therefore, fundamental that clinical educators identify and apply models of best practice, based on research of the supervisory processes that are relevant to the sa context. however, this can only be done through examination of current practices and the creation of models that can be used with current clinical educators and the current student population. clinical training of students involves direct instruction and mentoring, which are subject to change, depending on the students’ competency level. however, providing direct instruction can be hampered when clinical educators have not kept abreast with the latest information; provided additional time to work with weaker students; or modelled the correct techniques or behaviours. modelling students requires more time, which is not always feasible, as clinical educators assist students of varied abilities and learning styles. furthermore, direct instruction or mentoring can be affected by clinical educators working at placement sites off campus. when clinical educators are off campus, they are not readily available to assist students who may need them.[11] since clinical educators often do not work daily in an academic space, they sometimes regard patient care as more important than teaching and mentoring of student clinicians. however, clinical educators need to hold patient care and student clinical teaching in the same regard to improve the supervisory process. feedback is important in the supervision process. feedback from clinical educators can either be verbal or written and should reflect where the student is along the continuum of learning clinical work.[3,5,12] however, feedback can be difficult for clinical educators when students are not willing to receive it. feedback from clinical educators also informs the clinical curriculum and enables the department to provide the necessary support for students. this highlights the need for empirical documentation of clinical educators’ experiences and opinions on the effectiveness of the clinical curriculum, as well as their own supervisory processes. clinical supervision model there is no universally agreed-upon model of supervision in slp. asha[4] recognises anderson’s[13] continuum model, which is based on the developmental constructs that span a professional career. anderson’s continuum model is based on the premise that the amount and type of supervision change over time, as does the role of the clinical educator and student clinician. in anderson’s model, the student progresses through three broad stages of supervision: evaluation-feedback, transitional and self-supervision. anderson’s model also describes how the clinical educators’ style of supervision (direct/active, collaborative, consultative) changes as the  students progress through the abovementioned three stages. however, the literature has shown that clinical educators do not modify their behaviour relative to the students’ experience, knowledge, and developmental stage.[14] the incongruence between what clinical educators state and what they do, has been evident at clinical tutor meetings hosted by the department. recent advances in the arena of clinical supervision are being driven by a call for higher patient safety and evidence-based practice. this shift in correlating clinical supervision with quality health or rehabilitation services supports the need for formalising clinical supervision in slp. as  a  department, we need to determine how efficacious clinical supervision  is in working with diverse students in underserved contexts. the aim of  this study was to determine what the clinical educators’ facilitators and barriers are in the supervision of slp students. this article argues that an understanding of clinical educators’ experiences and perceptions of supervising students have explicit implications for student training in slp. methods research question: what are the perceptions of clinical educators about the supervisory process regarding supervision of undergraduate slp students in gauteng? research objectives • to identify and describe the barriers to the supervisory process of undergraduate slp students in gauteng. • to identify and describe the facilitators of the supervisory process of undergraduate slp students in gauteng. research design a qualitative, exploratory research design using a focus group was employed in this study. the design allowed the researchers to gain insight in and explore the depth and complexity of the supervisory process among clinical educators. context secondand third-year slp students are sent to clinical placement sites to provide therapy, twice a week for 7 weeks. students spend 3 hours at the placement site providing both individual and group therapy sessions under the supervision of a clinical educator. clinical language sites are in underserved, under-resourced and densely populated areas of johannesburg. the clinical educator to student ratio is generally 1:6. participants a purposeful convenience sampling strategy was used to select both second and third-year clinical educators involved in supervising undergraduate slp students in primary school contexts. the sample was represented by 8 clinical educators; all were female, with varying levels of experience. the 8  participants were recruited at a clinical educators’ meeting that is held bi-annually in the department. the inclusion criteria stipulated that clinical educators needed to be registered with the health professions council of south africa (hpcsa) (professional accreditation body) and have a minimum of 2 years' work experience after graduation and community service.[15] the hpcsa mandates that graduates in the profession may clinically supervise after working for 2 years.[15] the participants were also required to be proficient in english because it is the language of learning and teaching at the university of the witwatersrand. the description of the participants is shown in table 1. april 2021, vol. 13, no. 1 ajhpe 25 short research report data collection an interview schedule was used, and open-ended questions were generated from the relevant literature. after the departmental clinical educators’ meeting, participants were informed about the purpose and details of the study. all questions raised were answered. participation was voluntary and participants could leave at any time during the focus group discussions. once the consent forms were signed, focus group discussions began on the supervisory process. all these discussions were conducted in english. the focus groups were moderated by an experienced facilitator hired and orientated to the research study. the focus group discussions lasted ~1 hour. data responses were audio-recorded and then transcribed verbatim. any personal or identifying information mentioned by the participant was omitted from the transcript to maintain confidentiality. data analysis data were analysed according to the braun and clarke[16] 6-step procedure of thematic analysis, which included reviewing the data to become familiar with it, generating initial codes, searching for themes, reviewing potential themes, defining and naming themes and, finally, reporting on findings. the analysis of the data started with the researchers (re)reading the transcripts and listening to the audio-recordings to make notes. the purpose of the notes was to get a deeper understanding of what the participants were stating. then the researchers started the process of identifying and generating codes for potential themes. the initial codes included the actual meanings of what was stated and the researchers’ interpretation of it. after initial codes were generated, each researcher proceeded to search for themes. once each researcher had identified themes and reviewed them again for further analysis, they came together to compare, define and name agreed-upon themes for final reporting. trustworthiness trustworthiness was determined via credibility, dependability, and confirmability. credibility was determined by member checking, whereby the written responses were sent to participants to determine whether the researchers had captured the essence of what they wanted to convey.[17,18] dependability was achieved by detailing all aspects of the methodology, such as research design, description of participants, data collection, compilation of transcripts and data analysis. finally, confirmability was established by the researchers stating their position in terms of epistemology to represent the participants’ perspectives as unbiased. ethical approval ethical clearance was granted by the human research ethics committee of the university of the witwatersrand (ref. no. h18/11/24). results and discussion results are discussed in accordance with the research aims, as indicated in table 2. barriers to the supervisory process attitudes of students three out of 8 clinical educators reported that student clinicians did not always have a ‘good’ attitude during clinical sessions at the sites. the attitudes shown by students made it difficult for clinical educators to give feedback and constructive criticism, as students did not receive the feedback favourably: ‘students do not always do the things i ask them and get very defensive. i also find that these students are not always implementing feedback and changes that have been suggested to them.’ (participant 2) these findings are similar to those of davies et  al.[19] in their study of physiotherapy clinical educators. they found it stressful and difficult giving feedback to failing or borderline-performing students. failing students were an added burden to clinical educators. clinical educators reported that failing students required extra time, induced emotional stress, and sometimes presented with difficult personality (e.g. be overly emotional, overconfident, immature or have a poor work ethic). wium and du plessis[12] suggest that students need to become better at self-assessment, as those who are less competent tend to overestimate their clinical competence, making them less open to constructive feedback and change. a lack of self-assessment or reflection does not allow students to identify their areas of weakness and how they can improve these. therefore, it is imperative that reflection comprises part of clinical training for student clinicians. students need to be shown how to reflect and given time to reflect on their performance. reflective practice is one pillar in metacognition – monitoring and evaluation being the other two. moonsamy[20] states that, for this process to be effective, metacognition should happen before, during and after the intervention process. therefore, clinical educators need to exercise metacognition so that they can share their learning with students. this can be done using guided reflections so that both student clinicians and clinical educators can understand why students do what they do, why they feel in a particular way and how to best support them. furthermore, students often focus on marks and do not have a broader vision of learning and development. consequently, if the supervisory process develops a value-add proposition, student slps should transform their attitudes and see learning as a life-long attribute. table 2. research aims and themes aims themes barriers to supervision attitudes of students supervisor preparedness infrastructure at the clinical site facilitators to supervision feedback departmental support table 1. description of participants (n=8) variables n (%) race black 2 (25) white 3 (37.5) indian 2 (25) coloured 1 (12.5) supervising, years 0 2 3 (37.5) 3 5 3 (37.5) >5 2 (25) clinical site children’s home 2 (25) crèche 2 (25) school 4 (50) 26 april 2021, vol. 13, no. 1 ajhpe short research report supervisor preparedness five of 8 clinical educators felt that students were not adequately prepared for the clinical setting. clinical educators reported that students did not have appropriate theoretical knowledge because they struggled to apply and integrate theory with clinical practice. one supervisor commented on the impact that one weak student can have on other students due to the additional time needed to support that student: ‘it is difficult when you have a weak student at the clinic, because of the supervisor-student ratio it takes time away from the other students. i end up spending more time mentoring that [weak] student because they do not know what they are doing.’ (participant 4) these findings are supported in a study by kilminster and jolly,[21] where the importance of the structure and content of a clinic as reasons for the level of preparedness was commented on. in their study, many students felt that too much time was spent on case reviews and not enough on explaining theoretical issues or teaching related practical concepts.[21] students generally are aware that they may have difficulty with the application of knowledge; therefore, clinical educators need to know that their role goes beyond mentoring and includes teaching.[9] didactic training can be a powerful tool for enhancing student knowledge. however, clinical educators report that there is not always enough time at the clinic placement site to provide appropriate patient care, teach students and give feedback.[11] the levels of preparedness, therefore, can be attributed to the student and the clinical educators’ management and logistics. the levels of preparedness highlight the importance of students and clinical educators needing a clear idea of what they are doing and the expectations they have of each other. clinical educators should be provided with time to prepare, which should be built into their workload, as patient care and student training should be prioritised when working with students.[11] clinical educators should be given scope to further their own knowledge and training through research and continuing education forums to enhance their knowledge of student supervision. infrastructure at the clinical site six of 8 clinical educators identified the clinical placement sites as a barrier to clinical supervision in terms of resources, services  available and physical space. although many sites required slp services, clinical educators reported that many of them did not have space to accommodate all the students: ‘there are lots of children that need therapy, and the site is in dire need of services. but space is problematic for six students ...’ (participant 4) many clinical educators reported having to work in the hallway or outside: ‘we struggle a bit with space … we tend to try and use the corners of the room or find space outside.’ (participant 5) clinical educators also reported that the limited resources added additional stress to their clinical work. clinical educators reported feeling stressed because they had the added responsibility of negotiating and finding spaces for students to conduct therapy. sometimes the identified spaces were not conducive to optimal language therapy. one supervisor working at a school reported the following: ‘the school is very poor, and they do not have chairs. they do not always want to give us desks to use and i end up having to look for chairs, i have to keep telling them [the students] to be more independent.’ (participant 1)  previous studies have reported that the context students work in can impact negatively on their experience.[12,21] however, this is a barrier that is difficult to overcome in sa, where there is a need for services, but a lack of available resources. student clinicians and clinical educators need to become responsive to the context they are working in and be creative in where and how to work at the different sites. facilitators of the supervisory process feedback students were given an opportunity to provide written feedback on the clinical training experience and their clinical educators. this feedback was shared with the clinical educators, but the anonymity of the student was maintained. all 8 clinical educators reported on how student feedback had helped them to improve their supervision style and to understand what the students were thinking and feeling: ‘supervisor feedback was very helpful as you can get into the head of the students and see what difficulties they are having. you can also change your ways, and it helps you to see where they are coming from.’ (participant 8) another clinical educator commented on how it helped her to grow in her supervision, and she sees the difference in the students: ‘the feedback helped me to see what was and was not working for the students. i was able to adjust what i was doing and saw an improvement in the students and how they were performing at the clinic.’ (participant 2) gonsalvez et  al.[9] emphasise the importance of anonymised feedback as a way to measure clinical educators’ performance and that it should be given  consistently throughout the placement. this needs to be built into the clinical environment as a form of evaluation and to address issues at  the  site and with the clinical educators. furthermore, clinical educators need to be aware of the power relations inherent in the supervisory relationship and evaluate how they provide feedback so that the student  clinician does not feel powerless. likewise, clinical educators need to be aware of their positionality, cultural biases, or stereotype ‘thinking’ they bring to the clinical educator and student relationship.[22] being mindful of bias is  critical, especially bearing in mind sa’s history of discrimination. departmental support all 8 clinical educators commented on the importance of departmental support and how this assisted with supervising the clinic. one of the participants remarked on the type of support the department could include: ‘communication on dates and what is due when, constant emailing to find out the protocol … when we are assessing etc. … perhaps send us a guideline before the clinic commences as it is difficult to keep consulting the students – we need to be in control.’ (participant 6) the same participant suggested more communication with the lecturers: ‘…  need to be informing the lecturers more on what is happening in therapy.’ (participant 6) april 2021, vol. 13, no. 1 ajhpe 27 short research report the comments made by participants reflect that improved communication between internal and external clinical staff in training institutions is fundamental. the clinical educators commented that they would like more training and time to see the students on a one-to-one basis. these comments have been supported by dudding et  al.[22] and davies et  al.[19] with regard to training, research in the nursing discipline has correlated clinical supervision with improvements in the quality of patient care.[22] the field of medicine also argues that efficient supervision improves patient care. despite knowing that quality supervision improves patient outcomes, there are no international or national formalised training requirements for clinical education in slp. institutional support is very important,[9] as it provides the training department with the finances to hire more staff and decrease the workload of clinical educators, allowing more time to prepare and engage with students. moreover, by reducing the caseload of clinical educators, the importance of paying detailed attention is valued. developing student skills is very essential in the consolidation of learning and application. this is paramount, especially as the cohort of slp students have diverse learning needs. given the history of sa’s education systems, most students would benefit from academic and clinical support. conclusion in concluding, the findings of the study highlight clinical educators’ perceptions about supervision in relation to students, infrastructure, and feedback. reflecting on the input from clinical educators confirms their required support from the training programme. furthermore, a collaborative relationship should exist between clinical educators and students, and the training institution and clinical educators. for an effective collaborative relationship, open channels of communication are needed.[23] clinical training, therefore, needs to create awareness in students regarding introspection, insight, and metacognition. research has shown that the more knowledgeable person in the supervisory process needs to demonstrate their reflective thoughts so that students can learn how clinical educators think. all clinical educators need to practise and model their way of critical thinking. modelling critical thinking would allow students to recognise their own thinking, as well as new ways of thinking. students should then feel confident in making their thinking explicit in their planning and practice of slp therapy. clinical educators and students should also work collaboratively with individuals at each community site so that the solutions identified are relevant to the context. this, as indicated in the article, begins with training so that clinical educators take on the responsibility of being agents of change. curriculum transformation needs to include real, rather than ideal, contexts so that students’ practice is appropriate. study limitations and future directions most studies are cross-sectional, and it would be beneficial to provide clinical educators with training or an intervention and then measure the outcomes longitudinally. the study utilised a focus group that facilitated the construction of meaning from collective discussion and conversations.[24] however, in the future, it may be beneficial to interview individual participants and obtain more in-depth responses that are not influenced by others’ perspectives. the current research study identified that clinical educators favour additional tools and strategies to help them to enhance the supervisory process, which needs to be implemented and evaluated. another direction for this research would be to apply the same instrument to an increased number of clinical educators in the same and in different educational fields. in addition, student perceptions on the facilitators of and barriers to learning while at clinical practicum could also be explored. implications as many clinical educators are not always in the academic space, opportunities for ongoing training should be incorporated by the department. clinical educators should be given scope to further their own knowledge and training to enhance the learning experience of the students. students need to meet outcomes for clinical training set out by statutory bodies (e.g. the hpcsa); however, the context in which they are working should also be considered. the department needs to support sessional clinical educators and make sure their workload is manageable and that they have adequate time to prepare for clinical teaching, as they not only need to provide high-quality patient care but also theoretical teaching. the findings of this research highlight the importance of formalised training for clinical educators and better institutional communication. this study, therefore, contributes to understanding the facilitators of and barriers to the supervisory process of diverse students in underserved contexts. it has provided input into models of best practice and ways to improve clinical training and client service delivery. declaration. none. acknowledgements. the authors would like to thank all participants for their feedback. author contributions. am facilitated the focus group discussion, applied for ethical clearance, and wrote the literature review. sa wrote the methodology and results and discussion. sm added information to the literature review and wrote parts of the results and discussion, and wrote the conclusion. funding. none. conflicts of interest. none. 1. keeton n, kathard h, singh s. clinical educators’ experiences of facilitating learning when speaking a different language from both the student and client. bmc res notes 2017;10(1):1-8. https://doi.org/10.1186/s13104-0172874-4 2. culloty t, milne dl, sheikh ai. evaluating the training of clinical supervisors: a pilot study using the fidelity framework. cogn behav ther 2010;3(4):132-144. https://doi.org/10.1017/s1754470x10000139 3. milne d. can we enhance the training of clinical supervisors? a national pilot study of an evidence-based approach. clin psychol psychother 2010;17(4):321-328. https://doi.org/10.1002/cpp.657 4. american speech-language and hearing association. clinical supervision in speech-language pathology. 2008. www.asha.org/policy (accessed 22 july 2018). 5. wright j, needham c. the why, who, what, when, and how of supervision. perspect asha spec interest groups 2016;1(11):68-72. https://doi.org/10.1044/persp1.sig11.68 6. gillam rb, roussos cs, anderson jl. facilitating changes in supervisees’ clinical behaviors: an experimental investigation of supervisory effectiveness. j speech hear disord 1990;55(4):729-739. https://doi.org/10.1044/ jshd.5504.729 7. burkard aw, johnson aj, madson mb, et al. supervisor cultural responsiveness and unresponsiveness in crosscultural supervision. j couns psychol 2006;53(3):288-301. https://doi.org/10.1037/0022-0167.53.3.288 8. al kadri hm, al-moamary ms, elzubair m, et al. exploring factors affecting undergraduate medical students’ study strategies in the clinical years: a qualitative study. adv health sci educ 2011;16(5):553–567. https://doi. org/10.1007/s10459-010-9271-2 9. gonsalvez cj, wahnon t, deane fp. goal-setting, feedback, and assessment practices reported by australian clinical supervisors. aust psychol 2017;52(1):21-30. https://doi.org/10.1111/ap.12175 10. lee w-s, cholowski k, williams ak. nursing students’ and clinical educators’ perceptions of characteristics of effective clinical educators in an australian university school of nursing. j adv nurs 2002;39(5):412-420. https:// doi.org/10.1046/j.1365-2648.2002.02306.x 11. schiekirka-schwake s, anders s, von steinbüchel n, becker jc, raupach t. facilitators of high-quality teaching in medical school: findings from a nation-wide survey among clinical teachers. bmc med educ 2017;17(1):1-8. https://doi.org/10.1186/s12909-017-1000-6 12. wium am, du plessis s. the usefulness of a tool to assess reflection in a service-learning experience. afr j health professions educ 2016;8(2):178-183. https://doi.org/10.7196/ajhpe.2016.v8i2.586 13. anderson jl. the supervisory process in speech language pathology and audiology. boston: college hill press, 1988. 14. geller e, foley gm. broadening the ‘ports of entry’ for speech-language pathologists: a relational and reflective model for clinical supervision. am j speech lang pathol 2009;18(1):22-41. https://doi.org/10.1044/10580360(2008/07-0053 https://doi.org/10.1186/s13104-017-2874-4 https://doi.org/10.1186/s13104-017-2874-4 https://doi.org/10.1017/s1754470x10000139 https://doi.org/10.1002/cpp.657 http://www.asha.org/policy https://doi.org/10.1044/persp1.sig11.68 https://doi.org/10.1044/jshd.5504.729 https://doi.org/10.1044/jshd.5504.729 https://doi.org/10.1037/0022-0167.53.3.288 https://doi.org/10.1007/s10459-010-9271-2 https://doi.org/10.1007/s10459-010-9271-2 https://doi.org/10.1111/ap.12175 https://doi.org/10.1046/j.1365-2648.2002.02306.x https://doi.org/10.1046/j.1365-2648.2002.02306.x https://doi.org/10.1186/s12909-017-1000-6 https://doi.org/10.7196/ajhpe.2016.v8i2.586 https://doi.org/10.1044/1058-0360(2008/07-0053 https://doi.org/10.1044/1058-0360(2008/07-0053 28 april 2021, vol. 13, no. 1 ajhpe short research report 15. health professions council of south africa. regulations relating to the undergraduate curricula and professional examination. pretoria: hpcsa, 2012. 16. braun v, clarke v. research designs: quantitative, qualitative, neuropsychological, and biological. in: cooper he, camic pm, long dl, panter at, rindskopf de, sher kj, eds. apa handbook of research methods in psychology, vol. 2. washington, dc: american psychological association, 2012:57-71. https://doi.org/10.1037/13620-004 17. creswell jw, miller dl. determining validity in qualitative inquiry. theory pract 2010;39(3):124–130. https:// doi.org/10.1207/s15430421tip3903_2 18. padgett d. qualitative methods in social work research. los angeles: sage, 2008. 19. davies r, hanna e, cott c. ‘they put you on your toes’: physical therapists’ perceived benefits from and barriers to supervising students in the clinical setting. physiother can 2011;63(2):224-233. https://doi.org/10.3138/ ptc.2010-07 20. moonsamy s. metacognition: a tool for strategic thinking teachers when mediating in the classroom. in: walton el, moonsamy s, eds. making education inclusive. newcastle upon tyne: cambridge scholars publishing, 2015:113-129. 21. kilminster sm, jolly bc. effective supervision in clinical practice settings: a literature review. med educ 2001;34(10):827-840. https://doi.org/10.1046/j.1365-2923.2000.00758.x 22. dudding cc, mccready v, nunez lm, procaccini sj. clinical supervision in speech-language pathology and audiology in the united states: development of a professional specialty. clin superv 2017;36(2):161-181. https://doi.org/10.1080/07325223.2017.1377663 23. moonsamy s. collaborative consultation. in: moonsamy s, kathard h, eds. speech-language therapy in a school context: principles and practices. pretoria: van schaik, 2015. 24. milward l. focus groups. in: breakwell gm, hammond s, fife-schaw c, smith ja, eds. research methods in psychology. london: sage, 2006:274-299. accepted 16 january 2020. https://doi.org/10.1037/13620-004 https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.3138/ptc.2010-07 https://doi.org/10.3138/ptc.2010-07 https://doi.org/10.1046/j.1365-2923.2000.00758.x https://doi.org/10.1080/07325223.2017.1377663 2 month 20xx, vol. x, no. x ajhpe research healthcare educationalists are faced with fewer clinical opportunities owing to a changing healthcare climate,[1] resource distribution towards primary healthcare,[2] increased student numbers,[3] and south africa (sa)’s unique quadruple burden of disease[4] that has an impact on the availability, variety and complexity of patients for student training. contributing to the challenges are the covid-19 pandemic, which also impacts the case mix and teaching platform used for student training. improving safe patient management[5] with limited resources[6] is also essential in sa healthcare education. additionally, the underpreparedness of students entering the tertiary education environment[7] and student dissatisfaction with the presented curricula[8] pose further challenges to national healthcare  education. healthcare training therefore requires adjustments and a widened training platform to ensure the continued throughput of skilled graduates.[9,10] simulation is defined by the healthcare simulation dictionary[11] as an educational methodology that involves designing a realistic situation where student learning and skills practice are facilitated. simulation, in the context of the present study, refers to the integration of a variety of simulation modalities in both immersive and practical skills-based, simulationbased learning experiences (sbles) in a healthcare training programme. the benefits of integrating simulation into healthcare education are undeniable,[12,13] and in light of all the challenges, the ability to produce learning opportunities when clinical practice settings are limited[14] is critical. simulation has also been used in the development of skills, ensuring both patient and student safety, and facilitating ethical conduct.[5] additionally, simulation addresses the learning needs of the current student population, making learning an interactive and realistic process that provides ‘hands-on’, student-centred education.[9] any programme innovation and/or integration requires educator preparation and training, taking into account curricular content, reasons for the proposed changes and the educator’s role in the programme.[15] detailed planning prior to the development, integration and execution of sbles is therefore essential,[15] and should aim to empower educators in  authentic  sble integration and decrease educator resistance to simulation integration.[16] a systematic review performed by the principal researcher (avdm) revealed few frameworks for healthcare simulation integration, published only in developed countries, between january 2005 and december 2017. of these identified frameworks, none was based in physiotherapy. the available simulation-based physiotherapy research focuses on integrating only selected simulation modalities or the training of specific skills, and does not present a framework for the integration of a variety of simulation modalities. this delphi survey aimed to develop a conceptual framework for the integration of simulation in sa undergraduate physiotherapy programmes. for the purpose of this article, one of the emerging themes, planning, has been explored in detail. background. the benefits of simulation in healthcare education are undeniable, and in the current healthcare climate, a drastic change in delivering healthcare training is critical. therefore, integration of simulation is essential, and necessitates detailed planning and well-trained educators. objectives. to develop a conceptual framework for the integration of simulation in south african (sa) undergraduate physiotherapy programmes. methods. a non-experimental descriptive research design using a modified delphi survey was conducted. results from a systematic review identifying simulation integration framework elements informed the delphi survey. a purposive sample of 15 healthcare educationalists from sa and abroad were approached to participate. data were analysed as percentages, and feedback was provided to panel members following each round. results. a response rate of 73.3% (n=11) was achieved. planning was explored as one of the themes. both institutionaland discipline-specific needs analyses were identified as essential (93%), and societal needs were useful to consider (64%). resource identification and sharing (84%) were regarded as vital, and expert collaboration in curriculum development (79%) with scaffolded skills integration (75%) was advised. the necessity for trained facilitators (93%) and educator role identification (71%) was evident. statements related to mastery learning/deliberate practice and the use of simulation for assessment purposes yielded the least consensus. conclusion. a constructively aligned curriculum based on both student and institutional needs and resource availability in guiding simulation integration was regarded as essential. educator competency in both the development and delivery of the programme, especially debriefing methods, is vital for optimising student learning. afr j health professions educ 2022;14(2):60-64. https://doi.org/10.7196/ajhpe.2022.v14i2.1446 how to plan for simulation integration into undergraduate physiotherapy training a van der merwe,1 msc (physiotherapy), phd (physiotherapy); r y barnes,1 phd (physiotherapy); m j labuschagne,2 mmed (ophthalmology), phd (hpe) 1 department of physiotherapy, faculty of health sciences, university of the free state, bloemfontein, south africa 2 clinical simulation and skills unit, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a van der merwe (gonzalesa@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. month 20xx, vol. x, no. x ajhpe 3 research methods design a descriptive research design using a modified delphi survey was utilised. statements were obtained from the systematic review, after which expert opinions were solicited regarding the content of the conceptual framework. a three-point likert scale with options ‘essential’, ‘useful’ and ‘not applicable’ was used. sampling and participants a purposive sample of 15  national and international healthcare educationalists in physiotherapy and/or other healthcare fields, as well as healthcare simulation experts, were identified (table  1). the majority of panel members were south africans, to provide a contextualised point of view unique to the sa environment and educational challenges. data collection panel members received an information leaflet detailing the study aim and procedure. a document explaining the sa undergraduate physiotherapy context was also provided to panel members to increase content validity. panel members were made aware that they would remain anonymous to one another, and that data would remain confidential. informed consent was obtained prior to participation. the delphi survey was distributed online by means of surveymonkey, with a 2-week completion deadline per round. data were analysed, followed by an authors’ consensus meeting to ensure that all comments and suggestions were accurately incorporated during the subsequent round, to limit bias.[17,18] a continuous iteration and feedback between panel members was used throughout the survey to achieve shared understanding on the topic. statements failing to achieve 70% consensus, panel member comments and the consensus meeting outcome were formulated into subsequent survey rounds.[17] statements achieving consensus were removed from subsequent rounds. data analysis in line with previous delphi surveys in similar research areas,[17,19] consensus was defined as ≥70% of panel members agreeing on the inclusion or exclusion of a statement. stability was declared when individual panel member selections remained similar across survey rounds, with suggestions provided for the specific statement not resulting in further content or contextual changes, additions or omissions.[19] data saturation was achieved when the repeated rounds yielded either a convergence of panel member opinions, or individual response stability per statement. pilot study a pilot study was performed with one healthcare educationalist experienced in both simulation-based education (sbe) and the delphi process. minor grammatical changes were made following the pilot study. ethical approval the first survey round was developed after approval from the health sciences research ethics committee at the university of the free state (ref. no. hsrec 108/2017) was obtained. results data saturation was declared after survey round 3. an overall response rate of 73.3% (n=11) was achieved, with 4 panel members dropping out during the delphi survey. reasons for dropout were not explored. in round 3, 36.4% (n=4) of panel members were from outside the country, and 63.6% (n=7) were south african. data were analysed as percentages to assess whether consensus had been achieved per statement. due to limited justification regarding selected options or opinions related to statements by panel members, content analysis of comments could not be performed. feedback to participants therefore included only the summary of statements achieving consensus, as the provision of statistical results with no supporting information would have yielded less accurate results.[19] four themes, with supporting categories, emerged from the data, namely planning (n=12), implementation (n=3), evaluation (n=2) and revision (n=1). for the purpose of this article, both statements achieving consensus (appendix: https://www.samedical.org/file/1807) and stability (table  2) relating to the planning theme have been explored. when integrating simulation, the inclusion of both institutional and discipline-specific needs analyses was indicated as essential (93%), with a societal needs analysis regarded as useful (64%) by panel members. identification of available human (86%) and physical resources (73%) also achieved consensus, with 84% of panel members indicating that facilities should be shared between healthcare disciplines. a collaborative approach to curriculum development and integration (79%), with scaffolding of non-technical training aspects according to the learning outcomes (75%), was deemed essential. although no other statements detailing the role of the educator achieved consensus, defining the role of the educator was viewed as vital (71%), and the identified role(s) should guide essential facilitator training (93%), notably in debriefing methods (100%). the inclusion of peer assessment as part of mastery learning/deliberate practice in formative assessments was table 1. expert panel targeted to be recruited for the delphi survey area of expertise n nationality profession healthcare educationalists and simulation experts (conducted simulation-based research, congress presentations, published work) 6 2 international, 4 sa national: nursing educationalist and simulation expert (n=1); general* (n=3); international: physiotherapy (n=1); general* (n=1) medical simulation expert (conducted simulation-based research, congress presentations, published work) 6 3 international, 3 sa national: medical specialist† (n=3); international: medical specialist‡ (n=3) healthcare simulation facility directors 2 2 sa n/a physiotherapy educationalist with simulation expertise (congress presentation, currently not published in sbe) 1 1 sa n/a sa = south africa; n/a = not applicable; sbe = simulation-based education. *a participant described as general is a qualified healthcare professional working in a simulation unit or centre with various healthcare professions students. †national medical simulation experts included two anaesthesiologists and one general medical practitioner. ‡international medical simulation experts included 2 anaesthesiologists and 1 surgeon. 4 month 20xx, vol. x, no. x ajhpe research judged as useful (73%), with statements relating to educators assessing the achievement of mastery learning (55%) and the use of sbles for summative assessment (55%) remaining in dissensus. no consensus could be reached regarding to whose satisfaction sbles should be repeated – individual students (55%) or the educator (55%). it was noted that the development of specific assessment tools for sbles was viewed as essential (83%). according to 64% of panel members, the inclusion of a self-reflection component in sbles should be considered. discussion sa may experience challenges, including lack of funding and resources, national healthcare deficits and an underprepared and diverse student population,[3,8] when adopting educational strategies designed for a developed economy. the need for thorough planning, involving all stakeholders, to successfully integrate and sustain simulation in a programme is evident from this study. financial constraints[6] negatively impact the availability of both human and physical resources in tertiary healthcare education, and institutional investigation into the practicality and benefits when planning simulation integration is essential. the integration of simulation-based learning should, however, not be equated with high costs and high-technology facilities.[13] instead, lateral, resource-smart planning, interprofessional collaboration and shared facilities could ensure simulation-based learning for all. considering the call for curriculum decolonisation by sa students,[8] the advent of the fourth industrial revolution (4ir) and an emerging adult learner population entering tertiary education, both participants and authors viewed it as vital to carefully develop sble outcomes aligned with discipline-based and institutional needs.[16,20] in a culturally, linguistically and ethnically diverse country[7] shifting towards primary healthcare,[2] the authors were concerned that the execution of a societal needs analysis when aiming to integrate simulation was only viewed as useful and remained in dissensus, with no supporting feedback provided by panel members. this might be due to panel members viewing societal needs as being addressed through adherence to minimum standards required by the healthcare governing body, the health professions council of sa (hpcsa). it should, however, be noted that the minimum criteria expected of undergraduate healthcare students are internationally benchmarked, and may not result in the unique sa societal needs being optimally met. acknowledging the role of contextual differences when aiming to integrate standardised education models is essential,[16] and disregarding differences could reduce the educational impact of simulation on student learning. because simulation is used only in pockets of certain sa healthcare education disciplines,[14] the collaborative development of an expertly revised, contextually appropriate, scaffolded and constructively aligned curriculum that integrates sbles according to educational principles is essential. in the participants’ opinion, sbe experts are indispensable in the planning process to identify existing curricular components that could benefit from or be replaced by sbles, enhancing the achievement of programme outcomes. mindful sble design during the planning phase, guided by best practice and national regulatory body guidelines, is vital table 2. statements achieving stability during the delphi survey category stability statements related to planning round essential, % useful, % n/a needs analysis identified societal needs should form the background context of sbles, depending on the desired learning objectives for each planned learning experience. 3 64 mastery learning/ deliberate practice the educator’s role in formative sbles, not used for formal assessment, would be that of facilitator and providing feedback. 3 64 the educator’s role in summative sbles is that of post-simulation feedback/debriefing and discussion. further options regarding assessment will be explored in theme 3. 3 40 40 students should be allowed to redo all formative sbles until they have reached their individual level of satisfaction. this would be dependent on the course structure, available time and resources. 3 55 educators should identify which formative simulation-based learning experiences, according to the set learning outcomes, should be repeated until an educator’s set benchmark is achieved. this would be dependent on the course structure, available time and resources. 3 55 attainment of the educator-set benchmark for identified summative sbles should be assessed by the educator at all times. options for peerand/or self-assessment are provided in the following questions. 3 55 assessment all sbles should have an element of self-reflection. 3 64 educators should identify which sbles are to be used for summative assessment. only these identified assessments should be performed on a one-to-one student-educator basis. 3 55 educators should identify which sbles could accommodate a peer-assessment element, and it should be implemented as such. 3 55 educators should identify which sbles are to be used for formative assessment. only the identified assessments should be performed on a one-to-one student-educator basis. an element of peer-assessment could be added if deemed appropriate by the educator. 3 45.5 note: the percentage stability achieved is indicated under the corresponding importance option; ‘round’ refers to the delphi round where stability was achieved. n/a = not applicable; sble = simulation-based learning experiences. italic text represents supplemental clarification provided to panel members. month 20xx, vol. x, no. x ajhpe 5 research to optimally employing available physical and human resources, and will ensure that developed sbles are focused on achievable outcomes. defining the educator’s role in sbles was viewed as essential by panel members, although no consensus could be reached regarding the specific role of the educator during either formative or summative assessments. as sa educators are directly involved throughout the sble planning, implementation and evaluation phases,[21] sa panel members possibly viewed the term ‘educator’ as interchangeable and synonymous with that of facilitator. panel members not familiar with using simulation for summative assessment may also have been challenged owing to sbles currently not being used in sa other than for assessing practical skills in some healthcare disciplines. the delphi results indicated that the absence of universal, standardised simulation terminology might have caused panel members to interpret the term ‘educator’ incorrectly, as an instructor of learning, rather than both instructor and facilitator of learning. it is therefore essential to provide a clear indication during the planning phase of what is expected of the educator in terms of their role in the integration of simulation, to identify  where additional educator training and/or resources would be required. with only anecdotal evidence available regarding the use of simulation in sa physiotherapy education, the authors support the panel members’ opinion regarding the necessity of contextualised educator training for their  required roles, namely sble development, providing constructive feedback and debriefing. completion of accredited training programmes should ensure the achievement of learning outcomes[15,20] through a uniform strategy pertaining to the teaching, evaluation and certification of integrated sbles. receiving feedback and/or taking part in a debriefing session following sble participation is the essence of sbe in facilitating learning through performance-based feedback and/or reflecting on individual performance through addressing student needs.[22] various feedback and/or debriefing sources and timings have been reported.[15,22,23] panel members concurred that identification of the timing of feedback and/or debriefing, including the debriefing method and tool used, should be included in the planning phase to allow for both student and facilitator preparation. further discussion regarding debriefing will be addressed in a follow-up article where the implementation phase of this conceptual framework will be presented and discussed. the clarification of student roles in preparation for sble participation is vital during the planning phase.[24] planning should include time allocation for acquainting students, who might not be familiar with the educational practice of simulation, with the simulated environment, sble outcomes, theoretical content and selected instructional methods. the term ‘instructional methods’ was included in the delphi survey based on results from the systematic review, and refers to the overall educational methods, irrespective of the mode of simulation, used during the sbles.[23] panel members indicated that technical and non-technical skills could not be taught in isolation, which is supported by the literature.[13] preparing healthcare professionals for adverse events, problem-solving in limited resource environments and multifaceted patient and/or team consultations and treatments is equally important as theoretical preparation for clinical practice. using sbles in training for healthcare professionals could potentially develop the skills required to navigate difficult and emotionally demanding situations.[12] panel members suggested that where relevant, non-technical training aspects should be scaffolded to the sble, and in accordance with the learning objectives. collaborative planning and design of sbles with these skills in mind would not only provide better preparation of graduates for changing healthcare practice, but also instil the value of self-care. although positive effects relating to skills transfer to the clinical setting have been demonstrated,[12] both mastery learning and deliberate practice are, according to both the literature[15] and panel member comments, extremely time consuming and resource intensive. only one mastery learning and deliberate practice statement achieved consensus, which could possibly reflect the panel members’ hesitation when confronted with published best practices[25] and the realistic impact on time and resources. the overarching aim of the statements presented to panel members was to identify if and when sble repetition should be integrated into the curriculum, thereby focusing on the core similarity between mastery learning and deliberate practice, resulting in the amalgamation of these two concepts. when viewing the elements of mastery,[12] it is clear that mastery is not based solely on the acquisition of individual skills. instead, it involves a progression from skills competence and integration toward skill application. considering the impact of the covid-19 pandemic,[1] the 4ir[6] and the attributes required of physiotherapy graduates, integrating a combination of  skills during an sble could be more useful for achieving integrated learning. the only mastery learning/deliberate practice statement reaching consensus by round 3 indicated that participants viewed it as essential to add a peer-assessment element to mastery learning and deliberate practice sessions. this practice would free up educator time and could be beneficial, as peer assessment has been shown to increase student learning, contribute to collaboration skills and foster reflection.[24] as mastery learning and deliberate practice are deeply embedded in the constructivist learning theory as part of experiential learning, formative assessments will provide students with feedback for reflection, with the aim of identifying implications for action. this action cycle can then be measured by means of summative assessment to ascertain whether skill mastery has occurred, thereby completing kolb’s cycle for experiential learning[21] and assessing the top tier of miller’s[26] pyramid of clinical competence. with a shrinking clinical platform, increasing interest in the use of sbles for the summative assessment of healthcare professionals has been reported.[24] however, sbles are viewed as safe[20] and forgiving learning spaces, and formal assessment could potentially lead to undue fear hindering the learning experience. maintaining a safe learning environment could explain why stability was only achieved in the delphi survey on statements relating to the student-to-educator ratio during formative and summative assessments, as sbles are not routinely used during either immersive or practical skills-based assessments in sa healthcare education.[27] the use of sbles for summative assessments therefore requires further investigation. if, however, sbles were to be considered for use, especially in summative assessments, identification of valid and reliable assessment tools during the planning phase is essential,[25] which was confirmed by the panel members. the panel members amended the term ‘self-assessment’ to ‘self-reflection’, better illustrating the internal reflection process required of the student when planning sble integration and design. although no consensus was achieved regarding the inclusion of self-reflection in all sbles, preparing students with problem-solving, teamwork, reasoning and reflection skills is essential when taking the 4ir into account.[1] self-reflection is an invaluable attribute, as students are expected to identify their professional and personal shortcomings, and subsequently plan and adapt to address these shortcomings. 6 month 20xx, vol. x, no. x ajhpe research conclusion meticulous planning is crucial prior to integrating simulation in a programme, in order to identify simulation-based goals and allow for effective decisionmaking and resource allocation. planning simulation integration should be done in accordance with resource availability, desired competencies, learning outcomes and consideration of both institutional and student needs. a definite need for educator competency in both the development and delivery of the programme, especially debriefing methods, has to be emphasised to achieve optimal student learning. non-standardised terminologies used in sbe, the varied roles sa educators are required to fulfil in relation to simulation and the lack of use of sbles for assessment purposes might have impacted on panel members’ interpretation of statements and opinions regarding what might be possible in a resourceconstrained environment. the authors recommend the further exploration of student role clarification with regard to their inclusion in the assessment process through peer assessment, provision of the necessary assessment training and focused training in both providing and receiving constructive feedback. lengthy statements populated the delphi survey, which might have been difficult to respond to. the authors suggest that to obtain diverse opinions, pilot studies should include at least two to three delphi survey experts. furthermore, we advise that delphi piloting should also include piloting of the feedback process, to ensure the optimal use of the delphi methodology. the covid-19 pandemic has led to a drastic change in delivering healthcare training, and negatively impacted the clinical training platform for undergraduate healthcare students. well-planned simulation integration may assist in ensuring the continued throughput of skilled graduates, and undergraduate healthcare students who are still able to work collaboratively and demonstrate adaptability to their fragmented learning environment. the planning theme of the conceptual framework enabled us to present a detailed means of addressing current healthcare education challenges in sa by means of simulation integration. declaration. the research for this study was done in partial fulfilment of the requirements for avdm’s phd (physiotherapy) degree at the university of the free state.acknowledgements. dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. author contributions. all authors contributed to the article. avdm developed the protocol and collected the data for the larger study from which this research emanated. avdm wrote the first draft of the manuscript; ryb and mjl contributed to the interpretation of the data and writing of the article; avdm made the final editorial adjustments to the manuscript; all authors approved the final version of the article. funding. national research foundation (nrf) (grant number ttk180418322303); health and welfare sector education and training authority (hwseta). conflicts of interest. none. 1. ferrel mn, ryan jj. the impact of covid-19 on medical education. cureus 2020;12(3):e7492. https://doi. org/10.7759/cureus.7492 2. maillacheruvu p, mcduff e. south africa’s return to primary care: the struggles and strides of the primary health care system. j global health 2014,4(2):10-14. https://www.ghjournal.org/south-africas-return-toprimary-care-the-struggles-and-strides-of-the-primary-health-care-system/ (accessed 1 september 2020). 3. academy of science of south africa. reconceptualising health professions education in south africa, 2018. assaf, 2018. http://research.assaf.org.za/handle/20.500.11911/95 (accessed 1 september 2020). 4. basu d. diseases of public health importance in south africa. south afr j public health 2018;2(3):48. https:// doi.org/10.7196/shs.2018.v2.i3.72 5. phillips ac, mackintosh sf, bell a, johnston kn. developing physiotherapy student safety skills in readiness for clinical placement using standardised patients compared with peer-role play: a pilot non-randomised controlled trial. bmc med educ 2017;17(1):133. https://doi.org/10.1186/s12909-017-0973-5 6. allen s. deloitte insights: 2020 global health care outlook. laying a foundation for the future. london: deloitte development llc, 2020. https://documents.deloitte.com/insights/2020globalhealthcareoutlook (accessed 1 september 2020). 7. singh rj. current trends and challenges in south african higher education. s afr j higher educ 2015;29(3):17. https://doi.org/10.20853/29-3-494 8. mekoa i. challenges facing higher education in south africa: a change from apartheid education to democratic education. afr renaissance 2018;15(2):227-246. https://doi.org/10.31920/2516-5305/2018/ v15n2a11 9. johnston cl, wilson jc, wakely l, walmsley s, newstead cj. simulation as a component of introductory physiotherapy clinical placements. n z j physiother 2018;46(3):95-104. https://doi.org/10.15619/ nzjp/46.3.02 10. wright a, moss p, dennis dm, et  al. the influence of a full-time, immersive simulation-based clinical placement on physiotherapy student confidence during the transition to clinical practice. adv simul 2018;3(1):3. https://doi.org/10.1186/s41077-018-0062-9 11. lopreiato jo (ed). healthcare simulation dictionary. 2016. https://www.sesam-web.org/media/documents/ sim-dictionary1.pdf (accessed 8 september 2020). 12. mcgaghie wc, harris ib. learning theory foundations of simulation-based mastery learning. simul healthc 2018;13(3s suppl 1):s15-s20. https://doi.org/10.1097/sih.0000000000000279 13. kneebone r, nestel d, bello f. learning in a simulated environment. in: dent ja, harden rm, hunt d (eds.). a practical guide for medical teachers. 5th ed. london: elsevier, 2017:92-100. 14. thurling ch. the design and development of a programme for simulation best practices in south african nursing education institutions. phd thesis. johannesburg: university of the witwatersrand, 2017. http:// wiredspace.wits.ac.za/handle/10539/23150 (accessed 8 september 2020). 15. motola i, devine la, chung hs, sullivan je, issenberg sb. simulation in healthcare education: a best evidence practical guide. amee guide no. 82. med teach 2013;35(10):e1511-e1530. https://doi.org/10.31 09/0142159x.2013.818632 16. chung hs, issenberg bs, phrampus p, et  al. international collaborative faculty development program on simulation-based healthcare education: a report on its successes and challenges. korean j med educ 2012;24(4):319-327. https://doi.org/10.3946/kjme.2012.24.4.319 17. avella jr. delphi panels: research design, procedures, advantages, and challenges. int j doct stud 2016;11:305-321. https://doi.org/10.28945/3561 18. hallowell mr. techniques to minimise bias when using the delphi method to quantify construction safety and health risks. paper presented at the construction research congress, seattle, washington, usa, 5 7 april, 2009. https://ascelibrary.org/doi/10.1061/41020%28339%29151 (accessed 8 september 2020). 19. slade sc, dionne ce, underwood m, et  al. consensus on exercise reporting template (cert): modified delphi study. phys ther 2016;96(10):1514-1524. https://doi.org/10.2522/ptj.20150668 20. khamis nn, satava rm, alnassar sa, kern de. a stepwise model for simulation-based curriculum development for clinical skills, a modification of the six-step approach. surg endosc 2016;30(1):279-287. https://doi.org/10.1007/s00464-015-4206-x 21. spies c. a strategy for meaningful simulation learning experiences in a postgraduate paediatric nursing programme. phd thesis. bloemfontein: university of the free state, 2016. https://scholar.ufs.ac.za/ handle/11660/4803 (accessed 8 september 2020). 22. cheng a, eppich w, sawye t, grant v. debriefing: the state of the art and science in healthcare simulation. in: nestel d, kelly m, jolly b, watson m (eds.). healthcare simulation education. new york: wiley blackwell, 2018:158-164. 23. chiniara g, cole g, brisbin k, et al. simulation in healthcare: a taxonomy and a conceptual framework for instructional design and media selection. med teach 2013;35(8):e1380-e1395. https://doi.org/10.3109/0142 159x.2012.733451 24. viggers s, østergaard d, dieckmann p. how to include medical students in your healthcare simulation centre workforce. adv simul 2020;5:1. https://doi.org/10.1186/s41077-019-0117-6 25. association for simulated practice in healthcare. simulation-based education in healthcare: aspih standards framework and guidance. aspih, 2016. https://aspih.org.uk/standards-framework-for-sbe/ (accessed 8 september 2020). 26. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9):s63-s67. 27. swart r, duys r, hauser, nd. sass: south african simulation survey – a review of simulation-based education. south afr j anaesth analg 2019;25(4):12-20. accepted 1 september 2021. https://www.ghjournal.org/south-africas-return-to-primary-care-the-struggles-and-strides-of-the-primary-health-care-system/ https://www.ghjournal.org/south-africas-return-to-primary-care-the-struggles-and-strides-of-the-primary-health-care-system/ https://documents.deloitte.com/insights/2020globalhealthcareoutlook https://doi.org/10.20853/29-3-494 http://dx.doi.org/10.7196/07294.937.98x http://wiredspace.wits.ac.za/handle/10539/23150 http://wiredspace.wits.ac.za/handle/10539/23150 https://doi.org/10.28945/3561 130 october 2020, vol. 12, no. 3 ajhpe research the lack of attention to geriatric care training in health professions curricula is concerning given the rapid increase in the number of people aged ≥60 years in south africa (sa).[1] most older adults in sa access health services at primary care level. nursing and medical graduates who are at the forefront of primary care services must be prepared to care for the increasing number of older adults needing care for chronic and age-related health conditions. however, studies indicate that the level of primary care provided to older adults in sa is inadequate, due to a lack of appropriate training of health professionals.[2,3] older adults are prone to multiple health conditions, and thus require co-ordinated care to preserve function and improve their quality of life.[4] reports of polypharmacy and adverse drug reactions in elderly patients are ascribed to fragmented and inappropriate management of older adults.[5] the world health organization highlights the need for greater interdisciplinary team skills among primary care providers to improve the care of older adults.[6] while interprofessional collaboration and care are inherent in general nursing practice, there is little inclusion of interprofessional education (ipe) within nursing education to prepare graduates to provide co-ordinated care to older adults.[7] it is therefore critical that geriatric care training be included in all undergraduate (ug) health professions curricula, and that training includes ipe. ipe occurs ‘when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes’.[8] such a collaborative approach has the potential to reduce healthcare costs and care dependencies in the aged. despite the evident need for geriatric care training of nurses in sa, the sa nursing council has removed specialist gerontology from nursing curricula. gerontology and geriatrics has also been neglected in undergraduate health professions education worldwide, and in sub-saharan africa in particular.[9] furthermore, nursing and medical undergraduate curricula in sa are developed and implemented independently of each other. it is therefore unclear whether these programmes adequately equip graduates to care for older adults as part of a multidisciplinary team in primary care. a situational analysis was therefore required to identify the strengths, weaknesses, opportunities and threats of current nursing and medical curricula at the university of kwazulu-natal (ukzn), sa, in preparing graduates to care for older adults. this study aimed to analyse teaching and assessment of geriatric topics in the ug nursing and medical curricula at the ukzn, and explore potential opportunities to enhance ipe relevant to the care of older adults. methods this mixed-methods study was conducted by a document review of module handbooks, study guides and an electronic curriculum platform used for the ug medical programme. in addition, semi-structured interviews were conducted with key informants (n=5) involved in teaching and curriculum development. data relating to each geriatric curriculum were analysed according to geriatric content, teaching methods and assessment per year background. the population in south africa is ageing rapidly. however, health professionals are reportedly unprepared to provide quality care for the elderly population. a situational analysis of curricula is required to identify the extent to which current training addresses the needs of elderly populations. objectives. to investigate the undergraduate medical and nursing curricula at a south african university regarding geriatric care training, and explore possible learning opportunities to enhance health professions education in geriatric care. methods. this descriptive exploratory study was conducted through document review and semi-structured interviews with health professions educators. results. in both curricula, a problem-based learning approach was combined with classroom and bedside teaching. a wide range of geriatric topics was covered in each programme, four of which were common to both, i.e. falls, urinary incontinence, dementia and chronic non-communicable diseases. nursing students were exposed to geriatric patients in multiple settings, while medical students saw geriatric patients mainly in hospitals and community clinics. geriatric content in both programmes was integrated into other modules, and there was no independent assessment of geriatric competencies. conclusion. although a multitude of geriatric learning objectives were included in both nursing and medical training programmes, there was limited coverage and a lack of discrete assessment in this field. opportunities to enhance the current curricula include discrete assessment of geriatric care competencies, and increased interprofessional education. however, faculty development and additional resources would be required in both programmes. afr j health professions educ 2020;12(3):130-133. https://doi.org/10.7196/ajhpe.2020.v12i3.1349 a review of geriatric care training in the undergraduate nursing and medical curricula at the university of kwazulu-natal, south africa k naidoo,1 mb chb, mcfp (sa); f waggie,2 phd; j m van wyk,3 phd 1 discipline of family medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 interprofessional education unit, university of the western cape, cape town, south africa 3 department of clinical and professional practice, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: k naidoo (naidook7@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2020, vol. 12, no. 3 ajhpe 131 research of study (tables 1 and 2). content and thematic analyses were conducted. ethical approval was obtained from the ukzn biomedical research ethics committee (ref. no. be287/18) prior to data collection between july and september 2019. both undergraduate nursing and medical degrees are offered in the college of health sciences at the ukzn. the programme for the nursing degree (bn) is 4 years long, and the medical degree (mb chb) 6 years. results health professions educators representing both curricula were found to be cognisant of the increasing number of older adults requiring primary healthcare services, and agreed on the importance of training students to care for older adults. however, they expressed concerns about increasing the teaching on geriatric care owing to time constraints of the programme and other priorities such as maternal and child health that have to be accommodated in the curriculum. two main themes relevant to geriatric care training emerged from interviews with participants. these were patient-centredness and exposure of students to patients in authentic settings. patient-centredness refers to understanding the patient as a whole person rather than merely a person with an illness.[10] this was explicitly addressed in the nursing but not the medical curriculum: ‘we have to teach them to be patient-centred. however, compassion fatigue is so common.’ (nurse educator, >10 years’ teaching experience) ‘they also do preventive and promotive health with the elderly, talking to them about diet, exercise, loneliness.’ (nurse educator, >20 years teaching experience) participants representing both programmes reflected that patient-centred care for older adults could be undermined by the negative influence of role models during clinical training: ‘i think that they see from other sisters or doctors that the old are left in the corners to die.’ (nurse educator, >15 years’ teaching experience) an analysis of curriculum documents revealed that geriatric teaching in both disciplines involved a problem-based learning (pbl) approach (tables 1 and 2). there is early exposure of students to paper-based cases, followed up with classroom and bedside teaching in later years of study. both the nursing and medical curricula include teaching on a wide range of geriatric topics, of which four were common to both programmes, i.e. falls, dementia, urinary incontinence and chronic non-communicable diseases (fig. 1). nursing students had clinical exposure to geriatric patients in multiple settings, such as in the community, primary care, residential facilities table 1. geriatric teaching and learning in undergraduate nursing programme year of study curriculum components details assessment 1 case-based discussions with pbl approach 4 × patient studies covering falls, nutrition, wound care, urinary incontinence, bereavement and palliative care, pain management, activities of daily living written tests, short questions residential care nursing 1 week allocation to residential care; history-taking and basic nursing care written tests 2 community evaluation no geriatric component 3 clinical geriatric experience allocation to wards, skills and procedures triple jump, osce, written test 4 psychogeriatrics 6 weeks of mental health block spent with residential and ambulatory geriatric patients with mental health conditions reflective journals, written cases, triple jump, osce 4 primary healthcare 40 hours in clinics – exposure to older patients with chronic illnesses reflective journals, written cases, triple jump, osce pbl = problem-based learning; triple jump = three-stage method of assessment used in pbl; osce = objective structured clinical examination. table 2. geriatric teaching and learning in undergraduate medical programme year of study curriculum components details assessment 1 principles of geriatrics 1-hour lecture mcq 2 none none 3 lecture + case-based discussions with pbl approach 12 lectures; case discussions covering prescribing for the elderly, legal and ethical issues of ageing, physiological changes of ageing, dementia, comprehensive geriatric assessment, urinary incontinence, falls, infections, frailty, confusion, syncope and osteoporosis mcq, ospe 4 lectures + ward rotations lectures; clinical tutorials over 12 weeks covering dementia, comprehensive geriatric assessment, falls, urinary incontinence, infections, frailty, confusion, syncope and osteoporosis portfolio, dosce 5 ward rotations 6 weeks of clinical experience with inpatients, 1 week of hospice attachment; bedside teaching mcq, long case 6 ward rotations 7 weeks of clinical experience with inpatients mcq, dosce, portfolio, long case pbl = problem-based learning; mcq = multiple choice questions; ospe = objective structured practical examination; dosce = directly observed clinical assessment. 132 october 2020, vol. 12, no. 3 ajhpe research and hospitals, whereas medical students saw geriatric patients mainly in hospitals and community clinics. the limited exposure of medical students to older adults in the community was acknowledged as a limitation of the medical curriculum: ‘they need to see more ambulatory patients, with multiple conditions, and to be able to communicate with these patients.’ (medical educator, >20 years’ teaching experience) teaching and assessment of geriatric content in both programmes was integrated into other modules, with no sub-minima applied in the assessment of geriatric topics. ipe was not included in either programme. participants perceived that the large numbers of students enrolled in the already crowded curricula would hinder the implementation of ipe. ‘being problem-based, and with big classes, we can’t address everything.’ (nurse educator, >15 years’ teaching experience) health professions educators in both programmes said that they were not only inadequately prepared, but also inadequately resourced to implement ipe or to expand current geriatric teaching. discussion this study highlighted the strengths and weaknesses of current geriatric training of nursing and medical students. both curricula include teaching and learning on a range of geriatric topics, unlike many other training institutions in sub-saharan africa.[11] however, there were discrepancies between the geriatric topics covered in each curriculum. a notable finding of the study was the absence of collaboration with other health disciplines in the delivery of geriatric care training. this lack of collaboration and of a common foundation of geriatric conditions raises concerns not only about possible curricular gaps, but also about the ability of nursing and medical graduates to co-manage elderly patients in a patient-centred and efficient manner. there is an evident need for relevant stakeholders, including community representatives, to reach a consensus on the minimum core competencies in geriatric care for health professionals. the pbl approach used in both curricula provides an effective means of educating students on core geriatric topics, and of addressing psychosocial and teamwork issues relevant to the care of older adults. multiple common geriatric topics were identified in this study that involve management by a multidisciplinary team, such as dementia care. however, teaching on these topics did not include input from other disciplines. models of ipe that include case-based pbl taught by educators from different disciplines such as nursing and medicine are feasible options to introduce ipe in this institution.[12] however, health professions educators in both disciplines would need faculty development in order to effectively develop and implement ipe for geriatric care training. although there is some exposure to older adults in the community, the programme would benefit from greater exposure to community-dwelling older adults, as this has been shown to improve patient-centredness and attitudes of students towards older adults.[13] most older adults in sa are cared for at primary care level or in the community, and require professional health services that include preventive and promotive health services. training should therefore occur in these authentic settings to prepare graduates to care for the majority of older adults in sa. the lack of independent assessment of geriatric topics makes it difficult to ascertain whether graduates actually possess the necessary knowledge, skills and attitudes to care for older adults. further investigation is required into graduate competencies in geriatric care. threats to geriatric care training in both programmes included time constraints and lack of confidence of educators to implement ipe. one suggestion to improve students’ geriatric care competencies was to maximise the learning opportunities in facilities where interprofessional collaboration was practised. unfortunately, this model of care was not practised at most of the clinical training sites. this study highlighted the need to expand current teaching and assessment relevant to the care of older adults in each discipline, and to ensure greater concordance between nursing and medical training programmes regarding primary care for older adults. this will enable graduates to work together in functional teams at primary care level to provide co-ordinated and quality care to older adults. further investigation is required into the geriatric curricula of other health professions programmes in the college, such as occupational therapists and physiotherapists. conclusion there are opportunities to maximise student learning and readiness to co-manage older patients in primary healthcare facilities by ensuring that students learn together in interprofessional teams. however, faculty development is required to upskill educators on ipe. variable coverage of geriatric topics in each programme highlighted the need for consensus on the minimum geriatric core competencies for health professionals. declaration. none. acknowledgements. the authors would like to acknowledge the sub-saharan africa-faimer regional institute (safri) for their encouragement of this study. falls dementia urinary incontinence chronic ncds prescribing drugs frailty confusion ethics osteoporosis palliative care infections wound care adl residential care pain management cva nursing medicine fig. 1. domains of geriatric care in the medical and nursing curricula. (adl  = activities of daily living; cva = cerebrovascular accident; ncds = non-communicable diseases.) october 2020, vol. 12, no. 3 ajhpe 133 research author contributions. kn conceptualised and undertook the study under the supervision of jvw and fw. kn prepared the manuscript and jvw and fw reviewed and approved the final article. funding. none. conflicts of interest. none 1. day c, ndlovu n, gray a. health and related indicators 2018. s afr health rev 2018(1):139-250. 2. kalula sz. the quality of health care for older persons in south africa: is there quality care? conference paper. esr review: econ soc rights s afr 2011;12(1):22-25. 3. abudu-birresborn d, mccleary l, puts m, yakong v, cranley l. preparing nurses and nursing students to care for older adults in lower and middle-income countries: a scoping review. int j nursing stud 2019;92:121-134. https://doi.org/10.1016/j.ijnurstu.2019.01.018 4. aboderin ia, beard jr. older people’s health in sub-saharan africa. lancet 2015;385(9968):e9-e11. https://doi. org/10.1016/s0140-6736(14)61602-0 5. saka sa, oosthuizen f, nlooto m. potential inappropriate prescribing and associated factors among older persons in nigeria and south africa. int j clin pharm 2019;41(1):207-214. https://doi.org/10.21203/rs.2.15400/v1 6. world health organization. interprofessional collaborative practice in primary health care: nursing and midwifery perspectives. geneva: who, 2013. 7. maree c, van wyk h. interprofessional health education to improve collaboration in the south african context: a realist view. trends nursing 2016;3(1):1-17. https://doi.org/10.14804/3-1-41 8. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. http://whqlibdoc.who.int/hq/2010/who_hrh_hpn_10.3_eng.pdf (accessed 17 march 2020). 9. tanyi pl, pelser a. the missing link: finding space for gerontology content into university curricula in south africa. gerontol geriatr edu 2019;40(4):491-507. https://doi.org/10.1080/02701960.2018.1428579 10. balint e. the possibilities of patient-centered medicine. j royal coll gen pract 1969;17(82):269. 11. frost l, liddie navarro a, et al. care of the elderly: survey of teaching in an ageing sub-saharan africa. gerontol geriatr educ 2015;36(1):14-29. https://doi.org/10.1080/02701960.2014.925886 12. thompson s, metcalfe k, boncey k, et al. interprofessional education in geriatric medicine: towards best practice. a controlled before-after study of medical and nursing students. bmj open 2020;10(1):1-14. http://doi.org/10.1136/ bmjopen-2017-018041 13. mendoza de la garza m, tieu c, schroeder d, lowe k, tung e. evaluation of the impact of a senior mentor program on medical students’ geriatric knowledge and attitudes toward older adults. gerontol geriatr educ 2018;39(3):316-325. https://doi.org/10.1080/02701960.2018.1484736 accepted 19 june 2020. https://doi.org/10.1016/j.ijnurstu.2019.01.018 https://doi.org/10.1016/s0140-6736(14)61602-0 https://doi.org/10.1016/s0140-6736(14)61602-0 https://doi.org/10.21203/rs.2.15400/v1 https://doi.org/10.14804/3-1-41 http://whqlibdoc.who.int/hq/2010/who_hrh_hpn_10.3_eng.pdf https://doi.org/10.1080/02701960.2018.1428579 https://doi.org/10.1080/02701960.2014.925886 http://doi.org/10.1136/bmjopen-2017-018041 http://doi.org/10.1136/bmjopen-2017-018041 https://doi.org/10.1080/02701960.2018.1484736 september 2021, vol. 13, no. 3 ajhpe 203 research why was the idea necessary? the covid-19 pandemic continues to dominate the globe, driving transformation in our daily work and home environments. in south africa (sa), health profession educators were forced to implement innovative and creative changes to teaching and learning practices in order to complete the 2020 academic year and deliver graduates amidst a global pandemic. the school of pharmacy (sop) at the university of the western cape (uwc) is the only provider of pharmacy education in the western cape province of sa. close collaboration between uwc and local public sector healthcare providers facilitates work-based learning for our undergraduate pharmacy students. this partnership ensures that our graduates are well prepared to become pharmacists who will make significant contributions to the healthcare needs of the communities they serve. the patient care experience (pace) programme is a 30-credit module, which provides finalyear bpharm students with direct patient-focused experiences in the clinical setting. the primary goal of the pace programme is to provide students with real-life opportunities to practise and develop pharmaceutical care skills. these skills include identifying, solving and preventing medicationrelated problems in patients with commonly encountered conditions in the context of sa’s public healthcare sector. prior to 2020, final-year pharmacy students were exposed to patient care in various clinical training platforms over a period of 10 weeks. two rotations of 5 weeks each were completed in a hospital and a community clinic setting respectively. various tasks, activities and assignments were completed which focused on the optimisation of pharmaceutical care provided by pharmacists.[1,2] these clinical activities took place under the guidance and supervision of sop clinical staff and specific on-site preceptors (pharmacists), who guided learning and served as mentors for professional development of the students. however, in 2020, experiential learning in the workplace could not take place as scheduled. healthcare facilities restricted access to essential staff only, in order to reduce the spread of the sars-cov-2 virus, and the increased workload meant facility staff did not have the capacity to tutor university students. the sop clinical staff were therefore compelled to utilise the digital arena to create live and asynchronous remote clinical learning activities as a substitute for traditional facility-based clinical training. the switch to emergency remote teaching[3,4] highlighted inequalities in terms of access to the internet, connectivity issues, and device and data availability. many students experienced major challenges in the first few months of the more restrictive levels of lockdown. what was tried and tested? hands-on clinical training, with the focus on pharmaceutical care, had to be extensively re-imagined and re-developed in order to provide ‘real-world’ simulated case studies, activities and assignments in a virtual clinical setting similar to the working environment of a clinical pharmacist. the revised pace programme was converted to a 9-week online course consisting of 1 week of orientation and 8 weeks of patient cases covering a variety of clinical conditions. the online course was then followed by 2 weeks of on-site healthcare facility-based experience. the electronic institutional learning management system used by uwc is the ikamva platform (sakai, apereo foundation, usa) for teaching, assessment and communication with students. simulated patient cases were created on a weekly basis, using the online lessons function of ikamva. these lessons incorporated text, audio-enhanced lecture slides (powerpoint), simulated patient medical folders, supporting videos and voice recordings (conversations between pharmacist and patient and/ or prescriber). these weekly patient cases presented in ikamva lessons functioned like an internet webpage. the sop clinical staff would develop and upload all the information relevant to each case on a single page to create an intuitive system that students could easily navigate through at their own pace. various individual and group activities designed to assist learning had to be completed by the end of each week. successful achievement of learning outcomes was evaluated from student submissions of completed patient-care plans (identifying medicine-related problems, medicine therapy recommendations, safety and efficacy monitoring) and completion of online quizzes. a vital component of the pace programme focuses on communication skills in the healthcare setting. sbar (situation, background, assessment, recommendation) was identified as a reliable and approved communication tool to reduce medication errors and to improve communication in the healthcare setting and ultimately improve patient safety.[5] this is incorporated into the pace programme to strengthen communication among healthcare professionals. during the 2020 programme, our students were provided with different simulated case studies. each student then prepared a 5-minute video during which the case was presented using the sbar approach. the video-recorded case review was uploaded onto the ikamva site for assessment by the relevant sop clinical staff member. the case review assessment was evaluated using a standardised scoring rubric that assessed the students’ actual knowledge and understanding, as well as their ability to communicate crucial medication-related issues from the case at hand. a virtual live oral assessment was subsequently conducted by the relevant staff member with the individual student, using google meet or whatsapp video chat. an additional intervention that was preventative in nature was the implementation of an online mentorship programme. each sop clinical staff member was assigned a group of 16 or 17 students to mentor. the reflection on remote teaching and learning of a final-year bpharm clinical training module during a pandemic m viljoen, bpharm, msc, phd; r coetzee, bpharm, mpharm, pharmd; n hoffman, bpharm; j mccartney, msc, dippharm, phd; e upton, bpharm, mpharm; m van huyssteen, bpharm, msc, phd school of pharmacy, department of pharmacology and clinical pharmacy, faculty of natural sciences, university of the western cape, cape town, south africa corresponding author: m viljoen (mviljoen@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:mviljoen@uwc.ac.za 204 september 2021, vol. 13, no. 3 ajhpe research purpose of mentorship was to engage with the students on a regular basis, identify any concerns or issues, discuss their ongoing experiences, provide suggestions and support for students and refer students for further support if necessary. this was done by scheduling virtual informal ‘chat’ sessions on a weekly or fortnightly basis. students could suggest topics for discussion and the mentor would provide support, tips and guidance. these sessions were not compulsory, so student attendance was guided by self-need and interest. what will be kept in the pace programme? from the educators’ perspective, invaluable new skills were rapidly learnt and implemented in order to transform the pace module to an online format. the nature of the workload was very different, time-consuming and complex, in that we were developing new simulated cases and resources. however, this turned out to be beneficial on different levels, and will now complement and enhance the student learning experience in future years. the successful use of a variety of electronic resources established that remote teaching and learning is feasible but everyone agreed that there is still no substitute for real-life experience. the initial 9 weeks of online orientation and simulated clinical exposure prepared the pharmacy students for the drastically shortened on-site clinical rotation time of 2 weeks in health facilities, as illustrated by the students’ feedback obtained from the module evaluation at the end of the semester. ‘it allows for on-site learning which is valuable. the cases we dealt with in the weeks really prepared me for the hospital rotation. the assignments and tasks are in alignment with the course objectives. it was well organised and i think it’s objectives were strongly met.’ ‘i feel that our knowledge is really tested and we learn more on site than in class and it is exciting to be able to apply the knowledge we have acquired from books.’ ‘the only weakness was the short time spent in the facility.’ ‘unfortunately because of covid-19 we only had 2 weeks to complete the pace rotation so it felt a bit overwhelming that everything was packed in the 2 weeks.’ the majority of student feedback comments were positive. it seemed as if the online component prepared them well for the actual clinical exposure, which was an added strength and a byproduct of the pandemic restrictions. it was evident from the collective experiences of the sop clinical staff that the ikamva platform was pivotal in creating an intuitive learning environment to set up clinical case scenarios as electronic lessons, to incorporate voice notes (simulated between patient and pharmacist or pharmacist and clinician), and to use videos made by students as part of their case presentations to enhance the concepts of pharmaceutical care. these methods can most likely also aid in developing clinical case studies which closely mimic practice within the sa setting, and can be introduced to secondand third-year pharmacy students as authentic and valid preclinical preparation for the pace programme in their final year. online assessments, conducted using question pools set up on the ikamva platform, proved to be robust when incorporating the randomisation function and ensuring large numbers of questions per section. the majority of the final-year pharmacy students actively engaged online, taking responsibility for their own learning. students described how these changes richly enhanced their learning experience despite the educational challenges associated with the switch to remote teaching as a result of the covid-19 pandemic. ‘it’s draining, but worth it.’ ‘this course is very transformative. it collates everything we have done in all 4 years of undergrad and even broadens our classroom knowledge.’ ‘very practical, very realistic to our scope of practice and the lecturers did a great job in assisting us with the content and patient cases.’ ‘the efforts from facilitators and staff was impeccable. we felt supported and an environment that encouraged self learning, open discussion, built confidence and reasoning skills.’ the year of 2020 will be imprinted in our memories as a time of anxiety, fear, desperation and uncertainty. however, 2020 will also be remembered as a time of great reflection, innovation, perseverance and the realisation that teaching and learning can be done differently and effectively and still achieve the desired outcomes and positive experiences within the sa tertiary educational system. declaration. none. acknowledgements. appreciation to all bpharm final-year students of 2020 who provided input in the evaluation of the pace programme. the specific students and staff members provided the authors with written permission for photos, videos and artefacts to be included in the manuscript submission as part of the video excerpt. author contributions. equal contributions. funding. none. conflicts of interest. the authors, as sop clinical staff, were all lecturers involved in the 2020 pace programme. evidence of innovation 1. van huyssteen m, bheekie a, coetzee r, et al. preceptor reflections on the community health clinical rotation for fourth year pharmacy students at the university of the western cape. s afr pharm j 2019; 86(1):53-56. http://www.sapj.co.za/index.php/sapj/article/view/2675 (accessed 22 february 2021). 2. mccartney j, coetzee r, salasa m, de beer c. collaborative practice: can work based learning benefit both students and healthcare professionals? s afr pharm j 2020; 87(2):35-37. http://www.sapj.co.za/index.php/ sapj/article/view/2819 (accessed 22 february 2021). 3. hodges c, moore s, lockee b, trust t, bond ma. the difference between emergency remote teaching and online learning. 27 march 2020 under license from creative commons by-nc 4.0 international license. https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-onlinelearning (accessed 22 february 2021). 4. council of higher education. quality assurance guidelines for emergency remote teaching and learning and assessment during the covid-19 pandemic in 2020. https://firebasestorage.googleapis.com/v0/b/ che2020-c5efd.appspot.com/o/website%2fq0q2svsligf1.pdf ?alt=media&token=a9091867-a851-4bc5-a26d50e95cfffa84 (accessed 22 february 2021). 5. world health organization. communication during patient hand-overs. who collaborating centre for patient safety solutions, 1 (3), may 2007. https://cdn.who.int/media/docs/default-source/integratedhealth-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers. pdf ?sfvrsn=7a54c664_4&ua=1 (accessed 22 february 2021). accepted 22 april 2021. afr j health professions educ 2021;13(3):203-204. https://doi.org/10.7196/ajhpe.2021.v13i3.1498 http://www.sapj.co.za/index.php/sapj/article/view/2675 http://www.sapj.co.za/index.php/sapj/article/view/2819 http://www.sapj.co.za/index.php/sapj/article/view/2819 https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning https://firebasestorage.googleapis.com/v0/b/che2020-c5efd.appspot.com/o/website%2fq0q2svsligf1.pdf?alt=media&token=a9091867-a851-4bc5-a26d-50e95cfffa84 https://firebasestorage.googleapis.com/v0/b/che2020-c5efd.appspot.com/o/website%2fq0q2svsligf1.pdf?alt=media&token=a9091867-a851-4bc5-a26d-50e95cfffa84 https://firebasestorage.googleapis.com/v0/b/che2020-c5efd.appspot.com/o/website%2fq0q2svsligf1.pdf?alt=media&token=a9091867-a851-4bc5-a26d-50e95cfffa84 https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers.pdf?sfvrsn=7a54c664_4&ua=1 https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers.pdf?sfvrsn=7a54c664_4&ua=1 https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers.pdf?sfvrsn=7a54c664_4&ua=1 https://doi.org/10.7196/ajhpe.2021.v13i3.1498 june 2022, vol. 14, no. 2 ajhpe 49 research community members play a central role in engaged learning and teaching approaches that could include pedagogies such as community-based education (cbe), and interprofessional education (ipe).[1] cbe refers to learning activities that use the community as a learning environment, in which students, facilitators, members of the community, and other  stakeholders actively engage in and throughout the educational experience.[2] the community, in cbe, is therefore the anchor that grounds this learning and teaching approach. ipe ‘occurs when two or more professionals learn about, from and with each other to enable effective collaboration and improve health outcomes’.[3] a south african faculty of health sciences established a rural ipe initiative that included 17 lifestyle-group sessions per year. the aim of these sessions is to facilitate collaboration between community members diagnosed with diabetes mellitus and health professions ipe student groups (dietetic, occupational therapy, physiotherapy, medicine, nursing and optometry students). the outcomes are to share health information among participants, equip rural communities with essential competencies towards re-futuring’ of healthcare, and foster accountable lifestyle practices. the two hours-a-week lifestyle-group sessions included a variety of topics proposed by the lifestyle group members, as well as collaborative activities prepared by each ipe student group. it is therefore vital to acknowledge communities’ (lifestyle-groups) central role in this learning approach, and to determine their relational experiences with interprofessional students in a rural health initiative. literature related to relational experiences is primarily found in the realm of psychology, where it revolves around relationship therapy[4] and relational theory.[5] sontag[6] describes relational experience as relating to the quality, purpose and intensity of relationships. dutton and heaphy’s[7] conceptualisation of high-quality relations focuses on three subjective relational experiences – positive regard, mutuality and vitality. positive regard is the experience of an individual in positive relationships with other individuals, and being accepted and recognised by others.[8,9] individuals experience mutuality when they sense they are actively participating in a positive relationship. mutuality refers to a change in the connection derived from mutual vulnerability, empathy and responsiveness. relational vitality refers to feelings of positive stimulation by others and a heightened sense of positive energy.[7] subjective relational experiences can lead to higher levels of self-efficacy; it can facilitate engagement and innovation, as individuals exhibit particular behaviours when they are cognitively vigilant and emotionally connected to others.[10] common-interest groups that actively involve community members as partners in their own health and have a transformative effect on those communities is a consequence of these commonalities.[11] to facilitate participation by community members from different cultural, socio-economic and political backgrounds, roos[12] states that they might  communicate their relational experiences better visually. research using visual projective data collection methods, such as the mmogo method,  is intended to deepen understanding of the social, cultural and contextual aspects underlying human behaviour[13-15] and, in the present study, relational experiences. mmogo (a setswana word) refers to interpersonal relatedness, togetherness, co-construction, and/or background. a south african faculty of health sciences created a forum for the community to voice their relational experiences with interprofessional students through visual projections. no other studies that explore such experiences using the mmogo method could be located. objective. to gain an understanding of the relational experiences of community members participating in lifestyle-groups as part of a rural health initiative with interprofessional student groups. methods. the mmogo method is a qualitative, structured, observation technique. participants constructed visual projections representing specific relationships. thereafter, during a group discussion, participants explained the meaning of their projections. the visual data were analysed according to their literal presentation and subjective, symbolic meaning. a thematic analysis was used for the transcribed data. results. thirteen of the 24 visual projections were of a quality that allowed visual analysis; all 24 members participated in the discussions. light was identified as an overarching theme to represent the community-student interaction. sub-themes and categories associated with light were healthier lifestyles (knowledge sharing, lifestyle transformation, improved health outcomes), solidarity (reciprocity, collaboration, person centredness, multidimensional approach) and affirmation (gratitude and acceptance). conclusion. though some statements by participants related to health education as opposed to health dialogue highlighted areas requiring improvement, the findings correlated with the outcomes prescribed for students by this rural health initiative. emotional connections in relational experiences could facilitate higher levels of self-efficacy in communities. the question is whether a stronger emphasis on health dialogue can be a catalyst for improved self-efficacy. afr j health professions educ 2022;14(2):49-54. https://doi.org/10.7196/ajhpe.2022.v14i2.1531 relational experiences of community members participating in a rural health initiative with interprofessional students r botha, phd; a joubert, phd; h morgan, boccther; m wilmot, boccther office of community-based education, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: r botha (botharw@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1531 mailto:botharw@ufs.ac.za 50 june 2022, vol. 14, no. 2 ajhpe research interpersonal threads.[15] personal projections are the emotional experiences that can be conscious at the personal level: what people know; sensory perceptions; and what involuntarily influences people’s thoughts, feelings, memories and actions.[16] collective-level experiences are common and unique to groups owing to heredity and socialisation.[17] personal and collective experiences are produced within culture and society.[18] research that involve communities, conventionally uses questionnaires, interviews and focus groups. a study associated with relational experiences used interviews and semi-structured guides to assess community perspectives of their student engagement.[19] community members were included in developing the interventions. language barriers, community protocols and community fatigue influenced the student-community interaction. another example of research incorporating relational experiences was a study undertaken by van schalkwyk and marais.[20] their research endeavoured to describe educators’ relational experiences with learners with fetal alcohol spectrum disorder. thematic analysis of semi-structured interviews and focus group data revealed that relational experiences are determined by educators’ practical knowledge of the effects of limited intellectual abilities and impaired social functioning (community characteristics) in the learning  environment (socio-economic factors). in both these studies, the authors allude to but do not extrapolate the characteristics of high-quality relational experiences. it was challenging to contextualise and define relational experiences in reference to a community-based interprofessional education initiative in a rural, primary healthcare environment, as no such studies were found. in the present study, the researchers investigated the relational experiences of community members participating in a rural health initiative with interprofessional student groups using visual projections. the findings of the study could enhance the faculty’s understanding of relational experiences and of the quality of engagement between lifestyle-group members and ipe student groups. this understanding of relational experiences could furthermore assist this faculty of health sciences to improve collaboration between lifestyle-group members and ipe student groups. purpose to gain an understanding of the relational experiences of community members participating in lifestyle-groups as part of a rural health initiative with interprofessional student groups. methods the meta-theoretical paradigm informing the mmogo method is constructionistic and interpretivistic, and adopts an onto-epistemological approach where ‘…the object and the measuring agencies (in this study referring to the visual projections) emerge from, rather than precede, the intraaction (with students) that produces them.’[12,21] it is proposed as a qualitative research methodology[16] for a narrative inquiry design. lifestyle-group members, constructing visual projections that signify a specific relationship, followed by the members elaborating on their representations during a facilitated group discussion, achieved this. the co-researchers additionally used open-ended questions such as ‘from where did the light come?’ and ‘are there others that agrees with him?’ to further prompt discussion.[12] the visual projections are created using malleable clay, beads of different sizes and colours, and dried twigs.[22] in the present study, the unit of analysis included members of two lifestyle-groups in two rural towns (n=50), of whom 24 volunteered to participate in the study. a co-researcher (a lifestyle-group facilitator) informed the lifestyle-groups about the research during their weekly meeting using information and informed consent forms available in english, afrikaans and sesotho (regional language). members who volunteered provided verbal and written consent for the discussion to be audio-recorded and their visual projections to be digitally photographed. data collection the health sciences research ethics committee approved the study (hsd2019/1786). two co-researchers conducted the sessions that were primarily conducted in the language of preference (afrikaans), while an interpreter translated to sesotho when necessary. the session started with an introduction, orientation and expectations related to the study. the participants’ rights were clarified and the rules of engagement were negotiated. participants were informed of their right to withdraw from the study at any time, without negative consequences. a co-researcher posed a research question: ‘create a picture using the clay and beads that displays your relationship with the students of health sciences’. participants were given one hour to construct the visual projections. on completion, participants explained the meaning of their visual projections, which was enriched through group discussion. interaction with other participants allowed time for shared experiences. a number was allocated to the visual projections and photographs were taken. data analysis two sources of data were obtained: visual data (photos), and textual data, consisting of verbatim transcriptions of recorded discussions,[14] which were translated to english. the researchers analysed the 24 visual projections according to the specific projection created and its relevance to the research question, the literal presentation and subjective, symbolic meaning. this analysis, guided by the participant group discussions and the quality of the projections, resulted in only 13 projections being included for the visual data analysis. the assumption underlying this procedure is that the visual projections are expressions of something not yet consciously recognised or conceptually formulated.[23] the researchers verified the verbatim transcripts. the textual data extrapolated from the verbatim transcripts of the 24 participants was explored using thematic analysis.[24] trustworthiness in the current study, the principles of trustworthiness – namely credibility, transferability, dependability and confirmability – were adhered to during collection, analysis and presentation of findings. a reliable and valid qualitative research methodology ensured trustworthiness. co-researchers addressed possible bias through applying a non-judgmental, respectful and non-partial approach towards participants during the research process. the group discussion allowed the participants’ voices to be heard, and the co-researchers could clarify and explore uncertainties. making use of investigator triangulation contributed to a reduction in bias.[25] results thirteen visual projections from two rural towns referred to as t and s were selected, based on their quality and alignment with the purpose of the study. findings from the visual data were correlated with the participants’ feedback on their created projections. the thematic analysis of participant narratives revealed an overarching theme, namely light, and june 2022, vol. 14, no. 2 ajhpe 51 research three sub-themes, namely healthier lifestyles, solidarity and affirmation. integration of the visual and textual data presented the different categories associated with the overarching theme and sub-themes, as shown in fig. 1. overarching theme the golden thread throughout the findings articulated into ‘light’ as the overarching theme. the overall positive feedback from participants regarding their engagement with students were expressed in a variety of visual projections, where all pointed to the experience as enlightening. the literal presentation and subjective, symbolic meanings of two visual projections in table  1, for example, support this finding (t2, t5). light was not only visualised, but also verbalised: ‘we received the light’ (t15), ‘and presented in other forms … if you look at the different colours, there is green and bling (symbolising students) … but here is black beads. here is a problem.’ (t11) participant s3 unpacked light further, by creating a visual projection of the source of light: cosmic elements. the engagement with different students (cosmic elements) was seen as a source of change and growth (light). the theory of causality infers newton’s third law of motion, simplified as cause and effect.[26] the presence of interprofessional student groups in the two rural towns and their involvement in the lifestyle-groups affected a variety of interconnected aspects of the community members’ lives. these aspects are illustrated by three sub-themes associated with light, namely healthier lifestyle, solidarity and affirmation. sub-theme 1: healthier lifestyle the literal presentation and subjective, symbolic meaning of the first sub-theme is presented in table 2. three other visual projections substantiate the identified sub-theme: • community mobilisation, through a collaborative gardening project, motivated members to become self-reliant and to adhere to a healthier lifestyle. (t6) • a lifestyle change was triggered through engagement with students. (t7) • the heart represents the passion and love that was ignited through interaction with students. the beads and the texture represents the change that happened. (t9) a healthier lifestyle was experienced by participants owing to the influence of collaborating with students in a variety of initiatives that enriched their individual and collective lives. the categories under healthier lifestyle include knowledge sharing, lifestyle transformation, improved health outcomes and self-reliance. a statement that was categorised as knowledge sharing was that ‘what they teach us individually, they must also teach other people in the community.’ (t9). participants t2 and t15 provided group input and stated: ‘we didn’t know how to control this thing [diabetes mellitus], we ate any old way, we ate everything, and anything, any time.’ the statement ‘so that we can know how we must live, how we should eat and how we should be.’ (t2) and echoed by t3 and t7, relates to lifestyle transformation. this was reiterated by the group input: ‘they brought changes to our lives.’ (t14, t15). improved health outcomes were declared by five participants (t2, t3, t4, t7, t9), using statements such as ‘now i feel that it’s right. now i know exactly how to manage it [diabetes mellitus]. like high blood pressure, foods you eat that are not right.’ (t2). this sentiment was also reflected by group input: ‘yes, now we know how to manage the thing in the right way.’ (t4,  t6, t14, t15). the category of self-reliance was expressed through similar statements: but we can only build the path, and the people in the community must then help each other. so, … when the students are no longer around, that those who remain behind in the community, that we still help each other. (t6, t9, s3). feedback from the group discussion was: ‘then we understand, and then we can achieve a great deal.’ (s4). knowledge sharing contributed to a lifestyle transformation that promoted self-reliance. participating in the lifestyle groups promoted particular behaviours, as members were cognitively vigilant and emotionally connected to others.[10] sub-theme 2: solidarity the literal presentation and subjective, symbolic meaning of solidarity is presented in table 3. the sub-theme of solidarity is justified by the  visual projections created by  five participants  (t3, t11, t15, s3, s5). overarching theme sub-themes healthier lifestyles solidarity light a�rmation knowledge sharing reciprocity gratitude lifestyle transformation collaboration acceptance improved health outcomes personcentredness self-reliance interprofressional approach categories fig. 1. thematic analysis of the visual and textual data. 52 june 2022, vol. 14, no. 2 ajhpe research table 1. visual projection of light (t2, t5) image literal presentation subjective, symbolic meaning participants’ feedback candle holder, candle, wash-basin important different elements necessary to create light. students are co-creators of light. now, the candle is the light … that i feel here in the community. here, i received much light, as i learnt many things … i was in the dark, and received light. pot with candle, flat surface the candle represents the co-created light. the candle holder extends above the candle, so that light can endure and flourish. what i made here is a bottle and a candle (light). we may not use a candle holder, as the candle could fall. the candle can’t fall from the bottle. table 2. visual projection of the road to a healthier lifestyle (t15) image literal presentation subjective, symbolic meaning participants’ feedback four human figures walking along a road; house with an individual the road to a healthier lifestyle is created through the community being open and accepting and valuing the collaborative relationship with the students. i’ve built my little house and here i’m sitting. here come the students. i welcome them into my home. they examine me and we have a lovely chat. table 3. visual projection of solidarity (s2) image literal presentation subjective, symbolic meaning participants’ feedback ten human figures (students); the community (middle) solidarity is displayed through the holding of hands and an interconnectedness with the community (the sticks). my picture here shows us there in s [town name] with our students… who always come to visit us. these other things are our people who are always present. we stand close together so that we can always do things together. june 2022, vol. 14, no. 2 ajhpe 53 research the  interpretation of the visual projections as solidarity were justified by participant feedback: the twigs that are bound together at the top represents a common course or collaboration. this collaborative structure also provides a safe environment. (t3). the shapes that form a circle represent the different students coming together around the community. the way in which the shapes are connected is multidimensional, indicating collaboration and the different aspect [of the rural initiative]. (t11). similarly, the visual projections of t15, s3 and s5 can also be associated with solidarity – a deeper inter-relational experience. this high-quality relation is a consequence of acceptance and recognition by others in a positive relationship.[7] the categories under solidarity are reciprocity, collaboration, person centredness and an interprofessional approach. reciprocity, which describes the equal mutualistic nature of the relational experiences, is clear from the statement: ‘where we can calmly learn from one another.’ (s3). use of the word ‘we’ and ‘everyone’ in the next two individual statements could be interpreted collaboration: ‘we built that house for the flowers, we built the greenhouse together [referring to a lifestyle-group activity] (t3). ‘everyone helped, and so on. (s2). this was infused by the group input: ‘the hands holding hands, and we, who share everything.’ (s5) the reciprocity and collaboration can be attributed to actively involving all participant in the activities and learning process. the feedback by participant t11 indicates person centredness: ‘here in the centre, this is the patient.’ where there was group input: ‘as we are sitting here, we are all good, and they [students] are all good too, because they are bringing us good outcomes.’ was added by t3 and s4. participants also experienced an interprofessional approach to healthcare evident in the statement: ‘there are different shapes. it’s not only one type of student. here is a student who’s a doctor, here’s a physiotherapy, and then here is one that checks the eyes. and each one of them sees another aspect.’ (t11). the group concurred: ‘every student has his part with us, because they examine everything.’ (t6, t14). the interprofessional and community-driven approach to the lifestylegroup activities aligns with the concept of doing with instead of doing for. lifestyle-group participants experienced mutuality when they felt like active participants in a positive relationship.[7] sub-theme 3: affirmation the literal presentation and subjective, symbolic meaning of affirmation is presented in table 4. gratitude for the collaboration with and acceptance of students into the community were the two categories under the sub-theme of affirmation. multiple feedback related to gratitude was provided by individual participants: ‘thank you very much for helping me.’ (t3, t4, t11, t15, s3,  s5). ‘we are glad that you are there, and we wish they could stay, they should not abandon us. they mean something.’ (s2). the group input (‘they helped me so much.’) (t4) indicates similar feelings. acceptance of students into the community was expressed though feedback such as: ‘i welcome them into my home. they examine me and we have a lovely chat.’ (t15, s4). input from the group included: ‘but now, the students helped us to have a chat when they came to our homes.’ (t6). the categories above indicate a strong sense of community receptiveness and appreciation of the contribution made by the interprofessional students. the involvement of interprofessional students in the lifestyle-groups affected a variety of interconnected spheres, as discussed. however, the researchers also found evidence of a persistent, paternalistic view of university involvement in communities. community members may not have realised the implication of the words: and to tell us what we must do. (t14). then come the students and they taught us. (s1). the student tells me what i should stress about, and what i shouldn’t stress about. (s3). the statements above by participants seem to contradict this rural health initiative’s collaborative, person-centred approach. the affirming nature of the relationship does, however, incorporate relational vitality, as the interactions provide evidence of positive stimulation and an increased sense of positive energy among members.[7] the above findings as supported by the literature presented are further elaborated on and must be read in conjunction with the discussion below. discussion the impetus for this study was the desire to gain an understanding of the relational experiences of lifestyle-group members participating in a rural health initiative with interprofessional student groups relational experiences are measured by determining how the purpose, intensity and quality of relationships contribute to achieving specific outcomes and, in the context of this study, health-related outcomes. an important outcome achieved in this study was a resonant understanding among participants of the value of lifestyle-groups. light as an overarching theme can be extrapolated throughout the feedback not only in relation to the visual projections and corroborating verbal input from discussions where the sub-themes can be seen as quintessential thereof, but also as a radiating table 4. visual projection of affirmation (s5) image literal presentation subjective, symbolic meaning participants’ feedback building with individual; vehicle (student transport); pet community values and appreciation of engagement and collaboration with students. this is here, at the clinic. this is me, here. they take us there, to the clinic, or they come to us. i like the student; here you can see how i’m smiling. 54 june 2022, vol. 14, no. 2 ajhpe research source of energy necessary for life. the combination of different colours making up light could represent the collaboration associated with ipe. findings of this study aligned with some of the intended rural ipe initiative’s outcomes, as is evident in the sub-theme of healthier lifestyle, and its categories of knowledge sharing, lifestyle transformation, self-reliance and improved health outcomes. the sub-theme of solidarity, which refers to a readiness to act or respond to a ‘stranger’, reflects the intensity of the relational experience between students and community members. in the context of a rural health initiative, the participants’ visual projections illustrate the achievement of emotional, cognitive and/or imaginative readiness.[27] the present study also found that solidarity calls for a certain generosity of perception, which manifests in the categories of person centredness and interprofessional approach. community members and students have the ‘will to find the other unthreatening in his or her otherness and to acknowledge the legitimacy of the call of the other upon me’.[27] this ‘will’ and ‘acknowledgment’ is evident in the feedback that reports on collaboration and reciprocity. the categories of gratitude and acceptance under the sub-theme of affirmation describe the quality of achievement of the lifestyle-groups’ intended goals. during the group discussions were instances where lifestyle-group members stated, ‘then come the students and they taught us.’ (s1) which indicates health education (one-way communication; telling; doing for). a key component of this rural health initiative was collaboration and promoting health dialogue (two-way conversation; discussion; doing with) with lifestyle group members. without health dialogue, very little or no input from lifestyle-group members may place them in a subservient and passive role in their relationship with students. including community members in the assessment, development and execution of health interventions helps to build a foundation for developing  the interactive community partnerships that are at the core of cbe.[28,29] integrating the community in this way assists in building trusting relationships and enables academics to improve their understanding of the various community nuances. integration also allows academics to gain insight into the needs and opinions of the community and, furthermore, serves as a guide to adapt interventions to accommodate unique community identities. conclusion the lifestyle-group members’ visual projections and discussions illustrate sincere relational experiences of community members. these relational experiences can be described as of high quality displaying positive regard, mutuality and relational vitality.[7] the projections of relational experiences are consequences of intertwining the community’s and students’ quests for improved health outcomes. the findings endorse the premise of the initiative, though some comments indicate areas requiring improved practices; e.g., health dialogue instead of health education. it is anticipated that promoting sincere high-quality relational experiences and associated engagement, and true reciprocal relations in the lifestyle-groups, will  facilitate the development of higher levels of health dialogue and self-efficacy. declaration. none. acknowledgements. the authors thank the members of the two community groups that participated in the research, and also mrs h human who assisted with language editing and translation. author contributions. the authors declare that this article is our collective and original work. where necessary, recognition has been given to the work of others. dr r botha: researcher, corresponding author; professor a joubert: researcher, co-author; ms h morgan: data gathering, co-author; mrs m wilmot: data gathering, co-author. funding. the university of the free state. conflict of interest. none. 1. university of the free state (ufs). engaged scholarship guide for academics and community partners. n.d. https://www.ufs.ac.za/docs/librariesprovider43/community-engagement-documents/resources-tab/academicstaff-eg.pdf ?sfvrsn=4b006e20_2 2. talib zm, baingana rk, sagay as, van schalkwyk sc, mehtsun s, kiguli-malwadde e. investing in communitybased education to improve the quality, quantity, and retention of physicians in three african countries. education health 2013;26(2):109-114. 3. world health organization. framework for action on interprofessional education & collaborative practice. geneva: world health organization; 2010. 4. castonguay lg, hill ce, editors. transformation in psychotherapy: corrective experiences across cognitive behavioral, humanistic, and psychodynamic approaches. washington: american psychological association psycnet; 2012. https://psycnet.apa.org/record/2011-30086-000 5. comstock dl, hammer tr, strentsch j, cannon k, parsons j. relational cultural theory: a framework for bridging relational, multicultural, and social justice competencies. j counselling and development 2008;86(3):279-287 https://onlinelibrary.wiley.com/doi/abs/10.1002/j.1556-6678.2008.tb00510.x 6. sontag a. relational experience design. how to use experience design to build meaningful relationships. 2016. https://medium.com/@andysontag/relational-experience-design-73f7beb9e7aa (accessed 24 april 2019). 7. dutton je, heaphy ed. the power of high-quality connections at work. in: cameron ks, dutton je, quinn re, editors. positive organizational scholarship. san francisco: berrett-koehler; 2003; p. 263-278. 8. mcleod s, rogers c. simple psychology. 2014. https://www.simplypsychology.org/carl-rogers.html#selfw (accessed 24 april 2019). 9. maslow a. motivation and personality. 2nd ed. new york: harper & row; 1970; p. 188. 10. kahn wa. psychological conditions of personal engagement and disengagement at work. acad management j 1990;33:692-724. 11. anderson e, mcfarlane j. community as partner: theory and practice in nursing. 3rd ed. philadelphia: lippincott, williams & wilkins; 2006. 12. roos v. understanding relational and group experiences through the mmogo-method. 1st ed. new york: springer; 2016. 13. boddy c. projective techniques in market research: valueless subjectivity or insightful reality? int j market res 2005;47(3):239-254. 14. keller c, fleury j, perez a, ainsworth, b, vaughan, l. using visual methods to uncover context. advancing qualitative methods 2009;18:428-435. 15. roos v. the mmogo-method: an exploration of experiences through visual projections. qual res psychol 2012;9(3):249-261. https://doi.org/10.1080/14780887.2010.500356 16. jung cg. memories, dreams, reflections. new york: pantheon books; 1961. 17. harris as. living with paradox: an introduction to jungian psychology. pacific grove: brooks/cole; 1996. 18. nelson g, prilleltensky i. community psychology: journeys in the global context. in: nelson g, prilleltensky i, editors. community psychology: in pursuit of liberation and well-being. new york: palgrave macmillan; 2005. 19. mbalinda sn, plover cm, burnham g, et  al. assessing community perspectives of the community based education and service model at makerere university, uganda: a qualitative evaluation. bmc int health hum rights 2011;11(1):s6. 20. van schalkwyk j, marais s. educators’ relational experiences with learners identified with fetal alcohol spectrum disorder. s afr j educ 2017;37(3):1-9. 21. barad k. meeting the universe halfway: quantum physics and the entanglement of matter and meaning. durham, nc: duke university press;2007. 22. roos v, redelinghuys a. analysing visual data with text and the mmogo-method: experience of meaning during the third trimester. in: roos v, editor. understanding relational and group experiences through the mmogomethod. new york: springer; 2016; p. 119. 23. jung cg. modern man in search of a soul. london: routledge and kegan paul; 1933. 24. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3:77-101. 25. sharan bm, tisdell ej. qualitative research: a guide do design and implementation. 4th ed. san francisco: jossey-bass; 2016. 26. richmond sa. newton and hume on causation: alternative strategies of simplification. history of philosophy quarterly 1994;11(1):37-52. 27. sheffield ec. service in service-learning education: the need for philosophical understanding. high school journal 2005;89(1):46-53. 28. lasker r, weiss e. broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. j urban health 2003;80(1):14-47. 29. roussos s, fawcett s. a review of collaborative partnerships as a strategy for improving community health. ann rev public health 2000;21:369-402. accepted 23 june 2021. https://www.ufs.ac.za/docs/librariesprovider43/community-engagement-documents/resources-tab/academic-staff-eg.pdf?sfvrsn=4b006e20_2 https://www.ufs.ac.za/docs/librariesprovider43/community-engagement-documents/resources-tab/academic-staff-eg.pdf?sfvrsn=4b006e20_2 https://psycnet.apa.org/record/2011-30086-000 https://onlinelibrary.wiley.com/doi/abs/10.1002/j.1556-6678.2008.tb00510.x https://medium.com/ https://www.simplypsychology.org/carl-rogers.html#selfw https://doi.org/10.1080/14780887.2010.500356 ajhpe issn 0256-9574 african journal of health professions education 2011, vol.3 no.2 ajhpe african journal of health professions education december 2021, vol. 13, no. 4 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state werner cordier university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 short communication 212 pathology lexicon a-z: a multilingual glossary app l govender, j geitner, n tyam, f c j botha, s a anat, j yeats 214 features of the research proposal genre made easy for undergraduate occupational therapy students m c ramafikeng short research report 215 learn-teach-learn: evaluating a south african near-peer teaching programme r spies, h lee, i esack, r hollamby, c viljoen 218 is blended learning the way forward? students’ perceptions and attitudes at a south african university n b khan, t erasmus, n jali, p mthiyane, s ronne research report 222 evaluation of assessment marks in the clinical years of an undergraduate medical training programme: where are we and how can we improve? h brits, g joubert, j bezuidenhout, l van der merwe 229 medical students’ perceptions of global health at the university of cape town, south africa: the gap between interest and education m potter, p naidu, l pohl, k chu 235 the knowledge and attitudes of final-year medical students regarding care of older patients k naidoo, j van wyk 240 nominal group technique review of the emergency care content of the clinical skills module in the undergraduate medical programme at the university of the free state d t hagemeister 246 understanding of clinical reasoning by undergraduate students and clinical educators in health and rehabilitation sciences at a south african university: the implications for teaching practice h talberg, f camroodien-surve, s l amosun 252 development of a feedback framework within a mentorship alliance using activity theory a g mubuuke, i g munabi, s n mbalinda, d kateete, r b opoka, r n chalo, s kiguli 259 a comparative analysis and evaluation of the naturopathic curriculum in south africa w ericksen-pereira, n v roman, r swart 264 teaching about disability and food security in the school of health sciences, university of kwazulu natal, south africa h e lister, k mostert, m pillay 270 nursing students’ perceptions regarding feedback from their educators in a selected higher education institution in kwazulu-natal, south africa l m rathobei, m b dube cpd questionnaire september 2021, vol. 13, no. 3 ajhpe 161 research why was the idea necessary? (what was the problem?) online in a hurry at midnight, thursday 26 march 2020, south africa (sa) was declared a state of disaster and entered a nationwide lockdown to curb the rapid spread of covid‑19. south africans were instructed to stay home and all but essential services closed down. educators immediately started utilising technologies to transform a massive amount of academic content onto a virtual platform. an acceptable alternative had to be offered to students to save the academic year. unique content what do a new campus orientation, class‑ representative election, meeting the deanery and lessons learnt by senior students have in common? nothing, except for 300 first‑year medical students and a 1‑week first‑year compulsory course that had to be converted to an online experience. this was the challenge that presented itself to the lecturer. the module ‘introduction to the study of medicine’ is a 1‑week course designed to do just that. newly selected first‑year medical students had to be introduced to the medical campus, the structure of the faculty of healthcare sciences and the healthcare system of sa. students needed to be informed of campus activities, student committees, student support, campus layout, campus security, library services, administrative arrangements, financial responsibilities and what would be expected of them as medical students. this module is not an academic course although it is credit bearing. students received a collated completion‑mark at the end of the week. this course kicks off the new students’ journey to becoming doctors. for educators this provides a valuable opportunity to lay the foundation for professional integrity, ethical practice, benevolence, respect, commitment to excellence and justice in healthcare.[1] pedagogy to probity for medical students, cognitive skills, such as clinical reasoning and procedural or academic skills, can be and have been taught effectively online.[2,3] first‑year students are at the onset of the process of developing their identity as learners, novice health professionals and future clinicians. to train well‑rounded doctors, human values need to be embedded and fostered early and sustained across the lifelong process of learning.[1] conveying these narratives is essential and can easily disappear in an online platform. what was tried? (intervention) five different online interventions were created to orientate, include and entice the students (fig. 1). a sense of inclusion and belonging: by students for students ‘co‑creation occurs when learners and educators work collaboratively with one another to create online resources and activities.’[4] the co‑creation of online materials has benefits for both learners and educators. learners are more engaged and self‑efficient and online materials are improved, authentic and innovative.[5] with the concept of co‑creation in mind, the final‑year class representative was asked to record an orientation video (https://youtu. be/yi7znn7sqo8) aimed at introducing new students to the medical campus. the result was a witty, entertaining video capturing all the interesting features of the campus with insights from experiences of a fellow student. in addition, the second‑year class representative conducted a panel discussion including the dean, deputy‑dean (teaching and learning) and the chairperson of the school of medicine (https://youtu.be/ykxihc0u6q0). the second‑ year class rep was selected because she had been in the first‑years’ shoes not too long ago, and had a good sense of what information would have made her first‑year journey easier. the new first‑year students voiced deep appreciation towards both senior students for creating these videos, since it fostered a sense of belonging and inclusion – something that is extremely difficult to create in an exclusively online environment. participatory management communication is vital in times of uncertainty, as is students’ participation in aspects related to their sphere of control. when students are given choices, they will take ownership of processes and decision‑making. this is difficult enough in a contact environment, but applying these principles in an online environment is even more tricky. therefore, when the first‑year class representative had to be selected, the lecturer was faced with the challenge of unfamiliarity among student peers regarding volunteering as a candidate and the process of voting. to facilitate the process, the lecturer sent out a communique to inform students about the class‑rep election. a pedagogy to probity h roos,1 mb chb, mmed; i (j c) lubbe,2 phd 1 school of health systems and public health, faculty of health sciences, university of pretoria, south africa 2 department for education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: h roos (heleen.roos@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. bringing it together 'escape room' participatory management class-rep selection introductions panel discussion deanery orientation senior student sharing induction animated video fig.1. online initiatives developed. https://youtu.be/yi7znn7sqo8 https://youtu.be/yi7znn7sqo8 https://youtu.be/ykxihc0u6q0 mailto:heleen.roos@up.ac.za 162 september 2021, vol. 13, no. 3 ajhpe research digital pin‑up board (padlet) was created and volunteers could paste their photos and a short campaign message on the board. students could then vote anonymously (by way of ‘likes’) for their choice of representative. this was a highly effective and uncontested approach. assess without distress medical students have higher rates of mental health challenges compared with the general population, as evident even before the covid‑19 pandemic.[6] stressors contributing to excessive strain among medical students include a high academic workload, competitiveness, constraints in work‑life balance, family demands, financial difficulties, and exposure to human suffering.[7] the covid‑19 pandemic contributes adversely by exacerbating dormant or already existing mental health conditions in medical students, but can also precipitate additional anxiety that may affect their physical, emotional and mental well‑being.[8] long‑standing social distancing, being away from campus without peer interaction, difficulty with online learning, fear of being infected by covid‑19 or dealing with loved ones being sick with covid‑19 are some of the stressors experienced by medical students as a result of the pandemic.[8] in an attempt to alleviate some of the stress, an element of competitive fun and game‑based learning and assessing was introduced into the module.[9] in collaboration with the educational consultant, a digital ‘escape room’ was created. the ‘escape room’ focused on all aspects of knowledge accumulated at the end of the week. this was a fun and stress‑ free way to reinforce and assess those concepts. the design principles were based on the ‘magic circle’ of challenge, response and feedback.[9] students thoroughly enjoyed the innovative method of assessment and student feedback was overwhelmingly positive. lessons learnt sharing the burden, communication and student participation accessibility should not be assumed. students with difficulty in obtaining web connections, data and devices should be identified early and supported. lectures and any asynchronised discussions should be recorded and made available to students who were unable to connect at the time. familiar platforms should be utilised, preferably pre‑existing learning management systems, to ease navigation for both students and educators. including students in producing lecture material immediately triggers attention and interest. this also fosters a sense of belonging and kinship among peers. senior students are looked up to with a sense of ‘if they can do it, so can we’. what i will keep in my practice although the transition to a virtual platform happened hastily out of necessity, it did not happen without reflection. utilising available technologies innovatively can be achieved by collaborating with educational specialists. alternative methods of content delivery, suitable for distant instruction, were designed and introduced. from the above initiatives, i will definitely keep all of them – even if we transition back to on‑campus facilitation. the welcome and introduction video made by the senior students was a major ‘hit’ and brought a fresh perspective into the week. in pre‑pandemic times, it would have been close to impossible to get senior management in one room simultaneously and have a junior student interview them, getting up close and personal. with this approach, students were introduced to senior management, with the latter revealing a more personal aspect that would not have been achieved with a face‑to‑face setup. students felt included in the vision and mission of the faculty. the escape room converted a boring online test into an innovative and engaging activity. selecting the class rep via a digital pin‑up board and voting system saved time, and was effective and efficient. students loved these initiatives and participated with much enthusiasm as reflected by their feedback report. what i will not do i will never go back to a lecture‑based module where students are passive recipients of information. i will not attempt to convey large amounts of information that students are not able to relate to and interact with. i will not assume that students are not able to contribute to material and structure that make lectures more appealing to their peers. declaration. we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. consent was obtained from all parties involved in the evidence of innovation. acknowledgements. none. author contributions. equal contributions from both authors. funding. publication was funded by the school of health systems and public health, university of pretoria. conflicts of interest. none. evidence of innovation 1. goh p‑s, sandars j. using technology to nurture core human values in healthcare. mededpublish 2019. published online 5 december 2019. https://doi.org/10.15694/mep.2019.000223.1 2. pei l, wu h. does online learning work better than offline learning in undergraduate medical education? a systematic review and meta‑analysis. medical education online 2019;24(1). published online 17 september 2019. https://www.tandfonline.com/doi/full/10.1080/10872981.2019.1666538?src=recsys (accessed 1 march 2021). 3. vaccani j‑p, javidnia h, humphrey‑murto s. the effectiveness of webcast compared to live lectures as a teaching tool in medical school. med teacher 2014;38(1). published online 13 october 2014. https://doi.org/10.3109/01 42159x.2014.970990 4. bovill c, cook‑sather a, felten p, et  al. addressing potential challenges in co‑creating learning and teaching: overcoming resistance, navigating institutional norms and ensuring inclusivity in student‑staff partnerships. higher educ 2016;71(2):195‑208. https://doi.org/10.1007/s10734‑015‑9896‑4 5. mercer‑mapstone l, dvorakova sl, matthews k, et al. a systematic literature review of students as partners in higher education. int j students partners 2017;1(1). https://doi.org/10.15173/ijsap.v1i1.3119 6. mousa oy, dhamoon ms, lander s, dhamoon as. the md blues: under‑recognised depression and anxiety in medical trainees. plos one 2016;11(6):e0156554. https://doi.org/10.1371/journal.pone.0156554 7. hill mr, goicochea s, merlo lj. in their own words: stressors facing medical students in the millennial generation. med educ online 2018;23:1530558. https://doi.org/10.1080/10872981.2018.1530558 8. sandars j, correia r, dankbaar m, et  al. twelve tips for rapidly migrating to online learning during the covid‑19 pandemic. mededpublish 2020;9(1):82. https://doi.org/10.15694/mep.2020.000082.1 9. plass jl, homer bd, kinzer ck. foundations of game‑based learning. educ psychol 2015;50(4):258‑283. https:// files.eric.ed.gov/fulltext/ej1090277.pdf (accessed 1 march 2021). accepted 30 june 2021. afr j health professions educ 2021;13(3):161‑162. https://doi.org/10.7196/ajhpe.2021. v13i3.1527 https://doi.org/10.15694/mep.2019.000223.1 https://www.tandfonline.com/doi/full/10.1080/10872981.2019.1666538?src=recsys https://doi.org/10.3109/0142159x.2014.970990 https://doi.org/10.3109/0142159x.2014.970990 https://doi.org/10.1007/s10734-015-9896-4 https://doi.org/10.15173/ijsap.v1i1.3119 https://doi.org/10.1371/journal.pone.0156554 https://doi.org/10.1080/10872981.2018.1530558 https://doi.org/10.15694/mep.2020.000082.1 https://files.eric.ed.gov/fulltext/ej1090277.pdf https://files.eric.ed.gov/fulltext/ej1090277.pdf https://doi.org/10.7196/ajhpe.2021 212 december 2021, vol. 13, no. 4 ajhpe short report pathology, or the study of disease, is fundamental knowledge for the healthcare practitioner.[1] health sciences students are typically required to describe and interpret gross pathology specimens. these specimens are organs or tissues displaying key features of a disease. description of their pathological features requires proficiency in unique terminology. this terminology includes precisely tailored adjectives or metaphors (particularly food terms) with which the novice may be unfamiliar – for example, the ‘verrucous’ appearance of certain tumours and the ‘bread-andbutter’ appearance of fibrinous pericarditis. in the south african context where many students are second-language speakers of english,[2] pathology terms may be particularly challenging.[3] the university of cape town (uct) pathology learning centre is a facility holding more than 4 000 pathology specimens, and is an integral part of ‘practical’ pathology teaching for health sciences students. to support teaching and learning, we sought to develop a tool to clarify terminology for macroscopic pathology. approach we developed a pathology glossary in the form of a mobile application (app), as our students tend to have continual access to their cellular phones, and when on campus have free internet access via international roaming service, eduroam. pathology lexicon a-z (pathlex) offers definitions, photographs and multilingual translations intended to make the terminology as accessible as possible. it contains an expanding alphabetical list of descriptive terms. each term is explained in non-technical english, alongside a high-quality photograph of a specimen to which the term is correctly applied. image sizes have been carefully chosen to create the best balance between image size and quality. additionally, an audio clip is available for users to hear the english term spoken. with the assistance of subject specialist and language specialist translators, each term in pathlex has been translated into afrikaans and isixhosa (fig. 1). these languages align with those taught in the health sciences undergraduate programmes at uct, and represent the most prevalent non-english languages of the region. linguistic challenges during the development of pathlex have been complex, beginning with discerning which terms to include and which likely did not need clarification. the precise descriptive terms used in pathology often reflect subtle differences in tissue appearance, and translation into everyday language required careful thought. furthermore, translations were especially problematic where particular terms were not known to exist in isixhosa. in such instances, it was necessary to replace single-word pathology terms with phrases. the app is available as a free download on android and ios platforms, with no mobile network operator partnerships. outcomes the work of pathlex is in alignment with ongoing work in multilingualism, glossary development and learning, as outlined in uct’s language plan.[2] in developing pathlex, we encountered both linguistic and technical challenges. technical challenges included acquiring the necessary knowledge and skills for app-building on both the android and ios platforms. the app was launched in 2020, and this was timely due to, but also hindered by, the move to remote teaching brought about by the covid-19 pandemic. moving forward, we intend to actively promote pathlex to our students, and conduct formal research on this project. the research that we envision will unpack the design, development and implementation of the app, and how it may shape student learning. app sustainability has been conceived in terms of ongoing refinements to isixhosa translations, through review by an isixhosa first-language pathologist now on staff. in addition, we have updated teaching material to direct students to make use of the app. it is a non-exhaustive lexicon at this stage, and we will be looking to add new macroscopy terms and a microscopy glossary, if feasible. pathology lexicon a-z: a multilingual glossary app l govender,1 mb chb, pg dip (hpe); j geitner,2 bcom (hons); n tyam,3 ba (hons), ma; f c j botha,4 mb chb, fc (path) sa anat; j yeats,2 mb chb, fc (path) sa viro 1 division of anatomical pathology, faculty of health sciences, university of cape town, south africa 2 pathology learning centre, division of anatomical pathology, faculty of health sciences, university of cape town, south africa 3 multilingualism education project, centre for higher education development, university of cape town, south africa 4 pathcare laboratories, george, south africa corresponding author: l govender (lynelle.govender@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. fig. 1. representative screenshots from (anonymized, name of app removed) mobile application. note that for the sample word shown at right, ‘bosselated’, no direct translation exists in isixhosa or in afrikaans. in isixhosa the phrase ‘maqhuqhuva abhombosholo’ (rough fig. 1. representative screenshots from pathology lexicon a-z mobile application. note that for the sample word shown at right, ‘bosselated’, no direct translation exists in isixhosa or in afrikaans. in isixhosa the phrase ‘maqhuqhuva abhombosholo’ (rough surface with small knobs around) has been used to explain the term, and in afrikaans three similar adjectives are employed – ‘geboggeld/knopperig/uitgebult’ (humped/knobbly/bulging). mailto:lynelle.govender@uct.ac.za december 2021, vol. 13, no. 4 ajhpe 213 short report declaration. none. acknowledgments. we acknowledge the valuable contributions of dr ayanda mfokazi, a pathologist who has joined this project to assist as a subject specialist and translator. author contributions. all the authors complied with the international committee of medical journal editors’ rules of authorship and were part of conceptualising, formulating and editing the article. although the initial draft was prepared by the first author, subsequent work on the manuscript included essential input from all authors. funding. none. conflicts of interest. none. 1. marshall r, cartwright n, mattick k. teaching and learning pathology: a critical review of the english literature. med educ 2004;38(3):302-313. https://doi.org/10.1111/j.1365-2923.2004.01775.x 2. paxton mij. ‘it’s easy to learn when you using your home language but with english you need to start learning language before you get to the concept’: bilingual concept development in an english medium university in south africa. j multiling multicult dev 2009;30(4):345-359. https://doi.org/10.1111/10.1080/01434630902780731 3. ahmed h, ogala wn, ibrahim m. culinary metaphors in western medicine: a dilemma of medical students in africa. med educ 1992;26(5):423-424. https://doi.org/10.1111/j.1365-2923.1992.tb00195.x accepted 6 september 2021. afr j health professions educ 2021;13(4):212-213. https://doi.org/10.7196/ajhpe.2021. v13i4.1490 https://doi.org/10.1111/j.1365-2923.2004.01775.x https://doi.org/10.1111/10.1080/01434630902780731 https://doi.org/10.1111/j.1365-2923.1992.tb00195.x https://doi.org/10.7196/ajhpe.2021.v13i4.1490 https://doi.org/10.7196/ajhpe.2021.v13i4.1490 march 2020, vol. 12, no. 1 ajhpe 22 research prehospital emergency medical care systems have traditionally focused on ‘stopping the bleeding’ and other forms of acute medical intervention. however, in 1996, the us national highway traffic safety administration recognised the role of emergency medical service (ems) personnel in health promotion and injury prevention: ‘emergency medical services (emss) of the future will be community-based health management that is fully integrated with the overall health care system. it will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring.’[1] approaches to integrating emergency care and primary healthcare have subsequently been explored internationally.[2,3] in 2015, the professional board for emergency care, health professions council of south africa (hpcsa), adopted a position statement on social determinants of health.[4] this statement committed the professional board to review the ems scope of practice and protocols to be explicitly inclusive of health promotion and preventive care.[4] the position statement also called on all providers of ems education to educate students and practitioners on the importance of social determinants on health outcomes, and their role in identifying and responding to social determinants of health. this call is consistent with the 2008 report of the world health organization (who) commission on social determinants of health, which called on ministries of health and education, in collaboration with institutions offering health education, to make social determinants of health a standard and compulsory part of the curriculum of medical and health practitioners.[5] social determinants of health are conditions in which people are born, grow, live, work and age. these circumstances are shaped by the distribution of wealth, power and resources at global, national and local levels.[5] however, little practical guidance is provided in these documents as to the most effective pedagogical methods by which to introduce social determinants of health into the emergency medical care curriculum. it is therefore imperative that ems educators explore and share knowledge on experience of contextually relevant learning activities that serve to achieve this purpose. service learning is one such activity that has been used in education of medical and other health science students. it combines the academic curriculum with service to a community in such a way that both background. the inadequacy of training with regard to the social determinants of health in medical education has led to calls for a greater public health focus in medical and health education. this call is no less applicable to the education of emergency care students and other emergency care personnel than to any other category of healthcare practitioner. emergency care personnel work within communities and are therefore uniquely positioned to identify social causes of poor health and to play a pivotal role in addressing such issues through education, community engagement, advocacy and referral. objectives. to analyse emergency care students’ community-based service-learning projects (slps); to explore the application as an educational tool; to improve their understanding of the social determinants of health and the need and potential for emergency care personnel to become critical actors in addressing the social causes of ill health. methods. emergency care students (n=80) from three academic years were requested to submit portfolios with narrative reflections on their slps. the study was approached from an interpretivist paradigm, and it employed a phenomenological methodology to ascertain the meaning ascribed by emergency care students to their lived experiences through participation in slps. thematic concerns were abstracted and discussed in the context of calls for health and medical curricula to place greater focus on the social determinants of health, and the implications for educating emergency care and other medical personnel. results. among emergency caregivers, service learning promoted a practical understanding of the social determinants of health and a sense of social responsibility in communities. emergency care students can make a positive difference in the lives of individuals and communities. students were exposed to existing resources and developed an understanding of the challenges and opportunities related to working in communities. the students were enriched by involvement in communities and developed self-awareness, teamwork and other important organisational skills. conclusions. this study corroborates slps as a pedagogical tool to understand the social determinants of health, and the need and potential for emergency care personnel to become critical actors in addressing social causes of ill health. slps should therefore be an important tool of emergency care educators – responding to calls of the world health organization’s commission on social determinants of health for greater prominence to be given to disease prevention and health promotion in medical and health science curricula. afr j health professions educ 2020;12(1):22-26. https://doi.org/10.7196/ajhpe.2020.v12i1.1152 social determinants of health in emergency care: an analysis of student reflections on service-learning projects s g d harrison,1 llm, mph, btech emc; j scheepers,2 ba, ba hons, ma; l d christopher,1 mtech emc, hd ed; n naidoo,1 phd, mph, hd ed, btech emc 1 department of emergency medical sciences, faculty of health and wellness sciences, cape peninsula university of technology, cape town, south africa 2 service-learning and civic engagement units, cape peninsula university of technology, cape town, south africa corresponding author: l d christopher (lloydc@cput.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 23 march 2020, vol. 12, no. 1 ajhpe research the community and students are primary beneficiaries, and the goals should equally provide service to the community and promote student learning. service learning should be distinguished from co-operative education and internships, in which students are the primary beneficiaries, and the primary goal is to foster student learning.[6] where service learning has been used in health sciences education, it has provided a structured means for engagement between higher-education institutions and communities, and has demonstrated potential for community benefit and enhancement of student learning if properly planned and implemented.[7,8] research setting in ems education, however, there are few documented examples of the use of service learning.[9,10] the experience of the cape peninsula university of technology (cput), which incorporates service learning in the curriculum of emergency care students, is therefore instructive in providing needed practical guidance to higher-education institutions when responding to the policy imperative to introduce social determinants of health into emergency care curricula. service-learning projects (slps) constitute a significant component of the primary health care course (comprising 40% of the overall course assessment), which all emergency care students at cput are required to complete in groups.[11] this course is in the second year of the programme, and due to its related pragmatic philosophy and level description lends itself well to social determinants of health applications. slps, however, can be implemented in any subject in any academic year in urban, rural or peri-urban areas, but are probably most sustainable when not in direct competition with other programme needs and when the resource intensity is feasible. this component of the course is jointly facilitated by cput’s department of emergency medical sciences and its centre for community engagement and work integrated learning. the latter acts as the primary liaison and facilitator in partnerships between faculty staff, community and service agencies (civil society or state) and in so doing acts as translator, diplomat and matchmaker, to ensure reciprocal benefits inherent in a sustainable and effective slp. the lecturer designs the service-learning approach, establishes learning outcomes and plans for the evaluation of learning, including implementing reflection techniques to facilitate students’ drawing of meaning from the experience. students are guided through the experiential component of the service-learning module to foster a strong relationship with the community and service agencies, and to integrate active citizenship and social awareness through the curriculum. service agencies provide relevant information on service and/or community needs and take a lead in collaboratively designing service placements that address real community needs and meet the stated learning outcomes for learners. orientation and training to prepare students for active involvement may be provided, as well as supervision and evaluation of students’ verified sense of responsibility. all role-players collaborate to create an environment that supports education and development and also to establish a context with increased capacity for contributions to strengthen community resilience and social capital. the student role is to participate in activities that prepare them for the role of learner and service provider; to actively engage in service delivery in the community; to reflect on the personal and professional meaning of the experience; and to accept responsibilities inherent in community engagement, including ethical assistance, responsible behaviour and respectful relationship building. students are required to plan, implement and evaluate a small-scale community engagement project, putting principles of primary healthcare into practice. the lecturer provides groups with curriculum outcomes; and group members conduct a situational analysis together with the community to identify the need and hence the focus of the project. the reflective practice included group discussions and consensus finding followed by peer appraisals of project conceptions and presentations. progress reports or requests for guidance are presented in each academic term, and at the end of a subject a group presentation is done with involvement of service agencies. a comprehensive technical and/or narrative report is also submitted. project themes during the 3-year study period are listed in table 1. this study analyses cput emergency care students’ reflections on their experience of slps. objectives the aim of the study was to evaluate students’ reflections regarding the potential application of slps as an educational tool to equip emergency care students to improve their understanding of the social determinants of health, as well as their potential as emergency care personnel to become critical actors in addressing the social causes of ill health. the objectives were: • to analyse emergency care students’ reflections on their participation in service learning • to assess in what respects, if at all, emergency care students perceive their participation in service learning to have contributed to their understanding of social determinants of health • to assess in what respects, if at all, emergency care students perceive their participation in service learning to have contributed to their understanding of their potential to become critical actors in addressing social causes of ill health • through inductive reasoning, to confirm if service learning is a pedagogic tool to understand social determinants of health and the need for ems personnel to become critical actors in addressing social causes of ill health. methods the study was conducted within an interpretivist paradigm, which acknowledges that the researcher’s own experience and values may affect research processes and outcomes.[12] this is helpful, as the researchers, as insiders, intend risk of bias to assist rather than confound the analysis. a qualitative, phenomenological study design was selected as most appropriate to understand the lived experiences of emergency care students table 1. service-learning project themes alcohol and drug abuse fires and injuries first aid gender-based violence hopelessness housing patient rights smoking swimming safety march 2020, vol. 12, no. 1 ajhpe 24 research involved in slps. the study analysed the narrative reflections on slps submitted to cput’s department of emergency medical sciences by 80 emergency care students over a 3-year period. these reflections are particularly appropriate for phenomenological research, as the primary healthcare subject guide only requires these to be ‘individual reflections on experience and learning derived from participation in the group project’,[11] thereby facilitating voice and reflexivity on the part of participants. all slp narrative reflections submitted by students in the previous 3 years, and obtained from the department’s archives, were included to prevent unfair exclusion and to ensure that valuable insights were not missed in the sampling process. the inclusion of slp groups from 3 academic years was intended to minimise biases or distortions arising from class groups or project topics. group portfolios or reflective reports were submitted at the end of the project, as well as formal group presentations based on a community engagement exercise (guided by curriculum content) with regard to: planning of the intervention, implementation of the intervention, monitoring and evaluation of the intervention and summary findings. the portfolio/report quality guidelines/assessment criteria[11] included: • project evaluation, e.g. evaluation by participants or beneficiaries of project outcomes (creative forms of evaluation were encouraged); an overall comprehensive, critical and honest reflection on the successes, shortcomings and lessons; individual reflections on experience and learning derived from participation in the group project • the portfolio – well organised, professionally presented, and suitably referenced • effective project planning, incorporating all relevant components of the planning cycle • clear theory of change, linking project activities to intended outcomes, supported by sound research, and evidence of successful implementation of the project • evidence of benefit to both the cput student community and at least one stakeholder in the broader community • effective and accountable financial management of all aspects of the project in accordance with relevant procedures • contribution of all members to group outcomes, appropriate credit of team members, and demonstration of original thought and critical reflective practice throughout • an understanding of primary healthcare theory and an ability to apply theory into practice • comprehensively evaluated work with a range of self-, peer and participant monitoring. consistent with the phenomenological study design,[12] data analysis – considering the responses to the abovementioned criteria – abstracted themes from the narrative reflections to the extent that they were relevant to the aims and objectives of the relevant slp. the level of abstraction stopped when futility, stability or consensus themes emerged. thematic concerns were grouped, labelled and defined, with examples provided by means of direct quotations from the reflections. evaluation criteria specific to the trustworthiness of portfolio evaluation included member checking (by presenting conceptions and defending project appraisals), prolonged engagement (the project spanned an academic year) and triangulation (within and between projects). with regard to ethical concerns, unfair exclusion was avoided. the inclusion of three cohorts over 3 years was intended to minimise inherent biases or distortions arising from class groups and slp topics. data analysis did not include student names or identifiable information. the study was limited, as it considered the application of service learning from the perspective of participating students only, and focused on the self-reported educational benefit to the participating learners. it did not take into account direct perceptions of stakeholders in communities where the projects were undertaken, or set out to evaluate direct benefit to the communities that were serviced by the slps. the risk of coercion is negated by the retrospective nature of the data. in summary, slp group self-reflections were submitted, assessed and archived. these data sources were retrieved by sgdh, anonymised and then initially analysed by sgdh and js. the analysis was confirmed by nn and ldc, who independently assessed the slp reports. author consensus on the themes was of interest, as js is an external service-learning expert to the department, while nn and sgdh are public health champions and ldc is an emergency care expert. ethical approval ethical approval (ref. no. ems/15/14) was obtained from the department of emergency medical sciences, faculty of health and wellness sciences, cput. results eight different themes relevant to the study objectives were identified from the students’ reflections. these are presented in table 2, together with some of the verbatim quotes from students to substantiate the themes. themes have been clustered into levels, i.e. macro, meso and micro: • at a macro level, themes relate to broad societal implications. specifically, the macro level of reflections refers to an overall understanding of social determinants of health, primary healthcare, health promotion and disease prevention. • at a meso level, themes relate to communities. specifically, the meso level of reflections refers to an understanding of the interaction between ems personnel and communities, impact of slps on communities, availability of community-based resources, and challenges and opportunities that characterise work in communities. • at a micro level, themes relate to individuals. specifically, the micro level of reflections refers to the impact of service learning on the individual student in relation to personal growth and development, improved selfawareness, and personal understanding of organisational and team issues. discussion the study results confirmed that service learning among ems students promoted learning at the macro (societal), meso (community) and micro (individual) levels. at a macro level, the results confirmed that service learning enabled ems students to deepen their understanding of the linkages between health status in communities and social determinants of health, such as housing, sanitation and nutrition. service learning thereby practically reinforced theoretical teaching about social determinants of health, including the potential for upstream (macro level) disease prevention and healthpromotion strategies to reduce the incidence of injuries and diseases that emergency care students encounter daily. 25 march 2020, vol. 12, no. 1 ajhpe research at a meso level, service learning generated a newly found awareness of social responsibility among students and their potential to make a difference in the lives and future of individuals and communities. the awakening of this social awareness among emergency care students is especially important in the sa context, where a shortage of emergency care in the public sector is compounded by competition from the private sector and emigration. [13] students also learnt about the resources and dynamics at play within communities, and developed an appreciation for the intrinsic knowledge and systems in these communities. the reflections suggest that naive preconceptions of some students that community engagement is a form of charity, were quickly dispelled. at a micro level (downstream), students acknowledged that they had been profoundly changed by the service-learning experience. the reflections suggest that the world view of students was challenged by experiences, and that they had to draw from internal resources in a way that they had not previously experienced. they also developed practical skills in relation to working as a team and managing projects. from a perspective of educational theory, the evidence that students were challenged and changed by their experience positions service learning in ems education as a form of transformational learning, which has been defined as a process of learning where there is not only an increase in knowledge, but also a radical shift in a learner’s perspective and understanding of the world.[14] the student’s reflections suggest that, by putting theoretical knowledge of social determinants of health into practice, service learning among ems table 2. themes and quotations from student reflections level theme verbatim quotations macro (societal) service-learning promoted a practical understanding of social determinants of health ‘medical services aren’t the only thing that is needed to improve a person’s health, but proper housing, water, food and sanitation are also important. with this project, we and other service sectors helped to provide these basic primary healthcare needs in the community.’ ‘by us joining the community in building houses, with clean running water and sanitation for people living out on the street, we are preventing any harmful disease they can develop … we formed part of the upstream prevention strategies; strategies that are implemented before the disease can begin.’ meso (community) emergency caregivers have a social responsibility in communities ‘in retrospective reflection, we have learnt that with the privilege of learning medicine, comes the responsibility of helping those less fortunate than we are.’ ‘i have learnt about how much power we have as emergency carers being the first contact with the healthcare system and how important our role is in the community and how we conduct ourselves.’ emergency care students can make a positive difference in the lives of individuals and communities ‘we feel that our project will leave a lasting footprint on the community, and building on it will help to save and improve the lives of many.’ ‘i believe that being destitute and homeless has the ability to destroy all hope and dignity among any individual, and i feel that our group truly brought a breath of fresh air, and restored their faith in humanity.’ students were exposed to existing resources available to communities ‘the organisations out there that are doing amazing work on [gender-based violence], is something i had not realised and having the privilege to meet and talk to a few different types, all focusing on this world-wide issue, gave me a fresh perspective.’ ‘[the non-governmental organisation partner] said some very nice things, but i think that they focused more on their donors and themselves, rather than the volunteers and the people’s lives that they were changing.’ students developed an understanding of the challenges and opportunities related to working in communities ‘if i had to start the project from the very beginning, i would go out to the community and find out what are the problems directly affecting the community and target the people who can sustain the project as well as everyone else.’ ‘the first thing i noticed was that there was a language barrier, most if not all of our participants were xhosa-speaking individuals, with english as their second language.’ micro (individual) students were enriched by involvement in communities ‘we started out trying to contribute towards the wellbeing of others. while this may have been accomplished, we had walked ourselves away with a greater appreciation of our own lives.’ ‘it was truly a life-changing event and i grew as a person from this experience.’ students developed self-awareness and, in particular, learnt about their strengths and weaknesses ‘it was extremely tiring and at times i felt like quitting, but being constantly surrounded by the positive attitudes of people, and being reminded why i was there (in madiba’s legacy), i made sure i wouldn’t give up, despite my anger and frustrations at times.’ ‘we have learnt that we as individuals are empowered and have the knowledge and have all the necessary tools in our armoury to empower and educate the community in a positive way.’ students developed teamwork and other important organisational skills ‘we have learnt to function well as a team, but vital to teamwork are communication, co-ordination, balanced member contributions, mutual support, effort and cohesion. also, we learnt that the group leader needs to delegate.’ ‘during my involvement in this project, i have realised how much effort and work are put into organising an event and ensuring it runs smoothly.’ march 2020, vol. 12, no. 1 ajhpe 26 research students is consistent with john dewey’s notion of situational learning. the need for situational learning is premised on dewey’s understanding that the acquisition of knowledge in a situation enhances its usability through recall and application. if knowledge is separated from experience, it is forgotten and cannot be transferred to new experiences.[15] the service-learning experience of ems students also conforms well with dewey’s criteria for projects to be ‘truly educative’, as summarisd by eyler and giles,[15] i.e. that they: (i) generate interest; (ii) are intrinsically worthwhile; (iii) present problems that awaken new curiosity and create a demand for information; and (iv) cover a considerable time span and are capable of fostering development over time. however, the last of these criteria suggests that the learning potential of these projects could be enhanced even more if service learning was to be expanded in the curriculum beyond the duration of a 1-year subject. conclusions ems education tends to be characterised by a focus on acute management of medical conditions, such as haemorrhage control, cardiopulmonary resuscitation, fluid replacement and drug administration. while these types of intervention are critical, an exclusive biomedical focus in ems education denies students an appreciation of the limitations of biomedical interventions in the overall improvement of health outcomes of individuals and communities. a narrow biomedical model is also likely to fail to produce graduates who recognise that they are ‘uniquely positioned to play a key role in proactively identifying and responding to social determinants of health in communities – thereby contributing to health promotion and disease prevention’.[3] the call by the professional board of emergency care for all providers of ems education to educate students and practitioners on the importance of social determinants on health outcomes, and their role in identifying and responding to social determinants of health, is therefore fundamentally important. this acknowledges that educational institutions offering ems education and training must heed the who’s call to make social determinants of health a standard and compulsory part of the curriculum of medical and health practitioners. the challenge to educators is now to translate this policy into educational practice in the most effective way possible. this study corroborates service learning as a practical and effective pedagogical tool through which to respond to policy imperatives to introduce social determinants of health into ems curricula. student reflections at macro, meso and micro levels support a finding that service learning significantly contributes to ems students’ understanding of social determinants of health, and enables them to recognise and explore their potential to become critical actors in addressing social causes of ill health. through increasing students’ knowledge of social determinants of health, and effecting a radical shift in learners’ perspectives and understanding of the world, service learning offers an opportunity for transformational learning in ems education. it is accordingly recommended that all institutions offering ems education not only review their curricula to ensure that social determinants of health are fully integrated in the theoretical teaching of ems, but also consider the implementation of service learning as a means to enable students to reinforce theory by practice through situational learning. as experience of implementing service learning in ems education develops, there is a need for further research and knowledge sharing in relation to the most effective ways of optimising the benefit to both students and communities through the service-learning modality. while the experience of service learning among other health science disciplines is instructive, it is important that knowledge is shared among ems educators of how to ensure that service learning remains relevant to ems practice and that students draw these linkages. it is also vital that service learning promotes an understanding among communities of the role of ems in health-promotion and disease-prevention initiatives. as this body of experience and knowledge grows, it will ensure optimisation of the effectiveness of service learning as a pedagogical tool in ems education. declaration. none. acknowledgements. we acknowledge the support of the department of emergency medical sciences and service-learning/civic engagement units at the cape peninsula university of technology towards this research project. author contributions. sh and js collected the data and wrote the first draft of the manuscript. lc and nn supervised the project, edited the manuscript, responded to reviews and approved the final article. funding. cape peninsula university of technology. conflicts of interest. none. 1. national highway traffic safety administration. emergency medical services: agenda for the future. washington: nhtsa, 1996. 2. anderson p, petrino r, halpern p, tintinalli j. the globalization of emergency medicine and its importance for public health. bull world health organ 2006;84(10):835-839. https://doi.org/10.2471/blt.05.028548 3. kizer kw, shore k, moulin a. community paramedicine: a promising model for integrating emergency and primary care. california: california healthcare foundation, 2013. 4. health professions council of south africa. position statement on social determinants of health. pretoria: hpcsa, 2015. 5. commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. geneva: who csdh, 2008. 6. borges nj, hartung pj. service learning in medical education: project description and evaluation. int j teach learn higher educ 2007;19(1):1-7. 7. diab p, flack p. benefits of community-based education to the community in south african health science faculties. afr j prim health care fam med 2013;5(1). https://doi.org/10.4102/phcfm.v5i1.474 8. association of faculties of medicine of canada. an environmental scan of best practices in public health undergraduate medical education. ottawa: afmc, 2009. 9. gum l, dix k, ingerson c, clarke p. riverland rural emergency care students connecting with communities. abstract, tenth national rural health conference. cairns, australia, 17 20 may 2009. cairns: national health rural health alliance inc., 2009. 10. naidoo n, knight se, martin lj. conspicuous by its absence: domestic violence intervention in south african pre-hospital emergency care. afr safety promotion j 2013;11(2):76-92. 11. cape peninsula university of technology. primary health care 1: subject guide 2014. cape town: department of emergency medical sciences, cput, 2014. 12. groenewald t. a phenomenological research design illustrated. int j qualitative methods 2004:3(1):42-55. https://doi.org/10.1177/160940690400300104 13. govender k, grainger l, naidoo r, mcdonald r. the pending loss of advanced life support emergency cares in south africa. afr j emerg med 2011;2(2):59-66. 14. bamber p, hankin l. transformative learning through service-learning: no passport required. educ train 2011;53(2/3):190-206. https://doi.org/10.1108/00400911111115726 15. eyler j, giles d. the theoretical roots of service-learning in john dewey: toward a theory of service-learning. michigan j comm service learn 1994;1(1):77-85. accepted 16 september 2019 https://doi.org/10.2471/blt.05.028548 http://dx.doi.org/10.4102/phcfm.v5i1.474 https://doi.org/10.1177%2f160940690400300104 https://doi.org/10.1108/00400911111115726 april 2021, vol. 13, no. 1 ajhpe 77 research morrow[1] distinguishes between gaining access to an institution of learning and access to knowledge. to facilitate the latter, one needs to ascertain what students know about a subject to inform teaching to scaffold the learning process. the development of valid and reliable instruments is essential to guide and thus enhance teaching and learning activities. moreover, in the absence of pass or fail decisions associated with summative assessments, a low stakes baseline or formative assessment provides a less intimidating experience and an ideal starting point to establish what students know. importantly, these baseline assessments offer an opportunity to elucidate cognitive and content knowledge gaps that may exist.[2,3] this is valuable information, as students from diverse educational and socioeconomic backgrounds may be provided with access to an institution, but may not have access to the subject knowledge that is required to succeed. in the south african (sa) context, there are a few tailor-made test instruments that explore students’ preparation for university. the health sciences placement tests developed by the alternative admissions research project (aarp), currently the centre for educational testing for access and placement (cetap), were used by wadee and cliff[4] to predict academic success during the first year of study. the individual component scores of the test were aligned with biology, chemistry, physics, sociology, psychology and fundamentals of medical and clinical sciences to identify specific predictor domains of student success in a medical degree. allers et al.[5] used medical students’ national senior certificate (nsc) and national benchmark test (nbt) results to compile profiles of successful students and those who failed physiology, and to identify predictors for success in physiology. an earlier study at the university of cape town (uct) focused on developing a mathematical literacy questionnaire to identify which students entering the mb chb programme were in need of extra mathematical literacy interventions. the diagnostic tool showed a moderate improvement post intervention in the mathematical literacy of these students.[6] potgieter and davidowitz[7] developed the chemistry competence test to probe the school-university interface in sa for the level of conceptual understanding of chemistry. their study is similar to ours; however, none of these instruments addresses constructs obtained from grade 12 life sciences that are aligned to topics in the first-year anatomy and physiology curricula. in sa, the school-leaving (grade 12) examinations, administered by the department of basic education, measure whether students have acquired the knowledge and skills needed to exit the school system and enter tertiary-level education. some students admitted to the first-year mb chb, physiotherapy and occupational therapy programmes may not have studied and completed life sciences as a grade 12 subject, but rather mathematics and physical science, as these are entrance requirement subjects. even for students who have studied life sciences, given the variation in curriculum design and pedagogies employed by the various public and private high schools in sa, the grade 12 marks for life sciences do not give a dependable indication of a student’s foundational knowledge for first-year health professional courses. there are often huge variations in students’ cognitive, problem-solving and reasoning skills[8] that emerge background. universities in south africa use the grade 12 school-leaving examinations to measure whether students have the knowledge and skills needed to enter tertiary-level education. however, there is much discussion on the effectiveness of these assessments to measure the preparedness of students for their first year at university. to facilitate the appropriate teaching and learning of anatomy and physiology, there is a need to assess students’ baseline knowledge of life sciences at entry to their first year at university. objectives. to develop and refine an anatomy and physiology foundational knowledge assessment (a&p foundational knowledge assessment), which looks back to the content of the grade 12 life sciences curriculum and forward to the first-year anatomy and physiology curricula. methods. three hundred and seventy-one first-year students (occupational therapy, physiotherapy and mb chb) wrote the a&p foundational knowledge assessment. classic item and test analysis was done using iteman 4.3 software (assessment systems corp., usa). results. the kuder-richardson formula 20 (kr-20) reliability score, which ranges from 0 to 1, was 0.64 for all the students. for mb chb students, the kr-20 value was lower (0.57) compared with that for occupational therapy and physiotherapy students (0.66). the kr-20 scores for the 21 physiology and 16 anatomy items were 0.48 and 0.57, respectively. a kr-20 score of >0.50 is considered acceptable. the mean difficulty index (range 0 1) for physiology was 0.60, and the mean discrimination index was 0.15. for anatomy, the mean item difficulty index was 0.57 and mean discrimination index was 0.21. conclusion. based on the acceptable reliability value, the assessment was shown to be an effective instrument to measure students’ foundational knowledge in human anatomy and physiology, which is part of life sciences. afr j health professions educ 2021;13(1):77-82. https://doi.org/10.7196/ajhpe.2021.v13i1.1226 development of a baseline assessment tool to establish students’ foundational knowledge of life sciences at entry to university l pienaar,1 msc; r prince,2 msc; a abrahams,3 phd, pgdip (health professional education) 1 department of health sciences education, faculty of health sciences, university of cape town, south africa 2 centre for educational testing for access and placement, centre for higher education development, university of cape town, south africa 3 department of human biology, faculty of health sciences, university of cape town, south africa corresponding author: a abrahams (amaal.abrahams@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 78 april 2021, vol. 13, no. 1 ajhpe research from the different schooling experiences in this country. sa studies have also shown that in the physical sciences, students with poor cognitive and problem-solving skills often struggle in their first year at university.[9,10] poor performance has been linked to the lack of dialogical discourse, rote learning and failure of teachers to ensure that students actively engage with the content.[11] students in t h e health sciences are taught anatomy and physiology in their first year, with the assumption that they have acquired the prerequisite foundational knowledge and cognitive skills from their grade 10 12 curricula. currently, when students enter t h e i r first year at university, there is no assessment to measure their level of knowledge and to identify those who may benefit from early academic support in anatomy and physiology. consequently, students who fail the anatomy and physiology courses must repeat these, or are placed in an extended degree programme.[12] in our study, we describe the development and refinement of a novel baseline assessment, which aligns content of the grade 12 l ife sciences curricula with content that is relevant to the first-year anatomy and physiology curricula. methods study design the study describes the development of a baseline assessment to determine students’ foundational knowledge of human anatomy and physiology on entry to university. psychometric analysis was performed to measure the reliability of the test instrument. characteristics of the study population (sampling) and procedure a total of 371 students admitted into the first-year mb chb, physiotherapy and occupational therapy programmes completed the multiple-choice assessment. these undergraduate programmes in the health sciences faculty offer anatomy and physiology courses during the first semester of the first year. whereas the admission requirements for the first year at university vary, it is expected that all students should have mathematics and physical sciences or life sciences to be eligible for acceptance into the different programmes. at the higher education institution where the study was conducted, the minimum entrance requirements for first-year mb chb students is at least 60% for mathematics, physical sciences and english and at least 50% for the 3  next best subjects. the entrance requirements for the first year in the division of physiotherapy are that students obtain at least 50% for all subjects, which must include mathematics and physical sciences or life sciences. for the division of occupational therapy, students are required to have obtained at least 50% for all subjects, which must include physical sciences or life sciences and mathematics (or 60% for mathematical literacy). all students wrote the same nsc examination, and therefore were expected to have acquired the foundational knowledge and cognitive skills in the subjects. a 37-item 4-option (single best answer) multiple-choice assessment was developed and administered during the first week of lectures on the university’s online learning system. the responses of participants (including the questions) were exported into an excel spreadsheet (microsoft corp., usa) for further analysis by a test development co-ordinator. participants’ names and student numbers were anonymised by the primary investigator (aa). only students who gave consent and were ≥18 years old at the time, were eligible participants. development of the data collection instrument the pool of multiple-choice assessment items was developed by the principal investigator and co-investigators to explore students’ cognitive skills and conceptual knowledge in anatomy and physiology. the content for the selected items was based on the content of the 2012 2015 grade 12 final life sciences examination papers and relates to the curriculum covered in the first-year anatomy and physiology courses. the items were evaluated by 2  disciplinary experts to ensure adequate coverage of the domain and field of anatomy and physiology. the researchers carefully selected the distractors for each item, based on content and concepts that past students found challenging. this was done to give researchers a better understanding of students’ knowledge, misconceptions and reasoning abilities at the start of the academic year. each of the items for the anatomy and physiology foundational knowledge assessment (a&p foundational knowledge assessment) was rated according to the cognitive domains of bloom’s taxonomy. this taxonomy is frequently[13-16] used to classify the cognition required in multiple-choice items. the items were designed with specific focus on bloom’s taxonomy categories of knowledge and comprehension, as these were thought to be the most appropriate at an entry level to first-year anatomy and physiology.[17] for each of the items, the knowledge domain and comprehension required to solve the problem were analysed and documented in a specification table (table 1) before administering the test. this helped to shed light on the students’ level of understanding of the concepts and sub-concepts of the content tested. topics included: homeostasis, anatomical terminology, levels of organisation of the human body, body systems, the endocrine system, development and inheritance. in 2016, the assessment was piloted using data from 134 students in the first-year anatomy and physiology courses to allow for revision and refinement. table 1. classification of each item in each domain assessed into the cognitive levels of bloom’s taxonomy bloom’s taxonomy categories items in each domain, n medical students, mean (sem) occupational therapy and physiotherapy students, mean (sem) p-value level 1: knowledge 26.59 (4.20) 21.18 (4.66) <0.0001 physiology 10 anatomy 11 level 2: cognitive skills (comprehension) 26.43 (4.29) 21.13 (4.66) <0.0001 physiology 11 anatomy 5 sem = standard error of the measurement. april 2021, vol. 13, no. 1 ajhpe 79 research analysis item difficulty and item discrimination were calculated for each item of the assessment using iteman version 4.3 software (assessment systems corp., usa).[18] the classic test theory (ctt) analysis[19] allowed insight into the reliability of the overall test and of the anatomy and physiology domains independently. individual questions were analysed according to: (i) reliability of the test without the item; (ii)  item difficulty; (iii)  discrimination indices; and (iv)  correlation indices. the total scores, standard deviations, standard error of the measurement (sem) and distribution scores were also calculated using the ctt iteman software. analysis was performed on the whole group and by splitting the students into 2 groups – the mb chb students in one group and the combined physiotherapy and occupational therapy students in another group. the reason for splitting the students into the 2 groups is that, in the health sciences faculty, not only are the admission requirements similar for the occupational therapy and physiotherapy students, but these students register for the same anatomy and physiology course in their first year. data collected were coded by a research assistant. the coded data were recorded in an excel program (microsoft corp., usa) and later transferred to spss version 25 (ibm corp., usa). in addition to the abovementioned analyses, the mean and distribution scores of the 2 groups were compared with each other. ethical approval the proposal received ethical approval from the human research ethics committee of the faculty of health sciences at the university of cape town (ref. no. hrec 7982016). results overall reliability, item difficulty and discrimination performance of the baseline assessment analyses were performed on the test as a whole and on the 37 items consisting of 2 domains: anatomy and physiology. for the 2 student cohorts, using the kuder-richardson formula 20 (kr-20), the test had an overall reliability of 0.64  (alpha), with the sem at 2.53. as an assessment, the instrument demonstrated an acceptable level of reliability, given that it was a low-stakes assessment with only 37 items. the small sem shows that the observed scores were closely distributed around a student’s ‘true’ score. we then evaluated the  performance for each of the items by analysing the pointbiserial correlation discrimination indices (rpbis). this was done to ascertain how well the item differentiated between lowand high-scoring students and how easy or challenging each item was, expressed as an item difficulty index (p-value). items were deemed difficult if the index was ≤0.25 and easy if it was ≥0.95. the discrimination index ranges from ‒1 to +1. here, negative scoring items are considered to have poor discrimination, given that low-scoring students were more likely to choose the correct option than high-scoring students. a discrimination index of ≥0.2 was considered to offer the best discrimination.[20-22] overall, the mean score for all the test items was 21.73, with 59% of students answering the items correctly (mean p=0.59). of the 37 items, 6 items were flagged as not discriminating well, with 2 of the 6 items having negative discrimination and 2 of the 6 items having a p-value of 0.1 0.2. overall, item difficulty was reasonable, although the item discrimination index of all 37 items would need to be reviewed, as the mean rpbis of 0.18 was lower than expected (table 2). reliability, item difficulty and discrimination performance in the anatomy and physiology domains the physiology and anatomy domains consisted of 21 and 16 items, respectively. individually, the domains demonstrated lower reliability than the overall assessment, with physiology kr-20 at 0.48 and anatomy kr-20 at 0.57. given the small number of items in each domain, it is not surprising that the reliability tended to be on the low end of acceptable, as reliability is a function of the number of items in a test. the mean item difficulty index (p-value) for physiology was 0.60, with a lower mean discrimination index of 0.15, whereas anatomy had a mean item difficulty index (p-value) of 0.57 and a marginally higher mean discrimination index of 0.21. overall, some of the items in the physiology domain failed to discriminate the high-scoring students from those who achieved lower scores. the items that failed to discriminate would need to be reviewed; for anatomy the item discrimination was reasonable. the anatomy items were only slightly more challenging, with students achieving a correct score of 56.6% compared with physiology at 60.4% (table  2). the combined scores for all the items and the distribution of raw scores for physiology and anatomy, respectively, were normally distributed. the two domains had a low correlation of 0.37, indicating that what was being tested was distinct (fig. 1). comparison of test scores for medical, physiotherapy and occupational therapy students in addition to establishing the overall reliability of the assessment, we were  interested in determining whether the occupational therapy, physiotherapy and medical students performed similarly or differently in the baseline assessment. the baseline assessment scores of the medical students were slightly higher than those of the occupational therapy and physiotherapy students. the mean test scores for the medical students for  the anatomy and physiology test was 26.03. of the 227 medical students, an average of 59% answered the items correctly. in comparison, the occupational therapy and physiotherapy students (n=144) had a mean score of 20.06  for the anatomy and physiology test, where 53% of the students answered the items correctly. we then compared the students’  results on  the baseline assessment with those of their final grade 12 life sciences  results  for both medical, occupational therapy and physiotherapy students. of the 371  registered first-year students, the table 2. item difficulty and discrimination for all scored items in each domain domain items, n mean (sd) minimum score maximum score mean p-value mean rpbis items scored, n 37 21.73 (4.25) 10 34 0.59 0.18 physiology 21 12.68 (2.69) 5 19 0.60 0.15 anatomy 16 9.05 (2.45) 0 16 0.57 0.21 sd = standard deviation; rpbis = point-biserial correlation discrimination indices. 80 april 2021, vol. 13, no. 1 ajhpe research majority had studied life sciences (n=356) (medical, n=217; physiotherapy and occupational therapy, n=139). fewer than 10% of students reported not having studied life sciences (medical, n=11; physiotherapy and occupational therapy, n=4). medical students entered university with a slightly higher final school grade for life sciences than physiotherapy and occupational therapy students. the mean life sciences grade for medical students was 88% (n=217) (range 74 100%). the physiotherapy and occupational therapy grade was 71.50% (n=139) (range 47 94%). the results of the baseline assessment showed a similar trend as for the life sciences grades, as medical students scored slightly higher than occupational therapy and physiotherapy students for anatomy and physiology. when we compared the performance of students based on bloom’s taxonomy in knowledge and comprehension (table  1), the medical students scored significantly higher in both cognitive categories than occupational therapy and physiotherapy students. this aspect of the research will be explored in greater detail in another study, focused on the understanding of the life sciences conceptual knowledge and problemsolving skills students possess at the start of the academic year. reliability of the test for the 2 student groups the test had a lower reliability for the medical students (0.57), with a larger sem (2.78) than for the occupational therapy and physiotherapy students, where the test reliability score was (0.66), with an sem of 2.66. when calculating the reliability of the individual domains of anatomy and physiology for each discipline, the test achieved lower reliability. in physiotherapy and occupational therapy, the anatomy and physiology domains achieved a reliability of 0.60 and 0.42, respectively, whereas for m edical students a slightly lower reliability was achieved for anatomy (0.52); physiology was higher (0.43). discussion this study describes the development and refinement of an assessment instrument that aims to establish students’ foundational knowledge of human anatomy and physiology learnt in grade 12 life sciences. the benefits of such an assessment can be to inculcate content expertise, alter attitudes, promote student growth and offer an opportunity to receive feedback from peers and lecturers.[23] moreover, the assessment can also provide an opportunity for lecturers to understand students’ prior knowledge[24,25] and to use this information to inform teaching.[26,27] establishing the knowledge that students bring into learning spaces is less well explained in the literature.[28] the baseline assessment administered to first-year health sciences students shows potential as an efficient and acceptable method to establish students’ prior knowledge. ideally, assessments that inform pass or fail decisions, such as summative examinations, should have a reliability coefficient of >0.8.[29] this is because the consequences of these decisions have an impact on the students’ future, whereas the aim of the baseline assessment was to inform teaching and learning. in our study, the assessment achieved a modest reliability of 0.64, which is lower than assessments that examine student preparedness.[4,7] it can be attributed to the fact that we purposely selected key themes that  served as indicators of entry-level foundational knowledge. this resulted in a limited number of items generated, and the associated shorter length of test administration most likely played a part in the lower reliability that is usually associated with formative assessments (0.70 0.79).[30] even in light of the reliability score, this instrument provides a way to gather information to benefit teaching and learning, as it looks back to the content of the grade 12 life sciences curricula and forward to first-year anatomy and physiology  curricula. in this way it links prior knowledge with knowledge of the forthcoming subject. using this test, we were able to determine that ~60% of students had basic knowledge to build on as they entered university. previous studies have shown that students who performed well in secondary school subjects were more likely to perform well at university.[31,32] medical students who entered with higher grade 12 life sciences grades performed better in the baseline assessment. the multiple-choice baseline assessment performed differently across the 2 groups, with lower reliability achieved in the medical students’ group. reliability can be affected by the formulation of the items, such as a mistake on the correct scoring key. other factors that can affect reliability are poorly prepared students guessing correctly and well-prepared students somehow justifying the wrong answer.[33,34] in the assessment, only 6 items were found to be problematic. the majority (57%) of the items were developed at the knowledge level, which may have 80 70 60 50 40 30 20 10 0 fr eq u en cy , n 80 70 60 50 40 30 20 10 0 fr eq u en cy , n 70 60 50 40 30 20 10 0 fr eq u en cy , n 10 15 20 25 30 35 overall score, n (correct) 0 5 10 15 anatomy score, n (correct) 5 10 15 20 physiology score, n (correct) fig.  1. distribution of the raw scores across combined and individual domains (anatomy and physiology). april 2021, vol. 13, no. 1 ajhpe 81 research contributed further to the difference in performance between the 2 groups. for the continued use of the baseline assessment, the items must be reviewed and adapted to accommodate the range of student groups being tested, as well as increasing both the number of questions and length of the test.[35] indirectly, this baseline assessment also provided an opportunity for students to access and retrieve information that was learnt previously, which may be used in the future.[36,37] this retrieval facilitates learning even if the attempt is unsuccessful,[36] as it shows students where their knowledge gaps are. in this way, students can adjust their learning strategies. as can be observed from the test scores, students possess a reasonable level of understanding of the subject. where it is shown that students do not possess the required content knowledge early in the academic programme, it offers an opportunity to effect changes to teaching, such as academic support interventions.[38] in our study, students were offered additional support alongside the course when their test score was ≤55%. (the results of this study will be reported in a future publication.) instituting these types of interventions is especially important where students who work with patients need to use their science knowledge to inform clinical decisions. using a less intimidating low-stakes baseline assessment may clarify the concepts that link prior knowledge to current experiences. lessons learnt a range of criteria exists that supports the development of rigorous assessment instruments that can withstand internal and external scrutiny. we set out to develop a reliable instrument, while giving attention to validity and  the educational benefit.[39] during the development process, we  were mindful to ensure that the instrument assesses students’ knowledge at the  appropriate cognitive level, using the relevant content. the results indicate that additional work is required to improve the quality of the items to consistently achieve accurate results. alongside the criteria mentioned in  developing the instrument, we also paid attention to fairness and feasibility.[40] using a method of assessment that students have some familiarity with from high school is helpful, especially if the assessment is to be taken early in the year. the items were reviewed for content validity and language by lecturers associated with the programmes and educationalists to ensure that english additional language speakers were not negatively affected. a baseline assessment used to inform teaching can be challenging to administer early in the course, where class schedules are set in advance. in our faculty, timetable planning in some instances is done months or a year in advance, which limits the freedom of introducing assessment for learning opportunities. within a structured curriculum, the emphasis is often on gaining content knowledge and developing appropriate formative and summative assessments, which dictate the timetable. the success of developing baseline assessments to inform teaching and learning not only requires the buy-in from relevant stakeholders, but should be core to the design of a first-year curriculum. conclusion establishing baseline assessments clarifies assumptions regarding the knowledge of students when starting university study. it enables lecturers to create scaffolded learning opportunities to bridge the gaps in knowledge, and in doing so helps to facilitate access to subject knowledge. while we recognise that to establish statistical levels of reliability, repeated assessment opportunities are needed until an optimal level of reliability is achieved, this may not always be required if a low-stakes assessment directed at learning is developed. declaration. none. acknowledgements. we thank ms stevie biffen, a research assistant at uct, for her contribution to data capturing, and prof. shirley pendlebury and ms vera frith, uct, for their helpful comments on the manuscript. author contributions. lp contributed to the design of the research, analysis and writing 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anatomy and physiology instructor pedagogy. adv phys educ 2014;38(4):321-329. https://doi.org/10.1152/advan.00061.2014 39. schuwirth lwt, van der vleuten cpm. changing education, changing assessment, changing research? med educ 2004;38(8):805-812. https://doi.org/10.1111/j.1365-2929.2004.01851.x 40. van der vleuten cpm. the assessment of professional competence: developments, research and practical implications. adv health sci educ 1996;1(1):41-67. https://doi.org/10.1007/bf00596229 accepted 16 january 2020. https://doi.org/10.1080/07924360120043621 https://doi.org/10.1080/07924360120043621 https://doi.org/10.1080/02602930500352857 https://doi.org/10.1016/bs.plm.2016.03.003 https://doi.org/10.1016/bs.plm.2016.03.003 https://doi.org/10.1002/ase.250 https://doi.org/10.1152/advan.00061.2014 https://doi.org/10.1111/j.1365-2929.2004.01851.x https://doi.org/10.1007/bf00596229 june 2021, vol. 13, no. 2 ajhpe 96 short report a case study is an innovative teaching and learning strategy that is grounded in case-based learning (cbl).[1] cbl is a form of inquiry-based learning that fits on the continuum of structured and guided learning, which prepares students for clinical practice, using authentic clinical cases that mimic the real world.[2] a systematic review indicated that case study is a teaching strategy that has been used to help students in nursing and medicine to learn about spirituality.[3] however, there are no studies in occupational therapy (ot) education regarding the use of a case study. there is a need for research in the ot paradigm about the relevancy of a case study to enhance the holistic approach of body-mind-spirit. the requirements of a case study that helped the second-year ot students to apply their knowledge and skills throughout the semester of the ot and chronic diseases module are presented in table 1. methods exploratory-descriptive qualitative research was conducted to explore ot students’ experiences of using case study as a teaching strategy to learn about spirituality. the kirkpatrick framework of evaluation of educational interventions related to perception, knowledge, skills, attitudes and behavioural changes guided the study.[4-6] purposive sampling with a maximum variation was used to recruit and select participants (n=32), who were registered for a second-year ot module in 2018. three research assistants simultaneously conducted and audiotaped three focus group discussions with only 25 second-year students, who consented to participate in the study. the students’ responses related to the questions about their understanding of spirituality and experiences of using the case study were transcribed verbatim. atlas.ti8 windows (atlas.ti, germany) was used to thematically analyse the transcribed data through familiarisation, coding, refining and reviewing, and naming of the themes. this was a peer-examined  process with an audit trail to enhance credibility and confirmability. ethical approval ethical approval was obtained from the university of the western cape human and social science research ethics committee (ref. no. hs18/4/5). results and discussion theme 1: importance of a case study the first theme contextualises the importance of a case study in facilitating learning among ot students’ journey, which assisted them to learn about spirituality. the findings from the first theme corroborate with levels 1 and 2 of kirkpatrick, which indicate that a case study provided the students with learning experiences for acquisition of concepts:[4,5] ‘spirituality is about connectedness with your surroundings even the people around you. i did not know that spirituality is like the internal part. if your spirit is positive, you are going to bring out that energy. it  includes prayer that connects self with the greater being. now, i have the background of spirituality; i could see when we went to our client in strand.’ ‘it [case study] really helps you to understand the bigger picture, and to look at every little aspect to form a conclusion based on assessing every little thing; it is an effective teaching method.’ background. a case study is a teaching strategy that is used in other professions, such as nursing and medicine; however, there are no studies that focus on the experiences of occupational therapy (ot) students regarding the use of a case study to learn about spirituality. objectives. to explore undergraduate ot students’ experiences of using a case study as a teaching strategy to learn about spirituality. methods. exploratory-descriptive qualitative research was conducted, using purposive sampling to select and recruit second-year ot students (n=25) who consented to participate in the study. transcribed data from three focus group discussions were thematically analysed through a credible process. results. two major themes were identified. theme 1, the importance of a case study as a teaching method, deals with students’ learning experiences of using a case study. theme 2, skills learnt through a case study, highlights profession-specific and academic skills that students managed to acquire and apply by using a case study as a learning strategy. conclusion. this study provided insight into the ot students’ experiences of using a case study. the findings are consistent with previous research that focuses on the use of a case study as a teaching strategy, which enabled students to apply their knowledge in a real-life situation by recognising and solving problems through engaging in critical reflection and using various skills. this work contributes to existing knowledge of health sciences education by providing teaching and learning strategies that educators may use to facilitate students’ engagement in collaborative learning. afr j health professions educ 2021;13(2):96-98. https://doi.org/10.7196/ajhpe.2021.v13i2.1354 exploring experiences of using a case study as a teaching strategy to learn about spirituality in occupational therapy education t g mthembu,1 bsc ot, mph, phd; a rhoda,2 bsc pt, msc, phd 1 department of occupational therapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: t g mthembu (tmthembu@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://atlas.ti https://doi.org/10.7196/ajhpe.2021.v13i2.1354 mailto:tmthembu@uwc.ac.za 97 june 2021, vol. 13, no. 2 ajhpe short report ‘it gives you a picture of the person rather than learning from a textbook that a client has this. it gives the person’s image, not just what they do in everyday life but understanding of [what] the person believes; the person goes to church and pray. it helps us to understand the client on a spiritual level. it help us learn how we can adapt our intervention.’ ‘it also made me understand like what is happening in the real world rather than just reading it but actually going there asking questions.’ the students experienced a sense of belonging and becoming because they collaborated with each other as part of student-centred and peer learning, using available educational opportunities for teamwork. this finding corroborates with level 2 of kirkpatrick, which highlights the importance of self-assessment, growth and self-efficiency:[4,5] ‘when you are doing case studies you are in groups, you learn to like the opinions of others; you learn how to acknowledge their opinions, strengthens and your relationship with your colleagues because you need each other.’ ‘i think that everything that you need is there, and you have resources around you, lecturer, friends and group so you can help yourself out if you are willing to try.’ ‘you learning everything for yourself to better your own knowledge.’ ‘i have realised that in group work you grow as a person because you learn about your strengths and weaknesses. there is a room to fix your work ethic and it helps with reflection.’ the students shared that they were able to use scaffolding strategies to dismantle a case study into manageable pieces, which enabled them to learn about the person-environment inter-relationship: ‘by using case studies you learn the ability to break things down and interpret all the little pieces one by one, so you know like not just looking at it as like a big chunk of steak. you know, you cut the steak up and then you know it is easier to eat kind of a thing.’ ‘the part that helped me while in the community; we had to break down all the social injustices. since we already learnt about social injustices so we could use our knowledge.’ ‘it was a good way for us to work in a group because we all came from different backgrounds like ethnically, racially and religiously everywhere from different backgrounds, it was a very good way to see things from a different perspective.’ the findings in theme 1 further support level 3 of kirkpatrick, which fostered behavioural changes among the students to apply their knowledge of social injustices while in community settings.[5] theme 2: skills learnt through a case study the second theme deals with profession-specific and academic skills that students learnt using a case study, which are substantiated by acquisition of kirkpatrick level 2 skills.[4,5] ot students gained profession-specific skills related to activity analysis and reflection: ‘case study is a little bit so you are breaking up your case into little pieces. it makes it easier to see and it teaches new skills on how to do an activity analysis.’ ‘you actually reflect upon what you should have done and what you should do and what you shouldn’t have done so i think that is where you better understand it based on the case study that was given.’ the students incorporated the gained educational skills related to information management and research as part of the case study to seek, discern and apply their knowledge in a real world: ‘it encourages you to go find out information about the real world, you have to experience that and use literature and do research. i learned how to reference really well.’ the students gained confidence with personal skills (leadership, goal setting and creativity) that helped them to develop interpersonal interaction and flexibility, while solving complex problems with others: ‘i had to take the lead and i had to do everything. it actually worked a lot by using time management as well and taking things step-by-step … i learned how to delegate tasks and be able to trust people with something important, as my academics.’ ‘ot skills are like completely thinking out of the box you know and adapting yourself to a situation where you have no idea what to do ... there is no basis of understanding or anything. you are thrown into the deep end and you are afloat.’ ‘i learnt setting a goal by this day or that date, i want to accomplish this and you feel like you accomplished, and it actually boost your confidence.’ these findings support level 2 of kirkpatrick and case-based learning because the students immersed themselves in their learning, which enabled them to gain more educational skills related to thinking/problem-solving and psychomotor and social skills if they are provided with learning opportunities.[1-8] overall, the findings of the current study indicate that students had a better understanding of spirituality as an internal energy that connects self with nature and others. the findings further show that the construction of a case study enabled the students’ involvement, i.e. they table 1. requirements for a case study in occupational therapy and chronic diseases module students expectations • students were allocated to groups of 5 each and were expected to work together to design their case study, as part of sharing the workload • students were expected to apply the knowledge gained from classroom activities and a real-world situation • students had to identify and assess an older adult with chronic conditions (e.g. diabetes, hypertension, rheumatoid arthritis and amputation) using the world health organization international classification of functioning, disability and health to conceptualise a client in the community and design a case study • students had to give feedback on their progress and how they brainstorm regarding their case study • students had to access accredited journals in the library to search for articles related to their case study, and then summarise the literature in their own words • students were expected to use appropriate knowledge, research, referencing (mechanics) and peer feedback, digital and ethical reasoning, as well as quality of presentation (powerpoint clear, not colour blind) • students were expected to prepare a presentation of their case study as part of their evaluation • students were expected to make recommendations for the clients’ adaptations, which makes the students engage with older adults in the real world. june 2021, vol. 13, no. 2 ajhpe 98 short report felt that they were involved in their learning and that they were part of the real world. study limitations the results cannot be generalised to other professions or institutions, as they apply to ot students in an institution of higher learning. conclusion the objective of this study was to explore ot students’ experiences of using a case study as a teaching strategy to learn about spirituality. based on the findings, it is clear that the use of case study helped them to learn about the importance of clients’ spirituality and themselves as spiritual beings. study results further indicated that the students achieved a variety of learning skills, including brainstorming, searching, reading and using the literature, researching and referencing, reflecting, scaffolding, collaborating and assessing. declaration. none. acknowledgements. we would like to thank the institution of higher learning for granting permission to conduct the study, the participants for sharing their experiences, the sub-saharan africa-faimer regional institute (safri) and the research assistants. author contributions. tgm conceptualised the study, applied for ethical clearance, reviewed the literature and wrote the methodology, results, discussion and conclusion. ar supervised and critically reviewed the article. funding. none. conflicts of interest. none. 1. rybarczyk bj, baines at, mcvey m, thompson jt, wilkins h. a case-based approach increases student learning outcomes and comprehension of cellular respiration concepts. biochem molec biol educ 2007;35(3):181-186. https://doi.org/10.1002/bmb.40 2. thistlethwaite je, davies d, ekeocha s, et  al. the effectiveness of case based learning in health professional education. beme guide number 23. med teach 2012;34(6):e421-e444. https://doi.org/10.3109/014215 9x.2012.680939 3. mthembu tg, wegner l, roman nv. teaching spirituality and spiritual care in health sciences education: a systematic review. afr j physical activity health sci 2016;22(4:1):1036-1057. 4. kirkpatrick j, kirkpatrick wk. the kirkpatrick four levelstm: a fresh look after 50 years. 2009. https:// openspaceconsulting.com/wp-content/uploads/2019/06/kirkpatrick-four-levels-wp-updated.pdf (accessed 26 march 2020). 5. hooper b, king r, wood w, bilics a, gupta j. an international systematic mapping review of educational approaches and teaching methods in occupational therapy. br j occup ther 2013;76(1):9-22. https://doi.org/10.42 76%2f030802213x13576469254612 6. howe t, sheu c, hinojosa j. teaching theory in occupational therapy using a cooperative learning: a mixedmethods study. j allied health 2018;47(1):66-71. https://doi.org/10.5014/ajot.2016.70s1-po3020 7. govender p, mostert k. making sense of knowing: knowledge creation and translation in student occupational therapy practitioners. afr j health professions educ 2019;11(2):38-40. https://org/10.7196/ajhpe.2019. v11i2.1123 8. unin n, bearing p. brainstorming as a way to approach student-centered learning in esl classroom. procedia social behav sci 2016;224:605-612. https://doi.org/10.1016/j.sbspro.2016.05.450 accepted 17 august 2020. https://doi.org/10.1002/bmb.40 https://doi.org/10.3109/0142159x.2012.680939 https://doi.org/10.3109/0142159x.2012.680939 https://openspaceconsulting.com/wp-content/uploads/2019/06/kirkpatrick-four-levels-wp-updated.pdf https://openspaceconsulting.com/wp-content/uploads/2019/06/kirkpatrick-four-levels-wp-updated.pdf https://doi.org/10.4276%2f030802213x13576469254612 https://doi.org/10.4276%2f030802213x13576469254612 https://doi.org/10.5014/ajot.2016.70s1-po3020 https://dx.doi.org/10.7196/ajhpe.2019.v11i2.1123 https://dx.doi.org/10.7196/ajhpe.2019.v11i2.1123 https://doi.org/10.1016/j.sbspro.2016.05.450 cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can checkthe answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/007/01/2011 (clinical) cpd 93 july 2012, vol. 4, no. 1 ajhpe 1. true (a) or false (b): physiotherapy students in nigeria awarded clinical teachers with doctoral degrees a higher rating for their teaching attributes. 2. true (a) or false (b): in nigeria, physiotherapy students from different programmes awarded similar ratings to their teachers. 3. which south african university’s perceived strength in physiology teaching is the use of active teaching and learning strategies such as group work? a. university of limpopo medunsa campus b. stellenbosch university c. university of cape town d. university of the witwatersrand e. walter sisulu university f. university of kwazulu-natal. 4. which south african university’s perceived strength in physiology teaching is the use of tutorials (small group teaching) in 2nd year to integrate knowledge gained in lectures? a. university of limpopo medunsa campus b. stellenbosch university c. university of cape town d. university of the witwatersrand e. walter sisulu university f. university of kwazulu-natal. 5. true (a) or false (b): with regards to managing change, the right people are your most important asset. 6. true (a) or false (b): with regards to managing change, academic excellence is the goal of all tertiary training institutions. 7. true (a) or false (b): with regards to managing change, faculties of health sciences make a very real difference in peoples’ lives. 8. true (a) or false (b): regulations in faculties of health sciences form the foundation of managing a programme. 9. true (a) or false (b): in terms of health care in south africa, budget mechanisms and principles have to be revised to produce a coordinated health structure with clearly defined quality health outcomes. 10. true (a) or false (b): the minister of health in south africa has identified 8 focus areas within institutions to improve the quality of health care. 11. true (a) or false (b): south african institutions of higher education have to train health professionals who are primarily suited to work internationally. 12. true (a) or false (b): children born from 1994 onwards are regarded as the z-generation. 13. true (a) or false (b): the term ‘bubble-wrapping’ refers to the manner in which parents have raised children born in 1994 and onwards. 14. true (a) or false (b): generation-z people value the opinions of other people. 15. true (a) or false (b): one of the 10 core activities of the gale and grant model of change management used in the process of widening access to the allied health sciences programmes at the university of cape town was ‘the identification of a shared problem’.  16. true (a) or false (b): the curriculum review management team (crmt) at the university of cape town did not encounter resistance to the change management process aimed at widening access to undergraduate allied health sciences education.  17. true (a) or false (b): the population groupings (profile) of students in the school of health and rehabilitation sciences at the university of cape town did not show widened access after the transformation process.  18. true (a) or false (b): in many countries in africa there is difficulty attracting postgraduate students to anaesthetics as it is often perceived as a mid-level worker specialty. 19. true (a) or false (b): dietetics students considered intra-personal professionalism attributes more important than public or inter-personal professionalism attributes throughout all student years. 20. true (a) or false (b): dietetics students only consider ‘not letting personal beliefs influence care’ as an important component of professionalism when they reach more senior years of study. cpd july 2012 september 2021, vol. 13, no. 3 ajhpe 205 research why was the idea necessary? in higher education institutions (heis), student evaluation of course outcomes is a standard that must be met by all programme course convenors to improve teaching quality and to deliver a student-centred curriculum.[1] in the faculty of health sciences (fhs) at the university of cape town (uct), all first-year health sciences students (fyhsc) are required to register for two compulsory courses becoming a professional (bp) in the first semester and becoming a health professional (bhp) in the second semester. both courses constitute the faculty’s core curriculum. we follow a participatory and experiential educational approach, framed around an understanding of sound professional relationships as the focus of bp, and primary healthcare and disability as the focus of bhp. students work collaboratively in small groups of 10 12, with a qualified facilitator, either on a tuesday, wednesday or thursday afternoon. during the 2020 academic year, following the declaration of covid19 as a global pandemic[2] and the subsequent declaration of the national state of disaster in south africa (sa),[3] educators had to prepare for digital migration[4] to online learning. at uct, this migration was referred to as emergency remote teaching (ert).[5] while students were granted an extended vacation, educators had two weeks to adapt to an ert mode of delivery. uct introduced students to online tutorials that supported an adjusted ert curriculum in the first week of term 2. for bp and bhp, we adjusted training sessions with facilitators to make provision for variables that were likely to impact teaching and learning, such as the students’ diverse backgrounds and learning environments; electricity load-shedding by eskom; and data distribution and consumption patterns. considering the urgency with which we had to implement adaptations to teaching and learning, at the end of semester 2 we modified an existing survey tool so that we could source realistic feedback from students. using a qualitative design approach, which was limited to evaluating adjustments to only bhp curriculum content, we asked three probing questions. these were tailored to evaluate students’ experiences of lectures, weekly group tutorials and assessments (table 1). this report sought to evaluate students’ experiences of ert with the aim to ascertain benefits and challenges of the learning experience, and to inform planning for a blended learning approach in 2021.[6] what was tried? with teamwork as one of the key learning outcomes in bhp, students were introduced to public health to appreciate efforts to reorientate services to prevent ill-health and protect communities through the organised efforts of society.[7] as lockdown regulations barred access to communities and health facilities, we substituted site visits with virtual visits to provide students with authentic experiences. we revised bhp course assessments and replaced an essay with an open-book assessment consisting of multiplelearning during a pandemic: evaluating university of cape town firstyear health sciences students’ experiences of emergency remote teaching n o mapukata, msc med, msc health care management; s k toto, bsc occ therapy school of public health and family medicine, faculty of health sciences, university of cape town, south africa corresponding author: n o mapukata (ntsiki.mapukata@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. table 1. modified survey tool q1: lectures q2: weekly group tutorials q3: site visits q4: mc q/saq, open book q5: online group presentations what were the benefits of receiving content as recorded lecture videos? what were the benefits of participation in weekly group tutorials using an online approach? what were the benefits of undertaking virtual site visits to communities and health facilities? what were the benefits of evaluating your knowledge and understanding using an mcq/saq in an open-book approach? what were the benefits of online presenting as a group (prerecorded or live)? what were the challenges in sourcing lecture videos online? what were the challenges in undertaking group work in this manner? what were the challenges regarding learning about communities/facilities if content was presented in a prerecorded format? what were the challenges of being assessed in this manner? what were the challenges of being assessed in this manner? if you were presented with options, would you prefer content to be delivered online, face to face in lecture theatres or would you rather have access to both formats (online and face-to-face)? if you were presented with options, what would be your stated preference regarding weekly tutorial sessions (online or face-to-face)? if you were presented with options, what would be your stated preference for community and health facility site visits? if you had an option, would you prefer to continue with an mcq/saq assessment  (open book) or would you prefer to present your knowledge in the essay format? if you were presented with options, would you prefer your group presentations to be assessed online (prerecorded) or online (live) or face-to-face in front of your classmates? q = question; mcqs/saqs = multiple-choice questions/short-answer questions. mailto:ntsiki.mapukata@uct.ac.za 206 september 2021, vol. 13, no. 3 ajhpe research choice and short-answer questions (mcqs/saqs) that assessed students’ understanding of applied knowledge in context.[8] for example, to test students’ understanding of the concept of health for all (hfa), each student was asked to draw up an hfa manifesto for the fhs in preparing for a term of office in the health sciences students council. this exercise was critical in identifying what students considered to be priority needs for a community of health sciences students. many students mentioned access to equitable healthcare, some even suggesting the establishment of a student clinic on the health sciences campus or at groote schuur hospital. interestingly, this was one of the students’ demands during the 2016 #occupyfhs student movement. other priority areas were access to healthy meals at the canteen, and a more specific request was the delivery of medication to students living with conditions such as hiv and tuberculosis (tb). lessons learnt the course evaluation that was structured to evaluate students’ experiences of ert yielded a response rate of 67% (n=262), which taught us many valuable lessons. lectures. most of the participants (66%; n=258) were in favour of blended teaching approaches and assessments that included face-to-face and prerecorded lectures: ‘i was able to take notes while watching the videos and re-watch certain parts.’ participant 7 another benefit of ert that was mentioned by a few participants was the opportunity to manage one’s own time and being in control of the learning experience: ‘i love the flexibility of online learning in terms of time and study hours. also, more importantly, the ability to catch up lectures and pause them and rewind and re-watch for me, that makes a big difference in learning because i can learn at my own pace.’ participant 23 for a third of participants, ert denied them the validation and authenticity that come with attending lectures, where they can engage their lecturers: ‘for myself, i remember the content of a lecture much better when i can both see and hear the lecturer, so it becomes difficult to learn when i cannot see the lecturer.’ participant 37 we also learnt that learning is not always consumed in structured settings and that we should focus on the attitude to learning: ‘ability to switch off the cameras and even attend the meeting while lying on the bed.’ participant 34 ‘online learning was greatly beneficial … i found lecture halls distracting.’ participant 180 some participants reported that they experienced technical challenges, while a few struggled to negotiate study time in their natural environments: ‘technology just fails us at times … i don’t know how many times my laptop crashed this semester and that was really stressful for me.’ participant 205 ‘another challenge i faced was balancing between household duties and schoolwork, as staying at home all day came with taking on more responsibilities.’ participant 226 group sessions. with the implementation of ert, we approached group sessions with the student in mind. contact sessions were negotiated with each group and were offered synchronously or asynchronously on a preferred platform, such as forums on vula (uct student portal), zoom, whatsapp or microsoft teams: ‘i learnt how to work with people virtually, which i think will really help me in my career.’ participant 1 this was not without its challenges, as the students in the groups were very diverse: ‘another thing that was a hindrance was how my group members and i came from different backgrounds.’ participant 115 weekly training sessions with facilitators provided opportunities for us to receive feedback about the performance of each student. in that regard, it was possible to monitor the performance of individual students and refer to faculty if they faced challenges that were likely to impact learning outcomes. mcq/saq. we replaced one essay and introduced students to a combined mcq/saq assessment. most participants (66%; n=258) preferred to have an option of substituting one essay with an mcq/saq assessment and reiterated the value of being in control of their learning experience: ‘it helped to test my knowledge of the work we have covered during the semester. i was able to assess whether i understood the work or not.’ participant 35 ‘this approach is less time consuming than presenting knowledge in an essay format.’ participant 29 virtual site visits. there was an appreciation of learning about primary healthcare and the healthcare system through virtual visits: ‘the videos really helped me understand healthcare in the south african context. it was informative and helped me understand the theory. i got to experience south africa’s people and its healthcare systems in much more depth than my textbooks.’ participant 101 online group presentations. although there was stated preference to submit prerecorded online group presentations by several participants (62%; n=242), there was an acknowledgement that for some groups connectivity and communication presented major challenges: ‘the challenges were with group participation in an online format. there were sometimes data issues or problems recording, some people were difficult to contact and thus contributed less than others. there is less accountability in an online format to group set commitments.’ participant 241 what will i keep in my practice? considering the size of our 2020 class (n=391), we attributed technological challenges to students being based in contexts that were sometimes illdefined and could not facilitate learning.[4] having access to prerecorded group presentations when these are recorded on site is a practice we wish to maintain. it was easier to moderate group presentations and institute quality control measures than work from memory. what will i not do? although it was possible to mitigate an emerging crisis, only 44.5% (n=174) of participants preferred virtual visits. in replacing community september 2021, vol. 13, no. 3 ajhpe 207 research and healthcare facility visits with virtual site visits (qr code), lack of contentment among students was attributed to missed opportunities to experience contextualised visits to health facilities:[4] ‘we were not able to ask questions or have our own first-hand experiences and perspectives.’ participant 52 nonetheless, participants acknowledged and appreciated the objective of the exercise, as the virtual visits ensured their safety from covid-19: ‘we were not at risk of encountering covid patients in the facilities where they would be treated.’ participant 63 conclusions the bhp course evaluation offered insights regarding aspects of ert that fyhsc students considered most valuable and challenging.[1] it facilitated conversations where their input contributed to our deliberations as we prepared to pursue a blended approach[4] in a ‘physically-distanced, lowdensity campus’.[6] declaration. none. acknowledgements. we are grateful to tsuki xapa, the class of 2020 and the bp/ bhp facilitators. author contributions. nom conceptualised the study. skt developed the qr code. both authors contributed to the final manuscript. funding. none. conflicts of interest. none. evidence of innovation 1. hammonds f, mariano gj, ammons g, chambers s. student evaluations of teaching: improving teaching quality in higher education. perspect pol pract high educ 2017;21(1):26-33. https://doi.org/10.1080/13603 108.2016.1227388 2. world health organization. who director-general’s opening remarks at the media briefing on covid-19, 11 march 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-atthemedia (accessed 3 february 2021). 3. south africa. disaster management act 57 of 2002, as amended.  https://www.gov.za/documents/disastermanagement-act-declaration-national-state-disaster-covid-19-coronavirus-16-mar  (accessed 3 february 2021). 4. adedoyin ob, soykan e. covid-19 pandemic and online learning: the challenges and opportunities. interact learn environ 2020:1-3. https://doi.org/10.1080/10494820.2020.1813180 5. university of cape town. from the vc’s desk. covid-19 update: uct commences term 1 vacation immediately. 2020. https://www.news.uct.ac.za/article/-2020-03-15-covid-19-update-uct-commences-term1-vacation-immediately (accessed 3 february 2021). 6. university of cape town. from the dvc’s desk. undergraduate teaching and learning at uct first semester 2021. 2020. https://www.news.uct.ac.za/article/-2020-12-07-undergraduate-teaching-and-learning-at-uctfirst-semester-2021 (accessed 3 february 2021). 7. zweigenthal ve, pick wm, london l. career paths of public health medicine specialists in south africa. front public health 2019;7:261. https://doi.org/10.3389/fpubh.2019.00261 8. rose s. medical student education in the time of covid-19. jama 2020;323(21):2131-2132. https://doi. org/10.1001/jama.2020.5227 accepted 2 august 2021. afr j health professions educ 2021;13(3):205-207. https://doi.org/10.7196/ajhpe.2021.v13i3.1483 https://doi.org/10.1080/13603108.2016.1227388 https://doi.org/10.1080/13603108.2016.1227388 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-athttps://www.gov.za/documents/disaster-management-act-declaration-national-state-disaster-covid-19-coronavirus-16-mar https://www.gov.za/documents/disaster-management-act-declaration-national-state-disaster-covid-19-coronavirus-16-mar https://doi.org/10.1080/10494820.2020.1813180 https://www.news.uct.ac.za/article/-2020-03-15-covid-19-update-uct-commences-term-1-vacation-immediately https://www.news.uct.ac.za/article/-2020-03-15-covid-19-update-uct-commences-term-1-vacation-immediately https://www.news.uct.ac.za/article/-2020-12-07-undergraduate-teaching-and-learning-at-uct-first-semester-2021 https://www.news.uct.ac.za/article/-2020-12-07-undergraduate-teaching-and-learning-at-uct-first-semester-2021 https://doi.org/10.3389/fpubh.2019.00261 https://doi.org/10.1001/jama.2020.5227 https://doi.org/10.1001/jama.2020.5227 https://doi.org/10.7196/ajhpe.2021.v13i3.1483 17 december 2011, vol. 3, no. 2 ajhpe abstracts possible limiting factors for upgrade of dental therapists to dental surgeons in zambia clemence marimo correspondence to: clemence marimo (chikacle@gmail.com) context and setting zambia has one academic institution offering a 3-year training programme in oral health and the graduates or dental therapists are deployed as primary oral health caregivers. the need for a dental degree training programme in zambia has been acknowledged by senior officials in the ministries of health and education. why this idea was necessary the upgrade offers the dental therapist new professional and academic horizons for growth while offering wider and more comprehensive dental services. what was done a hundred and twenty self-administered questionnaires with open-ended and closed questions were distributed among dental therapists in zambia. semi-structured interviews were conducted with key stakeholders in the school of medicine and the ministry of health. the responses in the semistructured interviews identified the strengths, weaknesses, opportunities and threats to the upgrading of dental therapists to dental surgeons. results and impact there was a 44% response rate with almost equal gender distribution and 62% were married though 24% had spouses not in formal employment. seventy five per cent of respondents had 0 3 dependants and 41% had qualified more than 10 years ago. just more than half of the respondents (55%) were in the 25 34-year age group and 45% had acquired postqualification additional courses in and outside the health sector. upgrade programme the majority of respondents (66%) preferred a full time programme to improve job opportunities and skills (52%) over 4 years (51%) with morning face-to-face didactic sessions (62%). sixty one per cent preferred a state grant and/or scholarship as a funding mechanism for the upgrade programme. all respondents confirmed their interest to undertake the upgrade programme despite constraining personal demographics. professional activities the majority of respondents (62%) saw between 11 and 40 patients while 30% saw more than 50 patients on average every week. similarly, 90% of respondents referred less than 5 cases for further management. soft-tissue pathoses were the least referred (14%) clinical condition while fractures, tooth impactions and jaw tumours ranged from 24% to 33%. despite the high number of patients seen on average every week and a national hiv infection rate above 10%; the small number of cases referred with soft-tissue pathoses could be due to limited diagnostic and management skills of the dental therapist. a large pool of prospective candidates in dental therapists and bachelor of human biology graduates and the lack of funds were the strength and chronic weakness respectively for the programme. however, opportune developments included the signing of memoranda of understanding in a public-private partnership and the presence of building infrastructure at the copperbelt university. sited threats to the programme were donor fatigue and withdrawal due to abuse of donor funds. upgrading dental therapists to dental surgeons would widen their scope of career progression, service delivery and research. use of a social network to develop reflective and reasoning skills in the context of clinical practice michael rowe correspondence to: michael rowe (michael@realmdigital.co.za) context and setting professional practice relies largely on the development of practice knowledge that is often tacit and hidden to the student. however, it can be developed through the sharing of experiences and the guided assistance of a more knowledgeable other. the theory of assisted performance is a teaching approach that can be used to structure learning activities that help students develop complex reasoning skills. the framework suggests modelling, contingency management, feedback, questioning, instruction and cognitive structuring as a means of facilitating deeper understanding. why the idea was necessary developing an understanding of reasoning and reflection in clinical practice is challenging and often not an explicit part of the formal curriculum. as such, educators may benefit from a more practical approach that can be integrated into teaching practice. however, while reflection and reasoning are acknowledged to be important components of clinical practice, there is little in the formal curriculum to develop these processes. in addition, the use of emerging technologies to enhance communication has received little attention in the context of clinical education, particularly in developing countries. what was done the study was conducted within a south african university physiotherapy department. a private social network was created and all thirdand fourth-year students registered as users. students were given an assignment in which they shared their clinical experiences as reflective blog posts, as well as needing to question and comment on each others’ work. using the features of a social network for the assignment created a framework for participant interaction that was directed towards exposing their understanding and ways of thinking about complex ideas and clinical situations. student narratives were analysed qualitatively using predetermined themes derived from the theory of assisted performance. southern african faimer regional institute (safri) poster day, cape town, march 2011 and sa association of health educationalists (saahe) conference, johannesburg, july 2010 abstracts 18 december 2011, vol. 3, no. 2 ajhpe results and impact using features of the social network, the author was able to model desirable behaviour and highlight assignment expectations to the students. appropriate behaviour was encouraged, while inappropriate behaviour (should it have arisen) could have been dealt with immediately. feedback was given to students regularly throughout the process, rather than just once at the end. questioning student perceptions, belief systems and responses to situations was used to stimulate further research and reflection. in some cases, explicit instruction was used to guide students through challenging scenarios. finally, the blog posts helped expose students’ thinking and understanding, allowing the author to create individual cognitive structures to build on what they already knew, thereby scaffolding the process. it seems that emerging online technologies such as social networks can be used to effectively facilitate reflective and reasoning skills among undergraduate students in authentic clinical contexts. however, the teaching and learning activities need to be implemented within a pedagogical framework that allows the facilitator to guide student development. this approach can also be beneficial in exposing and exploring the deeper, hidden understandings of the culture within professions, which students often struggle with. clinical educators should explore the use of emerging technology to develop clinical and ethical reasoning that are essential components of practice knowledge in the health professions. mentor attributes influencing positive learning experiences at clinics angelika reinbrech-schutte, marietjie van rooyen, rhena delport correspondence to: angelika reinbrech schutte (angelika.schutte@ up.ac.za) context the longitudinal clinic attachment programme for students (l-cas) was introduced in 2008 and links all medical students at the university of pretoria to one of 52 primary healthcare clinics around pretoria. the programme is based on academic service learning (asl) principles. as part of this experiential learning, students visit their clinics, and with the support of their appointed mentor, practise skills and contribute to service delivery. aim/purpose evaluation of the mentor programme was necessary, as it has a large number of variables, e.g. level of education, expertise and skills. a great variation in impact on service delivery, interpersonal relationships and learning opportunities at clinics was perceived. the objectives were to determine students’ overall experience of mentors, focusing on the different groups of mentors (university-appointed doctors; university-appointed nurses; clinic managers; clinic staff) and factors contributing to a positive learning experience. what was done a survey, comprising of one open-ended and 26 quantitative questions, was developed after focus group interviews and a pilot study with nominal group discussions were held with 7 randomly selected second-year students. most first-year medical students completed the survey as part of l-cas activities, using the umfundi survey tool. the statistix programme was used to analyse the data. qualitative analysis was done of additional comments given by students to understand the quantitative data. ethical approval was obtained from the university of pretoria. results and discussion a total of 227 students participated, of whom 68 were mentored by clinic staff, 41 by clinic managers, 99 by up-appointed nurses and 19 by upappointed doctors. mentor type was significantly related to experience of the mentor (p<0.001). the experience was perceived as excellent by 68% of students mentored by up mentor doctors; 59% by up mentor nurses; 37% by clinic managers and 40% by clinic staff, while 25%, 34% 11% and 11% of students regarded the experience as average or poor. mentees’ experience of the mentor was significantly associated with the degree of rapport the mentor had with the group, whether the mentor was engaging and interesting, and whether the mentor motivated and listened to them (p<0.0001). approximately 50% of students agreed that they had learnt a lot from their mentors, while 20% disagreed or strongly disagreed. of the attributes that relate to academic support the mentor’s ability to demonstrate clinical practice was most significantly associated with experience followed by constructive feedback and availability of the mentor to help (p<0.0001). of the 112 students who perceived the experience with the mentor as excellent, 88% thought there was a clear plan at the beginning of every visit (p<0.0001). mentor assistance with language difficulties was also significantly associated with positive experience (p<0.0001). conclusion positive learning experiences are strongly associated with personal and relational attributes of mentors, as well as feedback and academic support given to students. from the results of this study a mentor support programme will be developed, aiming to provide every student with an equally standardised learning experience of good quality. use of a social network to develop reflective and reasoning skills in the context of clinical practice michael rowe correspondence to: michael rowe (michael@realmdigital.co.za) context and setting professional practice relies largely on the development of practice knowledge that is often tacit and hidden to the student. however, it can be developed through the sharing of experiences and the guided assistance of a more knowledgeable other. the theory of assisted performance is a teaching approach that can be used to structure learning activities that help students develop complex reasoning skills. the framework suggests modelling, contingency management, feedback, questioning, instruction and cognitive structuring as a means of facilitating deeper understanding. why the idea was necessary developing an understanding of reasoning and reflection in clinical practice is challenging and often not an explicit part of the formal curriculum. as such, educators may benefit from a more practical approach that can be integrated into teaching practice. however, while reflection abstracts and reasoning are acknowledged to be important components of clinical practice, there is little in the formal curriculum to develop these processes. in addition, the use of emerging technologies to enhance communication has received little attention in the context of clinical education, particularly in developing countries. what was done the study was conducted within a south african university physiotherapy department. a private social network was created and all thirdand fourth-year students registered as users. students were given an assignment in which they shared their clinical experiences as reflective blog posts, as well as needing to question and comment on each others’ work. using the features of a social network for the assignment created a framework for participant interaction that was directed towards exposing their understanding and ways of thinking about complex ideas and clinical situations. student narratives were analysed qualitatively using predetermined themes derived from the theory of assisted performance. results and impact using features of the social network, the author was able to model desirable behaviour and highlight assignment expectations to the students. appropriate behaviour was encouraged, while inappropriate behaviour (should it have arisen) could have been dealt with immediately. feedback was given to students regularly throughout the process, rather than just once at the end. questioning student perceptions, belief systems and responses to situations was used to stimulate further research and reflection. in some cases, explicit instruction was used to guide students through challenging scenarios. finally, the blog posts helped expose students’ thinking and understanding, allowing the author to create individual cognitive structures to build on what they already knew, thereby scaffolding the process. it seems that emerging online technologies such as social networks can be used to effectively facilitate reflective and reasoning skills among undergraduate students in authentic clinical contexts. however, the teaching and learning activities need to be implemented within a pedagogical framework that allows the facilitator to guide student development. this approach can also be beneficial in exposing and exploring the deeper, hidden understandings of the culture within professions, which students often struggle with. clinical educators should explore the use of emerging technology to develop clinical and ethical reasoning that are essential components of practice knowledge in the health professions. 19 december 2011, vol. 3, no. 2 ajhpe june 2021, vol. 13, no. 2 ajhpe 129 research in 2014, the world health assembly (wha) resolution a67.19 called on countries to strengthen and ensure equitable access to palliative care (pc). [1] this resolution also stated that pc education should form an ‘integral component’ of ongoing education, and that disciplines working routinely with patients  with life-threatening illnesses should receive intermediatelevel pc training.[1] the resolution was supported by african countries who signed the kampala declaration, and by the south african (sa) department of health (the sa national policy framework and strategy on palliative care).[2,3] however, to date, no dedicated funding has been set aside to strengthen palliative care in sa. the need for integration of pc has never been more strongly felt than in the current african cancer care situation. the burden of cancer cases is rapidly increasing in lowand middle-income countries. although situations differ from country to country, many patients generally present late, and struggle to access oncology care timeously.[4] in africa, long distances to oncology centres and long waiting lists to receive oncology services compound the problem of access to pc. the barriers to the integration of pc into the health system and oncology care are well described, and some of these are the lack of available pc training and the misconception that pc is only needed for end-of-life care.[5] academic cancer centres in sa provide training for radiation and/or clinical oncologists. these specialist trainees not only care for patients who require curative treatments, but frequently also serve the many patients whose care is of palliative intent. in response to the need for and the importance of pc in oncology care, especially in africa, the university of cape town (uct) developed a pc curriculum at the intermediate level. background. following a world health assembly call in 2014 to strengthen palliative care, the south african (sa) department of health approved this strategy as part of the sa national policy framework and strategy on palliative care. in 2016, the university of cape town, together with the college of radiation oncology of sa, identified the need to integrate palliative care (pc) into the oncology curriculum. in collaboration with the cancer association of sa, a research project was developed to introduce a 12-module curriculum at five teaching hospitals. the aim of this research was to evaluate the impact of a 1-year pc course within the training programme for specialist oncologists in sa. objective. to determine the reaction of oncology registrars and their supervisors to the course to determine changes in knowledge and skills, and to determine the application in oncology practice. methods. this study was a mixed-method prospective evaluation of an educational intervention. the educational programme used a blended learning method to train and support registrars (n=32) and facilitators (n=5) across five universities from august 2017 to september 2018. evaluation feedback was electronically collected to determine the registrars’ reactions to the course materials. pre and post multiple-choice questions (mcqs) were used to review their knowledge. focus group discussions (fgds) were used to explore reactions, change in knowledge and skills and how registrars integrated pc into their daily work. results. there was an overwhelmingly positive reaction to the pc course by the oncology registrars and their supervisors. the training was found to be feasible, and the topics addressed appropriate. concerns previously raised by the college of radiation oncology of sa regarding the feasibility and appropriateness of the course and material were found to be unsubstantiated. the poor mcq results can be ascribed to poor sequencing of the execution of the question. however, the mcqs in modules 7 and 8 (symptom management) demonstrated the most significant change in knowledge and skills (symptom management). the fgds demonstrated a perceived change in knowledge and skills, especially for communication skills and pain and symptom management. the fgds also indicated that the registrars’ approach to pc changed in that they were able to integrate the principles of pc into practice, and now saw pc as an essential component of oncology. lastly, registrars and their supervisors felt that the course addressed topics that formed part of their daily clinical work. conclusion. this research supports the view that pc training is an essential component of oncology training in the sa setting. pc forms part of the daily practice of oncologists, and a structured curriculum prepares clinicians to be able to integrate evidence-based pc into the practice of oncology if they receive appropriate training. supervisors of the oncology training programme and registrars are confident that the training of 12 modules across 1 year is feasible and appropriate. afr j health professions educ 2021;13(2):129-134. https://doi.org/10.7196/ajhpe.2021.v13i2.1268 evaluating palliative care training in the oncology registrar programme in south africa r krause,1 mb chb, m fam med, mphil (pall med); j parkes,2 mb chb, da (sa), fc rad onc (sa); d anderson,2 mb chb, fc rad onc (sa); n hartman,3 phd; l gwyther,1 mb chb, bsc (pall med), phd 1 department of public health and family medicine, faculty of health sciences, university of cape town, south africa 2 department of radiation oncology, faculty of health sciences, university of cape town, south africa 3 education development unit, faculty of health sciences, university of cape town, south africa corresponding author: r krause (rene.krause@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1268 mailto:rene.krause@uct.ac.za 130 june 2021, vol. 13, no. 2 ajhpe research the intention was to strengthen the oncology curriculum and align it with international standards and the sa national framework and strategy on palliative care.[3,6] the curriculum was developed after a process of consultation, drawing from a survey among trainees, exploring the knowledge and attitudes towards pc. a focus group discussion (fgd) among experts in cancer care, including both academic and private oncology and pc experts, was also conducted, drawing on international recommendations on pc training.[7,8] the conclusions drawn from this process included that pc should indeed form part of all oncology services, that pc is a critical part of oncology training, that pc training should be delivered in a structured curriculum with well-defined outcomes, that pc training should be provided early in the training, that pc should form part of the summative academic assessment and that communication skills should be a critical component of the course. these findings were presented to the college of radiation oncologists of sa at the examiners’ meeting held in october 2016. a general agreement was reached that a pc course should be delivered to new registrars in oncology over a 1-year programme, to be conducted from august 2017 to september 2018, that should include 12  modules. concerns were raised around the feasibility of such a course in an already full curriculum, and therefore not all universities participated in this pilot project. the course used a mixed mode of teaching, with online content and monthly facilitation sessions. the main modules included principles of pc (5%), communication skills (40%), pain and symptom control (30%), ethical and legal aspects around end-oflife care (5%), the implementation of advance directives (5%), bereavement and interdisciplinary teamwork (5%) and burnout and compassion fatigue (5%) (table 1). it was also agreed that such a course should demonstrate evidence of improvement in teaching and learning outcomes in order to justify implementation, and that this would be best shown as part of a research project. problem statement before the introduction of this course, there was no structured pc curriculum within the sa oncology specialist training programme. additions to an already full curriculum should not overburden trainees, should be appropriate for the sa setting and should demonstrate improvement in teaching and learning outcomes of oncology trainees. the rationale for this study was to evaluate a 1-year palliative care training module within the oncology curriculum. methodology all oncology training centres across sa were invited to participate in the course, but owing to logistical constraints, only five universities participated (uct, stellenbosch university, walter sisulu university, the university of kwazulu-natal (ukzn) (pietermaritzburg) and the university of the free state). the main reason cited for not participating was resource constraints. facilitators were trained at a 2-day workshop at the beginning of the course. during the workshop, the training team familiarised the facilitators with the vula e-learning website and training materials, and upskilled them in communication skills and in providing student feedback. the modules were developed via a collaborative approach between oncology and pc. the final modules addressed concepts around self-care, and were developed with the help of psychologists. five preand five post-training multiple-choice questions (mcqs) were developed for each assessment. communication skills were assessed using a modified calgary-cambridge method.[9] the communication skill assessment formed part of the formative assessment, and provided an opportunity for registrars to receive feedback on their communication skills. the facilitators also met monthly online to discuss the new learning material and to reflect on the previous month’s lectures. each site had a monthly meeting in which the material was discussed, and a task was completed to apply new theory learned. the participating universities invited all specialist trainees to participate in the research project, and assured them that their training would not be affected if they decided not to participate. thirty-two oncology trainees from the five universities participated. these trainees included sa and international registrars. although the course was geared towards adult pc, a paediatric oncology trainee also participated. continuous evaluation of the course was made essential, and was used to demonstrate whether there was evidence of improvement in the identified proficiencies. the course was evaluated using the theory of the adapted version of the kirkpatrick triangle.[10] the best evidence medical education (beme) collaboration adapted a version of the kirkpatrick triangle called ‘kirkpatrick’s hierarchy’ system to higher education for evaluation.[10,11] this modified version was adopted to measure ‘soft outcomes’ of the course together with short-term and tangible outcomes. a mixed mode of evaluation was used to measure both quantitative and qualitative data to determine a comprehensive review of teaching activity.[10] this enabled the researcher to capture the softer nuances of the impact of the course. one of the objectives of the course was to evaluate the oncology trainees’ reaction to teaching and learning by completing anonymous online evaluations. these evaluated the structure of the course, the relevance of the discussion groups, the course material and the applicability of the material in daily clinical practice. fgds were conducted to determine trainees’ perceived change in attitudes and perceptions towards pc. the second objective was to determine the trainees’ change in knowledge and skills by asking them to complete preand post-training mcqs after each module. the third objective was to determine the application of knowledge and skills of pc in oncology practice by interviewing the supervisors of trainees. change in organisational practice and benefit to patients were not included in this study. the quantitative data gathered were statistically analysed, and the qualitative data were analysed by the research team using thematic analysis. the researchers familiarised themselves with the transcripts collected. through inductive and iterative processes, themes were identified, and table 1. modules and content module topic 1 principles of palliative medicine in oncology 2 communication skills: basic principles 3 communication skills: breaking bad news 4 communications skills: conversations around serious illness and care planning 5 communication skills: managing conflict 6 pain management 7 gastrointestinal symptoms 8 dyspnoea and delirium 9 constitutional and treatment-related symptoms 10 end-of-life care 11 the role of the oncologist providing comprehensive care 12 self-care june 2021, vol. 13, no. 2 ajhpe 131 research were adjusted and/or confirmed. confirmation bias was limited by using a multidisciplinary research team and an anonymous evaluation platform, and by including feedback from senior supervisors. ethics approval was obtained from the uct human research ethics committee (ref. no. hrec 851/2016). ethics approval was also obtained from the ethics departments of all the universities who participated in this study (ukzn ref. no recip 299/17; other universities letters provided). twelve online modules were developed with mcqs. results feedback from the five sites indicated that trainees participated enthusiastically, and that the material resonated with their daily experiences. the vula e-learning site provided researchers with the number of times the site was visited by the registrars (fig. 1) up to 6 months after the completion of the course, and data on resources most used (table 2). videos were the most frequently used resource, and the site was most often visited when communication skills were addressed. the videos that were most watched were those on pain management (174 views) and breaking bad news (125 views). the written resource the registrars used most was ‘guide to the treatment of cancer pain’.[12] there was excellent attendance at the monthly meetings. although not all registrars completed the required online preparation, there was active participation by all at the meetings themselves. unfortunately, owing to workload restrictions, only a 1-hour meeting was allocated per module. this should ideally be longer, as each module generated enthusiastic discussions that had to be cut short. the modules that generated the most discussion were communication, self-care, end-of-life care and comprehensive care. this may be due to these subjects not having been part of any formal oncology training in the past. these modules are also very emotive, and the meetings allowed the registrars to express and debate ideas that would be difficult to discuss in a forum or chat room. the registrars often incorporated real-life cases into these meetings, which helped add a valuable practical side to the course. the structure of the modules (fig. 2), the relevance of the discussion groups (fig.  3), the appropriateness of the course material (fig. 4) and of the applicability of the material in daily clinical practice (fig. 5) were anonymously evaluated. modules 7 and 8 received 100% positive feedback. this evaluation also assisted in reviewing modules for further courses (module 4 was not evaluated owing to technical difficulties, so is excluded from the figures). the changes between the preand post-test results of the mcqs were analysed by running repeated sample t-tests on each module. the differences between the preand post-test results are generally not statistically significant, except for those from module 1 and module 7, which demonstrated negative (module 1) and positive (module 7) outcomes in terms of a change of knowledge. in modules 5 and 8 the sample size was small,[5] tending to significance (p=0.099 and 0.089, respectively). this may require further exploration in a larger group to determine whether the effect is real. the small number of participants completing the mcqs was the main reason that the statistical tests were not of any value. the problem was not the construction of the mcq questionnaire, but rather the way that it was situated within the programme, and the fact that it was not made obligatory. online assessment may not be the best form of assessment if it is not rigorously enforced. focus groups in general, better feedback information was obtained from the fgds than from the assessment documents. data were analysed using systematic thematic analysis with inductive coding. the fgd notes were read and reread, and discussed with the research team. themes emerged as shown in table 3. theme 1: attitudes towards the course positive feedback it was clear that registrars deal with pc on a daily basis. the course introduced topics that form part of their daily work. there was an overwhelmingly positive attitude towards the course, and all registrars felt that they wanted to continue with it. the course changed their approach to pc, and most stated that pc is part of oncology care. many felt that the course highlighted the fact that pc is an essential component of oncology training not only for palliative patients, but for better management of all oncology patients: ‘it is actually part of the bread and butter of oncology in my experience and there is so much that we’ve learnt throughout the module with regards to palliative care.’ student, ukzn (stuk) ref 3 ‘for palliative care is, even in the nonmetastatic setting, in patients with curable intent or radical intent, there is still so much that you can learn from palliative care in terms of communication skills, breaking bad news and so i found it extremely important in the oncology setting.’ stuk ref 4 negative feedback it was an adjustment for the registrars to become online students. there was also variability in terms of the different facilitators at each university, which affected registrars’ attitude towards the course. registrars also felt that table 2. resources most frequently opened resource vula visits, n pain module mp4 174 breaking bad news mp4 125 serious illness conversation mp4 91 dyspnoea in end-stage cancer mp4 89 the oncologist providing comprehensive care 81 end-of-life care 74 2017 2018 2019 500 450 400 350 300 250 200 150 100 50 0 si te v is it s, n mar apr may jun jul aug sept oct nov dec jan feb mar apr may jun jul aug sept oct nov dec jan feb mar study period 141 54 316 49 54 222 432 285 201 63 200 187 326 116 406 150 183 207 196 77 21 55 18 7 1 fig. 1. vula visits by registrars over course period, n. 132 june 2021, vol. 13, no. 2 ajhpe research many of the skills were not mentored to them, because supervisors had no training in pc. this lack of comprehensive training affected integration into the daily care of patients: ‘that one is just an it challenge, where sometimes every time you needed to log in.’ student, stellenbosch university (stus) ref 3 ‘i think, i know is probably idealistic thinking but i do think that not, maybe if you could have like a crash course version for even consultants … i also think it will be good for them to understand what it is that we are learning in the curriculum and it would help them support us when we try to apply these things in the day-to-day dealing with patients in clinic and all of these.’ student, university of cape town (stuu) ref 3 theme 2: workload and structure of the course feasibility the registrars felt that the workload was achievable and that the course was feasible in their own setting. the supervisors’ concern was that some registrars did not prepare for lectures beforehand. there were some concerns about how to better teach communication skills and mentoring, and about how to use these in current clinical practice: ‘i have to just generalise i would say that the curriculum is quite comprehensive and that the pace at which the curriculum was presented was a good, manageable for the students and for the facilitator and that the variety of faculty brought depth and richness to the curriculum.’ supervisor, stellenbosch university (supus) ref 1 ‘i know this is not the question but um, probably the communication part is something that is still struggling to, you know, kind of apply practically just because of the kind of feasibility of it in our setting.’ stuu ref 1 ‘i think a negative thing for me was that during the course, most of the time, most of the students did not, you know, did not prepare beforehand.’ supervisor, university of the free state ref 1 structure of the course registrars wanted short, precise and very practical material. they enjoyed the video material and group interactions. however, supervisors felt that the course needed to be more academic, with journal articles and assessments built in, in order to engage registrars in their capacity as postgraduates: ‘i think it will be nice to be, maybe interactive with the other groups in other parts of the country.’ stus ref 1 ‘… felt that the videos were very, very nice.’ stuu ref 4 ‘i also feel that way and i do think that it sometimes takes the academics out of it. we mustn’t take the academics out of it.’ supuu ref 7 100 90 80 70 60 50 40 30 20 10 0 module % positive neutral negative 1 2 3 5 6 7 8 9 10 11 12 fig. 3. participant (registrar) evaluation of discussion group relevance. 100 90 80 70 60 50 40 30 20 10 0 module % positive neutral negative 1 2 3 5 6 7 8 9 10 11 12 fig. 2. participant (registrar) evaluation of module structure. 100 90 80 70 60 50 40 30 20 10 0 module % positive neutral negative 1 2 3 5 6 7 8 9 10 11 12 fig. 4. participant (registrar) evaluation of appropriateness of course material. 100 90 80 70 60 50 40 30 20 10 0 module % positive neutral negative 1 2 3 5 6 7 8 9 10 11 12 fig. 5. participant (registrar) evaluation of ability of course material to assist registrars in daily practice. table 3. focus group discussions theme 1: attitude towards the course positive negative theme 2: workload and structure of the course feasibility structure modules theme 3: application in the workplace theme 4: integration of palliative care principles into oncology june 2021, vol. 13, no. 2 ajhpe 133 research modules the module that contributed most to registrars’ learning was communication skills. the registrars felt that this assisted them in learning and development beyond working with pc patients: ‘i also think that communication and breaking bad news is the main thing.’ stuf ref5 ‘…will improve my way of relating to patients. and i found it very valuable when i was doing my exams because it helped me really communicate very well during the oral exams. communications were very key both to the question, in taking history and also to the examiners.’ stuu ref 6 pain management was a vital component to the course, and this was supported by supervisors and by registrars: ‘i can say that i have seen changes and it will mostly be around pain management.’ supus ref1 ‘i think the module on pain control and it was more i think the practical advice that you as a palliative care physician could actually offer, that you can’t really get in textbooks which were very, very useful.’ stuu ref 1 self-care was a new topic introduced into oncology as a formal component in the curriculum: ‘…think for me probably the one module that stood out the most for me was the self-care. i think at the end of the day as a clinician in order for you to be able to manage your patient well, you have to be physically, mentally, you have to be mentally, you know, in the right space to be able to treat with, to deal with your patient.’ student eastern cape ref 1 theme 3: application in the workplace the registrars indicated that the course contributed to their daily practice and that it gave them the confidence to manage situations that they confronted regularly and in which they had not previously received training. the training also contributed to their approach to dealing with patients for curative intent, and they stated that they could use the skills in activities other than patient interactions: ‘it gave us a bit more confidence to approach a lot of the topics. so we were able to manage our patients a bit more confidently with good backing and theoretical knowledge of each subject matter.’ stuk ref 2 ‘i can say that i have seen changes and it will mostly be around pain management.’ supus ref 1 theme 4: integration of pc into oncology the course enabled registrars to integrate key concepts in pc: pc starts at diagnosis; holistic care; teamwork; pain and symptom control; and the involvement of the family. the course also enabled registrars to see the role of a pc team in the care of oncology patients: ‘i feel is very important because we deal with a lot of patients that require palliative care and palliative care being not just for the end-stage patients, at beginning, right from the beginning from the diagnoses.’ stus ref 1 ‘we generally tend to focus more towards chemotherapy and radiation not forgetting the more important biopsychosocial, the psychosocial part of it. so it made us more aware of trying to address those problems providing us with insight into an approach to these problems and enable us to provide holistic management in all aspect of care.’ stukref6 ‘i think also is good to also be aware of your own limitations. you know to be aware that there are palliative care facilities and the team of palliative care specialists. to know when your role, you know, i have done all i can and i need to call someone else in.’ stuf ref 1 discussion the course was developed using minimal resources but with strong collaboration among groups. the collaborators were the departments of palliative medicine (uct), radiation oncology (uct), health professional education (uct), radiation oncology (stellenbosch university), a private palliative care physician and the cancer association of sa (cansa). it used blended learning to enable facilitation in different oncology settings and to support facilitators across sa. the facilitators came from five universities, which enabled a community of trainers to develop. blended learning is a new method of learning and assessment for many registrars and supervisors, and some registrars found this challenging. in future, more time needs to be spent initially familiarising registrars and supervisors with an online teaching platform. although blended learning has its challenges, it enables support and development of more geographical sites in integrating pc into a curriculum using minimal resources. the first objective of this research was to determine the reaction of oncology registrars and their supervisors to a pc course. there was an overwhelmingly positive reaction towards the course, and it surpassed our expectations. concerns from supervisors about issues such as the feasibility and appropriateness of the course and material were unsubstantiated. pc training in oncology is feasible, and the topics addressed were appropriate. this was supported by both anonymous evaluation forms and qualitative data from the fgds. the modules on communication skills and pain and symptom management were found to be the most valuable components of the course for registrars. this was supported by evaluation forms, data from the vula site and fgds. self-care was also found to be a valuable component of the course, and may be included in more programmes, according to comments received from the fgds. the second objective was to determine changes brought about in knowledge and skills in pc. some negative aspects of this study were that there were generally no statistically significant changes in preand posttest results, and that there was poor completion of the online assessment. knowledge in practical aspects such as pain and symptom control improved, however. the fgds demonstrated that the registrars’ knowledge of what pc is and how they could integrate the principles in their daily work improved. the third objective was to determine the application of knowledge and skills of pc in oncology practice. the registrars felt that the course made oncology ‘more fluid’, which enabled them to move between diseasespecific care and a patient-centred approach, and between a curative and a palliative approach, more easily. the course addressed topics that formed part of their daily work. the skills and knowledge most applicable in the oncology setting are communication skills and pain and symptom management. these skills therefore need to be core components that must be included in all oncology curricula. however, these competencies do not stand alone, and are best managed if the principles of pc are integrated into all components of care. 134 june 2021, vol. 13, no. 2 ajhpe research conclusion internationally, pc is an essential component in oncology training, and should be incorporated into the sa specialist oncology training programme.[1] pc forms part of the daily practice of oncologists, and a structured curriculum enables clinicians to practise using an evidence-based approach. this provides registrars with confidence when managing a patient with pc needs. supervisors of oncology training and registrars in the present study proved confident that the training of 12 modules across 1 year is feasible and appropriate. these skills are part of daily practice, and support the wha resolution 67.19 that pc training is an integral component of oncologist training: ‘intermediate training should be offered to all health care workers who routinely work with patients with life-threatening illnesses, including those working in oncology, infectious diseases, paediatrics, geriatrics, and internal medicine.’[1] the sustainability of this course can only be ensured by advocating for strong collaboration between academic oncology units and academic pc units. pc training must also become available to the oncologist who has not been previously exposed to it, through short courses. this may serve as a module to integrate pc into other disciplines. declaration. this study formed part of rk’s phd research. acknowledgements. cansa. author contributions. rk: data collection; rk and lg: analysis; all authors: manuscript writing; all authors: scientific input. funding. cansa. conflicts of interest. none. 1. world health assembly. strengthening of palliative care as a component of integrated treatment within the continuum of care. geneva: world health organization, 2014. 2. african palliative care association. kampala declaration. kampala: 5th international african palliative care conference, 2016. 3. national department of health, south africa. national policy framework and strategy on palliative care 2017 2022. pretoria: ndoh, 2017. 4. bray f, jemal a, grey n, ferlay j, forman d. global cancer transitions according to the human development index (2008 2030): a population-based study. lancet oncol 2012;13(8):790-801. https://doi.org/10.1016/s14702045(12)70211-5 5. aldridge md, hasselaar jg, garralda e, et al. education, implementation, and policy barriers to greater integration of palliative care: a literature review. palliat med 2016;30(3):224-239. https://doi.org/10.1177/0269216315606645 6. smith tj, temin s, alesi er, et  al. american society of clinical oncology provisional clinical opinion: the integration of palliative care into standard oncology care. j clin oncol 2012;30(8):880-887. https://doi. org/10.1200/jco.2011.38.5161 7. gwyther l, parkes j, anderson d, hartman n, krause r. building a palliative care curriculum for oncologists. specialist forum 2018;18(4):42-43. 8. gamondi c, larkin p, payne s. [core competencies in palliative care: an eapc white paper on palliative care education – part 1]. european association of palliative care, 2013. eur j palliative care 2013;20(2):86-91. 9. kurtz sm, silverman jd. the calgary-cambridge referenced observation guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. int j med educ 1996;30(2):8389. https://doi.org/10.1111/j.1365-2923.1996.tb00724.x 10. yardley s, dornan t. kirkpatrick’s levels and education ‘evidence’. med educ 2012;46(1):97-106. https://doi. org/10.1111/j.1365-2923.2011.04076.x 11. praslova l. adaptation of kirkpatrick’s four level model of training criteria to assessment of learning outcomes and program evaluation in higher education. educ assess evaluation account 2010;22(3):215-225. https://doi. org/10.1007/s11092-010-9098-7 12. south african cancer pain working group. guide to the treatment of cancer pain in south africa. 2015. https://painsa.org.za/wp-content/uploads/2016/02/a5-guide-to-treatment-of-cancer-pain-2015.pdf (accessed 7 june 2021). accepted 24 june 2020. https://doi.org/10.1016/s1470-2045(12)70211-5 https://doi.org/10.1016/s1470-2045(12)70211-5 https://doi.org/10.1177/0269216315606645 https://doi.org/10.1200/jco.2011.38.5161 https://doi.org/10.1200/jco.2011.38.5161 https://doi.org/10.1111/j.1365-2923.1996.tb00724.x https://doi.org/10.1111/j.1365-2923.2011.04076.x https://doi.org/10.1111/j.1365-2923.2011.04076.x https://doi.org/10.1007/s11092-010-9098-7 https://doi.org/10.1007/s11092-010-9098-7 https://painsa.org.za/wp-content/uploads/2016/02/a5-guide-to-treatment-of-cancer-pain-2015.pdf 196 september 2021, vol. 13, no. 3 ajhpe research why was the idea necessary? the covid-19 lockdown and social-distancing guidelines introduced in march 2020 have implications for health professions education. face-toface teaching was suspended in some cases, and the groups of students allowed in physical spaces severely curtailed by social-distancing rules.[1] the covid-19 restrictions were also instituted in the clinical practice areas and theatres of academic hospitals in bloemfontein, south africa. this resulted in limited access to routine clinical and emergency cases for fourthand fifth-year medical students of the university of the free state (ufs). as part of their anaesthesia rotation, students needed access and exposure to these clinical and emergency cases to fulfil the minimum training requirements set out in their curriculum. these cases included ultrasound techniques and administration of general anaesthesia, as well as the administration of spinal anaesthesia, airway management and cardiopulmonary resuscitation (cpr). owing to covid-19 restrictions, fourthand fifth-year students were not allowed in theatres, where they had usually been exposed to these cases. what was done? (intervention) to overcome this lost clinical exposure, the department of anaesthesia, in collaboration with the clinical skills and simulation unit, developed a programme for fourthand fifth-year medical students. the programme consisted of guided skills and simulation sessions. these sessions covered the following four clinical areas: cpr and airway management, spinal anaesthesia, general anaesthesia, and ultrasound. the fourthand fifth-year residency in the department of anaesthesia consisted of nine students for each year group over a 1-week period. these nine students visited the skills and simulation unit twice during the week (fifth-years on tuesdays and thursdays and fourth-years on wednesdays and fridays). each visit consisted of four sessions. session one involved all nine students training on cpr and airway management for one hour. the group was then split into three smaller groups to engage in guided sessions. these sessions were ultrasound skill, spinal anaesthesia skill and a simulation of the administration of general anaesthesia. the small groups spent one hour on each session and rotated through all the sessions while adhering to and observing covid-19 social-distancing protocols.[2] the facilitators for the four sessions were medical officers and registrars (anaesthesia specialist trainees) assigned by the department of anaesthesia. train-the-trainer videos and material were provided to each facilitator during a train-the-trainer session before the first undergraduate residency. this was done to ensure consistent quality and content of the sessions. each session had its own predetermined outcomes as defined by the department’s curriculum. the theoretical background lectures that the students usually received in a classroom before their residency were moved to an online learning platform (blackboard) for remote learning. students used the online learning platform to familiarise themselves with the theoretical background of the four clinical areas before they attended the skills and simulation sessions. cpr, airway and spinal anaesthesia skills were conducted on part-task trainers, while ultrasound was performed on a standardised patient using an ultrasound machine. the administration of general anaesthesia simulation used a high-fidelity manikin (simman 3g (laerdal medical, usa)). the general anaesthesia simulation was divided into three phases which included the induction phase, the maintenance phase, and the emergence phase. after each phase, the simulation was paused, and the students and facilitator debriefed and created an opportunity for feedback and questions. multiple scenarios were created, and a group could encounter an adverse event during any of the phases. students were given a technical overview of the manikin and how to use it before the first simulation experience. it was anticipated that there might be a difference in knowledge, skills and confidence between fourthand fifth-year students, with fifth-year students having had clinical exposure in 2019, and fourth-year students having no exposure to the clinical area. after the first two weeks, it was found that this difference was bigger than anticipated. this led to a slight deviation in the simulation where the facilitator guided the fourth-years during their simulation experience instead of only observing them. lessons learnt from informal feedback from students and facilitators, it was learnt that students could immerse themselves in the sessions as they were directly responsible for each decision and not just observing a case. this sense of ownership of the decisions made improved students’ confidence, clinical reasoning and skills. what will be kept in practice? as covid-19 restrictions eased in the hospitals, students had more time back on the clinical platform. however, it was decided to keep aspects of the skills and simulation sessions as they proved useful tools for students to practise skills in a safe environment and afforded them the opportunity to be decision-makers during the simulation. although skills and simulation training are already strategies followed for medical students at the ufs, these specific sessions were not part of the day-to-day simulation activities for fourthand fifth-year students. the fourth-year part of the programme was changed to keep the ultrasound session. the fifth-years’ programme was mostly kept intact, although students continued visiting the skills and simulation unit only once per week instead of twice as the clinical platform became available again. anaesthesia skills and simulation training during the covid-19 pandemic r van wyk,1 bcomm (it), phd (hpe); e w turton,2 mb chb, dip pec (sa), da (sa), mmed (anaes), fca (sa) 1 clinical simulation and skills unit, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of anaesthesia, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: r van wyk (vanwykr3@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:vanwykr3@ufs.ac.za september 2021, vol. 13, no. 3 ajhpe 197 research what will not be done? the spinal anaesthesia practical session was removed from the fourth and fifth-year programme as the skill is being taught in the clinical area. it was also decided to remove the administration of general anaesthesia simulation for the fourth-years. this was done as a result of a decision by the department of anaesthesia to increase their clinical time to give them an opportunity to observe more cases. declaration. none. acknowledgements. the staff of the department of anaesthesia, faculty of health sciences, university of the free state. author contributions. equal contributions. funding. none. conflicts of interest. none. evidence of innovation 1. arandjelovic a, arandjelovic k, dwyer k, shaw c. covid-19: considerations for medical education during a pandemic. med ed publish 2020;9(1):87. https://doi.org/10.15694/mep.2020.000087.1 2. khan h. an adaptation of peyton’s 4-stage approach to deliver clinical skills teaching remotely. med ed publish 2020;9(1):73. https://doi.org/10.15694/mep.2020.000073.1 accepted 26 april 2021. afr j health professions educ 2021;13(3):196-197. https://doi.org/10.7196/ajhpe.2021.v13i3.1505 https://doi.org/10.15694/mep.2020.000087.1 https://doi.org/10.15694/mep.2020.000073.1 https://doi.org/10.7196/ajhpe.2021.v13i3.1505 editorial being different, or making a difference? g van zyl 2 forum south african association of health educationalists (saahe) distinguished educator for 2012 wendy mcmillan 3 articles physiotherapy students’ perception of their teachers’ clinical teaching attributes a y oyeyemi, a l oyeyemi, a a rufai, s m maduagwu, h n aliyu 4 determinants of effective medical intern training at a training hospital in north west province, south africa ni ni sein, john tumbo 10 medical physiology education in south africa: what are the educators’ perspectives? mark tufts, susan higgins-opitz 15 comparison between mmed anaesthesia programmes in the sadc farai daniel madzimbamuto 22 what do dietetics students think professionalism entails? d marais, m l marais, j visser, c boome, d c m taylor 28 processes in widening access to undergraduate allied health sciences education in south africa seyi l amosun, nadia hartman, viki janse van rensburg, eve m duncan, elmi badenhorst 34 patient-centred continuing professional development for canadian physicians brenda lovell, raymond lee 40 abstracts fifth national conference of the south african association of health educationalists (saahe): 'from practise to practice’, bloemfontein, 21 23 june 2012 44 cpd cpd questionnaire 100 editor vanessa burch deputy editor juanita bezuidenhout editorial board adri beylefeld university of the free state juanita bezuidenhout stellenbosch university vanessa burch university of cape town enoch n kwizera walter sisulu university patricia mcinerney university of the witwatersrand jacqueline van wyk university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk assistant editor emma buchanan technical editors marijke maree robert matzdorff melissa raemaekers paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse online manager gertrude fani hmpg board of directors m veller (chair) r abbas m lukhele d j ncayiyana j p de v van niekerk issn 1999-7639the ajhpe is published by the health and medical publishing group. the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200.. fax (021) 685-1395. e-mail: publishing@hmpg.co.za ajhpe african journal of health professions education july 2012, vol. 4 no. 1 contents article 4 july 2012, vol. 4, no. 1 ajhpe objective. students’ perspectives on clinical teaching attributes can contribute to knowledge on teaching and learning in clinical education. the objective of the study was to report on nigerian physiotherapy students’ perceptions of the clinical teaching skills of their teachers. design and setting. a cross-sectional survey conducted in five physiotherapy training institutions in nigeria. subject. physiotherapy students (n=203) in the clinical phase of their training participated in the study. outcome measure. the validated 25-item mcgill clinical teacher evaluation (cte) tool was used to rate the students’ perceptions of the attributes of their clinical teachers. results. overall the students rated their teachers high on the cte scale; women rated their teachers higher than their male counterparts. clinical teachers who are academicians and /or had doctoral degrees were rated higher than clinicians and /or those with bachelor degrees only. students from two long established programmes not only rated their teachers higher, but were also more satisfied and positively challenged during clinical rotations than those from relatively new programmes. conclusions. this study found that overall nigerian physiotherapy students rated the teaching attributes of their clinical teachers highly. the nature of the work appointment (academic or clinical) of their teachers, as well as highest level of academic qualification achieved, influenced student ratings of their teachers. students found the clinical rotations offered by well-established programmes more challenging and satisfying. ajhpe 2012;4(1):4-9. doi:10.7196/ajhpe.132 introduction the outcome of learning in health profession training may be influenced by the attributes and overall behaviours of the teachers. according to duncan,1 student learning could be maximised if a student is first inspired by the teacher, then provided with motivation and then taught. however, clinical teaching is believed to be different from the traditional classroom teaching because it requires key attributes including one-to-one evaluation and smallgroup management skills.2 bench3 has described three versions of physiotherapy clinical education organisation. the internal version is one in which both the foundational and clinical sciences theory and students’ clinical experience are provided in the same institution. this insular training mode typically based in hospitals existed during the early stage in the development of physiotherapy as a profession and no longer exists today. in an external version now prevalent in the usa, students’ affiliation experiences take place in free-standing hospitals, clinics and centres. prevalent in the british commonwealth countries including nigeria is the bridge version in which clinical experiences take place mainly in a teaching hospital specifically affiliated to the university. important clinical teaching behaviours identified among physiotherapist teachers include: offering opportunities to practise technical and problemsolving skills, friendliness and positive regard towards students, showing enthusiasm for teaching and sensitivity to patients’ needs.4,5 asking questions in an intimidating manner, correcting students in front of patients, basing judgement on indirect evidence, not recognising extra effort, afterhour unavailability, and not setting time limits for teaching activities were identified as hindering behaviours.5 however, previous studies on physiotherapy clinical instruction were limited to developing theories and models on clinical education and were conducted in a few developed countries.5-9 from the literature, an ideal clinical education experience is one that takes place in a learning atmosphere that allows for establishing a mutually beneficial student-supervisor relationship.5-7 maximised learning following clinical instruction is deemed best achievable if the teachers have formal preparation on teaching.4,6-8 furthermore, the extant literature shows that a desirable clinical experience is one that can facilitate the connection between theory and practice,10 and is subjected to ongoing peer evaluation for quality physiotherapy students’ perception of their teachers’ clinical teaching attributes a y oyeyemi, a l oyeyemi, a a rufai, s m maduagwu, h n aliyu department of physiotherapy, college of medical sciences, university of maiduguri, nigeria a y oyeyemi, dhsc, associate professor a l oyeyemi, msc, lecturer i a a rufai, msc, lecturer ii s m maduagwu, msc, associate lecturer h n aliyu, bsc, assistant lecturer corresponding author: a l oyeyemi (alaoyeyemi@yahoo.com) article 5 july 2012, vol. 4, no. 1 ajhpe improvement.7 involving students in a humanistic and rigorous approach to practice, and being a professional that students would want to emulate, were associated with a positive perception of effective teachers.11 students’ perspectives on clinical teaching attributes can contribute to knowledge on teaching and learning in clinical education and represent consumers’ input that could improve teaching quality. feedback on clinical teaching obtained from students have the potential benefits of improving the effectiveness of teachers.12 this study is the first attempt at assessing clinical teaching in physiotherapy education in nigeria. the objective of the study was to report on nigerian students’ perceptions of the clinical teaching skills of their teachers. entry-level physiotherapy education in nigeria is a bachelor degree earned after five years of university education, the first two-and-a-half to three years of which is spent in the preclinical phase of their training. in the clinical phase experienced clinicians and academic staff teach students in the teaching hospitals. upon graduation, new professionals undergo a one-year internship in an accredited teaching or specialist hospital centre under the direction and supervision of experienced physiotherapists. the term academician, in this study, is used to describe a universityemployed physiotherapist who teaches foundational and clinical courses and also provides clinical instruction to students during rotations. the term clinician as used in the present study refers to a physiotherapist employed by a teaching hospital and who provides clinical instruction to students. in nigeria, both academicians and clinicians serve as clinical teachers involved in teaching students during clinical rotations. methods study design and sample a cross-sectional survey design was used to collect information from 203 physiotherapy students in the clinical years of their training from five universities located in four of the six geopolitical zones in nigeria. there are no physiotherapy training institutions in two geopolitical zones in the country (north-central and south-south). one of the four zones (southwest) has three training institutions from which two were randomly selected and sampled. one was selected in another zone (south-east) with two training institutions, while the sole training institutions in two other zones (north-west and north-east) were sampled. in february 2009, prospective participants were informed in a cover letter accompanying the questionnaires that completion of the questionnaires implied consent to participate and anonymity was assured. no name or any identification was required on the questionnaire that took about 20 minutes to complete. participants were instructed to place their completed survey in an enclosed envelope and to drop them in a box secured, locked and placed in one of the classrooms in each of the institutions. eight weeks after the survey distribution, two of the researchers (alo and sm) and two designated research workers collected the boxes from the institutions (obafemi awolowo university and university of ibadan, in the south-west zone; university of nigeria in the south-east zone; bayero univeristy in the north-west zone; and university of maiduguri in the north-east zone). a total of 230 questionnaires were distributed and 206 were returned. all except three were usable, giving a combined response rate of 88%. this study was approved by the institutional review board of the authors’ institution. instrument in order to explore questions posed in the study, the mcgill clinical teacher evaluation (cte) tool was selected based on the recommendations of five physiotherapists’ clinical teachers each with at least 15 years of practice experience and over 10 years of experience teaching students in the clinics. the mcgill cte tool is a previously validated instrument utilised in assessing physician clinical tutors’ effectiveness in several studies.13,14 the 43-item physical therapist clinical instructors’ behaviour instrument, identified in the literature, was not used because of a lack of information on the psychometric properties of the instrument.4 the mcgill cte tool was selected by consensus because of its clarity, brevity, ease of application, summative value, and also because the experts agreed that all the items in the tool represent the behaviours expected of physical therapist clinical instructors. the survey questionnaire consisted of three parts. part i required basic student demographic information such as age, gender and clinical year in the programme. the students were also asked to provide information on the gender, highest academic degree and specialty rotation of the teachers who taught them in the clinic at the time of the study. the students were also asked how challenging, in a positive sense, and how satisfied they were with their clinical experience. in part ii, respondents completed the 25-item mcgill cte tool that lists 25 attributes of effective clinical teachers anchored on a 5-point likert scale from ‘very strongly agree’ (5) to ‘very strongly disagree’ (1). the higher the total agreement score, the better the rating on the attribute. examples of attributes listed include ‘my clinical teacher should: “be enthusiastic and understanding” ; “be interested in social and psychological aspects of illness”; “inspire confidence in my knowledge of the subject”; “emphasize concepts rather than factual recall”; and “pose problem for students to solve”.’ the mcgill cte tool was previously validated for evaluating physicians but has not been utilised for other health professionals. the tool was therefore assessed for reliability among nigerian physiotherapy students in a pilot study. a reliability coefficient of 0.73 was obtained following its completion by 20 respondents at two separate times within a two-week interval, indicating moderate reproducibility. data analysis for each completed questionnaire, we entered the agreement rating on each of the items on the cte tool and the total agreement score. data analysis was done using spss software (version 15). descriptive statistics were computed for all items and independent t-tests and one-way analysis of variance (anova) were used to determine the influence of clinician teacher demographic variables on each attribute of effective clinical teaching and on the total agreement score. chi-square analysis was used to evaluate student satisfaction with the clinical experience offered by each of the programmes. the level of significance was set at an alpha level of 0.05 or less. results the mean (standard deviation) age of the students was 23.8 (+2.6) years and the majority were men (59.6%, n=121). students were completing a range article of clinical rotations including medicine (22.2%, n=45), neurology (14.8%, n=30), orthopaedics (18.7%, n=38) and other clinical rotations (14.3%, n=29). thirty nine per cent (n=80) of the students were in the second year of the clinical phase of their training (table 1). clinicians employed by the respective teaching hospitals taught the overwhelming majority of students (77.3%, n=157); academicians employed by the respective universities taught very few students (17.2%, n=35). most of the students did not know whether their teachers had had any formal education training or not (56.2%, n=114). almost half (46.8%, n=95) of the clinical teachers had attained a masters’ degree; few students (8.9%, n=18) did not indicate the highest degree of their teachers (table 2). the mean total agreement score was 100.6 (+25.2), indicating that overall students felt their teachers possessed the attributes of effective clinical teachers. attributes for which the students scored their teachers highest were those related to having an interest in helping students to learn (4.49+1.32), dealing with colleagues and staff in a friendly manner (4.45+1.16), and laying emphasis on clinical skills for patient management (4.42+1.24). students scored their teachers lowest on items related to challenging points presented in text and journals (3.54+1.32), conveying enjoyment of associating with students (3.76+1.27) and availability of teachers for discussion (3.93+1.33) (table 3). data were also analysed to evaluate differences in total agreement ratings and individual item ratings of the mcgill cte tool, according to programme. overall students in the oau and uib programmes rated their teachers significantly better (oau = 114.15+23.54; uib = 103.94+24.25; p<0.05) than their counterparts in the other programmes (buk = 99.77+26.89; unn = 98.84+21.62; uma= 88.00+32.31). students in these two programmes also rated their teachers higher than those of two or more other programmes on 16 of the 25 items of the mcgill tool (table 4). differences in individual item ratings and total agreement ratings, according to the demographic profile of students and their teachers, were also evaluated. women students rated their teachers significantly higher (mean=106.4, sd 22.2 v. 96.7, sd 27.0; p=0.008) and clinical teachers employed by the respective universities (academicians) were rated higher than those employed in the teaching hospitals (clinicians) (mean=107.9, sd 26.5 v. 99.8, sd 23.6; p=0.048). clinical teachers with doctoral degrees were rated higher than those with bachelor degrees (mean=106.61, sd 24. 1 v. 94.92, sd 21.1; p=0.036); no significant difference in the ratings between teachers with bachelor degrees and those with master’s degrees was observed (table 5). just over half the students surveyed (52.7%, n=107) indicated that they were satisfied or very satisfied with their clinical experience and the majority (82.5%, n=165) found the clinical experience challenging or very challenging (table 6). table 1. demographic characteristics of participating students (n=203) variables n % gender women 82 40.4 men 121 59.6 year in the clinic first 57 28.1 second 80 39.4 third 66 32.5 clinical rotation* medicine 45 22.2 obstetrics & gynaecology 15 7.4 neurology 30 14.8 orthopedics 38 18.7 paediatrics 34 16.7 others (icu, sports, etc.) 29 14.3 programmes unn 97 47.8 university of ibadan 13 6.4 buk 40 19.7 oau 27 13.3 university of maiduguri 26 12.8 * subtotals on discipline of clinical rotation do not add up to 203 because of missing data. unn = university of nigeria, nsukka; buk = bayero university, kano; oau = obafemi awolowo university. table 2. profile of clinical teachers variables n % gender of teacher* male 140 69.0 female 36 17.7 designation of teacher* clinician 157 77.3 academician 35 17.2 highest degree of teacher bachelor 52 25.6 masters 95 46.8 doctorate 38 18.7 unknown 18 8.9 formal training of teacher* yes 45 22.2 no 35 17.2 don’t know 114 56.2 specialty of teacher* neurology 37 18.2 orthopaedics 45 22.2 paediatrics 31 15.3 exercise physiology 23 11.3 kinesiology 7 3.4 others 33 16.3 * subtotals on subjects do not add up to 203 because of missing data. 6 july 2012, vol. 4, no. 1 ajhpe article 7 july 2012, vol. 4, no. 1 ajhpe identifiable trends on satisfaction with clinical experience, by programme, were also observed (x2=27.97, p=0.032). more students from oau (70.4%) and uib (69.3%) reported they were either very satisfied or satisfied with their clinical experience compared with students from buk (53.9%), unn (41.3%) and uma (30.7%). students from oau (92.3%) and uib (92.3) also reported that their clinical experience was more challenging, in a positive sense, than the students from uma (81.4%), unn (81.1%) and (buk (76.9%),(x2= 27.97, p=0.032) (data not shown). discussion this study is, to the best of our knowledge, the first published use of the mcgill clinical teacher evaluation tool as an instrument for rating the attributes of clinical teachers in a profession other than medicine. the study found that senior physiotherapy students (in their clinical years of training) from five nigerian universities rated the teaching attributes of their clinical teachers highly. this clearly indicates that students acknowledge the presence, and recognise the value, of effective teaching attributes in their teachers. the level of attributes of clinical teachers, as reported in this study, were comparable to those reported by medical students and residents in some medical and residency training centers in the usa.15 the findings in the present study cannot, however, be directly compared with those of previous studies of physiotherapy teachers6,8 because different instruments were used to rate the attributes of clinical teachers in these studies. higher ratings of clinical teachers by students in the oau and uib programmes, compared with students at unn, buk and uma, are noteworthy. two features of the oau and uib programmes that differ from the others, may explain this finding. firstly, the oau and uib programmes are older programmes, having been established in 1966 and 1977 respectively, whereas the unn, buk and uma programmes were established in 1987, 1990 and 2003 respectively.16 secondly, at the time of this study there was a difference in the level of seniority of academic teaching staff at the different institutions. in the oau and uib programmes there was one teacher each at the rank of professor and at least five lecturers at the rank of senior lecturer. the programmes at unn, buk and uma did not have any teaching staff at the rank of professor; unn had only one senior lecturer, while buk and uma did not have any senior lecturers on their full-time staff. table 3. order of agreement of student ratings of the attributes of effective clinical teachers using the mcgill cte rating instrument attribute agreement x sd my clinical teacher: is interested in helping students to learn 4.49 1.32 deals with colleagues and staff in a friendly manner 4.45 1.16 emphasises clinical skills, not lab tests for patient management 4.42 1.24 inspires confidence in his/her knowledge of subject 4.41 1.25 is clear and understandable in his/her explanations 4.41 1.19 encourages students to take responsibility for their own learning 4.30 1.19 encourages students to think 4.28 1.22 provides opportunities for discussion with students 4.25 1.31 dependability of attendance is good 4.23 1.19 encourages students to ask questions 4.22 1.35 invites comments rather than providing all the answers to students 4.21 1.22 displays good judgment in decision making 4.20 1.22 is interested in social and psychological aspects of illness 4.14 1.28 attitude to patients fits my concept of professional behaviour 4.13 1.27 poses problems for students to solve 4.12 1.25 is enthusiastic and understanding 4.11 1.16 emphasises concepts rather than factual recall 4.07 1.22 emphasises problem-solving approach rather than solutions per se 4.03 1.11 provides feedback and direction to students 4.01 1.18 presents divergent viewpoints for contrast and comparison 3.97 1.20 is usually well prepared for teaching sessions 3.97 1.18 teaching is suited to the level of students’ sophistication 3.95 1.29 is usually readily available for discussion 3.93 1.33 conveys enjoyment of associating with students and his/her colleagues 3.76 1.27 occasionally challenges points presented in text and journals 3.54 1.32 article 8 july 2012, vol. 4, no. 1 ajhpe secondly, at the time of this study, the student populations at unn, buk and uma were more than those at uib and oau, while the staff numbers were either less or at best comparable with those of uib and oau.17 as a result, according to programme quality criteria set by the national universities commission (nuc), the official programmes accrediting agency in nigeria, the oau and uib programmes had better staff-to-student ratios and better staff category mixes.18 it is likely that better clinical teacher ratings, and greater challenge and satisfaction with the clinical experience at oau and uib, compared with the other three programmes, can be attributed to these differences. more research needs to be conducted to substantiate these propositions. higher ratings of the teaching attributes of academicians may be explained by a general assumption that the main role of academicians is teaching while that of clinicians is clinical practice. academicians, who teach in both the classroom and clinic setting, are likely to have had more teaching experience than their clinician counterparts who only teach in the clinical setting. also, better rating of clinical teachers with doctoral degrees suggests that the latter may influence student perceptions of their teachers’ clinical teaching attributes or confer some real teaching advantage. once again, further research is needed to better understand these differences observed in this study. findings in a study such as this one are based on self-reported student perceptions and should be interpreted with caution. for example, although higher academic qualifications such as a doctoral degree may improve teaching ability, it would be too simplistic to conclude that one necessarily follows the other. as with any self-reported survey, the students in the present study may have provided responses they felt would be acceptable to the researchers. participants may have also held back responses they believed could portray their teachers as lacking in effective clinical teaching attributes. the study data were anonymised in an attempt to limit these potential sources of bias, but further work is needed to triangulate the findings presented in this study. furthermore, due to the positive wording of the items in the cte scale, the responses of the participants may also have been affected by the respondent set. conclusions overall, nigerian physiotherapy students rated the clinical teaching attributes of their teachers highly, and they were also satisfied and felt positively challenged during their clinical rotations. women students rated their teachers higher than men students; clinical teachers who are academicians (university employees) were rated higher than their counterparts who are clinicians (hospital employees); and clinical teachers holding doctoral degrees were rated higher than those holding master’s or bachelor degrees. also, the students from two long-established programmes, compared with students in relatively new programmes, rated the teaching attributes of their teachers higher and reported being more satisfied and positively challenged during their clinical rotations. while the latter findings may relate to better staff:student ratios and staff category mixes, the former table 4. differences, by programme, in student agreement ratings of selected attributes of effective clinical teachers using the mcgill cte rating instrument attributes group differences f-value p-valueoau uib buk unn umd my clinical teacher: is enthusiastic and understanding 4.63 4.33 4.08 4.05 3.46 4.07 0.003 emphasises concepts rather than factual recall 4.84 4.30 4.03 3.96 3.62 3.91 0.005 provides opportunity for discussion 4.70 4.77 4.25 4.20 3.68 2.64 0.035 encourages students to think 4.89 4.69 4.28 4.24 3.54 4.85 0.001 occasionally challenges points presented in text and journals 4.32 3.67 3.43 3.40 3.38 2.71 0.032 conveys enjoyment of associating with students and his/her colleagues 4.50 3.90 4.03 3.45 3.52 4.47 0.002 provides feedback and direction to students 4.58 4.17 4.15 3.82 3.71 2.72 0.031 displays good judgment in decision making 5.11 4.40 4.00 4.03 4.00 7.09 0.000 deals with colleagues and staff in a friendly manner 5.07 4.58 4.54 4.34 3.92 3.83 0.005 teaching is suited to the level of students’ sophistication 4.32 4.80 4.10 3.79 3.54 2.86 0.025 invites comments rather than providing all the answers to students 4.78 4.42 4.31 4.13 3.62 3.41 0.010 is interested in helping students to learn 4.96 4.92 4.43 4.55 3.62 3.80 0.005 presents divergent viewpoints for contrast and comparison 4.80 4.10 4.08 3.80 3.50 4.58 0.002 emphasises problem-solving approach rather than solutions per se 4.56 4.26 4.16 3.88 3.65 2.98 0.020 encourages students to take responsibility for their own learning 4.70 4.36 4.25 4.43 3.48 4.26 0.003 total agreement rating 114.15 103.93 99.77 98.84 88.00 4.11 0.003 oau = obafemi awolowo university; ui = university of ibadan; buk = bayero university kano; unn = university of nigeria nsukka; umd = university of maiduguri. values under group differences are mean values based on one-way anova. article 9 july 2012, vol. 4, no. 1 ajhpe finding warrants further investigation because it may be of real consequence. if clinical teachers employed at universities and/or holding doctoral degrees have better clinical teaching attributes than other teaching staff, potential reasons for this observation need to be identified. this may have significant implications for faculty development and the selection of clinical teachers in the health professions. competing interests. no conflict of interest is associated with this manuscript. references 1. duncan pw. one grip a little stronger. phys ther 2003;83:1114-1122. 2. knox je, morgan j. important clinical teachers behaviour as perceived by university faculty, students and graduates. j adv nurs 1985;10:25-30. 3. bench j. on organizational model of clinical education. j allied health 1999;28:179-183. 4. emery m. effectiveness of the clinical instructor: students’ perspective. phys ther 1984;64:1079-1083. 5. jarski rw, kulig k, olson re. clinical teaching in physical therapy: student and teacher perceptions. phys ther 1990;70:173-176. 6. onuoha ar. effective clinical teaching behavious from the perspectives of the students, supervisors and teachers. physiotherapy 1994; 80:208-214. 7. cross v. the professional development diary: a case study of one cohort of physiotherapy students. physiotherapy 1997; 83:375-383. 8. walker em, openshaw s. educational needs as perceived by clinical supervisors. physiotherapy 1994;80:424-431. 9. strohschein j, hagler p, may l. assessing the need for change in clinical education practices. phys ther 2002; 82: 160-170. 10. steward b. the theory/practice divide: bridging the gap in occupational therapy. br j occup ther 1996; 59: 264-268. 11. elnicki dm, kolarik r, bardella i. third-year medical students’ perceptions of effective teaching behavous in multidisciplinary ambulatory setting. acad med 2003; 78(8):815-819. 12. litzelman dk, stratos ga, marriott dj, lazaridis en, skeff km. beneficial and harmful effect of augmented feedback on physicians’ clinical teaching performances. acad med 1998;73(3):324-332. 13. mcleod pj. faculty perspectives of a valid and reliable clinical tutor evaluation program. eval health prof 1991;14:333-342. 14. mcleod pj, james ca, abrahamovwicz m. clinical tutor evaluation: a 5 year study by students on an inpatient service and residents in an ambulatory care clinic. med educ 1993;27:48-54. 15. kripalani s, pope ac, rask k et al. hospitalists and teachers: how do they compare to subspecialists and general medicine faculty. j gen intern med 2004;19:8-15. 16. physiotherapy training programs in nigeria. http://www.nigeriaphysio.org/ physiotherapy-education-programs-in-nigeria.html (accessed april 2010). 17. oyeyemi a, utti v, oyeyemi l, onigbinde t. knowledge, attitude and willingness of nigerian physiotherapy students to provide care for patients living with acquired immunodeficiency syndrome. physiother theory pract 2007;3(5):1-10. 18. national universities commission (nuc). accreditation procedures for academic programmes in nigerian universities. national universities commission 1999. table 5. factors impacting on the total agreement rating of clinical teachers by students variables (n) mean (sd) test used p-value gender 2.673† 0.008 women (78) 106.44 (22.22) men (116) 96.72 (26.95) clinical year of study 0.231†† 0.794 first (50) 102.36 (29.71) second (79) 100.76 (25.49) third (65) 99.14 (21.05) designation of clinical teacher clinician (148) 99.83 (23.61) 1.772† 0.048 academician (35) 107.89 (26.53) gender of clinical teacher 0.714† 0.476 female (35) 97.71 (24.43) male (133) 101.31 (26.99) formal education training of clinical teacher 1.330†† 0.267 yes (44) 97.07 (27.72) no (34) 96.32 (17.85) don’t know (107) 102.85 (26.12) academic qualification of clinical teacher 2.616†† 0.036 bachelor degree (48) 94.92 (21.07) master’s degree (92) 101.41 (23.79 doctoral degree (38) 106.61 (24.07) †independent t-test ††f-values from one-way anova. table 6. student satisfaction with the clinical experience variables n % how satisfied are you with the clinical experience? very satisfied 27 13.3 satisfied 80 39.4 neutral 71 35.0 dissatisfied 23 11.3 very dissatisfied 2 1.0 how challenging, in a positive sense, is the clinical experience?* very challenging 75 36.9 challenging 90 44.3 neutral 28 13.8 unchallenging 7 3.4 * subtotals do not add up to 203 because of missing data. article 34 july 2012, vol. 4, no. 1 ajhpe the purpose of this manuscript is to describe the processes followed in initiating and managing widening access to allied health sciences education at the university of cape town, south africa. in response to national higher education policy imperatives in south africa and in anticipation of the first cohort of outcome based education (obe) school leavers entering tertiary education, the school of health and rehabilitation sciences at the university launched an extensive intraand cross-programme transformation project in 2004. the project afforded four undergraduate professional programmes, namely audiology, occupational therapy, physiotherapy and speech therapy, an opportunity to address common educational and contextual drivers. these included, among others, the need for increased access and throughput of historically under-represented students in higher education. an advisory task team, named the curriculum review management team (crmt), was engaged in envisaging, navigating and containing a complex sociopolitical process involving many stakeholders with disparate ideas, practice approaches, and focal concerns. the use of the gale and grant model of change management, augmented by the community of practice conceptual framework, to assist with these processes is described. ajhpe 2012;4(1):34-39. doi:10.7196/ajhpe.138 introduction since the transition to democracy in south africa in 1994, the higher education and healthcare sectors have experienced changes aimed at eliminating the legacy of racially fragmented and unequal education and healthcare systems that were inherited from apartheid. these changes attempted to steer the systems towards the goals of economic development, social reconstruction, and equity.1 the reorganisation of the distribution and character of the previous 36 higher education institutions into 22 eliminated the rigid racially exclusive institutions. this was further strengthened by the comprehensive redesign of higher education curricula based on the national qualification framework, which was operationalised on an outcome-based education (obe) system in the high school, and assumed to meet the needs of all students regardless of their environment, ethnicity, economic status, or disabling condition.2 similarly, the national health policy focused on promoting equity, accessibility and utilisation of health services, and training of human resources.3 the 2009 annual report of the health professions council of south africa revealed that 5 081 physiotherapists, 2 946 occupational therapists, and 1 676 audiologists/speech therapists registered with the council in 2008 to serve a population of about 49 million people. the population was made up of ‘african’ (79.3%), ‘white’ (9.1%), ‘coloured’ (9.0%), and ‘indian/ asian’ (2.6%) in line with the racial classification of the apartheid era. the non-white population groups remained under-represented in these allied health professions. the report also indicated that in the 8 universities offering undergraduate allied health sciences education, there were 1 648 physiotherapy, 1 579 occupational therapy, and 495 audiology/speech therapy students. the proportion of students from the white population group was highest. trends on graduation between 1995 and 2004 (table 1)4 revealed that the 2010 occupational therapists were made up of 11% africans, 7.7% coloureds, 7.8% indian/asians, and 73.5% whites. there were 2 697 physiotherapists made up of 14.2% africans, 9.6 % coloureds, 12.1% indian/asians and 64.1% whites. there were also 1 125 audiologists/speech therapists made up of 7% africans, 4.6% coloureds, 14.8% indian/asians and 73.6% whites. responding to these needs, the faculty of health sciences, university of cape town (uct) developed a strategic plan in 1999, which included the processes in widening access to undergraduate allied health sciences education in south africa seyi l amosun, nadia hartman, viki janse van rensburg, eve m duncan, elmi badenhorst department of health and rehabilitation sciences, faculty of health sciences, university of cape town seyi l amosun, phd education development unit, faculty of health sciences, university of cape town nadia hartman, phd viki janse van rensburg, phd department of health and rehabilitation sciences, faculty of health sciences, university of cape town eve m duncan, phd department of human biology, faculty of health sciences, university of cape town elmi badenhorst, mphil corresponding author: seyi amosun (seyi.amosun@uct.ac.za) article 35 july 2012, vol. 4, no. 1 ajhpe transformation of the faculty from a faculty of medicine to the faculty of health sciences that would be led by the values of health equity and social justice embodied in the primary health care philosophy. this was a significant shift given the faculty’s location in a university founded in 1829 for people of european descent, and the faculty’s origin in medicine, established in 1920, to initially provide 6-year training of medical students.5 health and rehabilitation sciences came 37 years later with a diploma programme in physiotherapy, which was upgraded in 1972 to a 4-year bsc honours programme. similar 4-year degree programmes in occupational therapy and logopaedics (audiology, speech therapy) were established in 1975 and 1980, respectively. though uct professes to be an ‘open’ university, only token non-white students were admitted in the past. traditionally, admission into any of the four undergraduate programmes was based on performance in the national senior certificate examination, with emphasis on english, mathematics, biology or physical science. the admission policy of the faculty was later modified to provide appropriate measures for the redress of past inequalities and align with the aspirations of the country to widen access to higher education. the faculty attempts to admit the best qualified students from all population groups using three main tools – the mark obtained in the national senior certificate examination; the national benchmark test which assesses levels of proficiency in academic literacy, quantitative literacy and mathematics, and a biographical questionnaire which assesses nonacademic skills including community involvement and leadership qualities. the ultimate goal of the policy is to fill a class with a diverse group of students reflecting the demographics of the country, with the faculty leadership advancing student-centered learning as a transformatory educational goal. table 1. graduating trends in undergraduate occupational therapy, physiotherapy, and audiology/speech therapy education programmes in south africa graduating trends by population groups year undergraduate programmes african coloured indian/asian white 1995 occupational therapy 19 13 10 154 physiotherapy 31 11 11 155 speech therapy and audiology 2 3 13 66 1996 occupational therapy 20 18 10 157 physiotherapy 32 23 13 167 speech therapy and audiology 5 1 16 78 1997 occupational therapy 16 19 16 148 physiotherapy 24 24 19 168 speech therapy and audiology 4 9 7 89 1998 occupational therapy 20 11 20 161 physiotherapy 35 25 31 172 speech therapy and audiology 10 6 11 84 1999 occupational therapy 21 16 22 146 physiotherapy 40 25 36 180 speech therapy and audiology 4 7 12 83 2000 occupational therapy 10 20 26 159 physiotherapy 47 24 48 176 speech therapy and audiology 3 6 13 88 2001 occupational therapy 20 18 20 153 physiotherapy 40 26 26 170 speech therapy and audiology 9 0 17 86 2002 occupational therapy 23 16 16 155 physiotherapy 36 37 50 171 speech therapy and audiology 9 4 29 92 2003 occupational therapy 41 16 15 156 physiotherapy 54 32 50 189 speech therapy and audiology 10 9 21 90 2004 occupational therapy 41 15 9 154 physiotherapy 44 33 41 181 speech therapy and audiology 23 7 27 102 article 36 july 2012, vol. 4, no. 1 ajhpe as the university considers the white and indian/asian population groups as privileged, applicants from these population groups would require higher scores than applicants from the african and coloured population groups to stand a chance of being admitted into the undergraduate programmes in the faculty. following the recommendations of a faculty task team in 2000, the five ‘allied health’ departments – communication sciences and disorders, occupational therapy, nutrition and dietetics, nursing and midwifery, and physiotherapy – were amalgamated into a single department, named the school of health and rehabilitation sciences (shrs). it was assumed that the establishment of the shrs offered opportunity to increase undergraduate student numbers in order to ensure greater diversity in the demographics of students. a review of the curricula of each undergraduate programme was also recommended to ensure appropriateness and alignment across the shrs, and seizing the potential for developing multidisciplinary courses. in 2001, the shrs developed a 5-year operational plan (2002 2006) which included widening access into the undergraduate programmes, and the implementation of the goals of the plan was delegated to the director of the school at the time (sla) in 2002. the process of implementing the plan could only proceed in 2004, after necessary time had been given to addressing areas of contestation relating to organisational restructuring associated with the shift to becoming a school. transformation of the four undergraduate programmes in audiology, occupational therapy, physiotherapy and speech therapy, to foster equity of access and outcomes in the programmes, was prioritised. as there is no information on the processes to widen access to undergraduate allied health sciences programmes in south africa, the purpose of this manuscript is to describe the processes followed in initiating and managing the transformation of four undergraduate allied health sciences programmes towards widening access in a local university in south africa, and the challenges encountered during the processes. the description of the processes includes how the gale and grant model of change management, augmented by the community of practice conceptual framework,6 was used. the authors of this manuscript had a direct role in the processes to be described, acting as members of an advisory task team to the director of the shrs. the authors are therefore reflecting on the processes in envisaging, navigating and containing a complex socio-political process, which involved many stakeholders with disparate ideas, practice approaches and focal concerns, rather than presenting the outcome of the usual accroutements of research.7 the manuscript may be helpful to the other seven universities offering undergraduate allied health sciences programmes in south africa, or any groupings grappling with training professionals in diverse societies to promote heath for all. the transformation process the first cohort of obe school leavers entering tertiary education was imminent and the challenge was how to proceed given a dearth of information on academic programme transformation in south africa. an approach was identified based on the model of change management as proposed by gale and grant,6 which identified ten core activities. these are identification of a shared problem, obtaining the power to act, designing the innovation to be introduced, consulting with interested parties, wide publicity of the process, and reaching agreement on a detailed plan. the remaining core activities include implementation of the innovation, provision of support for the innovation, modification of plans if necessary, and the evaluation of the outcomes. this paper addresses only what is entailed in identification of a shared problem and obtaining the power to act, which were central concerns of the curriculum review management team (crmt). the other activities suggested by gale and grant6 extend to the ambit of wider groupings of participants who were eventually brought into the transformation process. in starting with identification of a shared problem, the focus was the curriculum. as experienced educators, it was recognised that the curriculum had to be point of entry before addressing who the students would be and what they would be bringing. in addition, the higher education qualification council (heqc) had developed curricula guidelines setting the academic credits required for the 4-year professional programmes. hence it was necessary to review alignment with the heqc guidelines, which showed that existing undergraduate curricula were already overloaded by 20 30%. it is well understood that overloaded curricula impact negatively on the quality and nature of student learning and tend to have financial implications for students as well that, in turn, impedes their learning. restructuring to eliminate overload was clearly a shared problem for the school. turning to the students, and following framework of scott et al.,8 analyses of throughput rates were conducted. they proposed that throughput data would raise issues about access and equity on the one hand (giving opportunity to students who were previously disadvantaged educationally), and the quality of educational process the students were taken through (including the support made available to help such students overcome learning difficulties). completion time and drop-out rates would serve as indicators as to whether reviews of educational processes were required to align equity student intakes with equity student graduation rates. this approach provides opportunities to reflect on the relationship between access, equity and table 2.throughput of six cohorts of undergraduate students (1995 2000) in the school of health and rehabilitation sciences, university of cape town, south africa admission time taken to complete total completed exclusionsrace 4 years 5 6 years african 42 (9.0%) 9 (21.4%) 11 (26.2%) 20 (47.6%) 9 (47.4%) coloured 67 (14.3%) 35 (52.2%) 16 (23.9%) 51 (76.1%) 4 (21.1%) indian/asian 27 (5.8%) 17 (63.0%) 4 (14.8%) 21 (77.8%) 1 (5.3%) white 331 (70.9%) 276 (83.4%) 23 (6.9%) 299 (90.3%) 5 (26.3%) total 467 337 (72.2%) 54 (11.5%) 391 (83.7%) 19 (4.1%) article 37 july 2012, vol. 4, no. 1 ajhpe quality, the practical tensions and challenges faced by different stakeholders in the implementation of strategies to improve access, teaching and learning, and the theoretical underpinnings of teaching and learning approaches. the data emerging from the analysis of six cohorts (n=467) of undergraduate students (1995 2000) in each of the school’s programmes indicated that the shrs did indeed have a shared problem. the analysis revealed that students from previously disadvantaged population groups were under-represented in admission into the programmes, took longer periods to complete the programmes, and had higher exclusion rates (table 2). commencing with identification of a shared problem, the model of change management6 enabled establishing the ‘need or benefit’ based on the conjunction of local and national imperatives. essential at this stage was the development of a common understanding of the problem-need-benefit relationship. the ‘problem-need’ focuses on achieving equity in healthcare delivery that can be promoted with increasing access of previously excluded population groupings into higher education. the benefit will be an increase in non-traditional graduates willing and able to serve in under-represented communities. it was necessary to develop a discourse that embodied this relationship among the small advisory team driving this process. this prepared the group for the critical next stage, which was gaining the ‘power to act’ by growing ownership of conceptualisation among key people through using a combination of positional power (through the director of srhs), political power (through the deanery of the faculty of health sciences), expertise (through education development unit of the faculty of health sciences), and relevant evidence. discourse here refers to the formation of a language with concomitant social and cultural practices which are contextspecific and which have economic, historical and political implications.9 the process of creating a discourse for transformation for equity, access and quality among members of the advisory team was equivalent to the members constituting themselves as centripetal participants in evolving a community of practice that clarifies appropriate and relevant language for action.10 the action being multifold, involved elaborating the ideology of equity, access and quality, and the establishment of processes and structures for managing the change process to recruit supporters and enactors of transformed practices. a community of practice refers to a group of individuals who have consciously, through collaborative learning in a particular social context, co-constructed the shared knowledge, skills, attitudes and values to function as full, knowledgeable participants in the particular context. these individuals derive meaning from their identity as participating coconstructors of knowledge and collaborate with newcomers in order that they in due course become full, knowledgeable participants of the same grouping or community. widening ownership of the discourse by extending the community of practice, and thereby acceptance of the shared nature of the problem, entailed presenting the findings of curricular overload and inequities in access and throughput to all academic staff of shrs. having accepted the nature of the problem, the school embarked on a series of workshops to identify aspects of the programmes that would need to be reviewed in order to eliminate the obstacles to widening access to under-represented students. the outcome was the establishment of task teams to develop and implement strategies in (i) curriculum transformation (which entailed multiple dimensions, namely, trimming the contents of the overloaded curricula for each programme but ensuring contextual relevance, promoting conceptual coherence across courses within a year of study as well as across years of study, student-centered learning, and creating opportunities for multi-disciplinary learning); (ii) marketing and student recruitment (which entailed visiting high schools in less-resourced communities to raise awareness of these professions, training programmes and employment opportunities in private and public sectors); (iii) retention and throughput rates (which entailed reviewing academic factors contributing to retention and throughput rates of students from under-resourced communities, and development of strategies for improvement); and (iv) identification of non-academic factors that negatively impact the academic performance of students and contributed to premature exit from the programmes, and development of strategies to overcome these factors. the establishment of task teams conferred on the centripetal participants the ‘power to act’, to continue the process with the support given by the task teams.6 the teams also contributed to growing and widening the community of practice in programme transformation for equity, access and quality through their participation in the process of refining and elaborating the discourse introduced by the centripetal participants. as ‘newcomers’, the teams undertook further analyses which included review of departmental records on students’ profiles, throughput rates per population group, analysis of the relationship between schooling background, mother-tongue language and academic performance, as well as interviews with a student sample regarding possible impact of socio-economic factors on academic performance. the teams then researched best practice and generated proposals for action. the process and products of the teams enabled the participants to develop knowledge and skills in aspects of education beyond their disciplinary specialism, and in so doing began the journey of moving from being legitimate peripheral participants to becoming centripetal participants, and thereby strengthening the community of practice.10 however, the deepening and expansion of the community of practice essential to constituting a critical mass for transformation generated complexity with the multiple reinterpretations of the language, social and cultural practices for transformation and related economic and political implications. co-ordination and planning emerged as an essential function for depth and expansion. the details of the processes in the task teams are not included in this manuscript. challenges encountered and formation of the crmt in 2006 the formal process of transforming the undergraduate programmes commenced and two major challenges were immediately encountered. the first challenge was the complexity in planning and co-ordinating the processes. there were multiple processes going on simultaneously, focusing on various aspects of the programmes. these processes involved role players at different levels, and included academic staff, clinical educators, course convenors and students in shrs, the deanery, undergraduate education committee, and the administrative managers for academics and finance in the faculty. at the level of the western cape province where the university is located, the managers of the various clinical and fieldwork learning facilities, and local disability interest groups were included in the processes. the second challenge was an initial resistance to the process, mostly from the academic staff, especially the heads of the various programmes. the process was complicated by the history and tradition of functioning and behaviours in the former independent departments, particularly in the areas of planning, teaching and resource allocation. this loss of ‘independence’ article 38 july 2012, vol. 4, no. 1 ajhpe likely contributed to the resistance encountered. in addition, we encountered the political nature of the process as we observed overt and covert forms of resistance emanating from a multiplicity of interests and influences, internal and external to the shrs that attempted to shape the process through the influence and exercise of power in various forms. it was helpful to have a dedicated group able to stand-back and identify the various forms of resistance and advise both faculty and departmental leadership on the nature of resistance. on commencement of the processes, the focus of the initial centripetal participants, director of shrs (author sla) and director of education development unit (co-author nh), was how to navigate and strengthen these processes in the face of the two challenges encountered. within a year their capacity was enhanced with the addition of three persons (co-authors) whose ideological disposition and expertise were pivotal to the community of practice. the group was later referred to as the crmt. members of the group were all proponents of the philosophy of comprehensive primary health care and student-centred curricula, as well as being committed to the elimination of institutional barriers to equity, access and quality. the collective expertise encompassed knowledge of national and regional perspectives for positioning of health and rehabilitation sciences (sla, ed), knowledge about the university (sla, nh), experience and research in undergraduate curriculum development (nh), teaching and student learning (vjvr), and student diversity (eb). while crmt evolved as ‘consultant’ to the director of the school, it acquired an additional responsibility of compiling the annual budget for the process of transforming the programmes. the emergent functions generated additional tensions of accountability given that crmt was an informal advisory group. the complexity of the process required crmt to create a map of action and timetable for the entire process, and in fortnightly meetings, reviewed actions, processes and structure to identify what was and was not working. brainstorming to produce plans of strategic action that included addressing the pockets of resistance as they emerged became the standing agenda for reports to the director of shrs, including the new director appointed in 2007. overcoming the overt and covert forms of resistance emanating from various interest groups sometimes required recruiting the assistance of the faculty executive leadership. in addition, crmt created opportunities for conversations in the school to listen to and respond to anxieties among the staff. also, crmt facilitated staff development programmes that equipped staff with the language and tools for thinking about education and themselves as educators, thus increasing the number of academic staff who engaged in informed dialogue about the relationship between secondary and tertiary education. this process kept the discourse of widening access in higher education alive in the school. thus crmt assumed an advisory and ‘planning’ role for the overall transformation process, as well as the dedicated task of managing the change process by means of repeated iterations between the 10 core activities in the model of change management proposed by gale and grant.8 the process of transformation in higher education in south africa has been complicated, among others, by significant cultures that resist de-racialising changes within higher education in the terms posed under transformation discourses.11-12 similar resistance has been reported in other countries as attempts at widening participation in higher education through preferential admission of previously under-represented students have produced mixed outcomes.13-14 on the one hand, there are opportunities for students to learn from and challenge one another, enriching both the classroom experience and more widely the breadth of the knowledge base within the higher educational institution. on the other hand, the process requires changes in the way in which higher education is conceived of, developed and organised, and provides challenges to existing practices of learning and teaching. in table 3. profile of 1st-year undergraduate students in the school of health and rehabilitation sciences (2008 2010), university of cape town total intake african coloured indian/asian white non-south african audiology 2008 13 31% 38% 15% 15% 0% 2009 21 66% 14% 10% 0% 10% 2010 21 48% 10% 14% 28% 0% occupational therapy 2008 57 7% 12% 2% 79% 0% 2009 55 18% 20% 11% 51% 0% 2010 51 31% 20% 2% 45% 2% physiotherapy 2008 58 14% 46% 2% 38% 0% 2009 67 30% 27% 3% 40% 0% 2010 62 34% 32% 3% 31% 0% speech therapy 2008 22 0% 23% 14% 63% 0% 2009 30 10% 20% 3% 60% 7% 2010 26 12% 19% 12% 54% 3% article 39 july 2012, vol. 4, no. 1 ajhpe the shrs, the first cohort of students was admitted into the transformed programmes in 2009. separate structures to assist students with academic and non-academic issues were established to ensure retention and success. the transformed programmes and student support structures were established in accordance with the recommendations from the relevant task teams. table 3 reflects the changes in the population groupings of the students admitted in 2009 and 2010, compared with 2008 before the implementation of the transformed programmes. conclusion the gale and grant model,6 augmented by the community of practice conceptual framework, contributed to understanding the processes necessary for widening access and achieving equity in completion rates in the minimum time for all four programmes in the school. access, retention and success became the organising framework for the work of the task teams. the establishment and functioning of crmt was essential to initiating and maintaining this framework. it was also pre-emptive in diagnosing and interpreting moments of serious resistance. workshops facilitated by crmt members and addressing concerns raised by various stakeholders, proved an effective means of managing most overt and some of the covert resistance. flexibility and accommodation during these sessions contributed to widening the community of practice. references 1. mooney g, mcintyre de. south africa: a 21st century apartheid in health and health care? med j austr 2008;189(11/12):637-640. 2. ensor p. curriculum. in: cloete n, fehnel r, maassen p, moja t, perold h, gibbon t, eds. transformation in higher education: global pressures and local realities. cape town: juta academic press;270-295; 2002. 3. department of health 1997 white paper for the transformation of the health system in south africa. http:/www.doh.gov.za/docs/policy/white/white_paper/healthsys97_01. html (accessed 17 august 2010). 4. south african qualifications authority. analysis of the national learners’ records database, report 2. 2007; http://www.saqa.org.za/docs/reports/hetrenz/2007/report.pdf (accessed 10 september 2010). 5. louw jh. a brief history of the medical faculty, university of cape town. south african medical journal 1979;56(22):864-870. 6. gale r, grant j. managing change in a medical education context: guidelines for action. medical teacher 1997;19(4):239-249. 7. maccarrick g. curriculum reform: a narrated journey. medical education 2009;43:979-988. 8. scott i, yeld n, hendry j. a case for improving teaching and learning in south african higher education. higher education monitor. 2007; no. 6. pretoria: council on higher education. http://www.che.ac.za/documents/d000155/index.php (accessed 10 september 2010). 9. gee jp. the social mind: language ideology and social practice. series in language and ideology. new york: bergin & garvey, 1992. 10. lave j. situating learning in communities of practice. in lave j, wenger e, eds. situated learning: legitimate peripheral participation. cambridge university press, 1991. 11. lehmann u, andrews g, sanders d. change and innovation at south african medical schools – an investigation of student demographics, student support and curriculum innovation. south african health review 2000. durban: health systems trust, 2001. 12. mabokela ro, evans ma. institutional mergers and access: the case of north-west university. africa education review 2009;6(2):208-223. 13. garvey g, rolfe ie, pearson sa, treloar c. indigenous australian medical students’ perceptions of their medical school training. medical education 2009;43:1047-1055. 14. shaw j. the diversity paradox: does student diversity enhance or challenge excellence? journal of further and higher education 2009;33(4):321-331. 102 december 2012, vol. 4, no. 2 ajhpe article infrastructure in africa to support multi-centre international trials in radiation oncology is presently limited.1 particularly in the sub-saharan region, challenges include inadequate training of investigators, limited resources, and a lack of socio-political support. this results in few locally derived publications2 for evidence fully applicable to the local context. goals of the international atomic energy agency (iaea) include increasing capacity in lowand middle-income countries to conduct locally relevant clinical studies,3,4 participate in multi-centre international trials,4 and develop evidence-based clinical practices.5 present strategies to build capacity include direct participation in randomised trials within which learning does occur, fellowships and doctorates, although these are even more limited in number, and training courses in research methods and statistics. such courses are typically aimed at trainees (undergraduate and postgraduate students) and junior staff. a pilot course for training-in-context in statistics and research methods: radiation oncology t r madzima, d abuidris, a badran, m boshoff, t erlwanger, n tsikai, g w jones peel regional oncology programme, credit valley hospital, mississauga on, canada t r madzima, hbsc g w jones, md, frcpc national cancer institute, university of gezira, wadmedani, sudan d abuidris, md radiation oncology department, ain shams university hospital, cairo, egypt a badran, md charlotte maxeke johannesburg academic hospital, south africa m boshoff, mb chb radiotherapy department, parirenyatwa group of hospitals, harare, zimbabwe t erlwanger, md n tsikai, md department of radiation oncology, university of toronto on, canada g w jones, md, frcpc corresponding author: g w jones (gjones@cvh.on.ca) objectives. inadequate training of investigators in statistics and research methods in africa contributes to having limited local evidence and infrastructure to support multi-centre international trials. methods of teaching junior oncology professionals tend not to emphasise research discovery, or the roles of emotional engagement and social networking in facilitating effective and efficient learning. we developed a strategy for teaching research methods and statistics in-context, centred on a shared international and practical research project. design. an african research network (afres) was created and members conducted a pilot clinical registry study to acquire real-time data over a 4-month period in 2011. following study closure, a proto-course consisting of 7 modules, each orientated to a practical topic in study development, implementation and reporting was administered over 18 weeks to all eight afres members. a survey of participants was conducted to evaluate the impact of this training strategy. results. this strictly voluntary project had 5 of 8 afres members engaged in the process. within one year, we generated and submitted two manuscripts and two news items for publication. participants reported an increased understanding of the principles of evidence-based practice, research methods and interest in pursuing future research initiatives. conclusion. a novel strategy to build international research infrastructure in africa, grounded in a practical and relevant project, and which is collaborative and engaging, appears to be efficient and effective. ajhpe 2012;4(2):102-106. doi:10.7196/ajhpe.157 article the iaea sponsored an african regional cooperative agreement for research (afra) 4-day training course in ethiopia, in december 2010, on research methods and statistics, and two dozen trainees and staff in radiation medical sciences and oncology disciplines participated.6 the course included lectures on research ethics, good research questions, design, data management, basic statistics and end-reporting. a third of the time was applied to a daily laboratory practical for developing and presenting draft protocols for possible randomised trials: three were done, one per small group of students. at the end students provided feedback and expressed concern about math and statistics anxiety, and too few active learning experiences. statistics anxiety7,8 and passive learning9,10 are well-recognised problems in the literature. students also expressed concerns over working at home in relative isolation, with few opportunities for networking and publications, and having few easy-to-do projects for low-resource environments. methods to overcome critical barriers to learning and research include improving both emotional engagement and social networking. the concept of emotionally charged learning has been called ‘hot-cognition’.11 this implies that thinking, feeling, and acting, together in an educative experience, are synergistic and can change the ‘meaning’ of the experience.9,10 further, opportunities for networking and sharing projects may allow for peer-topeer education, for efficiencies through sharing, and for a reduced sense of isolation.12 for example, the academic clinical oncology and radiobiology research network (acoorn, uk) has demonstrated the importance of research networks in delivering research through its role in facilitating the work of radiographers.12 a shared research experience may increase motivation and the number of research products. students at the afra course also expressed concerns about little-to-no prior training in the principles of evidence-based medicine or evidencegenerating research,13 understanding medical literature and practice guidelines, and knowing whether such evidence (most being of ‘western’ origin) could apply to contexts in africa. overcoming emotional, cognitive and social barriers to learning and research productivity is central to increasing the body of local evidence that can inform clinical practice.1 despite legitimate student concerns, and advances in pedagogic theory, increasing the capacity for radiation oncology research and evidence-based practice has relied more on conventional approaches. these can fail to leverage the making of ‘meaning,’9,10 working with emotions and establishing social networks,14 and so can fail to develop skills and transfer knowledge and skills into clinical practice to promote research.4 as extensions to conventional teaching approaches, present international initiatives include a virtual university,15 and very limited technical exercises (e.g. image-guided contouring of organs in the pelvis).16 these have not yet been evaluated as to their impact. meanwhile, some locales such as in south africa and zimbabwe have introduced one or two compulsory research projects required for qualification to practise in radiation oncology. such projects are done individually by trainees, and few are within a clear pathway towards sound critical appraisal of literature, or towards participating at national and international levels in research, once qualification to clinical practice has occurred. under these new requirements, it is unknown how many of today’s trainees will pursue a research-orientated career, and whether this will be greater than in the recent past. in africa, a strategy to teach junior oncology professionals (trainees and junior staff) in research methods, data management and statistics must be practical for a limited-resource environment. it should provide active learning in relevant context, mimic practice of research, and utilise emotional engagement and social networking. such training can build research infrastructure and promote learning in the principles and practices of evidence-based medicine. in this paper we report the pilot testing of a strategy using teaching modules aligned with an authentic and potentially publishable research project done by the participants. to mimic the iaea international trials we used a centralised data management centre, and our research project was trans-national and also relevant to local contexts, resource limitations and participant interests. methods we piloted a strategy of training centred on a practical, shared project, that is relevant to contemporary clinical practice and collaborative international research, and to which we attached sequential, domain-specific learning modules. more akin to an apprenticeship, trainees completed all steps within a 1-year cycle, from research idea to submitted manuscript.17 we conducted a survey of participants to evaluate the personal impact of this strategy. independent of the completed afra course in ethiopia, 8 radiation oncology trainees were e-mailed (by gj, one of the attending faculty members in afra) to create an african research network (afres) and conduct a shared pilot clinical registry project to acquire real-time data, in 2011, of patterns of practice and treatment. four of 8 afres members (3 trainees in africa and 1 staff radiation oncologist in canada) agreed to jointly conduct the study, and of the 8 members only the 7 junior afres members were students of the minicourse. initially a short protocol was written along with a single page form for data collection. the study was implemented over 4 months (24 dec 2010 1 may 2011). local ethics approval was obtained by the 4 investigators for this prospective observational study, having no randomisation. each participant documented patient, disease and treatment data for their consecutive curative and palliative cases (described in full elsewhere),17 and submitted forms to the data and methods centre (dmc) in canada for analysis. following closure of the pilot registry study, the afres proto-course was developed to teach 7 junior afres members about methods and statistics (table 1). this provided a collaborative learning environment over 18 weeks (aug dec 2011) using e-mail communications every week from the dmc, with participants free to multi-way communicate by e-mail and facebook (group, and as individuals). modules consisted of two parts, one providing 7 12 questions about the subject matter, in some cases referent to the pilot project, and one providing summary answers to the questions, between 4 10 pages of singe-spaced text with diagrams. the 7 modules were orientated to a practical topic (e.g. ‘grant-reviewing’ the protocol, discussion of ethics, study implementation, data management, analyses and ‘peer-reviewing’ the manuscript) (table 1). therefore, this was both an educational exercise and a critical reporting of data and statistical findings of the practical project. midway through the course, a survey was conducted that included: • current gaps in a participant’s knowledge of a subject • relevance of afres material • interest in participating in future research as a result of the pilot project • barriers to participation • the value of this educational experience. december 2012, vol. 4, no. 2 ajhpe 103 104 december 2012, vol. 4, no. 2 ajhpe article opportunity for continual feedback existed from week to week, which also facilitated a dynamic learning environment customised to student-specific needs. the writing component of this 1-year project (manuscripts and related news items) constituted the final modules. results the registry study included 107 cancer cases, demonstrating feasibility of an international clinical registry. delays in obtaining ethics approval at some centres did limit the number of cases accrued to the study. there was 99% completion for requisite data. heterogeneity of clinical practice was observed, and its implications for technology transfer and ongoing international trials are described in a separate manuscript.17 briefly, results from this non-iaea project indicate continuing relevance to the ongoing trials of the iaea17 and difficulties relying on data from some international organisations about african contexts.18 overall, it is clear that 5 of 8 afres members participated in this pilot project to sufficient depth to constitute a relative success in both the research and teaching aspects. notably, there are two submitted manuscripts and two new items generated by the strategy which are career-relevant. from an education, training and clinical perspective, this project demonstrates higher statistical teaching at the level of international table 1. afres pilot course schedule and modules date of e-mails (mondays) phase (issue to explore is sent out and feedback from participants) sources of the e-mails issue under consideration (for each 2-week cycle) aug 22 issue 1 data centre research question and protocol elements of a good research question; purpose, objectives and format of a protocol; role of ilterature; study design outcome measures; sample size; and statistical plan aug 29 feedback loop afres participants issue summary to follow from data centre sept 12 issue 2 data centre variables and forms principles of a good form and rules for formatting; standardising of variables and formats; sources of bias; and relevance to data quality sept 19 feedback loop afres participants issue summary to follow from data centre sept 26 issue 3 data centre ethics and implementation issues scientific review and ethics assessment of pilot registry study; patient risk, confidentiality, consent; and potential barriers to implementation oct 3 feedback loop afres participants issue summary to follow from data centre oct 10 issue 4 data centre data management approaching data & cleaning data; identifying outliers; and handling missing values oct 17 feedback loop afres participants issue summary to follow from data centre oct 24 issue 5 data centre descriptive statistics their use in summarising the data-set; and use of graphical methods nov 7 feedback loop afres participants issue summary to follow from data centre nov 14 issue 6 data centre association statistics & regression analyses association v. causation; tests of significance; covariates; adjustments; and reporting findings nov 21 feedback loop afres participants issue summary to follow from data centre nov 28 issue 7 data centre manuscript ‘registry study’ & ethics ‘closure letter’ participating in writing the manuscript, and closing letter to ethics committees dec 5 feedback loop afres participants appraisal of this ‘mini-course’ [survey] december 2012, vol. 4, no. 2 ajhpe 105 article collaboration, focusing on local concerns and practices. the registry approach was positively evaluated. participants identified the collaboration of countries and support from the dmc as the most beneficial aspects of this practical, learning-in-context exercise. the material presented during the course was well received by afres participants. the survey showed that prior to this afres pilot project, gaps in knowledge of research methods and statistics were consistent among participants. they identified a poor grasp of formulating relevant and feasible research questions, developing forms for data collection, and applying statistical methods. one participant wrote about gaps: ‘in knowing how to approach and identify the appropriate category of research i am willing to embark on and what necessary variables are needed’. another expressed ‘more concern on the statistical part [of research]’. the afres course material (table 1) was scored as relevant to trainee experiences (mean = 3.3 on a 5-point scale, 1 5 where 1 = ‘not relevant at all’ and 5 = ‘very relevant’). in contrast, future relevance after graduation was scored uniformly as 5. as a result of participation in afres, a majority expressed increased understanding of research methods, principles of evidence-based practice, and interest in pursuing future research. this suggests that the pilot course, using newer methods of teaching, was more effective than the conventional training course which these trainees had experienced in ethiopia. barriers to participation in the project included participants studying for, or the writing of, final examinations, their administrative workloads, country-specific political disruptions, intermittent internet access, and some resistance by local senior staff members to collaborative, international studies. for example, one participant wrote: ‘... we need to analyse our situation in africa [with too] few clinicians [who are] facing all kinds of cancer … [and] have no dedicated assistants like research nurse, statistician, and can’t hire any.’ the pilot project highlights key obstacles to implementing international projects and training junior professionals. however, we estimate that the amount of time expended related to the ethiopia course by the faculty and by the students was similar to the time expended on the afres pilot project, but the second of these was decentralised and involved no travel or hotel costs. therefore we conclude that our strategy is no more labour intensive than conventional methods, and it may be less expensive. discussion regardless of where one is in the world, there are sets of skills essential to evidence-based practice and participating in research.13 conventional methods of teaching and associated theories of education have come under criticism for being less efficient for, or relevant to, professionals in clinical practice. ‘learning-in-context’ was the theme of the last international conference on teaching statistics, held in july 2010.13 possibly, newer methods of teaching skills are essential to optimise training and to help transfer learning into improving clinical practice, and into clinical careers with a research component. we build on more contemporary theories of education14 and practice with a pilot project exploring the feasibility of learning in context in a collaborative project. consistent with theory regarding emotional arousal and social networking,14 our voluntary project had 5 of 8 individuals engaged in the process. within 1 year we were able to generate manuscripts for publication, and 2 news items. students demonstrated some research skills (e.g. form completion and manuscript review) and acquired insight into what is required in a career in research. our students provided evidence towards meeting canmeds 2000 criteria in pre-qualification training for clinical practice.19 we have identified several lines of potential improvement to our strategy. we sequentially conducted a project and then a proto-type course. the practical and teaching parts of the course may be reconfigured and integrated into a woven pattern that covers the complete arc from idea generation to manuscript submission. the afres coordinator (gj) was the primary writer for the project protocol, with afres members acting as reviewers. however, a strategy that involves group members co-writing a protocol would be more valuable, with each taking a section. the early goal should be a shared vision and orientation to the project. as a prototype, the mini-course was limited to 7 modules. a future project would include many more modules or a book with lots of tables and lists (as one participant has suggested). this project was not funded; participation was purely voluntary, resources were limited, and competing responsibilities of trainees hindered full participation. overcoming challenges remains an issue, and education theories do not identify professional and socio-cultural contexts that can restrict learning. greater resources (e.g. per-case funding) could give greater rates and more time for participation in the project, and greater learning in the associated mini-course. we targeted only radiation oncology trainees who had attended an afra course, who were a convenience sample. however, junior professionals who have qualified for clinical practice might be a more appropriate group for our strategy. some additional options include integrating our strategy with an afra-like course (pre-, in-, and post-course activities), using our strategy for junior staff to fulfil criteria for probation prior to participation in international trials, and establishing a true continent-spanning network with data centre support (data management and investigator training) to assess heterogeneity20 and its determinants in clinical practice. methods of learning-in-context for clinicians at the beginning of their professional careers are strategically positioned to develop skills, to provide useful local data to develop evidence-based practice, and to develop positive attitudes to research. individuals may realise the research potential of routine daily activities which can stimulate local research initiatives,20 refine and add skills, and prompt interest in international research. a project such as a real-time registry of patterns of practice demonstrates a participant’s capacity to consistently manage and follow patients. these are criteria for participating effectively in funded, international, randomised trials. a combination of conventional teaching strategies plus methods with ‘hotcognition’ and in-context learning may be optimal. conclusion we have reported the results of a pilot test of a strategy centred on an authentic, collaborative and engaging research project with teaching modules for research methods, data management and statistics. findings suggest that it is more efficient and effective than conventional teaching methods. overcoming emotional, cognitive, social and professional barriers to learning and research productivity may increase the amount of local evidence informing clinical practice, build the research infrastructure for loco-regional studies, and increase participation rates in international clinical trials. given the success of this pilot project, we recommend a definitive test of this strategy with an educational research protocol. 106 december 2012, vol. 4, no. 2 ajhpe article references 1. engel-hills pc. radiation therapist research in africa: overcoming the barriers to reap the rewards. j radiother prac 2009;8:93-98. [http://dx.doi.org/10.1017%2fs1460396908006547] 2. nwogu ce, ezeome ee, mahoney m, okoye i, michalek am. regional cancer control in south eastern nigeria: a proposal emanating from uicc-sponsored workshop. west afr j med 2010;29(6):408-411. 3. national research council. cancer control opportunities in lowand middle-income countries. washington, dc: the national academies press, 2007:263-264. http://www.nap.edu/openbook.php?record_ id=11797&page=263 (accessed 1 september 2012). 4. international atomic energy agency (iaea). coordinated research activities annual report and statistics for 2010, 2011:1. http://www-crp.iaea.org/html/2010-annual-report.pdf (accessed 1 september 2012). 5. international atomic energy agency (iaea). iaea annual report 2006:34. http://www.iaea.org/publications/ reports/anrep2006/anrep2006_full.pdf (accessed 1 september 2012). 6. afrrcan regional cooperative agreement for research, development & training related to nuclear science & technology (afra). regional training course on methodology of clinical research in radiation oncology, 30 nov 4 dec 2010, addis ababa, ethiopia. 7. hulsizer mr, woolf lm. a guide to teaching statistics: innovations and best practices. malden, ma: wileyblackwell, 2009:99-101. 8. williams a. online homework vs. traditional homework: statistics anxiety and self-efficacy in an educational statistics course. technology innovations in statistics education, 2012;6(1):5. 9. novak jd, gowin db. learning how to learn. cambridge university press, 1984:5. 10. gowin db, alvarez mc. the art of educating with v diagrams. cambridge books online. cambridge university press, 2005:xvi,193 http://books.google.ca/books?id=dacnbqczbiac&printsec=frontcover&sourc e=gbs_ge_summary_r&cad=0#v=onepage&q&f=false (accessed 1 september 2012). 11. abelson rp. computer simulation of ‘hot’ cognition’ in computer simulations of personality. in: tomkins ss, messick s, eds. computer simulation of personality. new york: wiley,1963:277-298. 12. heap g, stones n. networking to deliver research: research radiographers within the academic clinical oncology and radiobiology research network (acorrn). j radiother prac 2009;8:87-92. [http://dx.doi. org/10.1017/s1460396908006560] 13. jones gw. evidence-generating research and evidence-based medicine. the 8th international conference on teaching statistics (icots-8). ljubljana, slovenia, 11-16 july 2010. publications the international association for statistical education (iase): session 1a1. http://www.stat.auckland.ac.nz/~iase/publications/icots8/ icots8_1a1_jones.pdf , and conference theme at http://icots.net/8/abouttheme.php 14. lefrancois gr. theories of human learning: what the professor said. 6th ed. wadsworth:cengage learning, 2012:300-318. 15. international atomic energy agency. virtual university and regional training network for cancer control: iaea responds to critical human resources shortages in africa. http://www.iaea.org/newscenter/news/2010/ canceruniversity.html (accessed 1 september 2012). 16. european society for radiotherapy & oncology (estro). school of radiotherapy and oncology. http://www. estro-education.org/pages/default.aspx (accessed 1 september 2012). 17. madzima tr, boshoff m, abuidris d, tsikai n, jones gw. a successful clinical pilot registry of four radiation oncology practices in africa and ontario. central afr j med 2012 (in press). 18. sankaranarayanan r, swaminathan r, lucas e. cancer survival in africa, asia, the caribbean and central america (survcan). iarc sci publ 2011:162. 19. frank jr, jabbour m, tugwell p, et al. skills for the new millennium: report of the societal needs working group, canmeds 2000 project. annals royal college of physicians and surgeons of canada, 1996. http://rcpsc.medical. org/canmeds/canmeds_e.pdf 20. mackillop wj. health services research in radiation oncology. in: gunderson l, tepper j, eds. clinical radiation oncology. 3rd ed. philadelphia: pa elsevier, 2012. september 2021, vol. 13, no. 3 ajhpe 189 research why was the idea necessary? traditionally there has always been a one-month elective opportunity for third-year medical students at the univesity of pretoria, south africa. in pre-pandemic years, students have used this elective to explore a future area of specialisation and/or gain practical experience at a self-selected suitable health facility or placement. the completion mark for the elective was based on the submission of a student-generated reflective report about their experience. this practice was, however, severely challenged in the prevailing covid-19 pandemic with movement restrictions and concerns about transmission. therefore, a decision was made and supported by the deanery to explore the possibility of a virtual self-paced online elective for 300 medical students. of note here is that not only were these students adjusting to lecture-led online-synchronised classes, but they also had never before been exposed to online learning in the form of massive open online courses (moocs) as part of their formal qualification. what was tried? after consultation with a few academics and an education innovation consultant, an online bouquet of free moocs and other sponsored courses centred on the roles of the competency framework of the health professions council of south africa (hpcsa) was proposed.[1] the roles of ‘leader and manager’, ‘health advocate’ and ‘professional’ were identified as ones that had not been traditionally focused on in the medical curriculum. these roles would be the focus of this elective. it was envisaged that students would engage in self-directed learning and emerge with knowledge and competencies in familiar and new topics that may spark the concept of lifelong learning in this cohort of students. the virtual elective consisted of one compulsory course related to leadership and management, two courses related to any of the identified roles, any two medical or non-medical courses of the student’s choice from the linkedin learning platform and, finally, the assessment. courses were selected from reputable online global health sites, as well as a private higher educational institution – the foundation for professional development – that allowed students to access their sponsored courses for a limited period. the university also granted students access to the licenced linkedin learning package that was subscribed to for staff members. weekly reports were provided at the online school of medicine meeting. communication was key during this endeavour and explicit instructions were placed on the learning management system (lms) of the institution. frequent announcements were sent, and the class representative was utilised as a go-between for two-way communication, distributing information and reporting on challenges experienced by the students. a designated technical person from the one mooc service provider as well as an administrative staff member were available to assist with log-in and other technical issues.. a description of the available courses and instructions on how to access them was provided on the lms. the content of courses ranged from digital and financial literacy to gender-based violence and covid-19 management. apart from the courses on linkedin learning that could be a few minutes in duration, most of the other courses would take from two to 25 hours to complete, with certificates being issued on completion. for reporting and assessment purposes, a excel (microsoft corp., usa) template was created for the students, who downloaded their own personal copy of the interactive template. the template consisted of a sunburst graphic that, when populated with details of the courses completed, would update in real time and provide a colourful illustration of the hpcsa roles and competencies that students addressed in the elective, as well as alluding to gaps that they would need to strengthen in the remaining years of their medical studies. a  second tab required them to complete a three-column kla-sheet for each of the courses, briefly describing ‘i knew this already’, ‘this was new to me – i learnt something useful from the course’, and finally ‘this was useful – this is how i am going to apply it to my life/medical journey’. this reflection would contribute to the metacognition of students. to pass the elective and in accordance with the institution’s record-keeping policy, students had to upload a zip folder of the certificates of completion that they obtained for the chosen courses and the excel sheet. incorporating some gamification, prizes consisting of vouchers from an online medical shop, as well as virtual or face-to-face opportunities with medical doctors fulfilling the roles of a leader and manager, health advocate and professional, were awarded to randomly selected students (lucky draw). for quality improvement purposes, the medical education office traditionally co-ordinates the end of module feedback. owing to the nature of this elective, questions about the attainment of competencies, course selection and the likelihood of a virtual elective for future student cohorts were added. the lessons learnt the disruptive and frustrating impact of the covid-19 environment on the students was underestimated and although support and referrals were offered when it was brought to the co-ordinator’s attention, the available resources of the institution should have been highlighted and reinforced throughout the elective. in addition, the inequities of data, connectivity and digital fluency also came to the fore. in lieu of supporting the students, submission deadlines were extended and assessment approaches and techniques were adapted to accommodate differences and address challenges. however, what became evident was that online resources that allow students to become more digitally literate, as well as opportunities to raise other issues (such as data shortages), must be created well in advance of such an endeavour. not only do students need to be made aware of the avenues available to raise concerns, but they may also need further communication on responsible data usage. for future electives that may incorporate online courses as a component, dedicated administrative support and technical resources, as well as possible collaborative relationships with service providers are vital. a ray of sunshine in the covid‑19 environment, with a virtual sunburst elective a turner, mb chb, mmed, fcphm, dip hiv man (sa); i (j c) lubbe, msocsc, med, phd; w ross school of health systems and public health, faculty of health sciences, university of pretoria, south africa corresponding author: a turner (astrid.turner@up.ac.za) this open‑access article is distributed under creative commons licence cc‑by‑nc 4.0. mailto:astrid.turner@up.ac.za 190 september 2021, vol. 13, no. 3 ajhpe research what will we keep in our practice? the access of undergraduate students to the linkedin learning platform was piloted in this elective. as a pilot, students would have access until march 2021. the continued use of the platform, with the possibilities of directing students to specific topic pathways and being able to have data analytics about their course completion and other topic selections, for example, is attractive and worth exploring further. secondly, the sunburst excel template – if adapted and used systematically each year – could be the mechanism for all health sciences students to reflect on while also graphically see their progress in the hpcsa roles and associated competencies that they are expected to attain upon graduation. based on personal communication to the co-ordinator and class representative, the undergraduate students thoroughly enjoyed the elective and there is a definite educational, personal and professional benefit to include an online component in future electives, not only to underscore the importance of these often neglected hpcsa roles, but also to ensure wellrounded qualified health professionals. based on a study that will evaluate the data obtained from the elective, the collaborative practices that were formed may be revisited to use in the continuing teaching experience of students. what will we not do? after thoughtful personal reflection, sound boarding with peers and analysing the students’ reflective reports, we have come to the following conclusion: change is inevitable and sometimes we need a pandemic to force us to innovate, adapt and improve. therefore, we have committed to the following: • we will never revert to the pre-pandemic elective for students where they were not guided regarding choice or held accountable for those choices and their own learning. the covid-19 environment presented us with a long-overdue opportunity to assess and revamp the elective and its intended outcomes. • although it was done for the safety of students, we will not, when it is possible, go back to a purely virtual elective. as students thrive in a bestof-both environment (and thus a hybrid approach to teaching, learning and assessment), the elective should make provision for that. students will benefit from a more hybrid approach addressing both the need for authentic clinical exposure during the elective, as well as acquiring the transferable, but often neglected, hpcsa affective roles and competencies. • we will not limit the use of the interactive sunburst to only this module. the ‘virtual sunburst elective worksheet’ is a constructive tool that could be used in future electives to ensure that students – and educators – in our institution keep track of their academic growth through the years, as well as a tool to indicate where more attention is necessary. this will become a ‘living’ tool to display their growth and development. • finally, we will not be complacent but continuously seek more innovative ways to improve the curriculum towards one that is person-centred and values-based. evidence of innovation declaration. none. acknowledgements. the authors would like to thank the following individuals and committees for their contribution towards the elective: professor r green and professor v steenkamp (faculty of health sciences, university of pretoria), professor je wolvaardt and ms h kilani (school of health systems and public health), dr e matsebatlela (international elective & education office, university of pretoria), ms e thue (learning and development, department of human resources, university of pretoria), dr g wolvaardt and his staff (foundation for professional development) and finally, the members of the academic quality assurance committee (university of pretoria). author contributions. equal contributions. funding. none. conflicts of interest. none. 1. health professions council of south africa. core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. hpcsa; 2014. https://chs.ukzn.ac.za/ libraries/news_events/mdb_core_competencies_-_english_-_final_2014.pdf (accessed 24 february 2021). accepted 11 may 2021. afr j health professions educ 2021;13(3):189-190. https://doi.org/10.7196/ajhpe.2021.v13i3.1509 https://chs.ukzn.ac.za/libraries/news_events/mdb_core_competencies_-_english_-_final_2014.pdf https://chs.ukzn.ac.za/libraries/news_events/mdb_core_competencies_-_english_-_final_2014.pdf https://doi.org/10.7196/ajhpe.2021.v13i3.1509 march 2022, vol. 14, no. 1 june 2021, vol. 13, no. 2 ajhpe 118 research assessment defines what should be learnt and assesses the quality of the knowledge obtained. different outcomes may require different assessment methods. it is often necessary to integrate various methods of assessment to evaluate the attainment of a learning outcome. similarly, various learning  outcomes can also be evaluated via one assessment method. the assessment results generated by the assessor consist of information regarding the students’ performance and their achievement of the learning outcomes.[1,2] with the shift from teacher-centred learning to outcomes-based studentcentred learning, there has been a move away from what will be taught to outline the outcomes that the student is expected to achieve by the end of the course. in outcomes-based learning, outcomes are based on the knowledge, skills and competencies that need to be achieved by the student.[3] all educational teaching and resources need to be related to the learning outcomes to assist students with achieving this goal. therefore, outcomesbased assessments need to be aligned with learning outcomes.[4] learning outcomes refer to statements of what the learner is expected to know, understand and comprehend by the completion of the learning process. a unit of learning includes knowledge, skill and methodological outcomes.[5] ideally, the learning outcomes should be written in a way in which these competencies can be assessed. the aim of medical education is to educate students so that they can transform knowledge into practice as junior doctors. to achieve this, the lecturer defines the knowledge that needs to be obtained and how that will be achieved. therefore, the lecturer has to structure this in such a way that the student knows what is required to obtain that knowledge and translate it into the appropriate actions. this is best achieved if the verbs from bloom’s taxonomy are used to describe the learning outcomes.[6,7] assessment should assist students to validate their achievement of outcomes.[6,8] it is a challenging task to ensure that assessments are valid, reliable, fair, and that teaching methods and assessment tools are aligned with learning outcomes. poor assessment practice and malalignment between outcomes and assessment result in negative comments, student dissatisfaction and poor performance.[8] assessment in medical education is vital to the medial student and the public, as it results in competent, capable doctors. assessment is the driving force that ensures that students learn, and students will learn what they think will be assessed. assessment tools must support the course and allow students to demonstrate that they have achieved the defined learning outcomes in a fair, valid and reliable manner. assessments should allow students to demonstrate the vastness of their knowledge and their skills.[9] courses at medical schools should employ a range of assessment tools that are appropriate for testing the curricular outcomes. the intended assessment tools should not disadvantage the medical students or the patients who may be used in clinical examinations.[10-12] as student numbers increase and issues pertaining to patient privacy and confidentiality come to the fore, medical schools need to review their current assessment practices. assessments should be conducted across the teaching period, not just at the end, as the process and product of learning need to be assessed continuously. formative assessments are for learning, thus assisting students background. medical education empowers students to transform theoretical knowledge into practice. assessment of knowledge, skills and attitudes determines students’ competency to practice. assessment methods have been adapted, but not evaluated, to accommodate educational challenges. objectives. to evaluate whether assessment criteria align with obstetrics learning outcomes. methods. we conducted a collaborative action research study, in which we reviewed and analysed learning outcomes and assessments according to bigg’s model of constructive alignment. data were analysed as per levels of bloom’s taxonomy. results. final-year students have two 3-week modules in obstetrics, with 75% overlap in learning outcomes and assessments. ninety-five percent of learning outcomes were poorly defined, and 11 22% were inappropriately assessed. summative assessments were comprehensive, but continuous assessments were rudimentary without clear educational benefit. there is a deficiency in assessment of clinical skills and competencies, as assessments have been adapted to accommodate patient confidentiality and increasing student numbers. the lack of good assessment practice compromises the validity of assessments, resulting in assessments that do not focus on higher levels of thinking. conclusion. there was poor alignment between assessment and outcomes. combining the obstetrics modules, and reviewing learning outcomes and assessments as a single entity, will improve the authenticity of assessments. afr j health professions educ 2021;13(2):118-122. https://doi.org/10.7196/ajhpe.2021.v13i2.1247 do we assess what we set out to teach in obstetrics: an action research study s adam,1 mb chb, fcog (sa), mmed (o&g), cert maternal and fetal medicine (sa), phd (o&g); i lubbe,2 bsocsc, msocsc, med, phd (higher education studies); m van rooyen,3 mb chb, mmed (fam med) 1 department of obstetrics and gynaecology, faculty of health sciences, university of pretoria, south africa 2 department for education innovation, faculty of health sciences, university of pretoria, south africa 3 department of family medicine, faculty of health sciences, university of pretoria, south africa corresponding author: s adam (sumaiya.adam@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i2.1247 mailto:sumaiya.adam@up.ac.za 119 june 2021, vol. 13, no. 2 ajhpe research to take control of their learning by assessing their own work. summative assessments occur after teaching has taken place. medical students, who are adult learners, are responsible for their own self-regulated learning.[13] the balance between formative and summative assessments increases student engagement, and assists in developing self-regulated learners.[14] assessment tools should be valid, reliable and of an equal standard, as high-stakes decisions are based on them.[12] the grading of assessments needs to be standardised and as objective as possible. other components are adequate and timeous feedback to students, and the use of different types of assessments to accommodate different learning styles,[15-17] as this provides students with various ways to demonstrate their knowledge and skills. when students are close to graduating, their knowledge, skills and attitudes must be thoroughly assessed to determine their fitness to practise.[18] hence the appropriateness of learning outcomes and assessment practices, as well as their alignment with each other, their validity and reliability, needs to be constantly reviewed and adapted.[19] the data obtained from assessments are evidence of learning, which require analysis and interpretation (fig.  1).[14] data can be qualitative or quantitative, and the way we analyse data depends on the purpose of the assessment. analysis of data can give information on students’ successes or weaknesses, revision of questions, modification of teaching, or review of course content and learning outcomes. furthermore, if the information obtained is discussed in a community of practice, different perspectives are shared, resulting in greater understanding.[14] good assessment practice drives student learning, and informs the lecturer about the quality of the teaching and the learning experience of the student. in this study, we evaluated whether the obstetrics assessments align with the learning outcomes of the course offered at the university of pretoria, south africa (sa). methods the study design was collaborative action research (fig.  2),[20-22] which reviewed the current undergraduate obstetrics assessment practices at the university of pretoria. this study focused on the high-stakes obstetrics examination for final-year medical students. medical students have two 3-week workplace-based rotations in obstetrics in their final year of their undergraduate training. one rotation is spent at a tertiary-level hospital in an academic department (referred to as obstetrics), while the other is spent at a district hospital (referred to as community obstetrics). these rotations function independently and each has its own high-stakes examination. formative assessments during rotation contribute to the final mark of both rotations. the formative assessment for the obstetrics rotation consists of a logbook, essay and single best answer (sba)-type questions, and 2 spot scenariobased questions (objective structured clinical examination  (osce)). the summative assessment consists of 5 scenario-based questions (osces) and an oral discussion based on a virtual patient (objective structured patient examination (ospe)). the community obstetrics formative assessment consists of a portfolio of patients managed at a district-level hospital. the summative assessment comprises sba-type questions and ‘fire-drills’/simulations of obstetrics emergencies (students are aware of the 5 possible scenarios for the simulations). align education programme to outcomes specify/modify learning outcomes report conclusion and response plan analyse and interpret data collect data examine implementation select/design assessment fig. 1. the assessment cycle.[14] cycle 1 plan: implement tools that ensure validity, reliability, fairness; workshop on good assessment practice implement: to improve assessment practice using tools and information provided observe: review the assessments following the workshops; analyse data reflect: review �ndings with educational and content experts. plan how to improve assessment practice further plan: describe learning outcomes and assessments as per bloom's taxonomy implement: compare alignment of assessment and learning outcomes (2018 assessments) observe: analyse data reflect: review �ndings with content and education experts cycle 2 fig. 2. action research method. june 2021, vol. 13, no. 2 ajhpe 120 research first action research cycle data were obtained from a review of assessments conducted in the 6  student group rotations (obstetrics and community obstetrics) in the 2018 academic year. as no learning outcomes were defined, these were defined as per bloom’s taxonomy[7] and millers pyramid of clinical competence,[23] in keeping with the first-day competencies,[18] with other content experts. learning outcomes were defined after the assessments, but as part of this study, before the analysis of this study. • plan 1: the components of the obstetrics assessments were described with regard to their structure and the level of bloom’s taxonomy tested.[7] • implement 1: thereafter, the alignment of assessment and outcomes was evaluated using bigg’s model of constructive alignment.[6] the data were analysed with the aid of an excel spreadsheet 2019 (microsoft corp., usa) and tick-sheets. • observe 1: the results were analysed collaboratively with educational and content specialists. • reflect 1: recommendations for improvement of the assessment practice were communicated to the course co-ordinator. second action research cycle plan 2: the training of facilitators in good assessment practice was identified as a significant gap. • implement 2: all facilitators involved in obstetrics teaching, learning and assessment were invited to a workshop on good assessment practice, which was hosted by the educational consultant. furthermore, tools to improve validity, reliability and fairness of assessments (e.g. blueprints, rubrics, moderation) were implemented during march april 2019. • observe 2: the third assessment of the first semester was evaluated for content and construct validity. • reflect 2: the findings were again discussed with educational and content experts, and strengths and weaknesses identified. third action research cycle a plan was devised to further improve the assessment practice and address problem areas. ethical approval ethical approval for this study was obtained from the faculty of health sciences research ethics committee (ref.  no.  164/2018), university of pretoria. results the two 3-week modules, viz. obstetrics and community obstetrics, function as separate entities. ninety-five percent of the learning outcomes were poorly defined and there was a 75% overlap in learning outcomes and assessment practices between the modules. summative assessments were comprehensive, but formative assessments were rudimentary, without a clear educational benefit. a deficiency in the assessment of clinical skills and competencies was thus identified. the lack of rubrics, blueprinting and moderation decreases the validity of assessments. as a result, assessment did not focus appropriately on the higher levels of thinking and doing. the learning outcomes for the obstetrics and community obstetrics rotations were similar, thus leading to an overlap in assessments. therefore, the assessments for both rotations were combined and analysed together (table  1 (http://ajhpe.org.za/public/files/1247-table.pdf ) and table  2 refer to the first action research cycle). lower-order-thinking outcomes,[7] such as knowledge, understanding and application, were assessed comprehensively, but higherorder-thinking outcomes,[7] such as analysing, evaluating and creating, were inadequately assessed, even though this was a high-stakes assessment of an sa national qualifications framework (nqf) level 8 qualification.[18,24] furthermore, most of the assessments focused on factual and conceptual principles. even though obstetrics is a practical-based discipline, the assessment of procedural skills was deficient (table  2). graduate attributes include being a self-regulated, reflective learner.[18,25] however, metacognition was not assessed adequately (tables 1 and 2). the alignment of assessments and outcomes was poor (table  3). while the outcomes were fairly distributed across the knowledge dimension,[26] the assessments focused more on the knowledge and cognitive domains rather than on procedural and metacognitive knowledge. this led to a 22% over-assessment of lower domains and a 44% under-assessment of higher domains (table 3). the results of this action research cycle were discussed with education and content experts and communicated to the department of obstetrics and gynaecology, in particular the head of department and the course co-ordinator. areas for improvement that were identified included review of the learning outcomes, education of facilitators of learning regarding good assessment practice and use of tools to ensure a valid, reliable and fair assessment of students, especially as they were assessed in their rotation groups every 7 weeks, i.e. 6 rotation assessments per year. table 2. assessments (implement 1) rotation assessments factual, % conceptual/ principle, % procedural, % metacognitive, % obstetrics logbook -  -  11.1 -  sba 11.1 11.1 -  -  essay 11.1 11.1 -  osce 11.1 11.1 -  ospe 11.1 11.1 -  community obstetrics logbook -  -  14.3 14.3 cases -  14.3 -  -  sba 14.3 14.3 -  -  fire drills 14.3 -  14.3 -  sba = single best answer; osce = objective structured clinical examination; ospe = objective structured patient examination. table 3. alignment of outcomes and assessments (implement 1) factual, % conceptual/ principle, % procedural, % metacognitive, % outcomes 61.7 61.7 61.7 36.4 assessments 72.7 73 39.7 14.3 mismatch 11 11.3 ‒22 ‒22.1 http://ajhpe.org.za/public/files/1247-table.pdf 121 june 2021, vol. 13, no. 2 ajhpe research in the next cycle, the learning outcomes were reviewed by the department of obstetrics and gynaecology, a study guide outlining the curriculum and expectation was made available to students, and all facilitators of learning were invited to a departmental workshop on good assessment practice. the workshop included discussions on constructive alignment, bloom’s taxonomy,[7] how to construct sba-type questions, analysis on assessments and tools to ensure fair, reliable, valid assessments, such as blueprinting, rubrics and moderations. at the same time, the academic quality assurance committee of the school of medicine, university of pretoria, proposed that all high-stakes exit assessments in the various disciplines would be audited to ensure validity, reliability and fairness. the third assessment of the first semester in 2019 was reviewed for fairness,  validity and reliability. it was noted that there was little or no improvement in the sba questions, with only 6/15 (40%) questions assessing  higher-order thinking. the questions were sometimes inappropriate, with  ambiguous detractors and poor structure. one essay question was well constructed, while the other question was vague. the memorandum for the essay question did not provide enough detail to ensure objectivity in mark allocation. the current osce is a paper-based scenario-based assessment. thus, knowledge and cognition,[26] rather than clinical skills, are assessed. the questions in this component of the assessment included a fair distribution of lower-orderand higher-order-thinking questions.[7] the ospe is a paper-based assessment of an approach to a clinical scenario. a virtual patient is used to ensure fairness (all students have the same case) to circumvent issues of patient privacy. students have 15 minutes to prepare for discussion of a scenario, following a discussion of their approach to the case with the examiner. again, there was a good balance of lower-order and higherorder thinking,[7] but clinical skills[26] were not assessed. rubrics and blueprinting were not used in planning this assessment. whereas internal moderation did occur, this was superficial and only the osce and ospe were reviewed, without access to the study guide or learning outcomes. these findings were again discussed with educational and content experts, and will be discussed with the course co-ordinator to identify problems in adhering to good assessment practice. discussion assessment in medical education is important to the student, the programme and the public. assessment needs to be continuous and frequent, workplace based where possible, aligned with expected learning outcomes, using tools that meet minimum requirements for quality, and involving the wisdom and experience of multiple facilitators to assess students’ progress.[27] the assessment of clinical competence in medical education is becoming increasingly complex, with larger student numbers, fewer clinical training sites and issues pertaining to patient privacy and confidentiality. traditionally, clinical evaluation assessment methods consisted primarily of lecturer observations during clinical rotations (workplace-based assessment), oral  assessments (usually with live patients), and multiplechoice assessments. increased clinical workload, discontent with traditional methods of clinical skills assessment by students and facilitators of learning, and developments in the fields of psychology and education have led to the formation of new modalities, which do not employ live patients for clinical assessments. therefore, standardised patients (simulated or virtual) are used to assess performance.[28] however, this approach needs to be evaluated and improved so that all expected graduate competencies are adequately assessed,[18] especially procedural skills.[26] the current assessment practice needs to be evidence based, locally developed and student driven, with an understanding of educational outcomes and non-cognitive assessment factors. a major problem identified in this action research is that facilitators of learning in medical education are content experts, but are not trained in good educational practice. the current curriculum is therefore executed in the manner in which the facilitators may have been taught or as it was passed on to them. they are usually not reflective facilitators of learning, as teaching and learning is not their key area of interest. this is contrary to the attributes of an educator.[9,25] instructional planning, delivery and assessment are probably sub-optimal owing to the lack of knowledge of education. professionalism as an educator may be compromised by competing interests, such as clinical work and service delivery, or research. collaborative action research is required to address these major challenges in medical education, especially in high-stakes assessments. best practices in the context of systems and institutional culture and how to best train staff to be better assessors need to be instituted to ensure that graduates meet expected outcomes and possess attributes such as being a lifelong learner, self-reflective practitioner and contributing member of society.[18,25] finally, we must remember that expertise in medical graduates, not merely competence, is the ultimate goal. medical education does not end with graduation from a training programme, but should represent a career that includes ongoing learning and reflective practice.[18,25] conclusion the assessment practice in medical education has evolved. however, there is poor alignment between assessment and outcomes and absence of surety of valid reliable assessment practice. the employment of good educational practice will improve the authenticity of assessments, but 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https://sites.google.com/site/wongyauhsiung/edu-5033-principles-and-practice-of-assessment/l2-i-learning-theories-ii-assessment-of-learning https://sites.google.com/site/wongyauhsiung/edu-5033-principles-and-practice-of-assessment/l2-i-learning-theories-ii-assessment-of-learning https://doi.org/10.3102/0013189x018008004 http://www.herrmann.com.au/pdfs/articles/thetheorybehindhbdi.pdf http://www.herrmann.com.au/pdfs/articles/thetheorybehindhbdi.pdf https://doi.org/10.1080/03075079.2016.1152463 https://doi.org/10.1080/03075079.2016.1152463 https://www.hpcsa-blogs.co.za/wp-content/uploads/2017/04/mdb-core-competencies-english-final-2014.pdf https://www.hpcsa-blogs.co.za/wp-content/uploads/2017/04/mdb-core-competencies-english-final-2014.pdf https://doi.org/10.1023/a https://doi.org/10.1080/0305763840100307 https://doi.org/10.1080/0305763840100307 https://doi.org/10.33524/cjar.v13i2.37 https://www.researchgate.net/deref/http%3a%2f%2fdx.doi.org%2f10.1007%2f978-981-4560-67-2?_sg%5b0%5d=7wc2mn43b5xpazmazw_kbgzzio9js2y7vgvgvhmqnoqor-ouwfpdt_lh-uf_cswbd6epl63ue1so7ofjvuigu5wzrq.cbftrwvwst0axv7pac5wbah44nt3smehsjz0tknri6hjzxjwmqjxdtshvr_c1f7g5u0zxcsxxq0d4ywa9jvhxa https://doi.org/10.1097/00001888-199009000-00045 http://www.saqa.org.za/docs/brochures/2015/updated nqf levevl descriptors.pdf http://www.saqa.org.za/docs/brochures/2015/updated nqf levevl descriptors.pdf http://www.srku.edu.in/pdf/3 graduate attributes desired for 21st century(1).pdf http://www.srku.edu.in/pdf/3 graduate attributes desired for 21st century(1).pdf https://www.ucdenver.edu/docs/librariesprovider279/default-document-library/blooms_taxonomy_worksheet6cfe02e6302864d9a5bfff0a001ce385.pdf?sfvrsn=a3d666ba_0 https://www.ucdenver.edu/docs/librariesprovider279/default-document-library/blooms_taxonomy_worksheet6cfe02e6302864d9a5bfff0a001ce385.pdf?sfvrsn=a3d666ba_0 https://doi.org/10.3109/0142159x.2010.500704 https://doi.org/10.1177/0163278704267044 article 28 july 2012, vol. 4, no. 1 ajhpe background. members of a profession are committed to codes of ethics and professionalism. the aim was to determine which professionalism attributes dietetics students deem important and relevant to their profession. methods. a total of 109 dietetics students from two universities in the western cape, south africa, completed a demographic questionnaire and were required to sort a pack of cards containing 90 attributes of professionalism into 11 piles, ranging from ‘least agree’ to ‘most agree’. an element of forced choice was introduced by restricting the number of cards in each of the 11 piles (q-sort). pqmethod 2.11 was used for data analysis, ranking items by their mode score and giving an indication of which items were most consistently favoured. results. professionalism attributes considered most important included protect confidential information, trust, respect patients’ right of shared decision making, honesty, good clinical judgment, communication skills and carry out professional responsibilities. interpersonal professionalism attributes were considered more important than intrapersonal or public professionalism. conclusion. this study suggests that professionalism attributes are not attained continuously for dietetic students. the findings should form an integral part of dietetic and other health sciences curriculum planning to ensure that the assessment of these attributes is relevant and consistent with development over the years. ajhpe 2012;4(1):28-33. doi:10.7196/ajhpe.165 introduction a profession (‘a dedication, promise or commitment publicly made’1) is an occupation whose core element is work based upon the mastery of a complex body or knowledge of skills. it is a vocation in which knowledge is used in the service of others and its members subscribe to codes of ethics and professionalism. these commitments form the basis of a social contract between a profession and society, which in return grants the profession the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation.2 professionalism encompasses a number of attitudes, values and beliefs. in addition to the minimum requirements involved in mastering appropriate expertise and technical abilities, students and practitioners are expected to demonstrate a defined set of professional ‘competencies’.3 there are many different qualifications for the definition of professionalism within the scope of health sciences, most of which concur with the central themes of competence, commitment to the highest standard of excellence, integrity, honesty, morality, ethics, altruism, accountability, honour, autonomy, self-regulation, responsibility and respect for patients, society and the profession.2-6 there is a vast body of evidence that the medical profession has invested considerable time and resources globally to inculcate professionalism among medical students, but little evidence that other health professional groups have taken up this challenge.4 the health professions council of south africa (hpcsa) was established by statute (health professions act 56 of 1974, south africa) to provide for the control over the training, registration and practices of south african practitioners of 12 health professions, including dietetics. registration as a health care practitioner with the hpcsa confers on a practitioner the right and privilege to practice a profession and requires a lifelong commitment to good professional and ethical practices and an overriding dedication to the good of one’s fellow humans and society. in this spirit the hpcsa has ethical guidelines to which practitioners are required to adhere, which underlie professional and ethical practice. the professional board for dietetics in south africa requires certain generic skills for dietetics graduates7 and in 2008 the south african standards generating body (sgb) compiled minimum exit outcomes for the curricula of dietitians which include the professional attributes which students need to demonstrate upon completion of the degree. what do dietetics students think professionalism entails? d marais, m l marais, j visser, c boome, d c m taylor division of human nutrition, stellenbosch university and division of applied health sciences, university of aberdeen, scotland d marais, b nutr, m nutr, phd division of human nutrition, stellenbosch university ml marais, bsc diet j visser, bsc diet, m nutr c boome, bsc diet, mba school of medical education, the university of liverpool dcm taylor, bsc, med, ma, phd corresponding author: debbi marais (debbi.marais@abdn.ac.uk) article 29 july 2012, vol. 4, no. 1 ajhpe influencing the development of character traits and behaviours associated with professionalism remains one of the most difficult core content areas in health professionals’ education.8 it has been suggested that the primary means to harness professional behaviour is through the experience of early clinical contact.9 the proposed ideal time for appropriate assessment of professional behaviour may be during the student’s internship, when practitioners have the opportunity to move professionalism into the forefront by direct observation and implement systematic approaches to lowering the incidences of professional error.6 the assessment of professionalism has been reported as being a complex, multistage task that involves observation, description, and the determination of values,3 probably best described by david stern, who describes professionalism as ‘something hard to define but recognisable when observed’.5 it is therefore clear that there is a need to develop teaching and assessment methods regarding professionalism among undergraduate health professional students.4 during the dietetics undergraduate programme, students’ ‘professionalism’ is assessed at various stages of their development and progression throughout the programme. based on this assessment, graduates are provided with a reference from the university regarding their professionalism, which potential employers may use to make a decision regarding the employability of the person. it is important to note that the emergent trend in terms of employability of health professionals is that although technical skills are still essential, employers increasingly expect strong ‘generic/soft skills’ indicative box 1. ninety attributes of professionalism – themes according to van de camp’s three-fold model of professionalism interpersonal attributes public attributes intrapersonal attributes meeting the demands for adequate contact with patients and other health care professionals meeting the demands society places on the professional meeting the demands to function in the profession as an individual altruism or selflessness ask help when necessary avoiding misuse of power benevolence* be responsive to patients’ and colleagues’ age, gender and disabilities* be sensitive be thoughtful caring communication skills compassion* educate patients* give patients information they understand* honesty# honour integrity# interpersonal skills not ripping people off participation relationships with colleagues/team reliability# respect# respect patients’ right of shared decision making* response to instruction responsibility# sensitivity to a diverse population service suspension of self-interest tolerance# treat patients politely* willingness to admit errors in judgment willingness to take time to complete work# accountability adherence to guidelines autonomy of professional associations be knowledgeable blow the whistle if necessary calling carry out professional responsibilities clear professional values commitment commitment to continuity of care competence deliverance of quality duty enhancing welfare of community excellence expert authority fight for and guarantee standards faith in life’s meaning and value high level of expertise humanistic values humility justice leadership method and thoroughness negotiation professional awareness and sensitivity professional conduct protect confidential information response to stress self-regulation simplicity social contract submission to an ethical code technical competence transparent rules trust understanding history use of explicit standards absence of impairment being well-organised courage critical analysis critique deal with high levels of uncertainty flexibility goodwill good clinical judgment know limits of professional competence lifelong learning maturity morality motivation not letting personal beliefs influence care self-awareness self-improvement temperance value dietetic work intrinsically virtue *ethical patient care. #positive personal attributes. article 30 july 2012, vol. 4, no. 1 ajhpe of good character traits and a positive work ethic. it is therefore essential that the assessment of these attributes is relevant and consistent with the student’s development over the years. furthermore, it is acknowledged that educators have a fundamental role as gatekeepers to the profession, ensuring that graduates act professionally.10 the acknowledged difficulty with instruments currently used to assess professionalism is that the instruments focus on a seemingly unassailable set of attributes which students are expected to attain. it seems also that the attainment of these attributes is not instantaneous, indicating the need to determine whether it is continuous or staged over the years of study.11 taylor advises that the ‘theory of professionalism must be constructed in dialogue with those we are instructing’ and as such, the first step is to determine what students understand by the term ‘professionalism’.12 to take up this challenge for dietetics, this observational, cross-sectional descriptive study determined which attributes of professionalism dietetic students deem important and relevant to their profession. the objectives were to identify the professionalism attributes deemed most important, to classify attributes within the themes of interpersonal, public or intrapersonal professionalism and to determine whether the attainment of these professionalism attributes is continuous or staged over time. methods all students registered for a four-year bsc dietetics course in the western cape (offered by stellenbosch university and the university of the western cape) during 2007 and willing to participate, were included in the sample. the estimated sample size of 163 was calculated as a representative sample of the 1 068 dietetics students registered nationwide in 2007 (95% confidence level and 7% error). students had to be able to understand english or afrikaans, as these are the language mediums of the universities involved. the validated q-sort methodology previously used in a study conducted with medical students at the school of medical education, liverpool university was followed.12 the 90 professionalism attributes identified by van de camp et al. are the basis of the study.13 the investigators of this study did not edit the list of attributes as it was clear after consultation of the international code of ethics and the international standards of good practice in nutrition and dietetics,14 that all professionalism aspects specifically related to dietetics were included in the list of 90. an addition rationale not to change the attributes list was to be able to draw comparisons with other studies. the 90 attributes (box 1) were translated into afrikaans and a definition for each item was developed in both languages. these translations and definitions were peer-reviewed by three registered dietitians and facevalidated during the pilot study. the pilot study included six registered dietitians from the division of human nutrition, stellenbosch university as respondents. the pilot study also field-tested the procedures to ensure smooth implementation. during a brief information session to each year group at the two universities, students were requested to allow half an hour to complete the task. each class was provided with an appointment sheet on which students were requested to select one half-hour slot. the 90 attributes, each on a separate card (in english and afrikaans) were given to the student. the students were then asked to sort the cards into 11 piles, ranging from ‘least agree’ to ‘most agree’. the number of cards allowed in each pile was restricted to a specific number per pile (fig. 1) to introduce an element of forced choice so that the overall pattern conformed to a normal distribution – this is called a q-sort. the strength of the q-sort is that it forces people to identify concepts that they feel are important from a large list. detractors from q-sort claim that most q-sorts are performed on too few subjects to yield enough statistical power to justify such detailed analysis. however, q-sorts have been shown to have a high test-retest reliability (better than 0.8), and remain stable over a number of years (under controlled conditions).15 in performing the q-sort, a quiet environment was chosen, with a table and a chair per student. up to six students completed the task simultaneously with six different sets of cards. after signing the informed consent form and completing the demographic questionnaire in either english or afrikaans, each individual student was given a pack of cards containing the statements. the task was explained using a standardised script. a template for packing the cards, indicating the pattern of forced choice, was provided to ensure that students all got the same instructions. students performed the task separately, without discussion. the students were given as long as they needed to sort the cards into piles relating to the extent to which they agreed with each statement. they were allowed to consult a standardised list of terms and definitions (in english and afrikaans) and were allowed to change their mind about the position of individual cards between piles. each pile had to contain the requisite number of cards before the task was considered as completed. the research assistant then recorded the position of each statement on the template onto a data-capturing page for each student. each student was allocated a unique identifier to link to the demographic data that were held separately. ethics approval was provided by the human research committee, faculty of health sciences, stellenbosch university (project no: n07/08/183). data analysis data were analysed using descriptive statistics (frequencies and percentages) for demographics. the pqmethod 2.11 programme was used to input and analyse the q-sort data (scoring from 0 for ‘least agree’ to 10 for ‘most agree’). the attributes were then ranked by their mode score, giving an indication of which items were most consistently favoured, or dismissed as unimportant. the 90 professionalism attributes were further classified according to three themes namely interpersonal professionalism (meeting the demands for adequate contact with patients and other health care professionals), public professionalism (meeting the demands society places on the profession) fig. 1. distribution of cards used in a 90-item q-sort. article 31 july 2012, vol. 4, no. 1 ajhpe and intrapersonal professionalism (meeting the demands to function in the profession as an individual) (box 1).13 the mean modal value for each of the themes was compared using anova at a significance level of p<0.05 across all four years and per year group. the bonferonni test was used when more than two levels of the nominal variable were involved. results of the 163 registered dietetics students at the two selected universities, 109 (67% response rate) participated in the study. the majority of the students were first-year students (n=35, 32%) followed by 30 (28%) second-year students, 26 (24%) fourth-year students and 18 (17%) third-year students. the sample was mostly female (n=99; 91%) which is consistent with the demographics of the profession.16 professionalism attributes students (n=109) sorted the 90 professionalism attributes according to the q-sort providing a normal distribution. results show that the attributes of protect confidential information, trust, respect patients’ right of shared decision making, honesty, good clinical judgment, communication skills and carry out professional responsibilities, were deemed the most important (mode above 7) according to the mode score achieved (table 1). when comparing the mean modal value for the three themes per year group (fig. 2), it seems that the interpersonal professionalism attributes are deemed more important throughout the four years as compared to public and intrapersonal attributes. this gap increases especially after the first year when all three themes of professionalism appear almost equally important to the students. public and intrapersonal themes of professionalism are of fairly equal importance throughout the four years of the course. in the third year there is a statistically significant difference between interpersonal and intrapersonal professionalism attributes (p=0.0405). within the interpersonal attributes regarding adequate contact with patients and other health professionals, 15 attributes were rated more important (mode >7) in at least one of the years of study. attributes related to ethical patient care as well as positive personal attributes and communication skills were identified as most important. the positive personal attributes of respect and reliability as well as compassion, patient education, respecting shared decision-making seem to become more important in the third year when students start interacting with patients. in the fourth year, the most important attributes were responsibility and reliability possibly as a result of students’ more reflective stance. fewer (10) of the intrapersonal professionalism attributes regarding being able to function in a profession as an individual, were deemed more important (mode >7) in at least one of the years of study. good clinical judgment was consistently deemed important over the four years. interestingly, attributes such as being well-organised, temperance and valuing dietetic work intrinsically were deemed important in the first year, but not as important in any of the consecutive year groups. during the second year, lifelong learning and morality were deemed most important and in the third year this changed to flexibility and not letting personal beliefs influence care. at the graduate stage of the fourth year, issues of motivation, knowing the limits of professional competence and lifelong learning became the most important attributes. fifteen of the public professionalism attributes regarding meeting the demands of society, were deemed more important (mode >7) in at least one of the years of study. protecting confidential information was deemed as important for the first three years of study. in the first year of study, the attributes of being knowledgeable, commitment, delivering quality, continuity and high levels of expertise were deemed most important. in the second year of study the other attributes of dietetics being a calling, professional conduct, competence and thoroughness became important. in the third year of study, being knowledgeable, excellence, professional conduct and responsibility were deemed most important. the emphasis shifts for public attributes in the fourth year of study when competence and carrying out professional responsibility is seen as most important and having clear professional values and fighting for and guaranteeing standards become important. it is interesting that the feeling of dietetics being a ‘calling’ becomes a lot less important at this stage. discussion although a smaller sample size of 109 dietetics students participated, the sample can still be seen as representative of dietetics students nationally table 1. mode scores of professionalism attributes indicating the most agreement (7 and above on a scale of 0 10) and least agreement (3 and below) for dietetics students (n=109) professionalism attributes mode most agreement (mode of 7 or more) protect confidential information 8 trust 7 respect patients’ right of shared decision making 7 honesty 7 good clinical judgement 7 communication skills 7 carry out professional responsibilities 7 least agreement (mode of 3 or less) appreciate literature and arts 0 understanding history 0 simplicity 2 critique 3 humility 3 social contract 3 transparent rules 3 fig. 2. mean mode values for the three themes of professionalism (elements of van de camp’s model) over the bsc dietetics course. article 32 july 2012, vol. 4, no. 1 ajhpe (95% confidence level and 9% error). the professionalism attributes deemed most important by the dietetics students are in agreement with the attributes outlined in the most relevant documents to dietetics7,14 stipulating the minimum requirements for qualification as a dietitian. in comparison with the mode scores obtained by medical students in the liverpool study following the same methodology as this study,12 it is evident that many of the key professional attributes are common between the two groups (table 2). similar findings were also found for physical therapy programmes in australia.4 there appears to be small differences in emphasis where some aspects are deemed more important but not necessarily unimportant when forced to make a choice. although the hpcsa does not differentiate between health professionals in sa regarding professional and ethical guidelines, it may well be that different health professions use different terminology and concepts and have varying natures of liability which could influence the understanding of certain attributes. competence for example was scored lower by dietetic students. one possible explanation is that medical students usually specialise after graduating whereas dietetics students are expected to have expertise in all three areas of dietetics upon graduation, resulting in a different concept of competence. an interesting aspect for future investigation would be whether the fact that dietetics is a female-dominant profession has any impact on the importance of specific professionalism attributes. the finding that dietetics students favour the interpersonal professionalism attributes, especially in the third year, is corroborated by the study done among medical students,12 and it is perhaps unsurprising as this is when the dietetics students start to experience a great deal of patient contact. it is clear that the attainment of professionalism aspects is staged across the four years of study. some attributes remain important throughout, but others seem to be dependent on the students’ exposure to patient care and the level of responsibility. in the first year, students have almost no patient contact and courses are generally basic theoretical components with little application, making assessment of professionalism by faculty basically impossible. these first-year students seem to feel that meeting the demands of other people is equally as important as meeting those of society in terms of commitment and expertise and inwardly such as being well-organised. in the second year, students may have very limited patient contact, mostly on an observational level, resulting in little opportunity for assessment of professionalism by faculty. they are however exposed to seeing other professionals ‘at work’, which may explain why they feel professional conduct and competence are more important and dietetics is seen as a ‘calling’. they also seem to realise the value of lifelong learning, which has been reported for medical students who are said to acquire an understanding of the need for lifelong commitment towards keeping abreast with the constantly changing advances in medical science and technology.17 moral values seem to become more important, which may possibly be as a result of the broader social and cultural context that these students are increasingly exposed to. the shift of emphasis on personal attributes versus practice is supported by the third-year students, indicating that flexibility and not letting personal beliefs influence care became more important. in the third year students start becoming involved in patient care in various settings and it is clear that this influences their interpretations of professionalism at this stage. attributes that relate to the feelings and behaviour towards the patient and positive personal attributes regarding expertise and excellence to meet societal expectations become very important. it is also at this stage that there is a significant emphasis on the interpersonal professionalism attributes. during the final year students enter an internship where they have daily contact with patients, the community and/or other health professionals and their professionalism is assessed continuously in terms of these interactions. at this stage the students seem to turn a little inward and start rating attributes such as being responsible, reliable and competent as most important but also knowing your own limits and realising that this is a lifelong journey that requires the professional to have clear values and provide a high standard of service. conclusion the professionalism attributes that dietetics students deem important are in line with what is required by the professional dietetics bodies and associations for dietetics graduates. the key professional attributes deemed most important by both dietetics and medical students are: communication skills, honesty, good clinical judgment, protect confidential information, respect rights of patients’ shared decision making and trust. dietetics students also followed the same trend as medical students in that interpersonal professionalism is considered more important than attributes of intrapersonal or public professionalism. clearly, the attainment of professionalism attributes are is not continuous but staged over time, differing between years of study. it is recommended that further research is conducted to determine whether those attributes deemed as important while studying, change with work experience. furthermore, to determine whether the various work spheres of dietetics such as academia, therapeutic dietetics, community nutrition or food service management, would influence which attributes of professionalism are deemed most important. ultimately, a tool could be devised to provide an index of professionalism against which student progress could be mapped, in order to shape graduates who are competent and equipped for professional life. acknowledgements. funding for the research was provided by the stellenbosch university firlt fund (funding of innovative research in table 2. mode scores of professionalism attributes deemed most important by medical students in the liverpool study (n=99) as compared to dietetics students in the western cape study (n=109) professionalism attribute medical dietetics competence 10 6 communication skills 8 7 ask for help when necessary 8 6 give patients information they understand 8 6 honesty 8 7 professional conduct 8 6 good clinical judgment 7 7 protect confidential information 7 8 know limits of professional competence 7 6 respect patients’ right of sharing in decision making 7 7 integrity 7 4 trust 7 7 article 33 july 2012, vol. 4, no. 1 ajhpe learning and teaching). the authors declare that they have no competing interests. references 1. pellegrino ed. medical professionalism: can it, should it survive? j am board fam pract 2000;13(2):147-1492. pmid: 10764200 2. steinert y, cruess s, cruess r, snell l. faculty development for teaching and evaluating professionalism: from programme design to curriculum change. med educ 2005;39(2):127-136. pmid: 15679679 3. kirk lm, blank ll. professional behaviour – a learner’s permit for licensure. n engl j med 2005;353(25):2709-2711. pmid: 16371638 4. davis sd. teaching professionalism: a survey of physical therapy educators. journal of allied health 2009;38(2):74-83. pmid: 19623788 5. arnold l, stern dt. what is medical professionalism? in: stern dt, ed. measuring medical professionalism. oxford, oxford university press: 2006. 6. shrank wh, reed va, jernstedt gc. fostering professionalism in medical education: a call for improved assessment and meaningful incentives. j gen intern med 2004;19(8):887-889. pmid: 15242476 7. south african qualifications authority (saqa) document, professional board for dietetics, february 2001. 8. wagner p, hendrich j, moseley g, hudson v. defining medical professionalism: a qualitative study. med educ 2007;41(3):288-294. pmid: 17316214 9. goldie j, dowie a, cotton p, morrison j. teaching professionalism in the early years of a medical curriculum: a qualitative study. med educ 2007;41(6):610-617. pmid: 17518842 10. cohen j. professionalism – the critical element in health care education. medical and health education reform symposium apr 2009. mayo clinic. usa http://www. mayoclinic.org/healthopolicycenter/2009-summary-session3.html (accessed 21 july 2010). 11. hilton sr, slotnick hb. proto-professionalism: how professionalisation occurs across the continuum of medical education. med educ 2005;39(1):58-65. pmid: 15612901 12. taylor dcm. development of an instrument to assess professionalism in medical students, master of arts dissertation, university of liverpool, liverpool, 2009. 13. van de camp k, vernooij-dassen mj, grol rp, bottema bj. how to conceptualize professionalism: a qualitative study. med teach 2004;26(8):696-702. pmid: 15763872 14. international confederation of dietetics (icd). underpinnings of quality professional practice. a discussion paper for action. from the board of directors international confederation of dietetic associations, 2007. 15. brown sr. political subjectivity applications of q methodology in political science. new haven and london: yale university press, 1980 16. evans s. evolution, evidence and enterprise: women in leadership in the australian healthcare industry. nutrition and dietetics: the journal of the dietetics association of australia.http://goliath.ecnext.com/coms2/gi_0199-669645/evolution-evidence-andenterprise-women.html (accessed 28 june 2008). 17. macpherson c, kenny n. professionalism and the basic sciences: an untapped resource. med educ 2008;42:183-188. pmid: 1823009. cpd questionnaire 132 december 2012, vol. 4, no. 2 ajhpe cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/007/01/2011 (clinical) numerous approaches to learning, types of learning and definitions of learning are discussed in this month’s articles. are the following statements true (a) or false (b)? 1. e-learning: an important pedagogy in higher education which encompasses an instructional method that combines community service with didactic learning. 2. distance learning: the transfer of knowledge via the internet, intranet or through other digital means such as previously recorded audiovisual media or satellite television. 3. cooperative learning: thinking, feeling and acting together in an educative experience are synergistic and can change the ‘meaning’ of an experience. 4. blended learning: a set of learning facilitation tools will be utilised, such as formal classes (lectures), internet-supported activities and electronic discussion forums. 5. service learning: when learners help one another to learn, maximising their own and each other’s individual and collective potential. there are concepts that are key to some of the articles in this month’s issue. are the following statements true (a) or false (b)? 6. a useful method to determine the way in which knowledge is classified and framed. 7. a powerful methodology for academic development strategies with a focus on writing for publication. 8. a process of assisting academics to publish by highlighting the ideas and information they have from which to choose information for an article. 9. a holistic view of the patient, which includes shared control of the consultation, decisions and management. 10. a framework for the instructor to develop appropriate activities for their course and introduce them in an effective sequence. several disciplines are represented in the articles. are the following statements true (a) or false (b) regarding the articles in which these disciplines are mentioned? 11. dentistry: an interactive component including the use of multimedia technology will be introduced to the course. 12. nursing: students were required to design and develop an interactive computer-based quiz with preand post-intervention questions to assess the knowledge of, and also to educate, attendees regarding the prevention and management of a health condition. 13. radiography: at the end of each session, participants were expected to share their work with a critical reader who provided the participant with feedback. 14. primary healthcare: focus-group discussions were conducted that included students’ experiences of looking for and examining patients. 15. radiography: a questionnaire was designed to evaluate current practices, knowledge and skills. based on the articles you read in this issue, for each of the following scenarios an approach or principle has been identified that will best address the issue at hand. are they true (a) or false (b)? 16. students do not want to see patients in an active teaching role, and are in favour of more contact time with clinicians, whose time they appear to have valued highly. they are prepared to sacrifice contact-time with patients. use doctor-centred approach. 17. healthcare professionals are not able to address the global crises in inequity and health worker shortage. facilitate transformative learning. 18. learning is not self-regulated. individuals relinquish control over and responsibility for their own learning. use a blended learning approach. 19. in a clinical assessment scenario, students are allocated different patients with a spectrum of conditions, based on availability. use standardised patients. 20. methods of learning do not emphasise the roles of emotional engagement and social networking in facilitating effective and efficient learning. foster collaborative learning. december 2012 230 december 2021, vol. 13, no. 4 ajhpe research global health is the study and practice of improving health equity worldwide.[1] the academic field of global health is developing rapidly, leading to  the  establishment of global health departments and dedicated centres at universities worldwide. this situation is mirrored with global surgery, or the equitable access to timely and quality surgical care, which was identified as a key global health priority in 2015.[2] there is increasing recognition that global health competencies should be formally incorporated into medical school curricula, especially in lowto middle-income countries (lmics), where many global health conditions, such as hiv/aids and tuberculosis, as well as maternal mortality and equitable surgical access, have a disproportionate footprint.[3] since its inaugural meeting in 2008, the consortium of universities for global health (cugh)  set out to identify and describe 11 core domains of competency in global health to address the rapid expansion of global health  programmes without a standardised curriculum to guide them. the domains described by cugh focus on interprofessional knowledge and skills for working within the field and are intended to be applicable across disciplines at four levels of competency.[4] these competencies serve as important tools for setting assessable standards for knowledge and performance in medical school training, and are critical to curriculum development and evaluation.[4] with ongoing research to identify perspectives of global health competencies needed in undergraduate training in settings outside of north america, many of the core competency domains remain relevant while other discipline-specific competencies have emerged.[4] addressing healthcare disparities through the lens of global health requires local perspective and ownership to bring about sustainable change.[1] sa, an upper middle-income country, has one of the most inequitable healthcare systems in the world, with a fractured health system and resource distribution between the public and private health sectors.[5] the incoming national health insurance (nhi)  proposes a substantial reorganisation of the current healthcare system to achieve health equity and, as such, adopts many of the same core principles espoused by cugh[4] and the sustainable development goals (sdgs) 1, 2, 3, 5 and10.[6] sa medical schools provide formal education in public health, a discipline from which 7 of the cugh principles were adapted.[4] students may gain indirect exposure to global health concepts and competencies through public health curricular activities, or directly through self-directed extracurricular involvement (such as student societies and research). nevertheless, global health education (ghe)  is yet to be widely implemented in sa medical schools and, to date, the university of cape town (uct) does not include cugh domains in its curriculum. while student perceptions of global health have been well described in several high-income country (hic)  settings,[3,7,8] cugh competencies were developed with a focus on students in north background. global health competencies are an increasingly important part of medical training; however, there is currently no integrated formal global health curriculum at south african (sa) medical schools, and perceptions of medical students towards global health have not been reported. objectives. to describe sa medical students’: (i)  perceptions of global health; (ii)  access to global health education (ghe); (iii)  awareness of global surgery as a global health priority; and (iv) perceived relevance of select medical specialties to global health. methods. medical students at the university of cape town (uct), sa, were invited to complete a 35-item survey over 2 months in 2018. the survey was designed on redcap (research electronic data capture) and distributed by email. all responses were anonymised and self-reported. results. of 1 640 medical students, 245 (18%)  completed the survey. only 66 (27%)  reported ghe in medical school, whereas 213 (87%)  reported a career interest in global health. childhood in a rural setting was a positive predictor of a career interest in global health, while lack of medical resources and infrastructure in resource-limited communities was the most commonly cited barrier to a career in global health. most students identified family medicine and infectious diseases as the two most important specialties in global health delivery. the majority of students had limited insight into global surgery, which ranked low as a past and future global health priority. conclusion. uct medical students are interested in global health careers, but lack formalised ghe or global surgery education during their medical studies to support and encourage integrating global health into their future careers. afr j health professions educ 2021;13(4):229-234. https://doi.org/10.7196/ajhpe.2021.v13i4.1338 medical students’ perceptions of global health at the university of cape town, south africa: the gap between interest and education m potter,1 mb chb; p naidu,2 mb chb; l pohl,3 mb chb; k chu,4 mph 1 livingstone hospital, gqeberha, south africa 2 centre for global surgery, department of global health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 department of surgery, faculty of health sciences, university of cape town, south africa 4 centre for global surgery, department of global health, faculty of medicine and health sciences, stellenbosch university, cape town; and department of surgery, faculty of health sciences, university of cape town, south africa corresponding author: m potter (matthew.potter@alumni.uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1338 mailto:matthew.potter@alumni.uct.ac.za december 2021, vol. 13, no. 4 ajhpe 231 research america; hence, there is a paucity of literature describing perceptions held by medical students from lmics and sa, in particular. surgical care is a key component of universal health coverage and is recognised as a core specialty in the global health agenda.[2] however, a previous study conducted in the usa demonstrated little knowledge of global surgery concepts.[9] determining sa medical students’ perceptions of global health may assist in identifying gaps in knowledge related to cugh domains of global health competency, and may inform the development of context-relevant ghe. the objectives of this study were to describe sa medical students’: (i)  perceptions of global health; (ii)  access to ghe; (iii)  awareness of global surgery as a global health priority; and (iv)  perceived relevance and contribution of select medical specialties to global health. methods setting this study was conducted at the faculty of health sciences, uct. study design a 35-item survey was adapted from a survey administered to us medical students,[9] eliciting an interest in global health, as well as knowledge of global health definitions and competencies under cugh domain 1 (global burden of disease) and domain 2 (globalisation of health and healthcare).[4] additional questions added in our adapted survey included further demographic and global surgery-specific questions. our survey was designed on redcap (research electronic data capture)  version 8.4.3 (vanderbilt university, usa)  and distributed by email to all 1 640 medical students (first sixth year) at uct. the survey was voluntary, and all responses were self-reported and anonymised. the survey included basic demographic information, including place of birth, rurality of childhood setting and previous residence in another lmic. participants were asked if they had received any form of ghe, which was defined as any formal (curriculum based)  or informal class/workshop/course (online or offline)  that provided teaching of global health concepts and/or competencies. global health knowledge and career interest were ascertained. interest in a career was reported as a percentage of a participant’s career dedicated to global health work; a threshold of 50% was used to model predictors of interest in a career in global health. self-reported perceptions of disciplines within global health were included. respondents were allowed to select up to five statements that they perceived as being appropriate definitions of global health. knowledge of global surgery as a global health priority was assessed, with specific questions on key global surgery publications. the perceived relevance and contribution of medical specialties to global health were also ascertained: participants selected 2 medical specialties that they perceived to have had the greatest impact on global health in the past  25  years; the 2 medical specialties that they perceived as potentially having the greatest impact on global health in the next 25 years; the 2 medical specialties that should be global health priorities, but are not currently prioritised by national or international agendas; and the single medical specialty that serves as the best indicator of a robust health system in terms of its contribution towards achieving universal health coverage, which is embodied by the world health organization (who)-defined objectives of equity in access, quality and cost-effectiveness of the specific medical specialty.[10] the options for these questions were limited and included emergency medicine (em), family medicine (fm), infectious diseases (id), obstetrics and gynaecology (obgyn), paediatrics, psychiatry, surgery and ‘other’ (for which respondents provided a specific medical specialty not listed above). participants were also asked to compare 5 medical specialties – fm, obgyn, id, em and surgery – regarding several characteristics, using a 5-point likert scale. study population preclinical students were defined as those in the first, second or third year and clinical students as those in the fourth, fifth or sixth year of the bachelor of medicine and surgery (mb chb) degree programme. data analysis data were exported from redcap and all analyses were performed on rstudio version 1.1.442 for apple (rstudio inc., usa). descriptive statistics were used to characterise likert-type questions. continuous variables were expressed as means (with standard deviation (sd))  or medians (with interquartile range (iqr)). categorical data were presented as frequencies and percentages. continuous variables were compared using either student’s t-test (for normally distributed data)  or wilcoxon’s rank-sum test (for skewed data). depending on the distribution of data, either χ2 or fisher’s exact test was applied to compare categorical data. logistic regression was used to identify associations with interest in a global health career. several factors were evaluated through univariate regression and those with p<1.0 were included in the multivariate analysis. a p-value of <0.05 was considered statistically significant. ethical approval ethical approval was given by the uct human research ethics committee (ref. no. hrec 2018/111). participant consent was obtained electronically; there was no benefit or risk to participants. results demographics the survey was emailed to 1 640 uct medical students and completed by 245 (18% response rate). of these, 150 (61%)  were preclinical and 95 (39%) were clinical students. one hundred and sixty-four (67%) identified as female and 81 (33%)  as male. the majority of respondents (n=228; 93%) were born in sa, and 34 (14%) had lived in another lmic for at least 1 year. two hundred and nine (85%) reported childhood in an urban setting and 36 (15%) in a rural setting (table 1). global health education the majority of respondents (n=170; 73%) reported no previous formal or informal ghe. there was no significant difference between preclinical and clinical students (p=0.1). perception of global health concepts respondents perceived the following to be in line with the concept of global  health (fig.  1): equitable access to healthcare (n=151; 62%); free healthcare (n=126; 52%); healthcare in other countries (n=106; 43%); healthcare in  poor countries (n=104; 42%); and the proposed nhi in sa (n=38; 16%). 232 december 2021, vol. 13, no. 4 ajhpe research knowledge of global surgery as a global health priority one hundred and twenty (49%) respondents accurately identified that more than a quarter of the global burden of disease are from surgical conditions. one hundred and forty-five (59%) respondents were aware that the majority of surgical conditions worldwide occur in lmics. twenty-two percent (n=54) accurately identified trauma as the greatest cause of annual mortality in persons <45 years of age worldwide.[1] fifty (20%)  respondents were aware of the lancet commission on global surgery, while 86 (35%)  had knowledge of the world health assembly (wha)  declaration on essential and emergency surgical procedures – two landmark publications in the field of global surgery (fig. 2). global health career interest a total of 213 (87%)  participants expressed interest in incorporating global health into their career. the mean (sd) of desired career time and effort for global health endeavours was 41 (27)%. there was no significant difference between preclinical and clinical students (p=0.67). the most commonly perceived barrier to a career in global health (table  2)  was available medical resources and infrastructure in resource-limited communities (n=156; 72.6%), followed by lack of exposure to global health training in early career (n=145; 67.4%). sixty-seven (25%)  participants perceived a lack of role models as a barrier to incorporating global health into their careers. predictors of global health career interest logistic regression was used to model factors associated with global health career interest (table  3). on univariate analysis, the following factors were associated with an increased likelihood of global health career interest: being born in a foreign country (odds ratio (or) 3.6; p=0.02); being raised in a lowto middle-income household (or 2.1; p=0.05); and a childhood in a rural setting (or 2.16; p=0.04). on multivariate analysis, there were table 1. demographic characteristics of surveyed uct medical students characteristic n (%)* students 245 age (years), median (iqr) 21.14 (2) gender female 164 (67) male 81 (33) place of birth south africa 228 (93) international 17 (7) lmic† 13 (5) hic‡ 5 (2)  experience living in other lmic yes§ 34 (14) community of origin urban 209 (85) rural 36 (15) clinical volunteer experience in underserved communities yes 124 (51) no 121 (49) uct = university of cape town; iqr = interquartile range; lmic = lowto middle-income country; hic = high-income country. *unless otherwise specified. †botswana, china, democratic republic of the congo (drc), malawi, nigeria, tanzania, togo, zambia, zimbabwe. ‡canada, uk, germany, hong kong, south korea. §angola, botswana, china, drc, kenya, malawi, mozambique, nigeria, tanzania, togo, zambia, zimbabwe. table 2. global health perceptions among uct medical students current career interest n (%) surgical field 107 (44) surgery (any)  80 (33) obstetrics 24 (10) anaesthetics 3 (1) non-surgical field 138 (56) internal medicine (any) 58 (24) public health 21 (9) emergency medicine 18 (7) psychiatry 15 (6) paediatrics 14 (6) family medicine 4 (2) unspecified 9 (2) interest in career in global health yes 213 (87) received global health teaching yes 67 (27) barriers to pursuing a career in global health lack of resources in south africa 145 (59.2) exposure 132 (54) length of training 100 (41) inability to travel abroad 79 (32.2) lack of longitudinal care 77 (31.4) ethical issues 72 (29.4) lack of training programmes 71 (29) lack of role models 65 (27) other 3 (1.2)  uct = university of cape town. more equal access to healthcare in sa free access to healthcare healthcare in other countries healthcare in poor countries nhi 70 60 50 40 30 20 10 0st u d en ts w h o s el ec te d e ac h d e� n it io n o f g lo b al h ea lt h , % 62 52 43 42 16 fig. 1. student perceptions of global health definitions. (sa = south africa; nhi = national health insurance.) december 2021, vol. 13, no. 4 ajhpe 233 research no significant associations with an interest in a global health career. previous ghe (n=66; 27%)  was not associated with a career interest in global health (or 1.21; p=0.51), nor was there a significant association with having a specific career choice and wanting to work in global health practice. other predictors assessed included gender, year of study and student society involvement, but these were not found to be significantly associated (table 3). perceptions of contributions by specific medical specialties to global health perceptions of the contribution of various medical specialties to global health are shown in fig.  3. id was the most common response (n=171; 70%), followed by obgyn (n=107; 44%)  and fm (n=98; 40%). id (n=111; 45%), fm (n=99; 40%) and obgyn (n=68; 28%) were also perceived as the medical specialties that would have the highest global health impact during the  next 25 years. surgery ranked low for both its  perceived impact  on global health delivery in the past 25 years and in the next 25 years (n=28; 11% and n=41; 17%, respectively). psychiatry (n=125; 62%)  and surgery (n=51; 21%) were considered the top two specialties that respondents believed  should be global health priorities, but that are not currently prioritised by national or international agendas. fm (n=172; 70%)  was the most commonly selected medical specialty as the best indicator for a robust health system in terms of universal health coverage, while surgery was the least common (n=1; <1%). id was regarded as having the largest focus on preventive care and being the most likely medical specialty in which to integrate a career in global health. fm was regarded as the most cost-effective specialty to address global health in resource-limited settings. surgery ranked lowest in all fields. discussion the current study found that the majority of uct  medical students reported no formal or informal ghe. nonetheless, most students were interested in incorporating global health in their future careers; this interest should be leveraged. the knowledge and perceptions of students towards global health help to inform the contextual discourse around the field; however, with such limited exposure to ghe, factors contributing to these perceptions should be explored and approaches for addressing misperceptions through focused ghe prioritised. the hiv/aids epidemic, which has affected southern africa disproportionately compared with other regions, defined the field of global health as uniting international funders, scientists and civil society to work together to reduce new infections and decrease mortality.[11] due to its infectious disease origins, general perceptions of global health are often narrow and not inclusive of other essential fields. in addition, because global health is historically derived from public health,[11] as well having a strong focus on health access and equity, it is often limited to more traditionally ‘primary healthcare’ specialties such as fm and obgyn.[12] this limitation may account for the perceptions held by uct students and their prioritisation of medical fields within global health. today, global health examines health priorities transnationally and espouses a multifaceted, table 3. associations with global health career interest by uct medical students univariate analysis multivariate analysis predictor of global health career interest or ci p-value or ci p-value gender female 1.59 0.89 2.89 0.10 0.60 0.33 1.03 0.06 male (ref.) year of study preclinical 1.07 0.62 1.87 0.79 clinical (ref.) country of birth foreign 3.60 1.13 13.47 0.02 1.67 0.79 3.53 0.17 south africa (ref.) previously lived in another lmic yes 1.45 0.65 3.21 0.35 no (ref.) level of household income lmi 2.10 1.84 2.36 0.05 1.57 0.91 2.71 0.07 hmi (ref.) childhood setting type rural 2.16 1.00 4.79 0.04 2.05 0.95 4.40 0.06 urban (ref.) previous gh-related volunteer work yes 1.21 0.70 2.1 0.51 no (ref.) uct = university of cape town; or = odds ratio; ci = confidence interval; ref. = reference; lmic = lowto middle-income country; lmi = low to middle income; hmi = high to middle income; gh = global health. 0 10 20 30 40 50 7060 22 49 35 20 2 22 59 i am aware that trauma is the greatest cause of annual mortality in persons <45 years of age worldwide i am aware that >25% of the global burden of disease is attributable to surgically treatable conditions i am aware of the world health assembly declaration on essential and emergency surgical procedures i am aware of the lancet commission on global surgery i am aware of the bellwether procedures i am aware that 5 billion people lack access to surgical care worldwide i am aware that the majority of surgical conditions worldwide are in lmics fig. 2. global surgery knowledge of medical students. (lmics = lowto middle-income countries.) 234 december 2021, vol. 13, no. 4 ajhpe research interdisciplinary approach to addressing health challenges that are no longer restricted to diseasebased and clinical interventions.[12] global health leaders and advocates have imperatively called for the inclusion of medical school curricula to improve the preparation of medical students to engage with and understand the tenets of global health.[4,12] students’ knowledge of global surgery was very limited. surgery was consistently ranked low in terms of its contribution across various perceived aspects of global health. furthermore, it was considered as the medical field that was least amenable to a career in global health. recently, however, surgery has been shown to be an indispensable field within the scope of global health.[13] surgery requires strong infrastructure with regard to training, interdisciplinary co-operation and cost-effectiveness, and has been proposed as the best indicator of a robust healthcare system.[2] however, <1% of medical students agreed with this statement. this undervaluing of global surgery was also found in a comparable us study,[3] recapitulating the existing global misperception that surgery is a costly and inefficacious component of healthcare and has historically been neglected on the global health agenda.[14] our study also provides invaluable insights into how students prioritise other fields within global health. notably, unlike surgery, where participants demonstrated limited insight into its significant contribution towards global health, the majority of students held an astute perception of current underservice of mental health and its warranted inclusion in the global health agenda, exemplified by its inclusion in the sdgs.[6] much of global health should be prioritised in lmics; therefore, formal ghe in africa is imperative. however, global health centres and training programmes are unintuitively concentrated in hics.[1] in 2017, ughe was launched in rwanda, marking the first african dedicated global health centre that incorporated global health concepts throughout the medical school curriculum. it defined a new type of educational system in healthcare with an african identity – restructuring curricula to equip medical students to deliver equitable health services.[15] as far as we are aware, this is the only african medical school that has incorporated specific global health competencies into their formal curriculum, and not formally using cugh domains. sa medical schools should consider restructuring their medical school currciula to incorporate formal global health competencies using the cugh framework.[16] with the increasing view that health between countries is inter-related, it has been argued that all medical students should be provided dynamic training in core global health competencies that can be applied across all medical fields, and to address perceived gaps in ghe.[17] to amend inaccurate perceptions of  global health and to improve the preparation of medical students, specific global health learning outcomes, including global surgery, have been proposed.[18] nevertheless, there is no consensus on standardisation in ghe.[1,9]  moreover, redefining the global health  agenda  in sa also provides an opportunity to address key misperceptions highlighted by this study and to  integrate previously neglected fields,  particularly global surgery. the  perceptions highlighted in this  study may help to inform key gaps in knowledge and areas of focus for a contextspecific global health curriculum. we  suggest that formal global health competencies be incorporated into sa medical school curricula, guided by the cugh framework. in the past, ghe of hic students has largely hinged on the provision of a clinical or research rotation in lmics.[9] these elective experiences not only have a significant impact on student development in clinical skills and cultural competencies,[19,20] but are also an independent predictor of interest in a global health career and future practice in underserved communities.[21-23] as is the case at many other universities, students spend the major part of their training in the resource-limited public sector health system, often working in health facilities in extremely poor neighbourhoods and witnessing health inequities. notably, students from a perceived rural childhood setting were more interested in pursuing a career in global health. mirroring global trends, sa rural communities are typically poorer and experience greater barriers in accessing quality healthcare.[24] this exposure to learning in resourcepoor settings is uniquely positioned to engage sa students in a global health curriculum. sa has the capacity to harness the benefits of training in resource-poor settings and integrate this training into a global health curriculum to foster future global health leaders. developing a comprehensive global health medical school curriculum for the sa context requires interdisciplinary input and collaboration. furthermore, a wider variety of skills and knowledge training is required to analyse the impact of major social, economic, political, cultural and environmental factors that influence healthcare.[12] study limitations we acknowledge that this study has several limitations. this was a single-institution study previous 25 years next 25 years most underserved in the gh agenda signi�es a robust healthcare system 200 180 160 140 120 100 80 60 40 20 0 r es p o n se s, n infectious diseases obgyn family medicine psychiatry surgery 171 107 98 7 28 111 99 68 41 41 19 50 69 151 51 25 18 172 5 1 fig. 3. medical student perceptions of medical fields as global health priorities. (gh = global health; obgyn = obstetrics and gynaecology.) december 2021, vol. 13, no. 4 ajhpe 235 research and may not be representative of the perceptions of students of other sa institutions; there was a relatively low response rate; and the responses were self-reported (as opposed to validated or standardised questions), which are subject to bias owing to varying interpretation of the questions by different participants. while the survey highlighted some key perceptions, the response options limited the depth of response interpretation, potentially warranting future qualitative interviewand focus group-based research. further research should be undertaken to evaluate students’ perceptions of what should be included in a future global health curriculum. conclusion ghe is gaining traction as a potentially influential tool for achieving health equity and for broadening the scope of future health professionals, particularly in lmics.[25] this study suggests that while the majority of uct medical students are interested in a career involving global health, they need a more formalised education curriculum. interpreting students’ attitudes towards and perceptions of global health may help to inform an appropriate curriculum in sa. incorporating specific ghe into medical curricula may serve to amend the misperceptions and encourage future leaders in global health. cugh’s 11 global health competency domains could be a useful framework. declaration. none. acknowledgements. i wish to thank prof. kathryn chu, dr priyanka naidu and ms megan naidoo for their guidance and support. author contributions. conception of  the study:  mp, lp, kc; literature  review: mp; data cleaning: mp; statistical analysis: mp, pn; data interpretation: mp, pn lp, kc; writing of the article: mp, pn; review/editing of article: mp, pn, lp, kc. funding. none. conflicts of interest. none. 1. gukas id. global paradigm shift in medical education: issues of concern for africa. med teach 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gjerde cl, rothenberg d. career influence of an international health experience during medical school. fam med 2004;36(6):412-416. https://doi.org/10.1186/s12909-015-0483-2 24. harris b, goudge j, ataguba je, et al. inequities in access to health care in south africa. j public health policy 2011;32(suppl 1):s102-s123. https://doi.org/10.1057/jphp.2011.35 25. liu y, zhang y, liu z, wang j. gaps in studies of global health education: an empirical literature review. glob health action 2015;8:25709. https://doi.org/10.3402/gha.v8.25709 accepted 5 november 2020. https://doi.org/10.1080/01421590701814286 https://doi.org/10.1016/j.surg.2015.02.009 https://doi.org/10.1016/j.aogh.2017.07.002 https://doi.org/10.1186/1475-9276-10-48 https://doi.org/10.1097/acm.0b013e3181970a37 https://doi.org/10.1097/acm.0b013e3181970a37 https://doi.org/10.1016/s0140-6736(10)62058-2 https://doi.org/10.1056/nejmp1305297 https://doi.org/10.1056/nejmp1305297 https://doi.org/10.1016/s0140-6736(03)14276-6 https://doi.org/10.1016/s0140-6736(03)14276-6 https://doi.org/10.3402/gha.v7.23943 https://doi.org/10.1016/s0140-6736(09)60332-9 https://doi.org/10.15171/ijhpm.2017.56 https://doi.org/10.1051/pmed/2011026 https://doi.org/10.1097/acm.0b013e31816094fc https://doi.org/10.1016/s0140-6736(11)61582-1 https://doi.org/10.1097/acm.0b013e3182a6a7ce https://doi.org/10.1111/medu.12477 https://doi.org/10.1186/s12909-016-0820-0 https://doi.org/10.1186/s12909-015-0483-2 https://doi.org/10.1057/jphp.2011.35 https://doi.org/10.3402/gha.v8.25709 ajhpe issn 0256-9574 african journal of health professions education december 2012, vol. 4 no. 2 25 august 2010, vol. 2, no. 1 ajhpe abstracts 25 june 2011, vol. 3, no. 1 ajhpe ties, or that they were unsure. respondents indicated that institutional and departmental involvement in service learning for academics, students and community participation was minimal. although three respondents attended training sessions, all indicated that they would either like to receive information about the national service learning policy guidelines, or attend training sessions on service learning. conclusion it can therefore be concluded that the academics and clinical supervisors are willing to participate in activities to overcome the challenges identified. it is therefore recommended that a tailor-made training programme be designed to address the needs of the school of nursing in order to institutionalise service learning in the undergraduate nursing programme. integrating primary health care principles in clinical teaching melanie alperstein correspondence to: melanie alperstein (melanie.alperstein@uct.ac.za) context and setting primary health care (phc) was adopted as a lead theme for curriculum transformation by the health sciences faculty of the university of cape town in 1994. however, integration of phc in clinical teaching remains limited at the secondary and tertiary levels of care. prior to embarking on this project, recent experience and data from the department of medicine suggest that clinicians at all levels of the health care system can apply these principles in clinical teaching if they are familiar with them. the established clinician education course (cec) provided an ideal opportunity to modify a module to focus on teaching the phc principles as relevant to clinical teaching. why the idea was necessary different strategies to integrate the phc principles in all clinical teaching are necessary for holistic individual and community health care. the cec was chosen as one approach to provide clinicians with an approach, and the skills and knowledge needed to impart to students the importance and application of the principles of phc in clinical care. what was done a module of the cec was re-designed and introduced in 2010. an indepth qualitative study was conducted with 8/15 (53%) of the participants who completed the module. participants completed a preand post-module questionnaire on their knowledge of phc and their perceptions of integrating phc principles in their own clinical practice and teaching. this was followed by observation of their clinical teaching and an in-depth semi-structured interview. the data related to preand postmodule knowledge of phc were analysed using basic tools of discourse analysis. the rest of the data from the questionnaires, in-depth interviews and observations were triangulated and analysed according to the impact of the course on different levels using freeth et al.’s modification of kirkpatrick’s model for evaluation of educational outcomes at different levels. results and impact participants’ post-module knowledge shifted from disorganised, point form, concrete examples to a more coherent understanding of phc and the phc principles. seven participants, 3 each from family medicine and speech therapy and audiology and one from psychiatry, claimed to already be using the phc principles in their clinical teaching prior to the course. this was corroborated by observation of their clinical teaching and/or further explanation in the semi-structured interview. the aspect that all identified as needing further attention, and where greater insight was gained, related to equity of care and violation of human rights within the health care system. the last participant from a tertiary speciality was finding it more difficult to incorporate the phc principles. all eight had identified areas of action for individual and organisational change in the future. ‘…it’s about changing the country and i’m saying to them can we make a difference to healing the nation. so they’ll be laughing about it because it is lofty ideals, but phc is about that, it is about lofty ideals. it’s about healing the nation.’ introducing case-based learning in decentralised nursing programme sindi mthembu correspondence to: sindi mthembu (mthembus1@ukzn.ac.za) background/context the approach to teaching and learning in rural decentralised settings has predominantly been didactic. to introduce a more student-centred approach, a case-based learning programme focussing on primary health care (phc) was undertaken. aim/purpose this project aimed to facilitate the introduction and implementation of case-based teaching and learning approach in a decentralised phc programme at the school of nursing. method/what was done an exploratory descriptive needs assessment survey was administered to 65 phc programme facilitators. the survey canvassed their perceptions on case-based learning and their ability to construct cases and facilitate case-based teaching in the classroom. it also explored their resource(s) constraints. results and discussion the participants were positive towards case-based learning approach. however, they acknowledged limitations in their skills to design cases and facilitate teaching sessions. they also identified a lack of resources which would hinder the successful implementation of the programme. two capacity development programmes were conducted to facilitate the construction of cases and enhancing facilitators with the skills to facilitate case-based classrooms culminating with drafts of a case study booklet and facilitators’ manual. a mobile suitcase library was introduced with all the necessary resources for the phc programme. conclusion/take home message this project will help the school to produce a different kind of graduate who will be in possession of transferable core skills. effective mechanisms for close monitoring of students’ learning and early identification of students with problems will be enhanced. continuous support is needed for facilitators to gain confidence in cased-based teaching. december 2021, vol. 13, no. 4 ajhpe 241 research medical graduates are rightfully expected to be competent in managing clinical emergencies. south african (sa)  regulations that govern undergraduate medical curricula, however, are fairly quiet about the matter, and in the absence of a national ‘standard’ curriculum, approaches to how  to  convey these capabilities might vary widely between the eight sa medical schools. internationally, bodies representing emergency medicine and emergency physicians, such as the international federation for emergency medicine and the american college of emergency medicine, have published recommendations on the emergency content of undergraduate medical training.[1,2] at the university of the free state (ufs), the mb  chb undergraduate medical programme runs over 5  years and is divided into the pre-clinical and clinical phase. at the beginning of their third year, the medical students receive seven 3-hour lecture blocks and two practical sessions (totalling 4  hours per student)  during the ‘clinical skills’ module. these sessions form  part of the students’ introduction into clinical practice in phase 2, which spans semesters 4 and 5. in phase 3 (semesters 6 10), the students are exposed to clinical emergency conditions and their management during the rotations in specific medical disciplines. without a department of emergency medicine at the ufs, there is currently no integrated emergency care curriculum, with only limited co-ordination between the different stakeholders. nominal group techniques (ngts)  were initially introduced in the 1960s as a project management tool, allowing a structured approach to the identification of ‘client’ needs and the development of projects in response to such demands.[3] the ngt is regarded as a ‘consensus’ tool, producing prioritised outcomes to guide a project implementation,[4,5] and  has been  gainfully applied in the assessment of a new undergraduate nursing sciences[6] and a redesigned undergraduate medical programme,[7] and in the evaluation of courses within undergraduate medical programmes.[8,9] the ngt has been credited for being creative by containing dominant  group  members and allowing quieter members to express their ideas.[3,10] this study will hopefully contribute to the continuous critical review of current teaching practices to improve the quality of the mb chb programme and optimise the competencies of graduates. objective the aim of this study was to explore undergraduate medical students’ perceptions of the strengths and weaknesses of the current emergency care clinical skills module, and to identify, with the help of technical experts, available or desirable solutions to address some of the challenges. the specific objectives were: • to identify the strengths and weaknesses of the current approach as background. handling medical emergencies is essential for medical practitioners. medical students at the university of the free state have an emergency care block in their third year. nominal group technique (ngt) has been introduced for programme development, and has been used for the assessment of educational programmes. objectives. to identify the strengths and weaknesses of the current teaching programme, as experienced by the students, and to obtain advice from lecturers on available resources and additional requirements. methods. a two-stage ngt was used to identify strengths and weaknesses of the programme from the ‘clients’ (students), and for the ‘experts’ (clinicians and educators)  to suggest possible improvements. two ngt sessions were conducted with students that had either recently (third-year students)  or 2 years ago (fifth-year students) been exposed to the module. students were asked to identify positive and negative aspects. based on these sessions, two further ngts were conducted with groups of ‘experts’ from the school of medicine, asking for suggestions for improvement in the current resources, and for additional resources necessary. results. students valued the practical skills obtained and some of the format of the teaching, but requested an increase of practical content, as well as additional tools and modes of teaching. lecturers suggested co-ordinating outcomes to clarify basic concepts and to use additional media, but emphasised the need for human resources, teaching tools and functional clinical equipment. conclusion. ngt provides a valuable tool to obtain critical suggestions from students and lecturers for improvement of the clinical teaching of emergency care. afr j health professions educ 2021;13(4):240-245. https://doi.org/10.7196/ajhpe.2021.v13i4.1321 nominal group technique review of the emergency care content of the clinical skills module in the undergraduate medical programme at the university of the free state d t hagemeister, ba, mph, emmb, fafallgmed, da, dip hiv man (sa), dire department of family medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: d hagemeister (hagemeisterdt@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021 mailto:hagemeisterdt@ufs.ac.za 242 december 2021, vol. 13, no. 4 ajhpe research experienced and expressed by the students who were exposed to the module • to identify existing resources and potential new approaches based on the insights of local technical experts (academic clinicians/educationalists) • to include the refined findings of this study in future teaching practice • to establish a baseline for future empirical research on health professions education in emergency care in the mb chb programme at ufs. methods in this study, a prospective, cross-sectional, qualitative approach was applied. as part of ongoing efforts to improve undergraduate medical education at ufs, it was decided to use the ngt to assess the experiences of undergraduate students who had participated in the clinical skills module either recently (current third-year students) or 2 years ago (current fifth-year students). this assessment was complemented by a second round of two ngts with academic clinicians/educationalists involved in the teaching, who were asked to ‘respond to’ or ‘work with’ the findings of the first round. approval was obtained from the health sciences research ethics committee, ufs (ref. no. hsrec 111/2017), and permission was granted from the authorities at the university. written informed consent was obtained from all participants. participation in the research was voluntary, and due to the nature of the method, results or statements are not attributable to an individual, and confidentiality of the participants was maintained throughout the process. data collection and processing in keeping with the processes described in the literature, four research assistants who had received prior instructions facilitated the ngt sessions. after a brief introduction and explanation of the process, a silent round of idea generation took place. the participants were subsequently asked to present one of their ideas each, which was captured on a flip chart. this was repeated until no additional ideas were presented. the ideas as written down were then discussed for clarification, and where the group felt that two ideas overlapped and should be combined, this was done. this revised list was put up for ‘voting’ when each participant was asked to choose the most important statement (5 points), second-most important (4 points) down to the fifth-most important statement (1 point). ideas were ranked according to the number of votes each idea received. the ngt sessions followed the structure suggested by gallagher et  al.[10] an overview of the process and stages is given in table 1. in the case of a large number of participants, the group was split into two desks, where the process, as described above, took place with a second round of ranking and voting to combine the results from the two desks added. study population first-round ngt – undergraduate medical students medical students from two different year groups at ufs who had previously done the emergency care clinical skills module constituted the study population for the first round of the ngt. this included the third-year class, who had done the module earlier in the year, and the fifth-year class, who had completed the module 2 years previously and had been exposed to most of the clinical rotations, thus having a better overview over the full clinical content of the mb chb programme. with the assistance of class representatives, purposive sampling within the current thirdand fifth-year classes was done, with the aim of achieving good gender and ethnic representation in samples from each of the two academic years, ideally totalling 10 15 participants per session. second-round ngt – technical experts academic clinical staff on the joint staff establishment for the school of medicine, together with affiliated lecturers in the clinical disciplines and university staff from the school of medicine (e.g. programme director, departmental teaching and learning co-ordinators and academic staff of the simulation and skills unit)  constituted the total study population for the technical expert group. based on the concept of purposive sampling,[11] a good representation of clinical disciplines and professional functions was aimed for when recruiting the total of 10  15 participants for the second round of the ngt process. results four ngt sessions were conducted in september 2017. after conducting the ngt process (idea generation, clarification, vote to rank at the individual desk), the ranked statements, as listed in tables 2, 3, 4 and 5, were obtained, with the number of votes for each statement. the results are presented separately for the two rounds (undergraduate students and technical experts). for referencing in the discussion section, responses are coded in the tables. the code for the students consists of the question (student question 1/2 = sq1/sq2), year group (third-years = 3; fifth-years = 5) and the final ranking. for example, ‘sq1.3.4’ refers to student question 1, third-year group, fourth-ranked response. the code for the technical experts consists of the question (expert question 1/2 = eq1/eq2), ngt session (panel 1 = 1; panel 2 = 2)  and the ranking. for example, ‘eq2.1.5’ refers to expert question 2, first ngt session (panel 1) and fifth-ranked responses. first-round ngts (undergraduate students) the two sessions with undergraduate students included 10  thirdyear medical students (4 men and 6 women, 2 of whom only joined for the second question) and 18 fifth-year medical students (4 men and 14 women). because of the number of fifth-year students (18), the ngt for this group was run at two desks concurrently, with an additional round of clarification and voting added to consolidate the results from the two desks into one. table 1. stages of the nominal group technique* 1 introduction 2 silent generation of ideas in writing 3 listing of ideas on flip chart (round-robin) 4 discussion of ideas on flip chart 5 ranking to select the ‘top-10’ ideas 6 voting on ‘top-10’ ideas 7 break 8 discussion of vote 9 re-ranking and rating revised ‘top-10’ items 10 conclusion of nominal group (and selection of representatives) *modified from gallagher et al.[10] december 2021, vol. 13, no. 4 ajhpe 243 research second-round ngts (technical experts)  the second round of ngt sessions was held with academic clinicians and health educationalists in two separate events with 8 (panel 1)  and 7 participants (panel 2), respectively. panel 1 comprised 1 female and 7 male participants. these included consultants and medical officers from the departments of trauma, family medicine and surgery as well as a paramedic and an information technology (it)/technical support staff member. panel 2 comprised 2 female and 5 male participants. this panel included consultants and medical officers from the departments of family medicine, anaesthesiology and internal medicine as well as from the clinical simulation and skills unit. discussion students’ ngt the students’ responses did not contain any critical comments about individual table 2. ranked responses to student question 1 (sq1): ‘write down what you valued the most in the emergency care clinical skills module (mcli3713) in the third year’ (n=28) third-year medical students (n=10) fifth-year medical students (n=18) rank* responses (score) rank* responses (score) sq1.3.1 learn to save somebody from dangerous situation/basics of how to save somebody’s life (25) sq1.5.1 practical solutions/physically doing on manikins/invited ems personnel/ exposure to ems people and ride-along (73) sq1.3.2 engaging environment/enthusiasm of lecturers/individual attention (24) sq1.5.2 well-structured/practical skills/theory series and practicals/use of scenarios in training and evaluation (64) sq1.3.3 immediately know what to do (20) sq1.5.3 snake-bites interesting/‘defib’/lectures and choking session (35) sq1.3.4 something practical for the first time (15) sq1.5.4 interaction with consultants fixing mistakes/during osce immediate remediation (32) sq1.3.5 content well rounded/comprehensive (12) sq1.5.5 the timing before our hectic clinical years/helped on other modules (29) sq1.3.6 different aspect of medicine from just a normal gp (9) sq1.5.6 lecturer knowledge sharing – real-life stories (23) sq1.5.7 benchmarked mark of 80% made me feel competent/presence of fifth-year medical students during exam/privacy for examinations (13) ems = emergency medical services; osce = objective structured clinical examination; gp = general practitioner. *e.g. sq1.3.1 = student question 1 (sq1), third-year nominal group technique session (3), first-ranked statement (1). table 3. ranked responses to student question 2 (sq2): ‘write down suggestions on how to improve the emergency care clinical skills module (mcli3713)’ (n=28) third-year medical students (n=10) fifth-year medical students (n=18) rank* responses (score) rank* responses (score) sq2.3.1 start with a practical session/combine class (theory) and practical sessions (31) sq2.5.1 more exposure to emergency equipment/information on how to perform defibrillation/nebulisation and practical exposure/short instructions on paper/how to use defibrillation/anaesthetic machine/where to put three leads (53) sq2.3.2 more time to practise the skills/more time and equipment made available to practise (24) sq2.5.2 incorporate medical emergencies, e.g. pulmonary oedema/thyroid storm (45) sq2.3.3 module guide more structured/module guides must be available from the beginning (organisation better)/ case studies at the end of a session (22) sq2.5.3 improve module guide/workbook/more complete notes in module guide/ properly bound module guide/outcomes for theory (37) sq2.3.4 more practical sessions (19) sq2.5.4 lack of continuous evaluation/more assessment during the course/‘mock osce’ (29) sq2.3.5 videos must be available and students know where to find them/expose to real world and see what they do (pelonomi trauma) (15) sq2.5.5 more videos of skills (27) sq2.3.6 emergency care should count more towards your module mark (5) sq2.5.6 role/responsibilities in an emergency (when you are not on duty/airport/ rta)/kit – what to keep in car/on you in case of emergency in public setting (24) sq2.3.7 get prof. x to summarise (present) the basic life support lecture (4) sq2.5.7 clinical scenarios were lacking: what is taught must be assessed/spacing out stations during exams (21) sq2.5.8 boring lectures (17) sq2.5.9 in the content: knowing what to say to family members while waiting in emergency situation/near drowning/water-orientated sessions/wound management/not specific when say ‘give pain relief ’ or ‘fluids’, etc. (15) osce = objective structured clinical examination; rta = road traffic accident. *e.g. sq2.3.1 = student question 2 (sq2), third-year nominal group technique session (3), first-ranked statement (1). 244 december 2021, vol. 13, no. 4 ajhpe research lecturers, and only one lecturer was mentioned by name, to the effect that this lecturer should present a specific topic (sq2.3.7). students in both years appreciated the course’s practical value in enabling them to address lifethreatening situations (sq1.3.1, sq1.3.3, sq1.3.4, sq1.3.6, sq1.5.1, sq1.5.4, sq1.5.6 and sq1.5.7), which is in keeping with international literature.[12,13] as the module is taught at the beginning of, and as an introduction to, the clinical years in the mb chb programme, this is to be expected, but also shows that the module met the students’ expectations in this regard. the way the content was delivered also enjoyed positive feedback in some aspects (sq1.3.2, sq1.3.5, sq1.5.2, sq1.5.4 and sq1.5.5). when it came to students’ suggestions for improvements (question  2), the ‘practical theme’ again dominated, with clear requests to increase the practical parts of the learning experience (sq2.3.1, sq2.3.2, sq2.3.4, sq2.5.1, sq2.5.4 and sq2.5.7). in addition to this, the students requested changes to the resources (‘module guide’/‘case studies’ – sq2.3.3; and sq2.5.3, ‘videos’/‘real world’ – sq2.3.5 and sq2.5.5), hinting at the use of blended learning/flipped classroom techniques.[14,15] based on their greater clinical exposure, the fifth-year students also requested additions to the content (specific clinical emergencies – sq2.5.2; specific scenarios  – sq2.5.6; and dealing with family members and staff – sq2.5.9), while the third-year students were more concerned with administrative issues (‘mark’ sq2.3.6)  and the role of a specific esteemed lecturer (‘prof. x’ – sq2.3.7). further comparing the thirdand fifth-year students, the latter displayed a more differentiated appreciation of technical aspects (‘manikins’ – sq1.5.1; ‘scenarios’ – sq1.5.2; ‘fixing mistakes’/‘immediate remediation’ – sq1.5.4; ‘real life stories’ – sq1.5.6), probably owing to their greater exposure to clinical teaching by the time of the ngt session. the fifth-year students also addressed the different professions/ranks in the health system in a more differentiated way (‘ems personnel’ – sq1.5.1; ‘consultants’ – sq1.5.4), again probably owing to their greater exposure to the system. comments on the timing of the module about the other clinical teaching are only possible in retrospect (sq1.5.5). technical experts’ ngts clinicians and educationalists put a strong emphasis on the clarification of outcomes and concepts in the module (eq1.1.1, eq1.2.1, eq1.2.3), suggesting a proper ‘scaffolding’ of the content in the vygotskian sense, rather than a mere accumulation of clinical conditions.[1,16] table 4. technical experts question 1 (eq1): ‘write down suggestions, given current resources and based on the comments of the students, what you think can be done to improve the module content and delivery’ (n=15) first expert panel (n=8) second expert panel (n=7) rank* responses (score) rank* responses (score) eq1.1.1 module guide outcomes/condense the content (decide on what is important on that level) (27) eq1.2.1 basic principles/clarifying concepts, e.g. what is a cardiac arrest/recognise emergency situations, e.g. low blood sugar/students must understand what is the purpose of their actions/integrate physiology/anatomy, etc./explain clearly/knowing when to stop the resuscitation (26) eq1.1.2 integrating practical bits into the theory content (22) eq1.2.2 visual aids/props in lectures, e.g. talk about airways – show it/combination of theory and simulation/make use of visual aids/stimulate their interest/ more use of simulation (22) eq1.1.3 summary structured lecture: ‘flipped classroom approach’/ more videos, blackboard media server, (practical station), short videos before class, login on blackboard/ online resources for blended learning (knowing the equipment) (21) eq1.2.3 what are the general outcomes of this module (what level)?/start the first day and explain the bigger picture: one piece build onto the other (14) eq1.1.4 incorporation of different models (e.g. simulation, skills lab, manikins), more dedicated time in the skills lab (obtain signatures)/small group rotations (18) eq1.2.4 continuous evaluation/mock exam/practical sessions/more credits/marks for this module/assess the students/students accept responsibility (11) eq1.1.5 what the content of the module should be in the lecture (well structured)/integrating with other modules later-on (taking the current level of knowledge into account)/build on the existing knowledge obtained (e.g. pharmacology, etc.) by introducing the practical aspect (basic critical care)/ having simple structured (standard) approaches (pals/ atls etc.) (17) eq1.2.5 standardise the teaching material (approach – who are we holding our standards up to)/practise under guidance of professional (10) eq1.2.6 a) longitudinal emc training/start in semester 5 and continue to semester 10 (8) b) two weeks of emergency care/smaller groups/rotations practicals and tutorials (8) eq1.2.8 e-learning/blackboard for content/questionmark/more time for practicals/ make use of technology (cellphone) to look at videos etc. on youtube/for teaching them how to find information (4) eq1.2.9 drowning/near drowning should be included – submersion injuries (2) pals = paediatric advanced life support; atls = advanced trauma life support; ems = emergency medical services. *e.g. eq1.2.3 = expert question 1 (eq1), second panel (2), third-ranked statement (3). december 2021, vol. 13, no. 4 ajhpe 245 research with regard to the mode of delivery of the content, emphasis was again placed on the importance of practical aspects (eq1.1.2)  and the use of ‘stimulating’ methods, including simulation exercises (eq2.1.2, eq1.1.4) as well as online resources and videos (eq1.1.3, eq1.2.8). continuous evaluation of the students and the inclusion of mock examinations would also aid the learning process (eq1.2.4), mirroring the emphasis on ‘assessment drives learning’ in the literature.[17,18] standardisation of the teaching materials and the management approaches was suggested to improve the consistency of the teaching (eq1.1.5, eq1.2.5). the content should be integrated with and linked to modules in earlier and later parts of the programme (eq1.1.5, eq1.2.6)  and this was mentioned under both questions 1 and 2 (also eq2.2.5). when considering additional resources, the top priority was the availability of well-trained facilitators, or in other words, human resource management and development issues (eq2.1.1, eq2.2.1, eq2.2.6), including it training for the ‘older folks’ (eq2.1.6). the availability of equipment for teaching, simulators and videos was the second major theme (eq2.1.2, eq2.2.4), including the availability of appropriate clinical equipment at the actual clinical service delivery sites (eq2.2.8). additional ideas that came up were the opportunities offered by the changed language policy of the university, which potentially frees up resources (eq2.1.5), the utilisation of other emergency care personnel such as the emergency medical services (ems)  and their training facilities (eq2.1.3), and the creation of a question bank of multiplechoice questions for formative and summative assessment (eq2.2.7). lastly, the general need for additional financial resources was expressed (eq2.2.3). implementation of ideas/suggestions in the next run of the module after the ngts, additional practical cpr training sessions and mock examinations have been included as suggested during the research, while much more work remains to be done regarding a general overhaul of the content and structure of the module, possibly in connection with a major review of the undergraduate curriculum. weaknesses and possible confounders firstly, it needs to be acknowledged that the relatively small sample from both student groups might not be regarded as fully representative for the respective years. an additional quantitative, questionnaire-based vote on the finding by a larger sample could have added reliability through ‘triangulation’.[7] given the 2  years between the exposure to the module of the two year groups, staff attrition and reworking of course content might have introduced differences between the two ‘runs’ of the same module. on the side of the ‘technical experts’, the composition of the group and the absence of some disciplines (due to lack of response from certain departments) might have biased the outcomes. the results of the two sessions in the second round of ngts, with the technical experts, have not been consolidated into a single ‘rank order’ as suggested by some authors.[19,20] conclusion through the use of a two-staged ngt, it was possible to gain valuable feedback from undergraduate students who had experienced the teaching in the module that was under review. both the positive comments and suggestions for improvement as expressed during this process led to fruitful discussions with the team of academic clinicians and educators who were currently involved in the programme. as also reported in other studies, the use of the ngt provides concise and ‘easy-to-apply’ results on the needs of the ‘users’ (students) and the possible approaches from the ‘experts’. by involving both ‘sides’ in this two-staged ngt, the experts respond directly to the identified challenges. further evaluation will be necessary to measure the actual impact of this research, including the implementation of the findings. table 5. technical expert question 2 (eq2): ‘write down suggestions on what additional resources and structures might be needed and how these would influence the delivery of the module content’ (n=15) first expert panel (n=8) second expert panel (n=7) rank* responses (score) rank* responses (score) eq2.1.1 more dedicated facilitators for emergency care, not only in family medicine (27) eq2.2.1 trained manpower. make use of various professions, e.g. nursing, emergency personnel/well-trained facilitators/instructors (25) eq2.1.2 somewhere to go to watch videos and access equipment (same space)/standardising the equipment (23) eq2.2.2 who takes ownership/where will advanced life support fit in/what level do we teach emergency care? (18) eq2.1.3 a) include road-shifts with ems as clinical practice/more clinical time in the hospital setting (22) b) alternative training method in instances of no actual resources (table exercises)/using resources at other faculties (expanding your footprint of resources) (22) eq2.2.3 more funding (12) eq2.1.4 eq2.2.4 more simulators/more equipment (10) eq2.1.5 capitalise on one-language policy (8) eq2.2.5 vertical integration of emergency care in the program/structure the curriculum (9) eq2.1.6 it training for the older folks (3) eq2.2.6 possibility of after-hour teaching such as acls (extra teaching time/ practicals)/skills training facilities must be available; facilitators also (7) eq2.2.7 build a question bank (6) eq2.2.8 decent clinical equipment in hospitals (3) ems = emergency medical services; acls = advanced cardiovascular life support; it = information technology. *e.g. eq2.2.3 = expert question 2 (eq2), second panel (2), third-ranked statement (3). 246 december 2021, vol. 13, no. 4 ajhpe research several challenges identified by the students, and some of the suggested solutions, are beyond the scope of the current research, which was focused narrowly on the emergency care teaching occurring in the third year. a more comprehensive approach to review the overall framework of emergency care teaching in the undergraduate programme is currently projected to cover these aspects. declaration. none. acknowledgements. the author gratefully acknowledges prof. yvonne botma, sr rynsie hattingh, mrs nokuthula tlalajoe and dr joleen cairncross for their help in conducting the nominal group technique sessions. ms theanette mulder is much appreciated for her support in editing the manuscript. author contributions. sole author. funding. none. conflicts of interest. none. 1. hobgood c, anantharaman v, bandiera g, et  al. international federation for emergency medicine model curriculum for medical student education in emergency medicine. emerg med australas 2009;21(5):367-372. https://doi.org/10.1111/j.1742-6723.2009.01213.x 2. american college of emergency physicians. guidelines for undergraduate education in emergency medicine. irving: acep, 2015. https://www.acep.org/patient-care/policy-statements/guidelines-for-undergraduateeducation-in-emergency-medicine/#sm.00001ogy4kwqeodpat4wmro3ufk77 (accessed 18 september 2018). 3. delbecq al, van de ven ah. a group process model for problem identification and program planning. j appl behav sci 1971;7(4):466-492. https://doi.org/10.1177/002188637100700404 4. allen j, dyas j, jones m. building consensus in health care: a guide to using the nominal group technique. br j community nurs 2004;9(3):110-114. https://doi.org/10.12968/bjcn.2004.9.3.12432 5. jones j, hunter d. consensus methods for medical and health services research. bmj 1995;311(7001):376-380. https://doi.org/10.1136/bmj.311.7001.376 6. chapple m, murphy r. the nominal group technique: extending the evaluation of students’ teaching and learning experiences. assess eval high educ 1996;21(2):147-160. https://doi.org/10.1080/0260293960210204 7. lloyd-jones g, fowell s, bligh jg. the use of the nominal group technique as an evaluative tool in medical undergraduate education. med educ 1999;33(1):8-13. https://doi.org/10.1046/j.1365-2923.1999.00288.x 8. dobbie a, rhodes m, tysinger jw, freeman j. using a modified nominal group technique as a curriculum evaluation tool. fam med 2004;36(6):402-406. 9. lancaster t, hart r, gardner s. literature and medicine: evaluating a special study module using the nominal group technique. med educ 2002;36(11):1071-1076. https://doi.org/10.1046/j.1365-2923.2002.01325.x 10. gallagher m, hares t, spencer j, bradshaw c, webb i. the nominal group technique: a research tool for general practice? fam pract 1993;10(1):76-81. https://doi.org/10.1093/fampra/10.1.76 11. henning e, van rensburg w, smit b. finding your way in qualitative research. pretoria: van schaik, 2004. 12. ten eyck rp, tews m, ballester jm. improved medical student satisfaction and test performance with a simulationbased emergency medicine curriculum: a randomised controlled trial. ann emerg med 2009;54(5):684-691. https://doi.org/10.1016/j.annemergmed.2009.03.025 13. morris mc, conroy p. development of a simulation-based sub-module in undergraduate medical education. ir j med sci 2019;(epub ahead of print). https://doi.org/10.1007/s11845-019-02050-3 14. parandavar n, rezaee r, mosallanejad l, mosallanejad z. designing a blended training program and its effects on clinical practice and clinical reasoning in midwifery students. j educ health promot 2019;8:131-131. https:// doi.org/10.4103/jehp.jehp_22_18 15. nakanishi t, goto t, kobuchi t, kimura t, hayashi h, tokuda y. the effects of flipped learning for bystander cardiopulmonary resuscitation on undergraduate medical students. int j med educ 2017;8:430-436. https://doi. org/10.5116/ijme.5a2b.ae56 16. tews mc, hamilton gc. integrating emergency medicine principles and experience throughout the medical school curriculum: why and how. acad emerg med 2011;18(10):1072-1080. https://doi.org/10.1111/j.15532712.2011.01168.x 17. phillips aw, smith sg, straus cm. driving deeper learning by assessment: an adaptation of the revised bloom’s taxonomy for medical imaging in gross anatomy. acad radiol 2013;20(6):784-789. https://doi.org/10.1016/j. acra.2013.02.001 18. keeley mg, gusic me, morgan hk, aagaard em, santen sa. moving toward summative competency assessment to individualise the postclerkship phase. acad med 2019;94(12):1858-1864. https://doi.org/10.1097/ acm.0000000000002830 19. mcmillan ss, kelly f, sav a, et al. using the nominal group technique: how to analyse across multiple groups. health serv outcomes res methodol 2014;14(3):92-108. https://doi.org/10.1007/s10742-014-0121-1 20. van breda ad. steps to analysing multiple-group ngt data. soc work pract res 2005;17(1):1-14. accepted 17 august 2020. https://doi.org/10.1111/j.1742-6723.2009.01213.x https://www.acep.org/patient-care/policy-statements/guidelines-for-undergraduate-education-in-emergency-medicine/#sm.00001ogy4kwqeodpat4wmro3ufk77 https://www.acep.org/patient-care/policy-statements/guidelines-for-undergraduate-education-in-emergency-medicine/#sm.00001ogy4kwqeodpat4wmro3ufk77 https://doi.org/10.1177/002188637100700404 https://doi.org/10.12968/bjcn.2004.9.3.12432 https://doi.org/10.1136/bmj.311.7001.376 https://doi.org/10.1080/0260293960210204 https://doi.org/10.1046/j.1365-2923.1999.00288.x https://doi.org/10.1046/j.1365-2923.2002.01325.x https://doi.org/10.1093/fampra/10.1.76 https://doi.org/10.1016/j.annemergmed.2009.03.025 https://doi.org/10.1007/s11845-019-02050-3 https://doi.org/10.4103/jehp.jehp_22_18 https://doi.org/10.4103/jehp.jehp_22_18 https://doi.org/10.5116/ijme.5a2b.ae56 https://doi.org/10.5116/ijme.5a2b.ae56 https://doi.org/10.1111/j.1553-2712.2011.01168.x https://doi.org/10.1111/j.1553-2712.2011.01168.x https://doi.org/10.1016/j.acra.2013.02.001 https://doi.org/10.1016/j.acra.2013.02.001 https://doi.org/10.1097/acm.0000000000002830 https://doi.org/10.1097/acm.0000000000002830 https://doi.org/10.1007/s10742-014-0121-1 march 2022, vol. 14, no. 1 ajhpe 3 research physical distancing and heightened infection prevention and control mechanisms compromised the possibility of learning and teaching clinical skills during the covid-19 pandemic.[1] the synchronous interaction of educators and students in specific environments, such as simulation laboratories or hospitals, seemed to be impossible, and emergency remote teaching strategies did not adequately support the learning and teaching of clinical skills. furthermore, remote locations, such as homes, were not ideal for the learning and teaching of clinical skills.[2] health professions education institutions had to adopt innovative educational strategies for the learning and teaching of clinical skills during the covid-19 pandemic. the school of nursing at the university of the free state (ufs) houses one of the largest undergraduate degree nursing programmes in south africa (sa). the programme’s educators adhere to high standards of nursing education, including intensive clinical skills training. students ordinarily spend an equal amount of time in the simulation laboratory and in the workplace to learn clinical skills. educators typically teach clinical skills in the simulation laboratory weekly, and preceptors supervise these skills at the various clinical placement sites.[3] the objective structured clinical examination (osce) is the summative assessment method for clinical skills, moderated and pitched at the same difficulty index for each year group. the covid-19 pandemic challenged the school of nursing leadership to adopt innovative educational strategies. this article reports on the outcomes of implementing an innovative educational strategy on the learning and teaching of clinical skills by exploring educator and student experiences, which could provide insights into ways to adapt learning and teaching in response to crises. the innovative education strategy: clinical skills boot camps underpinned by the theory of deliberate practice,[4] the school of nursing adopted boot camps after the hard lockdown as an innovative educational strategy to enhance the learning and teaching of clinical skills during the covid-19 pandemic. deliberate practice is understood as a type of purposeful and systematic learning of skills requiring focused attention, and is conducted to improve performance.[5] boot camps are synonymous with conventional training camps, such as those in the military, where specific skills are learnt, and the school of nursing adopted the practice for their particular situation.[6] at the school of nursing, the boot camps had the dual aim of developing foundational clinical skills for undergraduate nursing students, including sessions missed during the higher levels of lockdown, and preparing the students for the ‘new’ workplace environment. each student year group was allocated a week at the simulation laboratory. each year group was then split into smaller groups to attend their boot camp on specific days of the week. the module outcomes determined the nature and number of clinical skills to be taught per boot camp. all the students received a video recording of the clinical skills prior to the boot camp to prepare for the session. on the day of the boot camp, the group of students was further split into smaller manageable groups, which were stationed in smaller venues of the simulation laboratory with a preceptor. equipment and materials related to the clinical skills for the day were made available in all the venues. a central venue hosted the leading session facilitator, who provided foundational information about background. educational institutions were compelled to adapt their educational strategies during the covid-19 pandemic. the innovation of boot camps as a strategy for learning and teaching clinical skills was applied by a school of nursing immediately after the hard lockdown in south africa. objectives. to describe the outcomes of implementing an innovative educational strategy for the learning and teaching of clinical skills in an undergraduate nursing programme. methods. the study comprised a parallel convergent mixed-methods design. qualitative data were collected from educators (n=7) involved with the boot  camps, while the quantitative data comprised module evaluations by 219 students and summative practical assessment scores. thematic analysis  through an inductive approach was applied for the qualitative data, while central tendency and frequencies were used to analyse the quantitative data. results. three themes emerged from the narrative data, i.e. rationalising the boot camps, executing the boot camps and learning from the boot camps. quantitative data support each of the themes. the boot camps appeared to have been appreciated as an emergency innovative educational strategy, with improved student assessment outcomes. conclusions. the covid-19 pandemic forced education institutions to adopt a variety of innovative educational strategies. boot camps appear to have positively influenced the learning and teaching of clinical skills at a school of nursing. there is a need for robust longitudinal research evaluating the long-term effect of such innovative educational strategies. afr j health professions educ 2022;14(1):3-7. https://doi.org/10.7196/ajhpe.2022.v14i1.1497 an innovative educational strategy for learning and teaching clinical skills during the covid-19 pandemic c n nyoni, phd; a e fichardt, phd; y botma, phd school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c n nyoni (nyonic@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i1.1497 mailto:nyonic@ufs.ac.za 4 march 2022, vol. 14, no. 1 ajhpe research the relevant clinical skill before a demonstration, while being live streamed to the other smaller venues. students in smaller venues watched the leading facilitator via live streaming, after which they had opportunities for clarification from their preceptor. all the students in the small groups then demonstrated the taught skills to the preceptor, who immediately provided feedback. this intervention commenced after the hard lockdown and continued during 2020. purpose of the study the purpose of this study was to describe the outcome of implementing boot camps on the learning and teaching of clinical skills by describing: • the experiences of students regarding the learning of clinical skills through boot camps during the covid-19 pandemic • the experiences of educators regarding the teaching of clinical skills through boot camps during the covid-19 pandemic • the influence of boot camps on students’ clinical summative assessment outcomes. methods research design this study was executed through a parallel convergent mixed-methods research design.[7] population and sampling seventeen nurse educators from all levels of the undergraduate nursing programme who were directly involved with the boot camps, as well as 234 nursing students, comprised the study population. census sampling was used to include all study participants. the assessment outcomes from the summative osces for 2019 and 2020 for all the year groups were also included in this study. data collection two parallel methods aligned with the mixed-methods research design were used to collect data. qualitative data were collected through in-depth interviews during january and february 2021. data were collected from 7 participants by means of a virtual platform at a mutually convenient time. the virtual platform limited physical contact and reduced the likelihood of transmitting the coronavirus. after introductions and words of welcome, participants were asked to describe their experiences of the boot camps regarding the teaching of clinical skills during the covid-19 pandemic. being an experienced qualitative researcher, the interviewer used validation, open-ended questions and probing. each interview was recorded with the participant’s permission and electronically transcribed. quantitative data were collected from student module evaluations and their summative osce scores. students were informed about the research and that they were consenting by completing the module evaluation. the module evaluation form was tailor made to reflect each student’s experiences of the boot camps. students completed a module evaluation form anonymously at the end-ofthe-year summative osce. final osce marks at the middle of the year and at the end of the year per year group for 2019 and 2020 were accessed, coded and collated. data analysis the data were analysed to address each of the objectives of this study. thematic analysis was used to analyse the qualitative data.[8] initially, the data were transcribed verbatim and uploaded to atlas.ti software (atlas.ti, germany) for qualitative data analysis. study participants reviewed their transcripts for confirmation and correction. the subsequent step involved applying various coding methods, such as initial, axial, in vivo, open, descriptive and structural coding. the final step applied pattern coding in grouping the outcomes of the second step into themes. a  biostatistician analysed the quantitative data by describing the measures of central tendency and comparing the mean assessment scores between the performances in 2019 and 2020. ethical approval this study was approved by the health sciences research ethics committee (hsrec) of the university of the free state (ref. no. ufs-hsd 2020/2064/2601). the head of the school of nursing granted permission to access assessment-related data. all participants included in the study consented in writing to participate. ethical considerations, such as voluntary participation, informed consent, privacy and confidentiality, were considered throughout the study. results seven nurse educators and 219 undergraduate nursing students participated in the study. fig.  1 shows the breakdown of the number of students who responded per level. the three overarching themes from the qualitative analysis are integrated with the quantitative findings. theme 1: rationalising the boot camps the educators in this study acknowledged the dire consequences of the covid-19 pandemic on clinical skills teaching. the covid-19-related lockdown meant that students could not learn clinical skills at home, and without an intervention such as the boot camps, there was no foreseeable students per study year, % 1st, 30 2nd, 35 3rd, 27 4th, 8 fig. 1. number of students per level. http://atlas.ti http://atlas.ti march 2022, vol. 14, no. 1 ajhpe 5 research approach of teaching clinical skills to the nursing students (please note that all direct quotations are reproduced verbatim and unedited): ‘honestly, i still look back then and wonder what else could have been done – there was no other way than this approach to teach[ing] those skills … students would have been left behind and possibly not even graduate.’ (participant 6) educators perceived the unstable and risky clinical environment at the time as not conducive to clinical skills teaching. students were not allowed  in the covid-19 wards, and some of the facilitators were also high-risk candidates for covid-19. consequently, 199 (92.9%) of the students agreed that boot camps enhanced their learning of clinical skills (table 1). theme 2: executing the boot camps the participants identified variations in the execution of the boot camps, depending on the level of the students, the number of students, and the number of skills to be taught. despite a prescribed approach for the boot camps, each level adopted a strategy suitable for them: ‘it is essential to understand that one size does not fit all; there should be consideration of the number of students and number of skills to facilitate. we applied the strategy as we saw fit for our level.’ (participant 1) the educators felt that the students had issues during the boot camps. according to the educators, the students did not prepare sufficiently for the sessions, seemed tired and also overwhelmed by the number of clinical skills during a boot camp session. approximately 60% of the students found the workload during the camps manageable, but 9 (4.11%) students found the camps too long, while 21 (9.59%) students reported information overload (table 2): ‘the poor students, we were expecting a lot from them. can you imagine learning 11 clinical procedures in one day? we posted the videos for these procedures, but really do you think they would prepare – for 11 procedures?’ (participant 6) the process of executing the boot camps was enabled by the facilities within the school of nursing, the teamwork among the educators and the support from the institutional leadership. however, the educators expressed exhaustion owing to the repetitive nature of the boot camps and the timeintensiveness, while 21 (9.59%) of the students reported information overload (table 3): ‘i do not want to be in any boot camp again, i have never felt this tired. but my colleagues were good; they supported me and the facilities at the lab made the situation even better.’ (participant 7) theme 3: learning from the boot camps the educators learnt from the boot camp experience through the reflection on their practice, which enabled them to improve their practice and teaching of clinical skills: table 1. results from the module evaluation form strongly disagree disagree negative agree strongly agree positive n/a item f (%) f (%) ∑ (%) f (%) f (%) ∑ (%) f (%) 1.8 the facilitation of the clinical skills helped me to learn, n=217 3 (1.38) 7 (3.23) 10 (4.61) 125 (57.60) 80 (36.87) 205 (94.47) 2 (0.92) 1.7 i understood what i was supposed to learn during the boot camps, n=218 4 (1.83) 12 (5.50) 16 (7.34) 133 (61.01) 68 (31.19) 201 (92.20) 1 (0.46) 1.1. the use of boot camps to learn clinical skills enhanced my learning, n=219 4 (1.83) 15 (6.85) 19 (8.68) 121 (55.25) 78 (35.62) 199 (92.9) 1 (0.46) 1.14 the infection prevention control mechanisms learnt during the boot camps were relevant for the clinical environment, n=214 4 (1.87) 9 (4.21) 13 (6.07) 121 (56.54) 76 (35.51) 197 (92.06) 4 (1.87) 1.10 the assessment of the clinical skills learnt during the boot camps was fair, n=218 3 (1.38) 17 (7.80) 20 (9.17) 140 (64.22) 56 (25.69) 196 (89.91) 2 (0.92) 1.2 i felt motivated to learn clinical skills during the boot camps, n=219 3 (1.38) 24 (10.96) 27 (12.33) 124 (56.62) 67 (30.59) 191 (87.21) 1 (0.46) 1.3 i was provided with adequate support during the boot camps, which helped to be successful, n=219 4 (1.83) 26 (11.87) 30 (13.70) 124 (56.62) 65 (29.68) 189 (86.30) 1.12 the educators treated all students fairly during the boot camps, n=216 6 (2.78) 16 (7.41) 22 (10.19) 119 (55.09) 70 (32.41) 189 (87.50) 5 (2.31) 1.9 the feedback provided to me during the boot camps was valuable, n=216 3 (1.39) 23 (10.65) 26 (12.04) 113 (52.31) 75 (34.72) 188 (87.03) 2 (0.93) 1.11 the feedback on my assessment tasks helped me understand my mistakes, n=216 3 (1.39) 24 (11.11) 27 (12.50) 115 (53.24) 71 (32.87) 186 (86.11) 3 (1.39) 1.6 i was satisfied with the resources that were made available to me during the boot camps, n=217 3 (1.38) 31 (14.29) 34 (15.67) 123 (56.68) 59 (27.19) 182 (83.87) 1 (0.46) 1.5 i felt comfortable to express myself during the boot camps, n=217 3 (1.38) 30 (13.82) 33 (15.21) 118 (54.38) 63 (29.03) 181 (83.41) 3 (1.38) 1.4 the workload during the boot camps was manageable, n=218 13 (5.96) 54 (24.77) 67 (30.73) 113 (51.83) 38 (17.43) 151 (69.27) 1.13 i felt comfortable working in the clinical environment during the covid-19 pandemic, n=218 29 (13.30) 57 (26.15) 86 (39.45) 93 (42.66) 37 (16.97) 130 (59.63) 2 (0.92) 6 march 2022, vol. 14, no. 1 ajhpe research ‘we were able to re-think the strategy as we implemented it. it got better, i think, in the second semester although there were many skills to be taught.’ (participant 3) the quantitative data provided evidence of learning among students. there was an overwhelmingly positive response from the students to the boot camps (table 1). the students’ 2020 marks in all 4 osces were significantly higher than those of the previous year (table 4). discussion this study describes the outcomes of implementing boot camps as an innovative educational strategy for the learning and teaching of clinical skills in an undergraduate nursing programme. the results present the perceived reasons for the boot camps, the process of enacting the boot camps, and the outcomes of the boot camps. these camps appeared to have influenced the learning and teaching of clinical skills during the covid-19 pandemic positively. however, the strategy was appreciated as an emergency solution in response to covid-19 and is not regarded as suitable for longterm educational purposes. various factors seemed to have enabled the boot camps, i.e. the infrastructure, the educators and the leadership within the institution. caliskan and zhu[9] argue for organisational culture and milieu as integral in supporting the adoption of educational innovations. the organisational culture may include the agency, the people, the resources and the mechanisms that support the synergistic interaction of these variables.[10] the adoption of an educational strategy, such as boot camps, may not result in similar outcomes as reported in this article owing to the unique nature of the institution in question. however, a similar strategy, underpinned by deliberate practice based on institutional realities and organisational culture, may yield improved educational outcomes. the outcomes of the implementation of the boot camps as an educational intervention aligned with the first two levels of the kirkpatrick evaluation model (level 1 and level 2).[11] students and educators alike appeared to value the boot camps. they reflected that it was worth their time and effort, even though some consequences seemed negative, such as tiredness and the general concern of overload. the quantitative strand of the study also reflected learning with improved assessment outcomes. these positive outcomes aligned with the key tenets of deliberate practice, where practising more intensively and intently contributed to learning and mastery of skills.[12] the literature supports the need for educational  interventions to meet the highest levels of the kirkpatrick evaluation model (level 3 and level  4),[13] which were beyond the scope of this study. more robust longitudinal research approaches should be instituted that would evaluate the impact of innovative educational strategies adopted in crisis situations on student competence in the clinical environment. table 2. frequency of students’ comments regarding the boot camp comment f (%) no comments 171 (78.44) it was a positive experience 2 (0.92) it was helpful 27 (12.39) receiving feedback from the test was good 1 (0.46) lecturers should provide an overview of the boot camp 2 (0.92) shorter but more frequent boot camps 4 (1.83) reduce the workload 3 (1.38) arrange more boot camps to practise 5 (2.29) make videos/audios available after boot camps 2 (0.92) it was overwhelming 1 (0.46) table 3. frequency of student’ comments regarding hindering of their learning comment f (%) no comments 139 (63.47) too long 9 (4.11) information overload 21 (9.59) time management 6 (2.74) could not prepare everything 3 (1.37) not enough time to practise 10 (4.57) poor quality of videos 17 (7.76) inconsistency among lecturers 1 (0.46) uncertainty of lecturers 2 (0.91) not having a lecturer in every room 4 (1.83) listening to a recorded lecture 4 (1.83) late uploading of videos 3 (1.37) table 4. comparison of osce marks student groups osce year n (mean) minimum maximum pr (>|t|) first year middle of the year 2019 102 (59.39) 30 81 0.1386 2020 80 (62.25) 24 89 end of the year 2019 101 (59.39) 34 78 0.0087 2020 71 (64.16) 24 87 second year middle of the year 2019 82 (61.13) 27 93 0.2965 2020 88 (59.21) 38 79 end of the year 2019 83 (64.04) 33 90 0.0019 2020 81 (57.27) 20 83 third year middle of the year 2019 66 (56.87) 30 78 0.0001 2020 64 (68.12) 35 91 end of the year 2019 65 (63.76) 31 81 0.6715 2020 62 (62.85) 32 88 fourth year end of the year 2019 68 (72.73) 53 83 0.0115 2020 62 (75.77) 58 87 osce = objective structured clinical examination. march 2022, vol. 14, no. 1 ajhpe 7 research conclusions disruption to health professions education institutions creates a need for innovative educational strategies aimed at continued learning. the boot camps, implemented during the covid-19 pandemic, resulted in positive outcomes for the learning and teaching of clinical skills. however, the adoption of such an educational strategy to other settings hinges upon several factors, including organisational culture and infrastructure availability. future research in this setting could evaluate the clinical competence of students. declaration. none. acknowledgements. mr cornel van rooyen is acknowledged for the quantitative data analysis, and dr ruth albertyn for her critical insight into the manuscript. ms jackie viljoen is acknowledged for language editing of the article. author contributions. all authors contributed to the conception, design, and execution of this study. funding. none. conflicts of interest. none. 1. al-balas m, al-balas hi, jaber hm, et  al. distance learning in clinical medical education amid covid-19 pandemic in jordan: current situation, challenges, and perspectives. bmc med educ 2020;20:341. https://doi. org/10.1186/s12909-020-02257-4 2. puljak l, čivljak m, haramina a, et  al. attitudes and concerns of undergraduate university health 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& wilkins, 2010. 8. saldana j. the coding manual for qualitative researchers. 3rd ed. thousand oaks: sage, 2016. 9. caliskan a, zhu c. organisational culture and educational innovations in turkish higher education: perceptions and reactions of students. educ sci theory pract 2020;20(1):20-39. https://doi.org/10.12738/jestp.2020.1.003 10. kolster r. structural ambidexterity in higher education: excellence education as a testing ground for educational innovations. eur j high educ 2020;11(2):1-18. https://doi.org/10.1080/21568235.2020.1850312 11. gamtessa lc, tiyare ft, kebede km. evaluation of helping babies breathe and essential care for every baby training in southern nation’s nationalities and people’s region, ethiopia: applying a kirkpatrick training evaluation model. bmc res notes 2020;13(1):567. 12. hambrick dz, oswald fl, altmann em, meinz ej, gobet f, campitelli g. deliberate practice: is that all it takes to become an expert? intelligence 2014;45(1):34-45. https://doi.org/10.1016/j.intell.2013.04.001 13. cahapay m. kirkpatrick model: its limitations as used in higher education evaluation. int j assess tools educ 2021;8(1):135-144. https://doi.org/10.21449/ijate.856143publishedathttps://ijate.net/https://dergipark.org.tr/en/ pub/ijate accepted 10 may 2021. https://doi.org/10.1186/s12909-020-02257-4 https://doi.org/10.1186/s12909-020-02257-4 https://doi.org/10.1186/s12909-020-02343-7 https://doi.org/10.1016/j.ijans.2014.04.001 https://doi.org/10.1016/j.ecns.2016.10.005 https://doi.org/10.3389/fphar.2016.00188 https://doi.org/10.1097/nne.0000000000000894 https://doi.org/10.12738/jestp.2020.1.003 https://doi.org/10.1080/21568235.2020.1850312 https://doi.org/10.1016/j.intell.2013.04.001 https://doi.org/10.21449/ijate.856143publishedathttps http://ijate.net/https http://dergipark.org.tr/en/pub/ijate http://dergipark.org.tr/en/pub/ijate october 2020, vol. 12, no. 3 ajhpe 103 research intimate care comprises physical touch that involves inspection of, and physical contact with body parts, which can cause embarrassment to the patient and the nurse.[1] it is further described as task-orientated touch to areas of the patient’s body that might create feelings of discomfort, anxiety and fear or might be misinterpreted as having a sexual purpose.[2] patients seek physical or psychological care at healthcare institutions. nurses provide care that meets the needs of the patient, and these needs may require a nurse to be physically and psychologically close to a patient. this closeness could include exposure of private body parts, touching of the naked body and sharing of intimate information with a total stranger. when providing physical care, touch is necessary and an essential and intrinsic part of a caring profession,[3] as it facilitates communication between the nurse and the patient. the interactions between a nurse and a patient are classified as intimate because they cross the patient’s physical and psychological private zones.[4] during intimate care, a nurse and a patient need to establish a relationship in a confined space, where a patient has to allow a stranger to access his/her body’s most intimate parts and, in turn, the nurse has to see and touch a body that is not theirs.[5] touching the patient’s body may initiate feelings of discomfort,[3] because the care involves parts of the body that need to be touched. there is reluctance in using the concept ‘intimate care’ in the nursing profession. this is based on the assumption that establishing an intimate care relationship with a patient is a violation of the personal and professional ethical boundaries between nurse and patient.[6] however, in the execution of their duties, nursing students are expected to touch areas of a patient’s body that are considered private and emotionally sensitive. many nurses are young, inexperienced with regard to social maturity and responsibility, and may struggle to take on the professional responsibility of providing intimate care to diverse patients, who are strangers to them.[7] professional intimate care responsibility is entrusted to students, and they are expected to excel at it. however, little is known about how nurses learn, rehearse and incorporate appropriate touch strategies, and there is no model for the use of intimate care/touch in a non-sexual context.[1,2] nursing students also receive limited instruction in this regard from nursing education institutions (neis).[8] young nurses are rudely awakened to the reality of intimate care work once they are placed in the clinical area. at the onset of training, they do not necessarily understand the degree to which nursing care includes intimate care and the discomfort they may experience in such situations.[7] to add to the complexity of this issue, south africa (sa) is challenged with increased gender-based violence against women and children.[9] within this context, men and women choose caring careers, such as nursing. the patriarchal and socially constructed gender roles, which perceive nursing as a female profession,[10] may make it even more difficult for male nursing students to provide professional intimate care or touch. the touch from a man is sexualised and, sometimes, viewed as suspicious.[1] these perspectives are further strengthened by media reports of male paedophiles and sexual offenders.[11] in an attempt to protect nurses, mauritian nursing uses a gender-segregation approach, where male and female patients background. the concept of intimate care is not freely used in nursing education and practice. nursing students provide basic nursing care that requires physical and psychological closeness to diverse patients. during the execution of some basic nursing care, patients’ body parts that are considered intimate, private and sexual, are exposed and touched. this encounter with a patient’s naked body may bring about feelings of anxiety, embarrassment and discomfort for nursing students and patients. objective. to develop and describe a model for facilitating the teaching of intimate care to nursing students in south africa. methods. the study was conducted at two nursing education institutions (neis) in gauteng province. a qualitative, theory-generating, research design that is explorative, descriptive and contextual in nature was used to develop a model for facilitating the teaching of intimate care to nursing students. a combination of stages of theory-generating approaches was used to identify and define the main concept. the structure and process of the model were visually portrayed and described. results. the findings of this study demonstrate that intimate care is not facilitated in neis and nursing students are not well prepared and supported to provide intimate care to diverse patients competently, confidently and comfortably. facilitating the teaching of intimate care to nursing students was identified as the main concept. based on this, a model to facilitate the teaching of intimate care to nursing students was therefore proposed, described and visually illustrated. conclusion. the developed model will assist nurse educators in facilitating the teaching of intimate care in neis and in providing continuous support to nursing students. it will empower students to implement intimate care competently, comfortably and confidently, enabling them to establish nurse-patient intimate care relationships based on trust, respect and dignity. afr j health professions educ 2020;12(3):103-108. https://doi.org/10.7196/ajhpe.2020.v12i3.1367 demystifying sexual connotations: a model for facilitating the teaching of intimate care to nursing students in south africa s shakwane, phd; s mokoboto-zwane, phd college of human sciences, department of health studies, university of south africa, pretoria, south africa corresponding author: s shakwane (shakws@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 104 october 2020, vol. 12, no. 3 ajhpe research and nurses are separated. this move was deemed relevant to deal with the sexualisation of touch, which suggests the risk of sexual abuse and molestation by the misuse of position and power. male nurses were believed to make sexualised advances towards female patients, and male patients were likely to do the same towards female nurses.[12] the constitution of the republic of south africa is based on the values of ubuntu (humaneness).[13] chapter 2(10) pronounces that human dignity must be respected and protected, and section 12(2) indicates that every person has the right to bodily and psychological integrity.[14] neis are responsible for preparing nursing students to provide intimate care, while ensuring that it is done with respect and safeguarding of the dignity and integrity of the patient. many scholars[1,7] have focused on the experiences of male nurses when providing intimate care and the strategies used to protect them. little is known about the experiences of female nursing students. nurse educators ought to create safe environments that simulate intimate care experiences for male and female students. neis must create cultural congruent nursing education, which encourages behaviour and decisions that are dignified and appropriate with regard to cultural values, with meaningful, beneficial and acceptable intimate care provision.[15] methods this article forms part of a larger theory-generative study, using a qualitative research design. the larger research project had two phases: an empirical and a theory-generative phase. this paper presents the latter, which was aimed at developing a model for facilitating the teaching of intimate care to nursing students in sa. it describes a model to facilitate the teaching of intimate care. the three steps of model development, adapted from chinn and kramer,[16] as well as from walker and avant,[17] are discussed. the first step is concept clarification, which allows the researcher to identify, classify and define the main concept. the second step is the construction of the relationship statement to create the meaning of the model. the third step is the description of the model structure and process. step 1: concept clarification a concept is a mental image of a phenomenon, an idea or a construct about a thing or action. concepts help in identifying the similarity of experiences that are equivalent by categorising all the things that are alike.[17] the main concepts in this study are identified, classified and defined to ensure clarity, as set out below. identification of the main concepts structuring a model requires identification of concepts that will form the basis of the model. a model emerges because of the conviction that the existing knowledge and theories are not adequate to represent a phenomenon.[16] for this study, the concepts were derived from the research findings in the empirical phase. the analysis of data in the empirical phase revealed that intimate care is not considered a skill that needs to be taught to nursing students. this is evident by its exclusion in the curriculum of neis in sa. nursing students are taught procedural principles of nursing care, but not intimate care or touch. they do not know how and when to prepare a patient for touch. failure to teach intimate care to nursing students has led to experiences of embarrassment, discomfort, anxiety and fear when executing intimate care and have caused some patients to judge intimate care or touch as sexual or inappropriate.[18] how intimate care or touch is experienced by the nurse or patient is based on their culture, religion, age, gender and sexual orientation.[12] empirical data also show that nursing students in clinical placement are not given adequate support when experiencing challenges in this regard. lack of preparation of and support for nursing students with regard to intimate care may adversely affect them emotionally and professionally,[18] and patients may not receive quality care. therefore, there is an imperative for neis to facilitate the teaching of intimate care. based on the findings of the empirical study, ‘facilitating the teaching of intimate care’ was identified as the main concept used to develop a model. classification of the main concepts the main concept was classified using the survey list in dickoff et al.[19] table 1 displays the integration of the survey facts into the presented model. definition of the main concept the main concept was defined using these three steps: the dictionary definition, contextual (subject) definition and exemplary or model case.[16] to clarify the main concept, i.e. facilitating the teaching of intimate care, table 1. intimate care model classification[18] agent nurse educators recipients nursing students procedure neis should acknowledge and accept that intimate care is a skill that needs to be taught and learnt by nursing students intimate care should be included in the nursing programme or curriculum and be taught to nursing students dynamic neis’ willingness to integrate intimate care as a subject, a clinical objective and procedure in their curriculum competency of nurse educators in teaching and simulating intimate care skills age, culture, gender and sexual orientation of nursing students, nurse educators and patients orientation of professional nurses in clinical facilities in facilitating, supervising and supporting nursing students when providing intimate care context at neis, where nursing students are enrolled in the r425 nursing programme, and at clinical facilities, where nursing students are allocated to clinical exposure, practice and competencies terminus to improve nurse educators and nursing students’ competence in providing intimate care to patients of different cultures, ages, genders and sexual orientations this will be facilitated by teaching intimate care to nursing students at neis neis = nursing education institutions. october 2020, vol. 12, no. 3 ajhpe 105 research each of the four core words that comprise the concept was defined separately, and their attributes were combined. after exploring the dictionary and contextual definition of each word, a list of essential and related attributes was identified. the theoretical definition of the concepts in the model is defined in table 2. step 2: construction of relationship statements of the model relationship statements structurally interrelate the concepts of the model. these statements declare a relationship between two or more concepts.[16] provision of intimate care requires a nursing student to touch a patient, and it also requires a patient to allow a nursing student, who is a stranger, to touch parts of his/her body that are considered intimate, private and sexual. this care takes place in a confined private space. nursing students are often not well prepared to provide such care. therefore, facilitating the teaching of intimate care allows nursing students to gain intimate care knowledge and skills. the central concept suggests that nurse educators need to prepare and support nursing students by facilitating the teaching of intimate care for nurses to provide such care competently, confidently and comfortably. step 3: description of the model the context, purpose and assumptions of the model are discussed. context of the model sa is a diverse democratic country – students from different backgrounds are recruited to the nurse training programme. nursing students are trained to provide care that is non-discriminatory and culturally sensitive,[28] and maintains the dignity and integrity of a patient. intimate care and touch have a different meaning to different people, based on their sociocultural construction of the human body and touch. nursing educators need to facilitate the process of teaching intimate care to nursing students to enable them to be aware of their own cultural and religious values regarding caring for a fragile body of a person who differs from them. intimate care knowledge and skills must include cultural, religious and ethical teaching regarding the human body and nakedness, and humanistic simulation must be used as an effective intimate care teaching strategy. simulation can enable and encourage nursing students to provide intimate care in a safe environment and expose them to the simulated reality of a human body during intimate care. nurse educators also need to provide clinical support to nursing students when they render intimate care to patients in a clinical facility. table 2. theoretical definition of the concepts concept definition facilitating an interactive learning process, which is goal orientated and dynamic, and in which learners and educators work together in an atmosphere of genuine mutual respect[20] facilitation takes place in the classroom, clinical laboratory and clinical facilities teaching a mental process that produces beneficial and purposeful student learning through the use of appropriate procedures[20] teaching in nursing education is a task-orientated process, which focuses on skills and knowledge it aims at producing a skilled, knowledgeable, useful and willing nurse[21] intimate care basic nursing care routines that involve procedures, such as provision or assistance with hygiene and urinary and faecal elimination intimate care involves physical or psychological closeness between a nurse and a patient the nurse comes into contact with a patient’s body and the patient must allow a nurse to touch his or her body this type of care is viewed as an invasion of personal or private space, because the body parts that are exposed and touched are considered to be private, sexual or intimate[18] feelings of discomfort, embarrassment, fear and anxiety may be experienced by the nurse and patient[18] the nurse’s touch may be misinterpreted as inappropriate or sexual competence this refers to the ability of a nurse to integrate cognitive, affective and psychomotor skills when delivering nursing care[22] competency assists in professional and interpersonal decision-making for the practice role in the context of the nursing profession[23] it also includes having insight and awareness of one’s expertise and limitations[24] confidence this is a human quality demonstrated through an efficient act, appearance and performance, resulting in a positive outcome the process and outcome of the action are evaluated, subjectively and objectively, by the person and by others who observe the behaviour[25] comfort kolcaba[26] defines comfort in nursing as the satisfaction of basic human needs for relief, ease or transcendence arising from a healthcare situation that is stressful it means being in a state of physical or mental comfort, content and undisturbed it also means being easy to associate with and deal with people therapeutic nurse-patient relationship this is a planned, time-limited and goal-directed connection between a nurse and a patient it protects the patient’s dignity, autonomy and privacy, allowing for the development of trust and respect[27] in this model, a therapeutic nurse-patient intimate relationship will mean a mutual intimate relationship established by a nurse and a patient, based on trust, respect and dignity 106 october 2020, vol. 12, no. 3 ajhpe research purpose of the model use of this model is specific to nursing education and clinical practice. it seeks to facilitate the teaching of intimate care to nursing students in sa, thereby ensuring that the following objectives are achieved: • the facilitation of teaching of intimate care at neis and ensuring that teaching of intimate care is facilitated by using simulation as an effective teaching method for intimate care provision. • the adoption of the proposed model for intimate care instruction as a framework for nurse educators when teaching intimate care knowledge and skills to nursing students. the latter will be more empowered to provide intimate care competently, comfortably and confidently, regardless of gender, age, religion, culture and sexual orientation. • the model provides practical guidelines to prepare nurse educators for their role as facilitators of intimate care. assumptions of the model the assumptions are the basic givens or accepted truths that are fundamental to theoretical reasoning. they are structural components of a theory that is taken for granted or thought to be true without systematically generated empirical evidence. they are assumed to be true within the model, because they are reasonable.[16] the assumptions of this model are: • nurse-patient interaction occurs during the provision of basic nursing care to diverse patients. most basic nursing care procedures are intimate, as they require physical closeness and touching of a patient. • nursing students are not well prepared or trained to provide intimate care to diverse patients competently, comfortably and confidently. during the implementation of intimate care, the patient’s private space is invaded, either physically or psychologically. this care can awaken feelings of embarrassment, anxiety, fear and discomfort for nursing students and patients alike. patients can sometimes misinterpret the nursing students’ touch as sexual or inappropriate. neis and clinical facilities do not provide sufficient support to nursing students when they are faced with intimate care conflicts. the structure and process are described below. the model for facilitating the teaching of intimate care is the researchers’ recommended framework for improving the provision of intimate care to diverse patients competently, confidently and comfortably. the model advocates for the facilitated teaching of intimate care to nursing students. they will be more empowered with intimate care knowledge and skills, and will be supported when experiencing difficulties in the execution or provision of intimate care. the structural presentation of this model is displayed in fig. 1. the model consists of four steps, i.e. step 1: intimate care conflict; step 2: intimate care facilitation; step 3: intimate care support; and step 4: therapeutic nurse-patient intimate relationship. these steps are discussed below. step 1: intimate care conflict intimate care conflict is based on the diversity of nursing students and patients receiving nursing care. the participants in intimate care ic c o n �d en ce st ep 4 : t h er ap eu ti c n u rs e -p at ie n t in ti m at e re la ti o n sh ip ic simulation and practice ic implementation relationship based on trust, respect and dignity ic competence ic support ic competence ic c o m fo rt ic adoption by neis nurse educator facilitating ic nursing students receiving ic facilitation development of ic objective, clinical guidelines and tools ic simulation diversity culture religion sexual orientation gender age experiences embarrassment misinterpretation discomfort anxiety lack of supports te p 1 : i c c o n � ic t st ep 2 : i c fa ci lit at io n st ep 3 : i c s u p p o rt fig. 1. model for facilitating the teaching of intimate care.[18] (ic = intimate care; nei = nursing education institution.) october 2020, vol. 12, no. 3 ajhpe 107 research implementation are from diverse cultural and religious backgrounds, with different gender, age and sexual orientations. nursing students bring with them sociocultural values and beliefs about touch and intimacy. for many, such practices occur within the safety of family and intimate relationships.[29] the nursing students’ background influences the beliefs and behaviours in caring for diverse patients.[30] the intimate care conflict is assumed to be based on nursing students often not being well prepared to provide intimate care to diverse patients.[14] when providing intimate care, many nursing students experience embarrassment and discomfort. there is also the possibility that intimate care could be misinterpreted as inappropriate or sexual by the patient. these experiences have led to intimate care conflict between nursing students and patients.[18] during the execution of intimate care, nursing students may transgress their internalised social and cultural taboos. this contradiction may leave them feeling confused and vulnerable.[29] lack of intimate care knowledge, skills and support from neis and clinical facilities may lead to intimate care conflict. step 2: intimate care facilitation • neis adopting the intimate care concept: neis should acknowledge and adopt intimate care as a knowledge and skill that needs to be taught to nursing students. intimate care should be included in the nursing curriculum – in theory and practice. intimate care objectives/outcomes, procedural steps/ strategies and assessment tools should be developed and included in the nursing students’ clinical procedure manual and clinical outcomes. • nurse educators facilitating the teaching of intimate care: in the study by o’lynn and kraustcheid,[8] they show that intimate care instruction empowered male nursing students to feel more comfortable and maintain dignity, comfort and respect regarding the patient. simulation is a strategy that can be used to facilitate the teaching of intimate care. crossan and mathew[7] indicate that a humanistic form of simulation is needed to facilitate intimate care teaching. mainey et al.[14] used mask-ed simulation to facilitate intimate care education. this simulation approach is considered a humanistic form of simulation, as the educator becomes immersed in the teaching session by wearing a silicone mask and body parts, and is thus able to engage with students through the character of a patient. the students experienced both the physical and emotional aspects of providing safe intimate care, they developed confidence and felt more comfortable about providing such care.[4,14] • nurse educators delivering intimate care knowledge, skills and guid ance to nursing students: nurse educators need to be intimate care competent, comfortable and confident. nurse educators are trained in humanistic simulation of intimate care, such as using mask-ed simulation. the discussion of sociocultural and ethical issues related to intimate care and touch needs to be included. the training will assist them in dealing with their personal issues and experiences of intimate care. • nursing students receiving facilitated teaching in intimate care: nursing students are the recipients of intimate care knowledge, skills and guidance. they can discuss their diverse sociocultural, religious or other convictions in a safe environment. they participate in a humanistic simulation activity, where they experience the reality of intimate care. this simulation allows them to discover that the patient is at the centre of intimate care and is treated with respect and dignity. step 3: intimate care support currently, when nursing students interact with strangers and their bodies during the execution of intimate care, they are often given very little or no support in this regard during their educational preparation.[7] the third step assumes that the second step was implemented, i.e. that nursing students have received intimate care teaching, which was facilitated through discussion and humanistic simulation. they demonstrate that they have acquired the knowledge and skills required for the provision of intimate care and can be trusted to provide such care. nursing students are now more competent, comfortable and confident in providing intimate care to patients of different genders, ages, cultures, religions and sexual orientation. step 4: therapeutic nurse-patient intimate relationships mainey et al.[14] define intimate care as the nurse-patient interaction, where the nurse enters the person’s private zone, providing task-orientated care. the fourth step is based on the assumption that, if nursing students are knowledgeable, skilled and supported in the provision of intimate care, they will be better able to establish therapeutic nurse-patient intimate care relationships. intimate care conflicts are reduced, and nursing students can negotiate and establish an intimate therapeutic relationship based on trust, respect and dignity. moreover, patients are more likely to accept the provision of intimate care, without misinterpreting it as inappropriate or sexual. both nurse and patient enter a trustful, respectful and dignified relationship. ethical approval the paper forms part of a larger theory generative qualitative study approved by unisa’s health studies research ethics committee (ref. no. hshdc/496/2015). study limitations this paper presents the steps used to develop a model for facilitating the teaching of intimate care. the model has not yet been implemented or operationalised at neis in sa. the researchers have presented the model to various stakeholders in neis in the public and private sectors. they are in the process of implementing and evaluating the model for clarity, consistency, simplicity, generality and accessibility. conclusion and recommendations this article comprises a comprehensive description of a model for facilitating the teaching of intimate care, using the three steps of model development as supported by chinn and kramer[16] and dickoff et al.[19] a graphic representation of the model enhanced the structural clarity of the concepts within the model. the purpose of developing this model was to empower nursing students with intimate care knowledge and skills. the model must be operationalised in nursing education, practice and research. further research studies should be conducted to evaluate the effectiveness and feasibility of the model. it is envisaged that the developed model will empower nursing students to provide intimate care competently, comfortably and confidently. they will be able to establish nurse-patient intimate care relationships based on trust, respect and dignity. research should also be done to understand the patients’ experiences of intimate care. 108 october 2020, vol. 12, no. 3 ajhpe research this will give a voice to the patients and add value to developing acceptable intimate care strategies in an african context. declaration. none. acknowledgements. we acknowledge the gauteng department of health, selected neis for granting permission to conduct the study, and nurse educators and students who participated in the study. author contributions. the authors worked together on the manuscript. ss wrote the first draft and smz reviewed and corrected it before submission. ss and smz revised the manuscript according to the reviewers’ comments. ss takes full responsibility for the study. funding. none. conflicts of interest. none. 1. harding t, north n, perkins r. sexualizing men’s touch: male nurses and the use of intimate touch in clinical practice. res theory nurs pract 2008;22(2):88-102. https://doi.org/10.1891/1541-6577.22.2.88  2. lehn-christiansen s, holen m. ambiguous socialisation into 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https://doi.org/10.1891/1541-6577.22.2.88 https://doi.org/10.1016/j.nedt.2019.01.002 https://doi.org/10.1177/0193945914527356 https://doi.org/10.1016/j.colegn.2018.08.001 https://doi.org/10.1111/j.1440-1800.2009.00481.x https://doi.org/10.1111/j.1466-769x.2007.00318.x https://doi.org/10.1111/j.1466-769x.2007.00318.x https://doi.org/10.1016/j.nepr.2013.04.007 https://doi.org/10.1016/j.nepr.2013.04.007 https://doi.org/10.3928/01484834-20140211-08 https://doi.org/10.1177%2f1097184x12438001 https://doi.org/10.1111/j.1365-2648.2012.05952.x https://doi.org/10.1111/j.1365-2648.2012.05952.x https://doi.org/10.12968/bjon.2015.24.6.335 https://doi.org/10.1016/j.ijnurstu.2013.09.013 https://doi.org/10.1016/j.ijnurstu.2013.09.013 https://hdl.handle.net/10520/ejc51951 https://doi.org/10.1016/j.ecns.2017.12.001 https://doi.org/10.3928%2f01484834-20100115-02 https://doi.org/10.1111/j.1365-2354.2008.00993.x https://doi.org/10.3928/00220124-20080201-12 https://doi.org/10.3928/00220124-20080201-12 https://doi.org/10.1016/j.nedt.2005.03.002 https://www.researchgate.net/publication/281068340 https://doi.org/10.1111/j.1365-2648.1994.tb01202.x https://doi.org/10.1111/j.1365-2648.1994.tb01202.x http://www.nanb.nb.ca>pdf>practice-stand https://doi.org/10.7748/ns2010.12.25.13.42.c8121 https://doi.org/10.7748/ns2010.12.25.13.42.c8121 https://doi.org/10.3928/01484834-20051101-05 https://doi.org/10.4102/curationis.v38i2.1517 https://doi.org/10.4102/curationis.v38i2.1517 260 december 2021, vol. 13, no. 4 ajhpe research naturopathy is a system of complementary medicine (cm) that emphasises prevention, treatment and promotion of optimal health through the use of therapeutic methods and modalities which encourage the self-healing process – the vis medicatrix naturae.[1] philosophical underpinnings guide naturopathy, which focuses primarily on the prevention of illness through education, lifestyle and dietary changes.[2,3] over 100  000 naturopaths currently practise globally.[4] naturopaths have been practising in south africa (sa) since the 1950s.[5] currently only one higher education institution (hei) in sa offers naturopathic training as a 5-year course. this consists of a 3-year undergraduate bachelor of science in complementary health sciences (bsc chs) degree, which provides the foundation for the professional 2-year postgraduate bachelor of complementary medicine in naturopathy (bcm naturopathy) degree. the training programme started in 2002 a time when there was no benchmark available to serve as a roadmap for the development of the course. in 2010 the world health organization (who) benchmarked the minimum standards for the education and training of naturopaths which included listing the curriculum and the number of training hours required for minimum competency.[1] this guideline, as well as subsequent documents,[6] aimed to set standards for training to ensure the safety of the public, create awareness of the different levels of training for naturopaths, to assist governments in regulating and accrediting practitioners and ultimately to promote the integration of naturopathy into the public health system.[1] in 2016, based on the findings of a global survey of naturopathic educational institutions, the world naturopathic federation (wnf)[3] established that there is global uniformity in the type of curriculum used in naturopathic training programmes. the use of a comparative and benchmarked template affords the opportunity to engage in suggested corrective action.[7] in the present study, the sa curriculum was compared and evaluated against the who and wnf curricula, in order to establish whether the curriculum meets the minimum requirements. a systems view of relevant training heis demonstrate how inputs from students, staff, faculty and various other resources can potentially help to transform and improve both the training and outcomes of an institution. this study used input from graduates. using comparative analysis of the curricula as well as graduate reviews, recommendations for improvement to the sa naturopathic programme were made. methodology this research used a sequential qualitative methodological approach, consisting of two stages. the first stage was a comparative document analysis, based on the major categories and the courses in each category of the naturopathic curriculum proposed by the who,[1] the wnf roots survey which summarises the curricula taught in 30 different countries across all continents, [4] and the sa curriculum. the second stage consisted of a purposively sampled graduate review of the programme. all registered naturopaths who had graduated between 2007 and 2016, and whose email contact details could be traced, were invited to participate background. naturopathy has been taught at tertiary level in south africa (sa) for 18 years. this research paper examines the naturopathic curriculum to determine whether it is benchmarked to international standards and meets the needs of graduates in practice. it is the first research paper that critically reviews the curriculum of a complementary alternative medicine profession taught at a higher education institution (hei) in sa. objective. to critically review the naturopathy curriculum taught at an sa hei. methods. this research used a sequential two-stage qualitative methodology. in stage one, a comparative document analysis was conducted using the curriculum recommended by the world health organization (who), the world naturopathic federation (wnf) and the university of the western cape. stage two consisted of a graduate review of the curriculum. eighteen graduates participated in the review by providing input on all the subjects in the curriculum via email. the responses were summarised and thematically analysed. results. it was found that the sa curriculum is aligned to international curricula. graduate inputs suggest a restructuring of the curriculum so that subjects which are core to naturopathic training can be taught in greater depth over a longer period of time. conclusion. the subjects offered in the sa naturopathic curriculum are on par with international standards. concerns raised by graduates suggest a need for a restructuring of the curriculum to develop a deeper understanding of the curriculum to ensure that graduates are competent to meet the changing healthcare needs of the population. afr j health professions educ 2021;13(4):259-263. https://doi.org/10.7196/ajhpe.2021.v13i4.1276 a comparative analysis and evaluation of the naturopathic curriculum in south africa w ericksen-pereira,1 phd; n v roman,2 phd; r swart,3 phd 1 school of natural medicine, university of the western cape, cape town, south africa 2 child and family studies, university of the western cape, cape town, south africa 3 dietetics and nutrition, university of the western cape, cape town, south africa corresponding author: w ericksen-pereira (wericksenpereira@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1276 mailto:wericksenpereira@gmail.com december 2021, vol. 13, no. 4 ajhpe 261 research in the research via email. thirty-eight emails were sent explaining the purpose of the research. included in the email was the ethics clearance document and the document summarising all the subjects in the training course, divided into the bsc and bcm degree courses. participants were requested to: (i) provide comment on all the subjects covered in the curriculum; and (ii) make suggestions for improvements if they felt it was necessary to do so. over a period of 2 months, 3 reminders were sent and 18 participants responded. these responses represent a spread across the years from the first cohort of graduates of the naturopathy programme to the 2016 graduates. half of the respondents were in full-time practice as naturopaths. the response rate was higher among participants who graduated later. responses were coded in order to protect the identity of the participants. the responses were summarised and thematically analysed based on the frequency of an occurring theme. results stage 1: comparison of curricula an analysis of the three documents found that the curriculum could be divided into four major categories consisting of the basic sciences, clinical sciences, naturopathic studies and clinical training. this is summarised in table 1. table 1. a comparison of curricula who wnf south african curriculum basic sciences: anatomy physiology pathology basic sciences: hours – basic + clinical sciences combined: 1 200+ anatomy physiology pathology basic sciences: hours – 2 000 biotechnology chemistry medical bioscience medical microbiology pathology pharmacology physics clinical sciences: patient history taking clinical assessment physical examination first aid and emergency medicine hygiene and public health clinical sciences: hours basic + clinical sciences combined: 1 200+ patient history taking clinical assessment physical examination clinical sciences: hours – 900 patient history taking clinical assessment physical examination emergency medicine general medicine naturopathic studies: naturopathic history and practice nature cure nutrition hydrotherapy botanical medicine homeopathy and tissue salts bach flower therapy stress management lifestyle counselling light therapy electrotherapy iridology soft-tissue therapies aromatherapies acupuncture naturopathic studies: hours – 950 minimum naturopathic history, principles and philosophy clinical nutrition applied nutrition hydrotherapy botanical medicine homeopathy counselling and naturopathic psychotherapy pharmacology energetic therapies physical manipulation massage and soft-tissue techniques. naturopathic studies: hours – 1 200 naturopathic principles and philosophy nutrition hydrotherapy botanical medicine tissue salts bach flower therapy stress management lifestyle counselling light therapy electrotherapy iridology soft-tissue therapies aromatherapies thermal therapy clinical training: hours – 400+ clinical training: hours – 1 200+ clinical training: hours – 1 200+ additional subjects: hours – 650 computer literacy primary health care principles of natural healing english for educational development complementary healing systems interdisciplinary health promotion health psychology study of human development total number of hours of naturopathic training: 1 500+ hours 4 000+ hours 5 950 hours who = world health organization; wnf = world naturopathic federation. 262 december 2021, vol. 13, no. 4 ajhpe research it was found that the sa curriculum falls into the same categorisation of subjects as that stated in the who[1] and the wnf[4] documents and offered a wider range of subjects in the basic sciences. while the basic science subjects of anatomy, physiology and pathology are offered in the sa curriculum, it also offers physics, chemistry, biotechnology and pharmacology. these subjects provide a foundation which fosters an understanding of the various biochemical processes and their impact on the body at a cellular level.[8] the curriculum also offers a number of additional subjects which cover various topics, such as psychology and introduction to natural health and healing systems, and provides foundational courses, such as computer literacy and english for educational development (eed) which addresses the sa context. when the total number of training hours were compared, it was found that the sa training programme exceeded the minimum recommended training time determined by the who[1] and wnf.[9] the sa programme meets the minimum clinical training hours set by the wnf but has a bigger emphasis on the basic and clinical sciences component, and exceeds the minimum number of hours recommended by the wnf by 1 700 hours. stage 2: graduate review the following themes were identified: responses to the bsc (complementary health sciences) programme: theme 1: limited relevance of the course while there was a general agreement that most of the subjects in the undergraduate bsc degree were essential as a foundation to the bcm degree, the relevance of the following subjects for the course was questioned. english for educational development (eed): it is an elective taught in the first year. respondents questioned the need for this english component when the medium of instruction at the university was english. it was felt that students needed ‘to have a basic knowledge of xhosa and afrikaans in order to communicate with people from different walks of life especially in the western cape region’ (participant 8). computer literacy: this is a compulsory subject for all first-year students. its relevance was questioned because it was felt to be too basic as most students were computer literate by the time they entered university. respondents felt that a competency assessment would determine if students needed to do this course, proposing that it ‘should be an elective for those who never really used computers’ (participant 10). theme 2: important to the course but the content needs to change the participants all agreed on the following subjects being important to the course as they provided a foundation for understanding concepts which would be taught later in the course – but the participants found the content did not fulfil this expectation. complementary health sciences 201: this subject was deemed to be important to the course as it introduced students to the different cm professions taught at the university. however, respondents felt it to be ‘very superficial’ and ‘not detailed enough’ and needed to have more ‘depth’ added to the course contents (participant 2). it was suggested that a greater focus on ‘philosophies of the different complementary healing systems would provide some insight into how and why the different healing systems practise in a particular way’ (participant 7). pharmacology 204: all respondents agreed on the importance of the subject to understand the pharmacokinetics of commonly prescribed drugs. however, there needed to be a greater ‘focus on drug-herb interactions as naturopaths use herbs as a part of their treatment and many of the patients naturopaths see are already using chronic medication’ (participant 9). it was also felt that the course needed to be more focused ‘on the effects of polypharmacy as this is what practitioners see in practice’ (participant 11). nutrition 211 and 221: these subjects were seen to provide the foundation of nutrition and it was suggested that ‘the course should be extended to include functional and nutritional therapy and be introduced from the first year’ (participant 17). primary healthcare: the aim of this subject is to introduce students to the sa public healthcare system and create awareness of the needs of the communities who access the system. there was consensus among all respondents that this subject does not achieve the objective of getting all students to understand ‘how the whole health system in sa works and where naturopathy fits into the bigger south african context’ (participant 18). general medicine 301: introduces students to common pathologies and disease presentation. there was consensus on the importance of the course. however, owing to the course content being ‘a lot and overwhelming’ (participant 4), it was suggested that ‘the content needs to be covered over a two-year period’ (participant 6). theme 3: important to the course but method of delivery needs to be improved these courses were acknowledged by all participants to be crucial to understanding the anatomy and physiology of the body. the main concern with these subjects was the method of delivery and the challenges experienced with assessment. medical biosciences 111, 121, 231 and 232: these subjects were acknowledged as being key to understanding pathology and the disease process in the rest of the curriculum as they cover anatomy and physiology. respondents felt that, ‘due to the volume of work and the difficulty of the work, the quality of teaching and assessment needed to be improved on’ (participant 6). it was suggested that the ‘number of lectures per week needs to be increased as well as the number of tutorials and assignments’ (participant 2). theme 4: mixed comments comments on these subjects varied and could not be categorised into any one theme. however, it is important that the responses are reflected as they contribute to the evaluation of the curriculum. principles of natural healing 111: this subject introduces students to the theories and principles which underpin natural medicine. the responses could be divided into three categories: • unable to recall – one-third of the respondents reported not being able to recall any of the course content • the contents needed to change – as ‘it was very superficial – it didn’t provide a sound basis for understanding how natural medicine differs from conventional medicine’ (participant 3). • important to the course but poor delivery – ‘this course is a foundation to understanding what natural medicine is, therefore it should be taught properly with more student engagement’ (participant 1). biotechnology 216: this subject builds on the first-year science courses and is aimed at developing an understanding of how the living systems’ organisms work. it also develops the basic skills needed to do research in laboratories. december 2021, vol. 13, no. 4 ajhpe 263 research responses to this subject ranged from those who questioned the relevance of the course, while others felt that it was necessary but ‘the focus should be on nutritional biochemistry, which would be more relevant for naturopaths’ (participant 9). others felt that that this course was only relevant for those students who intended ‘to follow a career path that required laboratory work/skills’ (participant 10). study of human development 211 and health psychology 224: in these subjects students are introduced to the various developmental theories and the various biological, psychological and social factors which influence health respectively. the responses to these subjects were similar and ranged from ‘i can’t remember much of the course’ (participant 4), ‘i’m not sure how it all integrates together’ (participant 5) to ‘it was a offered on a very basic level’ (participant 9). interdisciplinary health promotion: this subject creates awareness in students of the need to work together as an interdisciplinary team in order to maximise patient health outcomes. responses ranged from those who felt the course was important because ‘the more different health professions are exposed to one another, the better the opportunity for inter-professional co-operation which is in the patient’s best interest’ (participant 15) while others felt that ‘it was poorly structured and taught’ (participant 2) and they ‘didn’t understand what they were supposed to get out of the course’. (participant 6) responses to bcm (naturopathy) programme this programme is a postgraduate professional degree. completion of the bsc (chs) degree is a prerequisite for entry into the bcm (naturopathy) programme. all subjects in the curriculum are fundamental to the naturopathy training programme. the responses from the participants were summarised into the following themes: theme 1: relevance of course there was only one subject where the relevance of the course was questioned. from the responses received, it is clear that it was not the relevance of the course itself but the research topics which students were given. research project 508: the research project component is the practical application of research skills in a research project. most participants questioned the relevance of the research project topics as ‘the research project consumed a disproportionately large amount of time’ (participant 5) and it was not related to what the students were studying. as a result the project, and by implication the course, was deemed to be ‘a waste of time’ (participant 7) as the ‘research topic had no relevance to the profession we were studying’ (participant 1). theme 2: content needs to change most participants identified the following subjects as needing to have some aspect of the content changed. counselling skills 410: this subject aims to develop the skills to enable students to counsel patients. it is taught in the final year of the programme. all participants agreed on the importance of counselling to the training programme but felt that the course needed to ‘be extended over a full year and the content expanded to include the theories underpinning counselling as well as develop the skills to enable them to use it effectively within a consultation’ (participant 5). ethics, jurisprudence and practice management: this course introduces students to the various ethical theories and the legislation as it pertains to the registered allied health professions council of south africa (ahpcsa) professions. participants all found the subject very important, interesting and also relevant but there was consensus that ‘the practice management component needs to be expanded on in order to better prepare students to run their own practice’ (participant 8). differential diagnosis: the respondents agreed on the importance of the subject as it develops the knowledge and skills to arrive at a differential diagnosis but felt that it needed ‘greater depth using practical examples’ (participant 11) and should be ‘integrated into other subjects so that students can understand how the different parts are all connected’ (participant 2). treatment modalities: these subjects are fundamental to the naturopathy programme, teaching the philosophy and principles, as well as the various treatment methods which naturopaths use in practice. the general view regarding the course was that it required the teaching of all treatment practices in the legal scope of practice (sop). however, all treatment practices should not be allocated an equal amount of teaching time as the view was expressed by some of the participants that the treatment practices taught impact on the graduates once they are in practice: ‘treatment practices taught should be focussed on practice, what is affordable and realistic on implementation – for example the various physical therapies, botanical medicine’ (participant 1). it was felt that a standardised curriculum needs to be developed based on the sop. the following comment summarised the view of the majority of participants on the nutrition component of the course: ‘as dietary intervention is the cornerstone of naturopathy, nutrition should be taught throughout the duration of the programme, not only in the second and third year of the bsc programme’ (participant 13). responses to the overall programme restructure the curriculum: most of the participants made recommendations for changes to the curriculum so that there is improved scaffolding and ‘integration of subjects in order for naturopathic subjects to be taught earlier as two years is not enough to teach a naturopathic course’ (participant 6). this would entail removing subjects from the curriculum deemed to be irrelevant to the course so that more time could be spent on teaching the naturopathic curriculum in greater depth. recommendations for restructuring of the programme included a bigger emphasis on the teaching of nutrition as the 2-year curriculum is specific to naturopaths and has ‘too much content which is overwhelming and there isn’t enough time to practice the knowledge and skills in a clinical setting’ (participant 4). discussion the sa naturopathy curriculum was found to exceed the curriculum benchmarked by the who.[1] it also compares favourably to international curriculum established by the wnf.[4] the curriculum places emphasis on the basic sciences in the curriculum. while knowledge of the biochemical and physiological processes is important in understanding disease processes and treatment,[8] this has to be balanced with adequate clinical training as it is here that the theoretical knowledge is integrated into practical clinical training and patient care.[10] baer[11] suggests that naturopathy, in an attempt to legitimise naturopaths’ training, has increasingly incorporated the basic sciences into their programmes. clinical training is crucial for developing the necessary competencies to ensure that graduates are safe, competent practitioners – and re-evaluating the time allocated to the different components of the training is necessary to ensure that there is a balance in 264 december 2021, vol. 13, no. 4 ajhpe research the hours allocated to the theoretical component and clinical training. this was reflected in some of the comments in the graduate review. the graduate review looked at the curriculum from a different perspective. often graduates are not consulted for input on their training programmes, but their input on the evaluation of a programme potentially offers opinions which could improve the programme[12] and provide insights into possible deficits in the programme.[10] this could stimulate curricular debate and ultimately changes beneficial to future students of the programme. in order to ensure that a curriculum remains relevant to address the health needs of a country, it is necessary to regularly review the curriculum[12] to ensure that students are prepared to meet the challenges of a changing health system. [13] concerns raised by graduates in respect of the curriculum need to be weighed up in terms of the competencies expected of graduates within the sa health system as determined by the professional body, the ahpcsa. for all the participants, it was more than a year or longer since they graduated from the naturopathic programme and they had been working in various capacities in the healthcare sector. the response from graduates indicated a recognition of the importance of most subjects in the programme. however, the relevance of having certain subjects in the programme was questioned by all respondents. the inclusion of these subjects needs to be considered in terms of the population of students who are enrolled in the course. the university population is drawn from diverse communities, cultures and age groups,[14] and students from impoverished communities and rural areas may not have the requisite english language or computer literacy skills to succeed academically at university. thus, subjects such as computer literacy and eed are important for students to ensure that they develop the requisite skills necessary to succeed at university. by participating in eed, students engage with each other and this helps to break down language[14] and cultural barriers. primary health care and interdisciplinary health education are important co-curricular subjects for they provide students in the faculty of community health sciences with the opportunity to develop an understanding of the sa health system, the different medical professions and how they work together interprofessionally within the health system[15] in order to address the healthcare needs of their patients. these subjects have to be integrated into the broader curriculum so that there is a scaffolding of skills and knowledge to ensure that students have acquired the skills and knowledge which they need in the senior years.[16] one of the main challenges of the naturopathic curriculum appears to be related to the need to integrate the curriculum on both a horizontal and vertical level so that all subjects in the curriculum are offered in sufficient depth. as the complete 5-year curriculum comprises the basic sciences, a clinical science component, and a naturopathic theoretical component, as well as the additional subjects discussed above, horizontal integration at every year level would help students to understand how the different subjects and concepts[17] are related to each other. vertical integration allows students to understand how the different subjects are scaffolded, allowing a deeper understanding of the inclusion of different subjects in a curriculum. integration in an undergraduate medical curriculum encourages clinicians to critically view and review their subject matter and methods of diagnosis and therapy.[16] findings from this research suggest that there is a need for a restructuring of the naturopathic programme to ensure that the curriculum is relevant and ensures that graduates have the necessary knowledge and skills to competently practise their profession within the sa healthcare system. one of the limitations of this research was the small sample size. however, there are less than 100 registered naturopaths in sa, and of these, less than half are graduates of the tertiary programme. there was a 47% response rate. another limitation was that responses were obtained via email. some of the participants went into great detail in their responses while others kept their responses very brief. conducting this research via face-to-face interview may have resulted in more in-depth responses from all participants. this research focused on the subjects taught and excluded a deeper analysis of the content of the subjects in the naturopathy curriculum. conclusion in order to ensure that the naturopathic programme remains relevant and contextual to the demands of the public, there is a need for a regular review of the programme to allow all aspects of the programme to constantly improve. this ensures that graduates achieve an acceptable level of competency and professionalism. further research into the re-curriculisation of the programme and a critical evaluation of the content could assist in developing a programme which ensures that naturopathy graduates are competent to meet the current challenges of the sa health system when they are in practice. declaration. none. acknowledgements. grateful thanks to all the naturopaths who took the time to participate in this research. author contributions. wep was the research lead; nr and rs assisted with research design and editing of the article. funding. nrf sabbatical grant 98206. conflicts of interest. none. 1. world health organization. benchmarks for training in traditional/complementary and alternative medicine: benchmarks for training in naturopathy: geneva: who, 2010. http://apps.who.int/medicinedocs/ documents/ s17553en/s17553en.pdf (accessed 27 april 2019). 2. pizzorno je, murray mt. textbook of natural medicine. vol 1, 3rd ed. missouri: churchill livingstone elsevier, 2006. 3. wardle j, oberg eb. the intersecting paradigm of naturopathic medicine and public health: opportunities for naturopathic medicine. j altern complement med 2011;17(11):1079-1084. https://doi.org/10.1089/acm.2010.0830 4. hausser t, lloyd i, yánez j, cottingham p, turner rn, abascal a. world naturopathic federation naturopathic roots report. 2016. www.worldnaturopathicfederation.org (accessed 24 november 2017). 5. ericksen-pereira w, roman n, swart r. an overview of the history and development of naturopathy in south africa. health sa 2018;23. https://doi.org/10.4102/hsag.v23i0.1078 6. world health organization. traditional medicines strategy 2014-2023: geneva: who, 2013. http://apps.who.int/iris/ bitstream /10665/92455/1/9789241506090_eng.pdf (accessed 9 december 2018). 7. chinta, r, kebritchi m, ellias j. a conceptual framework for evaluating higher education institutions. int j educ manag 2016;30(6):989-1002. https://doi.org/10.1108/ijem-09-2015-0120 8. levin b, schmidt mh, bland js. functional medicine in natural medicine. in pizzorno je, murray mt, editors. textbook of natural medicine. vol 1, 3rd ed. missouri: churchill livingstone elsevier, 2006. 9. world naturopathic federation. wnf education and credentials. ontario: world naturopathic federation, 2018. http://worldnaturopathicfederation.org/wp-content/uploads/ 2019/11/wnf-education_and_credentials_complete. pdf (accessed 30 march 2020). 10. doane gh, brown h. recontextualizing learning in nursing education: taking an ontological turn. j nurs educ 2011:50(1). https://doi.org/10.3928/01484834-20101130-01. 11. baer ha. the socio-political status of u.s. naturopathy at the dawn of the 21st century. med anthropol q 2001;15(3):329-346. http://www.jstor.org/stable/649583. 12. mubuuke ag, businge f, kiguli-malwaddle e. using graduates as key stakeholders to inform training and policy in health professions: the hidden benefit of tracer studies. afr j health professions educ 2014;6(1):52-55. https://doi. org/10.7196/ajhpe302 13. mukinda fk, goliath cd, williams b, zunza m, dudley ld. equipping medical students to address health systems challenges in south africa. afr j health professions educ 2015;7(1 suppl 1):86-91. https://doi.org/10.7196/ajhpe.511 14. bharuthram s, kies c. introducing e-learning in a south african higher education institution: challenges arising from an intervention and possible responses. br j educ technol 2013;44(3):410-420. https://doi.org/10.1111/j.14678535.2012.01307.x 15. blue av, zoller js. promoting interprofessional collaboration through co-curricular environment. health interprof pract 2012;1(2):ep1015. https://doi.org/10. 7772/2159-1253.1015 16. dahle l, brynhildsen j, fallsberg b, rundquist i, hammer m. pros and cons of vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum: examples and experiences from linkoping, sweden. med teach 2002;24(3):280-285. 17. blumberg p, mostrom am, bendl b, kimchuk a, wolbach k. a model for integration of content, concepts and context within separate courses: making explicit the connections among disciplines. problems, resources, and issues in mathematics undergraduate studies 2005;15(1):59-80. https://doi.org/10.1080/10511970508984106 accepted 26 november 2020. http://apps.who.int/medicinedocs/ https://doi.org/10.1089/acm.2010.0830 http://www.worldnaturopathicfederation.org https://doi.org/10.4102/hsag.v23i0.1078 http://apps.who.int/iris/bitstream http://apps.who.int/iris/bitstream https://doi.org/10.1108/ijem-09-2015-0120 http://worldnaturopathicfederation.org/wp-content/uploads/ https://doi.org/10.3928/01484834-20101130-01 http://www.jstor.org/stable/649583 https://doi.org/10.7196/ajhpe302 https://doi.org/10.7196/ajhpe302 https://doi.org/10.7196/ajhpe.511 https://doi.org/10.1111/j.1467-8535.2012.01307.x https://doi.org/10.1111/j.1467-8535.2012.01307.x https://doi.org/10 https://doi.org/10.1080/10511970508984106 ajhpe african journal of health professions education june 2022, vol. 14, no. 2 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of pretoria werner cordier university of pretoria rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university champion nyoni university of the free state anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria ceo dr vusumusi nhlapho executive editor bridget farham head of department: education &publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org head of unit: editorial claudia naidu technical editor kirsten morreira head of unit: production emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 editorial 42 the birth of an association: creating african leaders in health professions education w cordier, a dreyer, l keiller, d manning, c n nyoni, j van wyk, j e wolvaardt forum 44 riding the waves: challenges to medical specialty training during the covid-19 pandemic in south africa a bangalee, v bangalee 47 ethical dilemmas in projectivised multisite research r steyn research 49 relational experiences of community members participating in a rural health initiative with interprofessional students r botha, a joubert, h morgan, m wilmot 55 using log diaries to examine the activities of final year medical students at decentralised training platforms of four south african universities a dreyer, l c rispel 61 how to plan for simulation integration into undergraduate physiotherapy training a van der merwe, r y barnes, m j labuschagne 66 undergraduate medical students’ readiness for online learning at one south african university: implications for decentralised training a m ingratta, s e mabizela, a z george, l green-thompson 72 a journey through interprofessional education: students’ perspectives of teamwork in a transforming curriculum a hendricks, n hartman, l olckers 78 the development of research competence amongst specialist registrars in south africa: challenges and opportunities for research education and capacity development k moxley 83 the lived experience of health science students’ participation in an inter-professional community-based stroke class m kloppers, f bardien, a titus, j bester, g inglis-jassiem 89 postgraduate students' experiences with learning management systems at a selected nursing education institution in kwazulu-natal n g mtshali, a harerimana, v n mdunge, s z mthembu cpd questionnaire article 19 june 2011, vol. 3, no. 1 ajhpe introduction there has been increasing recognition of the importance of quantitative literacy (ql) in higher education curricula.1-3 ql, also known as numeracy, differs from mathematics in that ql is a practice that is embedded in a specific context, and in which data analysis and interpretation play a prominent role.2,4,5 many academic disciplines, such as those in the health sciences, make complex demands in terms of ql for which traditional mathematics courses do not adequately prepare most students.6 for example, although the study of statistics is important for medicine,7 it does not usually form part of a student’s prior mathematical experience. in countries like south africa, where broadened access is a priority and students begin their study of medicine immediately after leaving secondary school, there is a need for curriculum changes that reduce the ‘articulation gap’8 which exists in many cases between the ql demands of curricula and the students’ ql competencies. curriculum changes that reduce this articulation gap are important for promoting success in tertiary study for students with disadvantaged educational backgrounds. the literacy demands of many curricula are, however, often implicit. in studying a programme such as medicine, students are expected to be (or become) competent quantitatively literate practitioners within many disciplines. ql can be seen as a set of practices imbedded in the contexts of the various disciplines that students are ‘apprenticed’ to.9 university lecturers, who are competent practitioners in their own disciplines, including its quantitative aspects, may not recognise explicitly the quantitative demands of the discipline or their assumptions about students’ ql competencies, both of which can act as barriers to learning. definition of ql ql is the ability to manage situations or solve problems in practice, and involves responding to quantitative (mathematical and statistical) information that may be presented verbally, graphically, in tabular or symbolic form; it requires the activation of a range of enabling knowledge, behaviours and processes and it can be observed when it is expressed in the form of a communication, in written, oral or visual mode.2 ql (numeracy), like other literacies, is construed as social practice.10 however, to engage with situations requiring the practice of ql one must also draw on the practices of the disciplines of mathematics and statistics themselves. the level of the mathematical or statistical knowledge and competence required obviously depends on the context; so for example a quantitatively literate public health specialist would need a high level of competence in statistical reasoning whereas a quantitatively literate histologist would need significant spatial visualisation ability. in this paper we will present our analysis of the ql competencies demanded by the textual materials in a first-year integrated human biology/epidemiology/biochemistry course at the university of cape town (uct). this course is based on a supported problem-based learning (pbl) curriculum, using paper ‘cases’ which integrate material from several disciplines, such as medical biochemistry, anatomy, histology, physio logy and public health. supporting activities include lectures, tutorials, practical activities, dedicated-reading resource packs, critical reasoning activities as well as a ql intervention. the ql intervention includes exercises designed to assist all students in acquiring the ql competencies required to solve the problems presented in each of the disciplines in the pbl paper cases. students who need additional support are identified by testing and receive assistance by means of ql tutorials. initially, the ql abstract setting. when designing a medical curriculum, assumptions that are made about students’ quantitative literacy (ql) competencies often lead to demands that students are unable to meet. in order to improve the match between the literacy demands of the curriculum and the literacy competencies of students, the demands need to be examined critically and the assumptions made explicit. curriculum changes that reduce the articulation gap between demands and competencies are particularly important for broadening access and promoting success, in tertiary study, for students with disadvantaged educational backgrounds. objectives. the objectives of this study are to survey the ql implicitly and explicitly contained in a course curriculum, in a manner that could be useful for the following purposes: • raising awareness in health science lecturers of the nature and extent of the ql demands of their course materials • developing the theory relating to best practice for ql development in health sciences • informing the design of ql interventions. method. we focus on the analysis of the ql competencies required of a student engaging with text-based learning materials in the curriculum of a first-year integrated human biology/epidemiology/biochemistry course. for the analysis we use a framework, which classifies quantitative material according to a mathematical and statistical dimension and a competencies dimension. results and conclusions. a range of examples is presented which illustrate that the implicit ql demands of this first-year course curriculum are substantial and varied. towards understanding the quantitative literacy demands of a firstyear medical curriculum vera frith1, geney gunston2 1centre for higher education development, university of cape town 2geney gunston, department of human biology, university of cape town correspondence to: vera frith (vera.frith@uct.ac.za) article 20 june 2011, vol. 3, no. 1 ajhpe intervention focussed on the explicit demands of the discipline of public health. however, as students continued to struggle, it became apparent that it was necessary to examine the curriculum to identify the ql demands of all the relevant disciplines. the supported pbl curriculum of the mb chb programme at uct is an example of a secondary academic ‘discourse’11 that the students are expected to master. in fact the mb chb programme comprises multiple discourses as it includes several academic disciplines and the pbl pedagogy. gee11 contends that mastery of a secondary discourse requires exposure to activities in functional settings and teaching which breaks material down analytically into its component parts, to clarify the practices of the discourse to students. northedge12 describes the role of the teacher as subject expert designing activities that will coach students in mastering the unfamiliar practices of the academic discourse. this view of the purpose of learning activities underpins the design of the ql exercises and tutorials. we seek to better understand the ql challenges experienced by the students in the secondary discourse of the mb chb curriculum, so as to design ways to facilitate mastery of the ql practices of the medical disciplines involved. objectives the objectives of this study are to survey the ql implicitly and explicitly contained in the course curriculum, in a manner that could be useful for the following purposes: • raising awareness in health science lecturers of the nature and extent of the ql demands of their course materials • developing the theory relating to best practice for ql development in health sciences • informing the design of ql interventions. the understanding of textual materials does not require the full range of ql competencies demanded by the curriculum, which also includes more active tasks, such as practical activities, which students complete both individually and collaboratively. the textual materials do however indicate the minimum ql requirements of the course and provide an accessible sample of the quantitative competencies assumed by the curriculum. method the framework used to analyse the ql demands of the curriculum13 consists of two dimensions. the first (mathematical and statistical dimension) classifies the mathematical and statistical ‘big ideas’ that are involved, while the second (quantitative competencies dimension) describes the range of enabling knowledge, behaviours and processes required. the categories within each of these dimensions are elaborated in tables i and ii.13 since the data in this study consist of text-based learning resources, the first three categories in table ii, dealing with the competencies necessary for making meaning from representations, will mostly be used. the last three categories describe competencies that are more likely to be exercised in tasks such as tutorial discussions, practical exercises and written assignments. the framework is however provided for completeness. in order to develop an understanding of the quantitative demands of the course, all the printed materials made available to students as well as those posted on the intranet (including powerpoint slideshows of lectures) were examined. these materials can be loosely categorised under the subject headings: medical biochemistry, human biology and public health. human biology includes anatomy, physiology and histology. selected illustrative examples of textual materials will be presented. these will be primarily classified according to the mathematical and statistical dimension, but a brief analysis according to the quantitative competencies dimension will also be included for each example presented. results the results of the analysis of the ql competencies required to successfully engage with the text-based learning materials in this first-year course will be presented by discipline. medical biochemistry in order to make sense of the biochemistry materials provided, students need to have a good understanding of numbers, ratios, the relationships between variables and the terminology used to describe quantitative ideas, units of measurement, shapes and structures. extensive demands are made on students’ ability to visualise structures in three dimensions and to interpret two-dimensional diagrams representing three-dimensional structures. a well-developed sense of the relative sizes of molecular and cellular structures described or illustrated in the texts is expected. illustrations may combine structures that vary in size by orders of magnitude. the example in fig. 1 shows a series of diagrams from the table i. framework for analysing mathematical and statistical dimension quantity, number and operations for example: • measurement and units of measurement • different types of number and their representations • orders of magnitude • calculation and use of calculators relationships for example: • symbolic and graphical representations of mathematical relationships • algebra change and rate of change for example: • absolute and relative descriptions of change, e.g. percentage change • rates expressed as ratios and as gradient of graphs shape, dimension and space for example: • geometry of shapes • scale factors in diagrams and micrographs • representations of 3d structures in 2d data representation and analysis for example: • graphical and tabular representations of data • descriptive and inferential statistics chance and uncertainty for example: • theoretical and experimental probability • measures of risk article 21 june 2011, vol. 3, no. 1 ajhpe prescribed textbook, representing the structure of protein. the following caption accompanies the figure: ‘(a) the primary structure is composed of a linear sequence of amino acid residues of proteins. (b) the secondary structure indicates the local spatial arrangement of polypeptide backbone yielding an extended α-helical or β-pleated sheet structure as depicted by the ribbon. (c) the tertiary structure illustrates the three-dimensional conformation of a subunit of the protein; while the quaternary structure (d) indicates the assembly of multiple polypeptide chains into an intact, tetrameric protein.’14 in order to make sense of the representation in fig. 1, students must recognise and understand that it consists of several different kinds of representation, ranging from a symbolic depiction of a molecule to a semi-representational picture of the 3d structure of the ‘intact tetrameric protein’.14 they also need to understand the implicit changes in scale between the diagrams as well as the meanings of the quantitative terms used in the text. at the same time, students need to navigate the connections between the text in the caption and the diagrams provided. the relevant elements required from the ‘quantitative competencies’ dimension of the framework are: • knowing the conventions for the representation of quantitative information in … diagrams … (visual representations) • identifying connections and distinction between different representations of quantitative concepts • understanding a verbal description of a quantitative concept/situation/process • deriving meaning from diagrammatic representations of spatial entities. use of complex graphical representations of the relationships between variables, as shown in fig. 2,14 the oxygen uptake curves for haemoglobin and myoglobin, makes significant demands on students’ ability to interpret graphical representations and understand the subtleties of thinking about rates of change. to use the diagram in fig. 2 to enhance their understanding of the function of haemoglobin, students must appreciate that this is an idealised curve in which each point on the curve theoretically represents a specific state of oxygen partial pressure and consequent oxygen saturation. it is not a curve that can be interpreted by thinking about what happens over time as the blood moves from one part of the body to another (which is the kind of interpretation most students are familiar with for example from introductory physics courses). most importantly, students must reason about rates of change and understand how the shapes of the curves represent changes in rate of change of oxygen saturation (with respect to table ii. framework for analysing quantitative competencies dimension knowing • knowing the meanings of quantitative terms and phrases (verbal representations) • knowing the conventions for the symbolic representation of numbers, measurements, variables and operations • knowing the conventions for the representation of quantitative information in tables, charts, graphs, diagrams and objects (visual representations) identifying and distinguishing • identifying connections and distinction between different representations of quantitative concepts • identifying the mathematics to be done and strategies to do it • identifying relevant and irrelevant information in representations deriving meaning • understanding a verbal description of a quantitative concept/situation/process • deriving meaning from representations of data in context • deriving meaning from graphical representations of relationships • deriving meaning from diagrammatic representations of spatial entities • translating between different representations applying mathematical techniques • using mathematical techniques to solve a problem or clarify understanding for example: calculating, estimating, measuring, ordering, modelling, applying algebraic techniques etc. higher order thinking • synthesising information or ideas from more than one source • logical reasoning • conjecturing • interpreting, reflecting and evaluating expressing quantitative concepts • representing quantitative information using appropriate conventions and language • describing quantitative ideas and relationships using appropriate language fig. 1. example of a two-dimensional representation of idealised threedimensional structures. powerpoint slide from a lecture on levels of protein structure. the diagram is reproduced from the biochemistry textbook.14 article 22 june 2011, vol. 3, no. 1 ajhpe pressure) and to interpret these changes in terms of the physical context. the relevant elements from the ‘quantitative competencies’ dimension of the framework are: • knowing the conventions for the representation of quantitative information in … graphs … (visual representations) • deriving meaning from graphical representations of relationships • interpreting, reflecting and evaluating. human biology: anatomy and histology to understand anatomical descriptions and diagrams, students must have a sense of the relative sizes of objects described and the ability to interpret representations at a range of different scales of magnification, which are not always explicitly specified. diagrams provided are two-dimensional representations of three-dimensional parts of the body, requiring an understanding of the point of view (front, back, from below, etc.), the conventions of using cut-away drawings and cross-sections and the mental ability to situate objects within a three-dimensional frame of reference, using the technical language of anatomy. human biology: physiology the material covered in the physiology textbook and in lectures requires the application of numerical insights in the interpretations of a range of (physical and chemical) contexts, for example, the quantification of pressure or the measurement of acidity using a logarithmic scale. understanding the disciplinary content often requires students to integrate their knowledge of algebra and geometry and to interpret the mathematics in context. furthermore, the materials place fairly high demands on students in terms of the ability to visualise three-dimensional objects. some diagrams also include a mixture of realistic representation and ‘simplifying’ distortions of the actual shapes and relative sizes of physical objects, which must be distinguished by the students in order to interpret them correctly. to understand such descriptions and diagrams, students must have a sense of the relative sizes of objects described and the ability to interpret representations at a range of different scales of magnification. in some cases diagrams are layered inscriptions that have two levels of abstraction within one representation and which require special interpretation skills.15 an example is where a representation of physical entities (such as cells or tissues) is combined with symbolic representations of conceptual entities (such as chemical symbols representing reactions taking place). this kind of representation is also common in biochemistry texts. the physiology materials make use of a very wide variety of diagrammatic and graphical representations, some of which are presentations of information derived from data, such as bar charts, pie charts, and scatter plots (see fig. 3). in some of these cases the representations are quite complex, requiring fairly high levels of interpretation ability. for the example in fig. 3 to contribute to students’ understanding, amongst other things they must be able to understand what it means to say that one variable ‘predicts’ the values of another variable and recognise how this kind of representation can be used to support this kind of statement. they need to appreciate that each plotted point represents a pair of measurements of two variables associated with one individual. they must have a sense of the notion of error in measured data and understand the basis for the concept of a best-fit line and why it is useful. they need also to know what the correlation coefficient is and what one can conclude from its given value (‘r = 0.85’). the relevant elements from the ‘quantitative competencies’ dimension of the framework are: • knowing the meanings of quantitative terms and phrases (verbal representations) • knowing the conventions for the symbolic representation of numbers, measurements, variables and operations • knowing the conventions for the representation of quantitative information in … charts ... (visual representations) • deriving meaning from representations of data in context • interpreting, reflecting and evaluating. public health quantitative concepts and techniques are fundamental to the discipline of epidemiology, and the demands made on students’ ql in this component of the course are extensive. the measures used in epidemiology, such as incidence and prevalence and other indices, like birth rates, require fig. 3. example of the results of analysis of data from a powerpoint slide used in a lecture on obesity and energy balance. fig. 2. example of a graphical representation of a relationship governing a chemical process from a powerpoint slide from a lecture on protein function. the diagram is reproduced from the biochemistry textbook.14 article 23 june 2011, vol. 3, no. 1 ajhpe sophisticated proportional reasoning and a fluent use of numerical techniques related to proportions and ratios. understanding the concepts in the textbook and other readings also requires critical interpretation of a wide range of data representations and a basic understanding of statistical analysis. a very common way of presenting data is in the form of tables. these apparently simple representations can be very dense and difficult to interpret, particularly if they contain mixtures of absolute quantities and relative measures, such as percentages. to extract useful information from even a simple table, students need to be able to ask questions like ‘what comparisons does the structure of the table facilitate?’, ‘what was used as the denominator in calculating percentages?’ and ‘what trends is the table intended to display?’ conclusion this analysis provides an overview of the ql demands of the textual learning materials for an integrated human biology/epidemiology/biochemistry course in the first year of the mb chb programme at uct. the ql demands of the curriculum were found to be extensive and varied. examination of the course materials revealed that the ways in which the disciplines are presented in texts assumes a well-developed ability to interpret graphical representations of processes and of data. this is the feature that is probably the most demanding in terms of quantitative reasoning and competence. anatomy, physiology and histology make extensive use of diagrams to demonstrate structures in three dimensions. a clear understanding of and familiarity with the concepts of scale and magnification is thus essential in these disciplines. medical biochemistry and physiology, in particular, require the ability to interpret a variety of different complex visual representations. the degree of algebraic or computational ability required in this course is moderate, but proportional reasoning is fundamental to understanding, especially in the discipline of public health. this discipline also requires reasoning about probabilities and familiarity with data representations and statistical analysis. the analysis was performed with the aims of raising awareness in health science lecturers of the nature and extent of the ql demands of their course materials and informing the design of ql interventions to reduce the gap between the demands of curricula and students’ ql competencies. although studying mathematics at school must contribute towards a student’s ql competency, it is a fallacy to assume that even a successful mathematics student will necessarily be sufficiently quantitatively literate in a context of a programme such as medicine. other subjects, such as physical science, biology or geography may contribute towards a student’s ql, but many students will not have been exposed to data analysis and statistics in anything but a superficial way. understanding the ql challenges experienced by students and designing interventions to facilitate mastery of the ql practices of the medical disciplines are important for promoting success in tertiary study, especially for students with disadvantaged educational backgrounds. acknowledgements we are grateful to our colleagues in the department of human biology and division of medical biochemistry for allowing access to their teaching materials and the use of examples from their lectures for this paper. we also thank dr rachel alexander for help with preparing this paper. declaration of interest we declare that there are no relationships relevant to this paper that could be viewed as presenting a potential conflict of interest. references 1. chapman a. academic numeracy: developing a framework. literacy and numeracy studies 1998;8(1):99-121. 2. frith v, prince r. quantitative literacy. in: griesel h, editor. access and entry level benchmarks, the national benchmark tests project. pretoria: higher education south africa, 2006:28-34,47-54. 3. steen la. achieving quantitative literacy: an urgent challenge for higher education. washington dc: the mathematical association of america, 2004. 4. hughes hallett d. achieving numeracy: the challenge of implementation. in: steen la, editor. mathematics and democracy, the case for quantitative literacy. usa: the national council on education and the disciplines, 2001:93-98. 5. kelly s, johnston b, baynham m. the concept of numeracy as social practice. in: kelly s, johnston b, yasukawa k, editors. the adult numeracy handbook: reframing adult numeracy in australia. broadway, nsw: adult literacy and numeracy australian research consortium, 2003:35-49. 6. hughes hallett d. the role of mathematics courses in the development of quantitative literacy. in: madison bl, steen la, editors. quantitative literacy: why numeracy matters for schools and colleges. princeton: national council on education and disciplines, 2003:91-98. 7. emanuel ej. changing premed requirements and the medical curriculum. journal of the american medical association 2006;296(9):1128-1131. 8. scott i, yeld n, hendry j. higher education monitor no. 6: a case for improving teaching and learning in south african higher education. pretoria: the council on higher education, 2007. 9. lave j. the culture of acquisition and the practice of understanding. in: kirshner d, whitson ja, editors. situated cognition: social, semiotic and psychological perspectives. mahwah, nj: erlbaum, 1997:17-35. 10. street b. applying new literacy studies to numeracy as social practice. in: rogers a, editor. urban literacy: communication, identity and learning in development contexts. hamburg: unesco institute for education, 2005:87-96. 11. gee, j. social linguistics and literacies: ideology in discourses. 2nd ed. london: routledge/falmer, 1996. 12. northedge a. enabling participation in academic discourse. teaching in higher education 2003;8(2):169-180. 13. frith v, prince r. a framework for understanding the quantitative literacy demands of higher education. south african journal of higher education 2009;23(1):83-97. 14. baynes jw, dominiczak mh. medical biochemistry. philadelphia: elsevier mosby, 2005:18,36. 15. roth wm, pozzer-ardenghi l, han jy. critical graphicacy. dordrecht: springer, 2005. article may 2013, vol. 5, no. 1 ajhpe 30 participatory action research: the key to successful implementation of innovations in health professions education a g mubuuke,1 bsc, mphil (hpe); b leibowitz,2 med, phd 1 college of health science, makerere university, kampala, uganda 2 centre for teaching and learning, stellenbosch university, stellenbosch, south africa corresponding author: a g mubuuke (gmubuuke@gmail.com) background. health professions training is undergoing major innovative changes aimed at improving the quality of health professionals. unfortunately many of these innovative changes in training have met resistance from lecturers and students simply because they are just imposed on them. one way of ensuring acceptability and success of innovative and evidence-based training methods in health sciences could be the use of participatory action research approaches. objectives. to explore the experiences of students and lecturers as well as identify potential benefits regarding the use of a participatory action research approach in a real learning context. methods. this was an action research study using a participatory approach. research findings. participants reported satisfaction with the action research process and said it was a valuable learning experience. key benefits of participatory action research identified included: empowering and actively engaging participants, combination of scholarly work, learning and immediate action, promotion of collaborative inquiry and team-work in initiating changes in training. conclusion. participatory action research has the potential to result in acceptable and sustainable educational innovations because it involves the active involvement of all stakeholders affected by these interventions. ajhpe 2013;5(1):30-33. doi:10.7196/ajhpe.208 health professions education has undergone major transformations and innovations. such innovations are in areas like curriculum reforms, faculty development, new methods of student selection, advances in technology and new methods of training.[1] many of these reforms have been informed by educational research from lecturers in training institutions.[1] however, innovations have sometimes been resisted by both lecturers and students, even when they have been guided by evidence-based educational research.[2] this is partly due to the fact that such reforms are often imposed on lecturers and students to implement.[2] a key issue fuelling resistance to change by lecturers and students is the lack of active participation and engagement in these reforms.[3] one way of addressing this challenge could be to use participatory action research (par) methods to make many of the innovations acceptable to all stakeholders. in this paper we discuss the potential of par in health sciences training. this was part of a larger study conducted on feedback in which par was used. reason and bradbury[4] defined par as a form of research that focuses on the effects of a researcher`s actions on routine practice within a particular context. the goal of such research is to engage people and improve performance in a chosen area of concern.[4] these key ingredients of par have also been alluded to by chatterton et al.,[5] as well as by other authors in reported literature.[6-8] cahill[9] cautions that: ‘the challenge for par researchers who are serious about social change is to think through how to effectively provoke action by research that engages, that reframes social issues theoretically, that nudges those in power, that feeds organizing campaigns, and that motivates audiences to change both the way they think and how they act in the world.’ active participation by all members therefore remains the focal point in the research process. action in par signifies that the research process is geared towards generating activities that lead to change within a context. it is such activities that eventually address the identified need in the community.[8] par is an interpretive approach concerned with subjective interpretations of reality lived by individuals. this type of research surpasses mere publications in journals, but has social implications that affect the real lives of people engaged in it and creates strong relationships between researchers and participants. chatterton et al.[5] therefore pointed out key elements of par as: • it focuses on bringing change, actively engaging all people within a community to work towards this change. • it is unique to a particular context as it revolves around unique needs within a particular group of people. • it emphasises teamwork and active collaboration, where researchers and participants work together to analyse a problem situation and generate actions to solve the problem. • it is an iterative process involving actions and constant reflection during the process. • it creates awareness among participants about their current situation and the need to take action to create change. despite the potential advantages of par in sustaining innovations in health professions education, many educators in the health field have given it little attention. the purpose of this study was to explore the potential of par in successfully implementing the use of a structured feedback form for students` assignments in a resource-constrained health sciences institution. this was part of a larger study that investigated the use of qualitative formative feedback in teaching and learning. however, in this paper the authors focus on the par approach in the process. articlearticle 31 may 2013, vol. 5, no. 1 ajhpe methods research design the study was qualitative par done at makerere university college of health sciences (makchs). study participants the study included all second-year undergraduate medical radiography students and their teachers at makchs. there were 18 students in total and 9 teachers, i.e. a total of 27 participants. data collection methods initially, focus group discussions were conducted with second-year medical radiography students and teachers. there were four focus groups, one with teachers and three with students. each student group had six participants. interview questions for the focus groups explored participants` experiences of feedback. the responses were audio-recorded and then transcribed. after analysis of the interview data, two meetings were held with the participants to design a written feedback form; one meeting was held with the teachers and the other meeting with students. in the meeting with teachers, a structured feedback form for student written assignments was designed. the form was then discussed with the students in the second meeting to get their input as well. the structured feedback form was then implemented. students were given one assignment every 2 weeks for 8 weeks. teachers provided written feedback on the assignments using the form. the written feedback was given to each of the students 3 days before the next assignment to enable them to act on the feedback received. at the end of the 8 weeks, a second round of focus group discussions was conducted to explore the experiences of participants regarding the feedback process. data analysis thematic analysis was used. analysis commenced even as data collection proceeded. as data collection and analysis progressed, codes were developed, refined and revised in an iterative process. ongoing data collection, comparisons of codes within and between interviews confirmed and clarified the codes. clustering and partitioning of codes led to the emergence of categories that were also iteratively refined, revised and related to each other. established categories of data were classified into themes. quality assurance the focus group discussions were conducted in a quiet place and questions used were first pre-tested. all responses were audio-recorded verbatim and each group would listen to the recorded interview before leaving to make clarifications. data were securely kept and participants were often consulted during analysis to validate the emerging themes. participants read through the draft reports written out of this study and agreed that their experiences were represented. ethical issues participants provided written consent. responses were kept confidential from the rest of the public. nobody was identified by name. permission to carry out this study was jointly granted by the review boards of the faculty of health sciences, stellenbosch university, and the college of health sciences, makerere university. research findings the findings focused on the par process. two major themes emerged from analysis of data: (i) experiences of par; and (ii) potential benefits of par. in both themes, the idea of collaboration and stakeholder empowerment in health professions education innovations was evident. experiences of par approach it was evident that prior to this study none of the participants had any previous experiences in par. both teachers and students reported that they had never been told about par before, and it was a whole new experience to them. the participants however admitted that actively participating in such a research process had a great impact on them. the following key comments illustrate their experiences: 'this is a whole new experience for me. i have never been engaged in such a research process where i am a study participant at the same time almost working as a researcher. it has been a learning point for me and has introduced me to a new method of giving research a humanistic touch,' one lecturer said. another lecturer commented: ‘the way we have been actively involved to come up with a feedback form is quite interesting. sometimes innovations fail simply because the primary users are never involved. if the form had been just imposed on us, i doubt if it would have been accepted. at some point it even felt like it is not a research process. i have learnt a lot from this exercise.' this was a whole new experience for the students as well. the following statement summarises the common expressions students gave: ‘we thought we were not doing research initially as all activities involved seemed to fit in well in our learning schedules. in fact we thought it was another teaching method being introduced. personally as a student, i had never seen any of my teachers giving me a research report to give him comments. i am proud to have been part of this.’ the above observations are significant, though not surprising. teachers and students in health sciences view research from a positivist paradigm and are novices to the more interpretive and constructivist par approach, which explains the whole new experience observed. potential benefits of par participants generally reported that the whole research process was beneficial to them and probably to the institution. the perceived benefits accruing from par were further explored. key among these were that par results in both knowledge generation and immediate action, gives stakeholders authority to direct the research process, addresses real contextual needs, promotes team work and collaboration. these were evident in some of the responses from participants: 'i have learnt that if all of us get involved in formulating new policies in this institution, life would be much easier for us’, one lecturer said. another lecturer reported: ‘this kind of process promotes team work and collaborative inquiry in our work. in the end, we come up with a product that we have all contributed to and this is likely to be more acceptable article may 2013, vol. 5, no. 1 ajhpe 32 because all fears are settled during the process. i wish our leaders in this institution could employ such participatory approaches.' students’ comments equally pointed out the benefits of the whole process. ‘this process has empowered and engaged me to positively contribute to how i learn. now i feel valued in the whole teaching and learning process by my lecturers`, one student said. another student said, ‘… teamwork and empowerment have come up as strong factors in this process. this is what today’s health professionals need to solve challenges in communities. we all need to work together and contribute ideas towards a common desired goal.’ analysing the responses from both themes, it can be observed that the participatory approach created a sense of collaborative teamwork among lecturers and their students. at the same time it can be deduced that the process empowered participants to actively take part in activities that directly impact on them on a day-to-day basis. discussion the major purpose of this study was to explore participants' experiences of par and potential benefits of the whole process. analysis of data revealed that it was a rewarding experience to all participants. the greatest advantage of par appears to be the active involvement, collaboration, engagement and empowerment of stakeholders in the process of initiating changes in health professions training.[10,11] in many situations, changes are just imposed on teachers and students in the hope that they will implement them, ignoring their inputs. this study has shown that actively engaging and empowering lecturers and students in educational innovations and changes is likely to yield not only acceptance, but also sustainability. cameron[12] alluded to this observation. actively engaging all stakeholders in educational innovations is also one way of fostering teamwork and collaboration in health professions institutions. additionally, par is likely to promote a culture of collaborative inquiry, teamwork, continued learning and ownership of actions within a community. in this study, both teachers and students worked together as a team to design the feedback form. it is most likely that this teamwork approach contributed to the ownership of the intervention introduced. additionally, most participants also viewed it as a learning process. this therefore makes par a form of educational process where participants combine doing research, leading to scholarly work as well as learning in a real contextual work environment.[13] it also empowers participants to gain skills of taking control of their teaching and learning needs within their context; these skills can then be applied as more needs arise. the idea of teachers involving students in such research processes also provides an opportunity for students to contribute to changes and innovations that influence and affect their learning. with the current advocacy of training change agents in health professions,[1] par is one way of achieving this as both teachers and students work together to implement new ideas in their work environments. despite the fact that par was a rewarding and satisfying experience to all participants, it seemed all new to them. this is probably because par was a new paradigm to many lecturers and students in this institution. such a research process involves continued active participation and engagement of all stakeholders likely to be affected by the research outcomes.[6] this approach has not been common in this institution. perhaps this explains why some participants even felt they were not doing research. however, it was exciting to note that many drew longlasting lessons from the exercise. the implication of this is that such lecturers and students can then transfer the knowledge and skills obtained to other situations within their contextual environments in which they can use a similar approach to initiate changes in a collaborative and engaging manner. although par is likely to sustain innovative changes in health professions training, it has received little attention in health sciences institutions. why is this so? the answer is not straightforward, but largely lies in lack of skills and exposure of faculty members to this type of research. one way of mitigating this is through faculty development programmes that emphasise the role of educational research in general and par in particular within health sciences training. this study has highlighted some key benefits of engaging in such a process. the major contribution of this study is that an educational intervention (the structured feedback form) was successfully implemented and accepted by both lecturers and students within the context of a resource-limited setting using a participatory and teamwork approach. however, the authors are cognizant of the fact that the positive observations noted could have been partly influenced by other factors and not solely attributed to the researchers’ intervention or process involved. despite all this, the study still identifies key attributes of par that are likely to influence the successful implementation and sustainability of innovations in health professions education, especially in resource-limited settings. more studies using the same approach in other settings are however still needed to supplement the observations identified in this study. additionally, more studies are needed to compare acceptability of educational innovations using par and traditional conventional research paradigms, such that a comparative discourse is presented. the major limitation of this study was the small numbers of participants and potential bias arising from non-probability sampling. nonetheless, this study could be a basis for using par in other contexts. conclusion this study has revealed that par has the potential to empower, involve and actively engage all stakeholders in significant innovations in health professions training. when people actively participate and contribute to such innovations, they are more likely to be accepted and implemented as originally intended, especially in resource-constrained settings. acknowledgement. the foundation for advancement of international medical education and research (faimer) supported the larger study, of which this substudy was part. references 1. ngassapa od, kaaya ee, fyfe mv, et al. curricular transformation of health professions education in tanzania: the process at muhimbili university of health and allied sciences (2008-2011). journal of public health policy 2012;33:s64-s91. [http://dx.doi.org/10.1057/jphp.2012.43] 2. fullan m. change in higher education: understanding and responding to individual and organizational resistance. jvme 2007;34(2):85-92. [http://dx.doi.org/ 10.3138/jvme.34.2.85] 3. hillis dj. managing the complexity of change in postgraduate surgical education and training. anz j surg 2009;79(3):208-213. [http://dx.doi.org/ 10.1111/j.1445-2197.2008.04840] 4. reason p, bradbury h. handbook of action research: participative inquiry and practice. london: sage, 2001. 5. chatterton p, fuller d, routledge p. relating action to activism: theoretical and methodological reflections. in: kindon s, pain r, kesby m, eds. participatory action research approaches and methods: article 33 may 2013, vol. 5, no. 1 ajhpe connecting people, participation and place. routledge studies in human geography. london: routledge, 2007. 6. greenwood dj, whyte wf, harkavy i. participatory action research as a process and as a goal. human relations 1993;46(2):175-192. [http://dx.doi.org/10.1177/001872679304600203] 7. mcintyre a. participatory action research. los angeles: sage publications, 2008. 8. tolman dl, brydon-miller m. from subjects to subjectivities: a handbook of interpretive and participatory methods. qualitative studies in psychology. new york: new york university press, 2001. 9. cahill c. participatory data analysis. in: kindon s, pain r, kesby m, eds. participatory action research approaches and methods: connecting people, participation and place. routledge studies in human geography. london: routledge, 2007. 10. kindon sl, pain r, kesby m. participatory action research approaches and methods: connecting people, participation and place. routledge studies in human geography. london: routledge, 2007. 11. street ct, meister db. small business growth and internal transparency: the role of information systems. mis quarterly 2004;28:473-506. 12. cameron j. linking participatory research to action. in: kindon s, pain r, kesby m, eds. participatory action research approaches and methods: connecting people, participation and place. routledge studies in human geography. london: routledge, 2007. 13. campbell j. a critical appraisal of participatory methods in development research. international journal of social research methodology 2002;5(1):19-29. [http://dx.doi.org/ 10.1080/13645570110098046] 176 september 2021, vol. 13, no. 3 ajhpe short report why was the idea necessary? thirty-four registered nurses enrolled for the postgraduate emergency nursing programme at the department of nursing science at a university in south africa (sa), starting in february 2020. the programme consists of a theoretical and a practical component. typically, learning and teaching occur through face-to-face contact for four hours per week in the classroom, and work-integrated learning (wil) comprises 32 hours per week. the lecturer and clinical facilitators accompany students in an emergency department for at least three hours per week for ~28 academic weeks. students have specific clinical learning outcomes to master during the wil. on 15 march 2020, the sa government declared a national state of emergency in respect of the covid-19 pandemic. tertiary education activities came to a halt and face-to-face contact was replaced with online activities – a new challenge for both students and lecturer. in addition to the university’s formal online teaching and learning system, announcements were communicated through email and padlet, an informal online platform. however, this individualised communication between students and lecturer was slow, and many students asked similar questions. students were often unable to access the formal and informal teaching and learning systems, as they were in clinical practice dealing with the covid-19 pandemic, wearing their ‘space suits’ (personal protective equipment), causing student and lecturer frustration. like other healthcare professionals working ‘at the coalface’, students indicated that they felt isolated and disengaged,[1] and considered discontinuing the programme. whatsapp was regarded as a potential supportive strategy because it promotes quick and easy communication, expands social networking,[2] is related to positive learning outcomes,[3] and encourages student interaction.[4] the present short report aims to describe the use of whatsapp as a support strategy for emergency nursing students during the covid-19 pandemic. what was tried (the intervention) as all students had smartphones and used whatsapp to communicate, the lecturer started a whatsapp group, including all emergency nursing students, the clinical facilitators involved in the various hospitals (private and public), and the lecturer. the platform would allow the lecturer and clinical facilitators to maintain connection with students, increasing the students’ access to support and information. whatsapp facilitated, for example, the sharing of academic, logistical arrangements, and circulating interesting cases and new developments in clinical practice. communication on the group’s whatsapp from 1 march to 31 december 2020 was exported in portable document format (pdf). using thematic analysis, all authors individually analysed the data manually and agreed on themes. the three themes that emerged were system, academic and emotional support. the ufs faculty of health research committee approved the research proposal (ref. no. 842/2020) and all emergency nursing students and clinical facilitators signed informed consent. whatsapp provided a space for immediate support during deployment, as well as academic and emotional support. table  1 shows some messages from whatsapp communications that support the three themes identified. the lessons learnt the lessons learnt are discussed in terms of the three themes identified below. system support through whatsapp communication, the lecturer became aware that emergency nursing students’ employers demand full-time service. emergency nursing students rotating through other disciplines (e.g. operating theatre or critical care units) as part of the clinical component were redeployed to the emergency department. contrary to the service managers’ actions, students envisioned continuing and completing the emergency nursing programme and expected to complete the rotation placements. the health services viewed students as employees and frontline workers, demanding more from them, contributing to increased stress and uncertainties. students confronted an instantaneous change in practices and ways of working. the lecturer and clinical facilitators were aware of the tension and could focus on support and interventions to ensure a favourable outcome for employer and student, such as writing letters to hospital management to explain that the programme is continuing online. collaboration with the clinical facilitators was invaluable as they understood the students’ fears and uncertainties and provided direction and support to students on the whatsapp group. the core lessons learnt relating to system support were being aware of students’ stressors and having open communication and collaboration between academic institutions, health services and students. academic support the lecturer strived to provide immediate feedback on academic concerns to relieve some of the students’ immediate distress. the lecturer responded to the pandemic by adapting the curriculum. the emphasis shifted to support students in what they were dealing with in clinical practice, such as ‘happy hypoxaemia’ and associated conditions and treatment modalities of covid-19, instead of focusing on chest injuries as planned. furthermore, learning was no longer restricted to classroom contact time because the learning platform changed to online. suddenly, teaching and learning became a 24-hour service,[5] were directly related to practice, and consequently more authentic. the present study confirms cetinkaya’s[6] views that learning occurs whatsapp as a support strategy for emergency nursing students during the covid‑19 pandemic y botma,1 phd; t heyns,2 phd; c filmalter,2 phd; c nyoni,1 phd 1 school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of nursing science, faculty of health sciences, university of pretoria, south africa corresponding author: y botma (botmay@ufs.ac.za) this open‑access article is distributed under creative commons licence cc‑by‑nc 4.0. mailto:botmay@ufs.ac.za september 2021, vol. 13, no. 3 ajhpe 177 short report unconsciously and that students learn more effectively if an image accompanied the whatsapp message. shared information included, for example, articles, new protocols, and links to youtube videos. additionally, whatsapp was used to stimulate student engagement, e.g. posting chest radiographs or arterial blood gases, and then asking students questions. students were also posting concerns and questions and indicated when they required guidance about theory and practice.[7] whatsapp provided peer-to-peer as well as student-lecturer-clinical facilitator support.[8] the unrestricted open communication platform promoted student-generated learning opportunities in real time, e.g. re-structure patients’ movement through the emergency department, and intubate and mechanically ventilate a patient diagnosed with covid-19. through whatsapp, lecturers, clinical facilitators and peers could facilitate theory-practice integration. students negotiated deadlines for assignments, as shown in table  1, with leniency from the lecturer, who understood the students’ context and struggles as ‘coalface’ workers. it is the lecturer’s responsibility to maintain a balance between the effects of the pandemic on students and the expected outcomes of the programme. therefore, continuous critical reflection is required to know when to expect more from the students and when to give them some space. it is important to look at the comments made by each student – sometimes, one needs to answer the question for the group or give additional support, e.g. give an online lecture on arterial blood gas analysis. the lecturer should discern when an individual needs specific support. the above text highlights the importance of adaptability and leniency of stakeholders and their ability to encourage theory-practice integration through whatsapp. additionally, student-generated learning opportunities strengthen a student-centred educational approach. emotional support peer support flourished as students experienced the same uncertainties. communication on the platform reminded the lecturer that students are human beings with unique ways of coping with a crisis. some students took control and continued as if the crisis was an everyday occurrence, while others either withdrew, harboured ideas of suicide or used the pandemic as an excuse for not meeting deadlines and requirements of the programme. furthermore, students, clinical facilitators and lecturer continued to build a trusting relationship through whatsapp. like the respondents in gon and rawekar’s study,[5] students found the increased availability of the lecturer and clinical facilitators supportive. bano et  al.[9] reported that spending time on whatsapp positively influenced students’ psychological wellbeing, as reflected in one of the quotes: ‘thank you for being such a caring, kind, and understanding [lecturer and clinical facilitator] these times. you have gone above and beyond for us and we appreciate you so much! [clinical facilitator] ...thank you for your compassion & support during this time for making yourself available to students…’ the availability of peers, lecturer and clinical facilitators through whatsapp is paramount for emotional support. what will i keep in my practice? the present research supports cetinkaya’s[6] finding that whatsapp’s use as supportive technology should be encouraged, as part of blended learning requires further research. one should acknowledge that whatsapp cannot replace other e-learning platforms such as blackboard but should be used in conjunction with other online platforms. whatsapp was a valuable tool to use in a crisis and may be beneficial for open communication between students and learning facilitators beyond the covid-19 crises. the student group found it easy to share information, maintain contact, give feedback and create and maintain social relationships. the use of whatsapp promoted the transfer of learning as practice-based questions were posed, and students and learning facilitators deliberated possible solutions and referred to information sources. including the clinical facilitators was vital to enhance everyone’s experience, and enabled specific, focused clinical facilitation in practice. what will i not do? communication and support through whatsapp groups were unrestricted, making the lecturer available to students for close to 24 hours in a single day. the unrestricted communication times were uncomfortable for the lecturer, as students would send messages to the group at odd hours. perpetual exposure to student issues in the clinical environment through this unrestricted whatsapp group could contribute to lecturer burn-out. therefore, in the future, whatsapp will only be used as student support – guided by common guidelines known by students and lecturer. declaration. none. author contributions. equal contributions. acknowledgements. none. table 1. examples of excerpts that support the themes theme excerpts deployment lecturer: ‘no class tomorrow.’ student: ‘so then we should arrange to work because we are going to short hours as class days also count as hours.’ clinical facilitator: ‘yes, if no class, then you should work to have enough hours.’ lecturer: ‘please do not go to work, you still have assignments to do so that you don’t fall behind.’ academic support lecturer: ‘morning – myself and x have uploaded two chest x-rays on padlet. you can interpret the chest x-rays, send to me via email. i will then send you the correct answers. you may use the practice session as one of the chest x-rays that you need to do in the vgk 201 practical book. we will sign it for you. just make a note in the book.’ student a: ‘when is “the end of this week” – today or tomorrow? can we still submit tomorrow?’ student b: ‘would also like to know.’ student c: ‘think it’s monday.’ lecturer: ‘monday is 100%.’ a student posted the following link: ‘something interesting on the modes of ventilation https:// www.facebook.com/164130603642941/ posts/2960162874039686/’ emotional support lecturer: ‘i have uploaded interesting information on sustainable wellbeing. have a look if you want to and if you find it valuable or not, please let us know on whatsapp.’ student: ‘exam stress – i am out of my width. am so disconnected i can scream.’ 178 september 2021, vol. 13, no. 3 ajhpe short report funding. none. conflicts of interest. none. evidence of the innovation 1. fernández-castillo r, gozález-caro m-d, fernández-garcía e, et  al. intensive care nurses ’ experiences during the covid-19 pandemic: a qualitative study. nurs crit care 2021;26(5):397-406. https://doi. org/10.1111/nicc.12589 2. goswami s, kobler f, leimeister jm, krcmar h. using online social networking to enhance social connectedness and social support for the elderly. in: international conference on information systems ,12 15 december 2010, saint louis, missouri, usa. 3. raiman l, antbring r, mahmood a. whatsapp messenger as a tool to supplement medical education for medical students on clinical attachment. bmc med educ 2017;17(1):7. https://doi.org/10.1186/s12909-017-0855-x 4. goyal a, tanveer n, sharma p. whatsapp for teaching pathology postgraduates: a pilot study. j pathol inform 2017;8(6). online. https://doi.org/10.4103/2153-3539.201111 5. gon s, rawekar a. effectivity of e-learning through whatsapp as a teaching learning tool. mvp j med sci 2017;4(1):19. https://doi.org/10.18311/mvpjms/0/v0/i0/8454 6. cetinkaya l. the impact of whatsapp use on success in education process. int rev res open distrib learn 2017;18(7):1-8. https://doi.org/10.19173/irrodl.v18i7.3279 7. mesquita ac, zamarioli cm, fulquini fl, de carvalho ec, angerami els. social networks in nursing work processes: an integrative literature review. rev da esc enferm 2017;51(1):1-11. https://doi.org/10.1590/s1980220x2016021603219 8. schepers j, wetzels m. a meta-analysis of the technology acceptance model: investigating subjective norm and moderation effects. inf manag 2007;44(1):90-103. https://doi.org/10.1016/j.im.2006.10.007 9. bano s, cisheng w, khan an, khan na. whatsapp use and student’s psychological well-being: role of social capital and social integration. child youth serv rev 2019;103:200-208. https://doi.org/10.1016/j. childyouth.2019.06.002 accepted 10 may 2021. afr j health professions educ 2021;13(3):176-178. https://doi.org/10.7196/ajhpe.2021.v13i3.1517 https://doi.org/10.1111/nicc.12589 https://doi.org/10.1111/nicc.12589 https://doi.org/10.1186/s12909-017-0855-x https://doi.org/10.4103/2153-3539.201111 https://doi.org/10.18311/mvpjms/0/v0/i0/8454 https://doi.org/10.19173/irrodl.v18i7.3279 https://doi.org/10.1590/s1980-220x2016021603219 https://doi.org/10.1590/s1980-220x2016021603219 https://doi.org/10.1016/j.im.2006.10.007 https://doi.org/10.1016/j.childyouth.2019.06.002 https://doi.org/10.1016/j.childyouth.2019.06.002 https://doi.org/10.7196/ajhpe.2021.v13i3.1517 a maximum of 3 ceus will be awarded per correctly completed test. september 2021, vol. 13, no. 3 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire september 2021 a ray of sun in the covid-19 environment with a virtual sunburst elective 1. in the virtual sunburst elective, which role does the medical curriculum traditionally not focus on? a. leader b. medical expert c. communicator d. collaborator. stimulating students’ critical thinking skills in pharmacology using case report generation 2. in stimulating students’ thinking skills in pharmacology, which constant challenge do students who undertake undergraduate pharmacology experience? a. applying concepts and principles b. learning concepts and principles c. assessing concepts and principles d. evaluating concepts and principles. adapting an undergraduate dental objectively structured clinical examination (osce) during covid-19 3. in adapting an undergraduate dental osce during covid-19, which stakeholder needs to know the osce process? a. educators b. healthcare practitioner c. standardised patients d. students. whatsapp as a support strategy for emergency nursing students during the covid-19 pandemic 4. in using whatsapp as a support strategy for students, what was an identified limitation? a. clinical facilitator fatigue b. lecturer burnout c. transfer of learning d. unrestricted communication. breaking the isolation: online group assignments 5. in online assessments by student groups, what will be the purpose of future assignments? a. autonomy and reflection b. feedback and resilience c. reflection and action d. thinking and doing. innovative mentorship: implementation of an online mentorship programme for south african medical internship and junior doctors in kwazulu-natal 6. in mentoring medical interns and junior doctors, what was not recommended for future practice? a. engaging interns after hours b. involving senior faculty c. overloading the programme d. recording sessions for absent interns. how a global pandemic fuelled an all-time career high 7. in how the pandemic fuelled an all-time career high, which one of the simulated patients was the student’s favourite? a. covidinska mullet b. covidshire zoya c. genaecovid lock d. zoya lochdowniokov. synchronous online pharmacy skills group work – a breakout room toolbox for teaching 8. in the toolbox for breakout rooms, what was the purpose of case-based learning? please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. cpd questionnaire september 2021, vol. 13, no. 3 ajhpe a. connecting theory and practice b. enhancing transfer of learning c. integrating blended learning d. limiting social isolation. an innovative, remote supported problem-based learning (spbl) model in a south african medical curriculum during covid-19 9. in an innovative remote spbl model, what limitation influenced effective group interaction? a. asynchronous digital learning platform b. non-academic commitments c. peer held accountability d. utilisation of lower critical thinking skills. pedagogy to probity 10. in innovations in health professions education, which electronic application supported the conduct of student elections? a. flipgrid b. padlet c. vimeo d. whatsapp. from work-integrated learning to virtual case studies: navigating an alternative to fieldwork in paediatric occupational therapy 11. in navigating alternatives to fieldwork in paediatric occupational therapy, what did the students value in this alternative approach to fieldwork? a. improved patient outcomes b. inclusion of subject matter experts c. repetitiveness and familiarity d. social isolation and virtual learning. plotting through the pandemic 12. in plotting through the pandemic, what was the role of students in the electronic maternity case record? a. creating the website b. no direct role c. reviewing the website d. supplying resources for learning. saving student interaction by saving the starks 13. commonly used gamification principles include the following, apart from: a. leaderboards b. competition c. summative assessment d. timed activities. the reality of virtual reality at a south african university during the covid-19 pandemic 14. offline desktop-based clinical simulations conducted on a traditional computer with a mouse and keyboard may increase: a. interpersonal communication skills b. psychomotor skills used in clinical practice c. critical reasoning skills in health professions d. authentic interprofessional competencies. teaching pharmacology online: not just another narration 15. scholarship relating to socioconstructivist theory is often based on the works of: a. bernstein b. vygotsky c. piaget d. kolb. reflection on remote teaching and learning of a final year bpharm clinical training module during a pandemic 16. the second step in the sbar model of appropriate communication between individuals relies on: a. analysis of treatment options b. developing interprofessional networks c. providing steps to resolve any issues experienced d. elaborating on the circumstances of the problem. learning during a pandemic: evaluating university of cape town firstyear health sciences students’ experiences of emergency remote teaching (ert) 17. ert refers to the implementation of: a. classes with an increased ratio of face-to-face teaching relative to online learning b. transfer of learning activities to the online space temporarily c. assessment strategies that can be conducted both online and face-to-face d. flexible teaching models that allow for personalised instruction. ‘goldilocks anatomy’ – data-conserving anatomy video tutorials during emergency remote teaching 18. when implementing ert, it is important to: a. provide more information, rather than less information a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) september 2021 cpd questionnaire september 2021, vol. 13, no. 3 ajhpe b. use the highest resolution of figures, videos and audio c. only use synchronous learning opportunities d. keep resources short and succinct to optimise learning. bringing literature to life: a digital animation to teach analogue concepts in radiographic imaging during a pandemic: lessons learnt 19. kolb’s educational model states that students learn via: a. engagement with new experiences b. applying theory to practice c. repetition reinforcing behavioural changes d. continuous re-assessment of complex tasks. a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) september 2021 article 3 december 2011, vol. 3, no. 2 ajhpe introduction the educational system for medical laboratory sciences in east africa, which began about 1960,1 has resulted in the production of a pool of medical laboratory technologists with the responsibility to carry out routine diagnostic laboratory tests in hospitals and health centres. many of these technologists have the diploma in medical laboratory technology awarded after 3 4 years of intensive studies and hospital training, in line with the legacy of the former institute of medical laboratory technology of london (now the institute of biomedical science), which oversaw the training of medical laboratory technologists in most of anglophone africa in the post-colonial era.1 the majority of these technologists do not possess the research skills and competencies required to advance in the biomedical sciences profession or in a health care career. access to postgraduate education is also limited because they are often required to undertake undergraduate education that does not give recognition to their prior learning and experiences. the need for highly qualified personnel with clinical laboratory orientation to manage pathology laboratories in east africa and contribute intellectually to health science research in a region challenged by many epidemic diseases,2 led to the development and introduction of bachelor’s degree programmes for medical laboratory sciences by several universities in the region. the graduates of these programmes were expected to be better prepared to address the issues and challenges facing health care in eastern africa. shortages in the supply of qualified biomedical scientists persist in most parts of east africa as a result of the chronic phenomenon of ‘brain drain’.3 based on the call for educational curricula that are relevant to societal needs4,5 and on the general need for manpower scale-up in the health sector in developing countries,6 this study proposed that medical laboratory technologists with diplomas could be skilled up for higher roles in biomedical sciences in uganda by the introduction of a bridging postgraduate diploma programme in medical laboratory sciences. this would serve as a link between the diploma and a master’s degree. methods a needs assessment was carried out to determine the credibility of this proposition as a means of scaling up human resources in the biomedical sciences, the need for the programme in uganda, and the preferred mode of programme delivery. to achieve the desired objectives, a survey of the stakeholders was undertaken using a self-administered questionnaire. approval for the study was obtained from the institutional review and ethics committee of the kampala international university, western campus, ishaka, uganda. stakeholders were analysed and prioritised using a power interest grid.7 the list included members of regulatory bodies such as the allied health professionals council (ahpc), the ministry of health, university administrators and academic staff, technologists working in hospitals and universities, and medical laboratory sciences students in the diploma and bachelor degree programmes. a questionnaire addressing the specified objectives was developed and standardised with the assistance of faculty and fellows of the southern africa faimer regional institute in cape town, south africa. a pilot study was then conducted to validate the questionnaire. after obtaining informed consent, the questionnaires were self-administered to the study participants, who included all medical laboratory technologists in uganda that the investigators could access, academic staff of the kampala international uniskilling up medical laboratory technologists for higher roles in biomedical sciences: a needs analysis christian c ezeala, phd, msc, micr, csci (uk) assistant professor, department of health sciences, college of medicine, nursing, and health sciences, fiji national university, suva, fiji (this work was done in the department of medical laboratory sciences, kampala international university, wc, bushenyi, uganda) correspondence to: christian ezeala (christianezeala@yahoo.com.au; christian.ezeala@fnu.ac.fj) abstract introduction: uganda is in short supply of biomedical scientists with competencies in research and professional services. to date the educational system for medical laboratory technologists in uganda has produced many technologists with diplomas that do not qualify them for entry into postgraduate education. one potential way to address the problem is to offer medical laboratory technologists, who have a diploma, further training to bridge the gap between the diploma qualification and a higher qualification such as a master’s degree. we would like to propose the development of a postgraduate diploma programme in medical laboratory sciences that will form a link between the diploma and a master’s degree programme. methods: to develop a curriculum that will address this need, a nationwide needs assessment was conducted to determine stakeholders’ recognition of the need for the programme and the preferred modes of programme delivery. national stakeholders were identified and prioritised and a questionnaire was developed and piloted. the questionnaires were distributed to the stakeholders in makerere university, mbarara university of science and technology, and kampala international university. data were analysed using qualitative and quantitative methods. results: a response rate of 83% was recorded; 96% agreed that the programme was needed, and 93% wanted it developed immediately. reasons given for this need included scaling up of manpower, production of better-qualified scientists, more opportunities for medical laboratory scientists, technological development, and improving health care services. conclusion: this study has demonstrated the need for further training of medical laboratory technologists in uganda. this will address the manpower shortages in biomedical sciences and empower the technologists to become biomedical scientists. article 4 december 2011, vol. 3, no. 2 ajhpe versity, western campus, staff and students of the mbarara university of science and technology, mbarara, staff working in and students training in the mulago hospital diagnostic laboratories, kampala, students and staff of the makarere university, kampala, and staff of the ahpc and the ministry of health. no calculation of sample size was undertaken as the study intended to include every accessible stakeholder. follow-up on the questionnaires was by personal visits and phone calls. the returned questionnaires were then analysed quantitatively and expressed as percentages, and qualitatively to categorise the opinions expressed by the respondents. two independent analysts used open inductive coding to generate descriptive codes. these were harmonised by the two analysts and sorted into frames and used to deductively recode the original texts. these identified coding frames were then reorganised into themes. results ninety questionnaires were sent out and 75 were returned, giving a response rate of 83%. fifteen of the respondents were from mulago hospital, 9 from makerere university, 22 from mbarara university of science and technology, 25 from kampala international university, 1 from ahpc, and 1 from the ministry of health. due to logistic reasons, stakeholders from the university of gulu in northern uganda and the school of health technology in jinja could not be reached. by occupation, 26.7% of the respondents were academic/managerial staff, 38.7% were technologists, and 34.6% were students in medical laboratory sciences. the academic qualifications of the participants in the study are shown in fig. 1. as can be seen, more than one-third of the respondents were diploma holders and about one-quarter each were postgraduate degree holders or certificate holders. quantitative analysis of the questionnaires, as shown in table i, indicates that the vast majority of respondents (96%) agreed that the postgraduate diploma programme would be an effective way of scaling up human resources in biomedical sciences. altogether 93.3% of participants agreed that the programme should be developed and implemented immediately. with regard to the mode of programme delivery, 32 participants wanted a full-time programme, 36 preferred a part-time programme, and 12 favoured distance education, while 2 welcomed online studies (fig. 2). analysis of the qualitative responses in support of the introduction of the postgraduate diploma programme yielded seven themes, which included manpower scale-up in medical laboratories, production of better-qualified and more competent medical laboratory personnel, creation of more opportunities for medical laboratory technologists, improved medical laboratory and health care services, professional development in medical laboratory sciences, more technological development in the biosciences in uganda, and aligning uganda with current trends in other countries. those who disagreed with the introduction of the programme stated that undergraduate degree programmes were already in place and should be strengthened, and diploma holders should compete with high-school leavers to obtain a place in undergraduate degree programmes. other opinions expressed by the stakeholders were that the programme should be open to both diploma and first degree holders in other biological sciences who may wish to join medical laboratory sciences, that it should also address issues of professionalism and specialisation which the available undergraduate programmes do not sufficiently address, and that it should cater for the needs of bachelor of medical laboratory sciences degree holders whose performance in the undergraduate programme may not qualify them for entry into master’s degree programmes. discussion the importance of a well-educated and motivated workforce in the health care sector is well recognised. in 2008, the world gathered in kampala, uganda, to discuss issues and challenges facing the health workforce globally, and to identify strategies to address the workforce crisis.8 among the conclusions and recommendations of that global forum were ‘… the expansion of education and training for all groups of health workers…’ and ‘education and curricular focused on the health needs of the country…’. the results of this survey support these recommendations and highlight the need for further training of medical laboratory technologists in uganda. the stakeholders are calling for an immediate scaling up and skilling up of human resources in the pathology laboratories and in biomedical sciences. they believe that the development and implementation of a curriculum for the postgraduate diploma programme table i. responses to questions on the need for a postgraduate diploma programme in uganda strongly disagree disagree no opinion agree strongly agree introduction of the programme will scaleup human resources in health 0 2 1 21 51 the programme is needed now 0 3 2 33 37 fig. 1. qualifications of the respondents (%). fig. 2. preferred mode of programme delivery (no. of respondents). article in medical laboratory sciences would be a credible means of achieving this goal. there was substantial support for the development of the programme, with 68% of the stakeholders strongly supporting it. this could be interpreted as a yearning for postgraduate education by this underrepresented group of health care workers. that 93% of the respondents supported the immediate development and implementation of the programme should interest the education and health ministries and the educational institutions in uganda who should embrace the programme and create the much needed access to higher degree programmes for these technologists. by doing so, they would be responding to the clarion call for unrestrained access to higher education by all groups, and help further development of the skills of this category of health workers.9 this will also increase the number of qualified and specialised faculty in the biomedical sciences, and create an educational curriculum that addresses the relevant needs of this sector of the health care industry. the qualitative aspects of the study provided useful insights into other potential benefits of the programme. staffing the health care laboratories with highly qualified personnel would result in higher-quality laboratory services, and promote innovation and the creation of appropriate technologies suited to the country’s needs. the expected end result would be a significant improvement in health care services. a limitation of this study could arguably be related to the failure to sample some sections of the country. this may raise validity questions if these findings are generalised to those sections. however, when these results are interpreted with the understanding that the majority of the stakeholders in the country reside and work in the areas sampled, then these findings could be seen to validly reflect the views and opinions of the average stakeholder in uganda. we are therefore recommending that the ugandan government set up machinery for the immediate development and implementation of a postgraduate diploma programme for medical laboratory sciences in ugandan universities. summary and conclusion the results from this study demonstrate the perceived need for a postgraduate diploma programme in medical laboratory sciences in uganda and support the development of a curriculum for such a programme. the majority would like immediate development of the programme in ugandan universities in the hope that it will improve health care services, provide better opportunities for medical laboratory sciences, and which could result in technological development in uganda. the preferred modes of study were full-time and part-time, although a minority would still welcome distance learning and online studies. acknowledgements the author is grateful to the safri faculty and fellows for supporting the project and to the safri institute for providing the fellowship that led to this work. mrs mercy ezeala assisted with data analysis. references 1. international federation of biomedical laboratory sciences. internaional directory of medical laboratory science education 2004. http://www.ifbls.org/ e58d4a47-37e9-4cd1-a4e0-a6c2fbb9f7af/finaldownload/downloadid249544d76a1d0fac8b483db2544d305f/e58d4a47-37e9-4cd1-a4e0a6c2fbb9f7af/files/idmlse%20web2_0.pdf (accessed 5 july 2011). 2. gray ip, carter jy. an evaluation of clinical laboratory services in sub-saharan africa: ex africa semper aliquid novi? clinica chimica acta 1997;267(1):103-128. 3. dovlo d. the brain drain in africa: an emerging challenge to health professionals’ education. journal of higher education in africa 2004;4(3):1-18. 4. akinmusuru jo. the curriculum as a living document for achieving education for sustainable development. http://gc.aau.org/e58d4a47-37e9-4cd1-a4e0a6c2fbb9f7af/finaldownload/downloadid-772659974c5d182ddf9003e9a97ec4bf/e58d4a47-37e9-4cd1-a4e0-a6c2fbb9f7af/papers/joe_o_%20 akinmusuru_full20.pdf (accessed 5 july 2011). 5. schoenfeld ah. looking toward the 21st century: challenges of educational theory and practice. educational researcher 1999;28 (7):4-14. 6. global health workforce alliance. health workers for all and all for health workers: the kampala declaration and agenda for global action. geneva, switzerland: who, 2008. http://www.who.int/workforcealliance/forum/2_declaration_final.pdf (accessed 5 july 2011). 7. mind tools. stakeholder analysis. http://www.mindtools.com/pages/article/ newppm_07.htm (accessed 15 july 2008). 8. task force for scaling up education and training for health workers: global health workforce alliance. scaling up, saving lives. geneva, switzerland: who, 2008. http://www.who.int/workforcealliance/documents/global_health%20 final%20report.pdfhttp://www.who.int/workforcealliance/documents/global_ health%20final%20report.pdf (accessed 5 july 2011). 9. burdick w. challenges and issues in health professions education in africa. medical teacher 2007;29(9): 882-886. 5 december 2011, vol. 3, no. 2 ajhpe april 2021, vol. 13, no. 1 ajhpe 41 research the world economic forum identified complex problem solving, critical thinking skills that facilitate it and creativity as the top skills needed in 2020 and beyond.[1] critical thinking broadly consists of three components, i.e.  information, processing (thinking) skills and the habit of using the processed information to direct behaviour.[2] in the health professions, the ability to gather information and evaluate associated assumptions and evidence to guide courses of action are key to preventing and solving problems.[3] numerous studies reported that high-fidelity simulations are useful to improve critical thinking, decision-making, confidence, all-round communication skills and readiness for practice,[4-6] and in medical and nursing education, it is extensively used to link classroom teaching to clinical practice.[7-10] the essence of simulation-based education in healthcare is to expose students to real-life situations without the risk of harming patients, while they pursue specific learning outcomes.[11,12] the innate authentic nature of highfidelity simulations can however profoundly increase students’ cognitive load, which may affect their learning experience and clinical performance. the incorporation of cognitive load theory (clt) to facilitate the development of simulations that consider the cognitive interplay between working memory and long-term memory to optimise learning,[13] is therefore indicated. clt is based on the principle that a person’s working memory – the part concerned with learning and problem solving – has a limited capacity when dealing with novel information. however, when the working memory can access appropriate information stored in the long-term memory, its capacity seems to be limitless.[14] students’ total working memory load or cognitive load consists of the sum of the intrinsic cognitive load and the extraneous cognitive load. intrinsic load (il) refers to the inherent difficulty of the information or simulation, while extraneous load (el) mostly refers to suboptimal instructional design factors that do not enhance learning.[15] should either one or both components exceed working memory capacity, learning will be impaired. in developing simulation scenarios, educators should therefore consider the inherent difficulty of the scenario and increase students’ working memory capacity accordingly by way of populating their long-term memories with the necessary information prior to the simulation.[15] several interacting scenario elements that need to be considered simultaneously during the simulation, should preferably not be based on skills not yet mastered,[15] and a simulation requiring e.g.  clinical reasoning, decision-making and complex communication, should be written around radiographic procedures that students can competently perform without much thinking. it is, however, also true that a slightly excessive cognitive load often results in associated increased learning,[14] and educators’ challenge is to find the balance between an increased cognitive load that stimulates and motivates students and one that impairs learning.[15] this article reports students’ responses in terms of problem solving and new insights following the incorporation of clt into a high-fidelity simulation specifically designed to facilitate critical thinking. prepopulation background. problem solving and critical thinking are top future skills. high-fidelity simulations improve critical thinking, but also increase students’ cognitive load, possibly limiting their learning. educators should therefore consider learning outcomes, problems that require critical thinking, the relationship between working and long-term memory, and intrinsic and extraneous cognitive loads when developing simulation scenarios. objective. to report on the application of cognitive load theory (clt) and students’ responses in terms of problem solving and new insights during and after a simulation experience. methods. a high-fidelity simulation, targeting multilevel communication, teamwork and prioritisation of learning outcomes, was designed according to clt. eighty students participated in presimulation knowledge, skills and attitudes acquisition and 10 participated in the simulation. a qualitative descriptive design was followed and data were collected through video/audio recordings of the simulation and reflection session, supported by educator and critical observer notes. qualitative content analysis allowed comprehensive summarisation of students’ problem-solving abilities and emerging new insights. results. eighty second-year radiography students formed the target population, with 10 simulation participants comprising the sample. communication with health professionals was good, but lacking towards patients. intraprofessional team collaboration was suboptimal, but interprofessional team collaboration was good. students were mostly unfamiliar with the prioritisation responsibility. upon reflection, students came to new insights regarding teamwork and prioritisation. conclusion. after application of clt, critical thinking to facilitate problem solving during simulation was suggested and post-simulation reflection facilitated new insights. the exposure of large groups to the benefits of simulation validates further investigation. afr j health professions educ 2021;13(1):41-46. https://doi.org/10.7196/ajhpe.2021.v13i1.1313 cognitive load theory in simulations to facilitate critical thinking in radiography students a louw, brad, brad hons, mtech rad, dtech rad department of medical imaging and radiation sciences, faculty of health sciences, university of johannesburg, south africa (at the time of the research reported in this article) corresponding author: a louw (rooirokkie.al@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 42 april 2021, vol. 13, no. 1 ajhpe research of students’ long-term memory banks and their working memories’ problem-solving abilities during the simulation are described, insights that emerged during post-simulation reflection are discussed and shortcomings and future research needs are identified. the simulation scenario itself and timing of the different interplaying elements are detailed elsewhere.[4] methods a qualitative descriptive design[16,17] was used and data were collected by means of two video/audio recordings of the simulation and reflection session, supported by four critical observers’ notes and the educator’s observation notes. data were analysed through qualitative content analysis.[16] whereas multiple sources verify the data, and descriptive and interpretive validity is enhanced by the nature of the qualitative descriptive study design,[18] the researcher’s educational involvement and lens are acknowledged to be considered by the reader. context the simulation was conducted in an on-campus high-fidelity simulation laboratory and involved 80 radiography students in the first month of their second year. as part of their educational programme, all 80 students were actively involved in the presimulation scaffolding of knowledge, skills and attitudes, and all received information regarding the research study and what participation would entail. all were told they could withdraw from the study at any time and that non-participation would not disadvantage them. ten students volunteered and signed informed consent to participate in the simulation and be video/audio recorded. students were assured that all recorded material would be kept safe and confidential as research data. preparation an interprofessional, stress-loaded, multicase simulation scenario was designed to target specific learning outcomes, i.e. multilevel communication, teamwork and prioritisation. students did not receive explicit lectures on the outcomes – these were at best only implied through the hidden curriculum of various modules. as these higher cognitive skills incorporated various interacting elements and involved some problem solving, it constituted a high il that required thorough preparation of students’ long-term memory banks with basic knowledge, skills and attitudes. this would expand students’ working memory capacity to allow optimal consideration of all the interacting elements and problem solving required during the simulation. table  1 shows the preparation process that was scaffolded over 3 weeks. offering strategy and content considered the limited capacity of the working memory to deal with new information, and both started with the simplest information, escalating in complexity over time.[13,14] small-group discussions are powerful social learning platforms and groups consisted of 5 students who each received clinical training in different settings, resulting in discussions that represented rich conglomerations of clinical experience, underpinned by the academic content addressed during the previous weeks. considering the broad definition of critical thinking, which contains the components of information, thinking about (discussing) the information, and allowing the thinking (discussing) to direct decisions and actions,[2] students were well prepared for the simulation once they progressed through the scaffolding steps. simulation five days prior to the simulation, the 10 volunteering students were briefed. table 2 shows how prebriefing minimised their el, which would not contribute to learning. table 2 also indicates the different roles that the students fulfilled. detail about the simulation scenario and the tasks to be performed was unknown to the participants until the simulation started. primary simulation tasks entailed chest and elbow imaging, but learning outcomes involved secondary tasks, such as multilevel communication, teamwork and prioritisation. anchoring the scenario on first-year projections considered two clt facts: (i)  working memory capacity is limited unless it can draw knowledge and skills from long-term memory;[14] and (ii) primary and secondary tasks use working memory as a cognitive resource. resources for secondary tasks therefore depend on resources remaining once primary tasks are completed.[19] as preparation, prebriefing and choice of primary tasks aimed to avail most of the students’ working memory capacity for secondary tasks, the simulation il was increased to mimic a realistic situation in the casualty department of a small hospital in south africa (sa). a  range of events presented the 3 student radiographers with several interacting elements and an array of problems that required critical thinking. table  3 shows the elements that increased il, problems that emerged throughout the simulation and critical thinking components that were needed to address each. the emotional impact of the simulation on individuals and students’ personal coping strategies is not included. table 1. cognitive load theory and presimulation preparation of 80 students’ long-term memory banks scaffolding steps before simulation, weeks learning mode offering strategy content purpose 4 synchronous classroom discussions chest and elbow imaging revision of first-year syllabus nat in paediatric patients introduction of new content 3 asynchronous readings, videos, website links posted onto university’s learning management system additional trauma chest, elbow and nat image appearance information and procedural guidelines when sensing possible nat cases preparing students for confident and knowledgeable participation in forthcoming small-group discussions 1 social small-group discussions of worksheets posted onto learning management system trauma chest, elbow and nat images with probing questions to clearly indicate to students their learning goal, provide an opportunity to relate their existing knowledge to new information, focus their attention on important aspects and stimulate critical thinking through challenging questions nat = non-accidental trauma. april 2021, vol. 13, no. 1 ajhpe 43 research ethical approval the educational study obtained ethical clearance from the research ethics committee of faculty of health sciences of the host university (ref. no. rec-01-71-2016), where the researcher was a radiography educator who used simulation to achieve active student involvement that embraces thinking about, understanding of, and thus learning of curricular content. results and discussion results are presented and discussed in the acceptable qualitative tradition, alongside literature references and participant quotations. critical thinking and problem solving during simulation the 10 radiography student participants represented 3 cultural groups and 6 clinical training centres. there were 2 males and 8 females – all were >18  years old. there were 2 role-play nurses, 1 played the baby’s family member, 4 served as critical observers and 3 remained student radiographers. qualitative content analysis of the simulation video/audio recording, supported by the educator’s observation notes, focused on a close  and low inference description of the content.[16] primary simulation tasks, i.e. low il chest and elbow imaging, were performed well. performance of secondary tasks and progression towards the learning outcomes are described in the following paragraphs. critical thinking occurs when students are motivated and challenged to engage in higher-level thought processes.[20] the simulation was therefore developed to spark students’ interest and enthusiasm by incorporating high il secondary tasks, presenting multilevel communication, teamwork and prioritisation problems as challenging elements. competent clinical reasoning, decision-making and reflective problem solving are subcomponents of critical thinking,[21,22] and where problems were adequately solved, it is accepted that students engaged in critical thinking. multilevel communication communication challenges required students to adapt their communication styles between patients, a family member, nurses and a doctor. they found the non-routine task of communicating their image observations to the doctor challenging but necessary, owing to the radiologist’s absence. students’ knowledge regarding chest and non-accidental trauma image appearances and complications equipped them to communicate the adult’s tension pneumothorax and the baby’s fractures with its implications accurately, resulting in prompt, appropriate management. communication with nurses and the family member was professional, but minimal with ‘patients’. as the patients were manikins, it could have contributed to this shortcoming; alternatively, students may have over-focused on other scenario elements. teamwork intraprofessional team collaboration (among student radiographers) was not optimal. students seemed unsure of who-should-do-what and much time was initially wasted by incoherent actions. however, once the second patient’s imaging started, workflow improved. the simulation introduced students to the concept of interprofessional team collaboration (among all staff) to mutually pursue optimal patient care. while they seemed to have fitted into this expanded dimension relatively well, the reflection session revealed that much learning took place in this regard. prioritisation students found prioritisation of patients and imaging requests the biggest challenge. they ignored several requests for the baby’s chest imaging while  they were busy with the adult’s elbow and only responded after a final urgent call from the nurses, indicating immediate need of radiographs. on  the positive side, students did consider the benefits and risks of imaging the pregnant adult (and fetus) and promptly proceeded with chest imaging. regarding all these targeted learning outcomes, students applied their existing knowledge, skills and attitudes, made decisions and acted accordingly. all three components of critical thinking were thus used to address the various problems that arose, even though not all actions were optimal at all times. post-simulation reflection and critical thinking reflection (debriefing) immediately after a simulation is considered the most important component of a simulation, as it consolidates learning that (often subconsciously) took place during the simulation.[23] it allows students to develop new insights that direct their future performance as a result of learning through experiencing.[24] it is a vital cognitive step in the critical thinking process, as the identification and evaluation of what  did/did not work are essential to improve knowledge and problemsolving skills.[27] to limit unintended bias resulting from the educator’s expectations and to ascertain whether students can come to new insights by themselves, post-simulation reflection was led by the 4 critical observers, and formative educator input was minimal. to assist them, observers were each given an table 2. cognitive load theory and prebriefing of 10 simulation participants factors increasing extraneous load strategy to minimise extraneous load effect stress and anxiety during simulation students invited to familiarise themselves with the fictitious scenario setting, available equipment and accessories in the simulation laboratory students were prepared in terms of venue layout, capabilities and limitations of equipment and accessories students informed of 10 roles to be filled: 3 student radiographers, 2 nurses, 1 patient family member and 4 critical observers they decided who would take up which roles students could imagine possible role nuances, and a sense of self-determination was introduced students informed of time frames of different components: simulation, image interpretation and reflection students knew in advance what their participation would entail students received aim and objectives of simulation students could anticipate possible challenges incorporated into the scenario 44 april 2021, vol. 13, no. 1 ajhpe research observation guide, as well as the simulation aim and objectives to focus their observations during the simulation and to guide the reflective discussion. the 10 radiography students contributed to the reflection from their personal radiography contexts. findings are based on content analysis of a video/audio recording of the reflection session, supported by the critical observers’ notes. table 3. cognitive load theory, emerging problems and critical thinking elements that increased intrinsic load emerging problems critical thinking components scenario staged on sunday morning, 03h00 limited staff, qualified radiographer elsewhere students expected to function autonomously regarding full range of imaging responsibilities embedded knowledge, skills, attitudes thinking about it in current context making appropriate decisions no radiologist students expected to comment on x-ray images embedded image evaluation and interpretation knowledge and skills applying it to displayed images making appropriate judgements about commenting to doctor setting: casualty department with 1 mobile x-ray unit routine projections may need adaptations according to patients’ conditions embedded knowledge, skills, attitudes applying it to current context adjusting routine procedures to ensure optimal care 2 patients needing simultaneous imaging students to consider urgency of adults’ chest and elbow v. baby’s chest embedded knowledge, attitudes applying it to current patients’ clinical history and conditions prioritising to promote optimal care 1st patient: adult, 38 weeks’ pregnant, involved in high-impact motor vehicle accident (chest and elbow) students to consider benefits and risks of irradiating pregnant patient and fetus embedded knowledge, skills, attitudes relating it to clinical condition of adult and fetal development plus benefits and risks to both – in case of imaging and non imaging applying techniques to limit fetal radiation making appropriate decisions to promote optimal adult and fetal care adult’s chest image indicates tension pneumothorax potentially fatal, needs immediate management embedded knowledge regarding recognition and implications of tension pneumothorax applying it to current context, realising doctor is occupied but needs to be informed urgently communicating imaging outcome appropriately to facilitate optimal care 2nd patient: 18-month-old baby (chest) baby’s condition serious and deteriorating, causing stress to all staff students to continuously act professionally embedded knowledge, skills, attitudes applying it to current situation making conscious decisions: demonstrating confidence, competence and control baby’s chest image indicates several rib and clavicle fractures in various healing stages previous lower-extremity images indicate metaphyseal fractures injury combination highly suggestive of nat students expected to realise implications embedded knowledge regarding recognition of injuries and possible implication of injury combination applying it to current context, realising doctor may not immediately realise implications communicating observation and possible implications appropriately to facilitate optimal care baby’s family member disrupts imaging, challenging students’ patience, communication skills and general professional demeanour students to continuously act professionally embedded skills, attitudes applying it to current situation, realising possible legal implications of suspected nat case acting appropriately and communicating professionally both ‘patients’ were high-fidelity manikins, producing realistic verbal sounds: adult moaning and baby crying ‘patient’ distress sounds can cause stress in students students to continuously act professionally embedded skills, attitudes applying it to current situation acting professionally real-life, casualty unit, additional ‘patients’, heart-rate monitors, ringing telephones and verbal staff communications authentic clinical environment and realistic distracting elements challenged students’ professionalism embedded skills, attitudes applying it to current situation acting professionally: displaying general team coherence aimed at optimal patient management and care nat = non-accidental trauma. april 2021, vol. 13, no. 1 ajhpe 45 research observers initiated the discussion by highlighting positives and negatives regarding basic radiographic skills, after which they addressed higherorder skills required during the simulation. group cohesion seemed strong, students appeared to feel safe to reflect honestly and did not try to defend their less ideal decisions, but rather explained their thoughts. as they were from different clinical settings, a variety of perspectives emerged, resulting in widening everyone’s outlook on how to recognise sub-optimal decisions and adjust future approaches appropriately. the simulation was designed to challenge students in terms of communication, teamwork and prioritisation, and most of the dialogue fitted into these targeted learning outcome categories, with evidence of a fourth category, i.e.  situational and mental preparedness. communication the imaging team spontaneously admitted their lack of patient communication and ascribed it to the intenseness of the scenario. this suggests that their working memories were slightly under-capacitated to cope with all the scenario elements: ‘… you just think, you don’t explain to the patient …’[4] teamwork the group realised the need for imaging team members to decide beforehand on who-should-do-what, to prevent haphazardness: ‘i was confused … i did not know what to do first, if it will be ok.’ the two who role-played nurses provided additional nursing perspectives towards the inter-professional team collaboration concept: ‘this scenario made me appreciate other people’s professions …  the nurses have a lot on their shoulders …’[4] it was also realised that optimal patient care requires different teams to assist each other: ‘next time … when the doctor is busy with the patient, i will think to give her the lead apron to carry on with her work – this is something i was never thinking of before.’[4] prioritisation students admitted that the situation that prompted them to interrupt the adult’s elbow imaging in favour of the baby’s chest, was new to them: ‘i was not sure if we could, if we could not, as i have never been in that situation before.’[4] prioritisation with its implied responsibility was much discussed, and students started realising the importance of thinking about multiple simultaneous imaging requests and the role of imaging in the immediate management of different patient conditions: ‘… now i know the importance of decision-making … i will think about a decision … what should be done first.’[4] situational and mental preparedness an additional learning outcome echoed by the whole group, was that of situational and mental preparedness: ‘these things happen for real. if you are not used to such scenarios, you always gonna be chilled …  the reality is we need patients like this to prepare you mentally.’[4] teaching strategies that allow students to think about learning content are vital  to understanding it, and active engagement with learning content instead of passive listening to a lecture, cultivates critical thinking.[25,26] the emergence of the untargeted learning outcome, as well as discussions around the three targeted outcomes, indicated the presence of  the three basic critical thinking components during the reflection session. all students had knowledge of the simulation happenings, thought about it, discussed it in relation to their prior knowledge and  expertise, and came  to new insights that will affect their future behaviour in similar situations: ‘like now, we kind of learnt what to do. we’ve seen what – like – most people [in the team] think about it.’[4] conclusion clt was applied in the preparation and execution of a high-fidelity simulation that aimed to achieve the learning outcomes of multilevel communication, teamwork and prioritisation. several problems related to these outcomes were embedded in the scenario and required critical thinking for solving strategies. students’ decisions were not optimal in all cases, but problems were mostly managed well, suggesting largely adequate cognitive resources and application of three basic critical thinking components. post-simulation reflection allowed students to communicate with each other in seeking and finding solutions[27] and indicated that students can come to new insights by themselves, without formal instruction. as simulation provides a platform where students can learn from their mistakes without harming patients,[11,12] the simulation was considered successful, as it exposed students to problem solving through critical thinking and sensitised students and educator to professional practice components in need of attention. study findings are not optimal, as students’ problem-solving abilities were not summatively assessed and formative judgement was based solely on the educator’s long-standing expertise in the radiography domain. there was also no attempt to measure students’ cognitive loads, as knowledge on the precise gauging of il and el is lacking.[28] the major shortcoming of the simulation, however, was the inclusion of only 10 of 80 students. to provide equitable education to all, further research into simulation strategies to hone the critical thinking skills of large groups within the constraints of curricula, timetables and available venues, is indicated. declaration. none. acknowledgements. the author acknowledges all the students and simulation laboratory staff of the faculty of health sciences, university of johannesburg, who participated in this simulation experience in 2017. author contributions. al conceptualised and executed the study and wrote the article. funding. none. conflicts of interest. none. 1. gray a. the 10 skills you need to thrive in the fourth industrial revolution. world economic forum: agenda. 2016. https://www.weforum.org/agenda/2016/01/the-10-skills-you-need-to-thrive-in-the-fourth-industrial-revolution/ (accessed 13 january 2020). 2. foundation for critical thinking. critical thinking as defined by the national council for excellence in critical thinking. 1987. http://www.criticalthinking.org/pages/defining-critical-thinking/766 (accessed 13 january 2020). 3. alfaro-lefevre r. critical thinking, clinical reasoning, and clinical judgement: a practical approach. 6th ed. philadelphia: elsevier, 2017:3. 4. louw a. high fidelity simulation based training in radiography. in: horsted a, ed. new innovations in teaching and learning in higher education. faringdon: libri, 2017:263-287. 5. hayden jk, smiley ra, alexander m, kardong-edgren s, jeffries pr. the ncsbn national simulation study: a longitudinal, randomized controlled study replacing clinical hours with simulation in pre-licensure nursing education. j nurs regulat 2014;2(5):s3-s40. https://doi.org/10.1016/s2155-8256(15)30062-4 https://www.weforum.org/agenda/2016/01/the-10-skills-you-need-to-thrive-in-the-fourth-industrial-revolution/ http://www.criticalthinking.org/pages/defining-critical-thinking/766 https://doi.org/10.1016/s2155-8256(15)30062-4 46 april 2021, vol. 13, no. 1 ajhpe research 6. moyer s. large group simulation: using combined teaching strategies to connect classroom and clinical learning. teach learn nurse 2016;11(2):67-73. https://doi.org/10.1016/j.teln.2016.01.002 7. ericsson ka. deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. acad med 2004;79(10):s70-s81. https://doi.org/10.1097/00001888-200410001-00022 8. rosen kr. the history of medical simulation. j crit care 2008;23(2):157-166. https://doi.org/10.1016/j. jcrc.2007.12.004 9. buckley t, gordon c. the effectiveness of high fidelity simulation on medical-surgical registered nurses’ ability to recognise and respond to clinical emergencies. nurse educ today 2011;31(7):716-721. https://doi.org/10.1016/j. nedt.2010.04.004 10. friederichs h, weissenstein a, ligges s, moller d, becker jc, marschall b. combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. adv physiol educ 2014;38(4)343-347. https://doi.org/10.1152/advan.00039.2013 11. bradley p. the history of simulation in medical education and possible future directions. med educ 2006;40(3):254-262. https://doi.org/10.1111/j.1365-2929.2006.02394.x 12. alinier g, harwood c, harwood p, monatgue s, ruparelia k. immersive clinical simulation in undergraduate health care professional education: knowledge and perceptions. clin simul nurs 2014;10(4):e205-e216. https:// doi.org/10.1016/j.ecns.2013.12.006 13. bong cl, fraser k, oriot d. cognitive load and stress in simulation. in: grant vj, cheng a, eds. comprehensive healthcare simulation: paediatrics. switzerland: springer international publishing, 2016:3-17. 14. van merriënboer jjg, sweller j. cognitive load theory in health professional education: design principles and strategies. med educ 2010;44(1):85-93. https://doi.org/10.1111/j.1365-2923.2009.03498.x 15. fraser kl, ayers p, sweller j. cognitive load theory for the design of medical simulations. simul healthcare 2015;10(5):295-307. https://doi,org/10.1097/sih.0000000000000097 16. sandelowski m. focus on research methods. whatever happened to qualitative description? res nurs health 2000;23:334-340. https://doi.org/10.1002/1098-240x(200008)23:4%3c334::aid-nur9%3e3.0.co;2-g 17. neergaard ma, olesen f, andersen rs, sondergaard j. qualitative description – the poor cousin of qualitative research? bmc med res methodol 2009;9(52). https://doi.org/10.1186/1471-2288-9-52 18. maxwell ja. understanding and validity in qualitative research. harvard educ rev1992;62(3):279-300. 19. brünken r, steinbacher s, plass jl, leutner d. assessment of cognitive load in multimedia learning using dualtask methodology. experiment psychol 2002;49(2):109-119. https://doi.org/10.1027//1618-3169.49.2.109 20. roberts tg, dyer je. the relationship of self-efficacy, motivation, and critical thinking disposition to achievement and attitudes when an illustrated web lecture is used in an online learning environment. j agric educ 2005;46(2):12-23. https://doi.org/10.5032/jae.2005.02012 21. jackson m, ignavaticius dd, case b. conversations in critical thinking and clinical judgement. sudbury, ma: jones & bartlett, 2006. 22. facione nc, facione pa. critical thinking and clinical reasoning in the health sciences: an international multidisciplinary teaching anthology. millbrae, ca: california academic press, 2008. 23. konia m, yao a. simulation ‒ a new educational paradigm? j biomed res 2013;27(2):75-80. https://doi.org/10.7555/ jbr.27.20120107 24. kolb da. experiential learning: experience as the source of learning and development. 2nd ed. new jersey: pearson education, 2015. 25. paul r. the state of critical thinking today. 2004. http://www.criticalthinking.org/pages/the-state-of-criticalthinking-today/523 (accessed 13 january 2020). 26. tsui ll. fostering critical thinking through effective pedagogy: evidence from four institutional case studies. j high educ 2002;73(6):740-763. https://doi.org/10.1353/jhe.2002.0056 27. harasym ph, tsai t, hemmati p. current trends in developing medical students’ critical thinking abilities. kaohsiung j med sci 2008;24(7):341-355. https://doi.org/10.1016/s1607-551x(08)70131-1 28. leppink j. cognitive load theory: practical implications and an important challenge. j taibah univ med sci 2017;12(5):385-391. https://doi.org/10.1016/j.jtumed.2017.05.003 accepted 1 april 2020. https://doi.org/10.1016/j.teln.2016.01.002 https://doi.org/10.1097/00001888-200410001-00022 https://doi.org/10.1016/j.jcrc.2007.12.004 https://doi.org/10.1016/j.jcrc.2007.12.004 https://doi.org/10.1016/j.nedt.2010.04.004 https://doi.org/10.1016/j.nedt.2010.04.004 https://doi.org/10.1152/advan.00039.2013 https://doi.org/10.1111/j.1365-2929.2006.02394.x https://doi.org/10.1016/j.ecns.2013.12.006 https://doi.org/10.1016/j.ecns.2013.12.006 https://doi.org/10.1111/j.1365-2923.2009.03498.x https://doi,org/10.1097/sih.0000000000000097 https://doi.org/10.1002/1098-240x(200008)23:4%3c334::aid-nur9%3e3.0.co;2-g https://doi.org/10.1186/1471-2288-9-52 https://doi.org/10.1027//1618-3169.49.2.109 https://doi.org/10.5032/jae.2005.02012 https://doi.org/10.7555/jbr.27.20120107 https://doi.org/10.7555/jbr.27.20120107 http://www.criticalthinking.org/pages/the-state-of-critical-thinking-today/523 http://www.criticalthinking.org/pages/the-state-of-critical-thinking-today/523 https://doi.org/10.1353/jhe.2002.0056 https://doi.org/10.1016/s1607-551x(08)70131-1 https://doi.org/10.1016/j.jtumed.2017.05.003 research 56 november 2013, vol. 5, no. 2 ajhpe micro, meso and macro issues emerging from focus group discussions: contributions to a physiotherapy hiv curriculum h myezwa,1 phd; a stewart,1 phd; p solomon,2 phd 1 department of physiotherapy, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 department of physiotherapy, faculty of health sciences, mcmaster university, hamilton, canada corresponding author: h myezwa (hellen.myezwa@wits.ac.za) background. physiotherapy in south africa has not defined its contribution to the management of hiv. as part of developing an appropriate hiv/ aids physiotherapy curriculum, focus group discussions (fgds) with physiotherapy clinicians and educators were undertaken. objectives. to understand the perceptions and experiences of hiv management in refining an hiv physiotherapy curriculum. methods. six focus groups chosen using purposive sampling ensured representation from experienced and newly qualified academics and clinicians. interpretive content analysis strengthened the knowledge areas required in practice and attitudes based on the groups’ experiences of hiv management. concepts were identified, and deand recontextualised to develop categories and themes. results and discussion. five themes emerged: the need to include hiv in the physiotherapy curriculum; a physiotherapy-specific hiv curriculum; co-ordinated curriculum design; underlying concerns relating to hiv management and inclusion in the curriculum; and the need for professional development. further analysis and abstraction highlighted micro, meso and macro issues. micro issues included content, while meso-level concerns included perceived gaps in the curriculum and recommendations to respond to issues such as therapists’ coping and burnout, therapists’ attitude to hiv, and organisational problems threatening the application of knowledge regarding this condition. at a macro level, participants felt that the political nature of hiv and curriculum structure were problematic and that there was a need for continuous staff development. conclusion. a list of topics related to hiv, which tallied well with evidence in the literature and patients’ clinical presentations, emerged. the need for a complex, well-designed programme for the physiotherapy management of hiv emerged and was informed by the difficulties experienced at the micro, meso and macro levels of the curriculum. ajhpe 2013;5(2):56-62. doi:10.7196/ajhpe.191 south africa has a high hiv/aids prevalence, with a national provincial mean of 18.1% (range 15.4 20.9%) in adults aged 15 49 years, with an interdistrict range of 5.3 46 %.[1] its high prevalence and progression to a chronic condition highlight the importance of its inclusion in all health professional education programmes, including physiotherapy. hiv/aids is a pervasive condition affecting most body systems. it therefore has implications for physiotherapy education and practice. its chronic nature and relevance to physiotherapy, within the framework of rehabilitation, are related to the restoration of mobility and function. objectives to develop an appropriate hiv/aids physiotherapy curriculum, an investigation of the interaction between hiv patients and physiotherapists, an assessment of patient problems, and an audit of the physiotherapy curricula of all the training institutions in south africa was undertaken. [2-4] the objective was to determine physiotherapists’ perceptions of important hiv/aids curriculum topics to be included in undergraduate physiotherapy programmes. shepard and jensen’s[5] taxonomy of micro, meso and macro issues was used to guide the investigation and data analysis. the macro environment includes society, healthcare, higher education, and knowledge related to physiotherapy, and therefore deals with large-scale issues that influence the curriculum. van den akker[6] defines the meso level as dealing with issues that affect curriculum implementation at an operational level (fig. 1). the micro level addresses issues that effect students’ clinical practice and reasoning, including curriculum content. methods a qualitative methodology, i.e. focus group discussions (fgds), was used to collect data. clinicians and academics were purposively chosen to describe their knowledge, experience, beliefs and perception about hiv.[7] the clinicians were from three departments in hospitals with high numbers of hiv-positive patients. based on a curriculum audit done at 8 universities,[4] one of the participating academic physiotherapy departments had an extensive hiv course. departments two and three had courses outlined with moderate and limited content, respectively. table 1 outlines the characteristics of the sample. sample and sampling a total of 47 physiotherapists comprised academics and newly qualified and experienced clinicians, the focus group size ranging from 5 to 12 (table 1). the study was approved by the human research ethics committee, university of the witwatersrand. written permission was sought from the heads of the hospital departments and universities and all participants. confidentiality was assured by all identifiers being excluded. trustworthiness and transferability of the data were ensured by purposive sampling, consideration of the results of the preceding studies, data saturation and findings from the literature.[4] development of the interview guide a literature review and the three studies described above were used to develop the questions used in the focus groups. these were then sent to two physiotherapists with expertise in hiv for comment and validation. mailto:hellen.myezwa@wits.ac.za research november 2013, vol. 5, no. 2 ajhpe 57 data collection in an initial pilot study two observers critiqued the way in which the fgds were conducted and suggested 4 further questions and clarification of another. the results were used in the study. the discussions were audio recorded and transcribed verbatim by a professional transcriber. data analysis process an interpretive content analysis using a constant comparison method was utilised to analyse the data.[8] the transcribed data were analysed vertically and concepts were identified separately.[9] after examination of the data, similar concepts were tallied around one phenomenon, i.e. categorised. transcribed data were inspected in repeated rounds to tally similar concepts, ensure that no concepts were missed and identify new categories where necessary. the concepts of the first author and an independent researcher for all six sites as shown in table 1 (attained a mean of 90% (sd ±2) (range 86 92%). two experienced researchers were given the list of concepts and asked to provide a separate list of categories for comparison. eleven of the 17 categories were congruent. some of those not congruent were reworded or amalgamated with other categories. once the categories were finalised, axial coding was done.[10] the first author (hm), together with another qualitative researcher, discussed the links and the contextual associations of the categories. the categories were ranked and linkages identified. member checking was done to ensure accuracy by sending the transcribed scripts with the concepts identified[11] to the clinical and academic groups involved. themes were identified from the categories. the literature on curriculum design was used to further analyse the emerging themes. these themes were then assessed to determine whether they belonged to a micro, meso or macro environment,[5] and are discussed as such. this study ensured transferability by obtaining samples from different settings. credibility was achieved through engagement in the fgds, utilisation of the information from preceding studies, peer examination of the conduct of the initial fgds, subsequent peer review and criticism allowing for improvement and clarity in the next fgds. a rigorous process of content analysis, with several layers of abstraction and member checking by peers and participants, added to the credibility of the study. results and discussion figs 1, 2 and 3 are a schematic presentation of all the findings. further abstraction revealed how the specific content identified could be linked to the taxonomy of educational knowledge. figs 2 and 3 relate to knowledge, attitude, practice and skills, and examples are given in tables 2 4, representing the micro, meso and macro levels, respectively. using further abstraction the researchers could link the specific course content proposed to curriculum input as well as the broader curricular issues that are illuminated by applying the micro, meso and macro taxonomy, as shown in fig. 1. for example, where participants expressed knowledge gaps in areas such as neurology, when to exercise, implications for exercise and the need for emotional support, further analysis was undertaken. in the first analysis these aspects were grouped under ‘needs’, as shown at the micro level. successive analyses separated the ‘needs’ relating to knowledge and other categories, such as coping, and further abstraction was done.[5] in addition, the information elicited was compared with patient needs from the previous study4 as well as the literature, and omissions were identified. figs 2 and 3 show the results of this process. physiotherapy course content at the various levels micro level the micro level ‘physiotherapy content needs’ showed a wide range of topics under 5 main themes, i.e. factual knowledge and information, application of knowledge, skills, thinking skills and application, information analysis and table 1. focus group sample participants institution (n) institution (n) experience (years) mean (±sd) hospital physiotherapy departments (3) hospital 1 (12) hospital 2 (8) hospital 3 (5) 3.3 (±2.8) 5.8 (±4.1) 1.9 (±1.1) academic institutions (3) institution 1 (5) institution 2 (10) institution 3 (7) 11.9 (±6.2) 8.2 (±6.6) 14.5 (±13.5) macro meso micro outcomes of the 1st data analysis environmental taxonomy taxonomy 1. need for the curricula 2. large-scale implications 3. mechanics and structure of the curriculum 4. further training needs of quali�ed sta� 1. current gaps 2. threats to content 3. personal attitudes 4. coping and therapist burn-out 1. physiotherapy content 2. prognosis 3. prevention 4. counselling 5. large scale implications concepts categories 1. 1b. 1c. 2. 2a. 2b. 2c. 2d. 2e. 2f 2f.1 need for hiv in curriculum need for curriculum current felt and perceived gaps physiotherapy content content of curriculum prognosis role of physiotherapist in hiv large-scale implications prevention physiotherapists self-protection coping and therapist burn-outpart of self protection. 2g. 3. 4. 5. 6. 7. counselling personal attitudes to h/a mechanics/structure of curriculum threats to content concerns of clinicians and academics further training needs themes 1. 2. 3. 4. 5. need for curriculum curriculum — specific to physiotherapy underlying concerns curriculum design contiuous prfessional development fig. 1. schematic presentation of hiv curricula taxonomy. 58 november 2013, vol. 5, no. 2 ajhpe application. table 2 outlines these micro-level needs for one theme for physiotherapy content. remaining themes. under the theme application, categorised under treatment approaches, were: physiotherapy management, concepts such as the relationship between cd4 counts v. mobility/function, effective physiotherapy interventions, when to exercise, dealing with general weakness, self-protection, and counselling. knowledge application and philosophy included the role of physiotherapy in hiv and the need for inclusion of physiotherapy-related management principles. information analysis and application of understanding included aspects such as hiv aetiology and prognosis, medical treatment, prognostic information and changes, understanding overall management, treatment, arv therapy and its secondary complications, and public health implications, e.g. prevention efforts and community implications for hiv. although the pathology concerning physiotherapists was elicited from the literature, the fgds highlighted how pathology specifically interplays with hiv and issues specifically related to this condition, such as recurrence of illness, hiv staging in relation to physiotherapy, disclosure, case variation and comorbidities. a quote from one of the participants illustrates some of the difficulties: ‘there’s such emphasis on strokes and on paraplegia and all of that, and you come here and so many of the patients you see have peripheral neuropathies … transverse myelitis and painful feet, peripheral neuropathy … myopathy.’ topics that emerged from the fgds were similar to those described in the literature,[12-14] i.e. physiotherapy content, prognosis, prevention, counselling and large-scale implications of hiv. the fgds highlighted the need for factual knowledge on pathology and management of impairments and understanding hiv presentation, particularly its episodic nature, how arvs affect presentation and staging, as well as disclosure issues. these were considered to be gaps in the curriculum that complicate the application of hiv knowledge. clinical therapists explained how poor disclosure made it difficult to tackle real issues if the patient was unwilling to openly discuss their hiv status,[15] as stated here: ‘the difficult part is that often the patient himself doesn’t know that he’s positive. they often find that out … when he’s already in hospital and you’re not supposed to talk about it. but it’s a policy, a national issue. i haven’t come up with a plan to help tackle it. at this juncture we are a bit under pressure to follow regulations.’ the ‘state of non-disclosure may instil the fear of being infected into physiotherapists’.[16] physiotherapists’ responses to hiv should be enhanced by more sensitive training/practice, and some of these issues were evident in the mesolevel concerns. physiotherapists wish to play an active part in the management of patients with hiv/aids and indicated the need for the curriculum to clearly define the role of the therapist in hiv management, including specific roles in a rehabilitative versus palliative setting and acute versus chronic patient management. furthermore, clinicians needed clarity on the principles governing treatment of hiv patients and effective evidence-based micro level further abstraction categories themes application application of knowledge and philosophies information analysis and application factual knowledge -conditions -counselling -disclosure omissions across all levels: micro meso, and macro -approach to managment of hiv -hiv-related conditions -arv-cd4 v. mobility -e�ective interventions -self-protection -identify for physiotherapists -application of principles and -public health implications -large-scale implications -comorbities 1. physiotherapy content 2. prognosis 3. prevention 4. counselling 5. large-scale implication ethics within hiv management fig. 2. micro level. results of secondary analysis. meso further abstraction categories themes gaps threats personal attitudes coping and therapist burn-out macro needs for hiv large-scale implications mechanics and structure training needs no further abstraction needed -knowledge gaps -clinical -structural -psychomotor -individual perception and response -knowledge gaps -clinical -structural -psychomotor -individual perception and response -perception of whose responsibility hiv is -approach to including content -increased input of appropriate content -approach and method of information delivery -approach and methods of including hiv -speci�c knowledge gaps -clinical-re�ective practice -structural-perceived need for inclusion and relevance of hiv -psychomotor-coping burn-out, loss of hope, negative fig. 3. meso and macro levels. results of secondary analysis. research november 2013, vol. 5, no. 2 ajhpe 59 research table 2. micro level needs, part 1: physiotherapy content physiotherapy content knowledge categories themes quotations • episodic nature/recurrence of illness • approach – good nutrition, good drugs and mobility • pathology and patient staging – relation to physiotherapy • arvs – implication, application, effectiveness/noneffectiveness, role, mechanisms, complications and programmes • disclosure issues (challenge laws and charters) omissions determinants of hiv disease and relationship to virology and hiv prevalence • hiv staging and classification in sa • activity, limitations, and participation restrictions • hiv management approaches • approach to management of hiv • factual knowledge and information • application of knowledge ‘we spend so much time with the patients … we’re not, ... , equipped to be able to say, ok, you’re hiv positive, ... may be it’s because we don’t have this knowledge or we’re not confident enough to say: from here, with a cd4 count of less than 10, you may not have very long to live.’ • case variation and common medical problems, e.g. psychiatric conditions, neurological conditions (stroke, peripheral neuropathy), input into specific areas such as orthopaedics, chest conditions, co-incidental co-morbidities, depth of common conditions omissions common impairments such as pain, energy drive, dyspnoea, spectrum of mental effects, body mass, voice and speech functions how hiv causes impairment • hiv implications for physiotherapy and disease aetiology, physiotherapy-specific input • what is the practical approach to the hiv patient? • managing the very ill • conditions associated with hiv • factual knowledge and information • application of knowledge ‘i think it’s so vast and that it actually connects with so many other conditions that we could integrate it. hiv is part of everything because hiv affects your pathology, your recovery, your rehab, whatever.’ table 3. meso level: gaps perceived in the current curriculum concepts category theme quotations • clinical picture • no practical application • lack of clear picture of hiv staging • need for numbers to quantify problem • contact with hiv-positive teachers clinical gaps perceived in the current curriculum ‘i think the most important thing is the number of patients we see because that will determine its importance.’ • fragmented approach to hiv input (especially in adults) structural ‘when we were students and we did human behavioural sciences in sociology in first year, we did do quite a lot on hiv socio-economic implications, etc., etc. so i just felt that because we weren’t in the situation we didn’t realise the prevalence of hiv in south africa and things like that. i mean, we had just come out of school, we were still in our own – you know, getting out of the home kind of thing, and getting into reality. so, i mean, the implications didn’t really hit home until we got here.’ part of self-protection • loss of hope • loss of morale • effect of hiv on personal level psycho-motor needs coping and therapist burn-out ‘suffering is a huge issue out here. we watch caregivers suffer as they try cope with their daughter who is going to die before them.’ • staff overload • other health workers • physiotherapists structural effects 60 november 2013, vol. 5, no. 2 ajhpe physiotherapy interventions. the application of rehabilitation models, principles and ethics in the management of hiv/aids is also an important aspect of defining hiv rehabilitation.[17] one recently qualified participant said: ‘uhm, the way that i treat my patients is, i tell the truth as much as i possibly can. i talk about the side effects, i talk about everything and i think if everybody was trained in that, if the physio sees a patient and thinks ag, this patient had a stroke, they’re a goner, and i can’t be bothered ...’. this information points to the need for a comprehensive approach to the management of hiv patients, including prevention, treatment and a professional and an empathetic disposition towards people with hiv/aids. counselling was also seen as important for comprehensive patient management, but was absent. the benefits have been well documented in the literature[18] (tables 2 4). other missing components were the determinants of hiv disease, staging of hiv, physiotherapy management approaches, and a patient screening system. the effect of hiv on body systems and their interplay must also be included in the curriculum, e.g. the effect of hiv on both the pulmonary and haematological systems and its contribution to dyspnoea (tables 2 4). some academics mentioned the need to include the effect of exercise on hiv, and clinicians felt that a clearer position and guiding principles on implementation programmes for exercise and function were needed. there was an unclear link to clinical reasoning in areas such as function and mobilisation: ‘yes i have seen that people with a cd4 of 150 are non-functional and others with a cd4 of 2 are up and about’. understanding the true prognosis of hiv was seen as an important prerequisite to managing hiv, as it has profound effects on the attitudes and affective consequences experienced by therapists. meso level meso-level issues can potentially affect the implementation of a curriculum if not carefully incorporated at the planning stage. four themes emerged that were directly related to gaps in the curriculum: issues related to personnel, i.e. coping and burn-out; perception; attitude; and structural threats. table 3 describes one section of the content. other themes under the meso level are outlined below. remaining themes. personal attitudes to hiv/ aids: clinicians and academics admitted their knowledge gaps regarding hiv and its prognosis, with the predominant perception of hiv being a death sentence. some academics perceived the inclusion of hiv/aids as a threat and as interference in their undergraduate training programme. structural and organisational threats, e.g. in one academic institution medical personnel – not physiotherapists – determined the hiv content for the physiotherapy curriculum. in addition, clinicians found clinical decision-making difficult because of high hiv patient loads. with such large numbers of hiv patients, ethical issues and value judgements presented problems that can be addressed in the curriculum. under the theme current gaps in knowledge, some practitioners thought that topics such as hiv staging were theoretical and not practical. one clinician said: ‘hiv is so all-encompassing, it takes bits and pieces from so many different areas of physiotherapy: from neurology, the respiratory, when you get patients who end up with tb signs, all sorts of things. to draw everything together would be useful.’ on a personal level, coping and therapist burnout were experienced with both psychomotor and affective effects, i.e. loss of hope and morale, physiotherapy worthiness, and the effects of hiv. the lack of clarity of the physiotherapist’s role seems to result in a dilemma where practitioners question the extent of their patient management. clarity of roles is important for professionals’ ability to advocate and place themselves in the management continuum of a condition as well as having the confidence to market their professional contribution.[17] puckree et al.[19] suggested more practical education on the physiotherapist’s role and clinical practice on how to handle patients with hiv. the episodic nature of hiv requires that the therapist is aware of this constant flux and its effect on their management roles.[20] table 4. macro level: mechanics/structure of curriculum concept category theme quotations • stand-alone initial phase/ microbiology, clinical sciences • co-ordinated input • integrated approach • focus on principles approach to content mechanics/ structure of curriculum ‘you do not teach the treatment of diseases but rather the principles applied to the management of conditions.’ ‘i wanted to say it’s actually very difficult to make it a subject on its own because it’s actually duplicating – it should be incorporated in each specific field.’ • increased hiv content • increased depth and breadth • comprehensive input • avoid repetition content related ‘so i think it’s quite a holistic approach, but it’s on a basic level, it’s not too involved … .’ ‘… but i also think we should concentrate more on diverse things, like, we’re now getting more patients on arvs, so what now? i think that’s where we should be focusing on … .’ • evidence based • active learning • problem-solving approach • lecturers to have relaxed attitudes to hiv • teaching methods – ward rounds, interactive, lively approach and methods ‘they have to read the evidence of the article content and the article has to have relevance to the patient. so you know, make them active learners.’ ‘we bring them to the water, now they must drink.’ research november 2013, vol. 5, no. 2 ajhpe 61 research finally, the application of appropriate attitudes and behaviours included counselling, disclosure and clinical decision making. table 2 shows how personal attitudes play an important role in determining the management of persons living with hiv/aids. therapists battle with their own perceptions of hiv being a death sentence, with being judgemental and with their own beliefs regarding hiv. the perception was that lecturers exhibit their personal attitudes in the way they teach the subject. ‘i think a lot of the time we actually get taught in a way that [whispers] [name] is hiv positive. you know, like, if we just get told a bit more positively … [clinician]. all studies on the inclusion of hiv in the curriculum have shown that training diminishes negative attitudes, enhances willingness to treat, promotes appropriate practice behaviour and contributes towards becoming a more patient-centred health provider.[21-23] therefore, the macro-level effect on an hiv curriculum is important as it may help to obtain a better understanding of the condition, how to implement training and how to solve some of the attitudinal problems. macro level four themes emerged here: curriculum structure; whether it should include large-scale implications; need for an hiv curriculum; and continuous training and development. table 4 outlines one of the macro-level themes and categories. macro-level issues include society, the healthcare environment, the higher education system and the knowledge related to physiotherapy, therefore dealing with large-scale implications influencing a curriculum.[5] participants supported an integrated, evidence-based curriculum. a mixed position was evident in ‘how to’ include hiv in the curriculum and ‘how much’ information there should be. one of the supporting views for an integrated topic is: ‘when it stood on its own, i didn’t understand the connections with the physiotherapy profession. i mean it was, like, greek [clinician].’ the pervasive nature of hiv, which affects all body systems, supports its integration into all topics of the curriculum and not being a ‘stand-alone’ topic. newly qualified clinicians were surprised at how many patients were hiv positive, irrespective of diagnosis, and emphasised the need to integrate hiv into all fields being taught. no literature could be identified that describes the advantages or disadvantages of integrating a pervasive condition into an educational curriculum. however, the complexity of hiv/ aids has been recognised through the need to address its social, biological and ethical perspectives.[23] hiv is transcendent in that it affects all aspects of human life, requiring a comprehensive approach. however, participants cautioned on the danger of ‘overkill’: ‘careful about overkill. you mustn’t be repeating the same thing … .’ while an academic said, ‘i wanted to say it’s actually very difficult to make it a subject on its own because it’s actually duplicating – it should be incorporated in each specific field’. reservations with regard to overloading of the physiotherapy curriculum are not surprising as this is an expected reaction to change. jones et al.,[24] in assessing the response to curricular change in medical schools, reported that change is compromised by resistance to change and the need for a high degree of autonomy among faculty members. nevertheless, results show that efforts are being made to include hiv in all universities represented in these focus groups. [2] two other themes emerged relating to the perception of hiv management as a political issue and that it should be left to education authorities. much animated debate took place in all 6 groups on whether there was a need to include hiv in the curriculum, with one group proposing that the physiotherapy curriculum was not responding to the clinical setting: ‘there are so many different presentations that often they come up with the strangest, newest, weirdest presentations that are unbelievable’. generally, political desirability and the obligation to be informed about hiv were important reasons given for curricular inclusion of hiv, supported by the following quotes by academics: ‘i think it’s actually expected of us ... it’s a political issue’. ‘my opinion, i don’t think it must be in the curriculum. not necessarily in the curriculum but i think it must be part of the department of education’s something ?’ a position such as this does not give the impression of developing curriculum programmes that respond to changes in a macro environment. some participants strongly supported the inclusion of large-scale implications and called for better co-ordination of content. practitioners and academic staff established a link between their role as therapists and the impact of managing hiv, but seemed to be in a state of confusion about how to implement this. the foregoing may be attributed to some physiotherapists having little understanding of social determinants and being entrenched in the medical model of management. hiv/aids profoundly affects the entire individual and is complex, is stigmatised and has socio-economic implications. it therefore calls for professionals, including physiotherapists, to fully embrace a biopsychosocial paradigm for managing these patients.[25,26] conclusion a central theme emerging from the fgds is that clinicians and academics felt it was important to include hiv/aids into the physiotherapy curriculum. there were, however, two strongly non-aligned views: those who felt it was important to limit the role to traditional training, and the opposing view of a professional trained within an environmentally and politically sensitive context. the complexity of shared experiences, opinions, misconceptions and gaps in knowledge of both clinicians and academics revealed the need for a complex well-designed programme for the physiotherapy management of hiv. some of the difficulties experienced revealed a range of mesoand macro-level issues that may affect the content and implementation of a curriculum in which the management of hiv is fully integrated into all fields. these fgds elicited contextually specific input that added to the information obtained from the literature and an evidence-based patient profile. the list of topics that emerged was taken to the next level of validation for a contextually informed hiv curriculum tested for consensus using a delphi technique. acknowledgement. we gratefully acknowledge financial assistance from the medical research council of south africa (mrc) and the carnegie trust fund. references 1. unaids. world aids report. geneva: unaids, 2009. 2. myezwa h. mainstreaming hiv into physiotherapy curriculum. phd thesis. johannesburg: university of the witwatersrand, 2008. 3. myezwa h, stewart a, mbambo n, et al. status of referral to physiotherapy among hiv positive patients at chris hani baragwanath hospital, johannesburg, south africa, 2005. south african journal of physiotherapy 2005;63:27-31. 4. myezwa h, stewart a, musenge e, et al. assessment of hiv-positive in-patients using the international classification of functioning, disability and health ( icf), at chris hani baragwanath hospital, johannesburg. african journal of aids research 2009;8:93-106. [http://dx.doi.org/10.2989/ajar.2009.8.1.10.723] 5. shepard kf, jensen g. handbook for teaching physical therapists. woburn, usa: butterworth heinemann, 2002. 6. van den akker jjh. curriculum perspecticves: an introduction. in: van den akker j, kuiper w, hameyer u, eds. curriculum landsacape and trends. dordrecht, the netherlands: kluwer aademic publishers, 2003. 7. babbie e, mouton j. the practice of social research. cape town: oxford university press, 2003. 8. charmaz k. grounded theory in the 21st century. in: denzin n, lincoln ys, eds. handbook of qualitative research. 2nd ed. london, uk: sage publications, 2000:507-535. 9. tesch r. the mechanics of interpretational qualitative analysis. qualitative research analysis types and soft ware tools. basingstoke: the falmer press, 1992. 10. macallan dc. wasting in hiv infection and aids. j nutr 1999;129:238-242. 11. kielhofner g. research in occupational therapy: methods of inquiry for enhancing practice. philadelphia: davis, 2006. http://dx.doi.org/10.2989/ajar.2009.8.1.10.723] 62 november 2013, vol. 5, no. 2 ajhpe 12. balogun ja, kaplan mt, miller tm. the effect of professional education on knowledge and attitudes of physical therapist and occupational therapist students about acquired immunodeficiency syndrome. physical therapy 1998;78:1073-1083. 13. puckree t, chetty bj, govender v, et al. are physiotherapy graduates adequately prepared to manage hiv/aids patients? south african journal of physiotherapy 2004;60:7-10. 14. schlotfeldt p, potterton j. physiotherapy students knowledge and attitudes to the treatment of patients with hiv infection. johannesburg: university of the witwatersrand, 2002. 15. myezwa h, stewart a, solomon p, et al. topics on hiv/aids for inclusion into a physical therapy curriculum: consensus through a modified delphi technique. journal of physical therapy education 2012;26:50-62. 16. salati f. the knowledge and attitudes of pts towards patients with hiv/aids in lusaka province, zambia. cape town: university of the western cape, 2004. 17. solomon p, guenter d, salvatori p. integration of persons with hiv in a problem-based tutorial: a qualitative study. teach learn medical 2003;15:257-261. [http://dx.doi.org/10.1207/s15328015tlm1504_08] 18. the voluntary hiv 1 counseling testing study group. efficacy of voluntary hiv 1 counselling and testing in individuals and couples in kenya, tanzania and trinidad: a randomised control trial. lancet 2000;356:103-112. [http://dx.doi.org/10.1016/s0140-6736(00)02446-6] 19. puckree t, chetty b, govender v, et al. physiotherapists and human immunodeficiency virus/acquired immune deficiency syndrome: knowledge and prevention. a study in durban, south africa. international journal of rehabilitation research 2002;25(3):231-234. [ http://dx.doi.org/10.1097/00004356-20020900000009] 20. o’brien k, davis a, strike c, young n, bayoumi a. putting disability into context. factors that influence the experiences of ‘disability’ for adults living with hiv/aids. vancouver, canada: wcpt, 2007. 21. seacat jp, inglehart mr. education about treating patients with hiv infections/aids: the student perspective. journal of dental education 2003;67:630-640. 22. held sl. the effects of an aids education program on the knowledge and attitudes of a physical therapy class. physical therapist 1993;73:156-164. 23. solomon p, salvatori p, guenter d. interprofessional professional problem-based learning course on rehabilitation issues in hiv. medical teacher 2003;25:408-413. [http://dx.doi.org/10.1080/0142159031000137418] 24. jones r, higgs r, de angelis c, et al. changing face of medical curricula. lancet 2001;357:699-703. [http://dx.doi. org/10.1016/s0140-6736(00)04134-9] 25. worthington c, myers t, o’brien k, et al. rehabilitation in hiv/aids: development of an expanded conceptual framework. aids patient care & stds 2005;19:258-271. [http://dx.doi.org/10.1089/apc.2005.19.258] 26. eisner ew. curriculum ideologies. the educational imagination. 3rd ed. new york: macmillan, 1992:47-107. appendix. implications from 3 studies and a literature review informing key concepts and questions for the focus group discussion key findings/conclusions concept questions • dynamics and determinants of the pandemic • physiotherapists’ role in patient management • preventive measures • what preventive measures are taught? • low referral status to physiotherapy by health workers and medical practitioners • knowledge gaps among qualified physiotherapists • physiotherapists’ role in education • what do you think the physiotherapists’ role is in hiv management? • patients’ age range, and marital and employment status. impact of these factors on their support structures • physiotherapists’ role in patient management • socioeconomic implications • should large-scale implications of hiv disease be included in physiotherapy education and practice? • pervasive nature of hiv – impact on all key body systems (pathophysiology) and problems (impairments) manifesting at impairment level – voice and speech functions, haematological, respiratory, digestive, metabolic, endocrine and musculoskeletal • subsequent association between impairments and activity limitations • depth and breadth of input • should hiv be taught on its own within physiotherapy curriculum? • should hiv stand alone? • what considerations determine the depth and breadth of and input on hiv? • are there any specific areas that should be taught that therapists are likely to encounter and treat in hiv-positive patients? • deficiencies in professionalism or hiv knowledge that should be addressed in the curriculum[21] • current deficiencies • level and type of integration, • hiv as ‘stand alone’ • should hiv be integrated into other areas such as paediatrics, neurology, orthopaedics, public health and the community? • basics of philosophy, goals, coursework, clinical experiences and evaluation processes influence the curriculum[5] • beliefs, values, practices • what beliefs, values, and practices are important for the delivery of prevention, treatment and care? • physiotherapy philosophy promotes well-being through holistic healthcare as part of the multi-disciplinary team. through these efforts it contributes to a comprehensive healthcare delivery system. association between impairments, and activity limitations, e.g. muscle strength affecting one’s activity level • underlying treatment principles • what principles have you identified as being important for delivering prevention, treatment and care in hiv, specifically for physiotherapists? • basics of philosophy, goals, coursework, clinical experiences and evaluation processes influence curriculum. it must respond to current physiotherapy developments, changing environment and human healthcare needs • curriculum content • are there any specific areas that should be taught that therapists are likely to encounter and treat in hiv-positive patients? • teaching methods need due consideration[5] • a factor that was pertinent to students’ attitudes to hiv included personally knowing someone who is hiv positive[21] • problem-based learning models[23] • teaching methods • what methods of teaching could be utilised? research http://dx.doi.org/10.1207/s15328015tlm1504_08] http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1097/00004356-200209000-00009] http://dx.doi.org/10.1097/00004356-200209000-00009] http://dx.doi.org/10.1080/0142159031000137418] http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1089/apc.2005.19.258] article november 2013, vol. 5, no. 2 ajhpe 63 background. a need for professional development in the training of registrars was identified by the school of medicine, university of the free state (ufs), bloemfontein, south africa, in 2007. objective. to develop the module on health care practice (hcp) (gpv703) to address these shortcomings. methods. a quantitative study, enhanced by qualitative data, was conducted. a self-administered questionnaire that included a rating scale and open-ended questions was used. the quantitative responses were analysed using microsoft excel, and the qualitative data were edited, categorised and summarised. results. the questionnaire was completed by 95% (n=38/40) of registrars. the quantitative questions, regarding the orientation session, content and applicability of the content of the module, showed satisfactory to very good responses. of the 40 surveys collected from registrars, 77.5% (n=31/40) were completed by heads of department (hods). the surveys showed a significant improvement in registrar competence: 17 were given an aboveaverage rating and 14 an average rating; there were no below-average ratings. discussion. the module on hcp, which is part of the mmed programme, addressed aspects required by registrars to develop and/or enhance their skills, knowledge and professional behaviour with regard to ethics, practice management and patient communication. registrars were generally satisfied with the content and presentation of the module. the open-ended questions raised concerns about aspects of patient communication and electronic learning. these need to be addressed to improve the quality of the module. conclusion. the module on hcp (gpv703), as implemented by the ufs, is successful in addressing key aspects often neglected because of the strong clinical focus of a medical programme. ajhpe 2013;5(2):63-67.doi:10.7196/ajhpe.195 a reflection on professional development of registrars completing a module in health care practice j bezuidenhout,1 phd; m m nel,1 phd; g j van zyl,2 phd 1 division of health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: j bezuidenhout (bezuidj@vfs.ac.za) in south africa, the programme for the training of medical specialists (registrars) in a particular discipline leads to the postgraduate master in medicine (mmed) and/or the colleges of medicine qualification. the programme creates opportunities for postgraduate education and training in specific specialist disciplines ranging over a 4or 5-year period. registrars are appointed in specific departmental posts in the various specialties at the university of the free state (ufs) in bloemfontein, south africa, by the department of health. registrars completed their undergraduate training at one of the 8 south african medical schools or elsewhere, obtaining the qualification medicinae baccalareus, chirurgiae baccalareus (mb chb).[1,2] the need to train registrars in aspects related to ethics, practice management and patient communication was identified by various reports from the health professions council of south africa (hpcsa) (unethical practice and misconduct)[3] and in meetings with various schools of medicine and deans.[4] the module evaluates registrars with regard to the latest international tends in ethics, hpcsa requirements for the management of a practice, and proper conduct related to communication when dealing with patients. since 2008, registrars at ufs are required to complete the health care practice (hcp) module as part of the mmed programme. it is offered during the first 24 months of registrar training and is a compulsory, attendance-based module in each of the disciplines. an orientation session is offered in addition to sessions on ethics, practice management and patient communication. the orientation session highlights the training outcomes and course content of the mb chb programme, and focuses on the importance of this content and on outcomes, regulations and requirements related to the module, as well as on the use of the blackboard learning management system (lms) (blended-learning approach).[2] the expectations of, and requirements for, registrars in training undergraduate students to become successful interns are presented during the orientation session. the hcp module has been developed specifically to enable each registrar to address their unique needs as far as ethics, practice management and patient communication are concerned. the main task of the facilitators (module leaders, module presenters, heads of department (hods) and consultants in the specific disciplines) is to support registrars in the learning process. various sessions are presented within the initial 24-month period of registrar training on sections of the module to provide an opportunity for all registrars to attend at a convenient time.[3] in the hcp module, the emphasis is on professional practice – where the focus is on action in clinical practice – and the purpose of mastering the required knowledge and skills is termed application, and not merely to know or to know how. learning by doing is central to the module and therefore practical application receives considerable attention. the ability to apply knowledge that has been gained (or revisited) is of extreme importance in clinical education, training and research. learning needs for the hcp module were identified, as registrars raised concerns about the lack of knowledge related to practice management, patient communication skills and a world-driven focus on the ethical treatment of patients.[5] the staff concerned with the development and presentation of the programme have expertise in the fields of health sciences, health professions education and higher education. therefore, the programme is presented within the context of education for a particular health discipline. educationists in health sciences and other subject specialists are involved co-operatively to ensure contextualisation. guest presenters, i.e. clinicians, health sciences professionals and other professionals, facilitate the contextualisation and application of the content of the module.[5] research mailto:bezuidj@vfs.ac.za 64 november 2013, vol. 5, no. 2 ajhpe research objectives the objectives of the study were to: • investigate whether the module on hcp addresses the needs identified by the school of medicine, ufs, in the training of registrars regarding issues outside their specific clinical disciplines, as required by and needed as professionals. • improve the quality of the module by identifying shortcomings and retaining aspects of importance as identified by the respondents. • obtain the opinion of hods on registrars regarding ethical insight, patient communication and practice management. • determine whether the module has had an impact on professional conduct and knowledge of ethics, patient communication and practice management. methods the study was quantitative, enhanced by qualitative methodologies. a questionnaire consisting of a 4-point rating scale (1= very weak, 2 = weak, 3 = satisfactory, 4 = very good) with open and closed-ended questions was developed.[4] it included items related to: (i) the content of the hcp module; (ii) aspects of the module that were regarded as most beneficial; (iii) aspects of the module regarded as least beneficial; (iv) how the school of medicine could assist with the improvement of registrar training and assessment; and (v) feedback from the hods regarding registrars' insight into ethics, patient communication and practice management in their specific discipline.[3] a questionnaire consisting of three sections was designed to address the outcomes of the module, investigate the experiences of registrars in the module, and obtain comments from hods on registrars’ competence in ethics, practice management and patient communication after completing the hcp module. their findings, based on desired behaviour and feedback, were presented during academic discussions. changes before and after completion of the module was the main focus of interest. the quantitative responses were statistically analysed using microsoft excel© and the qualitative statements were then categorised and summarised.[6,7] our intent was for the quantitative data to be verified by means of the qualitative results, which aimed to identify aspects of the module that were satisfactory and those that needed to be addressed to improve quality.[8] data were collected after every session and the questionnaire was submitted after completing the initial 24 months of training. we used the qualitative data to augment and provide additional sources of information on the module.[6] informed consent was obtained before completion of the self-administered questionnaire. ethical approval to conduct the study was obtained from the ethics committee of the faculty of health sciences, ufs. permission to involve staff and students in the study was obtained from the head of the school of medicine and the vice-rector, teaching and learning, ufs. results registrars (n=40) completed the newly introduced module gpv703 from 2009 to 2011 and 95% (n=38) completed the questionnaire. forty questionnaires were handed out, and two respondents opted not to participate in the study. of the questionnaires collected, 77.5% (n=31) were completed by hods. registrars showed ‘satisfactory to very good’ responses for the questions related to the orientation session, content and applicability of the content of the module (table 1). results shown in table 1 demonstrate that the majority of registrars were positive towards the module with regard to presentations and content. certain aspects, such as the usefulness of the module content in an e-learning format and the contents of the patient lecture on communication, need attention. other presentations, i.e. the ethics component of the module, were well received. registrars were less satisfied with the e-learning (blended learning) component of the module, as many of them did not have access to internet facilities on the various educational platforms. they experienced constraints related to bandwidth of the electronic blackboard lms environment. the ufs also experienced technical difficulties related to the infrastructure, limiting accessibility to the blackboard lms. in the section on patient communication, many registrars were unfamiliar with the skills related to communication. one of the speakers presented the subject matter inadequately and out of context and not as required by registrars in their professional context. this was reflected in the responses and rating. qualitative data from questionnaires responses to the open-ended questions were divided into categories according to their respective headings. responses by registrars and hods were allocated to themes, coded under their respective headings, and separated into responses dealing with orientation, ethics, practice management and patient communication. qualitative responses from registrars to the question of which aspect(s) of the module were most beneficial are included, excluding repetitive phrases and statements (table 2). responses from registrars on the question of how the school of medicine can assist with the improvement of registrar training are given in table 3. table 1. quantitative responses from registrars regarding the orientation session, content and applicability of the health care practice module (gpv703) questions set on elements of the orientation and content of the module n registrars' rating of the items on a likert scale (%) 1 very weak 2 weak 3 satisfactory 4 very good 1. orientation to aim and outcomes of module 38 0 5.3 73.9 21.1 2. availability of module guide 37 5.4 0 62.2 32.4 3. usefulness of module content in e-learning format 36 2.8 11.1 66.7 19.4 4. introductory lecture on medical undergraduate education 37 0 8.1 54.1 37.8 5. contents of ethics lecture 38 0 0 42.1 57.9 6. contents of practice management lecture 38 0 0 55.3 44.7 7. contents of patient lecture on communication 34 2.9 26.5 44.1 26.5 8. relevance and applicability of module content for my own discipline 37 0 8.1 67.8 24.3 november 2013, vol. 5, no. 2 ajhpe 65 table 2. qualitative responses from registrars on the question of which aspect(s) of the health care practice module (gpv703) were most and least beneficial sessions most beneficial aspects least beneficial aspects orientation undergraduate training • ‘answered many questions.’ • ‘better knowledge of undergraduate modules and composition of course.’ • ‘training in the lectures (for a good foundation).’ • ‘addresses topics that do not usually receive attention/not exposed regularly. insight into undergraduate training which we are directly involved in.’ non-clinical part of training • ‘firstly, i understand the students’ role and planning.’ • ‘better understanding of student training.’ • ‘making aware of the non-clinical part of training.’ outcomes of the programme • ‘it was a bit premature.’ • ‘preparation for work when i'm done.’ • ‘brought insight into the goals of student training.’ • ‘questions posed made me think about these aspects of my career.’ ‘orientation and undergraduate medical training. introductory lecture on medical undergraduate education.’ ethics insight into the application of ethics in the health system • ‘ethics lectures were of great value. medico-legal aspects of permission update on ethics and the changes the state is envisioning for health was very good. introduced information and broader understanding on ethics.’ • ‘ethics lectures and health professions council of south africa (hpcsa) guidelines were well presented and the module guide to practice management.’ • ‘consultation/presentations from non-medical professionals: improved insight into health system. very applicable.’ • ‘applicable clinical and practical examples were given to make ethics clearer and understandable.’ value of ethics for registrars and undergraduate students • ‘must be made compulsory for all registrars every year! it prepared me for the outside world.’ • ‘i enjoyed the ethics lectures. it should also be presented at undergraduate level.’ registrars were generally satisfied. practice management holistic approach in management of practice and handling of patients • ‘it complements my academic learning. it encourages holistic approach in the management of patients. in future, one will be able to handle patients.’ • ‘it exposed us to an aspect of medical practice not thought about during medical training. the aspect discussed during the lecture involved practice management, ethics, communication and billing, which can be implemented both while training and in practice.’ • ‘it prepared me for private work and taught me more on government's plans with nhi.’ • information on the new planned national health system.’ ethics in practice management • ‘new insight in hpcsa rules regarding ethics and practice management was enlightening and to practise ethically and accordingly. gained new insight in especially ethical matters regarding pathology practice.’ • ‘i realised that certain things i would like to include into my practice did not fit in with the ethical guidelines, like sharing a practice with someone practising alternative medicines.’ practice rules and regulations • ‘good information on practice rules and regulations. better insight in respect of the decisions that need to be taken to improve the health system and all the stumbling blocks at management level.’ legal aspects of a practice • ‘the legal and financial considerations to take into account when establishing a private medical practice, different type group practice, their advantages and disadvantages, billing arrangements, prescribed minimum benefits, advertising, malpractice insurance, utilisation management, communication skills, importance and ethics were very insightful.’ • ‘content of training sessions not completely relevant and applicable for the discipline.’ 66 november 2013, vol. 5, no. 2 ajhpe research table 2 (continued). qualitative responses from registrars on the question of which aspect(s) of the health care practice module (gpv703) were most and least beneficial sessions most beneficial aspects least beneficial aspects patient communication • ‘the communication lecture held practical benefits and examples. the communication lecture focused on what a patient expects during a consultation. furthermore the communication lecture helped with interpersonal relationships.’ • ‘patient communication was a poor lecture. very little applicable.’ • ‘session on patient communication: radio announcer had little relevance.’ • ‘aspects such as communication – we have already had undergraduate communication as a subject.’ general comments • ‘exposure to certain aspects, e.g. research, which you would not necessarily do in your practice. better understanding of resources available, e.g. article research etc.’ • ‘some of the lectures were presented in the middle of primary exams. not a good time. here it is aimed more at cpd marks to non-registrars as opposed to the training of registrars.’ • ‘possibly a refresher course could be presented later for those interested, closer to the end of the course, especially practice management.’ • ‘the time of the evening, together with other clinical work and preparation. three hours on a night is too much. rather divide it into sessions. i don't know if it will make a difference in how doctors work.’ • ‘never knowing when the classes are, told at last minute.’ table 3. improvements in registrar training programme sessions computer-related issues • ‘install “up to date” at the hospital's computer for internal medicine ward, references and clinics. in consideration of the available resources, i think the training at this stage should not be altered too much. more focus on research. more focus on general illnesses prevalent in sa – hiv, tb, etc.’ • ‘training on computer work and looking for information for projects.’ ethics • ‘more information on international norms, values, ethical issues and especially practice management, in order that we can also have an idea of how other countries function – most specialists will at one stage or another be exposed to specialists from other countries.’ • ‘maybe in-house discussions on clinically relevant ethical dilemmas.’ time constraints • ‘schedule classes early, please let all disciplines know sufficiently in time. we have outreach clinics that we must attend, which often conflicts with gpv703 classes. we need more time to make alternative arrangements, please.’ • ‘sometimes there is more focus on the work that should be done than on training.’ • ‘academic time should not be lost due to personnel shortage. shorter but more sessions. difficult to sacrifice 3 hours per night. two or three sessions of 45 minutes maybe more acceptable.’ • ‘i suggest that the lectures all take place on one day, where all registrars are made available for lectures presented. the lectures can then be focused more on registrars.’ • ‘more available time for research.’ • ‘allocating time for research required to complete mmed degrees.’ e-learning • ‘they can put interesting articles on the e-learning website on a regular basis.’ academic platform, training and government issues • ‘continual pressure on the government for a bigger budget to improve working conditions regarding equipment, consumables, etc.’ • ‘apply determined academic time, in spite of personnel shortage. more tender time. maybe more information on practice management.’ • ‘in my opinion, i believe the improvement can come with addition of more aspects to gpv703, for example, how to build good working interdepartmental relations.’ • ‘optimise current sessions. more practical guidance in research. current sessions already very good, but would like to know which part done at e.g. biostatistics, and when they should be consulted.’ • ‘think we have more than ample opportunity in our department to improve learning. (self-study and own motivation is important, but it is the student's own responsibility.)’ general • ‘create opportunity to attend lectures/courses dealing with relevant topics. quarterly registrar meetings where concerns and problems can be raised.’ • ‘lectures and/or information pieces in respect of the business aspects and financial implications of establishing and running a practice (part-time and full-time). more courses like gpv703.’ editorial november 2013, vol. 5, no. 2 ajhpe 67 research assessment by hods on registrars' comprehension, insight and application of ethics, patient communication and practical management in their specific disciplines are given in table 4. discussion knowledge of ethics, patient communication and practice management is essential for the practice of clinical medicine. these skills are needed by all practitioners, especially those in private practice (the majority of doctors in south africa). the study results showed that the module on hcp addresses these aspects during the training of registrars. the majority of registrars were satisfied with the presentations and content of the modules. this was not the case for the presentation on communication skills. more information is needed to better understand the problems associated with this topic in which the content was not presented in an appropriate professional context. e-learning challenges also need to be addressed. because e-learning is often a problem in the developing world, its use needs to be carefully reconsidered. ethics is frequently discussed in interviews epitomising its role in clinical practice. registrars have made a huge contribution to improve the quality of the hcp module. they contributed significantly to assist the school of medicine with regard to presentation times, multiple presentations, quality of presenters and aspects related to module content. other aspects directly related to the training of registrars were referred to hods. registrar feedback provided a platform to identify shortcomings in their training and was shared with hods in a feedback session. improvements suggested by registrars are fairly simple to address (table 3). the results showed that hods observed a general improvement in registrars' insight, comprehension and application related to ethics, patient communication and practice management in this module, i.e. they observed progress and scored the registrars, but were reluctant to comment on or motivate their answers. this progress was based on their previous (superficial) observations and evaluations of registrars. of the 31 questionnaires completed by hods, 17 registrars were given an above-average and 14 an average score on the selected criteria. no registrars received a below-average score. hods indicated that they were under pressure as a result of staff shortages and service delivery needs and requested that they are not asked to participate in the completion of the questionnaire in future, i.e. their inputs would not be sustainable. the opinions of hods on registrars' insight into ethics, patient communication and practice management obtained from the present study will be used to adapt the hcp module and select appropriate presenters for the future. conclusion the module on hcp (gpv703), as implemented by the ufs, is successful in addressing key aspects often neglected because of the strong clinical focus of a medical programme. acknowledgements. we gratefully acknowledge assistance received from participating students and medical school staff involved in data collation. we appreciate the input of prof. vanessa burch (uct) related to editing and insight in writing this article. references 1. university of the free state. selection information for mbchb students. faculty of health sciences. school of medicine. bloemfontein: university of the free state, 2009:1-10. 2. university of the free state. yearbook of the faculty of health sciences. school of medicine. post-graduate/advanced degrees and diplomas. bloemfontein: university of the free state, 2011. 3. van der merwe w. the worcester cbe model. faculty of medicine. stellenbosch: university of stellenbosch, 2011. 4. hugo j. the university of pretoria cbe model. pretoria: university of pretoria, 2012. 5. nel mm, van zyl gj, bezuidenhout j. module in health care practice (gpv 703) for mmed programme: bloemfontein: university of the free state, 2007. 6. johnson rb, onwuegbuzie aj. mixed methods research: a research paradigm whose time has come. educational researcher 2004;33:14-26. [http://dx.doi.org/10.3102/0013189x033007014] 7. creswell jw. research design: qualitative and quantitative approaches. california: sage publications, 1994. 8. creswell jw. educational research. planning, conducting, and evaluating quantitative and qualitative research. 3rd ed. new jersey: pearson prentice hall, 2008. table 4. comments from heads of department interviewed theme comments ethics • ‘her feeling is that ethical handling of a patient is part of who you are and comes naturally. the session on ethics made her aware of her relationship with patients but did not mention her colleagues or society.’ • ‘ethics has been neglected in the training of registrars. the registrar’s patient communication skills really progress after the attendance of the gpv703 module. i think the module “ripens” registrars for the real life situations and environment they would face once they completed their studies.’ • ‘own experience and feedback received from fellow colleagues indicate a good comprehension and feeling of ethical aspects in the treatment of patients. she has insight with regard to ethical relations with patients, colleagues and industry.’ • ‘own experience and feedback from colleagues reflect good insight on ethical issues encountered in patient care and good communication skills.’ patient communication • ‘she gave good feedback on guidance on communication skills. the registrar has excellent bedside manners and is thorough in explaining to patients.’ • ‘have good communication skills with parents and children as patients. organisational skills during service delivery situations is satisfactory.’ • ‘she experienced the patient communication and speaker as not applicable to her need and level of communication with patients. after her explanation i understood her opinion.’ • ‘the student did not experience the lecture on patient communication as relevant and applicable in her context of work.’ practice management • ‘the session on practice management is still far away in her mind but gave her good insight on what awaits her. she has an opinion of her future career but is unsure where she wants to practice.’ • ‘she has good insight in the ethical relationship between doctor and patient, but also with her colleagues and the rest of the industry. practice management is far removed and futuristic. we informed her that she must start to position herself for the future and its realities in having her own practice in a healthcare system.’ general • ‘comments to the module development team from hods.’ • ‘one can feel proud on what has been achieved with the module.’ http://dx.doi.org/10.3102/0013189x033007014] september 2021, vol. 13, no. 3 ajhpe 167 research the problem south africa (sa) declared a state of disaster on 15 march 2020 due to the global covid-19 pandemic and went into a national hard lockdown, initially for 21 days from 27 march 2020.[1] the entire population was requested to stay at home, not to leave their homes unless seeking essential goods or services, and only essential workers were allowed to go to work. in response to the lockdown measures, tertiary educational institutions suspended faceto-face academic activities.[2] the covid-19 pandemic abruptly disrupted traditional teaching and learning at these institutions. there was, therefore, very little time to prepare alternative teaching methods, resulting in a rapid transition to remote online learning platforms. the university of kwazulunatal (ukzn) student population originates from diverse backgrounds and remote locations. although the logistics of ensuring that all students receive the necessary tools to participate in remote online activities were challenging, it ensured teaching and learning continuity during the pandemic. academics were compelled to change their teaching strategies and deliver content using online applications, e.g. web conferencing and learning management systems (lmss). inverting the classroom was adopted as a teaching strategy, as data for internet connectivity is very expensive in sa,[3] and time spent online with students needed to be optimised. transitioning to the remote online learning platform was a steep learning curve for both academics and students. online learning for a multifaceted pharmacy module was challenging, as clinical application for case studies and patient counselling role-plays, practical skills and tutorials on calculations all required facilitated group work. for the latter, students had to participate actively in the session, stimulating their ability to apply knowledge and critical thinking skills, and further encouraging them to engage with each other and the course content. the intervention this article shares our experience of attempting to facilitate group-work sessions on an online platform. a combination of teaching and learning approaches was used to cater for the students’ learning styles. these included the inverted classroom,[4] case-based learning,[5] peer learning, lmss and web-conferencing breakout rooms.[6] a contructivism[7] theory was used, as the students were in their final year and were able to draw on their knowledge from previous years. a new way of thinking for conducting group work for clinical skills practical and tutorial sessions, traditionally requiring face-to-face interaction, is presented. the innovation merges various pedagogies for teaching and learning with web-conferencing software to adapt group work for an online interface and can be employed in health professions teaching. pharmacy students are required to apply their theoretical learning to pharmacy practice. practical skills include appropriate patient interaction; counselling; and conducting pharmaceutical calculations during the dispensing process. these aspects are easily engaged with during face-toface sessions. to mimic such sessions on an online platform, we used an integrated approach to teaching and learning with a toolbox that supported the constructivist’s view to knowledge. the basis of this teaching strategy is the belief that students learn best when they gain knowledge through exploration and active learning. this was coupled with the inverted classroom approach and case-based and peer learning. the toolbox for synchronous online practical skills sessions was designed to incorporate 3 phases: phase 1. this is the pre-session phase, which used the inverted classroom approach, whereby students were provided, a few days in advance, with the content pre-readings pertaining to the topic. these readings and tutorials on calculations were posted on the lms for students to attempt individually before discussing their solutions during group work. phase 2. this is the in-session phase, which used the case-based learning approach, where each case was designed to represent a pharmacist faced with a patient. this was done to ensure that each student engaged in good pharmaceutical care approaches in line with the good pharmacy practice guidelines for sa. case studies containing patient counselling scenarios pertaining to the content topic were only provided during group work. the in-session phase made use of: (i) breakout rooms for small-group discussion of cases; and (ii) the main session for group presentations to the class. phase 3. this is the post-session, which used polls to obtain feedback on the session. ukzn uses moodle as its lms, and the zoom web-conferencing plugin was integrated as an activity on moodle for ease of access and use. this plugin enabled academics and students to access the web-conferencing software seamlessly. links were set up in lms and authentication was via the lms login. the breakout rooms feature allowed one to divide the main session into ≤50 separate sessions. this enabled the entire class student complement to be divided into smaller, separate parallel sessions ‒ the ideal solution for synchronous online group work. breakout rooms were created. students were allocated to the rooms for group discussions and worked on the case study/tutorial for an allocated period of time. features in the breakout room included audio, video, chat, screen-sharing and ask for help from the host. the number of breakout rooms was created based on the class, enabling rooms to have ~8 participants per room. the students were initially automatically assigned by the web-conferencing software to a room to avoid any bias in the allocation process. for multiple tutorial sessions, students were manually allocated to the same group for ease of grading group work. assistance was offered to the students, as the academic/host was able to visit the breakout rooms, or students could request assistance. at the end of the group-work session, the breakout rooms were closed and students returned to the main session to present their work using multiple applications, such as ms powerpoint (microsoft corp., usa) and ms word (microsoft corp., usa) when sharing their screens with the entire class. synchronous online pharmacy skills group work: a breakout room toolbox for teaching v a perumal-pillay, bpharm, bsc hons, mmedsci (pharmac sci), phd; f walters, bcom (info systems), pgdip (bus admin), mba discipline of pharmaceutical sciences, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: v a perumal-pillay (perumalv@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:perumalv@ukzn.ac.za 168 september 2021, vol. 13, no. 3 ajhpe research a toolbox for synchronous online pharmacy skills group work using webconferencing breakout rooms was developed and implemented (table 1). lessons learnt for facilitators. there is improved efficiency with ≥2 facilitators. this ensured that the main session was always manned to assist students who experienced connectivity issues or latecomers, allocating or re-allocating them to their room. this allowed the remaining facilitators to visit each room to observe or contribute to the live discussions. ideally, academic facilitators should visit each breakout room every 10 minutes to moderate discussions and pose questions to encourage participation, thereby moving passive learners to active learners to maintain similar impact of face-to-face group work. we used the polling function as a quick spot test to gauge understanding of a concept during a session and for feedback after a session. this enabled adapted learning. for students. they required orientation to the concept of breakout rooms at the outset and during the first two sessions they could familiarise themselves with this format for online group work. the group work required them to engage with the content provided, moving them from passive to active learners. students were innovative during these breakout room sessions, demonstrating role-plays for patient counselling and ms powerpoint (microsoft corp., usa) and ms word (microsoft corp., usa) presentations using screen-share to present worked calculations. students became familiar with breakout rooms and eventually attended sessions with preprepared content and engaged in fruitful discussions.  what will i keep in my practice? this integrated approach to teaching and learning is beneficial to health professions education, as learning occurs through the application of concepts. the intervention is a student-centred approach to learning, creating an environment increasingly conducive to learning, where students table 1. toolbox for synchronous online pharmacy skills group work constructivism approach to online teaching phase 1 pre-session instructions select the exercise for the session and upload content to the lms • provide content pre-readings pre-allocate case study numbers to groups • example: 4 groups ‒ each group is allocated a different case study, numbered from 1 to 4 • provide this only in-session to ensure that students complete all pre-reading material before attending online group-work sessions so that they are able to apply this content to the case during group-work discussions phase 2 in-session • instructions set the scene for the day’s topic • provide a brief lecture on the salient points of the topic highlighted from the prereadings • outline the exercise/activity for the day assign students to breakout rooms • manually or automatically label breakout rooms • name according to group numbers or with the allocated case study numbers to assist students with easy identification of their allocated group and to assist the academic when grading group work provide the instructions to students before opening breakout rooms • instruct students to click the ‘join’ pop-up message to join the breakout room when invited to do so • instruct students not to leave the breakout room for any reason. if disconnected for some reason, advise students to rejoin the meeting and provide their group/case number in the chat box on rejoining the meeting to be reassigned to the correct breakout room • inform students to ‘ask for help’ from the facilitators by clicking on that exact feature inside the breakout room • advise students to discuss answers and work together on an electronic document for presentation during the main discussion session when breakout rooms close • inform students of the time allocation for discussion and preparation of presentations set time limit for the breakout rooms • close breakout rooms automatically or send out a broadcast message to all breakout rooms a few minutes before closing the rooms to notify students of the remaining time to complete their group work  phase 3 post session instructions obtain feedback • set up and run a poll at the end of the session • encourage students to post further questions on the discussion forum in the lms to be addressed by peers and academics lms = learning management system. september 2021, vol. 13, no. 3 ajhpe 169 research feel valued as they share their understanding on topics. case-based learning used human cases to link theory to practice and allowed for simulation of the actual working environment, which was especially useful during students’ role-play demonstrations.[5] group work promotes teamwork and improves professional communication skills. interpersonal and communication skills for patient counselling from role-plays were effectively demonstrated. this method of synchronous online group work ensured that the positive learning outcomes were maintained during the pandemic and students were able to engage with their peers on an academic platform during a time of isolation and uncertainty. going forward, this method of teaching can be seamlessly integrated in a blended learning pedagogy for pharmacy skills. conclusions the use of the integrated teaching and learning pedagogy approach, moodle and zoom breakout rooms allowed the toolbox to be successfully applied to numerous synchronous online pharmacy skills group-work sessions. this ensured continuity in teaching and facilitated group-work discussions during a difficult period in education. since the majority of students are millennial learners[8] and are technology savvy, they adapted to the remote online teaching and navigated the zoom breakout rooms with ease. the toolbox is intended to be a quick get-started guide for academics wanting to conduct face-to-face group-work sessions for practicals and tutorials on an online platform. this guide could further assist individuals who have a fear of technology by guiding them through the use of breakout rooms for group-work teaching. such innovative methods for teaching may also be used for blended learning and employed at distance-learning institutions. declaration. none. acknowledgements. dr va perumal-pillay is a university of kwazulu-natal (ukzn) developing research innovation, localisation and leadership in south africa (drill) fellow. drill is an nih d43 grant (d43tw010131), which was awarded to ukzn in 2015 to support a research training and induction programme for early career academics. the content is solely the responsibility of the authors and does not necessarily represent the official views of drill and the national institutes of health. author contributions. vapp and fw jointly contributed to the conceptualisation of the study; equally contributed to the writing of the manuscript; and both read and approved the final manuscript. funding. none. conflicts of interest. none. evidence of innovation 1. south african government. minister blade nzimande: implementation of measures by the post school education sector in response to coronavirus covid-19 pandemic. 2020. https://www.gov.za/speeches/ minister-blade-nzimande-implementation-measures-post-school-education-sector-response (accessed 20 december 2020). 2. south african government. disaster management act: regulations to address, prevent and combat the spread of coronavirus covid-19: amendment. 2020. https://www.gov.za/documents/disaster-management-actregulations-address-prevent-and-combat-spread-coronavirus-covid-19 (accessed 20 december 2020). 3. bottomley e. sa has some of africa’s most expensive data, a new report says – but it is better for the richer. business insider, 5 may 2020. https://www.businessinsider.co.za/how-sas-data-prices-compare-with-therest-of-the-world-2020-5#:~:text=south%20africa%20ranks%20at%20148,t%20afford%20bulk%20data%20 packages (accessed 13 august 2021). 4. tolks d, schäfer c, raupach t, et al. an introduction to the inverted/flipped classroom model in education and advanced training in medicine and in the healthcare professions. gms j med educ 2016;33(3):46. https:// doi.org/10.3205/zma001045 5. mclean sf. case-based learning and its application in medical and health-care fields: a review of worldwide literature. j med educ curric dev 2016;3:39-49. https://doi.org/10.4137/jmecd.s20377 6. koohang a, riley l, smith t, schreurs j. e-learning and constructivism: from theory to application. interdiscipl j e-learn learn object 2009;5(1):91-109. https://doi.org/10.28945/66  7. larekeng sh, yassi ah, najib m, badaruddin b. exploring the millennial learners’ attributes and needs in educational environment. els j interdiscipl stud human 2019;2(3):389-397. https://doi.org/10.34050/els-jish. v2i3.7642 accepted 2 august 2021. afr j health professions educ 2021;13(3):167-169. https://doi.org/10.7196/ajhpe.2021.v13i3.1525 https://www.gov.za/speeches/minister-blade-nzimande-implementation-measures-post-school-education-sector-response https://www.gov.za/speeches/minister-blade-nzimande-implementation-measures-post-school-education-sector-response https://www.gov.za/documents/disaster-management-act-regulations-address-prevent-and-combat-spread-coronavirus-covid-19 https://www.gov.za/documents/disaster-management-act-regulations-address-prevent-and-combat-spread-coronavirus-covid-19 https://www.businessinsider.co.za/how-sas-data-prices-compare-with-the-rest-of-the-world-2020-5# https://www.businessinsider.co.za/how-sas-data-prices-compare-with-the-rest-of-the-world-2020-5# https://doi.org/10.3205/zma001045 https://doi.org/10.3205/zma001045 https://doi.org/10.4137/jmecd.s20377 https://doi.org/10.28945/66 https://doi.org/10.34050/els-jish.v2i3.7642 https://doi.org/10.34050/els-jish.v2i3.7642 https://doi.org/10.7196/ajhpe.2021.v13i3.1525 editor vanessa burch deputy editor juanita bezuidenhout editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk assistant editor emma buchanan technical editors marijke maree melissa raemaekers robert matzdorff paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse online manager gertrude fani hmpg board of directors m raff (chair) r abbas m lukhele d j ncayiyana t terblanche m veller issn 1999-7639 the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. fax (021) 681-1395. e-mail: publishing@hmpg.co.za the ajhpe is published by the health and medical publishing group. contents editorial why publish? (about medical and health professional education in africa) marietjie de villiers 2 articles skilling up medical laboratory technologists for higher roles in biomedical sciences: a needs analysis christian c ezeala 3 improving undergraduate clinical supervision in a south african context e archer 6 the needs of biomedical science training in africa: perspectives from the experience of young scientists denis zofou, seye abimbola, carmelle t norice, moses samje, zoumana isaac traore, oyewale oyediran a, chinedu oraka, daudi mussa kadigi 9 short reports one-on-one consultation on protocol development and statistics analysis in health sciences postgraduate students elena n libhaber, merryll vorster 13 perceptions of female medical students on gender equality gains at a local university ellenore meyer-van den heever, jose frantz 15 abstracts southern african faimer regional institute (safri) poster day, cape town, march 2011 and sa association of health educationalists (saahe) conference, johannesburg, july 2010 17 cpd 20 ajhpe african journal of health professions education december 2011, vol. 3 no. 2 ajhpe african journal of health professions education december 2021, vol. 13, no. 4 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town guest editors champion nyoni university of the free state werner cordier university of pretoria international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 short communication 212 pathology lexicon a-z: a multilingual glossary app l govender, j geitner, n tyam, f c j botha, s a anat, j yeats 214 features of the research proposal genre made easy for undergraduate occupational therapy students m c ramafikeng short research report 215 learn-teach-learn: evaluating a south african near-peer teaching programme r spies, h lee, i esack, r hollamby, c viljoen 218 is blended learning the way forward? students’ perceptions and attitudes at a south african university n b khan, t erasmus, n jali, p mthiyane, s ronne research report 222 evaluation of assessment marks in the clinical years of an undergraduate medical training programme: where are we and how can we improve? h brits, g joubert, j bezuidenhout, l van der merwe 229 medical students’ perceptions of global health at the university of cape town, south africa: the gap between interest and education m potter, p naidu, l pohl, k chu 235 the knowledge and attitudes of final-year medical students regarding care of older patients k naidoo, j van wyk 240 nominal group technique review of the emergency care content of the clinical skills module in the undergraduate medical programme at the university of the free state d t hagemeister 246 understanding of clinical reasoning by undergraduate students and clinical educators in health and rehabilitation sciences at a south african university: the implications for teaching practice h talberg, f camroodien-surve, s l amosun 252 development of a feedback framework within a mentorship alliance using activity theory a g mubuuke, i g munabi, s n mbalinda, d kateete, r b opoka, r n chalo, s kiguli 259 a comparative analysis and evaluation of the naturopathic curriculum in south africa w ericksen-pereira, n v roman, r swart 264 teaching about disability and food security in the school of health sciences, university of kwazulu natal, south africa h e lister, k mostert, m pillay 270 nursing students’ perceptions regarding feedback from their educators in a selected higher education institution in kwazulu-natal, south africa l m rathobei, m b dube cpd questionnaire may 2014, vol. 6, no. 1 ajhpe 41 research nearly three decades after the discovery of the human immunodeficiency virus (hiv), acquired immunodeficiency syndrome (aids) epidemics continue to pose significant challenges to low-income countries in sub-saharan africa and to impact on the attrition rate, level of motivation, professional practices and absenteeism from work of healthcare workers.[1] about 90% of hiv infections among healthcare workers occur in developing countries, where occupational safety procedures are often neglected.[2] while a cure and an effective vaccine have not been found for aids, many people living with hiv/aids in nigeria are still being denied access to treatment.[3-5] it is a generally believed that, given the widespread stigmatisation of hiv/aids patients, even among healthcare workers, including doctors and dentists,[6,7] the behaviour towards people living with aids (plwa) continues to play a vital role in care and treatment. fear of contagion, concerns for safety, poor attitude and unwillingness to provide care to plwa among healthcare personnel and students remain widespread.[7,8] consequently, students’ knowledge and the attitude of healthcare professionals and students towards plwa continue to be of interest. healthcare workers’ attitude remains a core reason why many nigerians living with hiv/aids are denied access to treatment.[5,9-12] a previous study has shown that medical students in the usa believed that their education had not prepared them to safely treat plwa,[8] and taiwanese dental students were found to be more willing to treat hepatitis b virus (hbv)and hepatitis c virus (hcv)-infected patients than those with hiv infection.[13] recently, sudanese dental students felt that they were not well prepared for their future task of treating patients with hiv/aids.[14] another study showed that on average 60% of nigerian dental students were willing to care for plwa.[5,9] a widespread poor attitude and disposition among students may continue after completion of their studies. the goal of any professional education is to produce practitioners with competencies in the technical and non-technical aspects of practice. technical competence is the ability to perform a specific task in a given situation, while non-technical competence involves the nuances and understanding that enable a practitioner to communicate effectively with patients and other healthcare professionals and select appropriate treatment and procedures.[15] therefore, a preferred professional programme should prepare students with the necessary cognitive, psychomotor and affective skills, including a positive disposition to provide care and perform procedures on patients with any condition, including transmissible diseases such as aids. it has been shown that a willingness to treat patients with hiv/aids may be related to knowledge of the disease process, recognition of its background. nearly three decades after the discovery of the human immunodeficiency virus (hiv), acquired immunodeficiency syndrome (aids) epidemics continue to pose significant challenges to low-income countries in sub-saharan africa. objective. to assess medical and dental students’ willingness to perform specific techniques and procedures on people living with aids (plwa). methods. a survey was done among medical and dental students (n=304) at a nigerian university using a 21-item questionnaire that elicited responses on sociodemographic characteristics and willingness to perform specific techniques and procedures. analysis of variance (anova) and an independent t-test were used to determine the influence of sociodemographic variables. multiple regression analyses were used to determine the predictors of willingness. results. the cohort of medical and dental students was willing to care for plwa. almost all medical students were either undecided or unwilling to perform mouth-to-mouth resuscitation. a higher proportion of dental students were either undecided or unwilling to assist during surgery, tooth extractions and other procedures they considered to be invasive. more medical than dental students were willing to carry out surgical procedures. previous personal encounters with aids patients, religion, and satisfaction with instructions influenced medical and dental students’ willingness to care for plwa, while knowing a family member living with aids (r2=0.22, p<0.001) was the strongest predictor of willingness to care for plwa. conclusion. extensive use of clinical clerkships and exposure through direct experience are viable strategies necessary for optimising and enhancing medical and dental students’ dispositions to perform procedures and care for plwa. ajhpe 2014;6(1):41-44. doi:10.7196/ajhpe.201 medical and dental students’ willingness to administer treatments and procedures for patients living with aids a y oyeyemi,1 dhsc; u s jasper,2 bmr; a oyeyemi,3 phd; s u aliyu,4 med; h o olasoji,5 bds; h yusuph,6 mbbs 1 department of medical rehabilitation (physiotherapy), university of maiduguri, maiduguri, borno state, nigeria and dominican college program in physical therapy, orangeburg, new york, usa 2 department of medical rehabilitation (physiotherapy), university of maiduguri, maiduguri, borno state, nigeria 3 department of physiotherapy, university of jos teaching hospital, jos, plateau state, nigeria 4 department of physiotherapy, university of maiduguri teaching hospital, maiduguri, borno state, nigeria 5 department of oral and maxillofacial surgery, university of maiduguri teaching hospital, maiduguri, borno state, nigeria 6 department of medicine, university of maiduguri teaching hospital, maiduguri, borno state, nigeria corresponding author: u s jasper (jaspersnd64@gmail.com) mailto:jaspersnd64@gmail.com 42 may 2014, vol. 6, no. 1 ajhpe research manifestations, and understanding of its modes of transmission.[16] however, knowledge alone may not be sufficient to guarantee optimal care for patients with stigma-associated conditions such as aids. as contributors to healthcare, students’ willingness to use specific procedures allows for the identification of areas of concern that can be focused on during training to optimise behaviour in managing plwa or any other contagious disease. the literature shows that previous studies indirectly investigated medical and dental students’ willingness to care for plwa using global attitudinal items. none of these studies utilised clinical scenarios to elicit willingness responses.[5,9,11,13-17] only a few studies assessed willingness towards procedures such as mouth-to-mouth resuscitation.[8,10] therefore, the aim of our study was to assess medical and dental students’ willingness to perform specific common procedures during medical and dental care of plwa. materials and methods sample participants in this study were medical and dental students in the last two years of their professional training at the college of medical sciences, university of maiduguri, borno state, nigeria,who were willing to participate. a total of 304/385 students surveyed returned their questionnaires, translating to a response rate of 78.9%. instrument a two-part 21-item questionnaire designed by held,[18] and adapted by balogun et al.,[19] was used in this study. part 1 elicited sociodemographic information on previous experience with plwa and previous aids educational instructions. part 2 elicited students’ willingness to perform five selected techniques or procedures or care unique to their discipline on a 5-point likert scale, ranging from strongly willing (1) to strongly unwilling (5). all five items on the subscale were worded positively to minimise the inherent contamination and response shift bias due to social desirability phenomena.[20] the minimum and maximum scores for the subscale were 5 and 25, respectively, and the higher the subjects’ total score, the less the willingness to provide services for plwa. held[18] and balogun et al.[19] reported reliability coefficients of 0.80 and 0.76, respectively, for the willingness subscale of the instrument. in a separate nigerian study, oyeyemi et al.[21] reported correlation coefficients ranging between 0.72 and 0.88 for the subscales of the instrument, including the willingness subscale. the willingness subscale for medical students was adapted from a scale used to assess physicians’ willingness in a previous study,[7] while the willingness subscale for dental students was developed by the authors in collaboration with experienced dental practitioners in a teaching hospital. the content of the final document was judged to have face validity by two lecturers in the discipline. procedure a sample of convenience comprising medical and dental students in the college of medical sciences, university of maiduguri, participated in this survey. the questionnaire was handed to the students in their lecture halls at the university of maiduguri teaching hospital after lectures on topics unrelated to aids. prior to the study, ethical approval was obtained from the university of maiduguri teaching hospital ethical committee. anonymity was assured, while participants were also informed in a cover letter that completion and submission of the survey form implied consent. data analysis using spss version 16, descriptive statistics of means and percentages were computed and analysis of variance (anova) and independent t-tests were used to determine the influence of sociodemographic variables on willingness. multiple regression analyses determined the predictors of willingness to perform procedures. proportional differences were explored using chi statistics. differences were considered significant at an alpha level of 0.05. results the students’ mean age was 24.9 (sd±2.6) years. a total of 188 (61.8%) were male, 116 (38.1%) were female, and 218 (71.7%) did not personally know anyone living with hiv/aids. approximately 154 (51%) had previously been asked to provide care to plwa, 182 (59.9%) had experience in caring for plwa, and 300 (98.7%) had received instructions on hiv/aids. furthermore, 270 (88.8%) would care for plwa if asked to do so. medical students tended to have been asked to care for plwa more frequently (chi statistic = 12.15; p<0.001) and had more previous encounters with plwa (chi statistic = 85.25; p<0.001) than dental students (table 1). willingness to care for plwa the majority of medical students were willing to perform venepuncture (n=174; 75.3%) and insert arterial lines (n=17; 74.0%), while 143 (61.9%) were not willing to perform mouth-to-mouth resuscitation on plwa. a total of 126 (55%) medical students were willing to perform vaginal examinations, while 160 (69.2%) would assist with surgery for plwa. among dental students, 58 (78.8%) were willing to perform impression casting, while almost half (n=35; 48%) were unwilling to assist with an operation. only about 60% were willing to perform scaling and polishing (n=43; 59.6%,), and 25 (34.6%) and 34 (46.2%) were unwilling to perform tooth extractions and root canal therapy, respectively (table 2). the students’ mean overall willingness score was 13.4±4.0 out of a possible total score of 25. overall, medical students were either willing or undecided on responses with regard to performing venepuncture (2.2±0.9), inserting arterial lines (2.3±1.0), and performing surgery (2.4±1.1), while they were more undecided than willing to perform vaginal examinations (2.7±1.1). however, these students were mostly unwilling to perform mouth-to-mouth resuscitation on plwa (3.9±1.1). overall, dental students were willing to do impression casting (1.9±0.9) and willing or undecided to perform scaling and polishing procedures (2.6±1.2).they were mostly undecided about performing tooth extractions (2.9±1.1) and root canal therapy (3.2±1.2) and in assisting during operations (3.1±1.3). medical students’ willingness was significantly lower (p<0.001) to perform mouth-to-mouth resuscitation compared with other procedures. for dental students, there was no significant difference (p>0.05) between willingness to do scaling and polishing and tooth extractions; however, there was a significant difference between these and other procedures. also, willingness to perform impression casting was significantly better (p<0.05) than willingness to carry out other procedures. furthermore, there was no significant difference (p>0.05) with regard to willingness to assist with surgery and perform root canal therapy. there was a significant difference (p<0.05) between carrying out these tasks and others such as scaling and polishing, tooth extraction and impression casting (table 2). may 2014, vol. 6, no. 1 ajhpe 43 research influence of sociodemographic and previous encounters on willingness to care for plwa the effect of sociodemographics on overall willingness score in each discipline was assessed. among medical students, there was a significant difference in willingness by gender, with males being more willing to care for plwa (p<0.05). there was also a significant difference (p<0.05) in willingness by religious affiliation, as students who subscribed to the christian faith were more willing to care for plwa than their muslim counterparts (mean score: muslims = 13.08; christians = 14.02). moreover, students who answered ‘no’ to the question ‘have you ever refused to care for plwa?’ were more willing to care for plwa (p<0.05) than those who answered ‘yes’ (mean = 15.61 v. 13.37). among dental students, there was no significant difference by gender and religion (p>0.05). however, students who answered ‘yes’ to the question ‘have you ever been asked to care for plwa?’ were more willing to care for plwa (p<0.05) than those who answered ‘no’ (mean = 13.73 v. 11.21). students who know a family member with aids were more willing to care for plwa (p<0.05) than those who did not (11.9 v. 15.2). across both disciplines, those with previous experience of caring for aids patients were more willing to care for plwa than their counterparts who had not had any previous contact with such patients (p<0.001). when asked, ‘will you be willing to care for plwa?’ students who answered positively were more willing to care for plwa (p<0.05; mean = 13.4 v. 15.3 (medical); p<0.001; mean = 12.2 v. 16.8 (dental)) than those who answered negatively. students who chose hospital practice as their long-term goal were more willing to care for plwa (p<0.05; f=2.75 (medical); f=2.98 (dental)) than those who would prefer teaching. those who were satisfied with instructions on aids were more willing to care for plwa than those who were somewhat dissatisfied or not satisfied (p<0.05; f=3.78 (medical); f=2.91 (dental)). there was no significant difference in willingness by clinical year (p>0.05). in the final regression equation, knowing a family member living with aids was by far the strongest predictor of willingness (r2=0.22; p<0.001), followed in descending order by refusal to care for plwa (r2=0.20; p<0.001) and long-term goal (r2=0.18; p<0.001). discussion the majority (88.8%) of medical and dental students in this study were generally willing to care for plwa if asked to do so. the proportion of dental students who were willing to provide oral health services to plwa (88.8%) exceeds that of nigerian dental students in previous studies in which only about 60% expressed willingness.[5,9] the proportion is also higher than or comparable to nigerian dentists in two previous studies in which 63.6% and 78.4% of respondents, respectively, were willing to provide care to plwa.[22,23] this proportion can almost be compared with that of dental students in the usa (83%),[24] while it exceeded that in taiwan (49%),[13] india (75%),[11] iraq (75.5%)[25] and jordan (73.7%).[26] in the present study, the proportion of medical students (90.5%) who were willing to care for plwa if asked is higher than the 85% reported by tibdewal et al.[11] among indian medical students. it is higher than that reported among nigerian doctors (82%), in whom willingness was assessed using the same scale as in the table 1. students’ demographic characteristics and previous experience or encounters with plwa (n=304) independent variable medicine n (%) dentistry n (%) total n (%) chi-statistic p-value gender male female 147 (63.3) 84 (36.4) 41 (56.2) 32 (43.8) 188 (61.8) 116 (38.2) 17.053 <0.001 disciplines 231 (54.9) 73 (45.1) 304 (100) clinical year two 128 (55.4) 35 (47.9) 163 (53.6) 1.592 >0.05 three 103 (44.6) 38 (52.1) 141 (46.4) ever been asked to provide services for plwa yes no 130 (56.3) 101 (43.7) 24 (32.9) 49 (67.1) 154 (50.7) 150 (49.3) 0.053 >0.05 ever refused to care for plwa yes no 23 (10.0) 208 (90.0) 6 (8.2) 67 (91.8) 29 (9.5) 275 (90.5) 199.06 <0.001 ever cared for plwa yes no 146 (63.2) 85 (36.8) 36 (49.3) 37 (50.7) 182 (59.9) 122 (40.1) 11.842 0.001 know of family member or another plwa yes no 168 (72.7) 63 (27.3) 50 (68.5) 23 (31.5) 218 (71.7) 86 (28.3) 57.316 <0.001 will care for a plwa if asked yes no 209 (90.5) 22 (9.5) 61 (83.6) 12 (16.4) 270 (88.8) 34 (11.2) 183.211 <0.001 ever received instructions on aids yes no 230 (99.6) 1 (0.4) 70 ( 95.9) 3 (4.1) 300 (98.7) 4 (1.3) 288.211 <001 satisfied with instructions on aids yes no 141 (61.0) 90 (38.9) 39 (53.4) 34 (46.5) 179 (58.9) 121 (39.8*) 96.658 <0.001 plwa = people living with aids. *the subtotals do not add up to 304 because this phrase does not apply to those who did not receive any previous instructions on aids. on the items ‘satisfied with instructions’, those who responded being either somewhat dissatisfied or dissatisfied were merged together as the group that responded ‘no’. those who were satisfied or somewhat satisfied were merged together as the group that responded ‘yes’. clinical year three denotes the last year of training, while clinical year two denotes the penultimate year of training. 44 may 2014, vol. 6, no. 1 ajhpe research present study.[7] only 16.0% of medical students were willing to perform mouth-to-mouth resuscitation on plwa compared with 24%[10] and 72%[8] reported among medical students in india and the usa, respectively. the proportion of medical students willing to assist with surgery is comparable to the 60% reported by mohsin et al.,[10] but slightly lower than the 71% reported by kermode et al.[2] in a study among healthcare workers in rural india. overall, medical students were more willing to perform non-invasive procedures, such as venepuncture, and insert arterial lines, than performing vaginal examinations, which is considered to be an invasive procedure. dental students were also more willing to carry out less invasive procedures such as impression casting and scaling and polishing than root canal therapy and tooth extractions, which are considered to be invasive. this finding is consistent with that of mohsin et al.,[10] who reported an unwillingness among medical students to carry out invasive procedures involving aids patients. medical students were more willing to assist with surgery than dental students (69.2% v. 38.5%), probably because more of the former had previous experience of caring for plwa (63.2% v. 49.3%). the influence of religious affiliation on willingness to perform procedures is in agreement with the findings in one previous study that reported a more positive attitude among catholics than jewish students.[19] previous experience of working with aids patients was also associated with an increased willingness to care for plwa, a finding consistent with a recent report among nigerians doctors,[7] but at variance with one previous study on allied health professional students.[8] limitations of this study this single-centre study has limitations in terms of the generalisability of the findings. its results should be interpreted with caution because the students’ responses could have been affected by social desirability phenomena,[18] in which the students answered questions based on what they presumed is socially desirable. furthermore, the apparent disparity between students’ responses is evidenced by the overwhelming majority of them indicating that they would care for plwa if asked and their overall disposition that rates were undecided in 3 of the 5 procedures. this highlights the difficulty in predicting behaviour, and therefore the findings of this study should be interpreted cautiously. conclusion the cohorts of medical and dental students in the present study were willing to care for plwa if asked, but may be reluctant with regard to performing some common procedures on plwa. these students were more willing to carry out less invasive procedures than those which they considered to be invasive ones. previous personal encounters with plwa, satisfaction with instructions and answering ‘yes’ to the question ‘are you willing to care for plwa?’ influence students’ willingness to perform procedures on plwa. preferred practice settings, previous refusal to care for plwa when asked, and knowing a family member or some other plwa combined, predict willingness. this study suggests that extensive use of clinical clerkships and exposure through direct experience can enhance students’ disposition to perform procedures on plwa. references 1. marchal b, de brouwere v, kegels g. viewpoint: hiv/aids and the health workforce crisis: what are the next steps? trop med int health 2005;10(4):300-304. 2. kermode m, jolley d, langkham b, thomas ms, croft n. occupational exposure to blood and risk of bloodborne infection among healthcare workers in rural north indian healthcare settings. am j infect control 2005;33(1):34-41. 3. islam mt, mostafa g, bhuiya au, hawkes s, de francisco a. knowledge on, and attitude toward hiv/aids among staff of international organization in bangladesh. j health popul nutr 2002;20:271-278. 4. al-mazrou yy, abouzeid ms, al-jeffri mh. knowledge and attitudes of paramedical students in saudi arabia toward hiv/aids. saudi med j 2005;26:1183-1189. 5. oboro h, azodo c, sede m. perception of hiv/aids patients among pre-clinical dental students. int j infect dis 2008;12(suppl 1):e158. 6. mccarthy gm, koval jj, macdonald jk. factors associated with the refusal to treat hiv-infected patients: the results of a national survey of dentists in canada. am j public health 1999;89(4):541-545. 7. adetoyeje y, oyeyemi bo, bello is. physicians and aids care: does knowledge influence their attitude and comfort in rendering care? afr j health sci 2007;14:37-43. [http://dx.doi.org/10.4314/ajhs. v14i1.30844] 8. kopacz dr, grossman ls, klamen dl. medical students and aids: knowledge, attitudes and implications for education. health educ res 1999;14(1):1-6. 9. azodo cc, ehigiator o, oboro ho, et al. nigerian dental students’ willingness to treat hiv-positive patients. j dent educ 2010;74:446-452. 10. mohsin s, nayak s, mandaviya v. medical students’ knowledge and attitude related to hiv/aids. nat j comm med 2010;1(2):146-149. 11. tibdewal h, barad p, kumar s. comparing dental and medical students’ knowledge and attitudes toward hepatitis b, c and hiv infected patients in india – a cross-sectional study. j int oral health 2009;1:20-32. 12. ahmed si, hassali ma, abdul na. an assessment of the knowledge, attitudes, and risk perceptions of pharmacy students regarding hiv/ aids. am j pharm edu 2009;73(1):15. 13. hu sw, lai hr, liao ph. comparing dental students’ knowledge of and attitudes toward hepatitis b virus-, hepatitis c virus-, and hiv-infected patients in taiwan. aids patient care stds 2004;18(10):587-593. 14. nasir ef, astrøm an, david j, ali rw. hiv and aids related knowledge, sources of information, and reported need for further education among dental students in sudan – a cross sectional study. bmc public health 2008;8:286. [http://dx.doi.org/10.1186/1471-2458-8-286] 15. harden rm. international medical education and future directions: a global perspective. acad med 2006;81(12):s22-29. 16. erasmus s, luiters s, brijlal p. oral hygiene and dental students’ knowledge, attitude and behaviour in managing hiv/aids patients. int j dent hyg 2005;3(4):213-217. 17. cohen la, romberg e, grace eg, barnes dm. attitudes of advanced dental education students toward individuals with aids. j dent educ 2005;69(8):896-900. 18. held sl. the effects of an aids education program on the knowledge and attitudes of a physical therapy class. phys ther 1993;73(3):156-164. 19. balogun ja, kaplan mt, hoeberlein-miller t, anthony a, lefkowitz r, hsia l. knowledge, attitudes, and willingness of junior healthcare professional students to provide services for patients with acquired immunodeficiency syndrome. j phys ther edu 1998;12(1):57-63. 20. anastasi a. psychological testing. 5th ed. new york, ny: macmillan publishing, 1982. 21. oyeyemi y, oyeyemi l, akinwale g, aderibigbe i, alaba o, anjorin o. knowledge and affective traits of physiotherapy students to provide care for patients living with aids. s afr j physiother 2010;66(3):1-6. 22. uti og, agbelusi ga, jeboda so. are nigerian dentists willing to treat patients with hiv infection? nigerian dent j 2007;15(2):66-70. 23. utomi il, onajole at, arotiba jt. hiv/aids: knowledge and attitudes of dentists in south western nigeria. nigerian j health biomed sci 2008;7(1):36-41. 24. seacat jp, inglehart mr. education about treating patients with hiv infections/aids: the student perspective. j dent educ 2003;67(6):630640. 25. al-naimi rj, al-saygh gd. knowledge, attitude and health behavior of dental students towards hiv patients. al-rafidain dent j 2009;9(1):110-119. 26. ryalat st, sawair fa, shayyab mh, amin wm. the knowledge and attitude about hiv/aids among jordanian dental students: clinical versus pre clinical students at the university of jordan. bmc research notes 2011;4:191. [http://dx.doi.org/10.1186/1756-0500-4-191] table 2. willingness to care for plwa in each discipline items willing n (%) undecided n (%) unwilling n (%) mean (±sd) medicine perform vaginal examination perform surgical operation insert arterial lines perform venepuncture perform mouth-to-mouth resuscitation 126 (54.5) 160 (69.2) 171 (74.0) 174 (75.3) 37 (16.0) 49 (21.2) 30 (13.0) 41 (17.7) 39 (16.9) 51 (22.1) 56 (24.2) 41 (17.8) 19 (8.2) 18 (7.8) 143 (61.9) 2.7 (1.1)a 2.4 (1.1)a 2.3 (1.0)a 2.2 (0.9)a 3.9 (1.1)b dentistry perform scaling and polishing perform root canal therapy perform impression casting carry out tooth extraction assist with surgical operation 43 (59.6) 21 (28.8) 58 (78.8) 30 (40.4) 28 (38.5) 13 (17.3) 18 (25) 8 (11.5) 18 (25) 10 (13.5) 17 (23.1) 34 (46.2) 7 (8.6) 25 (34.6) 35 (48.0) 2.6 (1.2)c 3.2 (1.2)b 1.9 (0.9)a 2.9 (1.1)c 3.1 (1.3)b plwa = people living with aids. ‘willing’ denotes respondents who were either willing or strongly willing to perform a procedure or technique or provide care. ‘unwilling’ denotes respondents who were either unwilling or strongly unwilling to perform a procedure or technique or provide care. the lower the mean score, the better the willingness. means with different superscripts are significantly different (p<0.05) from each other, while those with the same superscript are not. http://dx.doi.org/10.4314/ajhs.v14i1.30844] http://dx.doi.org/10.4314/ajhs.v14i1.30844] http://dx.doi.org/10.1186/1471-2458-8-286] http://dx.doi.org/10.1186/1756-0500-4-191] 214 december 2021, vol. 13, no. 4 ajhpe short report undergraduate occupational therapy programmes in south africa require students to demonstrate competence in developing a research proposal and conducting the proposed research using appropriate methodologies.[1] research methods, therefore, form a significant part of the curriculum. groups of students are assigned a supervisor and research topic, and then embark on the research process. however, students generally perceive research as a daunting process. some of the difficulties that the author has observed over the years resonate with those reported in the literature, such as limited understanding of the research process,[2] working in a group and handling group dynamics.[2,3] students have also reported feeling overwhelmed by the increased workload associated with the research process, particularly when coupled with other course and life demands.[3] the research proposal is a genre, with specific textual features. elements of the introduction part of the proposal that are often challenging for students are: (i)  the focus of the research, which informs the background; (ii) the research problem; (iii) the rationale; and (iv) the significance of the research. approach in preparation for the initial supervision meeting with the group assigned to the author, the students had to individually submit a written task. the task comprised questions outlined in table 1. outcomes using accessible language made it easier for students to handle the textual features that define the structural form of an introduction to a research proposal. the supervisor facilitated a process of aligning students’ responses with relevant textual features of the introduction. for instance, question 1 established the students’ interpretation of the research focus. in the initial meeting, perspectives were shared, and through discussion, the group reached a common understanding. responses to question 2 indicated the students’ views of the importance and relevance/significance of the study, which motivated them to invest in the research process. question 3 enabled refining of the research problem and differentiating between the broader societal problem and the specific problem that necessitated the research. lastly, the assumptions shared for question 4 shed light on the researchers’ positionality. as an innovation in teaching, the task demonstrates a scaffolding approach that uses everyday language to facilitate handling of textual features of genre. through this task, the supervisor introduced the proposal development process in a non-threatening manner that drew on students’ prior knowledge. the outcome was early completion of the introduction of the proposal. students stated that the task increased their confidence and facilitated group cohesion, and feedback from assessors of the proposal presentations indicated that the students were more eloquent about their research, and answered questions with greater ease. declaration. none. acknowledgements. none. author contributions. sole author. conflicts of interest. none. funding. none. 1. south african qualifications authority. south african qualifications authority registered qualifications: bachelor of science in occupational therapy. pretoria: saqa, 2020. https://allqs.saqa.org.za/showqualification. php?id=3497 (accessed 12 october 2020). 2. imafuku r, saiki t, kawakami c, suzuki y. how do students’ perceptions of research and approaches to learning change in undergraduate research? int j med edu 2015;6:47-55. https://doi.org/10.5116/ijme.5523.2b9e 3. pearson rc, crandall kj, dispennette k, maples jm. students’ perceptions of an applied research experience in an undergraduate exercise science course. int j exercise sci 2017;10(7):926-941. https://www.ncbi.nlm.nih.gov/ pmc/articles/pmc5685073/ (accessed 10 november 2021). accepted 3 march 2021. afr j health professions educ 2021;13(4):214. https://doi.org/10.7196/ajhpe.2021.v13i4.1453 features of the research proposal genre made easy for undergraduate occupational therapy students m c ramafikeng, bsc (ot), msc (ot), phd (ed) division of occupational therapy, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa corresponding author: m c ramafikeng (matumo.ramafikeng@alumni.uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. table 1. research introduction task task question genre feature 1. what is the research trying to establish? focus of research 2. why is this topic important for: • occupational therapy in south africa? • occupational therapy as a profession? rationale and significance 3. what problem exists, that motivated this research? • the societal problem • the research problem research problem and background 4. what assumptions do you have about the topic or focus of this research? assumptions https://allqs.saqa.org.za/showqualification.php?id=3497 https://allqs.saqa.org.za/showqualification.php?id=3497 https://doi.org/10.5116/ijme.5523.2b9e https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5685073/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5685073/ https://doi.org/10.7196/ajhpe.2021.v13i4.1453 mailto:matumo.ramafikeng@alumni.uct.ac.za december 2021, vol. 13, no. 4 ajhpe 223 research the pass/fail decision in summative assessment for medicine and other professional qualifications holds many consequences for the various stakeholders.[1-3] failure, and having to repeat modules, has financial and emotional implications for students, while they may lose trust in the training institution.[4] student failure may affect throughput rates, as well as the reputation of the faculty or university.[4] however, passing an incompetent student may affect both patients and the healthcare system, e.g. through loss of life and avoidable expenses. it could also lead to misconduct claims against individuals or institutions.[5,6] miller[7] emphasises this important responsibility relating to assessment: ‘if we are to be faithful to the charge placed upon us by society to certify the adequacy of clinical performance … then we can no longer evade the responsibility for finding a method that will allow us to do so.’ if we are to be able to defend the outcome of high-stakes examinations, where the outcome has major consequences,[8,9] the assessment must meet the basic requirements of validity, reliability and fairness.[10,11] from a theoretical perspective, it is possible to improve the quality of assessment by addressing criteria such as validity, reliability and fairness.[12] an assessment is considered valid when it measures what it is supposed to measure.[13,14] in the case of clinical medicine, competence must be measured. validity in clinical assessment is usually evaluated using miller’s assessment framework.[15] according to this model, a valid assessment for competence must be on the ‘show how’ and ‘does’ levels. however, when validity is increased by assessing in real-life situations, the reliability of the assessment may decline, owing to subjective judgements and the lack of standardisation.[16] before the validity of an assessment can be evaluated, its reliability must be established.[1,4] the reliability of a clinical assessment is defined as the degree to which a test measures the same concept in different assessments and obtains stable or reproducible results.[17,18] reproducibility, a synonym for reliability, is described as the closeness of or variation in results of successive measurements of the same assessment carried out under the same or nearly the same conditions.[19] with any assessment, some form of ‘measurement error’ will occur. this error should be as low as possible to ensure accurate assessment. the calculation of this error determines the reliability of an assessment.[18] reliability can be evaluated using various measures, depending on the data that are available and what one wants to establish.[20] background. in high-stakes assessments, the accuracy and consistency of the decision to pass or fail a student is as important as the reliability of the assessment. objective. to evaluate the reliability of results of high-stakes assessments in the clinical phase of the undergraduate medical programme at the university of the free state, as a step to make recommendations for improving quality assessment. methods. a cohort analytical study design was used. the final, end-of-block marks and the end-of-year assessment marks of both fourth-year and final-year medical students over 3 years were compared for decision reliability, test-retest reliability, stability and reproducibility. results. 1 380 marks in 26 assessments were evaluated. the g-index of agreement for decision reliability ranged from 0.86 to 0.98. in 88.9% of assessments, the test-retest correlation coefficient was <0.7. mean marks for end-of-block and end-of-year assessments were similar. however, the standard deviations of differences between end-of-block and end-of-year assessment marks were high. multiple-choice questions (mcqs)  and objective structured clinical examinations (osces) yielded good reliability results. conclusion. the reliability of pass/fail outcome decisions was good. the test reliability, as well as stability and reproducibility of individual student marks, could not be accurately replicated. the use of mcqs and osces are practical examples of where the number of assessments can be increased to improve reliability. in order to increase the number of assessments and to reduce the stress of high-stake assessments, more workplace-based assessment with observed clinical cases is recommended. afr j health professions educ 2021;13(4):222-228. https://doi.org/10.7196/ajhpe.2021.v13i4.1379 evaluation of assessment marks in the clinical years of an undergraduate medical training programme: where are we and how can we improve? h brits,1 mb chb, mfammed, mhpe, fcfp; g joubert,2 ba, msc; j bezuidenhout,3 ba, hde, ba hons (psychol), pg dip (hpe), med (psychol ed), dteched; l van der merwe,4 mb chb, mmedsc, da (sa), phd (hpe) 1 department of family medicine, school of clinical medicine, university of the free state, bloemfontein, south africa 2 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa 3 department of health sciences education, faculty of health sciences, university of the free state, bloemfontein, south africa 4 undergraduate programme management, school of clinical medicine, university of the free state, bloemfontein, south africa corresponding author: h brits (britsh@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13ix.1379 mailto:britsh@ufs.ac.za 224 december 2021, vol. 13, no. 4 ajhpe research from a theoretical viewpoint, an assessment can be considered fair if everybody is subjected to the same assessment, under the same conditions, and all are marked by the same assessors using the same mark sheets.[21] in practice, an assessment is fair when the interpretation of the results is transparent and just, and when nobody is disadvantaged in the process.[22] one of the aims of assessment evaluation should always be to improve the quality of assessment for all stakeholders.[2] a fine balance should exist between traditional and innovative assessment methods, by selecting judiciously sound assessment methods above tradition or convenience.[9] the decision to change or improve assessment practices or to move towards more innovative assessments should be based on facts rather than preferences.[9] pass/fail decisions are made based on predetermined criteria. in high-stakes assessments, the accuracy and consistency of the decision to pass or fail a student are as important as the reliability of the test or assessment.[3,7,23,24] decision reliability is a term used to measure the consistency with which pass/fail decisions are made.[3] the best way to evaluate the reliability of a clinical assessment is to assess the same participants under similar circumstances on more than one occasion,[25] which is almost impossible in real-life situations. the reliability of an assessment can be improved by using standardised questions and mark sheets, and multiple and trained markers, and by increasing the number of questions.[20] a high correlation between the different test scores (r>0.7)  is indicative of test-retest reliability.[26] the undergraduate medical programme at the university of the free state (ufs) is a 5-year, outcomes-based programme that runs over 10 semesters. the clinical phase is presented from semesters 6 10. in the clinical phase of the programme, students are assessed in different disciplines. some disciplines are grouped together to form a module. for example, in the fourth year, the surgery module consists of general surgery, orthopaedics, ophthalmology and otorhinolaryngology. modules are presented in blocks. students rotate between different blocks to cover all modules presented in the specific year. at the end of each rotation (block), students are assessed by the end-of-block assessment. in the fourth year, students must pass all disciplines to progress to the fifth year. if students meet minimum requirements in the fifth year, but fail certain disciplines, they are required to repeat only the failed disciplines. admission to the final end-of-year assessment in the fourth and final year requires that students meet end-ofblock academic as well as attendance requirements. students in the fourth and final years must pass all disciplines in all the modules, including each of the clinical and theoretical components individually (if applicable), to pass the final end-of-year assessment.[27] regarding clinical cases, students must also pass more than 50% of the cases, irrespective of the overall clinical mark obtained. if a student fails the end-of-year assessment (in either fourth or final year), but meets minimum requirements for reassessment, the student is allowed to do a reassessment within 1 week of the end-of-year assessment.[27] the pass mark for assessments is predetermined at 50%, as per university regulations. no formal standard-setting process exits. assessments are blueprinted, and assessment rubrics or memoranda are moderated before assessments. fig. 1 shows a flow diagram of the assessment process. the end-of-block assessment and the end-of year assessment cover the same content, and are generally conducted by the same assessors (academic staff in clinical departments). both these assessments consist of theoretical as well as clinical assessments. different disciplines structure their assessments differently, which makes comparison between disciplines not feasible. no regulation or specific reason was found for conducting an end-of-year assessment after the end-of-block assessments, and it is possibly more traditional than evidence based. despite the implications of high-stakes assessment results – such as in the undergraduate medical programme – there are no guidelines for educational institutions to measure the quality of their assessments. therefore, educational institutions should institute quality assurance measures to ensure quality assessment, and be able to defend these results. the aim of this study was to evaluate the assessment results of highstakes assessments in the clinical phase of the undergraduate medical programme. as a first step to improve the quality of assessment in the clinical years of undergraduate medical training, the reliability of current assessments was established. this will assist to make recommendations for improving the quality of current assessments in the undergraduate medical programme, with validity, reliability and fairness in mind. the objectives were as follows: (i) to determine the decision reliability of the current summative assessments, and whether pass/fail decisions can be defended (ii) to determine the test-retest correlation between different assessments (iii) to compare the reliability results of different assessment methods. methods a cohort analytical study design was used. the study population consisted of all the fourth-year and fifth (final)-year undergraduate medical students at ufs who participated in the last end-of-block and end-of-year assessments of 2016, 2017 and 2018. the last end-of-block marks (obtained during the last rotation of the year)  and the end-of-year assessment marks obtained during the final assessment at the end of the academic year were used for data analysis. data were collected retrospectively. between the last end-ofblock assessment and the end-of-year assessment, no formal training and very little learning takes place, which makes these assessments comparable, but not identical. the authors used an aggregated approach to look at the reliability of assessments, as an individual approach was impossible owing to the variability in the way each discipline designs multiple choice questions (mcqs), clinical cases and objective structured clinical evaluations (osces) and/or objective pass and progress n o ad m is si on to s um m at iv e as se ss m en t fail and repeat year or module passfail fail pass end-of-block assessment reassessment second opportunity assessment end-of-year assessment admission fig. 1. flow diagram of assessment process and outcome in fourth and final years of the undergraduate medical programme, university of the free state. december 2021, vol. 13, no. 4 ajhpe 225 research structured practical evaluations (ospes). the reliability of the theoretical and clinical assessments was determined separately. theoretical assessments consisted of papers with mcqs only, and papers with a combination of mcqs and mostly short written questions. clinical assessments included clinical cases, osces and ospes. in clinical cases, the student assesses a patient unobserved and then reports on findings while the assessors clarify findings and ask predetermined questions. the term osce is used for assessments in the form of clinical stations with patients or simulated patients. students were directly observed at these clinical stations. the term ospe was used for assessment involving unmanned stations, where students had to interpret diagnostic investigations, e.g. x-rays or laboratory results. different disciplines use different combinations of assessments; however disciplines use the same combinations during end-of-block and end-of-year assessments. table 1 categorises the disciplines as either surgical or medical, indicates the study year(s)  in which a discipline is presented and lists the different assessment methods used for each discipline. general surgery, orthopaedics, urology, otorhinolaryngology, ophthalmology, anaesthetics and obstetrics and gynaecology are classified as surgical disciplines (n=7). internal medicine, paediatrics, family medicine, oncology and psychiatry are classified as medical disciplines (n=5). data collection student marks, corresponding with respective student numbers, were obtained from the official marks database used by the faculty of health sciences. this is an extensive database with numerous datasets, available in excel (microsoft, usa) spreadsheets for each student per discipline and per assessment. it is a secure database with password protection – only authorised access is permitted. all marks, including of reassessments, were used to compare final pass/fail outcome decisions. data management and analysis the department of biostatistics performed data analysis using sas version 9.4 (sas, usa). calculations were done per discipline for fourth-year and fifth-year students separately. the decision reliability between the final end-of-block and end-of-year assessment was calculated using 2 × 2 tables. due to the skewed data, kappa values could not be calculated[28] and a value ≥0.7 on holley and guilford’s[29] g-index of agreement (as an alternative for categorical judgement)  was considered as reliable. holley and gilford’s g-index of agreement allows for correlation in the presence of skewed data. as a final step to evaluate the pass/fail outcome decisions, the reassessment outcome decision was compared with the final end-of-block and end-of-year assessment outcome decisions. to determine test-retest reliability between final end-of-block and endof-year assessment marks, pearson correlation coefficients were calculated. a correlation coefficient ≥0.7 was considered as reliable.[26] the mean and standard deviation (sd)  of differences between endof-block and end-of-year assessment marks were calculated. this mean is used as an indication of assessment stability. the percentage of students whose  marks  for the end-of-block and end-of-year assessments differed by <10% for the two assessments was calculated to assess reproducibility. the assessment was considered reliable if the reproducibility was ≥80%. for clinical cases, the individual student marks obtained in consecutive assessments performed on the same day were also compared. the means of the different cases were compared to determine test consistency, and the variance in marks (sd)  obtained by individual students was calculated to determine reproducibility. ethical considerations, quality and rigour of data management ethical approval to conduct the study was obtained from the health sciences research ethics committee of ufs (ref. no. ufs-hsd 2019/0001/2304), and permission to use student data was granted by the relevant university authorities. all data were managed confidentially and only student numbers were used. no student or discipline is identified in the published results. results a total of 1 380 marks in a total of 26 administered assessments were evaluated. in table  2, the numbers of students included in the study per discipline are indicated for the different years. some disciplines are presented in only one of the study years (table 1). the study used the marks of 12 disciplines within the medical programme. decision reliability of pass/fail decisions in 2 of the 12 fourth-year assessments, and 7 of the 14 fifth-year assessments, the pass/fail decisions in the final end-of-block concurred with the end-ofyear assessments, and all students passed. in the remaining disciplines, there were between 92.5% and 98.9% agreement of the same pass/fail decision outcome between the end-of-block and end-of-year assessments. the g-index of agreement values ranged from 0.86 to 0.98. three fourth-year students obtained marks <50% in the final end-ofblock assessment. they subsequently failed the end-of-year assessment too, as well as the reassessment, and therefore had to repeat the year. no fifthyear students obtained marks <50% in the final end-of-block assessment, or failed the year. three fourth-year students and two fifth-year students passed the final end-of-block assessments, and then failed a subcomponent of a discipline/module in the end-of-year assessment. all these students qualified for reassessment, according to the rules, and all passed the reassessment and, therefore, passed the year. table 1. classification of disciplines, study years of presentation and types of assessment per discipline discipline classification study year assessment types a surgical 4 and 5 theory, clinical b surgical 4 and 5 theory, clinical c surgical 4 and 5 theory, clinical d surgical 4 theory e surgical 4 theory f surgical 5 theory, clinical g surgical 5 theory h medical 4 and 5 theory, clinical i medical 4 and 5 theory, clinical j medical 4 and 5 combined k medical 4 theory l medical 5 combined 226 december 2021, vol. 13, no. 4 ajhpe research test-retest correlation of end-of-block and end-of-year results in the fourth and fifth years, respectively, 12 and 15 assessments were compared for test-retest correlation. three assessments in the fourth year had correlation coefficients ≥0.70. none of the assessments in the fifth year had correlation coefficients ≥0.70. these results are displayed in table 3. stability of assessment marks per discipline table  4 summarises the differences between the final end-of-block and the end-of-year assessment marks per discipline and per study year. the mean differences between marks obtained in the final end-of-block and end-of-year assessments varied between –11.4% (discipline k, fourth-year group) and 7.5% (discipline f, fifth-year group), with discipline k emerging as a clear outlier. reproducibility and assessment methods the percentage of students whose final end-of-block and end-of-year assessment marks were within a 10% range varied between 33.3% (discipline k fourth year) and 98.9% (discipline i fifth year). the individual marks of students varied considerably, as indicated by the high sd, particularly for the fourth-year group. in table 5 these percentages are given for the different assessment methods. differences between marks for consecutive clinical cases in three disciplines, students were assessed on two or three clinical cases on the same day. the mean marks obtained per discipline were within 4.5% of each other. the marks that individual students obtained varied by between 0 and 45% for different cases in the same discipline. in table  6, the mean, sd, minimum and maximum of differences in student marks obtained for consecutive cases are indicated per discipline. discussion the results presented here may be considered representative of the selected study population, as all the student marks were available, in a usable format, in the database. the aim when evaluating the quality of an assessment should be to identify areas that can be improved in the assessment.[30] data for this study were obtained with this aim in mind rather than to pronounce judgement on the reliability of current assessment methods and practices. calculating the reliability of pass/fail outcome decisions using a kappa coefficient is described in the literature.[9,31] in this study, very few students failed, and the small numbers made the kappa statistic inappropriate for this measurement.[32] a g-index of agreement was, therefore, calculated.[28] in almost half (45.2%)  the disciplines investigated, the agreement between the outcomes obtained in assessments was 100%. for the remaining disciplines, the g-index of agreement was >0.85. the decision reliability on pass/fail outcome decisions for clinical assessments in the undergraduate medical programme at ufs can, therefore, be considered excellent. the comprehensive end-of-block assessments, the strict admission requirements to the end-of-year assessment and the reassessment opportunity may be reasons for this finding. each individual student result, as well as disciplinespecific results, are discussed at the examination admission and final table 2. students per discipline for different study years, n 4th year discipline 2016 2017 2018 a 30 37 26 b 30 37 26 c 30 37 26 d 30 37 26 e 28 37 27 f 21 22 17 g 21 22 17 h 21 19 19 i 22 22 16 5th year a 23 29 35 b 23 29 35 c 14 20 18 f 23 29 35 g 31 28 37 h 19 19 19 i 31 28 37 j 19 18 21 l 18 18 21 table 3. correlation between final end-of-block and end-of-year assessment marks, per discipline, study year and type of assessment discipline 4th year 5th year theory* clinical* combined* theory* clinical* combined* a 0.39*(p<0.01)  0.47 (p<0.01) 0.61 (p<0.01) 0.34 (p<0.01) b 0.32 (p<0.01) 0.48 (p<0.01) 0.23 (p<0.01) 0.24 (p=0.03) c 0.60 (p<0.01) 0.34 (p=0.01) 0.67 (p<0.01) d 0.80 (p<0.01) e 0.50 (p<0.01) f 0.57 (p<0.01) 0.40 (p<0.01) g 0.25 (p=0.01) h 0.61 (p<0.01) 0.62 (p<0.01) 0.35 (p<0.01) i 0.78 (p<0.01) 0.93 (p<0.01) 0.64 (p<0.01) 0.32 (p<0.01) j 0.23 (p=0.7) 0.66 (p<0.01) k 0.43 (p<0.01) l 0.46 (p<0.01) *correlation coefficient. december 2021, vol. 13, no. 4 ajhpe 227 research examination meeting to ensure defensible outcomes. with the current measures in place, and the addition of standard-setting to ensure accurate pass/fail decisions during end-of-block assessments, the necessity of an endof-year assessment may be reconsidered. the test-retest correlations were low, and did not reach a value ≥0.7 for any of the fifth-year students’ assessments. this indicates poor reliability for individual assessments. the reliability of an assessment can be affected by the students, the test and the markers.[17,20] student factors that could contribute to the low test-retest correlations include the fact that students who had passed the recent final end-of-block assessment might be confident about passing the end-of-year assessment, and then opt to study for disciplines/modules in which they had passed the end-of-block assessment some time ago. the added stress of high-stakes assessment, together with uncertainty about future work and placement, could also influence students’ performance. performance stress during high-stakes assessments is well described.[33,34] the effect of additional stress is unpredictable – it can have a positive or negative effect on academic performance.[35] more and regular low-stakes assessments may address the student factors described above. test factors that could have played a role in this study include the fact that even though the same content was assessed in both the final end-ofblock and end-of-year assessments, the questions differed, and no formal standard-setting was performed. furthermore, not all competencies can be tested in all assessments, and very few assessments performing summative assessments. competency in one case has poor reproducibility for another case.[1] finally, the markers stayed the same during both assessments, with the exception of a few additional external assessors. by increasing the number of assessments during rotations, the reliability of overall assessment can also be improved. the mean marks obtained in the end-of-block compared to end-ofyear assessments did not differ much. the exception was the theoretical assessment in one discipline in the fourth year, where the end-of-year mark obtained was 11.4% lower than the final end-of-block module mark. the reason for this difference is not clear, though moderation reports of these assessments could provide some insight. the small variation in the mean marks (end-of-block v. end-of-year) per discipline may be an indication that the assessments were of the same standard. however, the sd was high for all assessments, indicating large differences in the marks obtained by individual students in the two assessments. these differences occurred in theoretical as well as clinical assessments. poor validity of the assessments, or the student factors discussed above, may be reasons for these differences. table 4. differences between the end-of-block and end-of-year assessment marks, per discipline and study year discipline 4th year 5th year mean (sd)* mean (sd)* a theoretical 3.29 (11.04) –0.87 (7.25) a clinical –3.44 (9.21) –4.51 (7.63) b theoretical 1.90 (10.67) –0.06 (9.82) b clinical –1.22 (10.89) –0.64 (7.63) c theoretical 2.05 (6.81) 2.06 (8.62) c clinical 0.79 (6.12) d theoretical –1.91 (4.94) e theoretical –1.51 (6.27) f theoretical –2.29 (9.10) f clinical 7.45 (8.59) g theoretical –4.16 (10.63) h combined –0.78 (5.69) 1.11 (4.68) i theoretical 4.43 (4.75) 4.08 (6.01) i clinical –1.36 (2.10) –7.27 (7.36) j combined 2.65 (12.38) 0.97 (5.55) k theoretical –11.42 (12.84) l combined -1.44 (5.30) sd = standard deviation. *a positive mean indicates that end-of-year marks were higher than end-of-block marks, while a negative mean indicates that end-of-year marks were lower than end-of-block marks. table 6. differences in marks obtained for consecutive cases per discipline discipline case mean difference sd minimum maximum a 1 and 2 1.99 12.21 –32 45 1 and 3 1.85 12.78 –35 37 2 and 3 –0.15 12.98 –37 30 h 1 and 2 –2.32 14.99 –45 38 1 and 3 –4.36 14.55 –44 35 2 and 3 –2.04 13.20 –36 43 i 1 and 2 1.67 11.44 –25 30 sd = standard deviation. table 5. percentage of students whose final end-of-block assessment and end-of-year marks were within a 10% range, by discipline, year group and assessment method theory clinical mcq combined paper clinical case osce ospe 4th year, discipline a 67.7* 74.2 b 65.6† 64.5 c 88.3 d 95.7 e 91.4 h 91.5 i 90.2 98.9 j 56.7 k 33.3 5th year, discipline a 88.5 71.3 b 72.4† 81.6 c 75.0 90.4 f 69.0† 62.1 g 64.6 h 98.3 60.3 i 87.5 63.5 j 94.8 l 96.5 mcq = multiple choice question; osce = objective structured clinical examination; ospe = objective structured practical evaluation. *this assessment originally consisted of 30 questions, but the number of questions increased in 2017. †these assessments consisted of ≤30 or fewer questions per assessment. 228 december 2021, vol. 13, no. 4 ajhpe research assessment methods varied across disciplines, and therefore, direct comparisons could not be made between different assessment methods. for  theoretical assessments, mcq papers with >30 questions produced student marks within a 10% range, indicating reproducibility. reproducibility could not be proved for assessments with <30 questions. the reproducibility  of assessments can be improved by increasing the number of questions.[20] clinical osces yielded good reproducibility results, while ospes and clinical cases did not. patrício et al.[36] analysed the results of 366 articles on osces performed in undergraduate medical education, and concluded that osces produce reliable results and are feasible for assessing competence. an osce in itself is not reliable, but can produce reliable results if adequate sampling, good-quality questions and mark sheets, time allocation per station and trained assessors are used.[19,20,37] ospes lack clinical interaction and demonstration of competence, making ospes almost equivalent to written questions.[38] clinical cases or long cases are renowned for their poor validity and reliability.[39] evaluation of the marks obtained for consecutive clinical cases  revealed a high sd, despite a stable mean mark. a difference of up to 45% was observed in marks obtained for different clinical cases performed by the same student. a possible reason may be patient selection and reuse of patients for the assessment. it is difficult to find enough suitable, similar  and stable patients to use in clinical cases, making long cases less practical and reliable for summative assessment.[40] assessors also need to make subjective judgements of competence, which may influence reliability.  nevertheless, clinical cases have a definite role to play in low-stakes and formative assessment in which the aim is learning.[1] an advantage of using long cases is that a student can be assessed holistically on an actual case.[40] this advantage is lost when the student’s examination of the patient is unobserved, and is followed by the student reporting his/ her findings.[41] it has been calculated that 10 clinical cases are necessary to achieve acceptable reliability with clinical cases.[42] these numbers are only possible when workplace-based assessments are used.[9] based on the above, it is recommended that clinical cases only be used for formative assessment. although these results are setting-specific, the recommendations and conclusion can be applied to other settings as they are supported by the latest literature. reliability is only one aspect of quality assessment to ensure clinical competence. to achieve quality assessment of clinical competence, students should be assessed in real life, or in near-real-life situations. assessing clinical competence is a complex procedure, with many dimensions requiring different assessment methods.[1,30,43] the highest level of competence, according to miller’s[7] framework for assessment, is ‘does’. to ensure the competence of future medical professionals, we should assess them frequently, and in the workplace, and move away from overemphasis on high-stakes assessments.[44] miller[7] states that: ‘no single assessment method can provide all the data required for judgment of anything so complex as the delivery of professional services by a successful physician.’ however, real-life situations are not stable and reproducible. this poses challenges in ensuring the reliability of assessments.[45] it is important to take the quality of the assessment process as a whole into account, and to avoid merely focusing on validity, reliability or fairness as individual components to improve the assessment. study limitations the quality of pass/fail decisions for the individual assessments (end-of-block and end-of-year)  were not formally established before these assessments were compared with each other. however, the outcome of each assessment per student is discussed during the examination admission meeting and the examination results meeting to ensure accurate decisions. the validity and fairness of the assessments were not assessed in the present article. this article is only a step in the process to assess the quality of assessment. the end-of-block and end-of-year assessments that were compared are not identical, but comparable. it is almost impossible to get identical assessments in clinical medicine, as it is performed in real-life situations. results of students were grouped together per discipline, and not displayed per individual student per discipline. the aim of this article was not, however, to look at individual students or assessments, but at a collective. conclusion the reliability of pass/fail outcome decisions in clinical assessments in the undergraduate medical programme involved in this study was found to be good. the necessity of end-of-year assessment after comprehensive end-ofblock assessments may be questioned. the test reliability, as well as stability and reproducibility of individual student marks, were less acceptable. the use of mcqs and osces are practical examples where the number of assessments can be increased to improve reliability. in order to increase the number of assessments and to reduce the stress of high-stakes assessment, more workplace-based assessment with observed clinical cases can be recommended. declaration. this article is based on a phd study. acknowledgements. me hettie human for the language editing. author contributions. hb – conceptualisation of study, protocol development, data collection and writing of article; gj – assisted with concept and methodology, performed data analysis and assisted with interpretation and writeup; jb and ljvdm – promotors who assisted with conceptualisation and planning of the study, as well as critical evaluation and final approval of the manuscript. funding. none. conflicts of interest. none. 1. amin z, seng cy, eng kh (editors). practical guide to medical student assessment. singapore: world scientific publishing, 2006. 2. hays rb, hamlin g, crane l. twelve tips for increasing the defensibility of assessment decisions. med teach 2015;37(5):433-436. https://doi.org/10.3109/0142159x.2014.943711 3. möltner a, tımbıl s, jünger j. the reliability of the pass/fail decision for assessments comprised of multiple components. soc behav sci 2015;32(4):42. https://doi.org/10.3205/zma000984 4. najimi a, sharifirad g, amini mm, meftagh sd. academic failure and students’ viewpoint: the influence of individual, internal and external organisational factors. jehp 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g. reliability, precision or reproducibility of the measurements. methods of assessment, utility and applications in clinical practice. rev chilena infectol 2018;35(6):680-688. https://doi.org/10.4067/s0716-10182018000600680 18. pietersen j, maree k. standardisation of a questionnaire. in: maree k (editor). first steps in research. 7th impression. pretoria: van schaik publishers, 2016. 19. bartlett jw, frost c. reliability, repeatability and reproducibility: analysis of measurement errors in continuous variables. uog 2008;31:466-475. https://doi.org/10.1002/uog.5256 20. tisi j, whitehouse g, maughan s, burdett n. a review of literature on marking reliability research. report for ofqual. slough: national foundation for educational research, 2013. https://www.nfer.ac.uk/publications/ mark01/mark01.pdf (accessed 12 september 2019). 21. kane m. validity and fairness. lang test 2010;27(2):177-182. https://doi.org/10.1177/0265532209349467 22. gipps c. fairness in assessment. in: wyatt-smith c, cumming jj (editors). educational assessment in the 21st century. dordrecht: springer, 2009. 23. gugiu c, gugiu m. determining the minimum reliability standard based on a decision criterion. j exp educ 2018;86(3):458-472. https://doi.org/10.1080/00220973.2017.1315712 24. stoker hw, impara jc. 7 basic psychometric issues in licensure testing. in: impara jc (editor). licensure testing: purposes, procedures, and practices.lincoln, ne: buros, 1995:167-186. http://digitalcommons.unl.edu/ buroslicensure/12 (accessed 12 september 2019). 25. heale r, twycross a. validity and reliability in quantitative studies. evid based nurs 2015;18(3):66-67. https:// doi.org/10.1136/eb-2015-102129 26. sauro j. 2015. how to measure the reliability of your methods and metrics. https://measuringu.com/measurereliability/ (accessed 12 september 2019). 27. university of the free state. faculty of health sciences rule book. school of medicine. undergraduate qualifications 2019. https://apps.ufs.ac.za/dl/yearbooks/335_yearbook_eng.pdf (accessed 12 september 2019). 28. xu s, lorber mf. interrater agreement statistics with skewed data: evaluation of alternatives to cohen’s kappa. j consult clin psychol 2014;82(6):1219. 29. holley jw, guilford jp. a note on the g index of agreement. epm 1964;24:749-753. https://doi. org/10.1177/001316446402400402 30. opposs d, he o. the reliability programme. final report. london: ofqual, 2011. https://assets.publishing. service.gov.uk/government/uploads/system/uploads/attachment_data/file/578899/2011-03-16-the-reliabilityprogramme-final-report.pdf (accessed 12 september 2019). 31. mchugh ml. interrater reliability: the kappa statistic. biochem medica 2012;22(3):276-282. 32. sim j, wright cc. the kappa statistic in reliability studies: use, interpretation, and sample size requirements. phys ther 2005;85(3):257-268. https://doi.org/10.1093/ptj/85.3.257 33. attali y. effort in low-stakes assessments: what does it take to perform as well as in a high-stakes setting? educ psychol meas 2016;76(6):1045-1058. 34. beilock sl, carr th. on the fragility of skilled performance: what governs choking under pressure? j exp psychol gen 2001;130:701-725. 35. sandi c. stress and cognition. wires cogn sci 2013;4(3):245-261. https://doi.org/10.1002/wcs.1222 36. patrício mf, julião m, fareleira f, carneiro av. is the osce a feasible tool to assess competencies in undergraduate medical education? med teach 2013;35(6):503-514. https://doi.org/10.3109/0142159x.2013.774330 37. brits h, bezuidenhout j, van der merwe lj. a framework to benchmark the quality of clinical assessment in a south african undergraduate medical programme. s afr fam pract 2020;62(1):a5030. https://doi.org/10.4102/ safp.v62i1.5030 38. khan kz, gaunt k, ramachandran s, pushkar p. the objective structured clinical examination (osce): amee guide no. 81. part ii: organisation and administration. med teach 2013;35:e1447-1463. https://doi.org/10.310 9/0142159x.2013.818635 39. ponnamperuma gg, karunathilake im, mcaleer s, davis mh. the long case and its modifications: a literature review. med educ 2009;43:936-941. https://doi.org/10.1111/j.1365-2923.2009.03448.x 40. kamarudin ma, mohamad n, awang mn, siraj bhh, yaman mn. the relationship between modified long case and objective structured clinical examination (osce) in final professional examination 2011 held in ukm medical centre. procedia soc behav sci 2012;60:241-248. https://doi.org/10.1016/j.sbspro.2012.09.374 41. wass v, jolly b. does observation add to the validity of the long case? med educ 2001;35(8):729-734. https://doi. org/10.1046/j.1365-2923.2001.01012.x 42. wass v, jones r, van der vleuten c. standardised or real patients to test clinical competence? the long case revisited. med educ 2001;35(4):321-325. https://doi.org/10.1046/j.1365-2923.2001.00928.x 43. norman g. postgraduate assessment – reliability and validity. trans coll med s afr 2003;47:71-75. 44. liu c. an introduction to workplace-based assessments. gastroenterol hepatol bed bench 2012;5(1):24-28. 45. clauser be, margolis mj, swanson db. issues of validity and reliability for assessments in medical education. in: holmboe es, durning sj, hawkins re (editors). practical guide to the evaluation of clinical competence. 2nd ed. philadelphia: elsevier, 2018. accepted 3 december 2020. https://doi.org/10.1007/bf00596229 https://doi.org/10.1111/j.1365-2929.2005.02094.x https://doi.org/10.3109/0142159x.2013.788789 https://doi.org/10.1207/s15328015tlm1504_11 https://doi.org/10.4067/s0716-10182018000600680 https://doi.org/10.1002/uog.5256 https://www.nfer.ac.uk/publications/mark01/mark01.pdf https://www.nfer.ac.uk/publications/mark01/mark01.pdf https://doi.org/10.1177/0265532209349467 https://doi.org/10.1080/00220973.2017.1315712 http://digitalcommons.unl.edu/buroslicensure/12 http://digitalcommons.unl.edu/buroslicensure/12 https://doi.org/10.1136/eb-2015-102129 https://doi.org/10.1136/eb-2015-102129 https://measuringu.com/measure-reliability/ https://measuringu.com/measure-reliability/ https://apps.ufs.ac.za/dl/yearbooks/335_yearbook_eng.pdf https://doi.org/10.1177/001316446402400402 https://doi.org/10.1177/001316446402400402 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/578899/2011-03-16-the-reliability-programme-final-report.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/578899/2011-03-16-the-reliability-programme-final-report.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/578899/2011-03-16-the-reliability-programme-final-report.pdf https://doi.org/10.1093/ptj/85.3.257 https://doi.org/10.1002/wcs.1222 https://doi.org/10.3109/0142159x.2013.774330 https://doi.org/10.4102/safp.v62i1.5030 https://doi.org/10.4102/safp.v62i1.5030 https://doi.org/10.3109/0142159x.2013.818635 https://doi.org/10.3109/0142159x.2013.818635 https://doi.org/10.1111/j.1365-2923.2009.03448.x https://doi.org/10.1016/j.sbspro.2012.09.374 https://doi.org/10.1046/j.1365-2923.2001.01012.x https://doi.org/10.1046/j.1365-2923.2001.01012.x https://doi.org/10.1046/j.1365-2923.2001.00928.x 78 june 2022, vol. 14, no. 2 ajhpe research postgraduate medical training that ensures the development of professional competence is fundamental to the ability of future specialist doctors to provide safe and evidence-based care for their patients. in recent years, there has been much focus on competency-based medical education as an approach to meet these expectations.[1] although the definition of ‘competency-based medical education’ can be highly variable in the literature,[2] there is an agreement that physician competence involves multiple domains of ability (as discussed in more detail by frank et al.[1]) and not merely acquiring knowledge or a set of skills. competency frameworks now form the foundation of medical curricula in many countries.[1] one of the most widely used frameworks is the canmeds model, which was introduced by the royal college of physicians and surgeons of canada in 1996 to guide the incorporation of competency-based education throughout the medical curriculum. this framework defines a set of seven operationalised roles that represent ‘clusters of competencies’ that physicians are expected to master by the end of their training.[3] to promote evidence-based practice, the framework includes the role of being a scholar. the competencies of this role include a commitment to lifelong learning, the ability to appraise information critically, and the ability to facilitate learning and contribute to the creation of knowledge through research activities.[4] the inclusion of this role has emphasised scholarly work as an important aspect of medical training, especially to support the provision of evidence-based healthcare (ebhc). as such, many medical schools around the world expect trainees to participate in some form of research during their training.[5] in the african context, capacity and organisational structures for the development of ebhc are still limited in many countries.[6] previous studies  have demonstrated that health research productivity varies widely across africa and that south africa (sa) produces the bulk of research publications emerging from the continent.[7] there exists a growing number of continuing  professional development initiatives in the african region that focus on building research capacity.[8,9] it has also been acknowledged that providing a critical mass of clinical researchers is essential to address the need for improved health research capacity across the african continent.[10,11] in sa, the requirement for completing a research project (as  part of a master of medicine, mmed) for medical specialist registration was made mandatory from 2011.[12] it is perhaps unlikely that mmed research will contribute to a critical mass of clinical researchers because only very few specialists will enter research careers after graduating. a recent study by de beer et al.[13] indicated that only 37% of general surgeons engaged in research after qualification. this may be due to the limited number of academic posts at the nine sa medical schools. nevertheless, even for those specialists who do not continue with research after their training, scholarly experience is crucial for developing critical thinking and equipping sa doctors with competencies that support evidence-based practice. a growing body of literature has highlighted the several difficulties this requirement has introduced for many training centres,[14-17] some of which are likely to hamper the development of medical specialists who are competent in their role as lifelong scholars, and particularly in their ability to conduct and appraise research. to equip physicians with the competencies that support evidence-based healthcare, curriculum frameworks for medical education often promote scholarly activity as an essential component of training. many medical schools worldwide expect medical trainees to participate in some form of research during their undergraduate and postgraduate training. this requirement is especially important in africa, where there is also much need to develop clinical research capacity and an evidence base that is contextualised to the specific healthcare challenges on the continent. in south africa, the requirement for specialist trainees to complete a research project (as part of a master of medicine, mmed) was made mandatory from 2011 and has introduced several difficulties for many training centres. there is concern that institutions are failing to develop medical specialists who are competent in their role as scholars, particularly in their ability to conduct research. in this article, i review the south african literature that discusses the research component of medical specialist registration. in addition to summarising the challenges associated with mmed projects and recent efforts to address them, i interrogate whether the current status of mmed research education is likely to be contributing to the successful development of research competence among this unique group of postgraduates. by consolidating the current debate, i hope to encourage a point of departure between criticising the challenges and adopting proactive strategies to address them. there is a great need for medical educators to design innovative and learner-centred research education strategies that can better develop research competence among african healthcare professionals. afr j health professions educ 2022;14(2):78-82. https://doi.org/10.7196/ajhpe.2022.v14i2.1418 the development of research competence among specialist registrars in south africa: challenges and opportunities for research education and capacity development k moxley, phd centre for health professions education; and research development and support office, faculty of medicine and health sciences, stellenbosch university, bellville, south africa corresponding author: k moxley (karismoxley@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1418 mailto:karismoxley@sun.ac.za june 2022, vol. 14, no. 2 ajhpe 79 research therefore, the purpose of this conceptual article is to review and consolidate the literature that discusses mmed research and interrogate whether the current approach to research support and training is likely to be contributing to the successful development of scholarly competence among specialist trainees. i shall first summarise the various challenges associated with mmed research and then review recent efforts to improve research training and support for this unique group of postgraduates. finally, i  shall argue that current challenges offer medical educators and research capacity development services a unique opportunity to design innovative and learner-centred research education strategies that can better develop research competence among medical professionals. mandatory research component for medical specialist registration in sa before 2010, there were two routes to specialist registration in sa. one route was to do a full-time mmed, which included the requirement to complete a research project at only some institutions. universities awarded the degree after a successful internal examination. the other route used a prescribed syllabus set out by the relevant college of medicine, followed by the successful completion of the college fellowship examinations. the fellowship syllabus included training on research methodology, statistics, and clinical trial design but did not include the requirement for a research project. the health professions council of sa (hpcsa) expressed concern that the two programmes lacked uniformity across different institutions in terms of curricula, assessments, and exit outcomes, including for research knowledge and skills.[12] therefore, in 2010, the hpcsa defined new requirements for specialist registration, which included the need for trainees to demonstrate research competence by completing a research project.[12] there has been some agreement among mmed candidates and teaching  staff that the research component is an essential part of the specialist training curriculum and has the potential to improve evidencebased practice.[13–15,18] however, it has also received much critical resistance from various stakeholders. trainees are reported to feel ‘resentful’ of the directive,[19] and there has been consistent hope that the hpcsa might reconsider its decision.[20] the regulation requiring research completion was subject to legal action in 2015, when those trainees who had not met this requirement were denied hpcsa specialist registration.[21] the challenge was upheld, and trainees were granted a further two years to complete their research.[18] that trainees would resort to such drastic and adversarial action perhaps highlights the extent of their frustration and the challenges associated with the research component of specialist training. challenges associated with the mmed research requirement there are several challenges experienced by trainees, including inadequate research experience, limited supervision capacity, insufficient time protected from clinical service obligations, non-uniformity of mmed research requirements, and the absence of clear mmed research education strategies and outcomes across institutions. i shall now review each of these challenges in more detail. limited research experience among trainees because the mmed research component forms part of a master’s degree, the unspoken expectation is that mmed candidates should have the ability to think about and conduct their research at a level equivalent to those candidates undertaking master’s degrees in other fields. however, recent literature has highlighted that specialist trainees often lack the knowledge and skills required to complete a successful academic project.[16] this limited research expertise at the outset of specialist training is perhaps unsurprising, given that many current sa undergraduate curricula do not include mandatory exposure to research and historically placed little emphasis on evidence-based medicine.[22] most institutions offer medical students the opportunity to conduct only a small, elective research project during their undergraduate training. overall, this means that the sa specialist trainee ‘is not the standard master’s research postgraduate’ and has unique research training needs.[19] limited mmed research supervision capacity the supervision strategy used for mmed research is the traditional masterapprentice model in which a supervisor guides the student through the process of research. unfortunately, one of the greatest challenges faced across training institutions relates to the limited supervision capacity for mmed research projects. as discussed by aldous et  al.,[20] many specialists do not fulfil the regulatory requirements for supervision, as set out by the sa council for higher education. any specialists who pursued the college fellowship examinations before 2010 are not considered to have a suitable ‘qualification in a relevant field of study higher than, or at least at the same level as, the exit level of the postgraduate programme’ they intend to supervise.[23] historically, very few sa clinicians held doctorates. therefore, it is possible that the current staff contingent at many medical schools still comprises a limited number of ‘suitably qualified’ supervisors,[20] although this number will grow as institutions graduate more mmed candidates.[14] an important consideration is that even when specialists have master’s or doctoral degrees, this experience does not necessarily translate into research excellence.[14] rout et  al.[24] note that many mmed research supervisors are ‘relatively inexperienced and may be as much in the dark as the students.’ furthermore, having a postgraduate degree does not guarantee having developed into a successful research supervisor.[14] although efforts to develop research supervision capacity are beyond the scope of the current review, there is a need for professional development programmes that can adequately equip specialists with the necessary pedagogical and research skills to adequately supervise mmed research projects. limited time to conduct and supervise mmed research the limited time available to conduct and supervise research is often foremost in debates surrounding the mmed degree. like any other research  for degree purposes, the mmed research project from planning to execution to final write-up requires ‘an enormous investment of time’ for both candidates and their supervisors.[14] the mmed research project accounts for 25% of the specialist training curriculum; that is, 120 credits and a concomitant 1 200 notional hours.[25] however, when the hpcsa introduced the requirement for completing a research project, specialist training time was not increased to accommodate the additional time required to conduct research.[15,20] insufficient time protected from clinical service obligations causes a tense employee-student dynamic during training. furthermore, the added workload and severe time constraints relating to an 80 june 2022, vol. 14, no. 2 ajhpe research already overburdened academic curriculum and heavy clinical workloads likely account for why  the mmed once represented the qualification with the lowest completion rate.[26] there are several consequences of mmed research non-completion, including delayed specialist registration. this, in turn, could reduce the number of specialists available for appointments which could ultimately undermine healthcare service delivery.[17,19] recently, grossman[19] demonstrated that most registrars could finish their research projects within the four-year specialist training programme, but this is often at the expense of being able to engage fully with final exam preparation. uncertainty about research education goals, strategies and outcomes as emphasised by frank et  al.,[2] medical curricula that follow frameworks for competency-based education should explicitly define the required competencies of graduates and ensure that these are taught, assessed, and acquired. however, there is some disagreement in the literature about how research competence should be developed and assessed among sa specialist trainees. the only requirements for mmed research laid out by the hpcsa include (i) the completion of a relevant research project; (ii) the demonstration of appropriate theoretical knowledge; (iii) the compilation of a research protocol according to required norms; (iv) regular progress reports; and (v) the presentation of results in the format of a dissertation according to acceptable scientific norms.[12] because the hpcsa is not a training body, it is ultimately incumbent upon the universities to interpret these requirements, provide mmed research training and supervision, manage assessment, and ensure the acquisition of research competence among trainees.[15] in general, and much like specialist training before 2010, there appears to be no uniform teaching and learning strategy for mmed research between institutions and disciplines. this includes a lack of clear guidelines on the nature and scope of research and research training, outcomes, and assessment.[15,17] it follows that trainees and their supervisors tend to have a poor understanding of research expectations and ‘there is no clear target at which students might aim when assaying what is expected of them.’[22] rout et al.[17] insist that the best way to demonstrate research competence is by generating a dissertation or publication, because these allow for assessment of the ‘transformative aspects of learning (critical reasoning, synthetic reasoning, scientific thinking, and inquiry-led problem-solving).’ grossman suggests that dissertations in the form of publication-ready manuscripts should be the preferred option for mmed research because they reduce time-to-completion and improve conversion rates to accredited publications.[19,27] however, others have argued that mmed research ‘was never intended to result in a publication, but to produce an examinable document that demonstrates a practical understanding of the research process’[17] and therefore emphasises that undertaking original research should be encouraged but not mandatory.[15] of most significant concern is that despite meeting the dissertation requirement, many specialists ‘still cannot meaningfully critique published medical literature, or explain the meaning of a p-value or a 95% confidence interval.’[22] in response to this debate, some authors have called for alternatives to the dissertation to assess research competency.[15,22] for example, rodseth et al.[22] suggest that some type of formal examination process should assess scholarly competence. extending this concept, biccard et al.[15] recommend the introduction of a national research educational programme, structured as a course-work master’s programme. while these suggestions have merit, the examination of a dissertation is a mandatory component of master’slevel training, as laid out by the south african department of higher education and training.[25] therefore, despite non-uniformity regarding other aspects of mmed research, the requirement for output in the form of an examinable manuscript should provide at least one point of agreement across training sites. debates and uncertainty around an appropriate educational strategy for mmed research could have negative implications for research supervision, the research experience, and the overall value of mmed research as a component of the specialist training programme. the consequences of poor research competence the ultimate purpose of clinical research is to contribute evidence  that can  inform clinical decision-making  and  public health practices. however, rodseth et  al.[22] argue that mmed research seems to lead to ‘a  constant stream of inconclusive, and often irrelevant research that adds to publication pollution and undermines research reliability.’ concern has been raised that many mmed projects include surveys, audits or small observational studies[22] that are ‘inadequately powered to draw meaningful conclusions.’[15] biccard et al.[15] emphasise that ‘poorly conducted research does more harm than good’ because not only is ‘bad research’ a waste of resources in terms of time, effort and money, but it also raises ethical concerns owing to the pointless exposure of research participants to risk  and inconvenience.[15] furthermore, should mmed candidates manage to publish poor-quality research, this could have negative consequences for health policy, government spending on health services provision, and patient health outcomes. stakeholders involved in the mmed research process need to be mindful that they are not advancing clinical care or the research competencies of trainees by allowing them to undertake and publish ‘shoddy science’. mmed candidates are increasingly encouraged to publish their research but institutions should also carefully consider whether this might set a precedent for rewarding poor-quality research. arguably, it is in the institutions’ interest to encourage and support high-quality mmed research if they are to uphold their status as centres of research excellence. if the research project is to remain a mandatory component of specialist training, then there is an urgent need for institutions to revise current research education strategies and the institutional research culture that inevitably guides research practices. strategies to develop research competence among mmed candidates frank et  al.[2] emphasise that curriculum planning should be ‘explicitly tied’ to the needs of students. mmed candidates represent a unique cohort of postgraduate researchers; they face distinct challenges and have very specific research training needs compared with the ‘typical’ master’s student.[19] in particular, mmed candidates require ‘intensive instruction on fundamental research principles’ and the training available should be ‘specific to their field, relevant to their needs and appropriate to the stage of their research journey.’[19] training institutions have attempted to expand existing research training and support services to better accommodate registrars, but grossman[19] highlights that ‘inflexible, generic, scheduled faculty research techniques courses fail the andragogic needs’ of mmed candidates. therefore, medical faculties need to develop student-centred research support and supervisory models that can better meet the training needs of specialist trainees. in terms of supervisory models, rout et  al.[17] suggested using a collaborative cohort model (ccm) as opposed to the traditional apprenticejune 2022, vol. 14, no. 2 ajhpe 81 research master model of supervision. this model involves joint supervision between a disciplinary supervisor (who may be relatively research-naïve) who takes responsibility for the clinical aspects of the research and one research process supervisor (who may be unfamiliar with the disciplinary context) who enhances the scientific process.[14] aldous et al.[20] found that this model of supervision, in conjunction with an innovative modular approach to research, could ensure timely research completion. despite their success, aldous et  al.[20] experienced logistical challenges, including the need to repeat some training sessions owing to the constraints of clinical workloads. there is still a great need to find solutions to the constraints of time and registrar non-attendance at contact-based lectures and workshops. technology-aided teaching approaches may prove to be useful in this context. for example, the blended learning model, which involves a complementary mixture of online learning and face-to-face contact sessions, lends itself to the development of structured or modular progression through the research process and has the added advantage of introducing flexibility into the teaching and learning environment. blended learning has proven to be useful for research education elsewhere,[28,29] and has the potential to address some of the challenges associated with mmed research in sa. the success of research training and support strategies ultimately relies on students being able to access these services. there have been calls for the department of health to recognise the academic requirements of specialist training and allocate time for this to both trainees and their  supervisors.[14] how exactly this should be implemented remains unclear. anecdotally, i know of some disciplines that allocate their trainees a two-week block for research activities. while this decision is well-intentioned, merely providing protected research time does not guarantee success, especially if candidates lack explicit direction and guidance on how to use this time effectively. therefore, although the provision of protected research  time will begin to address mmed research training challenges, there is also a need to provide more structured support during this time. supervisors are well placed to provide this support and arguably play a critical part in teaching or role modelling the ‘ways of being and doing’ in the research community. for this to be effective, supervisors themselves need to feel equipped to function as legitimate members of the scholarly community. the current debate around mmed research tends to focus on the plight of the trainees, but the experiences and professional development of research supervisors also warrant attention. there is a need for greater discussion around ways that institutions can better support mmed research supervisors. finally, there might also be merit in exploring the ‘calibration of standards, and expectations across institutions’ as well as the uniform standards of marking 'consistent with the educational goals of the master’s research programme and the rigours of scientific discourse.’[17] further to this aspect is the need for those involved in the research process, including research supervisors, to make explicit the unwritten and perhaps ‘hidden’ outcomes of mmed research, including its possible value in strengthening ebhc. conclusion in this review, i have attempted to consolidate the current debate around sa mmed research. by providing this summary, i hope to encourage a point of departure between criticism of the challenges and adopting proactive strategies to address them. failing to meet the research education needs of specialist trainees and their supervisors could have deleterious consequences for the quality of academic literature, the research excellence of training institutions, and the practice of ebhc, both locally and abroad. although there have been some efforts to provide research training and support that cater to the unique needs of mmed candidates and their supervisors, there is still much opportunity for innovation in sa clinical research education. within the broader african context, there is some evidence of the development and evaluation of programmes that seek to build research capacity among health professionals.[6,8,9] however, there is still limited focus on the educational impact of research experience during medical training and the effectiveness of research capacity development initiatives provided within african medical schools. declaration. none. acknowledgements. i wish to acknowledge colleagues within the centre for health professions education who supported this review and generously provided their insight regarding postgraduate learning and teaching. author contributions. sole author. funding. none. conflicts of interest. none. 1. frank jr, mungroo r, ahmad y, et  al. toward a definition of competency-based education in medicine : a  systematic review of published definitions. med teach 2010;32(8):631-637. https://doi.org/10.3109/014215 9x.2010.500898 2. frank jr, snell ls, ten cate o, et  al. competency-based medical education : theory to practice. med teach 2010;32(8):638-645. https://doi.org/10.3109/0142159x.2010.501190 3. tuhan i. mastering canmeds roles in psychiatric residency: a resident’s perspective. can j psychiatry 2003;48(4):222-224. 4. frank jr, snell l, sherbino j. canmeds 2015 physician competency framework. ottawa: royal college of physicians and surgeons of canada; 2015. http://canmeds.royalcollege.ca/en/framework (accessed 18 march 2020). 5. solaja o, skinner t, mcgregor t, siemens r. canmeds scholars: a national survey on urology residents’ attitudes towards research during training. can urol assoc j 2018;12(4):e191-e196. https://www.ncbi.nlm.nih. gov/pmc/articles/pmc5905553/ (accessed 19 may 2020). 6. forland f, rohwer ac, klatser p, boer k, mayanja-kizza h. strengthening evidence-based healthcare in africa. evid based med 2013;18(6):204-206. https://doi.org/10.1136/eb-2012-101143 7. uthman oa, wiysonge cs, ota mo, et al. increasing the value of health research in the who african region beyond 2015 reflecting on the past, celebrating the present and building the future: a bibliometric analysis. bmj open 2015;5(3):1-8. https://doi.org/10.1136/bmjopen-2014-006340 8. young t, naude c, brodovcky t, esterhuizen t. building capacity in clinical epidemiology in africa: experiences from masters programmes. bmc med educ 2017;17(1):1-10. https://doi.org/10.1186/s12909-017-0885-4 9. nachega jb, uthman oa, ho ys, et  al. current status and future prospects of epidemiology and public health training and research in the who african region. int j epidemiol 2012;41(6):1829-1846. https://doi. org/10.1093/ije/dys189 10. ezeh ac, izugbara co, kabiru cw, et al. building capacity for public and population health research in africa: the consortium for advanced research training in africa (carta) model. glob health action 2010;3(1). https:// doi.org/10.3402/gha.v3i0.5693 11. ijsselmuiden c, marais dl, becerra-posada f, ghannem h. africa’s neglected area of human resources for health research the way forward. s afr med j 2012;102(4):228-233. https://doi.org/10.7196/samj.5377 12. health professionals council of south africa. subcommittee for postgraduate education and training. new requirements for the registration of specialists in south africa. 2010. https://isystems.hpcsa.co.za/uploads/editor/ userfiles/downloads/medical_dental/petm (accessed 14 march 2020). 13. de beer mm, karusseit vol, pienaar bh. perspectives of south african general surgeons regarding their postgraduate training. s afr j surg 2014;52(3):67-71. https://doi.org/10.7196/sajs.1993 14. rout c, sommerville t, aldous c. mmed cohort supervision: a path out of the swamp? 2015;105(4):275-276. https://doi.org/10.7196/samj.9338 15. biccard bm, dyer ra, swanevelder jl, coetzee jf, shafer sl. is the hpcsa requirement for a research dissertation for specialist registration the best option? s afr j anaesth analg 2017;23(4):4-6. http://www.sajaa. co.za/index.php/sajaa/article/view/2027/0. 16. patel n, naidoo p, smith m, loveland j, govender t, klopper j. south african surgical registrar perceptions of the research project component of training: hope for the future? s afr med j 2016;106(2):169-171. https://doi. org/10.7196/samj.2016.v106i2.10310 17. rout c, aldous c, hift r. response to concerns expressed in the journal regarding the hpcsa requirement for registrar (mmed) research. s afr j anaesth analg 2018;24(2):48-49. 18. szabo cp, ramlall s. research competency and specialist registration: quo vadis? s afr med j 2016;106(12):11831185. https://doi.org/10.7196/samj.2016.v106i12.11217 19. grossman es. how long does it take a registrar to complete the compulsory research project enabling specialist registration? s afr med j 2019;109(4):254-258. https://doi.org/10.7196/samj.2019.v109i4.13377 20. aldous c, clarke d, van wyk j, rout c. avoiding the distant elephant: a model to approach the research component of specialisation. bmc med educ 2016;16(1):4-9. https://doi.org/10.1186/s12909-016-0661-x 21. padayachee k. ‘specialist’ doctors in fight with council. the mercury. https://www.pressreader.com/south-africa/ the-mercury-south-africa/20160503/281668254176128. 3 may 2016. 22. rodseth rn, wise r, bishop d. polluting the well. s afr j anaesth analg 2017;23(6):9976. 23. council for higher education. criteria for programme accreditation. http://nr-online.che.ac.za/html_ documents/che_accreditation_criteria_nov2004.pdf. 2004 (accessed 18 march 2020). 24. rout c, aldous c, hift r. response to concerns expressed in the journal regarding the hpcsa requirement for registrar (mmed) research. s afr j anaesth analg 2018;24(2):48-50. http://sajaa.co.za/index.php/sajaa/article/ view/2087 https://doi.org/10.3109/0142159x.2010.500898 https://doi.org/10.3109/0142159x.2010.500898 https://doi.org/10.3109/0142159x.2010.501190 http://canmeds.royalcollege.ca/en/framework https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5905553/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5905553/ https://doi.org/10.1136/eb-2012-101143 https://doi.org/10.1136/bmjopen-2014-006340 https://doi.org/10.1186/s12909-017-0885-4 https://doi.org/10.1093/ije/dys189 https://doi.org/10.1093/ije/dys189 https://doi.org/10.3402/gha.v3i0.5693 https://doi.org/10.3402/gha.v3i0.5693 https://doi.org/10.7196/samj.5377 https://isystems.hpcsa.co.za/uploads/editor/userfiles/downloads/medical_dental/petm https://isystems.hpcsa.co.za/uploads/editor/userfiles/downloads/medical_dental/petm https://doi.org/10.7196/sajs.1993 https://doi.org/10.7196/samj.9338 http://www.sajaa.co.za/index.php/sajaa/article/view/2027/0 http://www.sajaa.co.za/index.php/sajaa/article/view/2027/0 https://doi.org/10.7196/samj.2016.v106i2.10310 https://doi.org/10.7196/samj.2016.v106i2.10310 https://doi.org/10.7196/samj.2016.v106i12.11217 https://doi.org/10.7196/samj.2019.v109i4.13377 https://doi.org/10.1186/s12909-016-0661-x https://www.pressreader.com/south-africa/the-mercury-south-africa/20160503/281668254176128 https://www.pressreader.com/south-africa/the-mercury-south-africa/20160503/281668254176128 http://nr-online.che.ac.za/html_documents/che_accreditation_criteria_nov2004.pdf http://nr-online.che.ac.za/html_documents/che_accreditation_criteria_nov2004.pdf http://sajaa.co.za/index.php/sajaa/article/view/2087 http://sajaa.co.za/index.php/sajaa/article/view/2087 82 june 2022, vol. 14, no. 2 ajhpe research 25. council for higher education. the higher education qualifications sub-framework. 2013. https://www.ru.ac.za/media/ rhodesuniversity/content/institutionalplanning/documents/heqsf_2013.pdf. (accessed 18 march 2020). 26. mbali c. education: revisiting the purpose of a master’s. mail and guardian; 4 october 2011. https://mg.co.za/ article/2011-10-04-revisiting-the-purpose-of-a-masters/ 27. grossman es. publication rate of 309 mmed dissertations submitted between 1996 and 2017: can registrars fulfil hpcsa form 57 med amendments? s afr med j 2020;110(4):302-307. https://doi.org/10.7196/samj.2020.v110i4.14339 28. evans kh, thompson ac, o’brien c, et al. an innovative blended preclinical curriculum in clinical epidemiology and biostatistics: impact on student satisfaction and performance. acad med 2016;91(5):696-700. https://doi. org/10.1097/acm.0000000000001085 29. moromizato t, garcia-larsen v, soeteman d, et  al. addressing the gap in clinical research education: implementation of the introduction to clinical research training-japan program. j gen fam med 2018;19(6):188-190. https://doi.org/10.1002/jgf2.204 accepted 24 february 2021. https://www.ru.ac.za/media/rhodesuniversity/content/institutionalplanning/documents/heqsf_2013.pdf https://www.ru.ac.za/media/rhodesuniversity/content/institutionalplanning/documents/heqsf_2013.pdf https://mg.co.za/article/2011-10-04-revisiting-the-purpose-of-a-masters/ https://mg.co.za/article/2011-10-04-revisiting-the-purpose-of-a-masters/ https://doi.org/10.7196/samj.2020.v110i4.14339 https://doi.org/10.1097/acm.0000000000001085 https://doi.org/10.1097/acm.0000000000001085 https://doi.org/10.1002/jgf2.204 cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can checkthe answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/007/01/2011 (clinical) cpd 20 december 2011, vol. 3, no. 2 ajhpe cpd december 2011 1. true (a) or false (b): thirty-two per cent of female 4th-year medical students reported having the perception that they were not taken seriously by their patients because they were female. 2. true (a) or false (b): ninety per cent of female 4th-year medical students felt that there was a difference in how they were viewed as professional due to their gender. 3. true (a) or false (b): a 4th-year female medical student was asked to step down from assisting a caesarean section in favour of a male student. 4. true (a) or false (b): with regard to statistician consultations, research protocol development consultations represented 35% of consultations. 5. true (a) or false (b): with regard to statistician consultations, 10% of consultees were from psychiatry. 6. true (a) or false (b): problems with biomedical research included that the necessary materials are shipped cold or frozen from abroad, and would perish. 7. true (a) or false (b): forty per cent of african students reside out of their country of origin. 8. true (a) or false (b): in 2004 it was estimated that in africa (except south africa) there were 200 researchers of any field per million population. 9. true (a) or false (b): the student pathways study shows very few of the students who leave their institutions prematurely do so because they cannot afford to stay. 10. true (a) or false (b): a national survey on hiv/aids prevalence rate among students at south african universities showed 3.4% positivity. 11. true (a) or false (b): injuries due to violence are the second leading cause of death in south africa. 12. true (a) or false (b): insight into the student/supervisor relationship was not improved after a clinical supervision course. 13. true (a) or false (b): participants’ motivation to attend a short course in clinical supervision was mainly intrinsic. 14. true (a) or false (b): the interprofessional nature of a clinical supervision course was refreshing. 15. true (a) or false (b): medical laboratory technologists with a diploma could be skilled up for higher roles in biomedical sciences in uganda through the introduction of a bridging postgraduate diploma programme in medical laboratory sciences. 16. true (a) or false (b): thirty-two participants wanted a full-time bridging programme in medical laboratory sciences. 17. true (a) or false (b): staffing the healthcare laboratories with highly qualified personnel would result in the creation of appropriate technologies suited to uganda’s needs. 18. true (a) or false (b): the theory of assisted performance is a teaching approach that can be used to structure learning activities that help students develop complex reasoning skills. 19. true (a) or false (b): teaching and learning activities using emerging online technologies like social networks need to be implemented within a pedagogical framework that allows the facilitator to guide student development. 20. true (a) or false (b): teaching and learning activities using emerging online technologies can also be beneficial in exposing and exploring the deeper, hidden understandings of the culture within professions. september 2021, vol. 13, no. 3 ajhpe 159 research why the need for innovation? work-integrated learning (wil) is a crucial component of learning in the undergraduate occupational therapy (ot) programme. wil provides essential work exposure, allows for theory-practice integration and forms part of the 1 000 clinical hours required by the health professions council of south africa (hpcsa), in order for graduates to be registered as occupational therapists. in march 2020, with the implementation of covid-19 restrictions, ot training – characterised by regular face-to-face contact between lecturers, students and service users – had to transform rapidly to virtual contact sessions. although the hpcsa adapted regulations to allow for alternatives to traditional wil, navigating the transformation to alternative clinical learning activities was challenging for teaching staff. lecturers were concerned about whether they would be able to guide students to reach the learning outcomes of the curriculum. the world federation of occupational therapy suggested case studies as an alternative to fieldwork.[1] although case study presentations are authentic in content, they have the limitation that they may be more difficult for students to conceptualise than face-to-face interactions. furthermore, case studies do not allow students the opportunity to gain hands-on experience. however, recent research strongly supports the appropriate use of case-studies,[2,3] and the decision was made to adopt virtual case studies as part of a polysynchronous approach[4] to present students with alternatives to wil. the challenge was to incorporate case studies in such a way that the authentic learning experience for the students was enhanced, as face-to-face interaction with service users was prohibited because of covid-19 restrictions. what was implemented? six experts in different fields of paediatric ot were invited to virtually present a case study on google meet. experts were selected from diverse contexts (e.g. rural clinic, urban private school, special school) and the service users in the case studies had different conditions as discussed in the curriculum (e.g. severe disability, autism spectrum disorder, sensory integration dysfunction). online, synchronised presentations occurred once a week over six weeks. experts were provided with detailed guidelines to structure their presentations. the experts gave the medical history (including clinical information), as well as a description of influencing environmental and ethical factors. experts were requested to include photographs of the service user’s environment, their available equipment and resources, as well as photographs of the service user (provided informed consent was obtained). furthermore, experts shared their own selection of assessments and interventions implemented for this case. the expert then referred the case to the students who had to deliberate and collaborate in their small groups to complete: (i) a professional reasoning tool; and (ii) their intervention plan and first intervention session. professional reasoning in ot is the process used by practitioners ‘to plan, direct, perform, and reflect on client care’.[5] therefore, students were guided to integrate prior knowledge and new information relevant to the case within the professional reasoning tool. the students then used this information to produce the intervention plan and their first intervention session. emphasis was placed on prioritising intervention outcomes with consideration of the service user’s context, as this is a priority – particularly in resource-limited contexts.[6,7] the module co-ordinator visited the groups in their break-out ‘rooms’ throughout the day to provide guidance. during the next virtual session, one group had the opportunity to present their completed professional reasoning tool as well as intervention plan and intervention session to the class. the presentations were informal yet structured to allow for discussion and reflection between lecturers and students. students received constructive, formative feedback, as the intent was to facilitate interaction, discussion and debate regarding issues pertaining to the case. after the completion of each presentation, all students were required to complete a guided reflection on their own learning. individual assessment was in the format of a portfolio of evidence, containing (per case) the student’s completed professional reasoning tool, intervention plan and intervention session, together with his/her own guided reflection. a rubric guided the allocation of marks for the portfolio. the rubric focused on the individual student’s ability to: (i) write and edit documentation in a professional manner; (ii) compile a comprehensive portfolio (i.e. did he/ she complete all the activities?); (iii) reflect deeply on the case studies; (iv) identify and specify a variety of suitable resources appropriate to the case studies; and (v) evaluate the intervention plans. what have we learnt? several lessons were learnt though the implementation of this approach. these will be supplemented with quotations from student feedback (shared with permission). firstly, students gained experience and professional reasoning skills to plan the intervention process for six extremely diverse clients. within typical clinical placements, this would not be possible as specific practice settings tend to provide services to children with similar diagnoses or impairments, often from one particular context. although the students were unable to execute their intervention plans with the service users, the exposure and experience gained by students far exceeded lecturers’ expectations. one student wrote in her feedback: from work-integrated learning to virtual case studies: navigating an alternative to fieldwork in paediatric occupational therapy k van niekerk,¹ b occ ther, m eci, phd aac; k uys,1 b occ ther, b occ ther hons, m aac, phd; i (j c) lubbe,2 bsocsc, msocsc, med, phd 1 department of occupational therapy, faculty of health sciences, university of pretoria, south africa 2 education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: k van niekerk (karin.vanniekerk@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:karin.vanniekerk@up.ac.za 160 september 2021, vol. 13, no. 3 ajhpe research ‘i value the variety of cases we did. which we would not necessarily had gotten in a practical fieldwork.’ an additional benefit of the approach was that it enabled various experienced occupational therapists (lecturers and experts) to collaborate in facilitating learning for the students. the clinical subject matter experts synthesised information from different practice areas of the curriculum into the one case study each presented. students received valuable information from the expert presenter to visualise the complexity of the case and approach it as if they were shadowing the expert. students were therefore required to link different areas of practice when planning intervention. students commented in their feedback: ‘i enjoyed doing all the different cases and seeing a broader perspective on the different areas of paediatric ot. seeing the different diagnoses and how the therapists treating those children intervened in each case was really insightful and i think we’ll always remember these cases.’ ‘i enjoyed the case studies as it changed the theory into a practical component.’ ‘i valued that experienced lecturers from different fields presented these cases to us.’ ‘i valued that the cases were presented so comprehensively to us.’ the group work ensured that the learning activity could be taken full circle to a final product that could be presented to the class. students discussed and debated issues pertaining to the case within their groups and had to agree on a collective approach. the students’ interactions allowed for critical reflection and inductive and deductive reasoning.[8] these processes became evident during the presentation sessions, as the students were able to interact and produce substantive counterarguments to comments from lecturers and peers, as they had truly engaged with the material. furthermore, to complete the reflective questionnaire after every case, students had to reflect individually on their own growth. from the quality of reflections received as part of the portfolio, lecturers identified that students found this activity challenging, although some could identify the value of this practice. one student observed: ‘it was really insightful to reflect on the different cases for the portfolio. it helped me realise what i learnt in the module.’ students seemed to value the repetitiveness and familiarity of the consistent teaching and learning process used every week. as the weekly expectations and process remained the same, the students could focus on the complexities of each case study. lecturers could observe the increase in confidence and competence in the students every week. furthermore, students showed a deep appreciation for this new and unconventional approach to teaching, acknowledging the added benefit to their own growth, development and learning. two students commented: ‘i valued all the effort the lecturers made to provide us with a rich education during the online learning period.’ ‘even if the third-years of 2021 go back to normal practicals, i would encourage you to try and incorporate the 6 different cases that we did into their year, because that was definitely where i learnt the most.’ what will we keep in our practice to continue improving our student training? as the use of case studies with clinical subject matter experts proved to be a valuable learning experience for the students, we will continue to use the concept in our training, even in the post-pandemic context. as students will possibly be able to return to (limited) fieldwork placements in the near future, we plan to repurpose these case studies and incorporate them into the skills mix, giving students the best of both worlds. the assessment rubric will be refined and validated to make the assessment criteria more explicit and easier to interpret. students found it difficult to comprehend that assessment would not focus exclusively on their ‘actual product’, but rather on their metacognition and reflection on their learning during the process. this shift in focus should be incorporated throughout the curriculum. because many students found reflection a valuable, albeit difficult and abstract, concept to master, we will introduce guided reflection from the onset – supporting students in developing this essential skill. although covid-19 has caused many a sleepless night for lecturers in the health sciences, adapting our approaches to teaching and assessment has radically expanded our horizons. this experience will infuse our teaching with new ways of guiding our students to face the challenges of service provision in the 21st century. declaration. the authors declare  that this submission is original and has not been submitted to any other journal. acknowledgements. the authors would like to thank all the experts and students for their participation and valuable contributions. author contributions. kvn: conception and design of the work; drafting the article. kvn and ku: involved in teaching and learning activities to collect data; analysis and interpretation; development and presentation of video material. ku and il: critical revision of the article. kvn, ku and il: final approval of the version to be published. funding. none. conflicts of interest. none. evidence of innovation 1. world federation of occupational therapy. wfot minimum education standards statement. 2020. https:// wfot.org/news/2020/covid-19-and-wfot-minimum-education-standards-statement (accessed 15 february 2021). 2. popil i. promotion of critical thinking by using case studies as teaching method. nurse educ today 2011;31(2):204-207. https://doi.org/10.1016/j.nedt.2010.06.002 3. allen dd, toth-cohen s. use of case studies to promote critical thinking in occupational therapy students. j occup ther educ 2019;3(3). https://doi.org/10.26681/jote.2019.030309 4. dalgarno b. polysynchronous learning: a model for student interaction and engagement. proc ascilite 2014 annu conf aust soc comput tert educ 2014;673-677. 5. boyt schell b. professional reasoning in practice. in: blesedell crepeau e, cohn e, boyt schell b, eds. willard & spackman’s occupational therapy. 11th ed. baltimore: wolters kluwer health/lippincott williams & wilkins, 2009: 314-327. 6. van stormbroek k, buchanan h. novice occupational therapists: navigating complex practice contexts in south africa. aust occup ther j 2019;66(4):469-481. https://doi.org/10.1111/1440-1630.12564 7. ryan s, hills c. context and how it influences our professional thinking. in: robertson l, ed. clinical reasoning in occupational therapy: controversies in practice. hoboken, new jersey: blackwell publishing, 2012: 63-92. 8. stott a, hobden p. implementation challenges influencing the efficacy of group-work tasks that require inductive or deductive reasoning during physical sciences lessons. j educ 2019;(77). https://doi.org/10.17159/i77a02 accepted 15 june 2021. afr j health professions educ 2021;13(3):159-160. https://doi.org/10.7196/ajhpe.2021. v13i3.1528 https://wfot.org/news/2020/covid-19-and-wfot-minimum-education-standards-statement https://wfot.org/news/2020/covid-19-and-wfot-minimum-education-standards-statement https://doi.org/10.1016/j.nedt.2010.06.002 https://doi.org/10.26681/jote.2019.030309 https://doi.org/10.1111/1440-1630.12564 https://doi.org/10.17159/i77a02 https://doi.org/10.7196/ajhpe.2021.v13i3.1528 https://doi.org/10.7196/ajhpe.2021.v13i3.1528 research november 2015, vol. 7, no. 2 ajhpe 155 in 2010, a skills centre came into operation at the medunsa campus of the university of limpopo, which is situated 25 km north-west of pretoria, south africa. the medical core curriculum skills list was revised and skills that could be taught in simulated situations were listed for each of the 6 academic years. since 2011, all 6th-year students have been required to manage 3 simulated clinical emergencies in small groups during the orientation period of the family medicine rotation. the skills incorporated in these simulations are cardiopulmonary resuscitation (cpr), airway suctioning, placement of an oropharyngeal airway (opa), endotracheal intubation, bag-valve-mask (bvm) ventilation and defibrillation. as the 2012 final-year students had not had exposure to the simulated emergency skills training currently scheduled for 4th-year students, their emergency skills training comprised apprenticeship in real-life clinical situations. their formal emergency training was limited to cpr in their 4th year and endotracheal intubation and bvm ventilation in their 5th year of study. there was no evidence that these students had had opportunities to practise emergency skills during their practical rotations or of their competence and confidence when performing these skills. traditional bedside teaching, based on the apprenticeship model of education, cannot be relied on to provide adequate and comprehensive clinical skills training.[1] the healthcare systems (reduced hospital stay and a rapid advance in diagnosis and treatment technologies) have made this teaching method less effective, resulting in a sharp decline in standards of acquisition of clinical skills among medical students. the drawbacks of an apprenticeship methodology of skills acquisition (where learning is left to chance and is unobserved by teachers) can, however, be overcome by structured and observed training in skills centres.[2] growing evidence validating medical simulation as an educational tool has promoted its use beyond the instruction of physicians-in-training,[3] and skills centres have become an established part of training for healthcare professionals. clinical skills centres provide students with the opportunity to practise clinical techniques on manikins and simulators in a safe environment, without affecting the quality of patient care. this has changed the centuries-old approach to learning medical procedures by first practising on a patient, to one where competency is first demonstrated on a simulator. simulation training, especially in emergency skills, is designed in such a way that healthcare providers can learn from practising in a situation that they are likely to encounter. it ensures that patients are not put at unnecessary risk by exposure to novice or out-of-practice caregivers,[4] and is also conducive to the conducting of objective assessments. there is considerable debate on how accurately students assess their own competence. several studies have shown that medical students’ self-perceived competence correlates poorly with objectively assessed competence.[5] apart from inadequate self-assessment skills, biased selfevaluation in applied settings can also be ascribed to the overconfidence phenomenon. ‘we don’t know what we know, but we are confident we do … not only are we wrong, but we are confident that we are right!’[6] a more serious problem that has been identified is that individuals at the lowest levels of mastery lack the metacognitive understanding of what actually constitutes mastery, leading them to greatly overestimate their own skills.[6] background. at medunsa, pretoria, south africa, the training of final-year medical students includes the management of simulations that incorporate, inter alia, the following emergency skills: cardiopulmonary resuscitation (cpr), defibrillation, airway suctioning, oropharyngeal airway placement, endotracheal intubation and bag-valve-mask ventilation. other than cpr, all emergency training of the 2012 student group was by means of apprenticeship in clinical rotations. therefore, there was no evidence of the students’ competence or confidence with regard to their performance of emergency skills. objectives. to explore the effect of simulated skills training and assessments on medical students’ competence and confidence when using the skills required to manage clinical emergencies. method. a one-group pretest post-test quasi-experimental design was used, with a convenience sample (n=82) comprising final-year medical students from 3 of the 6 annual family medicine rotations. the participants’ competence (knowledge and selected emergency skills as per curriculum) and confidence were assessed before training. the intervention comprised training in relevant theory, demonstrations and supervised hands-on practice. the post-training assessments were a repeat of the pretraining assessments. results. the improvement in participants’ confidence and competence levels when performing all the emergency skills on completion of the demonstrations and hands-on practice was highly significant (p≤0.001). participants were unanimous in their opinion that pre-assessments had enhanced their learning experience. conclusions. the strategy of teaching/learning and assessment of emergency skills in simulation was highly effective in enhancing the competence and confidence of medical students when managing a clinical emergency. however, students appeared to be overconfident, which could be ascribed to ignorance, and possibly indicates that feedback during training should be improved. afr j health professions educ 2015;7(2):155-157. doi:10.7196/ajhpe.229 effect of simulated emergency skills training and assessments on the competence and confidence of medical students i treadwell, dcur, hed skills centre, sefako makgatho health sciences university (formerly medunsa campus of the university of limpopo), pretoria, south africa corresponding author: i treadwell (ina.treadwell@gmail.com) research 156 november 2015, vol. 7, no. 2 ajhpe competence and confidence are terms used for expressing beliefs about one’s ability to perform an activity. confidence refers to self-assurance arising from an appreciation of one’s own abilities,[7] while in this study competence refers to the ability to perform a clinical skill successfully or efficiently. competence can, however, be thwarted by a lack of confidence; however, misguided overconfidence in professional capabilities may have serious professional and malpractice consequences.[8] clinical experience and the level of confidence have no predictive value in performance assessments when using standardised simulated scenarios. as self-confidence is not a reliable indicator of skills competence, it is important to measure both confidence and competence.[9] final-year medical students have a sound theoretical knowledge of emergency procedures,[10] but how confident and competent are they in performing these procedures? objective the objective of this study was to explore the effect of simulated skills training and assessments on final-year medical students’ competence and confidence in performing skills required to manage clinical emergencies. method the study was conducted at the skills centre at medunsa. the population of mb chb vi students (n=176) was divided into 6 groups that rotated, as per curriculum, through 6 blocks of various disciplines during the year. a convenience sample (n=82) was used, comprising all the consenting students from 3 of these groups during their family medicine rotation. ethical clearance was granted by the medunsa research and ethics committee and informed consent was obtained from participants. a one-group pretest post-test quasi-experimental design was used to determine the effect of skills training and assessment on students’ competence and confidence in performing emergency procedures. pretraining assessments of participants’ competence (knowledge and selected emergency skills as per curriculum) and confidence were administered. the intervention comprised 3 training and practice sessions of 30 minutes each: (i) adult cpr and defibrillation; (ii) adult endotracheal intubation; and (iii) resuscitation of a paediatric patient (cpr, airway suctioning, placement of an opa, and bvm ventilation). three groups, each comprising 9 10 students, rotated through the 3 stations, each manned by 2 lecturers who supervised the students and, by implication, provided them with feedback. the post-training assessments were a repeat of the pretraining assessments. preand posttraining assessments were conducted on the same day to minimise the threat of maturation and history. to prevent social desirability bias the questionnaires were administered by the researcher, and responses to questionnaires were not accessible to the lecturers. the preand post-training questionnaires comprised a 4-point likert scale for self-report of confidence levels in performing 6 skills: cpr, clearing the airway by suctioning, placement of an opa, endotracheal intubation, bvm ventilation and defibrillation. a statement on the effect of skills assessment prior to the teaching session was added to the post-training questionnaire. the multiple-choice questions (mcq) test, used before and after the training, comprised questions relevant to the range of skills. the test was compiled and verified by 4 lecturers involved in emergency care training. the objective structured clinical examination (osce) assessment tools were compiled and tested to assess objectively the skills performed at each of the 3 osce stations. a pilot study with 43 students in the first family medicine rotation of 2012 was conducted to determine the viability of the instruments and timing of the activities. these results were not included in the study. results the results of the mcq test, questionnaires and osce were captured on an excel spreadsheet. the test and osce results before and after the teaching sessions were compared using fisher’s exact test. all statistical tests were two-sided and p-values ≤0.01 were considered significant. the mean scores of the preand post-training tests and osce assessments, the differences (improvement) and significance thereof are shown in table 1. the responses to the 4 categories of the likert scale were summarised by frequency counts and percentages. the preand posttraining percentages of ‘competent’ outcomes (a combination of responses in category 1 (very confident) and category 2 (confident)) were compared using fisher’s exact test. the mean scores of the preand post-training confidence table 1. differences in the mean scores of preand post-training assessments (n=82) assessments training mean score pretraining, % mean score post-training, % difference, % significance, p-value mcq test 42 64 21 0.0001 osce station 1 paediatric resuscitation 23 74 51 0.0001 osce station 2 cpr and defibrillation 19 81 62 0.0001 osce station 3 endotracheal intubation 16 52 37 0.0001 table 2. differences in preand post-training confidence levels in performing emergency skills (n=82) skill confidence pretraining, % confidence post-training, % difference, % significance, p-value airway suctioning 66 100 34 <0.001 placement of opa 33 99 66 <0.001 bvm ventilation 81 100 19 <0.001 endotracheal intubation 30 94 64 <0.001 cpr 87 100 13 <0.001 defibrillation 33 96 64 <0.001 table 3. value of pretraining assessment (n=82) value of osce strongly disagree, % disagree, % agree, % strongly agree, % created awareness 0 0 9 91 enhanced learning 0 0 12 88 research november 2015, vol. 7, no. 2 ajhpe 157 levels, the differences (improvement) and significance thereof are given in table 2. participants were unanimous (combination of category 1 (strongly agree) and category 2 (agree)) in their opinion that the pretraining osce had made them aware of their learning needs and the osce experience had enhanced their learning during the teaching session (table 3). discussion the lowest mean osce score was for endotracheal intubation (16% pretraining and 52% post-training). the medical students seem to find this emergency skill the most problematic. the literature shows that medical graduates feel inadequately prepared for performing an endotracheal intubation and it is recommended that more emphasis be placed on training medical students in this skill.[11] the improvement of participants’ competence in performing emergency skills in the post-training osce was highly significant (p<0.001). this improvement corresponds to the findings in a study on residents’ improved competence in critical resuscitation procedures following an intensive simulation-based training programme.[12] the literature reports low confidence levels and poor self-assessment of proficiency with regard to procedural skills among medical students entering clinical rotations. their confidence improved significantly after a course in procedural skills.[13] our results likewise indicate a highly significant increase in confidence levels when performing each of the skills. students reported that the pretraining assessment (osce) improved their learning. this was similar to a report indicating that students who were evaluated prior to their training performed better in the post-training evaluation than a control group who had not been evaluated before training.[14] a limitation of this study was that, although the students seemed alarmingly overconfident, the data were unsuitable to statistically determine the correlation between competence (scores in percentages) and confidence (4 categories). an additional limitation was that individual feedback, as implied during supervised hands-on sessions, was not monitored. the absence of a correlation between confidence and grades could be the result of a lack of appropriate and clear feedback.[4] students’ inflation of their abilities might be caused by ignorance rather than arrogance;[15] such exaggerated judgements might be the result of an absence of feedback or failure to incorporate feedback into self-perception.[5] students tended to overestimate their own abilities. high-quality feedback[15] could act as an antidote to such inaccurate self-assessment. conclusion the strategy of teaching/learning and assessment of emergency skills in simulation proved highly effective in enhancing the competence and confidence of medical students in their management of a simulated clinical emergency. the improvement of students’ performance and confidence levels on completion of demonstrations and hands-on practice was highly significant (p<0.001). the students appeared to be overconfident before engaging in this teaching/learning strategy. their confidence levels escalated significantly on completion of the simulation, but were unfounded when compared with the proficiency scores. this confirms a finding previously reported in the literature that self-confidence is not a reliable indicator of skills competence.[10] recommendations as students’ confidence levels were higher than their actual competency levels in the performance of emergency skills, it is recommended that training in the latter be expanded to include high-quality individual feedback. the effect of such individual feedback and its role in enhancing self-perception should be further researched. acknowledgements. i would like to acknowledge the help and contributions of staff from the skills centre (h havenga, m theron, y uys, b randa, k kgasi, t zana and t van dyk), the department of family medicine (drs k hlabyago, h mabuza, s nyalunga, c barua, i govender and j ndimande) and the students who participated in this study. references 1. remmen r, derese a, scherpbier a, et al. can medical schools rely on clerkships to train students in basic clinical skills? med educ 1999;33(8):600-605. [http://dx.doi.org/10.1046/j.1365-2923.1999.00467.x] 2. ahmed am. role of clinical skills centres in maintaining and promoting clinical teaching. sudan j public health 2008;3(2):97. 3. meguerdichian da, heiner jd, younggren bn. emergency medicine simulation: a resident’s perspective. ann emerg med 2012;60(1):121. [http://dx.doi.org/10.1016/j.annemergmed.2011.08.011] 4. brookes l. developing simulation training for medical emergencies. medscape interview, paul preston. http:// www.medscape.com/index/list_6121_1 (accessed 15 november 2012). 5. lai nm, teng cl. self-perceived competence correlates poorly with objectively measured competence in evidence based medicine among medical students. bmc med educ 2011;11(1):25. [http://dx.doi.org/10.1186/1472-692011-25] 6. heath l, dehoek a, locatelli sh. indirect measures in evaluation: on not knowing what we don’t know. practical assessment, research and evaluation 2012;17(6). http://pareonline.net/pdf/v17n6.pdf (accessed 15 november 2012). 7. oxford dictionaries. http://oxforddictionaries.com/definition/english/confidence (accessed 20 march 2013). 8. elzubeir ma, rizk dee. assessing confidence and competence of senior medical students in an obstetrics and gynaecology clerkship using an osce. educ health 2001;14(3):373-382. 9. hansen m, oosthuizen g, windsor j, et al. enhancement of medical interns’ levels of clinical skills competence and self-confidence levels via video ipods: pilot randomized controlled trial. j med internet res 2011;13(1):e29. [http://dx.doi.org/10.2196/jmir.1596] 10. remes v, sinisaari i, harjula a, helenius i. emergency procedure skills of graduating medical doctors. med teach 2003;25(2):149-154. [http://dx.doi.org/10.1080/014215903100092535] 11. ochsmann eb, zier u, drexler h, schmid k. well prepared for work? junior doctors’ self-assessment after medical education. bmc med educ 2011;24(11):99. [http://dx.doi.org/10.1186/1472-6920-11-99] 12. langhan ts, rigby ij, walker iw, howes d, donnon t, lord ja. simulation-based training in critical resuscitation procedures improves residents’ competence. cjem 2009;11(6):535-539. 13. stewart ra, hauge ls, stewart rd, rosen rl, charnot-katsikas a, prinz ra. a crash course in procedural skills improves medical students’ self-assessment of proficiency, confidence, and anxiety. am j surg 2007;193(6):771-773. [http://dx.doi.org/10.1016/j.amjsurg.2007.01.019] 14. li q, ma el, liu j, fang lq, xia t. pre-training evaluation and feedback improve medical students’ skills in basic life support. med teach 2011;33(10):e549-e555. [http://dx.doi.org/10.3109/0142159x.2011.600360] 15. deangelis t. why we overestimate our competence? american psychological association 2003;34(2). http:// www.apa.org/monitor/feb03/overestimate.aspx (accessed 13 november 2012). editorial 2 july 2012, vol. 4, no. 1 ajhpe as a faculty of health sciences we have regular internal and external evaluation of our programmes, which, among other things, impact on our regulations. i view these regulations as the signs on a map, guiding us as lecturers and students. the regulations are therefore very important and form the foundation of managing a programme and assisting students in navigating programmes in a structured manner. at a recent faculty meeting with some of our senior colleagues at the university, the remark was made that ‘in the faculty of health sciences the regulations are usually different’. this statement triggered me to pose the question: ‘is it true?’ my immediate response is: ‘yes, but only to a degree.’ i now pose the question to you: ‘are we, as faculties of health sciences, and as health professionals, different and what is different about us?’ there are a number of issues that one can raise as being different within health sciences and for health professionals. health sciences education is based in the worlds of education and health, but surely the principles of education and specifically higher education stay the same, irrespective of the discipline? one can argue that we train professionals, but so do other faculties at our universities. the difference is glaringly obvious to me: it is in the training platform that we utilise, especially the partnerships that we need to develop and nurture to effectively train health professionals for south africa. i am referring here specifically to the clinical years, where we train health sciences students in health facilities, and have to work closely with the national department of health and the provincial departments. this reminded me of a public statement1 made in 2009 by a number of health professionals in the faculty of health sciences, university of the free state, regarding the state of these platforms, that links to an article by jp van niekerk2 referring to the state of academic health and the continued erosion of state support to teaching hospitals. although this statement was made 3 years ago by a single institution, i believe that it and the jp van niekerk article still resonate with members of all faculties of health sciences. this statement dealt with the academic platform – specifically the annual budget deficit that became the norm, and the subsequent impact this had on service delivery, training and research obligations of the faculty of health sciences. it also referred to the despair of health professionals about the annual deterioration of health indicators in the province. one of the areas explored was how to effectively influence healthcare management at all levels, in order to firstly guard against the further destruction of the services, training and research abilities, and secondly to actively engage the provincial department and the university to influence resource allocations to allow for sustainable academic excellence at the training institutions. academic excellence was confirmed as the goal of all tertiary training institutions, uncompromising in its effort. the role of faculties of health sciences is to perform both free of interference and as an expression of academic freedom. this allows professionals to maintain standards on the one hand and to achieve excellence through careful planning and execution on the other. excellence is consequently both a roadmap and a defensive wall. we still acknowledge that service delivery falls primarily in the domain of the provincial department of health, but service delivery at all levels is addressed by various departments in faculties of health sciences. the continual plea is therefore made that budget mechanisms and principles have to be revised to produce a co-ordinated health structure with clearly defined quality health outcomes, and the continuous commitment is expressed that at all times there will be support to the department in its efforts to create better healthcare for all. it is apparent that certain interactions are necessary and that we are indeed different as faculties of health sciences in the sense that we play a significant role in service delivery and providing health care for all, both inside and outside the environment of training and research. viewed from another perspective, one can argue that faculties of health sciences make a very real difference in peoples’ lives. i prefer the latter lens. in his address during the roll-out of the national health insurance3 to stakeholders, the minister of health, dr motsoaledi, indicated that there are a number of actions to be taken. this coincided with a lecture i attended by dr van zyl,4 ceo of sanlam, dealing with various aspects of managing change at a university and the business world. dr van zyl referred to ten rules that create success stories. i want to mention two that are significant to me. the first is: ‘the right people are your most important asset’ and the second is ‘back to basics’. if one considers these two rules, the minister is correct in addressing the back-to-basics issues where six focus areas are identified within the institutions to improve the quality of healthcare. the rule regarding the right people being your most important asset refers to the faculties of health sciences and health professions education. we can ensure that we train the right people for the environment that they need to function within, suitably adapted to address the needs of the community. i want to change my original question from: ‘are we that different? to ‘do we want to make a difference?’ my answer is that, as institutions of health professions education, we as health professionals need to make a shift and to indicate clearly that we all want to collectively make a difference. the challenge now is to convince our stakeholders of our sincerity and integrity. 1. mollentze wf, van zyl gj. universitas academic health complex: national asset or provincial liability? s afr med j 2009;99(8):546. 2. van niekerk, jpde v. eating our academic seed corn. s afr med j 2007;97(9):797. 3. motsoaledi ap. address on nhi. bethlehem: ministry of health, 9 may 2012. 4. van zyl j. lecture: managing change at a university and business world. sanlam group executive. lecture: bloemfontein, 11 may 2012. ajhpe 2012;4(1):2. doi:10.7196/ajhpe.176 being different, or making a difference? g van zyl dean, faculty of health sciences, university of the free state g van zyl research 88 november 2013, vol. 5, no. 2 ajhpe factors influencing the recruitment and retention of faculty at the catholic university of health and allied sciences, bugando, mwanza, tanzania s e mshana,1 md, mmed, phd; m manyama,2 md, msc, phd 1 department of microbiology/immunology, school of graduate studies, catholic university of health and allied sciences, bugando, mwanza, tanzania 2 department of human anatomy, weill bugando school of medicine, catholic university of health and allied sciences, bugando, mwanza, tanzania corresponding author: s e mshana (mshana72@yahoo.com) background. attracting and retaining faculty is essential for the success of any higher learning institution, especially in the newer medical institutions in tanzania. aim. to determine the factors favouring the recruitment and retention of faculty at the catholic university of health and allied sciences (cuhas), bugando, tanzania, between november and december 2011. methods. using standardised self-administered questionnaires, respondents were asked to rank a range of factors that might influence their recruitment and retention on a 4-point likert scale. results. of the 55 questionnaires distributed, 42 (76%) were returned. opportunity for professional growth, support from colleagues, opportunities for promotion, support for scholarly activities, and staff collegiality were the top 5 factors that made the faculty take up cuhas positions and remain at cuhas. salary was the most important factor for recruitment, and retention in 7.1% of the faculty surveyed. conclusion. the majority of the academic staff surveyed were junior; they cited opportunity for professional growth as the most important factor in recruitment and retention at cuhas. ajhpe 2013;5(2):88-90. doi:10.7196/ajhpe.246 the university of health sciences in tanzania plays a critical role in the training and development of new health workers.[1] currently, tanzania has 7 medical schools: the muhimbili university of health and allied sciences (muhas), the catholic university of health and allied sciences (cuhas), the kcmc medical college (kmc), the hubert kairuki memorial university (hkmu), the international medical and technical university (imtu), the college of health sciences of dodoma (udom), and the saint francis college of health and allied sciences (sfuchas). the increase in the number of medical colleges is not proportional to the increase of faculty members in the country. a review of these institutions reveals that the total number of faculty in all the medical schools is about 431, with about 59 faculty members teaching at more than one institution.[2-7] most of the medical schools have a sub-optimal number of academic staff, and newer colleges have so far been dependent on visiting faculty for basic and clinical teaching,[1] in addition, most medical schools in tanzania have been increasing the intake of medical students while the numbers of faculty have remained almost the same. the current medical student-to-fulltime faculty ratio is 6, 8, 9, 18, 24 and 26 for muhas, kcmc, cuhas, hkmu, udom and imtu respectively. this disproportion may compromise the quality of teaching, and of future health professionals and, ultimately, the country’s health system. cuhas is 10 years old and, as do other medical schools in tanzania, faces significant shortages of both clinical and basic science faculty. cuhas started in 2003 with 10 students and 20 faculty members.[2] currently, the admission is about 150 students but the increase in faculty has not been proportional to increases in student admissions. at present, the number of full-time academic staff teaching the md programme is 83,[8] which is half of the number of faculty required. at cuhas alone, more than 20% of advertised funded posts are unfilled. most medical graduates in tanzania are employed by the government to work in its hospitals or in public academic institutions. a small number of graduates are employed by private hospitals or non-governmental organisations (ngos) to work in different capacities. however, a significant number of those employed by government either report and work briefly or do not report, owing to low pay and poor working conditions, and instead join ngos or migrate abroad to seek better-paid work. of those employed by government, 60 are sponsored each year for various mmed programmes in the country. the factors contributing to the low recruitment rate at cuhas have not been critically investigated. in addition, there are no clearly stipulated retention strategies in place. intervention strategies to address the faculty shortage should be tailored to the needs of institutions, departments and individuals. it is therefore necessary to conduct a critical needs analysis of factors that influence recruitment and retention at cuhas, as this will help in planning and implementing faculty development plans. methods this survey was conducted between november and december 2011 at cuhas. the target population included all full-time faculty members from the rank of tutorial assistant to professor. the main tool for data collection was self-administered questionnaires, developed after focus group discussion[9] mailto:mshana72@yahoo.com research november 2013, vol. 5, no. 2 ajhpe 89 with the faculty. the survey included demographic variables (gender, academic rank, number of years at cuhas) and other questions to measure the faculty's experiences of and attitudes to university policy regarding recruitment and retention strategies, promotion criteria, workload, remuneration, other sources of funds, research opportunities and faculty development strategies. respondents were asked to rank each factor that might influence recruitment and retention on a 4-point likert scale of: ‘very important’, ‘important’, ‘less important’ and ‘does not apply’. data were analysed using spss computer software, version 10. tutorial assistantship was separated in the analysis as this position is a training post, and these participants' responses were likely to be very different from other faculty in other positions. results of 83 faculty, 55 consented to participate in this anonymous survey and, out of the 55, a total of 42 (76%) were returned and analysed. of 42 academic staff at cuhas, 32 (76.6%) were male. the posts were tutorial assistants (16), assistant lecturers (3), lecturers (16), senior lecturers (5) and associate professors (2). opportunity for professional growth, support from colleagues for creative ideas, opportunities for promotion, financial support for scholarly activities and staff collegiality were the top 5 factors that influenced faculty in their decision to take up a cuhas position. the top 5 factors that were ‘very important’ and ‘important’ for faculty to remain at cuhas were the opportunity for professional growth, opportunities for professional contributions, opportunities for promotion, staff collegiality, and that the position was still the best available. all tutorial assistants admitted that opportunity for professional growth and opportunities for professional contribution were important/very important factors in their decision to accept cuhas employment (table 1). the most important factor for faculty to take up a cuhas position and remain there was opportunity for professional growth, which was mentioned by 73% of the faculty. salary was found to be very important/important for recruitment and retention by 66.7% and 73.8% respondents, respectively. regarding the one most important factor for participants, salary was mentioned in only 7.1% of the faculty surveyed. discussion the human resources to teach medical doctors at cuhas are more limited than other universities, such as kcmc, muhas, makerere and nairobi school of medicine, in east africa.[10] some departments at cuhas depend entirely on visiting lecturers, which might have a negative influence on table 1. percentage of respondents indicating that each reason was ‘very important’ or ‘important’ in their decision to accept a cuhas employment offer and to remain at cuhas recruitment retention all respondents (n=42) ta (n=16) other (n= 26) all respondents (n= 42) ta (n= 16) other (n= 26) opportunity for professional growth 95.2 100 92.3 88.1 93.4 84.6 support from colleagues for creative ideas 92.9 87.5 96.1 85.7 93.7 80.7 opportunities for promotion 85.7 81.2 88.5 80.9 75.0 84.6 financial support of scholarly activities 78.6 93.8 69.2 69.0 81.3 61.5 staff collegiality 73.8 68.8 76.9 76.2 68.8 80.8 opportunities for professional contributions 69.0 100 84.6 88.0 81.2 92.3 this was my best offer 66.7 81.2 40.0 73.8 87.5 65.3 cuhas reputation 64.3 62.5 65.4 66.6 43.8 80.7 benefits 64.3 87.5 50.0 61.9 68.8 57.7 salary 61.9 68.8 57.7 52.4 50.0 53.8 location in mwanza city 61.9 81.3 50.0 35.7 37.5 34.6 opportunity for a mentor 59.5 62.5 57.7 69.0 62.5 73.0 classroom and laboratory facilities 57.1 50.0 61.5 61.9 62.5 61.5 library resources 57.1 56.3 57.7 54.8 50.0 57.7 professional manner in resolving conflict 57.1 50.0 61.5 57.1 50.0 61.5 student attitudes toward academics 54.8 56.3 57.7 71.4 75.0 69.2 social attitude of cuhas community toward minorities 54.8 43.8 61.5 50.0 43.8 53.8 technical support 52.4 50.0 53.8 61.9 43.8 73.1 housing costs 50.0 56.3 46.1 47.6 50.0 46.2 committees on which i am expected to serve 42.8 43.8 42.3 40.4 31.5 46.2 social attitudes of cuhas community toward majority 28.6 43.8 19.2 45.2 37.5 50.0 number of persons of colour in my department 14.3 12.5 15.3 09.5 06.3 11.5 ta = tutorial assistant. 90 november 2013, vol. 5, no. 2 ajhpe the development of these departments and ultimately affect the quality of education offered. shortages of academic staff in tanzania’s medical schools are endemic, problematic and worsened by the emigration of academicians.[1] in the present study, different factors were found to influence recruitment and retention in a newly established medical school in tanzania. previous studies found that small salaries, limited career options, heavy teaching loads, growing enrolment and the absence of equipment and support staff were the main barriers to retain faculty staff.[11] these factors have been confirmed by the study at cuhas, where the most important factor influencing faculty to accept a cuhas position and remain at cuhas was opportunity for professional growth; this was especially important for young academic staff with the rank of tutorial assistant and assistant lecturer. in contrast to previous studies,[12] which reported that academic salaries severely restricted the recruitment and retention of faculty staff, salary was reported in the present study as the most important factor influencing recruitment and retention in only 7.1% of respondents. consequently, though salary is perceived as important, other factors such as opportunity for professional growth, support from colleagues for creative ideas, opportunities for promotion, financial support for scholarly activities, and staff collegiality should also be considered when universities draft policies for recruitment and retention. conclusions at cuhas, bugando, opportunity for professional development, personal contribution and support of scholarly activities are important factors that influence recruitment and retention of the best academic staff. the university should focus on these factors to attract and retain more academic faculty members, and urgently needs a clear faculty development policy to ensure recruitment and retention. further in-depth analysis of posts and surveys in other universities is warranted so that generalised recommendations can be made to the management of universities in tanzania. acknowledgements. the authors acknowledge the technical support of dr morona and ezzmina ally. references 1. touch foundation. action now on the tanzanian health workforce crisis. expanding health worker training – the twiga initiative. june 2009. http://www.touchfoundation.org/uploads/assets/documents/twiga%20 initiative_6xvt2zlh.pdf (accessed 15 march 2011). 2. catholic university of health and allied sciences: cuhas prospectus 2012. http://www.bugando.ac.tz/ attachments/prospectus_2011_2012.pdf (accessed 3 february 2013). 3. university of dodoma. http://chas.udom.ac.tz (accessed 3 february 2013). 4. hubert kairuki memorial university. hkmu prospectus. http://www.hkmu.ac.tz (accessed 3 february 2013). 5. kilimanjaro christian university college. kcmc prospectus. http://www.kcmuco.ac.tz (accessed 3 february 2013). 6. international medical and technological university. imtu prospectus. http://www.imtu.ac.tz (accessed 3 february 2013). 7. muhimbili university of health and allied sciences. http://www.muchs.ac.tz/index.php/about-muhas/a-briefhistory (accessed 20 december 2012). 8. lowenstein sr, fernandez g, crane la. medical school faculty discontent: prevalence and predictors of intent to leave academic careers. bmc medical education 2007;7:37. [http://dx.doi.org/10.1186/1472-6920-7-37] 9. kitzinger j. qualitative research: introducing focus groups. bmj 1995;31:299. 10. makerere university prospectus. http://docs.mak.ac.ug/sites/default/files/2008_prospectus%203jb%20backup. pdf (accessed 3 february 2013). 11. mullan f, frehywot s, omaswa f, et al. medical schools in sub-saharan africa. lancet 2011;377:1113-1121. [http://dx.doi.org/10.1016/s0140-6736(10)61961-7] 12. dahlstrom j, dorai-raj a, mcgill d, et al. what motivates senior clinicians to teach medical students? bmc medical education 2005;5:27. [http://dx.doi.org/10.1186/1472-6920-5-27] research http://www.touchfoundation.org/uploads/assets/documents/twiga%20 http://www.bugando.ac.tz/ http://chas.udom.ac.tz http://www.hkmu.ac.tz http://www.kcmuco.ac.tz http://www.imtu.ac.tz http://www.muchs.ac.tz/index.php/about-muhas/a-brief-history http://www.muchs.ac.tz/index.php/about-muhas/a-brief-history http://www.muchs.ac.tz/index.php/about-muhas/a-brief-history http://dx.doi.org/10.1186/1472-6920-7-37] http://docs.mak.ac.ug/sites/default/files/2008_prospectus%203jb%20backup http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1186/1472-6920-5-27] 26 march 2022, vol. 14, no. 1 ajhpe research as the covid-19 pandemic ravaged through country-level health systems with crippling effects on world economies, new norms had to be set for social interaction and daily living. institutions of higher education were not spared in this pandemic and centres for learning across the globe were forced to either close or opt for innovative teaching and learning platforms. student teaching and learning were expected to continue, notwithstanding the restrictions of lockdown and social distancing measures.[1] many higher education institutions strategised by transitioning from classroom settings to virtual platforms to facilitate learning, and thereby salvaged the 2020 academic year. however, training of health professionals, including dental professionals, is based on the union of three fundamental pillars: theory, laboratory practice and clinical practice.[1] while the theoretical aspects of a dental curriculum can be delivered through online teaching methods, clinical training is highly specialised. it is essential to acquire the basic clinical skills for competency, such as the administration of dental local anaesthesia and the restoration or extraction of a tooth, depending on the required scope of practice for the health professional.[2] south african (sa) institutions of higher learning opted to transit to remote teaching and learning, using online platforms for most of the curriculum content, but this came with several challenges. students’ challenges included having access to electronic devices, internet access and a conducive learning environment within a family household. a further challenge with dental training was to find a balance between maintaining a safe environment for students and continuing with dental clinical practice, while reducing potential risk of infection to students and clinical staff.[3] the move from classroom-based teaching to an online platform was made at the beginning of the pandemic. chang et  al.’s[4] study showed that all lectures, including problem-based lectures, were moved online. with sa into the second and the third wave in march/april 2021, online learning needed to continue. the researchers in the chang et  al.[4] study concluded that the covid-19 virus had forced dental educators to revolutionise dentistry and that there was a need to develop new technology and a new model for dental education. online and e-learning modules were popular and enhanced learning experiences.[5] blended learning is an approach where online learning is combined with face-to-face teaching. given the positive feedback reported by mehta et al.,[5] it would appear that students could be supportive of this approach to learning. while a blended learning approach was widely advocated for health sciences training in higher institutions in sa, it is unclear how undergraduate dental therapy and oral hygiene students responded to the transition in the learning environment owing to the covid-19 pandemic. there is limited published evidence on the contextual influences on theory-based and clinical teaching in undergraduate dental training during covid-19, as well as students’ understanding and preparedness for learning during the pandemic. such information could be critical in guiding and shaping undergraduate dental curriculum development, specifically background. many institutions of higher education transitioned from classroom-based settings to remote settings as a response to the covid-19 pandemic. however, it is unclear how undergraduate dental therapy and oral hygiene students responded to this transition in the learning environment. objectives. to explore undergraduate dental students’ knowledge, perceptions, attitudes and practices related to clinical and theory-based learning at a south african university. methods. a mixed-methods approach comprising a concurrent dominant status design (quan/qual) was used. therefore, the study was a crosssectional quantitative survey with descriptive qualitative data. an online, self-administered questionnaire with openand closed-ended questions was developed to gain insights into students’ knowledge, perceptions, attitudes and learning practices during the covid-19 pandemic. results. most respondents (n=86; 80.4%) agreed that they had the necessary skills to engage with online learning (p=0.04). respondents in the first year (n=25; 76%), second year (n=24; 73%) and third year (n=32; 28%) were either unsure or did not agree that they understood online platform-based lectures better than classroom-based lectures. the major emergent themes included external (internet connectivity) and internal (students’ coping skills) barriers to online learning. conclusions. this study highlighted dental student challenges in embracing the blended approach of teaching and learning. while this may be a new norm for curriculum delivery, it is important to include student input in curriculum-related decision-making processes. afr j health professions educ 2022;14(1):26-32. https://doi.org/10.7196/ajhpe.2022.v14i1.1482 undergraduate dental students’ perspectives on teaching and learning during the covid-19 pandemic: results from an online survey conducted at a south african university using a mixed-methods approach r moodley, phd; s singh, phd; i moodley, phd discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: r moodley (moodleyra@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i1.1482 mailto:moodleyra@ukzn.ac.za march 2022, vol. 14, no. 1 ajhpe 27 research when responding to sudden disruptions in the teaching and learning environment. it was therefore important to determine the undergraduate dental students’ knowledge and attitudes towards learning during the covid-19 pandemic. this study aimed to contribute to curriculum planning and review by determining undergraduate dental students’ knowledge, attitudes and  practices related  to  clinical and theory-based learning during covid-19. methods research setting and context the study was located in an institution offering undergraduate dental training in sa. there are currently two 3-year undergraduate degree programmes offered by the discipline of dentistry, i.e. bachelor of dental therapy and bachelor of oral hygiene – the latter commenced in 2020. this study was conducted at the end of the second semester in 2020. students had therefore already been through 9 months of teaching and learning during the pandemic. research design a mixed-methods approach comprising a concurrent dominant status design (quan/qual) was used. therefore, the study was a cross-sectional quantitative survey with descriptive qualitative data. the online survey comprised both openand closed-ended questions. the study examined knowledge, perceptions and practices of undergraduate dental students’ learning during the covid-19 pandemic and described their attitudes towards teaching and learning. participants the study population included all full-time students registered at the discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, sa, for both programmes and across all 3 study levels. the total number of students registered for the 2020 academic year was 156, consisting of year 1 (n=55) (bachelor of dental therapy, n=38; and bachelor of oral hygiene, n=17); year 2 (n=54); and year 3 (n=47). the social media platform whatsapp was used to recruit participants through a snowball sampling technique. an invitational message was sent to the first student to consider participation in the study. the message included a link to the informed consent documents and survey questionnaire. once the student clicked on the link, he/she had to give consent by clicking on the relevant icon. the participant was then given a choice to complete the survey and to forward the survey link to the next student, with each participant remaining anonymous. the link remained open for ~6 weeks to allow students to participate. data collection and analysis data were collected using an online, self-administered questionnaire to gain insights into the students’ knowledge, attitudes and practices towards learning during the covid-19 pandemic. the researchers developed the data collection tool, which comprised 4 sections: section a covered student demographics; section b comprised knowledge; section c included attitudes; and section d covered practices. the questionnaire used mainly closed-ended questions, requiring likert-scale format responses ranging from 1 (strongly agree), 2 (agree), 3 (not sure), 4 (disagree) to 5 (strongly disagree), and 2 open-ended questions to obtain qualitative data for more in-depth information. the open-ended questions included: what are the barriers that hinder online teaching? how can online teaching be improved? the questionnaire was administered in the english language, which is the medium of instruction in the undergraduate dental training programmes. all completed questionnaires were coded (e.g. p1) to maintain participant anonymity. data obtained from the questionnaires were captured onto an excel spreadsheet (microsoft corp., usa) and analysed thereafter. the quantitative data were analysed using spss version 25.0 (ibm corp., usa). data analysis included univariate descriptive statistics such as frequency and mean distribution. an inferential statistical technique, the pearson χ2 test, was used to determine a relationship between the independent variable (year of study) and the dependent variables (knowledge, attitudes and practices), with p<0.05 established as being statistically significant. the qualitative data (obtained from the open-ended questions) were analysed using thematic analysis. the 6-step process as described by braun and clarke[6] was used for data analysis. the responses from each student were first transcribed verbatim. the data were coded and then organised into code groups. each code group was further examined for patterns and emergent themes. two members of the research team coded the data and explored the emergent themes independently. thereafter, both members compared their findings and finalised the main themes and sub-themes together. confirmability was established by quoting the actual responses of students.[6] reliability/validity was achieved by conducting a pilot study among 5 first-year students. these data were not included in the final study. confirmability was maintained by all 3 researchers, who ensured that the data received were from the participants. dependability was achieved by all 3 researchers, who compared the data for accuracy. credibility was maintained by the use of scientifically validated data collection methods, while transferability was established through the descriptions of the location of the study, sampling, time frame and data analysis. these descriptions could contribute to its application in other contexts. ethical approval ethical approval was received from the humanities and social sciences research ethics committee, university of kwazulu-natal (ref. no. hssrec/00001601/2020) and gatekeeper permission was obtained prior to commencement of this study. results there was a total of 111 participants in the study, with a response rate of 70.5%. more than half of the study population were female (n=72; 68%), while 1.9% (n=2) preferred not to disclose their identity. ninety percent (n=97) of participants were registered for the dental therapy programme. there was almost an equal number of respondents over the 3 years of study: year 1 (n=33; 30.8%), year 2 (n=33; 30.8%) and year 3 (n=41; 38.3%). quantitative data analysis knowledge and perceptions towards learning the majority of respondents (n=88; 82.2%) understood blended learning to be a combination of online lectures, face-to-face contact and self-study (table  1). only 11 first-year students (10.3%) and 6 second-year students (5.6%) did not agree or were unsure. most respondents (n=86; 80.4%) agreed that they had the necessary skills to engage with online learning and videos (p=0.04). thirty first-year students (90%), 28 second-year students (85%) and 38 third-year students 28 march 2022, vol. 14, no. 1 ajhpe research (93%) agreed that procedural videos and live demonstrations were better to understand than online learning. the majority of respondents agreed that online learning had prepared them to take charge of their learning process (n=84; 78.5%). a significant statistical association was seen between participants’ online learning preparedness to take charge of learning and having the necessary skills to engage with online learning (p=0.00). in response to whether online learning helped them to engage better with other students in their class, only 7 third-year students (17%), 12 secondyear students (36%) and 14 first-year students (42%) agreed. attitudes towards learning there were varied responses to perceived support from peers during the lockdown. about 18 first-year students (55%), 15 second-year students (45%) and 25 third-year students (61%) indicated that peer support was available. the results suggested that more peer support occurred in the third year of study. the majority of respondents across all 3 years of study (first year (n=25; 76%), second year (n=24; 73%) and third year (n=32; 28%)) were either unsure or did not agree that they understood online platformbased lectures better than classroom-based lectures. the results show that online learning was a significant stressor across all 3  years, with the majority of students agreeing (first year (n=22; 67%), second year (n=20; 61%) and third year (n=30; 73%)). most of the students (n=78; 73%) were concerned that they would transmit the virus to their family after patient contact. the majority of respondents (first year (n=27; 82%), second year (n=28; 85%) and third year (n=37; 90%)) agreed with the statement: ‘i hope that covid-19 would go away so that teaching and learning at university will return to the way it was.’ learning practices participants agreed the student-teacher contact time was decreased during the pandemic (n=81; 76%). respondents also agreed that they could not engage fully with online learning because of their home responsibilities (n=73; 68%). there was a significant association between gender and engagement with online learning due to home responsibilities (p=0.04). students agreed on the importance of maintaining social distancing in any student-related group activity (n=99; 93%). maintaining social distancing in a group activity could be related to being worried about transmitting the virus to family from patients, staff and students (p=0.01). almost half of the respondents were in their first year (n=18; 55%) and second year (n=19; 58%), while 41% of third-year students (n=17) agreed that they did not socialise with their friends owing to covid-19. qualitative data analysis what are the barriers that hinder online teaching? the major themes emerging from data analysis were related to external (environmental challenges) and internal barriers (students’ coping skills) to online student learning. the external barriers highlighted the extent to which poor or intermittent internet connectivity, inadequate data supply and frequent interruptions in electricity supply (as a result of ongoing power cuts or load shedding) impacted on undergraduate learning in the identified study sample. table 1. participants’ responses to knowledge and perceptions of learning during covid-19, n=107 questions responses first-year students, (%) second-year students, n (%) third-year students, n (%) p-value blended learning is a combination of online lectures, face-to-face contact and self-study strongly agree 12 (11.2) 11 (10.2) 14 (13.1) 0.5 agree 10 (9.4) 16 (15) 25 (23.4) unsure 8 (7.5) 6 (5.6) 2 (1.9) disagree 3 (2.8) 0 0 strongly disagree 0 0 0 i have the necessary skills to engage in online learning and videos strongly agree 8 (7.5) 8 (7.5) 7 (6.5) 0.9 agree 18 (16.8) 18 (16.8) 27 (5.2) unsure 6 (5.6) 4 (3.7) 6 (5.6) disagree 1 (0.9) 2 (1.9) 1 (0.9) strongly disagree 0 1 (0.9) 0 procedural videos and live demonstrations are better to understand than online learning strongly agree 19 (17.8) 21 (19.6) 24 (22.4) 0.9 agree 11 (10.2) 7 (6.5) 14 (13.1) unsure 3 (2.8) 4 (3.7) 1 (0.9) disagree 0 1 (0.9) 2 (1.9) strongly disagree 0 0 0 online learning has prepared me to take charge of my own learning process strongly agree 12 (11.2) 12 (11.2) 11 (10.2) 0.1 agree 14 (13.1) 16 (15) 19 (17.8) unsure 7 (6.5) 3 (2.8) 6 (5.6) disagree 0 1 (0.9) 3 (2.8) strongly disagree 0 1 (0.9) 2 (1.9) online learning helps me to engage better with other students in my class strongly agree 6 (5.6) 2 (1.6) 2 (1.9) 0.01 agree 8 (7.5) 10 (9.4) 5 (4.7) unsure 11 (10.2) 5 (4.7) 12 (11.2) disagree 6 (5.6) 11 (10.2) 13 (12.1) strongly disagree 2 (1.9) 5 (4.7) 8 (7.5) march 2022, vol. 14, no. 1 ajhpe 29 research the change in the learning environment during the lockdown period, where students were sent back home, also seemed to have impacted on the learning environment. respondents reported being distracted at home, but more importantly, they were required to contribute to household chores. this task-shifting compounded the distraction; the home environment was therefore not conducive to learning (table 2). concurrently, respondents reported poor personal coping skills that could be construed as an internal barrier to online learning. these included poor concentration during online lectures, limited student-lecturer interaction and lack of peer-assisted support in learning. from a clinical skills development perspective, respondents pointed out that online learning failed to address the acquisition of clinical or practical  skills adequately. an exclusive focus on the online training platform  without any exposure to the clinical or practical environment meant that respondents were not sufficiently trained for the translation of theory into clinical practice. this was seen as a significant limitation of focusing only on online teaching in the undergraduate programme (table 3). another criticism of online learning was related to the delivery of lectures. respondents suggested that the current delivery of some lectures was not conducive to a stimulating learning environment (table 4). how can online teaching be improved? while respondents criticised the delivery mode of certain lecture sessions, they believed that opportunities did exist to improve and stimulate students’ interest in online learning. therefore, more effort was required from lecturers to increase and stimulate student engagement in the learning environment. some suggestions included monitoring student attendance and finding innovative methods to create a more conducive online learning platform (table  5). there was a reported need to reorganise the training programme so that shorter online contact sessions were held, with a more equitable distribution of learning tasks for self-directed learning, and clear instructions of the learning tasks to be conducted. other suggestions included the increased use of videos that could provide practical demonstration of the clinical concepts and procedures discussed. there was also a reported need for more student-lecturer interaction and the availability of recorded lectures. respondents believed that it was necessary to consult with students to determine their readiness and coping abilities with online learning (table 5). as mentioned above, there was a need for more data availability and better internet connectivity, although respondents expressed awareness that challenges with internet connectivity were outside the scope of the university teaching programme. table 2. participants’ responses to attitudes towards learning during covid-19, n=107 questions responses first-year students, n (%) second-year students, n (%) third-year students, n (%) p-value i received lots of academic support from my peers during the national lockdown period strongly agree 4 (3.7) 4 (3.7) 5 (4.7) 0.9 agree 14 (13.1) 11 (10.2) 20 (18.7) unsure 6 (5.6) 4 (3.7) 5 (4.7) disagree 9 (8.4) 11 (10.2) 7 (6.5) strongly disagree 0 3 (2.8) 4 (3.7) i understand my lectures better on online-based than during classroom-based lectures strongly agree 3 (2.8) 2 (1.6) 1 (0.9) 0.7 agree 5 (4.7) 7 (6.5) 7 (6.5) unsure 10 (9.4) 5 (4.7) 12 (11.2) disagree 11 (10.2) 7 (6.5) 16 (15) strongly disagree 4 (3.7) 12 (11.2) 5 (4.7) i hope that covid-19 will go away so that teaching and learning at university will return to the way it was strongly agree 20 (18.5) 21 (19.6) 23 (21.4) 0.9 agree 7 (6.5) 7 (6.5) 14 (13.1) unsure 4 (3.7) 4 (3.7) 2 (1.9) disagree 2 (1.9) 1 (0.9) 2 (1.9) strongly disagree 0 0 0 i can acquire clinical skills by watching online videos related to clinical practice strongly agree 3 (2.8) 3 (2.8) 1 (0.9) 0.5 agree 7 (6.5) 7 (6.5) 12 (11.2) unsure 12 (11.2) 9 (8.4) 8 (7.5) disagree 4 (3.7) 3 (2.8) 9 (8.4) strongly disagree 7 (6.5) 11 (10.3) 11 (10.3) i am worried that i may transmit covid-19 to a family member owing to my contact with patients, staff and other students strongly agree 6 (5.6) 20 (18.5) 16 (15) 0.8 agree 15 (14) 6 (5.6) 15 (14) unsure 5 (4.7) 3 (2.8) 6 (5.6) disagree 3 (2.8) 4 (3.7) 4 (3.7) strongly disagree 4 (3.7) 0 0 online learning has stressed me out strongly agree 11 (10.2) 11 (10.2) 17 (15.9) 0.4 agree 11 (10.2) 9 (8.4) 13 (12.1) unsure 6 (5.6) 3 (2.8) 7 (6.5) disagree 2 (1.9) 7 (6.5) 2 (1.9) strongly disagree 3 (2.8) 3 (2.8) 2 (1.9) 30 march 2022, vol. 14, no. 1 ajhpe research discussion while respondents indicated preparedness for online learning, the majority of study participants across all 3 years of study were either unsure or did not agree that they understood the online platform-based lectures better than the classroom-based lectures. this finding is supported by other studies where students requested a repetition of the classes when the normal academic programme resumed.[7] furthermore, only a few students in rafi et  al.’s[7] study supported the notion of continuing online classes once the regular classroom-based teaching was reinstated. abbasi et  al.[8] reported that medical students perceived e-learning as not ideal and preferred face-to-face learning. these findings, however, are contrary to those of a study conducted in shiraz, iran, where a virtual learning package was found to be more effective than a lecture-based package.[9] these results suggest that the value placed on face-to-face classroom/clinical environment teaching should not be ignored, and indicate that clinical learning must consider the context-specific needs of the individual undergraduate training programme. our study participants understood that blended learning is a combination of online lectures, face-to-face contact and self-study. as we navigate through this time, we hope that this method is carried into the future and is continued rather than reverting to traditional face-to-face methods only. additionally, students’ learning experiences appear to be influenced by the year of study and whether the focus is on theory-based or clinical training. as part of the training programme, the final-year students are more involved in chairside learning and clinical training. second-year students are engaged in preclinical training and clinical practice. in the final year, students are involved in restorative dentistry, minor oral surgery clinics and diagnostics clinics. the second-year students participate in restorative dentistry, minor oral surgery preclinical training and prevention dentistry clinics. there must therefore be an acute understanding of where the student is positioned in the undergraduate training programme and efforts should be put in place to support both traditionally based lectures and online learning, where applicable.[10] a hybrid approach to medical education is supported by other studies, but its effectiveness could be dependent on factors such as academic and institutional support.[11,12] respondents in this study emphasised the need for clinical exposure as part of the undergraduate training. this finding is supported by hammond et  al.,[13] who also reported that online teaching and learning cannot substitute real-world patient contact and time in the clinical environment. additionally, youtube links, virtual patient management and whatsapp videos can be used to build student knowledge,[1,14] but even the most advanced technologies cannot replace chairside training.[2] clinical teachers and students need to adapt to this changing environment and live in the ‘new normal’.[2] students in the current study agreed that student-teacher interaction decreased with online teaching, which was consistent with the results of the abbasi et  al.[8] study, where 84% of students rated e-learning as having less student-teacher interaction. engagement with the teacher is a dynamic process, where the students need the teacher’s presence, and the teacher needs to know that the students are paying attention at the other end. in  the abbasi et  al.[8] study, the students desired the interaction. our study participants recommended that notes be uploaded on the learning channel before lectures, and a discussion and more lecturer-student interaction occur rather than a powerpoint presentation by a lecturer. similarly, dumford and miller[15] reported that participants in their study had less exposure to effective teaching methods and that lower-quality interactions were observed with online teaching. the findings therefore suggest that dental teaching staff require more support and training for improved online teaching. this study also highlighted that, even though participants understood the importance of social distancing, they were concerned about infecting someone with the virus at home after treating patients in clinical dentistry. table 3. participants’ responses to learning practices during covid-19, n=107 questions responses first-year students, n (%) second-year students, n (%) third-year students, n (%) p-value i think it is important to maintain social distancing in any student-related group activity strongly agree 23 (23.4) 25 (23.4) 27 (25.2) 0.9 agree 8 (7.5) 5 (4.7) 11 (10.2) unsure 0 2 (1.9) 1 (0.9) disagree 1 (0.9) 1 (0.9) 2 (1.9) strongly disagree 1 (0.9) 0 0 i don’t socialise with my friends owing to covid-19 strongly agree 8 (7.5) 10 (9.4) 4 (3.7) 0.2 agree 10 (9.4) 9 (8.4) 13 (12.1) unsure 2 (1.9) 4 (3.7) 4 (3.7) disagree 11 (10.2) 6 (5.6) 16 (15) strongly disagree 2 (1.9) 4 (3.7) 4 (3.7) during lockdown, i could not engage fully with online learning because of my responsibilities at home strongly agree 12 (11.2) 9 (8.4) 14 (13.1) 0.5 agree 8 (7.5) 14 (13.1) 16 (15) unsure 3 (2.8) 0 4 (3.7) disagree 4 (3.7) 7 (6.5) 4 (3.7) strongly disagree 5 (4.7) 3 (2.8) 3 (2.8) student-teacher contact time is decreased strongly agree 11 (10.2) 11 (10.2) 15 (14) 0.5 agree 11 (10.2) 16 (15) 17 (15.9) unsure 7 (6.5) 2 (1.9) 4 (3.7) disagree 3 (2.8) 3 (2.8) 3 (2.8) strongly disagree 1 (0.9) 1 (0.9) 2 (1.9) march 2022, vol. 14, no. 1 ajhpe 31 research these responses were further echoed in the qualitative data analysis. this analysis suggested that students struggled to cope with these changes in the physical learning environment, as indicated above. in a multi-country study, similar concerns were observed among 92% of dentists who were concerned regarding infection of their family at home.[16] covid-19 stressors, such as difficulty to concentrate, fear, sadness, poor mental health and anxiety, could also be overwhelming for many individuals.[17] the results of this study indicated that study participants could not engage fully in online learning because of responsibilities at home, and that the majority hoped that the ‘virus would go away so that they can return to normal’. one of the themes arising from this study was that respondents indicated that lack of preparedness to deal with the changes in the learning environment could contribute to lack of confidence in self-directed learning. these study findings are consistent with those of choi et al.,[18] who reported that 59.3% of students in their study felt less prepared and 22.7% felt less confident than before online learning. moreover, the quality or lack of internet connectivity and frequent electricity outages threatened the connectivity viability of online learning. this finding is in contrast to that of rafi et al.,[7] who indicated that ‘network and power failure’ was the main barrier facing participants in their study. respondents highlighted the need to be included in curriculum-related decision-making processes through the use of student surveys. this suggested a need for inclusive decision-making, where the student is also a stakeholder in undergraduate training. therefore, inclusive planning and recognition of the duality in student roles and responsibilities are required in undergraduate training. interestingly, there was an inconsistency in the data. while students reported that they had adequate support during online learning, respondents further indicated that they could not engage fully with the online platform. this inconsistency may be due to under-reporting or over-reporting of data for social desirability. study strengths and limitations this study provided valuable insights into online teaching and learning during the current pandemic; however, some limitations were noted. the study focused only on students’ perspectives on learning during the pandemic. more research is required on dental academics’ perspectives on teaching during this period. the generalisability of the findings is limited to the participating institution of higher education. the whatsapp portal for conducting the research could have been a challenge for students who do not use this social media platform. the lack of respondent accountability in online surveys can affect the quality of the responses; therefore, questions needed to be short and unambiguous. snowball sampling has its limitations, as the researchers have no control of the study population. sampling bias table 4. themes related to barriers to learning sub-themes student responses external barriers (environmental challenges) poor or intermittent internet connectivity ‘connectivity issues is one of the major aspects that hinders online learning.’ (p10) inadequate data supply ‘online learning especially lectures are heavily dependent on network and data coverage, 2 things which are usually [out] of the students’ control, there have been several instances where students were unable to attend lectures due to this.’ (p22) frequent interruptions in electricity ‘technical problems like wifi not working properly, and load-shedding does affect how online lectures are conducted.’ (p46) internal barriers (students’ coping skills) poor personal coping skills ‘i am unable to do online learning at home because i do not have my own study space or time to study because i have to take care of the elders at home.’ (p76) ‘sometimes i can’t concentrate because of where i am because there may be noise sometimes, i sometimes have network problems and i find it hard to ask questions online.’ (p39) limited studentlecturer interaction ‘minimal teacher-student interaction.’ (p9) inadequate exposure to clinical or practical learning ‘because we do work that are more practical rather than theoretical, it’s hard! we have to practice what we do physically and online teaching only covers our theoretical knowledge [acquisition].’ (p23) online learning environment is not stimulating ‘online sessions in which we have to listen to a voice reading everything exactly as is on each and every slide.’ (p74) table 5. recommendations to improve online teaching sub-themes student responses opportunities to improve online learning reorganisation of the training programme ‘if notes are arranged properly onto moodle [the learning management system]. if for some reason we cannot connect to a lecture, we can [still] learn on our own. if we were supplied with past [examination] papers and other materials such as reading extracts/articles, it will be easier to apply our mind and knowledge. it would be better if everything was organised better.’ (p60) ‘some lecturers used the method of [handing out the lecture presentations] before-hand to be read over and then during the lecture session instead of the notes being read out, practical and thought-provoking questions were asked, i felt like this allowed me to attain information more than just the lecturer doing a [regular] powerpoint presentation. i feel other modules and lecturers could attempt a similar strategy for online learning.’ (p22) more use of audiovisual aids ‘doing demonstrations of procedures that students do in the clinic. more tutorials are needed to make sure that students are engaging more with their work.’ (p46) ongoing engagement with learners ‘conduct a survey to find out how many students will be able to engage with online learning, if some won’t be able to, ask what is the matter and how can it be fixed.’ (p27) ‘promoting group work ‒ assessments and tutorials to properly prepare for tests and exams.’ (p50) 32 march 2022, vol. 14, no. 1 ajhpe research and sample representation can be a problem with the snowballing technique. however, the researchers mitigated this challenge by sending several reminders using the invitational link for students to consider participating in the study. the response rate of 70% further suggested that adequate sample representation was obtained to answer the research question. conclusions this study highlights dental student challenges when embracing the blended approach of teaching and learning. while this may be a new norm for delivery of the curriculum, the study suggests that it is important to include student input in curriculum-related decision-making processes. declaration. none. acknowledgements. the researchers would like to thank all the participants in this study. author contributions. rm: data collection, data analysis, interpretation of the quantitative results and manuscript preparation and writing. ss: data analysis, interpretation of the qualitative results, manuscript preparation, writing and final editing. im: literature review, methodology, manuscript preparation and writing. funding. none. conflicts of interest. none. 1. chavarría-bolaños d, gómez-fernández a, dittel-jiménez c, et al. e-learning in dental schools in the times of covid-19: a review and analysis of an educational resource in times of the covid-19 pandemic. odovtos int j dental sci 2020;22(3):69-86. https://doi.org/10.15517/ijds.2020.41813 2. sharka r, abed h, dziedzic a. can undergraduate dental education be online and virtual during the covid-19 era? clinical training as a crucial element of practical competencies. mededpublish 2020;9. https://doi. org/10.15694/mep.2020.000215.1 3. iyer p, aziz k, ojcius dm. impact of covid‐19 on dental education in the united states. j dent educ 2020;84(6):718-722. https://doi.org/10.1002/jdd.12163 4. chang t-y, hong g, paganelli c, et al. innovation of dental education during covid-19 pandemic. j dent sci 2021;16(1):15-20. https://doi.org/10.1016/j.jds.2020.07.011 5. mehta s, clarke f, fleming p. an assessment of student experiences and learning based on a novel undergraduate e-learning resource. br dent j 2016;221(3):131-136. https://doi.org/10.1038/sj.bdj.2016.563 6. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. 7. rafi am, varghese pr, kuttichira p. the pedagogical shift during covid 19 pandemic: online medical education, barriers and perceptions in central kerala. j med educ curric dev 2020;7. https://doi. org/10.1177%2f2382120520951795 8. abbasi s, ayoob t, malik a, et al. perceptions of students regarding e-learning during covid-19 at a private medical college. pak j med sci 2020;36(suppl 4):s57-s61. https://doi.org/10.12669%2fpjms.36.covid19-s4.2766 9. moazami f, bahrampour e, azar mr, et al. comparing two methods of education (virtual versus traditional) on learning of iranian dental students: a post-test only design study. bmc med educ 2014;14(1):1-5. https://doi. org/10.1186/1472-6920-14-45 10. sheikhaboumasoudi r, bagheri m, hosseini sa, et  al. improving nursing students’ learning outcomes in fundamentals of nursing course through combination of traditional and e-learning methods. iran j nurs midwif res 2018;23(3):217. https://doi.org/10.4103%2fijnmr.ijnmr_79_17 11. rajab mh, gazal am, alkattan k. challenges to online medical education during the covid-19 pandemic. cureus 2020;12. https://doi.org/10.7759%2fcureus.8966 12. comas-quinn a. learning to teach online or learning to become an online teacher: an exploration of teachers’ experiences in a blended learning course. recall 2011;23(3):218-232. https://doi.org/10.1017/ s0958344011000152 13. hammond d, louca c, leeves l, et al. undergraduate medical education and covid-19: engaged but abstract. med educ online 2020;25:1781379. https://doi.org/10.1080/10872981.2020.1781379 14. kulkarni c, wei kp, le h, et  al. peer and self assessment in massive online classes. acm transact comput human interact 2013;20(6):1-31. https://doi.org/10.1145/2505057 15. dumford ad, miller al. online learning in higher education: exploring advantages and disadvantages for engagement. j comput high educ 2018;30(3):452-465. https://doi.org/10.1007/s12528-018-9179-z 16. ahmed ma, jouhar r, ahmed n, et  al. fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak. int j environ res public health 2020;17(8):2821. https://doi. org/10.3390/ijerph17082821 17. centers for disease control and prevention. pandemics can be stressful. https://www.cdc.gov/coronavirus/2019ncov/daily-life-coping/managing-stress-anxiety.html (accessed 16 june 2020). 18. choi b, jegatheeswaran l, minocha a, et  al. the impact of the covid-19 pandemic on final year medical students in the united kingdom: a national survey. bmc med educ 2020;20(1):1-11. https://doi.org/10.1186/ s12909-020-02117-1 accepted 2 august 2021. https://doi.org/10.15517/ijds.2020.41813 https://doi.org/10.15694/mep.2020.000215.1 https://doi.org/10.15694/mep.2020.000215.1 https://doi.org/10.1002/jdd.12163 https://doi.org/10.1016/j.jds.2020.07.011 https://doi.org/10.1038/sj.bdj.2016.563 https://doi.org/10.1177%2f2382120520951795 https://doi.org/10.1177%2f2382120520951795 https://doi.org/10.12669%2fpjms.36.covid19-s4.2766 https://doi.org/10.1186/1472-6920-14-45 https://doi.org/10.1186/1472-6920-14-45 https://doi.org/10.4103%2fijnmr.ijnmr_79_17 https://doi.org/10.7759%2fcureus.8966 https://doi.org/10.1017/s0958344011000152 https://doi.org/10.1017/s0958344011000152 https://doi.org/10.1080/10872981.2020.1781379 https://doi.org/10.1145/2505057 https://doi.org/10.1007/s12528-018-9179-z https://doi.org/10.3390/ijerph17082821 https://doi.org/10.3390/ijerph17082821 https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html https://doi.org/10.1186/s12909-020-02117-1 https://doi.org/10.1186/s12909-020-02117-1 article � december 2009, vol. 1, no. 1 ajhpe article background primary health care (phc) is an equity-driven approach to health care1 that formed the foundation of south african national health policy under the new democratic government in 1994. in august 1994 the faculty of medicine (later renamed the faculty of health sciences) at the university of cape town (uct) adopted a policy on the phc approach in order to equip its graduates with the values and skills necessary to meet the changing demands of the new national health system. this policy committed the faculty to make the phc approach central to its teaching, research, clinical service, and engagement with communities.2 the phc lead theme: key principles and sub-themes the following key principles of the phc approach have guided the phc directorate in leading the development of a cross-disciplinary phc lead theme in transformed health sciences curricula for multi-professional learning:3,4 1. promoting equity and human rights in health care. 2. displaying bio-psychosocial and cultural sensitivity towards the patient. 3. practising health promotion at the individual and population level. 4. promoting evidence-based health care. 5. treating patients at the appropriate level of care. 6. promoting multi-professional health care. 7. promoting broad inter-sectoral collaboration. 8. encouraging communities to assert their rights and interests. 9. monitoring and evaluating the effectiveness, efficiency and equity of health services. the authors each carry primary responsibility from within the phc directorate for teaching and assessing principles 2 4 above, which are central to the phc sub-themes of culture, psyche and illness (cpi); health promotion (hp); and evidence-based practice (ebp) in the 6-year medical (mb chb) curriculum. the first cohort of students under the transformed mb chb curriculum graduated in december 2007. culture, psyche and illness cpi encompasses the disciplines of psychology, psychiatry, social science, and medical anthropology. cultural competence and the bio-psychosocial aspects of patient care are being integrated into medical education internationally,5 and are recognised as core competencies in south africa, with its diversity of languages, cultures, customs, belief systems, and family structures. the culturally prescribed forms in which patterns of disease and illness symptoms present and are interpreted and treated add to this complexity. biomedicine and traditional healing practices also have their own culturally prescribed forms of communication, behaviour and roles.6 medical students are introduced to the social science and psychological theory that underpins cpi by means of supported problem-based learning (pbl) group sessions in the first 3 years of their 6-year training. they discuss how the cultural, psychological and social context in the case scenarios affects the pattern of disease, while being encouraged to reflect on their own culture and the culture of biomedicine and the health system. student learning about cpi is carried through to the clinical rotations in the latter half of the curriculum by means of teaching ward rounds. in the 4th-year general medicine ward round, for example, a medical anthropologist (lv) joins the consulting physician and selects a number of appropriate cases for students to interview. students then participate in a tutorial with lv to explore their insights into the bio-psychosocial history and cultural context of the selected patients. an annual multi-disciplinary portfolio-based exam is used to assess student knowledge about clinically relevant bio-psychosocial information, multi-professional teamwork and correct referral procedures, as well as testing skills in professional communication, and in anthropological observation and analysis. health promotion students learn to apply behaviour change theories and hp approaches in patient consultations during the first 3 years of the curriculum. in the 4thyear public health rotation they are placed at different community-based learning (cbl) sites to assess public health problems identified by community stakeholders and to plan and implement hp projects to address the prioritised health needs. these placements aim to develop awareness of the importance of community participation as a health right, the application of hp ethics, the planning cycle process, teamwork and critical reflection. students learn skills in planning, organising, facilitation, presentation, and developing and pre-testing mass media. it is anticipated that they will learn to use advocacy, mediation and enablement as long-term strategies in addressing the health needs of the patients and communities that they serve. integrating the primary health care approach into a medical curriculum: a programme logic model james irlam, bsc, bsc (med) hons, mphil mpoe johannah keikelame, rgn, bsocsci, mphil lauraine vivian, bsc hons, msc, phd primary health care directorate, faculty of health sciences, university of cape town corresponding author: james irlam (james.irlam@uct.ac.za) 9 december 2009, vol. 1, no. 1 ajhpe article evidence-based practice ebp has been defined as the practice of integrating skills in retrieving, appraising, and applying valid research evidence with clinical expertise in making health care decisions in the best interests of patients.7 wide variations in the use of clinically proven interventions, often to the detriment of patient care, highlight the many gaps between current research and clinical practice. students are taught in their 4th-year public health rotation how to formulate focused clinical research questions and to critically appraise journal papers with regard to study validity and clinical applicability. this teaching builds on prior learning about epidemiological study design and the concepts of validity, bias and confounding. the critical appraisal sessions complement student work in undertaking a literature review and developing a research protocol for an epidemiological field survey at the cbl sites. students are assessed on their ability to appraise a journal paper by means of a written exam at the end of the rotation. at the end of the 6th-year family medicine rotation, students are assessed on their ability to clearly communicate evidence about the benefits and risks of treatments to role-playing patients in a primary care consultation, and to reflect afterwards on their personal evidence-based learning needs. a programme logic model programme logic models are tools used by programme managers and evaluators to clarify the structure and internal logic of programmes at table i. a programme logic model for evaluating sub-themes of the phc lead theme in the medical curriculum of the university of cape town sub-theme learning objectives teaching and learning activities learning outcomes outcome indicators methods cpi understand cultural and supported pbl demonstrate cultural portfolio tasks student evaluation bio-psychosocial aspects of health and bio-psychosocial understand portfolio tasks competence multi-disciplinary student interviews complementary and portfolio (mdp) osce traditional health practices medical ward round tutorials demonstrate review of portfolio understand the role of observational skills tasks the multiprofessional team understand principles of equity apply principles of understand mechanisms for multi-professional appropriate referrals teamwork apply principles of equity make appropriate referrals hp understand behaviour change group projects apply behaviour change marks for group projects, review of group theories and approaches seminars theories and approaches assignments, and projects understand the planning reflective journals develop and implement reflective journals student evaluation cycle process written assignments a health promotion multi-disciplinary interviews with project portfolio (mdp) osce course convenor, site facilitators, students, community stakeholders structured observations of community based learning ebp formulate structured class lectures formulate a well marks for written clinical questions structured office structured clinical exam and soo access current oral (soo) exam question marks on standard research evidence self-reflection on soo search for the evidence test of ebp competence critically appraise appraise the validity validity of evidence of the evidence understand the statistical, clinical, and public health significance of research results article 10 december 2009, vol. 1, no. 1 ajhpe various stages of their development. table i presents a model to clarify the learning objectives for each of the sub-themes of cpi, hp, and ebp, as well as the teaching and learning activities used to deliver course content, the short-term learning outcomes, the indicators for assessing student performance, and the methods to be used for data collection. this programme logic model will provide a useful framework for future monitoring and evaluation of the phc sub-themes of cpi, hp, and ebp within the medical curriculum of the university of cape town. ethics committee approval: none required. conflict of interest: none. references 1. world health organization. declaration of alma-ata. international conference on primary health care, alma-ata, ussr, 6 12 september 1978. geneva: who. http://www.who.int/hpr/nph/docs/declaration_almaata.pdf (accessed 1 september 2009). 2. uct faculty of medicine. the primary health care approach and the university of cape town medical school. www.primaryhealthcare.uct.ac.za (accessed 1 september 2009). 3. mayers p, alperstein m, duncan m, olckers l, gibbs t. not just another multiprofessional course! part 2: nuts and bolts of designing a transformed curriculum for multi-professional learning. medical teacher 2006; 28(2): 152-157. 4. duncan m, alperstein m, mayers p, olckers l, gibbs t. not just another multiprofessional course! part 1. rationale for a transformative curriculum. medical teacher 2008; 28(1): 59-63. 5. astin ja, sierpina vs, forys k, clarridge b. integration of the biopsychosocial model: perspectives of medical students and residents. academic medicine 2008; 83(1): 28-36. 6. boutin-foster c, foster jc, konopasek l. physician, know thyself: the professional culture of medicine as a framework for teaching cultural competence. academic medicine 2008; 83(1): 106-111. 7. sackett dl, rosenberg wmc, muir gray ja, haynes rb, richardson ws. evidence based medicine: what it is and what it isn’t. bmj 1996; 312: 71-72. may 2014, vol. 6, no. 1 ajhpe 17 research practice within the clinical arena is recognised as the best means of socialising students into the physiotherapy profession[1-5] and is known to make up an integral part of the undergraduate training of all health professionals.[6] clinical training facilitates the transference of classroomtaught skills and knowledge into practice. in addition, it provides students with the opportunity to learn the behaviours and attitudes necessary for successful professional practice, and to develop negotiation, assertive, organisational and administrative skills while becoming aware of social contexts and resources, in order to be socially responsible.[6] of concern is how the knowledge acquired by students in the classroom is transferred to, and applied within, clinical placements.[4,7] in a situation where clinical educators work within the clinical arena and academics cover theoretical and practical content but spend less time supervising students in clinics, the expectations of clinicians and academics may differ widely, which may result in a disparity between the taught curriculum and the needs of the clinical placements, affecting the preparedness of students for competent clinical practice.[8] consequently, some students may struggle to make the shift from the classroom to the clinical setting, and seem to lack the ability to transfer the skills they have been taught into patient management.[3,4,9-11] the authors just cited propose that the difficulty may also be related to students’ lack of generic skills and professional behaviour. their research on the skills required by physiotherapy and medical students to achieve success in clinical practice emphasises the need to balance core skills and knowledge of basic sciences against generic competencies. these generic skills include communication, interpersonal skills, awareness of one’s own attitudes, a continued commitment to independent learning, the ability to adapt and change, and clinical reasoning.[4,9,12,13] the need for change in clinical education models, to ensure reinforcement of both the specific and generic skills needed for professional clinical practice, has been highlighted.[4] an area that has not received adequate attention is the extent to which students perceive themselves to be prepared to enter clinical practice for the first time. there is little published research as to whether they themselves are aware of areas in which they might have received inadequate preparation.[3,10] as there is a link between perceived competence in clinical skills and the ability to perform adequately with regard to patient management,[14,15] the students' perception of their own ability may be an important predictor of actual performance. the present article investigates physiotherapy students’ perceptions of their own readiness as they shift from a classroom foundation to clinical reality. it also aims to explain some of these perceptions with reference to the unique positioning of clinical educators within the university of cape town (uct)’s division of physiotherapy’s framework. traditionally, clinicians and academic staff have been responsible for the onsite clinical training of physiotherapy students. rodger et al.[16] looked at clinical training across a range of allied healthcare disciplines, including physiotherapy, noting how changes in staffing at clinical sites, increasing student numbers, and diversification of the clinical platform have affected the ability of clinicians to support clinical education initiatives. as a result, universities have increasingly had to rely on contracted outside personnel to assist clinical training.[4] this approach, however, can be problematic. such personnel often have very little paedagogical training, and input to students is varied objective. to determine the perceived level of preparedness for clinical practice of third-year physiotherapy students. design. a prospective, descriptive study, using questionnaires to determine subjective perceptions and clinical test marks for objective measures of performance, was undertaken. two different cohorts were recruited of third-year students entering clinical practice for the first time. method. a 17-item questionnaire relating to areas of competence was developed. results of questionnaire scores and test scores from the 2 cohorts were amalgamated and analysed. participants were grouped according to their clinical placement. the internal consistency of the questionnaire was tested using cronbach’s alpha. as this was high at 0.847, the individual scores were added together and the mean score calculated. analysis of variance (anova) was used to establish if there was a significant difference in scores across different areas of competency and on test marks, across the different clinical settings. main outcomes measure. means and 95% confidence intervals of the mean scores of each component of competence indicated a significant difference between the scores (p<0.001). one-way anova and post hoc analysis revealed that the students perceived themselves as better prepared in affect (generic skills) than for intervention and overall preparedness ((f(4, 264)=4.8601, p<0.001). there were no significant differences between the competency mean scores (f(4,53)=0.804, p=0.528), or in the mean test scores, across the placements (f(4, 77)=0.438, p=0.781). results. most of the students perceived their level of preparedness as relatively high across all areas of competence, regardless of placement. students also achieved satisfactory (>60%) test scores, indicating realistic estimations of their ability. conclusion. the sense of readiness confirms the alignment of the classroom curriculum and clinical expectations, which has largely come about through the positioning of permanent clinical educators as essential links between the classroom and the clinical setting. ajhpe 2014;6(1):17-22. doi:10.7196/ajhpe.219 do physiotherapy students perceive that they are adequately prepared to enter clinical practice? an empirical study h talberg, bsc (physio), mphil (hes); d scott, bsc (physio) department of health and rehabilitation sciences, division of physiotherapy, university of cape town, south africa corresponding author: d scott (des.scott@uct.ac.za) mailto:des.scott@uct.ac.za 18 may 2014, vol. 6, no. 1 ajhpe research and inconsistent, leading to high dissatisfaction levels.[17] this situation may be in contrast to permanent academic staff, who are increasingly being required to undergo training in educational skills.[1] context at uct, physiotherapy is offered as a 4-year bachelor of science degree within the department of health and rehabilitation sciences. a challenge facing the division of physiotherapy is to prepare students for the significant changes in healthcare delivery within the south african context, as highlighted by shear et al.[18] the design of the undergraduate curriculum should balance the need to provide undergraduate students with a strong foundation in the basic sciences, appropriate physiotherapy-specific skills and techniques, as well as developing critical thinking and the necessary generic skills needed in clinical practice. ultimately, the obligation of the physiotherapy curriculum is to prepare students for the workplace, which is practical, socially interactive and contextually varied.[7,11] the initial 2 years of the programme concentrate on the basic sciences and principles of physiotherapy. clinical exposure starts in the second year, with weekly sessions of supervised group clinical work. from the third year of study, students work independently in a variety of clinical settings, rotating through general hospitals, paediatric sites, care of the elderly, neuromuscular skeletal (nms) clinics and community areas. in their fourth and final year, students work increasingly fulltime in more complex clinical areas. students require numerous skills to manage their own patient load at the different clinical sites. the theoretical, technical and generic skills needed are similar to those previously discussed by several authors.[4,9,13] for the purpose of this study, they have broadly been divided into: • theoretical knowledge • planning of an assessment and treatment • execution of an intervention • generic skills such as communication, time management, confidence and emotional readiness • overall sense of readiness, i.e. the students’ confidence that they are competent to practice at a third-year level. at each site, students are supported by weekly clinical educator visits. these teaching sessions guide students in applying the above skills. since 2009 at uct, permanent clinical educators have been appointed to academic posts to support clinical education. in addition to being responsible for facilitating learning in clinical settings, the clinical educators participate on an equal footing with academic lecturers in all departmental activities, including curriculum planning. at the end of every clinical rotation of a 5-week block, each student’s performance is evaluated by a clinical educator and a clinician. the evaluation takes the form of a practical exam on a patient and an overall block performance mark, together comprising a clinical mark for each student. objective the aim of this study was to examine the extent to which 3rd-year physiotherapy students are adequately prepared for independent clinical practice. both subjective and objective data were used. the study objectives, in 2 cohorts of 3rd-year physiotherapy students, were to: • determine whether the majority of students felt adequately prepared for their first independent clinical block • examine whether there was any difference in the median rating of students’ overall levels of preparedness across the different clinical placements • establish links between assessment outcomes as evidenced by block marks and students’ perceived preparedness. method design this was a descriptive study utilising prospective student questionnaires to determine subjective perceptions and clinical test marks for the objective measures of performance. participants the study took place over 2 years, with participants from 2 different cohorts of 3rd-year students being recruited. students were asked to volunteer to participate in the questionnaire after being explained its purpose by the researchers, who were permanent clinical educators. students repeating the 3rd-year clinical course were excluded from the study as only initial readiness for practice was being assessed. instrumentation questionnaire a self-developed questionnaire was used which consisted of 17 items related to key areas of novice competence. items were chosen based on the literature[9,12,13] and the researchers’ own experiences in dealing with 3rd-year students entering clinical practice for the first time. the areas of readiness were broadly linked to the following components: • theoretical knowledge of conditions seen in the clinical placement • planning – which included questions on ability to obtain relevant information from patient folders, conduct a subjective and an objective evaluation, and identify and analyse patient problems • intervention – which included execution and adaptation of practical skills and decision-making on treatment length • generic competencies such as communication, time management, confidence and emotional readiness • measure of perceived overall readiness for practice. answers were rated on a likert scale from 1 to 5. the responses were made anonymously, but students were asked to provide their gender and in which clinical area they were placed. (there were 4 17 students in each placement, so identification of student responses was not possible.) a senior lecturer in the education development unit, uct, reviewed the questionnaire to ensure content validity. it was then piloted on 10 4th-year physiotherapy students. feedback from the pilot study resulted in some minor grammatical changes being made. testing procedure the questionnaire was administered in a lecture venue during the penultimate week of the first clinical block. participants were informed of the purpose, benefits and risks of the study, as well as their right to withdraw at any stage. all participants completed an informed consent form (appendices 1 and 2). questionnaires were handed out and collected by the researchers, but there was no interaction between the students and the researchers after the procedure had been explained. ethical considerations ethical clearance for the study was obtained from the human research ethics committee of the faculty of health sciences, uct (hrec ref. 157/2012). students were assured of anonymity and that the information obtained would may 2014, vol. 6, no. 1 ajhpe 19 research be used by the researchers for the purpose of an article only. statistical analysis results from the 2 cohorts were amalgamated and entered into an excel spreadsheet and imported into statistica for analysis. the participants were grouped according to their first clinical block within one of the following areas: paediatrics, general hospital, nms clinic, care of the elderly, and community. descriptive statistics were used to describe the frequency of responses to each question. the internal consistency of the 17-item instrument was tested using cronbach’s alpha and, as this was high, at 0.847, the individual scores were added together and the mean score calculated for each student. an independent t-test was then used to compare the results of the two cohorts, and anova was used to establish if there was a significant difference in different areas of competency, student scores on the block performance mark and on the questionnaire, across the different clinical settings. results demographics of the sample there were a total of 93 students entering clinical practice − 50 in the 1st and 43 in the 2nd cohort. however, as repeating students had been excluded and only volunteering 3rd-years were included as participants, a total of 67 students took part in the study. forty-one respondents were female and 18 male. eight participants failed to indicate gender. the number of respondents was highest in paediatric areas (17) and lowest in community placement (4) (table 1). students reported a median of 3 4 (moderate to good) preparation on every item (table 2). they reported their own preparation for the block as good (median 4) and were confident in their ability to extract information from patients (median 4) and their folders (median 4). they were satisfied with their ability to communicate, both with patients (median 4) and clinical staff (median 4), with 12 and 17 reporting excellent preparation in this area. although their initial confidence levels were poor (median 2), these had improved to ‘good’ at the end of the block (median 4). the mean scores for each section and the total score indicated that the components related to theoretical understanding and generic competencies (affect) had the highest mean score, whereas the students scored themselves lowest in terms of overall preparedness for the block (fig. 1). one-way anova revealed that the students perceived that they were better prepared in some areas than others (f(4, 264) = 4.8601, p<0.001). post hoc analysis indicated that the difference was between the higher affect (generic skills) scores and the lower perception of preparation for intervention and overall preparedness. comparison of total questionnaire scores across placements although the scores in nms were the highest, there were no significant differences between the mean scores of the different placements (f(4, 53)=0.804, p=0.528) (fig. 2). mean score of clinical marks across the different clinical areas there was no significant difference between the mean scores of the clinical marks allocated to the first cohort of students (67.3±5.8) and the second cohort (68.03±6.5; t=-.54, p=0.46). they were therefore amalgamated and anova indicated that there was also no significant difference in the mean scores across the areas (f(4, 77)=0.438, p=0.781) (fig. 3). (note that the marks of all students were included in this analysis and not only those who filled in the questionnaire.) discussion the results indicate a surprisingly high perception of preparedness, by the majority of students, on starting their first independent clinical block. this was contrary to the expectations of the authors and to much of the literature.[4,6,9,10,12,13] the scores are particularly high in the areas of communication with both patients and staff. it may seem contradictory that despite feeling prepared, the students’ confidence levels were low at the start of clinical block. however, it would be unlikely that students who had never treated patients would feel confident before entering the clinical arena. they appeared to gain considerable confidence over the course of the block. how realistic were the self-reports of clinical competencies? some studies have linked the validity of self-reporting to actual ability.[19-21] in this study, it appears that the students did not overestimate their own ability as the cohort achieved similarly satisfactory clinical mark scores from all the clinical placements, with an average ranging from 65 68% − a ‘satisfactory’ table 1. placements attended by respondents on their first block placement n (%) hospital 13 (19.4) paediatrics 17 (25.4) care of the elderly 11 (16.4) neuromuscular skeletal 13 (19.4) community 4 (6.0) missing information 9 (13.4) total 67 (100) 74 73 72 71 70 69 68 67 66 65 64 63 62 61 % theory planning a�ect intervention overall preparedness fig. 1. means and 95% cis of the mean scores of each component (n=58; 9 missing). there is a significant difference between the scores (p<0.001). 20 may 2014, vol. 6, no. 1 ajhpe research performance, according to marking guidelines. however, it is impossible to correlate scores when the replies were anonymous, and there might have been individual discrepancies between perception and objective measurement. this sense of preparedness and competence can perhaps be attributed to an improved alignment between the taught curriculum and the needs of the clinical arena, as discussed by other authors.[4,7,11] students confirmed that they had adequate and appropriate theoretical knowledge to manage the pathologies encountered in clinical practice. this alignment has been supported by the inclusion of clinical educators within academic teaching clusters, at uct. these clusters meet regularly to review course content and objectives. input from clinical educators ensures that course content matches the health needs of the population, which students manage at clinical sites, as recommended by stevens.[22] by facilitating the link between the students’ theoretical knowledge and its practical application, the clinical educators are able to build on the students’ ability to implement and manage an intervention.[4,23] interestingly, most students reported a low sense of perceived overall preparedness on starting their first clinical block; but, when asked to rate their preparedness for specific competencies in theoretical knowledge, planning, intervention and even generic skills (affect), they reported adequate levels of preparedness. this rating might indicate that, despite being anxious on starting independent clinical practice, they felt supported by the clinical educators throughout the block, ensuring a safe learning environment in which to implement their knowledge and improve their confidence in their abilities, as suggested by a systematic review of education models.[17] contrary to concerns in the literature that students were less prepared in terms of generic skills, the respondents reported a higher level of perceived competence in generic skills (affect) (with a mean score of just under 70%) than in areas of specific clinical competence in implementing an intervention (which has a mean score of just over 65%). clinical educators are also ideally positioned as appropriate role models for students, by reinforcing professional behaviours and generic skills within the clinical arena,[24] which could explain the students’ confidence in these skills. the appointment of permanent academic clinical educators with additional training in educational skills[1] has resulted in a more standardised approach to supervision and a uniform understanding of the level of competence required to perform adequately within clinical practice at 3rd-year level. this conclusion is supported by the fact that there was no significant difference in students’ overall preparedness or the marks obtained, across the different clinical placements. similarly, there was no difference in marks between the two different cohorts. the consistency of clinical marks speaks to similar expectations among uct clinical educators. fewer students were placed in the community block as this is a new placement. the large confidence intervals in both the total scores and the clinical block placements are indicative of the small number of respondents and the need to develop an appropriate assessment for performance in a nontraditional physiotherapy training setting. 76 74 72 70 68 66 64 60 58 62 56 54 hospital paediatrics care of elderly nms community to ta l % fig. 2. mean total scores per clinical placement area (n=58). (nms = neuromuscular skeletal.) 78 76 74 72 70 68 66 64 62 60 hospitals nms communitycare of elderly paediatrics c lin ic al m ar k fig. 3. clinical marks across the placements (n=78 as all 3rd-year students in the 2 cohorts were included). may 2014, vol. 6, no. 1 ajhpe 21 research limitations of the study include the need to rely on self-reporting, which may produce biased results. in addition, the questionnaire was answered anonymously and consequently the responses could not be linked with the clinical performance marks. it might be that there is little correlation between perception of preparedness and objective clinical performance. it would appear that, in general, the students at uct are given adequate training, preparation and support within the academic and clinical arenas, enabling them to perform competently when independently responsible for patient management for the first time. conclusion according to the literature in clinical education, students often struggle to make the transition from the classroom to the clinical arena.[3,4,9-11] in contrast, this study demonstrates that 3rd-year physiotherapy students at uct felt adequately prepared, across all aspects of clinical competencies, on their entry to clinical practice. the level of preparedness was not affected by which clinical setting they were sent to. this sense of preparedness was mirrored by their assessment marks, showing satisfactory averages across all clinical placements. this sense of readiness speaks to the alignment of the classroom curriculum and clinical expectations within the division of physiotherapy at uct, implying that the basic sciences, technical and generic skills, and application of ideas taught during the 2 preclinical years do align with the needs of the client population, seen at clinical placements. the alignment has come about through extensive curriculum review, leading to both horizontal and vertical alignment across the years of training. this has coincided with the appointment of permanent clinical educators, each specialising in a particular field, as vital links between the classroom and the clinical setting, which could have enhanced the preparedness of physiotherapy students at uct. we recommend that the integration of clinical and theoretical teaching be a major focus of physiotherapy training. the employment of academic, permanent clinical educators who, together with academic lecturers, developed an appropriate curriculum has helped to bridge the gap between theory and clinical practice. references 1. devlin m, samarawickrema g. the criteria of effective teaching in a changing higher education context. higher education research & development 2010;29(2):111-124. [http://dx.doi.org/10.1080/07294360903244398] 2. laitinen-väänänen s, talvitie u, luukka m-r. clinical supervision as an interaction between the clinical educator and the student. physiother theory pract 2007;23(2):95-103. 3. frantz jm, rhoda aj. assessing clinical placements in a bsc physiotherapy program. internet journal of allied health sciences and practice 2007;5(3):1-6. 4. strohschein j, hagler p, may l. assessing the need for change in clinical education practices. phys ther 2002;82(2):160-172. 5. richardson b. the way forward – how and why ? advances in physiotherapy 1999;1(2):13-16. 6. ernstzen dv, bitzer e, grimmer-somers k. physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: a case study. medical teacher 2009;31(3):102-115. [http://dx.doi.org/10.1080/01421590802512870] 7. ramklass ss. an investigation into the alignment of a south african physiotherapy curriculum and the expectations of the healthcare system. physiotherapy 2009;95(3):216-223. 8. cross v. begging to differ? clinicians’ and academics’ views on desirable attributes for physiotherapy students on clinical placement. assessment and evaluation in higher education 1998;23(3):295-310. [http://dx.doi. org/10.1080/0260293980230306] 9. clouten n, homma m, shimada r. clinical education and cultural diversity in physical therapy: clinical performance of minority student physical therapists and the expectations of clinical instructors. physiother theory pract 2006;22(1):1-15. 10. jones m, mcintyre j, naylor s. physiotherapy 2010;96(2):169-175. [http://dx.doi.org/10.1016/j.physio.2009.11.008] 11. broberg c, aars m, beckmann k, et al. a conceptual framework for curriculum design in physiotherapy education – an international perspective. eur j physiother 2003;5(4):161-168. [http://dx.doi.org/10.1080/14038190310017598] 12. cross v. the same but different. physiotherapy 1999;85(1):28-39. 13. dean sj, barratt al, hendry gd, lyon pm. preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. med j aust 2003;178(4):163-166. 14. colbeck cl, cabrera af, terenzini pt. learning professional confidence: linking teaching practices, students’ selfperceptions, and gender. the review of higher education 2013;24(2):173-191. [http://dx.doi.org/10.1353/rhe.2000.0028] 15. morgan pj, cleave-hogg d. comparison between medical students’ experience, confidence and competence. med educ 2002;36(6):534-539. 16. rodger s, webb g, devitt l, gilbert j, wrightson p, mcmeeken j. clinical education and practice placements in the allied health professions: an international perspective. j allied health 2008;37(1):53-62. 17. lekkas p, larsen t, kumar s, et al. no model of clinical education for physiotherapy students is superior to another: a systematic review. aust j physiother 2007;53(1):19-28. 18. shear m, sanders d, van niekerk r, hobdell h, reddy s. education of health professionals for a restructured health system − whose responsibility should it be? s afr med j 1997;87(9):1104-1107. 19. barnsley l, lyon pm, ralston sj, et al. clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence. med educ 2004;38(4):358-367. 20. spitzer r, kroenke k, williams j. validation and utility of a self-report version of prime-md. jama 1999;282(18):17371744. 21. mabe p, west s. validity of self-evaluation of ability: a review and meta-analysis. j appl psychol 1982;67(3):280-296. [http://dx.doi.org/10.1037/0021-9010.67.3.280] 22. stevens dp, kirkland kb. the role for clinician educators in implementing healthcare improvement. j gen intern med 2010;suppl 4:s639-643. [http://dx.doi.org/10.1007/s11606-010-1448-0] 23. oyeyemi ay, oyeyemi al, rufai aa, et al. physiotherapy students’ perception of their teachers’ clinical teaching attributes. african journal of health professions education 2012;4(1):4-9. 24. paice e, heard s, moss f. how important are role models in making good doctors? bmj 2002;325(7366):707-710. table 2. perceived competency: median scores obtained on each question (n=67) non-existent (1) poor (2) moderate (3) good (4) excellent (5) median range overall preparedness for block 0 2 47 18 0 3 2 4 own preparation before block 0 4 28 32 3 4 2 5 theoretical knowledge of conditions encountered 1 6 35 24 1 3 1 5 ability to obtain information from patient folder 0 4 18 38 5 4 2 5 confidence in subjective evaluation 0 3 19 38 7 4 2 5 ability to objectively assess patients 0 10 37 19 1 3 2 5 ability to identify patient problems 0 11 32 21 3 3 2 5 ability to identify appropriate interventions 0 8 33 26 0 3 2 4 adequacy of practical skills 0 7 39 20 1 3 2 5 application of practical skills 1 11 34 18 3 3 1 5 ability to adapt physiotherapy treatment 0 5 32 27 3 3 2 5 ability to decide on cessation of treatment 0 8 34 23 2 3 2 5 ability to communicate with patient 1 3 16 35 12 4 1 5 ability to communicate with clinical staff 1 1 6 42 17 4 1 5 time management skills 0 5 27 30 5 4 2 5 initial confidence levels 2 34 24 6 1 2 1 5 confidence level at end of block 0 2 15 42 7 4 2 5 emotional preparedness for block 1 15 25 24 2 3 1 5 average number of responses in each category 0.4 7.7 27.8 26.8 4.1 http://dx.doi.org/10.1080/07294360903244398] http://dx.doi.org/10.1080/01421590802512870] http://dx.doi.org/10.1080/0260293980230306] http://dx.doi.org/10.1080/0260293980230306] http://dx.doi.org/10.1016/j.physio.2009.11.008] http://dx.doi.org/10.1080/14038190310017598] http://dx.doi.org/10.1353/rhe.2000.0028] http://dx.doi.org/10.1037/0021-9010.67.3.280] http://dx.doi.org/10.1007/s11606-010-1448-0] 22 may 2014, vol. 6, no. 1 ajhpe research appendix 1 information and informed consent form for students dear student general information the study has been approved by the faculty of health sciences human research ethics committee reference number 157/2012. the uct clinical educators are attempting to improve the standard of clinical education by researching whether 3rd-year physiotherapy students are adequately prepared for clinical practice in their first clinical block. as part of the study, you will asked to complete an anonymous questionnaire. the questionnaire will be administered during one of your lecture periods during your fourth week of clinicals. in conjunction with the questionnaire, the researchers may need to access your marks from the 1st clinical block of 3rd year. the information obtained from this questionnaire will be used solely by the researchers for the completion of a journal article and will not be made available to other parties. informed consent i confirm that the exact procedures and possible complications of the above research have been explained to me. i understand that i may ask questions at any time during the data collection. i realise that i am free to withdraw from the study without prejudice at any time, should i choose to do so. i have been informed that all the information required by the researchers will be held in strict confidentiality, and will be revealed only as part of statistical analyses. i have carefully read this form. i understand the nature, purpose and procedure of this study. i agree to participate in this research project of the uct clinical educators. name (in full) of student: signature: date: researchers: appendix 2 questionnaire please complete the following: date of birth: sex (male/female): clinical block: using the scale 1=non-existent, 2=poor, 3=moderate, 4= good, 5=excellent, please rate the comments below, by circling the number that best matches your opinion. 1. rate your theoretical knowledge of the conditions you encountered on your first block 1 2 3 4 5 2. rate your ability to obtain information from the patient’s folders within the designated time period 1 2 3 4 5 3. rate the confidence with which you were able to conduct a subjective evaluation 1 2 3 4 5 4. rate your ability to objectively assess your patients 1 2 3 4 5 5. rate your ability to identify your patient’s problems 1 2 3 4 5 6. rate your ability to identify appropriate interventions for the stated problems 1 2 3 4 5 7. rate the adequacy of the range of practical skills you have been taught in the classroom. 1 2 3 4 5 8. rate your ability to apply these practical skills when managing your patients on your first block 1 2 3 4 5 9. rate your ability to adapt and/or cease physiotherapy treatment 1 2 3 4 5 10. rate your ability to communicate effectively with the patients 1 2 3 4 5 11. rate your communication with staff members at your clinical sites 1 2 3 4 5 12. rate your time management while on the block 1 2 3 4 5 13. rate your own preparation done before the block 1 2 3 4 5 14. rate your initial confidence level in managing your first clinical block 1 2 3 4 5 15. rate your confidence level towards the end of the block 1 2 3 4 5 16. rate your emotional preparedness for managing situations faced on the first block 1 2 3 4 5 17. rate your overall preparedness for the block 1 2 3 4 5 66 june 2022, vol. 14, no. 2 ajhpe research the global shift towards decentralised training – that is, expanding the platforms available for the clinical training of undergraduate medical students beyond central tertiary academic complexes to community-based settings – aims to produce more health professionals who better meet the needs of the societies they serve.[1] in addition to extending the training platform, decentralised training enhances the student experience[2] and improves the likelihood of graduates of both urban and rural origin working in rural and remote areas.[3] the potential for decentralised training to improve the ‘quantity, quality and relevance’[1] of south african (sa) health professionals has resulted in calls for a national commitment to adopt a comprehensive policy on decentralised clinical training.[4] as with many other sub-saharan african countries, sa’s ability to train sufficient healthcare  practitioners to meet the country’s needs is constrained by limited resources.[5] the maldistribution of healthcare practitioners has been referred to as ‘a particularly critical issue’.[6] a model of decentralised training for the sa context developed at a workshop held in 2015 involving the country’s nine medical schools identified  the availability of information and communications technology (ict) as one of five critical factors for successful decentralised training.[7] the  benefits of online learning have located icts in the mainstream of medical curricula,[8] where it is at least as effective as traditional lecture-based learning in terms of knowledge and skills gained.[9] the  benefits of online learning include reducing the costs associated with delivering educational content, facilitating the scalability of educational interventions and improving the availability of and access to educational content.[9] the united nations and the world health organization have acknowledged the  value of online learning as a useful tool to address global health education needs, ‘especially in developing countries’.[9] however, ‘the  potential of online learning to enhance medical education assumes a certain level of institutional readiness in human and infrastructural resources that are not always present in lowand middle-income countries’.[10] digital divides related to socioeconomic conditions, such as differential access to ict and variable proficiency,[11] present a particular challenge in low-income and resource-constrained settings. variables such as student and staff access to ict, access to broadband internet, and a lack of ict skills and confidence due to variations in the intensity and nature of internet usage may impact the success of online learning.[9,12] lambrechts,[13] in relation to refugee students in england, described how an accumulation of barriers to access to higher education could lead to a ‘super disadvantage’. sa is the most unequal country in the world,[14] with demography acting as a proxy for socioeconomic status. despite efforts to diversify medical education, with preferential selection processes in place at individual universities,[15] background. decentralised teaching has the potential to transform medical education but requires greater use of online learning to address some of the challenges of decentralised teaching in lowand middle-income countries. given the digital divide that exists in south africa (sa), it is necessary to establish the extent of student readiness for the broader implementation of online learning. objectives. to determine medical students’ device ownership, usage and attitudes towards online learning at the university of the witwatersrand, johannesburg. methods. a cross-sectional survey of first-, thirdand sixth-year students was conducted in 2017. the questionnaire included openand closed-ended questions. quantitative data were analysed using frequency and custom tables and kruskal-wallis one-way analysis of variance (anova) tests. openended responses were analysed using content analysis. results. the survey response rate was 48.5% (448/924). no significant differences in device usage and attitudes towards online learning were observed across the 3 years of study. most respondents (99%) owned internet-capable devices, and >90% wanted some degree of online learning. the perceived barriers included poor internet connectivity on university campuses and the high cost of data in sa. conclusion. the majority of respondents owned internet-capable devices and requested more online learning, but the socioeconomic disparities in the country raise concerns about students’ readiness. wider online learning requires policy decisions to ensure not only access to devices and data but also the implementation of online learning in ways that avoid further disadvantaging already disadvantaged students. institutional barriers must be addressed before an expanded online learning environment can be considered. afr j health professions educ 2022;14(2):66-71. https://doi.org/10.7196/ajhpe.2022.v14i2.1433 undergraduate medical students’ readiness for online learning at a south african university: implications for decentralised training a m ingratta,1 mb bch; s e mabizela,2 ma (psych); a z george,2 phd; l green-thompson,3 mb bch, phd 1 department of internal medicine, helen joseph hospital, johannesburg, south africa 2 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 3 faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: a z george (ann.george@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1433 mailto:ann.george@wits.ac.za june 2022, vol. 14, no. 2 ajhpe 67 research persistent inequalities in primary and secondary education, even more than 25 years into the new democratic dispensation that replaced the apartheid regime, contribute to racial inequalities in access and success at tertiary institutions.[14,16] the digital divide that exists in sa has been referred to as ‘digital apartheid’[17] because of its demarcation along racial lines. given this context, the expanded usage of online learning in higher education should not contribute to further inequalities in student success. the medical school at the university of the witwatersrand (wits university), established in 1919, accounts for 13% of the annual national first-year intake to the nine medical schools.[15] students are admitted via two routes to the 6-year undergraduate bachelor of medicine and bachelor of surgery (mb  bch) at wits university. school leavers enter the first year of study (mbbch  1) while graduates enter the third year of study. students start their clinical training in mbbch  4, progressing to clinical clerkships at distributed training platforms by the final year of study. wits university partners with several government departments to train students at decentralised facilities. the decentralised facilities range from primary healthcare centres and community health centres in the city of johannesburg to hospitals in the urban and peri-urban areas of gauteng province (a  central province in sa), to more remote district and regional hospitals in the mostly rural areas of north west province (~70  km from the university) and mpumalanga province (~400  km from the university). wits university introduced rurality as a selection criterion for admission to the medical degree in 2015, as part of the government initiative to address unequal access to higher education. the present study was conducted in 2017 towards a master of medicine degree. it aimed to determine students’ device ownership and usage of these devices, and attitudes towards online learning in the medical degree at wits university. the study represents the most recent comprehensive survey of medical students’ readiness for online learning at this institution. given the move towards more decentralised training at sa medical schools,[7] the potential role for online learning to facilitate this training, and the digital divide that exists in the country, a better understanding of context-specific students’ needs will allow resources to be directed appropriately and strategically. student access to and engagement with online learning have become relevant during the recent rapid shift to online learning during the 2020 covid-19 pandemic, both in central and distributed learning sites. the findings presented here could be of interest to medical schools in sa and other lowand middle-income countries that intend to implement or increase the usage of online learning. methods a descriptive, cross-sectional, online and paper-based survey was distributed to a convenience sample of first-year (n=255), third-year (n=350) and finalyear (n=319) medical students. these years of study were selected as they represent critical transition points in the curriculum – an entry year for school leavers (first year), a year in which the pedagogy changes from lectures to case-based learning (third year) and a year consisting of clinical clerkships (final year). the estimated sample size for the study, treating this as an online survey only, was 272/924 students, or a response rate of 29.4%. this sample size was estimated using a confidence interval of 95% with a 5% margin of error. the questionnaire was adapted from two published surveys.[18,19] the survey was generated using redcap (research electronic data capture; vanderbilt university, usa). a pilot study conducted with 19  student volunteers from the mbbch 5 group led to the questionnaire being edited for clarity. the final survey included both openand closed-ended questions about respondents’ demographic data, ownership of devices, device usage to support learning, including access to and reliability of internet connection, and readiness and willingness regarding online learning. the survey was administered between september and november 2017. links to an informational video detailing the upcoming study were circulated by class representatives to three cohorts via class facebook and whatsapp groups for 1  month before the roll-out of the survey. the final survey was distributed via student email addresses, the university learning management system and advertisement posters with quick response (qr) codes. paper-based versions of the survey were circulated in lectures for each of the cohort years. a detailed information sheet provided with both the online and paper-based versions requested that students agree to participate in the survey before commencing. data from the paper-based surveys were manually entered into redcap. there were no duplicate online entries. the data in redcap were exported to excel (microsoft corp., usa) for cleaning. incomplete entries were removed. quantitative data were analysed using spss version 25 (ibm corp., usa). frequency tables were used to analyse demographic data. kruskal wallis one-way analysis of variance (anova) tests were used to understand the mean difference in different items by the year of study (yos). all tests were conducted at a significance level of p=0.05. the openended responses were analysed using conventional content analysis. the human research ethics committee of the faculty of health sciences at wits university approved the study (ref. no. m170340). results the overall response rate was 48% (448/924). of the 924 students surveyed, 56% of all first-year (142/255), 41% of all third-year (143/350) and 41% of all sixth-year (132/319) students participated in the survey. the overall completion rate for the survey was 81% (364/448): mbbch  1 – 88.7%, 126/142; mbbch  3 – 88.1%, 126/143; and mbbch  6 – 84.8%, 112/132. the sample demographics for gender and age reflected those of the target population; however, white students were over-represented while black students were under-represented (table 1). about one-third (33.9%) of the black students in the target population participated in the survey, compared with nearly half (45.2%) of the white students. table  2 shows the number of devices by yos. only three first-year students did not own a device. most respondents (99.2%; 361/364) owned one device, with 92.8% (335/361) owning two or more devices. smartphones were the most common device (97.3%; 354/364), followed by laptops (94.2%; 343/364), tablet computers (51.6%; 188/364), desktop computers (31%; 113/364) and standard mobile phones (15.1%; 55/364). there were no statistically significant differences by yos for ownership or access to a smartphone, laptop or desktop: • smartphone: mbbch1 mean rank = 181.70, mbbch  3 mean rank = 183.16, mbbch 6 mean rank = 182.66, h (corrected for ties)=0.156, df=2, n=364, p=0.925. • laptop: mbbch  1 mean rank = 180.19, mbbch  3 mean rank = 184.15, mbbch 6 mean rank = 183.24, h (corrected for ties)=0.596, df=2, n=364, p=0.742. • desktop computer: mbbch 1 mean rank = 181.26, mbbch 3 mean rank = 188.60, mbbch 6 mean rank = 177.04, h (corrected for ties)=1.117, df=2, n=364, p=0.527. 68 june 2022, vol. 14, no. 2 ajhpe research most respondents (89%) used their devices where they lived, with laptops the most frequently used device (fig. 1). students made infrequent usage of the university computers available in teaching hospitals, campus libraries and instructional spaces, with most students accessing them weekly (36%; 131/364) or monthly (30%; 108/364). only 11% (40/364) accessed the university computers daily, while another 11% (40/364) used them annually. most respondents (82%) used their own data to connect to the internet, as opposed to the university wifi networks (62%) and free wifi networks (21%). free wifi networks include free wifi in provided by the city of johannesburg in areas surrounding the university, and free wifi available in coffee shops. there was no statistically significant difference by yos in the frequency of data usage: mbbch  1 mean rank = 183.53, mbbch3 mean rank = 175.04, mbbch  6 mean rank = 189.74, h (corrected for ties)=2.551, df=2, n=364, p=0.279. nor was there a significant difference in use of university wifi: mbbch 1 mean rank = 177.17, mbbch 3 mean rank = 189.29, mbbch 6 mean rank = 180.86, h (corrected for ties)=1.006, df=2, n=364, p=0.605. forty-five percent of respondents were willing to use data that they had purchased to access the internet for learning. when respondents were not willing to use data that they had purchased, it was because data is expensive (n=121) and because they viewed it as the university’s responsibility to provide them with internet access (n=42). of those who used data they had bought to access the internet for university work, 63 respondents stated that they did so willingly. in contrast, other respondents stated that they had no choice because they needed it to complete university work (n=55), found the university wifi unreliable (n=27) or found their own network more reliable (n=17). students’ suggestions to improve their experience of university-provided wireless networks included the provision of faster and more reliable wifi (n=188), improved wifi coverage (n=123) and better ict support (n=4). most respondents (68%) felt adequately prepared to use the technologies needed in their courses when they entered the university. thirty-six percent wished they had been better prepared to use institution-specific software such as the university’s learning management system, with 20% wishing they had been better prepared to use basic software such as office and windows explorer (microsoft corp., usa). fig.  2 shows the respondents’ attitudes and dispositions to using technology when asked to place themselves on a 100-point scale bound by opposite terms. the numbers reflected in fig. 2 indicate positive dispositions (enthusiast, supporter, early adopter or technophile) and attitudes (useful, beneficial or enhancement) towards online learning. the overall score for attitude towards online learning was 75 points, and for disposition towards online learning was 70 points. table  3 shows respondents’ preferred teaching approach. most (86%) preferred courses that have some online (62.4%) and mostly online components (23.6%). only 6.3% preferred courses that are purely face-toface, while 4.1% preferred fully online courses. no statistically significant results were observed across the 3 years: mbbch  1 mean rank = 178.54, mbbch 3 mean rank = 182.79, mbbch 6 mean rank = 186.63, h (corrected for ties)=0.473, df=2, n=364, p=0.789. feeling that ‘online learning benefits learning’ was respondents’ primary reason for wanting online learning (fig.  3), while connectivity issues were the major reason they were not in favour of online learning. the major reason for preferring face-to-face learning was the opportunity for interpersonal interaction, while the major reason against face-to-face table 1. sample and population demographics characteristic mbbch 1, n (%) (n=126) mbbch 3, n (%) (n=126) mbbch 6, n (%) (n=112) total respondents, n (%) (n=364) total cohort, n (%) (mbbch 1, 3 and 6) (n=924)† gender male 54 (38.3) 47 (33.3) 40 (28.4) 141 (38.7) 378 (40.9) female 71 (32.1) 79 (35.8) 71 (32.1) 221 (60.7) 546 (59.1) other 1 (50.0) 0 1 (50.0) 2 (0.5) 0 age, years <21 53 (36.8) 48 (33.3) 43 (29.9) 144 (39.5) 419 (45.3) 21 24 59 (36.0) 57 (34.8) 48 (29.3) 164 (45.1) 399 (43.2) 25 29 13 (27.1) 19 (39.6) 16 (33.3) 48 (13.2) 84 (9.1) >29 1 (12.5) 2 (25.0) 5 (62.5) 8 (2.2) 22 (2.4) race* black 62 (47.6) 34 (26.2) 34 (26.2) 130 (35.7) 383 (41.5) white 31 (22.6) 58 (42.4) 48 (35.0) 137 (37.6) 303 (32.8) asian/indian 22 (33.8) 22 (33.8) 21 (32.4) 65 (17.9) 190 (20.5) coloured 5 (25.0) 9 (45.0) 6 (30.0) 20 (5.5) 48 (5.2) other 6 (50.0) 3 (25.0) 3 (25.0) 12 (3.3) 0 *race as classified by statistics south africa.[20] †based on admission data. table 2. device ownership (n=364) number of devices mbbch 1, n (%) mbbch 3, n (%) mbbch 6, n (%) total, n (%) 0 3 (2.4) 0 (0) 0 (0) 3 (0.8) 1 9 (7.1) 9 (7.1) 8 (7.1) 26 (7.1) 2 56 (44.4) 55 (43.7) 36 (32.1) 147 (40.4) 3 37 (29.4) 47 (37.3) 54 (48.2) 138 (37.9) 4 12 (9.5) 6 (4.8) 10 (8.9) 28 (7.7) ≥5 9 (7.1) 9 (7.1) 4 (3.6) 22 (6.0) june 2022, vol. 14, no. 2 ajhpe 69 research learning was the difficulties experienced with travelling to the university for these sessions. fig.  4 shows the types of technologies that students would like their teachers to use more, and less, for teaching and learning. videos or multimedia resources (96%) were the technologies that respondents wanted  their teachers to use more. social media was the least preferred teaching tool. discussion respondents’ patterns of device ownership and usage showed no significant differences across the 3  years of study. most of the respondents owned devices, were positively disposed towards technology usage, requested that their teachers use more online learning and were willing to use their own devices in teaching and learning spaces. poor and unreliable connectivity in university spaces meant that students used their devices on campuses infrequently and relied on data they had purchased, mainly where they lived. given that smartphones were ubiquitous, the potential for more online learning, especially mobile learning, makes this a feasible option for teaching across both centralised and remote training platforms. the findings, however, raise vital questions about student, staff and institutional readiness for the broader implementation of online learning. respondents’ patterns of device ownership and usage are similar to those reported in other studies. nearly all respondents had access to a device, with smartphones being the most common device, followed by laptops. these findings are similar to the 2017 educause centre for analysis and research (ecar) survey,[21] which found that laptops are critical to the academic success of undergraduate students in the usa. the prevalence of smartphones is unsurprising, given that people in the age group 18  -  34  years are more likely to own a smartphone than older people, in both developed and developing countries.[22] the value placed on mobile devices for learning by the respondents is in keeping with studies on medical students laptop, smartphone, tablet standard % % computer, mobile % phone, % free wifi zones o� campus 13 32 17 28 teaching hospital 2 37 27 33 campus library 30 43 3 39 instructional spaces 14 53 40 39 place of residence 89 75 77 83 250 200 150 100 50 0 % fig. 1. most common locations where students used devices to support their studies. (percentages exceed 100% because respondents were asked to indicate all areas in which they used their devices.) technophobe late adopter critic reluctant to use technophile early adopter supporter enthusiastic about technology enhancement bene�cial useful distraction burdensome useless student dispositions toward technology student attitudes toward technology 74 80 78 67 72 68 67 fig.  2. student attitudes and dispositions towards technology. (students were asked to place themselves on a 100-point scale bound by opposite terms. the numbers indicate positive attitudes (useful, beneficial  or  enhancement) and dispositions (enthusiast, supporter, early adopter or technophile) toward online learning.) table 3. preferred teaching approach (n=364) approach, n (%) mbbch 1, n (%) (n=126) mbbch 3, n (%) (n=126) mbbch 6, n (%) (n=112) total, n (%) no online components 5 (3.96) 10 (7.9) 8 (7.1) 23 (6.3) some online components 86 (68.3) 75 (59.5) 66 (58.9) 227 (62.4) mostly but not completely online 28 (22.2) 31 (24.6) 27 (24.1) 86 (23.6) completely online 5 (4.0) 3 (2.4) 7 (6.3) 15 (4.1) no preference 2 (1.6) 7 (5.6) 4 (3.6) 13 (3.6) 70 june 2022, vol. 14, no. 2 ajhpe research globally.[23,24] kaliisa and picard[25] suggest an increasing trend in mobile learning in higher education in africa. the increased growth in access to mobile devices projected in sa[26] has implications for the mobile learning required for decentralised training platforms. the relatively low cost, internet capability and multifunctionality of these mobile devices promote their popularity and ownership among students,[27] and create opportunities for more personalised learning. although there was an overall positive disposition to online learning, at least 20% of the respondents felt underprepared, on entry to university, to use the university’s learning management system, standard microsoft office applications and internet browsing. given the survey response rate of 48%, this finding suggests a strong need for additional training to promote equitable access for all students, especially with the preferential selection for students from rural areas. respondents’ preference for a combination of online and face-to-face teaching is similar to other studies’ findings that medical students still attribute greater value to face-to-face learning, and regard online learning instead as a useful supplement to, but not a replacement for, faceto-face teaching.[9,28] a blended learning approach could be more appropriate in the sa context; bagarukayo and kalema[29] found that sa student populations within and between institutions had variable baseline ict skill sets and learning preferences, which a blended approach could mitigate. the primary barrier to online learning identified by the respondents was the poor quality of the university wifi network and its variability across different teaching and learning spaces. an unreliable network forces students to purchase mobile data, potentially compromising those from lower socioeconomic backgrounds. data costs in sa are as much as 134% more expensive compared with other brics nations, making it more difficult for students to purchase data.[30] the recent covid-19 pandemic focused attention on several of the issues highlighted by our findings, as higher education institutions globally had to consider student access to devices and wifi, and technological proficiency, in the move to emergency remote teaching.[31,32] like universities globally, wits university was forced to move its teaching and learning programme online. while the findings from our 2017 study suggest that students were ready and willing to undertake extended online learning across the 3  transition years sampled, many students at our institution were not ready to learn remotely during the pandemic. the university had to urgently procure laptops and negotiate data packages for students, resulting in delays in the academic programme. barteit et al.[5] attribute the failure of online 0000 0000 a g ai n st fa ce -t o -f ac e le ar n in g fo r f ac eto -f ac e le ar n in g a g ai n st o n lin e le ar n in g fo r o n lin e le ar n in g 0000felt that online learning bene�ts learning wanted more online resources wanted to learn how to use technology problems connecting to the network experienced di�culties with online learning had di�culties relating to accessing devices poor functionality of the university lms poor structure of online resources preferred interpersonal interaction in lectures and tutorials for initial understanding found lectures and tutorials useful for explaining concepts and interactions wanted hands-on learning preferred conventional learning (face-to-face) wanted to be able to take notes during lectures and tutorials preferred in-person or paper-based assessments over online assessments regarded attending teaching sessions as a university requirement experienced di�culties with travelling to the university felt that lectures are boring or not needed 7 9 1 4 14 23 38 42 74 4 8 8 16 43 7 108 319 fig.  3. reasons for respondents’ preference for online and face-to-face learning modalities. (lms = learning management system.) multimedia resources learning management system early warning systems online quizzes/practice tests live lecture capture (i.e. record live lecture for later use/review) simulations or educational games prerecorded lectures (for viewing before face-to-face sessions) student response systems social media as a teaching and learning tool 20 52 21 19 28 47 50 27 9 21 68 7 37 56 6 25 62 5 33 55 3 39 57 respondents, % never occasionally all the time 47 31 15 –60 –40 –20 0 20 40 60 80 100 18 fig. 4. preferences for types of online learning. (percentages <100 are accounted for by the ‘i don’t know’ category not included in the figure. the negative percentages account for the ‘never’ category.) june 2022, vol. 14, no. 2 ajhpe 71 research learning to substantially improve medical education and, ultimately, healthcare provision, in lowand middle-income countries to the lack of a comprehensive system-wide approach that goes beyond providing online learning as a technology. online learning should be integrated into local educational contexts and aligned with national strategies. the need to avoid further disadvantaging already disadvantaged students by the indiscriminate and undiscerning use of online learning in medical education requires policy decisions that will ensure access to ict devices and data and the successful implementation of online learning to promote student engagement. the survey response rate of 48% is higher than the typical low rate of 21 30% for online surveys.[19] the higher rate could be attributed to using a combination of online and paper-based surveys. the under-representation of black students and the over-representation of white students raises the possibility of non-response bias. given that demography is often a proxy for economic status in sa,[14,17] the overall results and the results within each cohort year might be different if the respondents’ racial demographics were more reflective of the population. a further limitation of this study is that it relied on self-reported data. ongoing studies such as this one are essential for determining student readiness for online learning, especially when the student demographics at medical schools are likely to change, with preferential selection for students from rural areas. in addition to issues around access to technology and connectivity, students from rural areas are more likely to have low entrylevel skills when entering higher education,[33-35] which, based on the vast socioeconomic discrepancies that persist in the country,[14] may extend to the ict skills and proficiency required for online learning. a more systematic and inclusive framework of implementation and evaluation is required for successful online learning. conclusion the majority of respondents owned internet-capable devices and requested more online learning, but the socioeconomic differences in the country raise concerns about students’ access to devices and readiness to use them. the institutional barriers must be addressed before an expanded online learning environment can be considered. the datasets generated and analysed during this study are available in the university of the witwatersrand repository, wiredspace, at http://doi. org/10.17605/osf.io/8n3ys. any request for de-identified sample data will be considered by the data access committee on a case-by-case basis. declaration. the research for this study was done in partial fulfilment of the requirements for ami’s mmed degree at the university of the witwatersrand. acknowledgements. the medical students who took part in the pilot, advertising campaigns and survey completion; irma mare for her assistance with redcap. author contributions. all authors made substantial contributions to the design, data collection, analysis, drafting and final approval of the manuscript. all authors were involved with revising the manuscript for critically important intellectual content. all authors read and approved the final manuscript. the primary investigator (ami) has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. funding. this work is based on the research supported in part by the national research foundation of sa (nrf) for the grant, unique grant no. 107106. the grant holder acknowledges that opinions, findings and conclusions or recommendations reported in this article are those of the author(s), and that the nrf accepts 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https://doi.org/10.2196%2f12449 6. volmink j. reconceptualising health professions education in south africa. s afr j sci 2018;114(7/8):1-2. 7. de villiers mr, blitz j, couper i, et  al. decentralised training for medical students: towards a south african consensus. afr j prim heal care fam med 2017;9(1):1-6. https://doi.org/10.4102/phcfm.v9i1.1449 8. ellaway r, masters k. e-learning in medical education part 1: learning, teaching and assessment. med teach 2008;30(5):455-473. https://doi.org/10.1080/01421590802108331 9. al-shorbaji n, atun r, car j, majeed a, wheeler e. elearning for undergraduate health professional education: a systematic review informing a radical transformation of health workforce development. london: world health organization, 2015. 10. frehywot s, vovides y, talib z, et al. e-learning in medical education in resource constrained lowand middle-income countries. hum resour health 2013;11(4):1-15. https://doi.org/10.1186/1478-4491-11-4 11. attewell p. the first and second digital divides. sociol educ 2016;74(3):252-259. https://doi.org/10.2307/2673277 12. o’doherty d, dromey m, lougheed j, hannigan a, last j, mcgrath d. barriers and solutions to online learning in medical education – an integrative review. bmc med educ 2018;18(1):1-11. https://doi.org/10.1186/s12909-0181240-0 13. lambrechts aa. the super-disadvantaged in higher education: barriers to access for refugee background students in england. high educ 2020;80:803-822. https://doi.org/10.1007/s10734-020-00515-4 14. world bank. overcoming poverty and inequality in south africa: an assessment of drivers, constraints and opportunities. washington, dc: world bank, 2018. 15. van der merwe l, van zyl g, st clair gibson a, et  al. south african medical schools: current state of selection criteria and medical students’ demographic profile. s afr med j 2016;106(1):76-81. https://doi.org/10.7196/samj.2016. v106i1.9913 16. prince r. predicting success in higher education: the value of criterion and norm-referenced assessments. pr  res high educ 2016;10(1):22-38. 17. brown c, czerniewicz l. debunking the ‘digital native’: beyond digital apartheid, towards digital democracy. j comput assist learn 2010;26(5):357-369. https://doi.org/10.1111/j.1365-2729.2010.00369.x 18. dahlstrom e, brooks cd, pomerantz j, reeves j. students and technology research study: survey instrument. 2016. https://library.educause.edu/resources/2016/6/2016-students-and-technology-research-survey-instrument (accessed 1 february 2017). 19. farley h, murphy a, johnson c, et al. how do students use their mobile devices to support learning? a case study from an australian regional university. j interact media educ 2015;1(14):1-13. http://doi.org/10.5334/jime.ar 20. statistics south africa. mid-year population estimates, 2018. pretoria: stats sa, 2018. 21. brooks d, pomerantz cj. ecar study of undergraduate students and information technology, 2017. louisville, co: ecar, 2017. https://www.educause.edu/-/media/files/library/2017/10/studentitstudy2017.pdf?la=en&hash=04478b 28cb4679b64ced7412222a49924fec67a1 (accessed 10 february 2018). 22. pouschter j. smartphone ownership and internet usage continues to climb in emerging economies. washington: pew research centre, 2016. 23. yavner sd, pusic mv, kalet al, et al. twelve tips for improving the effectiveness of web-based multimedia instruction for clinical learners. med teach 2015;37(3):239-244. 24. chase tjg, julius a, chandan js, et  al. mobile learning in medicine: an evaluation of attitudes and behaviours of medical students. bmc med educ 2018;18(152):1-8. https://doi.org/10.1186/s12909-018-1264-5 25. kaliisa r, picard m. a systematic review on mobile learning in higher education: the african perspective. turkish online j educ technol 2017;16(1):1-18. 26. o’dea s. smartphone users in south africa 2014-2023. statista, 27 february 2020. https://www.statista.com/ statistics/488376/forecast-of-smartphone-users-in-southafrica/ (accessed 28 february 2020). 27. sandars je, frith gs. mobile learning (m-learning). in: dent ja, harden rm, eds. a practical guide for medical teachers. 4th ed. london: churchill livingstone, 2013:231-236. 28. ellaway rh. digital medical education. in: dent ja, harden rm, editors. a practical guide for medical teachers. 4th ed. london: churchill livingstone, 2013:221-230. 29. bagarukayo e, kalema b. evaluation of elearning usage in south african universities: a critical review. int j educ dev using inf commun technol 2015;11(2):168-183. 30. seeth a. high data costs challenged; low-income households hit the hardest. city press, 2 march 2018. https:// www.news24.com/citypress/news/high-data-costs-challenged-low-income-households-hit-the-hardest-20180302 (accessed 2 april 2020). 31. iyer p, aziz k, ojcius dm. impact of covid-19 on dental education in the united states. j dent educ 2020;84(6):718722. https://doi.org/10.1002/jdd.12163 32. affouneh s, salha s, khlaif zn. designing quality e-learning environments for emergency remote teaching in coronavirus crisis. interdiscip j virtual learn med sci 2020;11(2):1-3. https://doi.org/10.30476/ijvlms.2020.86120.1033 33. mabizela se, george az. predictive validity of the national benchmark test and national senior certificate for the academic success of first-year medical students at one south african university. bmc med educ 2020;20(1):1-10. 34. maringe f, osman r. transforming the post-school sector in south africa: limits of a skills-driven agenda. s afr j high educ 2016;30(5):120-140. https://doi.org/10.20853/30-5-616 35. walton r, bowman b, osman r. promoting access to higher education in an unequal society. s afr j high educ 2015;29(1):262-269. https://doi.org/10.20853/29-1-462 accepted 26 february 2021. http://doi.org/10.17605/osf.io/8n3ys http://doi.org/10.17605/osf.io/8n3ys https://doi.org/10.2196%2f12449 https://doi.org/10.4102/phcfm.v9i1.1449 https://doi.org/10.1080/01421590802108331 https://doi.org/10.1186/1478-4491-11-4 https://doi.org/10.2307/2673277 https://doi.org/10.1186/s12909-018-1240-0 https://doi.org/10.1186/s12909-018-1240-0 https://doi.org/10.1007/s10734-020-00515-4 https://doi.org/10.7196/samj.2016.v106i1.9913 https://doi.org/10.7196/samj.2016.v106i1.9913 https://doi.org/10.1111/j.1365-2729.2010.00369.x https://library.educause.edu/resources/2016/6/2016-students-and-technology-research-survey-instrument http://doi.org/10.5334/jime.ar https://www.educause.edu/-/media/files/library/2017/10/studentitstudy2017.pdf?la=en&hash=04478b28cb4679b64ced7412222a49924fec67a1 https://www.educause.edu/-/media/files/library/2017/10/studentitstudy2017.pdf?la=en&hash=04478b28cb4679b64ced7412222a49924fec67a1 https://doi.org/10.1186/s12909-018-1264-5 https://www.statista.com/statistics/488376/forecast-of-smartphone-users-in-southafrica/ https://www.statista.com/statistics/488376/forecast-of-smartphone-users-in-southafrica/ https://www.news24.com/citypress/news/high-data-costs-challenged-low-income-households-hit-the-hardest-20180302 https://www.news24.com/citypress/news/high-data-costs-challenged-low-income-households-hit-the-hardest-20180302 https://doi.org/10.1002/jdd.12163 https://doi.org/10.30476/ijvlms.2020.86120.1033 https://doi.org/10.20853/30-5-616 https://doi.org/10.20853/29-1-462 articlearticle 37 may 2013, vol. 5, no. 1 ajhpe background. currently, clinicians who move into academia may not have the necessary skills for this transition. given that most health professionals are socialised into their professional roles as clinicians, the shift to academia requires a second socialisation into the academic role. there is a body of existing research that suggests that the transition for clinicians as they become lecturers in higher education is challenging. aim. this study aimed to determine the subjective experiences of young academics in their transition from clinicians to clinical educators/academics. in particular, participants were asked to identify the factors that acted as facilitators or barriers to their transition from clinician to academic. methods. the study employed a phenomenological framework. participants (n=7) were a group of clinical educators/lecturers involved with undergraduate students at an identified institution. unstructured interviews were conducted. following each interview, audio-recordings were transcribed verbatim and all data were anonymised. data were analysed manually by each author and consensus was reached on the identified themes. results. the mean age of participants was 31 years, with an average of 8.4 years of clinical experience and 3.4 years of academic/clinical education experience. the transition experience from clinician to academic is discussed according to two themes, i.e. intrinsic factors (confidence, competence, personality, and ability to draw on personal experience) and extrinsic factors (supportive environment, peer relationships, mentoring, understanding institutional rules and regulations). conclusion. the findings identified both intrinsic and extrinsic factors that may facilitate or hinder the transition process. intrinsic factors such as uncertainty and personality influences or extrinsic factors such as supportive environments can interact to thwart the adjustment or transition of new staff. despite individual differences, there is an essence to the experience of the adjustment to academic, as evidenced by the reaching of saturation in a relatively small sample. based on the results, it is evident that there is a clear need for staff development initiatives related to internal motivation of the individual and supportive extrinsic factors to successfully make the transition to clinical education. ajhpe 2013;5(1):37-41. doi:10.7196/ajhpe.224 exploring the subjective experiences of allied health professionals in their transition from clinical educators to academia: barriers and facilitators to successful transition j m frantz,1 phd; m r smith,2 phd 1 department of physiotherapy, university of the western cape, south africa 2 department of psychology, university of the western cape, south africa corresponding author: m r smith (mrsmith@uwc.ac.za) health professions education seeks qualified professionals with a wealth of clinical expertise and experience. the decision to become an academic can be made at any time in a health professional’s career. this process may evolve while being a student, clinician and/or clinical educator. making the career transition from clinical practice to academia requires new skills and work adaptations. in addition, once health professionals have gained extensive clinical experience, they may decide to use their experience in the academic setting. given that most health professionals are socialised into their professional roles as clinicians, the shift to academia requires a second socialisation into the academic role. allied health professional programmes rely heavily on the support of clinicians in the areas of clinical education to augment current staffing complements or to assist in providing teaching relief and/or supervision. many of these clinical educators have limited or no training as educators.[1] clinical educators provide specific expertise from their professional practice but are also expected to provide quality education to undergraduate students in clinical practice across the spectrum of allied health professions.[2] the first years of academic life for academics or clinical educators are stressful because of the many roles they must assume.[2] almost two decades ago, the literature highlighted that ‘there are challenging balances and tensions between different tasks: teaching, scholarship, research, consultancy, community service and administration. priorities have to be made between them, by academics and institutions.’[3] in more recent research it was highlighted that the three main areas of performance among academics include teaching, research and administration, and it has become imperative that all academics find a balance between these performance areas.[4] clinicians moving into higher education not only have to become familiar with a new environment, culture and expectations, but also have to demonstrate their educational professional development. there is a small body of existing research that suggests that the transition for clinicians as they become lecturers in higher education is challenging. the current forms of support for academics in their first year of academic life include orientation into general policies and procedures, induction into the philosophy of teaching and learning, marks administration systems, research and publication and institutional operational plans and goals. these forms of support may not always be effective.[5] within the growing era of quality assurance and accreditation, the issue of the essential competences that all educators must possess becomes sharply focused. if defined, these competences would help to indicate what educators are supposed to teach, what students are expected to learn, but most importantly how equipped educators must be in order to teach.[6] it is thought that in south africa we currently have a model where the majority of educators, teaching on degree programmes for allied health article may 2013, vol. 5, no. 1 ajhpe 38 professionals, primarily have a clinical background, a small number have an educational background and an even smaller group have both. the optimal performance of educators is contingent on a set of needs including, but not limited to, the resources, infrastructure and institutional support as key factors that influence the success of an educator.[7] to support new academics in understanding the institutional hierarchy, promotion opportunities and academic responsibilities and requirements, it would assist if those in charge understood the experiences of those who are going through it.[6] at the institution in the current study, the majority of new academic staff recruited to a faculty of health sciences are experienced practitioners in their field but may have limited experience in education. to facilitate smooth transition, for permanently appointed academics, they are provided with an opportunity to attend the university’s induction day and induction teaching and learning workshops. contract staff, however, are not afforded the same opportunity. there has been informal grumbling among contract staff regarding the lack of information pertaining to expectations and responsibilities of an academic; therefore, this should be a concern. with the high number of contract staff within health sciences faculties, there is a need to understand the concerns of young academics to identify relevant strategies to assist in the transition process. this study aims to determine the subjective experiences of new clinical educators/academics during their transition from a clinical background to academia. the study attempts to identify the factors that acted as facilitators or hindrances to this transition. an understanding of these experiences could inform strategies designed to facilitate optimal adjustment to and functioning in an academic role. methodology research question and setting this study enquired about the experiences of clinicians in their transition to academia, with particular emphasis on the factors that assisted or hindered their successful adaptation. the research was conducted at a historically disadvantaged university within a faculty of community and health sciences in which degree programmes are offered that lead to registration with the health professions council of south africa, e.g. for physiotherapists, occupational therapists, dieticians, nurses, social workers, psychologists and biokineticists. to this end, professionals from these disciplines are employed within departments in the faculty (e.g. psychology). the gender ratio of staff in this faculty is 75% female and 25% male. research design the study employed a phenomenological framework to describe the meaning of the lived experiences of clinicians in their transition into academia. as per the conventions of phenomenological inquiry, five major procedural concerns were highlighted: (i) bracketing preconceived ideas to understand the transition through the voices of the participants (epoche); (ii) formulating a prompt question and enquiry that explore the meaning of the transition by asking participants to describe their everyday lived experiences; (iii) collecting data from individuals who have made the transition from clinical work into academia; (iv) analysing data through the methodology of reduction and a search for all possible meanings; and (v) reporting an improved understanding of the essence of the experience, recognising that a single unifying meaning of the experience exists. participants clinical educators, defined as individuals employed part-time or full-time by the university primarily to provide clinical education of undergraduate students at practice sites and with varying involvement responsibilities as an academic, were purposively identified for inclusion in the study. the inclusion criterion was that they were all relatively new to clinical education (i.e. <4 years). fifteen eligible academics from the departments represented in the faculty were invited to participate in the study. their distribution was as follows: physiotherapists (9), occupational therapists (2), psychologists (1), biokineticists (1) and social workers (2). seven clinical educators in the department of physiotherapy accepted the invitation to participate in the study. before the interview, the eligibility of each participant was verified by completing a ‘prior experience’ questionnaire in which they had to report their prior experience and career history to ensure their suitability for the study. ethical considerations permission to conduct this study was obtained from the relevant university ethics committees (16 july 2012). participants were assured that participation was voluntary and that they had the right to withdraw at any stage of the study without any negative effect. they were also informed of the measures taken to ensure confidentiality and anonymity, particularly in the reporting and dissemination of findings. once satisfied that they were informed about what participation would entail, they granted written consent to participate in the study. data collection unstructured interviews were conducted with a prompt question about participants’ subjective experiences of the transition from clinicians to academics. the prompt question was developed in three phases: first, relevant literature was reviewed to extrapolate possible questions that could address the aims of the study. second, the possible questions were distilled into a general interview schedule for a semi-structured interview to identify domains of interest. this schedule was piloted with three lecturers who were excluded from the main study. third, the domains and the feedback from the piloting were used to formulate a prompt question that accurately reflected the aims of the study. the prompt question was: ‘please share your experiences in transitioning from clinicians to academics. particularly reflect on the factors that assisted or hindered your adjustment/ transition.’ procedure the data collection commenced after consent by participants. the interviews were conducted by one of the authors who is a senior clinical psychologist trained in phenomenological inquiry and lasted between one hour and 90 minutes. this researcher was somewhat familiar with three of the participants, based on limited interaction with them outside of the study, e.g. attending general faculty meetings. interviews were conducted off-site from the university at a neutral location where participants could engage more comfortably. interviews were audio-taped with participants’ permission. analysis following each interview, audio-recordings were transcribed verbatim by an independent transcriber. the transcripts were anonymised as the other researcher/author was more familiar with the participants as either a previous lecturer or colleague. at the time of conducting the research this articlearticle 39 may 2013, vol. 5, no. 1 ajhpe researcher was deployed elsewhere in the faculty. the data were analysed by both researchers/authors using thematic analysis in the following steps: (i) transcribed interviews were read and compared with audiotaped recordings and field notes to verify accuracy; (ii) transcripts were read by each author and consensus was reached on the identified themes. emerging themes were coded and then classified into categories; (iii) after the themes and categories had been developed, a further trustworthiness check was done by searching the transcripts for content that could disprove the primary findings. member checking of the primary findings was done with all participants.[8] despite the small number of interviews saturation was reached. results and discussion the sample included two male (m) and five female (f) academics/clinical educators. the ages of the participants ranged from 22 to 41 years, with a mean of 31 years. the average work experience among participants was 8.4 and 3.4 years for clinical experience and clinical education/academia, respectively. three participants were employed fulltime (p) and four were contract workers (c). all participants had completed a basic 4-year professional degree. the experience of making the transition from clinician to academic is discussed according to two main themes, i.e. intrinsic and extrinsic factors (table 1). intrinsic and extrinsic motivational factors should be considered when attempting to predict success.[9] intrinsic factors confidence and competence participants reported that the initial part of the journey from clinician to academic was challenging and placed strain on their ability to cope. ‘… i think in the beginning it was very overwhelming and very intense …’ ‘it’s challenging and it’s difficult because i’m just starting out but i like it.’ in response to the demands placed on them, they often experience feeling as though they were not adequately prepared for academia. this often manifested as lacking in confidence and feeling incompetent, as illustrated by the quotes below: ‘… it was hard … i didn’t always feel competent …’ ‘… i felt that i wasn’t up to it yet; i felt that there is so much that i should learn and look at my professors where they are and what they are doing, the way they think, way they engage, all of that and i felt to a certain extent that there was so much that i had to do. it made me feel anxious …’ the feeling of lacking confidence and competence is an intrinsic factor that potentially impacts adversely on adjustment. it particularly influences whether and how support is accessed. this finding is consistent with those in other studies[9] that highlighted that such feelings could cause the individual to adopt an attitude of defensive pessimism to manage their anxiety if not addressed early. in addition, factors that generate anxiety and stress in turn interfere with performance.[10] among these participants there were varied ways of dealing with their lack of confidence. this variation was attributed to personality differences, as reflected in the category of personality below. personality how participants experienced and dealt with these emotions was closely linked to their personality and their personal experience. ‘i’ve always wanted to be good at what i do and so i think i’m very driven to understand what i’m doing and to be better at it.’ some participants highlighted that owing to their strong personality, they were able to take control of situations and position themselves as the person of authority. ‘... so i made it quite clear in the beginning this is my module i’m teaching it, my rules apply combined with the university rules so don’t run behind my back …’ other participants felt less confident to take charge when they did not know the process. they also indicated that it becomes more difficult to maintain your position of authority if students perceive you to be struggling or not to be qualified. ‘… i feel like as an academic you want to try and do your best, try and come across as confident and competent to the students and if you have to repeatedly correct yourself in front of the students then you lose a lot of credibility which is difficult.’ ability to draw on personal experience participants identified their ability to draw on their experiences as students, clinicians and professional and personal life as an important means of coping with the adjustment to academic life and managing the demands of teaching and learning, as illustrated by the quotes below: ‘my experience definitely influenced the way i started to teach students and it was based on my past experience and for me it was difficult to incorporate … the new things we are trying to do …’ ‘i think over the years of being a physiotherapist i developed a rapport with people and [this helped me] to speak with people and deal with different personalities.’ similarly, participants also highlighted that having studied at the institution as an undergraduate or postgraduate student positively contributed to the table 1. themes and categories themes categories intrinsic factors confidence competence personality ability to draw on personal experience extrinsic factors supportive environment peer relationships mentoring departmental culture institutional rules and regulations article may 2013, vol. 5, no. 1 ajhpe 40 transition from clinician to academic as they could draw on their understanding of the institution. the ability to draw upon experiences speaks to the capacity for reflexivity and increased self-awareness, which can be very functional. extrinsic factors supportive environment participants felt that a supportive environment played a major role in their transition from clinician to academic. the supportive environment included peer relationships (colleagues at the same academic level), mentoring relationships (more senior academics as mentors and role models), and departmental culture (e.g. organisational thinking, work allocation and infrastructure). peer relationships. on entering academia, we rely on informal networks of mentoring among colleagues (peers) to continue the educational process.[10] ‘support from the staff and colleagues … just asking if you need help and you not sure how to do this … there is always someone who will answer your question and guide you …’ this quote also illustrates the importance of the willingness of the new clinical educator/academic to make use of support. this demonstrates how willingness to make yourself vulnerable and use support or seek advice as an intrinsic factor also assists in identifying and appreciating the available support as an extrinsic factor. mentoring. high-quality professional environments (well-known colleagues) often assist younger academics[11] and act as role models. ‘… they [senior colleagues] were quite easily approachable and willing to teach us …’ departmental structure. the quality of facilities and equipment along with a tapered teaching load … often assist younger academics.[11] participants identified the supportive structure of the department in which they were deployed as an integral part of their successful transition. ‘… i think an important aspect was the supportive structure …’ ‘… i’m very fortunate to be in a department like i am in, it’s incredibly supportive and the thing that i think really changed my perception is that from day one there was this idea of … what is your plan, what is your goal not in so many words what’s your five year plan now that you are an academic ...’ institutional rules participants identified comprehension of institutional rule as an important factor in their transition. knowledge of institutional rules was perceived to be a facilitator of successful adjustment and a predictor of survival and promotion. as such, some participants expressed a keen interest in learning institutional operations. ‘yes, i want to understand how the institution works because if i’m going to progress in the institution i need to understand how that works.’ this interest or eagerness to learn contributes positively to an intrinsic motivation to succeed; however, accessing these rules and regulations was perceived as a challenge. ‘i think it’s got a lot to do with the actual rules of the university and i don’t know if there were things i was supposed to do to try and prepare myself in some way, but if there was i didn’t know where to find them.’ participants questioned how and when new academics are introduced to the rules of the institution formally rather than through the informal sources of support identified above. therefore, not knowing the rules explicitly becomes a barrier to the adjustment of a new academic. conclusion and recommendations the process of the transition from clinician to academic may be influenced by a number of factors. the findings of this study identified both intrinsic and extrinsic factors that may facilitate or hinder the transition process. intrinsic factors, such as uncertainty and personality influences, or extrinsic factors, such as supportive environments, can interact to thwart the adjustment or transition of new staff. despite individual differences, there is an essence to the experience of the adjustment to academic as evidenced by the reaching of saturation in a relatively small sample. given the potentially negative impact of the feelings of fear and failure reported by participants, it becomes imperative to have interventions. the need for staff development initiatives related to internal motivation of the individual and extrinsic factors that support the individual is imperative for young academics to succeed. higher education institutions are urged to adopt a more systematic and multi-tiered planning for the development of new staff. in particular, a far more thorough preparation for the changing role in teaching to ameliorate the pressure of entry into academia noted for new academics and to prepare them for their teaching role is necessary.[3] future studies should consider obtaining the subjective experiences of newly appointed clinicians to determine if these findings hold across other disciplines in the health professions. future studies can also include reflective methodologies such as journals, as well as participator action research methods where the research is imbedded in the transition and induction of new staff. recommendations for staff induction and support inductions for new staff could articulate the differential role functions for health professionals’ transition into academic roles. this could include reflections on the experience of others and will provide a sense of normalisation and dispel the myth that incumbents should know what to do because they are qualified professionals. orientation of new staff could be expanded to include process groups over the probationary period that can be both diagnostic and supportive. institutional rules should be made explicit to new staff and attention paid to how these rules translate at departmental and individual level. extrinsic factors such as departmental culture, work load planning and management, mentoring and supportive peer relationships should be intentionally fostered. the potential impact of intrinsic factors in this process can be delineated using a number of formats in psycho-educative processes. reflection and limitations of the study the major limitation of the study was the sample size (n=7). however, it was still proportional to the number of new clinical educators in the designated faculty. the sample only included staff from one discipline. this limitation is understood in terms of its potential exclusion of other experiences, but does not detract majorly from the article since the sample still reflected the largest group of eligible participants. given the stated aim of extracting the subjective experiences of clinical educators, the over-representation of one discipline was acceptable and generalisations were made accordingly. article 41 may 2013, vol. 5, no. 1 ajhpe another potential concern was that the participants were known to the researchers – albeit in differential capacities. one researcher was known in the capacity as an educator, senior member of staff and member of management. the other was known in a limited capacity to only some participants, as stated above. the process of data collection attempted to ensure that participants’ ability to share freely was not overly compromised by seeking neutral spaces, avoiding engagement of the more-known researcher in the data collection process, drawing on the professional training of the second researcher and anonymising transcripts prior to conducting analysis. after every interview a debriefing and reflective process was conducted with each participant. all seven reflected that participation was cathartic and enabled them to think about their experiences and speak about feelings that were difficult to share in other contexts. their familiarity with the researchers and positive feelings toward them contributed to a feeling of safety, resulting in a deepened level of sharing and reflection. references 1. montoya i, kimball o. marketing clinical doctorate programs. j allied health 2007;36(2):107-112. 2. fagan-wilen r, springer dw, white bw, et al. the support of adjunct faculty: an academic imperative. soc work educ 2006; 25(1):39-51. [http://dx.doi.org/10.1080/02615470500477870] 3. kogan m, moses i, el-khawas e. staffing higher education. london: kingsley, 1994. 4. frantz jm, rhoda a, struthers p, phillips j. research productivity in a physiotherapy department. a case study. african journal of health professions education 2010;2(2):17-20. 5. mcarthur-rouse f. from expert to novice: an exploration of the experiences of new academic staff to a department of adult nursing studies. nurse education today 2008; 28(4):401-408. [http://dx.doi.org/10.1016/j. nedt.2007.07.004] 6. kahanov l, eberman l, yoder a, kahanov m. culture shock: transitioning from clinical practice to educator. int j allied health sci prac 2012;10(1):1540-1580x. 7. collins j. the needs of an educator. jacr 2005;2(11):914-918. [http://dx.doi.org/10.1016/j. jacr.2005.02.010] 8. neumann wl. social research methods: qualitative and qualitative approaches. toronto: allyn and bacon, 2000. 9. walker c, greene b, mansell r. identification with academics, intrinsic/extrinsic motivation, and self-efficacy as predictors of cognitive engagement. learning and individual differences 2006;16:1-12. [http://dx.doi. org/10.1016/j.lindif.2005.06.004] 10. meyer l, evans i. motivating the professoriate: why sticks and carrots are only for donkeys. high educ man pol 2003;15(3):150-167. 11. mathieu m. an integrated approach to academic reinforcement systems. high educ man pol 2003;15(3):25-40. article may 2013, vol. 5, no. 1 ajhpe 42 introduction. educating students in a multi-cultural society is a challenge as teachers, students and the community they serve all tend to represent various social groups. skills alone are not adequate for competency in understanding cultural aspects of consultations. a combination of knowledge, skills and attitude is the most widely accepted current approach to teaching culturally competent communication to medical students. collaborative reflection on narratives of experienced clinicians’ cultural encounters served to construct an understanding of how to develop these attributes. process. an interest group of medical teachers met to address the specific needs of teaching a relevant cross-cultural curriculum. participants offered narratives from their professional life and reflected on these encounters to understand how to improve the current curriculum to better address the needs of the students and patients they serve. results. through narratives, participants were able to reflect on how their experience had allowed them to develop cultural awareness. all stories represented how attitudes of respect, curiosity and unconditional positive regard were held above all else. the process of collaborative reflection with peers unpacked the complexity and potential in the stories and different learning opportunities were discovered. learning was personalised because the stories were based on real experiences. conclusion. the use of collaborative reflection on narratives of clinical encounters could facilitate insights about cultural aspects of medical practice. elements such as curiosity, respect and unconditional positive regard are illustrated in a unique way that allows students to appreciate the real-life aspects of cross-cultural clinical encounters. ajhpe 2013;5(1):42-45. doi:10.7196/ajhpe.234 cross-cultural medical education: using narratives to reflect on experience p diab,1 mb chb, mfammed; t naidu,2 ma (clinpsych), pg dip (health promotion), phd; b gaede,1 mb bch, mmed (fammed); n prose,3 md 1 department of rural health, college of nursing and public health, university of kwazulu-natal, durban, south africa 2 department of behavioural medicine, college of nursing and public health, university of kwazulu-natal, durban, south africa 3 department of paediatrics and dermatology, duke university medical center, durham, north carolina, usa corresponding author: p diab (diabp@ukzn.ac.za) the modern world has become a global village with a multi-cultural society. institutions have a mandate to educate students, as well as a social responsibility to provide a service to the community. educating students for this environment has become a challenge, as traditional methods of communicating and relating have changed. balancing the demands of efficient and effective healthcare delivery, while serving the needs of a multicultural society, has become a formidable undertaking. the university of kwazulu-natal (ukzn) is part of the global, multicultural village and the multi-cultural issues encountered in this context are in many ways similar to those encountered by international institutions. the students and staff at the nelson r mandela (nrm) school of medicine encompass a wide range of ethnic, language, social, cultural and class backgrounds. patients accessing state healthcare represent a considerable diversity in ethnicity, class, language, social life and culture. predictably, challenges arise when health practitioners, with varied sociocultural backgrounds, are tasked with teaching students with such diverse backgrounds – often different to their own – how to interact with patients, who may represent a further range of socio-cultural groups. it is not uncommon to find practitioners, students and patients who concurrently represent more than one social grouping. therefore, innovative approaches to teaching about culture in the clinical context are required.[1] healthcare provider-patient relationships have become an important aspect of medical curricula. as healthcare moves from a patriarchal to a patientcentred approach, healthcare providers find it necessary to improve their relationships with patients, beyond clinical practice alone.[2] improved healthcare provider-patient relationships, addressing the patient’s agenda and involving the patient as part of the team, have become vital components to healthcare delivery. achieving these objectives can be learned by improving communication skills.[3,4] as part of curriculum 2010, communication skills at ukzn’s nrm school of medicine were included early in the curriculum and integrated throughout the pre-clinical and clinical years. however, it is acknowledged that skills alone are not adequate for competency in communication, especially where there is disparity between healthcare providers’ and patients’ cultural frameworks.[4] a combination of knowledge, skills and attitude supported by reflective practice appears to be the most widely accepted current approach to teaching culturally competent communication to medical students.[3,4] knowledge alone is insufficient to promote cultural competence. attitude, skills and reflective practice are essential.[4] curiosity and genuineness are important tools to level power disparities between clinicians and patients, creating contexts that are conducive for patients to develop a relationship of trust and share information. reflective practice is widely regarded as a method to improve professional practice in a range of professions.[5] it is encouraged in medical education where programmes attend to developing medical students’ communication and reflective skill.[6-10] collaborative reflection is a practice in which ideas articlearticle 43 may 2013, vol. 5, no. 1 ajhpe and experiences are exchanged with others to enhance professional practice.[11-13] it is considered essential for enhancing the quality of reflection.[9,14] building on basic reflection in teaching, which is generally restricted to the ‘how to’ of teaching, collaborative reflection involves broadening the range of reflection to consider the moral, political, and emotional aspects of the education-related issues under discussion.[11] in this paper we track the process of how we used collaborative reflection to arrive at an understanding of applying medical educators’ practical experiences to their teaching of cultural competency to medical students. tigelaar et al. note that little is known about how peer meetings stimulate educators to reflect and it seems useful to examine educators’ communication processes during such meetings.[11] we elucidate a process in which medical educators realised, through collaborative reflection, how they used narratives of their experiences of cultural disparity in clinical encounters to develop their own cultural competency skills. this process led to the understanding that collaborative reflection of shared narratives in clinical encounters could be used in teaching about culture in clinical encounters. it has been noted that culture and the ‘situatedness’ of physician and patient influence telling and listening in important ways.[15] these experiences are difficult to replicate or recreate outside of sharing narratives of such experiences. in the process of deconstructing elements of these types of encounters for teaching purposes or providing generic vignettes of ‘typical’ cross-cultural clinical encounters, certain important elements are lost. primary among these is the human element of the clinician’s personal experience and reflection. in addition, the richness and complexity of real stories are difficult to replicate in vignettes and case studies structured for teaching purposes. the latter tend to be ‘cleaned up’ and purged of conflicting ideas, themes and content to facilitate teaching and avoid confusing students. we would argue that it is uncertainty, conflicting ideas, messiness and real-world feel present in authentic clinical encounters that contain the material to advance students’ understanding of the cultural implications in clinical encounters. process/methodology an interest group of medical educators/health practitioners was formed at ukzn to discuss how the curriculum could best be adapted to address the specific needs for a relevant culturally competent curriculum. participants in the group represented a wealth of knowledge and experience in crosscultural communication, came from various disciplines (family medicine, behavioural medicine, medical education, and public health) and had a keen interest in enhancing teaching practice. during the meeting, the group of six participants discussed various methods to incorporate cultural aspects into medical education. it emerged that the members of the group consistently used the method of recounting narratives of personal or colleagues’ experiences to illustrate a cultural aspect relevant to medicine. the stories which were spontaneously narrated illustrate the complexity of the dynamics between participants and patients in a crosscultural milieu. group participants reflected with each other on their past experiences in similar or related clinical encounters to understand the meaning of their own and patients’ behaviour in these encounters. through this process narratives were recognised as a valuable tool that could be used in curriculum development, illustrating to the group as a whole how to improve the current curriculum to better address the needs of the students and patients. participants then used a process of collaborative reflection to develop a perspective on how narratives could be used in teaching to facilitate an in-depth and reflective understanding of culture in the clinical context. in the process of collaborative reflection the group participants listened to each other tell and re-tell narratives that illustrated positive examples of clinical cultural encounters. group participants collectively identified and agreed on themes or key elements that the narratives had in common, i.e. curiosity, respect and unconditional positive regard for patients. the participants held the view that these attitudes enhanced personal reflection, encouraging them to learn from mistakes and improve their consultations over the course of their careers. beyond the elements of curiosity, respect and unconditional positive regard narratives used by the clinicians shared the following elements, which contributed to their effectiveness in conveying the nuances of clinical encounters in which cultural issues were relevant. • the narratives were complex as they incorporated various elements, including unconventional clinical settings, multiple cultural dimensions, and multiple socio-cultural contexts. • they were real accounts of the personal perspective and credibility of the clinician narrating the story. the element of ‘reality’ of the narratives enhanced credibility. this could be explored from different angles by questioning the narrator. therefore, perspectives that the narrator had not previously explored could be uncovered. • the narratives were rich as they included great detail in terms of ethical and clinical content and emotional aspects. • the stories were dynamic as they were presented with the potential to be used and understood in different ways. different plot elements, characters and potential plot directions meant the audience had the choice of inhabiting different roles within the story. questions could be posed to facilitate deeper understanding and re-create real-life experiences, e.g. ‘what would you feel if you were me in this situation? how would you have reacted in this situation?’. • stories incorporated professional and personal reflections by the clinician/narrator. this paper utilises, as illustration, two of the many narratives related during the meetings. narrative 1 (dr j) ‘on a busy day in the outpatients’ department a young woman came for a consult. she was dressed in a pinafore and had a colourful handkerchief tied around her neck. she was reserved and answered quietly when i greeted her in isizulu and asked how i could assist her. she avoided eye contact and indicated that her problem was the isinye (bladder/lower abdomen). i nodded and stated that perhaps we should perform a pregnancy test, to which she agreed. without any other enquiries or exploration, i gave her instructions to go to the nurses’ station to have a urinary pregnancy test done. she seemed to expect this, and left the consultation room. article may 2013, vol. 5, no. 1 ajhpe 44 ‘when she returned she placed the open envelope with the result on the table, and i asked her what the result was. she looked down, but started smiling slightly. i started laughing, and she started laughing, relieved and very happy – she was pregnant. i continued the consultation, including arranging antenatal clinic, hiv testing for her and her partner and prescribing iron and folate supplements. at the end she gave me a hug and left.’ ‘a local custom for when a young woman is betrothed (ganile), is that she indicates this by wearing a handkerchief or cloth tied around her neck. in the lengthy process of formalisation of the marriage this is an important step, where the woman now starts living with her husband, and there is an expectation that she will become pregnant and demonstrate that she is able to bear a child. the knowledge of this custom and how it is signified, together with understanding the cultural limits of a young woman discussing reproductive health issues with an older man, was important to allow a focused and patient-centred consultation to take place. having worked in this community for some time, the event also indicated to me how the knowledge and respect of isizulu culture had become part of my consultations and facilitated the mutual demonstration of care.’ narrative 2 (ms s) ‘the military is known for a strict code that permeates all aspects of life and members are expected to conform to the military culture regardless of their culture of origin. one day i was referred a patient, sergeant sb, who presented with a pronounced tic. his head jerked involuntarily to over his right shoulder constantly. a neurologist who had examined the patient concluded that the condition was “functional”. the patient was visibly distressed and expressed his concern that the condition was preventing him from working. a note from his commanding officer confirmed that his sick leave was exhausted and leave for treatment for the condition would have to be specifically motivated for by the relevant health practitioner. sergeant sb consented to a session of hypnosis during which the tic disappeared. in the discussion following the hypnosis session sergeant sb confided that his presentation had been identified by his family and an isangoma (traditional healer/diviner) that had been consulted as the call to enter into a spiritual life and train to become an isangoma. he also revealed that he had been having dreams that were usually associated with the call to spiritual life.’ ‘sergeant sb was not keen to take up this call and was then required to participate in a series of rituals under the direction of an isangoma that would release him of this obligation.’ ‘as a clinical psychologist i occupied a role in which i could translate health issues yet also consider emotional and spiritual aspects of health. as a military psychologist, i held the legitimacy to sanction sergeant sb’s desired consultation with the isangoma. this encounter occurred fairly early on in my career but i find myself returning to it often in teaching both to clinical psychologists and medical students, as it seems to illustrate for me some important aspects of cultural interaction in the clinical encounters. firstly my relative inexperience with both military and zulu culture at the time compelled me to take a humble position in both arenas and adopt a curious, non-judgemental and respectful attitude. as different as they were, one thing that these two cultures held paramount was respect, seen as discipline in the military and hlonipha (respect) in zulu culture. in their extreme diversity these two cultures were joined in the common human understanding of respect for others. when i ascribed to this position as clinician i was able to effect a satisfactory agreement for all concerned. i had told this story to different audiences for different purposes but all with the underlying theme that this particular narrative represented a step in my ever-developing cross-cultural competence.’ reflections and discussion both narrators acknowledged that they had used the stories on various occasions and in various ways. the practice of repeated reflections in different contexts and to different audiences enhanced learning. each telling of the story was influenced by the varying purposes of the telling, i.e. whether it was at a job interview, peer consultation or teaching. the different audiences also influenced the telling. for example, bg would sometimes tell his story to illustrate how making assumptions, as he had in his narrative, could have negative consequences if one was not familiar with the cultural context or there were subtle factors which were not immediately evident. each re-telling had some impact on the narrator/participant whose own in-depth understanding of the narrative was enriched by the telling and seeing the familiar narrative from the audiences’ new perspective. participants noted that the stories illustrated important aspects of their practice, such as cultural sensitivity and recognition of culture-specific signifiers, respect, unconditional positive regard and curiosity. narratives had specific reference to how meaning was being given for the individual participant arising out of a process of reflective practice, reflecting on a clinical situation and wanting to make sense of what happened. the particular narratives had struck a personal and an emotional chord with the narrator and had acquired some significance as being illustrative of a moment of developing cultural competence in some way. the process of collaborative reflection with colleagues who were health professionals and medical educators offered the opportunity to examine the political, moral, cultural and social aspects of the narratives and discover how they could be used in teaching about culture in clinical practice. collaborative reflection led to understanding the significance of the narrator’s personal and emotional reflections on the stories in the teaching representing cultural sensitivity. unconditional positive regard, mutual respect, curiosity and willingness to share and learn created the context for learning. during collaborative reflection other group participants reflected on the narratives offered, exploring further possible dimensions of the interactions and additional interpretations. lessons from one narrative were reflected on with reference to other narratives. collaborative reflection facilitated the realisation among group participants that they had told specific stories about the development of their cultural competence in different ways and in different contexts before. it had offered yet another perspective for the narrators and for group participants. this process developed the narrative into a dynamic tool that could be used to illustrate what the clinician felt s/he had learned and what they could teach their students. each re-telling conveyed that the article 45 may 2013, vol. 5, no. 1 ajhpe narrative could be used for different purposes, depending which elements of the narrative were highlighted. collaborative reflection constructed the understanding that narratives of personal encounters by practising clinicians were a valuable resource. the medical consultation cannot be regarded as a culturally neutral context. curiosity, genuineness, respect and unconditional positive regard were seen as imperative preconditions to culturally competent practice.[16] the process of collaborative reflection about the narratives revealed that it was candid reflection and discussion with an attitude of genuineness, curiosity and unconditional positive regard in a respectful non-judgemental environment that could facilitate successful cultural interaction in clinical settings. conclusions in this paper we describe the process of using collaborative reflection on the narratives of clinical encounters to facilitate insights about cultural aspects of medical practice. we pose that these types of narratives offer the opportunity to clinicians, to colleagues and potentially to students to share in the clinicians’ insights with a depth, richness, complexity and real-life feel. furthermore, collaborative reflection allows for a deeper understanding and complexity of the encounter to be explored, pointing to important aspects to be included in the teaching. elements such as the clinicians’ attitude, curiosity, respect and unconditional positive regard are readily conveyed and illustrated when using a narrative first-person account of real clinicalcultural encounters. acknowledgements. the authors wish to acknowledge the contribution of various colleagues during the meeting and subsequent discussions and reflection. dr neil prose’s visit to south africa, hosted by ukzn, was sponsored by a fulbright specialist grant. references 1. sears kp. improving cultural competence education: the utility of an intersectional framework. medical education 2012;46:545-551. [http://dx.doi.org/10.1111/j.1365-2923.2011.04199.x] 2. mcwhinney ir. textbook of family medicine. 2nd ed. new york: oxford university press, 1997. 3. seeleman c, selleger v, essink-bot ml, bonke b. teaching communication with ethnic minority patients: ten recommendations. medical teacher 2011;33(10):814-819. [http:dx.doi.org/10.3109/0142159x.2011.600646] 4. betancourt jr. cross-cultural medical education: conceptual approaches and frameworks for evaluation. academic medicine 2003;78:560-569. [http://dx.doi.org/10.1016/s1607-551x(09)70553-4] 5. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. advances in health sciences education : theory and practice 2009;14(4):595-621. 6. aronson l. twelve tips for teaching reflection at all levels of medical education. medical teacher 2011;33(3):200205. [http://dx.doi.org/10.3109/0142159x.2010.507714] 7. boutin-foster c, foster jc, konopasek l. viewpoint: physician, know thyself: the professional culture of medicine as a framework for teaching cultural competence. academic medicine 2008;83(1):106-111. 8. clandinin j, cave mt, cave a. narrative reflective practice in medical education for residents: composing shifting identities. advances in medical education and practice 2010;2:1-7. [http://dx.doi.org/10.2147/amep. s13241]9. muir f. the understanding and experience of students, tutors and educators regarding reflection in medical education: a qualitative study. international journal of medical education 2010;1:61-67. [http://dx.doi. org/10.5116/ijme.4c65.0a0a] 10. teal cr, street rl. critical elements of culturally competent communication in the medical encounter: a review and model. soc sci med 2009;68(3):533-543. [http://dx.doi.org/ 10.1016/j.socscimed.2008.10.015] 11. tigelaar de, dolmans dh, meijer pc, de grave ws, van der vleuten cp. teachers’ interactions and their collaborative reflection processes during peer meetings. adv health sci educ theory pract 2008;13(3):289-308. [http://dx.doi.org/10.1007/s10459-006-9040-4] 12. nicholson sa, bond n. collaborative reflection and professional community building: an analysis of pre-service teachers’ use of an electrnic discussion board. journal of technology and teacher education 2003;11(2):259-279. 13. martin ja, double jm. developing higher education teaching skills through peer observation and collaborative reflection. innovations in education and training international 1988;35(2):161-170. 14. breiter c. education and mind in the knowledge society. mahwah, nj: lawrence erlbaum associates, 2002. 15. aull f. telling and listening. constraints and opportunities. narrative 2005;13(3):281-293. [http://dx.doi. org/10.1353/nar.2005.0015] 16. rogers cr. client-centered therapy. boston: houghton mifflin, 1951. article november 2013, vol. 5, no. 2 ajhpe 91 roles and attributes of physiotherapy clinical educators: is there agreement between educators and students? d v ernstzen, bsc, m phil division of physiotherapy, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa corresponding author: d v ernstzen (dd2@sun.ac.za) objectives. to determine which roles and attributes of clinical educators are perceived as important in creating a clinical learning environment that is conducive to learning, and if there were differences between the perceptions of undergraduate physiotherapy students and clinical educators. design. a cross-sectional survey in the form of a purpose-built questionnaire was conducted among physiotherapy students and clinical educators. setting. the study was performed at the division of physiotherapy, faculty of medicine and health sciences, stellenbosch university, south africa. participants. all enrolled undergraduate physiotherapy students (n=80) with clinical experience, and all clinical educators (n=37) involved in the delivery of clinical education were invited to participate. results. the educator roles that strongly influence the clinical learning environment were found to be those of technique demonstrator, mentor, assessor, knowledge provider and facilitator of learning. educators’ and students’ views about the role of the educator as role model, reflector, knowledge provider and technique demonstrator differed. participants agreed that the attributes of the clinical educator that are conducive to learning are approachability, recognising student abilities, and good communication skills. conclusion. the clinical educator is pivotal in the success of the physiotherapy clinical education programme. the study found similarities and differences about the role perceptions of educators and students. the differences might influence the learning experience, and it is recommended that expectations be clarified at the start of the clinical education programme. ajhpe 2013;5(2):91-94. doi:10.7196/ajhpe.252 research clinical education is an essential part of developing competence as a physiotherapist. the clinical environment creates a powerful learning environment by providing real-life and authentic situations for which problem solving, collaboration and action are needed. several skills can be learnt in the clinical learning environment, e.g. communication, professionalism, technical skills, clinical reasoning and documenting. numerous roleplayers are involved and consequently influence the clinical learning encounter, e.g. student/s, patients and caregivers, clinical educators and other healthcare providers. the interaction between clinical educators and students has been found to be most influential in affecting learning in the clinical environment.[1-3] indeed, laitinen-vaananen[4] found it to be the strongest element in developing expertise and forming professional identity in clinical education. the relationship between the clinical educator and the student has been found to be one of the most important aspects for effective supervision, more so than the supervisory methods used.[3] higgs[5] supports this notion by commenting that clinical educators play a major role in ensuring entry-level competence. there is also preliminary evidence that goodquality clinical teaching affects students’ performance positively.[6] the clinical educator is therefore pivotal in the achievement of learning outcomes.[7] however, delany and bragge[9] found incongruence between the expectations that students and clinical educators have about clinical learning encounters. in their qualitative study about perceptions on learning and teaching, they found that educators described their role as relating to imparting knowledge, while students highlighted the need for facilitation of learning. consequently, there was incongruence between educators and students about how to construct and develop knowledge. this incongruence could lead to inadequacies in the acquisition of clinical skills. the purpose of the present study was to determine which roles and attributes of clinical educators are perceived as important in creating a clinical learning environment that is conducive to learning, and if there are differences between the perceptions of physiotherapy students and clinical educators. the study was performed at the division of physiotherapy, faculty of medicine and health sciences (fmhs), stellenbosch university (su), south africa (sa). the undergraduate physiotherapy programme is a 4-year bachelor’s degree course. during the 3rd and 4th years of study, students make the transition from a classroom and practical laboratorybased curriculum to a clinical curriculum by working at different healthcare facilities. during this clinical experience, students are supported by a clinical lecturer and physiotherapy clinicians. clinical lecturers are appointed by su, whilst clinicians at the health facilities or schools are appointed by the provincial government of the western cape or the western cape education department. for the purpose of this study, clinical lecturers and clinicians are categorised as ‘clinical educators’, as both play a vital role in creating clinical learning environments. methodology research design the present study is a cross-sectional survey using a purpose-built questionnaire administered to physiotherapy students and clinical educators. the focus is on the clinical educator roles and attributes that foster an environment conducive to learning. the study formed part of a larger study focussing on effective clinical learning and teaching strategies.[9-11] participants all enrolled undergraduate 3rd(n=40) and 4th(n=40) year physiotherapy students at su with clinical experience, and all clinical educators (37) mailto:dd2@sun.ac.za 92 november 2013, vol. 5, no. 2 ajhpe research involved in the clinical education of these students were invited to participate in the survey. instrumentation a purpose-built questionnaire was distributed to eligible students and educators. the questionnaire comprised 3 parts focusing on demographic information, roles and attributes of the clinical educator, and clinical teaching and learning opportunities offered. participants had to choose the 5 most important roles and the 5 most important attributes of the clinical educator that contributed positively to learning in a clinical environment. prior to questionnaire development, a review of the literature was undertaken to establish factors that play a role in the clinical learning experience. a summary of the main themes identified were categorised according to the model of hesketh et al.[12] the themes were drafted into questions and questionnaires, which were made available in afrikaans and english. the su language centre assessed the language and user-friendliness of the draft questions. an experienced statistician was consulted to determine if the questions were suitably framed for statistical analysis. the content validity of the draft questions were assessed by 5 experienced higher-education practitioners. a pilot study was undertaken to determine if the questions and instructions were understandable, and to establish an estimated time for completion of the questionnaire. a sample consisting of 1 physiotherapy class and 2 clinical educators from another physiotherapy department in sa was recruited for this purpose. the questionnaire was administered to students by allocating time to complete the questionnaire during their final clinical rotation. the questionnaire was mailed to clinical educators with a stamped, self-addressed return envelope. every questionnaire was accompanied by a covering letter, including the aim of the study, return date for the questionnaire and contact information of the researcher. non-responders were followed up by sending a reminder e-mail. data analysis the questionnaire data were recorded in a purpose-built data-collection sheet in ms excel. data were analysed by a statistical programme (statistica 7), using proportions, means and appropriate variability measures. chisquare tests were used to determine differences between students’ and clinical educators’ questionnaire responses. the p-value was set at 0.05. ethical considerations the protocol for the study was approved by the health research ethics committee at fmhs, su. permission to undertake the study was obtained from the chairperson of the physiotherapy division. written informed consent was obtained from all participants. results the response rate to the questionnaire was 88% (n=70) for students and 62% (n=23) for clinical educators. table 1 provides a profile of the participants in terms of age, gender and experience. table 2 summarises the main roles and attributes that were selected by participants as important aspects of a productive clinical learning environment. the frequency with which each construct was selected is indicated for students, educators and in total. considering all selections, the roles of the educator as technique demonstrator, mentor, assessor, knowledge provider and facilitator of learning were the strongest perceptions. participants agreed on the important role of the clinical educator as mentor, facilitator of learning and as assessor. differences, however, existed between the role of the educator as role model, reflector, knowledge provider and technique demonstrator. this was confirmed by the p-values for these constructs being <0.05. from table 2, it can be seen that differences exist ibetween the opinions of students and educators in the importance of the role of educator as the provider of knowledge, and as technique demonstrator. clinical educators also valued their role as reflector and role model more than students did. participants agreed that the attributes of the clinical educator that were conducive to learning were approachability, recognising student abilities and good communication skills. both groups of participants assigned had a low selection frequency for the interpersonal skills of the educator. the only construct where a statistical difference existed between the two groups was the educator as listener, with educators valuing listening skill more than students did. discussion delany and bragge[8] emphasise the need to align learning and teaching expectations between students and clinical educators to achieve learning outcomes. the results of the study found similarities and dissimilarities between the perceptions of clinical educators and students about the most important roles and attributes of the clinical educator in creating a productive clinical learning environment. it is notable that both educators and students in this study attached a high value to passive learning strategies where students might not be actively involved in the learning activity, i.e. the educator as technique demonstrator and knowledge provider. in the context of this study, there was consequently a strong emphasis on the educator being central to the process of knowledge construction. the above finding differs from the current notions of the educator as manager and co-creator of knowledge, and the student as active participant in the learning process.[14] when interpreting the above findings, one needs to consider that there were 2 groups of student participants (3rd-year and a 4th-year group). the more junior students could therefore have influenced the result towards a more structured and guided approach, which would be supported by delany and bragge’s view[8] that the priority of the learner changes over time from ‘what to know’ towards ‘how to learn’. another consideration is that students’ and educators’ personal beliefs about knowledge and knowledge construction (their epistemologies) influence the way that teaching and learning roles are approached and adapted in clinical placement settings. meanings and purposes attached to the clinical teaching and learning roles are thus shaped by our personal conceptions.[13] delany and bragge[8] found that educators viewed themselves as imparting information strategically and incrementally to build students’ knowledge (thus to transmit knowledge), whilst students required more active learning strategy involving collaboration and taking responsibility for their own learning. this view is in keeping with rolfe and sansonfisher,[14] who emphasise that effective self-directed learning skills enhance motivation to learn and clinical competence. in the current study, students selected a process of knowledge transmission from educator to student, whilst educators emphasised learning by facilitation, mentoring and rolemodelling. the above findings might indicate that context, as well as the role of the clinical educator, plays a role in clinical knowledge production. the expectations that students and educators have of each other is therefore a dynamic process. it is recommended that these expectations be clarified between the students and educators and perhaps even the higher education institute and healthcare facility involved. a surprising finding was the low selection rate of students for the role of the educator as role model, which is contradictory to learning theories. in editorial november 2013, vol. 5, no. 2 ajhpe 93 research the social cognitive theory of bandura (as cited in schunk[15]), role modelling is a powerful means of teaching values, attitudes and patterns of thought and behaviour. the difference in the results for the clinical educator as role model in this study could be twofold: one is that the students underrated the powerful role that the educator has as a role model; and secondly, the educator as role model might have been seen as incorporated in other roles of the clinical educator. student participants in this study did not place great value on reflection with the educator, which indicates that this aspect may have to be included as a formal learning activity for it to be recognised as a learning experience. participants might have been unaware of the process and value of reflection. it has been highlighted in previous reports[9] that, if reflection is not specified as a learning activity, students do not realise that it is happening. these findings have been confirmed by muir[16] who found that students and their medical educators had an incomplete understanding of reflection as a learning process. she therefore recommended that students should be clearly informed about critical and ongoing reflection as professional and personal development. reflection is important, as clinical experience alone does not facilitate learning, but reflection on experience and on learning is necessary to enhance learning. reflection should therefore be planned as part of the experiential process − in this case, the clinical encounter with the patient. reflection on professional experience is increasingly accepted as a critical attribute for healthcare practice, and there is some evidence that it has a positive impact on performance.[17] further research on reflection for learning in the clinical education context is needed. study limitations the study findings can only be generalised to similar contexts. participants in the study could only report on learning experiences and clinical educators to whom they were exposed. exposure to different clinical learning environments, such as different educators and learning activities, may provide different findings. most of the participants were female, and a gender bias could therefore exist. no distinction was made between senior and junior students, and it is acknowledged that their perceptions about environments conducive to learning might differ. the study focused on the clinical educators’ influence on learning, but a more holistic study that includes personal, professional, contextual and organisational factors is advisable. table 2. the perceptions of staff and students about the roles of the clinical educator which are conducive to learning in the clinical environment role students n (%) educators n (%) total (%) (n=93) p-value technique demonstrator* 99 (69) 70 (16) 91 0.00 mentor 91 (64) 83 (19) 89 0.24 assessor/evaluator 83 (58) 83 (19) 83 0.98 knowledge provider* 83 (58) 52 (12) 75 0.00 facilitator of learning 93 (65) 96 (22) 71 0.64 reflector* 37 (26) 74 (17) 46 0.00 role model* 30 (21) 87 (20) 44 0.00 questioner 40 (28) 26 (6) 37 0.23 counsellor 30 (21) 13 (3) 26 0.11 friend 11 (8) 4 (1) 10 0.85 other 0 (0) 4 (1) 1 0.00 attribute students n (%) educator n (%) total (%) (n=93) p-value approachable 91 (63) 83 (19) 88 0.34 recognises student abilities 67 (58) 83 (19) 77 0.98 good communication 67 (58) 65 (15) 73 0.07 supports the student 63 (44) 43 (10) 58 0.10 respects the students 53 (37) 61 (14) 55 0.50 organised 56 (39) 48 (11) 54 0.51 not prejudiced 49 (34) 57 (13) 51 0.51 enthusiasm 49 (34) 52 (12) 49 0.76 interpersonal skills 41 (29) 35 (8) 40 0.57 shows concern for student 39 (27) 17 (4) 33 0.06 listener* 9 (7) 35 (8) 16 0.01 self-confident 10 (8) 17 (4) 13 0.46 *p<0.05. more than 1 selections were possible. table 1. profile of the case population and participants 3rd-year students 4th-year students clinical educators population number in category 40 40 37 gender 39 female 1 male 35 female 5 male 34 female 3 male average age (±sd) 21.53 (±1.78) 22.73 (±1.74) 37 (±7.51) participants number of participants 38 32 23 gender 37 females, 1 males 29 female, 3 male 23 females average age (±sd) 21.45 (±1.66) 22.25 (±2.45) 37.26 (±7.33) clinical learning experience (years) 1 2 years in clinical education 5.78 average editorial 94 november 2013, vol. 5, no. 2 ajhpe research conclusion the study confirms that the clinical educator is pivotal in the success of a physiotherapy clinical education programme. the roles of the clinical educator that contribute to a productive learning environment in this context include technique demonstrator, mentor, assessor, knowledge provider and facilitator of learning. a clinical educator who is approachable, recognises students’ abilities and has good communication skills will contribute to an environment conducive to learning. the findings of this study agree with the large body of international literature about supportive clinical learning environments. similarities and differences were found between role expectations of students and educators. the study indicated that incongruence about the roles of the educator might exist between educator and students concerning the educator as role model, reflector, technique demonstrator, knowledge provider and listener. these might influence the learning experience of the student. it is therefore recommended that these expectations be clarified at the start of the clinical education programme, and that the context of the learning situation be considered when planning learning events. acknowledgements. the authors thank the participants for their time and input. funding. the fund for innovation and research into teaching and learning, centre for teaching and learning, stellenbosch university, south africa, contributed to this study. references 1. chan dsk. combining qualitative and quantitative methods in assessing hospital learning environments. int j nurs stud 2001;38(4):447-459. 2. harden rm, crosby jr. amee guide no 20: the good teacher is more than a lecturer – the twelve roles of the teacher. medical teacher 2000;22(4):334-347. [http://dx.doi.org/10.1080/014215900409429] 3. kilminster sm, jolly bc. effective supervision in clinical practice settings: a literature review. medical education 2000;34:827-840. [http://dx.doi.org/10.1046/j.1365-2923.2000.00758.x] 4. laitinen-vaananen s, talvitie u, luukka mr. clinical supervision as an interaction between the clinical educator and the student. physiotherapy theory and practice 2007;23(2):95-103. 5. higgs j. managing clinical education: the programme. physiotherapy 1993;79(4):239-246. [http://dx.doi. org/10.1016/s0031-9406(10)60705-5] 6. stern dt, williams bc, gill a, gruppen ld, woolliscroft jo, grum cm. is there a relationship between attending physicians’ and residents’ teaching skills and students’ examination scores? academic medicine 2000;75(11):1144-1146. 7. cross v. perceptions of the ideal clinical educator in physiotherapy education. physiotherapy 1995;81(9):506-513. 8. delany c, bragge p. a study of physiotherapy students' and clinical educators' perceptions of learning and teaching. medical teach 2009;31(9):e402-e411. 9. ernstzen dv, bitzer em, grimmer-somers k. physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: a case study. medical teach 2009;31(3):e102-115. [http://dx.doi. org/10.1080/01421590802512870] 10. ernstzen, dv, bitzer, em, grimmer-sommers k. physiotherapy students’ and clinical teachers’ perspectives on best teaching and learning practice: a qualitative study. south african journal of physiotherapy 2010;66(3):25-31. 11. ernstzen dv, bitzer em. the roles and attributes of the clinical teacher that contribute to favourable learning environments: a case study from physiotherapy. south african journal of physiotherapy 2012;68(1):9-14. 12. hesketh ea, bagnall g, buckley eg, et al. a framework for developing excellence as a clinical educator. medical education 2001;35(6):555-564. [http://dx.doi.org/10.1046/j.1365-2923.2001.00920.x] 13. higgs j, mcalister l. being a clinical educator. adv health sci educ theory pract 2007;12(2):187-200. [http://dx.doi.org/10.1007/s10459-005-5491-2] 14. rolfe ie, sanson-fisher rw. translating learning principles into practice: a new strategy for learning skills. medical education, 2002;36(4):345-352. [http://dx.doi.org/10.1046/j.1365-2923.2002.01170.x] 15. schunk dh learning theories. an educational perspective, 4th ed. new jersey: pearson education , 2004. 16. muir f. the understanding and experience of students, tutors and educators regarding reflection in medical education: a qualitative study. int j med educ 2010;1:61-67. [http://dx.doi.org/10.5116/ijme.4c65.0a0a] 17. koole s, dornan t, aper l, et al. does reflection have an effect upon case-solving abilities of undergraduate medical students? bmc medical education 2012;12:75. [http://dx.doi.org/10.1186/1472-6920-12-75] http://dx.doi.org/10.1080/014215900409429] http://dx.doi.org/10.1046/j.1365-2923.2000.00758.x] http://dx.doi.org/10.1016/s0031-9406 http://dx.doi.org/10.1016/s0031-9406 http://dx.doi.org/10.1080/01421590802512870] http://dx.doi.org/10.1080/01421590802512870] http://dx.doi.org/10.1046/j.1365-2923.2001.00920.x] http://dx.doi.org/10.1007/s10459-005-5491-2] http://dx.doi.org/10.1046/j.1365-2923.2002.01170.x] http://dx.doi.org/10.5116/ijme.4c65.0a0a] http://dx.doi.org/10.1186/1472-6920-12-75] ajhpe african journal of health professions education march 2022, vol. 14, no. 1 ajhpe is published by the south african medical association head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 9 & 10, lonsdale building, gardner way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.editorialmanager.com/ajhpe editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors champion nyoni university of the free state werner cordier university of pretoria rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal gonzaga mubuuke makerere university anthea rhoda university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria general manager dr vusumusi nhlapho executive editor bridget farham head of publishing diane smith i tel. 012 481 2069 email:dianes@samedical.org managing editors claudia naidu naadia van der bergh technical editors kirsten morreira production & distribution officer emma jane couzens senior designer clinton griffin online support gertrude fani issn 2078-5127 editorial 2 ...and then there was covid p mcinerney research 3 an innovative educational strategy for learning and teaching clinical skills during the covid-19 pandemic c n nyoni, a e fichardt, y botma 8 justice as fairness in preparing for emergency remote teaching: a case from botswana m s mogodi, d griffiths, m c molwantwa, m b kebaetse, m tarpley, d r prozesky 13 teaching and learning considerations during the covid-19 pandemic: supporting multimodal student learning preferences f ally, j d pillay, n govender 17 module evaluation for emergency remote teaching – an oral hygiene case study during the covid-19 pandemic m cupido, n gordon, n behardien 26 undergraduate dental students’ perspectives on teaching and learning during the covid-19 pandemic: results from an online survey conducted at a south african university using a mixed-methods approach r moodley, s singh, i moodley 33 the effect of the initial months of the covid-19 national lockdown on mmed training activities at the university of the free state c meyer, c barrett, g joubert, n mofolo cpd questionnaire 15 december 2011, vol. 3, no. 2 ajhpe introduction gender bias has been entrenched in healthcare education, research and clinical practice.1 in a review paper addressing gender bias in medicine, wong stresses why this should receive attention when medical curricula are constructed. he highlights that gender inequities are still apparent in health, as much of the current medical knowledge is based on the ‘male norm’. this bias within healthcare and the medical educational system has been reiterated by many within and outside of the profession. a recent study done in the united states2 found that simply increasing the number of female students recruited for health education has not eliminated either gender bias present in the curriculum or the discrimination against women whilst participating in medical education. in 2002 the world health organization adopted a gender policy committing itself to promoting gender equality and equity in health and to redressing health inequities that are a consequence of gender roles and unequal gender-relations in society.3 key to achieving this goal is to make gender considerations an integral part of the pre-service training curricula of health professionals. some of the major challenges of such initiatives include institutional resistance and difficulties in involving key faculty and, in particular, male colleagues in this process. in order to understand the integration needed, it is important to understand the working definitions of gender inequality and gender discrimination. gender inequality refers to disparity between individuals due to gender. sexism, also known as gender discrimination or sex discrimination, is the discrimination against a person (usually female) in opportunity or employment based on their sex.4 up to the early 1980s a south african woman could not open a bank account without the permission of her husband or father. only in the 1990s with the acceptance of the bill of rights did women receive formal recognition that they were viewed as equal citizens under section 9 of the constitution.5 previous laws condoned prejudice in various ways: white women were not allowed to contribute to the working force in all business areas under the old common law. black women were viewed as minors under previously applied customary laws and that excluded them from the right to own property or the rights to their children as legal guardians. because of their race and gender black women were doubly discriminated against.6 the male-dominated history of the medical profession kept south african women from pursuing a medical career until early in the previous century. in 1947 mary susan malahele-xakana became the first black woman to register as a medical doctor in south africa.7 since 1994, education policy-making in south africa has focused on the transformation of education to improve access, quality, equity and redress for learners in line with the principles enshrined in the constitution. a recent editorial in the samj8 stated that although there has been a feminisation of the profession in recent years, equity remains elusive: women have not populated the specialisation fields or attained leadership positions in line with the current statistics on females in the profession. the research field was a previously disadvantaged university, with mostly black students. the hope was that the data generated would reflect on and contrast the inequalities known to exist in wider society with the previous marginalisation of people-groups not only based on gender, but also on race. building on previous international research, the aim of the study was to contribute to the understanding of women’s experiences on gender discrimination and inequality while participating as learners in health education. the research question was whether the medical educational system could be perpetuating the inequalities or contributing to the restoration of the disparities known to exist. methodology the study included all fourth-year female medical students at a university in south africa. all female fourth-year medical students (n=72) who were willing to participate in the study were included. the cohort of students identified consisted primarily (92%) of students who were of african origin. a quantitative approach consisting of an observational, descriptive study design was applied. data were collected by means of self-administered questionnaires. each question consisted of a ‘yes’ or ‘no’ answer box, with the option to comment or elaborate on the answer. face and content validity of the questions were accounted for by means of a literature review as well as review of the questionnaire by more than one peer as well as a bio-statistician. informed consent was obtained from all participants. permission for the study was also granted and ethical clearance obtained from the medunsa research ethics committee and the school of medicine. consenting students completed the questionnaires after a series of four ethics lectures, of which the last two learning sessions focussed on equality, equity and vulnerable groups. after completion of the questionnaire, students were asked to put it in a box stationed at the front of the class. the statistical analysis was of a descriptive nature, where the responses in the different categories were summarised by frequency counts and percentages. the analysis of the open-ended questions was by means of describing and coding the data according to identified themes. coding was done through and inductive, open process. results of the total number of questionnaires distributed, 48/72 fourth-year female medical students responded, yielding a response rate of 68%. of the respondents, 32% reported having the perception that they were not taken seriously by their patients because they were female. in addition, 24% reported that they were not taken seriously by their male peers. however, it was reported by 94% that their learning facilitators took them seriously as women in the medical profession. short report perceptions of female medical students on gender equality gains at a local university ellenore meyer-van den heever1, jose frantz2 1head of bio-ethics department, university of limpopo, medunsa campus 2department of physiotherapy, university of the western cape correspondence to: ellenore meyer-van den heever (ellenoremeyer@hotmail.com) 16 december 2011, vol. 3, no. 2 ajhpe although a large majority (83%) of the respondent did not feel that they were discriminated against while in training, approximately 17% reported feeling discriminated against. in addition, 51% felt that ‘there was a difference in how we are viewed as professional due to our gender’. the majority of the respondents (93%) felt that men and women are equals as healthcare professionals. the author identified the four main themes from the open-ended responses, and this is presented in table i. discussion at the start of the millennium the world health organization adopted a gender policy that committed itself to promote gender equity and equality by implementing gender considerations into the curricula of health professionals’ education.9 although this was implemented into a programme at the above university, the gender bias is still evident. policy alone cannot enforce change against the subtler tones of discrimination, but it should be lived by those in the medical profession on a continuous basis. each professional contributes to a society that not only allows women equal opportunities, but views women as deserving of those opportunities. curricular changes addressing gender inequality should be adopted on a broader curricular level to have significant impact and address the subtler tones of gender discrimination experienced in health education. conclusions the findings indicate the necessity for additional support for women in medicine as well as addressing the gender role assumptions evident in the educational experience through curriculum reform. acknowledgements we thank francois pr de villiers for supervising the study. references 1. wong yl. gender competencies in the medical curriculum: addressing gender bias in medicine. asia-pacific j public health 2009;21:359. http://aph.sagepub. com/content/21/4/359 (accessed may 2011). 2. butler km, mason j. does gender still matter?: women physicians’ selfreported medical education experiences. student summer scholars. 2010. paper 45:1-2. http://scholarworks.gvsu.edu//sss/45 (accessed may 2011). 3. the constitutional court of south africa. http://www.constitutionalcourt.org.za/ text/rights/know/women.html (accessed may 2010). 4. oxford dictionaries online. http://oxforddictionaries.com/definition/ sex+discrimination (accessed sept 2011). 5. south african history online. biography: mary susan malahele-xakane. http:// www.sahistory.org.za/pages/people/bios/xakana-m.htm (accessed jan 2011). 6. world health organization. integrating gender into the curricula for health professionals. department of gender, women and health (gwh). meeting report: 4-6 december 2006:1. 7. kleintjes s. gender equity in south african education: 1994-2004: conference proceedings. hsrc publication: l chrisholm, j september. 2006:29. 8. ncayiyana dj. feminisation of the south african medical profession – not yet nirvana for gender equity. s afr med j 2011;101:5. 9. science museum. women in medicine brought to life: exploring the history of medicine. http://www.sciencemuseum.org.uk/broughttolife/themes/practisingmedicine/women (accessed jan 2011). 10. world health organization. integrating gender into the curricula for health professionals. department of gender, women and health (gwh). meeting report: 4-6 december 2006. short report table i. themes, categories and respondent responses theme category respondents' experience quote educational experience patient’s response participants noted that patients would call them nurse or sister, while calling their male colleague doctor i would not make it in this profession because i am soft, emotionally weak and too sympathetic peer response participants responded that they were viewed as weak, inferior to men and not able to lead a group hierarchy in medical training role models preference the obstetrician preferred a male assistant i was asked to step down from assisting a caesarean section responsibilities family responsibility women working in the department often had dual loyalties as women we could not equally share the burden of work expected from a registrar sexual harassment power relationships comments and suggestions of a sexual nature research 158 november 2015, vol. 7, no. 2 ajhpe one of the guiding principles of the teaching and performance of a medical intervention is to ‘firstly do no harm’. gaining access to a patient’s circulatory system for the purpose of administering fluid and/or medications is commonly achieved through a procedure that involves piercing of the skin with a needle and inserting a cannula into a vein. while intravenous (iv) cannulation is a relatively common procedure routinely performed by a number of healthcare professionals, it has the potential to create unintended adverse effects. subjecting patients to medical procedures in the absence of a clearly established need may be considered an unethical form of ‘overtreatment’. conversely, failing to perform an intervention when it is clearly indicated is equally undesirable. therefore, it is important for medical professionals and educators to ensure that there is a real need or an indication for iv cannulation before students perform the procedure. the university of johannesburg (uj) is one of four higher education institutions in south africa (sa) that currently offers a 4-year professional bachelor degree in emergency medical care. iv cannulation is a clinical procedure that is taught in the second year of study. the didactic approach followed at uj is to firstly teach and assess theoretical knowledge and understanding of the procedure with regard to the technique, indications, risks and benefits. the procedure is then demonstrated, practised and assessed in a simulated environment, making use of an iv trainer (medium-fidelity manikin). thereafter, students are required to demonstrate performance of the procedure a set number of times on real patients. while this creates a desire in students to perform iv cannulation when the opportunity presents itself, as mentioned above, it is essential to seek clear indications to prevent unnecessary exposure of patients to potential adverse effects. the department of emergency medical care at uj currently teaches four indications for iv cannulation in the prehospital setting, which are well supported in the literature. these include: (i) administration of iv fluid in an effort to reverse hypovolaemic and associated dehydrated states; (ii) administration of iv medications; (iii) securing iv access in the case of acutely ill, high-acuity ‘priority 1’ or ‘code red’ patients; and (iv) obtaining blood samples/specimens for further laboratory testing. we aimed to assess the extent to which emergency medical care students may have been accessing patients intravenously during the course of their clinical learning, without a clear indication. method a retrospective quantitative design was used comprising 5 893 cases from an existing database, emergency medical database and analysis system (emdata), which contains prehospital patient care records relating to students’ clinical learning, facilitated by the department of emergency medical care at uj. data from two consecutive academic years were extracted using structured query language (sql) statements and analysed to establish the number and percentage of the following patients seen by students over that period: • those who received iv cannulation. • those who received iv cannulation and iv medication, but <500 ml of fluid. • those who received iv cannulation and >500 ml of fluid, but no iv medication. • those who received iv cannulation, >500 ml of fluid and iv medication. • those who were cannulated, acutely ill, high-acuity priority 1 patients, but who did not receive >500 ml of fluid or iv medication. • those who received iv cannulation, but were not acutely ill, high-acuity priority 1 patients, and did not receive iv medication or >500 ml of background. intravenous (iv) cannulation is a commonly performed procedure that is taught to a number of health science students. as with most invasive medical interventions, there is a possibility of unintended adverse effects. therefore, iv cannulation should only be performed for a clearly established need. objective. to assess the extent to which emergency medical care students, during the course of their clinical learning, establish iv access in patients without a clearly documented indication. methods. a retrospective analysis of historical data from a clinical learning database was done to investigate whether patients seen by students over a 2-year period received iv cannulation in line with indications taught to students. results. of the 5 893 cases reviewed, 1 862 (32%) were cannulated intravenously. of these, 426 (23%) did not have a clearly documented indication that had been taught for the procedure. therefore, these patients may potentially have been ‘overtreated’. conclusion. this study demonstrates that a high number of iv lines were established by students, with no clearly documented indication. this potential overtreatment may in part be attributed to pressures placed on students to achieve the minimum prescribed number of skills. such practices remain common in medical education and may be detrimental to the patient. medical educators need to ensure that students value the patient rather than the procedure. further research needs to be conducted to investigate and identify other possible reasons for overtreatment of patients by medical students. afr j health professions educ 2015;7(2):158-160. doi:10.7196/ajhpe.273 student compliance with indications for intravenous cannulation during clinical learning c vincent-lambert,1 nd aet, nhd pse, nhd fst, btech emc, mtech ed, phd, hpe; b van nugteren,2 nd emc, btech emc 1 department of emergency medical care and podiatry, faculty of health sciences, university of johannesburg, doornfontein campus, south africa 2 department of emergency medical care, faculty of health sciences, university of johannesburg, doornfontein campus, south africa corresponding author: c vincent-lambert (clambert@uj.ac.za) research november 2015, vol. 7, no. 2 ajhpe 159 fluid. this would constitute the cohort for whom there was no clearly documented taught indication supporting performance of the procedure. consequently, based on the data extracted from the database, this cohort of patients may have potentially been unnecessarily cannulated or ‘overtreated’. results table 1 summarises the cases per category. discussion research in the sa prehospital emergency care education environment is in its infancy. consequently, there is currently limited published literature describing the practices of local emergency medical care students. in an attempt to compare the abovementioned findings with the existing literature, we performed a literature search in the medline database using medical subject headings (meshs) and textwords: ‘iv cannulation’ [mesh], ‘prehospital’ [mesh] and ‘emergency medical services’ [mesh]. articles published over the past 15 years were prioritised. these searches highlighted that there was limited international literature on emergency medical care students and the performance of iv cannulation. patients who were cannulated intravenously the percentage of patients (32%) in this study who received iv cannulation was found to be lower than that in international studies. gausche et al.[1] found that 84% of the patients in their study were cannulated intravenously. two other studies found that peripheral iv cannulation had been performed in 57% and 58% of patients, respectively.[2,3] the lower percentage of patients who received iv cannulation in relation to international figures may be because, in sa, ambulances transport many low-acuity ‘stable’ ambulatory patients who do not require any form of prehospital medical intervention, but merely need transport to hospital.[4] another reason may be that students work with ambulance crews whose scope of practice does not include iv cannulation. as students may only practise within the scope of the registered supervisor, they would not have been able to perform this skill – even if it were indicated. patients who were cannulated intravenously, received iv medication, but <500 ml fluid there were 23% of patients in this category compared with 71% who received only iv medication in the minville et al.[2] study. one reason may be that many of the ambulance crews in sa with whom the students work qualified at the intermediate life support level. sa intermediate life support providers have few iv medications in their scope of practice, yet are still able to establish an iv line. patients who were cannulated intravenously, received >500 ml fluid, but no iv medication of the patients who were cannulated, 32% received fluid resuscitation. this is higher than the percentage reported in similar international studies, where only 7% and 5% of patients received fluid resuscitation, respectively.[1,2] the difference may be attributed to the higher incidence of trauma (with associated blood loss) to which sa emergency services respond. sa has one of the highest motor vehicle accident rates in the world. violence and injuries are the second leading cause of death and lost disability-adjusted life-years in sa. the overall injury death rate of 158/100 000 population is nearly twice the global average.[5] another possible reason is that local basic and/ or intermediate life support providers spend longer in the prehospital environment than their international counterparts.[6] additional time spent treating and transporting patients allows for more fluid to be administered. patients who received >500 ml fluid together with iv medication a total of 289 (16%) of the study patients received both iv medication and >500 ml of fluid. this could not be compared with international studies, as those reviewed did not identify these patients as a separate group. acutely ill, high-acuity priority 1 patients cannulated intravenously, but who did not receive >500 ml fluid or iv medication as mentioned above, one of the taught indications for establishing iv access is obtaining iv access in the acutely ill, high-acuity priority 1 patient so that, should rapid deterioration occur during transit, the iv line is already in place. one hundred and twenty-six (7%) of the patients who received iv cannulation were categorised as high-acuity priority 1, but did not receive iv medication or >500 ml of fluid. this percentage is much lower than the 24% described in the minville et al.[2] study. the reasons for this difference are not clear; it could be related to a failure by ambulance personnel and students to properly assess the patient and correctly predict deterioration. patients who were cannulated intravenously, but not categorised as high-acuity priority 1, received no iv medication and not >500 ml fluid four hundred and twenty-eight (23%) of the patients did not have a clearly documented indication for iv cannulation, suggesting that they may have been potentially overtreated. this finding is similar to the 22% and 29% of iv lines that remained unused in the studies by allen et al.[7] and pace et al.,[3] respectively. however, the percentage is considerably lower than the 56% unused iv lines in the gausche et al.[1] study. as mentioned above, there is a paucity of literature describing the clinical education and training practice of emergency medical care students. despite a number of searches, no studies could be found describing overtreatment of patients by such students. the reasons for overtreatment may include over-eagerness of the student and a desire to practise and master newly found clinical skills. barsuk et al.,[8] in dealing with medical education and learning, highlight the potential of simulation-based learning to assist in achieving minimum table 1. cases per category category n (%) number cannulated intravenously 1 862/5 893 (32) received iv medication, but not fluid resuscitation* 431/1 862 (23) received fluid resuscitation,* but no iv medication 590/1 862 (32) received fluid resuscitation and iv medication 289/1 862 (16) high-acuity (p1), but received no iv medication or fluid resuscitation* 126/1 862 (7) received no iv medication or fluid resuscitation and not high-acuity (p1) 426/1 862 (23) iv = intravenous; p1 = priority 1. *fluid resuscitation was defined as the administration of >500 ml fluid. research 160 november 2015, vol. 7, no. 2 ajhpe standards and mastery of clinical skills prior to interactions with real patients. jantz and mcgaghie[9] rightfully note that while many medical education programmes demand the performance of a set number of skills and procedures, the numbers are not scientifically validated. nonetheless, the setting of minimum numbers naturally creates pressure on student and educator alike. observations and feedback from students and educators in our emergency medical care environment are that there is indeed pressure to perform skills and interventions for the purposes of teaching, learning and assessment. this study showed that of the 5 893 patients seen by students during the 2-year period, 1 862 (32%) received iv cannulation and, of these, 426 (23%) did not have a clearly documented taught indication for the procedure. this evidence suggests that these patients may potentially have been overtreated. subjecting patients to medical procedures in the absence of an evidencebased need may be considered an unethical form of overtreatment. conversely, failing to perform an intervention when it is clearly indicated is equally undesirable. therefore, it is incumbent upon medical professionals and educators to ensure a real need or an indication for a procedure such as iv cannulation before performing the procedure. it is also acknowledged that emergency medical care students work under direct supervision. the power-authority relationship between them and their clinical mentors may limit their autonomy to make clinical decisions. such findings are interesting and applicable to emergency medical care students and educators. medical educators should consider recent evidence and research in the area of simulation-based learning, as this appears to be an under-used didactic approach, which, if properly implemented, may reduce current overreliance on patient contact. conclusion of all the patients cannulated intravenously, few had medications administered via the established iv line. a higher number of patients received >500 ml of fluid than in similar international studies. in a number of patients an iv line had been established, yet they did not receive medications or clinically significant volumes of fluid, and were not documented as acutely ill, high-acuity priority 1. in such cases the indication to perform this procedure was unclear, and therefore these patients may have been overtreated. while iv cannulation remains a relatively common procedure routinely performed by a number of healthcare professionals, it has the potential to create unintended adverse effects. this study demonstrates that students established a significant number of iv lines – without a clearly documented indication. this potential overtreatment may in part be attributed to pressure placed on students to achieve a prescribed minimum number of skills. the value of quantitative approaches to determine clinical competence based purely on the performance of a skill or procedure a set number of times may be questioned, because many of the targets are not scientifically validated. despite this, such practices remain common in medical education and may be detrimental to the patient. medical educators need to ensure that their students value the patient rather than the procedure. further research needs to be conducted to investigate and identify other possible reasons for overtreatment of patients by medical students. ethical considerations. ethical clearance for the study was granted by the uj’s faculty of health sciences academic ethics committee. protection of the patient’s rights to privacy. the researchers (cvl and bvn) signed a confidentiality agreement, stating that the information they had access to remained confidential. in light of the research design it was not necessary to identify individual students, patients, supervising practitioners, emergency medical service providers or receiving medical facilities. the researchers only extracted data from the database on the premises of uj. the files remained password protected and were deleted after data extraction was complete. references 1. gausche m, tadeo re, zane mc, lewis rj. out-of-hospital intravenous access: unnecessary procedures and excessive cost. acad emerg med 1998;5:878-882. 2. minville v, pianezza a, asehnoune k, cabardis s, smail n. pre-hospital iv line placement assessment in the french emergency system: a prospective study. eur j anaesthesiol 2006;23:594-597. 3. pace sa, fuller fp, dahlgren tj. paramedic decisions with placement of out-of-hospital intravenous lines. am j emerg med 1999;17:544-547. 4. geldenhuys n. the use of ambulances to transport patients to the emergency department of a public hospital in johannesburg [research report]. johannesburg: university of johannesburg, 2011. 5. seedat m, van niekerk a, jewkes r, suffla s, ratele k. violence and injuries in south africa: prioritising an agenda for prevention. lancet 2009;374:1011-1022. [http://dx.doi.org/10.1016/s0140-6736(09)60948-x] 6. van hoving dj, smith wj, wallis la. comparison of mean on-scene times: road versus air transportation of critically ill patients in the western cape of south africa. emerg med j 2008;25:136-139. [http://dx.doi. org/10.1136/emj.2007.051540] 7. allen b, reisdorff ej, d’agostino j, brown b, shah cp, thakur rk. prehospital iv access: what is the impact? prehosp emerg care 1997;3:191-195. 8. barsuk jh, cohen er, vozenilek ja, o’connor lm, mcgaghie wc, wayne db. simulation-based education with mastery learning improves paracentesis skills. j grad med educ 2012;1:23-27. [http://dx.doi.org/10.4300/ jgme-d-11-00161.1] 9. jantz ma, mcgaghie wc. it’s time for a stat assessment of bronchoscopy skills. am j respir crit care med 2012;8:703-705. [http://dx.doi.org/10.1164/rccm.201208-1398ed] editorial december 2012, vol. 4, no. 2 ajhpe 95 this edition showcases work from south africa, but having relevance to the african continent as a whole. the papers concerned serendipitously all have the same theme – that of addressing the human resource challenges in healthcare delivery in african communities. hugo et al.1 describe the structure of the curriculum that has been developed to provide south africa’s underserved populations with ‘generalist’ practitioners who work in district level hospitals under the supervision of doctors. the first graduates of this curriculum, rolled out at three of sa’s eight health sciences faculties, are now at work and a recent evaluation2 has confirmed the success of this educational strategy in boosting health delivery personnel. draper et al.3 describe development of a standardised patient programme in the primary healthcare-orientated mb chb curriculum that has been in place for the last decade at the university of cape town. they describe the usefulness of such a programme as a stepping stone to ‘real’ patient interaction in the third year for second-year students who currently have no ward or clinician time. oltmann4 describes use of aspects of bernstein’s pedagogic device to review and re-align the pharmacy curriculum at rhodes university while colleagues srinivas and wrench5 of the school of pharmacy at the same institution describe an innovative service-learning elective aimed at teaching final-year pharmacy students about the key role they can play in health promotion in a country – mirroring those in the rest of the continent, where there is double jeopardy in the burden of disease borne by the populace in the form of infectious disease and non-communicable disease. the importance of e-learning in serving sa’s future dentists, facilitating learning in paediatric dentistry, is highlighted and evaluated in the paper by mohamed and peerbhay6 of the university of the western cape. the need to assist radiographers in achieving qualifications in the specialised radiology fields that characterise modern radiological diagnosis and ways to achieve this is the substance of an elegant qualitative and quantitative study by du plessis et al.7 of the central university of technology, bloemfontein. finally, since progress in healthcare depends on research, a single faculty’s strategy to develop research capacity is elegantly outlined in the report from frantz8 of the department of physiotherapy, university of the western cape. and madzima et al.9 describe the creation of a rich pilot course, tailored for africa and aimed at offering junior oncology professionals (trainees and junior staff ) training-in-context in research methods, data management and statistics. lastly, colleagues will be delighted to share in the good news that ajhpe has been accredited for inclusion in the department of higher education and training’s approved list of south african journals. 1. hugo jfm, slabbert j, louw jm, marcus ts, du toit ph, sandars je. the clinical associate curriculum – the learning theory underpinning the bcmp programme at the university of pretoria. african journal of health professions education 2012;4(2):128-131. [http://dx.doi.org/10.7196/ajhpe.188]. 2. doherty j, couper i, fonn s. will clinical associates be effective for south africa? s afr med j 2012;102(11):833835. [http://dx.doi.org/10.7196/samj.5960] 3. draper ce, moller n, aubin l, edelstein g, weiss r. developing a standardised patient programme in a primary healthcare curriculum: a needs analysis. african journal of health professions education 2012;4(2):97-101. [http://dx.doi.org/10.7196/ajhpe.170] 4. oltmann c. using aspects of bernstein's pedagogic device to review and re-align the pharmacy curriculum at rhodes university. african journal of health professions education 2012;4(2):96. [http://dx.doi.org/10.7196/ ajhpe.103] 5. srinivas sc, wrench ww. evaluation of a service-learning elective as an approach to enhancing the pharmacist's role in health promotion in south africa. african journal of health professions education 2012;4(2):107-111. [http://dx.doi.org/10.7196/ajhpe.108] 6. mohamed n, peerbhay f. introducing dental students to e-learning at a south african university. african journal of health professions education 2012;4(2):123-127. [http://dx.doi.org/10.7196/ajhpe.179] 7. du plessis j, friedrich-nel h, van tonder f. a postgraduate qualification in the specialisation fields of diagnostic radiography: a needs assessment. african journal of health professions education 2012;4(2):112-117. [http:// dx.doi.org/10.7196/ajhpe.160] 8. frantz jm. a faculty development strategy among academics to promote the scholarship of research. african journal of health professions education 2012;4(2):118-122. [http://dx.doi.org/10.7196/ajhpe.177] 9. madzima tr, abuidris d, badran a, et al. a pilot course for training-in-context in statistics and research methods: radiation oncology. african journal of health professions education 2012;4(2):102-106. [http://dx.doi. org/10.7196/ajhpe.157] ajhpe 2012;4(2):95. doi:10.7196/ajhpe.206 human resource challenges in healthcare delivery in african communities janet seggie editor, samj 60 may 2014, vol. 6, no. 1 ajhpe research against the backdrop of current emerging and re-emerging diseases, there is a need for accurate and prompt clinical and laboratory diagnosis. the recognition of new infectious agents, the global emergence of antimicrobial resistance and the potential for acts of bioterrorism stress the need for the continuous improvement of laboratory personnel’s knowledge. laboratory medicine is pivotal to the effective management of disease, playing a role in 60 70% of decisions related to hospital admission, prescribed medication and discharge of patients.[1] this dependence on laboratory data places the medical laboratory scientist in a prime position with regard to the management and care of patients. one of the major challenges for improving healthcare programmes in sub-saharan africa is the lack of quality laboratory services, mainly due to the limited availability of well-trained technical and managerial laboratory personnel.[2] critical to achieving the united nations millennium development goals is the improvement of healthcare workers’ performance.[3] continued professional development is generally understood to be crucial for the development and improvement of the quality of healthcare delivery services.[4] training of healthcare workers is an important motivating factor, and is also associated with improved performance of clinical procedures.[5,6] in-service training is important for better performance and could either employ an on-site or off-site training module.[7] it is recognised as a key means by which staff are provided with the necessary knowledge and skill to improve overall institutional performance and achieve the objectives of the organisation.[8] in-service training is expected to be conducted regularly and to involve different categories of workers of an organisation so that their skills contribute to the attainment of the organisational goals or objectives.[8] although management experts and the nigerian government have identified the importance of training and development in various white papers, these goals of the public service have mostly not been achieved.[9] findings from a nigerian study involving healthcare workers in nine public primary healthcare centres in a local government area showed that none of them had received in-service training during the 2 years before the study.[10] the situation is unlikely to be any different in the private sector in nigeria. while medical laboratory scientists in nigeria play an important role in qualitative healthcare delivery, little is known about the extent, type and focus areas of their in-service training. the present study aimed to determine the proportion of medical laboratory scientists with in-service training in benin city, nigeria, and in the areas covered by such training programmes. methods study population practising medical laboratory scientists (n=127) (42 males and 85 females) were recruited for this study. seventy-nine participants were from the public sector and the remaining 48 from the private sector, all of them having >1 year post-qualification work experience. a detailed questionnaire (appendix 1) was used to obtain relevant information from study participants. in-service training included all onand off-site training received. informed consent was obtained from all participants prior to completion of the questionnaire. background. training and re-training of healthcare workers is pivotal to improved service delivery. objective. to determine the proportion of practising medical laboratory scientists with in-service training in benin city, nigeria and areas covered by these programmes. methods. medical laboratory scientists from benin city (n=127) (public (n=79) and private (n=48) sectors) were recruited for this study. a detailed questionnaire was used to obtain relevant information from all enlisted participants. results. eighty-four (66.1%) of all medical laboratory scientist volunteers (n=127) reported to have attended an in-service training programme. this was significantly associated with gender (male v. female: 80.9% v. 58.8%; odds ratio (or) 6.071; 95% confidence interval (ci) 2.510 14.685; p<0.0001). only 9/84 (10.7%) participants reported to have had at least one in-service training session during the last 12 months. attendance was significantly affected by qualification (p=0.029), area of specialisation (p=0.003) and affiliation (p=0.005). irrespective of affiliation, self-sponsorship of in-service training programmes was most frequently reported by study participants. training received by respondents was mainly in instrumentation and diagnostic techniques. conclusion. attendance of in-service training programmes during the last 12 months was poor. training programmes were mostly funded by participants. regular training of medical laboratory scientists by the relevant authorities and agencies is advocated. ajhpe 2014;6(1):60-63. doi:10.7196/ajhpe.268 continuous professional training of medical laboratory scientists in benin city, nigeria b h oladeinde,1aimls, msc; r omoregie,2 msc, mphil; i odia,3aimls; e o osakue,4 aimls, bmls 1 department of medical microbiology, college of health sciences, igbinedion university, okada, edo state, nigeria 2 school of medical laboratory sciences, university of benin teaching hospital, benin city, edo state, nigeria 3 institute of lassa fever research and control, irrua specialist hospital, irrua, edo state, nigeria 4 department of pathology, igbinedion university teaching hospital, okada, edo state, nigeria corresponding author: b h oladeinde (bamenzy@yahoo.com) mailto:bamenzy@yahoo.com may 2014, vol. 6, no. 1 ajhpe 61 study approval was obtained from the edo state ministry of health, benin city, nigeria. statistical analysis data were analysed using the chi-squared and odds ratio (or) tests graphpad instat. statistical significance was set at p<0.05. results a total of 84/127 (66.1%) medical laboratory scientists reported to have attended an in-service training programme. attendance was significantly associated with gender (male v. female: 80.9% v. 58.8%; or 6.071; 95% confidence interval (ci) 2.510 14.685; p<0.0001). only 9/84 (10.7%) participants with training reported to have had attended at least one training programme during the 12 months before the study (table 1). participants working in public institutions and those with phd degrees were significantly more likely (p=0.005 and p=0.029, respectively) to have undergone continuous professional training activities. with regard to area of specialisation, medical microbiologists were significantly more likely (p=0.003) to have been engaged in in-service training (table 2). self-sponsorship of in-service training programmes was the most prevalent among respondents (table 3). training was largely in the area of instrumentation and diagnostic techniques (table 4). research table 1. medical laboratory scientists with in-service training characteristics participants, n with training, n (%) or 95% ci p-value ever received training male 42 34 (80.9) 6.071 2.510 14.685 <0.0001 female 85 50 (58.8) 0.165 0.068 0.398 received training in last 12 months male 34 3 (2.9) 0.709 0.165 3.057 0.733 female 50 6 (12.0) 1.409 0.327 6.070 or = odds ratio; ci = confidence interval. table 2. in-service training of medical laboratory scientists with regard to qualification, specialisation and affiliation characteristics participants, n with training, n (%) or 95% ci p-value highest qualification aimls 57 42 (73.6) 6.071 0.029 bmls 42 21 (50.0) 0.165 msc 23 16 (69.5) phd 5 5 (100.0) area of specialisation medical microbiology 62 49 (79.0) 0.709 0.003 chemical pathology 39 17 (45.9) 1.409 haematology 22 16 (72.7) histopathology 4 2 (50.0) affiliation public institutions 79 60 (75.9) 3.158 1.468 6.792 0.005 private institutions 48 24 (50.0) 0.317 0.147 0.681 or = odds ratio; ci = confidence interval; aimls = associate of the institute of medical laboratory science; bmls = bachelor of medical laboratory science; msc = master of science; phd = doctor of philosophy. table 3. sponsorship of training programme with regard to affiliation of medical laboratory scientists training characteristics participants with training, n employer, n (%) self, n (%) ngo, n (%) affiliation public institutions 60 12 (20.0) 48 (80.0) 13 (21.7) private institutions 24 1 (4.2) 22 (92.7) 2 (8.3) total 84 13 (15.5) 70 (83.3) 15 (17.9) ngo = non-governmental organisation. 62 may 2014, vol. 6, no. 1 ajhpe discussion a major challenge in improving healthcare programmes in sub-saharan africa is the lack of quality laboratory services. this is mainly due to the limited availability of well-trained technical and managerial laboratory personnel.[2] the human resources crisis in the healthcare sector in lowand middle-income countries is currently receiving increased global attention.[3] to the authors’ knowledge, this is the first study to assess continuous professional training received by practising medical laboratory scientists working in the public and private sectors in nigeria. irrespective of area of specialisation, 84 (66.1%) of all medical laboratory scientists participating in this study reported to have received in-service training. however, only 9 (10.7%) participants with such training had attended a course during the 12 months before the study. this is less than the 94.7% reported in a malawian study among a group of healthcare workers comprising nurses, medical assistants, clinical officers, a laboratory technician and a dental therapist.[4] in recent years, clinical procedures have undergone tremendous changes in that manual handling of samples has gradually given way to an automated approach in many clinical laboratories. issues relating to risk assessment, procedures for safe use of recombinant dna technology and transport of infectious materials have also been updated.[11] although a fair number of respondents (84 (66.1%)) reported to have participated in continuous professional training, the number with such training during the 12 months prior to this survey was poor, which may represent gaps in knowledge of current diagnostic and managerial laboratory techniques. gender was associated with attendance of in-service training, with male respondents being 3 15 times more likely than female respondents to have ever received training. in-service training, depending on whether it employs an onor off-site training module, can be both expensive and time consuming. female respondents in this study, apart from their professions, are very likely to be homekeepers and mothers and may therefore, owing to domestic pressures, not readily engage in continuous professional training. however, more females than males had received some form of training in the last 12 months, even though the difference failed to reach statistical significance. this may be related to the current advocacy on women empowerment. in nigeria, the first generation of medical laboratory scientists was given the professional qualification aimlt or aimls (associate of the institute of medical laboratory technology of nigeria), which is equivalent to a degree. however, current medical laboratory science graduates from various nigerian universities are awarded the bmls (bachelor of medical laboratory science). the development of the medical laboratory science profession in nigeria has closely followed the same pattern as in the uk. respondents with bmls degrees in this study were significantly less likely (p=0.029) to have been engaged in continuous professional training. professional development opportunities for health workers in nigeria are limited.[12] recipients of the bmls degree (first degree) are unarguably younger professionals, as the awarding of this degree is a recent development in nigeria. such respondents are therefore more likely to occupy the lower ranks in laboratories and receive smaller monthly wages. they may therefore not enjoy favourable consideration for selection in training programmes compared with senior colleagues and may also lack the financial ability to undertake such a programme with self-sponsorship. with regard to specialisation, medical microbiologists were significantly more likely (p=0.003) to have been involved in in-service training than other laboratory staff. infectious diseases account for the majority of deaths in sub-saharan africa.[13] many local and international intervention agencies have focused on diagnosis, prevention and treatment of these diseases, with frequently organised seminars and workshops for healthcare workers and the general public. this emphasis on infectious disease, which falls within the domain of the medical microbiologist, may be responsible for the observed trend in this study. respondents working in the public sector were observed to be significantly more likely (p=0.005) to have received in-service training than those in the private sector. the public sector is run and funded by the government of nigeria, which allocates significant annual funds to its operations. healthcare workers in this sector may therefore enjoy comparatively better funding with regard to workshops and seminars than those in the private sector, which may have accounted for the observations made in this study. irrespective of affiliation of respondents, involvement of employers in providing sponsorship for training programmes for medical laboratory scientists was the least observed. self-sponsorship was the most common form of funding for in-service training events reported. this may again explain the poor attendance of training programmes during the 12 months prior to this survey. despite the recognition of the importance of training by management experts and government, as expressed in white papers on various reforms in nigeria, the experience of manpower training and development in the nigerian public service has been one of more ruse and waste.[9] consequently, many workers in nigeria, because of limited opportunities for continuous professional development, may have taken their destinies in their own hands to self-fund and engage in personal training to increase their skills. needs assessment of laboratory staff and laboratory operations is vital for customising training content.[2] the generation of data through disease surveillance and notification systems is critical for appropriate planning, disease-outbreak investigations, emergency preparedness and responses.[14] the trend observed in this study, where management's input in training programmes was minimal, may not translate to improved service delivery, as training sought and obtained may not be tailored to the specific needs of the time, organisation and community. participants who sponsored their own training programmes may also be unwilling to transfer acquired knowledge to other co-workers to personally remain indispensable in a specific work area. there is a need for increased involvement of management in the articulation and sponsorship of in-service training programmes for medical laboratory scientists. research table 4. specific areas of training received by medical laboratory scientists variables participants with training, n (%) training areas received instrumentation and diagnostic techniques 34 (40.5) laboratory biosafety 13 (15.5) internet and computer technology 12 (14.3) prevention of hospital-acquired infection 17 (20.2) quality assurance 3 (3.6) may 2014, vol. 6, no. 1 ajhpe 63 training was mostly received in the area of instrumentation and diagnostic techniques. the provision of accurate and prompt diagnosis of diseases can be greatly enhanced by increased knowledge in novel diagnostic technologies. for example, the recognition of new infectious agents and the global emergence of antimicrobial resistance make this investment justifiable. sadly, however, emphasis on such areas as biosafety and quality assurance was low. the safety of laboratory personnel working in diagnostic laboratories is critical in ensuring the continued delivery of laboratory services. safety training programmes are essential in maintaining safety awareness among laboratory and support staff.[11] laboratory quality assurance has been summarised as the total process that guarantees the right result, at the right time, on the right specimen, from the right patient, at the right price.[15] this includes procedures beyond the analytical phase of laboratory testing such as collection of appropriate specimens and registration of specimens to clear reporting of results, cutting across preanalytical, analytical, post-analytical and managerial aspects of laboratory organisation. poor emphasis on training in such critical areas such as quality assurance may undo the impact of other training received and jeopardise quality of test results, as mistakes from analytical procedures alone have been reported to account for a minimal percentage of errors in the clinical laboratory testing process.[16,17] conclusion in summary, 84/127 (66.1%) volunteer medical laboratory scientists reported to have attended an in-service training programme. however, the percentage of volunteers who received training during the 12 months prior to the survey was poor, as was employers’ involvement in training needs of laboratory workers. adequate assessment of training needs and effective criteria for the selection of training participants are crucial to the success and overall impact of laboratory service delivery. there is a need for strengthening of laboratory capacity by increasing the emphasis on the training needs of laboratory personnel by the relevant authorities and agencies. intervention and donor agencies such as the us presidential emergency plan for aids relief (pepfar), which are involved in the strengthening of laboratory capacity, can provide funds and other training needs to build the capacity of laboratory personnel in nigeria. acknowledgement. the authors thank all laboratory scientists who participated in this study. references 1. oladeinde bh, omoregie r, osakue eo, onifade aa. evaluation of laboratory request forms for incomplete data at a rural tertiary hospital in nigeria. n z j med lab sci 2012;66:39-41. 2. marinucci f, medina-moreno s, wattleworth m, paterniti ad, redfield r. new approach to in-service training of laboratory professionals in sub-saharan africa. int j biomed lab sci 2011;1:1-6. 3. dieleman m, gerretsen b, van der wilt jg. human resource management interventions to improve health workers’ performance in low and middle income countries: a realist review. health res pol sys 2009;7:7. [http:// dx.doi.org/10.1186/1478-4505-7-7] 4. muula as, misiri h, chimalizeni y, mpando d, phiri c, nyaka a. access to continued professional education among health workers in blantyre, malawi. afr health sci 2004;4(3):182-184. 5. henderson ln, tulloch n. incentives for retaining and motivating health workers in pacific and asian countries. hum resour health 2008;6:18 [http://dx.doi.org/10.1186/1478-4491-6-18] 6. dubois c, singh d. from staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. hum resour health 2009;7:87 [http://dx. doi.org/10.1186/1478-4491-7-87] 7. oyitso m , olomukoro co. training and retraining nigerian workers to enhance task performance. interdiscipl j contemp res bus 2010;4(1):69-77. 8. danso h, adu mk, twum-ampomah mk, mprah rk. evaluation of in-service training for senior staff in a public university in ghana. j edu pract 2012;3(7):6-104. 9. okotoni o, erero j. manpower training and development in the nigerian public service. ajpam 2005;16(1):2-13. 10. mohammed as, idowu ie, kuyinu ya. structure of primary health care: lessons from a rural area in south-west nigeria. nigerian j clin med 2010;3(1):17-24. [http://dx.doi.org/10.4314%2fnicm.v3il.56576] 11. world health organization. laboratory biosafety manual. 3rd ed. geneva: who, 2004. http://www.who.int/csr/ resources/publication/biosafety/biosafety7/pdf (acessed 12 march 2013). 12. uneke c, ogbonna a, ezeoha a, oyibo p, onwe f, ngwu b. innovative health research group: the nigerian health sector and human resource challenges. the internet j health 2008;8(1):1-11. [http://dx.doi.org/10.5580/ d5a] 13. young f, critchley j, johnstone lk, unwin nc. a review of co-morbidity between infectious and chronic disease in sub-saharan africa: tb and diabetes mellitus, hiv and metabolic syndrome and the impact of globalization. globaliz health 2009;5:9. [http//dx.doi.org/10.1186/1744-8603-5-9] 14. bawa sb, olumide ea. the effect of training on the reporting of notifiable diseases among health workers in yobe state, nigeria. niger postgrad med j 2005;12(1):1-5. 15. arora dr. quality assurance in microbiology. indian j med microbiol 2004; 22(2):81-86. 16. bonini p, plebani m, ceriotti f, rubboli f. errors in laboratory medicine. clin chem 2002;48:691-698. 17. plebani m, carraro p. mistakes in a stat laboratory: types and frequency. clin chem 1997;43:1348-1351. research this exercise is aimed at assessing the type and frequency of in-service training received by medical laboratory scientists in benin city. your candid opinion on questions asked is highly solicited to guarantee the exactness of our conclusions. participants and affiliation confidentiality will be maintained. 1. gender ___________________________________________________ 2. area of specialisation _____________________________________________________________________________________________________________ 3. year of first degree in medical laboratory sciences ________________ 4 . highest academic/professional qualification with date (year) _____________________________________________________________________________ 5. type of affiliation ☐ public institution ☐ private institution 6. ever had training on your job? ☐ yes ☐ no 7. place of training ☐ within organisation ☐ outside organisation 8. specify areas of training received ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ 9. had training in the last year? ☐ yes ☐ no 10. sponsor of training programmes received (please indicate all sponsors of training programme) ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ appendix 1. questionnaire http://dx.doi.org/10.1186/1478-4505-7-7] http://dx.doi.org/10.1186/1478-4505-7-7] http://dx.doi.org/10.1186/1478-4491-6-18] http://dx.doi.org/10.1186/1478-4491-7-87] http://dx.doi.org/10.4314%2fnicm.v3il.56576] http://www.who.int/csr/ http://dx.doi.org/10.5580/d5a] http://dx.doi.org/10.5580/d5a] the ajhpe is published by the health and medical publishing group. the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. fax (021) 681-7099. e-mail: publishing@hmpg.co.za editor vanessa burch deputy editor juanita bezuidenhout editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor-in-chief janet seggie editor emeritus daniel j ncayiyana managing editor j p de v van niekerk deputy editor bridget farham assistant editor emma buchanan technical editors marijke maree robert matzdorff melissa raemaekers taryn skikne paula van der bijl head of publishing robert arendse production manager emma couzens art director siobhan tillemans dtp & design carl sampson anelia du plessis online manager gertrude fani hmpg board of directors m veller (chair) r abbas m lukhele d j ncayiyana j p de v van niekerk issn 1999-7639 ajhpe african journal of health professions education december 2012, vol. 4 no. 2 editorial 95 human resource challenges in healthcare delivery in african communities j seggie abstract 96 using aspects of bernstein’s pedagogic device to review and re-align the pharmacy curriculum at rhodes university c oltmann articles 97 developing a standardised patient programme in a primary healthcare curriculum: a needs analysis c e draper, n moller, l aubin, g edelstein, r weiss 102 a pilot course for training-in-context in statistics and research methods: radiation oncology t r madzima, d abuidris, a badran, m boshoff, t erlwanger, n tsikai, g w jones 107 evaluation of a service-learning elective as an approach to enhancing the pharmacist’s role in health promotion in south africa s c srinivas, w w wrench 112 a postgraduate qualification in the specialisation fields of diagnostic radiography: a needs assessment j du plessis, h friedrich-nel, f van tonder 118 a faculty development strategy among academics to promote the scholarship of research j m frantz 123 introducing dental students to e-learning at a south african university n mohamed, f peerbhay 128 the clinical associate curriculum ‒ the learning theory underpinning the bcmp programme at the university of pretoria j f m hugo, j slabbert, j m louw, t s marcus, p h du toit, j e sandars cpd 132 cpd questionnaire � december 2009, vol. 1, no. 1 ajhpe article it is well known that in the event of a person suffering a cardiac arrest, successful outcome is dependent on the time taken for resuscitation to commence.1 in cases of in-hospital cardiac arrest the most important predictor of a successful outcome is the ‘time to defibrillation’ interval.2 although all health care providers in contact with patients should be proficient at basic life support (bls), nurses in particular should be competent at bls, being the health care providers most likely to be the first respondents to an in-hospital cardiac arrest.3 bls proficiency includes the use of an automated external defibrillator (aed)4 and it is therefore expected that nurses trained in bls should be able to use this device. bls knowledge and skills tend to degrade and regular refresher training and practice is recommended.5 despite these international guidelines, studies have shown that, in the developed world, nurses’ bls skills can be surprisingly poor.6,7 no studies in the south african environment have yet been published with regard to bls competency among nursing staff. we decided to investigate bls competence among nursing staff at our hospital – a tertiary level teaching hospital – as a precursor to the implementation of a cardiac arrest team for this institution. for the cardiac arrest team to be effective, it was vital that the first respondents, i.e. the nursing staff, were bls competent. if lack of competence were to be shown, then further education and training would be required to improve the chances of survival after cardiac arrest at this hospital. method approval for the study was obtained from the ethics committee of the faculty of health sciences, university of the free state, and from the clinical head of universitas hospital, bloemfontein. the study was a cross-sectional survey and participation was voluntary and confidential. a questionnaire was designed by the authors and consisted of 19 questions divided into two sections: the first section (questions 1 10) dealt with the individual’s level of experience and access to bls training. the second section (questions 11 19; table i) tested their clinical a survey of nurses’ basic life support knowledge and training at a tertiary hospital m keenan, mb chb, da, registrar, department of anaesthesiology g lamacraft, mb bs, da, mrcp (uk), frca (uk), professor, department of anaesthesiology g joubert, ba, msc, associate professor, department of biostatistics university of the free state corresponding author: m keenan (michellekeenan@telkomsa.net) table i. questions used in the clinical knowledge section of the questionnaire question number question correct answer 11 you are walking past a patient’s room check the patient for responsiveness during visiting hours and are called by a relative who says that the patient has just collapsed. what should you do first? 12 if the patient is found to be unconscious, send someone for help while you open what should you do? the airway of the patient 13 how can you establish if the patient is breathing? look for chest expansion and feel for movement of air against your face 14 once you realise that the patient is unresponsive give 2 effective breaths and not breathing, what should the next step be? 15 while giving rescue breathing, which of the the chest rises while you are giving the breath following indicates that an adequate breath is received by the patient? 16 when are chest compressions indicated? when the patient has no pulse 17 where is the best site to assess the pulse? the carotid pulse 18 what is the ratio of chest compressions to 30 compressions to 2 breaths breaths that should be given to an adult in cardiac arrest if you are alone during the resuscitation? 19 what is the most important determinant of time from collapse to defibrillation survival in cardiac arrest patients? article � december 2009, vol. 1, no. 1 ajhpe article  fig. 1. adult bls health care provider algorithm, resuscitation council of south africa. 8 � december 2009, vol. 1, no. 1 ajhpe article knowledge of bls techniques. this section was presented as actual clinical scenarios and was based on information presented in the handbook bls for healthcare providers published by the american heart association (aha) in 2006.3 the bls algorithm for health care providers as published by the resuscitation council of south africa in 2006 was also used for reference, as shown in fig. 1 (reproduced without alteration with permission from the resuscitation council).8 the questionnaire was distributed on a single day to all nurses working in the wards, theatres and outpatient departments via the relevant unit managers. participation in the survey was completely voluntary and anonymous, and respondents were asked to complete it by ticking the most correct answer for each question. the completed questionnaires were collected later the same day by the researcher. results were summarised using frequencies and percentages. subgroups were compared using the chi-squared or fischer’s exact test as appropriate. results questionnaires were completed by 338 of the 405 nursing personnel on duty that day (83.4% response rate). administrators, student nurses and incomplete questionnaires were excluded, leaving a final sample size of 286 nurses. table ii shows the categories of nursing staff who participated in the study as determined by their qualification. for analysis the participants were divided into junior and senior staff based on their qualification. junior staff members included enrolled and auxiliary nurses and senior staff members included professional nurses, senior professional nurses and chief professional nurses. of the total sample group, 15.8% nurses indicated that they worked in a icu/high-care setting. this was of particular relevance in our setting as an icu sister will be allocated as one member of the cardiac arrest team. in the icu setting the staff consisted of 93.2% senior staff (i.e. professional nurse or higher qualification) and 6.8% junior staff. in the other areas there were almost equal numbers of junior and senior staff. a mark of at least 80% is the pass mark for the bls training course accredited by the aha. correct answers to 80% of the clinical resuscitation questions were given by 11% of respondents (fig. 2). as shown in fig. 3, four questions in the clinical knowledge section (i.e. questions 11 19 of the questionnaire) were answered particularly poorly. these were questions 14, 16, 18 and 19 respectively. one hundred and thirty-four nurses (47.0%) answered question 14, ‘once you realise that the patient is unresponsive and not breathing what should the next step be?’, correctly. the most common incorrect answer chosen was ‘start chest compressions immediately’. one hundred and seventy-two nurses (61.2%) answered question 16, ‘when are chest compressions indicated?’, correctly. the most common incorrect answer chosen was ‘when the patient is unresponsive’. seventy-eight nurses (27.7%) answered question 18, ‘what is the ratio of chest compressions to breaths that should be given to an adult in cardiac arrest if you are alone during the resuscitation?’, correctly. the most frequently chosen incorrect answer was ’15 compressions to 2 breaths’. twenty of the nurses (7.3%) answered question 19 correctly. this question dealt with the significance of defibrillation in a resuscitation. the most common incorrect answer was ‘time from collapse to starting chest compressions’. the outcomes for the clinical knowledge questions of the staff working in icu/high care were compared with those outcomes of the staff working in others areas of the hospital (fig. 4).           percentage of respondents to achieve pass mark fig. 2. percentage of respondents to achieve a pass mark. table ii. nursing qualifications of participants respondents staff qualification number percentage chief professional nurse 86 30.3 senior professional nurse 32 11.3 professional nurse 39 13.7 enrolled nurse 39 13.7 auxiliary nurse 88 30.8                            fig. 3. percentage of correct answers for each clinical question. article � december 2009, vol. 1, no. 1 ajhpe article question 12, regarding the unresponsive patient, was answered worse by the staff from icu compared with the staff in other areas; 70.5% v. 85% (p=0.0196). the most commonly chosen incorrect answer here was ‘to begin chest compressions’. in contrast, the icu staff achieved better outcomes in question 15: ‘while giving rescue breathing, which of the following indicates that an adequate breath is received by the patient?’, compared with staff from other hospital areas; 93.2% v. 81.1% (p=0.0505). the most common incorrect answer chosen by staff working in other areas of the hospital was ‘the pulse returns to normal’. both groups achieved similar outcomes for the remaining questions in the clinical knowledge section. a total of 76.5% of the nurses reported that they had had access to bls training before receiving their nursing qualification. there was a similar trend seen in access to bls training received by nurses post qualification, with 77.5% reporting that they had access to courses. of the 22.5% who reported no access to courses post qualification, 36 nurses also stated that they had not had access to bls training before receiving their qualification. hence, one may conclude that these 36 nurses (13.2%) have never been trained in basic resuscitation. there were differences with regard to access to training courses. of the junior nurses 73.6% had had access to bls courses compared with 81.1% of the senior staff. of those nurses who had had access to bls courses during their employment, 175 (93.1%) had attended, 60.9% within the last year. the most common reason given for not attending a training course was that they had been too busy with their daily duties. other reasons specified were staff shortages and one participant stated that only those qualified as professional nurses or more senior were eligible. one hundred and ninety-one nurses (68%) said that they had received training in the use of a defibrillator or aed for a resuscitation. however, of this group, only 15 nurses (8.2%) answered the clinical defibrillation question correctly. discussion this study gives insight into possible shortcomings in bls knowledge levels and training at a tertiary-level hospital in south africa. the practical aspect of bls, i.e. the clinical skills of the participants, were not assessed, and further studies are needed to explore this area. other limitations include the fact that reference material may have been used and participants could have worked together to answer the clinical knowledge questions, thereby influencing the accuracy of the results. the questionnaire was made available on one morning only and collected the same day to limit this, and only the nursing managers were aware that the study was to take place. we also did not determine whether participants had a degree or diploma in nursing. this should not be relevant as all nurses should be competent in bls. the study was anonymous and voluntary. however, those people who felt that their bls knowledge was inadequate, may have felt too intimidated to complete a questionnaire. the questionnaire was distributed to all nursing staff on duty in order to obtain as large a sample group as possible. the current pass mark for the bls course accredited by the aha, on which the clinical questions were based, is 80%. this course presents and tests up-to-date, evidence-based protocols and techniques. only 11.0% of the participants in this study achieved a pass mark. this is alarming in view of international recommendations that stress the mandatory maintenance of competency in bls skills for health care providers.2,3 ‘time from collapse to defibrillation’ has been accepted internationally as the most important variable in improving patient outcome, and should be performed by the first responder.3 this was poorly understood by the staff surveyed. and, in addition, 88 nurses, or 32%, indicated that they had never received any training in the use of a defibrillator. in order to reduce the time delay to defibrillation it is essential to train all possible first respondents in defibrillator use. with regard to nursing staff it should ideally become a routine skill and recognised as accepted nursing procedure.5 this study showed that the icu staff scored worse than the general staff in question 12 in the clinical knowledge section that dealt with the correct response to an unresponsive patient. this problem with question 12 could be due to the majority of their patients already being sedated and intubated. however, in view of the severely ill nature of the patients that they are caring for, it was expected that the knowledge of bls would be better than that of the general ward staff. indeed, the hospital cardiac arrest team is to include an icu nurse based on the presumption that they are more proficient in bls. access to undergraduate bls training was reported at 76.5%. this is unacceptably low as all health care providers should have this knowledge before graduating in their field. this is a finding that nursing educators need to investigate further. it also reiterates the need for continuing medical education. training provided by the employer can supplement this. especially concerning is that 36 of the nurses who indicated that they had not received bls training after receiving their qualification also reported no bls training during their studies. this highlights a possible major shortcoming in training that needs to be addressed. over three-quarters (77.5%) of the nurses indicated that they had had an opportunity to attend a postgraduate bls training course. of concern was the apparent discrepancy between the access to training with regard to level of seniority. a high percentage of nurses who had had access to courses had actually attended. yet only 60.9% of those had attended a course recently, i.e. within the last year. this is not in keeping with international recommendations. retention of cpr skills has been shown to be poor5 and the need for frequent updates should be emphasised. refresher training is recommended every 6 -12 months.2                             fig. 4. comparison of outcomes for each clinical question between staff working in icu/high care and other areas. � december 2009, vol. 1, no. 1 ajhpe article the most common reason given for not attending a bls course was that the participant was too busy with their daily duties. this could also be an indication that the participants or their unit managers did not place bls as a priority in their continuing medical education. staff shortages were highlighted as another factor, as well as the failure to offer courses to junior staff members. we compared our findings with a similar study published in nursing standard in 1993. it also used a questionnaire to test a group of uk nurses’ theoretical knowledge of basic life skills, based on the resuscitation council of the uk recommendations at the time.6 this survey also found poor knowledge in the sample population, as well as poor access to training. only 24% of their participants had received bls training within the last year. it was encouraging to see that this compares favourably to our setting in which 60.9% of our respondents who had had access to training indicated that they had attended a course within the last year. we hope that the introduction of a cardiac arrest team at this hospital will improve retention of bls knowledge by our nursing staff. by actively participating in the team our nurses will be performing bls more often and will gain the confidence and skills necessary to improve competence. conclusion despite a relatively good rate of attendance at recent bls courses, a significant number of nurses remain without any such training. although having received training, few nurses have retained the bls knowledge required for competency. action is needed to ensure all nurses receive bls training and practise this skill regularly in order to retain their knowledge. acknowledgements all nursing staff who participated in the survey. matron mabandla for her time and willingness to answer questions. references 1. cummins ro, sanders a, mancini e, hazinski mf. in hospital resuscitation. a statement for healthcare professionals from the american heart association emergency cardiac care committee and the advanced cardiac life support, basic life support, pediatric resuscitation, and program administration subcommittees. circulation 1997; 95(8): 2210-2212. 2. colquhoun m, gabbot d, mitchell s. cardiopulmonary resuscitation guidance for clinical practice and training in primary care. uk: resuscitation council, july 2001: 2-4. 3. coady em. a strategy for nurse defibrillation in general wards. resuscitation 1999; 42: 183-186. 4. hazinski mf, gonzales l, o’neill l. bls for healthcare providers student manual. american heart association 2006: 9-15. 5. finn jc, jacobs ig. cardiac arrest resuscitation policies and practices: a survey of australian hospitals. mja 2003; 179: 470-474. 6. crouch r, graham l. resuscitation. nurses skills in basic life support: a survey. nursing standard 1993; 7(20): 28-31. 7. nyman j, sihvonen m. cardiopulmonary resuscitation skills in nurses and nursing students. resuscitation 2000; 47(2): 179-184. 8. resuscitation council of south africa. basic life support for healthcare providers (adult and child), 2006. http://www.resuscitationcouncil.co.za/algpage3.pdf (accessed 28 january 2009). article 9 december 2011, vol. 3, no. 2 ajhpe introduction biomedical research is a powerful tool for solving health challenges in developing regions. the present study is aimed at describing the needs of biomedical science training in africa from the experience of young african scientists at home and in the diaspora. a total of 107 young scientists were recruited through existing international networks and interviewed via a web-based program, on the current status of biomedical research in their different institutions, as well as the major obstacles faced and their aspirations. this survey revealed that although considerable efforts have been made in strengthening research capacity in africa, much remains to be done. biomedical research in africa is seriously hindered by obstacles such as lack of infrastructure, expertise, energy supply, institutional support and financial support from governments. we encourage applied research and public-private partnership to foster implementation of research findings into goods and services for public benefit. background with the disproportionately large share of the global burden of communicable and non-communicable disease in sub-saharan africa, one would expect that the solutions to these problems be home-grown. unaccountably, the capacity for this is grossly lacking. an overwhelming majority of african countries fall well below the average on standard indices of science and technology capacity.1 the infrastructural and legislative environment in many african countries is not conducive to research.2 moreover, over the years, africa has witnessed a steady loss of university staff, which has led to low scientific research output, weak preparation of the next generation of african biomedical scientists, and doubt about the capacity of african universities to produce globally competitive graduates.3,4 biomedical research is a powerful tool for solving health challenges. therefore various initiatives are underway to strengthen biomedical research capacity in africa.1,2,5,6 these activities are largely based on input from senior scientists in africa and abroad. in order to give voice to young african and african diaspora scientists on these issues build afreca! (build african research capacity), a global network of young scientists, was recently started. build afreca! represents africa’s rising pool of scientific talent. the present survey is the first effort at defining the needs of biomedical research training in africa and of africans. this study describes the needs of biomedical science training in africa from the experience of young scientists. the findings address policy makers, service providers, governments, academic institutions, and students to assess and strengthen capacity building in africa. methods the survey was based on voluntary, anonymous participation and involved 107 young scientists and postgraduate students from english and french-speaking africa, studying or working in africa or outside continent. participants were recruited through existing international networks like build afreca!, african network for drug and diagnosis innovation (andi), african regional groups of the student council of the international society for computational biology (rgsc-iscb) and central africa nutrition graduate students network (agsnet-central africa). the questionnaire was designed in english and french, based on participants’ identification, institution and research area, obstacles encountered with the research work, needs, career plan and preferences. the questionnaire was filled by the participants online, via the monkey survey web-based program (www.surveymonkey.com). data collected with each version of the questionnaire were summarised using the monkey survey tool and exported into excel 2007 format. answers from the french version were translated into english and the two datasets were merged before analysis. results were expressed as frequency distributions for each question, and correlation between variables assessed by cross-tabulation (pearson’s chi-square test p<0.05). the statistical analysis was conducted with spss version 17.0 and epi info version 3.5.0.0. the charts and tables were designed on microsoft office excel 2007. the needs of biomedical science training in africa: perspectives from the experience of young scientists denis zofou1, seye abimbola2, carmelle t norice3, moses samje4, zoumana isaac traore5, oyewale oyediran a6, chinedu oraka7, daudi mussa kadigi8 1 biotechnology unit, university of buea, cameroon 2 national primary health care development agency, abuja, nigeria 3 columbia university medical scientist training program, columbia university college of physicians and surgeons, new york, usa 4 department of biochemistry and microbiology, faculty of science, university of buea, cameroon 5 parasitic disease epidemiology department, faculty of medicine pharmacy and dentistry, malaria research and training center (mrtc), molecular epidemiology and drug resistance unit (medru), mali 6 department of phamacology, faculty of pharmacy, university of ibadan, nigeria 7 zeta-12 research group, nnamdi azikiwe university teaching hospital, nigeria 8 dod/geis-tpdf influenza surveillance program, general military hospital-lugalo dar es salaam, tanzania correspondence to: denis zofou (zofden@gmail.com) article 10 december 2011, vol. 3, no. 2 ajhpe results study participants, site and affiliation overall, 107 people participated in the study; 37.4% were female and 62.6% male and 77.5% were below the age of 40 years. all the four regions of sub-saharan africa took part in the survey in addition to those in the diaspora. the highest number of respondents were from west africa (46.7%) followed by central africa (21.5%) then east africa (15.9%). while 81.3% of the participants were residing in their country of origin, 18.7% were currently working or studying outside their home country. while 48.35% of the participants were affiliated to a university, and 21.98% to a university/teaching hospital, 13.19% worked in a government/national and 16.48% in a non-governmental research institute. table i summarises the distribution of research participants by position and region of residence. participants’ position depends strongly on the type of the institution (x2= 91.68, p=0.0004). skills and research output the study participants had publications in both local and international journals in a wide range of topics. respondents who have published in peer-reviewed journals were 30.21% while 26.04% have written a grant application wholly or in part. respondents had presented their work at international conferences (34.97%), national conferences (17.48%), departmental/institution seminars (27.97%) or at laboratory/journal club meetings (29.37%). in general, a significantly high proportion of students who had presented at seminars and conferences were those receiving financial support from their host institutions (x2= 51.122, p=0.0108). research area and needs research areas of the respondents range from epidemiology and drug discovery to immunological and molecular biology. most respondents conduct research on infectious diseases, especially those that are prevalent in sub-saharan africa. only 6.7% (confidence limits 2.2%, 14.9%) of the researchers were involved in clinical trials. research techniques and methods in use presently or in the future were a major cause of concern as expertise and unavailability of equipment is a shortcoming to a number of exciting projects. needs range from the lack of basic facilities such as a laboratory space to sophisticated equipment (fig. 1). lack of training was also a major need raised by the respondents and field of training required varied from one institution to another. when all the desired fields of training were put together, the need varied from basic good laboratory practice (glp) and good clinical practice (gcp) to biostatistics and biotechnology. most of the respondents preferred training to be in the form of internships at expert research laboratories while some preferred workshops and seminars in their laboratories/institutions by visiting scientists (33.06%). a major drawback to research as indicated by most of the respondents is frequent faculty/institution strikes. the research or academic study of up to 46.43% of the respondents had been perturbed by strikes ranging from 3 months to more than 4 years. delay in research as a result of strike was significant (p<0.05). work plan after research training varied widely. work stations chosen include public-private research institutions, ngos, and faculty at a university. a good number of the respondents preferred to work in africa (54.65%; confidence limits 23.3%, 48.0%), followed by north america (19.77%) then europe (16.28%). research funding and brain drain issues only 16.92% of researchers based in their home country receive 100% financial support from their host institution, 63.08% who are also based in their home country receive no financial support at all. there was a significant difference in proportion between researchers who received financial support and those who did not receive (x2=55.190, p=0.003). the consistency of the support also varies widely from one region to another (cramer’s v=0.375; p=0.018). the diaspora comes first with 66.67% of the researchers receiving more than 50% of support from their host institution, followed by east africa (50%), southern africa (25%) and west africa (12.5%), while only 15% of students from central africa receive 10% of financial support from their institution. consequently, they are bound to either sponsor their research or seek funding elsewhere. access to scientific papers was a nightmare to some of the respondents. only 20.48% of the respondents had full access to scientific publications. limiting factors include lack of internet access or connection problems, frequent power failure, and/or lack of money to cover the costs. of the respondents, 36.9% were out of their country of origin in pursuit of education. there was a preference for overseas studies because of better training by experts abroad, access to well-equipped laboratories, the quest for knowledge of a particular technique, and/or acquisition of scholarship and good assistantship. better working conditions coupled to job security or good pay package served as a driving force for some choosing foreign countries for studies. limited research facilities in their country of origin (35.71%), limited research funding (28.57%), unemployment despite the expertise (12.86%) and the opportunity to transfer skills to scientists in resource-limited countries (21.43%) were reasons why some researchers prefer to work abroad. discussion from this survey some positive points were highlighted regarding capacity building for biomedical research in africa. a good number of african students have published in renowned journals and/or have had formal presentation of their works at national and international seminars/conferences. this observation may reflect growing interest in biomedical science on the continent and the emergence of north-south and south-south networks across africa. some of these include the multilateral initiative article on malaria (mim) with headquarters in cameroon, the african malaria network trust (tanzania), the newly created african network for drug and diagnostics innovation (andi), build african research capacity (build afreca!), african aids vaccine programme (aavp), etc. such organisations, if well designed and focused, are likely to foster biomedical research and its implementation.7 research and publication are crucial in medical education, and scientific publications represent a major element in the transfer of knowledge from clinicians and academics to potential users including decision markers.8 however, considering the population and available resources, africa is still far from the rest of the world, and there is serious concern about disparities across the continent. africa produces about 27 000 papers per year, which is about the same volume for the netherlands. between 1999 and 2008, egypt produced nearly 30 000 papers, which is about three times that for tunisia, its regional neighbour. in west-central africa, nigeria’s total publications for the same period was over 10 000, compared with roughly 6 500 for kenya, the leading research economy in east africa. south africa’s dominance, as might be expected, is even more pronounced: nearly 47 000 papers during 1999 2008, compared with the southern region’s next most prolific nation, tanzania, which fielded just over 3 000.9 nwaka et al. identified about 2700 institutions in 47 of the 53 african countries as lead institutions based on their position as corresponding institutions for articles cited in peer-reviewed journals. these findings clearly indicate the existence of significant health research and development capacity in africa, but the lack of intercontinental collaboration, coupled with low levels of investment, are the major factors hindering the continental research agenda and contributing to a lack of local ownership of research undertaken on the continent and suboptimal utilisation of available research capacity to address african health problems.10 the existing networks need to coordinate their complementary actions in order to be more effective and avoid wastage of resources in unnecessary replication of actions. according to the parliamentary office of science and technology,11 ‘the global approach to international development has shifted over the last few decades from developed countries telling developing countries how to address their own problems, to developing countries identifying their problems and working with developed countries to achieve the assistance they need’. efficacious mechanisms are therefore crucial for african countries to identify their needs and design appropriate solutions to solve them. at this point, the importance of public–private partnership (ppp) cannot be over-emphasised. the approach by andi to create centres of excellence across the continent is laudable and warmly welcomed since this will surely reduce some of the technological and socio-economic disparities encountered from one region to another. african governments should be more present to provide institutional and financial support and create an environment conducive to research and development, instead of relying on the lone support from developed countries. pan-african organisations like andi, amanet, build afreca! and others should be particularly encouraged and effectively supported by african governments. from this survey it was also observed that biomedical research in africa or by africans mostly consists of basic/fundamental research. the proportion of researchers involved in clinical trials is remarkably low. ironically, no economy in the world has prospered without a strong research policy and only few outreaches had been recorded from core-basic research. this implies that, to be able to make good use of its immense natural resources, africa should go beyond the exploratory fundamental research and implement findings to solve its numerous daily problems. for example, discovering new antimalarial leads could really alleviate the malaria burden only if these active ingredients are actually converted into medicines available on the shelves. therefore applied research and a fair collaboration with private sector and international bodies are strongly encouraged. students interviewed prefer web-based courses, short training programmes focusing on specific subjects and internships in laboratories with expertise as teaching methods. internships in laboratories with expertise are likely to boost technology transfer to developing countries although this is really effective only when coupled to infrastructure development and a powerful implementation policy. virtual conferencing and web-based courses may prove to be an effective low-cost strategy for conveying education to african scientists who otherwise would be deprived of the opportunity. unlike conventional programmes, they permit the involvement of a greater number of participants who would otherwise be unable to participate in events of this breadth owing to (i) limited travel fellowships, if any; (ii) lack of time to travel to distant conference locations; and (iii) insufficient accommodation and subsistence funds.12 therefore communication technologies should be given priority by public and private investments. however, it is urgent for african governments to revise their energy strategies and invest more in renewable energy, in order to facilitate communication and solve the recurrent table i. distribution of participants by region of origin and position at the research institution participant’s region of residence total position at institution central africa diaspora east africa southern africa west africa senior/principal investigator 1 1 0 2 3 7 postdoctoral fellow 0 4 0 0 2 6 phd student 15 7 1 1 7 31 master’s degree student 3 2 3 5 2 15 md student 0 0 0 0 2 2 research assistant 3 1 2 1 3 10 laboratory technician 0 0 0 0 3 3 bachelor degree student 0 0 0 0 3 3 other 0 0 1 1 7 9 total 20 15 7 10 32 86 nb: a total of 86 answers were recorded for the question on the participant’s position at their research institution. 11 december 2011, vol. 3, no. 2 ajhpe article 12 december 2011, vol. 3, no. 2 ajhpe energy supply problem that constitutes a major handicap for research in many african countries. human resources for scientific research are unacceptably lacking in africa. in 2004 it was estimated that in africa (except south africa), there were only 70 researchers of any field per million population, compared with 2 640/million in north america and 4 380/million in japan.8 the situation is aggravated by the phenomenon of brain drain in africa. this present study showed that about 40% of african students reside out of their country of origin. better working conditions coupled with job security or good pay packages represent the major driving forces for choosing foreign countries. for example, according to the world health report (2006) only 3.3% of nurses and midwives trained in kenya remain in their country for a career.4 this is clear evidence that developed countries continue to deprive developing countries of millions of dollars wealth of investments embodied in their human resources for health.13 if locally trained african experts migrate to developed countries because of better offers, it is obvious that those trained out of africa will hardly return home. therefore fighting brain drain requires dedicated strategies13 both at national and international levels: (i) research should be responsive to the country’s needs and priorities; (ii) sandwich programmes should have priority over full training programmes; (iii) training should be accompanied or followed by equipment support to facilitate in-home implementation of acquired knowledge; (iv) political strategies like visa restrictions could be applied in specific cases; (v) decision makers in developing countries should equally be trained towards development focused research strategy; and (vi) private sectors should be strongly encouraged as main actors in research implementation. conclusion from this first attempt to identify the needs of biomedical science training in africa from the perspective of young scientists, it clearly appears that although considerable efforts have been made towards strengthening research capacity in the african continent, much remains to be done. biomedical research in africa is seriously inhibited by preventable obstacles which include the lack of infrastructure, expertise and energy supply and institutional and financial support from governments. there is need for applied research in the form of clinical trials to really foster the implementation of research outcomes. there are enormous potentials embodied in african researchers. the continent would definitely experience exponential growth in health status and health innovation if african researchers are based in and focus their work on africa and her many health problems. therefore strategies to support african researchers in africa to better identify and combat africa’s health issues are greatly encouraged. competing interests the authors declare that they have no competing interests. acknowledgement we are very grateful to all the participants for their valuable contribution to this study. authors’ contribution dz designed the survey, translated the questionnaire, participated in the recruitment of research participants, statistical analysis of data collected and the write-up. sa contributed in editing of the questionnaire, recruitment of research participants and write-up. ctn participated in the conception of the project, design of the survey, recruitment of research participants and the write-up. ms participated in the write-up. zit contributed in the questionnaire design and recruitment of research participants. ooa, co and dmk participated in the recruitment of research participants. all the authors have read the final manuscript and approved the submission. references 1. wagner c, brahmakulam i, jackson b, wong a, yoda t. science and technology collaboration: building capacity in developing countries? mr-1357.0-wb. santa monica, ca: rand, 2008. 2. whitworth ja, kokwaro g, kinyanjui s, snewin va, tanner m, walport m and sewankambo n. strengthening capacity for health research in africa. lancet 2008;372 (9649):1590-1593. 3. anonymous. brain drain in africa joint statement by the network of african science academies 2009. http://www.nationalacademies.org/includes/nasacbraindrain09.pdf. 4. kirigia jm, gbary ar, muthuri lk, nyoni j, seddoh a. the cost of health professionals’ brain drain in kenya. bmc health services research 2006;6:89 doi:10.1186/1472-6963-6-89. 5. matee mi, manyando c, ndumbe pm, corrah t, jaoko wg, kitua ay. european and developing countries clinical trials partnership (edctp): the path towards a true partnership. bmc public health letter 2009;9:249. 6. tdr. building capacity for research tdr seventeenth programme report. 2005. 7. ntoumi f, djimdé aa, mbacham w, egwang t. the importance and future of malaria research in africa. am j trop med hyg 2004;71:4-6. 8. frantz m. identifying strategies to improve research publication output in health and rehabilitation sciences: a review of the literature. african journal of health professions education 2011;3(1):7-10. 9. adams j, king c, hook d. global research report africa. thomson reuters. leeds, uk. 2010. available at: http://thomsonreuters.com/content/corporate/docs/ globalresearchreport-africa.pdf 10. nwaka s, ilunga tb, da silva js, et al. developing andi: a novel approach to health product r&d in africa. plos medicine 2010;7(6): e1000293. 11. parliamnetary office of science and technology. scientific capacity in developing countries. postnote 2004;216:1-4. 12. gichora nn, fatumo sa, ngara mv, et al. ten simple rules for organizing a virtual conference anywhere. plos computational biology 2010;6(2):e1000650. doi:10.1371/journal. 2010. pcbi.1000650 13. kupfer l, hofman k, jarawan r, mcdermott j, bridbord k. strategies to discourage brain drain. bull world health org 2010;82(8):616-619. articlearticle 3 may 2013, vol. 5, no. 1 ajhpe background. evidence-based practice (ebp) is the process by which a clinician evaluates the quality of evidence before applying it in the management of a patient. many practitioners struggle to integrate this research-based evidence into their professional practice. blogs have been identified as useful pedagogical tools that can facilitate the sharing of ideas and clinical experiences among peers to reflect on diverse learning experiences. objectives. a qualitative research design was used to examine the use of reflective blogging to teach the process of ebp in physiotherapy. methods. a conveniently selected group of postgraduate students who were registered for an ebp module participated in the study. blogging was used to teach the process of ebp in physiotherapy using kolb's cycle as a guiding and an evaluative framework. students reflected on and shared their learning experiences in ways that exposed the limits of their understanding around certain concepts. results. the results reflect how students moved from assisted to independent performance by identifying gaps in their own understanding and finding the answers themselves. conclusion. reflective blogging was found to be a valuable tool for promoting meaningful learning activities among participants and assisted students in making sense of their shared experiences. it was also an effective tool to be used in teaching the process of ebp. ajhpe 2013;5(1):3-7. doi:10.7196/ajhpe.182 developing reflection and research skills through blogging in an evidence-based practice postgraduate physiotherapy module j m frantz, phd; m rowe, phd department of physiotherapy, university of the western cape, south africa corresponding author: j m frantz (jfrantz@uwc.ac.za) evidence-based practice (ebp) is the process by which a clinician evaluates the quality of evidence before applying it in the management of a patient, while taking into account the multifactorial nature of the problem.[1] it is a common misconception to equate ebp with the randomised control trial (rct), and even its founder has clarified that ebp ‘... integrates the best external evidence with individual clinical expertise and patients' choice’,[2] making no mention of rcts. ebp is core to clinical decision-making among health professionals, as it relates directly to the improvement of patient care through the application of external evidence.[3] however, many practitioners struggle to integrate this research-based evidence into their professional practice as well as justifying experience-based evidence in the face of limited research evidence.[1] when practitioners lack the confidence to utilise formal research, they risk becoming disempowered in an emerging culture of ebp whereby clinicians must show evidence of engaging with research.[4] for this reason, teaching the process of ebp is an essential task for clinical educators. reflection is an important component of learning that emphasises the relationship between past and present experiences, and has long been known to play a significant part in the development of higher order thinking skills.[5] even though the reflective process can be complex, there is evidence to suggest that sharing knowledge and practical experiences in a collegial environment can facilitate the development of reflective skills as it relates to clinical reasoning.[6-8] the difficulty of integrating reflection in learning, and particularly reflection during the ebp process, exists because the ‘reflection’ describes both a cognitive process and a structured learning activity. in this study ‘reflection’ was defined as the process of thinking about an experience that was linked to the learning objectives for the tasks related to the ebp module. this is in line with other studies which encourage educators to ‘incorporate strategies that encourage students to engage in all types of reflection’.[9] in addition, educators are encouraged to provide opportunities for reflection that are embedded in the curriculum in a way that ranges from the evaluation of simple tasks to evaluating and reflecting on more complex issues. david kolb's experiential theory[10] provides a conceptual framework that health professional educators can use to enhance the learning experience. there are four aspects of kolb's learning cycle, i.e.: (i) concrete experience; (ii) reflective observation; (iii) abstract conceptualisation; and (iv) active experimentation. learning can begin at any point of the cycle and the preferred point of entry for learners is an indication of their learning style.[10] it is important to use the process of experiential learning to make the basic principles of a subject relevant to the students.[11] the authors emphasised that experiential learning can be used to assist students in applying theoretical knowledge in practical situations. reflection is essential to this learning process as it can link the concrete experience to the abstract concept. learning is most effective when it occurs in a social context in which students are guided towards higher cognitive functioning by a more knowledgeable other.[12] there is some evidence that collaborative online tools such as wikis and blogs can help to expose the upper limits of students' understanding of a topic.[13] blogs are increasingly seen as useful pedagogical tools among health professional students, as they can facilitate a sharing of ideas and clinical experiences among peers in order to reflect on diverse learning experiences.[14,15] the act of writing is a useful part of the reflective process, as the student first constructs an idea mentally before writing it down. then, when reading over the written statement they have the opportunity to review the ideas and test their viability according to an established schema.[16] article may 2013, vol. 5, no. 1 ajhpe 4 this article examines the use of reflective blogging in teaching the process of ebp in physiotherapy. it describes the experiences of postgraduate students in south africa as they engage with each other around this process via blogging, using kolb’s experiential learning cycle as a framework. this framework enabled the authors to monitor the learning process of students as they reflected on their experiences in order to move from fact-based learning to a more abstract, but deeper, understanding of the work.[17] the research question we set out to answer was: ‘can reflective blogging help postgraduate physiotherapy students engage with the process of learning about ebp?’ methods research setting and sample the msc physiotherapy coursework programme offered a 14-week ebp module in the second year of postgraduate physiotherapy study at a south african university. the main aim of the module was to help students to determine the significance of research methods and reports as they relate to practice. on completing the module, students needed to derive a research question based on a clinical problem that they had identified, search through relevant literature, report on it, and then select evidence based on the quality of the research methods employed in the studies they chose. this included identifying, critically appraising and applying practicerelevant scientific evidence to answer the question that they had identified. students were then encouraged to reflect on and share their challenges and experiences during this process on a blog. the final product of the module was an article from each student that answered their research question, after having been through the ebp process. the postgraduate physiotherapy students (n=6) who were registered for the ebp module during the 2010 academic year participated in the blog. it was an on-site module which used a blended learning approach and catered for students from several african countries, including rwanda, zambia and tanzania, and who were diverse in terms of their background and proficiency in english. none of the participants, and one of the facilitators, had ever been exposed to blogging prior to this module. all the students had a minimum of two years’ clinical experience but had limited or no research experience. procedure a blog was set up using wordpress, and user accounts were created for all postgraduate students registered for the ebp module. tasks within the module included identifying a research question; identifying the parameters for a search using the pico (population, intervention, comparison, outcome) method; conducting a search; evaluating the methodological quality of the identified articles; and finally writing a systematic review using the articles they had gathered. the module facilitator provided students with links to additional resources relevant to the task or discussion in class and on the blog at that particular time, providing guidance and support in a ‘just-in-time’ fashion.[18] the authors held a workshop at the beginning of the module, during which students were able to explore the blog and familiarise themselves with its features. throughout the module we were available to assist students with both conceptual and technical challenges that arose. students were encouraged to post reflective entries describing their learning experiences, perspectives on their personal development and challenges they experienced during each ebp task. they needed to read each other’s blog posts and give feedback or advice in the comments section of each post. there was no expectation of the number of responses that each student had to make and therefore some commented more than others, but all students contributed. the blog ran from 7 march to 25 june; comments were made during this period. at the onset, students posted a few short, simple quotes, but later the posts written by students showed that they began to take control of the blog by sharing their thoughts and ideas. there was also an increase in the number of students’ comments in their later posts, as well as in the length of the comments, perhaps showing students’ increasing confidence in their own voices. the module facilitator also participated in the discussion by giving feedback and guidance based on the students' posts and comments. the aim was to develop their reflective skills and lead them to a better understanding of the ebp process using vygotsky's notion of the zone of proximal development.[12] fig. 1 presents an example of one of the module tasks, with student comments below. research design this study was undertaken using action research techniques. within the process of action research, kolb's cycle of learning[10] was used both as a learning tool and an evaluation framework. the emphasis was on reflection during the learning process, as opposed to merely learning facts.[5] the blog created this reflective process, creating a space for students to expose their current and prior knowledge around the process of learning ebp. this would then allow the facilitator to guide them to higher levels of understanding. see for the four stages of kolb's cycle and their relationship to this study. ethical considerations students were not obligated to participate in the blog as it was not a requirement of the module (although the tasks for the module were fig. 1. screenshot of the blog highlighting one of the tasks, with student responses below. articlearticle 5 may 2013, vol. 5, no. 1 ajhpe posted on the blog), and informed consent was obtained from each student who allowed their responses to be included in the study. the blog was private and students' reflections were not public-facing. in addition, each student could decide to be anonymous when posting reflections and commenting on each other’s work. all students had access to computers and the internet and therefore none was disadvantaged by the use of the technology. data analysis monitoring of activities, comments and posts on the blog was qualitatively analysed using pre-determined themes based on kolb’s framework. relevant quotes in each theme were identified by the first author and further insight regarding students’ reflective learning experiences was highlighted by the second author. consensus was reached by both authors on which quotes best explained the themes. participants were consulted on the relevance of the quotes under the various thematic headings. the results of the students' and facilitators' blog interactions are presented below in a narrative format. results and discussion at each stage of kolb's cycle within the module students reflected on and shared their learning experiences in ways that exposed the limits of their understanding around certain concepts. this allowed the facilitator and their peers to provide feedback around those experiences to encourage further reflection. through this guidance, students were assisted to develop deeper levels of understanding around the topic being discussed. finally, students moved from assisted to independent performance, characterised by identifying gaps in their own understanding and finding the answers themselves. therefore, as they moved through the tasks posted on the blog, they shared with each other, gave feedback, facilitated each other’s reflective process and moved towards self-directed learning. the results below present quotes that reflect each stage of kolb's cycle. stage 1 of kolb's cycle: experiential learning students were encouraged to engage with each of the six tasks related to the ebp process as they were posted on the blog by the facilitator. the following quotes highlight students' experiences and challenges while working through these tasks. ‘i would like to share the experience i went through ... this proved to not be an easy task as there proved to be limited literature around the area ....’ ‘with some abstracts, it was difficult to get the sense of the study. some of the abstracts were difficult to review since there was [sic] limitations in drawing out the specific conclusions of the study like finding the study design which forced the search in the in [sic] original article.’ six learning tasks related to the ebp process were posted on the blog to engage students through active learning experiences. literature indicates that blogs ‘provide a forum for academic discourse that reaches beyond the scope of a module and which augments the knowledge creation throughout a student's enrolment in a module or higher education program’.[19] this is supported by the findings of this study, which highlights the interaction between students around sharing their experiences and additional information as they worked on the module tasks. after receiving feedback from the facilitator and their peers, they would have the opportunity to reflect further and reach a better understanding of the concept. this feature of blogs has been highlighted by other researchers[14] who suggested that blogs could offer health science students opportunities for better understanding of clinical learning experiences. stage 2 of kolb's cycle: reflective observation students reflected on each task that they had completed and then posted their thoughts on how it related to the ebp module. their reflections emphasised the challenges and opportunities they experienced, as well as how they responded to them. the screenshot in fig. 2 shows students engaging with each other around one reflective post that was related to a task on methodology during the module. the need for reflection as part of the experiential learning cycle, and the development of competence in ebp, was also reinforced by use of the blog. students were encouraged to step out of ‘doing’ and into reflecting table 1. blogging activities as they related to kolb’s cycle of learning stages of kolb's cycle of learning blogging activity stage 1 experiential learning (the process of doing something) the facilitator posted six learning tasks onto the blog that were related to the ebp module. each task built on the outcomes of the previous one, leading students through the process of identifying and evaluating evidence upon which to base practice stage 2 reflective observation (reviewing or reflecting on the experience) students were encouraged to write reflective blog posts based on their challenges and experiences as they worked through the tasks. they were also encouraged to read and comment on each others' reflective posts stage 3 abstract conceptualisation (drawing conclusions from the experience) students identified relationships between their own reflections on past and present experiences, as well as on the reflections of others as they related to the module tasks and the process of learning about ebp stage 4 active experimentation (planning or trying out what was learnt) one of the module outcomes was for students to write an evidence-based article, as well as a group article co-authored by all of the students. this gave them the opportunity to actively practise the skills that they had gained during the module article may 2013, vol. 5, no. 1 ajhpe 6 and analysing their experiences and challenges. they shared their own reflections, and commented on the reflections of others, which encouraged debate and externalised their thinking during task completion. this allowed their peers and the facilitator to guide them to deeper levels of understanding around certain topics through feedback. stage 3 of kolb's cycle: abstract conceptualisation students wanted to take control of their own learning and through their blogging experiences discovered the confidence to do so. following a reflective debate, they negotiated taking control of the module by initiating the discussion topics themselves. they spent time highlighting the value of the module, the process that they went through and reflected on how ebp could be incorporated in the future. ‘dear bloggers, i’m just curious, why is a systematic review the highest ranking level of evidence yet no one goes to the field to collect data, analyse and give a data based result like a rct or a quasi study.’ ‘ooh! i seem to be enjoying writing the introduction, and you know why? because i have most of the literature that i find important in this task during my systematic article search phase. interesting, is it always like this or am i offline? well i do not mean that it is easy, but i find it easier than if i was to start from the scratch ….’ ‘having had a plan (written) from the start and implementing it along the process, then the methodology part is easier to work out according to the guide, it amounts to what my plan to conduct the study was. this still drives me to feel that being systematic from the beginning has made things easier down the road.’ by sharing their views and reflections on the blog, students tried to make sense of their new learning experiences as they related to their own personal growth. this involved deeper thinking in order to interpret, understand, and make links and comparisons between the new experiences and what they already knew. peers were found to be encouraging and supportive during the process by helping to address the learning needs of others. they were a compelling source of sharing information and encouraging personal learning as they were less threatening and enhanced deeper learning outcomes.[15] however, peer feedback alone did not seem to facilitate deep reflection, which generally only occurred when the facilitator engaged with the students. this is supported by other researchers who found that receiving peer feedback could, in some cases, actually hamper reflection.[16] there may be several reasons for this, including students modifying their written reflection as a result of knowing that their peers would be reading it. the facilitator also noticed that although students were engaging with each other’s reflections and with the tasks on the blog, it was often at different levels. this enabled the facilitator to provide specific feedback to individuals to guide their learning experience at an individual level. stage 4 of kolb's cycle: active experimentation as part of the process of active experimentation, students were expected to use what they had learned in order to write an article to be submitted for publication. they also used the opportunity to reflect how this approach to teaching and learning could be used effectively for themselves as they moved forward as practitioners and researchers. ‘ebp as part of our masters program has therefore contributed to a swing of insight pertaining to what a physiotherapist at our level should do in terms of practice and putting pieces of knowledge together. this course (ebp) came at a time when our knowledge on research was a key higher… our writing knowledge has been refined; our aspiration for further writing has been inspired. now that we have been using a technologically viable resource (a blog), allow me to propose that this should not be the end of an interaction that adds knowledge.’ ‘these experiences are interesting and what it has made me realise as a lecturer is that teaching tools and techniques are not as effective as providing the student with the opportunity to apply the tools or techniques for themselves.’ ‘i first acknowledge that my generation is one that is quite deep into the didactic learning. all along our learning process, writing of notes and face to face facilitation is what we have been through. blended learning comes with a few technological demands which may not be available always. however it gives an opportunity to share ideas and knowledge.’ in this study, students were provided with the opportunity to create their own learning experiences by being actively involved in the blog and through sharing their thoughts around the processes and challenges they faced during the ebp module. in order to become reflective practitioners, one needs to incorporate both reflective practice to identify problems and action research to provide solutions.[20] students took charge of the learning that needed fig. 2. screenshot showing an example of students’ reflections and engagement with each other. article 7 may 2013, vol. 5, no. 1 ajhpe to occur by questioning and constructing meaning from the information provided and seeking consensus among themselves on matters they did not understand. finally, students shared examples of how this process could be employed in the future, as they progressed towards independent learning practices. in addition, the facilitator realised the importance of interaction between students and educators and how reflection is a good way of developing critical self-appraisal. it can therefore be seen that using the blog led to the emergence of desirable learning activities, i.e. sharing, feedback, facilitation and self-directed learning, that were demonstrated to assist students as they moved through kolb's cycle of learning. at each stage of the process, students used the blog to expose their understanding of ebp, thereby allowing the facilitator to guide them to the next stage of the cycle. this led to a point where the students eventually took control of their learning by initiating discussion, developing consensus and using the skills they had acquired during the module to write an article for publication. conclusion previous studies have highlighted the use of blogs to encourage reflective practice and clinical reasoning among physiotherapy students.[15] this study has shown that blogging can also be used to teach the process of ebp in physiotherapy, and was found to be a valuable tool for promoting meaningful learning activities among participants and assisted students in making sense of their shared experiences. in addition, it assisted in promoting an intellectual community that was open to sharing ideas. we therefore posit that through the process of reflective blogging, students' learning can be enriched and they can become more reflective practitioners. references 1. jones m, grimmer k, edwards i, higgs j, trede f. challenges in applying best evidence to physiotherapy practice: part 2 – health and clinical reasoning models to facilitate evidence-based practice. internet journal of allied health sciences and practice 2006;4(4). issn 1540-580x  2. sackett dl, rosenberg wm, gray jm, haynes rb, richardson ws. evidence based medicine: what it is and what it isn’t. bmj 1996;312:71-72. [http://dx.doi.org/10.1136/bmj.312.7023.71] 3. sackett d, strauss s, richardson w, rosenberg w, haynes r. evidence-based medicine. how to practice and teach ebm. 2nd ed. edinburgh: churchill livingstone, 2000. 4. welch a. the challenge of evidence based practice to occupational therapy: a literature review. journal of clinical governance 2002;10(4):169-176. 5. higgs j, richardson b, dahlgren ma. developing practice knowledge for health professionals. london: butterworth-heinemann, 2004. 6. hanko g. increasing competence through collaborative problem-solving. london: david futol publishers, 1999. 7. jaques d. learning in groups. 2nd ed. london: kogan page, 1991. 8. mason l. fieldwork education: collaborative group learning in community settings. australian occupational therapy journal 1998;45:124-130. [http://dx.doi.org/10.1111/j.1440-1630.1998.tb00793.x] 9. donaghy m, morss k. an evaluation of a framework for facilitating and assessing physiotherapy students’ reflection on practice. physiotherapy theory and practice 2007;23(2):83-94. [http://dx.doi. org/10.1080/09593980701211952] 10. kolb d. experiential learning. englewood cliffs, new jersey: prentice hall, 1984. 11. montgomery k, brown s, deery c. simulations: using experiential learning to add relevancy and meaning to introductory courses. innovative higher education 1997;21(3):217-229. [http://dx.doi.org/10.1007/ bf01243717] 12. vygotsky ls. mind in society; the development of higher psychological processes. cambridge, ma: harvard university press, 1978. 13. hardman j. the developmental impact of communicative interaction. in: hook d, franks b, bauer m, eds. communication, culture and social change: the social psychological perspective. uk: palgrave, 2010. 14. boulos mnk, maramba i, wheeler s. wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. biomed central medical education 2006;6:41. [http://dx.doi. org/10.1186/1472-6920-6-41] 15. ladyshewsky r, gardner p. peer assisted learning and blogging: a strategy to promote reflective practice during clinical fieldwork. australian journal of educational technology 2008;24(3):241-257. 16. xie y, ke f, sharma p. the effect of peer feedback for blogging on college students’ reflective learning processes. the internet and higher education 2008;11(1):18-25. [http://dx.doi.org/10.1016/j. iheduc.2007.11.001] 17. kell c, jones l. mapping placement educators’ conceptions of teaching. physiotherapy 2007;93(4):273-282. [http://dx.doi.org/10.1016/j.physio.2006.11.011] 18. higdon j, topaz c. blogs and wikis as instructional tools: a social software adaptation of just-in-time teaching. college teaching 2009;57(2):105-109. [http://dx.doi.org/10.3200/ctch.57.2.105-110] 19. williams j, jacobs j. exploring the use of blogs as learning spaces in the higher education sector. australasian journal of educational technology 2004;20(2):232-247. 20. mcmahon t. ‘is reflective practice synonymous with action research?’ educational action research 1999;7(1):163-169. [http://dx.doi.org/10.1080/09650799900200080] 25 august 2010, vol. 2, no. 1 ajhpe abstracts 25 june 2011, vol. 3, no. 1 ajhpe ties, or that they were unsure. respondents indicated that institutional and departmental involvement in service learning for academics, students and community participation was minimal. although three respondents attended training sessions, all indicated that they would either like to receive information about the national service learning policy guidelines, or attend training sessions on service learning. conclusion it can therefore be concluded that the academics and clinical supervisors are willing to participate in activities to overcome the challenges identified. it is therefore recommended that a tailor-made training programme be designed to address the needs of the school of nursing in order to institutionalise service learning in the undergraduate nursing programme. integrating primary health care principles in clinical teaching melanie alperstein correspondence to: melanie alperstein (melanie.alperstein@uct.ac.za) context and setting primary health care (phc) was adopted as a lead theme for curriculum transformation by the health sciences faculty of the university of cape town in 1994. however, integration of phc in clinical teaching remains limited at the secondary and tertiary levels of care. prior to embarking on this project, recent experience and data from the department of medicine suggest that clinicians at all levels of the health care system can apply these principles in clinical teaching if they are familiar with them. the established clinician education course (cec) provided an ideal opportunity to modify a module to focus on teaching the phc principles as relevant to clinical teaching. why the idea was necessary different strategies to integrate the phc principles in all clinical teaching are necessary for holistic individual and community health care. the cec was chosen as one approach to provide clinicians with an approach, and the skills and knowledge needed to impart to students the importance and application of the principles of phc in clinical care. what was done a module of the cec was re-designed and introduced in 2010. an indepth qualitative study was conducted with 8/15 (53%) of the participants who completed the module. participants completed a preand post-module questionnaire on their knowledge of phc and their perceptions of integrating phc principles in their own clinical practice and teaching. this was followed by observation of their clinical teaching and an in-depth semi-structured interview. the data related to preand postmodule knowledge of phc were analysed using basic tools of discourse analysis. the rest of the data from the questionnaires, in-depth interviews and observations were triangulated and analysed according to the impact of the course on different levels using freeth et al.’s modification of kirkpatrick’s model for evaluation of educational outcomes at different levels. results and impact participants’ post-module knowledge shifted from disorganised, point form, concrete examples to a more coherent understanding of phc and the phc principles. seven participants, 3 each from family medicine and speech therapy and audiology and one from psychiatry, claimed to already be using the phc principles in their clinical teaching prior to the course. this was corroborated by observation of their clinical teaching and/or further explanation in the semi-structured interview. the aspect that all identified as needing further attention, and where greater insight was gained, related to equity of care and violation of human rights within the health care system. the last participant from a tertiary speciality was finding it more difficult to incorporate the phc principles. all eight had identified areas of action for individual and organisational change in the future. ‘…it’s about changing the country and i’m saying to them can we make a difference to healing the nation. so they’ll be laughing about it because it is lofty ideals, but phc is about that, it is about lofty ideals. it’s about healing the nation.’ introducing case-based learning in decentralised nursing programme sindi mthembu correspondence to: sindi mthembu (mthembus1@ukzn.ac.za) background/context the approach to teaching and learning in rural decentralised settings has predominantly been didactic. to introduce a more student-centred approach, a case-based learning programme focussing on primary health care (phc) was undertaken. aim/purpose this project aimed to facilitate the introduction and implementation of case-based teaching and learning approach in a decentralised phc programme at the school of nursing. method/what was done an exploratory descriptive needs assessment survey was administered to 65 phc programme facilitators. the survey canvassed their perceptions on case-based learning and their ability to construct cases and facilitate case-based teaching in the classroom. it also explored their resource(s) constraints. results and discussion the participants were positive towards case-based learning approach. however, they acknowledged limitations in their skills to design cases and facilitate teaching sessions. they also identified a lack of resources which would hinder the successful implementation of the programme. two capacity development programmes were conducted to facilitate the construction of cases and enhancing facilitators with the skills to facilitate case-based classrooms culminating with drafts of a case study booklet and facilitators’ manual. a mobile suitcase library was introduced with all the necessary resources for the phc programme. conclusion/take home message this project will help the school to produce a different kind of graduate who will be in possession of transferable core skills. effective mechanisms for close monitoring of students’ learning and early identification of students with problems will be enhanced. continuous support is needed for facilitators to gain confidence in cased-based teaching. a maximum of 3 ceus will be awarded per correctly completed test. june 2022, vol. 14, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/mpdp/038/205 (clinical) cpd questionnaire june 2022 relational experiences of community members participating in a rural health initiative with interprofessional students 1. categories of the sub-theme 'solidarity' include: a. interprofressional approach b. reciprocity c. collaboration d. self-reliance. the development of research competence amongst specialist registrars in south africa: challenges and opportunities for research education and capacity development 2. challenges associated with the mmed research requirement: a. limited research experience among trainees b. limited time to supervise mmed research c. limited mmed research supervision capacity d. uncertainty about research education goals. using log diaries to examine the activities of final year medical students at decentralised training platforms of four south african universities 3. the results of the study showed that students spent very little time on practising or learning new skills such as: a. communication b. decision-making c. advocacy d. problem-solving. the lived experience of health science students’ participation in an interprofessional community-based stroke class 4. three themes emerged from the data analysis, namely: (i) ipe wheel; (ii) tandem riding; and (iii) rolling effects (true/false). how to plan for simulation integration into undergraduate physiotherapy training 5. south africa experiences many challenges in adopting educational strategies designed for a developed economy, including: a. lack of funding b. lack of resources, c. national healthcare deficits d. a diverse student population. undergraduate medical students’ readiness for online learning at one south african university: implications for decentralised training 6. the study found that: a. most students were willing to use data that they had purchased to access the internet for learning. b. most students used their devices where they lived. c. most students felt adequately prepared to use the technologies needed in their courses. d. videos or multimedia resources were the technologies that students wanted their teachers to use more. a journey through interprofessional education: students’ perspectives of teamwork in a transforming curriculum 7. many studies have looked at entry-level students’ experiences of interacting with others, or the relationships between students from the various professions (true/false). postgraduate students' experiences with learning management systems at a selected nursing education institution in kwazulu-natal 8. the results of the study showed that student learners were provided opportunities for: a. self-directed learning b. reflective learning c. interactive learning d. ability and skills to use technology please note: the change in cpd question format comes from the accreditation bodies, who have informed us that cpd questionnaires must consist of a minimum of 5 questions, 80% of which should be mcqs with a minimum of 4 options and only 20% of which may now be in the form of ‘true or false’ answers. mcqs may be of ‘single correct answer’ or ‘multiple correct answer’ format. where the question states that more than one answer is correct, mark more than one of a, b, c or d (anything from two to all answers may be correct). for example, in question 1, if you think that a, b and c are correct (note that these are not necessarily the correct answers), mark each of these on the answer form. where the question states that only one answer is correct, mark the single answer that you think is correct. ajhpe 287.indd research october 2014, vol.6, no. 2 ajhpe 133 the education white paper 3, released in 1997, states that institutions of higher learning are faced with challenges ‘to redress past inequalities and to transform the higher education system to serve a new social order, to meet pressing national needs, and to respond to new realities and opportunities’.[1] tertiary institutions in south africa (sa) are therefore required to have initiatives in place to ensure that higher education is accessible to a diverse group of students.[2] students from diverse educational and socioeconomic backgrounds increasingly enter higher education – some with limited academic skills. hence, universities have to be creative in the manner that they select students, facilitate learning, support students’ needs, review curricula to meet pressing national needs, and respond to new realities and opportunities.[3,4] furthermore, the traditional teaching curriculum tends to burden students by placing excessive emphasis on memorisation and information overload.[4,5] even though students acquire a substantial volume of knowledge, they often cannot apply it in practice when required.[6] problem-based learning (pbl) programmes focus more specifically on the outcomes that learners are required to achieve,[7] although these programmes are not without shortcomings. a survey of medical students in 2005 at the university of auckland, new zealand, aimed to determine their confidence in basic science knowledge for safe medical practice. the results showed students being most confident in their behavioural science knowledge and least confident in their knowledge of pharmacology.[7] since 1965, when pbl was introduced at mcmaster university in canada as an innovative teaching approach to stimulate students to construct the most appropriate solution,[8] it has inspired many universities to implement pbl in their curricula. in pbl the learning process takes place when students are presented with real-life scenarios, which develop communication skills and provide opportunities for teamwork. prior knowledge is activated and critical thinking skills are developed through brain-storming activities, discussion, problem-solving and collaborative learning.[9,10] during this process, students acquire knowledge and find information through research, both occurring mainly without the presence of a teacher.[11] to respond to inequalities in the higher education system and the diverse population of students admitted to higher education programmes, curricula should be reviewed and developed accordingly.[4] in sa, curriculum development should carefully consider student profiles, curriculum requirements, and institutional and community needs. pharmacy education in most of sa institutions of higher education has been mainly didactic and subject-based, including a number of pure sciences. over the past decade, the role of the pharmacist has shifted from being medication-centred to patient-centred.[12] pharmacy graduates are therefore expected to bring into practice their particular expertise, including knowledge, attitudes and skills, to solve problems together with other professionals and patients. in response to the diversity of students applying to higher education institutions and the shift in the pharmacist’s role, the university of limpopo (ul), medunsa campus, pretoria, sa, in partnership with tshwane university background. students from diverse backgrounds increasingly enter higher education institutions. universities need to ensure that their programmes are responsive to these diversities. in 1999, the university of limpopo, medunsa campus, pretoria, south africa (sa), in partnership with tshwane university of technology, pretoria, sa, introduced a holistic teaching and learning approach with regard to the problem-orientated, integrated, thematic, modular-based bachelor of pharmacy programme, which included a student support mechanism. objective. to present access, pass, throughput and dropout rates of students in the problem-based learning bpharm programme over the 14-year period since its inception. method. the records of all bpharm applicants and those admitted to the course from 1999 to 2008 were reviewed. access, pass and throughput rates, and failure to complete the course, were determined for a cohort of students (n=458). results. all applications from 1999 to 2008 indicating pharmacy as first choice (n=3 307) were screened, with just more than half (n=1 832) of the applicants qualifying for the selection process. twenty-five per cent (n=458), resembling sa’s demographic racial group profile, were selected and entered the bpharm programme. from this cohort, the programme has produced 404 graduates (88.2%), with 74% completing the course in the minimum time of four years. the overall average pass rate for the 14-year period was 92.3%. finances, personal challenges and exclusions were some of the reasons why students did not complete the course. conclusion. the problem-based learning pharmacy curriculum yielded good pass and throughput rates for a diverse group of students. ajhpe 2014;6(2):133-137. doi:10.7196/ajhpe.287 access, pass, throughput and dropout rates: review of a problem-based learning bpharm curriculum at a previously disadvantaged university in south africa l a mabope, msc (biochemistry), msc (med); j c meyer, bpharm, msc (med), phd department of pharmacy, faculty of health sciences, university of limpopo, medunsa campus, pretoria, south africa corresponding author: l a mabope (lindi.zikalala@ul.ac.za) research 134 october 2014, vol.6, no. 2 ajhpe of technology (tut), pretoria, sa, introduced an integrated, modular pbl bachelor of pharmacy (bpharm) programme in 1999.[13,14] this article presents an overview of the access, pass, throughput and dropout rates of students in this programme. the integrated, modular problem-based learning programme the holistic ul, medunsa campus/tut bpharm programme was introduced in 1999, with only 30 students.[13,14] admission to the programme at firstyear level is through a selection process devised to include a diverse group of students and not solely based on academic merit. minimum requirements for entry into the selection process are based on the following matriculation prerequisites: mathematics, physical science, biology/life sciences and english (from level 4; ≥50%) and/or prior learning in the health sciences. applicants who meet these requirements are potentially invited for an admission assessment and a personal interview with two bpharm staff members. the three abovementioned selection components (academic record, potential assessment and interview score) are weighted and a combined percentage score is calculated for each applicant. applicants with the highest scores are selected, provided a minimum combined score of 60% is obtained. the final selection resembles sa’s demographic racial group profile, with a limited number of foreign students being considered. there are a maximum of 60 places per year owing to limited capacity and resources within the department of pharmacy. transition from school to university is often associated with frustration, stress, lack of selfconfidence and inability to cope, which may lead to failure and dropout.[15] another factor is that students come from a variety of home and educational backgrounds. the first module of the bpharm programme, known as orientation and induction, is designed to bring all students to a common starting point.[14] they are familiarised with the goals and process of pbl through active engagement with pbl examples. teaching and learning activities in this module are aimed at developing basic english proficiency, and computer, communication, interpersonal and life skills. the learning process is facilitated by trained staff members through interactive learning activities, e.g. workshops, role play, group discussions, oral presentations and practical experiences. most teaching and learning in the bpharm programme takes place in small groups (n≤10), with students equally distributed according to academic performance, maturity, gender and race. groups change after each semester to encourage participantdirected and collaborative learning. students are presented with a scenario or problem to solve or discuss according to the structured ‘7-jump process’, facilitated by a trained staff member.[13] the principles of the 7-jump process are taught to all students in the first module of the course and to new staff members during the induction phase. students are assessed by means of appropriate formative and summative assessment methods. formative assessment tasks include short tests, quizzes, assignments, individualised and/or group oral assessments, and clinical workbook activities. summative assessments include written examinations, objective structured practical examinations (ospe), and integrated content examinations using problem-solving exercises. the programme also includes communitybased service learning. students reflect on their experiences through paperor electronic-based course evaluations. students who are struggling academically are identified early in the programme, offered assistance and provided with a mentor, while those who face social and financial challenges are referred to the centre for academic excellence and the finance department. method a retrospective record review was conducted to collect data to determine access, pass, throughput and dropout rates for a cohort of bpharm students (n=458). in terms of access, records (biographical background, school academic records) of all bpharm applicants from 1999 to 2008 were obtained from ul, medunsa campus student administration. academic records (first to fourth year) of all students admitted to the bpharm programme (1999 2008) were obtained from the archive database, collated and reviewed in terms of pass rates, which had been validated and ratified by the examinations committee of the institution. notes in student files were reviewed to identify reasons for dropout from the programme. throughput and dropout rates were determined for the cohort of students who enrolled between 1999 and 2008, and graduated between 2002 and 2012. data relating to access, pass, throughput and dropout rates were analysed using descriptive statistics and expressed as frequency percentages and means. permission to collate and publish the data was obtained from the respective departmental heads of the ul, medunsa campus, and tut bpharm programmes. results access the bpharm selection process consists of two phases (table 1). from 1999 to 2008, applications (n=3 307) where pharmacy was indicated as first choice were screened. just more than half of these applicants (n=1 832; 55.4%) met the minimum table 1. bpharm applications and selection (1999 2008) phase 1: minimum requirements met phase 2: admitted to programme year applicants,* n n as % of applications n as % of phase 1 selection 1999 210 146 69.5 30 20.5 2000 250 146 58.4 35 24.7 2001 310 185 59.7 44 23.8 2002 327 121 37.0 54 44.6 2003 300 186 62.0 38 20.4 2004 286 186 65.0 52 28.0 2005 275 196 71.3 55 28.1 2006 327 155 47.4 47 30.3 2007 465 207 44.5 51 24.6 2008 557 304 54.6 52 17.1 total 3 307 1 832 55.4 458 25.0 average 331 183 56.9 46 26.1 *pharmacy indicated as first choice. research october 2014, vol.6, no. 2 ajhpe 135 requirements for selection (phase 1). these applicants entered the phase 2 selection process and were invited for the potential assessment and personal interview. in total, 25% of students (n=458) who met the minimum requirements for selection were accepted into the programme over the 10-year period. applicants who were admitted to the programme, as a proportion of those who entered the phase 2 selection process, varied over the years, ranging from 17.1% (2008) to 44.6% (2002). since the start of the bpharm programme in 1999, there was a steady increase in the number of applications received each year, with the exception of the period 2003 2005. gender and racial profi le of selected students the majority of students who were selected and registered for the ul, medunsa campus/ tut bpharm programme (1999 2008) were black (n=458; 78%) (fig. 1). approximately two-thirds (n=300; 66%) were female. non-sa students (n=54; 12%) in the programme were from botswana, swaziland, lesotho, zimbabwe, tanzania, zambia, nigeria, cameroon, gabon, malawi and kenya. pass rates the annual bpharm pass rates per level of study from 1999 to 2012 are shown in table 2. the pass rate is calculated as a percentage of students who passed all modules in a particular year. the annual average pass rate ranged from 86.1% (2009) to 97.7% (2003), with an overall pass rate of 92.3% for the past 14 years. on average, the pass rates for firstand secondyear students (90.2% and 89.7%, respectively) were slightly lower, but increased from second 80 70 60 50 40 30 20 10 0 % black white coloured asian female (n=300; 66%) male (n=158; 34%) 48 30 9 2 11 8 1 fig.1. gender and racial profi le of selected bpharm students (1999 2008). table 2. annual bpharm pass rates (1999 2012) level/year of bpharm study 1 2 3 4 year passed/ examined pass rate, % passed/ examined pass rate, % passed/ examined pass rate, % passed/ examined pass rate, % annual average pass rate, % 1999 29/30 96.7 96.7 2000 32/36 88.9 29/29 100.0 94.5 2001 43/46 93.5 30/32 93.8 28/29 96.6 94.6 2002 54/57 94.7 37/44 84.1 30/31 96.7 28/28 100.0 93.9 2003 40/40 100.0 56/60 93.3 36/37 97.3 30/30 100.0 97.7 2004 49/52 94.2 37/39 94.9 54/56 96.3 34/36 94.4 95.0 2005 44/54 81.5 45/49 92.0 39/41 95.0 54/55 98.2 91.7 2006 48/54 89.0 37/48 77.0 41/45 91.0 38/39 97.4 88.6 2007 48/53 90.6 53/56 94.6 38/40 95.0 40/41 97.6 94.5 2008 46/56 82.1 40/48 83.3 53/55 96.4 38/39 97.4 89.8 2009 57/70 81.4 46/53 86.8 32/40 80.0 52/54 96.3 86.1 2010 54/63 85.7 54/63 85.7 46/55 83.6 34/34 100 88.8 2011 52/61 85.2 55/60 91.9 57/62 91.9 44/46 95.7 91.2 2012 68/69 98.6 50/56 89.3 56/60 93.3 53/59 89.8 92.8 average 90.2 89.7 92.8 96.6 overall average pass rate 92.3 research 136 october 2014, vol.6, no. 2 ajhpe to third (92.8%) and again from third to final (96.6%) year. throughput and dropout rates table 3 shows that the selection process allowed various racial groups to access the 4-year fulltime bpharm programme. from the 1999 2008 student intake, it produced 404 graduates (88.2%) from the total number of students admitted (n=458) who met the exit-level competencies required by the sa pharmacy council. approximately three-quarters (74%) of these students completed the course in the minimum period of four years, while 13.7% took an additional 1 2 years. two students (0.4%) successfully appealed against academic exclusion from the programme and completed the course in seven years. twelve students (2.6%) are still in the programme, of whom three interrupted their studies at some stage, while the other nine students failed a year and are therefore in their fifth year of study. forty-two (9.2%) of the students admitted during 1999 2008 dropped out of the programme. of these, three died, one changed to a medicine programme after completion of the first year, and one dropped out owing to academic exclusion. other reasons for dropout, as noted in students’ files, included financial constraints, personal reasons, voluntary withdrawal owing to failure, and difficulty of the course. the dropout rate was proportionally highest among white students. discussion in general, the number of applicants for the bpharm programme increased over the years. although this programme is becoming more popular among matriculants, approximately half of all applications did not meet the basic requirements to enter the second phase of the selection process. secondary schools should guide learners to prepare themselves better for careers that interest them, or assist them in applying for programmes for which they qualify. applicants might meet the minimum selection requirements, but the bpharm programme has a limited number of places for new students owing to a lack of human resources and infrastructure. this situation is unfortunate because pharmacy has been identified as a scarce skills component and there is already a shortage of pharmacists in sa.[16] the ul, medunsa campus/tut bpharm selection considers sa’s demographic representation profile, but the programme does not attract many white, asian and coloured students. this could be attributed to ul, medunsa campus, still being viewed as a campus for black south africans, as in the pre-1994 years. recognition of prior learning related to the healthcare sciences gives mature applicants an opportunity to enter the course. when viewing the pass rates for the 1999 2008 cohort of bpharm students at ul, medunsa campus/tut, the overall average pass rate increased in the third (92.8%) and fourth (96.6%) years compared with the first (90.2%) and second (89.7%) years of study. the lower pass rates in the first two years could be the result of factors other than academic performance. from the literature it is evident that adjustment to university is of great concern in terms of intellectual and personal discoveries, independence in thought and behaviour, widening of horizons and growth in confidence.[17,18] the university experience can lead to failure, loss of confidence and possibly disillusionment,[19] especially during the first years of study. the ul, medunsa campus/tut bpharm programme, with its successful implementation of the pbl approach, stringent selection process and assessment methodology, maintained high pass rates during its first 14 years. this programme appears to be successful in addressing the educational needs of the students selected for the course. interventions to support students are necessary to maintain good pass rates. conclusion the selection process of the ul/tut bpharm programme is based on three criteria (academic performance and prior learning, potential test and personal interview), with final selection representing the demographics of the country. this process provides an opportunity for a diverse group of students to access the programme and is not based on academic achievement only. the use of pbl in the bpharm programme has been successful in achieving good pass and throughput rates over the past 14 years. recommendation the lower pass rates in the first two years of study, reasons for dropout and students not completing the degree in the minimum of four years, call for future investigation and subsequent relevant interventions. limitations this article is based only on the cohort of bpharm students at ul, medunsa campus/tut, and no comparisons are made with students in other programmes or from other universities. acknowledgements. the authors would like to thank ms m zweygarth for maintaining the bpharm database; prof. anthea rhoda for guidance and assistance with preparation of the manuscript; the 1999 2008 bpharm students; staff from the department of pharmacy, ul, medunsa campus, and the department of pharmaceutical sciences, tut, for their contribution to the success of the programme; heads of department for permission to access the bpharm archive database; and the director of the school of health care sciences and ul women’s academic solidarity association (ulwasa) for organising writing sessions for academic staff. references 1. council on higher education (che). education white paper 3: a programme for the transformation of higher education, 1997. http:// www.che.ac.za/documents/d000005/index.php (accessed 30 april 2013). table 3. bpharm throughput according to race: intake 1999 2008 black white coloured asian total total entered, n (%) 359 (78.4) 52 (11.4) 7 (1.5) 40 (8.7) 458 (100) completed 4 years, n (%) 268 (74.7) 38 (73.1) 6 (85.7) 27 (67.5) 339 (74) 5 years, n (%) 38 (10.6) 5 (9.6) 1 (14.3) 7 (17.5) 51 (11.1) 6 years, n (%) 9 (2.5) 1 (1.9) 0 2 (5) 12 (2.6) 7 years, n (%) 2 (0.6) 0 0 0 2 (0.4) total, n (%) 404 (88.2) still in programme 11 (3.1) 0 0 1 (2.5) 12 (2.6) dropout 31 (8.6) 8 (15.4) 0 3 (7.5) 42 (9.2) research october 2014, vol.6, no. 2 ajhpe 137 2. council on higher education (che). improving teaching and learning (itl) resources, 2004. http://www.che. ac.za/documents/d000087 (accessed 30 april 2013). 3. fraser w, killen r. factors influencing academic success or failure of first-years and senior students: do education students and lecturers perceive things differently? southafrican journal of education 2003;23(4):254-260. 4. amosun sl, hartman n, janse van rensburg v, duncan em, badenhorst e. processes in widening access to undergraduate allied health sciences education in south africa. african journal of health professions education 2012;4(1):34-39. [http://dx.doi.org/10.7196/ajhpe.138] 5. dornhorst ac. information overload: why medical education needs a shake-up. lancet 1981;2(8245):513-514. 6. brown b, skau k, wall a. learning across the curriculum: connecting the pharmaceutical sciences to practice in the first professional year. am j pharm educ 2009;73(2):36. 7. insull p, blyth p. basic science confidence in senior medical students from the university of auckland, new zealand: results of the 2005 senior students survey. n z med j 2006;119(1247):u2364. 8. barrows hs, tamblyn rm. problem-based learning: an approach to medical education. new york: springer, 1980. 9. karimi r. interface between problem-based learning and a learner-centered paradigm. adv med educ pract 2011;2:117-125. [http://dx.doi.org/10.2147/amep.s12794] 10. steck tr, dibiase w, wang c, boukhtiarov a. the use of open-ended problem-based learning scenarios in an interdisciplinary biotechnology class: evaluation of a problem-based learning course across three years. j microbiol biol educ 2012;13(1):2-10. [http://dx.doi.org/10.1128/jmbe.v13i1.389] 11. visconti cf. problem-based learning: teaching skills for evidence-based practice. perspectives on issues in higher education 2010;13(1):27-31. [http://dx.doi.org/10.1044/ihe13.1.27]. 12. kiersma me, plake ks, newton gd, mason hl. factors affecting prepharmacy students’ perceptions of the professional role of pharmacists. am j pharm educ 2010;74(9):161. 13. enslin g. a closer look at bpharm programmes university of limpopo (medunsa campus) and tshwane university of technology. s afr pharm j 2008;75(9):16. http://www.sapj.co.za/index.php/sapj/article/download/453/415 (accessed 10 december 2012). 14. summers rs, haavik c, moola f, lowes m, enslin g. pharmaceutical education in the south african multicultural society. am j pharm educ 2001;65:150-154. 15. levy s, earl c. student voices in transition: the experiences of pathways students. hatfield, pretoria: van schaik, 2012. 16. south african pharmacy council. pharmacy human resources in south africa. pretoria: sapc, 2011. http:// www.e2.co.za/emags/phrsa/pageflip.html (accessed 12 december 2012). 17. singaram vs, dolmans dhjm, lachman n, van der vleut cpm. perceptions of problem based learning (pbl) group effectiveness in a socially-culturally diverse medical student population. educ health 2008;21(2):116. 18. davidowitz b. infusing adjustment issues into the curriculum in a science foundation programme. in: leibowitz b, van der merwe a, van schalkwyk s, eds. focus on first-year success. perspectives emerging from south africa and beyond. stellenbosch: sun media, 2009:195-208. 19. scott i. first-year experience as terrain of failure or platform for development. in: leibowitz b, van der merwe a, van schalkwyk s, eds. focus on first-year success. perspectives emerging from south africa and beyond. stellenbosch: sun media, 2009:17-36. june 2022, vol. 14, no. 2 ajhpe 89 research learning management systems (lms) are indispensable teaching and learning tools in nursing education,[1-4] and in recent years lms have become a cornerstone to support online learning, particularly during the covid-19 pandemic.[5-8] online learning, particularly the use of lms, has grown exponentially in the sphere of general education, with information and communication technology (ict) integrating the active learning principles of reflection, interaction and engagement.[1,9,10] an lms such as modular object-orientated dynamic learning environment (moodle) provides a comprehensive educational process through its extensive educational content, control, monitoring and eval uating of knowledge quality,[11] hence improving educational outcomes.[4,12] using an lms has major implications for students and institutions, as it provides opportunities to create a well-designed, student-centred, interactive, affordable, efficient and flexible online learning environment.[13,14] furthermore, lms helps students to access learning resources and communicate with each other and teachers, both synchronously and asynchronously.[15] synchronous online learning involves interaction between students and facilitators at a specified time, despite the students and facilitators being in different places. the interaction is live, and requires all participants to be available for the specified period of time when the classes are held. synchronous online learning can take the form of texts, chats and/or video conferencing.[16,17] teachers and students experience synchronous learning as being social, with students feeling like participants rather than isolated.[18,19] asynchronous online learning allows students to work at their own pace and preferred times, and can include email or online conferencing. the most important element of this type of learning is that students need not be present at the same time or in the same place as the other students with whom they are communicating or from whom they are learning, although they might be online at the same time by chance or plan.[16] asynchronous online learning is the most revolutionary aspect of online learning, freeing students from time and space restrictions.[15,20] learning management platforms encourage peer interaction, with students obtaining personalised guidance from the facilitator when necessary.[21] the facilitator brings value to the course by holding participants accountable for the various learning objectives. through the interactive component of facilitated online learning, the facilitator can judge whether the participant grasps the content. increased demand for online learning has provided many opportunities for teaching institutions, students and faculty, but has raised a number of challenges, including designing and implementing e-learning platforms such as moodle, providing the required infrastructure, and ensuring adequate computer literacy of students and faculty.[2,22,23] further hindrances background. learning management systems (lms) are indispensable teaching and learning tools in nursing education, and in recent years, lms have become a cornerstone to support online learning, particularly during the covid-19 pandemic. the south african (sa) e-education policy requires every teacher and learner in the education and training sector to be information and communication technology (ict)-capable, and able to use icts confidently and creatively to help develop the skills and knowledge they need as lifelong learners to achieve their personal goals and be full participants in their global communities. objective. to investigate postgraduate students’ experiences with learning management systems at a selected nursing education institution in kwazulu-natal province, sa. method. an exploratory, descriptive research design was used, and the whole population of 16 postgraduate nursing education students who were exposed to moodle as a learning management system participated in the study. qualitative data were collected through semi-structured interviews, followed by focus group discussions, with thematic analysis used to analyse data. results. this was the first time that most participants had been exposed to an online learning course, and the experience made them feel empowered as it provided enabled reflection and deep learning. participants indicated that the range of interactions and level of engagement determined the eventual level of knowledge constructed. the online facilitator played a central role in guiding and supporting students, and ensuring that they achieved the learning outcomes. the online learning benefits included increased socialisation, convenience and flexibility, asynchronicity and accessibility of learning material. the challenges were the lack of real-time response, financial cost and technical issues. conclusion. an intense ict orientation for students is recommended to ensure that they are informed of the requirements before starting the online course. the online facilitators must be more visible in the online space, participate more often in discussions and stimulate constructive dialogue. afr j health professions educ 2022;14(2):89-97. https://doi.org/10.7196/ajhpe.2022.v14i2.1163 postgraduate students’ experiences with learning management systems at a selected nursing education institution in kwazulu-natal province n g mtshali,1 phd; a harerimana,2 phd; v n mdunge,3 mn; s z mthembu,3 phd 1 school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 2 school of nursing and midwifery, college of healthcare sciences, james cook university, townsville, australia 3 kwazulu-natal college of nursing, kwazulu-natal department of health, pietermaritzburg, south africa corresponding author: a harerimana (alexis.harerimana@my.jcu.edu.au) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1163 mailto:alexis.harerimana@my.jcu.edu.au 90 june 2022, vol. 14, no. 2 ajhpe research to the use of technology in nursing education include a lack of access to internet and ict facilities, insufficient knowledge to use electronic devices, difficulty accessing required information, expensive internet subscription and the high cost of computers.[13,24,25] the literature indicates that lack of time and motivation on the part of faculty members poses a challenge to integrating ict in nursing education.[2,24,25] in order to meet the increased demand for nurses and simultaneously keep up with modern technology to meet students’ needs, nursing education institutions face the challenges of changing not only their traditional pedagogical beliefs about teaching, but also the way they design nursing education.[26-28] further complicating this milieu is the fact that the nursing curriculum is historically mandated and based on a model recognised as unresponsive to student preferences and needs.[29] this leaves nurse educators wondering what students perceive as appealing and motivating in their online learning experiences. this study, therefore, aimed to investigate postgraduate nursing students’ experiences regarding their interactions while participating in an online course at a selected nursing education institution in kwazulu-natal (kzn) province, south africa. methods the exploratory, descriptive research design was guided by the naturalist interpretive paradigm to understand human thoughts and actions, as well as obtain deep insights and information about the phenomenon of online learning from the perspective of postgraduate nursing students. this approach allowed the researcher to examine life experiences in an effort to understand and give meanings to each phenomenon.[30] the research setting was a nursing department at a selected university in kzn that offers both undergraduate and postgraduate nursing programmes. at the postgraduate level, the department started an online learning course in the mid-1990s, and later adopted an online learning platform, a modular object-orientated dynamic learning environment (moodle), which was used for the first time in the 2009/2010 cohort of postgraduate students. the sample size was 16 participants who were purposively selected, all of whom were enrolled in an online learning module in the master of nursing programme. qualitative data were collected through 16  individual in-depth interviews, each taking an average of 20 30 minutes, followed by two focus group discussions (fgds), which took 1  hour, using a semi-structured interview guide consisting of five participants. the first part of the questioning for both the interviews and focus group discussions related to how students experienced online learning, and their attitudes toward the phenomenon. the second part explored students’ perceived benefits, advantages, disadvantages or challenges of online learning, and their recommendations for improving online courses. thematic analysis was used to analyse the data as per braun and clarke’s[31] step-by-step process. this is a deductive, flexible qualitative research method for identifying, analysing and reporting patterns (themes) within the data. to ensure academic rigour and trustworthiness, the following strategies were used: credibility, transferability, dependability and confirmability.[32] credibility was ensured through a dense description of the collected data, and triangulation by combining the in-depth interviews, fgds and analysis of the documents to clarify and validate the meaning of behaviours. transferability was ensured through a detailed description of the research participants, methodology and interpretation of the results, to allow future researchers to determine whether the findings could be applied to another research study. to ensure dependability, the researcher conducted data quality checks or audits, peer review coding and consultation with qualitative researchers. confirmability was ensured by taking field notes, recording and transcribing the interviews for cross-checking and verification. ethical clearance was obtained from the university of kzn’s humanities and social sciences research ethics committee (ref. no. hss/0940/011m), with gatekeeper permission being obtained from the selected nursing education institution before embarking on the data collection process. codes were assigned to transcripts instead of participants’ names to ensure anonymity and confidentiality. results of the 16 participants in this study, the majority were female (n=13), and most (n=13) were in the age group between 20 and 35 years, while a few were aged >35 years (n=3) (table 1). table 2 summarises the themes and subthemes that emerged from the study. students’ online learning experiences it emerged that the students were provided with opportunities for: (i) selfdirected learning; (ii) reflective learning; (iii) interactive learning; and (iv)  ability and skills to use technology. self-directed learning this was the first time that most participants had experienced an online learning mode of content delivery, with some indicating that it met their educational and technical needs. it empowered them to be self-directed students, with participants noting: ‘it was the first time i engaged in such a learning methodology, and the experience was a great one … for the first time in my life, i felt in control of my learning and felt in charge.’ (student 6) ‘my experience is that the online learning course facilitated my initiative, i had to drive my own learning, i learnt to be self-paced, as i had to make decisions on when and where to access the course, took note of the due dates for discussions and posting of the learning activities.’ (student 10) table 1. sociodemographic characteristics student code gender age group, years fgd 1 female 31 35 fgd 1 2 female 20 25 fgd 1 3 female 20 25 fgd 2 4 female 26 30 fgd 1 5 female 20 25 fgd 1 6 female 20 25 7 female 26 30 8 male 31 35 fgd 2 9 male >35 fgd 2 10 female >35 11 female 20 25 12 female >35 fgd 2 13 male 31 35 14 female 20 25 fgd 2 15 female 20 25 16 female 26 30 fgd 1 fgd = focus group discussion. june 2022, vol. 14, no. 2 ajhpe 91 research reflective learning the participants indicated that the nature of the online learning discussions provided them with time for reflection on their learning, and opened a safe space for dialogue where they did not feel as threatened by others as they did in the face-to-face classroom setting. they preferred this mode of learning, as evident in the following quotes from the fgds: ‘online learning allowed us to debate our viewpoints freely, without the fear of the facilitator or other students judging you or passing remarks or expressing negative facial gestures.’ (fgd 1) ‘we could work independently and be able to come out with your own ideas … it was interesting that you could also agree with people independently not being influenced by how you are thinking.’ (fgd 2) interactive learning they not only learned by reflection, but also by exploration, introspection and interaction with the facilitator and other students, and sharing information within the group. the online learning experiences encouraged deep learning, as indicated by the following observations: ‘i found it better than the face-to-face because with texting, it’s easy to think about what is learnt, correct and refine what i wanted to communicate to the rest of the group … rather than just open classroom discourse because with the latter what you have said you cannot take back.’ (student 3) ‘understanding of the readings has to be greater when you’re a student online than when you’re in the classroom, because these are your ideas, you have to pull ideas from the readings, gave a deep thought from them and from various other resources then responded.’ (fgd 1) ability and skills to use technology the participants indicated that in order for their learning experience to be fruitful and productive, they needed to be technologically comfortable and confident in their ability to use computers. while the majority had some computer skills, they initially found the new experience of online learning challenging, which made them feel anxious, stressed and/or apprehensive, as indicated by the following views: ‘i was comfortable since i had the skill already of using the computer, but it was frustrating and stressful at first because i was exposed to this type of learning for the first time. my skills eventually grew from strength to strength.’ (student 7) ‘once you engage with online learning … your computer and searching skills become sharp and you gain confidence as you practise all the time so i can say it was a good learning experience.’ (student 9) ‘i gained computer skills and it became more and more interesting.’ (student 2) some indicated that they had thought they knew how to use technology, but did not realise how much depth it had in terms of the skills required. some had not felt comfortable using the technology and had to quickly develop computer skills to bridge the gap, as indicated: ‘i had minor computer skills, although i didn’t have formal computer training … i like the computer and i use it a lot preparing my stuff. online learning really improved my technology skill and confidence.’ (student 14) ‘i would say i had some background knowledge and confidence on technology use; however, with online learning, i was unsure because i had never been exposed to it before … but because i knew how to use the computer, it wasn’t really difficult.’ (student 11) ‘i was uncomfortable and had no confidence because i had little technology experience but with the help of the colleagues, i slowly gained the skill and managed to pull through.’ (student 3) ‘while i had some skills, it was not enough, but as the course progressed i developed the skill.’ (student 16) table 2. themes and subthemes theme subtheme students’ online learning experience self-directed learning reflective learning interactive learning ability and skill to use technology degree of interaction and engagement student-to-student interaction student-to-facilitator interaction student-to-content interaction role of the facilitator technical support, encouragement, motivation benefits of online learning increased socialisation convenience and flexibility accessibility asynchronicity challenges of online learning lack of real-time response financial cost of the technology technical issues internet and computer access recommendations for improvement provide timeous feedback from the facilitator improve and enhance online learning experiences invite subject experts to visit online space 92 june 2022, vol. 14, no. 2 ajhpe research the participants had mixed feelings, with some perceiving online learning as individually paced, autonomous, motivating and competitive, as reflected in their comments: ‘i think when you’re an online student, you have to pull ideas from the readings and from various other resources … and they are your own ideas to others.’ (student 4) ‘it felt more competitive because i could see everyone’s work; i wanted to outdo the other people … and at the end, get satisfaction from it and that for me was rewarding and encouraging.’ (student 13) ‘i had to read extensively and engage with the material twice or even thrice because i needed to understand it … i needed to push so as to be at par with others.’ (student 1) degree of interaction and engagement interaction emerged as an important aspect of online learning, being described as the opportunity to access a range of opinions and information. the participants revealed how the degree and/or level of interaction with other students and the facilitator was an essential aspect of the learning process and student success. it was increasingly possible for them to interact with one another, even when geographically separated. most cited interactivity as the most beneficial aspect of online learning. the sub-categories that emerged were: (i) student-to-student interaction; (ii) student-to-facilitator interaction; and (iii) student-tocontent interaction. student-to-student interaction the students used one another as resources and for support by commenting on the information they collected from various resources, and the observations and experiences of others. they felt that the peer student interactions were open and active, with a high degree of intellectual engagement, with online discussions viewed as useful, well thought out, of a deep-learning nature and requiring them to be active learners, as indicated by their comments: ‘i believe my role was to participate and communicate with other students and discuss the things that were part of the curriculum module we were doing.’ (student 4) ‘interactivity was really important for all students. the way the discussion forums were structured really helped us to be grounded in what we were learning.’ (student 2) ‘the level of engagement was amazing … it was professional and everybody was active, you could not have dodged, you had to write own view then other people would critically analyse and debate around one’s thought until the views were clear and acceptable to all.’ (fgd 1) while many participants were satisfied with the level of online interactions and engagements, some of them felt that the student-to-student interactions and levels of engagement were insufficient and not up to the level they had expected them to be. only a few students initiated the discussions and debated the issues, generally the same few, while some students took a long time to respond to postings and had to be probed by the facilitators to interact. this is illustrated in the following extracts: ‘we were struggling to all engage as a group … other students would post one comment as though it was a task to be fulfilled yet in my views and understanding, the module was meant to allow ongoing conversation … the interaction was poor in my view.’ (fgd 1) ‘there were few students who would initiate the discussions but it took too long for others to respond thus rendering the whole discussion slow and dragging for long.’ (fgd 2) ‘at first there was not much interaction, as individual just posted their work and nobody would comment … the facilitator had to stimulate the discussion and even invite us by names to get us started.’ (fgd 1) student-to-facilitator interaction and engagement the facilitator was viewed as supportive and very helpful, giving instructions relating to the module, providing various other communication or feedback and guiding the online discussions. some participants stated that: ‘the facilitator engaged us in critical debates and provided topics that would stimulate active debates and deliberations.’ (fgd 1) ‘we would sometimes find comments from our facilitator, showing us where we were in terms of the course content … she would also highlight where we needed to go for more information.’ (fgd 1) ‘the facilitator monitored our discussions and encouraged those who were less involved to put effort up to the extent of assigning specific work for them.’ (fgd 2) ‘she was good … diligent to check if we had done the work like posting of the task, she would always remind us about the deadlines so that we can put effort.’ (fgd 2) student-to-content interaction and engagement the online learning experience allowed for interaction with and about the content, and afforded the students an opportunity to interact with the module content before interacting with the other students and/or facilitator, as indicated in their comments: ‘in the past, interactions only occurred in the classroom, and almost solely between teachers and students … now we are introduced to the modern e-learning interaction tool which makes the learning experience more worthwhile and valuable.’ (fgd 1) ‘interactions among students and the facilitator and the content can be independent of time and place.’ (fgd 2) ‘online learning afforded us more time to read our books, understand the content well before clicking into moodle. you must have understood the section before being challenged by others … be able to defend your views.’ (fgd 1) role of the facilitator the most important role of the online facilitator was to model effective teaching and learning. furthermore, facilitators were responsible for keeping the discussions on track, contributing special knowledge and insights, weaving together various discussion threads and course components, and maintaining group harmony. technical support, encouragement and motivation participants perceived the facilitators’ online role and qualities as very important for facilitation and enhancement of learning. they regarded the facilitator as giving technical support, encouragement and motivation, as indicated in the following excerpts: june 2022, vol. 14, no. 2 ajhpe 93 research ‘as adults who were not used to the computer, the support and encouragement she offered were great and remarkable which made us to pull through till the end of the course … at the same time, making sure we achieve the learning outcomes.’ (fgd 2) ‘our facilitator had a positive attitude and very supportive, you would think you are doing great because of the encouraging comments, once commended us on the depth of the discussions we were engaged on.’ (fgd 1) ‘since i was not comfortable with the technology, she eased my frustration by giving technological support and guidance which was evident in the orientation she conducted and throughout the module, since she knew that we were not familiar with technology and as they say … technology immigrants.’ (student 9) while most participants revealed that the facilitator was approachable, non-judgemental, supportive and professional, some perceived that there was an element of anonymity in the online environment, as indicated by the following views: ‘when we were meeting face-to-face and motivated us to keep up the good effort. she was concerned about the problems we were facing as online beginners, and she would ask us individually.’ (fgd 1) ‘the facilitator was helpful to those students who were shy and not as verbal … however, i feel that our relationship with the facilitator lacked personal connection.’ (fgd 2) ‘obviously, face-to-face interactions and body language were absent … i was just thinking about the missing piece and uncomfortable … you need connectedness with the facilitator.’ (fgd 1) benefits of online learning the students found the true power of online learning in its potential to share and exchange information, and its convenience and flexibility in allowing them to work at their own pace. four subthemes emerged: (i)  increased socialisation; (ii)  convenience and flexibility; (iii)  asynchronicity; and (iv) accessibility. increased socialisation the participants viewed their relationships with other students as increased socialisation. they shared information, supported each other, worked with groups and made a continuous effort to improve their writing skills, as their colleagues read all their work. they valued each other’s contributions and perceived a sense of equality in the course, as noted in the following: ‘the online environment is a public and permanent academic platform … everyone is able to see one’s strengths and weakness of others … but usually, we were supportive to each other.’ (fgd 2) ‘the online environment provided an opportunity to learn about other students’ clinical practices … and to connect with people from other countries.’ (fgd 1) convenience and flexibility many of the participants described flexibility and convenience as the most beneficial features of the online learning environment. as adult students, they appreciated the flexibility of being able to control time, place and pace, as indicated below: ‘i already had experience with computer, but i still learned new ways to optimise my use. the benefits were that you attend to your work twentyfour seven at your own tempo … you are not confined in one place in one time; any time is suitable especially as mature learners.’ (student 4) ‘i could attend my online tasks or assignment anywhere … anytime at my own convenience … that was nice. for me the benefits are the flexibility of time … eh … i think it’s a good method for adult learners.’ (student 2) ‘you access it wherever, whenever … you pace yourself, you decide when you want to do the work … for me that was the key benefit … it allowed me to conduct my work in my own space, at my own speed, at my own suitable time.’ (student 13) asynchronicity asynchronous learning refers to learning where the instructor, the learners and other participants are not engaged in the learning process at the same time, and there are no real-time interactions. asynchronous online learning allowed the students to work on their own, anywhere, in their own time and to log into the online space whenever they were ready. participants indicated that the asynchronous discussions and chats allowed time for reflection, to mull over ideas, refer back to previous messages and take any amount of time to prepare for responses, as reflected in the following comments: ‘the module gave us more time to think about what we wanted to post … i could make my point, write everything out, and made sure i wrote what i wanted to write.’ (student 7) ‘you can express your thoughts without interruption … you have more time to reflect on and respond to discussions and other students’ comments, and since the time frame is longer you are able to refine responses before posting.’ (fgd 1) ‘of course, we didn’t have a situation where people would want to take over the class discussion … instead, we all had opportunities of thinking hard of what we wanted to say and the shy people could also participate more … everyone got to say what they wanted to say.’ (fgd 2) accessibility of learning material the participants regarded the online environment as flexible and convenient, and providing access to many resources. technical support was available to students from the facilitator and their fellow students, and the course-ware and related tools facilitated learning. they highlighted the benefit of course orientation, as it eased the stress related to the online learning experience, as indicated below: ‘e-learning was very good because one can combine family life and career together and learn at the same time.’ (fdg 2) ‘i enjoyed learning and using the internet and finding articles online … that was really exciting and fun.’ (student 1) ‘the orientation was good, the facilitator showed us what was expected from us, how to use password and log on, write and post messages, we did that repeatedly and told us that was the manner we were to communicate and interact.’ (fgd 1) ‘the orientation afforded us the opportunity to get acquainted with the programme and how we could navigate through the system.’ (fgd 2) challenges of online learning while online learning may have numerous benefits, the participants mentioned some of the challenges that had hampered their learning experiences. the most frequently mentioned ones were: (i) lack of real-time response; (ii) financial cost; (iii) technical issues; and (iv) issues of internet and computer access. 94 june 2022, vol. 14, no. 2 ajhpe research lack of real-time response in the online learning experience, students found it difficult to work with peers on group work, with the majority not actively participating in the work assigned to the group. another drawback of working online was that they did not receive immediate feedback from the facilitator or their peers. unlike the more traditional way of learning, where they would receive help or prompt feedback during a class, they had to wait to get responses from peers and/or the facilitator, as some explained: ‘you felt like you were just all alone. i just thought i was typing into space or something … and there was no one on the other side.’ (student 10) ‘the feedback from the facilitator i think it was not enough because after the deliberations about the activities with other students about the topic posted to us, the facilitator’s comments will be delayed … we needed her input right when we were also online.’ (student 8) ‘feedback from the facilitator was not as expected … i guess it’s because she had so much workload during this semester, i was not sure about the validity of our discussions in terms of meeting the module objective.’ (fgd 1) ‘you do expect feedback so that you know that you are in the right path and that was very limited … sometimes until the next topic is commenced … you see there were set dates for postings and we needed to know if we were in the right direction before proceeding to the next tasks.’ (fgd 2) financial cost financial cost emerged as a challenge, as some participants had to purchase computers and arrange for internet access, costs that they had not catered for, as indicated in the following excerpts: ‘it was costly for me, because i had other plans. i did not know that the module was going to be conducted online, i had to buy a laptop and also had internet installed.’ (student 12) ‘the cost was a challenge because i had to travel to the university lan from work or home to access the computer and internet … eventually, i had to buy the laptop which was not budgeted for.’ (student 2) ‘i had to apply for the internet to be installed at home because it was not possible to make through the whole module without internet, and when you have internet, you worry about the cost.’ (student 1) technical issues some participants highlighted their frustrations with the technological problems they encountered, which sometimes distracted them from effectively contributing to the online learning sessions: ‘most of the time i used to access online at home it frustrated me because my system was not of good quality, the bandwidth was limited and slow operating.’ (student 11) ‘losing my postage was quite stressful you would only realise when there is no response towards your discussion and another problem which made me feel like a fool when i was unable to edit or delete the posted message when i discovered it had flaws.’ (student 16) ‘sometimes i was not able to access moodle and thus would not be able to contribute to the discussions. this was wearisome because i would lose important engagements with my peers … it meant having double sessions the next time you access the online class.’ (student 6) issues of internet and computer access issues related to internet and computer access surfaced as a matter of concern for most of the participants, with some only being able to access the online material at home where they had little technological support, while others had computer access both at home and at work. some participants had no computer at home, and had to travel to an internet café or the university to access the online module, as a number of students explained: ‘i did not have access to computer and internet at home, so i had to drive to the campus or drive to the internet café to attend to the online tasks and activities assigned to us. i had a computer with internet at home but i was not familiar with the technology at times i would struggle to try to log in to access material but with the help of the children i ended up doing it on my own.’ (student 15) ‘i was particularly disadvantaged by the fact that i did not have access to the internet at home or in my office so i had to go to the campus or drive to the internet café.’ (student 8) ‘at the commencement of the module, i had no computer and no internet and could not access the work at home which was an inconvenience on my side but i bought the computer … as time progressed i had the internet installed.’ (student 14) students’ recommendations for improvement three recommendations emerged from this study: (i)  getting timeous feedback from the facilitator; (ii)  improving and enhancing online experiences; and (iii) inviting experts on the subject to visit the online space. timeous feedback from the facilitator participants suggested that timeous feedback from the facilitator was very important, and students reported that they wanted prompt responses to technical problems, as expressed in the following excerpts: ‘i think being accessible … i mean the facilitator … and responding in an appropriate time frame would help because if we type our posting … we hanged on, waiting for responses.’ (student 11) ‘it is just responding and knowing that the facilitator is actively involved in what we are doing that makes all the difference.’ (student 2) improve and enhance online learning experiences the participants also highlighted a number of recommendations that they felt would improve and enhance the online learning experiences. these included that the facilitator could be more objective and more encouraging of their contributions, and that the quality of the content could be enhanced to ensure that it was always relevant to the subject being covered. these recommendations are reflected in the following statements: ‘the use of various learning options can stimulate student participation and interaction … few examples include small online group discussions, polling activities and one-on-one message exchanges to name what i can think of.’ (student 5) ‘the facilitator should always consider such things as the tone and content of the posting and time of the posting in relation to the tasks at hand.’ (student 16) ‘the online facilitator needs to be content if two or three well-articulated, major points are communicated in a particular thread of discussion.’ (fgd 1) ‘it is important that the material is always relevant, questions and activities developed for students should relate to the student’ experiences.’ (fgd 2) inviting experts on the subject to visit the online space one participant suggested that it would be a good idea to invite an expert(s) on the subject to visit the online space to comment on the students’ postings, as stated in the following quote: june 2022, vol. 14, no. 2 ajhpe 95 research ‘guest experts could be invited to join the online conversation with students to respond to posted contributions or so … students can then ask them questions.’ (fgd 1) discussion lms and online learning have gained popularity in recent years, particularly during the covid-19 pandemic.[8,33-35] the pandemic has forced academic institutions to suspend their face-to-face classes, and students to learn remotely in order to maintain social distancing.[33,34] studies have reported that online learning provides people with flexibility, convenience and varied learning opportunities.[33,36-38] online learning systems such as moodle help nursing students to meet their educational needs, improve their technical skills and be self-directed, reflective and collaborative.[4,39-40] online learning provides the opportunity to access online reading material and participate in discussions and doing assignments. online learning allows students to reflect upon each message posted, provide an adequate response and participate in a thoughtful manner, which is more considered and reflective than is possible in a faceto-face session.[2,13] collaboration among students is essential in online learning. it allows them to support each other and work within online groups, as allocated by their facilitator, and make continuous efforts to improve their writing skills as colleagues read all their work.[13,25] the use of technology requires the users to have a certain level of competence, with vonderwell et al.[41] noting that a good understanding of the required tasks and adequate writing skills were needed by online students to explain themselves fully and appropriately, and was influential to the success of the discussions. they found that online learners who were inexperienced and lacked writing skills struggled to comply with the writing conventions that emerged in the discussions, which made them appear less competent and unable to complete the course requirement. it is essential to ensure that the students have adequate computer skills on enrolment to avoid the technology-mediated learning environment’s challenges. online learning is challenging for students with limited digital skills, and students may experience anxiety, fear and/or apprehension.[42] in this study, students reported not being comfortable using technology at the course outset, and they had to make a concerted effort to develop computer skills to bridge the gap. supporting these findings were meyer et al.,[43] who contended that they had experienced feelings of discomfort and insecurity during the initial phase of their online study due to their inadequate level of information technology (it) skill, but that after initial feelings of chaos and not trusting their abilities, they started to take charge of the situation by developing the necessary skills. being computer illiterate adversely affects students’ learning, and requires more training before embarking on the course.[44,45] students who are computer illiterate find online learning difficult and not an ideal medium for learning, as they have to learn and interact with the instructor, students and content without having the necessary technology skills.[18,46] access to the internet and a computer positively or negatively affected the students’ learning outcomes and their perception of online learning, as reported in this study. takalani[18] found that many students did not own personal computers, and therefore had to work at designated venues or centres where they could access the necessary resources. other studies[46-48] also found that while some students had computers, not all had internet connections in their residential areas. the difficulties they faced gaining internet access made online learning a challenge. access to a computer and the internet allows students to fully enjoy online learning benefits, including convenience and flexibility, interactions with colleagues and facilitators, and active engagement in their learning, irrespective of where they are.[2,13,49,50] the facilitator plays an important role in online learning, and can enhance student engagement and deeper learning. according to vonderwell et al.,[41] the instructor’s feedback is an essential element of online engagement and is important for student learning. the authors suggested that instructors need to guide the learning and facilitate discussions by responding to individual students’ questions and to the class as a whole.[41] liu et al.[51] concur with the findings of this study in that an online facilitator should use various instructional techniques that foster understanding of the key concepts of the course and provide timeous feedback. in contrast to these findings, ivers et al.[52] indicated that their participants complained that they had experienced a lack of instructions and communication from the instructor, which left them feeling overwhelmed, excluded and intimidated by the online experience. although the use of moodle for the online learning environment was experienced positively in this study, several challenges were reported that hampered student experiences, such as lack of real-time response, financial costs and technical issues. unlike face-to-face classroom situations, where students can receive help or prompt feedback during lessons, the participants indicated that online sessions required them to wait to get a response from their peers and the facilitator. this finding echoed that of kim et al.,[53] whose participants stated that they found online learning very challenging when there was a lack of opportunity to receive feedback or answers in real time. wang and woo[54] also highlighted a lack of immediate response from others as a challenge, with students not participating simultaneously. in this study, the participants also felt that the lack of realtime responses led to social isolation and ineffective group work. according to miers et al.,[55] students missed the social information they gain from face-to-face interactions within group activities, as online learning lacks the personal touch of being able to see someone. this results in the absence of eye contact or the ability to interpret body language, expressions and non-verbal behaviour and feel reassured of acceptance within a group. the findings are consistent with those of gallagher-lepak et al.,[56] where participants reported that they felt out of the loop and experienced feelings of aloneness in the online environment. financial cost also emerged as a challenge to those who had no computer and internet facilities at home. according to meyer et al.,[43] students in their study were not sufficiently informed regarding the additional finances required for the course, such as fees for a computer and the internet. furthermore, childs et al.[57] noted that students voiced concern about their online course’s financial implications, as they had been compelled to purchase computers, printers and internet access when it was not available at home or work. another issue that was noted by knowles and kerkman[58] was the financial implication for students who are not computer literate and therefore take a long time to do their readings on the internet, particularly if the internet is accessed via a cybercafé.[59] the participants in this study highlighted frustrations with the technological problems they encountered, which were viewed as distracting them from effectively contributing to the online learning sessions. meyer et al.[43] reported that their participants experienced frustrations owing to technical problems 96 june 2022, vol. 14, no. 2 ajhpe research and a lack of technical know-how, which compromised their participation. these results are consistent with those of other researchers,[60-62] who state that students’ frustrations and dissatisfactions resulted from technical problems and lack of technical support for it management. other researchers[62,63] have also referred to technical issues, arguing that computer glitches and slow operating systems distract students from contributing effectively in their learning. these it problems need to be tabled as expected challenges to students at the start of the course, with suggestions about the actions that need to be taken when they manifest. in order to improve the experience, the participants in the present study suggested effective facilitation of online learning and timely feedback from the facilitator. facilitators need to encourage passive students to be more active, as participation is the hallmark of online learning.[56] according to lofstrom and nevgi,[64] relevance and meaningfulness of learning activities and content are central to the transferability of knowledge, which instructors should keep in mind when designing material for use with technological devices. this sentiment is further echoed by berge,[65] who argued that instructors must develop activities for students that relate to the topic and are relevant to their experiences. conclusion the use of technology in education, particularly lms for online teaching and learning, has numerous advantages owing to its flexibility and ability to offer learning to students irrespective of time and place, with self-directed, reflective and collaborative learning being key pillars. while students perceived the use of moodle as an lms positively, it is important to take into consideration the challenges that hamper online learning outcomes. these include insufficient computer literacy among the students, poor facilitation of online learning and financial constraints to purchase it equipment and services. therefore, it is essential to enhance students’ computer skills at the beginning of their enrolment through an intense ict orientation and continuous pedagogical and technological support in an online learning environment. the facilitator’s role is vital in a technology-mediated learning environment, and needs to be visible in the online space, participating in discussions and stimulating constructive dialogue. providing students with computers and access to the internet and online resources would improve their motivation to work collaboratively in an online learning environment. the future of online learning lies in a transformative education that embraces technology and strives to ensure that students benefit fully from a platform that enables self-directed reflection and constructive engagement with others at a time and place that suits them. declaration. none. acknowledgements. we thank all the participants who took part in this study. author contributions. all authors complied with the international committee of medical journal editors’ authorship rules, and formulated and conceptualised the article. the initial drafts and subsequent work on the manuscript included the inputs of all authors. funding. none. conflicts of interest. none. 1. buthelezi l, van wyk j. the use of an online learning management system by postgraduate nursing students at a selected higher educational 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learning: benefits, challenges, and suggestions. internet higher educ 2005;8(4):335-344. https://doi.org/10.1016/j.iheduc.2005.09.005 54. wang q, woo hl. comparing asynchronous online discussions and face‐to‐face discussions in a classroom setting. brit j educ tech 2007;38(2):272-286. https://doi.org/10.1111/j.1467-8535.2006.00621.x 55. miers me, clarke ba, pollard kc, rickaby ce, thomas j, turtle a. online interprofessional learning: the student experience. j interprof care 2007;21(5):529-542. https://doi.org/10.1080/13561820701585296 56. gallagher-lepak s, reilly j, killion cm. nursing student perceptions of community in online learning. contemp nurs 2009;32(1/2):133-146. https://doi.org/10.5172/conu.32.1-2.133 57. childs s, blenkinsopp e, hall a, walton g. effective e‐learning for health professionals and students’ barriers and their solutions. a systematic review of the literature findings from the hexl project. health info lib j 2005;22(s2):2032. 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communities in online courses. quart rev distance educ 2007;8(1):9-24. https://www.proquest. com/docview/231180604/fulltextpdf/2f0378456a1c4575pq/1?accountid=16285 (accessed 12 march 2022). 64. lofstrom e, nevgi a. from strategic planning to meaningful learning: diverse perspectives on the development of web-based teaching and learning in higher education. brit j educ tech 2007;38(2):312-324. https://doi.org/10.1111/ j.1467-8535.2006.00625.x 65. berge zl. facilitating computer conferencing: recommendations from the field. educ tech 1995;35(1):22-30. https://www.jstor.org/stable/44428247 (accessed 12 march 2022). accepted 18 may 2021. https://doi.org/10.1007/s10758-020-09475-1 https://doi.org/10.1088/1742-6596/1840/1/012062 https://doi.org/10.1080/15391523.2007.10782485 https://doi.org/10.1016%2fj.childyouth.2020.105355 https://doi.org/10.4314/sajhe.v21i3.25715 https://www.ajol.info/index.php/ict/article/view/109512 https://www.ajol.info/index.php/ict/article/view/109512 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https://doi.org/10.1111/j.1467-8535.2006.00625.x https://www.jstor.org/stable/44428247 october 2016, vol. 8, no. 2 ajhpe 135 research one of the realities of contemporary society is the rapid emergence and growth of a knowledge-based economy owing to the use of information communication technology (ict). undoubtedly, universities are major roleplayers in knowledge generation.[1] this function of universities underpins the development of postgraduate (pg) students as competent knowledge generators and scholars. however, the ict revolution is challenging many universities to transform their traditional approach towards research supervision into knowledge production.[2] the research supervision process is expected to transform research candidates into knowledge producers and managers, with research supervisors playing an informed, supportive role in students’ research journeys. the dynamics and complexities of the current environment demand a change from conventional research supervision processes. before 2000, pg students were full-time resident students, thus making it easy for supervisors to have close, personal and individualised contact with them.[2] the current environment, however, demands a change, as the old model is unsuitable for students and supervisors, who are now both more mobile. furthermore, an increasing number of pg students work full time, making the traditional model of supervision inappropriate and obsolete.[3] trudgett[4] acknowledges that high-quality supervision is strongly associated with the capacity of academic staff. pg research supervision requires sound knowledge in terms of research methodology, and facilitation and management skills from research supervisors. in developed countries, research supervision is one of the competencies of nursing education programmes. however, this is not the case in countries where the curriculum of health professionals appears static and outdated,[5] as in south africa (sa). until 2012, the sa nursing council (sanc) did not include research supervision in the training curriculum of nurse educators. this has been identified as a weakness, given that a nursing qualification requires a research project at both diploma and degree level.[6] nurse educators have been learning to supervise research through trial and error, and/or by informal training, such as workshops. this gap in the training of nurse educators may result in low inand output in the research supervision process. this, in turn, decreases the nature of support, guidance and facilitation provided to pg nursing students and consequently the reduced throughput of these students. between 2000 and 2006, at the college of health sciences, university of kwazulu-natal (ukzn), durban, sa the average drop-out rate at master’s level for thesisbased coursework was 56%, while the completion rate for master’s and doctoral students averaged 11% and 10%, respectively.[7] furthermore, studies reported a rapidly increasing number of pg students, most of whom were underprepared with regard to research.[8-10] with the foregoing in mind, the following research questions directed this study: • what perceptions do pg nursing students have of research supervisors? • which factors influence the manner in which pg nursing students perceive the expertise of their research supervisors? a coursework master’s degree is one of the pg education health professionals programmes aimed at increasing professionalism in the discipline. research constitutes 50% of the credits of the degree;[11] therefore, information on research supervision processes from pg nursing students would be useful in improving and enhancing the quality of the supervision. this could have a positive effect, resulting in an increase in the output of pg students. background. scientific advancement, particularly in the area of information communication technology (ict), challenges the mode of knowledge advancement at universities. such challenges are especially evident in the area of postgraduate (pg) research supervision, particularly in the light of the changing students’ demography, whereby there is a radical shift from full-time campus-based students to part-time students. this challenge is compounded by many countries not considering research competency as a requirement for pg supervision – the result of static and outdated curricula. objective. to explore the perceptions of pg nursing students with regard to the research supervision process. methods. a quantitative research study was conducted at the university of kwazulu-natal (ukzn), durban, south africa using non-convenience sampling. the pg research experience survey questionnaire was adapted for the current study. ethical clearance was obtained from ukzn’s ethics committee. the population consisted of the pg coursework master’s nursing students who were registered for the research project module during 2012. a total of 56 students participated, with a response rate of 70%. data were analysed using the statistical package for the social sciences 19 (spss 19) (ibm corp., usa). results. the findings revealed that more than half of the respondents (66.2%; n=37) rated the level of support from research supervisors as moderate on a scale of low to high. the period of research supervision, mode of attendance and status within the university were identified as factors influencing the perceptions of support from research supervisors. conclusion. this study recommends that, to improve the quality of research supervision, there is a need to include a research supervision module in the curriculum of nurse educators and to adopt online research supervision, underpinned by the extensive use of ict to accommodate both part-time and full-time pg students. afr j health professions educ 2016;8(2):135-139. doi:10.7196/ajhpe.2016.v8i2.294 research supervision: perceptions of postgraduate nursing students at a higher education institution in kwazulu-natal, south africa c muraraneza,1 mn; f mtshali,1 phd; s z mthembu,2 phd 1 department of nursing, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 kwazulu-natal college of nursing, department of health, pietermaritzburg, south africa corresponding author: s z mthembu (sindizama@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 136 october 2016, vol. 8, no. 2 ajhpe research methods this study comprised a quantitative and descriptive research method using non-convenience sampling, and was done at a selected university in kwazulu-natal, a province of sa. the pg research experience survey (pres) questionnaire of the higher education academy in the uk[12] was adapted for this study. to assess research processes, 10 items were added to the instrument. the reliability of the research instrument was checked by a pilot study of five coursework master’s nursing students from the school where this study took place. these students did not participate in the final study. cronbach’s α test was performed (α=0.91), indicating strong reliability of the instrument. the same results were obtained in a previous study done by abdullah and evans,[13] without the 10 additional items. ethical clearance (hss/0363/012m) was obtained from the university’s research ethics committee. the questionnaire and informed consent forms were sent to all the coursework master’s nursing students who had registered for the research project module during the 2012 academic year. the questionnaire was sent via the students’ e-mail addresses with the assistance of the pg administrative office. in addition, hard copies were also given to the respondents who preferred this means of participation. eighty questionnaires were distributed and 56 students participated, i.e. a response rate of 70%. the data were analysed using the statistical package for the social sciences 19 (spss 19) (ibm corp., usa). the tool comprised a 4-point likert scale varying from 1 (strongly disagree) to 4 (strongly agree). descriptive statistics such as frequencies, percentages, means and standard deviations were used to describe the quantitative data. inferential statistical methods were used to test the relationships among variables to identify factors that influence how pg students perceive their research supervisors. a p-value ≤0.05 was considered to be significant. results sociodemographic characteristics of respondents the mean age of the respondents was 43.02 years. the minimum period of research supervision was 5 months, while the maximum was 36 months (3 years), with a mean of 14 months. the largest proportion of the total sample consisted of females (83.9%; n=47), with males representing only 16.1% (n=9). the majority of respondents (80.4%; n=45) were part-time students, while 19.6% (n=11) were full-time students. there were 46 (82%) local and 10 (18%) international students. less than half of the sample (46.4%; n=26) had a bachelor of nursing degree, while 10% (n=5) had a bachelor of nursing: advanced practice (bnap) degree, and 44.6% (n=25) had an honours degree in nursing. the sociodemographic characteristics of the sample are given in table 1. research supervisor skills one of the areas explored in this study is the students’ perception of their supervisors’ skills and knowledge of the subject area. more than half of the respondents (60.7%; n=34) strongly agreed that their supervisors had skills and subject knowledge to adequately supervise them. about 66% (n=37) strongly agreed that they were guided with regard to the nature of the project expected at master’s level. however, less than half of the respondents (44.6%; n=25) moderately agreed that their supervisors made an effort to understand them, while 41.1% (n=23) strongly agreed with the statement. conceptualisation of research the conceptual phase is the first phase of the research process that refers to the developing and refining of abstract ideas.[14] the perceptions of pg students in the conceptual phases were also described. results of these descriptions showed that 51.8% (n=29) of the respondents strongly agreed, while 33.9% (n=19) moderately agreed that they were given good guidance in selecting and refining their research topic. only 37.5% (n=21) strongly agreed that they had been given guidance in the formulation and refinement of the purpose and objectives of the study, whereas 53.5% (n=30) moderately agreed. with regard to the theoretical or conceptual framework, respondents reported quite a low level of support from their supervisors. only 30.3% (n=17) strongly agreed that they had been guided in relation to the choice of the theoretical or conceptual framework appropriate to their topic of study, while 39.3% (n=22) moderately agreed. more than a quarter of the respondents (28.6%; n=16) moderately disagreed that they received sufficient support in the choice of the theoretical or conceptual framework. the level of support received in terms of the literature review was higher compared with that received for the theoretical or conceptual framework. a quarter of the respondents (25%; n=14) strongly agreed, while 55.3% (n=31) moderately agreed that they had been guided by their research supervisors regarding the literature review component of their projects. less than half of the respondents (46.6%; n=25) strongly agreed, while 41.1% (n=23) moderately agreed that they had been given good guidance in terms of their research methodology, as depicted in table 2. nature of support from research supervisors pg students’ perceptions of assistance from their research supervisors during data collection, data analysis, and report writing were explored. the findings of this study revealed that 62.5% (n=35) of respondents were table 1. sociodemographic characteristics of the sample sociodemographic variables attributes n (%) gender female 47 (83.9) male 9 (16.1) marital status single 7 (12.5) married 39 (69.6) divorced 9 (16.1) widow 1 (1.8) mode of attendance full time 11 (19.6) part time 45 (80.4) status within university national 46 (82.0) international 10 (18.0) previous academic qualification bachelor's degree 26 (46.4) bachelor of nursing (advanced practice) 5 (10.0) honours 25 (44.6) current nursing specialisation nursing management 12 (21.4) nursing education 10 (17.9) community health 13 (23.2) mental health 6 (10.7) midwifery 7 (12.5) critical care and trauma 8 (14.3) october 2016, vol. 8, no. 2 ajhpe 137 research busy with the data collection phase at the time of the study. of these, 22.8% (n=8) strongly agreed that they had received good guidance from their research supervisors with regard to data collection, 40% (n=14) moderately agreed, whereas 28.6% (n=10) moderately disagreed. among the respondents, 53.6% (n=30) had reached the stage of data analysis. of these, 16.7% (n=5) strongly agreed that they had received good guidance from their research supervisors at this stage, 43.3% (n=13) moderately agreed, whereas 36.7% (n=11) moderately disagreed. only 50% (n=28) were eligible to respond to the statement with regard to report writing. of these, 25% (n=7) strongly agreed that they had received good guidance, while 42.8% (n=12) moderately agreed, and 28.6% (n=8) moderately disagreed. nature of feedback students’ perceptions of the feedback provided and their relationship with research supervisors were explored. more than half of the respondents (62.5%; n=35) strongly agreed, while 33.9% (n=19) moderately agreed that their research supervisors had provided helpful feedback on their progress. however, only 33.9% (n=19) strongly agreed that they were receiving feedback within a reasonable time period, while 37.5% (n=21) moderately agreed. the majority of the respondents (67.9%; n=38) strongly agreed that they enjoyed a professional relationship with their research supervisors, 21.4% (n=12) moderately agreed, and 10.7% (n=6) moderately disagreed. among the respondents, 71.4% (n=40) strongly agreed and 21.4% (n=12) moderately agreed that they had not felt subject to harsh criticism by their research supervisors while they were receiving feedback. all scores of students’ perceptions of their research supervisors were combined to describe the overall perception of the levels of support (table 3). the majority of the respondents (66.1%; n=37) perceived a moderate level of support from their research supervisors, 32.1% (n=18) a high level of support, and only 1.8% (n=1) a low level of support. furthermore, the overall mean perceptions of research supervisors’ support was 3.23 out of 4, i.e. 80.7% indicating perception of a high level of support. discussion sociodemographic characteristics of respondents the findings of this study indicate that the respondents were predominantly female (83.9%). this confirms the findings of other studies, where the nursing profession has been portrayed as a predominantly female profession since its foundation.[15] adult pg students face many challenges, such as family commitments, work commitments and financial burdens, which they have to overcome. these challenges may affect their academic achievement.[16] the challenges are much greater if they are part-time students, as they have to manage their time and effort with regard to other commitments, including their jobs and families. the majority (55.3%) of respondents spent >10 months under supervision – the time expected table 2. students’ perceptions of research supervisor(s) students’ perceptions sdi, n (%) md, n (%) ma, n (%) sa, n (%) mean (sd) my supervisor(s) have the skills and subject knowledge to adequately support my research project 2 (3.6) 2 (3.6) 32 (18) 34 (60.7) 3.50 (0.73) my supervisor(s) give me guidance about the nature of the research project and the standards expected at master’s level 1 (1.8) 4 (7.2) 14 (25) 37 (66) 3.55 (0.71) my supervisor(s) give me guidance about the time frame so that the dissertation may be submitted on time 3 (5.4) 3 (5.4) 19 (33.9) 31 (55.3) 3.39 (0.82) my supervisor(s) make a real effort to understand any difficulties i face 2 (3.6) 6 (10.7) 25 (44.6) 23 (41.1) 3.23 (0.78) i have been given good guidance in topic selection and refinement by my supervisor(s) 8 (14.3) 19 (33.9) 29 (51.8) 3.37 (0.72) i have been given guidance in formulation and refinement of purpose and objectives of the study by my supervisor(s) 1 (1.8) 4 (7.2) 30 (53.5) 21 (37.5) 3.28 (0.67) my supervisor(s) guided me on the choice of the theoretical framework most appropriate to the study 1 (1.8) 16 (28.6) 22 (39.3) 17 (30.3) 2.98 (0.82) my supervisor(s) provide helpful feedback on my progress 2 (3.6) 19 (33.9) 35 (62.5) 3.59 (0.56) my supervisor(s) give me feedback in reasonable time 1 (1.8) 15 (26.8) 21 (37.5) 19 (33.9) 3.03 (0.83) i have received good guidance in my literature search from my supervisor(s) 2 (3.6) 9 (16.1) 31 (55.3) 14 (25.0) 3.02 (0.75) i have received good guidance on the methodology of my project from my supervisor(s) 1 (1.8) 7 (12.5) 23 (41.1) 25 (46.6) 3.27 (0.75) i have received good guidance from my supervisor(s) during data collection 3 (8.6) 10 (28.6) 14 (40.0) 8 (22.8) 2.77 (0.91) i have received good guidance from my supervisor(s) during data analysis 1 (3.3) 11 (36.7) 13 (43.3) 5 (16.7) 2.73 (0.78) i have received good guidance from my supervisor(s) during report writing 1 (3.6) 8 (28.6) 12 (42.8) 7 (25.0) 2.89 (0.83) the relationship between the supervisor(s) and me has been purely professional 6 (10.7) 12 (21.4) 38 (67.9) 3.59 (0.78) my supervisor(s) gave feedback that did not make me feel like she is attacking me as a person 2 (3.6) 2 (3.6) 12 (21.4) 40 (71.4) 3.61 (0.73) overall mean of perceptions of research supervisor(s) 3.23 sdi = strongly disagree; md = moderately disagree; ma = moderately agree; sa = strongly agree; sd = standard deviation. table 3. levels of support received from research supervisor(s) levels of support n (%) low 1 (1.8) moderate 37 (66.1) high 18 (32.1) total 56 (100.0) 138 october 2016, vol. 8, no. 2 ajhpe research to complete the research project for both part-time and full-time pg students. students are required to register and pay for each year of their research project. moreover, the university loses funding from the government if students do not graduate within the expected time frame, as stipulated in the new funding framework for public higher education institutions (heis) in sa.[17] in light of these, delayed throughput constitutes a waste of resources for both students and institutions. this places an extra burden on research supervisors, who have to supervise more students than expected – with decreased funding. therefore, scholarship development is compromised for both pg students and research supervisors. mccormack[18] asserts that the difference between expected and perceived research supervision is the major contributing factor to the drop-out rate of pg students. nature of support respondents were generally satisfied with the support of their research supervisors. a large proportion (60%) strongly agreed that their supervisors have the subject knowledge and skills to adequately support their research projects. lessing and schulze[10] assert that many master’s degree students acknowledge the competence of their research supervisors. however, only 55% of the respondents strongly agreed that their supervisors provided guidance regarding the time frame for submitting their dissertations. this could be due to the workload and/or lack of expertise of research supervisors. however, the degree to which research supervisors take students’ concerns seriously increases the students’ trust in them.[19] the results of this study show that fewer than half of the participants (44.6%) believed that research supervisors understood respondents’ difficulties. it is noteworthy that almost half of the respondents (51.8%) were highly satisfied with the guidance regarding topic selection and refinement. these results agree with those of lessing and schulze,[10] who indicate that students are generally satisfied with the support they receive from research supervisors in terms of guidance in the choice of an appropriate framework. some research supervisors are perceived as having little expertise with which to assist pg students during the conceptual phase of the research project. consequently, it is pertinent to train research supervisors to provide good guidance in terms of this critical aspect of the research process. designing and planning of the study the designing and planning phase follows and depends strongly on the conceptual phase. winsett and cashion[20] assert that a research method is determined by research questions. therefore, the research method for a study depends on the problem of the study, rather than the objective of the researchers. to successfully complete research therefore requires that students be guided by a supervisor who has an in-depth knowledge of the correct and relevant methodology. the findings of this study underscore the fact that fewer than half (46.6%) of the respondents strongly agreed that they had received good guidance on research methodology from their research supervisors. in light of this finding, it is concluded that most research supervisors at the university where this study was conducted were not effective in providing good guidance on research methodology. the outcome of the conceptual phase and the designing and planning phase is the actual research proposal. if students receive little or no guidance while creating their research proposal and obtain negative feedback from academics with reference to their proposal presentation, they become discouraged and demotivated with regard to the research process[21] and may therefore disengage themselves from the study. this has a negative effect, which results in late completion of their degree, while some even abandon their studies. the majority of respondents perceived guidance from research supervisors in the empirical and analytical phases of the research to be moderate. this demonstrates that research supervisors do act as facilitators, which could be a source of drive and motivation to continue with a research career. more than half of the respondents (62.5%) strongly agreed that they received helpful feedback on their progress, which is considered a source of motivation. this means that these respondents perceive their research supervisors as having the facilitation skills to encourage them to achieve their full potential. research supervisors are perceived as sometimes providing delayed feedback. this could be due to the traditional face-toface model currently used in the selected school, while the majority of the respondents are part-time students with full-time jobs. consequently, communication between students and supervisors is often delayed. it is noteworthy that there is a need for capacity building among research supervisors at pg level to enable them to adopt other than face-to-face methods, such as internet conferencing, wikis, skype, and accommodating part-time students more effectively. the period of research supervision and the time the student spends with his/her supervisor were also identified as factors that influence how pg students perceive their research supervisors. spearman’s rho test of these variables produced an output of −0.322 (p=0.016), which indicates a negative correlation. this suggests that when students spend a longer time with their supervisors owing to the extended duration of the research period, familiarity may breed contempt and they may consider their supervisors to be less capable. effective research supervisors are those who guide, mentor and assist the students to complete their degrees in the expected minimum time frames. it emerged that there was a significant relationship between perceived research supervision and mode of attendance (part time and full time). the result of the mann-whitney u-test was 143.00 (p=0.031). full-time pg students were more satisfied with their research supervisors (mean rank 38.00) than part-time students (mean rank 26.18). this study underscores the traditional model of face-to-face supervision benefiting full-time students, but disadvantaging part-time students.[2,15] the traditional model is often characterised by slow throughput rates, unacceptable behaviour by research supervisors, disputes between students and supervisors and a general lack of clarity regarding procedures and regulations for the supervision process.[15] it is difficult for part-time students who are employed full time to meet with their research supervisors during working hours. therefore, there is a need to incorporate an online research supervision model to accommodate part-time pg research students. nonetheless, the implementation of such a model should be done carefully, as it requires expertise by research supervisors in both research and online facilitation skills. furthermore, students participating in this manner require adequate computer skills; both students and research supervisors need to be sufficiently prepared for this model. to minimise isolation, research seminar strategies would need to be encouraged to support the model so that the practical implications of supervising research and receiving supervision can be managed. gender, age and marital status did not influence students’ perceptions of research supervisors. currently, heis accommodate all students without discrimination on the basis of age, gender and marital status. given that adult students are very motivated to pursue their studies, they perform october 2016, vol. 8, no. 2 ajhpe 139 research well because they are fully engaged with the research work.[22] previous qualifications do not influence the perceptions of research supervisors, as pg students are recruited based on specified standards as stipulated in the college of health sciences handbook.[23] there was also no difference in terms of current specialisation, possibly because pg students in this study were assigned to research supervisors by the school without considering their specialisation. conclusion and recommendations the results of this study show that the majority of respondents acknowledged their supervisors as being adequately knowledgeable and skilled to support their research projects. however, many of the respondents only moderately agreed that their supervisors understood their difficulties. a high level of satisfaction was also found relating to guidance on topics. most respondents displayed moderate satisfaction regarding the formulation of the purpose and objectives of their research. however, fewer than half strongly agreed that they had received good guidance from their research supervisors on research methodology. this implies that the majority of students perceived their research supervisors as being less skilled in research methodology. overall, the majority of respondents were moderately satisfied with the support of their research supervisors. the findings also revealed an inverse relationship between the duration of supervision and respondents’ perceptions of the ability of research supervisors. full-time pg students were more satisfied with their research supervisors than part-time students. this study emphasises how the traditional model of face-to-face supervision benefits full-time students, but disadvantages part-time students. the findings also indicate that there is no relationship between the perceptions of research supervisors and gender, age, marital status, previous qualification and current specialisation in nursing. to improve the quality of research supervision, there is a need to include a research supervision module in the curriculum of nurse educators to build the capacity of research supervisors with regard to the entire research process. furthermore, to explore the power of technology, it is necessary to adopt online research supervision to accommodate both part-time and full-time pg students. references 1. blass e, jasman a, shelley s. postgraduate research students: you are the future of the academy. futures 2012;44(2):166-173. doi:10.1016/j.futures.2011.09.009  2. zhao f. transforming quality in research supervision: a knowledge-management approach. quality higher educ 2003;9(2):187. doi:10.1080/1353832032000104807 3. severisson e. research supervision: supervisory style, research-related tasks, importance and quality, part 1. j nurs manag 2012;20(2):215-223. doi:10.1111/j.1365-2834.2011.01361.x 4. trudgett m. western places, academic spaces and indigenous faces: supervising indigenous australian postgraduate students. teach higher educ 2011;16(4):389-399. doi:10.1080/07294360.2014.890576 5. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 6. south african nursing council. regulations concerning the minimum requirements for registration of the additional qualification in nursing education, 2010. http://www.sanc.co.za/regulat/reg-ned.htm (accessed 19 july 2016). 7. tettey wj. challenges of developing and retaining the next generation of academics: deficits in academic staff capacity at african universities. calgary: university of calgary, 2010. 8. millberg lg, berg l, lindström i, petzäll k, öhlén j. tensions related to implementation of postgraduate degree projects in specialist nursing education. nurse educ today 2011;31(3):283-288. doi:10.1016/j.nedt.2010.11.012 9. singh s. an intervention to assist students with writing their dissertations and theses. s afr j higher educ 2011;25(5):1020-1030. 10. lessing a, schulze s. postgraduate supervision: students’ and supervisors’ perceptions. acta academica 2003;35(3):161-184. doi:10.4314/sajhe.v16i2.25253  11. college of health sciences. college of health sciences handbook. durban: university of kwazulu-natal, 2013. 12. hodsdon l, buckley a. postgraduate research experience survey. york: higher education academy, 2011. 13. abdullah mnly, evans t. the relationships between postgraduate research students psychological attributes and their supervisors supervision training. procedia soc behav sci 2012;31:788-973. doi:10.1016/j.sbspro.2011.12.142  14. brink h, van der walt c, van rensburg g. fundamentals of research methodology for health professionals. cape town: juta, 2006. 15. council on higher education. postgraduate research and supervision. pretoria: che, 2007. 16. ismail a, abiddin nz, hassan a. improving the development of postgraduates’ research and supervision. int educ studies 2011;4(1):78-89. doi:10.5539/ies.v4n1p78 17. department of education. a new funding framework: how government grants are allocated to public higher education institutions. pretoria: doe, 2004:1-20. 18. mccormack c. tensions between student and institutional conceptions of postgraduate research. studies higher educ 2004;29(3):319-334. doi:10.1080/03075070410001682600 19. segrott j, mcivor m, green b. challenges and strategies in developing nursing research capacity: a review of the literature. int j nurs studies 2006;43(5):637-651. doi:10.1016/j.ijnurstu.2005.07.011 20. winsett rp, cashion ak. the nursing research process. nephrol nurs j 2007;34(6):635-643. 21. ssegawa jk, rwelamila pd. the research skill factor as a cause for high postgraduate attrition rate. j engineer design technol 2009;7(3):293-322. doi:10.1108/17260530910998703. 22. quinn fm, hughes sj. quinn’s principles and practice of nurse education. 5th ed. delta place: nelson thornes, 2007. 23. college of health sciences. college of health sciences handbook. durban: university of kwazulu-natal, 2012. http://dx.doi.org/10.1016/j.futures.2011.09.009 http://dx.doi.org/10.1080/1353832032000104807 http://dx.doi.org/10.1111/j.1365-2834.2011.01361.x http://dx.doi.org/10.1080/07294360.2014.890576 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/http://www.sanc.co.za/regulat/reg-ned.htm http://dx.doi.org/10.1016/j.nedt.2010.11.012 http://dx.doi.org/10.4314/sajhe.v16i2.25253 http://dx.doi.org/10.1016/j.sbspro.2011.12.142 http://dx.doi.org/10.5539/ies.v4n1p78 http://dx.doi.org/10.1080/03075070410001682600 http://dx.doi.org/10.1016/j.ijnurstu.2005.07.011 http://dx.doi.org/10.1108/17260530910998703. article december 2012, vol. 4, no. 2 ajhpe 97 article the use of standardised patients (sps) in medical education is well documented in the usa and other developed settings, where sps are used for teaching,1-2 the development of communication skills,2-3 and the assessment of clinical competence through objective structured clinical examinations (osces).1,4 vu and barrows have defined an sp as ‘a real or simulated patient carefully coached to present a patient problem accurately and in a standardized manner for all examinees’.5 medical students taught with sps have shown similar levels of competence to those taught using inpatients6 and virtual patients.7 the use of the ‘ideal sp’ (a real patient with first-hand experience of a condition, who also has knowledge and teaching skills) seems to offer significant benefits, particularly in the development of certain skills and attitudes among students.8,9 reported challenges for sps relate to their emotional wellbeing and physical stamina, but are outweighed by benefits to learners, patients and educators.9 in fact, a systematic review described sp experiences as ‘positive’, ‘enjoyable’ and ‘empowering’ and students’ experiences as generally positive and valuable.8 however, since sp programmes require significant resources, medical schools in developing countries (such as on the african continent) more commonly utilise real patients for teaching and assessment. subsequently, literature on sps in medical education mostly originates from developed countries, with little information on its relevance in the african setting. the phc approach the notion of ‘patient-centredness’, while central to many western medical curricula, has particular historical relevance in african medical schools as it underpins the primary healthcare (phc) philosophy laid out at alma ata in 1978.10 in south africa, the phc philosophy has been central to health reforms in the post-apartheid era and has ideological relevance in the country’s medical curricula. the patientcentred nature of phc challenges the traditional medical model by denouncing inequality in care, by acknowledging the right of people and communities to be involved in decision-making, and by viewing healthcare as a collaborative act.11 developing a standardised patient programme in a primary healthcare curriculum: a needs analysis c e draper, n moller, l aubin, g edelstein, r weiss department of human biology, university of cape town c e draper, ma, phd clinical skills centre, department of medicine, university of cape town n moller, rn, rscn, ba, pg dipned l aubin, rn/midwife, educator of adults diploma g edelstein, gn/midwife, intensive nursing science, community nursing science, advanced nursing education, mphil r weiss, mb chb, mphil corresponding author: c e draper (catherine.draper@uct.ac.za) background and objectives. the use of standardised patients (sps) in medical education is well documented, mostly in developed settings. the aim of this study was to conduct a needs analysis for the development of a patient-centred sp programme within a primary healthcare (phc)-led curriculum at the university of cape town (uct) in south africa, and to make recommendations for its development. methods. a mixed methods study was conducted which included focus groups with fourth-year medical students (n=17), a questionnaire for thirdyear medical students (n=181), a questionnaire for patients who were examined by students (n=28), and quantitative tracking of patient-student encounters. results. while students experienced significant challenges in sourcing suitable patients for interviewing and examination, the majority placed such value on the interaction with real patients that benefits outweighed the challenges. for students, challenges included seeing patients who had minor or no clinical signs in order to complete their portfolio tasks. for patients (especially those with clinical signs) it included being examined multiple times by students. despite this, most patients expressed a desire to play a role in students’ education. the study revealed areas of tension and inconsistency with the philosophies of a phc curriculum, specifically in the areas of patients’ rights and the role of patients as ‘active teachers’. conclusions. an sp programme at uct could help with the skills development in second year. however, this role should include exploring the doctor-patient-student power relations with students, with a view to encouraging a more patient-centred professional identity for students. ajhpe 2012;4(2):97-101. doi:10.7196/ajhpe.170 article 98 december 2012, vol. 4, no. 2 ajhpe article in defining a patient-centred approach to the clinical consultation, illingworth12 identifies two essential components: a holistic view of the patient, which includes the patient’s perspective and feelings, and shared control of the consultation, decisions and management. phc-orientated curricula should therefore include teaching-learning activities that create opportunities for a power shift towards the patient. bleakley and bligh13 advocate early and sustained patient contact as the basis of a patient-centred curriculum, suggesting that this mutually beneficial dialogue between student and patient (with the doctor/educator in a supporting role) informs the development of a truly patient-centred professional identity. this is a departure from the traditional approach, where the patient plays a more passive and supportive role in the doctor-student relationship.13 local context and background medical students at the university of cape town (uct) follow a phcled, spiral, integrated problem-based learning (pbl) curriculum with minimal patient contact in the first 2 3 years. clinical interviewing and examination skills are taught by clinical skills educators (nurses) during the 2-year clinical skills course, and students generally practise their technique on each other until their third year, when they can start seeing patients in the adjoining tertiary hospital as a self-directed learning activity. however, the students and educators complain of serious logistical challenges in sourcing patients that have clinical symptoms and signs and are willing and well enough to manage multiple student examinations. the situation is complicated by the fact that inpatients at ‘teaching’ hospitals often have multiple co-morbidities unsuited to undergraduate student training. during this time, students are marginally exposed to sps through tutorials with the patient partners, a group of elderly, trained rheumatoid arthritis patients. trained role-players are also used as ‘patients’ for osce assessments. however, lack of funding and the faculty’s perceptions about the value of sps in the african context make it difficult to attract and retain suitable sps. in developed settings sps have been shown to play an important role where access to patients is a challenge, for example if patients are not suitable for undergraduate teaching, patients are too ill or unwilling to be examined, or staff are not available to teach in these settings.2 the question was raised whether a local sp programme could address these challenges with similar success. this programme – potentially called partners in clinical training – would also need to be embedded in the phc approach, with explicit emphasis on patientcentredness and patients’ human rights. to make recommendations regarding the development of such a programme, it was decided to explore the experiences and perceptions of third-year medical students and ward patients during and after the final 8 weeks of the clinical skills course which is a large self-directed learning component and takes place in the clinical areas. research aim the main aims of this study were to investigate the need for a sp programme at this institution, and identify specific challenges relevant to a phc-led curriculum. a secondary aim was to highlight areas where the existing research on sps may differ from that in the african context. methods a mixed methods study was conducted that included focus groups, student and patient questionnaires, and quantitative tracking of patient-student encounters. focus groups while the study focused on third-year students and their patients, it was decided to use fourth-year medical students’ ward experiences to identify relevant themes. three focus group discussions (n=17) were done, and were facilitated by a trained, experienced qualitative facilitator. the groups reflected the racial and gender diversity in the class. students were not given an incentive to participate, but refreshments were provided. the discussions were audio-recorded, and findings were used to identify key issues for developing a third-year student questionnaire. students were asked to discuss their challenges and experiences of working with real patients and with sps (patient partners) in a teaching environment, whether they thought that ward patients’ human rights were being infringed through these student encounters, and their views and recommendations on a sp programme at uct. student questionnaire an online questionnaire, based on themes identified by the senior students’ focus groups, was compiled by the research team and administered to thirdyear students at the end of their 8-week clinical skills course (n=181, 97% response rate). students were given the option to comment on any point if they wished to. all students gave consent to participate, and were aware that their participation was voluntary and anonymous. patient interviews ward patients who were examined by third-year students and gave consent to participate in the study (n=27) were interviewed by clinical skills educators. it was felt that patients were already familiar with the educators, and that brief, structured interviews rather than written questionnaires would pre-empt potential difficulties arising from low literacy levels or limited language proficiency. structured questions, based on themes identified by focus groups, were used. patients were asked how they felt about being examined (even repeatedly) by third-year students, whether they felt obliged to see students, what they thought of the students, and how they personally experienced the encounters. patients were also asked to share their opinion on the role and rights of the patient in hospital (in this case, a tertiary, academic facility). quantitative tracking of patient-student encounters data were collected on patient-student encounters by the clinical skills educators over the 8-week block to identify what the specific challenges were in sourcing ward patients. data analysis focus group discussions were transcribed verbatim, and a process of constant comparative analysis14 was used to generate summaries of the discussions. the themes were structured according to the following categories: • general comments • experiences of looking for and examining patients • patient rights • benefits and challenges of having real ward patients december 2012, vol. 4, no. 2 ajhpe 99 article • experiences of working with patient partners • recommendations for an sp programme. student questionnaire data were analysed for frequencies, and patient questionnaire data were analysed for content. the results of the tracking of patient-student encounters were summarised to identify key trends. approval for this study was granted by the human research ethics committee of the university of cape town (rec ref 038/2011). results fourth-year students’ perspectives fourth-year students agreed that practising clinical examination and interviewing skills, and learning how to interact with patients, were key learning outcomes in third year and prepared students for the clinical rotations in fourth year. however, finding enough patients was described as ‘chaotic’, ‘frustrating’ and ‘time consuming’. students sometimes had to pressure ward patients into being examined. despite these challenges, students placed great value on these interactions with real patients, and felt that it outweighed the time spent finding suitable patients. the majority of students believed that sps have a role to play but should not replace real patient interaction, as they felt they could learn more from interviewing an ‘unprepared’ (real) patient. sps were seen as most useful in second year during students’ introduction to examination and historytaking skills. the ideal sps should have clinical signs and be knowledgeable about their disease, and should not be ‘artificial’ or too different from a real patient. surprisingly, students from one focus group expressed rather strongly that patients should not be made responsible for teaching, and that when patients took on an active teaching role, this created an uncomfortable shift in the power dynamic. these students believed that clinicians, not patients, should teach medical students (about a disease or condition), and many students vocalised a desire for more teaching time with clinicians. third-year students’ perspectives third-year students strongly echoed the difficulty of finding suitable patients and the value of real patients, and generally agreed about the usefulness of an ‘ideal’ sp in some teaching situations (results in table 1). only 23% agreed that a knowledgeable sp could replace a clinical tutor, and some used the opportunity to praise their clinicians. similar to the fourthtable 1. third-year student questionnaire results how would you describe your experience of interacting with the selected ward patients? never sometimes often 1. i felt like i was pressurising/harassing patients, because they were not willing to speak to me 26% 72% 2% 2. real ward patients made a big difference in improving my history-taking and clinical examination skills 0% 6% 94% 3. real ward patients were extremely useful in the development of my interpersonal skills, such as approaching a patient, building rapport, and managing difficult patients 0% 12% 88% 4. i felt like i wasted a lot of time looking for patients 36% 51% 13% 5. there were times i felt unable to help my patient 22% 63% 15% 6. as a 3rd-year student, i felt less valued in the wards 37% 53% 10% what challenges did you experience while looking for and interacting with ward patients? 7. there weren’t enough patients for all the students to see 17% 61% 22% 8. there wasn’t enough time to see all the patients 32% 45% 23% 9. patients were too sick or confused to speak to us 17% 81% 2% 10. patients were too tired to speak to us, or were sleeping 5% 81% 14% 11. patients were not there when we went to look for them 16% 79% 5% 12. i couldn’t understand or speak the patients’ home language 29% 69% 2% in your opinion, what role could standardised patients (sps)* play in the training of medical students? strongly disagree disagree neutral agree strongly agree 13. students should be able to regularly practise their clinical examination skills with sps 2% 0% 7% 47% 45% 14. students should be able to regularly practise their history-taking skills with sps 2% 3% 12% 43% 40% 15. sps should have real physical signs 2% 2% 14% 30% 52% 16. a knowledgeable sp can replace a clinical tutor to teach a particular topic 17% 30% 31% 17% 5% 17. the benefit of interacting with real patients in the wards (rather than sps) is outweighed by the time spent and frustration of looking for suitable patients 2% 7% 16% 38% 37% 18. even though it is an unavoidable part of medical training, i feel that repeated examinations by students infringes on patients’ human rights 9% 25% 37% 21% 7% *definition provided: ‘a standardised patient is ideally a real patient, with real physical signs, that is used repeatedly for examinations and exams with students, and will have had some training on how to present their history and give feedback to students.’ 100 december 2012, vol. 4, no. 2 ajhpe article year students, many expressed a desire for more tutorial time with clinicians, with one student suggesting that patient contact time be sacrificed. another wrote that ‘a curriculum with sps and real patients is ideal, but nothing can replace the time spent with clinicians’. notably, only 28% felt that repeated examinations by students infringed on patients’ rights, while 74% admitted that the patients they examined were at times reluctant to see them. many students chose to comment further on this point, either justifying their actions (‘as long as they give consent’) or describing their discomfort with the situation (‘there is no honour in treating poor people like they are poor’). it is ironic that while most students justified repeated examination of patients, two students commented that sps would find it a ‘major inconvenience to be examined so frequently’. some students alluded to issues of patients’ rights in their responses, and some of these related to the treatment of patients by clinicians. one student wrote that her clinician cut visiting hours short so that the students could examine the patient. ‘we were hounding his bed area like hawks ... i was shocked and offended because in ... we are taught to treat our patient like a human being and yet when we are exposed to the real clinical environment, patients are treated as learning objects with no rights or feelings.’ patients’ perspectives all the patients commented that ‘students had to learn’ and many said that they enjoyed the experience, as long as they were not too tired, which often was the case with repeated examinations (one patient said she saw three groups of third-year students in one day). while only one patient admitted to being pressured into seeing students, five patients were non-committal or deflected the question. others responded that they knew that they could say no if they felt ill, and felt comfortable doing so. all patients found students to be polite, professional and kind. one patient remarked that: ‘they treated me with such dignity. in fact they treated me better than my own family.’ patients generally expressed the desire to play a role in students’ learning, but none commented on their rights as patients. patient-student encounters data on patient-student encounters included the number of third-year students needing to see patients (210 per week), the number of ward patients suitable for examination (110 per week), the number of times these patients were seen by third-year students (10 times per week), how often patients refused to be examined by third-year students (approximately 30 per week), and whether the selected patients had clinical signs (75%). in the context of this study, ‘suitable for examination’ can be defined as patients having clinical signs and not being too ill (for example, not out of breath, not too infectious, coherent). the decision on suitability is made by the clinical skills educators, based on their experience of what is conducive for patient-student encounters, and these educators approach patients and ask them if they are willing to be seen by students. having patients with clinical signs is not always necessary, but definitely adds value to the students’ learning, such as providing an opportunity for students to integrate skills with recognising pathologies. the key issues that emerged from the tracking of patient-student encounters were that students often had to see patients who had minor or no clinical signs in order to complete their portfolio tasks. common respiratory conditions such as tuberculosis were not examined because patients were too ill. patients with clinical signs were seen multiple times by students, and since these patients were also targeted by senior students, they often refused further contact sessions. it also emerged that when asked by the educator, patients often agreed to be examined, only to send the students away when they arrived. some patients accepted ‘incentives’ to see students, such as soft drinks, crisps, or magazines. discussion the findings support students’ claims that they struggle to find suitable patients for practising essential skills; however, it seems that their experience of interacting with real patients far outweighs the challenges. the data also confirm what we already know from the literature: that students value sp encounters11,15 most during the early (preclinical) years, and that most patients enjoy being part of the educational process.7 however, two unexpected issues were raised related to the curriculum’s phc orientation. these issues may highlight some of the differences between the african context and other contexts where sp research has previously been conducted. further research may be necessary to explore these differences in more detail. the first refers to the students’ relative ambiguity about patients’ rights. due to the legacy of apartheid and the atrocities perpetuated by some health professionals, the uct medical curriculum has a strong ideological focus on human rights in health, especially in the first two years. however, it seems that boundaries between the need to examine patients and uphold their rights may become more blurred outside of the classroom, especially when a clinician does not role model professional behaviour. certainly, the many comments they wrote would suggest that at least students were not comfortable in these situations and the pressure put on patients. the fact that the majority of students had at times perceived their patients to be a reluctant participant seems to be excused by the recurring theme voiced by both students and patients: ‘students have to learn’. these findings emphasise the need to ensure that the human rights of patients remain a key thread through the clinical years of the curriculum. furthermore, the findings regarding the unprofessional behaviour of some clinicians highlight the reality that principles taught in theory do not always translate into the reality of a clinical situation. the second issue refers to what bleakley and bligh13 call ‘traditional doctorled medical education’. as much as they valued real patient interaction, the majority of students did not want to see patients in an active teaching role, and were in favour of more contact time with clinicians, whose time they appeared to have valued highly. this suggests that students may be in favour of this ‘traditional doctor-led medical education’, and that they were in support of the traditional power dynamic between patients and doctors. bleakley and bligh’s13 ‘authentic patient-centred model’ with collaborative knowledge production between student and patient is still a long way off, even in this phc-orientated curriculum. with clinical interviewing and examining largely being a self-directed learning activity, the experiences and perceptions of students are extremely important factors in making decisions about developing an sp programme. it is clear that sps are not the solution for the third-year course; rather, december 2012, vol. 4, no. 2 ajhpe 101 article these findings should be used to drive efforts to extend the teaching platform outside of the tertiary setting. phc settings could be ideal for the development of clinical interviewing and examination skills. an sp programme could be very useful to second-year students who currently have no ward or clinician time at all, providing a stepping-stone to ‘real’ patient interaction in third year. sps could also be trained to provide valuable feedback to second-year students on their clinical skills at this level. however, there may be yet another, more fundamental, role for sps that is worth exploring in an sp programme, i.e. guiding students to the place where they view interaction with patients as ‘collaborative knowledge production’ rather than ‘practising their (clinician-taught) skills’. this study is limited by the small sample size of patients interviewed, as well as the limited scope of the questions posed to patients. using a trained qualitative facilitator for interviews, instead of educators, may provide more in-depth understanding of how patients attempt to balance their educational responsibility with their patient rights, and how they view their place in a government-funded health system. exploring this aspect would be essential to the development of a phc-orientated sp programme. conclusion rather than developing an sp programme to provide additional learning opportunities for clinical students, a programme that is aimed specifically at pre-clinical students may be more valued, and help to bridge the gap between students’ pre-clinical and clinical experience. the design of the programme should also include activities that explore power relations between doctors, patients and students. such a programme may contribute to developing a truly patient-centred approach to clinical teaching and learning, and usher in the notion of ‘partners’ instead of ‘patients’ at this institution. references 1. howley ld, gliva-mcconvey g, thornton j. standardized patient practices: initial report on the survey of us and canadian medical schools. med educ online 2009;14:7. [http://dx.doi.org/10.3885/meo.2009.f0000208] 2. myung sj, kang sh, kim ys, et al. the use of standardized patients to teach medical students clinical skills in ambulatory care settings. med teach 2010;32(11):e467-e470. [http://dx.doi.org/10.3109/0142159x.2010.507713] 3. rickles nm, tieu p, myers l, chung v. the impact of a standardized patient program on student learning of communication skills. am j pharm educ 2009;73(1):4. 4. adamo g. simulated and standardized patients in osces: achievements and challenges 1992-2003. med teach 2003;25(3):262-270. [http://dx.doi.org/10.1080/0142159031000100300] 5. vu nv, barrows hs. use of standardized patients in clinical assessments: recent developments and measurement findings. educational researcher 1994;23(3):23-30. 6. gilliland wr, pangaro ln, downing s, et al. standardized versus real hospitalized patients to teach historytaking and physical examination skills. teach learn med 2006;18(3):188-195. [http://dx.doi.org/10.1207/ s15328015tlm1803_1] 7. triola m, feldman h, kalet al, et al. a randomized trial of teaching clinical skills using virtual and live standardized patients. j gen intern med 2006;21(5):424-429. [http://dx.doi.org/10.1111/j.15251497.2006.00421.x] 8. wykurz g, kelly d. developing the role of patients as teachers: literature review. bmj 2002;325(7368):818-821. [http://dx.doi.org/10.1136/bmj.325.7368.818] 9. jha v, quinton nd, bekker hl, roberts te. strategies and interventions for the involvement of real patients in medical education: a systematic review. med educ 2009;43(1):10-20. [http://dx.doi.org/10.1111/j.13652923.2008.03244.x] 10. world health organization – united nations children’s fund. declaration of alma-ata. international conference on primary health care; 6 12 september 1978, alma-ata, ussr. http://www.who.int/hpr/nph/ docs/declaration_almaata.pdf (accessed 11 may 2012). 11. mcdonald jj. primary health care: medicine in its place. london: earthscan publications, 1992:54-72. 12. illingworth r. what does ‘patient-centred’ mean in relation to the consultation? clin teach 2010;7(2):116-120. [http://dx.doi.org/10.1111/j.1743-498x.2010.00367.x] 13. bleakley a, bligh j. students learning from patients: let’s get real in medical education. adv health sci educ theory pract 2008;13(1):89-107. [http://dx.doi.org/10.1007/s10459-006-9028-0] 14. thorne s. data analysis in qualitative research. evid based nurs 2000;3:68-70. [http://dx.doi.org/10.1136/ebn.3.3.68] 15. bell k, boshuizen hp, scherpbier a, dornan t. when only the real thing will do: junior medical students’ learning from real patients. med educ 2009;43(11):1036-1043. [http://dx.doi.org/10.1111/j.1365-2923.2009.03508.x] editorial board editor-in-chief vanessa burch university of cape town international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria ntombifikile mtshali university of kwazulu-natal marietjie nel university of the free state ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state hmpg editor janet seggie consulting editor jp de v van niekerk deputy editor bridget farham editorial systems manager melissa raemaekers scientific editor kerry gordon technical editors emma buchanan robert matzdorff taryn skikne paula van der bijl head of publishing robert arendse production assistant neesha hassan art director brent meder dtp & design carl sampson anelia du plessis online manager gertrude fani issn 1999-7639 ajhpe is published by the health and medical publishing group (pty) ltd co registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za 28 main road (cnr devonshire hill road), rondebosch, 7700 | +27 (0)21 681 7200 all letters and articles for publication must be submitted online at www.ajhpe.org.za editorial 49 milestones for the ajhpe – what have we achieved in four years? v burch plenary lecture 50 le bon dieu est dans le détail – reflections on being a beaver d prozesky research 56 micro, meso and macro issues emerging from focus group discussions: contributions to a physiotherapy hiv curriculum h myezwa, a stewart, p solomon 63 a reflection on professional development of registrars completing a module in health care practice j bezuidenhout, m m nel, g j van zyl 68 career and practice intentions of health science students at three south african health science faculties c naidu, j irlam, p n diab 72 student and staff perceptions and experiences of the introduction of objective structured practical examinations: a pilot study j m frantz, m rowe, d a hess, a j rhoda, b l sauls, l wegner 75 training on prevention of violence against women in the medical curriculum at the university of ibadan, nigeria o i fawole, j van wyk, a adejimi 80 ten key elements for implementing interprofessional learning in clinical simulations i treadwell, h s havenga 84 skills training of junior medical students: can peer teaching be the solution? i m mutwali, a n hassan 88 factors influencing the recruitment and retention of faculty at the catholic university of health and allied sciences, bugando, mwanza, tanzania s e mshana, m manyama 91 roles and attributes of physiotherapy clinical educators: is there agreement between educators and students? d v ernstzen 95 shortage of faculty in medical schools in tanzania: a case study at the catholic university of health and allied health sciences m manyama, s e mshana, r kabangira, e konje short report 98 experiential learning outside the comfort zone: taking medical students to downtown durban, south africa n prose, p diab, m matthews correspondence 100 lack of research skills teaching not just an african education issue t i lemon 101 cpd questionnaire ajhpe african journal of health professions education | november 2013, vol. 5 no. 2 mailto:publishing@hmpg.co.za http://www.ajhpe.org.za editorial 2 december 2011, vol. 3, no. 2 ajhpe why publish? (about medical and health professional education in africa) two recent experiences have provided me with much food for thought about the publication need in medical and health professional education in africa, and the lament about the lack of such publishing in, about, and out of africa. i was privileged to attend the africa regional consultative workshop for health care improvement, catalyzing and institutionalizing quality improvement, from 17 to 21 october 2011 near kampala, uganda. the conference was expertly organised by the regional centre for quality and health care (rcqhc) at makerere university at a modern, wellequipped and scenic venue. it was, however, my fellow africans who attended the meeting who left a lasting impression on me. there were 150 or so dedicated, talented, enthusiastic, friendly, caring and warm health professionals and health service managers from a range of african countries. the unique format of the meeting made it possible to learn about the impressive work that people are doing in their part of the continent. there was an abundance of innovation, expertise, resilience and moreover excellence on quality improvement in health on display. i was surprised by my own surprise as we have become conditioned to hearing only the negative things about africa. back in south africa and ten days later i read the sub-saharan african medical schools study (samms) article ‘medical education in subsaharan africa: a literature review’ authored by sr greysen et al., and published in medical education.1 this extensive literature review looked at what is published on medical education in africa in order to ‘promote a broader understanding of the history and current status of medical education in sub-saharan africa’. they came up with a rich haul of work showcasing developments and innovation. the authors pointed out that there is a lack of publications on medical education in most parts of the continent. they highlighted the dire need to develop medical education as a scholarly discipline and concluded by stating that ‘medical education as a field of inquiry and practice specific to the sub-saharan africa region is underdeveloped’. many of you will testify to similar experiences like mine at the kampala conference ─ amazing work on medical and health professional education is happening in africa. this brings me back to the title of this editorial. why should we publish, and why should we publish on medical and health professional education in africa? is it because ‘that which you cannot see does not exist’? let me try to answer the question by looking at the how. in africa we like to tell stories, we learn from stories, we are strong on stories. if you are reading this editorial you are interested in the work of this journal, and you have a story to tell. tell your story, as it is. you are the expert on your story, and there will be something for someone to learn from your experience. telling your story (on paper of course) will change you; the reflection on your story will stimulate ideas on how you can improve on what you are doing. this may even help you to make a bigger contribution to the community you are serving, and maybe even the health of the people on the continent. the next step is to think about how others can learn more from your story. do a small evaluation on your project. write it up again. reflect on what has happened, why did it happen, and how can it be improved? now, instead of only producing a description of your work, see if you can investigate it in such a way that you can analyse the effect or lack thereof; in other words, move your work beyond observation alone. you, your students, your communities, and africa will benefit. engage in ways in which you can produce work which yields results that you can use to justify your educational practice, and explore how your research can contri bute to clarifying why and how certain interventions work and others not.2 in what is being regarded as seminal work on health professional education, frenk et al.3 argue that the education of health professionals has not remained in step with the realities of the 21st century. this they attribute to, amongst others, a range of curricula issues relating to relevance, fragmentation, lack of alignment, limited emphasis on interprofessional activities, imbalances, including an over-reliance on technical skills that limits the potential for a more encompassing approach to patient care. let me conclude with an inspiring quote from this article: ‘ultimately, reform must begin with a change in the mindset that acknowledges challenges and seeks to solve them. (this) is a long and difficult process that demands leadership and requires changing perspectives, work styles, and good relationships between all stakeholders … professional educators are key players since change will not be possible without their leadership and ownership. so too are students and young professionals ...’ i want to argue that africa’s medical and health professional educators already have these qualities. it is just a matter of us telling our stories. marietjie de villiers deputy dean: education faculty of health sciences stellenbosch university e-mail: mrdv@sun.ac.za 1. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, sewankambo n, mullan f. medical education in sub-saharan africa: a literature review. medical education 2011;45:973-986. 2. cook da, bordage g, schmidt h. description, justification and clarification: a framework for classifying the purposes of research in medical education. medical education 2008;42:128-133. 3. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, fineberg h, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010; 376:1923-1958. marietjie de villiers and peter arimi of the hiv/aids office usaid/east africa. article may 2013, vol. 5, no. 1 ajhpe 34 background. the university of the witwatersrand introduced a new curriculum in 2003 where students could gain admission to the medical programme at two levels: directly as school leavers or following a degree as graduate entrants at the third year of study. from this point both groups of students continue in a combined class in a single curriculum. objective. to determine the experiences of the fifth cohort of graduating students from a medical programme following curricular transformation. method. a quantitative descriptive study was undertaken using a semi-structured questionnaire with both openand closed-ended questions. there were 201 students in the graduating class, all of whom were invited to complete the questionnaire. results. a 74% response rate was obtained, of which 66% were school leaver entrants and 34% were graduates. among the best experiences there were 59 comments relating directly to the programme. the worst experiences included perceptions of the lack of standardisation in clinical exams and feelings of inadequacy in relation to pharmacology and microbiology. just under three-quarters of the participants felt ‘adequately prepared’ for the clinical years; 82% of the participants stated that they would make changes to the programme. conclusion. the placement of this evaluation at the conclusion of formal assessments may have contributed to the depth of responses and openness of respondents in the completion of the questionnaire. we highly recommend the value of obtaining data on students’ experiences and opinions of a programme at the point of exit from the programme. ajhpe 2013;5(1):34-36. doi:10.7196/ajhpe.210 experiences of graduating students from a medical programme five years after curricular transformation: a descriptive study p mcinerney, phd; l p green-thompson, mb bch, fca (sa), mmed; d m manning, phd centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: p mcinerney (patricia.mcinerney@wits.ac.za) the south african medical education curricular landscape has changed over the last two decades.[1] many of the innovations have attempted to embrace the ideals of the ‘five-star’ doctor first espoused by boelen[2] in 1993 and reinforced by local guidelines from the health professions council of south africa (hpcsa). the focus of these changes has been the development of student-centred learning and a biopsychosocial approach to healthcare which is best learnt and delivered at the primary healthcare level. the development of reflective lifelong learners is another feature of these innovations. the university of the witwatersrand introduced a new curriculum in 2003. students were able to gain admission to the medical programme at two levels: directly as school leavers or following a degree as graduate entrants at the third year of study. from this point both groups of students continue in a combined class in a single curriculum. it had all the hallmarks of an innovative modern international curriculum. the transformed curriculum produced the first graduates in 2006. students spent two years in a hybrid problem-based learning programme arranged in organ-system blocks. the problem-based learning process is supported by content-based lectures and learning topics. the teaching of applied anatomy and physiology, pathology, pharmacology and clinical skills is integrated together with themes related to the patient-doctor relationship, the community-doctor relationship and personal and professional development, including bioethics and evidence-based medicine. early clinical exposure was ensured through one health practice day a week at the teaching hospitals on the academic circuit. the final two years of the programme were made up of six weekly rotations through the clinical disciplines, which include an integrated primary care (ipc) block in the final year. each of these rotations is concluded with a summative assessment which is immediately followed by remediation – if required. student learning during this period is guided by a list of case competencies graded for the level of competence to be attained. the primary method of instruction remains teaching at the bedside. the clinical teachers are encouraged to consider the following during these teaching sessions: epidemiology, patient communication, quality of care and its evidence base, follow-up care, the multidisciplinary team, appropriate levels of healthcare delivery and the impact of resource constraints in patient management. in 2010, the fifth cohort of students graduated from the revised curriculum. this group was chosen to reflect on their experiences of the curriculum in terms of their achievement of outcomes in the domains of knowledge, skills and professional behaviour. the objective of the study was to determine the experiences of the fifth cohort of graduating students from a medical programme following curricular transformation. curriculum evaluation is integral to curriculum development and implementation.[3] students are important stakeholders in the curriculum. graduates of medical programmes have been followed up at varying intervals after their graduation[4,5] to determine how well they were prepared for practice. watmough et al.[6,7] interviewed graduates from both old and new curricula to compare perceptions of preparedness for practice. data collected after graduation are valuable in that it reflects the experiences of practitioners, compared with data collected at the point of graduation which has not been influenced by post-graduation experiences.[8] articlearticle 35 may 2013, vol. 5, no. 1 ajhpe methods a quantitative descriptive study was undertaken using a semi-structured questionnaire with both openand closed-ended questions. the questionnaire established the respondents’ route of entry to the programme, explored students’ best and worst experiences of the curriculum, their perceptions of assessment throughout the curriculum and their perceived level of preparation for the final two years by the earlier years of the programme. the respondents were asked what changes they would make to the programme, if they felt changes were needed. they were able to make any general comments. permission to undertake this study was obtained from the human ethics research committee in the faculty of health sciences, university of the witwatersrand. following their last final examination session, students were invited to participate in the study through the voluntary completion of the questionnaire. subject information sheets and questionnaires were given to students and a box was provided for students to return their completed questionnaires anonymously. completion of the questionnaire was taken as consent. responses to the close-ended questions were captured in an excel spreadsheet and the open-ended questions were analysed using a qualitative approach, where similar responses were grouped together and categorised. results of the 201 students in the graduating group, 149 completed the questionnaire, giving a 74% response rate. of these, 66% were school leaver entrants and 34% were graduates, a similar representation to that of graduates in the class. in an open-ended question participants were asked to describe their best and worst experiences of the programme. among the best experiences there were 59 comments that related directly to the programme, with statements such as the ‘integration of the subject matter’, ‘being taught to think out of the box’, ‘learning to communicate with patients’ and ‘the mix of a diversity of people in the programme who have different skills and viewpoints’. there were 31 comments that related directly to clinical practice, with participants commenting on the experience of becoming part of the healthcare system and around relating to patients and their diagnoses compared with learning facts from a textbook. among the best experiences were comments related to the teaching that participants had received – ‘being taught by the best in the field’. likewise, several of the worst experiences also related directly to the programme. among the 50 comments in this category were the perceptions of the lack of standardisation in clinical exams and the feelings of inadequacy in relation to pharmacology and microbiology. consistent with the lack of standardisation in the clinical exams were the comments related to inconsistencies in teaching and learning methods at the different learning sites. the pressure of examinations every six weeks were also related to as ‘worst experiences’. there were two open-ended questions about assessment, the first of which asked respondents to comment about their overall experience of assessment in the programme. of the 149 respondents, 40 (26.8%) made a global comment that the assessments were ‘good’, ‘okay’ or ‘fair’, and three did not answer this question. many of these respondents were included among those who elaborated on the assessments. these additional responses could be categorised into clinical assessments (61 comments); theoretical assessments (22 comments); and general comments (10 comments). the majority (54.1%) of the comments about clinical assessment referred to the subjectivity of the examiners and 18% to the varying standards between the different clinical sites. despite the frequency of examinations being listed in an earlier question as a ‘worst experience’, only 6.6% of the comments referred to the frequency of examinations as being a negative factor in the assessments. the second of the questions asked participants to comment on the relationship between learning and assessment. while 46 (30.8%) did not answer this question, 99 (66.4%) gave responses that could be categorised into clinical assessments, theoretical assessments and general comments. in the category clinical assessments there were approximately 2.5 times the number of negative comments compared with positive comments. the most commonly mentioned negative comments were that clinical assessments tend to include aspects not taught in the ward, because they were not seen; that learning for clinical work and assessment are two different aspects; assessors’ expectations being too high for the period of exposure in the discipline; and a tendency for the ‘most interesting patient’ to be used in exams. the positive comments were if ‘people were willing to teach, it made a difference to the assessment’ and that learning and assessment correlated most of the time. there was a total of 22 comments in the category of theoretical assessment, with the most frequent comment (10; 45.4%) being that mcqs are not related to the learning objectives, with the most common clinical conditions often not being asked. four participants felt that the frequency of exams made the assessment exam driven, resulting in ‘cramming’ for exams. in the general category were comments such as ‘assessment is not a true reflection of one’s knowledge’ and ‘projects were often very time consuming and the amount learned was not proportional to the time put in’. just under three-quarters (107; 72%) of the participants felt ‘adequately prepared’ for the clinical years. twenty (13%) felt that they were well prepared and 22 (15%) felt that they were not prepared. none of the respondents who felt well prepared for the final years reported a need for change in the early clinical exposure. in contrast, of those who felt adequately prepared or unprepared for the final two years 27 (21%) felt that more clinical exposure would have improved their levels of preparedness. a participant who felt s/he was adequately prepared for the clinical years stated ‘i wish i had applied myself better in gemp i and ii [third and fourth year] in order to make gemp iii and iv [fifth and sixth year] easier’, and another wrote ‘you’ll never be prepared clinically to enter the wards, this comes with time and exposure’. ‘even though there was not extensive clinical exposure, the theoretical exposure gave me some confidence when going to the hospitals’, demonstrates how participants linked the theoretical and clinical components of the programme in their responses. the greater majority (122; 82%) of the participants stated that they would make changes to the programme. changes suggested by 111 (91.3%) of this group fell into four categories, i.e. clinical, theory, teacher and other. the majority of the suggestions were in the categories clinical (68%) and theory (71%). the most frequent suggestion in the clinical category was to begin practical work earlier. in the theory category two suggestions received an equal number of responses – the request for specific courses in microbiology and pharmacology and for some rotations such as internal medicine to be increased in length. teacher-related comments were few and each seemed to address a different aspect. in the ‘other’ category a range of comments were made from a request for the administration of the programme to be article may 2013, vol. 5, no. 1 ajhpe 36 improved to a request for a ‘mixer’ at the beginning of the third year so that the entire class is given an opportunity to get to know each other. discussion the high response rate of 74% as well as the range and depth of the responses to the open-ended questions is an indication that the graduating students appreciated the opportunity to reflect on their experiences in the programme and express their opinions on what they found to be most and least valuable. one of the intentions of the new curriculum was to encourage students to become reflective practitioners, as suggested by schön, who encouraged the integration of theory and practice.[9] we believe that the demonstration of these insights is evidence of appropriate professional attitudes, one of the attributes of the five-star doctor. many of the positive comments related specifically to integration of theory and practice which supported problem solving. there are a number of comments that emphasised the confidence which students felt in their clinical competence, shown by their feeling of being adequately prepared for the clinical years. the negative comments which focused on the subjectivity and lack of standardisation in assessment of some of the clinical disciplines raise concern, as standardisation is a necessary condition for reliability and validity of assessment.[10] the comments on written examinations which are not aligned with objectives, and the selection of clinical cases with diagnoses which are not necessarily important or common, are further indications that issues of content and construct validity may require further attention. additional written assignments are often experienced by students as consuming a greater amount of time relative to the learning benefits derived. this sentiment is shared by other students in studies of reflective portfolios.[11] the students’ suggestions for earlier clinical practice were interesting, as the new curriculum actually does introduce clinical experience a year earlier than prior to 2003. it is however likely that the time allocated in the weekly ‘health practice days’ may not be used as effectively as possible and further changes should be considered. teaching and learning of both microbiology and pharmacology remain areas of concern, confirming the findings of a recent major study in which smuts established a gap in these areas of knowledge for recent medical graduates.[12] smuts compared the performance of interns who were the last graduates of the old curriculum with the first graduating class of the new curriculum and found that both groups lacked confidence in their ability to prescribe. similar findings have been reported in other studies,[7,13,14] indicating that this is widely recognised as an area of concern in medical degree programmes. one of the limitations of this study was the wide range of responses obtained in the open-ended questions. this made analysis and categorisation of results difficult. while this limited the ability to measure the frequency of a particular experience, it has highlighted areas for structured questionnaires in future research. the findings of the study are valuable as a contribution to the evaluation of the programme from the point of view of the participants’ experiences in the acquisition of knowledge and skills as well as the development of professional attitudes and behaviours, i.e. levels 1 3 of kirkpatrick’s evaluation model.[15] the placement of this evaluation at the conclusion of formal assessments may have contributed to the depth of responses and openness of respondents in the completion of the questionnaire. the strength of the findings of this study are twofold. firstly, respondents had just completed a final assessment in their programme and yet were prepared to complete the questionnaire as evidenced by just under threequarters of the class returning the questionnaire. furthermore, respondents did not confine themselves to the space provided for each question. several wrote in the margins or made use of space at the bottom of the page, demonstrating the students’ commitment to providing constructive feedback on the programme. their responses demonstrated considered thought to educational concepts. as a result, important areas have been identified for curricular modification and further faculty development. we highly recommend the value of obtaining data on students’ experiences and opinions of a programme at the point of exit from the programme. references 1. seggie jl. mb chb curriculum modernisation in south africa – growing doctors for africa. africa journal of health professions education 2010; 2(1):8-14. 2. boelen c. frontline doctors of tomorrow. world health 1994;47:4-5. 3. goldie j. amee education guide no.29: evaluating educational programmes. medical teacher 2006;28(3):210224. [http://dx.doi.org/10.1080/01421590500271282] 4. schmidt hg, vermeulen l, van der molen ht. longterm effects of problem-based learning: a comparison of competencies acquired by graduates of a problem-based and a conventional medical school. med educ 2006;40:562-567. [http://dx.doi.org/10.1111/j.1365-2929.2006.02483.x] 5. prince kjah, van eijs pwlj, boshuizen hpa, van der vleuten cpm, scherpbier ajja. general competencies of problem-based learning (pbl) and non-pbl graduates. med educ 2005;39:394-401. [http://dx.doi.org/10.1111/ j.1365-2929.2005.02107.x] 6. watmough s, o’sullivan h, taylor d. graduates from a traditional medical curriculum evaluate the effectiveness of their medical curriculum through interviews. bmc med educ 2010;10:65 [http://dx.doi.org/10.1186/l4726920-9-64] 7. watmough s, o’sullivan h, taylor d. graduates from a reformed undergraduate medical curriculum based on tomorrow’s doctors evaluate the effectiveness of their curriculum 6 years after graduation through interviews. bmc med educ 2010;10:65. [http://dx.doi.org/10.1186/1472-6920-10-65] 8. green-thompson l p, mcinerney p, manning dm, mapukata-sondzaba n, chipamaunga s, maswanganyi t. reflections of students graduating from a transforming medical curriculum in south africa: a qualitative study. bmc med educ 2012;12:49. [http://dx.doi.org/10.1186/1472-6920-12-49] 9. schön da. educating the reflective practitioner. san francisco, california: jossey-bass inc, 1987. 10. downing sm, haladyna tm. validity threats: overcoming interference with proposed interpretations of assessment data. med educ 2004;38:327-333. [http://dx.doi.org/10.1046/j.1365-2923.2004.01777.x] 11. rees ce, shepherd m, chamberlain s. the utility of reflective portfolios as a method of assessing first year medical students’ personal and professional development. reflective practice: international and multidisciplinary perspectives 2011;6(19):3-14. [http://dx.doi.org/10.1080/1462394042000326770] 12. smuts kb. effects of curriculum change on medical graduates’ preparedness for internship. johannesburg: university of the witwatersrand, 2011. 13. woodward ca, ferrier bm. the content of the medical curriculum at mcmaster university: graduates’ evaluation of their preparation for postgraduate training. med educ 1983;17:54-60. [http://dx.doi. org/10.1111/j.1365-2923.1983.tb01094.x] 14. han wh, maxwell srj. are medical students adequately trained to prescribe at the point of graduation? views of first year foundation doctors. scott med j 2006;51(4):27-32. [http://dx.doi.org/10.1258/rsmsmj.51.4.27] 15. morrison j. abc of learning and teaching in medicine: evaluation. bmj 2003;326:385-387. [http://dx.doi. org/10.1136/bmj.326.7385.385] 26 may 2015, vol. 7, no. 1 ajhpe research botswana has significant healthcare challenges; the effects of the ‘brain-drain’ and hiv in southern africa have been well described. effective leadership is required to successfully strengthen botswana’s health system and address these challenges. however, there is a persistent need for more leadership in healthcare, especially in underserved areas.[1,2] physicians have a unique role in health system improvement, given their significant influence.[3,4] some have specifically called for physicians to be ‘change agents’ who drive the strengthening of health systems.[3-6] fortunately, there is a growing consensus that physicians can be taught leadership skills.[1,7,8] graduate medical education (gme) is an ideal time and setting to begin teaching leadership, as many physicians first exercise their leadership skills in the clinical training environment.[7,9] in botswana, the recent establishment of a number of residency programmes highlights the ideal time to investigate physician leadership. medical educators aim to train physicians towards a set of competencies. for example, in botswana the residency programme curricula have been informed by the canadian medical education directives for specialists (canmeds) physician competency framework, developed by the royal college of physicians and surgeons of canada in the 1990s, updated in 2005 and currently being updated for 2015.[10,11] other medical education organisations utilise similar competency frameworks.[5,12,13] while gme traditionally focused on clinical training, these frameworks include additional competencies. even though the frameworks are comprehensive, competent physicians are not necessarily effective leaders. the reason may be found in the most widely cited (neocharismatic) leadership theories, including the hypothesis that for leaders to be effective they must be perceived to be leaders by those they lead.[14] having the competencies of a physician, may not be sufficient to ensure effectiveness as a leader. an important question for botswana is whether the use of canmeds alone will produce not only competent physicians, but also effective physician leaders. if physician leadership is perceived differently in botswana from what is explicitly described in the canmeds framework, these differences could inform the gme curriculum. to date, the canmeds 2015 update has had only limited input from one southern african country (canmeds administrative staff (canmeds@royalcollege.ca), question about canmeds, 2014 – personal communication). alternatively, if perceptions of physician leadership are well described by canmeds, it would lend validity to use of the framework to shape physician leadership education. while canmeds 2005 and the draft 2015 update include the concept of leadership, both tend to describe it in nonspecific terms (appendix 1). understanding perceptions of physician leadership in botswana could deepen our understanding of the terms used in the frameworks, such as ‘collaborative leadership', 'followership’ and ‘personal leadership skills’. to understand perceptions of physician leadership in botswana, we focused on botswana’s two main teaching hospitals, princess marina hospital (pmh) in gaborone and nyangabgwe referral hospital (nrh) in francistown. we concentrated on perceptions of physicians in internal medicine because of their primary roles in the academic hospital environment, and as internal background. physician leadership is essential for the strengthening of health systems, especially in underserved settings such as sub-saharan africa. to be effective, leaders must be perceived as such by their community. it is unknown how perceptions of physician leadership in botswana compare with those of the canadian medical education directives for specialists (canmeds) physician competency framework, which is used to shape the training of botswana’s future physicians. objective. to examine if the perceived competencies of physician leadership in botswana are specifically named in the canmeds framework and thereby inform botswana’s graduate medical education. methods. we conducted focus groups discussions with nurses, interns, medical officers and specialists at princess marina hospital and nyangabgwe referral hospital. key questions focused on describing the qualities of physician leadership. for data analysis we used inductive content coding and comparison with the canmeds frameworks. results. forty-eight clinicians participated and 111 unique codes were assigned to 503 comments. eighty-four per cent of comments corresponded to the canmeds 2005 competencies; many were captured within the competencies of the medical expert (13.0%), communicator (17.8%), collaborator (15.6%), scholar (14.9%) and professional (31.3%) roles. about 5% of comments mapped to the draft canmeds 2015 update, and 11.5% were not specifically described in either version of canmeds, including charisma and decisiveness. conclusion. the canmeds frameworks specifically address most of the competencies perceived as important for physician leadership in botswana. additional perceptions were identified that may require the attention of existing and aspiring physician leaders and their teachers to ensure they attain and maintain their effectiveness as leaders. afr j health professions educ 2015;7(1):26-31. doi:10.7196/ajhpe.312 perceptions of physician leadership in botswana l sokol-hessner,1 md; b m tsima,2 md; c j dine,3 md; b masheto,4 md; j a shea,3 phd; j masunge,4 md; o nkomazana,2 mb chb, fcophth, msceh 1 university of pennsylvania, internal medicine residency program, global health track, philadelphia, usa 2 university of botswana school of medicine, gaborone, botswana 3 university of pennsylvania, department of medicine, philadelphia, usa 4 nyangabgwe referral hospital, francistown, botswana corresponding author: l sokol-hessner (lhessner@bidmc.harvard.edu) may 2015, vol. 7, no. 1 ajhpe 27 research medicine was one of the first residency programmes introduced at the university of botswana. we also included nurses, as they have traditionally held many of the leadership positions in botswana’s health system and work closely with physicians at all levels of training.[15] methods study design and participants we conducted focus group discussions in march 2010. all participants worked in the medical wards at pmh and nrh and voluntarily took part after being recruited via verbal announcements on the wards by study investigators. each focus group consisted of one type of medical professional (nurses, interns, medical officers and specialists) at each of the two hospitals for a total of eight groups. interns have completed medical school and medical officers have completed an internship, while specialists have completed a residency. the ethical committees at the botswana ministry of health, pmh, nrh, and the university of pennsylvania approved the project. procedures and statistical analysis we designed the moderator script to elicit participants’ perceptions of qualities necessary for physician leadership. the focus group guide from previous work[16] was reviewed by researchers familiar with qualitative research in botswana. in the lead question participants had to recall a scenario where they either acted as or observed a physician leader and describe the qualities that made the physician a good leader. discussion was primarily in english – the official language of the hospital environment – but participants were encouraged to express themselves in the local language (setswana), if preferred. we recorded and transcribed each session, and a reviewer from botswana translated as necessary. inductive content coding was used to analyse the data. two persons (bm, lsh) reviewed transcripts and analysed text content to identify the main themes. an iterative process of revision was used to develop a coding scheme, which was then approved by the entire research team before training a third reviewer (bmt) who was not involved in creating the scheme. two reviewers (bmt, lsh) then worked independently to recode each transcript, and differences in coding were reconciled collaboratively. where the reviewers could not reconcile their differences, the coding by the reviewer from botswana was used for the final analysis. trustworthiness of the analysis was examined by member checking and comparing the themes to leadership models from previous work. we then compared the focus group comments with the language used in the canmeds 2005 physician competency framework and the publicly available information about the upcoming canmeds 2015 update. comments that were not clearly represented in either of the canmeds versions were organised into categories informed by a review of the physician leadership literature. results fifteen nurses, 12 interns, 12 medical officers, and 9 specialists participated. nineteen of the participants were from pmh and 29 from nrh. twentyfive (52%) were women. inductive content coding generated 111 unique codes in our coding scheme; these were assigned to 503 comments. kappa ranged from 0 to 1.0, and a median of 0.66. some participants discussed leadership in the contexts of education, administration or research scenarios, but most described physician leaders in terms of their role in healthcare teams. table 1 shows the number and percentage of comments and the canmeds 2005 roles with which table 1. focus group perceptions specified by canmeds 2005, n=422 (83.9%)* medical expert, n=55 (13.0%) is knowledgeable, smart, or competent 21 is humble 5 has practical skills 4 spends time with patients 3 examines patients (i.e. ‘laying on of hands’) 3 treats patients holistically 3 has good judgement 3 acknowledges shortcomings 3 is resourceful 3 is knowledgeable about patients 2 is knowledgeable about traditional medicine 2 is hands-on 1 applies knowledge in context 1 is cautious 1 communicator, n=75 (17.8%) listens 17 is approachable 12 communicates 10 communicates with colleagues 7 communicates with patients 7 communicates proactively 3 communicates with patients in terms they understand 3 communicates with relatives 3 justifies his/her reasoning 3 respects patient beliefs or opinions 2 respects patient confidentiality 2 is empathetic or reassuring 2 avoids unnecessary barriers between themselves and patients 1 addresses patient concerns 1 is transparent 1 documents properly 1 collaborator, n=66 (15.6%) is not a dictator and does not abuse power 10 asks for and considers input from colleagues, even subordinates 10 works well in teams 9 is knowledgeable about the team 7 relates well with others 6 addresses and solves problems 6 does not humiliate 4 has the interest of the team in mind or promotes team spirit 3 is proactive or takes initiative 3 is willing to learn from colleagues 3 delegates 2 continued ... 28 may 2015, vol. 7, no. 1 ajhpe research they matched best. within that group of comments, most focused on the competencies of the medical expert (13.0%), communicator (17.8%), collaborator (15.6%), scholar (14.9%) and professional (31.3%) roles and very few on the health advocate or manager role. an additional 4.6% of all comments were best matched to the draft 2015 update (table 2), and 11.5% of comments did not fit easily into either version of canmeds (table 3). below we expand upon themes. perceptions of physician leadership and canmeds 2005 medical expert being a medical expert was very important to participants – they commented on the importance of being knowledgeable, smart and competent 21 times, the single most common comment overall. practising comprehensive patient care, including ‘taking time with the patient’, being aware of alternative medicine and applying knowledge in the socioeconomic context were also seen as important aspects of leadership. communicator communication had many aspects: ‘you should have good communication skills, to the patients, to your subordinates … to … your superiors’. listening well and approachability were key: ‘there should be no fear of being reprimanded’. as one participant said, ‘[proactive communication] should start on admission, straight away until discharge’. collaborator respect, support and encouragement were fundamental to teamwork: ‘… help us feel that … you can see how we are struggling to make things better … show appreciation to [the team]’. not being a ‘dictator’ was mentioned many times: ‘often people … turn leadership into a dictatorship, thinking that they will succeed, and that’s very dangerous’. table 1. (continued) focus group perceptions specified by canmeds 2005, n=422 (83.9%)* collaborator (continued) searches for underlying problems 2 is able to take direction from others 1 manager, n=21 (5.0%) is organised 9 is knowledgeable about the work environment or system 5 is disciplined or focused 5 is able to navigate the system they work in 2 health advocate, n=10 (2.4%) advocates for patients 3 is knowledgeable about the community 3 is knowledgeable about the culture 3 collaborates with communities 1 scholar, n=63 (14.9%) gives constructive feedback 10 guides others 8 is willing to learn 6 teaches 6 accepts criticism 5 acknowledges achievements and appreciates others 5 does research 4 keeps up to date 3 is academic 3 encourages 3 practises evidence-based medicine 2 gives feedback 2 is a mentor 2 is willing to change 1 seeks constant improvement 1 is reflective or evaluative 1 gives advice 1 professional, n=132 (31.3%) is professional† 15 is fair or impartial 12 respects and values others 12 is a model or leads by example (i.e. exemplary) 12 is committed or dedicated 9 is hard working 6 is honest or straightforward 6 takes responsibility 6 is accessible 5 is thorough 5 is patient 5 is trustworthy 4 continued ... table 1. (continued) focus group perceptions specified by canmeds 2005, n=422 (83.9%)* professional (continued) has good morals or is a good person 4 has botho 4 is reliable 3 is accountable 3 is non-judgemental 3 is compassionate 3 is able to control their emotions or manage their personality 3 acknowledges mistakes 2 is non-racial 2 balances confidence and humility 2 is presentable 1 meets targets 1 is respected by the community 1 is determined 1 is forgiving 1 is flexible 1 *number of comments; denominator for % is all comments. †always conduct themselves as a leader, even in situations where they have not been formally appointed. may 2015, vol. 7, no. 1 ajhpe 29 research participants felt strongly that leaders should search for underlying problems and their solutions, as one participant explained: ‘when there is a problem, a good leader should be bold enough to … confront it’. the ability to delegate was essential: ‘a good leader … has to be able to use the mind of others … he has to know how to utilize those under him’. asking for help was perceived as a strength: ‘[a leader] shouldn’t be … shy to ask … for a second opinion if he feels he’s failing … they should accept opinions from their subordinates’. manager there were few comments about being a manager. several participants said: ‘it’s very essential, as a … good leader, to manage your time’. understanding the work environment and healthcare system was of strategic importance: ‘research about everything that is … happening, like in the unit that you are’. another said: ‘even when the system is very difficult, you have to find your way … around the system’. health advocate there were also very few comments about this role. one participant said: ‘you have to have your patient’s best interest, everything will come from that’. another explained: ‘if you see a need for that patient to be done … you have to convince whoever is against that idea that it should be done for the patient’. scholar the importance of seeking constant self-improvement was described in several ways, especially with regard to being up-to-date and evidence based: ‘i think also you have to be academic. they have to know what the latest journals are saying … because as a leader, you should be able to make such decisions when your juniors come [to you with questions].’ other participants emphasised teaching and giving feedback: ‘you should be able to be a good teacher … because [your students] are going to end up where you are’. ‘a good leader is one who comes to you and says, “i think you need to improve on these areas”.’ being a mentor, giving advice and guiding others were also important: ‘you … have a group of young … newly qualified doctors who have no clue what the world of medicine is like … you need to mentor it’. another participant said: ‘for me a leader is the one who guides, or who shows where is the path, the route’. professional of all the canmeds roles, the professional was mentioned most (26% of all comments), and participants were most impassioned about this role: ‘in medicine you should expect somebody to assume some level of professionalism … we deal with human beings, you miss a boat, somebody loses their life’. many noted that leaders always conduct themselves as such, even when they are not in a formal leadership role. other aspects of being a professional included commitment, work ethic, honesty, fairness, impartiality, a sense of morals and accountability. participants also mentioned leaders needing to have botho. one of botswana’s former presidents said: ‘botho is a state of being humane, courteous and highly disciplined ... the value attached to life is central to the principle of botho’.[17] a focus group participant said: ‘botho [means] you know how to treat every human being right, and you know to respect everything’. being a role model was mentioned many times: ‘a leader should live an exemplary life … because if you just act professionally in front of the people you are leading, and outside that, you act like … somebody i don’t know, i want to take you as a pretending leader’. the importance of leading by showing was described several times: ‘before people follow you, you must be a model … if i expect my houseman to work up until 5:30, i must also be willing to work … . i expect my houseman to do a lumbar puncture, i should be able to do a lumbar puncture.’ leaders also needed to have humility and balance: ‘you should be cautious of what conclusions you reach’; another said: ‘that’s the … leadership skill, to know how to react, you need to know when to be flexible, but you need to know when to put your foot down as well’. table 2. additional focus group perceptions of physician leadership specified in the draft canmeds 2015 update. new canmeds 2015 language not present in the 2005 version is delineated in italics, n=23 (4.6%)* medical expert 7 (30.4%) promotes accountability or holds others accountable 7 enabling competencies: 4.1 establish the roles of the patient and all team members for follow-up on investigations, response to treatment, and consultations, and ensure that the agreed follow-up occurs leader (previously manager) 14 (60.9%) has a vision or plan 10 sets expectations or targets 4 role description: at a system level, physicians contribute to the development and delivery of continuously improving healthcare and engage others to work with them toward this vision scholar 2 (8.7%) is innovative or creative 2 key concepts: clinical innovation there were no additional comments mapping to the communicator, collaborator, health advocate or professional roles. *number of comments, denominator for % is all comments. table 3. additional focus group perceptions of physician leadership not specified by canmeds 2005 or the 2015 draft, n=58 (11.5%)* charismatic 26 (44.8%) is inspiring or motivating 9 unifies 6 is passionate about their work 4 is friendly 4 is likeable 2 has a good attitude 1 decisive 29 (50.0%) is confident or assertive 13 is decisive or takes a stand 8 is firm 8 miscellaneous 3 (5.2%) is experienced 2 distinguishes themselves 1 *number of comments, denominator for % is all comments. 30 may 2015, vol. 7, no. 1 ajhpe research perceptions of physician leadership and the draft canmeds 2015 update medical expert the updated language in one of the enabling competencies refers to the concept of accountability (table 2). a participant said: ‘part of what leaders do also is help other people be accountable, not just themselves’. leader (formerly manager) the authors of the expert working group for the manager role in the 2005 framework decided to change the name of the role to leader for the 2015 update and for the first time included the concept of vision. ‘… a good leader is one who would have … short term and long term goals.’ an example of how to set targets to engage one’s team was: ‘ok, i can see that this is the way that things are being done, but my dream and my goal is for us to develop in this field and ultimately move to … this level. so how can we reach that level?’ another said, ‘i also think a good leader should have a vision … so that he’s able to guide his team where … they are going in the right direction’. scholar the key concepts for this role in the 2015 update include innovation, and one of the participants said: ‘a good leader should also be innovative. bringing in new ideas’. additional perceptions of physician leadership there were a number of comments on perceived qualities of physician leadership that were not clearly identified in canmeds 2005 or the draft 2015 update. charismatic the ability to be a positive figure was identified many times: ‘for you to inspire other people, you should show passion to your work. you shouldn’t be called to come and do your work. you should come and look for work.’ physician leaders ‘get people to do stuff, but … they don’t fight with them … they just make things happen’. another participant offered a key insight: ‘[the leader] may have a very brilliant idea, but if she comes and says … it’s her idea [then we won’t do it] … but if she comes and puts it on the table, we discuss, it becomes our idea … then we will do it all’. decisive there were >30 comments about having a ‘strong personality, somebody who … is … comfortable with [themselves]’. participants felt this was necessary for teams to have confidence in their leaders. discussion our study is the first to describe the overlap between the perceived competencies of physician leaders and an existing gme competency framework used in botswana and much of southern africa. eighty-four per cent of the comments by focus group participants were consistent with the canmeds 2005 framework, while 5% were consistent with language found in the draft 2015 update. these focused on the concepts of vision – which has been noted in multiple other physician leadership studies[4,7-9] – and promoting accountability. the results suggest that training physicians according to the canmeds framework, especially after the 2015 update, will cover most of the perceived competencies for effective physician leadership. although more comments were consistent with the professional than any other role, the single most common comment was about being a knowledgeable, smart, competent medical expert. the centrality of medical expertise for physician leaders has been previously noted[3,16] and was validated by our participants, who primarily referred to physician leadership in the context of clinical teams in the hospital. beyond the perceptions that matched well with the two versions of canmeds, we found that >11% of comments were about charisma and decisiveness. neocharismatic leadership theories are the most widely cited outside of medicine;[14] therefore it is not surprising that our focus groups perceived charisma to be important. to date, the concept of decisiveness has not been a prominent part of the leadership literature and may be worth investigating further. nevertheless, the perceptions not captured in the canmeds frameworks may be part of how healthcare providers in botswana would consider the terms ‘collaborative leadership’, ‘followership’ and ‘personal leadership skills’, which are used by the authors of the canmeds 2015 update. notably absent from the comments were the roles of health advocate and manager. although it is not clear why these roles were emphasised less often, it is not a novel occurrence. an evaluation of the canmeds framework in canada found that many programmes had not used the health advocate or manager roles in their curricula as often as the other roles.[10] based on other physician leadership work, especially focusing on administrative and executive leadership positions, we know that these roles are often very important and therefore may require additional attention when designing curricula.[4,9] future work may explore why participants did not mention these skills more frequently. our study had several limitations. we only investigated one setting with a limited number of providers, which may limit the generalisability of the results to other contexts. this is mitigated somewhat by the similarities between the leadership competencies identified and those described in previous work.[7,16] secondly, although clinicians in botswana are from many different cultures, our study was not designed to determine how these cultures may view physician leadership. awareness of cultural differences may be an important part of developing effective physician leadership assessment tools and training programmes.[4] thirdly, participants in focus groups may have been unwilling to discuss certain characteristics in the presence of others. attempts were made to minimise this effect by ensuring that groups were composed only of colleagues of the same clinical training, emphasising anonymity of comments, and conducting groups in a non-judgemental way. conclusion our research on perceptions of physician leadership demonstrates good congruence with the gme framework used in botswana and reveals insights that can inform aspiring and established leaders and their teachers. some have been sceptical about whether the competencies of physician leadership can be taught,[8] but as we have shown, most of what nurses, interns, medical officers and specialists in botswana perceive as important for physician leadership are already part of gme curricula. future work could include the use of innovative educational methods, such as structured individualised learning plans to teach and reinforce leadership competencies.[4,7,9,18] in addition, the development of physician leadership assessment tools could strength physician leadership training.[9,18] competencies that are measured will be more highly valued, both by educators and students. may 2015, vol. 7, no. 1 ajhpe 31 research references 1. levey s, hill j, greene b. leadership in health care and the leadership literature. j ambulatory care manage 2002;25(2):68-74. 2. o’neil ml. human resource leadership: the key to improved results in health. hum resour health 2008;6(1):10. 3. reinertsen jl. physicians as leaders in the improvement of health care systems. ann intern med 1998;128(10):833-838. 4. farrell jp, robbins mm. transformational leadership. leadership competencies for physicians. health forum j 1993;36(4):39-42. 5. scottish deans’ medical curriculum group. the scottish doctor. 2007. http://www.scottishdoctor.org/ (accessed 29 december 2014). 6. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 7. kuo ak, thyne sm, chen hc, west dc, kamei rk. an innovative residency program designed to develop leaders to improve the health of children. acad med 2010;85(10):1603-1608. [http://dx.doi.org/10.1097/ acm.0b013e3181eb60f6] 8. taylor ca, taylor jc, stoller jk. exploring leadership competencies in established and aspiring physician leaders: an interview-based study. j gen intern med 2008;23(6):748-754. [http://dx.doi.org/10.1007/s11606-008-0565-5] 9. crites ge, ebert jr, schuster rj, shuster rj. beyond the dual degree: development of a five-year program in leadership for medical undergraduates. acad med j assoc am med coll 2008;83(1):52-58. 10. frank j, ed. the canmeds 2005 physician competency framework. better standards. better physicians. better care. ottowa: the royal college of physicians and surgeons of canada, 2005:9-24. 11. frank j, snell l. draft canmeds 2015 physician competency framework – series i. ottawa: the royal college of physicians and surgeons of canada, 2014. http://www.royalcollege.ca/portal/page/portal/rc/common/ documents/canmeds/framework/framework_series_1_e.pdf (accessed 29 december 2014). 12. acgme. common program requirements: general competencies. 2007. http://www.acgme.org/outcome (accessed 29 december 2014). 13. general medical council. tomorrow’s doctors – outcomes and standards for undergraduate medical education. 2009. http://www.gmc-uk.org/tomorrowsdoctors_2009.pdf_39260971.pdf (accessed 29 december 2014). 14. dinh je, lord rg, gardner wl, meuser jd, liden rc, hu j. leadership theory and research in the new millennium: current theoretical trends and changing perspectives. leadersh q 2014;25(1):36-62. 15. dube a, jooste k. the leadership characteristics of the preceptor in selected clinical practice settings in botswana. curationis 2006;29(3):24-40. 16. dine c, kahn j, abella b, asch d, shea j. key elements of clinical physician leadership at an academic medical center. j grad med educ 2011;3(1):31-36. [http://dx.doi.org/10.4300/jgme-d-10-00017.1] 17. mogae f. his excellency mr festus gontebanye mogae, president of the republic of botswana, independence day message to the nation. 2003. http://www.botswanaembassy.org/092903_1.html (accessed 29 december 2014). 18. epstein rm, hundert em. defining and assessing professional competence. jama 2002;287(2):226-235. appendix 1. use of the word ‘lead’ in the context of leadership, in the canmeds 2005 framework and draft 2015 update canmeds 2005 collaborator – enabling competencies – 1.10. where appropriate, demonstrate leadership in a healthcare team manager – enabling competencies – 4. serve in administration and leadership roles, as appropriate. 4.2. lead or implement a change in healthcare draft canmeds 2015 rename manager role to leader definition: ‘as leaders, physicians develop, in collaboration with other healthcare leaders, a vision of a high-quality healthcare system and take responsibility for effecting change to move the system toward the achievement of that vision’ major content changes include: ‘although diverse opinions were expressed, common ground was found with regard to the need for physicians’ personal responsibility, active engagement, and contribution (as ways of conceptualizing leadership)’ key concepts include: ‘collaborative leadership’, ‘followership’, ‘leading change’, and ‘personal leadership skills’ key competencies include 3. demonstrate leadership in professional practice 3.1 develop their leadership skills 3.2 facilitate change in healthcare to enhance services or outcomes 3.3 design and organise elements of healthcare delivery 8 march 2022, vol. 14, no. 1 ajhpe research national lockdown regulations under 2020 covid-19 pandemic conditions necessitated drastic changes to medical education globally, including in botswana. to ensure that the academic year could be completed when students were no longer allowed on campus, the department of medical education (dme) conducted a needs assessment to determine readiness for emergency remote teaching (ert) of the faculty of medicine (fom), university of botswana (ub). ert has been used as the ‘least-worst option’ to school closure,[1] ensuring that student learning continues and the academic year is not entirely lost to the pandemic. ert is a temporary alternative to faceto-face or blended teaching approaches, enabling  institutions to continue educational programmes quickly during a crisis.[1] as the transition to ert happens under extraordinary circumstances, it requires rapid, adaptive planning and implementation. this is contrary to formal online teaching that is characterised by rigorous planning, familiarity and reliability. unlike established online learning programmes where students already understand the technology and learning necessities, during the covid-19 pandemic students who were enrolled in traditional programmes suddenly found themselves in varying ert situations, sometimes without appropriate tools to participate fully.[2-5] technical capacity and capability are critical factors in technology-driven programmes and projects.[6-8] normally, universities have technological infrastructure[2,4] and libraries to ensure equal access and academic success for all students. as institutions migrate to ert, these support structures become inaccessible, shifting the responsibility for access from the university to the learner.[2,3] in such situations, it is not uncommon for learning to be designed around publicly available, non-education-designed platforms such as youtube, whatsapp, zoom and google meet.[4] because of the shift towards learners providing their own ‘access for learning’, inequalities that are generally invisible become visible behind the availability of, and access to, university resources.[2,3] ert can amplify existing inequalities, such as lack of access to appropriate technologies (digital divide),[9] lack of understanding of using appropriate technologies (digital use divide),[10] and inability to use technology to ensure optimal learning (lack of digital fluency).[2] these divides are exacerbated by inequalities in conditions for studying provided by students’ homes.[2] in the covid-19 era, when a campus is closed, some students have limited or no options to participate in technology-driven ert programmes; justice becomes a critical consideration for equitable education. according to john rawls,[11] the notion of justice as fairness is centred around two principles. the first is that each ‘person has an equal claim to a fullyadequate  scheme of equal basic rights and liberties, which scheme is compatible with the same scheme for all’. secondly, ‘social and economic inequalities are to satisfy two conditions: first, they are to be attached to positions and offices open to all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit of the least advantaged members of society’.[11] using rawls’ theory of justice as fairness, the first principle suggests that each student has an equal claim to a fully adequate strategy of learning, disadvantaging none. the second suggests that the inevitable inequalities in students’ social and economic situations must be remedied by a structure of learning that ensures equal opportunity to the background.  the covid-19 pandemic necessitated drastic changes to undergraduate medical training at the university of botswana (ub).  to save the academic year when campus was locked down, the department of medical education conducted a needs assessment to determine the readiness for emergency remote teaching (ert) of the faculty of medicine, ub.  objectives. to report on the findings of needs assessment surveys to assess learner and teaching staff preparedness for fair and just ert, as defined by philosopher john rawls.  methods.  needs assessment surveys were conducted  using office 365  forms distributed via whatsapp, targeting medical students and teaching staff during the 5 undergraduate years. data were analysed quantitatively and qualitatively.  results. ninety-two percent (266/289) of students and 73.5% (62/84) of teaching staff responded. surveys revealed a high penetration of smartphones among students, but poor internet accessibility and affordability in homes. some teaching staff also reported internet and device insufficiencies. only whatsapp was accessible to students and teaching staff. conclusions. for equitable access to ert in the future, the surveys revealed infrastructural improvement needs, including wider, stronger, affordable wifi coverage within botswana and enhanced digital infrastructures in educational institutions, with increased support for students. afr j health professions educ 2022;14(1):8-12. https://doi.org/10.7196/ajhpe.2022.v14i1.1481 justice as fairness in preparing for emergency remote teaching: a case from botswana m s mogodi,1 mb chb, mhpe; d griffiths,2 phd; m c molwantwa,1 mbbs, mphil (hpe); m b kebaetse,1 phd; m tarpley,1 mls; d r prozesky,1 mb chb, phd 1 department of medical education, faculty of medicine, university of botswana, gaborone, botswana 2 division of studies in education, wits school of education, university of the witwatersrand, johannesburg, south africa corresponding author: d griffiths (dominic.griffiths@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i1.1481 mailto:dominic.griffiths@wits.ac.za march 2022, vol. 14, no. 1 ajhpe 9 research most disadvantaged students, e.g. by providing technological infrastructure for equal accessibility. thus, those with less who need more are catered for, to balance the claims of those who need less because they have more. this distribution will enable fair equality of opportunity, levelling the challenges of ert for all students and ensuring, for rawls, ‘the greatest benefit of the least advantaged’.[11] these principles guided dme’s design of strategies to ensure fairness and equality when planning ert. in this article, we report on findings of needs assessment surveys conducted to assess learner and teaching staff preparedness for fair and just ert at ub. methods study design a needs assessment was conducted of student and teaching staff access to adequate, affordable wifi, digital equipment and learning materials in their homes. two surveys were developed ‒ for students and teaching staff, respectively (supplementary files: https://www.samedical.org/file/1803; https://www.samedical.org/file/1804).[12] study setting soon after ub’s fom was founded in 2009, it received a medical education partnership initiative (mepi) grant that financed learning infrastructure.[13,14] most students are government sponsored and receive a laptop. although botswana has a high penetration of cellular phones,[15] internet access is relatively expensive and not commonly used, especially non-cellular highspeed internet.[9] study population and sampling all 289 undergraduate medical students and the 84 medical teaching staff were included in the study. study instrument to develop two needs assessment instruments, we drew from our professional experience, from an understanding of our context and from the literature. instruments were not validated owing to emergency time constraints; however, we met regularly to develop and discuss instruments to ensure their face validity. the questionnaires included some open-ended questions that enabled us to collect qualitative information. the instruments asked participants about: • availability of devices during lockdown • internet access and availability • internet speed and reliability • software application and online platform usage ability • regular use of university email • availability of learning or teaching materials (electronic or hard copies) • where they resided during the lockdown. additionally, students were asked regarding the cost of mobile data, and lecturers were asked about their ability to teach their disciplines online. the instruments used english, the language of instruction at ub. data collection the deputy dean sent a word document (microsoft, usa) comprising the survey to all class representatives to distribute to students via whatsapp. each class representative collected and collated the responses into a single document and returned it to the researchers. the deputy dean sent teaching staff a link to an office 365 forms (microsoft, usa) questionnaire. a reminder to staff was sent twice before the questionnaire was closed 2 weeks later. responses from students and staff were then collated in office 365 forms. data analysis questionnaire response data were exported to excel spreadsheets (microsoft corp., usa). a frequency analysis was performed on the quantitative data, yielding percentage distributions of responses for each item. qualitative data were analysed using thematic analysis. the narrative responses to the questionnaires were read several times and grouped into categories and themes with supporting quotes as they emerged. the research team met to reach consensus regarding the themes. ethical approval ethical approval was granted by the botswana ministry of health and wellness research development division (ref. no. hpdme 13/8/1). participation was voluntary and data collection anonymous. results response rates were encouraging: students ‒ 92.0% (n=266/289) and teaching staff ‒ 73.5% (61/83). students reported a variety of devices available at home, and several methods of internet access, predominantly mobile data access (table 1). many found home internet speed unsatisfactory. students’ reports of the skills and software required for ert varied considerably. table 1. students’ devices, internet access and speed, office 365 forms use and ert skills, n=266 devices and internet n (%) devices available smartphone only 38 (14.3) laptop only 7 (2.6) both devices 221 (83.1) access to the internet mobile data 191 (71.8) mobile internet 9 (3.4) wifi (with or without mobile data) 51 (19.2) cable 9 (3.4) none stated 6 (2.3) evaluation of the speed of internet service at home fast 19 (7.1) average 133 (50.0) poor 114 (42.9) comfort in using ms office 365 forms never used 100 (37.6) somewhat comfortable 124 (46.6) very comfortable 42 (15.8) reported skills needed for ert ms word 195 (73.3) ms powerpoint 204 (76.7) transfer of files using bluetooth 94 (35.3) moodle 48 (18.0) zoom/skype 43 (16.2) ert = emergency remote teaching; ms = microsoft. https://www.samedical.org/file/1803 https://www.samedical.org/file/1804 10 march 2022, vol. 14, no. 1 ajhpe research many had never used office 365 and relatively few were comfortable with it. students reported not checking university email (95%) or private email (44%) regularly, and most (64%) did not remember their university email password (table 2). most, but not all, students had study material at home, such as textbooks or study notes (table 2). with regard to teaching staff, 96.7% of respondents had reasonable home internet access, but unreliable in 16.4% of cases, while 96.7% had all or some of the material they needed for teaching available. all had at least one device needed for ert, but confidence with using this technology varied considerably. only 21.3% had all the material they needed for teaching available (table 3). qualitative data further informed these findings. four major themes were generated: digital access as gatekeeper to ert; technological pedagogical knowledge; non-technological challenges to equity under ert; and attitudes towards justice under ert. digital access as gatekeeper to ert teaching staff noted that equity of internet access is needed among staff and students to engage in ert meaningfully: ‘i think the key is having access to the internet for both the teachers and students … then teaching can take place.’ (fac51) students agreed that: ‘[a]dequate speed internet access’ (ms130) is the basic infrastructure that acts as gatekeeper to ert, and specified the challenges impeding such equity. mobile data bundles allow students to circumvent expensive internet connectivity, but the bundles available to most students are limited to social media platforms: ‘the data bundle that i subscribe to does not allow me to surf the net; hence the reason i cannot check my emails as i am only limited to social networks like whatsapp.’ (ms17) alternative mobile data bundles are not enough for activities that require significant data: ‘the available mobile data bundle we subscribe for daily is … not enough for video streaming.’ (ms210) data bundles depleted quickly: ‘it is a challenge to access the internet since i rely on buying internet bundles which also do not last long.’ (ms220) some students preferred more affordable ‘time-bound’ bundles and only had access at night: ‘to access the internet i normally subscribe for night surfers to access internet between 11 pm and 5 am.’ (ms219) technological pedagogical knowledge staff reported struggling to adapt problem-based learning sessions or plenary sessions for asynchronous online teaching. ert was judged more appropriate for knowledge outcomes than for practical training: ‘online teaching is an option … which will better work for knowledgebased outcome[s].’ (fac57) table 2. students’ email use, textbook and study material availability variable description yes, n (%) no, n (%) total, n regular use of university email 20 (7.5) 246 (92.5) 266 remembering university email password 94 (35.9) 168 (64.1) 262 regular use of private email 149 (56.0) 117 (44.0) 266 textbooks available 217 (81.6) 49 (18.4) 266 textbooks and/or study notes available 251 (94.4) 15 (5.6) 266 table 3. staff devices, internet access and speed, office 365 forms use and ert skills, n=61 devices and internet n (%) devices available smartphone 54 (88.5) tablet 17 (27.9) laptop 60 (98.4) desktop 1 (1.6) access to the internet wireless/wifi 40 (65.6) adsl through landline 15 (24.6) cellular/mobile data, e.g. 3g, 5g 3 (4.9) mobile internet, e.g. hotspot, internet dongle 3 (4.9) ub network 3 (4.9) other 2 (3.3) evaluation of the speed of internet service at home reliable 51 (83.6) unreliable 10 (16.4) confidence in using ms office 365 forms never used 5 (8.2) somewhat confident 41 (67.2) very confident 15 (24.6) reported skills needed for ert ms word 55 (90.2) ms powerpoint 57 (93.4) whatsapp 59 (96.7) pdf reader 38 (62.3) zoom 42 (68.9) skype 40 (65.6) transferring files using bluetooth 22 (36.1) moodle 5 (8.2) availability of material needed for teaching all 13 (21.3) some 46 (75.4) none 2 (3.3) use of email office email checked regularly 50 (82.0) personal email checked regularly 57 (93.4) overall confidence in teaching with technology very comfortable 5 (8.2) comfortable 39 (63.9) somewhat uncomfortable 16 (26.2) very uncomfortable 1 (1.6) ert = emergency remote teaching; adsl = asymmetrical digital subscriber line; ub = university of botswana; ms = microsoft. march 2022, vol. 14, no. 1 ajhpe 11 research staff skill sets also showed mismatches with student skill sets, e.g.: staff struggled to download documents from whatsapp. some admitted they preferred platforms such as zoom or teams because they were accustomed to face-to-face teaching. non-technological challenges to equity under ert students detailed numerous learning challenges arising from their living at home during the lockdown: ‘as you know, we require a lot of time to study. here [at] home, there is other work i have to carry out because i am here, e.g. cleaning, cooking twice a day, etc. therefore, it might not be easy to concentrate and focus very well.’ (ms25) additionally: ‘[t]he home is not suitable since we share rooms and the house is not big enough to have some private space and quietness to study, so studying during lockdown is very difficult.’ (ms143) lack of basic utilities was also highlighted: ‘[n]o electricity in [the] home, so i have difficulty in charging my smartphone ‒ its battery lasts for about 4 hours and needs to be charged again.’ (ms99) such challenges are unequally distributed across the student population and beyond the amelioration of teaching staff. attitudes towards justice under ert students showed strong awareness that they require support to attain equitable access to the internet: ‘[i] am willing to comply if we are going to be given wi-fi allowance.’ (ms140) overall, staff supported ert as an appropriate response to the teaching and learning challenges caused by the pandemic, saying that: ‘[o]nline training should [be] the way forward’ (fac06) and ‘[w]e can encourage distant learning.’ (fac60) their comments highlight various inequities, however. some staff used familiar face-to-face pedagogies via zoom or teams, tacitly abandoning the aim of equity. others aimed to increase equity through adapted pedagogies and delivery methods: ‘i think most students … will have access to social media (mostly whatsapp) so we have to explore it more and make it work as it may be the most pragmatic way to get learning material and any other communication to students.’ (fac43) other teaching staff directly rejected ert because of the accessibility gap: ‘[u]ntil i see the data i am concerned that a quarter or more of the students will not have the connectivity and/or financial wherewithal to meaningfully participate.’ (fac26) discussion the digital divide is a global challenge, not only an issue for lowand middle-income nations. the covid-19 pandemic exposes variations of wifi access and affordability, digital equipment access and electronic information literacy in countries including australia, the usa, those in the eu,[16-18] as well as in sub-saharan africa.[19-21] although classed by the world bank as an upper-middle-income country, botswana has a gini index of 60.5, the fourth highest in the world,[22] indicating an extreme gap between citizens with low and high incomes. we sought to explore the readiness of the fom to develop a fair and just ert programme. the high response rate provided somewhat representative concrete data. in general, teaching staff had better, but not total access to devices and university facilities, which enabled their participation in ert. students had reasonable access to devices and study materials, but faced significant challenges with internet access and speed. the skills and software needed to facilitate this access when at home, where some students’ environments were not conducive to learning, were also challenging. our findings suggest the conceptual power of rawls’ theory of justice as fairness in preparing for a fair and just ert programme. from the beginning, rawls’ first principle ‒ that of the right to equality in ert ‒ was accepted. the second principle was more challenging: designing a structure that would ensure that the opportunities for ert would be equitably distributed, particularly benefiting students with the least access. our findings also complicate the notion of a single digital divide, with challenges to learning ranging from inequitable internet access to a mismatch in digital skills across generations between staff and students. the south african association of health educationalists recommend that ert programmes be simple, low technology, mobile friendly and asynchronous rather than synchronous.[6] these recommendations apply to low-income countries, but our study in an upper-middle-income country confirms that designing ert according to the needs of students from resource-challenged homes, who are disadvantaged by the lack of access to devices, connectivity, and learning materials, is a prerequisite for justice as fairness.[2,5] our ert needs assessment proposes ert guided primarily by this disparity of means, and the need to find a structure that would ensure a fully adequate scheme of equal basic rights to the entire group, while distributing opportunities equally, and particularly benefiting the least advantaged members of the relevant group.[23] the study emphasises how constraints external to an ert programme can be defining of its success and fairness; in our case the defining constraint was internet access. many students reported that they could not afford data for several hours per day in the long term. the university did attempt negotiations with data providers and after many months obtained some limited financial support, but not before the return to campus. without access to the internet through data or campus networks, equitable ert is almost impossible. the study findings and literature suggest that students and staff need university information technology (it) support in moving to a new way of learning and teaching,[24-26] most notably training in using appropriate applications (apps).[27] student skills were not sufficient to use synchronous platforms and they did not use email on a regular basis (tables 1 and 2). these disadvantages, along with the high cost of reliable internet access, meant that the social messaging app, whatsapp, would possibly be ideal because it would support the ‘cheaper’ mobile data bundles that most students use for internet access (table  1). this situation has implications for pedagogy: study material must be ‘data light’, e.g. word documents, as many students would be unable to access videos and large pdf documents (table 2). staff would also require training in using whatsapp and adapting its functionality for teaching. teaching practical skills remotely would be 12 march 2022, vol. 14, no. 1 ajhpe research challenging while students are learning remotely. although justice as fairness can be the directing goal (no system achieves it perfectly),[23,25,28,29] we should not expect to achieve it perfectly in the current emergency situation. while it might be tempting to resort to a utilitarian approach, institutions should rather consider a justice as fairness approach as recommended by rawls, to ensure equitable access to learning for all students. study strengths and limitations strengths of this needs assessment included the high response rate among students and staff. the up-to-date representative data from staff and students regarding their preparedness for ert, enabled evidence-based practice. the  implication of this work is that when ert is designed, fairness  and equity for the most disadvantaged students should be considered. our needs assessment process for ert could be a model for other universities, particularly those with poor infrastructure, during another pandemic-like situation. limitations of the study include the absence of formal piloting and validation of the tool due to the emergency state during which this needs assessment was conducted, and the exclusion of support staff in the process. future research could consider studying what steps the university should take to remedy the deficiencies found in this research, and the students and staff satisfaction with ert that resulted from the needs assessment. conclusions fair and just medical education was critically important during the uncertain time of the 2020 covid-19 global pandemic. rawls’ principle of justice as fairness provides a possible theoretical grounding for deciding whether particular technical and educational solutions would be acceptable. the 2020 pandemic will not be the last emergency faced by botswana and other countries with similar economic structures. therefore, the data gathered in botswana provide a useful snapshot that can influence educators and governmental authorities locally and across the continent to press for wider, stronger and more affordable wifi coverage in the country, as well as improved digital infrastructures in educational institutions, with increased support for students. declaration. none. acknowledgements. we acknowledge the medical librarians, ms dineo ketshogileng and mr khutsafalo kadimo, faculty of medicine, university of botswana, for their support with literature retrieval. we also thank the reviewers for their valuable inputs and maria prozesky for her careful editing. author contributions. all authors contributed to the conceptualisation, analysis, interpretation of findings and finalisation of the manuscript. funding. none. conflicts of interest. none. 1. hodges c, moore s, lockee b, trust t, bond a. the difference between emergency remote teaching and online learning. 2020. https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teachingand-online-learning (accessed 27 october 2020). 2. czerniewicz l, agherdien n, badenhorst j, et al. a wake-up call: equity, inequality and covid-19 emergency remote teaching and learning. postdigital sci educ 2020;2:946-967. https://doi.org/10.1007/s42438-02000187-4 3. toquero cm. emergency remote teaching amid covid-19: the turning point. asian j distance educ 2020;15(1):185-188. https://doi.org/10.5281/zenodo.3881748 4. rahiem mdh. the emergency remote learning 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https://doi.org/10.1007/s11150-020-09540-9 19. adarkwah ma. ‘i’m not against online teaching, but what about us?’: ict in ghana post covid-19. educ inf technol (dordr) 2020;16:1-21. https://doi.org/10.1007/s10639-020-10331-z 20. onyeka tc, iloanusi n, namisango e, et  al. project opus: development and evaluation of an electronic platform for pain management education of medical undergraduates in resource-limited settings. plos one 2020;15(12):e0243573. https://doi.org/10.1371/journal.pone.0243573 21. bakibinga-gaswaga e, bakibinga s, bakibinga dbm, bakibinga p. digital technologies in the covid-19 responses in sub-saharan africa: policies, problems and promises. pan afr med j 2020;35(suppl 2):38. https:// doi.org/10.11604/pamj.supp.2020.35.2.23456 22. gini coefficient by country. 2021. https://worldpopulationreview.com/country-rankings/gini-coefficient-bycountry (accessed 22 march 2021). 23. rawls j. theory of justice. revised ed. harvard: harvard university press, 1999. 24. association for medical education in europe. covid-19 webinars. 2020. https://amee.org/webinars (accessed 25 november 2020). 25. lancaster jw, stein sm, maclean lg, van amburgh j, persky am. faculty development program models to advance teaching and learning within health science programs. am j pharm educ 2014;78(5):99. https://doi. org/10.5688/ajpe78599 26. menon a, klein ej, kollars k, kleinhenz alw. medical students are not essential workers: examining institutional responsibility during the covid-19 pandemic. acad med 2020;95(8):1149-1151. https://doi. org/10.1097/acm.0000000000003478 27. mahamud zi, andrews fk, rockson ak. use of mobile phones to support coursework: evidence from wa polytechnic, ghana. ghana j dev stud 2015;12(1-2):195. https://doi.org/10.4314/gjds.v12i1-2.12 28. miller dg, pierson l, doernberg s. the role of medical students during the covid-19 pandemic. ann intern med 2020;173(2):145-146. https://doi.org/10.7326/m20-1281 29. woolliscroft jo. innovation in response to the covid-19 pandemic crisis. acad med 2020;95(8):1140-1142. https://doi.org/10.1097/acm.0000000000003402 accepted 5 august 2021. https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning https://doi.org/10.1007/s42438-020-00187-4 https://doi.org/10.1007/s42438-020-00187-4 https://doi.org/10.5281/zenodo.3881748 https://doi.org/10.26803/ijlter.19.6.1 https://doi.org/10.5281/zenodo.3881529 http://saahe.org.za/2020/04/teaching-remotely-navigating-uncertainty-the-digital-divide-and-social-justice-in-health-professions-education/ http://saahe.org.za/2020/04/teaching-remotely-navigating-uncertainty-the-digital-divide-and-social-justice-in-health-professions-education/ https://doi.org/10.1186/s12909-018-1264-5 https://doi.org/10.1177/0735633115571928 https://doi.org/10.1177/0735633115571928 https://doi.org/10.4102/sajim.v13i1.471 http://www2.ed.gov/about/offices/list/os/technology/index.html http://www2.ed.gov/about/offices/list/os/technology/index.html https://doi.org/10.1097/acm.0000000000000329 https://doi.org/10.1016/j.ijmedinf.2016.01.006 https://doi.org/10.1016/j.ijmedinf.2016.01.006 https://www.itu.int/en/itu-d/statistics/documents/publications/misr2017/misr2017_volume1.pdf https://www.itu.int/en/itu-d/statistics/documents/publications/misr2017/misr2017_volume1.pdf https://doi.org/10.2196/14825 https://doi.org/10.1371/journal.pone.0232032 https://doi.org/10.1007/s11150-020-09540-9 https://doi.org/10.1007/s10639-020-10331-z https://doi.org/10.1371/journal.pone.0243573 https://doi.org/10.11604/pamj.supp.2020.35.2.23456 https://doi.org/10.11604/pamj.supp.2020.35.2.23456 https://worldpopulationreview.com/country-rankings/gini-coefficient-by-country https://worldpopulationreview.com/country-rankings/gini-coefficient-by-country https://amee.org/webinars https://doi.org/10.5688/ajpe78599 https://doi.org/10.5688/ajpe78599 https://doi.org/10.1097/acm.0000000000003478 https://doi.org/10.1097/acm.0000000000003478 https://doi.org/10.4314/gjds.v12i1-2.12 https://doi.org/10.7326/m20-1281 https://doi.org/10.1097/acm.0000000000003402 56 may 2014, vol. 6, no. 1 ajhpe research dr howard barrows developed the standardised patient (sp) methodology in 1963 and questioned whether sp training is thorough, particularly with regard to history taking. insufficient training can lead sps to intellectualise their role playing, rather than become the characters they are playing. in such cases the portrayal of the characters comes across as too memorised, with little transmitted energy and little or no congruence regarding the character.[1] congruence of patient portrayals congruence is the state of agreement, harmony, conformity, or correspondence, taking all aspects of patient portrayals into consideration.[2] it also involves the practice of personalising perception, critical thinking and creative management of multiple realities as behavioural congruence. it is the concept of being real – not playing a role – and being free from pretence.[3] all of the above are relevant to sp portrayals. it became clear that congruent character development with regard to sps was necessary to identify and rectify the abovementioned challenges. more specifically, the development of three-dimensional (3d) characters became essential. this was achieved by empowering sps with adequate information and knowledge, which led to true standardisation of patient portrayals. local context and background at the medunsa campus of the university of limpopo, south africa, sps have been used for 12 years in the family medicine and primary healthcare training blocks during summative assessments. to protect the confidentiality of the content, the sps were issued with written case scenarios immediately prior to the start of an assessment and given approximately 1 hour to prepare. this strategy gave rise to the following problems: • because of lack of time for proper training, the interpretation of how a patient would normally portray an illness was often stereotyped and/ or unclear. this caused confusion between the student, the sp and the examiner. • the cues and subtexts of case studies were not sufficiently exhaustive/ explicit, and sps were frequently confronted with questions they had not been prepared for. • lack of appropriate and timely cues provided to facilitate conversation. • insufficient time for sps to internalise the characters and scenarios, resulting in incongruence regarding the verbal and non-verbal communication of the character in relation to the clinical or psychosocial condition. observing a facial expression while hearing a different emotion manifests as behavioural conflict and interferes with the believability of the portrayal. the abovementioned problems contributed to incongruence of sps’ portrayal of patients. objectives the aims of the study were to identify behavioural patterns depicting incongruency during sp portrayals, to train sps in rectifying incongruent background. incongruence of standardised patient (sp) portrayals is worsened when sps are given basic scenarios and too little background information on short notice. consequently, sps are confronted with questions they find difficult to answer owing to a lack of insight, internalisation and association with the role. objective. to determine whether training in characterisation enhances the congruence of sp portrayals. methods. sp encounters were recorded, after which the participating sps and students reflected on the congruence of the sps’ performances. the researchers analysed the videorecordings and reflections for incongruent behaviours. the findings were triangulated and themes of incongruency were established. the intervention comprised training of sps in the creation of subtext (the story behind the story), characterisation, and linking to and making use of emotion memory, with the aim of rectifying the observed incongruent behaviours. pre-training activities were repeated with cohort 2 students. results. two themes depicting congruence, i.e. internalisation of character and congruence of verbal and non-verbal communication, were identified. post-training outcomes revealed an improvement in all subthemes. applicable and real emotions, complementing verbal and non-verbal cues, gestures and appropriate use of voice and facial expression, led to believable/congruent role play and improved communication on various levels. conclusion. the post-training outcomes showed clear improvement regarding the congruence of sp portrayals. the changes can be contributed to sp training focused on 3d character development by creating subtext, providing basic clinical information, emotion memory, acting skills, managing energy levels, and not focusing on the scenario alone. ajhpe 2014;6(1):56-59. doi:10.7196/ajhpe.193 the effect of characterisation training on the congruence of standardised patient portrayals i treadwell,1 dcur, hed; l schweickerdt-alker,1 ba (hons) drama; d pretorius,2 msc (psych); m d hugo,3 mot (neuropaediatrics) 1 skills centre, faculty of health sciences, university of limpopo (medunsa campus), pretoria, south africa 2 department of family medicine, university of the witwatersrand, johannesburg, south africa 3 practice of medicine, faculty of health sciences, university of limpopo (medunsa campus), pretoria, south africa corresponding author: i treadwell (ina.treadwell@ul.ac.za) mailto:ina.treadwell@ul.ac.za may 2014, vol. 6, no. 1 ajhpe 57 portrayals and then to determine the effect of the training. methods a qualitative design was used to gather data on the congruency of sp portrayals through observations and reflections by students, researchers and sps during objective structured clinical examinations (osces) before and after an sp training session. medunsa’s research and ethics committee (mrec) approved the study protocol and informed consent was obtained from students and sps. the convenience student sample comprised two cohorts of 6th-year medical students (n=43) performing their end-of-block osces in family medicine. the sp sample included the four junior sps who participated in both osces. reflections prior to training sps in characterisation sp encounters with cohort 1 students during osce 1 were videorecorded. on completion of the osce, students and sps reflected separately on the incongruence/congruence of the sp performances and videos were analysed by the four researchers. the reflections of the participants were guided by questions and the discussions were audiorecorded. data analysis before training qualitative content analysis was done according to the steps described by creswell.[4] the four researchers made summative notes of the videorecorded verbal and non-verbal communication that they regarded as incongruent. interpretive validity was enhanced by summarising each individual researcher’s documented and interpreted observations and personal experiences. these notes were compared and discussed among the other researchers until consensus was reached on the characteristics of incongruent/congruent sp portrayals observed. the audiotaped focus group discussions of the students and sps were analysed similarly. corresponding information on characteristics of incongruence obtained from the three sources was grouped in categories, and then organised in themes. validity and synchronic reliability of the study were achieved by using these multiple sources of information (triangulation) (fig. 1).[5] training of sps the intervention comprised a 1-day workshop aimed at transforming the incongruent behaviour of sps identified during osce 1. the training focused on various aspects of creating a believable person behind the patient by finding the subtext relating to the specific scenarios (resulting in 3d character development and energy level management). to enhance their understanding, sps were given information on the pathology of the disease afflicting the ‘patient’. training also comprised updating basic acting skills (imagination, listening, emotional expression, use of voice, body movements) to enhance the congruence of their verbal and non-verbal communication. to facilitate sps to relate to emotions, improvisation exercises were incorporated in the training session. post-training reflections and data analysis a similar content analysis was performed on post-training observations and reflections on sp portrayals at osce 2 using the same scenarios with cohort 2 students. results reflections before training sps in characterisation two themes of congruence and characteristics of congruent behaviours emerged from the data obtained prior to the training of sps (table 1). theme 1 (pre-training). the sps experienced problems in internalising the patient’s character. student participants’ observations are summarised as sps being robotic, hesitant and inconsistent, appearing bored and tired: ‘he’s not answering your question … he has a fixed answer. give him a context of who his patient is … ’ ‘ … it was ver y robotic but i understand why because they are given a set number of parameters that we are supposed to elicit … ’ ‘ … only a small portion of patients are going to be hesitant like that … ’ sps reflected that they feared self-expression, were inconsistent and became tired: ‘i faked emotions and that made me tired.’ the researchers observed that the sps lacked confidence, were inconsistent and struggled to concentrate. theme 2 (pre-training). the sps’ portrayals lacked congruence of verbal and non-verbal communication at times. student participants observed the following incongruencies: ‘ ... the confusion was the body language … he looked “cheery” ... he said he was concerned … but he didn’t show it … ’ ‘ … he didn’t look like it (fears) bothered him … ’ sps acknowledged that they forgot to show symptoms: ‘ … i forgot to show the emotion of pain.’ the researchers found the facial expressions inadequate. reflections following training observations of the sps’ portrayals in osce 2 reflected improvement regarding the characteristics of congruence (table 2). theme 1 (post-training). problems in internalising the patient’s character. students reflected that sps were believable and trustworthy: ‘ … very real … sincere … like a real patient … believable.’ ‘ … she was staying in her role … giving what you were asking for … did not offer information … until a person comes and explores … that’s what people would do … ’ sps reflected that they understood the role, felt confident and could pace their energy: ‘ … we know you said we must go there and do whatever we were taught during the workshop … then we did exactly that so the doctors (assessors) were so impressed.’ ‘ ... like in the past i was trying to force those fake emotions. i was really getting tired … today from start to finish my energy levels were so high.’ research audiotapes: data collection and analysis (students) audiotapes: data collection and analysis (sps) videotapes: data collection and analysis (researchers) results compared and interpreted fig. 1. triangulation of data (sps = standardised patients). 58 may 2014, vol. 6, no. 1 ajhpe the researchers observed that the sps managed the information well and their portrayals were consistent. their energy levels improved and were maintained. theme 2 (post-training). incongruence of verbal and non-verbal communication. students observed that the symptoms portrayed made sense and that the emotional reactions complemented the verbal cues: ‘ … whenever she talked about a hysterectomy she’d take a deep breath … and then talk about it … she really doesn’t want the hysterectomy because [of ] her ideas behind it … ’ ‘ … her voice tone changed when she spoke … her body and voice were corresponding … you could see that she was really worried … ’ the sps felt they were able to portray real emotions: ‘ … what really helped me to show my emotions was the advice that you gave us from the workshop that i have to think of something that makes me like worry so that i need not fake my emotion … ’ ‘ … before the workshop i was constantly smiling, you know even if i had a problem. today i played a very sad patient … ’ the researchers found the sps’ gestures appropriate, reflecting the change of voice and expressing emotions were applicable. an unexpected finding was that examiner manipulation of the context and unclear scenario outcomes pose additional threats to congruence: ‘the assessor expects me to do what he wants me to do and that’s a bit difficult … he stopped the assessment and he wants to implement his thoughts on you … you must be consistent … ’ study limitations the insufficient 1-hour sp preparation time prior to osce 1, as well as the repeat of the simulations 6 weeks later, may have had an influence on the improvement in sp performance and character portrayal in osce 2. discussion the effect of training was measured by comparing postwith pre-training outcomes relating to characteristics of congruence, as reflected in the corresponding lines in tables 1 and 2. incongruent behaviours changed to congruent behaviours: • sps who lacked confidence and acted robotically became believable and managed the role well owing to better understanding. • hesitant and inconsistent behaviours changed to consistent portrayals executed with confidence. • low energy levels and problems with concentration changed to increased and maintained energy levels. having to remember details regarding the scenario will inevitably hamper the flow of communication and affect congruence. sps should be trained to focus with concentration and energy during the consultation and not try to remember the case scenario. they will then be able to focus on the student and interact spontaneously as the communication/consultation progresses. [6] as far as possible, sp encounters must be true and not different to the experience of a real patient.[7] for sps to be more congruent, they need to research table 1. themes of congruence and characteristics of incongruent behaviours before training theme characteristics as analysed/reflected students (n=22) standardised patients (n=4) researchers (n=4) internalisation of character robotic, not internalising fear of self-expression lack of confidence hesitant, inconsistent inconsistent inconsistent appeared bored/energy levels low faked emotions varied energy levels, struggling to maintain concentration congruence of verbal and non-verbal communication not in agreement forgot to show symptoms poor facial expression table 2. themes of congruence and characteristics of congruent behaviours post-training theme characteristics as analysed/reflected students (n=21) standardised patients (n=4) researchers (n=4) internalisation of character believable understood the role information well managed felt safe with the patient increase of self-confidence consistent standardised patients did not become tired increased energy levels, could pace the energy flow energy levels improved and maintained congruence of verbal and nonverbal communication symptoms made sense, emotional reactions complemented verbal cues could give real emotions gestures appropriate, change of voice, applicable emotions expressed may 2014, vol. 6, no. 1 ajhpe 59 know and give life to the person behind the patient. portraying a patient is therefore more than repeating a given case scenario; it is about penetrating patients’ psyches, i.e. their emotional and psychological make-up. at the very least, sps need to understand the needs, expectations and fears of a patient, as well as the biopsychosocial implications of their condition, to portray a congruent and believable patient. this should be explicitly defined in training materials.[6,7] subtext includes unspoken thoughts and motives of characters (what they really think and believe) and adds a third dimension to the character in the scenario. sps should be able to portray their symptoms with real emotions, incorporating hidden fears, hopes, beliefs and reactions to interventions. subtext therefore enables sps to supply additional circumstances to the character’s background and encourages them to ‘flesh out’ the role.[8,9] what happens beneath the surface of dialogue is what makes the performance exciting.[10] incongruence of verbal and non-verbal communication changed to revealing real emotions that complement verbal cues, appropriate gestures and voice use, which led to improved communication on various levels. once the subtext, which focuses on gesture, intonation, and expression, has been defined and the sps can adopt the patient’s character, their non-verbal signs should become congruent with those of the character. consequently, the student will be able to ‘hear’ what the sp is not telling them, but what has been ‘shown’ through non-verbal communication. this will keep the energy flowing and the consultation alive and true to a real patient encounter in healthcare. non-verbal modes of experience such as bodily responses are factors that enable an observer to become more aware of the unconscious affective component of emotional resonance and provide information enabling further cognitive processing.[11] awareness of bodily responses should therefore be facilitated as non-verbal aspects of experience. this enables the sp to portray a role as alive and real, which makes it effective.[9] sps’ spontaneity will be enhanced if they are able to identify with their own inner feelings and have the courage to allow these real feelings to manifest naturally. this will result in a more congruent character.[6] for example: pain is an internal physical sensation, accompanied by an emotional response made known in an external manifestation. it could entail the inability to move normally, the experience of body tension, the protection of the location where the pain is most intense, facial expressions, vocalisations, manner of speaking, tone, etc. only a suitably trained sp can remind the student that handling an affected limb carelessly worsens the pain.[9] although this study examined the effect of training on congruence, examiner manipulation during an assessment poses a threat to standardised, consistent role play – important for creating fair and equal circumstances for examinees.[12] sps should be trained to portray ‘the same patient in such a consistent way that each medical student will be presented with the same challenge every time’.[13] conclusion a congruent portrayal of a patient requires more than receiving a written case scenario. specific elements are needed for sps to communicate verbally and non-verbally to the extent that a patient role can become a live experience, where communication is more ‘real’, alive and interdependent.[13] incongruent performances of sps prior to focused training can be described as portraying: • unbelievable characters that fear self-expression and lack confidence and energy owing to poor internalisation of the character • non-agreeable verbal and non-verbal communication. the post-outcome training of characterisation showed a clear improvement in the congruence of sp portrayals. the changes can be contributed to the sp training that focused on subtext creation, 3d character development, energy level management, connection with their own emotions, their acting skills as well as the basic clinical information, and not only on the information given in the patient scenario. training also contributed to increased confidence levels with regard to self-expression. it can be assumed that when sps are used for role playing in clinical scenarios during examinations, authenticity is of paramount importance.[1] for sps’ portrayals to remain congruent, continuous training is essential as scenarios and characters change. references 1. lewis k, washington g. giants in sp education: the legacy of howard barrows. newsletter for the association of standardized patient educators 2011;10(2):7-9. http://www.aspeducators.org/files/pdfs/pdf1306854670 (accessed 27 may 2011). 2. online dictionary. http://dictionary.reference.com/ (accessed 1 august 2012). 3. cornelius-white jhd. congruence: an integrative five-dimension model. pcep journal 2007;6(4):230-237. [http://dx.doi.org/10.1080/14779757.2007.9688444] 4. creswell jw. research design: qualitative, quantitative, and mixed approaches. 2nd ed. thousand oaks, ca: sage publications inc, 2003:191-195. 5. struwig fw, stead gb. planning, designing and reporting research. cape town: pearson education, 2001:134. 6. wallace p. coaching standardized patients for use in the assessment of clinical competence. new york: springer publishing company, 2006:79,94. 7. monaghan ms, jones rm, schneider ef, et al. using standardized patients to teach physical assessment skills to pharmacists. am j pharm educ 1997;61:266-271. 8. mcgaw c, stilson kl, clark ld. acting is believing.10th ed. boston, usa: wadsworth cengage learning, 2009:162. 9. brodzinski e. theatre in health and care. houndmills, uk: palgrave/macmillan, 2010:136-137,146. [http:// dx.doi.org/10.1057/9780230293496] 10. beck a. radio drama: directing, acting, technical, learning & teaching, researching, styles, genres. http://www. savoyhill.co.uk/technique/subtext.html (accessed 21 november 2011). 11. tagar y. fundamentals of psychophonetic: the literacy of experience – the basic modes of non-verbal communication and their applications. cape town: persephone institute, 2006. 12. perera j, perera j, abdullah j, et al. training simulated patients: evaluation of a training approach using self-assessment and peer/tutor feedback to improve performance. bmc med educ. 2009;9:37. http://www. biomedcentral.com/1472-6920/9/37 (accessed 21 november 2011). 13. pretorius d, van rooyen m, reinbrech-schütte a. patient-centred communication and counselling – principles and practice. cape town: juta & company ltd, 2010:72. research http://www.aspeducators.org/files/pdfs/pdf1306854670 http://dictionary.reference.com/ http://dx.doi.org/10.1080/14779757.2007.9688444] http://dx.doi.org/10.1057/9780230293496] http://dx.doi.org/10.1057/9780230293496] http://www http://www ajhpe 350.indd research october 2014, vol.6, no. 2 ajhpe 161 trauma is a ubiquitous reality in south africa and severely injured patients may present to a range of institutions.[1-6] junior staff may be required to care for these patients in settings where they are not well supervised. many courses have been designed with the following educational outcome in mind: the improvement of the knowledge and skills of junior staff in the resuscitation and management of a trauma patient. the best-known such course is the advanced trauma life support (atls) course of the american college of surgeons, which was famously inspired by an incident over three decades ago when an orthopaedic surgeon and his family were involved in a plane accident in rural nebraska and received poor trauma care at the local hospital.[2,3] since then, the atls course has been propagated worldwide and has come to be regarded as the gold standard in terms of trauma education.[2,3] the atls course focuses on techniques and not on what could go awry in the trauma setting. since the turn of the millennium, there has been a growing awareness that error in healthcare is a significant cause of morbidity and mortality.[1-4] international and local research has demonstrated that human error is problematic in trauma care at dedicated high-volume centres and even more so in smaller centres where severely injured patients are occasionally seen by less experienced doctors. error theory suggests that the making of mistakes is not random, but follows specific patterns. if teaching staff are aware of possible errors, it may contribute towards reducing error incidence and impact.[3-6] educational programmes on error prevention and reduction make staff aware of errors. in light of this, the researchers applied the understanding of error prevention and reduction to trauma care education. cases where error contributed to an adverse outcome were documented and examined in detail using a taxonomy of error. this allowed educators the opportunity to convert individual cases into structured interactive teaching interventions. examples of four such cases are included in appendix 1. this study reports on the development and use of these anonymous case studies of human error as interactive teaching interventions for small groups of junior staff. to gauge the effectiveness of this intervention, we interviewed three interns who were exposed and three who were not exposed to the intervention about their understanding of human error. the intervention consisted of a seminar where junior doctors were given a brief overview of error theory followed by a detailed discussion of cases selected from morbidity and mortality meetings. this error training was mandatory for all junior doctors working in surgery. they were asked to analyse and discuss the cases in terms of chang’s taxonomy of error,[2] and to discuss the cases with senior clinicians. background. in resource-poor environments of the developing world, young and inexperienced interns and community service doctors are often responsible for treating trauma patients without sufficient supervision. time and experience are required for competency to develop, but in the understaffed environment of many hospitals time is often a constraint. educational interventions are needed to accelerate competency development of the novice doctor. method. the researchers designed an intervention using real cases and error theory to expand young doctors’ experiences of common trauma errors made in our setting. we analysed cases at the regular morbidity and mortality meetings and selected cases where error contributed to the condition of the patient. using error theory, these cases were presented to doctors with the objective to increase error awareness. to assess the success of this intervention, three doctors who were exposed to the intervention and three who were not exposed to it were included in the study using a structured interview. results. this study demonstrated that interns who had been exposed to the intervention had a broader understanding of how errors can compound a patient’s pathology and are often the result of systematic rather than individual failure. conclusion. the researchers focused on the rationale for and the development of an intervention for novice doctors to expose them to trauma experiences in the framework of understanding error. the immediate success of the intervention is illustrated in the structured interviews. further development of this intervention and more formal research into its pedagogical value are planned after formalisation of the intervention into a teaching curriculum for trauma doctors. this educational initiative will have to be part of a comprehensive multifaceted quality-improvement programme if it hopes to be successful. ajhpe 2014;6(2):161-164. doi:10.7196/ajhpe.350 an educational programme for error awareness in acute trauma for junior doctors c m aldous,1 bsc, bsc (hons), msc, phd; r searle,2 bsc, bsc (hons), msc, ma; d l clarke,3 mb chb, fcs (sa), mmedsci, mba, mphil 1 school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 school of education, college of humanities, university of kwazulu-natal, durban, south africa 3 pietermaritzburg metropolitan trauma service, department of surgery, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: c m aldous (aldousc@ukzn.ac.za) research 162 october 2014, vol.6, no. 2 ajhpe chang’s taxonomy classifies error into the following five complementary nodes, which equate to the general descriptive terms in brackets: • impact (how bad was the error?). this refers to degree of harm experienced as a result of the error. • type (what went wrong?). this refers to the failed processes of care, which we divided into broad categories, i.e. errors of resuscitation, errors of assessment, operative or technical errors and logistical failure. a patient may experience any number of a combination of failed processes. • domain (where did it go wrong?). • cause (why did it go wrong?). the researchers divided the causes into: • errors of planning • errors of execution • protocol violations • errors of omission • errors of commission. • prevention (what are we going to do about it?). all error reduction programmes need to develop interventions to reduce the incidence of error and limit its effect. four typical cases of error used in these seminars are provided in appendix 1. methods development of the intervention the researchers identified and analysed cases of error at the structured morbidity and mortality meetings, using a standard modern taxonomy of human error. the senior staff of the pietermaritzburg metropolitan trauma service were present at these weekly meetings. they provided a quorum of experienced trauma surgeons who identified appropriate cases, which were recorded for future use. they also identified human and systems errors in these cases by noting a number of sentinel events, which the researchers identified as indicators of error. these events included an unexpected readmission to the operating theatre, readmission to the icu, surgical site sepsis and delay in definitive treatment. an adverse event was defined as an unintentional, definable injury because of medical management, while an error was defined as failure to complete a planned action as intended, or use of an incorrect plan to achieve an objective. on review of the data from the morbidity and mortality meetings, we established that assessment failure is the major source of error and that junior staff tend to apply their observations to their preconceived view of reality, which more experienced staff are less likely to do. this phenomenon is referred to as cognitive dissonance. decision-making is a complex process and one tends to make a superficial assessment, especially in unfamiliar or stressful situations, and then resist prompts that should make one reconsider one’s initial assessment. furthermore, less experienced staff are more inclined to err by failing to act than by acting, and errors of omission far outweigh errors of commission.[3,4] we designed a trauma education intervention plan by working backwards from the known deficits towards a targeted learning programme that teaches the concept of error awareness. assessing the efficacy of the intervention a structured interview was designed to assess the efficacy of this intervention before implementing it as part of a formal curriculum for interns rotating through trauma surgery. interns (n=3) who had been exposed to the intervention >2 months before the interview, and those (n=3) who had not been exposed to it, were interviewed. the interview was conducted by an educationalist who had not been present at any of the seminars. after establishing whether the doctor had been exposed to the intervention or was familiar with the test case (case 1 (appendix 1)), it was presented to them. the following questions were asked: question a. mention the problems that occurred in the management of the child in case 1. question b. who, in your view, should be held accountable for the mistakes made in the treatment of this child? explain your response. question c. would you say that any of the problems were caused by lack of knowledge or semi-automatic behaviour? explain your response. question d. which mistakes were preventable? explain your response. results question a. both groups identified a range of problems that occurred in the management of the patient, lack of consultation with senior staff and various other issues concerning management of the patient. there was no qualitative difference between the responses of the exposed and the nonexposed groups. question b. the exposed group named several people who could be accountable, including the admitting doctor, doctors who continued with the treatment and nursing staff, whereas the non-exposed group mentioned only the admitting doctor. one response from a non-exposed doctor was as follows: ‘the admitting doctor who did the initial patient assessment is at fault. they should have asked for cvp insertion from someone else. there was poor communication with the burns unit. they did not follow protocols.’ the response from a doctor who was exposed read: ‘firstly, the admitting doctor …’, followed by an explanation. ‘secondly, the follow-up doctor …’, followed by an explanation. ‘thirdly, the nursing staff …’, followed by further explanation. question c. there was no qualitative difference between the responses of exposed and non-exposed groups. both groups cited semi-automatic behaviour because of work burden as the source of the problem as opposed to lack of knowledge. question d. when asked which mistakes were preventable and for an explanation, all the respondents said that all the errors were preventable, but the exposed group gave more comprehensive answers. to illustrate, a response from a non-exposed doctor stated: ‘all were completely preventable. the doctor did not follow the guidelines.’ a doctor in the exposed group gave the following response: ‘all errors were preventable. there should have been senior cover to ensure proper all-round care of this child. the nursing staff should have had enough basic knowledge of treatment of an injured child and ensured that proper treatment was given. there should have been a handover responsibility between interns and nurses and a senior in terms of wound treatment, fluid management and feeding.’ the three doctors who had been exposed to the intervention responded positively to the following questions: • did you find value in understanding error in trauma? • does your awareness of error in trauma affect the way you work? • do you view the morbidity and mortality meetings differently since you have been made aware of error in trauma? discussion any course aimed at training with regard to reduction in error or bias in trauma settings and care, especially as part of ongoing professional research october 2014, vol.6, no. 2 ajhpe 163 development, needs to be informed by learning theories that take account of the complex and dynamic nature of such situations, the range of choices medical staff can make and how they make them. because these relate not only to knowledge but also to professional practice, there is an emphasis on situated, experiential learning. case studies provide the means to do this. key theories that focus on learning in unstructured, multifaceted practical contexts relate to judgement and decision-making and the differences between novice and expert engagement in professional situations. these theories should inform training interventions, which need to be experiential, encourage interactive and collaborative learning and foster reflective practice if they are to ensure optimal learning. bleetman et al.[7] noted that ‘humans make errors in predictable and patterned ways. novices make errors due to incomplete knowledge, while experts make errors due to the intrinsic hazards of semi-automated behaviour.’ they identified four triggers of error, i.e. disturbance or interruption, disruption of normal sequencing, unexpected new tasks, or need for multitasking. cases incorporating these and the taxonomy of error can increase practitioner awareness and understanding. attempts to use such intuition in teaching or to raise awareness of these processes, require materials focused on improving metacognitive function through practice and reflection. therefore, the use of simulations and case studies provides useful methods to involve students actively in context-rich activities, providing a means to accumulate further experience through intensive practice and reflection in safe environments within a relatively short period. the interactive nature allows for feedback, which can contribute to improved reasoning processes and pattern recognition and create awareness of intuitive decision-making through reflection. cases may require participants to move rapidly through a process of recognition, decision and action, which fadde[8] terms reaction skills compared with deliberate and controlled actions. he indicates that it may take up to 10 years of practice and reflection to become an expert, and thus the role of instructional design is important in speeding up parts of the process. learners must move rapidly from surface features of a context which focuses on technical aspects to a more non-analytical pattern recognition process in order to generate early hypotheses, such as those of experts during stressful situations. he claims that scenario-based case studies aid transfer of learning because cases reflect authentic task design in a holistic fashion. in this study, drawing on these theories and using kolb’s reflective cycle, which moves participants from a concrete experience through reflective observation and abstract conceptualisation to active experimentation, the participants were able to reflect on various points of error.[9] in high-pressure situations novices ask questions about general things and work from more abstract principles, while experts ask more focused questions in the context of their hypotheses.[10-14] exposure to simulations, case studies and vignettes may be used to develop appropriate questioning processes, which provide the possibility to repeat practices regularly. importantly, simulations allow the introduction of various unexpected situations so that participants can respond to different cues. by using cases of error as teaching tools the researchers created a mechanism to introduce junior doctors to the unspoken issue of decision-making and priority setting in high-pressure situations where the information was incomplete. at least two months after their exposure to the intervention, the relevant doctors already showed a broader reasoning regarding error in trauma care. they perceived that errors can compound and accumulate and that the patient is also the responsibility of the healthcare system. the doctors who received training acknowledged experiential learning as an important outcome. trauma education and assessment have evolved significantly over the past three decades. several trauma courses for primary healthcare professionals have been developed, aiming towards a standardised approach to the acute care of the trauma patient. however, a major problem with acute trauma care in our environment is failure of assessment, which revolves around the inability of junior staff to associate potential pathology with a mechanism of injury. developing an intervention that teaches junior staff to be aware of error may assist with this problem. it is acknowledged that this assessment was carried out only once using a qualitative research approach that included three participants who were exposed to the intervention and three who were not exposed to it. further research into the didactic and pedagogical approach of the intervention and the long-term learning effects should still be done. conclusion incorporating cases of error and the formal discussion of error theory into clinical meetings assist junior doctors to become aware of the problem. as an isolated intervention, it is unlikely to reduce the incidence of the impact of human error and as such needs to be part of a multifaceted programme aimed at improving the quality of care. references 1. kohn lt, corrigan jm, donaldson ms, eds. to err is human: building a safer health system. atlanta, ga: national academies press, 2000. 2. chang a, schyve pm, croteau rj, o’leary ds, loeb jm. the jcaho patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. int j qual health care 2005;17(2):95-105. 3. clarke dl, gouveia j, thomson sr, muckart dj. applying modern error theory to the problem of missed injuries in trauma. world j surg 2008;32(6):1176-1182. [http://dx.doi.org/10.1007/s00268-008-9543-7] 4. clarke dl, aldous c, thomson sr. the implications of the patterns of error associated with acute trauma care in rural hospitals in south africa for quality improvement programs and trauma education. injury 2013;45(1):258288. [http://dx.doi.org/10.1016/j.injury.2013.04.011] 5. reason j. understanding adverse events: human factors. qual health care 1995;4:80-89. 6. reason j. human error: models and management. bmj 2000;320:768-770. 7. bleetman a, sanusi s, dale t, brace s. human factors and error prevention in emergency medicine. emerg med j 2010;29(5):389-393. [http://dx.doi.org/10.1136/emj.2010.107698] 8. fadde pj. instructional design for advanced learners: training recognition skills to hasten expertise. educational technology research and development 2009;57:359-376. [http://dx.doi.org/10.1007/s11423-007-9046-5] 9. kolb d. experiential learning. englewood cliff: prentice hall, 1984. 10. daley bj. novice to expert: an exploration of how professionals learn. adult educ quarterly 1999;49(4):133-147. 11. chi m, glaser r, rees e. expertise in problem solving. in: sternberg rj, ed. advances in the psychology of human intelligence. hillsdale, nj: erlbaum, 1982:7-75. 12. benner p. from novice to expert. am j nursing 1982;82:402-407. 13. groen g, patel v. the relationship between comprehension and reasoning in medical expertise. in: chi m, glaser r, farr m, eds. the nature of expertise. hillsdale, nj: erlbaum,1988:287-310. 14. kitchener ks, brenner h. wisdom and reflective judgment: knowing in the face of uncertainty. in: sternberg r, ed. wisdom: its nature, origins and development. cambridge: cambridge university press, 1990:212-229. research 164 october 2014, vol.6, no. 2 ajhpe appendix 1. error cases case 1 a 10-month-old baby sustained hot water burns to the face. the protocol at our institution states that all such patients must be admitted to the high-care unit, have intravenous access secured, and be discussed with the burns unit consultant on call for the night. although the extent of the burn was small, the distribution on the face and the baby's age made this a potentially much more severe injury than a similar burn on another part of the body. because of a technical difficulty, an intravenous line was not inserted; therefore the baby was admitted with instructions for oral feeds. the baby was admitted to the general ward, as the admitting staff thought it was a relatively minor burn. he did not feed well owing to facial swelling and became dehydrated. as the baby was in the general ward, he was overlooked during the weekend ward round. he was finally reviewed 48 hours after admission, was profoundly dehydrated and required urgent fluid resuscitation. he made an uneventful recovery and was discharged well 10 days later. case 2 a 28-year-old man was set alight during a domestic dispute. he sustained 60% mixed full-thickness burns. he was admitted to the nearest hospital (hospital 1), which discussed his care with the major burns centre (hospital 2). the latter hospital accepted him as they had an intensive care unit (icu) bed available. as the original receiving hospital did not have any icu facilities, he was transferred to a holding hospital in the metropolitan complex (hospital 3), which did have temporary icu facilities. he would be kept there pending transfer to hospital 2. he arrived at hospital 3 being ventilated. at this point hospital 2 was contacted again, but it did not, as previously thought, have an icu bed available. the patient could therefore not be transferred. in light of the fact that there was no definitive icu bed available at the temporary hospital and the burn was more extensive than previously thought, the therapeutic plan had to be altered to a palliative plan. case 3 a 31-year-old man was admitted to our institution within 30 minutes of being stabbed in the precordium. he had a massive left haemothorax, which was drained empirically with an intercostal chest drain. at insertion of the drain, he was noted to have palpable central pulses. he was transported to the operating room and underwent an emergency thoracotomy, which revealed an injury to his left ventricle. this was repaired, but the patient died an hour after the procedure. his peri-operative arterial blood gas revealed that he had been profoundly acidotic (table 1). on review of the case, it became apparent that the patient had spent at least 20 minutes in the emergency department prior to the surgical team being informed. at that point the patient could potentially have survived (table 2). during the time in the emergency department the staff had attempted to insert a central venous catheter, but this was abandoned when the patient deteriorated. it is likely that this delay converted a potentially salvageable injury into a fatal one. case 4 this patient arrived at 13h35 on a friday afternoon. she was a 29-year-old woman with a painful submandibular swelling of about 2 weeks’ duration secondary to a painful tooth. the nursing staff recorded a blood pressure of 75/50 mmhg and a pulse rate of 150 beats/minute. her temperature was 38.5°c. these readings were written in red pen in the outpatient folder, where there was no documentation of a diagnosis of septic shock. antimicrobials were given early; hence the icon of a tick. however, management of the patient did not follow the current surviving sepsis guidelines. these guidelines advocate rapid goal-directed fluid resuscitation and early administration of broad-spectrum antibiotics, followed by urgent surgical source control. although intravenous fluids were prescribed, there was no documentation of the type or volume of fluid, choice of intravenous line, whether a central venous pressure line was inserted and if there was any response to resuscitation. the admitting surgical staff member failed to recognise a patient in severe septic shock. he/she failed to recognise the need to secure a definitive airway followed by urgent surgical drainage and icu admission. the patient was sent to a general ward, where two hours later she deteriorated. by 19h10 she had impending upper airway obstruction with poor saturation readings. she required an emergency intubation followed by surgical debridement. table 1. peri-operative blood values parameter value arterial blood gas 21.30 mmhg ph 6.95 hco3 8.8 meq/l base excess -23.3 mmol/l lactate 7.7 mmol/l table 2. blood values after resuscitation parameter value arterial blood gas 21.00 mmhg ph 7.13 hco3 13.3 meq/l base excess -15.9 mmol/l lactate 8.3 mmol/l november 2015, vol. 7, no. 2 ajhpe 161 research globally, more than a billion people never consult a healthcare worker in their lives. inequitable and ineffective healthcare systems are weakened by a scarcity and maldistribution of the healthcare workforce.[1] together with other stakeholders, health professional schools can play a key role in reducing inequality and improving health equity. the global independent commission on education of health professionals for the 21st century (2010) calls for transforming institutional and educational approaches to better meet changing health systems needs.[2] furthermore, in late 2010, the global consensus for social accountability of medical schools (gcsa) urged schools to improve their response to current and future health-related needs and challenges in society and reorientate their activities accordingly.[3] from the above it follows that it is necessary for health professional schools to engage with the community as an essential strategy to achieve a diverse healthforce, increasing access to healthcare and eliminating health disparities. in south africa (sa), as in the rest of the world, community engagement plays an important part in higher education. reorientation of health professions education to an inclusive primary healthcare approach was called for in the white paper on the transformation of the healthcare system in sa.[4] some[5,6] argue that the educational programme for health care professionals should deliver graduates who are prepared for work in community settings, resulting from the move from fixed institutions, such as hospitals, to various settings in the community. community-based education (cbe) and service learning (sl) as a means of achieving greater social responsibility have become more prominent in health professions education worldwide. cbe in a medical context can be defined as learning activities that take place within communities and take into consideration the main health problems of the country, but do not directly engage the community in the design, conduct and/or evaluation of these activities.[7,8] sl has been defined as ‘an educational approach involving curriculum-based, credit-bearing learning experiences in which students (a) participate in contextualised, well-structured and organised service activities aimed at addressing identified service needs in a community, and (b) reflect on the service experiences in order to gain a deeper understanding of the linkage between curriculum content and community dynamics, as well as achieve personal growth and a sense of social responsibility. it requires a collaborative partnership context that enhances mutual, reciprocal teaching and learning among all members of the partnership.’[9] the faculty of health sciences at the university of the free state (ufs), bloemfontein, sa recognises the tremendous potential of cbe and sl to enhance health professions education, as both allow students to apply the information they learn in the classroom to real-world settings and provide an important avenue for self-reflection. cbe and sl contributed to the restructuring of clinical education in the faculty, and various modules using cbe and sl are offered throughout the different study years across the various programmes. in our faculty, cbe and sl vary, e.g. in terms of duration and number of outreaches. students’ ability to learn is to a great extent affected by their perception of the specific learning environment. perception in this study refers to the way students view, understand and interpret cbe and sl. if students have a background. a current challenge in the training of healthcare professionals is to produce socially responsive graduates who are prepared for work in community settings. community-based education (cbe) and service learning (sl) are teaching approaches used in the faculty of health sciences at the university of the free state (ufs), bloemfontein, south africa to address these challenges. students have different views with regard to cbe and sl, and by surveying these perceptions information can be gained on how to better integrate cbe and sl into learning programmes. objective. to investigate students’ perceptions of cbe and sl in a health sciences faculty. methods. nominal group discussion was conducted to identify topics to explore students’ perceptions of cbe and sl. a questionnaire was administered to all undergraduate health sciences students at ufs to survey their perceptions of cbe and sl. results. twenty different themes were identified that had a positive or negative impact on the students’ perceptions of cbe and sl. positive aspects included personal growth, exposure to a diversity of patients, gaining practical experience and enhancement of interand intrapersonal skills. however, the students perceived the following as negative or inadequate: the organisation of cbe and sl; availability of resources; attitude of healthcare professionals; and prior orientation. conclusion. cbe and sl need to be carefully implemented and managed to enhance the learning experience for students and produce socially responsive healthcare professionals who are equipped to address the healthcare challenges in their communities. afr j health professions educ 2015;7(2):161-164. doi:10.7196/ajhpe.333 implementing and managing community-based education and service learning in undergraduate health sciences programmes: students’ perspectives s b kruger,1 phd; m m nel,1 phd; g j van zyl,2 mb chb, mmed, phd 1 division of health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: s b kruger (krugersb@ufs.ac.za) 162 november 2015, vol. 7, no. 2 ajhpe research negative perception of the learning environment, they will have a negative attitude towards the learning that is expected to take place, which could result in less effort put into the task at hand and ultimately less learning. positive attitudes and perceptions may be encouraged by creating a better learning climate, ensuring the quality and quantity of the resources and gaining individual acceptance of the students.[10] it is important to understand students’ perceptions with regard to cbe and sl and take these into consideration in the design and implementation to enhance the students’ experiences, which will in turn enhance the success thereof and result in graduates who are more socially responsive, able and willing to work in community settings. methods study design a combination of methods was used to generate data; these findings were interpreted to form the basis for the recommendations on the improvement of cbe and sl. during phase i of the mixed-methods research design, data were collected by means of a nominal group technique. nominal group discussions were held with the class leaders to identify possible themes/ topics to describe the perceptions of health sciences students with regard to cbe and sl. these themes and topics were used to design a questionnaire, which formed phase ii of the research.[11] the questionnaire survey used a quantitative approach with elements of qualitative research. the aim of the survey was to obtain demographic information of the participants, explore the students’ perceptions regarding cbe and sl, and identify whether there are certain factors that influence students’ experiences of cbe and sl. the questionnaire contained both open-ended and closed questions, with various scaling methods, e.g. nominal measurements were used in the demography section, while a likert scale was used to obtain measurements from the closed questions in the other sections.[11] sufficient open space was provided after the open-ended questions so that respondents could write down their comments/responses. study population a questionnaire survey was administered to all students registered for undergraduate degree programmes in the faculty of health sciences, ufs, who participated in cbe and/or sl during 2011. of the 1 063 students registered, 792 (74.5%) completed the survey (table 1). the population included students instructed in either afrikaans or english, as well as male and female students. data collection questionnaires were handed out to students directly after an academic contact session, following their completion of the cbe or sl section in their respective modules. participation was voluntary and questionnaires were completed anonymously. students had 20 minutes to complete the questionnaire, which gave them adequate time to consider their answers. after completion of the questionnaires, the participants placed these in a box to ensure anonymity and confidentiality. data analysis quantitative data from the questionnaire surveys were analysed descriptively by the department of biostatistics, ufs, using frequencies and percentages for the categorical variables. the qualitative data were analysed by the researcher (sbk) by reading and reflection, identification of themes, establishment of patterns and connections, as well as coding. following the analysis of the data, both the quantitative and qualitative data were categorised into different themes. ethical approval was obtained from the ethics committee at the faculty of health sciences, ufs (ecufs no. 77/2011). results twenty different themes were identified and divided into aspects that had either a positive or a negative influence on the way students perceived cbe and/or sl. the themes are presented in table 2, together with some of the verbatim quotes from the students to substantiate the theme. discussion based on the information obtained by means of the questionnaire survey, it was clear that the students regarded cbe and sl as valuable and enjoyed it. they agreed that by means of cbe and sl they had the opportunity to experience the ‘human aspect’ of patients, could put their knowledge into practice, and learn about the roles and values of the multidisciplinary teams. cbe and sl improved their sensitivity towards other cultures, self-confidence, interpersonal communication skills, problem-solving skills and other professional competencies. however, a number of aspects that students perceived as negative were identified. consequently, certain recommendations could be made with regard to the improvement of cbe and sl in the faculty of health sciences, with a view to enhance the experiences of undergraduate health sciences students. the researcher proposes that when implementing and managing cbe and sl in undergraduate health sciences programmes, certain steps should be included to enhance the students’ experiences thereof and meet the underlying principles for which cbe and sl are intended (kruger sb. community based education and service learning: experiences of health sciences students at the university of the free state. unpublished doctoral thesis. bloemfontein: university of the free state, 2013). the steps proposed by sbk concur with those set out by the higher education quality committee (heqc)[11] for the development of a curriculum model for service learning, with certain key steps in the development of a cbe programme.[12] planning cbe and sl a number of important steps need to be taken when planning cbe and sl. the first step is to set clear module outcomes. it is crucial to ensure table 1. numbers of registered undergraduate students in the faculty of health sciences, ufs, who completed the questionnaire survey (n=792) academic programmes year of study totali ii iii iv v mb chb 128 0* 99 54 76 357 b occupational therapy 31 31 6 27 na 95 bsc physiotherapy 40 33 38 30 na 141 bsc dietetics 0* 0* 0* 18 na 18 b optometry 0* 0* 23 0* na 23 bsocsc (nursing) 60 27 30 41 na 158 total 259 91 196 170 76 792 na = not applicable, as these programmes are 4-year degree courses. * no cbe/sl in these study years. november 2015, vol. 7, no. 2 ajhpe 163 research that these outcomes address the healthcare needs of the community; clarify social, economic, cultural and political issues underlying the source of community needs; and enhance academic learning, personal growth and social responsibility of students. these outcomes should be clear, action orientated and measurable. the second step is to assign tasks to the learning outcomes that are applicable to the students’ level of knowledge and skills, in line with the outcomes and achievable in the community. thirdly, teaching methods can then be assigned to the different tasks. these teaching methods should be in the correct combination and level of students’ knowledge and skills to facilitate and support learning from communities and integration of experiential learning. the fourth and fifth steps are to assign assessment criteria and academic credits to the activities. the next steps may be done in any order or simultaneously. appropriate community service placements should be selected, with healthcare needs table 2. themes that influenced students’ perceptions of cbe and sl positive verbatim quotes by students achievement of personal growth ‘it helped me to grow as a person which made me more competent in my personal life.’ ‘gained personal growth and development.’ exposure to a variety of conditions/cases in their respective fields of study ‘diversity in the patient profiles.’ ‘it is challenging, there is a huge variety in patients.’ enhancement of social responsiveness ‘there it feels like i am actually making a difference.’ ‘it gives one a great sense of purpose.’ gaining interpersonal skills ‘to enhance personal relations with my peers and other professionals.’ ‘to be able to learn and experience with my fellow students.’ exposure to different cultures ‘working with different cultures.’ ‘give insight into other cultures.’ application of theoretical knowledge ‘it is nice to experience everything in practical and not only to learn in theory.’ ‘challenging. learn a lot more through experience.’ expanding theoretical knowledge ‘it gave me a new perspective and challenged me to search for solutions to some problems.’ gaining professional competencies ‘took me out of my comfort zone and i learnt new competencies.’ ‘had to make decisions yourself and bear responsibility. i enjoyed it.’ feeling valued in the community ‘to see how thankful the people are afterwards.’ ‘it was nice to see how thankful the less fortunate was for the help they receive.’ working in multidisciplinary teams ‘to see how the multidisciplinary team works and experiences the hospital environment.’ ‘it helps me to learn more about other fields.’ gradual introduction into clinical field ‘it gives one a viewpoint of how things in the future in your career can work from early on in your studies.’ negative poor organisation ‘to have set out schedules/time tables to minimize wastages.’ ‘place the students where there are learning opportunities other than being at a place yet you have nothing to do.’ ‘monitor students attendance regularly, it is bad that some students never attend sessions and lie and get away with that.’ negative attitude of healthcare professionals ‘the staff at the community centers should be encouraged to be more willing to teach.’ ‘only staff that are willing to be involved with students should be involved.’ feeling unproductive ‘place the students where there are learning opportunities.’ ‘theory in class does not match the practical aspects.’ exposure to traumatic situations ‘the necessary debriefing after traumatic experiences.’ ‘it gets overwhelming in the final year and there is very little support for the students, it gets very depressing at times.’ availability of resources ‘improve hospital conditions.’ ‘the clinics need proper equipment.’ communication difficulties ‘communication between the faculty and the skills providers at the community facilities needs to be improved.’ ‘an effort to communicate better with students as to the state of affairs.’ ‘learn sesotho.’ transport problems ‘transport must be available.’ ‘not all students have cars, organise transport.’ insufficient orientation ‘enough training beforehand should be conducted.’ ‘maybe prepare students in depth as to what is expected of them.’ unstructured reflection ‘reflections need to be more structured and done in private.’ research 164 november 2015, vol. 7, no. 2 ajhpe that relate to the set module outcomes, and students should have the appropriate skills and knowledge to address these needs. furthermore, community settings should provide students with exposure to a variety of pathologies, be able to accommodate the students and have the necessary resources. academic staff should plan the duration of cbe and sl activities and schedule them in the students’ academic rosters. time frames should be reasonable to successfully complete the activities. healthcare personnel from multiple professions and across disciplines have to be recruited and appointed. they should be knowledgeable, willing and able to supervise students and receive training with regard to their roles, responsibilities and module outcomes. sufficient transport should be arranged and a professional counsellor or psychologist should be available to assist students with traumatic emotional experiences. the final step that needs to be taken when planning cbe and sl is to orientate the students. orientation should include the following elements: • introduce the concepts of cbe and sl. • emphasise the importance of cbe and sl. • prepare students with regard to what to expect. • orientate students to module-specific content. • explain what is expected of students in terms of outcomes. • explain assessment criteria. • discuss student reflections and indicate the frequency, format and content. • inform students about support services, e.g. transport, psychologist. • divide students into groups (multicultural and different languages). • hand out schedules. • provide clear directions to community sites. • inform students about professional courtesy, ethics, rights and responsibilities. • discuss the different activities that students need to perform. • discuss possible challenges and problems that students may encounter and possible solutions. actions during cbe and sl the following actions should be executed on a continuous basis throughout the duration of cbe and sl: students’ attendance should be strictly monitored at all times. regular communication should take place between all stakeholders, including initial consultations with individuals at community settings and healthcare facilities at the beginning of cbe and sl to identify the broad healthcare needs of the community, negotiate cbe and sl activities and the aims and objectives of such activities, highlight the potential benefits for the community, and emphasise the importance of mutual respect and co-operation. other important actions are that academic staff should have regular meetings throughout the duration of cbe and sl at community settings and healthcare facilities with individuals, supervisors and students to ensure that everyone is working towards the same goal and objectives, confirm schedules for future cbe and sl, identify problems and challenges and discuss possible solutions. it should also be confirmed whether the necessary resources are available at the different sites where cbe and sl are planned. after cbe and sl on completion of cbe and sl it is important to celebrate the success with all the relevant role players and show appreciation for their respective inputs in the success of the initiative. allow students to evaluate cbe and sl and receive their inputs and feelings with regard to the experience. evaluate whether module outcomes have been met and students’ personal growth and social responsiveness have increased. these evaluations and recommendations may be used to adapt cbe and sl if necessary. conclusion the current challenge of health professionals’ training is that programmes should produce graduates who are prepared and willing to work in community settings to improve the current health status of individuals and groups and the health systems performance of the country in which they live. cbe and sl are teaching approaches to address this challenge. if cbe and sl could be implemented and managed successfully and students perceived it as positive learning experiences, they would acquire an understanding of the current health needs and challenges facing communities, have the opportunity to apply their theoretical knowledge, and learn in an environment that resembles their future professional career environment. moreover, they will be equipped with a number of professional competencies and skills, experience interprofessional and multidisciplinary teams working together and interact with different cultures, while their social responsiveness will be enhanced. the description of the perceptions of undergraduate health sciences students concerning cbe and sl generated from this study may be generalised beyond its local application as it may be applicable to other situations and groups. therefore, the researcher proposes expansion of the use of the survey instrument developed for the purpose of this study by other faculties at ufs and other faculties of health sciences, both locally and internationally, as a means of generating comprehensive information regarding students’ perceptions of cbe and sl in other settings, as well as encouraging future research in this regard. references 1. the training of health equity network. thenet’s social accountability evaluation framework version 1. monograph i. 1st ed. new york: thenet, 2011. 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 3. global consensus for social accountability of medical schools: position statements global consensus for social accountability of medical schools, 2010. http://healthsocialaccountability.org/ (accessed 10 january 2013). 4. department of education. a programme for the transformation of higher education. education white paper 3. notice 1196. pretoria: government printer, 1997. 5. frank b, adams mh, edelstein j, speakman e, shelton m. community-based nursing education of prelicensure students: setting and supervision. nurs educ perspect 2005;26(5):283-286. 6. nokes k, nickitas d, keida r, neville s. does service-learning increase cultural competency, critical thinking and civic engagement? j nurs educ 2005;44(2):44-53. 7. strasser r. community engagement: a key to successful rural clinical education. rural remote health 2010;10(3):1543. 8. kristina tn, majoor gd, van der vleuten cp. defining generic objectives for community-based education in undergraduate medical programmes. med educ 2004;38(5):510-521. [http://dx.doi.org/10.1046/j.1365-2929.2004.01819.x] 9. university of the free state (ufs). community service policy of the university of the free state. 2006. http:// supportservices.ufs.ac.za/dl/userfiles/documents/00000/357_eng.pdf (accessed 26 august 2015). 10. marzano rj. dimension 1: positive attitudes and perceptions about learning. a different kind of classroom: teaching with dimensions of learning. alexandria, va: association for supervision and curriculum development, 1992. http://files.eric.ed.gov/fulltext/ed350086.pdf (accessed 26 august 2015). 11. higher education quality committee (heqc). service-learning in the curriculum: a resource for higher education institutions. pretoria: council on higher education, 2006. 12. morgan s, smedts a, campbell n, sager r, lowe m, strasser s. from the bush to the big smoke – development of a hybrid urban community based medical education program in the northern territory, australia. rural remote health 2009;9(3):1175. ajhpe 367.indd research october 2014, vol.6, no. 2 ajhpe 129 postgraduate studies are necessary to fast-track human capital development and are within the broader national goals of higher education.[1] there is concern about prolonged completion times and low completion rates for postgraduate research students locally and internationally.[1,2] students should obtain their degree within a prescribed period.[1-3] postgraduate degrees are costly for the candidate, government and tertiary institution. few master’s degree candidates in south africa (sa) complete their studies within the minimum time,[1] while some do not finish at all.[4] in sa there is a shortage of qualified postgraduates[5] and slow or non-completion impacts negatively on student finances and morale, staff workload, university funding and future student intake. monitoring of success rates is therefore a critical requirement for any proposed improvement in postgraduate output. a master’s degree in pharmacy is offered at the department of pharmacy, university of limpopo, medunsa campus, pretoria, sa (henceforth referred to as the department). while the degree originally comprised research only, it may now be obtained by a combination of coursework and a minor dissertation. registration is for a minimum period of one year full-time or two years part-time. most students choose the coursework and research option, but few accomplish it in two years. in the past decade, academic internships have been introduced in the department, during which time students are expected to complete their degree over two years on a fulltime basis, in tandem with the sa pharmacy council academic internship programme.[6] the objective of this study, conducted in the department, was to establish completion rates with regard to postgraduate pharmacy candidates and identify factors affecting this goal. method a cohort of 100 students who enrolled in the msc (med) (pharmacy) degree between 2002 and 2009 was surveyed. this time frame was intended to allow for the completion of studies (even if delayed) and more accurate recall. the data collection instruments (questionnaire and database summary) were reviewed for content validity by the postgraduate administrative officer in the department and the study supervisor. the questionnaire was pilot-tested by administering it to three departmental staff members with postgraduate degrees from another department. the questionnaire covered the following areas: • demographic data • type of postgraduate degree and completion details (time taken, graduated or not) • motivation for studying • student/supervisor interaction (statements assessed on a likert scale) • social and economic variables (assessed on a likert scale) background. postgraduate degrees are costly for the candidate, government and tertiary institution. few master’s degree candidates complete their studies within the minimum prescribed time, while some do not finish at all. these two factors impact negatively on student finances and morale, staff workload, university funding and future student intake. objective. this study was conducted at the department of pharmacy, university of limpopo, medunsa campus, pretoria, south africa, to establish the completion rates of master’s degrees in pharmacy and identify the factors impacting on completion. method. a cohort of 100 students who enrolled in the msc (med) (pharmacy) degree between 2002 and 2009 was surveyed by means of an emailed questionnaire that was returned anonymously. results. women were more likely to complete their degree than men (53% v. 40%). full-time students had the highest completion rate (100%), followed by staff (78%). only 35.5% of part-time postgraduates and those who communicated more frequently with their supervisors received their degree. those who completed their degree also scored higher on quality of communication with and accessibility of the supervisor. those who did not complete their degree, scored low on their adjustment to tertiary education and ability to reach a balance between social and academic activities. finance was also a contributing factor for 40% of those who did not complete their degree. conclusion. completion rates in our degree course compare reasonably well with those in other studies. clarity about the roles and responsibilities of supervisors and students is of the utmost importance. being mostly present at the university plays a major role in the successful completion of a postgraduate degree. academic internship is the optimal route to a master’s degree in pharmacy, but if not possible close contact must be maintained between the student and university. ajhpe 2014;6(2):129-132. doi:10.7196/ajhpe.367 factors that influence msc (med) (pharmacy) completion rates at the medunsa campus of the university of limpopo, south africa b summers, bpharm, msc (med), phd; d i mpanda, bpharm department of pharmacy, university of limpopo, medunsa campus, pretoria, south africa corresponding author: b summers (beverley.summers@ul.ac.za) 130 october 2014, vol.6, no. 2 ajhpe researchresearch • stress management (assessed on a likert scale) • logistics of the research (assessed on a likert scale). permission was requested from the department and the university to gather student information from the hard-copy archives and electronic database. the research proposal was submitted to the school of health care sciences research ethics committee and approved by the medunsa campus research and ethics committee. students were contacted via email and telephonically using details in the database. the south african pharmacy council was approached for recent contact details if the departmental records were not up to date. social networks were also used to trace past students. a consent form, together with the questionnaire, was sent to the students. the questionnaire had no identifiers, and respondents could reply anonymously by fax or using a non-personalised email address. many students opted to respond from their listed addresses, which simplified the follow-up of non-respondents. several reminder emails were sent after one week. nonrespondents were contacted telephonically two weeks after questionnaire distribution. returned questionnaires were numbered and not linked to the return email addresses, i.e. these could not be associated with individual students. results completion details of target group sixty per cent of the target group of students (n=100) and 53% (32/60) of those who completed the degree were female. of the males, only 40% (16/40) completed their degree (table 1). occupation category at university the questionnaire was sent to 24 full-time postgraduate students (14 staff and 10 academic interns) in the group (n=100). the overall completion rate was 48%. it was highest for academic interns (90%, with the 10th intern still enrolled for the degree at the time of the study), followed by staff (78.6%). only 35.5% of part-time postgraduates completed the degree (table 2). time to complete while the pharmacy academic internship is spread over a minimum of two years, the postgraduate candidates took an average of 2.4 years to complete their degree and all ultimately finished. academic staff took an average of 3.2 years and other part-time students averaged 6.1 years, including interruption of study (registration for more than 4 years is no longer routinely possible according to university rules). the completion time for parttime candidates is a matter of concern. questionnaire responses of the postgraduates surveyed (n=100), 44 responded, 45 did not respond and 11 were not contactable. of the 44 respondents, 29 had completed the degree and 15 had not. gender distribution of respondents fig. 1 shows the completion rate by gender. sixty per cent of the target group and 57% of the respondents were female, indicating that the respondents were representative of the target group in terms of gender. fifty-three per cent of females and 40% of males in the target group completed their degree. of the questionnaire respondents, 81% of females and 43% of males finished their degree. hence, when comparing the completion rates of the target group with those of the respondents, there was a slight selection bias in terms of those who had completed the degree. research topic, workload and communication between supervisor and student the students in each group (degree completed/ not completed) who agreed or strongly agreed with the statements related to choice of topic, workload and communication with supervisor are presented in table 3. in all instances, students who had completed their degree gave more positive responses than those who had not. accessibility of the supervisor, and frequency and quality of communication between student and supervisor, appeared to play a role in completion of the degree. support systems and socioeconomic factors from tables 4 and 5 it can be seen that good time management with regard to adjustment to studying and achieving a balance between social table 1. target group: degree completion by gender females (60%) males (40%) total (100%) degree completed, n 32 16 48 degree not completed, n 28 24 52 table 2. degree completion rate by occupation completed occupation, n n % staff (14) 11 78.6 academic intern (10)* 9 90.0 neither of the abovementioned occupations (76) 27 35.5 *tenth intern still enrolled at time of study, but subsequently graduated. fig. 1. msc (med) (pharmacy) degree completion of respondents by gender (n=44). 46% 23% 20% 11% female completed male completed female not completed male not completed research october 2014, vol.6, no. 2 ajhpe 131 and academic activities appear to play a major role in successful degree completion. there was no difference in the percentage of students who were breadwinners, those who completed their degree and those who did not. however, financial constraints played a role in non-completion of the degree. discussion the findings of this study confirm much of the work done elsewhere in the world. postgraduate degree completion times for msc part-time students in the uk and australia are on average about 7 years.[2] the completion rates in our master’s degree course (48% overall) are slightly lower than those reported in developed countries.[7] cobb[7] reported that postgraduate completion rates were 56% in the usa, 65% in australia and 72% in the uk. our study results indicate that time management and motivation are critical, as the extent to which postgraduate students take ownership of their research will ultimately determine success.[8] an earlier australian study among education students[2] found that only 31% of master’s degree students who commenced a course in 1992 had completed it by 1999. the study also observed that completion rates were generally higher for full-time than part-time students. completion rates vary,[1] being higher for veterinary and other sciences and lower for the arts, social sciences and legal studies. the australian and our study found that women are more likely to complete a master’s degree course than men.[5] university-specific factors, such as province, history, endowment levels, population served, subjects offered, staff experience and possibly ethos,[1] explain a significant proportion of the variation in completion rates. in sa the average completion time for msc graduates in the health sciences, according to the council on higher education, is approximately three years table 4. adjustment to studying, home support and social/academic balance (n=44) question degree completed (n=29) (students who answered the question in the affirmative, %) degree not completed (n=15) (students who answered the question in the affirmative, %) adjustment to study: excellent/good 82.8 40.0 support from home: excellent/good 86.2 60.0 balance between social and academic activities: excellent/good 86.2 40.0 table 5. socioeconomic factors that may affect degree completion (n=44) question degree completed (n=29) (students who answered the question in the affirmative, %) degree not completed (n=15) (students who answered the question in the affirmative, %) breadwinner in family 37.9 40.0 funded by sponsor or in receipt of grant 55.2 33.3 piling up of social responsibility during study 44.8 60.0 study negatively affected by financial status 6.9 40.0 table 3. choice of research topic, workload and communication between student and supervisor (n=44) question degree completed (n=29) (students who answered the question in the affirmative, %) degree not completed (n=15) (students who answered the question in the affirmative, %) student chose own topic 100.00 66.7 student comfortable with topic 100.00 90.0 academic workload heavier than expected 58.6 46.7 handling of workload manageable 37.9 27.7 experienced a loss of academic interest 48.3 46.7 accessibility of supervisor: very accessible/accessible 86.2 40.0 communication interval, supervisor to student: weekly/monthly 55.1 20.0 communication interval, student to supervisor: weekly/monthly 51.7 26.7 supervisor’s knowledge: very high/high 82.7 46.7 quality of interaction between student and supervisor: excellent/good 79.3 53.3 contribution of supervisor towards making the project easy or difficult: always/sometimes 75.9 33.3 132 october 2014, vol.6, no. 2 ajhpe research across all fields,[1] but only 10% of master’s students at the university of the western cape completed their dissertation in three years.[9] clarity about the roles and responsibilities of supervisors and students is of the utmost importance. data about students’ perceptions offer crucial information about their expectations and to what extent these expectations can be met.[5] students must be adequately prepared in terms of what to expect in postgraduate study. the department has made the following interventions in the msc (med) (pharmacy) degree over the past few years: • an interview, a writing skills test and critical appraisal of a publication as part of the selection process, which helps to assess student potential and motivation prior to selection. • extension of the coursework over two years instead of one year, and selection of a research project early in the first year. this intervention means that students spend more time in the department, which supports them in the research process. • there are regular, bi-monthly progress meetings between the head of the department and supervisors to report on students’ achievement of ‘milestones’. in this way students who lag behind can be assisted. from our results it is clear that the regular ‘presence’ of the postgraduate student in the university environment plays a major role in successful postgraduate degree completion.[5] based on our findings, an academic internship is the optimal route to obtain a master’s degree in pharmacy. it is therefore regrettable and ironic that the medical research council (mrc) has recently opted to discontinue the allied health internship grant on which many of our master’s degree interns relied. since 2014, the mrc has diverted the funds to phd grants. however, in the sa context, how can students expect to progress to a phd level if they do not first complete a master’s degree? acknowledgements. we thank nikki williamson for her help with the data provision, and zakhele dlamini, bongani mbena and wesley phiri for their help with the data collection. references 1. council on higher education. higher education monitor: postgraduate studies in south africa. pretoria: council on higher education, 2009. 2. martin ym, maclachlan m, karmel t. postgraduate completion rates, occasional paper series, higher education division. australia: department of education, training and youth affairs, 1999. http://catalogue.nla. gov.au/record/55664 (accessed 15 july 2013). 3. lessing ac, schulze s. postgraduate supervision and academic support: student’s perceptions, university of south africa. south african journal of higher education 2002;16(2):139-149. http://uir.unisa.ac.za/bit (accessed 15 march 2012). 4. essa i. possible contributors to students’ non-completion of the postgraduate nursing diploma at stellenbosch university. research report. stellenbosch: stellenbosch university, 2010. http://www.scholar.sun.ac.za/bitstream/ handle/10019.1/.../essa_possible_2010.pdf ? (accessed 27 march 2012). 5. wingfield b. can we improve postgraduate degree throughput rates? south african journal of science 2011;107:11-12. [http://dx.doi.org/10.4102/sajs.v107i11/12.967] 6. south african pharmacy council (sapc). intern and tutor manual for the pre-registration experience of pharmacist interns. pretoria: sapc. 7. cobb f. factors affecting postgraduate research student completion rates: literature review and reflections for research. london: university of east london, uk, 2007. 8. burns n, grove sk. understanding nursing research. 3rd ed. philadelphia, pa: saunders, 2003. 9. sayed y, kruss g, badat s. students’ experience of postgraduate supervision at the university of the western cape. journal for further and higher education 1998;22(3):275-285. [http://dx.doi.org/10.1080%2f0309877980220303] december 2021, vol. 13, no. 4 ajhpe 265 research food security remains a significant challenge in south africa (sa), as in other economically developing countries, with persons with disabilities specifically being at risk of inadequate nutrition.[1] in sa, according to the general household survey of 2016, 22.3% of households had inadequate or severely inadequate access to food, 11.8% households experienced hunger and 13.4% individuals experienced hunger.[2] based on the same survey, 4.7% of south africans aged 5 years and older were classified as disabled.[2] persons with disabilities are vulnerable to food insecurity, because they are often economically marginalised and therefore chronically poor.[3] the relationships between poverty, food security and disability are bi-directional as one can cause the other.[4-6] for example, poverty results in limited purchasing power for food and limited intake, rendering the individual unable to work, further reducing available income. malnutrition arising from food insecurity may drive disability in individuals with chronic illnesses, such as hiv/aids, further limiting their ability to access, prepare and consume food. disability may therefore cause poverty and vice versa, especially if there is limited access to healthcare services[7] and inadequate community support. baro and deubel[8] argue that community involvement, new technologies and support from both international and national governments and non-governmental organisations (ngos) are vital to food security responses in africa. drimie and mclachlan[9] agree that solving the complex food security challenge requires an explicit transdisciplinary approach, including input from health sciences professionals. health sciences professionals work with individuals on a one-on-one basis and multidisciplinary teams are often in contact with persons with disabilities. community healthcare workers should also be aware of and able to assess the nutritional status of persons with disabilities, and be able to identify appropriate interventions to promote food security (table  1) in these individuals. many healthcare professionals work with persons with disabilities, and healthcare students should be trained to assess and work with affected persons. the extent to which the relationship between food security and persons with disabilities is covered in health sciences curricula is unknown, both internationally and in sa. we found no literature on the attitudes of educators towards teaching this subject, even though the subject is societally important. we aimed to discover the knowledge, attitudes and practices associated with including food security and disability into curricula in the school of health sciences at the university of kwazulu-natal (ukzn). methods we conducted an explorative cross-sectional online survey using closedand open-ended questions. we structured the questionnaire into three sections, background. food security is a significant challenge in south africa, especially for persons with disabilities. this topic is therefore important for educators in the health sciences. nevertheless, little is known about educators’ awareness of the relationship between food security and people with disabilities, or to what extent the topic is included in their curricula or what their attitudes are regarding this topic. objectives. we explored the knowledge and attitudes of educators pertaining to food security and people with disabilities. we assessed the current teaching practice associated with the food security of people with disabilities in the school of health sciences, university of kwazulu-natal. methods. thirty-five participants completed a cross-sectional online survey. the participants represented diverse disciplines including audiology, occupational therapy, optometry, physiotherapy, speech-language pathology and sports science. quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically. results. the participants had limited self-reported knowledge about the definition of food security. fewer than 60% of the participants reported a relationship between three of the dimensions of food security and disability, and 80% for one of the dimensions (food utilisation). of the participants, 88% did not teach food security and disability theoretically, and 80% did not teach it practically. according to the participants, students were not equipped to assess if their clients with disability had food security problems, and were unsure of appropriate interventions. conclusion. despite a lack of knowledge, participants had positive attitudes towards including food security into their teaching, although limited teaching existed at the time of the study. afr j health professions educ 2021;13(4):264-269. https://doi.org/10.7196/ajhpe.2021.v13i4.1251 teaching about disability and food security in the school of health sciences, university of kwazulu-natal, south africa h e lister,1 b occ ther, m dev studies; k mostert,2 bsc pt, mba, phd; m pillay,3 bsht, msppath, ded 1 discipline of public health, school of health sciences, university of kwazulu-natal, durban, south africa; and department of occupational therapy, school of health care sciences, university of pretoria, south africa 2 department of physiotherapy, school of health care sciences, university of pretoria, south africa 3 discipline of speech language pathology, school of health sciences, university of kwazulu-natal, durban, south africa; and speech and language therapy, massey university, auckland, new zealand corresponding author: h e lister (helga.lister@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1251 mailto:helga.lister@up.ac.za 266 december 2021, vol. 13, no. 4 ajhpe research based on a literature review, and input from a statistician, a research expert and an expert in food security. we established content validity by sending the questionnaire to five experts for review.[13] this panel determined whether the questions were understandable, easy to answer and appropriate for what the researcher was wanting to determine. the questionnaire was then piloted with three health sciences professionals not currently employed at ukzn, improving the clarity and content of the instrument. the population comprised all educators whose email addresses were received from the heads of departments within the professions of audiology, occupational therapy, optometry, physiotherapy, speech language pathology and sports science (n=70 in january 2017). a link to the survey, together with the information document and informed consent form, was emailed to all educators. thirty-five staff responded (response rate of 50%). table 2 depicts the demographics of the participants. quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically using nvivo 11 software. themes were established through three-level coding. data were coded in nvivo, using the exact words in the text, and descriptively, where the text was described and interpreted by the researcher. the study was approved by the humanities and social sciences research ethics committee at ukzn (ref. no. hss/1740/016). gatekeeper permission was also obtained from the registrar of ukzn. results knowledge of food security and disability we asked the participants if they understood the different dimensions of food security (table 1). participants either answered ‘no’, ‘somewhat’ or ‘yes’, and if they answered ‘yes’ or ‘somewhat’, we asked them to elaborate. table 3 indicates the participants’ self-reported understanding of the different dimensions of food security. upon further elaboration, the participants understood food availability as having sufficient quantities of food; food that is available (locally and internationally); that there is food being produced; the ‘percentage of fats, carbohydrates etc. (that are) contained in food’; or having access to good food for all in a group of people. participants understood food access as the ability to ‘get’ food, through finding the means, being in close proximity, affordability, ease of obtaining, or physical and economic access to nutritious food; all people having access to food; ‘the percentage of fats, carbohydrates etc. (that are) contained in the food’; or having ‘reliable and trusted access to food’. participants understood food utilisation as using food, either how they use it, or ‘how the body uses food’, how much food is eaten, for what purpose and ‘how much of a specific food group’ is used; using the ‘available channels to access food’; one’s ability to eat food that is available; the ‘correct consumption patterns of food’; the ‘ability of an individual to prepare regular meals using food’; or the ability of a person to choose what food is ‘good’. in addition, participants understood food stability as having sustained and sufficient food in terms of supply, over a period of time, at a given time, consistently and regularly; the shelf-life of food; ‘all the variables of food production and supply’; or ‘having food and being able to get food and eat food that is available. the final questions within this section gauged participants’ opinions regarding the relationship between the different dimensions of food security and disability. the dimensions were further explained within the question so that the participants had a clear understanding of the dimensions. refer to table 4 for findings. five themes, as seen in table 5, emerged from the data. the categories are represented under the four dimensions of food security. attitude about including food security and disability in the curriculum we provided the participants with 15 items that could possibly be included table 1. the four dimensions of food security food availability the supply side of food security, namely the availability of sufficient quantities of quality food coming from imports and domestic agriculture production. in other words, the level of food production, stock levels and net trade.[10,11] food access the income, expenditure and buying capacity of individuals or households.[11] therefore it takes into consideration whether the individual has enough resources to be able to acquire the appropriate quantity of quality, nutritious foods. food utilisation how individuals utilise food through adequate diet, sanitation and healthcare, so that they can reach a state of nutritional well-being;[12] therefore, how much food, and what and how individuals eat.[11] other components include food preparation, water, healthcare practices and intra-household food distribution. food stability the continuation of the other three dimensions over time, namely stability of availability, accessibility and proper utilisation conditions.[11] food stability may be affected by numerous conditions, e.g political instability, adverse weather conditions and economic factors, e.g. unemployment and rising food prices.[10] table 2. demographics of participants discipline n (%) educational level n (%) employment level n (%) employment type n (%) audiology 3 (9) bachelor’s degree 4 (12) senior tutor 8 (25) part-time 6 (18) occupational therapy 11 (32) master’s degree 22 (65) junior lecturer 18 (56) practical supervision only 1 (3) optometry 5 (15) doctoral degree 8 (24) senior lecturer 5 (16) full-time 26 (79) physiotherapy 6 (18) associate professor 1 (3) speech language pathology 5 (15) professor 0 sports science 4 (12) december 2021, vol. 13, no. 4 ajhpe 267 research in the curriculum. we asked participants to rank the items on a scale of 1 to 5, with 1 being ‘definitely exclude from teaching’ and 5 being ‘essential to include in teaching’. of the 15 items, 10 items were ranked by 80% of participants as either ‘important to include in teaching’ or ‘essential to include in teaching’. these were: • the definition of food security • the influence of the social context on food security • the influence of the environmental context on food security • the influence of the economic context on food security • the risk factors of food insecurity • the consequences of food insecurity • the macro factors influencing the food security of persons with disabilities • the micro factors influencing the food security of persons with disabilities • how to incorporate food security into the assessment of persons with disabilities • how to incorporate food security into the treatment of persons with disabilities. current practice of teaching about the relationship between food security and disability in the final section of the survey questionnaire, participants were asked, ‘do you currently teach anything about the relationship between disability and food security in clinical settings’ practically and theoretically, and ‘do you think students are currently equipped to treat and advise persons with disabilities who have food insecurity problems?’ theoretical teaching about the relationship between disability and food security of the participants, only 11.8% reported that they included something in their teaching about the relationship between disability and food security theoretically and 88.2% said that they did not. where it was taught, it was done in the study themes ‘accessibility issues on disability issues’; incorporating the social and economic context into assessment; within intervention required for visual problems (e.g. glasses) so that the individual with visual problems can see the food; and in referrals to a dietician. practical teaching about the relationship between disability and food security twenty percent of participants included teaching something about the relationship between disability and food security practically, while 80% did not include anything. the practical teaching occurred within assessment, intervention, and on a case-by-case basis. regarding assessment, if ‘the patient was found to have poor nutrition/low socio-economic status and disability then emphasis is placed on the vulnerability of the patient to this kind of crisis’; it is addressed if there is poor volition of the client to attend therapy and why this may be so; and in incorporating the social and economic context into assessment. regarding intervention, it was included for those who have visual problems, and referral to the dietician. educators’ opinion on whether students are equipped to treat and advise persons with disabilities who have food insecurity problems regarding the perception of participants on whether students are equipped to treat and advise persons with disabilities who have food insecurity problems, 37.1% stated that they felt students were somewhat prepared and 62.9% felt that students were unprepared. participants further explained that this situation was a curriculum problem (on why it was not included), that it may be covered in some places, should be included, or even that it should not be included as there was already an overload of teaching. participants felt that students learn incidentally and should be encouraged to think and treat holistically, and that they should make use of allied team members. in this way, food security is addressed within individualised healthcare, as opposed to only on a larger scale. these factors are integral to the realisation that it is essential to address disability and food security holistically within health sciences professions. discussion we assessed the knowledge, attitude about inclusion in teaching and the current teaching practice of educators regarding food security and disability in the school of health sciences at ukzn. educators had little theoretical understanding of the different dimensions of food security but once the dimensions were explained, they acknowledged the importance of the relationship between disability and food availability and that it should be included more extensively in the curriculum. knowledge: what the educators understood about the relationship between disability and food security despite not understanding the different dimensions of food security, health sciences educators showed a general appreciation for the relationship between food security and disability. more than 40% of participants (this study) stated that they did not understand the food security dimension. however, less than 12% of participants did not acknowledge the relationship between the different food security dimensions and disability. we were unable to find literature that specifically links the dimensions of food security to disability. we were, however, able to find examples of how food insecurity drives disability and vice versa. studies have shown, that food insecurity is associated with reduced physical and mental health status.[4-6] persons with disabilities experience high levels of poverty and unemployment.[14] this increases food insecurity of the individual and of the household.[5] food insecurity is also a barrier to accessing health care.[15] the sa department of agriculture[16] notes in its ‘integrated food security strategy for south africa’ that access to food may be affected because of disability. additionally, table 3. the self-reported understanding of the different dimensions of food security of participating educators* dimension no, % somewhat, % yes, % food availability 46 46 9 food access 46 46 9 food utilisation 57 34 9 food stability 60 34 6 *percentages have been rounded off, hence this dimension does not add up to 100%. table 4. educators’ opinions on the relationship between the different dimensions of food security and disability is there a relationship between this dimension of food security and disability? no, % yes, % do not know, % food availability 12 47 41 food access 3 80 17 food utilisation 9 54 37 food stability 3 54 43 268 december 2021, vol. 13, no. 4 ajhpe research malnutrition, considered under ‘food utilisation’, is a cause of disability.[17-19] malnutrition can be caused by the inability to feed. feeding can be impaired through different types of disabilities, e.g. cerebral palsy, which is characterised by low muscle tone that can cause difficulties in swallowing.[20,21] attitude: educator's attitudes to providing instruction about disability and food security we were unable to find any direct guidelines on what the curriculum content for the various professions within health sciences should be, as well as what table 5. themes and categories displaying the relationship between the different dimensions of food security and disability theme food availability food access food utilisation food stability the relationship between disability and food insecurity is bi-directional lack of food can cause and influence disability disability leads to food being inaccessible and conversely, poor access to food can lead to disability food insecurity can create or worsen the disability, yet food security improves health lack of food can lead to a disability disability, poverty and food insecurity are interlinked the food insecurity of persons with disabilities ‘is one of the contributors to poverty’ poverty leads to lack of food which leads to a disability. disability results in unemployment which results in less access to food disability leads to poverty which leads to lower quantity, less nutrition, less variety of food and inappropriate food choice lack of food stability leads to poverty and conversely poverty leads to lack of food stability disability influences food production, food preparation and feeding persons with disabilities are unable to contribute to food production disability affects the ability to grow food. disability affects the ability to prepare food. disability leads to poorer feeding, for example, in having a cleft lip or palate disability limits access to and preparation of food economic and social factors influence food security when there is greater availability of food fostered by a strong economy, this creates cheaper, more accessible and greater variety of food for persons with disabilities. however, ‘if the production and import is low or not sufficient, (and people rely on subsistence farming) people with disabilities suffer the most as they cannot produce food' on their own' economic and social factors affect the quality and frequency of food. the disability grant limits access to food (since it may not be sufficient for nutritious food, or is being used by the family) food security positively influences disability ‘access (to food) fosters wellness’ ‘if food is constantly available, this can positively impact the disability’ persons with disability who rely on their families are dependent on others to buy and prepare food, as well as feed them dietary requirements and food choice are influenced by disability persons with disability ‘have specific dietary requirements, hence food may be available but not necessarily accessible’ disability leads to poorer food choice as individuals may not be in control of choosing their food as they have to rely on what is handed to others. persons with disability may not have the cognitive capacity to be aware of what constitutes nutritious food december 2021, vol. 13, no. 4 ajhpe 269 research is needed in order to intervene appropriately with affected persons. when presented with relevant items to be included in the curriculum, participants placed much importance on these various themes. in sa, especially kwazulu-natal province, almost half of the people live in rural areas. rural areas are usually low-resource areas, where most of the population relies on subsistence farming, comprise single-income households and have inadequate access to resources. in this milieu, the relationship between food security and disability is vitally important and community health workers need to know how to approach the problem. practice: what educators already included in the curriculum about the relationship between disability and food security we were unable to find any information about what health sciences educators at other institutions teach about the relationship between disability and food security. in this study, we ascertained that, when included, this topic is not taught in a structured, explicit way, but rather as the need arises and as a part of the so-called hidden curriculum. the ad hoc way in which the topic is included also leads to the limited presentation of themes related to food security. for example, one participant teaches about intervention for persons with visual impairments, so that they can see the food (e.g. with glasses); however, visual impairments encompass a much broader range of consequences for food security. these individuals may experience difficulties in shopping, and accessing environments, as well as being able to prepare food and have a variety of food to eat (because of inaccessibility to materials).[22] food security should be addressed in individualised healthcare, to ensure that the intervention is person-specific, as opposed to being a generic solution. generic solutions do not cater for individuals who have specific needs. for example, having a food kitchen will not necessarily ensure that a person who requires a wheelchair will be able to access meals. study limitations this study was only conducted at one university. the study did not specify the results of the questionnaire in accordance with the various professions. the implications of including food security and disability into the curriculum may be different according to each profession’s scope of practice. we propose that the theory of food security should be included as a generic subject at firstor second-year level, with the theme adapting as students in different disciplines progress. recommendations one of the possible reasons for the lack of content in the curriculum is that the food security of people with disabilities living in rural areas is not currently being studied in sa. the prioritisation of research in this field would promote inclusion into the curriculum. further studies should be conducted among the health sciences professions at other universities in sa and cover how to include food security and disability into the curriculum. the health science professions should review how they can intervene with persons with disabilities who are food insecure. these issues should also be discussed with the health professions councils, including a review of the scope of practice, as well as the curriculum of the various disciplines with specific exit-level competencies being identified. conclusion according to the present study, educators had a limited subjective knowledge of food security at a specific school of health sciences. educators had a somewhat good understanding of the link between the different dimensions of food security and disability and they felt that more should be taught about disability and food security in the school of health sciences professions. including this content should enable students and graduates who deal with persons with disabilities who are at risk of food insecurity. if students learn about this link, they should have the necessary awareness to address food security to be able to intervene with their clients and patients holistically. for example, if someone with a swallowing disability does not have access to appropriate food, teaching them how to eat will not ensure that they receive appropriate nourishment. therefore, as food security is a baseline challenge which impacts all areas of functioning, rehabilitation can either remain incomplete or be unsuccessful if this basic need is not addressed. the study raised awareness among participants about the importance of food security and disability. the findings will be used to inform participants of gaps within their curricula, and ensure that this pertinent aspect of disability is addressed in student education. these aspects should be foregrounded by important discussions with the health professions council of south africa (hpcsa) to address the different disciplines’ scope of practice. declaration. none. acknowledgements. the work reported here was made possible through funding by the south african medical research council (samrc) through its division of research capacity development under the bongani mayosi national health scholars programme from funding received from the public health enhancement fund/south african national department of health. the content is the sole responsibility of the authors and does not necessarily represent the official views of the samrc. thank you to the samrc, the sub-saharan africa-faimer regional institute (safri) for their support of this project by a fellowship granted to the first author, and to the participants of the study. author contributions. all authors conceptualised the study. hl completed the data collection, km and hl analysed the data, and mp reviewed the data analysis. hl wrote the first article draft, and km and mp contributed to the integration and refinement of information for the article. mp provided the conceptual base for connecting food security and disability. funding. none. conflicts of interest. none. 1. quarmby ca, pillay m. the intersection of disability and food security: perspectives of health and humanitarian aid workers. afr j disabil 2018;7(0):a332. https://doi.org/10.4102/ajod.v7i0.322 2. statistics south africa. statistical release p0318 general household survey 2016. pretoria: statssa, 2016. 3. south african department of agriculture. food insecurity in sekhukhune. food security information; brief 1. 2006. http://www.fanrpan.org/documents/d00498/fivims_info_brief1_food_insecurity_sekhukhune. pdf (accessed 25 may 2017). 4. siefert k, heflin cm, corcoran me, williams dr. food insufficiency and physical and mental health in a longitudinal survey of welfare recipients. j health soc behav 2004;45(2):171-186. https://doi. org/10.1177/002214650404500204 5. nord m. disability is an important risk factor for food insecurity. 2008. https://www.ers.usda.gov/amberwaves/2008/february/disability-is-an-important-risk-factor-for-food-insecurity/ (accessed 20 june 2017). 6. huang j, guo b, kim y. food insecurity and disability: do economic resources matter? soc sci res 2009;39(1):111-124. https://doi.org/10.1016/j.ssresearch.2009.07.002 7. elwan a. poverty and disability. washington, dc: world bank, 1999. https://documents1.worldbank.org/ curated/en/488521468764667300/pdf/multi-page.pdf (accessed 20 june 2017). 8. baro m, deubel tf. persistent hunger: perspectives on vulnerability, famine, and food security in sub-saharan africa. annu rev anthropol 2006;35:521-538. https://doi.org/10.1146/annurev.anthro.35.081705.123224. 9. drimie s, mclachlan m. food security in south africa – first steps toward a transdisciplinary approach. food secur 2013;5(2):217-226. 10. fao. an introduction to the basic concepts of food security food security information for action. food security information for action: practical guides 2008; 1-3. https://www.fao.org/documents/card/en/ c/2357d07c-b359-55d8-930a-13060cedd3e3/ (accessed 20 june 2017). https://doi.org/10.4102/ajod.v7i0.322 http://www.fanrpan.org/documents/d00498/fivims_info_brief1_food_insecurity_sekhukhune.pdf http://www.fanrpan.org/documents/d00498/fivims_info_brief1_food_insecurity_sekhukhune.pdf https://doi.org/10.1177/002214650404500204 https://doi.org/10.1177/002214650404500204 https://www.ers.usda.gov/amber-waves/2008/february/disability-is-an-important-risk-factor-for-food-insecurity/ https://www.ers.usda.gov/amber-waves/2008/february/disability-is-an-important-risk-factor-for-food-insecurity/ https://doi.org/10.1016/j.ssresearch.2009.07.002 https://documents1.worldbank.org/curated/en/488521468764667300/pdf/multi-page.pdf https://documents1.worldbank.org/curated/en/488521468764667300/pdf/multi-page.pdf https://doi.org/10.1146/annurev.anthro.35.081705.123224 https://www.fao.org/documents/card/en/c/2357d07c-b359-55d8-930a-13060cedd3e3/ https://www.fao.org/documents/card/en/c/2357d07c-b359-55d8-930a-13060cedd3e3/ 270 december 2021, vol. 13, no. 4 ajhpe research 11. bajagai ys. basic concepts of food security: definition, dimensions and integrated phase classification. food & environment http://www.foodandenvironment.com/2013/01/basic-concept-of-food-security.html (accessed 20 june 2017). 12. fao. food security policy brief. http://www.fao.org/forestry/13128-0e6f36f27e0091055bec28ebe830f46b3. pdf (accessed 20 june 2017). 13. lawshe ch. a quantitative approach to content validity. personnel psychology 1975;28(4):563-575. 14. world health organization. world report on disability. malta. http://www.who.int/disabilities/world_ report/2011/report.pdf (accessed 20 june 2017). 15. anema a, vogenthaler n, frongillo ea, et al. food insecurity and hiv/aids: current knowledge, gaps, and research priorities. curr hiv/aids rep 2009;6(4):224-231. 16. south african department of agriculture. the integrated food security strategy for south africa. pretoria: government printer, 2002. 17. konje jc, ladipo oa. nutrition and obstructed labor. am j clin nutr 2000;72(1 suppl):291s-297s. https:// doi.org/10.1093/ajcn/72.1.291s. 18. kerac m, postels dg, mallewa m, et al. the interaction of malnutrition and neurologic disability in africa. semin pediatr neurol 2014;21(1):42-49. https://doi.org/10.1016/j.spen.2014.01.003. 19. wu l, katz j, mullany lc, et al. association between nutritional status and positive childhood disability screening using the ten questions plus tool in sarlahi, nepal. j heal popul nutr 2010;28:585-594. 20. arvedson jc. assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. dev disabil res rev 2008;14:118-127. https://doi.org/10.1002/ddrr.17 21. cox ms, holm se, lynch ak, et  al. specialised knowledge and skills in feeding, eating, and swallowing for occupational therapy practice. am j occup ther 2007;61:686-700. https://doi.org/10.5014/ajot.61.6.686 22. muurinen sm, soini hh, suominen mh, saarela rk, savikko nm, pitkälä kh. vision impairment and nutritional status among older assisted living residents. arch gerontol geriatr 2014;58:384-387. https://doi.org/10.1016/j.archger.2013.12.002 accepted 29 october 2020. http://www.foodandenvironment.com/2013/01/basic-concept-of-food-security.html http://www.fao.org/forestry/13128-0e6f36f27e0091055bec28ebe830f46b3.pdf http://www.fao.org/forestry/13128-0e6f36f27e0091055bec28ebe830f46b3.pdf http://www.who.int/disabilities/world_report/2011/report.pdf http://www.who.int/disabilities/world_report/2011/report.pdf https://doi.org/10.1093/ajcn/72.1.291s https://doi.org/10.1093/ajcn/72.1.291s https://doi.org/10.1016/j.spen.2014.01.003 https://doi.org/10.1002/ddrr.17 https://doi.org/10.5014/ajot.61.6.686 https://doi.org/10.1016/j.archger.2013.12.002 article 40 july 2012, vol. 4, no. 1 ajhpe introduction. improving clinical practice skills can enhance a patientcentred model of health care. the objectives of this study were to discover if physicians consider learning about elements of patient-centred care important, and whether the perceived importance is influenced by choice of medical speciality practised and/or number of years in clinical practice. methods. of 310 surveys returned, a total of 268 physicians from one province in canada were studied. on average, the participants had 16 years of practice experience with family medicine making up the largest component of the study cohort – 41%. physicians were asked how useful learning about specific topics would be to improve their communication with patients from different cultural or socioeconomic backgrounds. the self-report measures were examined using mean differences among specialities, gender, and correlation with years in clinical practice. results. the mean scores were above the scale midpoint for all specialities. the correlation data indicated a negative relationship between years in clinical practice and 2 of the 6 variables studied. women physicians rated learning about patients’ health beliefs higher than men but men rated patient communication skills higher than women. discussion. physicians rated the importance of incorporating principles of patient-centred care into their clinical practice highly, suggesting that they may benefit from practice interventions such as reflection. ajhpe 2012;4(1):40-43. doi:10.7196/ajhpe.129 introduction global advancements in information technology and healthcare systems have resulted in better-informed health consumers with far-reaching effects for medical practice and health systems worldwide.1,2 significant numbers of patients are using the internet to obtain health information on issues such as lifestyle factors, diseases, drugs and alternative therapies. this raises expectations and demands for higher standards of care.2 in addition, increases in chronic and emerging diseases, and the drive towards more community-based care, have meant greater emphasis on patient-centred care.1,3-5 the latter is best described as clinical care that recognises and responds appropriately to patients’ desire for information.6 these factors have increased the need for innovative educational interventions to support physicians addressing these demands.3,7 the increasing need for contextually relevant education has led to the emergence of continuing professional development as an approach to overcome some of the shortcomings of traditional continuing medical education.7 the use of didactic teacher-centred methods, as the predominant method of teaching, has not led to improved practice or better patient outcomes.4,5,8,9 providing learning opportunities in the workplace, observation, experience and practice are suggested ways of facilitating the transfer of new knowledge and skills to the practice environment.4 for example, in uruguay, emphasis is placed on physician identification of learning needs that utilise student-centred teaching methods.5 one hindrance to successful implementation is that the planning and financing of continuing education is occurring within health care systems facing cost and human resource constraints.3-5 this has raised questions about how educational reforms to facilitate lifelong learning can be achieved.3 in the primary care context, patient-centred care incorporates principles that are key to the biopsychosocial model of care proposed by a number of medical writers, such as engel.10 components of patient-centred care include: finding common ground to understand and respond to the patient’s unique needs, and consideration of the patient’s expectations of the physician.10 another component is practice knowledge, thought to originate from three sources: propositional knowledge derived from research and scholarship; professional craft knowledge, which may be tacit, gained from practice experience; and personal knowledge, comprised of intellectual and emotional maturity obtained from life experiences.10,11 the blending of these different forms of knowledge optimises patient-centred care and efficient care delivery.10,11 consideration of patient expectations of health care is important for a number of reasons, including the capacity to provide effective treatment, the influence that expectations have on health behaviours, adherence, and functional health status.12 more importantly, patient interactions may serve as potential indicators of professional learning needs and improvement patient-centred continuing professional development for canadian physicians brenda lovell, raymond lee winnipeg, manitoba, canada brenda lovell university of manitoba, winnipeg, manitoba, canada raymond lee corresponding author: brenda lovell (brendalee.lovell@yahoo.ca or lovellb@cc.umanitoba.ca) article 41 july 2012, vol. 4, no. 1 ajhpe required.12 patients’ expectations vary with different health problems, and over time as their experience and education increases. in general, patients expect high standards of professional competence, information about their health problem, and patient-centred communication.12 effective communication between physicians and their patients is a core clinical skill that is frequently included in residency and medical school curricula. however, providing patients with training in communication skills may lead to a more beneficial two-way engagement. trained patients participated more actively in the medical interview, were more compliant, recalled symptoms more accurately, and recorded better physiologically measured health outcomes.13 more investigation is needed to target the particular patient communication skills training needed for different clinical scenarios, methods of instructing patients, and how to assess their associated health outcomes.13 increased patient diversity has resulted in increasing need for physicians to use a language interpreter while obtaining a medical history. skills are required from both interpreter and physician to clarify the goals of the consultation and determine the main areas to be assessed.14 adequate information and training are needed to overcome the challenges associated with interpretermediated consultations. suitable training programmes for physicians are, however, limited.14,15 physicians have indicated that continuing professional development seminars to understand the advocacy stances of interpreters, cultural teaching, and improving communication and empathy with patients of different cultures, would support enhanced patient care.16 health beliefs are derived from factors such as family and cultural values, and personal experiences.17 values, beliefs and attitudes fashioned from one’s unique life experience guide behaviours and practices. one’s geographical place of residence and how one defines health are also important determinants of health beliefs and behaviours. for example, some rural canadians view health from a role perspective, meaning that they are able to work and meet family obligations.17 they also have higher poverty, shorter life expectancy, higher infant mortality, and engage in less prevention than urban canadians. this is just one example of how divergent patient health beliefs can be, and emphasises the need for physicians to have the ability to adjust to combinations of differing values and behavioural patterns, reflecting on their own attitudes and experiences.17 based on the preceding discussion of the literature, it is clear that training aimed at improving cross-cultural doctor-patient communication should address specific issues that include: (i) personal attitudes towards patients from different cultural and/or socioeconomic backgrounds; (ii) personal past experiences with people of different cultural and/or socioeconomic backgrounds; (iii) health beliefs of people of different cultural and/or socioeconomic backgrounds; (iv) expectations held by persons of different cultural and/or socioeconomic backgrounds about what a physician should do and how a physician should behave; (v) skills for working efficiently and effectively with interpreters; and (vi) patient communication and interaction skills. knowledge of these key factors that impact on the quality of cross-cultural doctor-patient communication can be evaluated using the cross-cultural doctor-patient communication needs assessment tool.18 using elements of this assessment tool, we set out to determine the extent to which physicians would value learning about patient-centred elements of clinical care useful for their practice, and whether any variations in the perceived usefulness of these elements existed across: (i) physician gender; (ii) discipline/specialty practised; and (iii) number of years in clinical practice. methods survey data were collected during the fall of 2006 in the province of manitoba, canada. a self-report questionnaire was distributed through the provincial medical association’s bimonthly newsletter to its members and by a direct mail-out from the researchers to the work addresses obtained from the college of physicians and surgeons of manitoba’s public-access website. the questionnaire’s cover letter stated that the study’s purpose was to examine how physicians interact and communicate with patients and cope with the demands of their practice. permission to conduct the study was granted by the university of manitoba health research ethics board. all completed questionnaires were mailed to the first author’s university office address. of 310 participants, 42 returned questionnaires that were unusable for various reasons (e.g. no longer practised in the province, retired, served as administrators, or extensive missing responses) leaving 268 usable returns. of the total respondents, 53% were from the provincial medical association and 47% were from the college of physicians and surgeons of manitoba. respondents were classified by specialty using an inductive approach. the physicians provided 33 distinct job descriptions, which were grouped into 10 specialties, with reference to the categories used in a prior research study.16 these categories were: family medicine (n=110), internal medicine (n=50), paediatric disciplines (n=30), surgical disciplines (n=20), residents (n=20), psychiatry (n=19), anaesthesiology (n=10), and obstetrics/ gynaecology (n=9). specialties with 10 or fewer respondents were merged – anaesthesiology was grouped with internal medicine (n=60) and obstetrics/ gynaecology were grouped with the surgical disciplines (n= 29). respondents were in clinical practice for a mean of 16.5 years (standard deviation (sd) 11.05); the mean percentage of time spent in primary care was 68% (sd 24), and the mean number of minutes spent per patient consultation was 19 minutes (sd 14.76). the importance of learning about cross-cultural communication needs was evaluated using six items from section d of the cross-cultural doctorpatient communication needs assessment.18 the items evaluated were: (a) your own attitudes towards patients from different cultural and/or socioeconomic backgrounds; (b) your past experiences with people of different cultural and/or socioeconomic backgrounds; (c) health beliefs of people of different cultural and/or socioeconomic backgrounds; (d) expectations held by persons of different cultural and/or socioeconomic backgrounds about what a physician should do and how a physician should behave; (e) skills for working efficiently and effectively with interpreters; and (f ) patient communication and interaction skills. participants indicated how useful learning about these issues would be for improving communication skills with patients of different cultural and/or socioeconomic backgrounds using a 5-point response scale (1=not at all, 2=not very, 3=somewhat, 4=fairly, 5=extremely). results table 1 reveals two significant gender-based differences. women physicians rated learning about the health beliefs of patients and patient expectations about how a physician should behave more useful than men physicians.the influence of specialty practised was compared using mean differences across article 42 july 2012, vol. 4, no. 1 ajhpe specialties. table 2 indicates that there were no significant differences. scores were at or above the scale midpoint for all statements, with the exception of residents and physicians practising in the surgical disciplines. psychiatry, paediatrics, and internal medicine recorded the highest means for almost all of the six statements, and family medicine recorded the highest mean score for learning about how patients could improve their communication and interaction skills. evaluation of the relationship between years of clinical practice and crosscultural doctor-patient communication skills needs was reported as pearson’s correlation coefficients. table 3 reveals two significant relationships. the more years of practice physicians had the less they rated the usefulness of learning about the health beliefs of patients and patient expectations about how physicians should conduct themselves. all six items evaluated in our study are indicators of patient-centred practice elements. physicians practising in all the different specialties overwhelmingly indicated that learning about each of the six selected aspects of crosscultural doctor-patient communication needs would be beneficial for career development and medical practice. discussion this study demonstrates some important findings about the value canadian physicians attach to learning about key aspects of doctor-patient crosscultural communication. our findings show that differences among physicians practising in the six major clinical specialties are not significant enough to warrant separate curricula or courses to teach cross-cultural communication skills. nevertheless, the observed differences suggest that cross-cultural communication skills may be more highly valued in some specialties than others. for example, all specialties indicated that skills to work effectively with interpreters were important, but especially so for psychiatry. this could be because translating patients’ thoughts and feelings during mental health assessments is particularly difficult for interpreters.15 family medicine scored the highest on patient communication skills. this may reflect the long-term nature of the relationships that family physicians have with their patients and the importance of self-care practices often carried out by their patients. internal medicine and paediatrics scored well above the midpoint in all six statements, thereby indicating the importance they attach to all aspects of cross-cultural doctor-patient communication. this most likely reflects the need to develop a good understanding of how patients and their families manage chronic illness, thereby enhancing diagnostic and treatment outcomes. research has shown that women physicians use more communication skills and emotions with patients during medical consultations than men physicians.19this may reflect the importance women attach to relationship building, and may also explain why women physicians in this study expressed a greater need to learn about patients’ health beliefs and expectations about how physicians should conduct themselves. male physicians did, however, score above the midpoint of the response scale for both of these skills, suggesting that all physicians recognise the importance of these two aspects of cross-cultural doctor-patient communication. a particularly interesting finding in our study was the observation that the longer physicians were in clinical practice the less they rated the usefulness of learning about the health beliefs of patients and patient expectations about how a physician should behave. this may be a sign that experienced physicians favoured clinical exposure as the better teacher, rather than continuing education activities such as seminars, lectures, etc. one approach to improving physician-patient communication, based on actual clinical practice, may be the use of purposeful reflection. the latter can be used to analyse lived experiences, recognise knowledge gaps, and formulate learning needs.3,11,20,21 research among medical students and practising physicians has indicated that reflection and observation were effective learning strategies, and important for practice.3,22,23 one approach may be the use of journal writing for reflecting on emotional reactions in daily practice, which may foster openness, awareness and stimulate learning about the impact of emotions on job satisfaction, morale and patient care.24 similarly, learning portfolios are useful for documenting reflective activities collected over a period of time, and can include a plan for undertaking learning, and documenting evidence of learning achieved.3,23,25 the use of these educational tools to promote reflection may be an important way of enhancing physician-patient communication, especially in the cross-cultural setting, among busy practising clinicians where traditional continuing medical education activities may be of limited value. this is an avenue of research worth exploring. acknowledgements. the authors thank celeste brotheridge for her assistance with the data analysis. an earlier version of this paper was presented by the first author at the 12th world congress on public health, istanbul, turkey, 27 april 1 may 2009. table 1. physician gender differences for the items evaluated education item male (n=159) mean (sd) female (n=109) mean (sd) cohen’s d (a) your own attitudes toward different cultural and/or socioeconomic backgrounds 3.14 (1.24) 3.02 (1.04) 0.10 (b) your past experiences with people of different cultural and/or socio-economic backgrounds 3.32 (1.14) 3.27 (1.12) 0.06 (c) health beliefs of people of different cultural and/or socioeconomic backgrounds 3.84 (0.95) 4.11 (0.93) 0.48* (d) expectations held by persons from different cultural and/or socio-economic backgrounds about what a physician should do and how a physician should behave 3.68 (0.95) 4.03 (0.94) 0.34* (e) skills for working efficiently and effectively with interpreters 3.58 (1.10) 3.67 (1.07) 0.08 (f ) patient communication and interaction skills 3.45 (1.17) 3.19 (1.15) 0.22† *p<0.01, two-tailed test. †p<0.05, two-tailed test. article 43 july 2012, vol. 4, no. 1 ajhpe references 1. richardson b, higgs j, abrandt dahlgren m. recognising practice epistemology in the health professions. in: higgs j, richardson b, abrandt dahlgren m, eds. developing practice knowledge for health professionals. london: butterworth-heinemann, 2004:114. 2. underhill c, mckeon l. statistics canada. health information and research division. getting a second opinion: health information and the internet. cat 82-003. health reports 19(1). ottawa: government of canada, 2008. 3. campbell cm, gondocz t. identifying the needs of the individual learner. in: davis d, barnes be, fox r, eds. the continuing professional development of physicians: from research to practice. chicago: american medical association, 2003:81-95. 4. mann kv. reflecting on the challenges facing continuing medical education today. med educ 2005;39:546-557. 5. margolis a, alvarino f, niski r, et al. continuing professional development of physicians in uruguay: lessons from a countrywide experience. j contin educ health prof 2007;27(2):81-85. 6. stewart m. towards a global definition of patient centred care. bmj 2001;322:1444-1445. 7. sachdeva ak. the new paradigm of continuing education in surgery. arch surg 2005;140:264-269. 8. davis d, o’brien thomson ma, freemantle n, wolf fm, mazmanian p, taylor-vaisey a. impact of formal continuing medical education: do conferences, workshops, rounds and other traditional continuing education activities change physician behavior or health care outcomes? jama 1999;282:867-874. 9. siddiqui zs, secombe mj, peterson r. continuous professional development – development of a framework for medical doctors in pakistan. j pak med assoc 2003;53(7):1-4. 10. stewart m, brown jb, donner a, et al. the impact of patient-centered care on outcomes. j fam pract 2000;49:796-804. 11. higgs j, andresen l, fish d. practice knowledge its nature, sources and contexts. in: higgs j, richardson b, abrandt dahlgren m, eds. developing practice knowledge for health professionals. london: butterworth-heinemann, 2004:51-69. 12. wensing m. patients’ expectations of treatment. in: jones r, britten n, culpepper l, et al., eds. oxford textbook of primary medical care, vol 1: principles and concepts. oxford: oxford university press, 2004:122-126. 13. cegala dj, marinelli t, post d. the effects of patient communication skills training on compliance. arch fam med 2000;9:57-64. 14. kachurkrajic e, altshuler l. cultural competence is everyone’s responsibility! medical teacher 2004; 26(2):101-105. 15. farooq s, fear c. working through interpreters. advances in psychiatric treatment 2003;9:104-109. 16. lovell bl, lee rt, frank e. may i long experience the joy of healing: professional and personal wellbeing among physicians from a canadian province. bmc fam pract 2009;10:18. 17. thomlinson e, mcdonagh mk, crooks baird k, lees m. health beliefs of rural canadians: implications for practice. australian journal of rural health 2004;12:258263. 18. shapiro j, hollingshead j, morrison e. primary care resident, faculty, and patient views of barriers to cultural competence, and the skills needed to overcome them. med educ 2002;36:749-759. 19. lovell bl, lee rt, brotheridge cm. gender differences in the application of communication skills, emotional labour, stress-coping, and well-being among physicians. archives, the international journal of medicine 2009; 2(3): 273-278. 20. plack mm, greenberg l. the reflective practitioner: reaching for excellence in practice. pediatrics 2005;116:1546-1552. 21. watling cj, brown jb. education research: communication skills for neurology residents: structured teaching and reflective practice. neurology 2007;69: 20-26. 22. windish dm, price eg, clever sl, magaziner jl, thomas pa. teaching medical students the important connection between communication and clinical reasoning. j gen intern med 2005;20:1108-1113. 23. parboosingh jt, badat mc, wooster dl. individualized learning strategies. in: davis d, barnes be, fox r, eds. the continuing professional development of physicians: from research to practice. chicago: american medical association; 2003:145-165. 24. howard j. the emotional diary a framework for reflective practice. education for general practice 1997;8:288-291. 25. wilkinson tj, challis m, hobma so, et al. the use of portfolios for assessment of the competence and performance of doctors in practice. med educ 2002;36:918-924. table 2. differences across specialties on six items evaluated residents (n=20) mean (sd) family (n=110) mean (sd) psychiatry (n=19) mean (sd) surgical (n=29) mean sd internal (n=60) mean (sd) paediatric (n=30) mean (sd) (a) your own attitudes toward different cultural and/or socioeconomic backgrounds 3.10 (1.21) 3.07 (1.20) 3.47 (1.39) 2.72 (1.07) 3.17 (1.11) 3.15(0.99) (b) your past experiences with people of different cultural and/or socio-economic backgrounds 3.35 (1.31) 3.26 (1.09) 3.22 (1.56) 3.10 (1.21) 3.45 (1.03) 3.52 (0.89) (c) health beliefs of people of different cultural and/or socioeconomic backgrounds 4.00 (0.86) 3.90 (0.93) 4.00 (1.05) 3.72 (0.80) 3.70 (0.96) 4.11 (0.92) (d) expectations held by persons from different cultural and/or socio-economic backgrounds about what a physician should do and how a physician should behave 3.95 (0.89) 3.89 (0.87) 4.00 (1.16) 3.62 (0.90) 3.77 (1.00) 3.86 (1.08) (e) skills for working efficiently and effectively with interpreters 3.55 (1.19) 3.56 (1.10) 4.22 (1.17) 3.38 (0.98) 3.78 (0.96) 3.78 (0.97) (f ) patient communications and interaction skills 2.95 (1.00) 3.50 (1.13) 3.16 (1.77) 3.21 (1.15) 3.42 (1.15) 3.39 (0.96) table 3. correlation between years of experience and the six items evaluated (a) your own attitudes toward different cultural and/or socio-economic backgrounds 0.00 (b) your past experiences with people of different cultural and/or socio-economic backgrounds -0.03 (c) health beliefs of people of different cultural and/or socio-economic backgrounds -0.13* (d) expectations held by persons from different cultural and/or socio-economic backgrounds about what a physician should do and how a physician should behave -0.14* (e) skills for working efficiently and effectively with interpreters -0.01 (f ) patient communication and interaction skills -0.07 *p<0.05, two-tailed test. ajhpe issn 0256-9574 african journal of health professions education 2011, vol.3 no.1 december 2021, vol. 13, no. 4 ajhpe 247 research transitioning from classroom to clinical setting presents multiple challenges for health science students. these challenges range from a lack of generic skills and professional behaviours to difficulties translating the taught skills and theory into patient management, raising further concerns about the existence of a ‘theory-practice gap’.[1] even under the supervision of clinical educators (ces), students struggle with the complexity of the clinical situations they encounter. ces are also challenged when facilitating students’ learning in these complex clinical contexts, while providing effective service to patients.[2] skill in clinical reasoning (cr) is necessary to guide students and educators in assessing, assimilating, retrieving and/or discarding components of information that affect patient care.[3,4] failure to develop cr is considered one of the key reasons for students’ lack of confidence and effectiveness in the clinical area, ultimately influencing their academic success.[5] while the explicit development of cr is a foundation requirement of entry-level practice education,[6] it cannot be assumed to develop in the absence of specific educational strategies.[4] therefore, ces need to create learning opportunities that explain the multidimensional nature of cr to students to support them in developing these capabilities and scaffold the development as they progress through their clinical years. ‘until well into the 17th century, academic medicine was almost exclusively a theoretical affair. reasoning played an important role, but it was exclusively employed to defend theses or to construct logical arguments, rather than to arrive at diagnoses or to select therapies.’[7] over the years, there were many attempts to integrate theoretical knowledge with clinical experience, and thus the value of teaching cr to students became more evident. however, cr is not taught explicitly in all health profession educational programmes. another challenge is the existence of different interchangeable terminologies, definitions and concepts for cr.[3,8-10] differences among healthcare professionals regarding the cr processes were also noted. while medical professionals focus on a cognitive psychology perspective, nursing or physiotherapy professionals adopt an interpretive and sociocultural lens that goes beyond the cognition.[6] these discrepancies possibly contributed to a potential mismatch between ces’ and students’ understanding of cr, and how learning and teaching may be facilitated.[10] it could also account for the lack of student awareness of the cues being provided by the ces, which ultimately results in a lack of development in the area. therefore, it seems that educators and students would benefit from attempts to develop a common understanding of the concept of cr and its terms. understanding the cr process is challenging.[11] in the broadest and most general sense, it ‘can be summarised as the thinking and decision making of a health care provider in clinical practice,’[11] leading to clinical decisionmaking. cr was also defined as ‘an inferential process used by practitioners background. clinical reasoning (cr) is a skill acquired by students under supervision of clinical educators (ces) when transitioning from classroom to clinical practice to optimise patient care. however, intraand inter-professional differences in the definition and facilitation of cr have been reported. at the university of cape town, a teaching development grant was obtained and used for a staff development initiative aimed at improving the cr skills of undergraduate health and rehabilitation students. objectives. to gain insight into the understanding of cr among ces and a cohort of third-year students across 4 professional programmes, using an interpretive approach. methods. the ces responsible for third-year supervision (n=45) were invited to take part in a self-developed electronic survey and an initial workshop that explored their understanding of cr. the qualitative survey data, as well as workshop feedback and discussion, were analysed. students’ understanding was explored during focus group discussions. results. there were areas of commonality and differences among ces. they agreed on a cyclical step-like process to cr and the need to cue students to develop this expertise in clinical settings. the approach of ces in occupational therapy was client focused; physiotherapy ces described a higherorder thinking; and audiology and speech and language pathology ces described a structured procedure informed by evidence. students were unable to conceptualise a complete picture to reasoning and decision-making. conclusion. the difference between students’ understanding of cr and their poor awareness of strategies employed by ces to facilitate reasoning could account for difficulties in transitioning from classroom to practice. this scenario suggests that divisions need to look at creating more purposeful strategies to teach students about the cr process and how the facilitation may occur within the clinical setting. afr j health professions educ 2021;13(4):246-251. https://doi.org/10.7196/ajhpe.2021.v13i4.1293 understanding of clinical reasoning by undergraduate students and clinical educators in health and rehabilitation sciences at a south african university: the implications for teaching practice h talberg, mphil (hes); f camroodien-surve, m eci; s l amosun, phd department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa corresponding author: h talberg (heather.talberg@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1293 mailto:heather.talberg@uct.ac.za 248 december 2021, vol. 13, no. 4 ajhpe research to collect and evaluate data and to make judgments about the diagnosis and management’ of patients’ concerns.[12] it includes the application of cognitive and psychomotor skills based on theory and evidence, as well as the reflective thought process to direct individual changes and modifications in specific patient situations. current research in cr suggests that the process of applying knowledge and skill, integrated with the intuitive ability to vary an examination or treatment based on reflection and interaction to achieve a successful outcome for an individual patient, separates expert clinicians from novices. teaching cr needs to be made tangible so that students can merge it into their own developmental processes in clinical practice,[13] utilising a range of capabilities – cognitive, metacognitive, social and emotional skills – during clinical decision-making.[6] acknowledging that cr is a core competence of healthcare professional education in linking theory to practice, it is important to know if ces create the necessary active learning environments for students to enhance cr. at the university of cape town (uct), the department of health and rehabilitation sciences (dhrs) offers 4-year undergraduate programmes in audiology, occupational therapy (ot), physiotherapy (pt)  and speech and language pathology (slp). the programmes are structured with the basic sciences and introductory profession-specific courses taught in the first 2 years. limited clinical exposure is introduced in the second year, focusing on communication skills, clinical interviewing and basic examination skills. students move to more independent practice in their third year and are exposed to a range of diverse clinical settings: hospitals, clinics, schools, non-governmental organisation (ngo)-run sites and old-age care facilities. during their fourth year, clinical hours are increased, with students working in tertiary care and complex environments. on-site clinical training is provided largely through ces employed by the university. although there are some differences in the organisation of clinical education across the 4 undergraduate programmes, the students spend 4 6 weeks on each block placement. the ces generally give 1 4 hours per week of individual facilitation to their respective students across their allocated sites. working with clinicians or site personnel, ces are required to optimise learning opportunities and ensure that student learning outcomes are met. learning is enhanced through group teaching and peer-led sessions. formative assessments are offered midway in a placement, and students’ written portfolios create additional learning opportunities to facilitate growth and improvement before summative end-of-block assessments. although not always stated explicitly, developing cr is one of the key goals of clinical teaching.[13] yet, cr as a concept is not formally taught in undergraduate programmes in the dhrs, except in ot. the two main steps in the cr process involve gathering and analysing information (diagnostic reasoning)  and deciding on therapeutic actions specific to a patient’s circumstances and wishes (therapeutic reasoning).[13] differences have been reported in the thinking processes between ‘expert’ and ‘novice’ healthcare practitioners. in the context of student training in the dhrs, ces are the expert healthcare professionals, while the students attempting to merge classroom theory with clinical reality are the novices. two questions emerged from this scenario: (i) how is cr being taught in the dhrs at uct?; and (ii) are the differences in teaching of cr part of the barrier in students’ inability to integrate their theoretical knowledge into clinical practice? to respond to these questions, the dhrs applied for and obtained a teaching and development grant (tdg)  from the department of higher education and training in 2014 to address the difficulties that students experience in transitioning from their second year to their third and fourth clinical years – moving from a theoretical to a more clinical paradigm. the broad purpose of the grant was to observe teaching practices in clinical courses, develop improved teaching strategies among ces across the 4 different programmes and work at improving student performance in profession-specific clinical courses. a staff development initiative was conceptualised, which was aimed at developing an educational approach to teaching cr to students across the 4 professional programmes in the dhrs. it was hypothesised that the developed framework will improve the experiences of students in their integration of theoretical knowledge into clinical practice. to achieve this outcome, the tdg-funded programme undertook the following 5 key activities over a 3-year period: • the collection of baseline data on: (i)  the understanding of students and ces regarding cr; (ii)  teaching strategies used by ces to facilitate students’ cr; and (iii) challenges faced by ces in developing cr. • the training of ces through workshops on cr, identifying the challenges students encountered and to target strategies to facilitate reasoning. • informing students of the teaching strategies, followed by evaluating the awareness of the use of these strategies in the clinical setting. • monitoring and evaluating the impact of the developed framework. • development of a training tool for ces regarding cr. this article draws on some of the survey information obtained in the collection of baseline data, the initial facilitated workshop with third-year ces and the focus group discussions with third-year students. it aims to: • provide insight into the initial understanding of cr among ces across divisions. • provide insight into the initial understanding of cr among third-year students across the 4 undergraduate professional programmes in the dhrs. • discuss differences and similarities in the understanding of the cr process between ces and students and the implications thereof. it is assumed that if ces and students share similar views or have an awareness of each other’s perceptions of cr, the education process is likely to be more effective. methods at the start of the project, a decision was made to investigate thirdand fourth-year students and ces separately. it was presumed that there would be different issues raised in the different years, possibly requiring different facilitation. hence, only third-year students and ces were included in this phase, with the hope of repeating the process for fourth-year students at a later stage. all the ces involved in teaching of third-year students in the 4 professional programmes (n=45)  were invited to take part in a selfdeveloped electronic survey that was conducted via survey monkey. the researchers, some of whom had ce roles, were excluded from the data collection process. the questionnaire was developed with the assistance of the education development unit (edu), taking into account the overall outcomes of the project. this review provided some validation of the questionnaire, and all stakeholders reached agreement regarding the relevant questions. there was no piloting process, and all information december 2021, vol. 13, no. 4 ajhpe 249 research obtained was used.  informed consent was obtained from the ces before the administration of the survey questionnaire, which was completed anonymously. the first part of the questionnaire sought information regarding the ces’ clinical teaching experience and expertise, formal teaching education and years of professional experience. three open-ended questions were then posed: • what is your description of cr? • how would you facilitate cr with a student who struggles with the integration of theoretical knowledge in clinical practice? • what are the main problems associated with enhancing cr in third-year students entering clinical practice? a response rate of 35.5% (n=16)  was achieved, comprising 7 pts, 4 ots, 3 audiologists, and 2 slps. the qualitative data were extracted by an independent assistant and core phrases highlighted for analysis by the researchers. this baseline survey information was explored further in a facilitated workshop for third-year ces. of the ces invited, 24 attended. ces were provided with literature on various forms of cr and small-group interdisciplinary discussions on types of cr introduced. ces were then encouraged to reach consensus on their own understanding of the process of cr and what steps students ultimately would need to go through and understand when working with clients for successful outcomes. these conclusions are presented in the results section. discussions on strategies and problems encountered in the cr facilitation process were tabled and formed the basis for subsequent workshops. these discussions are not within the scope of this article. purposeful sampling was used to recruit third-year students in audiology, ot, pt and slp for focus group discussions around the topic of cr. the recruitment invitation was sent through the university’s electronic communication site (vula)  on the individual clinical pages of each of the 4 academic programmes. separate focus groups were also planned for each discipline, as it was important to appreciate each discipline’s understanding of cr, as well as how each discipline experienced the teaching of cr. all  175  registered third-year students were eligible to participate. of these, 9 pt, 5  ot and 4 slp students and 1 audiology student participated. the response rate was very low, probably because the timing was close to the end of academic year examinations. consequently, a single focus group discussion was held for each of the 3 professional programmes, i.e. ot, pt and slp. the audiology student was interviewed separately. students were informed of the purpose of the study and signed informed consent forms, as well as a confidentiality agreement before participation. the groups were audio-taped and facilitated by a ce from a professional discipline different to that of the students in their group. this was to avoid any preconceived bias with regard to how teaching happened in that specific discipline, and to ensure that students would feel more open to discussion by not ‘knowing’ the facilitator. each group was asked the same 3 core questions: • what is your understanding of cr? • what are the difficulties you experience with cr in practice? • how do you pick up cr cues given by the ce? however, the depth of discussion could develop at the discretion of the facilitator. these questions aligned to the questions asked in the initial survey of ces. the findings of the first question are reported in this article. the audio-recording of each focus group discussion and interview was transcribed and analysed as a single case.[10] an inductive approach was used to analyse the transcription. the principal investigator did an initial analysis, highlighting the core findings. the researchers then worked in pairs to further discuss, analyse and define key areas in line with the research focus. for the purpose of this article, 2 authors again reviewed the core data. where there were differences in opinion or interpretation, the third author was approached to assist in reaching a consensus. ethical approval ethical approval (ref. no. hrec/ref 693/2014)  to use the information in the first phase of the project for research purposes, was obtained from the human research ethics committee, uct. results survey of clinical educators the educational profiles of the ces are presented in table  1. the average years of experience as a ce at uct was 6.9 (2 30)  years. ces spent an average of 6 hours per week in direct supervision of the students. the sites where ces were mostly deployed for clinical supervision are presented in table 2. clinical educators’ description and understanding of clinical reasoning the pts described cr as a ‘higher order thinking process in the clinical setting’, highlighting the concepts of ‘gathering information, interpreting and creating hypothesis, utilizing information as part of an intervention, and then reflection on outcomes’. one of the ces described cr as ‘… the process used to make sense of all the information gathered on a patient and then how to use the information to identify and analyse (by linking theory to observations) the patient’s problems, plan and implement an appropriate intervention and re-evaluate the outcome, using reflection’. the ots had a clear theoretical construct of cr, framing it in terms of whether it was ‘procedural, narrative, conditional etc.’, talking about ‘conscious cognitive application and procedural categories of thinking about table 1. the educational profile of clinical educators (n=16) profile response, n educational qualifications bsc 9 msc 5 phd 2 had prior teaching or educational training in the form of short courses 11 had prior training specific to clinical reasoning 6 table 2. sites where clinical educators were mostly deployed for supervision of third-year students primary site of clinical supervision response, n tertiary hospitals 4 district hospitals 6 community healthcare facilities 1 schools 4 non-governmental organisations 1 250 december 2021, vol. 13, no. 4 ajhpe research thinking’. none of the other disciplines framed the process using theoretical terminology. the other noticeable feature regarding ot decision-making was that it was very client focused, using information on the clients’ circumstances and values to support their reasoning. the audiologists’ ces seemed to have the most procedural approach to decision-making, speaking about collecting information in a ‘structured way’ and being guided by clinical protocols and diagnosis in management. the slp ces described cr as ‘the process that a person uses to formulate an opinion on management of a case’. slps also referred to using the theoretical knowledge to assist clinical decision-making. workshop 1 for clinical educators twenty-four ces completed the first workshop and agreed to have their comments and opinions recorded for study purposes. they all indicated an improvement in their own understanding of cr after the workshop (table 3). most participants agreed that workshop 1 gave them new insights into the process of cr and that it confirmed their pre-existing ideas about cr (table 4). through discussion, there was disciplinary agreement that cr is a comprehensive, cyclical process. this was elaborated on by all participating ces to create a 4-step concept of the cr process (fig. 1). the first step involved gathering of information, which occurred in multiple ways. it drew on reading, listening and visual cues relating to a specific client and context. many ces perceived this as the integration and/or application of their theoretical knowledge into clinical practice. step 1 led to step 2, where, after appropriate clinical assessment, interpretation of the gathered information allowed them to generate a working hypothesis or diagnosis. the interpretation was used in step 3, which involved the management of the client. these first 3 steps happened logically, as treatment decisions linked to theory and knowledge that were gained through experience. decisions were then prioritised for maximum effect. in step 4, overall effectiveness was constantly monitored through reflection and outcome measures. students’ focus groups data from students revealed that there were differences in their understanding of cr. the pt students (n=7)  struggled to voice a clear definition or understanding of cr. they focused mostly on their relationships with the ces, and how this either facilitated or hindered their learning on clinical block placements: ‘strategies that do work, having a good relationship, supervisors who are really patient, who are willing to help, knowledgeable, available and just approachable to be honest.’ the students’ responses showed their lack of awareness of strategies employed by their ces to guide them, as they considered the questions posed by their ces as a hindrance rather than a facilitator of the cr process: ‘you need to be able to go to your supervisor and say “i’ve clinically reasoned to come to this conclusion of what i’m doing” and then to be able to say that that’s right and that’s wrong or just guide you on the right path, um, instead of asking further questions and being like why did you think, you’ve got the answer there, you know what i mean. be more straightforward.’ the slp students (n=4) described cr as transference of knowledge obtained in the classroom, accessing evidence, considering contextual relevance and being able to formulate an intervention plan. there was a strong table 3. clinical educators’ levels of agreement after workshop 1 (third year) level of agreement workshop gave me new insights into the process of clinical reasoning workshop affirmed my pre-existing ideas about clinical reasoning disagree 0 0 neutral 2 3 agree 12 11 strongly agree 10 10 total 24 24 table 4. clinical educators’ ratings of their levels of knowledge before and after workshop 1 (third year) please use a scale of 0 5 to rate your knowledge before and after the workshop (1 = i know nothing about this; 5 = i understand this completely) before the workshop (average) after the workshop (average) difference (average) clinical reasoning (as a general concept) 3.4 4.3 1.0 steps in the clinical reasoning process 2.8 4.1 1.3 hypothetico-deductive reasoning 2.4 4.0 1.6 reasoning based on pattern recognition 3.0 4.1 1.1 narrative reasoning 2.6 4.1 1.6 procedural reasoning 2.9 4.1 1.2 interactive reasoning 2.7 4.1 1.5 conditional reasoning 2.5 4.0 1.5 pragmatic reasoning 2.5 4.1 1.6 re�ecting gathering interpreting utilising fig. 1. the 4-d model of appreciative inquiry.[1] december 2021, vol. 13, no. 4 ajhpe 251 research emphasis on the importance of supporting their practice with the literature/ evidence. they seemed to understand that in addition to the evidence that was required, you had to think and reason about whether it was relevant to context and that this process defined reasoning: ‘you still have to take whatever information you have and make it patient specific.’ ‘um and what i’ve seen as well is that clinical reasoning can be something that can actually come out of the clinical setting and that particular type because for instance if today i plan that i’m going to do aim a because joseph duffy [name of author in the literature] did it and he found that it works for patients with aphasia and i find that with my patient it doesn’t work well because of the context that i’m in. if i restructure whatever he said and do it in a way that is context specific and tailored for my patient, i can write it down with the rationale that is backed by duffy’s evidence.’ one of the audiology students saw cr as a more procedural process. situations that differed from the regular caseload could not be easily reasoned through, leaving students unable to make decisions about assessment and treatment: ‘they are going to feel uncomfortable when you test the ear, so i wasn’t prepared for that. i think it was only mentioned once or twice in my course so when i actually assessed this patient, i was quite flustered because i didn’t really know what to do.’ the ot students (n=5)  saw cr as the ability to problem solve, reflect in action and evaluate in hindsight. one student commented: ‘it kinda got, like why did you do that, and i had to think about why they did that, … and just be forced to go, this is why i did this, this is why i did that.’ another ot student stated: ‘reflection is a big part of it, um, which we obviously did throughout our blocks and also like you, clinical reasoning happens while you [are] doing a session so, in action or out of action.’ the ot students displayed a theoretical knowledge of reasoning strategies and approaches, which was different to that of the other students. however, although they grasped the idea, they did not draw out the process as comprehensively as the ces, and did not describe all the steps they would go through in the decision-making process. discussion over a 3-year period, several tdg-funded key activities were carried out to address the difficulties that undergraduate students in the dhrs at uct experience in transitioning into the clinical years of their education programmes. this article reports on the initial stages of the activities, which aimed to gain insight into the understanding of cr among ces and students. according to the literature, there were discrepancies among ces regarding basic cr terms,[8,9] and there seemed to be initial differences in the focus of the description of cr among the ces of the different disciplines that took part in the baseline survey. the pts focused on the process that required a higher-order thinking in the clinical setting. the ots framed their description as client focused. the ces for audiology and slp focused on structured procedure that was informed by evidence from the literature.  however, through a workshop process, it became clear that, although the naming of the cr type or core descriptors may have differed, there was an underlying agreement that cr is a cyclic step-like process, whereby information is obtained, processed, used and reflected on to provide the best care for clients. in contrast, students did not portray the same understanding of the cr process. unlike some students who perceived cr as an instrumental, clinician-centred process that is dependent on knowledge and context,[10] pt  students linked cr to relationships with ces and how they could facilitate or hinder learning. for ot students, their understanding was related to the process of identifying the problems that were most important to the patient.[12] students in audiology and slp would require clinical decision-making skills when appraising the available evidence in an effort to select the most appropriate treatment.[12] the data showed that there is a gap between ces and students’ perceptions of the process of cr and the components that need to be in place for reasoning to develop.[11] educators seem to share a common understanding of the components of the reasoning process and can define the steps  involved. however, it is apparent that they see this as a cyclical process, where one step leads to another, drawing on multiple cues and information.[4] students, however, do not seem to grasp the entirety of the process or note when ces are trying to develop their cr. they recognise parts of what is required, but do not seem to easily put it all together. this process may be developmental in nature, changing as they progress through the clinical years, moving from novice to more independent practice. even the ot students, who had the strongest sense of what reasoning relied on and could label the types of reasoning strategies they needed to use, did not break the process down as succinctly as the ces or note the cues used by ces to facilitate cr. they are formally taught reasoning strategies as part of a preclinical course, which clearly puts them ahead of the other disciplines in recognising aspects needed for cr. perhaps the best alignment between ces and students was in the audiology discipline, where procedure seemed to be key. this alignment could speak to the nature of the work that audiologists are involved in, especially at a thirdyear level. however, this observation cannot be generalised. study limitations the sample size, particularly of students, provides a limited view of the topic. unfortunately, the long-term intention to complete focus group discussions with fourth-year students, which may have added deeper insight into the understanding of cr development across clinical years, was not feasible within the period of funding. this remains an area for investigation. conclusion cr is a complex, learnt process that needs to be explicitly taught and guided in the clinical setting. there are inter-disciplinary differences among ces in defining cr across the health and rehabilitation sciences. this speaks to the different scopes of the professions within clinical contexts. however, when probed, all the disciplines recognised the complex cyclic nature of the process, which relies on multiple cues and inputs for success. of concern are the differences between ces and their students. this leads to students potentially missing key cues from ces guiding them through the cr process and a lack of awareness that the ce is stimulating the process. this 252 december 2021, vol. 13, no. 4 ajhpe research mismatch may be consistent with the literature, alluding to the gap between theoretical knowledge and its clinical implementation. divisions need to consider how to minimise the disconnect between ces and students to reduce the gap. explicit teaching around the nature of cr and the strategies of facilitation by ces could aid in this process. future research although not discussed within the scope of this article, there are some common strategies that can be drawn on to guide students entering clinical practice. these include formal training with students around types of reasoning and strategies used by ces to facilitate cr, as well as a conscious effort by educators to make their own thinking practices of cr visible to students during sessions. the facilitation of the students’ cr process through shared awareness is the key to closing the gap and aligning the mismatch between the perceptions of ces and students as to what cr entails. declaration. none. acknowledgements. the author acknowledges the assistance of clinical educators ms naila edries khan (physiotherapy)  and ms tasneem mohomed (occupational therapy), and prof. francois cilliers (education development unit (edu)) in co-ordinating the project. author contributions. ht and fc-s: main body of the article, discussion and conclusions; sla: literature review and introduction, content oversight and flow. funding. the project was funded by a department of higher education and training development grant aimed at faculty development. conflicts of interest. none. 1. newton jm, billett s, jolly b, ockerby cm. lost in translation: barriers to learning in health professional clinical education. learn health soc care 2009;8(4):315-327. https://doi.org/10.1111/j.1473-6861.2009.00229.x 2. dhaliwal g. developing teachers of clinical reasoning. clin teach 2013;10(5):313-317. https://doi.org/10.1111/ tct.12082 3. simmons b. clinical reasoning: concept analysis. j adv nurs 2010;66(5):1151-1158. https://doi.org/10.1111/ j.1365-2648.2010.05262.x 4. wu b, wang m, grotzer ta, liu j, johnson jm. visualizing complex process using a cognitive-mapping tool to support the learning of clinical reasoning. bmc med educ 2016;16(216). https://doi.org/10.1186/s12909-016-0734-x 5. wrenn j, wrenn b. enhancing learning by integrating theory and practice. int j teach learn high educ 2009;21(2):258-265. 6. ajjawi r, smith m. clinical reasoning capability: current understanding and implications for physiotherapy educators. focus health professional educ 2010;12(1):60-73. 7. custers ejfm. training clinical reasoning: historical and  theoretical background. in: ten cate o, custers e, durning s, eds. principles and practice of case-based clinical reasoning education, innovation and change in professional education. heidelberg: springer, 2018. https://doi.org/10.1007/978-3-319-64828-6_2 8. musgrove jl, morris j, estrada ca, kraemer rr. clinical reasoning terms included in problem solving exercises? j grad med educ 2016;8(2):180-184. https://doi.org/10.4300/jgme-d-15-00411.1 9. dhaliwal g, ilgen j. clinical reasoning: talk the talk or just walk the walk? j grad med educ 2016;8(2):274-276. https://doi.org/10.4300%2fjgme-d-16-00073.1 10. cruz eb, moore ap, cross v. a qualitative study of physiotherapy final year undergraduate students’ perceptions of clinical reasoning. musculo sci pract 2012;17(6):549-553. https://doi.org/10.1016/j.math.2012.05.013 11. furze j, black l, hoffman j, barr jb, cochran tm, jensen gm. exploration of students’ clinical reasoning development in professional physical therapy education. j phys ther educ 2015;29(3):22-33. https://doi. org/10.1097/00001416-201529030-00005 12. atkinson hl, nixon-cave k. a tool for clinical reasoning and reflection using the international classification of functioning, disability and health (icf) framework and patient management model. phys ther 2011;91(3):416430. https://doi.org/10.2522/ptj.20090226 13. delany c, golding c. teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators. bmc med educ 2014;14:20. https://doi.org/10.1186/1472-6920-14-20 accepted 19 november 2020. https://doi.org/10.1111/j.1473-6861.2009.00229.x https://doi.org/10.1111/tct.12082 https://doi.org/10.1111/tct.12082 https://doi.org/10.1111/j.1365-2648.2010.05262.x https://doi.org/10.1111/j.1365-2648.2010.05262.x https://doi.org/10.1186/s12909-016-0734-x https://doi.org/10.1007/978-3-319-64828-6_2 https://doi.org/10.4300/jgme-d-15-00411.1 https://doi.org/10.4300%2fjgme-d-16-00073.1 https://doi.org/10.1016/j.math.2012.05.013 https://doi.org/10.1097/00001416-201529030-00005 https://doi.org/10.1097/00001416-201529030-00005 https://doi.org/10.2522/ptj.20090226 https://doi.org/10.1186/1472-6920-14-20 ajhpe 345.indd research 138 october 2014, vol.6, no. 2 ajhpe simulation-enhanced medical education involves training where simulation is used as a valuable addition to traditional clinical experiential learning, and is a reliable and valid measurement tool to assess performance in a practice environment.[1,2] simulation techniques include the following: computer-enhanced manikins, part-task trainers, computerbased virtual reality simulation, simulated patients and procedural skills simulation.[3] for the purpose of this study, all the techniques were included. it is important to emphasise that simulation training and clinical practice must be integrated at all levels.[4] furthermore, simulation may sometimes be the only way to expose students to the management of less common conditions, while it also enables them and experienced practitioners to keep their skills up to date.[5] patient safety is a matter of prime importance and should be addressed in the education and training of medical students worldwide.[5] however, from a patient safety and ethical perspective, students are not frequently exposed to training in acute adult or paediatric emergencies and other conditions that require urgent and swift action.[6] the consequences of limited training, with an anticipated high margin of error, may have disastrous outcomes for patients when students or new graduates are expected to respond to these emergency situations in the clinical arena. the need for a sustainable, feasible and affordable plan to address this shortcoming can be managed with clinical simulation. with simulation, students’ training can be enhanced through experiential learning regarding the correct management of these situations, resulting in better prepared and more competent graduates. therefore, exposure to uncommon and rare conditions using clinical simulation may play an invaluable role in the training of healthcare students. clinical simulation in continuing professional development (cpd) programmes may be regarded as one of the cardinal applications in keeping qualified healthcare professionals updated, and its role must not be underestimated. the burden of hiv and tuberculosis (tb) epidemics in south africa (sa), africa and other developing countries, e.g. india and cambodia, has an influence on the change in case mix. the leading causes of death in sa are hiv/ aids, tb, interpersonal violence and road traffic injuries.[7] the tb prevalence in sa in 2006 was 998/100 000 population, which is considerably higher than in cambodia, the democratic republic of the congo, ethiopia and mozambique. hiv/aids was estimated to be responsible for 31% of all deaths in sa in 2000, according to the revised sa national burden of disease estimates.[7] the prevalence of hiv infection in communities in sa is approximately 30%.[8-10] in the developing world, the hiv pandemic and associated opportunistic infections, as well as the ever-increasing burden of tb, play fundamental roles in the change in case mix. the increasing incidence of infectious and parasitic diseases from 6.3% in 1971 to 7.4% in 1982 at groote schuur hospital, cape town, sa, reflects the change in case mix.[11,12] training of medical students has to include infection-related causes of death and a wide spectrum of other conditions. with the current case mix in academic and public sector hospitals in sa and the need to train students in the largest possible range of diseases and conditions, the training platform should be expanded. this platform has shifted to primary healthcare, with a decrease background. the burden of hiv and tuberculosis epidemics in south africa (sa), africa and developing countries in other parts of the world has an influence on the change in case mix. shortages of beds in training hospitals and the need to train more healthcare professionals contribute to the saturation of the teaching platform. clinical simulation as a tool to enhance the education and training of medical students in sa and recommendations in this regard were investigated. objective. to obtain recommendations regarding the development of simulation training, assessment facilities and programmes, and determine whether simulation training could enhance medical education and training in the developing world. methods. qualitative research methods, including semi-structured interviews with international simulation experts and focus group interviews with heads of department and lecturers of the local medical school, were used to generate data. results. a set of recommendations regarding the introduction of simulation training at an sa medical school was developed to improve patient safety, create a better training environment, and address the healthcare education challenges in sa hospitals. conclusion. the incorporation of simulation into medical curricula and the development of clinical simulation training facilities for healthcare professionals in sa could bridge the gap currently experienced in health sciences education in the country. the recommendations outlined in our study may assist other medical training institutions in the developing world in setting up simulation training facilities. ajhpe 2014;6(2):138-142. doi:10.7196/ajhpe.345 recommendations for the establishment of a clinical simulation unit to train south african medical students m j labuschagne,1 mb chb, mmed (ophth), phd; m m nel,2 phd; p p c nel,3 phd; g j van zyl,4 mb chb, mfammed, phd 1 clinical simulation and skills unit, school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 division of health sciences education, faculty of health sciences, university of the free state, bloemfontein, south africa 3 school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 4 faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m j labuschagne (labuschagnemj@ufs.ac.za) research october 2014, vol.6, no. 2 ajhpe 139 in beds at teaching hospitals.[10-13] all these factors have a substantial effect on the number of patients available for training purposes, and ultimately on the quality and competence of healthcare professionals graduating from medical schools.[12-14] sa appears to lack a sufficient number of medically skilled professionals in all areas of healthcare, especially in the public sector, to meet the needs of its population. according to an article in the bulletin,[14] published by the health professions council of south africa (hpcsa), 47 669 qualified medical and dental practitioners and 14 970 medical and dental students were registered with the council in 2012. sa has approximately 5 000 practising medical specialists, but needs 13 000; similarly, there are 13 000 practising general practitioners, but an additional 20 000 are required.[15] to train more healthcare professionals, especially general medical doctors and specialists, medical schools have to admit more students to meet the demand.[10,14] as increasing numbers of students enter medical schools and compete for a limited number of clinical encounters, problems regarding the provision of sufficient opportunities to train on actual patients are emerging.[4] the case mix has an impact on the quality of training of medical students and practitioners eventually entering the workforce. the steady decline in the number of hospital beds has a considerable effect on the adequacy of the training platform.[12] simulation-enhanced medical education can be used to address the shortcomings resulting from the aforementioned factors. clinical simulation training provides opportunities for students to be exposed to conditions unsafe for patients, or when high-risk, low-incidence conditions, such as congo fever and malignant hyperthermia, are involved. the intention at the university of the free state (ufs), bloemfontein, sa, is to introduce simulation training as an essential component of the medical training programme in a structured and systematic manner. in this study, a set of recommendations regarding the introduction of simulation training and assessment was developed at our medical school. the objective was to improve patient safety, create a better training environment, and address the challenges regarding saturation of the training platform and the skewed burden of disease in sa hospitals. methods this is a qualitative study using elements of grounded theory to develop recommendations for the establishment of a simulation training centre and the management of simulation in medical curricula. the study was conducted in two parts, namely (i) semistructured interviews with international experts; and (ii) focus group interviews with heads of department and lecturers at ufs. approval to conduct the research was obtained from the ethics committee of the faculty of health sciences, ufs (etovs 122/2010). semi-structured interviews these were used to explore key international experts’ attitudes towards and perceptions of simulation training. an interview guide in the form of a list of open-ended questions or topics was developed by mjl with the help of a literature review (table 1). occasionally, additional questions arose during the semistructured interview process; the data were included in the research. target population directors, managers, teaching staff and technical staff members of the society for simulation in healthcare (an accredited simulation centre in the usa), a simulation centre in the uk, and congress attendees at the international meeting on simulation in healthcare held in new orleans, usa, in 2011, were requested to participate in the semi-structured interviews. written consent was obtained from the participants. data collection and analysis the interviews, using the same interview guide, were conducted by mjl. all interviews were audio-recorded, transcribed by mjl and checked by an independent person who was not part of the study. field notes contributed to the process. the qualitative data were analysed using a grounded theory approach during which there was constant comparison of data. the stages of data analysis were coding, categorisation and theory generation.[16] theory was built by seeking patterns in data until saturation of data was reached. reliability and trustworthiness reliability of semi-structured interviews was ensured by using the same interview guide and researcher to conduct all the interviews in the same manner. trustworthiness of data was determined by the researcher’s ability to categorise into themes, define the categories and show the association with the interview question. focus group interviews the purpose and emphasis of the focus group interviews were to obtain information on the insights, attitudes, responses and opinions of the heads of department and lecturers in the school of medicine, ufs. target population the groups were comprised as follows: heads of department were interviewed in one group and lecturers in the school of medicine in a second group. during the focus group interviews, the opinions and attitudes of the participants were sought concerning the potential impact of a simulation centre on enhancing the education and training of medical students, and the integration of such training in the curriculum offered by the school of medicine. the focus group interview guide was piloted by the facilitator and an independent observer, after which no changes were required. focus group process, data collection and analysis a standard procedure for conducting the focus group interviews was used.[17] the question put table 1. interview guide for semi-structured interviews with international experts question 1. what role can simulation play as an additional mode for undergraduate medical training? 2. how can simulation be integrated into the current undergraduate medical curriculum? 3. what role can simulation play in the assessment of undergraduate medical students? 4. what lessons did you learn by using simulation as an undergraduate training tool? 5. in your opinion, what are the important factors to take into account in the planning of a simulation centre? 6. what recommendations can you make to take into account when acquiring simulators? 7. what is your advice on the financial considerations for a simulation centre? 8. can you describe the staff requirements for a simulation centre? 9. what lessons did you learn regarding the planning and implementation of a simulation centre? 140 october 2014, vol.6, no. 2 ajhpe research to both focus groups was: ‘what is your personal opinion and attitude concerning the value that a simulation centre can have in the training of medical students in the school of medicine, university of the free state?’. the participants’ contributions were audio-recorded and transcribed by mjl. an independent observer and the facilitator checked the transcriptions for verbatim accuracy. participants confirmed that they were satisfied with the transcriptions. the data were analysed according to a grounded theory approach, which included a process of open, axial and selective coding, categorisation and theory generation.[16,18] the objective was to look for trends and patterns that reappeared in a single focus group or among the two different focus groups.[19] data collection and analysis were continued until saturation of data was reached. reliability and trustworthiness reliability of the focus group interviews was ensured by using a consistent method during the interviewing procedure, using the same facility and facilitator for the two focus group interviews and performing data analysis and transcription of recordings as described. trustworthiness of content analysis of the focus group interview was determined by the researcher’s ability to categorise data, define categories and show the connection with the focus group question. data analysis was controlled by the same independent researcher who controlled the data generated by the semi-structured interviews. results participants (n=9) in the first focus group interview were lecturers from the following clinical departments: anaesthesiology, family medicine, internal medicine, otorhinolaryngology, paediatrics and child health, and surgery. the second focus group (n=7) comprised heads of the following clinical departments: anaesthesiology, critical care, dermatology, family medicine, internal medicine, oncology and ophthalmology. four focus areas emerged during the interviews. the first focus area regarding personal opinions contributed to the topic of the development and implementation of a simulation centre. consensus was reached that it was essential to develop a simulation unit for the school of medicine, ufs. because of a general lack of knowledge on simulation training, the need for information seminars to familiarise the lecturers with this tool was identified. it should be incorporated in the development process of the simulation centre. the second area focused on the topic of personal attitudes of participants. these were mainly positive towards the establishment of a simulation training unit, although a few negative attitudes were identified that could be linked to the lack of knowledge noted in the first focus area. the value of a simulation unit in the school of medicine was the third focus area that emerged. the additional benefits to the current curriculum regarding patient safety and training in a non-threatening environment were highlighted, ethical aspects of training with simulators were considered, and the added value of assets and human resources was identified. the fourth focus area concentrated on the training of medical students. the themes that emerged included the curriculum, skills development, multidisciplinary training, change in case mix, decreasing training platform, simulators and aspects of assessment. the focus group interviews added a dimension to the research in the sense that the emphasis was on determining the ideas and feelings of individuals with regard to certain issues relating to simulation enhancement of medical education and training. semi-structured interviews were conducted with international simulation experts (n=12), who thought that simulation training should be well planned and fully integrated in the curriculum as a required component of the different modules. the role of clinical simulation as an addition to the current undergraduate medical curriculum was addressed with the first semi-structured interview question. the recommendations were that simulation should provide a nonthreatening environment where students can improve their clinical skills and competence, receive additional training on diseases that are seldom seen, and apply theory in clinical practice. the use of standardised patients is especially useful in the training of skills pertaining to communication, and general and interdisciplinary teamwork. the improvement of patient safety is another advantage of incorporating simulation in the curriculum. the more relaxed environment where students can assess and practise acute or unusual situations will improve patient safety and equip students for real-life situations after they have qualified. the integration of simulation as an undergraduate training tool was addressed with semi-structured interview questions two and four. simulation should be integrated into the curriculum as a required component and not merely as an optional extra. simulation can be used to teach components of the curriculum such as experiential learning, decision-making and clinical reasoning skills. train-the-trainer programmes are essential for the successful integration of simulation and the simulation unit. incorporating simulation in and aligning it with the curriculum will not be problem free and a few such difficulties were mentioned, e.g. contact hours, funding, and persuading lecturers to include simulation exercises in their curricula. the third semi-structured interview question dealt with assessment tools and criteria for assessment of clinical competence of undergraduate medical students in a simulation unit. general aspects such as the assessment of higher levels of bloom’s taxonomy, miller’s model of competence and problems with implementation of assessment modules were discussed. formative assessment of reasoning skills, debriefing and interpersonal skills testing were discussed. the use of simulation for qualification and recertification purposes was evaluated and considered. the fourth semi-structured interview question dealt with simulation as a training tool, e.g. with regard to teamwork training, patient safety, psychological competence and reasoning skills. debriefing is a crucial component of simulation training. its use in formative assessment and the training of trainers was discussed. factors to consider in the development and implementation of a new simulation unit for the school of medicine, faculty of health sciences, ufs, were evaluated and semi-structured interview questions five to nine dealt with these issues. the planning of a simulation centre comprised the teaching programmes, physical spaces, technology, equipment and supplies required for the establishment of such a unit. semi-structured interview question six evaluated all the aspects regarding the simulators and the manufacturers of the equipment. the financial aspects involving the establishment of the simulation centre were analysed with semi-structured interview question number seven. the staff requirements for a simulation centre were examined with semi-structured interview question number eight, and the last question dealt with aspects regarding the planning and implementation of such a centre. research october 2014, vol.6, no. 2 ajhpe 141 the data gathered from the semi-structured interviews were triangulated with those of the focus group interviews and literature review to compile recommendations. the key outcome of this study was to make recommendations regarding the development of simulation training, assessment facilities and programmes to help alleviate the training platform saturation in sa. based on the semi-structured and focus group interviews, a number of recommendations were proposed (table 2). when simulation is introduced as an instructional medium to enhance medical education and training, it should include (i) establishment of a clinical simulation centre; and (ii) staff development programmes. discussion the key findings of this study emphasise the following: (i) recognising that the medical curriculum can be enhanced by clinical simulation; (ii) integrating simulation as a required component of the curriculum; and (iii) incorporating assessment to determine whether students have mastered the content and achieved the objectives. simulation training could be introduced early in the foundation phase as part of the training of basic skills to build medical knowledge, e.g. history taking, core physical examination and communication skills, followed by clinical skills training of procedures and physical examination and protocols in the preclinical phase. more advanced discipline-specific simulation is introduced in the clinical phase of the curriculum – an approach concurring with the findings of the survey conducted by the american association of medical colleges on medical simulation in medical education.[20] this mode of training should be dynamic, with students continuously moving back and forth between theoretical, simulation and clinical training, representing the vertical and horizontal integration of simulation into the curriculum. this dynamic is a unique addition, fulfilling the needs of students with different competency levels, identified in the focus group interviews and often encountered in sa medical schools. it should include train-thetrainer courses (fig.1). the educational needs and objectives of the curriculum should dictate the acquisition of simulators to address specific exit competencies of a technical and non-technical nature required by the hpcsa. by incorporating standardised patients and hybrid simulation into scenarios, the training of non-technical skills could add significant value to simulation training, but can pose challenges to educators. according to the canmeds framework, the following competencies and roles are required for healthcare workers: medical expert, communicator, collaborator, manager, table 2. recommendations based on outcomes of semi-structured and focus group interviews role players the following role players were identified for involvement in the establishment of a simulation unit: • academic staff and technical support staff of simulation centre • other simulation centres locally, nationally and internationally – input and collaboration • public willing to be trained and to participate as standardised patients • university supplying a platform and an infrastructure for development of a centre • health professions council of south africa (hpcsa) and other international regulatory bodies as appropriate • management of academic and training hospitals • private hospitals • pharmaceutical companies • qualification authorities • continuing professional development (cpd) programmes teaching and learning teaching and learning recommendations to integrate simulation successfully into curricula include the following: • vertical and horizontal integration of simulation into the curriculum as a dynamic process • creation of a safety culture • ethical aspects of student training can be addressed • cultural differences and religious affiliations can be addressed • team training and interdisciplinary training can be addressed • computer-based simulation will improve reasoning skills and clinical thinking • creation of self-directed and instructor-based learning opportunities • introduction of training sessions for hospital staff, cpd programmes and recertification programmes with simulation as additional instructional medium assessment recommendations regarding the use of simulation as an assessment tool include the following: • define skills, choose the appropriate simulation task and select the correct simulation tool to assess selected skills • assess the reliability of the tools • support the validity of the test scores • implement the correct debriefing techniques • implement simulation as a tool for certain aspects of formative, summative, qualifying and recertification assessment establishing a simulation training unit recommendations regarding the establishment of a simulation training unit include the following: • simulation spaces: simulation rooms for one-on-one training, multipurpose simulation rooms, highfidelity simulation rooms, procedural simulation rooms and the accompanying control rooms • classroom spaces: preand debriefing sessions, formal lectures • administrative areas: reception, offices, storage • electronic equipment: audiovisual equipment, computers and telephones for each simulation area • equipment and supplies: equivalent to the equipment and supplies used in hospitals • simulators: part-task trainers, low-, mediumand high-fidelity simulators to comply with the objectives and needs of the curriculum. standardised patients, hybrid simulations • staff establishment: the head of the unit should be medically trained, and the simulation co-ordinator(s) must have a healthcare background. other personnel should include a standardised patient co-ordinator, a technical and information technology staff member, a multimedia specialist and administrative staff • financial support from government, university, commercial companies and suppliers, and private and public hospitals, and private donations 142 october 2014, vol.6, no. 2 ajhpe research health advocate, scholar and professional.[21] students can be trained and assessed with regard to these aspects in clinical simulation exercises and standardised patients can play a very important role. the ethical aspects regarding cultural differences, language differences and religious affiliations could also be addressed with simulation. team and interdisciplinary training in actual clinical and simulated settings should be incorporated in educational programmes, because teams make fewer mistakes. the ability to practise without risk must be weighed against the cost of using simulation technology.[22] benefits of simulation and cpd training include patient safety, a safer training environment for healthcare workers, a supportive, non-threatening environment and reduced working hours as clinicians perform procedures successfully more often the first time.[23,24] conclusion saturation of the training platform has a severe impact on tertiary medical training institutions in sa and can be attributed to several factors, e.g. bed shortages, pressure on secondary and tertiary level beds due to the high burden of hiv and tb in sa, pressure on the teaching platform and influence on the case mix that students are exposed to.[12] more healthcare staff should be trained at all levels. with the limited growth of academic teaching facilities, the shift to primary healthcare and the revitalisation of primary level facilities, the pressure on the teaching platform in training hospitals will increase even more.[11-13] the use of clinical simulation training addresses an urgent need with regard to the expansion of the training platform in face of the increasing student numbers, as mentioned by the sa healthcare plan and the implementation of the national health insurance scheme.[10] the development of clinical simulation facilities for the training of medical students and other healthcare professionals in sa will, it is hoped, bridge the current shortcomings in health sciences education in the country and assist other african countries in setting up similar facilities using the recommendations outlined in the current study. references 1. gropper r, harnett n, parker k, et al. th e path to simulated learning: developing a valid and reliable tool to evaluate performance of radiological technology students in patient interactions. j allied health 2010;39(1):28-33. 2. scalese rj. energising medical education through simulation: powering minds, not just machines. proceedings of the 6th asia pacifi c medical education conference (apmec), 19 22 february 2009, singapore. singapore: apmec, 2009. 3. kahn k, tolhurst-cleaver s, white s, simpson w. simulation in healthcare education. building a simulation programme: a practical guide (amee guide no. 50: curriculum planning). dundee: association for medical education in europe (amee), 2011. 4. maran nj, glavin rj. lowto high-fi delity simulation – a continuum of medical education? med educ 2003;37(suppl 1):22-28. [http://dx.doi. org/10.1046/j.1365-2923.37.s1.9.x] 5. gaba dm. th e future of simulation in health care. qual saf health care 2004;13(suppl 1):i2-i10. [http://dx.doi.org/10.1136/ qshc.2004.009878] 6. ziv a, small sd, wolpe pr. patient safety and simulation-based medical education. med teach 2000;22(5):489-495. 7. bradshaw d, groenewald p, laubscher r, et al. initial burden of disease estimates for south africa, 2000. s afr med j 2003;93(9):682-688. 8. burch vc, tarr g, morroni c. modifi ed early warning score predicts the need for hospital admission and inhospital mortality. emerg med j 2008; 25(10):674-678. [http://dx.doi.org/10.1136/emj.2007.057661] 9. de vries e, raubenheimer p, kies b, burch vc. acute hospitalisation needs of adults admitted to public facilities in the cape town metro district. s afr med j 2011;101(10):760-764. 10. department of health, south africa. national department of health strategic plan 2010/11-2012/13. http://www.doh.gov.za/docs/ stratdocs/2010/part3.pdf (accessed 27 march 2013). 11. benatar sr, saven a. morbidity trends in the medical wards at groote schuur hospital – 1971 and 1982. s afr med j 1985;67(24):968-974. 12. burch vc, benatar sr. rational planning for healthcare based on observed needs. s afr med j 2006;96(9):796-802. 13. bateman c. th ree-year closure for cape flats gangland resuscitation/ trauma hospital. s afr med j 2012;102(11):823-824. 14. health professions council of south africa. a snapshot review. th e bulletin 2013:48-49. http://www.hpcsa.co.za/downloads/press_ releases/bulletin/2013/bulletin_magazine_2013.pdf (accessed 7 june 2013). 15. hudson m. where have all our practitioners gone? th e bulletin 2011:20-24. http://www.hpcsa.co.za/downloads/press_releases/hpcsa_ bulletin_2011.pdf (accessed 6 june 2013). 16. byrne m. grounded theory as a qualitative research methodology – brief article. aorn journal 2001;73(6):1155-1156. [http://dx.doi. org/10.1016/s0001-2092(06)61841-3] 17. krueger ra. designing and conducting focus group interviews. www.eiu.edu/~ihec/krueger-focusgroupinterviews.pdf (accessed 20 september 2010). 18. mertens dm. research and evaluation in education and psychology: integrating diversity with qualitative, quantitative and mixed methods. 2nd ed. th ousand oaks, ca: sage publications, 2005. 19. lewis mj. focus group interviews in qualitative research: a review of the literature. action research e-reports. http://www.fh s.usyd.edu.au/ arow/arer/002.htm (accessed 20 september 2010). 20. passiment m, sacks h, huang g. medical simulation in medical education: results of an aamc survey. 2011. https://www.aamc.org/ download/259760/data/ (accessed 20 february 2014). 21. frank jr, danoff d. th e canmeds initiative: implementing an outcomes-based framework of physician competencies. med teach 2007;29(7):642-647. [http://dx.doi.org/10.1080/01421590701746983] 22. gordon ja, wilkerson wm, shaff er dw, armstrong eg. ‘practicing’ medicine without risk: students’ and educators’ response to highfi delity patient simulation. acad med 2001;76(5):469-472. [http:// dx.doi.org/10.1097/00001888-200105000-00019] 23. falcon h, greenspan d. nhs education south central (nesc). strategy for clinical simulation training 2008-2011. http://www.nesc. nhs.uk/pdf/nesc_innov_clinical_simulation_training_strategy_ pfd_20090701.pdf (accessed 18 june 2011). 24. glavin rj. skills, training, and education. simulation in healthcare 2011; 6(1):4-7. [http://dx.doi.org/10.1097/sih.0b013e31820aa1ee] preparation phase preclinical phase of curriculum clinical phase of curriculum medical education and training enhanced with clinical simulation general skills clinical skills clinical simulation train-the-trainers courses clinical simulation theoretical training clinical training in clinical immersion clinical simulation fig. 1. schematic model of vertical and horizontal integration of simulation in a medical curriculum. 10 may 2014, vol. 6, no. 1 ajhpe research innovative educational approaches must meet 21st century healthcare and education requirements. professional educators and students (as future professionals) are healthcare stakeholders who must take responsibility for meeting the challenges of improving healthcare for patients and populations by attending to the knowledge, skills and attitudes of future healthcare professionals.[1] current undergraduate students, or generation y (also referred to as millennials or the net generation), born between 1981 and 2000, have a distinct profile and characteristics as a result of the era during which they were born.[2] they are said to be confident and ambitious, preferring specific learning styles, including active experiential learning and multitasking, and communication technology for information access and interpersonal relationships.[3,4] their world has been shaped by the informationcommunication technology (ict) revolution, and global social, political and economic changes that have an impact on their attitudes and behaviours.[5] this discourse has led to a trend in health sciences education, i.e. incorporating technology to address the challenges found in teaching and learning.[6] an awareness of generation y’s characteristics is essential when addressing current issues and planning future strategies in academic medicine.[7] however, caution should be exercised when attempting to separate myth from reality regarding the core behaviours and attitudes of generation y students. an understanding of how different generations view each other, and exploring the impact on teaching and learning, should precede any intended changes to education.[8] limited empirical data regarding generation y characteristics beyond the hype portrayed in the popular media are available, and a more conservative view regarding the sweeping claims about ‘digital natives’ is advisable.[8,9] we aimed to explore the characteristics of generation y health sciences students that impact on the teaching-learning environment. information was obtained on the shared and contrasting perceptions of students and lecturers, typical characteristics of generation y students, and issues of significance that may impact on health sciences education and then scrutinising these in light of current pedagogical theory. for this purpose, a questionnaire survey was designed based on the literature regarding generation y, including aspects pertinent to health sciences education.[2,3,6,10] the study hypothesised that by gaining a better understanding of generation y students, uncovering misunderstandings or conflicting perceptions between students and lecturers and discovering students’ unique needs, the strategies for health sciences education in the 21st century may be improved. four key elements pertinent to educating generation y students in health sciences were identified as relevant to this study, including the educational environment, generation y students’ personal attributes, their learning styles and needs, and issues of professional communication between students, lecturers, patients, colleagues, families and peers. this approach aligns with the pedagogical principles for effective practice in undergraduate education (table 1).[11,12] methods this cross-sectional study was performed using a quantitative research design. participants all students in their second or final year of undergraduate study in the schools of medicine, allied health professions and nursing in the faculty background. health sciences education in the 21st century must recognise the changing profile of students, which includes an understanding of the characteristics of generation y students (born between 1981 and 2000) as future healthcare professionals. objective. to examine the perceptions of students and lecturers regarding generation y students in health sciences that might impact on teaching and learning in a south african setting. methods. a quantitative research approach was used to determine undergraduate students’ and lecturers’ perceptions of generation y students in the faculty of health sciences, university of the free state, bloemfontein, south africa. anonymous questionnaires were used to obtain information. results. the study population included students (n=616) and lecturers (n=71). despite some shared perceptions about generational characteristics, students and lecturers differed significantly on many issues. unlike lecturers, students perceived themselves as being ambitious (not arrogant) and possessing superior cognitive skills. despite desiring a vibrant and stimulating learning environment, students wanted face-to-face contact with lecturers. poor intergenerational communication also emerged as a pertinent issue. conclusion. identification of intergenerational issues that may impact on teaching and learning may contribute to developing novel educational approaches acceptable to both lecturers and students. ajhpe 2014;6(1):10-16. doi:10.7196/ajhpe.307 how we see ‘y’: south african health sciences students’ and lecturers’ perceptions of generation y students l j van der merwe,1 mb chb, mmedsc, phd; g j van zyl,2 mb chb, mmed, phd; m m nel,3 phd; g joubert,4 ba, msc 1 department of basic medical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa 2 office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 3 division health professions education, faculty of health sciences, university of the free state, bloemfontein, south africa 4 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: l j van der merwe (merwelj@ufs.ac.za) mailto:merwelj@ufs.ac.za may 2014, vol. 6, no. 1 ajhpe 11 of health sciences, university of the free state (ufs), bloemfontein, south africa, were invited to participate in the study. students were requested to voluntarily complete an anonymous questionnaire during academic contact sessions in march 2010. second-year students were included in the sample because of the assumption that they would have adapted to their course and university environment by the end of their first year. the opinions of older, more mature students with some exposure to the working environment of their respective occupations were obtained. these included fourth and fifth-year students in the five-year mb chb course and fourth-year students in the other fouryear courses, with the exception of third-year students in the three-year bsc radiation science course. the target population (n=668) included second-year (n=277) and senior (n=391) students (2010 figures from the directorate institutional research and planning, ufs). lecturers were also invited to voluntarily complete an anonymous questionnaire online or in printed format. questionnaire survey the questionnaires, based on recommended guidelines,[13] were available in afrikaans and english, the languages of instruction at ufs, where a parallel language policy is followed.[14] undergraduate students’ and lecturers’ perceptions regarding statements about generation y students were determined employing a modified 4-point likert scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree). for reporting purposes, responses 1 and 2 were grouped together to indicate disagreement, and responses 3 and 4 to indicate agreement with statements. the questionnaires for students and lecturers were similar, with the exception of the sections on demographic and personal information. pilot study a pilot study included 10 third-year students and two lecturers from the schools of medicine, allied health professions and nursing, respectively. no changes to the questionnaires were required after the pilot study. data analysis statistical analysis of quantitative data was done by a biostatistician using the sas programme[15] to calculate frequencies and percentages for the categorical variables and means, and standard deviations or percentiles as appropriate for the numerical variables. associations between categorical variables were determined using contingency tables with 95% confidence intervals (cis) for the differences in percentages and chi-square tests or fisher’s exact tests where the expected numbers in the cells of tables were small. a p-value <0.05 was considered to be statistically significant. ethical requirements ethics approval was obtained from the ethics committee of the faculty of health sciences, ufs (ethics approval no. etovs 205/09). results demographic information table 2 shows the demographic details of the students and lecturers who participated in the study. a total of 616 students completed the survey during march 2010 (response rate 92.2%). students from the school of medicine comprised table 1. key elements pertinent to the educational approach for generation y students aligned with theoretical frameworks informing undergraduate education[11,12] four key elements seven good practices twelve attributes of quality a. educational environment 1. give prompt feedback 2. encourage student-faculty contact i. assessment and prompt feedback ii. out-of-class contact with faculty iii. emphasis on early years of study b. personal attributes 3. encourage co-operation among students 4. emphasise time on task iv. collaboration v. adequate time on task vi. synthesis of experiences c. learning styles and needs 5. encourage active learning vii. active learning viii. integration of education and experiences ix. ongoing practice of learned skills d. professional communication 6. communicate high expectations 7. respect diverse talents and ways of learning x. high expectations xi. respect for diverse talents and learning styles xii. coherence in learning table 2. demographic data of the participants undergraduate students school in the faculty of health sciences medicine allied health nursing lecturers variable total % total % total % total % gender, n 322 226 68 71 male 158 49.1 40 17.7 10 14.7 25 35.2 female 164 50.9 186 82.3 58 85.3 46 64.8 ethnicity, n 320 226 68 69 black 1 28.4 9 4.0 32 47.1 2 2.9 white 202 63.1 211 93.4 34 50.0 67 97.1 other 27 8.5 6 2.6 2 2.9 0 0 home language, n 321 224 68 69 english 42 13.1 31 13.8 3 4.4 12 16.9 afrikaans 188 5 867 183 81.7 33 48.5 57 80.3 black african indigenous language 91 28.3 10 4.5 328 47.1 2 2.8 research 12 may 2014, vol. 6, no. 1 ajhpe 52.3% (n=322) of the sample; 36.7% (n=226) were from the school of allied health professions and 11.0% (n=68) were nursing students. the majority of students were white (72.7%; n=448) and afrikaans speaking (66.1%; n=407). english was the first language of only 12.3% (n=76) of all students. of the remaining students, 21.4% (n=132) were black african, with an indigenous language as their mother tongue. the remainder of the cohort included indian (n=5), asian (n=3), and mixed-ancestry (coloured, n=24) students. three students did not specify their ethnicity. seventy-one lecturers participated in the survey – a response rate of 34.5%, which falls within the norm of 35 40% described for studies at organisational level.[16] the respondents included 47 (66.2%) lecturers from the school of medicine, 20 (28.2%) from the school of allied health professions, and four (5.6%) from the school of nursing. they were mostly female (60.6%), afrikaans speaking (80.3%) and white (95.7%), of whom 34.3% (n=23) were born between 1944 and 1960 (baby boomers), and 64.2% (n=43) between 1961 and 1980 (generation x). one participant represented generation y (born between 1981 and 2000).[10,17] summary of significant findings from questionnaire surveys the results from the questionnaire surveys reflected the perceptions of students and lecturers regarding generation y students, and are presented according to the key elements of the educational framework used in this study (table 1). educational environment. students and lecturers agreed that generation y students cannot imagine a world without technology, function best in a structured, organised environment and regard a team environment as optimal for learning. table 3 summarises statements where significant differences were observed between students and lecturers. significantly more lecturers than students indicated that generation y students prefer empathetic role models (students 71.3%, lecturers 95.5%), need motivational leadership (students 71.5%, lecturers 90.5%), or need guided supervision, preferably by an older mentor (students 56.7%, lecturers 80.9%). compared with lecturers, less than 50% of students agreed that generation y students prefer an anonymous, open online environment (students 28.0%, lecturers 82.1%), or consider the internet to be a way of life rather than just a form of technology (students 47.5%, lecturers 93.9%). significantly more students agreed that generation y students grew up in a structured, organised environment (students 89%, lecturers 29.7%) and are used to obeying rules (students 93.3%, lecturers 29.7%). students and lecturers agreed that generation y students think that lecturers should give each student individual feedback on a regular basis, and that when a lecturer gives negative feedback, they should explain or justify it. significantly more lecturers indicated that generation y students want immediate, personal access to lecturers whenever it suits them (students 46.7%, lecturers 86.8%), and that they prefer positive feedback because negative feedback is destructive (students 54.4%, lecturers 88.2%) (table 3). personal attributes. students and lecturers agreed that generation y students are friendly and pleasant, display positive, assertive behaviour, are optimistic about the future, appear confident and have a high self-esteem. table 4 illustrates statements where significant differences were seen between students and lecturers. table 3. significant differences between perceptions of students and lecturers regarding the educational environment of generation y students students lecturers respondents agree* respondents agree* statement n n (%) n n (%) p-value (95% ci) generation y students … think the internet is more than technology, it is a way of life 613 291 (47.5) 66 62 (93.9) <0.0001 (39.5 53.5) … prefer the anonymous, open online environment 610 171 (28.0) 67 56 (82.1) <0.0001 (44.2 63.9) … prefer empathetic role models 606 432 (71.3) 67 64 (95.5) <0.0001 (18.1 30.4) … need motivational leadership 593 424 (71.5) 63 57 (90.5) 0.0012 (10.9 27.1) … need guided supervision, preferably by an older mentor 612 347 (56.7) 68 55 (80.9) <0.0001 (14.1 34.3) … grew up in a structured, organised environment 611 544 (89.0) 64 19 (29.7) <0.0001 (47.9 70.8) … are used to following rules 610 569 (93.3) 64 19 (29.7) <0.0001 (52.2 75.0) … want immediate, personal access to lecturers whenever it suits them 612 286 (46.7) 68 59 (86.8) <0.0001 (31.1 49.0) … prefer positive feedback because negative feedback is destructive 612 333 (54.4) 68 60 (88.2) <0.0001 (25.2 42.4) ci = confidence interval. * includes the categories ‘strongly agree’ and ‘agree’ on the questionnaire likert scale. research may 2014, vol. 6, no. 1 ajhpe 13 a significantly higher proportion of lecturers indicated that generation y students are self-centred (students 17.6%, lecturers 72.5%), may seem arrogant (students 27.5%, lecturers 59.4%), feel entitled to benefits not yet earned (students 19.6%, lecturers 69.6%), want instant gratification and are not willing to wait for delayed rewards (students 30.0%, lecturers 73.9%) or think that they are entitled to everything they want (students 23.3%, lecturers 72.1%). significantly more students than lecturers agreed that generation y students are ambitious (students 97.4%, lecturers 65.2%), have high expectations of success (students 95.7%, lecturers 77.9%), are motivated to achieve success (students 98.7%, lecturers 85.6%) and aim to achieve a work-life balance (students 98.4%, lecturers 74.6%). learning styles and needs. students and lecturers agreed on some of the learning needs of generation y students, e.g. that real-life simulations are a valuable way to learn new skills, technology is essential, visual data are better than text data, face-to-face contact with lecturers is essential to understand a subject, e-learning is not better than face-to-face contact, learning should be tailored to individual student needs, group work is a key element of learning and generation y students want a constantly changing learning environment. table 5 illustrates statements where significant differences between the opinions of students and lecturers were seen. significantly more students agreed that learning is about discovery and exploration (students 90.7%, lecturers 50.8%), experience is a better learning platform than lectures (students 90.5%, lecturers 61.5%), and it is important to incorporate one’s own experiences into the learning experience/process (students 89.9%, lecturers 70.8%). in addition, a significantly greater proportion of students agreed that generation y students can multitask (students 77.4%, lecturers 50%), are active learners (students 87.9%, lecturers 47%), take responsibility for their own learning (students 96.6%, lecturers 49.3%), have good critical thinking skills (students 46.8%, lecturers 27.3%), learning content should be intellectually challenging (students 85.5%, lecturers 57.6%) and students should collaborate on subject content decisions (students 62.7%, lecturers 39.1%). a significantly higher percentage of lecturers agreed that generation y students struggle with in-depth learning (students 41.0%, lecturers 89.4%), find it difficult to manage large volumes of written information (students 76.2%, lecturers 93.9%), and find structured supervision frustrating (students 26.8%, lecturers 64.2%). professional communication. undergraduate students and lecturers agreed that generation y students communicate well with people from diverse cultures. table 6 illustrates statements with significant differences between students and lecturers. lecturers and students had contrasting views on the ability of generation y students to communicate using technology rather than personal interaction (students 14.0%, lecturers 82.4%), e.g. text messaging rather than face-to-face contact (students 14.9%, lecturers 74.2%). significantly more lecturers also agreed that generation y students find it difficult to communicate with older individuals (students 40.3%, lecturers 70.6%), think that older generations do not understand how to communicate with them (students 42.6%, lecturers 83.8%), and table 4. significant differences in percentage between students and lecturers agreeing with statements regarding generation y students’ personal attributes students lecturers respondents agree* respondents agree* statement n n (%) n n (%) p-value (95% ci) generation y students … are motivated to achieve success 615 607 (98.7) 67 58 (86.6) <0.0001 (3.9 20.4) … may seem arrogant 612 168 (27.5) 69 41 (59.4) <0.0001 (19.9 44.1) … are self-centred 613 108 (17.6) 69 50 (72.5) <0.0001 (43.9 65.8) … feel entitled to benefits not yet earned 613 120 (19.6) 69 48 (69.6) <0.0001 (38.7 61.3) … are ambitious 615 597 (97.1) 69 45 (65.2) <0.0001 (20.5 43.2) … have high expectations of success 611 585 (95.7) 69 53 (77.9) <0.0001 (7.8 27.8) … want instant gratification and are not willing to wait for delayed rewards 613 184 (30.0) 69 51 (73.9) <0.0001 (32.9 54.9) … think they are entitled to everything they want 614 143 (23.3) 68 49 (72.1) <0.0001 (37.6 60.0) … aim to achieve work-life balance 615 605 (98.4) 67 50 (74.6) <0.0001 (13.3 34.2) ci = confidence interval. * includes the categories ‘strongly agree’ and ‘agree’ on the questionnaire likert scale. research 14 may 2014, vol. 6, no. 1 ajhpe have a casual approach that may appear to lack professionalism (students 38.1%, lecturers 89.9%). significantly more students were of the opinion that generation y students are good communicators (students 90.0%, lecturers 42.6%), can maintain close, personal relationships (students 94.7%, lecturers 66.7%) and often have superficial, online relationships (students 91.8%, lecturers 79.4%). discussion current strategies tailored to the educational needs of generation y students are mostly based on limited data and vague statements derived from the popular literature.[18] this study provides a comprehensive overview of the personal attributes, preferred learning styles and needs, communication behaviours and educational environment requirements of generation y students from the perspective of students and lecturers, providing scientifically generated evidence that may inform innovative teaching-learning strategies. we observed major differences in perceptions between students (as members of generation y) and lecturers (who belong to previous generations), which may foster conflict and misunderstanding and contribute to the contemporary view that teaching this generational cohort is an important challenge in health sciences education.[19] students and lecturers shared a positive view that generation y students are friendly and pleasant, confident, assertive and optimistic about the future. however, while students viewed themselves as ambitious and motivated for success, lecturers regarded them as self-centred, arrogant, displaying a sense of entitlement and demanding instant gratification. creating an understanding and awareness of such intergenerational conflicting perceptions should contribute to limiting frustration and fostering good relationships between students and practising clinicians in health sciences table 5. significant differences in percentage between students and lecturers agreeing with statements regarding the learning needs of generation y students students lecturers respondents agree* respondents agree* statement n n (%) n n (%) p-value (95% ci) generation y students … think experience is a better learning platform than lectures 611 553 (90.5) 65 40 (61.5) <0.0001 (16.9 41.0) … feel it is important to incorporate own experiences in learning 613 551 (89.9) 65 46 (70.8) <0.0001 (7.8 30.4) … think learning is about discovery and exploration 614 557 (90.7) 65 33 (50.8) <0.0001 (27.6 52.3) … think traditional lectures are outdated 606 241 (39.8) 64 35 (54.7) 0.0211 (2.1 27.7) … are active learners 612 538 (87.9) 66 31 (47.0) <0.0001 (28.6 53.3) … have good critical thinking skills 613 525 (85.5) 66 18 (27.3) <0.0001 (47.1 69.3) … can multitask 611 473 (77.4) 66 33 (50.0) <0.0001 (14.9 39.9) … struggle with in-depth learning 603 247 (41.0) 66 59 (89.4) <0.0001 (40.0 56.8) … find it difficult to manage large volumes of written information 614 468 (76.2) 66 62 (93.9) 0.001 (11.1 24.4) … should collaborate on subject content decisions 611 383 (62.7) 64 25 (39.1) 0.0002 (11.1 36.2) … think that learning content should be intellectually challenging 612 523 (85.5) 66 38 (57.6) <0.0001 (15.6 40.1) … learn only what is necessary to pass assessments 613 251 (41.0) 65 59 (90.8) <0.0001 (41.8 57.9) … take responsibility for own learning 614 593 (96.6) 67 33 (49.3) <0.0001 (35.3 59.4) … find structured supervision frustrating 612 164 (26.8) 67 43 (64.2) <0.0001 (25.4 49.4) ci = confidence interval. * includes the categories ‘strongly agree’ and ‘agree’ on the questionnaire likert scale. research may 2014, vol. 6, no. 1 ajhpe 15 education. the importance of constructively managing generational diversity in academic medicine has been highlighted previously.[20-23] while our results show that students and lecturers agreed that an organised educational environment incorporating teamwork and individual positive feedback is optimal for learning, significantly more students thought that generation y students are accustomed to structure and obeying of rules (table 3). significantly fewer students believed that generation y students need supervisory mentoring by empathetic role models or prefer the anonymity of technology. therefore, the current literature advocating extensive use of technology in teaching and learning, based on the assumption that generation y students prefer such an approach, may be somewhat misleading.[5,24,25] our findings support those advocating a more conservative view that innovative technology may not address all the challenges faced in higher education today.[8,26] in this study, students and lecturers agreed that vibrant and fitting learning environments incorporating visual stimulation, simulation and technology are ideal. however, the importance of face-to-face contact with lecturers was valued and should not be disregarded in favour of the predominant use of e-learning strategies. a learning environment appropriate for generation y students should therefore strike a balance between nurturing students’ cognitive skills through personal interaction with lecturers (as mentors and facilitators of learning), relevant use of innovative technology and practical experiential learning activities. students perceived themselves as responsible, active learners, with the ability to multitask – a view not shared by lecturers. significantly more lecturers thought that students struggle with in-depth learning and handling vast amounts of information, and become frustrated by structured supervision. on the other hand, students emphasised the value of experiential learning that is intellectually challenging and allows for collaborative input. these contrasting perceptions confirm students’ confidence in their higher-order thinking skills, and emphasise the need for employing a student-centred approach in health sciences education. adult learning principles, embodied by self-directed learning and active engagement, include creating an environment characterised by freedom of expression and mutual helpfulness, encouraging students’ commitment and dynamic contribution to learning by incorporating their prior knowledge and experience and providing opportunities to practise concepts and skills.[27] students and lecturers concurred that generation y students communicate well with people of diverse cultures. however, significantly more students thought that they were good communicators capable of maintaining healthy interpersonal relationships, while lecturers perceived them to be more adept at communicating by means of technology, and that intergenerational miscommunication and students’ seemingly casual and unprofessional approach hampered their professional communication. the contrast between students who regard themselves as good communicators (in spite of the detrimental effects of technology on their interpersonal relationships) and lecturers who think generation y students have limited communication skills, may contribute to challenges arising in the teaching and learning environment. in this study, students matched the typical view of generation y as a wired and connected cohort whose face-to-face communication abilities have deteriorated owing to information-communication technology applications in their daily life. therefore, lecturers should take note of students’ need for guidance and role-modelling in developing communication skills. the value of effective communication in health sciences education cannot be overestimated, as future healthcare professionals must be equipped to effectively interact with patients, colleagues, families and community. the importance of developing and updating clinical communication skills training table 6. differences between students’ and lecturers’ perceptions regarding aspects of professional communication behaviour of generation y students students lecturers respondents agree* respondents agree* statement n n (%) n n (%) p-value (95% ci) generation y students … are better at communicating with technology than with personal interaction 613 86 (14.0) 68 56 (82.4) <0.0001 (58.9 77.8) … prefer text messaging to face-to-face contact 612 91 (14.9) 66 49 (74.2) <0.0001 (48.5 70.3) … find it difficult to communicate with older generations 613 247 (40.3) 68 48 (70.6) <0.0001 (18.8 41.8) … think older generations don’t understand how to communicate with them 613 261 (42.6) 69 57 (83.8) <0.0001 (31.7 50.8) … have a casual approach that may appear to lack professionalism 614 234 (38.1) 69 62 (89.9) <0.0001 (43.7 59.8) … often have superficial online relationships 612 562 (91.8) 63 50 (79.4) =0.0012 (2.2 22.7) … can maintain close personal relationships 607 575 (94.7) 66 44 (66.7) <0.0001 (16.6 39.6) … are good communicators (verbal/non-verbal) 611 550 (90.0) 68 29 (42.6) <0.0001 (35.4 59.4) ci = confidence interval. *includes the categories ‘strongly agree’ and ‘agree’ on the questionnaire likert scale. research 16 may 2014, vol. 6, no. 1 ajhpe is well documented.[28] however, generation y students may be prejudiced against training in intergenerational and interpersonal communication skills due to their perceived superior communication proficiency. a limitation of the study is the self-reported data and that students may have felt a compulsion to participate, as the questionnaires were administered during an academic contact session. the anonymous and voluntary nature of their participation was explicitly mentioned, both in the prior briefing and the questionnaire, to eliminate such bias. secondly, the study may not represent students in other health sciences faculties in south africa. while a relatively large cohort of students (n=616) and lecturers (n=71) were included in the study, the number of participants could be expanded to include data from other health sciences faculties. the small number of lecturers compared with the number of students has an impact on the significance of differences between the groups. finally, qualitative exploration of the quantitative findings reported in this publication may yield greater in-depth insight, triangulate the findings (increase validity) and contextualise the knowledge gained. conclusion when considering the design and development of an educational framework, it is imperative that the teaching and learning environment of the 21st century and the needs of generation y students are taken into account. this includes identifying areas of misunderstanding between students and lecturers that lead to conflict and impaired relationships. key focus areas include personal attributes, learning styles and needs, communication skills, and the appropriate educational environment for this generational cohort. this study provided comprehensive data revealing shared perceptions and distinct differences between generation y students and lecturers that indicate possible misperceptions or potential unrecognised needs that should be examined further to contribute to progress in health sciences education. acknowledgements. the authors would like to acknowledge the undergraduate students and academic staff members who participated in the study; dr daleen struwig, medical writer, for technical and editorial assistance with preparation of the manuscript; and professor vanessa burch, chair of clinical medicine, university of cape town, for conceptual and editorial advice in planning and preparing the manuscript. declaration of interest. partial funding for this study was obtained from a postgraduate bursary from the research committee, school of medicine, faculty of health sciences, ufs. references 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[http://dx.doi.org/10.1097/acm.0b013e31825ccbb4] research http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.3928/01484834-20090716-08] http://dx.doi.org/10.5580/26e7] http://net.educause.edu/ir/library/pdf/erm0342.pdf http://dx.doi.org/10.1080/01421590601176380] http://dx.doi.org/10.1097/acm.0b013e3181acf408] http://dx.doi.org/10.1097/acm.0b013e3181acf408] http://dx.doi.org/10.1111/j.1467-8535.2007.00793.x] http://dx.doi.org/10.1080/01421590701798737] http://dx.doi.org/10.1097/00006223-200701000-00007] http://dx.doi.org/10.1002/tl.8006] http://www.uj.ac.za/en/research/statkon/documents/statkon%20questionaire!20design.pdf http://www.ufs.ac.za/dl/userfiles/documents/00000/335_eng http://dx.doi.org/10.1177/0018726708094863] http://dx.doi.org/10.1016/s0001-2092 http://www http://dx.doi.org/10.1097/00001888-200506000-00003] http://dx.doi.org/10.1111/j.1553-2712.2009.00601.x] http://dx.doi.org/10.1111/j.1553-2712.2010.00985.x] http://net.educause.edu/ir/library/pdf/erm0051.pdf http://net http://dx.doi.org/10.1007/s11412-009-9066-8] http://dx.doi.org/10.7899/1042-5055-22.1.23] http://dx.doi.org/10.1097/acm.0b013e31825ccbb4] article may 2013, vol. 5, no. 1 ajhpe 14 context and setting. academics face difficulties when trying to include public health in the medical curriculum. the first hurdle is an already overloaded curriculum and the second the marginal interest in the healthy on the part of those who are mainly concerned with the ill. one overlooked potential opportunity for inclusion in the curriculum is the elective and, in particular, the self-constructed elective of third-year medical students at the university of pretoria. why the idea was necessary. not only does public health have to compete with the powerful clinical interests among students, but students are also not in a position to identify opportunities in the community that could offer meaningful learning opportunities for an elective in public health. what was done. an action research study design used an online survey to explore the factors that students take into account when constructing an elective experience. these factors determined the final design of a public health elective which was subsequently advertised to third-year medical students at the university of pretoria as a possible option. results and impact. disappointingly, no student enrolled for the elective. subsequent investigation of students’ actual choices resulted in a deeper understanding of students’ unvoiced needs. it would appear that a successful public health elective needs to be like a mini-skirt − long enough to cover the subject, but short enough to hold interest. academics considering innovations in public health could benefit from this complexity in design. ajhpe 2013;5(1):14-18. doi:10.7196/ajhpe.196 the bottom line: tailoring a public health elective to students’ needs j e wolvaardt,1 bcur, mph, pgche; v burch,2 mb bch, mmed, phd, fcp (sa), frcp (london); d c cameron,3 mb chb, mpraxmed, mphil, fcfp (sa); p h du toit,4 ba, hed, ba (hons), bed, med, dti, phd 1 school of health systems and public health, university of pretoria, pretoria, south africa 2 faculty of health sciences, department of medicine, university of cape town, cape town, south africa 3 foundation for professional development, department of family medicine, university of pretoria, pretoria, south africa 4 department of humanities education, university of pretoria, pretoria, south africa corresponding author: j e wolvaardt (liz.wolvaardt@up.ac.za) academics face difficulties when trying to include public health in the medical curriculum. the first hurdle is an already overloaded curriculum and the second the marginal interest in the healthy on the part of those who are mainly concerned with the ill.[1] the general disinterest in public health has been consistent despite the shifts in medical education over the past century from science-based approaches of flexner to problem-based learning and most recently to system-based approaches.[2] one key influence in the system-based approach has been the global consensus on social account ability of medical schools – a document that holds vital clues for the inclusion of public health in the medical curriculum.[3] public health and social accountability the social accountability of medical schools is defined as ‘the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation they have a mandate to serve’.[4] the characteristic of social accountability that considers the priority health concerns of the community as the departure point for education, research and service is well aligned with the values and scope of public health (or population health). a population health perspective encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of culture, health status, and health needs of the populations of which that patient is a member.[5] the public health values of relevance, quality, cost-effectiveness and equity of health care are the very same values that underpin social accountability.[6] with a gini co-efficient of 0.57 (2010), south africa is currently one of the most inequitable countries.[7] this inequity extends to the health system, with the majority of resources being utilised by the minority of the population.[8] in a country such as south africa where a key value of public health – equity – is under pressure, the need to be socially accountable is especially acute. public health in the medical curriculum at the up the inclusion of public health in the medical curriculum at the university of pretoria (up) is conceptualised as a golden thread and is included over the duration of the programme. the school of health systems and public health (shsph) is responsible for inclusion of public health as a prominent curriculum theme as required by the health professions council of south africa’s regulations that guide the education of medical students.[9] because the medical curriculum is characterised by a focus on individual health, opportunities to include public health topics are limited. space in the curriculum is not the only limitation – the shsph is a postgraduate school with limited academic staff burdened by other academic responsibilities. currently, medical students at up have an elective module at the end of their third year. traditionally, less than a handful – and none since 2007 – do a public health elective. one reason for the low numbers is that students have to conceptualise and organise what they want to do (elective) versus the approach where students can choose from a list of pre-organised activities (selective). articlearticle 15 may 2013, vol. 5, no. 1 ajhpe students cannot choose what they do not know. because much of their experience has either been classroom or hospital based, they do not have the social capital to identify community-based organisations that could provide meaningful, rich opportunities for learning. community-based organisations provide highly contextualised environments and community intimacy as well as a range of activities that address the socio-economic determinants of health. the activities of these civil society structures hold the opportunity to advance students’ ability to construct meaning of the structure and function of the health system and emphasise the services that their future patients can be referred to in this sector. communitybased electives provide a unique opportunity to promote professional understanding of their ‘social and public purpose’ as doctors.[10] in addition, public health electives are a way of encouraging interest in public health in general and in careers in public health in particular,[11,12] as well as promoting social accountability.[13] electives as a strategy to include public health the purpose of electives in medicine is primarily to enhance emerging clinical skills and related attributes and virtues in different environments, including community settings.[14] in the literature, public health electives are strongly aligned to global or international health electives with a focus on student preparation, risks and effect on the hosting institution.[15-20] irrespective of foreign or local settings, public health electives hold the potential to construct meaning about health policies and services.[14] this engagement with the health system requires students to face the psycho-social issues that affect health within the community, especially health behaviours, health risks, public health issues and social, cultural and environmental factors.[14] a community-based elective promotes constructing meaning of different value systems and socio-cultural models.[14] well-designed electives also promote generic attributes such as self-regulated learning and critical reflection as part of professional development.[14] to overcome the lack of space in the curriculum and the theoretical overload, a strategy of developing a community-based public health elective was explored. objective this study explored the characteristics of community-based public health electives that would meet the needs of third-year medical students at up. methods this descriptive cross-sectional study formed part of an overarching action research study design. a 13-item questionnaire with eight close-ended likert scale questions and five open-ended questions was designed from the literature. the questionnaire was only available in english. ethical clearance was granted by up’s health sciences ethics committee (73/2011). a pilot study was done with a group of fifth-year medical students and valuable feedback was obtained with regard to both the wording of the questionnaire and the composition of the elective. third-year medical students were made aware of the project via a fiveminute briefing that formed part of the routine briefing by the education office that co-ordinates the elective. the modified survey was created with the online survey monkey software and launched by sending a class-wide e-mail with a hyperlink to the survey. a total of 241 e-mails were sent. eleven e-mails bounced, of which six were resolved and resent. when it became clear that there may have been a misconception, as students thought only those who were interested should respond to the e-mail, a second classwide e-mail was sent. the wording of the second e-mail was more explicit and an sms message was sent to the class representative to ask students to read their e-mail. an attempt was made to include all the students by also putting up a poster outside the lecture hall. data obtained from the online survey were exported to microsoft office excel 2007 for analysis. qualitative thematic analysis of the open-ended responses was done by hand using inductive coding. the electronic data were stored in a password-protected file on the researcher’s computer during analysis. the initial plan of designing a range of public health electives – each with a focus on one aspect, such as health promotion – was revised based on the feedback from the pilot group. it was clear that students would rather engage in a range of activities, and therefore a community-setting with wide-ranging public health opportunities was needed. a non-governmental organisation (ngo) active in the inner-city of pretoria was identified. this ngo works with inner-city inhabitants, including the most vulnerable (street children, the homeless, the abused) and ostracised (foreigners, drug users and commercial sex workers), and services include running a clinic, crèches, etc. the choice of this ngo would allow for exploration of health systems while additional activities such as visiting the zoo for a session on zoonosis and working on mobile hiv counselling and testing units were also incorporated to provide students with a broader view of public health. a poster campaign was designed using wordplay and the image of a popular movie. the ‘first class in public health: the inner city elective’ poster was pasted on the dedicated notice boards of the third-year medical students. the poster was augmented by a breakdown of the envisaged activities and a sign-up sheet with contact numbers of the elective coordinator. setting the study setting was at the faculty of health sciences, up. subjects the study population consisted of third-year medical students at up in 2011. results as many as 113/236 (47.9%) students accessed the online survey. of these, 106 completed the survey (93.8%). interest in an elective with a public health theme real interest was shown in a hands-on public health elective as 28.1% (n=25) respondents who were interested, with another 49.4% (n=44) reporting that they might be interested but needed more detail. twenty respondents (22.5%) had no interest. factors that influence the choice of elective proximity to home (n=38; 35.8%) was not a particularly important factor in elective choice, in stark contrast with the 62.3% (n=66) who wanted to deepen their learning (fig. 1). article may 2013, vol. 5, no. 1 ajhpe 16 one factor that has to be kept in mind when designing an elective is the financial burden that a community-setting elective could pose for students in terms of travel and accommodation expenses – another benefit of using an inner-city location. twenty-two (24.7%) respondents thought an amount less than r500 would be reasonable for the one-month period. a similar proportion (n=27; 30.3%) thought that an amount larger than r1 000 was reasonable, while 46.1% (n=41) opted for the middle range of r500 r1 000. other factors that influence their choice respondents were invited to share any other factor(s) that they personally consider important when choosing an elective. three themes emerged from the data: institutional factors that support learning; the learning setting; and the opportunity to practise. respondents were vocal about the need for institutional factors that support learning: ‘it must be well organised, and the staff at the relevant facility where we will do our elective must be well informed of our presence and reason for being there.’ the learning setting was also important in that ‘i would like to do my elective in a friendly environment where it is conducive to learn and has enough equipment for me to use’. the need to put into practice that which has been learnt was evident: ‘i would like to choose an elective that will allow me to actively participate, as opposed to simply observing various procedures, and ‘somewhere where i will be able to do something and not just told to watch.’ area of interest respondents were invited to give detail of their specific area of interest and among the 68 respondents who provided more detail it was notable that the majority (n=47) named a clinical specialty such as paediatrics and in many cases more than one specialty. eleven respondents were interested in the practical application of theory: ‘anything. the point is that we understand a lot more if we already understand the theory and then experience the clinical aspects of it.’ some were more adventurous: ‘something that is not in the curriculum but is promising in the evolution and improvement of medicine will teach on how to break new ground and to think outside of the box.’ a single respondent identified a need for positive role-modelling as part of professional identity formation: ‘i want to be with a helpful doctor not a person who is going to make me feel awkward and stupid.’ two respondents mentioned public health topics: ‘i want to know the indirect impact of hiv on the living conditions of children heading households in namibia’ and the ‘interaction between the patient and the health care system.’ number of settings variation existed in the opinions of respondents concerning single versus multiple settings (table 1). previous community experience a substantial proportion of respondents (n=40; 44.9%) recorded experience working in a community setting prior to their medical studies and in some cases recorded more than one previous experience. a handful reported exposure via a previous degree or via school: ‘went on community based camps with my school where we helped out in rural schools, old age homes and homes for disabled people.’ what was prominent was the early exposure for their studies through voluntary work in a wide range of clinical settings or in social projects/ outreach: • ‘i volunteered at an hct clinic during holidays.’ • ‘i volunteered in the accident and emergency unit at [hospital] during high-school.’ • ‘girl child project in [country] where we assisted in orphanages.’ • ‘i was involved in a youth development programme (our own initiative) back home.’ predictably, respondents were generally positive that they had a good understanding of the health-related needs and problems facing the community in which they live (fig. 2). discussion the initial interest in a public health elective among the respondents was encouraging. important information for the design of the elective was that although there was no clear preference for an elective that was close to home (35.8%), there were limits in that the associated financial cost was an important factor with the majority of students (70.7%), indicating table 1. percentage of respondents’ elective workplace choices statement yes no does not matter number of responses i would prefer to work in only one place during the elective 32.1 (n=25) 30.8 (n=24) 37.2 (n=29) 78 i would prefer to work in more than one place during the elective 54.1 (n=40) 14.9 (n=11) 31.1 (n=23) 74 70 60 50 40 30 20 10 0 the place i go to must be on a public transport route the place i go to must be close to home i want to learn more about something that is already in the curriculum i want to learn more about something that is not in the curriculum fig. 1. importance of location and content when choosing an elective (number of responses). articlearticle 17 may 2013, vol. 5, no. 1 ajhpe a preference for less than r1 000 for the month. the decision to use only one setting was strengthened by respondents’ weak responses that did not show any clear preference regarding working in only one place during the elective. this finding suggested that the number of settings was less important than the content. this provisional conclusion was overthrown by the actual final choices of students. similarly, the marginal majority (54.1%) who, in response to the converse question regarding preferences of number of settings, stated a preference for working in more than one place, held an unexpected meaning that was not clear at the time. respondents preferred electives whose content offered an opportunity to deepen their learning of what is already in their curriculum (62.3%). this preference is especially problematic for designing public health electives, as the subject is not prominent in the curriculum and unlikely to be uppermost in students’ thoughts. the preference for electives with clinical content was supported by the responses to the question what they were currently considering as a choice. almost 70% (47/68) of respondents listed a clinical discipline. this pattern of clinical preference is to be expected. it can also be found elsewhere, with the majority (54%) of american medical students delivering medical care to underserved populations as a prevention elective.[21] these findings strengthened the argument for a pre-designed public health elective. the responses to what other factors are considered important in their choice of elective the theme of ‘institutional factors that support learning’ unwittingly echoed the findings of a study that reported the pivotal link between satisfaction with the learning environment and burnout of medical students.[22] the implication for elective design was clear – avoiding haphazard arrangements for learning would be vital. ostensibly many students had already had previous community experience beyond the scope of their medical studies and the majority (58%) agreed that they understood the health-related needs of the communities in which they live. clearly, any public health elective would have to challenge students to revise their view of their competence regarding public health. enrolment in the elective ultimately, no student enrolled for the local public health elective (one student chose a public health topic but did this in mauritius). upon review it became clear that one significant barrier was the design that followed the pattern of a one-month period. although the university documents refer to a four-week period for students to learn about one area of medicine, this is not enforced. a review was done of the 230 submitted forms and it was found that 77 (33.5%) students did not want to be hemmed in by the stated restrictions and divided their electives into two, three and even four different activities. in contrast to the online survey where approximately 70% of students listed a clinical choice, the actual final choices revealed that 97.5% of choices were clinical. emergency medicine was the single biggest choice (57 students). disciplines with multiple sub-specialties such as surgery had 75 students and internal medicine (and sub-specialties) had 74 students. general practice was reasonably well represented (38 students). conclusion the respondents’ view that they would like to work in more than one setting was misunderstood as meaning within multiple settings of public health. the analysis of actual choices revealed a different meaning – a need to work across disciplines. the sharp decline in interest in a public health elective from when the online study was done to the actual choices made is strongly suggestive that the one-month design was a barrier. it is now clear that public health needs to tuck into a space among the clinical electives and it will be necessary not only to design an elective that meets the needs of students (distance, price, hands-on, well-planned and well-executed) but will also pose less of a commitment of time. as a result of this study the design of the 2012 public health elective has undergone significant changes and a one-week elective with a one-week optional extension is planned. this attempt at bringing about change by introducing an innovative strategy to promote public health might have some significance for other academics who are contemplating the call in the lancet for the ‘expansion ... into primary care settings and communities, strengthened through external collaboration as part of more responsive and dynamic profession education systems’.[23] this research suggests that meeting the call for a systems-based approach requires health educators to simultaneously understand what students might consider a good fit. acknowledgement. this project forms part of the requirement of the southern african faimer regional institute fellowship programme. references 1. woodward a. public health has no place in undergraduate medical education. j public health med 1994;16(4):389-392. 2. maeshiro r, johnson i, koo d, et al. medical education for a healthier population: reflections on the flexner report from a public health perspective. acad med 2010;85(2):211-219. [http://dx.doi.org/10.1097/acm.0b013e3181c885d8] 3. global consensus for social accountability of medical schools, 2010. http://my.ibpinitiative.org/community. aspx?c=c5357538-ce2a-4627-94f6-6110addbe047 (accessed 14 february 2011). 4. boelen c, heck je. defining and measuring the social accountability of medical schools. geneva: world health organization,1995:1-32. 5. riegelman rk, garr dr. evidence-based public health education as preparation for medical school. acad med 2008;83:321-326. [http://dx.doi.org/10.1097/acm.0b013e318166abe7] 6. woollard rf. caring for a common future: medical schools’ social accountability. med educ 2006;40:301-313. [http://dx.doi.org/10.1111/j.1365-2929.2006.02416.x] 7. bosch a, rossouw r, claassens t, du plessis b. a second look at measuring inequality in south africa: a modified gini coefficient. school of development studies, university of kwazulu natal, 2010. contract no.: working paper no. 58. 50 45 40 35 30 25 20 15 10 5 0 strongly disagree disagree somewhat uncertain agree somewhat strongly agree fig. 2. responses regarding good understanding of community health-related needs and problems. article may 2013, vol. 5, no. 1 ajhpe 18 8. coovadia h, jewkes r, barron p, sanders d, mcintyre d. the health and health system of south africa: historical roots of current public health challenges. lancet south africa series 2009;374:817-834. [http://dx.doi. org/10.1016/s0140-6736(09)60951-x] 9. department of health. regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine. government notice no. r.139. pretoria: department of health, 2009:1-14. 10. elam cl, sauer mj, stratton td, skelton j, crocker d, musick dw. service learning in the medical curriculum: developing and evaluating an elective experience. teach learn med 2003;15(3):194-203. 11. rosenberg sn. a survey of physicians who studied public health during medical school. am j prev med 1998;14:184-188. [http://dx.doi.org/10.1016/s0749-3797(97)00065-2] 12. jeffrey j, dumont ra, kim gy, kuo t. effects of international health electives on medical student learning and career choice: results of a systematic literature review. fam med 2011;43(1):21-28. 13. carney jk, hackett r. community-academic partnerships: a ‘community-first’ model to teach public health. education for health 2008;21(1):1-6. 14. murdoch-eaton d, green a. the contribution and challenges of electives in the development of social accountability in medical students. medical teacher 2011;33:643-648.[http://dx.doi.org/10.3109/014215 9x.2011.590252] 15. holmes d, zayas le, koyfman a. student objectives and learning experiences in a global health elective. j commun health 2012;37:927-934. [http://dx.doi.org/10.1007/s10900-012-9547-y] 16. anderson kc, slatnik ma, pereira i, cheung e, xu k, brewer tf. are we there yet? preparing canadian medical students for global health electives. acad med 2012;87(2):206-209. [http://dx.doi.org/10.1097/ acm.0b013e31823e23d4] 17. imperato pj. a third world international health elective for us medical students: the 25-year experience of the state university of new york, downstate medical center. j commun health 2004;29(5):337-373. 18. wendland cl. moral maps and medical imaginaries: clinical tourism at malawi’s college of medicine. am anthropol 2012;114(1):108-122. [http://dx.doi.org/10.1111/j.1548-1433.2011.01400.x] 19. sharafeldin e, soonawala d, vandenbroucke jp, hack e, visser lg. health risks encountered by dutch medical students during an elective in the tropics and the quality and comprehensiveness of preand post-travel care. bmc med educ 2010;10(89):1-6. [http://dx.doi.org/10.1186/1472-6920-10-89] 20. hardcastle t. medical electives in south africa. s afr med j 2010;100(4):194. 21. eckhert nl, bennett nm, grande d, dandoy s, eckhert nl. teaching prevention through electives. acad med 2000;75(7):s85-9. [http://dx.doi.org/10.1097/00001888-200007001-00013] 22. dyrbye ln, thomas mr, harper w, et al. the learning environment and medical student burnout: a multicentre study. med educ 2009;43:274-282. [http://dx.doi.org/10.1111/j.1365-2923.2008.03282.x] 23. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] article 68 november 2013, vol. 5, no. 2 ajhpe career and practice intentions of health science students at three south african health science faculties c naidu,1 msocsci; j irlam,1 bsc hons, mphil; p n diab,2 mb chb, mfammed 1 primary health care directorate, faculty of health sciences, university of cape town, south africa 2 department of rural health, university of kwazulu-natal, durban, south africa corresponding author: c naidu (claudia.naidu@uct.ac za) background. the distribution and accessibility of healthcare professionals as well as the quality of healthcare services are significantly affected by the career choices of medical and other health science graduates. objective. while much has been reported on the career intentions of medical students, little is known about those of their counterparts in the health sciences. this study describes the career plans of non-medical health science students at three south african health science faculties, and identifies some key motivating factors. methods. a self-administered survey of firstand final-year health science students was conducted at the health science faculties of the universities of cape town, kwazulu-natal and limpopo. all data were entered into epidata software and exported for analysis using ibm spss statistics 19.0. results and discussion. the overall response rate was 47% (n=816). over half of all respondents (57%, n=467) intended to work after completing their undergraduate studies, 38% (n=177) of these in a rural area. the most popular choices were private hospitals (58%, n=273), tertiary hospitals (53%, n=249) and private practices (51%, n=249). thirty-two per cent (n=258) of respondents intended to further their studies. just over half of all respondents intended to work in another country (51%, n=418), primarily motivated by career development, financial reasons and job opportunities. conclusion. the findings demonstrate that health science students, similar to medical students, are influenced by a multitude of factors in making career choices. this emphasises the relevance to all health science disciplines of national strategies to address the maldistribution of healthcare professionals. ajhpe 2013;5(2):68-71. doi:10.7196/ajhpe.202 the challenges facing the south african health system have been well documented, and the supply and distribution of healthcare professionals is recognised as a strategic priority in developing the health system to ensure equity and improvement of health outcomes.[1-3] rural communities are the worst off, with some areas having 14 times fewer doctors per 100 000 people than the national average.[4] many urban communities are also significantly underserved, as only 30% of doctors work in the public sector to serve 85% of the population.[5] health has been defined by the world health organization (who) as ‘a state of physical, mental and social wellbeing and not merely the absence of disease’,[6] which emphasises that a health system following a total healthcare approach is holistic and multi-disciplinary. access to a range of healthcare professionals is therefore a key component of the healthcare delivery system, and these professionals play a particularly significant role in rural and underserved areas. healthcare workforce programmes therefore need to address the broader spectrum of healthcare professionals, as occupational therapists, physiotherapists, speechlanguage pathologists, dieticians and radiographers have been recognised as scarce-skills professions alongside medical doctors, dentists and pharmacists. the career choices of all health science students affect the future availability and distribution of healthcare professionals, as well as the quality of service that the healthcare system is able to deliver.[7] various factors have been identified that influence postgraduate primary care specialties and the recruitment and retention of healthcare professionals in rural and underserved communities.[8,9] these factors include place of origin, exposure to rural and underserved communities, curriculum and training programmes and a multitude of financial, professional and lifestyle issues. [10] information about the career choices and practice plans of young health science graduates is therefore necessary to identify and plan strategies to increase the quantity and quality of human resources and to adequately meet the needs of the most vulnerable communities. objectives while many studies have investigated the future aspirations and career intentions of medical students, similar research on students in the other healthcare disciplines remains scarce. this paper reports on a particular aspect of a larger study undertaken as a collaboration between three south african medical schools to investigate the career aspirations of firstand final-year health science students. it was informed by a qualitative phase that explored the career aspirations of rural health science students.[11] other papers resulting from this study are pending or have been accepted for publication. this paper provides insight into the career choices and future practice plans of health science students at three health science faculties, and identifies some key motivating factors. methods during august october 2011, a cross-sectional, anonymous, selfadministered survey was conducted among firstand final-year health science students at three south african health science faculties − the university of cape town (uct), the university of kwazulu-natal (ukzn) and the university of limpopo (ul). the questionnaire was mostly closeresearch mailto:claudia.naidu@uct.acza november 2013, vol. 5, no. 2 ajhpe 69 research ended, with some open-ended questions for clarification and explanation. it was distributed to students at times appropriate to their schedule, either to the entire class at one time or to groups of the class when they were on campus. participation in the study was voluntary, and the anonymity and confidentiality of respondents were assured. data were collected on demographic characteristics, educational backgrounds, career intentions and practice decisions of respondents. they were asked to identify particular factors which influence their career and practice choices. all data were entered into epidata software and exported for analysis using ibm spss statistics 19.0. significance testing was performed by means of chi-square tests of association. open-ended responses were collated and coded into broad categories. ethical approval for the study was granted by the ethics committees of all three participating faculties (hrec 353/2011; hss/0966/09; and mrec/m/63/2010:ir). results this manuscript primarily reports on the survey results of the non-medical health science students, hereafter referred to as health science students, although comparisons are made with their medical counterparts, where relevant. the overall response rate for health science students was 47% (n=816), with minimal variation by institution; 163 of uct respondents (49%), 277 of ukzn respondents (42%) and 376 of ul respondents (50%) completed the questionnaire. demographic data of all 816 health science respondents, over 97% (n=789) were south african citizens, the mean age for firstand final-year students was 19 and 22 years, respectively, and over two-thirds were female (70%, n=574). fifty-eight per cent (n=472) were black, 19% (n=153) indian, 16% (n=129) white and 6% (n=49) coloured. these racial proportions varied across institutions, with ul having a significantly higher proportion of black respondents (96%, n=359), ukzn a significantly higher proportion of indian respondents (49%, n=135) and uct a significantly higher proportion of white respondents (48%, n=78). english was the predominant language for respondents at uct (72%, n=117) and ukzn (68%, n=188), while sepedi (30%, n=112), xitsonga (14%, n=42), and tshivenda (12%, n=44) were the most common first languages for respondents at ul. sixty-one per cent (n=496) of respondents classified their homes as being situated in an urban area, and 38% (n=311) in a rural area. across institutions, these results varied significantly as 63% (n=237) of respondents from ul self-reported to be of rural origin, compared with 19% (n=59) of ukzn, and only 13% (n=21) of uct (table 1). this was expected as limpopo province has the highest rural profile of all provinces in south africa. thirty-five per cent (n=180) of first-year students and 45% (n=126) of final-year respondents were of rural origin. both uct and ukzn had higher proportions of students of rural origin in their first year (17% and 21%, respectively) compared with those in their final year (9% and 7%, respectively). thirty-one per cent (n=252) specified their homes as being in a city, 26% (n=213) in a village, 19% (n=158) in a township and 15% (n=123) in smaller towns. this differed greatly between institutions; for example only 4% (n=7) of uct respondents’ homes were in a village compared with 48% (n=180) of ul respondents. a total of 66% (n=537) of respondents had attended high school in an urban area, and the remaining 33% (n=267) in a rural area (1% of respondents did not answer this question, n=12). table 1. origin, home and school setting of respondents at three south african health science faculties (n=816) university students surveyed (n) rural-origin students (%) ruralbased school (%) home setting (%) city township village small town farm university of kwazulunatal 277 19 14 44 11 9 25 10 university of limpopo 376 63 56 5 31 48 9 2 university of cape town 163 13 12 67 9 4 14 6 total 816 38 33 31 19 26 15 9 table 2. motivations which most influenced students’ choice of institution in which to work, by medical school (%) (n=467) motivation university of limpopo university of kwazulunatal university of cape town total want to serve community 51 49 50 50 financial reasons 64 61 46 59 learning opportunities 50 54 59 53 career development 55 57 58 56 opportunities to work independently 37 34 50 39 exposure to modern technology 28 23 18 24 supervision 17 15 10 14 70 november 2013, vol. 5, no. 2 ajhpe research educational data respondents were drawn from a range of disciplines in the health sciences, three-quarters of whom were completing their undergraduate degree in either pharmacy (21%, n=168), physiotherapy (19%, n=155), occupational therapy (19%, n=156), sports sciences (8%, n=65) or speech-language pathology (7%, n=53). sixty-four per cent (n=522) of respondents were in their first year of study, and the remaining in their final year (34%, n=281). these ratios were particularly influenced by the composition of ukzn respondents, where 88% (n=244) of respondents were first-year students, compared with approximately half of the respondents at uct (52%, n=85) and ul (52%, n=193). career plans work and study intentions over half of all respondents (57%, n=467) intended to work after completing their undergraduate studies, while another 32% (n=258) intended to further their studies. the remaining students were either uncertain about their future plans (3%, n=25) or answered this question incorrectly or not at all (8%, n=52). the preference for working over studying was consistent across all institutions. of the 258 health science student respondents who wished to further their studies, most chose medicine (50%, n=134), physiotherapy (18%, n=46), dentistry (17%, n=45), pharmacy (16%, n=42), and commerce (10%, n=25). choice of area and institutions in which to work thirty-eight per cent (n=177) of those intending to work after graduation would like to work in a rural area, while 56% (n=262) would prefer working in an urban area. respondents of rural origin were significantly more likely to prefer working in a rural area than their urban-origin counterparts (66% v. 22%, p<0.01). no difference was found between the preferences for rural practice between the first-year respondents and those in their final year (38% v. 39%, p=0.1). a substantially greater proportion of health science students from ul (49%, n=83) preferred to work in a rural area compared with their counterparts at ukzn (31%, n=60) and uct (33%, n=33). medical students were more likely to prefer working in a rural area than health science students (52% v. 38%, p<0.05). respondents were also asked to identify which institutions they preferred work in. the most popular choices were private hospitals (58%, n=273), tertiary hospitals (53%, n=249), private practice (51%, n=236) and district hospitals (51%, n=236). this was in contrast to medical students who indicated highest preferences for working in district hospitals (63%, n=193) and much less preference for private hospitals and private practice (36% and 32%, respectively). respondents’ choice of institution (table 2) was mostly motivated by financial reasons (59%, n=274), career development (56%, n=262), learning opportunities (53%, n=248), and wanting to serve the community (50%, n=274). in contrast, medical students were found to be most motivated by wanting to serve their community (65%, n=197). respondents at ukzn and ul were more highly motivated by financial reasons (61% and 64%, respectively) than respondents from uct (46%). intentions to work outside south africa just over half of all respondents intended to work in another country for some time (51%, n=418); however, respondents at ukzn (51%, n=141) and ul (45%, n=168) were less likely to want to go overseas than their counterparts at uct (66%, n=108, p<0.10). just under two-thirds of these respondents intended to work in another country for more than three years (63%, n=264), and only 14% (n=57) intended to work for a year or less. those wanting to work in another country were more likely to be of urban than rural origin (55% v. 45%, p<0.01), and medical students were found to be less likely to want to work in another country than their health science counterparts (43% v. 51%, p<0.01) – a pattern consistent across all the institutions. female respondents were less likely than males to want to work in another country, although this difference was significant but not substantial (49% v. 52%, p=0.05); and the slight preference which final-year students had for wanting to work overseas over respondents in their first year of study was not found to be statistically significant (49% v. 56%). this was true across all institutions with the exception of uct, where 74% of final-year students intended to work overseas compared with 59% of first-year students (p=0.05). career development was the most important motivation for respondents wanting to work in another country (51%, n=212), followed by financial reasons (48%, n=201) and job opportunities (43%, n=181). the most popular destinations included the uk (33%, n=138), usa (17%, n=72), australia (12%, n=49) and european countries (9%, n=36). community service preferences the most significant factors in respondents’ choice of location for their community service were: to gain good experience (42%, n=323), to be table 3. motivations for choice of location for community service (%) (n=771) (missing: n=31) motivations: community service university of limpopo university of kwazulunatal university of cape town total closer to home 39 42 44 41 good supervision 14 9 38 17 adequate patient exposure 19 16 33 25 to gain good experience 32 33 80 42 to move to a different province 6 5 28 10 to stay in same province 7 8 18 10 hospital recommended by a friend/colleague 3 3 23 7 to experience work in a rural area 16 12 31 17 opportunity to continue lifestyle pursuits 10 10 30 14 november 2013, vol. 5, no. 2 ajhpe 71 research closer to home (41%, n=314), and to obtain adequate patient exposure (25%, n=192) (table 3). discussion this research supports the findings of similar reports on career intentions of south african medical graduates.[7,9,12] the demographic analyses across institutions indicate that although there were more rural-origin students in total (38%) than in an earlier study (26%), which included medical, dental, physiotherapy, and occupational therapy students across all nine health science faculties,[13] the proportion is significantly inflated by the high rural composition (63%) from ul. the general predominance of urban-origin students, particularly in the ukzn and uct cohorts, is concerning in light of growing international recommendations that students of rural origin should be granted preferential admittance.[8,14] however, the significantly higher proportion of rural-origin first-year compared with final-year students at ukzn and uct may be indicative of this increasing trend. on the other hand, it may be indicative of a higher number of rural-origin students who drop out of courses, as it is well acknowledged that students from rural areas face a range of challenges, have special needs, and are at highest risk of academic failure.[15] in contrast to studies involving medical students, there was no significant difference between preferences of firstand final-year students for working in rural areas.[7] as with medical students, however, the results show that rural preference was strongest for respondents of rural origin, which is consistent with evidence that rural background is the single factor most strongly associated with rural practice.[8,10] the findings indicate that any institutional admission-selection strategy designed to increase the intake of students of rural origin needs to be implemented across all health science disciplines and not be limited to medical students. the high numbers of respondents who intended to work in another country for a period of three years or longer are consistent with predictions that emigration rates will increase; over half of healthcare professionals have expressed such an intention.[3] plans to work in another country appear to be most strongly influenced by geographical origin, an association consistent with findings by de vries et al.[12] in their study on career plans of final-year medical students across the eight south african medical schools. the factors that mostly motivate health sciences students’ intention include career development opportunities, financial interests, and job opportunities, as reported elsewhere.[3,16] health science respondents were generally found to be less likely to work in a rural area, more likely to want to work in another country, and less motivated to serve their communities than their medical counterparts. this finding is significant as much attention is paid to the workforce shortages and migration behaviour of medical graduates, whereas non-medical healthcare professionals are an equally scarce but a much needed resource. their career choices significantly impact on the delivery of healthcare and the overall health of the nation. respondents were motivated by several different factors in their choice of workplace/institution and location for community service. which factor or combination of factors are the most influential in making these choices is difficult to interpret from this cross-sectional survey of career intentions, which may not be a true reflection of respondents’ future choices and behaviour. this highlights the need for longitudinal tracking of medical students and graduates to determine the evolution of students’ career decisions. the survey design was relatively easy to administer, and the use of closedand open-ended questions provided both quantitative and limited qualitative data. the overall response rate was consistent across the faculties, although a significantly higher response from firstyear ukzn students may undermine the findings of the study population of all first-year students. conclusion this study describes the career intentions of health science students of both rural and urban origin in their first and final years of study in three of the nine faculties of health sciences in south africa. the findings support previous research on career and practice decisions of medical students and graduates and show that, similar to medical students, a multitude of factors influence health science students’ career choices. compared with medical students, health science students appear less interested in serving their own and/or rural communities, and are more interested in working in the private sector and in other countries. more research is needed to understand these preferences and to identify educational interventions that encourage healthcare profession students to enter and remain in general practice and in areas of need. it is recommended that health science institutions across south africa implement multi-professional tracking projects to obtain systematic longterm data on their students and graduates, the education and training programme, and the overall outcome of the health professions education programme. understanding how the educational programmes, training environments and learning experiences impact on students’ attitudes, values and practice behaviour is critical to producing healthcare professionals who are committed to serving the needs of our society. acknowledgements. this research was funded by the collaboration for health equity through education and research (cheer). the authors would like to thank the students for their participation in this research, and all individuals involved in data collection and data entry across the participating universities. references 1. coovadia h, jewkes r, barron p, et al. the health and health system in south africa: historical roots of current public health challenges. health in south africa 1. lancet 2009:374:817-834. [http://dx.doi.org/10.1016%2fs01406736%2809%2960951-x] 2. department of health, south africa. human resources for health, south africa hrh strategy for the health sector: 2012/13 2016/17. pretoria: department of health, october 2011. http://www.doh.gov.za/docs/ stratdocs/2011/hrh_strategy.pdf (accessed 22 august 2012). 3. george g, quinlan t, reardon c. human resources for health: a needs and gaps analysis of hrh in south africa. health economics and hiv&aids research division (heard). university of kwa-zulu natal: durban, south africa, 2009. 4. mills ej, schabas wa, volmink j, et al. should active recruitment of health workers from sub-saharan africa be viewed as a crime. lancet 2008:371:685-688. [http://dx.doi.org/10.1016%2fs0140-6736%2808%2960308-6] 5. rural health advocacy project and partners. the who global policy recommendations on increasing access to health workers in remote and rural areas through improved recruitment and retention: the south african context. discussion document. johannesburg: rhap, 2011. 6. world health organization. constitution of the world health organization  -  basic documents. 45th ed. supplement. geneva:who, 2006. www.who.int/governance/eb/who_constitution_en.pdf (accessed 23 aug 2012 ) 7. dambisya ym. career intentions of unitra medical students and their perceptions about the future. educ for health 2003;16(3):286-297. [http://dx.doi.org/10.1080%2f13576280310001607442] 8. wilson nw, couper id, de vries e, reid s, fish t, marais bj. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural and remote health 2009;9:1060. 9. couper id, hugo jfm, conradie h, mfenyana k, members of the collaboration for health equity through education and research. influences on the choice of healthcare professional to practise in rural areas. s afr med j 2007;97(11):1082-1086. 10. reid s, couper id, volmink, j. educational factors that influence the urban-rural distribution of health professionals in south africa: a case-control study. s afr med j 2011:101(1):29-33. 11. diab pn, flack ps, mabuza lh, reid sj. qualitative exploration of the career aspirations of rural origin health science students in south africa. rural and remote health 2012;12(4):2251. 12. de vries e, irlam j, couper i, kornik s and members of the collaboration for health equity trough education and research. career plans of final year medical students in south africa. s afr med j 2010;100:227-228. 13. tumbo jm, couper id, hugo jfm. rural-origin health science students at south african universities. s afr med j 2009;99(1):54-56. 14. somers gt, strasser r, jolly b. what does it take? the influence of rural upbringing and sense of rural background on medical students’ intention to work in a rural environment. rural and remote health 2007;7:706-716. 15. mcmillan wj, barrie rb. recruiting and retaining rural students: evidence from a faculty of dentistry in south africa. rural and remote health 2012;12:1855-1864. 16. burch v, mckinley d, van wyk j, et al. career intentions of medical students trained in six sub-saharan african universities. educ for health 2011;24(3):614-630. http://dx.doi.org/10.1016%2fs0140-6736%2809%2960951-x] http://dx.doi.org/10.1016%2fs0140-6736%2809%2960951-x] http://www.doh.gov.za/docs/ http://dx.doi.org/10.1016%2fs0140-6736%2808%2960308-6] http://www.who.int/governance/eb/who_constitution_en.pdf http://dx.doi.org/10.1080%2f13576280310001607442] december 2021, vol. 13, no. 4 ajhpe 219 short report the adoption of blended learning (bl) to support higher education has been slowly introduced over the past few decades in the majority of universities in africa and other developing contexts. the covid-19 pandemic has, however, radically revolutionised the manner in which education is delivered. the adoption of online teaching and learning is unprecedented and presents a unique opportunity for the delivery of education in the future. technology has been used to deliver learning material, and to enhance communication and administration to stimulate and promote an effective learning environment.[1] elearning tools have been integrated into the classroom, which has resulted in bl. bl includes activities that involve combining traditional face-to-face (f2f)  and technology-facilitated online interaction between teachers and students.[2] enhanced access to the internet and local area network connections, inclusive of information technology support, has increasingly advanced the application of elearning in some parts of many developing countries. the rapid development and wide application of elearning, online and in-class teaching methods complement each other and are beneficial for students and teachers.[3] from a pedagogical viewpoint the intention of health science education is to prepare students with essential knowledge, skills, strategies and techniques to develop solutions and resolve problems.[1] overall, students demonstrate increased retention rates, better utilisation of content, increased collaboration and engagement, resulting in improvement of knowledge, skills and attitudes.[4] however, online learning tools can be costly and difficult to accept for educators and students who are resistant to change, are apprehensive about new technology and have literacy limitations.[5] other difficulties include insufficient technical/user support, poor network capacity/stability, limited access and infrastructure capacity, inadequate organisation and co-ordination.[5] perceptions and attitudes towards higher education may differ among students of contrasting educational and cultural backgrounds regarding teaching and learning, thus affecting their academic decisions, expectations and performance. several other variables influence students’  attitudes and perceptions towards bl, including but not limited to age, gender, learning styles, prior experience with computers and technology acceptance.[6] many students accessing higher education in the south  african (sa)  context come from underprivileged schools and disadvantaged socioeconomic environments. they have limited or no access to school or community libraries, computers and essential services, such as electricity.[7] similarly, in other african countries, such as ghana[8] and nigeria,[9] poor infrastructure development and connectivity at universities, especially in rural communities, pose significant challenges to online learning. all students may therefore not be familiar with various types of technology and may not have positive perceptions, particularly towards elearning. yet, this method is largely being promoted in higher education institutions. as the university of kwazulu-natal (ukzn)  incorporates bl in forms of online lecture materials and other electronic sources to supplement traditional f2f methods of learning, it is important to understand students’ perceptions and attitudes to bl. background. the covid-19 pandemic has forced higher education institutions to rethink delivery of education. blended learning (bl), particularly online/elearning, has become the life support for continued education. bl is a pedagogical approach that combines online asynchronous and/or synchronous and face-to-face (f2f) interaction between lecturers and students, enabling learning to occur independently of time or place. perceptions and attitudes of students towards bl are important predictors of success. objective. to determine the attitudes and perceptions of audiology and speech-language pathology students towards bl at the university of kwazulunatal (ukzn), durban, south africa. methods. a descriptive survey design with quantitative methods of analysis was used. eighty-six participants completed an online questionnaire through google forms. the tool demonstrated good internal consistency, with a cronbach α score of 0.82. results. most participants agreed that combining traditional and elearning – bl – improves learning skills and enables more student involvement in learning. comparisons between attitudes and year of study yielded a statistically significant association, with senior students having a more positive attitude towards bl than second-year students (p=0.003). attitudes between male and female participants were generally similar; however, females felt that bl helped them to understand lecture material better and to increase interaction (statistically significant; p=0.021). while 93% perceived the online platform, moodle, which is used by ukzn, as being useful, only 51% indicated that it improved efficiency of learning to a great extent. conclusion. despite the challenges around connectivity, computer illiteracy, system and technical problems, students concluded that bl enhanced the learning experience and fostered a student-centred approach to teaching and learning. afr j health professions educ 2021;13(4):218-221. https://doi.org/10.7196/ajhpe.2021.v13i4.1424 is blended learning the way forward? students’ perceptions and attitudes at a south african university n b khan, mph; t erasmus, baud; n jali, baud; p mthiyane, baud; s ronne, baud discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: n b khan (khanna@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2021.v13i4.1424 mailto:khanna@ukzn.ac.za 220 december 2021, vol. 13, no. 4 ajhpe short report methods this study aimed to determine the attitudes and perceptions of audiology and speech-language pathology (slp)  students towards bl. a descriptive survey design with quantitative methods of analysis was implemented. the study population comprised all 178 audiology and slp students from year 2 to year 4 at ukzn. there were 6 participants in the pilot study. of the remaining 172, 86 completed a structured self-administered questionnaire, yielding a response rate of 50%. most of the participants (80%; n=68) were female; 59% (n=50)  were from the discipline of audiology and 53% (n=45) from the third year of study. most (60%; n=52) of the students came from quintile 4 and 5 schools (quintile 1 represents the poorest schools and quintile 5 the most affluent schools), 50% (n=43)  indicated that their homes were in urban areas, and 55% (n=47) lived at a university residence while studying. for most participants (54%; n=46)  isizulu was their home language. the questionnaire was developed by adapting questions from a study conducted by aladwan et  al.[10] and consulting the relevant research articles. the questions related to participants’ exposure to and understanding and acceptance of bl; frequency of online activities; attitude and perceptions towards bl-enabling learning activities and outcomes; and ease of use of the online platform, its functionality and challenges encountered. it comprised closed-ended and open-ended questions, where participants could elaborate on or explain their perceptions and attitudes, as well as likert scales. data were collected online using google forms. to ensure that the questionnaire and online system were appropriate for the main study, a pilot study was conducted with 6 students. information obtained revealed that the length of the questionnaire was appropriate, the questions were not ambiguous, and it took students ~10 15 minutes to complete. the documents made available to participants on google forms included an information document, the consent form and the questionnaire. for the purpose of this research study, both descriptive and inferential statistics were used. non-numerical data were coded and entered on excel (microsoft corp., usa) and then exported to spss version 26 (ibm corp., usa)  for analysis. the descriptive statistics were displayed in the form of frequencies and percentages. pearson’s χ2 tests were used to determine associations between gender and attitudes; discipline and attitudes; and levels of students and attitudes. fisher’s exact test was used if any column had <5 entries. non-parametric tests, i.e. the wilcoxon rank-sum test and kruskal-wallis test, were used for data that did not follow the normal distribution to make comparisons between the two groups of continuous measures. the one-way analysis of variance (anova) was used to compare the group means. the confidence level was set at 95%, with a significance level of 0.05. the data analysis was done in consultation with a statistician. ethical approval ethical approval to conduct the study was obtained from the humanities and social sciences research ethics committee (hssrec), ukzn (ref. no. hss/0314/0194). gatekeeper access was provided by the registrar of the university and academic leaders of the respective disciplines. results about 74% (n=64) of participants had access to the internet outside of the main university premises, with 95% (n=82)  accessing the internet daily. however, only 40% (n=34)  accessed the moodle online system on a daily basis – 61% (n=52) accessing it for ≤20 hours per month, mainly for quizzes, uploaded videos and assignments. most participants (89%; n=77)  agreed that a combination of traditional and elearning is effective; improves learning skills (83%; n=71); enables students to be more involved in learning (84%; n=72); and encourages participation (84%; n=72). however, 38% (n=33)  indicated that bl can be challenging. participants had to rank the learning method in order of preference: 79% (n=68)  indicated the f2f learning method, followed by 63.3% (n=57)  bl and 46.5% (n=40)  the elearning method. there was a statistically significant association between table 1. challenges experienced with the moodle online platform and recommendations for improvement challenges, n=58 n (%) recommendations, n=48 n (%) no difficulties user friendly 9 (16) no suggestions no concerns 10 (21) connectivity and access issues poor internet connection/network issues/bandwidth speed/limited wi-fi/no internet 13 (22) training of staff and students training of staff orientation for computer-illiterate students tutorials on moodle use 5 (10) system and technical difficulties issues with uploading and downloading lecture material/takes too long several restrictions on the system 11 (19) lecturers better organisation of material upload lectures prior to lecture time add appropriate captions to lecture notes display content notifications 16 (33) lecturer issues quizzes are confusing lecture notes not uploaded in time no content notifications 13 (22) improve moodle platform efficiency effectiveness organisation 11 (23) personal factors computer illiteracy leads to frustration not adequately interactive 6 (10) technical accessibility improve system capacity increase uploading document size 6 (13) training and orientation regarding moodle little guidance given to students about how to use moodle 6 (10) december 2021, vol. 13, no. 4 ajhpe 221 short report the year of study and whether there was a preference for bl or f2f learning. thirdand fourth-year students had a more positive attitude towards bl than f2f learning than second-year students, which was statistically significant (p=0.003)  (fisher’s exact test). students from urban and rural areas preferred f2f learning to the other methods; however, more students from rural areas indicated this as a preference (statistically significant; p=0.037)  (fisher’s exact test). male and female participants’ attitudes towards bl were similar; however, more females agreed/strongly agreed that bl reinforces interaction (p=0.021) (fisher’s exact test). pearson’s χ2 test revealed that isizulu-speaking participants were more likely to agree that bl improves learning skills (p=0.042); allows for joint participation (p≤0.001); allows for more reading for assignment preparation (p≤0.001); and that the material was well organised on moodle (p=0.035). the wilcoxon’s rank-sum test showed that there was a slight mean difference between the disciplines. audiology students had a more positive attitude (mean (standard deviation (sd))  1.94 (0.818))  than slp students (2.33 (0.645)), and for the former bl was more meaningful than f2f learning, as it incorporated online discussions (statistically significant; p=0.023). the anova test showed that with regard to perceptions, significant differences were noted between disciplines, with slp students perceiving that bl was more convenient than f2f learning (f (1, 84)=4.53; p=0.036)  and that bl contributes towards in-depth thought about a module (f (1, 84)=5.81; p=0.018). participants were asked to rate the moodle platform as either useful, not useful or unsure. the majority of participants (93%; n=80) described it as useful, but only 51% (n=44) perceived it as improving the efficiency of learning greatly. pearson’s χ2 test revealed that there was a statistically significant relationship between those who had access to the internet and found bl to be more convenient than those who did not have access and found f2f learning more convenient (p=0.025). an open-ended question was administered, which was related to the challenges experienced with the online learning platform moodle and recommendations for improvement. fifty-eight participants responded to the question on challenges experienced with 16% (n=9) reporting no difficulties, while the other participants provided 5 key areas of concerns. of the 48 that responded to recommendations, 21% (n=10) stated that they had no suggestions or concerns for the moodle online platform and the other participants provided 4 main areas of recommendations (table 1). discussion the majority of participants in the current study had access to the internet on the university premises and at off-campus residences, while >80% of the 250 students in 3 universities in north-eastern nigeria did not have access outside of the university.[9] access to the internet in various developing contexts is known to be problematic given the inadequate infrastructure and connectivity, especially for students residing in rural areas, even in the sa context. there therefore needs to be a concerted effort by all stakeholders to ensure access in rural communities, perhaps starting at the level of schools. having adequate access to the internet on campus, in campus residences and private access could be one of the reasons that students in the current study had a more positive attitude towards bl. it was encouraging that most students preferred f2f learning and were also positive regarding bl. a study of medical students in india found an increasingly positive attitude to bl in fourth-year students, who were more prepared to be independent learners than first-year students, who have a preference for educator-directed learning.[6] this could also be due to the familiarity with the system, its functionality and having gained more computer literacy and self-directed learning skills.[11] in constructing successful bl, course organisers must decide in advance which parts of the curriculum are to be delivered f2f and which can be delivered online or by another modality of elearning. the balance between f2f education and elearning is delicate, depending on factors such as learning outcomes, student level, electronic resources and trainer’s experience. measures should be taken to prevent students who lack computer skills from becoming disadvantaged or frustrated and developing computer-hostile attitudes. a study was conducted at an sa university in the western cape province of students who did not have prior access to technology in their home or community, who did not feel proficient with computers, and who were not comfortable with online tasks. [7] their limited knowledge of computers and bl also had an impact on how frequently they used bl.[7] it is suggested that all students entering university need to complete a compulsory computer literacy-certificated short course to ensure that they are proficient regarding online learning activities. moreover, lecturer training in pedagogy and technology, administrative and technical support to ensure better organisation of course material, uploading material on time and verification of the uploaded material play an important role in the success of bl programmes. continuous feedback from students about electronically delivered material is therefore important and should be included in the course evaluation. future research to determine how the effects of bl translate to clinical audiology and slp practice should be undertaken. the results of the current study are in agreement with those of other studies on the effectiveness of elearning as part of bl, which showed that students’ engagement was increased and their perception of the educational environment was improved. however, further research in this area is still necessary before lecturers can make assumptions regarding the long-term effects of bl in clinical education. the current study was based on attitudes and perceptions of benefit. perhaps future studies could measure actual benefit and outcome using different methods, and determine responses related to preferences. a limitation of our study was that it was conducted at one university and had a small sample size, thereby limiting generalisability. conclusion bl is effective in improving students’ skills, enhancing the learning experience and fostering a student-centred approach to teaching and learning. it can help students develop 21st century skills, such as communication, information literacy and the use of digital technologies, for a range of purposes. a blended approach to clinical education does have potential in addressing the highly contextual and complex health needs that are essential to perform competently in clinical practice. although elearning is an established and effective approach in health science, as demonstrated in other research studies, it should not replace traditional learning, as students in this study showed a preference for contact teaching. bl is probably a better approach than purely web-based/online teaching. all educational formats have strengths and limitations, bl being no exception, necessitating careful design, training, implementation and evaluation. declaration. none. acknowledgements. we acknowledge the contributions of all the study participants. 222 december 2021, vol. 13, no. 4 ajhpe short report author contributions. nbk, te, nj, pm, sr contributed equally to writing of the article. te, nj, pm, sr contributed to the research proposal development, data collection and research project, supervised by nbk. funding. none. conflicts of interest. none. 1. albarrak a, alabdulkarim l. students’ attitudes and satisfaction towards blended learning in the health sciences. in: uslu f, ed. proceedings of adved15 international conference on advances in education and social sciences, 12 14 october 2015, istanbul, turkey. http://www.ocerint.org/adved15/ (accessed 8 september 2021). 2. hua l, goodwin d, weiss a. traditional vs blended learning of pharmacology. optom educ 2013;39(1):28-34. 3. felea m, dobrea m, albastroiu i. blended learning in higher education – a romanian student’s perspective. in: roceanu i, ed. proceedings of the 13th international scientific conference elearning and software for education, 27 28 april 2017, bucharest, romania. bucharest: carol i national defence university publishing house, 2017. 4. bagarukayo e, kalema b. evaluation of elearning usage in south african universities: a critical review. int j educ dev inform comm tech 2015;11(2):168-183. 5. arkorful v, abaidoo n. the role of e-learning, the advantages and disadvantages of its adoption in higher education. int j educ res 2014;2(12):401-403. 6. nanda b, bhattacharjee m, chawla o, et  al. incorporating e-learning as a tool for medical education in india: investigating student perspectives. j educ tech health sci 2018;5(1):25-30. https://doi.org/10.18231/23938005.2018.0006 7. bharuthram s, kies c. introducing e-learning in a south african higher education institution: challenges arising from an intervention and possible responses. br j educ tech 2013;44(3):410-420. https://doi.org/10.1111/j.14678535.2012.01307.x 8. kumi-yeboah a, young w, boadu k. 21st century distance learning in sub-saharan africa: distance and blended learning in ghana. in: ololube np, ed. advancing technology and educational development through blended learning in emerging economies. hershey, pa: igi global, 2013:142-158. 9. apuke o, iyendo t. university students’ usage of the internet resources for research and learning: forms of access and perceptions of utility. heliyon 2018;4(12):e01052. https://doi.org/10.1016/j.heliyon.2018.e01052 10. aladwan f, fakhouri n, alawamrah a, rababah o. students’ attitudes toward blended learning among the students of the university of jordan. modern applied sci 2018;12(12):217-227. https://doi.org/10.5539/mas. v12n12p217 11. birbal dr, ramdass dm, harripaul mc. student teachers’ attitudes towards blended learning. j educ hum dev 2018;7(2):9-26. https://doi.org/10.15640/jehd.v7n2a2 accepted 30 november 2020. http://www.ocerint.org/adved15/ https://doi.org/10.18231/2393-8005.2018.0006 https://doi.org/10.18231/2393-8005.2018.0006 https://doi.org/10.1111/j.1467-8535.2012.01307.x https://doi.org/10.1111/j.1467-8535.2012.01307.x https://doi.org/10.1016/j.heliyon.2018.e01052 https://doi.org/10.5539/mas.v12n12p217 https://doi.org/10.5539/mas.v12n12p217 https://doi.org/10.15640/jehd.v7n2a2 forum 4 may 2015, vol. 7, no. 1 ajhpe social justice and equity are important principles in african health sciences education, leading to awareness of the social and economic determinants of health among our graduates. however, more forces of exclusion exist than our current curricula recognise. in this article, i review the health consequences of the social exclusion of lesbian, gay, bisexual, transgender and intersex (lgbti) people. i then present a curricular framework for educators who are interested in teaching about sexual orientation and gender identity. a recent curricular review at the university of cape town’s faculty of health sciences revealed profound gaps in teaching about sexual orientation and gender identity.[1] there is no evidence that the curricula at other south african (sa) or african health education institutions are significantly different. sexual orientation and gender identity are not health hazards per se, but the social exclusion of lgbti people leads to significant health disparities. homophobia, the irrational fear and hatred of lgbti people, and heteronormativity, a social construct that makes lgbti identities invisible and assumes that heterosexual relationships are the norm, are powerful constructs that have direct and indirect impact on lgbti people’s health. as a marginalised group, and compared with heterosexual peers, lgbti people experience higher levels of depression, suicide and substance abuse, and are at higher risk for sexually transmitted diseases, including hiv.[2] because of mistrust in the health system, lgbti people are less likely to utilise health promotion services, e.g. gynaecological cancer screenings, and are therefore at higher risk for non-communicable diseases.[3] current sa health policies recognise that transgender people, as well as men who have sex with men, are particularly vulnerable populations.[4] nevertheless, lgbti people continually experience discrimination, harassment, and even denial of care by healthcare professionals.[5,6] in countries where legislation penalises homosexuality or homosexual behaviour, lgbti people may even risk arrest when seeking healthcare. homophobia continues to be a problem in medicine worldwide,[7] and it is important to note that it not only decreases the quality of care for lgbti patients, but also marginalises lgbti health professionals. the above-mentioned factors make a compelling argument for the need to teach our health professionals about sexual orientation and gender identity, in order to challenge their attitudes and behaviours, and to equip them with knowledge relevant to lgbti patients.[2] training in health professions education is a formative experience for future doctors, nurses and allied health professionals. in order to educate non-discriminatory professionals, it is imperative that their experiences include sufficient opportunities to learn about sexual orientation and gender identity, the healthcare needs of lgbti people, and ways to provide such care in a compassionate and nonjudgmental manner. opportunities for teaching about sexual orientation and gender identity there are many opportunities for teaching about sexual orientation and gender identity in health professions curricula (table 1). among these are first and foremost patient-provider interaction training, but also clinical subjects and contact with health professionals in the field. these professionals can model appropriate care and interest in lgbti patients, mentor lgbti students, and conduct research on lgbti health-related issues. sexual orientation and gender identity cannot and should not be taught in one specific course, but rather be spiralled through the curriculum to enable students to challenge their own attitudes, and learn about specific lgbti health issues and the psychosocial well-being of lgbti people. courses that endeavour to develop students’ skills in patient-provider interactions are a key opportunity to challenge students’ attitudes and equip them with knowledge to care for lgbti patients. aspects of sexual orientation and gender identity should be included when discussing professional behaviour with students, with an emphasis on the ethical background. sexual orientation and gender identity are not taught in african health professions curricula. in order to improve the quality of care for lesbian, gay, bisexual, transgender and intersex (lgbti) patients, health professionals need to shift their attitudes towards sexual orientation and gender identity, and learn about specific lgbti health needs. discussion. the curricula of african health professions education provide various opportunities to include teaching about sexual orientation and gender identity. various disciplines can teach sexual orientation and gender identity issues in their context by challenging heteronormativity and highlighting specific lgbti health concerns, and can do so more successfully with interactive teaching approaches that hold more potential than formalised lectures. rights-based teaching frameworks should include sexual orientation and gender identity as markers of difference. to achieve this, educators need to build capacity to teach about these issues, and support lgbti students in their institutions. conclusion. teaching about sexual orientation and gender identity is urgently needed in african health professions education, but it is complex. this article presents strategies to incorporate sexual orientation and gender identity into the curricula of medical schools, nursing colleges, and the allied health sciences. afr j health professions educ 2015;7(1):4-7. doi:10.7196/ajhpe.359 strategies to include sexual orientation and gender identity in health professions education a müller, dr med gender health and justice research unit, faculty of health sciences, university of cape town, south africa corresponding author: a müller (alexandra.muller@uct.ac.za) forum may 2015, vol. 7, no. 1 ajhpe 5 obligation to provide care without judgment. courses that address diversity offer a chance to talk about difference based on sexual orientation and gender identity. case studies and student exercises can encourage students to think outside of the heteronormative paradigm, e.g. by including an lgbti patient, or a patient’s same-sex partner with whom students need to communicate. when students learn to take patient histories, they can be engaged by conducting a sensitive and thorough sexual history that includes ways to ask about sexual orientation and gender identity. teaching students table 1. sexual and gender minority health content in health professions courses course potential lgbti content educational outcomes patient-provider interaction training discuss professional behaviour and non-judgmental care with regard to sexual orientation and gender identity address students’ attitudes towards non-heteronormative identities include lgbti patients, or patients with same-sex partners in case studies and patient-provider communication exercises history-taking: teach gender-neutral language (‘partner’ instead of ‘wife/husband’, etc.) taking sexual histories: include information about sexual orientation, gender identity and non-heteronormative sexual practices awareness of sexual and gender minority identities, heteronormativity, transand homophobia as impacting on access to healthcare recognition of professional standards and conduct of care with regard to sexual and gender minorities ability to provide culturally competent, non-judgmental care to sexual and gender minority patients human biology and development discuss sexual orientation and gender identity as part of physiological psychosocial development awareness of sexual and gender minority identities understanding of development and influences on sexual orientation and gender identity public health and primary healthcare use rights-based frameworks to address sexual orientation and gender identity with regard to: • access to healthcare • social determinants of health • health disparities understanding of sexual orientation and gender identity as social determinants of health ability to assess the social context and health risk factors of sexual and gender minority patients knowledge of health disparities and the impact of discrimination and social exclusion paediatrics discuss gender behaviour and gender norms discuss the difference between sexual orientation and gender identity in sexual development case studies discuss the impact of homophobia, family and peer pressure on adolescent mental health understanding of development and influences on sexual orientation and gender identity ability to differentiate between biological sex and socially constructed gender, and assess sociocultural impact of the latter understanding of the impact of discrimination and social exclusion on the health of teenage sexual and gender minority patients ability to provide clinically competent care to young sexual and gender minority patients obstetrics and gynaecology discuss lesbian health concerns, such as: • higher cancer risks (than heterosexual population) • little uptake of preventative services, including cancer screenings • higher risks of sexual violence, and subsequent hiv/ sti risks discuss health prevention needs of transgender men knowledge about specific health concerns for lesbian and bisexual women ability to provide clinically competent care to sexual and gender minority patients psychiatry discuss the historical pathologisation of lgbti identities and impact thereof address the psychological impact of social and internalised homophobia discuss mental health risks of sexual and gender minority patients discuss sexual and gender minority patients’ experience of violence and health consequences understanding of historical context and resulting barriers to care for sexual and gender minority patients ability to provide clinically competent care to sexual and gender minority patients urology discuss health prevention needs of gay men and transgender women ability to provide clinically competent care to sexual and gender minority patients infectious diseases include epidemiological information about hiv prevalence among men who have sex with men discuss adequate prevention methods for people engaging in non-heteronormative sex ability to provide clinically competent care to sexual and gender minority patients sti = sexually transmitted infection. forum 6 may 2015, vol. 7, no. 1 ajhpe to frame questions in a non-heteronormative manner will help them to identify their own assumptions and biases about sexual behaviour.[8] furthermore, they will learn about sexual practices beyond the scope of ‘traditional’ heterosexual behaviour, which will in turn enable them to give adequate information to lgbti patients. issues of sexual orientation and gender identity are likely to arise in a number of medical disciplines. the teaching presented in these disciplines should build on the introductory information about sexual orientation and gender identity from the early years. clinical educators play a key role in reminding students to ask questions about sexuality in a non-heteronormative and non-judgemental way, and can shift passive to active learning by asking students to work on issues of sexual orientation and gender identity within a particular case. it is imperative that discussions around sexual orientation and gender identity refrain from judgemental or moral characterisations, and rather focus on the challenges that lgbti people encounter in contexts of homophobia and heteronormativity. the following section presents opportunities to teach sexual orientation and gender identity in human biology, public health and primary healthcare, paediatrics, obstetrics/gynaecology, psychiatry and infectious disease. courses in human biology and human development offer a good opportunity for an introduction to sexual orientation and gender identity. the advantage of these courses is that they reach a large student audience, and put sexual orientation and gender identity in the context of normal psychosexual development. furthermore, they are usually in the early years of health professions education, and bring lgbti visibility and attitudinal change to students’ attention from the beginning. of concern is that the information on sexual orientation and gender identity in these lectures may be dated or inaccurate, and that students will not be able to engage as much with the content in formalised lectures and seminars. including sociologists/ anthropologists in an interdisciplinary team might be a helpful pedagogical approach. discussions of social determinants of health, barriers to accessing healthcare, and health disparities, taught in public health and primary healthcare, offer the opportunity to include an analysis based on sexual orientation and gender identity. lgbti people face significant barriers when accessing care in public health facilities, and often avoid seeking care out of fear of homophobic treatment.[9] a rights-based framework can address sexual orientation and gender identity when discussing non-discriminatory care, and can be reinforced by the patient rights charter[10] and batho pele principles[11] (in sa, or relevant documents in other african countries), and professional codes of conduct. paediatrics and adolescent medicine can address gender behaviour and gender norms, which are often associated with sexual orientation. children who present with gender atypical behaviour provide an opportunity to discuss gender identity issues and the distinction between sexual orientation (sexual and emotional attraction) and gender identity (one’s sense of being male or female). this can be deepened when teaching about sexual development and puberty. discussing the role of parental and peer pressure in conforming to gender norms can contribute to shape an understanding of the experiences of long-standing depression and poor self-esteem frequently expressed by lgbti youth. obstetrics/gynaecology, with its focus on women’s health, offers opportunities to teach about lesbian health. lesbian women seek routine breast and cervical cancer screening less often than heterosexual women, might have higher risks for endometrial and ovarian cancer, and their providers underestimate their risk of cervical cancer.[2] in sa, lesbian women are at a high risk of experiencing sexual violence, which places them at higher risk for contracting sexually transmitted diseases, including hiv.[12] these topics can be included to address the current lack of awareness of these issues. some of the many topics suitable for psychiatry are the history of pathologisation of lgbti identities and the psychological impact of societal and internalised homophobia as well as lgbti people’s experiences of violence. these topics can be explored with the help of local lgbti organisations, who are usually willing to provide testimony of lgbti experiences for students, and facilitate direct interaction with lgbti individuals. the hiv prevalence among sa men who have sex with men is estimated to be 13%[13] and the self-reported hiv prevalence among lesbian and bisexual women is 10%.[12] including this information in infectious disease courses will make students aware that lgbti people are at high risk, and can teach them about prevention methods that are relevant to lgbti people. challenges to implementation health professions education exists in a wider societal and cultural context.[14] despite overwhelming evidence of precolonial non-heterosexual identities,[15] existing homophobic attitudes are often justified by the argument that homosexuality is ‘un-african’ or ‘violates religious values’. such deep-seated cultural and religious prejudices are difficult to challenge, and, if situated at faculty level, can impact the manner in which topics are taught. challenging these attitudes at the faculty level is therefore an important imperative to teaching sexual orientation and gender identity. a directive from professional boards (such as the health professions council of south africa and the south african nursing council) could provide the necessary motivation and guidance to include sexual orientation and gender identity in existing curricula. teaching by example we know that role modelling is an important way in which attitudes are fostered.[16] lecturers and clinical educators need to become lgbtiaffirming role models for students. to accomplish this, faculty should also be encouraged to learn about sexual orientation and gender identity, e.g. through continuing professional development (cpd) courses, departmental presentations, or journal clubs. departments that have opportunities to include sexual orientation and gender identity topics can be approached and offered consultation to integrate these issues into their curriculum. lgbti students study in an institutional environment that is often heteronormative and homophobic,[17] and should be supported by faculty staff. information about lgbti support services (e.g. through local lgbti organisations) can easily be made available to all students. staff should encourage the creation of an lgbti student group, and make mentors available to individual students who need assistance with homophobic struggles. this can enable lgbti students to contribute to conversations with heterosexual students where it is safe for them to do so, and can foster the individual interactions that are most effective in addressing homophobia. in my experience, students are often integral to introducing sexual orientation and gender identity into curricula by demanding to be taught about these topics. forum may 2015, vol. 7, no. 1 ajhpe 7 conclusion addressing homophobia and remedying the effects of heteronormativity in health sciences curricula is complex. it requires awareness and attitude shifts from educators, which are prerequisites to introducing teaching about sexual orientation and gender identity to students. the curriculum provides multiple opportunities to incorporate such issues, but these opportunities will need to be framed in larger conversations about social inclusion and exclusion to successfully prepare health professions students to provide quality care to lgbti people. references 1. müller a. teaching lesbian, gay, bisexual and transgender health in a south african medical school: addressing the gap. bmc med educ 2013;13:174. 2. mayer kh, bradford jb, makadon hj, stall r, goldhammer h, landers s. sexual and gender minority health: what we know and what needs to be done. am j pub health 2008;98(6):989-995. [http://dx.doi.org/10.2105/ ajph.2007.127811] 3. aaron dj, markovic n, danielson me, et al. behavioral risk factors for disease and preventive health practices among lesbians. am j pub health 2001;91(6):972-975. 4. south african national department of health. national strategic plan on hiv, stis and tb, 2012 2016. pretoria: department of health; 2012. http://www.doh.gov.za/docs/stratdocs/2012/nspfull.pdf (accessed 4 november 2012). 5. lane t, mogale t, struthers h, mcintyre j, kegeles sm. 'they see you as a different thing': the experiences of men who have sex with men with healthcare workers in south african township communities. sex transm infect 2008;84(6):430-433. [http://dx.doi.org/10.1136/sti.2008.031567] 6. wells h, polders l. gay and lesbian people’s experience of the health care sector in gauteng. research initiative of the joint working group conducted by out lgbti well-being in collaboration with the unisa centre for applied psychology; 2006. http://www.out.org.za/index.php/library/reports# (accessed 29 january 2015). 7. o’hanlan k, robertson p, cabaj rp, schatz b, lock j, nemrow p. homophobia as a health hazard: report of the gay and lesbian medical association. j gay lesbian med assoc 1997;1:25-39. 8. cavanaugh rm. obtaining a personal and confidential history from adolescents. j adolesc health care 1986;7:118-122. 9. müller a. barriers to health care for south african lesbian, gay, bisexual and transgender people. poster presented at the 9th public health association of south africa (phasa) conference, 24 27 september 2013, cape town, south africa. 10. department of justice. patients’ rights charter. http://www.justice.gov.za/vc/docs/policy/patient%20rights%20 charter.pdf‎ (accessed 5 may 2014). 11. department of health, kwazulu-natal. batho pele principles. http://www.kznhealth.gov.za/bathopele.htm (accessed 5 may 2014). 12. sandfort tgm, baumann lrm, matebeni z, reddy v, southey-swartz i. forced sexual experiences as risk factor for self-reported hiv infection among southern african lesbian and bisexual women. plos one 2013;8(1):e53552. [http://dx.doi.org/10.1371/journal.pone.0053552] 13. lane t, raymond hf, dladla s, et al. high hiv prevalence among men who have sex with men in soweto, south africa: results from the soweto men’s study. aids behav 2011;15(3):626-634. [http://dx.doi.org/10.1007/s10461-009-9598-y] 14. müller a, crawford-browne s. challenging medical knowledge at the source: attempting critical teaching in the health sciences. agenda: empowering women for gender equity 2013;27(4):25-34. 15. epprecht m. heterosexual africa? the history of an idea from the age of exploration to the age of aids. athens, oh: ohio university press, 2008. 16. yesidia mj. changes in physicians’ attitudes toward aids during residency training: a longitudinal study of medical school graduates. j health soc behav 1996;37:179-191. 17. rose p. review of experiences of the institutional culture of the medical faculty, university of cape town. uct: uct students’ representative council, 1995. june 2022, vol. 14, no. 2 ajhpe 55 research the inclusion and utilisation of decentralised training platforms (dtps) are important in the transformation and scaling-up of medical education to overcome shortages, address inequities and support universal health coverage (uhc).[1] dtps refer to any education or learning environment outside a tertiary hospital and the main university campus, and include a primary healthcare (phc) facility, district or regional hospital, or non-governmental or community-based organisation that is used for health professional education and training.[2] in concert with global developments, the academy of science of south africa (sa) has underscored the importance of decentralised training of health professionals,[3] while several scholars have highlighted the transformational potential of dtps in increasing medical graduate output and improving outcome competencies.[2,4] notwithstanding an encouraging increase in the scholarly focus on dtps,[4-7] there is a dearth of research on dtps in sa, especially on the activities of medical students and the time spent on these activities. log diaries or logbooks have been used extensively in educational research to document the range of clinical exposure and learning opportunities available to undergraduate medical students, and the quality of these learning encounters.[8-16] these log diary studies have demonstrated the value of community-based education,[16] and the patient demography, clinical content and process of general practice.[10,12,13,15] however, the majority of these studies have been conducted in australia, canada, the uk and the usa. in sub-saharan africa, very few log diary studies on undergraduate medical education could be found. as part of a larger study on medical students’ and junior doctors’ preparedness for the reality of practice in mozambique, frambach et al.[17] used log diaries with the junior doctors. the study found that the six junior doctors who completed the log diary highlighted the challenges that they faced in balancing the need for healthcare delivery with personal survival.[17] the methodology for the study among medical students was a survey, rather than log diaries. in sa, a 2008 log diary study examined the perceived educational value and enjoyment of a rural clinical rotation for medical students.[18] completed by 25 medical students, the study found that well-functioning rural healthcare centres contributed to skills development required for general practice and working in resourcelimited settings.[18] we could not find published studies since 2008 that have used log diaries to examine the activities of final-year medical students at dtps. these final-year students are expected to complete integrated primary care  (ipc) rotations at various dtps in the majority of undergraduate medical education programmes in sa. the dtps tend to be district or small regional hospitals but include a network of phc facilities and community-based activities. the duration of the ipc blocks varies from 6 to 12  weeks.[19] notwithstanding minor variations, the ipc objectives are similar across the different universities, namely that final-year students can  provide person-centred curative care and background. an important strategy in the transformation and scaling up of medical education is the inclusion and utilisation of decentralised training platforms (dtps). objective. in light of the dearth of research on the activities of medical students at dtps, the purpose of this study was to determine how final-year medical students spent their time during the integrated primary care (ipc) rotation at a dtp. methods. the study was conducted at sefako makgatho health sciences university (smu), the university of kwazulu-natal (ukzn), the university of the witwatersrand (wits) and walter sisulu university (wsu). at each of the participating universities, a voluntary group of final-year medical students completed a log diary by entering all activities for a period of 1 week during the ipc rotation. the log diary contained five activity codes: clinical time teaching time, skill time, community time and free time, with each subdivided into additional categories. the data were analysed for students at each university separately, using frequencies and proportions. results. a total of 60 students volunteered to complete the diaries: at wsu n=21; ukzn n=11; wits n=18; and smu n=10. at each university, students reported that they spent large amounts of time on clinical activities: wsu=46.0%; ukzn=33.8%; wits=29.6%; and smu=44.1%. they reported low amounts of time spent on community-based activities: wsu 0.8%; ukzn 7.6%; wits 6.8%; and smu 0.0%. conclusion. students reported that they spent a sizeable proportion of their time on clinical activities, while reported time spent on community-based activities was negligible. the transformation potential of dtps will only be realised when students spend more time on community-based activities. afr j health professions educ 2022;14(2):55-60. https://doi.org/10.7196/ajhpe.2022.v14i2.1471 using log diaries to examine the activities of final-year medical students at decentralised training platforms of four south african universities a dreyer, mph; l c rispel, phd department of family medicine and primary care, division of rural health, university of the witwatersrand, johannesburg, south africa corresponding author: a dreyer (abigail.dreyer@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1471 mailto:abigail.dreyer@wits.ac.za 56 june 2022, vol. 14, no. 2 ajhpe research develop  competencies  in  general practice, disease prevention and health maintenance.[21,22,26] the purpose of this study was twofold: firstly, to quantify how final-year medical students spent their time during the ipc rotation at a dtp; and secondly, to determine student perceptions of the educational value of the various activities. the study is part of a broader doctoral study that aims to analyse and compare dtps and their utilisation in undergraduate medical education at four sa universities. methods study setting the study was conducted at four sa universities: walter sisulu university (wsu) in the eastern cape province; the university of kwazulu-natal (ukzn) in kwazulu-natal province; the university of the witwatersrand (wits) in gauteng province; and the sefako makgatho health sciences university (smu) in gauteng province. the study sites have been described elsewhere.[22] study design this was an educational research study, comprising a quantitative analysis of the log diaries of final-year medical students at the four participating universities. selection of participants the original plan was to ensure diversity for the log diary study, and to recruit a random sample of final-year medical students from a list of purposively selected dtps used for the ipc rotation at each participating university. prior to study commencement and to assist data collection, the principal researcher (ad) consulted extensively with academic class co-ordinators and medical student representatives at each university. the consultation revealed that the planned approach of random selection was unlikely to work in practice. hence the approach to student selection was changed. firstly, the principal researcher selected the period between june and october 2018 to ensure that the data collection did not interfere with student examination preparation. secondly, the principal researcher requested medical students to volunteer to keep the log diaries during the ipc rotation. this request was sent out through the various student communication channels, and the student representatives. the principal researcher liaised with the student representatives, who agreed to distribute the request for voluntary participation, together with the contact details of the principal researcher. following the request for voluntary study participation, interested students at each university made contact with the principal researcher. development of data collection instrument following a review of the literature, the 2001 log diary tool of murray et al.[13] was adapted, as it was available in the public domain, and contained all the possible categories of student activities engaged in when completing  rotations at the dtps. we developed an electronic version of the log diary for direct uploading onto redcap (research electronic data capture; vanderbilt university, usa),[20] a secure, web-based application designed to support data capture for research studies. the log diary was divided into hourly activities, recording a 24-hour period. the log diary contained five activity codes, derived from the ipc learning activities: a  =  clinical time; b = teaching time; c = skill time; d = community time and e = free time or activities of daily living. for each of these activity codes, a further coded breakdown was recorded in the log diary. the students also had to record whether the clinical activity was supervised, and who did the supervision. in the log diary, students were requested to indicate their perceptions of the educational value of the activity, the skills acquired during the activity, a rating of activity enjoyment, and whether the skills could have been acquired in the classroom at the main campus. the electronic diary was piloted with five final-year students at wits university, outside the planned data collection period. the pilot identified various problems, such as the looping and repetitive nature of the information that could affect participation and the completion of the log diary. the students suggested a paper-based version of the log diary. hence, each day was condensed to fit onto one sheet of a4 paper size. fields that were repetitive were converted into tick boxes for ease of completion. the aim of the tick boxes was to minimise errors during recording of activities. an example of the final log diary is shown in fig. 1. data collection once the students had volunteered for study participation, the principal researcher emailed them the study information letter and consent form. once the consent form was returned, a copy of the log diary was forwarded electronically. at wsu, the principal researcher arranged that a printed log diary be collected from a central point at the university prior to leaving the main campus for the dtp rotation. some students requested an electronic copy of the log diary, which was emailed to them. each student also received a brief set of guidelines for completing the log diary. students were instructed to exclude the first rotation week at the dtp when completing the diary, as the first week is often used for orientation activities and is not a true reflection of the ipc rotation. the log diary focused on the 7  days of the second week, when they were requested to record their activities in the log diary. data analysis the hard and electronic copies of students’ log diaries were stored in a locked, secure cupboard and on a password-protected computer, respectively. each diary was assigned a number code to prepare for analysis and to ensure confidentiality. the diaries were grouped by university to allow for comparisons. the information in the completed diaries was captured using redcap, and then exported to stata version 16 (statacorp, usa) for analysis. only descriptive analysis was conducted. although students used a 24-hour period to record activities, we used a 10-hour day from 08h00 to 18h00 as a typical final-year medical student day. the activity code e (free time), which includes sleeping, daily ablutions and travelling, was renamed activities of daily living. ratings of enjoyment and educational value were analysed as continuous variables on a three-point scale: great value, some value or no value. ethical considerations the human research ethics committee (hrec) medical of the university of the witwatersrand in johannesburg provided ethical approval for the study (ref. no. m170704). given the deviation from the original study protocol for the recruitment of students, the principal researcher obtained an amendment from the wits hrec. all ethical guidelines were adhered june 2022, vol. 14, no. 2 ajhpe 57 research to, including a detailed information sheet, informed consent, voluntary participation, confidentiality and anonymity of respondents. results background characteristics across the four universities, 60 students volunteered to complete the diaries: 21 students from wsu (1 female, 20 male); 11 students from ukzn (8  female, 3 male); 18 students from wits (8 female, 10 male); and 10  students from smu (4 female, 6 male). during the data collection period, ukzn and smu experienced student protests, resulting in five incomplete diaries from ukzn and six incomplete diaries from smu that were excluded from analysis. the 60 students were spread across 32 different sites, which included three phc facilities and 24 sites in rural settings. as per the log diary + fig. 1. log diary for medical students’ activities. 58 june 2022, vol. 14, no. 2 ajhpe research guidelines, 26 students completed the log diaries in the second week of the ipc rotation, with the remainder in weeks 3, 4 and 6, respectively. time spent on each activity fig. 2 shows the proportion of student time spent on the five categories on the log diary form. the clinical activities at the dtps ranged from 29.6% at wits to 46.0% at wsu. clinical activities included assisting in theatre, performing medical procedures and ward rounds. the students indicated that the majority of clinical activities were supervised, ranging from 88.2% at ukzn to 99.5% at wsu. medical doctors supervised the clinical activities in the majority (85.9%) of instances, although other categories of health professionals also assisted with supervision. teaching time included attending a seminar/ meeting, teaching by a preceptor, teaching by other staff, contact with main campus, selfdirected learning, and reading or study. time spent on teaching ranged from 19.4% at wsu to 31.7% at wits. students recorded low amounts of time on skill  acquisition. similarly, students recorded low amounts of time spent in the community, ranging from no time at smu to 7.6% at ukzn. fig. 2 shows that at all four universities, students indicated that they spent similar proportions of time on activities of daily living, namely travelling, waiting, cooking, eating or shopping. perceived educational value notwithstanding clear guidelines on rating of the educational value of the various activities during their ipc rotation, the majority of the students rated the clinical and educational activities. in light of the missing data on skill and/or community activities, table  1 only focuses on their rating of clinical and educational activities. table  1 shows that there were variations in the students’ ratings of the value of the clinical activities. across the four universities, ukzn was the only university where students rated 6.1% of the clinical activities to be of no value. students’ rating of clinical activities of great value ranged from a low of 14.4% at wits, to a high of 50.7% at wsu. in terms of educational activities, four students at ukzn (2.9%) and two at wits (1%) rated these activities as having no value. their rating of educational activities of great value ranged from a low of 9.7% at wits, to a high of 60.3% at wsu. discussion this study used log diaries with a voluntary group of final-year medical students to measure the proportion of time spent on each of five pre-determined categories of activities at the dtps of four sa universities. the study found that there were variations in the time spent on clinical activities, from 29.6% at wits to 46% at wsu. we could not find similar studies focusing on medical student activities in other lowand middle-income settings. although not directly comparable, worley et  al.[16] found that patient contact (i.e. clinical activities) in canada was higher when students were based at community sites than when students were based at secondary or tertiary hospitals. encouragingly, the participating students reported adequate supervision of the clinical activities. mubuuke et  al.[23] have highlighted the importance of adequate supervision to the professional growth of undergraduate medical students. across the four universities, the majority of students reported that the clinical activities were of some or high value. at wsu, slightly more than half of students (50.7%) rated the clinical activities as of high value, similar to the ratings of students at smu (46.1%) and ukzn (48%). in contrast, only 14.4% of the wits students rated the clinical activities as of high value. a 2019 wits study that examined final-year medical students’ ratings of service-learning activities during an ipc block found that students reported positively on the educational value of the majority of clinical time teaching time skill time community time activities of daily living activity type wsu ukzn wits smu ti m e sp en t, % 50 45 40 35 30 25 20 15 10 5 0 wsu ukzn wits smu 46.0 33.8 29.6 41.1 19.5 26.7 31.7 26.4 2.2 0.2 0.0 0.9 0.8 7.6 6.8 0.0 31.5 31.7 31.9 31.6 fig.  2. student records of activities and time spent at decentralised training platforms, by university. (wsu = walter sisulu university; ukzn = university of kwazulu-natal; wits = university of the witwatersrand; smu = sefako makgatho health sciences university.) table 1. students’ rating of educational value of clinical and educational activities at dtps activity type wsu ukzn wits smu clinical students, n 21 11 18 10 activities with great value, n (%) 204 (50.7) 87 (48.3) 28 (14.4) 76 (46.1) activities with some value, n (%) 198 (49.3) 80 (44.4) 166 (85.6) 89 (53.9) activities with no value, n (%) 13 (7.3) total activities rated, n 402 180 194 165 educational students, n 18 10 18 10 activities with great value, n (%) 141(60.3) 38 (27.3) 24 (9.6) 28 (43.8) activities with some value, n (%) 93 (39.7) 97 (69.8) 222 (89.5) 36 (56.2) activities with no value, n (%) 4 (2.9) 2 (0.9) total activities rated, n 234 139 248 64 dtp =decentralised training platform; wsu = walter sisulu university; ukzn = university of kwazulu-natal; wits = university of the witwatersrand; smu = sefako makgatho health sciences university. june 2022, vol. 14, no. 2 ajhpe 59 research clinical activities.[19] however, the 2019 study used a different methodology to the present study, and this might account for the differences in findings. the higher student ratings at the three universities compared with wits could be due to a more established clinical focus in the programme offered at wits. as our study was conducted among a voluntary group of students at each of the four universities, further research is needed to determine whether there are significant differences across different universities, and the factors that influence these differences. in this study, students indicated that they spent between 19.5% (wsu) and 31.7% (wits) of their time on teaching activities at the dtps. the teaching time included self-directed learning, which would be expected of final-year medical students, as they are on the cusp of entering the medical profession. the variations in the time spent on educational activities across the four universities might be a reflection of the actual dtps. our study could not determine the proportion of time spent on self-directed learning. however, a university of pretoria study[24] among fifth-year medical students found that these students reported high amounts of time on self-directed learning, which led to a review of the assumptions about the importance of formal teaching. the majority of students in the present study rated the educational activities as of high or some value. similar to the rating of clinical activities, a minority of wits students (9.7%) rated the educational activities as of high value, compared with the majority at wsu (60.3%). further research is needed to elicit the reasons for these inter-student and inter-university variations. students indicated that they spent very little time on practising or learning new skills. these skills include clinical, communication, decisionmaking, problem-solving and advocacy skills. the small proportion of time spent on such skills might be because of the emphasis placed on clinical skills training in the years leading up to the final year. a study[25] among students from the ukwanda rural clinical school at stellenbosch university identified improved confidence in their clinical skills and decision-making skills linked to their placement at the rural dtps. the low proportion of time spent on skills might be a function of the week in which the diary was completed, the lack of opportunities available to the students, and/or the characteristics of the dtp. nonetheless, it is a missed learning opportunity that students were not able to learn or practise a range of skills, including advocacy skills, at the dtps. advocacy is an essential undergraduate health professional competency in the health system context of working in rural and other under-served areas in sa,[21] and addressing the shortages of health personnel in rural areas.[25,27] at smu, students recorded that they spent no time on community activities, which include home visits and health promotion activities. similarly, at wsu, students recorded that they spent less than 1% of their time on community activities, while wits and ukzn students recorded that they spent 6.8% and 7% of their time, respectively, on community activities. this is of great concern, as the transformation potential of dtps lies in immersion and exposure to communities, developing relationships with communities, learning about the social determinants of health, encouraging students to return to rural and underserved areas and to have a greater commitment to social accountability. [23,28-30] further research is needed to determine whether and why so little time was reportedly spent on phc and community-based activities during the ipc rotation. across all four universities, students recorded that they spent  almost one-third of their time on activities of daily living. while this might reflect the nature of the dtps, the findings suggest that there is potential to reorient the ipc rotation toward phc and community-based activities. study limitations and strengths despite extensive efforts to achieve a representative group of final-year medical students at each university, the study is limited by the volunteer sample of 60 final-year medical students. at both smu and ukzn, student participation was affected by the prolonged protests during 2018. these student volunteers who completed the log diaries are likely to differ from other students. hence, the study findings are not generalisable to other finalyear medical students. notwithstanding careful guidelines for data entry, and regular follow-up with students, the missing information is a major limitation, especially in terms of gauging the educational value of the few reported community activities. nonetheless, there are several strengths to the study. the methodology of log diaries is innovative in capturing the activities and time spent at dtps. the method allows for accurate recall of activities and ensures confidentiality and anonymity of participants. the log diary entries have generated new knowledge on the activities of medical students during the ipc rotation, such as the bias towards clinical activities and a relative absence of community exposure or immersion. this knowledge is important because medical doctor shortages in phc and in rural and underserved areas remain acute yet are critical to overcome to achieve uhc and the goals of the proposed national health insurance system in sa.[31] the lessons for future log diary studies are careful preparation, extensive consultation with and orientation of students prior to data collection, and possible daily submission of completed log diaries to pick up missing data at an early stage. direct entry using mobile phone technology should also be explored. conclusion this log diary study set out to quantify how final-year medical students spent their time during the ipc rotation at a dtp, and to determine student perceptions of the educational value of the various activities. students reported that they spent a sizeable proportion of their time on clinical activities, while reported time spent on community-based activities was negligible. the bias toward clinical activities was also shown by students’ completed ratings of the educational value of these activities, while the few community-based activities were left unrated. the policy implication of the study findings is that the transformation potential of dtps in undergraduate medical education will only be realised when there is prioritisation of phc and community-based activities. declaration. none. acknowledgements. we acknowledge the contributions of all the study participants, and dr duane blaauw and dr janine white for the assistance with preliminary data analysis and the helpful discussion regarding the reporting measures. author contributions. ad – conceptualisation of study, protocol development, data collection, data analysis and interpretation and writing of article; lcr – supervisor for the study and contributed to conceptualisation, development, analysis and interpretation, as well as critical evaluation and final approval of the manuscript. 60 june 2022, vol. 14, no. 2 ajhpe research funding. this research was partially supported by the consortium for advanced research training in africa (carta). carta is jointly led by the african population and health research centre and the university of the witwatersrand and funded by the carnegie corporation of new york (grant no. b 8606. r02), sida (grant no. 54100113), the deltas africa initiative (grant no. 107768/z/15/z) and deutscher akademischer austauschdienst. the deltas africa initiative is an independent funding scheme of the african academy of sciences (aas)’s alliance for accelerating excellence in science in africa (aesa) and supported by the new partnership for africa’s development planning and coordinating agency (nepad agency) with funding from the wellcome trust (uk) and the uk government. the statements made and views expressed are solely the responsibility of the fellow. lcr holds a south african research chair, funded by the national research foundation. ad held a thuthuka grant, funded by the national research foundation for 2017-2019. conflicts of interest. none. 1. world health organization. global strategy on human resources for health: workforce 2030. geneva: who, 2016. 2. de villiers mr, blitz j, couper i, et  al. decentralised training for medical students: towards a south african consensus. afr j prim health care fam med 2017;9(1): a1449. 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of health. national health insurance policy: towards universal health coverage. pretoria, republic of south africa: ndoh, 2017. accepted 2 july 2021. https://doi.org/10.4102/phcfm.v9i1.1449 https://doi.org/10.7196/samj.2018.v108i6.13214 https://doi.org/10.1186/s12909-018-1412-y https://doi.org/10.1186/s12909-017-1050-9 https://doi.org/10.22605/rrh4337 https://doi.org/10.1046/j.1365-2923.1999.00336.x https://doi.org/10.1111/j.1365-2923.1980.tb02255.x https://doi.org/10.1007/bf02914521 https://doi.org/10.1080/0142159021000012595 https://doi.org/10.1080/0142159021000012595 https://doi.org/10.1046/j.1365-2923.2001.01053.x https://doi.org/10.1001/jama.286.9.1035 https://doi.org/10.1111/j.1365-2923.1990.tb02451.x https://doi.org/10.1080/01421590412331285397 https://doi.org/10.1046/j.1365-2923.1999.00336.x https://doi.org/10.7196%2fajhpe.2019.v11i2.906 https://doi.org/10.7196%2fajhpe.2019.v11i2.906 https://doi.org/10.1016/j.jbi.2008.08.010 https://doi.org/10.1080/2331186x.2021.1906493 https://doi.org/10.1080/20786204.2011.10874117 https://doi.org/10.1080/20786204.2011.10874117 https://doi.org/10.1186/s12913-021-06178-w https://doi.org/10.1186/s12913-021-06178-w https://doi.org/10.4103/1357-6283.120703 https://doi.org/10.4103/1357-6283.120703 https://doi.org/10.1080/10872981.2017.1320185 https://doi.org/10.1111/j.1466-7657.2003.00215.x may 2014, vol. 6, no. 1 ajhpe 3 research interprofessional education (ipe) emphasises interactive learning with and from members of other professions, aimed at improving patient care.[1] interdependence in education and the understanding and appreciation of the roles, responsibilities and skills of other care workers are vital to strengthen health systems.[2] it has been advocated that an interprofessional approach should be integrated in the education of health professionals[1] to contribute to overcoming difficulties in communication and teamwork in care services, as well as helping to change attitudes and reduce stereotyping between professional groups.[3] despite increased recognition and a variety of initiatives, projects and events, and a sentiment that things are headed in the right direction,[4] many healthcare professionals enter practice without sufficient training in the delivery of interprofessional care.[2] the learning outcomes extend across the range of relevant knowledge, skills and attitudes deemed necessary for confidence and capability in the practice of collaborative care.[5] by participating in collaborative care activities, students are challenged to interpret what happened and construct meaning through their personal experience. this new construct of meaning is then incorporated into the student’s existing knowledge.[6] the context for clinical education can be created in a simulation exercise with a safe, structured and supportive environment that links the lecture room and clinical practice.[5] a simulation also seems to have a beneficial effect on the acquisition of technical skills, the development of higher cognitive skills such as clinical reasoning and decision making, analytical and communication skills, and on psychomotor and procedural skills.[7] as trauma resuscitations require a co-ordinated response from a diverse group of healthcare providers and form part of the curricula of a variety of professions, it was decided to create an ipe event that reflects the reality of a traumatised patient during the acute phase of his injury. the focus of this one-time event was on short-term outcomes such as clinical skills, knowledge and attitudes required for shared management of a traumatised patient. aim the aim of this study was to explore the effect of an interprofessional clinical simulation on medical students. method a mixed-methods study was done on the effect of interprofessional clinical simulation on medical students at the medunsa campus skills centre of the university of limpopo, 25 km north-west of pretoria, south africa. the following tools were developed and reviewed by the medical and nursing lecturers from the skills centre: (i) a 20-item multiple choice question (mcq) test related to trauma management, validated by five lecturers involved in clinical simulation; (ii) a scenario for the simulation of the management of a multiply traumatised patient; and (iii) a guidance and assessment tool, based on a theoretical and skills competency framework for students of both professions, to determine the outcomes, responses, and actions, and the required equipment. ethical permission was obtained from the medunsa research and ethics committee. the simulation comprised two acute phases: the pre-hospital phase: a standardised patient (sp) portrayed a 25-yearold technician who had been working on the roof of the skills centre when his screwdriver fell and rolled away. he managed to grab the screwdriver but lost his balance and fell about 6 m from the roof. he sustained injuries to his chest and a stab wound to his right arm. students were expected to provide emergency care and transport the patient to the emergency room. background. teamwork as an outcome for graduates implies the understanding and appreciation of the roles, responsibilities and skills of other professions. an interprofessional education (ipe) event was initiated as a simulated management of a multiply traumatised patient in the acute phases of his injury, relevant to both medical and nursing students. the objective was to explore medical students’ reflections on the value of this clinical simulation. method. a mixed-methods study was done, using a convenience sample of 5th-year medical students (n=96). participants wrote a multiple-choice question (mcq) test and either actively participated in the simulation or observed the actions through a one-way mirror. the simulations were facilitated by experienced skills trainers. on completion, the participants repeated the mcq test and took part in a facilitator-led debriefing. the latter was audiotaped and students could submit written reflections. written comments and transcripts of the audiotapes were analysed thematically. results. participants’ average test scores improved significantly (p<0.001) from 63.5% before the simulation to 68.6% thereafter. five themes emerged from the reflections: (i) difficulties with implementing knowledge and skills; (ii) importance of teamwork; (iii) skills necessary for teamwork; (iv) effect of being observed by peers; and (v) ipe in the curriculum. conclusions. medical students gained clinical knowledge during the simulation and became aware of their lack of skills, knowledge, and opportunities to acquire and practise skills required for effective teamwork. ajhpe 2014;6(1):3-5. doi:10.7196/ajhpe.231 the effect of an interprofessional clinical simulation on medical students i treadwell,1 dcur, hed; m van rooyen,2 mmed (fam med), mb chb; h havenga,1 ils practitioner; m theron,1 msocsc 1 skills centre, faculty of health sciences, university of limpopo (medunsa campus), pretoria, south africa 2 department of family medicine, university of pretoria, south africa corresponding author: i treadwell (ina.treadwell@ul.ac.za) mailto:ina.treadwell@ul.ac.za 4 may 2014, vol. 6, no. 1 ajhpe research the initial in-hospital phase: the sp was replaced by a high-fidelity simulator to simulate difficulty in breathing due to a pneumothorax as well as a deep stab wound to his right upper arm. students had to provide initial emergency care as a team. sample attending the simulation was mandatory for 5th-year medical students (n=120). those who were willing to participate in the study signed an informed consent form and became the convenience sample (n=96), i.e. the participants. fourth-year nursing students (n=39) were also invited to join the exercise. sixteen students consented, but withdrew from the study before participating in the simulation. both student groups had already completed lectures on trauma in their respective curricula and had acquired psychomotor skills in the skills centre required to manage a traumatised patient. pre-simulation both student groups were orientated in class on what was expected of them in the simulation, using a video featuring the facilitators resuscitating the ‘patient’. after signing consent forms the participating students wrote the mcq test. simulation as there were many students and only three afternoons available, the simulation was duplicated in concurrently running sessions. the students were divided into six groups of about 25 students. three medical students and one nursing student from each group were invited to take part in the simulated resuscitations, while the rest observed, guided by a checklist, through one-way mirrors. the team was expected to manage the patient’s airway and assess his breathing, oxygen saturation, blood pressure as well as levels of consciousness and pain. they had to administer oxygen, stabilise the cervical spine with head blocks, obtain a history, do a full secondary assessment to identify the simulated injuries, insert two intravenous lines, perform a needle decompression of the chest, suture the laceration on his arm, assess the distal pulses and motor function, pass a urinary catheter and insert a nasogastric tube. students also had to provide information to and comfort the patient throughout. at this stage the nursing students withdrew from the study and were replaced by newly registered nurses. the simulations were facilitated by teams of experienced medical, nursing and paramedic skills trainers. on completion of the simulation, the participants repeated the mcq test and took part in a facilitator-led debriefing that was audiotaped. they also completed a post-simulation questionnaire on readiness for ipe and perceptions of their own and other professions. the findings and written comments on the post-simulation questionnaire will be reported in a separate paper. the comments and transcripts of the debriefing audiotapes were individually analysed by three researchers who reached consensus on five themes and used verbatim quotations to illustrate some of the respondents’ views. results the average percentages for the preand post-simulation mcq tests were calculated and compared using the mcnemar test.[8] the mean score for the post-simulation test (68.6%) was significantly (p<0.001) higher than that for the pre-simulation test (63.5%). qualitative content analysis was done on the optional written comments on post-simulation questionnaires and the audiotapes of the post-simulation debriefing. the four researchers made summative notes of the verbal and non-verbal communications and their personal experiences. these notes were compared and discussed and the corresponding items of information were grouped together and organised in themes. the following five themes emerged: theme one: implementation of knowledge and skills participants experienced difficulty in translating theory into practice during the simulation. some factors contributing to erring, such as not noticing the patient’s level of consciousness decreasing, may have been the added pressure of performance, time limitation due to the reality of dealing with a dying patient, lack of structure in their thought processes, and realising possible lack of long-term retention of studied material. ‘it’s tougher than you think, because someone is crashing there, the blood pressure is going down and you think you’re losing the person and your mind slips.’ ‘my biggest challenge was remembering what needs to be done … , everything just comes and comes. it was just "chakalaka" [spicy south african vegetable relish] and all mixed up.’ ‘i realised that in order for one to be perfect, one needs to practise, practise and practise. the theory is there, but application is confusing.’ ‘overwhelming, you try to remember stuff that you learnt, but it was not coming.’ they also realised that their skills needed some practice and appreciated the opportunity to practise in a safe invironment: ‘rather make mistakes on something that is not living than killing someone inadvertently in casualty. i would have made these mistakes and the patient would have died.’ theme two: importance of teamwork participants reported the following: • a clearer understanding of the nurses’ scope of practice: ‘i did not realise that she [nurse] could suture the arm … ’ ‘they [nurses] are very capable of taking care of a patient, even more than i and have lots of advice to give and experience to share.’ • that teamwork provides a platform to share ideas, exchange information and learn from one another: ‘ … other professions are as important as mine and i must trust their judgement and be open minded to learn from them.’ • their understanding that a team doesn’t function effectively if team members do not trust, appreciate and respect each other: ‘i learned, as a member of the health team, we have to respect each other and not look down upon another profession as each profession in the team is important in its own right.’ ‘they [nurses] are there to help us with the patient problem and are very useful because they remind us what we have not done.’ ‘ … it is important to value the judgement of colleagues.’ it was interesting that participants observed that the nurses perceived themselves to be not as valuable as other team members. ‘other professions [nurses] should stop limiting themselves and stop sitting in the corner, they should stand right next to the doctor.’ • that working as a team creates a feeling of achievement and will improve patient care: ‘we cannot stand alone and do the work, we need other professions to do the work better.’ ‘we need to involve other disciplines more to achieve optimum care for our patients … ’ ‘working together is wonderful.’ may 2014, vol. 6, no. 1 ajhpe 5 research theme three: skills needed for working as a team participants realised which skills, other than clinical skills, they need to acquire: leadership. they reflected on the need to clearly delegate work and direct team members.[9] ‘in the beginning there was no leader … no one took the initiative to start the whole thing.’ ‘i have learned how to take [the] lead [in] an emergency situation, and also how to follow another colleague when he is in charge of an emergency.’ clear communication. this competency is most commonly emphasised as needed for collaborative practice and teamwork. there was a realisation that the team members need to articulate more clearly.[10] ‘i have to be a good leader and have good communication skills.’ ‘i did not know who should suture the wound, no orders were given.’ ‘we lacked on the communication part.’ theme four: effect of being observed by peers some of the participants who actively participated in the simulation in front of their peers reflected that they felt intimidated and nervous, as they were being watched by their peers. the large number of onlookers, and because everybody was not as exposed to critisism as the participants in the simulation, added to their uneasiness. ‘i think this is a good initiative, but it should be done by small numbers of students so that participation is maximum with no bystanders only the examiner, so that students can confidently participate without psychological inferiority and fear due to the large number of group mates.’ ‘i was nervous because i was being watched.’ theme five: ipe in the curriculum participants expressed the need for ipe to become a formal part of their curriculum as they realised the need for better understanding of professional roles. students also realised the potential of learning from each other: ‘we strongly need to interact with other professions. we should start working together or have tutorials/discussions to improve on our knowledge and skills.’ ‘it should be done on a regular basis.’ discussion ipe was generally well received by participants. the outcomes concur with recent studies that report participants’ positive attitudes towards this mode of education, gains in their knowledge (understanding of roles and care content), team skills, leadership, and communication.[1] one key competency of interprofessional collaborative practice for patient-centred care not addressed by participants was negotiation for conflict resolution.[11] participants noted that the simulation in a controlled environment was a good learning experience, supported by the increase in test scores. however, the significant increase in knowledge, as measured by the mcq test related to trauma management, can be ascribed not only to learning with members of another profession but also to the repetition of the test and the simulation itself. participants experienced difficulty in translating the theory they acquired in class into practice and prioritising actions during the simulation. strategies such as interactive and experiential teaching are well suited for enhancing their practical skills and considered essential to the successful delivery of ipe within student groups with diverse levels of experience.[3] simulation provides the ideal educational strategy, as it demands practical experience with an interactive element that is authentic and true to the principles of adult learning.[10] the use of ‘real’ patient scenarios in simulation is therefore highly valued as a vehicle for small-group, mixed professional learning.[12] interdependence in education also highlights the importance of understanding and appreciating the roles, responsibilities and skills of other healthcare workers.[2] ipe literature reviews describe the outcomes as the development of team-related competencies such as mutual respect, role knowledge and clarification, patient-centred care, and team communication. interprofessional teams form an integral part of the vision of interdependence in education and highlight the importance of understanding and appreciating the roles, responsibilities and skills of other healthcare workers.[2] it is noteworthy that some participants felt intimidated being observed and preferred less exposure to peers, especially those they did not know. being watched is intimidating,[13] and discomfort due to peer assessment is reported as having a negative impact on the co-operative, non-judgemental atmosphere of groups.[14] participants commented on the need for ipe to become a formal part of the curriculum, which concurs with the general satisfaction with these training activities expressed in the literature.[1] a global scan on ipe revealed that, although research evidence shows that ipe should be a mandatory component of every health professional’s education, only 38% reported that this activity was mandatory for all students.[15] conclusion medical students gained clinical insight during the simulation and became aware of their lack of skills and knowledge, as well as the value of shared learning. evidence from the literature and perceptions of our students indicate that ipe could be very beneficial to all students if integrated into the formal curriculum, with sufficient time for all students to participate, preferably without being observed and assessed by peers. our study confirms that ipe at medunsa is a beneficial mode of education and in future should foster an interest in designing and delivering these structured learning experiences in the various curricula at our institution. ipe events have the potential to expand students’ understanding of the contribution made by other professionals and to give them the opportunity to acquire and practise skills required for effective teamwork. references 1. abu-rish e, kim s, choe l, et al. current trends in interprofessional education of health science students; a literature review. j interprof care 2012;26(6):444-451. [http://dx.doi.org/10.3109/13561820.2012.715604] 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/s0140-6736(10)61854-5] 3. forte a, fowler p. participation in interprofessional education: an evaluation of student and staff experiences. j interprof care 2009;23(1):55-66. [http://dx.doi.org/10.1080/13561820802551874] 4. kanter sl. can we improve interprofessional team-based patient care without calling 911? acad med 2012;87(3):253-254. [http://dx.doi.org/10.1097/acm.0b013e31824aabcd] 5. hammick m, freeth d, koppel i, reeves s, barr h. a best evidence systematic review of interprofessional education: beme guide no. 9. med teach 2007;29(8):735-751. [http://dx.doi.org/10.1080/01421590701682576] 6. teunissen pw, scheele f, scherpbier ajja, et al. how residents learn: qualitative evidence for the pivotal role of clinical activities. med educ 2007;41(8):763-770. [http://dx.doi.org/10.1111/j.1365-2923.2007.02778.x] 7. blackstock fc, jull ga. high fidelity patient simulation in physiotherapy education. australian journal of physiotherapy 2007;53(1):3-5. [http://dx.doi.org/10.1016/s0004-9514(07)70056-9] 8. mcnemar’s test. statistic solutions. http://www.statisticssolutions.com/academic-solutions/resources/directoryof-statistical-analyses/mcnemars-test/ (accessed 10 march 2014). 9. suter w, arndt j, arthur n, parboossingh j, taylor e, deutchlander s. role understanding and effective communication as core competencies for collaborative practice. j interprof care 2009;23(1):41-51. [http://dx.doi. org/10.1080/13561820802338579] 10. bligh j, bleakley a. distributing menus to hungry learners: can learning by simulation become simulation of learning? med teach 2006;28(7):606-613. [http://dx.doi.org/10.1080/01421590601042335] 11. macdonald mb, bally jm, ferguson lm, et al. knowledge of the professional role of others: a key interprofessional competency. nurse educ pract 2010;10(4):238-242. [http://dx.doi.org/10.1016/j.nepr.2009.11.012] 12. howden s, cable s, harrasi sa, et al. evaluating a strategy to assist undergraduate healthcare students to gain insights into the value of interprofessional education experiences from recently qualified healthcare professionals (hsap repository module: m10246 2011). edinburgh: the higher education academy, queen margaret university, 2011. http://repos.hsap.kcl.ac.uk/content/m10246/1.1/ (accessed 3 december 2012). 13. practical doc. practical observation techniques. http://www.practicaldoc.ca/teaching/practical-prof/ observation-feedback/practical-observation-techniques/ (accessed 1 april 2013). 14. papinczak t, young l, groves m. peer assessment in problem-based learning: a qualitative study. advances in health sciences education theory and practice 2007;12(2):169-186. [http://dx.doi.org/10.1007/s10459-005-5046-6] 15. rodger s, hoffman sj. where in the world is interprofessional education? a global environmental scan. j interprof care 2010;24(5):479-491. http://dx.doi.org/10.3109/13561820.2012.715604] http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1080/13561820802551874] http://dx.doi.org/10.1097/acm.0b013e31824aabcd] http://dx.doi.org/10.1080/01421590701682576] http://dx.doi.org/10.1111/j.1365-2923.2007.02778.x] http://dx.doi.org/10.1016/s0004-9514 http://www.statisticssolutions.com/academic-solutions/resources/directory-of-statistical-analyses/mcnemars-test/ http://www.statisticssolutions.com/academic-solutions/resources/directory-of-statistical-analyses/mcnemars-test/ http://www.statisticssolutions.com/academic-solutions/resources/directory-of-statistical-analyses/mcnemars-test/ http://dx.doi.org/10.1080/13561820802338579] http://dx.doi.org/10.1080/13561820802338579] http://dx.doi.org/10.1080/01421590601042335] http://dx.doi.org/10.1016/j.nepr.2009.11.012] http://repos.hsap.kcl.ac.uk/content/m10246/1.1/ http://www.practicaldoc.ca/teaching/practical-prof/ http://dx.doi.org/10.1007/s10459-005-5046-6] ajhpe issn 0256-9574 african journal of health professions education may 2013, vol. 5 no. 1 article 22 july 2012, vol. 4, no. 1 ajhpe objectives. there are 19 physician anaesthesia training programmes within the 16 southern africa development community (sadc) region countries, all based in 7 countries. with a new mmed anaesthesia programme starting in botswana, the study sought to compare the curricula of these programmes, identifying the similarities and differences. design. course programme directors were contacted for information, other information was sought from the internet and following up literature references. follow-up telephone and email conversations were used to fill in gaps where possible. document analysis and tabulation of results were done. results. of the 19 programmes there was little or no information on 6 (2 in the democratic republic of the congo (drc) and 4 in madagascar). of the remaining 13 programmes, 8 are in south africa. the south african and botswana programmes use competency-based training (cbt) and use both the college fellowship and the mmed simultaneously. the remaining programmes in zimbabwe, malawi and tanzania use a traditional curriculum and are entirely mmed programmes. in general the faculties are small, resulting in small trainee intakes. programme duration is generally 3 years in east africa (including tanzania – a sadc member) and 4 years in southern africa. entry requirements are generally similar but internal organisation of the courses differs. this is important for meeting regional harmonisation policies. conclusions. this paper adds to the literature and discusses some of the key issues facing training programmes in the region. a mixture of college fellowshipand university-based mmed programmes with new thinking on curriculum will be required to grow the specialty’s role in service delivery. ajhpe 2012;4(1):22-27. doi:10.7196/ajhpe.156 introduction there is a global concern that africa’s health workforce is inadequate in quantity and quality. the continent is the hardest hit by the ‘skills drain’ crisis of health workers. the establishment of a medical school in botswana with both undergraduate and postgraduate courses is of national and regional importance because it adds to the training capacity in the region. with its small population and relatively developed economy it is expected that the national needs will be met in a reasonably short period of time and the training focus can then shift to training for the region. the ‘region’ is essentially the southern africa development community (sadc) (fig. 1), but botswana has been attractive to people from further afield because of its stable economic and political history. the university of botswana inaugurated a new medical school in august 2009. as well as initiating an undergraduate programme, there has been urgency in setting up postgraduate medical courses. this has been driven by a shortage of batswana doctors in the health system. over the last 10 years nearly 1 000 batswana have been sent outside the country (australia, ghana, ireland, south africa, uk and west indies) to train. only about 60 are currently on the botswana health professions council (bhpc) register. it is hoped that by providing local training, more batswana graduates will remain in botswana, while the postgraduate courses will attract back some of those abroad. this has been the case with other training programmes elsewhere in africa.1 the postgraduate anaesthesia curricula currently used in countries such as the uk, australasia and north america are being changed to a competencybased training (cbt) model structured around the canmeds graduate profile.2 this is the approach the university of botswana school of medicine (ubsom) is using in its undergraduate and mmed curricula design. comparison between mmed anaesthesia programmes in the sadc farai daniel madzimbamuto senior lecturer, department of anaesthesia and critical care medicine, university of botswana school of medicine, gabarone, botswana farai daniel madzimbamuto corresponding author: farai madzimbamuto (faraitose@hotmail.com) fig. 1. southern africa development community (sadc) countries. source: sarua (http://www.sarua.org). article 23 july 2012, vol. 4, no. 1 ajhpe traditional curricula tend to focus mainly on the examination process and are designed to meet examination needs. teaching in such programmes is mostly didactic and teacher-focused. it is seen as less resource-intensive compared with the cbt model, which relies on intensive and repetitive assessment of competencies. some universities in the region have been reluctant to take on the new medical curriculum design model on resource grounds. finally, it is part of the sadc programme to make the educational programmes in the region mutually registerable through harmonisation of curricula.3 in the longer term, a cbt model for curriculum design may achieve this goal. aim there is a paucity of published literature on the development of anaesthesia training programmes in africa and their current activities. all the training programmes in the sadc region, including those in south africa, do not train enough to meet their national needs, let alone regional needs. documenting the features of the current programmes could facilitate discussion about how best to develop these programmes for the future and standardise learning in existing programmes within the sadc region. literature review anaesthesia is one of the postgraduate medical courses that started in 2011 at ubsom. this programme joins others in the region in the democratic republic of the congo (drc), madagascar, malawi, south africa, tanzania and zimbabwe; several other countries do not have programmes, e.g. zambia, lesotho, swaziland, mozambique, angola, mauritius and the seychelles. challenges to the development of anaesthesia as a specialty in sub-saharan africa are many. as a service, it supports many other disciplines, whose development is thereby limited. different models of training physician anaesthetists are operating in the region simultaneously. the universitybased masters in medicine (mmed) programmes are preponderant over the college fellowship-based training format. south africa combines the college format, through the south african colleges of medicine, with the university-based mmed. in the east, central and southern african college of surgeons qualification, surgical training using the fellowship format is available alongside the mmed programmes but this is not the case in anaesthesiology. however, the college qualification, whether from south africa or abroad, is recognised by the health professions registering bodies in the region. mmed programmes in sub-saharan africa, with the exception of south africa, started at makerere university, kampala, uganda, in surgery in the late 1960s. the first group qualified in 1970, but little has been published in the literature about them.1 the early programmes were modelled on those of the uk colleges and graduates were eligible to sit the final exam of the royal college of surgeons of edinburgh. this was essential to validate the mmed qualification and give it credibility among african medical graduates who did not want to have an inferior postgraduate qualification imposed on them. later programmes in the region used the experience of makerere university and others to develop their own programmes.1 anaesthesia training programmes in the region are independent of each other, with the exception of the malawi mmed in anaesthesia which is linked to 2 years of training in south africa through the university of cape town. the mmed in zimbabwe was linked to the stoke school of anaesthesia with trainees spending 6 months of the 4-year programme in the uk. although not in the sadc, the programmes in many parts of africa are linked to external programmes such as uganda to canada, rwanda to canada and the usa, etc.4 although partners for the botswana programmes have not yet been identified, it is anticipated these will be south african institutions. south africa has had two separate systems of certifying anaesthetists since the 1950s; training leading to a fellowship of the college of anaesthetists (fca) of the colleges of medicine of south africa and the university-based mmed (anaesthesia).5 more recently there has been recognition of the need for uniform certification based on the college of anaesthetists examinations to standardise the quality of training across the 8 different medical schools. in the east central and southern african regions, which include all the sadc countries, the surgical associations have established a college of surgery which offers a fellowship programme with training decentralised to include district hospitals.6 this programme runs alongside the mmed (surgery) programmes offered by the various universities. establishment of programmes at ubsom has taken into account current training practices globally as well as regionally. in addition to questions about harmonisation of higher education programmes in africa, and the sadc in particular, the programmes speak to the differences between the mmed programmes in the region.3 no literature could be found on programmes in the francophone parts of the sadc. the francophone west africa region is even more poorly resourced than the sadc region.7 in many countries the departments of anaesthesia are still organised within the surgical departments, limiting their development and profile as attractive postgraduate career options.8,9 methods universities in the sadc region that run postgraduate training programmes in anaesthesia were identified and contacted. the programme directors were contacted through the dean’s office. ‘significant other’ programmes, such as at makarere university, were considered as they have had a major influence on mmed programmes in the region and have the same regulations across the east african community (eac), which includes one member of the sadc, tanzania. a consent form was used to enrol participants. follow-up telephone or email discussions were conducted with programme directors to obtain additional information, where needed. questions that often needed additional information related to numbers of trainees per intake, staff in the department, external links and methods of assessment. it was often difficult to get simple answers about intakes and staffing levels because both varied widely from year to year for some institutions. the websites of the institutions were searched for information about the respective mmed curricula. individuals in departments were also contacted where information was lacking or deficient. this was done by telephoning the departments or searching the journal literature for authors from those departments. course descriptions of methods of instruction, assessment and evaluation were recorded and tabulated for comparison (table 1). other information was collected for providing background and any local context, such as: course article 24 july 2012, vol. 4, no. 1 ajhpe duration, any changes during this period and whether the programme has accreditation in other countries. results there are 102 universities in the sadc region (table 2), out of which 23 have medical schools (8 medical schools in south africa). only 7 of the 16 sadc countries have physician postgraduate anaesthesia training programmes. angola and mozambique do not have any such programmes. the drc and madagascar (french-speaking) have physician postgraduate programmes modelled on a different system to the mmed. limited information was obtained from the drc but none from madagascar. only 4 countries have more than one medical school in the region, these being the drc (2), madagascar (4), south africa (8) and tanzania (3). historically universities in the region have been state-owned or parastatal institutions with funding from the local government. a number of universities are now privately owned and funded. these may be supported by faith-based organisations (kilimanjaro christian medical college (kcmc), tanzania), or independent funding (hubert kairuki university, tanzania). it can be seen in table 3 that there is a very wide variation in the number of anaesthetists in each country and the ratio of anaesthetists to the population. all the statistics reflect serious shortages compared with well-resourced countries where anaesthetists average 1:10 000 population. some countries such as botswana and malawi are completely expatriate-dependant for physician anaesthetists, many of whom are on short-term contracts. the duration of training programmes varies from 3 to 5 years. most postgraduate anaesthesia programmes currently consist of a basic science part i and clinical part ii training process. tanzania is part of the east african community (eac – together with kenya, uganda, rwanda and burundi) as well as the sadc. within the eac all the state universities (except rwanda) have shortened their programmes to a 3-year mmed programme with a 1-year part i component. in tanzania, kcmc has retained the 4-year mmed. in south africa part i of the fca is pre-programme, and the part ii longer. the entry requirements for the training programmes are broadly the same. after students obtain the mb bs/mb chb (md in tanzania) qualification, a variable period of internship (ranging from 2 to 3 years) is required to achieve table 1. sources of information on mmed programmes in the sadc region country programme director website journal articles personal communication botswana university of botswana school of medicine course regulations syllabus none none congo , drc university of kinshasa university of lubumbashi none yes syllabus (contact found through following journal references) madagascar none none none none malawi university of malawi college of medicine course regulations syllabus none none personal communication south africa colleges of medicine of south africa university of cape town university of the free state university of kwazulu-natal limpopo university (medunsa) university of pretoria stellenbosch university walter sisulu university university of the witwatersrand pretoria : course regulations syllabus and regulations (cmsa) course regulations (uct) regulations/syllabus (ufs) mmed handbook (ukzn) prospectus (medunsa) programme intake (all) staff establishments (all) prospectus (wsu) none college of anaesthetists sa regulations course regulations tanzania kilimanjaro christian med college muhimbili university of health and allied sciences (muhas) course regulations (kcmc) course regulations (muhas) none information about intake zimbabwe college of health sciences, university of zimbabwe course regulations syllabus none none information about intake table 2. postgraduate physician anaesthesia programmes in the sadc sadc countries universities medical schools postgraduate anaesthesia programmes countries with mmed (anaesthesia) programmes (n) 16 102 23 (8 in sa) 19 (8 in sa) 7 article 25 july 2012, vol. 4, no. 1 ajhpe full registration as a medical doctor. the degree of anaesthetic experience each candidate brings pre-programme is very variable. in the traditional undergraduate curriculum, anaesthesia consisted of a few didactic lectures and a short rotation of exposure through an anaesthesia department. during internship in some countries, there is a rotation in anaesthesia in the central (zimbabwe) or district/rural hospitals (south africa). in countries where there is a diploma in anaesthesia (da), this is variably used as a requirement (south africa), an added advantage (uganda) or a barrier course into the mmed programme (zimbabwe). trainees who do not progress to the mmed level still have considerable anaesthesia skills to work in district areas where the skills of a specialist anaesthetist may not be fully utilised. part ii of the postgraduate anaesthesia programmes consists of clinical training and a dissertation. the dissertation is aimed at developing the research skills of trainees. it is not clear from the requirements of many programmes whether publication is a required outcome, but publication standard is expected at all institutions. with the exception of 6 of the 8 south african universities, all the anaesthesia departments in the sadc region have few academic staff, usually less than 5. the anaesthesia departments are usually staffed by nurse anaesthetists, clinical officers, etc., who deliver a substantial amount of the workload. the trainee intakes are correspondingly small, being generally 5 or less. in south africa, through a combination of joint academic and service appointments, and large secondary level hospitals with anaesthetic specialists, university departments have a large pool of anaesthetic specialists who augment the academic staff. their intakes are larger, being at least 10 annually. discussion the results (table 1) illustrate the difficulty in obtaining and comparing information about anaesthesia training programmes in africa. there is very table 3. structure of mmed programmes in the sadc region country (number of local physician anaesthetists ) number of physician anaesthetists per population (million) programme title duration (years) entry qualification first part second part curriculum academic staff/ numbers of trainee per intake botswana (none) (only expats): for ~2 million mmed (1 programme) 4 mb bs + 2 years 2 years + part i year 4: part ii + dissertation cbt 2:6 gaborone congo (drc) (50) ~1:1 200 000 2 programmes 5 mb bs + 2 years year 5: final exam traditional kinshasa? lubumbashi ? madagascar ? :20 million population 4 programmes mb bs + 2 years ? malawi 1:13 million (many expats) mmed (1 programme) 4 mb bs + 2 years year 1: part i year : part ii + dissertation traditional 1:2 south africa (900) 1:55 000 mmed, fca (8 programmes) 4 mb bs + 2 years 6/8 prog da + part i, fca pre-entry year 4: part ii + dissertation cbt 8 : ? medunsa 6 : ? walter sisulu university 22+:10 university of pretoria 60+:10 university of the witwatersrand 20+:10 university of the free state 40+:10 university of kwazulu-natal 40+:10 university of cape town tanzania (13) 1:3 million mmed (2 programmes) 3, 4 mb bs + 2 years year 1: part i yr 3/4: part ii + dissertation traditional ?:5 muhimbili 1-2:1 kilimanjaro zimbabwe (35) 1:350 000 mmed (1 programme) 4 mb bs + 2 years year: da year 2: part i yr 4: part ii+ dissertation traditional 1-4:5-10 cbt = competency-based training; da = diploma in anaesthetics. article 26 july 2012, vol. 4, no. 1 ajhpe little in the published literature and there are also significant differences and similarities in the structure of the programmes. publication in this area clearly needs to develop. historically the qualification in anaesthesia was at diploma level which started in the uk in 1934. some programmes have dispensed with the da while others have separated it from the mmed (south africa). the zimbabwe programme has a 1-year diploma integrated into the mmed with part i forming the second year of the programme. this is a qualification that is underutilised, especially where basic anaesthesia skills are needed to support mid-level health workers.11 with the growth of family medicine as a specialty in africa, the da could allow for a new lease on life for districtlevel hospital specialists. the part ii and the mmed programme as a whole are designed to produce a generalist anaesthesia specialist through a series of rotations in the main subject areas of anaesthesia, such as obstetric, neurosurgical, thoracic, ear, nose and throat (ent), paediatric, orthopaedic and trauma anaesthesia, as well as intensive care medicine and pain management. the cbt model states explicitly what outcomes are expected from the training and each rotation, whereas in the traditional curricula these are only stated in general terms. two countries (9 programmes) use cbt in the region. a dissertation is required in addition to the clinical rotations. in a study from the university of nairobi, where 285 dissertations were completed by mmed trainees in the department of surgery (including 46 by anaesthesia trainees) over a 22-year period, there is no report of a publication.8 there was one phd, however. there are no reports from other mmed programmes. abroad the duration of training is increasing; in part because of reduced working hours for doctors, but largely because of the expanding role and complexity of the anaesthetic domain. critical care, pain medicine and emergency medicine have expanded in addition to the growing role of anaesthetists in hospital quality of care improvement. it cannot be argued that shortening the duration of training programmes to 3 years makes a significant impact on the number of anaesthetists in service (table 3) as the programmes generally have small annual intakes and national service requirements are enormous. one-year diplomas (e.g critical care medicine) and 2-year subspecialty mphil and ms (e,g. paediatric anaesthesia) programmes have been added to some mmed programmes as a way of extending training time. the small number of specialist anaesthetists in academic departments does not allow an opportunity for the specialty to develop as a critical mass is not achieved. the departments of anaesthesia are sometimes found within surgical departments where they are dominated and overshadowed, or exist in environments where service attitudes minimise the role of physician anaesthetists. the clinical workload is large and the mid-level anaesthetists (nurse anaesthetists, clinical officers, etc.) who do most of the basic anaesthesia and are present in larger numbers, are neither in a position to develop the specialty nor affect service delivery. most of the programme graduates leave for private practice after a short period, disperse thinly across a wide range of hospitals or leave the country. the result is that numbers grow slowly and critical mass is not achieved. other consequences are that the training programmes themselves renew slowly and recent developments take time to be assimilated. in view of the many issues facing anaesthesia in sub-saharan africa in general, and the individual countries in particular, it may be opportune for a discussion about what kind of anaesthesia training programmes do, or want to, produce. the service load is disproportionate to the numbers of anaesthetists and the programmes will never meet the demand in their current form. an anaesthetist ‘for service’ (the current product) essentially takes over where the mid-level health worker’s capability ends. what are needed are probably, additionally, higher level skills to develop and supervise the whole anaesthesia service. the canmeds1 explicitly defines the skills to be achieved over a range of domains, which allows for definition of a locally relevant skills mix. with small faculties come small intakes. it is possible to increase intakes by devolving training over a group of hospitals (‘school of anaesthesia’ or ‘teaching platform’). this also brings ‘service’ specialists into the teaching/ training domain and increases teaching capacity for a variety of cadres, not just physician anaesthetists. the low profile of anaesthesia and its relatively poor perception among medical students is partly because it is overshadowed by surgery, but also because it is perceived as a non-medical (or mid-level health worker) specialty. this perception may limit recruitment to programmes (many programmes in africa suffer recruitment shortage) but the perception can be changed by greater engagement of anaesthetists with undergraduate teaching and public and global collaborations in anaesthesia training. conclusion this paper adds to the literature, as well as discussing some of the key issues facing anaesthesia training programmes in the region. anaesthesia as a specialty in africa is small and struggling to attract physician trainees while trying to emerge out of the shadow of surgery and find a balance with the middle-level health worker role. a mixture of college-based fellowship and university-based mmed programmes with new thinking on curriculum design is required to grow the specialty’s role in service delivery and academic scholarship. references 1. loefler ijp. symposium: surgical training: a short history of surgical training programmes in eastern africa. east central afr j surgery 1998;5:55-61. 2. canmeds 2005. the royal college of physicians and surgeons of canada, http://www. royalcollege.ca/public/resources/aboutcanmeds (accessed may 2012). 3. hahn k. towards a sadc area of higher education. nepru research project no 30. http;//wwwisis.unam.na/hivdocs/unicef/socio-economic/nepru?nnr30 (accessed 2 july 2012). 4. enright a. anaesthesia training in rwanda. can j anesth 2007;54:935-939. 5. degiamis e, oettle gj, smith md, et al. surgical education in south africa. world j surg 2009:33:170-173. 6. lane r. surgical education and training in the cosecsa region. east and central african journal of surgery 2009;14:1-12. 7. lokossou th, zoumenou e, secka g, et al. anaesthesia in french-speaking sub-saharan africa. acta anesth belg 2007;58:197-209. 8. magoha gao, mgumi zww. training surgeons in kenya at the university of nairobi teaching hospital. east afr j med 1999:76:462-464. 9. jochberger s, ismailova f, banda d, et al. a survey of the status of education and research in anaesthesia and intensive care medicine at the university teaching hospital in lusaka, zambia. archives of iranian medicine 2010:13:5-12. 10. hodges sc, mijumbi c, okello m, et al. anaesthesia services in developing countries: defining the problems. anaesthesia 2007;62:4-11. 11. gordon pc, mfm james. the role of the college of medicine diploma in anaesthesia in southern africa. s afr med j 1999;89:416-418. article 27 july 2012, vol. 4, no. 1 ajhpe appendix anaesthesiologists: north american terminology (and some continental european countries) for a physician with specialist training and certification in anaesthesia. in north american nomenclature ‘anaesthetist’ refers to a non-physician who is trained and works in anaesthesia roles. anaesthetist: in the british (and commonwealth) system it is generally applied to physician anaesthetists, qualified and in training. for other anaesthesia providers the term is qualified, such as ‘nurse anaesthetist’. sometimes the term ‘physician anaesthetist’ is used to make the distinction. mid-level anaesthetist: non-physicians trained to give anaesthesia. in some countries these are nurses (zimbabwe, botswana, and uganda), clinical officers (tanzania, kenya) or technicians (zambia, mozambique). mid-level health worker: same as mid-level anaesthetists but trained for other fields such as obstetrics, internal medicine, etc. professional associations use both terms in their names. often the use of the term anaesthesiologists indicates that no mid-level health workers are included in the association e.g. south african society of anaesthesiologists (sasa) or kenya society of anaesthesiologists (ksa) or to conform to naming styles of other societies (botswana society of anaesthesiologists). most societies in the british commonwealth countries use the term anaesthetists. health professions councils and employers in the region tend to use the terms ‘specialist anaesthetist’ for fully trained physician anaesthetists. may 2015, vol. 7, no. 1 ajhpe 47 research blended learning, the ‘thoughtful integration of online and face-to-face-instruction’,[1] is rapidly increasing in the higher education arena. subsequently, a body of research has begun to develop that investigates the incorporation of technology into teaching and learning practices across disciplines and on various topics.[2] in health professions education, early consensus in the literature was that students were satisfied with e-learning or blended learning – an effective method of instruction.[3] furthermore, blended learning has been identified as a possible means of bridging the gap between theory and clinical knowledge in health professions education.[4] included in the body of research related to blended learning in health professions education, the use of videos in presenting patients for problembased learning (pbl) cases has been shown to enhance the overall learning experience and engagement of medical students, and in turn supported a patient-centric perspective in the training of students.[5] this study aimed to add to the body of research on the effectiveness of blended learning and apply the use of technology to a pbl physiotherapy module. the addition of videos and blogging was implemented to enhance the engagement of students in the pbl module by extending the dialogue platform available to the students. the results of the study indicate that planning and implementation of innovation in teaching and learning should be done with careful consideration of student preference and level of competency with new technology. this article is therefore presented to aid health professions educators in their planning during the pre-implementation phase of an innovation in blended learning. literature in the literature, blended learning is often used interchangeably with e-learning. the danger is that technology-enhanced teaching/learning, which might include mostly online teaching approaches, is not adequate in describing what a blended learning approach entails.[6] blended learning requires educators to adapt the method of instruction and overall planning of their modules. at the core of blended learning, is the underlying premise that teaching and learning practice incorporates both online and face-toface instruction and has been dubbed to be one of the greatest trends in higher education practice within the past 10 years.[7] the literature provides a variety of definitions of pbl. there are six core characteristics that underpin the various definitions of pbl, two of which are that learning is student centred and new information is acquired through selfdirected learning.[8] research has shown that students exposed to pbl are better equipped in the real world owing to their increased retention of knowledge, enhanced integration and application of basic science concepts into clinical contexts and subsequent enhancement of their intrinsic interest in the subject matter.[9] however, pbl cannot be used in isolation to achieve the level of transfer to the clinical environment to the exclusion of other measures.[10] using technology together with pbl in a blended learning approach has been found to have a positive impact on students’ learning outcomes.[11] students have reported a high satisfaction and usage rate of e-learning tools in pbl programmes implemented in medical schools.[12] ultimately, students and staff alike have found that e-learning enhances both teaching and learning by enabling learners to achieve increased motivation, performance and retention rates of knowledge, skills and attitudes.[3] it would be of value to explore the benefits of this approach within physiotherapy.[13] background. early indications are that blended learning in health professions education has a positive influence on student satisfaction and learning. this is encouraging, as the call to incorporate technology in teaching and learning in higher education is increasing. the student voice in the planning and implementation of blended learning strategies is, however, not adequately addressed in many of the studies to date. objective. to utilise videos and blogging in a problem-based learning physiotherapy module to enhance student engagement with content of problembased cases. methods. students completed a needs-analysis and engagement question naire. videos made by students were uploaded to the learning management system and subsequent use of these videos was recorded. two focus group discussions were held to evaluate students’ perceptions of the blended learning strategies. results. students perceived the level of engagement during case presentation periods to be satisfactory, but unsatisfactory outside of such periods. focus group discussions identified the technology used in this study as being inappropriate for this population. students had specific expectations of the roles of staff and students. there was a perceived lack of skill with regard to the use of the technology chosen. conclusion. there is a need for the student voice to be heard with regard to both the rationale for implementation and the type of technology used in blended learning strategy innovations. this study recommends that student-generated videos of clinical skills could be implemented successfully with adequate support from staff. afr j health professions educ 2015;7(1):47-50. doi:10.7196/ajhpe.371 a lesson in listening: is the student voice heard in the rush to incorporate technology into health professions education? l keiller,1 bsc (physio), mphil (hse); g inglis-jassiem,2 bsc (physio), msc (physio) 1 centre for learning technologies, division of teaching and learning enhancement, stellenbosch university, cape town, south africa 2 division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: l keiller (lkeiller@sun.ac.za) 48 may 2015, vol. 7, no. 1 ajhpe research a number of authors have expressed concern regarding the apparent focus of blended learning research on technology and institutional benefits to the exclusion of pedagogy and theoretically supported application.[2,6] where the research has included the student perspective, it reported on their attitudes, knowledge and experience of information, communication and technology tools rather than providing insight into the participatory role in the design and revision of the initiative.[14] there is, however, a trend in higher education research to recognise the student voice more explicitly.[15] furthermore, the most cited research regarding blended learning largely focuses on the learning outcomes to be reached with implementation of such a strategy,[2] but provides limited insight into the potential that eliciting the student voice in planning these interventions could provide. methods this empirical study was conducted with a group of third-year physiotherapy students enrolled in the applied physiotherapy module at the division of physiotherapy, stellenbosch university (su), south africa. ethical approval was granted by the health research ethics committee at the faculty of medicine and health sciences, su (n11/07/240). students (n=40) and staff (n=1) provided their consent to participate in the study. context a hybrid pbl strategy has been the main method of instruction for third-year undergraduate physiotherapy students at su since 2007. this strategy consists of 36 cases, with a total of 10 hours of contact time available for each case. a case is initiated with a tutorial session on day 1, followed by a practical session on day 2, and a feedback session on day 3. students would generally begin with the next case on the same day as the feedback session of the preceding one. module feedback from students and staff has consistently expressed concern with regard to the quality and depth of engagement with case content since inception. intervention students were invited to attend a training session on how to access and utilise a university-based blogging platform for discussion of case content and for post-study reflections. they were also provided with access to a hand-held video camera, with the aim of recording practical skills done during the practical component of each pbl case. a self-administered engagement questionnaire was completed by all students prior to and upon completion of the study period[16] (addendum a). this was preceded by a needs analysis survey that aimed to identify perceptions of the staff and students of the need for enhanced engagement in the module. videos made by students were loaded on the learning management system and usage statistics monitored. digitally recorded semi-structured focus group interviews were held with two groups of students immediately after the intervention period. these were transcribed and thematically analysed. results the needs analysis survey was completed by 18 students (45%). the survey identified students’ perceptions of engagement at two different time points, i.e. during the completion of the pbl case and outside of that time period. with regard to engagement over the 3 days in which a case is presented, students perceived themselves to be engaged in the discussion and practical sessions of the cases (fig. 1). students have the perception that case materials are unsatisfactory and that they are not provided with enough time to fully engage with content for each case. they perceived themselves as being less engaged with case content and to have limited ability to recall the practical skills covered in the cases (fig. 2). the self-administered, validated, engagement questionnaire showed that students perceived that they were actively engaged in pbl cases both prior to and on completion of the study period. with regard to the intervention, one student utilised the video camera to make two videos in a single case practical session. these two videos were accessed 23 times on the learning management system. students did not access the blogging platform throughout the study period. five themes emerged from the thematic analysis of the focus group discussions. these are graphically represented in fig. 3, with supporting quotes for clarification. students perceived the intervention to be flawed in that they had to spend extra time collecting the video camera, which they considered to be unwieldy, and setting it up during the practical session. this was perceived to be unnecessary use of their time. they were unfamiliar with the practice of blogging and gave this as a reason for not accessing the blog even after the training session they attended for this purpose. furthermore, 16 14 12 10 8 6 4 2 0 strongly disagree disagree neutral agree strongly agree i feel that students are actively engaged in discussions during tutorial sessions i feel that students are actively engaged in practising their techniques in the practical sessions i feel that students are actively engaged in discussions during feedback sessions fig. 1. student perceptions of engagement during case sessions. strongly disagree disagree neutral agree strongly agree 9 8 7 6 5 4 3 2 1 0 i am satis�ed with the current learning material generated from applied physiotherapy cases i feel that the students are engaging in discussions related to cases after the case has been concluded i feel that students are able to recall practical techniques related to a speci�c case when needed in the clinical setting i feel that students are given enough time to fully understand and research each case scenario fig. 2. student perceptions of engagement after case completion. may 2015, vol. 7, no. 1 ajhpe 49 research they indicated that the intervention was not a priority for them as it was not a compulsory assessment-related activity. finally, students considered it the responsibility of the lecturers to facilitate the increased engagement with cases, also staff-generated videos. discussion students in the hybrid pbl module responded to the needs analysis survey with their perceptions of a lack of engagement with case material and, worryingly, their inability to recall clinical techniques in relation to specific pathological conditions. this was interpreted by the researchers as a positive indication that the implementation of videos and blogging may be useful to address these issues in addition to the evidence in the literature for a more blended learning approach. however, the lack of participation in the study prompted us to investigate the underlying reasons for the students’ response to the intervention and their expectations with regard to the methods used to increase engagement in pbl sessions. students’ perceptions, as highlighted by the focus group discussions, were useful in identifying the limitations of the strategies employed in this study. if we as a research team had adequately engaged with students in planning with regard to the technology used and method of generating videos, the possibility of a higher participation level could have been realised. students perceived the videos of clinical skills as important for their learning, but ultimately expected lecturers to take responsibility for generating and providing access to the videos. the perception of this cohort is similar to what has been previously reported, where students rate the facilitator/academic staff member as being integral to their ability to become self-directed learners in pbl.[17] furthermore, the usefulness of clinical simulations in a digitally recorded format, when developed and provided by academic staff, has been shown to be effective in preparation for clinical placements in allied health professions education.[18] one of the most important lessons learnt while conducting this study, was the need to approach innovations in teaching and learning practices as an opportunity to support students to change their modus operandi for learning. applying principles of change management has been shown to be necessary in an international setting.[19] the eight strategies recommended consist of three phases, the first being to introduce the concept and establish its relevance, then to make it happen, and finally to engage in activities to ensure sustainability.[19] a recommendation from this study is therefore to ensure student participation in the selection of technological devices, method of sharing and availability of recorded techniques. to meet this recommendation, the academic staff would need to investigate the use of mobile devices if students are to participate in the recording of techniques. should academic staff recognise the need, in consultation with students on the usefulness of these student-generated videos, the assessment opportunity thereof will time engagement technology issues lecturer responsibility student responsibility ‘[videos/blogging] will mean doing double the work.’ ‘our class is not ready blogging yet unless it’s for a mark or money.’ • • • • • • • • • • ‘lecturers putting important information on blog will encourage students to go to it.’ ‘lecturers should bring the video camera into the session.’ ‘would be good to have tripod and plinth set up before start of session.’ ‘i don’t have internet in my room ... [to access blog/video].’ ‘unless the facilitator is encouraging engagement, students keep quiet.’ ‘depends on the group that you are in [on whether or not they are engaged in the case discussion].’ ‘not enough time between cases to re�ect and �ll in the gaps and sharing information between groups.’ ‘no time for reviewing videos and going through case work.’ fig. 3. themes identified from focus group discussions on the inclusion of blended learning strategies in a problem-based learning module in an undergraduate physiotherapy curriculum. 50 may 2015, vol. 7, no. 1 ajhpe research need to be investigated. we envisage adding assessed student-generated videos to a database or a repository as a viable option for expanding learning opportunities for undergraduate physiotherapy students. the rationale is that if students are required to demonstrate a clinical skill for assessment purposes, the quality of the videos would be of a sufficient nature for use as a resource. cell phone technology allows students to use their own devices to record these videos and would therefore eliminate the difficulty students had with the video camera provided for them in this study. the practice of generating their own videos for a database could furthermore have a positive impact on their clinical skills.[20] alternatively, if physiotherapy curricula should implement the use of video recording for student learning, the following should be considered: infrastructural technology changes to practical venues, provision of technical support, and staff-generated videos of core techniques. the videos would then be a learning resource for students as opposed to an additional task. conclusion this study highlights the necessity for a deeper understanding of the study population in addition to the literature before following the call to include technology in teaching and learning. evidence from the literature and results of this study support a collaborative effort in the planning of blended learning innovations. even though the participation level and self-directed learning were not clearly evident, we maintain that technology can be used to enhance engagement for students. in hindsight, success is dependent on sufficient planning and implementation of various strategies to ensure optimal participation and satisfaction of both academic staff and students. references 1. garrison dr, kanuka h. blended learning: uncovering its transformative potential in higher education. the internet and higher education 2004;7(2):95-105. [http://dx.doi.org/10.1016/j.iheduc.2004.02.001] 2. halverson lr, graham cr, spring kj, drysdale js. an analysis of high impact scholarship and publication trends in blended learning. distance education 2012;33(3):381-413. [http://dx.doi.org/10.1080/01587919.2012.723166] 3. ruiz jg, mintzer m, leipzig rm. the impact of e-learning in medical education. acad med 2006;81(3):207-212. [http://dx.doi.org/10.1097/00001888-200603000-00002] 4. rowe m, frantz j, bozalek v. the role of blended learning in the clinical education of healthcare students: a systematic review. med teach 2012;34(4):e216-221. [http://dx.doi.org/10.3109/0142159x.2012.642831] 5. bizzocchi j, schell r. rich-narrative case study for online pbl in medical education. acad med 2009;84(10):14121418. [http://dx.doi.org/10.1097/acm.0b013e3181b6ead0] 6. graham cr, woodfield w, harrison jb. a framework for institutional adoption and implementation of blended learning in higher education. the internet and higher education 2012a;18:4-14. [http://dx.doi.org/10.1016/j.iheduc.2012.09.003] 7. graham c. blended learning systems: definition, current trends, and future directions. in: bonk cj, graham cr, eds. the handbook of blended learning: global perspectives, local designs. san francisco, ca: pfeiffer (an imprint of wiley), 2006:3-21. 8. hmelo-silver ce, barrows h. goals and strategies of a problem-based learning facilitator. interdisciplinary journal of problem-based learning 2006;1(1):21-39. [http://dx.doi.org/10.7771/1541-5015.1004] 9. groves m. problem-based learning and learning approach: is there a relationship? advances in health sciences education 2005;10:15-326. [http://dx.doi.org/10.1007/s10459-005-8556-3] 10. wittert ga, nelson aj. medical education: revolution, devolution and evolution in curriculum philosophy and design. med j aust 2009;191(1):35-37. 11. taradi sk, taradi m, radic k, pokrajac n. blending problem-based learning with web technology positively impacts student learning outcomes in acid-base physiology. adv physiol educ 2005;29(1):35-39. [http://dx.doi.org/10.1152/advan.00026.2004] 12. gurpinar e, zayim n, ozenci cc, alimoglu m. first report about an e-learning application supporting pbl: students’ usages, satisfactions, and achievements. turkish online journal of educational technology 2009;8(2):55-62. 13. willet g. development of a prototype computer-based instruction module: foundational neuroscience for physical therapy students. the internet journal of allied health sciences and practice 2004;2(2):1-9. 14. wilkinson a, while ae, roberts j. measurement of information and communication technology experience and attitudes to e-learning of students in the healthcare professions: integrative review. journal of advanced nursing 2009;65(4):755-772. [http://dx.doi.org/10.1111/j.1365-2648.2008.04924.x] 15. maunder re, cunliffe m, galvin j, mjali s, rogers j. listening to student voices: student researchers exploring undergraduate experiences of university transition. higher education 2012;66(2):139-152. [http://dx.doi.org/10.1007/s10734-012-9595-3] 16. o’malley kj, moran bj, haidet p, et al. validation of an observation instrument for measuring student engagement in health pressions settings. eval health prof 2003;26(1):86-103. [http://dx.doi.org/10.1177/0163278702250093] 17. lee y, mann k, frank b. what drives students’ self-directed learning in a hybrid pbl curriculum. adv health sci educ theory pract 2010;15:425-437. [http://dx.doi.org/10.1007/s10459-009-9210-2] 18. williams b, brown t, scholes r, french j, archer f. can interdisciplinary clinical dvd simulations transform clinical fieldwork education for paramedic, occupational therapy, physiotherapy, and nursing students? journal of allied health 2010;39(1):3-10. 19. quinn d, amer y, lonie a, blackmore k, thompson l, pettigrove m. leading change: applying change management approaches to engage students in blended learning. australian journal of educational technology 2012;28(1):16-29. 20. maloney s, storr m, morgan p, ilic d. the effect of student self-video of performance on clinical skill competency: a randomised controlled trial. adv health sci educ theory pract 2012;18(1):81-89. [http://dx.doi.org/10.1007/ s10459-012-9356-1] addendum a items and scoring guide for the student self-report of engagement measure* 1. i contributed meaningfully to class discussions today. 2. i was not paying attention most of the time in class. 3. i contributed my fair share to class discussions. 4. i participated in class discussions today. 5. i talked in class with other students about class material. 6. i was mostly a passive learner in class today. 7. i paid attention most of the time in class. 8. i was mostly an active learner in class today. 9. most students were actively involved in class today. note: response categories for all items ranged from 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), to 5 (strongly agree). subscale totals were calculated by reverse scoring items 2 and 6 and averaging the nine items. *o’malley kj, moran bj, haidet p, seidel cl, et al. validation of an observation instrument for measuring student engagement in health professions settings. evaluation and the health professions 2003;26(1):86-103. [http://dx.doi.org/10.1177/0163278702250093] article 118 december 2012, vol. 4, no. 2 ajhpe research capacity development is a global issue that faces all health professionals as it aims to enhance a profession through providing evidence for intervention strategies and thus assist in improving the quality of the healthcare delivered. however, when it comes to identifying strategies to promote the scholarship of research among health professionals, the published evidence on which to ground this advice is admittedly weak. research capacity development is about producing ability through creating the necessary infrastructure, environment, culture and credibility to enable individuals and departments to undertake these activities.1 many health professional academics lack research qualifications and experience, as the majority are clinicians moving into academia. therefore, it is essential for new academics to actively engage in the process of creating a research portfolio. in a systematic review of literature on the promotion of research productivity among academics,2 it was found that departments needed an overall approach that translated into clear strategies which were well managed and evaluated. the authors further highlighted three main conclusions from their study: • capacity building has been identified as important for enhancing the quality of professional education and the calibre of health professionals, which ultimately impacts on patient care. • very little is reported regarding the processes and outcomes involved in research capacity building initiatives. • academic departments need to adopt a clear overarching approach and well-defined strategies, and must ensure effective communication, leadership and managerial commitment regardless of the specific interventions taken to develop capacity. this paper presents an argument for using participatory action research (par) as a powerful methodology for academic development strategies with a focus on writing for publication, a key component of research capacity development. academic development programmes in many academic institutions may be optional or compulsory and participation may be part of a formal review system allowing promotional opportunities for academics. such systems are becoming more commonplace as there is an increased call for accountability and performance from academics. academic development has been operationalised as ‘an organised set of activities supporting growth toward competence in various dimensions of an academic’s role’.3 meeting the needs of new academics remains a challenge. they may find it difficult to strike a balance between clinical supervision, teaching, research and administration. the literature indicates that academic development programmes focus primarily on improving teaching skills and research skills and facilitating professional development.4 the complex demands placed on university teachers, and the changing roles and work tasks related to these demands, are commonly known. many academics in health professions education have not received formal training in areas such as teaching, research and clinical supervision but skills have been learned over time through practice. a faculty development strategy among academics to promote the scholarship of research j m frantz department of physiotherapy, university of the western cape j m frantz, phd, professor corresponding author: j m frantz (jfrantz@uwc.ac.za) background. identifying strategies to promote the scholarship of research among health professionals is essential. the published evidence on which to ground this advice is weak. aim. this paper presents an argument for using participatory action research as a powerful methodology for academic development strategies that focus on writing for publication, a key component of research capacity development. method. participatory action research was used and participants were all full-time academics in a department in a faculty of community and health sciences. various strategies were adopted to promote the scholarship of research in this department, depending on the experience of the academic and at which stage they were in their academic careers. results. following the intervention strategies the participants were able to use the skills obtained in various activities relating to academia, and most of them were successful in publishing their work. conclusion. it is evident that through the process of participatory action research, participants are able to identify their needs, design an action plan, implement the action plan and reflect on the progress made during the process. creating a conducive environment with resource and human support assisted in creating an environment that promoted the scholarship of research. ajhpe 2012;4(2):118-122. doi:10.7196/ajhpe.177 december 2012, vol. 4, no. 2 ajhpe 119 article according to kolb5 ‘learning is the process whereby knowledge is created through the transformation of experience. knowledge results from the combination of grasping experience and transforming it.’ the use of par in this study has been defined as ‘research which involves all relevant parties in actively examining together current action (which they experience as problematic) to change and improve it. par is not just research which, it is hoped, will be followed by action. it is action which is researched, changed and re-researched within the research process by participants. it aims to be active co-research, by and for those to be helped. it can also not be used by one group of people to get another group of people to do what is thought to be best for them ‒ whether to implement a central policy or an organisational or a service change. instead, it tries to be a genuinely democratic or non-coercive process whereby those to be helped, determine the purposes and outcomes of their own inquiry.’6 action research is therefore a process in which participants examine their own practice systematically and carefully, using the techniques of research.7 in academia, the idea is that academics learn to publish by incorporating the disciplined inquiry that is characteristic of action research, i.e. planning a course of action to address challenges currently experienced, enacting their plans based on their own time frames, observing the effects, and reflecting on the results for the purpose of informing future practice. par can be carried out within the context of the academic’s environment. the aim is that the action research process will help the academic to improve practice. within all the definitions of action research, there are four basic themes that emerge, which include: the empowerment of participants; collaboration through participation; acquisition of knowledge; and social change. researchers have highlighted that ‘to become scholars, academics must develop competencies such as strategies and skills, self-reflection, and support circles’.8 by conducting action research, we aim to structure opportunities where academics can continuously reflect on where they are in the process within the necessary support circles. this paper describes the process of action research in enhancing research capacity among health professionals as part of an academic development strategy in a specific department. methods research setting the institution identified in this study has an institutional operational plan that expects faculties, departments and individuals to have goals in the following areas relating to research: • increase publication in accredited journals (at least 1.5 articles per academic per year) • increase postgraduate qualifications of academics (75% should have doctorate degrees by 2014) • increase the intake of postgraduate student numbers to 50%. the faculty of community and health sciences at the university of the western cape has adopted these institutional goals for the academic departments and individual academics. within the physiotherapy department in the faculty, it was decided that each faculty member should pursue a higher degree (msc or phd) and contribute to the body of research knowledge through publication. research design this study uses par, as it was identified as appropriate to build a research culture and to develop research capacity within our department. participants participants involved in the study were all full-time academics in the physiotherapy department in the faculty of community and health sciences. of the 10 academics, four were full-time contract staff and the remaining six were full-time permanent staff. three of the participating academics were new, with less than three years’ experience, and four had between 3 and 10 years’ experience. three academics who acted as mentors had more than 10 years’ experience. the group had a range of 5 15 years of clinical experience. strategy within this participatory approach, the department adopted various strategies, such as the identification of a research development officer from among the senior staff, bi-weekly research development meetings, study leave rotations, a research day per week for staff, and writing workshops. one of the key strategies employed was dedicated writing interventions for specific groups (participants were grouped based on research experience) in the department, which will be used as the key example in this paper. a summary of the participants for each stage of the intervention is presented in table 1. the process involved the phases of action research as indicated in table 2. separate group discussions were held by a senior academic with each group and the needs of each group identified. the aims of the research development strategy and envisaged outcomes were also discussed. during phase 1 a needs analysis of all academics in the department was conducted through informal discussions, followed by designed interventions and evaluation of the impact of the interventions. following the needs analysis, the department embarked on faculty development retreats with three workshops conducted during the june recess period: • writing a narrative review • how to write a systematic review • writing a funding proposal. each workshop was carefully designed and organised by me and a work file organised for each participant. each workshop began with an introduction to the three days and the envisaged outcome. following the introduction the participants were given specific tasks appropriate for writing a publication and a time allocation to work towards completing individual tasks. participants also received workbooks containing the relevant literature for each activity of the workshop. at the end of each session, participants were expected to share their work with a critical reader who could be a peer or senior academic and who provided the participant with feedback. senior academics in the department supplied the framework for support and academic leadership to the more junior academics. the impact of this intervention was assessed in several ways. prior to the workshop, participants had completed a brief questionnaire describing their goals with regard to writing for publication. immediately after the 120 december 2012, vol. 4, no. 2 ajhpe article workshop, the participants discussed and shared their perceptions of the workshop’s format and usefulness. at three-monthly intervals, academics were asked to report on their progress and indicate any assistance needed. in writing this paper, quotes from the various sessions highlight the impact of the academic development programme at the various stages. results and discussion the stages of the action research model are used to present the process of the academic development model and the impact. the faculty development approach and environmental support that accompanied each stage are outlined. planning professional development planning is guided at institutional, departmental and individual level. at the planning stage of the faculty development cycle, academics were asked to identify their needs with regard to writing for publication to meet the institutional requirement of 1.5 articles per year. responses in identifying the needs were centred around personal needs: ‘i have no idea where to start writing an article.’ ‘what information do i have to write an article?’ ‘how can this impact on my phd?’ fa c u lty d e vel opm ent appro a c h . at this stage some senior academics were identified as mentors to help guide participating academics to identify data for a possible article. the process involved assisting academics in highlighting ideas and data from which to choose information for an article. in addition, the research development officer in the department ensured that the article was within the scope of the academic’s current work and not an additional academic burden. during this planning process the allocated mentor also identified the existing resources available to meet the mentee’s needs. in addition, by acting as mentors the senior academics played an active role in promoting the visibility and importance of research in the department. environmental support. creating a climate that emphasises innovation includes providing resources for workshops and other vehicles (google docs, social networks) for sharing ideas and exchanging information on effectiveness.9 support was provided by allocating dedicated research time for each academic on a weekly basis, and using third-stream income to organise writing workshops and ensuring that all staff have laptops to work off-site. acting all participating academics were provided with the opportunity to develop research skills through writing workshops and bi-weekly research meetings. academics were also held accountable for the use of dedicated research time to ensure that all staff had tangible outputs at the end of the year. the involvement of the participating academics at different phases allowed them to implement the information learnt during the workshop to enhance their own personal academic development. all information gained during the writing workshops and meetings became the responsibility of the individual to carry to completion. success was dependent on the individual’s drive and motivation, support from the surrounding environment, and the drive to carry the process through. ‘ i am able to use the information gained during this process to supervise my students more effectively.’ ‘ finding the time to complete this article is going to be a challenge.’ ‘ drafting this funding proposal is great to have a draft as opportunities arise.’ fa c u lty d e vel opm ent appro a c h . in the department of physiotherapy, academic development activities were geared towards providing ongoing support to ensure that each academic was able to keep the cycle going. the support strategies consisted of continued support by the mentors and monthly follow-up meetings with the departmental research development officer. the department continued with the use of critical readers for novice authors to share their work and obtain critical feedback. in addition, the bi-weekly research meetings were used to encourage and support new academics. environmental support.  the existence of an in-house faculty journal encouraged new academics to submit their work for peer review and publication. reflecting within the par cycle, reflection occurs when academics consider information on the effects of their past practice in terms of its implications for future practice. developmental gain depends on the quality and depth of this reflection, as it generates the next cycle of learning in defining a need to table 1. participants for each workshop variables how to write a narrative review how to write a systematic review? writing for funding proposals participants mentors 3 3 4 3 3 0 gender male female 1 2 2 2 0 3 academic status contract lecturer lecturer senior lecturer associate professor 3 1 3 1 2 years in academia <3 years 3 5 years 6 10 years >10 years 3 3 1 1 2 educational level busy with masters msc busy with phd phd 2 1 4 3 publications new author (<3) novice author (3 10) author with limited experience (11 20) established author (>20 publications) 3 4 1 2 december 2012, vol. 4, no. 2 ajhpe 121 article address or a general direction to pursue.9 the academics primarily used this new information to guide their postgraduate studies and write their research chapters. the three new academics were able to submit their articles for consideration in a peer-reviewed internal faculty journal and have since started new research projects and articles. ‘ submitting my first article was both exciting and scary … what if it’s not good enough?’ ‘ getting feedback during the process prepared me for the process of reviewer feedback.’ ‘how will i cope with rejection?’ faculty developmental approach. reflecting on the process using the three reflective directions, i.e. reflection-on-action, reflection-in-action and reflection-for-action, is a characteristic of par.10 during the workshops reflection-in-action was applied as participants were expected to write a section of the article, obtain feedback from a critical reader, reflect on the feedback and make the necessary changes before proceeding to the next stage. in the period after the workshop, reflection-on-action was used by participants who were asked to reflect on the skills and knowledge obtained during the workshops and to apply it in their academic writing. in addition, as part of the research development in the department, the participants table 2. the academic development process who? how? what? outcome phase 1 identifying the problem all participants per group informal discussions group 1: busy with master’s degree, need to write a good literature review group 2: busy with phd, need to conduct a systematic review as part of phd objectives group 3: phd holders need to obtain research funds for bigger project three different goals and needs according to stage in academic development phase 2 action plan: planning group 1: young academics group 2: academics registered for phd group 3: senior academics group discussions relating to current status and needs group 1: writing retreat with mentors to guide group 2: writing retreat with supervisors to guide group 3: writing retreat with several guidelines of funding agencies clear objectives defined for each group group1: how to write a narrative review linked to their master’s research topic group 2: how to conduct a systematic review linked to their phd topic group 3: writing for funding proposals linked to promotional status of each academic phase 3 taking action: acting all participants in separate groups group meetings to decide upon time, dates and venues suitable for the group co-ordinator organised funding and relevant literature for each session clear programme designed for each group. information needed prior to workshop identified and participants engaged in discussion to what they needed all participants were involved in decisionmaking process and were thus expected to reflect on the stage of the growth they are in. the participants were required to assess the status of their development and ensure that they would be at a certain level at the time of the workshops phase 4 evaluating: reflecting all participants in separate groups one-on-one sessions with mentors and group discussions groups reflected on the process and the achievements as individuals three funding proposals were submitted three articles were published from the literature review group in a peer-reviewed journal two systematic reviews were submitted, of which one was published two systematic reviews in progress phase 5 specifying learning: observing the effects participants and mentors focus group discussions applying the information learnt by participants in their supervision of students mentors learnt the process of feedback and how to deal with it participants had written articles and funding proposals knowledge translation from input to action 122 december 2012, vol. 4, no. 2 ajhpe article were expected to act as critical readers for other authors and also submit their work for further scrutiny among colleagues in the department. participants were asked to reflect on the phase of how they could use the knowledge and skills gained in their own professional development and the development of others. therefore, the phase of reflection-for-action was incorporated. environmental support. there is a culture of reflection on research in the department, thereby creating the opportunity for novice authors to enter into discussions on writing for publication. in addition, the research development officer encourages the participants via e-mail to continuously reflect on the process and challenges they are experiencing in completing the task. observing as the process continued, the academics learnt of their effectiveness through gathering data about impact. at a very basic level, they could judge this by simply looking at the comments from the critical readers as they went through the process. more information was gathered by submitting to a journal and getting reviewer feedback. the external review could be compared with previous feedback obtained from the critical readers and this new understanding can influence future articles. it is important for academics to continuously collect systematic and meaningful data to modify practice in the future. ‘ i’ve submitted my article … do i have the confidence to start another one [laugh]?’ ‘rejection … not easy. will i start again?’ ‘ the process was good, mentoring and encouragement from peers kept my momentum going.’ faculty development approach. at this point mentors needed to encourage academics to start the publication of new articles. as the participants complete their master’s degrees, they will be given the opportunity to supervise undergraduate research projects which can translate into publications ‒ as the outcome for these projects is an article. this par process assisted in the translation of knowledge into action. e nv i r o n m e n t a l s u p p o r t . doing research with more experienced authors enhanced growth and professional development. mentors in the department continue to assist in encouraging publications from both formal degree programmes and ongoing academic activities, such as undergraduate research. monitoring of research outputs and celebrating achievements can assist in promoting continuing publication. conclusion a research capacity development strategy must use academics’ needs as a departure point for designing activities that support them throughout the process. this paper highlights the process of engaging all academics in creating a research culture in a department and ensuring that the participants see the relevance of engaging in research. at the time of publication, within the narrative review group, all three participants had published articles in a peer-reviewed faculty journal. the systematic review participants had published one article in an accredited journal and two articles have been submitted to peer-reviewed journals. from the funding proposal group two proposals have been submitted to funders and to date one was successful in obtaining funding. investing in research capacity development strategies for academics should be high on the agenda of higher education institutions. references 1. d’auria d. building a research capacity for occupational medicine. occup med 2000; 50(2):79. 2. segrott j, mcivor m, green, b. challenges and strategies in developing nursing research capacity: a review of the literature. int j nurs stud 2006;43:637-651. [http://dx.doi.org/10.1016/j.ijnurstu.2005.07.011] 3. suplee p, gardner m. fostering a smooth transition to the faculty role. j cont educ nurs 2009;40(11):514-520. [http://dx.doi.org/10.10.3928/00220124-20091023-09] 4. wilkerson l, irby d. strategies for improving teaching practices: a comprehensive approach to faculty development. acad med 1998;73(4):387-396. 5. kolb d. experiential learning: experience as the source of learning and development. englewood cliffs, new jersey: prentice hall, 1984. 6. wadsworth y. what is participatory action research? action research international. paper 2. 1998. available online at: http://www.uq.net.au/action_research/ari/p-ywadsworth98.html (accessed 1 november 2012). 7. watts h. when teachers are researchers, teaching improves. j staff dev 1985;6(2): 118-127. 8. heinrich e, milne j, ramsay a, morrison d. recommendations for the use of e-tools for improvements around assignment marking quality. assess & eval higher educ 2009;34(4):469-479. 9. chism n. using a framework to engage faculty in instructional technologies. educause quarterly 2004:39-45. 10. schön d. the reflective practitioner. aldershot: ashgate publishing ltd, 1991. 98 november 2013, vol. 5, no. 2 ajhpe short report experiential learning outside the comfort zone: taking medical students to downtown durban n prose,1 md; p diab,2 mb chb, mfammed; m matthews,3 mb chb, doh 1 department of pediatrics and dermatology, duke university medical center, durham, north carolina, usa 2 department of rural health, school of nursing & public health, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 school of clinical medicine, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: p diab (diabp@ukzn.ac.za) introduction. the ability to communicate across cultures requires a combination of knowledge, skills and attitude. our current medical school curriculum includes innovative methods of teaching communicative knowledge and skills. our aim is to encourage students to examine their attitudes toward patients from social groups and cultures other than their own and, ultimately, to interact with empathy in a multicultural society. method. an experiential learning technique where students were given various tasks intended to improve their attitude towards cross-cultural learning. results. a number of students expressed appreciation at being in a multicultural group, having a shared experience, and engaging in open and respectful discussion about similarities and differences. conclusion. students need to be involved in activities that encourage them to examine their attitudes and develop respect for patients from cultures other than their own. we suggest ways in which learning experiences of this type can be integrated within the medical undergraduate programme. ajhpe 2013;5(2):98-99. doi:10.7196/ajhpe.256 the nelson r mandela school of medicine in durban was among the first south african tertiary institutions to educate black, indian, and coloured students under apartheid. the student body remains culturally and racially diverse, and each student is called upon, almost daily, to provide care for patients from cultural and racial groups other than their own. for this reason, teaching medical students to communicate effectively and empathically across cultures is one of the most important educational tasks. the literature on teaching cross-cultural communication suggests that educators must focus on three critical aspects: knowledge, skills and attitude.[1] the authors hypothesise that education about attitude (learning to recognise one’s own subtle biases and to appreciate and respect members of other cultures) has been particularly difficult to integrate into the medical school curriculum. in this article, we report on an innovative educational intervention that we hope can serve as a model for highlighting the need for empathy and teaching medical students to be more curious about, and respectful of, patients from cultural backgrounds other than their own. teaching and learning historically, the ability to communicate across cultures has been attributed to a combination of knowledge, skills and attitude.[1] knowledge is critical for our students, as we know that basic information about the healthcare beliefs of patients in kwazulu-natal is fundamental. a good doctor understands something about the role of the traditional healer, and has some knowledge of the alternative and complementary therapies commonly in use. ‘good doctors’ are also able to apply curiosity and enquire about practices with which they are not familiar. ‘checklists’ of key issues relating to practices of certain cultural groups have been suggested, but tend to reinforce racial and ethnic stereotypes rather than promote cultural competency. the role of effective communication skills in increasing empathy is well documented,[3] and our medical school curriculum uses small group learning with simulated patients to establish the essentials of doctor-patient communication. in addition, language skills play a large role in a region where approximately 80% of patients communicate primarily in isizulu. although many students may currently learn isizulu, it is not to a standard where they can comfortably converse with patients. the literature on teaching attitude has focused on the process of developing curiosity, respect, humility and self-awareness.[2] in her landmark essay, faith fitzgerald commented on the importance of curiosity among health professionals:[4] ‘what does curiosity have to do with the humanistic practice of medicine?’ ... i believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. to participate in the feelings and ideas of one’s patients — to empathize — one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds.’ in some medical schools, students are asked to write narratives or reflective portfolios about their clinical experiences and use these writings, along with small group discussions, to challenge their own stereotypes and beliefs about their patients and their families.[5] other programmes have been created in which students experience medical care from a patient’s perspective; or immersion experiences, where students live in a community for a period as part of their training and are thereby exposed to the culture and language of their patients. currently, teaching at medical school focuses mostly on knowledge and skills acquisition, with less emphasis on developing students’ attitudes; although, within the new curriculum, issues such as doctors’ social accountability and cultural competency are being addressed. the present report offers an example of how awareness of attitude may be incorporated as an important part of practice in the future. mailto:diabp@ukzn.ac.za november 2013, vol. 5, no. 2 ajhpe 99 methodology traditional learning focuses on rote or didactic teaching where there is a distinct teacher (the expert) and learners, whereas experiential learning focuses on the learner’s experience and the subsequent reflection on that experience, which promotes deeper learning by students. we decided to intervene in a way that challenged students’ acquired beliefs and value systems. with the help of colleagues who run a professional company that teaches cultural competency and self-awareness to executives, we arranged a tour of durban’s warwick triangle for a group of medical students. this area, a hub of economic and cultural diversity and situated a mere 10-minute drive from the ‘ivory tower’ of the university, provided the multicultural learning experience that was needed.[6] the group included a diverse range of students from secondto finalyear who volunteered for this experiential learning opportunity. outside the muthi [isizulu term for traditional remedy] market, each student and faculty member was given r10 (us$1.40), asked to purchase a specific herbal remedy, and to find out its use. each participant was additionally asked to seek advice about a specific health complaint, and to obtain some basic personal information about the vendor. on our return, we huddled in the parking garage, displayed our medications, and discussed them. we also discussed the feelings that were generated in each of us by this experience. ‘i realised we tend to be a bit insular,’ noted one student, ‘being at the muthi market helped us to know ourselves as doctors and humans.’ we ended the day with a tour of the juma masjid mosque, the largest in the southern hemisphere. we talked about the significance of ramadaan, and the two muslim students in our group took the lead in explaining their beliefs and rituals. in discussion afterwards, both hindu and christian students commented on the previously unimagined similarities of islam to their own belief systems. unfortunately, time constraints prevented a visit to the durban hindu temple and emmanuel cathedral, all located in the same area. results and reflection several days later, the students and faculty who participated in the tour reconvened at the medical school and reflected on the tour experience. a number of students expressed appreciation at being in a multicultural group, having a shared experience, and engaging in an open and respectful discussion about similarities and differences. to the astonishment of some, a number of black students felt as surprised and ‘out of place’ in the muthi market as did their white and indian counterparts. the overall impact on the students appeared to be very powerful. one student summarised her experience by saying: ‘we’re going to be serving society. we haven’t really understood who we are serving. what is our country about? who are we amongst? how can we help?’ another student reflected: ‘we are so used to being in a cocoon in medical school. when we step into someone else’s world, it opens a different channel.’ surely we were seeing glimpses of a ‘curiosity that converts strangers into people we can empathise with.’ conclusion the current curriculum focuses mainly on teaching students communication skills and knowledge of the isizulu language. more emphasis is required on developing attitudes of curiosity and respect by engaging in meaningful discussion with diverse people. by forming connections across cultures based on mutual respect, students can be made aware that people of other cultural groups have something important to teach them, if they only take the time to learn. an experience that takes students out of their ‘comfort zone’ seems to be particularly useful. ingrained beliefs and values are challenged, and students are encouraged to look at their own belief systems, and reflect on the ways in which their beliefs may influence them as doctors. we hope that experiences that foster cultural competency by engendering curiosity and respect can be integrated into the medical curriculum in a number of ways. our ability to create true transformation in medicine depends on creating opportunities such as these. as one student reflected, ‘there are so many things that unite us.’ acknowledgements. the authors express their gratitude to administrative staff from ukzn medical school for facilitating this experience through the consent of the dean of the medical school. they also wish to thank soweto style experience for providing the facilitators and funding for the tour. dr neil prose’s visit to south africa was sponsored by a fulbright specialist grant. references 1. betancourt jr. cross-cultural medical education: conceptual approaches and frameworks for evaluation. acad med 2003;78(6):56-569. 2. jenks ac. from ‘lists of traits’ to ‘open-mindedness’: emerging issues in cultural competence education. cult med psychiatry 2011;35(2):209-235. 3. winefield hr, chur-hansen a. evaluating the outcome of communication skill training for entry-level medical students: does knowledge of empathy increase? med educ 2000;34(2):90-94 4. fitzgerald f. curiosity. ann intern med 1999;130(1):70-72. 5. dasgupta s, charon r. personal illness narratives: using reflective writing to increase empathy. acad med 2004;79(4):351-356. 6. dobson r, skinner c, nicholson j. working in warwick: including street traders in urban plans. durban, south africa: school of development studies, university of kwazulu-natal, 2009:136. short report photo by lunga memela. may 2014, vol. 6, no. 1 ajhpe 45 research educational and cultural diversity are important factors to consider in undergraduate physiotherapy education. there are four principal aspects of student diversity, including learning styles, approaches to learning, orientation to studying and intellectual development.[1] for students to benefit most from their learning opportunities, they and the faculty should be aware of their learning styles and ability to solve problems.[2] felder and brent[1] state that students have different backgrounds, strengths, weaknesses, interests, ambitions, levels of motivation and approaches to studying. to enhance undergraduate physiotherapy education, educators should aim to become more aware of these diverse approaches to master new material.[3] learning styles are a useful instrument to help students and researchers understand how to improve the way they learn and teach, respectively. furthermore, it is important to know how students with different learning styles approach problem solving. learning styles or preferences are multifaceted ways in which learners perceive, process, store and recall what they are trying to learn.[4] studies on preferred learning styles among physiotherapy students were primarily conducted abroad in developed countries such as canada and australia.[2,5] the canadian study determined the learning styles and problem-solving abilities of physiotherapy students from their second to fourth year of a physiotherapy programme.[2] results revealed that the preferred style of learning among students in the 4-year undergraduate physiotherapy programme was to study the theory and then reflect on or experiment with it. their perceived problem-solving ability was similar to that of other undergraduate students, and was not related to their learning style.[2] the australian study determined the learning style preferences among occupational therapy, physiotherapy and speech pathology students.[5] the authors reported that optimal learning environments should take into consideration how students learn. although a consistent learning profile among this group of students could not be determined, the findings suggested that each profession attracts students with a range of learning styles. they highlighted the need to investigate correlations between learning styles, instructional methods, and academic performance of students in the health professions. in the present study the learning styles of a group of physiotherapy students at the university of the western cape, south africa were investigated. however, according to felder and brent,[1] it is not possible to tailor one’s teaching to suit every learning style or to teach with a one-sizefits-all approach, expecting all learners to benefit. methods research design the  study  employed a quantitative, cross-sectional research design. crosssectional studies are mostly used to determine prevalence; therefore this design was deemed appropriate.[6] participants all registered undergraduate physiotherapy students (n=246) for the 2012 academic year at the university of the western cape were invited to participate (table 1). background. undergraduate students at universities have different learning styles. to perform optimally, both they and their educators should be made aware of their preferred learning styles and problem-solving abilities. students have different backgrounds, strengths, weaknesses, interests, ambitions, levels of motivation and approaches to studying and educators should therefore aim to become more aware of the diverse approaches to learning. objective. to identify the various learning styles and problem-solving abilities of physiotherapy students at the university of the western cape, south africa. methods. undergraduate physiotherapy students (n=246) who were registered for the 2012 academic year participated in the study. three valid and reliable questionnaires, including the index of learning styles (ils), the problem-solving style questionnaire (pssq) and the learning style questionnaire (lsq), were used. responses were analysed statistically to establish the association between learning styles and problem-solving ability. results. a response rate of 72% was reported (n=177). for first-, second-, thirdand fourth-year students the response rates were 65/85 (76%), 53/67 (79%), 31/58 (53%) and 28/36 (78%), respectively. forty-five (25%) participants were male, 124 (70%) were female and 8 (0.04%) did not indicate their gender. the prominent learning styles were feeling (pssq), kinaesthetic (lsq) and visual-verbal (ils). males were prone to using the kinaesthetic learning style and females to a more visual learning style. the feeling group constituted 47% of the sample (39% males and 43% females). conclusion. the majority of students seem to learn by doing, although facts are important to them. it therefore might be important to first teach physiotherapy students concepts and then assist them to apply these in practice. ajhpe 2014;6(1):45-47. doi:10.7196/ajhpe.226 understanding the learning styles of undergraduate physiotherapy students d hess, bsc physiotherapy; j m frantz, phd department of physiotherapy, university of the western cape, bellville, south africa corresponding author: d hess (hess.danelle@gmail.com) mailto:hess.danelle@gmail.com 46 may 2014, vol. 6, no. 1 ajhpe research data collection three questionnaires were used to collect the data, including the index of learning styles (ils), the problem-solving style questionnaire (pssq) and the learning-style questionnaire (lsq). the ils was developed in 1991 and is based on the learning style model formulated by felder and silverman.[1] this questionnaire assesses preferences on four dimensions: active-reflective, sensing-intuitive, visual-verbal and sequential-global. the pssq places the student in one of four categories, i.e. sensing, intuitive, feeling or thinking.[7] in addition, the lsq classifies the student into three possible groups, i.e. visual, auditory, and kinaesthetic learning styles.[8] all the questionnaires have been used in studies with similar population groups as the current study. data analysis the data collected were captured and analysed using the statistical package for social science (spss) version 19.0. descriptive statistics  were used to summarise the frequencies of students in each learning style category and to determine whether the distribution of learning styles was different across the four years of the programme. predominant race and gender were also determined. inferential statistics using the independent sample test were employed to compare  learning style scores across the four years of the programme and to analyse the association between learning styles and problem-solving ability. results demographic data a response rate of 72% (n=177) was reported. for first-, second-, thirdand fourth-year students the response rates were 65/85 (76%), 53/67 (79%), 31/58 (53%) and 28/36 (78%), respectively. of the respondents, 45 (25%) were male, 124 (70%) were female and 8 (0.04%) did not indicate their gender. of all participants who responded, 107 (60%) were coloured, 31 (18%) were white, and 26 (15%) were black. thirteen students (7.3%) were grouped as ‘other’ and included indians, asians, and those who did not indicate their race. learning styles an overview of the learning styles of the participants is presented in table 2. based on the results of the lsq, more students were found to have a kinaesthetic learning style, followed by a visual learning style. males seemed to prefer a kinaesthetic learning style (p<0.05), while females had a more visual learning style. there was no significant association between race and year of study and the learning styles. in the ils questionnaire, the visual-verbal aspect of the students’ learning styles was more common (31%). in this category, females were more prone to this style of learning (p=0.00), and in the sequential-global category more males expressed a preference for this style (p=0.00). no significant gender and race differences were found between the other categories. in addition, there was a significant difference between senior-level (thirdand fourthyear) and junior-level (firstand second-year) students, the former being more active-reflective learners. the psq highlighted that the majority of students 75/177 (42%) were classified in the feeling group. however, there was no significant association with gender and year of study. within the thinking group, there was a significant association between gender and thinking, with males being more inclined to think matters through than females (p<0.005). although there was no significant association found between the learning styles and the problem-solving ability of the participants, there was an association between table 2. overall problem-solving and learning style no. questionnaire outcomes definition 1 problemsolving style questionnaire[7] this questionnaire divides the group of students into 4 categories, i.e. sensing, intuitive, feeling and thinkingsensing 43/177 intuitive 35/177 feeling 75/177 thinking 24/177 2 learning-style questionnaire[8] this questionnaire groups students into three categories, i.e. visual, auditory and kinaestheticvisual 64/177 auditory 42/177 kinaesthetic 71/177 3 index of learning styles[8] this questionnaire assesses preferences in four dimensions (active/reflective, sensing/intuitive, visual/verbal, and sequential/ global) of a learning style model. visual learners remember best what they see, i.e. pictures, diagrams, flow charts, time lines, films, and demonstrations. verbal learners get more out of words, i.e. written and spoken explanations. everyone learns more when information is presented both visually and verbally active-reflective 37/177 sensual-intuitive 45/177 visual-verbal 55/177 sequential-global 40/177 table 1. number of students registered in the programme (n=246) year of study students, n male female first 85 20 65 second 67 16 51 third 58 15 43 fourth 36 11 25 may 2014, vol. 6, no. 1 ajhpe 47 research the kinaesthetic type of learning style and the problem-solving method of feeling (table 3). discussion the current study assessed the learning styles and problem-solving approaches of undergraduate physiotherapy students registered at the university of the western cape. the students who were registered for the programme came from diverse cultural and socio-economic backgrounds, as indicated in the results. in addition, they were found to be more practically orientated, but still needed both visual and verbal cues. gender influenced the learning style, with males seeming to process information in different ways than females. males seemed to use more of a thinking process. this differed from another study, which focused on the learning styles of entry-level physiotherapy students. the results showed that these students preferred to learn new material by reviewing, observing or thinking as opposed to actively doing or planning.[9] in another survey, where gender and learning styles were assessed, there was a significant difference between the learning styles and gender.[10] the results of this study showed that styles leaning towards didactic teaching appealed more to males, as these are primarily abstract and reflective. it was also reported that females learned better in hands-on and practical settings, emphasising the sphere of the affective and doing. therefore, the results of the study by philbin et al.[10] show that when females are watching and feeling or doing and thinking they learn best, and when males are thinking and watching they learn best. similarly, the current study reported that males tended to lean more towards thinking than females, who tended to be more visual. this indicates that females wanted to be stimulated visually by watching. kolb’s theory states that a preferred learning style influences the problemsolving ability of a person.[2] wessel et al.[2] further state that for students to make the most of their learning opportunity educators should be aware of their learning style and ability to solve problems. the study also assessed the learning style and problem-solving ability of students, and the results showed that there was no association between learning style and perceived problem-solving ability. the results from the current study were the same, even though more than one learning style questionnaire was used. similarly to what was found in the present study, the learning style preferences of first-year undergraduate occupational therapy students in australia demonstrated a greater preference for kinaesthetic learning.[11] this may indicate a preference for learning through practice or simulation. even though a range of learning styles were found in the australian study, instructional approaches seem to be required.[11] in contrast, mountford et al.[9] found that entry-level physiotherapy students preferred to learn new material by reviewing, observing or thinking as opposed to actively doing. conclusion based on the three questionnaires used it was demonstrated that the majority of the students learn by doing, although facts are important to them. therefore, physiotherapy students may learn better if the concepts they are taught in theory are applied in practice. this is supported by the fact that the highest number of students fell in the kinaesthetic learning style category. to effectively utilise this learning style, the educator should provide the learner with real-life experiences and simulations. implications for practice lecturers should be aware of the different learning styles of students and address this either by changing their teaching practices or ensuring that their learning styles are used to their full effect. it is important to understand students and to be aware that they have different attitudes to learning. this should be used to create a teaching experience that will impact positively on the students’ learning experiences and for finding a balance between the extremes in each learning dimension.[1,12] all learning style preferences cannot always be accommodated but awareness can help to enhance methods of teaching and thus methods of learning. limitations it must be emphasised that these results are an indication of the students’ learning preferences and an even better indication of the preference profile of a group of students (e.g. a class), but should not be over-interpreted. acknowledgements. the authors would like to thank the national research foundation (nrf) for funding that allowed the first author to participate in a staff development programme and conduct an educational project. references 1. felder r, brent r. understanding student differences. journal of engineering education 2005;94(1):57-72. 2. wessel j, loomis j, rennie s, brook p, hoddinott j, aherne m. learning styles and perceived problem-solving ability of students in a baccalaureate physiotherapy programme. physiotherapy theory practice 1999;15:17-24. [http://dx.doi. org/10.1080/095939899307865] 3. carmo l, gomes a, pereira f, mendes a. learning styles and problem solving strategies. paper presented at the 3rd e-learning conference; 7 8 september 2006, coimbra, portugal. 4. lujan h, dicarlo s. first-year medical students prefer multiple learning styles. advan physiol educ 2006;30:13-16. [http://dx.doi.org/10.1152/advan.00045.2005] 5. brown t, cosgriff t, french t. learning style preferences of occupational therapy, physiotherapy and speech therapy students: a comparative study. the internet journal of allied health sciences and practice 2008;6(3):1-12.  6. mann c. observational research methods. research design ii: cohort, cross-sectional, and case-control studies. emerg med j 2003;20:54-60. [http://dx.doi.org/10.1136/emj.20.1.54] 7. duff a. note on the problem solving style questionnaire: an alternative to kolb’s learning style inventory? educational psychology: an international journal of experimental educational psychology 2004;24(5):699-709. [http://dx.doi.org/10.1080/0144341042000262999] 8. cassidy s. learning styles. an overview of theories, models, and measures. educational psychology: an international journal of experimental educational psychology 2004;24(4):419-444. [http://dx.doi.org/10.1080/0144341042000228834] 9. mountford h, jones s, tucker b. learning styles of entry-level physiotherapy students. adv physiother 2006;8:128-136. [http://dx.doi.org/10.1080/14038190600700278] 10. philbin m, meier e, huffman s, boverie p. a survey of gender and learning styles. sex roles 1995;32(7/8):485-494. 11. french g, cosgriff t, brown t. learning style preferences of australian occupational therapy students. australian occupational therapy journal 2007;54:58-65. [http://dx.doi.org/10.1111/j.1440-1630.2007.00723.x] 12. montgomery s, groat l. student learning styles and their implications for teaching. in: friesen e, kristjanson c, eds. teaching at the university of manitoba. winnipeg, man: university teaching services, 1998;10:1-8. table 3. association between problem-solving ability and learning styles (n=177) problem-solving style questionnaire thinking intuitive sensing feeling learning-style questionnaire visual 8 12 17 27 auditory 6 4 14 19 kinaesthetic 10 19 12 29 index of learning style active-reflective 4 8 11 15 sensual-intuitive 10 6 6 17 visual-verbal 6 15 15 29 sequential-global 4 11 11 14 http://dx.doi.org/10.1080/095939899307865] http://dx.doi.org/10.1080/095939899307865] http://dx.doi.org/10.1152/advan.00045.2005] http://dx.doi.org/10.1136/emj.20.1.54] http://dx.doi.org/10.1080/0144341042000262999] http://dx.doi.org/10.1080/0144341042000228834] http://dx.doi.org/10.1080/14038190600700278] http://dx.doi.org/10.1111/j.1440-1630.2007.00723.x] the ajhpe is published by the health and medical publishing group. ajhpe african journal of health professions education may 2013, vol. 5 no. 1 the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. e-mail: publishing@hmpg.co.za editorial 2 are we socially accountable educators? l p green-thompson articles 3 developing reflection and research skills through blogging in an evidence-based practice postgraduate physiotherapy module j m frantz, m rowe 8 clinical educators’ self-reported personal and professional development after completing a short course in undergraduate clinical supervision at stellenbosch university a m s schmutz, s gardner-lubbe, e archer 14 the bottom line: tailoring a public health elective to students’ needs j e wolvaardt, v burch, d c cameron, p h du toit 19 a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision k mostert-wentzel, j frantz, a j van rooijen 26 moving from conversation to commitment: optimising school-based health promotion in the western cape, south africa f waggie, n laattoe, g c filies 30 participatory action research: the key to successful implementation of innovations in health professions education a g mubuuke, b leibowitz 34 experiences of graduating students from a medical programme five years after curricular transformation: a descriptive study p mcinerney, l p green-thompson, d m manning 37 exploring the subjective experiences of allied health professionals in their transition from clinical educators to academia: barriers and facilitators to successful transition j m frantz, m r smith 42 cross-cultural medical education: using narratives to reflect on experience p diab, t naidu, b gaede, n prose abstract 46 simple learning tools to improve clinical laboratory practical skills training b taye cpd 47 cpd questionnaire editorial board editor-in-chief vanessa burch university of cape town deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape associate editors julia blitz stellenbosch university david cameron university of pretoria francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of the witwatersrand michelle mclean bond university, ql, australia ntombifikile mtshali university of kwazulu-natal deborah murdoch-eaton university of leeds, uk marietjie nel university of the free state carmen oltmann rhodes university glynis pickworth university of pretoria ben van heerden stellenbosch university marietjie van rooyen university of pretoria jacqueline van wyk university of kwazulu-natal gert van zyl university of the free state hmpg editor janet seggie consulting editor jp de v van niekerk technical editors emma buchanan kerry gordon marijke maree robert matzdorff melissa raemaekers taryn skikne paula van der bijl head of publishing robert arendse production manager emma couzens art director brent meder digital designer siobhan tillemans dtp & design carl sampson | anelia du plessis online manager gertrude fani issn 1999-7639 june 2022, vol. 14, no. 2 ajhpe 61 research healthcare educationalists are faced with fewer clinical opportunities owing to a changing healthcare climate,[1] resource distribution towards primary healthcare,[2] increased student numbers,[3] and south africa (sa)’s unique quadruple burden of disease[4] that has an impact on the availability, variety and complexity of patients for student training. contributing to the challenges are the covid-19 pandemic, which also impacts the case mix and teaching platform used for student training. improving safe patient management[5] with limited resources[6] is also essential in sa healthcare education. additionally, the underpreparedness of students entering the tertiary education environment[7] and student dissatisfaction with the presented curricula[8] pose further challenges to national healthcare  education. healthcare training therefore requires adjustments and a widened training platform to ensure the continued throughput of skilled graduates.[9,10] simulation is defined by the healthcare simulation dictionary[11] as an educational methodology that involves designing a realistic situation where student learning and skills practice are facilitated. simulation, in the context of the present study, refers to the integration of a variety of simulation modalities in both immersive and practical skills-based, simulationbased learning experiences (sbles) in a healthcare training programme. the benefits of integrating simulation into healthcare education are undeniable,[12,13] and in light of all the challenges, the ability to produce learning opportunities when clinical practice settings are limited[14] is critical. simulation has also been used in the development of skills, ensuring both patient and student safety, and facilitating ethical conduct.[5] additionally, simulation addresses the learning needs of the current student population, making learning an interactive and realistic process that provides ‘hands-on’, student-centred education.[9] any programme innovation and/or integration requires educator preparation and training, taking into account curricular content, reasons for the proposed changes and the educator’s role in the programme.[15] detailed planning prior to the development, integration and execution of sbles is therefore essential,[15] and should aim to empower educators in  authentic  sble integration and decrease educator resistance to simulation integration.[16] a systematic review performed by the principal researcher (avdm) revealed few frameworks for healthcare simulation integration, published only in developed countries, between january 2005 and december 2017. of these identified frameworks, none was based in physiotherapy. the available simulation-based physiotherapy research focuses on integrating only selected simulation modalities or the training of specific skills, and does not present a framework for the integration of a variety of simulation modalities. this delphi survey aimed to develop a conceptual framework for the integration of simulation in sa undergraduate physiotherapy programmes. for the purpose of this article, one of the emerging themes, planning, has been explored in detail. background. the benefits of simulation in healthcare education are undeniable, and in the current healthcare climate, a drastic change in delivering healthcare training is critical. therefore, integration of simulation is essential, and necessitates detailed planning and well-trained educators. objectives. to develop a conceptual framework for the integration of simulation in south african (sa) undergraduate physiotherapy programmes. methods. a non-experimental descriptive research design using a modified delphi survey was conducted. results from a systematic review identifying simulation integration framework elements informed the delphi survey. a purposive sample of 15 healthcare educationalists from sa and abroad were approached to participate. data were analysed as percentages, and feedback was provided to panel members following each round. results. a response rate of 73.3% (n=11) was achieved. planning was explored as one of the themes. both institutionaland discipline-specific needs analyses were identified as essential (93%), and societal needs were useful to consider (64%). resource identification and sharing (84%) were regarded as vital, and expert collaboration in curriculum development (79%) with scaffolded skills integration (75%) was advised. the necessity for trained facilitators (93%) and educator role identification (71%) was evident. statements related to mastery learning/deliberate practice and the use of simulation for assessment purposes yielded the least consensus. conclusion. a constructively aligned curriculum based on both student and institutional needs and resource availability in guiding simulation integration was regarded as essential. educator competency in both the development and delivery of the programme, especially debriefing methods, is vital for optimising student learning. afr j health professions educ 2022;14(2):61-65. https://doi.org/10.7196/ajhpe.2022.v14i2.1446 how to plan for simulation integration into undergraduate physiotherapy training a van der merwe,1 msc (physiotherapy), phd (physiotherapy); r y barnes,1 phd (physiotherapy); m j labuschagne,2 mmed (ophthalmology), phd (hpe) 1 department of physiotherapy, faculty of health sciences, university of the free state, bloemfontein, south africa 2 clinical simulation and skills unit, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a van der merwe (gonzalesa@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i2.1446 mailto:gonzalesa@ufs.ac.za 62 june 2022, vol. 14, no. 2 ajhpe research methods design a descriptive research design using a modified delphi survey was utilised. statements were obtained from the systematic review, after which expert opinions were solicited regarding the content of the conceptual framework. a three-point likert scale with options ‘essential’, ‘useful’ and ‘not applicable’ was used. sampling and participants a purposive sample of 15  national and international healthcare educationalists in physiotherapy and/or other healthcare fields, as well as healthcare simulation experts, were identified (table  1). the majority of panel members were south africans, to provide a contextualised point of view unique to the sa environment and educational challenges. data collection panel members received an information leaflet detailing the study aim and procedure. a document explaining the sa undergraduate physiotherapy context was also provided to panel members to increase content validity. panel members were made aware that they would remain anonymous to one another, and that data would remain confidential. informed consent was obtained prior to participation. the delphi survey was distributed online by means of surveymonkey, with a 2-week completion deadline per round. data were analysed, followed by an authors’ consensus meeting to ensure that all comments and suggestions were accurately incorporated during the subsequent round, to limit bias.[17,18] a continuous iteration and feedback between panel members was used throughout the survey to achieve shared understanding on the topic. statements failing to achieve 70% consensus, panel member comments and the consensus meeting outcome were formulated into subsequent survey rounds.[17] statements achieving consensus were removed from subsequent rounds. data analysis in line with previous delphi surveys in similar research areas,[17,19] consensus was defined as ≥70% of panel members agreeing on the inclusion or exclusion of a statement. stability was declared when individual panel member selections remained similar across survey rounds, with suggestions provided for the specific statement not resulting in further content or contextual changes, additions or omissions.[19] data saturation was achieved when the repeated rounds yielded either a convergence of panel member opinions, or individual response stability per statement. pilot study a pilot study was performed with one healthcare educationalist experienced in both simulation-based education (sbe) and the delphi process. minor grammatical changes were made following the pilot study. ethical approval the first survey round was developed after approval from the health sciences research ethics committee at the university of the free state (ref. no. hsrec 108/2017) was obtained. results data saturation was declared after survey round 3. an overall response rate of 73.3% (n=11) was achieved, with 4 panel members dropping out during the delphi survey. reasons for dropout were not explored. in round 3, 36.4% (n=4) of panel members were from outside the country, and 63.6% (n=7) were south african. data were analysed as percentages to assess whether consensus had been achieved per statement. due to limited justification regarding selected options or opinions related to statements by panel members, content analysis of comments could not be performed. feedback to participants therefore included only the summary of statements achieving consensus, as the provision of statistical results with no supporting information would have yielded less accurate results.[19] four themes, with supporting categories, emerged from the data, namely planning (n=12), implementation (n=3), evaluation (n=2) and revision (n=1). for the purpose of this article, both statements achieving consensus (appendix: https://www.samedical.org/file/1807) and stability (table  2) relating to the planning theme have been explored. when integrating simulation, the inclusion of both institutional and discipline-specific needs analyses was indicated as essential (93%), with a societal needs analysis regarded as useful (64%) by panel members. identification of available human (86%) and physical resources (73%) also achieved consensus, with 84% of panel members indicating that facilities should be shared between healthcare disciplines. a collaborative approach to curriculum development and integration (79%), with scaffolding of non-technical training aspects according to the learning outcomes (75%), was deemed essential. although no other statements detailing the role of the educator achieved consensus, defining the role of the educator was viewed as vital (71%), and the identified role(s) should guide essential facilitator training (93%), notably in debriefing methods (100%). the inclusion of peer assessment as part of mastery learning/deliberate practice in formative assessments was table 1. expert panel targeted to be recruited for the delphi survey area of expertise n nationality profession healthcare educationalists and simulation experts (conducted simulation-based research, congress presentations, published work) 6 2 international, 4 sa national: nursing educationalist and simulation expert (n=1); general* (n=3); international: physiotherapy (n=1); general* (n=1) medical simulation expert (conducted simulation-based research, congress presentations, published work) 6 3 international, 3 sa national: medical specialist† (n=3); international: medical specialist‡ (n=3) healthcare simulation facility directors 2 2 sa n/a physiotherapy educationalist with simulation expertise (congress presentation, currently not published in sbe) 1 1 sa n/a sa = south africa; n/a = not applicable; sbe = simulation-based education. *a participant described as general is a qualified healthcare professional working in a simulation unit or centre with various healthcare professions students. †national medical simulation experts included two anaesthesiologists and one general medical practitioner. ‡international medical simulation experts included 2 anaesthesiologists and 1 surgeon. https://www.samedical.org/file/1807 june 2022, vol. 14, no. 2 ajhpe 63 research judged as useful (73%), with statements relating to educators assessing the achievement of mastery learning (55%) and the use of sbles for summative assessment (55%) remaining in dissensus. no consensus could be reached regarding to whose satisfaction sbles should be repeated – individual students (55%) or the educator (55%). it was noted that the development of specific assessment tools for sbles was viewed as essential (83%). according to 64% of panel members, the inclusion of a self-reflection component in sbles should be considered. discussion sa may experience challenges, including lack of funding and resources, national healthcare deficits and an underprepared and diverse student population,[3,8] when adopting educational strategies designed for a developed economy. the need for thorough planning, involving all stakeholders, to successfully integrate and sustain simulation in a programme is evident from this study. financial constraints[6] negatively impact the availability of both human and physical resources in tertiary healthcare education, and institutional investigation into the practicality and benefits when planning simulation integration is essential. the integration of simulation-based learning should, however, not be equated with high costs and high-technology facilities.[13] instead, lateral, resource-smart planning, interprofessional collaboration and shared facilities could ensure simulation-based learning for all. considering the call for curriculum decolonisation by sa students,[8] the advent of the fourth industrial revolution (4ir) and an emerging adult learner population entering tertiary education, both participants and authors viewed it as vital to carefully develop sble outcomes aligned with discipline-based and institutional needs.[16,20] in a culturally, linguistically and ethnically diverse country[7] shifting towards primary healthcare,[2] the authors were concerned that the execution of a societal needs analysis when aiming to integrate simulation was only viewed as useful and remained in dissensus, with no supporting feedback provided by panel members. this might be due to panel members viewing societal needs as being addressed through adherence to minimum standards required by the healthcare governing body, the health professions council of sa (hpcsa). it should, however, be noted that the minimum criteria expected of undergraduate healthcare students are internationally benchmarked, and may not result in the unique sa societal needs being optimally met. acknowledging the role of contextual differences when aiming to integrate standardised education models is essential,[16] and disregarding differences could reduce the educational impact of simulation on student learning. because simulation is used only in pockets of certain sa healthcare education disciplines,[14] the collaborative development of an expertly revised, contextually appropriate, scaffolded and constructively aligned curriculum that integrates sbles according to educational principles is essential. in the participants’ opinion, sbe experts are indispensable in the planning process to identify existing curricular components that could benefit from or be replaced by sbles, enhancing the achievement of programme outcomes. mindful sble design during the planning phase, guided by best practice and national regulatory body guidelines, is vital table 2. statements achieving stability during the delphi survey category stability statements related to planning round essential, % useful, % n/a needs analysis identified societal needs should form the background context of sbles, depending on the desired learning objectives for each planned learning experience. 3 64 mastery learning/ deliberate practice the educator’s role in formative sbles, not used for formal assessment, would be that of facilitator and providing feedback. 3 64 the educator’s role in summative sbles is that of post-simulation feedback/debriefing and discussion. further options regarding assessment will be explored in theme 3. 3 40 40 students should be allowed to redo all formative sbles until they have reached their individual level of satisfaction. this would be dependent on the course structure, available time and resources. 3 55 educators should identify which formative simulation-based learning experiences, according to the set learning outcomes, should be repeated until an educator’s set benchmark is achieved. this would be dependent on the course structure, available time and resources. 3 55 attainment of the educator-set benchmark for identified summative sbles should be assessed by the educator at all times. options for peerand/or self-assessment are provided in the following questions. 3 55 assessment all sbles should have an element of self-reflection. 3 64 educators should identify which sbles are to be used for summative assessment. only these identified assessments should be performed on a one-to-one student-educator basis. 3 55 educators should identify which sbles could accommodate a peer-assessment element, and it should be implemented as such. 3 55 educators should identify which sbles are to be used for formative assessment. only the identified assessments should be performed on a one-to-one student-educator basis. an element of peer-assessment could be added if deemed appropriate by the educator. 3 45.5 note: the percentage stability achieved is indicated under the corresponding importance option; ‘round’ refers to the delphi round where stability was achieved. n/a = not applicable; sble = simulation-based learning experiences. italic text represents supplemental clarification provided to panel members. 64 june 2022, vol. 14, no. 2 ajhpe research to optimally employing available physical and human resources, and will ensure that developed sbles are focused on achievable outcomes. defining the educator’s role in sbles was viewed as essential by panel members, although no consensus could be reached regarding the specific role of the educator during either formative or summative assessments. as sa educators are directly involved throughout the sble planning, implementation and evaluation phases,[21] sa panel members possibly viewed the term ‘educator’ as interchangeable and synonymous with that of facilitator. panel members not familiar with using simulation for summative assessment may also have been challenged owing to sbles currently not being used in sa other than for assessing practical skills in some healthcare disciplines. the delphi results indicated that the absence of universal, standardised simulation terminology might have caused panel members to interpret the term ‘educator’ incorrectly, as an instructor of learning, rather than both instructor and facilitator of learning. it is therefore essential to provide a clear indication during the planning phase of what is expected of the educator in terms of their role in the integration of simulation, to identify  where additional educator training and/or resources would be required. with only anecdotal evidence available regarding the use of simulation in sa physiotherapy education, the authors support the panel members’ opinion regarding the necessity of contextualised educator training for their  required roles, namely sble development, providing constructive feedback and debriefing. completion of accredited training programmes should ensure the achievement of learning outcomes[15,20] through a uniform strategy pertaining to the teaching, evaluation and certification of integrated sbles. receiving feedback and/or taking part in a debriefing session following sble participation is the essence of sbe in facilitating learning through performance-based feedback and/or reflecting on individual performance through addressing student needs.[22] various feedback and/or debriefing sources and timings have been reported.[15,22,23] panel members concurred that identification of the timing of feedback and/or debriefing, including the debriefing method and tool used, should be included in the planning phase to allow for both student and facilitator preparation. further discussion regarding debriefing will be addressed in a follow-up article where the implementation phase of this conceptual framework will be presented and discussed. the clarification of student roles in preparation for sble participation is vital during the planning phase.[24] planning should include time allocation for acquainting students, who might not be familiar with the educational practice of simulation, with the simulated environment, sble outcomes, theoretical content and selected instructional methods. the term ‘instructional methods’ was included in the delphi survey based on results from the systematic review, and refers to the overall educational methods, irrespective of the mode of simulation, used during the sbles.[23] panel members indicated that technical and non-technical skills could not be taught in isolation, which is supported by the literature.[13] preparing healthcare professionals for adverse events, problem-solving in limited resource environments and multifaceted patient and/or team consultations and treatments is equally important as theoretical preparation for clinical practice. using sbles in training for healthcare professionals could potentially develop the skills required to navigate difficult and emotionally demanding situations.[12] panel members suggested that where relevant, non-technical training aspects should be scaffolded to the sble, and in accordance with the learning objectives. collaborative planning and design of sbles with these skills in mind would not only provide better preparation of graduates for changing healthcare practice, but also instil the value of self-care. although positive effects relating to skills transfer to the clinical setting have been demonstrated,[12] both mastery learning and deliberate practice are, according to both the literature[15] and panel member comments, extremely time consuming and resource intensive. only one mastery learning and deliberate practice statement achieved consensus, which could possibly reflect the panel members’ hesitation when confronted with published best practices[25] and the realistic impact on time and resources. the overarching aim of the statements presented to panel members was to identify if and when sble repetition should be integrated into the curriculum, thereby focusing on the core similarity between mastery learning and deliberate practice, resulting in the amalgamation of these two concepts. when viewing the elements of mastery,[12] it is clear that mastery is not based solely on the acquisition of individual skills. instead, it involves a progression from skills competence and integration toward skill application. considering the impact of the covid-19 pandemic,[1] the 4ir[6] and the attributes required of physiotherapy graduates, integrating a combination of  skills during an sble could be more useful for achieving integrated learning. the only mastery learning/deliberate practice statement reaching consensus by round 3 indicated that participants viewed it as essential to add a peer-assessment element to mastery learning and deliberate practice sessions. this practice would free up educator time and could be beneficial, as peer assessment has been shown to increase student learning, contribute to collaboration skills and foster reflection.[24] as mastery learning and deliberate practice are deeply embedded in the constructivist learning theory as part of experiential learning, formative assessments will provide students with feedback for reflection, with the aim of identifying implications for action. this action cycle can then be measured by means of summative assessment to ascertain whether skill mastery has occurred, thereby completing kolb’s cycle for experiential learning[21] and assessing the top tier of miller’s[26] pyramid of clinical competence. with a shrinking clinical platform, increasing interest in the use of sbles for the summative assessment of healthcare professionals has been reported.[24] however, sbles are viewed as safe[20] and forgiving learning spaces, and formal assessment could potentially lead to undue fear hindering the learning experience. maintaining a safe learning environment could explain why stability was only achieved in the delphi survey on statements relating to the student-to-educator ratio during formative and summative assessments, as sbles are not routinely used during either immersive or practical skills-based assessments in sa healthcare education.[27] the use of sbles for summative assessments therefore requires further investigation. if, however, sbles were to be considered for use, especially in summative assessments, identification of valid and reliable assessment tools during the planning phase is essential,[25] which was confirmed by the panel members. the panel members amended the term ‘self-assessment’ to ‘self-reflection’, better illustrating the internal reflection process required of the student when planning sble integration and design. although no consensus was achieved regarding the inclusion of self-reflection in all sbles, preparing students with problem-solving, teamwork, reasoning and reflection skills is essential when taking the 4ir into account.[1] self-reflection is an invaluable attribute, as students are expected to identify their professional and personal shortcomings, and subsequently plan and adapt to address these shortcomings. june 2022, vol. 14, no. 2 ajhpe 65 research conclusion meticulous planning is crucial prior to integrating simulation in a programme, in order to identify simulation-based goals and allow for effective decisionmaking and resource allocation. planning simulation integration should be done in accordance with resource availability, desired competencies, learning outcomes and consideration of both institutional and student needs. a definite need for educator competency in both the development and delivery of the programme, especially debriefing methods, has to be emphasised to achieve optimal student learning. non-standardised terminologies used in sbe, the varied roles sa educators are required to fulfil in relation to simulation and the lack of use of sbles for assessment purposes might have impacted on panel members’ interpretation of statements and opinions regarding what might be possible in a resourceconstrained environment. the authors recommend the further exploration of student role clarification with regard to their inclusion in the assessment process through peer assessment, provision of the necessary assessment training and focused training in both providing and receiving constructive feedback. lengthy statements populated the delphi survey, which might have been difficult to respond to. the authors suggest that to obtain diverse opinions, pilot studies should include at least two to three delphi survey experts. furthermore, we advise that delphi piloting should also include piloting of the feedback process, to ensure the optimal use of the delphi methodology. the covid-19 pandemic has led to a drastic change in delivering healthcare training, and negatively impacted the clinical training platform for undergraduate healthcare students. well-planned simulation integration may assist in ensuring the continued throughput of skilled graduates, and undergraduate healthcare students who are still able to work collaboratively and demonstrate adaptability to their fragmented learning environment. the planning theme of the conceptual framework enabled us to present a detailed means of addressing current healthcare education challenges in sa by means of simulation integration. declaration. the research for this study was done in partial fulfilment of the requirements for avdm’s phd (physiotherapy) degree at the university of the free state.acknowledgements. dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. author contributions. all authors contributed to the article. avdm developed the protocol and collected the data for the larger study from which this research emanated. avdm wrote the first draft of the manuscript; ryb and mjl contributed to the interpretation of the data and writing of the article; avdm made the final editorial adjustments to the manuscript; all authors approved the final version of the article. funding. national research foundation (nrf) (grant number ttk180418322303); health and welfare sector education and training authority (hwseta). conflicts of interest. none. 1. ferrel mn, ryan jj. the impact of covid-19 on medical education. cureus 2020;12(3):e7492. https://doi. org/10.7759/cureus.7492 2. maillacheruvu p, mcduff e. south africa’s return to primary care: the struggles and strides of the primary health care system. j global health 2014,4(2):10-14. https://www.ghjournal.org/south-africas-return-toprimary-care-the-struggles-and-strides-of-the-primary-health-care-system/ (accessed 1 september 2020). 3. academy of science of south africa. reconceptualising health professions education in south africa, 2018. assaf, 2018. http://research.assaf.org.za/handle/20.500.11911/95 (accessed 1 september 2020). 4. basu d. diseases of public health importance in south africa. south afr j public health 2018;2(3):48. https:// doi.org/10.7196/shs.2018.v2.i3.72 5. phillips ac, mackintosh sf, bell a, johnston kn. developing physiotherapy student safety skills in readiness for clinical placement using standardised patients compared with peer-role play: a pilot non-randomised controlled trial. bmc med educ 2017;17(1):133. https://doi.org/10.1186/s12909-017-0973-5 6. allen s. deloitte insights: 2020 global health care outlook. laying a foundation for the future. london: deloitte development llc, 2020. https://documents.deloitte.com/insights/2020globalhealthcareoutlook (accessed 1 september 2020). 7. singh rj. current trends and challenges in south african higher education. s afr j higher educ 2015;29(3):17. https://doi.org/10.20853/29-3-494 8. mekoa i. challenges facing higher education in south africa: a change from apartheid education to democratic education. afr renaissance 2018;15(2):227-246. https://doi.org/10.31920/2516-5305/2018/ v15n2a11 9. johnston cl, wilson jc, wakely l, walmsley s, newstead cj. simulation as a component of introductory physiotherapy clinical placements. n z j physiother 2018;46(3):95-104. https://doi.org/10.15619/ nzjp/46.3.02 10. wright a, moss p, dennis dm, et  al. the influence of a full-time, immersive simulation-based clinical placement on physiotherapy student confidence during the transition to clinical practice. adv simul 2018;3(1):3. https://doi.org/10.1186/s41077-018-0062-9 11. lopreiato jo (ed). healthcare simulation dictionary. 2016. https://www.sesam-web.org/media/documents/ sim-dictionary1.pdf (accessed 8 september 2020). 12. mcgaghie wc, harris ib. learning theory foundations of simulation-based mastery learning. simul healthc 2018;13(3s suppl 1):s15-s20. https://doi.org/10.1097/sih.0000000000000279 13. kneebone r, nestel d, bello f. learning in a simulated environment. in: dent ja, harden rm, hunt d (eds.). a practical guide for medical teachers. 5th ed. london: elsevier, 2017:92-100. 14. thurling ch. the design and development of a programme for simulation best practices in south african nursing education institutions. phd thesis. johannesburg: university of the witwatersrand, 2017. http:// wiredspace.wits.ac.za/handle/10539/23150 (accessed 8 september 2020). 15. motola i, devine la, chung hs, sullivan je, issenberg sb. simulation in healthcare education: a best evidence practical guide. amee guide no. 82. med teach 2013;35(10):e1511-e1530. https://doi.org/10.31 09/0142159x.2013.818632 16. chung hs, issenberg bs, phrampus p, et  al. international collaborative faculty development program on simulation-based healthcare education: a report on its successes and challenges. korean j med educ 2012;24(4):319-327. https://doi.org/10.3946/kjme.2012.24.4.319 17. avella jr. delphi panels: research design, procedures, advantages, and challenges. int j doct stud 2016;11:305-321. https://doi.org/10.28945/3561 18. hallowell mr. techniques to minimise bias when using the delphi method to quantify construction safety and health risks. paper presented at the construction research congress, seattle, washington, usa, 5 7 april, 2009. https://ascelibrary.org/doi/10.1061/41020%28339%29151 (accessed 8 september 2020). 19. slade sc, dionne ce, underwood m, et  al. consensus on exercise reporting template (cert): modified delphi study. phys ther 2016;96(10):1514-1524. https://doi.org/10.2522/ptj.20150668 20. khamis nn, satava rm, alnassar sa, kern de. a stepwise model for simulation-based curriculum development for clinical skills, a modification of the six-step approach. surg endosc 2016;30(1):279-287. https://doi.org/10.1007/s00464-015-4206-x 21. spies c. a strategy for meaningful simulation learning experiences in a postgraduate paediatric nursing programme. phd thesis. bloemfontein: university of the free state, 2016. https://scholar.ufs.ac.za/ handle/11660/4803 (accessed 8 september 2020). 22. cheng a, eppich w, sawye t, grant v. debriefing: the state of the art and science in healthcare simulation. in: nestel d, kelly m, jolly b, watson m (eds.). healthcare simulation education. new york: wiley blackwell, 2018:158-164. 23. chiniara g, cole g, brisbin k, et al. simulation in healthcare: a taxonomy and a conceptual framework for instructional design and media selection. med teach 2013;35(8):e1380-e1395. https://doi.org/10.3109/0142 159x.2012.733451 24. viggers s, østergaard d, dieckmann p. how to include medical students in your healthcare simulation centre workforce. adv simul 2020;5:1. https://doi.org/10.1186/s41077-019-0117-6 25. association for simulated practice in healthcare. simulation-based education in healthcare: aspih standards framework and guidance. aspih, 2016. https://aspih.org.uk/standards-framework-for-sbe/ (accessed 8 september 2020). 26. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9):s63-s67. 27. swart r, duys r, hauser, nd. sass: south african simulation survey – a review of simulation-based education. south afr j anaesth analg 2019;25(4):12-20. accepted 1 september 2021. https://doi.org/10.7759/cureus.7492 https://doi.org/10.7759/cureus.7492 https://www.ghjournal.org/south-africas-return-to-primary-care-the-struggles-and-strides-of-the-primary-health-care-system/ https://www.ghjournal.org/south-africas-return-to-primary-care-the-struggles-and-strides-of-the-primary-health-care-system/ http://research.assaf.org.za/handle/20.500.11911/95 https://doi.org/10.7196/shs.2018.v2.i3.72 https://doi.org/10.7196/shs.2018.v2.i3.72 https://doi.org/10.1186/s12909-017-0973-5 https://documents.deloitte.com/insights/2020globalhealthcareoutlook https://doi.org/10.20853/29-3-494 https://doi.org/10.31920/2516-5305/2018/v15n2a11 https://doi.org/10.31920/2516-5305/2018/v15n2a11 https://doi.org/10.15619/nzjp/46.3.02 https://doi.org/10.15619/nzjp/46.3.02 https://doi.org/10.1186/s41077-018-0062-9 https://www.sesam-web.org/media/documents/sim-dictionary1.pdf https://www.sesam-web.org/media/documents/sim-dictionary1.pdf https://doi.org/10.1097/sih.0000000000000279 http://wiredspace.wits.ac.za/handle/10539/23150 http://wiredspace.wits.ac.za/handle/10539/23150 https://doi.org/10.3109/0142159x.2013.818632 https://doi.org/10.3109/0142159x.2013.818632 https://doi.org/10.3946/kjme.2012.24.4.319 https://doi.org/10.28945/3561 https://ascelibrary.org/doi/10.1061/41020%28339%29151 https://doi.org/10.2522/ptj.20150668 https://doi.org/10.1007/s00464-015-4206-x https://scholar.ufs.ac.za/handle/11660/4803 https://scholar.ufs.ac.za/handle/11660/4803 https://doi.org/10.3109/0142159x.2012.733451 https://doi.org/10.3109/0142159x.2012.733451 https://doi.org/10.1186/s41077-019-0117-6 https://aspih.org.uk/standards-framework-for-sbe/ may 2014, vol. 6, no. 1 ajhpe 37 research introduction of a learning management system at the kilimanjaro christian medical university college l killewo,1 ba; e lisasi,1 md, mph; g kapanda,1 msc; d tibyampansha,1 bs; g ibrahim,1 ba, mph; a kulanga,1 mba; c muiruri,2,3 mph; n fadhili,1 mca; d wiener,2,5 as; a wood,5 ba; e kessi,1 md, mmed, msc; k mteta,1,4 md, mmed; m ntabaye,4 dds, phd; j a bartlett,1-3 md 1 kilimanjaro christian medical university college, moshi, tanzania 2 duke university school of medicine, durham, north carolina, usa 3 duke global health institute, durham, north carolina, usa 4 kilimanjaro christian medical centre, moshi, tanzania 5 learning content management system, durham, north carolina, usa corresponding author: l killewo (amlucy2000@yahoo.com) background. medical schools in africa face daunting challenges including faculty shortages, growing class sizes, and inadequate resources. learning management systems (lms) may be powerful tools for organising and presenting curricular learning materials, with the potential for monitoring and evaluation functions. objective. to introduce a lms for the first-year medical student curriculum at the kilimanjaro christian medical university college (kcmu co), in moshi, tanzania, in partnership with the duke university school of medicine (durham, north carolina, usa). methods. observations were made on the requisite information technology (it) infrastructure and human resource needs, and participation in training exercises. lms utilisation was recorded, and two (student and faculty) surveys were done. results. the kcmu co it infrastructure was upgraded, and an expert team trained for lms implementation. an introductory lms workshop for faculty had 7 out of 25 invitees, but attendance improved to more than 50% in subsequent workshops. student attendance at workshops was mandatory. use of the lms by students rapidly expanded, and growing faculty utilisation followed later. by the end of the second semester, online examinations were offered, resulting in greater student and faculty satisfaction owing to rapid availability of results. a year after lms introduction, 90% of students were accessing the lms at least 4 days/week. a student survey identified high levels of satisfaction with the lms software, quality of content, and learning enhancement. conclusion. lms can be a useful and efficient tool for curriculum organisation, administration of online examinations, and continuous monitoring. the lessons learned from kcmu co may be useful for similar academic settings. ajhpe 2014;6(1):37-40. doi:10.7196/ajhpe.260 sub-saharan africa faces an extraordinary burden of human disease, with a dire shortage of healthcare providers to address this burden.[1] the training of medical doctors is essential, but current training capacity falls far short of meeting anticipated needs. about 167 000 new doctors will be needed in sub-saharan africa by the year 2015, but only 30 000 are expected to graduate in this period.[1] ministries of health and education, and the private sector, have responded by opening many new medical schools across the continent, and mandating that each school rapidly expand its class size.[1] despite these efforts, the delivery of medical education in sub-saharan africa faces great challenges, including poor infrastructure, inadequate number of medical schools, insufficient number of faculty members, poor compensation for faculty and graduates, and a continued increase in student enrolment without a commensurate increase in faculty numbers and infrastructure to accommodate the changes.[1] creative interventions to overcome these challenges are sorely needed, including the use of modern technologies and teaching methods that optimise medical student learning, despite limited resources. one approach to enhance efficiency and organisation is the use of a learning management system (lms). lms has been defined as ‘a software application or web-based technology that is used to plan, deliver or access a particular learning process’.[2] in upperand middle-income countries, lmss are extensively used in universities and businesses for organising and sharing learning materials, communications, and evaluating students/learners. in a survey of 25 african countries, 4 major impediments to successful utilisation of lmss were identified:[2] (i) knowledge of lms was limited, with only 49% responding that they had used a lms for teaching and 52% for learning in the previous 12 months. furthermore, they had limited knowledge of the broad capabilities of a lms, with only approximately 50% of respondents demonstrating knowledge of 18 specific lms features; (ii) infrastructure shortcomings in internet bandwidth and steady electricity supply were major impediments to usage. this was supported by a study of computers, the internet and medical education in africa which revealed that internet speeds were rated as ‘slow’ or ‘very slow’ by 25% of respondents, with the percentage rising to 58% in east africa.[3] in addition, the ratio of computers to students was 1:0.123;[3] (iii) training in the use of lms was limited, and 25% of respondents indicated a history of less than 2 hours of training in lms use; and (iv) a lack of shared content and open educational resources within africa. a recent survey of medical schools in resource-constrained lowand middle-income countries revealed that a limited number in sub-saharan africa were employing a lms for the management of their curriculum and students, and none had systematically examined their impact.[4] mailto:amlucy2000@yahoo.com 38 may 2014, vol. 6, no. 1 ajhpe research similar to other medical schools in sub-saharan africa, the kilimanjaro christian medical university college (kcmu co) in moshi, tanzania, has experienced rapid growth in medical student class size, increasing from 15 when it opened in 1997 to 154 in 2011. in 2010, kcmu co received funding from the united states government through the medical education partnership initiative (mepi),[5] a programme designed to assist sub-saharan africa by increasing the number and quality of physicians, to increase their retention in underserved areas, and to improve research capacity. with this support, kcmu co introduced an lms in october 2011 to manage the first-year curriculum and the incoming first-year students. methods setting kcmu co is located in moshi, tanzania, and is one of 6 tanzanian medical schools. it is overseen by the good samaritan foundation, and has 3 faculties offering 16 different health-related degrees. its principal clinical training site is the kilimanjaro christian medical centre (kcmc), one of 4 referral hospitals in tanzania serving an estimated population of 16 million. similarly to many other sub-saharan medical schools, kcmu co has rapidly expanded its class sizes in the past 10 years. fig. 1 shows the dramatic increase in the numbers of admitted students from 1997 2011. unfortunately, the increase in the number of admitted students has not been accompanied by increases in faculty size or other key infrastructure components. as a result, faculty are overwhelmed and teaching obligations decrease in priority. in an informal survey conducted at kcmu co in 2010, faculty delivered less than 40% of their scheduled lectures to students. as a result, students were forced to pursue self-directed and group learning, frequently without faculty guidance or teaching. the mepi leadership team visited the duke university school of medicine (durham, north carolina, usa) to evaluate different options for an lms intervention, including proprietary and open-source software. important considerations were a proven record of successful hosting of medical school curricula, ease of use by students and faculty, availability of programming support, ability to deliver online examinations, monitoring and evaluation functions, and ability to easily track system activities and usage. the lms chosen for intervention was developed by the duke university school of medicine, a key kcmu co partner. it was developed specifically for medical education at duke, and is known as the learning and curriculum management system+ (lcms+). lcms+ is now manufactured, marketed and maintained by lcms+ inc., durham, north carolina, usa. lms team development empowered by the kcmu co and kcmc leadership, a team was developed to support the lms intervention, led by an lms specialist with a background in information technology (it) and some experience in managing educational applications. she travelled to duke for training, and had weekly conference calls with the lcms+ developers. in addition, the lcms+ developer travelled to kcmu co to assist with on-site training. she was supported by three it specialists who oversaw the development of a fibre optic cable network on campus and internet and intranet july 2011 sept 2011 nov 2011 jan 2012 feb 2012 preparation for online examinations o�cial launching online examination administration acquisition of lcms+ introduction of lcms+ system introduction and training for students continuous system support, training and usage monitoring training for faculty, sta� and students receiving and uploading examinations to the system preparing computers, computer rooms and invigilators examination administration feedback from faculty and student surveys communicated with potential users call for course materials submission development of security and user privileges uploading course materials first training to faculty members system work plan and usage system set-up, con�guration and testing (duke system development and kcmu co sta� co-ordinating activities closely) system content familiarisation and customisation fig. 2. lcms+ implementation timeline. 0 20 40 60 80 100 120 140 160 n u m b er o f a d m it te d s tu d en ts admission year 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 fig. 1. growth in kcmu college medical school admissions from 1997 to 2011. editorial may 2014, vol. 6, no. 1 ajhpe 39 editorial services. the timeline for the development of the lcms+ team and initial implementation is shown in fig. 2. training of kcmu co faculty, students and staff once the lcms+ was installed and ready for use, the kcmu co dean informed faculty about its planned introduction. a carefully organised introductory training workshop was held in september november 2011 for kcmu co faculty, students and staff, followed by an online examination workshop in january 2012. on-demand training and ongoing support services continued to be offered at individual to departmental levels. it was decided to initiate lcms+ implementation with the first-year medical students entering in october 2011, and in subsequent years the lcms+ would be extended by one class each year. survey assessments surveys were developed to assess faculty and student feedback on the lcms+. all surveys were conducted anonymously online. faculty and students were surveyed in february march 2012 to solicit feedback following the introduction of online examinations. students completed a survey on lcms+ in december 2012, following completion of the first semester in their second year. our lcms+ survey adapted delone and mclean’s[6] updated information systems success model as a way to explicitly measure and assess success. we chose this model because of its success metrics, which are specifically designed for the e-learning context. the lcms+ student survey consisted of 15 questions using a 5-point likert scale for responses (1 = strongly disagree to 5 = strongly agree), and focused on the quality of the software, quality of content, learning enhancement, complaints, and preferences for future content. mean scores were calculated for student responses, and strength of consensus measure (scns) was applied to test for response consistency. ethical clearance all research related to the mepi was reviewed by the kcmc research ethics committee, and was exempted from a full review because of its focus on education. participation in the study assessments by faculty, staff and students was preceded by verbal consent. all survey results were anonymous. results workshop participation at the first workshop to introduce faculty and staff to lcms+, only 7 out of 25 invited members attended. an informal survey of faculty revealed the expectations summarised in table 1. a second workshop was offered in late january 2012, near the start of the second semester, and 42/60 invited faculty and staff attended. workshops for students were held in october 2011 and january 2012, and participation was mandatory; 154 students attended each workshop. lcms+ utilisation utilisation rapidly increased during the first months of lcms+ availability. by january 2012, after 3 months of lcms+ activity, 220 students (including medical and master’s students) and 34 faculty had accessed the system. in december 2012, a year after implementing lcms+, a survey of 2nd-year medical students revealed that 90% of them were accessing the lcms+ at least 4 days/week, and 57% were accessing it 6 7 days/week. online examinations eight faculty and 116 students responded to the online examinations survey. six faculty members (75%) reported that they were able to prepare online examinations in a week or less; the remaining 2 needed 2 weeks. six faculty members reported that previously they had needed more than 2 weeks to grade ‘paper’ exams, whilst online examinations were graded instantaneously. all faculty members answered that they had a positive experience with online examinations, and 100% indicated that they planned to continue to use them in future. of 116 students responding to the survey, 88% preferred online to paper examinations. most (72%) students stated that they preferred online examinations because of the short turnaround time to receive feedback on their examination grades. most (85%) felt that the multiple choice questions were clearly written, although only 20% of students felt that enough time had been allocated to answer each question. research table 1. informal survey of faculty attitudes – first workshop percentage of faculty (n=7) attitude 50 fear of change and adapting to the new system 40 did not believe that the system could work in an african setting, particularly at kcmu co 10 eager to learn and see how the system was going to change and improve the culture of teaching and learning table 2. lcms+ student survey mean scores and consensus measures category mean scores consensus measure, % quality of software 3.93 77 user friendly 4.3 85 stability 3.7 73 security 4.0 80 interactivity 3.7 73 quality of content 4.19 84 well organised 4.2 84 effectively presented 4.0 81 appropriate length 4.0 81 clearly written 4.3 85 use for learning 4.5 91 up-to-date 4.2 84 clear course objectives 4.1 83 appropriate terminology 4.2 85 used effectively 4.2 85 learning enhancement 4.2 83 stronger analytical skills 4.3 87 faster learning 4.3 85 better individual learning 4.3 87 less dependent on library 4.1 81 flexible study schedule 4.3 86 better communication 3.9 77 editorial 40 may 2014, vol. 6, no. 1 ajhpe student surveys a total of 154 2nd-year medical students participated in the student surveys on lcms+, representing the entire class that had utilised lcms+ since entering medical school in october 2011. the mean scores by category and consensus measures are in table 2. overall, the mean scores ranged from 3.7 4.5, with a consensus measure of 73 91%. in the category of quality of software, the mean scores were 3.7 4.3 with consensus measures of 73 85%. in the category of quality of content, the mean scores ranged from 4.0 4.5, with consensus measures of 81 91%. in the category of learning enhancement, the mean scores ranged from 3.9 4.3, with consensus measures of 77 87%. complaints about lcms+ were also solicited; the most common were late posting of materials (25%), difficulty in submitting assignments (21%), student misuse of bulletin boards (16%), downloading and printing of documents (14%), and difficulty contacting lecturers (11%). preferences for future content and services expressed by at least 50% of students included access to online libraries (86%), access to previous tests and answers (79%), e-mail notification of announcements (67%), access to previous study materials (60%), and discussion groups/wikis (52%). discussion the introduction of lcms+ at kcmu co has proven successful, with rapid utilisation by students and faculty, online testing with strong preferences in favour of this method from students and faculty, and highly favourable student surveys supporting the use of lcms+, with a high degree of consensus. compared with paper examinations, online examinations have reduced paper usage, and printing and labour costs. in addition, faculty time spent on script marking and producing examination report was greatly reduced, and students appreciated the rapid turnaround of examination grade feedback. the original intent in introducing lcms+ at kcmu co was to focus on implementation exclusively with medical students, progressing from the first-year class in 2011 and adding one new medical student class per year. however, the demand for lcms+ access spread rapidly within the college, and lcms+ is now used to support the curricula of 3 medical school classes and 3 master’s in medicine programmes. two new staff specialists have been hired to address the increased demand for lcms+ services. taken together, these observations suggest outstanding value for lcms+ in organising, presenting and testing curricular content. three of the top 5 complaints about lcms+ relate to late postings, student misuse of bulletin boards, and difficulty contacting lecturers − issues that relate to users and not to the system itself. the lcms+ has the capacity to evolve with time, and will in the future respond to kcmu co student requests for the addition of materials such as online libraries, previous study materials and tests, and discussion groups. the published experience of other sub-saharan african schools of medicine is limited, and does not include similar assessments of user satisfaction.[4] the university of kwazulu-natal described 6 academic programmes using moodle as an lms, largely within their school of nursing.[7] they identified computer access as an obstacle to implementation, with difficult access during working hours and a lack of personal computer access outside working hours. the university of colombo in sri lanka described their experience with using moodle as an lms beginning in 2007, and performed a random survey of 100 medical students[7] of whom 99% responded that the lms material was useful, and faculty enthusiasm was described as ‘high’.[8] the use of lcms+ by kcmu co offered important advantages for implementation. it was specifically designed to host medical school curricula, and most of the programming development was complete prior to its adoption at kcmu co. technical support has been provided gratis by the duke university school of medicine and lcms+, inc., in recognition of the long-standing 17-year partnership between kcmu co and duke. other sub-saharan african schools of medicine may find the cost of this proprietary software to be an obstacle, and may wish to utilise open-source software such as moodle. they should be aware of the programming support needs if they elect to pursue the option of moodle or other open-source software. the use of electronic aids in medical education may have significant impact, especially in lowand middle-income countries where faculty shortages are common. however, when they are introduced, careful planning and preparation is essential. frehywot et al.[4] identified 4 critical strategies for ensuring the success of e-learning interventions: institutional support, technical expertise in it, adequate infrastructure and support systems, and faculty and student engagement. the experience of kcmu co in lcms+ implementation underscores the importance of these factors. there are a number of limitations to these observations. firstly, we have described implementation, rapid uptake and utilisation, and highly favourable subjective responses to the introduction of lcms+. however, we do not have objective evidence of improved medical student performance. secondly, we had the unique opportunity to invest in educational infrastructure with mepi support, and to access lcms+ from duke university at no cost. thirdly, we do not have any comparative data on the use of other lmss in medical education within resource-limited settings. lastly, the survey instruments used were internally developed and had not undergone validation. there were some challenges caused by system users: late posting of materials, student misuse of bulletin boards, and difficulty contacting lecturers. we have found that users were lacking knowledge on how to efficiently and effectively use the system. these issues have been addressed. provision of education to users can help to solve these problems. conclusion the introduction of lcms+ at kcmu co has assisted with curricular organisation, presentation and testing. it has been rapidly adopted by the students and faculty with very favourable responses. other schools of medicine in sub-saharan africa may wish to implement similar efforts. conflict of interest. this study was supported by the medical education partnership initiative and health resources and services administration award t84ha21123. dw and aw are employees of lcms+, inc.; jab and cm are employees of duke university, which has a financial interest in lcms+, inc. the authors of this article have no conflict of interest to report. references 1. mullan f, frehywot s, omaswa f, et al. medical schools in sub-saharan africa. lancet 2011;377(9771):1113-1121. [http://dx.doi.org/10.1016/s0140-6736(10)61961-7] 2. unwin t, kleessen b, hollow d, et al. digital learning management systems in africa: myths and realities. open learning 2010;25(1):5-23. [http://dx.doi.org/10.1080/02680510903482033] 3. williams cd, pitchforth el, o’callaghan c. computers, the internet and medical education in africa. med educ 2010;44(5):485-488. [http://dx.doi.org/10.1111/j.1365-2923.2009.03602.x] 4. frehywot s, vovides y, talib z, et al. e-learning in medical education in resource constrained lowand middleincome countries. hum resour health 2013;11:4. [http://dx.doi.org/10.1186/1478-4491-11-4] 5. medical education partnership initiative. fostering african medical education community of excellence, 2011. http://mepinetwork.org/about-mepi/coordinating-center.html (accessed 28 february 2013). 6. holsapple cw, lee-post a. defining, assessing and promoting e-learning success: an information systems perspective. decision sciences journal of innovative education 2006;4(1):67-85. [http://dx.doi.org/10.1111/ j.1540-4609.2006.00102.x] 7. mars m. building the capacity to build capacity in e-health in sub-saharan africa: the kwazulu-natal experience. telemed j e health 2012;18(1):32-37. [http://dx.doi.org/10.1089/tmj.2011.0146] 8. rajapakse s, fernando d, rubasinghe n, gurusinghe s. e-learning in medical education: guide supplement 32.6 − practical application. med teach 2009;31(5):452-453. [http://dx.doi.org/10.1080/01421590902833036] research http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1080/02680510903482033] http://dx.doi.org/10.1111/j.1365-2923.2009.03602.x] http://dx.doi.org/10.1186/1478-4491-11-4] http://mepinetwork.org/about-mepi/coordinating-center.html http://dx.doi.org/10.1111/j.1540-4609.2006.00102.x] http://dx.doi.org/10.1111/j.1540-4609.2006.00102.x] http://dx.doi.org/10.1089/tmj.2011.0146] http://dx.doi.org/10.1080/01421590902833036] 84 november 2013, vol. 5, no. 2 ajhpe skills training of junior medical students: can peer teaching be the solution? i m mutwali,1 md; a n hassan,2 md 1 department of surgery, faculty of medicine, alzaiem alazhari university, sudan 2 department of microbiology, faculty of medicine, alzaiem alazhari university, sudan corresponding author: i m mutwali (ismatwally@yahoo.ca) background. the system-based curriculum of the medical college of alzaiem alazhari university, sudan, entails skills training for pre-clerkship students. the increased demands on full-time trained clinical teachers cannot be solved by employing part-time staff owing to the poor financial incentives that are offered. objectives. to verify the feasibility of implementing a peer tutor model for skills training of junior students and to establish whether this model can overcome the shortage of clinical teachers. methods. eight selected and trained peer tutors participated in teaching certain aspects related to the basic skills module to 2nd-year students (n=144). three sessions were prepared, conducted and implemented by peer tutors. the effectiveness of the experience was evaluated by an objective structured clinical examination (osce) and two questionnaires. results. junior students received the peer teaching sessions favourably and requested a continuation of the process. the performance of the tutees was good. peer tutors enjoyed and benefited from this teaching method without it negatively affecting their own learning. discussion. our study demonstrated that a peer teaching educational model is feasible and can contribute to solving the problem of skills training of junior medical students. the peer teaching model is effective, provided the tutors are well trained and the educational experience is supervised. conclusion. peer-assisted learning is effective and beneficial for both tutors and tutees in resource-limited environments. it can contribute towards addressing the problem of skills training of junior medical students where there is a shortage of trained clinical teachers. ajhpe 2013;5(2):84-87.doi:10.7196/ajhpe.235 research peer-assisted learning ‘is the act or process of gaining knowledge, understanding or skill from students that are either at a different or equivalent academic level’.[1] informal peer teaching usually takes place in the clinical skills laboratory (csl) as mutual teaching, where students alternate between the roles of teachers and learners.[1] peer teaching for undergraduate skills training is widely accepted by tutees, provided that peer tutors receive good training and the teaching sessions are supervised by experienced staff members.[2] the skills training of undergraduate medical students during preclinical and clinical rotations typically entails small-group teaching sessions, thereby increasing the load on clinical teachers. these increased demands on the limited number of trained clinical teachers in a developing country – in this case, sudan – created a need for other resources. there were two possibilities: (i) to recruit part-time clinical educators, which proved to be difficult because of the unattractive financial incentives; or (ii) peer teaching. various studies highlight the benefits of peer teaching, demonstrating that it improves the examination performance of the tutees,[3,4] and establishes reciprocal social, psychological and cognitive support.[5] both peer tutors and learners benefit from peer teaching, as the former can improve their learning habits, acquire new advanced perceptions towards the subject matter, and increase their skill competence. peer learners can acquire new skills and knowledge and feel relaxed in the presence of their peer teachers.[6,7] this cognitive and social congruence promotes a more relaxed teaching environment.[8,9] the increased number of medical students and hence the increased demands on the limited number of trained staff encourage the adoption of the peer teaching method.[10] the limited resources at the faculty of medicine of alzaiem alazhari university (aau), sudan, the shortage of trained clinical educators and the increasing numbers of medical students created a need for a teaching strategy that is effective, feasible and contributes towards solving the problem of skills training for preclinical medical students. objectives the aims of our study were to investigate the feasibility of implementing a peer teaching model for skills training of junior medical students, to establish its effectiveness and to verify whether peer teaching can help to solve the problem of skills training of junior students in developing countries with limited resources. methods a mixed observational study was conducted. a near-peer teaching model was selected, bearing in mind that senior students have enough clinical experience for effective skills teaching. the criteria for selection of peer tutors included: senior students (clerkship students), voluntary participation, cumulative grade point average ≥3.3, personal motivation, and former experience of informal peer teaching. all 2nd-year students (n=144) in their basic clinical course were involved in the study as learners. they were mailto:ismatwally@yahoo.ca november 2013, vol. 5, no. 2 ajhpe 85 research informed about the educational experience and that they were to be trained by peers under supervision of the staff. training of peer tutors peer tutors (n=16) were selected and received 8 weeks of training sessions on the principles, concepts and theories of adult learning and skills teaching in the csl. they practised how to assess the students formatively and give feedback, demonstrate the five steps of skills teaching in the csl, set the objectives of the skills training sessions and prepare handouts and checklists for their teaching sessions. eventually, only 8 peer tutors participated in the study; the other 8 graduated and left the faculty. peer learners were divided into groups (n=11 or 12) per peer tutor. every group attended three 2-hour sessions, which were prepared and presented by peer tutors. the staff were present during some of the sessions to help solve administrative problems and to observe the training. the training for learners was done on models, manikins and simulated patients, and thereafter in teaching hospitals. each peer tutor supervised one or two groups. nine skills were selected for practice, including intramuscular and intravenous injections; intravenous line insertion; measurement of blood pressure, pulse rate, respiratory rate, and body temperature; insertion of a nasogastric tube; and urethral catheterisation. data collection data regarding tutors’ and peer learners’ perceptions and benefits of peer teaching were collected by means of two separate questionnaires using the 5-point likert scale (from strongly disagree = 1 to strongly agree = 5). both questionnaires included an open-ended question about the opinion of the tutors and learners on peer teaching. the questionnaires were handed out to tutors and learners at completion of the educational experience. in addition, learners` performance was assessed by an objective structured clinical examination (osce) at the end of the training course. the osce, composed of 6 stations (each of 5 minutes’ duration) in the csl, using models, manikins and simulated patients, was used to verify that the learners had acquired all the required skills taught by peers. it was organised by the peer tutors and supervised by trained clinicians who did not participate in teaching. this study was approved by the research committee of the faculty of medicine of aau. data analysis version 16 spss software was used to analyse the data. all values of the descriptive statistical anlyses were expressed as percentages (mean±sd). the scores of the 5-point likert scale were calculated and similarly expressed as percentages to indicate agreement or disagreement of tutors and tutees with regard to the statements in the questionnaires. results out of the total number (n=144) of 2nd-year students, 100 (69.4%) responded to the questionnaire of the tutees’ perceptions. forty-six volunteer peer tutors wished to participate in peer teaching; however, only 16 were eligible and selected for training, but eventually only 8 participated in the study. all 8 peer tutors who participated in the study responded to the postintervention questionnaire. the peer teaching programme was successfully implemented, all scheduled sessions were conducted, there was no absenteeism among the peer learners, and both tutors and learners were very enthusiastic. peer learners who participated in the programme accepted the usefulness and benefits of peer teaching (table 1). about half of the peer learners (48%) thought that there was not enough time for practising the newly acquired skills. overall, the peer learners rated peer teaching as good or excellent (89%), with a mean likert scale of 4.25/5. the osce held at the end of the training course for assessing students’ competence showed a success rate of 100% (table 2). in the open-ended question, most of the peer tutees were of the opinion that peer teaching is a good learning experience and an excellent way to learn skills. participants also mentioned that peer teaching increased their confidence levels, making it easy for them to ask the tutors questions. the only negative aspect mentioned was that they did not have enough time to practise. they concluded that they support the continuation of this model of education. some of the learners’ comments are given below: ‘it is a good experience to be taught by our peers, but i think three sessions are not enough.’ ‘the only negative aspect is that we did not have enough time to practise.’ ‘peer teaching is a great way of learning.’ ‘tutoring by peers was fun and full of knowledge.’ ‘the experience makes me more confident.’ ‘it is a good experience because we feel at ease when asking the peer tutors.’ table 1. peer learners’ agreement on the usefulness of peer teaching at alzaiem alazhari university, sudan, 2011 question participants (n=100) agreement (%)* mean (/5)±sd 1. learning objectives were clearly defined by tutors 96 4.37±0.63 2. peer tutors were well prepared for each session 85 4.06±0.99 3. peer tutors enthusiastic for teaching 82 4.14±0.83 4. peer tutors were skilful 89 4.15±0.87 5. peer tutors demonstrated the skills satisfactorily 85 3.99±0.67 6. i acquired new skills 87 4.08±0.79 7. i gained new information 91 4.22±0.66 8. we allowed enough time to practise skills 52 3.27±1.29 9. peer tutors provided constructive feedback 68 3.67±0.99 10. peer teaching should continue for skills training 79 4.02±1.06 *note: agreement is defined as a score of 4 or 5 on a 5-point likert scale. 86 november 2013, vol. 5, no. 2 ajhpe research peer tutors demonstrated that participating in teaching junior students did not affect their learning programme as senior students and that it was an enjoyable experience. the responses of peer tutors regarding their perception of peer teaching are given in table 3. these comments emphasised the need for more and continuous training of tutors, the necessity for continuation of the programme, and the improvement of the teaching environment in the csl. discussion a mixed qualitative/quantitative observational study was conducted to determine: (i) the attitude of our junior medical students towards peer teaching; (ii) whether they accepted it and found it a useful tool for acquiring skills; (iii) its effectiveness; and (iv) the students’ skills competence. our study demonstrated that a peer-teaching educational model is feasible in a resource-limited context, provided it is well organised, the peer tutors are trained, and there is supervision. our selected peer tutors were all well trained for a period of 8 weeks before commencement of teaching. they all demonstrated the steps and methods of teaching skills, and prepared a written model of handouts and checklists for their training sessions. this finding is consistent with the conclusion that peer teaching in undergraduate clinical skills training is a feasible and an accepted method if tutors receive enough training and the process is supervised.[2] many studies in medical education during the last decades have documented peer teaching and demonstrated its value in clinical education.[1,6,10 ] our results add further proof of its suitability as a training tool in a developing country. the study demonstrated that junior medical students received peer teaching favourably. they gained new knowledge and acquired skills, and both peer tutors and peer learners benefited from the educational experience. peer tutors benefited by improving their knowledge and acquiring the skill of teaching, without affecting their own learning programmes as senior medical students.[12,13] the peer learners were at ease when communicating with peer tutors, an aspect which can be related to the cognitive and social congruence highlighted by many studies.[5,8,9] the results of our study are in agreement with those of previous studies documenting the benefits of peer teaching in medical education.[4,6,7-9,11] the peer teaching experience was successful, demonstrating its effectiveness and benefits. it also showed that peer teaching can help to solve the problem of skills teaching to junior medical students in a resource-limited environment. peer learners and peer tutors agreed on the importance of continuation of this programme, and some of the participants requested the inclusion of this model as a formal method in the curriculum. an increasing number of medical students and time constraints on clinical teaching staff (due to increased demands) are leading to the adoption of this method of teaching.[10] formal adoption of peer teaching into curricula can develop medical students’ knowledge, skills and attitude.[3] the criteria that we used for selection of tutors did not differ from those in the literature. [13] tutees commented that there was not enough time to practise the skills taught, which could be related to the limited number of peer tutors and the relatively large number of learners for each tutor. however, this issue can be solved by allocating 5 6 learners per tutor. to the best of our knowledge, this is the first educational experience using formal peer teaching for skills training in sudan. the results and tutees’ acceptance should encourage other medical colleges in sudan to formally employ peer teaching to overcome the shortage of trained clinical teachers. by adoption of peer teaching as a formal method of skills training, the increased involvement and demands on trained clinical teachers will decrease, so that they can spend more time with senior students and on patient care. formal adoption of peer teaching does not rule out the role of trained clinical teachers in the teaching of junior students. they also have an important role in training peer tutors, watching their performance and giving them advice for improvement. to increase the benefits of our peer-teaching experience, the number of skills and tutors should be increased. there should be a follow-up table 3. peer tutors’ responses regarding peer teaching at alzaiem alazhari university, sudan, 2011 peer tutors (n=8) question agree/disagree (%)* mean±sd 1. peer teaching interfered with my learning as a senior student* 100 4.75±0.46 2. participating in peer teaching improved my skills 100 4.75±0.46 3. peer teaching helped me to gain more knowledge 100 4.75±0.46 4. i was well informed and trained for peer teaching 100 4.62±0.51 5. i felt comfortable participating in teaching and evaluating peers 100 4.62±0.51 6. trained peer tutors can participate effectively in skills teaching 100 4.87±0.35 7. participating in peer teaching encouraged me to teach mates 75 4.00±0.75 8. my overall rating for peer teaching 100 4.62±0.51 *note: agreement is defined as a response of 4 or 5 on a 5-point likert scale for questions 2 8, and disagreement as a response of 1 or 2 for question 1. table 2. the osce scores of peer learners’ competence at alzaiem alazhari university, sudan, 2011 grade and (score) students (n=144) n (%) a (≥80) 69 (47.5) b+ (75<80) 51 (36.7) b (65<75) 24 (15.8) c+ (60<65) c (50<60) f (<50) osce = objective structured clinical examination. november 2013, vol. 5, no. 2 ajhpe 87 research evaluation of the students’ performance to establish whether they can retain what they have acquired with regard to the next clinical rotation. randomisation of learners is an important issue as well as inclusion of controls. conclusion our study demonstrated that a near-peer teaching model for teaching skills to junior medical students, that entails a limited financial cost and a moderate administrative effort, can be an effective tool for teaching and can contribute towards solving the problem of skills training of junior medical students in a resource-limited country. the results of our study suggest that peer teaching can be adopted as a mode of teaching clinical skills and can be incorporated into the curriculum to improve skills training and to participate in solving the shortage of the trained staff. references 1. henning jm, weider tg, marty mc. peer-assisted learning in clinical education: literature review. j athl train 2008;43(3):84-90. 2. peter w, markus s, bernd k, et al. undergraduate technical skills training guided by student tutors. analysis of tutors` attitude, tutees acceptance and learning progress in an innovative teaching model. bmc med educ 2008;8:18. http://www.biomedcentral.com (accessed 28 august 2010). [http://dx.doi. org/10.1186/14726920-8-18] 3. bruke j, fayaz s, graham k, matthew r, field n. peer-assisted learning in the acquisition of clinical skills: a supplementary approach to musculoskeletal system training. med teach 2007;29:577582. [http://dx.doi. org/10.1080/01421590701496867] 4. wang jg, walderep td, smith tg. formal peer-teaching in medical school improves academic performance: the musk supplemental instructor programme. teach learn med 2007;19(2):216-220. [http//:dx.doi. org/10.1080/1040133070136455] 5. lockspeiser tm, o`sullivan p, teherani a, muller j. understanding the experience of being taught by peers: the value of social and cognitive congruence. adv health sci educ theory pract 2008;13:361-372. [http://dx.doi. org/10.1007/s10549-006-9049-8] 6. escovitz es. using senior students as clinical skills teaching assistants. acad med 1990;65(12):733-734. 7. glynn lg, mac farlene a, kelly m, cantillon p, murphy aw. helping each other to learn – a process evaluation of peer-assisted learning. bmc med educ 2006; 6:18. http://www.biomedcentral.com/1472/6/18 (accessed 5 july 2010). [http://dx.doi.org/10.1186/ 1472 -6-18] 8. rodrigues j, sengupta a, mitchell a, kane c, maxwell s. the south-east scotland foundation doctor teaching programme – is near-peer-teaching feasible, efficacious and sustainable on regional scale? med teach 2009;31(2):e51-e 57. [http://dx.doi.org/10.1080/ 01421590802520915] 9. leeper h, chang e, cotter g, et al. a student design and student led sexual history-taking and learning for second year medical students. teach learn med 2007;19(3):293-301. [http://dx.doi.org/10.1080/10401330701366770] 10. ten cate o, during s. peer-teaching in medical education: twelve reasons to move from theory to practice. med teach 2007;29(6):591-599. [http://dx.doi.org/10.1080/0142159071606779] 11. weyrech p, celebi n, schrauth m, maltner a, lammerding-koppel m, nikendei c. peer-assisted versus faculty staff-led skills laboratory training: a randomised control trial. med educ 2009;43(2):113-120. [http://dx.doi. org/10.1111/j.1365-2923.2008.03252x] 12. nestel d, kidd j. peer-assisted learning in patient-centred interviewing : the impact on student tutors. med teach 2005;27(5):439-444. [http://dx.doi.org/10.1080/01421590500086813] 13. yu tc, wilson nc, singh pp, lemanu dp, hawken sj, hil ag. medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. adv med educ pract 2011;2:157-172. http://www.biomedcentral.com http://dx.doi.org/10.1186/14726920-8-18] http://dx.doi.org/10.1186/14726920-8-18] http://dx.doi.org/10.1080/01421590701496867] http://dx.doi.org/10.1080/01421590701496867] http://dx.doi.org/10.1007/s10549-006-9049-8] http://dx.doi.org/10.1007/s10549-006-9049-8] http://www.biomedcentral.com/1472/6/18 http://dx.doi.org/10.1186/1472-6-18] http://dx.doi.org/10.1080/01421590802520915] http://dx.doi.org/10.1080/10401330701366770] http://dx.doi.org/10.1080/0142159071606779] http://dx.doi.org/10.1111/j.1365-2923.2008.03252x] http://dx.doi.org/10.1111/j.1365-2923.2008.03252x] http://dx.doi.org/10.1080/01421590500086813] 13 december 2011, vol. 3, no. 2 ajhpe introduction according to publications in the uk and usa1-3 there is a lack or limitation in the knowledge of research methodology, statistics, and critical appraisal skills of medical literature evaluation among registrars and clinicians. as a consequence, utilisation of biostatistical consultation services became necessary and is provided in the most prestigious academic hospitals and medical schools of the world.4-6 in south africa (sa) as a result of rules changes by the health professional council of sa (hpcsa) to become a specialist, a compulsory qualification in research was added. therefore courses in research methodology, applied statistics and scientific writing were implemented since 2007 at the university of the witwatersrand and from 2009 biostatistical consultations were conducted. in order to evaluate the utilisation of biostatistical services at the academic medical platform of the faculty of health sciences, a review of one-on-one consultations was undertaken. thus the purpose of this study was to determine the extent and the utilisation of the one-on-one biostatistical consultations during the year 2010 at the medical school of the university of the witwatersrand. methods consultations were performed by one research methodologist and statistical expert at two academic medical institutions of the university of the witwatersrand (medical school and at chris hani baragwanath academic hospital) between january and december 2010. every consultation was counted separately regardless of the number of times needed to address the same project. each session was booked in advance and the duration ranged between 40 and 60 minutes. the results presented in this study were completed and compiled by the expert from data collection sheets which included consultees’ position and field, date, nature and/ or purpose of the consultation and type of project. data were reported as frequencies and percentages with the correspondent 95% confidence interval (ci95%) for each institution as well as for the combined sites. results in total 235 one-on-one biostatistical consultations were performed at two academic medical institutions of the university of the witwatersrand between january and december 2010. a total of 144 consultations, 61%, ci95% (55 67%) and 39 %, ci95% (49 61%) were completed at medical school and chris hani baragwanath academic hospital. biostatistical consultations were divided into two wide topics: research protocol development (study design, sample size calculation, etc.) and statistical analysis (data entry, data coding, appropriate statistical tests and results interpretation) which represented 35%, ci95% (29 41%) and 65%, ci95% (59 71%) of the consultations respectively. fig. 1 shows the distribution of biostatistical consultations per site, according to consultees and purpose of the consultation. the majority of the consultees were medical doctors seeking advice to get degrees such as master in medicine and phd; 55% (129/235) and 19% (45/235) respectively, rather than medical students or staff researchers working for the university of the witwatersrand with non-degree purpose. the median and range of consultations per month at medical school and at chris hani baragwanath academic hospital were 12 (8 17) and 7 (0 20), respectively. the more frequent medical fields of the consultees were psychiatry (30%) followed by emergency medicine/family medicine (16%) and anaesthetics (15%) at the medical school site. however, at the chris hani baragwanath academic site internal medicine was the department with more bookings (34%), followed by anaesthetics (18%) and psychiatry (12%). conclusions the results of this study were similar to those found in several academic research institutions between 1999 and 2005 in the usa.4 changes in critical legislation provided the catalyst for many clinicians training to be specialists to embark on research which they may not have done, given their high workloads in delivering healthcare. these changes also unveiled the previously hidden anxieties of being unable to cope with research, in particular statistics. courses were put in place and immediately were over-subscribed. ultimately the success or otherwise of these courses will be measured in throughput rates. south africa is a country desperately short of doctors and specialists and research requirements should not become a limitation to qualifying. conflict of interest: none. ethics: a waiver was received from the hrec (medical) faculty of health sciences, university of the witwatersrand. short report one-on-one consultation on protocol development and statistics analysis in health sciences postgraduate students elena n libhaber, merryll vorster school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg correspondence to: elena n libhaber (elena.libhaber@wits.ac.za) fig. 1. biostatistical consultations per site. 14 december 2011, vol. 3, no. 2 ajhpe references 1. west cp, ficalora rd. clinician attitudes toward biostatistics. mayo clinic proc 2007;82(8):939-943. 2. miles s, price gm, swift l, shepstone l, leinster sj. statistics teaching in medical school: opinions of practising doctors .bmc medical education 2010;10:75. 3. rao g, kanter sl. physician numeracy as the basis for an evidence-based medicine curriculum. acad med 2010;85:1794-1799. 4. deutsch r, hurwitz s, janosky j, oster r. the role of education in biostatistical consulting. statist med 2007;26:709-720. 5. parker ra. estimating the value of an internal biostatistical consulting service. statist med 2000;19:2131-2145. 6. lesser ml, parker ra. the biostatistician in medical research: allocating time and effort. statist med 1995;14:1683-1692. short report 64 may 2014, vol. 6, no. 1 ajhpe physiotherapy clinical students’ perception of their learning environment: a nigerian perspective a c odole,1 phd; n a odunaiya,2 msc; o o oyewole,3 phd; o t ogunmola,2 bpt 1 physiotherapy department, college of medicine, university of ibadan, ibadan, nigeria, and school of research and postgraduate studies, faculty of agriculture, science and technology, north west university, mafikeng campus, south africa 2 physiotherapy department, college of medicine, university of ibadan, ibadan, nigeria 3 physiotherapy department, olabisi onabanjo university teaching hospital, sagamu, nigeria corresponding author: a c odole (adesola_odole@yahoo.com) background. a favourable environment has a positive and significant impact on students’ learning, academic progress and well-being. the present study was undertaken to identify the perceptions of physiotherapy students in their clinical years of their learning environment at the college of medicine, university of ibadan, nigeria. methods. a focus group discussion involving 12 undergraduate physiotherapy students was used to obtain information about their perception of their learning environment. six students from two clinical levels of study were recruited through a simple random sampling technique. the focus interview guide was developed based on information obtained from the dreem questionnaire and literature review. the interviews were analysed using the identified themes from dreem and grounded theory for emerging subcategories. results. five descriptive themes and several subcategories were identified: (i) context of learning (course objectives, student focused/teacher centred, active learning); (ii) context of teachers (knowledgeable teachers, provision of formative assessment, approachable lecturers, cordial teacher-student relationship); (iii) context of students’ perception of their academic skills (understanding the subject); (iv) context of atmosphere (adequacy of facilities, e.g. chairs, classrooms, library, books); and (v) context of social life (religious activities, social functions, school-related social activities). conclusion. most students perceived their learning environment as good, especially with regard to student-teacher relationships. some of the teachers were described as knowledgeable, and as providing formative assessment. however, students perceived their learning as being teacher centred. to facilitate an excellent learning environment, particular attention needs to be paid to availability of physiotherapy textbooks in the college library, sufficient appropriate furniture in classrooms, and provision of a functioning departmental library. the findings from this study may provide insights for teachers who wish to enhance the effectiveness of their teaching and of their students’ learning. ajhpe 2014;6(1):64-68. doi:10.7196/ajhpe.248 research a favourable environment has a positive and significant impact on students’ learning, academic progress and wellbeing.[1] eliciting students’ perception of the learning environment is a useful basis for modifying it and improving its quality, and provides students with a voice through which they can share their experience in the school.[2] this information, gained through questionnaires, interviews and focus groups, can be used to enhance the strengths and address the weaknesses of the institution.[3] an environment conducive to learning, for example with comfortable learning rooms, a receptive clinical environment and motivated, skilled and approachable teachers, is believed to increase learner motivation, which in turn leads to better engagement in learning and improved performance.[4] identification of factors that will improve the learning environment, and an understanding of how students learn, will therefore help the teach er to facilitate learning and plan a curriculum to improve learning outcomes.[5] evaluation of the educational environment comprehensively assesses what is happening and how things are in the school.[1] interest in the role of the learning environment in undergraduate medical schools has been increasing.[2] particular attention has been paid to students’ perception of their learning environment in nursing education.[6] in a study carried out in malaysia, medical students perceived that their teachers were good at communicating with them, and that their teaching helped them to develop professional competence. they also considered the overall atmosphere of the school as comfortable, and reported better-than-average social lives.[1] in a study from australia, health science students perceived that the environment was positive, and also that the teaching was student centred. they reported that the environment had a positive impact on their achievement and success.[7] however, there appears to be no published qualitative study on perceptions of the learning environment among physiotherapy students in nigeria. it is important to provide empirical information on how these students perceive their learning environment in order to improve their engagement in learning and their performance. this study therefore explored the perceptions of physiotherapy students in their clinical years of their learning environment at the college of medicine, university of ibadan, nigeria, with the intention of using the findings from the study to enhance the strengths and address the weaknesses of the institution, and so improve the learning environment. methods a qualitative methodology was used to investigate the students’ perceptions of their learning environment. the study sought to explore individual student experiences, which are considered valuable for improving understanding of mailto:adesola_odole@yahoo.com may 2014, vol. 6, no. 1 ajhpe 65 research aspects of the experience of the education environment. the study could be described as phenomenological in nature.[8] it has been suggested that a focused discussion is suitable when the informants are involved in more or less the same situation. using this method, the informants received support to describe their cognitive and evaluative meaning around a theme, i.e. in this context focusing on their views of and thoughts about their learning environment.[9] before commencement of the study, ethical approval was sought and obtained from the university of ibadan/university college hospital research ethics committee. each student involved signed an informed consent form in which ethical issues were addressed, including guaranteed confidentiality and freedom to withdraw from the study at any time. statements on confidentiality were included in the informed consent form. students’ names were not included in the recordings. the focus group discussion involved 12 of a total of 54 undergraduate physiotherapy students (26 at level 400 of study and 28 at level 500 – these are the full clinical years of study at the university). six students were selected from each level through a simple random sampling technique (fishbowl technique), in which 6 names were picked randomly from a bowl containing the names of the level 400 students and another 6 from a bowl containing the names of the level 500 students. the students whose names were picked were invited to participate in the study. the focus interview guide was developed based on information obtained from the dundee ready education environment measure (dreem) questionnaire[10] and literature review. it was assessed for content validity by five physiotherapy educators at a departmental seminar. the dreem is a 50-statement, closed-ended questionnaire developed to assess the learning environment of educational establishments.[10] it has been found to have good internal consistency.[10-12] each of the 50 items falls into 1 of 5 categories: students’ perceptions of learning; students’ perceptions of teachers; students’ academic self-perceptions; students’ perceptions of atmosphere; and students’ social self-perceptions.[7] the focus guide included the five questions listed below. the discussion was conducted in english, the official language of communication/study in nigeria. question 1: what are some of your challenges in the learning process? probe: is the teaching student centred? are course objectives provided at the start of the course? is teaching teacher centred? is the teaching period put to good use? does the teaching emphasise the long term more than the short term? question 2: what can you say about the whole teaching process in physiotherapy? probe: are the teachers knowledgeable? (method of teaching, studentteacher relationship, and teachers’ organisation, preparation and feedback). question 3: what are your views on your learning environment? probe: how conducive is it to learning? (infrastructure, facilities, library, equipment). question 4: does studying physiotherapy have any influence on your social life? how? probe: does studying physiotherapy restrict you from, or expose you to social life? do you have time for other things apart from academic activities? how is your relationship with lecturers and students? how often do you make new friends? question 5: is there anything more you would like to share with regard to your learning environment? probes were used in each question to clarify participants’ responses and elicit more complete responses to the question. the interview focus guide was used to guide the moderator and maintain uniformity in the topic that was being explored; to obtain more information, further questions were asked and probed by the moderator. we acknowledge that some questions in the focus guide were directional, even though this appears to be a limitation in qualitative studies. before commencement of this study, many of the students had complained informally about their learning environment to some lecturers. moreover, a study from nigeria had reported challenges faced by medical students in the learning process.[13] experience in our learning environment reveals that students tend to respond better to questions that are directional. in addition, in the nigerian cultural context, asking a direct question will elicit comprehensive information rather than evasive responses. the focus group discussion was guided by a facilitator (a postgraduate student from the institute of child health, college of medicine, university of ibadan) who is knowledgeable and trained in focus group discussion. the participants were encouraged to talk freely and spontaneously. three discussion sessions were held, the first between male students from both levels of study, the second between female students, and the third with males and females combined. this was done in order to encourage the students to provide fuller information, as we thought that gender could influence their responses – we considered that some intimate issues such as cases of sexual assault on both males and females would be better explored in separate groups. each session lasted for about 60 minutes. the sessions were audio recorded, and an observer also took notes. the recorded information was transcribed verbatim, and content analysis of the transcripts was carried out by two individuals knowledgeable in qualitative analysis. they transcribed independently and later met to arrive at a consensus.[9] the themes were taken from the dreem questionnaire, while substantive statements relevant to the question and common descriptive subcategories were identified using the grounded theory approach.[5,9,14] even though some of the themes have been identified in the literature, we were of the opinion that they may not strictly apply to our cultural context, where elders dominate and whatever they do is supposed to be right, so we still needed to explore the perceptions of the students. however, we felt that we could be guided by established themes from previous studies [1,2,7] content thematic analysis was used to analyse the information that emerged. results and discussion five themes identified from the dreem questionnaire were used in the analysis of the information obtained (table 1). these are the context of students’ perception of learning, the context of students’ perception of teachers, the context of students’ perception of their own academic skills, the context of students’ perception of their learning environment, and the context of students’ perception of their social life. students’ perception of learning providing quality learning experiences is the goal and responsibility of all educational programmes, and assures student, faculty and programme success.[15] the aim of this theme was to explore the university of ibadan undergraduate physiotherapy clinical students’ perception of learning. three subcategories that emerged from this theme were teacher-centred teaching, optimal use of the lecture period by teachers, and provision of course objectives. we wanted to address students’ views of the teaching activities, such as whether they received course objectives, whether they found that the teaching period was being put to good use, and whether 66 may 2014, vol. 6, no. 1 ajhpe research learning was student focused and encouraged active learning, as opposed to a teacher-centered approach. the majority (9) of the participants reported that some lecturers did not utilise their lecture periods adequately. a participant stated: ‘the teaching time isn’t put to good use by some lecturers.’ another student said: ‘we do not receive learning objectives for some of our courses, and some lecturers do not tell students they will not be around for classes and they keep us waiting, which i think is not helpful to the student.’ another said: ‘some of them are still using the old style of lecturing where they just dictate their old lecture notes without updating.’ the learning problems experienced by these students could be explained in terms of the cultural perspective: ‘elders are always right: they have good reasons for whatever they do, they cannot be wrong and must not be challenged.’ teachers with this attitude do not see it as their responsibility to give learning objectives to students, nor do they feel they owe students an explanation for being absent or late for lectures. they are often not studentcentred in their teaching, and students perceive their approach as being teacher-centred. in order to enhance learning, students should perceive it as an activity that transcends ordinary teaching. it should be characterised by teachers inspiring, supporting, actively involving and communicating with their students.[16] we propose that the provision of learning objectives to students at the beginning of a course helps them to take responsibility for their learning and provides opportunities for them to develop autonomy by selfdirected learning.[17] lecturers in the nigerian context may need to absorb new sets of values that would facilitate students’ learning. students’ perception of teachers the theme was introduced with the purpose of exploring the students’ perception of their teachers. the subcategories that emerged from this theme were the student-teacher relationship, feedback and formative assessment of students, and teachers’ knowledge of taught courses. teachers facilitate transmission of knowledge, and they constitute part of the learning environment. a knowledgeable, motivated, skilled and approachable teacher is likely to increase learners’ motivation, which in turn leads to better engagement in learning and improved performance.[18] students’ positive perception of their teachers has been recognised as an important characteristic of effective learning experiences in a previous study.[19] the teacher or facilitator is one of the most powerful variables in the educational environment. his or her actions, attitudes (e.g. evidenced by tone of voice or comments made), enthusiasm, and interest in the subject will affect learners indirectly.[20] a teacher should aim to provide an environment in which learners feel safe to experiment, voice their concerns, identify their lack of knowledge, and stretch their limits.[20] physiotherapy educators should be responsible for teaching physiotherapy students how to provide healthcare safely, efficiently and effectively in potentially multicultural environments. physical factors can make it difficult for learners and teachers to relax and pay attention. ensuring adequate breaks and being mindful of the physical environment are part of the teacher’s role.[20] an environment conducive to learning may provide insights for teachers who wish to increase the effectiveness of their teaching and their students’ learning. for example, it may be relatively easy to change how feedback is given to students, to make classroom sessions more interactive, or to ‘check in’ with the class more frequently. it has been suggested that teachers may not be aware of effective and/or innovative strategies used by their colleagues in the same institution. one simple approach to faculty development could be to provide a forum for faculty members to share their ‘best practices’ for teaching.[19] teachers’ knowledge half of the participants reported that the lecturers were knowledgeable generally, while others had varied perceptions of their teachers’ knowledge. one participant said: ‘i will say generally that they are knowledgeable, but i can classify our lecturers into two groups. one group is those … who lecture for lecturing’s sake, but the other group are those who lecture you for future purpose, they lecture you so that you can know, so that you can apply it in your practice, they lecture you like they know this thing.’ another participant said: ‘… based on the confidence with which lecturers answer questions in class, i feel that not all the lecturers are knowledgeable. some lecturers prove to be more knowledgeable, based on the way they answer the questions and give us stuff.’ we believe that students can assess their teachers’ knowledge of taught courses. they all have the course content and curriculum at the beginning of the session. they are being taught to take responsibility for their learning, and all of them can access information on the internet and from textbooks. the ability of lecturers to give in-depth but comprehensible explanations reassures students that their teachers have good knowledge of the courses that are being taught. feedback and formative assessment four of the participants reported that the teachers provided feedback, and 2 participants reported that impromptu tests are given for assessment of learning (formative assessment). a participant said: ‘… 60 70% of the lecturers give impromptu tests to assess our knowledge on what they taught us, and if they observe from our scores that we didn’t get the questions right they will still want to revise with us.’ impromptu tests can be used table 1. themes and description of the responses category theme description 1 context of learning teacher-centred teaching, optimal use of the lecture period by teachers, provision of course objectives 2 context of teachers knowledgeable teachers, provision of formative assessment, approachable lecturers, cordial teacher-student relationship 3 context of students’ perception of their academic skills understanding the subject, translation of theoretical knowledge to application 4 context of atmosphere inadequate facilities (chairs, classrooms, library, books) 5 context of social life religious activities, student-related social activities, social functions may 2014, vol. 6, no. 1 ajhpe 67 research for formative assessment of students’ learning, whereby the lecturers use test scores to identify areas that need to be made clearer to the students. students’ scores are not used in the summative assessment; instead, they provide feedback on areas that need more work. student-teacher relationship an excellent learning environment should include student-teacher interaction, not just teachers imparting knowledge to students.[18] almost all (10) of the participants reported that most of their lecturers were approachable, and 5 reported that they had a cordial relationship with their teachers. one participant said: ‘the relationship between the teachers and lecturers is cordial.’ another said: ‘they can talk to you any time, even when you do not understand what they taught you in class, you can walk to their offices and they will re-explain to you without asking any question. most of them are approachable.’ another said: ‘the interaction between the lecturers and the students is just like between children and their parents.’ most of the participants compared their student-teacher relationships with those in other departments in the faculty. a participant said: ‘… relating to other departments, i think it’s good. most of the lecturers keep open doors; some will even give you their number, so you can give feedback. some of them extend it to a personal level.’ most participants reported that some of their lecturers were friends with them on facebook. in addition, a participant said: ‘the relationship is so cordial, and it encourages a more conducive environment for learning. we do not have to become hypertensive because our lecturer just walked in!’ the students take courses from various departments and faculties in the university in their preclinical levels of study (first to third years), and also share accommodation with students from other departments and faculties. these experiences enabled them to compare student-teacher relationships in the physiotherapy department with those in other departments. the participants’ responses highlight the vital importance of students’ perception of their teachers. they reported that some of the lecturers appeared more knowledgeable than others in terms of how well they were able to explain the content of the courses. few reported on the provision of feedback. most of them stated that the teachers were approachable, and they all reported that teacher-student relationships were cordial. most added that their teachers were friends with them on facebook, possibly suggesting social interaction between the students and the teachers. according to stronge et al.,[21] social interactions between teachers and students encourage students to learn and achieve. such interaction, and the provision of an environment in which students feel free to voice their concerns, identify their lack of knowledge and stretch their limits, will therefore facilitate learning.[4] one study found that teachers do not only teach; they also perform many other non-teaching tasks and functions (e.g. administrator, counsellor and friend).[22] it has been reported that a teacher who spends time interacting socially with students, works directly with them, and demonstrates a sense of fun and willingness to participate in a friendly and personal manner, is considered to be effective.[18] physiotherapy educators act as role models for students, and therefore need to have highly developed cultural awareness, cultural knowledge, cultural sensitivity and cultural competence.[23] remembering names and involving learners in setting ground rules are ways in which mutual trust can be built up. feedback on performance, a vital part of teaching, should be done constructively and with respect for the learner; safety can be compromised through humiliation, harassment, and threat of forced disclosure of personal details.[20] teachers should attempt to get a sense of what students know and can do, as well as their interests and passions, and what each student cares about and wants to do.[24] students’ perception of their academic skills this context addressed students’ views of their learning strategies, and problem-solving skills they have developed to prepare themselves for the physiotherapy profession. it has been suggested that there is an intimate relationship between students’ perceptions of the quality of their courses in higher education and the approaches to studying that they adopt in those courses.[25] most of the participants read to gain more complete understanding rather than just to pass. one student said: ‘initially when i was in preclinical school, my idea … was just to read and pass, but now i understand better that it is not all about reading and passing but it is about doing and knowing the basis of what you do, which i think is more important.’ the students perceived that what they were being taught in the classroom could be applied in the care of their patients once they were in clinical practice. at the clinical level of their studies, it was apparent that they had achieved higher levels of cognition (application, analysis, synthesis and evaluation) in addition to lower levels of cognition (knowledge and comprehension). students with a deep approach to learning have the intention of understanding, engaging with, operating within and valuing a question.[26] they are interested in learning for its own sake, wanting to understand ideas for themselves and not because of the marks they will score. the majority of the respondents reported that learning is not all about reading and passing, but about the ability to apply the theory. cognitive learning, a highly active process largely directed by the individual, involves perceiving the information, interpreting it on the basis of what is already known, and then re-organising the information into new insights or understanding.[27] cognitive learning theory includes several wellknown perspectives, such as gestalt, information processing, cognitive development, situated cognition and social cognition theory. students’ perception of their learning atmosphere student perceptions of a good learning atmosphere encourage deep approaches to studying and influence learning outcomes both directly (perceptions of outcomes) and indirectly (perceptions of approaches to outcomes).[28] this theme addressed our students’ perception of their learning environment (how relaxed the atmosphere is during lectures, whether infrastructure is adequate, whether there are opportunities to use and develop interpersonal skills, availability of recommended books in the library). the question asked was ‘what are your views about your learning environment?’ the majority (10) of the participants reported that it presented many challenges, especially with regard to infrastructure. participants commonly reported that the chairs in the lecture room were uncomfortable and of poor quality, and there were too few chairs. a participant said: ‘the chairs are bad and it is very difficult sitting on this chair for 2 4 hours.’ another said: ‘we do not have good chairs for learning, we have so many bad chairs and we are just managing and patching.’ another added: ‘the chairs are not enough, two lectures cannot be held simultaneously, for example the 400 and 500 level students cannot hold classes simultaneously.’ apart from the inadequate chairs, a participant also said: ‘the classrooms are so clumsy, there are not enough spaces for lectures, some of the time we use rooms meant for practical classes for lectures.’ 68 may 2014, vol. 6, no. 1 ajhpe research in addition to complaints about the chairs and the classrooms, the majority (75%) of the participants reported that the department did not have a functioning library to promote additional reading. a typical response was: ‘there are no facilities for further reading like a library.’ elaborating, one participant said: ‘we do not have physiotherapy books, even in the medical library in the college, so there is nothing to fall back on after getting stuff in class.’ a participant also emphasised the scarcity of physiotherapy textbooks in the bookshop: ‘i went around the college bookshop and the only books i could see were more of medical books, dental books and nursing books, you can count the number of physiotherapy books. i was very annoyed.’ the learning environment is not limited to student-teacher interaction, teaching and learning activities, but also includes good physical structures and facilities.[29] these include good (and sufficient) chairs, sufficient classrooms suitable for their purpose, a well-equipped library and access to relevant books, all of which are important for optimal learning outcome. students’ social life we asked the question ‘does physiotherapy restrict or expose you to social life?’ this question could be regarded as a leading one; however, in our context students respond better when they are directed. the intention was to capture information on how the course has impacted on participants' social life. while one respondent felt that ‘social life depends on the individual’, most (8) of the participants reported that their social lives involved schoolrelated social activities (quiz competitions, sports, students’ carnivals), and attending fellowship (i.e. religious activities), and social functions such as weddings and birthday parties. one participant said: ‘social life for me is school.’ almost all the participants (n=11) reported that their physiotherapy studies did not hinder their participation in social activities, one stating: ‘physiotherapy does not restrict my social life, you just need to plan your time well.’ another went into more detail: ‘physiotherapy permits us to socialise like during the hall week, physiotherapy allows us to go out for dinners.’ a very enthusiastic participant said: ‘one thing physiotherapy is known for is social gathering, we do it to the peak. i give it to them thumbs up!’ a social learning environment equips students with the tools necessary to collaborate with teachers and peers and participate in activities both inside the classroom and beyond the walls of the school. a safe social networking/ learning environment can extend the relationship between students to allow continued dialogue and collaboration after school hours.[30] most of the participants concluded that their social life was good, and that physiotherapy did not restrict their social life. conclusion this qualitative study, which appears to be the first on physiotherapy students’ perception of their learning environment in nigeria, indicated that most students perceived their learning environment as good, especially with regard to student-teacher relationships, although fewer described their teachers as knowledgeable and as providing formative assessment. most also felt that their social lives were not restricted by studying physiotherapy. however, students perceived their learning environment to be inadequate in terms of facilities such as the library, chairs and classrooms. they also reported that some teachers did not make good use of lecture periods. the findings highlight some of the strengths and weaknesses of the learning environment at the college of medicine, university of ibadan, as perceived by physiotherapy students. the strengths could be enhanced and the weaknesses addressed in order to improve the situation. the results of the study cannot be generalised to all physiotherapy institutions in nigeria, as we focused on one institution (the university of ibadan), but further studies could be carried out elsewhere. furthermore, our students’ perception of their learning environment could be evaluated on an ongoing basis, as part of quality assurance. finally, the findings may provide insights for teachers who wish to enhance the effectiveness of their teaching and their students’ learning. we recommend that workshops on biomedical education be organised. in particular, these workshops should address cultural issues that impact negatively on students’ learning. references 1. arzuman h, yusoff msb, chit sp. big sib 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[http://dx.doi.org/10.1186/1472-6920-11-34] 24. bransford jd, brown al, cocking rr. how people learn: brain, mind, experience, and school. expanded edition. washington, dc: national academy press, 2000. 25. richardson jte. students’ perceptions of academic quality and approaches to studying in distance education. br educ res j 2005;31(1):7-27. [http://dx.doi.org/10.1080/0141192052000310001] 26. mckimm j. learning theories. 2002. http://www.faculty.londondeanery.ac.uk/e-learning/setting-learningobjectives/toolbox%20-%20%20learning%20theories.pdf (accessed 23 february 2012). 27. hammond l, austin k, suzanne o, rosso j. how people learn: introduction  to  learning  theories. 2001. www. stanford.edu/class/ed269/hplintrochapter.pdf (accessed 23 february 2012). 28. lizzio a, wilson k, simons r. university students’ perceptions of the learning environment and academic outcomes: implications for theory and practice. studies in higher education 2002;27(1):27-52. [http://dx.doi. org/10.1080/03075070120099359] 29. demiroren m, palaoglu o, kemahli s, ozyurda f, ayhan ih. perceptions of students in different phases of medical education of educational environment: ankara university faculty of medicine. med educ online 2008;13(1):8. [http://dx.doi.org/10.3885/meo.2008.res00267] 30. braungart m, braungart r. applying learning theories to healthcare practice. 2007. http://www.jblearning.com/ samples/0763751375/chapter2.pdf (accessed 23 february 2012). http://dx.doi.org/10.1080/01421590500151054] http://dx.doi.org/10.1080/01421590500151054] http://dx.doi.org/10.1136/bmj.326.7393.810] http://dx.doi.org/10.1136/bmj.326.7393.810] http://dx.doi.org/10.5116/ijme.4e66.1b37] http://dx.doi.org/10.1080/09593980701378157] http://dx.doi.org/10.1016/j.nepr.2012.04.009] http://dx.doi.org/10.1016/j.nepr.2012.04.009] http://dx.doi.org/10.1080/01421590500046387] http://dx.doi.org/10.1080/01421590500046387] http://dx.doi.org/10.1080/13576280400002445] http://dx.doi.org/10.1080/13576280400002445] http://dx.doi.org/10.3109/01421599709034208] http://dx.doi.org/10.1152/advan.00106.2010] http://dx.doi.org/10.5116/ijme.50e5.e19a] http://dx.doi.org/10.5116/ijme.50e5.e19a] http://dx.doi.org/10.1080/10401330801991667] http://dx.doi.org/10.1080/10401330801991667] http://dx.doi.org/10.3109/14038196.2012.671848] http://www.conference.niesg/paperycovert/as00616.pdf http://dx.doi.org/10.1186/1472-6920-11-34] http://dx.doi.org/10.1080/0141192052000310001] http://www.faculty.londondeanery.ac.uk/e-learning/setting-learning-objectives/toolbox%20-%20%20learning%20theories.pdf http://www.faculty.londondeanery.ac.uk/e-learning/setting-learning-objectives/toolbox%20-%20%20learning%20theories.pdf http://www.faculty.londondeanery.ac.uk/e-learning/setting-learning-objectives/toolbox%20-%20%20learning%20theories.pdf http://www.stanford.edu/class/ed269/hplintrochapter.pdf http://www.stanford.edu/class/ed269/hplintrochapter.pdf http://dx.doi.org/10.1080/03075070120099359] http://dx.doi.org/10.1080/03075070120099359] http://dx.doi.org/10.3885/meo.2008.res00267] http://www.jblearning.com/ 25 december 2009, vol. 1, no. 1 ajhpe 1. true (a) or false (b) – click on the correct answer: graduate entry students and matric entry students are equally efficient at using self-directed learning time in problem-based learning programmes. 2. true (a) or false (b) – click on the correct answer: the solo taxonomy is a useful way of describing the depth of knowledge required when defining learning outcomes in a curriculum. 3. true (a) or false (b) – click on the correct answer: basic life support skills knowledge can be adequately assessed using a simple 9-question survey. 4. true (a) or false (b) – click on the correct answer: programme logic models can be used to design and develop courses or programmes. 5. true (a) or false (b) – click on the correct answer: service learning has not been shown to assist in educating communities about basic health issues. 6. true (a) or false (b) – click on the correct answer: contrary to expectations, community-based learning experiences do not help students become familiar with the reality of health care resource constraints in south africa. 7. true (a) or false (b) – click on the correct answer: electronic on-line learning activities are a good way to learn teamwork. 8. true (a) or false (b) – click on the correct answer: tutor assessment during problem-based learning sessions correlate well with student performance in summative examinations. 9. true (a) or false (b) – click on the correct answer: electronic portfolios do not promote reflection in clinical practice. 10. true (a) or false (b) – click on the correct answer: multimedia lectures can be used to explain complex concepts in small chronological steps. 11. true (a) or false (b) – click on the correct answer: moodle is a free electronic database facility that can be used to develop online portfolio activities. 12. true (a) or false (b) – click on the correct answer: simulation is a useful way to teach clinical procedural skills. 13. true (a) or false (b) – click on the correct answer: mind maps may be used to promote integration across disciplines in teaching programmes. 14. true (a) or false (b) – click on the correct answer: all health care professionals must attend a course in clinical trials practice before engaging in clinical trials research. 15. true (a) or false (b) – click on the correct answer: medical students are keen to have formal teaching in communication and counselling skills. 16. true (a) or false (b) – click on the correct answer: an electronic patient record registry is an easy way of keeping track of clinical skills exposure in workplacebased learning setting. 17. true (a) or false (b) – click on the correct answer: good patient communication skills have not been shown to improve patient compliance with treatment plans. 18. true (a) or false (b) – click on the correct answer: blackboard-based teaching is popular because it provides more time for students to think about and understand the material being presented. 19. true (a) or false (b) – click on the correct answer: mind maps can be used to develop a problem-solving approach to clinical teaching. 20. true (a) or false (b) – click on the correct answer: electronic case registries can also be used to characterise the nature and extent of clinical exposure in training programmes. cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/012/07/2009 (clinical) cpd december 2009 article 72 november 2013, vol. 5, no. 2 ajhpe student and staff perceptions and experiences of the introduction of objective structured practical examinations: a pilot study j m frantz, phd physiotherapy; m rowe, phd physiotherapy; d a hess, bsc physiotherapy; a j rhoda, phd physiotherapy; b l sauls, bsc physiotherapy; l wegner, msc phsyiotherapy department of physiotherapy, university of the western cape, bellville, cape town, south africa corresponding author: m rowe (mrowe@uwc.ac.za) background. the objective structured practical examination (ospe) is widely recognised as one of the more objective methods of assessing practical skills in healthcare programmes, including undergraduate physiotherapy curricula. objectives. to obtain feedback from both students and staff who were involved in the introduction of an ospe in 2011, in order to refine and standardise the format throughout the curriculum. methods. a qualitative research design was used. data were gathered through a questionnaire with semi-structured open-ended items and focus group discussion. participants were all third-year undergraduate physiotherapy students (n=47) and all staff members (n=10) in the 2011 academic year who were exposed to the ospe format or were involved in the first ospe. results. the main concerns raised by both students and staff were: (i) pressure due to time constraints and how this might affect student performance; and (ii) the question of objectivity during the assessment. however, their initial concerns changed as they experienced the ospe in a more positive manner owing to the structure and objectivity of the process of implementing the ospe. conclusion. while both students and staff reported positive experiences, the challenges that emerged provided valuable insight in terms of refining the ospe format in this undergraduate physiotherapy department. ajhpe 2013;5(2):72-74. doi:10.7196/ajhpe.218 research assessment of clinical competence is an essential component of health professions education, requiring educators to make informed decisions that measure students’ clinical knowledge and skills accurately. such clinical assessments have often been challenged by a lack of objectivity. the objective structured clinical examination (osce) was originally developed in dundee in the mid-1970s[1] with the aim of assessing clinical competence in an objective, structured way. bartfay et al.[2] and major[3] highlighted the fact that using the osce format introduces standardisation that aims to improve objectivity in assessment. when using the osce method, clinical competencies are assessed as students move through a number of ‘stations’ where they are individually graded using precise criteria in the form of a checklist. the term objective structured practical examination (ospe) was derived from the osce in 1975, when it was modified to include practical examination.[4] the ospe, like the osce, tests students’ ability to perform a practical skill rather than what they know. however, while the osce focuses on assessing clinical competence, the ospe is designed to assess competence in performing a practical skill outside the clinical context. the ospe has several distinct advantages over other forms of practical assessment, including the fact that it can be used as a summative assessment to evaluate individuals’ performance in the practical skills component of the module, as well as for formative evaluation where the student gets feedback as part of the learning process. in addition to its role in assessment, an ospe includes a focus on the individual competencies being tested, and the examination covers a broader range of practical skills than a ‘traditional’ examination.[5] the traditional examination in this department was an unstructured evaluation of different techniques, and was neither valid nor reliable, since every student was seen by a different examiner and given a different assessment task. in the ospe, an individual’s ability to perform a technique is tested in a more objective manner because all candidates are exposed to the same predetermined set of techniques and questions, which minimises the subjectivity of the assessment.[6] mastering practical skills is an important aspect of a course like physiotherapy,[7] which means that its assessment component will influence the learning strategies of students.[8] however, if an assessment task is to achieve the desired outcome, it has to employ instruments that yield valid, accurate data which are consistent and reliable. in addition, inter-rater variability among examiners can be large, being informed by differences of opinion that are based on the subjective perception of individual examiners. [9] this lack of objectivity among examiners assessing practical skills was a problem area identified in this undergraduate physiotherapy department in the western cape, south africa, and a departmental decision was made to pilot the ospe. the aim of this study was to determine the perceptions and experiences of students and staff following the introduction of the ospe format in the department. since the ospe was a new format for assessing practical competence, specifically developed to enhance objectivity, students and staff were approached and asked to describe their experiences and perceptions of the process following its initial implementation. the importance of both students’ and staff attitudes and perceptions of the training programme in undergraduate health professions education was acknowledged. method design the study utilised qualitative data-gathering methods in the form of a questionnaire with open-ended questions and a focus group. a focus mailto:mrowe@uwc.ac.za november 2013, vol. 5, no. 2 ajhpe 73 research group was chosen because it encourages participants to share ideas and experiences, creating meaning that may not have emerged independently.[10] both staff and students completed the questionnaire immediately after the first ospe in the department in march 2011; only staff members were asked to participate in the focus group discussion. setting and sample the survey sample included all third-year undergraduate physiotherapy students (n=47) who were registered for the 2011 academic year. they were the first to be exposed to the ospe format. all staff members (n=10) involved in the ospe were also included. one year later, a focus group discussion was held among the staff members who were involved in the initial implementation of the ospe (n=8). this delay allowed for the assessment format to be developed and refined based on student and staff experiences and informal feedback. ospe implementation the ospe was conducted in most of the core physiotherapy modules in the third year of the programme and consisted of four stations, each assessing one practical skill. two parallel tracks were used to move students through the stations more quickly, so that eight stations were used to test four practical skills. students proceeded through each station, completing a practical technique and answering a related theoretical question. an additional two people assisted the staff members conducting the ospe, one handling the logistics of moving students between venues, and the other keeping time (students had to complete each station within a predetermined period). the lecturer responsible for the module prepared assessment rubrics for each station, set up stations with the necessary equipment, ensured that there were enough examiners, and selected a spacious venue for the ospe. rubrics were reviewed by all examiners involved in the ospe before the assessment date. data collection instrument two instruments with open-ended questions were developed to collect data for this study. the seven questions asked to students focused on concerns, time issues, challenges, improvements, impact of the change in format for assessment of practical skills, and positive and negative aspects of the ospe. the four questions posed to the staff focused on concerns, challenges, improvements, and the amount of practical skills covered. the items were based on reviews of the available literature and were circulated among academic staff in the physiotherapy department for face and content validity. the focus group discussion was conducted with the staff members and lasted for 45 minutes. procedure students were given the questionnaire as they left the assessment venue and asked to complete it on the same or the following day. staff completed the questionnaire directly after the ospe assessment. after one year of using the ospe process in the department, staff were invited to participate in a focus group discussion. data analysis survey data were transcribed into word processing files. focus group data were transcribed verbatim. themes were identified from the transcriptions by two reviewers and areas of disagreement were discussed until consensus was reached. the open-ended questions were analysed using braun and clarke’s[11] six-phase guide to conducting a thematic analysis. phase 1 involves familiarising oneself with the data, and phase 2 requires initial codes to be generated. the next step is to identify themes. the researcher also reviews the themes under consideration and then defines and names them. lastly, the results are reported. ethical considerations permission to conduct the survey was obtained from the head of the physiotherapy department and informed consent was obtained from all participants. both students and staff were informed that they were not required to participate, and non-participation did not negatively impact on either staff members or students. anonymity and confidentiality were ensured by not gathering personally identifiable data. results and discussion there was a response rate of 20/47 (42.6%) among the students and 7/10 (70.0%) among staff. four themes were found in the responses of students and staff regarding the use of the ospe: time (initial reaction v. post event), increased pressure, role of the examiner, and format of the ospe. time the length of time allocated per station was highlighted as a concern by all the participants, with both staff and students worried that the time allocated at each station was not enough. ‘… i was also concerned about logistical issues such as “fixed” time constraints imposed on students to conduct the necessary tasks in a specific time frame, and as they need to stick within the given time frame.’ (staff member) ‘… are we going to get enough time to do everything?’ (student) ‘… would not have time to mentally process the question and perform the treatment. basically time constraints …’ (student) these concerns are similar to those highlighted by abraham et al.,[12] who reported in a quantitative study that more than 50% of the participants felt that time was a concern during an ospe. in addition, hasan et al.[13] indicated that although time does seem to be a problem with the ospe, it should not become an exercise of how fast students can perform the technique, but rather focus on how well they can perform it. as a result, one of the changes made to the approach has been that lecturers consult with each other about the time needed to complete each station. each station has to be completed within the same length of time, and stations are run simultaneously, students starting each station at the same time and being required to stop at the same time and then move on to the next station. increased pressure the ospe appears to create more pressure than ‘traditional’ practical assessment methods, and is therefore more stressful.[12] this concern was raised by both the students and the examiners in the current study. staff felt pressured to hurry through their instructions to the students, and students felt intimidated, which did not allow them to perform to the best of their ability. ‘… there was tremendous pressure on the examiner to give instructions and to ask the question …’ (staff member) ‘… was too intimidating, could not perform to my best ability …’ (student) 74 november 2013, vol. 5, no. 2 ajhpe research this anxiety was reported at the beginning of the process, but the literature has indicated that students’ anxiety tends to decrease after the assessment begins[14] and that they generally perform well.[15] it is noted that the increased anxiety could also be because staff and students were being asked to do something new. despite the initial stressful experience, students have come to view ospes in a favourable light in this department. ‘… it was okay; i only had to concentrate on one task at a time.’ (student) ‘… yes, but positively. everything was more equal.’ (student) ‘… yes, in the end i felt it was long enough to get to the station and have a bit of a “breather”.’ (student) role of the examiner the question of prompting students was raised by both staff and students. the feeling among the staff was that there was a need for consistency from one student to the next. according to major,[3] in an ospe/osce the examiner is assigned to one station and measures students’ performance using a predetermined checklist or rubric. objectivity is ensured by setting out standards such as no prompting, all students receiving the same instructions, and having a rubric guide for allocating marks. each staff member is then informed of the requirements at each station before the ospe/osce commences. ‘the lecturers should ask the question in the same way, and if they are going to give a hint, then the next person should get the same treatment.’ (staff member) students, on the other hand, felt that the examiner/lecturer should be allowed to assist more. ‘i understand that no prompting was allowed, but if the student is misinterpreting the question, could the lecturer maybe steer them in the right direction?’ (student) these challenges highlighted by both the students and the staff indicate that there is still a need to improve the way in which the ospe assessment is currently conducted. efforts should therefore be made to ensure that both staff and students experience the ospe as an objective assessment for all. when the process of ospes were implemented in this department, staff members decided that in order to maintain objectivity no hints would be given to students. format of the ospe concerns were initially expressed by staff members that the new format might be problematic for the students. the main concerns included the change to the new format, the length of time allocated to each station, and the understanding of the roles of the examiner and the student. before the ospe, the lecturer responsible for the module should ensure that all staff and students know what is expected of them. ‘i was concerned whether students would be able to make the transition from the old format to the ospe format.’ (staff member) ‘i found the [theory] question of the task disturbed the students’ thought processes on executing the activity.’ (staff member) however, it became evident that students experienced the new format in various ways. ‘well organised and efficient.’ (student) ‘it may have impacted on my performance as i was rushing as i did not know what to expect for the first round.’ (student) the main advantage of an ospe format is that it improves the objectivity of the assessment by ensuring that each student performs the same technique in front of the same examiner. in addition, when questions are included in the assessment, they are uniformly presented to students. finally, the presence of the checklist and rubric mean that all students are assessed in a fair and accurate manner, as all examiners are basing their marks on the same performance criteria.[16] conclusion this pilot study provides insight into the challenges experienced when introducing the ospe assessment format into the undergraduate curriculum. the study determined the experiences and perceptions of students and staff members who were involved in the initial implementation of the ospe in this physiotherapy department. the main challenges raised by both students and staff were the impact of the time constraint on student performance, and examiner objectivity during the ospe. the ospe remains a more objective method of assessment than the traditional method that was previously used in the physiotherapy department. this pilot study provided valuable feedback in the process of refining and standardising the ospe format in the department. major outcomes that emerged following evaluation of the process were that lecturers now work collaboratively to plan the assessments, and that standardised assessment methods produce less anxiety in the students as they become more familiar with the ospe. finally, evaluation of the teaching and learning process was identified as an essential aspect of improving practice and continues to be used in the department. references 1. harden rm, gleeson fa. assessment of clinical competence using an objective structured clinical examination (osce). asme medical education booklet no. 8. med educ 1979;13(1):39-54. [http://dx.doi. org/10.1111/j.1365-2923.1979.tb00918.x] 2. bartfay wj, rombough r, howse e, leblanc r. the osce approach in nursing education: objective structured clinical examinations can be effective vehicles for nursing education and practice by promoting the mastery of clinical skills and decision-making in controlled and safe learning environments. can nurs 2004;100(3):18-25. 3. major d. osces – seven years on the bandwagon: the progress of an objective structured clinical evaluation programme. nurs educ today 2005;25(6):442-454. [http://dx.doi.org/10.1016/j.nedt.2005.03.010] 4. harden rm, cairncross rg. assessment of practical skills: the objective structured practical examination (ospe). studies in higher education 1980;5(2):187-196. [http://dx.doi.org/10.1080/03075078012331377216] 5. ananthakrishnan n. objective structured clinical/practical examination (osce/ospe). j postgrad med 1993;39(2):82-84. 6. mitchell ml, henderson a, groves m, dalton m, nulty d. the objective structured clinical examination (osce): optimising its value in the undergraduate nursing curriculum. nurse educ today 2009;29(4):398-404. [http:// dx.doi.org/10.1016/j.nedt.2008.10.007] 7. world confederation for physical therapy. wcpt guideline for physical therapist professional entry level education. london: wcpt secretariat, 2011:1-42. 8. scouller k. the influence of assessment method on students’ learning approaches: multiple choice question examination versus assignment essay. higher education 1998;35(4):453-472. 9. boursicot k, roberts t. how to set up an osce. clin teach 2005;2(1):16-20. [http://dx.doi.org/10.1111/j.1743498x.2005.00053.x] 10. babbie e, mouton j. the practice of social research. cape town: oxford university press, 2006. 11. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. [http://dx.doi. org/10.1191/1478088706qp063oa] 12. abraham r, raghavendra r, surekha k, asha k. a trial of the objective structured practical examination in physiology at melaka manipal medical college, india. adv physiol educ 2009;33(1):21-23. [http://dx.doi. org/10.1152/advan.90108.2008] 13. hasan e, ali l, pasha a, arsia j, farshad s. association of the pre-internship objective structured clinical examination in final year medical students with comprehensive written examination. med educ online 2012;17:1-7. [http://dx.doi.org/10.3402/meo.v17i0.15958] 14. brosnan m, evans w, brosnan e, brown g. implementing objective structured clinical skills evaluation (osce) nurse registration programmes in a centre in ireland: a utilisation focused evaluation. nurse educ today 2006;26(2):115-122. [http://dx.doi.org/10.1016/j.nedt.2005.08.003] 15. nicol m, freeth d. learning clinical skills: an interprofessional approach. nurse educ today 1998;18(6):455461. [http://dx.doi.org/10.1016/s0260-6917(98)80171-8] 16. wolf k, stevens e. the role of rubrics in advancing and assessing student learning. the journal of effective teaching 2007;7(1):3-14. http://dx.doi.org/10.1111/j.1365-2923.1979.tb00918.x] http://dx.doi.org/10.1111/j.1365-2923.1979.tb00918.x] http://dx.doi.org/10.1016/j.nedt.2005.03.010] http://dx.doi.org/10.1080/03075078012331377216] http://dx.doi.org/10.1016/j.nedt.2008.10.007] http://dx.doi.org/10.1016/j.nedt.2008.10.007] http://dx.doi.org/10.1111/j.1743-498x.2005.00053.x] http://dx.doi.org/10.1111/j.1743-498x.2005.00053.x] http://dx.doi.org/10.1191/1478088706qp063oa] http://dx.doi.org/10.1191/1478088706qp063oa] http://dx.doi.org/10.1152/advan.90108.2008] http://dx.doi.org/10.1152/advan.90108.2008] http://dx.doi.org/10.3402/meo.v17i0.15958] http://dx.doi.org/10.1016/j.nedt.2005.08.003] http://dx.doi.org/10.1016/s0260-6917 article may 2013, vol. 5, no. 1 ajhpe 26 background. recent evaluation of the interdisciplinary health promotion (ihp) course offered by the university of the western cape (uwc) at schools revealed that the needs expressed by the schools had not changed in the last five years. objectives. this paper describes the process that was undertaken to identify specific interventions that would have an impact on the schools and, in turn, the broader community, and provides an overview of the interventions conducted in 2011 2012. methods. a stakeholder dialogue explored notions of partnership between the university and the schools, sustainability of health promotion programmes in the schools, and social responsiveness of the university. an action research design was followed using the nominal group technique to gain consensus among the stakeholders as to which interventions are needed, most appropriate and sustainable. results. a comprehensive plan of action for promoting health in schools was formulated and implemented based on the outcome of the stakeholder dialogue. conclusion. the study’s findings reiterate that an ongoing dialogue between schools and higher education institutions is imperative in building sustainable partnerships to respond to health promotion needs of the school community. ajhpe 2013;5(1):26-29. doi:10.7196/ajhpe.207 moving from conversation to commitment: optimising school-based health promotion in the western cape, south africa f waggie, bsc (pt), msc (pt), phd; n laattoe, ace (adult ed), mphil ed; g c filies, bsc (ot), mphil (health sced) interdisciplinary teaching and learning unit, faculty of community and health sciences, university of the western cape, south africa corresponding author: f waggie (fwaggie@uwc.ac.za) the notion of social responsiveness of higher education institutions is more than just maintaining contact with ‘clients’. it is about universities engaging in a dialogue with various stakeholders to learn more about the communities and how services are valued and implemented, and to encourage and initiate services that will contribute to the development of communities. furthermore, it considers accountability by building mechanisms to incorporate transparency about all choices made and to assure the involvement of civil society.[1] this article describes the process undertaken by the interdisciplinary teaching and learning unit (itlu) in the faculty of community and health sciences (fchs) at the university of the western cape (uwc) to identify specific health promotion programmes needed at schools, which would impact on the school and in turn the broader community more effectively. higher education and social responsiveness historically, there is a strong community service ethos in south african higher education institutions and most institutions identify community service as part of the universally recognised functions of the modern university, i.e. teaching, research and outreach.[2] the south african higher education act of 1997 emphasises the establishment of a single co-ordinated higher education system that responds to the needs of south african communities served by higher education institutions.[3] furthermore, the act states that higher education ‘must provide education and training to develop skills and innovations necessary for national development and successful participation in the global economy and must be restructured to face the challenges of globalization’.[3] importantly, the act also demands that new, flexible and appropriate curricula be developed to integrate knowledge with skills, and that the standards be defined in terms of learning outcomes and appropriate assessment procedures. this can best be achieved through community engagement and service learning.[4] moreover, given the extent of worldwide economic and social problems, and the current socio-economic climate in the country, there is an increasing pressure on south african higher education institutions to become socially responsive and bridge the gap between higher education and civil society. braskamp and wergin suggested that one of the ways for higher education institutions to narrow the gap between themselves and civil society is to ‘become active partners with parents, teachers, principals, community advocates, business leaders, community agencies, and general citizenry’.[5] in line with these current imperatives, south african universities are engaging more closely with communities and developing a scholarly basis for such engagement by integrating the universities’ core business of teaching, research and service.[6] a need for a different approach to health professions education has therefore emerged, one in which universities need to produce health professionals who are socially accountable and can respond effectively to the needs of the 21st century. the world health organization (who) defines social accountability of educational institutions as ‘… the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve. the priority health concerns are to be identified by governments, healthcare organisations, health professionals, and the public.’[7] recently, the lancet commission concluded that health professions education has not adapted to the ever-increasing health demands of communities and has produced ill-equipped graduates because of ‘fragmented, outdated and static’ curricula.[8] furthermore, the commission identified challenges for health professions education which included: (i) mismatch with societal needs; (ii) poor teamwork; (iii) weak leadership; (iv) predominant focus on tertiary care at the expense of primary healthcare; and (v) health professionals working in silos. the commission recommended that articlearticle 27 may 2013, vol. 5, no. 1 ajhpe instructional and institutional reforms need to take place within the health professions educational system to address these challenges. response of the faculty of community and health sciences the development of the interdisciplinary health promotion (ihp) course was an innovative curricular transformation for health professions education at uwc. the course is based on the pedagogy of service learning and is one of the ways in which the fchs responded to the aforementioned challenges. the purpose of the ihp was to equip the students with basic knowledge and skills of health promotion and apply these through the implementation of health promotion projects in schools. recent thought in health promotion emphasises social change, environmental development, and development of capacities and opportunities for communities, and has the potential to support and sustain better health.[9,10] however, the sustainability of improved health is dependent on the approaches, theoretical foundations, intentions and outcomes of health promotion programmes. according to sanders et al.,[11] the need for comprehensive action focusing on the social determinants of health is well overdue, particularly in sub-saharan countries. this implies that health professionals need a solid understanding of the social factors which influence health, the experiences and needs of communities, and the challenge of partnerships and collaborative practice. since the inception of the ihp in 2001, health promotion theory has been applied in a particular setting, i.e. primary schools in ‘disadvantaged’ communities. students are expected to plan, implement and evaluate health promotion projects in the schools. theory is taught on campus and the health-promoting schools (hps)[12] approach is used to guide students in the application of their health promotion projects. a health promoting school constantly strengthens its capacity as a healthy setting for living, learning and working.[13] at any one time there are nine schools involved in the programme. each year an average of 360 students from the following health professional programmes participate in the course: social work, dietetics, occupational therapy, physiotherapy, and school of natural medicine, dentistry and oral hygiene. students are assigned to an interdisciplinary class of approximately 35 students. the academics are recruited from the disciplines involved in the course; on average there are nine interdisciplinary classes, each with an academic staff member. supervisors are also recruited from within the university to facilitate student learning in the schools. most of the student health promotion projects are aligned with the life orientation (lo) curriculum of the western cape education department (wced), although there are projects that address broader issues impacting on the schools and learners. these include abuse, violence, communicable diseases including hiv/aids, noncommunicable diseases, life skills, hygiene, nutrition, citizenship, children’s rights, leadership, bullying, and drug abuse. problem statement annually, a document was published which contains summaries of the participating schools’ data and information pertaining to student projects, learner and educator numbers, number of classes, governing bodies, infrastructure, extramural activities, access to health and social services, and views of the educators on the health-promoting schools approach. the school information was collected by the itlu staff and each school was afforded the opportunity to verify and rectify the information. topics for student health promotion projects were provided by the co-ordinating educator at each school. during the editing and preparation of the 2009 document, it emerged that feedback and needs expressed by the schools had not changed since 2005. to address this dilemma, a stakeholder dialogue was organised to explore how the ihp course can impact on schools and the broader community more effectively. methods an action-research design[14] was employed, as it allowed the researchers to gain consensus among the stakeholders on how the course can impact on schools and the broader community more effectively, and to develop an intervention collectively with the stakeholders. the participants of the study included the following stakeholders who were involved in the ihp: (i) school community: the principals, educators and parents; (ii) faculty staff: academics and supervisors; (iii) service providers: school nurses and nongovernment organisations; and (iv) community health forum members. data were collected using the nominal group technique[15] to gain consensus among the stakeholders on how the course can impact on the school and the broader community. procedure and analysis all stakeholders involved in health promotion in the schools where the ihp is offered were invited to a dialogue held on 18 october 2010 at uwc. tables were set up in a group work format to represent each of the nine schools involved. the participants were asked to align themselves with their particular school, resulting in a good representation of the stakeholders working in that particular school. the moderator discussed the importance of dialogue, the participants’ contribution and how the outcomes of the stakeholder dialogue would be used. the findings of the annual school information, highlighting the problems, were presented. the groups were then introduced to a question: ‘what are the challenges experienced in the school?’. the participants had to consider the question individually and then their ideas were captured on a flip chart. a plenary session followed, where each recorded idea was discussed to determine clarity and importance. the moderator then facilitated a consensual process where the ideas were prioritised and recorded. the five action areas of the hps were used as a guide to categorise the challenges raised by the schools (table 1). using the same process, the participants were then asked to return to their groups and the following questions were posed: ‘what is possible, how can we use our limited time and resources more creatively? how do we begin to impact the school and broader community more effectively?’ a plenary session followed where the interventions required at the various schools were recorded by the moderator (table 1). results the challenges put forward by the groups were categorised according to the components of the hps, as illustrated in table 1. table 2 represents the interventions needed at specific schools as expressed by the various stakeholders. programmes that address teacher support and classroom management were stated as a priority for all the schools. four schools listed the need for sport enhancement programmes, and staff development programmes were needed at three schools. programmes focusing on literacy, counselling, motivational talks and parental involvement were mentioned by two schools. the following programmes were needed by individual schools: numeracy, coping skills, conducting a article may 2013, vol. 5, no. 1 ajhpe 28 learner profile, evaluation of a feeding scheme, and the identification of at-risk learners. to address the needs illustrated above, the following three recommendations were made by the stakeholders: • a strategic planning session should be held with each school, stakeholders and community members to explore a vision for promoting health and to develop an action plan within the current limitations and constraints of the university and the school. • the health promotion projects of the university students conducted in the school should address broader issues of the school and not only those identified in the lo curriculum. • all stakeholders including the community members must be included in the design and delivery of the ihp. health promotion programmes 2011 2012 in line with the recommendations of the stakeholders, the following programmes were implemented by the staff in the itlu in collaboration with various uwc departments. exploring a vision for health promotion in schools presentations were done by itlu staff either with the entire educator body or with key educators in schools, mandated to drive health promotion programmes. workshops were also convened on campus to encourage relationship building with principals and educators. these focused on promoting health in schools utilising the hps, and educators and principals were also encouraged to share challenges, solutions and experiences with one another. health promotion projects to address broader issues in schools student projects included gathering information for the evaluation of feeding schemes, and students also developed projects to enhance sport in schools. in addition, itlu community engagement activities contributed towards relationship building through staff development workshops. these workshops focused on teacher support and classroom management. a principals’ forum was initiated, which was facilitated by itlu staff. the forum included school social workers and circuit management from wced. furthermore, itlu notified other departments within the faculty and university of the interventions identified at the stakeholder dialogue. consequently, a collaboration was established with the interdisciplinary centre of excellence in sport science and development (icessd) at uwc, which included educators and community members linked to the respective schools in funded, accredited courses. the course was followed by a conference and sports day where educators were afforded the opportunity to network and engage with a broad range of stakeholders actively involved in sport services in schools. an opportunity was also afforded to a community member linked to a school to attend an accredited and funded course on substance abuse offered by the community engagement unit at uwc. table 1. challenges identified at participating schools components of hps challenges at schools develop healthy school policies that will assist the school community in constantly addressing its health needs schools do not have policies for health promotion; these are therefore required development of the school as a supportive environment for the development of health attitudes and practices ignorance within families regarding health issues discipline problems among learners rampant social problems, such as abuse and violence experienced by learners and community lack of sustainable health promotion programmes lack of commitment of stakeholders community action that involves the school and broader community in taking ownership of and seeking ways to address their collective health needs by accessing resources for health ownership of health promotion programme by the school community is required poverty alleviation projects to be initiated by the school community, as poverty is experienced by the majority of learners awareness, support and educational activities to reduce early sexual activity among learners development of personal skills of members of the school community, thus enabling them to improve their own health and influence the health of others parental and community involvement is needed. parents require motivation and skills to identify, initiate and lead projects in the schools and community generally low level of literacy among learners and community shortage of trained educators to initiate or assist with implementing a health promotion programme at the school management skills required for school governing bodies an understanding of the ‘health promoting school’ concept is needed by the school community access to appropriate services to address the health needs of the school community schools not currently benefiting from the school feeding scheme should be referred to it to alleviate the problem of under-nutrition among learners a general lack of resources and infrastructure in schools too few visits from school nurses and other health professionals intersectoral collaboration between the department of education, department of health and the non-governmental sector is required. while all of these agencies offer services in the schools, there is no collaboration no access to appropriate service providers no proper referral systems for vulnerable or sick learners safe rooms are needed at all the schools hps – health-promoting schools article 29 may 2013, vol. 5, no. 1 ajhpe further collaboration has seen the formalisation of a programme with the centre for student support services (leadership and social responsibility unit) in which students addressed a vast range of issues such as numeracy and literacy in schools through participative programmes with the learners. schools were also invited to join the hps forum hosted by the school of public health. inclusion of stakeholders and community members in the design and delivery of the ihp course the itlu staff visited schools to present an overview of the course and discuss course content. subsequently, a planning meeting was held where it was agreed by the educators that their role in the success of student learning is vital and that they will be more active in guiding the students during the classroom-based activities. educators also requested follow-up sessions for further information about the content of the course. students were engaged in a look, listen and learn activity in which they went on a walkabout on the school grounds and in the surrounding communities. this was conducted by both educators and community members, who were also invited to participate in a health promotion course offered by the itlu to facilitate a better understanding of health promotion in schools. twelve educators participated in the course during the september school holiday. conclusion in line with brennan’s[1] notion of social responsiveness in higher education, the process of engaging with civil society commenced with the stakeholder dialogue. on reflection, this proved to be a key contributing factor in the successes achieved thus far, as it allowed the university to learn more about the communities and the needs of stakeholders. in addition, the process has allowed stakeholders to be guided by various health promotion approaches appropriate to the specific interventions as identified by the schools. the first and second stages of the action research process revealed that, despite the successes achieved, promoting health in schools faces many challenges; however, the foundations have been laid for on-going dialogue. a key lesson learnt is that the importance of building strong partnerships should not be underestimated and that the time and activities required cannot necessarily be anticipated. measurement of impact implies a longer-term process; therefore, this ongoing process will be monitored and evaluated periodically with an impact evaluation planned after 2015. acknowledgements. the authors thank the participating schools and all participants of the stakeholder dialogue. furthermore, the authors wish to acknowledge the academics and supervisors for their contribution to the success of the course, ms jill ryan, research assistant and mrs cornelia fester, the administrator. references 1. brennan j. higher education and social change. higher education 2008;56:381-393. [http://dx.doi.org/ 10.1007/ s10734-008-9126-4] 2. subotzky g. alternatives to the entrepreneurial university: new modes of knowledge production in community service programs. higher education 1999;38:401-440. 3. republic of south africa. higher education act no. 101 of 1997. government gazette 390 (no. 18515). pretoria: government printer, 1997. 4. bender cjg, daniels p, lazarus j, naudé l, sattar k. service-learning in the curriculum. a resource for higher education institutions. higher education quality committee (heqc). pretoria: council on higher education, 2006. 5. braskamp l, wergin j. forming new social partnership. in: tierney w, ed. the responsive university: restructuring for higher performance. baltimore: johns hopkins university, 1998. 6. university of the witwatersrand (wits). draft policy on the integration of service learning to teaching learning and research. johannesburg: university of the witwatersrand, 2003. 7. world health organization. division of development of human resources for health. defining and measuring the social accountability of medical schools. geneva, switzerland; c1995. http://whqlibdoc.who.int.ezproxy. uwc.ac.za/hq/1995/who_hrh_95.7.pdf (accessed 23 august 2012). 8. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 9. keleher h. health promotion principles. in: keleher h, macdougall c, murphy b, eds. understanding health promotion. new york: oxford university press, 2007:12-28. 10. keleher h, macdougall c, murphy b. approaching health promotion. in: keleher h, macdougall c, murphy b, eds. understanding health promotion. new york: oxford university press, 2007:3-13. 11. sanders d, stein r, struthers p, ngulube tj, onya h. what is needed for health promotion in africa, band-aid, live aid or real change? critical public health 2008;18 (4):509-519. [http://dx.doi.org/10.1080/09581590802503076] 12. world health organization. who global school health initiative: helping schools to become health promoting schools. fact sheet 92:6. geneva: who 1998. 13. world health organization expert committee. comprehensive schools health education and promotion. geneva: who, 1997. 14. nieuwenhuis j. qualitative research design and data gathering techniques. in: maree k, ed. first steps in research. pretoria: van schaik publishers, 2007:113-115. 15. burrows t, findlay n, killen c, dempsey se, hunter s. using nominal group technique to develop a consensus derived model for peer review of teaching across a multi-school faculty. journal of university teaching and learning practice 2011;8(2): 8. table 2. specific interventions as indicated by schools interventions school 1 2 3 4 5 6 7 8 9 staff development literacy numeracy counselling teacher support motivational talks coping skills parental involvement learner profile feeding scheme evaluation enhancement of sport at-risk learners research november 2013, vol. 5, no. 2 ajhpe 75 objectives. to determine the knowledge and skills of final-year medical students in managing victims of violence against women (vaw), and to describe the extent to which vaw is included in the undergraduate curriculum of the college of medicine, university of ibadan. method. a mixed-method study design was used that collected qualitative data through a review of curriculum documents and interviews of departmental heads (or their representatives) of 6 departments in the college. a semi-structured, self-administered questionnaire was used to collect quantitative data from 109 final-year students. results. the response rate was 85.1% and respondents’ mean age was 25.2±3.1 years. physical, sexual, psychological and economic abuse was found by 73.8%, 72.6%, 54.8% and 44.0% respectively, of the students. most students (77.4%) felt it was part of their duty to ask patients about abuse. students with previous training about violence were more likely to be knowledgeable (odds ratio (or) 1.64; 95% confidence interval (ci) 0.61 4.42) and skilled (or 1.27; 95% ci 0.53 3.05). men had better knowledge and skills than women. vaw was not included as a topic in the curriculum. conclusion. most students were willing to ask patients about abuse but lacked the fundamental knowledge and skills to do so. faculty at the college agreed to review the curriculum to improve students’ knowledge and management skills regarding vaw. ajhpe 2013;5(2):75-79. doi:10.7196/ajhpe.222 training on prevention of violence against women in the medical curriculum at the university of ibadan, nigeria o i fawole,1 mb bs, msc (epid and bio), fnmc (ph); j van wyk,2 bsc (ed), phd; a adejimi,3 mb bs, mph (comm med), fwacp 1 department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria 2 department of clinical cognition, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 department of community medicine, college of medicine, university of ibadan corresponding author: o i fawole (fawoleo@ymail.com) violence against women (vaw) has become a major public health and human rights issue. this social evil occurs in all countries, irrespective of social, economic, religious and cultural traditions. notably, the increasing incidence of battering, rape, domestic violence, honour killings, human trafficking, prostitution, forced and early marriages, female genital mutilation and sexual slavery was noted by the secretary-general of the united nations, at the 4th world conference on women.[1] deeply rooted african tradition and culture have been blamed for most of the physical and psychological customs that perpetuate vaw.[2] to illustrate, wife-beating is perceived as normal in african marital relationships,[3,4] and the custom of inheriting a woman as part of her deceased husband’s estate has left many women poor, homeless and vulnerable to abuse. while most african countries have amended or passed gender-sensitive laws to stem the tide of violence and prejudice against women, concern remains over the lack of enforcement of such legislation[5] in a region characterised by widespread armed conflict, poverty and social inequality, which result in continued exploitation and abuse of vulnerable groups.[2,6] results of the demographic and health survey in nigeria of 2008 indicated that 28% of women aged 15 49 years had experienced physical violence since the age of 15, and that 15% had experienced physical violence in the 12 months prior to the survey.[7] epidemiological evidence suggests that vaw affects the health and wellbeing of women in many ways, resulting in fatal (homicide, suicide and aids-related deaths) and non-fatal (physical injury, chronic pain syndromes and gastro-intestinal disorders) outcomes.[8] physical and sexual violence further affects the mental health of victims, and has resulted in behavioral outcomes such as alcohol and/or drug abuse and high sexual risk-taking behavior.[8] evidence suggests that women are likely to disclose intimate partner violence to healthcare practitioners,[7] but the latter's inadequate training may leave them unable to recognise or, where disclosed, unable to respond to victims of abuse. concern has also been raised about reports[9] of women suffering abuse or neglect at the hands of healthcare practitioners and the perceived reluctance of health personnel to discuss physical and sexual violence with patients who disclose being in violent relationships.[8] medical schools with gender-based violence curricula have played an important part in the promotion of good maternal and child health outcomes. research indicates that physicians trained in vaw are significantly more likely to screen for signs of abuse.[10] there is also increasing debate about the efficacy of curricular approaches and the most effective educational techniques to be used for training.[11] realising the central role of medical schools in preparing a future generation of practitioners and citizens, there is consequently a need to educate medical students about the treatment, referral system and impact of vaw when managing victims. however, little research is done in the african context about the prior experiences of medical students of vaw and their attitudes to treating victims of abuse. the present study was therefore conducted to determine perceptions and the level of competence (knowledge, skills) to manage victims of vaw among the final-year student cohort and the extent to which the topic is taught in the college of medicine at the university of ibadan, nigeria. method the college of medicine trains medical and dental students. it includes a 950-bed tertiary health facility − the university college hospital. medical students rotate through the faculty of public health in their 3rd, 4th and 5th years of study. students similarly rotate for periods of approximately 6 8 weeks through each of the 6 clinical blocks in their final year. a mixed methods approach was used in this descriptive, analytical cross-sectional study. quantitative data was collected through a selfadministered questionnaire that collected data on students’ knowledge of mailto:fawoleo@ymail.com research 76 november 2013, vol. 5, no. 2 ajhpe vaw, factors influencing their acquisition of knowledge and skills, and the extent to which they had prior training on the topic. the final part of the questionnaire explored students’ perceptions and attitudes towards abusers and victims, their levels of empathy for those in abusive relationships, and their skills in managing abused patients. final-year medical students (n=128) in their 5th year of study constituted the primary respondents, while faculty members were the secondary respondents. faculty members included staff responsible for bedside teaching and lecturing from family medicine, paediatrics, obstetrics and gynaecology, accidents and trauma, dentistry and public health. a qualitative data analysis of curriculum documents including module and course information on the bachelor of medicine and bachelor of surgery (mb bs) course were undertaken. in-depth interviews were also conducted with key faculty informants from each of the 6 departments to verify the extent of coverage of vaw in the curriculum. the questions explored included the availability of a programme on vaw, content covered, teaching methods, competencies of trainers, and suggestions to improve students’ competence concerning vaw. the questionnaire was adapted from previous studies.[12,13] a pilot study was conducted with 20 students enrolled in their 4th year of study at the school. each questionnaire took about 20 minutes to complete. the questionnaire was amended to improve clarity and reduce ambiguity. a copy can be obtained from the corresponding author. the qualitative data were transcribed, cleaned and coded, and themes identified. descriptive analysis, frequencies, means and standard deviations were performed on the data, using statistical software stata 11.0. bivariate analysis using the chi-squared (χ2) test was used to determine the associations between variables. significant variables in the bivariate analysis were entered into a logistic regression model to determine the strength of the associations. p-values <0.05 were considered significant. ethical clearance for the study was obtained from the joint university of ibadan/university college hospital institutional review board (ui/ec/11/0103). results demographic data a hundred-and-nine students (n=128; 85.1%) participated in the study. the mean age of the primary respondents ranged from 16 to 39 years with a median age of 24 years. most students were male (59.6%), and 73.4% were from the yoruba ethnic group. awareness of vaw seventy-seven per cent of the respondents indicated an awareness of vaw. their descriptions of the term varied, e.g. the maltreatment of either sex, violence to women, physical assault, beating and/or battery, and forms of physical, sexual and psychological (mental) violence. knowledge of vaw physical violence. most respondents (73.8%) could give at least one correct example of a physically violent act. physical violence was described as beating (46.4%) and slaps (15.5%). sexual violence. about three-quarters (72.6%) of the respondents gave at least one correct example of a sexually violent act, while 11.9% gave 2 or more examples. sexual violence was mostly (67.8%) described as rape. psychological violence. slightly more than half (54.8%) gave an example of a psychologically violent act, while 6% mentioned 2 correct examples. psychological violence was described as verbal abuse and insults (32.1% and 7.1% respectively). economic violence. economic violence was described as financial deprivation (17.9%), not allowing a woman to work (14.3%), and lack of care (5.9%). respondents’ knowledge of what an act of economic violence comprised was stated by 44%; 5% could mention 2 such acts. signs and symptoms suggestive of vaw. complaints of aches and pains were made by 90.4%. students also mentioned other symptoms including abortions (86.9%), fractures (78.6%), sexually transmitted infections (66.7%) and headache (66.7%). perceptions of vaw magnitude of vaw. regarding the attitudes of students as indicated in table 1, most of the student respondents perceived vaw to be a common problem in their environment. fifty-two respondents (61.9%) thought it was common (experienced by 10% of the population) while 26.2% thought it was very common (experienced by 15% of the population). only 11.9% believed it was rare (experienced by <5% of the population). asking patients about vaw. most (77.4%) students regarded it as part of their duty as physicians to enquire about violence, and many (67.9%) were willing to do so. those who were not willing to engage with patients thought that it would intrude on the private life of their patients (57.1%), and some students (42.9%) believed it would be demeaning to enquire about vaw. students’ confidence about discussing the topic with patients. student responses varied on the extent to which they were confident about asking patients about vaw. eighty-one per cent were very confident to ask about depression, 73.8% were very confident to ask about beatings, and 54.8% were very confident to ask about rape. thirty-six per cent reported little confidence to ask about rape, while 9% were not confident at all to enquire about any aspect of the topic. table 1. student respondents’ attitude to screening and care of victims statement agree n (%) not sure n (%) disagree n (%) it is an intrusion into the patient’s private life 17 (20.2) 19 (22.7) 48 (57.1) it will be part of my role as a physician 65 (77.4) 16 (19.1) 3 (3.6) i do not think it will offend the patient 47 (56.0) 27 (32.1) 10 (11.9) i think it will offend the patient 21 (25.0) 27 (32.2) 36 (42.9) i am willing to do so 57 (67.9) 21 (25.0) 6 (7.1) table 2. knowledge, attitude, confidence and skills scores of student respondents scores mean±sd maximum median knowledge 2.44±0.92 5 3.0 attitude 4.0±1.6 7 4.0 confidence 4.9±1.5 6 5.0 skills 12.2±3.2 21 12.0 research november 2013, vol. 5, no. 2 ajhpe 77 attitude towards victims. less than half (44.0%) of respondents indicated that they would be sympathetic towards a woman who chose to remain in a violent relationship, while 48.8% felt that the abused victim did not deserve the experience and that violence was wrong. skills and competencies most respondents indicated not being very skilled to treat victims of violence. for instance, only 14.3% stated that they were very skilled and could detect the warning signs and symptoms of vaw. less than 10% (9.5%) of the respondents reported being very skilled at treating and providing medical care to victims, and 57% admitted to having some skill to do so. knowledge, attitude, confidence and competence scores knowledge, attitude, confidence and competence scores were awarded by giving one mark for every correct statement. tables 2 4 indicate the questions posed to students to ascertain their knowledge, skills and attitude towards victims of violence. a mean knowledge score of 2.44±0.92 was obtained from 5 knowledge statements. a mean attitude score of 4.0±1.6 was obtained from a maximum of 7 statements, while a mean confidence score of 4.9±1.5 was recorded from 6. the maximum obtainable competence (skills) score was 21, and a mean attitude score of 12.2±3.2 was obtained. using the 75th percentile as the cut-off for respondent scores, 60.7% (51) were knowledgeable on vaw, 47.6% (40) were very confident, 25% (21) had a positive attitude to managing victims of vaw, and 40.5% (34) were skilled in the management of victims. older students were 5 times more likely to be knowledgeable (aor 4.89; p=0.003) and to have better attitudes (aor 4.55; p=0.008) towards victims of violence. male students had more knowledge of vaw, and female students had better attitudes to victims. students who reported prior training on violence were more likely to have adequate knowledge (aor1.64; p=0.33), and better attitudes (aor 1.38; p=0.53) and skills to manage victims (aor 1.26; p=0.59). suggestion to improve knowledge and skills student opinions were sought on how to improve their knowledge and skills on case management relating to vaw. their responses included that the table 4. logistic regression analysis of factors associated with good knowledge, attitude and competence scores profile adequate (n=84) or (95% ci) p-value positive (n=84) or (95% ci) p-value skills (n=84) or (95% ci) p-value age <25 years >25 years 1 4.89 (1.69 14.12) 0.003 1 4.55 (1.48 13.99) 0.008 1 1.00 (0.42 2.39) 1.00 sex female male 1 2.44 (0.89 6.65) 0.82 1 0.64 (0.23 1.74) 0.38 1 1.27 (0.53 3.05) 0.59 training no yes 1 1.64 (0.61 4.42) 0.33 1 1.38 (0.51 3.70) 0.53 1 1.26 (0.54 3.04) 0.59 table 3. student respondents’ perceived skills to manage vaw victims activity very skilled n (%) some skill n (%) not skilled/ don’t know n (%) recognising/detecting vaw (e.g. picking up warning signs and symptoms and/or screening techniques for patients suspected to be at risk) 12 (14.3) 45 (53.6) 27 (32.1) taking history on vaw episodes (e.g. frequency and severity of episodes, involvement of other family members, access to dangerous weapons, contributing factors such as alcohol and drugs) 11 (13.1) 54 (64.3) 19 (22.7) examining vaw victim (laboratory or side-room investigations, microbiology swabs etc.) 7 (8.4) 37 (44.0) 44 (47.6) treatment of and medical care for victims 8 (9.5) 46 (54.9) 30 (28.6) counselling and facilitating the development of a safety plan with the victim (e.g. establishing with the patient if it is safe to go home and, if not, discussion of options, referral for help, admission to hospital as temporary place of safety) 14 (16.7) 48 (57.1) 22 (26.2) managing/counselling the perpetrator if he/she is in the setting together with the victim 9 (10.7) 40 (47.6) 35 (41.7) discussing coping skills for victims of family violence or those in abusive relationships 6 (7.1) 46 (54.8) 32 (38.1) table 5. student respondents’ suggestions for improving their knowledge suggestion (n=39) n (%) include in curriculum 13 (33.3) clinical teaching and case studies 3 (7.7) publicise in media 3 (7.7) short courses and workshop 3 (7.7) group discussion 1 (2.6) no response 9 (23.1) 78 november 2013, vol. 5, no. 2 ajhpe ta bl e 6. s um m ar y of fa cu lt y re sp on de nt s on te ac hi ng a bo ut v a w fi na lye ar de pa rt m en ts is th er e a cu rr ic ul um to te ac h st ud en ts a bo ut v a w ? r ea so ns fo r no t t ea ch in g va w h ow p re pa re d ar e fa cu lt y fr om yo ur d ep ar tm en t t o te ac h ab ou t va w ? h ow c an v a w b e in cl ud ed in th e cu rr ic ul um ? 1 ‘p re se nt ly th er e is n o pr og ra m m e in p la ce , b ut w he n w e se e su ch ca se s an d if th er e ar e m ed ic al s tu de nt s ar ou nd , w e us e th at a ve nu e to ta lk to th em ’. ‘ w he n w e se e ca se s of v a w , w e ca ll th e st ud en t ar ou nd , e ve n in o ur n or m al c lin ic al s es si on s; to pi cs th at h av e to do w ith p hy si ca l a ss au lt ca n be a ss ig ne d to a ny d oc to r to p re se nt to th em to d is cu ss .’ ‘it c an b e at tr ib ut ed to tw o re as on s: o ur in st itu tio n an d n at io na l u ni ve rs ity c om m is si on d o no t h av e it in th e cu rr ic ul um ’. ‘m os t o f o ur c on su lta nt s an d re si de nt s ha ve n ev er h ad fo rm al tr ai ni ng o n va w b ut th ey ap pr ec ia te it s im po rt an ce ’. ‘t he p ro gr am m e sh ou ld c ut a cr os s pr im ar y sc ho ol , se co nd ar y sc ho ol s an d te rt ia ry e du ca tio n; e ve ry bo dy sh ou ld b e in vo lv ed . p ub lic e nl ig ht en m en t i s ne ed ed s o th at p eo pl e ca n be a de qu at el y in fo rm ed ’. 2 ‘it is w he n w e se e a pa tie nt th at w e te nd to te ac h, e ith er in th e cl in ic o r on th e be ds id e. if w e se e su ch c as es , s om e of o ur re si de nt s w ill w or k on it b ut w e ha ve n o st ru ct ur ed le ct ur es ’. ‘i do n’ t t hi nk w e sh ou ld le t t he m p us h te ac hi ng it to u s. v a w s ho ul d be ta ilo re d no t o nl y to w ar ds th e he al th s ec to r, ot he rs sh ou ld d o th e te ac hi ng to o’. ‘c on su lta nt s an d re si de nt s sh ou ld ge t m or e tr ai ni ng .’ ‘v a w is a to pi c th at is g et tin g a lo t o f i m po rt an ce . t he re s ho ul d be m or e tr ai ni ng o n ho w to h el p w om en , in p ar tic ul ar , w ho n ee d he lp , a nd a ls o ho w to g et th em to w he re th ey c an g et th is h el p’. 3 ‘i do n’ t t hi nk th er e is a ny th in g in … [ na m e of d ep ar tm en t] o n th at e xc ep t i n fo re ns ic m ed ic in e w he re s ig ns o f b at te ri ng a re m en tio ne d’. ‘i f t he g yn ae co lo gi st c ou ld b e co nv in ce d, it is g oo d to h av e at le as t a to pi c on it . a ls o, in d ep ar tm en ts th at d ea l w ith s oc ia l a sp ec ts o f l ife s uc h as p re ve nt iv e m ed ic in e an d he al th p ro m ot io n, a to pi c of a s em in ar ca n be d ed ic at ed to v a w ’. 4 ‘w e ha ve n o di re ct le ct ur es o n ge nd er a nd v io le nc e, n on e w ha ts oe ve r. bu t w e ha ve s em in ar s on s oc ia l … [ na m e of de pa rt m en t] w hi ch w e co nd uc t w ee kl y, s o if th ey s ee a c hi ld , th ey fo llo w th e ch ild h om e, a nd ta lk a bo ut th e su rr ou nd in g ci rc um st an ce s, h om e an d fa m ily is su es , e .g . i f t he m ot he r or ch ild h as b at te ri ng is su es o r an y is su es r el at in g to g en de r. fo r th e cl in ic al a sp ec t o f t he p ra ct ic e, w e se e ch ild re n w ho h av e be en a ss au lte d an d m os t o f t he m a re fe m al es , a nd if th e st ud en ts ha pp en to b e in th e cl in ic a t t he ti m e, th ey a ls o ge t t o le ar n ab ou t it’ . ‘i f t he g yn ae co lo gi st c ou ld b e co nv in ce d, it is g oo d to ha ve a t l ea st a to pi c on it . a ls o in d ep ar tm en ts th at d ea l w ith s oc ia l a sp ec ts o f l ife s uc h as p re ve nt iv e m ed ic in e an d he al th p ro m ot io n, a to pi c of a s em in ar c an b e de di ca te d to v a w ’. 5 ‘w e do n ot h av e va w in o ur u nd er gr ad ua te c ur ri cu lu m ; m os t o f th e te ac hi ng o n va w is in th e po st gr ad ua te m od ul e’. ‘t he c ur ri cu lu m th at w e ha ve h as b ee n th er e fo r a lo ng ti m e, a nd if y ou lo ok a t t he tr en dy th in gs a bo ut r ep ro du ct iv e ri gh ts , va w a nd o th er is su es o nl y be ca m e to pi ca l in th e la st o ne o r tw o de ca de s’. ‘i ha ve n o fo rm al tr ai ni ng . i a m ju st in te re st ed in th e to pi c be ca us e i w or ke d on s ex ua l v io le nc e as p ar t o f m y po st gr ad ua te w or k’. ‘it s ho ul d be in co rp or at ed in to th e cu rr ic ul um ; t ha t w ill s tim ul at e do ct or s to k no w th at v a w e xi st s an d to lo ok o ut fo r it’ . 6 ‘w e do n’ t g o in to th e in -d ep th a sp ec t o f i t, w e ju st ta lk to th em ab ou t d om es tic v io le nc e un de r re ha bi lit at iv e m ed ic in e or fa m ily he al th ’. ‘a s pa rt o f a w or ks ho p an d w he n i w as d oi ng m y m ph , p ar t o f so m e co ur se s an d oc ca si on al ly in se m in ar s, i h av e le ar nt a bo ut v a w ’. research november 2013, vol. 5, no. 2 ajhpe 79 topic should be taught or included in the curriculum (25.7%); dealt with in teaching practice (17.9%) and addressed through case demonstrations (11%). a summary of the student suggestions is provided in table 5. training/teaching received on vaw thirty-nine student respondents (46.4%) received some formal training in vaw. nearly 31% (12) received their teaching at medical school. other sources were the church, parents and electronic media. most (58.3%) teaching was in the final year of medical school, and was primarily offered by teachers from the departments of public health; obstetrics and gynaecology; and psychiatry. teaching was mostly delivered as didactic lectures (83.3%) by doctors (66.7%) and social workers (16.7%). interviews with faculty members (see table 6) revealed an absence of teaching about vaw in their formal programme. of the 39 respondents who received formal training on vaw, 20.5% had training on how to detect warning signs and symptoms, 25.6% could take history on vaw incidents, 25.6% could examine victims, 33.3% could provide treatment or medical care to victims, and 28.2% could provide counselling to perpetrators. most (51.2 64.1%) respondents stated that they would like these issues addressed in their teaching curriculum. reasons for the non-inclusion of vaw in the curriculum and faculty’s view on their expertise in training on the topic were captured in interviews with the departmental representatives and indicated in table 6. most of the interviewees admitted to not having had previous formal training on vaw. discussion although students demonstrated satisfactory knowledge of signs and symptoms, they lacked knowledge of the types of vaw. their knowledge was best on physical and sexual violence, with psychological and economic aspects less known. knowledge levels of the cohort might have been lower, as nonparticipation by some might have been due to a perceived lack of knowledge. previous studies that assessed knowledge and perceptions of medical students were conducted predominantly in developed contexts[10] and highlighted the value of exposing and training students on a vaw programme. studies have also expressed concern over inadequate training on intimate partner violence.[14] in the present study, men surprisingly demonstrated better knowledge of vaw which might have been due to their increased exposure or that some might have been perpetrators of vaw. older respondents, probably owing to their more extensive life experiences, and those who had been trained, also demonstrated better knowledge. this improved knowledge should ultimately translate into improved attitudes, screening procedures and case management during clinical practice. many students had an accurate estimation of the magnitude of vaw in society and correctly perceived it their duty to ask patients about violence. some were, however, not sympathetic towards women who chose to remain in violent relationships, and even expressed the view that such an abused victim then deserved the experience. this perception is similar to that of nurses in a study in rural south africa.[15] research has indicated that some of these incorrect perceptions could still be challenged and changed during training.[10] females empathised better with victims, possibly owing to knowledge of friends, family, neighbours or themselves being in similar situations. this aspect was, however, not explored in this study. most students admitted to having limited skills in managing victims of violence, which we suggest probably reflects the lack of training in this issue. the results suggest the need for an integrated institutional curriculum on vaw. this need was confirmed in the interviews with faculty who reiterated a commitment to include education about vaw; some reported sporadic teaching even in the absence of a formal curriculum. some departments were aware of the need to review their curricula. most faculty members interviewed further acknowledged a need for personal training on vaw, and agreed to institute training for students. it was felt that an effective training programme would promote student learning and expedite professional and personal development. two limitations to the study need noting. firstly, students might have gained prior knowedge on vaw from sources outside the school; and secondly, the expertise of tutors and students on women’s issues in public health might have confounded some of the observed associations. similarly, the academic abilities of the students might have influenced the results. however, these are likely to affect knowledge and not skills. nevertheless, the results still show the need to improve current teaching on the topic. conclusion while most students were willing and considered it their duty to ask patients about abuse, they lacked the fundamental knowledge and skills to do so effectively. this study affirmed the need for both faculty and students to be trained on issues relating to vaw, and to receive skills and awareness training on how to screen patients, which may include an institutional plan or protocols for routine screening and dealing with emergencies. there is also a need for a faculty policy to integrate these efforts. the results from this study serve as a basis for reviewing the curriculum and enlisting currently committed members of faculty to enhance and improve students’ knowledge, skills and attitudes on this important topic. references 1. committee on the elimination of discrimination against women. report of the committee on the elimination of discrimination against women. new york: united nations general assembly, 55th session, 2000. 2. okereke go. violence against women in africa. african journal of criminology and justice studies 2006;2(1):1-35. 3. human rights watch. defending human rights worldwide: world report 2002. http://www.hrw.org/wr2k2/ africa.html (accessed 23 march 2013). 4. human rights watch. world report women’s right division 2001. http://www.hrw.org/wr2k1/africa/index. htm (accessed 23 march 2013). 5. united nations commission of human rights. general assembly resolution 2003/45 of 23 april 2003. elimination of violence against women. e/cn/4/2003/l. geneva: uno, 2003. http://www.unhchr.ch/ huridocda/huridoca.nsf/0/92369a7e29927af3c1256d1f004196ce (accessed 30 august 2013). 6. archer r. ghanaian women demanding protection from violence. accra: womensenews, 22 april 2002. http://www.feminist.com/news/news29.html (accessed 30 august 2013). 7. national population commission (npc). nigeria demographic and health survey 2008. abuja, nigeria: national population commission and icf macro, 2009. 8. heise l, ellsberg m, gottemoeller m. ending violence against women. http://www.infoforhealth.org/pr/l11/ violence.pdf (accessed 23 march 2013). 9. jaffre y, prual a. midwives in niger: an uncomfortable position between social behaviours and health care constraints. soc sci med 1994;38(8):1069-1073. 10. feder gs, hutson m, ramsay j, et al. women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta analysis of qualitative studies. arch intern med 2006;166:22-37. 11. abraham a, cheng t, wright j, et al. assessing an educational intervention to improve physician violence screening skills. pediatrics 2001;107(5):e68. 12. botha g. teaching undergraduate medical student’s issues relating to family violence. cape town: south african faimer regional institute, 2008. 13. sugg nk, thompson rs, daine c, et al. domestic violence and primary care: attitudes, practices and beliefs. arch fam med 1999;8(4):301-306. 14. frank e, elon l, saltzman le, et al. clinical and personal intimate partner violence training experiences of us medical students. j womens health 2006;15(9):1071-1079. 15. kim j, motsei m. women enjoy punishment: attitudes and experiences of gender-based violence among phc nurses in rural south africa. soc sci med 2002;54(8):1243-1254. http://www.hrw.org/wr2k2/ http://www.hrw.org/wr2k1/africa/index http://www.unhchr.ch/ http://www.feminist.com/news/news29.html http://www.infoforhealth.org/pr/l11/ the ajhpe is published by the health and medical publishing group. ajhpe african journal of health professions education june 2011, vol. 3 no. 1 editor vanessa burch deputy editor juanita bezuidenhout editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk assistant editor emma buchanan technical editors marijke maree robert matzdorff paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse online manager gertrude fani hmpg board of directors m raff (chair) r abbas m lukhele d j ncayiyana t terblanche m veller issn 1999-7639 the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. fax (021) 681-1395. e-mail: publishing@hmpg.co.za contents editorial setting standards in health sciences education – a wake-up call scarpa schoeman 2 articles discourse of final-year medical students during clinical case representations h botha, gi van schalkwyk, j bezuidenhout, sc van schalkwyk 3 identifying strategies to improve research publication output in health and rehabilitation sciences: a review of the literature jm frantz, sl amosun 7 effects on quality of care and health care worker satisfaction of language training for health care workers in south africa michael e levin 11 challenges and opportunities related to postgraduate evidence-based practice module using blended learning jm frantz, s himalowa, w karuguti, a kumurenzi, d mulenga, m sakala 15 towards understanding the quantitative literacy demands of a first-year medical curriculum vera frith, geney gunston 19 abstracts southern african faimer regional institute (safri) poster day, cape town, march 2011 and sa association of health educationalists (saahe) conference, johannesburg, july 2010 24 cpd 26 article 15 july 2012, vol. 4, no. 1 ajhpe context. most south african medical schools have, in the past decade, introduced changes in their curricula. in our experience we have found that such changes can affect students’ knowledge and understanding of physiology. aim. the current study was undertaken to determine the perceptions of educators regarding the impact of curricular change on the knowledge and understanding of physiology by medical students in south africa. methods. a survey of physiologists teaching medical students in south african medical schools was undertaken by means of a questionnaire. results. there were 20 participants in the current study. demographic data revealed that they came from 6 out the 8 south african medical schools; 80% had phds; 70% had been teaching physiology for more than 10 years and that a similar percentage (80%) were experienced in teaching three or more physiological systems. in addition, 20% of the current participants had additional educational qualifications. in the opinion of the physiologist educators surveyed, 60% felt that although current medical students found it more difficult to understand basic physiology concepts and that, compared with students 5 10 years ago, their knowledge of physiology was more limited, the students nevertheless were better able to integrate their physiology knowledge with clinical subject knowledge. the respondents were divided as to whether or not current medical students found it more difficult to understand pathophysiology than those students 5 10 years ago. in addition, nearly 60% of the staff surveyed were concerned that physiology, as a cognate discipline in south africa, was under threat due to medical curricular change. discussion and conclusion. the results of the survey provide a snapshot of the current state of medical students’ knowledge and understanding of physiology in south africa from the educators’ perspective. it would be interesting to know whether the concerns raised by the participants reflect an international trend. physiologists and curriculum planners/ organisers need to take cognizance of the issues highlighted in the current study. ajhpe 2012;4(1):15-21. doi:10.7196/ajhpe.148 introduction in 2001 the traditional 6-year medical curriculum at the nelson r mandela school of medicine (nrmsm), university of kwazulu-natal, was phased out and replaced with a new 5-year problem-based learning (pbl) curriculum. despite being implemented in different ways,1,2 pbl has a number of common characteristics, including facilitated small-group learning, active learning stimulated through using cases or problems, framework lectures with minimal expert inputs, and themes which emphasise an integrated and multidisciplinary approach.3 from 2006 there have been several modifications of the pbl curriculum at nrmsm, which have included a reduction in the pbl approach in fourth year to enable more clinical bedside teaching, and the introduction of a basic science module at the beginning of first year. these curricular modifications were introduced to address the concerns expressed by clinicians, basic science teachers, the health professions council of south africa and medical students themselves. various aspects of the pbl curriculum at nrmsm have been documented previousl4-6 and more recently by ourselves.7 initially the pbl at nrmsm was delivered over the first 4 years of study with the 5th year retained for clinical teaching. it became increasingly evident to the authors, in our dual roles as both pbl facilitators and expert teachers on this programme, that there were apparent gaps in students’ knowledge of physiology, a perception that was shared by our clinical colleagues. a subsequent survey was conducted by us in which nrmsm students were asked to what extent they thought physiology was essential for their understanding of pathology, interpretation of patients’ clinical signs and presenting symptoms, and analysis of laboratory results. the questionnaire also probed the difficulties that students experienced in understanding large group resource sessions (lgrs) on clinical and physiological topics. the majority of the students surveyed indicated that greater interaction with experts was needed since they were experiencing difficulties both in terminology and in grasping essential physiology concepts. interestingly, abu-hijleh and co-workers, in their study of the effectiveness of a pbl module on the cardiovascular system, also found a substantial majority of their students (90%) identified shortcomings in their knowledge pertaining to the physiology of this system.8 in our study of student perceptions, medical physiology education in south africa: what are the educators’ perspectives? mark tufts, susan higgins-opitz discipline of physiology, school of medical sciences, faculty of health sciences, university of kwazulu-natal mark tufts, msc susan b higgins-opitz, phd corresponding author: mark tufts (tufts@ukzn.ac.za) article 16 july 2012, vol. 4, no. 1 ajhpe the students also highlighted the need for an understanding of physics (electrocardiogram interpretation), chemistry (acid-base balance), biochemistry (gastrointestinal tract physiology) and an ability to integrate knowledge, as required for an understanding of renal physiology, for example.7 physiology is well known to be a discipline that presents most students with a challenge. a number of papers have highlighted this fact from the view of both students and staff alike.7,9-12 in 2007 michael13 reported on a survey which was conducted on faculty members into the factors that were required for the learning of physiology and those that make physiology difficult to learn. a number of key issues were identified: need for an understanding of physics and chemistry, and physiological phenomena at different organisational levels simultaneously; a failure of students to appreciate the integrative nature of physiological mechanisms; and the tendency for students to compartmentalise information. as teachers of physiology, we can fully relate to these findings and the observations made previously by somjen.9 most south african medical schools have recently undertaken curricula changes similar to those at nrmsm.14 in the light of our findings and experiences, and that of others, we were prompted to undertake the current study. the focus thereof was the impact that curricular changes may have had on the teaching of physiology, and students’ understanding and knowledge of physiological concepts. this paper thus details the results obtained from a questionnaire survey of a sample of south african medical physiology educators. method the survey was conducted at the 2009 conference of the physiological society of southern africa (pssa) and includes data from 20 academics, most of whom attended the conference. the inclusion criteria for participation included permanent, full-time teachers of physiology to medical students at the time of the survey. physiologists who do not teach medical students or those who only teach related subjects, such as histology and biochemistry, were excluded from the study. ethical approval (w301/05) for the study was obtained from the biomedical research ethics committee, university of kwazulu-natal. informed consent was obtained from each participant prior to administration of the questionnaire, a copy of which is included in table 1 (overleaf ). the 2-page questionnaire was made up of 4 themes and comprised questions with simple yes/no options, 4-point likert scale ratings (1=strongly agree and 4=strongly disagree) as well as a number of open-ended questions. the first theme was concerned with obtaining relevant bibliographic data from the respondents; the second theme explored the specific areas he/she taught and the textbooks used. the perception of physiology teachers on the ability of current medical students to understand basic concepts were probed in theme 3 as well as a comparison with the abilities of those students studying 5 10 years ago. information regarding the way that physiology was incorporated into the medical curriculum at their institution, the way it was taught, the perceived challenges of teaching physiology and the possible threat that curricular changes may have on physiology as a cognate discipline, made up theme 4. results the results of the study are presented in tables 2 4 and figs 1 3. theme 1: demographic data of participants the 20 medical physiology educators who were included in the survey came from 6 of the 8 medical schools in south africa (table 2). the 6 medical schools represented by the participants were equally split between historically white universities (predominantly academically advantaged students) and black universities (predominantly academically disadvantaged students). the highest qualification of the majority of the respondents (80%) was a phd, with 25% (4/16) of these also being medically qualified. in addition, 20% (4/20) of the current participants had additional educational qualifications. in terms of years of teaching experience, 45% (9/20) of those surveyed had greater than 15 years of experience, whereas only 1 (5%) participant had been teaching for less than 5 years. theme 2: areas taught and textbooks prescribed/ recommended fig. 1 depicts that 70% of those who participated in the current survey were experienced in teaching three or more physiological systems. the six participants, who reported teaching only two of the 10 major physiology systems/topics (as listed in table 3), were from four different institutions, had between them four phds and two masters degree qualifications and only one had less than five years physiology teaching experience. similarly, the three physiology educators who reported teaching all 10 topics had between them 2 phds and 1 masters degree qualifications, teaching table 2. profile of the participants (n=20) in the survey conducted institutions (number of participants) rank* phd mb chb teaching qualification years of experience >5 5 10 10 15 >15 university of cape town (1) 1sl 1 1 0 1 university of kwazulu-natal** (2) 1ap; 1p 2 0 1 2 university of limpopo (medunsa)** (3) 2l; 1sl 1 0 1 1 1 1 university of stellenbosch (3) 2sl; 1p 3 2 0 1 1 1 university of the witwatersrand (7) 1l;1sl; 3ap; 2p 7 1 0 2 3 2 walter sisulu university for technology & science** (4) 1l; 2sl; 1ap 2 0 2 1 3 overall (20) 4l; 7sl; 5ap; 4p 16 4 4 1 5 5 9 *l = lecturer; sl = senior lecturer; ap = associate professor; p = professor. the ranks given above are those as reported in september 2009. **represents universities that were traditionally reserved for non-white students, i.e. academically underprepared students. article 17 july 2012, vol. 4, no. 1 ajhpe   table 1. questionnaire used in the current study questionnaire   physiology  teaching  and  medical  curriculum  change  in  south  africa   we   are   currently   conducting   research   of   medical   curricular   changes   in   south   africa,   with   a   particular   emphasis   on   how   these   curricular   changes  have  impacted  on  students’  basic  understanding  and  knowledge  of  physiological  concepts.    we  would  like  to  extend  an  invitation   for   you   to   participate   in   this   survey,   the   results   of   which   will   be   published   and   presented   at   relevant   conferences.   your   completion   and   return  of  this  survey  will  imply  your  consent  to  participate  in  the  study.    please  be  assured  that  your  name  will  be  kept  strictly  confidential.   should  you,  for  any  reason,  decide  at  a  later  stage  that  you  do  not  wish  the  information  we  have  obtained  from  you  be  used  in  any  way,   you  will  of  course  be  free  to  contact  us  and  we  will  disregard  your  inclusion  in  the  survey.   your  participation  in  this  survey  is  greatly  appreciated.   mark  tufts  and  sue  higgins-­‐opitz,  school  of  medical  sciences,  university  of  kwazulu-­‐natal     1.  i  am  currently  employed  at  ……………………………………………  (institution)   2.  my  highest  qualification  is                            (please  tick  as  appropriate)   b.sc.  (hons)           m.sc           ph.d               mbchb                       other  ……     please  specify…...................................     3.  i  have  a  formal  postgraduate  qualification  in  education                     yes  /  no            if  yes,  please  specify  ………………………………………………………………………….………   4.  my  current  academic  rank  is    ……………………………………………….   5.  my  total  teaching  experience  at  a  tertiary  level  is          <  5  years,    5-­‐10  years,    10-­‐15  years,    >  15  years          (please  circle  as  appropriate)   6.  briefly  list  the  areas  of  physiology  you  have  taught  to  medical  students:   ……………………………………………………………………………………………………….………………………………………………………………………………………… …………………………….……………………………………………………………………………………………………………………………………………..   7.  which  physiology  textbooks  do  your  medical  students  use?    indicate  whether  these  are  prescribed  (p)  or  recommended   (r).   list  ……………………………………………………………………………………………………….…………………………………………………………………….   8.  explain  how  physiology  is  taught  to  medical  students  in  your  faculty:     explain……………………………………………………………………………………………………...……………………………………………………………………………… ……………………………………….……………………………………………………………………………………………………     for  the  following  questions,  please  circle  answers  as  appropriate  where  1  =  strongly  agree,  2  =  agree,  3  =  disagree,  4  =  strongly  disagree.       9.  in  my  opinion,  the  overall  knowledge  of  physiology  of  our  current  medical  students  is  more  limited  than  students  who  graduated          5  to  10  years  ago                       1      2        3      4   10.  i  am  concerned  that  physiology  as  a  cognate  discipline  is  under  threat  as  a  result  of  medical  curricula  change                 i)   in  south  africa             1      2      3      4           ii)   at  my  institution             1      2      3      4   11.  in  my  opinion,  our  current  medical  students  are  better  able  to  integrate  physiology  with  clinical  subjects  than  students  5  to  10                years  ago                       1      2      3      4   12.  in  my  opinion,  our  current  medical  students  have  difficulty  understanding  basic  physiology  concepts       1      2      3      4   13.  in  my  opinion,  our  current  medical  students  have  more  difficulty  understanding  pathophysiology  than  students  5  to10  years  ago                             1      2      3      4   14.  from  your  experience,  list  the  strengths  and  weaknesses  of  the  teaching  of  physiology  to  medical  students  at  your  institution?   ……………………………………………………………………………………………………….…………………………………………………………………………………………………   ……………………………………………………………………………………………………………………………………………………………………………………………………………   15.  please  indicate  your  preferred  ways  for  us  to  clarify  information  you  have  given  us  for  follow-­‐up  purposes   (please  tick  as  appropriate)                            telephonically         email        personal  appointment           contact  details:    ………………………….      ………………………………….   thank  you  so  much  for  taking  the  time  to  complete  this  questionnaire   mark  tufts  &  sue  higgins-­‐opitz   article 18 july 2012, vol. 4, no. 1 ajhpe experience ranging from five to more than 15 years, and were also from different institutions. table 3 also gives the numbers and percentages of the participants who reported teaching each of the major physiology systems/ topics. the most common texts cited by the participants were books authored by ganong (8 times), guyton (8 times), sherwood (9 times) and silverthorn (6 times). physiology teachers at all the institutions represented in the study, with the exception of one, cited both ganong and guyton either as a prescribed or recommended textbook. the use of sherwood and silverthorn was limited to either 2 or 3 institutions, respectively. as shown in fig. 2, the majority of respondents in this study cited 2 or more texts. theme 3: comparison between current and past medical students as perceived by participating physiology teachers in the opinion of the physiologists surveyed, approximately 60% felt that current medical students, compared with students who trained 5 10 years ago, found it more difficult to understand basic physiology concepts and that their knowledge of physiology was more limited (survey questions 12 and 9, respectively; fig. 3). interestingly, a similar proportion reported that the current medical students were better able to integrate physiology with clinical subjects (question 11). the respondents were divided as to whether or not current medical students find it more difficult to understand pathophysiology than students who trained 5 10 years ago (question 13; fig. 3). theme 4: physiology teaching at the institutions of the survey participants details of the medical curricula and the way in which physiology is incorporated and taught in the institutions of participating physiology teachers are summarized in table 4. the perceived strengths and weaknesses of the teaching of physiology to medical students at these institutions are also enumerated (survey questions 8 and 14). finally, while most thought that physiology was not under threat at their own institutions, nearly 60% of the staff surveyed were concerned that physiology, as a cognate discipline in south africa, is under threat due to medical curricular change (question 10 of the questionnaire). discussion despite the fact that only 20 physiologists participated in the current survey, the results provide us with a snapshot of the current state of medical students’ knowledge and understanding of physiology in south africa from the perspective of their educators. as a group, it should be noted that they represent the voice of well-qualified (80% phd) and experienced medical physiology educators; 70% of the respondents had more than 10 years of physiology teaching experience and taught a median of five physiological systems (range 2 10). fig. 1. graphic representation of the numbers of physiology systems/topics taught by the study participants. table 3. overview of the major physiology systems/topics taught by the study participants physiology systems/topics study participants, n (%) neurophysiology 13 (65) cardiovascular physiology 13 (65) endocrine physiology 60 (12) renal physiology 12 (60) respiratory physiology 11 (55) gastrointestinal physiology 9 (45) acid-base physiology 9 (45) reproductive physiology 9 (45) nerve and muscle physiology 9 (45) blood and immune system physiology 8 (40) fig. 2. the number of physiology textbooks recommended or prescribed by medical physiology teachers participating in this study. fig. 3. percentage of respondents who agreed and disagreed with the statements posed in survey questions 9, 11, 12 and 13, respectively. article 19 july 2012, vol. 4, no. 1 ajhpe table 4. perceptions of physiology teaching staff regarding the teaching of physiology to medical students at their institutions institution length and structure of medical curriculum* mode of physiology teaching perceived strengths perceived weaknesses university of limpopo medunsa campus 6-year programme traditional lecture-based course with practicals and tutorials taught in the second year of study use of active teaching and learning strategies such as group work large classes; resource and staff constraints; background of students (perceive pbl to be a way forward) stellenbosch university 6-year programme three phases: phase i – foundation (12 months); phase ii – clinical medicine (42 months); phase iii – clinical consolidation (18 months) didactic teaching in an integrated systemsbased curriculum taught primarily in phase ii theoretically physiology is better integrated the different systems are not sufficiently integrated resulting in physiology knowledge that lacks coherence and is fragmented university of cape town 6-year programme year 1 – foundation courses (12 months); year 2 and 3 – integrated health care systems, including physiology (24 months); years 4 6 – clinical disciplines based on a pbl programme with supplementary lectures and practicals; physiology is integrated with other subjects, mainly anatomy. physiology learning is integrated with that of other subjects lack of emphasis and depth of physiology concepts university of the witwatersrand school leavers’ programme (6 years) year 1 – foundation courses (12 months). lecture-based medical science and humanities courses (12 months) years 3 and 4– integrated health care systems, including physiology (24 months) years 5 and 6 – clinical disciplines (24 months) graduate entry medical programme (gemp) (4 years) same as years 3 to 6 of the school leavers’ programme in the second year it is lecture, practical and tutorial-based; students are expected to be able to apply their knowledge to clinical problems in the third and fourth years, it is integrated as part of various learning topics covered in the medical curriculum integration of physiology with anatomy and biochemistry in second year; use of tutorials (small group teaching) in 2nd year to integrate knowledge gained in lectures; strong emphasis on application loss of the 3rd year pathophysiology course due to implementation of the gemp; problems associated with physiology teaching and learning in the gemp are isolated lectures; poor integration; and some inadequately prepared students; the introduction of the gemp has placed additional burdens on 2nd year students viz. modules they now have to complete walter sisulu university 5 year (60 months); 3 phases with 4 themes in each phase a 6-year programme, in which phase iii has been extended, was introduced in 2010 pbl programme with lectures where necessary; systems-based in phase i and clinical disciplines in phases ii & iii knowledge that students have of physiology is integrated with other learning in-depth knowledge of physiology seems to be lacking article 20 july 2012, vol. 4, no. 1 ajhpe the findings of the current survey corroborate an earlier study on what medical students at nrmsm perceived the challenges of learning physiology in a pbl curriculum to be.7 the students surveyed strongly felt that the basic conceptual foundations that are required for the understanding of physiological concepts were lacking. it is thus noteworthy that these sentiments are mirrored in the responses of the physiology educators surveyed in the current study regarding students’ knowledge and understanding of basic physiology concepts. it is encouraging to note that despite this, medical students of today (as reported by a majority of the physiology educators surveyed) still appear be able to integrate their physiology knowledge with clinical subjects. one possibility is that students are able to integrate the physiology knowledge they possess into clinical scenarios. it is worth noting that the responses of medically qualified physiology educators regarding integration with clinical subjects were divided equally. an analysis of the educators’ perceived strengths and weaknesses of physiology teaching at their respective institutions identified a common theme. whilst integration was recognised as a strength, the educators as a whole were concerned that the fragmentation of physiology learning inherent in the pbl approach was resulting in a lack of depth and understanding of physiology by their medical students, particularly in terms of the basic concepts underpinning the learning of physiology. it would seem that students are expected to apply their knowledge before mastering the basics. there is thus a need to interrogate these perceptions further through more in depth analyses such as follow-up interviews with both medical physiology educators and teachers of clinical medicine. a review of the available literature revealed that there is a dearth of studies that deal with the perceptions of staff relative to that of students concerning physiology teaching and learning. papers dealing with staff perceptions fall into three broad categories: the opinions of staff within the same faculty,15 the opinions of various faculty staff members within a country,16-18 and feedback from faculty staff across the globe.9,13,19,20 in only one of all these surveys9 was south africa represented, albeit by less than 2% (2/116) of the responses received. the course content, in terms of the range of topics and textbooks used comprised part of these surveys. as was the case in the current study, the textbooks of choice in medical courses globally were ganong and guyton, while similar physiological topics were taught. sefton20 in the 2005 claude bernard distinguished lecture, drawing on her experiences of running national and international physiology teaching workshops, set out and discussed the various contexts and challenges facing physiology teachers worldwide. some of these included the avoidance of unnecessary duplication, agreement on consistent terminology, defining what is to be learnt and to what depth, the use of on-line resources and the flexibility thereof. these sentiments were endorsed by lau in 2004, when he stated in the case of teaching pharmacology in a pbl setting that ‘the major problem perhaps is not whether pbl is effective for the teaching of pharmacology, but rather whether learning of pharmacology is effectively integrated into pbl’.19 although a substantial number of physiology staff participating in the current survey felt that physiology as a cognate discipline was being affected detrimentally by the various medical curricular changes that have taken place in the past decade, this perception was not uniform across all the institutions surveyed. educators at one institution all agreed that in south africa physiology was under threat whilst in two institutions there was a 50:50 split. none of the physiology educators in the remaining three institutions agreed. this difference could not be attributed to whether the institutions were formerly disadvantaged or not. there are a number of limitations to the current study. firstly, only approximately 40% of the total number of full-time physiology educators in south africa who teach medical students participated in the survey. secondly, two of the medical schools, the university of pretoria and the university of the free state, were not represented. thirdly, there were instances where staff at the same institution differed substantially in their perceptions, making interpretation of some of their responses difficult. however, every attempt was made to verify the factual information given by staff, including visiting the websites of the respective medical schools. conclusion the survey reported on here serves to highlight the challenges faced by both physiology educators and curriculum designers, particularly in the case of pbl curricula. educators need to ensure that medical students gain both the scope and depth of physiology knowledge and understanding that table 4. continued university of kwazulunatal 5 years (60 months) years 1 3 – pbl year 4 – predominantly clinical with some pbl year 5 – clinical rotations (a 6-year programme was introduced in 2010 in which phase iii was extended) year 1 – 6 weeks of lectures on an introduction to basic sciences remainder of year 1 and years 2-3 physiology material integrated into cases according to themes of approximate 6 weeks duration, with occasional didactic lectures in theory the pbl concept is sound lack of physiology practicals emphasising basic physiological concepts. this means that students are required to apply basic physiological concepts to complex pathophysiological phenomena without having first mastered basic physiology knowledge *additional details obtained from respective websites. article 21 july 2012, vol. 4, no. 1 ajhpe they need without losing their ability to integrate this knowledge within clinical disciplines. this may entail physiologists adopting a more active and participatory style of teaching and learning.20 on the other hand, medical curriculum designers and organisers need to be sensitive to the perceptions of experienced and well-qualified physiologists, and ensure that the exposure of students to physiology, and indeed all other basic sciences in the curriculum, is adequate. the importance of physiology to medical studies should not be underestimated since, as has been previously reported,7 the way it is taught does have an impact on student learning. this paper makes a strong case for improved communication between curriculum designers and basic scientists teaching students in the early years of undergraduate medical programmes. both parties have valid concerns and all need to be addressed in mutually beneficial ways such that student learning is enhanced. conflicts of interests. none. acknowledgements. the authors wish to thank all the physiologists for participating in the study and for giving them valuable insights into their perceptions and experiences in the teaching of physiology to medical students. references 1. norman g. problem-based learning makes a difference. but why? can med assoc j 2008;178:61-62. 2. savin-baden m. disciplinary differences or modes of curriculum practice? who promised to deliver what in problem-based learning? biochem mol biol educ 2003;31:338-343. 3. mclean m. what can we learn from facilitator and student perceptions of facilitation skills and roles in the first year of a problem-based curriculum? bmc med educ 2003;3:9. 4. mclean m. sometimes we do get it right! early clinical contact is a rewarding experience. education for health 2004;17:42-52. 5. van wyk j, madiba te. problem based learning at the nelson r mandela school of medicine. east central african j surg 2006;11:3-9. 6. singaram vs, dolmans dhjm, lachman n, van der vleuten cpm. perceptions of problem-based learning (pbl) group effectiveness in a socially-culturally diverse medical student population. educ health 2008;21:2. 7. tufts ma, higgins-opitz sb. what makes the learning of physiology in a pbl medical curriculum challenging? student perceptions. adv physiol educ 2009;33:187-195. 8. abu-hijleh mf, kassab s, al-shboul q, ganguly pk. evaluation of the teaching strategy of cardiovascular system in a problem-based curriculum: student perception. adv physiol educ 2004;28:59-63. 9. somjen gg. report of the worldwide survey on teaching physiology. adv physiol educ 1999;22:6-14. 10. abdul-ghaffar ta, lukowiak k, nayar u. challenges of teaching physiology in a pbl school. adv physiol educ 1999;22:140-147. 11. silverthorn du, thorn pm, svinicki md. it is difficult to change the way we teach: lessons from the integrative themes in physiology curriculum module project. adv physiol educ 2006;30:204-214. 12. modell hi. helping students make sense of physiological mechanisms: “the view from inside”. adv physiol educ 2007;31:186-192. 13. michael j. what makes physiology hard for students to learn? results of a faculty survey. adv physiol educ 2007;31:34-40. 14. burch vc. chapt 2. overview of medical education in south africa. in: burch vc. assessment practices in a developing country. doctoral dissertation at erasmus university rotterdam. 2007. isbn 978-0-620-38223-6. 15. ghosh s, pandya h. implementation of integrated learning program in neurosciences during first year of traditional medical course: perception of student and faculty. bmc medical education 2008;8:44-52. 16. dawsonsaunders b, feltovich pj, coulson rl, steward de. a survey of medical school teachers to identify basic biomedical concepts medical students should understand. acad med 1990;65:448-454. 17. bartoszeck ab. teaching medical physiology in brazil. adv physiol educ 1992;8:s12-s15. 18. lau y-t. problem-based learning in pharmacology: a survey of department heads in taiwan, china. acta pharmacol sin 2004;25:1239-1241. 19. ajp report. why do we teach physiology the way we do? an analysis of national characteristics. adv physiol educ 1998;19:s34-s45. 20. sefton aj. charting a global future for education in physiology. adv physiol educ 2005;29:189-193. 128 december 2012, vol. 4, no. 2 ajhpe article the bachelor of clinical medical practice (bcmp) is a new degree designed to create a new category of mid-level medical workers for south africa. it has been offered at the university of pretoria (up) since 2009. up produced its first 44 graduates in 2011. using the opportunity to innovate learning and teaching, the bcmp programme has also created an opportunity to design, monitor and evaluate the continual transformation of this curriculum through an action research-driven curriculum development approach. as scholars in health science and higher education, we are aware of being knowledgeable about our practice, because ‘if you really want to improve your own teaching, you must understand what that something is’.1 the practice of healthcare, health science and health education is multidimensional. as such, it requires a complementary theoretical framework where a number of theories intersect to address this complexity. in this curriculum, we integrate the concepts of authentic learning, whole-brain learning, selfdirected and self-regulated learning, as well as co-operative learning into a transformative educational model. to realise this conceptual framework, considerable emphasis is placed on facilitating learning and participatory action research. our approach is in keeping with the call made by the commission on education of health professionals for the 21st century for the education of health professionals to move into the ‘third-generation’ of educational reform. ‘all health professionals in all countries should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patientand population-centred health systems as members of locally responsive and globally connected teams.’2 they describe third-generation education reform as moving from informative to formative and then to transformative learning that results the clinical associate curriculum ‒ the learning theory underpinning the bcmp programme at the university of pretoria j f m hugo, j slabbert, j m louw, t s marcus, m bac, p h du toit, j e sandars department of family medicine, faculty of health science, university of pretoria j f m hugo, mb chb, mfammed, professor j m louw, mb chb, dtm&h, mmed (fam med), senior lecturer t s marcus, bsc (econ) (london school of economics, univ london), ma (univ of lodz, poland), phd sociology (univ of lodz, poland), extraordinary professor m bac, arts (rotterdam), mmed (fam med), md, senior lecturer department of humanities education, faculty of education, university of pretoria j slabbert, bsc (hons), bed, med, ded, thed, associate professor and senior lecuter p h du toit, ba, hed, ba (hons), bed, dti, med, phd, senior lecturer leeds institute of medical education, university of leeds, england j e sandars, mb chb, msc, md, frcgp, mrcp, certed, senior lecturer corresponding author: j f m hugo (jannie.hugo@up.ac.za) the bachelor of clinical medical practice (bcmp) is a new degree at the university of pretoria (up), designed to create a new category of mid-level medical workers, namely clinical associates. up produced its first 44 graduates in 2011. the bcmp created the opportunity to innovate learning and teaching through designing, monitoring and evaluating the transformation of the curriculum as action research. drawing on the theories and practices of authentic learning, self-directed learning, whole-brain learning and collaborative learning, the curriculum has been transformed. the potential of this curriculum extends beyond the formal education part of the programme ‒ into clinical associate practice, healthcare practice and, potentially, general medical and healthcare education. ajhpe 2012;4(2):128-131. doi:10.7196/ajhpe.188 article december 2012, vol. 4, no. 2 ajhpe 129 in the development of healthcare workers who are change agents, or in the case of our context agents of transformation. this transformation is for the new graduates to change the way they look at health and social care (in its widest sense) so that these healthcare processes can lead to improved quality of care, improved health outcomes and being responsive to local contexts ‒ not blindly applying evidence-based medicine out of context. moreover, through ‘novel forms of learning that transcend the classroom’2 this approach to education is expected to produce greater numbers of healthcare professionals who will be able to address the global crises in inequity and health worker shortage. such transformative curricula and pedagogy challenge us to look not only to knowledge, skills and competencies but also to the way of being. this requires attention to human qualities, which can be acquired through authentic learning.3,4 authenticity and education as learning takes place in a highly complex world, education needs to address the nature of knowledge (epistemology), how knowledge is applied (practice), new meaning constructed and the way of being (ontology) in education. authenticity distinguishes between an internal human environment (inner being) and outer influences and realities. authenticity and the way of being centre around identity. as a new profession clinical associate learners and practitioners constantly have to define for themselves and others who they are and what they do. the challenge of identity is central in the bcmp programme, for individual learners and the profession. below, we set out some of the key concepts that inform our understanding and approach to learning in the bcmp curriculum. authentic learning authentic learning is not about finding things but finding ourselves.5,6 in authentic learning being infuses doing, which promotes knowing as a process of constructing new meaning. for the bcmp curriculum this means that each learner creates his/her own understanding of the knowledge and skills needed for quality clinical practice and to deal with his/her own life and task as a clinical associate in the health team. in the bcmp curriculum the learners engage in patient care from the start of the course and it is through this practical engagement that they learn. components of authentic learning authentic learning requires whole-brain learning.7 whole-brain learning is one of an array of theories on learning styles.8 it draws from research on how thinking, learning, creating, solving problems, communicating, etc. happen in the brain. according to de boer et al.9 the left hemisphere of the brain is involved in logical, analytical, quantitative and rational thinking, while the right hemisphere deals with conceptual, holistic, intuitive, imaginative and non-verbal thinking. drawing from this understanding herrmann10 proposed a model of four quadrants where each quadrant relates to a complex of neural cortices, areas shown to be involved in thinking. while all four quadrants together form the thinking area of the brain, each quadrant has distinct clusters of cognitive functioning that play out differently in individuals. in other words, they give rise to differences in learning preferences and styles of facilitating learning between learners and between facilitators of learning that reflect specific brain functioning at an individual level. whole-brain learning is about the need for a variety of learning methods to accommodate these differences. since all varieties and combinations of these functions are present among any group of learners, facilitators of learning responsible for the design of learning opportunities need to acknowledge the particularity of individual learner learning preferences and plan flexible ways of facilitating learning. learning occurs within individuals and with and between other people and objects, i.e. it is both an individual and a social practice that extends beyond individuals to groups of people as a community of practice.11 authentic learning also involves co-operative learning, which starts from the assumption that ‘none of us is as smart as all of us’.12 co-operation is a central tenet of learning in the bcmp curriculum. this is both because it is a valued educational strategy and a critical part of the expected professional practice of clinical associates. they are expected to function in teams, under the supervision of medical practitioners while their position as mid-level clinicians, by definition, places them at the interface of different streams of professional thinking and makes them potential facilitators of interprofessional practice. co-operative learning occurs when learners help one another to learn, maximising their own and each other’s individual and collective potential. authentic learning is self-directed. drawing on the theory of self-regulated learning, it occurs when individuals become active participants in their own process of learning, making conscious use of learning strategies and techniques to ensure that their learning goals are achieved.13,14 in medical education, these essential skills of self-directed learning are required for success in academic and clinical contexts.14 self-directed learning is integrated in meta-learning and co-operative learning through the mechanism of facilitated learning that takes account of whole-brain learning. learning as multiple cycles all the abovementioned learning theories rely heavily on the concept of a learning cycle. self-directed learning is typically conceptualised as a cyclical process with before (or forethought), during (or performance), and after (or self-reflection) phases (see zimmerman13 for a social-cognitive perspective on self-regulation). similarly, co-operative learning involves group discussion of tasks and problems, identification of learning needs, active individual or group work, reflection and constructing of new meaning. authentic learning is also construed as cyclical in nature. according to slabbert et al.4 the authentic learning cycle starts with the learner’s immersion in a real-life experience, followed by a (self-directed or facilitated) reflection on the experience, that in turn leads to the construction of the meaning of the experience by the learner. the cycle ‘ends’ with an exploration of a new real-life experience, where the learner uses the preceding experience(s) to do something creatively new. 130 december 2012, vol. 4, no. 2 ajhpe article in the bcmp curriculum, learning is understood as multiple cycles of executing tasks at individual learner and group level as well as for the healthcare teams in which they work. meta-learning learning about learning or meta-learning is also a constant feature in all the abovementioned theories. meta-learning is higher-order, self-regulated authentic learning. it is the process by which individuals take control over and responsibility for their own learning. in whole-brain learning metalearning is the individual’s ‘voyage of discovery’, his/her journey to find out who he/she is, what he/she is capable of, and what meaning this has for his/ her life as a professional. in the bcmp curriculum, meta-learning is made visible and operational for both facilitators of learning and learners, so that it becomes a constant expectation of learning. facilitating learning from the above, it should be obvious that authentic learning, wholebrain learning, co-operative learning and self-directed learning cannot be taught by traditional teaching methods. the historical practice in formal medical education is that knowledge is first taught or learnt through, often passive, information-based acquisition and then gradually applied through exposure to the real-life situations of clinical practice. a different approach is required which is inside-out (learner to real life) rather than outside-in (lecturer to learner) with emphasis on learning to be rather than learning to know. in this paradigm, learning takes place through the activities of being, doing and knowing. in practice this means that the facilitator of learning needs to create learning opportunities that are meaningful and challenging. real-life experiences are key to facilitating learning and are often the starting point of learning. however, facilitating learning also needs to ensure that actual learning takes place, and that it is ongoing, progressive and cumulative. given established dominant practices, we recognise that it is extremely difficult for learners and facilitators of learning in the bcmp curriculum to radically redirect their practice towards facilitated learning that starts with ‘real life’. facilitating learning is itself ‘a unique professionalism with very distinctive characteristics regarding its purpose, functions, requirements, actions, and options. in fact, in a very concrete fashion and a significant sense, facilitating learning is the direct opposite of the concept of teaching.’4 the notion that facilitation is an integral and a necessary part of authentic learning means that it is an integral part of how the bcmp curriculum is constructed and practised. fig. 1. action research for innovation model.18 december 2012, vol. 4, no. 2 ajhpe 131 article facilitating self-directed learning for authentic learning is important, especially to ensure that learners set clear learning goals and opportunities to reflect on both what they have learned (outcomes) but also on how they have learned (process). this meta-learning about the process helps the learners to set new goals and new strategies to achieve these goals. action learning and action research as the purpose of the involvement of all participants in the bcmp programme (learners and lecturers alike) is professionalism, the principles of action learning15 are applied and form part of action research. in the bcmp curriculum learners and lecturers use action learning as a process that incorporates the same principles as self-directed learning.16 as a multidisciplinary team comprising health science and higher education specialists we aim to fully participate in educating professional clinical associates in a continuous fashion. we are enaged in various action researchrelated processes and activities, including workshops, meetings, peer mentoring and individual action research spirals. the innovative idea is that we try to apply the assumptions of the learning theories that we have brought together under the umbrella of authentic learning and professionalism to do action research on all aspects of the bcmp curriculum. this includes inter alia curriculum development, facilitating learning, assessment, learner learning and professional development of all academic staff involved. we consider our action research as constructivist learning (an epistemology stance that drives our research) and the entire intervention as forward looking and innovative. the complexity and uniqueness of our beliefs, experiences, values and virtues as participants in the bcmp curriculum are constructed as ‘a living learning’17 that serves as the theoretical framework for our professional learning. the asset-based action research model that we follow is depicted in the visual representation in fig. 1. the steps followed in this sequential, cyclic model (depicted by the thick line of the spiral in the middle) demonstrate the processes that we follow to develop our curriculum. the de-routing spirals, each with their own cycles, are included to indicate the complexity of the action research process. conclusion the bcmp programme creates a unique opportunity to systematically develop a curriculum through a facilitated learning paradigm that incorporates learning theories that are individually and collectively transformative, and to do this in a way that is action research informed. the potential of this curriculum extends beyond the formal education part of the programme into clinical associate practice, practice of the healthcare team and potentially medical and healthcare education more generally. it needs to match the transformative potential that the new profession of clinical associates promises for the healthcare system. it does not take away the many challenges that confront the bcmp programme and us as facilitators of learning, managers, learners and researchers. as individuals and professionals the success of this endeavour depends on our ability to participate deeply in the curriculum and practice. references 1. ramsden p. learning to teach in higher education. london: routledge, 1999. 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. education of health professionals for the 21st century: a global independent commission. lancet 2010;376(9756):1923-1958. 3. barnett r. the will to learn – being a student in the age of uncertainty. maidenhead: mcgraw-hill open university press, 2007. 4. slabbert ja, de kock dm, hattingh a. the brave ‘new’ world of education: creating a unique professionalism. cape town: juta and company, 2009. 5. purpel de, mclauren wm (jr). reflections on the moral and spiritual crisis in education. new york: peter lang, 2004. 6. ackoff r, greenberg dj. turning learning right side up: putting education back on track. upper saddle river, nj: wharton school publishing, 2008. 7. herrmann n. the creative brain. 2nd ed. usa: qubecor printing book group, 1995. 8. coffield f, moseley d, hall e, ecchelstone k. learning styles and pedagogy in post-16 learning: a systematic and critical review. london: learning and skills research centre, 2004. 9. de boer a, steyn t, du toit ph. a whole brain approach to teaching and learning in higher education. sajhe 2001;15(3):185-193. 10. herrmann n. the whole brain business book. new york: mcgraw hill, 1996. 11. boylan m. school classrooms: communities of practice or ecologies of practices? paper presented at the first socio-cultural theory in education, september 2005. manchester university, uk. 12. johnson dw, johnson rt. using cooperative learning in mathematics. in: davidson n, ed. cooperative learning in mathematics. san francisco, ca: addison wesley, 1990:103-125. 13. zimmerman bj. attaining self-regulation: a social-cognitive perspective. in: boekaerts m, pintrich p, zeidner m, eds. handbook of selfregulation. orlando, fl: academic press, 2000:13-39. 14. sandars j, cleary tj. self-regulation theory: applications to medical education: amee guide no. 58. med teach 2011;33(11):875-886. 15. teare r, prestoungrange g. revans university – the university of action learning: accrediting managers at work in the 21st century. scottland: prestoungrange university press, 2004. 16. zuber-skerritt o. a generic model for action learning and research programs within organizations. alarj 2000;5(1):41-50. 17. mcniff j, whitehead j. all you need to know about action research. london: sage publications, 2006. 18. du toit ph. multidissiplinêre samewerking: ‘n noodsaaklikheid vir onderwysinnovering.  journal of humanities 2012;52(2):236-251. 112 december 2012, vol. 4, no. 2 ajhpe article over the past two decades, imaging in diagnostic radiography has experienced rapid advances in computer technology. these advances also apply to specialised imaging such as magnetic resonance imaging (mri), computed tomography (ct), vascular interventional angiography (via) and mammography. specialised imaging demands a high level of knowledge and skills since radiographers have to operate state-of-the-art, computerised imaging technology and interpret complex anatomical structures. these advances have increased the diversity of imaging examinations and associated imaging technologies and resulted in many radiographers being required to extend their individual scope of practice.1 the introduction of educational programmes on a postgraduate level offering specialised training will contribute to the vision of many south african (sa) universities of technology to be globally connected institutions focusing on the needs of southern african and african students to support graduates with skills and competencies in appropriate technologies.2 the offering of further education in specialised imaging will also benefit other southern african countries such as botswana, namibia, zambia and malawi, also called the southern african development community (sadec) countries, as there are an increasing number of students applying at sa universities for further study, having acquired an undergraduate qualification in their own country. through appropriate education and training, value will be added to lifelong learning in the workplace to the benefit of the employer and the community at large. diagnostic radiographers will thus have the opportunity to work towards a postgraduate qualification in the specialised fields of diagnostic radiography and not only in general diagnostic radiography. the aim of the research was to survey qualified diagnostic radiographers (with a qualification in general diagnostic radiography) at the central university of technology, free state (cut) in bloemfontein, sa, to assess whether there is a need for a postgraduate learning programme in the specialised fields of diagnostic radiography. aspects included in the investigation were the need for diversification into specialisation field training, the structure and preferred modules to be included in a postgraduate learning programme and the mode of delivery preferred by the radiographers for such a postgraduate programme. also investigated was the importance of role extension for future training purposes, and the desire among employers in the region to employ diagnostic radiographers with a formal postgraduate qualification in specialised imaging. the following section contextualises the need for further training as supported by the literature and elaborates in more detail the methodology followed to a postgraduate qualification in the specialisation fields of diagnostic radiography: a needs assessment j du plessis, h friedrich-nel, f van tonder radiography, faculty of health and environmental sciences, central university of technology, bloemfontein j du plessis, brad hons, mahes h friedrich-nel, mrad, phd hpe higher education studies, university of the free state, bloemfontein f van tonder, ba (hons), med, phd (didactic/curriculum studies) corresponding author: j du plessis (duplesj@cut.ac.za) introduction. current education and training in radiography in south africa does not address the need for training in the specialisation fields of diagnostic radiography sufficiently. methods. to address this problem, a needs assessment was conducted by means of quantitative questionnaires, qualitative interviews and a focus group discussion. the main aim of the needs assessment was to determine the need for a postgraduate qualification in the specialised fields of radiography. the possible structure of such a programme and the preferred mode of delivery were also investigated. results. the results of the study emphasise the need for structured postgraduate programmes in the different specialisation fields of diagnostic radiography. conclusion. responding to this validated need for postgraduate qualifications in the specialisation fields in the profession, recommendations are made towards the development of such postgraduate programmes in the higher education framework in south africa, promulgated in 2007. ajhpe 2012;4(2):112-117. doi:10.7196/ajhpe.160 december 2012, vol. 4, no. 2 ajhpe 113 article accumulate the data. this is followed by a summary of the results, a brief discussion on the findings and recommendations for future implementation. conceptual framework in many countries the development of the role of the radiographer by acquiring postgraduate qualifications in specialised imaging has slowly progressed since the late 1980s. currently it is common practice for radiographers in countries such as the united kingdom (uk) and the united states of america (usa) to report on examinations such as barium studies, screening mammography studies and injuries of the skeletal system after having acquired a postgraduate qualification in pattern recognition. this development has been heavily directed, within both the clinical and academic environments, by radiologists acting as clinical teachers, mentors and advisors to academic course design and assessment.3 in sa, radiography training is currently offered at two traditional universities and seven universities of technology (uots) in conjunction with hospitals where students do their work-integrated learning (wil) (experiential learning). undergraduate education and training in diagnostic radiography at the uots is currently a three-year diploma qualification (at level 6 of the south african qualifications authority (saqa)). this undergraduate qualification is structured to include all basic aspects of general diagnostic imaging. it also includes a substantial wil component to gain competencies and skills in all general diagnostic procedures.4 most uots also offer a btech degree in diagnostic radiography, radiation therapy and nuclear medicine (at level 7 of saqa). the btech degree in diagnostic radiography is structured for the student to acquire knowledge and skills in research methodology, management principles and practice and general diagnostic imaging procedures. the degree does not include any modules focusing on education and training in the specialisation fields such as mri, ct, via or mammography and is thus presented as a general diagnostic qualification.4 however, some uots offer training in ultrasound at btech level. the cape peninsula university of technology (cput) is currently the only institution offering a qualification in mri, this only over the past few years. a ct course was started in 2006 at cput.5 these two courses are not offered at btech level but are accredited with the health professions council of sa (hpcsa). in contrast, many institutions abroad offer postgraduate training in the specialised fields of diagnostic radiography. the confederation college in ontario, canada, offers a comprehensive two-and-a-half-year undergraduate programme, which prepares radiographers for entry into the profession. in addition, this college provides graduates with postgraduate opportunities to specialise in ultrasound, mri and ct.6 the college of radiographers in the uk7 offers a variety of postgraduate qualifications, up to doctorate level, in the specialisation fields of diagnostic radiography. curtin university of technology in perth, australia8 presents a postgraduate course up to master’s level that extends the range of career options available for radiographers. this qualification provides an opportunity for senior positions in radiology departments to be awarded to radiographers who are able to demonstrate proven specialised academic and practical abilities. a range of options is available to prospective students to cater for the variety of specialised categories (ultrasound, nuclear medicine) and specialisation fields (ct and mri). the university of australia in sydney presents a postgraduate course that aims to advance the knowledge, skills and attributes of medical radiation professionals in their field of specialisation. prospective students choose from ct, mri, advanced nuclear medicine, advanced radiation therapy, breast imaging, clinical studies, bone mineral densitometry and radiographic image interpretation (pattern recognition).9 midwestern state university in the usa offers a discipline-specific master’s degree in radiologic science (msrs) with options for specialisation in ct and mri.10 the university of teeside in the uk11 presents a postgraduate course which includes radiographic studies and covers also contemporary issues in health and social care, vulnerable client groups, advanced imaging modalities such as ct, mri, ultrasound and digital imaging technology, and research methodology. the aforementioned training possibilities are only some of a wide variety available at training institutions for radiography abroad. in contrast, the current national curriculum, approved and accredited by the hpcsa and saqa, offers master’s-level qualifications only in the form of a dissertation, in all the categories of radiography, as an exhaustive search of the web pages of training institutions in sa indicated.12 no accredited, structured postgraduate qualification in the specialised fields could be found. research methodology a needs assessment was undertaken accumulating data by means of a quantitative questionnaire, qualitative interviews and a focus group discussion. the questionnaire was designed to evaluate current practices, knowledge and skills in the specialised fields of diagnostic radiography among diagnostic radiographers and to set these against an assessment of the education that is needed to meet current and forthcoming professional demands. the questionnaire consisted mainly of closed questions; a few open-ended questions were included. an interview guide was compiled for the personal interviews (radiographers and employers) and the focus group discussion, following analysis of the questionnaire results. the main aim of the few open-ended questions and of the questions set for the interviews and the focus group discussion was to support or clarify replies from the respondents to the questionnaires. the questionnaire was pilottested by participants who had a formal qualification in general diagnostic radiography; radiographers participating in the pilot study did not receive the final questionnaire. study participants the study was limited to diagnostic radiographers currently employed in bloemfontein and kimberley, including those in both the public and private sectors. assistant radiographers (supplementary radiographers) were excluded from the research as their qualification level was unsuitable to access a postgraduate qualification. qualified diagnostic radiographers currently doing their compulsory community service were included in the research. the names and contact numbers of 129 radiographers were obtained. after elimination of the assistant radiographers, a total of 120 diagnostic radiographers were included. four employers and 10 diagnostic radiographers were selected to be interviewed. participants for the focus group discussion were purposefully selected by the researcher, and 114 december 2012, vol. 4, no. 2 ajhpe article included three lecturers in the programme radiography at cut, and four chief radiographers who were involved on a regular basis in the ‘hands-on’ training of diagnostic radiographers in the specialisation fields. data analysis the researcher coded the questionnaire data, appropriate questions were grouped together and data were entered into microsoft excel. open-ended questions were summarised using a thematic approach. the interviews and focus group discussion were recorded, transcribed and summarised. results summaries from the results were used to describe the demographic data of the respondents, the profile of the organisations within which the respondents were employed, the position of the respondents in the organisations, the educational and professional background of the respondents, and respondents’ perceived needs for further education in the specialisation fields of diagnostic radiography. of 54 radiographers in private practice, 22 responded (40.7%) while 41 of 66 (62%) practitioners in the public service responded, giving an overall response rate of 53.4%. the majority of the respondents (62.5%) were in possession of a three-year national diploma in diagnostic radiography (fig. 1). the highest level of educational achievement among the respondents was an honours or btech degree in diagnostic radiography (7.9%). only 6 (9.4%) of the respondents indicated that they were involved in further studies. all radiographers who indicated that they were engaged in further studies (9.4%) are currently enrolled for a btech degree in diagnostic radiography. only two of the ten radiographers who participated in the interviews are currently enrolled for further study and none of the four chief radiographers participating in the focus group was enrolled for further study. the lack of motivation to enrol for further study among radiographers participating in the interviews and in the focus group discussion can be summarised as follows: ‘the limited promotion opportunities in the profession, as it is currently structured, together with the lack of acknowledgement through better remuneration are the main impacting factors on the reluctance of radiographers to enrol for further studies. also impacting negatively on radiographers’ motivation to study further, is the employers’ reluctance to allow radiographers to take study leave to attend classes.’ however, personal interviews with the four employers suggested that wrong perceptions may exist among the radiography workforce in the free state and northern cape region. three employers indicated a willingness to offer a radiographer higher remuneration if the radiographer could handle more responsibilities as a result of an additional qualification. employers stated that they were in need of highly trained radiographers who could be trusted to successfully handle difficult examinations in general radiography and especially in the specialised imaging modalities. the shortage of radiologists in our country, which was confirmed in the interviews with the four employers, seems to be the main motivating factor. only one of the employers was not particularly interested in employing radiographers with further qualifications; this employer, by implication, gave high priority to the financial aspect of the practice. the four employers indicated staff shortages as the major reason for their unwillingness to relieve staff from work to attend classes. they indicated that any radiographer absent from duty in order to attend classes had a huge impact on service delivery and patient throughput. this inevitably impacts heavily on the business financially, especially in the private sector. however, all four employers indicated recognition of the value of a properly trained staff member who would be able to handle additional responsibilities successfully and a willingness to allow study leave on condition that not too many staff members applied for it at the same time. an unexpected constraint to further study, which was not addressed in the questionnaire, surfaced during the interviews with the 10 selected radiographers and was confirmed by all the participants in the focus group discussion. this was the lack of real initiatives by the cut to develop courses for radiographers for further study. the results depicted in fig. 2 confirm that only 5% of the respondents had received additional academic education (aae) in one or more of the specialisation fields. the vast majority of radiographers in the study received additional training from a product specialist (pps) and/or a senior radiographer (psr) (fig. 2). in the questionnaire survey, 17% of the respondents indicated that they had attended some workshops or seminars fig. 1. percentages of current qualifications of the respondents. fig. 2. percentages of the type of training received in the specialisation fields. aae = additional academic education; pps = professional training by a product specialist; psr = professional training by a senior radiographer; aws = attendance of workshops and seminars. december 2012, vol. 4, no. 2 ajhpe 115 article to upgrade their knowledge and skills for working in the specialisation fields. only 2% indicated that they had received other training in the specialisation fields, but did not specify the type of training. training in the specialisation fields by a psr and/or pps was confirmed by all the participants (10) in the interviews, who also indicated that they had had to wait 4 5 years before being trained, since seniority at the institution earned preference. this waiting period was confirmed and explained in the focus group discussion by the chief radiographers responsible for the training in the specialisation fields. according to these radiographers it is difficult to train more than one person at the same time in any of the specialisation fields due to the complexity of all interlinked aspects that must be addressed during training. as can be seen from fig. 3, 73% of the respondents preferred both academic education (ae) and professional education (pe) in the specialisation fields of diagnostic radiography. three per cent of the respondents indicated that they prefer academic education only and 2% indicated that they prefer no education. during the personal interviews, the respondents indicated that their major reason for a preference for both ae and pe was the fact that radiography is a profession with a strong wil (experiential learning) component. without the necessary skills and competencies (contextual knowledge) to perform an examination, all the conceptual knowledge (attained via ae) would be worthless − the only worthwhile way to learn a skill is to apply contextual knowledge in practice (attained by pe). fig. 4 indicates that the bulk of the respondents (91%) opted for either part-time study (50%) or a blended learning model (41%). only 3% of the respondents opted for full-time study and 6% for a distance-learning model. to clarify the educational concepts to the radiographers in clinical practice, the terms ‘part-time study’, ‘blended learning’ and ‘distance learning’ were explained as follows: • part-time study applies to students who are employed full-time as radiographers and can attend classes only outside working hours, implying that the course is presented over a 2-year period instead of 1 year • blended learning suggests that a variety of learning facilitation tools will be utilised such as formal classes (lectures), internet-supported activities, electronic discussion forums, etc. • distance learning indicates that students never have to attend classes since all learning material, including assessment, is delivered and managed electronically (internet, etc.). all participants in the interviews and focus group discussion opted for a blended learning model. the reason for their choice was that all of them were permanently employed diagnostic radiographers and most were married with families who depended on their income. therefore, the only possible way for them to engage in further studies would be on a part-time basis. this explains the 50% vote for part-time study and the 41% vote for a blended learning model found quantitatively (fig. 4). as can be seen from the pie graph (fig. 5), 83% of the respondents preferred a higher education qualification structured into different modules. only 17% of the respondents opted for a purely research-based qualification on a master’s level. personal interviews with the 10 selected radiographers confirmed a choice of modules (electives), e.g. a year-long module respectively for two of the four specialisation fields (mri, ct, via and mammography). they however agreed that the research dissertation should be compulsory for a master’s degree qualification. the use of both a quantitative and qualitative mode of inquiry proved to be particularly valuable in the research reported here. uncertainties from the questionnaire results were generally clarified and validated in the interviews and focus group discussion with the radiographers and the employers. conclusions and recommendations regarding the way forward for a postgraduate learning programme in the specialisation fields in diagnostic radiography at the cut are portrayed in the following section. fig. 3. percentages of educational preferences in the specialisation fields. ae = academic education; pe = professional education. fig. 4. percentages for preferred mode of delivery. ft = full-time study; pt = part-time study; bl = blended learning; dl = distance learning. fig. 5. preferred structure of a future higher education programme. rheq = research higher education qualification; sheq = structured higher education qualification. 116 december 2012, vol. 4, no. 2 ajhpe article discussion and recommendations the main aim of the research was to assess whether there is a need for a postgraduate programme in the specialisation fields of diagnostic radiography in the free state and northern cape region of sa. from the literature it became apparent that such postgraduate training programmes are not widely offered by training institutions in sa, and in this study we established that all participating radiographers received only ‘hands-on’ training by a product specialist or a senior radiographer in the specialised modalities of radiography. unfortunately the questionnaire did not make provision for gathering more information regarding the type of ‘hands-on’ training or the institution where training was achieved. this might be considered a limitation in the questionnaire. at undergraduate level, the student is furnished with a broad overview of the relevant factors that render students competent to practise general radiography. however, rapid advances in technology have stimulated an increasing realisation that, to be effective and competent in practice, radiographers need to pursue some form of postgraduate specialisation to stay abreast and to deliver quality imaging to their patients. results from the quantitative survey, as well as comments from the qualitative part of the survey, were generally in favour of postgraduate training in the specialisation fields of diagnostic radiography. in light of the recognition to obtain further training, the low educational achievement among diagnostic radiographers was explored in the interviews and focus group discussions. from the discussions it was clear that this situation can partly be ascribed to the lack of postgraduate educational opportunities in the region. in addition, significant constraints curtailing further training included staff shortages and the lack of rewards or incentives. the participants in the research sample firmly expressed their need for acknowledgement of achievement of further qualifications. the vast majority of participants opted for a structured qualification instead of a purely research-based qualification. these participants stated that they would like to have the option to study in the specialisation field/s of their choice. the participants also added their views on the preferred modules for a future programme. it was furthermore considered important by the participants in the interviews that wil (experiential learning) be part of any postgraduate higher education programme. based on the results of the research the authors would like to suggest a number of recommendations that should be considered when planning provision of future higher education programmes in diagnostic radiography at the cut: • both academic and professional training should form part of a future higher education programme (as indicated by 73% of the participants (fig. 3)). such a programme should be structured with a formal academic component (conceptualisation of knowledge) and a component to monitor the achievement of skills and capabilities (contextualisation of knowledge) in clinical practice. a portfolio of evidence might be feasible to assess the attainment of practical competencies and skills in specialised imaging. • a future higher education programme should be structured with regular contact sessions (perhaps one per term), after which the student should work independently on assigned projects and the development of skills and competencies. all learning material should be available online and electronic learning and assessment should be actively utilised. • since the majority of the participants (62.5%) in this study are in possession of a national diploma in radiography (level 6 on the higher education qualifications framework (heqf)) with only 7.9% in possession of a btech degree (level 7 on the heqf), the following is recommended when planning provision of future higher education programmes in diagnostic radiography at the cut: • an advanced diploma (level 7 on the heqf)13 in the specialisation fields as a stepping stone (progression) for radiographers in possession of a national diploma qualification (level 6 on the previous heqf). according to the heqf13 this qualification would offer an intensive, focused and applied specialisation which meets the requirements of a specific niche in the labour market, in this case the specialisation fields in radiography. programmes offering this qualification would provide an advanced diploma graduate with a deep and systematic understanding of current thinking, practice, theory and methodology in an area of specialisation. it is therefore particularly suitable for continuing professional development. • a postgraduate diploma (level 8 on the heqf)13 in the specialisation fields to allow for vertical progression of radiographers in possession of a btech degree (level 7 on the previous heqf) and those who aspire to obtain a master’s qualification in radiography. the heqf13 designates this qualification for working professionals who wish to undertake advanced reflection and development by means of a systematic survey of current thinking, practice and research methods in an area of specialisation, in this case the specialisation fields in radiography. this qualification would demand a high level of theoretical engagement and intellectual independence. a sustained research project is not required, but the qualification might include conducting and reporting research under supervision. • a master’s degree (level 9 on the heqf).13 as the majority of the respondents in this study (83%, fig. 5) chose a structured master’s qualification, the proposed master’s programme could comprise a coursework programme (modules), requiring a high level of theoretical engagement and intellectual independence, and a research project, culminating in presentation of a dissertation. in the latter case, a minimum of 60 credits (of the 180 credits) at level 9 of the new heqf would be devoted to conducting and reporting research.13 a number of electives could be offered at the discretion of the provider, depending on the number of credits allocated for each elective. a higher certificate (level 5 on the heqf)13 and an advanced certificate (level 6 on the heqf)13 qualification are not recommended for radiographers with a national diploma or btech degree qualification, who aspire to progress vertically on their career path, as these two qualifications are respectively pegged at a lower (higher certificate) level than the current national diploma (level 6) and a level lower (advanced certificate) than the current btech degree (level 7). the main limitation to this research is the inclusion of only a part of the radiography profession in sa (free state and northern cape region) in the needs assessment. however, the possibility of attaining a postgraduate qualification was deemed by the majority of participating respondents as december 2012, vol. 4, no. 2 ajhpe 117 article necessary for progress in their own careers, as well as for the status of the profession as a whole. furthermore, most participants in the qualitative section of the research were of the opinion that the study material and mode of delivery, if chosen with careful consideration, could be beneficial to their knowledge base and could help with the improvement of the quality of radiography services in sa and the sadec countries to the community at large. responding to the needs identified in this research, the current research-based master’s degree qualification might be effectively adjusted to accommodate our findings and therefore include options for specialisation in diagnostic radiography. references 1. hardy m, snaith b. role extension and role advancement – is there a difference? a discussion paper. radiography 2006;12(4):327-331. 2. cut (central university of technology, free state). mission and vision statement, 2010. 3. prime nj, paterson am, henderson pi. the development of a curriculum – a case study of six centres providing courses in radiographic reporting. radiography 1999;5:63-70. 4. cut (central university of technology, free state). calendar: chapter 21:345,357,359. http://www.cut.ac.za/ web/mission (accessed 25 april 2010).speelman a. discussion at the 24th international radiology congress. cape town: south africa, 12-16 september 2006. 5. confederation college, thunder bay, ontario, canada, 2009. http://www.confederationc.on.ca/medicalradiation/ calendar/default.asp (accessed 12 april 2009). 6. the college of radiographers. directory of post-graduate courses. london, united kingdom, 2009. http://www. sor.org/public/pdf/post-graduate_directory07.pdf (accessed 3 may 2009). 7. curtin university of technology. perth, australia, 2008. http://handbook.curtin.edu.au/courses/18/185507.html (accessed 7 may 2008). 8. the university of australia. sydney, australia, 2009. http://www.usyd.edu.au (accessed 7 may 2009). 9. midwestern state university. department radiologic science. witchita falls, texas, 2009. http://hs2.mwsu.edu/ radsci/index.asp (accessed 4 may 2009). 10. university of teeside. school of health sciences. teeside, united kingdom, 2009. http://www.tees.ac.uk/ postgraduate_courses/health_&_social_care/pgdip_msc_diagnostic_radiography_(pre-registration).cfm (accessed 5 may 2009). 11. saqa (south african qualifications authority). http://regqs.saqa.org.za/search.php (accessed 5 november 2009). 12. heqf (higher education qualifications framework). government gazette, 30353, 5 october 2007. research november 2015, vol. 7, no. 2 ajhpe 187 ethics in healthcare is an important determinant of the professional out comes for occupational therapists' daily professional practice.[1] the health professions council of south africa (hpcsa) places great emphasis on ethical behaviour towards clients and expects registered professionals to act accordingly.[2] occupational therapy (ot) students are expected to work in a variety of contexts and they experience many sources of conflict in their fieldwork practice on a daily basis, while at the same time upholding professional values, responsibilities and duties. this conflict results in ethical dilemmas, such as when an individual faces two or more equally stressful alternatives that are mutually exclusive.[3] according to pauly et al.,[1] moral conflict is closely associated with the ethical dimensions of practice. in accordance with the occupational therapy professional board’s minimum standards for the training of occupational therapists, the curricula should include ethics as part of the undergraduate training programme.[4] research indicates that ot students are mostly aware of the correct course of action, but often feel constrained to act in another way as a result of institutional and/or societal rules.[5] ethics training strives to facilitate critical thinking, objective analysis and clinical reasoning skills to equip students with the ability to make an impartial and unbiased decision in different contexts and diverse client populations, which enhances students’ learning experiences.[6] ethical training is guided by a consequential framework, where the outcome should guide the behaviour of clinicians, or a rule-based (deontological) approach, where rules (i.e. codes of ethics) should guide the conduct of a professional. according to the hpcsa’s sub-committee, ethics training should focus on a careful and systematic reflection of the analysis of moral discussions and behaviour in the healthcare environment,[1] which is a hybrid between the aforementioned approaches. metz[7] makes an interesting statement by arguing that ‘… [t]oday’s dilemmas make tomorrow’s rules’. as ethics evolves over time, the challenges currently faced by professionals and the decisions they make accordingly, become the standard of future practice. therefore, it is imperative for healthcare educators to understand the issues students face in their everyday fieldwork practice and equip them to deal with these ethical issues. objectives the objective of this research was to determine the issues that students face in their fieldwork practice and address these in an ethical manner. methods as the aim of the study was to hear the voice of the student, it was decided to use qualitative methodology, where the focus is not on refining any hypothesis, but on a narrative investigation into the field of experience of the research participants. a non-probability sampling technique was used by interviewing a cohort of 30 final-year ot students from a university in south africa (sa). as this study is exploratory, purposive sampling was employed, where certain individuals with specific experiences were identified.[3] the inclusion criteria were the following: english speaking; ot final-year student; student registration with the hpcsa; registration at a sa university. data were collected using an open-ended questionnaire. no individual was coerced into completing the questionnaire and all students were assured that they could leave the study at any time. anonymity was ensured – no personal identifiers were recorded (i.e. name, surname or student number). the study protocol received ethics approval. as the aim of qualitative research is not to make a statistical generalisation to any population beyond the sample surveyed, no control group was background. ethics training strives to facilitate critical thinking, objective analysis and clinical reasoning skills to equip students with the ability to make an impartial and unbiased decision in different contexts and diverse client populations. this enhances students’ learning experiences. occupational therapy (ot) students are expected to work in a variety of contexts. they experience many sources of conflict in their fieldwork practice on a daily basis, while at the same time upholding professional values, responsibilities and duties. objectives. to determine the issues that students face in their fieldwork practice and address these in an ethical manner. methods. qualitative research was done among fourth-year ot students by means of an open-ended questionnaire. results. three major themes relevant to ethical issues were identified: professional-student relationship; professional boundaries; and disclosure of information and keeping information confidential. conclusion. the salient themes identified reflect the primary ethical tensions in the international literature from the uk and canada, but little evidence has been reported from south africa. taking cognizance of this, those who are involved in the training of healthcare professionals should incorporate the identified issues in the class discussions. for many students their fieldwork practice may be their first experience with some of the aforementioned issues. alluding to these in a safe environment (class situation) and equipping the students with a framework of analysis are very important. afr j health professions educ 2015;7(2):187-189. doi:10.7196/ajhpe.396 ethical dilemmas experienced by occupational therapy students – the reality n nortjé,1 dphil; j de jongh,2 phd 1 department of dietetics, faculty of community and health sciences, university of the western cape, bellville, south africa 2 department of occupational therapy, faculty of community and health sciences, university of the western cape, bellville, south africa corresponding author: n nortjé (nnortje@uwc.ac.za) research 188 november 2015, vol. 7, no. 2 ajhpe included in the study. the reliability or consistency of the data analysis in qualitative research is an evolving process, and the interpretation thereof can differ vastly.[7] the authenticity of the data is very important, which refers to the concept that a fair, honest and balanced account of social life − from the viewpoint of someone who lives through it daily[8] − has been given. qualitative data analysis is generally based on organising the data into categories based on themes and coding the latter to derive salient themes. this is achieved by organising the data into categories by using themes and concepts. in this study, the participants’ answers were coded using an opencoding technique, where general themes were identified and each answer was coded accordingly. once the first round of coding was complete, a second round was conducted, i.e. axial coding. during this phase, the researchers organised the themes and coded each into subthemes to ascertain whether or not there were any relationships between subthemes from the initial opencoded themes. once all subtheme relationships were identified, a final round of coding took place, whereby selective coding was performed and salient themes were identified, together with any subtheme relationships. these, as well as the final salient themes, are presented in the results section. results this section reports on the most significant themes identified after the data were analysed by applying the methodology discussed above. three major themes relevant to ethical issues were identified and are presented below to give voice to the students and illustrate the meaning. professional-student relationship for many students an ethical dilemma occurs when they are unsure how to approach a situation where they disagree with a qualified ot with regard to an alternative form of therapy they believe is in the best interest of the client. students often feel that they do not have the authority to approach a senior staff member (or report them in severe cases) and cannot question the behaviour of qualified therapists, as it could possibly cause tension and even impact negatively on their results/reports. one student observed: ‘while doing practical i built up good interpersonal relationships with the staff and clients. however, just before mid-practical evaluation, my supervisor called me in to discuss a complaint that she has received from the clinician at the placement. the clinician asked the supervisor to inform me that i was not behaving in a professional manner (i was too friendly with the clients) and that i needed to tone down my friendliness. this was discouraging and impacted negatively on my group sessions. i had difficulty to decide whether to be true to myself and behave the way i did initially in order to maintain good interpersonal relationships with the group members and ensure effective intervention or do what the clinician said in order not to be marked down on professional behaviour.’ professional boundaries being in a caring profession, where students frequently are confronted with the vulnerabilities of clients, it is often difficult to distinguish between professional and unprofessional behaviour. furthermore, because the student often also engages with clients on a personal level, the latter feel they can trust the students and will often share information that could be deemed as outside the scope of practice. this conduct is in itself not commendable, as it contravenes the boundaries of a professional therapeutic relationship. however, as students are still learning about these boundaries, they are often hesitant to be firm because they are afraid it would impact negatively on their relationship, resulting in clients taking advantage of them. the following is an example of such an issue, as highlighted by a student: ‘during fieldwork i was required to build relationships with clients. i was able to build extremely good interpersonal relationships with all my clients however with one of my clients it became uncomfortable. he asked me if i could bring him dvds to watch as it was boring at the rehabilitation centre. i did so and we built up a good relationship with each other, however he kept asking me to bring him things such as food. i knew that i needed to draw the line, but was cautious as it would affect our relationship with each other.’ disclosure of information and keeping information confidential students are often in despair as they are not sure what to do with confidential information that other members of the multidisciplinary team have shared with them. the following illustrates the issue: ‘during my placement at a school there was one particular teacher that i worked closely with as i saw individual clients from her class as well as ran groups with the learners. often the teacher would speak about the learners in an inappropriate manner, making fun of them, openly disclosing information or just speaking about them in a negative manner. it was difficult for me to know what to do.’ furthermore, the students are uncomfortable with the places where and manner in which the information-sharing happens – often in non-private settings such as hallways or classrooms. most students are aware of their duty to protect client confidentiality, and often witness how other members of the healthcare professions team show a lack of respect for client confidentiality. ‘as i worked in a multidisciplinary team at a drug rehab centre a nurse (whose consulting rooms were next to my office) was seeing one of the clients and she was scolding her about having a sexually transmitted infection (sti) and that she should not be having sex because she is still a minor. the nurse also accused the client of “sleeping around” and stated that it was the reason why she had the sti. unfortunately, the nurse did not close the door while she was speaking to the client and almost all of the male clients at the rehabilitation centre, who were coming from a group session with the counsellor, had heard the nurse disclose this client’s illness and because she did not close the door, the male clients were also able to see who the client was – therefore putting her at risk. this made me feel uncomfortable as i was unsure how to handle the situation.’ discussion the salient themes identified by this study echo the primary ethical tensions seen in the international literature from the uk and canada,[9,10] but little evidence has been reported from sa. this discussion adopts a critically reflective position to contemplate the described experiences of students in light of peers from the uk and canada and to participate in a discussion about the consequences for professional practice, educational reforms, and policy issues. the findings highlight the salient themes of ethical dilemmas that ot students face during fieldwork practice. these ethical issues will be employed to inform a framework that could be used to assist them in their ethical reasoning process. the aim of any framework is to create critical thinking, where nothing should be taken for granted; instead, the practitioner should ask critical questions about conventions, opinions and sentiments and ultimately be aware of incorrect reasoning that could influence the practitioner in accepting positions that are not supported by analytical arguments and evidence. research november 2015, vol. 7, no. 2 ajhpe 189 professional-student relationship for most of the students conflict arose when there was a difference of opinion that contributed to moral differences. the sensitivity of the students towards the issue could be the result of the ethics training that they received.they consequently know what to expect of the different role players in the therapeutic setting. moral differences are often difficult for students to understand as they might not have had exposure per se to similar circumstances to ascertain the correct way to behave in such situations. in an attempt to address this, we draw on the work of immanuel kant, who developed the obligation-based theory in which he argues that one should rest one’s moral judgements on reasons that also apply to others who are similarly positioned.[11] therefore, the ability to make a moral decision should be guided by a combination of practical reasoning (experience) and pure reasoning (not having had any experience). however, the act should be guided by what kant calls a universal maxim/imperative, which states that one’s behaviour in a situation should be of such a manner that, should it become universally applicable, it would be to the benefit of humanity at large.[12] the focus of deontology is not the end result of an action, but rather whether the action itself is morally acceptable. through applying this framework, the students should soon realise that what is good is not always right and what is bad is not always wrong. being able to take this metaposition will enable students to deal with issues of conflicting value systems. when students feel that the opinion of their senior is not morally justifiable (applying kant’s universal maxim) they should report the behaviour, even though the outcome could potentially be negative. professional boundaries allan[13] defines a boundary as ‘an imaginary line between behaviour that is generally appropriate when a therapist acts in a professional capacity, and behaviour that is not’. similar to kant’s assertion that experience is a guiding factor in moral behaviour, the same applies to setting boundaries. as boundary setting is very subjective and influenced by factors such as public morality, professional standards and culture, a feeling of unease will develop with a young practitioner if his/her boundaries have been crossed. the hpcsa’s guidelines assist practitioners in drawing boundaries by advising who should not be treated (i.e. family members, friends, people bringing gifts). the setting of boundaries assists the young practitioner to conduct therapy professionally, creates safe environments for clients and sets parameters within which services are delivered. the primary concern in establishing and managing boundaries with clients must be in the best interests of the client. students should be careful not to disclose too much personal information (e.g. personal cell phone number); self-disclosure should be well considered and the motivation of such disclosure should be well examined. another important aspect of drawing boundaries is guided by the clothing a practitioner wears. research indicates that a person’s clothing may convey a very powerful symbolic message.[14] as a general guiding rule, clothing should be neat but conservative and always take the work environment into account. confidentiality there seem to be inconsistencies in the students’ understanding of privacy and confidentiality. although the two are very closely linked, there are distinct differences. privacy refers to the notion of access to others, whereas confidentiality is restricted to information, how it relates to accessing such information and how it is applied.[15] confidentiality is not only an ethical principle, as enshrined in the principle of respect of autonomy,[12] but is also addressed by the hpcsa’s guidelines for good practice in the health care professions.[16] brody[17] argues that confidentiality is central to preserving the human dignity of clients and that patient autonomy (concept of self-rule, where clients are informed) should always be considered. therefore, it is unethical for members of the healthcare team to discuss clients’ information outside a clinical setting; they should refrain from doing so. strengths and limitations the strengths of this study include the importance and veracity of actual accounts of students’ ethical experiences, the extent to which similar themes occurred among the participants, and the possibilities that the study opens for further research and education. limitations of this study include the limited generalisation of the results and the geographical representation of the participants, as the research was conducted only at one institution in sa. conclusion and recommendations this article highlights the complex ethical dynamics that students experienced in fieldwork practice. they were taught some basic ethics, which might have sensitised them to the issues identified above. taking cognizance of this, those who are involved in the training of healthcare professionals should incorporate the identified issues in class discussions. for many students, their fieldwork practice may be their first experience with many of the abovementioned issues. alluding to these in a safe environment (class situation) and equipping the students with a framework of analysis are very important. once the students have the ability to objectively remove themselves from a specific situation and realise that the focus of the case should not be themselves but rather the patients/ clients and the benefit of the latter, then only will they be able to apply their critical thinking abilities. formal classroom time should be spent on creating critical thinking abilities, simulating as many situations as possible and alluding to the difference in people’s ethical and moral reasoning abilities, which should be taken into consideration when applying the skills the students are taught. furthermore, educators should realise the importance of listening to the voice of the students and learn from the students’ experiences as they inform where there is a need to address certain issues. collaboratively, this could contribute to the quality of ethics education and services rendered by healthcare professionals. references 1. pauly bm, varcoe c, storch j. framing the issues: moral distress in health care. hec forum 2012;24:1-11. 2. health professions council of south africa (hpcsa). proposed core curriculum on human rights, ethics and medical law for health care practitioners. 2006. http://www.hpcsa.co.za/downloads/radiography/core_ curriculum_on_human_rights_ethics_and_medical_law.pdf (accessed 10 february 2014). 3. nortjé n. ethical tensions faced by dietetic students during fieldwork. s afr j clin nutr 2014;27(3):128-131. 4. health professions council of south africa (hpcsa). professional board for occupational therapists, medical orthotics/ prosthetics and arts therapy. minimum standards for the training of occupational therapists. pretoria: hpcsa, 2009. 5. atwal a, caldwell k. ethics, occupational therapy and discharge planning: four broken principles. australian occupational therapy journal 2003;50(4):244-251. 6. diab p, naidu t, gaede b, prose n. cross-cultural medical education: using narratives to reflect on experience. afr j health professions educ 2013;5(1):42-45. [http://dx.doi.org/10.7196/ajhpe.234] 7. metz mj. some ethical issues related to hearing instrument dispensing. seminars in hearing 2000;21(1):63-74. 8. neuman wl. basics of social research – qualitative and quantitative approaches. 2nd ed. boston: pearson, 2007:108-139. 9. barnitt r. ethical dilemmas in occupational therapy and physical therapy: a survey of practitioners in the uk nhs. j med ethics 1998;24:193-199. 10. kinsella ea, park aj, appiagyei j, chang e, chow d. through the eyes of students: ethical tensions in occupational therapy practice. revue canadienne d’ergotherapie 2008;75(3):176-183. 11. beauchamp tl, childress jf. principles of biomedical ethics. 5th ed. new york: oxford university press, 2001. 12. kant i. groundwork for the metaphysics of morals. in: nadelhoffer t, nahmias e, nichols s, eds. moral psychology – historical and contemporary readings. chichester, uk: wiley blackwell, 2010. 13. allan a. the law for psychotherapists and councellors. 2nd ed. somerset west: inter-ed publishers, 2001. 14. allan a. law and ethics in psychology: an international perspective. somerset west: inter-ed publishers, 2008. 15. sim j. client confidentiality: ethical issues in occupational therapy. br j occupational ther 1996;59(2):56-61. 16. health professions council of south africa (hpcsa). guidelines for good practice in the health care professions – confidentiality: protecting and providing information (booklet 10). pretoria: hpcsa, 2008. 17. brody h. the physician/patient relationship. in: vearch rm, ed. medical ethics. boston: jones and barlett, 1990. forum this presentation uses a literature review to examine the context of the conference theme – ‘from practise to practice’. it interrogates who our current cohort of students are and what this means for how they should be taught. the presentation is premised on the assumption that quality teaching and learning has the potential to develop skilled and competent health practitioners. further, it assumes that effective learning depends on the appropriateness of the teaching, and that appropriate teaching is impossible without an understanding of who the learners are. to this end, the presentation commences with an examination of the current cohort of students – those who entered health sciences programmes in 2012. thereafter, discussion turns to appropriate teaching strategies for these students. the 2012 cohort are ‘mandela’s children’, born in 1994, the year of south africa’s democracy. international literature identifies them as the ‘z-generation’ – those born into or growing up in a world of internet, computers, mobile phones and social networking. they are digital natives’, used to receiving information fast, enjoying parallel processes and multitasking, and preferring graphics to text. they function best when networked, thrive on instant gratification and frequent rewards, and prefer games to serious work. this literature suggests further that the 1994 cohort are ‘bubble wrapped’ by over-managing parents. they have had little access to independent play, and their non-school time was scheduled for extra lessons and extramurals so as to ensure that they had a competitive edge on peers. they have been taught that everything is within reach and that self-belief is essential for success. as a consequence, other people’s opinions are rarely important. in competing to stay on top, they have few mechanisms for dealing with failure. thus anxiety and depression are common. yet, the literature is not conclusive. further studies identify these young people as altruistic, and social and environmentally concerned and active. it emphasises their voluntarism and their motivation to serve. clearly, the 1994 cohort is diverse. the extent of this diversity is stark when the south african literature is reviewed. only 5% of the 1990 birth cohort gained a university exemption. many south african schools lack electricity or toilet facilities, and 92% of schools currently do not have functioning libraries. few university students have access to all the digital devices characteristic of the z-generation. many do not have enough money for food and textbooks. many, as a consequence, repeat academic years at university. any enterprise to support student learning from ‘practise’ to ‘practice’ must recognise this student diversity. the presentation goes on to outline the current literature on ‘personalised learning’, which manifests in the health sciences as ‘competency-based education’. it is argued that authentic competency-based education implies an individualised curriculum, but acknowledges that class sizes prevent such an approach. strategies to individualise learning, within the real constraints of the clinical context, are outlined. suggestions are made for pre-clinical consultations, negotiated personalised outcomes for clinical sessions, student self-reflection, and post-clinic feedback. the presentation concludes with suggestions for further reading. ajhpe 2012;4(1):3. doi:10.7196/ajhpe.174 south african association of health educationalists (saahe) distinguished educator for 2012 keynote address to saahe ensuring effective practice: understanding who our students are professor wendy mcmilllan faculty of dentistry, university of the western cape professor wendy mcmilllan 3 july 2012, vol. 4, no. 1 ajhpe march 2022, vol. 14, no. 1 ajhpe 33 research the first sars-cov-2 (covid-19) infection in south africa (sa) was recorded on 5 march 2020.[1] in response to the pandemic and in order to ‘flatten the curve’ and delay the spread of covid-19, the sa government announced a 21-day national lockdown effective 27  march 2020, which was extended for 2  more weeks. five alert levels were announced, with alert level  5 measures and regulations being the most stringent and alert level 1 the most lenient. alert level 4 lockdown was implemented on 1 may, level 3 on 1 june, level 2 on 18 august, and level 1 on 21 september 2020.[2] consequently, as with all universities countrywide, the university of the free state (ufs) had to change from a contact delivery mode to remote multimodal teaching, learning and assessment, with ensuing challenges. these measures also affected postgraduate training. registrars are medical doctors receiving 48  60  months of supervised postgraduate training in public health hospitals to gain specialist-level expertise. registrars are both master’s (mmed) students and healthcare workers  – essential staff who had to continue working in hospitals during the lockdown. tension exists between these dual roles, especially when service delivery affects training. in teaching hospitals, registrars often perform the bulk of clinical service delivery. this situation continues during the covid-19 pandemic and many of the registrars are working on the frontline of the pandemic, often being deployed to function in areas outside their scope of practice, the effect of which should not be overlooked.[3] the risk of contracting covid-19 in the workplace remains concerning. by 13 august 2020, at least 240 healthcare workers had died due to covid-19 in sa, with 1 644 reported infections among doctors in the country.[4] the compulsory research component of the mmed curriculum at the ufs[5] entails two modules, namely research methodology and a minidissertation. according to the milestones stipulated by the ufs, the research methodology module (12 credits) must be completed within 24 months of registration, and the mini-dissertation (64  credits) should be completed prior to enrolling for the colleges of medicine of sa (cmsa) final assessment. in the past, some registrars struggled to complete their research projects within the minimum residency period. although a reduced clinical workload due to covid-19 might provide an opportunity to work on academic activities, including research,[6] it is not known what effect the initial months of the national lockdown had on registrars at our institution. the aim of the study was to determine the effect of the initial months (26 march 30 june 2020) of the covid-19 lockdown on mmed training activities at the ufs. the objectives were: (i) to describe the registrars’ demographic and health profile relevant to the pandemic; (ii) to determine the effect of the lockdown on mmed research progress; (iii) to describe the effect on postgraduate academic activities and the clinical training environment; and (iv) to determine how these factors were inter-related. methods study design a cross-sectional study using an anonymous self-administered questionnaire was conducted at the faculty of health sciences, ufs, in bloemfontein, sa. setting the ufs, with its main campus in bloemfontein, is one of nine universities in sa that offer medical specialist training programmes (mmed). the faculty of health sciences at the ufs comprises five schools, namely the school of clinical medicine, school of pathology, school of biomedical sciences, school background. shortly after the first case of sars-cov-2 infection (covid-19) had been reported in south africa, a national lockdown was declared. subsequently, the university of the free state (ufs) changed from a contact delivery mode to remote multimodal teaching, learning and assessment. objectives. to determine the effect of the initial months of the covid-19 lockdown on mmed training activities at the ufs, specifically the demographic and health profile of students, research progress, academic activities and the clinical training environment. methods. a cross-sectional study using an anonymous self-administered questionnaire was used. all registered mmed students at the ufs were eligible to participate. results. a response was obtained from 134 (51.9%) of 258 registrars, most of whom were included in the analysis (n=118; 45.7%). significant associations between the effect of the covid-19 lockdown on day-to-day clinical work and the ability to work on mmed research (p<0.01) and self-directed learning time (p<0.01) were noted. changes in domestic circumstances affecting mmed research were reported by 26.9% of respondents. worsening or new symptoms of stress were reported by 40.0% of respondents. conclusion. the initial months of the covid-19 lockdown might have far-reaching implications for registrars’ academic progress. registrars experienced adverse psychosocial consequences that might impede their academic progress. afr j health professions educ 2022;14(1):33-42. https://doi.org/10.7196/ajhpe.2022.v14i1.1466 the effect of the initial months of the covid-19 national lockdown on mmed training activities at the university of the free state, south africa c meyer,1 phd; c barrett,1 mb chb, mmed (int med); g joubert,2 msc; n mofolo,1 mb chb, mfammed 1 school of clinical medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, school of biomedical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c meyer (meyerc@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2022.v14i1.1466 mailto:meyerc@ufs.ac.za 34 march 2022, vol. 14, no. 1 ajhpe research of health and rehabilitation sciences and school of nursing. the mmed is offered in the school of pathology (six disciplines, one of which is currently in abeyance) and the school of clinical medicine (25 disciplines, three of which had no registrars enrolled at the time of the study). the health professions council of sa (hpcsa) accredited training platforms for specialist training in the free state are universitas academic hospital, pelonomi academic hospital, national hospital, the free state psychiatric complex and 3 military hospital in bloemfontein, as well as robert mangaliso sobukwe hospital in kimberley in the neighbouring northern cape province. all training is performed in public hospitals. participant selection mmed students (registrars) from all disciplines and registered as postgraduate students in the faculty of health sciences were eligible to participate in the survey. measurement a questionnaire was designed by the researchers (appendix: https:// www.samedical.org/file/1809) considering the requirements set for mmed training by the different stakeholders in medical specialist training, namely the training institution (ufs), the registration body (hpcsa), the examining body (cmsa) and the employers of the registrars (e.g. the free state province department of health or the national health laboratory service (nhls)). the researchers represent various elements of mmed training in the institution, namely the head of the school of clinical medicine (nm), mmed research co-ordinator (cm), research methodology module leader (gj) and clinical research director (cb). based on their experience in mmed training, the questionnaire was face-validated by the researchers. a pilot study was not performed. the postgraduate office of the faculty of health sciences sent an email requesting participation to all registrars, with a link to the information document and questionnaire, on 14  june 2020, followed by two reminder emails before closing on 30  june 2020. the questionnaire could be completed within 10  minutes on various electronic devices. participation was voluntary and anonymous. all data from the questionnaire were automatically captured via the redcap (research electronic data capture; vanderbilt university, usa) survey software hosted at the ufs. statistical analysis statistical analysis was performed by the department of biostatistics, faculty of health sciences, ufs, using the statistical analysis software package sas/ stat version 9.4 (sas institute inc., usa). results were summarised by frequencies and percentages (categorical variables) and means and standard deviations or percentiles (numerical variables). associations between categorical variables were analysed using χ2, or fisher’s exact test in the case of sparse cells. qualitative data obtained from responses to the open-ended question were analysed by thematic analyses. ethical considerations approval to perform the study was obtained from the heads of the schools of pathology (sop) and clinical medicine (socm), and the dean of the faculty of health sciences. the study was approved by the health sciences research ethics committee (ref. no. ufs-hsd2020/1029/30006) and the vice-rector: research, ufs. results the questionnaire was distributed to all 258  registrars registered in the socm (n=238) and the sop (n=20) at the time of the survey. in total, 134  responses were received (51.9% response rate), with 118  responses, representing 45.7% of the registrars at the ufs, included in the analysis. sixteen incomplete questionnaires were excluded. response rates of 43.3% (n=103/238) and 60.0% (n=12/20) were obtained from the socm and the sop, respectively. three respondents did not indicate their department of registration. demographic and health profile of registrars at the ufs table 1 summarises the demographic data of the participants compared with the total ufs registrar population. a similar number of male (49.6%) and female (50.4%) respondents participated in the survey. more than half of the respondents (51.7%) were 30 34 years of age, and 28.3% were in their second year of study. extension of residency time was reported by 12.0% (n=9/75) of registrars in a 4-year programme, none (n=0/6) in a 4.5-yearprogramme and 6.3% (n=2/32) in a 5-year programme. the majority of the respondents (74.1%) were married, living together or had a life partner. the median number of people living in the household was 3 (range 1 10). one-fifth (20.5%) of the respondents resided alone. at the time of the survey, the majority of the respondents (98.2%) were not living with a person who had been diagnosed with covid-19, while 2 (1.8%) had family members awaiting results. slightly more than a quarter (26.9%) of respondents reported changes in their domestic circumstances that had an effect on the progress of their mmed research, with 38.0% reporting that an adult in their household had been retrenched or suffered a salary reduction. the health profile of respondents relative to covid-19, their psychiatric history and psychological response to covid-19 are summarised in table 2. approximately 60% (n=70; 59.3%) of respondents had no underlying comorbidities regarded as poor prognostic factors for covid-19, 11 (9.3%) respondents did not select any of the options, leaving one-third (n=37; 31.3%) of respondents who reported comorbidities. a body mass index >30  kg/m2 and hypertension were reported by 14.8% and 13.0% of respondents, respectively, while two or more poor prognostic factors were reported by 12.2% (n=14/115) of respondents. as shown in table 2, 57.4% of respondents reported no previous or current psychiatric diagnosis, while some chose not to disclose a psychiatric diagnosis or did not select any option (7.0% and 7.8%, respectively). major depression, anxiety disorder and burnout were reported by a number of respondents: 17.4%, 13.9% and 13.0%, respectively, while 19.6% (n=21/107) had two or more concomitant psychiatric diagnoses. no new psychiatric diagnosis or worsening of psychiatric symptoms was reported by 39.1% of respondents, while some respondents preferred not to indicate which psychiatric symptoms worsened, selected ‘other’, or did not answer the question (1.7%, 1.7% and 7.8%, respectively). worsening or new symptoms of stress were reported most frequently (40.0%). more than one new psychiatric symptom or worsening of psychiatric symptoms was reported by 18.3% (n=21/115) of respondents, and 22.1% (n=25/113) experienced worsening of two or more psychiatric symptoms. effect of the lockdown on mmed research progress the respondents’ feedback related to the effect of the lockdown on their mmed research progress is summarised in table 3. https://www.samedical.org/file/1809 https://www.samedical.org/file/1809 march 2022, vol. 14, no. 1 ajhpe 35 research table 1. sex, age, marital status, field of specialisation and duration in training programme of respondents compared with the iuniversity of the free state (ufs) registrar population at the time of survey variable survey respondents (n=118), n (%) ufs registrar population (n=258), n (%) sex (n=117) male 58 (49.6) 158 (61.2) female 59 (50.4) 100 (38.8) age (years) (n=116) 25 29 20 (17.2) 19 (7.4) 30 34 60 (51.7) 124 (48.1) 35 39 19 (16.4) 62 (24.0) 40 44 9 (7.8) 25 (9.7) ≥45 8 (6.9) 28 (10.9) marital status (n=116) single 29 (25.0) married/living together/life partner 86 (74.1) divorced/separated/widowed 1 (0.9) specialisation (n=115)* school of pathology (n=12): minimum duration of degree: 4 years anatomical pathology 6 (5.2) 8 (3.1) chemical pathology 0 (0) 1 (0.4) haematology and cell biology 2 (1.7) 5 (1.9) medical microbiology 2 (1.7) 3 (1.2) medical virology 2 (1.7) 3 (1.2) school of clinical medicine (n=103): minimum duration of degree: 4 years anaesthesiology 13 (11.3) 26 (10.1) community health 0 (0) 1 (0.4) dermatology 2 (1.7) 3 (1.2) family medicine 6 (5.2) 17 (6.6) internal medicine 15 (13.4) 26 (10.1) neurology 2 (1.7) 3 (1.2) nuclear medicine 1 (0.9) 1 (0.4) oncology 3 (2.6) 9 (3.5) otorhinolaryngology 1 (0.9) 3 (1.2) paediatrics and child health 10 (8.7) 25 (9.7) psychiatry 10 (8.7) 17 (6.6) minimum duration of degree: 4.5 years ophthalmology 6 (5.2) 9 (3.5) minimum duration of degree: 5 years cardiothoracic surgery 2 (1.7) 7 (2.7) clinical imaging sciences 7 (6.1) 12 (4.7) forensic medicine 1 (0.9) 5 (1.9) neurosurgery 1 (0.9) 5 (1.9) obstetrics and gynaecology 9 (7.8) 20 (7.8) orthopaedic surgery 5 (4.4) 17 (6.6) paediatric surgery† 3 (1.2) plastic surgery 1 (0.9) 3 (1.2) surgery 7 (6.1) 18 (7.0) urology 1 (0.9) 8 (3.1) year of study (n=113) 1 21 (18.6) 48 (18.6) 2 32 (28.3) 69 (26.7) 3 23 (20.4) 49 (19.0) 4 19 (16.8) 41 (15.9) 5 15 (13.3) 41 (15.9) >5 3 (2.7) 10 (3.9) *there are currently no registrars registered for clinical pharmacology and medical genetics degrees. the emergency medicine and clinical pathology degrees are currently in abeyance. †responses from registrars in paediatric surgery are included in surgery. 36 march 2022, vol. 14, no. 1 ajhpe research the vast majority of respondents had completed the research methodology module (89.9%), but 46.2% had not yet obtained final institutional ethics committee approval for their research protocols. nearly a quarter of the respondents who were >24  months into the programme (23.3%; n=14/60) had missed the milestone of obtaining institutional ethics approval by 24  months of residency time. sixty-seven (57.3%) of 117 respondents reported doing retrospective data collection. a fifth (n=9/41; 22.0%) of respondents who conducted prospective studies were in the data collection phase at the time of the survey. with regard to the registrars on extension of residency time, 5 had not yet completed their research, 1 reported preparing a protocol, 1 reported being in the process of collecting data and 3 were writing the final research report. in terms of the effect of the covid-19 lockdown on time available to spend on mmed research, 46.5% of respondents reported no change. however, 27.1% of respondents reported that they had less time, and 9.7% reported that they had no time to work on mmed research. with reference to adhering to the ufs milestones for mmed research, 49.6% of the respondents reported that the lockdown had affected their ability to comply with the requirements, while 25.7% reported no effect on compliance. specific challenges related to their mmed research were reported by a notable number of respondents. sixty-three (53.4%) respondents reported increased domestic duties due to lockdown, while psychological effects of working during the covid-19 pandemic and the clinical workload related to covid-19 were reported by 43.2% and 35.6%, respectively. approximately one-third (31.4%) reported challenges with caring for and schooling children at home. other challenges included restricted access to the library/librarian (27.1%), problems with access to patients or data (14.4%) and difficulties presenting the research proposal at a departmental research meeting (11.0%). forty-two participants responded to an open-ended question pertaining to challenges experienced during the lockdown. themes that emerged were challenges regarding research and academic activities (35.7% of those responding to this question), challenges regarding the clinical working environment (7.1%), responsibilities towards children (47.6%), increased domestic responsibilities (42.9%) and emotional (14.3%) and financial challenges (9.5%). effect of the lockdown on postgraduate academic activities and the clinical training environment the effects of the lockdown on postgraduate academic activities and the clinical training environment are summarised in table 4. only 8.6% reported that face-to-face academic meetings continued, while the use of electronic platforms only or a combination of electronic and face-toface academic meetings was reported by 48.7% and 18.0%, respectively. cancelling of all academic meetings was reported by 24.8% of respondents. in terms of the frequency of postgraduate academic meetings, 50.9% of respondents reported a decrease in the number of meetings, while 24.1% reported that no meetings took place. regarding the effect of lockdown on self-directed learning time, similar numbers of respondents reported that less time (37.1%) or more time (35.3%) was available. two-thirds of respondents reported that the lockdown affected their ability to comply with the cmsa logbook, clinical rotations and clinical exposure. half of the respondents reported that they felt adequately prepared and trained to work in the frontline of the covid-19 pandemic. it was noteworthy that 45.2% of respondents reported a decrease in their dayto-day clinical workload and activities, while 27.8% reported no change in workload. with regard to after-hours workload and activities, 38.3% of respondents reported unchanged conditions. a similar number (37.4%) reported an increase in their after-hours workload. slightly more than half of the respondents (51.3%) reported that they were part of a covid-19 task team or involved in covid-19 clinical work. the vast majority of respondents (74.6%) reported anxiety when nominated to a covid-19 task team or when performing covid-19 clinical work, although only 30.1% reported having direct contact with covid-19 patients in the clinical environment. most respondents (84.4%) expressed concern about infecting family members owing to the nature of the clinical training environment. most (n=80/116; 69.0%) respondents were satisfied with the communication received from the ufs faculty of health sciences table 2. registrars’ feedback on physical and psychiatric healthrelated questions question n (%) respondent reported sars-cov-2 infection (n=115) yes 0 (0) no 113 (98.3) tested, awaiting results 2 (1.7) reported poor prognostic factors for covid-19 (n=115)* none or no option selected 79 (68.7) body mass index >30 kg/m2 17 (14.8) cardiovascular disease 2 (1.7) chronic kidney disease 1 (0.9) chronic pulmonary disease 10 (8.7) current cancer 0 (0) diabetes 4 (3.5) immunosuppression 1 (0.9) hypertension 15 (13.0) organ transplant 0 (0) other risk factors 5 (4.3) use of biologics 1 (0.9) reported previous or current psychiatric diagnosis (n=115)* none or no option selected 75 (65.2) anxiety disorder 16 (13.9) bipolar mood disorder 0 (0) burnout 15 (13.0) major depression 20 (17.4) post-traumatic stress disorder 3 (2.6) prefer not to say 8 (7.0) other 0 (0) stress 8 (7.0) reported new or worsening psychiatric symptoms (n=115)* none or no option selected 49 (42.6) anxiety disorder 25 (21.7) bipolar mood disorder 0 (0) burnout 23 (20.0) major depression 5 (4.4) post-traumatic stress disorder 1 (0.9) prefer not to say 2 (1.7) other 2 (1.7) stress 46 (40.0) sars-cov-2 = severe acute respiratory syndrome coronavirus 2; covid-19 = coronavirus disease 2019. *more than one option was allowed. march 2022, vol. 14, no. 1 ajhpe 37 research postgraduate administration office regarding studies and research, while 40.0% (n=46/115) were satisfied with the communication received from the free state province department of health and their respective departments about clinical workload and wellbeing. table 5 shows the association between the responses regarding the effects of covid-19 lockdown on day-to-day clinical work, being seconded to a covid-19 task team or requested to work with covid-19 patients, and changed circumstances at home that affected mmed research progress on the one hand, and responses regarding the ability to perform certain mmed-related tasks on the other. a significant association was noted between the effect of the covid-19 lockdown on day-to-day clinical work and how the ability to work on mmed research was affected (p<0.01), with those with an increased workload being more likely to report less time to work on mmed research and self-directed learning time (p<0.01). no association between changes in the day-to-day clinical workload and ability to adhere to mmed milestones (p=0.20) was found. table 3. registrars’ feedback pertaining to mmed research-related questions question n (%) research methodology module (n=118) completed research methodology module 105 (89.0) not completed research methodology module 13 (11.0) current status of the mmed research project (n=117) mmed research not started yet 14 (12.0) preparing a protocol 28 (24.0) protocol submitted to hsrec 12 (10.2) hsrec final approval obtained 5 (4.3) collecting data 19 (16.2) analysing data 7 (6.0) preparing final manuscript 12 (10.3) manuscript submitted for assessment 7 (6.0) corrections completed and research passed 2 (1.7) preparing manuscript for publication 5 (4.3) published mmed research 6 (5.1) study design (n=116) descriptive 65 (56.0) cross-sectional study 19 (16.4) cohort study 12 (10.3) case-control study 3 (2.6) randomised controlled clinical trial 4 (3.5) systematic review or meta-analysis 3 (2.6) case report 1 (0.9) case series 0 (0) not yet decided 9 (7.8) type of data collection (n=115) prospective 42 (36.5) retrospective 66 (57.4) not yet decided 7 (6.1) effect of covid-19 lockdown on mmed research (n=114) more time to work on mmed research 19 (16.7) time to work on mmed research is unchanged 53 (46.5) less time to work on mmed research 31 (27.2) no time to work on mmed research 11 (9.7) effect of lockdown on supervisor feedback (n=113) easier to obtain feedback from supervisor 6 (5.3) feedback from supervisor unchanged 57 (50.4) harder to obtain feedback from supervisor 19 (16.8) nothing to discuss with supervisor 19 (16.8) no supervisor yet 12 (10.6) effect of lockdown on ability to adhere to mmed research milestones (n=113) ability to adhere to mmed research milestones affected 56 (49.6) no effect on mmed research milestones 29 (25.7) too soon to say 28 (24.8) hsrec = health sciences research ethics committee; covid-19 = coronavirus disease 2019. 38 march 2022, vol. 14, no. 1 ajhpe research increased day-to-day clinical workload and being seconded to a covid19 task team or requested to work with covid-19-positive patients were both reported to affect registrars’ ability to comply with the requirements of the cmsa logbook, clinical rotations and clinical exposure (p=0.04 and p=0.02, respectively). no association was noted between being seconded to a task team or requested to work with covid-19 patients and the ability to work on mmed research (p=0.76), the ability to adhere to the milestones for mmed research (p=0.77) or self-directed learning time (p=0.26). registrars who experienced lockdown-related changes in domestic circumstances that affected mmed research progress were more table 4. registrars’ feedback pertaining to the academic programme and clinical training environment question n (%) type of postgraduate academic meetings (n=117) all academic meetings cancelled 29 (24.8) electronic platforms used for academic meetings 57 (48.7) face-to-face academic meetings continued 10 (8.6) combination of electronic and face-to-face academic meetings 21 (18.0) frequency of postgraduate academic meetings (n=116) academic meetings cancelled 28 (24.1) less frequent academic meetings 57 (50.9) frequency of academic meetings unchanged 22 (19.0) more frequent academic meetings 7 (6.0) effect of covid-19 lockdown on self-directed learning time (n=116) more time for self-directed learning 41 (35.3) no change in self-directed learning time 32 (27.6) less time for self-directed learning 43 (37.1) effect of covid-19 lockdown on ability to comply with cmsa logbook, clinical rotations and clinical exposure (n=115) effect reported 78 (67.8) no effect reported 37 (32.2) self-reported preparedness to work in frontline of covid-19 pandemic (n=115) adequately prepared and trained 57 (49.6) inadequately prepared and trained 58 (50.4) effect of covid-19 on day-to-day clinical workload and activities (n=115) workload less than before 52 (45.2) workload unchanged 32 (27.8) workload more than before 31 (27.0) effect of covid-19 on after-hours workload and activities (n=115) workload less than before 28 (24.4) workload unchanged 44 (38.3) workload more than before 43 (37.4) nomination to covid-19 task teams or covid-19 clinical work (n=115) yes 59 (51.3) no 56 (48.7) type of task team (more than one option was allowed) (n=59) national department of health task team 1 (1.7) provincial department of health task team 1 (1.7) hospital-specific task team 21 (35.6) department-specific task team 20 (33.9) clinical work with covid-19 patients 40 (67.8) other 5 (8.5) reported anxiety when nominated to covid-19 task team or covid-19 clinical work (n=59) yes 44 (74.6) no 15 (25.4) direct contact with any covid-19 patients in clinical training environment (n=113) yes 34 (30.1) no 79 (69.9) concern expressed about infecting family due to nature of clinical training environment (n=115) yes 97 (84.4) no 18 (15.7) covid-19 = coronavirus disease 2019; cmsa = colleges of medicine of south africa. march 2022, vol. 14, no. 1 ajhpe 39 research likely to report less or no time for research (p<0.01), and an inability to adhere to mmed research milestones (p<0.01). the frequency of departmental meetings was not associated with day-to-day clinical workload, after-hours workload or being seconded to a task team or requested to work with covid-19-positive patients. among the respondents who had been seconded to a covid-19 task team or requested to work with covid-19-positive patients, an association was noted between feeling inadequately prepared and trained to work on the frontline of the pandemic and experiencing anxiety when requested to work with covid-19-positive patients. of the respondents who reported that they were adequately prepared and trained to work on the frontline of the pandemic, approximately twothirds (62.5%) nonetheless reported anxiety when requested to work with covid-19 patients, compared with 88.9% of those who reported that they did not feel adequately prepared and trained (p=0.02). discussion this study showed that the initial months of the covid-19 lockdown affected registrars’ mmed research progress, postgraduate academic activities and the clinical training environment. the most notable health concern was an increase in the incidence and worsening of selfreported stress. the response rate for this questionnaire was similar to a previously published study sampling registrars in sa.[7] departments with the highest percentage of responses in both the sop and the socm were in line with the departmental size. the self-reported prevalence of obesity and hypertension was lower than that of the general sa population[8] and healthcare workers in limpopo province.[9] the prevalence of burnout among respondents was markedly lower than previously reported.[10-14] compared with medical students and medical doctors, fewer respondents reported depression[11,15] and anxiety disorder.[15] under-recognition of burnout, depression and anxiety among registrars might have contributed to the low prevalence of burnout in our study. although it was alarming that 40% of respondents experienced worsening of stress so early in the pandemic, the reported stress was lower than covid-19-related stress levels experienced by the general sa population, which increased by 56% between the start of the pandemic and mid-october 2020.[16] healthcare workers, including registrars, working on the frontline of the covid-19 pandemic experience symptoms of depression, anxiety, insomnia, distress, fear for family, friends and co-workers and fear of infecting people at home. concerns about the discomfort of isolation, resource allocation and availability of personal protective equipment have been raised by healthcare workers both locally and abroad.[17-20] many of these concerns were echoed in our findings. despite satisfactory interaction among registrars, the postgraduate office and clinical departments, psychological support was lacking. screening for burnout and psychological symptoms is a necessary intervention that should be considered when facing global disease outbreaks. the present study was not designed to identify the causes and contributing factors for psychiatric conditions. the tension between the dual role of healthcare worker and student in the covid-19 era has recently highlighted the challenge of balancing priorities of patient care and training, including access ta bl e 5. a ss oc ia ti on b et w ee n lo ck do w nre la te d ef fe ct s an d th e ab ili ty to p er fo rm c er ta in m m ed -r el at ed ta sk s a re a of a ca de m ic a nd r es ea rc hre la te d ta sk s af fe ct ed b y lo ck do w n ef fe ct o f l oc kd ow n on d ay -t oda y cl in ic al w or kl oa d, n ( % ) se co nd ed to a ny ta sk te am o r re qu es te d to w or k w it h c o v id -1 9po si ti ve p at ie nt s, n (% ) c ha ng ed c ir cu m st an ce s at h om e th at af fe ct ed m m ed r es ea rc h pr og re ss , n ( % ) le ss u nc ha ng ed m or e ye s n o ye s n o a bl e to w or k on m m ed r es ea rc h n= 11 1 n= 11 1 n= 10 7 m or e tim e 12 ( 25 .0 ) 3 (9 .4 ) 4 (1 2. 9) 11 ( 19 .6 ) 8 (1 4. 6) 1 (3 .5 ) 18 ( 23 .1 ) u nc ha ng ed ti m e 29 ( 60 .4 ) 16 ( 50 .0 ) 5 (1 6. 1) 23 ( 41 .1 ) 27 ( 49 .1 ) 10 ( 34 .5 ) 39 ( 50 .0 ) le ss ti m e 4 (8 .3 ) 11 ( 34 .4 ) 16 ( 51 .6 ) 17 ( 30 .4 ) 14 ( 25 .5 ) 13 ( 44 .8 ) 16 ( 20 .5 ) n o tim e 3 (6 .3 ) 2 (6 .3 ) 6 (1 9. 4) 5 (8 .9 ) 6 (1 0. 9) 5 (1 7. 3) 5 (6 .4 ) a bl e to a dh er e to th e m ile st on es fo r m m ed r es ea rc h n= 11 0 n= 11 0 n= 10 7 ye s 20 ( 41 .7 ) 18 ( 58 .1 ) 18 ( 58 .1 ) 27 ( 48 .2 ) 29 ( 53 .7 ) 21 ( 72 .4 ) 32 ( 41 .0 ) n o 17 ( 35 .4 ) 4 (1 2. 9) 7 (2 2. 6) 14 ( 25 .0 ) 14 ( 25 .9 ) 7 (2 4. 1) 22 ( 28 .2 ) to o so on to s ay 11 ( 22 .9 ) 9 (2 9. 0) 6 (1 9. 4) 15 ( 26 .8 ) 11 ( 20 .4 ) 1 (3 .5 ) 24 ( 30 .8 ) se lfdi re ct ed le ar ni ng ti m e n= 11 4 n= 11 4 n= 0 m or e tim e 24 ( 47 .1 ) 10 ( 31 .3 ) 6 (1 9. 4) 17 ( 28 .8 ) 23 ( 41 .8 ) u nc ha ng ed ti m e 17 ( 33 .3 ) 12 ( 37 .5 ) 2 (6 .5 ) 16 ( 27 .1 ) 15 ( 27 .3 ) le ss ti m e 10 ( 19 .6 ) 10 ( 31 .3 ) 23 ( 74 .2 ) 26 ( 44 .1 ) 17 ( 30 .9 ) a bl e to c om pl y w ith r eq ui re m en ts o f c m sa lo gb oo k, cl in ic al r ot at io ns a nd c lin ic al e xp os ur e n= 11 3 n= 11 3 n= 0 ye s 35 ( 68 .6 ) 17 ( 53 .1 ) 25 ( 83 .3 ) 46 ( 78 .0 ) 31 ( 57 .4 ) n o 16 ( 31 .4 ) 15 ( 46 .9 ) 5 (1 6. 7) 13 ( 22 .0 ) 23 ( 42 .6 ) c m sa = c ol le ge s of m ed ic in e of s ou th a fr ic a. 40 march 2022, vol. 14, no. 1 ajhpe research to surgical cases and clinical exposure.[3,21] the reduced clinical caseload has caused some training programmes to change their didactic, surgical and clinical education to accommodate the consequences of the pandemic, while at the same time, institutions have been rethinking their assessment and graduation requirements.[6,22-26] in light of the covid-19 pandemic, the senate of the cmsa, the examining body for specialist medical qualifications in sa, announced the postponement of oral/clinical/practical examinations of the first semester of 2020 to the second semester of 2020.[27] while the hpcsa has given guidance on how undergraduate medical training could continue during the covid-19 pandemic, they failed to provide input on the management of postgraduate training, with the exception of a general announcement that practitioners were expected to continuously update their professional knowledge and skills to effectively manage patients in the context of the pandemic and other health conditions of public health importance.[28] at a media briefing on 14  may 2020, higher education minister blade nzimande announced that ‘[f ]rom 1 june 2020, all institutions would offer forms of remote multimodal flexible teaching and learning, supported by approved resourced plans.’[29] remote multimodal teaching has certain shortcomings, and especially does not address all the needs of clinical training and the current requirements for logbooks, as stipulated by the cmsa. covid-19 has prompted educational transformation and stimulated the debate on work-based assessment by the cmsa and identification of entrustable professional activities in sa, which could be regarded as positive outcomes of the pandemic. covid-19 and the lockdown may well affect timeous completion of residency for many registrars, given the large number who reported that lockdown affected cmsa logbook requirements, clinical rotations and experience, and the reduction or cancellation of academic meetings. these factors may have far-reaching implications. in the free state province, registrar employment contracts expire at the end of the allocated residency time. consequently, registrars who do not complete their residency within the stipulated time may be left insufficiently prepared for examinations, as well as unemployed. registrars likely to be most affected were those who were already behind their first milestone (obtaining final ethics committee approval for the research component of the mmed by 24  months) early in the pandemic, which represents 23.3% of the respondents in this cohort. various other factors should be considered when deciding on extension of residency time. it is important to identify registrars who experienced a higher day-to-day clinical workload due to the covid-19 lockdown. their increased workload affected both the ability to work on their mmed research and their self-directed learning time. both increased day-to-day clinical work and being seconded to a task team or requested to work with covid-19-positive patients affected registrars’ ability to comply with cmsa logbook requirements, clinical exposure and rotations. conversely, the lockdown resulted in cancellation of elective surgeries and significant reductions in both non-traumaand trauma-related surgical admissions in the initial month of the lockdown (27 march 30 april 2020), which might further affect registrars’ ability to comply with logbook requirements.[3,30] it is concerning that over a quarter of registrars experienced changes in domestic circumstances that affected their mmed research, significantly associated with no or decreased time to do research, resulting in nonadherence to the required milestones. such challenges may have had farreaching consequences on the demand for registrars’ time, and may further affect their academic progress. considering these factors, the ufs and the free state department of health (fsdoh) made provision for the extension of residency time for several registrars. at this stage, the long-term impact of extending residency time on the institution and the country is unclear. from what we have learnt from the effects of the initial months of the covid-19 lockdown, we recommend that departments frequently monitor individual registrars’ clinical exposure, logbook requirements, portfolio of learning, academic milestones and research progress. this will allow for informed decisions on timeous and appropriate interventions. in line with how adult postgraduate training should be structured, learning through feedback and reflection is especially relevant to mitigate delayed academic progress during the covid-19 pandemic. ‘modernised’ workplacebased assessment (wpba) and feedback are strong tools in the mmed training armamentarium to evaluate individual registrar progress to inform appropriate remedial actions.[31,32] the importance of wpba, as well as the supporting role of the clinical supervisor and mentor during this time, cannot be overemphasised. in order to support registrar research during the lockdown, we recommend frequent departmental research meetings, scheduled supervisor-student consultations and targeted remedial interventions where necessary. all of these actions are easy to implement on a virtual platform. structured mentoring programmes, which have been shown to be useful in improving research productivity and clinical skill advancement, may also benefit registrars.[33] the covid-19 lockdown has not only affected training and research, but also examinations. the cmsa postponed the 2020 first semester clinical examinations, as well as the second semester 2020 examinations. in light of this and the aforementioned factors, the training institution (ufs) and employers (fsdoh and nhls) were required to make provision for extension of residency time. long-term sequelae of the covid-19 pandemic may make it necessary for universities, the cmsa and the hpcsa to review the minimum duration of mmed courses in order for registrars to fulfil the requirements for clinical experience and to complete their research. our study highlights the need to invest in registrar wellness. registrars who suffer psychological consequences of the pandemic should be referred to the appropriate staff/registrar wellness programmes. a registrar wellness programme should be established in collaboration between the training institution, the employer and trainees, with interventions both at organisational and individual level. establishment of a registrar wellness programme will require dedicated leadership, a wellness committee, regular needs assessments, assessment of trainee wellness, targeted interventions and regular reassessment.[34] although the present study did not investigate the role of peer support, it is acknowledged as an important aspect of resident support. peer support groups are easy to implement and require minimal resources. ‘ice-cream  rounds’ (icrs)[35] have been implemented in some canadian institutions where trainees can discuss their work challenges and offer support with the aim of building resilience. icrs have been shown to normalise challenges in medical training, decrease stress, reduce feelings of burnout and anxiety and improve collegiality between students, and can also be hosted virtually.[36-39] departments should capitalise on the important role that peer support can play in specialist training and research. further research to determine the causes and extent of the psychosocial stressors of registrars during the pandemic may identify other targeted interventions. we acknowledge that registrars who were adversely affected by the lockdown might not have had or made time to complete the questionnaire. march 2022, vol. 14, no. 1 ajhpe 41 research conversely, it could be argued that those who did complete the questionnaire might have used it as an opportunity to express their concerns. we further acknowledge that the respondent population was not entirely similar to the ufs registrar population, with a higher percentage of female respondents and a slight over-representation of respondents from younger age groups. departments with the highest percentage of responses in both the sop and the socm were in line with the departmental size. a limitation of the study was that it did not investigate the role of the clinical supervisor and mentor or peer-registrar support in the workplace during the initial months of the covid-19 lockdown. this support/lack of support could thus not be reported on. furthermore, we did not investigate the challenges that supervisors might have encountered during this time, which also warrants further investigation. conclusion the impact of the initial months of the covid-19 lockdown may have farreaching implications on registrars’ academic progress at the ufs. registrars reported significant disruptions in clinical training, classroom teaching and mmed research progress that may impair their academic progress. the initial months of the covid-19 lockdown also had an adverse psychosocial impact on registrars and their families, which may further impede their mmed research and academic progress. declaration. none. acknowledgements. the authors acknowledge the registrars who participated in this study despite the difficult time that they experienced due to the covid-19 pandemic, and dr  daleen struwig, medical writer/editor, faculty of health sciences, ufs, for technical and editorial preparation of the manuscript. author contributions. cm, cb, gj and nm were jointly responsible for the development of the protocol, data collection and writing of the manuscript. gj was responsible for the statistical analysis of data. all the authors approved the final version of the article. funding. none. conflicts of interest. none. 1. national institute for communicable diseases. coronavirus disease 2019 (covid-19) caused by a novel coronavirus (sars-cov-2): guidelines for case-finding, diagnosis, management and public health response in south africa. https://www.nicd.ac.za/wp-content/uploads/2020/03/nicd_doh_covid-19_guidelines_8_ march_2020_final.pdf (accessed 26 october 2020). 2. south africa. covid-19/novel coronavirus. https://www.gov.za/coronavirus (accessed 26 october 2020). 3. al-benna s. impact of covid-19 on surgical registrars’ education and training. s afr j surg 2020;58(2):55-58. https://doi.org/10.17159/2078-5151/2020/v58n2a3323 4. staff reporter. 240 healthcare workers have died from covid-19 in sa, infection rate 5%. independent online, 13 august 2020. https://www.iol.co.za/news/south-africa/240-healthcare-workers-have-died-from-covid-19-insa-infection-rate-5-1954db22-d379-4aac-b1c6-01864a27848c (accessed 26 october 2020). 5. university of the free state. faculty of health sciences. rule book: postgraduate degrees and diplomas, 2020. https://apps.ufs.ac.za/dl/yearbooks/353_yearbook_eng.pdf (accessed 26 october 2020). 6. schwartz am, wilson jm, boden sd, moore tj jr, bradbury tl jr, fletcher nd. managing resident workforce and education during the covid-19 pandemic: evolving strategies and lessons 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wellness during covid-19. can med educ j 2020;11(5):e84-e86. https://doi.org/10.36834/cmej.70251 accepted 5 may 2021. https://www.nicd.ac.za/wp-content/uploads/2020/03/nicd_doh_covid-19_guidelines_8_march_2020_final.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/nicd_doh_covid-19_guidelines_8_march_2020_final.pdf https://www.gov.za/coronavirus https://doi.org/10.17159/2078-5151/2020/v58n2a3323 https://www.iol.co.za/news/south-africa/240-healthcare-workers-have-died-from-covid-19-in-sa-infection-rate-5-1954db22-d379-4aac-b1c6-01864a27848c https://www.iol.co.za/news/south-africa/240-healthcare-workers-have-died-from-covid-19-in-sa-infection-rate-5-1954db22-d379-4aac-b1c6-01864a27848c https://apps.ufs.ac.za/dl/yearbooks/353_yearbook_eng.pdf https://doi.org/10.2106/jbjs.oa.20.00045 https://doi.org/10.7196/samj.2016.v106i2.10310 https://doi.org/10.7196/samj.2016.v106i2.10310 http://www.hsrc.ac.za/en/research-outputs/view/6493 http://www.hsrc.ac.za/en/research-outputs/view/6493 https://doi.org/10.1080/20786204.2011.10874153 https://doi.org/10.7196/samj.2019.v109i9.13667 https://doi.org/10.7196/samj.2019.v109i9.13667 https://doi.org/10.1080/20786204.2013.10874418 https://doi.org/10.1080/20786190.2016.1198088 https://doi.org/10.1080/20786190.2016.1198088 https://doi.org/10.4300/jgme-d-09-00054.1 https://doi.org/10.4102/phcfm.v10i1.1568 https://doi.org/10.4102/phcfm.v10i1.1568 https://doi.org/10.7196/samj.2019.v110i1.14151 https://doi.org/10.7196/samj.2019.v110i1.14151 https://www.medicalbrief.co.za/archives/survey-sas-stress-levels-up-by-56-since-start-of-pandemic/ https://www.medicalbrief.co.za/archives/survey-sas-stress-levels-up-by-56-since-start-of-pandemic/ https://doi.org/10.1001/jamanetworkopen.2020.3976 https://doi.org/10.1001/jamanetworkopen.2020.3976 https://doi.org/10.7326/m20-1083 https://doi.org/10.1056/nejmp2005234 https://mg.co.za/health/2020-08-06-health-workers-afraid-of-passing-covid-to-family/ https://mg.co.za/health/2020-08-06-health-workers-afraid-of-passing-covid-to-family/ https://doi.org/10.3171/2020.3.jns20965 https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/en/covidwho-125564 https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/en/covidwho-125564 https://search.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/en/covidwho-279400 https://search.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/en/covidwho-279400 https://doi.org/10.1097/ju.0000000000001155 https://doi.org/10.1056/nejmp2018570 https://doi.org/10.1056/nejmp2018570 https://doi.org/10.1016/j.bja.2020.08.016 https://doi.org/10.1016/j.bja.2020.08.016 https://cmsa.co.za/view_news_item.aspx?newsid=147 https://www.hpcsa.co.za/uploads/events/announcements/hpcsa_covid-19_guidelines_final.pdf https://www.hpcsa.co.za/uploads/events/announcements/hpcsa_covid-19_guidelines_final.pdf https://pmg.org.za/committee-meeting/30224/ https://doi.org/10.7196/samj.2020.v110i9.15025 https://doi.org/10.7196/samj.2017.v107i9.12655 https://www.cmsa.co.za/view_document_list.aspx?keyword=transactions https://doi.org/10.4300/jgme-d-18-00650.2 https://doi.org/10.1513/annalsats.201612-1006ps https://www.mcgill.ca/thewelloffice/our-services/pgme/wellness-support/wellness-curriculum/ice-cream-rounds https://www.mcgill.ca/thewelloffice/our-services/pgme/wellness-support/wellness-curriculum/ice-cream-rounds https://med-fom-pgme.sites.olt.ubc.ca/2017/01/17/ice-cream-rounds-what-it-is-and-how-to-bring-it-to-your-program/ https://med-fom-pgme.sites.olt.ubc.ca/2017/01/17/ice-cream-rounds-what-it-is-and-how-to-bring-it-to-your-program/ https://doi.org/10.1017/cem.2018.381 https://doi.org/10.36834/cmej.69253 https://doi.org/10.36834/cmej.70251 abstracts 18 december 2009, vol. 1, no. 1 ajhpe abstracts using simulation in the clinical skills centre (csc) to achieve competency in the practical procedures in a critical care nursing programme elize archer e-mail: elizea@sun.ac.za context and setting the critical care (general) nursing programme in the faculty of health sciences, stellenbosch university, south africa, is a 1-year postgraduate course. the practical component of the course consists of a number of individual practical procedures and case presentations. the individual practical procedures are tasks required of a critical care nurse in their daily work, e.g. suctioning of the intubated patient and administering of intravenous drugs. in order for students to be able to do a case presentation they need to understand and integrate the critically ill patient’s disease process as well as the medical and nursing management. to pass the case presentations satisfactorily is often a challenge as a much higher cognitive level is expected than when performing the individual practical procedures. why the idea was necessary during the course of the programme weekly individual clinical guidance is provided to the students at the bedside in the critical care units. the purpose of these bedside sessions is for the students to discuss the critically ill patients with a critical care nurse educator in order to develop their integration, reasoning and case presentation skills. students however tend to use these teaching opportunities to practise and to be assessed on individual practical procedures. therefore, graduates will often have the skills to do individual practical procedures required by a critical care nurse, but because they find it difficult to integrate and understand the patient’s disease process they lack insight in the holistic picture of the patient. it is therefore often difficult for them to handle situations when their patients’ condition deteriorates and they become unstable. what was done a case study design was used for this study. the practical procedures identified as suitable for simulation were demonstrated, practised and assessed in simulation in the csc. the study focused on describing how the tutors and students involved experienced the use of simulation as well as how the use of the csc for reaching competency in some of the practical procedures impacted on the available teaching time in the clinical settings. evaluation of results and impact the result of completing the majority of the practical procedures in simulation in the csc was that • more time was available for the students to practise doing case presentations with the critical care nurse educators during their clinical teaching sessions • students and tutors valued the use of simulation and enjoyed the sessions in the csc. the issue of how successful the transfer of learning from the csc to the clinical areas takes place poses very valid questions when it comes to simulation. it is vital that students should be able to transfer the learning that has occurred in the simulated setting to the clinical context. further research on this subject could serve to establish whether students can apply the procedures they have been assessed on in the csc equally well on patients, or, if not, what measures can be implemented to facilitate this process. they went, they saw, they learned adriana a beylefeld e-mail: beylefeldaa.md@ufs.ac.za context and setting learning is most effective when it occurs in context. similarly, transfer of skills from lecture hall to workplace is most likely when the educational situation closely resembles the work situation. at the university of the free state school of medicine first-year students are required to establish a link between discipline-based knowledge they acquire in a core module, the ability they develop to think critically about their learning in a fundamental module, and economic and social realities of the free state region. to this end, provision is made for real-world experiences in the form of clinic visits, whereupon students are expected to write reflectively about their learning. why the idea was necessary medicine is increasingly establishing itself as a profession that is accountable to the changed needs of society by using real-world community-located experiences and reflection to promote cognitive learning gains, personal growth of students, and also civic engagement. however, despite strong encouragement from the general medical council and other directive bodies to develop students’ reflective thinking skills, very little has been published on personal reflection (as distinguished from scientific reflection referred to as evidence-based medicine) during the undergraduate phase of medical curricula. the purpose of this study was to determine whether integration of disciplinary core learning with the skill of reflection had been achieved. evidence was sought that exposure to a challenging situation resulted in an awareness and communication of uncomfortable feelings related to attitudes that the school of medicine values in student doctors. what was done a content analysis was performed on 42 students’ reflective writing assignments completed in 2009. mcmillan’s (1997) three-dimensional theoretical construct, which includes affective, cognitive and behavioural components, was used for organising data in the following four themes: feelings of comfort; feelings of discomfort; willingness to engage in positive actions; and realisation of the worth of the experience. recurring patterns of thought and frequency of concepts related to the different themes were recorded. evaluation of results and impact the most frequently reported positive feeling was that of empathy for patients waiting patiently in long rows to receive medical attendance (41). south african association for health educationalists 2008 and 2009 congresses held in cape town 19 december 2009, vol. 1, no. 1 ajhpe abstracts a substantial number of students (13) were stimulated to look forward to the prospect of practising as doctors as witnessed by their confidence about having chosen the ‘right’ career. negative comments were mostly related to the lack of financial, physical and human resources at the clinic. the realisation that they had held unrealistic expectations about the provision of primary health care was profound (72). cognitive gains became visible in their conviction about the importance of good communication (15) and showing respect for others (10). the visit further made them realise that what they learn in class is actually ‘true’ in practice (13). the study confirmed that the community-located learning experience had helped first-year students to ‘see’ in ways that they had never seen before. while the findings may not be generalisable, insight was gained into undergraduate medical students’ experiences and attitudes in primary health care settings. service learning: experiences of first-year community engagements by radiography students of the central university of technology, bloemfontein rené w botha e-mail: rbotha@.cut.ac.za context and setting service learning is ‘a credit-bearing educational experience with organised service activities that meet identified community needs and reflect on the service activity in such a way as to gain further understanding of course content’. using service learning as a facilitation method in resource-based disciplines such as radiography is challenging. why the idea was necessary in a recent survey it was established that only two of six radiography programmes at tertiary institutions in south africa are currently using service learning. the aim of the study in progress is to investigate and describe the service learning experiences of third-year radiography students and community partners. what was done service learning priorities need to be identified by the community rather than being imposed on them by outsiders. in discussions with students, it was found that most rural communities did not know about medical imaging and they were not aware of services provided by the free state department of health (fsdoh). third-year radiography students were divided into three groups, each with its own identified rural community. learners visited the communities, contacts were identified and groundwork for two follow-up visits was laid. students decided to concentrate on the dissemination of information related to medical imaging in general and more specifically on mammography, ultrasound and bone densitometry. each group performed a dramatised presentation and grade 12 learners and contact persons at each site evaluated the presentations using different rubrics. the radiography facilitator’s assessment rubric evaluated whether students included all the outcomes in their presentations. after the interventions radiography students had to complete a structured reflection adapted from zlotkowsk, et al. evaluation of results and impact from the grade 12 assessments (n=150) it is clear that the presentations and slide shows were well received, with an average score of 81.4%. evaluating the content grade 12 learners assigned a score of 77.8%, indicating that the information was new, useful and empowering (they would be able to tell others). the contact persons (n=5), who were all teachers, felt that some of the content was beyond learners’ grasp; this opinion was not shared by the grade 12 learners. elocution and the predominant use of english was a problem in some instances. the students’ reflection reports demonstrated evidence of educational benefit, including reinforcement of previous knowledge, involvement in own knowledge creation and development of teamwork skills. the students experienced the presentations as confidence building and indicated that they would like to become more involved in community initiatives. our findings suggest that service learning initiatives have educational benefit and also provide communities with strategic health-related information. a mind-map approach to develop a clinical problem-solving process and to facilitate learning of clinical associate students kate hammond, andrew truscott corresponding author: a truscott (andrew.truscott@wits.ac.za) context and setting after recommendations in the pick report on human resources for health, the national department of health recognised the need for a new category of mid-level health professional, designated clinical associate, to work within the health service in district hospitals. why the idea was necessary the university of the witwatersrand aimed to establish a degree programme which would incorporate biomedical, psychosocial and clinical sciences and would produce graduates able to integrate information from these areas when performing their duties, so as to ensure an adequate standard of clinical care. the course would be taught mainly in district hospitals by family physicians. what was done a mind-map cycle was developed to achieve integration across disciplines and to develop a clinical problem-solving approach. the cycle is based on a patient complaint; it begins by generating the likely causes of the problem and then analysing relevant structural and functional aspects. this knowledge is incorporated into the process of taking a hypotheticodeductive history and carrying out a physical examination, so as to obtain an appropriate assessment. the cycle continues with the comprehensive management of the patient, including drug and non-drug treatment, appropriate procedures and investigations, communication with patients and with members of the health care team, referral, medicolegal and ethical issues and factors relating to improvement of patient care such as relevant data collection. evaluation of results and impact the cycle, which has so far been used for the first 9 months of the new degree, has helped to structure the curriculum, course content, teaching and assessment methods. the use of mind maps has been applied to the development and promotion of self-learning and group-learning skills. literature confirms the value of a defined structure to help students organise their knowledge effectively. a cyclic mind-map approach has been used in the development of the curriculum for a new degree for training of mid-level workers. it is being used to facilitate learning and shows potential value in assisting with integration of theory into a clinical problem-solving process. abstracts 20 december 2009, vol. 1, no. 1 ajhpe abstracts harnessing the potential of online performance tasks to promote active learning: wishful thinking or a reality? alwyn p hugo, adriana beylefeld e-mail: gnanaph.md@ufs.ac.za context and setting the university of the free state encourages active engaged learning in a blended learning environment. aligned to this, active engaged learning is one of the intended critical outcomes of the mb chb programme. to meet this challenge performance tasks in an online environment need to be student centred and not only instructional in nature. why the idea was necessary 1. to describe active learning opportunities in the online component of a module on general skills in the mb chb programme. 2. to report innovative teaching and learning practices that have the potential to stimulate active learning. what was done three types of learning opportunities included in the online component of the module on general skills were selected for their potential to stimulate active learning: independent individual learning; group/social learning; and reflective learning. the 9 individual and 6 group-based learning episodes focus on information technology, competency in communication, teamwork, social responsibility and general life skills, such as selfregulation. evaluation of results and impact the potential of the learning opportunities to stimulate active learning was deduced from module evaluation questionnaires, follow-up nominal group interviews and module marks obtained in 2008. it was reasoned that positive student experiences related to high potential for engaged learning and negative student experiences to low potential for engaged learning. in general, students reported positively on the following online activities: opportunities for applying information technology skills; team activities that focused on interaction and reasoning; reflective writing assignment; research techniques; referencing; and scientific presentation of a community-based project. students reported negatively with regard to activities that focused on the monitoring of group progress and selfregulation. an average performance mark of 86% for general skills was interpreted as reflecting a positive learning experience in the module. feedback from students, triangulated with student performance in the module, suggests that except for minor issues the completion of online learning experiences indeed stimulate active engaged learning. portfolio-based assessment of general skills: development and evaluation of an interim solution alwyn p hugo, adriana a beylefeld e-mail: gnanaph.md@ufs.ac.za context and setting the school of medicine at the university of the free state has used paper-based portfolios to assess critical outcomes in the module mea153 on general skills since 2000. in 2007 this module was relocated to a blended-learning environment. the electronic portfolio solution native to moodle, the learning content management system (lcms) used by the ufs at that stage, was not active. consequently, the authors developed and investigated an interim assessment solution. a database-driven web interface was formatted into a reflective assessment portfolio with artefact collection. why the idea was necessary to describe the functioning of the reflective assessment portfolio and report student evaluations regarding acceptability and effectiveness of the assessment method. what was done students were required to engage in 15 online learning activities that develop skills in the use of information technology, social and scientific communication, research technique, referencing, reflective writing, teamwork and self-regulation in the moodle lcms. students accessed the portfolio from moodle. through the management interface of the portfolio, students uploaded completed assignments to a designated web server and reflected on completed learning activities. all reflections and uploaded file names (linked to individual student numbers) were captured in the web-based database. reflections per learning opportunity were assessed with a rubric that monitored identification of personal strengths and weaknesses in the completion of the learning activity. the lecturer logged marks for assessed learning activities and reflections in the database. all information regarding completed learning activities, i.e. marks, reflections and artefacts, were displayed in the student-specific portfolio interface. students’ perspectives regarding the reflective portfolio-based assessment episodes were captured through a module evaluation questionnaire in 2008 (n=139). structured and free-text responses were collected. evaluation of results and impact structured student responses ranged from negative (10%), indifferent (37%) to positive (53%) in 2008. open-ended responses indicated that students actively engaged with the online learning episodes. the uploading of completed assignments and the reflection on the learning tasks required in the reflective assessment portfolio compelled students to keep abreast of performance tasks and assignments in the module. postgraduate training preferences of walter sisulu university medical graduates enoch n kwizera e-mail: ekwizera@wsu.ac.za context and setting one of the goals of the 24-year-old walter sisulu university (wsu) medical school is to produce ‘doctors … who are self-directed and lifelong learners that will be able to adapt to changing local and global circumstances, keep up with developments in their profession, and have the necessary motivation and background to acquire relevant specialised qualifications to advance their own careers and to fulfil the needs of the country’. why the idea was necessary as part of on-going programme evaluation, there was a need to document postgraduate (pg) training statistics of wsu medical graduates; to identify disciplines with paucity of such training; and to recommend rectifications for such paucity. what was done this was a descriptive study of wsu medical undergraduates’ pg training pattern over the period 1992 2008, but only looked at doctors who 21 december 2009, vol. 1, no. 1 ajhpe abstracts graduated between 1990 and 2004, because graduates of 2005 and later were still engaged in community service or internship at the time of the study. data were gathered by means of focus group discussions with wsu medical graduates in the country’s major cities (port elizabeth, east london, durban, cape town, johannesburg, pretoria), and by directly contacting graduates by telephone, e-mail, or sms. graduate demographics were extracted from a database for all wsu medical undergraduates since 1985 to date. evaluation of results and impact although this is still ‘work in progress’, preliminary data showed that between 1990 and 2004 wsu had 111 ‘traditionally’ trained graduates and 334 pbl-trained doctors, and that at least 31.5% of the former and 23.7% of the latter had as of early 2008 either completed, or were engaged in, pg training (data on pbl doctors were less complete). irrespective of curriculum, nearly all the specialties pursued by wsu medical graduates were clinical, the order of preference being as follows: paediatrics > o&g ≥ surgery > internal medicine > family medicine. female graduates dominated paediatrics and family medicine, while males dominated surgery and o&g – patterns that match local and international trends. more than 99% of those who had specialised were practising 200 km or more away from their alma mater. besides a very few in pathology, no wsu medical graduates had opted for specialisation in basic biomedical sciences. it is concluded that the wsu faculty of health sciences is succeeding in motivating its medical graduates to achieve one of its major goals, namely continuing medical education/professional development and specialisation. however, the paucity of wsu medical graduates choosing careers in basic biomedical sciences as well as the apparent failure of wsu medical graduates who specialise to return to their alma mater are concerns that need to be addressed urgently by the institution. self-directed learning behaviour in a problembased learning curriculum dianne manning e-mail: dianne.manning@wits.ac.za context and setting the university of the witwatersrand admits two-thirds of its medical students into the 6-year mb bch programme directly from school and onethird as graduates into mb bch iii. the two groups are thus merged in the last 4 years of the degree known as the graduate entry medical programme (gemp). a key objective of the gemp curriculum is to promote self-directed learning (sdl) by using problem-based learning (pbl). it is assumed that graduates entering the programme are mature, responsible, and competent learners who will readily display self-motivated approaches to learning, while the matric-entrant learners will acquire these skills in the programme. why the idea was necessary five years after the introduction of the new curriculum, there was some concern that not all students were displaying the anticipated levels of sdl activity. the aim of this study was to investigate the approaches that both matric and graduate entrants have adopted to studying in the gemp. what was done the research was conducted as a retrospective cohort study of the gemp ii class of 2006. quantitative data were collected using an anonymous likert scale questionnaire. biographical data included entry point into the gemp, age, socio-cultural group and home language. the questionnaire return rate was 60%, with over-representation of white and graduate entrants, and under-representation of indian, black and matric-entrant students. semi-structured focus group interviews were used to add qualitative data. the graduate entry students reported a greater tendency than matric entrants for: • using the scheduled free time effectively • reading outside of the course objectives and course materials • making use of recommended websites • finding additional interesting websites to supplement and enhance learning. the older graduates in particular indicated a greater inclination to read articles in medical journals and reported being more focused on a long-term goal of medical practice rather than on the short-term goal of passing exams. use of textbooks was reported fairly evenly across the different groups, with black students making most use of the library books. when examined from the perspective of home language and socio-cultural group, the afrikaans-speaking students showed the greatest and the indian students the least tendency towards adopting a selfdirected approach. evaluation of results and impact the results indicate that after a year in the gemp, the graduate-entrant students reported a more mature and robust approach to sdl than the matric entrants. while this was in keeping with the expectations for the graduate entrants, the results also suggest that since sdl activity is statistically correlated with age, there may be little difference between the graduates with a 3-year bachelor’s degree and the matric entrants who have completed 2 years of the mb bch degree. as the curriculum is producing the anticipated levels of sdl, the results suggest that some established models of learning may be socially derived and resistant to change. the introduction of appropriate formative and summative assessment tools that promote and reward the intended approaches are currently being considered. aligning learning with outcome objectives and assessment dianne manning, detlef prozesky corresponding author: dianne manning (dianne.manning@wits.ac.za) context and setting the design principles of the curriculum in the first 2 years of the graduate entry medical programme (gemp) at the university of the witwatersrand include development of self-directed and life-long learning, while requiring students to develop a holistic approach to patient care with an emphasis on understanding the essential concepts, core principles and underlying mechanisms of the basic and human sciences that underpin clinical practice. it is possible, however, to create a tension between encouraging self-directed learning on the one hand, and defining the essential core curriculum on the other. in the gemp the former is encouraged through the use of problem-based learning (pbl) and the latter by providing students with faculty-prescribed learning objectives linked to the criterion-referenced assessments. why the idea was necessary after the implementation of the curriculum it became evident that alignment between the curriculum outcome objectives and the assessments was not being achieved consistently. we therefore found it useful to abstracts 22 december 2009, vol. 1, no. 1 ajhpe abstracts introduce a simple framework for guiding the process of defining the appropriate learning objectives and aligning these with the relevant assessment criteria. what was done defining the core curriculum in terms of a set of learning outcomes requires identification of the necessary content areas, as well as careful specification of the academic depth at which that content is to be covered. the second of these presents the greater challenge. we have found the solo (structure of learning outcomes) taxonomy described by biggs and collis (1982) to be a valuable tool for this purpose. the taxonomy describes five levels of learning in terms of outcome descriptors: • prestructural: no appropriate knowledge • unistructural: identify, define • multistructural: list, combine, classify, etc. • relational: compare, explain, analyse, apply, etc. • extended abstract: generalise, hypthesise, etc. although solo overlaps the more traditional taxonomy of bloom, we have found it to be more easily understood and consistently applied. all learning outcomes for gemp years 1 and 2 are now defined by the solo level descriptors and are aligned with the assessments through the use of the same descriptors. although self-directed learning is still promoted by designating certain content areas for student-driven research, the required learning is framed by the level descriptors specified in the objectives. for example, while studying a case of childhood malnutrition, students are required to find information which fulfils the following objectives: 1. define protein energy malnutrition (unistructural) 2. list the typical features seen in a child with kwashiorkor (multi structural) 3. compare the features of kwashiorkor, marasmus and marasmic kwashiorkor with reference to the welcome classification (relational) 4. explain the pathophysiology of the typical presenting features of protein energy malnutrition (relational). the associated assessment tests these concepts at the applicable levels and should therefore be aligned with the intended learning. evaluation of results and impact faculty have responded positively to a clearly defined structure on which to base learning outcomes, students are assured of the level required for knowledge acquisition, and both content and construct validity of the assessments have been enhanced. assessment of medical students’ views to the introduction of communication and counselling skills training amam chinyere mbakwem, janet ngozi ajuluchukwu, adewale david oke, casmir ezenwa amadi e-mail: ambakwem@hotmail.com context and setting the college of medicine of the university of lagos runs a 6-year discipline-based undergraduate programme. the formal teaching of communication skills in not included in the medical school’s curriculum as in most of the medical schools in nigeria. attention is therefore not paid to the acquisition of these skills which are fundamental to a successful medical practice for both teachers and students. why the idea was necessary communication skills in medical practice are critical for information gathering, diagnosis, treatment, patient education and health team interactions. good communication skills are the most important determinants of patients’ satisfaction with care and adherence, and decrease the risk of malpractice lawsuits. surveys suggest that most people want to get health information from a professional and that counselling from health professionals can be effective both in reducing lifestyle risks and supporting self-management of chronic diseases. most doctors either do not realise the importance of patient education and counselling, lack the basic communication skills, or are too busy to do so. formal training in communication and counselling skills is not included in our school’s current curriculum. we therefore evaluated the knowledge of communication skills among medical students at the college of medicine, university of lagos, and their views on the inclusion of formal instruction in these skills in their curriculum. what was done an anonymous questionnaire was distributed to two cohorts of students – preclinical and clinical. this consisted of a demographic section, an open-ended question on the meaning of communication and counselling, and a section for students’ self-rating of their communication and counselling skills on a likert scale. they also rated the importance of doctors’ communication and counselling skills on the outcome of patient management and of the inclusion of formal skills training in their curriculum. data were analysed quantitatively for means and proportions. qualitative data were analysed using the grounded theory. evaluation of results and impact a total of 238 students (52 final year and 186 preclinical) completed the questionnaire. most of the students – 92.8% and 81.3%, respectively – felt good communication and counselling skills were very important in patient management. most students – 70% and 60%, respectively – rated their communication and counselling skills above average. however, the majority (96%) felt it was important to teach communication skills and 92% wanted counselling skills instruction in their curriculum. there was no significant difference between the clinical and preclinical students’ rating of importance of communication skills, self-rating of their skills, and desire for formal instruction. most of the students felt communication is ‘being able to deliver information’ and that counselling is ‘advising your client on what course of action to take’. however, a few students had the correct knowledge of communication and counselling. our medical students (preclinical and clinical) are aware of the importance of communication skills in patient management and would like formal training despite the above-average self-rating of their skills. students’ willingness to receive formal instruction is probably a better reflection of their proficiency, considering their limited understanding of these skills. educational by-products of an e-portfolio technological pilot project karien mostert-wentzel, detken scheepers corresponding author: karien mostert-wentzel (karien.mostert@ up.ac.za) 23 december 2009, vol. 1, no. 1 ajhpe abstracts context and setting electronic portfolios are becoming a key technology application in higher education. the department of physiotherapy participated in a pilot project of the blackboard (bb) e-portfolio run by the department of education innovation (ei) at the university of pretoria. previously, the department of physiotherapy used a paper-based filing system to keep records of student activities required by statutory bodies. why the idea was necessary managing this document warehouse was time consuming and needed much space. we wanted to test the technical capabilities of the portfolio system and the user-friendliness of filing, storing and retrieving artefacts, and to investigate the feasibility of students acting as designers of their own portfolios. what was done three lecturers formulated learning outcomes for the development of an individual portfolio from two final-year modules. with the assistance of ei, we developed a customised template based on the outcomes. students populated their portfolios with: (i) reflections on their learning during (a) a clinical placement (unstructured), and (b) use of the e-portfolio (structured); and (ii) other information such as the type of conditions treated, and activities previously completed online. we orientated students (n=48) on the task and using the e-tools during a two-hour interactive session in a computer laboratory. the timetable made provision for this assignment, and on-campus computers with internet access were available. the portfolios were assessed. evaluation of results and impact the text of the students’ reflections on their experience of developing an e-portfolio was coded and main themes were identified. on the basis of students’ reflections their opinions were generally positive. they commented on utilising the portfolio to monitor and guide their development over the course of their studies. they also remarked on the benefits of reflecting on their own past learning, learning from other students’ experiences, and the benefits of the portfolio for continuous professional development. this last-mentioned finding suggests the importance of the portability of a portfolio after a student leaves an institution. students were also positive about collaborative learning as users may access others’ portfolios if owners of these portfolios give permission. they appreciated the ease of use and flexibility in developing their portfolios. students named time pressure, a lower level of computer literacy than other class members, and slowness of the on-campus computers as obstacles during their experience. facilitating factors were thorough preparation, orientation and training, previous exposure to the system and ongoing support. participation in this pilot study enriched both the curriculum and the participants. during their own reflection, lecturers discovered indirect positive educational effects of participation in the e-portfolio pilot. one positive effect was the identification of potential areas of improvement in the overall programme, e.g. to introduce structured individual reflection earlier in the curriculum (instead of oral reflections in a group) and to involve clinical supervisors to assist learning and assessment by using an e-portfolio. students achieved the learning outcomes and mastered additional competencies, such as confidence using technology, even though they used the e-portfolio for only two months. scientific basis and good clinical practice: evaluation of uct course geraldine philotheou, bridget wirley-birch, raymond abratt corresponding author: geraldine philotheou (geraldine.philotheou@ uct.ac.za) context and setting the medicines control council (mcc) of south africa requires health care professionals and all others involved in conducting clinical trials and studies to attend a training course in good clinical practice (gcp) every 3 years. the international conference on harmonization published guidelines on good clinical practice for use when generating clinical trial data for submission to regulatory authorities. this guidance is the industry standard and its observance has been legislated with some modifications in south africa. regular clinical trials – scientific basis and good clinical practice courses have been offered at the university of cape town (uct) from 2005 to 2008. independent evaluations of these courses were conducted by health care educators. why the idea was necessary as a quality-improvement measure each course was evaluated in order to judge its success and benefit to the participants. a learning history approach of planning, reflective evaluation, analysis, report, feedback and application was used to reveal opportunities or potential weaknesses of the courses. what was done the half-day training courses conducted twice a year at uct are designed to include the scientific and ethical basis of gcp. the content covers the syllabus put forward by a european science foundation advisory group, but gives particular attention to the south african local context and the vulnerable populations. presenters come from multidisciplinary backgrounds and have links to formal bodies (e.g. human ethics research committees and clinical trial units) and are therefore able to give insight into underlying principles of gcp. content covered includes the scientific basis of clinical trials; ethical considerations, including those related to the vulnerable population; new drug development and the role of the mcc; documentation issues; and audits. a case scenario is used to clarify important principles, and there is a panel discussion for interaction with participants. participants at each course were a multidisciplinary group of about 100. feedback forms were used to obtain broad perceptions regarding the course. participants were asked to rate statements around the presenters, the panel discussion and the course as a whole on a 5-point likert scale – from ‘strongly agree’ to ‘strongly disagree’. in addition, free-form responses required a response in the participant’s own words to open-ended questions. these were analysed qualitatively and provided more detailed feedback. five courses were evaluated and yielded an average return rate of >80%. the evaluations in each case provided recommendations for modification of subsequent courses. evaluation of results and impact evaluation of the five courses offered in 2005 2008 showed similar results. rated responses to statements for each course consistently indicated that participants considered the presentations, panel discussion and course as a whole as valuable and worth while. the strengths of the course were seen as: the calibre of the presenters who were knowledgeable and members of the uct research ethics committee, a local course abstracts 24 december 2009, vol. 1, no. 1 ajhpe of acceptable length, the reasonable cost and that it was offered regularly. themes emerging from the analysis of the free-form responses showed that the course satisfied a real need by providing a forum within which practical and ethical problems encountered in research could be discussed and practical problems addressed. a consistent difficulty, however, has been the diverse target group. although all attendees were involved in research they came from different educational backgrounds and therefore the level of the discourse was at times inaccessible to some of the participants. although this course is designed to satisfy mcc accreditation regulations, requests were repeatedly made to cover research other than drug development. the course has improved since 2005 owing to the ‘learning history’ cycle of evaluation, analysis, and reporting modifications based on the evaluations. participants have called for a follow-up or refresher course over and above the basic course which is now run annually. in accordance with adult learning theory recommendations were made that the follow-up course should be more participatory and take place in an active learning setting. an electronic pre-hospital emergency care registry for the management of clinical learning christopher stein e-mail: cstein@uj.ac.za context and setting clinical learning comprises an important learning opportunity in all years of study for the national diploma and bachelor’s degrees in emergency medical care at the university of johannesburg. placement of students for clinical learning, and the management and quality assurance of their activities during and after work in the field, is both complex and time consuming. why the idea was necessary students are required to record clinical data for each patient interaction and, together with evaluation data, submit these as a portfolio of clinical learning activity. the volume of raw data generated by this exercise was difficult for lecturers to assess and manage when in non-electronic format. it was also very difficult to obtain any kind of summary information regarding exposure to clinical skills for individual students or groups and thus assess the adequacy of clinical learning at any point in time. what was done a web-based clinical learning registry was designed and first implemented within the department in 2001. students followed the same procedure for point-of-care clinical data recording on paper, but were required to enter these data into the registry using the department’s computer laboratory. the registry’s design incorporates a user interface with data input validation, an input navigation form sequence specific to patient characteristics and an automated screening of existing patient care records for completeness each time a student logs in. a more detailed student evaluation tool was added to the registry in 2006. accumulated and summarised clinical learning data are available to lecturers during the course of the year through a separate user interface. this includes standardised reports on students’ usage of the system, numbers of patient care records entered, summaries of clinical skills performed and compliance with clinical skill and patient care record requirements. correctness of electronic patient care records, compared with the paper version, and the presence of required signatures are assessed by audits of randomly drawn patient care records for each student. once used for management of clinical learning, patient care records from each year are accumulated – the registry currently contains more than 20 000 of these records. evaluation of results and impact the powerful features of data aggregation and summary made possible by electronic storage, retrieval and manipulation have made management and quality assurance of clinical learning easier and more efficient. data from the registry have played a vital role in characterising the nature and extent of clinical skills exposure, a task that was not previously feasible. the registry is an invaluable source of data for both clinical and educational research. two articles, one clinical and one investigating exposure of students to clinical skills, have already been published in international emergency medicine journals based on registry data accumulated between 2001 and 2007. within the last two years three other universities in south africa offering similar programmes have approached the department and requested access to the registry for management of their own clinical learning activities. work on refining the registry for commercial release in the future has already begun. ajhpe 288.indd research october 2014, vol.6, no. 2 ajhpe 169 at the start of the 21st century, van der vleuten et al.[1] made a passionate plea for the need of evidence in health professions education (hpe). they voiced their concern that teaching is dominated by intuition and tradition, rather than by science, and that empirical verification is as important for the teaching domain as it is in professional clinical practice. in addition, recent calls have been made for hpe to reform and re-establish relevance through addressing population-based healthcare problems and keeping up with fast-changing contexts.[2] responding to these imperatives will require drawing on a foundation of evidence that has been established through research into hpe. greysen et al.[3] describe the status of hpe in sub-saharan africa (ssa) in a review of the existing literature. they suggest that while certain topics are well described, including human resource planning priorities, curricular innovations, the ‘brain drain’, and internal drain due to the lop-sided burden of disease demanding most resources, key issues such as specialist training, programme outcomes, assessment and the establishment of hpe as a specific research domain have been largely neglected. simply increasing research outputs in neglected areas will not, however, be sufficient. the nature of the research that is undertaken in such areas, as well as its focus and practical relevance are important considerations.[4-6] cook et al.[7] explored the research performed in hpe and described a framework for classifying the purpose of educational research articles. their work argued for a move beyond descriptive studies and comparisons of interventions (justificatory studies) to clarificatory studies from which models and theories are developed, and according to which predictions are made. these studies use every step of the scientific method, starting with observations, and building on previous research. o’sullivan et al.[8] join the conversation about the nature of hpe research by advocating for more collaborative research. they argue that, in the cycle of abstract theory generation to concrete practical needs and back, collaboration will enhance generalisability through obtaining a larger study sample and a shared intellectual process. the argument is no longer that we should perform hpe research, but that we need to engage more in clarificatory research, and to further strengthen the work, we also need to collaborate more frequently. the origins of hpe research can be traced back to the 1950s. the development of hpe into an independent discipline occurred more recently, and was followed by the establishment of well-structured hpe units.[9] today, hpe research is typically led by an hpe researcher and/or development unit/centre/department. in south africa (sa) it is only in the background. to generate evidence in and for health professions education (hpe) that can enable reform and establish new relevance, a comprehensive hpe research foundation is required. gaps identified in the sub-saharan africa (ssa) hpe literature should be addressed, while a need for more clarificatory and collaborative research to strengthen evidence has been expressed. relatively few hpe centres exist in ssa. at stellenbosch university’s faculty of medicine and health sciences (fmhs) the centre for hpe was established in 2006, followed by an hpe research unit in 2011. objectives. to determine and analyse the current status of educational research in the fmhs, thereby contributing to conversations around an hpe research agenda for africa. methods. a database of all hpe-related research was compiled, followed by a desktop analysis of all documents pertaining to current educational research projects in the fmhs in 2012, categorising projects according to: general information; sites where research was conducted; research focus; and research purpose. all data were recorded in an excel spreadsheet and a descriptive analysis was performed. results. there were 106 projects, mostly aimed at undergraduate programmes. more than half focused on teaching and learning, while a few focused on assessment. a number of projects were community-based or involved national and/or international collaborations. only 20% of projects were classified as clarification research. discussion. educational research appears healthy in the fmhs, but more clarificatory and macro-projects are required. the profile of research is similar to the ssa profile. a research strategy relevant and feasible in our context has to be established with a shift to areas beyond our professional/ institutional boundaries, posing hpe questions of relevance to south africa and the african continent. ajhpe 2014;6(2):169-173. doi:10.7196/ajhpe.288 building a research agenda in health professions education at a faculty of medicine and health sciences: current research profile and future considerations j bezuidenhout,1 mb chb, fcpath (sa), mmed (anatomical pathology), phd; s van schalkwyk,1 phd; b van heerden,1 mb chb, mmed, msc; m de villiers,2 mb chb, fcfp, mfammed, phd 1 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 teaching and learning, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: j bezuidenhout (jbez@sun.ac.za) researchresearch 170 october 2014, vol.6, no. 2 ajhpe last 15 20 years that hpe research has found fertile ground, and only in the last decade that hpe units have been established at various universities across the country. yet, the reality is that all universities in sa function in a resource-constrained environment, and in this context, hpe and related research is still often regarded as an optional luxury, with the demands placed on practitioners often focusing on service.[10,11] context at stellenbosch university (su)’s faculty of medicine and health sciences (fmhs) the centre for health professions education (chpe) was established in 2006. since its inception the chpe has committed itself to the promotion and support of hpe research, as is apparent from its vision statement: ‘the centre will provide outstanding academic leadership in health professions education, aimed at creating relevant health care provision in africa’.[12] to this end a unit for health professions education research was established within the chpe in 2011. the purpose of the unit is to develop and drive a unified research agenda for relevant educational research in the fmhs. as a first step it was necessary to determine and analyse the current status of educational research in the faculty. this profile could then serve as a departure point for developing a comprehensive hpe research strategy. the aim of this article is to share the results of this analysis and in so doing contribute to prevailing conversations around an emerging hpe research agenda for africa. furthermore, we hope to inform the ongoing development of hpe research in ssa through critical reflection on the implications of our findings. methods during 2011 the principal investigator met with all the heads of divisions, centres and departments (n=35) in the fmhs to introduce the hpe research unit and to determine what hpe research was performed in the departments/divisions/centres. none of them was a non-responder at this stage. a database of all hpe-related research was subsequently compiled and followed up with a desktop analysis of all documents that pertained to educational research projects in the fmhs that were current in 2012. to complete the database the su and fmhs websites were searched for documents with information related to current hpe research projects (e.g. research proposals, descriptions of research in progress, etc.). in addition, all divisions, departments and centres in the fmhs were contacted in 2012 and requested to provide any additional information relating to hpe research in their environments that was available internally and had not yet been documented. as all the departments/divisions/ centres had already provided information in 2011, non-responders to the supplementary request in 2012 were not followed up. during analysis, any reference in the texts to students and lecturers, teaching, learning, assessment, supervision, educational faculty development (fd) and curriculum were taken as being indicative of hpe research. ethical approval was obtained from the human research ethics committee at the fmhs (ethics reference no. n12/04/017). four main categories (table 1: (1) general information (title of research project; academic programme in which the research was done; participating divisions/department/centres); (2) sites where research was conducted; (3) focus of the research; and (4) research purpose of the project) were regarded as relevant to provide us with a comprehensive profile of hpe research in the fmhs. these categories would answer the questions: in which programmes was the research conducted? where was it conducted (e.g. on the teaching platform, collaborations external to the institution)? in which areas of hpe and for what purpose was hpe research performed? the available information was organised into these categories by one of the authors. the programmes in which hpe research was being performed included mb,chb (undergraduate medical); four allied health programmes (physiotherapy, occupational therapy, speech, language and hearing therapy and dietetics), mmed (resident training) and other postgraduate programmes, collectively grouped (pg). to classify the different research focus areas (category 3), we used a framework (table 2) that was developed at the fmhs to identify focus areas for hpe research in the rural clinical school (rcs).[6] based on the titles of the research projects, each research project was also classified according to its purpose, as proposed in the framework by cook et al.,[7] described above. all data collected were recorded in a spreadsheet in excel and a descriptive analysis was performed. table 1. criteria used to classify existing hpe research projects 1. general information of research project a. title of research project b. academic programme in which research is performed i. undergraduate programmes: mb,chb (medicine) physiotherapy occupational therapy dietetics speech, hearing and language therapy ii. postgraduate programmes: research masters masters in medicine (mmed) phd c. participating disciplines/centres/divisions/departments 2. site where research is conducted (rural, cape metropole/tac) and collaborations beyond fmhs (national, african continent, international) 3. research focus, according previously developed research framework[6] 4. research purpose according to cook et al.[7] hpe = health professions education; tac = tertiary academic complex; fmhs = faculty of medicine and health sciences. table 2. research focus according to research framework[6] framework n % assessment: design 3 2.8 assessment: evaluation 1 0.9 curriculum: design 12 11.3 curriculum: evaluation 8 7.5 faculty development 9 8.5 teaching and learning innovations: design 30 28.3 teaching and learning innovations: evaluation 31 29.2 student recruitment and retention 12 11.3 total 106 research october 2014, vol.6, no. 2 ajhpe 171 results the study identified 106 active educational research projects in the fmhs in 2012. table 3 shows the distribution of the projects in terms of programmes, undergraduate or postgraduate, sites of research and external collaborations. most projects were being conducted at undergraduate level with 49 (46%) of the projects focusing on the mb,chb programme. in 11 of the projects at least 3 undergraduate programmes were collaborating on the research. of these 11 projects, 6 focused on interprofessional education (ipe). eighteen (37%) of the projects in the mb,chb programme were led by a chpe staff member. there were 19 (17.9%) research projects in hpe at postgraduate level, the majority of these in disciplines that were performing research on the mmed (resident) training and 9 (8.5%) projects that focused on fd. although 72 (67.9%) of the research projects were concentrated at the tertiary academic complex (tac), there were a number of projects with a wider reach that included clinical training sites in the cape metropole (3.8%), rural training sites (5.7%) such as worcester and hermanus, or represented collaborations with other sa (4.7%), african (2.8%) or uk-based (2.8%) institutions (table 3). thirteen projects (12%) involved collaborations between the tac, cape metropole and rural areas. in terms of the research areas, the results showed that hpe research in the fmhs in 2012 focused mainly on teaching and learning innovations, with 30 projects (28.3%) on the design and 31 (29.2%) on the evaluation of such innovations, followed by research on aspects of the curriculum, with 12 (11.3%) that focused on curriculum design and 8 (7.5%) on its evaluation. student recruitment and retention received some attention with 12 (11.3%) of the projects, while there was less focus on fd (9 projects, 8.5%) and assessment (only 3 projects (2.8%), 2 focusing on development of assessment and 1 on the evaluation of assessment). table 2 provides details on the results of the analysis of the research focus according to the rcs framework. regarding the purpose of research according to cook et al.[7]’s classification, 54 (50.9%) projects were classified within the justification group. descriptive research projects represented 31 (29.2%), with 21(19.8%) clarification studies. table 4 provides more details on these categories. discussion we were heartened to find 106 research projects on hpe in the fmhs at the time of the study (2012). in addition, the extent of hpe research activities in the mb,chb programme was equally pleasing, perhaps reflecting an emerging need for evidence-based hpe in our faculty. the high percentage of mb,chb-related projects led by a member of the chpe can partially be ascribed to the fact that the current director of the mb,chb programme is also the director of the chpe. additionally, the clinical skills laboratory, the coordinator for ipe and service learning, most rcs-related research and mb,chb student support are all located in the chpe. the smaller allied health programmes also showed positive embracing of hpe research. while only 11 of the 106 projects involved three or more undergraduate programmes (mb,chb and at least two of the allied health programmes), the fact that 6 of these focused on aspects of ipe could be interpreted as a positive move towards fostering interprofessional learning as a first step towards the interdependence of health professionals.[2] in the review of existing hpe literature in ssa, greysen et al.[3] emphasise the lack of scientific publications on hpe and the need for addressing important, neglected topics, such as solution implementation, specialist training, programme outcomes, assessment and the development of hpe as a specialised field of inquiry. the results of our study show some alignment with these recommendations. when examining the projects according to table 3. classification according to academic programme and place where research was performed academic platforms collaborations rural* only cape metropole† only tac only tac, cape metropole and rural national africa international total (%) undergraduate mb,chb and at least two of the allied health programmes 3 7 1 11 (10.3) of which 6 focus on ipe allied health (one of the four programmes) 1 3 10 4 18 (16.9) mb,chb 2 1 38 6 2 49 (46.2) postgraduate 12 1 3 2 1 19 (17.9) faculty development 5 1 2 1 9 (8.5) total (%) 6 (5.7) 4 (3.8) 72 (67.9) 13 (12.3) 5 (4.7) 3 (2.8) 3 (2.8) 106 tac = tertiary academic complex; ipe = interprofessional education. *rural refers to sites removed from the central faculty and outside the borders of the cape metropole. †cape metropole includes teaching sites within the borders of the cape metropole, but not at the central site. these sites are usually in poor, underserved communities. table 4. classification according the purpose of the research as described by cook et al. [7] n (%) mb, chb allied health all ug pg fd description 31 (29.2) 11 5 3 7 5 justification 54 (50.9) 27 10 5 8 4 clarification 21 (19.8) 11 3 3 4 0 total 106 49 18 11 19 9 ug = undergraduate; pg = postgraduate; fd = faculty development. allied health includes physiotherapy, occupational therapy, dietetics and speech, hearing and language therapy. researchresearch 172 october 2014, vol.6, no. 2 ajhpe the rcs research framework (table 2), it is worthwhile noting the emphasis on teaching/learning innovations and their evaluation. secondary emphasis was on student recruitment and retention, particularly student support (11.3%), and on curriculum design and curriculum evaluation (18.8%). the dearth of projects on assessment (3.7%) is, however, a cause for concern. in 2004 schuwirth and van der vleuten[14] advocated for a return to an emphasis on underlying concepts and reflection when investigating assessment. in the context of transformative learning and interdependence it becomes even more relevant to interrogate existing assessment practices, and to develop assessment strategies and practices that will stand up to such scrutiny. another aspect that attracts attention is the paucity of projects focusing on fd (7.6%). the reasons for this were not pursued in the current research. however, potential explanations may include the lack of capacity in the chpe at the time of the study to focus on fd interventions and consequently perform research in this area. anecdotally, the argument is often made by staff that there is no time to attend fd activities because of the emphasis on clinical service-related activities. this could be discouraging to potential researchers. mclean et al.[13] clearly demonstrated the relationship between fd and the overarching outcomes of hpe, and it is therefore important to further interrogate this shortcoming. research into the faculty’s understanding of, and commitment to, fd requires urgent attention. this was also emphasised by frenk et al.[2] in their recommendations to bring hpe into the 21st century. we are, therefore, pleased to report that since completion of this study, additional support to develop a strategy and plan for educational fd has been secured, and that this strategy and plan have been developed. we are currently implementing the plan and this implementation is being researched. in view of greysen et al.’s[3] recommendations, it is unsatisfactory that less than 20% of projects focus on postgraduate education, mostly on resident training programmes. on the other hand, on a continent where there is a chronic shortage of even general medical practitioners, it is perhaps justifiable that the current emphasis on educational research is predominantly at undergraduate level. the focus on interventions and their evaluation represents, based on cook et al.’s [7] classification, description or justification studies, but not clarification. although we identified more projects as clarificatory projects than cook did (19.8% v. 12%), our classification was based on the titles of the projects only. in addition, our focus was on active research projects, not on completed, published work as was the case in his analysis. it may also be argued that less clarificatory projects reach publication as they are more likely to be complex studies, and therefore more vulnerable to the difficulties associated with reaching the submission for publication stage. innovative educational interventions such as the rcs and other decentralised clinical training platforms, afford us the opportunity to base research projects in these environments, and to investigate aspects of the interventions that are of interest, especially in relation to the retention of health professionals in rural[15] and underserved areas. it is therefore not surprising that 23 of the projects are situated rurally or in the cape metropole. the question arises as to whether our findings are relevant to other institutions or environments in africa. as suggested earlier, a comparison of our results with greysen et al.’s[3] demonstrates that the pattern of research at the fmhs, su mimics that of hpe publications from africa. one of the important issues when designing hpe research is that, although description and evaluation of interventions are essential, it is vital also to progress to the level of clarification. much of our innovation and creativity is based on unique solutions for specific problems in our context, but often many can be used in other situations or other contexts as well, and thus do not have merely local relevance. however, to demonstrate this effectively we should not only describe and evaluate the interventions, but also explore the underlying theory, or use the interventions as a springboard to develop models and generate new theoretical perspectives. to investigate the transferability of research in the local context or to strengthen research by conducting multi-institutional studies, joint planning at interand trans-professional and inter-institutional level is important – from silos and competition to collaboration and success.[13] as only 10% of our projects include partners outside of the institution, this is clearly an area that offers opportunities for further development. however, collaboration can be difficult, and it is hard work. there is often a culture of competition that starts at discipline and profession level and can hamper efforts to collaborate. it therefore requires commitment, perseverance and skills in leadership, conflict and change management, and project management. in the spirit of interdependence and to ensure the most effective use of capacity, it is logical that collaboration will be beneficial.[8] in addition, collaboration models interdependence and teamwork to our students.[16] one of the benefits of collaboration is that it will also assist in building relationships internally and externally, locally and internationally. to facilitate collaboration, existing networks like the foundation for the advancement of international medical education and research (faimer), association for medical education in europe (amee), association for the study of medical education (asme), the network towards unity for health and the medical education partnership initiative (mepi) can be of great value. if competitiveness and collaboration are not regarded as ‘either/or’ problems to be solved, but rather as polarities to be managed so as to leverage the strengths (upsides) of both and to steer away from the downsides, this may also contribute to success.[17] conclusion in conclusion, we described a process of determining the status quo with regard to educational research in a faculty of medicine and health sciences with a view to developing an agenda for hpe going forward. the profile of our active research is similar to the profile of published literature on hpe in africa. the next step will be to develop a research strategy that is relevant and feasible in our context. an effective chpe and specifically an hpe research unit will play a crucial role in driving this process that will endeavour to generate theory and provide results that can be translated into improved practice. at the heart of this approach should be collaboration at interprofessional and inter-institutional levels. as previously stated, o’sullivan et al.[8] make a strong case for collaborative research as the research questions we typically address in hpe are often interdisciplinary in nature.[8] we may argue that our work is inherently collaborative, but that such collaboration is often only within our institutions. we infrequently cross the boundaries to other institutions and countries to work on truly collaborative endeavours.[18] a move towards areas beyond our professional and institutional boundaries and to posing hpe questions in the context of health in sa and africa could address the arguments made for evidence and scientifically sound information. this evidence can then be used for the advancement of understanding hpe and decision-making regarding educational options.[1,19] research october 2014, vol.6, no. 2 ajhpe 173 references 1. van der vleuten cpm, dolmans dhjm, scherpbier ajja. the need for evidence in education. medical teacher 2000;22(3):246-250. [http://dx.doi.org/10.1080/01421590050006205] 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s0140-6736(10)61854-5] 3. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, sewankambo n, mullan f. medical education in sub-saharan africa: a literature review. med educ 2011;45(10):973-986. [http://dx.doi.org/10.1111/j.1365-2923.2011.04039.x] 4. mcmillan w. moving beyond description: research that helps improve teaching and learning. african journal of health professions education 2010;1(2):4-7. 5. ringsted c, hodges b, scherpbier a. ‘the research compass’: an introduction to research in medical education: amee guide no. 56. medical teacher 2011;33(9):695-709. [http://dx.doi.org/10.3109/0142159x.2011.595436] 6. van schalkwyk s, bezuidenhout j, burch vc, et al. developing an educational research framework for evaluating rural training of health professionals: a case for innovation. medical teacher 2012;34(12):1064-1069. [http:// dx.doi.org/10.3109/0142159x.2012.719652] 7. cook d, bordage g, schmidt hg. description, justification and clarification: a framework for classifying the purposes of research in medical education. med educ 2008;42(2):128-133. [http://dx.doi.org/10.1111/j.1365-2923.2007.02974.x] 8. o’sullivan ps, stoddard ha, kalishman s. collaborative research in medical education: a discussion of theory and practice. med educ 2010;44(12):1175-1184. [http://dx.doi.org/10.1111/j.1365-2923.2010.03768.x] 9. kuper a, albert m, hodges bd. the origins of the field of medical education research. acad med 2010;85(8):13471353. [http://dx.doi.org/10.1097/acm.0b013e3181dce9a7] 10. burch v. does africa need another journal? african journal of health professions education 2009;1:1. 11. seggie jl. mb chb curriculum modernisation in south africa – growing doctors for africa. african journal of health professions education 2010;1(2):8-14. 12. centre for health professions education, faculty of medicine and health sciences, stellenbosch university: vision. http://sun025.sun.ac.za/portal/page/portal/health_sciences/english/centres%20and%20institutions/ chse%20%28centre%20of%20health%20sciences%20education%29/about%20us (accessed 27 november 2013). 13. mclean m, cilliers f, van wyk jm. faculty development: yesterday, today and tomorrow. medical teacher 2008;30(6):555-584. [http://dx.doi.org/10.1080/01421590802109834] 14. schuwirth lwt, van der vleuten cpm. changing education, changing assessment, changing research? med educ 2004;38(8):805-812. [http://dx.doi.org/10.1111/j.1365-2929.2004.01851.x] 15. couper i, worley ps, strasser r. rural longitudinal integrated clerkships: lessons from two programs on different continents. rural and remote health 2011;11:1665-1675. 16. cruess sr, cruess rl, steinert y. role modelling: making the most of a powerful teaching strategy. bmj 2008;336(7646):718-721. [http://dx.doi.org/10.1136/bmj.39503.757847.be ] 17. johnson b. polarity management: identifying and managing unsolvable problems. amherst: hrd press, 1996. 18. bezuidenhout j. collaboration: hope for the future. african journal of health professions education 2010;2:2. 19. gruppen l. creating and sustaining centres for medical education research and development. med educ 2008;42(2):121-122. [http://dx.doi.org/10.1111/j.1365-2923.2007.02931.x] ajhpe 2009, vol.1 no.1 african journal of health professions education short report 8 may 2015, vol. 7, no. 1 ajhpe training within clinical disciplines is often challenging. in this paper, the author seeks to critically reflect on and evaluate the principle of justice in student training using vignettes to describe dilemmas that surfaced during the clinical placement of students. fieldwork placement is mandatory in most clinical training programmes. in an attempt to facilitate learning through integration of theory and praxis, one is faced with the challenge of creating these ‘real life’ situations for students in which opportunities are provided for application of knowledge and skills learnt in the lecture room. it is postulated that certain factors are essential for determining a successful learning experience, viz. a well-planned placement, with sufficient time for the clinical educator to meet individual students regularly throughout the placement and for sufficient clients to be available for each student. given the constraints within institutions in terms of human resources, availability to accommodate students, client turnovers, etc., certain training programmes may lean towards repeatedly using a particular facility to provide the required fieldwork experience. an example below is described to highlight some of the challenges in such a situation. a case example while transformation within health science faculties is progressing in south africa (sa), teaching has shifted from central hospitals to secondary and district hospitals, community health centres and rural areas.[1] in this example, a chronic-care facility has been re-used as a venue for training of occupational therapy students (in a 4-year undergraduate degree programme). the facility is a specialised hospital with 175 beds, providing services to chronically ill clients in need of nursing care. approximately 10 15 students are placed in each rotation, which may very well be viewed as ‘exploitation’ of the facility for training purposes. after review of events that occurred in this facility, the author was bound to pose the question: at what cost to the clients are students provided with these necessary periods of knowledge and skill development? table 1 lists vignettes of three patients’ experiences. the examples are quoted from anecdotal evidence, i.e. informal discussions and observations within this facility. reflections and discussion as an academic/clinical educator and congruently as an observer within this context, i noted the following as concerns: • the issue and concern over sustainability of services, which raises the question of whether it is ethical to provide a standard of care or intervention that differs from the normal routine services provided in such settings. the contravention of common-law duty of continuation of intervention is raised, as seen in thabo’s case. • issues around identification of clients for rehabilitation intervention and perceived incidental or consequential exclusion of others, as in mary’s case. • clients receiving intermittent services appeared to be disadvantaged by this prevailing system, as described in alan’s case. these sporadic services raise the question of whether placement of students is disadvantageous to an under-resourced facility. the ethical dilemmas above are commonly found in the provision of health services. distributive justice[2] (how to dispense or allocate resources); nonmaleficence[3] (the obligation to avoid doing harm directly or indirectly); and paternalism[2] (making decisions for others in what is considered to be their best interests) are issues that are often raised. consequently a number of occupational injustices[4] were identified, viz. occupational deprivation[4] (when persons cannot engage in occupations that are necessary and meaningful to them because of factors outside their control) as in mary’s case; occupational alienation[4] (when people experience a prolonged disconnectedness, emptiness, and/or sense of meaninglessness) as in alan’s case, and occupational imbalance[4] (when some people are over-occupied and others are under-occupied). distributive justice: severe limitation of resource personnel and need for services when ethically arguing for equal access to healthcare for all, the principle of justice and its derivative, distributive justice, is essential. under section 27 of the sa constitution,[5] access to healthcare is a recognised right, and in order to achieve success in the provision of health services, there is a need for human rights and ethicolegal principles to be adhered to as monitors of this process. the onus is on the state and therefore staff employed by the state to ensure that steps are taken to realise these rights. however, the provision of the rights depends on whether resources are available. reid and cakwe[1] highlighted human resource challenges faced by health sciences faculties in sa. lack of resources has terminated blocks which had one of the fundamental precepts in the training of students in a clinical discipline involves appropriate placement and supervision in order for learning outcomes to be achieved. as an academic/clinical educator, one is at times faced with dilemmas in student placement that challenge one’s personal and professional ethics. this paper highlights one case example that describes student training and the impact on service delivery. afr j health professions educ 2015;7(1):8-9. doi:10.7196/ajhpe.405 an ethical dilemma: a case of student training, intermittent service and impact on service delivery p govender, bot, mot, camag discipline of occupational therapy, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: p govender (née naidoo) (naidoopg@ukzn.ac.za) short report may 2015, vol. 7, no. 1 ajhpe 9 previously involved students in community-based projects. this burden has at times been reduced through university and government collaboration. notwithstanding this, should students then be placed in under-resourced settings given that the general public suffers from the consequence of any decision pertaining to resource distribution and therefore access to healthcare?[2] autonomy, beneficence and non-maleficence[4] the notion of autonomy accepts that a mentally/legally competent client has the capacity to understand, reflect, reason and make an informed decision. in the context of rehabilitation services, this would imply that a mentally/ legally competent individual would be able to make an independent decision on whether or not to receive services. therapists, on the other hand, are obliged, by virtue of their registration with the health professions council of south africa, to allocate services primarily on the basis of need. the reality in this setting is that clients are screened, based on their individual needs, and the issue of the client’s willingness to receive these services is raised (autonomy), despite informed consent. it could be argued that provision of services, albeit intermittently, benefits the client. in many rural sites where there are few therapists, students provide a service that would otherwise not have existed.[2] in this case the placement of students could be seen as an act of beneficence.[4] students prepare detailed handovers with recommendations for continued intervention when they leave. alan’s experience however demonstrates that clients could feel a sense of abandonment, loneliness and experience negative emotions. this may be a violation of the principle of non-maleficence. this ‘harm’, though not envisaged, needs to be considered at both the referral and handover stages as the service provided is not acting in the best interest of the client (beneficence). according to the patient’s rights charter to which all practitioners ascribe, no client may be abandoned by a healthcare practitioner, who initially took on the responsibility for the client’s health.[1] clients are therefore assured of continuity of care. conclusion training of students within natural clinical environments other than lecture rooms appears to succeed only when specific supports and accommodations are provided to both students and the recipients of the service. while an opportunity for optimal learning, these situations often raise issues of ethical and moral responsibilities that tug at one’s own professional intentions. in the effort to reach outcomes as required by an educational curriculum, the goal of ensuring optimal healthcare to clients remains a paramount professional ethical responsibility. this report was intended to highlight just a few ethical dilemmas that surfaced in one setting. the author remains challenged in ensuring that there is balance between what students can contribute, the demands teaching places on the system for support, and carefully managing ethical principles while ensuring sustainability of these educational initiatives. acknowledgement. the author would like to acknowledge mrs n motala for her insights into the bioethics and health law. references 1. reid sj, cakwe m. the contribution of south african curricula to prepare health professionals for working in rural or under-served areas in south africa: a peer review evaluation. s afr med j 2011;101:34-38. 2. dhai a, mcquoid-mason d. bioethics, human rights and health law. principles and practice. cape town: juta, 2011. 3. gelling l. ethical principles in healthcare research. nursing standard 1999;13(36):39-42. 4. duncan m, watson r. transformation through occupation: towards a prototype. in: watson r, swartz l, eds. transformation through occupation. london: whurr publishers, 2004:301-318. 5. constitution of the republic of south africa. act 108 of 1996. butterworth’s statutes of south africa, february 2007. http://www.gov.za/sites/www.gov.za/files/images/a108-96.pdf (accessed 16 april 2015). table 1. vignettes vignette 1 thabo* is a 34-year-old african male, admitted to the facility 3 years ago from a respite unit. diagnosed with stage three, symptomatic retroviral disease, with a cd4 count of 180. he is currently on highly active antiretroviral therapy. he suffered a bilateral cerebrovascular accident 5 months ago and has comorbidities of hepatitis b and encephalomyelitis. thabo was referred to a third-year student with a focus on therapeutic intervention (rehabilitation). rehabilitation was clientcentred towards achieving goals aimed at improving thabo’s quality of life at this stage of care. he responded well to interventions, making gains in his overall motivation, endurance and ability to execute personal management tasks with assistive devices and adaptations. later that year, he was referred to a secondyear student with a focus on assessment. this process was used as a reassessment of the gains thabo had made in therapy; however, there were no sustained therapeutic interventions. in the period between these two rotations of students thabo did not receive any rehabilitation (approximately 3 4 months). vignette 2 mary* is a 68-year-old afrikaans-speaking lady who has been residing in the facility for 15 years because of the degenerative nature of her condition (multiple sclerosis). she has symptoms related to loss of sensitivity, general muscular weakness, spasms, incoordination and chronic pain. she is bowel and bladder incontinent and has an unstable mood. she is in a ward with 15 other clients, 10 of whom were engaged in rehabilitation with students. mary would often verbalise to the students the need to be part of the programme; however, she had not been identified as requiring intervention by the resident rehabilitation therapists. she would often be seen lingering outside therapy areas, and at times in emotional outbursts, swearing profanities at her fellow in-patients who received interventions, indicative of the apparent preference for some clients over others. vignette 3 alan,* a 48-year-old indian male, was diagnosed with a severe traumatic brain injury and c4 complete spinal injury following a hijacking and assault incident. he was admitted to the unit from a rehabilitation setting. he had undergone 8 months of rehabilitation prior to admission. he was allocated to a student in the first rotation in the year and benefitted from individual and group rehabilitation. the students left by mid-year and a new group of students returned 2 months later. during this time, alan received minimal intervention. when approached to consent to treatment by another student, alan refused, indicating his refusal was due to non-sustainability of services. *names have been changed to maintain confidentiality. research may 2014, vol. 6, no. 1 ajhpe 33 research currently, radiography students are faced with the challenge of having to learn factual information, while being taught how to interpret the information available to them to problem solve and reflect on their judgement within a given clinical context.[1,2] problem solving is a vital competency for healthcare professionals in an era of rapidly advancing technology.[3,4] it requires critical thinking, and improves the quality of a clinical service offered and the efficiency of delivering such a service.[5] therefore, enabling students to problem solve will in turn improve clinical competence.[4] to improve problem-solving skills of radiographers, problem-based learning (pbl) has been incorporated in the radiography curriculum in certain institutions in africa, one of which is the makerere university in uganda. pbl was first introduced into medical education in the 1960s in ontario, canada for physicians.[2] it is a popular teaching method, utilising problem-solving skills, and has been used successfully for some radiography, nursing and paramedic curricula.[6,7] however, a gap still exists in the literature on the assessment of problem-solving abilities in radiography. the skill can be defined as the student’s ability to use objectives and operations to reach a specific goal within certain constraints.[8] it requires inference, involving the identification of factors to come to reasonable conclusions.[3,9] a student who demonstrates good problem-solving skills considers relevant information to deduce judgements, inferences, statements, beliefs and opinions. this competency encompasses the ability to query evidence, present alternatives and draw conclusions.[9] freeman and lewis[8] highlight four components of problem solving, i.e. goal (the solution), objects (what can be used to reach the goal), operations (permitted actions in reaching the goal) and constraints (limitations). in addition, they identify the concept of well-defined problems (all necessary information is given) and ill-defined problems (little or no information is given). in the health sciences, most problems fall into the latter category.[8] the competency requires critical thinking, which causes individuals to constantly improve their skills for personal and professional growth, thus enabling healthcare workers to make more informed decisions in the clinical environment.[4,10] therefore, teaching students to problem solve allows the practitioner to integrate theory and practice, improves clinical reasoning and addresses the needs of the patient owing to clinical efficiency and better patient care.[4,5,10] the south african qualifications authority (saqa) added a new dimension to teaching, learning and assessment with the publication of the critical cross-field outcomes that students need to attain in addition to the programme outcomes. critical thinking and problem solving are listed among the 12 outcomes. although the publication dates back to 1995, it is valid to question the ability of third-year radiography students to attain these specific outcomes, as information in this field in a radiography context is lacking.[11] in the south african context, problem-solving skills among radiography students have not been assessed. the ability of the students to demonstrate problemsolving skills needed to be explored so that the department of radiography could develop a more explicit curriculum to facilitate these competencies. the aim of this study was to evaluate the problem-solving skills of thirdyear radiography students at a comprehensive south african university. methods a descriptive exploratory research design was used to collect both quantitative and qualitative data. the study design was selected to explore, background. developing the problem-solving skills of student radiographers is imperative for encouraging critical thinking and allowing them to work efficiently in an era of rapidly advancing technology. students’ ability to demonstrate these skills was studied so that the department of radiography, at a comprehensive university in south africa, could develop a more explicit curriculum to facilitate these competencies. objective. to assess problem-solving skills of third-year radiography students at a comprehensive south african university. methods. the study employed a descriptive exploratory design. the participants’ responses to vignettes (in the form of clinical scenarios) were analysed using a likert scale and action verbs developed for evaluating evidence of problem-solving skills and providing quantitative data. field notes were made while analysing responses to each question, providing qualitative data. results. the findings indicate that the majority of participants demonstrated a minimal ability to problem solve in a vignette. this implies that to improve problem-solving skills of student radiographers, there is a need for curriculum adjustment to nurture and encourage this competency. conclusion. facilitators need to be taught methods to integrate problem solving into the curriculum, and learning material must be adjusted to accommodate problem solving for this skill to become part of the programme outcomes. ajhpe 2014;6(1):33-36. doi:10.7196/ajhpe.297 problem-solving abilities of radiography students at a south african university t pieterse,1 mtech (radiography); h lawrence,1 dtech (radiography); h friedrich-nel,2 phd (health professions education) 1 department of radiography, university of johannesburg, south africa 2 central university of technology, bloemfontein, south africa corresponding author: t pieterse (traceyp@uj.ac.za) mailto:traceyp@uj.ac.za 34 may 2014, vol. 6, no. 1 ajhpe identify and describe themes and patterns in the data, which were then used to judge the students’ problem-solving skills.[12] students were asked to pose a solution to a scenario-based vignette, constructed by the researcher, and tailor made for radiography students to extract problem-solving skills in a radiography context. the participants’ skills were then assessed using a rubric designed by the researcher (appendix 1) after a literature review to obtain information on current and popular data collection tools used in the assessment of this competency in higher education. the rubric consisted of a list of attributes integral to problem solving, supported by concepts found in the literature. these included understanding of the problem, planning of an appropriate solution, ability to carry out the plan correctly and logically, and ability to evaluate the result.[3] each vignette was assessed by assigning a score from 1 (not at all) to 4 (to a large extent), and this information was used to generate the quantitative data. in addition, the researcher wrote extensive field notes, indicating the thought processes of the participants for each attribute identified as integral to problem solving. by reading participants’ responses to each vignette, as advocated by creswell,[13] the researcher reflected on the data, reread the participants’ responses and assigned a value according to the likert scale as well as attributes identified for each vignette. in addition, the researcher made notes inductively on the thought processes relating to the participants’ responses to the specific vignette, thus generating qualitative data. the quantitative data were therefore further supported by the qualitative data. the vignette designed to extract the critical thinking skills of problem solving used in this study was as follows: ‘a 36-year-old female patient presents to the imaging department with a 5-day history of numbness and pins and needles in her right arm. the patient is 8 weeks’ pregnant. the referring physician has requested a radiograph of the lumbar spine. apply your knowledge to the above scenario and hypothesise what you would do in the above situation.’ the attributes integral to problem solving were then assessed. the cohort for this research study consisted of third-year radiography students (n=73) at a south african university. a single-stage sampling design was used as a sampling frame, which could be developed from the number of students registered. furthermore, a non-probability sampling approach was used for convenience, the researcher’s access to the third-year radiography students and their availability. the study sample consisted of 59% (n=43) of the total cohort of registered students. ethical clearance was given by the ethics committee of the faculty of health sciences of the university concerned. permission to conduct the study was obtained by the head of the department of radiography at the university where the study was conducted. participants were recruited once informed consent was obtained and confidentiality was ensured by assigning numbers to participants. the researcher gave the problem-solving vignette to the students, who were instructed to respond in writing. participants were reminded of their voluntary participation, and responses to the problem-solving vignette were collected by the class representative and handed back to the researcher. the vignette was handed to the participants once the researcher was assured that they had gained the theoretical knowledge and had attended the practical demonstration relating to the topics of the problem-solving vignette. to ensure that participants did not discuss their answers, the vignettes were handed out in an assessment environment, in the presence of an invigilator. on completion of the vignette, the researcher assessed the problemsolving skills of participants using the 4-point likert scale according to the attributes identified for problem-solving skills. detailed field notes of each participant’s response to the vignette were compiled. to ensure the validity of the vignettes, a field expert was consulted to verify the suitability of questions used prior to data collection. the selfdesigned measurement rubrics used in this study were also verified by a field expert. this ensured that the use and measurement of the problemsolving vignette were appropriate and applicable to problem-solving skills, and based on the theoretical and practical knowledge that the student had gained to answer the vignette. in addition, triangulation of data by statistical analysis and the generation of themes,[13] as well as the use of an independent coder, further ensured validity of the research process. reliability was ensured through consultation with an independent coder to review students’ responses to vignettes, only after the researcher had reviewed and documented the responses. by comparing results with the independent coder, consensus was achieved regarding the rating for a particular student’s response, thereby avoiding any bias from the researcher. observation of 10 subjects or events by an independent coder is considered adequate judgement to ensure inter-rater reliability, as advocated by burns and grove.[12] another indication of the reliability of a measurement tool is its internal consistency.[14] statistical analysis of cronbach’s coefficient alpha was performed for problem-solving skills measured in this study, its value achieved being 0.924 with four items on the scale. dependability was ensured by triangulating data collection, as well as by providing a dense description of the research methods.[15] the numerical data were analysed statistically using spss. the qualitative data were analysed as suggested by creswell,[13,16] by coding the information, generating themes from the codes and interpreting the meaning of the data. this was achieved by reading the participants’ responses to each vignette, reflecting on the data and re-reading the responses. this method enabled the researcher to make in-depth field notes inductively while assigning a value (according to the 4-point likert scale) for each of the attributes identified to rate the participants’ responses to the vignette. the field notes were then coded, forming themes, and verbatim quotes were added as supportive evidence. results measurement of problem-solving skills was subdivided into four attributes (understood the problem, planned an appropriate solution, carried out the plan correctly and logically, and evaluated the result) considered integral for demonstrating problem solving. the attributes were scored on a 4-point likert scale. the mean score for the participants’ ability to demonstrate problem-solving skills was 2.32, indicating a minimal ability to problem solve. of the 43 participants, 20.4% could problem solve to a large extent, while 29.7% showed no problem-solving skills. it is interesting to note that 46.5% of participants understood the problem, 14% planned an appropriate solution and 11.6% carried out the plan correctly and logically. quantitative data fig. 1 illustrates the ability of participants to demonstrate the attributes of problem-solving skills. almost half of the group understood the problem, while the majority were unable to plan a solution and carry out an research research may 2014, vol. 6, no. 1 ajhpe 35 research appropriate plan. just over 40% of participants in this vignette were able to evaluate the result to a minimal level. table 1 indicates the mean score for the attributes demonstrating problem-solving skills. the standard deviation (±sd) ranges from 0.926 to 1.194. looking at this large variation in sd, and with reference to fig. 1, one can observe that although the total mean score for participants to demonstrate problem-solving skills was minimal, some participants achieved a moderate score and others a ‘not at all’ score, proving a greater degree of variability for this skill. qualitative data the quantitative data are further supported by the results of the qualitative data. the vignette called for each participant to demonstrate problem-solving skills by determining that the examination requested did not correlate with the clinical symptoms and providing a possible course of action. compounding the problem was the fact that the patient was 8 weeks’ pregnant. the participants’ answers to the vignette led to the generation of the following theme: ‘inability to analyze the problem’. the researcher concluded that participants have the ability to identify problems that may exist in the vignette, but are unable to identify solutions, or they propose solutions that are not feasible in the given scenario. the following verbatim quotes were extracted from the participants’ vignettes to support this theme: ‘i would suggest that the patient has an mri of the lumbar spine . . .’ – participant 42. ‘first i would advise her to go to another physician for second opinion, if she is willing i would do ap, lateral and oblique views for the lumbar spine, and a ap pelvis . . .’ – participant 29. ‘considering that i will never do the lumbar spine i will do only the right arm lateral to see if the pins are still aligned . . .’ – participant 35. ‘pins and needles down the arm would be an indication a cervical examination not lumbar. the patient being pregnant will also limit the amount of views . . .’ – participant 49. discussion participants in this study very clearly understood the problem by highlighting the obvious (that the patient was 8 weeks’ pregnant), but then neglected to notice that the patient’s history did not correlate with the requested radiographic examination. as participants were unable to reflect on the vignette as a whole, their problem-solving ability was limited, with many unable to link the clinical information given and the examination requested – therefore not recognising the problem. participants who correctly identified the mismatch between the clinical information given and the examination requested were not sure of the correct procedure to follow. this led to some participants being unable to suggest a reasonable solution to the problem and some resorted to refusing to x-ray the patient. a study by fero et al.[17] on nursing students’ critical-thinking skills yielded similar results to those found in the current investigation, revealing that 75% of student nurses did not meet overall expectations relating to a given simulation designed to test for problem-solving ability. most nursing student errors were associated with problem recognition and reporting findings to the referring doctor. almost half of the participants in fero’s et al.'s study correctly recognised the problem, while 100% were unable to justify their decisions.[17] in the current study, participants realised that they should not take a radiograph of a pregnant patient, but seemed unable to design an appropriate path to follow. again, when faced with a problem to solve, participants tended to refer the matter to a qualified radiographer who would instruct them with regard to a course of action, or take over the patient from them, thereby eliminating the student from the problem-solving process. this minimal ability to problem solve could be due to students not being given the opportunity to think for themselves. in busy imaging departments, students tend to step aside when complications arise, and allow the qualified radiographer to take the lead. very often students table 1. ability of participants to demonstrate attributes of problem-solving skills (n=43) attributes for critical thinking skills: problem solving mean score (maximum = 4) standard deviation (sd) understood the problem 2.84 ±1.194 planned an appropriate solution 2.23 ±1.088 carried out the plan correctly and logically 2.19 ±1.052 evaluated the result 2.00 ±0.926 total mean 2.32 ±1.065 50 45 40 35 30 25 20 15 10 5 0 understood the problem planned an appropriate solution carried out the plan correctly evaluated the result critical-thinking attributes not at all minimally moderately to a large extent 16 .3 30 .2 46 .5 7 34 .9 20 .9 30 .2 14 34 .9 23 .3 30 .2 11 .6 32 .6 44 .2 14 9. 3 pa rt ic ip an ts , % fig. 1. participants demonstrating attributes of problem-solving skills. research 36 may 2014, vol. 6, no. 1 ajhpe might continue with another patient, instead of following through with the initial patient and assisting the qualified radiographer. the findings of this study are unique to the radiography setting and provide a platform for further studies in problem solving in radiography education. a literature survey revealed that problem-solving skills can be taught to students using various methods that should be integrated into the curriculum. however, before educators can expect students to demonstrate problemsolving skills, facilitation of these skills must be incorporated into the academic programmes.[3,5,18] conclusion the results of this investigation demonstrate that the majority of radiography students who participated in this study were unable to problem solve to a large extent in a written clinical scenario, and therefore the current students will not have the ability to optimally apply these skills in a clinical setting. regretfully, this study has revealed that radiography educators at the university concerned have not adequately facilitated the development of problem-solving skills among third-year radiography students. therefore, interventions are required to meet the standards stipulated by saqa. implementation of role-play, video-taped simulation sessions, use of case studies, as well as integrated assessments are modalities that should be included in the curriculum to encourage and nurture problem-solving skills and in turn improve clinical efficiency of student radiographers. acknowledgement. we acknowledge the staff qualification project of the university of johannesburg. references 1. spencer c. critical thinking in nursing: teaching to diverse groups. teaching and learning in nursing 2008;3:87-89. 2. kowalczyk n, leggett td. teaching critical-thinking skills through group-based learning. radiologic technology 2005;77(1):24-29. 3. castle a. defining and assessing critical thinking skills for student radiographers. radiography 2009;15:70-76. 4. distler jw. critical thinking and clinical competence: results of the implementation of student centered teaching strategies in an advanced practice nurse curriculum. nurse education in practice 2007;7(1):53-59. 5. agwu kk, ogbu soi, okpara e. evaluation of critical thinking application in medical ultrasound practice among sonographers in south-eastern nigeria. radiography 2007;13:276-282. 6. edwards h. critical thinking and the role of the clinical ultrasound tutor. radiography 2006;12(3):209-214. 7. kiguli-malwadde e, francis b, gonzaga ma. attitudes and perceptions of students and teachers about problem based learning in the radiography curriculum at makerere university, uganda. european journal of radiography 2009;1:156-162. 8. freeman r, lewis r. planning and implementing assessment. london: kogan page, 1998:236. 9. facione pa. critical thinking: what it is and why it counts. millbrae: measured reasons and the california academic press, 2011. http//www.insightassessments.com (accessed 22 august 2011). 10. popil i. promotion of critical thinking by using case studies as teaching method. nurse education today 2011;31:204-207. 11. south african qualifications authority. qualifications and unit standards, qualification id number 66949. http://www.saqa.org.za (accessed 23 march 2010). 12. burns n, grove sk. the practice of nursing research: conduct, critique and utilization. 5th ed. st louis: elsevier, 2005:232. 13. creswell j. research design: quantitative, qualitative and mixed methods approaches. 2nd ed. london: sage, 2003:190-195. 14. pallant j. spss survival manual. 3rd ed. glasgow: bell and bain, 2007:6. 15. de vos as. research at grass roots: for the social sciences and human services professions. 4th ed. pretoria: van schaik, 2011:443-444. 16. creswell j. qualitative inquiry and research design: choosing among five approaches. 3rd ed. los angeles: sage, 2013:186-188. 17. fero lj, o’donnell jm, zullo tg, et al. critical thinking skills in nursing students: comparison of simulationbased performance with metrics. journal of advanced nursing 2010;66(10):2182-2193. 18. castle a. assessment of the critical thinking skills of student radiographers. radiography 2006;12:88-95. 19. kiah cj. a model for assessing critical thinking skills. conference proceedings: annual student assessment conference of the virginia assessment group and the state council of higher education for virginia, 1993. appendix 1. problem-solving rubric[8,19] 1 = not at all 2 = minimally 3 = moderately 4 = to a large extent • understood the problem (interpretation, identifies essentials of the goal to be achieved) • planned an appropriate solution (generation, addresses core issues, uses a feasible plan, plan is reasonable for achieving goal) • carried out the plan correctly and logically (strategising, steps in achieving the goal are clearly set out) • evaluated the result (reflection, strengths and weaknesses identified) http://www.insightassessments.com http://www.saqa.org.za ajhpe 211.indd 124 october 2014, vol.6, no. 2 ajhpe research it is important that academics have a common definition of the scholarship of teaching.[1] for academics in the faculty of community and health sciences (fchs) at the university of the western cape (uwc), bellville, south africa, to have a scholarly approach to teaching could mean that they are familiar with the latest evidence relating to their subject, being informed by current ideas for teaching that subject, evaluating and reflecting on their teaching practices, sharing characteristics of excellent and scholarly teaching, and communicating, disseminating and investigating their teaching practices. at uwc, the scholarship of teaching has become a priority as part of the institutional operational plan 2010 2014 for the professional development of the teaching community.[2] the department, discipline and level of study are important factors in linking research and teaching.[3] educators’ teaching should also be informed by the purpose that the university has identified for itself.[4] in this way, teaching will be driving the purpose in the manner that it has been conceptualised and organised. in line with the developments at uwc, the fchs has highlighted the following goal as part of its teaching and learning plan for 2010 2014: ‘to provide opportunities for an excellent teaching and learning experience that is contextually responsive to the challenges of globalization and a society in transition, and which enhances students’ capacity as change agents’.[2] to achieve this goal, teaching must be evidence based. the scholarship of teaching is one way to facilitate the process of integrating research into teaching activities. scholarship is a synonym for research and identifies it as the scholarship of discovery, where new knowledge is added through the process of inquiry and investigation.[5] various authors have defined the scholarship of teaching.[6-8] the definitions include the scholarship of teaching as ongoing learning about tutoring and the demonstration of such knowledge; publications, and ultimately engagement with existing knowledge on teaching; self-reflection on teaching in one’s discipline; and publicly sharing ideas about teaching within the discipline. similarly, healey[1] stated that ‘the scholarship of teaching involves engagement with research into teaching, critical reflection of practice, and communication and dissemination about the practice of one’s subject’. it is therefore evident that in the scholarship of teaching there should be definite evidence of research. however, according to boyer’s expanded definition of scholarship as cited by glassick,[9] it should include research and the scholarship of integration, application and teaching. according to some of the literature, broader definitions of scholarship have emerged where authors maintain that ‘creative teaching with effectiveness that is rigorously substantiated, educational leadership with results that are demonstrated and broadly felt, and educational methods that advance learners’ knowledge are consistent with the definition of scholarship’.[10] higher education (he) faces demands for increased public accountability and the benefits of strengthening the link between research and teaching. these institutions are expected to provide future students with an excellent teaching and learning experience, informed by up-to-date research. every student should study in an environment that is informed by research, scholarship and up-to-date practice and knowledge. both undergraduate and postgraduate programmes should develop generic skills for effective background. the scholarship of teaching involves the integration of research into teaching activities, critical reflection of practice, and communication, and dissemination of the practice of one’s subject. however, it is not clear what the needs of academics in the faculty of community and health sciences at the university of the western cape, bellville, south africa, are with regard to integrating research into their teaching practices. objective. to present the findings of the views, perceptions and experiences of academics in the abovementioned faculty regarding their understanding and integration of research into their teaching activities. methods. the study followed a cross-sectional research design. data were collected by means of an electronic questionnaire to explore the academics’ views and perceptions with regard to the integration of research into their teaching and related experiences. data were analysed using the first two phases of the appreciative inquiry process as a guideline. results. it was evident that participants had a clear understanding of research. the majority understood that the scholarship of teaching involved both the lecturer and the learner and, most importantly, the conducting of research to share it with others. conclusion. findings from the needs assessment can be used as a guideline to assist in strategies for staff development. academics need to give equal attention to both teaching and research. the scholarship of teaching facilitates this through the integration of research into teaching. ajhpe 2014;6(2):124-128. doi: 10.7196/ajhpe.211 integrating research into teaching: needs assessment for staff development j de jongh,1 phd; j frantz,2 phd; a rhoda,2 phd 1 department of occupational therapy, faculty of community and health sciences, university of the western cape, bellville, south africa 2 department of physiotherapy, faculty of community and health sciences, university of the western cape, bellville, south africa corresponding author: j de jongh (jdejongh@uwc.ac.za) october 2014, vol.6, no. 2 ajhpe 125 research engagement in society and the workplace.[11] the scholarship of teaching through research has the potential to contribute abundantly to the field of he.[12] even though there is considerable emphasis on enhancing the links between teaching and research, the challenge of how to better integrate these two activities remains. there is still work to be done to ensure that academics within he institutions believe that the scholarship of teaching is valued as much as other research activities.[13] contemporary university systems increasingly show evidence of having entrenched the separation of research and teaching in their committee structures, development of research centres, selection and promotion criteria, funding and workload models. this has contributed to the paradoxical position that, while promoting research-led teaching, universities view these two activities as separate and bound. this disruption of a relationship between research and teaching challenges the traditional model of universities where academic staff are both teachers and researchers. it is not clear whether academics at fchs integrate research into their teaching practices. therefore, a needs assessment was done to assist in developing strategies and educational programmes to facilitate such a process.[14] the first two phases of the appreciative inquiry (ai) approach were used as a guideline to assess the needs of academics with regard to integrating research into their teaching practices.[15] ai is a strength-based change process based on the premise that academics are change agents who possess knowledge and experience that can make a difference. the process of ai is based on asking the right questions, focuses on building relationships on strengths rather than weaknesses, and is iterative.[16] the ai process has five phases: (i) defining the need for an intervention (establishing the focus and scope of the inquiry); (ii) discovering what is good and has worked (appreciating what it is and how it can be used); (iii) dreaming what might be; (iv) designing what should be; and (v) creating what will be.[17] this article forms part of a larger study that incorporated all the phases of the ai approach, but attempts to present the findings of an initial needs assessment exercise with academics to better understand their views, perceptions and experiences on research, scholarship of teaching, methods, and activities to integrate research into their teaching practices. findings from the first two phases of the ai model, i.e. defining the need for an intervention and discovering what has been successful, will be presented to inform the faculty about the development of strategies to assist academics on integrating research into their teaching practices. methods research design a cross-sectional study design was used to investigate and describe the participants’ views on research, scholarship of teaching, methods, and activities to integrate research into their teaching practices. data collection a questionnaire and letter on the purpose of the study were circulated electronically to all participants. the questionnaire (appendix 1) consisted of two sections. section one entailed the demographic information of the participants and section two consisted of seven open-ended questions that allowed the participants to share their views, perceptions and experiences on defining research, activities to integrate research into teaching, understanding of the scholarship of teaching, and methods to promote and develop the scholarship of teaching in the teaching modules. data analysis data were analysed thematically using a qualitative approach and according to the definition of research and the scholarship of teaching, including activities to promote and develop the scholarship of teaching in the teaching modules. three researchers independently identified the key concepts from the participants’ feedback on the seven open-ended questions. consensus was reached among the three researchers regarding the key concepts. participants’ perceptions and experiences were described and supported by their statements. this process of data analysis highlighted the views, perceptions and experiences of the participants in integrating research into their teaching activities. ethical approval was obtained from the research ethics committee at uwc (reg. no. 11/3/14). results the findings of section one of the questionnaire are presented to provide a demographic overview of the participants (table 1). the findings of section two are presented according to the first two phases of the ai framework, i.e. the defining and discovery phases. section one: sociodemographic information of the participants of the 10 departments in the faculty, only six responded, i.e. sport, recreation and exercise science, occupational therapy, physiotherapy, social work, school of natural medicine and the interdisciplinary teaching and learning unit, yielding a 60% response rate in terms of departmental representation. the four departments that did not respond were dietetics, nursing, psychology and school of public health, the main reason being prior engagements on participation dates. of all the possible respondents (n=95), only 21 (22%) responded. of these, the majority were female (76%) and their academic status was at a lecturer table 1. sociodemographic information (n=21) variable n (%) gender male female 5 (24) 16 (76) academic status associate lecturer lecturer senior lecturer associate professor 3 (14) 16 (76) 1 (5) 1 (5) lecturers undergraduates postgraduates both other (no indication) 14 (67) 3 (14) 3 (14) 1 (5) publications none peer reviewed, accredited 13 (62) 8 (38) 126 october 2014, vol.6, no. 2 ajhpe research level (76%) and beyond. the majority (67%) were primarily involved in undergraduate teaching and the class sizes ranged from 15 to 150 students. all the respondents had decision-making capacity in their own modules. only about one-third (38%) had published academic articles previously; one of them had published half of the papers. the majority (62%) had not published previously. section two: defining phase participants’ understanding of research and the scholarship of teaching all the participants, except one, understood research as a process with specific steps to be followed. one participant stated: ‘research is an investigating process into a specific topic of interest or need in your field of speciality in order to gain a better understanding of a specific aspect and to create knowledge through your findings.’ furthermore, all the repondents defined research to be organised and systematic and that the process should have a specific outcome or purpose. another respondent stated: ‘it is a scientific enquiry conducted in an area of interest to the researcher with the purpose of contributing to a body of knowledge.’ it was therefore evident that the majority of the respondents understood that research involved systematically setting realistic goals to achieve specific outcomes. the respondents experienced defining the scholarship of teaching as challenging. the majority experienced it as assisting them in increasing their expertise as a teacher. one participant stated: ‘it will assist a person in reflecting and improving on the teaching strategies … .’ most reflected on how important it was to understand the scholarship of teaching, as it could assist them in understanding the learning needs of their students. another state ‘… assist us to better our own teaching practices to help students learn better.’ respondents felt that it was important to turn their teaching activities into research projects that could be shared with other colleagues: 'writing up your teaching practices and using the data to conduct scientific enquiry contributing to a body of knowledge on teaching and learning in higher education.’ less than half of the respondents indicated that they had little or no understanding of the term. one of them stated: ‘i don’t know.’ from the findings it was evident that most of the participants understood that the scholarship of teaching involved both the lecturer and the learner and should include a research component that could eventually be disseminated to others. section two: discovery phase methods of improving and promoting student awareness regarding the integration of research in the teaching modules all the participants gave examples of learning activities they had used to improve students’ awareness regarding the integration of research in their teaching modules. the various learning activities were research based and/or research led. they used learning activities, such as assignments, where students were expected to do research on the literature on a specific topic taught in class and apply research methods to answer a question. case studies were used where students had to link their case with their fieldwork to present their findings. from the findings, on an ongoing basis, the participants linked the content taught in class with current evidence in the literature. participants also indicated that they included relevant articles in their course and highlighted that the academic level of the students influenced the degree to which research was incorporated in their teaching module. one participant who taught second-year students, said: ‘my focus is more on the basic skills needed for research. i therefore try to include a lot of literature review and understanding how to read research journals.’ a participant who taught postgraduate students referred them back to the latest evidence and gaps in knowledge that could be addressed. some of the participants still experienced research and teaching activities as separate entities because they did not plan their teaching modules with the specific purpose of integrating research into their teaching activities. one participant stated: ‘… this is a process in the making, being that these initiatives are being coordinated throughout the department as a fairly new concept. this is brought upon by the attendance of teaching and learning workshops and research workshops.’ methods and activities used by participants to improve and promote the scholarship of teaching in their teaching modules from the findings, the majority of participants could indicate how they had attempted to promote and develop the scholarship of teaching in their teaching modules. they used different methods, e.g. peer review, course evaluation by students, attending workshops for personal development and understanding, reflecting on their own teaching strategies and methods, a variety of teaching activities to enhance students’ learning experiences, implementation of evidence-based practice, and publications (table 2). table 2. activities to integrate research into teaching level of student learning activity objective method level of research undergraduate assignments enable awareness of research by searching the literature and using research methods students must research content for their assignment include data collection methods, e.g. surveys or interviews to answer a question research based research tutored case studies link cases in clinical settings to a research question students recruit participants relevant to the topic, interview them, analyse the information and present their findings research based evidence-based teaching ensure that all information provided is evidence based link content taught to students and current evidence in the literature, including relevant articles in the course reader research led postgraduate articles in assessment integrate articles as a method to find answers examination questions are supported by articles that students need to discuss critically research led situational analysis determine the population need according to the student and support it with literature students relate to current situations in the country and find relevant literature that addresses the issues, e.g. policy analysis research based october 2014, vol.6, no. 2 ajhpe 127 research only a few participants indicated that they did not know and were unsure how to improve and promote the scholarship of teaching in their modules. however, they did observe the potential for including it in their teaching activities. the few participants who held senior positions and had more experience in teaching students, especially on a postgraduate level, were more specific in how to promote the scholarship of teaching in their modules. one participant stated: ‘… allowing students to provide input on a question and then analysing the responses or by analysing a policy document.’ discussion the objective of the study was to understand academics’ views, perceptions and experiences of research, scholarship of teaching, methods, and activities to integrate research into their teaching activities. the findings revealed that the academics had a clear understanding of research and did attempt to engage students in the process of research. research is defined as ‘a detailed study of a subject, especially in order to discover (new) information or reach a (new) understanding’.[18] it improves teaching because researchers use personal experiences rather than second-hand knowledge.[19,20] however, the majority of academics in fchs could not reach consensus regarding the definition of the scholarship of teaching, the concept being unfamiliar to many academics at universities.[21] the scholarship of teaching goes beyond scholarly teaching and is driven by a desire to understand how students learn effectively and how teaching influences this process.[22] the concept is therefore student focused and has two main components: (i) the use of creativity to develop original materials; and (ii) a systematic evaluation of one’s teaching practices. academics experience a different relationship between research and teaching. although the integration of research and teaching has been identified as key in enhancing, developing and informing one’s teaching practices, this approach is difficult to achieve when the two activities have for some time been seen to be at odds with each other.[23] therefore, the integration of these two activities must be more public and transparent for evaluation by peers.[8] it was also evident that the academics were at different levels regarding the extent to which they had adopted a scholarly approach to teaching. from the literature it is suggested that staff from the same or different disciplines should engage in dialogue to promote the sharing and dissemination of good teaching practices so that they may learn from one another and consequently change their teaching practices.[23] the first two phases of the ai framework allowed the researchers the opportunity to practise how to use a framework to share experiences and ideas about their teaching and encourage one another to use the information shared to improve their teaching. however, there are many more ways of linking research and teaching than students who learn about subject knowledge through lectures. academics may model research-based approaches in the manner they teach by adopting an inquiry-based learning approach.[1,19] however, discussion of research-led education and the scholarship of teaching is complicated by different terms being used in the literature and in practice to refer to the same idea, e.g. research led, research based, research informed. from the literature[25] it is suggested that a distinction may be made between the following: • research-led teaching, where students learn about research findings, the curriculum content is dominated by staff research interests, and information transmission is the main teaching mode. • research-orientated teaching, where students learn about research processes, the curriculum equally emphasises the processes by which knowledge is produced as learning that has been achieved, and staff try to engender a research ethos through their teaching. • research-based teaching, where students learn as researchers, the curriculum is largely designed around inquiry-based activities, and the division of roles between teacher and student is minimised. limitations a limitation is that only six out of 10 departments at fchs participated in this survey and, of all possible respondents, the response rate was only 22%. furthermore, there were only a few male participants, the reason being that 80% of the staff at fchs are female. implications for further research programmes implemented based on this needs analysis will be evaluated to determine their effectiveness. as this was the first phase of a larger study, the information identified will be used to develop and implement an intervention where academics are provided with methods of teaching that are research based. implications for education principles to enable transfer of research knowledge into teaching have been proposed in literature:[25,26] • academics need to be active in research so that their teaching is research informed. good research is necessary for good teaching. • academics need to consider effective teaching methods such as studentfocused teaching and the stimulation of students’ critical thinking by providing them with research training and knowledge. an increase in student engagement could facilitate a deeper understanding through inquiry-led learning. • academic departments need to appropriately balance the research and teaching workload of academics so that experienced research-active staff are engaged in teaching across all levels. formal processes to stimulate research-informed teaching must be considered. • at a broader level, the university should create an academic community of practice where academic departments, disciplines and the university network of professionals interact through face-to-face settings to disseminate research knowledge to a wider community. conclusion following the defining and discovery phases of the ai process, this study has focused on academics’ understanding of the integration of research into their teaching practices and their successes. it was evident that the majority of the academics considered teaching and research as separate entities. it is anticipated that the implementation of the next phases of the ai process should illuminate the way forward to assist academics with the practice of the scholarship of teaching. for teaching and research to receive equal attention, the scholarship of teaching could facilitate the integration of research into teaching activities. references 1. healey m. developing the scholarship of teaching in higher education: a discipline-based approach. high educ res dev 2000;19(2):169-189. [http://dx.doi.org/10.1080/072943600445637] 2. faculty of community and health sciences. teaching and learning operational plan. bellville: university of the western cape, 2010. 3. elton l. research and teaching: conditions for a positive link. teach high educ 2001;6(1):43-56. [http://dx.doi. org/10.1080/13562510020029590] 128 october 2014, vol.6, no. 2 ajhpe research 4. boughey ca. institutional difference: neglected consideration in the scholarship of teaching and learning. international journal for the scholarship of teaching and learning 2011;5(2):1-6. 5. bernstein d. finding your place in the scholarship of teaching and learning. international journal for the scholarship of teaching and learning 2010;4(2). 6. kreber c, cranton pa. exploring the scholarship of teaching. j high educ 2000; 71:476-495. [http://dx.doi. org/10.10.2307/2649149] 7. richlin l. scholarly teaching and the scholarship of teaching. new dir teach learn 2001;86:57-68. [http://dx.doi. org/10.1002/tl.16] 8. martin e, benjamin j, prosser m, trigwell k. scholarship of teaching: a study of the approaches of academic staff. in: rust c, ed. improving student learning: improving student learning outcomes. oxford: oxford centre for staff development, oxford brookes university, 1999:326-331. 9. glassick ce. boyer’s expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. acad med 2000;75(9):877-880. 10. fincher rm, simpson de, mennin sp, et al. scholarship in teaching: an imperative for the 21st century. acad med 2000;75(9):877-894. 11. hunt c. national strategy for higher education to 2030. hunt report 2011. dublin: department of education and skills. 12. brew a. higher education research and the scholarship of teaching and learning: the pursuit of excellence. international journal for the scholarship of teaching and learning 2011;5(2):3. 13. young p. out of balance: lecturers’ perceptions of differential status and rewards in relation to teaching and research. teach high educ 2006;11(2):191-202. 14. billings d. preparing nursing faculty for information-age teaching and learning. comp nurs1995;13:268-270. 15. frantz j, rhoda a, de jongh j. using appreciative inquiry to develop a research capacity development programme. s afr j high educ 2013;27(1):48-59. 16. coulson n, goldstone c, ntuli a, et al. developing capacity for health: a practical approach. johannesburg: heinemann, 2010. 17. acosta a, douthwaite b. appreciative inquiry: an approach for learning and change based on our own best practices. the institutional learning and change brief 6. 2005. http://www.cgiarilac.org (accessed 6 june 2012). 18. cambridge dictionaries online. 2003. http://dictionary.cambridge.org. (accessed 6 june 2012). 19. visser-wijnveen gj, van driel jh, van der rijst rm, et al. relating academics’ ways of integrating research and teaching to their students’ perceptions. stud high educ 2012;37(2):219-234. [http://dx.doi.org/10.1080/030750 79.2010.536913] 20. hutchings p, shulman ls. the scholarship of teaching: new elaborations, new developments. change: the magazine of higher learning 1999;31(5):10-15. [http://dx.doi.org/10.1080/00091389909604218] 21. baume d. editorial. int jacad dev 1996;1:3-5. 22. willcoxson l, manning ml, johnston n, et al. enhancing the research-teaching nexus: building teaching-based research from research based teaching. int j teach learn high educ 2011; 23(1):1-10. 23. dobbins k. enhancing the scholarship of teaching and learning: a study of the factors identified as promoting and hindering the scholarly activities in one faculty. international journal for the scholarship of teaching and learning 2008;2(2):1-8. 24. griffiths r. knowledge production and the research-teaching nexus: the case of the built environment disciplines. stud high educ 2004;29(6):709-726. [http://dx.doi.org/10.1080/0307507042000287212] 25. amaratunga rdg, senaratne s. principles of integrating research into teaching in higher education: a knowledge transfer perspective. in: second annual built environment education conference recruitment and retention: the way forward. london: bloomsbury, 2006. 26. allen mn, field pa. scholarly teaching and scholarship of teaching: noting the difference. int j nurs educ scholarsh 2005;2(1):1094. appendix 1. questionnaire gender ☐ male ☐female academic status ☐ assistant lecturer ☐ lecturer ☐ senior lecturer ☐ associate professor ☐ professor level of teaching ☐ undergraduate ☐ postgraduate ☐ both undergraduate and postgraduate what is the size of your classes? in the last three years, how many articles have you published in ☐ peer-reviewed journals ☐ peer-reviewed, accredited journals what is your definition of research? do you participate in the decisions about what you teach (modules)? ☐ yes ☐ no share how you improve student awareness regarding research in the courses that you teach share what activities you include in your programme that are designed to engage students in a variety of research-based activities share your ideas on how you think your teaching strategies can relate to research what is your understanding of the scholarship of teaching and learning? how could you promote and develop the scholarship of teaching and learning in the modules that you teach? 32 may 2015, vol. 7, no. 1 ajhpe research most students struggle with the transition from school to university[1] because the latter expects and rewards different academic practices from those valued at school.[2] students who are the first in their families to attend university are the most vulnerable, as they have little opportunity to anticipate or prepare for the challenges of higher education.[3] objectives the objective of this study was to understand the relationship between students’ experiences of school-university transition and academic performance. this article offers insight into how transition is experienced by students who are first in their families to attend university and those who come from schools and families that prepared them for university. it explains the manner in which students engage with the university’s academic environment by examining students’ assumptions about their control over this environment. the article shows how these assumptions result in some students being better positioned for integration into the practices rewarded by university. the article then concludes by drawing on insights from the study to make recommendations for supporting all students in their transition from school to university. literature review two theoretical frameworks were used to understand students’ engagement with the academic environment and their assumptions about academic success. identity wendt[4] defines identity as ‘role-specific understandings and expectations about self ’, which are acquired ‘by participating in … collective meanings’. identities are fastened, unfastened and refastened in cultural spaces[5] – in the case of this study, in schools and universities. identity fastening occurs through the activities in which people engage to be recognised as insiders.[5] students enter university with the fastened academic identity of ‘school learner’, which encompasses the practices expected and rewarded at school. identity unfastening occurs when people are required to take on and demonstrate the practices of a different cultural context.[5] achieving success at university requires competence in practices that are usually different from those engaged in at school. identity refastening occurs when new practices are incorporated into current practices or when they replace existing practices.[5] attribution attributions are the causal explanations that people give of their experiences.[6] these explanations depend on people’s beliefs with regard to their own capacity to predict and influence their environment.[6] attribution theory is used to explain how individuals use the information they gather about their experiences to form causal judgements.[6] attribution theory has been used to understand how university students draw on personal perceptions to explain academic performance.[7] two concepts from attribution theory which have been used to understand higher education are pertinent to the study – causality and controllability. causality refers to the explanation that students give regarding the causes of their performance.[6] students who assume an internal locus of causality explain performance with reference to internal factors, such as skills, ability and effort.[6] those who assume external locus of causality attribute performance to external factors, such as task difficulty and luck.[5] controllability refers to students’ perceptions of whether the cause of their performance is within their control.[5] students who perceive themselves as having control over their performance (i.e. background. most students experience the transition from school to university as challenging. first-generation students are particularly vulnerable, as they receive little preparation for the expectations of university. objective. to understand the relationship between preparation for university, transition experiences, and academic performance in the first two years at university. methods. sixteen second-year dentistry students were interviewed in this qualitative pilot study. their marks for the first 18 months at university were accessed. two theoretical frameworks were used to analyse the data – academic identity and attribution. analysis resulted in four groupings: academically competent middle-class students, academically struggling middle-class students, academically struggling working-class students and academically competent working-class students. results. findings suggest that students’ academic performance is influenced by social class and assumptions of controllability and causality. assumptions about control over their environment influenced how they engaged at university. these assumptions resulted in some students being better positioned for integration into the practices rewarded at university. irrespective of social class, those who attributed academic performance to factors outside their control performed less well. conclusion. the study suggests that interventions are required that help all students to control their academic performance. attributional retraining (ar) has the potential to assist students who attribute academic performance to causes beyond their control. the article concludes with suggestions for ways in which ar might be implemented to assist all students towards obtaining competent academic performance. suggestions are also made for further large-scale studies. afr j health professions educ 2015;7(1):32-38. doi:10.7196/ajhpe.356 identity and attribution as lenses to understand the relationship between transition to university and initial academic performance w mcmillan, bprimed, bed, pgdip (pp), ded faculty of dentistry, university of the western cape, tygerberg campus, cape town, south africa corresponding author: w mcmillan (wmcmillan@uwc.ac.za) may 2015, vol. 7, no. 1 ajhpe 33 research controllability within) attribute success or failure to effort.[5] students who perceive performance to be beyond their control (i.e. controllability without) attribute success or failure to luck or the actions of others. students who believe that they are in control perform better academically than those who do not have this belief.[7] methods this qualitative pilot study examined the relationship between academic identity, perceptions of causality and control, and academic performance for a group of students at a south african university. qualitative research allows for complex descriptions of people’s experiences.[8] the qualitative approach allowed insight into students’ transition experiences and their explanations of their performance.[8] a pilot study design was selected as this was an exploratory study. findings from exploratory studies have the potential to highlight salient issues for large-scale confirmatory studies.[9] the study elicited students’ retrospective perceptions of the school-university transition and examined their explanations of academic performance. the pilot cohort consisted of 16 dentistry students in their second academic year. the cohort comprised eight of a group of 11 students who had participated in transitionexperience focus-group interviews the previous year, and a further eight who joined the cohort in their second academic year. all 16 came from a single class of 23 firstyear dentistry students. in their first year, all 94 dentistry students were randomly allocated to one of four smaller classes for a core module. one of these classes, comprising 23 students, was selected for the pilot study. the cohort encapsulates a relevant range in relation to the wider population of first-year dentistry students at the study site because of the random allocation of students to smaller classes.[10] table 1 indicates academic performance, social class and race of cohort members. the final percentages for first-year modules and modules completed in the first semester of the second year were elicited to understand students’ academic performance during their transition period and at the time of the interviews. the terms african, indian, coloured (mixed race), and white are racist nomenclature of apartheid. the legacy of apartheid, and its disparate distribution of resources along race lines, has resulted in a classed post-apartheid society based predominantly on previously racialised divides.[11] the use of race terms in this study highlights that legacy. for the study, ‘working class’ was used to signal students whose home and school were located in working-class areas, who were first in their family to attend university, and who were funded by the national student financial aid scheme available to students from low-income families. ‘middle class’ was used to signal students whose home and school were located in middle-class suburbs, who had family experience of university, and who were funded by their families. semi-structured one-on-one interviews were conducted with the 16 students in the first semester of their second year. interviews allow for a deeper understanding of the social phenomenon being studied than that available through closed-ended questionnaires.[12] semi-structured interviews consist of a series of questions exploring key areas of a study.[12] the interview for this study probed academic identity and experiences of school-university transition, including academic performance. eliciting insights from second-year students allowed for their reflection regarding the transition. their experiences were no longer immediate; yet, the academic performance consequence of these experiences was apparent to them. the interviews were transcribed. using the theoretical framework for analysis the literature[2,3,13-17] suggests that race and social class are major signifiers in school-university transition and university academic performance. it also highlights that middle-class schools and families prepare young people for university by making overt the practices that are rewarded there.[2] middleclass schools incorporate activities and develop learning strategies that prepare learners for university.[2] working-class students, who are first in their families to attend university, receive little of this type of preparation.[2] without having experienced university, their families cannot anticipate the challenges of higher education.[3] schools with large populations of working-class children seldom provide these learners with information about university, and most rely on teaching strategies that require learner compliance – strategies ill-matched with the requirements for an autonomous university learner.[2] in south africa, the situation for working-class students is exacerbated by the legacy of apartheid, where schools for such learners continue to be under-resourced, over-crowded, and frequently staffed with under-qualified teachers.[2] reed’s[5] framework of identity as ‘fastened’, ‘unfastened’ and ‘refastened’ in cultural spaces such as universities was considered appropriate for understanding how students engaged with the expectations of university. the core concepts for analysis were fastened identity (evidence of students’ assumptions about what is required for academic success), unfastened identity (evidence that students recognised the practices required for university success) and refastened identity (evidence that students realised that they had to adopt or incorporate and use new practices so as to be successful). initial analysis suggested that identity played a significant role in how students engaged with university expectations – with consequences for academic performance. generally, middle-class students performed well (table 1). they evinced an identity that recognised the practices required for university success – ‘[it] wasn’t too bad, i could cope – you have to concentrate on work’ [ghalid]; ‘i have always managed and this is the next step’ [yasmine]; and ‘that was the only thing – you have to study continuously’ [antjie]. in contrast, most working-class students struggled academically. struggling was defined as failing any module or participating in a supplementary or special examination. these students’ university academic identities were less well established. they appeared unaware or unsure of what they needed to do to be successful – ‘i thought i was handling it. but when i got to the exam i wasn’t. it was so easy at school and i thought it would be the same at varsity but it was totally different. it is very upsetting when you work so hard and you see nothing’ [ronel]. however, identity did not explain the performance of all students. there were middle-class students who struggled academically (table 1, group b) and working-class students who performed well (table 1, group d). social class and race – and their associated access to educational resources – fell short of providing a full explanation of academic performance in the transition to university. a further theoretical framework was required to understand the anomalies. closer scrutiny of the interview transcripts suggested that a theoretical framework which could explain students’ perceptions of their own power over their academic performance had the potential to explain the anomalies. four concepts of attribution theory were used to analyse the data – internal locus of causality (performance attributed to internal factors such as skills, abilities, efforts), external locus of causality (performance attributed to external factors such as difficult tasks, luck), controllability within (performance perceived to be within an individual’s control, e.g. through personal effort), and controllability without (performance perceived to be outside an individual’s control and attributed to actions of others). results analysis using both frameworks resulted in four groupings within the pilot cohort – academically competent middle-class students, academically struggling middle-class students, academically struggling working-class students, and academically competent working-class students. 34 may 2015, vol. 7, no. 1 ajhpe research being middle class and feeling in control middle-class students who performed well (group a: ghalid, yasmine, antjie, nadia, sandra, sanette) came from homes where there was a familiarity with university. they had aspects of university identity embedded in their school identity. at school they had learnt the foundational practices that are valued at university. they thus incorporated new practices into their existing fastened academic identities, rather than unfastening their school academic identities. they attributed success to their own efforts, and argued table 1. student demographics and academic performance pseudonym social class location race location first-year academic performance second-year (first semester) academic performance group a (middle-class students who performed well) ghalid* middle class indian marks between 64% and 90% marks between 64% and 77% yasmine* middle class mixed race marks between 55% and 74% marks between 55% and 83% antjie* middle class white marks between 50% and 73% marks between 55% and 71% nadia middle class white marks between 64% and 79% marks between 66% and 89% sandra* middle class white marks between 58% and 74% marks between 52% and 77% sanette* middle class white marks between 57% and 82% marks between 55% and 75% group b (middle-class students who struggled academically) ibrahim middle class indian marks between 55% and 75% marks between 47% and 73% one supplementary examination valencia middle class indian failed one module in first semester – transferred to ‘intervention provision’ passed all intervention modules at end of year failed two modules in first semester of second year of registration (i.e. second semester of ‘intervention provision’) – required to leave the programme kerusha middle class indian failed one module at the end of first semester – transferred to ‘intervention provision’ failed two modules in ‘intervention provision’ – required to leave the programme group c (working-class students who struggled academically) ronel working class mixed race marks between 47% and 75% one supplementary examination marks between 61% and 75% christel working class mixed race marks between 45% and 72% one supplementary examination marks between 40% and 62% one supplementary examination nelson* working class african failed one module in first semester – transferred to ‘intervention provision’ failed two ‘intervention provision’ modules at year end – required to leave the programme registered for oral hygiene – one supplementary examination at end of first semester craig* working class mixed race failed one module in first semester – transferred to ‘intervention provision’ passed all intervention modules at end of year passed all modules in ‘intervention provision’ – transferred back to mainstream at end of first semester nadia* working class mixed race marks between 48% and 76% one supplementary examination marks between 63% and 67% group d (working-class students who performed well) fathima working class mixed race marks between 62% and 77% marks between 64% and 85% minette working class mixed race marks between 53% and 71% marks between 51% and 71% *students who participated in the first-year focus-group interviews. may 2015, vol. 7, no. 1 ajhpe 35 research that as they had the prerequisite skills for academic competence, all they had to do was apply effort and use their skills and abilities. table 2 shows these students’ understandings. the ‘identity’ column indicates identities as fastened, but incorporating practices expected at university. students’ perceptions of the match between the expectations of university and their own taken-for-granted assumptions about what was required for success at university are shown. the ‘attribution’ column illustrates these students’ sense of inner control and causality. being middle class and feeling that things are beyond your control group b (ibrahim, valencia, kerusha) comprised middle-class students who came from schools and homes that prepared them for university. they should, therefore, have had aspects of university identity embedded in their school identities. there should have been no need for them to unfasten their school academic identities. in order to ensure academic success they only had to incorporate new practices into their existing identities. however, their testimonies indicated that they were unaware of the prerequisite practices at university, and as they did not recognise them, they did not incorporate them. instead, their testimony was focused on non-academic challenges. they experienced varying degrees of academic failure. the difference between their accounts and those of group a students related to attribution. group b students felt that they lacked control over their academic performance. they assumed an external locus of causality, attributing performance to external factors such as task difficulty or luck. controllability, for them, was ‘without’. they perceived their performance to be outside their control. they attributed their academic performance to the actions of others. table 3 shows these students’ understandings. the ‘identity’ column shows their failure to recognise that alternative practices were required table 2. group a: middle-class students who feel in control student identity attribution ghalid ‘at the school that i went to, they drilled it into you that you are going to have a lot of problems and you have to learn how to deal with it. when human biology started, that was a shock. we had a high volume of work and you had to learn to cope and plan your day and to study for the tests. but the first year wasn’t too bad. i could cope.’ ‘i have the ability. you keep yourself motivated and positive, and then you can cope. it comes down to you as a person. you have got to be strong willed. it is what you make of it.’ yasmine ‘some students psyche themselves up, “oh my word, we have so much work to do.” i just went with it because i knew university was going to be a change. i think the school i went to prepared us for that change. i don’t find it challenging.’ ‘it was because of something that was in place, who i am in general. i came with the mindset that i would manage. i have always managed. this is the next step.’ antjie ‘maybe it is just what we studied at school or maybe i paid more attention in class. you have to study continuously. the workload over the period of time is just a lot more, not too much, but it is a lot.’ ‘i don’t do really well, but i am not going to fail. i have never had that fear of failing. it is not an easy course, but i do have the intelligence to do it.’ nadia ‘everyone used to tell me that when you go to university, it’s not like school, no-one will guide you. it wasn’t like that. i managed.’ ‘you had to deal with it. i can never leave it and say i am happy if i just make it.’ sandra ‘it is since i was little i learnt that i had to study hard. the workload was much more than i was used to at school. but the work wasn’t that bad.’ ‘my time management is good. i never write tests without studying everything. so i feel good about myself.’ sanette ‘i learnt at school that if you don’t learn, you won’t get the marks. i managed fine.’ ‘i am not worried about it. i am quite good with organising my time. i know that i passed all my subjects.’ table 3. group b: middle-class students who do not feel in control student identity attribution ibrahim ‘first-year at university is overwhelming. you don’t know where to go for support. you don’t know what to do. things come from your personal life and pressure. it was a bad luck car. i wasn’t worried about the academics, but i was worried about the car. and then i failed.’ ‘i failed the two tests and the exam. the first one everyone failed. i think it is the way they set the papers. they ask you a question and if the answer is not the way they want it, you are not going to get the marks. sometimes it is out of your control. it makes you feel useless.’ valencia ‘i think the main issue was leaving home and the fact that my grandmother passed away when i wasn’t there. everything went downhill from there. it was more emotional and personal.’ the teaching methods – it was up to us rather than the lecturer to teach us. i get completely lost and then i don’t feel like doing it. you are just completely put off and demotivated.’ kerusha ‘i don’t know why i failed. i didn’t have a problem with the work. i didn’t feel that i lacked working last year because i did put in and it was disappointing that i failed because i don’t go out much. i do my work. so i don’t honestly know why i didn’t make it.’ ‘you get into it with one lecturer because they lecture for about a two-week period and then all of a sudden there is a change, and you need to change because they have different teaching styles. the chances of you struggling are quite big. and the lecturer was scary. we were hesitant to go up to him. we weren’t allowed to re-write despite the amount of failures.’ 36 may 2015, vol. 7, no. 1 ajhpe research for competence at university. the ‘attribution’ column shows how, as a result of their lack of awareness and consequent discouraging university performance, these students assumed that they lacked control over their performance. being working class and feelings that things are beyond your control without preparation for university,[2] it was unsurprising that the group c working-class students (ronel, christel, nelson, craig, nadia) evinced difficulty making the transition and consequently struggled academically. there was disjuncture between their school academic identities and the expectations at university. there was therefore no possibility for these students to incorporate new practices into their existing academic identities. they were required to unfasten their school identities to build new academic identities. however, in order to do so, they had to recognise the inadequacy of their existing practices and identify suitable practices. there was no evidence that these students did so. indeed, many of them – despite writing supplementary or special examinations, or even failing modules – argued that they were coping at university. those who acknowledged that they were struggling appeared disorientated. this evidence is presented in the ‘identity’ column in table 4. unable to explain or understand their academic performance, these students attributed their poor performance to factors beyond their control. these perceptions are indicated in the ‘attribution’ column. being working class and feeling in control the working-class students in group d (fathima, minette) performed well. while it may be argued that they too were not prepared for university,[2] there was evidence that they recognised that different practices were required and what these practices were. they therefore unfastened their school identities and refastened them with ways endorsed at university. this evidence is presented in the ‘identity’ column of table 5. the refastening of these students’ identities was influenced by the way in which they understood causality and controllability. both students were clear that success was dependent on personally taking responsibility for practising what they had learnt, thus emphasising their perception of internal locus of control over academic success. these perceptions are presented in the ‘attribution’ column. table 4. working-class students who do not feel in control student identity attribution ronel ‘i did fail a subject. it was a shock. i thought i was handling it. at school i could study parrot fashion and i thought it would be the same at varsity. when the test comes, it is all those things i didn’t go over.’ ‘i could handle the workload but i am not good with calculations and i have a problem with theory. the lecturers should say, “come and see me about your paper.” that is what they did in high school.’ christel ‘the course it rather easy. for clinical dentistry i actually had a sup for the exam – i think i was studying wrong for that. but i felt okay – nothing was difficult.’ ‘this year i had a problem. the class lecturers aren’t nice – strict. i can’t approach them to ask a question.’ nelson ‘for me, it was just that i am struggling with time management. i know that i am smart. i am doing fine.’ ‘life in residence was not good. because ba students are making a noise all the time, i wasn’t able to study. i started to fail. also, life sciences – we were about 400. there is a noise with people talking and you can’t hear the important stuff. and, there is this problem with lecturers. they tell you, “no, i can’t do this for you”.’ craig ‘last year, it wasn’t as easy as i thought it would be or as fabulous as people make out that university would be. i didn’t really know what is going on and what is important and what i had to concentrate on.’ ‘there are certain people like myself who passed the whole year through, but just failed in the exams by 3 or 4%. and then i found out that some people, who didn’t make it, still passed. this girl told me that this guy got a certain percent and he still managed to get a supplementary and to go through to second year.’ nadia ‘i had quite a few re-writes throughout last year but in the end, actually i got good results, so i was happy with that. i think i am okay.’ ‘a lot of us, we have re-writes. i did everything that i thought he wanted and he just gave me zero. i know of someone who got zero and all his information in his answer was right but it just wasn’t in the format that the lecturer wanted. i think it is very unfair. it breaks you.’ table 5. working-class students who feel in control student identity attribution fathima ‘my first year was a big jump. i only got in the 50s in first year. then i realised i wanted to achieve more and i had to work hard and get better results.’ ‘i think that i am a very hard working person and i will go the extra mile and strive to do it. but there were mentors who helped us. i basically learnt how to balance everything.’ minette ‘the workload was a shock. everything was different. it was a different way of studying. we had to use logic and understanding.’ ‘i definitely know what to do better because academic literacy helped me a lot with everything. now i can’t go out as much as i want to and i always have to say i can’t go out because i have to study now.’ may 2015, vol. 7, no. 1 ajhpe 37 research discussion this study suggests that students’ academic performance is shaped by social class and race and assumptions of controllability and causality. social class and race played a significant role in the extent to which students were prepared for higher education. however, social class and race do not provide a comprehensive explanation of academic performance for a significant minority of university students. irrespective of race or social class, the students who attributed performance to internal factors and perceived the cause of their performance to be within their control were academically more successful. this finding is in keeping with a growing call to investigate the role that human agency plays in social phenomena, such as academic success.[18] it may therefore be argued that decisions regarding student support cannot be based only on assumptions about social class, race, and academic preparation. these factors alone do not explain academic performance. however, race and social class should be taken into account when planning student development.[19] such interventions may nevertheless fail to assist all students entering university. the study suggests that additional support may be required to help students take personal control over their performance. the need for this support appears to transcend the extent to which a student has been prepared for university. some students who came from universityorientated backgrounds indicated feelings of powerlessness when discussing their academic competence. empirical studies argue that attributional retraining (ar) has the potential to change the perceptions of students who attribute performance to causes beyond their control.[7,20] these studies suggest that helping students to change their causal beliefs about factors that affect their academic performance leads to improved performance.[21] students are assisted to develop a sense of personal control over academic activities and to believe that success is achievable.[22] ar encourages students to attribute poor performance to explanations that imply that failure can be reduced or success can be repeated.[22] findings from these studies indicate that students who relocate control as internal, perceive effort as a salient explanation for performance and, consequently, experience increased confidence and motivation, and strive for achievement.[7] the ar intervention involves teacher-mediated viewing of a motivational video, talk, interview or drama. these motivations encourage students to adopt controllable explanations of failure, such as insufficient attention or inappropriate study techniques. motivational input is followed by individual activities intended to consolidate learning from the motivation. effective follow-up activities include providing students with key point summaries, opportunities to put learning from the motivation into practice, requiring students to practise thinking from an internal causality perspective (such as recording as many reasons as possible for why their grades should improve), and reflective activities (such as writing and discussing what they perceive to be important aspects of the ar session).[7,21,22] to be effective, ar interventions require a consolidation activity in which students apply or reflect on what they have learnt.[7] the provision of support in the form of ar is not unproblematic, especially in an sa context, where the barriers to learning in higher education are overwhelming.[23] ar alone should not be expected to engender the belief that success is achievable, as students from backgrounds not able to prepare them for university might fail, and blame ‘lack of effort’ for that failure. however, integrating ar into academic support programmes offers a mechanism for helping students to reflect on their learning and the strategies they adopt when learning. motivational input would allow them to recognise their enormous potential – how, even in the face of adverse academic preparation, they have been selected for university because they have already demonstrated their potential to succeed. framing academic support activities as providing the tools to turn potential into academic competence provides further motivation. such an approach acknowledges both students’ real disadvantages and their potential to develop competence in areas of initial limitation. combining academic support activities with ar goes some way to providing first-generation university students with the kind of insider information that middle-class students bring to university. such ar would make explicit what competencies (such as time management, independent note-taking, reading and writing extended text) are required in order to be successful at university, would support students in the development of these competencies, and would provide students with opportunities to reflect on and critically evaluate their use of these competencies. for middle-class students, ar may have benefits when introduced as suggested in the literature – as a mechanism that encourages students to attribute poor performance to explanations that imply that failure can be reduced or success repeated.[22] through reflection on academic performance and associated academic practices, these students might be taught to recognise the contributory factors (e.g. time management or concept mastery) to academic performance. successful strategies can then be repeated and appropriate ones for addressing shortcomings taught, practised and evaluated – thus facilitating the development of an explanation of academic performance within the control of the student. conclusion this study drew on the voices of second-year dentistry students and the theoretical tools of academic identity and attribution theory to understand the relationship between transition to university and initial academic performance. race and social class and perceptions of control were found to play a role in students’ academic performance. suggestions from the literature regarding ar were adapted to propose ways to assist students towards competent academic performance. the limitations of this study should, however, be taken into account when considering the wider applicability of the findings. this was a smallscale pilot study. however, the rich data that are accumulated from such studies allow for the highlighting of salient issues for further investigation.[9] larger-scale qualitative studies are required to confirm the validity of the findings from this pilot study. quantitative questionnaire-based studies, designed from the findings of larger qualitative studies, would allow for the survey of substantial numbers of students and further validation of the findings. ultimately, a diagnostic tool might be developed to allow academically struggling students to identify how their academic practices contribute to their academic performance. academic support activities could then be developed to assist students to become more academically competent. by using the diagnostic tool and participating in support activities students will have opportunities to perceive their academic development and their academic performance as within their control. acknowledgements. i would like to thank all the students who took part in the research, willingly sacrificed their time and shared their experiences of transition to university. 38 may 2015, vol. 7, no. 1 ajhpe research references 1. scalon l, rowling l, weber z. ‘you don’t have like an identity … you are just lost in a crowd.’ forming a student identity in the first-year transition to university. journal of youth studies 2007;10(2):223-241. 2. mcmillan w. understanding diversity as a framework for improving student throughput. education for health 2007;20:71. http://www.educationforhealth.net/ (accessed 23 october 2013). 3. mcmillan w. ‘they have different information about what is going on’: emotion in the transition to university. higher education research and development 2014;33:1123-1135. 4. wendt a. anarchy is what states make of it. international organization 1992;46:391-426. 5. reed g. fastening and unfastening identities: negotiating identity in hawaii. discourse: studies in the cultural politics of education 2001;22(3):327-339. 6. weiner b. attribution theory in organizational behaviour: a relationship of mutual benefit. in: martinko m, weiner b, lords r, eds. attribution theory: an organisational perspective. boca raton: crc press, 1995:3-6. 7. perry r, hall n, ruthig j. perceived (academic) control and scholastic attainment in higher education. higher education handbook of theory and research 2005;16(1):837-851. 8. mcmillan w. finding a method to analyse qualitative data: using a study of conceptual learning. j dent educ 2009;73:53-64. 9. thabane l, ma j, chu r, et al. a tutorial on pilot studies: the what, why and how. bmc med res methodol 2010;10:1. [http://dx.doi.org/10.1186/1471-2288-10-1] 10. calder j. survey research methods. med educ 1998;32:636-652. 11. bertelsmann stiftung. south african country report. gutersloh, germany: bertelsmann stiftung, 2012. www. bti-project.org/uploads/tx_itao.../bti_2012_south_africa.pdf (accessed 27 january 2014). 12. silverman d. doing qualitative research. london: sage, 2000. 13. li d. they need help: transfer students from four-year to four-year institutions. the review of higher education 2010;33(2):207-238. 14. pugh g, coates g, adnett n. performance indicators and widening participation in uk higher education. higher education quarterly 2005;59(1):19-39. 15. reay d, david m, ball s. degrees of choice: class, race, gender and higher education. staffordshire, uk: trentham books, 2005. 16. reay d. exclusivity, exclusion, and social class in urban education markets in the united kingdom. urban education 2004;39(5):537-560. 17. reay d. class, authenticity and the transition to higher education for mature students. the sociological review 2002;50(3):398-418. 18. archer m. the reflexive imperative in late modernity. cambridge: university press, 2012. 19. sikakana c. supporting student-doctors from under-resourced educational backgrounds: an academic development programme. med educ 2010; 4:917-925. 20. wilson t, damiani m, shelton n. improving the academic performance of college students with brief attributional interventions. in: aronson j, ed. improving academic achievement: impact of psychological factors on education. san diego, ca: academic press, 2002:88-108. 21. perry r, hechter f, menec v, et al. enhancing achievement motivation and performance in college students: an attribution retraining perspective. research in higher education 1993;34:687-723. 22. perry r. perceived (academic) control and causal thinking in achievement settings. canadian psychology/ psycholigue canadienne 2001; 4(4):312-331. 23. ndebele n, badsha n, figali b, gevers w, pityana b, scott i. a proposal for undergraduate curriculum reform in south africa: the case for a flexible curriculum structure. report of the task team on undergraduate curriculum structure. discussion document. pretoria: che, 2013. may 2014, vol. 6, no. 1 ajhpe 23 research background medical education needs to prepare graduates for clinical practice by providing them with the basic clinical skills, knowledge and attitudes that they require once they commence their internship years.[1,2] newly qualified medical graduates are required to progress swiftly from apprentices to practitioners as they move from the relatively protected academic environment to service in the public health system. in south africa, this system is characterised by considerable variability in terms of resources and management. in recent years medical education has included a wide range of innovative teaching and learning approaches, particularly in the domain of clinical skills training.[3,4] even if these innovations are typically based on sound pedagogical principles, it is necessary to evaluate their effectiveness. these studies often seek to obtain the perceptions of interns regarding the extent to which their undergraduate years prepared them for the internship experience.[3,4-7] while some of the studies adopt qualitative methods by conducting semi-structured interviews to elicit student perspectives,[8] a survey design to reach larger numbers of interns is a common approach. evaluation studies provide insight into the intern’s experience and point to a number of generic issues. the first year of internship is often described as stressful. during this year interns are responsible for patient care, learn new skills and assist in procedures without prior experience.[1,2,6] some interns find the application of their knowledge to practise rather challenging.[6] an australian study reported that interns felt well prepared to conduct basic procedures, complete ward round documentation, complete routine patient assessment, request investigations, review ecgs and communicate with other staff.[7] however, this group described feeling less prepared for handing over to night staff, managing medication and fluid status, assessing unstable patients, admitting patients and communicating with parents and families. other studies describe how intern confidence in their skills increased over time,[6,8] while qualitative studies add a richer texture to the picture of preparedness as interns identified issues such as the ‘stress of transition’ and the difficulty of dealing with others, with uncertainty and with death.[8] these studies are strongly context bound, which raises questions as to their applicability in south africa. in his 2002 study on community service (cs) for health professionals in south africa, reid[9] called for health sciences faculties ‘to address the gaps between the skills and attitudes of their graduates and the realities of the health of the south african public as experienced by community service professionals’. we would argue that the need to address these deficiencies includes the internship experience, which falls between formal studies and the cs year, and that south african studies investigate these gaps. although there are broad guidelines with regard to what should be included in undergraduate medical curricula internationally,[10] and most countries have national guidelines or regulations such as those promulgated by the south african minister of health in consultation with the health professions council of south africa (hpcsa),[11] interns reflect the training that they received at the institutions at which they studied. the way in which curricula are conceptualised, the teaching approaches that are adopted (e.g. traditional models, problem-based learning, competency-based approaches), and the clinical training locations (e.g. academic hospitals, primary care clinics, rural schools), influence the student’s experience and, therefore, the intern’s sense of preparedness. background. the primary aim of undergraduate medical training at south african medical schools is to prepare the graduates adequately for internship. if we are to attain this objective, it is crucial to evaluate the ability of our graduates to cope with the demands of internship. objective. to determine the extent to which first-year interns from stellenbosch university (su) considered that their undergraduate education prepared them for internship. methods. the preparedness for internship questionnaire (pique) is based on hill’s preparation for hospital practice questionnaire, with additional questions covering core competencies and exit outcomes that su has determined for its medical curriculum. participants were asked to respond to a series of statements preceded by ‘my undergraduate medical training prepared me to … ’, and also two open-ended questions. su’s mb chb graduates of 2011 (n=153) were invited to participate in the online survey. results. although the response rate was only 37%, graduates generally thought they had been well prepared for most mainstream clinical activities. however, there were areas in which respondents considered they could have been better prepared, specifically pharmacology, medicolegal work, minor surgery and the non-clinical roles that interns encounter. conclusion. pique appears to be a useful tool that can assist with curriculum renewal by highlighting areas that graduates feel they could be better prepared for. this challenges us to identify how curricula and teaching can be adjusted accordingly. ajhpe 2014;6(1):23-27. doi:10.7196/ajhpe.318 pique-ing an interest in curriculum renewal j blitz,1 m prax med; n kok,2 mph; b van heerden,2 mmed (int); s van schalkwyk,2 phd 1 division of family medicine and primary care, stellenbosch university, parow, south africa 2 centre for health professions education, stellenbosch university, parow, south africa corresponding author: j blitz (juliablitz@sun.ac.za) mailto:juliablitz@sun.ac.za 24 may 2014, vol. 6, no. 1 ajhpe research the profile of the stellenbosch doctor is articulated as follows: ‘ … doctors who have the knowledge, skills and attitudes to optimally utilise the opportunities available during the two-year internship so as to function autonomously in the primary health care sector thereafter, and who have acquired the ability and insight to develop further personally and professionally.’[12] in recent years the mb chb programme at su has undergone significant reform. these changes have consistently been informed by prevailing trends in medical education and the body of scholarship with regard to teaching, learning and assessment. this has resulted in changes to both the nature and structure of clinical exposure during the six years of the programme, and we considered it necessary to explore the extent to which our graduates feel prepared for internship. while we routinely evaluate all our programmes by student feedback, tracking the opinion of graduates occurs less frequently. our research question was therefore to determine the extent to which our graduates felt prepared for internship. our intention was twofold: to provide some validation for the ongoing curriculum renewal activities and to present a snapshot of the perceptions of our graduates at a particular point in their internship. we aimed to use the findings to inform decision-making with regard to future refinement of our curriculum. methods a survey design was adopted. as this study was nested within a larger research project, ethical approval for the survey was obtained as part of the former study (hrec approval: n12/03/014). the preparedness for internship questionnaire (pique) was designed based on the preparation for hospital practice questionnaire (phpq) used by hill et al.[2] in their 1998 study in australia. to customise the questionnaire for our context, additional questions were included to ensure that we covered the range of core competencies that had been adopted by the faculty and the profile of the stellenbosch doctor.[12] the final questionnaire comprised two sections. section 1 asked the participants to respond to a series of 48 statements preceded by ‘my undergraduate medical training prepared me to … ’. it was emphasised that they were not being asked whether they were exposed to training in these areas, but rather how prepared they considered themselves to carry out these functions/tasks (appendix 1). a rubric was given to the participants for their scoring (table 1). section 2 of the questionnaire comprised two open-ended questions, asking interns to elaborate on three competencies that they believed they were particularly well prepared for and three competencies that they could have been better prepared for in their role as interns. face validity was confirmed by five faculty experts. changes were made based on comments and suggestions by the team. the questionnaire was translated into afrikaans and the accuracy of the translation was checked by re-translating back into english. after piloting the survey with second-year interns (n=5) to assess validity, some of the questions were rephrased for clarity. after obtaining ethics approval, we sourced contact information for 153 of the 177 su mb chb graduates of 2011 who were in their first year of internship. an invitation to participate in the online survey was e-mailed to them. the survey was available from july to september 2012 using the university’s online web-based e-survey service. up to four reminders were sent to nonresponders during the duration of the survey. a unique anonymised identifier was assigned to each respondent. results the response rate was 37% (n=56). responses were captured on an excel spreadsheet. the likert-scale questions were subjected to descriptive analysis, while the open-ended questions were organised thematically. firstly, we calculated a mean overall preparedness score per intern (fig. 1). those who scored 4.5 or higher were deemed to be ‘fully prepared’. ‘well prepared’ interns were placed between 3.5 and 4.4, and so forth. importantly, there were no interns who felt less than ‘fairly well prepared’ across the full set of questions. the responses to each task were then analysed. for the purposes of reporting, responses of ‘fully prepared’ and ‘well prepared’ were combined as ‘well prepared’, while ‘a little prepared’ and ‘not prepared’ were combined as ‘less than adequately prepared’. we then reported on the tasks where the frequency of ‘well-prepared’ or ‘less than adequately table 1. scoring rubric used in questionnaire 1 not prepared i did not know how to do this/i do not feel prepared to do this yet, even with supervision 2 a little prepared i was rather unsure of how to do this/i needed someone to guide me through the process 3 fairly well prepared i was fairly sure of my ability/i was willing to try with some help 4 well prepared i felt that i knew how to do this/i could do this, but would have liked to have someone to check my work 5 fully prepared i knew how to do this really well/i felt able to do this well without any assistance 0 5 10 15 20 25 30 35 40 interns (n) fully prepared (mean score 4.5 5.0) well prepared (means score 3.5 4.4) fairly well prepared (mean score 2.5 3.4) a little prepared (mean score 1.5 2.4) not prepared (mean score 1.0 1.4) fig. 1. number of interns per overall preparedness category. may 2014, vol. 6, no. 1 ajhpe 25 research prepared’ was deemed to be significant by being more than one standard deviation above the mean. a significant number of interns thought that they had been ‘well prepared’ for the tasks listed in fig. 2. observing the score per task (potential range: 1 5), the mode was 5 for ‘carry out a comprehensive physical examination’, ‘carry out basic ward procedures (e.g. drips, catheters)’, ‘treat each patient as an individual’, and ‘approach senior staff for help when i feel uncertain’. undergraduate training seems to be delivering on these important basic tasks. it also appears that training occurs in an environment in which students feel able to admit to being uncertain and to ask for help. although the responses pointed more to preparedness than lack thereof, it is instructive to review those tasks for which a significant number of the interns felt ‘less than adequately prepared’ (fig. 3). the task for which the greatest number of interns in the cohort felt ‘less than adequately prepared’ was knowing how to approach medicolegal documentation. when observing the tasks across the 5-point scale, however, there were only three tasks for which more than one or two interns felt that they had been ‘not at all prepared’. these were knowing what to do with medicolegal documentation (n=8), knowing their professional role and responsibility in the event of social protest (n=6), and selecting drugs on the basis of the cost versus risks and benefits (n=4). of the 15 interns who had overall preparedness scores in the ‘fairly well prepared’ (lowest) category, the majority considered that they were ‘less than adequately prepared’ for the tasks set out in fig. 4. the responses to the open-ended questions clarified issues for which the interns thought they could have been better prepared. these included: • small surgical procedures – dermatological and minor theatre procedures • emergency medicine – being responsible for a resuscitation • dealing with the workload – knowing how to triage patients, and time management • work relationships – conflict at work, dealing with differences of opinion • personal issues – stress management, life-work balance in the face of long hours • management of common conditions. these open-ended questions also provided additional information on what interns believed they were well prepared for. these included: • working life – long hours and a good work ethic • confidence to do the ward work and make decisions • advanced clinical abilities – drawing up a differential diagnosis and forming a management plan. 0 10 20 30 40 50 60 70 80 90 100 respondents (%) well prepared fairly well prepared less than adequate preparedness carry out a comprehensive physical examination carry out basic ward procedures (e.g drips, catheters) approach senior sta� for help when i feel uncertain take responsibility for the care of the patient maintain attitudes appropriate to the practice of my profession appreciate the importance of group dynamics when working withing a team enviroment draw up a comprehensive assessment of a patient fig. 2. tasks for which a significant number of the respondents felt ‘well prepared’. 0 2 4 6 8 10 12 interns (n) justifying drug uses on the basis of their mechanism of action knowing what to do with the medicolegal documentation dealing with relatives of patients in distressing situations critically evaluating research as it relates to their clinical experience feeling able to tell a patient that they have a terminal illness selecting drugs on the basis of the cost versus their risks and bene�ts well prepared fairly well prepared less than adequate preparedness fig. 4. tasks for which the majority of fairly well-prepared interns (n=15) felt ‘less than adequately prepared’. 0 10 20 30 40 50 respondents (%) know what to with medicolegal documentation justify drug uses on the basis of their mechanisms of action select drugs on the basis of the cost while considering their risks and bene�ts know my professional role and responsibility in the event of social protest deal with relatives of patients in distressing situations carry out basic surgical procedures critically evaluate research as it relates to my clinical experience well prepared fairly well prepared less than adequate preparedness fig. 3. tasks for which a significant number of respondents felt ‘less than adequately prepared’. 26 may 2014, vol. 6, no. 1 ajhpe research discussion in general, graduates from su considered that they had been well prepared for most mainstream clinical activities. however, there were also areas respondents thought they could have been better prepared for. these primarily included the domains of pharmacology, medicolegal work, minor surgery, and the non-clinical roles encountered by them. it is prudent to recognise that the aim of internship in south africa, regulated by the hpcsa, is two years of additional experiential learning for mb chb graduates. it can only be performed in hpcsa-accredited institutions and under the supervision of senior medical practitioners. adequate completion of the internship requires proof of competence by supervisors and satisfactory completion of a standardised logbook designed by the hpcsa. it is, therefore, also recognised that certain knowledge and clinical skills and even attitudes could potentially be acquired during the internship years rather than during undergraduate medical training. this begs the question: are there clear expectations of what training should be completed prior to internship, and what can be expected during this period? as some graduates are allocated to non-teaching hospitals for their internship, one can speculate whether the supervising staff are likely to teach the tasks in which the graduates thought they were less than adequately prepared. although the response rate was only 37%, the findings of this study are reassuring as they suggest that medical graduates from su perceive themselves to be adequately prepared for evaluating and managing individual patients, and for essential clinical duties and responsibilities associated with good patient care. activities that a significant number of su graduates considered themselves less than adequately prepared for mostly relate to administrative duties, but also to some important clinically related knowledge, skills and attitudes with regard to pharmacology, teamwork, breaking bad news, dealing with patients’ relatives, evidence-based medicine and quality improvement practice. the above findings may point towards opportunities for change in the content of the su medical curriculum. some of these issues have already been recognised and addressed, e.g. the introduction of clinical pharmacology and emergency medicine modules in the penultimate year of the six-year programme, as well as a longitudinal evidence-based healthcare theme extending over the entire curriculum. recent international and national developments in health professions education are beginning to impact on south african training institutions and curricula.[13] these include the importance of transformative learning to aid our graduates in becoming leaders and change agents in the health system. interdependence in education relates to, inter alia, the ability of su graduates to function optimally in healthcare teams and as change agents.[14] the finding that 16% of this cohort of graduates felt less than adequately prepared to participate in activities that contribute to the effectiveness of the healthcare facility in which they worked, indicates a need for training change agents that are better prepared for such activities. more than 85% of the cohort, however, felt well prepared to appreciate the importance of group dynamics when working within a team. this seems to indicate that the emphasis we place on interdisciplinary education in the su curriculum has the desired outcome. our results suggest that it may be necessary to help clinician teachers to find ways to expose students to tasks such as completing medicolegal documentation and breaking bad news, as well as activities such as team dynamics and dealing with patients’ relatives. there may also have to be more opportunities for students to practise some of the basic procedures such as lumbar punctures and intercostal drain insertions while under the supervision of clinical teachers during undergraduate training. conclusion the current international focus on the social accountability of medical schools has become important for the medical and dental professions board of the hpcsa. one of the main characteristics of a socially accountable training institution is its willingness to track its graduates and measure their performance after they leave the institution. this study is a first attempt at determining how well recent su graduates are prepared for functioning as interns. however, it is not a trivial task to determine which outcomes should be achieved during undergraduate training and which should be left to the relatively unpredictable environment of internship training. one would assume that basic clinical competence in the management of common and emergency conditions is a definite prerequisite for entering internship. other non-lifesaving competencies related to matters not directly linked to the care of individual patients and best learnt in an experiential manner, might be safely relegated to the period of internship training, assuming that this be under adequate supervision. performing basic surgical procedures are skills that might best be learnt during internship – with adequate supervision and teaching skills. this highlights the need for ongoing discussion between universities and those responsible for internship supervision to clarify what each party can reasonably expect of the other. this survey highlights issues relevant to curriculum content. we should therefore ensure that curricular outcomes at su include these tasks. as a team interested in faculty development, we also observe that there might be implications for ongoing professional development of clinicians as teachers. many of the tasks for which the graduates believed they were less well prepared for are covered in existing curricular outcomes and most are part of everyday practice in any clinical training environment. this survey has provided insight into areas that could be pursued in helping clinician teachers to instruct students more effectively regarding tasks that they feel inadequately prepared for. pique appears to be a tool that can help with measuring the preparedness of medical graduates for their internship and for assisting with the ongoing renewal of curricula by highlighting areas for which su graduates feel they could have been better prepared. as many of these appear to be in nonclinical areas, it challenges us to identify which elements of curriculum renewal are required to ensure that our graduates are well prepared for most of what awaits them in internship. acknowledgements. the researchers gratefully acknowledge funding from the us president’s emergency plan for aids relief (pepfar) through health resources and services administration (hrsa) under the terms of t84ha21652 via the stellenbosch university rural medical education partnership initiative (surmepi). the researchers further acknowledge the contributions made by the rest of the rcs longitudinal study team: professors m de villiers, j bezuidenhout and h conradie and dr t fish, as well as martie van heusden and sam van rensburg for translating and verifying the afrikaans version of the questionnaire. may 2014, vol. 6, no. 1 ajhpe 27 research references 1. abuhusain h, chotirmall sh, hamid n, o’neill sj. prepared for internship? ir med j 2009;102:82-84. http://www.imj.ie// viewarticledetails.aspx?articleid=3304 (accessed 10 october 2012). 2. hill j, rolfe ie, pearson s, heathcote a. do junior doctors feel they are prepared for hospital practice? a study of graduates from traditional and non-traditional medical schools. med educ 1998;32:19-24. 3. millan lpb, semer b, rodrigues jm, gianini rj. traditional learning and problem-based learning: self-perception of preparedness for internship. revista da associação médica brasileira 2012;58:594-599. 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[http://dx.doi.org/10.1111/j.1365-2923.2009.03604.x] 9. reid sj. community service for health professionals. in: ijumba p, ntuli a, barron p, eds. south african health review. durban: health systems trust, 2002:136-160. 10. world federation for medical education. basic medical education. denmark: wfme office, 2012. 11. health professions council of south africa. health professions act 56 of 1974. regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine. government gazette 31886, 19 february 2009. 12. faculty of medicine and health sciences, stellenbosch university. the profile of the stellenbosch doctor. http:// sun025.sun.ac.za/portal/page/portal/health_sciences/english/new%20education/mbchb/profiel%20nuwe%20 kurrikulum%20finaal.pdf (accessed 5 march 2013). 13. van heerden bb. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2013;103:21-22. [http://dx.doi.org/10.7196/samj.6463] 14. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] appendix 1. preparedness for internship questionnaire my undergraduate medical training prepared me to: 1. handle most clinical emergencies 2. cope with stress caused by my work 3. recognise my own clinical limitations 4. carry out basic surgical procedures 5. discuss health risk behaviours with patients 6. maintain attitudes appropriate to the practice of my profession 7. cope with my own emotions in distressing clinical situations 8. evaluate the impact of family factors on illness 9. discuss relevant preventive health strategies with patients 10. serve in administration and leadership roles if necessary 11. carry out basic ward procedures (e.g. drips, catheters) 12. justify drug uses on the basis of their mechanisms of action 13. continually evaluate my own performance 14. draw up a comprehensive assessment of a patient 15. understand the interaction of social factors with disease 16. appreciate the importance of a patient’s cultural/ethnic background 17. balance my work and personal life 18.take responsibility for the care of the patient 19. apply my knowledge of basic sciences to clinical conditions 20. manage ‘difficult’ patients 21. appreciate the impact of poverty and unemployment on illness 22. feel able to tell a patient that they have a terminal illness 23. evaluate my learning experience 24. carry out a comprehensive physical examination 25. behave in a calm manner in difficult situations 26. invest time in developing my skills appendix 1 (continued). preparedness for internship questionnaire my undergraduate medical training prepared me to: 27. appreciate the importance of group dynamics when working within a team environment 28. know how to prioritise my day`s activities 29. select drugs on the basis of the cost versus their risks and benefits 30. participate in activities that contribute to the effectiveness of the healthcare facility in which i work 31. feel competent to counsel a distressed patient 32. record clinical data systematically 33. be sensitive to the needs of nursing staff 34. provide education to patients 35. demonstrate efficient and appropriate use of diagnostic procedural skills 36. treat each patient as an individual 37. deal with dying patients 38. approach senior staff for help when i feel uncertain 39. identify my own learning needs 40. critically evaluate research as it relates to my clinical practice 41. co-ordinate a comprehensive patient management plan with allied health professionals (e.g. physiotherapists) 42. know my professional role and responsibility in the event of social protest 43. know how to approach ethical dilemmas 44. deal with my emotion when a patient of mine dies 45. know what to do with medicolegal documentation 46. function effectively in a resource-constrained environment 47. know how to respond to the healthcare needs of the community within which i have been placed 48. deal with relatives of patients in distressing situations continued... http://www.imj.ie// http://dx.doi.org/10.1590/s0104-42302012000500018] http://dx.doi.org/10.1590/s0104-42302012000500018] http://dx.doi.org/10.1186/1472-6920-12-23] http://dx.doi.org/10.1186/1472-6920-7-38] http://dx.doi.org/10.1186/1472-6920-7-38] http://dx.doi.org/10.1111/j.1445-5994.2007.01502.x] http://dx.doi.org/10.1071/ah10885] http://dx.doi.org/10.1111/j.1365-2923.2009.03604.x] http://sun025.sun.ac.za/portal/page/portal/health_sciences/english/new%20education/mbchb/profiel%20nuwe%20 http://sun025.sun.ac.za/portal/page/portal/health_sciences/english/new%20education/mbchb/profiel%20nuwe%20 http://dx.doi.org/10.7196/samj.6463] http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1016/s0140-6736 article may 2013, vol. 5, no. 1 ajhpe 8 clinical educators' self-reported personal and professional development after completing a short course in undergraduate clinical supervision at stellenbosch university a m s schmutz,1 bsc physiotherapy; s gardner-lubbe,2 phd mathematical statistics; e archer,3 bcur hons, mphil (higher education) 1 division of physiotherapy, faculty of medicine and health sciences, stellenbosch university, parow, cape town, south africa 2 department of statistical sciences, university of cape town, cape town, south africa 3 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, parow, cape town, south africa corresponding author: a m s schmutz (amsschmutz@sun.ac.za) background. in 2007, a supervision course in undergraduate clinical supervision was developed at the faculty of medicine and health sciences at stellenbosch university in south africa. the target group was inter-professional clinical educators that are involved in student education on the clinical platform. although the course participants were professionals and specialists in their own fields, the majority of clinical educators have very little or no knowledge of adult education. the supervision course aims to develop clinical supervision skills of clinical educators by exposing these supervisors to basic principles of education and specifically clinical teaching, resulting in quality education for undergraduate students. the aim of this study was to determine the impact of this short course on the personal and professional growth of the clinical educator. methods. a qualitative study was performed, including an open-ended questionnaire that provided opportunity for the clinical educators to elaborate freely on their strengths, weaknesses and areas of desired improvement before and after the supervision course, and a semi-structured individual interview after the supervision course. the questionnaire data were categorised according to strengths, weaknesses and areas of desired improvement. an inductive approach was used to analyse the qualitative data. key themes that emerged from the interviews were identified and grouped together in categories. results. the results are summarised in table format to identify themes with supporting quotes. conclusion. although a small sample, this study demonstrates the personal and professional growth reported by attendees of a clinical supervision short course. ajhpe 2013;5(1):8-13. doi:10.7196/ajhpe.194 background in 2007, a short course in undergraduate clinical supervision (supervision course) was developed at the faculty of medicine and health sciences (fmhs) at stellenbosch university (su) in south africa, that has subsequently also been presented nationally.[1] this supervision course is one of the faculty development initiatives to renew or assist faculty to perform their various roles effectively and aims to develop clinical supervision skills of clinical educators.[2] the fmhs offers five undergraduate programmes in health sciences and therefore it was decided to follow a multidisciplinary team approach in the planning, constructing and implementation of this supervision course. clinical teaching is seen as a student-centred learning process which involves the translation of theory into the development of clinical reasoning skills.[3] effective clinical educators use several distinct, and sometimes overlapping, forms of knowledge during clinical teaching. [4] in addition, clinical teaching typically incorporates affective domains necessary for ethical client care and professionalism.[3] clinical educators therefore require more than just subject expertise to be effective in facilitating the transformation of students into professionals in the clinical setting.[1,2,4 ] clinical educators who are invited to attend the supervision course are from the multidisciplinary programmes of bsc dietetics, b occupational therapy, bsc physiotherapy, b speech-language and hearing therapy and mb chb. the supervision course consists of 1 contact session of 8 hours presented over 1 day. topics that are discussed include the roles of the clinical educator,[5] how adults learn, learning in the clinical environment, techniques of facilitating learning, assessment and feedback to students. [1] a study guide is provided for self-study, and within 6 weeks after attendance the clinical educator has to submit a reflective assignment on a recently completed supervision session. the clinical educator receives a certificate on completion of the assignment with continuous professional development points.[1] material provided in the supervision course includes recent literature, discussions and activities such as role play of the newly acquired teaching skills that encouraged the development of professional and personal growth of the participants. after the first presentation of the supervision course, a study was done to establish the relevance and appropriateness of the course.[1] the results indicated that the course participants were of the opinion that the course was appropriate and valuable. no drastic changes were suggested.[1] the aim of this follow-up study was to describe the clinical educators' perceptions before and after attending the supervision course. we were specifically interested in the professional and personal development of clinical educators in the clinical context, defined as growing in the perceived competence of skills and the characteristics related to clinical teaching. methods and analysis all clinical educators who attended the last two supervision courses in 2010 were invited to participate in this study. this included a pre-post articlearticle 9 may 2013, vol. 5, no. 1 ajhpe table 1. themes that emerged from the open-ended self-assessment questionnaire, with examples of supporting quotes strengths/ weaknesses area of activity of the clinical educator sub-components of the area *quotes – before the supervision course *quotes – after the supervision course strengths role model satisfying patients having extensive clinical experience to draw from as a supervisor mutual respect enjoying my job i aim to be a good role model i care about helping students to reach their potential encouraging students honesty and openness punctual being on time with marking assignments enthusiastic enthusiastic and motivated to channel subject matter willingness to put in extra effort good listener i enjoy being with the students and facilitating their professional growth approachable being approachable availability to students; approachable information provider lecturing, directing, motivation knowledge of the field enthusiastic and motivated to channel subject matter facilitator of learning lecturing to advise on practical issues in clinical setting, informal discussions and guiding students, thus aiming that they apply knowledge significant clinical experience leader, i'm able to create a learning environment for students directing a desire to encourage students to do their best ... fostering a rewarding and professional relationship with students organising ability to break information into smaller chunks and explain in a user-friendly format good experience and knowledge in subject matter planning i'm able to guide students planning and good time management motivating the ability to help students build bridges between theoretical knowledge and practical application; basically guiding their insights through prompts motivating students planner organisational skills and planning i am consistent and put high value in my responsibilities; i plan ahead assessor/examiner feedback good at providing feedback to students; i am assertive planning and good time management, able to give feedback giving positive feedback ... my ability to do continuous assessment of the student as the affiliation progresses good listener, fair and equal evaluation objective feedback not related to students' personality acknowledging students’ strengths and limitations 'weaknesses' helps focus the student continued... article may 2013, vol. 5, no. 1 ajhpe 10 questionnaire consisting of three open-ended questions that provided opportunity for the clinical educators to elaborate freely on their strengths, weaknesses and areas of desired improvement before and after the supervision course, and a semi-structured individual interview after the supervision course. the questionnaire data were categorised according to strengths, weaknesses and areas of desired improvement while an inductive approach was used to analyse the qualitative data. key themes that emerged from the interviews were identified and grouped together in categories. open-ended questions the three open-ended questions were completed by clinical educators before and after completion of the supervision course. thirty participants completed the open-ended questions before attending the short course and 19 participants completed the open-ended questions after the supervision course. due to unforeseen commitments in the clinical settings as well as time-related issues, not all the clinical educators who completed the openended questionnaire initially, completed it again. the questionnaire data were categorised according to strengths, weaknesses and areas of desired improvement. semi-structured individual interviews after the supervision course all the clinical educators were invited to take part in semi-structured individual interviews. fifteen clinical educators took part in the individual semi-structured interviews. due to logistical difficulties, six of the clinical educators answered the semistructured individual interviews electronically. one person conducted the interviews with the clinical educators. the interviews were digitally recorded and transcribed verbatim. these data were analysed by one of the authors, using an inductive approach to identify key themes and patterns. the key themes that emerged were confirmed by one of the table 1. (continued) themes that emerged from the open-ended self-assessment questionnaire, with examples of supporting quotes strengths/ weaknesses area of activity of the clinical educator sub-components of the area *quotes – before the supervision course *quotes – after the supervision course weaknesses assessor/examiner up to date with lecture notes lack of formal training, lack of curriculum knowledge still need to put in more planning need to make expectations clear prior to the clinical content; time management journal clubs feedback feedback – don't know when to give it to students, always scared that i may hurt their feelings … negative feedback – tend to always sugarcoat things which may lead to confusion/ misunderstanding; not always structured enough i am often worried that feedback might be ‘de-motivational’ to students – especially if they are experiencing difficulties my feedback skills improved, but i feel that there's still room for improvement assessment assessment of students assessment – adjusting expectations to the level of a student 'spoon-feeding’ – i tell them the answers if they don’t know it assessments of students inexperience, especially regarding assessment [sic] planner assertiveness can be more assertive not always assertive enough patience patience levels with students who do not co-operate impatient; trying to do too much at a time sometimes a little impatient with the process of learning; too lenient with students at times being overly protective of students i need some assistance in planning techniques; problem solving needs some assistance perfectionist and expect that of them time management time management time management tendency to spend too much time with students ✳ some quotes have been translated from afrikaans to english for the purpose of this manuscript. articlearticle 11 may 2013, vol. 5, no. 1 ajhpe clinical educators who took part in this study after the themes were tabulated. ethical approval for this study was obtained from the health research ethics committee of stellenbosch university (n10/03/067). informed consent was requested from all participants prior to commencement of the study, and anonymity of the supervision course participants was respected throughout the study procedures. results a total of 30 clinical educators completed the informed consent forms initially. open-ended questions it is clear that ‘encourage’, ‘advise practical issues’, ‘outcome based’, ‘students apply knowledge’, ‘acknowledge student strength and limitations’, ‘break information into small chunks’ and ‘guiding’ are particularly viewed as strengths before the training. after the training, phrases like ‘relationship with students’, ‘mutual respect’, ‘facilitation’ and ‘leader’ are quoted more often. the phrases between the column headings ‘before: strengths’ and ‘after: strengths’ were quoted by some as strengths before the training and by others (or the same participants) as strengths after the training. similarly, ‘curriculum knowledge’, ‘unclear expectations’, ‘patience’, ‘journal clubs’ and ‘prepared demos’ feature as weaknesses in the questionnaire before training. weaknesses and areas for improvement are fairly similar (in close proximity on the plot). after the training the main weaknesses mentioned were ‘new techniques’, ‘time management’, ‘flexibility’, ‘overly protective of students’, ‘delegating’, ‘teaching skills’, ‘perfectionist’ and ‘discussion skills’. the phrases that were used by some as strengths, others as weaknesses and both before and after the training are ‘role model’, ‘directing’, ‘communication’, ‘teaching’, ‘problem solving’, ‘level of student’, ‘demonstration’ and ‘punctual’. harden and crosby identified 12 roles of the teacher that can be summarised in 6 areas of activity.[5] the six areas include: teacher as information provider, the teacher as role model, the teacher as facilitator, the teacher as assessor, the teacher as planner and the teacher as resource developer.[5] these areas of activities were used for analysis of the open-ended questions. the themes that were identified from the open-ended questions, with supporting quotes, are presented in table 1. some phrases were quoted as strengths prior to the supervision course and by others (or the same clinical educators) as strengths after the supervision course. semi-structured individual interviews the themes that were identified from the semi-structured individual interviews, with supporting quotes, are presented in table 2. discussion the aim of this study was to explore and describe clinical educators' perceptions before and after a supervision course intervention. we were specifically interested in the professional and personal development of clinical educators in the clinical context, defined as growing in the perceived competence of skills and the characteristics related to clinical teaching. this is congruent with literature, where participants reported an increase in knowledge and educational principles and gains in teaching skills,[2] which confirms that faculty development serves to develop competence in members of staff. the open-ended questions referred to strengths and weaknesses. it was interesting that the strengths and weaknesses could overlap, or in fact be the same. we suggest that clinical educators develop over time or they are at different levels of their own supervising journey. another issue refers to the 12 various roles of the clinical educator that are written about in harden and crosby and categorised into 6 areas of activity of the teacher. [5] from our study 5 areas of activity were clearly identified as part of the strengths: role model, information provider, facilitator of learning, assessor/examiner and planner. the areas of activity that were identified as weaknesses included assessor, assertiveness and time pressures. time pressures are mentioned as a challenge of clinical teaching in spencer, as well as competing demands, being clinical, administrative and research.[4] some clinical educators highlighted summative assessment and time management as weaknesses. these areas are not directly addressed in the material of the supervision course, although formative assessment is. the importance of faculty development encompassing a whole variety of training opportunities to address all the needs of educators can thus not be over-emphasised. literature confirms that we should continue to build on the success of such an initiative and develop programmes that extend over time to allow for cumulative learning, practice and growth.[2] also, due to time constraints, many of the clinical educators could not take part in the full research study. this underlines the issue of time-related commitments. some of the feedback received from clinical educators during the semistructured individual interviews indicated that their own supervision skills developed and improved from giving too much information or spoon-feeding, to facilitating. reilly mentions that in talking to learners, the educator's own clinical reasoning is the most powerful predictor of a learner's satisfaction and that this is not the same as talking off the top of one's head, a habit common among ineffective teachers.[6] bearing this in mind, it was deducted that these clinical educators were indeed growing into being more effective teachers. conclusion clinical educators experienced change and personal growth after completion of the supervision course. the importance of broad faculty development at stellenbosch university is accentuated in these themes as not one course can cover all the relevant roles and expectations of clinical educators. we therefore recommend a development plan for all clinical educators and to utilise all opportunities to enhance the learning of clinical educators and eventually the learning and teaching of students. it would be interesting to investigate longitudinal cases of individual clinical educators over a longer period of time. we experienced some limitations that deserve expanding on. our sample size was small because of the small number of participants accommodated during the supervision course. the questions used in the semi-structured individual interviews had limited scope and can be developed for future use. the inclusion of multidisciplinary clinical educators diluted some of the data. in future studies it would be interesting to also compare same disciplines with each other as well as the multidisciplinary group. article may 2013, vol. 5, no. 1 ajhpe 12 table 2. themes that emerged from open-ended individual semi-structured interviews, with examples of supporting quotes questions themes *quotes from clinical educators what were your expectations of the supervision course and have they been met? to increase knowledge and improve skills ... we actually only have knowledge in our own subject, but we don't have any knowledge in terms of educational techniques or the correct way of doing things you do something every week and you do the same thing, and i did want to be exposed to more innovative ways of supervising and tutoring cpd points i expected to get cpd points, and sorry, i'm being honest what is your view of clinical supervision? positive teaching skills and learning methods ... it's a scientific skill we have to acquire ... often people graduate and they are just told to supervise students and no one has taught them, no one has modelled behaviours for them and they go and do their own thing, and often you are just doing the wrong thing all the time it's vitally important and underestimated you can make or break a student motivation ... so i motivate them positively ... student relationship it’s actually quite exciting to see that happen, to see the students take the stuff and grow and quickly, quickly get skills and so on under their belt negative time management, delegation being pressurised: no time, rushing, rushing! negative feedback feedback: sometimes you don't always know how to say something to a student, especially in my case, because i am scared; i do not want to get the student into trouble so i say nothing how would you describe your previous supervision sessions? (before supervision course intervention) too much talking/lecturing giving student too much info uncertainty due to lack of knowledge not letting students participate more in the process ... i'm a bit of a spoon-feeder ... dominating, not facilitating ... own limitations regret most: at that stage, my own lack of subject knowledge was probably the biggest problem with the supervision how would you describe your relationship with students during supervision? (after supervision course intervention) professional i try very hard to have a good professional relationship with all the students role model ... students are motivated and see you as motivating and inspiring and so on ... approachable i'm very relaxed, so i like to be approachable and i hope that they would see me in that way and that they could ask me anything too friendly too good sometimes, a bit too friendly how would you describe your supervision sessions after completion of the supervision course? importance of role model i think that i strive to have a relationship of respect and professional relationships with students, and i try to motivate them to do more and to think more and to read more and to be interested in a case and not just seem interested in the material it's about being interested myself and pointing out other little things about it and telling them what they need and what the implications are and so on the other thing that i've also learnt is that you are a role model, that what you do will have impact on what the students do at the end of the day continued... article 13 may 2013, vol. 5, no. 1 ajhpe acknowledgements. we would like to extend a word of appreciation to m van heusden for involvement and leadership during the study as well as conducting all the individual semi-structured individual interviews. the research was funded by the fund for innovation and research into learning and teaching (firlt), stellenbosch university, south africa. references 1. archer e. improving undergraduate clinical supervision in a south african context. ajhpe 2011:3(2):6-8. 2. steinert y, mann k, centeno a, et al. a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: beme guide no.8. medical teacher 2006;28:497-526. 3. mcallister l, lincoln m, mcleod s, moloney d. facilitating learning in clinical settings. cheltenham, uk: nelson thornes, 1997. 4. spencer j. abc of learning and teaching in medicine – learning and teaching in the clinical environment. bmj 2003;326:591-594. 5. harden rm , crosby j. amee guide no 20: the good teacher is more than a lecturer – the twelve roles of the teacher. medical teacher 2000;22(4):334-347. 6. reilly bm. inconvenient truths about effective clinical teaching. lancet 2007;370:705-711. table 2 (continued). themes that emerged from open-ended individual semi-structured interviews, with examples of supporting quotes questions themes *quotes from clinical educators planned ... i am more structured now; i'm not a very structured person generally feedback i have become a lot more aware of the importance of feedback and how i give feedback student responsibility being more aware of guiding students to think about the answer/ find the answer by asking themselves the right questions instead of just telling them the answer indicators of change i try to facilitate more than to teach, get them involved and responsible for their own learning ... moving away a bit from spoon-feeding, bit more facilitating ... it's a work in progress what are your goals for future supervision sessions? skill to incorporate even more techniques assessment i think i would definitely like to improve on my assessment of the students ... formative assessments earlier in the block so that you've got more time to fix things, and if you need to do it again, you can do it again planning so, i have found that i tend to plan, actually sit down and have a block plan role model ... to be a good role model how would you define your own personal growth after completion of the supervision course? confidence i feel more comfortable and confident teaching the students or demonstrating techniques to the students growth/learning i feel like it’s just begun i think i see a bit more the bigger picture ... my understanding of learning has much improved and that changed the ways i am teaching skills gaining some skills that i have not thought of before literature the articles just gave you a different insight of your role and how you can improve ... *some quotes have been translated from afrikaans to english for the purpose of this manuscript. 11 december 2009, vol. 1, no. 1 ajhpe article problem-based learning (pbl) is now an accepted component of medical school programmes in many parts of the world, such as the usa, canada, the uk, the middle east, asia1-3 and africa, including south africa. in pbl the small-group tutorial environment is believed to not only support the development of knowledge of the disciplines included in the course but also to foster result-orientated professional skills such as teamwork, clinical reasoning, communication ability and information literacy.4,5 in this system, tutors and experts advise students, enabling them to actively and independently develop learning skills for the processing, organisation, understanding, evaluation and application of scientific and clinical information to real-life situations. pbl is also believed to promote lifelong self-directed learners.6 the mb chb programme at walter sisulu university (wsu) follows a curriculum designed on the ‘spices’ model, i.e. the student-centred, problem-based, integrated, community-orientated model, that has electives and a systematic organisation. student assessment methods in pbl are diverse and include: modified essay questions (meqs), individualised process assessment (ipa), objective structured practical/clinical examination (ospe/osce), tutorial continuous assessment (tut), multiple choice questions (mcqs), one best answer questions (obas), extended matching questions (emqs), and short/long essay questions (seq/leqs). studies have been conducted to analyse the students’ comparative performances in these different modes of assessments, identifying the pros and cons.7 the mb chb iii programme at the wsu integrates the four broad disciplines of anatomical pathology, pharmacology, chemical pathology and microbiology. students register for integrated modules arranged in four blocks; the assessment is also integrated, and marks are allocated to blocks, not to individual disciplines. the main modes of assessment in this programme are meqs, tuts, ipas and ospes. background. problem-based learning (pbl) is now an accepted component of many medical school programmes worldwide. our university also follows the pbl ‘spices’ model for mb chb iii. the assessment modalities used are the modified essay questions (meq), objective structured practical examination (ospe), individualised process assessment (ipa) and tutorial continuous assessment (tut). this study was done to compare the students’ performances in individual assessment components with the final mark to determine the correlation between these parameters. materials and methods. the study was retrospective, descriptive and analytical, based on the integrated marks of all the mb chb iii students at walter sisulu university (wsu) in 2007. assessment marks were stratified according to blocks and different types of assessment (meq, tut, ospe, ipa). regression analysis was used to compute and scrutinise these vis-à-vis their correspondence with the final marks for each block. results. three hundred and seventy-nine block assessment marks of 96 students from 4 blocks of mb chb iii were analysed and the correlation between the assessment components and final mark were compared. regression analysis showed good correlation when analysing the assessment modality versus the final mark for the meqs (r=0.93, 0.93, 0.94, 0.96), followed by ospes (r=0.71, 0.70, 0.76, 0.77) and ipas (r=0.62, 0.51, 0.68, 0.77). however, correlation was not significant with the tut. conclusion. there was good correlation between the students’ performance in the majority of assessment modalities and the final mark in the different blocks of the mb chb iii examination. there may be a need to make tutorial assessment methods more objective, partly by additional tutor training. correlation between different pbl assessment components and the final mark for mb chb iii at a rural south african university mirta e garcia-jardon, md, msc, associate professor, department of anatomical pathology ernesto v blanco-blanco, md, msc, professor and head, department of chemical pathology vivek g bhat, mb bs, md, senior lecturer, department of medical microbiology sandeep d vasaikar, md, associate professor, department of medical microbiology enoch n kwizera, mb chb, msc, phd, professor and head, department of pharmacology andrez stepien, mb chb, phd, professor and head, department of anatomical pathology faculty of health sciences, walter sisulu university, mthatha, eastern cape, south africa corresponding author: vivek bhat (vivekbhat2005@yahoo.com) table i. calculation of the final mark final mark continuous assessment (60%) end-of-block exam (40%) meq 1 + meq 2 tut ospe ipa 45% 15% 10% 30% article 12 december 2009, vol. 1, no. 1 ajhpe article computation of the final mark for each block involves both the continuous assessment component and the end-of-block exam components. the weighting of the different assessment components in the calculation of the final mark is shown in table i. the pass mark is 50%, and students scoring ≥75% pass with distinction. the objective of this study was to determine the correlation between the different components of the continuous assessment and the final examination mark with regard to students’ performance in each of the four blocks. this would provide an insight into the students’ formative and summative performance-related aspects of our pbl system. materials and methods the study was retrospective, descriptive and analytical based on the integrated marks of all the mb chb iii students at wsu in 2007. continuous assessment and end-of-block components were determined according to the weighting shown in table i, and summed up to give the final mark. continuous assessment comprises meqs (scenario-based) and tutorials. the former are paper/pencil exams that test for content mastery across the blocks, involving content of the four disciplines. tutorials are smal-group learning sessions, case based and student centred, conducted on 2 weekly-based sessions of 3 hours each, to small groups. mid-block formative assessment is done, and end-of-block summative assessment is reflected in table i. ospe is a round of ‘stations’ measuring selected components of the block content. ipa is the exercise which duplicates, for an individual student (and faculty examiners), the process carried out in tutorial groups. assessment marks were stratified according to blocks and the different types of assessment (meq, tut, ospe, ipa). regression analysis was used to compute and scrutinise these vis-à-vis their correspondence with the final marks for each block with the help of epinfo 6 statistical software. the correlation coefficient (r) was used to assess the degree of dependence between each of the assessment components and the final mark. results there were 96 students in the mb chb iii programme at wsu in 2007. a total of 379 block assessment marks with their respective 4 assessment types were compared. regression analysis showed good correlation when analysing the assessment modality versus the final mark for the meq (r=0.93, 0.93, 0.94, 0.96 with p<0.001 for all values), followed by ospe (r=0.71, 0.70, 0.76, 0.77 with p<0.001 for all values), and ipa (r=0.62, 0.51, 0.68, 0.77 with p<0.001 for all values). however, correlation was not significant with the tut. meq correlation with final marks was the highest, followed by ospe for blocks 1, 2, 3 and 4 respectively (figs 1 5). stratified analysis per block showed increasing positive correlation (for meq and ospe), with the progress of the blocks with the highest coefficient being that of the meq for block 4 (fig. 5). trends in tut and ipa block marks did not show significant difference as blocks progressed. fig. 1. correlation between assessment components and final mark, block 1.  fig. 2. correlation between assessment components and final mark, block 2.  fig.3. correlation between assessment components and final mark, block 3.  fig. 4. correlation between assessment components and final mark, block 4. 13 december 2009, vol. 1, no. 1 ajhpe article discussion the development of effective student assessment techniques in pbl is challenging because of its student-centred focus and emphasis on selfdirected learning,8 which are in contrast to traditional learning systems. effective assessment tools should be able to judge students’ performance and progress through the course in a fair and objective manner. also, they must ensure that students derive the maximum benefits from pbl and that the pbl process itself is being conducted effectively for the given environment.9 some of the important principles of assessment are that the students should be assessed in a context similar to that in which they learn, and that the assessment should be appropriate to the developmental level, the subject matter and the programme outcomes.9,10 at wsu an effort is made to approximate these principles by using the assessment methods described in this article. the meqs are a series of questions based on patient problems. they test the students’ understanding and integration of concepts and their ability to relate this to patient problems, rather than testing mere factual recall. it is evident in the present study that students who performed well in the meqs also tended to perform well in the end-of-course exams. this supports the idea that meqs are a good way of assessing in-course performance. in the tuts, the tutor assesses the students’ knowledge base, clinical reasoning and decision-making skills, self-directed learning, collaborative work, attitudes and professionalism.11 in this article we do not demonstrate such a close correlation between the tutor assessments and the final course mark. this has been demonstrated in previous work.12,13 one of the reasons could be the number of attributes or competencies that tutors are expected to assess at a time, as it may be difficult to assess many people objectively simultaneously. it is also probable that some of the students may do well when they have a set of learning issues to prepare from one case study for presentation and discussion, but then tend to falter when confronted with the larger scope of entire systems in the end-ofblock summative assessments. additionally, there may be other variables that contribute to the decreased reliability in tutorial assessment, including a lack of clarity regarding the true domains being assessed (i.e. skills related to the process of learning/self-directed learning versus acquisition of specific biomedical content), inadequate observation of relevant student performance, and lack of support from teachers for the method itself or for the manner in which the assessment is implemented.5, 14-16 the ipa 1 component consists of a long case with sequential disclosure of information. students complete given ’tasks’ and hand in their answers before the next part of the case/problem is given to them. this is followed up by the ipa 2 – a viva voce – and is a discussion-based, integrated examination. the ospe is being increasingly used in many institutions for reasons such as objectivity and reliability.13,16 like a practical meq, students rotate through a series of timed, 5-minute stations. at each station, they are given tasks that cover practical and clinical aspects of the four broad disciplines. in the present study, there was good correlation between these components and the final mark for the block, supporting the use of these assessment methods. there was an increasing trend of correlation with the meqs as the blocks progressed (shown by increasing correlation coefficients) compared with the other assessment modes, although the significance is unclear. it could represent an incidental finding, as it does not appear to convey any specific information regarding students’ performance dynamics. there is a need for further evaluation of the different assessment tools in pbl and for comparing and correlating them to identify and implement objective and optimal assessment modalities in the dynamic pbl environment. conclusion there was good correlation between the students’ performance in the majority of assessment modalities and the final mark in the different blocks of the mb chb iii examination. it supports the use of this panel of examinations as a useful model for a pbl programme. there is a need to improve the quality of tutor assessments, which may be achieved by providing assessment training for pbl tutors. acknowledgements the authors acknowledge the walter sisulu university faculty of health sciences for providing the data used in the study. note. permission to conduct the study and to publish the findings was requested and obtained from the faculty of health sciences. there is no conflict of interests. references 1. kwan cy. what is problem-based learning (pbl)? it is magic, myth and mindset. cdtl brief 2000; 3: 1-2. 2. bligh j. problem-based, small group learning. bmj 1995; 311: 342-343. 3. ravi shankar p. problem-based learning: the right direction for medical teaching? med princ pract 2008; 17: 171-172. 4. norman gr, schmidt hg. the psychological basis of problem-based learning: a review of the evidence. acad med 1992; 67: 557-565. 5. dalrymple kr, wong s, rosenblum a, wuenschell c, paine m, shuler cf. pbl core skills faculty development workshop 3: understanding pbl process assessment and feedback via scenario-based discussions, observation, and role-play. j dent educ 2007; 71: 1561-1573. 6. carrera li, tellez te, d’ottavio ae. implementing a problem-based learning curriculum in an argentinean medical school: implications for developing countries. acad med 2003; 78: 798-801. 7. norcini jj, mckingley dw: assessment methods in medical education. teacher and teaching education 2007; 23: 239-250. 8. harden rm, sowden s, dunn wr. some educational strategies in curriculum development: the spices model. med educ 1984; 18: 284-297. 9. waters r, mccracken m. georgia institute of technology. assessment and evaluation in problem-based learning. available from www.succeed.ufl.edu/papers/ fie97/fie97-010.pdf (accessed 21 april 2009). fig. 5. correlation between assessment components and final mark.  article 14 december 2009, vol. 1, no. 1 ajhpe 10. friedman bm. the role of assessment in expanding professional horizons. med teacher 2000; 22: 472-477. 11. elizondo-montemayor ll. formative and summative assessment of the problem based learning tutorial session using a criterion-referenced system. jiamse 2004; 14: 8-14. 12. epstein rm. assessment in medical education new engl j med 2007; 356: 387396. 13. eva kw. assessing tutorial-based assessment. adv heath sci educ 2001; 6: 243257. 14. valle r, petra l, martinez-gonzalez a, rojas-ramirez ja, morales-lopez s, pina-garza b. assessment of student performance in problem-based learning tutorial sessions. med educ 1999; 33: 818-822. 15. govaerts mj, van der vleuten cp, schuwirth lw, muijtjens am. broadening perspectives on clinical performance assessment: rethinking the nature of in-training assessment. adv health sci educ theory pract 2007; 12: 239-260. 16. natu m v, singh t. objective structure practical examination (ospe) on pharmacology students’ point of view. indian pharmacol 1994; 26: 188-189. editorial board editor-in-chief vanessa burch university of cape town international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria ntombifikile mtshali university of kwazulu-natal marietjie nel university of the free state ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state hmpg editor janet seggie consulting editor jp de v van niekerk deputy editor bridget farham editorial systems manager melissa raemaekers scientific editor ingrid nye technical editors emma buchanan paula van der bijl head of publishing robert arendse production assistant neesha hassan art director brent meder dtp & design carl sampson anelia du plessis online manager gertrude fani issn 1999-7639 ajhpe is published by the health and medical publishing group (pty) ltd co registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za 28 main road (cnr devonshire hill road), rondebosch, 7700 | +27 (0)21 681 7200 all letters and articles for publication must be submitted online at www.ajhpe.org.za editorial 2 interprofessional education – is it ‘chakalaka’ medicine? v burch research 3 the effect of an interprofessional clinical simulation on medical students i treadwell, m van rooyen, h havenga, m theron 6 are further education opportunities for emergency care technicians needed and do they exist? c vincent-lambert, j bezuidenhout, m jansen van vuuren 10 how we see ‘y’: south african health sciences students’ and lecturers’ perceptions of generation y students l j van der merwe, g j van zyl, m m nel, g joubert 17 do physiotherapy students perceive that they are adequately prepared to enter clinical practice? an empirical study h talberg, d scott 23 pique-ing an interest in curriculum renewal j blitz, n kok, b van heerden, s van schalkwyk 28 student doctors (umfundi wobugqirha): the role of student-run free clinics in medical education in cape town, south africa s c mendelsohn 33 problem-solving abilities of radiography students at a south african university t pieterse, h lawrence, h friedrich-nel 37 introduction of a learning management system at the kilimanjaro christian medical university college l killewo, e lisasi, g kapanda, d tibyampansha, g ibrahim, a kulanga, c muiruri, n fadhili, d wiener, a wood, e kessi, k mteta, m ntabaye, j a bartlett  41 medical and dental students’ willingness to administer treatments and procedures for patients living with aids a y oyeyemi, u s jasper, a oyeyemi, s u aliyu, h o olasoji, h yusuph 45 understanding the learning styles of undergraduate physiotherapy students d hess, j m frantz 48 health-promoting schools as a service learning platform for teaching health-promotion skills l m du plessis, h e koornhof, l c daniels, m sowden, r adams 52 using graduates as key stakeholders to inform training and policy in health professions: the hidden potential of tracer studies a g mubuuke, f businge, e kiguli-malwadde 56 the effect of characterisation training on the congruence of standardised patient portrayals i treadwell, l schweickerdt-alker, d pretorius, m d hugo 60 continuous professional training of medical laboratory scientists in benin city, nigeria b h oladeinde, r omoregie, i odia, e o osakue 64 physiotherapy clinical students’ perception of their learning environment: a nigerian perspective a c odole, n a odunaiya, o o oyewole, o t ogunmola abstracts 69 sixth national conference of the south african association of health educationalists (saahe): ‘information to transformation’, umhlanga, 27 29 june 2013 115 cpd questionnaire ajhpe african journal of health professions education | may 2014, vol. 6, no. 1 mailto:publishing@hmpg.co.za http://www.ajhpe.org.za 170 november 2015, vol. 7, no. 2 ajhpe research stress among medical students is a universal cross-cultural phenomenon with many risk factors.[1-12] causes of stress include exogenous, endogenous, academic and non-academic factors. stress and distress among medical students may lead to physical, psychological and academic difficulties; damaging effects on empathy, ethical conduct, and professionalism; personal consequences such as substance abuse, broken relationships, and suicidal ideation; and also contribute to burnout and dropout.[13-15] examples of institutionally provided medical student support services directed at reducing stress include counselling, wellness programmes, cognitive behavioural approaches, and peer mentor programmes.[16-18] transport challenges were recently highlighted as a major source of stress among medical and allied healthcare students.[19] in this article we describe the lack of personal transport as a major and prevalent sociocultural cause of stress among underprivileged south african (sa) medical students. furthermore, we present our practical experience and offer some financial information with regard to developing and implementing a student transport service for economically disadvantaged medical students at the university of the free state (ufs), bloemfontein, sa. it is hoped that other medical schools may find the data and information helpful to replicate a similar student-centred transport initiative aimed at alleviating financial and emotional pressures, which may have a positive effect on medical students’ academic performance. we used ‘underprivileged’ and ‘economically disadvantaged’ interchangeably and defined these terms as a student group who, compared with their privileged or economically advantaged class peers with adequate financial means to enable easy access to private transport (a car), is forced to use the costly, untimely and dangerous public transport system in our city to commute between the hospitals of our training platform. before the inception of this project, underprivileged students without access to private transport had to rely on expensive, untimely and sometimes dangerous public minibus taxis to commute between the five different clinical sites of the ufs medical school training platform. during the preproject needs analysis, students reported that their annual cost to use public minibus taxis solely for their medical training needs was between zar5 000 and zar5 500. this led to undue and added financial, emotional and academic stress owing to the additional logistical pressures. many of them were struggling to cope with the academic demands of their medical studies. virtually all of the participating economically disadvantaged students have bursaries; hence, they have very little money left to pay for out-of-pocket expenses of local taxi transport. some students reported that they often had to decide between affording the cost of travelling and having a meal. institutional background the 110-year-old ufs is 1 of 24 public universities in sa, of which 8 (including the ufs) have medical schools. with its 8 faculties (including health sciences, comprising schools of medicine, nursing, and allied health professions), 3 campuses, and >31 000 students, including >720 medical students, ufs is one of the oldest institutions of higher learning in sa. the school of medicine (som) is situated on the main ufs campus in bloemfontein, the capital city of the free state province. the som has a 5-year background. in many parts of the developing world the lack of consistent and affordable transport may be a serious obstacle to education and a unique sociocultural cause of stress among undergraduate students. objective. to determine the student-perceived benefits of a faculty-led, grassroots student transport service for economically disadvantaged medical students. the service has been newly developed and implemented at the school of medicine, university of the free state, bloemfontein, south africa. methods. a brief qualitative questionnaire survey, with likert scales and free text, was administered to participants in the student transport project after its first 21 months of operation. students’ views of the impact and effect of the project on their circumstances were surveyed. results. during its first 2 years of operation, the student transport project was used by 116 students in their clinical third fifth years, representing 16.6% of students in these years of training. all the participating students using the shuttle service were from previously disadvantaged communities and were economically disadvantaged. a survey among the participating students yielded an 84% response rate; they all felt that the service significantly reduced their levels of financial and emotional stress, and many believed that the project positively impacted on their academic performance and assisted them in remaining in medical school. conclusion. the basic, but novel, student transport service described in this article can have a dramatic effect in reducing medical student stress and, potentially, improving academic performance and success. it is hoped that others in lesser-developed countries in africa and beyond may replicate such a student-centred transport initiative at their schools. afr j health professions educ 2015;7(2):170-175. doi:10.7196/ajhpe.352 a faculty-led solution to transport-related stress among south african medical students s schoeman,1 mb chb, mmed, phd; g van zyl,2 mb chb, pg dip in health administration and community health, mfammed, mba, phd; r a smego (deceased),3 md, mph, facp, frcp, dtm&h 1 department of internal medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 3 school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: s schoeman (schoemanfhs@ufs.ac.za) november 2015, vol. 7, no. 2 ajhpe 171 research undergraduate medical curriculum, a parallel language medium of instruction (afrikaans and english streams of separate language instruction), and uses the 5 medium-to-large state teaching hospitals in the greater bloemfontein area to deliver its clinical training. the university has a 64% black student body population, while the som had the following student body racial demographics during the implementation phase of the project: white or indian (72%), and black or coloured (28%). the reasons for the difference in overall student racial profiles between the greater ufs and som are mainly due to the fixed ratio (50/50) and numbers of first-year students (140) enrolled annually into the medical programme’s parallel-medium language classes (70 in each class) and the relative higher attrition rate of students in the english class. the afrikaans instruction class is a predominantly white class, with some coloured (mixed race) students, whereas the english class is largely constituted of ethnically black african, indian and coloured students, with some white students. transport challenges and related stress were identified as a possible contributing factor to the higher attrition rate in the english class groups – this was a motivating factor to develop this project. project description the project is housed in the som. the phase iii committee, which administers the clinical phase of the mb chb (medical) programme, is the curricular committee that oversees the project under the leadership of the project’s academic managers, operational lead (the first author), and chair of the phase iii committee. other project personnel include an administrative officer as secretary for the phase iii committee. she also manages the project on a day-to-day basis and deals with all the related administrative matters. she reports to the academic project manager, and together they run the operational side of the project. students wishing to use the service must complete and sign the project application and indemnity form before a semester ticket is issued. the cost of a semester ticket, which is heavily subsidised by corporate sponsors, is billed to the ufs student accounts system of the relevant student. this was an important step and a huge help from the university, because the billing method enables the bursary providers to cover the transport cost, as it is viewed as an official student expense. to keep the administrative load regarding tickets and access to the project manageable, students must commit for an entire semester. if they wish to leave or join the project during the semester, the cost of the ticket remains unchanged and no refunds are issued. this strategy has proven to be very successful, as it encourages students to make informed and well thought through decisions at the start of each semester with regard to joining or leaving the project, and discourages ad hoc users. the project is funded from two sources: corporate donors and the participating students’ bus ticket sales each semester. the start-up funds were provided by three corporate donors: netcare, a national private healthcare provider, which donated the two vehicles (~zar600 000), pps financial services, which gave a zar114 000 cash donation, and pfizer (sa), which donated zar57 000. the student transport project began operating on 11 april 2011. it proved an instant success with regard to easing the transport concerns and problems of the students. it was officially launched on 30 september 2011, with local and national media invited. the students’ elected representatives from each year group (third fifth year) form part of the project’s management team who keep in touch with their needs and provide feedback on the system. during 2011 and 2012, 59 and 57 students, respectively, were part of the project. table 1 provides a breakdown of the numbers and percentages of the total annual cohort involved in the project. although the project is open to all students in the clinical phase of the medical curriculum (final 2.5 years of the 5-year programme), all (100%) of the students who enrolled for the project were in the english class and black african, indian or coloured. therefore, to date, all the students engaged in the project were from previously disadvantaged communities (under the previous apartheid government) that had no access to private transport. the cost of the service for students per semester was zar1 200 during 2011 (pro rata from april to june) and zar1 350 in 2012, which was billed to their individual student ufs accounts. the project team, with funds made available from the som phase iii committee (zar24 000), had designated car ports erected for the buses to protect the vehicles from the weather during times when they are not in operation. students can hop on and off the bus at any of the hospitals en route. the shuttle service operates 7 days a week and on public holidays. the fourthand fifth-year medical students use the shuttle during the entire academic year (january november, i.e. first and second semesters). the third-year students join the clinical phase of their training (phase iii) in the second semester of their third year. therefore, the project carries more students and makes more weekday trips in the second semester (third fifth years) than in the first semester (fourth and fifth years only) of each academic year. table 2 table 1. students involved in the transport project 2011 2012 academic year n class cohort, % n class cohort, % third 23 19 (23/119) 9 8 (9/118) fourth 23 21 (23/107) 32 26 (32/125) fifth 13 11 (13/121) 16 15 (16/108) total 59 17 (59/347) 57 16 (57/351) table 2. shuttle times for the ufs student transport project departs from ufs back at ufs shuttle, n first semester weekdays 06h15 07h15 1 07h15 08h30 2 12h00 13h00 2 17h30 18h30 1 22h30 23h15 1 weekends and public holidays 07h30 08h30 1 10h30 11h10 1 22h30 23h15 1 second semester weekdays 06h15 07h15 1 07h15 08h30 2 11h00 12h00 1 12h00 13h15 2 17h30 18h30 1 22h30 23h15 1 weekends and public holidays 07h30 08h30 1 10h30 11h10 1 22h30 23h15 1 172 november 2015, vol. 7, no. 2 ajhpe research provides an illustration of trip times of the shuttle during the respective semesters. the two shuttles conducted 1 021 trips in 2011 and 1 596 in 2012. a trip is defined as one circle route from the ufs som building to the 5 affiliated teaching hospitals in the greater bloemfontein area, and back to the som building. there are 2 bus drivers who share the transport duties for 7 days a week. their official work uniform consists of ufs polo shirts and name badges. there are two 15-seat passenger shuttles (minibuses) – both equipped with satellite tracking devices (installation cost zar7 000 and annually zar7 000 for licences) that provide information regarding the whereabouts of the buses at all times and log the information of every trip. project data are kept on the tracking company’s server for 6 years. the drivers were paid zar60 per completed trip in 2011. their fee is raised annually in line with ufs inflation salary adjustments. the project’s administrative manager receives a small monthly stipend for being ‘on call’ after hours if problems should arise. the total operational costs for the project in the 21 months of operation were zar386 640. the project ended in 2012 with a positive balance of approximately zar160 000, which provided sufficient operating capital to continue with the project into 2013. the project also developed a standard operating procedure (sop) for the 2 drivers (appendix a). copies signed by the drivers are kept on file. students are also aware of the sop, as it is placed on blackboard®, the school’s educational management system. keys to the buses are kept securely in a combination safe in the som when the buses are not in use. because of the operating hours described in table 1, the drivers have electronic access cards to enable them to enter the som building after hours to fetch and return the keys before and after each trip, respectively. methods the students who took part in this research study signed consent forms so that the authors may use their data and publish the findings. the ufs faculty of health sciences ethics committee approved the study (ethics committee no. ecufs 33/2013). the research questions for this study were: (i) how many students are using the transport project; and (ii) what was the perceived impact of the transport project on the participants of the project with regard to their finances, stress levels, academic performance and wellbeing? we reviewed our project registration forms to calculate the number of students using the project annually and invited all of them to complete a simple and quick self-administered likert-scale questionnaire to evaluate the impact and effect of the project. the students could also add some free text comments to elucidate their responses. the survey (appendix b) was circulated during december 2012 to the graduating fifthyear students (n=16) and in the first semester of 2013 to the students involved in the project at that stage (n=40). therefore, a total of 56 student participants were invited to take part in the study. results during its first 2 years of operation, the student transport project was used by 116 students in their clinical years 3 5, representing 16.6% of students in these years of training during 2011 2012 (table 1). the response rate for this study (survey component) was 84% (47/56). the results of the student survey of the perceived impact and effect of the project are shown in table 3. table 4 reports on selected student testimonials with regard to the student transport project during its first 21 months of operation. discussion the project represents a student-centred, facultydriven grassroots initiative that developed as a result of a faculty-perceived student need. although it is explicitly stated in the regulations of our medical programme that transport arrangements between the som and our various training platform hospitals are the responsibility of individual students, the faculty members at the ufs som recognised that many of the students do not have the personal financial means for transport costs. hence, we see this project as an outflow of our social responsibility to support our economically disadvantaged students to succeed in medicine. within the first 21 months of operation, the student transport project has become a notable and visible institutional success. it is available to clinical medical students who require it; however, it is not a personalised system for individual participants. the participating students’ responses to the project have been overwhelmingly positive. the data from tables 3 and 4 show that the transport project had a positive influence on their academic experience and performance. furthermore, students reported that the service significantly reduced their levels of financial and emotional stress, and many believed that the project helped them to remain in the medical programme. the perception that faculty members in the som care about the welfare and difficult circumstances of many of the participating students was enhanced by the project (tables 3 and 4), which is helpful for fostering positive staffstudent relationships in the medical school. from table 1 it is evident that only a subgroup of students use the service and that most students do not need the project to facilitate their table 3. perceived impact of transport project statement number rated statement mean likert scale finding* (n=47) 1 overall, the student transport project has positively influenced my medical school experience. 4.6/5 2 the student transport project has helped alleviate financial pressures for me. 4.6/5 3 the student transport project has helped alleviate emotional/ psychological pressures for me. 4.2/5 4 i feel that the student transport project has had a positive impact on my academic performance at ufs. 4.1/5 5 i feel that the student transport project has been a major factor in allowing me to stay in medical school. 3.7/5 6 i feel that the department of medicine is truly concerned for the wellbeing and success of students. 4.7/5 7 i believe that the student transport project would not have been created without the concern and support of the faculty in the department of medicine. 4.7/5 *based on a likert scale of 1 5 (lowest to highest level of agreement) – see appendix b for details. november 2015, vol. 7, no. 2 ajhpe 173 research transport needs. students who are not using the project presumably prefer to use their own cars or make use of ‘lift-clubs’ with fellow students. both of these options are probably more expensive, as they are not subsidised by corporate donors, but they are more personalised and convenient. however, the som realises that this does not imply that they are without some of the same stressors (e.g. finances and academic pressures) that the project students experienced. although this study did not directly measure the number of students without access to routine private transport for their medical training needs, and given the negative aspects outlined in this article about the public transport system in bloemfontein, the study does give a good indication of the percentage of senior medical students (16.6%, table 1) in our medical school who are reliant on travel support to meet their medical training needs. student affairs and financial aid offices at medical schools typically provide a range of academic and personal support services designed to help students succeed; these may play a crucial role in aiding students to stay in the academic programme. in the developed world, one does not usually consider student transport as a significant source of student stress and hardship[6] because of the ability of students to provide their own transport or the availability of adequate public transport. in much of the developing world, however, a lack of consistent or affordable transport may be a real obstacle to successful employment and education.[19] as educators, our ultimate goal is the success of the medical students in becoming competent and caring physicians. our efforts in curriculum development and student supervision and assessment are directed towards realisation of this goal. at times, however, the success of students becomes critically dependent on non-educational efforts that take place outside the classroom or clinical arena. the role of non-academic student supportive services is often overlooked when evaluating the educational success of students. the kind of basic, but novel, student transport service described in this article may be helpful in reducing medical students’ stress and, potentially, improving academic performance, as suggested by the students’ feedback in this research project. acknowledgement. we acknowledge the important role and support of our corporate partners towards this project and in assisting future medical doctors in southern africa – netcare; pps financial services; and pfizer (sa). we also acknowledge the efforts and drive of the late professor raymond smego junior to publish this article and make this project known to healthcare professionals. he sadly passed away in december 2012. references 1. jaffri n, jaleel a. stress level in medical students. j coll physicians surg pak 2012;22(6):416. [http://dx.doi. org/06.2012/jcpsp.416416] 2. nuallaong w. correlation between stressors and academic performance in second year medical students. j med assoc thai 2011;94(suppl 7):s81-s85. 3. al-dubai sa, al-naggar ra, alshagga ma, rampal kg. stress and coping strategies of students in a medical faculty in malaysia. malays j med sci 2011;18(3):57-64. 4. abdulghani hm, alkanhal aa, mahmoud es, ponnamperuma gg, alfaris ea. stress and its effects on medical students: a cross-sectional study at a college of medicine in saudi arabia. j health popul nutr 2011;29(5):516-522. 5. koochaki gm, charkazi a, hasanzadeh a, saedani m, qorbani m, marjani a. prevalence of stress among iranian medical students: a questionnaire survey. east mediterr health j 2011;17(7):593-598. 6. dyrbye ln, harper w, durning sj, et al. patterns of distress in us medical students. med teach 2011;33(10):834-839. 7. gomathi kg, ahmed s, sreedharan j. psychological health of first-year health professional students in a medical university in the united arab emirates. sultan qaboos univ med j 2012;12(2):206-213. 8. baykan z, naçar m, cetinkaya f. depression, anxiety, and stress among last-year students at erciyes university medical school. acad psychiatry 2012;36(1):64-65. 9. benbassat j, baumal r, chan s, nirel n. sources of distress during medical training and clinical practice: suggestions for reducing their impact. med teach 2011;33(6):486-490. 10. voltmer e, kötter t, spahn c. perceived medical school stress and the development of behavior and experience patterns in german medical students. med teach 2012;34(10):840-847. [http://dx.doi.org/10.3109/0142159x.2012706339] 11. fan ap, kosik ro, su tp, et al. factors associated with suicidal ideation in taiwanese medical students. med teach 2011;33(3):256-257. 12. nagpal sj, venkatraman a. mental stress among medical students. natl med j india 2010;23(2):106-107. 13. dyrbye ln, shanafelt td. medical student distress: a call to action. acad med 2011;86(7):801-803. table 4. a selection of individual student narratives on the impact and effect of the transport project • this project helps us to have safe and reliable transport. this project is most valuable during the evening especially for the female students. • this has been a great help to me and i just want to thank internal medicine department, the dean and all the corporate sponsors for keeping this initiative going. • thank you very much for making our academic experience easier. we saw out serious previous struggle with transport and we were very worried. • it is important to keep this transport project going because it is very important to people like us without cars and also makes us stress free. • this project has helped me a lot with regards to participate at the hospital and also the lectures. i am always on time and i manage to prepare my work and patients on time. thank you. • this project has relieved a lot of pressure on me as a student, it is highly beneficial and important. • the transport project has been very helpful, it wouldn’t have been possible for some of us to travel between the hospitals. thank you very much!! • the student transport project is a very helpful transport system to those with no personal transport. it is important that even in the upcoming generation the system stays in use. • i was one of the students who used to use public minibus taxis and i really appreciate and am thankful every day that the project was started and continues. thank you. • thank you very much for your efforts, i cannot imagine how i would have managed to go and come back from hospitals at night (23h00), really personally you have helped me a lot. please no matter what, do not stop helping us, we really truly appreciate. thank you once more. • it has truly alleviated the stress and we’ve been able to safely travel between the faculty and hospital. it has especially helped us in regard of our evening calls that end at 23h00. • i don’t have a car and the transport project has at least alleviated that stress because i no longer worry about how i will get to pelonomi/national hospital. the amount we pay is very reasonable considering it’s for 6 months. on saturdays and sundays, it will be nice if there was transport that leaves at 17h30 as well, as well as on public holidays. all in all, transport project is a real great help!! • the staff of the student transport project is very accommodating and concerned about our wellbeing. it is an absolute pleasure to work with them. the project has been a great help to a lot of us, especially financially. it is not a lot of us students who have cars and having the transport project – it takes some pressure off. • i do not know how i would have worked without the transport project. some of the time you finish working at 11pm and you do not have money to call a private taxi. also, we are very grateful for the shuttle drivers, they are very understanding when sometimes we are released late from the call they always wait for us. thank you very much. 174 november 2015, vol. 7, no. 2 ajhpe research 14. dyrbye ln, power dv, massie fs, et al. factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of us medical students. med educ 2010;44(10):1016-1026. [http://dx.doi. org/10.1111/j.1365-2923.2010.03754.x] 15. chang e, eddins-folensbee f, coverdale j. survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. acad psychiatry 2012;36(3):177-182. 16. thomas se, haney mk, pelic cm, shaw d, wong jg. developing a program to promote stress resilience and self-care in first-year medical students. can med educ j 2011;2(1):e32-e36. 17. barker ta, ngwenya n, morley d, jones e, thomas cp, coleman jj. hidden benefits of a peer-mentored ‘hospital orientation day’: first-year medical students’ perspectives. med teach 2012;34(4):e229-e235. 18. mcgrady a, brennan j, lynch d, whearty k. a wellness program for first year medical students. appl psychophysiol biofeedback 2012;37(4):253-260. [http://dx.doi.org/10.1007/ s10484-012-9198-x] 19. omigbodun oo, odukogbe aa, omigbodun ao, yusuf ob, bella tt, olayemi o. stressors and psychological symptoms in students of medicine and allied health professions in nigeria. soc psychiatry psychiatr epidemiol 2006;41(5):415-421. [http://dx.doi.org/10.1007/s00127-006-0037-3] appendix a. standard operating procedures for shuttle drivers ufs school of medicine transport project version 3. 1 august 2012 (valid for 1 year – august 2013) 1. drivers must under no circumstances deviate from the normal prescribed route. this exposes the shuttles to possible theft and hijackings. shuttles are fitted with gps tracking devices and checks are done regularly. regarding the 23:00 drop-off, you may drop particular students who paid the extra ‘home drop fee’, close to their homes. the other students must be dropped on the prescribed route. 2. drivers are to ensure that they themselves and all passengers wear seatbelts at all times when the shuttle is in operation. 3. drivers must never drive faster than 60 km/h, except if it is a case of extreme urgency and must report this to mrs nel or dr schoeman on the first working day after the incident. 4. drivers must follow the road rules and drive politely and never drive recklessly or in a manner that causes discomfort to any passenger. passengers are encouraged to report good and bad driving. 5. never stop in the street to pick up or drop off a student. 6. drivers must never talk on their cell phones while driving the bus. please ask a student to answer your phone. it’s illegal to talk on a mobile phone and drive. 7. drivers must log trip details in logbook before and after each trip. 8. the logbook and drivers rota are used to calculate remuneration on a monthly basis. 9. when no students arrive for the trip at the different pick-up points, park the bus and complete the log book. the tracker system will indicate movement of the shuttle and remuneration will only be paid when the ufs pick-up route is completed. 10. drivers must report damage to the shuttle immediately upon return to the faculty (next day if after hours) and inspect vehicle before he takes responsibility for it, otherwise he will be held responsible. 11. drivers must collect and replace the keys to the shuttles in the security safe provided by the project. tags and codes to the safe must never be shared with any other person outside of the project team (i.e. drivers and management team – dr schoeman and mrs nel). 12. drivers must check the validity of students’ tickets before admitting them on the shuttle. 13. drivers must ensure the neatness of the interior of the shuttles and report to management if students are messy in the shuttles. 14. in case of a hi-jack, press the panic button if possible. co-operate with the hi-jackers and do not put yourself or the passengers’ (if any) lives in danger. 15. if you are suspicious of someone following you, try to get the licence plate number or description of the car and report it to the nearest police station. 16. defer all students’ special requests to dr schoeman or mrs nel. 17. an up-to-date list of all the students participating will be available in each shuttle. 18. regarding the petrol cards: 18.1 the card may only be used for the vehicle identified on the card. 18.2 please make use of the bloemgate service outlet in nelson mandela drive. 18.3 always check that the card you receive back is yours. 18.4 report a stolen or lost card immediately to mrs nel. 18.5 check that the slip is printed clearly and give it to mrs nel who will file it. please take note: drivers who transgress these sops will be subject to disciplinary procedures and could face possible dismissal. signed: at _______________________ on ____________________20_____ name and surname:________________signature: __________________ dr f h s schoeman:_________________admin officer: _______________ november 2015, vol. 7, no. 2 ajhpe 175 research appendix b. student questionnaire about the student transport project school of medicine key 1 = strongly disagree 2 = disagree 3 = uncertain 4 = agree 5 = strongly agree student transport project survey • overall, the student transport project has positively influenced my medical school experience 1 2 3 4 5 • the student transport project has helped alleviate financial pressures for me 1 2 3 4 5 • the student transport project has helped alleviate emotional/psychological pressures for me in relation to my medical studies 1 2 3 4 5 • i feel that the student transport project has had a positive impact on my academic performance at ufs 1 2 3 4 5 • i feel that the student transport project has been a major factor in allowing me to stay in medical school 1 2 3 4 5 • i feel that the department of internal medicine is truly concerned for the wellbeing and success of students 1 2 3 4 5 • i believe that the student transport project would not have been created without the concern and support of the academic staff in the department of internal medicine 1 2 3 4 5 additional comments: research 208 november 2015, vol. 7, no. 2 ajhpe professional identity underpins an individual’s perspective in the way they evaluate, learn and make sense of their professional practice.[1] higher education institutions are being put under increasing pressure to prepare students for the world of work[1] by producing autonomous graduates who have the ability to make evidence-based decisions in line with their values in rapidly changing, complex and contradictory situations.[2] this requires practice-based curricula that contribute to the development of professional identities. medical educators have therefore attempted to conceptualise professional identity development in terms of their teaching and learning contexts.[3-5] social identity theory has been proposed and applied as one conceptual framework for the understanding of professional identity development, as it aims to define and explain the social and individual factors and processes that influence an individual’s sense of belonging to a specific social group, which encompasses professional groups.[3-7] in pharmacy education, the development of a professional identity has remained problematic, which may largely be attributed to the dearth of literature that properly defines, teaches and assesses professionalism.[8] a recent study among firstand third-year pharmacy students found that a professional identity is underpinned by a sound knowledge of basic science[9] instead of professional practice. some postulate that the lack of pharmacy students’ socialisation into professional practice may be a reason for the so-called ‘crisis in professionalism’.[10] a recent systematic review of higher education literature revealed a general scarcity of articles that comprehensively define and explore the teaching and learning of professional identity development.[1] nonetheless, the literature seems to agree on a two-pronged approach to underpin development of a professional identity during higher education: (i) it should enable student participation in experiences likely to be encountered in professional practice (also referred to as professional socialisation); and (ii) it should facilitate the student’s ability to make meaning[2] of these experiences through reflection and critical self-reflection.[1,2,11,12] the purpose of this enquiry was to identify and describe first-year pharmacy students’ professional identity and determine whether it changed during the first semester of the ‘introduction to pharmacy’ course. in this article, sequential written assignments in the form of reflective critical incident reports were analysed. the structure of this article is as follows: firstly, some of the concepts of professional identity development are discussed, primarily in terms of social identity theory.[13] secondly, the learning environment is contextualised in terms of the processes of socialisation and reflection. lastly, the findings attempt to align students’ progressive descriptions of ‘what it means to be a pharmacist’ with concepts of social identity theory that charaterise the identity development process. professional identity formation and learning according to the social identity theory, a person usually has a number of social identities [13] (e.g. gender, age, language, culture, socioeconomic class, personality type, occupation) that contribute to the construction of an allencompassing self-identity. each social identity is contextualised in terms of the status of the specific social group (e.g. women, 30-something, afrikaans, white, middle class, introvert, pharmacist) and power relationships in society,[14] which shape a social group’s stereotypical image (or ‘social title’). through the cognitive process of self-categorisation, an individual may choose to identify with certain social groups.[3] this identification background. professional identity underpins an individual’s perspective in the way they evaluate, learn and make sense of their professional practice. in pharmacy education, the development of a professional identity has remained problematic, which may largely be attributed to the dearth of literature that properly defines, teaches and assesses professionalism. objectives. to identify and describe first-year pharmacy students’ professional identity and determine whether it changed during the first semester of the ‘introduction to pharmacy’ course. methods. students had to write three sequential reflective reports in which they were expected to identify critical experiences since their enrolment. these served as reference points from which they could frame their sense of professional identity. after grading, each set of reports was ordered according to total marks allocated, of which every tenth report was selected for thematic analysis. results. baseline reports indicated that students had a largely stereotypical view of the pharmacist as medicine supplier. subsequent reports showed a shift in perspective, as students articulated a more complex role for the pharmacist, distinguished between the pharmacist’s role and that of other health professionals, and formulated the pharmacist’s positive value for society. conclusion. our findings describe the attempts of first-year pharmacy students to internalise a professional identity during a first-semester module. by applying concepts of social identity theory to sequential reflective assignments, an emerging professional identity could be interpreted, which was denoted by an increasing sense of belonging to the pharmacy profession. afr j health professions educ 2015;7(2):208-211. doi:10.7196/ajhpe.423 the meaning of being a pharmacist: considering the professional identity development of first-year pharmacy students m van huyssteen, phd; a bheekie, phd school of pharmacy, faculty of natural science, university of the western cape, bellville, south africa corresponding author: m van huyssteen (mvanhuyssteen@uwc.ac.za) research november 2015, vol. 7, no. 2 ajhpe 209 process defines who a person is – the in-group (e.g. pharmacist) – as well as who a person is not – the out-group (e.g. doctor/nurse). group membership is usually associated with cultivating increasingly positive attitudes towards the in-group by appreciating its diversity and differentiating this diversity from out-groups.[3] the development of an in-group mentality is made accessible when an individual choosing to assume that social identity (e.g. pharmacist) participates in activities associated with the group (e.g. dispensing of medicine) or social engagements that require the salience of that social identity (e.g. advising patients about medicine). there is a natural tendency to link good attitudes to the in-group, resulting in the out-group being thought of as the opposite of the in-group (bad attitudes). these attitudes towards the out-group tend to have a homogenising effect in the mind of the individual, which gives rise to social stereotyping of this group. the ‘development of a professional identity’ is primarily concerned with the process of integrating a new social identity into an individual’s self-identity. the identity reconstruction process is dependent on the socialisation of an individual in appropriate roles and forms of participation in the community, and the ability to make meaning of socialisation encounters.[13] the aim of providing students with professional socialisation encounters (such as interacting with pharmacists, evaluating what they do, or actively seeking information about the profession[9]) is to increase the salience of professional identity, thus providing the opportunities to add personal meaning to the new social identity. this experience of the making of meaning allows students to construct their own ‘knowledge of ’ the profession as opposed to ‘knowledge about’ the profession (which they are taught in class). by doing so, students are provided opportunities that might cultivate a sense of belonging to the professional group, as ‘one cannot develop a practice-centred identity simply by learning about the practice’.[10] the internalisation of a professional identity involves a change in what we know and how we know what we know. thus, pharmacists may interpret their professional identity in different ways, as the process of internalisation is heavily dependent on a person’s ability to shape a coherent meaning.[15] meaningmaking is limited by the level of complexity of an individual’s frame of reference (beliefs, feelings and values), which is dependent on cognitive, emotional and social aspects of self-identity.[15] therefore, the internalisation of a ‘new’ identity involves an increase in the complexity of an individual’s perspective or frame of reference.[12] the latter may become more complex if it is to be identified, analysed and challenged through critical reflection and self-reflection.[2] initially, this process may manifest in students through feelings of discomfort, confusion and contradiction. it is important for them to be aware that feelings of discomfort are potential markers of a shift in identity[5] and for teachers to facilitate this understanding for students to drive their own growth. setting and structure of enquiry the school of pharmacy, university of the western cape (uwc) launched its new curriculum in 2013, which included two pharmacy-focused modules for first-year students. this was the first time that staff from the school of pharmacy had been involved in teaching first-year students. this article focuses on the first-semester module entitled ‘introduction to pharmacy’. the aim of this module was to announce the start of the journey in becoming a pharmacist, focusing specifically on the concept of ‘what it means to be a pharmacist’. our enquiry was primarily explorative and descriptive in design. it comprised sequential reflective written assignments (fig. 1), embedded within a continuum of didactic lectures providing explicit ‘knowledge about’ pharmacy and pharmacists, interspersed with socialisation encounters and group reflection. three sequential written assignments followed the structure of a reflective critical incident report.[11] each assignment consisted of a short narrative account of a critical experience identified by the student, interpreted as a significant learning moment, turning point or moment of realisation, which they thought contributed to their personal or professional identity development. the purpose of the first assignment was to gauge the first-year students’ interpretations of ‘what it means to be a pharmacist’ before introducing the pharmacy curriculum and influence of lecturers (fig. 1). this assignment served as a reference point from which later shifts in students’ descriptions could be determined. the first socialisation component for the students was a service-learning experience at a primary school in an underserved community in cape town. the students were tasked to talk to groups of learners (grades 4 7) for 1 hour, trying to establish what the learners knew about factors affecting their health. the service-learning experience was followed by a 2-hour group reflection on campus.[12] the purpose of group reflection was for students to share experiences that tended to be different or contradictory to their personal frame of reference (beliefs and morals about the world). contradictions between a personal frame of reference and real-world experiences may lower an individual’s self-esteem and thus threaten the professional identity development process. dialogue with different group members offers as many perspectives for the interpretation of the incident and eases the initial contradiction, affording a more inclusive interpretation of the experience. the second written assignment focused specifically on a critical incident that written assignment 1 socialisation 1 group re�ection written assignment 2 socialisation 2 and 3 written assignment 3 fig. 1. sequence of investigation. research 210 november 2015, vol. 7, no. 2 ajhpe enabled students to examine their self-identity and how their personal frame of reference correlated or did not correlate with their interpretation of their professional identity. the second socialisation component was an interprofessional learning component completed at the interdisciplinary teaching and learning unit at uwc. it required students to participate in interprofessional group work (with students studying dentistry, occupational therapy, etc.) for 2 hours once a week over 7 weeks, and covered topics of health, social development and primary healthcare as part of their first-semester module. the third socialisation component was an opportunity for students to attend a talk and engage with 3 guest pharmacists for ~1 hour, each practising in a different sector of pharmacy (industry, public primary healthcare and hospital (clinical) sector). these interactions aimed to expose students to a variety of potential role models and practice environments and it was hoped to reduce the perception of the stereotype pharmacist.[3] the three sequential written assignments formed part of the formative assessment mark for the module. each assignment was graded according to a reflection rubric that included four main assessment criteria: clear and expressive description of the critical incident; analysis of how the incident contributed to the understanding of self, others and the profession; open, non-defensive self-appraisal of one’s own frame of reference; and language structure and use. feedback on assignments focused on stimulating the students to re-examine their frame of reference relative to their experiences (on or off campus). the allocation of marks for each sequential assignment incrementally increased for the analysis and self-appraisal criteria and decreased for description and structure criteria to explore the depth of their critical analysis skills. the first and third assignments were marked by one individual assessor, but the second assignment was marked by three independent assessors using the reflection rubric. inter-assessor variability should not have a marked effect on the findings of this investigation, as the grades of the students do not necessarily correlate with the strength of their professional identity. the grades were used as a tool to facilitate the sampling process. each set of assignments (first, second and third) was ranked in order of the highest to the lowest score, of which every tenth assignment was sampled. thematic analyses were done separately for each set of assignments. results and discussion findings are presented in the order in which the assignments were written. the first set of assignments showed that students largely viewed the pharmacist as different from themselves and described critical incidents from the patient’s perspective. students tended to describe the stereotypical role of the pharmacist, with most of the critical incidents relating to medicines. students’ perceived knowledge about ‘medicine’ was dominated by images of pharmacists dispensing it and advising people on how to administer it. there were isolated examples of caring and professional conduct. students tended to describe a pharmacist in terms of having scientific knowledge (mainly chemistry and biology) closely related to the requirements for being accepted into the pharmacy course, probably because this is what they had been exposed to. students were not cognizant of the values of socialisation skills. these overwhelmingly stereotypical descriptions of the poorly communicating, independent and intelligent pharmacist were in line with findings from a previous interdisciplinary study conducted in the uk with neophyte undergraduate students (including audiologists, doctors, midwives, nurses, occupational therapists, pharmacists, physiotherapists, podiatrists, radiographers and social workers) who had to rate the professional attributes of different types of healthcare workers.[7] in another study from the uk, which compared the perception of professional identity between firstand third-year pharmacy students, the former tended to delay their identity development until they acquired a broad scientific knowledge.[9] the abovementioned findings reinforce the notion that early professional identity development during pharmacy education is particularly weak. this is hardly surprising, as the students are mainly exposed to the natural sciences at the school of pharmacy rather than professional practice during their first year. after the first socialisation encounter, the second set of assignments described students’ first experiences of ‘being’ a pharmacy student. one student noted that ‘i felt appreciated and important’. another student described this in terms of her feeling of belonging to the profession: ‘as pharmacy students we were wearing our lab coats and lanyard as to respect and represent the pharmacy job, so that even the learners can see we did not send ourselves, but we have been sent.’ the previous two quotes described students’ experiences of ‘being perceived as’ pharmacy students rather than ‘being’ pharmacy students. this is not surprising, as they have had little exposure to the pharmacy practice setting. other students described experiences with a more internal focus of their engagements with others. this was evident from some students expressing their feelings of unease at the new responsibility that went with ‘being’ a pharmacy student: ‘these children were letting me into their lives and it was up to me to listen and practise confidentiality with the important information that they had rendered on my shoulders.’ by making some of the roles of the pharmacist accessible, students could start identifying qualities of a pharmacist, such as empathy, adaptability, compassion and humility, on the basis of personal experience and not only from what they were taught in class. students realised that the role of the pharmacist did not only require (stereotypical) knowledge and skills, but demanded personal maturity and the development of self-responsibility. this realisation seemed to add value to and respect for the role of the pharmacist in society, as illustrated below: ‘the reason why this incident had this effect on me i think it’s because i did not know that becoming a pharmacist was all about care taking and making a great change in someone’s life not by just dispensing medicine but also helping them by giving them advice and because i had little knowledge before going to that school but now i am no more in that nut shell.’ in the third set of assignments some students started to express their perceptions of the undervalued role of the pharmacist in society. with regard to identity development, this may suggest that students were starting to identify with pharmacists as the in-group by delineating professional boundaries with out-groups, as noted in the following: ‘the doctor is the custodian of diagnosis and the pharmacist the custodian of medicines.’ furthermore, students reported a broader and deeper understanding of the role of the pharmacist. they valued the core competencies that pharmacists were required to attain when handling medicines, i.e. discovery and design of new products and industry-linked activities such as manufacture, storage and distribution of bulk supplies. they also seemed to articulate the attributes that a good pharmacist should have, e.g. communication as an especially valuable skill. students expressed their desire to be more engaging/patient-centred and asserted to fulfil this role in future. furthermore, they commented on the personal growth they experienced during this course: ‘not only have i learnt so much about the pharmacy research november 2015, vol. 7, no. 2 ajhpe 211 profession but i have come to know many things about myself that i was unaware of.’ this is especially important, because a complex frame of reference, usually associated with maturity, is important for the reflective ability needed to develop a strong professional identity. [2,5,15] limitations of this enquiry include that the results were based on selfreport and linked to a mark for formative assessment, which might have made the students identify with a pharmacist more positively than was the case. another limitation might have been that students’ professional socialisation encounters did not occur in a pharmacy and were not facilitated by a pharmacist, i.e. an atypical practice environment. this environment may have diluted the experience of a pharmacist identity in favour of a more generic healthcare worker identity (non-traditional pharmacist identity). however, this is a common problem in pharmacy education, where some educators perceive the role of the pharmacist to be more ‘traditional’, while others recognise the need of being a more active participant and decision-maker in the healthcare team and with the patient.[8] this distinction is important because it seems to be the cause of the ‘realistic disenchantment’ that some pharmacy students experience during the latter years of study, when confronted with the gap between theory and practice.[8] conclusion our findings describe first-year pharmacy students’ attempts to internalise a professional identity during a first-semester module. by applying concepts of social identity theory to sequential reflective assignments, an emerging professional identity could be interpreted, which was denoted by an increasing sense of belonging to the pharmacy profession. it is recommended that studies on professional identity continue to track the development of identity over the undergraduate period, as ongoing inconsistencies may develop between theory and practice – the traditional role of the pharmacist being increasingly assumed by the student. the idea of an evolving identity is in line with a more general assumption in higher education, i.e. that ‘educators must now design curricula that will help graduates engage with a constantly shifting professional identity. rather than help build armour that they can then face the world and their clients with over the course of their career, educators must now help students to see that they are constantly becoming professionals and that their identity development is increasingly fluid.’[1] references 1. trede f, macklin r, bridges d. professional identity development: a review of the higher education literature. studies in higher education 2012;37(3):365-384. [http://dx.doi.org/10.1080/03075079.2010.521237] 2. lewis p, forsythe gb, sweeney p, et al. identity development during the college years: findings from the west point longitudinal study. journal of college student development 2005;46(4):357-373. [http://dx.doi. org/10.1353/csd.2005.0037] 3. burford b. group processes in medical education: learning from social identity theory. med educ 2012;46:143152. [http://dx.doi.org/10.1111/j.1365-2923.2011.04099.x] 4. goldie j. the formation of professional identity in medical students: considerations for educators. med teach 2012;34:e641-e648. [http://dx.doi.org/10.3109/0142159x.2012.687476] 5. jarvis-selinger s, pratt dd, regehr g. competency is not enough: integrating identity formation into the medical education discourse. acad med 2012;87(9):1185-1190. [http://dx.doi.org/10.1097/acm.0b013e3182604968] 6. adams k, hean s, sturgis p, et al. investigating the factors influencing professional identity of first year health and social care students. learning in health and social care 2006;5(2):55-68. 7. hean s, macleod clark j, adams k, et al. will opposites attract? similarities and differences in students’ perceptions of the stereotype profiles of other health and social care professional groups. journal of interprofessional care 2006;20(2):1-20. [http://dx.doi.org/10.1080/13561820600646546] 8. rutter pm, duncan g. can professionalism be measured? evidence from the pharmacy literature. pharmacy practice 2010;8(1):18-28. 9. taylor kmg, harding g. the pharmacy degree: the student experience of professional training. pharmacy education 2007;7(1):83-88. [http://dx.doi.org/10.1080/15602210601149383] 10. duncan-hewitt w, austin z. pharmacy schools as expert communities of practice? a proposal to radically restructure pharmacy education to optimize learning. am j pharmaceutical educ 2005;69(3):370-380. 11. branch wt. use of critical incident reports in medical education. j gen intern med 2005;20:1063-1067. 12. mezirow j. an overview on transformative learning. in: illeris k, ed. contemporary theories of learning: learning theorists … in their own words. new york: routledge, 2009:90-105. 13. tajfel h. human groups and social categories: studies in social psychology. cambridge: cambridge university press, 1981:1-369. 14. hogg ma, abrams d. social identitifications: a social psychology of intergroup relations and group processes. london: routledge, 1998:1-268. 15. kegan r. in over our heads: the mental demands of modern life. massachusetts: harvard university press, 1994:1-396. november 2015, vol. 7, no. 2 ajhpe 165 research for various reasons training in clinical communication has become separated from other aspects of medical education and tends to be dealt with early in the curriculum.[1] performing a clinical procedure involves two sets of skills – those related to conducting the procedure and those related to communicating with the patient. although inextricable in practice, these sets of skills are usually taught separately, often by different departments in an institution.[2] teachers of clinical communication, whether faculty or clinically based, may not share the learning goals for acquiring communication skills, which may lead to a disjointed learning experience for students.[1] as clinicians are expected to integrate technical with communication and other professional skills, these should not be taught separately. nontechnical skills, although essential in carrying out a clinical procedure on a conscious patient, can be ignored in simulation-based teaching.[2] other disadvantages of simulation include learning in isolation from the clinical context and assessment practices that traditionally focus only on the technical elements of clinical procedural skills.[3] in an effort to avoid these possible disadvantages of simulation, realistic clinical scenarios can be created by linking bench-top models with simulated patients (sps). students can then perform procedures in a safe environment, where many of the contextual cues of clinical practice are recreated.[2] sps are usually lay people who are trained to portray a patient with a specific condition. when trained to play a role during an examination in a consistent way – one which does not vary from student to student – they are referred to as standardised patients. seamless integration of the procedural and communication skills is a process that requires practice and reflection. reflection, defined as awareness or analysis of one’s own learning or thinking processes, is regarded as an essential skill in learning and metacognition.[4] reflection on action stimulates the student to consciously re-evaluate the experience and decide what could be done differently the next time he/she is in the same situation. structured reflection after a clinical encounter, either oral or written, is therefore a useful strategy to enhance learning and reasoning.[1] at the university of limpopo (medunsa campus) in ga-rankuwa, 25 km north-west of pretoria, south africa, students are introduced at the beginning of their medical degree programme to procedural and clinical communication skills as separate skills. during the first 3 years, the focus is on history taking and communication skills; the focus widens to include consultation skills in their third year. procedural skills include urine testing, venepuncture, intravenous infusions, basic clinical examination of adults, including vital signs and anthropometric measurements, palpation of a pregnant abdomen, normal delivery and repair of an episiotomy. several disciplines, in collaboration with the skills centre, are responsible for the teaching and assessment of these skills. these preclinical students have limited experience of the clinical workplace and working with patients. the ultimate accomplishment would be the integration of their acquired skills in a patient-centred consultation in preparation for their years of clinical training and future role as doctors. assessing the students through a patient-centred consultation will provide an opportunity to explore their ability to integrate skills and background. an effective patient-centred consultation requires the seamless integration of procedural (technical) and communication skills. research has shown that the two sets of skills should not be taught or assessed separately; yet, clinical communication education has become separated from other parts of medical education. objectives. to assess students’ performance of integrated procedural and clinical communication skills in a simulated consultation, and analyse and interpret their reflections on the value and challenges of these integrated assessments. methods. a mixed-method study was conducted to assess a convenience sample of 207 third-year medical students’ integration of procedural and consultation skills in a simulated patient consultation and explore their self-assessment and reflections on the value of the assessment. results. the average percentages scored for procedural and communication checklist items were compared. facilitators and participants scored procedural skills significantly higher, indicating poor integration of communication skills. a thematic analysis of written reflections revealed that students learned by: (i) experiencing an authentic consultation; (ii) integrating their procedural and communication skills as well as their knowledge and skills; (iii) experiencing the assessment as learning; and (iv) becoming aware of the effects of emotion. conclusion. although the majority of students were not able to integrate their skills in performing a simulated consultation, they nonetheless appreciated the value of the assessment as a learning experience. afr j health professions educ 2015;7(2):165-169. doi:10.7196/ajhpe.334 preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation i treadwell, dcur, hed skills centre, sefako makgatho health sciences university (formerly medunsa campus of the university of limpopo), pretoria, south africa corresponding author: i treadwell (ina.treadwell@gmail.com) 166 november 2015, vol. 7, no. 2 ajhpe research allow lecturers to determine the influence of this assessment approach on their learning. the questions that arise are how well preclinical medical students integrate procedural and clinical communication skills, despite having acquired them separately during various academic blocks; and how these students learn by being assessed in a simulated consultation that requires integrated skills. it is hoped that this research will provide sufficient evidence of the importance of using sps in integrated objective structured clinical examinations (osces) at medunsa and will pave the way to the enhancement of the integration of procedural and communication skills throughout the medical curriculum. objectives the aims of the study were: (i) to determine preclinical medical students’ ability to integrate procedural and communication skills in a simulated consultation; and (ii) to determine which aspects of the simulated consultation they valued as a learning experience. the objectives were: • to assess students’ performance of integrated procedural and clinical communication skills in a simulated consultation • to analyse and interpret students’ reflections on the value and challenges of the integrated assessments. methods a mixed-method study was conducted: a descriptive study to observe and assess students’ performance in the consultation osce and a qualitative inquiry to explore participants’ reflections on their learning through the integration of procedural and clinical communication skills in a simulated consultation. a qualitative inquiry was appropriate in studying process evaluation, as participants’ reflections are considered a key process.[5] the population included all students enrolled in the third year of medical studies at medunsa in 2012 and who were assessed during the mandatory end-of-year osce. all students (n=250) signed an informed consent form, but the data of only 207 (83%) were used owing to incomplete assessment records. ethical clearance for conducting the study was obtained from the medunsa research and ethics committee. this newly introduced osce was conducted during the only free time available in the students’ timetable, and it allowed for only a 15-minute assessment per student. four scenarios were developed by a panel, comprising the third-year students’ practice co-ordinator and 4 facilitators from the skills centre. the panel ensured that the scenarios for the consultations were structured in such a way that they were balanced with regard to difficulty and time allowed to perform the required skills. each scenario comprised skills the participants had acquired during the first 3 years of study. these included the essential history data, vital signs and instructions on the focused physical examination, and 2 skills to be performed on a young, female standardised patient (box 1). an assessment checklist was compiled for each consultation by combining previously used instruments for the individual skills, including items covering the communication skills required in the scenario. each item on the checklist was rated ‘competent’, ‘incompetent’ or ‘not done’. content validity of the assessment checklists was assured by 4 facilitators involved in teaching procedural and clinical communication skills, who validated the appropriateness of the items on the checklists. all activities took place in the skills centre. prior to the osce, the participants were orientated regarding the expectations of a sp-centred consultation, and the individual assessment checklist was made available online to ensure that learners were aware of the task requirements and major components of a given task. the advantages of students having access to assessment tools before practical examinations are supported in the literature.[6,7] neal et al.[7] demonstrated that trainees provided with a checklist beforehand performed significantly better in their medical management and non-technical performance during a simulated episode. participants had the opportunity for revision and supervised practice of the individual skills mastered in their first year of study. on completion of each osce session, the participants assessed their performance using a checklist, similar to the one used by the assessor. they also recorded their reflections in writing, guided by two questions: (i) did the integration of communication and procedural skills on an sp help you to learn?; and (ii) what did you experience as valuable and challenging in the osce? reflections were written individually and directly after assessments to ensure that students’ views were not influenced by discussions with fellow participants. the quantitative data collected in the study were captured on excel spread sheets. data capturing was verified and validity checks were performed as part of the data-cleaning process. the average percentages of competent performances in procedural and clinical communication skills items were compared using the fisher exact test. all statistical tests were two-sided and p-values ≤0.001 were considered significant. a systematic process was used to identify themes from the written reflections. the researcher and the third-year co-ordinator read and reflected upon the data independently. they identified the themes and categories that emerged. thus, they indexed and sorted the data using the constant comparative method.[8] the themes and categories that emerged were identified through iterative (thematic) analysis. consensus on the 4 main themes was reached through further perusal of the data. quotations were used to illustrate some of the participants’ views in their own words, adding to the validity and reliability of the results. results participants’ performance of procedural and clinical communication skills the average scores allocated by the facilitators were compared with the average self-assessment scores of the participants. the facilitators and box 1. example of an osce scenario and instructions mrs … is a 27-year-old woman who is making her first visit to the antenatal clinic. the clinic nurse has already: • obtained her history: lmp (2012/01/01), edb (2012/10/01), gravida 2 and para 1 • checked her temperature (37°c), pulse (80 bpm) and weight (78 kg) • given her health education about lifestyle issues (importance of good nutrition and avoidance of tobacco, alcohol and drugs) use this time to plan your consultation with mrs … , which must include the following procedures: • abdominal palpation to determine the gestation and lie of the fetus • blood pressure measurement • urine test november 2015, vol. 7, no. 2 ajhpe 167 research participants scored procedural skills significantly higher than communication skills (table 1). there was a highly significant improvement in both procedural skills (table 2) and communication skills (table 3) as scored by facilitators and participants in the second osce for the 53 participants who scored <60% in the first osce. as in the first osce, the communication skills were scored significantly lower than the procedural skills by facilitators (21% lower) and participants (13.5% lower). participants’ written reflections on the value and challenges of the integrated assessment almost all participants (94%) reported that the integration of communication and procedural skills on an sp had helped them with their learning. themes identified in the analysis of participants’ reflections on what they regarded as valuable to their learning and challenging about the osce correlated with some recognised learning strategies (authentic learning, integrative learning, assessment as learning) and the impact of emotions on learning. authentic learning (materials and activities framed around ‘real life’ contexts) • two recurring values emerging from participants’ responses were that the learning was realistic and relevant: ‘doing a consultation as required in practice is relevant and more realistic.’ ‘a real consultation helps the learning process.’ ‘it felt real ... communicating while doing procedures.’ ‘the osce gave us a chance to know what to expect and deal with it in real settings.’ • the use of sps humanised the consultation and was the most important element in making the consultation realistic: ‘having a “real” patient puts things into perspective.’ ‘working with a real person makes the skill come alive.’ ‘i learnt that there is much more to a patient than just the condition.’ ‘i realised the importance of not just examining patients as if they were objects.’ ‘one can see a facial expression if not comfortable when a procedure is done on him.’ • various aspects of sp encounters challenged the participants: ‘it was a challenge to explain the concepts to the patient.’ ‘having to explain to the patient some words like vocal fremitus … .’ ‘i did not make the patient feel at ease. he must have been traumatised.’ ‘encounters with a patient [sp] is intimidating but helps exploring yourself and learning from your own mistakes.’ ‘communication was a challenge – i was thinking about what the assessor wanted to hear and not considering the patient.’ • the participants commented on the value of the experience in preparing them for future interactions with patients: ‘it resembles more or less the situation you will be in in the future.’ ‘it gave me the opportunity to practise what i would do in real life.’ ‘time was a challenge … [osce] valuable for time management.’ • the scenario provided a realistic simulation which outlined the step-by-step process of a consultation. participants appreciated the value of the structure in helping them to conduct the consultation: ‘the preparation … helped me to do the skill in a systematic manner.’ ‘sometimes i had to wait and recall what is next, it is not in me yet.’ ‘remembering sequence and doing procedure accurately was a challenge.’ ‘being a doctor and deciding what to do next made me enjoy the osce.’ ‘it is motivating for me to look back at the stuff i have learned in first year and second year. i also learned some new stuff. i now see that medicine is a life learning process.’ integrative learning • integration of knowledge and procedures: [the osce] ‘ … allowed us to integrate knowledge and skills we have acquired in the last 3 years.’ it [the osce] ‘ … integrates everything we have learnt but … doing what i have read was a challenge.’ ‘the procedures seem easy when going through them theoretically.’ ‘when theory is put into practice … you understand the procedure and become confident in performing it.’ ‘correlating the information to the procedure helps to understand the reason for doing certain procedures.’ ‘having to take the blood pressure and relate it with the history and talking to the patient helps thinking and integrating what i have learned.’ table 1. facilitator and participant scores for procedural and communication skills (n=207) procedural skills communication skills difference significance assessor % sd % sd % p facilitators 71.3 17.1 50.8 21.9 20.5 <0.0001 participants 68.8 19.6 54.3 23.1 14.6 <0.0001 table 2. facilitator and participant scores for procedural skills of participants who repeated the osce (n=53) osce 1 osce 2 difference significance assessor % sd % sd % p facilitators 54.8 13.4 83.5 11.4 28.7 <0.0001 participants 60.6 19.7 75.7 16.3 15.1 <0.0001 table 3. facilitator and participant scores for communication skills of participants who repeated the osce (n=53) osce 1 osce 2 difference significance assessor % sd % sd % p facilitators 32.7 14.7 61.9 21.8 29.2 <0.0001 participants 39.3 16.2 62.2 20.1 22.9 <0.0001 168 november 2015, vol. 7, no. 2 ajhpe research • integration of procedures and communication: this was the first occasion where participants were required to integrate both aspects of a consultation, providing them with insight into the challenges posed. ‘the osce made me aware of the importance of incorporation of skills and communication – i didn’t realise it was this important.’ ‘integration is a challenge … speaking and doing skills.’ ‘synchronising the whole procedure and getting good rapport with the patient.’ assessment as learning • participants reported feeling under pressure when preparing for the assessment and becoming aware of what they lacked: ‘the osce was a good idea but nerve wracking – it forced me to learn. students only learn well when pressure is put on them.’ ‘osces help me to practise and make learning a nice but challenging experience.’ ‘skills need a lot of practice – even if you think you know them. practice makes perfect.’ ‘helps you to see your weak points and where you must improve.’ ‘showed me that i wasn’t prepared and i have to put in extra effort.’ ‘i found out where i’m still lacking.’ ‘it made me aware of the silly mistakes that can be done in the ward.’ ‘i realised that skills need to be constantly done in order to perfect the skill.’ impact of emotion on learning • participants experienced stress and the desire to cope with the situation: ‘the osce stresses you up … it helps to get used to the situation.’ ‘great learning experience to work under pressure … learn to calm down.’ ‘it gives you a feel of what it will be like and calm the nerves before you are in a situation where there is no one to assist you.’ ‘anxiety … i need to find a way to deal with it … try to stay composed.’ • some participants viewed their anxiety/stress/nervousness as the reason for their failure to perform better: ‘i was so nervous i fumbled the whole thing.’ ‘nervous … forget to mention vital stuff.’ ‘being scared makes it harder.’ ‘i was shaking and nearly pricked myself.’ • others experienced positive emotions: ‘gain confidence in interacting with your patients.’ ‘it made me feel confident enough to face patients at hospital.’ ‘it made it more real, somewhat more enjoyable.’ ‘being the doctor and deciding what to do next made me enjoy the osce.’ ‘i loved the adrenaline that working against time gives you.’ ‘communication is always fun but the challenge was trying not to mess up with skills.’ discussion the students, who were taught communication skills by different departments and separately from procedural skills in the skills centre, performed significantly worse in communication skills than in procedural skills when both were required in a consultation. such an obvious divide in performance on two sets of skills could be the effect of a neglect of interpersonal skills in simulation-based teaching of procedural skills.[2] this is aggravated by assessment practices that focus only on the technical elements of clinical procedural skills,[3] which is currently the case at medunsa. almost all the students in the study experienced the osce as a valuable learning experience. this also became apparent in the second osce, where the scores of the students who were repeating the osce increased significantly in both the procedural and communication items. similar to findings by kneebone et al.,[2] students seemed to have learned through reflecting on their performances, and by using rating scales and checklists identical to those of the facilitators. the improved performance may also have been influenced by students’ awareness of their shortcomings, gained through reflection on their experience. students perceived the value of the osce as being its similarity to an encounter with a real patient. learning is best achieved in an authentic learning environment in circumstances that resemble the real-life application of knowledge.[9] nestel et al.[10] emphasise that scenarios should provide realistic simulations and prove feasible in terms of time, facilities and resources. scenario-based assessments should reflect real-world issues of patient-centred care. the authentic experience in this study was created primarily through the use of sps, who humanised the consultation and posed the challenges of dealing with human beings. walker et al.[11] observed that sps provide students with an experience that is consistent with reality, increasing the validity and depth of the learning experience. authenticity with regard to preparation for future patient encounters was also valued. providing a concrete learning experience had a positive impact on students’ learning processes. experiential learning, or learning by doing, emphasises the role of experience as central to the learning process. it engages students and challenges their ideas and beliefs, encouraging them to create new knowledge.[12] learners must link their current experiences with those in the past and in the future.[13] the many varieties of integrative learning include integrating skills and knowledge from multiple sources and experiences and applying theory to practice in various settings.[14] students realised the value of integrating knowledge and skills that they had learnt in their first year with that which they were learning in the current year. building on information promotes learning and follows the constructivist theory that learning takes place in context. the consultation evoked a deep approach to learning through students seeking to understand the process through integration. promoting student reflection on their learning processes may enable the successful transfer of these integrated skills to other procedures.[2] nestel et al.[10] recommend that all tasks in a scenario should be contextualised, requiring students to combine technical, communication and other professional skills. supporting the findings of kneebone et al.,[2] students found the opportunity to integrate valuable communication and procedural skills and believed it was an appropriate learning experience. consumers of healthcare services are increasingly demanding more considerate communication in healthcare. this may be achieved, inter alia, by including clinical communication education at all levels of the undergraduate curriculum.[1] in 1983, newble, quoted by al-kadri,[15] observed that assessment drives learning. since then, this point has been viewed as well proven, despite supportive evidence being fairly limited. several researchers have aimed to explore the relationship between assessment and learning. until recently, the effect of assessment on students’ learning was unclear.[16] in this study, assessment drives learning in that students are put under pressure to prepare for the osce. benitez,[17] however, believes that november 2015, vol. 7, no. 2 ajhpe 169 research formative assessment – not summative assessment – drives learning. he makes the distinction that formative assessment is for learning and summative assessment is of learning, the latter being the more appropriate in making high-risk decisions. assessment not only serves as motivation to learn skills and aid the facilitator in determining what students have learnt, but helps students to identify gaps in their learning.[18] by applying assessment criteria, students self-assess what they know, or have done, and what they need to know or do next.[19] students who are learning to judge the quality of their work against well-defined criteria ‘are developing invaluable skills for lifelong learning’.[20] curriculum developers should be encouraged to consider the influence of assessments on what and how their students learn.[10] every experience evokes emotions, which is an important factor that affects thinking.[20] emotion may in some cases be facilitative, but it may also impede learning.[21] as this was the participants’ first experience of a simulated consultation, it seemed obvious that students’ emotions were more likely to be anxiety and stress rather than a sense of enjoyment. students can learn and perform better when feeling excited about the subject matter,[22] but anxiety may distract students’ learning efforts by interfering with their ability to attend to tasks, as was reported by some participants. in some situations, emotions may influence the attentional processes, while in others they may directly influence the encoding and decoding of information.[21] students in this study experienced stress and the desire to cope with the situation. epstein[23] believes that once one has recognised negative emotions leading to maladaptive behaviours, one can implement strategies to gain control of those emotions. this corresponds to sylwester’s[24] belief that students can learn how and when rational processes may be used to override their emotions, or to hold them in check. sylwester also points out that activities that evoke emotions, such as simulations, may provide ‘important contextual memory prompts’ that will be helpful in recalling information during closely related events ‘in the real world’. conclusion conducting an osce during which preclinical medical students were required to integrate their separately acquired procedural and communication skills in a simulated consultation, showed a deep divide between these two sets of skills. the poor performance in communication skills compared with procedural skills was repeated in the re-assessment. this may have been the detrimental effect of procedural and communication skills being taught and assessed separately and not in context. it is an indication that communication skills are neglected when teaching procedural skills and that the average student is not able to integrate these skills without practice. it appears that learning took place during this assessment and reflection event. students learned from an authentic consultation: they integrated their procedural and communication skills and their knowledge and skills, they experienced the assessment as learning, and they became aware of the impact of emotion on their learning. acknowledgements. i would like to thank all the facilitators from the skills centre and the lecturers from the practice of medicine division centre, university of limpopo (medunsa campus) who participated in the study. a special word of thanks to dr verona sukrajh for help in identifying reflection themes and valuable comments with regard to the protocol and manuscript, and to prof. herman schoeman, who did the statistical analyses. references 1. brown j. clinical communication education in the united kingdom: some fresh insights. acad med 2012;87(8):1101-1104. [http://dx.doi.org/10.1097/acm.0b013e31825ccbb4] 2. kneebone r, kidd j, nestel d, asvall a, paraskeva p, darzi a. an innovative model for teaching and learning clinical procedures. med educ 2002;36(7):628-634. [http://dx.doi.org/10.1046/j.1365-2923.2002.01261.x] 3. kneebone r, nestel d, yadollahi f, et al. assessing procedural skills in context: exploring the feasibility of an integrated procedural performance instrument (ippi). med educ 2006;40(11):1105-1114. [http://dx.doi. org/10.1111/j.1365-2929.2006.02612.x] 4. merriam-webster online dictionary. metacognition definition. 2012. http://www.merriam-webster.com/ dictionary/metacognition (accessed 26 july 2013). 5. de vos as, strydom h, fouché cb, delport csl. research at grass roots. pretoria: van schaik, 2011. 6. unt health centre for learning and development assessment – measurement tools. http://www.hsc.unt.edu/ departments/cld/measurementstools.cfm (accessed 17 may 2013). 7. neal jm, hsiung rl, mulroy mf, et al. asra checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. region anesth pain med 2012;37(1):8-15. [http://dx.doi.org/10.1097/ aap.0b013e31823d825a] 8. corbin j, strauss a. basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. los angeles, ca: sage, 2008. 9. herrington t, herrington j, eds. authentic learning environments in higher education. hersley, pa: information science publishing, 2006. 10. nestel d, kneebone r, nolan c, akhtar k, darzi a. formative assessment of procedural skills: students’ responses to the objective structured clinical examination and the integrated performance procedural instrument. assessment and evaluation in higher education 2011;36:171-183. [http://dx.doi.org/10.1080/02602930903221469] 11. walker s, armstrong kj, jarriel aj. standardized patients. part 4: training. international journal of athletic therapy and training 2011;18(2):20-23. http://www.academia.edu/1136199/standardized_patients_part_4_ training (accessed 29 july 2013). 12. kolb ay, kolb da. learning styles and learning spaces: enhancing experiential learning in higher education. acad manag learn educ 2005;4(2):193-212. [http://dx.doi.org/10.5465/amle.2005.17268566] 13. rogers c. defining reflection: another look at john dewey and reflective thinking. teachers’ college records 2002;104(4):842-866. 14. association of american colleges and universities (aacu), carnegie foundation for the advancement of teaching (cf). a statement on integrative learning. integrative learning: opportunities to connect, march 2004. 15. al-kadri hmf. does assessment drive students’ learning? phd. maastricht university, the netherlands. http:// arno.unimaas.nl/show.cgi?fid=25484 (accessed 7 august 2013). 16. norman g, neville a, blake jm, mueller b. assessment steers learning down the right road: impact of progress testing on licensing examination performance. med teach 2010;32(6):496-499. [http://dx.doi.org/10.3109/0142 159x.2010.486063] 17. benitez j. does assessment drive learning? academic life in emergency. 2013. http://academiclifeinem.com/doesassessment-drive-learning/ (accessed 3 august 2013). 18. prozesky d. assessment of learning. comm eye health 2001;14(38):27-28. 19. organisation for economic co-operation and development (oecd). formative assessment: improving learning in secondary classrooms. policy brief. 2005. http://www.oecd.org/edu/ceri/35661078.pdf (accessed 23 july 2012). 20. darling-hammond l, orcutt s, strobel k, kirsch e, lit i, martin d. feelings count: emotions and learning. the learning classroom 2013:89-95. http://www.learner.org/courses/learningclassroom/support/05_emotions_ learning.pdf (accessed 6 august 2013). 21. pandey r. how do emotions aid in the learning process? cognitive science and artificial thinking. 2012. http:// www.researchgate.net/post/what_emotions_do_in_learning_process (accessed 23 july 2012). 22. oatley k, nundy s. rethinking the role of emotions in education. in: olson d, torrance n, eds. handbook of education and human development: new models of learning, teaching and schooling. cambridge: blackwell, 1996. 23. epstein b. how emotions affect learning. horizon academy. http://www.horizon-academy.org/siteresources/ data/templates/t2.asp?docid=659&docname=how%20e (accessed 23 july 2013). 24. sylwester r. how emotions affect learning. educ leadership 1994;52(2):60-65. http://www.ascd.org/ publications/educational-leadership/oct94/vol52/num02/how-emotions-affect-learning.aspx (accessed 3 august 2012). editorial november 2013, vol. 5, no. 2 ajhpe 49 when the african journal of health professions education was launched in 2009, we set out to achieve the following: ‘the ajhpe is an open access peer-reviewed journal which focuses on disseminating research results of work focusing on the education of health professionals, specifically, but not exclusively, in africa.’ using this statement of intent as a yardstick, it is useful to reflect on the milestones achieved (or not) in the first four years of publication. the first milestone for any journal has to be visibility in the international community. in this regard, we have done exceptionally well. we were picked up on the international ‘radar’ within 18 months, in a review article focusing on medical education in sub-saharan africa (ssa). the paper was published in medical education, a top-rated international health professions education journal.[1] ‘despite these efforts, medical education as a specialty or research focus for faculty staff is still not frequently described in the literature. we were able to identify only one journal dedicated to the broader study of health professions education in ssa: the african journal of health professions education, established in 2009.’ the second most important milestone for any journal is a clear commitment to its target authors and audience. so, are we a voice for all the health professions or are we just another ‘medical education’ journal populated by papers dealing largely with the education of medical students and doctors? to date, we have published the work of health sciences professionals from 21 disciplines and even the work of health sciences students. the professions other than medicine include nursing, dentistry, physiotherapy, speech and language disorders, human nutrition, radiography, emergency care, medical scientists, medical anthropologists, biostatistics and bioethics. these data speak clearly of an active policy to promote the publication of work across the full spectrum of healthcare professionals. the third mandate of our journal is to represent the academic voice of ssa. so, are we just a south african journal that lays claim to a broader african footprint − or are we serving our mandate? while this has proven to be a challenge for the editorial team, who are working hard at bringing nonsouth african work into a very competitive market, we have made substantial progress. we've published work from 13 african countries representing 26 health sciences institutions; this represents almost a quarter of all ssa ‘medical schools’ that responded to the largest medical school survey in ssa – the subsaharan african medical school study (samss) conducted in 2009.[2] while we have a long way to go, it is clear that providing extra support and guidance for entry-level authors places publication status within their reach. it is worth noting that non-sa authors have featured particularly well in the genre of short papers or abstracts. this is an indication of the preliminary nature of much of the work, but such is the road to scholarship, and this journal clearly plays a key role in the process. these data demonstrate that short reports (up to 1 500 words, 1 figure or table, and 5 references) have a real role to play in the development of novice authors and should not be abandoned in the ajhpe. while our african footprint is clear, one could ask whether the quality of work that we publish has attracted any writers from outside africa? again, the answer is a pleasant surprise. we have attracted authors from leading universities in north america (duke university, the university of michigan, columbia university, the university of toronto, mcmaster university, manitoba university), the uk (leeds university, liverpool university, aberdeen university) and as far afield as australia (flinders university). the real excitement about the participation of these universities is that they have all written in partnership with an african university, often outside south africa; this speaks of empowerment rather than colonisation. another goal expressed in the statement of intent was to discuss issues particularly relevant to ssa, i.e. the developing world. a useful measure of the extent to which this has been achieved is to glance at the titles of the guest editorials. we have touched on the need for a health professions education journal for ssa, reasons for writing about health professions education in africa, making an educational difference in the world, the concept of social accountability, and the human resource issues affecting healthcare in africa. before i close, we need to reflect on the future of the ajhpe. a key determinant of survival in the publishing world is the academic status of a journal. as many of our readers and authors will know, we were accredited by the department of higher education and training in 2012 and we are now a subsidy-generating journal. this might already have had an impact on the journal because we have trebled our submissions and doubled our publication output in the past 12 months! so, the academic viability of the journal has been established and the upward trajectory is one that needs to be maintained and supported. accordingly, we look forward to receiving many more submissions from more diverse health professions representing more institutions of higher learning from more countries on this continent in 2014. and finally, what exciting developments lie ahead in 2014? since our inception, we have been fully supported by the health and medical publishing group in conjunction with the south african medical association. this has been en extremely successful relationship, as documented in this editorial. as of 2014, we will be funded by the foundation for professional development, an education provider with whom many of you may be familiar. the organisation has an excellent track record as a provider of high-quality health professionals training courses and other cpd activities, and i believe that this sets the stage for new opportunities in the year to come! i wish all readers and perusers a time of rest and rejuvenation in the coming weeks, and an academically and professionally successful and challenging 2014. vanessa burch editor-in-chief african journal of heath professions education 1. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, mullan sf. medical education in sub-saharan africa: a literature review. med educ 2011;45:973-986. 2. mullan f, frehywort a, omaswa f, et al. medical schools in sub-saharan africa. lancet 2011;277:1113-1121. ajhpe 2013;5(2):49. doi:10.7196/ajhpe.346 milestones for the ajhpe – what have we achieved in four years? 17 august 2010, vol. 2, no. 1 ajhpe article introduction within the revised, integrated, problem-orientated, 6-year undergraduate medical curriculum that was implemented in the school of medicine at the university of pretoria in 1997, there have been attempts to change not only content, but also teaching methods. however, much of the teaching has continued to use a lecture-based information transfer method, which trigwell called a teacher-focused method.1 since 2001, the department of family medicine had been responsible for a 5-week afternoon-only block which was presented to all fifth-year medical students (a class of approximately 210 students).the objective of the block is to enable students to integrate and apply their previously acquired knowledge to primary care clinical situations, as preparation for their student intern complex rotations in family medicine. during the period of 2001 2006 the students persistently evaluated this block as one of the two worst blocks in the curriculum. this was despite minor annual adjustments to the objectives, teaching methods or assessment. as a result of there being no evidence of a beneficial effect of these minor changes, the department of family medicine made a decision to do a major curriculum revision of this block for 2007. one of the innovations was to shift the teaching from the previous didactic method to the more student-focused method of reciprocal peer teaching, referred to by the epithet – to teach is to learn twice.2 this approach encourages a constructivist approach for the student to explore the course content in a way that leads to better understanding and more effective learning. it is also aligned with strategies of the south african council on higher education for student academic development.3 such an approach requires the academic staff to make an equally radical change from merely transferring information to facilitating the grasping of new concepts. all academic members of the department of family medicine had previously had their keirsey temperament type determined and we had knowledge of the needs of various temperament types during times of change. this article reports on whether an academic staff member’s temperament might influence their adaptation to a new teaching style that encourages student involvement and changes their role to that of facilitator. method the class was divided into eight student groups and each group became an ‘expert’ on one of eight themes, which they in turn taught to the rest of the class. each of these eight themes was facilitated by a different member of academic staff, who ranged from newly appointed senior lecturers to senior professors, with a range in the length of their teaching experience. they all had previous clinical and didactic teaching experience and were chosen as a theme facilitator because of their expertise in the content area of that theme. all the members of staff were part of all the discussions around the change in teaching strategy. although all involved academic staff attended the university’s obligatory education induction course,4 we did not think that this would be sufficient in supporting them to make the changes necessary to be able to implement this new strategy. a staff development plan was therefore created. this included offering staff an opportunity to learn more about student-focused methods of facilitating learning, such as the concept and logistics of reciprocal peer teaching and encouraging the use of facilitation (rather than teaching) skills. the approaches to teaching inventory (ati) was developed by trigwell et al.1 to measure teachers’ approaches to teaching. it has two scales, abstract introduction. a section of the undergraduate curriculum was revised due to consistently poor student evaluation. the chosen didactic method for achieving this change was reciprocal peer teaching. this innovation may have required academic members of staff to adapt to a new teaching style. method. staff members determined their keirsey temperament and were given a report on its interpretation. they participated in training on student-focused teaching techniques and completed the approaches to teaching inventory (ati) of their preferred approach to teaching. their subsequent sessions with students were videotaped and analysed for features of student-focused, as opposed to teacherfocused, teaching. results. there was a link between temperament type and apparent delivery of student-focused teaching. staff members’ perceptions of their approach to teaching did not correspond to their actual teaching behaviour. discussion. staff development strategies could take into account individual temperaments in order to direct their professional development for the full spectrum of flexible teaching skills. alternatively, teaching teams should be created in a way that takes account of different temperament types. conclusion. temperament does play a key role in adaptation to innovation. is temperament a key to the success of teaching innovation? jj blitz1, mr van rooyen1, da cameron1, gp pickworth2, ph du toit3 1 department of family medicine, faculty of health sciences, university of pretoria 2 department for education innovation, university of pretoria 3 department of curriculum studies, faculty of education, university of pretoria correspondence to: marietjie van rooyen (marietjie.vanrooyen@up.ac.za) article 18 august 2010, vol. 2, no. 1 ajhpe article namely the information transfer/teacher-focused scale (referred to here as teacher-focused) and the conceptual change/student-focused scale (referred to here as student-focused). each scale consists of 11 items with the maximum score for each scale being 55. there are no norms for the scales as responses to the inventory are relational and are specific to the context in which they are collected. teachers who adopt one approach in one context can adopt another approach in a different context. all academic staff members completed an ati based on their general approach to teaching, rather than by reflecting on one particular teaching episode. this was administered by the faculty’s education adviser, who had also been a member of the team that presented the university’s education induction course, at which these concepts had been discussed. an additional staff development strategy was to ensure that all members of staff had completed the keirsey temperament sorter (kts-ii) accessed from http://www.keirsey.com/sorter/instruments2.aspx?partid=0. this is a free, self-completed personality questionnaire designed to help people better understand their behaviour. it was envisaged that providing this information would improve academic staff’s understanding of themselves, their roles in teaching and learning and their own management style. these questionnaires were interpreted by a member of staff trained in keirsey interpretation, who gave each member of staff their results with a brief report. each of the academic staff members had an orientation session with the whole class in the first week of the block, when they introduced their theme to the class. during the subsequent two weeks each academic staff member had two obligatory facilitation sessions with his or her theme group. the goal of these sessions was to facilitate the group in becoming both experts and teachers of the objectives of their theme. each academic staff member’s theme orientation session, as well as the two obligatory facilitation sessions, were taped and observed by a peer who had undergone the same training and an adviser from the faculty of education, who was blinded as to the staff member’s kts type. the theme facilitators had been asked to use the orientation session to model some of the student-centred methods of facilitating learning, as well as to focus the session on outlining the basic concepts related to their theme. the two facilitation sessions were to be used only to facilitate the students’ learning and preparation for their peer teaching sessions, not for teaching by the academic staff member. criteria used to decide whether the facilitator was student-centred or teacher-centred were: • the position of the facilitator in the group/venue • body posture and body language of the facilitator • guidance to students regarding both content and process • feedback given to students on the process of their lesson plans in terms of the chosen teaching method, the appropriateness thereof and the quality of their application of that method • his/her role in the group process. results for each of the eight academic staff members, their keirsey temperament, their ati and their teaching behaviour observed on the video were recorded. table i column a gives the first-level kts results of the eight academic staff members who were involved in the teaching of the undergraduate block. the number next to each staff member’s temperament indicates the strength of their score in that aspect. table i column b gives the ati results of the eight academic staff members who were involved in the teaching of the undergraduate block. the maximum score in both approaches is 55. six of the eight members of staff scored as teaching more to a student-focused concept-changing purpose. it can be seen that there is no relationship between the ati responses and either kts type or observed teaching behaviour. table i column c gives the assessment of the observer as to whether teacher-focused or student-focused methods had been used during the orientation and facilitation session(s). in contrast to their ati responses, three of the facilitators who claimed to favour a concept-changing style actually focused on information transfer in their facilitation sessions. one of the facilitators, whose score for the ati was slightly higher on the scale of information transfer, was found to use a concept-changing style. table i . tabulation of findings for eight members of academic staff a b c keirsey temperament sorter approaches to teaching inventory observed teaching behaviour observant (s) or introspective (n) first level of type information transfer (it) conceptual change (cc) teacherfocused studentfocused kts type max = 20 max=55 max=55 nt n 20 abstract 26 52 x nf n 17 abstract 26 46 x nf n 15 abstract 36 32 x nf n 12 abstract 35 49 x sj s 15 concrete 26 49 x sj s 14 concrete 31 51 x sj s 12 concrete 39 37 x sj s 12 concrete 31 46 x 19 august 2010, vol. 2, no. 1 ajhpe article keirsey’s first level of description of temperament types is the difference between whether a person more easily uses an abstract, introspective ‘n’ or a concrete, observant ‘s’ process. from their kts scores, four of the facilitators are mainly introspective and four are observant. for the purpose of this paper none of the other levels are analysed. discussion it appears that in observed teaching performance there is a clear match between those facilitators who are predominantly introspective, abstract thinkers (n temperament) and a concept-changing student-focused approach to teaching. there seems to be an equally clear match between the observant, concrete thinkers (s temperament) and the use of an information transfer teacher-focused style of teaching. the results of this study seem to indicate that differences in temperament do have an effect on the ability to adopt new teaching styles. data have been published that seem to show personality type (mbti terminology) affects choice of medical specialty,5,6 learning style 7 and an ability to be innovative.8 unlike the myers-briggs interpretations, keirsey9 sees temperament like the rings of a tree. at the inner ring a person’s behaviour is either introspective (n) or observant (s). the second ring determines whether or not an individual’s temperament is co-operative or pragmatic. the third ring indicates whether an individual’s communication is directive or informative. and the fourth ring indicates whether an individual is expressive or attentive in their interaction with their environment. he believes that someone cannot observe and introspect at the same time and that the extent to which people are being observant or are being introspective has a direct effect on their behaviour. when people perceive the world through their senses they are being observant (s). these people are more ‘down to earth’, more concrete in their worldview, and tend to focus on practical matters such as food, shelter and their immediate relationships. they talk primarily about the external, concrete world of everyday reality: facts and figures, work and play, home and family, news, sports and weather – all the who-what-when-where-and how much of life. observant teachers keep instruction focused on a narrow range of choices, and usually concentrate on factual and concrete questions. when people reflect, introspect and pay attention to what is going on inside their heads they are being introspective (n). these individuals, in contrast, tend to focus on abstract concepts and like to see the big picture before they examine the smaller details. while they may appear to have their heads in the clouds, they are able to imagine what might be and can thus adapt fairly easily to change. introspective teachers are likely to have a wide range of choice of learning opportunities. they also tend to focus on questions of conjecture, such as ‘what if ... ?’ at times, of course, everyone addresses both concrete and abstract topics, but in their daily lives, and for the most part, concrete people talk about reality, while abstract people talk about ideas. one of the better known models of learning is kolb’s experiential learning model.10 this is composed of four elements which form a spiral of learning: • concrete experience • observation of and reflection on that experience • formation of abstract concepts based upon the reflection • testing the new concepts • (repeat). kolb’s resultant learning-style inventory (lsi) divides learning preferences along two continuums: active experimentation-reflective observation and abstract conceptualisation-concrete experience. the result is four types of learners: converger (active experimentation-abstract conceptualisation), accommodator (active experimentation-concrete experience), assimilator (reflective observation-abstract conceptualisation), and diverger (reflective observation-concrete experience). it can be seen in table ii that the concrete experience-abstract conceptualisation axis fits neatly with the ‘concrete s’ and ‘abstract n’ continuum in the keirsey temperaments, again emphasising the opposite nature of these two poles. it may be that one’s learning style closely determines one’s most comfortable teaching style. therefore it may be possible that particular medical disciplines with higher proportions of certain temperament types will have higher proportions of certain learning styles and thus teaching styles. in terms of innovation of teaching within these disciplines, these proportions need to be taken into account. in adopting a teacher-focused approach, teachers focus on what they do as teachers, or on the detail – individual concepts in the syllabus or textbook, or the teacher’s own knowledge structure – without acknow ledgement of what students may bring to the situation or experience in the situation. they see their role as mainly transmitting information based upon that knowledge to their students. in adopting this approach to teaching, forward planning, good management skills, use of an armoury of teaching competencies, and the ability to use information transfer are seen as important. in adopting a student-focused approach, teachers have a studentfocused strategy with the aim of changing students’ ways of thinking and learning about the subject matter. they focus their attention on the students and monitor their perceptions, activities and understanding. transmission is seen to be necessary, but rarely sufficient. they assume students construct their own knowledge, so the task of the facilitator is also to challenge current ideas through questions, problems, discussion and presentation. this approach includes a mastery of teaching techniques, including those associated with transmission. transmission elements of the teacher-focused approach are included in the studentfocused approach, but the student-focused element is not a part of the teacher-focused approach. because it includes both transmission and table ii. kolb’s learning styles and keirsey temperaments* kolb’s learning styles keirsey temperaments doing (active experimentation) watching (reflective observation) s sensing observant feeling (concrete experience) accommodating diverging n intuiting introspective thinking (abstract conceptualisation) converging assimilating *modified from http://www.businessballs.com/kolblearningstyles.htm article 20 august 2010, vol. 2, no. 1 ajhpe concept change, a student-focused approach is considered to be a more sophisticated or complete approach than the more limiting teacher-focused approach.1 if one takes into account actual behaviour of the eight members of staff in this study, it is clear that it is at variance with their responses to the ati. one explanation of this could be that the staff are ‘test-savvy’ – they have memorised the theory of what they were taught in various education sessions that they have attended (they know what the ‘right’ answer is). another explanation may be that they could be responding to the overt expectation of the head of department that they should attempt to incorporate facilitation of learning into their educational practice. however, their actions seem to prove that their behaviour has more consistently remained with their temperament type than been changed by staff development interventions. in a situation where they were being observed doing something new, they may have had difficulty actually shifting away from ‘what they do with ease’ (the way they, as established teachers, have always taught before). many staff development courses are based on attendance, with little or no evidence of behaviour change. on the basis of the findings of this research, it could be suggested that different temperament types may adopt different andragogical methods more easily than others. this has implications both for those who are concrete thinkers as well as those who are abstract thinkers. teachers who have a preference for observant and concrete thinking are often referred to as being the stabilisers, traditionalists or guardians and are an important factor in keeping the status quo. for the most part, they prefer keeping to the tried and trusted ways of doing things, enjoying the well-planned activities that have been proven to work over time. although willing to learn new approaches to teaching, they prefer to keep things the same unless they perceive an important need to change, in which case they require a logical step-by-step explanation and guidance on how to change and ample time to make the change. as stated, they are reluctant to jump into any new educational reform movement. those who have a preference toward introspective and abstract thinking are considered to be the idealists or advocates who take pride in their own unique identity and are committed to seeing their students express themselves as authentic. they often have an orientation to the outer world of possibilities, whereas their intuition often draws them to new ways of doing things as they grasp new concepts readily. conclusion innovation . . . is generally understood as the successful introduction of a new thing or method . . . innovation is the embodiment, combination, or synthesis of knowledge in original, relevant, valued new products, processes, or services.8 keirsey was trying to understand what people ‘do’ (his theory is based on observed behaviour) under varying circumstances. this is not to say that people are ‘stuck’ in these behaviours, just that it requires them to perceive a change of circumstances requiring a different behaviour, or to make a conscious choice to use a different behaviour. looking at the results of this study, it was clear that the facilitators with the introspective temperament used the student-focused concept-change method of facilitating learning that had been tried in this case. in order to respond to all the learning styles described by kolb, academic members of staff would need to be flexible in their approach to teaching and move into behaviours where they are less comfortable. that is, for the concrete observer to incorporate more abstract, student-focused concept-changing approaches and for the abstract introspective to incorporate more concrete, information-transfer approaches. within the context of team teaching, another strategy could be simply to develop the inherent skills of each individual according to their temperament type. this would require a focused design for flexibility within the team. the challenge is to complement generic faculty development initiatives with individual follow-up, taking each person’s temperament type into consideration. in future an understanding of each member’s temperament might be used to predict who will adapt more easily to different ways of teaching. by understanding his or her kts, an individual could be more supported and his/her preferences taken into account when implementing educational development for academic staff. this would allow more focused interventions when attempting to optimise staff teaching behaviour. ultimately, there needs to be assessment of academic staff’s responses to educational development initiatives with feedback on observed behaviour. a strategy for a member of academic staff to broaden their teaching styles should probably take the following into account: • recognise your own style and how it influences the way you teach. • teach from your strength, but broaden your skills. • if you prefer to lecture, allow some time for discussion, and vice versa. • if you prefer to teach facts and details, also discuss theories and concepts, and vice versa. without striving for developmental support of the broadest possible flexibility in teaching styles, either within each individual or within the teaching team, innovation will continue to be more difficult to achieve. from this study, it is recommended that further research be done on a larger sample size. if our findings are confirmed, it could be recommended that determination of the temperament type of all those involved in teaching become a routine part of staff development. determining, acknowledging and using academic staff members’ temperament types seem to be key to the success of innovation in teaching. references 1. trigwell k, prosser m, ginns p. phenomenographic pedagogy and revised approaches to teaching inventory. higher education research & development 2005; 4: 349-360. 2. whitman na. peer teaching: to teach is to learn twice. ashe-eric higher education report no. 4. washington dc: association for the study of higher education, 1988. 3. council on higher education. improving teaching and learning (itl) resources. pretoria, south africa. 2004. 4. department for education innovation, university of pretoria. education induction course 2006. http://web.up.ac.za/default.asp?ipkcategoryid=9391 (accessed 12 april 2010). 5. friedman cp, slatt lm. new results relating the myers-briggs type indicator and medical specialty choice. j med educ 1988; 4: 325-327. 6. katz j, lamperti a, gaughan jp. mbti types, gender, and residency selection. journal of psychological type 2007; 67: 51-57. 7. newble di, entwistle nj. learning styles and approaches: implications for medical education. med educ 1986; 29: 162-175. 8. luecke r, katz r. managing creativity and innovation. boston, ma: harvard business school press, 2003. 9. keirsey d. keirsey temperament versus myers-briggs types,1999. http://www. keirsey.com/difference.aspx (accessed 12 april 2010). 10. kolb da, fry r. toward an applied theory of experiential learning. in: cooper c, ed. theories of group process. london: john wiley, 1975. 15 december 2009, vol. 1, no. 1 ajhpe short report introduction medical teachers have conventionally been using different teaching methods to educate medical students previously dominated by blackboard and slide projectors. more recently audiovisual aids such as video tapes and multimedia have been introduced. critics of multimedia feel that it is expensive, too time consuming, and isn’t worth the time and effort.1 a learner’s learning style, whether visual, auditory or kinesthetic, is usually resistant to change.2 hence it is likely that mismatches exist between the learning styles of medical students and the teaching styles of medical teachers. this study was undertaken to determine 2nd-year medical student teaching-aid preferences during classroom instruction in a medical college in india. methods a focus group of 10 medical teachers of 2nd-year medical students were asked for their views on the advantages and disadvantages of blackboard, overhead projector, slide projector and multimedia as a teaching tool. based on these views a questionnaire was prepared using a 5-point likert scale. it was given to 93 5th-semester students at government medical college, bhavnagar. these undergraduate students attended classroom lectures by different teachers using blackboard, transparency, 35-mm slides and multimedia (computer) teaching modalities. the students were asked to voluntarily complete the survey to evaluate their preferences to specific presentation methods. the study was approved by the local ethics committee. statistical analysis was done by kruskal-wallis one-way analysis of variance on ranks using spss software trial version. observation and results table i shows that blackboard teaching scored more in the following points: • facilitated interaction between student and teacher • aroused interest in learning • helped to hold attention in class • more helpful to grasp the content • better able to cope with teaching speed of teacher • more useful in small group (10 20) • increased ability to think and understand. table i shows that multimedia teaching scored more in the following points: • room illumination • allowed better inclusion of content • enhanced visual quality of text and figure • made better use of examples and illustrations • more useful in large group (50 100) blackboard and multimedia teaching scored equally in the following: • stresses relevant and important information • best to summarise lecture the overall preference of students was distributed equally between blackboard teaching and multimedia teaching. slide-projector teaching was the least preferred, followed by the overhead projector. discussion the overall preference of students was distributed equally between blackboard teaching and multimedia teaching. this is an interesting finding because the literature suggests that students prefer computer-assisted teaching modalities.3 the effectiveness of multimedia depends on how it is used in relation to instruction. when multimedia is used to supplement regular instruction, gain in achievement is consistent, but when it is substituted for traditional instruction achievement results are mixed. the inability to move away from the computer desk inhibits a teacher walking freely across the room. hence, when the faculty tends to focus on the technology the students feel ignored. in this study students rated blackboard-based teaching more highly for ‘facilitating interaction between teachers and students’, ‘coping with teaching speed of teacher’, and ‘arousing interest in learning’ and ‘holding attention in classes’. this may be because older, more experienced teachers tended to use this teaching modality, while younger teachers usually opted for multimedia computer-based lecturing. the students also felt that blackboard teaching was ‘more helpful in grasping the content’ and facilitated an ‘increased ability to think and understand’. this is most likely owing to the fact that blackboard-based delivery considerably reduces the speed of lecture delivery, thereby facilitating understanding and grasping. the old model of lectures and note taking has been found to be unsuccessful in making efficient use of faculty time for allocatstudents’ perception of different teaching aids in a medical college s n baxi, md, associate professor in pathology c j shah, md, assistant professor in physiology r d parmar, md, assistant professor in microbiology d parmar, md, assistant professor in forensic medicine c b tripathi, md, professor in pharmacology government medical college, bhavnagar corresponding author: seema baxi (seemabaxi@yahoo.com) short report 16 december 2009, vol. 1, no. 1 ajhpe ing information to large groups of learners.4 this was also felt by our students who were of the opinion that the blackboard is ‘more useful in instructing small groups’. a multimedia approach was favoured by 40 subjects in this study. this could be owing to the fact that the respondents come from a diverse background of different states across india and also from tribes and creeds. multimedia has been shown to be effective for classes with students from different backgrounds.4 the choice of multimedia by medical students is also not surprising, as multimedia material has been shown to explain complicated topics with the aid of pictures, graphs, animations and simulations.5 multimedia lectures can present complex concepts in small, chronological steps that aid students’ ability to comprehend information in a meaningful way. by using overhead projections (ohp) or 35-mm slide presentations it is easy to put much information on one page /slide. when a large volume of information is presented in this manner, working memory capacity can be overloaded and useful note taking becomes difficult.6 this could be the main reason why the students did not prefer ohp and slide presentations, although both these aids share a few of the advantages of computer presentations such as proper illumination and better display of figures and graphics. motion on the screen is important to holding viewer attention. this is also lacking in both ohp and 35-mm slides, whereas animation plays a major role in multimedia design. conclusion this study showed that an equal number of students preferred blackboard-based or multimedia-based lectures. teachers should take note of the reasons why a significant number of students still prefer ‘outdated’ teaching modalities compared with computer-based presentations. the reasons for this preference need to be taken into consideration when using multimedia modalities to present lectures to students. references 1. perry t, perry la. university students’ attitudes towards multimedia presentations. british journal of educational technology 1998; 29: 375-377. 2. murray-harvey r. learning styles and approaches to learning: distinguishing between concepts and instruments. br j educ psychol 1994; 64: 373-388. 3. george g, sleeth rg. technology-assisted instruction in business schools: measured effects on student attitudes. international journal of instructional media 1996; 23: 239-240. 4. nantz ks, lundgren td. computer assisted instruction; high technology and education. college teaching 1998; 46: 53-57. 5. kussmaul c, dunn d, bagley m, watnik m. using technology in education. college teaching 1996; 44: 123-126. 6. stone ll. multimedia instruction methods. journal of economic education 1999; 30: 265-275. table i. acceptance of instruction media by 2nd-year medical students ohp blackboard multimedia slide project p 1. allowed better inclusion of content 13 29 53 21 <0.001 2. enhanced visual quality of text and figure 14 16 57 22 <0.001 3. room illumination 14 23 34 16 <0.001 4. facilitated interaction between student and teacher 16 50 30 17 <0.001 5. make better use of examples and illustrations 15 37 46 20 <0.001 6. aroused interest in learning 10 42 36 17 <0.001 7. helped to hold attention in class 10 50 32 20 <0.001 8. more helpful to grasp the content 13 44 33 13 <0.001 9. better able to cope with teaching speed of teacher 10 44 33 16 <0.001 10. stresses relevant and important information 18 39 38 10 <0.001 11. more useful in large group ( 50 100) 17 30 48 13 <0.001 12. more useful in small group (10 20) 16 46 38 13 <0.001 13. increased ability to think and understand 11 52 28 15 <0.001 14. best to summarise lecture 14 40 41 12 <0.001 15. overall i prefer teaching aid x 12 39 40 6 <0.001 article may 2013, vol. 5, no. 1 ajhpe 46 abstract simple learning tools to improve clinical laboratory practical skills training b taye, bsc, mph addis ababa university, college of health sciences, addis ababa, ethiopia corresponding author: b taye (bineymt@gmail.com) context and setting in ethiopia, clinical laboratory education started in 1954 at the pasteur institute (institute de pasteur), which is now the school of medical laboratory sciences in addis ababa university college of health sciences. the school offers bsc and masters programmes in clinical laboratory sciences. this project was implemented in the undergraduate programme. why the idea was necessary proper execution of clinical laboratory tests is essential in assisting physicians to make appropriate decisions. a misdiagnosis or error that results from deficient laboratory skills can have a significant negative impact on patient treatment outcomes. health professionals who rely on these tests have concerns about the competence of medical laboratory science graduates. surveys of faculty and students, as well as observation of practical training, previously found that competencies were not well defined and detailed task descriptions did not exist. consequently, teaching was inconsistent and students’ skills acquisition varied widely. we hypothesised that introducing standardised practical learning guides and assessment checklists would contribute to addressing this problem. what was done firstly, the faculty team attended a workshop on instructional materials development presented by jhpiego ethiopia. then, using results from structured questionnaires and interviews with instructors and students, a standardised learning guide and assessment checklists were prepared by the faculty and reviewed by experts. the learning guide contains objectives for the skills being taught, scenarios and instructions for the skills to be performed, required materials, and time allowed to finish the procedure. the assessment checklists include detailed steps for performing the skills. pre-assigned marks for each step are provided in three different categories: ‘performed correctly’, ‘attempted but not performed correctly’ and ‘not performed’. the learning guide and checklists were introduced in haematology practical sessions. first they were distributed to instructors and third-year medical laboratory students prior to the first practical session to familiarise them with the skills to be performed. instructors used the learning guides and assessment checklists consistently throughout the course. feedback from instructors and students was collected to assess their perceptions of, and learning experiences with, the new tools. results and impact baseline evaluation of students showed that 73% were not fully familiar with the practical skills after the previous training. fifty-eight per cent of students responded that instructors did not use consistent procedure manuals and only 42% felt that the existing practical sessions would help them to achieve competence. sixty-three per cent of the students claimed that practical skills assessment methods were not clear, 58% felt they were not fair and 90% responded that instructors did not consistently use checklists for assessing practical skills. after introduction of the new tools, 87% of the students responded that these were very specific and effective for learning practical skills. both the instructors and students agreed that checklists were appropriate for assessing detailed activities objectively and reduced bias. however, a few instructors thought that using the checklists was time consuming. future plans include assessing long-term retention of skills acquired using the new tools. ajhpe 2013;5(1):46. doi:10.7196/ajhpe.198 44 july 2012, vol. 4, no. 1 ajhpe abstracts oral and poster presentations patient simulations in developing clinical reasoning skills in undergraduate paramedic learners at the central university of technology r g campbell background/context: advanced life support (als) paramedics in south africa practise a form of emergency medicine in the out-of-hospital context with limited resources and diagnostic tools. avoidable patient care errors in an emergency setting, specifically in diagnosis, are well described in the literature. effective clinical reasoning has proven to reduce diagnostic error. als paramedic training has traditionally been skillsand protocol-driven with little or no attention to clinical reasoning skills. aim/purpose: to demonstrate the contribution that patient simulations make to the development of clinical reasoning in third-year learners in the undergraduate national diploma: emergency medical care (ndip emc) programme at the central university of technology (cut). methods: third-year emc learners were provided with an interlinking framework of tasks and activities that highlight clinical problems and require clinical reasoning skills to solve. each third-year learner was subjected to 4 simulated patient assessments followed by a case report on each. a significant focus of the case report was a discussion on differential diagnosis and reflection using the clinical reasoning process and evidence for best practice. exposure to patient simulations by learner groups from 2006 2011 prior to formal assessment was analysed. results of assessed patient simulations and reflective reports from 2006 2011 were analysed for performance improvements. results and discussion: the preliminary results demonstrate performance improvement among all learner groups over 4 assessed patient simulations. conclusion/take-home message: the anticipated outcome of this study is to demonstrate the importance that patient simulations have in developing clinical reasoning skills in third-year learners in the ndip emc programme at cut. since patient simulations are introduced in the programme as early as first year, it is suggested these skills can be developed from earlier on in the programme. practise on standardised patients (sps) for practice a c jacobs, y botma, m j mackenzie, l van dyk background/context: in 2011 the school of nursing invested in training staff in simulation. since then, simulations using standardised patients and high-fidelity human simulators were implemented. the school of nursing views simulations as a learning opportunity and sees learning as an active process of creating own knowledge. outcomes, teaching and learning opportunities, and assessments are constructively aligned. aim/purpose: to share our experiences of standardised patients (sps) in simulations. methods: themes are developed in accordance with the teaching and learning model of the school of nursing. because simulation is seen as a learning opportunity, simulation with sp is aligned with the outcomes and assessment strategies of the theme. developing a simulation scenario for sp occurs according to a standardised template. second-year nursing students completed the theme on airflow limitation in which the theory and clinical skills were learned. the sp simulation scenario focussed on a patient with asthma in a primary healthcare setting. simulation footage was analysed by the module coordinators, sp co-ordinator and educational advisor. results and discussion: students enjoyed the experience but also identified their own limitations and mistakes. they were able to plan their own learning needs. even fourth-year nursing students identified with the second-year students and recognised behaviour that they exhibit in their own practice and the need to improve. conclusion/take-home message: standardised patients enhance learning and may contribute to bridging the theory-practice gap. practise makes perfect: a real-life challenge for facilitation of learning hanlie pitout background/context: real-life challenges as part of teaching are important in facilitating learning. a real-life challenge that was introduced during 2011, as part of my fundamentals of occupational therapy curriculum, was for students to create a traditional cooking area for the hospital, where patients could practise traditional cooking, simulating patient’s home environment. aim/purpose: the purpose of the action research study was to evaluate student response to a learning opportunity presented as part of a subject where managing services is taught. changing the way that learning is facilitated and adapting the outcomes accordingly provided an opportunity for growth for both the facilitator and students alike. methods: students were asked to reflect at different stages during the project. initially they had to reflect on their understanding and expectations of the project. they had to present their planning and progress regularly through the process to peers and lecturers. students' reflections on the process and their growth throughout were recorded. fifth national conference of the south african association of health educationalists (saahe): 'from practise to practice’, bloemfontein, 21 23 june 2012 ajhpe 2012;4(1):44-99. doi:10.7196/ajhpe.178 45 july 2012, vol. 4, no. 1 ajhpe abstracts results and discussion: the students experienced personal and professional growth during their participation in this real-life challenge. they had the opportunity to apply the theory that they had learned on project management, teamwork, planning and organising, in a real-life environment. the end product was visible and of benefit to the hospital where the project was executed. the hospital now has the facilities and equipment to present traditional cooking activities. conclusion/take-home message: providing a real-life challenge to students instead of teaching a predominantly theoretical course proved to be beneficial. students received recognition form peers and other departments for their knowledge and skills. they received the opportunity to practice their project management skills and experienced the results of inadequate planning and insufficient teamwork first-hand in a supportive environment. reviving the sp – authentication breathes life into the sp h schweickerdt-alker background/context: although simulated/standardised patients (sps) are used in many institutions, especially in portraying roles on given short scenarios, the scope of how much they could mean is still not fully understood. often they are merely regarded as breathing manikins and are not used to their full potential. the creation of three-dimensional (3d) characters by implementing authenticity allows the sps to become the person behind the patient and to deliver a realistic true-to-life portrayal. aim/purpose: describe the effect of authenticity of patient portrayal by sps. methods: through experience as an sp the importance of playing a ῾person behind a patient’ or a 3d character, became evident. as an sp facilitator the opportunity arose to share this knowledge with sp trainees and coach them to understand and become 3d characters. the character traits, emotional background, personality etc. and the subtext (meaning behind the words) of a patient were examined and worked into the scenario as part of the patient as a ῾whole’ human being. results and discussion: the sps portrayed roles more realistically, and their energy levels, enjoyment of the work and dedication improved. verbal and non-verbal communication of the sps became more congruent. facial expressions became real. they became more believable characters with more depth. this allowed the students to delve into the person behind the patient to get to the actual root of the problem. conclusion/take-home message: if sps are trained to be authentic, they come closer to the person they are portraying as patients. this dimension gives the students the opportunity to listen to what the sp (patient) is not telling them – to read between the lines – and to get as much out of their training as possible. the sessions with the sps become a more exciting and authentic learning process. clinical skills unit: addressing the needs for continued professional development (cpd) in allied health professions s van vuuren, m nel school for allied health professions and biostatistics, university of the free state background/context: the monitoring of continued professional education in south africa became the responsibility of the health professions council of south africa (hpcsa). the hpcsa has implemented a compulsory continued professional development (cpd) programme to ensure that health practitioners update their professional knowledge and skills to the benefit of their clients/patients. a study by phillips concludes that higher education institutions have a responsibility towards alumni regarding cpd. most of these development sessions are currently the improvement of knowledge and not necessarily skills. with the completion of the clinical skills unit (csu) of the school for allied health professions (sahp) in 2011, one of the aims was to develop the unit as an institute for cpd activities. aim/purpose: to investigate the need for an institute for cpd among dieticians, occupational therapists and physiotherapists. methods: the study had a descriptive and comparative nature. questionnaires (n=258) were distributed to qualified dieticians, occupational therapists and physiotherapists from the free state and northern cape provinces, south africa. to ensure reliability, 10% of the sample was tested after 1 month. ethical approval was obtained to conduct the investigation. results and discussion: round-one questionnaires were distributed among respondents; 127 professionals responded. the study population was mainly female (97.6%), with 56% from the free state. respondents were mostly employed in the public sector (71.7%) and attended cpd activities in bloemfontein (65.9%). the majority of previous cpd activities were theory (70.6%), but most of the respondents (85%) indicated that they would prefer small-group learning. respondents also expressed a need to observe experts, especially with regards to intervention skills. the majority of respondents agreed that the csu can address their cpd needs. there were no significant differences between the 3 groups of professionals. conclusion/take-home message: developing the university of the free state csu as a provider of cpd activities can address the needs of allied health professionals. an investigation into participation trends by wheelchair basketball players at the zimbabwe paralympic games: a case study of bulawayo bhekuzulu khumalo, ignatius onyewandume, sungwon bae, shadreck dube background/context: physical activity and sports for participants with functional limitations and activity restrictions are increasingly being referred to within the framework of adapted physical activity (apa) (sherrill, 2004; steadward et al., 2003; winnick, 2005), health promotion (riley et al., 2008), rehabilitation medicine (roe et al., 2008), special olympics (shapiro, 46 july 2012, vol. 4, no. 1 ajhpe abstracts 2003; farrell et al., 2004) and paralympics (higgs and vanlandewijck, 2007). the ipc recognises 6 different disability groups: amputees, athletes with cerebral palsy (cp), blind or visually impaired athletes, spinal cord injury athletes, and athletes with an intellectual/learning disability. this research focuses on amputees, spinal cord injury athletes and the other athletes with a physical disability, who participate in wheelchair basketball. disability or the disablement process is manifested in the interaction between the individual and his/her environment. this research was guided by the un accessibility for the disabled document, designed to guide and set standards for built environment accessibility by the disabled. aim/purpose: to investigate (i) challenges faced by wheelchair users in the use of public transport and roads; (ii) participation trends in wheelchair basketball; and (iii) reasons for participation or non-participation in basketball by physically disabled persons in zimbabwe’s bulawayo city. methods: randomly selected wheelchair basketball players from 2 clubs in bulawayo were interviewed and group discussions carried out. seventeen people (9 males and 8 females) were interviewed. results and discussion: the results show that the barriers to participation are a result of an unfriendly and non-adapted transport system, poverty, lack of access to equipment and non-adapted facilities providing health and safety risks over and above accessibility challenges. conclusion/take-home message: this research revealed a list of barriers to wheelchair sports participation, opening avenues for further research in the areas of mainstreaming and paralympic sports participation in zimbabwe. the need and value of teaching knowledge and skills among family medicine registrars marietjie de villiers, francois cilliers, nicoline herman, francois coetzee, klaus von pressentin, martie van heusden background/context: postgraduate students specialising in various medical fields (registrars) work fulltime in the health services and are usually involved in the training of undergraduate medical students. this mostly involves individual or small-group clinical supervision and feedback, but some registrars are also doing formal lectures. registrars, however, very seldom receive any training on how to teach. aim/purpose: this study reports on phase 2 of a larger research project seeking to investigate the influence of a module on teaching and learning on family physician trainees and its effect on their teaching practices. phase 1 results were reported at the 2011 saahe conference. in phase 2, current registrar perceptions of their role as medical specialists, attitudes towards teaching, and confidence with and participation in teaching activities were explored for groups before and after the module. methods: in-depth interviews were conducted with 11 purposively selected final-year students in the mmed family medicine programme at stellenbosch university after completing the module. two focusgroup interviews were held with a total of 7 third-year students before commencing with the module. interviews were digitally audio-recorded, transcribed and thematically analysed. ethical clearance was obtained for the study. results and discussion: both student year groups emphasised the need for the inclusion of a module on teaching and learning in their training. the final-year students were more confident than the third-year students in terms of performing small-group and one-on-one teaching, as well as doing presentations. stress levels for presentations were similar for both groups, but final-year students had reduced stress levels for one-on-one teaching. conclusion/take-home message: registrars-in-training expressed a clear need to be proficient in teaching practices even at an early stage of their studies. although only the perceptions of respondents were ascertained, these aligned with qualities expected of competent teachers. a reflection on professional development of registrars completing a module in healthcare practice g j van zyl, j bezuidenhout, m m nel background/context: the mmed professional training and the skills required by registrars are generic in nature. these skills were trained in the module in healthcare practice (gpv 703). aim/purpose: this research evaluated registrars' experiences of the module, including quality assurance, improvement of content and mode of presentation. module development was specifically aimed to offer each registrar the scope to address the unique needs concerned with ethics, practice management and patient communication. methods: the study was a quantitative study enhanced by qualitative methodologies. guest presenters (clinicians, health sciences and other professionals) facilitated the contextualisation and application of the content of the module. a self-administered questionnaire included a rating scale and open-ended questions was completed by participant registrars to evaluate presentations. results and discussion: a total of 40 registrars who completed the newly introduced module gpv703 from 2009 to 2010 participated in the study. informed consent was obtained before completion of the self-administered questionnaire. thirty-one heads of department (hods) helped with the evaluation. thirty-eight (95%) of the 40 registrars completed the questionnaire. registrars reported a total satisfactory and very good combination mean percentage of 91% for the questions related to the orientation session, content and applicability of the module. thirty-one (77.5%) of the 40 questionnaires collected, were completed by hods on the insight of registrars in gpv. registrars found the lectures on ethics to be most valuable and an important aspect for the treatment and management of patients. conclusion/take-home message: value was added and aspects required by registrars to develop and/or enhance their skills, knowledge and professional behaviour with regard to ethics, practice management and patient communication were addressed. 47 july 2012, vol. 4, no. 1 ajhpe abstracts integration of learning in an undergraduate medical programme at the university of the witwatersrand shalote rudo chipamaunga background/context: one of the key concepts underpinning the reformed mb bch undergraduate programme of the university of the witwatersrand has been to apply the principles of integration as a strategy to enhance learning. integration is one of the cornerstones of current medical programme reform in the world. horizontal and vertical integration of content from relevant basic sciences and pathological, humanistic and clinical disciplines requires specific efforts. there is evidence that integration assists students to assimilate and apply what they have learned more effectively, and thus enhance the goal of achieving professional competence. aim/purpose: to outline the application of phenomenography as a unique qualitative research approach for collection of data on student and staff views on integration. methods: individual face-to-face interviews and focus-group discussions are being conducted to collect data from the following study samples as they continue in the 2012 programme: cohort 1: the 2011 class of mb bch 1; cohort 2: the 2011 class of mb bch 2; cohort 3: the 2011 class of mb bch 3; cohort 4: the 2011 class of mb bch 4; cohort 5: the 2011 class of mb bch 5; teachers of medical students in years 1 6 of the programme; and academic staff involved in developing/reviewing the 6 years of the reformed mb bch programme. results and discussion: this is work in progress (data collection is ongoing). conclusion/take-home message: determining the effectiveness of integration requires obtaining the views of those who experience it. phenomenography is one of the best methods of investigating students’ experiences in education. a document review of the mb chb curriculum to inform enhancement of undergraduate public health (ph), evidencebased healthcare (ebhc), health systems and services research (hssr) and infection prevention and control (ipc) teaching anke rohwer,taryn young, lilian dudley, fidele mukinda, neil cameron, bart willems, shaheen mehtar, frederick marais, angela dramowski, ben van heerden background/context: stellenbosch university, through a medical educational partnership initiative grant, aims to enhance the skills of medical professionals in hiv/aids and tb care in rural and underserved communities, and to increase research capacity in this field. strengthening the knowledge and skills of ebhc, ph, ipc and hssr among undergraduate medical students is key to this initiative. aim/purpose: we conducted a document review of the mb chb curriculum at stellenbosch university, to describe the current content of ebhc, ipc, hssr and ph teaching, and to inform strategies to enhance the curriculum. methods: four teams identified area-specific competencies aligned with the canmeds framework. each team reviewed all 64 theoretical and clinical module guides and extracted learning outcomes relating to areaspecific pre-specified competencies, using standardised data extraction forms. learning outcomes were classified as knowledge, skill or attitude. ῾knowledge’ outcomes were assessed based on bloom’s taxonomy of cognitive functioning by matching the verb contained in the learning outcome to the appropriate level of the taxonomy. results and discussion: ebhc, ipc, hssr and ph are covered to varying degrees. teaching is confined to specific modules and not explicitly integrated in a stepwise fashion, progressing from lower levels of knowledge to acquisition of skills and practical competencies throughout the curriculum. as this study was based purely on information in the module guides, it did not aim to comprehensively capture actual learning taking place in various teaching contexts. to supplement data, interviews with lecturers and tutors, and a survey with recent graduates will be undertaken. conclusion/take-home message: national health priorities should direct the competencies needed by health science students. this document review is the first part of a situational analysis which will inform the enhancement of ebhc, ph, ipc and hssr teaching offered at undergraduate level. going rural: an analysis of the first year of implementation of an innovative medical education model s van schalkwyk, j bezuidenhout, h conradie, m de villiers, t fish, b van heerden background/context: in 2011, 8 final-year medical students from stellenbosch university commenced year-long clinical training at 2 sites on the ukwanda rural platform. two models were adopted: a traditional discipline-based clinical rotation programme at the regional hospital and the longitudinal integrated model at a district hospital. while students were required to complete the same summative assessment as their peers at the central hospital, a number of curriculum innovations were implemented. aim/purpose: this benchmarking study, supported by surmepi was undertaken to determine the success of the first year of implementation of the programme to inform future refinement of the model. methods: the formative evaluation adopted a mixed-methods approach. after obtaining ethical clearance, 22 in-depth interviews (with students, preceptors and administrators) and one focus-group interview (with homebased carers) were conducted. the transcribed recordings were analysed using atlas ti. comparative analyses between the results of the rural-based students v. students at the central hospital were undertaken. results and discussion: students described their enhanced self-confidence and improved skills. themes less explored in the literature, such as continuity of patient care and feeling part of a team and community, also emerged. students explained how the experience had influenced their thinking and had encouraged self-study. the preceptors described their personal learning experiences – sentiments that were echoed by the healthcare workers on the rural platform. also evident was how community-based activities had 48 july 2012, vol. 4, no. 1 ajhpe abstracts heightened social awareness. the comparative analyses highlighted trends which require further exploration. conclusion/take-home message: the findings of our study exhibit congruence with existing literature and provide critical insights for future iterations of innovative rural education models. the resultant learning experiences are potentially transformative encouraging socially accountable practices. generic learning skills in academically-at-risk medical students: a development programme bridges the gap v c burch, g gunston, d shamley, c sikakana, d murdoch-eaton background/context: a major global challenge of medical education is widening access and enrolling students from diverse educational backgrounds. given the increased risk of attrition, development programmes have been established to improve the throughput of these academicallyat-risk students. while these programmes acknowledge the importance of generic skills development in promoting academic success, there are no reports documenting the impact of these programmes on changes in the students’ skills profiles. aim/purpose: determine whether (i) academically-at-risk students, entering medical school at the university of cape town (uct), have a different generic skills profile compared with conventional students; and (ii) the change in skills profile of these students after completing a 12-month intervention programme (ip). methods: a previously validated questionnaire was used to document students’ self-reported practice of, and confidence in, generic skills including information handling, managing own learning and technical, numeracy, it and organisational skills. the survey was self-administered at the beginning and end of first year after completing the ip. results and discussion: four hundred and thirteen first-year medical students were enrolled in the study (99% participation) and 77 (19%) entered the ip after failing semester 1. there was a significant difference in the practice of, and confidence in 5/6 categories of generic skills between the ip students and conventional students upon entry to medical school. at the end of first year, after completing the ip, there was no significant difference between the practice of, and confidence in 5 of the 6 categories of generic skills between the ip students and conventional students. sixty-two ip students (81%) successfully completed first year. conclusion/take-home message: academically-at-risk students entering medical school at uct lack a range of key generic learning skills. ip participation closes the skills gap and results in a first-year completion rate of 81%. do students calibrate their confidence after being informed of their assessed competence? t p yeow, k c tan, l c lee, j blitz background/context: this research was conducted at penang medical college in malaysia, among 3rd-year medical students who were learning practical skills prior to the start of their clinical rotations. aim/purpose: we confirmed that self-perceived confidence in practical skills is not an accurate reflection of competence in our student population. we were interested to determine whether students calibrated their confidence after receiving feedback on their assessed competence. methods: one hundred and fifteen third-year medical students underwent a 13-week practical skills module. students were invited to rate their confidence for each skill preand postmodule on a scale from 1 (don’t know what this skill is) to 6 (fully expect that i am able to teach this skill to a junior colleague). at the end of the module, their performance in a selection of these skills was assessed by means of an osce. on completion of the osce, students were given their performance checklists with feedback. they then rated their confidence for the last time. we analysed changes in preand post-osce confidence against whether they had passed or failed the osce stations. results and discussion: sixty-two of 115 students who completed all confidence ratings were included for analysis. the majority of students with high-confidence pre-osce maintained this, regardless of whether they failed the osce or not, despite being informed of their poor performance. in response to open-ended questions added to the final confidence rating scale, 84% of students were unsatisfied with their performance during osce while 66% believed the osce performance did not accurately reflect their competence. conclusion/take-home message: self-assessed confidence in practical skills was not calibrated in response to being informed of osce performance. lack of calibration may be affected by students’ inherent character, selfreflective skill and their confidence in the assessment process. the effect of simulated emergency skills training and assessments on the competence and confidence of medical students i treadwell background/context: medunsa’s skills centre came into operation in 2010. the skills teachable in simulation were listed for 6 academic years to integrate theory and scheduled clinical practica. sixth-year medical students have to manage 3 simulated clinical emergencies in small groups during the orientation period of the family medicine block. the skills incorporated in these simulations include basic life support, airway suctioning, oropharyngeal airway placement, endotracheal intubation, bag-valve-mask ventilation and defibrillation. the 2012 6th-year students’ emergency training was only through apprenticeship in real-life clinical situations. there is no evidence that these students had opportunities to practise these 49 july 2012, vol. 4, no. 1 ajhpe abstracts skills during their clinical rotations or how competent and confident they are to perform emergency skills. aim/purpose: to determine the effect of skills training and assessments on the competence and confidence of senior medical students in performing emergency skills. methods: a one-group preand post-test quasi-experimental design is being used. a convenience sample will comprise students of 3 family medicine rotations (february to june 2012). pre-testing: (i) questionnaire to determine participants’ exposure to the above name skills during their training and their confidence levels in performing these skills; (ii) mcq test on the skills; (iii) osce to determine the participants’ competence. interventions: (a) lectures and demonstration on skills; (b) supervised hands-on practise. post-testing: (i) questionnaire on training experience, mcq and osce. results and discussion: the questionnaire responses will be summarised by frequency counts and percentages. the percentages of ῾favourable’ outcomes before and after the teaching sessions will be compared using the mcnemar test. the mean likert scale scores, tests scores and osce results obtained before and after the teaching and practise sessions will be compared by using the paired t-test. conclusion/take-home message: research is ongoing. results and conclusions will be discussed at conference. rural longitudinal integrated clerkships: lessons from two programs on different continents ian couper, paul worley, roger strasser background/context: flinders university in australia has had a rural longitudinal integrated clerkship for selected medical students, the parallel rural community curriculum, since 1997. the northern ontario school of medicine (nosm) in canada introduced a similar clerkship for all nosm students in 2007. an external evaluation of both programs was conducted, in 2006 and 2008, respectively. aim: to analyse similarities and differences between these 2 programmes. methods: the evaluation took the form of a cross-sectional descriptive study conducted in each school using focus-group and individual interviews, involving students, faculty, preceptors, health service managers and community representatives. interviews were analysed for emerging themes based on a grounded theory approach. common themes were tabulated and validated. the themes for the 2 sites were compared and contrasted to assess similarities and differences. results and discussion: interviews and focus groups were conducted with 87 people at flinders and 39 at nosm. all participants felt that the programs produced confident and skilled students. the educational value of the programs was expressed in terms of continuity of care, longitudinal exposure, development of relationships, mentoring, teamwork, and participatory learning. common concerns were related to issues of standardisation, ensuring exposure to all specialist disciplines, communication, support for students and preceptors, isolation, dealing with personal issues, and the process of site selection. conclusion/take-home message: the rural longitudinal integrated clerkship approach to teaching the core clinical components of the undergraduate medical curriculum has a positive impact on both students and clinicians, as demonstrated in 2 different sites on 2 continents. feet of clay? no! our model of the learning effects of assessment seems robust francois cilliers, lambert schuwirth, cees van der vleuten background/context: an intervention based on a validated model should result in better outcomes than a less theoretically grounded effort. while much research links assessment and learning, few models exist to explain the links that are typically observed. no models have been validated or have gained traction to inform intervention design. using grounded theory, we proposed a model linking assessment and pre-assessment learning. we are in the process of validating this model. aim: to explore the model's generalisability in varied assessment contexts. methods: cross-sectional surveys of 593 students at 3 universities were undertaken. a purpose-made questionnaire was developed, comprising pairs of written situational tests using the logic of the key-features approach. the chi-square statistic was used to determine significance for associations between assessment factors and learning effects. the frequency of involvement of mechanism factors was calculated. as the most stringent test of the model, we focused on the model’s 21 weakest associations. ethical approval was obtained. results: the response rate was 45.9%; 15/21 associations between assessment factors and learning effects were significant (p<0.00625) across institutions. the role of 7/8 assessment factors, all 8 learning effects and all 10 mechanism factors were substantiated. three mechanism factors (agency (25.7%), response efficacy (21.4%) and response value (14.6%)) mediated the majority of associations. conclusion: model validation is an ongoing process these results are but one link in a chain of evidence. the support for the weakest associations bodes well for future studies of the model’s stronger associations. these results bring us one step closer to a model that could meaningfully inform assessment-based interventions. the role and responsibilities of higher education institutions (hei) regarding peer mentoring y botma, s hurter, r kotze background/context: this presentation reports on the postgraduate critical care students’ mentoring of the third-year undergraduate nursing students during integrated work-based learning in the critical care units. 50 july 2012, vol. 4, no. 1 ajhpe abstracts aim/purpose: the purpose of the research was to describe what the higher education institution (hei) could do to improve this mentoring programme. methods: a qualitative descriptive design was used. the nominal group technique was used to gather data from the mentors and mentees. data from the groups were combined and qualitatively analysed into themes. thereafter the themes were quantitatively ranked. results and discussion: the themes, ranking from the highest to the lowest, were orientation, organisation, mentoring process, characteristics of the mentor, and feedback to the mentor. findings suggest that the hei does not always optimally support the mentoring programme. it is recommended that more than one communication medium be used to disperse information among role-players. heis should develop mentors, monitor their interactions with mentees and give them feedback on their mentoring skills. it is also the responsibility of the hei to select mentors that match the desired profile of mentors. conclusion/take-home message: main tasks of the hei are to: (i) develop guidelines for the mentors and mentees; (ii) develop memorandum of understanding; (iii) develop the mentors; (iv) support mentors; (v) create and maintain open communication channels to all parties; (vi) monitor mentoring process; and (vii) provide feedback to mentors and mentees. st. george’s university school of medicine (sgusom): innovative student academic support in the basic sciences glen jacobs background/context: sgusom is located in the caribbean island of grenada in the west indies and the majority of the students are from the united states. performance on standardised measures to enter into medical schools is lower for these students than for students attending united states medical schools. sgusom students out-perform students from all other caribbean schools of medicine and for 2010 equalled the first-time pass rate of 92% in the us and canada on the united states medical licensing examination (usmle) step 1, a standardised examination of basic science knowledge. an astonishing achievement. aim/purpose: to identify academic student support practices which may contribute to enhance student learning and academic performance in the basic sciences. methods: comparing basic intake and outtake performance data of students on standardised examinations. results and discussion: on average sgusom students perform equally as well on usmle step 1 as students who took the basic sciences in the united states medical schools, even though their performance on standardised measures is lower. we have identified innovative practices at sgusom that we believe contribute to enhanced performance and that have become part of the learning culture of the university. this includes a unique department of educational services, specialised advising system, academic enhancement program, imbedded small-group learning and review groups, sonic foundry and sakai. conclusion/take-home message: the philosophy at sgusom is that once a student gets admitted to the university, it is a responsibility of the institution to help them succeed without compromising standards. this is done in a most efficient way by providing an effective student support system as well as sufficient resources. this support should be part of the medical school culture and not an add-on. ‘for most of s africans, we don’t just speak’: a qualitative investigation into collaborative heterogeneous pbl group learning v s singaram, c p m van der vleuten, d h j m dolmans background/context: an enhanced interaction across the racial, ethnic and cultural divide is particularly relevant for medical students as it prepares them for practising medicine in a multicultural community. collaborative approaches such as problem-based learning (pbl) may provide the opportunity to bring together diverse students, but their efficacy in practice and the complications that arise due to the mixed ethnicity needs further investigation aim/purpose: this study explores the key advantages and problems of heterogeneous pbl groups from the students’ and teachers’ opinions. methods: focus groups were conducted with a stratified sample of secondyear medical students and their pbl teachers. discussions were transcribed and analysed using atlas-ti. results and discussion: several themes describing opportunities, challenges and recommendations emerged. these included uniting diverse students and preparing them to work in multicultural societies. challenges included segregation, non-participation due to inequalities, social status, language barriers and differing levels of academic preparedness. conclusion/take-home message: the presence of a multi-cultural student population at a learning institution does not necessarily mean that there will be positive interactions in intercultural collaborative learning activities. students and staff need special diversity skills training and continuous feedback. a dual perspective on a goal-directed mentoring programme for a junior lecturer in the department of speech-language pathology and audiology a m wium, f mahomed background/context: the benefits of mentoring in higher education are well documented. in order to orientate and integrate a new staff member in the department of speech-language pathology and audiology a mentoring programme was introduced. both the mentor and the mentee were seeking to develop professionally. the mentee, who had limited experience in higher education, required support in the academic environment and in teaching and learning. communal goals were developed according to personal needs and were met through a process of goal-directed mentoring. 51 july 2012, vol. 4, no. 1 ajhpe abstracts aim/purpose: the aim was to develop a blueprint for a mentoring programme to be used with junior staff in the department of speechlanguage pathology and audiology. methods: specific goals were identified at the onset of the mentoring programme. the data collected was obtained from continuous reflections by the mentor and the mentee, peer review and self-evaluation. the process and the outcomes of the mentoring programme were documented and presented as a portfolio. results and discussion: the results are based on the experiences and reflections of both the mentor and the mentee. goal-directed mentoring appears to be effective as benefits, such as personal and professional growth and empowerment of the mentee, were identified and documented by both. from this symbiotic relationship both parties experienced the process as meaningful and were motivated. future needs were identified. conclusion/take-home message: goal-directed mentoring combined with continuous reflection by both the mentor and mentee created the opportunity for professional and personal growth. such a mentoring process can be used to advance the academic careers of staff. bcmp student experiences of professionalism during clinical rotations m o mapukata-sondzaba background/context: medical professionalism as a set of behaviours that transcends personal values, beliefs and attitudes to incorporate ethical and moral principles, is considered to be a covenant between society and the medical practitioners. as a desired state, an understanding of the attainment of professionalism not as an event but rather as a process obligates both the academic and the clinical tutors to cooperate for the good of the patient. aim/purpose: to assess congruency between the academic and clinical training environment with regards to professionalism by reviewing bachelor of clinical medical practice (bcmp) student experiences of professionalism during clinical rotations. methods: following 5-week attachments in 5 purposely selected clinical departments, 25 final-year bcmp students reflected individually on their personal experiences of professionalism in the workplace for 3 of the rotations. qualitative methods were used to group emerging themes from 69 portfolios. bcmp student experiences of professionalism were analysed from an ethical perspective, guided by hpcsa guidelines for healthcare professionals. results and discussion: bcmp students reflected positively on the respect for patients, compassion and care that they observed in paediatrics. professional integrity was recognised as a context-specific attribute for admitted patients. role modelling was experienced in emergency medicine and in paediatrics. the lack of privacy between cubicles in the wards was perceived as compromising privacy and confidentiality of patient information. inadequate communication, attitudes of staff, resources and cultural issues were some of the attributes that compromised patient care. conclusion/take-home message: bcmp students demonstrated congruency on professionalism by integrating theoretical knowledge with their experiences during clinical training rotations. they were able to recognise positive and negative contextual attributes of professionalism and identify individuals who they perceived as role models. creating an educational environment that fosters agency and social accountability in health professionals ellenore meyer, alwyn louw background/context: social accountability of medical schools is defined as ῾the obligation to direct their education, research and service activities towards addressing priority health concerns of the community, region or nation they have a mandate to serve.’ balancing global principles with context specificity necessitates an understanding of the african context of community, including the concept of ubuntu. medical educators play a central part in providing relevant activities that will foster agency and social accountability. purpose: evaluating the effect of this bio-ethics module on second-year medical students’ knowledge of, and attitudes towards, social accountability. method: the study evaluated an educational intervention; using a pre and post-intervention test design. qualitative and quantitative data were collected as part of a mixed-methods strategy in a survey by means of a questionnaire. the questionnaire focused on learners’ views on community, social accountability and ubuntu. qualitative data were analysed and coded according to themes. coding was performed through an inductive open process. ethical clearance was obtained. the educational intervention entailed an in-class learning experience in small groups at the hand of multiple case examples over 4 weeks. results and discussion: eighty-five per cent of 2nd-year students in the sample group completed questionnaires. on average, learners’ knowledge regarding social accountability improved – the differential on the quantitative component preand post-intervention was +11.2% (p=0.0033). qualitative data revealed a positive development of students’ views and attitudes about their roles as health professionals having an agency and social accountability. take-home message: embedding the principle of ubuntu in the bio-ethics module has the potential to equip and inspire learners to fulfil their role as socially accountable change agents. introducing basic medical isizulu to medical students for communication purposes – did it work? l molefe background/context: teaching isizulu to gemp 1 medical students at the university of the witwatersrand became necessary in 2011 as problems of communication continued between english-speaking health workers and african language speakers. 52 july 2012, vol. 4, no. 1 ajhpe abstracts aim/purpose: (i) to create a moderate background for students who do not speak isizulu; (ii) to increase basic communication skills in isizulu for those who have little to no background in the language; (iii) to straighten communication skills among mother-tongue speakers as well; (iv) to minimise cases where nurses become doctors’ interpreters; and (v) to protect patient privacy. methods: teaching material was created using the gemp 1 block system; isizulu sentences were created using the history taking questions and answers. grammar and terminology from the blocks also formed part of the lessons. the same material was placed on a website for students to access., with video clips of a lecturer teaching isizulu to promote correct pronunciation. tutorials are managed by gemp 1 students who speak isizulu, with the help of a lecturer. results and discussion: some students perceived that the course added to their study load. hence, attendance was high in the beginning but decreased later. mother-tongue isizulu speakers never attended, while those with half the background of the isizulu speakers attended occasionally. only those with no background at all attended. however, the first osce saw an 80% pass rate, even in the final exam. gemp 1 students of 2012 have shown incredible interest in the course. their current attendance is immeasurable. this is partly because the course was not introduced as additional work, and also because the students understand the communication problem that this course is attempting to address. conclusion/take-home message: it is hoped that more african languages will be included in the same programme in the future. more basic isizulu communication teachers may also emerge from the course. diagnose before you prescribe: a faculty needs assessment for a faculty development programme in ahfad tahra s al-mahdi background/context: ahfad university for women (auw) is the pioneer in female education and empowerment in sudan. ahfad medical school (asm) was established in 1990 to produce the right type of graduates for its context through an innovative community-orientated curriculum. due to many factors, the asm curriculum has gradually deviated to a more conventional form. in 2008 winds of change arrive in the shape of a partnership with the american university of beirut (aub). this mandated a university-wide move towards a more student-centred approach. ahfad educational development centre (aedc) was established to support faculty in coping with new demands, through various faculty development (fd) activities. unexplainably, asm faculty attendance of these activities was consistently low. purpose: to identify faculty’s professional development needs (pdns) prior to designing a suitable fdp. methods: pdns were assessed in a 1-day workshop through small-group discussions. consequently, a questionnaire was generated to prioritise the different areas and capture the desired format, duration and timing of fd activities. both tools targeted full-time faculty (n=56 teacher). fortyeight members attended the workshop (85%), of whom 28 answered the questionnaire (50%). results and discussion: eight fd areas were identified: assessment, classroom management, curriculum evaluation, instructional planning, instructional methods, research, student support, and technology. the different areas were prioritised from the mostto the least-needed and the desired format (workshop), duration (1-day) and days (e.g. saturdays) for the fd activities. the workshop established some important recommendations which were translated into actions during the project duration: conduction of longitudinal workshops on assessment, implementation of a new exam format, involvement of students in their education, regular faculty meetings and reform of some courses. take-home message: allow teachers to identify their own professional development needs; they will be more committed to filling identified gaps. the value of standardised video demonstrations as an educational tool in clinical skills training l de bruyn, j lombaard background/context: in clinical skills training, pre-clinical mb chb students are taught the art of managing a patient during a clinical consultation. the nature and volume of the study matter necessitates longer teaching time and smaller student groups. the class is therefore divided into 6 groups. this implies that a session must be presented on 6 consecutive days by the clinical department responsible for the particular session (e.g. urology). this is extremely labour-intensive and problematic for clinicians who are also service providers in clinics and hospitals. aim/purpose: to determine whether standardised video demonstrations of clinical presentations are of educational value in the clinical skills course. methods: video recordings were made of presentations given by the designated clinician. the subjects included history-taking or performing a clinical examination. these were edited and their educational value enhanced by adding classifications, summaries and explanatory photographs of the content presented. at the end of their clinical skills course, the students (n=113) completed an anonymous questionnaire to determine their perception of the value of these video demonstrations. the results were analysed and presented as a percentage for this qualitative study. results and discussion: the majority of students (78%) responded positively and found the presentations of clinical examinations to be of educational value. conclusion/take-home message: presentation of the components of the clinical consultation, e.g. taking a patient’s history or performing a clinical examination, by means of video demonstrations is perceived as a valuable educational tool by students. this method has the advantage of replacing the consultants’ repetitive presentations, allowing them to use their limited time to facilitate students’ practising the physical examination and also, that each student receives exactly the same tuition. 53 july 2012, vol. 4, no. 1 ajhpe abstracts faculty development – a policy review ian couper, patricia mcinerney background/context: as part of the development of the guidelines for the scaling up of transformative health professional education, the world health organization requested that a policy brief be written for the second core group meeting. aim/purpose: to understand the issues and challenges related to faculty development with respect to medical, nursing and midwifery education, in order to make policy recommendations. methods: a review of the literature was conducted of faculty development, specifically in relation to the teaching role of faculty members in terms of issues, challenges, impacts and outcomes. results and discussion: the issues and challenges related to the development of faculty for the teaching role are described in 7 broad areas: the multidimensional roles of health professionals; attitudes towards teaching; conflicting opportunities; the shortage of teachers; the increased demand for physicians, nurses and midwives; developing health professionals for a teaching role; and rewards for teaching. assessing the impact on outcomes of faculty development initiatives is difficult due to limited focus in the literature on systematic evaluations of interventions using rigorous methodologies. conclusion/take-home message: faculty development does impact positively on educational practices, and possibly on outcomes, but a supportive faculty environment, with rewards and incentives for teaching, requires broader institutional change. recommendations for policy changes are made in relation to health professional schools, government and accrediting bodies. improving basic surgical skills for final-year medical students mohamed labib background/context: the medical undergraduate curriculum at the university of zambia's school of medicine is mainly knowledge-based, with more theory than hands-on educational activities.hospitals employing medical graduates often express concern at the inexperience of new interns in basic surgical skills. in self-assessment questionnaires, students reported little clinical procedural experience. aim: to measure the efficacy of a basic surgical skills workshop for senior undergraduate students, as well as retention of skills gained. methods: a practical skills workshop was conducted in order to set learning goals for the final study year through simulation. three 1-day suturing and knot-tying workshops were held, where students were invited to acquire the necessary knowledge and learn skills of suturing. sixty-three undergraduates participated in the workshops. the suturing skills of the students were assessed before and after training using a checklist. in every workshop, a preand post-training questionnaire was used to assess student knowledge about sutures and perceptions about the workshop. sixtythree students attended the workshop for the first time; 31 had a second assessment after 3 months. results and discussion: teaching and assessment of technical skills in operation theatres is difficult due to pressure on theatre time, ethical issues and medico-legal concerns. all students completed the preand post-training questionnaires; 95% who passed the assessment said that the training improved their practical skills and theoretical knowledge. out of 31 students who went for the second assessment, 24 (77%) passed. conclusion: teaching of basic surgical skills is viable and beneficial. basic surgical skills should be taught to all medical students regardless of their career aims, and such training is needed periodically. acknowledgment: dr johan demper. the role and position of clinical simulation as an additional component to current undergraduate medical curricula m j labuschagne, m m nel, g j van zyl, p p c nel background/context: clinical simulation cannot replace clinical training on real patients, but should be a required enhancement to the undergraduate medical curriculum. the integration process was investigated and recommendations were made. aim/purpose: (i) to explain the vertical integration of clinical simulation as instructional medium in a current medical curriculum; (ii) to explain the horizontal integration of simulation into an existing undergraduate medical curriculum; and (iii) to describe the role of clinical simulation in the curricula to develop leadership skills, group training and inter-professional skills of students and to improve patient safety. methods: a literature review, semi-structured interviews with international simulation experts, and focus-group interviews with lecturers of the clinical phase of the undergraduate medical programme at the university of the free state were conducted, analysed and interpreted. results and discussion: the author aims to propose ways to integrate clinical simulation as an essential enhancement of undergraduate medical education and training. the integration of simulation into the curriculum, from the first to the final year, is described as vertical integration. the horizontal integration of theory, skills training and clinical training, will be discussed. there should be a continuous movement between the different components. the role of clinical simulation to develop leadership skills, group training and inter-professional skills of students will be highlighted. the important aspect of patient safety and how simulation can play a role in the improvement of patient safety will be highlighted. conclusion/take-home message: clinical simulation can be integrated successfully into current medical curricula as an enhancement of undergraduate medical education and training. 54 july 2012, vol. 4, no. 1 ajhpe abstracts simulation taxonomy and conceptual framework, as proposed by the canadian network for simulation in healthcare in a south african context m j labuschagne, m m nel, p p c nel, g j van zyl background/context: much confusion exists in the literature regarding simulation taxonomy and terms are used haphazardly in the literature. the canadian network for simulation in healthcare proposed a taxonomy and conceptual framework for simulation in healthcare in 2011. aim/purpose: (i) to explain the 4 levels of the framework; (ii) to standardise the terminology, educational tools and educational experiences in clinical simulation; and (iii) to make it applicable for the south african context. methods: a literature review, semi-structured interviews with international simulation experts and focus-group interviews with lecturers of the clinical phase of the undergraduate medical programme at the univeresity of the free state were conducted, analysed and interpreted. results and discussion: the terminology used in clinical simulation is currently not standardised and confusion exists in the literature, with terms used haphazardly. the author aims to explain the taxonomy and the conceptual framework for simulation in healthcare as proposed by the canadian network for simulation in healthcare. the levels include instructional medium, simulation modality, instructional methods and presentation. the taxonomy and conceptual framework will be used to describe and standardise the terminology, educational tools and educational experiences in clinical simulation. the proposed framework is easy and simple to use, and is useful for instructional design and research. the application of aspects for the south african situation will be discussed. conclusion/take-home message: the standardisation of terminology, educational tools and educational experiences in clinical simulation is essential for descriptive purposes in research and publications. the effect of clinical simulation on inter-professional learning of healthcare students i treadwell background/context: an outcome for newly graduated healthcare workers highlights the importance of teamwork and the understanding and appreciation of the roles, responsibilities and skills of other care workers. the majority of students are, however, not exposed to formal inter-professional learning (ipl) events in order to form realistic expectations of each others’ roles and scope of practices. since studies indicate that ipl is facilitated by experiential learning, the skills centre at medunsa introduced inter-professional trauma simulations using high-fidelity simulators and sps. senior medical, nursing and occupational therapy students are scheduled to take part in these events. aim/purpose: to assess the effect of clinical simulation on the interprofessional learning of healthcare students. methods: a quasi-experimental study will be performed in may 2012, using a convenience sample of medical, nursing and occupational therapy students. pre-testing will comprise a written test and an interdisciplinary education perception scale (ieps) will be used to determine participants’ attitudes towards other disciplines. the simulation will include active prehospital, initial in-hospital and follow-up management of a traumatised patient by cohort 1 participants, while observed by cohort 2 participants. post-testing will be a repeat of the test and ieps. video recordings will be rated by an expert panel as well as both cohorts. focus groups will be held on role clarification, additional needs and self-directed learning. results and discussion: the percentages of ῾favourable’ ieps outcomes before and after simulation sessions will be compared by the mcnemar test. mean likert scale scores before and after simulations will be compared by the paired t-test. agreement between student and panel assessments will be measured by the kappa statistic. qualitative focus-group assessments will be summarised descriptively. results will be reported and discussed. conclusion/take-home message: to be discussed at conference. the effect of training in characterisation on the congruence of standardised patient (sp) portrayals l schweickerdt-alker background/context: although simulated/standardised patients (sps) are used in many institutions in south africa, the scope of how much they could mean is still not fully understood. often they are given scenarios on too short notice. due to the lack of time for proper training regarding the interpretation of the role, the sps are confronted with questions that they find difficult to answer and often their portrayals are stereotyped and/or incongruent. in an attempt to face and rectify these challenges, the need for character development was identified. aim/purpose: to assess the effect of training with regard to characterisation (creating a three-dimensional person behind the patient) on the congruence of sp portrayals. methods: a quasi-experimental study will be conducted at medunsa. the convenience sample will comprise ±50 sixth-year medical students, allocated as per curriculum to the family medicine blocks in april and may 2012 and the 4 least experienced sps at the skills centre. pre-testing: the performance of 4 sps in identical scenarios will be captured on video during an osce. sp and student reflections on the congruence of sp performances will be captured and transcribed. the characteristics of congruence will be identified by 3 sp trainers. intervention: training of sps on characterisation with emphasis on the identified characteristics of congruence. post-testing: repeat of pre-testing procedures will be done during a second osce and the results will be compared with the pre-testing results. results and discussion: the effect of training will be measured for preand post-outcomes of defined characteristics of congruence. where applicable, the fisher's exact test will be used for significant changes in outcomes. p-values <0.05 will be considered to be significant. the results will be discussed at the conference. 55 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion/take-home message: to be discussed at conference. does increased authenticity in practise improve patientcentred care in practice? b y uys background/context: simulation strategies such as using low-fidelity patient simulators (manikins) and standardised patients (sps) are implemented to enhance the competency of students before encountering patients in practice. one of the aims of using sps is to create more authentic (more lifelike) simulated learning experiences. such experiences should help bridge the gap from practise (simulated) to practice (encounter with live patients) where patient-centredness is of crucial importance. aim/purpose: to determine the effect of enhanced authenticity in simulated skills training on patient-centred care rendered by nursing students. methods: a pre-experimental design, the post-test only design with a comparison group, was used. the study is being conducted at the university of limpopo (medunsa campus) and the george mokhari hospital situated in ga-rankuwa. cohort 1 participants will be trained to administer an intramuscular injection using a manikin while cohort 2 participants will be trained using an sp with a strap-on device. on completion of the training, cohorts 1 and 2 will be observed and objectively assessed in may 2012 on their procedural skills and patient-centred care, while administering an intramuscular injection to a patient in hospital. a comparison will be made in the patient-centred care rendered by the cohorts. results and discussion: results will be captured in data spread sheets during analysis of observation patterns and interactions. data will be quantified and the entire variety of statistical analyses will be utilised. conclusion/take-home message: to be discussed at the conference. the influence of podcasting on undergraduate medical students at the faculty of health sciences, stellenbosch university s h walsh, m r de villiers background/context: the podcasting (or vodcasting) of lectures has been shown to benefit students. students mostly use them for revision and test preparation. this mixed study correlates undergraduates’ 2011 respiratory block marks with the 2012 class, as well as qualitative feedback from students and lecturers. aim/purpose: to determine (i) whether undergraduate medical students find podcasting to be a useful addition to lecture attendance; (ii) whether the availability of podcasts influenced the respiratory block test scores; and (iii) how lecturers perceived podcasting. methods: lectures in the respiratory block of the mb chb ii course were converted into podcasts and placed on webstudies, where students could view or download them. end-of-block class scores were compared with those of the previous year. the marks of the students who downloaded the podcasts were statistically compared with those who did not. the opinions of the students and lecturers were obtained by means of separate questionnaires at the end of the block. results and discussion: students: 78% used the podcasts; 88% thought that all lectures should be podcasted; 88% of students used podcasts for clarifying concepts not fully grasped in class; the 82 podcasted lectures were viewed/ downloaded 1 737 times (an average of 21 times each); compared with 2011, the end of block marks improved. lecturers: 70% thought that the process was stress-free or extremely stress-free; 80% thought the podcasts did not influence class attendance or even translated into any improvements. conclusion/take-home message: our students mostly found podcasts beneficial for clarifying concepts that they did not grasp in class. we are continuing to podcast the entire 2nd year’s lectures and will evaluate the effect that this has. the expectations of postgraduate students and supervisors: both sides of the coin h friedrich-nel, j l mackinnon, s queener background/context: the literature on postgraduate supervision is clear that a supervisor and a postgraduate student may not always operate from the same platform when expectations regarding the completion of the research project are discussed. as such, the expectations of the supervisor may focus on engagement, interaction and formative assessment. the needs of the student on the other hand may be completely different. the student, in need of support may need a life-coach, friend and adviser. aim/purpose: the question is whether a blue print exists for ῾realistic expectations’ from the parties, and how these expectations are communicated. methods: a qualitative study exploring the opinions of faculty and students was conducted with an american university as a case study. students and faculty from various schools participated voluntary in interviews according to a structured interview schedule after approval was obtained for the study. responses were captured during the interview and verified with the interviewee at the conclusion of the interview. data were investigated for common themes that emerged, and grouped. results and discussion: fifteen students and 23 faculty members participated in the study. although the responses from students and supervisors varied, the majority of the student responses indicated that the supervisor has to provide guidance and/or support throughout the research process, establishing a helpful/supportive relationship. the supervisor on the other hand is open about expectations, namely that the student needs to work hard, learn, accept constructive criticism, be committed during the research process, do their best, and successfully accomplish the degree. conclusion/take-home message: given the challenges that we face in south africa with postgraduate student completion and the preparedness of 56 july 2012, vol. 4, no. 1 ajhpe abstracts supervisors, it is of value to translate the results obtained in the study to the south african context. the paper will communicate these results and reflect critically on the local context. ‘fit for purpose’: graduates of a new emergency medicine programme heike geduld, leana wen, lee wallis, vanessa burch background/context: the first emergency medicine (em) training programme in africa started in cape town in 2004 as a joint division between the university of cape town (uct) and stellenbosch university (sun). upon graduation, many of the junior faculty were quickly drafted into roles as managers, teachers and mentors, to support the developing academic programme and provincial healthcare service delivery needs. aim: the aim of the study was to evaluate self-assessed competencies including medical expert, scholar and manager of graduates of the em program. faculty development needs were also be identified, in order to develop an appropriate development plan for faculty and inform the postgraduate em training curriculum. methods: this descriptive study formed part of a larger formal programme evaluation process. the study population included the 30 graduates of the first 4 years of the em training (2004 2007). participants were asked to complete a questionnaire and a structured interview by a single researcher not connected to the program. participants were surveyed regarding their perceptions of training, evolving career plans and self-identified competencies and deficiencies for fulfilling their current jobs. participation was voluntary and responses were recorded anonymously. results and discussion: twenty-seven of 30 (90%) participants were sampled; 14 (52%) were in academic posts, 4 (15%) were in non-academic clinical posts and 9 (33%) had temporary posts; 21 (72%) were still in cape town. participants felt that their training had provided them with appropriate clinical and procedural skills, but management, research and teaching skills were lacking. formal management training was cited as necessary. lack of clear career prospects and progression was concerning. conclusion: while the em training programme provides excellent clinical knowledge and skills training, there are deficiencies in academic, management and leadership competencies. potential solutions identified include graduated responsibilities during training, fellowships and formal faculty development programs. the impact of training in pattern recognition on the ability of diagnostic radiographers to interpret images accurately lynne hazell background/context: diagnostic radiographers in south africa could provide an interpretation of an image to a recognised practitioner in the clinical situation within their scope of practice. in many south african departments there is a shortage of radiologists resulting in delayed or no reports to referring doctors. in order to meet the needs of the country, south african radiographers need to become multi-skilled radiographers. empowering radiographers with pattern-recognition skills could address the problem in many south african departments aim/purpose: to assess the ability of qualified diagnostic radiographers in a gauteng government hospital to apply pattern recognition and interpret a radiograph after training in musculoskeletal pattern recognition. methods: the study employs a pre-/post-test model and an intervention training of radiographers in musculoskeletal pattern recognition. nine radiographers volunteered to participate. the radiographers identified whether an image was normal or abnormal and then provided a comment on the abnormal images. after the pre-test, training in the application of pattern recognition for the musculoskeletal system was provided. results and discussion: accuracy of the image interpretation demonstrated a significant improvement in the post-test. the participants identified normal and abnormal images accurately. the comments on the images also showed a significant change from the number of incorrect comments on the images to partially or completely correct comments in line with the reference standard. conclusion/take-home message: the intervention – training in pattern recognition of the musculoskeletal system to enable image interpretation – appears to have been successful. to empower the diagnostic radiographers in these hospitals with the skills to provide image interpretation, a training programme would need to be developed. sustainability of a postgraduate diploma in transfusion medicine: results from semi-structured interviews and a delphi survey vernon j louw, marietjie m nel, john f hay background/context: quality education in transfusion medicine is key to delivering a safe and cost-effective blood service. a number of factors affect the long-term viability and sustainability of such a programme, particularly in a poorly resourced context with a limited number of clinicians trained in this field. aim/purpose: to determine and test the criteria that are key to programme sustainability when developing a model for the academic development and implementation of a postgraduate diploma in transfusion medicine. methods: qualitative and semi-quantitative approaches were followed to determine and test the criteria considered to be important in programme sustainability. a literature survey was conducted, followed by semistructured interviews with national and international transfusion medicine experts, and a delphi survey. results and discussion: fifty-five criteria were identified from the semistructured interviews. consensus was reached on 41 criteria and stability was reachedc on a further 13. elements essential to programme sustainability were identified and ranked in order of importance. 57 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion/take-home message: literature on programme sustainability in the field of transfusion medicine is virtually non-existent. this study identified a number of elements essential to the long-term viability of such a programme. this should prove useful to any institution developing a postgraduate training course in transfusion medicine. feedback of examiners as learning opportunities for supervisors and postgraduate students m m nel, g j van zyl background/context: the requirements that theses and dissertations in the health professions education programme should meet, are that they should demonstrate the candidate’s familiarity with the relevant literature, their research skills, and their ability to write a proper report on their research. a thesis should, in addition, make an original and significant contribution to the subject field. as far as research is concerned, the candidate should prove that they are fully conversant with the research methods and techniques of their specific subject field and that they have mastered and are able to use the research methods and techniques of the particular subject field. as far as the report is concerned, they should be able to document the research problem and objective, the research setup or design, method, results and conclusions in a proper scientific (systematic and logical) manner. the work should bear evidence of the candidate’s analytical skills, critical stance and substantive insight. aim/purpose: to analyse the feedback in 115 reports of examiners. methods: quantitative and qualitative approaches were used. an empirical, non-experimental research design was followed in this descriptive study. results: the findings of the study are reported on by means of a description and a discussion. the findings are used to make recommendations on postgraduate education as far as the selection of a research theme, problem statement, literature review, research methodology, analysis and interpretation of results and documentation of the report, etc. conclusion: the role that defined criteria and clear recommendations can play was of utmost importance. with this study an attempt was made to emphasise feedback of examiners as learning opportunities for supervisors and postgraduate students. narrative inquiry in identity construction research: what do we do with these stories? lakshini mcnamee background/context: in the human and social sciences, narrative methods are widespread in identity construction and professional development research. however, there is a noticeable lack of narrative research into the development of medical practitioners. empirical strategies for analysing personal narratives are scarce in medical education. even in studies that have reportedly generated suitable qualitative data, analyses are limited to thematic approaches, and structural analysis of narrative form remains neglected. this progress report describes an ongoing study using narrative inquiry to examine the learning processes and identity construction of newly qualified doctors (nqds). aim/purpose: to gain a better understanding of the school-to-work transition and internship experiences of nqds. methods: autobiographical reflections of nqds (generated by a previous study) were examined using socio-linguistic methods, using a socio-cultural theoretical framing of ῾situated learning’ in ῾communities of practice’. a modified labovian classification of clauses was applied to storied events. close attention was paid to language, discourses and narrative form (telling of narrative rather than referential aspects alone). inferences were made regarding participants’ self-categorisation and positionality in relation to various social groups encountered in practice. results and discussion: identity construction of nqds is not fixed, and as newcomers their identities were in a state of flux. they experienced various degrees of angst due to unfamiliar systems, burdensome responsibility and their sense of how others perceived them. individuals aligned themselves with other interns and healthcare professionals according to perceived strengths. learning opportunities afforded by different environments varied considerably, however, participants demonstrated intentionality, judging their own situations, negotiating their individual progress and choosing trustworthy sources of assistance or guidance. conclusion/take-home message: early career learning viewed from a social practice perspective offers a meaningful way to study identity construction of nqds. the professional development of medical practitioners is a complex process where identity construction is implicated along with the development of knowledgeable skill. relational aspects of persons play an important role in determining practice. evaluation of a web-based module on evidence-based medicine (ebm) for family medicine specialist in training at stellenbosch university anke rohwer, taryn young, susan van schalkwyk background/context: practising evidence-based medicine (ebm) using current best evidence in making healthcare decisions typically involves 5 steps: phrasing answerable questions, searching for relevant studies, critically appraising it for validity and usefulness, applying results, and auditing the process. acquiring basic knowledge and skills of ebm is essential for successful implementation and subsequent improvement in healthcare quality. enhancing ebm knowledge and skills at postgraduate level is a key strategy of stellenbosch university’s (su) medical educational partnership initiative grant which aims to enhance skills of medical professionals in rural and underserved communities. su’s family medicine division offers a 12-week online ebm module to specialists in training during their first year which could be expanded to other specialists in training. aim/purpose: to formatively evaluate the ebm module to inform further enhancement of delivery and content. 58 july 2012, vol. 4, no. 1 ajhpe abstracts methods: a mixed-methods approach was adopted. this consisted of a document review comparing learning outcomes to ebm competencies; semi-structured interviews with tutors; and a survey of the students. ethics approval was obtained. results and discussion: the module content addressed 4 of the 5 main ebm competencies, although learning outcomes were poorly defined. most students had a positive attitude towards ebm and the module, however some felt they needed more support from tutors. interviews highlighted the need for more advanced technologies to support learning, to respond to questions and address difficult concepts in real time. the importance of ebm teaching to specialists in training was also emphasised. conclusion/take-home message: results show that the content of the ebm module is adequate in addressing 4 of the 5 main ebm competencies. there is a need to incorporate modern technologies like social media, screencasts, blogs and more interactive sessions to create a more authentic learning environment. similar modules are needed for other specialists in training. ‘teaching teamwork’ alan barnard background/context: the teachers of palliative medicine at the university of cape town (uct) work in a team of 3 palliative care trained professionals: a nurse, a doctor and a social worker. an element of the teaching is the importance of interdisciplinary teamwork. this is both taught in a didactic session (small-group lecture and a subsequent tutorial). the teamwork is also modelled by the teachers in the classroom and at the bedside (with clinical ward staff ) during the clinical pharmacology ward round. the teachers and the students have never had the opportunity formally to comment on this aspect of the teaching, and this evaluative research is an attempt to address this gap. purpose: to understand the experience of the teachers and students in the fourth-year palliative medicine programme at uct in respect of the interdisciplinary team approach to palliative medicine, so as to improve teaching and learning in this important field. results: a qualitative analysis of interviews with the teachers in this programme and the reflective commentaries of the students will be presented to illustrate the experience of teamwork teaching and learning in this programme. impact: the results are expected to be valuable to all health professional educators who are concerned about team functioning in the graduates of their programmes, and the functioning of teaching teams within the programmes. a ‘toolkit’ for the promotion of undergraduate research: when students talk to students g i van schalkwyk, h botha, j bezuidenhout, j blitz, s c de vries background/context: conducting research as an undergraduate medical student has been shown to encourage later research interest among these students, and to also develop their critical reasoning and information literacy skills. at our institution, despite there being opportunities within the curriculum for medical students to complete research projects, few avail themselves of the opportunity to carry the process through from obtaining ethical clearance to eventually disseminating results via presentation or publication. aim/purpose: led by 2 final-year medical students who had completed a number of research projects as part of their studies, we sought to develop an instrument that would encourage and guide undergraduate health sciences students in conducting research. our ultimate aim is to increase undergraduate research output at stellenbosch university’s faculty of health sciences. methods: the process of developing the artefact which has become known as the ̔ toolkit’ was initiated by the 2 students who are also the primary authors. drawing on their experiences, which included first author publications, they sought to specifically address those aspects of the research process that they had found to be challenging or of value. a number of experienced researchers acted as supervisors on the project. results and discussion: the toolkit, which is presented in a student-friendly format, comprises 3 documents. the first offers general guidelines on planning, designing and implementing a research project. this is followed by a discussion of quantitative and qualitative research methodologies respectively. in each case the importance of sharing one’s findings with peers is encouraged. twenty students attended a saturday seminar during which the toolkit was explained and distributed – a marked increase in the number of students expressing interest in undergraduate research over previous years. conclusion/take-home message: encouraging research at undergraduate level has the potential to enhance the student’s learning experience. facilitating such participation with innovative, student-driven interventions provides an important catalyst. perceptions among university of johannesburg emergency medical care students towards mandatory physical training andrew makkink, phoenix bean background/context: physical fitness plays an integral part in the performance of emergency service duties by both male and female emergency service personnel. the duties of emergency service personnel often comprise heavy aerobic content and muscular strength components that are best performed by practitioners who are in good physical condition. the university of johannesburg’s department of emergency medical care acknowledges the need for improved physical condition among emergency service personnel, and has addressed this need by implementing 59 july 2012, vol. 4, no. 1 ajhpe abstracts a mandatory physical training programme for all students enrolled in the bachelor of emergency medical care (bemc) programme. aim/purpose: the aim of this study was to analyse the perceptions of emc students towards the mandatory physical fitness programme and its facilitation on the bachelor of emergency medical care programme. methods: a 26-question survey was conducted and the responses of 66 (63%) participants were quantitatively analysed. results and discussion: the results suggest that the students generally enjoy participating in the training sessions. there is, however, a need for improved structuring and better objective setting, to assist students in reaching expected outcomes of the program. the majority of the students felt that the programme had benefited them physically and had motivated them to improve their own health, physical condition and lifestyle choices. conclusion/take-home message: the mandatory training programme is an essential and indispensable component of the bemc course, that has a significant impact on the students lifestyles, their own health and their physical condition. it should be considered crucial for improving and maintaining adequate physical condition in prospective emergency service personnel of south africa. is drama meaningful in healthcare education? margaret hugo, louise schweickerdt-alker background/context: mb chb iii students choose from a group of at least 10 selective courses which do not teach them about medicine per se. they attend the course throughout the year, and receive a mark at the end as proof that they have learnt something other than just becoming a medical practitioner. at medunsa, drama has been offered since 2009; 20 25 students attend the course annually. the program: learning about oneself, visualisation, the voice, movement, connecting with an audience, writing plays, rehearsing, performing, and working with stage make-up, props, lighting and music. students perform in the children’s wards and in front of their peers. a ῾test’ at the end of the year is written in groups, where they discuss the following: value of the course, development of communication skills and use of the acquired skills with patients. they voice experiences in discussion groups, throughout the year. aim: the ongoing question of the lecturers is: what value can a creative course have in the teaching and learning of medical students? methods: a qualitative analytic method was employed. results: lively discussions mostly result in positive feedback, although negative feedback is appreciated and encouraged. personal issues are faced, growth take place and confidence is gained. the students get to know their own unique abilities, learn to trust themselves and to appreciate their own unique way of communicating. their energy levels increase. they learn sensitivity and trust in teamwork. empathy is enhanced and the holistic concept increased. inner creative abilities are developed which help with effective problem solving. conclusion: creative courses facilitate students to look at and experience themselves, as well as patients and patients’ life worlds differently. personal growth is essential in developing a professional attitude, which in the end prepares them to render effective, comprehensive clinical care. from colour-blind to rainbow-brained: using whole brain learning (wbl) principles in physiotherapy education a human, p h du toit background/context: institutional changes in higher education call for innovative ideas in teaching practices. the scholarship of teaching and learning requires scholarly enquiry into student learning to inform the practice of teaching. learning style flexibility in teaching practice can bridge the gap between the individual learner (and their preferences) and the design and delivery of the facilitation of learning. as a facilitator of learning (fol) i wanted to engage in critical discourse regarding my teaching practices by implementing innovative ideas in my class room based on the principles of wbl. aim/purpose: this study aimed to determine the effect of facilitating whole brain learning (wbl) on the teaching practice of the fol in the department of physiotherapy, medunsa. methods: a participatory action research method was applied in an attempt to transform facilitation of learning in the second-year module on paediatrics/child health. triangulation of qualitative and quantitative data collected from questionnaires, peer-review, and reflections were performed. results and discussion: despite differences in learning style preference between the fol and the second-year physiotherapy students, i was able to accommodate and challenge my learners on various levels. my professional development in my teaching practice within the context of the 7 roles of the educator as observed and experienced by my second-year physiotherapy students is explained. evidence is presented that wbl principles assist in improving facilitation of learning on multiple levels and seems to increase the students’ satisfaction and creates an environment conducive to learning. conclusion/take-home message: as fol we must be flexible in our teaching and learning styles in order to accommodate and challenge all students in class so that they can maximise their human potential. this participatory research project formed a foundation for further research and reflective practice in our department and institution. perceptions of preceptors regarding expected competencies of final-year midwifery students of mulago school of nursing and midwifery, uganda margaret milly kabanga, fikile mtshali, sarah kiguli background/context: midwifery training at mulago school of nursing and midwifery (mtsnm) was traditional, teacher centred until curriculum was changed and implemented competence-based training (cbt) model. however, there are complaints by qualified midwives (preceptors) who 60 july 2012, vol. 4, no. 1 ajhpe abstracts supervise and mentor students during clinical placement, regarding expected competencies of final-year midwifery students. aim/purpose: this study was designed to explore and document perceptions of preceptors regarding expected competencies of final-year midwifery students of mtsnm. the study findings would provide a basis for quality improvement in midwifery training in uganda. methods: a cross-sectional descriptive study was conducted at mulago hospital, a clinical placement site for midwifery students. qualitative data collection methods were employed. seven focus-group discussions (fgds) were conducted with 33 preceptors, purposively selected from clinical placement areas including labour wards, postnatal clinics and family planning clinics. an interview guide was used to conduct fgds. two investigators worked independently to review and analyse transcripts for contents and emerging themes. results and discussion: students are expected to have knowledge in family planning methods, and antenatal, delivery and postnatal care. desired skills include examination of patients during antenatal, delivery/postnatal period, communication/interpersonal skills, decision-making, management of procedural skills including delivering babies, inserting contraceptive devices and intravenous lines. students are expected to portray attitudes such as professionalism and ethical practice. gaps identified were mainly professionalism, communication and interpersonal skills. causes of competencies included inadequate mentorship and supervision of students by preceptors. conclusion/take-home message: preceptors of midwifery students should be empowered with cbt knowledge to enable them to effectively provide mentorship and support to midwifery students of mtnsm. implementation of osces in assessment of postgraduate students in the department of obstetrics and gynaecology, makerere university college of health sciences mike n kagawa, john tumbo, elsie kiguli, sarah kiguli background/context: the department of obstetrics and gynaecology (o&g) has been in existence for over 30 years and offers a 3-year fulltime course leading to the award of a master of medicine (o&g) of makerere university. several methods have been used to assess clinical skills of postgraduate students. in an effort to improve assessment, osces were introduced about 5 years ago. aim/purpose: to evaluate the implementation of osces from 2008 to 2011. methods: through a descriptive cross-sectional study, observation of the osce process, key informant interviews with the head of department (hod) and course coordinators, desk review of external examiners’ comments and a retrospective evaluation of students’ osce scores, was performed. results and discussion: osce formulation was done by a committee of the hod, course coordinators and senior faculty. there were 5 7 osce stations of 15 minutes each. there was, however, no osce blue-print and the examiners were not trained. the venue was spacious but with little auditory/visual privacy. real patients and models, as opposed to simulated patients, were used. most students scored above the university pass mark of 60%. the average score of the students ranged from 48.6±9.5 to 84.8±6.5 for year 2, and 54±7.6 to 84.0±7.6 for year 3. there was no feedback given to the students. conclusion/take-home message: the osces were generally well conducted with adequate preparation and good students’ performance according to the pass mark. there is need to develop an osce blue-print and train examiners, organise feedback to students and improve on privacy between the candidates. ‘we are becoming doctors!’: the social context of problembased learning for developing professional identity dianne manning background/context: the concept of a community of practice as a social learning environment offers a useful framework with which to interrogate student engagement with the intended learning. the medical programme of the university of the witwatersrand uses problem-based learning (pbl) as a vehicle for integrating knowledge and introducing an approach to clinical reasoning. interaction with the small-group facilitator and meaningful participation in pbl tutorials thus provides students with access to discipline-based discourse and opportunities for developing professional identities. aim: to understand the role of the pbl facilitator as an agent and role model in students’ construction of meaning and development of professional insights. methods: a mixed-methods cohort study design was used. fourthyear medical students were invited to complete an anonymous selfadministered questionnaire and to participate in semistructured focusgroup discussions. questionnaire data, consisting of responses to 7-point likert scale items, were analysed using descriptive statistics. focus-group discussions were audio-recorded, transcribed and analysed qualitatively for emergent themes. data from the questionnaires and interviews were triangulated. results and discussion: the results clearly indicated the importance of the specific social context of the pbl group interaction for effective engagement with the medical discourse. the role of the facilitator was identified as the most important factor for guiding students in developing professional ways of thinking. the pbl tutorial thus provides a valuable opportunity for students to start creating professional identities as medical practitioners and developing personal trajectories into the practice. take-home message: pbl facilitators in a medical programme need not be subject experts in the tutorial content, but should preferably be medically qualified. where human resources are limited, facilitators from different backgrounds should be assisted in developing ways of thinking which are appropriately aligned with the clinical reasoning process. 61 july 2012, vol. 4, no. 1 ajhpe abstracts understanding the role of a supervisor during the integrated primary care (ipc) rotation for final-year medical students p n mnqapu, l du toit, n sondzaba, i couper background/context: as part of medical training, final-year medical students complete a 6-week integrated primary care (ipc) rotation in urban or rural sites. the purpose of the ipc rotation is to familiarise medical students with primary healthcare and to develop and enhance students’ clinical skills. during the rotation students are allocated to a local supervisor at the site. aim/purpose: the aim was to understand the role of the supervisor from both the supervisors and the students’ perspectives, and to assess how supervisors see their role in terms of their responsibilities to students, comparing these with student expectations. methods: data used was obtained from ipc rotation student post-placement questionnaires in 2011 and from 2011 supervisors questionnaire. the aim of the supervisors’ questionnaire was to establish their understanding of their role. data from both were entered in excel and analysed for common themes. results and discussion: the study has identified common characteristics of what the student and supervisor perceive the role of the supervisor to be, such as being a role model and truly being willing to teach. dedication to patient care and a good work ethic were furthermore identified as key characteristics. both identified common traits of mentors, and classified a mentor and a role model as the same thing. conclusion/take-home message: the results showed that there is an overlap in understanding what the role of the supervisor is among both students and supervisors. assessment of rational prescribing skills in the written exitexamination at the medical school of the university of the witwatersrand. assessment of rational prescribing skills in the written exitexamination at the medical school of the university of the witwatersrand shirra moch, devika naidoo, lionel green-thompson background/context: prescribing medicines is the primary intervention that doctors offer to influence their patients’ health; however concerns have been expressed about the extent to which graduates are prepared by medical schools to assume prescribing responsibility. aim/purpose: to analyse the exit-level written assessment component of final-year students in the graduate entry medical programme (gemp) at the university of the witwatersrand, johannesburg with respect to fitnessfor-purpose (validity) to test rational prescribing skills. methods: permission to conduct the study was obtained from the human ethics research committee (medical) of the university of the witwatersrand, clearance number m080949. examination questions were selected via an adjudicative process to determine a prescribing mark. question items were then analysed according to bloom’s revised and the solo taxonomies. the theoretical framework of constructive alignment was used to interrogate fitness-for-purpose and the knowledge structures of the skills were explored using a bernsteinian lens. results and discussion: a comparison of ῾a-type’ (single best answer) multiple choice questions (mcqs) with ῾r-type’ (extended matching) mcqs paradoxically highlighted students’ greater proficiency in the r-type questions (p<0.0001). both bloom’s and solo taxonomies indicated that students scored well on questions which tested recall and application of knowledge, but struggled with questions involving evaluation. questions were poorly distributed according to harries’ delineation of prescribing skills to be tested. examination marks showed that 83.6% of students were competent to prescribe according to the graduating standards of the university. conclusion/take-home message: despite high examination scores, this study illustrates a lack of constructive alignment between assessment requirements, curriculum delivery and course objectives. curricular components including problem-based learning and horizontal integration constrained epistemic access to the structure of rational prescribing knowledge and the exit-level written assessment does not sufficiently test rational prescribing skills. peer-tutoring in a language code-switching lecture as strategy for educators in multilingual classes sandra du plessis background/context: educators have the responsibility to prepare students for the future, and to be successful in their task with multilingual students, they have to incorporate certain teaching approaches and strategies, as well as modifications, in their presentations. one of the challenges is to use language creatively in the multilingual classroom, and language codeswitching (the switching from one language to another) may be one method of experimenting with language. educators who cannot language codeswitch themselves, may employ peer-tutoring. peer-tutoring is a promising strategy in multilingual classes in higher education, by which individualised help may be provided to students in a large groups. through peer-tutoring the home language (l1) of the students may be a resource in an english-only environment where educators are not proficient in the students’ l1. aim/purpose: the aim was to evaluate the effectiveness of peer-tutoring as teaching strategy during language code-switching in a multilingual firstyear classroom. methods: a descriptive design within the quantitative framework was selected. a questionnaire was designed as data collection instrument and was completed by first-year students after peer-tutoring in a language codeswitching lecture. results and discussion: in the results the linguistic profile of the students is presented to illustrate the complexity of the situation. in addition an evaluation of the peer-tutoring strategy reveals that the majority of the students experienced peer-tutoring positively and provides some directions for future implementation. other linguistic support needs are also identified by the students. 62 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion/take-home message: by reinforcing students’ conceptual base in their l1, a foundation may be provided for long-term growth in english skills. language code-switching is currently recognised as a teaching strategy in multilingual classrooms. it is suggested that l1 can support especially first-year students in higher education to understand curriculum content and new concepts. the autopsy as a teaching tool in forensic medicine for undergraduate students: a university of pretoria experience l du toit-prinsloo, v tredoux, g saayman background/context: the use of the autopsy in teaching medical students has strong historical precedent. as large numbers of unnatural deaths in south africa require medico-legal investigation by medical practitioners, it is important that undergraduate medical students receive some training and exposure to the field of forensic medicine. the scope and nature of such training remains a topic of uncertainty and discussion, while the possible vicarious effects of – and the attitude of students to – this activity requires careful consideration. aim/purpose: to assess the attitudes of senior medical students towards the autopsy as a training tool in the medical curriculum at the school of medicine, university of pretoria. methods: mb chb v students attend daily forensic autopsy at the pretoria medico-legal laboratory, for a continuous period of 2 weeks. students were requested to comment on their experience, voluntarily and anonymously, regarding the general impression and rating of the rotation and to comment on strengths, weaknesses, opportunities and threats which may have been experienced. results and discussion: of the approximately 220 students who were enrolled in mb chb v. 95% of students provided feedback. the overall experience appears to have been a very positive one, with an 8.2/10 overall rating for the block. however, 64 students indicated that they felt psychologically unprepared for the block and that they experienced it as emotionally traumatising, with some students stating that they experienced nightmares due to the exposure. conclusion/take-home message: exposure of students to forensic autopsies may be a valuable training modality, but more research is needed as to the possible vicarious effects and the emotional support which students may require, before and after such exposure. early exposure to physiology: challenges faced by health science students and their teachers susan b higgins-opitz, mark a tufts, lihle qulu, sabiha essack background/context: health science students at the university of kwazulunatal perform better in their professional as compared with their physiology modules. pass rates of physiology modules, particularly in the first-year basic physiology module taught in the first semester when students are still adapting to university, have steadily declined. our data has also shown a strong correlation between these students’ performance in their first class test and their final performance. aim/purpose: to devise a strategy identify struggling students early i.e. before they write the first class test, so that appropriate interventions can be made to prevent them failing the module. methods: using a short questionnaire, students’ attendance of tutorials, financing of their studies, and their perceived relevance of physiology to their future professions were probed. following the first class test, failing students were invited to complete a second questionnaire in which attendance of teaching sessions, perceived reasons for their poor performance, and their plans for improvement in subsequent evaluations were explored. student results and demographics were obtained from the module records. results and discussion: one hundred and eighty students completed the first questionnaire, which represented 83% of the class. 73% of the respondents were first-year students and therefore had not been risk assessed, while 44% (n=77) of students failed test 1, which mirrored the failure rate of the entire class (46%). the questionnaire results indicated that most students were positive about physiology and recognised its relevance. almost 50% (36/77) of failing students completed the second questionnaire, 28 of whom were first-time students. analysis of their responses revealed that the majority of students (>60%) who eventually passed the module (n=8), had plans that specifically addressed their problems. conclusion/take-home message: based on these findings, we have embarked on a more interactive strategy centred on e-learning and earlier monitoring of struggling students. primum non nocere: the preparation of university of the witwatersrand medical students in pharmacology – a student perspective p keene, s moch, d manning background/context: medical education literature reflects a global concern about the pharmacology education of medical students and its ability to produce junior doctors who have the knowledge and skills to prescribe drugs safely and appropriately. formal pharmacology teaching in the university of the witwatersrand mb bch degree takes place in the 3rd and 4th years, consisting primarily of lectures within a systembased, integrated curriculum. a pbl case each week contextualises appropriate pharmacological management. assessment is integrated and no subminimum is required. aim/purpose: to determine: (i) whether senior students are confident in their pharmacology knowledge acquired in the formal phase; (ii) attitudes to learning pharmacology and the factors contributing to this. methods: this study was conducted by 5th-year mb bch students in the compulsory research component of the curriculum. an anonymous questionnaire was administered to 5thand 6th-year students, consisting of 29 fixed-response items, (28 graded by a 5-point likert scale), and 5 63 july 2012, vol. 4, no. 1 ajhpe abstracts open-ended questions. results were respectively analysed in excel and thematically. results and discussion: while satisfied with the quality of the course as delivered, they indicated that their knowledge was insufficient both for the senior years of their course and for practice once qualified. the lack of a subminimum and consequent strategic failure to learn the subject contributed strongly to this. the lack of alignment of the curriculum to clinical experience and insufficient contextual learning were also problematic. conclusion/take-home message: assessment drives learning – this course needs to be assessed more extensively and requires a subminimum in order to ensure that students gain sufficient knowledge. enhancement of registrar competence through professional development in completing a module in healthcare practice j bezuidenhout, m m nel, g j van zyl background/context: a need for professional development in the training of registrars was identified by the school of medicine, university of the free state, in 2007. registrars have not always been trained in aspects outside their specific clinical disciplines as required for professionals. aim/purpose: this part of the research focused on responses from registrars regarding the orientation session, content and applicability of the module in healthcare practice (gpv703). module development was specifically aimed with a view to offer each registrar the scope to address the unique needs in as far as ethics, practice management and patient communication are concerned. methods: the study was a quantitative study enhanced by qualitative methodologies. a self-administered questionnaire was completed by registrars evaluating the presentations made. the questionnaire included a rating scale and open-ended questions. results and discussion: a total of 40 registrars completed the newly introduced module gpv703 from 2009 to 2010 and participated in the study. informed consent was obtained before completion of the selfadministered questionnaire. thirty-eight (95%) of the 40 registrars completed the questionnaire. registrars showed a total satisfactory and very good combination mean percentage of 91% for the questions related to the orientation session, content and applicability of the content of the module. thirty-one (77.5%) of the 40 questionnaires collected, were completed by hods on the insight of registrars in gpv and it was found that registrars showed significant improvement in content and applicability. registrars found the lectures on ethics to be most valuable as an important aspect in the treatment and management of patients. conclusion/take-home message: value was added and aspects required by registrars to develop and/or enhance their skills, knowledge and professional behaviour with regard to ethics, practice management and patient communication were addressed. strive towards excellence in medical education. health professions education (hpe): faculty needs assessment at the university of zimbabwe, college of health sciences m m chidzonga background/context: faculty development has assumed great significance in meeting the diverse roles and responsibilities of health professions educator. hpe training facilities are desirable. purpose: no facility designed to train/guide hpe issues exists at uzchs. this study was designed to assess the faculty hpe needs so as to guide the establishment of a facility that offers relevant services. methods: a cross sectional survey using a self-administered questionnaire was used: socio-demographics, teaching experience, academic grade, education/experience/training in hpe issues, willingness to participate in and time to be allocated to hpe activities and the format they should take, the use and role of technology were assessed. perceived knowledge/ importance of hpe issues was assessed using a 7-point likert scale. results/discussion: the departmental response rate was 96% (22/23); overall response rate was 37% (74/201); 54% of the respondents were male, 34% in the age group 36 50 years; 54% were in the lecturer grade with less than 10 years teaching experience , relatively young and inexperienced. this should make training more acceptable and more useful before they are entrenched in their own ways. curriculum development and finding relevant tools and aids were identified as important and faculty had least knowledge; regular seminars and online courses were the preferred formats for educational activities. power point presentations, 96% (71/74), most commonly used and the least used was web-based courses (10%) (7/74); 99% (73/74) indicated willingness to participate in hpe activities; 36% (27/74) preferred 2 hours per week; 58% (43/74) suggested the activities be compulsory. conclusion: the junior/young faculty with limited knowledge of hpe issues is appreciative of their importance willingness to train. the proposed hpe unit will be driven by the identified faculty needs. perspectives of south african general surgeons regarding their postgraduate training m m de beer, h pienaar background/context: one of the most critical stages in the professional life of new surgeons is residency training, and the objective of a surgical residency programme is to ensure that newly trained surgeons are competent to deliver the relevant skilled services to their patients. because of the fact that the curriculum has not been revised for a number of years, the need arises to consider adapting the curriculum to changing needs and circumstances. aim/purpose: the aim of the study is to determine communal strong and weak points in the training of general surgeons in south africa, as well as to provide guidelines for the possible improvement of the current system. methods: the population group comprised of all qualified general surgeons in the country. data collection was done by means of a questionnaire sent to 64 july 2012, vol. 4, no. 1 ajhpe abstracts the population group via e-mail. the number of responses was statistically adequate, and analysis of the data was done to extract the main themes. results and discussion: the 4 main areas of questioning in the survey were: theoretical knowledge, research training, operative technique training, and practice-related needs. the discussion will cover all the main categories, and elaborate on each of them in detail. conclusion/take-home message: a discrepancy exists in the need of practising general surgeons in south-africa, and the training that is being provided. by examining the shortcomings, as well as the strong points of the current training programme, a more applicable curriculum can be established in the future. improving facilitation of problem-based learning through monitoring, feedback and professional development m alperstein background/context: a primary healthcare-led curriculum, with problembased learning (pbl) as a philosophy and teaching methodology, was implemented in the university of cape town's mb chb programme in 2002. a small core of pbl facilitators has remained constant, but there has been a rapid turnover of many facilitators annually. quality of facilitation across pbl groups has been highlighted in the literature. a pbl monitoring project arose from concerns of course convenors regarding quality of pbl facilitation. for the education development unit (edu), it was to ascertain the aspects of training that needed more attention to promote improved quality of facilitation in pbl. aim/purpose: this evaluative paper aims to demonstrate shifts in facilitation following monitoring, feedback and further professional development. methods: the edu facilitated the development of a monitoring tool and coordinated a standardised monitoring project in 2009 and 2011 across the first 3 years of the programme. in 2009 and 2011, 4 experienced facilitators were recruited and trained to use the monitoring tool developed in 2009. data were collected by the 4 facilitators by observing 32 out of 60 pbl facilitators in 2009, and 25 facilitators in 2011. observations were recorded on the monitoring tool. quantitative and qualitative data were captured electronically and analysed for results. results and discussion: aspects identified as needing improvement in 2009 were focused on in pbl training in 2010. all facilitators monitored were given individual feedback on their strengths and areas needing improvement. the 2011 results showed improvement in all aspects monitored. some aspects, while showing improvement since 2009, still need further development. these findings will be reported on in the presentation conclusion/take-home message: the quality of pbl facilitation could be improved by means of individual monitoring and ongoing professional development. initial outcomes of the dundee ready educational environment measure (dreem) among final-year clinical associate students at the university of the witwatersrand lilo du toit, abigail dreyer, mpumi mnqapu, ian couper, audrey gibbs background/context: the bachelor of clinical medical practice (bcmp) is a 3-year degree programme leading to qualification as a clinical associate. the aim is to produce a mid-level healthcare worker that will work under supervision of the doctor in the team of clinicians in district hospitals. most of the training takes place in district hospital sites. the ongoing development of the curriculum and of training sites is key in the implementation of the programme. continuous monitoring and evaluation is necessary to improve quality. aim/purpose: to assess the perception of the educational programme and training environment among the first cohort of clinical associate students, during their final year at the university of the witwatersrand (2011). methods: the dundee ready educational environment measure (dreem) is a standardised tool used to evaluate students’ perceptions of their educational environment. dreem questionnaires were completed by 22 of the 25 final-year clinical associate students during 2011. this data was analysed using excel to explore initial trends in perceptions. results and discussion: the dreem is a useful tool for evaluating the perceptions of health professional students. results from the first round of data collection explore issues for the implementation of clinical associate training in different educational environments. collecting such data longitudinally would be invaluable in improving the educational environment, and therefore the learning of clinical associate students. conclusion/take-home message: a number of interesting issues emerge for consideration at management level. it is envisioned that the dreem questionnaire will be used for at least 3 years to track and monitor perceptions among students of the learning environment for the bcmp degree. reflecting on the quality of teaching and learning in the internal medicine module j m m koning background/context: obtaining student feedback is one of the ways in which the quality of a module can be measured. alternatives to the current module evaluation form of the fifth-year internal medicine module are being explored. aim/purpose: (i) to evaluate the quality of teaching and learning that takes place in the fifth-year internal medicine module using a modified student course experience questionnaire (sceq); (ii) to critically reflect on the findings in this pilot study and use them to implement changes. methods: an action research strategy was used in this study. the sceq, which was developed by oxford university, was modified by dr saretha brussouw for use at the ufs. this 32-question questionnaire was filled out 65 july 2012, vol. 4, no. 1 ajhpe abstracts by the fifth-year students at the end of their rotation at internal medicine. the data from 7 different scales was analysed. results and discussion: 112 students completed the questionnaire (40 english and 71 afrikaans). the scores for the satisfaction, generic skills and motivation scales were high. 70% of the students reported that they were satisfied, but there was a significant difference between the afrikaans and the english students. the teaching and appropriate workload scales had the lowest scores. almost 20% of the students thought the outcomes were not clear. a large number said that they did not know what was expected from them. 40% said that the workload was inappropriate. significant differences were found between the 2 language groups in the scales measuring generic skills, motivation and satisfaction. conclusion/take-home message: the modified sceq is a helpful tool to assess quality of teaching and learning. however, due to the lack of space for explanatory free text, the reasons for negative findings and differences between language groups could not be elucidated. a document which clearly states the expectations was included in the 2012 module guide. a programme is underway to ensure that the outcomes are better described. nurses’ experience of the transition from student to professional practitioner in a public hospital in lesotho a m makhakhe, m williams, e bornman background/context: newly qualified professional nurses in lesotho experience a non-caring environment, marginalisation, negative attitude and lack of support, resulting in questioning their choice of profession. aim/purpose: the aim of this study was to identify the experiences of newly qualified nurses and to develop guidelines to support them in their transition from student to professional practitioners. methods: an explorative, descriptive, contextual, qualitative research design was chosen. the sample consisted of newly qualified professional nurses who worked in a public hospital in lesotho for a period of one year or less at the time of the study. data collection took place by means of semistructured individual interviews with 10 newly qualified professional nurses and a focus-group interview with 8 newly qualified professional nurses. results and discussion: content analysis of the data in the qualitative tradition was independently done by 2 coders who identified 4 themes and 10 sub-themes. the identified themes included culture shock, competence, vision for the future, competence and support from management with subthemes of emotional reactions, limited resources, knowledge, attitudes and skills. these newly qualified professional nurses felt they were sufficiently prepared with knowledge and skills, but a restrictive clinical environment resulted in feelings of despondency, an attitude of blaming and not applying their capabilities. they viewed themselves as change agents for the future though. guidelines to ease the transition from student nurse to professional practitioner were developed to address professional expectations and to enhance collaboration between the training institutions, the hospital, the ministry of health and social welfare and the newly qualified nurses. conclusion/take-home message: clear guidelines and orientation programmes are needed with specific attention to welcoming, addressing expectations, code of conduct, monitoring and mentoring to ease the transition period from student to professional practice in future. service learning in pharmacy: instilling professionalism through sequential institutionalisation of an undergraduate service-learning programme m b akleker, a bheekie, n butler background/context: at uwc school of pharmacy, service learning in pharmacy (slip) was introduced as a pharmacotherapy initiative (2002) directed to final-year pharmacy students. slip had a strong service bias and competency component, training students for the roles they would fulfil as pharmacy interns. an independent evaluation of slip found that while the course enabled students to be technically competent and prepared for internship, values-based professionalism was lacking. aim: to produce pharmacy graduates who are technically competent and socially able. course expansion to the third and second years was aimed at exploring critical issues that underpin values-based professional practice; including social injustice, cultural competency and poverty. methods: slip 4, targeted toward final-year students, boasts technical competency as a core focus area. a series of 3 rotational blocks (1 week each) allows service activities. slip 3, directed to third-year students, entails students examining issues around social injustice and cultural barriers in the context of medicine use. the course comprises a single exposure to a phc clinic and informal settlement. students are assessed by way of a group project to fulfil a community need. slip 2, directed to second-year students, focuses on developing professional communication skills. results and discussion: the outcomes from slip 3 service projects include various community-targeted endeavours, such as drug awareness campaigns at schools, sustainable feeding schemes by way of community driven vegetable gardens, and educational initiatives such as the establishment of learning centres in informal settlements. students report that these exposures are ῾eye-opening,’ and that the experience would mould their future professional practice. early exposure to professional interface (slip 2) supports the development of inter-professional communication skills. conclusion: learning opportunities that nurture technical and social and cultural competencies are more likely to produce graduates capable of addressing social injustices. community service learning for mb chb students, medunsa debbie barnard background/context: mb chb i iv students learn about interacting with the community, identifying health needs and reacting to it, learning at the same time from that interaction, while simultaneously rendering a service to the community. successful training takes collaboration and the community 66 july 2012, vol. 4, no. 1 ajhpe abstracts is a highly effective collaborative partner in the training and education of medunsa’s medical students. method: by taking the mb chb i iv students to the clinics and into the community for facilitated interaction with the community itself, new knowledge/meaning surfaces with each contact period, which enriches the overall learning experience of the students. results: this results in learning about the community and its needs while simultaneously rendering a service to the community. conclusion: service to the public/community is the core of the medical profession. medical students at the university of limpopo, medunsa are trained to be committed to rendering humanistic care, improving the health of the community and serving the public (aamc, 1998). they are taught to have insight into the needs of the community beyond the individual patient in order to serve the community needs, and to address community concerns and involve community partners in addressing these needs. healthcare is approached as a partnership with the client, where the patients are involved in their own wellness and healing process. take-home message: medical students should receive learning experiences outside of the classroom, clinic room and hospital room, in order to become integral parts of the communities in which they will practise medicine. how does the community benefit from community-based education? p diab, p flack background/context: community-based education (cbe) has become a primary teaching and learning platform in all health sciences globally. there is a significant body of literature that explores the pedagogy and in particular the benefits of cbe to students. however there is little evidence in the literature from the perspective of the other role players in cbe, particularly the community partners. aim/purpose: the aim of the study was to explore how community-based education is perceived by the various stakeholders, in the provinces of limpopo, kwazulu-natal and western cape. this paper reports on the benefit to the community and what challenges need to be addressed in order for this to be an effective partnership. methods: data was collected at multiple established training sites, through focus-group interviews with participants identified through purposeful sampling. an open–ended interview guide was used and interviews were conducted in the vernacular, audio-taped, transcribed verbatim and then where necessary translated into english. data analysis was aided with the use of nvivo. ethical clearance was obtained from the participating universities’ ethical boards as well as the provincial departments of health and participating healthcare institutions. results and discussion: benefits ranged from reducing work load in the healthcare facilities, promoting more holistic patient care and clinicianpatient interactions to the reciprocal nature of such learning where students could enhance the knowledge of local practitioners as well as gain practical training during their interactions. the tension between service delivery and teaching is an aspect that needed to be addressed in order to balance the needs of the patients, the students and the supervisors. conclusion/take-home message: in order for cbe to be beneficial to the community partner, the programme needs to be well structured, the students and community well prepared and student activities more aligned to community needs. recommendations from this research will be valuable in evaluating existing cbe programmes. integration of service learning (sl) into the 2nd-year bsc physiotherapy paediatric and child health module a human background/context: service learning (sl) links the classroom curriculum (theory) with a community need and then collaborate with community members in improving service delivery (lorenzo et al., 2006). medunsa’s community engagement and sl initiatives include missionary of charity (moc) in klipgat, a children’s home close to the medunsa campus, run by the sisters of mother teresa (roman catholic church). this home serves klipgat and the surrounding communities by caring for mainly children with physical disabilities and mental disorders, aids orphans, and abandoned children. aim/purpose: the aim of the study was to determine the effect of sl as an integral part of the 2nd-year bsc physiotherapy paediatric curriculum. physiotherapy students can be given the opportunity to apply theory in a practical setting (experiential learning) and gain a deeper understanding through reflection. methods: an action research approach has been applied in order to guide the curriculum and assessment of the bsc second-year physiotherapy students. a structured sl initiative was implemented, with the outcomes of some of the paediatrics modules aligned with the services delivered to moc. as part of the experiential learning students were divided into groups and had to implement certain physiotherapeutic assessment and treatment principles, write it in the form of a case study, and do a reflection on their active learning experience. results and discussion: students were introduced to the principles of experiential and active learning as well as reflective practice. reflections of students indicated that this real-life challenge was an overall positive experience despite their initial fear and uncertainty. conclusion/take-home message: implementing and integrating sl at the second-year level seem to have a positive impact on student learning and assists in establishing community service delivery. integration of sl at junior levels can assist in developing graduates that can become facilitators of change within their communities. 67 july 2012, vol. 4, no. 1 ajhpe abstracts the utilisation of video as primary content delivery medium for staff development of health professions educators nico baird, marietjie m nel and sonet b kruger background/context: we are living in a digital age, and even today with so many tasks being performed by computers, people are still the driving force in every organisation. staff development can be seen as a continuous process. the development can begin at anytime but if successful will end at retirement or beyond. it encompasses the process in which staff engages to prepare themselves, continuously update themselves, and the constant revision and reflection of their own performance in their daily endeavours. aim/purpose: the study forms part of a master’s degree in the health professions education programme with the view to determine the value of the use of online video as primary medium for content delivery for staff development of health professions educators. methods: a quantitative study was done with minimal qualitative feedback included in the questionnaire. a course was created with 3 sections. content was delivered to the participants. after the completion of the course sections, the health professions educators complete a short survey, which consisted of multiple choice questions and minimal open-ended questions. results and discussion: findings indicated the value of online video as primary content delivery medium and will be made available as part of the presentation. conclusion/take-home message: staff development opportunities can be improved and expanded through an innovative educational approach. the impact of podcasting on students and student learning gegory doyle background/context: in south africa the use of technology in teaching and learning does not compare with that in first world countries and new technologies often take longer to implement. the use of podcasting in institutions of higher learning in south africa is minimal. this study took place at the university of cape town (uct) and explores the impact of this technology among medical students. podcasting is a technological intervention where lectures are audio recorded which in turn are downloaded by students via a web interface, often to a mobile device. in general podcasts have been found to be useful to students involved in distance learning. yet there is little evidence on the impact of podcasting at a contact university. aim/purpose: this presentation investigates undergraduate student engagement with podcasts and looks at the issue raised most often by lectures – lecture attendance. the fear is that if lectures are podcasted students would no longer attend lectures. methods: educators involved in teaching second-year medical students agreed to have their lectures recorded over a period of 5 months. students were asked to complete a survey prior to the pilot to determine any preconceived ideas and implicit knowledge they had about podcasting. also they completed a post-survey which focused on how they used the podcasts and how useful they found them. in addition a log file which automatically kept track when a podcast was downloaded was kept. results and discussion: the information provided via the surveys and log file was used to determine how the students viewed, used and interacted with the podcasts. conclusion/take-home message: lecture attendance was not affected. not all students were interested in the podcasts; it does not cater for all learning styles. podcasting made no noticeable difference to class performance, but anecdotal evidence exists that it made a difference to individual students. the usability and benefits of an electronic learning management system in learning clinical skills at medunsa h havenga background/context: blackboard, an electronic learning management system, was introduced in 2011 and became fully operational in 2012. in the skills centre the system is being used as repository for learning material and assessment tools as well as for communication and as tool for monitoring and tracking of student activity on the system. it is essential to be aware of how latest technology can be used to enhance learning and therefore vital to monitor not only the students’ perceptions on the usability of the system and their actual activity profiles but also to determine the value of the system for their learning experiences in clinical skills learning. aim/purpose: to assess the perceived usability, as well as use and benefits, of the electronic learning management system in learning clinical skills. methods: the sample comprises 4th-year medical students (cohort 1) and 3rd-year nursing students (cohort 2). prior to each practise session a pre-test is done on relevant learning material. an online survey will be completed at the end of the block to gather data on the usability of the learning management system (ease of access, communication, suitability and quality of teaching material); the value for learning; the usefulness of the tools; transferability of material to clinical practice (cohort 2 only) and recommendations for using web-based learning tools as learning aids. a descriptive analysis of the outcomes will be done. a logical regression will be performed with student performance (pass or fail) as the dependent variable and with selected relevant questions in the survey as predictor variables. a correlation between students’ performance and their activity profiles and perceptions will be done. results and discussion: results will be discussed at the conference. conclusion/take-home message: conclusions to be discussed at conference. 68 july 2012, vol. 4, no. 1 ajhpe abstracts alternative teaching method for anaesthesiology residency of third-year students c l odendaal, a hugo, b j s diedericks background/context: the department of anaesthesiology investigates alternative teaching methods for a 2-week residency of third-year medical students. aim/purpose: sixteen basic anaesthetic subjects are presented the blackboard e-learning platform. two groups (8 students) rotate alternatively 2-weekly in (i) theatres for practical demonstration of anaesthesia theory and (ii) visimed computer unit for student centred self-study of anaesthetic theory on blackboard. formative and summative assessments (from ~600 subjectspecific multiple choice questions) as well as written peer-evaluation assignments form the computer-based learning. the lecturer follows all computer-based learning closely and assesses peer-evaluations to verify the peer-learning process. all computer-based learning generates marks and form part of a portfolio that further includes a log book with 20 confirmed clinical tasks that must be completed and confirmed by an anaesthetist’s signature and proof of 3 attended anaesthetic cases logged on a theatre chart. methods: an anonymous questionnaire to evaluate the programme is completed by students at the end of residency. continuous analysis of the questionnaire and outcomes of the programme help to plan interventions and strengthen residency programme. results and discussion: results are reported from one group of 105 third-year students that completed the first rotation of the programme. the enthusiasm by which the students approached the programme was significant. problems were minimal; the most important issue was limited time to achieve proper clinical experience. portfolio marks were excellent. conclusion/take-home message: accommodating a 2-week residency needed an alternative approach due to time, staff and theatre space constraints in the department of anaesthesiology. the residency relies on student-centred computer-based learning to master anaesthetic theory and a structured exposure to clinical work. the first results and impressions are positive, indicating that the residency is realistic and effective in achieving outcomes as set in the mb chb programme at the university of the free state. turning an osce into a vosce j lombaard, l de bruyn background/context: the objective structured clinical examination (osce) is a performance-based assessment tool which is used to evaluate the medical students’ clinical competency in taking a history, performing a physical examination and simple procedures. the osce consists of stations through which students rotate and are assessed by lecturers using standardised checklists. it is a widely recognised assessment tool, but does have disadvantages. aim/purpose: the aim of this study is to determine whether a videotaped osce (vosce) can be used as an alternative assessment method and has advantages over a traditional osce. methods: a sample group of 41 pre-clinical students were assessed in this qualitative explanatory study. during their semester 4 osce these students had to perform the procedure of venapuncture. they were evaluated by lecturers using standardised checklists. these students were again evaluated during their semester 5 module osce performing the same procedure. this time however it was a vosce. the students were asked to complete a questionnaire anonymously regarding the vosce station. results and discussion: during the semester 4 osce, 6 different lecturers assessed these students and their average scores for the station fluctuated between 58% and 85%. the average score of the 41 students was 65%. in the vosce the station was assessed by one lecturer who watched all the video recordings. the average score for the station was 70.2%.the majority of afrikaans students preferred the traditional osce station, but the majority of the english group preferred the vosce station. the whole group, however, wanted a cd copy of their assessment for learning purposes. conclusion/take-home message: a vosce has advantages over the traditional osce regarding reliability and saving resources e.g. number of examiners. students’ performance was not influenced negatively by the vosce station. tutoring scientific subject matter in students’ mother tongue a louw, m de villiers, m van heusden background: teaching in a country with different academic languages offered special challenges to institutions that cater for these languages. the languages english and afrikaans are both used as languages of instruction at stellenbosch university. however, at the faculty of health sciences, chemistry for health sciences for entry-level students is only offered in english. this could cause understanding and interpreting problems, because some students studied chemistry only in afrikaans in the preceding years. faculty put an intervention into place where all the afrikaans and other african language speaking students could voluntary attend small tutor groups facilitated by senior students. the primary purpose of the groups was to create a safe space for students to communicate about chemistry in their mother tongue. aim: to determine the impact formally structured chemistry tutor groups in the students’ mother tongue, have on their knowledge, skills and attitude towards the module. methods: a mixed method research approach was used to generate data in an effort to determine the effectiveness of the intervention. focus groups and individual interviews with students and tutors, were used for qualitative data collection. data from a questionnaire as well as summative results were also collected and analysed for triangulation purposes. results and discussion: participating students performed very well. although the objectives of the small group were aimed at translating content of the course into the mother tongue language of the participants, it also offered other benefits. these benefits included the development of essential generic skills e.g. group work, effective communication and peer learning of these students. 69 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion: providing space where students can communicate in their mother tongue about specific subject matters, assist in enhancing learning of that subject, as well as enhancing the development of critical generic skills that students need to function at an optimal level at university. aligning clinical assessment practices with the prosthetic dentistry curriculum r d maart background/context: removable prosthetic dentistry is a fourth-year module of the undergraduate dentistry programme which consists of a large clinical component. clinical tests were introduced and implemented as an additional clinical assessment method. the intention of introducing the clinical tests was an attempt to ensure that students were assessed fairly, that their theoretical knowledge and the ability to apply it clinically were properly assessed, and to provide feedback. aim/purpose: to compare the relationship between the students’ performance in the clinical tests and daily clinical grades with their theoretical performance in this module. the second part of the study explored the academic staff s’ perceptions of the clinical test as clinical assessment tool. methods: this was a case study design with a mixed methods approach. record reviews of the results of students who completed this module in one year were used, and included 110 students. the data analysis was done with the assistance of a statistician. three full-time lecturers within the prosthetic department were interviewed. the analytical abstraction method was used to assist with the qualitative data analysis; first the basic level of analysis was done in the narrative form, followed by second higher level of data analysis. results and discussion: there appeared to be hardly any relationship between the students’ clinical daily grade assessment marks and their theory marks. it appeared that there is a better correlation of the clinical test mark and the theory mark, than clinical daily mark and the theory mark. this finding related well with the lecturers’ views that the clinical tests were more reliable as a clinical assessment tool than the daily clinical mark. conclusion/take-home message: the clinical test as an assessment tool is well accepted by the supervisors and they agreed that it is more reliable and accurate than the clinical daily grade assessment method. learning approaches used by students in the department of emergency medical care at the university of johannesburg colin mosca, andrew makkink, christopher stein background/context: the relevance of identifying different learning approaches used by students lies in how these impact the way that the learner engages with the learning material, and how this in turn impacts the overall learning experience. the main distinction lies in that the surface approach is generally relied upon when the aim of learning is to ῾momentarily’ perform well in assessments as opposed to the deep approach, where the aim of learning lies in the understanding and interpretation of the learning material. understanding the approach used by learners can provide important information on learner adaptation to the learning content and environment, and the learning strategies adopted in each of the specific years of academic study. aim/purpose: the aim of this study was to examine learning approaches used by students in a 4-year professional degree programme in emergency medical care. methods: the research was conducted using the biggs r-spq-2f questionnaire which was voluntarily completed by registered students of bemc degree programme. a likert scale method was used to facilitate the interpretation of the results of the survey. results and discussion: data analysis demonstrated that the majority of students in the bemc programme use a deep approach to learning. of the deep learners, year-one learners were mostly intrinsically motivated to adopt a deep approach, while years 2 to 4 were mostly extrinsically motivated to adopt a deep learning approach. of the learners that scored as having a surface learning approach, none were found to be surface motive learners, meaning that the surface learners were extrinsically motivated to adopt a surface learning approach. conclusion/take-home message: although there is no significant difference between learning approaches between years, further research is needed to determine whether or not approaches change during the course of a student’s studies. does the gender of examiners determine the academic performance of medical students? d j h niehaus, e jordaan, l koen background/context: final-year medical students in the department of psychiatry at the university of stellenbosch perform oral exit examinations. we had previously reported that the gender combination (female-female) of the examiners predicted (p=0.029) poorer student outcomes, but the sample size was insufficient to determine whether specific characteristics of these combinations could account for this finding and we therefore now report on a much larger sample. methods: the class and examination marks (from all disciplines) of 685 final-year medical students (2008 2011) were analysed. odds ratio calculations were done based on thresholds identified by bland-altman statistical analysis. group status was determined by the gender distribution of examiners and the additional variables evaluated included the examiner’ age, first language, experience in examination and area of expertise. results: the majority of examiner pairs was male-female (62.9%), followed by male-male (25.0%) and female-female (12.1%). the mean mark in the psychiatry oral exit examination was 62.3% (sd 9.1) and the overall examination mark was 62.8% (sd 8.8). twelve students failed psychiatry during the period of observation. the examiner’s gender was a predictor (p=0.015) for the psychiatry oral exit examination marks. 70 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion: this study suggests that the choice of examiners in oral exit examinations in psychiatry requires careful consideration in order to ensure a fair assessment of student abilities. developing clinical reasoning: reasons for progression and non-progression t c postma background/context: third-year dental students engage with case-based pre-clinical clinical reasoning training at the school of dentistry, university of pretoria. they are assessed using a standardised case-based progress test, which is repeated in the subsequent clinical study years. action research shows that some students demonstrate progress in clinical reasoning skills over time while others don’t. the reasons for this phenomenon are unknown. aim/purpose: this study explores students’ perspectives on the reasons for progression and non-progression in developing clinical reasoning skills. methods: two focus groups (8 students each), more or less representative in terms of race, and gender were purposively selected. individuals in group 1 achieved at least 9% or more improvement in clinical reasoning scores after one year while individuals in group 2 achieved little or no progression. the dicotomy between the groups was based on improvement in clinical reasoning decisions over time and not on actual academic performance. the the focus groups were voice-recorded, transcribed and qualitatively analysed. the university’s health sciences ethics committee provided ethical clearance. results and discussion: students that had shown progression expressed appreciation for the case-based training. they were focussed on the main outcome of comprehensive patient care and provided constructive criticism to improve the system. students who had not shown progression expressed less appreciation for the case-based training. although they provided constructive criticism, they tended to be self-centred in their discussions, complaining about the feedback and a lack of structure, and displayed selfhandicapping behaviours such as poor time management. some were not aware of available learning opportunities. conclusion/take-home message: the students who had demonstrated progress in clinical reasoning skills seem to be able to reflect and learn independently. those who did not demonstrate progress may need more structure and intensive feedback, as well as formative feedback about behavioural aspects such as time management and professionalism. a board game for medical microbiology and infectious diseases: do academic members of staff think it can work? m c struwig, a a beylefeld, g joubert background/context: innovative teaching and learning strategies have become part of medical training, and educational games are increasingly used to enhance the process of mastering subject content. students in the faculty of health sciences, university of the free state, experience medical microbiology as an exceptional challenge because of unfamiliar terminology and the extensive volume of work. consequently, many students believe that medical microbiology could be a major contributor to failing an academic year. a board game, med micro fun with facts (mmfwf), based on trivial pursuittm principles, was developed to stimulate secondyear medical students’ interest in microbiology, and to expose them to the subject content of an infections module in an informal way involving active group dynamics. aim/purpose: when a novel approach to teaching and learning is considered, evaluation of the instrument or process should not be limited to the students for whom it is intended. therefore, the purpose of this descriptive study was to corroborate students’ positive experiences of the mmfwf game, by having it evaluated by academic members of staff. methods: members of staff participated in direct observation of the play process. the nominal group technique was used to identify their perception of the game as a learning tool. feedback was analysed to investigate the potential viability of the innovation, and comments were interpreted in terms of the criteria of the diffusion of innovation theory. results and discussion: the game itself and the play process generated positive feedback from staff members. measured against the criteria of diffusion of innovation theory, the game meets the requirements for an innovation to be accepted. its relative advantage, observability, compatibility, level of complexity, and trialability has been confirmed by the participants’ feedback. conclusion/take-home message: supplementary to formal lectures, mmfwf has the potential to enhance students’ learning experiences in medical microbiology. how can i help the students visiting my practice to learn more? m van rooyen background/context: each 4th-year medical student from the university of pretoria visit a primary care practitioner (pcp) for 2 weeks. they submit a reflective photo-story report on their experiences and their personal and academic growth after the visit. to identify whether the objectives of the visit have been met and to describe the experiences of students, the reflective reports are qualitatively analysed. a second purpose of the analysis is to propose strategies that can be implemented by the pcps to optimise the learning experience of the students in their practices. aim/purpose: using a qualitative analysis of 4th-year medical students’ photo-story reflections to propose strategies for physicians hosting these students in their practices, to optimise learning opportunities. methods: a qualitative approach to analyse the narratives of the photo-story reports was used. main and sub-themes were identified in terms of the topics reflected upon. quotes from the narratives were selected to support the themes. each quote was scrutinised for evidence of learning taking place. 71 july 2012, vol. 4, no. 1 ajhpe abstracts results and discussion: the main themes were identified as: the impact the visit had on the student, the emotions they experienced, working with the physician, interacting with patients and the clinical care of patients. conditions where learning generally happened were identified as when students felt comfortable, confident or happy and inspired, they actively participated, they were challenged, they could see the advantage of learning and they received feedback. conclusion/take-home message: strategies that practitioners can use to optimise the learning experience of students in their practice are proposed. strategies include active participation, reflection, creating a positive environment, challenging experiences, active learning plans and quality time with patients. the state of educational research at the faculty of health sciences, stellenbosch university juanita bezuidenhout, ben van heerden, marietjie de villiers background/context: since its inception in 2006, the centre for health sciences education (chse) has committed itself to the promotion and support of health sciences education research in the faculty of health sciences (fhs) at stellenbosch university. it played a pivotal role in initiating research, and collaborating with researchers in other disciplines within the faculty, the university, nationally and internationally. therefore in april 2011 a research unit for health sciences education was established within the chse. aim/purpose: to establish a research framework for educational research in the fhs by firstly determining the educational research that is currently performed within the fhs. methods: a document analysis was performed to collect information regarding existing projects. all projects were classified according to programme; research focus; location of research and discipline/division/ departments involved. results and discussion: there are 106 educational research projects, mostly at undergraduate level, of which 50% are in the mb chb programme. more than 50% of projects focus on teaching and learning design or evaluation, while very few focus on assessment. all 5 undergraduate programmes are represented in educational research with only 9 medical disciplines focusing on postgraduate education. although most projects are within the fhs, a number of projects are situated in communities and also national and international collaborations. only 20% of projects are classified as clarification research; the rest as justification or description research. conclusion/take-home message: educational research appears healthy in the fhs, but it is essential to establish macro-projects with comparative, collaborative and/or longitudinal aspects. these would reinforce the results and interdisciplinary cooperation, lead to better use of current capacity and promote trans-professional and interdisciplinary cooperation. research projects which are explanatory in nature must be developed. recommendations are made on how to achieve these aims. from undergraduate research report to publication g joubert, m c struwig background/context: during their second and third years of study in the 5-year undergraduate medical programme at the university of the free state, students plan, perform and report on a research project in small groups of 3 5 students, under the guidance of a clinical study leader. aim/purpose: we report the experiences of the module leader, faculty medical writer, and study leaders in taking undergraduate student research reports to publication. methods: in this descriptive study with both quantitative and qualitative elements, the approximately 300 projects completed in the decade since their introduction were reviewed for suitability for publication. the research reports that have already been submitted for publication were reviewed in terms of publication success and comments received by reviewers. results and discussion: approximately a third of the student projects are considered publishable. the main reason for not pursuing publication in the remainder is small sample sizes or low response rates. forty-three student projects have been submitted for publication and have all been published. the methodology of the student projects is generally sound, as their protocol is evaluated as part of the research methodology module, and is reviewed by the institutional ethics committee. analysis is done or verified by biostatisticians. what is often lacking in the student reports is an understanding of the topic. as a reviewer has stated: ῾the introduction is rather inappropriate and does not give an adequate picture of the topic’. similarly, students often lack insight into the meaning of their results, and struggle to write a thorough discussion. conclusion/take-home message: undergraduate student research reports can be published successfully, if one acknowledges the limited knowledge and insight of pre-clinical students into the specific field. the introduction and discussion sections thus generally need to be rewritten, which circumvents problems regarding inadvertent plagiarism and incorrect referencing. health professions students’ beliefs of and learning strategies for acquiring xhosa philip lewis, m r de villiers background/context: in keeping with evidence that communication in a patient’s mother tongue improves quality of care and patient outcomes, the faculty of health sciences at stellenbosch university (sufhs) has embarked on an extensive initiative to implement xhosa training in the clinical consultation in all 5 of its undergraduate courses. other than anecdotal evidence, it would appear that little is really known about the preconceived ideas students from different language backgrounds have about xhosa language learning and in particular, their (i) beliefs, and (ii) the language learning and communication strategies they employ to master the language. aim and objectives: the objectives of this study are to gain insight into the nature and identity of sufhs students’ language learning beliefs and the 72 july 2012, vol. 4, no. 1 ajhpe abstracts strategies they employ learning xhosa; determine whether students from different language backgrounds reflect similar xhosa language learning beliefs and language learning and communication strategies; and identifying factors that will enhance effective xhosa language teaching and learning. methods: a survey comprising of a 31-likert scale closed answer options followed by open question options was conducted with 48 students from the divisions speech-language and hearing therapy and human nutrition in the faculty. statements used in the survey were divided into the following categories, i.e., aptitude, motivation, the nature of language learning, communication strategies and difficulty of language. results: the study is currently in progress and it is anticipated that the preliminary findings of this ongoing study will be available from april 2012. these results will be reported in this presentation. we plan to use the results to further compare with other undergraduate programmes envisaged to begin learning xhosa from july 2012; as well as findings of a post-course survey which will be conducted in october 2012 to determine whether students leaning strategies and beliefs reflected in the pre-questionnaire remain prevalent. conclusion: we hope that the findings from this study will provide useful insight into students’ xhosa language learning beliefs and trends which will be used to focus, guide and improve xhosa teaching and learning interventions at sufhs. a novel method of data collection alma snyman, francois cilliers background/context: the use of group methods to collect data can pose a number of problems. this is especially true when engaging with a group of participants who work together within a specific department or hierarchy. the lack of anonymity is one of the most inhibiting problems in such situations and one that motivates us to search for new methods of facilitating participation. participlan is a method of facilitation originally used to facilitate meetings, group discussions and workshops in the business world. this method of facilitation uses visual mapping to stimulate group participation and the free flow of ideas in a non-threatening environment. aim/purpose: to introduce the participlan method and share the experience of this novel data collection method with colleagues who want to engage with groups during the data collection process. methods: the experience of the presenter will be used to illustrate the possibilities and results of using this novel method of data collection to engage with a group of health sciences educators. results and discussion: the participlan method was recently used with great effect to create a positive, non-threatening and engaging process of data collection in a research project focused on the assessment of professional behaviour in health sciences education. in addition to the issue of anonymity being addressed, equal participation by all group members were also facilitated and a concise visual record of data was generated during the sessions. conclusion/take-home message: there are existing methods of group facilitation that offer possibilities in terms of reliable data collection for research purposes. it is possible to guarantee anonymity during a participatory group session for data collection. participlan is an example of a novel, valuable method of data collection. acute shortage of faculty at school of medicine of the catholic university of health and allied health sciences, tanzania mange manyama, stephen mshana, steve justus, ralf graves and fikile mtshali background: the number of medical schools and student intake in tanzania has increased 3-fold in the last decade in response to the growing population and health needs. however, there has not been a corresponding increase in the number of faculty, resulting in a critical shortage at these institutions. aim/purpose: this study was conducted to determine the extent and nature of the faculty shortage at the school of medicine, catholic university of health and allied sciences (cuhas). results from this study will aid the school in planning future interventions to address the shortage. methods: a cross-sectional descriptive survey approach was used to gather information from department heads and university records on the number of faculty and students at cuhas. results and discussion: at the time of this study, the school of medicine had a total of 86 faculty and 700 undergraduate students and residents. of the entire faculty, 40 (46.5%) work as full time and 46 (53.5%) as part time. the department of surgery had a higher number of faculty while the psychiatry and ophthalmology departments had the lowest. over 50% of departments had shortages of 30% or more of the required number according to departments requirements/wishes. the extent of the shortage was determined based on department requirements/wishes since there is no existing policy for specifying the faculty required per department. the world federation for medical education (wfme) recommends that the teacherstudent ratio should be relevant to the various curricular components and the appropriate number of faculty should be determined by departments implementing the curriculum. conclusion/take-home message: the shortage of faculty is likely to compromise the quality of teaching and therefore the competence of future health professionals. various interventions are recommended including establishment of a residents-as-teachers programme and faculty development programs to help meet the shortage and groom faculty for leadership roles in finding solutions to improve health professions education in tanzania. the impact of brief quality improvement projects (qips) by medical students claire van deventer, ian couper, nontsikelelo sondzaba background/context: since 2006 final-year medical students do qis as part of their primary care block in gauteng and north west province. 73 july 2012, vol. 4, no. 1 ajhpe abstracts aim/purpose: to report on the qi reports done in the north west province between 2006 and 2008. methods: the triggers, methods and outcomes of the projects are reported. results and discussion: mother and child projects comprised 30% of the qi’s, followed by health education (25%), emergency room, chronic illness and observation (all 13%) and administrative issues (6%). most of the methods used were questionnaires followed by training sessions and posters or information brochures. the outcomes were mainly shortterm knowledge improvement and some systems improvement, e.g. wellorganised emergency rooms. conclusion/take-home message: even very short projects can have an influence on clinic staff and patient care as well as helping students to learn particular skills. support of hss-ta in the implementation of national continuing education strategy for the mohsw r m mpemi, s h phafol, m theko background/context: lesotho, like many african countries, faces challenges of shortage of human resources for health (hrh) due to migration to other countries. this has led to a grave decline in key health indicators. in an effort to retain the scarce hrh, the mohsw with assistance from its health development partners (hdps) has developed a 5-year national continuing education strategy (ces). the health systems strengthening technical assistance (hss-ta) plays a key role in facilitating the implementation of this strategy. hss-ta is an mcc/mca funded project, that focuses on 4 main areas of health reform processes: (i) developing human resources capacities and competences (hrcd); (ii) supporting the ministry’s process of decentralisation of health services; (iii) developing the health management information system (hmis); and (iv) strengthening the ministry’s ability to coordinate and oversee health research activities. the poster will focus on the first area – hrcd. aim/purpose: to illustrate the support and achievements of hss-ta in the implementation of the mohsw national ces, 2010 2015. methods: desk review of documents from inception of the project to date, stakeholders’ interviews and observations. results and discussion: training activities are coordinated by the hr directorate of the mohsw and hdp support one training plan. as of 31 march 2012, 1 212 participants from different cadres of hrh were trained on different health-related topics and a draft competence-based curriculum for nursing assistants is available. conclusion/take-home message: there are a variety of ways in which hrh could be retained and providing continuing in-service training has proved to be one of the best mechanisms. retaining hrh needs a concerted effort from both the ministries of health and hdp. service learning in pharmacy: student reflections on changes in the health service a bheekie background/context: service learning is institutionalised in undergraduate pharmacy training at the university of the western cape (uwc). strengthened partnerships between uwc school of pharmacy and the department of health, western cape initiated service learning across several tiers of the healthcare system. student objectives were to contextualise learning during service provision. aim/purpose: the aim of this investigation was to assess student reflective reports of practice patterns within the health services, that they would consider changing. methods: final-year pharmacy students engaged in routine service activities under the direct supervision of pharmacy service staff for a week, for 3 academic terms. after the session, students offered feedback to the service facilitator, and actively engaged in a guided reflection session on campus with an academic facilitator. the reflective report typically focused on a practice theme that they had experienced or observed during the service session. students were exposed to different healthcare sites for each service learning week. after the 3rd service learning week (2011), students gained profound insight into the public health service sector. the theme for the reflective report focused on identifying a practice pattern that students felt they would like to change and indicated how that change could be achieved. results and discussion: preliminary qualitative analyses of the reports indicated that students would consider changes in several service aspects. among others improving staff language proficiency and inculcating a positive attitude, promoting greater engagement on medication therapy management were emerging themes. service and reflection prompt students towards personal and professional transformation. conclusion: reflection contextualises learning and sensitises students to dissonance between theory and the health service. pharmacy students can emerge as change agents towards quality service delivery. enhancing the inter-professional interface through early exposure of undergraduate pharmacy students to the healthcare environment n butler, a bheekie background/context: senior undergraduate pharmacy students at the university of the western cape (uwc) undertake extensive experiential learning within a structured and institutionalised service-learning programme. aim: to extend the experiential learning component to entry-level pharmacy students within the context of a module on primary healthcare (phc) and development. methods: students, within the first month of their first term of pharmacy studies, initiate, arrange and undertake a visit to a phc clinic. this 74 july 2012, vol. 4, no. 1 ajhpe abstracts telephonic communication is structured and supervised by a staff member; students complete a tracking sheet containing details of the interaction. a prior assignment served to develop specific interview skills. during the visit they compile information by observation and interviews with both staff members and patients, to critically assess the facility in terms of adherence to phc principles. a current innovation (2012) entails including a reflection session after the visit, intended to introduce students to reflective thinking and to allow a sharing of experiences around their first inter-professional encounter and the impact of the visit on their communication skills and self-identification as a potential healthcare provider. results and discussion: pre-exposure data collection on expectations showed an overwhelmingly positive towards the visit as a potential learning experience; nervousness was the dominant emotion expressed. the strategies of prior development of interview skills and structured, guided and supervised telephone communication both served to overcome their apprehension and enhance their confidence, communication skills and professional identity. conclusion: student development in terms of both embedding knowledge and enhancing professionalism is nurtured through early exposure to experiential learning. this serves to support the notion that it is possible to use an alternative approach to extended classroom-based instruction prior to practice exposure. challenges in caring for post-stroke clients in low socioeconomic settings: a community health nursing experience rosemary duduzile mbatha-ndaba background/context: community health nursing students conduct part of their clinical practice in communities. they go on home visits to work with clients of different health needs. home visiting to clients who are cared for at home post stroke, has unravelled a number of challenges to students, faculty and home-based care workers. the country (botswana) has prioritised community home-based care as a strategy to address the overburdened inpatient care services resulting in the need for additional health manpower to attend to varied health needs of clients cared for at home. aim/purpose: this presentation discusses various constraints, repeatedly reported by students, during home visits, in the endeavour to improve the care of a client who has had a stroke, maximise body function, and prevent complications. methods: this is a clinical experience while working with community health nursing students in the communities. results and discussion: constraints which students cannot do anything about create anxiety and frustration when evaluating the plan and efficacy of care rendered against the time spent with the client. some of these clients have been in the same state of health for several years. conclusion: it concludes that from the planning process, faculty need to be involved in guiding and supporting the student as he/she implements and evaluates the care. the long-envisaged multidisciplinary home-based care team is overdue. this may necessitate an increase in the numbers of healthcare professionals and/or creating a cadre which can be ῾stretched’ to render several care activities which are currently inadequately offered. the development of inter-professional learning sites at community-oriented primary care (copc) health posts by multi-professional teams m van rooyen, r jansen, a reinbrech-schutte background/context: in 2011, the re-engineering of primary healthcare (phc) was promulgated by the minister of health. this innovation involves moving the focus of intervention from institutions (clinics and hospitals) to the community. up health sciences, with collaborators, is setting up health posts in a model. nine such sites are being established. l-cas is a medical-education-through-experiential-service-learning initiative that was implemented in the up school of medicine. the programme faces logistical challenges, like limited space and resources at the clinics that are threatening to impact negatively on it. aim/purpose: the adaptation of l-cas by supporting the development of learning sites at the copc health posts, in answer to the posed challenge by the minister, and other logistical difficulties. methods: a participatory action research project was initiated to evaluate, review and adopt the l-cas program. this project includes questionnaires, focus groups and a workshop. results and discussion: after the initial round of evaluations a number of proposed changes were identified including the development of interprofessional learning, creating a more diverse learning platform, exploring partnerships with students from other faculties working in the same communities, and continue the research. one of the challenges faced by implementing these proposed changes in the copc sites, is limited space. through the community engagement division of the university, a partnership was formed between the faculties of health sciences and construction engineering to build physical structures at the sites. these structures could provide an academic meeting place, academic resources, consultation rooms, office space and safe parking facilities. conclusion/take-home message: exposing students through service learning to address the needs of the community, based on the copc health post model. medical students will receive exposure through the medical-educationthrough-experiential-service-learning initiative and construction economics students will receive exposure through the construction-education-throughphysical-construction-service-learning. connecting the dots: elearning during public health fieldwork paula barnard-ashton, dianne manning university of the witwatersrand background/context: the 4th-year occupational therapy students attend a 3-week rural community fieldwork placement for public health. the 75 july 2012, vol. 4, no. 1 ajhpe abstracts placements are typically under-resourced, and the students are ῾virtually cut-off ’ from accessing learning materi¨als and online library resources. connectivity during this placement could be facilitated through supplying students with pre-paid data on a tablet-computing device. purpose: this study investigated the relationship between use of tablet computing for learning during rural fieldwork and the self-reported perceived knowledge gain of the students. methods: post ethical clearance, a preand post-test survey design was used. the students completed an initial survey of their perceived knowledge (on a 5-point likert scale) for each of the 16 rural fieldwork learning objectives (ro’s), as well as 32 other-setting fieldwork objectives (oo’s). the survey was re-administered after their 4th fieldwork rotation. students were assigned to groups by the department. seven students on rotation 1 and 2 did not take the devices with them on their rural placement (control). the 13 students on rotation 3 and 4 took a minimum of 1 device/ pair, on their rural placement (experimental). the data was organised into 4 clusters: control group’s rural objectives (cgro); control group’s other objectives (cgoo); experimental group’s rural objectives (egro); experimental group’s other objectives (egoo). results and discussion: t-test analysis of the preand post-test data for each cluster showed significant difference in all clusters with a highly significant difference for the egro’s (p=0.000145). a greater difference in the perceived knowledge gain was found in the likert scale of the egros (average gain of 0.9), compared with the other clusters (egoo=0.4; cgro=0.5; cgoo=0.4). a one-way anova showed this to be significant (p=0.046). take-home message: there is self-reported perceived benefit to students having connectivity and access to online resources during rural fieldwork place technology in emergency medicine teaching in south africa: are we ready for 2.0? heike geduld background: enthusiasm for web 2.0 and technology usage in medical education is high. in the field of emergency medicine there is a move to an increasing and diverse amount of electronic resources. however in postgraduate education students are generally on the wrong side of the ῾digital divide’ and their focus is primarily on shop-floor learning. aim: the aim of the study was to survey technology literacy among the staff and students in the division of emergency medicine at the university of cape town/stellenbosch university, to determine levels of access to technology, confidence with standard software and tools, and the current usage of technology in teaching and learning. methods: a google-form electronic survey was sent to 62 participants (42 registrars, and 20 faculty members). the survey included open-ended questions on attitudes towards technology for learning. participants had to rate their confidence with search engines, word processing, presentation and referencing software. participation in the study was voluntary. all responses were anonymous. results and discussion: forty-eight of 62 (77%) responses were received: 30/42 (71%) registrars and 18/20 (90%) faculty. two (4%) had no access to a computer and the internet at home. 39/48 (81%) respondents were able to access the internet at work, mostly (21; 44%) using smartphones. confidence was high with using word-processing programs (45; 94%), presentation software (46; 96%), social-networking sites (37; 77%) and search engines (36; 75%). more people read online journals (38; 81%) compared with printed journals (15; 32%). respondents were generally positive but emphasised the need for local content. technology should ῾complement not replace’ traditional learning. conclusion: technology may provide a means for students to access upto-date clinical information and an always accessible teaching platform, however mature learners are not necessarily as familiar with or confident in using technology. training is essential before instituting technology-based interventions. a needs analysis/situational analysis for professional development distance learning courses for doctors in rural areas of sudan shahd osman background/context: the continuous professional development centre (cpdc) in khartoum aims to assist all health professionals in sudan to use continuous professional development (cpd) more effectively. however, in rural areas difficulties of accessibility, finance and manpower are limitations. aim/purpose: the study aims to identify the distance learning (dl) courses needed for doctors in rural areas, and assess the technologies needed to implement and support dl. methods: a descriptive pilot study was used. qualitative data was collected using in-depth interviews with instructors’ representative of courses provided by the cpdc and its technical support department. a focusgroup discussion with doctors was held in al gezira; and a questionnaire was developed and then completed by a stratified sample of forty doctors working in rural areas of al gezira province. results and discussion: in-depth interviews with cpdc members indicated the need for a material production unit with technical support and instructional designers and a need for co-facilitators in rural areas. the results of the questionnaire indicated electricity was available for more than 12 hours/day for (85%) of participants. computers were available for (92.5%); and internet connectivity good or excellent for (72.5%). nearby technical support was available for only (57.5%). courses which participants considered of greatest need included: basic life support (85%), trauma life support (75%), advanced life support (62.5%), severely ill child (62.5%) and patient at risk (62.5%). computer skills were important for the professional development of (80%), but only (40%) felt very competent with their skills. other courses that were suggested the cpdc could offer were ultrasound, and ῾when to refer’ course. 76 july 2012, vol. 4, no. 1 ajhpe abstracts conclusion/take-home message: though cpdc has reasonable equipment to start dl, technical support must be addressed. courses delivered should target the rural doctors’ needs. courses aimed at improving computer skills may be offered to ensure benefit from dl. the use of automated integrated management of childhood illness guideline in primary healthcare in the western cape in south africa hilary rhode, bob mash background/context: the imci guidelines provide a standardised integrated approach to delivering quality care for children under 5 years of age. nurses in south africa are currently using a paper-based guideline. the automated guideline in the format of a convertible personalised computer tablet aims to improve training in imci and the quality of clinical decision making in primary care. the automated guideline has been designed to systematically navigate through the imci algorithm reducing errors and making it more effective. this study evaluated the use of automated guidelines in improving the training of nurses and use of the imci guidelines in primary care settings in the western cape. aim/purpose: the purpose of this research is to evaluate the use of automated guidelines in improving the training of clinical nurse practitioners (cnps) in the use of integrated management of childhood illness guidelines in primary healthcare setting in the western cape. methods: a sample size of 30 professional registered nurses was selected from a population of 100 nurses who attended the 1-year postgraduate diploma in clinical nursing science at stellenbosch university. descriptive study design compared cohorts of cnp’s who used and did not use the automated guidelines during training and subsequent practice. the study was conducted in rural and urban primary healthcare centres in the western cape. results and discussion: results compare the cnp’s knowledge of the imci guidelines at the end of the imci training course in those using and not using the automated version; the cnp’s adherence to the imci guidelines in practice following the imci training course when using and not using the automated version and the experience of those cnp’s who use the automated guidelines. conclusion/take-home message: the use of automated guidelines shows the potential for improving adherence to imci guidelines in the western cape. evidence regarding information communication technology used by generation y students in health sciences education l j van der merwe, g j van zyl, m m nel, g joubert background/context: challenges in health sciences education include effectively engaging the current cohort of so-called generation y students (born 1981 2000), who are said to display typical characteristics due to sharing a common place in history. this includes the impact of information technology and a uniquely south african educational context. aim/purpose: the aim of this study was to formulate an educational approach for the generation profile of undergraduate students at the faculty of health sciences, ufs, by discovering whether common perceptions describing generation y are accurate and how differences in perceptions impact on the teaching-learning environment. methods: a mixed-methods research design was used. in phase one, concurrent triangulation, quantitative and qualitative data were gathered simultaneously in a questionnaire survey for undergraduate students and academic staff members respectively. in phase 2, sequential explanatory design, a focus-group interview held with academic staff members yielded qualitative data, followed by incorporation of a literature survey and the results of the questionnaire survey and focus-group interview in order to formulate the educational approach as indicated in the aim of the study. results and discussion: results indicated that there was agreement between undergraduate students and academic staff members with many of the positive characteristics attributed to generation y, e.g. confidence, but differences existed regarding perceived weaknesses, e.g. an attitude of entitlement. their values and behaviour, communication and learning styles, skills and needs, and environment and shaping events revealed an information-communication technology connected cohort with poor interpersonal communication abilities desiring structured guidance and role-modelling. this distinctive profile necessitates a bespoke educational approach. conclusion/take-home message: the focus for effective educational practices by well-equipped lecturers should be on the involvement of students by means of teaching-learning approaches that are appropriate and balanced, as well as theoretically sound, within a suitable, relevant environment. podcasting lectures for second-year medical students at the faculty of health sciences, stellenbosch university s h walsh, m r de villiers background/context: the podcasting of lectures has been shown to benefit students. students mostly use them for revision and test preparation. lectures in the respiratory block of the mb chb ii course were converted into podcasts and placed on webstudies, where students could view or download them as a measure to improve the success rate of the class. aim/purpose: the aim of this study was to determine whether undergraduate medical students find podcasting a useful addition to lecture attendance. further objectives included whether the availability of podcasts influenced the respiratory block test scores; and lecturers’ experience of podcasting. methods: questionnaires were sent to the students and lecturers at the end of the block. end-of-block class scores were compared with those of the previous year. the marks of the students who downloaded the podcasts were statistically compared with those who did not. a focus-group interview was held with the students who assisted with the podcasting in the class. 77 july 2012, vol. 4, no. 1 ajhpe abstracts results and discussion: the 82 podcasted lectures were downloaded and viewed 1 737 times (an average of 21 times each). 78% of the students used the podcasts and 88% thought that all lectures should be podcasted. 88% of students used podcasts for clarifying concepts not fully grasped in class. the focus group identified benefits and challenges and ways to deal with it. 70% of the lecturers thought that the process was stress free or extremely stress free and 80% thought the podcasts did not influence class attendance or even showed an improvement. the test marks of the class improved. conclusion/take-home message: our students mostly found podcasts beneficial for clarifying concepts they did not grasp in class. the feedback provided useful pointers for change, including clarification around copyright issues and that we will be continuing to podcast the entire second year’s lectures. training needs on violence against women in a medical curriculum at the university of ibadan, nigeria o i fawole background/context: medical practitioners are in an ideal position to be able to mitigate the impact of violence on the health of women. they manage women with various health conditions and are thereby able to educate, screen and treat victims. aim/purpose: to determine final-year medical students’ knowledge and skills in managing vaw victims and describe extent to which vaw was taught by faculty in the college of medicine, university of ibadan, nigeria. methods: quantitative data was collected from 109 students using semistructured self-administered questionnaire. qualitative data was collected by review of documents and modules and interview with one key informant faculty each from 6 departments in the college, namely: family medicine, paediatrics, obstetrics and gynaecology, accidents and trauma, dentistry and public health. results and discussion: response rate was 85.1%. mean age was 25.2±3.1 years. sixty-five (59.6%) were males. physical, sexual, psychological and economic violence was known by 73.8%, 72.6%, 54.8% and 44.0%, respectively. majority (77.4%) felt it was part of their duty to ask patients about abuse. less than half (46.4% or 39) had ever received training on vaw, most of which were formal lectures (83.3%). students with previous training were more likely to be knowledgeable (or 1.64; 95% ci 0.61 4.42) and skilled (1.27; 0.53 3.05). males had better knowledge and skills than females (or 2.44; 0.89 6.65 and 1.27; 0.53 3.05 respectively). the review of curriculum documents revealed that the topic had not been included for teaching. key informants admitted to not having a formal teaching programme, although public health, family medicine and obstetrics and gynaecology stated they occasionally mentioned it at teachings. conclusion/take-home message: while most students were willing to ask patients about abuse, they lacked fundamental knowledge and skills to do so. the present teachings should be enhanced to improve knowledge and management skills. faculty agreed to review the curriculum. point-of-care ultrasound in madagascar: what should be core knowledge? work in progress rabenandrasana hajasoa alain, juanita bezuidenhout background/context: although use of point-of-care diagnostic ultrasound (dus) is an increasingly valuable diagnostic tool to the general practitioners (gps), providing adequate dus training in madagascar is difficult due to the lack of standardisation. detailed international training guidelines for those who are using or wish to use this imaging technique are underutilised. purpose: the purpose of this study is to determine the required content for undergraduate clinical ultrasound and training in madagascar. methods: questionnaires based on the who: technical report series, 1998 and the joint review committee on education in diagnostic medical sonography (usa) guidelines and addressing content, were distributed randomly to gps (n=41) and all faculty (n=11) at university hospital of toamasina, madagascar. the data were collected and were entered on surveymonkey® and analysed. results: completed questionnaires were received from 38 gps and 9 faculty members (90% response rate). they agreed that ultrasound instruction should start with second-year medical students (43% gps and 36% faculty). based on their priority rankings, dus instruction should focus on: physics that underlie ultrasound (92% gps, 89% faculty) and diseases relevant to madagascar (79% gps; 89% faculty). based on these results, ultrasound training was initiated in 2011. student evaluation was obtained at the start of in 2012. based on these results, concomitant video and/or tele-medicine should be used to supplement lectures. conclusions: these findings indicated that it is possible to adapt international guidelines for use in madagascar. concomitant video and or tele-medicine in addition lectures will be valuable. us educational materials can therefore also serve to advance e-learning, reaching a larger number of health practitioners, resulting in creating a virtual learning environment. reflections of graduating medical students: a qualitative study lionel green-thompson, patricia mcinerney, dianne manning, ntsiki mapukata-sondzaba, shalote chipamaunga, tlangelani maswanganyi background/context: the 6-year medical programme at the university of the witwatersrand admits students into the programme through 2 routes – school entrants and graduate entrants. graduates join the school entrants in the third year of study for a transformed curriculum called the graduate entry medical programme (gemp). in years 1 and 2 of the gemp, the curriculum is structured into system-based blocks. problem-based learning is applied in these 2 years. the curriculum adopts a biopsychosocial approach to healthcare, which is implemented through spiral teaching and learning in 4 main themes – basic and clinical sciences, patient-doctor, community-doctor and personal and professional development. in 2010 this programme produced its fifth cohort of graduates. 78 july 2012, vol. 4, no. 1 ajhpe abstracts methods: we undertook a qualitative, descriptive and contextual study to explore the graduating students’ perceptions of the programme. interviews were conducted with a total of 35 participants who volunteered to participate in the study. the majority of the participants interviewed participated in focus-group discussions. the interviews were transcribed verbatim and analysed using tesch’s 8 steps. ethics approval for the study was obtained from the human research ethics committee of the university of the witwatersrand. findings: six themes were identified – 2 separate programmes, problembased learning and garmins (navigation system), see patients for real, being seen as doctors, assessment: of mice and mcq’s, a cry for support and personal growth and pride. participants were vocal in their reflections of experiences encountered during the programme and made several insightful suggestions for curriculum transformation. the findings suggest that graduates are exiting the programme confident and ready to begin their internships. conclusion: qualitative methods provide a valuable tool for the evaluation of programmes. participants felt adequately prepared by the programme for their internship. concerns were raised about variability in learning opportunities as well as assessment. a survey of the conditions treated by 3rdand 4th-year physiotherapy students at the university of cape town during placement in general hospitals lunelle pienaar background/context: clinical practice is the mainstay of training of physiotherapy students. the hpcsa requires that students spend at least 1 000 hours in the clinical arena. what is unclear is how students spend their time while in the hospitals. aim/purpose: this study aims to document the most common conditions treated, the intervention techniques used, and the time spent on administration and patient treatment respectively. methods: students were asked to complete an on-line questionnaire regarding their practice. as this was initially planned as a simple audit, no ethical approval was sought. results and discussion: seventeen students who completed the survey were included in the study. one hundred and ninety new patients were recorded; most common conditions were respiratory (75) and orthopaedic (38). the 4th-year students treated more respiratory conditions (30%) compared with 3rd years (13%). third-year students had more orthopaedic conditions (13%) compared with 4th years (10%). third-year students included technique of gait re-education (51%) in treatment whereas 4th years included chest physiotherapy (43%). third-year students spent more time on 219 treatments (37.1, sd 13.2). fourth-year students spent less time (28.7, sd 19.0) on their 460 treatments (t=5.8, p>0.001) and significantly more time writing up patient records (15.2, sd 12.2) than 3rd years (10.0, sd 6.5) (t=6.0, p<0.001). conclusion/take-home message: further work is needed to explore the influence of conditions students encounter in clinical practice and the application of practical skills. problem-based learning at ukzn – pedagogy, people and paradigms t e sommerville background/context: some forty-odd years after problem-based learning (pbl) was introduced to higher education, its strengths and weaknesses and its widespread application have been documented. most evidence emanates from first world settings, in quantitative terms, making comparisons with traditional teaching methods. aim/purpose: ten years after pbl’s introduction in ukzn’s medical school, i examined the form of pbl pedagogy practised in a diverse, multi-racial, multi-cultural, multi-lingual, multi-educational, developing-world setting, through the eyes of students, staff members and institution. methods: qualitative study using interviews with 19 students and 6 staff members, analysed using nvivo and compared with institutional statements, using bernstein’s theory of classification and framing as an analytical framework. results and discussion: faculty documents reflected a conventional type of pbl: student-centred, self-directed, collaborative learning in response to a ῾problem’. interviews, in contrast, revealed a picture of a strongly classified and framed pedagogy. the boundary between everyday and medical knowledge was significant (in slightly different ways) for both students and staff, who had differing views of interand intra-disciplinary boundaries. seven different conceptions of ῾integration’ were voiced. local perceptions of pbl differ from the theoretical view of a weakly classified and framed pedagogy. the everyday-medical boundary is delineated chiefly by differences in discourse, rather than by the language of pedagogy. differing perceptions of interand intra-disciplinary boundaries can be related to curriculum and faculty structures. the range of conceptions of ῾integration’ probably relates to conceptions of the knowledge structure of medicine. the field has been regarded as akin to the natural sciences – in bernstein’s terms, a hierarchical knowledge structure. conclusion/take-home message: medicine is largely a horizontal knowledge structure, comprising a number of distinct regions with minimal overlap. this leads to dissonant perceptions of ῾integration’. the pedagogy applied should strive actively to assimilate disparate areas of knowledge. breaking bad news: public health electives for medical students liz wolvaardt, david cameron, vanessa burch background/context: the hpcsa has decided to include public health in the medical curriculum. this headline intention is difficult to implement: lack of clarity of content; lack of interest by students and an overloaded 79 july 2012, vol. 4, no. 1 ajhpe abstracts curriculum remain challenges. at our university one opportunity is the one-month elective in the third year. purpose: as students self-design their elective, few design one in public health as students cannot choose what they do not know. students also lack the social capital to identify meaningful learning opportunities in the community. simultaneously medical schools should demonstrate social accountability that considers the priority health concerns of the community for education, research and service. this elective could address the goals of learning and social accountability. methods: post ethical clearance, an action research study used a voluntary 10-item online student-needs survey to inform the development of an inner-city elective. the elective was marketed and a review of actual choices conducted. results and discussion: 106 students participated and 25 (28.1%) showed interest with another 44 interested but needing details. the majority (n=66) preferred to do an elective that would deepen their knowledge of something already in their curriculum. proximity to home (n=38) and public transport access (n=18) were unimportant. open-ended responses revealed 3 themes that influence elective choice: institutional factors that support learning; the setting and opportunity to practice. two named public health topics as an interest. the bad news is that no students enrolled for this elective. the 230 elective forms showed that 33.5% (n=77) of students divided their electives into 2 or more activities. possibly this group includes those who expressed interest, so a one-month elective (irrespective of the number of activities included) is inappropriate. take-home message: it seems like public health electives should be like miniskirts. long enough to cover the topic but short enough to be interesting. computer-based simulation as e-learning tool m j labuschagne, m m nel, g j van zyl, p p c nel background/context: computer-based simulation and game play are new emerging e-learning tools. the use of computer-based simulation can be an e-learning tool that can be utilised to add a new dimension to e-learning. computer-based simulation can be used to assess higher order skills. aim/purpose: (i) list e-learning tools; (ii) describe the tools for the different e-learning categories; (iii) explain the uses, advantages, disadvantages and assessment possibilities for computer-based simulation and game play. methods: a literature review, semi-structured interviews with international simulation experts and focus-group interviews with lecturers of the clinical phase of the undergraduate medical programme at the ufs were conducted, analysed and interpreted. results and discussion: the author will give as background, some of the e-learning tools that are available to develop online lectures and activities. the aspects that will be discussed include: content/course or learning management system (cms/lms); synchronous collaboration applications; computer tools/applications (including asynchronous collaboration applications); game play or game simulation software. the tools for the different categories will be discussed and the author will elaborate especially on computer-based simulation options, the uses, advantages and limitations and the options that are available for developing flat screen simulation to use in simulation centres and online. conclusion/take-home message: computer-based simulation and simulation games can be useful tools to be added to the e-learning toolbox. computer-based simulation and virtual games can be used to assess higher order skills. developing an e-learning platform to complement xhosa and afrikaans language teaching and learning: a stellenbosch university faculty of health sciences initiative philip lewis, leandra khoury, m r de villiers background/context: communication problems experienced between healthcare professionals and patients are well documented and perceived as a major barrier to quality healthcare. stellenbosch university faculty of health sciences (sufhs) has embarked on a range of innovative roll-out initiatives to empower students with the necessary xhosa communication skills to improve patient quality care. this presentation demonstrates a novel e-learning platform, specifically designed to complement formal lectures and to enhance students’ xhosa language skills. aims: this project aims to develop and design a range of task-based activities and interactive assessment procedures to assist students in learning xhosa for use in the clinical consultation, and prepare them for their simulated osce’s. the implementation is informed by a study investigating students’ perceptions and application of the e-learning platform for xhosa. methods: the presentation describes the application of the xhosa e-learning platform design as well as the development of the course material consisting of various interactive text-to-speech language learning activities and assessment procedures. the e-learning course is designed to be hosted on blackboard, which is sufhs’s learning management system (lms), and will be in the format of a sharable content object reference model (scorm) module. results: currently 20 students from the division of human nutrition are appraising the effectiveness and application of the e-learning material. these findings will be made available from october 2012, and will lend itself to further analyses to improve the application of future e-learningrelated developments as well as further ways to support and reinforce future students’ xhosa communication skills. take-home message: south africa is faced with huge language barrier challenges in the healthcare sector. the sufhs e-learning course is not only designed to complement xhosa lectures to improve language proficiency but also to prepare students in clinical communication contexts. we trust that by developing this novel e-learning course material we will be able to greatly enhance the learning of an african language for health professionals in order to improve patient care in our health services. 80 july 2012, vol. 4, no. 1 ajhpe abstracts fostering lecturer-student engagement using the social network (facebook) in an undergraduate radiography course s mdletshe background/context: engagement with the students in higher education (he) is critical to their success with their studies. in radiography engagement is more critical because the students spend half of their academic time in the clinical environment for work integrated learning (wil). this implies that they only have direct access to the lecturer during half the academic time which negatively impacts on effective student engagement. effective engagement is enhanced by communication with the students. aim/purpose: this presentation reports on an intervention to address the challenge of student engagement based on the use of facebook (fb) as a communication tool with the third-year radiography students at the university of johannesburg (uj). the presentation focuses on the experience of the author in using this tool and how it impacted on student engagement. methods: the author noted the lack of communication with the students and the negative impact this had on engagement. in response to this, the author decided to use fb as a communication tool with the students by creating a fb page and called it ῾radiography thirdyr diagnostic.’ results and discussion: the use of this tool showed enhanced communication between the students and the lecturer, which positively affected studentlecturer engagement. conclusion/take-home message: student-lecturer engagement can be greatly enhanced by using the various platforms of currently available social networking tools. what academic advisors need to provide better student support – lessons from a malaysian medical school c p l tan, j bezuidenhout, j j blitz background/context: academic support programmes have an important role in addressing the needs of students experiencing difficulties. a quality assurance exercise by the national accreditation body highlighted that academic staff involved in non-academic counselling had no prior training. aim/purpose: the purpose of this study was to investigate the current practice(s) of academic advisors in a malaysian medical school in order to determine their needs and to make recommendations for a faculty training programme. methods: focus-group discussions (fgds) involving 10 academic advisors were conducted using a semi-structured interview schedule. results and discussion: study participants demonstrated some instinctive understanding of their role (especially as role models in their professional development) although they did not have clear guidelines. they strongly expressed a need for training in counselling skills and better administrative support. there was some reluctance to undertake the task of academic advising as there were no perceived rewards or incentives. conclusion/take-home message: the training of academic advisors needs to be addressed in faculty development programmes. strong institutional administrative support is important with efficient channels of communication to academic advisors on student performance and other relevant information. teaching activities need due institutional recognition and reward. a pilot study on the validity and reliability of an assessment using r-type mcqs lunelle pienaar, gregory doyle background/context: the faculty of health sciences at the university of cape town uses a problem-based learning medical curriculum which focuses on developing problem solving abilities rather than recalling facts. it is therefore best that the assessment instruments should focus on problem solving. more r-type mcqs asking students to solve problems based on information provided in a clinical case-based scenario have been included. r-type mcq or extended matching items (emis) have approximately 8 options and 2 or more items. the extensive list of options reduces chance of guessing and recognition of correct answers. literature sees this as a better alternative to a-type mcqs where the limited number of options (usually 4 or 5) encourage guessing. application of theory and problem solving can be tested in the same emi as it allows greater range higher order reasoning to be tested. aim/purpose: to determine whether using emis rather than a-type mcqs will result in a more reliable and valid assessment instrument based on the difficulty and discrimination. methods: one of the fifth-year medical papers was analysed. the 193 students answered a paper containing 5 emi sets with 34 items and 16 best of 4 a-type mcqs the item difficulty and discrimination for the emis and a-type mcqs were determined. results/discussion: the emis’ mean discrimination and difficulty was 0.2 and 78% respectively. whereas the a-type mcqs mean difficulty was 70% and the discrimination the same, 0.2. conclusion/take-home message: the small sample of test items made it difficult to demonstrate validity and reliability. a larger study with more items needs to be conducted to determine which mcq type results in a more valid and reliable assessment. do you know your brain dominance status? a participatory action research project in the school of healthcare sciences, university of limpopo, medunsa campus a human, h pitout, a m wium background/context: multi-disciplinary teamwork is considered best practice and is essential for the efficacy of service delivery. the 3 disciplines of physiotherapy (pt), occupational therapy (ot) and speech-language pathology and audiology (slpa) are therefore expected to work together as 81 july 2012, vol. 4, no. 1 ajhpe abstracts team during service delivery. the intention of this research was to enhance collaboration between these 3 professions by using the herman brain dominance instrument (hbdi) to determine the learning preferences of each discipline in an effort to create a better understanding of each other. aim/purpose: a collaborative action research project was conducted by 3 facilitators of learning (fol) to compare the brain dominance profiles and learning style preferences within and between these disciplines. in each discipline, the brain dominance of second-year students and the fol was determined to improve teaching and learning practices as well as collegial collaboration. methods: within a participatory action research approach the brain dominance and learning preferences of second-year students (n=82) from the various departments were determined as baseline data by using the hermann brain dominance instrument (hbdi) (herrmann, 1996). the data was quantitatively analysed. the findings informed changes to be made to the teaching practices and collaboration of the respective fol. results and discussion: similar brain profiles and learning preferences were noted across the 3 disciplines as the majority preferred learning primarily in the b quadrant (sequential/organised), and secondary in the a quadrant (analytical/intellectual), which is predominantly left brain. the results obtained enhanced teaching and learning practices and contributed towards the professional development of the fol. conclusion/take-home message: the knowledge accrued contributed towards improved communication, collaboration and understanding on various levels (individual, departmental and school). it is therefore recommended that similar studies be conducted at other tertiary institutions in south africa. an educational approach for the generation profile of undergraduate students in the faculty of health sciences, university of the free state l j van der merwe, g j van zyl, m m nel, g joubert background/context: challenges in health sciences education include effectively engaging the current cohort of so-called generation y students (born 1981 2000), who are said to display typical characteristics due to sharing a common place in history. this includes the impact of information technology and a uniquely south african educational context. aim/purpose: the aim of this study was to formulate an educational approach for the generation profile of undergraduate students at the faculty of health sciences, ufs, by discovering whether common perceptions describing generation y are accurate and how differences in perceptions impact on the teaching-learning environment. methods: a mixed-methods research design was used. in phase one, concurrent triangulation, quantitative and qualitative data were gathered simultaneously in a questionnaire survey for undergraduate students and academic staff members respectively. in phase 2, sequential explanatory design, a focus-group interview held with academic staff members yielded qualitative data, followed by incorporation of a literature survey and the results of the questionnaire survey and focus-group interview in order to formulate the educational approach as indicated in the aim of the study. results and discussion: results indicated that there was agreement between undergraduate students and academic staff members with many of the positive characteristics attributed to generation y, e.g. confidence, but differences existed regarding perceived weaknesses, e.g. an attitude of entitlement. their values and behaviour, communication and learning styles, skills and needs, and environment and shaping events revealed an information-communication technology connected cohort with poor interpersonal communication abilities desiring structured guidance and role-modelling. this distinctive profile necessitates a bespoke educational approach. conclusion/take-home message: the focus for effective educational practices by well-equipped lecturers should be on the involvement of students by means of teaching-learning approaches that are appropriate and balanced, as well as theoretically sound, within a suitable, relevant environment. the usefulness of a tool to assess reflection skills in servicelearning in the department of speech-language pathology and audiology, medunsa a m wium, s du plessis background/context: service-learning is a credit-bearing educational experience which requires students to reflect on the service activity in order to develop a deeper understanding of course content and relate these to the scope of practice within the discipline, as well as to develop a sense of social/ civic responsibility. reflection following a clinical learning experience helps to organise the students’ thoughts, provides them with a permanent record of their experiences, allows them to talk about their experiences to each other, and share their thoughts and feelings. second-year students in the department speech language pathology and audiology are engaged in service learning at a rural site on a weekly basis and reflect on their experiences. the researchers had a need to assess reflection skills to monitor the students’ personal and professional growth and therefore developed an assessment tool to this purpose. aim/purpose: the aim was to determine the usefulness of a tool to assess students’ reflection skills in the department speech-language pathology and audiology, medunsa. methods: the data was obtained retrospectively from the reflection diaries of the students. these reflections were analysed and scored with a matrix. scores were compared over the course of the academic year to measure change. results and discussion: the assessment tool proved to be useful in documenting change in reflection skills over time. the reflections portrayed an increased sense of social responsibility, problem solving and insight. conclusion/take-home message: guided reflection conducted on a regular basis is key to the service-learning experience and contributes to 82 july 2012, vol. 4, no. 1 ajhpe abstracts professional and personal growth. reflection is an integral part of effective practice and meaningful service delivery. infection prevention and control practices in sa revealed through teaching and assessment strategies m theron background/context: the national infection prevention and control (ipc) policy & strategy for healthcare facilities was introduced in 2007. research conducted by the department of health in 2011 showed that there are only 253 ipc practitioners in south africa, not all of them trained. policy states that there should be one practitioner for every 200 occupied beds. this shortage of trained ipc practitioners in the country led to the development of a theory and practice integrated ipc short learning program. training programmes could also lead to the identification of shortcomings in ipc practices. aim/purpose: to highlight the shortcomings of ipc practices through reflection on a short learning programme. methods: the ipc short learning program, based on unit standards (nqf level 7) was presented during 7 contact sessions. facilitation of the programme comprised teaching and assessment strategies such as group work, class activities, reflection reports and assignments. narrative information and records were obtained from the participants’ written learner activities, reflection reports and conversations in class. the main shortcomings of ipc in practice were identified and the needs of the candidates were revealed. results and discussion: ipc was viewed as an additional task, added to the daily work load of most of the candidates. policies, protocols and hospital acquired infection statistics were not available. ipc teams and committees were absent at most healthcare facilities. the learning experience and quality assurance projects of the candidates improved ipc practices in their healthcare settings. conclusion/take-home message: the short learning program equipped ipc practitioners with the knowledge and skills needed to provide high quality care through appropriate implementation, evaluation and improvement of ipc practices in healthcare facilities. teaching medical students quality improvement in health claire van deventer, nontsikelelo sondzaba background/context: 6th-year medical students involved in a 6 week integrated primary care block are expected to do a facility audit and based on that or other observed problems initiate a quality improvement (qi) project. aim/purpose: to assess the qi reports of 6th-year students from 2005 2010. methods: an observational study of qi reports done by students. project reports assessed and compared to site marks, indicators of learning assessed and individual and group marks compared. results and discussion: of 274 projects undertaken, 223 (81.4%) were available for evaluation. geographical placements and qi themes were categorised. management issues were most frequently identified as being problematic followed by chronic illnesses. understanding and applying the principles of qi was partially achieved and gaps were identified for future projects. the most common intervention was training of personnel and design and distribution of posters or pamphlets. conclusion/take-home message: most qi projects were well thought out and relevant to the chosen setting. in the majority of cases, a great deal of effort and creativity went into the process and skills other than clinical skills were employed such as writing, presentation of data in graphs and tables. integration of theory and practice was achieved only partially. emergency medical care student opinions of a reflective journal andrew makkink background: students in the first year of study of a 4-year bachelor’s degree in emergency medical care at the university of johannesburg are required to complete a reflective journal in which they reflect on a number of various situations and skills that they have been exposed to within the clinical learning environment. information of student opinions of this tool may provide important strategies at improving the format and structure of the reflective journal, and potentially also the reflection process. aim/purpose: the aim of this study was to examine student opinions of the reflective journal and to assess a number of areas related to its relevance within the learning environment. methods: a questionnaire containing open-ended questions, forced-binary and likert-type scales was developed wherein students registered in their first year of study were able to assess various aspects of the reflective journal. data was captured and analysed using microsoft excel and reported on descriptively. results and discussion: most students understood what the purpose of a reflective journal was and assigned a positive value to the reflective journal. interestingly, many students did not regularly make entries into their journal as was expected with most leaving their entries to the last minute. there were a number of interesting trends observed when analysing whether students would prefer an online or written format for the journal. although students are often observed discussing cases, most students did not read other students’ journals, nor allow others to read their own. conclusion/take-home message: the reflective journal has an important place in the work-integrated learning (wil) environment. the challenge is to use it to encourage reflective thinking in our students by ensuring their active involvement in developing their skills as reflective practitioners. 83 july 2012, vol. 4, no. 1 ajhpe abstracts illuminative evaluation of the final-year prosthodontic component of the oral health science curriculum p d moipolai background/context: a hybrid problem-based learning curriculum was introduced in the early 2000s in the school of oral health sciences, and since its inception no evaluation of the innovation had been done. it was felt necessary to undertake such a project to adjudicate the worth of the reform. this was to determine whether goals were being achieved and that the programme remained relevant and did what it set itself to do. aim/purpose: the aim of the study was to use a qualitative evaluation approach to assess the impact of curriculum change at classroom level and to evaluate how a department had reformed its teaching and learning strategies. additionally, it was to evaluate how this curriculum operated in its own terms. this approach was employed to illustrate how an evaluation strategy was used to assess classroom practices following institutional curriculum reform. methods: illuminative evaluation as a research method in the qualitative paradigm was utilised. from july through october 2007 small-group teaching involving problem-based learning, led by 2 faculty from the department of prosthodontics were observed. six 2-hour long small-group sessions, were observed. in-depth follow-up interviews with students and faculty were conducted. the plan, as outlined in the instructional system, was held up against the reality through observations in the classroom. results and discussion: by and large the findings illustrated that much of what was planned was realised, with the more experienced staff member teaching more or less to the plan. however, from the themes that were inductively derived from analysis of the data, it was clear that integration of content knowledge and critical thinking necessary to assist in the comprehensive management of dental patients was not as robust as would be expected from the students at this level during their training. conclusion/take-home message: this finding illustrates the importance of using qualitative evaluation approaches as a mechanism to assess curriculum change efforts. development of a specific approach to facilitate knowledge in augmentative and alternative communication across two learning contexts a m wium, m mophosho background/context: hpcsa exit level outcomes specified by the hpcsa, requires that students in speech-language pathology and audiology are competent to provide services to clients who require augmentative and alternative communication (aac). such clients present with severe communication problems and their assessment and intervention, as well as management is complex. to ensure high quality teaching and learning 2 facilitators of learning at 2 universities collaborated to develop a specific teaching approach for aac. such an approach accommodates all learning preferences and therefore consists of multiple teaching methods, of which assessment (as teaching method) is one. aim/purpose: to determine the outcomes of a specific approach that facilitates learning of final-year students in aac. methods: the students at both campuses received similar learning experiences, learning material and assessments. in both instances the process of facilitating learning was evaluated by both students and a peer to increase the validity of the findings. the results obtained from assessing the students were compared and factors were identified which could have affected the results. results and discussion: the results obtained showed that learning was facilitated by using a multi-method approach but that the specific context had to be taken into account. conclusion/take-home message: a ῾one-size-fits-all’ assures effective learning and teaching but that this approach is not necessarily the best option to ensure quality in teaching. specific factors need to be considered, especially for students in a semi-rural context. peer teaching at the university of zimbabwe: understanding the learning needs chiratidzo e ndhlovu, jose frantz background/context: at the university of zimbabwe (uz), clinical skills training occurs during the 3rd year of a 5-year undergraduate medical curriculum. the clinicians providing the bedside training are ῾content experts’ but most are not trained medical educators. given the declining senior clinician numbers, it is proposed that interns and masters in medicine (mmed) students be formalised as clinical teacher assistants (ctas). purpose: to determine the experiences of the third-year medical students and the learning needs of interns and mmed students. methods: a mixed qualitative and quantitative design using 2 focus-group discussions (fgd) and self-administered questionnaires was employed. the target sample was 60 interns and 32 mmed students. 12 participants were purposively selected per fgd. all data were entered into microsoft excel. the qualitative data were analysed using the broader themes of strengths, weaknesses, opportunities and threats. the quantitative data was analysed using stata 10 (stata corp lp). ethics clearance was obtained from the institutional review board. results and discussion: the response rate was 21(35%) interns and 7 mmeds (22%). nine (75%) medical students and 8 (67%) interns turned for the fgd. from the fgd, using ῾real’ patients was a strength; weaknesses included the classes being too large and students feeling ῾ignored’ by their trainers. 10 (48%) interns perceived themselves as <5% of their time teaching. both groups (100%) reported ῾high or some confidence’ in teaching the medical students. clinical load was a major barrier to teaching. only one of the mmeds and none of the interns felt they ῾belonged’ to uz. take-home message: there is urgent need to address the sense of ῾not belonging’ to the training institutions as well as balancing teaching and service delivery if clinical skills training by peers is to be introduced. 84 july 2012, vol. 4, no. 1 ajhpe abstracts students’ perception of their readiness for the clinical area b masava, t munangatire, c n nyoni, m m shawa background/context: paray school of nursing in thaba tseka, lesotho was established in 1977. the school then offered the certificate in nursing assistant which was a 1-year programme. the institution operated with one permanent faculty member and part-time teachers from within paray hospital. over the years the institution has grown, it had its first intake of the diploma in general nursing in 2009. however, the institution is facing challenges in the training of future nurses for lesotho. the current enrolment is 97 against a staff faculty of 6 nurse educators and 2 clinical instructors. these staff members are responsible for the 2 programmes being offered by the institution. notably there is over burdening of the nurse educators who can teach up to 6 courses per semester. this compromises the quality of preclinical training of students. the school does not have fully equipped clinical skills laboratory, that may aid the learning of vital nursing skills necessary in the clinical area. in addition to these challenges, the clinical area where the students are mostly attached has several noted shortcomings, namely; lack of variety of both patients and departments, unavailability of material to use in nursing care and poor supervision as majority of staff in the hospital are nursing assistants who profess difficulty in supervising a student for senior position. these challenges then prompted the researchers to then determine the perception of the students regarding their preclinical preparation and whether they perceive themselves to be ready for clinical placement in spite of all challenges they are meeting. aim/purpose: to improve preclinical training of nursing students. methods: self-administered questionnaires in english or sesotho to be given to 30 second-year students. questionnaire will be analysed utilising descriptive statistics, in determining frequency among variables. data is to be presented in graphs and tables. results and discussion: in progress. conclusion/take-home message: in progress. improving objective structured clinical examinations (osce) practice in kampala international university (kiu) a o ogah, e m kiguli background/context: kampala international university (kiu) medical school was established in 2007, and adopted the osce as a form of clinical assessment in 2010. since then, there has been effort to improve the quality of the examinations to meet with international standards. aim: to describe osce practices and examination outcomes at kiu teaching hospital and to assess faculty knowledge on conducting osces. methods: both quantitative and qualitative methods were used. the study was conducted in 5 clinical departments (internal medicine, paediatrics, obstetrics and gynaecology, surgery and psychiatry). thirty examiners and 17 graduating medical students at the july 2011 exit examination were involved. the examiners’ knowledge was assessed using a self-administered semi-structured questionnaire. the osce setup and process was observed using a checklist. five key informant interviews were conducted with heads of departments. results and discussion: examiner response rate was 86.7%. surgery declined to conduct osce. only 16 (61.5%) examiners could correctly write osce in full. fourteen (53.8%) had heard about osce only from the faculty. twentyfour (92.3%) had never heard of blueprinting nor of standard setting. osce was highly accepted but 23 (88.5%) examiners believed that osce alone was not sufficient for clinical assessment at the exit examination. prior organisation was fairly done. examinations were delayed for 2 hours and information sharing was common. there was neither a blueprint nor standard setting. the manned and unmanned stations ratio: >1:1. the differences in the mean marks and pass-rate between the manned (62.2%, 100%) and unmanned (45.8%, 35.3%) stations were significant (t-test and p<0.005). conclusion: faculty knowledge and practice of osce were poor. examiners’ scores probably overrated the students’ performance. there is need to set up an osce committee to conduct osce training workshops, encourage all departments to participate and develop guideline for the faculty. developing clinical reasoning: pre-clinical case-studies or lectures? – student feedback t c postma background/context: pre-clinical case-based training was introduced as a teaching method for third-year dental students at the school of dentistry, university of pretoria in 2009. the aim of the case-based training is to develop the students’ clinical reasoning skills as part of a comprehensive patient management (cpm) module. the module stretches over 3 years and the skills that are acquired pre-clinically are applied in the subsequent 2 clinical years. prior to 2009 the pre-clinical course was lecture-based. aim/purpose: this study explores differences in course feedback between students who received pre-clinical case-based training (cbt) and those who received lecture-based instruction (lbi). methods: a standardised student feedback questionnaire was administered (100% response rate) at the end of the fourth and fifth study years (2009 2011). students were asked to rate the course relevance, training alignment with course outcomes, assessment’s contribution to learning, faculty competence, knowledge integration, their own clinical reasoning ability, and the extent of the gap between the pre-clinicaland clinical years, using a visual analogue scale. t-tests were used to compare the feedback of the cbt and lbi groups. results and discussion: fourth-year students who received cbt (n=99) rated the relevance of the course, training alignment with course outcomes, assessment’s contribution to learning, faculty competence, and the knowledge integration between subjects in the same study year significantly (p<0.05) higher compared with those who received lbi (n=51). the cbt group also perceived the jump to the first clinical year to be significantly (p<0.05) smaller compared with the lbi group. fifth-year students in the cbt group (n=43) gave similar feedback. the fifth-year lbi group (n=95) 85 july 2012, vol. 4, no. 1 ajhpe abstracts scored the course organisation, knowledge integration between subjects of different study years, and their self-perceived treatment planning ability significantly (p<0.05) lower compared with the cbt group. conclusion/take-home message: according to student feedback, preclinical case-based training is more effective to prepare students for the clinical setting compared with a lecture-based approach. student support initiatives in the department of internal medicine j m m koning background/context: the undergraduate students often perceive the fifthyear internal medicine module as extremely difficult to pass. over the last few years 3 challenges were identified which contribute to this perception, namely a negative attitude towards the module, underlying emotional challenges and surface learning among the students. utilising the process of transformative reflection, a variety of student support initiatives has been introduced by the department to try to change these perceptions. aim/purpose: to identify the different initiatives undertaken in the undergraduate internal medicine module. methods: an audit of all student support initiatives in the undergraduate programme of the department of internal medicine was undertaken in 2011. the results of the audit will be described. results and discussion: a departmental education committee drives these initiatives. all departmental staff, and those of departments of cardiology, neurology and dermatology, give their input at an annual strategic planning meeting, which focuses on teaching and learning. the internal medicine module has a year group tutoring system in which the tutor has weekly meetings with the students. students’ photographs are taken and circulated to encourage staff to know the students. extensive feed-back is sought from students and taken into consideration when planning any changes. students with attitude or emotional problems are seen by the year group tutors. these students are referred to kovsie counselling or a private psychologist. since 2011 internal medicine is also part of the university’s natp programme. conclusion/take-home message: having a structured student support programme in a clinical department is extremely beneficial. as a result of these initiatives the general attitude of students towards internal medicine has improved. the support rendered contributed to the academic success of a number of students who had been identified with emotional challenges. from january 2012 the support programme was expanded to include workshops on stress management, self-esteem and time management. the ufs school of medicine transport project anne-marie nel, scarpa schoeman background/context: the clinical training component of the university of the free state’s medical curriculum is presented at 5 different hospitals in the greater bloemfontein area. previously, our underprivileged students and many international students, who do not have access to private transport, had to rely on the costly and often dangerous public transport system (taxi's) in bloemfontein to commute between these hospitals. this placed enormous pressure on the students’ time, monetary resources and most probably their academic performance. aim/purpose: this need and challenge was recognised by the medical school and a plan was made to address the issue and provide assisstance to the students. a business plan was developed and, with gracious corporate sponsorship, the school of medicine transport project was implemented in april 2011. the main aim of the project is to support the underprivileged medical students’ academic performance and study efforts by removing a logistical hurdle and enable them to focus more on their studies and be successful. by providing daily and regular dedicated transport for them, they do not have to stress about making use of expensive, untimely and unsafe taxi’s. methods: the students buy semester tickets, currently at a cost of r1 350 per semester, to make use of the service. this money, together with the sponsorship money, is used towards covering the operational costs. regular trips each day are carried out by 2 dedicated drivers, committed to ensuring that the students arrive safely and on time at their different destinations. results and discussion: the appreciation of the students benefitting from this project cannot be expressed in words. it is clear from the student’s dayto-day testimonies that the project is certainly having its desired impact and effect on their educational experience. the satisfaction of their thankfulness and overwhelmed gratitude is definitely worthwhile. conclusion/take-home message: coming together is a beginning; keeping together is progress; working together is success. training needs assessment for a group of medical educators at al neelain university, sudan sara l brair background/context: quality of teaching practice is an important determinant of graduating doctor competency. in order to achieve this, special emphasis has to be put on the educational development of teachers. al neelain university does not offer medical education courses to teachers; therefore, there is a need to offer such courses and to train teachers in order to improve the quality of education being offered to undergraduate and postgraduate students. aim: al neelain university decided to start a programme of regular training in medical education to all staff working in the institution. the aim of the study was to find out needs and priorities of medical educators at al neelain university regarding such a medical education training programme. methods: medical educators had to rate a predetermined list of medical education topics so as to start their training programme according to the topics most important to their educational practice. 86 july 2012, vol. 4, no. 1 ajhpe abstracts a questionnaire containing a list of all medical education topics was circulated among full time academic staff. answers were rated on a 5-point likert scale of importance. the mean results were calculated for each topic and topics were arranged in a descending order of importance. results: response rate was 77.50%. analysis of the questionnaire showed that among the ῾most important’ topics was student-teacher relationship with a mean value of 4.45. among the ῾important’ topics was microteaching with a mean value of 4.22. ῾moderately important’ topics were philosophies of learning and concept learning with a weighted mean of 3.36. among topics rated as ῾of little importance’ was qualitative research with a weighted mean of 2.59. no topics were rated as ῾not important’. conclusion: the study showed that among ῾most important’ topics is student-teacher relationship, therefore it was recommended to start the training programme with this topic. improving health professions education in sub-saharan africa: what are the needs? elsie kiguli-malwadde, francis omaswa, fitz mullan, seble frehywot background/context: the us government through the presidents emergency plan for aids relief (pepfar), health research and systems management (hrsa) and national institute of health (nih) awarded grants to 13 african institutions in 12 countries. the aim is to increase numbers and quality of healthcare workers and retain them where they are most needed, strengthening medical education system infrastructure and improving locally relevant research capacity in africa. results/findings: the grants are unique in that the schools identified their needs and addressed them accordingly. some emergent themes were identified. most school projects are focussed on curriculum development, faculty development and improving the learning environment through skills laboratories and elearning. the greatest numbers of efforts are aimed at undergraduate training. in the area of curriculum development, schools are reviewing the competencies for their graduates and also the methods of delivery. this is aimed at producing graduates that can meet the needs of their communities. many schools are focussing on training teachers mainly in the basic sciences subjects where there is a great need. all schools are embracing the use of technology in teaching so as to improve access to the internet and educational resources. schools are also establishing research support centres to help improve research. these are aiming at training faculty and students in research methods and ethics, mentoring young faculty and students in conducting research. conclusion: the aim of all this is to try to combat the human resource crisis which though global is worst in sub-saharan africa. the health workforce is an important integral part of health systems strengthening. it is hoped that strengthening the component of training will lead to improvement of population health. expert tutors’ role in capacitating educators in health training institutions in lesotho m c earle, r m marck-katumba, j e chikuse, m m tlapu, n e mabitle, s h phafoli background/context: the ministry of health and social welfare (mohsw) of lesotho is faced with a challenge of shortages human resources and inadequate continuous professional development of educators in health training institutions. the mohsw with assistance from its health development partners developed a 5-year national continuing education strategy to address these challenges. the millennium challenge corporation/millennium challenge account (mcc/mca) contracted the national institute of health and welfare, finland (thl), functioning in lesotho as health systems strengthening technical assistance project (hss-ta project), to recruit 6 expert tutors. the role of the expert tutors is to capacitate the national health training college and the christian health association of lesotho training institutions. the main terms of reference for the expert tutors are: curriculum development, training programme development and implementation, training programme management, quality assurance in training, and monitoring and evaluation. aim/purpose: to illustrate the role of the expert tutors in capacitating educators in health training institutions in lesotho. methods: the needs were identified through focus-group discussions and individual interviews, self-administered questionnaires, as well as review of documents and observation. results and discussion: areas identified for capacitating were: curriculum development, teaching skills, quality assurance, assessment and measurement, mentorship and preceptorship. induction of tutors, research, management structures, strategic planning, clinical laboratories and student support. workshops and mentoring activities were conducted. educators at the training institutions were also exposed to conferences, symposiums and special educational capacity building events. conclusion/take-home message: it is evident that a pool of experts can contribute positively to maximise the quality of human resources for health. recommendation is made for countries with scarce resources to have a pool of experts to be used nationally for capacity building in health education. factors influencing recruitment and retention of faculty at catholic university of health and allied sciences (cuhas) – bugando, mwanza, tanzania stephen e mshana1, mange manyama1, steve justus1, ralf graves2, enoch kwizera3 1. catholic university of health and allied sciences-bugando, mwanza, tanzania; 2. faimer, philadelphia, usa; 3. walter sisulu university, mthatha, south africa. background/context: attracting and retaining faculty is essential for success of any higher learning institution. this has become a major challenge for 87 july 2012, vol. 4, no. 1 ajhpe abstracts higher educational institutions, especially in the newer medical institutions in tanzania. aim: this study was conducted to determine factors favouring recruitment and retention of faculty at cuhas – bugando. methods: using standardised self-administered questionnaires developed after focus-group discussion; a cross-sectional survey was conducted. respondents were asked to rank each factor that might influence recruitment and retention on a 4-point likert scale of: ῾very important’, ῾important’, ῾less important’ or ῾does not apply’. data were analysed using spss. results and discussion: of the 55 questionnaires distributed, 42 (76%) were returned and analysed. the ranks of faculty surveyed were tutorial assistants (16) assistant lecturers (3), lecturers (16), senior lecturers (5) and associate professors (2). opportunity for professional growth, support from colleagues for creative ideas, opportunities for promotion, financial support for scholarly activities and staff collegiality were the top 5 factors which made faculty take up cuhas positions; and the same factors were cited as very important or important determinants of respondents remaining at cuhas. the most important factor for the faculty to accept a cuhas position and remain at cuhas was the opportunity for professional growth. salary was the most important factor for recruitment and retention in only 7.1% of the faculty surveyed. conclusion: the majority of academic staff surveyed were junior and their opportunity for professional growth was the most important factor cited by them in favouring recruitment and retention at cuhas. the university should focus on providing such opportunities to create a favourable environment to attract and retain more academic faculty. further study in relation to other academic ranks is warranted to generate additional recommendations for the owners of these universities in tanzania. stress in medical students in a problem-based learning curriculum s s naidoo, j m van wyk, k moodley, s higgins-opitz background/context: an unintended consequence of any educational programme is the development of maladaptive stress in students. many studies have shown that this can impact on students’ health and their academic outcomes. aim: this cross-sectional study was conducted to explore the prevalence of stress in a diverse cohort of final-year medical students in a problem-based curriculum. methods: a qualitative study was conducted among 94 students representing 66% of the final-year medical cohort in 2008. semi-structured interviews were conducted. data was thematically analysed. results and discussion: seventy eight per cent (n=73) of the participants experienced stress during the programme. of these 49 (67%) were female and 24 (33%) were males. differences were identified between the different racial groups of students. participants identified the following as the main sources of stress: academic-related issues, time management, language difficulties and financial problems. individual lifestyle adaptations, family support and religious structures and study groups were reported strategies used by students to cope with stress. conclusion/take-home message: maladaptive stress is a serious problem in medical students. curriculum designers need to take cognizance of this and take appropriate action to minimise this. all students (including seniors) need guidance and support to manage their time and workload effectively. factors influencing nursing students’ absenteeism from scheduled learning events k kgasi, m randa background/context: student absenteeism creates a negative classroom environment that makes students attending class uncomfortable and the lecturer irritable. it also disturbs the dynamic teaching-learning environment and adversely affects the overall well-being of classes. absenteeism is seen as a waste of educational resources, time and human potential. it causes repetition of teaching, wasting lecturers’ and students’ time. student absenteeism in undergraduate studies is a concern as it results in inefficient or inadequate learning and poor academic performance in certain instances. aim/purpose: to explore the factors resulting in absenteeism among undergraduate nursing students. methods: a qualitative, descriptive explorative research design will be conducted at the university of limpopo, medunsa campus. the focus groups will be held in may 2012. voice recording and field notes will be made during the interviews. the voice recordings will be transcribed and exported to a qualitative data analysis package. content analysis will be done to conclude valid inferences from the data. coding of qualitative data, content analysis and development of themes will be done. the factors influencing undergraduate nursing students’ class attendance will be determined. results and discussion: the data will be presented in the form of graphs, tables and statements. recommendations will be made to improve class attendance. conclusion/take-home message: conclusions to be discussed at conference. using impulse reviewer training sites to engage students in basic research s smith, m barkhuizen, p d theron, d j joubert, i seale, l jones background/context: one option to expand student understanding of basic research is by mentoring and training students as reviewers for the journal impulse. impulse is an international, online neuroscience journal for undergraduate publications. submissions are reviewed by students 88 july 2012, vol. 4, no. 1 ajhpe abstracts worldwide under faculty guidance, and articles are immediately published online, as they are accepted. aim/purpose: as the faculty advisor of a review training site with impulse, many of the concepts of basic research can be introduced through the experience of reviewing primary submissions to the journal. the online journal has been publishing undergraduate neuroscience articles since 2003. currently, the international team of reviewers comprises students that have come from over 65 universities and 10 countries (one in sa – the first site outside us). most reviewers are affiliated with reviewer training sites, where they receive formal training on reviewing. however, the particulars of that training vary from site to site. methods: dr stephanie smith (mb chb), lecturer at the department of basic medical sciences, ufs (sa), was introduced to impulse in october 2010. dr smith acts as faculty advisor for a review team consisting of marizna barkhuizen (associate editor), pd theron, daniël j joubert and inge seale (current 4th-year medical students). these students have completed an undergraduate research project as part of their curriculum. dr smith meets with the review team to discuss their comments on submissions as they arrive. the associate editor compiles the final comments of the team, sends it to the editor-in-chief, who merges all the comments from the different teams into the final review, again, under the guidance of a faculty advisor. this process assures both maximal involvements of as many reviewers as wish to participate as well as professional quality. this final review, commented on by as many as 50 reviewers world-wide, is then sent back to the corresponding author. conclusion/take-home message: faculties are encouraged to consider ways they might enhance the research experience of their undergraduates by hosting a reviewer training site at their institution. evaluation of a workshop to teach techniques for large-group teaching l p green-thompson, p mcinerney background/context: the south african higher education environment is characterised by teaching in large groups of lectures. this is particularly significant in the health sciences environment where there is a growing pressure to increase the numbers of students trained for these scarce skill professions. a 2-hour workshop was conducted by the authors using many of the techniques described in the literature as encouraging active learning. these included buzz groups in pairs, feedback during presentation, automated responses (clickers) and minute papers. aim/purpose: to describe the process used in this faculty development workshop on large-group teaching and comment on the evaluation of this workshop. methods: an evaluation of the workshop was conducted using the minute paper (a recognised technique to enhance active learning). participants were asked to list what they had learnt and what they would use in their ensuing lecturing practice. a second evaluation will be conducted as a second part to this process. results and discussion: all 30 participants completed a minute paper and had a positive response to the workshop. the participants commented positively on the use of the minute paper as the means of evaluation. the learning by the faculty attending the workshop covered a range of areas – new ways of engaging students (20%), active learning techniques (43%), different theories of learning (10%), effective use of power point (30%) and use of clickers (17%). the workshop evaluation has demonstrated that faculty members need training at different levels for large-group teaching. many respondents commented that seeing active learning techniques in action was important. conclusion/take-home message: when conducting faculty development activities, it is important that the theory being taught is also experienced by the participants. workshops and symposia teaching and learning a clinical skill dason evans objectives: this workshop aims to explore how educational theory can inform teaching within medical education. by the end of this interactive workshop, participants will: (i) understand the key choices required in planning clinical skills teaching; (ii) review the major factors affecting student learning; (iii) apply these factors affecting learning in order to critique traditional and more modern approaches to teaching a clinical skill. methods: this interactive workshop will have 2 main components. firstly, participants will teach a simple skill in small groups (no prior knowledge required) and observers within each group will be asked to deconstruct the main choices that were made in doing so. from this the participants will identify some of the key principles to consider when planning and delivering clinical skills training, and these will be related to the literature. these are likely to include aspects from the competency model (purnell, 1998), level of skill (simpson, 1972); instructor behaviour including scaffolding, just in time information (van merrienboer and de croock, 2002), timing of feedback etc; and training design choices including part task vs whole task training, overtraining, spacing and duration (patrick, 2002) the second half of this workshop will ask the participants to identify the key factors affecting student learning through a snowballing exercise. we will use this framework to critique 4 models for clinical skills teaching and learning – the 4-stage/acls approach (peyton, 1998), cagne’s instruction events (o’connor, 2002), the evans-brown approach (evans and brown, in press) and the michels’ framework (michels et al., 2012). outcomes: this workshop will be of interest to those with some experience of teaching clinical skills who would like to know more about how educational theory may validate and help them improve their practice. it will also be relevant to those involved in clinical skills curriculum design and in staff development around clinical skills. 89 july 2012, vol. 4, no. 1 ajhpe abstracts transforming your ‘working’ environment into a place of ‘learning: how to do the job and learn/teach d murdoch-eaton working in a busy clinical environment with the immediacy of pressing and urgent tasks can leave health professionals with a feeling that they never have time to ῾learn’ on the job. contributing to this frustration (and perceived workloads) are the needs of students, also wanting help, guidance and teaching in the clinical environment. this workshop will look at how to facilitate your working environment to become a more effective ῾learning’ environment, utilising the expertise and experiences of the workshop participants together with development of contextually workable ideas integrating workplace learning with adult learning theories and principles. using adult learning theories to plan assessment david taylor when students learn they follow a clear sequence of 4 learning domains, recall, elaboration, organisation and reflection. one of the difficult aspects of designing assessment is working out which learning domains we are testing with each type of question or activity. another is ensuring that we are not only testing recall. the final problem is determining how to give meaningful and useful feedback to the students following or during the assessment. based on a simple plan of adult learning we will work in pairs or small groups to either develop or improve our assessment strategies, to meet each of these objectives. abuse: acknowledgement and action in the medical curriculum theme: ethics veronica mitchell background/context: abuse exists in the south african health system. it occurs in diverse forms at health-care facilities and students frequently confront examples in their clinical contacts. when they witness unprofessional behaviours they face dilemmas, often not knowing how to respond. at the university of cape town, the department of obstetrics and gynaecology has created spaces in the curriculum opening opportunities to explore these difficult issues. aim: this workshop aims to empower participants to initiate conversations about the reality of human rights violations in the clinical teaching platforms. by sharing our experiences in using interactive tutorials, we plan to raise awareness on these challenging matters and to promote change. this workshop will allow participants to learn how these issues have been successfully addressed in a medical student environment. it will provide the attendees with techniques and skills to introduce similar methods in their own environments. methods: at the workshop we will use a participatory methodology to initiate a collective dialogue among educators. the methods and the results from our facilitated student workshops will be explored by attendees so that techniques may be successfully employed in their own situations. existing literature underpinning abuse causes and an innovative reflective framework will be shared. results: the learning outcomes will be tabled and the students’ feedback after the teaching sessions will be presented so that participants can judge their usefulness and applicability to their circumstances. discussion: moving from silence to dialogue on issues concerning abuse requires innovative approaches and trusting relationships. by collaboratively exploring the realities of practice into which students are immersed, transformative practices can be promoted. take-home message: abuse is a difficult topic to address in a training curriculum. innovative methods have contributed towards developing students’ awareness and ability to respond in a sensitive and appropriate fashion to abuse in the workplace. student support ... what a challenge ... ? theme: selection/support/retention aziza bawoodien background/context: student support forms an integral part of endeavouring to optimise student success and throughput. stellenbosch university has a multi-, transand interdisciplinary approach to student support. the core team consists of an educationalist, family physician, and clinical and educational psychologist. we also utilise the services of speech and language therapists, psychiatrists and university social and financial services. much experience has been derived from working with students and the interventions implemented, with many successes and some failures. aim/purpose: to generate discussion between participants. best practice methodologies utilised by peer faculties could be determined, and the development of a network of student supporters could be fostered. methods: a workshop by means of case studies, hold with fellow student supporters to create and stimulate group discussions. the case studies will be representative of the different modalities of support or interventions utilised. all attempts at maintaining confidentiality of the cases under discussion will be ensured by removing all characteristics that could serve as identifiers of the cases. attempts will also be made to minimalise marginalisation or stereotyping of characters based on language, religion or cultural groups unless specific reference has a pertinent influence on the discussion of the case. results and discussion: the discussions generated may identify evidencebased pedagogical and psychological theories and practice, on which student supporters can build to enhance own practice and to develop further research in this field. conclusion/take-home message: it is the moral obligation of institutions to enable students selected into programmes in the health sciences to succeed and progress back into society to fulfil societal commitments and service delivery. 90 july 2012, vol. 4, no. 1 ajhpe abstracts the design, implementation and evaluation of the new academic tutorial programme in the school of medicine at the university of the free state with a view to improve throughput rates and student retention m jama, m koning, l damons background/context: student retention has been and is still a challenge for universities internationally and nationally. in an effort to improve throughput rates and student retention, the school of medicine at the university of the free state (ufs) has, in collaboration with the centre for teaching and learning (ctl), among other strategies designed and implemented a new academic tutorial programme (natp). this is a structured programme designed to increase mastery of content in ῾highrisk’ modules. the programme was first implemented in the pre-clinical phase of the mb chb programme in 2007 and extended to the clinical phase in the department of internal medicine since 2011. purpose: the purpose of the symposium is to describe and discuss how the natp has been customised and how it has contributed in improving the throughput rates and student retention in the ufs school of medicine. type of workshop/symposium: presentation and discussion of the natp by the 3 authors. intended outcomes: (i) explain the design, implementation and evaluation of the natp; (ii) elucidate how the natp has contributed towards the academic performance of students; and (iii) share the views of the tutors who have been involved in the natp. healthcare students’ inter-professional learning in a skills centre i treadwell background/context: an outcome for newly graduated healthcare workers highlights the importance of teamwork and the understanding and appreciation of the roles, responsibilities and skills of other care workers. the majority of students are however not exposed to formal inter-professional learning (ipl) events in order to form realistic expectations of each others’ roles and scope of practices. since studies indicate that ipl is facilitated by experiential learning, the skills centre at medunsa introduced interprofessional trauma simulations using high-fidelity simulators and sps. senior medical, nursing and occupational therapy students are scheduled to take part in these events. aim/purpose: at the end of the workshop participants should be able to develop events for ipl learning in their respective institutions. structure: (1) share with participants our experience in: (i) simulated management of a traumatised patient in the pre-hospital, initial in-hospital and outpatient phases by an inter-professional team of undergraduate students; (ii) effect of ipl on students’ attitudes towards and perceptions of roles and responsibilities of a profession other than their own. (2) individual identification by participants of feasible opportunities in their own institutions. (3) facilitation of small groups in the development of a (i) tool to prepare for selected ipl events, based on a template comprising the scenario and sequence of events, pre-requisite skills and knowledge, expected outcomes, problem identification, equipment, sp training, moulage, preparation of students, management of problems based on the model of clinical judgment; (ii) mark scheme for technical and non-technical skills. constructing high quality multiple choice questions (mcqs) scarpa schoeman background/context: although the use of mcqs is a popular and costeffective method of assessment in healthcare education, the quality of the questions can sometimes be problematic. this adds more variables to the eventual outcome of the assessment and increases the inherent difficulty of the assessment. to maximise the advantages and reduce the technical disadvantages the national board of medical examiners (nmbe) have written a manual on the lessons they as a body have learned in the last 20 years of running large scale mcq licensing exams for medical students in the usa. the valuable tips and pitfalls they highlight in their manual will form the basis for this workshop. aim/purpose: the aim of this workshop is to facilitate participants in the writing of high quality mcqs, based on the 2003 nmbe manual. this will be done by explaining which types of mcqs are the most appropriate to use in assessing clinical knowledge of medical (or other healthcare) students. apart from some general guidelines on writing good mcqs, the presenter will focus on how to write mcq that will assess clinical application of medical knowledge in particular. methods: during the first component of the workshop, the basic concepts and principles of writing high quality mcqs will be shared (summarising the nmbe manual). in the second component the participants will have the opportunity to build new or modify their mcqs under the guidance of the presenter. participants are requested to bring a charged laptop to the workshop with the idea to work on their own mcqs electronically. the presenter will provide examples and templates for the different mcq formats. diagnostic reasoning – how can we help? janet grant this workshop will look at the nature of clinical problems and the challenges of making a diagnosis. the importance of the content, organisation and accessibility of information in the clinician’s memory will be stressed. common errors will be reviewed. participants will be invited to complete the diagnostic thinking inventory to analyse their own thinking, as well as undertaking a variety of teaching and learning exercises that can be used to help students and trainees to improve their own clinical reasoning and diagnostic processes. 91 july 2012, vol. 4, no. 1 ajhpe abstracts social accountability: crafting the southern african definition l p green-thompson centre for health science education, university of the witwatersrand background/context: a global consensus on the social accountability of medical schools was achieved at the end of 2010. there is a growing international trend towards the development of health professions education which are responsive to the needs of the society’s in which the education occurs. the author is embarking on postgraduate studies in the area of social accountability; in particular, looking at the nature of the professional who a society identifies as socially accountable. the workshop will assist in defining the role players/stakeholders in the local health environment. purpose: the aim of this workshop will be to examine what social accountability means in the southern african context. establishing and reenforcing networks to reflect on the characteristics of a socially accountable health professional. type of workshop: interactive with small-group discussion. intended outcomes: at the end of this workshop, participants will have (i) developed a common understanding of social accountability; (ii) reflected on the characteristics of the individual health professional and the features of their practice which make them socially accountable. now that i believe in simulation, where do i start (without excessive costs)? bosseau murray this workshop will present methods to introduce cost-effective simulation based on a needs analysis, i.e. identifying weak areas in the present curriculum? what do the trainees not ῾get’? many concepts of simulation focus on videotaping a crisis event with a full human, robotic simulator, and then debriefing (reflecting with) the participants, using the videotape. such a system typically requires a financial investment in a full human simulator (us$25 000 – 250 000), plus a high fidelity simulation facility (us$ millions). however, there are alternatives based on an understanding of (a) the very broad range of simulators (e.g. part task trainers and flat-screen simulators starting at us$100s 1 000s) and (b) the ῾strategies to use simulators’ (see introductory plenary abstract). description of the workshop: the workshop participants will be introduced to various cheaper simulator alternatives (including home-grown equipment, flat-screen simulators, and commercial lung simulators.) the participants will also be given an outline of the elements of a simulation session. the participants will then split up into smaller groups. each group will plan and develop (under guidance) a training session appropriate for a specific level of trainee, based on an identified need. the simulators selected for each group will include: a homemade simulated lung using endotracheal tubes and anaesthesia reservoir bags (cost us$25); a flat-screen simulator programme (anesoft) to practise drugs and dosages needed during crisis ($100); a simple resuscitation mannequin with an electrocardiogram (ecg) and pulse oximeter simulator producing vital signs (many bio-medical departments have ecg and pulse oximeter simulators to test equipment, and most healthcare training institutions already own resuscitation mannequins).after reconvening, the various newly developed scenarios will be discussed and further developed. an open question-and-answer period will encourage further specific discussion. examples of successful (published) scenarios will be given, as well as inter-professional education (ipe). conclusion: based on the needs of the trainees, there are multiple innovative and cost-effective ways to start using simulation to gain experience with this teaching modality. using experiential learning in your teaching practice – a practical workshop j brown experiential learning is a popular way of teaching and learning in medical education; it is particularly helpful to skills and professionalism learning, and can be applied to any topic that requires students to try out new behaviours or skills in small groups and receive feedback on performance. this workshop will provide participants with an opportunity to take part in an experiential-learning group and try out facilitation skills in a practical way. by the end of the workshop participants will: (i) have explored a working model of a roleplay session including the importance of feedback; (ii) have taken part in a roleplay session as either a learner, facilitator or simulated patient; and (iii) have reflected on the use of experiential learning as part of the teaching repertoire. teaching teachers to teach large groups l p green-thompson, p mcinerney background/context: there are increasing numbers of students being taught in health science faculties across the country. while many institutions have espoused small-group learning as ideal, there are many situations in which teaching a large group of students can be both effective and appropriate. purpose: the aim of this workshop will be to explore the techniques of active learning which may be employed in a large-group teaching environment. type of workshop/symposium: skills workshop, in a large venue, which will encourage the participation of all those attending. intended outcomes: at the end of this workshop, participants will be able to (i) reflect on their own learning styles and link these to dominant theories of adult education; (ii) reflect on the use of lectures as a means of learning knowledge; (iii) evaluate a range of active teaching strategies and situations in which these may be applied; and (iv) use an automated response system. abstracts 92 july 2012, vol. 4, no. 1 ajhpe engaging with the challenges of small-group learning lorna olckers, lindiwe dlamini background/context: the education of health science students has undergone significant change. in keeping with the principles of the primary healthcare approach, graduates must be able to work effectively in dynamic diverse multi-professional teams. in order to facilitate this type of learning, teaching methodologies have shifted from didactic to student-centred small-group techniques. small-group facilitators therefore need to be able to work with both ῾task’ and ῾process’ and understand how groups function including group processes, phases and dynamics. they also need to be able to balance the needs of individual group members against those of the student group itself. this can be extremely challenging. purpose: the purpose of this workshop will be to explore and further develop understanding and experience in small-group facilitation techniques. type of workshop/symposium: this workshop will be experiential and participant-centred. educational and group theory will be used to explore small-group learning techniques including ῾task’ and ῾process’, group dynamics and processes. participants will be asked to draw on their own experiences. intended outcomes: small-group learning is about more than achieving outcomes. this workshop will explore this complex but exciting process and assist educators with techniques in small-group facilitation. clinical skills teaching in a medical environment lin de bruyn clinical skills unit, school of medicine, university of the free state background/context: clinical skills facilities where preclinical medical/ nursing students are taught to manage patients. activities include teaching and practising procedures, taking a patient’s history, examination of patients. problems encountered are related to: numbers of students, assessment, ῾patients’ on whom to practise skills related to managing a patient, selection and procurement of manikins, care of manikins and equipment etc. purpose: to identify and discuss mutual challenges and possible solutions/ strategies to resolve the problems related to clinical skills teaching. type of workshop/symposium: open round-table discussion of matters submitted by attendees, lead by representatives from the various clinical skills teaching facilities. intended outcomes: to be able to use the information gathered to the advantage each clinical skills facility. 140 october 2016, vol. 8, no. 2 ajhpe research despite being one of the most frequently used investigations in medical practice, studies in the 1990s revealed that some doctors lack basic skills when interpreting an electrocardiogram (ecg).[1,2] these findings were disturbing, as the optimal management of a number of potentially lifethreatening conditions requires prompt and accurate interpretation of an ecg. recommendations were made to improve the teaching of ecg interpretation.[1] regrettably, even in the 21st century, studies suggest that medical schools struggle to equip students with the knowledge and skills to interpret ecgs.[3-5] this has also been the case at the school of medicine (som), university of the free state (ufs), bloemfontein, south africa, with external examiners in the final examinations repeatedly commenting on the poor performance of students in interpreting ecgs. one of the reasons why students struggle to interpret ecgs could be that most medical education teachers have primarily had lecture-based experiences, with no role-models who employed other strategies, such as tutoring.[6] because of limited training on how to teach students, these teachers are more proficient as traditional lecturers and subject matter experts. understandably, they tend to feel uncomfortable in assuming the role of a tutor. when they assume this role, they become passive and uninvolved, which is contrary to the principles of tutoring, which require active learning strategies.[6] these are student-centred strategies that engage students in learning activities, providing opportunities to reflect, evaluate, analyse and synthesise information, thus improving memory and test performance.[7] generally, most tutor programmes are peer facilitated and led, with senior students assuming these roles. there has been debate on whether tutors should be content experts, with some arguing that a number of content experts do not necessarily have the skills to facilitate the process of learning. however, the main focus in tutoring is to combine the process of learning and mastery of content;[8] hence the importance of training tutors. at ufs, all the tutors undergo compulsory training, during which they are equipped with skills to apply active learning strategies. this is also the case with registrars who tutor final-year students with regard to ecgs. context undergraduate training for medical students at som, ufs is offered as a 5-year programme, leading to a degree in medicine (mbchb) and is structured in three phases. in phases i and ii, the content of the curriculum is arranged in thematic or system-based modules, while phase iii is devoted to clinical medicine. students commence clinical training in their 3rd year, during which they are introduced to internal medicine, surgery, paediatrics, obstetrics and gynaecology, and psychiatry. training in ecg interpretation includes formal lectures on electrophysiology during the preclinical years, and didactic ecg interpretation lectures during the clinical years.[9] new academic tutorial programme in an attempt to improve final-year medical students’ knowledge and skills in ecg interpretation, the department of internal medicine developed a tutorial programme in 2011 to form part of the new academic tutorial programme (natp). natp is one of the university’s support programmes established in 2007, designed to provide students with the opportunity to receive feedback on their understanding of concepts and further help them to develop the required skills to maximise their chances of success in module-specific assessment. the design and implementation of the programme is based on the principles of supplemental instruction.[10] this is an academic support programme that was developed at the university of background. since the 1990s, studies have reported the inability of medical schools to equip students with knowledge and skills to interpret an electrocardiogram (ecg). this has also been the case at the school of medicine, university of the free state, bloemfontein, south africa, with external examiners in the final examinations repeatedly commenting on the poor performance of students with regard to interpreting ecgs. subsequently, the department of internal medicine designed small-group tutorials using animations and analogies as methods to improve the ecg interpretation skills of students. objectives. to improve students’ ability to interpret ecgs and assess their perceptions of the tutorials. methods. a questionnaire was administered to 67 final-year medical students after their internal medicine rotation in 2012. the objective of the questionnaire was to obtain feedback on students’ experiences and perceptions of ecg tutorials. results. although the results do not provide evidence that the above mentioned methods improved the students’ competency to interpret ecgs, the limited findings from their perceptions might assist in the further use and improvement of such an approach to facilitate learning. conclusion. this article highlights the responsive efforts and willingness of registrars in the department of internal medicine to improve the teaching of a major and frequently used investigation such as the ecg, and how registrars formalised these two methods into tutorials. afr j health professions educ 2016;8(2):140-143. doi:10.7196/ajhpe.2016.v8i2.451 the electrocardiogram made (really) easy: using small-group tutorials to teach electrocardiogram interpretation to final-year medical students m p jama,1 bcur, pgdch, mhe, phd; j a coetser,2 mb chb, mmed (int med) 1 division of health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of internal medicine, medical education unit, school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: m jama (jamamp@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 141 research missouri, kansas, usa in 1973, with the objective to specifically increase academic performance of students in traditionally ‘high-risk’ subjects as opposed to ‘high-risk’ students.[10,11] unlike the peer-facilitated model used in supplemental instruction and other departments at the university, where senior students tutor junior students, tutorials in the department of medicine are facilitated by registrars. all the tutors in natp, including registrars, are trained, equipping them, for example, with skills to facilitate learning using active learning strategies. at som, the programme is customised by using small-group tutorials to equip students with knowledge and skills to interpret an ecg. although the attendance is not compulsory, all final-year students attend the ecg tutorials. initially, only one tutorial session per small group was offered, but on demand by the students, it was later increased to two sessions on consecutive days. in the first session, the electrophysiological principles behind ecg tracings of common cardiac conditions are reviewed. methods such as animations and analogies are used to facilitate learning and promote retention of knowledge. the second session is more practical and various ecg examples are interpreted by applying principles learnt in the previous session. small-group tutorials small-group tutorials have been advocated as a way of promoting active learning for medical students, thus providing opportunities for interactive demonstrations,[12,13] as is the case for medical students at ufs. this method of teaching is an important component of medical education, especially in curricula that employ problem-based learning.[13] steinert[14] identified characteristics of small-group teaching that include the following: (i) tutor characteristics; (ii) a non-threatening group atmosphere; (iii) group interactions; (iv) clinical relevance and integration; and (v) pedagogic material that encourages problemsolving and thinking. moreover, small-group teaching is one of the common features of teaching in the clinical years, especially when facilitated by a respected staff member who is a role-model.[15,16] clinical medical teachers seem willing to facilitate small-group teaching.[15,17] however, the challenge facing medical schools is to implement programmes that allow these teachers to act as role-models and mentors for students.[18] opportunely, in the case of som, natp has provided an environment for willing registrars to act as tutors and become role-models and mentors. small-group discussions have been found to enhance retention of knowledge, while positively affecting motivation and activation of prior knowledge.[19] in combination with these tutorials, the registrar/resident responsible for teaching ecgs incorporated animations and the use of analogy to assist students in gaining knowledge and skills in ecg interpretation. animations teachers are constantly looking for ways to integrate theory and practice by using new technology, thus helping students to experience innovative, more attractive and effective forms of learning.[20,21] using methods such as animations, phenomena that might be difficult to visualise can be illustrated, with the possible added advantage of depicting dynamic information explicitly.[20-23] computer animations can be used effectively in medical education by illustrating dynamic changes over time and location, while facilitating understanding of complex concepts, systems, or structures, thus allowing visualisation of relationships among component parts.[20] the use of animations in teaching and learning contributes to what ruiz et al.[23] refer to as cognitive theory of multimedia learning, which purports that ‘people receive and process information via two separate but interdependent pathways, one for verbal (words) inputs and another for visual (images) inputs’. consequently, learning can be more effective when information is received via visual and verbal inputs. also, animations can support the knowledge-building process.[24] the visualisations and symbols enhance human cognitive capacities and facilitate transfer of concepts and information, but they must be accompanied by preand post-explanations and discussion to address misinterpretations.[24] applying these ideas, the registrar responsible for the ecg small-group tutorials designed animations using paint (microsoft, usa) and powerpoint (microsoft, usa) to enable students to visualise ecg changes. in particular, an animation was used to explain the prolongation of the pr interval, depicting the heart and its conduction system on the left and an ecg tracing on the right, where the pr interval prolonged subsequent to the impulse delay in the atrioventricular node. analogies another method employed during the tutorials was the use of an analogy, which is defined as a process where similarities between two concepts are identified. one concept is familiar (the analogue) and the other unfamiliar, usually a scientific concept (the target).[25] stated differently, analogies assist in describing or explaining unfamiliar concepts or phenomena by referring to another situation that is similar to the situation being considered.[25] bryce and mcmillan[26] also refer to the term ‘bridging analogies’, where the learner is taken from the easily understood everyday base analogy to the target concept through a series of intermediate analogies intended to smooth the transition between familiar and unfamiliar concepts. teachers can therefore integrate analogies in their teaching to assist students’ conceptual understanding of a phenomenon, mindful that most students must be familiar with the analogy for it to be effective.[27] a familiar analogy was used in the tutorials to create context, provide a general outcome, and bridge unfamiliar and familiar concepts by referring to the popular movie, the matrix, produced by the wachowski brothers in 1999. just as the main character neo and his counterparts were able to discern real-world images in squiggles on a computer screen, a student could, by the completion of the sessions, expect to ‘see’ what is occurring in the conduction system of the heart by looking at the squiggles of an ecg tracing. during the session, students were often encouraged to go into the ‘matrix mode’ when dealing with gradually more complex ecg problems. another successful analogy was used to assist students with the conceptual understanding of a grade 2 atrioventricular block (mobitz type 1) (fig. 1). fig. 1. wenckebach v. the disinterested girlfriend. in this analogy, a boyfriend sends his girlfriend an email, represented by the p-wave (a). the girlfriend’s reply is represented by the qrs complex (b), while the time she takes to reply is represented by the pr interval (c). as the girlfriend loses interest, she takes even longer to reply (the increasing pr interval), until one day, she does not reply (d). ultimately, the boyfriend gets a new girlfriend (e). 142 october 2016, vol. 8, no. 2 ajhpe research methods a questionnaire was administered to 67 final-year medical students after their rotation in internal medicine in 2012. of these students, 25 were from the english and 42 from the afrikaans class. students were requested to write about their experiences and perceptions of the ecg tutorials. a response rate of 100% was achieved. the main objective of the questionnaire was to obtain information on the students’ self-perception of the ecg tutorials, which can broadly refer to a variety of variables, such as academic success or failure.[28] moreover, students’ performance can be associated with how they feel about themselves, with some studies suggesting that there is a positive relationship between self-perception and academic outcomes.[29] in some cases, students’ self-perception can be better predictors of academic performance than objective measures.[30] in this study, self-perception refers to the final-year students’ own perception of how the use of small-group tutorials aided them in interpreting ecgs. the responses from the questionnaire were read and re-read to obtain a sense of the data, thus discovering meanings, patterns and connections.[31] furthermore, the data were coded to break these down into categories and themes, and to conceptualise and link the themes to the students’ written responses.[32] three main categories were identified: (i) positive perceptions; (ii) negative perceptions; and (iii) suggestions. results tables 1 3 show the three main categories, themes, number of responses per theme and examples of actual statements from students. discussion although the results are limited to a small group of students, most of them had positive perceptions about the tutorials. it seems as though the tutorials might have assisted these students to simplify and clarify ecg interpretation. the use of microsoft paint and power point as animations might have aided in visualising difficult phenomena and making the information explicit.[20-23] also, it seems as if the use of animations and analogies within the small-group tutorials provided the students with an approach to and an understanding of the interpretation of an ecg. the use of the matrix movie, encouraging the students to go into a ‘matrix mode’ and the girlfriend and boyfriend analogy might have aided them with understanding more complex phenomena, thus assisting with conceptual understanding.[27] table 1. positive perceptions theme students, n (%) actual statements tutorials aid in simplifying/ clarifying ecg interpretation 27 (40) ‘session was most informative and simplified.’ ‘the ecg tutorial helped me to understand interpreting an ecg in a much more easy and meaningful way.’ ‘it gave me a lot of clarity.’ ‘i enjoyed this method of teaching, it is simple and understandable.’ tutorials help with an approach to interpreting an ecg 23 (34) ‘very helpful in my approach to ecgs and helped a lot with practical ways to interpret an ecg when you do not have ages to sit in front of the ecg.’ ‘it gave me a stepwise approach to interpret an ecg. after having these tutorials, i was able to interpret ecgs at the internal medicine morning meetings, anaesthesiology and paediatrics.’ ‘it helped me in forming a good approach to ecgs and therefore took away the daunting feelings.’ ‘i am now able to approach all the ecgs because of the teaching i’ve received.’ tutorials aid in understanding an ecg 20 (30) ‘the ecg tutorials were extremely helpful. i understood more of the interpretation of the ecg than i did in any other lecture.’ ‘for the first time i understood the ecg and physiology of it and could remember it later on. he was exceptionally practical. months later i am still applying what he has taught me.’ ‘it helped me to understand an ecg and gave me a systematic way to interpret an ecg. it was very helpful.’ ‘ecg has been taught to us since the 2nd year in physiology. i only really understood it after dr …'s tutorial.’ ‘made ecg more understandable and comprehensive for me; a broader knowledge and allowed me the ability to ask questions in an interactive informative class setting.’ tutor characteristics 10 (15) ‘he is patient with students who are struggling to grasp content and unlike other consultants when he explains.’ ‘dr … was insightful, patient and friendly.’ ‘dr … is an amazing doctor, and his patience with us and willingness to help us, really inspired us greatly!’ ‘dr … was friendly and enthusiastic.’ ‘the environment was relaxed and you were able to feel comfortable to ask questions table 2. negative perceptions theme students, n (%) descriptions preferred other tutorials 2 (3) ‘it was a good session for revision, but the ecg session we paid for presented by people from outside the faculty was of great value.’ ‘session presented by dr … was a good “recap” on what i already knew, but i think it lacks detail, because i wouldn’t have been able to understand it from the beginning.’ no impact experienced 1 (1) ‘not yet – because i had it late in my rotation.’ october 2016, vol. 8, no. 2 ajhpe 143 research another positive aspect was the tutor’s characteristics.[14] this was possibly supported by the training that the tutor received, combining the process of learning and mastery of content with the tutorials being facilitated by a subject expert who is also a clinical medical teacher.[8] although the majority of this small number of students had positive perceptions about the tutorials, a small number (4%) had negative perceptions. the latter finding must be investigated; more especially the discovery that students have to pay outsiders to teach them. this study has implications for teaching and learning in the undergraduate medical curriculum at som, ufs. based on responses from students, it is apparent that ecg interpretation tutorials need to be provided earlier in the medical curriculum and the number of sessions must be increased. judging from the statements about the need for extra tutorials, introducing these earlier in the curriculum, expanding the sessions into a lecture series, and the appreciation expressed for these sessions, one can conclude that the students had a need for more comprehensive, integrated and practical training on ecg interpretation. they were even willing to seek outside help. conclusion although the small-group tutorials and incorporated methods such as animations and analogies are relatively new and have only been evaluated in one group, from the limited data provided it seems as if these methods might have assisted towards equipping students with the knowledge and skills to interpret an ecg. as these tutorials are relatively new, there is a need to conduct a longitudinal study to evaluate the impact of tutorials on the academic performance of students. this article further places the spotlight on the responsive efforts and willingness of registrars in the department of internal medicine, ufs to improve the teaching of such a significant and frequently used investigation as the ecg. acknowledgements. this research forms part of the new academic tutorial programme in the centre for teaching and learning at ufs. references 1. gillespie md, brett ctf, morrison wg, pringle sd. interpretation of the emergency electrocardiogram by junior hospital doctors. j accid emerg med 1996;13(6):395-397. doi:10.1136/emj.13.6.395 2. montgomery h, hunter s, morris s, naunton-morgan r, marshall rm. interpretation of electrocardiograms by doctors. bmj 1994;309(6968):1551-1552. doi:10.1136/bmj.309.6968.1551 3. mahler sa, wolcott cj, swoboda tk, wang h, arnold tc. techniques for teaching electrocardiogram interpretation: self-directed learning is less effective than a workshop or lecture. med educ 2011;45(4):347-353. doi:10.1111/j.1365-2923.2010.03891.x 4. matthias ta, indrakumar j. competency of final year medical students in ecg interpretation – an experience of a medical school in south asia. asian stud med j 2013;13(6):1-6. 5. jablonover s, lundberg e, zhang y, stagnaro-green a. competency in electrocardiogram interpretation among graduating medical students. teach learn med 2014;26(3):279-284. doi:10.1080/10401334.2014.918882 6. dolmans dhjm, gijselaers wh, moust jhc, de grave ws, wolfhagen ihap, van der vleuten cpm. trend in research on the tutor in problem-based learning: conclusions and implications for the educational practice and research. med teach 2002;24(2):173-180. doi:10.1080/01421590220125277 7. smith cv, cardaciotto la. is active learning like broccoli? student perceptions of active learning in large lecture classes. j scholar teach learn 2011;11(1):53-61. 8. leary h, walker a, shelton be, fitt mh. exploring the relationships between tutor background, tutor training, and student learning: a problem-based learning meta-analysis. interdisc j prob based learn 2013;7(1):40-66. doi:10.7771/1541-5015.1331 9. university of the free state. faculty of health sciences yearbook. bloemfontein: ufs, 2013. 10. university of the free state. new academic tutorial programme: a_step. centre for teaching and learning. bloemfontein: university of the free state, 2013. 11. dawson p, van der meer j, skalicky j, crowley k. on the effectiveness of supplemental instruction: a systematic review of supplemental instruction and peer-assisted study sessions literature between 2001 and 2010. rev educ res 2014;84(4):609-639. doi:10.3102/0034654314540007 12. walton h. small-group methods in medical teaching. med educ 1997;31(6):459-464. doi:10.1046/j.13652923.1997.00703.x 13. euliano ty. small group teaching: clinical correlation with a human patient simulator. adv physiol educ 2001;25(1-4):36-43. 14. steinert y. students’ perceptions of effective small-group teaching. med educ 2004;38(3):286-293. doi:10.1046/ j.1365-2923.2004.01772.x 15. branch wt jr. small-group teaching emphasizing reflection can positively influence medical students’ values. acad med 2001;76(12):1171-1172. doi:10.1097/00001888-200112000-00001 16. kaufman d, mann kv. basic sciences in problem-based learning and conventional curricula: students’ attitudes. med educ 1997;31(3):177-180. doi:10.1111/j.1365-2923.1997.tb02562.x 17. hendry gd, ryan g, harris j. group problems in problem-based learning. med teach 2003;25(6):609-615. doi:10.1080/0142159031000137427 18. dolmans dhjm, schimdt hg. what do we know about cognitive and motivation effects of small group tutorials in problem-based learning? adv health sci educ 2006;11(4):321-336. doi:10.1007/s10459-006-9012-8 19. gracía rr, quirós js, santos rg, gonzález sm, fernanz sm. interactive multimedia with macromedia flash in descriptive geometry teaching. comput educ 2007;49(3):615-639. doi:10.1016/j.compedu.2005.11.005 20. pinter r, radosav d, čisar sm. analyzing the impact of using interactive animations in teaching. int j comput commun contr 2012;7(1):147-162. 21. lauer t, müller r, ottmann, t. animations for teaching purposes: now and tomorrow. j univers comput sci 2001;7(5):420-433. 22. o’day dh. the value of animations in biology teaching: a study of long-term memory retention. cbe life sci educ 2007;6(3):217-223. doi:10.1187/cbe.07-01-0002 23. ruiz jg, cook da, levinson aj. computer animations in medical education: a critical review of literature. med educ 2009;43(9):838-846. doi:10.1111/j.1365-2923.2009.03429.x 24. falvo da. animations and simulations for teaching and learning molecular chemistry. int j technol teach learn 2008;4:68-77. 25. treagust df. the evolution of an approach for using analogies in teaching and learning science. res sci educ 1993;23(1):293-301. doi:10.1007/bf02357073 26. bryce t, mcmillan k. encouraging conceptual change: the use of analogies in the teaching of action-reaction forces and the ‘at rest’ condition in physics. int j sci educ 2005;27(6):737-763. doi:10.1080/09500690500038132 27. harrison ag, treagust df. teaching with analogies: a case study in grade 10 optics. j res sci teach 1993;30(10):1291-1307. doi:10.1002/tea.3660301010 28. meltzer l, katzir t, miller l, reddy r, roditi b. academic self-perceptions, effort, and strategy use in students with learning disabilities: changes over time. learn disabil res pract 2004;19(2):99-108. doi:10.1111/j.1540-5826.2004.00093.x/pdf 29. saunders j, davis l, williams t, williams h. gender differences in self-perceptions and academic outcomes: a study of african american high school students. j youth adolesc 2004;33(1):81-90. doi:10.1023/a:1027390531768 30. colbeck cl, cabrerra af, terenzini pt. learning professional confidence: linking teaching practices, students’ self-perceptions, and gender. rev higher educ 2001;24(2):173-191. doi:10.1353/rhe.2000.0028 31. de vos as. combined quantitative and qualitative approach. in: de vos as, strydom h, fouchè cb, delport csl, eds. research at grass roots for the social sciences and human service professions. pretoria: van schaik, 2005. 32. nieuwenhuis, j. qualitative research designs and data gathering techniques. in: maree k, ed. first steps in research. pretoria: van schaik, 2007. table 3. suggestions theme students, n (%) descriptions earlier provision of tutorials 11 (16) ‘i advise that the class should be given in the 4th year already.’ ‘could have been of value to have something like it in the 4th year – for repetition.’ ‘i would have preferred to practise this earlier in the 3rd or 4th year, because it would have helped me much more to interpret ecgs in the ward.’ ‘i would just suggest that it should be presented in the 4th year already and again in the 5th year for revision.’ ‘i feel that the ecgs should be dealt with earlier in the course, since it is asked a lot in the wards, but our knowledge is limited.’ ‘feel that it would be more of value earlier in the course.’ ‘i think it would have been better if we already had this lecture in our 4th year with dr … .’ ‘i feel that the tutorial should be presented early in the 4th year at the start of internal medicine rotation; it would be of much greater value then.’ need for more ecg tutorials 8 (12) ‘my only wish is that we could have more sessions with him, not only starting in the 5th year but in the 4th year.’ ‘i think more sessions should be included in the 5th year.’ ‘would like more sessions with dr … .’ ‘perhaps an additional session would help even more.’ http://dx.doi.org/10.1136/emj.13.6.395 http://dx.doi.org/10.1136/bmj.309.6968.1551 http://dx.doi.org/10.1111/j.1365-2923.2010.03891.x http://dx.doi.org/10.1080/10401334.2014.918882 http://dx.doi.org/10.1080/01421590220125277 http://dx.doi.org/10.7771/1541-5015.1331 http://dx.doi.org/10.3102/0034654314540007 http://dx.doi.org/10.1046/j.1365-2923.1997.00703.x http://dx.doi.org/10.1046/j.1365-2923.1997.00703.x http://dx.doi.org/10.1046/j.1365-2923.2004.01772.x http://dx.doi.org/10.1046/j.1365-2923.2004.01772.x http://dx.doi.org/10.1097/00001888-200112000-00001 http://dx.doi.org/10.1111/j.1365-2923.1997.tb02562.x http://dx.doi.org/10.1080/0142159031000137427 http://dx.doi.org/10.1007/s10459-006-9012-8 http://dx.doi.org/10.1016/j.compedu.2005.11.005 http://dx.doi.org/10.1187/cbe.07-01-0002 http://dx.doi.org/10.1111/j.1365-2923.2009.03429.x http://dx.doi.org/10.1007/bf02357073 http://dx.doi.org/10.1080/09500690500038132 http://dx.doi.org/10.1002/tea.3660301010 http://dx.doi.org/10.1111/j.1540-5826.2004.00093.x/pdf http://dx.doi.org/10.1023/a:1027390531768 http://dx.doi.org/10.1353/rhe.2000.0028 17 december 2009, vol. 1, no. 1 ajhpe letter to the editor: i wish to use this opportunity to introduce readers of the african journal of health professions education to the mphil in health sciences education (hse) programme that has been offered by the centre for health sciences education (chse), faculty of health sciences, stellenbosch university, since 2008, in collaboration with the faculty of education and the centre for teaching and learning at the same university. the programme was developed with assistance from educational experts from all the above-mentioned environments as well as professor peter bouhuijs, professor emeritus of medical education, maastricht university, and extraordinary professor, stellenbosch university. the 2-year programme is offered in mixed-mode format as either a structured or research masters degree. a week-long face-to-face contact session takes place at the beginning of each of the 2 academic years (february) at the chse. the remainder of the programme is offered by way of distance learning using the webct/blackboard platform. the structured programme is modular, with 12 modules presented over the 2 years, including one elective module per year. a research assignment in the final year carries 60 of the programme’s 180 saqa credits. the other modules are all assessed by way of written assignments. there are currently 26 students enrolled in the programme – students from all parts of south africa as well as botswana, ghana and pakistan. they are all part-time students and represent a spectrum of health professionals, including nurses, speech-language and hearing therapists, physio therapists, medical doctors, etc. in the public and private sectors and at all managerial levels, including one dean. the programme has recently received the honour of being recognised by the foundation for the advancement of medical education and research (faimer) (http://www.faimer.org/) in the usa as one of four such programmes worldwide for which faimer fellows and fellows of its four regional institutes can enrol with a scholarship from faimer. the other three programmes are offered by the universities of maastricht, dundee and chicago-illinois. readers can obtain more detailed information about the programme at http://www.sun.ac.za/chse or by writing to me at bbvh@sun.ac.za. professor ben van heerden mphil in hse programme coordinator director, chse information about the mphil in health sciences education at stellenbosch university 176 november 2015, vol. 7, no. 2 ajhpe research the confidence and competence levels of primary healthcare (phc) nurse specialists are essential skills that are required when assessing a patient holistically. the phc nurses need excellent clinical skills and require basic knowledge to think critically and analytically. good confidence and competence levels will enable these specialists to think beyond the normal practice, be creative and innovative in finding better ways to assess and manage their patients, and ensure a safe and cost-effective practice. for phc nurses to be confident and competent when assessing a patient, it is suggested that they are taught in a student-centred environment.[1] moreover, to ensure that phc students are eventually safe and competent practitioners, it is essential that they develop their skills by practising and be declared competent before working in a clinical setting. by practising their clinical skills as a learning strategy, the students simultaneously improve their levels of competence and confidence. it was observed in the clinical field that if the confidence and competence levels of the phc nurses are inadequate when assessing patients, they are unable to assess the patient effectively and holistically. it is a concern when assessing a patient in the clinical field, as the safe management of patients may be seriously compromised. ‘simulation is an approach to teaching and learning which is defined as a device that presents as a simulated patient (or part of a patient and interacts appropriately with the actions taken by the simulation practitioner).’[2] educators have suggested that active learning and student participation produce better educational outcomes.[1] according to langlois and thach,[3] there is no single way of teaching in a clinical setting. clinical teachers may adapt their styles to reflect the situations that arise. however, various educationalists describe approaches to learning in the cognitive, affective and psychomotor domains by emphasising bloom’s taxonomy.[4] larkin and burton[5] further argue that using the framework of bloom’s taxonomy of educational objectives assists staff members to critically evaluate the patient’s scenario to prevent future patient complications. it measures the cognitive, affective and psychomotor domains. bloom’s taxonomy has long been the average framework among clinical nurse educators and staff development co-ordinators for designing learning experiences, thus providing general guidance in the development of learning objectives.[6] ming su et al.[7] state that the revised bloom’s taxonomy provides a framework to help educators to clarify their proposed objectives and design suitable education and assessment methods. furthermore, harton[6] states that learning in each domain builds on previously acquired knowledge – from simple to complex. according to meyer and van niekerk,[4] achieving the ultimate level in each domain depends on mastering previous levels. students may not be able to solve problems if they do not know what the problem involves or how to go about solving it. therefore, educators must systematise the actions for students so that they are able to carry them out. the planned systemisation guides educators in selecting teaching and assessment strategies.[4] the use of a human patient simulator (hps) provides a method by which students can participate in clinical decision-making, practise skills and observe outcomes from clinical decision-making.[8] according to brannan et al.,[8] it was anticipated that the use of the hps may develop students’ cognitive skills and clinical confidence levels. it is important that students are fully prepared when assessing and examining patients. bloom’s taxonomy is the focus of cognitive, affective and psychomotor domains, which are essential approaches to learning.[4] background. given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the students’ perception of using simulation laboratories. objectives. a descriptive qualitative research design was used to determine whether participants ‘believe’ they have gained competence and confidence to assess a patient holistically. methods. purposive sampling of 10 individual interviews and a focus group of 7 participants was drawn from primary healthcare students who successfully completed the programme the preceding year. data were collected by 2 trained fieldworkers and transcribed by the researcher (nn). ethical approval was obtained from the health research ethics committee, faculty of medicine and health sciences, stellenbosch university, cape town, south africa, and informed consent from the participants. results. the data that emerged from the data analysis were coded and categorised into themes and subthemes. the following 5 themes emerged: simulation as a teaching method; a manikin offering effective learning; confidence in clinical practice; structure of the course; and a support system. the researcher compiled a written account of the interpretations that emerged from the data analysis and verified these with the fieldworkers. furthermore, member checking was done on 2 of the participants from the focus group and 2 of those from the individual interviews to validate the transcribed data. the findings suggest that the manikin should be upgraded regularly and be able to register a response. data showed that the students are in favour of simulation as a foundation phase in their programme, but preferred to be introduced to a human being. conclusion. simulation as a clinical teaching method ensured a good foundation phase, but students felt more competent and confident after practising on humans. afr j health professions educ 2015;7(2):176-179. doi:10.7196/ajhpe.363 nursing students’ perception of simulation as a clinical teaching method in the cape town metropole, south africa n nel, bcur, mcur, pgnd: health assessment, treatment and care, pgnd: management, pgnd: education; e l stellenberg, dcur, rn, rm division of nursing, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: n nel (natalievdmerwe@sun.ac.za) november 2015, vol. 7, no. 2 ajhpe 177 research lamb[9] substantiates that students’ clinical confidence may increase with simulator experience, as simulation enables the student to practise skills before working with patients. to ensure that phc students eventually become skilled and competent practitioners before entering the clinical field, it is essential to develop their skills by practising. the principal investigator (pi) observed – in the clinical field – that if the confidence and competence levels of the phc nurses are inadequate when assessing patients, they are unable to assess patients holistically. a phc nurse working in a clinical field must be able to apply the necessary skills and knowledge required when assessing a patient holistically. haigh[10] argues that simulated practice in university settings offers the potential for reflection and deep learning. a deep approach to learning is student centred and involves a search for understanding. students must therefore think actively about what they are doing. one of the elements that fosters a deep approach is active learning, where the student is actively involved.[4] clinical simulation is a method of active learning that offers students a wide range of learning opportunities, including ways of applying theory to practice by bringing principles learned in the classroom to life.[1] by using simulation as a teaching method, it prepares students to face real-life situations. according to stefanski and rossler,[11] simulation has come to the forefront as an effective teaching modality in teaching the science of nursing. it is important that students are fully prepared when assessing and examining patients. however, the pi observed that phc students studying at our university failed to adequately acquire the required clinical confidence and competence to assess the ‘real’ patient. at this university these students predominantly practised and acquired their clinical skills with laboratory simulations. many students verbalised that they did not feel competent or confident to assess patients holistically after having practised on artificial manikins. this raised serious concerns for academic lecturers who applied this teaching and learning strategy, as ultimately patient safety might seriously be compromised. this study explored the perceptions relating to the use of laboratory simulation, a method applied to teach clinical skills to postgraduate phc students to specifically develop their clinical confidence and competence levels as required of phc nurses in clinical practice. purpose of the study the first level of care, according to the phc policy applicable in south africa (sa), prescribes that it should be managed by phc nurses without the support of medical practitioners.[12] access to quality public services is the rightful expectation of all sa citizens.[12] most of these citizens are employed in a no-work, no-pay service and therefore expect an effective and efficient service. by completing this study, the appropriate learning strategy was identified and applied to produce confident and competent phc nurses to ultimately ensure an effective and efficient service in phc. the purpose of this article is therefore to describe the research based on the perceptions of students who followed the phc postgraduate programme at a selected university in sa. as part of developing clinical competence and confidence, these students were first exposed to the use of the simulation laboratory before they had any clinical encounter with a patient. problem statement with regard to the discussion above, the low confidence and inadequate competency levels demonstrated by phc students in the clinical field, despite their interaction in a simulation laboratory, may compromise patient safety. it therefore became imperative that a scientific investigation be undertaken to explore the perceptions of postgraduate phc students who used simulation laboratories as a learning strategy. research question the following research question guided the study: ‘what are the perceptions of postgraduate phc students utilising simulation laboratories as a clinical teaching method?’ objectives were set to determine whether participants ‘believed’ that they had gained competence and confidence to assess the patient holistically. methods research design and sample this study followed a descriptive qualitative approach that explored the perceptions of postgraduate phc students who were taught clinical skills utilising simulation laboratories. the target population comprised parttime phc students who obtained the diploma in primary health care in 2010 at the university chosen for the purpose of this study in the cape town metropole in sa. this university was selected purposefully as it enrolled an average of 120 students per year who followed a postgraduate diploma in phc. this university specifically used simulation laboratories as a teaching method to teach clinical skills to these students. a purposive sample of 10 individual interviews and a focus group of 7 participants was drawn from this population of successful students. these students were purposively selected to ensure the variability of the sample. more participants would be drawn should data saturation not be achieved after the 10th interview. data saturation was met after these interviews. pilot study a pilot study was conducted on one of the participants to test the feasibility of the study; these results are not included in this study. trustworthiness the trustworthiness of this study was established according to guba and lincoln.[13] credibility credibility was assured by being satisfied that the participants understood the questions well and agreed to the accuracy of the transcribed data. member checking was done with 2 of the participants from the focus group and 2 from the individual interviews to have the transcribed data validated. transferability a conceptual theoretical framework based on bloom’s taxonomy and the use of more than one method of data collection strengthened transferability. dependability dependability was assured by the use of a tape recorder to ensure that all the information given by the participant was recorded. a second fieldworker took notes during the interviews with the participants. all interviews were conducted in the same manner by using an interview guide. the data were transcribed and analysed after each interview and verified by a fellow researcher, 2 fieldworkers who collected the data, and an expert in qualitative research. the researcher and fieldworkers discussed the transcribed data and clarified differences of opinion to ensure that the 178 november 2015, vol. 7, no. 2 ajhpe research interpretation of the transcripts was congruent with the recorded interview. the analysis of the data and the themes and subthemes was further verified by the supervisor of the researcher. conformability member checking was done. hence, the participants in this study were given an opportunity to be informed of the results of the study and make further recommendations. the participants, however, did not make any further recommendations. data collection an interview guide was designed based on the objectives of the study, the literature review and the researcher’s professional experiences. two trained fieldworkers were responsible for collecting the data to prevent bias, as the researcher is a lecturer at the university. participants were quoted verbatim in the transcriptions, as it assisted in confirming the data collected. thereafter, the researcher read and reread the transcriptions. one of the fieldworkers had a guideline with open-ended questions, which guided the interviews in order to collect the data. the fieldworker conducted the interviews in the university’s seminar room – in agreement with the participants. the participants gave signed permission that the interviews could be recorded with the use of a tape recorder. the second fieldworker, a phc nurse, had no role in the interviewing of the participants but documented and recorded the interviews. ethical considerations consent was obtained from each participant for taking part in the study and the use of audioand written recordings of the interviews. the participants were assured of anonymity. permission to conduct this study was obtained from the health research ethics committee, faculty of medicine and health sciences, stellenbosch university. all ethical principles were adhered to. data are locked and stored in a safe place for at least 5 years – only the pi has access to the safe. data analysis the transcription of the interviews was done by the researcher to familiarise herself with the data. in this manner she became familiar with the data as these were gathered. data were analysed according to tesch’s[14] 8-step model. the data that emerged from the data analysis were coded and categorised into themes and subthemes. coding, elaboration and recording continued until no new insights appeared. the written account of the interpretations that emerged from the data analysis was verified with the fieldworkers. presentation of findings the first theme was labelled ‘simulation as a teaching method’, where participants spoke willingly about their perception of simulation during their 1-year postgraduate diploma in phc studies. a number of participants stated that the use of simulation prepared them for what to expect in the clinical setting. ‘it helped me a lot, it gave me an idea how to start and where to start … .’ ‘ … for me i would say that simulation was the foundation of, … but not the ultimate.’ the second theme related to ‘a manikin offers effective learning’. the use of a manikin is one of the simulation methods the students were exposed to – they felt that the manikin was outdated. they also thought that communication was a very important aspect and wanted ‘something’ to communicate with them. they expressed the need to be exposed to different anatomical challenges of human beings before entering the clinical field. ‘with a doll, you don’t know are you working too rough or too soft, because the doll can’t tell you that, they can’t communicate.’ the third theme was ‘confidence in clinical practice’. participants indicated that they gained confidence when exposed to practising on human beings. even though they practised repeatedly on manikins, their confidence developed slowly. a few of the participants stated that their confidence developed with time. it took them a few months of practising to be confident enough to examine a patient. ‘i practised on my family and that gave me confidence cause you interact with a person while you learn.’ the fourth theme was the ‘structure of programme’. when asked whether it was feasible to use simulation in phc, all 17 participants agreed that it must be used. they verbalised the need to interact with patients at an earlier stage; hence the reason why they did not find the manikin effective as a clinical teaching method. ‘if i had a choice then i would have wanted the practical to start in the clinics.’ the fifth theme consisted of the ‘support system’. simulation is a good starting point; however, students expressed the need to be introduced to a human being before entering the clinics. they took the initiative to practise on their family or friends at home to build their confidence. most of the participants stated that the support and practice sessions among students were wonderful and benefited them in their studies. ‘ ... we were a team, and worked as a team. we helped each other that way, if we forgot something the other one remembered it.’ discussion the results have shown that the use of simulation as a teaching method in postgraduate teaching of phc nurses’ skills is effective to some extent. it is pivotal that the phc nurses are well prepared to assess a patient competently and confidently, as the safety of patients’ lives are at stake. according to ward-smith,[15] simulation learning is used to promote clinical competence and reflective thinking skills. the norms and standards set out by the department of health[12] emphasise that phc is at the heart of the strategy to change the health services in sa. an integrated package of essential phc services available to the entire population will provide a solid foundation for a single, unified health system. phc nurses, after completion of a postgraduate programme in phc, become independent clinical nurse practitioners in the sa context and are expected to function without the support of a doctor. there was much debate among members of the focus group about the use of manikins as a learning method. some of the participants felt that manikins were not needed, but agreed that they were a good starting point, while most enjoyed working with them. most of the participants emphasised that they should be introduced to a human being, because the manikins were anatomically ‘perfect’ and differed from human beings, who have excess fat and skinfolds, which are absent in manikins. the participants also november 2015, vol. 7, no. 2 ajhpe 179 research found it problematic that the manikin could not communicate verbally and non-verbally, creating a barrier in developing affective skills and obtaining subjective data during an assessment phase – a much-needed requirement when assessing patients. to develop competence, multiple practice sessions are required to enable a student to competently assess a patient, as this is a gradual process. furthermore, competence in assessing patients should include practising on human beings. positive and negative opinions were obtained from the participants with regard to their perceptions of simulation laboratories. all the participants finally agreed that simulation is a ’good starting point’ in the clinical programme. moreover, they referred to simulation as a foundation phase that prepares them for what to expect when working with a patient. the participants felt that the use of simulation is positive in a clinical programme, but would have preferred to be introduced to a human being before working with patients, as the human being made them feel more confident. the use of an hps provides a method by which students can participate in clinical decision-making and practice skills and observe outcomes from clinical decision-making.[8] according to brannan et al.,[8] it was anticipated that the use of the hps may develop students’ cognitive skills and confidence levels. the cognitive domain involves knowledge and development of intellectual skills, including the recognition of specific facts, procedural patterns, and concepts that serve in the development of intellectual abilities and skills.[16] the participants felt that by practising on people individual confidence to assess a patient increased. the results of the study are supported by bloom’s taxonomy. firstly, the students obtain new knowledge, which is the theory of the programme that forms part of the cognitive domain. to develop competence, theory is applied by practising on the manikin in order to become competent. during the progression of their skills the students develop the affective domain, which does not happen if only simulation is used. during practice sessions the students start contemplating new ways of becoming more skilled and competent, which supports the psychomotor domain. the study focused on the perception of the postgraduate phc students utilising simulation laboratories at one university. it excluded other institutions offering a similar programme. the study excluded other disciplines such as medicine and physiotherapy, which also have a clinical component in their programmes. further research is therefore recommended in this regard. conclusion the participants in the 1-year postgraduate diploma in phc perceived the use of simulation laboratories as positive, yet felt that they should be introduced to reality at a much earlier stage of the programme. practising on human beings as models made them more competent and confident to assess patients holistically in the clinical field. simulation is an excellent teaching method to prepare the student in terms of what to expect and a starting point for the development of confidence, but the results showed that by practising on a human being prepared them for the clinical setting. it is suggested that the manikins should be upgraded on a regular basis and match the actual clinical setting. in this manner the use of simulation as a teaching strategy may complement the clinical setting, to which students will ultimately be exposed. acknowledgements. the authors would like to thank the students who agreed to participate in this study. references 1. haider e. clinical simulation: a better way of learning? nurs manag (harrow) 2009;16(5):22-23. 2. gaba dm.the future vision of simulation in health care. quality and safety in health care 2007;12(1):2-10. 3. langlois j, thach s. teaching and learning styles in the clinical setting. family medicine 2001;33(5):344-346. 4. meyer s, van niekerk s. nurse educator in practice. cape town: juta, 2008. 5. larkin bg, burton fj. evaluating a case study using bloom’s taxonomy of education. aorn j 2008;88(3):390402. [http://dx.doi.org/10.1016/j.aorn.2008.04.020] 6. harton bb. clinical staff development: planning and teaching for desired outcomes. j nurses staff dev 2007;23(6):260-268. 7. ming su w, osisek pj, starnes b. applying the revised bloom’s taxonomy to a medical-surgical nursing lesson. nurse educ 2004;29(3):116-120. 8. brannan jd, white a, bezanson jl. simulator effects on cognitive skills and confidence levels. j nurs educ 2008;47(11):495-500. 9. lamb d. could simulated emergency procedures practices in a static environment improve the clinical performance of a critical air support team (ccast)? a literature review. intensive and critical care nursing 2007;23:33-42. 10. haigh j. using simulation to prepare students for interprofessional work in the community. j nurs educ 2007;7(2):95-102. 11. stefanski rr, rossler kl. preparing the novice critical care nurse: a community-wide collaboration using the benefits of simulation. j contin educ nurs 2009;40(10):443-451. [http://dx.doi.org/10.3928/00220124-20090923-03] 12. department of health. the primary health care package for south africa – a set of norms and standards. pretoria: government printer, 2000. http://www.doh.gov.za/docs/policy/norms/full-norms.html (accessed 2 may 2011). 13. guba eg, lincoln ys. fourth generation evaluation. beverly hills: sage, 1985. 14. tesch r. qualitative research: analysis types and software tools. bristol: farmer, 1985. 15. ward-smith p. the effect of simulation learning as a quality initiative. urol nurs 2008;28(6):471-473. 16. clark dr. big dog & little dog’s performance juxtaposition: bloom’s taxonomy of learning domains, 2010. http://www.nwlink.com/~donclark/hrd/bloom.html (accessed 2 may 2011). research 30 may 2016, vol. 8, no. 1 ajhpe this article explores how vygotsky’s zone of proximal development (zpd) can be applied to the teaching and learning of health science professionals in higher education. zpd provides a conceptual understanding of how developmental potential might be understood within health science education in south africa (sa). vygotsky [1] defined zpd as ‘the distance between the actual developmental level as determined by independent problem-solving and the level of potential development determined under adult guidance or in collaboration with more capable peers’. furthermore, it celebrates the importance of the ‘social other’. according to vygotsky,[1] social interaction precedes development, and consciousness and cognition are the end-products of socialisation and social behaviour. zpd refers to a conceptual space/ gap between what students know and what they need to know.[1] this space generates a unique opportunity for academics to design learning activities that may facilitate the development of student agency and preparedness. lecturers are therefore mediators in zpd for student learning to occur and for students to become more active as learners. thus the interaction between lecturer and student encourages more positive outcomes for the latter. in sa, the education needs at universities include addressing a general lack of academic preparedness, multilingual needs in english-medium settings, large class sizes and inadequate curriculum design.[2] the challenge for higher education institutions not only relates to increasing the throughput of students and diversity of the student population, but also involves the provision of quality education. many university courses are theory driven, without much thought to students’ real-world experiences. therefore, their ability to link theory and practice may be compromised.[2] a higher education report on student experiences posits that the existing cohort of students is not necessarily underprepared, and that failure to succeed lies more in systemic weaknesses in higher education.[3] therefore, there is a need for academics to fully understand students’ thinking to deliver educational practices that will allow them to achieve their full potential, while bearing in mind that learning takes place on the basis of social activity.[4] while sa’s higher education system leads that of its african peers in research and postgraduate attainment, it is deeply affected by the same educational inequalities and poor educational performance that characterise the school system.[5] furthermore, there is an indication that students who are not sufficiently prepared are not equipped to deal with self-directed approaches.[6] in a crosscultural study, considerable variation is observed between students in four settings with regard to perceptions of preparedness for higher education.[7] lecturers are important role-players in the learning context for students, and the latter, in turn, are important role-players in the teaching environment for lecturers.[8] one of the principal objectives of a health science course is that students should progressively gain the ability to identify the relevant learning issues. these should encompass all disciplines to facilitate an adequate understanding of the clinical situation in need of improvement and to enable students to formulate clinical judgements and action plans. each student’s prior knowledge helps to inform other students in the class by identifying essential learning needs.[9] therefore, educational experiences are only as effective as students’ engagement with them,[10] because students determine how much effort is required to engage in the learning process, and real learning takes place through this engagement. ‘agentic’ has been used to describe students who assert agency in their learning. billet[11] describes them as ‘learners who are pro-active and engaged in making meaningful and developing capacities in ways that are intentional, effortful and are actively critical in constructing their knowledge’. therefore, students’ readiness to take up and engage with the invitations being offered to them is central to their learning.[11] guided by vygotsky’s zpd, the purpose of this study was to examine the relationship between students’ perceptions of their preparedness, learning experiences and agency in the faculty of community and health sciences (fchs), university of the western cape (uwc), cape town, south africa. the context for this study is an interprofessional health sciences faculty. approximately background. one of the more discernible needs that challenges universities is addressing the level of preparedness of students entering the higher education environment. students expect to participate in active learning, while at the same time adopting a certain level of agency to successfully pass through higher education. objective. to determine the relationship between student preparedness, learning experiences and agency of students in the faculty of community and health sciences (fchs), university of the western cape (uwc), cape town, south africa. methods. a cross-sectional study was conducted on 266 (n=578) conve nience sampled 3rd-year students in the fchs. data were collected with an instrument constructed from items of evaluation from the departments in the fchs and other validated instruments. results. findings suggest that 3rd-year students perceive themselves as moderately prepared on enrolling at uwc (mean (sd) 13.74 (1.86)); current learning experiences are favourably indicated (94.04 (15.32)). on average, students perceive themselves to be agents of their own learning (51.56 (8.79)). furthermore, a significantly positive relationship was found between learning experiences and agency. conclusion. this study broadens our understanding of the vygotskian perspective of the zone of proximal development, where students bring their own knowledge, interact with lecturers who scaffold their learning, and then become agents in their own learning. afr j health professions educ 2016;8(1):30-32. doi:10.7196/ajhpe.2016.v8i1.490 relationship between student preparedness, learning experiences and agency: perspectives from a south african university n v roman,1 phd; s titus,2 ma; a dison,3 phd 1 department of social work, faculty of community and health sciences, university of the western cape, cape town, south africa 2 department of sport, recreation and exercise science, faculty of community and health sciences, university of the western cape, cape town, south africa 3 teaching and learning, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: s titus (sititus@uwc.ac.za) research may 2016, vol. 8, no. 1 ajhpe 31 2 700 undergraduate students are enrolled across nine departments/schools (nursing; physiotherapy; occupational therapy; social work; psychology; dietetics; natural medicine; public health; and sport, recreation and exercise science). we are not aware of studies that have examined the relationship between the variables for this study. methods this article forms part of a larger study that sought to investigate the learning needs of health science students at a university in southern africa. a cross-sectional study was conducted on 266 (n=578) 3rd-year students from eight departments/schools in the fchs. sample participants for this study were a convenience sample of 266 students in their 3rd year of study towards a degree registered in a health science faculty. academic co-ordinators for 3rd-year programmes in the faculty allowed the research assistants access to their 3rd-year classes. data were collected using a modified self-administered instrument completed by students from eight different departments/ schools that offer undergraduate programmes. research instrument the questionnaire was constructed from other relevant ones, including that by v bozalek et al. (unpublished report on the competitive research grant received from the council for higher education, 2008). the instrument consists of scales and subscales that measure preparedness, learning experience, prior learning experience, self-esteem, perceptions of academic literacy and numeracy skills, and student agency. the instrument was piloted before implementation to determine the time it would take to complete, and to ascertain whether there were any items that would require amendments. the instrument showed high reliability with a cronbach α of 0.85. procedures departments and schools in the health sciences faculty were invited to participate in the study. all departments assigned a 3rd-year cohort to the project. students from these cohorts were invited to participate and provided informed consent. data were collected face-to-face by research assistants assigned to the project. these assistants informed participants of the objectives of the project, the nature of the questionnaire, that participation was voluntary, and that they could withdraw at any time without undue consequences. the questionnaire took approximately 15 20 minutes to complete. permission to conduct the research was obtained from the senate research grants committee and the ethics committee at uwc. all information was strictly confidential and pseudonyms were used to protect anonymity of the participants. data analysis data were double captured in microsoft excel 2010. after matching both sets of data, the clean data were imported into spss statistics version 20 (ibm, usa) for analysis by means of descriptive and inferential statistics. descriptive statistics included percentages, means and standard deviations. crosstabulations were conducted in terms of gender. inferential statistics included a correlation and linear regression analysis. an r-value of 0.0 0.2 suggests a weak relationship, 0.3 0.5 a moderate relationship and 0.6 1.0 a strong relationship. results four hundred questionnaires were distributed to the 3rd-year students (n=578), of which 266 were returned, indicating a response rate of 67%. seventytwo percent of the respondents were female. the majority of respondents were from the psychology department (table 1). the mean (sd) age of the participants was 23.57 (4.91) years. english was the first language of the majority of participants (48%); 61% did not have work experience before entering university; 47% considered their socioeconomic status as average; 41% had previously attended a historically disadvantaged school (41%); and 58% identified themselves as coloured. for the purpose of this study, historically disadvantaged schools are those situated in poverty-stricken areas, mostly townships, rural and farm areas, which are characterised by poor socioeconomic conditions and poor educational infrastructure and resources.[12] the results in table 2 show that the majority of students considered themselves to be moderately prepared (13.74 (1.86)) and their learning experiences to be favourable (94.04 (15.32)). on average, students perceived themselves to be agents of their own learning (51.56 (8.79)). further crosstabulations were conducted in terms of gender. the results suggest that 43% of females and 38% of males were moderately prepared for university, even though the majority of participants were female. moreover, a correlation indicated significant positive relationships between student learning experiences and student preparedness (r=0.16; p<0.01), as well as student learning experiences and student agency (r=0.34; p<0.05). no relation ship was found between student preparedness and student agency. two linear regression analyses were conducted (table 3) to predict student agency. student learntable 1. demographic profile of students in the faculty of community and health sciences, uwc variables students, n (%) gender female 187 (72.5) male 71 (27.5) faculty of community and health sciences psychology 80 (30.1) nursing 55 (20.7) sport, recreation and exercise science 35 (13.2) physiotherapy 30 (11.3) social work 24 (9.0) dietetics 15 (5.6) natural medicine 16 (6.0) occupational therapy 9 (3.4) ethnicity coloured 151 (58.1) black 75 (28.8) indian 17 (6.4) white 17 (6.4) living arrangements both parents 123 (47.7) only mother 49 (19.0) in residence 33 (12.8) only father 1 (0.4) language english 123 (47.5) afrikaans 66 (25.5) isixhosa 52 (20.1) type of school previously attended historically disadvantaged school 107 (41.3) ex-model c school 98 (37.8) independent school 30 (11.6) work experience prior to entering university no 161 (61.0) yes 103 (39.0) perceived current socioeconomic status very disadvantaged 13 (5.0) disadvantaged 38 (14.7) average 122 (47.3) advantaged 73 (28.3) very advantaged 12 (4.7) research 32 may 2016, vol. 8, no. 1 ajhpe ing experiences in the classroom accounted for 11.3% of the variance for student agency. student preparedness did not predict student agency. discussion this study provides the first known information with regard to the relationship between student preparedness, learning experiences and agency. a large proportion of students are enrolled in the psychology and nursing fields – two of the largest departments in the faculty; however, the responses are a representation of a range of views from students across the faculty. participants reported that they were moderately prepared for university. this is not surprising, as a significant number of students are underprepared when entering higher education settings,[13] regardless of gender. while the current challenge facing higher education institutions is not only about increasing throughput in terms of numbers and diversity of student population, it also involves ensuring quality education. therefore, educational needs at universities should include addressing a general lack of academic preparedness, multilingual needs in english-medium settings, large class sizes and inadequate curriculum design.[2] despite the moderate level of preparedness, a positive relationship between perceptions of student preparedness and learning experiences was observed. one of the major factors relating to low graduation rates in sa higher education is underpreparedness of students.[14] therefore, if students are better prepared for higher education before entering university, their experience in higher education should be greatly enhanced. however, it is a huge undertaking for a higher education institution to attempt to redress inequalities in the formal education system to address the underpreparedness of students. these findings are similar to those of brüssow and wilkinson [15] with regard to learning experiences and underprepared students, where students also had favourable learning experiences. many university courses are theory driven, and assume that students have knowledge of real-world experiences that lead to them linking theory and practice.[2] the higher education report on student experiences suggests that students are not necessarily underprepared, and that failure to succeed lies more in systemic weakness than in higher education.[3] this implies a need for a deeper understanding of students who strive to achieve their full potential. this study showed a positive relationship between learning experiences and student agency. much has been said about poor graduation rates and a diminished learning culture among students. this study negates these arguments, proving that there is an indication that students who have a better learning experience take more responsibility for their own learning. the results also provide an understanding of the vygotskian perspective of the role of the learning experience for underprepared students to become agents of their own learning, i.e. that lecturers provide the learning experience for students to function optimally and be self-directed within the space of the zpd. student agency cannot and should not be ignored in the teaching and learning process.[16] students’ power (their agency) cannot be ignored as they negotiate their needs, which can be overdetermined by their social background, available resources, campus organisations and external pressures. agency is seen as an important empowering and disempowering factor, as it enables and constrains the interpretation of actions, society and social interactions with people.[14] conclusion this study was limited to one of the 24 higher education institutions in sa. the sample inclu ded a larger proportion of females, which may suggest a bias, but moderate preparedness was found for all students regardless of gender. the study indicates that there is a very enmeshed and complex relationship between teaching and learning, which may further be complicated by other factors, which were not the focus of this study. however, our study showed that students who are better prepared for the higher education setting have better learning experiences. these settings may provide higher education specialists with a unique opportunity in zpd to provide academic activities that enhance a positive learning experience. acknowledgements. the authors would like to acknowledge the participants in this study for their meaningful contribution, and the directorate of teaching and learning at the university of the western cape for their funding assistance. references 1. vygotsky ls. mind in society: the development of the higher psychological processes. cambridge, mass: harvard university press, 1978. 2. jaffer s, ng’ambi d, czerniewicz l. the role of icts in higher education in south africa: one strategy for addressing teaching and learning challenges. international journal of education and development using information and communication technology 2007;3(4):131-142. 3. council on higher education (che). access and throughput in south african higher education: three case studies. pretoria: che, 2010. 4. kinginger c. defining the zone of proximal development in us foreign language education. applied linguistics 2002;23(2):240-261. 5. fisher g, scott i. closing the skills and technology gap in south africa. background paper 3: the role of higher education in closing the skills gap in south africa. cape town: world bank, 2011. 6. mcmillan vk, parke s. remedial/developmental education approaches for the current community college environment. new directions for community colleges 1997;25(4):21-32. 7. byrne m, flood b. a study of accounting students’ motives, expectations and preparedness for higher education. journal of further and higher education 2005;29(2):111-124. [http://dx.doi.org/10.1080/03098770500103176] 8. richardson jte. students’ approaches to learning and teachers’ approaches to teaching in higher education. educ psychol 2005;25(6):673-680. [http://dx.doi.org/10.1080/01443410500344720] 9. cooke m. integrating knowledge in clinical practice. in: alavi c, ed. problem-based learning in health science curriculum. new york: routledge, 1995:104-115. 10. richards j, sweet l, billett s. preparing medical students as agentic learners through enhancing student engagement in clinical education. asia-pacific. j cooperative educ 2013;14(4):251-263. 11. billett s. developing agentic professionals through practice-based pedagogies. final report for australian learning and teaching council (altc) associate fellowship. strawberry hills, nsw: altc, 2009. 12. xaba m, malindi m. entrepreneurial orientation and practice: three case examples of historically disadvantaged primary schools. s afr j educ 2010;30(1):75-89. 13. slominsky l, shalem y. reading below the surface. students’ organization of content and form. council for higher education monitor 2010;10:81-109. 14. council on higher education (che). the state of higher education in south africa. pretoria: che, 2009. 15. brüssow s, wilkinson a. engaged learning: a pathway to better teaching. s afr j higher educ 2010;24(3):374-391. [http://dx.doi. org/10.4314/sajhe.v24i3.63444] 16. luckett k, luckett t. the development of agency in first generation learners in higher education: a social realist analysis. teaching in higher education 2009;4(5):469-481. [http://dx.doi.org/10.1080/13562510903186618] table 2. associations between variables variables minimum maximum mean (sd) student learning experiences student preparedness 11 19 13.74 (1.86) 0.16* student agency 26 78 51.56 (8.79) 0.34† student learning experiences 50 128 94.04 (15.32) *correlation significant at the 0.05 level (two-tailed t-test). †correlation significant at the 0.01 level (two-tailed t-test). table 3. regression analyses predicting student agency predictor b se b β δr² 1 constant (student agency) 45.52 4.55 student preparedness 0.44 0.33 0.09 2 constant (student agency) 33.04 3.56 student learning experiences 0.20 0.04 0.34* 11.3 *regression is significant at p<0.05 level. articlearticle background. limitations in physiotherapy curricula have been reported. work-based experiences, especially during compulsory community service, could inform curricula. objective. to develop a model of community service physiotherapy to guide curriculum reform. methods. in this appreciative inquiry, trained physiotherapy students conducted tele-interviews with newly graduated physiotherapists. twelve recently graduated community-service physiotherapists – heterogeneous in gender, mother tongue, university attended and work setting – were purposively recruited. two coders applied tesch’s coding technique to the transcripts; one did paper-based work and the other used atlasti software. consensus was reached and a member check done. results. four themes identified were: (i) the essence of community physiotherapy; (ii) the collaborative nature of community physiotherapy; (iii) prerequisites for a positive practice environment; and (iv) community physiotherapy as a gateway to personal growth and professional development. physiotherapists consult clients from varied cultural backgrounds, ages and health and disease profiles. health education is a key intervention, but clients emphasised therapeutic touch. team work enhances services, especially within a context of poverty, and prevents isolation. new graduates have to deal with inefficient management, lack of transport, inadequate equipment and needs resilience. they want discipline-specific supervision. conclusion. community physiotherapy makes specific demands, especially for novice therapists. service-learning in authentic diverse contexts would foster professional development and cultural competence. clinical competency should remain the backbone of the curriculum, complemented by competency in health education. different ways of reflection would facilitate lifelong learning and growth in attributes such as resilience, which is necessary for dealing with sub-optimal practice environments. ajhpe 2013;5(1):19-25. doi:10.7196/ajhpe.203 a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision k mostert-wentzel,1 mphyst, mba; j frantz,2 phd; a j van rooijen,1 phd 1 department of physiotherapy, university of pretoria, pretoria, south africa 2 department of physiotherapy, university of the western cape, cape town, south africa corresponding author: k mostert-wentzel (karien.mostert@up.ac.za) local healthcare practices should underpin competency-based curricula, drawing from global knowledge and best practices. in spite of the emphasis on the interrelatedness of healthcare education and the healthcare environment, and on the social accountability of institutions, ‘content, organisation, and delivery of health professional education have failed to serve the needs and interests of patients and populations’.[1] notwithstanding curriculum changes in response to demands in the health sector, limitations in physiotherapy curricula have been reported.[2] work-based training assessments to guide the development or improvement of education programmes are uncommon, also in physiotherapy.[3] integration of literature and policy documents or consulting with experts is used when developing entry-level programmes. however, newly graduated community-service physiotherapists would be a more appropriate source to determine enhancements needed in the undergraduate physiotherapy curriculum. compulsory community service as a strategy to improve staffing has been implemented in more than 70 countries.[4] since the inception of compulsory community service in south africa, the experience of a compulsory service year has been investigated in other professionals, such as dieticians,[5] speech-language therapists and audiologists[6,7] and physiotherapists.[2] some findings from these studies included system and management deficiencies, such as the lack of profession-specific supervision, limitations due to language and cultural diversity, and skills not covered sufficiently during training. on the positive side, most of these young professionals felt that they had gained skills and confidence and had meaningfully contributed to healthcare. recommendations from these studies focused on policy and management issues, and less on education, except for ramklass’s study. [2] this study was, however, limited to one education institution and one province. a further limitation of these studies is that they used research instruments with questions arranged along broad topics. with this approach participants may over-emphasise the constraints of their community-service experience, as was the case with speech-language therapists and audiologists in the study by paterson, et al.[5] only one concept in their model was positive, i.e. ‘professional growth and improved service’. this concept had no explicit elements listed in the model’s diagram. on the other hand, 14 elements were listed under ‘obstructions and constraints’ that led to ‘stunted professional growth and poor services’. the aim of our study was to explore the experiences of community-service physiotherapists during a compulsory community-service year in south africa as a point of departure for curriculum reform, using an appreciative inquiry framework.[8] a principle of this stance is that words shape reality, and that a positive approach creates energy, compared with traditional ways of investigation with questions about needs/challenges. in contrast to deficit approaches, appreciative inquiry uses what is already working well for possible further improvement. 19 may 2013, vol. 5, no. 1 ajhpe article may 2013, vol. 5, no. 1 ajhpe 20 methods study design this study used a qualitative contextual ex ploratory design. sample physiotherapists who were in their year of compulsory community service, or had completed it in the preceding four years, were approached to take part in the study. a combination of sampling methods was used. purposive sampling was employed where physiotherapists, known to the interviewers and who would be able to provide rich information, were recruited telephonically. in addition, snowball sampling led to four referrals. heterogeneousness in terms of gender, mother tongue, university attended, work setting (urban or rural), including community settings, clinics, and hospitals (public or military), guided the choice of participants. the first 12 participants who were willing to participate were included. a further seven physiotherapists who had done their compulsory community service during 2011 and 2012 were asked to verify the model. interview schedule the four distinct steps of appreciative inquiry, e.g. describe, dream, desire and design,[8] guided the development of the interview schedule. the first interview question probed interviewees’ highlights during their service year. the second question focused on desires for ideal physiotherapy service during such a year. the third inquired about recommendations for positive changes to reach a desired better future. procedure interviews were conducted by three trained finalyear physiotherapy students, after approval by the faculty ethics committee (reference: 26/09). they phoned each participant to explain the aim of the study, the format and the duration (approximately half an hour) of the interviews, and made an appointment for the next phone call. at the start of the second call the participant’s rights were explained, e.g. that continuation of the interview implied informed consent. participants were aware that the interviews were tape recorded, and that a second researcher was writing back-up notes. voice recordings were transferred to a computer as word media audio files. accompanying software allowed verbatim transcription to a microsoft word (2010) document. data analysis tesch’s inductive, descriptive coding technique was applied to the interviews.[9] a psychology intern under supervision of a researcher with a phd degree independently coded the transcripts. six steps were followed: the coder independently obtained a sense of the whole by reading through the transcripts. ideas that came to mind were jotted down. the coder then selected one interview and asked: ‘what is this about?’, thinking about the underlying meaning of the information. when the coder had completed this task for several respondents, a list was made of the topics. similar topics were clustered together and formed into columns that were arranged into major topics, unique topics and ‘leftovers’. the coder returned to the data with the list and tried out a preliminary organising scheme to see whether new categories and codes emerged. the coder found the most descriptive wording for the topics and turned them into categories, then endeavoured to reduce the number of categories by grouping together related topics. the data belonging to each category were assembled in one place and a preliminary analysis was performed. in parallel, the interviewers did paper-based open coding of units of meaning (phrases/sentences/ paragraphs), and 942 codes were generated. codes with similar meanings were integrated and the number was reduced to 75. the text was read again before codes were synthesised into 18 categories and four overarching themes. these two phases were followed by a discussion between the principal researcher and the independent coder to reach consensus. the categories were organised along the four steps of the appreciative inquiry process. the final phase of the data analysis was to integrate information from the four phases into one model. this qualitative research was made robust by attending to the aspects of trustworthiness. although the study period was approximately six months, the principal investigator has more than 15 years of experience of community-based physiotherapy, both as a manager at national level and as an educator responsible for community-based education. this prolonged engagement in the field enhances the credibility of the study. in addition, the telephone conference and a consultation meeting to gain consensus on codes, categories and themes served as peer review. in a member check the model and discussion were verified by post-community service physiotherapists. a dense description of the methods and procedures enhances the dependability of the findings. the interviews were conducted in a language that interviewees understood, and they were allowed to change to a different language, also understood by the interviewer. finally, various characteristics of the participants were described, making it possible for the reader to compare his/ her context with that of this study to augment the transferability of findings. results the sample (n=15) consisted of five males and 10 females of whom two were black and 13 were fig. 1. a community physiotherapy model. articlearticle 21 may 2013, vol. 5, no. 1 ajhpe white. two were graduates from the university of cape town, two from the university of the free state and 11 from the university of pretoria. six of the participants had done their community service year in 2008, six in 2007, two in 2006 and one in 2005. the seven who participated in the member-check process agreed with the model and provided further examples supporting the themes in the model. they were from the eastern cape (n=1), gauteng table 2. theme. design/co-constructing: overview of categories and sub-categories reflecting physiotherapists’ experiences of their community year from an appreciative-inquiry stance category sub-category physiotherapists voiced their concern with regard to the community year, which included a variety of challenges and identified important factors to consider to establish a valued-based, efficient community service challenges identified that might hinder the establishment of a valued-based community physiotherapy service • staff motivation • payment structure (community and public) • collaboration with important stakeholders • language barriers important factors to consider to establish a valued-based community physiotherapy service: • procedures • continuous training programmes • collaboration with • community caregivers • multi-disciplinary team member involvement • non-government officials • multi-targeted target population (focusing more on the less fortunate) • management and supervision structure • distribution of funds ensuring efficient community physiotherapy service • in collaboration with the multi-professional team and patients • assessment and re-assessment • mobile units (and transport) • support groups table 1. themes. appreciating and envisioning/dreaming: overview of categories and sub-categories reflecting physiotherapists’ experiences category sub-category physiotherapists expressed a sense of appreciation in terms of service delivery, productivity and unique contributing factors when working in a community setting the most satisfying experience when working as a community physiotherapist • service delivery (in community and solving individual problems; sense of appreciation by members) • making a difference • community engagement and forming relationships • ‘experiencing a community culture’ the productivity of community physiotherapists • ownership of physiotherapy • being part of a team (with community caregivers and within a multi-disciplinary team) the unique contribution of the physiotherapist to bettering the patients’ wellbeing • education programmes informing the community • adequate communication structures • support structures physiotherapists’ envisioned a need to better contribute to the wellbeing of community members by improving the compulsory community year, which includes the need for a better educational process, clearer identification of possible contributing factors (of the physiotherapist) and possibilities of improvement within the community dream for ideal future community physiotherapy • improved structures • communication • management • supervision • transport • consulting rooms • better distribution and allocation • funds • physiotherapists (in specific areas) • education programmes for communities article may 2013, vol. 5, no. 1 ajhpe 22 (n=4), kwazulu-natal (n=1) and north-west (n=1). one male took part in the member check. categories and sub-categories according to the appreciative inquiry framework are set out in tables 1 and 2. tables 3 5 contain quotations supporting the final four themes included in the model (fig. 1). discussion with the aim of informing the undergraduate physiotherapy curriculum, the study explored the experiences of newly graduated physiotherapists during a compulsory community-service year. the findings were integrated into a four-part model: (i) the essence of community physiotherapy; (ii) the collaborative nature of community physiotherapy; (iii) prerequisites for a positive practice environment; and (iv) community physiotherapy as a gateway to personal growth and professional development. the model is discussed in relation to the studies referred to in the introduction. a description of limitations of the study is followed by implications for the curriculum. the essence of community physiotherapy compulsory community service in physiotherapy provides comprehensive care in a variety of settings, from homes, clinics and schools to hospitals. in addition, a wide spectrum of conditions is treated, from hiv to pregnancy – over the lifespan of clients. community physiotherapists act as generalists, treating conditions that reflect the country’s quadruple burden of disease. they perform common community physiotherapy services. health education and promotion are prioritised in line with global and national policies. clients experience the services as beneficial. therapeutic touch, for example, is used – also by other therapists.[10] physiotherapists reported that services are orientated towards the needs of clients. in communityservice physiotherapy, the holistic team addresses broader issues than physical health – specifically poverty. where speech-and-language therapy professionals felt that contextual issues, such as poverty, fell outside their scope of practice,[7] physiotherapists acknowledged that these have to be dealt with by the healthcare team. the collaborative nature of community physiotherapy panellists were of the opinion that collaboration, the backbone of community physiotherapy, is impaired as a result of the lack of awareness about physiotherapy’s role in patient care and public health. doctors and members of target communities, among others, are ignorant about physiotherapy and other professions.[5] the inability to understand or speak the language of table 3. quotations in support of the categories of the themes ‘the essence of community physiotherapy’ and ‘the collaborative nature of community physiotherapy’ theme category quotations the essence of community physiotherapy • principle: client and community orientated • improved accessibility • focus on health education and counselling • variety of • clients • conditions • settings • underlying poverty • you mustn’t just think of physiotherapy when you’re in a community here; you must think more widely; what life skills can you give to them. there are a lot of possibilities in that area and working in a disciplinary group … it uplifts the community, because there’s a lot of poverty and that’s the main issue • you really have to consider the patient’s needs before you can actually … treat the patient well • community outreaches and speeches to schools … group classes … educating • through the education programme you get possible … solutions, and you know people can treat themselves [in future] if they have a problem • we found a lot … of neurological patients [who] didn’t know how to use crutches or didn’t know how to use their wheelchairs correctly • disability … orthopaedics … diabetes … high blood pressure … arthritis … the elderly … • we were involved in home visits … clinics … schools … community health centres hospitals • you got to consider the [vital] factors like money, and the person being the only breadwinner, and like they can’t take a day’s rest, or else they don’t get money the collaborative nature of community physiotherapy • taking hands • ignorance about physiotherapy role • language a common barrier • preventing professional isolation • physiotherapy [as] one professional group is not going to solve a community’s problems; just because there’re different scopes of problems and you need different people to solve those problems at different levels • the community health workers, they basically indicated vulnerable populations • so a lot of collaboration has to be done in the community; it’s not just one profession that can meet the needs of the community … we collaborated a lot with the people-withdisabilities organisations. • the people are … very grateful and willing to come … to the clinic. to make it … easier for them, well, we all go as a rehab[ilitation] team. so that’s quite productive, and everyone sees all the patients there at the same time • you know a lot of people still don’t understand the differen[ce] between physiotherapy and occupational therapy • [t]he language barrier – even though in the hospital you are provided with interpreters – was difficult articlearticle the communities where the community-service physiotherapists are placed also hinders collaboration, as voiced in similar studies.[7] to overcome this barrier, physiotherapists should learn some phrases in the local language and work with interpreters. a positive practice environment the panel identified factors that need to be in place to facilitate a positive working experience in the community setting.[11] these factors include effective management, sufficient infrastructure, equitable distribution of physiotherapists between different areas, and the availability of transport to health professionals and clients. findings from community medical doctors, dentists, speechlanguage-and-hearing therapy professionals and dieticians correspond.[7] as part of a positive working environment the community-service physiotherapists voiced a need for discipline-specific supervision and mentoring. again, this longing for professional support is not uncommon among health professionals.[6] a mentoring programme is indeed a pivotal component in continuous learning. community physiotherapy as a gateway to personal growth and professional development according to the panel, several factors contribute to the growing sense of being a professional physiotherapist. one factor is positive feedback from clients who see the physiotherapist as a helpful, significant team member. becoming familiar with clients' living conditions during home visits also facilitates appropriate, insightful and authentic intervention, another hallmark of professionalism. on the path to increased professionalism, personal characteristics such as resilience, creativity and perseverance assist in overcoming difficult demands and conditions. responsibilities are initially challenging, but skills improve gradually.[7] the five-stage model of the acquisition of mature skills succinctly explains the progression from being a rule-dependent novice to an expert who can draw on a collection of distinguishable situations and solutions.[12] during compulsory community service, improved functioning as a professional therapist is also reinforced through teamwork. other team members are a resource and prevent professional isolation, and discussions improve clinical decision making. however, not everyone enjoys the compulsory service year. only 35% of rehabilitation therapists who did compulsory community service in kwazulu-natal during 2005 would choose to apply for work in the public sector.[6] nevertheless, the compulsory community-service year had had a positive influence on a majority of physiotherapy graduates’ views of community work and a keener sense of social responsibility.[13] limitations even though this study contributes to the relative under-representation of research about health sciences education in africa, the findings can cautiously be generalised only to compulsory community-service physiotherapy in south africa. however, implications for the curriculum would be relevant to allied health educators, not only in developing countries, but also where practitioners work in taxing circumstances, such as deep rural and remote healthcare services, i.e. scotland, canada and australia, or in the public sector in general. table 4. quotations in support of the categories of the theme ‘prerequisites for a positive practice environment’ theme category quotation prerequisites for a positive practice environment • effective management • basic infra-structure • accessibility of services • discipline-specific supervision and mentoring • equitable distribution of therapists • because at the moment [recommendations] usually [travel] only from top to bottom, and from bottom only to middle management [level] [recommendations] never reach top management with your needs • well, number one, the clinics are badly run, staffed, and stocked, as such. so walk[ing frames] and crutches … are just not available. … and also patients can’t get transported • there is corruption. lots of the funds don’t get channelled to the right places. like the hospital takes a lot of the funds and – the people of the community – it doesn’t really reach them • we wanted to start [new services], but the region and the managers, they didn’t want us to • you must have the basic things like hot packs, interferential [machines], and also … posters in the community’s mother tongue • i would think a … computer admin[istrative] system that logs patient [visits] • physio[therapist]s that went to limpopo … [were] sent on courses that the government paid for, but the people that were put in [johannesburg] gen[eral] and bara[gwanath] hospitals weren’t even allowed leave [for courses]. so it is unequal • a work area that is big enough to either see a group of people to give group classes, or just have a plinth … to see individual patients. it’s just the space is very small; they give you … this corner where only one patient can fit in • i would recommend mobile units • vehicles that can travel … dirt and gravel roads because a lot of the times we couldn’t get to clinics due to a car that just couldn’t handle the roads • more supervision … i would have liked • i think in some areas you have an over saturation of community physiotherapists and in some areas you don’t; and it’s all … mediated by the government, where they put their people, so i think, if they could just better distribute the people 23 may 2013, vol. 5, no. 1 ajhpe article may 2013, vol. 5, no. 1 ajhpe 24 implications for the curriculum first, to be prepared for the nature of community-service physiotherapy, undergraduate physiotherapists must be exposed to a complex healthcare environment, in different settings, treating common conditions and risk factors contributing to the local burden of disease. a thorough understanding of social justice and the determinants of health, including poverty, is essential. hands-on clinical skills in physiotherapy were highlighted as being important. these clinical skills should therefore not be neglected in the quest for producing health promoters, however important the latter role. second, the collaborative nature of community physiotherapy implies that students must be exposed to interprofessional teams, as well as to role players in other sectors than health, such as organisations for disabled people. because collaboration requires knowledge of the roles of colleagues, graduates must be comfortable with promoting their profession. working with different cadres of workers is another essential collaboration skill. cultural proficiency is also essential for collaboration in communityservice physiotherapy. incorporating a local language in the undergraduate curriculum has the potential of improved collaboration with clients and staff. equally important is training in cultural competence and awareness of the social determinants of health to shape interventions. third, to foster a positive work environment, new graduates should set out to find a mentor, even in the absence of a formal mentoring system. students should, for example, be familiar with systems that are already in place, such as the south african society of physiotherapy ‘buddy’ system, where qualified physiotherapists are paired with new graduates, even if only via telephone. comparable studies, mentioned above, make recommendations for better management to improve the practice environment during compulsory community service. while instilling sound management and leadership principles in students, they should be prepared for far less than optimal working circumstances. fourth, therefore, undergraduate education should foster resilience as part of professional development. resilience is the ability to remain positive despite adversity. howe, et al.[14] suggest various strategies to facilitate resilience in undergraduate students, which range from goal setting, problem solving, work-life balance to reflection on practice and their own values and priorities. service-learning as an experiential andragogy is valuable for pro fessional development and cultural competence. service-learning placements can table 5. quotations in support of the categories of the theme ‘community physiotherapy as a gateway to personal growth and professional development’ theme category quotation community physiotherapy as a gateway to personal growth and professional development • identify formation strengthened by positive client feedback • an acquired taste • demands and difficult conditions harnessed by positive personal characteristics • gradual improvement in skills • familiarity with clients' living conditions facilitates appropriate, insightful intervention • the people are very grateful • we can actually make a difference … we … offer health services [to those] that can't really afford it • we make a huge impact; … you learn from the patients • so i find that very exciting: the challenges that you are faced with • there was no highlight! i didn’t enjoy it at all! • i’d have to say ... i think if you’re really motivated, you can really make it awesome • you get thrown into the deep end and … that is quite exciting; learning to find your feet and having to start – you know – use everything you’ve got. but still, it’s always unpredictable, always having to adapt and change and there’s always a challenge. so that was definitely very nice • focusing on what your goal is for that specific time and … even if there are bad moments. just keep on going ahead, you know, and pick up and go again • the thing is that when we were at [university], we thought of physiotherapy in some way, but when you start to see the physiotherapy [in the] real world, i think that is a bigger challenge • i think … it's a year that you gain a lot of experience • the positive thing that i have learned about the community is responsibility … i feel like i had a leap in my life • you [can]’t rely on … resources, so you use what you have, and you are lots more innovative • how to treat patients, how to communicate with patients; what works best, what doesn't work. as you progress through the year, you get better and better at what you do. so in the beginning it's a bit of a struggle • the fact that you get to see the environment the people live in, and therefore you have better insight into exactly, the home environment, and … the living setting of the person • getting to know the people, seeing … the cultures and leaning the different [languages] article 25 may 2013, vol. 5, no. 1 ajhpe also contribute to better understanding of health disparities and the interrelatedness between health and poverty. in service-learning students deal with real community needs in a reciprocal relationship. reflection, an essential element of service-learning, can take on different forms, such journal discussions, small group discussions that include community members, visual and oral presentations and even creative fine art artefacts. in this way the attribute of life-long learning is fostered. although these topics are common in health sciences education, uptake into curricula has been variable. all physiotherapy university departments in south africa have gaps in their community and public health curricula.[15] conclusion this exploration contributes to the clarification of the essence and collaborative nature of physiotherapy in public health, the prerequisites for such physiotherapy, and the contribution to the professional development and personal growth of newly qualified physiotherapists. reflection incorporated into service-learning clinical placements could contribute to prepare students for real-life work settings. the intention of the study was to derive implications for the curriculum from the participants’ narratives about the community-service year. further studies could investigate training needs more explicitly. acknowledgements. thank you to the participants and mses van der walt, redivo, bredenhann, eloff and essa for conducting the interviews and assistance with initial coding of the data; and to professor andré van zyl and ms barbara english for critical reading of the draft manuscripts. conflict of interest. the authors declare no conflict of interest. funding. the south african medical research council financially supported this study. however, the institution did not influence data collection and analyses or the decision to submit the manuscript to this journal. references 1. horton r. a new epoch for health professionals' education. lancet 2010;376(9756):1875-1877. [http://dx.doi. org/10.1016/s0140-6736(10)62008-9] 2. ramklass ss. an investigation into the alignment of a south african physiotherapy curriculum and the expectations of the healthcare system. physiotherapy 2009;95(3):216-223. [http://dx.doi.org/10.1111/ j.13652524.2009.00869.x] 3. lindquist i, engardt m, garnham l, poland f, richardson b. development pathways in learning to be a physiotherapist. physiotherapy research international 2006;11(3):129-139. [http://dx.doi.org/10.1002/pri.332] 4. frehywot s, mullan f, payne pw, ross h. compulsory service programmes for recruiting health workers in remote and rural areas: do they work? bull world health organ 2010;88(5):364-370. [http://dx.doi.org/10.2471/ blt.09.071605] 5. paterson m, green m, maunder emw. running before we walk: how can we maximise the benefits from community service dietitians in kwazulu-natal, south africa? health policy 2007;82(3):288-301. [http://dx.doi. org/10.1016/ j.healthpol.2006.09.013] 6. khan nb, knight s, esterhuizen t. perceptions of and attitudes to the compulsory community service programme for therapists in kwazulu-natal. south african journal of communication disorders 2009;56(2009):17-22. 7. penn c, mupawose a, stein j. from pillars to posts: some reflections on community service six years on. south african journal of communication disorders 2009;56(1):8-16. 8. richer m, ritchie j, marchionni c. 'if we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better healthcare work environments. journal of nursing management 2009;17(8):947-955. [http://dx.doi.org/10.1111/ j.1365-2834.2009.01022.x] 9. creswell jw, plano clark vl. designing and conducting mixed methods research. london: sage, 2007:275. 10. singh c, leder d. touch in the consultation [internet]. british journal of general practice 2012;62(596):147-148. [http://dx.doi.org/10.3399/bjgp12x630133] 11. drenkard k, swartwout e. introduction to positive practice environments and outcomes: state of the science – a commitment to optimal practice environments. journal of nursing administration 2011;41(7-8 suppl):s2-s3. [http://dx.doi.org/ 10.1097/nna.0b013e3182270395] 12. dreyfus se. the five-stage model of adult skill acquisition. bulletin of science, technology and society 2004;24(3):177-181. [http://dx.doi.org/10.1177/ 0270467604264992] 13. mostert-wentzel k, masenyetse l, dinat n, botha a, jonkers l, oosthuizen l. involvement in and views on social responsibility of members of the south african society of physiotherapy in gauteng province, south africa: a cross-sectional survey. south african journal of physiotherapy 2012;68(1):22-28. 14. howe a, smajdor a, stockl a. towards an understanding of resilience and its relevance to medical training. medical education 2012;46(4):349-356. [http://dx.doi.org/10.1111/j.1365-2923.2011.04206.x] 15. mostert-wentzel k, frantz j, van rooijen aj. status of undergraduate community-based and public health physiotherapy education in south africa. south african journal of physiotherapy 2013;69(1):1-10. 100 november 2013, vol. 5, no. 2 ajhpe lack of research skills teaching not just an african education issue to the editor: madzima et al.[1] address a very real issue in current medical and health education – lack of teaching of research skills. they have piloted workshops aiming to fill the void in research skills and statistics for those who want them, and i applaud them for their efforts. this shortcoming is not limited to south africa; teaching of research technique and skills is also lacking in the undergraduate curriculum in the uk, although statistics teaching is more than adequate. madzima et al. highlight the fact that the participants who took part in their study reported an increased understanding of evidence-based medicine and research methods, and an interest in possibly carrying out their own research in the future. research is of the utmost importance, as it increases the knowledge base that all health professionals rely on to enable us to practise relevant, up-to-date, evidence-based medicine. it is unfortunate that junior doctors and medical students are not being equipped with the skills needed to fill all the necessary competencies expected of a doctor. in the document ‘tomorrow’s doctors’,[2] the general medical council in the uk defines the outcomes for graduates as scholar, scientist, practitioner and professional. research is central to all these domains, as to be competent scholars and scientists we should be furthering the field; as practitioners we should be practising up-todate and relevant medicine; and as professionals we should be integrating the other three domains to provide an excellent patient experience. in summary, madzima et al. should be congratulated on their work and on contributing to a scheme that will benefit trainees and patients alike. thomas i lemon university hospital of wales, cardiff, wales, uk lemonti@cf.ac.uk 1. madzima tr, abuidris d, badran a, et al. a pilot course for training-in-context in statistics and research methods: radiation oncology. african journal of health professions education 2012;4(2):102-106. [http://dx.doi. org/10.7196/ajhpe.157] 2. general medical council, uk. tomorrow’s doctors. september 2009. http://www.gmc-uk.org/static/documents/ content/gmc_td_09__1.11.11.pdf (accessed 3 september 2013). ajhpe 2013;5(2):100. doi:10.7196/ajhpe.259 correspondence mailto:lemonti@cf.ac.uk http://dx.doi.org/10.7196/ajhpe.157] http://dx.doi.org/10.7196/ajhpe.157] http://www.gmc-uk.org/static/documents/ 80 november 2013, vol. 5, no. 2 ajhpe research this paper discusses 10 key elements for the design and implementation of interprofessional education (ipe) in a skills centre. the elements are based on published literature as well as on the experience of an ipe initiative, simulating the management of a multiple-traumatised patient in the acute and rehabilitation phases, by students from 4 professions: medicine, nursing, occupational therapy and physiotherapy. the key elements are interrelated and include the partners involved (learners, facilitators and patient simulator), the content, learning resources, setting, faculty development, logistics, learning strategies and evaluation. ajhpe 2013;5(2):80-83. doi:10.7196/ajhpe.233 ten key elements for implementing interprofessional learning in clinical simulations i treadwell, dcur hed; h s havenga, ils practitioner skills centre, faculty of health sciences, university of limpopo (medunsa campus), soshanguwe, polokwane, south africa corresponding author: i treadwell (ina.treadwell@ul.ac.za) interprofessional education (ipe) refers to healthcare students learning with, from and about one another to improve collaboration and the quality of patient care.[1] successful transition of students to competently workready health professionals requires an ability to work in healthcare teams[2] and should be addressed through ipe. the use of ipe to facilitate effective teamwork in healthcare is not novel and has been supported for about 40 years. despite increasing recognition of the importance of ipe[3] and collaborative teamwork being a world health organization (who) priority of action,[4] an international environmental scan commissioned by the who concluded that significant efforts are still required to ensure that ipe is designed, delivered and evaluated at a high standard. this finding was based on self-reports from 41 countries that ipe was often (i) not mandatory (88%); (ii) not based on explicit learning outcomes (34%); (iii) not assessed for what was learned (63%); (iv) not offered by trained facilitators (69%); and (v) not formally evaluated (30%).[3] ipe is an important paedagogy but there are certainly challenges and barriers involved in this effort. a systematic planning, development, and implementation process should be outlined before initiating ipe.[5] an ipe simulation was presented at medunsa for students from 4 professions: medicine, nursing, occupational therapy and physiotherapy. owing to large groups of students, the simulation was repeated 6 times. the simulation comprised 2 phases: (i) the acute phase requiring medical and nursing students to manage a multi-traumatised patient on admission to the emergency room, followed by (ii) a rehabilitation phase during which occupational therapy (ot) and physiotherapy (pt) students joined for a consultation with the patient at a clinic. we drew upon our experience of simulation as well as published literature to plan, develop and implement these ipe experiences. seven of the 10 elements of our planning, development and implementation concur with all the elements of a conceptual framework for interprofessional education and practice (developed by the mcgill educational initiative on interprofessional collaboration).[6] the elements are the partners involved (learners, facilitators and patient simulator), the content, learning resources, setting and faculty development. the remaining 3 elements are the logistics, learning strategies and evaluation. these 10 key elements for the design and implementation of ipe in a skills centre are discussed under separate headings but are interrelated, as each has an influence on the process of developing and delivering an ipe event. the 10 key elements 1. facilitators interprofessional education involves staff from different professional backgrounds learning and working together. commitment is required of faculty to engage in shared learning and dialogue which has the potential to encourage collegial learning, change thinking and support new working relationships.[7] the facilitation of ipe for a small group of students is a complex and demanding activity. facilitators need to display a wide range of attributes and competencies to ensure that they function effectively, as would be demonstrated in commitment to ipe, positive role modelling and valuing of diversity.[5] they should feel confident and secure about their knowledge base and their ability to facilitate diverse groups of interprofessional learners,[5] work creatively with small groups[8] and be able to plan, develop, implement, teach and evaluate ipe.[5] in the absence of top-down drivers for the implementation of ipe, lecturers committed to changing and improving healthcare education for improved patient management and safety, could serve as bottom-up drivers. it is advisable to include faculty who are creative and innovative – as well as interested in transformational change – when selecting professionals to take part in an event that is relevant to their curricula. one of our challenges for this initiative was similar to that reported in the literature – that the facilitators lacked training for teaching in an ipe environment.[5] the lecturers from the 4 professions invited to join the skills centre personnel in the planning and implementation of the ipe event were skilled clinical facilitators, strongly motivated and enthusiastic. 2. learners it is difficult to select training that is relevant for students from different healthcare professions; most studies limited the complexity by including no more than 4 professional groups.[6] the management of a multipletraumatised patient, as reflected in table 1, was selected as content for 3 reasons: (i) the management of traumatised patients forms part of undergraduate medical (5th year), nursing (4th year), ot (4th year) and pt (4th year) curricula; (ii) these senior students have already mastered the required individual clinical skills; and (iii) the skills centre is very wellsuited for trauma simulations. mailto:ina.treadwell@ul.ac.za november 2013, vol. 5, no. 2 ajhpe 81 the simulation matched the 5th-year medical students’ lectures on multiple trauma, and their attendance was mandatory. fourth-year nursing students were invited to join, as well as ot and pt students who were allocated to relevant clinical settings that made possible their reallocation to the skills centre for short periods. as there were large numbers of student and limited time, some students observed the simulations and assessed the actions using an assessment tool (table 2) as a guide. 3. patient simulators authenticity is an important mechanism for participants to have positive experiences; the simulation of patients by high-fidelity simulators and simulated/standardised patients (sps) plays a big part. for the present simulation, the high-fidelity simulator was programmed to display dyspnoea with decreased breath sounds on the injured side and was manipulated to appropriately change vital signs in response to treatment or deterioration in condition. separate low-fidelity arms were used for suturing and venous cannulation, and a pneumothorax trainer to prevent numerous invasive procedures being performed on the costly simulator. sp encounters must not be overly different from the experience with a real patient. for the sps to be more believable, they need to ' become the patient', with real emotions, and express the needs, expectations and fears of a patient. appropriate moulage and dress are also important. in our simulation, the sp was dressed in overalls, and a stab wound with controllable bleeding was created on the right arm, at the correct site where a penetrating wound could cause damage to the radial nerve. bruises and haematomas were added to improve authenticity of the patient. detail regarding the background, moulage and dress were carefully planned and documented to ensure effective sp training and accurate repetition of the event. 4. content teamwork has become a major focus in healthcare, as many of the high number of preventable medical errors are a result of dysfunctional or non-existent teamwork.[9] team-based skills such as communication and leadership are therefore vital for success in ipe events, and training in these non-technical skills is becoming a high priority.[10] the choice in setting the scene and creating learning situations in planning ipe is crucial to the learning that will occur. it is difficult to select training that will be relevant for students from different healthcare professions.[11] scenarios for the simulations should be customised to facilitate team interaction. the multidisciplinary and time-sensitive nature of trauma care especially requires teamwork and communication for treating the acutely injured patient.[12] trauma and communication skills were considered as common ground for a simulation appropriate for the 4 selected students groups, since these skills are included in their various curricula. the groups, however, have different roles and, as pointed out in the literature, they have different competencies and objectives as per the various curricula.[5] the content should therefore be appropriate for the stages in the curricula of students from all the participating professions. the simulation (table 1) comprised 3 scenarios (including pre-hospital and initial in-hospital phases that were at a level commensurate with the knowledge and experience of medical and nursing students) and a rehabilitation phase for the same patient that would be more suitable for the medical, pt and ot students. 5. learning resources the resources in the skills centre are appropriate for various simulations. the patient simulators, equipment and facility itself have a big influence on scenario planning. the flat roof of the skills centre and surrounding concrete slab made it ideal for scenario 1 to simulate a ‘fall from a height’. the facility also provided easy access to a room fitted with video recording equipment, which was used as the ‘emergency room’ for scenario 2. students not taking part in the resuscitation observed and assessed the activities through a one-way mirror or on plasma screen from the observation room. pictures of the prepared venues and equipment were taken and filed together with the requirements list to facilitate easy and correct preparation for similar simulations to follow. other resources include the instruments necessary for planning, implementation and evaluation of the simulation. they include an action guide (part of which is shown in table 2) that can be research table 1. scenarios and outcomes incorporated in simulation scenarios actions required 1. pre-hospital environment (medical and nursing students) a 25-year-old technician has fallen 6 m onto a concrete floor, sustaining possible cervical spine and thoracic injuries and a deep stab wound, caused by a screwdriver he was holding, to his right upper arm. perform a primary survey and identify possible injuries. apply a rigid cervical collar and direct pressure to the stab wound. obtain a sample history, perform a log-roll of the patient onto a spinal board and transfer to the emergency room. 2. emergency room environment (team work by medical and nursing students) a neck collar has been applied as well as a pressure bandage to his right upper arm. he has difficulty breathing but can still answer questions. full admission procedures excluded. integrate the assessment and reassessment of the patient’s airway patency, breathing, oxygen saturation, blood pressure, level of consciousness and pain. administer oxygen, stabilise the cervical spine with head blocks, obtain a history and do a full secondary assessment; start two intravenous lines; perform a needle decompression of the chest; discuss the need for a chest drain; suture the arm laceration and assess the distal pulses and motor function; pass a urinary catheter and insert a nasogastric tube. provide information and comfort patient throughout. 3. outpatients department (medical, ot and pt students) patient complains of an inability to extend his right wrist and fingers. he is concerned about the clumsiness of his hands and complains of tiredness when he walks up the stairs. his employer threatens to dismiss him. medical students: examine the patient’s hand and make a referral. ot and pt students: examine patient’s hand and explain plan for rehabilitation, including exercises and a splint. 82 november 2013, vol. 5, no. 2 ajhpe research used by the facilitator without the ‘done’ columns, as a guide to responses required during the simulation. it can also be used without the responses column by the observing students and facilitator to guide their assessments and follow-up discussions of the performances during the reflection session. 6. settings since teamwork needs to be learnt and practised in safe simulated settings to enhance resuscitation performance,[13] the skills centre was the ideal setting for simulating the management of a multiple-traumatised patient. every effort was made to customise the ipe so that it reflected appropriate, authentic and relevant service delivery settings, since authenticity is deemed important for a positive experience by participants.[6] 7. faculty development becoming a skilled educator in ipe is a process. faculty members need to have a shared understanding of the purpose and goal of ipe, and to engage in collaborative discussions. barriers to this strategy of teaching and learning at both the individual and the organisational level can be addressed by providing individuals with the knowledge and skills needed to design and facilitate ipe.[6] staff development to enable competent and confident facilitation of ipe is a key influence on the effectiveness of ipe.[6] topics should be aimed at integrating principles of teamwork into a healthcare system[5] and could include instruction on interactive teaching and learning, facilitated learning, group dynamics, technology, conflict resolution, assessment strategies for ipe[5] and experiential exercises; the latter provide opportunities for sharing facilitation tips. faculty members from various disciplines are given an opportunity to interact early in the process of initiating ipe. sharing experience is essential for team bonding and agreeing upon optimal strategies.[5] globally, only a third of facilitators undertaking ipe have not received any training.[3] none of the facilitators in our simulation had any formal training, but fortunately had the attributes described in the first key point. our experiences in this ipe event could be useful in future faculty development to promote ipe. 8. logistics traditional university curricula severely limit the time that students from different professions can learn together. apart from timetabling, formal ipe can also be restrained by factors such as space and lack of management support.[3] time: implementing this simulation was negotiated in the medical curriculum since suitable skills training was required for the management of severely traumatised patients. the only available time was on 4 friday table 2. part of guidance/assessment tool for scenario 2 actions sp/facilitator’s responses done yes no assess loc responds (glasgow = 15) administer o2 via non-breather mask stabilise the cx spine (head blocks) assess airway patency airway patent assess breathing patient is short of breath and moaning ‘i can’t breathe, it hurts’. rise and fall of chest asymmetrical use of accessory muscles and/or diaphragm present skin colour pale integrity of thorax (soft tissues and bones) bruise (r) attach to cardiac monitor hr 120; bp 110/80; rr 28 attach pulse oximeter saturation 92% 2 x ivs take bloods start warm fluid discuss chest drain secondary survey bilateral breath sounds reduced air entry on left trachea trachea central re-assess loc vital signs glasgow = 14 (mumbling) hr 120, bp 100/80, rr 30 o2 saturation saturation 88% air entry reduced on left side trachea trachea deviated to the right perform needle decompression breathing improves hr = heart rate; bp = blood pressure; rr = respiratory rate; loc = level of consciousness. november 2013, vol. 5, no. 2 ajhpe 83 research afternoons in 1 month. time was then negotiated for nursing, ot and pt students to attend the ipe events. groups: owing to time limitations and despite the fact that the simulations were duplicated for each event, there were about 20 students per simulation. although hands-on experience would have been ideal, some students could only observe. the schedule for the groups was made available well in advance. orientation: student preparedness should be seen as a prerequisite for clinical ipe. the facilitators produced a video of the scenario, which was used to orientate the students on the expected outcomes of the event and the skills they needed to revise. students then had the opportunity to indicate whether they wanted hands-on experience of the simulation or whether they would rather observe the process. a schedule of the facilitators’ responsibilities and roles was negotiated and made available to all. some facilitated the resuscitation while others manipulated the simulators or assessed the activities of the students by means of a checklist. 9. learning strategy the ipe event was based on kolb’s experiential learning theory, which includes a meaningful and relevant context, experiential learning, debriefing and reflection. students should be encouraged to actively partake and then review and reflect on their performance in order to identify their personal and professional learning requirements to achieve proficiency.[14] a number of studies have explicitly documented the inclusion of team reflection as part of their design.[6] the intervention for ipe should be based on shared outcomes, relevant to all groups, provided in a realistic educational context suitable for students with differing levels of previous ipe and skills training experience.[15] in our event, the context was trauma as explained under the content heading, and the experiential learning was reserved for only small teams of students because of time constraints. students were expected to take responsibility for the management of the patient by prioritising, making appropriate decisions, resolving their conflicts, and performing and delegating tasks. the teams as well as the facilitators and observing students who used a checklist to guide their observations, took part in the post-simulation discussion to reflect on the performance. 10. evaluation feasible assessment of ipl outcomes, especially those concerning teamwork and collaborative practice skills, presents a major challenge for educators.[1] seventy per cent of respondents to the who review on the status of ipe used a range of methods to evaluate ipe. student surveys were the most popular evaluation tool. additional methods include inter alia test results and reflective journals.[13] conclusions the 10 key elements cover the range of resources and processes required to implement an ipe event aimed at providing healthcare students with an opportunity to acquire awareness of professions and to develop collaborative skills. references 1. thistlethwaite j. interprofessional education: a review of content, learning and the research agenda. med educ 2012;46(1):58-70. [http://dx.doi.org/10.1111/j.1365-2923.2011.04143.x] 2. boyce ra, moran mc, nissen lm, chenery hj, brooks pm. interprofessional education in health sciences: the university of queensland health care team challenge. med j aust 2009;190(8):433-466. 3. rodger s, hoffman sj. where in the world is interprofessional education? a global environmental scan. j interprof care 2010;24(5):479-491. [http://dx.doi.org/10.3109/13561821003721329] 4. world health organization, 2010.  framework for action on interprofessional education and collaborative practice. geneva: who, 2010. 5. buring sm, bhushan a, brazeau g, conway s, hansen l, weatberg s. keys to successful implementation of interprofessional education: learning location faculty development and curricular themes. am j pharm educ 2009;73(4):60. [http://dx.doi.org/10.5688/aj730460] 6. purden m, fleischer d, ezer h, et al. the mcgill educational initiative on interprofessional collaboration: partnerships for patient and family-centered practice. http://www.interprofessionalcare.mcgill.ca/ projectoverview.htm (accessed 3 december 2012). 7. mccallin a. interprofessional practice: learning how to collaborate. contemp nurse 2005;20(1):28-37. [http:// dx.doi.org/10.5172/conu.20.1.28] 8. hammick m, freeth d, koppel i, reeves s, barr h. a best evidence systematic review of interprofessional education: beme guide no. 9. med teach 2007;29(8):735-751. [http://dx.doi.org/10.1080/01421590701682576] 9. lerner s, magrane d, friedman e. teaching teamwork in medical education. mt sinai j med 2009;76(4):318-29 [http://dx.doi.org/10.1002/msj.20129] 10. monkhouse sjw, jonas s, nageswaren s, rodd cd, king b. multidisciplinary trauma training: a uk first. education through simulation news. laerdal uk 2011:14;3-9. [http://dx.doi.org/10.1016/j.injury.2011.06.294] 11. lidskog m, löfmark a, ahlström g. learning through participating on an interprofessional training ward. j interprof care 2009;23(5):486-497. [http://dx.doi.org/10.1080/13561820902921878] 12. miller d, crandall c, washington c 3rd, mclauglin s. improving teamwork and communication in trauma care through in situ simulations. acad emerg med 2012;19(5):608-612 [http://dx.doi.org/10.1111/j.15532712.2012.01354.x] 13. cooper s, cant r, porter j, et al. rating medical emergency teamwork performance: development of the team emergency assessment measure (team). resuscitation 2010;81(4):446-452. [http://dx.doi.org/10.1016/j. resuscitation.2009.11.027] 14. corkin d, morrow p. interprofessional education; sustaining simulation in practice. education through simulation news. laerdal medical uk 2011;13:1-2. http://www.laerdal.com/uk/laerdal-simulation-newssummer2011.pdf (accessed 25 august 2012). 15. bradley p, cooper s, duncan f. a mixed methods study of interprofessional learning of resuscitation skills. med educ 2009; 43:912-922. [http://dx.doi.org/10.1111/j.1365-2923.2009.03432.x] http://dx.doi.org/10.1111/j.1365-2923.2011.04143.x] http://dx.doi.org/10.3109/13561821003721329] http://dx.doi.org/10.5688/aj730460] http://www.interprofessionalcare.mcgill.ca/ http://dx.doi.org/10.5172/conu.20.1.28] http://dx.doi.org/10.5172/conu.20.1.28] http://dx.doi.org/10.1080/01421590701682576] http://dx.doi.org/10.1002/msj.20129] http://dx.doi.org/10.1016/j.injury.2011.06.294] http://dx.doi.org/10.1080/13561820902921878] http://dx.doi.org/10.1111/j.1553-2712.2012.01354.x] http://dx.doi.org/10.1111/j.1553-2712.2012.01354.x] http://dx.doi.org/10.1016/j.resuscitation.2009.11.027] http://dx.doi.org/10.1016/j.resuscitation.2009.11.027] http://www.laerdal.com/uk/laerdal-simulation-news-summer2011.pdf http://www.laerdal.com/uk/laerdal-simulation-news-summer2011.pdf http://dx.doi.org/10.1111/j.1365-2923.2009.03432.x] 6 may 2014, vol. 6, no. 1 ajhpe research prior to 1980, there were neither professional qualifications nor a professional board for emergency care practitioners in south africa. emergency care training was fragmented and varied among provinces. a number of standardised short courses were introduced in 1985. these consisted of a 3-week basic ambulance attendant (baa), an 8-week ambulance emergency attendant (aea) and a 4-month critical care assistant (cca) course.[1-3] the baa, aea and cca short courses were initially offered as a form of in-service training by the provincial ambulance training colleges (atcs). the primary focus of the short courses was on clinical skills training. as a result, the scope of practice of short-course graduates was designed around rigidly defined medical directives and clinical protocols, leaving clinical decision making and governance to medical doctors. a shortage of qualified emergency medical doctors led to inadequate clinical governance being provided to emergency care workers who were increasingly being required to function as independent clinicians. to support the required levels of independent clinical decision making and practice, the need arose for formal higher education (he) qualifications in pre-hospital emergency care, which would be recognised, regulated and registered by the health professions council of south africa (hpcsa).[4,5] the first of these qualifications was a 3-year national diploma in ambulance and emergency technology (n dip aet), introduced in 1987. from 2003 onwards, a bachelor of technology degree in emergency medical care could also be obtained by completing an additional two years of part-time study, after obtaining the undergraduate 3-year n dip aet qualification.[4,5] apart from the cca course, which was extended to include an additional five months of clinical roadwork, the short courses remained relatively unchanged since their inception. in contrast, the he programmes continued to evolve via a number of extensive re-curriculation efforts. since january 2005, master’s and doctoral programmes have also been available to bachelor of technology (b tech) graduates.[6,7] with time, serious problems within short-course education and training structures began to emerge. the hpcsa became inundated with requests from multiple role players, all wishing to establish small colleges to offer the emergency care short courses.[8,9] as many as 60 providers were accredited by 2005 and the hpcsa began to receive numerous complaints regarding the quality of short-course training.[9] within a relatively short period the number of short course graduates, specifically from the basic ambulance courses, far exceeded the number of available posts. another challenge emerged as articulation between the short courses and the he qualifications became increasingly difficult owing to the everwidening knowledge gap. further frustrating the efforts of educators was the fact that the academic architecture of the short courses could not be aligned with the new national qualifications framework (nqf). they were also not compliant with south african qualifications authority (saqa) requirements for registration of qualifications on the nqf. saqa is the background. a recent review of emergency care education and training in south africa resulted in the creation of a new 2-year, 240-credit national qualifications framework (nqf) level 6 emergency care technician (ect) qualification. the national department of health (ndoh) view ects as ‘mid-level workers’ in the emergency care profession. concurrently, an existing 3-year national diploma and a 1-year btech programme were consolidated to form a single 4-year, 480-credit, nqf level 8 professional bachelor degree in emergency medical care (b emc). this study critically analysed and compared the ect mid-level worker qualification with the professional b emc degree to design a framework and bridging programme to support articulation between the two qualifications. methods. the researchers used an expository, retrospective critical analysis of existing documentation followed by a focus group discussion and a delphi questionnaire. these processes ultimately informed the design of the framework and contents of a bridging programme. results. similarities and substantial differences were identified between the ect and b emc qualifications in relation to scope, complexity and depth of knowledge. a framework for articulation was designed, which included a bridging programme for ect graduates wishing to enter the b emc degree programme. conclusion. the study predicted a strong sustained demand from ects as mid-level workers for further study and associated professional development. it is possible for graduates of the 2-year ect programme to articulate directly into the third year of the b emc degree through successful completion of a bridging programme. ajhpe 2014;6(1):6-9. doi:10.7196/ajhpe.285 are further education opportunities for emergency care technicians needed and do they exist? c vincent-lambert,1 phd; j bezuidenhout,2 dtech ed; m jansen van vuuren,2 phd, mmed fam 1 department of emergency medical care, university of johannesburg, south africa 2 division of health science education, university of the free state, bloemfontein, south africa corresponding author: c vincent-lambert (clambert@uj.ac.za) mailto:clambert@uj.ac.za may 2014, vol. 6, no. 1 ajhpe 7 research ‘body responsible for overseeing the development and implementation of the national qualifications framework, established in terms of the saqa act no. 58 of 1995’.[10] the nqf is a ‘framework on which standards and qualifications, agreed to by education and training stakeholders throughout the country, are registered’.[10] it became clear that a new approach was needed that could address important issues of lifelong learning, academic progression, career-pathing and general professional development within the emergency care industry. the challenge lay in designing a saqa and nqf-compliant education and training structure, which would meet the needs of the national department of health (ndoh) and the emergency care industry. together with input from role players, including the ndoh, the hpcsa reviewed the learning outcomes of the existing short courses. this led to the design of an evidence-based, formal, 2-year, 240-credit nqf level 6 emergency medical care technician (ect) qualification. the ndoh views ects as ‘mid-level workers’ within the emergency care profession. although new in south africa, mid-level health worker programmes are already in place in a number of other countries.[11] locally, similar to the ect, other mid-level worker programmes look set to be introduced in many other registered professions. these include medicine, radiography, and environmental health.[12] the first intake of ect students took place in 2007 at provincial atcs and at one university of technology.[13] at the he level, the 3-year national diploma and 1-year b tech programme were merged to form a single, 4-year, 480-credit, nqf level 8 b emc degree. this degree allows for direct articulation with relevant master’s and doctoral programmes. objective the main aim of the study was to design a framework and pathway to facilitate and support articulation between the ect mid-level worker qualification and the professional b emc degree. methods the researchers used an exploratory, sequential mixed-method design, which is characterised by a qualitative phase of research followed by a quantitative phase. this design is useful to explore a topic, using qualitative data before attempting to measure it quantitatively.[14] the qualitative phase of the study involved document analysis, a literature review and a focus group interview. the quantitative aspect of the study took place in the form of a delphi survey. with this design, the researcher critically compared the structure, learning outcomes and methods of delivery of the ect and b emc programmes. it also included identification of potential obstacles and challenges relating to articulation between the two qualifications. the subsequent findings were used to inform and refine the design of the framework for articulation and associated bridging programme.[14] literature review and document analysis the starting point in the research process involved a review of the literature around paramedic education and training, followed by an in-depth analysis of existing coursework and curricula documents relating to the ect and b emc programmes. this literature review and document analysis provided the researchers with a more thorough understanding of the similarities and differences between the ect and b emc qualifications. critical comparison of these two qualifications was further assisted by the identification and use of predetermined criteria similar to those used by saqa for the recording and registering of academic qualifications. selection of the saqa criteria was both logical and important as both qualifications had previously been lodged with saqa on similar templates. focus group interview seven purposively selected participants took part in a focus group interview. they comprised representatives of the professional board for emergency care, the ndoh (hr and training), principals of provincial health training structures (gauteng and limpopo) and academics from he institutions offering the b emc degree. the focus group interview focused on four key areas: • the need for articulation between the ect and b emc qualifications • how well the ect programme prepares graduates for further study in the nqf • the academic structure of the ect and b emc programmes • the need for a bridging programme, and potential problems associated with the bridging process/programme. the focus group interview was recorded and a verbatim transcript produced. content analysis was used and data were placed into common themes and categories. the delphi technique in the absence of literature addressing articulation between the relatively new ect and b emc programmes, other sources of information and data had to be explored. following the literature review, document analysis and focus group interview a delphi questionnaire was used to gather additional quantitative data on the content of and articulation between the two programmes. the delphi questionnaire was e-mailed to expert panel members purposely selected according to predetermined criteria. they completed the questionnaire electronically and e-mailed it back to the researcher after each of three rounds. the researcher analysed the responses from each of the panel members. the format of the delphi and statements remained consistent between the three rounds. for the purpose of this study, consensus was defined as having been achieved where at least 9/11 or 82% of the participants’ responses fell in the same range, i.e. 1 = essential/ agree, 2 = useful/undecided, or 3 = unnecessary/disagree, as indicated per statement.[13] the delphi questionnaire consisted of seven sections and 1 051 statements. the first three sections focused on eliciting views and opinions that could serve as potential solutions to the obstacles and challenges that educational managers are likely to face in articulating the mid-level worker ect graduate into the b emc programme. the remaining four sections focused on identifying potential learning outcomes for a bridging programme. the following sections of the delphi survey were selected to inform the framework for articulation:[13] section a. this section contained eight statements focusing on exploring participants’ views regarding the demand, desire and/or motivation for articulation between the ect and b emc and possible factors affecting such a demand. analysis of the statements and responses in this section confirmed that there is a real and sustained demand for articulation between the ect and b emc programmes. 8 may 2014, vol. 6, no. 1 ajhpe research section b. this section contained 19 statements focusing on the extent to which the ect programme prepares the graduate for further academic study within the nqf and, more specifically, to articulate into the b emc degree. analysis of the statements and responses in this section of the questionnaire confirmed that there are a number of differences and similarities between the learning outcomes of the 2-year ect programme and those covered during the first two years of the b emc degree. these differences and similarities become important when attempting to facilitate articulation between the two qualifications.[13] section c. this section contained 10 statements aimed at eliciting the participants’ views around the possible format and structure of a framework and bridging programme that may support academic articulation between the ect mid-level worker qualification and the b emc degree. analysis of the responses showed strong similarities and agreements regarding the themes and trends that emerged from the focus group discussion. results analysis of the data from the above research processes led to a number of important results and findings described below. these in turn were used to inform the design of the framework for articulation. • the primary function of the ect and b emc programmes is to produce mid-level workers and professional practitioners, respectively. therefore, the level of depth, complexity and scope of the two programmes differ significantly. there are however topics common to both programmes, i.e. a fundamental knowledge of anatomy, emergency medical care, professional practice and introductory rescue. • while the abovementioned similarities may assist in gaining the academic credits required for advanced placement within the b emc degree, differences in the scope and level of depth achieved in a number of areas preclude ect graduates from simply entering directly into the third year of the b emc degree. areas identified as requiring deeper understanding included physiology, diagnostics, general pathology and health sciences (chemistry and physics). • the didactic methodologies of the provincial colleges offering the ect programme were also seen as very different from those at universities offering the b emc programmes. • the ndoh has expressed a strong desire for ect graduates to spend some time working as mid-level workers before continuing their studies. certain academics are in favour of this, arguing that a period of work will consolidate knowledge and improve clinical skills before entering the degree programme. others argue that a break in studies is not always desirable due to potential knowledge decline. • there is a desire to limit the time away from work when ect graduates embark on further study. therefore it is suggested that the bridging programme be offered as a limited-contact programme.[13] a proposed framework for articulation is presented in fig. 1, followed by a brief discussion of the central key components. discussion the main factors driving the demand for articulation and further study appear to be the ects’ desire for increased recognition and status within the profession, enhancing their clinical scope of practice and enjoying associated benefits such as promotion and improved salaries. the process of articulation is not possible without completing the ect qualification. while certain members of the focus group panel did not feel that a period of work post qualification was necessary for ect graduates wishing to continue into the b emc degree, the majority consensus was that a period of clinical practice as an ect was indeed desirable.[12] the authors agree that ect graduates should make a contribution to the workforce as mid-level workers before moving into the degree programme so that the objective of the ect programme is not defeated, i.e. to produce additional numbers of qualified staff for local emergency services. furthermore, it is unrealistic to assume that every ect graduate will move on and obtain a professional degree. the framework proposes that at the end of their first year of practice, ects who wish to study further apply to enter a structured bridging programme (during their second year of clinical practice). the aim of this programme would be to prepare them for advanced placement in year three of the degree programme. applicants may also submit a portfolio documenting their clinical work and prior learning as well as continued professional development activities post qualification as an ect. the portfolio may be further developed and expanded while completing a bridging programme. vincent-lambert[13] showed that, although a number of similarities do exist between the 2-year ect programme and the first two years of the degree programmes, there remain a number of shortfalls in terms of the academic level and depth of knowledge in the following key areas: physics, chemistry, physiology, general pathology, diagnostics and selected areas of clinical exposure. the framework therefore includes a bridging programme with modules that focus on addressing the abovementioned knowledge gaps identified in the study. these need to be covered at the same academic level as those offered during years one and two of the degree programme. in summary, the main aim of the bridging programme would be to ensure that the foundation and core knowledge of an ect graduate, having year 1 year 2 graduate as an ect 1st year of clinical work 2nd year of clinical work two-year ect programme apply for bridging programme basic sciences physiology diagnostics pathology clinical learning portfolio application for credits/rpl for 1st year subjects application for credit/rpl for 2nd year year 1 year 2 year 3 year 4 graduate with degree b ri d g in g p ro g ra m m e fo u rye ar b h s em c p ro g ra m m e fig. 1. framework for articulation between the emergency care technician certificate and the professional degree in emergency medical care[13] (rpl = recognition of prior learning; bhs = bachelor of health sciences; ect = emergency care technician; emc = emergency medical care). may 2014, vol. 6, no. 1 ajhpe 9 research successfully completed the bridging programme, would be exactly the same as that of a b emc student at the end of their second year of study. this will allow ect diplomates who have completed the bridging programme to join the bachelor degree students who are entering their third year of the b emc programme. it is acknowledged that b emc degree programmes differ somewhat in terms of academic architecture, depth and content. therefore, each institution will need to compare the content of the suggested bridging programme with that of their physiology, diagnostics, general pathology, physics and chemistry modules. similarly, the awarding of academic credits and/or recognition of prior learning will be guided by the policies and procedures of the respective higher education institutions. conclusion there remains a shortage of tertiary-qualified emergency care workers in south africa, especially practitioners with advanced life-support skills. the majority of current emergency medical service staff lack formal qualifications and the new mid-level worker ect programme provides an exciting opportunity for entry into the nqf. mid-level worker programmes look set to remain and even expand with additional training providers being accredited each year in a number of professions. the subsequent demand of growing numbers of mid-level workers for further career development and learning opportunities may be partially addressed by creating opportunities for entry into bachelor degree programmes. this study predicts that there will be a sustained demand by ect graduates in the emergency care profession to further their studies and obtain the b emc degree. articulation between the ect programme and the third year of the b mec degree may indeed be possible through completion of a bridging programme. the first pilot of the bridging programme was conducted at the university of johannesburg with 10 ect graduates from the north west province during 2013. funding. this study was funded by the division health sciences education, university of the free state, and the faculty of health sciences, university of johannesburg. acknowledgements. we appreciate the input of professor vanessa burch, university of cape town, with regard to editing and insight in writing this article. references 1. health professions council of south africa. curriculum for the critical care assistant course. doc. 5. part 1. pretoria: hpcsa, 1999. 2. health professions council of south africa. curriculum for the ambulance emergency assistant course. doc. 4. part 1. pretoria: hpcsa, 1999. 3. health professions council of south africa. curriculum for the basic ambulance assistant course. doc. 2. part 1. pretoria: hpcsa, 1999. 4. health professions council of south africa. ec news: newsletter of the professional board for emergency care. pretoria: hpcsa, 2006. 5. south african qualifications authority. bachelor of technology degree. emergency medical care. pretoria: saqa, 2009. http://allqs.saqa.org.za/showqualification.php?id=71789 (accessed 15 march 2010). 6. south african qualifications authority. master of emergency medicine. pretoria: saqa, 2013. http://allqs.saqa. org.za/showqualification.php?id=88323 (accessed 30 april 2013). 7. south african qualifications authority. doctor of philosophy: emergency medicine. pretoria: saqa, 2013. http://allqs.saqa.org.za/showqualification.php?id=80926 (accessed 30 april 2013). 8. naidoo r. presentation at the second meeting of the professional board for emergency care, idle winds, hartebeespoort, 25 february 2011. 9. health professions council of south africa. ec news: newsletter of the professional board for emergency care. pretoria: hpcsa, 2009. 10. south african qualifications authority. the national qualification brochure. http://www.saqa.org.za/docs/ brochures/nqf-brochure.html (accessed 27 march 2013). 11. dovlo d. using mid-level cadres as substitutes for internationally mobile health professionals in africa. a desk review, 2004. http://www.human-resources-health.com/content/2/1/7 (accessed 20 june 2010). 12. university of witwatersrand. clinical associates, bachelor of clinical medical practice programme, 2013. http:// www.wits.ac.za/academic/health/entities/ruralhealth/10098/clinical_associates_bcmp_degree_programme.html (accessed 27 march 2013). 13. vincent-lambert c. a framework for articulation between the emergency care technician certificate and the emergency medical care professional degree. doctoral thesis. university of the free state, bloemfontein, 2012. 14. ivankova nv, creswell jw, plano clark vl. foundations and approaches to mixed methods research. in: maree k, ed. first steps in research. pretoria: van schaik publishers, 1995. http://allqs.saqa.org.za/showqualification.php?id=71789 http://allqs.saqa http://allqs.saqa.org.za/showqualification.php?id=80926 http://www.saqa.org.za/docs/ http://www.human-resources-health.com/content/2/1/7 http://www.wits.ac.za/academic/health/entities/ruralhealth/10098/clinical_associates_bcmp_degree_programme.html http://www.wits.ac.za/academic/health/entities/ruralhealth/10098/clinical_associates_bcmp_degree_programme.html cpd questionnaire cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. questions may be answered up to 12 months after publication of each issue. accreditation number: mdb001/015/01/2013 (clinical) 47 may 2013, vol. 5, no. 1 ajhpe true (a) or false (b): 1. reflective blogging can be a valuable tool for promoting meaningful learning activities among participants, and assisted students in making sense of their shared experiences. 2. reflective blogging can be used in teaching the process of evidence-based practice. 3. most clinicians involved in student teaching have a good understanding of the principles of adult education. 4. allocating continuing professional development (cpd) points to faculty development activities is an important priority. 5. medical students, taught in classrooms and hospitals, frequently choose community-based public health elective modules to gain novel educational experiences. 6. when medical students choose elective modules they consider financial cost, quality of learning support, ‘friendliness’ of the setting and opportunities to engage in activities, i.e. ‘do’ rather than just ‘watch’. 7. medical students who have experience working in a community setting prior to entering medical school are more likely to choose an elective module focusing on public health issues. 8. during compulsory community service, improved functioning as a professional therapist is not reinforced through teamwork.   9. a principle of the appreciative inquiry stance is that words shape reality.   10. building sustainable partnerships to respond to health promotion needs of the school community is essential. 11. social responsiveness in higher education should include the process of engaging with civil society 12. participatory action research is a good way of empowering and engaging study participants when introducing innovations in health sciences education. 13. participatory action research strategies are widely used by researchers in health sciences institutions. 14. health sciences faculties aspiring to be socially accountable should focus their research, teaching and service activities on local, national and regional priority health needs. 15. students who do not feel well prepared for their clinical years report a need for more early clinical exposure. 16. students view additional written assignments as not consuming a greater amount of time relative to the learning benefits derived.   17. staff development initiatives related to internal motivation of the individual is not a good tool to be used to support the individual to successfully transition to clinical education. 18. inductions for new staff in higher education institutions should address the differential role functions for health professionals transitioning into academic roles 19. collaborative reflection did lead to understanding of the significance of the narrator’s personal and emotional reflections on the stories in the teaching representing cultural sensitivity.   20. the medical consultation can be regarded as a culturally neutral context.    may 2013 we are pleased to announce that the number of ceus per test has been increased to 5. article article 14 december 2010, vol. 2, no. 2 ajhpe for the last 100 years, international medical education has mainly been located in large academic health centres or hospitals. clinical training in africa has largely followed this traditional model, with students based in large central hospitals, aside from occasional forays into the community. it is conventional wisdom that all elements of clinical practice can be taught in such a context, and students are left to apply the principles learnt there to any other contexts in which they may work. internationally there has been a move to more community-based training to ensure appropriate training as well as to address workforce issues. one such example, the parallel rural clinical curriculum (prcc), was initiated in the riverland region of south australia in 1997 by the flinders university school of medicine. students spend the entire year 3 (pre-final year) in general practices and regional or district hospitals, being supervised by general practitioners, with gaps being filled by local and visiting specialists. the purpose of this article is to share lessons from a case study of the flinders university prcc. data for this article were collected as part of an external evaluation of the prcc, conducted in 2006.1 design the qualitative component of the evaluation, used for this report, involved focus groups and individual interviews conducted by an external evaluator (ic). a standard question was posed, viz. ‘what is your experience of year 3?’ follow-up questions covered educational and social advantages and disadvantages of the programme, outcomes and achievements, and recommended changes. focus group discussions were held with students at four sites, viz. flinders medical centre (fmc) – the major academic tertiary hospital in adelaide – and the three prcc sites operational in 2006 (riverland, greater green triangle and hills mallee fleurieu). individual in-depth interviews were conducted with staff at each of the sites, faculty leadership, key informants in the health services and community members. interviews were recorded and transcribed. after anonymisation, transcriptions were imported into n-vivo 7 and analysed by coding data according to emerging themes. the research protocol was approved by the relevant ethics committees of the university of the witwatersrand and flinders university. results individual interviews were conducted with 87 people, representing a range of stakeholders linked to year 3 (table i). there were six focus group discussions which included 45 students. the results presented below are grouped under the axes of the flinders symbiotic model2 of clinical education in relation to four questions. 1. clinicians and patients: how to ensure that we train healers and not only technicians students in the prcc were very positive about their experience in terms of what they learnt about people and not only about medicine. through exposure to gps, specialists and other health workers, to hospital and community-based care, and to the range of patient presentations and needs, from minor to major, curative to preventive, rehabilitative or palliative, prcc students experience and come to understand comprehensive and holistic care. in contrast, at fmc there is a rapid turnover of patients and difficulties in finding suitable patients for students. a key element of the prcc is the focus on the undifferentiated patient as the basis for learning and the integration that happens through abstract objectives. to review data collected during an evaluation of the flinders university parallel rural community curriculum (prcc) in order to reflect on its relevance for medical education in africa. setting. the prcc offers a community-based longitudinal curriculum as an alternative for students in their pre-final year of medical training. design. individual and focus group interviews were conducted with students, staff, health service managers, preceptors and community members. results. students are exposed to comprehensive, holistic, relationshipbased care of patients, with a graded increase in responsibility. students have varying experience at different sites, yet achieve the same outcomes. there is a strong partnership with the health service. conclusions. the principle of balancing sound education and exposure to a variety of contexts, including longitudinal community-based attachments, deserves consideration by medical educators in africa. evaluation of the parallel rural community curriculum at flinders university, south australia: lessons learnt for africa i d couper division of rural health, department of family medicine, university of the witwatersrand, johannesburg, south africa p s worley school of medicine, flinders university, adelaide, australia correspondence to: i d couper (ian.couper@wits.ac.za) article 15 december 2010, vol. 2, no. 2 ajhpe this process. ‘the physician says go see this patient. we don’t know if that’s going to involve a cardio-type problem, a respiratory-type problem or a neurological type problem so we have to be ready for anything. and then when he questions us we’re not just in a medicine block, or just in an o&g block, we have to consider the whole range.’ the relationship between students and patients is a mutual one. practice managers and gps alike reported that patients enjoy students, take pleasure in being able to be part of teaching them, and appreciate the greater attention and longer consultations that students offer. 2. health service and university: how to develop learning cultures in smaller health services flinders offers a model of using all available local resources to educate students, based on an understanding of ‘many roads’ leading to one destination. the university has forged strong partnerships with the health service. there is a common understanding of the need for educational and service components within health care to work together. a commonly held belief among students was that those at other sites must be better off – ‘the grass is always greener no matter where you are’. this highlights the fact that all sites were seen to have strengths and weaknesses, and are suited to different students, which was cited as a reason to use multiple sites. the university’s involvement in prcc sites has a significant impact. gps spoke of the stimulation offered by their role as teachers, which has given ‘new meaning’ to their practice. it promotes quality of care and evidence-based practice. general practices appreciate their relationship with the university and with the students, taking great pride in being part of the academic endeavour and helping to train the future generation of doctors. there is a sense of purpose in being an ‘academic practice’. the local hospitals too were highly appreciative of the programme. a strong benefit of having students is seen to be the learning culture which has developed in these hospitals. by having students, the local health service is supported and developed. 3. government and community: how to make an impact on the workforce needs of all communities at the prcc sites, the buy-in from partners (faculty, gps, health service, local government, politicians) is impressive. there is a clear recognition of a common vision – to address workforce shortages in rural australia and to provide a good educational experience for students. stakeholders outside of the university have bought into the vision, adopted it as their own, support it – even financially in the case of some local governments – and are ready to defend it against threat. there is a feeling too within the flinders and broader community that the prcc has had a very positive effect in terms of improving attitudes towards rural practice. the prcc alone cannot solve the workforce problems. student selection was mentioned as an important issue, and it became clear that the prcc was most successful at sites, such as the greater green triangle, where postgraduate training opportunities also existed. 4. personal principles and professional expectations: how to instil values such as responsibility and teamwork in students students expressed the need for mentoring. fmc was reported by some as an unfriendly, unsupportive environment. in contrast, the prcc uses an apprenticeship model of training; students are individually mentored, guided and coached through the year, providing them with opportunities for personal growth in addition to educational development and ensuring that they acquire good clinical skills. concerns were raised about some of the role modelling that occurs at fmc, and whether enough emphasis is placed on teamwork and functioning co-operatively in a health care system. ‘are we producing doctors who actually consider themselves to be integral parts of teams rather than independent practitioners?’ in the prcc, students become integral and valued members of the professional team. in addition, prcc students are given graded responsibility, so that, instead of simply observing processes, or ‘clerking patients’ for learning purposes, they become responsible for the care of patients over time under supervision, which is an important learning experience. students are not just observers, but contribute directly to patient care. conclusions the flinders prcc programme offers a model for ensuring that students see their patients holistically, caring for them as people rather than simply being expert technicians, a perspective recognised to be critical in a number of guidelines on medical education internationally.3-5 the key ingredients of this are the continuity of relationship, both with doctors and other health care staff and also with patients, afforded by a longitudinal exposure in a community setting. integration of knowledge happens through practice and under the guidance of mentors. this is achievable in an african context, even if the model might look very different, using, e.g. clinics, health centres and district hospitals, and not only private gps. the flinders year 3 programme runs counter to the conveyor belt approach to medical education, offering a smorgasbord of opportunities for students. this allows the medical school to use every available health service resource and the students to explore their interests, select options appropriate to their learning styles and develop in their own ways, while still meeting a common goal. the final common exit examination protable i. summary of interviewees group category total university-based staff faculty leadership 6 academics (non-clinical) 9 clinicians academic co-ordinators (departmental or site based) 8 gps 19 other specialists 6 other hospital staff, e.g. clinical nurses 5 managers health service bureaucrats 8 practice managers 5 hospital managers (ceos, directors of nursing, etc.) 7 academic support staff administrators 10 community/local government representatives 4 total 87 article 16 december 2010, vol. 2, no. 2 ajhpe vides a standard that all must reach. research has shown that students in the prcc generally perform better than their peers in this exit examination.6 the assertion of one respondent that students deserve good education regardless of site may seem self-evident. what is interesting is that this was applied to the tertiary centre. as these centres change, becoming more acute in their focus and more high-tech as opposed to high-touch, their suitability as training sites for students must be re-considered. there are many educational experiences on which students can potentially miss out as the nature of tertiary centres changes, such as chronic care, ongoing care, continuity, first-contact care, exposure to common conditions, and contact with undifferentiated and ambulatory patients. the aim of flinders is that students are enabled ‘to undertake further training for any branch of medicine’. this should be true of all medical education. it is important to examine the training in africa to ascertain whether or not that is the case – whether students are indeed properly equipped, e.g. for rural and generalist practice, or mainly for specialised hospital practice. the flinders programme has had success in aligning the goals of the teaching institution and of the service in a common understanding of the role of both in developing a future workforce. working to obtain greater alignment between these two would make a difference in africa. we should be aligning not only with the tertiary sector, but even more so with the district hospital network. the role that medical education can play in peripheral, ‘non-academic’ health services cannot be over-emphasised. one of the arguments against training outside the walls of the tertiary institution has often been a concern about standards of care. while it may be argued that there already existed high-quality care in the rural areas chosen by flinders, it is clear that the presence of students and academics in these areas led to the development of a learning culture, stimulation of doctors and a general improvement in the quality of care provided, and validated them as legitimate places to work. this is surely also part of the mandate of the training institutions in africa – to improve quality of care through academic involvement, rather than ensuring that poor standards of care continue by eschewing involvement. flinders has developed a model, replicated in a number of other faculties in australia and around the world, that offers sound education while exposing students to a range of different contexts. while the resources in africa may be different, the principles nevertheless still demand consideration. references 1. couper i. evaluation of the parallel rural community curriculum at flinders university of south australia, in the context of the gemp year 3. final report. johannesburg: university of the witwatersrand, 2006. available at http://web. wits.ac.za/academic/health/entities/ruralhealth/articles.htm 2. worley p, prideaux d, strasser r, magarey a, march r. empirical evidence for symbiotic medical education: a comparative analysis of community and tertiarybased programmes. medical education 2006;40:109-116. 3. education committee of the general medical council. tomorrow’s doctors: recommendations on undergraduate medical education. london: general medical council, 2003. 4. simpson jg, furnace j, crosby j, et al. the scottish doctor – learning outcomes for the medical undergraduate in scotland: a foundation for competent and reflective practitioners. med teach 2002;24:136-143. 5. royal college of physicians and surgeons of canada. canmeds framework.2005. available at http://rcpsc.medical.org/canmeds/about_e.php (accessed 11 may 2009). 6. worley p, esterman a, prideaux d. cohort study of examination performance of undergraduate medical students learning in community settings. bmj 2004;328:207-209. editorial may 2013, vol. 5, no. 1 ajhpe 2 social accountability is about ensuring greater equity in the delivery of services to communities, especially those that are poor and marginalised. a world bank discussion document suggests that social accountability is manifested most strongly where there is good governance and an empowered community, which ultimately results in the increased effectiveness of developmental initiatives.[1] this discussion is echoed in the reflections of the lancet commission of 2010 which calls for the transformation of health professionals’ education across the world in an attempt to create graduates who are better able to read the communities they serve and respond appropriately to their needs.[2] the commission’s report places emphasis on the institutions that engage in educational projects becoming more accountable by increasing the co-operation between ministries of health and ministries that govern such projects.[2] this idea is captured in the evaluation framework offered by thenet for the assessment of institutional accountability.[3] the framework essentially gives life to the original who definitions of social accountability which called for educational institutions to respond to the needs of reference populations or communities through their research, service and educational endeavour.[4] perhaps the most important aspect of the questions asked in the framework are those in the section ‘what difference do we make?’.[4] it is the process of making a difference which becomes the most challenging part of what we do as health profession educators. an important part of making a difference is the development of a collective action in which we are able to convince the many role players of our integrity and sincerity.[5] both these attributes are key components of social accountability, which calls for joint responsibility of health science educators, partners in the service delivery training platforms as well as the communities served.[3,4] in many ways the call by the lancet commission for the graduation of change agents from our health science schools is dependent on how well developed the teachers are as agents of transformation.[2] transformative learning has been characterised as using past experiences through reflective process and arriving at newly constructed paradigms for how to view the world and respond to its needs.[6] teaching our graduates to be multidimensional practitioners has long been a theme in the competency-based discourse which is reflected in the evolution and application of the canmeds attributes.[7] these have gained wider recognition with the health professions council of south africa (hpcsa), embarking on a process of localising them to the south african context. however, the achievement of a transformative learning paradigm is dependent on the development of transformative teachers. kathleen taylor challenges teachers to teach with the specific aim of development in mind and asks the question of teachers: ‘what do you want your adult learners to walk away with at the end of your time together, developmentally speaking?’[8] if we are able to engage our learners with a developmental intent, then we are more likely to achieve learners capable of reflective examination of the communities in which they serve and in taylor’s words ‘recognize the need for more just, humane, and equitable economic and social structures and to work towards achieving those goals’. it is this goal that is the focus of the questions asked in the thenet’s evaluation framework.[3] all of us in the health science education community and beyond (institutions, movements, associations and individual practitioners) would do well to keep the following questions in mind in all of our teaching and learning endeavours: • how do we work? • what do we do? • what difference do we make? l p green-thompson mb bch, fca (sa), mmed centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa, and national chairperson, saahe lionel.green-thompson@wits.ac.za 1. malena c, forster r, singh j. social accountability. an introduction to the concept and emerging practice. social development papers, 2004. http://siteresources.worldbank.org/ intpceng (accessed 18 march 2013). 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s0140-6736(10)61854-5] 3. training for health equity network. thenet’s social accountability evaluation framework version 1, 2011. http://thenetcommunity.org/thenets-evaluation-framework/ (accessed 8 april 2013). 4. boelen c, heck je. defining and measuring the social accountability of medical schools, 1995. http://whqlibdoc. who.int/hq/1995/who_hrh_95.7.pdf (accessed 30 july 2012). 5. van zyl g. being different, or making a difference? african journal of health professions education 2012;4(1):2. [http://dx.doi.org/10.7196/ajhpe.176] 6. mezirow j. learning to think like an adult – core concepts of transformation theory. in: mezirow j and associates, eds. learning as transformation.1st ed. san francisco, usa: jossey-bass, 2000:3-33. 7. frank jr, danoff d. the canmeds initiative: implementing an outcomes-based framework of physician competencies. medical teacher 2007;29:642-647. 8. taylor k. teaching with developmental intention. in: mezirow j and associates, eds. learning as transformation.1st ed. san francisco, usa: jossey-bass, 2000:151-179. ajhpe 2013;5(1):2. doi:10.7196/ajhpe.264 are we socially accountable educators? research may 2015, vol. 7, no. 1, suppl 1 ajhpe 105 infection prevention and control (ipc) is a discipline that aims to prevent or control infection transmission in healthcare facilities and the community.[1] in south african (sa) healthcare facilities ipc is gaining increasing importance, forming one of six key priorities in the national core standards for health establishments.[2] medical graduates’ ipc knowledge base, attitudes and practices are established at undergraduate level.[3] although knowledge and skills are acquired through the taught curriculum, attitudes and practices are more often modelled on those of medical faculty and senior colleagues.[4] in many medical curricula, ipc is not taught as a stand-alone subject but rather as a ‘golden thread’ throughout undergraduate training. at stellenbosch university, ipc-related content is included within modules including microbiology, infectious diseases, clinical disciplines and clinical skills laboratory training. a situational analysis was conducted to assess the content, coverage and opportunities for enhancement of ipc teaching within the stellenbosch university’s mb,chb curriculum. the analysis included: development of ipc competencies for mb,chb students; a curriculum module review; a survey of recent mb,chb graduates and interviews with teaching faculty. the curriculum research was an activity of the stellenbosch university rural medical education partnership initiative (surmepi) and included four undergraduate knowledge areas: ipc, evidence-based health, public health and health systems and services research. this paper reports on medical graduates’ post-qualification experiences of ipc, as well as graduates’ and faculty perceptions of teaching and learning in ipc. methods ipc competencies key and enabling ipc competencies for stellenbosch university mb,chb students (table 1) were developed and refined in consultation with faculty mem bers and ipc expert practitioners, drawing on the canmeds framework[5] and international literature. this canadian-developed framework is widely used to define required competencies for medical doctors in each of seven ‘roles’ including: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. graduate survey an electronic questionnaire (distributed between january and june 2012) surveyed recent stellenbosch university medical graduates (2004-2010). likert scales and open-ended questions explored graduates’ opinions of the appropriateness, acceptability and relevance of undergraduate ipc teaching and learning, and their experiences of ipc practice post graduation. data were analysed using spss statistical software version 20 (quantitative data) and framework analysis aided by atlas.ti version 7.0 (qualitative data). one author coded all transcripts, while a second author coded 25% of the same data independently. there was more than 80% agreement between authors and we thus relied on the coding of the first author. we grouped codes into emerging themes for each question. comments from survey respondents who answered in afrikaans were translated into english. ethical approval was obtained from the stellenbosch university health research ethics committee (s11/10/004). background. knowledge, skills and desirable clinical practices in infection prevention and control (ipc) should be acquired during undergraduate medical training. although knowledge and skills are learnt in the formal curriculum, attitudes and practices are assimilated by observation and modelling. we investigated whether undergraduate teaching and learning of ipc at stellenbosch university adequately prepared graduates for medical practice. methods. a situational analysis of ipc teaching was conducted, including development of ipc competencies, a curriculum review, an email survey of mb,chb graduates and semistructured focus group or personal interviews with teaching faculty. qualitative data were assessed using a framework analysis approach. results. all graduate survey respondents who completed the ipc-related questions (n=180) agreed that teaching of ipc was important and most (156; 87.8%) felt that ipc teaching had adequately prepared them for practice. despite this perception, graduates encountered difficulty implementing ipc best practice owing to lack of management support for ipc and resource constraints. faculty members disagreed regarding the adequacy of ipc teaching and some were concerned that the curriculum failed to prepare graduates for medical practice. graduates and faculty felt strongly that undergraduate ipc teaching and learning could be improved by addressing suboptimal ipc practices and lack of clinician role models for ipc at training institutions. conclusion. ipc knowledge transfer appears adequate in most competency areas. however graduates struggled to implement ipc best practice in the clinical field. undergraduate ipc teaching and learning could be enhanced by development of clinician role models for ipc and strengthened ipc practices in training institutions. afr j health professions educ 2015;7(1 suppl 1):105-110. doi 10.7196/ajhpe.500 does undergraduate teaching of infection prevention and control adequately equip graduates for medical practice? a dramowski,1 mmed paed; f marais,2 phd; b willems,3 mb chb; s mehtar,4 fcpath (sa) and the surmepi curriculum review working group* 1 department of paediatrics and child health, stellenbosch university, cape town, south africa 2 division of community health, stellenbosch university, and western cape government health, cape town, south africa 3 division of community health, stellenbosch university, cape town, south africa 4 unit for infection prevention and control, division of community health, stellenbosch university, cape town, south africa * sade adeniyi, neil cameron, lilian dudley, charlyn goliath, fidele mukinda, anke rohwer, taryn young corresponding author: a dramowski (dramowski@sun.ac.za) research 106 may 2015, vol. 7, no. 1, suppl 1 ajhpe faculty interviews stellenbosch university faculty were involved in mb,chb teaching were identified from a list of undergraduate module (subject) convenors. nine proposed focus groups were created, according to content areas covered and/or module placement in the curriculum. each participant (module convenor) was informed of the study purpose, provided written consent and received documents in advance: the ipc key competencies for undergraduates (fig.1); the ipc curriculum module review findings; and the graduate survey report. trained interviewers captured all interview sessions on a digital voice recorder, with additional field notes. qualitative data were transcribed (with participants de-identified) followed by framework analysis,[6] aided by atlas. ti version 7.0 software. a master code list (appendix 1) was developed through discussion and consensus by the larger surmepi curriculum review working group. after all transcripts were reviewed, emerging themes, sub-themes and cross-cutting themes were identified. the coding process was conducted as described above. ethical approval was obtained from the stellenbosch university health research ethics committee (n12/11/081). results graduate survey a total of 375 of 980 recent medical graduates (38%) responded to the survey invitation, although only 180 (18.4% of the target population) com pleted all ipc-related questions (table 2). partially completed surveys were included in the analysis. all ipc section respondents (n=180) agreed it was important to learn ipc at undergraduate level. most (156; 87.8%) felt ipc teaching had adequately prepared them for medical practice. from a list of ten ipc competencies, most respondents (103/180; 57.2%) felt the topics had received adequate or comprehensive coverage in the curriculum (table 3). topics reported as inadequately covered were: occupational health; assessment of ipc policies/guidelines; and leadership/management in ipc. despite reports that training on the topic of sharps management was adequate, needle-stick injuries were common (fig. 1). graduates’ qualitative responses are included with the faculty interviews below. table 1. key competencies in infection prevention and control (ipc) for stellenbosch university medical graduates key competencies: medical graduates should be competent in these five core elements of ipc as applied in hospital, community and household settings. standard precautions transmission-based precautions aseptic procedures ipc policies & guidelines patient-provider education and empowerment must be able to apply and adhere to the correct procedure-based standard precautions in all clinical practices must be able to implement and adhere to the appropriate transmissionbased precautions for the prevention of infection must apply the correct aseptic procedure when using or inserting medical devices to prevent infection must understand the importance and implications of local ipcrelated legislation and requirements must understand the importance and benefits of ipc knowledge transfer between patients and healthcare staff, and possess the necessary skills in education and communication hand hygiene personal protective equipment use safe disposal of sharps injection safety decontamination of equipment clinical waste management airborne precautions droplet precautions contact precautions intravenous devices urinary catheters central venous lines endotracheal intubation suturing of minor wounds delivery of babies assisting with surgical operations notification of communicable disease epi surveillance system reporting of occupational risks/exposures exposure to blood and body fluids (sharps and splashes) general ipc measures prevention of diarrhoeal and respiratory disease tb infection control advocacy enabling competencies: medical graduates should have working knowledge of infectious disease pathogenesis, basic epidemiology, laboratory investigations, antimicrobial chemotherapy, prophylaxis and vaccination epi = expanded programme on immunisation, with surveillance including acute flaccid paralysis, neonatal tetanus, measles and adverse events following immunisation. 0 10 20 40 50 60 70 80 90 10030 3% 24% 54% 19% >5 nsi 3-4 nsi 1-2 nsi no nsi n si p er m ed ic al g ra d u at e total nsi reports fig. 1. needle-stick injuries (nsi) among recent medical graduates (n=167). not all survey respondents completed all sections of the survey and therefore participant numbers vary by question. research may 2015, vol. 7, no. 1, suppl 1 ajhpe 107 faculty interviews a total of 15 interviews were conducted: 20 participants completed 5 focus group interviews (2 7 participants each) and 10 completed individual inter views (as they were unable to attend their focus group date.) qualitative responses from the graduate survey and faculty interviews the themes emerging from the graduate survey and faculty interviews were remarkably similar. pertinent verbatim quotations appear below grouped in emerging themes and coded with unique participant numbers for graduates (g) and faculty (f). all graduates and many faculty members reported that ipc was an essential and relevant subject to their discipline, as well as the greater sa healthcare context: • f14 ‘infection prevention must be part of what we do every day. it is absolutely essential especially in south africa …’ • f15 ‘[ipc is]…probably one of the cornerstones particularly in our country … so we’re very cognisant of infection control … i think that would be very relevant to our students.’ although many faculty members agreed that the subject of ipc was relevant, there was disagreement as to how adequately it was addressed in the curriculum: • f05 ‘at undergraduate level we don’t really provide the basic principles of infection prevention and control. we do provide some specific principles as it applies to our discipline.’ • f11 ‘well in no part of my teaching do i do infection control at all and …. we probably should.’ • f08 ‘infection control … that definitely is addressed very well … previously it wasn’t like that.’ despite reporting that ipc was generally well taught, many graduates and faculty pointed out that ipc-related knowledge was seldom implemented in daily practice. graduates and faculty reported that this ‘know-do’ gap was perpetuated by a failure of clinicians in training institutions to model good ipc practice: • f04 ‘it is almost like we see it merely as a principle and that is where it stays… [ipc is] taught as principles but there is very little translation of these principles when they start in their clinical rotations…’ • g18 ‘do as i say, not as i do. we had quite a few theoretically sound lectures, but none of those measures were applied consistently in practice – particularly relating to tb infection control, the examples set were disastrously inadequate and even misleading.’ • f09 ‘then they get this hidden curriculum … where we teach things in the lecture halls and then in the hospital they get told n95 masks are for sissies. you don’t need a mask, just get out, just do the work... they see seniors not wearing gloves when they do invasive procedures, not washing their hands and so what we teach and what they see are not the same.’ • f03 ‘we can teach them whatever we want. i think many students follow what is modelled.’ table 2. graduate survey participant demographics (n=287)* year mb,chb degree obtained n (%) 2004 31 (10.8) 2005 53 (18.5) 2006 50 (17.4) 2007 31(10.8) 2008 39 (13.6) 2009 40 (13.9) 2010 43 (15.0) current employment position n (%) internship 41 (14.2) community service 39 (13.5) medical officer 82 (28.5) general practitioner 38 (13.2) registrar 70 (24.3) specialist 3 (1.0) other† 15 (5.2) * not all survey respondents completed all sections of the survey and therefore participant numbers for each question vary. †other = other medical-related post, other non-medical profession, unemployed. table 3. graduates’ opinion of ipc competency area coverage in the undergraduate mb,chb curriculum competency area* not at all/ inadequate n (%) basic n (%) adequate/ comprehensive n (%) hand hygiene 9 (5) 23 (12.7) 149 (82.3) use of personal protective equipment 14 (7.8) 32 (17.9) 133 (74.3) sharps management/needle-stick injury 8 (4.5) 14 (7.9) 156 (87.6) decontamination of equipment between patient use 20 (11.1) 41 (22.9) 118 (66.6) clinical waste management 35 (19.4) 52 (29) 93 (51.6) transmission-based precautions 19 (10.8) 40 (22.6) 118 (66.6) prevention of infection transmission during procedures 14 (7.9) 27 (15.3) 136 (76.8) assessment of ipc policy/guidelines for healthcare facilities 51 (28.5) 71 (39.7) 57 (31.8) motivation of hcw to adhere to ipc policies/guidelines 50 (28.2) 67 (37.9) 60 (33.9) occupational health and hcw rights to a safe work environment 62 (34.4) 71 (39.4) 47 (26.2) * not all survey respondents completed all sections of the survey and therefore participant numbers for each question vary. hcw = healthcare worker. research 108 may 2015, vol. 7, no. 1, suppl 1 ajhpe • g82 ‘the training in ipc is good, but healthcare workers are not afraid enough of contracting tb, so they don’t implement precautions… our senior consultants and registrars don’t set a good example.’ many faculty members felt that the curriculum did not adequately prepare graduates for practice in the sa context, and in particular that the training provided failed to equip graduates with skills to implement health system change. • f09 ‘they know all the fancy stuff, but the simple things that they need to do in practice they haven’t been taught.’ • f06 ‘they need to be prepared for a severely resource-constrained area … they need to have an attitude of how to adapt and to compromise, which maybe we are not preparing them for …’ • f01 ‘we teach students how the health system works, but okay, so what? the question is how do i improve the health system, how do i engage, how do i really make a change? … they don’t see that … in practice.’ • f09 ‘i think we need to focus more on making the students aware that when they go out with that degree that they should become the so-called change agents. they don’t see themselves as being able to make a difference in public health sector in that way.’ this perception was confirmed by graduates’ reports of challenges in implementing ipc best practice in sa healthcare facilities. graduates singled out facility managers for not providing adequate support for ipc, particularly lack of provisions and failure to implement ipc policies and best practice. resource constraints, including poor planning of facilities (especially isolation areas and ventilation) were commonly cited issues. • g45 ‘weak management with the attitude that “you must just make do with what is available” – even if it is not the right way to practise.’ • g66 ‘managers have limited insight into ipc matters, and are often ineffective and underqualified.’ • g18 ‘we have no recourse to improve matters or at the very least protect ourselves. administrators and peers are guilty of gross neglect of self and colleagues.’ • g54 ‘a breakdown in communication between managers and clinicians prevents ipc problems being addressed.’ • g63 ‘there are no isolation rooms available …’ • g30 ‘the most basic ipc provisions and protective equipment are not available … either due to budget constraints or mismanagement in the ordering of stock.’ • g66 ‘[there is] extremely poor planning of ventilation in healthcare facilities with a high tb burden.’ graduates were particularly concerned regarding the attitude of senior colleagues to occupational health and patient safety. they reported a general disregard of safety in the healthcare environment and a lack of accountability for deviation from ipc policies. • g178 ‘work-related injury is something most doctors encounter at least once in their careers, whether it’s hiv, hepatitis exposure or tb; i was amazed how much emotional stress these injuries create and worried by how little support there is for affected doctors.’ • g18 ‘doctors are forced to work in dangerous situations with unsafe sharps containers, lack of gloves, absence of n95 respirators, isolation facilities or adequate ventilation.’ • g05 ‘fellow staff and management disregard the importance of ipc; there is just an attitude of: no one cares and it’s nobody’s responsibility.’ • g120 ‘there are no consequences for ignoring ipc policies.’ given these realities of healthcare practice, how should the curriculum be adapted to better prepare medical graduates? faculty identified multiple barriers to inclusion of more ipc-related content in the mb,chb curriculum (grouped thematically into curriculum-related and practice-environmentrelated challenges). curriculum challenges • f15 ‘there is so little time so you are trying to do the best in that little time and impart as much of your discipline as you can. so you sort of prioritise on the important … and hope that somebody else will catch up somewhere along the line.’ • f01 ‘you never talk about infection [ipc], you don’t demonstrate it … it is not our responsibility. i just look after my small piece, you understand. so there is a big motivation in change management necessary for … academics within our faculty, to become role models themselves, to integrate these things themselves.’ • f01 ‘the challenge for the curriculum which contains these four components [ipc], is not just to integrate it into the curriculum because in a sense it is very, very difficult. it’s how to integrate it within the clinical care of a patient.’ practice environment challenges • f06 ‘… challenging things like infection prevention … we know what is the right thing to teach the student … but they will come and tell you tomorrow, when i get to the hospital this is not there. what must i do? then you teach them the next best thing which you know is not the right thing, and then the irony is, even when the best thing is there, they do the thing that’s wrong.’ • f04 ‘… groups of the students more and more mention of the lack of infection control in the hospitals or the disregard to [of ] established protocols.’ • f09 ‘we must train more medical students, wards are crowded, patients are overexamined, not enough staff to properly teach.’ despite these many challenges, faculty and graduates identified several opportunities for improvement of the ipc curriculum, and were generally supportive of integrating ipc teaching within other disciplines. • f06 ‘there are a lot of opportunities, we don’t necessarily use all of them but we try … if you teach a skill, obviously watch the infection prevention control related to that …’ • f14 ‘ … formal teaching is not good enough, we need to demonstrate, we need to be actively involved to be role models for students to actually see what we do in clinical practice.’ • g122 ‘empower students to address ipc issues – most training takes place in the clinical rotations and through the example set by senior staff. ipc guidelines must be effectively applied in the training institutions where students will learn either good or bad practices.’ • g50 ‘incorporate ipc into every practical exam. if you do not wash your hands or take the correct precautions – then you fail or get marked down.’ • g05 ‘improve the training environment – the actual hospitals and clinics. teach students to address ipc shortcuts in facilities assertively… if a student learns good ipc during clinical rotations lectures might even be unnecessary!?’ research may 2015, vol. 7, no. 1, suppl 1 ajhpe 109 discussion graduates’ universal agreement on the importance of undergraduate ipc teaching is unsurprising given sa’s high burden of communicable disease[7] and daily exposure of young doctors to infectious diseases. many respondents argued that ipc should receive greater emphasis in the curriculum, possibly indicating that at student level, the relevance of ipc to one’s future practice is underestimated. it is possible that recall bias may be present among graduates asked to comment on their experience of ipc teaching several years ago. notwithstanding this limitation, graduates were largely in agreement on areas of deficiency in the ipc curriculum. the ‘inadequately covered’ ipc topics (occupational health, ipc policies/guidelines, leadership/management in ipc) are all core competencies needed for medical practice. graduates reported extreme dissatisfaction with healthcare management and the lack of resources available for ipc. this perception is not unfounded as a recent baseline audit measured ipc compliance in south african healthcare facilities at only 50%.[8] although the vast majority of graduates agreed sharps management was well covered in the ipc curriculum, needle-stick injuries were common (with 81.4% of respondents reporting one or more injury since graduation). in a similar cohort of young doctors in the usa, early career sharps exposures were reported from 103 of 455 healthcare workers (22.6%).[9] it is well-demonstrated that knowledge alone will not necessarily alter practice. however, additional data are needed to explore potential contributing factors to the high sharps injury rate, e.g. fatigue, patient load, lack of sharps bins, unavailability of safety-engineered devices and recapping of needles. although over 80% of graduates reported that the ipc curriculum prepared them adequately for medical practice, the qualitative data were contradictory. graduates appeared ill-equipped to deal with challenges in sa healthcare facilities including ineffective management, resistance to change and lack of resources/basic provisions for ipc. given the nature of these challenges, curriculum enhancement alone is unlikely to improve graduates’ ability to address ipc practice issues. mb,chb graduates require generic skills to plan, implement, manage and measure health-related interventions. these so-called ‘soft skills’ of advocacy, healthcare management and communication (all prioritised in the canmeds model) would empower graduates to address ipc (and other quality improvement) issues. it is clear that graduates have the relevant knowledge to identify problems, but lack the skills and attitude to effect change. enhanced skills in advocacy, monitoring and evaluation and healthcare management (although not uniquely applicable to ipc) would better equip graduates to promote systems, attitudinal and behaviour change at their facilities. teaching of this skill set could be integrated in the clinical disciplines and emphasised within a new module called ‘doctor as change agent’ in the mb,chb v curriculum. role-modelling, the process in which ‘faculty members demonstrate clinical skills and manifest professional characteristics’[10] has a broad influence on undergraduate learning, including students’ attitudes and behaviours (both positive and negative).[11,12] although faculty members concurred that ipc was highly relevant, in almost all instances they did not incorporate ipc principles in their teaching. graduates noted that although faculty taught them the correct ipc principles, these same ‘clinician role models’ demonstrated contradictory attitudes and behaviours in daily practice. a negative institutional climate with widespread examples of undesirable ipc practice at their training facilities influenced students’ perceptions of ipc. the curriculum redevelopment process should acknowledge and address shortcomings in ipc practice at universityaffiliated training facilities as a priority. graduates and faculty supported the idea of integrating ipc within other disciplines. given the shortage of dedicated faculty to teach ipc and the ‘crowded’ curriculum, incorporation of ipc principles relevant to each clinical discipline would seem a practical solution. this would require recruitment of ‘ipc champions’ to lead the process of integration at departmental level. acknowledgement of ipc as an essential competency in all clinical disciplines should encourage faculty to become better role models and advocates for improved ipc practice in training institutions. this approach could (without the need for further didactic ipc teaching) produce young doctors who will per petuate the ipc best practices they observed during undergraduate training. conclusion medical graduates and faculty agree on the relevance and importance of ipc teaching in the mb,chb curriculum. graduates feel that most ipc topics are ade quate ly taught, preparing them well for medical practice. however, graduates and faculty report challenges in ipc best practice implementation including lack of leadership support and resource constraints. graduates identified a lack of clinician role models for ipc and highlighted the need to address incorrect ipc practices at their training facilities. faculty also argued that graduates should be trained as ‘change agents’ with expanded skills in healthcare management, health advocacy and quality improvement. future studies should determine what additional training is needed to empower medical graduates to become change agents (for healthcare quality improvement) in sa. acknowledgements. this research has been supported by the us president’s emergency plan for aids relief (pepfar) through health resources and services administration (hrsa) under the terms of t84ha21652 and via the stellenbosch university rural medical education partnership initiative (surmepi). we thank the stellenbosch university graduates and faculty members for their contribution to this research. special thanks to dr donald skinner for assistance with development of the master code list and management of the data analysis process using atlas.ti. references 1. mehtar s. understanding infection prevention and control. cape town: juta, 2010:1. 2. national department of health. national core standards for health establishments in south africa. pretoria: national department of health, 2011. 3. tavolacci mp, ladner j, bailly l, et al. prevention of nosocomial infection and standard precautions: knowledge and source of information among healthcare students. infect control hosp epidemiol 2008;29:642-647. [http:// dx.doi.org/10.1086/588683] 4. byszewski a, hendelman w, mcguinty c, moineau g. wanted: role models – medical students’ perceptions of professionalism. bmc med educ 2012;12:115. [http://dx.doi.org/10.1186/1472-6920-12-115] 5. frank j. the canmeds 2005 physician competency framework. better standards. better physicians. better care. ottawa: the royal college of physicians and surgeons of canada, 2005. 6. ritchie j, lewis j, eds. qualitative research practice: a guide for social science students and researchers. london: sage publications, 2003. 7. bradshaw d, groenewald p, laubscher r, et al. initial burden of disease estimates for south africa, 2000. cape town: south african medical research council, 2003. 8. national department of health. the national health care facilities baseline audit: national summary report. pretoria: national department of health, 2012. 9. kessler cs, mcguinn m, spec a, christensen j, baragi r, hershow rc. underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey. am j infect control 2011;39(2):129-134. [http://dx.doi.org/10.1016/j.ajic.2010.06.023] 10. irby dm. clinical teaching and the clinical teacher. med educ 1986;61(9 pt 2):35-45. 11. reddy st, farnan jm, yoon jd, et al. third-year medical students’ participation in and perceptions of unprofessional behaviors. acad med 2007;82(10 suppl):s35-s39. 12. woloschuk wi, harasym ph, temple w. attitude change during medical school: a cohort study. med educ 2004;38(5):522-534. research 110 may 2015, vol. 7, no. 1, suppl 1 ajhpe appendix 1. master code list for atlas.ti qualitative data analysis code-filter: all hu: faculty inter merged 1 -15 for analysis file: [c:\users\gges\documents\scientific software\atlasti\textbank\faculty inter merged 1 -15 for analysis.hpr7] date/time: 2013-11-11 11:24:35 concern challenges to the sa healthcare system: organisation, under resources, lack of facilities concern clinical skills v. research skills: tension between these; students not interested in research concern dept levels of interest: resistance from dept to teaching these 4 areas; relevance, lack of interest concern exposure to risky environments: students faced with risk of tb, crime, etc. concern impact of rotations: order of teaching; split between different facilities concern information overload: too much info, pressure concern lack of skills/knowledge: in dept/competencies/lack of appropriate examples/case studies concern lack of time: insufficient faculty members for teaching/load on academics – teaching, patients, research, etc. concern overload: too many students/space/facilities/patients for teaching; lack of appropriate context training facilities concern poor basic knowledge: difficulty in building on previous learning concern problems or concerns (general): concern problems with assessment practices: lack of relevant assessment; concern inappropriate assessment models/frameworks from other settings; module outcomes/examination content concern sa v. external agenda: students training to take up a career overseas concern sources of evidence: lack research examples/difficulty accessing info, search practice familiarity concern students’ lack of interest: anything reflecting students not wanting to engage with subjects concern theory v. clinical modules: disconnect and time between teaching certain subjects ipc general (anything that doesn’t fit in with the other ipc codes) ipc knowledge of competencies: discussion of anything related to expected competencies to be achieved by graduates ipc measures of evaluation: how the content is examined, both in theory and in practice ipc relevance to dept: relevance to their own department ipc relevance to faculty: what they thought of the subject teaching in their teaching, clinical and theory ipc relevance to medicine/health: relevance of the subject area within greater health context ipc teaching in dept: what they thought of the subject teaching in their teaching, clinical and theory ipc teaching in faculty: what their perception is of the subject’s teaching in the faculty ipc understanding of: anything that reflects participants understanding of subject partnership barriers to 4 subjects: any reflection on incorporating teaching, resistance to change partnership connection to faculty: how they felt connected to the faculty as a whole for their individual disciplines; main campus, other universities partnership connection to other depts: how they felt connected to other departments, joint teaching/practical work, any shared activities partnership co-operation: active co-operation, communication)partnership golden thread: presence of these 4 areas across the curriculum partnership integration: integration across the 4 areas with each other (integration into the whole curriculum, clinical teaching) partnership partnership in joint process (general) anything else related partnership shared vision: common vision of these 4 areas partnership silos where department exists on its own/operates independently, impact of silo thinking on the teaching of 4 areas (compartmentalised subject training) stud future for graduates: anything that happens when the graduate leaves su stud future in serving poor/rural: anything regarding underserved/rural/poor communities stud preparation of students (general) stud resilience training/coping skills: lack of capacity to cope, overload, disorganised teaching stud specialisation v. generalised training: anything touching on that theme stud student ethical practice: patient-centredness, ethical treatment of patients, prioritisation of patients univ changes in training over time: new curriculum v. old experience of faculty; demands for change (what is required to change the curriculum) univ doctors v. other professional doctors need different approach to training univ philosophy for training doctor graduate attributes/the ideal physician/health advocate univ process of degree training: the model of training undergraduates/postgraduates univ selection of students: who gets selected to do medical training? univ shared responsibility: lack of ownership/responsibility for university teaching 4 areas research november 2013, vol. 5, no. 2 ajhpe 95 research in the past 20 years, the number of medical schools, as well as their respective student enrolments, has increased substantially in sub-saharan africa (ssa).[1] unfortunately, these increases have not been matched by a parallel increase in the number of medical school faculty. as a consequence, faculty shortages in ssa medical schools are described as endemic, problematic and aggravated by the large-scale migration of healthcare workers seeking better remuneration and working conditions.[2] in tanzania, there is only 1 medical doctor for every 30 000 people, and 1 dentist for every 300 000.[3] these figures are well below the world health organization (who) recommendation of 1 doctor for every 1 000 inhabitants. [4] in an effort to address the shortage of doctors and other health workers in the country, the number of medical schools has been increased from 1 to 8 in the last decade. the employment of university faculty has, however, not kept pace with the larger number of medical schools and students, resulting in a critical shortage of teachers. heavy teaching loads, stringent recruitment and promotion criteria, lack of clear faculty development programmes, and poor remuneration are among the factors that have made recruitment and retention of faculty more difficult, further exacerbating the faculty shortage.[2] this issue may be compromising the training of future healthcare professionals and, ultimately, the healthcare systems of ssa. the catholic university of health and allied sciences (cuhas) was established in bugando, tanzania, in 2003. initially, the university offered only a single degree programme (doctor of medicine (md)) with an intake of 10 students per year. over a period of 10 years, there has been a tremendous increase in student enrolment as well as the development of new health-related courses at degree and diploma level. currently, the university has approximately 700 students enrolled in the md degree and other postgraduate and paramedical programmes. over the corresponding period, the increase in programmes and student enrolments has not been matched by an increase in teaching faculty and there is, therefore, an urgent need to initiate reforms and address the critical faculty shortage. the present study was conducted to determine the extent and nature of the faculty shortage at cuhas. results from this study will aid in planning future interventions to address the shortage of faculty at cuhas and possibly also other medical schools facing similar challenges. methods a cross-sectional descriptive survey approach was used. a self-administered questionnaire was used to collect information from deans, department heads and university records (prospectus, personnel manuals, etc.) about the number of faculty in different departments at cuhas. in the absence of policies specifying faculty quotas for individual departments, the head of each department was asked to estimate the number of additional faculty needed to sustain the curricular activities within the department. this background. the number of medical schools in tanzania, and their respective student enrolments, has tripled in the last decade in response to the growing population and healthcare needs. there has, however, not been a corresponding increase in the number of faculty, resulting in a critical shortage of teachers. objective. to determine the extent of the faculty shortage at the school of medicine, catholic university of health and allied sciences (cuhas), bugando, tanzania. methods. a cross-sectional descriptive survey was conducted of all heads of departments and their staff to determine the number of available and required faculty. postgraduate trainees were also interviewed about their role in undergraduate teaching activities. results. at the time of the study, the school of medicine had a total of 83 faculty and about 700 undergraduate students and residents. of the entire faculty, 32 (38.6%) worked as full-time employees and 51 (61.4%) as part-time employees. the department of surgery had the greatest number of faculty while psychiatry and ophthalmology had the smallest staff complement. over 50% of departments reported faculty shortages of 30% or more. postgraduate trainees confirmed that they were regularly called upon to teach medical students. conclusion. the critical shortage of faculty at cuhas is likely to compromise the quality of education offered and, as a consequence, the competence of healthcare professionals being trained in tanzania. interventions that may improve the situation include the establishment of a residents-as-teachers training programme, and a faculty development programme to groom junior faculty to take on leadership roles and develop strategies to improve the quality of health professions education in tanzania. ajhpe 2013;5(2):95-97. doi:10.7196/ajhpe.236 shortage of faculty in medical schools in tanzania: a case study at the catholic university of health and allied health sciences m manyama,1 md, msc, phd; s e mshana,2 md, mmed, phd; r kabangira,3 mb chb, mmed; e konje,4 bsc, msc 1 department of anatomy, catholic university of health and allied sciences, mwanza, tanzania 2 department of microbiology and immunology, catholic university of health and allied sciences, mwanza, tanzania 3 department of internal medicine, catholic university of health and allied sciences, mwanza, tanzania 4 department of epidemiology and biostatistics, catholic university of health and allied sciences, mwanza, tanzania corresponding author: m manyama (mmajfe@hotmail.com) mailto:mmajfe@hotmail.com research 96 november 2013, vol. 5, no. 2 ajhpe approach was used because the world federation for medical education (wfme) recommends that teacher-student ratios should be self-determined by academic departments implementing medical curricula.[5] department heads were also asked if they involved postgraduate trainees (registrars, residents) in undergraduate teaching activities. residents were also interviewed about their role in teaching medical students and what they thought would improve the teaching. the ethics research committee of cuhas approved the study, and informed written consent was obtained from all participants. data were entered onto a spreadsheet and analysed using spss version 11. results at the time of the study, the school of medicine had a total of 83 faculty and about 700 undergraduate students and residents. a total of 32 (38.6%) were employed as full-time staff and a further 51 (61.4%) were part-time. part-time faculty are either employees of bugando medical centre (which is used as the university teaching hospital) or visiting professors from other institutions in the country or outside tanzania. there are 39 (47%) faculty members teaching biomedical sciences subjects and 44 (53%) clinicians teaching clinical subjects. the department of surgery had the biggest staff complement (n=13) while psychiatry and ophthalmology had 1 faculty member each. about half of the departments at cuhas reported a faculty shortage of 30% or more, as estimated by the head of department and the respective members (table 1). teacher:student ratios in different educational settings were reported to be highest in small group activities such as bedside teaching and practical demonstrations. most of the residents interviewed were aware of their obligation to teach nurses, medical students and other junior colleagues, and indicated that formal training, especially in teaching skills, would improve their ability to do so. discussion almost every medical school in ssa has some degree of faculty shortage in the basic and clinical sciences.[2] the key findings of this study are consistent with this observation. this reality poses a significant threat to the existing health professions educational infrastructure because it places undue pressure on the small cadre of faculty, further increasing the likelihood of emigration or relocation to private organisations, non-governmental organisations or abroad. this study indicates that, while there was a shortage of faculty in almost all departments at the school of medicine, shortages were greater in some of the clinical departments. as indicated by the participants, this was most likely related to the resource-intensive nature of small group bedside or practical teaching. determining the optimal number of teaching faculty in a medical school is a difficult task. in the absence of international guidelines, the wfme recommends that teacher-student ratios be self-determined by the staff who deal with the academic demands of the various curricular components being taught by a given department or unit.[5] it is reasonable, therefore, to accept the data reported in this study as a reasonable estimate of the preclinical and clinical teaching needs at cuhas, rather than thinking of it as ‘wishful thinking’ in a resource-poor environment. to address the shortage of clinical faculty at cuhas, postgraduate trainees are used as teachers. internationally, it is well known that postgraduate trainees, even in well-resourced settings, play a critical role in the education of undergraduate clinical students; they spend about 20% of their time on teaching activities.[6] these residents, as elsewhere, indicated a need for training to improve the quality of education they offer.[7] such a strategy would be a most efficient way of increasing the pool of clinical teachers without the need to hire more faculty. the lack of teachers at cuhas has resulted in the practice of sharing faculty with other tanzanian medical schools; this raises concerns about the optimal length and sequencing of courses if visiting faculty are only available at certain times of the year and for limited periods. while this practice is not optimal, it could be significantly improved by explicitly creating teaching schedules that best address the collective educational needs of a cluster of medical schools. carefully co-ordinated planning could address issues of course duration and sequencing so that the quality of the education is not compromised. another strategy that could be used to address the faculty needs at cuhas is the use of faculty development programmes tailored to suit the needs of the institution and its departments and individuals. this would be an important step towards initiating and implementing reforms in educational capacity building. such programmes could offer faculty activities aimed at improving teaching effectiveness as well as grooming junior faculty for future leadership roles in the university. such programmes may also attract new faculty to the university. the present study has reported on faculty shortages at only 1 of the 8 medical schools in tanzania. while this is a major limitation, the table 1. distribution of faculty according to department department total number of faculty, n number of faculty needed, n* estimated faculty shortage (%) anatomy 4 7 43 physiology 5 8 38 biochemistry 3 6 50 microbiology 5 8 38 pathology 3 7 57 parasitology 6 100 pharmacology 5 10 50 community medicine 6 10 40 epidemiology 1 4 75 behavioural sciences 3 5 40 internal medicine 10 13 23 surgery 13 15 13 ophthalmology 1 4 75 psychiatry 1 4 75 anaesthesia 1 4 75 paediatrics 8 12 33 obstetrics and gynaecology 8 12 33 radiology 2 4 50 *estimated by the head of department and staff. research november 2013, vol. 5, no. 2 ajhpe 97 study sheds light on the challenges facing smaller ssa medical schools, about which little has been written, compared with bigger schools in south africa, nigeria, uganda and elsewhere.[2] what is reassuring about this study is that the developmental needs of medical schools, whether large or small, are similar; therefore common strategies need to be developed and shared across the african continent. acknowledgements. we thank the staff of cuhas for their co-operation during the process of data collection. we also thank cuhas, safri and the touch foundation for providing funding that enabled us to conduct this study. references 1. chen c, buch e, wassermann t, et al. a survey of sub-saharan african medical schools. human resources for health 2012;10:4. 2. mullan f, frehywot s, omaswa f, et al. medical schools in sub-saharan africa. lancet 2011;377(9771):1113-1121. [http://dx.doi.org/10.1016/s0140-6736(10)61961-7] 3. medical association of tanzania. http://www.mat-tz.org/downloads/doc.../16-mat-43rd-agm-proceedings.html (accessed 30 november 2012). 4. treat, train, retain. the global recommendations and guidelines on task shifting 2008. geneva, world health organization, 2008. 5. world federation for medical education. basic medical education. wfme global standards for quality improvement 2003; denmark: wfme, 2003. 6. snell l. the resident-as-teacher: it’s more than just about student learning. j grad med educ 2011;3(3):440-441. [http://dx.doi.org/10.4300/jgme-d-11-00148.1] 7. julian ka, o’sullivan ps, vener mh, wamsley ma. teaching residents to teach: the impact of a multidisciplinary longitudinal curriculum to improve teaching skills. med educ online 2007;12:12. http://dx.doi.org/10.1016/s0140-6736 http://www.mat-tz.org/downloads/doc.../16-mat-43rd-agm-proceedings.html http://dx.doi.org/10.4300/jgme-d-11-00148.1] october 2014, vol.6, no. 2 ajhpe 165 research curriculum reform has received an enormous amount of attention in the field of medical education in recent years, particularly after the world federation for medical education generated the edinburgh declaration of 12 principles for reforming medical education in 1988.[1] studies have shown that medical schools and students benefit from the evolution of curriculum change and innovation in constructing new curricula.[2-4] consequently, many medical schools worldwide have developed new curricula to produce medical graduates committed to lifelong, self-directed learning.[5,6] despite considerable changes in iranian medical education in the past three decades, curriculum reform has not yet been welcomed. therefore, the principal issue confronting medical education in iran is a lack of continuing curriculum reform, which is essential if the standard of healthcare and public health is to improve. the increased number of medical schools and medical students along with free medical education has, to some extent, remedied iran’s shortage of doctors so that all rural areas now benefit from the healthcare system. efforts to improve the organisation and provision of healthcare, however, have not led to improvements in the undergraduate medical curriculum.[7,8] owing to the insufficiency and inappropriateness of educational programmes, many medical students, who are considered to be the most talented students, leave the country halfway through their undergraduate education or just after graduation.[9] nearly all iranian medical schools still offer programmes based on the traditional system, i.e. a discipline-based approach with a teacher-centred structure in which each subject is taught independently and with little practical training. these programmes have been used in iran over the past 17 years, without much modification.[10,11] many teachers and students believe that the current medical curriculum has certain deficiencies in content, methods of teaching, examination system and specification of educational outcomes.[8,12] the aim of this study, therefore, was to investigate the perception of a group of students in different stages of medical study regarding the curriculum currently taught in medical schools in iran. a group of top-achieving students were selected as the greater capabilities of these students are believed to help them to cope better with different teaching methods and to increase their expectations from the courses. materials and methods considering the nature of the research questions, a qualitative research design was employed. participants were students who ranked 1 10 in the medical university entrance examination and those who succeeded in the international biology olympiad examination (held for high-school students) in the past eight years. they were selected through a purposive sampling technique. it should be noted how the student selection in iran is done. in many countries medical students are selected among top high-school students who meet a score requirement for their entrance, but in iran the students’ high-school average is not taken into account to study at an iranian medical university. iranian students from different parts of the country participate in a national entrance exam. therefore, 1 500 students from among some 700 000 students who take part in the natural sciences group entrance exam every year are accepted in the field of medicine. of this group, only 150 background. curriculum reform has received a great deal of attention in the field of medical education in recent years. many studies are being conducted worldwide to assess the deficiencies of current curricula in order to construct new ones. objective. to investigate the perception of a group of students regarding the curriculum currently being taught in medical schools in iran. methods. this qualitative research was conducted in a cohort of 20 top-achieving students who ranked 1 10 in the medical university entrance examination and those who succeeded in the international biology olympiad examination in the past eight years. these students were in different stages of their studies, ranging from the second term of study to clerkship to internship. several semi-structured focus group discussions were held and the results were extrapolated from the transcription of these sessions. results. the majority of medical students, regardless of the stage of study, were deeply concerned about the current curriculum. they believed that the existing discipline-based approach, teacher-centred curriculum and shortage of hospital-based learning were deficient and suggested that the lectures, handouts, and multiple choice question examinations should be blamed for the development of unskilled doctors. conclusion. there is a need for educational reform to contribute towards providing communities with doctors with better skills. ajhpe 2014;6(2):165-168. doi:10.7196/ajhpe.51 a qualitative survey of top-achieving undergraduate medical students’ perspectives of medical education: an iranian exploration p khashayar,1 ms; p khashayar,2 md 1 endocrinology and metabolism research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, and endocrinology and metabolism research center, endocrinology and metabolism research institute, tehran university of medical sciences, tehran, iran 2 osteoporosis research center, endocrinology and metabolism clinical sciences institute, tehran university of medical sciences, and endocrinology and metabolism research center, endocrinology and metabolism research institiute, tehran university of medical sciences, tehran, iran  corresponding author: p khashayar (patricia.kh@gmail.com) 166 october 2014, vol.6, no. 2 ajhpe research may continue their education at the tehran university of medical sciences, which is considered to be the top medical school and serves as a model for other medical schools in the country.[7] therefore, this university, considered to be an example to others, should set the example of best educational practice. there were approximately 62 students who met the criteria for this study, all of whom were successfully recruited. to achieve the objectives, semi-structured focus group discussions (fgds) were held with two 10-member groups, who were randomly selected among the students in different stages of study, ranging from the second term of study to clerkship to internship, under the supervision of study executives who played the role of tutors and managed the discussion sessions. two focus group interviews were conducted because the data collected from those two groups were suitable for trying to understand our research question. the focus group interviews were audio-taped and transcribed. ‘spot checking’ of transcripts was conducted to confirm their accuracy. the data were then analysed by organising them into categories, themes and quotes. the topics covered during the fgds consisted of the teaching approach and examinations. the participants were asked broad questions and encouraged to respond in narrative form, e.g. ‘can you explain to us more about the teaching methods and examinations?, ‘are you satisfied with the current teaching system, do you consider it to be successful?’, ‘does the current programme cover all your learning needs?’. considering that the current curriculum is divided into four sections (basic science (2.5 years), clinical science (1 year), clerkship (2 years) and internship (2 years)), participants were also asked to express their ideas regarding each section separately.[13] subsequent questions were extracted from the participants’ responses during the two focus group interviews. however, the overall aim was to allow participants to interpret their situation in their own words. results current teaching method from the discussions it emerged that the general teaching approach in many classes comprised teacher-centred, content-orientated lectures. a group of students were responsible for recording and transcribing the topics discussed in each class. this group believed that such a technique overcame the need for taking notes or even attending the classes, which were described as boring and useless. ‘we can learn the whole material by studying these handouts and consequently, achieve a good score on the exams.’ ‘using these handouts, we can benefit from our time all through the study semester, participate in various research programmes, and finally obtain an acceptable score.’ handouts the students also noted that most of the topics presented in these courses were similar to those of previous courses; therefore, the handouts were not really hard to prepare, even if the teacher prevented audio-taping of the courses. they also claimed that the examinations, which consisted mainly of multiple choice questions (mcqs), were designed based on the topics presented in class. using this source to study, they argued, was sufficient for answering the majority of the questions. many described their experiences by saying that they obtained low scores in the examination each time they studied reference books instead of the handouts. ‘studying such incomplete and redundant handouts does not help us in having a better understanding of the topic; they, though, guarantee our final score.’ they went on to say that the final scores play an important role in their future, adding that very high scores provided them with a wider range of choices to select a hospital for their clerkship or internship period. one of the students stressed that the existing teaching and evaluation approaches had suppressed his analytical ability and made him adopt a passive role in the education programme. deficiencies of the current curriculum the students were then asked to express their individual ideas regarding different sections of their education. all students were dissatisfied with the basic sciences curriculum. they mentioned that the content and structure of the basic sciences section (anatomy, histology, immunology, physiology, biochemistry and social sciences) have remained largely unchanged during the past years, adding that the material presented at these courses could not be applied in the clinical areas. the students also claimed that the relationship between the basic sciences and their later application in the clinical context was not made clear. therefore, many believed that a large part of the curriculum presented at this stage was clinically irrelevant. furthermore, first-year medical students criticised the memorising of a large volume of information. many of the senior students reported that they could not recall any of the information they had memorised owing to its irrelevance in later clinical issues. many of the students suggested that the basic sciences should be placed in a clinical context and be presented by a clinician. however, a small group believed that learning such topics is necessary to provide medical students with a basic knowledge. they therefore felt that the course was necessary to assist students with background knowledge for effective clinical practice. they were however unable to name the curriculum changes. most of the students were satisfied with the physiopathology course, where basic training in history taking and physical examination, general pathology, general microbiology, general pharmacology and laboratory medicine was presented mainly in the form of lectures, with limited patient exposure. the participants believed that the course was an appropriate introduction to clinical practice during their clerkship and internship. they added that this transition period was an appropriate time for lowering the ‘practice shock’ for medical students who had not yet worked in a ward. the absence of a structured educational programme, the incompatibility of the topics taught in the wards and the theoretical classes, and the overlap of the topics in different courses were the most important concerns for the clerkship section. during this latter period medical students are introduced to different specialties, including those of internal medicine, general surgery, paediatrics, psychiatry, obstetrics and gynaecology, dermatology, and ear, nose and throat. the students stressed that ward training depended on the patients admitted in each ward and the professor’s choice, indicating that it is impossible to guess the topic which would be discussed. they could therefore not prepare themselves before each session. many of them also claimed that the professors expected october 2014, vol.6, no. 2 ajhpe 167 research a great deal from the students, making the course really stressful and demanding: ‘according to the existing curriculum, we are expected to take proper history, do an accurate physical examination and provide the professor with the precise differential diagnoses; the professors, however, expect us to achieve the final diagnoses and sometimes even the proper treatment.’ they added that because different groups of medical students including those in clerkships, interns, and residents participated in bedside rounds, many of the topics discussed were of little value (too specialised) for students studying in the clerkship. internship is usually considered a preparation stage, where students gain skills required to become a physician. many believed that internship is a training course during which they should perform certain tasks on their own, explaining that there is a gap because of their experiences of the curriculum. ‘for many of us, internship is the first exposure to the patient. many of us have to perform certain procedures accurately during this stage while we are not really trained for them.’ ‘during clerkship, we are in charge of taking history and performing physical examination; during internship, however, we should tap the ascites fluid, measure cvp and many other similar procedures which we haven’t performed before. moreover, except for a short workshop, there is no other source which helps us with the procedures.’ the majority of the students confessed that they had learned the procedures from other students and performed these without supervision, while they knew that they were not capable of accurate work. ‘hospitals often rely on the work accomplished by interns; inserting intravenous lines, taking arterial blood gas (abg) and even ambu bag resuscitation, which can be done by nurses, are among the major responsibilities of an intern.’ a few students, however, argued that certain activities and courses had recently been added to their curriculum, stressing that these initial changes could be considered as part of a move towards improving the quality of teaching. ‘a few teachers use teaching methods such as brain storming in some of their sessions. some departments employ the objective structured clinical examination (osce) as an assessment tool to measure specified skills of medical students during clerkship. while many of the stations do not fulfill the criteria for an osce exam, employing an osce is a good enough step toward applying new approaches with the limited resources in our hospitals. moreover, the number of workshops and skill labs have increased in the past years, all of which signifies that medical teachers are looking forward to improve the quality of education in this university; the changes, however, are occurring on a slow pace.’ recently graduated students concluded that the clinical modules were not based on the fundamental requirement of the community’s needs. therefore, they graduated with a good knowledge of complicated and rare cases, while they are not really qualified to treat patients suffering from common diseases. ‘our pediatric teaching hospitals are all specialized hospitals in which we have frequently met patients suffering from metabolic diseases, rarely seen in the society, but as for more simple diseases such as flu, which account for the majority of cases referred to my office, i myself am not quite sure whether i am doing the correct thing or not.’ they also noted that certain topics are presented several times at different stages, whereas others are excluded because of time limitations. ‘the main reason contributing to multiple presentation of a specific topic may be the inappropriate relation between different departments and the absence of a structured curriculum. many teachers are unaware of what we have learned before; this not only results in the repetition of some topics but also the over-expectation of the teachers.’ ‘the main problem with the current curriculum is the fact that it is overcrowded with various topics particularly in the basic science where many of the presented material are useless. the overrepresentation of some subjects and lack of integration are other problems with this curriculum.’ the students were finally asked if they would choose to study medicine if they were given the choice again. except for two students, they still preferred medicine over other fields, despite all the concerns. discussion this study was undertaken to gain insight into students’ perceptions of the medical curriculum in iran. it generally seems that the majority of medical students interviewed were deeply concerned about the current curriculum. compared with teaching approaches and educational systems in other countries, which are based on self-directed learning, our educational system is based on a traditional curriculum.[13-18] this system follows a disciplinebased, teacher-centred and hospital-based approach, with no options or elective modules. similarly, portfolio learning and communication skills as tools for promoting formative assessment and professionalism have not been adopted in this curriculum.[7] many studies, however, have reported that traditional teaching approaches confine analysis, synthesis and creativity abilities in students, eliminating the motivation for critical thinking.[15,16,19,20] however, it seems as if the currently used evaluation system (mcqs based on lectures) in iranian medical schools forces students to memorise information rather than to gain a deeper knowledge. as a result, students prefer to spend a major proportion of their time reviewing their handouts rather than making use of updated reference books, deeming self-directed learning and searching for new materials a time-consuming and pointless task. the final outcome of the current educational and assessment system is superficial learning, which not only produces unprofessional physicians but also eliminates teamwork among students. in concordance with previous studies of the iranian curriculum, our findings revealed that little attention has been paid to curriculum development in iran, indicating that the existing curriculum does not equip doctors to meet the needs of the community that they will attend to.[7,8,21,22] it can therefore be argued that the majority of iranian medical educators have not taken the importance of the changing needs of the population and medical students seriously and are resisting any reform in this field. previous studies named the following as some of the factors accounting for the current concerns in the undergraduate medical education in iran: lack of suitable space 168 october 2014, vol.6, no. 2 ajhpe research for teaching in hospitals, overcrowding in hospitals, failure to involve medical teachers in the development of the curriculum, and poor level of medical teachers’ knowledge of innovative teaching and assessment methods.[21,22] conclusion there is an urgent need to move forward with educational reforms to help to provide communities with the necessary doctors. to achieve such a goal requires linking of theoretical and clinical instruction, extension of interdisciplinary and topic-related instruction, improvement of bedside training, fewer lectures, examination reforms, strengthening of general practice, and evaluation of teachers on a regular basis. additionally, developing national standards for various procedures may not only improve the quality of healthcare in different regions, but also upgrade medical schools to international standards. shahid beheshti university of medical sciences in tehran has recently provided medical students with an innovative course based on a newly developed integrative curriculum. they are aiming to compare the results of students graduating in this system with those of the traditional system. promising results of such a study might be a guarantee for an upcoming reform in the iranian medical curriculum. references 1. the edinburgh declaration. med educ 1988;22:481-482. 2. gaudet tw. integrative medicine: the evolution of a new approach to medicine and to medical education. integrative medicine 1998;1:67-73. 3. snyderman r, weil a. integrative medicine: bringing medicine back to its roots. arch intern med 2002;162:395-397. 4. remen r. recapturing the soul of medicine. west j med 2001;174:4-5. 5. lam ww, fielding r, johnston jm, tin ky, leung gm. identifying barriers to the adoption of evidencebased medicine practice in clinical clerks: a longitudinal focus group study. med educ 2004;38:987-997. 6. parsell gj, bligh j. the changing context of undergraduate medical education. postgrad med j 1995;71:397-403. 7. tavakol m, murphy r, torabi s. medical education in iran: an exploration of some curriculum issues. med educ 2006;11:5. 8. azizi f. the reform of medical education in iran. med educ 1997;31(3):159-162. 9. ronaghy ha, williams kn, baker t. immigration of iranian physicians to the united states. j med educ 1972;47(6):443-445. 10. tavakol m, mohagheghi ma, torabi s. the development of medical education in iran. clinical teacher 2008;5:125-128. 11. gharib r. a report on medical education in iran. j med educ 1966;41(8):791-796. 12. ronaghy ha, simon hj. effects of the islamic revolution in iran on medical education. the shiraz university school of medicine. am j public health 1983;73(12):1400-1401. 13. ministry of health and medical education. iranian medical curriculum. tehran: ministry of health, 1986. 14. karle h. global standards in medical education – an instrument in quality improvement. med educ 2002;36:604-605. 15. general medical council. tomorrow’s doctors. recommendations on undergraduate medical education. london: general medical council, 1993. 16. schwarz mr, wojtczak a. global minimum essential requirements: a road towards competence-oriented medical education. med teach 2002;24:125-129. 17. baozhi s, yuhong z. medical curricula in china and the usa. med teach 2003;25:422-427. 18. alshehri my. medical curriculum in saudi medical colleges: current and future perspectives. ann saudi med 2001;21:320-323. 19. chenot jf. undergraduate medical education in germany. german medical science 2009;7:2. 20. oliver r, sanz m. the bologna process and health science education: times are changing. med educ 2007;41(3):309-317. 21. sayarei aa. medical education: waiting for continuous integration or separation? tehran: ministry of health press, 2003. 22. marandi a. integration medical education and health services: the iranian experience. med educ1996;30:4-8. 4 may 2016, vol. 8, no. 1 ajhpe short report the gathering and interpretation of information related to teaching and mentoring is evolving. integral are the concepts of formative and summative assessment, during and at the end of teaching programmes, respectively. formative assessment refers to the information that is required to adjust teaching and learning during educational activities. students and teachers may benefit from the assessment process. the concept is difficult to quantify but may involve dynamic discussions, observation and practice analysis.[1,2] summative assessment meets the need for accountability standards and is performed at a particular time, usually at the end of training. it evaluates student knowledge and can be scored by comparison with a benchmark or standard. it may include a final project, a question paper or a senior recital. summative assessment only has formative value when the summative information is evaluated by students and teachers to guide practice and training methods.[1,2] training portfolios, which have been shown to improve learning, are defined as collections of trainees’ experiences that demonstrate active learning (dynamic process), achievement and assessment.[3,4] there is, however, no consensus as to the precise components of the portfolio, which usually includes aspects of formative and summative assessments. portfolios may include a logbook, attendance at symposia, institutional activities, peer-reviewed research and written examinations. a self-reflective written component, based on current patient care and management, has been suggested as a means to improve learning by selfreflection, self-monitoring and self-assessment (formative assessment).[1] self-reflective surgical activity may lead to immediate positive adjustment of an action and promote quality life-long learning skills. simultaneous additional objectives to this process include literature review, mentor feedback and formal documentation.[3,5] ideal portfolio implementation and its incorporation into generalised programmes remain unknown. it is also unclear how specific reflective portfolios benefit teaching programmes.[5] little is known about the potential benefit of sharing individual trainee experiences with other trainees.[3,4] for the concept to be successful, the trainee is encouraged to be autonomous and flexible in constructing the portfolio. the objective of this article is to describe the format of a vascular case portfolio (vcp) programme intended for south african (sa) vascular trainees. it integrates current training, educational and certification activities with formal portfolio organisation and assessment. the following aspects are discussed: current status of fellowship education and training; vascular portfolio; vcp programme; vcp template; facilitator, faculty and mentor responsibilities; and programme assessment. vascular fellowship training and education vascular trainees may enter a 2-year fellowship programme once they have registered as a specialist general surgeon. there are eight accredited (and university affiliated) vascular surgery training units in sa. between 8 and 10 trainees are active at any one time. national board certification (colleges of medicine of sa (cmsa)) is achieved after a minimum of 2 years. the current certification requirements are the compilation of a logbook (surgical cases), and success in the college examination: multiple-choice questions (mcqs) and viva voce. the vascular society of southern africa (vassa) is mandated by the cmsa to administer and prepare the examinations. vassa organises two to three dedicated fellowship seminars a year (attended by all fellows and a teaching faculty) which consist of didactic lectures and case presentations. vassa has recently included peer-reviewed research as an additional requirement. fellows are encouraged to visit centres of excellence and attend accredited symposia locally and abroad. vascular training portfolio the vascular training portfolio is the written summary to be submitted prior to participating in the cmsa examination: • logbook (surgical activity over the 2 years) • description and brief critical analysis of symposia attended and/or visits to training centres (should include benefit or criticism of activity/learning experience) • research • documentation related to vcps • other activity (trainee teaching, institutional activities, etc.) may be listed. reflective learning is considered an advanced form of learning; however, it has not been routinely incorporated into postgraduate and subspecialty educational surgical portfolios. the concept of training portfolios is not clearly understood by both trainees and teachers. subspecialty surgical programmes rely heavily on logbooks and other forms of formative assessment to certify candidates. case-based self-reflection in postgraduate training may be used as an additional educational tool and incorporated into the curricula vitae of trainees. we describe the method used to assess a vascular case, based on a self-reflective training method (vascular case portfolio). afr j health professions educ 2016;8(1):4-5. doi:10.7196/ajhpe.2016.v8i1.523 the development of a reflective vascular training portfolio: using a country-specific infrastructure j pillai, bsc, mb bch, fcs (sa), cert vascular surgery (sa); t b rangaka, mb bch, mmed; c yazicioglu, bsc, bhsc hons; t monareng, bds, mb bch, fcs (sa); m g veller, mb bch, fcs (sa), mmed division of vascular surgery, department of surgery, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: c yazicioglu (c_yazicioglu@yahoo.com) may 2016, vol. 8, no. 1 ajhpe 5 vascular case portfolio programme the objective of the vcp is to encourage trai nee reflection, self-assessment and subsequent self-monitoring of specific activities. this practice-based assessment involves selfevaluation of ‘real cases’ by filling in a standardised tem plate. the case assessment should be a dynamic assessment of a case of the trainee’s choice. the case portfolio should allow for flexibility and include a trainee’s experiences (e.g. competency, novel concept, complication). once the vcp document is completed, it will be forwarded to a facilitator who will ‘blind’ the document and attach a reference number. the facilitator will then forward the document to an exter nal mentor who will complete the vcp documenta tion by appropriate feedback and commentary. the facilitator will ensure ‘mentor blinding’ and return the vcp documentation to the trainee within 7 10 days. timely feedback facilitates appropriate trainee adjustment in subsequent practice. copies of vcp documents will be retained by the facilitator. a completed ‘blinded’ document will be forwarded to a fellow ship seminar faculty member (other than the mentor), who will present the document as a case report at a fellowship seminar (all fellows present). the faculty member will receive the vcp document at least 2 weeks prior to the fellowship seminar. further vcp evaluation and sharing of similar trainee experiences will be encouraged at the seminar. the vcp logistic will be explained to fellows, mentors, faculty members and facilitators prior to programme initiation. this will comprise a pre-programme fellowship meeting and subsequent written communication. vascular case portfolio template the discussion and learning experience should be autonomous, self-reflective and thought provoking. it may include positive, negative (complications) and novel experiences. the level of evidence and relevant papers should be discussed. mentor feedback should highlight specific learning issues and improvement (table 1). facilitator, faculty and mentor responsibilities the facilitator is essentially ‘task master’ who ensures trainee compliance (three vcps per year). the facilitator may stipulate prespecific target dates for each trainee and correlate this with fellowship seminars (anticipate four to six vcp discussions per seminar). appropriate telephonic and mail reminders are essential. the facilitator will compile a list of volunteer mentors and may allocate vcps to mentors with specific interests. ideally, the facilitator should be a member of the executive committee of vassa. the facilitator will keep records of all vcps submitted and will be responsible for mentor/trainee blinding and substitution with reference numbers. records may be submitted to vassa exco for future analysis of the programme. prior to fellowship symposia, the facilitator will submit appropriate vcps to faculty members for formal case presentation at the seminar. the vcp topic will be part of the seminar programme. the seminar faculty will present the vcp case and stimulate further discussion among fellows and all attendees. two faculty members will be tasked with assessing the quality of the vcp in a standardised format: • concise presentation of case • specific learning issue identified • evidence used to substantiate argument • demonstrate reflection with understanding of topic. standardised mentor feedback will include gaps in knowledge, existing knowledge, level of understanding, potential existing errors, specific suggestion on improvements and correlation with evidence. each point will carry a 1 5 grading. the vcp quality grading analysis will be submitted to the facilitator for record keeping (excel format). two sets of vcp mcqs (for each vcp) will be constructed as a separate faculty task and submitted to the examination convenor. a separate vcp mcq bank will be developed with a date allocation to each mcq. vascular case portfolio programme assessment various aspects of the programme will be assessed at different stages. compliance (number of vcps submitted per year) and subjective trainee satisfaction will be documented by the facilitator. vcp quality will be assessed during fellowship seminars. an independent assessment of vcp mcqs will be undertaken after each examination (compared with non-vcp mcqs). other assessments, such as overall candidate examination success v. rate/quality of vcp submissions, may be undertaken. incremental data collection will ensure continuous programme evaluation. conclusion while there is no consensus regarding an optimal fellowship curriculum vitae, the total vascular training portfolio will provide direction and standardisation of educational activity. self-reflective activities (vcp programme) may encourage ‘special interest’ development and motivate fellows towards specific research initiatives. merging an existing established educational and examination programme with a vcp programme allows for easy implementation. similar portfolio development programmes may also benefit other subspecialist trainees (e.g. gastrointestinal tract, trauma). if undertaken by various societies, future analysis of more robust multidisciplinary portfolios will provide invaluable educational information. references 1. boston c. the concept of formative assessment. practical assessment, research and evaluation 2002;8(9):1-8. http://pareonline.net/getvn. asp?v=8&n=9 (accessed 31 december 2012). 2. carnegie mellon university. formative and summative assessment. http : / / w w w. c mu . e du / t e a c h i n g / a s s e s s m e nt / b a s i c s / f or m at i v e summative.htm (accessed 31 december 2012). 3. hassan s. use of structured portfolio in surgical training of postgraduate medical education. educ med j 2011;3(2):32-43. [http:// dx.doi.org/10.5959/eimj.v3i2.63] 4. webb tp, merkley tr. an evaluation of the success of a surgical resident learning portfolio. j surg educ 2012;69(1):1-7. [http://dx.doi. org/10.1016/j.jsurg.2011.06.008] 5. buckley s, coleman j, davison i, et al. the educational effects of portfolios on undergraduate student learning: a best evidence medical education (beme) systematic review. beme guide no. 11. med teach 2009;31(4):282-298. [http://dx.doi.org/10.1080/01421590902889897] short report table 1. vascular case portfolio template fellow details year of training date title of case diagnostic studies medical management intervention evidence/literature (list papers) mentor feedback 16 may 2015, vol. 7, no. 1 ajhpe research ospe is an abbreviation for objective structured practical examination. in the literature the terms ospe and osce (objective structured clinical examination) are sometimes interchanged.[1] for the purpose of this article, the term ospe will be used, as this method is solely applied in the assessment of practical skills and not in the application of these skills in the clinical setting. the ospe consists of a circuit of stations that tests a variety of techniques to establish practical competence. it has been researched and shown to be an effective, valid, reliable and defendable assessment method in emergency medical training,[1] nursing,[2,3] physiology[4] and oral surgery.[5] at the university of the witwatersrand, johannesburg, south africa, the osce method is currently used in the graduate entry medical programme (medicine) and in the undergraduate nursing programme. the traditional, unstructured method of practical skills assessment has three variables, which have the potential to increase the subjectivity of the method[4,5] and consequently interfere with the assessment of the student. these variables include the student, examiner and technique.[1] the ospe method is an attempt to control examiner and technique variability. an attempt is also made to standardise the environment and process of the practical skills test.[4] currently, the students’ peers act as models during a practical skills test, which introduces a certain amount of standardisation as they are free from comorbidities that may complicate the assessment. the structured nature of the ospe decreases the variability of the examiner, which is especially important as they often have different levels of experience.[5] second-year students have not yet been exposed to the clinical area and during a practical skills examination, where a peer is used as a model, the outcome or effect on the patient cannot be judged.[6] at second-year level, the focus is on competency in technique rather than effectiveness of treatment. students are still learning the elements needed to execute the skills safely and effectively.[7] this makes it possible to control the practical skills test, including the examiner, technique and environment, to improve objectivity, consistency and fairness to all students. traditionally, physiotherapy practical skills have been assessed by a method that leaves room for subjective interpretation of competency and at times lacks the formative benefits of assessment. the ospe method attempts to control for the variability of the examination by providing examiners with a checklist that contains the micro-skills required from the student to be able to effectively complete the practical technique and by providing clear instructions to examiners, students and models. the influence that a change in method will have on student performance is as yet unclear. this study sought to evaluate the effect that a change in method of assessment would have on student performance and level of satisfaction. as such, the objective of this study was to describe and compare students’ and examiners’ perceptions of the ospe and traditional mark sheet in the assessment of students’ practical skills. a further aim was to compare the examiners’ ratings of students’ performances when using the ospe mark sheet with those of the traditional mark sheet. methods this was a quantitative, descriptive and comparative study. ethical clearance was granted by the human research ethics committee of the university of the witwatersrand. all second-year physiotherapy students and examiners participating in the practical tests were invited to participate in the study. informed consent was obtained from the students and examiners. students and examiners involved in supplementary practical tests were excluded. student and examiner satisfaction were assessed with self-administered questionnaires. student and examiner satisfaction questionnaires were developed.[8,9] background. traditionally, physiotherapy practical skills have been assessed by a method that relies on the subjective interpretation of competency by the examiner and lacks the formative benefits of assessment. objective. to describe and compare student performance and satisfaction and examiner satisfaction with regard to the objective structured practical examination (ospe) and traditional mark sheets during the practical skills assessment. method. students and examiners taking part in the second-year physiotherapy practical skills test were invited to participate by completing a series of questionnaires. performance of techniques was marked using both the ospe and traditional mark sheets. results. sixty-seven students and nine examiners participated in the study. students scored an average of 4.6% (sd ±16.4) better when using the traditional mark sheet. nonetheless, students and examiners expressed a preference for the ospe mark sheet. conclusion. the ospe mark sheet allows for increased objectivity, as the specific micro-skills are clearly listed and appropriately weighted. this resulted in increased satisfaction, but a decrease in marks obtained. by assessing the effect of implementation of the ospe method on performance and satisfaction, change in the current situation can be monitored. afr j health professions educ 2015;7(1):16-21. doi:10.7196/ajhpe.228 the implementation of the objective structured practical examination (ospe) method: students’ and examiners’ experiences b olivier, phd; v naidoo, msc physiotherapy; w mudzi, phd; h van aswegen, phd; j potterton, phd; h myezwa, phd; r roos, phd; l godlwana, msc physiotherapy; d maleka, phd, mph; s mtshali, msc physiotherapy; v ntsiea, phd, mph; a stewart, phd; m romm, msc pain; c humphries, msc physiotherapy; b watt, bsc physiotherapy department of physiotherapy, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: b olivier (benita.olivier@wits.ac.za) may 2015, vol. 7, no. 1 ajhpe 17 research content and construct validity and reliability were established. a group of 10 physiotherapists (not participating in the main study) were asked to critique the content of the questionnaires. the group consisted of academics, clinicians and students. suggestions were incorporated and questionnaires were modified accordingly. a pilot study was performed to establish the time taken to complete the questionnaires and to establish their reliability. each of the 10 students and the examiners participating in the pilot study were invited to complete the questionnaires twice over a period of five days. the development of the ospe mark sheets was done according to the following steps:[1] • second-year students were divided into groups of 10. • each group was given a technique to break down into micro-skills or steps. • a discussion took place between the groups. • where necessary, the list of micro-skills was added to or modified, or the sequence of performance changed. • this list was given to the lecturer who weighted each item according to her own perception of importance or difficulty. the weighting of micro-skills was performed by the lecturer and not by the students, as it was felt that experience was needed to judge certain microskills as being more important than others. • two weeks before each practical test, all examiners involved discussed the technique and weighting of each micro-skill. • during the practical test, each examiner made notes with regard to the original set of microskills for the technique being examined. possible concerns regarding the specific technique were to be discussed after the examination. • all techniques used during the practical test were re-evaluated and modified where necessary. during each practical test, there were six stations of five minutes each. one technique was examined at each station. stations 1 3 were assessed by one examiner at each station using the traditional mark sheet. stations 4 6 were assessed by two examiners at each station – one examiner used the traditional mark sheet and the other the ospe mark sheet. the ospe examiners moved to stations 1 3 halfway through the practical test. these two examiners were positioned at separate tables and not allowed to share their experiences during or immediately after the assessment. the behaviour of the examiners and the procedures were standardised at each station (addendum a). students were made aware of the information stated in the instructions to examiners (addendum a). for each micro-skill, a limited number of ratings was available to improve reliability.[8] a rubric was provided for clarity on the allocation of marks: 0/6=0% (incompetent); 2/6=33% (poor performance); 4/6=66% (satisfactory performance); 6/6=100% (excellent); and 2/4=50% (competent). if there was any discrepancy in the marks given by the traditional compared with the ospe mark sheet, the higher mark was awarded to the student. this ensured that students were not disadvantaged by participating in this study. directly after the practical test or examination, all students and examiners were given the first student and examiner satisfaction questionnaires, respectively, to complete. students and examiners were directed to separate rooms where they completed the questionnaires. participants were required not to discuss the questions or answers with one another, but merely to give honest answers. two days after the marks and practical mark sheets were returned to the students, they were asked to complete the second student satisfaction questionnaire, as it was argued that students’ perceptions may change after they received their marks. the same procedures were followed as described above for completing the first post-practical questionnaire. descriptive statistics were used to analyse the demographic details of the study sample. student and examiner satisfaction and student performance were analysed using frequencies and presented in tables as appropriate. student performance during the practical test using the traditional and ospe mark sheets was presented using means and standard deviations, while student performance using the two mark sheets was compared using a paired t-test. performance was compared at stations where a student was examined by using both the ospe and traditional mark sheets at the same time. results sixty-seven students took part in the study. the average age was 21.3 years (sd ±2.4). there were 10 (15%) male and 57 (85%) female students in the study sample. nine examiners participated in the study. of these, 3 (33%) were male and 6 (66%) were female. the overall student performance when using the ospe and traditional mark sheets is shown in table 1. the difference in student marks when using the ospe and traditional mark sheets (combined) is shown in table 2. the mean student mark was 4.6% higher when using the traditional mark sheet than with the ospe mark sheet. the student satisfaction with the practical test (soon after the test but before knowing their marks) is shown in table 3. table 1. the overall student performance when using the ospe and traditional mark sheets (combined) (n=563)* marks allocated via: mean, % ±sd ±sem correlation p-value traditional mark sheet 64.4 20.4 0.86 0.7 0.000 ospe mark sheet 59.8 18.8 0.79 sd = standard deviation; sem = standard error of mean. *marks allocated to the performance of different techniques were added together. table 2. the difference in student marks when using the ospe and traditional mark sheets (combined) (n=563)* marks allocated via: mean difference, % ±sd ±sem 95% ci t-value p-value traditional mark sheet minus ospe mark sheet 4.6 16.4 0.69 3.3 6.7 6.7 0.000 sd = standard deviation; sem = standard error of mean; ci = confidence interval. *marks allocated to the performance of different techniques were added together. table 3. general student satisfaction with regard to the practical test (n=67)* item agree, n (%) disagree, n (%) the practical test was fair 65 (97) 2 (3) in general i’m satisfied with the way the practical test was conducted 65 (97) 2 (3) *feedback from students directly after the practical tests, before they had access to their marks. 18 may 2015, vol. 7, no. 1 ajhpe research the majority of students thought that the practical tests were fair. those who disagreed on the fairness and general conduct of the practical test indicated that they perceived it as too rushed and were not given enough time ‘to think’. students’ views on the use of the two mark sheets are shown in table 4. on average, more students thought that the marks from the traditional mark sheets matched their own perception of their performance than the marks on the ospe sheet. however, on average more students thought using the ospe mark sheet was fairer compared with the traditional sheet. the student satisfaction with the two mark sheets after receiving their marks is shown in table 5. the students were satisfied with both the traditional and ospe mark sheets after receiving their marks. some students felt that the traditional mark sheet allowed for better marks to be obtained and that the examiners ‘think more about what you deserve rather than just giving ticks and crosses’. students who preferred the ospe mark sheet felt that the specific microskills that were listed made the process much more objective and ‘specific’. the examiners’ views on the use of the traditional mark sheet are shown in table 6. both the traditional and ospe examiners were satisfied with the general conduct of the practical examination. the examiner who indicated dissatisfaction with the way in which the practical test was conducted stated that more time was needed in between students to add up the marks. the examiners’ satisfaction with the two mark sheets is shown in table 7. more examiners were satisfied with the ospe mark sheet than the traditional one. the examiner who was dissatisfied with the ospe mark sheet indicated that the weighting of some of the micro-skills should be adapted to obtain a better reflection of the students’ overall performance. discussion before this study was conducted, practical tests in the university’s physiotherapy department were done where students’ ability to perform certain skills or techniques was evaluated. however, these practical tests were conducted in a partially unstructured manner, where the technique, examiner and environment were not controlled adequately. the traditional mark sheets left much room for the examiner’s subjective interpretation of components or micro-skills to be assessed and weighting of the former (addenda b and c). the marks awarded when using the ospe mark sheet were on average 4.6% lower than when using the traditional mark sheet; however, a relatively good correlation of 0.7 was found between the two types of mark sheets. the difference in marks may be because the ospe sheet has numerous microskills listed, each with a predetermined weighting. with the traditional mark sheet it is therefore possible that examiners may not notice if a student omitted a micro-skill, or that it may have been done in an incorrect manner. for example, when a contract relax technique of the knee is the being tested, the student may position the model’s leg incorrectly or may have forgotten to explain the findings to the model. each of these two micro-skills appear on the ospe mark sheet and should therefore be assessed in a uniform manner by all examiners. each micro-skill is allocated a predetermined weighting; therefore, all examiners will subtract the same amount of marks for a skill that is poorly executed or omitted. according to the literature, the ospe mark sheet gives a more valid presentation of a student’s true ability to perform a technique.[4,9] traditionally, students did not receive optimal formative benefits when the traditional mark sheet (addendum b) was used. this lack of benefit may be attributed to the lack of specificity as explained above and the need for extensive writing within the time allocated at each station. the time was not always enough to thoroughly assess the performance of the technique and write in enough detail what the student did correctly and incorrectly. table 4. student views on the use of the two mark sheets (traditional and ospe) (n=59)* item agree, n (%) disagree, n (%) the ospe marks i received matched my own perception of my performance 36 (61) 23 (39) the traditional marks i received matched my own perception of my performance 42 (71) 17 (29) mark allocation using the ospe mark sheet is fair 48 (81) 11 (19) mark allocation using the traditional mark sheet is fair 36 (61) 23 (39) the ospe mark sheet should be used in the practical examination in future 43 (73) 16 (27) the traditional mark sheet should be used in the practical examination in future 31 (53) 28 (47) *eight students did not complete the second student satisfaction questionnaire as they were absent on the day that the questionnaires were handed out. table 5. student satisfaction with the traditional and ospe mark sheets (n=59)* total mark sheet satisfied, n (%) dissatisfied, n (%) traditional 46 (78) 13 (22) ospe 48 (81) 11 (19) *feedback from students after they received their practical test marks. table 6. examiner satisfaction regarding the general conduct of the practical test (n=9) total question agree, n (%) disagree, n (%) in general i’m satisfied with the way the practical test was conducted 8 (89) 1 (11) table 7. examiner satisfaction with the traditional and ospe mark sheets (n=9) total mark sheet satisfied, n (%) dissatisfied, n (%) traditional 5 (56) 4 (54) ospe 8 (89) 1 (11) may 2015, vol. 7, no. 1 ajhpe 19 research feedback to the students was therefore often inadequate. larsen and jeppejensen[10] found that one of the greatest benefits of the ospe was immediate feedback. feedback motivated students and improved their learning. in this study, feedback was given a week after the practical test. by reviewing this delayed time frame, one can improve on formative benefits. in this study, students felt that the practical test was fair and were in general satisfied with the manner in which it had been conducted, even though they did not have access to their marks at that point in time. the abovementioned feedback is highlighted as students’ opinion had not yet been biased by the marks that they received for the practical tests. this finding is supported by ryan et al.[3] although student satisfaction could not be compared with that of previous years, the controlled environment and behaviours of examiners may have contributed to the positive attitude of the student. the negative impact of external factors, such as the effect of examiner behaviour on student performance, was emphasised by larsen and jeppe-jensen.[10] they also highlighted the importance of a positive atmosphere. furthermore, all students were marked by the same examiners, which decreased the variability in marks owing to mark differences. all these factors can contribute to student satisfaction. on average, students felt that the traditional mark sheet reflected their performance better than the ospe sheet. this may be the result of the marks showing a better performance when marked with the traditional mark sheet. students were satisfied with both the traditional and ospe mark sheets. even though their marks were lower when marked with the ospe sheet, they did report that they felt the ospe was fairer and should be used in practical tests in the future. feedback given in studies done by menezes et al.,[11] larsen and jeppe-jensen[10] and abraham et al.[4] confirm that students were in favour of the ospe. they also found that the ospe mark sheet was described as fair owing to the increased objectivity, which results from the specific micro-skills being clearly listed and appropriately weighted in each of the ospe mark sheets. the ospe also increases the inter-rater reliability when less experienced examiners are involved in marking practical tests, and in cases when examiners are marking stations on content that they have not taught the students.[8] human resource constraints makes it impossible for examiners to mark only those stations that are testing skills that they taught the students. chenot et al.[8] found moderate to good reliability when the mark allocation of less experienced examiners was compared with that of more experienced examiners when using the ospe and stated that training of examiners may improve reliability. examiners were satisfied with the conduct of the practical examination, regardless of which mark sheet was used. this finding is important as it excludes bias towards the practical tests that may not be related to a specific utilised mark sheet. it may also indicate that the specific guidelines given to examiners (addendum a) may have contributed to decrease uncertainty with regard to factors such as prompting and time keeping. improvement of these factors will increase inter-rater reliability.[8] larsen and jeppe-jensen[10] and qureshi[12] found that examiners perceived the ospe favourably and as a good test of clinical relevance. examiners in this study were satisfied with the ospe mark sheet, more so than with the traditional one. the process whereby ospe mark sheets were developed gave students the opportunity to learn, as it contributed to their development. the ospe mark sheet will be refined in future research, as chenot et al.[8] found greater reliability between micro-skills where mark allocation is dichotomous. the lower the number of options available, the lower the leeway for interpretation. they furthermore suggested that training of examiners can improve reliability in an ospe.[8] a traditional and an ospe examiner were present at only three of the six stations owing to human resource constraints. the best possible solution to this limitation was to move the three ospe examiners to different stations halfway through the practical test. participating examiners should preferably remain in their specific stations. examiners had different levels of experience, including clinical and practical examination experience. olivier et al.[13] found that there was a high correlation between examiners with a similar number of years of experience. to overcome the different levels of experience[1] all staff underwent a briefing session on behaviour, the practical test process and the mark sheet before the practical test was undertaken. conclusion practical examinations will always contain an element of subjectivity, but the amount of subjectivity can be limited by using the ospe mark sheet during practical tests. the clearly operationalised list of items that forms part of the ospe method of assessment makes it the most objective method available to assess the practical competence of students. although students and staff were satisfied with the traditional manner in which practical skills were assessed, the satisfaction arising from introducing an evidence-based, educationally sound method of assessment by using the ospe mark sheet in practical tests is shown. references 1. o’connor hm, mcgraw rc. clinical skills training: developing objective assessment instruments. med educ 1997;31:359-363. 2. kurz jm, mahoney k, martin-plank l, et al. objective structured clinical examination and advanced practice nursing students. j prof nurs 2009;25:186-191. [http://dx.doi.org/10.1016/j.profnurs.2009.01.005] 3. ryan s, stevenson k, hassell ab. assessment of clinical nurse specialists in rheumatology using an osce. musculoskeletal care 2007;5:119-129. 4. abraham rr, raghavendra r, surekha k, et al. a trial of the objective structured practical examination in physiology at melaka manipal medical college, india. adv physiol educ 2009;33:21-23. [http://dx.doi. org/10.1152/advan.90108.2008] 5. macluskey m, hanson c, kershaw a, et al. development of a structured clinical operative test (scot) in the assessment of practical ability in the oral surgery undergraduate curriculum. br dent j 2004;196:225-228. 6. medley d. teacher competency testing and the teacher educator. ablex: new jersey, 1984. 7. miller ga, galanter e, pribram kh. motor skills and habits. harmondsworth: penguin, 1970. 8. chenot jf, simmenroth-nayda a, koch a, et al. can student tutors act as examiners in an objective structured clinical examination? med educ 2007;41:1032-1038. 9. patricio mf, juliao m, fareleira f, et al. is the osce a feasible tool to assess competencies in undergraduate medical education? med teach 2013;35(6):503-514. [http://dx.doi.org/10.3109/0142159x.2013.774330] 10. larsen t, jeppe-jensen d. the introduction and perception of an osce with an element of selfand peerassessment. eur j dent educ 2008;12:2-7. [http://dx.doi.org/10.1111/j.1600-0579.2007.00449] 11. menezes rg, nayak vc, binu vs, et al. objective structured practical examination (ospe) in forensic medicine: students’ point of view. j forensic leg med 2011;18:347-349. [http://dx.doi.org/ 10.1016/j.jflm.2011.06.011] 12. qureshi ns. examiners’ perceptions of the objective structured clinical examination in colposcopy. j obstet gynaecol 2013;33:188-190. [http://dx.doi.org/10.3109/01443615.2012.737050] 13. olivier b, naidoo v, humphries c, et al. inter-examiner reliability when using the objective structured practical examination (ospe) mark sheet for physiotherapy practical examinations. s afr j physiotherapy 2013;wits special edition:21-28. 20 may 2015, vol. 7, no. 1 ajhpe research addendum a. instructions to examiners reading the question give the student time to read their question in silence before they start (±30 sec). greeting and politeness examiners should greet the students politely. put the student at ease by having a neutral expression on your face. prompting students if a student leaves out a step of the technique, you should prompt him/her. however: • you should wait until s/he has completed the whole skill before prompting, in case s/he remembers by her/himself • only prompt once • s/he will lose at least half the marks for that step keeping time: 5 minutes per station guide the candidate in terms of time – one prompt per station when needed. please send students away the moment the bell rings, even if they have not finished. general information • students have to talk to the patient/model throughout the exam – explain what they are going to do, their findings, etc. • whenever the student is doing a procedure which will not be relevant to discuss with the patient/model, the student has to tell the examiner what they are doing while they are doing it. • make sure that students don’t just talk without doing a technique. it is however important that they talk through the technique so that we don’t miss important steps that may not be so clear just from observing their actions. • some patients/models help students indirectly, e.g. by positioning themselves correctly. if you notice this please reprimand the model. • some lecturers wish to use the opportunity to teach students while they are examining them. please do not do this since it gives students tips for the following stations and it takes up time. students will receive their mark sheets back and will be able to learn from the feedback. • the student can make an appointment to discuss his/her performance with the examiner at a later stage. • examiners should write a short report after the prac test/exam on common errors made by students, as well as other problems encountered at their station. addendum b. physiotherapy examination form physiotherapy examination form name: ……………………………………………… date: ……………………… question/problem:………………………………………………………….………………………………… possible marks marks awarded 1. general 1.1 professional appearance & conduct 1.2 preparation of patient & equipment (including positioning) 1.3 interaction with patient (explanation, motivation, physical handling, respect & use of voice. 5 comments 2. technique 2.1 correct choice 2.2 demonstration 2.3 application of technique (appropriate hand position, rom, use of body weight, depth, sequence etc) 2.4 effectiveness of technique 40 comments 3. background knowledge and recording 5 total 50 percentage: ………………………………………….. signature: ……………………………………… may 2015, vol. 7, no. 1 ajhpe 21 research addendum c. example of ospe mark sheet physiotherapy examination form name: ______________________________________________ date: ___________ question/problem: demonstrate use of the contract relax technique to improve his knee flexion range of movement 1. general /5 professional appearance & conduct 0 1 preparation of area & equipment 0 1 2 interaction with patient (explanation, motivation, physical handling, respect & use of voice) 0 1 2 comments 2. technique /40 screening for contra-indications 0 2 4 positioning of patient – high sitting or prone 0 1 2 student places segment at the end point of limitation within the movement pattern 0 2 4 6 resistance is then given either to the restricted agonist (direct contraction) or to the antagonist (reciprocal relaxation) 0 2 4 6 allow a few degrees of motion to ensure that all the muscles in that group have been recruited 0 2 4 6 duration and intensity of contraction should be sufficient to generate a strong contraction (approx 5 sec ) 0 2 4 ask pt. to completely relax after which segment is passively/actively taken into new available rom 0 2 4 repeat procedure 0 1 2 explanation of findings to patient 0 2 4 general impression 0 1 2 comments: 3. background knowledge and recording difference between the contract relax and hold relax techniques? 0 2.5 5 the contract relax method uses an isotonic contraction while the hold relax uses an isometric contraction comments /5 total /50 percentage name of examiner: __________________________ signature: _____________ 48 may 2014, vol. 6, no. 1 ajhpe research frenk et al.[1] highlighted that professional health education has not kept pace with current global health challenges. fragmented, outdated and static curricula were largely to blame for producing ill-equipped graduates. re-design of professional health education is therefore necessary and timely. service learning is an educational method enabling students to learn and develop through active participation in thoughtfully organised service experiences that meet actual community needs.[2] howard[2] identified three criteria for service learning: a relevant and meaningful service provided to the community; enhanced academic learning for students; and a structured opportunity for reflection. bringle and hatcher[3] pointed out that students should reflect on activities to gain a deeper understanding of module content, gain a broader appreciation of their discipline, and enhance a sense of personal values and responsibilities. traditionally, medical schools attempted to meet the bulk of their students’ practical learning outcomes in healthcare facilities. in south africa, the burden of disease and the focus on strengthening of the primary healthcare (phc) service delivery in the country necessitate a move away from curative services to preventive approaches, with health promotion at the core, now more than ever before. this strengthening includes a shift from health facility-based services to community-based services. however, clinics and hospitals are not necessarily ideal settings for health promotion, as the target audience may not be ready to receive information and learn new skills, and waiting areas are often overcrowded. therefore, these settings are not conducive to teaching students health-promotion skills. the question arises where health sciences faculties should place their students to teach them the necessary skills and empower them to fully understand and perform health promotion. from the perspective of a settings-based approach to health promotion, schools could be an ideal service-learning platform, considering that children constitute a large population and schools are accessible over prolonged periods of time. schools are recognised places of learning, with existing structures and systems that provide opportunities for the integration of new knowledge and skills into the regular curriculum in an acceptable and a cost-effective manner. furthermore, the informal or ‘hidden’ curriculum of a school can significantly influence learners’ attitudes and behaviours. schools have the potential for accessing nearly the entire population of young people, including minority and disadvantaged groups.[4] learners can be reached at an influential stage, i.e. childhood and adolescence, and a school is a relatively sheltered learning environment. in the school setting education and learning are the norm and the wider community can be influenced, i.e. school personnel, families and community members. in 1995, the world health organization (who) launched its global school health initiative of health-promoting schools (hpss). an hps is defined as ‘a school that is constantly strengthening its own capacity as a healthy setting for living, learning and working’.[5] the foregoing background. health sciences students have traditionally been taught their practical skills in community health facilities. however, clinics and hospitals are not necessarily ideal settings for teaching students health-promotion skills. objective. to explore health-promoting schools (hpss) to teach stellenbosch university (su) undergraduate dietetic students health-promotion skills. methods. in this descriptive, cross-sectional study, students completed structured reflective journals and conducted interviews with teachers. the chief professional nurse interviewed the school principals. results. the students were positive about hpss, but only fully understood its implementation and practice after entering the school setting. they felt that they could play a role in increasing its efficacy. the teachers were positive about the initiative and thought that they had adequate knowledge to take it further, but were open to gaining more knowledge and insight. teachers and students had similar views on the role that students could play in hpss, including educating learners, parents and teachers on health and nutrition, assisting with growth monitoring and promotion, developing educational tools, obtaining various resources for schools, planning menus, budgeting for meals, and growing vegetables. resources required by the schools could best be addressed by a team of healthcare professionals in collaboration with government departments and with community support. conclusion. hpss offer extensive opportunities where su undergraduate dietetic students, and possibly other healthcare profession students, could serve the needs of communities while learning and practising health-promotion skills. ajhpe 2014;6(1):48-51. doi:10.7196/ajhpe.250 health-promoting schools as a service learning platform for teaching health-promotion skills l m du plessis,1 m nutrition; h e koornhof,1 m nutrition; l c daniels,1 m public health; m sowden,1 m nutrition; r adams,2 cpn 1 community nutrition, division of human nutrition, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 school health services, department of health, provincial government of the western cape, south africa corresponding author: l m du plessis (lmdup@sun.ac.za) we live in a world of problems which can no longer be solved by the level of thinking that created them. – albert einstein mailto:lmdup@sun.ac.za may 2014, vol. 6, no. 1 ajhpe 49 research initiative aims to advance the health of the community by using the school as a platform for health promotion and education. this may ultimately improve the health of school personnel, families, learners and the wider community, as nutritional education and promotion is a cardinal element in an hps.[5] according to waggie et al.,[6] many educators do not initiate or sustain the concept of hpss. it is viewed as an additional task by which they are not assessed, and which is the duty of the department of health and welfare. the who, however, states that in every country collaboration between the department of education and department of health is crucial for the hps concept to succeed. although the health sector has a longstanding relationship with schools, usually in screening and treating learners – while occasionally engaging in preventive measures[7] – the health and education agendas of schools are often in competition with each other. schools’ agendas are filled with educational material and teachers often struggle to find time to cover health topics.[8] the literature suggests that school health services could be more effective if attention is paid to working collaboratively on partnerships and if school health services are integrated with other components of an hps. more successful partnerships are possible, but need both the education and health sectors to work more closely together to develop organisational and interventional strategies consistent with the needs of the school community.[7] the newly launched south african integrated school health policy (ishp) was developed jointly by the department of basic education and department of health. this policy recognises the hps concept as a key component of its programme and focuses on the importance of nutrition.[9] objective bsc dietetics students at stellenbosch university (su) follow a 4-year undergraduate course. during their internship, 4th-year students do a 6-week community nutrition rotation in an urban setting. in deliberation with the western cape government: school health services, a servicelearning agreement was formulated to include a week-long hps exposure in the students’ community experience. this exposure includes assisting the school health team (consisting of a chief professional nurse, a professional nurse and an enrolled nurse) by weighing and measuring grade 1 learners as part of routine school health screening to assess early indications of growth problems. thereafter, students interpret the anthropometry and suggest appropriate action, where applicable. they perform a health education and promotion session with grade 1 learners as well as an advocacy presentation on the dietetics profession to secondary school learners. the aim of this study was to assess the experiences and opinions of 4th (final)-year dietetic students with regard to hpss as a setting to learn about health promotion and to identify opportunities in which they could play a role in optimising the hps initiative. furthermore, knowledge, attitudes, beliefs and practices (kabp) of teachers and school principals regarding the hps initiative and the role of nutrition in health were assessed. methods study design and population a descriptive, cross-sectional study was conducted in the western border area of the cape town city district, western cape, south africa. the study population consisted of 4th-year su dietetic students (n=17), teachers (n=30) and school principals (n=10) from 10 selected primary schools in a low socio-economic community, who consented to participate. data collection methods reflective journals. students were requested to write structured reflective journals regarding their experiences during the week of service learning in a school setting. questions students had to answer, or statements they had to consider in the reflections, included: their experience of the platform and how this influenced their thoughts/perceptions regarding the school setting as a service-learning platform for student training; the role they could play in the school environment; and whether the school(s) they visited required any additional resources to implement the hps initiative. they could also share additional thoughts they considered to be valuable. kabp survey. a questionnaire used for the structured interviews with teachers and school principals consisted of 12 open-ended and three closedended questions addressing the following aspects: • knowledge of the concepts of healthy nutrition and malnutrition and how these can be addressed in the school and community settings. • attitude towards and knowledge about the hps initiative. • beliefs regarding health-related knowledge and training needed in this regard. • practices to improve their schools’ health knowledge. the students acted as field workers and interviewed the teachers, while the chief professional nurse (co-investigator) interviewed the school principals. students were standardised in terms of ‘prompts’ for the interviews. pilot study a pilot study was conducted in one of the schools in the study area to test the face and content validity of the questionnaires. these results were excluded from the study data. minor adaptations were made to the questionnaires after the pilot study. data analysis qualitative data from the reflective journals and responses to the openended questions were regarded as transcribed text. the text was coded manually by two researchers to identify themes. themes were induced and established into units of meaning or codes. the data were read and re-read and notes were made to illustrate links between different themes and codes. the two researchers compared their findings and discussed different interpretations to reach consensus. ethical and legal aspects ethics approval to conduct the research was obtained from the health research ethics committee of the faculty of health sciences, stellenbosch university (ref.: n10/02/039). participation was voluntary and all participants were required to provide written informed consent before the study. coding of each questionnaire ensured anonymity and confidentiality of the participants. results the results were divided into two broad themes, i.e. experiences and opinions of undergraduate dietetics students; and knowledge, attitude and behaviour of the teachers and school principals. within the themes, seven categories emerged: (i) a positive attitude to hpss; (ii) the students’ role in hpss; (iii) community outreach; (iv) resources required (common themes); (v) importance of service-learning experience (students); (vi) suitability of 50 may 2014, vol. 6, no. 1 ajhpe research platform (students); and (vii) staff knowledge levels. there was an overlap of four of the categories in the two themes. experiences and opinions of undergraduate dietetic students the students were positive about the hps initiative, even before entering the schools, but only fully understood its implementation and practice when they worked in the school setting and engaged with schools that had been exposed to the initiative. ‘i think that this last week was a brilliant learning experience for us. only once health promotion in schools was seen in practice did i fully grasp the theory of it.’ ‘without this experience i would never have properly understood health promotion this well, thus i feel that it is an amazing platform for student training.’ ‘this experience made me realise the crucial need for … taking part in health promotion above just learning of the concepts.’ the students were of the opinion that schools are a good platform to instil nutritional concepts and basic health skills in young children, as the learners are an available and receptive target audience. they enjoyed the interaction with the eager learners and sensed the beneficial effect of health promotion on the learners, their families and the broader community. ‘this [exposure] proves once again to us students that there are ways to make changes in society.’ ‘the exposure to health promotion in schools made me realise that us as healthcare workers have to engage in the community and help them to help themselves.’ the students felt that they had a role to play in increasing the efficacy of this initiative and suggested becoming involved in educating learners, parents and teachers in health and nutrition. suggestions were made about how they could assist with growth monitoring and promotion, developing educational tools for use in the classrooms, planning menus, budgeting for meals for the school feeding schemes, advising on tuck shop items, and lending a hand with training in vegetable gardening. ‘we can design and create teaching tools regarding healthy lifestyles and nutrition and we can teach the children in creative ways.’ ‘i think our role with regard to the weighing and measuring helps with the identification and the assessment of the school’s nutritional status. the information that we provide can help with the early prevention measures … ’ resources needed by the schools, as noted by the students, included: a dietician who visits the schools once a week, nutritional education tools, funds, sports grounds, an equipped kitchen, first-aid kits, volunteers and proper sanitation. kabp of teachers and school principals teachers described hpss as a concept applied in schools where healthy eating habits and lifestyles are promoted, including the physical, mental and emotional well-being of learners. the link between a hungry child and subsequent poor school performance was also mentioned. 'you can’t teach a hungry child.’ teachers had a basic understanding of the concept of healthy nutrition, but struggled to describe malnutrition correctly. overall, the teachers were positive about and supported the hps initiative. factors contributing to their attitudes included remarks about well-fed children concentrating better, improving school facilities and personal hygiene, producing vegetables in school gardens, providing support to poor families and increasing children’s self-esteem. they felt that they had enough knowledge to apply the hps initiative, but were open to gaining more knowledge. a few teachers agreed that they lacked knowledge about the initiative. areas in which training was needed included first aid, healthy living, intervention strategies from specialists with health knowledge and nutritional requirements of children. teachers responded that dietetic students have a role to play in hpss by assisting with growth monitoring, alerting parents to nutritional problems, educating learners, teachers and parents about nutrition, as well as developing nutritional education tools. ‘the students’ presence makes the children feel special and helps the school healthcare team’s work load to be lighter.’ resources needed, as identified by teachers, included firstaid, screening and sports equipment, nutritious food for the national school nutrition programme (nsnp), vegetable seeds, and health resources. financial assistance, a designated plate and suitable cutlery for each child, and volunteers to assist with food preparation for the nsnp were also listed. teachers believed that the hps initiative could improve the nutritional status of their community. examples were addressing parents on such issues at parent-teacher meetings, and vegetable gardens and soup kitchens run by the school to assist the vulnerable and elderly in the community. discussion the need to shift the healthcare focus in south africa from curative to preventive, with health promotion at the core, has been expressed. the recently launched ishp envisages optimal health and development of school-going children and the communities in which they live and learn.[9] this vision supports the necessity to strengthen the hps initiative in the country. in an attempt to align the su bsc dietetics community nutrition curriculum with actions required from these relevant and updated policies, the authors investigated the school setting as a location where future dieticians could be taught the necessary skills to perform health promotion. in this study the students indicated that they only fully understood the hps initiative after they had been exposed to it. this illustrates that practical exposure to real-life health promotion scenarios should be an essential element of the professional health education curriculum. by observation and reflection students identified and reported concrete examples of health-promotion activities where they could become involved in furthering the initiative. dharamsi et al.[10] explored the international service-learning experience of three medical students and the value of critical reflection. in their study, students kept reflective journals and wrote essays including detailed accounts of their experiences. students noted an increasingly meaningful sense of what it entails to be vulnerable and marginalised, to create a heightened level of awareness of the social determinants of health and the related importance of community engagement, as well as developing a deeper appreciation of the health advocacy role and key concepts embedded within it. the reflective journals completed by the dietetic students in the study indicated that the criteria for service learning can be met when utilising the hps as a service-learning platform.[2] the lecturers’ response to the need for providing students with the opportunity to improve skills building in preventive healthcare therefore proved to be of value. may 2014, vol. 6, no. 1 ajhpe 51 research ridge et al.[8] highlighted an array of changes that take place in hpss. these include changes for the learners (e.g. increased awareness of health, happier learners who feel cared for, improved learning outcomes and health practices); changes for the school (e.g. proactive health strategies, improved staff morale, improved health and physical environment); and changes in community links (e.g. better networking, increased involvement and satisfaction of parents). the health-promotion skills acquired by students in the study included early health assessment for preventive action, and nutritional education and promotion in schools. the students and school staff could identify more opportunities where the students’ input could positively contribute to the improvement in the school nutritional environment, ultimately resulting in further healthy lifestyles in the school community. the reciprocity established between the school health service team, students, teachers and learners through this service-learning agreement can partially explain the overall positive attitude noted by students and teachers towards the hps initiative. a systematic review by wang en stewart[11] concluded that there is a need for more professional training for teachers in the hps approach, as well as more qualitative studies to assess future school-based nutritional promotion programmes. an evaluation of hpss in hong kong by lee et al.[12] found that there was insufficient staff training in health promotion and education. teachers can be perceived as role models for students and are central to a school’s functioning; hence interventions involving students may potentially change the health-risk behaviours of teachers. schools also provide a valuable link with parents and the community. involvement of parents, caregivers and local community members can act as strong reinforcement and support for strategies implemented in schools.[4] in the schools included in this study, the teachers and school principals could identify their own shortcomings and needs to optimise the hps initiative. they expressed their willingness to learn more and voiced concrete ideas of how the school community could benefit from the students’ involvement. furthermore, teachers were willing to work with the students and were eager to learn more. individuals and communities often have complex health needs and typically require professional inputs from more than one discipline to address issues regarding their health.[13] in 2001, a recommendation by the institute of medicine committee on quality of health care in america suggested that healthcare profession teams can best communicate and address these complex and challenging needs.[14] the resources needed by the schools, as identified by the students and teachers in this study, should be addressed by such a team. the hps platform furthermore lends itself to establishing opportunities for intraprofessional learning and teaching. with concerted efforts from different sectors (e.g. medical, dental, occupational therapy, physiotherapy, speech and audiology, nursing and dietetic students, as well as trans-faculty involvement), schools could be supported to access more resources and receive expert advice on best practice intervention strategies to further the health and well-being of the school community. this interprofessional approach may allow sharing of expertise and perspectives towards the common goal of restoring or maintaining an individual’s health and improving outcomes while combining resources.[15] conclusion and recommendations the new ishp embraces a comprehensive approach to ensure the health of all learners. higher education institutions have a responsibility to engage with communities and assist in addressing their needs. service learning is one way of fostering such engagement in a structured, practical way. an hps service-learning agreement offers abundant opportunities for undergraduate su dietetic students for health-promotion activities. this exposure should be extended to students of other healthcare professions. limitations using the students to conduct the interviews with the teachers as well as using reflective journals as a data collection instrument, could have led to incomplete data gathering owing to their limited experience in conducting research. acknowledgements. the authors wish to thank the su bsc dietetics fourthyear class of 2010, the metro western health district: school health services personnel – claudette september and pat scheffers – as well as the principals, teachers and learners who participated in the research. mrs m l marais is acknowledged for proofreading the manuscript. this research was supported by grants received from the su fund for innovation and research into learning and teaching (firlt) and the su faculty of medicine and health sciences, research development and support, term post for allied health professions, research assistance. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 2. howard j. service-learning course design workbook. university of michigan: edward ginsberg center for community service and learning, 2001:10-12. 3. bringle rg, hatcher ja. implementing service learning in higher education. journal of higher education 1996;67(2):221-239. 4. lynagh m, schofield mj, sanson-fisher r. school health promotion programs over the past decade: a review of the smoking, alcohol and solar protection literature. health promotion international 1997;12(1):43-60. 5. world health organization. global school health initiative. http://www.who.int/school_youth_health/gshi/en/ index.html (accessed 7 october 2013). 6. waggie f, gordon n, brijlal p. the school, a viable educational site for interdisciplinary health promotion. educ health 2004;17(3):303-312. 7. st leger lh. the opportunities and effectiveness of the health promoting primary school in improving child health – a review of the claims and evidence. health education research 1999;14(1):51-69. [http://dx.doi. org/10.1093/her/14.1.51] 8. ridge d, northfield j, st leger l, et al. finding a place for health in the schooling process: a challenge for education. australian journal of education 2002;46:19. 9. national departments of health and basic education. integrated school health policy. pretoria: department of health, 2012. 10. dharamsi s, richards m, louie d, et al. enhancing medical students’ conceptions of the canmeds health advocate role through international service-learning and critical reflection: a phenomenological study. medical teacher 2010;32:977-982. [http://dx.doi.org/10.3109/01421590903394579] 11. wang d, stewart d. the implementation and effectiveness of school based nutrition promotion programmes using a health promoting schools approach: a systematic review. public health nutrition 2013;16(06):1082-1100. [http://dx.doi.org/10.1017/s1368980012003497] 12. lee a, st leger l, cheng ff. hong kong healthy schools team. the status of health-promoting schools in hong kong and implications for further development. health promotion international 2007;22(4):316-26. [http:// dx.doi.org/10.1093/heapro/dam029] 13. bridges d, davidson r, odegard p, et al. interprofessional collaboration: three best practice models of interprofessional education. medical education online 2011;16:6035. http://med-ed-online.net/index.php/meo/ article/view/6035/html_115 (accessed 7 october 2013). 14. institute of medicine committee on quality of health care in america. crossing the quality chasm: a new health system for the 21st ccentury. washington, dc: national academy press, 2001. 15. barker k, oandasan i. interprofessional care review with medical residents: lessons learned, tensions aired – a pilot study. j interprof care 2005;19:207-214. http://dx.doi.org/10.1016/s0140-6736 http://dx.doi.org/10.1016/s0140-6736 http://www.who.int/school_youth_health/gshi/en/ http://dx.doi.org/10.1093/her/14.1.51] http://dx.doi.org/10.1093/her/14.1.51] http://dx.doi.org/10.3109/01421590903394579] http://dx.doi.org/10.1017/s1368980012003497] http://dx.doi.org/10.1093/heapro/dam029] http://dx.doi.org/10.1093/heapro/dam029] http://med-ed-online.net/index.php/meo/ research may 2016, vol. 8, no. 1 ajhpe 11 the university of kwazulu-natal (ukzn), durban, south africa (sa) has adopted a list of core competencies for medical students, derived from the royal college of physicians and surgeons of canada physician competencies (canmeds),[1] which includes as one of its key facets the role of communicator. some of the objectives are to develop rapport and trust between patients and healthcare providers from different cultural backgrounds, with a particular mention of respect for ‘diversity and difference, including … the impact of ethnicity, gender, religion, education and culture’.[2] training in clinical communication at ukzn follows the calgarycambridge method,[3] which stresses the importance of content (what information is obtained) and process skills (how information is obtained) in a medical interview, and places emphasis on a patient-centred method in which biomedical, contextual and patient perspectives are explored.[4] however, as a eurocentric model, it has been suggested that the method is not useful in a multicultural and multilingual society such as sa. the authors believe that such a model can be used in the sa context by stressing the importance of the patient’s perspective and the meaning that his culture brings to the consultation. the 2011 census showed that nearly 78% of people living in kzn speak isizulu, one of the province’s official languages, as a home language.[5] the ukzn’s bilingual language policy, approved in 2006, proposes that the university develops the use of isizulu as a language for communication, with particular emphasis on ‘professional/vocational training for undergraduate students’.[6] in a study by matthews,[7] the current isizulu module for 1st-year medical students, which provides basic vocabulary and grammar skills, has been shown to be insufficient to equip students to communicate effectively with their patients in a clinical setting. matthews recommended that a vertically integrated isizulu course for medical students be introduced to reinforce learning, concentrating on basic interpersonal communicative skills and appropriate terminology and vocabulary for a medical interview. neurocognitive theory has become an important framework for planning and guiding the development of teaching material in many disciplines and has been used as such for the isizulu video project. the attention, generation, emotion and spacing (ages) neurocognitive model describes how hippocampal activation improves long-term retention and retrieval of learnt material.[8] the four features of the ages model consider the following aspects of learning: getting information into the brain and encoding it; retention of memories; and retrieval of memories.[8] for learning to occur, full attention must be paid to the topic to be learnt, with concentrated focus on the task. davachi et al.[8] suggest that one method of doing so is to make learning situations as authentic as possible, e.g. with the use of advanced simulations. these authors state that the generation of memories or recall is optimised when learners are able to ‘contextualise, retain and apply knowledge in their own way’, and that using methods which are thought to be entertaining or novel may invoke positive emotions that enhance learning.[8] the final part of the model describes how spacing (distributing learning over time) and revisiting content lead to better longterm memory.[8] the use of videos as an audiovisual component in second-language teaching has been shown to be successful and relevant to the needs of learners.[9] furtherbackground. the role of communicator has been included as a key competency for health science students in south africa. owing to the population’s diverse language and cultural backgrounds, communication between patients and healthcare professionals is challenging. in this study, the attention, generation, emotion and spacing (ages) neurocognitive model of learning was used as a framework to create videos for language teaching for the vocational needs of students. objectives. to explore students’ views on the use of videos of simulated clinical scenarios for isizulu communication and language teaching and the development of cultural awareness. methods. videos were developed using firstand second-language isizulu speakers with scripts (verified by the university’s language board) based on authentic clinical settings. videos were shown to a target group of students, who were then interviewed in focus group discussions. audio recordings from the discussions were transcribed and analysed thematically in three categories, i.e. communication, language skills, and cultural awareness, using deductive coding based on the objectives of the research. results. students affirmed numerous benefits of the videos and commented on their use and further development. benefits described related well to the ages model of learning and fulfilled the learning requirements of communication teaching, language acquisition and cultural awareness. conclusion. the videos represent an innovative teaching method for the resource-constrained environment in which we work and are relevant to the 21st century learner. further evaluation and development of the tool using different scenarios and african languages is recommended. afr j health professions educ 2016;8(1):11-14. doi:10.7196/ajhpe.2016.v8i1.402 medical students’ views on the use of video technology in the teaching of isizulu communication, language skills and cultural competence p diab,1 mb chb, mfammed; m matthews,2 mb chb, doh, mph; r gokool,3 ba, ba hons, ma 1 discipline of rural health, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 school of clinical medicine, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 discipline of african languages, school of arts, college of humanities, howard college campus, university of kwazulu-natal, durban, south africa corresponding author: p diab (diabp@ukzn.ac.za) research 12 may 2016, vol. 8, no. 1 ajhpe more, videos have been demonstrated to be useful in teaching language for a specific purpose, i.e. for the vocational requirements of medical students.[10] other advantages of video technology in teaching communication are that it contains visual (body language) and auditory (speech patterns and rhythms) content.[9] it also has the advantage of being able to be offered on various platforms, such as learning management systems and public platforms, e.g. youtube, at a time and place convenient to the viewer,[11] and creates a link between theoretical teaching and its practical application. objectives the general objective of the study was to explore students’ views on the novel approach of using video clips as a language teaching tool in the context of the ages model. specific objectives were to explore how the videos improved their learning of communication skills, isizulu language skills and awareness of the cultural context of the consultation. methods the authors, being integrally involved in communication training at ukzn, identified the need to develop a means of communication teaching, where both english and isizulu were used, which would be able to teach language and communication skills simultaneously. where possible, scripts were developed in isizulu by second-language speakers, relying on their experience in authentic clinical settings. these were checked for grammatial and language accuracy by an isizulu tutor and other first-language isizulu speakers, including the language co-ordinator of the university. the scenarios are representations of real life, although none is factual in content or person. they focus on various clinical presentations and disease entities, and use the calgarycambridge framework. for the purpose of this study, only one of the videos was shown – a scenario involving a young woman who presented with lower-abdominal pain and menstrual problems, symptoms located in a cultural context of the patient to prove her fertility. the ‘patients’ in the videos were actors trained in communication skills at the ukzn clinical skills department. the ‘doctors’ were authors and colleagues comfortable in second-language isizulu, but with no formal training in the language at an academic level. the videos were filmed in a simulated setting by a professional videographer. final-year students in their family medicine rotation took part in the study. they were exposed to the video, and their comments with regard to communication skills, language and cultural learning were recorded in focus group discussions (fgds) and a self-reflection questionnaire (quest). ethical permission to perform the study was granted by the ukzn humanities and social sciences research ethics committee (hss/0312/013). permission was obtained from all relevant gatekeepers and individual consent from participating students. audio recordings of the fgds were transcribed and thematically analysed using inductive coding with the assistance of nvivo (version 9) (usa). results responses from students with regard to the video tool were overwhelmingly positive. only one student, who admitted to having a particularly poor understanding of isizulu, felt that she obtained very little benefit from the video as she had not paid attention to a subject that was not examinable at the time and that she found uninteresting. in general, students embraced the idea of using technology and new learning tools to enhance learning of doctor-patient communication skills and to assist with learning of a second language. although students were not specifically informed of the ages model of learning, they expressed the following comments about the videos in general. ‘i think the videos are actually quite good because i do not remember half the scenarios they gave us at school because they were written. you know, we are not paying attention, we dozed off, but i mean if you have seen it and remember it, i do not know, maybe it will be better.’ (fgd2) ‘and then if they make it available thereafter that is often a good reinforcement because it is one thing watching the video and then just going home, and then another thing watching it and then having to go over it and even watch it again when you have practised because then you actually realise how much you had forgotten though we can then pick up.’ (fgd2) ‘it will possibly also find ways of how to make zulu itself interesting as a language.’ (fgd2) communication skills students mentioned that they felt the videos demonstrated the importance of communication skills in terms of building the doctor-patient relationship. ‘how the doctor was communicating with the patient – it is something that we are taught … but something we overlook … if you are watching it time and time again then you learn.’ (fgd2) they also highlighted the importance of various process and non-verbal skills important in communication teaching, which were evident in the videos. ‘the encouragement.’ (fgd3) ‘… and eye contact.’ (fgd3) ‘your expression and body language … will determine your relationship with the patient in terms of trust.’ (fgd3) language skills students generally articulated the need to be able to communicate in isizulu with their patients. ‘it automatically creates a bond between doctor and patient.’ (quest 11) the importance of the spoken language was highlighted. ‘we will not be writing notes in zulu in as much as we will be taking a history in zulu. so it is the speaking part that is most important.’ (fgd1) students thought that another advantage of the videos was the learning of vocabulary and specific keywords and phrases within a specific context. the combination of hearing words in context and being able to relate them to the written word on the scripts was found to be very useful. ‘i think it is good, excellent to link it [language teaching] with video scenarios. if it is in context we can remember it better rather than getting a list of vocab.’ (fgd2) research may 2016, vol. 8, no. 1 ajhpe 13 ‘common words, common questions like “when did it start?”, “where does it refer to?” … simple things like that really would help.’ (fgd3) in addition to second-language isizulu speakers identifying the advantages the videos could have for them, first-language isizulu speakers felt that the videos could benefit their understanding of the language, especially in a medical context. ‘i am zulu. i am from a zulu background. but there are certain things that i cannot explain to patients in zulu because i do not know the terminology.’ (fgd2) enhancing cultural awareness students identified another objective as enhancing cultural awareness in consultations. they related many episodes where they had been exposed to situations in which an awareness of the patient’s cultural beliefs was vital to the consultation and reflected their need to improve their own cultural sensitivity. ‘i think you should be teaching [cultural awareness] because it is so common. it comes up so much wherever you are.’ (fgd2) the scenario shown to students highlighted a young woman who wanted to prove her fertility to her betrothed. one student accurately summarised the meaning of the scenario portrayed: ‘i think she was scared that if she does [not] have babies her husband is not going to marry her and i think the doctor acknowledged that and said she will try her best. and she did not judge her because her husband was going to leave her. she did not say what kind of husband is that who is going to leave you when you need him the most and stuff like that.’ (fgd3) technical aspects of the videos to develop the videos for future teaching, students were specifically asked about recommendations on technical aspects of development, utilisation and availability. ‘[the video] needs to be very clear and quite slow.’ (fgd3) ‘something like tutorials where students are broken into small groups and are given a scenario which two people simulate – one is a patient and the other one a doctor.’ (fgd1) ‘… the videos should be easily provided to the students that they can download from the website or to take home, watch on the computer and actually read the words … that would be a much easier and faster way of learning.’ (fgd1) ‘to have them available on your cell phone. oh! that would be amazing!’ (fgd2) students debated whether the videos should have subtitles on the screen, or if a separate script, with translation, should be made available. ‘if the subtitles are there you will end up focusing on them because you will end up not listening, just reading.’ (fgd3) ‘i think maybe the video and the printed [script]. if you have both of them you can hear how the word sounds and then you know.’ (fgd2) discussion the main objective of this article was to present and discuss students’ views on the use of video clips of simulations of authentic clinical situations to enhance communication and language skills in isizulu and develop cultural awareness for a medical consultation in line with ukzn’s language policy and plan. results of this exploratory study suggest that the use of such videos has many benefits. students indicated that the videos captured their attention and most expressed their interest in and enthusiasm for this teaching method. furthermore, students of the 21st century are technoliterate and very familiar with the use of audiovisual content, which many of them interact with and share on a daily basis. they articulated that hearing the language and observing visual cues while watching the relevant material in simulations of an authentic clinical setting would probably assist in the generation of new knowledge compared with traditional didactic teaching. the use of emotion to capture and hold a student’s attention is highlighted as a trigger to make learning more interesting and relevant – a concept supported by other authors.[8,12] the notion of spacing of content is well supported in the literature[8,13] and by students, who remarked on the advantages of being able to revisit content on the videos as frequently as required. by revisiting and reflecting on past experiences, students are able to make meaning of what they have learnt in the preclinical years and adapt it for future use in clinical settings. using video technology to teach communication skills through simu lated scenarios has been reported to be successful.[14-16] however, there is not much literature on the use of videos in second-language teaching. students sampled in our study noted that using the videos to identify and highlight process skills is particularly beneficial in a second-language context. students became sensitised to and remarked on the effectiveness of body language in engaging the patient, and realised that a willingness to use the patient’s language and simple techniques in the interview can improve the doctor-patient relationship and interaction. students highlighted the importance of being able to listen to isizulu as a spoken language, which would benefit them in learning pronunciation and specific keywords and phrases for their context. second-language teaching places much emphasis on listening and speaking compared with writing or reading the language. video technology has been shown to be very effective for this purpose.[9,17] moreover, the use of audiovisual media to enhance pronunciation, especially with regard to vocational-specific learning, has been documented in other international studies.[18,19] of particular interest was that first-language isizulu speakers felt they would also derive learning from exposure to the videos, especially with regard to medical terminology. in addition to the teaching of language skills, the videos provided a valuable opportunity for sensitising students to cultural influences in a medical consultation. part of understanding the patient’s perspective involves an appreciation of the patient’s life-world, which includes his understanding, cultural beliefs and past personal experiences.[20] students indicated that an awareness of their patients’ cultural perspectives will contribute to a shared understanding of concepts in the consultation and its outcome. study limitations as this was an exploratory study, it is limited in nature. only one video clip was shown to final-year students in the family medicine rotation. no formal evaluation has been conducted yet, although such plans are in place for 2014. (these evaluations have been commenced, but are still ongoing at research 14 may 2016, vol. 8, no. 1 ajhpe the time of publication.) with regard to the use of the video in the learning environment, it has been noted that a basic knowledge of the isizulu language and some technical ability are essential. recommendations owing to much interest and enthusiasm that this study has generated among students, the videos were presented to other role players including the medical students representative committee, information and communication technology services, language experts and members of the college of health sciences, ukzn. as a consequence of engagement with these role players, it was decided to formally include the series of videos in the curriculum. we have suggested that further research in implementing and evaluating the use of videos as a resource to enhance teaching and learning in the programme is undertaken. additional funding should be made available for the development of the project. it is hoped that this study will trigger dissemination of the teaching tool to various disciplines, schools and other institutions in sa. conclusion the value of teaching isizulu as a second language in vocational training is not disputed and communication skills have become a core competency of health education. because of current resource limitations, innovative teaching methods are required to deliver the necessary content. learning should also be relevant to the 21st century learner in a format that triggers an emotive and lasting response in the brain. the use of recorded, simulated representations of authentic clinical scenarios to fulfil these requirements requires further investigation and evaluation. references 1. frank jr, danoff d. the canmeds initiative: implementing an outcomes-based framework of physician competencies. med teach 2007;29(7):642-647. [http://dx.doi.org/10.1080/01421590701746983] 2. health professions council of south africa (hpcsa). core competencies for undergraduate students in the clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2012. 3. silverman j, kurtz s, draper j. skills for communicating with patients. 2nd ed. london, uk: radcliffe publishing, 2005. 4. kurtz s, silverman j, benson j, draper j. marrying content and process in clinical method teaching: enhancing the calgary-cambridge guides. acad med 2003;78(8):802-809. 5. statistics sa. census 2011 – the languages of south africa, 2011. http://www.southafrica.info/pls/procs/iac (accessed 8 april 2013). 6. university of kwazulu-natal. language policy and plan of the university of kwazulu-natal. durban: ukzn, 2013. 7. matthews m. vocation-specific isizulu language teaching and learning for medical students at the university of kwazulu-natal. durban: ukzn, 2013. 8. davachi l, kiefer t, rock d, rock l. learning that lasts through ages. neuroleadership journal 2010;3:53-63. 9. canning-wilson c, wallace j. practical aspects of using video in the foreign language classroom. internet tesl journal 2000;6(11):36-1. 10. belcher dd. trends in teaching english for specific purposes. ann rev appl linguistics 2004;24:165-186. 11. topps d, helmer j, ellaway r. youtube as a platform for publishing clinical skills training videos. acad med 2013;88(2):192-197. [http://dx.doi.org/10.1097/acm.0b013e31827c5352] 12. ledoux je. emotion, memory and the brain. sci am 1994;270(6):50-57. 13. litman l, davachi l. distributed learning enhances relational memory consolidation. learn mem 2008;15(9):711-716. 14. hurtubise l, martin b, gilliland a, mahan j. to play or not to play: leveraging video in medical education. j grad med educ 2013;5(1):13-18.  [http://dx.doi.org/10.4300/jgme-05-01-32] 15. fertleman c, gibbs j, eisen s. video improved role play for teaching communication skills. med educ 2005;39(11):1155-1156. [http://dx.doi.org/10.1111/j.1365-2929.2005.02283.x] 16. seif ga, brown d. video-recorded simulated patient interactions: can they help develop clinical and communication skills in today’s learning environment? j allied health 2013;42(2):e37-e44. 17. levy m. technologies in use for second language learning. modern language journal 2009;93(s1):769-782. 18. al-jarf r. online videos for specific purposes. j educ social res 2012;2:17-21. 19. cakir i. the use of video as an audio-visual material in foreign language teaching classroom. turkish online j educ technol 2006;5(4). 20. candlin s, roger p. communication and professional relationships in healthcare practice. equinox 2013:201. ajhpe contents.indd editorial board editor-in-chief vanessa burch university of cape town international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria ntombifikile mtshali university of kwazulu-natal marietjie nel university of the free state ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state elizabeth wolvaardt university of pretoria hmpg editor janet seggie consulting editor jp de v van niekerk deputy editor bridget farham editorial systems manager melissa raemaekers scientific editor ingrid nye technical editors emma buchanan paula van der bijl head of publishing robert arendse production coordinator bronlyne granger art director brent meder dtp & design carl sampson online manager gertrude fani issn 1999-7639 plagiarism is defined as the use of another’s work, words or ideas without attribution or permission, and representation of them as one’s own original work. manuscripts containing plagiarism will not be considered for publication in the ajhpe. for more information on our plagiarism policy, please visit http://www.ajhpe.org.za/ index.php/ajhpe/about/editorialpolicies ajhpe is published by the health and medical publishing group (pty) ltd co registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za 28 main road (cnr devonshire hill road), rondebosch, 7700 | +27 (0)21 681 7200 all letters and articles for publication must be submitted online at www.ajhpe.org.za editorial 117 does simulation-based training have a future in africa? v burch research 119 building on tinto’s model of engagement and persistence: experiences from the umthombo youth development foundation scholarship scheme a ross 124 integrating research into teaching: needs assessment for staff development j de jongh, j frantz, a rhoda 129 factors that influence msc (med) (pharmacy) completion rates at the medunsa campus of the university of limpopo, south africa b summers, d i mpanda 133 access, pass, throughput and drop-out rates: review of a problem-based learning bpharm curriculum at a previously disadvantaged university in south africa l a mabope, j c meyer 138 recommendations for the establishment of a clinical simulation unit to train south african medical students m j labuschagne, m m nel, p p c nel, g j van zyl 143 assessment of the education environment of senior medical students at the university of the free state, bloemfontein, south africa s schoeman, r raphuthing, s phate, l khasoane, c ntsere 150 making use of an existing questionnaire to measure patient-centred attitudes in undergraduate medical students: a case study e archer, j bezuidenhout, m kidd, b b van heerden 155 medical students’ clerkship experiences and self-perceived competence in clinical skills p katowa-mukwato, b andrews, m maimbolwa, s lakhi, c michelo, y mulla, s s banda 161 an educational programme for error awareness in acute trauma for junior doctors c m aldous, r searle, d l clarke 165 a qualitative survey of top-achieving undergraduate medical students’ perspectives of medical education: an iranian exploration p khashayar, p khashayar, m tavakol 169 building a research agenda in health professions education at a faculty of medicine and health sciences: current research profile and future considerations j bezuidenhout, s van schalkwyk, b van heerden, m de villiers book review 174 principles of medicine in africa 176 cpd questionnaire supplement 177 curriculum renewal in the health sciences ajhpe african journal of health professions education | october 2014, vol. 6, no. 2 ajhpe cpd.indd dear cpd client, we wish to take this opportunity to thank you for your continued support through the completion of our online cpd questionnaires as well as to share some exciting news with you. hmpg’s journal cpd questionnaires will be moving to the medical practice consulting (mpc) 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october 2014 true (a) or false (b): building on tinto’s model of engagement and persistence: experiences from the umthombo youth development foundation scholarship scheme 1. rural-origin students are more likely than urban-origin students to work in rural areas once they have completed their studies at an institution of higher learning in south africa. 2. academic and peer mentoring programmes and holiday work experiences may contribute to the academic success of rural-origin students training to become healthcare professionals in south africa. integrating research into teaching: needs assessment for staff development 3. institutions of higher learning, such as universities, should ensure that the teaching duties and research activities of academic staff remain clearly segregated so that the quality of their teaching is not adversely affected. 4. the scholarship of teaching requires active involvement of academic teaching staff, with research into teaching. factors that influence msc (med) (pharmacy) completion rates at the medunsa campus of the university of limpopo, south africa 5. completion of postgraduate studies is largely determined by the availability of adequate financial resources, and is less likely to be influenced by frequency and quality of communication between the supervisor and the student. 6. good time management is one of the most important factors contributing to the successful outcome of postgraduate studies. access, pass, throughput and drop-out rates: review of a problem-based learning bpharm curriculum at a previously disadvantaged university in south africa 7. selection processes for health sciences training programmes in south africa should largely focus on the academic achievements of applicants. 8. adjustment to university life is a complex process and may contribute to the increased attrition of undergraduate students in the first two years of study. recommendations for the establishment of a clinical simulation unit to train south african medical students 9. saturation of the academic clinical teaching platform in south africa is driving a move towards the increased use of simulation-based training to complement patient-based learning experiences in south african health sciences faculties. 10. simulation-based training should be limited in undergraduate clinical training programmes because it encourages students to perform potentially dangerous procedures on patients without recognising the need for appropriate supervision. assessment of the education environment of senior medical students at the university of the free state, bloemfontein, south africa 11. the dundee ready educational environment measure (dreem) is a useful tool for assessing the quality of the educational environment in health sciences training programmes. 12. there are no data to support the idea that the educational environment, in a programme or course, influences the effectiveness and academic success of students in medical training programmes. making use of an existing questionnaire to measure patient-centred attitudes in undergraduate medical students: a case study 13. undergraduate students become more empathetic towards patients as they reach the more senior years of medical training programmes. 14. questionnaires and surveys used to measure student attributes and/or opinions are likely to perform similarly in all countries and validation studies are not needed prior to using such instruments in a local setting. medical students’ clerkship experiences and self-perceived competence in clinical skills 15. most medical students, by the time they graduate, are not able to safely operate a basic defibrillator as part of advanced life support. 16. students have a very good idea of their clinical skills and so selfreporting is an accurate way of determining their clinical competence. an educational programme for error awareness in acute trauma for junior doctors 17. cases presented at morbidity and mortality meetings can be very useful when teaching junior doctors about error awareness in clinical practice. 18. the greatest source of error in clinical practice is assessment failure (wrong diagnosis). a qualitative survey of top-achieving undergraduate medical students’ perspectives of medical education: an iranian exploration 19. undergraduate medical students are not able to provide feedback about the relevance and appropriateness of medical curricula. 20. teacher-centred, discipline-based medical curricula are still being used in some parts of the world despite a global move to integrated, studentcentred programmes. research may 2015, vol. 7, no. 1 ajhpe 65 correspondence storymaking: an inter-professional learning experience to the editor: in response to the editorial in the may 2014 edition of ajhpe,[1] i would like to offer an example of medical students who were given an opportunity to engage in inter-professional learning. in july 2014, i supervised a special study module (ssm) for second-year medical students at the university of cape town (uct). students could choose a particular field of interest to deepen their understanding of a subject, as well as develop their research and academic writing skills. as a pioneer in the field of medical humanities in africa, and as a musician, prof. steve reid, head of the primary health care directorate, had been encouraging the availability of various arts-related modules as part of the ssm curriculum. as a dramatherapist, i supervised a module entitled ‘theatres of the psyche’. students were invited to investigate the role of the dramatic arts within a biopsychosocial approach in treating mental illness. the ssm included a practical component in a psychiatric setting, where we presented two storymaking sessions at valkenberg hospital, cape town. some reflections from a student are as follows: ‘we get taught a structured mainstream approach, seeing patients for their diseases. this experience helped me to understand a patient is more than their diagnosis, we have to see the person as a whole.’ hougham[2] wrote that stories can act as containers for our inner lives. by enacting various parts of a story, we come in touch with different parts of ourselves. when we engage with each other in this process, we can also begin to experience each other as whole beings, who constitute more than our designated roles in certain settings – in this case, the role of student, patient and therapist. another important outcome of this was a raised awareness of interdisciplinarity. at the start of this module, students were invited to attend a conference hosted by the south african association of dramatherapists (saad) and uct’s department of occupational therapy, entitled ‘healing and social transformation in mental healthcare in south africa’. this provided an opportunity to engage with a variety of professionals in the field of mental healthcare. here are the thoughts of one of the students: ‘i had the best time. the whole environment was unique. there was an openness and people were welcoming, not just to each other but also to new ideas. i aim to someday be a part of this sharing of knowledge and skills in order to draw from each other and complement each other’s unique techniques.’ d’alessandro and frager[3] concluded in their recent study that theatre and story are effective tools in teaching undergraduate medical students. the dramatherapist believes that ‘telling a tale enables each of us to know ourselves as someone who has a voice which is worth listening to, someone who can be heard and understood’.[4] it is my hope that the arts and medicine will continue to be partners in the training of knowledgeable, reflective and empathic healthcare professionals. with special thanks to aisha najjaar. marlize swanepoel primary health care directorate, faculty of health sciences, university of cape town, south africa marlize@wezside.co.za 1. editorial. does simulation-based training have a future in africa?afr j health professions educ 2014;6(2):117-118. [http://dx.doi.org/10.7196/ajhpe.534] 2. hougham r. numinosity, symbol and ritual in the sesame approach. dramatherapy 2006;28(2):3-8. 3. d’alessandro p, frager g. theatre: an innovative teaching tool integrated into core undergraduate medical curriculum. arts & health: an international journal for research, policy and practice 2014;6(2):191-204. 4. gersie a, king n. storymaking in education and therapy. london: jessica kingsley, 1990. afr j health professions educ 2015;7(1):65. doi:10.7196/ajhpe.542 148 october 2016, vol. 8, no. 2 ajhpe research since the 1990s, mentorship programmes as a means to support student doctors have become increasingly common.[1,2].although levison et al. [3] described mentoring as a voluntary relationship between a more experienced professional and an apprentice, many of the mentorship programmes for student doctors are strongly encouraged or compulsory.[2] unlike informal mentoring, which attracts high achievers, participants in formal mentorship programmes are more representative of the general student population.[4,5] therefore, formal mentorship programmes ensure that a broader range of student doctors become mentees, who have the opportunity to discuss career planning, work-life balance, personal problems, and study skills with their mentors.[5,6] mentorship of student doctors in a community of practice is more likely to transpire when there is a rapport between the mentor and the mentee.[7,8] mentors and student doctors who have experienced the same curriculum find it easier to build a rapport.[8] rapport is also improved when the demographic profile, personality traits, experiences, and personal and professional interests of the mentor correspond to those of the mentee.[5,9] this has led to the use of online matching systems that recommend potential faculty mentors to student doctors.[10,11] online systems are also used when mentors in developing countries are unavailable.[12] the appraisal process at the university of leeds, uk is a formal process for mentorship of a large cohort.[2,6,13] it starts with an appraisal scheduled in the academic calendar, where faculty members guide 1stand 2nd-year student doctors to reflect on their progress.[6,13] at the end of the appraisal, students fill in an appraisal record form where they state their personal goals, which will be discussed at the second appraisal meeting during the following year. students who need additional support are referred to the dean of students.[13] the university of the witwatersrand, johannesburg, south africa first implemented an adapted appraisal in 2008 for 3rd-year students. the 3rd year (the graduate entry medical programme 1 (gemp1)) is a particularly crucial time for student doctors, as they make a transition to the hospital and shadow doctors. graduate entrants also have to adjust to a new degree and in some cases to a new university. it was important to investigate the students’ perceptions of the appraisal process, as an adapted appraisal, which uses fewer resources, has not been researched. furthermore, current research suggests that only assigned mentors who receive training and support manage to develop a rapport with student doctors.[13,14] the purpose of this research was to understand students’ experiences of the adapted appraisal in order to provide suggestions to other medical schools hoping to establish similar programmes with restricted resources. therefore, the research questions for this study are: • what are students’ experiences of an adapted appraisal that uses fewer resources? • how can students’ feedback on the challenges faced during the appraisal process and the literature be merged to produce research-efficient solutions to these challenges? unlike the university of leeds, the university of the witwatersrand does not have the time or the personnel to schedule appraisal days during term time. while the university of the witwatersrand’s student support officer and staff from the centre for health sciences education (chse) co-ordinate the process, students and appraisers are responsible for arranging the initial appraisal and follow-up meetings. in 2011, the appraisal process began with a brief information session for the appraisers; approximately half of the 32 appraisers, all of whom participated in this process voluntarily, attended the information session, which was facilitated by dr l green-thompson, one of the staff members who originally initiated the appraisal, and the student support officer. as no follow-up appraisal was scheduled, students did not fill in an appraisal record form. instead, they were asked to complete a form before the appraisal as an aid to reflection on work-life balance, study habits, and career choice, which each appraiser then used to engage students in a 30-minute conversation. appraisers who believed that students required additional support referred them to the student support office. background. an appraisal model, a type of formal mentorship programme for a cohort of student doctors, is used at the university of leeds, uk. the university of the witwatersrand, johannesburg, south africa implemented an adapted version of the appraisal process that uses fewer resources. objective. to explore students’ experiences of the appraisal process in order to provide information to medical schools with limited resources, which seek to develop or refine their own mentorship processes. methods. a questionnaire containing likert-type scales and open-ended questions was distributed to students. students’ responses were analysed using descriptive statistics and content analysis. results. eighty-seven percent of the students had met with their appraiser once, and only 36% felt that they had built a rapport with their appraiser. students were more willing to discuss academic problems (87%) and less willing to discuss personal matters (51%) with their appraiser. conclusion. despite failing to build a rapport with their appraisers, students indicated that the chance to discuss academic and personal problems, and their appraisers’ advice on study and career matters, had been beneficial. to improve the rapport between students and appraisers a number of suggestions that require few or no additional resources are made. afr j health professions educ 2016;8(2):148-151. doi:10.7196/ajhpe.2016.v8i2.526 student feedback on an adapted appraisal model in resource-limited settings l arnold, ba, msc postgraduate centre, university of johannesburg, south africa corresponding author: l arnold (larnold@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 149 research the 17 appraisers who were university staff conducted appraisals in their offices, while the clinicians convened appraisals at teaching hospitals. the form students filled in before the appraisal had a space for completing details of a follow-up meeting; students could also contact their appraiser to suggest another meeting in 2011. while the appraisal at the university of leeds took place once each year for 2 years, it was envisaged that students at the university of the witwatersrand, especially those who were struggling with personal or academic problems, would visit their appraiser more often. if students had not met their appraiser by the end of the first quarter, an inquiry by the student support officer followed to ensure that students met with their appraiser at least once. methods data instrument the questionnaire contained open-ended questions and close-ended statements. the students responded to the statements using a 5-point likert-type scale, where options ranged from ‘strongly agree’ (1) to ‘strongly disagree’ (5). the statements were based on the questionnaire used by murdoch-eaton and levene,[13] but a few of these statements were adapted for the local context. for instance, statements referring to student-set goals were removed, as in the adapted appraisal follow-up meetings where these goals could be discussed were not prearranged. open-ended questions were added in consultation with chse staff, including prof. d manning and dr l green-thompson, who initiated the appraisal in 2008. these questions were added so that students could share their individual feedback on the appraisal process. ethics ethical approval for this study (ref. no. m111187) was obtained from the university of the witwatersrand’s human research ethics committee. data collection in 2012 the questionnaire was distributed to all former gemp1 students during a problem-based learning tutorial. students could then choose to complete the anonymous questionnaire and place it in a box outside their classrooms. this method of data collection was used so that students would not feel obligated to complete the questionnaire in the researcher’s presence. sample size of 296 former gemp1 students at the university of the witwatersrand, 93 (31%) completed the questionnaire. data analysis responses to the close-ended questions were typed into an excel spreadsheet before the percentages of students who strongly agreed and agreed with each statement were calculated. as very little research is available on the appraisal process, an inductive approach to thematic analysis, where the coding of data into themes and subthemes without reference to a prior coding framework, was used. the data were typed into excel verbatim. after examining the data, an initial list of codes that emerged from the data for each question was generated before related codes were arranged into organising themes and subthemes.[15] after a review of the themes and subthemes the researcher asked a colleague, prof. p mcinerney, who is well acquainted with the appraisal process, whether the themes and subthemes could be used to explain the raw data. the researcher then clarified the relationship between themes and subthemes through a ‘thematic network’.[15] after an examination of these thematic networks only the themes that were able to serve as an organising principle for a set of general ideas, without becoming repetitive or vague, were accepted.[15] once the essence of each theme was understood, a name that described the organising principle behind each theme was chosen. where the researcher had difficulty finalising the thematic networks or choosing an appropriate name for a theme, the advice of ms a magida, a researcher at the chse, was sought. results quantitative results ninety-three (31%) of the 239 students completed the questionnaire. the majority (81) of the students had met with their appraiser once, and the remaining 12 students had met with their appraiser two to four times. two of the 93 students did not complete the remaining questions and were removed from the dataset. the responses of the remaining 91 students for the six statements that were focused on the benefits of the appraisal process are shown in fig. 1. a high proportion of students agreed that they were comfortable expressing their opinions (92%) with their appraiser, or able to discuss academic matters (87%). slightly more than half of the students (51%) agreed that they could discuss personal matters with the appraiser. less than half of students agreed that they had built a rapport with their appraiser (36%), changed their attitude towards their study habits (49%), or changed their attitude towards their career (40%). the responses to the four statements on the administration of the appraisal process are shown in fig. 2. most of the students (81%) agreed that there was enough time for the appraisal discussion, and that the appraisal 92 87 51 36 49 40 100 90 80 0 70 60 50 40 30 20 10 st u d en ts ' r es p o n se s: 's tr o n g ly a g re e' a n d 'a g re e' , % i w as co m fo rta bl e t alk in g/ ex pr es sin g m y o pi ni on s i w as ab le to d isc us s m y ac ad em ic pr ob lem s a nd is su es i w as ab le to d isc us s pe rso na l m at te rs i fe el th at i d ev elo pe d a ra pp or t w ith m y a pp ra ise r ap pr ais er ’s c om m en ts ha ve ca us ed m e t o alt er m y a tti tu de s t ow ar ds m y s tu dy h ab its ap pr ais er ’s c om m en ts ha ve ca us ed m e t o alt er m y a tti tu de s t ow ar ds m y c ar ee r fig. 1. perceived benefits of participating in the appraisal process. 150 october 2016, vol. 8, no. 2 ajhpe research process had gone well (69%). fewer students (64%) agreed that they were well informed about the objectives of the appraisal and that the topics in the appraisal form were relevant. qualitative results answers to the open-ended questions were grouped into two themes: ‘benefits of taking part in this process’, and ‘the way forward for the appraisal process’ (tables 1 and 2). discussion only 36% of the students believed they had built a rapport with their appraiser. this lack of rapport could have stemmed from the fact that 87% of the students had met with their appraiser once, as evidenced by comments such as: ‘we only met once. there wasn’t much of a relationship.’ this lack of rapport also meant that students were less likely to change their attitudes towards their career or study habits after an appraisal, as shown by one student’s comment: ‘a stranger’s opinion of my marks makes no difference to my study ethic.’ however, one student commented that his/her study style was now focused less on his/her grades and more on understanding the work, and another wrote that he/ she had received ‘good advice from a more senior professional especially as i have no family members in the medical profession to discuss future opportunities with’. only 51% of students felt comfortable talking about personal problems with their appraiser. this means that an appraiser may not know when a student needs to be referred for counselling. although the following comment, ‘feeling uncomfortable to discuss personal matter [sic] with the appraiser but having realised the appraisers help that i might be in deep trouble, i went to see a psychologist and that helped me a lot,’ shows that an appraisal can help students realise that they need counselling. while students were reluctant to discuss personal matters with their appraisers, certain appraisers were commended for the ‘genuine’ concern that they had shown towards their students, and their ability to give students ‘a voice to express how i felt’. moreover, some students felt ‘reassured’ by the feeling that their appraiser was someone whom they could turn to if they experienced any problems in future. in light of previous findings that a shared curriculum helps to build rapport,[8] it is not surprising that students who were assigned to a former gemp1 student said that their appraiser understood their situation. as the appraisal was a reflective process, comments such as: ‘it keeps you in check knowing that someone is monitoring your progress,’ were unexpected. although students filled in their grades on the form before the appraisal, the appraiser had no access to their actual marks. a potential concern is that students could feel less receptive to discuss their problems with their appraiser if they mistakenly believe that they are being monitored. the value that students placed on the appraisal varied widely − while some suggested discontinuing or ‘scrapping’ the process altogether, others requested compulsory appraisal meetings scheduled in the timetable. some students resented being urged to attend the appraisal, and felt that they should decide if the appraisal would benefit them or that it was only necessary for struggling students, while others lamented that ‘i should have gone more frequently’. conclusions and recommendations although it was expected that students who struggled with academic or personal problems would meet with their appraisers more than once, 87% of students had only met their appraiser once. this created a situation where: (i) only 36% of students felt they had developed a rapport with their appraiser; and (ii) students were reluctant to discuss personal matters with their appraiser or take their appraiser’s advice. despite these negative findings, as with student doctors in other mentorship programmes, these students received advice on academic and personal problems.[6] a few students incorrectly assumed that the appraisers were there to monitor their progress. while these students felt more motivated by the thought of someone monitoring their progress, it can be argued that this table 1. benefits of taking part in the appraisal process theme category no benefits no relationship not needed unwilling to take advice academic study tips encouragement after poor marks an accountability partner career advice from someone in the profession personal my appraiser understood what i was going through he/she was genuinely concerned about me a voice to express how i felt a person i can approach in future table 2. the way forward for the appraisal process theme category way forward scrap it it should be voluntary compulsory process for some students should take more responsibility administrator should play a more central role 81 69 64 64 90 80 0 70 60 50 40 30 20 10 st u d en ts ' r es p o n se s: 's tr o n g ly a g re e' a n d 'a g re e' , % th er e w as su � cie nt ti m e f or th e ap pr ais al di sc us sio n th e a pp ra isa l p ro ce ss w en t w ell i w as w ell in fo rm ed ab ou t t he ob jec tiv es of th e a pp ra isa l th e t op ics in th e a pp ra isa l fo rm we re re lev an t fig. 2. feedback on the administration of the appraisal. october 2016, vol. 8, no. 2 ajhpe 151 research may impede them from developing a rapport with their appraiser. before future appraisals, faculty should stress the self-reflective nature of the appraisal so that students understand the appraiser’s role more clearly. students’ feedback on the form is completed before the appraisal and could be used to improve the form’s perceived relevance. while the university cannot allocate a significant amount of additional resources to select, or train and support faculty mentors, it is conceivable that the student support officer could be trained to manage this responsibility more effectively, or that their workload could be reduced during the appraisal period so that they are able to schedule meetings between appraisers and students. while accessing additional funds for a scheduled appraisal (e.g. as at the university of leeds) is unlikely, funds could be used to develop an online system that matches appraisers and students. if this system were designed to facilitate long-distance mentoring, the pool of appraisers could be expanded. these measures could help to strengthen the relationship between the appraiser and the student. limitations of the study and directions for future research this study was retrospective; only students who successfully completed the year at the end of 2011 received the questionnaire. if students had received the questionnaire in 2011, the views of students who would fail or drop out of the course would have been included. the viewpoints of the appraisers could also have added a different perspective to this study. acknowledgements. the author would like to thank prof. d manning and dr l green-thompson, who initiated the appraisal process and have continued to establish, maintain and refine the process to what it currently entails. i also wish to thank prof. p mcinerney and ms a magida for their assistance with the content analysis, and dr p lamberti for her editorial support. references 1. frei e, stamm m, buddeberg-fischer b. mentoring programmes for medical students. a review of the pubmed literature 2000 2008. bmc med educ 2010;10(32):1-14. doi:10.1186/1472-6920-10-32 2. mann mp. faculty mentors for medical students: a critical review. med teach 1992;14(4):311-319. doi:10.3109/01421599209018849 3. levison dj, darrow cn, klein cg, levison mh, mckee b. the seasons of a man’s life. new york: knopf, 1978. 4. kman ne, bernard aw, khandelwal s, nagel rw, martin dr. a tiered mentorship program improves number of students with an identified mentor. teach learn med 2013;25(4):319-325. doi:10.1080/10401334.2013.827976 5. dimitriadis k, von der borch p, störmann s, et al. characteristics of mentoring relationships formed by medical students and faculty. med educ online 2012;17(10):1-12. doi:10.3402/meo.v17i0.17242 6. murdoch-eaton dg, pell g, roberts t. changing approach to undergraduate studies documented during annual appraisal of medical students. med teach 2007;29(2-3):111-118. doi:10.1080/01421590601178006 7. ramanan ra, taylor wc, davis rb, phillips rs. mentoring matters. mentoring and career preparation in internal medicine residency training. j gen intern med 2006;21(4):340-345. doi:10.1111/j.1525-1497.2006.00346.x 8. mclean m. does the curriculum matter in peer mentoring? from mentee to mentor in problem‐based learning: a unique case study. mentoring tutoring: partnership learn 2004;12(2):173-186. doi:10.1080/1361126042000239929 9. seal k, mutha s. enhancing faculty mentoring of medical students. teach learn med 1996;8(3):174-178. doi:10.1080/10401339609539791 10. von der borch p, dimitriadis k, störmann s, et al. a novel large-scale mentoring program for medical students based on a quantitative and qualitative needs analysis. gms z med ausbild 2011;28(2):1-11. doi:10.3205/zma000738 11. störmann s, von der borch p, dimitriadis k. online matchmaking enables large-scale individual mentoring. med educ 2010;44(5):492-493. doi:10.1111/j.1365-2923.2010.03663.x 12. mbuagbaw l, thabane l. how to set up a long-distance mentoring program: a framework and case description of mentorship in hiv clinical trials. j multidiscip healthc 2013;6:17-23. doi:10.2147/jmdh.s397 13. murdoch-eaton dg, levene mi. formal appraisal of undergraduate medical students: is it worth the effort? med teach 2004;26(1):28-32. doi:10.1080/0142159032000150502 14. allen td, eby lt, lentz e. mentorship behaviours and mentorship quality associated with formal mentoring programs: closing the gap between research and practice. j appl psychol 2006;91(3):567-578. doi:10.1037/0021-9010.91.3.567 15. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. doi:10.1191/ 1478088706qp063oa dx.doi.org/10.1186/1472-6920-10-32 http://dx.doi.org/10.3109/01421599209018849 http://dx.doi.org/10.1080/10401334.2013.827976 http://dx.doi.org/10.3402/meo.v17i0.17242 http://dx.doi.org/10.1080/01421590601178006 http://dx.doi.org/10.1111/j.1525-1497.2006.00346.x dx.doi.org/10.1080/1361126042000239929 http://dx.doi.org/10.1080/10401339609539791 http://dx.doi.org/10.3205/zma000738 http://dx.doi.org/10.1111/j.1365-2923.2010.03663.x http://dx.doi.org/10.2147/jmdh.s397 http://dx.doi.org/10.1080/0142159032000150502 http://dx.doi.org/10.1037/0021-9010.91.3.567 http://dx.doi.org/10.1191/­1478088706qp063oa http://dx.doi.org/10.1191/­1478088706qp063oa research october 2014, vol. 6, no. 2, suppl 1 ajhpe 185 a variety of educational objectives have been postulated to be possible using a problem-based learning (pbl) approach. these include: (i) the structuring of knowledge to facilitate use in clinical contexts; (ii) the development of an effective clinical reasoning process; (iii) the development of selfdirected learning skills; and (iv) the increased motivation for learning’.[1,2] additional benefits of the pbl approach have been reported. these include improvement in problem-solving abilities, effective literature sourcing, increased ability to work in teams, as well as gaining the knowledge skills and expertise needed for clinical practice. [3,4] since 2006 it has been a legal requirement of the health professions council of south africa for new graduates to complete a year of community-based practice before registration as a professional physiotherapist. many of the settings where the community service is completed are lower socioeconomic rural areas with little or no professional guidance or supervision. the development of aforementioned skills through a specific didactic approach could be very useful for new graduates. the decision to introduce a pbl approach into the curriculum was not taken lightly because of the number of conflicting reports relating to pbl.[5-7] the major debate in the literature is that there is little conclusive evidence that pbl makes a measureable change in any of the aforementioned reported outcomes. a lack of any major effect size has been shown.[7] owing to the debate in the literature, a number of sessions examining the potential of introducing such a didactic approach were held with various experts in tertiary education and particularly in medical education. it was decided to introduce a hybrid problem-based module[1,8] during the third year of the 4-year physiotherapy training programme at stellenbosch university (su). this approach gave the benefit of using traditional pedagogies in the early years of training and then introducing a new method in the third year; therefore a hybrid model was used. a hybrid programme may provide a more structured learning environment and may be more appropriate for students.[8,9] in our case the third year of training is the one in which extensive exposure to the clinical platform is introduced. we decided to implement the module as the students were entering their clinical years. owing to the controversy surrounding the benefit of pbl, we wanted to compare the perceptions of students and staff of the effect of this didactic method on the specific outcomes for the module. context implementation generic outcomes for all cases (table 1) were established for the module; however, each case had specific outcomes that were aligned with some or all of the generic outcomes. these generic outcomes were aligned with the critical cross-field outcomes as required by the south african qualifications authority (saqa).[10] faculty members were divided into task teams and the case scenarios were designed. the cases were based on most prevalent conditions treated by undergraduate physiotherapy students in clinical settings.[11] the database used was developed by the department and recorded the pathologies seen by students during the 5 years prior to the implementation of the revised curriculum. the complexity of the cases was established and the cases were presented in order of increasing difficulty throughout the year. these cases were then organised into theoretical blocks, namely preclinical, basic, and intermediate. the students were exposed to the most basic and general cases before entering the clinical platform and then rotated in and out of a theory rotation and a clinical rotation for the remainder of the academic year. the multidisciplinary nature of management of patients with complex disease profiles and/or complex social circumstances was part of the focus of the cases. background. this paper presents the findings of a study completed to establish the differences between the lecturers’ and students’ perceptions of a hybrid problem-based learning (pbl) approach in successfully completing a pbl module in the third year of physiotherapy training at stellenbosch university. objectives. to assess the perception of the achievement of the pbl benefits, the module outcomes, the barriers to learning and positive aspects of the module. methods. a theory-based evaluation approach using both qualitative and quantitative methods was used. all students and lecturers involved with the new module were invited to participate in the study. the participants consisted of 37 students and 11 lecturers. the data were collected using questionnaires and focus group discussions for both groups. the different components of the theory (pbl methods) were used as the guiding themes for the analysis of the qualitative data. the quantitative (ordinal) data are presented using descriptive statistics. results. the results indicated that the module was enjoyed by both groups. the achievement of the generic outcomes for the module produced mixed results. areas of agreement and areas of differences in perceptions relating to the achievement of the expected pbl benefits are discussed. conclusion. pbl as a new methodology presents challenges for both groups; however, many of the benefits of pbl, in particular self-directed learning, were achieved. some areas of shortfall are discussed. ajhpe 2014;6(2 suppl 1):185-191. doi:10.7196/ajhpe.529 does a problem-based learning approach benefit students as they enter their clinical training years? lecturers’ and students’ perceptions s b statham, msc (physio); g inglis-jassiem, msc (physio); s d hanekom, phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: s b statham (sbs@sun.ac.za) research 186 october 2014, vol. 6, no. 2, suppl 1 ajhpe format of presentation each case was presented, discussed and completed in 3 days. the first session was an introduction to the case and the seven-step process for learning was used.[12] the second session on the second day was a practical session for all the practical skills needed for the treatment and/or management of the case. no new skills were taught in these sessions. students were required to adapt skills (when necessary) already acquired during the physiotherapy science module in the second year of study. during the final session on the third day, students presented the information which they had sourced to solve the clinical case and discuss the proposed management of the case.[13] monitoring this was organised by the module co-ordinator. the monitoring of the implementation process was done through regular focus groups with the students conducted by two of the researchers. additional feedback could be given via an anonymous suggestion box, individual student appointments and through formal feedback systems. meetings for the lecturers to discuss any problems that arose and plan the changes required were held on a regular basis, and any further training, e.g. group dynamics, was provided. assessment assessment of the students in this module was done through web-based multiple-choice tests after each theory block (four blocks) and a case-based integrated essay type exam which was conducted twice a year. the practical components of the module were assessed through directly observed practical skills tests (dops) which were performed on patients during clinical rotations.[14] methodology a theory-driven evaluation approach was used to provide a framework for the research of the study. [1,6,13,15-17] the theory used in this study included the basic components of a pbl approach: • if the students (small groups) are given appropriate (clear and easy to understand) cases (problems) to analyse and develop outcomes for, then the students (small groups) will work out a plan of action to solve the problem. • if the students work out the action plan, then they will learn where to find the resources to answer the problem. • if the students find the resources and necessary information, then they will be able to solve the problem. • if the students have solved the problem (using the resources), then they will learn the content (knowledge, critical reasoning and practical skills) of the cases and then they will be able to achieve the outcomes for the applied physiotherapy iii module. a concurrent mixed-methods approach included student questionnaires, lecturer questionnaires, student focus-group interviews, and lecturer focus-group interviews. the questionnaires yielded both quantitative and qualitative data. sampling purposive sampling was used and all students (n=39) and lecturers (n=11) participating in the new module were invited to participate in the study. from a class of 39 a total of 37 students took part in the study. data collection and procedure the formulation of the questions was based on the theory (provided above), thus giving guiding themes. this applied to the design of the questionnaires and the focus-group questions for both groups. the questionnaires were also reviewed by an external consultant, who has published widely in the field of pbl.[18,19] all changes and suggestions were included in the final questionnaires which used a five-point likert scale. the questionnaires were sent to a translator and were back-translated to ensure accuracy. all the data were collected post implementation of the module and before the final exams. ethical approval was obtained from su human research ethics committee (n08/10/301). all participants were voluntary and written informed consent was obtained from all participants before data collection. all transcripts were de-identified, thereby maintaining the anonymity of the participants, and numerical ciphers were used for all transcripts. the qualitative data generated by the focus groups were recorded using a digital voice recorder and were downloaded and saved on compact discs (cds) after the interviews. data management and analysis the quantitative data from the questionnaires were entered on an excel spreadsheet and statistical analysis was done using statistica 12. mann-whitney test for non-parametric data, χ2 test and frequency tables were calculated. this was done to establish if there was agreement between lecturers and students regarding the different aspects of the pbl methods of the module. table 1. generic outcomes for the applied physiotherapy module 1. to integrate the theoretical concepts and principles of the biomedical sciences (pharmacology, pathology), social sciences (psychology, sociology) within the concept of physiotherapy practice (client management) 2. have a sound knowledge of the medical and surgical management of the client, as well as disease processes applicable to physiotherapy intervention 3. understand the role of the other team members in the total management of the patient 4. have a basic knowledge of diagnostic tests (cxr, mri, blood gases) and understand their impact on patient management 5. execute the necessary evaluation techniques skillfully, with the necessary adaptations on a model 6. interpret the findings of an evaluation, formulate a physiotherapeutic diagnosis/hypothesis and prioritise problems 7. motivate the choice of selected physiotherapeutic interventions and/or the different approaches that can be followed in the management of patients 8. execute the selected physiotherapeutic interventions skillfully, with the necessary adaptations on a model 9. set specific, measureable, realistic aims that are attached to a time scale 10. source and analyse literature cxr = chest x-ray; mri = magnetic resonance imaging. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 187 the qualitative data were transcribed from the tapes by an independent transcriber, and thereafter analysed by an independent and experienced research assistant using content analysis.[20] this process included: familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising data; interpretation of data; and checking. the researchers checked the coding and themes to aid trustworthiness. both the questionnaires and the focus-group questions were designed by a researcher who was not involved in the module. the other researchers reviewed the questions to ensure that nothing had been excluded. data were collected by the independent researcher. results from a class of 39 a total of 37 students took part in the study. all 11 lecturers involved in the module took part in the study. the following results are presented detailing the perceptions of both the students and the lecturers on the achievement of the generic outcomes, the perceived positive aspects of the module and the barriers to learning. the results will be presented in the following order: quantitative results, qualitative responses by students and lecturers regarding the implementation of the pbl module, and finally the suggestions by both groups. quantitative results table 2 presents a summary of the results to the questionnaires. the agreement between the two groups was measured using the mann-whitney test for non-parametric data. as can be seen from the table there were a number differences between the students and the lectures. a p-value <0.05 indicates the two groups responded differently, and therefore no agreement between the groups was attained. the groups were in agreement most of the time so it appears that the module was successful as a whole. the differences between the groups will be dealt with in the discussion relating to each component of the pbl methods. tables 2 and 3 show there was agreement between the groups; however, this agreement was being unsure if the outcomes 9 (set specific measureable aims) and outcome 10 (source and analyse the literature) were achieved (table 3). table 2. mann-whitney test results: staff and student perceptions of the implementation of the module mann-whitney u-test (with continuity correction) by variable position responses p-value 2*1 sided exact p valid n lecturer valid n student cases easy to analyse 0.432 0.498 11 37 cases became more difficult 0.011† 0.016† 10 37 resource lists were useful 0.017† 0.024† 11 37 students could find more resources 0.225 0.319 11 37 facilitation helped with problem analysis 0.040† 0.082 11 37 facilitation helped with planning 0.490 0.513 11 37 facilitation students understood the cases 0.831 0.847 11 37 group work became easier 0.265 0.344 11 37 roles in the group ensure effective functioning 0.021† 0.038† 11 37 self-directed learning 0.455 0.513 11 37 knowledge was acquired 0.632 0.663 11 37 skills workshops enough time 0.717 0.749 10 37 skills workshops feedback given 0.411 0.465 10 37 skills workshops appropriate for cases 0.220 0.286 10 37 skills workshops helped in clinical 0.004† 0.006† 9 37 assessment aligned with cases 0.008† 0.012† 11 36 assessment aligned with practical skills 0.340 0.404 10 37 outcome 1 0.121 0.214 11 37 outcome 2 0.072 0.150 11 37 outcome 3 0.013† 0.031† 11 37 outcome 4 0.210 0.296 11 37 outcome 5 0.005† 0.011† 11 37 outcome 6 0.037† 0.049† 11 37 outcome 7 0.083 0.136 11 37 outcome 8 0.090 0.164 11 37 outcome 9 0.989 0.981 11 37 outcome 10 0.146 0.180 11 37 †marked tests are significant at p<0.05000. research 188 october 2014, vol. 6, no. 2, suppl 1 ajhpe the large number of neutral responses in these cases indicate that a large percentage of the cohort did not feel that the particular outcome had been reached, and both groups agreed on this. qualitative results table 4 presents the responses from both groups on the facilitators/benefits of the module, with the most comments first to enable recognising the most important facilitators/benefits as experienced by the two groups. table 5 presents the responses from both groups on the barriers to learning, with the most comments first to enable recognising the most important barriers to learning as experienced by the two groups. table 6 summarises the most important suggestions from the two groups. the similarities between the groups are notable and help with planning the improvements to the module. combined results the use of cases in the design of the cases both groups were positive about the cases being easy to analyse and focused; this is important as this is the basis of the pbl approach and a necessary step in the ability of the students to master this module. however, in the suggestions for improvement both groups suggested some revision of the cases. the students felt the complexity of the cases did not increase over the year (p=0.015). lecturers were more positive about the increasing difficulty of the case studies than the students were. lecturers used the pathology and clinical reasoning as guides to making the cases more difficult; this form of scaffolding should help the students. accessing resources the groups agreed on the ability of the students to find new resources. strategies to improve the students’ abilities to search for information included workshops with the librarians on searching techniques, providing the students with resource lists. however, they did not agree on finding the resource lists helpful (p=0.02). the lecturers were more positive about the lists than the students were. this is possibly due to table 3. frequency tables for outcomes 9 and 10 category all groups n=48 count (%) outcome 9 strongly disagree 1 (2.08) disagree 6 (12.50) neutral 20 (41.67) agree 19 (39.58) strongly agree 2 (4.17) outcome 10 disagree 3 (6.25) neutral 18 (37.50) agree 21 (43.75) strongly agree 6 (12.50) table 4. the main categories of the students’ and lecturers’ responses regarding the facilitators/benefits of the module students, n=37 responses, n comments improved clinical reasoning 17 ‘learnt how to do clinical reasoning and how to defend my answers in a group’. (sq1) translated ‘i really did learn to reason clinically better as well as became more independent in my own learning process and gaining of knowledge.’ (sq33) ‘much more practical and could apply it directly on my clincal blocks.’ (sq36) translated group work (positive) 13 ‘group work. it was nice to work with fellow physio students and to tackle & solve a problem.' (sq3) translated ‘the groupwork was fun! & i like the fact that we had such a broad spectrum of information to collect even if it was not necessarily important for the tests.' (sq12) translated ‘watched how other people noticed certain things & reasoned. learnt from others.’ (sq14) translated information gathering and organisation of information 9 ‘you were in charge of your own learning so that the onus was on you to gather all that you thought you required and from that establish your goals.’ (sq 35) ‘it taught us how to look for information on conditions & physio approach.’ (sq 5) personal growth 6 ‘personal growth especially the small classes and individual attention.' (sq2) translated ‘i was never bored.’ (sq10) translated ‘that i can look back now and say it was worthwhile and that i feel beter prepared for next year.' (sq13) translated ‘our class was very supportive and we worked together.' (sq7) translated real life issues 4 ‘it taught me to handle the situation realistically as if it was really happening. and learn realistically.' (sq24) translated ‘get a chance to apply your knowledge on cases that are relevant to everyday life.' (sq15) translated lecturers, n=11 increase students’ responsibility 10 ‘… that the students learn to take responsibility for their own learning.’ (lq9) ‘some students were able to identify their weaknesses and were able to find help within their groups.’ (lq10) ‘self-directed learning.’ (lq6) ‘increased participation of students.’ (lq8) changing critical thinking skills 2 ‘students have developed critical reasoning skills a lot quicker.’ (lq1) improvement in students’ confidence and attitude 2 ‘self-confidence of students.’ (lq6) ‘the students’ growth in dealing and adapting to the process.’ (lq5) sq = student questionnaire; lq = lecturer questionnaire. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 189 the fact that the resource lists were short, so as to guide the students but ensure that they still needed to find resources themselves. outcome 10 (ability to source and analyse literature) indicated the groups felt neutral about achieving this outcome. when combining the data, one could interpret this as the literature analysis being a skill that students find difficult to master. table 5. the main categories of students’ and lecturers’ responses to the barriers to learning in the module students, n=37 responses, n comments test and related matters 27 ‘clinical reasoning is tested in webct, but we never get a chance to demonstrate it even up to to-day. and today there was too little time to reason fully and show it.' (sq2) translated ‘it is another way of evaluating and one we have got... had to get used to.’ (sq19) translated ‘the shift from testing theoretical knowledge to testing clinical reasoning.’ (sq4) translated new methods of learning 12 ‘way of learning has to be adapted (difficult after 13 years to change your methods of studying.' (sq1) translated ‘study methods: i did not know how to study for the tests even up until now.’ (sq26) translated ‘changing studying methods to understanding rather than parrot fashion learning.’ (sq33) group work (negative) 11 ‘all members of the group according to me did not always deliver sufficient information/research and this really frustrated me a lot because i always want to be as comprehensive as it is possible to be.' (sq1) translated ‘groupwork is a problem if you like completeness, and then you get info from someone who gives very little and does not go to trouble. then i do it again later.’ (sq29) translated ‘group work trusting each member to get the relevant information.’ (sq33) quality assurance 10 ‘the fact that everyone has different information (different groups).' (sq20) translated ‘no quality assurance of the work that i learn.’ (sq24) translated ‘quality of work between groups.’ (sq32) translated facilitators and the process 7 ‘different facilitators told different groups to focus on different aspects.’ (sq9) ‘lecturers per group differed during the beginning and feedback, so you get different outcomes and ideas for each that eventually oppose each other.’ (sq2) translated practice session 6 ‘the practice sessions often focused too much on work covered in physio ii and not on specific tests and rx methods that were new in physio iii.’ (sq 5) ‘didn’t practise new techniques for long enough and spent too much time on old.’ (sq9) lecturers, n=11 lack of critical analysis 3 ‘unable to extract “relevant” to the cases info.’ (lq1) ‘students did not critically evaluate the literature and did not know the topic they presented to the group – just read.’ (lq3) web ct tests 3 ‘the unknown process, e.g. webct test (in the beginning).’ (lq8) ‘webct test ++ unclear? – suitability/appropriateness of our questions.’ (lq1) ‘webct – our setting of the questions improved during the year and the students became more familiar with the webct tests and that also reflected in their marks. although i felt that the preparation for the tests was left quite late; we could have circumvented some of the problems if we had done that. i think a lot of the students did not change their study methods although they were encouraged to do so. in terms of the integration of higher thinking the students were not doing that very well. i think that influenced how they performed and how they understood and answered the questions.’ (lfg 2) attitudes to learning 3 ‘students not taking responsibility for own learning.’ (lq2) ‘students did not attend all the sessions.’ (lq3) ‘students attitudes originally – very negative!!’ (lq1) ‘i had a practice session with them, before the time. i made special notes with different colours, etc. to motivate them to prepare and i explained what they should prepare and where to get the information. they arrived unprepared, not in the correct clothing for practising. they were also not motivated. the demands on the lecturer are increasing more and more and they are not co-operating.’ (lfg 3) translated group process 3 ‘some students worked so much harder than others – seemed that the hard workers always did the "difficult" or most important parts of the cases.’ (lq 3) ‘expectations of what each member’s role was in the group.’ (lq9) ‘in the cases that i was involved in, yes, i do think they reached their outcomes. there was one specific case when due to ineffective time management at the feedback session they did not discuss this one important thing, a lot of time was spent on other things but not this one so what we did was they came back half an hour early the next day to give feedback about this thing – we did it then.’ (lfg l2) literature source information 3 ‘skills to literature sourcing.’ (lq 7) ‘info that they brought back to the table wasn’t accurate but the lecturers don’t have time to check the notes.’ (lq 11) sq = student questionnaire; lq = lecturer questionnaire; lfg = lecturer focus group. research 190 october 2014, vol. 6, no. 2, suppl 1 ajhpe pbl facilitation the two groups agreed that the facilitation of the cases provided help with problem analysis, planning on the outcomes for the case and that the students understood each case at the end of the final feedback session. the lecturers found the facilitation process a challenge as it required a very different approach to the traditional teaching model. a number of workshops were held regarding the best way forward, and as can be seen from the results both groups were in agreement. group work the group work became easier through the year although the two groups did not agree that the roles helped with the effective group functioning (p=0.03). to help the development of effective groups the 7-jump process was used. the students were more positive in their answers to the group roles than the lecturers were. module outcomes as seen in table 2 the two groups’ responses were in agreement on seven of the ten outcomes. the responses showing agreement between the groups are divided into two groups: firstly, the agreement on achieving the outcomes; and secondly, agreement on being unsure if the outcomes had been achieved. for outcomes 1 (theoretical concepts), 2 (knowledge of medical and surgical management), 4 (knowledge of diagnostic tests), 7 (motivate for choice of physiotherapeutic interventions) and 8 (execute physiotherapeutic interventions), the results showed agreement between both groups, and they were positive about the achievement of the outcomes. for outcomes 9 (setting aims) and 10 (sourcing and analysing literature) both groups responded similarly, indicating that they were unsure if these outcomes were achieved. the responses that differed included outcomes 3, 5 and 6. for outcome 3 (understanding other team members’ roles) (p=0.03) students were more positive about achieving this outcome. for outcome 5 (executing evaluation techniques) (p=0.01) the students were positive about reaching this outcome, while lecturers were neutral about it. outcome 6 (interpreting findings to formulate a hypothesis for patient management) (p=0.04) indicated a significant difference between the two groups; again the students felt more positive than the lecturers did about the achievement of the outcome. in each case the students were more positive about the achievement of the outcome than the lecturers were. both execution of evaluation techniques and interpretation of findings require higher-order cognitive processes[21] and therefore a lot of practice; it is likely that the students will fully master these skills with further practice in their final year of training. the mixed response to the achievement of the outcomes gave valuable information that will be needed when the case design is adapted; it highlights the areas that need to be enhanced further. the lecturers tend to be more cautious because of their experience and responsibility to deliver competent physiotherapy graduates. practical skills sessions including a pbl approach in practical skills development is not commonly used, but because a hybrid model was used the basic knowledge and skills had been taught earlier in the course and the practical skills sessions could build on the students’ previous knowledge. both groups agreed that there was enough time allocated to learning the new skills, that feedback was provided to the students regarding their skills, and that the new skills were appropriate for the cases; however, they did not agree on whether the skills helped on the clinical platform (p=0.006); the students were positive about the skills helping them clinically and the lecturers were more negative about this achievement. the value of the skills sessions can also be seen in the achievement of outcomes 7 and 8 as these both worked specifically with physiotherapeutic modalities. barriers and facilitators facilitators. the students perceived the main benefits to be improved clinical reasoning, group work, information gathering and organisation, and personal growth. this links with the expectations of pbl. the lecturers perceived the main benefit to be an increase in students taking responsibility. this is the most common benefit voiced in the literature. both groups’ perceptions of the benefits are aligned with the expectations from the literature.[1-4] barriers. the most important feedback regarding adapting to the new learning method related to the perceptions of barriers. the students’ main barriers to learning in this module were tests, new ways of learning, group work, quality assurance and the case lecturers. numerous stressors or barriers to learning have been documented in the literature.[22-23] discussion students and staff differed in their perceptions of whether outcomes were reached. the mixed response to the achievement of the outcomes gave valuable information needed when adapting the case design as to the areas that need to be enhanced further. the responsibility of the lecturers to deliver competent professionals can be seen by their more cautious responses. the more cautious evaluation of the success of the new pedagogy has been reported.[22,24]it was surprising that both groups perceived that the module ensured that they had reached the more content-related outcomes, while uncertainty was expressed whether the more generic outcomes like literature sourcing were attained. the qualitative data presented a different picture. the students perceived the main benefits of the pbl module to be improved clinical reasoning, group work, information gathering, organisation and personal growth. the lecturers perceived the main benefit of the module to be an increase in students taking responsibility for self-directed learning. both groups’ perceptions of the benefits are aligned with the expectations from the literature.[1-4] the practical skills sessions were a very important part of the introduction of this module. including a pbl approach in practical skills development has not previously been reported. students and staff perceptions regarding the value of the skills on the clinical platform were different. the majority of students perceived that the skills sessions were beneficial to their clinical practice, while the minority of staff perceived the table 6. similarities between the students' and lecturers' suggestions students’ categories lecturers’ categories webct test revision (n=13) increased resources (n=8), lecturers’ support revision of cases (n=10) facilitation process (n=3) facilitation (n=10) revision of cases (n=3) practical sessions (n=8) changes in webct test (n=2) quality assurance (n=5) research october 2014, vol. 6, no. 2, suppl 1 ajhpe 191 skills sessions as clinically beneficial. it is possible that the staff perceptions were based on anecdotal negative feedback regarding student performance from clinicians. the clinical supervision of the third year cohort is done by ad hoc appointed clinical educators. staff therefore did not have firsthand experience of third-year students’ ability on the clinical platform. the most important feedback regarding adapting to the new learning method related to the perceptions of barriers. the students’ main barriers to learning in this module were tests, new ways of learning, group work, quality assurance and the case lecturers. these stressors are confirmed in literature.[22-23] this was a surprising finding as the didactic methodology was only utilised in the third-year of study and students had the benefit of lecture-based teaching methods in the first two foundational years. these stressors could thus be aligned with the implementation of the new pedagogy rather than the implementation of a specific pedagogy – in this case pbl. the experience of the students was not dissimilar to that of students in other countries when exposed to a new approach. however, these studies do not include practical skills and usually only the students’ perceptions are investigated. there was a wide range of student experiences, again reflecting the diversity of students who have very different approaches and learning styles. this has been reported in other studies.[5,13,22,24] however, the perceptions of lecturers are not well reported and add valuable insights.[25] we acknowledge a number of limitations to the methodology used which could influence the interpretation of results. we only reported on one cohort of students and staff and only after the first year of implementation. the inherent difficulty in implementing practice change has been widely reported. much of these uncertainties observed in student and staff perceptions could be related to practice change. data from this cohort of staff and students will be compared to later years to ensure a more comprehensive view of perceptions of the potential benefit of a hybrid pbl module. however, the data presented in this paper could be informative for programme designers who are thinking of implementing a hybrid pbl module. we acknowledge that the data provide a subjective view of students and staff perceptions of the effect of a hybrid pbl module. objective data are needed to measure the effectiveness of this module. conclusion lecturers and students enjoyed the hybrid pbl module and found the experience beneficial. both groups agreed that the content-related outcomes for the module were reached. students perceived the main benefits of the pbl module to be improved clinical reasoning, group work, information gathering, organisation and personal growth. the lecturers perceived the main benefit of the module to be an increase in students taking responsibility for their own self-directed learning. the value of the skills sessions on clinical performance needs further investigation. programme designers can use the hybrid pbl methods later in an academic programme requiring skills development, thereby using both new and traditional methods of teaching and learning. funding. this project received finlo funding from the centre for teaching and learning at stellenbosch university. author contributions. all authors contributed to the conception, design, analysis or interpretation of data. ss drafted the manuscript. all authors provided critical revision and approval of the manuscript version to be published. references 1. barrows hs. a taxonomy of problem‐based learning methods. med educ 1986;20(6):481-486. 2. norman g. problem‐solving skills, solving problems and problem‐based learning. med educ 1988;22(4):279-286. 3. morris j. how strong is the case for the adoption of problem-based learning in physiotherapy education in the united kingdom? med teach 2003;25(1):24-31. 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[http://dx.doi.org/10.1080/01421590802139732] 10 may 2015, vol. 7, no. 1 ajhpe research background the word ‘professions’, derived from the latin professio, refers to a public declaration of a belief, a faith or an opinion and implies that members of professions will act in certain ways and strictly adhere to a well-defined code of conduct.[1] professionalism is an important aspect of any high-level occupation; for medical doctors it is an important component of their contract with society.[2] there must be a clear definition of professionalism set out in a code of conduct and accepted by society, members of faculty of medical schools and their students. it should lend itself to change, as professionalism is dynamic, evolves and is multidimensional.[3] it is important to ensure that medical graduates know their code of conduct and understand what is implied by ‘professionalism’ in a work-related context. this is especially important in south africa (sa)’s rainbow nation’, where a number of threats, including restructuring of the healthcare system, fiscal constraints and conflicts of interest, may erode medical professionalism. the physician’s charter for the new millennium[4] is a representation of global opinion on the principles and commitments that pertain to medical professionalism. desirable professional attributes for medical staff include being a reflective practitioner, responding to social needs, evincing core humanistic values, being accountable, and committing to scholarship and excellence.[5-7] from an identified and agreed-on definition of ‘professionalism’, clear outcomes can be developed and its components become evident through corresponding behaviour. strong support exists for professionalism to be considered as an explicit learning outcome, a skill set or a competency.[8-11] the school of medicine, university of pretoria (up), sa, has employed a number of strategies to promote professionalism, i.e. a university of pretoria pledge for medical students has been developed and since 1996 it has been customary for final-year medical students to make their pledge at a special ceremony. it is similar to the declaration of geneva (2006) but, in addition, students pledge to remain competent practitioners through lifelong learning.[12] furthermore, in the course of restructuring the undergraduate medical curriculum at up (from 1997 onwards), a number of ‘golden threads’ were included in the curriculum, building progressively on what had been learnt in previous years.[13] these golden threads embody important non-physical, humanitarian knowledge, attitudes and professional skills that medical students should have at the end of their 6-year course. several of these threads – in particular those related to interpersonal skills, professional attitudes, teamwork and ethics – contributed to the development of what came to be called ‘soft skills’.[14,15] the soft skills project explored and described undergraduate medical students’ experiences of and viewpoints on soft skills and soft-skills development as part of their professional socialisation as doctors during the 6-year medical education programme.[14,15] students appeared to be more aware of their development of these soft skills within the new problem-orientated up medical curriculum than students in the traditional curriculum.[14,15] the concept of a local charter for professionalism developed in the course of formal and informal feedback during 2006 2007 from lecturers and medical students. it was clear that all professional standards needed to be defined more clearly within the medical curriculum. for example, background. components of professionalism in undergraduate medical studies at the university of pretoria (up) were previously defined as nine ‘golden threads’. although specific outcomes were formulated for the threads, the need for more explicit professional standards became increasingly evident. the restructuring of the health system in south africa contributed to the need for more explicit standards. the charter for medical professionalism was developed during 2006 2008 as a reference document within the local context to serve as a standard for professionalism in the medical curriculum. another aim was to guide academics in medical studies to act as good role models of professional behaviour. objective. to document the development of the charter for medical professionalism and to evaluate lecturer and student perceptions on the formulation of the charter to make appropriate changes and increase acceptance. methods. the project took the form of action research, and a working group comprising academics from up’s faculty of health sciences developed the charter from relevant source documents, employing thematic and content analysis and recursive abstraction. an online survey was conducted to assess lecturer and student acceptance of the charter. results. the outcomes-based approach was perceived as acceptable and appears to broaden the scope of assessment of professionalism. conclusion. inclusion of outcomes proposed by other work groups relating to research, practice management, teaching, mentoring and leadership roles of the medical doctor may be considered in future. afr j health professions educ 2015;7(1):10-15. doi:10.7196/ajhpe.223 developing an outcomes-based charter to direct teaching and assessment of medical professionalism r delport,1 msc, med, phd; c krüger,2 mb bch, mmed (psych), md, fcpsych (sa); m van rooyen,3 mb chb, mmed (fammed); g pickworth,4 dphil (psych) 1 skills laboratory, faculty of health sciences, university of pretoria, south africa 2 department of psychiatry, school of medicine, faculty of health sciences, university of pretoria, south africa 3 department of family medicine, school of medicine, faculty of health sciences, university of pretoria, south africa 4 department for education innovation, university of pretoria, south africa corresponding author: r delport (rhena.delport@up.ac.za) may 2015, vol. 7, no. 1 ajhpe 11 research from their assessment of medical students’ assignments on professionalism over 5 years of study, du preez et al.[13] concluded that such professional standards could be formulated in a charter that stated the principles and commitments relevant to up and to which all medical professionals should aspire. appropriate assessment of students’ professionalism, defined by the outcomes in the charter, would be of vital importance, as assessment reportedly drives learning.[16] assessment strategies purportedly not only raise awareness among students and faculty members of the core values of professionalism, but also demonstrate the importance of the development of these attributes to the institution.[5,6,17] therefore, continuous and diagnostic assessment would aid the early detection of unprofessional conduct and lead to timely remediation. from a previous survey it became evident that the charter should have a distinct local character, as the physician’s charter was not perceived as totally acceptable within the sa context by 76% of fifth-year medical students at up.[11] a subsequent cohort of fifth-year students was required to define professionalism, and described features of professionalism that could possibly be assessed.[18] a qualitative design was employed in this second study to explore students’ perceptions. attributes used to describe professionalism were grouped under four main domains: attitude and personal conduct; teamwork; patient care; and professional competence. although similarities with the physician’s charter were observed, most students expressed the opinion that the humanistic attributes of professional behaviour, such as empathy, good interpersonal relationships, integrity, respect, maturity and teamwork, were not obviously represented in the physician’s charter. van rooyen and treadwell[18] concluded that a locally acceptable charter should be developed for the school of medicine, up. it was envisaged that the charter should reflect the essence of the existing golden threads, the guidelines set by the health professions council of south africa (hpcsa) for professional conduct (hpcsa professional guidelines)[19] and up’s pledge for medical students. although other bodies were also in the process of defining outcomes for professionalism, e.g. the association of american medical colleges,[20] uk general medical council (gmc),[21] scottish deans medical curriculum group,[22] and royal college of physicians and surgeons of canada,[23] not all publications resulting from these international projects were consulted for the formulation of the charter within the up context. to summarise, the development of the up charter for medical professionalism was deemed necessary, as a need existed to explicitly define locally relevant standards of professionalism. defining specific outcomes and assessment criteria relating to medical professionalism would lend consistency to the teaching and assessment of professionalism throughout the medical curriculum and aid in the early detection and remediation of unprofessional conduct. furthermore, professional development of medical staff would result from their being informed about what was expected of a medical professionalism role model. methods the development of the charter was conducted as an action research project. qualitative data were generated from the sources listed below, using thematic and content analysis and recursive abstraction. a representative working group was comprised from the school of medicine, up, and included a health sciences education advisor, family physician-lecturer, department of psychiatry lecturer, and the procedural skills unit head. the project was conducted from november 2006 to november 2008. the sources used for the development of the charter were: • the university of pretoria pledge for medical students • the golden threads outcomes[13] • the hpcsa professional guidelines[19] • medical professionalism in the new millennium: a physician’s charter (participants in the medical professionalism project 2002)[4] • good medical practice, gmc.[21] all lecturers from the school of medicine were invited via corporate email to participate in the study. a survey was conducted to source anonymous feedback on the charter with the use of an online survey tool, survey monkey (http://www.surveymonkey.com). following incorporation of comments from lecturers, students were invited to participate anonymously in the survey via a pop-up message and link on the university’s learning management system. respondents had to select one of the following options: agree/reject/reword for the competencies, values and attributes within the domains of professionalism, and for the descriptors of how the competencies may become evident. consensus was reached within the working group on whether the student comments were too poorly worded for consideration or inappropriate and which changes should be made to the charter. the revised charter was then presented to lecturers at undergraduate teaching committee meetings, strategic meetings of the school of medicine, and induction programmes for newly appointed lecturers. no further proposals were made on invitation to improve the charter, suggesting general acceptance by faculty. ethical approval for the study ‘teaching/learning, assessment and monitoring of medical students’ professional conduct based on a charter for professionalism’ was granted by the ethics committee of the faculty of health sciences (no. 63/2007). consent was implied by anonymous participation. results complete responses were received from 52 lecturers in the school of medicine, 6 of whom were full professors, 9 associate professors, 20 senior lecturers, and 17 lecturers. the student response rate was 15.3%, after exclusion of incomprehensible, incomplete or obviously ridiculous responses. the number of respondents per year group 1 6 were 83, 21, 42, 15, 6 and 17, respectively. high levels of agreement in the selection and wording of items were observed in the responses of lecturers and students. the highest percentage for ‘reject’ (7.6%) was observed to relate to the following professional competence: ‘as a medical practitioner or student i am required to demonstrate knowledge and understanding of the principles of managed health care and health care systems in south africa with special reference to the differences between the public and private sector’. the highest percentage for rewording for any given item was 4.5%. this competency was formulated as follows: ‘as a medical practitioner or student i am required to demonstrate a relevant epidemiological approach’. table 1 presents all comments and suggestions made within the three domains of professionalism in relation to any of the listed requirements and how they become evident. table 2 lists the two domains with three separate statements in which relevant comments were made that were suggestive of a poor correlation between the proposed professionalism outcomes and the reality of the workplace. only 2% of respondents suggested that a descriptor of an outcome be reworded. the revised charter for medical professionalism is presented in table 3, highlighting what lecturers and students regard as locally relevant standards for medical professionalism. 12 may 2015, vol. 7, no. 1 ajhpe research table 1. specific feedback from student respondents about the three domains of professionalism domain original wording of item comment/suggested change professional competence problem-solving and critical thinking skills are evident when i: • formulate a management plan after negotiation with the patient/parent/guardian problem-solving and critical thinking skills are evident when i: • formulate a management plan before negotiation (to get an idea of what you plan to do), but am able to adapt it after discussion with patient/parent/guardian (once you have received a better idea of the situation) being knowledgeable of and applying relevant laws are evident when i: • demonstrate personal responsibility and ethical behaviour in my conduct addition to the end of the statement: • realising that one cannot be taught to be ethical and responsible in medical school but must do so in a personal capacity first • demonstrate a commitment to improving my knowledge and skills on a continuous basis • demonstrate a commitment to improving knowledge and skills where possible being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in sa are evident when i: • apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all i feel that this decision is usually not made by the doctor – it is made by the management running the hospital, and lack of resources to adequately treat patients is a common complaint in many places. this is not usually because of a lack of money, but rather bad management ethical values ethical values require me to: • strive to ensure the well-being of all members of society ethical values require me to: • strive to ensure the well-being of all members of society who seek my professional assistance acknowledging patient autonomy and empowering patients to make informed decisions are evident when i: • negotiate a treatment plan with patients acknowledging patient autonomy and empowering patients to make informed decisions are evident when i: • negotiate a treatment plan with patients that best meets both myself, the patients’ and their relatives’ needs acknowledging people’s human rights is evident when i: • respect a patient’s rights and needs acknowledging people’s human rights is evident when i: • respect a patient’s rights and needs as required from me by law and unspoken guidelines acknowledging patient autonomy and empowering patients to make informed decisions are evident when i: • respect their concerns and choices unless their choices stand to harm others, especially in the cases of adults making decisions for children personal attributes upholding and maintaining professional behaviour and relationships are evident when i: • show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations i will accept criticism only if it is fully informed and takes availability of hospital resources into account … but not stand for unfair and unjust treatment based on my level of education or my race table 2. specific feedback from student respondents suggestive of discordance between the proposed professionalism outcomes and workplace reality domain original wording of item comment/suggested change professional competence being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in south africa are evident when i: • apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all i feel that this decision is usually not made by the doctor – it is made by the management running the hospital, and lack of resources to adequately treat patients is a common complaint in many places. this is not usually because of a lack of money – but, rather, bad management personal attributes upholding and maintaining professional behaviour and professional relationships are evident when i: • show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations i will accept criticism only if it is fully informed criticism and if it takes availability of hospital resources into account … but not stand for unfair and unjust treatment based on my level of education or my race may 2015, vol. 7, no. 1 ajhpe 13 research table 3. the charter for medical professionalism: university of pretoria • this charter guides the professional practice of medical students and practitioners. both students and practitioners are required to commit themselves to: being informed of their professional responsibilities; a desire to maintain professional behaviour; and maintaining high standards of medical practice • students and practitioners should demonstrate (i) professional competence; (ii) adherence to ethical values; and (iii) the personal attributes that are associated with professionalism • this charter shows what is expected of students and practitioners in terms of all three of these components of professionalism and also sets out how professionalism is made evident in conduct 1. professional competence as a medical practitioner or student i am required to: • demonstrate problem-solving and critical thinking skills • keep good clinical records • demonstrate a relevant epidemiological approach • be knowledgeable and apply relevant laws with special reference to: • human rights • relationships (collegial, patient and personal) • unlawful conduct • patient procedures (e.g. involuntary admission, etc.) • demonstrate knowledge and understanding of the principles of managed healthcare and healthcare systems in south africa, with special reference to the differences between the public and private sectors • demonstrate a commitment to improving my knowledge and skills on a continuous basis making these skills and qualities evident • problem-solving and critical thinking skills are evident when i: • apply appropriate knowledge (anatomy, physiology, pathology, ethics, etc.) and skills (interpersonal, communication, physical skills, etc.) in the clinical assessment and treatment of patients • display an evidence-based approach while considering the availability of resources • formulate a management plan after negotiation with the patient/parent/guardian • accommodate in myself a degree of uncertainty in clinical decision-making and possible differences of opinion with others • keeping good clinical records is evident when i: • record information on the patient and matters relating to patient management in the appropriate format and regularly update this information • demonstrating a relevant epidemiological approach is evident when i: • determine the extent of the healthcare problem • plan and implement interventions using existing resources • apply appropriate methodology • being knowledgeable of and applying relevant laws are evident when i: • demonstrate knowledge of the south african constitution and relevant laws in my clinical practice • demonstrate personal responsibility and ethical behaviour in my conduct • being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in south africa are evident when i: • apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all • a commitment to continually improving my knowledge and skills for the improvement of my professional competence is evident when i: • practise evidence-based medicine • inform my practice with up-to-date information and research • engage in continuing professional development 2. ethical values ethical values require me to: • demonstrate an appropriate ethical approach to dilemmas in clinical practice and research • acknowledge people’s human rights • acknowledge patient autonomy and empower patients to make informed decisions • uphold honesty as a primary concern • strive to ensure the well-being of all members of society continued ... 14 may 2015, vol. 7, no. 1 ajhpe research discussion the charter for professionalism of the school of medicine, up, was developed to promote a common understanding of how professionalism may become evident, thus heightening student (and lecturer) awareness of professionalism and assuring consistency in the teaching and assessment of professionalism in medicine. to assure ‘buy-in’ from the school of medicine, the charter was specifically developed to accommodate the previously defined golden threads. other sources – as listed under methods – were included in the research process, and feedback from faculty and students was sourced in a local survey. generally, the survey responses supported the current form of the up charter. although the response rate of the students was relatively low, all years of study were represented. students are continually invited to comment on the charter as part of their reflection activities. comments made by students mostly provided evidence of buy-in, as they proposed subtle changes to the wording of specific outcomes. some of the comments, however, indicated that discordance might exist between the proposed professionalism outcomes and workplace reality, where resources to treat patients adequately are often lacking (table 1). the assessment of professionalism within the macro-societal domain may become complicated as a result of a dysfunctional system that needs to be accounted for. as proposed in the ‘assessment of professionalism: recommendations from the ottawa 2010 conference’,[24] future research may be directed towards exploring ‘professionalism assessment in complex clinical workplaces, including how individuals adapt to difficult or even dysfunctional health care systems and the gaps that arise between espoused values and actual practice’. the hallmark paper ‘health professionals for a new century: transforming education to strengthen health systems in an interdependent world’ proposes that a competencies-based approach within team-based learning be employed and that global learning should be strengthened.[25] the outcomes-based approach of the up charter is therefore in agreement with international trends, as it defines measurable or observable competencies, albeit within the sa context. cross-referencing between outcome frameworks is, however, indicated.[26] such an endeavour would aid in identifying gaps and promoting a common understanding of professionalism in the workplace, as is evident from the attributes or competencies proposed for the ‘global doctor’ (the tuning project (medicine), 2012).[27] the unique nature of professionalism as described and understood locally within different medical schools and healthcare disciplines should, however, be appreciated and maintained. agreement between the outcomes defined in up’s charter for medical professionalism and those defined in the tuning project,[27] tomorrow’s doctors,[28] the scottish doctor,[29] and the american board of internal medicine (abim) foundation,[30] is highly evident. what appears to be lacking in the up charter, however, is emphasis on research, practice management, and teaching, mentoring and leadership roles of the doctor. furthermore, identification of the attributes of the global doctor is table 3. (continued) the charter for medical professionalism: university of pretoria making these values evident • an appropriate ethical approach to clinical and research ethical dilemmas is evident when i: • identify ethical dilemmas in clinical practice and research • am accountable in my responses to these dilemmas • acknowledging people’s human rights is evident when i: • respect a patient’s rights and needs • treat people in a fair and just manner • acknowledging patient autonomy and empowering patients to make informed decisions are evident when i: • inform patients correctly of their treatment options • respect their concerns and choices • negotiate a treatment plan with patients • upholding honesty as a primary concern is evident when i: • demonstrate honesty in all my communications and dealings with patients and base all my dealings with patients on integrity • striving to ensure the well-being of all members of society is evident when i: • manage available resources responsibly 3. personal attributes the personal attributes of a medical student or doctor require me to: • uphold and maintain professional behaviour and professional relationships making these attributes evident • upholding and maintaining professional behaviour and professional relationships are evident when i: • demonstrate desirable personal attributes (such as compassion, empathy, honesty, tolerance, integrity, responsibility, trustworthiness, confidentiality, beneficence, respect for the primacy of the patient, transparency in decisions) in my relationships with patients • show respect in my demeanour, grooming, adherence to the appropriate dress code, punctuality and attendance • show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations • am able to handle conflict and make appropriate decisions and cope in a crisis • have good communication and interpersonal skills, such as knowing how to greet patients appropriately and listening well • show the ability to work in a team through delegating and making referrals appropriately, sharing with colleagues, valuing the input of all team members and recognising all contributions of the team. may 2015, vol. 7, no. 1 ajhpe 15 research commendable and merits contextualisation and inclusion in the up charter. in general, the outcomes-based approach appears to broaden the scope of assessment of professionalism beyond observing behavioural attributes. the charter is regarded as a working document and is intended to serve as a basis for local discourse on professionalism within a global and transdisciplinary context in health sciences. conclusion defining outcomes for professionalism in medical practice appears to be universally acceptable. this approach evidently makes professionalism more explicit and assessable and also broadens the scope of professionalism by virtue of defining new roles and responsibilities within the individual, interpersonal, and societal/institutional domains. acknowledgements. the authors would like to acknowledge the valuable contributions of former members of the charter for medical professionalism work group: ina treadwell, renata du preez and isobel van der westhuizen. references 1. merriam-webster.com 2012. http://www.merriam-webster.com/dictionary/professions (accessed 18 december 2012). 2. cruess rl, cruess sr. expectations and obligations: professionalism and medicine’s social contract with society. perspect biol med 2008;51(4):579-598. 3. hafferty fw, castellani b. the increasing complexities of professionalism. acad med 2010; 85:288-301. [http:// dx.doi.org/10.1097/acm.0b013e3181c85b43] 4. members of the medical professionalism project: abim foundation, acpbasim foundation, and european federation of internal medicine. medical professionalism in the new millennium: a physician’s charter. lancet 2002;359:520-522. [http://dx.doi.org/10.1016/s0140-6736(02)07684-5] 5. schuwirth l. professional development in undergraduate medical curricula from an assessment point of view. med educ 2002;36(4):312-313. 6. ten cate thj, de haes jcjmm. summative assessment of medical students in the affective domain. med teach 2000;22(1):40-43. [http://dx.doi:10.1080/01421590078805] 7. swick hm. toward a normative definition of medical professionalism. acad med 2000;75:612-616. [http:// dx.doi.org/10.1097/00001888-200006000-00010] 8. frank jr, danoff d. the canmeds initiative: implementing an outcomes-based framework of physician competencies. med teach 2007;29:642-647. [http://dx.doi.org/10.1080/01421590701746983] 9. harris p, snell l, talbot m, harden rm. competency-based medical education: implications for undergraduate programs. med teach 2010;32:646-650. [http://dx.doi.org/10.3109/0142159x.2010.500703] 10. van mook wnka, van luijk sj, o’sullivan h, et al. the concepts of professionalism and professional behaviour: conflicts in both definition and learning outcomes. eur j int med 2009;20:e85-e89. [http://dx.doi.org/10.1016/j. ejim.2008.10.006] 11. van rooyen m. the view of medical students on professionalism in south africa. sa family practice 2004;46(1):28-31. 12. world medical association. wma declaration of geneva. geneva: world medical association, 2006. http:// www.wma.net/en/30publications/10policies/g1/index.html (accessed 18 december 2012). 13. du preez rr, pickworth ge, van rooyen m. teaching professionalism: a south african perspective. med teach 2007;29:e284-e291. 14. joubert pm, krüger c, bergh a-m, et al. medical students on the value of role models for developing ‘soft skills’ – ‘that’s the way you do it’. south african psychiatry review 2006;9:28-32. [http://repository.up.ac.za/ handle/2263/15029] 15. bergh a-m, van staden cw, joubert pm, et al. medical students’ perceptions of their development of ‘soft skills’ – part ii: the development of ‘soft skills’ through ‘guiding and growing’. sa family practice 2006;48(8):15-15d. [http://repository.up.ac.za/handle/2263/15024] 16. epstein rm. assessment in medical education. n engl j med 2007;356(4):387-396. 17. papadakis ma, loeser h, healy k. early detection and evaluation of professionalism. deficiencies in medical students: one school’s approach. acad med 2001;76(11):1100-1106. 18. van rooyen m, treadwell i. pretoria medical students’ perspectives on the assessable attributes of professionalism. sa family practice 2007;49(4):17. 19. the health professions council of south africa. professional guidelines. http://www0.sun.ac.za/ruralhealth/ ukwandahome/rudasaresources2009/more/professionalguidelines.pdf (accessed 18 december 2012). 20. association of american medical colleges. learning objectives for medical student education: guidelines for medical schools, 1998. http://www.aamc.org/meded/msop/ (accessed 18 december 2012). 21. the uk general medical council. good medical practice. http://www.gmc-uk.org/guidance/good_medical_ practice.asp (accessed 18 december 2012). 22. the scottish deans medical curriculum group. http://www.scottishdoctor.org/ (accessed 18 december 2012). 23. the royal college of physicians and surgeons of canada. canmeds competency framework 2005. http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e. pdf (accessed 18 december 2012). 24. hodges bd, ginsburg s, cruess r, et al. assessment of professionalism: recommendations from the ottawa 2010 conference. med teach 2011;33(5):354-363. [http://dx.doi.org/10.3109/0142159x.2010.500703 ] 25. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 26. ellaway r, evans p, mckillop j, et al. cross-referencing the scottish doctor and tomorrow’s doctors learning outcome frameworks. med teach 2007;29(7):630-635. [http://dx.doi.org/10.1080/01421590701316548] 27. the tuning project (medicine) 2012. learning outcomes/competences for undergraduate medical education in europe. http://www.tuning-medicine.com/exec.asp (accessed 18 december 2012). 28. uk general medical council. tomorrow’s doctors 2009: a draft for consultation. https://gmc.e-consultation. net/econsult/uploads/td%20final.pdf (accessed 18 december 2012). 29. the scottish doctor, 2011. learning outcomes for attitudes, ethical understanding and legal responsibilities. http://www.scottishdoctor.org/node3.asp?id=0900000000 (accessed 18 december 2012). 30. the american board of internal medicine (abim) foundation. http://www.abimfoundation.org/professionalism/ physician-charter.aspxian-charter.aspx (accessed 18 december 2012). research may 2016, vol. 8, no. 1 ajhpe 45 assessment is an essential component of a medical curriculum and is used to measure and manage student progress. assessment further serves as an indicator of educational efficacy to institutions and teachers.[1] exit-level assessment is also important for reasons of public accountability and in the interest of patient protection.[1] medical schools are increasingly being challenged to provide evidence that the assessments used can discriminate between sufficiently and insufficiently competent students.[2,3] where exitlevel assessments are used for licensing and certification purposes, they are regarded as being ‘high-stakes’ and therefore have significant implications for the student, curriculum, institution and public.[4,5] the assessment of clinical competence is one of the most important tasks facing medical teachers and is used to certify a level of achievement at the end of a programme.[6,7] a range of methods are available to assess clinical competence. these include oral examinations, traditional long and short clinical cases, objective structured clinical examinations (osces), standardised patient-based assessments, and workplace-based assessments such as the mini clinical evaluation exercise (mini-cex) and direct observation of procedural skills (dops).[4,8,9] to make meaningful decisions about competence, the assessment needs to be sound. various standpoints have been put forward on how this soundness can be realised. for example, a programmatic approach to assessment has been advocated to achieve fitness for purpose with the assessments used.[10,11] norcini et al.[1] suggest that validity, reproducibility, equivalence, feasibility and acceptability are essential criteria for good or sound assessment. multiple methods, preferably in a variety of contexts to capture different aspects of performance,[7] also need to be considered. given the existence of established criteria to guide sound assessment practices, it would seem reasonable to assume that their application in medical education programmes is a priority for medical schools that hold themselves publicly accountable to ensure that assessments are seen as credible for all stakeholders. however, there appear to be few studies that have looked at exit-level assessment practices against such criteria.[4,8] an analysis of the assessment practices that are in place is a first step before investigating exit-level assessment against established criteria. there appear to be few studies in this area;[12,13] this study seeks to address the gap. as a starting point, the investigation concentrated on assessment in the final 18-month phase of the bachelor of medicine and bachelor of surgery (mb,chb) programme at stellenbosch university, cape town, south africa. currently, no overall map exists of assessments as practised during this period. creating such a map would help to provide an overall picture of what assessment takes place. a preliminary literature search for ‘mapping’ revealed that this term is often associated with ‘curriculum mapping’, ‘concept mapping’ and ‘mind maps’, which make use of visual or diagrammatic pictures instead of written or verbal descriptions to illustrate the relationships and connections between different components of a curriculum or concepts.[14,15] applying mapping to assessment practices or activities would appear to be a reasonable step forward. one way of analysing assessment activities is by focusing on how these are described in official faculty documents and student module study guides. the objective of the study was therefore to map current exit-level assessment practices as described in the documentation relevant to the final phase of a medical programme. the research question was: ‘what can be learned about the assessment of clinical competence at exit level of an mb,chb programme from an analysis of how this is described in student study guides provided for each of the modules in the final phase?’ background. assessment is an essential component of a medical curriculum. high-stakes exit-level assessment used for licensing and certification purposes needs to be sound. even though criteria for evaluating assessment practices exist, an analysis of the nature of these practices is first required. objective. to map current exit-level assessment practices, as described in institutional documentation. methods. this descriptive interpretive study centred on the document analysis of final-phase study guides of the undergraduate medical program me at stellenbosch university, cape town, south africa. results. the key findings were: (i) there is a diversity of methods and approaches to assessment in the final-phase modules; (ii) modules using similar assessment methods applied different credit weightings; (iii) similar assessment methods were described differently across the study guides; and (iv) study guides varied in the amount of information provided about the assessment methods. conclusion. there is a diverse range of assessment practices at exit level of the mb,chb programme at stellenbosch university. this in-depth analysis of assessment methods has highlighted areas where current practice needs to be investigated in greater depth, and where shifts to a more coherent practice should be encouraged. assessment mapping provides a useful reference for programme co-ordinators and is applicable to other programmes. afr j health professions educ 2016;8(1):45-49. doi:10.7196/ajhpe.2016.v8i1.546 mapping undergraduate exit-level assessment in a medical programme: a blueprint for clinical competence? c p l tan,1 mbbs (lond), mrcgp (uk), frcgp (uk), mphilhse; s c van schalkwyk,1 phd; j bezuidenhout,1 phd; f cilliers,2 mb chb, hons bsc (medsc) (medbiochem), mphil (higher education), phd 1 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 educational development unit, faculty of health sciences, university of cape town, south africa corresponding author: c p l tan (tanplchristina@gmail.com) research 46 may 2016, vol. 8, no. 1 ajhpe methods this descriptive interpretive study centred on a process of document analysis of the 2012/2013 study guides. in the final 18-month phase (which runs from july of one year to november of the following year) of the 6-year mb,chb programme at stellenbosch university, students rotate through 11 clinical modules varying in length from 3 to 7 weeks. ten of the modules represent one clinical discipline each, and the remaining module, health, disease and disability in the community, is shared by the divisions of family medicine and community medicine, and the centre for care and rehabilitation (table 1). detailed information relating to each module, including teaching schedules, duty rosters, projects and assignments, assessment methods and resource materials, is made available in study guides that are provided to all students and relevant faculty. in each module, three components contribute to the students’ final overall mark: in-module and end-of-module assessments and final module examinations are conducted in either april or november of the final year. the analysis of the 11 final-phase module study guides was undertaken in two stages. in the first stage, any available information pertaining to assessment conducted during the module (either in-module or end-of-module) and in the final examinations was gathered from the study guides. this collection included varying combinations of information with regard to the assessment schedules, written descriptions of methods of assessment, assessment checklists and marking grids, logbooks, proportion of marks allocated for each assessment method and weighting (relating to the calculation of students’ final overall mark for that module). as the study guides were written in english and afrikaans, the information provided in both language versions was compared to check whether it was the same (by investigator jb, who is fluent in both languages). the information was collated on an excel spreadsheet and categorised by modules and assessment methods to generate an overview of exit-level assessment in the programme and facilitate comparison between the modules. as this process proceeded, it became clear that there were some gaps in information in the study guides. in the second stage of data collection, all 11 module chairs (faculty who were in charge of organising and co-ordinating the individual modules) were invited to participate in clarificatory interviews to verify and add to the correctness of assessment-related information in the study guides. the module chairs were invited by letter and email, with a follow-up email being sent to non-responders 4 weeks after the initial invitation. at the time of the interview, informed consent was obtained from study participants. an interview schedule was drawn up to serve as a prompt during the interviews. notes were taken during the interviews, with additional notes recorded afterwards from memory recall. where necessary, the data on the spreadsheet were amended based on the additional information obtained from these interviews. ethical approval was obtained from the stellenbosch university health research ethics committee (ethics committee reference no. n13/01/009) and institutional permission from the stellenbosch university division of institutional research and planning to conduct this study. results the information provided in both the english and afrikaans versions of all 11 final-phase module study guides was confirmed to be the same. nine of the 11 module chairs consented to participating in interviews, 1 declined and 1 was unavailable. ultimately, 8 module chairs and 1 module team member were interviewed. interviews, lasting between 20 and 100 minutes, were conducted over a period of 7 weeks by investigator cplt. twenty-one different assessment methods were identified from the study guides. the results are summarised in tables 2 and 3 to illustrate the differences in methods used during the modules (in-module and end-of-module) and in the final module examinations. assessment methods used were grouped together under three main categories, i.e. (i) written; (ii) performancebased; and (iii) other forms of assessment that did not fall under the previous two categories. in drawing up the groupings, it became evident that there was no uniformity in how assessments were described. written assessments the most common format of written assessments was multiple-choice questions (mcqs), used by six modules. ‘written’ and ‘slide’ tests used in five modules signified some format of shortanswer questions (saqs), in which students were required to formulate responses to questions posed, based on a clinical scenario, clinical or laboratory investigations, or a photograph. in several instances, where information extracted from the study guides indicated similar terms being used by different modules, interviews revealed that the nature of the assessment was different. as an example, the slide test in modules 2 and 9 referred to the projection of a powerpoint presentation of clinical photographs on a screen while students were writing the test, whereas in module 7, this referred to a writtenformat assessment which ‘includes clinical material as well as special investigations’ (study guide 7), with ‘questions based around clinical scenarios’ (module chair d). ‘other written’ assessments were used in two modules. these included assignments that students were required to complete during the modules, such as an electronic literature search relating to a patient that the student had cared for during the module, and an evidence-based medicine presentation. performance-based assessments performance-based assessment methods included an assessment of clinical skills in a controlled setting in the form of an osce and/or objective structured practical examination (ospe), which was used in four modules. the number of stations was variable. the osce and ospe used in the final summative examination for module 4 comprised 16 active stations, each of 7 minutes’ duration, whereas the osce for module 8 had approximately 20 active stations, each of 5 minutes’ duration. ‘unprepared osce questions’ (study guide 4) that were used as an in-module assessment method in module 4 were described by module chair e to be of a written format and were used ‘to test knowledge’. the ospe in-module assessment for module 5 was described as including written clinical scenarios, use of videoclips table 1. modules in the final phase of the mb,chb programme at stellenbosch university anaesthesiology health, disease and disability in the community internal medicine obstetrics and gynaecology ophthalmology orthopaedic surgery otorhinolaryngology and head and neck surgery paediatrics and child health psychiatry surgery urology total: 11 modules research may 2016, vol. 8, no. 1 ajhpe 47 and interactive sessions with standardised patients (module chair f). the in module osce in module 11 was actually a combined oral and clinical case assessment. the use of clinical cases (involving real patients) was employed in five modules, varying from 15 to 30 minutes per case. module chairs pointed out that the number of cases used in the final examinations varied – from 1 (module 3) to 2 (module 7) and 3 (modules 1 and 6). the number of clinical cases used in the same module also differed when used for in-rotation assessment (e.g. modules 6 and 7 used 1 case each) compared with the final examinations (the same modules 6 and 7 used 3 and 2 cases, respectively). in two other modules (modules 9 and 11), there appeared to be some overlap between the use of clinical cases and oral assessment in the final examinations, as described by the respective module chairs. a number of ‘diverse clinical’ assessment methods was described in the study guides, comprising skills logbooks, portfolios, assessment of ‘practical ability’ (based broadly on history-taking and examination technique, mastery of skills prescribed in a logbook, ability to formulate and summarise clinical problems and develop a management plan); clinical examination method (based on specific physical examination techniques in that module); clinical case discussions and x-ray presentations to ward consultants; and oral assessment. this loose grouping was made by investigator cplt in the initial mapping of all assessment methods extracted from the study guides, as these methods shared a common clinical thread but did not fit into the two previously described groups of performance-based assessment methods. other assessments the remaining category of assessment methods used in 10 of the finalphase modules, primarily as part of in-rotation assessment, is labelled ‘other’. these methods dealt mainly with various aspects of professionalism. in four modules, although this assessment did not appear to carry an actual mark, the student was required to obtain a ‘satisfactory’ judgement. table 2. range of assessment methods used during the modules assessment methods (in-module and end-of-module assessments) module duration (weeks) written performance based contribution to final module mark, %mcq saq other written osce/ospe clinical cases diverse clinical other 1 3   written test (12.5)     clinical examination (12.5) clinical case discussion (12.5); clinical examination method (12.5) continuous (p/f) 50 2 3   slide test (25) clinical case studies (25)     skills logbook (5); practical ability (40) dedication and enthusiasm (5) 50 3 5           general oral and simulated clinical oral (50)   50 4 6 (15)     osce (10)     ward mark (25) 50 5 7 (10)     ospe (20)   portfolio (20) attitude (satisfactory/ unsatisfactory) 50 6 7 (15)       clinical (17.5)   continual (17.5) 50 7 6     electronic literature search (5)   clinical long case (40) clinical procedures (completed: yes/no); x-ray presentation (5) professional conduct (satisfactory/ unsatisfactory) 50 8 5 (5)   ebm presentation (5); work rehab task (2.5); physical rehab task (2.5); community project (12.5)     clinical portfolio (17.5) continuous tutor assessment (5) 50 9 3 (25) slide test (25)       skills logbook (p/f) dedication and enthusiasm (satisfactory/ unsatisfactory) 50 10 3 (17)     skills (in skills lab) (2) clinical (20)   attitude (1) 40 11 5   written test (20)   ‘osce’ (clinical and oral) (25) integrity assessment (5) 50 mcq = multiple choice question; saq = short answer question; osce = objective structured clinical examination; ospe = objective structured practical examination; ebm = evidence-based medicine; p/f = pass/fail. figures in parentheses refer to the percentage contribution to the final module mark. research 48 may 2016, vol. 8, no. 1 ajhpe structured marking guidelines to assist the assessment of this component were provided in the study guides for modules 7 and 8. for the remaining eight modules, module chairs confirmed that there were no guidelines and the allocation of marks was subjective. summary of results ten of the modules used at least one written and one clinical assessment method during the module, whereas module 3 relied on one method in the form of an oral assessment (table 2). on overall review of the final examinations (table 3), modules 1, 6 and 7 used a written and clinical assessment method. three modules (3, 10 and 11) used two clinical assessment methods. two modules (4 and 8) used a multiple station osce and/ or ospe format, and two modules (5 and 9) used an oral assessment format alone. information relating to the final examinations for modules 6 and 9 was not described in the study guides; this additional information was obtained only at the time of interview. there was no information available regarding the final examination in the module 2 study guide. the students’ final overall mark for each module was based on two components: the total marks awarded for the rotation (from in-rotation and end-of-rotation assessments) and those from the final examinations. in 10 of 11 modules, the weighting for these two components was equal. in the remaining module 10, 40% of the final overall mark was derived from the rotation marks and 60% from the final examination marks. as indicated by the figures in parentheses in tables 2 and 3, the weighting of individual assessment methods varies considerably between modules. discussion four key findings emerged from this study. firstly, there was a diversity of assessment methods and approaches in the final-phase modules. secondly, modules using similar assessment methods applied different weightings. a third finding was that the information provided about similar assessment methods was described differently in the various module study guides. these are not necessarily synonymous with what is described in the literature. and fourthly, study guides varied in the amount and detail of information provided about the assessment methods used in the respective modules. range of methods used the diversity of methods and approaches to assessment across the finalphase modules is similar to that reported in mccrorie and boursicot’s[12] uk study and by ingham[13] in australia. conversely, a single assessment method was used in several modules. the question is whether the (mix of ) methods are utilised in a way that is appropriate to exit-level assessment. miller’s[16] ‘pyramid’, often used to illustrate the multidimensional complexity of assessing clinical competence, moving upwards from reproduction or factual recall in the lower tiers of the ‘pyramid’ to demonstration and application at the summit, provides a useful framework for responding to this question. the study findings indicate that a substantial proportion of assessment still takes place at the ‘lower’ tiers of the pyramid. this finding raises questions about how this might influence the validity of decisions on the clinical competence of the student. analysis of how assessment is described in the student study guides does not provide sufficient information to draw final conclusions, and further research is required in this area. other questions deserving further study include whether the range of methods used is appropriate to the outcomes of the relevant exit-level modules and what the findings reveal about the validity of the opinions offered by external examiners. weighting of assessment methods modules using similar assessment methods applied different weightings, suggesting that the emphasis placed on the assessment method varied across modules. possible explanations include resource constraints table 3. range of assessment methods used for the final module examinations assessment methods (final module examinations) module duration (weeks) written performance based contribution to final module mark, %mcq saq osce/ospe clinical cases diverse clinical 1 3   written examination (12.5)   clinical examination (37.5)   50 2 3           50 3 5       clinical (17) general oral and simulated clinical oral (33) 50 4 6     osce and ospe (50)     50 5 7         oral (50) 50 6 7 (20)     clinical (30)   50 7 6   slide: written (25)   clinical (25)   50 8 5     osce (50)     50 9 3       clinical oral examination (50) 50 10 3     osce (24)  oral (36) 60 11 5       clinical, oral and x-ray discussion (50) 50 figures in parentheses refer to the percentage contribution to the final module mark. research may 2016, vol. 8, no. 1 ajhpe 49 (such as available assessors and space to conduct assessment), and the opinion of assessment conveners about the perceived merits of the chosen methods. wass et al.[8] have shown that weighting accorded to items per test or total test time can significantly affect reliability, but this has to be considered carefully with other established criteria for good or sound assessment in a high-stakes context. the reasons behind these decisions were beyond the ambit of this study, and these too warrant further investigation. description of assessment methods the study guides serve primarily as a reference for students and faculty to provide official information relating to each module. there was little uniformity in how assessments were described. the varying use of terms, such as osce and ospe, suggests that faculty in different modules may have a different understanding of similar assessment methods, which could impact on reliability and fairness. the absence of clear descriptions of what individual assessment methods entail could potentially lead to confusion and incorrect assumptions by students. defining and providing consistent and adequate information in the module study guides and official faculty documents regarding the assessment methods used would reduce any possible misunderstanding. incorporating this detail into faculty development programmes would also promote consistency in the future practices of assessors. variable in-rotation assessment practice without any descriptions or guidelines of how the marks are determined was noted in several modules, which could result in subjective interpretation and impact on fairness. these in-rotation assessments dealt mainly with aspects of professionalism. the assessment of professionalism is equally complex and requires a multidimensional approach. while itemised checklists and rating scales may not necessarily be the best solution, the introduction of some form of global overall rating could be considered as an alternative and go some way to addressing the difficulties of assessing aspects of behaviour or professionalism during placements.[7] ultimately, whether quantitative and qualitative measures are used, their utilisation in a defensible manner is key to making valid inferences. level of detail provided study guides varied in the number of assessment methods used in the respective modules and amount of detailed information provided. there were instances where there was no information regarding the final examination or the assessment methods used. study guides have the potential to help students to manage their own learning. one of their many uses as a management tool could be for examination preparation by providing information on the format and arrangements for assessment.[17] although the broad outlines in the stellenbosch university study guides are similar, a structured template could be used to provide guidance for uniformity in the writing detail. the way forward overall or central co-ordination of the assessment of the mb,chb programme could address some of the issues highlighted, such as the uniformity of detail and consistency of description regarding assessment methods in all the final-phase modules. one next step could be to investigate what exitlevel assessment actually takes place at stellenbosch university, and how this relates to what is described in the final-phase module study guides. this could be further expanded to study the exit-level assessment taking place at other medical schools in a similar context, such as in sub-saharan africa. exploring the reasons around choices of assessment methods, decisions on weighting, and clinical competencies considered appropriate for medical graduates could also be avenues for further research. conclusion this study provides an in-depth analysis of assessment methods across an undergraduate medical programme, highlighting the range and diversity of existing assessment practices at the exit-level phase of the mb,chb programme at stellenbosch university. a limitation of the research is that the findings reported are not necessarily generalisable to earlier phases of the mb,chb programme at the university. in addition, actual assessment practices and content will require separate verification. this study has highlighted potential areas where current practice needs to be investigated in greater depth, and where a shift to a more coherent practice should be encouraged. assessment mapping provides a useful reference for programme co-ordinators and the tool has applicability for other programmes. references 1. norcini j, anderson b, bollela v, et al. criteria for good assessment: consensus statement and recommendations from the ottawa 2010 conference. med teach 2011;33(3):206-214. [http://dx.doi.org/10.3109/0142159x.2011.551559] 2. health professions council of south africa. health professions act 56 of 1974. regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine. government gazette 31886, 19 february 2009. 3. general medical council. assessment in undergraduate medical education. advice supplementary to tomorrow’s doctors. london: general medical council, 2011. http://www.gmc-uk.org/static/documents/content/ assessment_in_undergraduate-web.pdf (accessed 20 february 2013). 4. roberts c, newble d, jolly b, reed m, hampton k. assuring the quality of high stakes undergraduate assessments of clinical competence. med teach 2006;28(6):535-543. [http://dx.doi.org/10.1080/01421590600711187] 5. norcini jj, lipner rs, grosso lj. assessment in the context of licensure and certification. teach learn med 2013;25(s1):s62-s67. [http://dx.doi.org/10.1080/10401334.2013.842909] 6. wass v, van der vleuten c, shatzer j, jones r. assessment of clinical competence. lancet 2001;357:945-949. 7. epstein rm. assessment in medical education. n engl j med 2007;356:387-396. 8. wass v, mcgibbon d, van der vleuten c. composite undergraduate clinical examinations: how should the components be combined to maximise reliability? med educ 2001;35(4):326-330. 9. wilkinson tj, frampton cm. comprehensive undergraduate medical assessments improve prediction of clinical performance. med educ 2004;38(10):1111-1116. [http://dx.doi.org/10.1111/j.1365-2929.2004.01962.x] 10. dijkstra j, van der vleuten cpm, schuwirth lwt. a new framework for designing programmes of assessment. adv health sci educ theory pract 2010;15(3):379-393. [http://dx.doi.org/10.1007/s10459-009-9205-z] 11. van der vleuten cpm, schuwirth lwt, driessen ew, et al. a model for programmatic assessment fit for purpose. med teach 2012;34(3):205-214. [http://dx.doi.org/10.3109/0142159x.2012.652239] 12. mccrorie p, boursicot kam. variations in medical school graduating examinations in the united kingdom: are clinical competence standards comparable? med teach 2009;31(3):223-229. [http://dx.doi. org/10.1080/01421590802574581] 13. ingham ai. the great wall of medical school: a comparison of barrier examinations across australian medical schools. australian medical student journal 2011;2(2):5-8. 14. harden rm. amee guide no. 21. curriculum mapping: a tool for transparent and authentic teaching and learning. med teach 2001;23(2):123-137. [http://dx.doi.org/10.1080/01421590120036547] 15. daley bj, torre dm. concept maps in medical education: an analytical literature review. med educ 2010;44(5):440-448. [http://dx.doi.org/10.1111/j.1365-2923.2010.03628.x] 16. miller ge. the assessment of clinical skills/competence/performance. acad med 1990;65(9 suppl):s63-s67. 17. harden rm, laidlaw jm, hesketh ea. amee medical education guide no. 16: study guides – their use and preparation. med teach 1999;21(3):248-265. [http://dx.doi.org/10.1080/01421599979491] 160 october 2016, vol. 8, no. 2 ajhpe research the education of health professionals has not kept pace with the major challenges involved in providing health security for all during the 21st cen tury.[1,2] despite professional regulatory bodies requiring certain competencies, which are featured in the teaching and learning policies of training institutions, these competencies are not necessarily embedded in the formal curriculum and are often assumed to be acquired through the ‘hidden’ curriculum.[3] professional competencies are seen to include, but go beyond, disciplinary expertise or technical knowledge – ‘they are the qualities that also prepare graduates as agents for social good in an unknown future’.[4] various frameworks are used by educational institutions worldwide to demonstrate the professional competence of graduates. for example, one of the participating universities in this study bases its professional competencies[5] (table 1, left column) on the canmeds competency framework developed by the royal college of physicians and surgeons of canada.[6] similar competency attributes are also embedded in the principles of a human rights-based approach (hrba), which centres around the primary rights and responsibilities of the rights holders (such as vulnerable population groups) and the corresponding duties of those responsible for improvements (duty bearers). for example, hrba principles emphasise participation, transparency, non-discrimination and sustainability.[7] thus, the professional competency attributes mentioned correspond with several of the human rights principles required by nutrition professionals to fulfil their roles as duty bearers, honouring their obligation towards the fulfilment of the relevant human rights of the rights holders.[8] the hrba also implies that nutrition professionals should not function in isolation. through transprofessional collaboration between several professions, such as nutrition, law, economy and agriculture, among others, sustainable solutions may be found to deep-rooted nutri tion problems.[8] such a transprofessional approach provides nutrition professionals with a combination of enabling competencies valuable to the development and implementation of policies and programmes aimed at addressing the myriad of nutrition-related challenges faced by vulnerable population groups. agreeing about many of the educational challenges of the 21st century, educators at universities in norway, south africa (sa) and uganda collaboratively developed the norwegian masters (noma) track module on nutrition, human rights and governance (further referred to as ‘the module’). funding was obtained from the norwegian government (through the centre for international cooperation in education (siu)).[9] participating students were registered for a master’s degree in nutrition at their respective universities. the 18-week module was presented for 6 weeks in each of the three countries and students had to adapt to different cultures and educational systems twice. noma students (n=22) were exposed to the associated culture shock, which caused some anxiety resulting from the absence of support systems and familiar surroundings and cultural practices. the available literature reports that international students are typically exposed to different beliefs about what constitutes knowledge, and how it should be learnt, taught and assessed.[10] furthermore, the transition period in a foreign country is associated with disorientation, insecurity and incomprehension, all of which may negatively affect the learning process and preclude skills transfer. during the transition period there may be a disparity between a background. in response to the challenge of the global health needs of the 21st century, four academic institutions in norway, south africa and uganda, each offering a master’s degree in nutrition, collaboratively developed the norwegian masters (noma) track module on nutrition, human rights and governance, integrating a human rights-based approach into graduate education in nutrition. objective. to capture students’ perceptions about the noma track module, focusing on the development of key competencies. methods. employing a qualitative approach, 20 (91% response rate) in-depth telephonic interviews were conducted with participating students, voice recorded and transcribed. through an inductive process, emerging themes were used to compile a code list for content analysis of the transcribed text. relevant themes were reported according to the professionals’ roles described by the canmeds competency framework. results. participation in the module enhanced key competencies in the students, e.g. communication skills and the adoption of a holistic approach to interaction with people or communities. their role as collaborator was enhanced by their learning to embrace diversity and cultural differences and similarities. students had to adapt to different cultures and educational systems. they were inspired to contribute in diverse contexts and act as agents for change in the organisations in which they may work or act as leaders or co-ordinators during interaction with community groups and policy makers. higher education institutions offering transnational modules should support lecturers to manage the inherent diversity in the classroom as a way of enhancing student performance. conclusion. the development of future transprofessional modules will benefit from the inclusion of desirable key competencies as part of the module outcomes by following a competency by design process. afr j health professions educ 2016;8(2):160-165. doi:10.7196/ajhpe.2016.v8i2.554 the noma track module on nutrition, human rights and governance: part 2. a transnational curriculum using a human rights-based approach to foster key competencies in nutrition professionals m l marais,1 bsc dietetics, dipl hospital dietetics, m nutrition; m h mclachlan,1 phd; w b eide,2 cand.real (oslo), dipl nutr (london) 1 division of human nutrition, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 department of nutrition, department of medicine, university of oslo, norway corresponding author: m l marais (mlm@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 161 research table 1. examples of professional roles and attributes enhanced through master of nutrition students’ participation in the noma track module ‘nutrition, human rights and governance’, as perceived by the students roles of hnps[5] summary of perceptions of noma track students selected quotes to illustrate the development of professional attributes as communicators, hnps effectively facilitate the carer/ service-user relationship and the dynamic exchanges that occur before, during and after interaction gained confidence in expressing own feelings communication with people from different cultures ‘i felt within the group i could ask the questions i needed to ask to get an understanding, because the others were better in english than we norwegians. sometimes they laughed at our understanding but i can handle that.’ (female student, norway) ‘and sometimes you don’t know what they are thinking and that can lead to a lot of confusion because you could potentially keep on saying things that annoy them, but in their culture they don’t complain … they just keep it inside or ignore it.’ (female student, sa) ‘[there is a] different way of thinking: as a norwegian person i may have understood one situation as positive and an african person may have understood the situation completely otherwise … you meet people and think everything is okay and that you are just behaving normally, but then you realise after a while that you have been rude or been perceived that you have been rude.’ (female student, norway) as collaborators, hnps effectively work within a team to achieve optimal service-user care (the community included) students from different countries embraced the diversity as a platform to grow as person and as a professional adapting to foreign cultures embracing cultural differences conflict management ‘there were some good interactions among the students. we got to know each other. by the time we left norway, we were very familiar with each other … eventually we became one team.’ (female student, uganda) ‘we respected the fact that we were from different cultures, we are different people raised up in different countries. so we needed to respect each other.’ (female student, uganda) ‘try not to compare it to your own culture or the culture you just been to, but you have to accept it that is just the way it is.’ (female student, norway) ‘what seems right in the one country, you realise was wrong in another.’ (female student, uganda) ‘from my perspective it is very strange not to help people, if you are insulted it is considered the norm to tell people how you feel … and for them not telling, disappointed me, because i don’t want to offend my friends … .’ (female student, norway) ‘when it comes to culture, it brings out a positive something. but as soon as it does not coincide with the other countries, then they bring up those issues of someone being offended.’ (female student, uganda) ‘i think it was good for me to learn the sa way of thinking, and to understand that the norwegian way of thinking is maybe more progressive and it is not the way of thinking as the rest of the world.’ (female student, norway) ‘if you put a bunch of people together that are basically strangers and you expect them to live together, study together, work together, travel together, you know … it gets hectic.’ (female student, sa) as managers, hnps are integral participants in organisations, organising sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the relevant systems prioritising time management problem-solving need to influence policy makers ‘i certainly feel more equipped and competent to work at a level where i am not just on the ground but i am able to work with … people who are possibly making policy decisions … .’ (female student, sa) ‘if you want to start a program or launch a project you should decide who you want to reach, how you want to reach them and what difference you want to see or make. to involve and empower people, e.g. if you distribute soup, how can you empower them instead of what you could gain … .’ (female student, sa) as health and nutrition advocates, hnps responsibly use their expertise and influence to advance the health and nutritional wellbeing of individuals, communities and populations inclusion of the community during the planning phase enhanced awareness of people’s needs representation of vulnerable groups advocacy for nutrition using hrba ‘if you have a patient sitting in front of you who has a malnourished child, not eating well is not the problem … there are so many other things; and you need to be able to tell them that … and speak to the people who can solve the other problems which you as a nutritionist cannot.’ (female student, sa) continued … 162 october 2016, vol. 8, no. 2 ajhpe research student’s learning expectations and accomplishments and those anticipated by lecturers.[10] in the first part of this series, marais et al.[9] reported the perceptions of noma students about the development and process of the noma track module, which presented students with different challenges. the objective of this article is to describe attributes associated with professional competence deduced from noma students’ own accounts of their experiences of the module. twenty noma students (16 female and 4 male), enrolled for a master’s degree in nutrition at universities from different countries (4 from norway, 7 from sa and 9 from uganda), consented to participate in the study (91% response rate). their mean age was 30.2 (standard deviation (sd) 6.0) years. some participants had between 1 and 18 years of working experience as community dietitians, nutritionists, research scientists or cooks, while others had only been registered students with no previous work experience.[9] methods data were collected during october and november 2012. as the students resided in different countries, two trained research assistants conducted in-depth interviews (35 125 minutes) telephonically in english. a discussion guide was used, based on topics and probes relevant to the module. an example of one topic was students’ experience of participating in the module and its effect on their personal skills and professional competencies. transcriptions were checked to ensure that the text was a true reflection of the recorded interviews and a systematic approach was used to analyse unstructured data. constant comparison of information ensured that the themes reflected the original data. an inductive process was followed, as themes emerging from the text were used to compile a code list and codetranscribed text, using a text analysis computer programme (atlas.ti version 6, germany). results from the study are reported in two articles. as reported in the first part of this series, the participants appreciated the module content, study visits, experienced lecturers and interactive teaching style.[9] another set of themes that emerged related to development of the competence required of nutrition professionals; the attributes displayed by the participants were grouped according to the seven professional canmeds roles and are presented in this article. ethics and legal aspects approval for the study was obtained from the health research ethics committee of the faculty of medicine and health sciences, stellenbosch university (ref. no. n12/08/044). informed written consent for voluntary participation as well as for voice recording of interviews was obtained from all participants. anonymity and confidentiality were maintained during interview transcription and whenever direct quotes were used. the transcripts and voice recordings were stored in protected files and the voice recordings were destroyed after 6 months. results the participants generally described the module as memorable and a once-in-a-lifetime opportunity, with ‘an incredible learning curve’. the study illustrates the concept of lifelong learning, as participants testified to professional development and personal growth resulting from the experience. this was also evident from the set of emerging themes grouped according to the different professional roles[5] that nutrition professionals table 1. (continued) examples of professional roles and attributes enhanced through master of nutrition students’ participation in the noma track module ‘nutrition, human rights and governance’, as perceived by the students roles of hnps[5] summary of perceptions of noma track students selected quotes to illustrate the development of professional attributes as scholars, hnps demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of knowledge diversity enhanced learning process intention to teach others about hrba ‘you were not just hearing the lecturer speak … just give you information … you’d go back and discuss. it wasn’t “this is the way it is … and there’s no other way”. you could engage … argue back and forth … and fight. you have an idea of how it can be applied in different settings.’ (female student, sa) as professionals, hnps are committed to ensure the health and wellbeing of individuals and communities through ethical practice, professionled self-regulation and high personal standards of behaviour improved understanding of the broad scope of factors having an impact on nutrition motivated to promote preventive care ability to incorporate human rights principles in own work ethic ‘not to just rush into something and try and change things but rather to look at the reason why you want to change things … what impact it will have on people’. (female student, sa) ‘i believe using the human rights way where you have inclusion … even the marginalised people, if they are involved in the planning, if you work to get an impact, then they will help you; to create a sense of ownership and responsibility for everyone.’ (female student, uganda) ‘i feel the impact will come. it’s not going to be an immediate thing where you suddenly see the light and that everything just flows smoothly. it is a process.’ (female student, sa) as healthcare and nutrition practitioners, hnps integrate all of the professional attribute roles, applying professionspecific knowledge and professional attitudes in their provision of person-centred care broadened understanding of their role as professional holistic approach to nutrition and human rights life changing ‘i don’t think i could have foreseen how it would change me or the way i look at things.’ (female student, sa) ‘my interest within the nutritional field is at a global level … and the prevention of diseases more than the clinical treatment of diseases. it made me more politically interested and i see my future more clearly than i did before.’ (female student, norway) hnp = health and nutrition professional. october 2016, vol. 8, no. 2 ajhpe 163 research must fulfil (table 1), i.e. those of communicator, collaborator, manager and leader, scholar, health (and nutrition) advocate and a professional, culminating in being a (nutrition) practitioner.[6] communicator: learning to effectively participate during dynamic exchanges students testified to personal growth as they grew more independent during the study period in foreign countries and gained confidence in expressing their feelings. even though the more reserved students were afraid of ‘saying anything wrong’ whenever sensitive issues were discussed, other students felt supported by the group and free to ask questions: ‘you learn when to keep quiet and when to say your say … to state why you disagree or have different ideas.’ (female student, sa) it was a source of frustration for some students when fellow students did not voice their opinion during the lectures. some identified communicating in english as a second language as a barrier, limiting spontaneous participation and self-expression at times. students willing to interact in a meaningful way learnt from each other how to participate in discussions and debates in a culturally sensitive manner. collaborator: learning to embrace differences participating students, being from different countries and studying at different universities, were introduced to perspectives, values and social norms that partially differed from those they were used to: ‘take it in your stride and inhale as much as you possibly could … look to compare … so many differences but so many similarities … .’ (female student, sa) overall, students embraced the opportunity to meet people from different nations and used the opportunity to find out ‘why they believe what they believe’. mature students or those who had been exposed previously to other world views and cultures seemed more tolerant of and respectful towards inherent differences. in this context, culture is understood in the broader sense; it is the total way of life in a society, which distinguishes members of human groups from others in terms of shared beliefs, ideologies and norms that influence actions.[11] these cultural differences were a potential source of misunderstanding and conflict; for example, differences in time management sometimes interrupted the teaching schedule. cultural differences became most pronounced in uganda and some of the foreign students adapted with difficulty. to enable co-operation and develop an understanding of different cultures required some effort, and awareness that there may be issues within one’s own culture or country unacceptable to foreigners. what was considered as rude or discourteous differed according to the cultural context. for example, in uganda, all conversations start with a reciprocal enquiry about each individual’s wellbeing before the actual conversation begins. in contrast, people in norway use fewer formalities, ‘if you want to do something, you don’t waste any time doing it’. additionally, in norway, religion is regarded as a private matter but in uganda it is discussed freely: ‘when it comes to culture, it brings out a positive something. but as soon as it does not coincide with the other countries, then they [foreign students] bring up those issues of someone being offended.’ (female student, uganda) diversity also provided many opportunities for interesting and sometimes heated debates, and those who were able to accept differences refined the skill of dealing with difficult situations. unknowingly, an ‘ignorant’ question was sometimes perceived as being offensive or it came across as being derogatory. for example, a lack of awareness that sometimes things in uganda are just accepted and not challenged created a situation where a student offended people by asking questions – according to the ugandan culture, it is rude to tell someone if they are in the wrong. people have different ways of coping with stress and unfamiliar situations. more than one student admitted that they needed to become more tolerant and to learn how to deal with conflict. one student mentioned that she initially became psychologically disengaged to avoid offending people by saying ‘something wrong’. the stress caused another student to overreact; she became emotional ‘where i didn’t expect i would have’. others learnt how to manage their own emotions and felt better equipped to handle difficult situations in future. manager: learning to enhance effectiveness ‘i certainly feel more equipped and competent to work at a level where i am not just on the ground but i am able to work with people who are possibly making policy decisions … . ’ (female student, sa) problem-solving skills were enhanced as students had to evaluate situations, identify areas for improvement and compare different countries. students felt better equipped to be part of an interor transprofessional group, as knowledge of the hrba ‘… adds to any professional that works with people, policies or scarce resources that you need to redistribute’. students learnt how to prioritise their responsibilities and how to manage large volumes of information. one student realised that ‘… time is a very, very important factor which i did not take into consideration [previously]’. according to their current job description, some students felt apprehensive about immediate implementation of an hrba, realising that to effectuate change, the usual planning process needed to be followed, requiring hard work and perseverance: ‘i feel the impact will come. it’s not going to be an immediate thing where you suddenly see the light and that everything just flows smoothly. it is a process.’ (female student, sa) health and nutrition advocate: learning to influence the wellbeing of individuals and communities students became aware that nutrition is interrelated and integrated, and that issues of food, nutrition and food security cannot be addressed without attention to broader sociocultural, political, economic and technical issues. they anticipated the future implementation of an hrba in their daily practice by assessing individuals in a holistic manner, involving the person/ community in decision-making processes and consulting the community about new projects: ‘not to just rush into something and try and change things but rather to look at the reason why you want to change things … what impact it will have on people.’ (female student, sa) some students were enthusiastic about newly acquired skills when advocating for nutrition or engaging with public officials or non-governmental organisations. another student was more cautious, as she realised that government officials may have a limited understanding of food as a human right. she regarded it a challenge for nutrition professionals who want to act as agents for change: 164 october 2016, vol. 8, no. 2 ajhpe research ‘we have to first teach people in government about human rights … because if they don’t understand it, they can’t accept nor implement it.’ (female student, uganda) scholar: lifelong learning the module provided students with a global perspective and challenged them on intellectual, emotional and physical levels. students felt enriched by being exposed to new concepts and unique experiences. it motivated them to share their knowledge with colleagues and to train other health professionals. students accepted the responsibility of acting or speaking on behalf of vulnerable groups in the future and providing accurate information about their situation. in various ways, diversity helped to develop a better comprehension of the module content. some male students expressed the opinion that diversity in the group prevented the module from becoming ‘static’. students with previous work experience were familiar with working in an interor transdisciplinary environment and could provide practical examples, explain specific situations or compare policies and programmes implemented in different countries. students from all countries benefited from new information about their own countries and found that they understood global events and processes better. other interests relevant to nutrition were developed, e.g. the interrelationship between nutrition, agriculture and political stability. professional: conducting ethical practice examples given above show that students embraced diversity and adopted a holistic approach, indicating their enhanced perception of professional and ethical practice. some students felt relieved when they realised that they did not necessarily need to conform to peer pressure and that they should remain true to their values. healthcare and nutrition practitioners: integrating their competencies overall, an awareness of hardship experienced by vulnerable population groups was developed, one which helped to foster a changed mindset, ‘… to give more than i receive. to look where i can make a difference …’. students’ passion for nutrition was reinvigorated, inspiring them to serve needy communities in a meaningful way. they finally realised the extent of their calling as dietitians/nutritionists, and that it included being ‘advocates and consultants for human rights’. noma students regarded themselves as privileged. they realised that they had previously had a narrow technical focus without a broader contextual understanding of food and nutrition security. they were now equipped to foster a person-centred approach, as part of a global network promoting the right to adequate food. discussion frenk et al.[1] argued that ‘tribalism of professions should be replaced with collaboration to optimise mutual learning opportunities across countries’. as an example of transnational education (where a student is in a different country than the host university and where academic qualification is obtained),[12] the development of the noma track module was brought about through successful collaboration between universities from different countries, with a willingness to form a network and share educational resources. in search of sustainable solutions to nutrition-related problems, the module strived to integrate human rights and nutrition using an hrba. professionals from both fields aimed at educating students to contribute to societies as they currently exist and for future changes as they evolve.[7,13] professionals representing both fields had as their objective the education of students, through whom current and future changes to societies will be influenced. the structure of the module was such that the noma students had to adapt to different cultures and educational systems every 6 weeks. even with the assistance of peers, international students still needed time to adjust to the different sets of social rules that regulate interaction and communication. kelly[10] suggests that while students are still adapting, they are less inclined to be interactive; this may have caused gaps in understanding, as lecturers and peers may have perceived students as being unwilling or unable to participate. it is particularly important for lecturers of transnational students to be aware of the potential for culture to influence student preferences and expectations and introduce sufficient flexibility into their approach to teaching to accommodate various nationalities, educational backgrounds, learning styles and language proficiencies.[14] lecturers may have had unrealistic assumptions about noma students’ competence, e.g. their ability to manage a large volume of literature.[9] even though international students may be english literate, using a second language may negatively affect their ability to participate optimally during interactive learning opportunities.[10] based on the findings of this research, it is recommended that the following aspects should be considered during the introduction of any transnational module: introductory lectures on world view, time management and academic writing (including referencing). academic institutions should strive to reduce the transition period for international students by reassessing whether the curriculum is culturally responsive and relevant to the needs of such students, making them feel included rather than excluded or disadvantaged. if not, the potential exists to promote surface learning and/or an inability to solve problems independently.[10] different teaching strategies to help the adaptation process and to enhance learning were employed in the module.[9] however, there is no single correct way to learn. ultimately, different learning cultures have the potential to stretch individual students beyond their established styles, and to develop learning strategies/approaches that are more adaptive. this may also create a greater capacity to engage in lifelong learning and professional development opportunities.[14,15] thus, lecturers need to consider carefully the choice of approaches that they encourage/discourage, and their use and development.[14] several noma students from different countries formed close relationships and it is possible that collaboration and understanding would have been further enhanced if more opportunities for socialisation were integrated in the module programme.[10,16] during the development of future modules for transnational students, the use of team bonding exercises, cross-cultural communication activities and allocation of mentors, to facilitate the adaptation process and to develop skills in collaboration and teamwork, may be considered.[10] the interviews revealed that some underlying tension and conflict during the training period may be ascribed to interpersonal differences. however, this may have been influenced by power differences between groups formed during the 4-month period, or caused by a lack of leadership, indicating the absence of a common group identity and resulting in misunderstandings october 2016, vol. 8, no. 2 ajhpe 165 research arising from poor communication.[17] there were situations that arose because of cultural insensitivity or poor communication that might have been avoided by proactively developing a mutually agreed process for handling disagreements within such a diverse group.[18] some students embraced diversity by learning more about observable elements (i.e. language) and hidden elements of cultural characteristics (i.e. customs).[19] noma students identified the need for an introductory lecture about cultural diversity to enhance mutual understanding.[9] however, students should also be advised that they will not always fully understand a foreign culture, that it is often helpful to assume the role of the ‘respected outsider’ and be encouraged to focus on commonality rather than separateness.[19] generally, the need to develop competence generates an intrinsic interest in what is being learnt.[10] students who previously had a strictly scientific approach to nutrition were drawn to participate in the module because of their keen interest in the link between nutrition and human rights. students were also introduced to aspects of political science and agriculture, nurturing the potential to join in public reasoning as informed citizens and on behalf of vulnerable groups.[1,2] after completion of the module several students were inspired to contribute in diverse contexts beyond their own countries[9] and to act as agents for change in the organisations in which they may work or act as leaders or co-ordinators during interaction with community groups and policy makers.[1,2] similarly to undergraduate module development, it is recommended that during the development of modules at a master’s degree level, a rigorous competency-based curriculum design process is followed, clarifying beforehand the competencies that the specific module should help to develop and, most importantly, how these competencies will be assessed. conclusion according to the recommendation made by the lancet commission to ‘promote quality, uphold a strong service ethic, and be centred around the interests of [individuals and] populations’, the noma track module addressed an integrated approach to human rights and nutrition. based on the perceptions of the students, it became evident that the professional competency attributes of a group of master of nutrition students were also enhanced. transnational and transprofessional education provided nutrition professionals the opportunity to broaden their competency base. besides learning to respect diversity and embracing cultural differences and similarities, the students learnt to see critical issues from the perspective of political, social and agricultural sciences. without this understanding, intolerance and prejudice often create a barrier to optimal intervention or education of a person/community requiring professional advice. the development of future transnational modules will benefit from the inclusion of professional competencies as part of the module outcome, by following a competency by design process. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 2. gillespie s, haddad l, mannar v, menon p, nisbett n, maternal and child nutrition study group. the politics of reducing malnutrition: building commitment and accelerating progress. lancet 2013;382(9891):552-569. doi:10.1016/s0140-6736(13)60842-9 3. barrie sc. a conceptual framework for the teaching and learning of generic graduate attributes. stud high educ 2007;32(4):439-458. doi:10.1080/03075070701476100 4. bowden j, hart g, king b, trigwell k, watts o. generic capabilities of atn university graduates. canberra: teaching and learning committee, australian technology network, 2000. http://www.worldcat.org/title/ generic-capabilities-of-atn-university-graduates/oclc/223603532 (accessed 2 july 2014). 5. faculty of medicine and health sciences, stellenbosch university. graduate attributes. stellenbosch: centre for health professions education (chpe), stellenbosch university, 2013. 6. frank jr, ed. the canmeds 2005 physician competency framework. better standards. better physicians. better care. ottawa: the royal college of physicians and surgeons of canada, 2005. http://www. royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_ full_e.pdf (accessed 2 july 2014). 7. united nations committee on economic, social and cultural rights (cescr). general comment no. 12: the right to adequate food (art. 11 of the covenant). new york: un cescr, 1999. http://www.refworld.org/ docid/4538838c11.html (accessed 2 july 2014). 8. the world conference on human rights. vienna declaration and programme of action, a/conf.157/23. new york: united nations general assembly, 1993. http://www.unhcr.org/refworld/docid/3ae6b39ec.html (accessed 2 july 2014). 9. marais ml, eide wb, mclachlan mh. the noma track module on nutrition, human rights and governance: part 1. perceptions held by master’s students. afr j health professions educ 2016;8(2):152-159. doi:10.7196/ ajhpe.2016.v8i2.553 10. kelly p, moogan y. culture shock and higher education performance: implications for teaching. high educ quart 2012;66(1):24-46. doi:10.1111/j.1468-2273.2011.00505.x 11. hofstede g. cultural differences in teaching and learning. fuhu conference on education and training in the multicultural classroom, copenhagen, 8 may 2008. http://fuhu.dk/filer/fbe/arrangementer/denmark%20 unlimited%20080508/fbe_geert_hofstede_teaching_learning.pdf (accessed 2 july 2014). 12. global alliance for transnational education (gate). http://tojde.anadolu.edu.tr/tojde6/journals_and_institutions/ gate.htm (accessed 2 july 2014). 13. conteh mb. human rights teaching in africa. the socio-economic and cultural context. secur dialogue 1983;14(53):53-67. doi:10.1177/096701068301400107 14. watson j, chapman j, adams j, nila uh. occupational therapy students’ approaches to learning: considering the impact of culture. br j occ ther 2006;69(12):548-555. doi:10.1177/030802260606901203 15. de vita g. inclusive approaches to effective communication and active participation in the multicultural classroom: an international business management context. active learn high educ 2000;1(2):168-180. doi:10.1177/1469787400001002006 16. rudman c. from passive to active – active learning methods in international human rights law. in: proceedings of the higher education learning and teaching association of southern africa (heltasa). stellenbosch university, 28 30 november 2012. http://www0.sun.ac.za/heltasa/pluginfile.php/2/course/section/2/heltasa%20 conference%20proceedings_2012.pdf (accessed 2 july 2014). 17. burford b. conflict and power as intergroup processes: not below the surface, but part of the fabric. med educ 2012;46(9):830-837. doi:10.1111/j.1365-2923.2012.04325.x 18. crose b. internationalisation of the higher education classroom: strategies to facilitate intercultural learning and academic success. int j teach learn higher educ 2011;23(3):388-395. 19. van oordt l, corn k. learning how to ‘swallow the world’: engaging with human difference in culturally diverse classrooms. j res int educ 2013;12(1):22-32. doi:10.1177/1475240913478085 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(13)60842-9 http://dx.doi.org/10.1080/03075070701476100 http://www.worldcat.org/title/generic-capabilities-of-atn-university-graduates/oclc/223603532 http://www.worldcat.org/title/generic-capabilities-of-atn-university-graduates/oclc/223603532 http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf http://www.refworld.org/docid/4538838c11.html http://www.refworld.org/docid/4538838c11.html http://www.unhcr.org/refworld/docid/3ae6b39ec.html http://dx.doi.org/10.7196/ajhpe.2016.v8i2.553 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.553 http://dx.doi.org/10.1111/j.1468-2273.2011.00505.x http://fuhu.dk/filer/fbe/arrangementer/denmark%20unlimited%20080508/fbe_geert_hofstede_teaching_learning.pdf http://fuhu.dk/filer/fbe/arrangementer/denmark%20unlimited%20080508/fbe_geert_hofstede_teaching_learning.pdf http://tojde.anadolu.edu.tr/tojde6/journals_and_institutions/gate.htm http://tojde.anadolu.edu.tr/tojde6/journals_and_institutions/gate.htm http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1177/030802260606901203 http://dx.doi.org/10.1177/1469787400001002006 http://www0.sun.ac.za/heltasa/pluginfile.php/2/course/section/2/heltasa%20conference%20proceedings_2012.pdf http://www0.sun.ac.za/heltasa/pluginfile.php/2/course/section/2/heltasa%20conference%20proceedings_2012.pdf http://dx.doi.org/10.1111/j.1365-2923.2012.04325.x http://dx.doi.org/10.1177/1475240913478085 may 2015, vol. 7, no. 1 ajhpe 55 research the term ‘learning approaches’ is used to describe what students do when engaging in the learning process, and what primarily motivates them to adopt a particular way of learning. several studies have been conducted to determine the learning approaches that specific groups of students use, and the factors in the various groups that motivate or develop their adopted learning approaches.[1] when defining learning approaches, there are two main categories, i.e. the deep learning approach (dla) and surface learning approach (sla). a consistent finding is that learning is a process and that approaches to learning are shaped by both intrinsic and extrinsic factors.[1] process of learning learning is a lifelong process that is a combination of three distinct variables: presage, process and product. biggs[2] conceptualised these variables into an interactive and interrelated system that can be used as a framework from which the process of learning can be understood. the presage variable comprises factors that exist before the learning experience (those aspects that the student brings into the learning environment) and is a combination of intrinsic and extrinsic factors. intrinsic factors consist of the personal and innate character traits of the student and can mean that a student is naturally hard working or not, dedicated or uncommitted, and represents the student’s attitude in the learning process.[1] extrinsic factors consist of the learning environment into which the student enters and include the structure of the educational programme, prescribed workload, teaching methods and forms of assessment.[1,3] research has shown that the learning environment alone can push a student towards a dla or an sla.[1,2,4,5] learning as a process may be shaped by both intrinsic and extrinsic factors.[1] dlas are associated with the student engaging with, understanding and making personal meaning of the content being learnt. however, slas result in the student relying on memorisation and fact recall in a manner that leaves the information unrelated and isolated from the underlying meaning of the content learnt. dlas are associated with ‘knowledge transformation’ and slas with ‘information reproduction’. the primary distinction is that the sla is generally relied on when the aim of learning is to momentarily perform well in an assessment. this does not reflect the level of competency achieved by the student in the tested subject matter; it is a reflection of their competency in being able to perform for assessments. the opposite is true for the dla, where the aim of learning lies in the understanding and interpretation of the learning material, with performance in assessments being a secondary, or even consequent, aim.[2,5,6] the bachelor of emergency medical care (bemc) is a 4-year professional degree programme leading to registration with the health professions council of south africa as an emergency care practitioner, the top tier of non-physician prehospital emergency care personnel. no formal study has yet been undertaken to determine student learning approaches and factors that may influence these in the bemc programme. this knowledge gap makes it difficult for academic staff to understand how students are adapting to the learning content and environment, and limits understanding of whether students are applying appropriate learning strategies within each specific year of study. additionally, insight regarding learning approaches may provide judgements to be made regarding the appropriateness of the bemc programme structure and success of employed teaching methodologies. background. students may primarily use either a deep learning approach (dla) or surface learning approach (sla) in response to their perceptions of the intrinsic and extrinsic factors within a given learning environment. by determining the learning approaches of students, one can provide important information on how they learn within an educational programme – information that can be used for various applications with regard to future structure and presentation of programme content. objectives. to determine which learning approaches (dla or sla) were being used by students in the bachelor of emergency medical care programme at the university of johannesburg, south africa, in each academic year of study. further objectives were to determine which intrinsic and extrinsic factors influenced these choices and to assess whether learning approaches differed significantly between academic years of study. methods. this study was conducted using a quantitative design and a validated 20-question survey instrument. data analysis was primarily descriptive, but also focused on whether there was a significant difference in learning approaches between the four years of study. results. seventy students participated in the study, giving an overall response rate of 85%. results showed that most students predominantly used a dla, and that there was no significant difference between the four academic years of study with regard to the predominant learning approach. more students appeared to be influenced to use a dla by extrinsic factors than intrinsic factors. conclusion. further research is needed to determine why students choose slas or dlas, and the influence of the educational environment on this process. afr j health professions educ 2015;7(1):55-57. doi:10.7196/ajhpe.393 learning approaches used by students in an undergraduate emergency medical care programme c mosca, btech emergency medical care; a makkink, btech emergency medical care, pdte; c stein, btech emergency medical care, btech education (post-school), phd (emergency medicine) department of emergency medical care, faculty of health sciences, university of johannesburg, south africa corresponding author: c stein (cstein@uj.ac.za) 56 may 2015, vol. 7, no. 1 ajhpe research objectives the objective of this study was to determine what learning approaches (dla or sla) were adopted by students in each academic year of study and whether these differed significantly between years in a manner consistent with a progression from sla to dla between year 1 and year 4. the primary hypothesis was that first-year students would mostly use slas and that there would be a transition to an increasingly dla from year 1 to year 4. our motivations for this reasoning were based mostly on our anecdotal observations that first-year bemc students are mainly poorly equipped to deal with a university-level academic workload and may therefore adopt an sla to cope with passing assessments. over time, and with academic progression from first to fourth year, we felt that this may change and a dla may be adopted. we thought that the factors influencing students in this way would most likely be extrinsic and part of the university learning environment. methods questionnaire the 20-item biggs r-spq-2f questionnaire was used to assess the learning approach that bemc students chose to adopt – dla or sla.[2] the questionnaire was specifically designed as a sensitive tool to identify student approaches to learning (sal) and has been previously validated.[7] it also contains a sub-scaling system that allows data interpretation in a way that can identify the factors influencing the learning approach that students use. the motive subscale is used to identify the intrinsic factors that motivate students to adopt either a dla or an sla, and the strategy subscale to identify the extrinsic factors of the learning environment that motivate students in this regard.[2] study sample and data collection all students registered for full-time study in the bemc programme at the university of johannesburg, south africa, were invited to take part in the study. those willing to participate and who signed the appropriate consent form were eligible to take part. consenting students completed questionnaires before or immediately after scheduled lectures. ethical approval to conduct the study was obtained from the faculty of health sciences academic ethics committee at the university of johannesburg. data analysis closed response data from completed questionnaires were captured onto a spreadsheet application and scored in accordance with the recommended scoring system. the main sal scores were used to determine whether students used a dla or an sla. answers for each specific approach were grouped and combined to reach an overall total. the group of questions with the highest total was considered indicative of the predominant learning approach of that particular respondent. scores were grouped by academic year of study (first to fourth). subscale data for surface and deep motive and strategy were also scored according to the questionnaire scoring system and grouped by academic year of study. differences in main sal and subscale scores across academic years of study were compared using the kruskal-wallis test, as the data in each group were found to be non-normal. spss (version 17.0, spss science, chicago, usa) was used for inferential data analysis and all statistical tests were considered significant at p<0.05. results response rate data are shown in table 1. the decrease in student numbers from first to fourth year is due mainly to the fact that the bemc programme was in the process of being phased in as a replacement for the previous national diploma in emergency medical care and did therefore not have a full complement of students in the third and fourth years. the distribution of grouped main sal scores across academic years is shown in table 2. groupings reflect the predominant approach to learning and participants were placed in either the dla or sla group based on their highest sal score, as described above. almost three-quarters of participants across all academic years were classified as having a dla and the remainder an sla. a trend in proportional classification across the academic years, from first to fourth, can be seen in table 2, with a progressive increase in those classified as having a dla and a corresponding decrease in those with an sla. results from analysis of the questionnaire subscales are shown in table 3. table 1. student responses by academic year academic year of study total responses, n registered students, n response rate, % first year 30 34 88 second year 16 19 84 third year 17 21 81 fourth year 7 8 88 total 70 82 85 table 2. distribution of main sal score groupings across academic years academic year of study deep approach, n (%) surface approach, n (%) first year 20 (67) 10 (33) second year 11 (69) 5 (31) third year 14 (82) 3 (18) fourth year 6 (86) 1 (14) total 51 (73) 19 (27) sal = student approaches to learning. table 3. distribution of sal deep and surface subscale score groupings across academic years academic year of study deep motive, n (%) deep strategy, n (%) surface motive, n (%) surface strategy, n (%) first year 14 (47) 6 (27) 0 10 (33) second year 4 (25) 7 (44) 0 5 (31) third year 4 (24) 10 (59) 0 3 (18) fourth year 1 (14) 5 (71) 0 1 (14) total 23 (45) 28 (55) 0 19 (100) sal = student approaches to learning. may 2015, vol. 7, no. 1 ajhpe 57 research of the 51 participants classified as adopting a dla, more were classified as adopting a deep strategy than being intrinsically motivated to follow a dla. furthermore, the proportion of participants falling into the deep motive category progressively decreased across academic years of study, while there is a corresponding increase in the proportion of participants classified as deep strategy. no participants in the sla group indicated that they were motivated to do so by intrinsic factors. results of the kruskal-wallis test were used to test the null hypothesis that there was no difference in sal main or subscale scores of learning approach across the four academic years of study (table 4). no significant differences were found for any of the sal scores. discussion the results of this study show a large proportion of students adopting a dla from their first academic year of study and this proportion increases further over the four years of study. these findings are in line with data from similar studies. this pattern has been seen in studies using either the biggs spq instrument or the entwistle-ramsden lancaster approaches to studying inventory.[8-10] however, the findings of the study by martenson[11] showed that an sla among four cohorts of medical students was the predominant approach. about two-thirds of first-year participants were classified as using a dla; this was unexpected and contrary to our hypothesis of a predominantly sla in this group. we reasoned that the academic workload and transition from school to university in a cohort that we have observed over time as being relatively poorly prepared for university study would induce an sla, if this had not already been the dominant approach for many participants at school. our results showed a 19% increase in the proportion of participants classified as adopting a dla from first to fourth year (table 2). this trend is in keeping with the literature, suggesting that many adult students tend to develop their use of dla over time – from junior to more senior academic levels of study. in many cases, this appears to be intrinsically driven as students develop skills required to apply dlas.[1-3,7] subscale data on whether the primary motivation for the dominant learning approach was intrinsic or extrinsic offer some additional information regarding the participants in our study. responses summarised in table 3 suggest that roughly half of the participants in the first year of study were intrinsically motivated to adopt a dla, i.e. they brought this learning approach with them into the learning environment. however, about one-quarter of participants in the same group were extrinsically motivated to adopt a dla, suggesting that they did this in response to the academic demands of the learning environment in which they found themselves.[1,4,6] entwistle and ramsden[12] have suggested that the learning approach of students is ultimately influenced by the learning environment and that effective learning is the result of a unique combination of the student’s preferred orientation to learning and the learning environment itself. the progression over four academic years of study, with intrinsic motivation for a dla becoming less prevalent and extrinsic motivation more prevalent (table 3), suggests that the learning environment, including teaching methodologies and assessment practices, may become more of a driver to adopt a dla. this is mirrored by the sla subscale results, showing a decreasing prevalence of extrinsic motivation for participants to follow an sla from first through to fourth year. no participants were identified as being intrinsically motivated to adopt an sla. although our study provides valuable information on the adoption of slas and dlas by students in our programme, more work is needed to understand in greater detail what drives these choices and in particular the role of the learning environment in this process. the proportional decrease across the four years of study in students adopting a deep motive (table 3) in particular, is a trend of some importance for future investigation and monitoring over time. future research in this area should be designed to follow one or more cohorts of students over the four years, which may clarify whether the trend observed in this study is still present longitudinally and, if so, whether any kind of intervention may be appropriate. limitations the sample used for this study was relatively small, although it comprised a cross-sectional picture of almost the entire bemc programme in our department at the time. the small number of fourth-year participants makes broader interpretation of the results difficult and there is a possibility that variance in this group may increase in future with increased size of the group. the small sample, and the very small fourth-year group size, increases the possibility of a type ii error in results of the inferential analysis presented in table 4. references 1. beattie v, collins b, mc innes b. deep and surface learning: a simple or simplistic dichotomy? account educ 1997;6(1):1-12. 2. biggs j, kember d, leung dyp. the revised two factor study process questionnaire: r-spq-2f. br j educ psychol 2001;71:133-149. 3. alkadhi s. learning theory: adult education: andragogy. [dissertation] monterey bay, calif.: california state university, 2008. 4. ames c. classrooms: goals, structures, and student motivation. j educ psychol 1992;84(3):261-271. [http://dx.doi.org/10.1037/00220663.84.3.261] 5. ramsden p. the context of learning in academic departments. in: marton f, hounsell d, entwistle n. the experience of learning: implications for teaching and studying in higher education. 3rd ed. edinburgh: university of edinburgh, centre for teaching, learning and assessment, 2005:198-213. 6. entwistle n. promoting deep learning through teaching and assessment: conceptual frameworks and educational contexts. tlrp conference, leicester, november 2000. http://www.ed.ac.uk/etl/docs. entwistle.pdf (accessed 8 october 2013). 7. lizzio a, wilson k, simons r. university students’ perceptions of the learning environment and academic outcomes: implications for theory and practice. stud high educ 2002;27(1):27-52. [http://dx.doi. org/10.1080/03075070120099359] 8. newble di, gordon mi. the learning style of medical students. med educ 1985;19(1):3-8. 9. emilia o, mulholland h. approaches to learning of students in an indonesian medical school. med educ 1991;25(6):462-470. 10. mattick k, knight l. the importance of vocational and social aspects of approaches to learning for medical students. adv health sci educ theory pract 2009;14(5):629-644. 11. martenson d. students’ approaches to studying in four medical schools. med educ 1986;20:532-534. 12. entwistle n, ramsden p. understanding student learning. london: croom helm, 1983:209. table 4. results of the kruskal-wallis test: difference in main student approaches to learning and subscale scores between academic years deep surface deep motive deep strategy surface motive surface strategy χ2 2.626 3.154 0.301 6.696 1.384 4.493 df 3 3 3 3 3 3 p 0.453 0.369 0.960 0.082 0.709 0.213 df = degrees of freedom. research 50 may 2016, vol. 8, no. 1 ajhpe in 2010, the lancet published recommendations of a global independent commission that aimed to establish a 21st-century vision for the education of health professionals.[1] in essence, health professional education must go beyond an emphasis on care for the individual patient and instil the importance of addressing broader social issues (social accountability). this study is based in an isolated, deep-rural area of kwazulu-natal (kzn), south africa (sa) and focuses on the umthombo youth development foundation (uydf) – a model that aims to address issues of social accountability through several strategies, including community involvement in health professional education. the world health organization (who) defines the social accountability of health professional education institutions as ‘the obligation to direct education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve’.[2] the world development report 2004 discussed two routes to link social accountability and education: a ‘long route’ and/or a ‘short route’.[3] in the long route citizens elect their representative politicians, who appoint or influence policy makers. the latter, in turn, form policies, taking into account the needs and preferences of citizens. the short route involves building a direct relationship between local clients (such as community members), healthcare services and health professional education institutions. any consideration of a short route for social accountability is particularly pertinent for an sa rural context, as the building of relationships between a local community and healthcare providers was prioritised in the communityorientated primary care (copc) approach initiated by sydney and emily kark in 1942. the karks founded a healthcare centre in pholela, an impoverished zulu tribal reserve in what was then the eastern province of natal; the two doctors expanded their medical work to include improving housing, increasing access to food, and seeking the views of community members in healthcare initiatives. their innovative approach inspired other projects around the world. the literature notes that although community involvement and social accountability were not described as explicit goals of copc, community involvement in healthcare is implicit in the shared understanding of social, physical and economic causes of health problems and in the design of copc interventions.[4] building on ideas of copc and an implicit need for community involvement, the aider (assess, inquire, deliver, educate and respond) model of medical education overtly considers social accountability through community partnerships.[5] unlike the original copc approach, the aider model proposes a continuous monitoring process that explicitly incorporates education and collaboration with underserved stakeholders. social accountability in health professional education would thus appear to require a tridirectional process of engagement between communities, healthcare providers and institutions of higher learning (ihl). there is a belief that such partnerships will create the connectedness required to accelerate advances in patient care, health professional education and research.[6] in theory, by allowing community members to directly engage with health professional training, the community can take some form of ownership of education and see the results of their efforts. a short route can strengthen what the world bank calls ‘client power’.[3] in rural sa, taking cognizance of the literature and recommendations around the importance of community involve ment in health professional service and education, the uydf model was initiated in 1999 and background. internationally, the development of partnerships between institutions of higher learning and the communities they serve is stressed as a priority. the umthombo youth development foundation (uydf) is an educational model developed in rural kwazulu-natal, south africa as a response to the scarcity of medical personnel in hospitals. community involvement in health professional education has become a key strategy in the model, and review of the model may provide lessons for other educators towards implementing community involvement in health professional education. objective. to review the uydf, with emphasis on aspects of community involvement. methods. this qualitative study used a social accountability theoretical framework. data were collected using the appreciative inquiry method and participants who were involved in the uydf model were interviewed. themes arising around community involvement were generated inductively. results. community involvement in health professional education grew from a funding requirement and has strengthened over time to become an integral component of the uydf model. community involvement occurred mainly at the student selection process, but continued during education and after graduation. participants suggested means by which community involvement could be strengthened. conclusion. the uydf successfully presents a model that facilitates community involvement in health professional education. lessons learnt could guide other models, and the uydf model could be strengthened by further research. afr j health professions educ 2016;8(1):50-55. doi:10.7196/ajhpe.2016.v8i1.559 the umthombo youth development foundation, south africa: lessons towards community involvement in health professional education l m campbell,1 phd, mb chb, mfammed, mmedsci, mphil, fracgp; a j ross,1 mb chb, dch, mmed (family medicine), fcfp; r g macgregor,2 phd, msc (agric), bsc hons, bsc agric 1 department of family medicine, college of health sciences, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 umthombo youth development foundation, hillcrest, south africa corresponding author: l m campbell (campbella@ukzn.ac.za) research may 2016, vol. 8, no. 1 ajhpe 51 has developed over time as a short route, as reflected within a copc approach. the explicit intent of the uydf model is to consider the responsibilities of health professional education beyond a narrow focus of individual patient care, and emphasis is placed on social accountability, including community involvement.[7] in the uydf model, the community are involved at several levels: representatives of the community (including tribal authorities) and members of a hospital board are directly involved in decisions with regard to selection. local patients and hospital staff have the opportunity to longitudinally interact with the students as the latter return to the hospital during vacations. students are required to carry out a community diagnosis and intervention as part of an undergraduate ‘selectives’ module. students return to work in the community after graduation. a review of the uydf model is available in the literature[7] and represented diagrammatically in fig. 1. there is an increasing amount of literature on how to measure social accountability in health professional education. there has been a call to standardise such measurements so that comparisons can be made and progress measured.[8] the who have adapted the aider model and formatted a group known as the education for health equity network (thenet), which has developed a framework to evaluate social accountability in health professional education.[8] the framework considers many factors, including community involvement in the form of partnerships between the community, healthcare providers and health professional education institutions.[8] although there is much literature on the need for local community involvement in health professional education, there is correspondingly less literature on how to practically ensure local community involvement. taking cognizance of thenet framework, this study considered practical questions with regard to the uydf model: (i) why was community involvement initiated?; (ii) how is community involvement achieved?; and (iii) how could community involvement be strengthened? study methods study design the study was cross-sectional, descriptive and employed qualitative methods. the theoretical framework was based on thenet framework around social accountability and community involvement in health professional training.[8] setting the study was conducted on persons involved in the uydf model and therefore the setting was mainly in the mosvold health subdistrict in ingwavuma in northern zululand in rural kzn, where the uydf model has been developed and implemented since 1999. the community served by the uydf is diverse and primarily served by mosvold hospital, which according to estimates by the department of health (2002) comprises about 108 000 people.[9] the population is rural and poor, with adult unemployment at 60%. only 5% of households have piped water and 3.6% have electricity.[9] government healthcare is provided by the hospital, 10 residential clinics and three mobile clinic teams. the ravages of apartheid are still obvious in the area, where schooling is generally poor, people are trapped in cycles of poverty and are geographically isolated, and access to an ihl is extremely limited. sa higher education, including health professional education, has undergone considerable transition since the dawn of the democratic era in 1994. in post-apartheid sa, access to higher education is linked intricately to the quest for social equity, and accessibility for marginalised students such as those from ingwavuma is crucial to the success of any attempts to achieve social justice. potential participants in qualitative research, potential participants are purposely selected as ‘information-rich’ and generally relatively small numbers of participants are studied in great detail.[10] potential participants were persons who have been involved in the uydf model and included: • community members • representatives of a local hospital • uydf founders, managers and mentors • graduates. several participants from mosvold hospital, such as doctors, nurses, occupational therapists and physiotherapists, play the dual role of healthcare providers and educators. they are involved in the day-to-day supervision and teaching of students who attend the hospital during vacations. data collection method data were collected using a method of appreciate inquiry (ai) – an approach aimed at constructive organisational change.[11] ai explores and builds on the positive features in an organisation and is based on the premise that meaningful and fundamental change occurs through discovering and valuing the strengths, assets, vision and ideals of the individuals in an organisation. ai focuses on what is working well (appreciative) by engaging people in asking questions and sharing their perspectives (inquiry). it has been used to successfully achieve collaborative change school marketing information about health science careers; grades and subjects needed; university application process; hospital open day the model graduates graduate support and development student mentoring support academic and social mentoring support comprehensive �nancial support university tuition and academic mentoring holiday work hospital open days voluntary work selection interviews employment graduation impact: well-resourced hospitals with local sta� o�ering comprehensive healthcare services to rural communities local hospital fig. 1. representation of the strategies involved in the uydf model. research 52 may 2016, vol. 8, no. 1 ajhpe in communities and organisations, including universities and medical schools.[12] in this study, based on the ai method, participants were interviewed and asked to describe their experiences, involvement and wishes around the uydf model. the interviews were tape recorded and transcribed to text. data analysis analysis involved a back-and-forth process searching for and coding themes, patterns and words; this is described fully in the literature.[10] the process involved immersing in data, i.e. becoming very familiar with the text to the point of knowing where particular quotations occur and getting a feel for the overall meanings and themes. scientific rigour traditionally, quantitative criteria to ensure methodological scientific rigour include a consideration of validity, generalisability and reliability. however, such criteria are generally not applicable to qualitative work, and this study used different methods to ensure that the process adhered to sound scientific research principles. we relied primarily on a concept of trustworthiness, which the literature describes as an important concept, as it allows researchers to describe the virtues of qualitative terms outside of the parameters that are typically applied in quantitative research.[13] throughout the study, trustworthiness was considered in terms of credibility, transferability, dependability, and confirmability.[13] credibility considers how congruent the reported study findings are with reality. methods to ensure credibility included prolonged engagement between participants and researchers; interviewing a wide range of participants; interviews at various sites; and the use of more than one person in data analysis. transferability relates to generalisability (the extent to which findings can be applied to other contexts), which was ensured by provision of in-depth details of the methods so that the reader can relate the findings to their own positions.[13] dependability equates to a positivist notion of reliability (another researcher using the same methods would find the same results). however, the study considered the changing nature of community involvement over time in the uydf and therefore reliability became problematic. dependability was achieved by fully describing processes, thereby enabling a future researcher to repeat the work, if not necessarily gain the same results. the concept of confirmability is the qualitative investigator’s comparable concern to objectivity, and steps must be taken to ensure that the findings are the result of the experiences and ideas of the informants, rather than the characteristics and preferences of the researcher. the role of triangulation by using several people for data analysis, the interviewer not being affiliated to the uydf, and the use of verbatim participants’ quotations are emphasised as a means to reduce any inadvertent investigator bias. ethical considerations permission to conduct the study was obtained from the research ethics committee at the university of kzn (ukzn). written permission was obtained from all key role players including the kzn provincial department of health, hospital managers and relevant authorities at ukzn. results data were collected over 3 months (june august 2014). thirteen people chose to participate and each interview lasted on average 1.5 hours. a brief description of the participants is presented in table 1. three main themes arose around community involvement: (i) why it was necessary to have community involvement; (ii) how such involvement was initially secured; and (iii) ways in which community involvement could be expanded. each of these themes is discussed below and verbatim quotations are provided from participants to illustrate the theme. why was community involvement considered necessary? participants indicated that in the uydf model, community involvement in health professional education was initially not flagged as a specific objective and involvement grew as an organic, ad hoc process resulting from need. the need was related to the low number of doctors coming to work in the area. reasons for the scarcity of doctors included changes to health professions council of south africa (hpcsa) registration requirements that created significant barriers for doctors from countries outside sa to work in kzn. an external potential source of funding for higher education for local students pivoted on a prerequisite of community involvement. ‘it was increasingly harder to get doctors to mosvold hospital because the registration requirements changed. we wanted to try and find local students because local scholars are much more likely to come back and work at your hospital. i went to medical education for south african blacks (mesab) and they said they would go 50/50: they would pay half for education if the community paid the other half.’ (f) (mesab was a collaborative effort by the usa and sa to support the training of black south africans in the health professions in an effort to improve healthcare for the black population of sa. mesab provided scholarships for black sa students at 26 sa universities and technikons, along with sundry training initiatives in community health clinics.) community involvement was also required owing to the nature of the uydf model that involves local tribal authority leaders and hospital personnel to interview and recommend potential students for support. ‘the scheme is based around the local hospital so it is critical that we had buy-in from the local hospital.’ (m) table 1. brief description of participants description of participant participants, n pseudonym uydf founder: doctor 1 f uydf manager 1 m uydf mentor: physiotherapist 1 me member of hospital board: nurse 1 n graduate: doctor 2 gd1, gd2 graduate: physiotherapist 1 gp graduate who chose to opt out of work-back contract: doctor 1 gnd graduate: social worker 3 gsw1, gsw2, gsw3 community members whose children graduated from the uydf 2 cm1, cm2 research may 2016, vol. 8, no. 1 ajhpe 53 how was community involvement achieved? participants implied that community involvement was secured by approaching two tiers of the community: (i) local tribal authorities; and (ii) the local hospital board. ‘i went to the tribal authority and told them about the problem of staffing and asked – do you think that every single person in ingwavuma could give us one rand? we know that there are 100 000 people so if we get one rand from every person, we can use that as a fundraising initiative. in january i had got back about r30 000. i then approached potential funders and showed them how serious the community was about supporting their children to access tertiary education.’ (f) ‘we could ask companies to match that money raised by the community.’ (nb) ‘at the hospital, the workers were also asked to contribute 50 rand to the scholarship. we did that. it was just a drop in the ocean but it was a start as funders matched what we had raised.’ (nb) this is a deeply impoverished community and willingness to contribute financially to the uydf could be regarded as a reflection of willingness to become involved with initiating and investing in the future of the process. participants illustrated how partnership between the community, local hospital and ihl was achieved through the uydf strategy of numerous stakeholders participating in student selection: ‘students apply to uydf by getting their application forms from the local hospital. then they are required to do one week voluntary work at the local hospital. selection takes place at the local hospital and the selection committee is made up of community representatives, someone from the hospital and someone from uydf.’ (m) ‘the committee ask the hospital what is needed that year and for example, if the hospital needs a pharmacist, then the committee are tasked to select students to study pharmacy.’ (nb) uydf strategies that deepen community involvement include advocacy and information sharing about a career in healthcare, which were carried out at local schools. ‘we are doing school outreach and school learners get informed about the various health science careers, including subjects and grades needed, university application process and deadlines.’ (me) ‘the hospital puts on an open day where learners are exposed to the various health sciences. the students do weekly voluntary work so the hospital is involved with the students from the start. involvement at the hospital continues as students return to the hospital to work during their vacations.’ (me) how could community involvement be strengthened? participants included two community members whose children had been supported by the uydf. their discussions revealed that ways to strengthen community involvement arose spontaneously, as these participants currently act as advocates in their communities – sharing information and encouraging young people to consider education as a health professional. ‘i am grateful for the uydf. if my daughter did not get the scholarship she may be having a baby by now or sitting at home doing nothing, or selling vegetables in the market. because she got the scholarship she is so excited … now it is my role to encourage young people. it is my task in the community to talk about the uydf scheme because i know that it is there and i know that young people can get it and go to university.’ (cm1) ‘i am spreading the gospel now to others because i see how the scholarship relieved me. i was struggling to take my daughter to the university and the uydf people came and resuscitated me.’ (cm2) ‘i would let more people know by going out to the schools and tell them about this uydf.’ (cm1) ‘i would ask the community to contribute more because i have seen other programmes where people request donations. they give kids papers and the kids request donations for r2 so we could do this same pattern for the uydf.’ (cm2) ‘the government will get more involved when they see that we are doing something and not just folding our arms. the government will subsidise if they see that there is something we are already doing and they can come and assist us.’ (cm2) ‘there are many churches here. we could ask for support from some.’ (cm1) these participants’ stories illustrate their gratitude to the uydf; they spontaneously began to act as champions for a cause and advocated on behalf of the uydf in their communities. perhaps such champions could improve this link between the community and the uydf if their role became formalised by strategies, including strengthening their involvement with information sharing about the uydf in the community (e.g. in schools); involvement in fundraising activities; advocating for political support; and asking religious organisations for support and funding. discussion since 1999 there have been paradigmatic shifts in health professional education, and ihl partnering with local communities is strongly recommended. in 2003, the world federation for medical education (wfme) called for a global accreditation of institutions offering medical education, a key component of accreditation being involvement of community stakeholders.[14] findings from this study illustrate that, although community involvement was not an explicit intention when the uydf was initiated in 1999, it has become integral to the ongoing growth and success of the model. the underprivileged community became deeply engaged in providing set-up funding for the uydf and it is encouraging that they realised the value of higher education. that leaders successfully mobilised households to raise funds is heartening, as many discussions around rural areas are presented in a predominately negative way.[15] the study can begin to question assumptions around community apathy and disempowerment and illustrates the success that can be achieved by opening dialogue between the community, healthcare providers and ihl. in sa, disadvantaged rural students’ access to an ihl has historically been understood as a unidirectional process, with ihl unilaterally selecting students. this process may entrench thinking that ihl is the hegemonic domain of knowledge production and students become passive beneficiaries research 54 may 2016, vol. 8, no. 1 ajhpe of this knowledge, with no requirement of linkage or accountability to their local communities. results from this study illustrate that the uydf challenges this process. the uydf model is seen to act as a catalyst to encourage a tridirectional accountable process between the community, health service provider and ihl. current community involvement in the uydf is enacted at three main levels: (i) selection; (ii) during education; and (ii) after graduation. these tiers of involvement are depicted diagram matically (fig. 2). involvement by the community is displayed, as they are integrally involved in deciding which categories of students are required for a particular year (e.g. pharmacists are selected during a specific year in response to an identified hospital need). this community involvement is linked to some degree of social accountability, as graduates have been selected to fit a need when they return to their community on graduation. this process of involvement of the community in selection, as offered in the uydf model, illustrates a copc short-route strategy that facilitates the development of ‘client power’ in shaping health professional education. interestingly, a community member mentioned involving politicians and thus was supporting a more long-route strategy towards community involvement. there may be increasing political will to support a model that links community involvement to health service delivery and health professional education, as community involvement in health is proposed to be an essential component of the proposed national health insurance programme.[16] participants suggested several ways in which community involvement in health professional education, through the conduit of the uydf, could be enhanced: increasing advocacy at schools; fund-raising; and lobbying politi cians. further research, taking cognizance of participants’ suggestions, may guide the uydf strategies around strengthening community involve ment. the uydf may also gain lessons from education other than health professional education, e.g. at ukzn the certificate of education (coe) focuses specifically on a link between ihl-student-community partnerships.[17] the pedagogy involved in the coe continually and actively draws on students’ narratives around their experiences of involvement in community development. the pedagogies are based on participatory methods such as group work, role play, discussion and stimulation. narratives described in the coe revealed that students struggle with multiple responsibilities, and conflict within their communities and educational institutes.[17] the uydf could advocate for ihl to similarly consider the potential value of students’ narratives. pedagogies to encourage community involvement in service provision and ihl could be strengthened by considering a community of practice (cop). it is formed by people who engage in a process of collective learning in a shared domain of human endeavour. a cop consists of groups of people who share a concern and passion for something they do or want to learn about. a cop could creatively involve community members becoming involved in student assessment. additionally, the uydf could advocate for the inclusion of community members in actively teaching students about what to expect in the field. such a strategy has been successfully implemented in the usa.[18] advocating for the consideration of students’ and community members’ narratives in health professional education may enable both students and communities not to regard an ihl as an ivory tower that looms over and looks down on society. an ihl can become an interactive, responsive knowledge resource that engages with students, healthcare providers and communities. taking cognizance of these suggestions, a potentially strengthened uydf model is represented diagrammatically (fig. 3). conclusion the uydf model did not initially aim to foster community involvement; however, partnerships between the uydf, community, healthcare providers and ihl developed as fundamental to success and sustainability. there was evidence that this short route of community involvement enabled the development of client power, as the community came to have direct influence on student selection to an ihl. the processes involved in developing the uydf model illustrate that rural communities value higher education and can be successfully mobilised to take action. the uydf model forms a responsive and accountable framework by which healthcare providers and ihl can engage with local communities. such partnerships are becoming essential for various reasons, including a future global accreditation of the education institution. participants provided some ideas around how to strengthen the uydf model, and further research could consider the implementation of such suggestions. the uydf could advocate for further strengthening of community involvement in health professional education by innovative strategies such as encouraging cop (community/healthcare provider/ihl) and having community members assess students. the challenges faced by students who come from a rural area are unique and different to the challenges faced by others, e.g. the community. pedagogies to ensure that the voices of students and communities are heard may include narratives in which the latter can learn about the challenges faced by students/doctors in a rural, isolated community and vice versa. the uydf model an interphase between the community and institute of health professional education after education graduate works in local community selection student selection involves the community during education students return to the local hospital during vacation during education strengthening community involvement is fore-fronted in pedagogies and curriculum (students and community) fig. 3. a strengthened uydf model for community involvement in health professional education. fig. 2. involvement of the community in the uydf model. selection: potential students carry out voluntary work at a local hospital. the hospital and community are involved in selection and selection is responsive to hospital needs throughout training: students return to work at the hospital during vacations after graduation: graduates work in the hospital research may 2016, vol. 8, no. 1 ajhpe 55 references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376 (9756):1923-1958. 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[http://dx.doi.org/10.1097/acm.0b013e3181c42acd] 13. lincoln ys, guba eg. naturalistic inquiry. newbury park, ca: sage publications, 1995. 14. world federation for medical education (wfme). basic medical education. wfme global standards for quality improvement. wfme office, copenhagen. 2003. http://www.wfme.org (accessed 8 november 2014). 15. nkambule t, balfour r, pillay g, moletsane r. rurality and rural education: discourses underpinning rurality and rural education research in south african postgraduate education research 1994 2004. s afr j higher educ 2011;25(2):341-357. 16. minister of health. nhi pilot presentation. http://www.doh.gov.za/docs/presentations/2012/nhipilot.pdf (accessed 5 november 2014). 17. harley a, rule p. exploring access as dialogue in an education and development certificate programme. in: dhunpath r, vithal r, eds. alternative access to higher education: underprepared students or underprepared institutions. cape town: pearson education, 2012. 18. westmoreland gr, counsell sr,  sennour y, et al. improving medical student attitudes toward older patients through a ‘council of elders’ and reflective writing experience. j am geriatric soc 2009;57(2):315-320. [http:// dx.doi.org/10.1111/j.1532-5415.2008.02102.x] ajhpe 397.indd research october 2014, vol.6, no. 2 ajhpe 143 students’ perceptions of their education environment (ee) have an undeniable impact on their study behaviour and academic progress.[1] if the ee of a medical school is positively perceived, it not only promotes intellectual activities, but also cultivates friendliness, co-operation, academic advancement and a sense of well-being.[2] therefore, the acknowledgement of the ee as a significant confounding factor for effective student learning and success[2] is fast becoming established.[3] in a medical school, the ee can be conceptualised as a social system comprising the learner, individuals who interact with the learner, intention of the interaction, setting in which the learner interacts with other individuals, and formal and informal rules that govern the interaction.[4] clapham et al.[5] described the ee as consisting of the following three major components: (i) the physical environment; (ii) the emotional climate; and (iii) the intellectual climate. factors such as the increasingly diverse student population in medical programmes and curricula innovation have triggered a heightened interest in evaluating the ee of medical schools.[6] in 2010, the health professions council of south africa (hpcsa) visited the university of the free state (ufs), bloemfontein, south africa (sa), to re-accredit their medical programme. in contrast to the other seven medical schools in sa, which offer a six-year programme, the mb chb degree at ufs comprises a five-year academic programme in three phases:[7] phase i: six months of six introductory modules. phase ii: two preclinical years of basic medical science modules to establish the foundation for the clinical years. phase iii: two-and-a-half clinical years during which the students apply their knowledge gained in phases i and ii to learn clinical medicine in the different clinical departments. in their report, the hpcsa accreditation panel raised concerns relating to the teaching platform at one of the training hospitals.[8] these concerns provoked further questions relating to the interaction of issues raised by the hpcsa and the perceived ee where students rotate during their clinical years (phase iii). despite anecdotal feedback through informal conversations and quarterly discussions between the students’ class representatives and the mb chb programme director, the ee, as perceived by phase iii medical students, has never been formally assessed on a departmental level. therefore, our objective was to assess the perceived ee in the clinical departments among the fourthand fifth-year ufs medical students. differences in perceived ee scores between different demographic groups were also assessed. methods the study was approved by the ethics committee of the faculty of health sciences of the ufs (ecufs 21/2012). participants the target population was all fourthand fifth-year ufs medical students in 2012 (n=124 and n=105, respectively). those repeating their final year were excluded, as they did not rotate through all the departments involved background. the education environment (ee) of a medical school plays a critical role in the learning of its students. the learner, other learners, teachers and the physical environment (campus and hospitals) influence the ee. in addition to recommendations of the health professions council of south africa (hpcsa) to revise the clinical training platform, staff and senior medical students occasionally experienced the ee in the clinical departments to be challenging. objective. to assess the perceived ee in clinical departments at the university of the free state, bloemfontein, south africa, among the 2012 fourth and fifth-year medical students. differences in perceived ee scores between different demographic groups were also assessed. method. only the departments where students rotated in both their fourth and fifth years (obstetrics and gynaecology, general surgery, paediatrics and neonatology, internal medicine, and psychiatry) were assessed. the dundee ready education environment measure (dreem) questionnaire was contextualised for each department and distributed among fourthand fifth-year medical students. questionnaires were self-administered and participation was voluntary. differences among demographic groups and departments were assessed using the mann-whitney u-test and kruskalwallis test (p<0.05). results. the overall response rate was 87.7%. the overall median dreem combined score for the departments was 137/200. paediatrics and neonatology was consistently top-rated, whereas obstetrics and gynaecology consistently received the lowest rating in all domains and subscale analyses. there were few significant differences between the dreem scores of demographic groups. conclusion. the overall ee in the clinical departments was mostly positive, although concerns were raised regarding some departments. ajhpe 2014;6(2):143-149. doi:10.7196/ajhpe.397 assessment of the education environment of senior medical students at the university of the free state, bloemfontein, south africa s schoeman,1 mb chb, mmed (uk); r raphuthing,2 medical student; s phate,2 medical student; l khasoane,2 medical student; c ntsere,2 medical student 1 department of internal medicine, medical education division, school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: s schoeman (schoemanfhs@ufs.ac.za) research 144 october 2014, vol.6, no. 2 ajhpe in the study. there were 111 male and 118 female students, of whom 105 and 124 received instruction and teaching in english and afrikaans, respectively. because of the ufs racial incident in 2008,[9] the students were asked to report their race to establish whether perceptions of racial discrimination existed in the ee of each department, yielding responses from 143 white and 86 black students. data collection the dundee ready education environment measure (dreem) was used because of its suitability in health sciences education[11] and reliability for measuring the ee in undergraduate medical education settings.[6] the dreem questionnaire is self-administered, and consists of 50 items scored on a likert scale to derive a total score out of 200.[11] five subscales assess the perceived ee relating to the students’ perceptions of teaching and learning (sptl), the students’ perceptions of the teachers (spt), the students’ academic self-perceptions (sasp), the students’ perceptions of the atmosphere (spa), and the students’ social self-perceptions (sssp).[11] each of the 50 items was contextualised by inserting the names of the relevant department in each statement, e.g. ‘i find the experience at general surgery disappointing’. five separate dreem questionnaires were administered for the departments of internal medicine, obstetrics and gynaecology, paediatrics and neonatology, surgery and psychiatry (appendix 1). these departments were chosen because they hosted both the fourth and fifth-year cohorts and the rotations through these departments add up to 81% and 75% of the total clinical rotation time of the fourth and fifth years, respectively.[7] departments not hosting both the fourthand fifth-year students were excluded to minimise recall bias and ensure that the reports on the perceived ee were current at the time of data collection. a pilot study was conducted using a group of three afrikaansand three english-speaking junior doctors who graduated from the ufs in the preceding academic year. to improve clarity and avoid ambiguity, minor contextual suggestions were incorporated into the questionnaire. to minimise the possible effect of translation errors, the dreem questionnaire was administered in english only. the pilot study confirmed that the english language used in the dreem questionnaire is basic enough for afrikaans students to comprehend. data were collected during meetings with the students, where the questionnaires were distributed and returned on completion. by completing the questionnaire, consent was given to participate in this study. of a potential 1 145 questionnaires over the five departments, 1 037 were returned, of which 1 004 were complete and therefore valid for inclusion in the data analysis. the response rate ranged from 86% to 89% (mean 87.7%) across the five departments. data analysis completed questionnaires were analysed with microsoft excel and spss version 20. the shapiro-wilk test was used to test for normality and results were summarised using medians and percentiles. dreem was calculated as a combined overall score across the five departments, and as individual scores for each department and each subset in each department. the mann-whitney u-test and kruskal-wallis test (p<0.05) were used to explore differences among demographic groups and departments. table 1. reliability statistics on the dreem questionnaire data completed dreem questionnaires (per department – all students) n cronbach’s α standard error of measurement (/200) internal medicine 204 0.95 5.8 obstetrics and gynaecology 196 0.94 6.6 paediatrics 202 0.93 5.0 psychiatry 199 0.94 5.8 general surgery 203 0.94 5.8 total 1 004 0.96 6.2 dreem = dundee ready education environment measure. d r ee m s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 internal medicine obstetrics and gynaecology paediatrics surgery psychiatry department fig. 1. overall dreem scores for the departments. the dots represent outliers falling outside 1.5 times the interquartile ranges of the dreem distributions (dreem = dundee ready education environment measure). research october 2014, vol.6, no. 2 ajhpe 145 results the reliability analyses of the contextualised dreem questionnaires are reported in table 1. the overall median dreem score across all departments, with the demographic variables included, was 137 (fig. 1). this equates to a ‘more positive than negative’ interpretation according to the published interpretation guidelines for the dreem questionnaire.[11] the students generally scored the perceived ee in paediatrics and neonatology the highest, with an overall median dreem score of 153, while the department of obstetrics and gynaecology scored the lowest overall median dreem score (106) (fig. 1). internal medicine had a median dreem score of 139, surgery 131 and psychiatry 145 (fig. 1). when compared, all the departmental distributions were statistically different (p<0.01). the perceived ee was similar for males and females across all departments. students’ perceptions of teaching and learning (sptl). the median scores for this subscale ranged from 62% to 75%, equating to the top half of ‘a more positive approach’ (50 75%) result bracket.[11] statistically significant differences in the sptl distributions were noted when comparing individual departments (p<0.01), except between psychiatry and internal medicine (p=0.054) and general surgery and psychiatry (p=0.169) (table 2). students’ perceptions of teachers (spt). four departments scored between 66% and 82%. this equates to a very positive result, ranging from ‘moving in the right direction’ (51 75%) to ‘model teachers’ (76 100%).[11] the only outlier of concern was noted in the department of obstetrics and gynaecology, which scored significantly lower than the other four departments, with a median score of 51% and hinging on ‘in need of some retraining (26 50%)’.[11] apart from this finding, statistically significant differences in the spt distributions were noted in all departments (p<0.01), except between internal medicine and psychiatry (p=0.302) (table 2). students’ academic self-perceptions (sasp). scores ranged from 63% to 75%, equating to the top half of ‘feeling more on the positive’ (51 75%) result bracket.[11] the departments of paediatrics and neonatology and psychiatry scored equally. besides this subscale being scored very positively overall, there were statistically significant differences in the sasp distributions among all departments (p<0.05), except between paediatrics and neonatology and psychiatry (p=0.119) (table 2). students’ perceptions of atmosphere (spa). all the departments scored in a range of 67 77%, except obstetrics and gynaecology, which received a disquieting score of 48%. this equates to four departments falling between the top half of ‘a more positive atmosphere’ (51 75%) to ‘a good feeling overall’ (76 100%) result brackets.[11] however, obstetrics and gynaecology was an outlier, falling in the disquieting ‘there are many issues that need changing’ result bracket.[11] furthermore, there were statistically significant differences in the spa distributions among all departments (p<0.001), except between psychiatry and paediatrics and neonatology (p=0.207) and general surgery and internal medicine (p=0.463) (table 2). students’ social self-perception (sssp). in this subscale, the scores for four departments ranged from 58% to 71%, except for obstetrics and gynaecology, which was an outlier (42%). this equates to four departments falling in the ‘not too bad’ (51 75%) result bracket.[11] however, obstetrics and gynaecology fell into the disquieting ‘not a nice place’ result bracket.[11] similar to the spa subscale, there were statistically significant differences in the sssp distributions among all departments (p<0.001), table 2. median percentage subscale results per domain and department department sptl, % spt, % sasp, % spa, % sssp, % internal medicine 71* 73* 72 67* 63* obstetrics and gynaecology 62 51† 63 48† 42† paediatrics and neonatology 75 82‡ 75* 77*‡ 71*‡ general surgery 67* 66 69 69* 58* psychiatry 69* 73* 75* 75* 71* sptl = students’ perceptions of teaching and learning; spt = students’ perceptions of teachers; sasp = students’ academic selfperceptions; spa = students’ perceptions of atmosphere; sssp = students’ social self-perception. *no statistical difference found in the subscale distribution analyses between individual departments. †disquieting results. ‡excellent results. year 4th 5th p=0.003 d r ee m s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 internal medicine obstetrics and gynaecology paediatrics surgery psychiatry department fig. 2. dreem scores of diff erent year groups for the departments. th e dots represent outliers falling outside 1.5 times the interquartile ranges of the dreem distributions (dreem = dundee ready education environment measure). researchresearch 146 october 2014, vol.6, no. 2 ajhpe except between psychiatry and paediatrics and neonatology (p=0.112) and general surgery and internal medicine (p=0.51) (table 2). both the fourth and fifth years scored an overall median dreem of 137 across all departments. paediatrics and neonatology attained the highest median dreem scores for both the fourth (150) and fifth (159) years (fig. 2). obstetrics and gynaecology achieved the lowest median scores for both the fourth (108) and fifth (105) years. the fifth-year students scored the perceived ee in the department of paediatrics and neonatology significantly higher (p=0.003) than the fourth-year students (fig. 2). in all the other departments the dreem distributions of the fourthand fifth-year students were the same. the students who received instruction and teaching in english scored the perceived ee in internal medicine significantly higher (p=0.004; median = 145) than those who received instruction and teaching in afrikaans (median = 135) (fig. 3). in the department of general surgery, the afrikaans cohort scored the perceived ee higher (p<0.001; median = 137) compared with the english cohort (median = 124), while the perceived ees were similar for both the english and afrikaans cohorts in the other departments (fig. 3). the younger students (20 24 age group) rated general surgery significantly higher (p=0.042; median = 131) than the older students (>25 years group) (median = 127) (fig. 4). however, there was no statistically significant difference noted in the ee rating in any of the four other departments (fig. 4). at internal medicine, the black students rated the ee higher (p<0.001; median = 149) than the white students (median = 132) (fig. 5). similarly, at obstetrics and gynaecology, the black students rated the ee higher (p<0.001; median = 114) than the white students (median = 101). however, at general surgery the opposite occurred, as the white students rated the ee higher (p<0.001; median = 135) than the black students (median = 120) (fig. 5). there was no statistically significant difference noted in the other two departments. discussion the overall dreem score for the five clinical departments was 137. this value falls in the same range (101 150) as that in some other studies, such as brown et al.[12] (137.3), riquelme et al.[13] (127.5) and demirören et al.[14] (117.63). this range means a ‘more positive than negative’ result.[11] it is, however, important to note that the dreem interpretation brackets are rather wide (50 points) and a score of 101 or 149 has a similar interpretation, which is not ideal. therefore, in our study the overall median dreem score of 137 is actually firmly in the top half of its dreem interpretation bracket and could possibly quite safely be interpreted as a ‘much more positive than negative’ ee. interestingly, in general, both the fourthand fifth-year medical students perceived the ee similarly, with a median dreem of 137 for each year group. from the reliability analyses (table 1) it was clear that the contextualised dreem questionnaires were extremely reliable (cronbach’s α >0.9 for all departments, together with a low standard error of mean (<7 dreem marks)).[15] these findings also support the validity of the instrument used and compares favourably with the findings of other studies on cronbach’s α of dreem (0.93).[16] at departmental level, it was noted that the median dreem scores for the departments ranged between 106 and 153. therefore, in each department the students perceived the ee as ‘more positive than negative’.[11] paediatrics and neonatology achieved the highest dreem score (153), which was in the ‘excellent’ range.[11] obstetrics and gynaecology, on the other hand, had the lowest dreem score (106), yet it was within the ‘more positive than negative range’.[11] comparing this score with a dreem score of 139 obtained in a study by varma et al.,[17] which only looked at the ee of obstetrics and gynaecology at different training platforms, it can be seen that in both studies the ee was perceived as ‘more positive than negative’,[11] but it is disquieting that the ufs department of obstetrics and gynaecology’s score was 33 points lower than that of the same department in the varma et al. [17] study and 25 points lower than the fourth-ranked department in our study. the reasons for the difference are being further explored by ufs. internal medicine obstetrics and gynaecology paediatrics surgery psychiatry department d r ee m s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 afrikaans english p=0.004 p<0.001 fig. 3. dreem scores of groups with diff erent language of instruction for the departments. th e dots represent outliers falling outside 1.5 times the interquartile ranges of the dreem distributions (dreem = dundee ready education environment measure). research october 2014, vol.6, no. 2 ajhpe 147 across most departments, the subscale analysis revealed positive to very positive results. paediatrics and neonatology was notably the top-performing department and achieved excellent scores in 4/5 subscales.[11] however, in contrast, obstetrics and gynaecology received some disquieting ratings in 3/5 subscales,[11] which included spt, spa and sssp. based on standard subscale interpretation,[11] students’ perceptions of internal medicine, psychiatry and general surgery were that teaching was helpful, relevant and useful and the teachers were moving in the right direction. the students were positive regarding their academic success and experienced the overall educational atmosphere as ‘more positive’. the sssp, while rotating at these three departments, was positively rated. based on the standard interpretation of subscales,[11] students at obstetrics and gynaecology indicated that teaching was helpful, relevant and useful and the teachers were bordering on the need for some retraining (in terms of influencing the ee). the students felt more positive regarding their academic success but thought that there was much that needed changing with regard to the education atmosphere. the sssp was that it was ‘not a nice place’. it is therefore apparent that certain aspects of the ee at obstetrics and gynaecology are problematic and not conducive to the ee of the students. based on the standard interpretation of subscales,[11] students at paediatrics and neonatology indicated that teaching was helpful, relevant and useful and the teachers were excellent. the students felt confident regarding their academic success and the overall educational atmosphere was very positive. the sssp was not too bad (positive). across all departments, fourthand fifth-year students ranked the ee as ‘more positive than negative’,[11] with overall median dreem scores of 137 for each year group. this was similar to that found in a ufs study (l m moja, h louw, g joubert – unpublished data, 2007). these authors used the dreem questionnaire to measure the ee of the entire faculty of health sciences at ufs. from that study it was reported that the fourthand fifth-year medical students had overall median dreem scores of 125 and 125, respectively. this fell in the same dreem result bracket as the current study, with the ee of the clinical years of the school of medicine being ‘more positive than negative’.[11] our study did however show an improvement of 12 points in the perceived ee in both year groups. overall, the language of instruction made little impact on the ee perceptions of the students. the only statistically significant effect was at general surgery, where the students in the afrikaans classes ranked the ee higher than those in the english classes, and at internal medicine, where the students in the english classes ranked the ee higher than those in the afrikaans classes. interestingly, gender differences had no influence on how students perceived the ee in any of the clinical departments, which is a very positive finding. generally, the age of the students made very little impact on their perceptions of the ee. the only statistically significant effect was noted at general surgery, where the younger age group ranked the ee higher than the older age group. the race of the students made a statistically significant impact on their ee perceptions in a majority (3/5) of the departments. these were internal medicine and obstetrics and gynaecology, where black students rated the ee higher than white students, compared with general surgery, where white students rated the ee higher than black students. in conclusion, the majority of clinical departments included in this study should be encouraged to continue with their good work to foster the positive ee for senior medical students. furthermore, feedback regarding the outcome of this study was given to the medical school and the relevant departments and positive steps have been initiated to conduct further research (individual dreem item analysis and some focus group discussions) into the areas where improvement in the ee is needed. limitations of this study included the following: • only five clinical departments were included. it would have been useful to have included all the departments in phase iii of the curriculum. • only fourthand fifth-year students partici pated in the study. it would have been useful to have d r ee m s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 internal medicine obstetrics and gynaecology paediatrics surgery psychiatry years 20 24 ≥ 25 department p=0.042 fig. 4. dreem scores of diff erent age groups for the departments. th e dots represent outliers falling outside 1.5 times the interquartile ranges of the dreem distributions (dreem = dundee ready education environment measure). researchresearch 148 october 2014, vol.6, no. 2 ajhpe included students in semester 6 (third year), as they are part of phase iii of the curriculum. however, due to limited time and resources, the scope of the study had to be restricted. references 1. soemantri d, herrera c, riquelme a. measuring the ee in health professions studies: a systematic review. med teach 2010;32:947-952. [http://dx.doi.org/10.3109/01421591003686229] 2. abraham r, ramnarayan k, vinod p, torke s. students’ perceptions of learning environment in an indian medical school. bmc med educ 2008;8(20):1-5. [http://dx.doi.org/10.1186/1472-6920-8-20] 3. dunne f, mcaleer s, roff s. assessment of the undergraduate medical education environment in a large uk medical school. educ health 2006;65(2):149-158. 4. american medical association. initiative to transform medical education: strategies for transforming the medical education learning environment. chicago, il: american medical association, 2008. 5. clapham m, wall d, batchelor a. ee in intensive care medicine use of postgraduate hospital ee measure (pheem). med teach 2007;29:184-191. 6. miles s, swift l, leinster sj. th e dundee ready education environment measure (dreem): a review of its adoption and use. med teach 2012;34:620-634.[http://dx.doi.org/10.3109/0142159x.2012.668625] 7. university of the free state (ufs). yearbook of the school of medicine. bloemfontein: ufs, 2012. 8. health professions council of south africa (hpcsa). accreditation of undergraduate medical education and training at the ufs. pretoria: hpcsa, 2010. 9. matlala c. th e free state four – race and racism in the press. media monitoring africa resources – media analysis, 19 may 2008. http:// www.mediamonitoringafrica.org/index.php/resources/entry/the_ freestate_four_race_and_racism_in_the_press/ (accessed 28 february 2012). 10. roff s, mcaleer s, harden r, et al. development and validation of the dundee ready education environment measure (dreem). med teach 1997;19(4):295-299. 11. mcaleer s, roff s. a practical guide to using the dundee ready education environment measure (dreem). amee guide 2001;23:29-33. 12. brown t, williams b, lynch m. th e australian dreem: evaluating student perceptions of academic learning environments within eight health science courses. int j med educ 2011;2:94-101. 13. riquelme a, oporto m, oporto j, et al. measuring students’ perceptions of the educational climate of the new curriculum at the pontifi cia universidad católica de chile: performance of the spanish translation of the dundee ready education environment measure (dreem). educ health 2009;22(1):1-11. 14. demirören m, palaoglu ö, kemahli s, özyurda f, ayhan ih. perceptions of students in different phases of medical education of ee: ankara university faculty of medicine. med educ 2008;13(8):1-7. 15. tavakol m, dennick r. making sense of cronbach’s alpha. int j med educ 201; 2:53-55. [http://dx.doi.org/10.5116/ijme.4dfb .8dfd] 16. de oliveira filho gr, vieira je, schonhorst l. psychometric properties of the dundee ready ee measure (dreem) applied to medical residents. med teach 2005;27(4):343-347. 17. varma r, tyagi e, gupta jk. determining the quality of educational climate across multiple undergraduate teaching sites using the dreem inventory. bmc med educ 2005;5(8):1-4. [http://dx.doi. org/10.5455/2320-6012.ijrms20131113] p<0.001 d r ee m s co re 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 internal medicine obstetrics and gynaecology paediatrics surgery psychiatry department race black white p<0.001p<0.001 fig. 5. dreem scores of diff erent races for the departments. th e dots represent outliers falling outside 1.5 times the interquartile ranges of the dreem distributions (dreem = dundee ready education environment measure). appendix 1. contextualised dundee ready education environment measure (dreem) questionnaire, school of medicine, university of the free state, bloemfontein, south africa: the education environment perceptions of senior medical students at the department of internal medicine (example) statements strongly agree (4) agree (3) unsure (2) disagree (1) strongly disagree (0) 1. i am encouraged to participate in internal medicine lectures 2. the lecturers in internal medicine are knowledgeable 3. there is a good support system in internal medicine for students who become stressed 4. i am too tired to enjoy internal medicine 5. learning strategies which worked for me before continue to work for me now at internal medicine 6. the teachers at internal medicine are patient with patients 7. the teaching at internal medicine is often stimulating 8. the teachers at internal medicine ridicule (humiliate) the students (afrikaans = verkleineer) continued... research october 2014, vol.6, no. 2 ajhpe 149 appendix 1 (continued). contextualised dundee ready education environment measure (dreem) questionnaire, school of medicine, university of the free state, bloemfontein, south africa: the education environment perceptions of senior medical students at the department of internal medicine (example) statements strongly agree (4) agree (3) unsure (2) disagree (1) strongly disagree (0) 9. the teachers at internal medicine are authoritarian (bossy) 10. i am confident about passing internal medicine 11. the atmosphere at internal medicine is relaxed during ward teaching 12. internal medicine is well time-tabled 13. the teaching at internal medicine is student-centred 14. i am rarely bored at internal medicine 15. i have good friends who rotate with me at internal medicine 16. the teaching at internal medicine helps to develop my competence 17. cheating is a problem at internal medicine 18. the internal medicine teachers have good communication skills with patients 19. my social life is good while rotating at internal medicine 20. the teaching at internal medicine is well-focused 21. i feel internal medicine is preparing me well for my profession 22. the teaching at internal medicine helps to develop my confidence 23. the atmosphere is relaxed during internal medicine lectures 24. the teaching time at internal medicine is put to good use 25. the teaching at internal medicine over-emphasises factual learning 26. last year’s work has been a good preparation for this year’s work in internal medicine 27. i am able to memorise all i need to in internal medicine 28. i seldom feel lonely at internal medicine 29. the teachers at internal medicine are good at providing feedback to students 30. there are opportunities for me to develop interpersonal skills at internal medicine 31. internal medicine has taught me a lot about empathy in my profession 32. the teachers at internal medicine provide constructive criticism 33. i feel comfortable socially at internal medicine 34. internal medicine seminars/tutorials have a relaxed atmosphere 35. i find the experience at internal medicine disappointing 36. i am able to concentrate well at internal medicine 37. the internal medicine teachers give clear examples 38. i am clear about the learning objectives at internal medicine 39. the internal medicine teachers get angry during teaching sessions 40. the internal medicine lecturers are well prepared 41. my problem-solving skills are being well developed at internal medicine 42. the enjoyment at internal medicine outweighs the stress 43. the atmosphere at internal medicine motivates me as a learner 44. the teaching at internal medicine encourages me to be an active learner 45. much of what i have to learn in internal medicine seems relevant to a career in medicine 46. overall, my rotation at internal medicine was pleasant 47. long-term learning at internal medicine is emphasised over short-term learning 48. the teaching at internal medicine is too teacher-centred 49. i feel able to ask the questions i want to at internal medicine 50. the students irritate the internal medicine teachers 22 may 2015, vol. 7, no. 1 ajhpe research the education of health professionals needs to respond to new health challenges, health science developments and health needs of society to strengthen the health system. frenk et al.[1] reported the findings of the lancet’s global independent commission into the education of health professionals for the 21st century, and stated that the education of health professionals has not kept pace with the major challenges of providing health security to all. some of the problems mentioned by the commission include: poor teamwork; narrow technical focus without broader contextual understanding; mismatch of competencies with regard to patient and population needs; episodic encounters rather than continuous care; and predominant hospital orientation at the expense of primary care. the commission believes that academic institutions are liable for these problems, as curricula are fragmented, outdated and static.[1] the training of healthcare professionals is indeed a challenge and needs to ensure that entry-level professionals are equipped with the necessary skills and competencies to provide the highest standard of care for their clients. in south africa (sa), the health professions council of south africa (hpcsa) promotes the health of all south africans ‘by determining standards of professional education and training and setting and maintaining the highest standards of professional and ethical behaviour for its registered healthcare professionals’.[2] this is achieved by establishing and monitoring the standards of professional education and training of the different healthcare professionals and setting standards for professional and ethical conduct of qualified professionals registered with the hpcsa. the different professional bodies each have guidelines that determine the content of the different courses, but the core ethical values and standards for good practice are generic and apply to all healthcare professionals. the core ethical values and standards for good practice are respect for persons, beneficence, non-maleficence, human rights, autonomy, integrity, truthfulness, confidentiality, compassion, tolerance and justice.[3] training for the healthcare professions has to include a comprehensive approach that addresses the needs of all south africans, including skills to provide health promotion, health prevention, and curative and rehabilitation services. healthcare professionals also need to be trained in social and technical skills to work together as a team.[4] since 1993, the healthcare system in sa has been expanded, transformed and revitalised, and parallel to this there have been major growth and developments in health science, professional education and training.[5] concurrently, an increased understanding of the value and need to include inter-professional education (ipe) in the training of healthcare students has developed.[1,6] ipe is defined as: ‘when two or more professions learn with, from and about each other to improve collaboration and the quality of care’.[7] ipe can be utilised to prepare healthcare students for effective inter-professional practice, as it enhances their knowledge and understanding of the skills, roles and responsibilities of other healthcare professions and builds an awareness of the value and importance of collaboration and teamwork. introduction. the training of healthcare professionals is faced with many challenges. to ultimately strengthen the health system, training has to respond to new health challenges, health science developments and societal needs. the bishop lavis primary health care project was established in 1993 and led to the establishment of the bishop lavis rehabilitation centre (blrc). the current inter-professional service delivery at the centre is based on the world health organization’s international classification of functioning (icf) model for holistic client-centred care. the objective of this article is to describe the students’ experiences of inter-professional education (ipe) through icf-based activities at blrc. methods. data were gathered from a retrospective review of student feedback forms from 2010 to 2012. content analysis was employed to identify key themes regarding ipe. results. inter-professional learning was found to occur spontaneously between the four allied health professions as a result of the icf model-driven activities at blrc. conclusion. feedback at the end of the students’ clinical placement was open ended and no information was asked specifically about ipe. more than half of the students spontaneously mentioned that learning about working in an inter-professional team as one of the highlights of their placement at blrc, has prompted the sharing of this information. this article offers a potential framework (icf) that fosters and supports the ipe philosophy in a clinical setting. afr j health professions educ 2015;7(1):22-25. doi:10.7196/ajhpe.289 students’ experiences of inter-professional education through international classification of functioning-based activities at a community-based rehabilitation centre m kloppers,1 moccther; h e koornhof,2 mnutr; j bester,1 mphil (higher education); f bardien,3 maud 1 division of occupational therapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 division of human nutrition, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 division of speech, language and hearing therapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m kloppers (maatje@sun.ac.za) may 2015, vol. 7, no. 1 ajhpe 23 research effective inter-professional teamwork is one way to improve healthcare delivery and maximise healthcare outcome.[8] the bishop lavis primary health care project[9] was established in 1993 as a result of a partnership between the faculty of medicine and health sciences at stellenbosch university (su), western cape government health authorities, city of cape town and bishop lavis community. the initial focus of this project was to assist with the reorientation of the healthcare services and deliver a comprehensive service. from the onset, an inter-professional approach was used involving nurses, family medicine practitioners, a physiotherapist, an occupational therapist, a social worker, a dietician and voluntary community workers. establishment of community participation was an integral part of the project, where students and staff have worked together with community volunteers and the community health committee with regard to service, research and community development. the bishop lavis rehabilitation centre (blrc) was established, which currently delivers an inter-professional service that includes physiotherapy (pt), occupational therapy (ot), speech-language and hearing therapy (slt), and dietetic (dt) students and community volunteers. a number of successful, sustainable community-based intervention programmes and activities have been established through this partnership. these programmes are needs driven and initiated by blrc’s inter-professional team in collaboration with the community, and are now independently managed by community members with support from blrc. examples of these programmes are the weekly stroke support group and bi-weekly exercise and aerobics group. the latter was established because of a need identified by the blrc team for physical activity and weight management to enhance the wellness of community members. in partnership with the community, members were trained and helped to establish the aerobics and exercise group, which is now independently managed by a community member. the services rendered at blrc are based on the world health organization (who)’s international classification of functioning (icf) model[10] for holistic patient-centred care. the icf model places the focus of assessment on ‘health’ and ‘functioning’ rather than ‘disability’ and ‘illness’. based on the icf model, the three domains of a client’s functioning, i.e. activity, participation and body functioning and structures, are addressed while taking into account the environmental and personal factors also influencing the client’s functioning.[10] research by kloppers[11] showed that a significant improvement in clients’ functioning is achieved with this approach. prevention and promotion activities performed by the blrc inter-professional team address these contextual factors. the western cape department of health’s plan for the re-engineering of primary healthcare[12] is currently being developed and focuses on teamwork and reaching clients in their home environments. the core services delivered to the bishop lavis community by blrc already encompass this vision.[11] this article describes how this service allows students to be trained in an inter-professional manner to ensure optimal and holistic client and community rehabilitation. a description of the services rendered at blrc explains the context in which the training takes place. description of blrc services in 1993, members of the faculty of medicine and health sciences, su, realised the need for a training platform within a community to give students an opportunity to become involved in and be exposed to primary healthcare and planning and delivery of healthcare services to a community, based on the needs of that community.[9,13] the services of blrc are planned and managed by a full-time su-appointed occupational therapist and physiotherapist with an inter-professional approach. services and care facilities in the centre are shared by all professions, which provides opportunities for informal inter-professional learning. blrc has developed services to address the health needs of the bishop lavis community and training needs of su students. it started with only occupational therapy and physiotherapy services being delivered at the centre and dietetic services at the community health centre, with sporadic contact for health promotion. speech-language and hearing therapy services started intermittently from 1995, owing to the lack of a full-time speech therapist at the centre. since 2004, this service has been offered on a fulltime basis during student trimesters. from 2012, dietetic students formed an integral part of the services rendered at the centre. approximately 92 students are trained at blrc annually, with average placement duration of 6 7 weeks per student. table 1 gives a breakdown of the number of students per programme. the number of hours worked per student per week ranges from 20 to 40. the generic aims for students’ involvement at blrc are as follows: (i) developing an understanding of the role and responsibilities of the different members of the rehabilitation team; (ii) assisting in the rendering of a comprehensive therapy service to the bishop lavis community by developing an understanding of the humanity of clients and willingness to take holistic responsibility for clients – broader than the defined professional role of caring; (iii) enabling the development and adoption of ethical values and standards for good practice, i.e. respect for persons, beneficence, non-maleficence, human rights, autonomy, integrity, truthfulness, confidentiality, compassion, tolerance and justice, as prescribed by the hpcsa; (iv) providing the opportunity to gain training in community-based rehabilitation; and (v) providing the opportunity for engaging in inter-professional communication and co-operation. the service rendered at the centre and in the community by the four disciplines and community volunteers is based on the icf model, which ensures a holistic approach to client care and community interventions. this is achieved by assessing clients’ and group members’ activity and participation needs and taking into account the environmental and personal factors that could influence performance. intervention services are planned in a weekly inter-professional team discussion. disciplines then co-ordinate their input according to the client’s needs to improve, adapt or maintain current functioning so that all involved can lead healthy and fulfilling lifestyles. table 1. students trained annually at the bishop lavis rehabilitation centre profession n study year dietetics 32 fourth (final) year occupational therapy 12 fourth (final) year occupational therapy 6 third year physiotherapy 15 fourth (final) year physiotherapy 18 third year speech-language and hearing therapy 9 fourth (final) year 24 may 2015, vol. 7, no. 1 ajhpe research the service, and how it lends itself to being inter-professional, is explained as follows: • management of clients on a one-on-one basis. students are encouraged to ‘shadow’ other professionals, with the clients allocated to them for management. they conduct joint treatment sessions so that clients receive comprehensive treatment where applicable. if more than one profession is involved in the treatment, the client’s name is added to the board in the student room and the names of the persons from the different professions involved in the client’s management are added to four columns next to the client’s name. this board facilitates communication between the different members of the inter-professional team. the goals for the client’s rehabilitation are discussed weekly with an inter-professional team and is facilitated by the occupational therapist and physiotherapist. referrals to appropriate services not delivered at blrc are also discussed and done as required. • therapeutic and rehabilitative groups. clients receive holistic input from inter-professionally designed group programmes to address all their rehabilitation needs. students have the opportunity to either present part of the programme or shadow other professionals presenting it. • home/work visits. as part of a client’s holistic rehabilitation, they are also treated in their home and work environment as needed. at least two different professionals should conduct the visit, which gives students the opportunity to experience the role/scope of other professions. • community outreaches. training of home-based carers and volunteers, and health education talks, are planned and implemented interprofessionally. students of at least two of the four professions are responsible for the planning and implementation of this service. the national health calendar and four seasons of health-promotion documents are used for planning the monthly themes covered in health education. all administrative duties at blrc are done in an inter-professional manner, e.g. documenting progress notes in one file per client, and co-ordinating the scheduling of clients’ appointments in diaries, as this ensures timeand cost-effective services. methods and analysis this qualitative study describes students’ experiences of inter-professional learning. data were obtained from anonymous student feedback forms. at the end of their clinical placement at blrc, students were requested to fill in feedback forms as part of the quality assurance process to optimise learning opportunities. the completion of student feedback forms is voluntary and anonymous and students were allowed to independently answer questions in a private area after completion of their final evaluation. the feedback forms contained open-ended questions about their learning experience at blrc, e.g. highlights and barriers of the clinical placement. no specific questions about inter-professional learning were included. convenience sampling was employed and all students completing clinical placement at blrc between 2010 and 2012 who handed in their forms were included in the study. a total sample of 124 out of a possible 209 students was obtained (dt: n=32; ot: n=46; pt: n=36; slt: n=10). ethical approval for using the data was obtained from the su health ethics research committee (x13/12/018). the anonymity of the students was maintained throughout data collection and no identifying information was used on the feedback forms during analysis. credibility of the data collection process was ensured by employing triangulation of data sources, as the collection time spanned over 3 years and consisted of four different groups of health professions students.[14] these qualitative data were analysed by employing an inductive approach, and three key themes relating to inter-professional work were identified. credibility, transferability and dependability were applied during the data analysis process to ensure trustworthiness of the findings. credibility was obtained by applying theoretical triangulation through reviewing of the most recent literature confirming or contradicting the themes that emerged from the data analysis. the coding of data was done by one of the researchers not involved in the supervision of the students, and peer review by the other three researchers by generating their own code lists, which were then compared with those of the first researcher. these codes were discussed and altered until consensus was reached.[14] transferability and dependability were obtained by giving a detailed description of the participants, research methodology and setting to determine applicability to a different setting and by using a sample of convenience.[14] results more than half of the students spontaneously answered that ‘working in an inter-professional team’ was a highlight of their placement at blrc. students felt that they learned a great deal about the role of other professions in the management of their clients and about the role of their profession. the three themes that emerged are described below and are illustrated by direct quotes from the different professionals. theme 1. inter-professional teamwork inter-professional teamwork encompasses the important aspects of clear communication between all, learning to work with one another and to respect the input of all towards addressing the needs of the client. ‘everyone gets an opportunity to give input on what would be best ... it felt like they did value our discipline in order to give the best to the patient.’ [dt, 2012] ‘i have learned a lot ... how important it is to communicate so that the different professions can complement each other.’ [ot, 2012] ‘to experience the way the multi-professional team should work together was a very good learning opportunity.’ [pt, 2011] ‘a good learning experience to be put in that situation and learn how to work with other professionals.’ [slt, 2012] theme 2. role identity of own profession this theme alludes to the important realisation by students of the scope of practice of their profession and affirmation of their career choice. ‘during the meeting i realised that dietetics has a strong focus on treatment and prevention but also includes rehabilitation, whilst the physio, occupational and speech, language and hearing therapists' biggest focus was rehabilitation.’ [dt, 2012] ‘working with all the different professions ... i feel much more confident ... that ot is what i want to do and why it is such a fulfilling occupation.’ [ot, 2012] ‘... helped me to learn in different ways, helped me to grow and contributed to my positive experience ... .’ [pt, 2011] ‘ultimately it made me a better therapist. it made me rethink my therapy goals and approach to therapy.’ [slt, 2011] may 2015, vol. 7, no. 1 ajhpe 25 research theme 3. role of other professions the importance of learning from one another and to take cognizance of the role and inputs of other professions are highlighted in this theme. ‘… was a nice learning experience where i got to see what other roleplayers of the inter-disciplinary team do.’ [dt, 2012] ‘working with all the different professions’ students and seeing where everyone fits into the team.’ [ot, 2012] ‘i enjoyed working with the multi-professional team and i was able to learn more about ots and slts and when referrals might be appropriate in the future.’ [pt, 2011] ‘listening to other professionals and understanding what their role is.’ [slt, 2012] the activities mentioned by students within these themes, which they noted as contributing to their learning opportunity while doing practical training at blrc, were weekly inter-professional team discussions, group therapy sessions, home visits and team socials. discussion at blrc, the who icf model is used because of its inclusive focus on health, well-being and functioning, ensuring optimal care for individuals and the community. the icf is therefore also acknowledged internationally as being suitable for educational and training purposes. although the different disciplines involved at blrc have their specific scope of practice, the icf model allows them to work collaboratively to achieve and provide holistic care for their clients. the use of the icf model guided and aligned assessment and management of clients by students from different professions, and then assisted in the collaborative planning of the diverse, profession-specific, yet suitable, interventions. the lancet’s global independent commission into the education of health professionals for the 21st century suggests that inter-professional education is one of the methods that will ensure effective teamwork.[1] the three themes identified in this study describe professional attributes that are important outcomes of inter-professional practice as well as essential qualities to achieve optimal and holistic client care that is realised when using the icf model. through their inter-professional teamwork, the students reported that they had not only developed a strong understanding of their own unique role and expertise, but also respect for each other’s roles and contribution towards client care. the themes identified are not unique, as nisbet et al.[6] also reported the vital role of ipe to assist students in developing effective interprofessional communication and teamwork competencies. further research is necessary to investigate the full potential of icf as a framework to support the ipe philosophy in a clinical setting. conclusion it seems as though the manner in which the centre is managed, with weekly inter-professional team discussions, team socials, joint home visits and treatment sessions, with the icf model guiding client-directed activities, spontaneously lends itself to ipe between students from different professions. icf-based activities not only ensured a holistic approach to client care, but also facilitated students learning from other professions and about their own profession. no specific information was requested regarding ipe in the feedback forms provided to the students. more than half of the students spontaneously mentioned learning about working in an inter-professional team as one of the highlights while at blrc, which prompted us to share this information. the value of this article is that it offers a potential framework (icf) that fosters and supports the ipe philosophy in a clinical setting. further investigation into the range and depth of this learning experience has been initiated. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 2. dhai a, mkhize b. the health professions council of south africa and the medical practitioner. continuing medical education 2006;24(1):8. 3. health professions council of south africa. guidelines for good practice in the health care professions – general ethical guidelines for the health care professions. booklet 1. the human rights, ethics and professional practice. pretoria: hpcsa, 2008. 4. declaration of alma-ata. international conference on primary health care, alma-ata, ussr, 1978. http://www. who.int/publications/almaata_declaration_en.pdf (accessed 23 january 2015). 5. schaay n, sanders d. international perspective on primary health care over the past 30 years. in: barron p, romareardon j, eds. south african health review 2008. durban: health systems trust, 2008:3-16. 6. nisbet g, hendry gd, rolls g, field mj. interprofessional learning for pre-qualification health care students: an outcomes-based evaluation. j interprof care 2008;22(1):57-68. [http://dx.doi. org/10.1080/13561820701722386] 7. caipe. interprofessional education – a definition. 2002. http://www.caipe.org.uk/resources/ (accessed 27 september 2012). 8. lê q, spencer j, whelan j. development of a tool to evaluate health science students’ experiences of an interprofessional education (ipe) programme. ann acad med singapore 2008;37(12):1027. 9. de villiers mr, asia mb, dreyer my, koornhof mhe, statham ms. training the primary health care team. sa fam pract 1996;17(3):111-117. 10. world health organization (who). towards a common language for functioning, disability and health icf. geneva: who, 2002. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf (accessed 27 september 2012). 11. kloppers m. die uitkomste wat fisies-gestremde kliënte bereik deur hul deelname aan rehabilitasie by ‘n gemeenskapsrehabilitasiesentrum in die wes-kaap. stellenbosch: stellenbosch university, 2012 (unpublished dissertation). 12. western cape department of health. re-engineering of primary health care for south africa. 2012. http://www. uwc.ac.za/usrfiles/users/280639/chw_symposium-nationalphc_reengineering.pdf (accessed 27 september 2012). 13. de villiers mr, dreyer y, howes f, et al. assessing the health needs of a community through participatory research. sa fam pract 1999;21(1):8-12. 14. krefting l. rigor in qualitative research: the assessment of trustworthiness. am j occup ther 1991;45(3):214222. [http://dx.doi.org/10.5014/ajot.45.3.214] 52 may 2014, vol. 6, no. 1 ajhpe research tracer studies are alumni surveys that attempt to track activities of graduates of an educational institution. [1] according to boaduo et al.,[2] tracer studies enable the contextualisation of graduates of a specific institution through a dynamic and reliable system in order to determine their career progression. such studies also enable the evaluation of training provided by institutions, graduates’ career paths, nature and status of employment, professional and job satisfaction, and geographical distribution.[3] it is particularly important for policy makers to assess the presence, status and distribution of the health workforce within a country or region, which subsequently contributes to planning.[1] health professions training institutions in africa have paid much attention to transform and align training with the health needs of communities and current global trends.[4] for example, teaching and learning have been modified, moving away from the traditional didactic teacher-centred approach to the student-centred, competency based, community-orientated and transformative learning approaches. all of these are aimed at improving the quality of graduates and providing them with the necessary skills and competencies to address community health needs. many health workers have completed this training. consequently, evaluation studies have been conducted at training institutions in africa and worldwide, aiming to further improve the training of future healthcare professionals. however, most of the aforementioned evaluation studies focus on the training process, including course delivery, materials, content, resources and tutor performance.[5] these evaluations normally culminate in curricular reviews and reforms facilitated by education experts, and graduates of these programmes are rarely consulted for their input. often, faculty in training institutions are detached from the workplace environment of many healthcare workers, the latter frequently being in a better position to offer opinions on how the training needs to be adjusted to meet the required demands on ground level. their responses can also gauge the level of satisfaction with the training in relation to work demands, which can assist trainers in initiating improvements in cases of dissatisfaction.[6] schomburg[3] suggests the use of tracer studies as a method of acquiring useful information from graduates to feed back into the training process. such information can be used to make the necessary adaptations to impart skills demanded in the work environment and to improve the quality of the training. it can also be used as a marketing tool for the institution’s programmes.[7-11] iloeje[12] reported that surveys of graduates are important tools for institutional development because of systematic feedback from former students. the opinion of former students and their retrospective assessment of the training are not only likely to stimulate curricular debates, which can be very useful to current or future students, but also to inform policy makers and institutions about the contribution of these professionals to national development.[13] the current study focused on tracing radiography graduates from makerere university, kampala, uganda over a 10-year period. radiography training at a bachelors degree level in uganda commenced in 2001 at makerere university. although training has been ongoing, there are no data regarding the career status of the graduates and the impact of their training on their lives or the healthcare system. the background. tracer studies are alumni surveys that attempt to track activities of graduates of an educational institution, which enable the contextualisation of these professionals through a dynamic and reliable system to determine their career progression. it also enables the gathering of information to feed back into training institutions and to inform policy bodies on key issues. the purpose of this study was to track career paths of radiography graduates in uganda, examine their contribution to their profession, and establish their opinions on how to improve training and inform policy. methods. a cross-sectional descriptive survey of radiography graduates who completed their training between 2001 and 2011 was conducted. names of graduates were obtained from university records and contact details were sought from the register of the uganda radiographers association, facebook, twitter, and friends. data were collected using a self-administered questionnaire distributed electronically to the students. in a few instances, the survey was completed telephonically. results. a total of 90 questionnaires were sent out; 72 (80%) were returned. the majority of the respondents (95.8%) were employed as radiographers at the time of the survey and were all satisfied with their work. a significant number were employed abroad, while those who remained in the country worked for private health facilities and only a few worked in government health facilities. key suggestions were identified to improve training and influence policy. conclusion. graduate radiographers were generally satisfied with their current work. many trained radiographers, however, are leaving the country, thereby creating a skills shortage in the government healthcare system. ajhpe 2014;6(1):52-55. doi:10.7196/ajhpe.302 using graduates as key stakeholders to inform training and policy in health professions: the hidden potential of tracer studies a g mubuuke, bmr, msc, mhpe; f businge, bmr; e kiguli-malwadde, mb chb, mmed, mhpe radiology department, school of medicine, college of health sciences, makerere university, kampala, uganda corresponding author: a g mubuuke (gmubuuke@gmail.com) mailto:gmubuuke@gmail.com may 2014, vol. 6, no. 1 ajhpe 53 graduates have also not been contacted to feed back their comments into the training programme for improvement of training. therefore, the aim of this study was to track the career paths of radiography graduates to examine the retrospective contribution of their training to their current work demands and to use their views to improve the training of current and future students in an attempt to influence policy formulation in healthcare planning. methods study design a cross-sectional descriptive study was conducted at the school of medicine, college of health sciences, makerere university, kampala, uganda. participants and sampling the study involved radiography graduates (n=90) who completed their training between 2001 and 2011. all were eligible to participate in the study and their names were obtained from makerere university records. the contact details of the graduates were sought and obtained from multiple sources, including the register of the uganda radiographers association, social media channels, e.g. facebook and twitter, and friends of former students. data collection data were collected using anonymised self-administered questionnaires distributed by e-mail to the graduates (n=90). questionnaire items were developed by the researchers from an initial critical review of the literature on the subject. the questionnaire was then piloted with two graduates and improvements were made before administering it to ensure validity of the instrument. information was sought regarding demographic information of the graduates, job placement profiles, factors vital to obtaining employment, and how the radiography curriculum was relevant to eventual job requirements. data analysis data were majorly quantitative and analysed by a statistician in the presence of the researchers. responses from the questionnaires were tallied, coded, counted and entered into an epi-info statistical package to obtain percentages and frequencies, the final data being presented by means of descriptive statistics. ethical issues the questionnaire did not identify the names of the respondents. they could opt out of te study at any one time. data were kept securely and only accessed by the researchers. ethical approval to conduct the study was granted by the review board, school of medicine, makerere university. results ninety questionnaires were sent out and 72 (80%) were returned. sociodemographic profiles the demographic characteristics of the respondents are summarised in table 1. all the respondents were registered with the uganda radiography board and allied health professionals council. being lawfully registered is therefore one manifestation that the qualification obtained was recognised and accredited by professional bodies. job placement profiles all respondents were employed at the time of this survey. table 2 illustrates job placement status and distribution at the time of the study. as all graduate radiographers were employed and satisfied with their work, it illustrates that the demand for radiographers in uganda and beyond is currently high. all the respondents working in radiography and imaging or related work reported holding more than one radiography appointment simultaneously, and all of them reported working in major urban centres. thirty (41.7%) reported practising radiography at three different venues. those who left uganda worked in kenya, cameroon, south africa, namibia, australia and the uk. therefore, many graduate radiographers left the country to work abroad, while those who remained worked for private health facilities, and very few sought employment in government health facilities. of the three radiographers who were not engaged in radiography-related work, two were operating private businesses unrelated to radiography and imaging and one was engaged in agriculture. on the survey tool, these three radiographers reported poor remuneration as the major reason for engaging in other work. research table 1. sociodemographic profiles demography % (n) gender males female 59.7 (43) 40.3 (29) age distribution (years) 25 29 30 34 >34 83.3 (60) 15.3 (11) 1.4 (1) marital status married single 16.7 (12) 83.3 (60) table 2. current employment and satisfaction status and distribution of radiographers employment status % (n) employed 100 (72) unemployed 0 (0) fulltime employment 97.2 (70) part-time employment 2.8 (2) employment related to radiography/imaging 95.8 (69) employment not related to radiography/imaging 4.2 (3) satisfaction with employment very satisfied satisfied less satisfied dissatisfied very dissatisfied 45.8 (33) 54.2 (39) 0 (0) 0 (0) 0 (0) distribution of radiography graduates ugandan public facilities ugandan private facilities outside uganda 5.8 (4) 68.1 (47) 26.1 (18) 54 may 2014, vol. 6, no. 1 ajhpe regarding satisfaction with their current work, 84.7% (n=61) said they were happy and satisfied with their work. with regard to further training, 25% (n=18) had either acquired a postgraduate qualification or were engaged in postgraduate training, leaving 54 (75%) without postgraduate education. factors that contributed to obtaining employment fifty (69.4%) of the respondents said their study record had bearing on obtaining employment as radiographers, indicating that many employers still value the academic merit of graduates. again, 50 (69.4%) said generic skills, including communication, interpersonal skills and problem-solving skills, were key to obtaining employment. twenty (27.8%) respondents indicated that limited experience was a major factor affecting their employment prospects and 10 (50%) of these said they had to first perform volunteer work at their workplace before finally being offered full-time jobs. relevance and satisfaction with regard to curriculum subjects the majority of the radiographers reported that various curriculum subjects were indeed relevant to their practice (table 3). the majority of respondents were generally satisfied with most subjects of the radiography curriculum, except two areas, i.e. x-ray image interpretation and research skills. all 72 respondents commented that being graduates, employers expected more input from them in giving opinions on x-ray images. community-based training courses were rated highly by the graduates. all respondents suggested that strengthening the research component in the radiography curriculum should be addressed, and 10 (13.8%) of them had been denied entering postgraduate studies owing to this. it can therefore be concluded that the curriculum is largely relevant to the current demands, but needs to be improved to address the identified gaps. discussion the majority of the graduates were in their mid-20s mid-30s as the study covered 2001 2011, bearing in mind that the radiography degree course started in 2001. more male than female graduate radiographers were trained during 2001 2011. although admission criteria do not discriminate on the basis of gender, more males than females tend to work in science professions in uganda. the majority of graduates were single, probably because many were establishing themselves and building up their careers. regarding training, most respondents cited the crucial role of generic skills (e.g. communication, inter-personal skills, and problem solving), besides technical knowledge and skills, in obtaining employment. it is therefore important to inculcate generic competencies such as professionalism, inter-disciplinary training, leadership, management, communication and inter-personal skills during radiography training. additionally, training of undergraduate radiographers needs to include basic aspects of image interpretation and reporting, research skills, independent student research projects, and more time for practical and clinical training. these are some of the key issues that need to be addressed urgently by, for example, curricular reviews. former radiography students clearly supported community health courses in the radiography curriculum. they normally undertake these during community placements, together with students from other disciplines, e.g. medicine, nursing, dentistry and pharmacy. these courses focus mainly on primary healthcare activities, community settings and community empowerment. the explanation for the observed interest in such courses is probably because students are then exposed to work in rural communities, where they are likely to be employed, away from teaching hospitals. additionally, students then have opportunities to interact closely with their colleagues from other disciplines, thus appreciating the role of teamwork in healthcare delivery. a significant number of graduate radiographers have left uganda to go abroad, while the remaining few hold more than two radiography positions in their daily work schedule, mostly in private urban health facilities. holding more than two jobs results from poor pay and the limited numbers of radiographers. this trend is not only limited to radiographers, but also applies to other health professionals and science graduates in uganda. many radiographers leave the country in search of training opportunities and career development. few radiographers have the opportunity to pursue postgraduate studies for career growth, mainly because uganda has had no accredited postgraduate programmes in this discipline. this drawback is found in many african countries outside south africa. when radiographers leave for further training abroad, many never return, further constraining the remaining workforce. therefore, training institutions, professional associations and other government bodies should initiate career advancement programmes locally. this is likely to reduce the number of radiographers who leave the country, as has been observed in other reported studies.[14] it is also possible for governments to formulate policies that call for rural community service programmes for newly qualified professionals, not only radiographers, but also other health professionals. in such a programme, new graduates can work in rural community facilities under supervision and be remunerated by government for at least a year before registration. this would benefit both the graduate and the government, with the former gaining much-needed experience and mastery of skills, and the latter maintaining a continued presence of health workers in underserved areas. it is implied that rural communities have a higher shortage of radiographers, as all respondents were working in the major urban centres. this could be because urban centres have more private health facilities and it is possible to be employed in more than one workplace. however, this study did not specifically set out to investigate disparities in radiographer distribution between rural and urban settings and the possible causes of such disparities. this is therefore an area that warrants further research. research table 3. satisfaction with radiography curriculum components component % (n) community health courses research skills plain radiography fluoroscopy computed tomography ultrasound mammography magnetic resonance imaging nuclear medicine dental radiography clinical/practical hours x-ray film interpretation/pattern recognition 100 (72) 27.7 (20) 100 (72) 100 (72) 100 (72) 100 (72) 76.4 (55) 66.6 (48) 68 (49) 100 (72) 62.5 (45) 13.8 (10) may 2014, vol. 6, no. 1 ajhpe 55 this study has highlighted that alumni surveys can generate useful information to feed back into the training process, thus enhancing the quality of teaching and learning. useful information can also be generated from tracer studies, which can assist in formulating policies aimed at retaining health workers in areas where they are most needed. although this study focused on radiography graduates, some findings are also most likely applicable to many other health professions. the study has some limitations. firstly, the researchers did not conduct individual interviews or focus group discussions to obtain qualitative experiences of the participants, mainly due to difficulties in accessing the participants physically. perhaps in-depth qualitative interviews or focus group discussions would have provided more data to supplement the questionnaire data. secondly, the study focused on radiography graduates from one institution and findings may not be fully applicable to those from other institutions or even to all other healthcare professions. however, the study still provides a foundation to further explore tracer studies to inform both training and policy decisions. conclusion this study has shown that tracer studies can be useful for gathering information that positively impacts on training and policy. the majority of graduate radiographers in this study were satisfied with their work, but made suggestions, such as improving their remuneration and reviewing curricular content, to address the current demands in the work environment. training institutions are therefore called upon to engage graduates as key stakeholders in enhancing learning, while government bodies are called upon to utilise the information from graduates to formulate appropriate policies that positively influence healthcare delivery. references 1. association for african universities. regional workshop on tracer studies of past university students, 2001. http://www.aau.org/ (accessed 1 june 2010). 2. boaduo nap, mensah j, babitseng sm. tracer study as a paradigm for the enhancement of quality course programme development in higher education institutions in south africa. paper presented at the educational colloquium, university of north-west, potchefstroom, south africa, 20 21 august 2009. http://webreg.uzulu. ac.za:8090/itsquery/showqualenrollment.jsp (accessed 10 october 2011). 3. schomburg h. handbook for graduate tracer studies. university of kassel, germany: centre for research on higher education and work, 2003. 4. kiguli-malwadde e, kijjambu s, kiguli s, et al. problem based learning, curriculum development and change process at faculty of medicine, makerere university, uganda. african health sciences 2006;6(2):127-30. 5. narman a. a tracer study evaluation of the moshi national vocational training centre (mvtc), tanzania. occasional paper, 1991;4(3), department of human and economic geography, göteborg. göteborg: göteborg university, 1991. 6. zembere sn, chinyama npm. the university of malawi graduate tracer study. blantyre: university of malawi, 1996. 7. andrew d, bankole o, olatunde a. labor market prospects of university graduates in nigeria. nigeria university system innovation project, november 2000. http://siteresources.worldbank.org/nigeriaextn/resources/ labor_market_univ.pdf (accessed 12 june 2012). 8. okebukola p. the state of university education in nigeria. abuja, nigeria: national universities commission, 2002. 9. ugwuonah ge, omeje kc. final report of tracer study research project on higher education and work. university of nigeria: institute for development studies,1998. 10. bennell p, manyokolo m. a lost generation: key findings of a tracer survey of secondary school leavers in south africa. international journal of educational development 1994;14(2):195-206. 11. bennet n, dunne e, carre c. skills development in higher education and employment. buckingham: society for research into higher education and open university press, 2004. 12. iloeje ic. graduates’ employment survey: a tracer study of the graduates of faculty of arts, agriculture and education, 1996. http:aau.org/studyprogram/reports/anyanwu.pdf-194k(accessed 4 may 2010). 13. harmening dm. technologist report overall job satisfaction, 10-ear prospective study examinees’ career patterns. laboratory medicines 1996;25(12):773-775. 14. mubuuke ag, kiguli-malwadde e, businge f, byanyima r. factors influencing students’ choices in considering rural radiography careers at makerere university. radiography 2010;16(1):56-61. [http://dx.doi.org/10.1016/j. radi.2009.09.003] research http://www.aau.org/ http://webreg.uzulu http://siteresources.worldbank.org/nigeriaextn/resources/ http://dx.doi.org/10.1016/j.radi.2009.09.003] http://dx.doi.org/10.1016/j.radi.2009.09.003] 194 november 2015, vol. 7, no. 2 ajhpe research the inclusion of ‘management’ competencies in medical curricula is widely propagated.[1-3] partly based on this requirement, dental practice management (dpm) is part of the undergraduate curriculum in the school of dentistry, university of pretoria, south africa (sa). in recent years, dpm has been presented in the fourth and fifth years of study and can be considered a major study unit in the undergraduate dental curriculum. teaching and learning in dpm typically include leadership, strategic management, financial management, personnel management, patient management, dentist-patient communication and marketing.[4] to date, from a student perspective, no information is available regarding the need for dpm as a subject in undergraduate dental curricula in sa. there is, however, some evidence in the literature that undergraduate dental students do not regard the development of management skills to be as important as the attainment of clinical skills.[5] dpm is likely to be relevant to those who aspire to become dental practice owners or managers in the private or public sector. it is debatable whether extensive teaching and learning in dpm will be perceived to be relevant by those who aspire to follow a career as employees only. the literature shows that the majority of dental graduates in sa aspire to enter private practice.[6] these trends may, however, be affected by the transformation in dental education during the past two decades. during this time, the profile of dental students changed from being male dominated to female dominated.[6] furthermore, social redress in correcting racial profiles at universities is actively being pursued.[6] it would therefore be valuable to investigate whether these demographic changes affect the career aspirations of dental students and if dpm is perceived to be relevant and necessary as a major subject in the undergraduate dental curriculum. this study sought to investigate students’ perceptions regarding the need for dpm as a subject in the undergraduate dental curriculum at the university of pretoria and to relate these perceptions to their future career aspirations. the study also aimed to identify perceptions of the students regarding the most important skills (other than clinical skills) they have to learn in the undergraduate dental curriculum. methods a cross-sectional survey was conducted in 2012 by means of an anonymous questionnaire among second-, third-, fourthand fifth-year dental students (n=228) at the university of pretoria’s school of dentistry. the research and ethics committees at the faculty of health sciences, university of pretoria approved the study protocol (91/2012). sample second-, third-, fourthand fifth-year dental students (n=228) at the university of pretoria’s school of dentistry were invited to take part in the research. questionnaire design in this pilot study a custom-designed questionnaire, in english, with openand closed-ended questions, was administered to the various cohorts; participation was voluntary and anonymous. the questionnaire was not piloted before. the researcher distributed the questionnaires to the students at the start of a routine lecture period (around midday). the students completed a consent background. the inclusion of ‘management’ competencies in medical curricula is widely propagated. there is some evidence in the literature that undergraduate dental students regard clinical skills as more important than management skills. objective. to investigate student perceptions regarding dental practice management (dpm) as a subject in the undergraduate dental curriculum at the university of pretoria, south africa (sa) and to relate these perceptions to their future career aspirations. method. a cross-sectional survey was conducted in 2012 by means of an anonymous questionnaire among second-, third-, fourthand fifth-year dental students (n=228) at the university of pretoria’s school of dentistry. results. of the 192 respondents, 92% (n=177) agreed that dpm should be a subject in an undergraduate curriculum, but there was no correlation with their career aspirations. leadership and management skills (77.6%), people skills (64.6%), communication and listening skills (46.4%) and personal style (42.2%) were seen as the most important non-clinical skills. students indicated their career aspirations as follows: private practice owners (45.3%, n=81), public sector and military (15.1%, n=27), working abroad (13.4%, n=24) and medicross/intercare (11.2%, n=21). there were statistically significant differences (p=0.001) among the study years with regard to private practice aspirations. most students (81.7%, n=156) indicated that they would specialise if afforded the opportunity. conclusion. in light of the prospects of the national health insurance (nhi) in sa, management and leadership skills will be vital to the successful longterm implementation of the nhi; hence, academic institutions and government should address these issues as a priority in their undergraduate curricula. afr j health professions educ 2015;7(2):194-198. doi:10.7196/ajhpe.408 dental students’ perceptions of practice management and their career aspirations s e van der berg-cloete, bchd, pgdip (com dent), mba, dhsm; l snyman, bchd, pgdip (clin dent), pgdip (prac man), pgche, mbl; t c postma, bchd, mchd (com dent), dhsm, phd; j g white, bchd, bchd (hons), dipl tertiary education, mba, phd  department of dental management sciences, school of dentistry, faculty of health sciences, university of pretoria, south africa corresponding author: s e van der berg-cloete (sophy.vanderberg-cloete@up.ac.za) november 2015, vol. 7, no. 2 ajhpe 195 research form, which clearly stated that participation in the study was voluntary and that they could refuse to participate or discontinue at any time without giving a reason. the researchers collected the completed questionnaires immediately on completion. participants were asked to indicate their year of study, race and gender. they also had to specify whether they would wish to specialise if given an opportunity. information on their previous exposure to public, military and private dental institutions was also elicited. furthermore, students had to state their long-term career aspirations. they were asked whether they would prefer to work as an employee in the public sector, military, at medicross/intercare (managed healthcare provider) or for a private dentist. alternatively, they could indicate whether they aspired to become a dental practice owner or business partner in a dental practice. an option was also provided to specify whether they wished to work abroad. there was an open-ended question regarding the ‘important skills other than clinical skills’; students had an option to indicate the four most important skills in terms of keywords. their responses were thematically coded. students then had to respond to whether they thought that dpm should be a subject in an undergraduate dental curriculum. the questionnaire contained a likert scale response choice of ‘strongly disagree’, ‘sometimes disagree’, ‘disagree’, ‘sometimes agree’ ‘agree’ or ‘strongly agree’ for the majority of the questions. an open-ended question where students were asked to write a reflection on why they thought dpm should/should not be a subject in an undergraduate dental curriculum, was also thematically coded. data analysis the coded data were captured on an excel spreadsheet and analysed using spss version 21. descriptive statistics included determination of frequencies. the χ2 test was used for bivariate associations between demographic variables (year of study, sex, race) and students’ perception of dpm as a subject in an undergraduate dental curriculum, their long-term career aspirations and their specialisation aspirations. a value of p<0.05 was considered statistically significant. results of the 228 targeted students, 192 (84%) completed the questionnaire. the number of students per year of study varied between 39 and 59. table 1 indicates that the respondents were mainly female (66.1%, n=127); 49.5% (n=95) were white, 33.0% (n=64) black, 11.5% (n=22) asian, and 2.6% (n=5) coloured. the remaining 3.1% (n=6) students did not indicate their race. the responses of students from asian descent were similar to those of the white students. similarly, the responses of the coloured students generally followed the trend of the black respondents. no further mention, therefore, is made in the results of the two minority groups of self-reported race. the majority (92%, n=177) of students agreed that dpm should be a subject in an undergraduate dental curriculum. responses to an open-ended question where students had to write a reflection on why they thought dpm should/should not be a subject in an undergraduate dental curriculum, included: ‘it is as important as clinical skills’; ‘it will help to run a business/private practice’; ‘it will assist us in knowing the external environment’; ‘it prepares one for what to expect in the business world’; ‘we as undergraduates may not see the importance now and may forget some information but one can see the role that it will play one day’. fig. 1 displays important skills other than clinical skills as perceived by the students. these include: (i) leadership and management skills (77.6%), such as teamwork, motivation, time-management, finan cial management, business and decision-making skills; (ii) people skills (64.6%), such as sympathy, caring, kindness, empathy, compassion and friend liness; and (iii) communication and listening skills (46.4%), and personal style (42.2%), such as thoroughness, tolerance, patience, positive attitude, enthusiasm and self-discipline. skills pertaining to ethics and professionalism, and entrepreneurial skills were mentioned less often. less than half (45.3%, n=81) of respondents (table  2) indicated their aspirations to become private practice owners, i.e. 50% (n=31) males and 42.7% (n=50) females. at least 44 (49.4%) of the white students indicated their intention to become private practice owners, while 39.7% (n=23) of black students indicated this option. these differences were not statistically significant. some respondents (15.1%, n=27) (table  2) mentioned that they intended to work in the public sector or the military. furthermore, 29.3% (n=17) of black students stated that they want to be employed in the public sector or in the military, while only 6.7% (n=6) of white respondents selected this option (χ2 test, p<0.001). twenty-one per table 1. breakdown of students’ gender, race and year of study variable n % gender female 127 66.1 male 65 33.8 self-reported race black 64 33.3 coloured 5 2.6 asian 22 11.5 white 95 49.5 not reported 6 3.1 year of study bchd ii 43 22.4 bchd iii 59 30.7 bchd iv 39 20.3 bchd v 51 26.6 total 192 2.1 6.3 10.4 17.2 42.2 46.4 64.6 77.6 0 10 20 30 40 50 60 70 80 90 percentage other (e.g. research, it) entrepreneurial skills professionalism ethics personal style communication and listening skills people skills leadership and management skills fig. 1. students’ perceptions of important non-clinical skills (it = information technology). 196 november 2015, vol. 7, no. 2 ajhpe research cent (n=21) of male respondents compared with 12% (n=12) of female respondents were interested in working in the public sector or in the military. this difference was not statistically significant. at least 13.4% (n=24) of the total respondents (table  2) expressed an intention to work overseas. a larger proportion of white respondents (14.6%, n=13) than black respondents (5.2%, n=3), which included a higher ratio of males (16.1%, n=10) than females (12.0%, n=14), indicated their intent to work overseas (not statistically significant). a further 11.2% (n=21) of respondents (table  2) displayed an interest in working at medicross/intercare. the ratio of female respondents (15%, n=17) interested in this option exceeded the ratio of male (7%, n=4) respondents (not statistically significant). there was virtually no difference between the white (11.2%, n=10) and black (12.1%, n=7) students regarding the medicross/intercare option. table 2 further indicates that 8% of the respondents (n=15) displayed an interest in working as an employee for a private dentist. white respondents table 2. career aspirations of secondto fifth-year dental students   self-reported race and gender public sector/ military medicross/ intercare work as employee for private dentist academic private dental practice owner overseas no career option indicated n % n % n % n % n % n % n % black (female) 7 25.0 4 14.3 2 7.1 3 10.7 10 35.7 2 7.1     black (male) 10 33.3 3 10.0 1 3.3 2 6.7 13 43.3 1 3.3     black (subtotal) 17 29.3* 7 12.1 3 5.2† 5 8.6 23 39.7 3 5.2     coloured (female) 1 25.0 1 25.0         2 50.0         coloured (male) 1 100.0 0 0.0         0 0.0         coloured (subtotal) 2 40.0 1 20.0         2 40.0         asian (female) 2 10.5 2 10.5     1 5.3 8 42.1 6 31.6     asian (male) 0 0.0 1 33.3     0 0.0 2 66.7 0 0.0     asian (subtotal) 2 9.1 3 13.6     1 4.5 10 45.5 6 27.3     white (female) 4 6.5 10 16.1 12 19.4 3 4.8 28 45.2 5 8.1 0 0.0 white (male) 2 7.4 0 0.0 0 0.0 13.5† 0.0 16 59.3 8 29.6 1 3.7 white (subtotal) 6 6.7‡ 10 11.2 12 13.5† 3 3.4 44 49.4 13 14.6 1 1.1 race not reported (female)           2 50.0 1 25.0 1 25.0 race not reported (male)           0 0.0 1 100.0 0 0.0 race not reported (subtotal)                 2 40.0 2 40.0 1 20.0 female (subtotal) 14 12.0 17 14.5 14 12.0‡ 7 6.0 50 42.7 14 12.0 1 0.9 male (subtotal) 13 21.0 4 6.5 1 1.6‡ 2 3.2 31 50.0 10 16.1 1 1.6                               total 27 15.1 21 11.7 15 8.4 9 5.0 81 45.3 24 13.4 2 1.1 * p<0.001 (χ2 test). † p<0.05 (fisher exact test). ‡ p<0.05 (fisher exact test). november 2015, vol. 7, no. 2 ajhpe 197 research (13.5%, n=12) were more likely to indicate this option than black respondents (5.2%, n=3) (fisher exact test, p<0.05). similarly, female respondents (12%, n=7) were more inclined to select this option than males (1.6%, n=1) (fisher exact test, p<0.05). of the total respondents, 5% (n=9) indicated an interest in becoming an academic, while 1.1% (n=2) did not indicate their future career aspirations (table 2). it should be noted that no statistically significant association could be found between the students’ career aspirations and their perception about the need for dpm in the undergraduate dental curriculum. most students (81.7%, n=156) felt that they would specialise if they were afforded the opportunity. less than half (43.2%, n=83) of the respondents had previous exposure to public or military service. only 39.6% (n=76) had exposure to medicross/intercare, while the majority (88.0%, n=169) had visited a private dental practice before. no statistically significant association could be shown between the students’ previous experiences of private and public dental care facilities and their potential career choices. discussion this study investigated the perceptions of dental students with regard to the need for dpm as a major study unit in an undergraduate dental curriculum. the findings of the current study that the majority of dental students who responded to the questionnaire considered dpm to be a necessary field of study in the undergraduate dental curriculum at the university of pretoria, correspond to similar research carried out abroad. the latter studies reported that students studying health sciences are indeed becoming increasingly aware of the need for business training.[7-9] qualified practising dentists also recognise the need for dpm education in the curriculum.[10] the findings of the current study are, however, unique, as they provide the first indication of dental students’ perceptions regarding the need for dpm in sa. clinical skills are generally considered extremely important, but ‘soft’ skills such as leadership, communication and dpm contribute to the success of practising health professionals. its importance in an undergraduate curriculum has been acknowledged.[11-13] the development of management skills is therefore becoming crucial for dentists to manage their practices successfully.[14-16] these skills are often neglected in undergraduate curricula despite tendencies that students recognise them as crucial.[17-20] in our study, students were asked to indicate the most important skills – other than clinical skills. from their responses it could be deducted that leadership and management were considered to be the most important skills to acquire other than clinical skills. this study is the first to point out that dental students regard leadership and management as priority skills. the students’ perception that dpm should be part of the dental curriculum at the university of pretoria is probably the result of their awareness of the complexity of the dental practice ‘business’ environment and changes facing dentists in the external environment.[21] these features are actively addressed in the undergraduate dental curriculum from the second year of study onwards as part of the integrated dentistry module (second year of study) and comprehensive patient management (cpm) module (third to fifth year of study) (cpm study guide – available from the authors). another possible reason for the overwhelming response that dpm should be a subject in the undergraduate dental curriculum may reflect the students’ career aspirations. no associations could, however, be found between the career aspirations of the students and their opinion about the need for dpm as a subject, also not when analysed in terms of the year of study. a few local and international studies have suggested that the majority of students opt for private practice rather than the public sector.[6,22-25] about 45.3% of the students indicated a vision of owning a private dental practice, with only 15.1% showing a desire to work in public health facilities or in the military. these findings are not surprising, as it is well known that government and the military have a fixed number of posts and many of the governmental posts in sa are annually filled by dentists in community service. private dental practice is, therefore, the most viable part of the market for a qualified dentist for employment in sa. the potential future strengthening of the public sector by means of the national health insurance (nhi) may, however, change these perceptions. in a study done in the uk, where there is a well-established national health service (nhs) with ample employment opportunities, a high ratio of students indicated an intention to work in the nhs.[26] another interesting finding of the current study is the much higher ratio of black students who indicated an interest to work in the public sector or the military compared with white students. the findings illustrate that, compared with males, female students (especially white females) who do not aspire to become private practice owners want to become employees in a private dental practice or work at institutions such as medicross or intercare. these trends are important to monitor in future as female dental students are in the majority. the abovementioned findings are indicative of differences that may exist among dental students with regard to career aspirations. this is important in sa, where political redress is continuously taking place. in the current study, white students are ~50% of the study sample, which is not reflective of the demographic profile of the country. the racial profile at the university of pretoria is however normalising over time, i.e. a higher ratio of black students will graduate in future. the study showed significant differences between the career aspirations of white and black students. it is important for tertiary institutions to be aware of the changing career aspirations of the emerging oral healthcare workforce, as this will assist in future planning and policy decisions in terms of the content of dental curricula. the current study provides valuable local data in this regard. the results also highlighted that the majority of the dental students at the university of pretoria would specialise if they were afforded the opportunity. conflicting evidence in this regard is available in the literature. freire et al.,[22] grytten and skau[27] and rashid et al.[28] showed that the majority of students wish to specialise, while marino et al.[23] and drinkwater et al.[29] indicated that the majority of students wanted to be general dentists only. male students were more likely to specialise, while females preferred to pursue an academic career. the findings also suggest that only a small percentage of local dental students are interested to employ their skills abroad. the relatively low percentage probably results from south africans having to pass an examination abroad (since 2000). it has become increasingly difficult for sa dentists to be employed in countries such as the uk.[30] conclusion the two main findings of this study are as follows: • secondto fifth-year dental students are of the opinion that dpm is an important part of the dental curriculum at the university of pretoria and regard leadership and management skills as being as important as clinical skills. 198 november 2015, vol. 7, no. 2 ajhpe research • sociodemographic differences exist in the career aspirations of dental students, which is important to take into account given the changing demographic profile of dental students. the greatest limitation of the current study is that the results are merely a snapshot of students’ perceptions at a single university in sa at a given point in time. the results can therefore not summarily be generalised with regard to other training institutions. this research should, however, be expanded to a national level, incorporating all the dental training institutions through a collaborative effort to investigate the need for management and leadership training. the questionnaire used in this pilot study appears to have rendered reliable results and can serve as the basis for future research. the opinions of academics and dentists from both the public and private sectors should also be sourced in future research projects. acknowledgements. the researchers acknowledge the positive attitudes and cooperation and inputs of the participating students. we thank barbara english, research office, faculty of health sciences, university of pretoria for her editing skills. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an 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[http://dx.doi.org/10.1080/01421590701746983] 4. university of pretoria. comprehensive patient management (tbw370-570) study guide. pretoria: university of pretoria, 2012. 5. cardall wr, rowan rc, bay c. dental education from the students’ perspective: curriculum and climate. j dent educ 2008;72(5):600-609. 6. lalloo r, ayo-yusuf oa, yengopal v. early-phase dental students’ motivations and expectations concerning the study and profession of dentistry. s afr dent j 2008;63(4):216-220. 7. barber m, wiesen r, arnold s, taichman rs, taichman ls. perceptions of business skill development by graduates of the university of michigan dental school. j dent educ 2011;75(4):505-517. 8. busari jo, berkenbosch l, brouns jw. physicians as managers of health care delivery and the implications for postgraduate medical training: a literature review. teach learn med 2011;23(2):186-196. [http://dx.doi.org/10. 1080/10401334.2011.561760] 9. jaarsma da, dolmans dh, scherpbier aj, van beukelen p. preparation for practice by veterinary school: a comparison of the perceptions of alumni from a traditional and an innovative veterinary curriculum. j vet med educ 2008;35(3):431-438. [http://dx.doi.org/10.3138/jvme.35.3.431] 10. khami mr, akhgari e, moscowchi a, et al. knowledge and attitude of a group of dentists towards the topics of a course on principles of successful dental practice management. j dent med 2012;25(1). 11. hobson rs. challenges to future dental education. br dent j 2009;206(3):125-126. [http://dx.doi.org/10.1038/ sj.bdj.2009.54] 12. jawale ba, bendgude v, husain n, thosar n, tandon p. soft skill appraisal for dentistry: a tool for positive practice management. j contem dent pract 2011;12(6):475-478. 13. plasschaert a, lindh c, mcloughlin j, et al. curriculum structure and the european credit transfer system for european dental schools: part i. eur j dent educ 2006;10(3):123-130. 14. bajaj a. good management underpins good clinical dentistry. vital 2010;7(4):16-18. 15. dunning dg, lange bm, madden rd, tacha kk. prerequisites in behavioural science and business: opportunities for dental education. j dent educ 2011;75(1):77-81. 16. willis do. using competencies to improve dental practice management education. j dent educ 2009;73(10):1144-1152. 17. abbas mr, quince ta, wood df, benson ja. attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. bmc med educ 2011;11(93):1-21. [http:// dx.doi.org/10.1186/1472-6920-11-93] 18. kalenderian e, timothé p. integrating leadership into a practice management curriculum for dental students. j dent educ 2010;74(5):464-471. 19. lennon ma, ireland rs, tappin j, et al. the personal dental service as a setting for an undergraduate clinical programme. br dent j 2004;196(7):419-422. 20. slavkin hc, lawrence l. incorporating leadership knowledge and skills into the dental education community. j dent educ 2007;71(6):708-712. 21. white jg. interacting forces influencing private dental practice in south africa: implications for dental education. s afr dent j 2008;63(2):80-85. 22. freire mcm, jordao lmr, de paula ferreira n, de fatima nunes m, queiroz mg, leles cr. motivation towards career choice of brazilian freshman students in a fifteen-year period. j dent educ 2011;75(1):115-121. 23. mariño r, au-yeung w, habibi e, morgan m. sociodemographic profile and career decisions of australian oral health profession students. j dent educ 2012;76(9):1241-1249. 24. scarbecz m, ross ja. the relationship between gender and postgraduate aspirations among firstand fourth-year students at public dental schools: a longitudinal analysis. j dent educ 2007;71(6):797-809. 25. stewart f, drummond j, carson l, theaker e. senior dental students’ career intentions, work-life balance and retirement plans. br dent j 2007;203(5):257-263. 26. gallagher je, patel r, wilson nhf. the emerging dental workforce: long-term career expectations and influences. a quantitative study of final year dental students’ views on their long-term career from one london dental school. bmc oral health 2009;9(35):1-9. 27. grytten j, skau i. specialization and competition in dental health services. health economics 2009;18(4):457-466. 28. rashid hh, ghotane sg, abufanas sh, gallagher je. short and long-term career plans of final year dental students in the united arab emirates. bmc oral health 2013;13(1):1-9. 29. drinkwater j, tully mp, dornan t. the effect of gender on medical students’ aspirations: a qualitative study. med educ 2008;42(4):420-426. [http://dx.doi.org/10.1111/j.1365-2923.2008.03031.x] 30. eaton k, balázs p. dentists’ migration to and from hungary between 1970 and 2005 and into the united kingdom between 1994 and 2005. oral health and dental management in the black sea countries 2008;7(4):3-11. research 202 november 2015, vol. 7, no. 2 ajhpe institutional context in 2009 the school of dentistry, university of pretoria, south africa implemented a novel integrated case-based approach during the third (preclinical) year of the undergraduate dental curriculum in a subject called comprehensive patient care (cpc).[1-4] the purpose was to scaffold the transfer from the preclinical year to clinical teaching and learning.[5] the case-based intervention was adopted in pursuit of relevance[5-7] and integration[8] through active learning[9] and problem-solving approaches[2,10].in the undergraduate dental curriculum.[3] the novel intervention aimed to improve the assessment of clinical reasoning[11,12] and the provision of formative feedback during the teaching, learning and assessment processes.[5,12] teaching and learning in the third year of study were designed to focus on tracer conditions (common oral diseases or conditions)[5,13,14] and were generally administered through scaffolded simulation activities.[5] the assessment plan included a test on the completion of patient administration forms used in the school. this was followed by three communication role-play exercises, simulating the communication during a clinical encounter[15,16] based on context-rich case studies, and a comprehensive clinical examination on a peer. the formative assessment contained 5 integrated clinical reasoning portfolio case-study exercises that simulate typical clinical cases dental students would encounter in their fourth year of study. these exercises included diagnostic and treatment planning decisions and required descriptions of the student’s reasoning. the final assessment comprised a progress test containing 32 multiple-choice questions (mcqs) based on a context-rich integrated case study covering the selected tracer conditions and formulated to test the ability of the students to diagnose and make decisions with regard to treatment planning. students wrote the same test at the end of the third, fourth and fifth years of study to monitor their progress in their clinical decision-making ability. the progress test was the only standardised assessment entity that measured the outcome of clinical reasoning over time. the other assessments had a pertinent formative purpose and may have varied; they could therefore not be used to measure the development of clinical reasoning over a period of time. all of the abovementioned activities have been integrated into clinical teaching and learning in a clinical setting during the fourth and fifth years of study. the problem an analysis of progress test data for 2009 2011 showed that some students improved their progress test scores while some did not. it should be noted that the non-progression group included students who obtained high, moderate, as well as low scores at baseline. this observation led to the investigation of possible reasons for progression and non-progression in clinical reasoning decision-making. a literature review revealed that psychological attributes such as ‘self-regulated’ learning and ‘self-handicapping’ behaviours may influence the learning of individual students. the concept of self-regulated learning self-regulated learning may be defined as a proactive way of acquiring knowledge, skills and competence.[17] those who engage in self-regulated learning set goals for themselves, display strategic thinking, and monitor their own academic performance and effectiveness. this is in stark contrast to students who merely react to what the environment enforces on them.[17] zimmerman and campillo[18] adapted a model of self-regulated learning from a publication titled ‘the nature of problem solving’. there is increasing empirical evidence to support the validity of the components of the model and the interactions. fig. 1 demonstrates the three phases of the model. the forethought phase precedes the performance phase, which is followed by a self-reflection phase. self-reflection is often followed by a new forethought stage for further or enhanced learning.[17] background. in 2009 a new case-based instructional design was imple mented during the preclinical year of study of the undergraduate dental curriculum of the university of pretoria, south africa. the objective of the educational intervention was to improve the development of clinical reasoning skills. to achieve this, systematic scaffolding, relevance, integration and problem-solving were actively promoted as part of teaching and learning. a student’s clinical reasoning was measured by a progress test containing 32 multiple choice questions (mcqs), formulated on a knowledgeapplication level. in 2011 it became clear that some students showed progression while others did not. objectives. this study was conducted to gauge the value of the case-based intervention with the aim of determining the need for further scaffolding and support, especially for non-progressing students. methods. the 2011 bchd iv cohort (n=48) was identified for the study. two semi-structured focus group discussions were conducted. group 1 (n=8) consisted of students who progressed ≥9%, while group 2 (n=8) comprised students who did not progress to the same extent. results. both groups lauded the scaffolding that the case-based curriculum provided. strategic thinking, goal orientation and self-regulation ability were identified in group 1. a lack of diligence, poor data-processing ability and a possible lack of interest were identified in group 2 students, who were unaware of learning opportunities. conclusion. there is a need for early identification of students lacking self-regulated learning and for providing timely feedback and support to progressively develop their clinical reasoning skills. afr j health professions educ 2015;7(2):202-207. doi:10.7196/ajhpe.411 self-regulation – the key to progress in clinical reasoning? t c postma, phd comprehensive patient management, department of dental management sciences, school of dentistry, faculty of health sciences, university of pretoria, south africa corresponding author: t c postma (corne.postma@up.ac.za) research november 2015, vol. 7, no. 2 ajhpe 203 the forethought phase is controlled by task analysis and self-motivation beliefs. task analysis can be described as a process of strategic planning and the setting of goals. self-motivation beliefs include goal orientation with self-efficacy beliefs – belief in your own abilities – and an interest in the task at hand, with distinct outcome expectations. for example, expectations of the achievement of ‘excellent’ assessment results could be seen as an indicator of being goal orientated.[17] the second phase is the performance, where self-control and self-observation are the key processes. self-control is a process of selfinstruction, displaying attention and focus. the adoption of task strategies and imagery are typical processes employed by self-regulated learners during this phase. self-monitoring is related to self-control and entails metacognitive monitoring and self-recording practices.[17] the third phase is self-reflection, which consists of self-judgement and self-reaction. self-judgement includes processes of self-evaluation and causal attribution.[17] the latter may be defined as the reasons (provided by the learner) for the cause of a specific event.[17] the learner might perceive the cause to be from an internal origin (a result of his or her personal behaviour) or an external source. self-judgement is followed by self-reaction, based on the individual’s perception of self-satisfaction. a lack of self-satisfaction might, for example, affectively stimulate a renewed forethought phase to continue the learning. adaptations to behaviour might also be made as a result of self-evaluation.[17] the concept of selfhandicapping behaviour in contrast to self-regulated learning, there is learning that might be impeded by a student’s personal behaviour.[19] self-handicapping may be viewed as being in direct contrast to self-regulation. some students employ self-handicapping strategies to protect and enhance their self-esteem.[19] those who employ self-handicapping strategies typically postpone their learning to the last minute and might subsequently blame the circumstances and the external environment rather than their lack of ability, motivation, and diligence.[19] those who are guilty of self-handicapping behaviour tend to project their lack of performance or failures away from themselves in an attempt to protect their own ability and self-worth.[20,21] self-handicapping has a negative correlation with a goal-setting approach in the academic environment.[22] objectives the first objective of this study was to compare qualitative feedback from progressing and nonprogressing fourth-year dental students with regard to the value of the case-based intervention they were exposed to in the preclinical year of study. the second objective was to identify selfregulating and self-handicapping behaviours[17,18] among the students, based on the differences in feedback. the third objective was to determine the need for additional student support to improve the educational intervention further. methods as the current study was part of a larger action research project that originated before 2009, the original protocol (153/2009) was amended in 2011 to include the following qualitative analysis fig. 1. the phases of self-regulated learning.[17] forethought phase performance phase self-re�ection phase • task analysis • self-motivation beliefs • self-control • self-observation • self-judgement • self-reaction • strategic planning • goal setting • goal orientation • interest in the task • outcome expectations • self-e�cacy beliefs • self-instruction • attention and focus • task strategies • imagery • metacognitive monitoring • self-recording practices • self-evaluation • causal attribution • self-satisfaction • adaptation return to the forethought phase focus group 1 focus group 2 –20 –15 –10 –5 0 5 10 15 20 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 fig. 2. distribution of the individual progress test score (%) differences between 2011 and 2010 for the 2011 bchd iv cohort (n=48). research 204 november 2015, vol. 7, no. 2 ajhpe as part of the evaluation of the newly implemented integrated case-based approach. sample selection the 2011 fourth-year bchd cohort was identified because they had the opportunity to clinically apply the knowledge they had gained in the preclinical (third) year of study. these students had completed the progress test more than once; therefore, their progress could be tracked. the fifth-year group, who were in the final phase of their undergraduate course at that stage, were not interviewed because of time constraints. study design the researcher identified semi-structured focus group discussions as the method of choice for data collection. such groups maintain a broad structure but allow for flexibility during the interview so that students may elaborate on their experiences. this may lead to the discovery of information that might have been restricted by an overly structured approach.[23] two groups of 8 students each from the 2011 fourth-year cohort were purposively selected by the researcher for focus group discussions.[23] these groups were arbitrarily differentiated according to their progression in terms of clinical reasoning (fig.  2) (measured by means of the progress test), which has been described in the introduction. focus group  1 consisted of students who appeared to have improved their progress test scores by ≥9%. focus group  2 comprised students who had either achieved lower progress test scores or had improved their progress test scores by ≤6%. informed consent the students gave written informed consent for their feedback to be included as part of the research project. table 1. positive student feedback about the value of the third-year case-based intervention in preparation for clinical teaching and learning focus group 1 focus group 2 relevance relevance • ‘i also feel it was very, very relevant and the fact that it is such a practical subject. you go out, you do the sessions, you take the patient as a case and you do it. it is not just theory that you have to go and study. ... so, it is practical and it is hands-on and also the type of information that is really useful. it is things that you use every single day. it is the reason behind the theory.’ • ‘i think it is very relevant and i learned a lot from it.’ (translated from afrikaans into english) integration integration • ‘so, in this subject you learn a little bit of this, and a little bit of that, and then when we got to do the treatment plan. everything comes together; you know where everything fits in, and how this affects that, and that affects that.’ • ‘ … opb is, like, the whole holistic thing … .’ • ‘ … and your perio, caries and endo and all those stuff … everything is in there. so if you go through it you won’t be surprised in the following year like [in] the fourth year. so, once you get that a patient ... is full [of ] pain … high blood pressure … everything together.’ • ‘ … because this is a subject that basically puts everything together, yes, that is cool.’ scaffolding scaffolding • ‘ … at the end when you knew what to do, it helped a lot to get your thinking right because you knew, okay, this is the way i have to … .’ • ‘ … and you also learn a lot of, like, diseases and names of things, and how to diagnose it … and do the treatment for it. so it helped a lot for me.’ • ‘i mean we’ve started the year on the 4th floor … and we’ve started looking in the mouth and we knew exactly what to do.’ • ‘okay, it did help a lot and i think it is a good thing that we have that. if we didn’t have that we would have been totally lost with your first patient. i would have freaked out; i can’t handle that.’ • ‘we are going to use treatment planning for the rest of our lives with all our patients, and if we didn’t learn it step by step with a good foundation then we never would have known how to do it. yes, it really helped a lot. i think it gave us a good foundation.’ • ‘it helps you, like, thinking on how to treat the patient, and you will actually have that much more confidence. the patient will also see that this person exactly knows what to do… .’ • ‘ … and then [it] also teaches you a lot about treating complex cases.’ • ‘i was pretty, pretty nervous when i saw my first patient, only to find out that, luckily, i knew something.’ • ‘i think it sets the basis from where you can work. it’s a lot different when you get a new patient rather than a friend … but it gives you a guideline from where you can work to, or what you can work from, or how to diagnose different caries and erosion and attrition … so it was a good baseline for us to work from.’ • ‘i also think the third-year cases really helped in putting a base on how to handle a patient, and all that, so it does help. so it must continue.’ • ‘ … for me, i feel it did really help a lot, like i don’t think it should be changed on my side because i feel, like, okay, on some patients you won’t be able to encounter everything, not all patients have the same problems …, so i feel the cases did add something that you didn’t, maybe, know, or see firsthand. so, for me it really did help.’ • ‘and, also, i feel that the case studies actually did help me, like, to prioritise my treatment … so, yes, for me it did play a role … .’ • ‘i feel the same; that it sets a baseline for you where you work from.’ feedback feedback • ‘we did the first one and then doctor … gave us corrections with the formats. ... yes, the first one, i did nothing right.’ • ‘i think the critique and the way they worked with us, it really helped us. i remember there was a case i had to do on endo. i didn’t know anything about endo ... and the process sticks in my mind because of the critique. if they were lenient i would probably go with my own way of thinking … the way they criticise, it is very beneficial for us … .’ opb = afrikaans abbreviation for comprehensive patient management (omvattende pasiëntbestuur). research november 2015, vol. 7, no. 2 ajhpe 205 table 2. strategic recommendations made during focus group 1 • ‘ ... the very first patient that a fourth-year gets handed shouldn’t be a complex, complex case so that you feel lost … so, maybe if there can be some decent screening, seeing that this is a patient … not like a patient that needs a partial denture, an endo, four extractions … has, like, perio on six of the teeth ... if it is just a bit of an easier case, the first one, and then they can throw you into the deep end.’ • ‘but i think if they included pictures like in the beginning … it is nice to see stuff that you’ve seen before especially if you have to set up a treatment plan. so i think if they can include pictures in the third-year stuff, it will make stuff so much easier.’ • ‘so, if they give you, say, an example of what to do, say, on tooth 11 diagnosis, prognosis, those things, those things, next line … i mean, it will make stuff so much easier, it will make the marking for them easier and the students will be better off.’ • ‘obviously, cpm includes prosthetics with the treatment plan as you still have to, like at the end, maybe the patient will have to get partial dentures but he doesn’t get into details …, if they can include … and a detailed part of prosthetics, then it will help a lot.’ • ‘i mean if we can actually get a subject like cpm for ortho and for prosthetics the performance will be so much better.’ • ‘ … they must try to maybe broaden everything.’ • ‘yes, everything that we do in our fourth year we have to practise in our third year.’ • ‘i know that some of the students, when they did partial dentures, then they said you can still save the teeth and when they got to prosthetics they told the patient, no, all the teeth have to be extracted, and then the patient has already been to five, six, seven, eight restorative sessions and then prosthetics tells them, no, sorry, extract the teeth. so it is not really very nice for the patient, or for the students … so, if they can just have some correlation between them … because otherwise you get so confused … .’ • ‘you came into fourth year and you don’t have a clue of how the files work, where did the patient actually get the files and the payments. the patient asks me that all the time and i don’t have an idea.’ table 3. negative student feedback from focus group 2 about the value of the third-year case-based intervention in preparation for clinical teaching and learning scaffolding • comment 1: ‘for me, the assignments or the case studies did nothing really help … .’ • comment 2: ‘the practical work that we’ve done on the buddies … did a good job for me, but the assignments ... ?’ • comment 3: ‘i think i’m hard-headed when it came to the case studies. i think they are great for other people … but for me? i had issues with the case studies and assignments. i prefer practical and theory.’ • comment 4: ‘i prefer modelling – it stays in my head – and a little bit of theory [rather] than case studies. i know case studies is the incorporation of it, but if i will rather act in it, than trying to figure out what somebody else is thinking … but when we come to practical and doing everything, it is good for me.’ • comment 5: ‘ … when you get into fourth year and you see your first patient and you don’t know where you have to be, you don’t know what to do … and you are asking everybody and it [is] wasting a lot of time.’ • comment 6: ‘but i feel it doesn’t actually teach us how to deal with difficult patients; like, i have the worst patient, like, i don’t know what to do because the patient was very angry because of the way he was treated and everything … so everything else was taken out on me ... , now, and i don’t know how to control the situation and then dr y had to step in.’ • comment 7: ‘it is only with the third, fourth case studies it starts getting better, but the first one definitely not. if you go and look at your answers and look at someone else’s answers they were totally different. there wasn’t really a set way to answer anything. yes, we were all confused about how to actually do the questions. so if there is a lecture before … we want this and this and this – whatever – then you will know better. because everyone’s case studies look different and i was always confused about how to answer them.’ data-processing ability • comment 8: ‘so, for me, case studies, i don’t want to lie, even my maths are like, oh yeah, very low … .’ diligence • comment 9: ‘ … the case studies we did, did not really prepare us for that test we wrote at the end. there were questions that i had never thought about in my life before. unless i did not complete the case studies properly? or did not understand them well enough?’ (translated from afrikaans into english) goal orientation • comment 10: ‘sometimes you don’t know how to prepare for it, like they say you have to go home and get this ready and do a slide show for this … sometimes it is a bit difficult to know what is expected of you to do … but otherwise it is okay.’ unaware of learning opportunities • comment 11: ‘so, we didn’t get feedback on any of the cases.’ • comment 12: ‘feedback. yes, because we never got feedback on the case studies, and what was expected and what the students never saw. because everything in a case study is said for a reason, and then just to know all the reasons, then you will know what to look for in that final test.’ • comment 13: ‘okay, i just remember we always got these pathology questions in the case studies that we were not always prepared for. they would say there is a white lesion in the back of your gums. how would you diagnose it, how would you treat it? we had no idea about pathology when we were in our third year … i always found those questions very difficult. i understand that we also should go and study or look up things but if we just had a bit of information … yes, if we were just a bit more prepared for it.’ research 206 november 2015, vol. 7, no. 2 ajhpe focus group procedures a dentist who was not directly involved with the intervention or with cpc, facilitated and voice recorded the focus groups discussion. to start the discussion, the facilitating dentist posed the following open-ended question to the students: ‘in terms of your own learning, how did you experience the case studies that were used in the third year of study to train your diagnosticand treatment-planning skills?’ the facilitator allowed the students to respond randomly in a paticipative manner. efforts were made not to lead the students in any way during the focus group session. however, the facilitator used probes for enquiring about how the students ‘experienced’ and ‘approached’ the case-based teaching and learning. when the session stagnated the students were questioned in a sequential order – as they were seated around the table – to respond to the facilitator’s questions. eventually all students were afforded an opportunity to speak. transcription and analysis an administrative member of staff of the school of dentistry transcribed the voice data[23] into text format. the dentist who facilitated the focus groups controlled the transcription, made corrections, and also performed thematic analysis[24] of the data. the protocol allowed for themes to be gradually identified and added in an open-ended fashion.[22] the researcher controlled the thematic analysis after the initial identification of themes by the facilitator of the focus groups. during this process, quotes from the discussion groups were reorganised by the researcher by merging themes with similar focus together into a single theme.[22] the quotes identified were tabulated per theme for both the sample groups. results only the focus group 1 discussion took place as originally scheduled. focus group 2 had to be rescheduled. positive feedback regarding acquisition of prior knowledge in preparation for clinical teaching and learning through the preclinical case-based approach is reported in table 1 for both focus groups. this feedback was thematically coded as follows: relevance; integration; scaffolding; and feedback. constructive feedback from focus group 1 to improve the teaching and learning in cpc is given in table  2. these comments contain a variety of suggestions to improve the existing scaffolding strategies further. similar suggestions were not obtained from focus group 2. comments generally relating to deficiencies in standardisation and calibration between faculty dominated the constructive feedback in focus group 2. one of these comments was: ‘so, yes, i think, just let the doctors be more on the same page.’ negative perceptions, predominantly originating from focus group  2 about the case-based approach, are listed in table  3. these results were thematically coded as follows: scaffolding; data-processing ability; diligence; goal orientation; unaware of learning opportunities; and attribution. in contrast to focus group 1, there were comments (table 3) that suggest that the scaffolding (comments 1 7) was not adequate for all the students of the second focus group. the results from focus group 2 also suggest that some of the individual students may have had data-processing problems related to the complex case studies (comment  8) and 1 student admitted a lack of diligence (comment 9), while another indicated a lack of awareness of what was expected (comment 10). none of these themes was similarly evoked in focus group 1. unlike the students from the first focus group, some students in group  2 did not know about the feedback given for each case study assignment (comments  11 and 12). some of them were not aware of the introductory lecture that was given on pathological lesions in the third year of study (comments 13). discussion this study sought feedback from fourth-year dental students regarding the value of the case-based interventions they were exposed to in the preclinical year of study. during the feedback process it was attempted to identify selfregulating behaviours[15,16] in those who progressed in clinical reasoning and self-handicapping behaviours,[17-20] in those who did not display progress. the discovery of differences in self-regulation in clinical reasoning between progressing and non-progressing students may warrant the introduction of additional scaffolding and support for students lacking self-regulation in the educational intervention. focus group 1 (progression group) – interpretation of the feedback students who improved their progress test scores over time thought that the third-year case-based intervention provided them with knowledge and skills that prepared them reasonbly well for the fourth year of study (table  1). positive remarks were made about the relevance of the teaching and learning, integration and the scaffolding of the transfer from the third to the fourth year of study. the feedback provided in focus group 1 (tables 1 and 2) can be interpreted as a positive appraisal of the preclinical case-based approach. constructive suggestions were made to improve the educational processes – not only at cpc but also in the broader undergraduate curriculum. the students suggested the need for improved integration with disciplines such as prosthetics and orthodontics, standardisation, a need for clinical images in the supportive information and more knowledge about the administration of the hospital. these suggestions indicate the interest in the educational process and strategic thinking. the responses can also be interpreted as the students having a goal-orientated approach to providing improved care to their patients.[17] these observations are related to the forethought phase of the self-regulation cycle (fig. 1).[17] the results suggest that the students may have reflected on aspects of the teaching and learning environment that could be improved so that they may improve their own clinical practice. focus group 2 (non-progression group) – interpretation of the feedback this group also made a substantial number of positive comments about the educational processes, which indicates some congruence with the attitudes and behaviours of the students in focus group 1. issues raised about relevance, integration, scaffolding and feedback were similar to those raised by focus group 1. compared with the results of focus group 1, focus group 2 highlighted several observations that could be related to self-handicapping behaviours.[19-22] the focus groups were advertised simultaneously to all parties concerned – verbally and in writing. students from focus group  2 arrived late for the feedback session, while others did not arrive at all. their excuse was that they could not find the unusual venue. the reasons for this behaviour remain speculative, but there appeared to be a lack of interest in the activity and a lack of proactive planning to ensure that they arrive on time. research november 2015, vol. 7, no. 2 ajhpe 207 comments 5 and 10 (table 3) hint towards a lack of strategic planning and suboptimal goal orientation (fig. 1).[17,18] comments 3, 4 and 7 suggest that some of the students may have lacked self-efficacy beliefs to meaningfully participate in the case study exercises. the students from this group (comments  11 13) were unaware of learning opportunities, which may also indicate absence or lack of interest during learning opportunities at the cpc unit. these observations relate to behaviours in the forethought phase of self-regulated learning and suggest that some students may have been lacking in task analysis and self-motivation beliefs (fig. 1).[17,18] comments  7 and 10 (table  3) might, however, also indicate a lack inability of self-instruction, while comment  10 is an admission of one of the students of a lack of diligence, which may be compared with a lack of focus and attention.[17,18] a lack of diligence is defined as a form of selfhandicapping behaviour.[19-22] these observations relate to behaviours in the performance phase of self-regulated learning and suggest that some students may have been lacking self-control behaviours (fig. 1).[17,18] some of the negative comments may be interpreted as the students attributing their inability to perform to the inadequacies of the case-based approach. for example, they tended to blame their own inefficiencies on the instructional design (comments 6 and 9, table 3) and a lack of feedback (comment 12). these observations imply inefficiencies in the self-reflection phase of self-regulated learning (fig. 1) in this group.[17,18] the negative findings of this qualitative study show that the case-based intervention may still need refinement in terms of scaffolding, feedback and student support, and suggest that scaffolding and support should not only focus on the subject matter itself, but actively provide support aimed at developing the students’ self-regulating ability. such an approach requires the early identification of students who display self-handicapping behaviours combined with appropriately designed feedback and tutor systems that could assist in the development of the students’ task analyses, motivational beliefs, performance and self-reflection abilities. this may also be applicable to other modules in the curriculum, but it might also be context specific.[25] the context of the current study is the development of clinical reasoning skills. it is pertinent to note that in terms of this study non-progressing students are not necessarily the ones who struggle to pass the course, but may be students with moderate or high marks. conclusion the results of this study provide some evidence of qualitative differences in the feedback of students in terms of ‘self-regulated learning’ between those who showed progression in clinical reasoning and those who did not progress. this study also suggests that the case-based intervention could further be improved by providing an additional scaffold to students who are at risk of not progressing in terms of their clinical reasoning ability. faculty should therefore focus on the early identification of students who are unable to regulate their own learning, and the provision of timely feedback aimed at devloping self-regulation abilities. although the extent of the current study is small and limited to the performance of a single cohort of students, the findings may be valuable in paving the way for future similar research projects by linking actual performance to self-regulatory behaviour in an authentic teaching and learning environment. acknowledgement. ms barbara english of the faculty of health sciences research office at the university of pretoria is thanked for the language editing. references 1. postma tc. evaluating the impact of adjunctive integrated case-based dental teaching and learning on clinical reasoning in a discipline-based teaching and learning environment. phd thesis. pretoria: university of pretoria, 2013:1-221. 2. snyman wd, ligthelm aj. the new pretoria curriculum. s afr dent j 2000;55(11):642-648. 3. university of pretoria, school of dentistry. the pretoria bchd qualification competencies. pretoria: university of pretoria, 2008. 4. seeliger je, snyman wd. a new approach to undergraduate dental education. s afr dent j 1996;51(12):746-749. 5. postma tc, white jg. developing clinical reasoning in the classroom – analysis of the 4c/id-model. eur j dent educ 2015;19(2):74-80. [http://dx.doi.org/10.1111/eje.12105] 6. ashton s. authenticity in adult learning. int j lifelong educ 2010;29(1):3-19. 7. biggs j. enhancing teaching through constructive alignment. higher educ 1996;32:347-364. 8. snyman wd, kroon j. vertical and horizontal integration of knowledge and skills − a working model. eur j dent educ 2005;9(1):26-31. 9. steinert y, snell ls. interactive lecturing: strategies for increasing participation in large group presentation. med teach 1999;21(1):37-42. 10. harden rm, davis mh. the continuum of problem-based learning. med teach 1998;20(4):317-322. 11. wass v, van der vleuten c, shatzer j, jones r. assessment of clinical competence. lancet 2001;357(9260):945949. 12. norcini j, anderson b, bollela v, et al. criteria for good assessment: consensus statement and recommendations from the ottawa 2010 conference. med teach 2011;33(3):206-214. [http://dx.doi.org/10.3109/0142159x.2011.551559] 13. kessner dm, kalk ce, singer j. assessing health quality − the case for tracers. n engl j med 1973;288:189-194. 14. darling mr, daley td. oral pathology in the dental curriculum: a guide on what to teach. j dent educ 2006;70:355-360. 15. white jg, kruger c, snyman wd. development and implementation of communication skills in dentistry: an example from south africa. eur j dent educ 2008;12(1):29-34. [http://dx.doi.org/10.1111/j.16000579.2007.00488.x] 16. white jg. strategy for teaching communication skills in dentistry. s afr dent j 2010;65(6):260-265. 17. zimmerman bj. investigating self-regulation and motivation: historical background, methodological developments, and future prospects. am educ res j 2008;45(1):166-183. 18. zimmerman bj, campillo m. motivating self-regulated problem solvers. in: davidson je, sternberg rj, eds. the nature of problem solving. new york: cambridge university press, 2003:239. 19. ommundsen y, haugen r, lund t. academic self-concept, implicit theories of ability, and self-regulation strategies. scand j educ res 2005;49(5):461-474. 20. covington mv. making the grade: a self-worth perspective on motivation and school reform. new york: cambridge university press, 1992. 21. urdan t, midgley c. academic self-handicapping: what we know, what more is there to learn? educ psychol rev 2001;13:115-138. 22. midgley c, urdan t. academic self-handicapping and achievement goals: a further examination. contemp educ psychol 2001;26(1):61-75. 23. gill p, stewart k, treasure e, chadwick b. methods of data collection in qualitative research: interviews and focus groups. br dent j 2008;204(6):291-295. [http://dx.doi.org/10.1038/bdj.2008.192] 24. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. 25. cleary tj, sandars j. assessing self-regulatory processes during clinical skill performance: a pilot study. med teach 2011;33(7):e368-e374. [http://dx.doi.org/10.3109/0142159x.2011.577464] 174 october 2016, vol. 8, no. 2 ajhpe research evidence-based medicine is defined as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’.[1] an initial focus on medicine later expanded to include all health professional disciplines, with evidence-based medicine becoming evidence-based practice.[2] as evidence-based practice emerged and grew, healthcare professionals and new graduates were expected to use and be confident in applying evidencebased practice skills.[3] the sicily statement on evidence-based practice states that on graduation, healthcare professionals must have the skills to search for and appraise new knowledge and apply it to their practice, as well as begin an appreciation for life-long learning, to be able to adapt to changes throughout their careers.[4] according to the sicily statement, the evidence-based practice process consists of five steps: (i) translation of uncertainty to an answerable question; (ii) systematic retrieval of best evidence available; (iii) critical appraisal of evidence for validity, clinical relevance and applicability; (iv) application of results in practice; and (v) evaluation of performance.[4] to perform these steps accurately requires skill, especially in the retrieval of appropriate evidence and critical appraisal. in the physiotherapy course currently offered by the university of the western cape (uwc), cape town, south africa the students are exposed to research in various modules where they are trained in epidemiology, research methods and literature appraisal. in addition, they personally conduct a research project, performing relevant statistical analyses. the relevant modules for these exposures are offered in the 3rd and final (4th) year of study. five of the 11 modules in the physio therapy course in the 3rd and 4th years expose the students to research and evidence-based principles. however, in this context and other current approaches to teaching these research skills the focus is primarily on gaining skills by participation in the research process, as part of which students must find and appraise evidence from research.[5] this highlights that teaching research methodology is inclined towards equipping students with the skills to conduct research rather than use research for evidence-based practice.[6] it is therefore currently unclear whether students are able to apply the principles of evidence-based practice to patient care. the study objectives were to determine the self-assessed literature-searching behaviour, self-perceived knowledge of critical appraisal skills and beliefs relating to evidence-based practice in final-year undergraduate physiotherapy students. methods design, setting and participants this study used an embedded mixed methods design, with a small qualitative component playing a supportive secondary role to the primary quantitative design. the study took place at a local physiotherapy department at uwc, which served as a clinical rotation for final-year physiotherapy students. a convenience sample of all final-year undergraduate physiotherapy students (n=36) registered for the 2012 academic year was approached to participate in the study. data collection data were collected using an existing questionnaire, the ‘critical appraisal of medical literature and evidence-based medicine: participants’ knowledge and needs assessment detailed training needs analysis form’.[7] the original questionnaire was developed to measure the basic knowledge of, skills in and beliefs about the main principles of evidence-based practice among allied healthcare professionals and complementary and alternative medicine healthcare practitioners. the questions were related to the participants’ background. health professionals and new graduates alike are expected to be efficient in applying evidence-based practice. research and evidencebased practice skills are taught in the research modules at university, but it is not clear whether students translate those skills into clinical practice. objective. to determine the self-assessment literature-searching behaviour, self-perceived knowledge of critical appraisal skills and evidence-based practice beliefs of final-year undergraduate physiotherapy students at a university in south africa. methods. this study used a quantitative approach, with a small qualitative component. a convenience sample of the final-year undergraduate physiotherapy students (n=36) registered for the 2012 academic year was approached to participate in the study. data were collected using an existing questionnaire. results. the study yielded a 75% response rate. with regard to literature-searching skills, 30% searched for literature more than once a week, 52% searched only for specific information and most had access to literature. students received their information from journal articles (85%), the internet and databases. they were slightly confident when it came to literature appraisal and believed that evidence-based practice was essential to their practice (96%), but expressed a need for more training (59%). their understanding of the evidence-based practice concept was limited because they based their treatment choices on content and other role-models, and related their choices to their previous patient experiences. conclusion. students believed that evidence-based practice was vital, yet their understanding of the concept was restricted when compared with the literature and they expressed a need for further training. afr j health professions educ 2016;8(2):174-177. doi:10.7196/ajhpe.2016.v8i2.580 self-assessment of final-year undergraduate physiotherapy students’ literature-searching behaviour, self-perceived knowledge of their own critical appraisal skills and evidence-based practice beliefs d a hess, msc (physiotherapy); j frantz, phd (physiotherapy) department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: d a hess (hess.danelle@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 175 research self-assessment of their literature-searching behaviour and self-perceived knowledge of their own critical appraisal skills and beliefs. responses were captured by multiple-choice answers and 6-point likert scales, and participants could indicate if they did not understand the question. the questionnaire also included questions about the participants’ confidence in assessing research methodology and items relating to their beliefs about evidence-based practice.[7] content validity of the questionnaire was achieved by asking experts (n=5) who have published in and taught evidence-based practice to complete the questionnaire. their feedback suggested the removal of all questions relating to qualified practitioners, as the questionnaire was to be completed by undergraduate students. their second recommendation was that reference to ‘evidence-based medicine’ should be changed to ‘evidence-based practice’. finally, two open-ended questions regarding the students’ rationale behind their treatment choices and their understanding of evidence-based practice replaced a single question on the participants’ understanding of evidence-based medicine. data collection procedure an information sheet describing the study in detail and a consent form ensuring the students’ anonymity accompanied the questionnaire. the students were advised that they could withdraw from the study at any time. the questionnaires were distributed by the researcher at the end of a class in the physiotherapy department. the students were asked to complete them and hand them back to the researcher. the study received ethical clearance from uwc, project number 12/3/12. permission to conduct the survey was obtained from the head of the department of physiotherapy. data analysis the quantitative data obtained from the questionnaire were captured using a microsoft excel (usa) sheet and exported for analysis with statistical product and service solutions version 21 (spss 21, ibm corp, usa). descriptive statistics were employed to analyse the data, which were presented in frequencies and percentages. the two open-ended questions were analysed thematically. firstly, emerging and common codes were identified. categories were developed from the codes and themes emerged from the common categories. an outside reviewer was approached by the researcher to check and validate the themes. results exposure to research methodology and access to literature a total of 27 students completed the questionnaire, yielding a response rate of 75%. the questionnaire initially explored the exposure of the participants to research and evidence-based practice principles. all the participants were exposed to epidemiology, research methods and literature appraisal. to implement evidence-based practice, participants needed to have access to literature, as it is an important component of evidence-based practice. therefore, determining whether students had access was important. in this study, all the participants had access to the internet (100%) and 85% indicated that they had access to a medical library. of the participants, 92% indicated that they had access to the internet on their own computers and 42% accessed the internet through university resources. literature-searching behaviour examining evidence in clinical practice is a skill that students need to implement evidence-based practice. this skill depends on how often students collect evidence, how often they read the literature and the type of material they use to find the evidence they need for their practice. the questionnaire established this by asking how often the students searched for evidence. thirty percent (n=8) indicated that they searched for literature more than once a week, 52% (n=4) only read literature for specific information, compared with 7% (n=2) who stated that they read literature every week, and 85% (n=23) retrieved information from journal articles to inform their practice. computer skills computer skills are necessary for the evidence-based practice process. results showed that 67% of participants had written an article using microsoft word, 93% had sent and received emails, 96% had used the internet to search for information, 89% had used the internet via a browser and 85% used databases such as medline and ebscohost. confidence and beliefs the respondents’ confidence in six skills was assessed. the results showed that 48% (n=13) felt they were slightly confident in assessing the study design and in assessing generalisability of research articles, 44% (n=12) stated they were slightly confident in evaluating statistical tests and principles and assessing the general worth of the article, 41% (n=11) indicated they were slightly confident in evaluating bias and 37% (n=10) were confident in assessing the adequacy of the sample size. four percent (n=1) stated they had no confidence in evaluating bias or statistical tests and principles. the students’ beliefs in evidence-based practice showed that 33% (n=9) both slightly disagreed and disagreed that original articles are confusing, 59% (n=16) strongly agreed that evidence-based practice is essential in their practice, and 37% (n=10) agreed and 22% (n=6) strongly agreed (a total of 16/27, 59%) that they feel they needed more training in evidence-based practice. with regard to confidence in assessing research evidence, 59% (n=16) slightly agreed that they were confident, 44% (n=12) slightly agreed, 33% (n=9) agreed and 4% (n=1) strongly agreed that systematic reviews are key to informing evidence-based practice, 52% (n=14) disagreed that evidence-based practice has little impact on an individual’s practice, 48% (n=13) only slightly agreed that they received good training in evidencebased practice, 44% (n=12) slightly disagreed that clinical judgement is more important than evidence-based practice, 37% (n=10) slightly disagreed that patient choices should override evidence-based practice, and 44% (n=12) slightly disagreed that evidence-based practice is a passing fashion. qualitative data there were two open-ended questions about the students’ perceptions of evidence-based practice. the first question aimed to explore what the students based their treatment choices on. it was evident from the information that students used literature, role-models, previous experience and patient preferences as evidence on which to base their treatment choices: ‘i read articles which support certain treatments.’ ‘… knowledge gained through clinical supervision sessions.’ ‘i use my knowledge of what has previously worked in practice.’ ‘… my findings during the assessments and patient’s preferences influence my choices.’ ‘knowledge gained through clinical supervision, applied physiotherapy lecture notes, textbooks.’ 176 october 2016, vol. 8, no. 2 ajhpe research the second question was about students’ understanding of the concept of evidence-based practice. the main idea that emerged was that evidencebased practice was ‘treatment that was based on information from journal articles’ and ‘treatment based on studies that show the effectiveness of a treatment technique’. quotes to support this include: ‘evidence-based practice is when you constantly look for current journal articles to back up why you have used a specific treatment for a patient and to use journal articles for research when you are unsure about a condition or treatment.’ ‘evidence-based practice is techniques that have been practised during a study and have been proven effective.’ discussion the objective of the study was to determine the self-assessment literaturesearching behaviour, self-perceived knowledge of critical appraisal skills and evidence-based practice beliefs among final-year undergraduate physiotherapy students at a local university in sa. although only a small number participated in the study, the information provides valuable data for future larger studies. the uwc physiotherapy programme, which was the setting for this study, teaches the principles of evidence-based practice in the form of research methodology lectures. this is similar to other physiotherapy programmes in sa and norway.[3,6] one study found that although research methods and statistics had been essential components of a bachelor’s programme at a norwegian university for a number of years, students continued to struggle with finding and using relevant and valid information such as research evidence.[3] the students received little, if any, practical guidance in clinical settings on how to apply research evidence to real patient management. in the same study,[3] the physiotherapy students did attempt evidence-based practice in the clinical setting. in our study, the students were only exposed to the basic skills of research in the 3rd and 4th years of study; the literature states that research skills and the skills of searching, appraising and applying research evidence to individual patients should be taught early and applied as an essential part of learning during the entire curriculum.[8] the majority of the study population indicated that they had access to computers as well as medical literature at university. this was the same for another sa study that also found students had access to the internet on campus.[9] contrary to the literature[3] that indicated that undergraduate students found it difficult to determine if research evidence was valid and applicable, the students in the current study showed some confidence in assessing research evidence. however, the insecurity of students transitioning to qualified practitioners who will engage in evidence-based practice was evident in their statements that they only felt slightly confident in literature appraisal and wanted more training in evidence-based practice. these findings were similar to those of a study of occupational therapists, which showed that students displayed less confidence when engaging with the processes of evidence-based practice.[10] this was also similar to the study in norway where it was evident that although students value evidencebased practice and recognise it as a vital part of clinical practice, they continue to feel that they need more training in it.[3] therefore, the need for more training in applying evidence-based practice is evident across disciplines. with regard to patients’ beliefs and evidence-based practice, the results showed that the majority of the students were in slight disagreement that the patients’ preferences should override evidence-based practice. this differed to what was found in the literature. in an australian study of occupational therapists, the majority agreed that evidence-based practice should be client centred, even though a third of the sample was uncertain,[10] and research conducted in the usa highlighted that evidence-based practice should be patient centred at all times.[11] a large number of students felt that systematic reviews informed evidence-based practice. similarly, randomised controlled trials, especially the systematic review of several randomised trials, are very likely to inform rather than mislead us and have become the ‘gold standard’ for judging whether a treatment does more good than harm.[1] thus, the need to create an understanding that evidence-based practice is not in lieu of patientcentred practice is essential. evidence-based practice is the integration of clinical expertise, patient values and the best research evidence into the decision-making process for patient care. clinical expertise refers to the clinician’s accumulated experience, education and clinical skills. the patient brings to the encounter his or her own personal preferences and unique concerns, expectations and values. the best research evidence is usually found in clinically relevant research that has been conducted using sound methodology.[12] considering this, the understanding of the concept of evidence-based practice in this study seems quite limited. the students based their treatment choices on articles, clinical supervision, knowledge of previous patient encounters, textbooks and what was taught in class. this was similar to findings from a survey that indicated that treatment choices were largely based on initial training and, to a lesser degree, on journal research articles.[13] conclusion the results of the questionnaire highlighted that more than half the sample searched for literature for specific information and the majority used journal articles to inform their practice. the majority also had access to computers and literature. less than half were, however, only slightly confident in appraising literature. they believed that evidence-based practice was important but felt they need more training. the students’ understanding of the concept of evidence-based practice was limited compared with the literature.[12] some based their treatment choices on content, clinical supervisors, what was taught in class and others’ journal articles. some believed evidence-based practice was the practice of basing treatment choices on sound clinical evidence and others believed it to be techniques found to be effective in a study. clinical relevance of findings the findings suggest that the final-year undergraduate students have an awareness of the concept of evidence-based practice; however, they do not seem to be implementing it completely in clinical practice. therefore, it may be worthwhile teaching the principles of evidence-based practice in the undergraduate clinical practice module and not just the research methodology module. other research has suggested that the incorporation of all five steps from the sicily model in clinical practice should be investigated.[6] study limitations the study had a small sample size and only final-year students from one university were approached to participate; however, the findings provide a basis from which health professions educators may operate when teaching evidence-based practice. october 2016, vol. 8, no. 2 ajhpe 177 research suggestions for further research it may be valuable to explore the teaching strategies used for the implementation of evidence-based practice into physiotherapy education and whether the evidence-based practice process should be taught in the clinical setting. references 1. sackett dl, rosenberg wm, gray ja, haynes rb, richardson ws. evidence based medicine: what it is and what it isn’t. bmj 1996;312(7023):71-72. doi:10.1136/bmj.312.7023.71 2. long k, mcevoy m, lewis l, wiles l, williams m, olds t. entry-level evidenced-based practice training in physiotherapy students: does it change knowledge, attitudes, and behaviours? a longitudinal study. internet j allied health sci pract 2011;9(3). 3. olsen nr, bradley p, lomborg k, nortvedt mw. evidence-based practice in clinical physiotherapy education: a qualitative interpretive description. bmc med educ 2013;13(1):52. doi:10.1186/1472-6920-13-52 4. dawes m, summerskill w, glasziou p, et al. sicily statement on evidence-based practice. bmc med educ 2005;5(1):1. doi:10.1186/1472-6920-5-1 5. french b. developing the skills required for evidence-based practice. nurse educ today 1998;18(1):46-51. 6. burger m, louw q. integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: reflections on a new approach. afr j health professions educ 2014;6(2):198-202. doi:10.7196/ajhpe516 7. hadley j, hassan i, khan k. knowledge and beliefs concerning evidence-based practice amongst complementary and alternative medicine health care practitioners and allied health care professionals: a questionnaire survey. bmc complement altern med 2008;8(1):45. doi:10.1186/1472-6882-8-45 8. glasziou p, burls a, gilbert, r. evidence based medicine and the medical curriculum. bmj 2008;337(3):704-705. doi:10.1136/bmj.a1253 9. rowe m, frantz j, bozalek v. physiotherapy student’s use of online technologies as part of their learning practices: a case study. s afr j physiother 2012;68(1):29-34. 10. bennett s, tooth l, mc kenna k, et al. perceptions of evidence-based practice: a survey of australian occupational therapists. aust occup ther j 2003;50(1):13-22. doi:10.1046/j.1440-1630.2003.00341.x 11. manske r, lehecka b. evidence-based medicine/practice in sports physical therapy. int j sports phys ther 2012;7(5):461-473. 12. sackett d. evidence-based practice. 2002. http://mcgrawhill.co.uk/openup/chapters/9780335244737.pdf (accessed 30 december 2015). 13. turner a, whitfield a. physiotherapists’ reasons for selection of treatment techniques: a cross-national survey. physiother theory pract 1999;15(4):235-246. doi:10.1080/095939899307649 http://dx.doi.org/10.1136/bmj.312.7023.71 http://dx.doi.org/10.1186/1472-6920-13-52 http://dx.doi.org/10.1186/1472-6920-5-1 http://dx.doi.org/10.7196/ajhpe516 http://dx.doi.org/10.1186/1472-6882-8-45 http://dx.doi.org/10.1136/bmj.a1253 http://dx.doi/org/10.1046/j.1440-1630.2003.00341.x http://mcgrawhill.co.uk/openup/chapters/9780335244737.pdf http://dx.doi.org/10.1080/095939899307649 research may 2016, vol. 8, no. 1 ajhpe 65 south africa (sa), like many countries in the modern world, is a rapidly changing society that represents individuals from a multitude of different cultures, beliefs and social backgrounds. research suggests that these contextual influences have a profound effect on how patients present to healthcare providers.[1] such a healthcare environment is complex for young health professions students, who have a life-world based on their own backgrounds and cultures, and may find relating to a patient with a different life-world challenging. (the concept of a life-world derives from the german term lebenswelt and refers to the individual and social influences on an individual’s life that result in the subjective manner in which the world is viewed through each individual’s eyes.) as educators, we stress the concept of transformative learning and teach students that they should have a patient-centred approach to the consultation, in which they take into account the patient’s ideas, beliefs, concerns and expectations,[2] but provide little context for students to enable them to negotiate problems of this nature. as such, they may find unfamiliar situations personally challenging or difficult to manage in the clinical environment, in which the context is determined largely by the community or patient’s cultural views and behaviours that determine language, thoughts, communication, actions, customs, beliefs and values. the ability to operate effectively within this environment is referred to as cultural competence and is defined by the usa’s centers for disease control and prevention (cdc) as ‘a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations’. sa’s situation is somewhat unique, as most international literature on cultural competence originates from countries in which there are ethnic minority groups from different cultures. a recent study at this medical school showed that at least a third of undergraduates come from cultural and ethnic groups[3] that differ from the dominant groups in the communities they serve. many different methods have been suggested for sensitising students to cultural differences. the checklist method of stereotyping cultures and providing a list of characteristics that should be expected has been shown not to be very useful, especially in dynamic societies.[4] another method of making students culturally aware is that of immersion into a host culture.[5,6] this may be effective, for example, for an emigrant learning a foreign language, but has tremendous logistical and safety implications when incorporated into an undergraduate curriculum, particularly with the large numbers necessary to increase throughput of medical students.[7] cultural tourism has been criticised for the way in which it places societies ‘on show’, with observers viewing the culture from an outsider’s point of view. it has, however, been shown to be extremely useful in raising awareness of cultural issues.[8] theory transformative learning theory, an adult learning theory, was used as a theoretical framework for the study. the original work in this field involved mezirow’s[9] notion of a ‘disorientating dilemma’ or life crisis, which resulted background. south african society is undergoing rapid changes, and includes people from different cultures, beliefs and social backgrounds. research suggests that these contextual influences have an important bearing on how patients present and relate to healthcare providers. medical students, too, have a life-world based on their own backgrounds and cultures, and may find relating to a patient with a different life-world challenging. objectives. to explore students’ awareness and perceptions of how psycho sociocultural factors in a multicultural society influence the consultation, and to suggest adaptations for teaching. methods. focus group discussions were conducted with final-year medical students in the family medicine rotation. some of the students had viewed a video of a consultation with an isizulu-speaking patient, and completed a self-reflection learning task. audio recordings were transcribed and analysed thematically. results. exposure to patients in the clinical years had made students aware of the challenges of cultural diversity, although they felt under-prepared to deal with this. students alluded to the influences of their own cultures, of cultural similarities as well as differences, the roles and behaviours of doctors and patients in cross-cultural consultations, the potential knowledge and experience gap that exists across cultures, and an awareness of the need for patient-centredness. conclusion. students should be assisted to improve their cultural competence. recommendations are made for using various methods, including critical incidents and visual learning to provide opportunities for reflexive practice and transformative learning. educators must be equipped to address learning objectives relating to cultural competence. afr j health professions educ 2016;8(1):65-68. doi:10.7196/ajhpe.2016.v8i1.562 an exploration into the awareness and perceptions of medical students of the psychosociocultural factors which influence the consultation: implications for teaching and learning of health professionals m g matthews,1 mb chb, doh, mph; p n diab,2 mb chb, mfammed 1 school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: m g matthews (matthewsm@ukzn.ac.za) research 66 may 2016, vol. 8, no. 1 ajhpe in perspective transformation. the theory involves learners transforming their perspectives by making meaning of their experiences through critically analysing underlying premises and previously held beliefs. it is useful in crosscultural contexts as, in this manner, individuals learn to change their frames of reference as they critically reflect on their assumptions and beliefs and consciously make plans that bring about new ways of defining and negotiating their worlds.[10] objectives the main objective of this article was to explore medical students’ awareness and perceptions of how behavioural, social and cultural factors in sa’s multicultural society influence the consultation and consequently their practice as future medical practitioners. the article highlights some of the frequently encountered complex cross-cultural situations that sa doctors face and, finally, recommends how teaching and learning can be adapted to address this in the current curriculum. specific objectives are: (i) to identify and describe emergent themes and attempt to understand their implications for the teaching and learning of health professions students; and (ii) to make recommendations for future practice that will promote transformative learning and perspective change. methods study setting the study comprised health professions educational research using a qualitative approach. it was conducted at the hospital sites where students were doing their rotations, teaching platforms that serve the nelson r mandela school of medicine of the university of kwazulu-natal, durban, sa. participants, sampling and data collection methods a group of 40 final-year medical students in their family medicine rotation was identified in july 2013. as part of this module, students lived and worked in groups of four at rural district hospitals where they were immersed in a host culture that was sometimes unfamiliar. prior to their departure, students received a lecture and tutorials on communication skills. this lecture was enhanced to include elements of crosscultural learning (group 1). a subset of this group was then shown a video that highlighted a clinical scenario in which a culturally sensitive topic was introduced (group 2). a further subset was shown the video and given a self-reflection questionnaire to complete (group 3). having had these teaching and learning opportunities, three groups of students were interviewed in focus group discussions (fgds) towards the end of their module. these were mixed groups in terms of first language, ethnicity and religion, and there were no exclusion criteria. a broad interview schedule was used to gather information on the students’ experience of culture in the consultation and of cross-cultural teaching and learning. the fgds were conducted at a pre-arranged time at the hospital sites. they were led by a research assistant from the school of nursing and public health, and attended by the researchers. data analysis audio recordings of the fgds were transcribed and analysed using inductive coding and thematic analysis.[11] the students’ responses to the selfreflection questionnaire were also included in the thematic analysis. for trustworthiness, the researchers analysed the transcripts separately, discussing and comparing emergent themes, and selected representative quotations and incidents referred to by the students. comments were referenced as being extracted from one of the three fgds, with no specific reference to individual students due to ethical constraints. ethics and consent ethics clearance for the study was granted by the university humanities and social sciences research ethics committee (hss/0312/013). necessary permissions were obtained from gatekeepers, and students gave individual consent. in the interviews, students were assured of anonymity and were not identified by name. they were informed that all contributions were voluntary, that the interviewers would not participate in assessment, and that there would be no negative consequences from participation in the focus groups. results while students had been sensitised to crosscultural issues by the teaching exposures, across the three groups of students there were no differences in responses from those who had been exposed to the video or self-reflection questionnaire. in addition, the students’ rural experience had presented opportunities for learning experiences. table 1 summarises the various themes and subthemes as the findings of this study. interactions and relationships certain students indicated an awareness of their own cultural influences that had the potential to influence their clinical interactions. some spoke on matters of relevance in their own religions and cultures, and shared with the group the influence that these may have on their practice of medicine: ‘you have to understand religious views also, you cannot have guys and girls together. like for us we are not allowed to go out with boys.’ (comment by a muslim student, fgd3) ‘... not someone who is pulling towards the east and you are pulling west.’ (fgd1) some participants had noted or discussed behaviours in health professionals that they consi dered inappropriate: ‘they were complaining about the doctors at [...] hospital. they were telling me that they hope that i do not become a doctor like that and like, we cannot even greet!’ (fgd2) ‘in the rural areas your stethoscope is way too powerful!’ (fgd3) ‘your patients will take for granted that you look the part, i mean you are black.’ (fgd1) students had been exposed to the concept of patient-centredness, and this was an important theme, with many referring to the importance of incorporating the patient’s perspective: ‘... all that stuff to show that you actually care about the patient as a whole and that actually shows the patient that you do not take them as a disease but as a person.’ (fgd 1) ‘... that patient centredness, for each patient it will not work out the same, you have to work out something that is right.’ (fgd3) table 1. results of study: summary of themes and subthemes themes subthemes interactions and relationships with self with other students with doctors with patients awareness of cultural diversity similarities differences gaps knowledge experience research may 2016, vol. 8, no. 1 ajhpe 67 awareness of cultural diversity certain students mentioned the need for cultural sensitivity in multicultural environments, and went on to note that there were, in fact, some previously unrecognised similarities among cultures: ‘so if you are going to be judgemental and putting your religion and culture there on the table, it will not work because we are all different.’ (fgd3) ‘there are actually a lot more similarities than differences.’(fgd1) gaps some students described incidents in which behaviours demonstrated insufficient knowledge of cultural practices: ‘... i know my granny would be like, i saw this white girl and she said this ... and there is also that thing that probably she does not understand me. she does not know what ‘ukugcabha’ [the use of scarification to treat symptoms] is, so i cannot explain what that is so let’s just leave it there. she says i should take these pills. i will just take them home and that is it and i will continue what needs to be done.’ (fgd2) ‘the patient kept saying to the consultant, he was calling her “mama,” not in a bad way, because he is respecting her. and then the consultant got offended and said “no, i am not your mom, i am your doctor!” for me, that was like ok, but the patient is trying to be respectful, not that he is saying you are old or something ... that is how we are taught, especially in blacks ... .’ (fgd1) ‘... we are not sensitised to each other’s cultures at all.’ (fgd1) specific anecdotes various participants recounted incidents that they found significant, provoking rich discussions in the groups. some examples are included for illustrative purposes. interesting discussions around aspects of african culture included content about isintu (traditional rituals); cultural beliefs such as thwasa (calling to be a sangoma or traditional healer); and the use of various types of muthi (traditional medicines), including herbal enemas and a therapeutic intervention called isithlambezo (traditional medicine used to induce labour). others referred to the abovementioned ukugcaba and the importance of iziphandla (a wrist bracelet of animal skin mainly used in rural communities).[12] some students spoke of how their lack of awareness of or misperceptions about some or all of these practices made their understanding of the patient’s perspective more difficult (various fgds). discussions also arose about other cultures, with the following brief narrative about muslim culture included for illustrative purposes. this anecdote is an example of how easily cross-cultural misunderstandings may arise: ‘... during an interview seeing this muslim patient, there was this young lady ... you could only see her eyes and there was a black registrar and she was not looking at him. eventually he asked, “what is wrong? why are you not looking at me? is there something wrong with your eyes maybe?” and she said, “no, this is how we are taught to; we do not look at the men in the eyes when we are speaking to them".' (fgd 1) discussion this objective of this article is to explore the awareness and perceptions of medical students of the psychosociocultural factors that influence the consultation. it describes emergent themes and mentions incidents in multicultural environments that were significant to students. in analysing the comments, it was noted that the responses reflected different individual levels of self-awareness and ability to cope with challenges. some students had considered the influence of their own cultures on their behaviours and interactions with colleagues, other health professionals and patients, and perceived to varying degrees that these differences had an important influence on successful communication. the study showed that many students experienced difficulty when dealing with cross-cultural contexts, and several students recognised knowledge gaps that exacerbated the problem. the impact of introspection was demonstrated by some students who showed greater self-awareness than others and had considered the influence of their personal, cultural and religious views. some participants realised that other people they encountered, either as colleagues or patients, also had similar innate factors or personal views that affected the consultation. some had noted negative role-modelling and lack of cultural sensitivity in more senior health professionals they had encountered in clinical rotations. exposure to patients from various cultures, particularly in the rural setting, had raised awareness of the challenges of cultural diversity, with several participants expressing the opinion that they felt under-prepared to deal with this. some made reference to insufficient exposure to information about the cultures of others, and expressed a need to engage with issues related to patients’ life-worlds and cultures to improve their own knowledge. several students narrated incidents that they considered important, and spoke of the difficulties they anticipated for their future practice as healthcare practitioners. implications for teaching and learning to improve teaching and learning, it is imperative that students in the health professions are equipped to deal with cultural diversity in a culturally competent manner. students need to gain an understanding of one another’s life-worlds. they need to develop appropriate attitudes and have the knowledge and skills to deal with challenges in multicultural professional environments. the roles and responsibilities of the educator in health professions education in fostering transformative learning thus cannot be overemphasised, as learners should be assisted to become aware and critical of long-held assumptions. perspective change can be achieved through an accumulation of transformations over a period of time, assisting students to redefine problems and improve their ability to respond to their patients’ cultural influences on health.[10] as mentioned above, many methods of teaching cultural competence have been used with varying degrees of success in other contexts. to understand another culture, one has to be self-aware and have a good appreciation of the influence of one’s own culture relative to that of others in practice – a realisation that may only occur after a certain degree of self-reflection and self-examination.[13] by reflecting upon past experiences and narrating experiences to others, rather than adopting a stereotypical approach, learners may begin to understand the complex factors that influence how a patient behaves when confronted with illness.[14] experiences such as those described by the students in the form of ‘difficult’ consultations or challenging experiences occur throughout a professional career, including in the undergraduate phase, and may be used as critical incidents to promote self-awareness and awareness of the influence of psychosociocultural factors that affect their patients. research 68 may 2016, vol. 8, no. 1 ajhpe students in the fgds were enthusiastic about sharing challenging experiences. we noted that the opportunities for sharing of the students’ narratives and discussions in the focus groups proved to be a fertile ground for new conversations between students themselves and the researchers about the challenges encountered in multicultural populations. because of this, it is the opinion of the authors that these learning spaces in the rural attachment should be supported to provide students with opportunities for deep reflective practice and transformative learning. we propose that gaps in knowledge and experience could be filled by maximising opportunities in existing structured teaching times in communication teaching and clinical rotations within the context of routine, everyday intercultural encounters, to reflect on their cultural significance and implications in context. they could also be addressed in a structured manner in cultural seminars or when teaching a language. opportunities exist for students to use engagement in deep reflection by journaling their experiences: how this has changed their insights and perspective, and what they have learnt. this would assist in creating the ‘change agents’ who are socially responsive and relevant to the populations they serve as healthcare professionals.[15] the authors have previously suggested the use of critical incident reflection and of video technology in the teaching and learning of communication to medical students.[14,16] as competition for teaching time already exists in the medical curriculum, it is suggested that further innovative methods be used to make this cultural learning generally available. thus, the university’s visual learning project, a repository of videos, could be used as a teaching platform for recorded scenarios illustrating appropriately selected cross-cultural consultations (with inputs from subject experts) to be critical incidents for discussion. these would allow students to improve their knowledge and reflect on challenges, while raising cultural awareness and contributing to cultural competence. additional functionality of the video software allows learners to conduct online discussions, and educators to provide feedback on the content as necessary. while students have long been taught the importance of a ‘patientcentred’ approach (which the study shows to have been assimilated), it is suggested that educators raise awareness of the person in an individual context, thus highlighting the concept of ‘person-centredness’, to assist in developing an empathic approach.[17] this locates the person in a somewhat more complex psychosociocultural context as opposed to a pure illness context, and may help to develop culturally competent healthcare practitioners who are sensitive to their patients’ perspectives in a deeper fashion, and therefore more equipped to respond appropriately. as specific recommendations to promote cultural competence in students, the authors suggest the following: • specifying the understanding of psychosociocultural influences in the consultation in learning objectives from early in the curriculum to raise awareness. • developing self-awareness in students by encouraging them to analyse how their own life-worlds affect their views. • filling knowledge and experience gaps about culturally sensitive problems. • specifying topics and critical teaching points for educators, with the implications for practice being the value of student involvement in material selection and the use of a task-based approach. • providing positive role-modelling and increasing the diversity in teaching staff to make it representative of the demographics of the province. • including cultural competence as a learning outcome and assessing it specifically as a competence in clinical assessments. study limitations the study was conducted using only three fdgs and self-reflection questionnaires. only final-year students were asked to participate, as the study was done after they had been exposed to the rural attachment of the final year. while this is the case, the results showed strong emergent themes that are generative in nature, and support the necessity for a response in terms of the introduction of innovative methods for the teaching and learning of cultural competence. this study highlighted the importance of developing reflexivity and cultural awareness at undergraduate level. however, the maintenance of this awareness after qualification is beyond the scope of the study. this study also does also not highlight the behavioural change that may/may not result from experience and/or exposure. novelty and significance of the work although a great deal of research is being done internationally in cultural competence, there is a lack of literature on cultural competence in medical students in the sa context. this article provides new and important insights into local healthcare contexts and can assist in making recommendations for teaching and learning, as well as contributing to the body of knowledge internationally on facilitating multicultural competence. acknowledgement. the study was funded by a grant from the university of kwazulu-natal teaching and learning office. references 1. napier a, ancarno c, butler b, et al. culture and health. lancet 2014;384(9954):1607-1639. [http://dx.doi.org/ 10.1016/s0140-6736(14)61603-2] 2. silverman j, kurtz s, draper j, van dalen j, platt f. skills for communicating with patients. oxford, uk: radcliffe publishing, 2005. 3. matthews m. vocation-specific isizulu language teaching and learning for medical students at the university of kwazulu-natal. masters dissertation. durban: university of kwazulu-natal, 2013. 4. seibert p, stridh-igo p, zimmerman c. a checklist to facilitate cultural awareness and sensitivity. j med ethics 2002;28(3):143-146. [http://dx.doi.org/10.1136/jme.28.3.143] 5. anderson k, friedemann m, buscher a, sansoni j, hodnicki d. immersion research education: students as catalysts in international collaboration research. int nurs rev 2012;59(4):502-510. [http://dx.doi.org/10.7416/ ai.2013.1926] 6. larson k, ott m, miles j. international cultural immersion: en vivo reflections in cultural competence. j cult divers 2010;17(2):44-50. 7. world health organization. transformative education for health professionals. 2006. http:// whoeducationguidelines.org/content (accessed 1 august 2014). 8. prose n, diab p, matthews m. experiential learning outside the comfort zone: taking medical students to downtown durban. afr j health professions educ 2013;5(2):98-99. [http://dx.doi.org/10.7196/ajhpe.256] 9. mezirow j. transformative dimensions of adult learning. san francisco, usa: jossey-bass, 1991. 10. taylor ew. intercultural competency: a transformative learning process. adult educ quarterly 1994;44(3):154-174. 11. miles m, huberman m. qualitative data: an expanded sourcebook. 2nd ed. thousand oaks, ca, usa: sage publications, 1994. 12. ellis c. communicating with the african patient. scottsville, sa: ukzn press, 2004. 13. helman c. culture, health and illness. london, uk: butterworth, 2007. 14. diab p, naidu t, gaede b, prose n. cross-cultural medical education: using narratives to reflect on experience. afr j health professions educ 2013;5(1):42-45. [http://dx.doi.org/10.7196/ajhpe.234] 15. van heerden b. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2013;103(1):21-22. [http:/dx.doi.org/10.7196/samj.6463] 16. diab p, matthews m, gokool r. medical students’ views on the use of video technology in the teaching of isizulu communication, language skills and cultural competence. afr j health professions educ 2016;8(1):11-14. [http:// dx.doi.org/10.7196/ajhpe.2016.v8i1.402] 17. slater l. person‐centredness: a concept analysis. contemporary nurse 2006;23(1):135-144. [http://dx.doi. org/10.5172/conu.2006.23.1.135] ajhpe issn 0256-9574 african journal of health professions education sponsored by www.foundation.co.za may 2014, vol. 6, no. 1 http://www.foundation.co.za ajhpe issn 0256-9574 african journal of health professions education november 2013, vol. 5 no. 2 50 november 2013, vol. 5, no. 2 ajhpe plenary lecture south african association of health educationalists distinguished educator award address le bon dieu est dans le détail – reflections on being a beaver d prozesky, bsc, mb chb, mcommh, phd centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: d prozesky (detlef.prozesky@wits.ac.za) i would like to thank the saahe executive very much for the honour of this award – i was not expecting it and i am not sure that i deserve it. it means a great deal to me. this morning, i wish to share a concept that all of us have used in the past, still use, and will always use in our educational work. it is more than a concept (or it should be – in fact, when it remains a concept and does not enter the realm of practice, it changes its nature, and becomes the opposite of what it should be). it is a concept that is common to all human endeavour and not only to education. let me start with the title of my talk to clarify this theme. i have been thinking for the past few months about today and about what i could usefully say to you, my esteemed colleagues in health science education. you know how it is – the exigencies of one’s work make certain ideas and themes rise and fall in importance and significance from month to month and year to year. and the idea that has been occupying my mind for some time now can be summed up in the words of gustave flaubert, the great french novelist of the 19th century: ‘le bon dieu est dans le détail.’ – ‘the good god is in the detail’. as far as i have been able to find out, flaubert is the person who coined that exact phrase, although it expresses what many have experienced before and since. it means, or i think flaubert meant, that whatever one does should be done thoroughly – details are important. many of us know and use the phrase in a significantly altered or opposite form: ‘the devil is in the detail’. this contrary saying encapsulates very neatly the situation to which i have just referred: when one is confronted with a situation or process that just will not work out and decides to ‘leave it like that’, not to search for that detail that is literally ‘bedevilling’ the whole – well then, the neglect will result in inefficiency, unhappiness, disillusionment, even chaos.we shall come back to this neglect and its consequences. what i propose is to examine how this idea has been put into practice – in the fields of health and education, and more widely (including my own experience) – and then draw lessons from these experiences about the nature of ‘detail’, what happens when we neglect it, and the great need for attending to it in our work as educators of health practitioners. we start with the man who seems to have coined the phrase, gustave flaubert. his seminal work madame bovary is widely considered to be one of the most influential novels ever written. this is not because the characters are particularly nice people – far from it – but because of the style in which he wrote, which contains two particular elements for us to note. firstly, his obsession with realism, with portraying the reality of his subject as objectively and scrupulously as possible. secondly (and linked to the first), his attention to detail in his work. flaubert himself explained how he went over each paragraph, each phrase, each word, repeatedly to get it ‘just right’ – looking for ‘le mot juste’, ‘exactly the right word’ (goodman, 2009). the point here is that a truly great result may need scrupulous and repeated attention to small details. another person who was fond of using the phrase ‘god is in the detail’ in his work and as a teacher was the well-known german-american architect of the 20th century, ludwig mies van der rohe. he was one of the leading exponents of the greatly influential ‘bauhaus’ school of architecture, first developed in germany in the 1920s. in the context of our investigation of ‘detail’, it is worth examining a few of the principles of the bauhaus school (barr, 1938). firstly: practitioners can no longer take refuge in the past but need to function in the modern world as vital participants, equipped with technical, social, economic, even artistic and spiritual skills and insights. they need to disregard traditional distinctions and separations between related disciplines and bring them together in a new and better synthesis. the point here is that the scope of detail needs to be wide, including an openness to new ideas and the ideas of others. secondly: manual experience of materials is essential, both in free experimentation and then, critically, in workshop practice. in the words of a bauhaus exponent: ‘it is harder to design a first-rate chair than to paint a second-rate painting – and much more useful’. the point here is that there is no detail that is too low to deserve attention, that is beneath the dignity of the creator. thirdly: rational design in terms of techniques and materials goes beyond utility – it should also have an aesthetic aim. the point here is that attention to detail is not to be seen as dull and boring but as a fulfilling creative act, producing a result greater, and more aesthetically pleasing, than the sum of its detailed parts. brave words! how did mies van der rohe’s bauhaus theories work out in practice? let us examine two very different buildings he designed (schulze, 1985). the seagram building in new york was designed to be the headquarters of a large company, and was completed in 1958. the work required very careful attention to major details such as the properties of building materials and physical stresses – but also to minor ones such as decorations and an interior garden. i leave it to you to decide: did it live up to the bauhaus principle of a design that goes beyond utility into beauty? the point here is that such a major undertaking requiring such detailed planning had a marked aesthetic quality on completion. plenary lecture the seagram building. mailto:detlef.prozesky@wits.ac.za november 2013, vol. 5, no. 2 ajhpe 51 the second mies van der rohe building is very different. the farnsworth house was designed as a weekend breakaway cottage for a doctor in rural illinois. it was completed in 1951. again, its seeming simplicity masks the technical complexity of building it with the materials available at the time. it stands on land subject to occasional flooding (hence the stilts) – yet the architect has turned that purely operational requirement into a feature that makes the building seem to float within the space of nature where it is situated. ‘we should attempt to bring nature, houses, and the human being to a higher unity’, he said. did he succeed? the point here is that even in a seemingly small project (compared with the seagram), careful attention to detail, approached from different perspectives, produced something almost magical. now we go to a completely different example. i have been fortunate in that my work takes me to interesting places and projects through the years, and i would like to select two of these, again with the goal of gaining additional insight into the nature and place of ‘detail’ in our work. in the city of hyderabad in the state of andhra pradesh in india, is the remarkable salar jung museum, housing the art collection of the prime ministers (the nawabs) of the princely rulers (the nizams) of hyderabad. through the generations, the jung family collected, among other treasures, an amazing assembly of so-called ‘miniatures’. these minute paintings are so detailed that one wonders how the artist could have executed them; here is an example (although not from salar jung). there is no end to the delicacy of detail: the hair and jewels of the empress nurjehan, her hands and ears, the tiny cup she holds, the material of her sleeves and turban. this attention to detail did not happen overnight. the miniatures were produced in studios supervised by renowned artists who trained and supervised new generations of painters of miniatures. the point here is that the ability to attend to detail is not automatically achieved – it may need training and supervision, and working together as a team. another example: i count it as one of the great blessings of my life that i was able over a period of eight years to work in the two world health organization onchocerciasis control projects in africa. in the course of these projects, i was able to do work in nine different countries, and also to attend regular project meetings at the who headquarters in geneva. in front of the main building in geneva is a statue of a small boy guiding a blind man with a stick. it is actually a monument to a very nasty disease that has been successfully contained, thanks to the efforts of many countries and organisations working together. it is for me one of the supreme examples of triumph following attention to detail. let me explain. onchocerciasis is a parasitic disease. the adult female worm is 50 cm long and lives in the subcutaneous tissues, causing unsightly nodules that are otherwise harmless. the problem lies in the millions of larvae or microfilariae produced by the adult worms. the larvae migrate to the skin in order to be picked up by the bite of a blackfly, which then transmits the infection to other humans. the larvae cause a widespread dermatitis with intractable itching; they also migrate to the eyes where they cause a chronic inflammatory process leading to irreversible blindness – all in all, a horrible disease. after much research in the 1960s and early 1970s, the first control programme started in 1974 (the second one is still continuing). two strategies were developed to deal with the scourge. the first was to eliminate the vector, the blackfly. this is where the attention to detail starts. blackflies breed in fast-flowing, well oxygenated water. this meant that all breeding sites in thousands of kilometres of rivers in eleven west african countries had to be treated with insecticide every week. these are rivers that also provide populations with water and fish, so the dose of insecticide had to be carefully titrated – enough to kill the larvae but not too much to harm the ecosystems. and of course the river flows vary with the seasons, so the dilution effect varies from month to month. so solarpowered flow monitoring stations were installed at regular intervals in all the main rivers, which sent information via satellite to a dutch university which then informed the helicopter companies doing the spraying weekly how to adjust their dosages. and this is only one of the many complexities about the larviciding that had to be dealt with. the blackfly developed resistance to the insecticide; epidemiological and entomological surveillance had to be carried out constantly; and civil wars intervened in sierra leone and côte d’ivoire. whenever any problems were uncovered, they were dealt with by immediate operational research with detailed action following as indicated by the research results (molyneux and davies, 1997). the second strategy was the yearly mass distribution to approximately 50 million people of the drug ivermectin, which kills the microfilariae and plenary lecture the farnsworth house. empress nurjehan. 52 november 2013, vol. 5, no. 2 ajhpe editorial so halts the progression of the disease in the individual, and eventually transmission of the disease as well. onchocerciasis is a disease of the ‘end of the road’, of small villages far from the main centres. health services in these areas are dysfunctional and communications are rudimentary, so tens of thousands of village volunteers had to be trained to collect the drug, distribute it, and report side-effects and coverage. the complexities of this process are mind-boggling, yet they were systematically researched and dealt with (my research dealt with motivation of the village volunteers and how to maintain it). the point here is that attention to detail is an intense, ongoing process; that it requires intellectual rigour and a large amount of hard work; and that it needs to be based on good information. a final, more medical example: pain and its management. we know that this is an area in which some doctors historically perform very badly – a recent study from the united states revealed that 25 30% of patients with cancer received treatment for their pain at all (fisch et al., 2012). there is no getting away from the complexity of pain, from all the detail surrounding how it is generated, and experienced, and therefore managed. in her work in hospice, cecily saunders clearly illustrated that we need to understand and work with the 4 elements of ‘total pain’: physical, social, emotional and spiritual. models of pain management include the world health organization’s approach to the use of analgesics in relieving cancer pain (who, 1996). is it surprising that the fifth and final phrase in the who model is ‘attention to detail’? the point here is that attention to detail makes a tremendous difference to really important issues. i learned much about ‘detail’ from these examples; i hope you have too. having embarked on this train of thought, i recalled a 2007 article in medical teacher by ronald harden. i am sure many of you are familiar with it: ‘outcome-based education – the ostrich, the peacock and the beaver’ (harden, 2007). so now you know where the second part of my title comes from. in this article, harden uses the metaphor in the title to depict three reactions to the introduction of outcome-based education – but one can really apply it to any major innovation in health science education. ostriches with their heads in the sand (which apparently they never do) ignore the innovation, and we hear the mantra ‘if it’s not broken, why fix it?’ peacocks proudly display their lists of outcomes and other plans, but that’s as far as it goes – the programme carries on much as before. finally there are the beavers, hard-working little chaps who beaver away at building their programmes, log by log and stick by stick, until there is an expanse of open water which provides teachers and students with new space to grow, and new food for thought and development. harden’s metaphor is clearly intimately linked to the issue of ‘detail’ – peacocks are what one could call ‘detail lite’ and beavers ‘detail heavy or rich’; the ostrich would get the rating of ‘zero’ (in which some soft drinks pride themselves). i am sure that each of us can with a little reflection remember examples in our own practice where ‘god was in the detail’, where the detail was properly attended to, and conversely where ‘the devil was in the detail’, where it was not. here are a few examples from my own experience. community-based education is central to much of what we are trying to achieve in the mindset of our graduates, in all programmes. they need to see that there is not only a place for them in district health services, but also that they can make a difference there, that elusive ‘difference’ to which so many of them refer when they come for their pre-admission interviews. but it is not enough to place the students in community settings, where they may hang around achieving very little and become progressively more bored and frustrated – immunised, in fact, against ever working in such settings. so what are the details that need attention here? i spent eight years in pretoria, slowly learning the details involved in creating a good community-based learning experience. here are some of them: transport (getting there safely and on time, good maps or exact gps coordinates); accommodation (clean, reasonably furnished, good food, a place to study, good connectivity); explicit, important and realistic objectives and ample opportunities to achieve these; welcoming and supporting staff, a place of one’s own to work, equipment to work with; student contribution to service delivery (so the local staff are happy) within the limits of their competence (so patients are safe) while also learning new skills (so students know they are learning and growing); the regular and encouraging presence of their teachers; being accompanied by a streetwise local when doing home visits; immediate follow-up of problems and complaints; and some opportunity for fun and recreation. if all of this is in place, and known to be in place, it leads to a sense of excitement, achievement, enjoyment – building student morale in a situation where many students expected to find nothing that they would enjoy. another example: for many years i've been teaching a module in a master’s course at the london school of hygiene and tropical medicine. the class comprises experienced ophthalmologists, optometrists and ophthalmic nurses from developing countries, and they normally arrive on the first day of the ‘health promotion, education and advocacy’ module, clearly not hoping for much. but at the end of the week, the students’ reactions show clearly that the week has worked; in preparing for today, i’ve been trying to work out why. again it is ‘detail’ that has been operating here. every year, the module is reviewed and enriched. its structure invites participation and draws on the many years of experience represented in the students. the learning is carefully planned not only to be active but also to be fun, with debates and quizzes. students are constantly encouraged to apply what they are learning to their own situations. students battling with english receive special attention plenary lecture the onchocerciasis statue at the who, geneva. november 2013, vol. 5, no. 2 ajhpe 53 editorial after class. and when i meet ex-students on my forays into eye care in africa and india, they always remember the module and the fact that it was a good learning experience – even 15 years later. there it is again – the richer the detail, the better the outcome. so at this point i’d like to formally introduce the concept of a continuum of ‘richness of detail’ as an important tool for health science educationalists – a continuum going from ‘zero’ to ‘lite’ to ‘rich’, with the implication that the closer one gets to ‘rich’, the better the result will be. i’m sure that many of you have noticed that this new principle is also related to one of the formulations of murphy’s law: ‘if something can go wrong, it will.’ which means i also have to give an example of what happens in ‘detail lite’ situations, in which case ‘the devil is in the detail’. at the moment, our unit is involved in a project to improve the quality of training of eye healthcare professionals (anything from ophthalmologists to midlevel ophthalmic nurses) in four countries in africa. on the one hand, the praises of what some of our colleagues there can achieve with so few resources can never be adequately sung. however, there are other cases (happily few) where lack of attention to detail on many levels has a paralysing effect: untidy classrooms, endless one-directional chalk-and-talk, absentee teachers, little clinical exposure in units teeming with patients, irregular assessments, few employment opportunities for graduates. in these cases, it is not primarily a question of resources but of detail – so much could be improved by more attention to detail. it is time now to turn to a couple of common educational concepts that i believe are intimately related to the ‘detail principle’. let us begin with student-centredness. i am sure that all of us have been familiar with this concept since harden, sowden and dunn (1984) introduced us to the spices model. this is what harden and his fellow authors say: ‘in a studentcentred approach to the curriculum … the emphasis is on the students and on what and how they learn. in contrast, in a teacher-centred approach, the emphasis is on the teachers and on what they teach.’ our task is to construct learning opportunities in such a way that they best facilitate students’ learning – not treating students as spoilt children whose every whim has to be satisfied (in fact, the large majority of sensible students don’t want that). in this context, i have found that there is a strong relationship between student complaints and missing detail: when students complain, they draw our attention to missing details – the complaints are early warning signs, if you like, that there is detail which has not been attended to. this leads us on to the closely related concept of student disillusionment. this phenomenon has been discussed in the literature for many years – for nursing, medical and other students (kopelman, 1983; last and fulbrook, 2003). a few common threads are reported in this phenomenon. students enter programmes with an idealised view of the profession they are about to enter but are progressively disillusioned by the examples of their teachers, and especially by the nature of the practical situation – so-called ‘reality shock’. frustration, disillusionment and burnout ensue, and the result is a mixture of what one study calls ‘sustained idealists, compromised idealists and crushed idealists’ (maben, latter and clark, 2007). i have experienced this often – the poor quality of student experiences, so contrary to what they were expecting, that at first irritates them and makes them complain: incomprehensible mcqs, poor marking, negative experiences in the wards, poor lecturing, and teachers who humiliate and belittle patients and students. then when the details remain unaltered, students subside into a kind of disgruntled resignation – ‘we know now that this is all we’re going to get’. the bloom is gone, they feel themselves surrounded by mediocrity, they just soldier on sullenly. the devil is in the detail here – the degree of disillusionment is directly proportional to the degree of neglect of detail. but when one experiences the converse, it is equally striking: when attention to detail fixes a longstanding problem, there may even be a kind of lazarus experience in students individually and in groups; i recall a medical student who had failed the previous year but later revelled in positive changes in the curriculum which left her ‘enthralled and enthused’, she said. 'god was in the detailæ again. then the learning environment. pace (1960) remarked that we can know everything about a medical school, its physical attributes, human resources and official policies – yet know nothing about what it is really like. genn (2001) has defined the educational climate as the perceived environment, representing the real world of medical school as the student experiences it. knowles (of adult education fame) pointed to the evidence that climate makes a unique and notable contribution to student success (knowles, 1970). that environment is important we all agree, and we rejoice in the good news from marshall and others that it can be measured and changed in spite of its many elements (marshall, 1978). but one thing is certain: its very complexity implies that producing a good learning environment is directly proportional to the amount of detail that we attend to in creating it. it is not rocket science, it is not hard to understand; but it needs a ‘beaver’ approach. this brings me back to harden and outcomes. the health professions council of south africa has produced an outcomes document for medical students, based on the canmeds document (frank ed., 2005). last year, i was involved in a process of evaluating to what extent the main role and six component roles of a graduate were really being attended to in our programme. the result was not bad, but there was clearly a lot left to do – not so much in the routine outcomes related to clinical practice that we are used to, but in the more complex but no less important ones such as: • develop a common understanding on issues, problems and plans with patients, families, colleagues and other professionals to develop a shared plan of care (‘communicator’ role) • participate effectively and appropriately in an interprofessional healthcare team in a variety of situations (‘collaborator’ role) • provide effective healthcare to geographically defined communities (‘manager’ role) • respond to the health needs of the communities that they serve (‘health advocate’ role) • maintain and enhance professional activities through ongoing learning, both as doctors and as responsible citizens (‘scholar’ role) • demonstrate a commitment to their patients, profession and society through ethical practice (‘professional’ role). these are difficult outcomes to produce and, if they are to become a reality, they need to be implemented – in detail. in the same vein, we also know now that we need to attend to current national and international imperatives in health science education, e.g. those in the recent lancet ‘transformative education’ article (frenk et al., 2010). moving our current programmes along to embrace outcomes related to leadership, social accountability and interdisciplinary partnership meaningfully will require attention to details worthy of a whole family of ‘beavers’. at this point, you may say, ‘detail is so boring!’ maybe – but it depends on how you approach it; it is also an opportunity for creative thinking (like mies van der rohe’s buildings). attention to detail can move from a bored ‘oh no, not that again.’ to an opportunity for innovation and experimentation. an example: faithful to the principle of early clinical exposure, we have for many years arranged a weekly ‘health practice day’ for third-year medical students, where they work in hospitals in the mornings and go to skills laboratories in the afternoon. to arrange satisfactory individual learning experiences for 300 students each morning has never worked plenary lecture 54 november 2013, vol. 5, no. 2 ajhpe editorial properly, despite years of effort (including a master’s dissertation investigating the issues). but this year we had the idea of introducing the ‘dashboard’ monitoring tool – using student feedback to grade every activity every day – and at last there is progress. so what did i learn from this journey? firstly that, while occasionally there may be a great vision for us to introduce to the educational world, the details are always there, awaiting our attention. secondly, there is a continuum of ‘richness of educational detail’ intimately related to our educational climate, to student centredness, to student morale, to the overall quality of our educational endeavour. then, finally, about ‘detail’ itself: • no detail is too low or insignificant to deserve attention • attention to detail can be a fulfilling creative act • detail produces a result greater, more aesthetically pleasing, than the sum of its detailed parts • detailed attention given to small projects can have a magical effect • the ability to attend to detail may need training and supervision • detail requires teamwork and openness to new ideas and the ideas of others • attention to detail is an intense and ongoing process requiring hard work • detail requires intellectual rigour and needs to be based on good information • a truly great result needs scrupulous and repeated attention to a broad range of details • attention to detail makes a tremendous difference to really important issues. in closing, two thoughts. the first is my apologia which comes at the end instead of the beginning of this talk. in thinking through ‘detail’ as i’ve done above, i of course became acutely aware of the times when i had been the one to neglect the details – where ‘the devil was in the detail’ because of me. so you may well quote to me what mark twain is reputed to have said, ‘to be good is noble; but to show others how to be good is nobler – and no trouble.’ then i have left to the last the word ‘detail’ itself. where does it come from? it is from an old french word ‘détailler’, to ‘cut up’. this is what tailors used to do (and still do, i suppose): cut out the smaller pieces of cloth that they need to sew together to make a splendid whole, like this quilt. why is it beautiful and useful? it’s the little pieces, the detail in it, that make it so. so; detail: attend to it well. do it with passion; do it with innovation; do it elegantly; do it with humility; do it as a team; do it as you transform your programmes. remember the ‘richness of detail continuum’. remember the beaver. remember: le bon dieu est dans le détail. references 1. barr, a.h. in bayer, h., gropius, w. and gropius, i. eds. (1938), bauhaus 1919-1928, new york: museum of modern art. 2. goodman, r. (2009), ‘the hermit of croisset: flaubert’s fiercely enduring perfectionism’, the writer’s chronicle, september, p.1. 3. fisch, m.j., lee, j.w., weiss, m., et al. (2012), ‘prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer’, journal of clinical oncology , 30(16), pp.1980-1988. 4. frank j.r. (ed.) (2005), the canmeds 2005 physician competency framework, ottawa: the royal college of physicians and surgeons of canada. 5. frenk, j., chen, l., bhutta, z.a., et al. (2010), ‘health professionals for a new century: transforming education to strengthen health systems in an interdependent world’, the lancet, 376(9756), pp.1923-1958. 6. genn jm. (2001), ‘amee medical education guide no. 23 (part 1): curriculum, environment, climate, quality and change in medical education-a unifying perspective’, medical teacher, 23(4), pp.337-344. 7. harden, r.m. (2007), ‘outcome-based education – the ostrich, the peacock and the beaver’, medical teacher, 29(7), pp.666-671. plenary lecture department group no. grade shadowing tutorial comments orthop. orthop. medicine 10 11 14 paeds. pulmonol. orthop. orthop. orthop. orthop. shadowing: students learnt a lot, but would potentially bene�t more during the musculoskeletal block. tutorial: students learnt a lot, good tutorial; unfortunately, the paeds ward had no endocrine patients. shadowing: would be more useful during the musculoskeletal block. tutorial: ten students to 1 patient meant that not all students could participate or learn e�ectively. shadowing: no shadowing at all; however, students do their own clerking and examination of patients. tutorial: doctor was very interesting and encouraged full participation. the 'dashboard' monitoring tool. november 2013, vol. 5, no. 2 ajhpe 55 8. harden, r.m., sowden, s. and dunn, w.r. (1984), ‘educational strategies in curriculum development: the spices model’, medical education, 18(4), pp.284-297. 9. knowles, m.s. (1970), the modern practice of adult education – from pedagogy to andragogy, englewood cliffs nj: prentice hall regents, pp.46-49. 10. kopelman, l. (1983), ‘cynicism among medical students’, journal of the american medical association, 250(15), pp.2006-2010. 11. last, l. and fulbrook, p. (2003), ‘why do student nurses leave? suggestions from a delphi study’, nurse education today, 23(6), pp.449-458. 12. maben j, latter s, clark jm. (2007), ‘the sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study’, nursing inquiry, 14(2), p.99. 13. marshall, r.e. (1978), ‘measuring the medical school learning environment’, journal of medical education, 53(2), pp.98-104. 14. molyneux, d.h. and davies, j.b. (1997), ‘onchocerciasis control: moving towards the millennium’, parasitology today, 13(11), pp.418-425. 15. pace, c.r. (1960), ‘five college environments’, college board review, 41, pp.24-28. 16. schulze, f. (1985), mies van der rohe: a critical biography. chicago and london: the university of chicago press, pp.252-257. 17. world health organization (1996), cancer pain relief (2nd edition), geneva: world health organization, p.16. editorialplenary lecture ajhpe 358.indd research october 2014, vol.6, no. 2 ajhpe 155 introduction the ultimate goal of medical education is to prepare students to become clinically competent doctors.[1,2] clinical competence has been defined as ‘habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of individuals and community being served’.[3] in a traditional curriculum, medical students are expected to acquire clinical competence through the apprenticeship model using the halstedian ‘see one, do one, teach one’ approach[4] as they rotate through clinical clerkships of medical and surgical disciplines. in a competence-based curriculum, essential competencies are identified and learning activities and strategies developed to facilitate attainment of these competencies.[5] from 1966 to 2011, the school of medicine, university of zambia (som-unza), lusaka, zambia, used a traditional curriculum model. in 2011 the school implemented a competence-based curriculum. its implementation followed the school’s self-evaluation against the world federation of medical education international basic medical education standards (wfme-ibmes).[6] this shift from the traditional medical education model to competence-based education also reflects a global paradigm shift towards competence-based education.[3,7] despite this shift, it was not known how undergraduate medical students at unza progressed in clinical skills acquisition through the different clinical years as the matter had not been investigated. in the literature, it is contentious whether or not students are competent in essential skills at graduation as discrepancies have been observed in skills they are expected to learn in a particular clerkship compared with what they actually learn.[8] for example, colberly and goldenhar[8] indicated that out of six recommended basic procedures (arterial puncture, insertion of nasogastric tube, phlebotomy, intravenous (iv) catheter insertion, lumbar puncture and foley catheter insertion), the majority of 4th-year students reported not performing four procedures (phlebotomy, iv catheter insertion, lumbar puncture and foley catheter insertion) during their acting intern rotation at cincinnati university, usa. these introduction. in a traditional curriculum, medical students are expected to acquire clinical competence through the apprenticeship model using the halstedian ‘see one, do one, and teach one’ approach. the school of medicine, university of zambia, lusaka, zambia, used a traditional curriculum model from 1966 until 2011, when a competence-based curriculum was implemented. objective. to explore medical students’ clerkship experiences and self-perceived competence in clinical skills. methods. a cross-sectional survey was conducted among 5th-, 6th-, and 7th-year medical students at the school of medicine, university of zambia, two months before the final examinations. students were asked to rate their clerkship experiences with regard to specific skills on a scale of 1 4 and their level of self-perceived competence on a scale of 1 3. skills evaluated were in four main domains: history-taking and communication, physical examination and procedural skills, professionalism, teamwork and medical decision-making. using the statistical package for the social sciences (spss), correlations were performed between experiences and self-perceived competence of specific skills, within domains and overall. results. of clinical students (n=197), 138 (70%) participated in the survey. the results showed a significant increase in the proportion of students performing different skills and reporting feeling very competent with each additional clinical year. overall correlations between experience and selfperceived competence were moderate (0.55). for individual skills, the highest correlation between experience and self-perceived competence was observed mainly with regard to medicaland surgical-related procedural skills, with the highest at 0.82 for nasogastric tube insertion and 0.76 for endotracheal intubation. conclusion. despite the general improvement in skills and self-perceived competence some deficiencies were noted, as significant numbers of finalyear students had never attempted important common procedures, especially those performed in emergency situations. deficiencies in certain skills may call for the incorporation of teaching/learning methods that broaden students’ exposure to such skills. ajhpe 2014;6(2):155-160. doi:10.7196/ajhpe.358 medical students’ clerkship experiences and self-perceived competence in clinical skills p katowa-mukwato,1,2 bsc, msc, phd candidate; b andrews,3,4 md; m maimbolwa,2 bsc, phd; s lakhi,3 mb chb, mmed, mph; c michelo,5 mb chb, mph, mba, phd; y mulla,6 mb chb, mmed, mch (orth), fcs; s s banda,1 mb chb, msc, mmed, phd 1 department of medical education development, school of medicine, university of zambia, lusaka, zambia 2 department of nursing sciences, school of medicine, university of zambia, lusaka, zambia 3 department of internal medicine, school of medicine, university of zambia, lusaka, zambia 4 department of internal medicine, vanderbilt university, nashville, tennessee, usa 5 department of public health, school of medicine, university of zambia, lusaka, zambia 6 department of surgery, school of medicine, university of zambia, lusaka, zambia corresponding author: p katowa-mukwato (patriciakatowamukwato@gmail.com)   researchresearch 156 october 2014, vol.6, no. 2 ajhpe discrepancies between what students are expected to learn and what they learn have resulted in a lack of competency in certain clinical skills, with a resultant negative impact on patients, medical students, junior doctors and the medical profession.[7, 9] in this regard, lai et al.[7] have suggested that it is important for medical schools to examine the progress in medical students’ clinical competence towards the end of their course as this provides a good indication of their ability as housemen and of the effectiveness of the curriculum. in addition, exploring the relationship between students’ exposure to and confidence regarding a range of practical skills might review specific strengths and deficiencies in their acquisition of these skills, and identifying the relationship could help to improve the effectiveness of the curriculum.[7] the objective of this survey was to explore students’ clerkship experiences and selfperceived competence in clinical skills prior to the implementation of the competence-based curriculum and the introduction of simulation methodology into the curriculum at som-unza. methods population description the duration of unza’s medical programme is seven years, resulting in a bachelor’s degree in medicine and a bachelor’s degree in general surgery (mb chb). the first two years are pre-medical, followed by two years of basic biomedical sciences and three years of clinical medicine. in the 5th year – the first clinical year – students have their first set of clerkships in internal medicine, general surgery, obstetrics and gynaecology and paediatrics and child health. in the second clinical year, clerkships are in psychiatry, ophthalmology, community medicine, dermatology, orthopaedics, ear, nose and throat, maxillofacial surgery, and radiology. in the 7th (final) year, students have their final set of clerkships to consolidate their skills in internal medicine, general surgery, obstetrics and gynaecology, and paediatrics and child health. design and sampling procedures the data stem from a medical student-based survey conducted in february 2012. a survey questionnaire was distributed to students two months prior to completion of their 5th, 6th and 7th years (the clinical years of the undergraduate medical education programme at som-unza). using a sampling frame that consisted of 5th (n=73), 6th (n=64), and 7th (n=60)year medical students, a convenient sample of all consenting clinical medical students completed the survey. instrument a questionnaire was administered to all eligible and willing clinical medical students. it obtained information on sociodemographic data, students’ year of study and completed clinical clerkships. students were also asked to rate their clerkship experiences with regard to specific clinical and procedural skills on a scale of 1 4 as follows: (i) never taught and never performed; (ii) taught, but never performed; (iii) performed once; (iv) performed two or more times. furthermore, the students were asked to rate their level of (self-perceived) confidence in performing the skills using the likert scale, where 1 = not confident, 2 = fairly confident, and 3 = very confident. the skills evaluated were in the following domains: history-taking and communication skills, physical examination, procedural skills in internal medicine, general surgery, obstetrics and gynaecology, paediatrics and child health, and psychiatry. other areas evaluated included professionalism, teamwork, decision-making, and decision on appropriate drug/other therapies. the major clinical skills and procedures of focus were based on a study conducted in 2004 at the university teaching hospital, lusaka, which identified and listed a number of commonly encountered procedures.[10] the top 10 were intravenous cannula insertion, urethral catheterisation, examination of the placenta, nasogastric intubation/lavage, abdominal/ ascetic tap, lumbar puncture, and vaginal examination. others were ear, table 1. medical students’ clerkship experience (number of times a clinical skill was performed) and self-perceived competence of physical examination skills at the school of medicine, university of zambia (2012) (a) percentage reporting performing a skill ≥2 (b) percentage reporting feeling very confident physical skills examination 5th year, n=51 6th year, n=34 7th year, n=53 p-value 5th year, n=51 6th year, n=34 7th year, n=53 p-value cardiovascular examination, and identifying/detecting s1, s2 51 (100) 32 (94.1) 53 (100) 0.059 (f) 36 (70.6) 19 (55.9) 44 (83.0) 0.023 s3, s4 25 (49.0) 18 (52.9) 39 (73.6) 0.026 4 (7.8) 4 (11.8) 15 (28.3) 0.013 diastolic murmur 23 (45.1) 18 (52.9) 37 (69.8) 0.035 8 (15.6) 2 (5.9) 14 (26.4) 0.044 systolic murmurs 43 (84.3) 27 (79.4) 49 (92.5) 0.200 22 (43.1) 10 (29.4) 38 (71.7) <0.001 pericardial rub 13 (25.5) 15 (44.1) 32 (60.4) 0.002 8 (15.7) 7 (20.6) 20 (27.7) 0.027 respiratory examination and performing tactile fremitus 48 (94.1) 31 (91.2) 48 (90.6) 0.782 36 (70.6) 21 (61.8) 44 (83.0) 0.080 auscultation to detect crackles, rhonchi, consolidation 50 (98.0) 31 (91.2) 53 (100) 0.062 (f) 34 (66.7) 22 (64.7) 46 (86.8) 0.024 general abdominal examination 51 (100) 33 (97.1) 53 (100) 0.246 (f) 47 (92.2) 25 (73.5) 51 (96.2) 0.003 breast examination to detect nodules 40 (78.4) 29 (85.3) 51 (96.2) 0.025 27 (52.3) 18 (52.9) 46 (86.8) <0.001 unless identified with a letter (f), p-values are based on the χ2 test of (a) association between year of training and performing a skill ≥2, and (b) association between year of training and feeling very confident. (f) indicates that fisher’s exact test was used to calculate the p-value. research october 2014, vol.6, no. 2 ajhpe 157 nose and throat examination, rectal examination and venous cut-down. it is expected that by the end of the undergraduate training, every student should have attempted these commonly performed procedures. prior to the administration of the survey questionnaire, four clinical experts representing the departments of internal medicine, general surgery, paediatrics and child health, and obstetrics and gynaecology reviewed the list of clinical skills. the clinical experts are academic staff of the university and are involved in the clinical teaching of medical students. they identified other practical procedural and clinical skills in addition to those described by banda.[10] therefore, the final list was based on consensus among the four experts. validity of the survey questionnaire was determined by the four clinical experts who considered and adjusted both the content and structure as indicated above. to test for internal consistence, a reliability analysis test was performed for all test items using the statistical package for the social sciences for windows version 11.0 (spss inc. chicago, illinois, usa) (spss), and cronbach’s alpha was 0.956. analysis data were analysed using spss. descriptive statistics and multivariate analysis were done and complex sample design was used to take into consideration the design effect (year of study taken as the primary cluster). percentages were calculated for clerkship experiences and level of confidence for each skill across different clinical years. for tables 1 and 2, likert scales were collapsed to create dichotomous variables as follows: (a) performed a skill more than once versus never or only once; and (b) very confident versus all other responses. chi-square or fisher’s exact tests were applied to determine significance of associations between: (i) clerkship experience (number of times a skill was performed) and year of training (tables 1a and 2a); and (ii) level of confidence and year of training (tables 1b and 2b). these p-values tested for significant differences across the three grade years, but did not compare any two years directly. unless identified with a letter (f), p-values are based on χ2. for table 3, ‘never taught, never performed’ and ‘taught, never performed’ were collapsed into one exposure category – ‘never performed’. correlation coefficients and spearman’s test were used to correlate level of exposure (3-point likert scale) versus confidence (3-point likert scale) for all finalyear students on a selected number of procedural skills (table 3). the level of significance was set at 0.05 for all items; therefore, all associations for which p<0.05 were considered significant. the overall correlation between experience and confidence using spearman’s rho was computed for all skills, and within each domain. furthermore, correlations between experience and level of confidence/ self-perceived competence were computed for selected procedural skills for final-year students. using previous literature, we determined that selfreported competence will be high if ≥70% of students reported being very competent in that skill, moderate if 50 69%, and low if <50%.[11] similarly, exposure to a skill is high if ≥70% of students reported having practised it two or more times, moderate and low for 50 69% and <50%, respectively. correlations between experience and confidence were assessed using spearman’s rho correlation coefficient. results participation and distribution out of 197 clinical students, 138 participated in the survey, giving a response rate of 70%. the highest response rate was among final-year students, where 53 out of 60 participated, giving a rate of 88%. this high response rate can possibly be attributed to the fact that final-year students are more interested in evaluating their experiences and confidence in clinical skills compared with the more junior students. the lowest response rate was among the 6th-year students; 34 of 64 participated, giving a response rate of 53%. for 5th-year students, 53 out of 73 participated, giving a response rate of 70%. regarding clerkship placement, all 5th-year students had their first set of clerkships in internal medicine, general surgery, obstetrics and table 2. medical students’ clerkship experience (number of times a procedure was performed) and self-perceived competence of 12 common clinical practical procedures at the school of medicine, university of zambia (2012) (a) percentage reporting performing a skill ≥2 (b) percentage reporting feeling very confident clinical practical procedure 5th year, n=51 6th year, n=34 7th year, n=53 p-value 5th year, n=51 6th year, n=34 7th year, n=53 p-value vaginal delivery 45 (88.2) 34 (100) 53 (100) 0.005 33 (64.7) 25 (73.5) 52 (98.1) <0.001 venepuncture and cannulation 51 (100) 32 (94.1) 51 (96.2) 0.236 (f) 47 (92.2) 24 (70.6) 48 (90.6) 0.009 bladder catheterisation 23 (45.1) 18 (52.9) 48 (90.6) <0.001 21 (41.2) 12 (35.3) 43 (81.1) <0.001 examining the newborn 33 (64.7) 33 (97.1) 48 (90.6) <0.001 21 (41.2) 18 (52.9) 32 (60.4) 0.144 abdominal paracentesis 12 (23.7) 12 (35.3) 40 (75.5) <0.001 11 (21.6) 11 (32.4) 34 (64.2) <0.001 nasogastric tube insertion 6 (11.8) 1 (2.9) 29 (54.7) <0.001 3 (5.9) 1 (2.9) 23 (43.4) <0.001 lumbar puncture 2 (3.9) 7 (20.6) 28 (52.8) <0.001 2 (3.9) 7 (20.6) 21 (39.6) <0.001 suturing 3 (5.9) 6 (17.6) 24 (45.3) <0.001 2 (3.9) 4 (11.8) 15 (28.3) 0.002 cpr 7 (13.7) 5 (14.7) 18 (34.0) 0.023 2 (3.9) 5 (14.7) 11 (20.8) 0.037 endotracheal intubation 0 (0) 2 (5.9) 12 (22.6) <0.001 1 (2.0) 3 (8.8) 8 (15.1) 0.059 acls 1 (2.0) 0 (0.0) 7 (13.2) 0.012 0 (0) 0 (0) 5 (9.4) 0.027 (f) use of a defibrillator 0 (0) 0 (0) 1 (1.9) 1.0 (f) 0 (0) 0 (0) 0 (0) unless identified with a letter (f), p-values are based on the χ2 test of (a) association between year of training and performing a procedure ≥2, and (b) association between year of training and feeling very confident with the procedure. (f) indicates that fisher’s exact test was used to calculate the p-value. cpr = cardiopulmonary resuscitation; acls = advanced cardiac life support. researchresearch 158 october 2014, vol.6, no. 2 ajhpe gynaecology and paediatrics and child health as defined by the curriculum. in addition to the first set of clerkships, all final-year students reported having had their third and final clerkships in internal medicine and general surgery and second and final clerkships in obstetrics and gynaecology and paediatrics and child health. students’ self-reported experience and confidence with selected physical examination skills are shown in table 1. for basic examination skills, such as cardiac auscultation for s1 and s2, respiratory auscultation, and abdominal examination, there were high levels of exposure across all years of training, with 90 100% performing the skill at least twice. the proportion of students who had identified s3 and s4, diastolic murmurs, pericardial rub and breast nodules more than twice, increased with each additional year of training. as expected, for all skills table 3. correlation of number of times performing selected procedures and level of confidence among final (7th)-year students at the school of medicine, university of zambia practical skill confidence level never performed performed once performed ≥2 correlation (rho) p-value nasogastric tube insertion,  n=51 not confident 8 (100) 2 (14.3) 0 0.818 <0.001*     fairly confident 0 11 (78.6) 7 (24.1) very confident 0 1 (7.1) 22 (75.9) endotracheal intubation, n=49 not confident 15 (79.0) 2 (11.1) 0 0.757   <0.001*     fairly confident 4 (21.0) 14 (77.8) 6 (50.0) very confident 0 2 (11.1) 6 (50.0) suturing, n=51 not confident 8 (80.0) 4 (23.5) 0 (0) 0.742   <0.001*     fairly confident 2 (20.0) 12 (70.6) 10 (41.7) very confident 0 1 (5.9) 14 (58.3) bladder catheterisation, n=52 not confident 1 (100) 1 (25.0) 1 (2.1) 0.721   <0.001*     fairly confident 0 3 (75.0) 3 (6.4) very confident 0 0 43 (91.5) lumbar puncture, n=49 not confident 2 (40.0) 5 (29.4) 0 0.637   <0.001*     fairly confident 2 (40.0) 11 (64.7) 8 (29.6) very confident 1 (20.0) 1 (5.9) 19 (70.4) cardiopulmonary resuscitation, n=51 not confident 5 (45.5) 5 (22.7) 0 0.578   <0.001*    fairly confident 6 (54.5) 15 (68.2) 9 (50.0) very confident 0 2 (9.1) 9 (50.0) advanced cardiac life support, n=48 not confident 23 (63.9) 1 (20.0) 1 (14.3) 0.542   <0.001*     fairly confident 13 (36.1) 4 (80.0) 1 (14.3) very confident 0 0 5 (71.4) examining the newborn, n=53   not confident 0 1 (20.0) 1 (2.1) 0.421   0.002*     fairly confident 0 4 (80.0) 15 (31.3) very confident 0 0 32 (66.7) abdominal paracentesis, n=52   not confident 2 (66.7) 0 1 (2.6) 0.357   0.009*     fairly confident 0 6 (60.0) 9 (23.1) very confident 1 (33.3) 4 (40.0) 29 (74.4) use of a defibrillator, n=49 not confident 39 (84.8) 1 (50.0) 1 (100.0) 0.113   0.440     fairly confident 7 (15.2) 1 (50.0) 0 very confident 0 0 0 venepuncture and cannulation, n=52 not confident 0 0 0 0.058   0.684     fairly confident 0 0 4 (8.0) very confident 0 2 (100) 46 (92.0) correlation coefficients and p-values are based on spearman’s test of correlation for level of exposure (3-point likert scale) v. confidence (3-point likert scale). *indicates column percentage for particular skill. research october 2014, vol.6, no. 2 ajhpe 159 the proportion of students feeling very confident with the various skills was highest among 7th-year students. it is however worth noting that for a number of skills – identifying s1 and s2, systolic murmurs, tactile fremitus, and general abdominal examination – 6th-year students demonstrated less confidence than 5th-year students. more than 80% of 7th-year students nearing graduation reported feeling very confident with auscultation of s1 and s2, tactile fremitus, pulmonary auscultation, abdominal examination, and breast examination to detect nodules. however, <30% reported feeling very confident with auscultation for s3 and s4, diastolic murmurs, or pericardial friction rubs. among the 12 listed procedural skills, venepuncture and cannulation had the highest proportion of exposure (>90% performed these at least twice), followed by vaginal delivery, which had been performed by >85% at least twice (table 2). for most procedural skills, there was an increase in experience with each additional clinical year and a corresponding increase in the proportion reporting feeling very confident. between the 6th and 7th years, increasing proportions of students had performed the following procedures often: bladder catheterisation (52.9 90.6%), abdominal paracentesis (35.3 75.5%), nasogastric intubation (2.9 54.7%), and suturing (17.6 45.3%), with very similar increases in confidence levels. other skills, such as vaginal delivery, lumbar puncture, and cardiopulmonary resuscitation, showed a gradual progression of experience from 5th to 6th to 7th year. the highest level of confidence was in conducting vaginal deliveries, where 98.1% of 7th-year students felt very confident. however, less than one-third of final-year students were very confident in five of the 12 listed common procedural skills, the lowest being in the use of a defibrillator (0%), followed by advanced cardiac life support (9.4%), endotracheal intubation (15.1%), cardiopulmonary resuscitation (20.8%), and suturing (28.3%). table 3 shows the detailed breakdown of exposure to different procedural skills for final-year students: never taught, taught but never performed, performed once or performed two or more times. in addition, table 3 shows the correlations between the number of times different procedural skills were performed and the level of self-perceived competence. the lowest correlation was with venepuncture and cannulation (0.058), and the highest with nasogastric tube insertion (0.82). for the correlations presented in table 3, overall correlation between experience and confidence for all skills across the different clinical years was 0.55. within domains, the correlation ranged from 0.15 for professionalism, teamwork and medical decision-making to 0.53 for medicaland surgical -related procedural skills. correlations in other domains were as follows: mental state examination – 0.21, history and communication skills – 0.34, physical examination skills – 0.47, and obstetrics and gynaecology-related skills – 0.52. additional data revealed a general improvement in self-confidence in professionalism, teamwork and medical decision-making with each additional clinical year. however, only 42.3% of final-year students reported to be very confident in making decisions regarding appropriate drugs/other therapies. a significant proportion of final-year students had never performed a number of common procedural skills, including suturing (20%), cardiopulmonary resuscitation (22%), endotracheal intubation (39%), advanced cardiac life support (75.0%) or using a defibrillator (94%). discussion there were substantial and significant increases in the levels of confidence and proportion of students performing different skills with each additional clinical year, especially for procedural skills. among the 12 listed procedural skills, vaginal deliveries, venepuncture and cannulation were most often performed (table 2). similarly, a large proportion of students across clinical years felt very confident in conducting vaginal deliveries, venepuncture and cannulation. from this survey, it was clear that by the end of the first year of clinical clerkship (5th year), all those surveyed reported to have inserted an intravenous cannula more than once, which is the first of the top 10 encountered procedures at the university teaching hospital. similarly, all final-year students had performed the procedure at least once. the proportions reported in this survey for intravenous cannula insertion are higher than those in previous studies; for example, an audit of clinical skills conducted among final-year medical students at the university of port harcourt in nigeria reported that only 4.8% of final-year students had never inserted an intravenous cannula.[12] the vast majority of 4th-year students at cincinnati university, usa, reported not performing intravenous cannula catheter insertion during their acting intern rotation.[8] while the majority of final-year students had performed skills such as venepuncture, cannulation, bladder catheterisation, normal vaginal deliveries and examination of the newborn more than twice, the survey showed that a good proportion had never performed some common procedural skills: cardiopulmonary resuscitation, advanced cardiac life support, nasogastric tube insertion, endotracheal intubation and suturing. this may be a curriculum implementation gap that needs to be addressed. of further concern, a large proportion of final-year students had never used a defibrillator. these findings should prompt educators of undergraduate medical students to find ways of, firstly, establishing a functioning skills monitoring system and, secondly, finding ways of addressing the gaps while training continues. other studies have reported a number of finalyear medical students or newly graduated doctors not attempting common procedural skills such as basic life support, nasogastric tube insertion, simple wound suturing, lumbar puncture, endotracheal intubation and thoracentesis.[8,12] the majority of skills that students never attempted are performed in emergency situations in which trial-and-error by students is not acceptable owing to its negative implications on patient outcomes. to improve the skills experience of undergraduate medical students, goldacre et al.[13] suggested the use of log books and skills laboratories. skills laboratories allow students to learn clinical skills in a safe, standardised and controlled environment, encouraging trial-and-error with the ability to rewind, rehearse and practise without negative patient outcomes, thus expanding on students’ hands-on experiences.[14,15] a recommendation would be to incorporate simulation methodology as an integral part of clinical years’ medical education to allow students to practise such skills on simulators. training in skills laboratories enables students to attain a specified level of confidence prior to practising on actual patients.[14,15] correlation between experience and confidence in procedural skills among final-year students was high in nasogastric tube insertion, followed by endotracheal intubation, suturing and bladder catheterisation (table 3). however, overall correlation for all skills across clinical years was moderate. within domains, there were also moderate correlations for medicaland surgicalrelated procedural skills, and obstetrics and gynaecology-related skills. on the other hand, low correlations were observed for history and communication skills, and physical examination. these findings suggest that increasing the students’ experiences may not necessarily result in a corresponding increase in self-confidence – similar to an observation by lai et al.[7] research 160 october 2014, vol.6, no. 2 ajhpe however, high correlations between experience and confidence were observed among procedural skills, implying that increasing the number of times a student performs a procedure may result in improved selfconfidence. some literature supports repetitive practice in building confidence among medical residents in certain procedural skills. for skills such as lumbar puncture, internal medicine residents reported needing 6 10 lumbar puncture experiences to reach a ‘comfortable threshold’, defined as the number of procedures at which two-thirds of the house staff reported being comfortable or very comfortable performing.[16] other factors that have been suggested facilitating development of self-confidence include direct supervision, feedback and deliberate practice.[2,7] limitations of the study one limitation of this study was that self-reporting of competence was used as opposed to objectively measured competence. it is generally accepted that competency may be better assessed using the objective structure clinical examination (osce), as self-reporting is more subjective. medical students also overestimate and underestimate their clinical performance.[17] as suggested by eva and regehr,[18] the fundamental cognitive limitation in the ability of humans to know themselves as others see them restricts the usefulness of self-assessment results. in assessing their level of experience, students were only asked whether they had performed a given skill up to two or more times, upon which they were requested to determine their confidence. the number of times students were requested to rate themselves could have been expanded to determine if the confidence level would continue to increase or if there is a threshold after which further increase may not result in further improvement in confidence. therefore, the minimum level of exposure to ensure confidence could not be determined. notwithstanding the above limitations, this comprehensive survey has marked out the progression of students with regard to clinical skills experiences and confidence across the three years of clinical medical education as a basis for future comparison. conclusion we have reported on the confidence levels of medical students performing different skills, with a demonstrated increase in confidence with each additional clinical year, especially for procedural skills. however, despite this general progress, some deficiencies were noted in that a significant number of final-year students had never attempted common important procedures, including basic life support, nasogastric tube insertion, suturing, endotracheal intubation and use of a defibrillator – findings that should trigger concern. however, the majority of skills that students never attempted are performed in emergency situations in which trial-and-error is not accepted owing to its negative implications on patient outcomes. we therefore recommend the incorporation of simulation methodology as an integral part of the clinical years of medical education to allow students to practise life-saving skills on simulators, and task trainers to improve their confidence and motivation to perform such procedures on actual patients with minimal errors. simulation-based medical education is therefore an important and critical interventional strategy for improved health outcomes. this calls for appropriate and focused investment in training if it is to be realised. ethical consideration the survey was conducted as part of the monitoring and evaluation activities of som; therefore an ethical waiver was obtained from som-unza’s research ethics committee. waiver reference number: 017.01.14. acknowledgements. we acknowledge the support of the research support centre at som-unza through the southern african consortium for research excellence (sacore)-wellcome trust (company no. 2711000), a charity (no. 210183) registered in england; and the national institutes of health (nih) through the medical education partnership initiative (mepi) programmatic award no. 1r24tw008873 entitled ‘expanding innovative multidisciplinary medical education in zambia’. references 1. association of american medical colleges. recommendations for clinical skills curricula for undergraduate medical education. washington, dc: association of american medical colleges, 2008. 2. duvivier rj, van dalen j, muijtjens am, moulaert vrm, van der vleuten cpm, scherpbier ajja. the role of deliberate practice in acquisition of clinical skills. bmc medical education 2011;11:1011. [http://dx.doi. org/10.1186/1472-692011 -101] 3. epistein rm, hundert em. defining and assessing professional competence. j am med assoc 2002;287:226-235. 4. mcgaghie wc, isenberg sb, cohen er, barsuk jh, wayne bd. does simulation based medical education with deliberate practice yield better results than traditional clinical education? a meta-analytic comparative review of the evidence. academic medicine 2011;86(6):705-711. 5. prihatiningsih ts. principles of developing a competence-based curriculum. http://www.fk.unair.ac,id/pdfiles/ pengembangankbk.pdf (accessed 26 april 2012). 6. world federation of medical education (wfme). international basic medical education standards (ibmes). denmark: association of american medical colleges, 2003. 7. lai nm, sivalingam n, ramesh jc. medical students in their final six months of training: progress in selfperceived clinical competence, and relationship between experience and confidence in practical skills. singapore med j 2007;48(11):1018-1027. 8. colberly l,goldenhar lm. ready or not, here they come: acting interns, experience and perceived competency performing basic medical procedures. society of general internal medicine 2006;22:491-494. 9. institute of health care improvements. improving outcomes for high risk and critically ill patients, 2010. http:// www.ihi.org/ihi/programs/collaboration/improvingoutcomesforhigh-risk (accessed 20 december 2011). 10. banda ss. the role of anatomy in clinical practice: a participant observation study of anatomy in clinical practice. medical journal of zambia 2004;35(1):8-15. 11. pierides k, duggan p, chur-hansen a, gilson a. medical student self-reported confidence in obstetrics and gynecology: development of a core clinical competencies document. bmc medical education 2013;13:62. [http://dx.doi.org/10.1186/1472-6920-13-62] 12. jebbin nj, adotey jm. an audit of basic practical skills acquisition of final year medical students in a nigerian medical school. ann afr med 2012;11:42-45. 13. goldacre m, lambert t, evans j, turner g. pre-registration house officers’ views on whether their experience at medical school prepared them. br med j 2003;326:1011-1012. 14. shanks d, wong ry, roberts mj, nair p, ma wy. use of simulator-based medical procedural curriculum: the learner’s perspective. bmc medical education 2012;10:77. [http://dx.doi.org/10.1186/1472-6920-10-77] 15. al-yousuf na. clinical skills laboratory as learning tool for medical students and health professionals. saudi med j 2004;25(5):549-551. 16. hicks c, gonzales r, anderson r, morton m, wigton r, anderson r. procedural experience and comfort level in internal medicine trainees. j gen intern med 2000;15:716-722. 17. blanchi-hartigan d. medical students’ assessment of self-performance: results from three meta analyses. patient education and counselling 2010;84(1):3-9. [http://dx.doi.org/ 10.1016/j.pec.2010.06.037] 18. eva kw, regehr g. self-assessment in the health professions: a reformulation and research agenda. academic medicine 2005;80:s46-s54. may 2015, vol. 7, no. 1 ajhpe 43 research patient-centredness requires pharmacists to view their patients as individuals with unique experiences.[1] each patient in their social context responds uniquely to verbal communication. traditionally, pharmacists have been regarded as dispensers of prescription medication.[2] they were trained to understand medication, focus on the product and give product information as the main approach to patients, and emphasise medication adherence as a goal. the move in the profession from product orientation (dispensing medication) to patient orientation requires expanding of their professional training.[3] the pharmacist’s professional role has matured to include provision of information, education, and pharmaceutical care services. this expanded role encapsulates a collaborative pharmacist-patient relationship in which both have roles and responsibilities.[4] to be patient-centred, pharmacists need to learn new ways of being with their patients and talking to them, which involves new knowledge and skills as well as innovative ideas to advance the profession towards this role. communication is mentioned in six of the 10 competence standards identified by the south african pharmacy council, which together form the minimum requirements for an entry-level pharmacist to be registered in south africa (sa).[5] developed communication skills are essential for the practising pharmacist and non-negotiable in building provider-patient relationships. effective communication is at the heart of patient safety and optimal health outcomes.[6] training pharmacists to be more aware of the impact of their natural communication style on their patients[7] and healthcare colleagues empowers them to move their professional role from product to patient focused. such awareness may prompt pharmacists to develop their interpersonal skills to address the human-centred elements of patient-centredness. the more advanced the communication skills of a pharmacist, the better he is equipped to assist patients.[8] personality type is an indicator of communication style and the myersbriggs type indicator® (mbti®) is an instrument based on the work of carl jung. according to the personality type framework, two people of the same type have the least chance of miscommunication. consider the four bipolar preference pairs[9] of the mbti®: • extroversion (e) and introversion (i). a focus on and energy from the outer world of people and activity v. a preference for an inner world of thoughts and feelings. • sensing (s) and intuition (n). a practical focus on facts and detail v. attention to patterns and possibilities. • thinking (t) and feeling (f). a focus on logic and analysis v. personal values and priorities. • judging (j) and perceiving (p). a tendency for decisiveness and preference for structure and control v. a tendency to keep options open and a preference for spontaneity and flexibility. a person is naturally inclined to prefer one of the preferences in each pair, which is usually better developed. this choice gives rise to a preference combination or personality type. the 16 personality type combinations are each associated with habitual preferences and behaviours. the mbti® is normally used in education to develop teaching methods that will meet the needs of the different types and to understand differences in motivation for learning. in communication training, the mbti® is regularly applied to learn approaches that are most likely to lead to agreement and co-operation, increase understanding by ‘talking the language’ of different types, and create a climate where differences are seen as valuable.[9] for the first time in pharmacy education, personality types were used as a non-judgemental tool that offers a framework to sensitise pharmacy background. the current movement in the pharmacy profession, from the product towards the patient, demands new educational approaches that support the exit-level outcomes of the south african pharmacy council as implemented in 2013. patient-centred communication calls for an ability to ‘walk in the patients’ shoes’. pharmacists, like others, are naturally inclined to think and treat others as they themselves perceive the world, which can result in miscommunication. objectives. to determine the prevalence of the 16 different myers-briggs type indicator® (mbti®) communication styles, and compare them with the prevalence of these styles in the south african (sa) population. furthermore, to determine the possibility of a pharmacy student interacting with a patient with a similar communication style. method. a novel way to sensitise pharmacists to the differences in people’s experiences, behaviours and communication styles is to introduce them to type theory with the mbti®. a survey design was used to determine 786 pharmacy students’ communication styles, using the mbti®. these students were enrolled for the subject ‘communication for pharmacists’ at the largest pharmacy school in sa. results. more students were consistently found with sensing feeling preferences than in the general sa population. the possibility that a pharmacy student might consult with a patient with a similar style varied between one and 414 chances out of 10 000 consultations. conclusion. this study highlights the importance and possibility of using the mbti® as part of communication training of pharmacy students. sensitising students to their own preferences and those of their patients empowers them to patient-centred communication. afr j health professions educ 2015;7(1):43-46. doi:10.7196/ajhpe.370 discovering the value of personality types in communication training for pharmacy students m j eksteen, bpharm, mpharm; m j basson, bsc hed hons, bsc, msc department of pharmacy practice, school of pharmacy, faculty of health sciences, potchefstroom campus, north-west university, potchefstroom, south africa corresponding author: m j basson (marietta.basson@nwu.ac.za) 44 may 2015, vol. 7, no. 1 ajhpe research students to their own communication style preference and its effect on their patients.[9] using the mbti® as part of the communication training of pharmacy students gives them the opportunity to appreciate and understand the differences between them as professionals and them and their patients. in this project, the mbti® was included in the training of pharmacists to empower them on their way to patient-centred care. more importantly, over the long term, pharmacy students will form better relationships with their patients, which in turn will result in improved medication adherence rates. this study identified the prevalence of the different communication styles among pharmacy students and determined the possibility of their interacting with a patient with a similar communication style. method this study is part of a larger project on teaching communication to pharmacy students. all students at a higher education training institution in sa, who enrolled from 2007 to 2012 for the semester subject ‘communication for pharmacists’, were part of the study population. as part of their training, they took the mbti® under supervision of a registered user.[9] the results were verified through workshops where students experienced the communication implications of their preferences in their future line of work. they also became aware of the implications of communication preferences other than their own. a survey design was used in this study. the information was collected for each group at the beginning of the semester subject and is used here to describe the study population at that single point in time. form g of the mbti®, a paper and pencil jungian-based inventory, was used as the measuring instrument. it consists of 126 items that measure the four bipolar preference pairs. descriptive statistics were used to describe the fourth-year students of 2007 2012 and compare them with the sa population in terms of the four bipolar preference pairs. in 2012, owing to a curriculum change, the communication course moved from the fourth to the third year and we had an opportunity to evaluate both year groups in one year. the third-year students (2012) were described and compared with the fourth-year students in the same year to establish whether the same pattern holds. finally, the probability that a pharmacy student will interact with a patient of a similar preference type, was calculated for the fourth-year students from 2007 to 2012 and the third-year students of 2012. to calculate the probability for equally likely outcomes, the probability (p) that an event occurs equals the number of favourable events divided by the number of possible events. for independent events, the probability that both events will happen equals p (event a) multiplied by p (event b).[10] the mbti® was used primarily as a teaching tool and the data for this project were analysed long after the students completed ‘communication for pharmacists’. the students’ names and numbers did not form part of the data analysed; therefore, no individual could be identified or implicated in the summary analysis. the project was executed by a registered mbti® user, especially the data collection and the verification of the results with the participants. the scope of this study was limited to the preferences of pharmacy students at a single pharmacy school in sa – the largest pharmacy school in the country[11] – and could form the basis for a broader, national research project from which it would be possible to generalise findings. results and discussion in sa, the pharmacy profession is currently dominated by women[11] and our study population (n=786) reflected this trend. of the 201 thirdyear students in 2012, 45 (22.4%) were male, and of the 585 fourth-year students between 2007 and 2012, 151 (25.8%) were male. mbti® preference distribution of fourth-year students from 2007 to 2012 when we observed the individual preferences of the fourth-year students, it was found that there were significantly more who preferred introversion, sensing, feeling and judging than in the general sa population (fig. 1).[12] this indicated that the proportion of students with a preference for feeling in the study population varied between 41% and 58%,[6] i.e. at least 12% above the 28.3% reported in the sa population.[12] there was a consistent over-representation of students with a preference for feeling compared with the general population. mbti® preference distribution of thirdand fourth-year students in 2012 when comparing the preference distribution of the third-year students with that of the fourth-year students (fig. 2), it was found that the preference distribution of the former followed the same pattern as that of the fourth-year students in 2012. both groups of 2012 students had preferences for introversion, sensing, feeling and judging compared with the general population in sa. these findings corroborate the analysis of the fourth-year students (2007 2012) % 2007 2012 fourth-year students south african population 90 80 70 60 50 40 30 20 10 0 e i s n t f j p 50.3 55.0 49.7 45.0 79 67.9 21 32.1 51.8 71.7 48.2 28.3 70.4 65.1 29.6 34.9 preferences fig. 1. preference distribution for fourth-year students between 2007 and 2012 compared with that in the sa population.[12] (e = extroversion; f = feeling; i = introversion; j = judging; n = intuition; p = perceiving; s = sensing; t = thinking.) % 2012 third-year students 2012 fourth-year students 90 80 70 60 50 40 30 20 10 0 e i s n t f j p 49.3 45.4 50.7 54.6 81.6 83.1 18.4 16.9 55.7 49.2 44.3 50.8 72.1 27.9 25.4 preferences 74.6 fig. 2. preference distribution for third-year students of 2012 compared with that of fourth-year students of 2012. (e = extroversion; f = feeling; i = introversion; j = judging; n = intuition; p = perceiving; s = sensing; t = thinking.) may 2015, vol. 7, no. 1 ajhpe 45 research overall. the findings showed that there are consistently more students per year group with a preference for sensing and/or feeling in the study population compared with the general population since 2007.[7] mbti® personality type distribution the mbti® types most strongly represented in the 2007 2012 study population were istj, isfj, estj and esfj. compared with the general population, it is clear that there were more isfjs and esfjs in the study population (fig. 3). in the sa population the least represented type is infj,[12] among the 2012 third-year students it is intp, and among the 2007 2012 fourth-year students it is intj. probability that a like-minded student and patient will interact probability was calculated using the values in fig. 3. a fourth-year student with the greatest possibility of interacting with a like-minded patient is an istj personality type (fig. 4). therefore, out of 10 000 consultations that the istj fourth-year student will conduct, only 352 are likely to be with an istj patient. participants who have the smallest chance (0.01%) to interact with a patient of similar type are third-year intp students in 2012, i.e. of 10  000 consultations that the student will conduct, only one might be with a patient with an intp preference. the same pattern held for the entire fourth-year population over the six years and for the 2012 cohort of third-year students. the likelihood of pharmacy students interacting with patients with similar preferences varies between one and 414 chances in 10 000, emphasising the importance for a pharmacy student to be aware not only of his own communication style or preferences, but also of the expectations that patients with other styles are likely to have of pharmacists in a professional setting. discussion for the first time in the communication training of pharmacy students at a higher education training institution, the personality type framework of myers and briggs was used to enable students to appreciate their own preferences and communication styles and those of others.[9] during the first part of this project, it was shown that the mbti® personality theory holds for pharmacy students,[7] even though they have been trained in a health environment. prompted by questions related to their professional practice, the students still responded habitually according to mbti® theory. the entire study population, irrespective of year of study, favoured the sensing-feeling preferences. compared with the sa population, it seems that a greater proportion of students at this pharmacy school tends to have sensingfeeling preferences, with the accompanying communication style implications.[13] patients with a preference for sensing might prefer to focus on detail and facts during communication, are anchored in current realities and common sense, and immediately apply what is communicated. however, patients with a preference for intuition might talk about possibilities and trends, are future orientated and may prefer to link and integrate information,[13] e.g. students with a preference for sensing who may focus on facts and details[7] have to realise 2012 third-year students 2007 2012 fourth-year students south african population entj personality type % 25 20 15 10 5 0 istj isfj infj intj istp isfp infp intp estp esfp enfp entp estj esfj enfj 20.9 17.8 15.9 16.0 1.9 2.7 1.0 1.4 4.5 3.9 4.5 3.6 1.9 0.4 2.22.4 19.8 5.5 1.7 3.9 4.7 2.5 4.22.7 6.5 5.5 3.5 5.0 4.0 3.9 2.5 3.1 17.0 15.4 9.0 11.8 3.5 3.0 2.42.9 5.9 3.5 2.2 6.4 20.8 5.2 6.05.0 fig. 3. the mbti® personality type distribution of the 2007 2012 fourth-year and 2012 third-year study population compared with the sa population.[12] (e = extroversion; f = feeling; i = introversion; j = judging; n = intuition; p = perceiving; s = sensing; t = thinking.) 2007 2012 fourth-year students 2012 third-year students personality type pr o b ab ili ty (% ) 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 istj isfj estj esfj 3.52 4.14 0.88 0.87 3.20 3.54 0.61 0.47 fig. 4. the four personality types in the study population with the greatest possibility to interact with like-minded patients in sa. (e = extroversion; f = feeling; i = introversion; j = judging; n = intuition; p = perceiving; s = sensing; t = thinking.) 46 may 2015, vol. 7, no. 1 ajhpe research that some patients with a preference for intuition may be interested in alternatives in a medication-related request. it was established that there were consistently more students with a preference for feeling than in the general population, which has positive implications for patient-centred care. patient-centred care requires the pharmacist to be able to strengthen the relationship with the patient, improve the patient’s knowledge about health, promote communication about important health-related matters and engage the patient to become involved in his own healthcare.[14] pharmacy students with a preference for feeling may have a natural tendency to empathise and develop rapport with their patients; appreciate their patients’ perspective; be supportive, nurturing and interested in their patients; and enjoy collaborating.[13] therefore, students with a preference for feeling may be naturally orientated towards patient-centred care. such students need to realise that patients with a preference for thinking might, for example, prefer objective, honest and frank feedback. these patients might prefer to debate and challenge medication information and request the pharmacist to list the pros and cons.[13] in conclusion, even an istj student among the fourth-year cohort, with the best chance of consulting with a like-minded patient, will not be attending to a patient with a similar personality type for 96.48% of the time. while some patients experience a specific behaviour as caring, others might experience it as non-caring.[15] it seems that central to the patient’s experience of patient-centred care is a set of pharmacist abilities, including seeing the patient’s point of view. a pharmacist who is familiar with personality type theory has a better chance to understand a patient’s experience. pharmacists do not need to know the personality type of each patient; they only need to be aware of the different preferences and be sensitive to the associated implications. recommendations the mbti® can be used as a tool to address the patient-centred communication training of pharmacists to support the shift in educational focus. such communication requires students to be aware not only of their own preferences and communication style, but also of the preferences of patients that are not similar to their own. this knowledge will help pharmacy students to grasp the world from the patient’s perspective, especially in terms of what the patient regards as meaningful. although the majority of the students preferred sensing-feeling, they should be aware of and sensitive to the communication expectations of patients with preferences other than their own. knowing about the behavioural and communication implications of the different mbti® preferences may enable students to move nearer to the ideal of treating their patients with empathy, respect and unconditional regard. even though there is a very small chance for a pharmacy student to interact with a patient of similar mbti® personality type, the former does not need to know what the personality type of each of their patients is; they only need to be aware of the different preferences and sensitive to the associated implications. consequently, pharmacy students will recognise the legitimate needs and associated meanings in their patients’ communication. conclusion knowing personality type will enhance the skills set needed by any pharmacist to address the specific requirements of patient-centredness. a broad understanding of the different preferences and associated communication style implications that the patient might have is key to recognising the different needs of patients. references 1. stewart m. towards a global definition of patient centred care. bmj 2011;322(7284):444-445. [http://dx.doi. org/10.1136/bmj.322.7284.444] 2. dinsmoor r. what your pharmacist can do for you: a resource often overlooked. asthma magazine 2003:27-29. [http://dx.doi.org/10.1067/mas.2003.2] 3. berenguer b, la casa c, de la matta mj, martin-calero mj. pharmaceutical care: past, present and future. curr pharm 2004;10(31):3931-3946. 4. worley mm, schommer jc, brown lm, et al. pharmacists’ and patients’ roles in pharmacist-patient relationship: are pharmacists and patients reading from the same relationship script? res soc adm pharm 2007;3:47-69. [http://dx.doi.org/10.1016/j.sapharm.2006.03.003] 5. south african pharmacy council. intern and tutor manual for the pre-registration experience of pharmacist interns. pretoria: south african pharmacy council, 2013:10-33. 6. boesen kp, herrier rn, apgar da, jackowski rm. improvisational exercises to improve pharmacy students’ professional communication skills. am j pharm educ 2009;73:35. [http://dx.doi.org/10.5688/aj730235] 7. basson mj, eksteen mj. pharmacists, communication preferences and care. prague, 2012. http:// w w w. i nte rd i s c ipl i n ar y. n e t / pro bi ng t h e b ou n d ar i e s / w p c onte nt / upl o a d s / 2 0 1 2 / 0 4 / t h e p at i e nt 2 mari%c3%abttabassonmarieteksteen-website-paper.pdf (accessed 26 november 2013). 8. sims lm, haines sl. challenges of a pharmacist-directed peer support program among adolescents with diabetes. j am pharm assoc 2003;51(6):766-769. 9. myers ib, mccaulley mh. manual: a guide to the development and use of the myers briggs type indicator. 2nd ed. palo alto: consulting psychologists press, 1985:1-309. [http://dx.doi.org/10.1331/ japha.2011.10041] 10. catley k, tipler mj. national curriculum mathematics. level 6. christchurch: caxton educational, 1997:125. 11. south african pharmacy council. pharmacy human resources in south africa. pretoria: south african pharmacy council, 2011:34. 12. taylor n, yianrakis c. south african mbti® form m data supplement. johannesburg: jopie van rooyen and partners, 2007:1-25. 13. dunning d. introduction to type and communication. california: cpp, 2003:1-54. 14. epstein rm, street rl. the values and value of patient-centered care. ann fam med 2011;9(2):100-103. [http:// dx.doi.org/10.1370/afm.1239] 15. quirk m, mazor k, haley hl, et al. how patients perceive a doctor’s caring attitude. patient educ couns 2008;72:359-366. [http://dx.doi.org/10.1016/j.pec.2008.05.022] cpd questionnaire cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can checkthe answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/015/01/2013 (clinical) november 2013 true (a) or false (b): 1. a key point of professor prozesky’s saahe distinguished teacher lecture is the observation that the ability to attend to detail is not automatically achieved; training, supervision and team work are needed. 2. the use of interprofessional education to facilitate effective teamwork in healthcare is an important concept that has been promoted for the past 40 years. 3. when using patient simulators in clinical training, it is important that the encounters resemble the likely experience with a real patient as closely as possible. 4. when training peer tutors, it is not necessary to prepare checklists for their training sessions. 5. when senior students are trained as peer tutors, they find that their own knowledge and skills also improve. 6. learning management systems are one way of addressing the need for increasing numbers of students to interact with faculty members in a more organised way. 7. a fear of change and adapting to a new system were the least important factors influencing attitudes towards implementing learning management systems. 8. incongruence between the expectations that students and their clinical educators have about clinical learning encounters could lead to inadequacies in the acquisition of clinical skills. 9. students’ and educators’ personal beliefs about knowledge and knowledge construction (their epistemologies) have little influence on the way that teaching and learning roles are approached and adapted in clinical placement settings. 10. the most important factor influencing faculty recruitment and retention for young academic members of staff at a new medical school in tanzania is the opportunity for personal growth and development. 11. physiotherapists need to focus exclusively on the medical model of illness in order to manage hiv patients effectively. 12. the role of physiotherapists in hiv management is not well defined. 13. e-learning in south african programmes for clinicians work well due to ease of internet access at clinical training platforms. 14. registrars enjoy attending an extra module added to their m med curriculum that addresses issues relevant to practice beyond direct clinical training, e.g. ethics, communication, etc. 15. alignment of the preclinical curriculum with the needs of future clients enables student to feel well prepared for their clinical placements. 16. when clinical educators are given additional training in educational skills, they have a less uniform understanding of the level of competence required to perform adequately in clinical practice. 17. final-year medical students who were not willing to engage with female patients about being victims of violence did not do so because they thought it would be demeaning to the patient. 18. final-year medical students in nigeria have a satisfactory knowledge of physical, sexual, psychological and economic types of violence against women. 19. the shortage of faculty at a medical school in tanzania is part of a continent-wide shortage of faculty to teach health professionals. 20. postgraduate medical trainees (registrars/residents) do not spend much time teaching medical students. a maximum of 5 ceus will be awarded per correctly completed test. november 2013, vol. 5, no. 2 ajhpe 101 http://www.cpdjournals.co.za editorial 2 may 2014, vol. 6, no. 1 ajhpe in this edition of ajhpe, an article by treadwell et al.[1] reports on the reflections of 5th-year medical students after participation in an interprofessional learning activity. i was struck by a comment made by one of the students: ‘my biggest challenge was remembering what needs to be done … it was just "chakalaka" and all mixed up.’ so what exactly is multiprofessional/interprofessional education? put quite simply, it is learning that occurs when two or more professions learn with, from and about each other to facilitate collaboration in practice.[2] globally, an ageing population and a rapidly rising prevalence of chronic diseases and accompanying disability have resulted in a shift in focus from cure to controlling of symptoms, and maximising patients’ level of functioning and quality of life while helping their families to cope with longterm illness. as a result of the skills and complexity of knowledge required to provide such care, specialisation in the respective healthcare professions is increasing. given this reality, it is clear that healthcare in the 21st century requires a team approach that calls upon a range of healthcare professionals with the requisite expertise needed to provide comprehensive care. despite the recognised interdependence of healthcare professionals, the approach to professional licensing remains uniprofessional, resulting in a significant measure of disconnect between pre-registration and postregistration practice where interprofessional care is essential. therefore, students enter their professional training with preformed and stereotyped perceptions of their profession and negative stereotypes regarding other professions, which leads to professional arrogance that hampers the development of collaborative relationships.[3] furthermore, there is considerable power in having control over a distinct body of knowledge; this cognitive exclusivity further undermines communication and development of effective relationships between different professions.[4] in traditional models of healthcare, the situation is further exacerbated because doctors usually prescribe the involvement of other healthcare professionals in the patient’s care, which leads to dominance and ineffective communication.[5] breaking out of this mould and changing the foundation of the relationships between healthcare professionals require radical revision of our teaching practices and student learning activities. while opportunities to engage in interprofessional learning experiences are increasing, they are mainly limited to specific events rather than routine practice. it is therefore not surprising that the students interviewed by treadwell et al.[1] lacked the appropriate communication and teamwork skills to manage a patient in a multiprofessional setting. the student’s ‘chakalaka’ comment is a powerful statement about the urgent need for large-scale interprofessional training programmes, rather than a few isolated events, to facilitate the development of interprofessional competence. so, where to now? firstly, social identity theory suggests that group membership is dynamic, context dependent and can shift in order that subgroups broaden their boundaries to regard themselves as members of an inclusive team of healthcare professionals. several studies have shown that interprofessional education early in undergraduate health professions education leads to better interprofessional communication.[6] therefore, the first step to remedy the current situation is the introduction of interprofessional learning activities in the early years of undergraduate training programmes. students need to work together long before they have had time to develop stereotypic approaches towards peers based on ignorance and arrogance. secondly, the core content of interprofessional education, including the core competencies required for effective teamwork such as respect between professionals, learning about professional roles and healthcare systems, leadership, conflict resolution and ethics, has already been outlined by organisations such as the world health organization.[7] undergraduate health professions curricula should include early interprofessional learning with an emphasis on the central values of professionalism (altruism, accountability, excellence, duty, advocacy, service, honour, integrity, respect for others and ethical and moral standards) and the acquisition of skills required for effective functioning in an multiprofessional team. thirdly, interprofessional practice allows each profession to independently contribute their expertise to the assessment of patients and management decisions. this is best achieved by organising the team around solving a common set of problems where each team member contributes a knowledge and skills set that augments and supports the contributions by others, thereby ensuring holistic management of the patient’s complex health problems. while individual team members preserve their specialised functions, each team member is sufficiently familiar with the concepts and approaches of others so that the roles of team members blur into a common understanding of the patient’s problems and management plan. the preceding discussion suggests that clinician educators need to focus on four key activities when teaching in an interprofessional setting: (i) allow the students to clearly identify the patient’s key clinical problems that require intervention; (ii) ask students to articulate the reasons why a multiprofessional team is required to address the clinical problems identified; (iii) allow each team member to make an independent contribution to addressing the patient’s healthcare needs; and (iv) ensure that the team develops a comprehensive management plan that encompasses all the contributions made by the respective team members. ultimately, respect for the expertise of each team member and shared decision-making, where the doctor is not dominant, is fundamental to successful interprofessional practice. undergraduate students from different professsions need broad and frequent exposure to interprofessional patient assessments and role models leading multiprofessional teams where respect, collaboration and shared decision-making can be experienced. two examples of this model of care include multiprofessional units dedicated to the care of stroke patients, and care of the elderly. such units could provide an excellent platform for undergraduate training in interprofessional practice. vanessa burch editor-in-chief african journal of health professions education vanessa.burch@uct.ac.za 1. treadwell i, van rooyen m, havenga h, theron m. the effect of an interprofessional clinical simulation on medical students. ajhpe 2014;6(1):3-5. [http://dx.doi.org/10.7196/ajhpe.231] 2. barr h. interprofessional education: 1997-2000. a review. uk centre for the advancement of interprofessional education (caipe) 2000. http://www.caipe.org.uk (accessed 2 may 2014). 3. boaden n, leaviss j. putting teamwork in context. med educ 2000;34:921-927. 4. hammick m. interprofessional education: concept, theory and application. j interprof care 1998;12:323-332. 5. atwal a, caldwell k. do all health and social care professionals interact equally: a study of interactions in multidisciplinary teams in the united kingdom. scand j caring sci 2005;19:268-273. 6. horak bj, o’leary kc, carlson l. preparing health care professionals for quality improvement. the george washington university george mason university experience. qual manag health care 1998;6:21-30. 7. world health organization. learning together to work together for health. report of a who study group on multiprofessional education of health personnel: the team approach. technical report no. 769. geneva: world health organization, 1988. ajhpe 2014;6(1):2. doi:10.7196/ajhpe.424 interprofessional education – is it ‘chakalaka’ medicine? mailto:vanessa.burch@uct.ac.za http://dx.doi.org/10.7196/ajhpe.231] http://www.caipe.org.uk editorial � december �009, vol. 1, no. 1 ajhpe africa is the only world region unlikely to meet the millennium development goals by 2015.1 at best africa could hope to do so by 2050! to achieve these goals by 2015 the continent requires one million additional health care workers.2 these startling facts paint a very bleak picture of access to basic health care in africa. indeed, data from a recent world health organization publication show that africa has the highest burden of disease relative to the available workforce globally.1 we live on a continent that experiences 24% of the global burden of disease, while having only 2% of the global physician workforce. these data clearly demonstrate the urgent need to train more health care workers in africa. currently there are at least 136 medical schools in sub-saharan africa; 11 countries have no medical school and 24 have only one medical school each.3 furthermore, limited data suggest that sub-saharan african countries frequently graduate fewer than 100 medical students per year. this means that the training platform in the subcontinent supplies fewer than 8 000 new doctors per year.4,5 while it is clear that the current training pipeline of african doctors is grossly insufficient for our needs, the situation is further compounded by the large-scale emigration of african doctors to well-resourced countries abroad. currently sub-saharan africa is the world region worst affected by the migration of health care professionals.6 it is estimated that there were approximately 65 000 african-born physicians and 70 000 african-born professional nurses working in a developed country in the year 2000.7 this represents, respectively, about 20% of africanborn doctors in the world and about 10% of african-born nurses. recent data show that south african and nigerian universities are the biggest producers of graduates who choose to work abroad. what then should our response to this desperate situation be? i believe that we need to expand the size of the training platform in africa, specifically sub-saharan africa, and address the challenge of large-scale migration. while the latter is a topic of hot debate in the literature, i think that too little attention is being paid to the training of more african health professionals. some counties have taken on the challenge of building a medical school, for example namibia and botswana, and this is clearly a step in the right direction. expanding the training platform obviously creates a need for more health professions educators. not only do we need more educators, but we need to train african educators of a high quality. this is where i believe the new journal is set to make a major contribution. as african health professions educators we face extraordinary challenges that are most acute in developing countries. we, as a collective body, are working creatively to deal with these challenges and we need a platform on which to share these innovations and learn from one another. solutions for african problems are most likely to originate in africa and so a forum to write about our work is needed. not only do we face infrastructural and human resource constraints, but our students frequently enter the higher education sphere from grossly inadequate schooling backgrounds and they face special challenges we need to address. once again i am of the opinion that we are best able to address these needs. dissemination of such valuable information is of paramount importance and the need for a journal for our continent is, i believe, essential. what then is the intention of the new journal? as the editor i wish to develop an academic platform which will allow experienced health professions educators to share their work and develop the scholarship of teaching and learning as relevant to our needs. i would also like to see the work of emerging educators published so as to advance their careers and promote educational research. thirdly, i am of the opinion that we need a journal that will build a profile of educational research in the developing world and make a valuable contribution to the body of emerging literature usually dominated by work from better resourced settings. the challenge to put an african footprint on the map of academic discourse relevant to health sciences education is, i believe, long overdue. in closing then, i would like to extend an invitation to my african colleagues to make a contribution to the journal and thereby contribute to the scholarship of education in the developing world. indeed, i would like to be so bold as to extend the invitation to fellow educators in other regions of the developing world to also make a contribution to the journal and foster the growth of a global community of educators who strive to achieve excellence against all odds. references 1. world health organization. world health report 2006: working together for health. geneva: who. http://www.who.int/whr/2006/en/ (accessed 11 november 2009). 2. chen l, evans t, anand s, et al. human resources for health: overcoming the crisis. lancet 2004; 364: 1984-1990. 3. faimer medical schools directory. www.faimer.org (accessed 11 november 2009). 4. eckert nl. the global pipeline: too narrow, too wide or just right. med educ 2002; 36: 606-613. 5. longombe ao, burch v, luboga s, et al. research on medical migration in sub-saharan african medical schools: usefulness of a feasibility process to define barriers to data collection and develop a practical strategy. education for health 2007; 20: 1. http://www.educationforhealth.net/ (accessed 11 november 2009). 6. mullan f. the metrics of the physician brain drain. new engl j med 2005; 353: 1810-1818. 7. clemens ma, pettersson g. new data on african health professionals abroad. human resources for health 2008; 6: 1. http://www.human-resources-health. com/content/6/1/1(accessed 11 november 2009). vanessa burch editor does africa need another journal? vanessa burch e-mail: vanessa.burch@uct.ac.za research 216 november 2015, vol. 7, no. 2 ajhpe the discourse on the nature of research supervision in higher education institutions has received much attention.[1] changes in the economic, political and workplace arenas of many developing countries have highlighted the contribution of research in higher education programmes towards a skilled workforce and in the overall global knowledge economy.[2] the higher education landscape in the south african (sa) context has not been exempt from these changes; many faculties, such as nursing, have increased the number of students accepted into their postgraduate programmes to respond to the demand of producing highly skilled graduates.[3-5] in the selected university, the department of nursing has seen an increase in the number of postgraduate students – from approximately 120 students in 2009 2010 to 207 in 2011 2012 (college of health sciences postgraduate and research annual report, university of kwazulu-natal, 2013). the selected department of nursing has 17 academic staff, 12 of whom are involved in postgraduate supervision. given the increased intake of postgraduate students, the central issue confronting research supervisors concerns how academics can achieve quality postgraduate research supervision and accelerate graduate throughput rates.[6,7] research supervisors at higher education institutions are increasingly challenged to facilitate the learning of postgraduate students from diverse backgrounds by innovative and progressive research supervision methods.[2] furthermore, postgraduate research supervision is increasingly seen as a teaching and learning construct that fosters deep learning and critical inquiry.[1] it therefore demands that academics be continuously trained with innovative methods to harness and develop this skill in postgraduate research supervision.[2,7] the latter is considered to be multifaceted, challenging academics to master the skill of facilitating learning and creating the supervision experience as a social learning construct for the student, coupled with supervising an increased number of postgraduate students.[4,7-9] the aim of this study was to explore the experiences and practices of nurse academics with regard to postgraduate research supervision. methods design a descriptive exploratory design underpinned the study. this design was considered appropriate to elicit the experiences and overall practice of the nurse academics regarding postgraduate research supervision. in-depth individual interviews were conducted with key informants – the nurse academics involved in postgraduate research supervision. setting and sample the selected department of nursing offers a postgraduate programme: a master’s in nursing (either coursework or fulltime research) and a phd in nursing (research only). there were 12 academics involved in postgraduate research supervision at the time of the study. given the small target population, non-probability purposive sampling was used. all academics had a minimum of at least 12 months and a maximum of 13 years postgraduate research supervision experience. the heterogeneity in the years of experience enhanced the shared experiences. background. the global landscape of higher education has repositioned itself, moving away from insular institutions towards open responsive systems of teaching and learning with an emphasis on cultivating a new mode of knowledge production. the south african higher education system has responded to these global changes by recognising the contribution of research productivity as a commodity within the overall worldwide knowledge economy. these changes have contributed towards an increased intake of candidates in many university faculties, including nursing, to meet the demand of producing highly skilled graduates. objectives. to explore and describe the current practices and experiences of nurse academics regarding postgraduate research supervision. methods. a descriptive exploratory design with in-depth interviews was used, and a self-reported questionnaire eliciting information on research supervision practices. results. three emergent themes were identified from the results of this study: a lack of standardised guidelines for nurse academics to effectively supervise postgraduate research; the pressure that nurse academics experience regarding postgraduate research supervision; other demanding roles of an academic, such as a high teaching and clinical workload. conclusion. the study demonstrated gaps in research supervision, shared frustrations such as feelings of isolation, and a lack of support systems. afr j health professions educ 2015;7(2):216-219. doi:10.7196/ajhpe.443 an exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a south african university j r naidoo,1 b nursing, m nursing (nursing research), phd nursing; s mthembu,2 b nursing, m nursing (nursing education), phd nursing 1 discipline of nursing, school of nursing and public health, university of kwazulu-natal, durban, south africa 2 kwazulu-natal college of nursing, pietermaritzburg, south africa corresponding author: j r naidoo (naidoojr@ukzn.ac.za) research november 2015, vol. 7, no. 2 ajhpe 217 data gathering and analysis each individual in-depth interview lasted 45 60 minutes and was guided by probing questions, which focused on eliciting the overall experiences and practices of postgraduate research supervision. the interviews were audio-recorded, transcribed and saved in ms word on a password-protected laptop. thematic analysis was used to identify emergent themes. a self-reported questionnaire eliciting information on postgraduate research supervision practices was also administered to each participant before the interview and was reported using percentages and frequency counts. the questionnaire focused on the mode of supervision, years of experience involved in research supervision, use of supervision contracts and models, and number of postgraduate students being supervised. the probing questions of the individual in-depth interview and the items of the self-reported questionnaire were informed by literature related to postgraduate research supervision. ethical considerations after institutional ethical approval (hss/0777/013), departmental permission was granted by the dean and head of the school. a letter stating the purpose of the study and detailing its nature was distributed to all participants, who were advised that they could withdraw from the study at any time without reason and that their participation was voluntary and had no bearing on their current positions in the department of nursing. there were no direct benefits to the study participants; however, the study results will have an aggregate benefit to the wider nursing department in terms of providing insight into the experiences and practices of research supervision. anonymity was maintained throughout data collection. no identifying information was requested from the participants. while the researcher was also an academic involved in postgraduate research supervision, the researcher bracketed and did not include her feelings, views and experiences of postgraduate research supervision from the collected data. the second researcher, with whom the main researcher reflected after the individual interviews, facilitated bracketing. trustworthiness trustworthiness of the findings was achieved through: (i) credibility; (ii) dependability; and (iii) triangulation. credibility was achieved by member checking of the themes that emerged from the interviews. this allowed for congruency in the researcher’s meaning of the data to that of the intended meaning from the participants. dependability of the data collected was ensured through an audit trail. given that this study had two researchers, both served as peer reviewers of the individual in-depth interviews, the level of probing, and the sequence in terms of how the data were collected. triangulation of data was achieved through the use of individual in-depth interviews, field notes during the interviews and a self-reported questionnaire. the use of multiple sources of data increased the certainness of the data gathered with regard to postgraduate research supervision. limitations of the study while efforts to avoid researcher bias was controlled by reflection and bracketing, the researchers being academics involved in postgraduate research supervision was a limitation. results sample description data saturation occurred after individual in-depth interviews with 7 parti cipants. table 1 presents a descriptive summary of the participants’ demographic characteristics with regard to their years of experience as academics and postgraduate research supervisors. experiences of postgraduate supervision (table 2) three prominent themes emerged during data analysis: (i) overwhelmed and frustrated; (ii) pressure to perform; and (iii) getting the balance right. overwhelmed and frustrated most participants experienced research supervision as an overwhelming task, expressing feelings of fear and loss of confidence as an academic when they initially started supervising. moreover, participants noted that they experienced a loss of control in managing their role as an academic, which they largely perceived as being focused on teaching and learning activities. participants who were less experienced with postgraduate research supervision reported feeling fearful with the expectation of accelerated graduate throughput. they further noted that they experienced the challenge of trying to meet the expectation of successful and quality postgraduate research supervision without clear guidelines to facilitate successful supervision: ‘when i started i was given students to start supervision … i didn’t know where to begin … there was nothing to guide me … no guidebooks ... .’ ‘ … i felt scared … not knowing what was research supervision and how to start doing this, and at the same time we are expected to have high completion rates … .’ ‘we are told about making sure our research students complete and graduate in the time given … one becomes afraid especially because some of us have not supervised masters students before.’ it also emerged that the role of supervision was perceived as overpowering compared with other tasks of an academic. this further increased anxiety and being overwhelmed by research supervision, as well as a feeling of being blinded by the lack of knowledge on how to effectively fulfil this role: table 1. sample characteristics variable mean range length of time as an academic (years) 6.2 3 12 length of time supervising (years) 4.7 2 10 master’s students being supervised at time of interview, n 7 2 12 students graduated, n 1 0 6 length of time per week supervising (hours) 8.5 3 10 sessions per month with each student, n 2 2 4 length of time per supervision session (hours) 1.5 1 2.5 table 2. postgraduate research supervision practices variable yes, n (%) no, n (%) mode of supervision contact (face to face) 7 (100) email correspondence 7 (100) skype/video-conferencing or related mode 2 (29) 5 (71) other: cohort/group 1 (14) 6 (86) use of a supervision contract 5 (71) 2 (29) use of models of supervision 1 (14) 6 (86) research 218 november 2015, vol. 7, no. 2 ajhpe ‘it is frustrating, research supervision takes most of my time … and i also teach clinical modules so need to do clinical rounds with the students as well … .’ ‘ … it becomes frustrating to manage all the roles and task of an academic … research supervision takes most of my time, especially if you are doing it for the first time … and at the same time we are expected to do research publications for ourselves … .’ contributing to the feelings of being overwhelmed and frustrated, there were no guidelines or models of research supervision that they could use to assist them. therefore, participants relied on their previous experience of being supervised in their own studies to guide them in research supervision. furthermore, their own experiences left them feeling doubtful and frustrated with the supervision: ‘ … there are no information or courses i attended … i have mainly focused on how i was supervised when i was a student … .’ ‘i supervise based on how i was supervised during my studies … you learn at the same pace as the student you are supervising, i feel uncertain if i’m doing the right thing … .’ ‘i am always feeling unsure if i am doing the right thing … there is nothing to guide us. you become frustrated not knowing the right way to do things.’ pressure to perform participants felt that they experienced pressure to perform with the research students allocated to them. there was awareness of an expectation from the institution to accelerate postgraduate graduation rates. furthermore, the participants who were new to research supervision noted the pressure they experienced with having to be skilled and providing quality supervision: ‘ … you always have a long list of postgrad students that need supervision … you have to finish them at a fast pace because next year your load just gets more … .’ ‘we are told they [students] need to be completed in the minimum time … our performance as an academic is based on how many students you can graduate.’ ‘some of us have just completed our own qualifications and we are expected to supervise … it puts a lot of pressure because students are expecting quality supervision … .’ some participants noted that the overwhelming pace of being expected to provide research supervision did not facilitate a learning pace where they could find their own niche area in the department of nursing and style of research supervision: ‘i try to read as much as i can on the student’s topic … but because i have so many students to supervise … it is difficult to get your own style to supervise.’ ‘there are many students … they all come to see you at the same time … one cannot think about what is my way of supervising … or to even think about what area is my area of research.’ getting the balance right participants had many mechanisms of coping with supervision, despite the absence of a formal postgraduate research supervision programme to support the academics. participants described strategies such as group or cohort supervision and using opportunities such as coffee mornings with postgraduate students to foster an equal relationship between student and supervisor. the participants felt that these efforts contributed towards a positive research supervision experience: ‘i find it easier to work on the same aspect with all my students … i get them all together and go over the theory of it … then we go back to individual contact supervision … it avoids repeating the same aspects to all the students … .’ ‘i make it very social for the first meeting, i try to break the barriers as much as possible … it helps students … gives them a space where they can feel free … to talk about their fears of research.’ participants also noted that postgraduate students’ expectations of what they wanted from their supervision experience added to the stress of supervising. a lack of clear role definition and task allocation of a supervisor has sometimes resulted in hostility and conflict with students, who expected more from the supervision relationship: ‘it is frustrating when students expect you to do things like editing and formatting the document … some even expect you to help with literature reviewing … they don’t want to learn these skills on their own.’ ‘i end up even doing grammar and editing and re-writing paragraphs … so i’m not sure if doing so much as part of supervision is also contributing to me feeling fatigued all the time with supervision … .’ participants thought that creating peer support learning among the students helped supervisors achieve a balance. they felt that this helps in alleviating the unexpected expectations that students tend to have in terms of their own self-directed learning and independence: ‘i like to have at least one session each semester where i get all my students together just for a update … this helps students to stay on track because they see where their colleagues are so they don’t want to fall behind … .’ ‘i encourage students to learn from one another … it becomes easier for them to network among each other … it helps me as well, because i’m not burdened with teaching each one the same thing.’ self-reflection and experiential learning facilitated postgraduate research supervision. participants used their own experience as a means of trying to improve their role as supervisor: ‘i try to improve how i supervise … i use previous supervision experiences with my current students … i try to do things differently to avoid the same mistakes … .’ discussion modes of supervision this study showed that a face-to-face supervision style was the predominant practice used. the literature supports this finding, arguing that more inexperienced academics use such traditional methods of supervision.[7] overwhelmed and frustrated inaccessibility of core information with regard to supervision models, styles and norms in effective supervision practices has been documented to contribute towards dissatisfaction among academics.[8,10] moreover, ineffective supervision and poor graduation rates were predominately reported in environments with few supervision support documents or little training.[1,2,5] this study confirmed the importance of these documented research supervision support factors, as feelings of being overwhelmed research november 2015, vol. 7, no. 2 ajhpe 219 and frustrated were expressed in the context of not having supervision support. we also found that in the absence of supervision guidelines or models participants relied on their own experience to supervise, which often left participants feeling doubtful and frustrated. the literature reports that poor guidelines and support structures for academics, especially novice supervisors, contribute towards negative experiences with regard to the student supervisor relationship, especially as supervisors experience difficulty in balancing the time constraints of other academic roles with the demands of producing graduates at an accelerated rate and at the same time ensuring quality research graduates.[2,4,11] pressure to perform the institutional expectation of accelerating postgraduate degree completion in the minimum time was a source of pressure for the supervision participants. many authors have noted that higher education institutions are accelerating postgraduate research as a response to the global trend of research productivity being regarded as a commodity in the knowledge production economy.[2,4,10] authors have supported our experiences that the drive for completion of postgraduate research supervision may contribute to frustration among academics, especially in terms of honing their own supervisory style.[2] moreover, the literature indicates that while university systems have changed in terms of the political and economic environment and the research funding contestability, academics have not been supported to cope within this changing context.[1,2,4] getting the balance right establishing an interactive supervisory style allows supervisors to cope with the changing context and multifaced roles of being a clinician, academic, research mentor and supervisor.[1,10,11] the use of peer mentoring and cohort supervision, such as that expressed in this study as coping strategies towards research supervision, has been documented as having many beneficial effects.[12] the findings indicated that academics try to cope with and adjust to the demanding context of providing postgraduate research supervision coupled with other academic roles. the study also showed the use of peer learning and cohort supervision as methods that participants used to try to establish a balance between their academic roles and research supervision. using forum sessions, cohort supervision and making the supervision interaction a social event is a method of allowing norms and expectations to be communicated early in the supervision relationship to avoid possible conflict and disharmony between student and supervisor.[10,11] it is also supported in the literature as a coping technique to assist supervisors in dealing with large supervision loads.[12] conclusion this study explored the current burden of supervision experienced by nurse academics. experiences of frustration, loss of control and difficulty in managing the multifaceted role of being an academic with a high number of postgraduate research students requiring supervision were expressed by the participants. furthermore, the study reported on the coping strategies such as peer-supported learning sessions, cohort supervision and making supervision a social interaction between student and supervisor. we highlighted the importance of standardised training sessions and guidelines to support novice academics in supervision. references 1. bruce c, stoodley i. experiencing higher degree supervision as teaching. stud high educ 2013;38(2):226-241. [http://dx.doi.org/10.1080/03075079.2011.576338] 2. mccallin a, nayar s. postgraduate research supervision: a critical review of current practice. teach high educ 2012;17(1):63-74. [http://dx.doi.org/10.1080/13562517.2011.590979] 3. council on higher education. postgraduate studies in south africa: a statistical profile. a report commissioned by the council on higher education. pretoria: council on higher education, 2009. 4. chireshe r. research supervision: postgraduate students’ experiences in south africa. j soc sci 2012;31(2):229234. 5. kishun r. the internationalization of higher education in south africa: progress and challenges. j stud int educ 2007;11(3):455. 6. rowley j. is higher education ready for knowledge management? int j educ dev 2000;14(70):325-333. 7. severinsson e. research supervision: supervisory style, research-related tasks, importance and quality – part 1. j nurs manage 2012;20:215-223. 8. halse c, malfroy j. retheorizing doctoral supervision as professional work. stud high educ 2010;35(1):9-92. [http://dx.doi.org/10.1080/03075070902906798] 9. manathunga c. the development of research supervision: ‘turning the light on a private space’. int j acad dev 2005;10(1):17-30. [http://dx.doi.org/10.1080/13601440500099977] 10. abiddon nz, ismail a, ismail a. effective supervisory approach in enhancing postgraduate research studies. int j human soc sci 2011;1(2):206-217. 11. halse c. ‘becoming a supervisor’: the impact of doctoral supervision on supervisors’ learning. stud high educ 2011;36(5):557-570. [http://dx.doi.org/10.1080/03075079.2011.594593] 12. wisker g, robinson g, shacham m. postgraduate research success: communities of practice involving cohorts, guardian supervisors and online communities. innov educ teach int 2007;44(3):301-320. [http://dx.doi.org/ 1080/14703290701486720] ajhpe 419 abstracts.indd may 2014, vol. 6, no. 1 ajhpe 69 abstracts rural electives: providing transformative learning opportunities and influencing choice of career: the stellenbosch university experience b willems* *bartwillemsza@gmail.com background. rural background and longitudinal rural clerkships for medical students including training at rural medical schools are established predictors for rural practice. considering that less than a third of all south african medical students originate from rural areas and are educated at urban universities, additional strategies are necessary to encourage rural career choices. objective. this study explores the benefits of a 1-month rural elective in influencing further rural practice and is funded by the stellenbosch university rural medical education partnership initiative. method. this qualitative study evaluated rural elective students’ learning experiences and possible influences on future career choice. online anonymised surveys and feedback from focus group discussions were analysed to identify recurring themes. results. students described the rural elective as an enriching experience and a positive opportunity facilitating exposure to the context in which they will ultimately work. adapting to environments with limited resources and populations with varying cultural backgrounds were embraced and valued by students. in addition, learning opportunities for community engagement and patient-centred care were seen to inspire students to return to rural areas. conclusion. rural electives provide transformative learning experiences that could influence urban-educated medical students’ choice of working in rural areas. further investigation of this model is recommended. innovative medical education models offering shorter periods of rural exposure may serve to enhance rural recruitment in south africa. a qualitative exploratory study: using medical students’ experiences to review the role of a rural clinical attachment in kwazulu-natal l campbell* *laura@hss.co.za background. there are challenges when considering that the main role of a rural clinical attachment for medical students is to encourage students to return after graduation to practise in rural areas; such a view may lead to relative neglect of other potential valuable roles of rural exposure. objective. this paper draws on the ‘force field model of teacher identity’ to describe medical students` experiences, illustrate the complexity of factors interacting during rural exposure, caution that experiences cannot be predicted and highlight the positive role of a rural clinical attachment. method. the study setting was a district hospital in rural kwazulu-natal and participants were four final-year medical students who had completed a compulsory attachment during their family medicine rotation. data were collected using photo-elicitation and analysed using the force field model. results. participants felt that, overall, it was a positive the experience. the effect of biography and contextual forces were not as strong as could be expected. institutional forces were important and programmatic forces tended to have a negative effect on experiences. participants particularly enjoyed being acknowledged and gained empathy around the difficult tasks of doctors. conclusion. the potential positive role of a clinical attachment may go beyond attracting students to practise in rural areas. experiences could be beneficial, irrespective of where the students select for future practice. there is a need for review of rural attachment curriculum and pedagogy. caution should be used when screening medical students for suitability to work in rural areas prior to rural exposure. experiential learning outside the comfort zone: taking medical students to downtown durban n prose,* p n diab, m matthews *diabp@ukzn.ac.za background. the ability to communicate across cultures requires a combination of knowledge, skills, and attitude. our current medical school curriculum includes innovative methods of teaching communicative knowledge and skills. the challenge is how to teach students how to interact with empathy in the multicultural society that awaits them. objective. various methods of teaching empathy have been utilised worldwide but this particular presentation reflects on an experiential learning activity that yielded positive results. method. a diverse group of pre-clinical students volunteered to take part in an experiential learning outing in the warwick triangle area of durban. a tour operator specialising in cross-cultural tours for business groups offered to facilitate the experience free of charge. students consented to the tour and permission was granted from the medical school dean for the opportunity. at the muthi market, students were divided into smaller groups and each group was asked to obtain a specific herbal medication and learn of its uses. the students also participated in a tour of the juma masjid mosque. several days later, the students met together again to debrief the experience. results. upon reflecting, students revealed that they were able to appreciate and gain a wealth of cultural knowledge and that they had begun to develop an attitude of curiosity about cultures other than their own. they were also able to learn from challenges that were encountered within a safe environment. the overall impact on the students appeared to be very powerful. a number of students expressed appreciation at being in a sixth national conference of the south african association of health educationalists (saahe): ‘information to transformation’, umhlanga, 27 29 june 2013 ajhpe 2014;6(1):69-113. doi:10.7196/ajhpe.419 oral and poster presentations 70 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts multicultural group, having a shared experience, and engaging in an open and respectful discussion about similarities and differences. conclusion. we believe that our students need to be involved in experiential learning that encourages them to examine their attitudes, and to develop curiosity about and respect for patients coming from cultures other than their own. we describe an innovative, experiential approach to learning, and suggest ways in which learning experiences of this type can be integrated into the mb chb programme. person-centred community-based interprofessional care: a strategic opportunity for service-learning to reform health professions education s snyman,* c goliath, h boshoff, n smit, p khati *ssnyman@sun.ac.za background. a lancet commission recently stated that person-centred and community-based care are key in reaching health equity. their recommendations to address health inequity have far-reaching implications for health professions education. it is the position of this paper that most of these recommendations could be addressed by an interprofessional servicelearning approach. objective. the aim of this study was to determine, before and after a interprofessional service-learning experience, how perceptions of students changed regarding (i) the roles of other health professions; and (ii) their approach to patients, clients and the community. method. the research followed a phenomenological school of thought in an interpretative paradigm with a qualitative-inductive approach. in-depth focus group interviews were conducted with 64 students before each rotation, directly afterwards, and a year later. interviews were conducted with 10 clients and six community-based carers before the students became involved and a year later. results. initially students expressed scepticism about teamwork with mostly negative perceptions about other health professions. they primarily practised a biomedical model of care with little understanding of the psycho-socialspiritual factors influencing health. clients and community-based carers felt disempowered, inferior and demotivated. directly after each rotation and a year later, students reported appreciation for the different professions and a positive attitude towards interprofessional bio-psycho-social-spiritual person-centred care. however, students experienced difficulty ensuring continuity of care due to the short duration of rotations. clients and community-based carers felt better equipped to take responsibility in promoting health, self-care and parenting. conclusion. service-learning can play a valuable role in facilitating healthy interprofessional teamwork in person-centred and community-based care. the challenge for the service-learning fraternity is to promote this pedagogy among health professions educationalists as a solution to equip students to contribute towards equity in health in the 21st century. from mixed expectations to change in professional practice: graduate perspectives of a rural clinical school experience s van schalkwyk,* j bezuidenhout, h conradie, n kok, b van heerden, m de villiers *scvs@sun.ac.za background. in 2011, the first cohort of eight medical students spent their entire final year at the ukwanda rural clinical school (rcs). as part of a 5-year, longitudinal evaluative research project to determine the impact of its implementation, a baseline study was conducted during the initial year that highlighted the potential of the rcs intervention to offer transformative learning experiences for the students. objective. the aim in the second year of the study was to track the 2011 cohort into their internship to discern the extent to which their rcs year still influenced their thinking and practice. method. focus group discussions had been held before this group entered the rcs. interviews were then conducted with them during 2011. in 2012, another set of in-depth interviews took place with the eight interns during the latter part of their first year of internship. in addition, a supervising clinician of each intern was interviewed telephonically. the transcripts were subjected to thematic content analysis. drawing on these four data sets, we used kirkpatrick’s model for evaluating educational outcomes to develop a matrix of the participants’ views, highlighting any shifts that occurred over time. results. it was evident from the analysis that the students’ initial uncertainties around the rcs were allayed during the year’s exposure (level 2a) and they felt confident that their clinical skills had grown (level 2b). as interns they described how this confidence manifested in their behaviour (level 3) and their professional practice (level 4a). this was often confirmed by the intern supervisor. conclusion. research claims made regarding the potential of an extended rural clinical experience to effect transformative learning are further confirmed by this study. several questions, however, remain unanswered, including the extent to which patient care (level 4b) is ultimately enhanced – the focus of the next phase of the larger study. establishment of a rural clinical school in kzn: using photovoice to elicit views of rural doctors and students p d mcneill,* p n diab, l campbell *mcneill@ukzn.ac.za background. the development of rural clinical schools is becoming a global and a south african phenomenon. providing a positive experience for staff and students as well as ensuring that the facility still offers a service to the community and fulfils teaching goals are all important concerns. it is hoped that such schools will promote recruitment and retention of rural staff and better sustain rural health services. method. purposive sampling of doctors and students working at a rural district hospital in kzn took place. this hospital has been identified as a potential site for a fully equipped rural clinical school within the foreseeable future. photovoice technique was utilised to elicit views of these participants as to what a rural clinical school would entail with the aim of planning such a school in the future. participants were asked to take photographs of what ‘life in a rural district hospital’ means to them and their interpretation of these photographs was explored in in-depth individual interviews which were audio-recorded and transcribed for analysis. ethical permission for the study was granted by ukzn humanities and social sciences research ethics committee (hss/0076/012). results. various photographs taken by participants will be discussed . these speak to the themes of respect for patients, empathy for rural doctors and an understanding of the community they serve. clinical and logistical challenges of rural hospitals are highlighted as well as the successes possible with restricted resources. may 2014, vol. 6, no. 1 ajhpe 71 abstracts conclusion. this presentation provides valuable insight in a novel manner as to the challenges and successes faced by rural district hospitals. it serves as a vital aid to inform strategic planning for developing a rural clinical school as well as feedback to teaching institutions on curriculum development. paramedic student perceptions, beliefs and attitudes towards work-place learning b de waal* *dewaalb@cput.ac.za background. workplace learning forms an integral part of emergency medical sciences educational programmes. as part of their learning programmes, paramedic students are required to participate in workplace learning, where they interact with patients in a real-world setting. the goal of workplace learning is to integrate theoretical principles into practice and develop intuitive knowledge for practice. however, the impact of these programmes is not well understood or documented; neither are the beliefs, attitudes and perceptions of the students. objective. this study aimed to provide insight into how students view workplace learning, identify possible barriers to learning and questions for future research. method. a cross-sectional descriptive survey was performed, utilising a self-administered questionnaire. a convenience sample of students currently registered at the cape peninsula university of technology for the national diploma in emerency medical care paramedic programme were asked to participate and complete the questionnaire. results. a 36% (54/150) questionnaire return rate was achieved. most participants indicated that they valued workplace learning, and that they enjoyed the experience. in total 98% of participants indicated that they believed experiential learning was directly related to more successful practice, post qualification. when asked about their clinical mentors, most participants indicated that they valued the input of mentors and considered them appropriately equipped to mentor them. despite this, 38% of participants indicated that it was not uncommon for mentors to treat them harshly. these participants were also more likely to express negative attitudes towards the value of experiential learning. conclusion. from the findings of this study it can be concluded that participants tend to view their workplace learning favourably; however, negative mentor-mentee relationships may strain or even affect these views, creating barriers to learning. the central recommendation from this research is, therefore, to evaluate mentoring capacity in the field and provide suitable interventions to improve mentoring systems, communication between mentors and educational institutions, and promote capacity building for mentoring in the workplace learning. clinical associates: the success road of small group discussions f peters* *frank.peters@up.ac.za background. clinical associates (clinas) are trained at three universities in south africa. they graduate with a bachelors degree in clinical medical practice (bcmp). the training of these clinas is based on distance and service delivery training on site in a hospital. after three years they are placed as clinas in a district hospital and always work under the supervision of a registered medical officer. objective. how to develop a clina in the curriculum, assessment and rotations of these clinas working at a clinical learning centre (clc) with distance learning from the middle of the first year until the end of the third year. method. when the clinas started in january 2011, a comprehensive study guide was handed to them at the 2-week contact session with the uiversity. a clc with distance learning and service delivery worked out a programme for small-group discussions and clinical rotations in the wards. these smallgroup discussions are based on problem-based discussions. the curriculum of these clinas was totally covered with twice-weekly small-group discussions results. the curriculum is divided in a 3-year clinical study and covers all the medical systems. assessments are done with observed consultations (mini cex) and patient studies, as an assignment, according their clinical rotations. the clinical rotations entitle that the clinas work certain hours in the hospital where the clc is based. we are currently in our 3rd year with this programme and two groups have graduated, completing the degree. therefore this is a reflective study on what was done in the past years. conclusion. small-group discussions with problem-based distance learning and service delivery can cover the curriculum, assessment and clinical rotations to be a competent clina. basic procedures required of 3rd-year medical students during internal medicine junior rotation at cuhas, tanzania k eveline,* j van wyk *ekonje28@yahoo.com background. tanzania has no standardised exit examination to certify the competency required of students at time of graduation. the lack of official documentation, use of different medical curricula, shortage of discipline experts and insufficient clinical exposures result in significant variation in the competencies of medical students. objective. this study aimed to identify the basic medical procedures that undergraduate medical students should acquire by the end of their junior rotation. it explored the existing level of exposure that students experienced and identified the gap in the 3rd-year curriculum. method. a cross-sectional descriptive study was designed to capture basic procedures using a self-administered structured questionnaire from 21 experts in the department of medicine. document analysis was done to explore on the gap in the curriculum. the logbooks of 75 students who completed junior rotation in december 2012 were used to determine the level of exposure to the procedures. results. the response rate was 71%. participants identified basic procedures that students should perform independently and under supervision. independent competence was needed for foley catheter insertion, venipuncture and iv drip insertion, and lumbar puncture while performing thoracentesis and paracentesis, and inserting a nasogastric tube should be done under supervision. the logbooks revealed that the majority of the students assisted with lumbar punctures (54.67%) and performed venipuncture (61.33%). of concern, a significant number of students (24%) did not practise or perform any procedure. the existing 3rd-year curriculum does not specify clearly the basic procedures that students have to be competent in. failure to perform basic skills in the junior and senior rotations leads to lack of competence at the end of training. conclusion. the logbook as an assessment tool is questionable in the absence of a quality assurance mechanism. there is a need for reviewing the curriculum. 72 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts comparing academic performance: rural versus ‘traditional’ medical training n kok,* j bezuidenhout, h conradie, m de villiers, t fish, b van heerden, s van schalkwyk *nkok@sun.ac.za background. as the number of health sciences students participating in prolonged rural-based training programmes increases, the key concerns for these students and faculty are the maintenance of academic standards and whether such training might negatively influence their academic results. at stellenbosch university’s ukwanda rural clinical school (rcs) medical students spend their final year being trained in either a regional or district hospital. they participate in the same final summative assessment as their peers at the academic training hospital although each of the end-of-rotation assessments includes patient portfolio presentations that are not part of the assessment at the academic training hospital. objective. the aim of this research was to compare the academic results of two successive cohorts of students trained at the rcs with those trained at the academic hospital. method. the six-year mb chb programme covers three phases, including a pre-clinical phase. results from the middle phase (final mark) and the late phase (end of rotation marks and exam results) were obtained from programme academic files, anonymised and analysed using statistica. anova and variance estimation tests were performed to explore and compare the results. results. although the 2012 cohort entered the rcs with higher average marks than the tygerberg students for most of the disciplines, their academic performance on the rural platform generally showed an increase relative to the tygerberg students. specifically, iobstetrics and gynaecology marks were significantly higher than those of the tygerberg students (70% v. 65%, p=0.002). there are possibly a number of reasons for this increase in academic performance, which includes the portfolio assessment. conclusion. based on the data from the two cohorts it would appear that completing the final year at the rcs did not affect the students` results negatively, but rather suggests that the rural training might have benefited performance in some disciplines. intervention to facilitate integration of traditional health practices in south african primary healthcare: a 3-year comparative preand posttest study m mammen* *mammen2010@gmail.com background. it is common knowledge that most africans grow up with treatments with traditional medicine (tm) and experiences of interactions with traditional healers (th). consequently, tm and th are part of the african culture. objective. the purpose of the study was to gauge the effect of interventions in order to increase medical students’ awareness, knowledge and attitudes towards practices in tm. method. this was a longitudinal study conducted at walter sisulu university among first-year medical students. pre-tests were administered in february in 2010, 2011 and 2012. these were followed up with post-tests in june in the respective years after exposure to four interventions: (i) gathering information from their family on medicinal plants that are used to treat different illnesses; (ii) collecting one medicinal plant and information about its use from their locality; (iii) presentations and discussions with th about the role of traditional healthcare in the community; and (iv) visiting a th’s practice. data were gathered through structured and standardised questionnaires in order to obtain sociodemographic factors, beliefs and attitudes. a paired chi-squared test was used to measure changes in beliefs, attitudes and practices of students pre-test and post-test. results. in 2010, of 98 students surveyed, 39%, 59% and 82% were males, females and blacks, respectively; in 2011, of 108 students surveyed, 49%, 51% and 88% were males, females and blacks, respectively; and in 2012, of the 118 students surveyed 42%, 58% and 89% were males, females and blacks, respectively. in 2010, only 45% had beliefs in tm, in 2011 and 2012, 57% had beliefs in tm. however, in 2010 and 2012, 51% and 53% had positive attitudes towards tm, respectively. in 2011, only 42% had a positive attitude. conclusion. after interventions, and despite the lack of change in belief in tm, there was a significant increase in positive attitude in 2010, 2011 and 2012, i.e. +78% change, p<0.0001; +108% change, p<0.0001; +50% change, p<0.001, respectively. short educational interventions can positively influence students’ attitude and practices towards tm. perceptions of graduate-entry medical programme (gemp) students of assessment in the gemp i and ii curriculum p mc inerney, d manning, p keene, a magida* *ayanda.magida@wits.ac.za background. in 2003 the faculty of health sciences at the university of the witwatersrand introduced a new medical programme for years iii vi of the mb bch degree programme, the graduate entry medical programme (gemp). gemp was designed as an integrated, problem-based programme with subject matter arranged in a series of 11 largely organ-system blocks. objective. the purpose of the study was to evaluate the views of gemp students on the assessment methods used in the gemp i and ii curriculum. method. an exploratory descriptive study was conducted among gemp iii students. a self-completion questionnaire was administered to the students. descriptive statistics were used to analyse the quantitative responses, and content analysis was used to analyse the open-ended responses. results. a total of n=136 students completed the questionnaires, 67% (n=91) were mb bch i and ii, 26% (n=35) were graduate entrants who entered the gemp i programme in 2011, and 6 % (n=8) were unknown. students’ responses showed that they perceived the methods of assessment used in gemp i and ii as valuable and content centred. they have also articulated that the practical component of gemp i and ii provided them with a solid foundation in clinical skills. they have articulated that practical skills are fairly executed and evaluated the established purposes of the various blocks. the students’ opinions concerning the methods of assessment are presented in four themes that emerged from the content analysis. these were: ‘examiner subjectivity’, ‘value of hospital visit days’, ‘standardised methods of assessment’ and ‘topics assessed’. one of the main concerns highlighted by the students is the lack of constructive feedback from lecturers. conclusion. gemp iii students have generally articulated a combination of positive and negative perceptions about the methods of assessment used in the gemp i and ii curriculum. gemp iii students favour practical forms of assessment more than the assessment of theoretical knowledge. may 2014, vol. 6, no. 1 ajhpe 73 abstracts innovatively adapting a programme to answer the challenges posed by the government and your own institution j j van rooyen, a reinbrech-schütte,* j hugo *angelika.schutte@up.ac.za background. in 2011, the minister of health promulgated the re-engineering of primary health care (phc). this innovation involves moving the focus of intervention from institutions (clinics and hospitals) to the community. university of pretoria (up) health sciences, with collaborators, is setting up health posts in a model. nine such sites are being established. l-cas is a medical-education-through-experiential-service-learning initiative that was implemented in the up school of medicine. the programme faces logistical challenges, such as limited space and resources at the clinics, that are threatening to impact negatively on it. objective. the adaptation of l-cas by supporting the development of learning sites at the copc health posts in answer to the posed challenge by the minister, and other logistical difficulties such as limited funding and resources. method. a participatory action research project was initiated to evaluate, review and adopt the l-cas programme. this project includes questionnaires, focus groups and a workshop. results. after the initial round of evaluations, a number of proposed changes were identified. these include the development of inter-professional learning, creating a more diverse learning platform, exploring partnerships with students from other faculties working in the same communities, and continuing the research. some of the main challenges faced are limited funding and resources, as well as negative attitudes of key role players. none of the mentors could be re-employed. innovative adaptations and restructuring of the department of family medicine were done to address these challenges. conclusion. constant re-evaluation and adaptation of a programme are necessary. this could be a very positive experience, provided that change management strategies are in place with the necessary support from key role players. facilitating work-integrated learning using the case method j du plessis* *duplesj@cut.ac.za background. in 2007, a new higher education qualifications framework was promulgated by the department of education in south africa. emphasis was for the first time placed on the required work-integrated learning component in the curriculum of envisaged new qualifications by the governing body. in the current wake of re-curriculation of the radiography profession from a national diploma to a professional bachelor degree with the promulgated inclusion of work-integrated learning, it became essential to investigate the facilitation of work-integrated learning through different teaching tools. objective. to investigate third-year radiography students’ conceptualisation and analysis of the content of case studies to facilitate the integration of knowledge as part of work-integrated learning. method. the 2012 and 2013 third-year radiography students were presented with case studies with different complexity levels and an accompanying set of questions. quantitative data were accumulated by marking the answers to the questions and categorising the answers broadly into four groups: (i) only limited information was used to formulate the answers; (ii) only some information was used to formulate the answers; (iii) most of the information was used to formulate the answers; and (iv) all the information was used to formulate the answers. results. the results indicate that most participants have a limited ability to engage with and critically analyse the content of the case studies. it furthermore indicates a lack of ability in most participants to integrate knowledge from all the different modules/subjects which they were assumed to have accumulated in their first and second year. conclusion. facilitators should acknowledge the use of case studies to teach the senior students in the work-integrated learning component of their course to stimulate the ability of critical thinking and problem solving by integrating all acquired knowledge and skills. interprofessional education in the faculty of health sciences, university of kwazulu-natal p flack* *flackp@ukzn.ac.za background. this paper describes a model of inter-professional education (ipe) used in the school of health sciences at the university of kwazulunatal. in this model ipe begins with a foundation module in the 1st year and is then picked up in an academic service learning or clinical module in the 4th year (final year). a theory module, placed early in the curriculum for health science students, was developed from a recognition of the necessity to educate health science students about the link between health, community and poverty, especially in developing countries. secondly, it was developed from a recognition of the need for dialogue between professionals or multiprofessional interaction. students complete this 13-week, 72-lecture module by presenting a health promotion workshop to secondary school learners, with the aim of increasing awareness about relevant health issues as well as exposing learners to various health professions as options for tertiary study or career choice. currently there is little further ipe until the 4th (final) year of study. at this point academic staff and students from three disciplines once again come together in a clinical or service-learning module. the aims of this module include the following: to develop skills for the facilitation of sustainable services in a community context, emphasising training of caregivers, community health workers and other significant individuals; to develop skills for working within a transdisciplinary model of service delivery. method. this paper presents an analysis of student texts, including reports, journals and exam responses to reveal what they learn from these modules. the focus is on what students learn from each other: about the other professionals, about service delivery, and about the reality and challenge of meeting the patients’ primary needs in a context of poverty. this paper is a reflection on the curriculum content, the pedagogy and the outcomes. results. a number of interesting themes emerge,in four key areas: changing attitudes to other professions; enhancing collaborative behaviour; change in attitude, knowledge and skills; gains in delivery of patient care. conclusion. it is imperative that in training health professionals for the south african context, there is a process of learning from and about each other, i.e. a shift towards ipe. 74 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts promoting interdisciplinary learning in a multidisciplinary faculty p a mc inerney* l p green-thompson, s moch, j d fadahun o s p goven *patricia.mcinerney@wits.ac.za background. the university of the witwatersrand offers undergraduate degrees in six health science professions. teaching and learning are usually discipline based with each discipline planning and implementing the curriculum individually. teachers may teach in other disciplines, but students generally do not learn together. method. the medical students begin clinical practica in their third year of study. at the beginning of the third year, students are allocated to wards to work with nurses. during this placement, students are required to participate in all the nursing activities, such as bathing and feeding of patients, bed making, and administration of medications. the value of this experience has been documented in students’ portfolios of learning. the second interdisciplinary experience that the medical students have been exposed to is having pharmacy students accompany them in the wards during their practica. there are usually 3 4 medical students and 1 2 pharmacy students who, as a group, are allocated to a particular ward. they are required to take patient histories and examine patients. results. students have described the value of both types of learning experiences, in particular noting the value of learning about the roles of other disciplines, the development of respect for what the other does, and the value for the patient when there is interdisciplinary care. the value of both these learning opportunities can be aligned with kolb’s experiential learning cycle. conclusion. interdisciplinary learning opportunities are valuable for both the student and the teacher as relations between the disciplines are fostered. interdisciplinary learning opportunities need to be identified and encouraged to promote multidisciplinary care. introducing sexual and gender minorities teaching v mitchell,*a kent, a muller, c gordon *nicamitch@mweb.co.za background. a curriculum mapping exercise at the university of cape town (uct) in 2012 revealed limited tuition in the field of lesbian, gay, bisexual and transgender (lgbt) persons’ health needs. following discussion by the faculty mb chb education committee, the department of obstetrics and gynaecology indicated a special interest to include the teaching of gender and sexual orientation issues in its curriculum. objective. to introduce sexual and gender minorities (sgm) teaching into the medical undergraduate clinical curriculum in a scholarly manner. method. the department of obstetrics and gynaecology made space available in the year 5 clinical timetable for student-led workshops. the workshop design is presented to students at their introductory gynaecology session. small groups of approximately 10 students select topics from a range of lgbt issues. they prepare and present to the larger group 6 weeks later. dialogue is facilitated by departmental educators and an expert in lgbt health. surveys conducted at the start of the group sessions are followed by interactive participatory presentations, which include videos of interviews, video-clips, powerpoint presentations, debates and personal insights. workshop evaluations provide student feedback. students also submit reflective commentaries at the end of the block as a compulsory task, with anonymity assured. qualitative analysis of the surveys and workshop evaluation responses will be presented. results. the classroom survey and students’ comments have reinforced widespread concern that this important aspect of patient care has previously been missing from undergraduate curricula. the workshops were enthusiastically prepared for and presented, with encouraging evaluation comments received. conclusion. healthcare for sexual and gender minorities is a neglected aspect of instruction in the mb chb clinical curriculum and its successful introduction at uct has been well received. all health science faculties should consider teaching curricular content specific to the needs of sexual and gender minorities. introduction of a personal and professional development module in the undergraduate medical curriculum b s subramaniam, s hande,* k ramnarayan *hande2010@gmail.com background. the mbbs curriculum of the melaka manipal medical college (mmmc) is a five-year academic programme with the first two and half years in india and the next part of the programme in malaysia. mmmc has adopted a six-strand curriculum introduced in september 2006. the personal and professional development (ppd) module runs vertically throughout the first part of the programme. objective. to introduce and sustain a ppd module in the undergraduate medical curriculum method. firstly, one hour per week of ppd was incorporated in the timetable for the first-year mbbs students. students were introduced to topics such as medical humanities, leadership skills, communication skills, ethics, professional behaviour and patient narratives. in the second year, students are required to pursue a group project of their choice, under a faculty mentor. a faculty co-ordinator was selected to identify and deliver relevant topics. all faculty were requested to select topics of their choice which they could conduct in an engaging manner. an assessment was made by two batches of students. results. the majority (80%) of students agreed that the module was well prepared. students assessed the modules as useful because they saw improvement in their affective skills. they rated the topics as ‘highly relevant’ to the medical course. faculty found the topics new and interdisciplinary. the handling such topics, and creating interest and engaging the students were a challenge. there was however a sense of sharing responsibility and workload by the faculty. conclusion. the positive response of the students towards the ppd module was encouraging. however, in order to sustain the module it needs to be reviewed and renewed frequently. social accountability: hearing community voices l green-thompson* *lionel.green-thompson@wits.ac.za background. social accountability of educational institutions has been defined as responding to defined communities’ needs in the area of research, service and education. the lancet commission has recommended the may 2014, vol. 6, no. 1 ajhpe 75 abstracts transformation of educational programmes in the health professions to produce graduates who are change agents responsive and accountable to the communities that educate them and in which they are called to serve. there is little information from rural communities in south africa about their expectations of medical practitioners. medical students at wits university have contact with rural communities in three provinces. method. focus groups were held in several communities in which wits medical students have clinical clerkships. these groups were selected together with the co-ordinators of the community sites, and included young people, traditional healers and older members of the community. the numbers in each group varied from 6 to 12 participants. participants were not in need of medical attention at the time of the interviews. some of the focus group discussions were conducted in the vernacular of that region with the aid of an interpreter. results. members of communities responded positively to the invitation to participate in the focus groups. three main themes have emerged from the focus group discussions: • doctor-patient relationships. participants generally reported negative experiences of their encounters with doctors in the public sector, with many perceiving the treatment received from the same doctor to be better in private practice. • respect and love. for many participants, social accountability of doctors is the expectation that doctors treat them with ‘respect and love’. • identification of health priorities. participants describe both social determinants and medical conditions as being a part of their communities’ health priorities. conclusion. while communities may not be familiar with the phrase social accountability, they are able to define their health priorities. in the context of these priorities there is an expectation that doctors’ behaviour is governed by their respect for patients. there is a need for increasing the active involvement of communities in developing the definitions of social accountability. communities may offer unique insights to how we develop social accountability thinking. peer review for social accountability of health sciences education: a model from south africa d michaels,* s reid, c naidu *des.michaels@uct.ac.za background. the collaboration for health equity in education and research (cheer) is unique in the composition of its members who represent all the faculties of health sciences in south africa. over the past 10 years cheer has conducted 18 peer reviews involving all the institutions. in august 2012 cheer embarked on its pilot peer review on social accountability in health sciences in south africa. objective. this paper shares lessons and insights from the pilot process. method. a descriptive study design, using qualitative methods which focused primarily on semi-structured interviews and focus group discussions, supplemented with supporting documentation, was employed. results. several key components of the review process that should be noted for future reviews on scial accountability were identified, i.e. (i) the composition of the review team; (ii) the review process; (iii) data collection and analysis; and (iv) the reporting process. peer review is a useful way of building consensus and a common set of values that become more explicit through the process. we found that six criteria, namely, values, reference population, partnerships, student profile, graduate outcomes and impact, provide the basis for establishing standards for reflecting social accountability in health sciences faculties. peer review is a process of institutional self-review supported by ‘a panel of critical friends’ and is useful when considered as part of the process of preparation for the formal accreditation review at health sciences educational institutions. conclusion. the cheer collaboration has entrenched the culture of peer review among all the faculties of health sciences in the country and thus laid the foundation for designing standards to reflect social accountability specific to south africa. however, it is universally applicable due to the diverse nature of the context of the various faculties of health sciences in south africa. the process followed and experience gained in south africa may therefore be useful in other countries. successful interventions to improve human resources for health: the stellenbosch university rural medical education partnership initiative m de villiers,* j nachega, k moodley, l dudley, s van schalkwyk *mads@sun.ac.za background. stellenbosch university was among 13 african universities awarded the medical education partnership initiative grant aimed at improving human resources for health in africa. surmepi specifically aims to improve the quality and quantity of healthcare workers, retention in areas of need, and regionally relevant research. method. the project focuses on the development and evaluation of innovative medical education models that aim to support rural and underserved communities. the project uses two foci, i.e. medical curriculum renewal and health systems strengthening and development, to render the delivery of transformative systems-based education. results. year three of the grant has shown significant outputs in training approximately 550 healthcare workers and faculty in public health, palsa plus, evidence based healthcare, infection prevention and control, and hiv/tb management. in addition, surmepi has provided 21 undergraduate students with funding for rural electives in the african region. eight phd and 18 masters students conducting research in rural areas have also been supported through mentorship and funding. a wide variety of research capacity building courses has been offered to undergraduate and postgraduate students, including faculty. interdepartmental collaborations have led to a more context-specific, systems-based approach to medical education integrally linked to the graduate attributes of su. electronic learning has been a cross-cutting theme in surmepi, resulting in a shift and recognition of the benefits of elearning for medical students at central and rural sites. surmepi has embarked on several african collaborations to develop family medicine and research capacity building in the region. conclusion. in the short time span of approximately three years, surmepi has achieved significant outputs that will ultimately contribute to the goal of transforming medical education and improving human resources for health in rural africa. 76 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts the relationship of health science faculties to their health service partners: implications for clinical teaching in south africa s reid,* d michaels, c naidu *cha.johnston@uct.c.za background. health science faculties in south africa largely rely on public health services for student access to patients for clinical learning in hospitals, clinics and other facilities on the service platform. the relationship between faculties and their respective provincial health service partners has been a source of concern, but has not been studied in south africa. objective. to describe the relationship between health science faculties in south africa and their respective service partners with respect to clinical teaching. method. a series of peer reviews following a standard protocol were carried out at nine health science faculties in south africa, including eight schools of medicine, from october 2009 to february 2013. review teams of four spent 3 days at each faculty interviewing university staff, health service staff, and students, and examining relevant documents. a comprehensive report on each review was produced and presented to the faculty concerned. an overview of the peer reviews is presented here. results. the nature of the relationships varied widely, ranging from transactional arrangements based on formal legal agreements at institutional level to informal arrangements at local level. generally relationships were found to be positive and mutually beneficial at local facilities, where students are well integrated into the delivery of services. sources of tension include too many students in facilities, lack of resources for clinical learning, and inadequate supervision. the variety of relationships are described and classified. conclusion. effective clinical teaching is highly dependent on a stable and conducive environment for access to patients by students and staff. this needs to be supported by institutional relationships that understand the challenges faced by each partner, as well as adequate resources for clinical learning. cross-cultural medical education: using narratives to reflect on experience p n diab, t naidu,* b gaede, n prose *naidut10@ukzn.ac.za background. educating students within a multicultural society has become a challenge as teachers, students and the community they serve all tend to represent various social groups. skills alone are not adequate for competency in understanding cross-cultural consultations. a combination of knowledge, skills and attitude is the most widely accepted current approach to teaching culturally competent communication to medical students. the utilisation of collaborative reflection is a useful tool in developing these attributes. method. an interest group of medical teachers met to address the specific needs of teaching a relevant cross-cultural curriculum. participants in the group offered narratives from their professional life and collaboratively reflected on these encounters in order to understand how to improve the current curriculum to better address the needs of the students and patients they serve. results. through narratives, participants were able to reflect on how their experience had allowed them to develop cultural awareness. all stories represented how attitudes of respect, curiosity and unconditional positive regard were held above all else. it was through collaborative reflection with peers that these stories were further enhanced and different learning opportunities discovered. these real stories with real patients also were able to personalise the learning opportunity for the listener. conclusion. the use of collaborative reflection on the narratives of clinical encounters could facilitate insights about cultural aspects of medical practice. elements such as curiosity, respect and unconditional positive regard are illustrated in a unique way that allows students to appreciate the real-life aspects of cross-cultural clinical encounters. social accountability: using a first-year project to advance the mission of a medical school j van wyk,* s knight *vanwykj2@ukzn.ac.za background. medical students generally struggle to understand the public health perspective of their studies in clinical medicine and can become disillusioned, disengaged and disappointed in their undergraduate public health curriculum if the relevance of the discipline does not become clear to them. a novel community service activity was introduced for firstyear medical students from the university of kwazulu-natal in 2012, which expects them to work in self-selected groups of 3 4 students in disadvantaged communities of their choice. they are required to spend at least 16 hours engaged in a community service in the community that are in close proximity to their term-time residence. in an effort to evaluate the first-year curriculum’s responsiveness to community needs, we draw on an amended framework by woollard and boelen (2012) to discuss the success and challenges of the making a difference project. method. data for this observational descriptive sectional study was collected in 2012 from the first-year student groups. we report on students’ reasons for having selected a specific community, their aspirations on how they had hoped to make a difference in the community, and how they learnt became transformed due to their engagement on the project. results. preliminary findings suggest that the project allowed students, who tend to alienate themselves when entering tertiary education, to engage with disadvantaged communities near their term-time residence in durban. they contextualised the theoretical knowledge learned on health systems in their module. students became aware and applied ethical principles in their interactions with diverse and vulnerable groups. some reported that it was a ‘humbling and a huge learning experience’ and finding ‘happiness in life’s simplest gifts such as friendship and acts of kindness’. conclusion. it is possible to devise a curricular intervention that develops generic attributes and research skills in students, assists them to understand the relevance of public health, and embraces principles of social accountability. community engagement on ward-based outreach teams: new context, new learning j hugo,* t marcus *jannie.hugo@up.ac.za background. the longitudinal community attachment for students (l-cas) at the university of pretoria for medical students has been running may 2014, vol. 6, no. 1 ajhpe 77 abstracts since 2008. since 2010 the department of family medicine, in collaboration with the tshwane district, developed ward-based outreach teams as part of the minister of health’s re-engineering of the primary healthcare initiative and part of the nhi pilot project in tshwane district. the initial successful ward-based outreach teams created a new context for community engagement. objective. to shift the engagement of students from a facility-based engagement to familyand home-based engagement within a communityoriented primary care (copc) framework in communities method. since 2012 students were allocated to clusters, each linked to a ward-based outreach team. the fourth-year medical students did most of their 16 days l-cas rotation at these sites, accompanying community health workers to homes, assisting with patient assessment and sharing knowledge with community health workers. in 2013 mmed registrars in family medicine were allocated to each of the ward-based outreach teams as part of family medicine postgraduate training. their role is to support and develop the ward-based outreach teams, do research and mentor medical students. results and conclusion. students’ experience is significantly different in the ward-based outreach teams compared with district clinics. the extent of poverty, the prevalence of epidemic conditions and social conditions, e.g. drug dependence, is much clearer in the communities. the structure and functioning of the ward-based outreach teams provide a structure for intervention and hope for successful intervention. early experiences of postgraduate and undergraduate students will be presented. ward-based outreach teams and re-engineering of primary health care provide a crucial context for community engagement and are excellent for learning while student engagement enhances their functioning. towards the development of a definition of service learning: converging conflicting mind maps h julie* *hjulie@uwc.ac.za background. research on the conceptualisation of community engagement and service learning indicates that concepts such as service learning, community engagement, community service and scholarship of engagement are used interchangeably. academics at the research institution were experiencing difficulties in implementing service learning because of their diverse and conflicting conceptualisations of it. objective. to develop a relevant construct of service learning for the school of nursing. method. this study used the nominal group technique as a means of gaining consensus from a diverse group of academic staff about the main concepts that should be included in the definition of service learning for a school of nursing. the following steps were used: 1. individual generation of ideas 2. recording of all participants’ ideas (in a round-robin format) 3. group discussion of all generated ideas (to organise the list and remove duplications) 4. preliminary vote to select the most important ideas 5. group discussion of the vote outcomes (including additions and further merging of overlaps) 6. final voting on the priority of items. results. the following concepts were ranked as the six most important by 13 key informants: equal tri-partnership; reflective practitioners, teaching and learning; community needs; community development; shared values and community engagement. conclusion. the strong consultation and democratic methods used within the nominal group process allowed the academics to take ownership of the development of a definition of service learning for the school. better consultation skills through quality improvement j hugo,* p kenny *jannie.hugo@up.ac.za background. block 16: health and health care. this is a 4 week rotation with 11 days in clinics. students do a quality improvement project as part of service learning, and patient care in district clinics. one of the key purposes of the block is to do patient-centred consultations. objective. to learn about quality improvement and peer review through improving their own consultation skills. method. students work in groups, which form the qi team with patients. they use a consultation peer assessment tool developed by the department, based on the leicester assessment package adapted to fit in the juggling model of consultation. this tool consists of a detailed checklist of main areas of facilitation, problem solving and collaboration and 3 open-ended questions: ‘what went especially well?’; what does he/she still need to improve on?’; and ‘how can i help him/her to achieve these improvements? they also get feedback from patients through the patient enablement instrument. within the qi cycle, students use the tool as standard to assess present practice through observed consultations. then they reflect on the current practice, make plans and change practice. in the last week they re-assess the consultations and then write a qi report. results. students report on significant improvement in consultation skills with specific reference to important elements of a patient-centred consultation, e.g. use of silence, hand washing, 3-stage assessment and plan, and collaboration with patients. patient feedback varied but had significant impact where it was specific. results of a qualitative assessment of qi reports will be presented. conclusion. qi of own consultations using a structured, detailed tool and involving peers and patients helps students to receive constructive feedback and improve their consultation skills. self-perceived confidence levels of community health workers to carry out their roles within the primary healthcare outreach teams a dreyer,* j frantz, i couper *abigail.dreyer@wits.ac.za background. community health workers (chws) will be employed by government and will be part of the ward-based primary healthcare outreach team. their role is seen in strengthening health promotion and prevention. the training of chws to fulfil their roles has been tasked to non-governmental organisations. the curricula contain the theoretical base but the practical application of the skills/abilities needed to fulfil their roles has not been included. objective. this study investigated the confidence levels of chws related to their roles and responsibilities within the ward-based outreach teams in a sub-district in the north west province. 78 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts method. levels of confidence were measured by means of a likert scale, which was distributed by means of an online survey. this was used to identify the areas for capacity building needed and to develop the training intervention. after completion of training the same survey was completed again and pre-/postcomparisons were made. data were captured using survey monkey, with analysis of frequencies and cross-tabulations on quantitative variables. results. the gender of participants was 98% female. participants had been working in their communities, doing home-based care, for more than two years prior to them being recruited for the outreach teams. there was a significant increase in the confidence levels regarding skills and ability post intervention. sixty-eight per cent of participants’ confidence levels in terms of working in ward-based teams increased post intervention. the participants not feeling confident to collect information shifted from 88% to 12% post intervention. conclusion. the mastery of skills needed to fulfil the tasks has a direct impact on the confidence of chws. their input in identifying the skills gap added to the value placed on the training. the impact of a service learning module on junior health sciences students a de villiers,* a j n louw, m h p van heusden *adeledev@sun.ac.za background. in the past, first-year medical and physiotherapy students participating in the extended degree programme (edp) spent eight weeks shadowing interns in a tertiary hospital during a clinical module. in 2011 student numbers had doubled from the previous year, making it impossible to accommodate the entire group in the clinical setting. consequently, the group was divided in two, allowing the one group to participate in a servicelearning project while the other spent four weeks in the clinical setting as before. the two groups switched after four weeks. method. a qualitative approach was used to determine students’ perceptions of the service-learning project. data were obtained from structured reflective reports about student experiences of the one-week period during which they taught first aid to high-school learners. open-ended, writtenresponse questionnaires were completed by students. at the end of the four weeks the project generated further useful data regarding the logistics and administration of the project as a whole. results. similar to findings reported in international studies, analysis of qualitative data indicated an increase in student motivation in terms of their studies and vocation; an enhanced sense of civic responsibility and social justice; improved group interaction and personal communicational skills; as well as an increase in compassion and a decrease in racism. conclusion. besides gaining first aid knowledge and skills, students spent time with a community they might not necessarily have encountered under normal circumstances. they became increasingly aware of the population they would be serving once they graduated as well as their role as professionals within this community. a service-learning teaching strategy may contribute in producing service-driven and culturally competent physicians as well as those who will serve as community leaders, for reasons such as the following: ‘... there are lessons one needs to experience rather than to be taught’. [edp i student]. rethinking the wheel: a clinical presentation-oriented internal medicine curriculum for south africa j a coetser* *coetserja@ufs.ac.za background. an increased emphasis on primary healthcare in south africa, a political mandate to align medical education with socio-epidemiological need, and the introduction of community-based education (cbe) at the university of the free state (ufs) havenecessitated review of the undergraduate curriculum in internal medicine. a clinical presentationoriented model is being developed. objective. to compile a consensus list of common clinical presentations and their respective differential diagnoses for medical patients in south africa. method. from march 2012 to january 2013, 11 expert work groups, each consisting of at least the unit head and one consultant of the ufs department of internal medicine subspecialties, were asked to compile a consensus list of the most common primary clinical presentations for patients presenting to their subspecialty, as well as the most common and important differential diagnoses for these presentations. the general medicine work group reviewed these lists for completeness and applicability to the south african primary healthcare setting. results. a total of 111 common clinical presentations were identified. the most frequently listed were tiredness/fatigue (50%), shortness of breath (50%), fever (50%), weight loss (50%) and chest pain (40%). for all presentations a total of 670 differential diagnoses were generated (clinical presentations/differential diagnoses): cardiology (10/48), endocrinology (28/137), gastroenterology (14/78), geriatrics (8/30), haematology (14/38), infectious diseases (19/109), nephrology (11/34), neurology (13/63), pulmonology (16/71) and rheumatology (12/62). conclusion. this study represents the first step towards developing an undergraduate clinical presentation-oriented curriculum that is tailor-made for south africa’s health milieu. does the bpharm curriculum of tut/ul (medunsa campus) prepare graduates to be competent community pharmacists? g m enslin,* j snyman, e m reeber, a a abisola, s i mahlangu, m c masingi, n f mogane, s b sombili *enslingm@tut.ac.za background. the joint tut/ul (medunsa) bpharm programme has been offered since 1999, using problem-based teaching and learning methodology with the aim of producing graduates with the required skills, knowledge and attitudes to serve the pharmaceutical care needs of the south african society. the contribution of the learning programme to the achievement of the required competency outcomes related to community pharmacy practice was investigated in this survey. objective. to identify the role of the bpharm learning programme in ensuring competency of pharmacists and interns in the community pharmacy sector. a survey was conducted to identify gaps in the curriculum and/or learning programme. possible measures to address these gaps are suggested. method. the curriculum and learning programme of the tut/ul (medunsa) programme were assessed against the 2004 competence standards of the south african pharmacy council. may 2014, vol. 6, no. 1 ajhpe 79 abstracts a cross-sectional survey of tut/ul (medunsa) bpharm graduates was conducted. a convenience sample of 19 pharmacists or interns working in the pretoria area were interviewed using a semi-structured questionnaire. ethical approval for the study was obtained from tut. results. the bpharm modules curriculum was found to address the requirements for competence in the community pharmacy sector. in the section of the questionnaire dealing with knowledge skills and attitudes, most participants identified the community pharmacy module as the module that prepared them best for community pharmacy practice. ten other modules were identified as helpful. as community pharmacy is one of four sectors for which students are prepared, this result was expected. interestingly, only five participants identified the work-integrated learning module in community pharmacy as helpful. the most important skills acquired at university, according to participants, were communication (74%), management skills (32%) and interpersonal skills (26%). of the competency standards selected as most relevant to community pharmacy, monitoring drug therapy and implementing a pharmaceutical care plan were reported as being moderately difficult or difficult to practise. conclusion.the study found that the curriculum adequately addressed all areas of knowledge, skills and attitudes to allow graduates, in their opinion, to practise competently as community pharmacists as specified in the competence standards of the south african pharmacy council. some recommendations were made with respect to preparing graduates to be mentors and to introduce mechanisms to focus on how to keep up to date with new laws and regulations, pharmacy management skills, pharmacovigilance and new drugs. oral hygiene lecturers’ perceptions of knowledge and curriculum issues at three training institutions in south africa g vergotine,* y shalem *glynnis.vergotine@wits.ac.za background. there has been growing discussion in the oral hygiene literature regarding knowledge and professionalisation that influences the field of practice. examining lecturers’ perceptions of knowledge, curriculum issues and ways of socialising students into the field will be help to investigate this. the results provided here are from a project in progress. objective. to examine south african oral hygiene lecturers’ perceptions of knowledge and their curricula. the purpose was to collate demographic information of the lecturers and to gain information on their perceptions of their curricula. method. fourteen questionnaires were delivered to full-time lecturers in oral hygiene (degree course). ethical approval was granted by the wits education ethics committee. results. seventy-one per cent (n=10) lecturers responded and demographics showed the following: 70% were ≥45year; 50% completed an educational qualification; 4 completed a masters degree and one a phd degree; and 90% had >14 years of teaching experience. with regard to what prepared them best for teaching oral hygiene students, 50% indicated that they drew from their qualification in oral hygiene, other degrees and education courses, while two indicated that they used their practice experience. all teach clinical subjects, with three teaching specialised areas. research activities varied according to qualifications and areas of interest. main resources selected for informing their teaching was textbooks and journals, while the internet and seminars were less frequently used. seventy per cent felt that oral hygiene specialises in prevention and health promotion. they indicated that oral hygiene knowledge is drawn from mostly dentistry, and less from anatomy, pathology and microbiology. disciplines such as psychology, sociology, education and nursing were not seen as contributing much to the knowledge base. all respondents were involved with curriculum development, planning and implementation. conclusion. the results showed that oral hygiene lecturers had the capabilities to be reflective about the knowledge needed for their curricula. a needs assessment of medical student education in the department of paediatrics and child health at the uzchs: towards a new curriculum h a mujuru,* j frantz *hmujuru@mweb.co.za background. the existing medical education curriculum in the university of zimbabwe college of health sciences (uzchs) was developed in 1985, reviewed and updated in 1992, and revised in 2006 to include hiv/aids. the degree to which this revised curriculum is being implemented and its adequacy in addressing current health problems is unclear. objective. to explore faculty perceptions of gaps in the paediatric aspect of the current medical curriculum. method. a qualitative study was conducted using an intervieweradministered questionnaire. all responses were recorded and transcribed manually. three independent assessors conducted the thematic analysis. results. of the 14 faculty, 10 (71%) were interviewed. there was an average of six years experience (2 34) and two lecturers (20%) had ever accessed the uzchs curriculum. themes that emerged included lack of alignment between content and student assessment to curriculum purpose, barriers to effective teaching, poorly structured clinical teaching, lack of understanding of different clinical teaching methods and inadequate time for year 5 students. there was consensus on appropriate assessment methods for both the written and clinical examinations but with no system of ensuring that the assessment was based on taught content. most faculty are junior and inexperienced and would benefit from guidance from an updated curriculum. though students have a logbook, most faculty teach on whatever cases are in the wards; this needs restructuring. an updated curriculum would guide student assessment in line with content taught. clinical teaching methods should be stated in the curriculum and faculty development workshops conducted to capacitate faculty. osce was the best clinical assessment method, with mcq and essays the best methods to assess students’ knowledge. conclusion. an updated curriculum is fundamental for guiding faculty on teaching and assessment of undergraduate students in paediatrics at uzchs. hivand aids-related essential competencies for nurses in south africa: nurse educators and nurses in clinical practice identification r r m modeste,* o adejumo *rmodeste@uwc.ac.za background. south africa has an enormous task of providing care and management to those who are affected by and infected with hiv. similarly to what is done around the globe, south africa has adopted the global move that when providing health services to patients living with hiv and aids, there should be provision of integrated services addressing various 80 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts patient needs through a continuum of care. as nurses form the bulk of healthcare professionals in south africa, they are primarily responsible for the care and management of patients living with hiv and aids. it has been reported that during pre-service training, nurses in developing countries are not adequately prepared for hiv and aids care and management. this highlights the need to adequately train nurses so that they are able to provide care in line with national priorities and strategies. objective. to identify nurse educators and nurses in clinical practice with regard to essential hiv and aids-related competencies for nursing care and management in south africa. method. the study was conducted as a qualitative approach with an exploratory design. the nominal group technique was used to conduct group discussions with nurse educators (lecturers) in six provinces. in addition, individual interviews were conducted with six nurses in clinical practice. results. from the analysis, 10 competency categories such as counselling, ethics and policies related to hiv and aids have been identified, with specific aspects of knowledge, skills and attitude providing further insight into what is expected for each category. conclusion. the findings of this study allow systematic integration of these competencies into the nursing undergraduate curriculum in south africa so that educators and practitioners are on the same page. engaging students through interactive e-guides and multimedia in a flipped classroom approach c botha,* g reitsma *chrisna.botha@nwu.ac.za background. technology has resulted in changing the classroom as the central point of learning to just one of the interfaces where learning takes place. the use of technology and specifically multimedia has extended the teaching-learning experience to outside the classroom. this motivated the lecturer of a second-year nutrition module to re-think her approach to teaching and learning by moving into a blended learning approach. objective. to report on the experiences of both the students and the lecturer in changing from a mainly traditional face-to-face class to a flipped classroom supported by technology in the form of an electronic interactive study guide. method. a mixed-method approach within an action research paradigm was followed. quantitative methods included a student survey on perceptions and expectation on the use of e-guides at the beginning of the semester, followed by a survey on their experiences at the end of the semester. qualitative methods included lecturer and student reflection as well as focus group discussions with students. results and conclusion. preliminary results indicate that the students were initially skeptical about the use of technology outside the classroom, but once they were used to the e-guide, they engaged more with the course content both inside and ouside of the classroom. problems experienced by the students were mainly of a technical nature. the lecturer indicated that she underestimated the planning, time and effort needed to change a traditional hard-copy study guide into an interactive e-guide. however, it would seem as if the incorporation of technology in a flipped classroom added significant value to the teaching-learning experience. the reasons why students experienced this blended learning environment as positive or negative still need to be investigated through focus group interviews at the end of the semester. ‘you expect me to do what?’ student experiences of strategies for enhancing engagement l keiller,* g inglis-jassiem *lkeiller@sun.ac.za background. the relationship and inter-relationship between the selfdirected learning and group phases of problem-based learning (pbl) are important for learning. third-year physiotherapy students have very little time to process and fully engage with pbl case content in their pbl curriculum at stellenbosch university (su). this could have implications for the way in which students understand and are expected to apply the knowledge in clinical settings. objective. to determine students’ experiences of the use of technology (videos and blogging) to enhance engagement with content in their pbl module. method. a mixed methodological approach was used. participants (n=40) completed a needs analysis survey regarding levels of engagement and pre and post-test self-assessment questionnaires. a video camera was available for recording practical techniques during cases and the blog forum for inter-class discussions. two focus group discussions were conducted and transcribed by independent research assistants. results. focus group discussions highlighted the students’ lack of selfdirected learning tendencies and their dependence on lecturers for enhancing engagement. the themes that emerged from the discussions were lecturer responsibility, student responsibility, engagement, technology issues and time. surveys showed that the students perceived themselves as actively engaged in pbl discussions during cases, but found that there was not enough time given for each case within the module. however, there was minimal use of the technology introduced by this study. conclusion. students recognise the value of videos for clinical practice, but do not want to take the responsibility for initiating this learning opportunity. a recommendation of this study is for a video database of clinical skills to be developed in a partnership between lecturers and students. the perspective of radiography students regarding practical demonstrations recorded on video b van der merwe* *bevdmerwe@cut.ac.za background. radiography students at cut spend up to 40 hours either in the classroom or in the clinical setting. students spend time in the clinical setting with qualified radiographers and radiologists, performing various radiological procedures. it is not possible to demonstrate every procedure individually to each student and some procedures are never observed by students. quality mentoring in the workplace is not guaranteed. large classes, and the unavoidable absence of students or lecturers, added to the challenge of exposing the students to the vast number of procedures covered in the curriculum. video recording of the demonstrations of the different procedures seemed the obvious solution to build a library of demonstrations of basic concepts consistent with those demonstrated in the classroom. objective. to determine if students benefit from video demonstrations and if the classroom demonstration is redundant. may 2014, vol. 6, no. 1 ajhpe 81 abstracts method. lecturers and the audiovisual department recorded video demonstrations of basic routine procedures with standardised patients. questionnaires were distributed to different student year groups after being exposed to the videos and the current demonstrations to determine the perception in terms of usefulness to their learning. results. this presentation comments on the advantages and disadvantages of the live demonstration compared with the video demonstration. videos appeal to different persons as it becomes very difficult for the students to interact with each other. one student summed it up: ‘i think it is beneficial for after class demonstrations as you see clearly in the video it sinks in, it falls into place’. conclusion. video tutorials need to be accompanied by well-defined instructional purposes and outcomes to be a powerful educational tool to engage the student in the learning process. ‘liking’ public health: exploring social media for teaching public health l wolvaardt,* l majake, p du toit *liz.wolvaardt@up.ac.za background. educators in public health report the limited curricular time, disinterest on the behalf of medical students and the scarcity of public health educators as major barriers to the inclusion of public health in the medical curriculum. social media holds the potential to overcome the time restrictions in busy clinical curricula as well as the opportunity to engage outside the lecture halls. such a strategy is, however, dependent on student participation in social media. objective. to determine the use of social media among medical students at the university of pretoria. to explore any associations between medical students’ use of social media and their knowledge of public health. method. a descriptive cross-sectional study. questionnaires with 1 openended question and 45 close-ended questions were distributed by research teams of medical students and academic staff in 2012. students completed the survey on site, as a 10-item test-your-knowledge quiz was included. results. a total of 589 medical students participated; 93% of respondents reported using facebook, with almost half (48.2%) accessing it several times a day. another 31.6% reported daily facebook use. google+ was the second most popular (67.1%) amongst respondents. no association was found between gender and the use of facebook, twitter or linkedin. there was a significant association (p=0.002) between male students and never using google+. students in third year and higher were more likely to use facebook several times a day (pearson χ2=54.29 (p<0.000)). a significant association was found between the public health knowledge score and those using facebook (daily and several times a day) scoring higher in the test (p<0.000). conclusion. social media – facebook in particular – is widely used and is therefore a feasible strategy for public health educators. the higher knowledge scores by regular users also suggest facebook could be a powerful educational strategy. adherence to adult learning principles and professional development among medical school faculty r r abraham,* a m ciraj, v pallath, k ramnarayan, a kamath *reemabraham@gmail.com background. professional development should not only aim by formal and informal means to help medical educators learn new skills, but also focus on developing insights into pedagogy and their own practice. understanding adult learning principles is essential to instil professional development. melaka manipal medical college (mmmc), manipal university, india, offers a five-year bachelor of medicine and bachelor of surgery (mbbs) programme. the faculty at mmmc are involved in teaching medical, dental and allied health science students. objective. to attemp to determine whether faculty members at mmmc perceive adult learning principles as a pathway for professional development. we were also interested to know whether any correlation existed between faculty perceptions of adult learning principles and professional development at three levels, i.e. individual, interpersonal and organisational levels. method. a questionnaire comprising items focusing on five adult learning principles (active participation, relevant learning, safe and non-threatening environment, constructive feedback, previous experiences) was designed. a second questionnaire focusing on professional development at three levels (individual level, interpersonal level, organisational level) was also designed. faculty members (n=42) were asked to reflect on the practices outlined in both these questionnaires on a 5-point scale. results. comparison of mean values of five adult learning principles revealed a high mean value for relevant learning followed by constructive feedback, previous experiences, safe environment and active participation. correlation analysis revealed a strong correlation between active participation and three levels of professional development and also between constructive feedback and three levels of professional development. conclusion. in the present study, overall, a strong correlation was observed between adult learning principles and the three levels of professional development. this study intends to provide a framework for professional development centred on a few practices based on adult learning principles. faculty recruitment and retention in the medical education partnership initiative (mepi) schools e kiguli-malwadde,* f omaswa *kigulimalwadde@gmail.com background. the us government awarded grants to 13 african institutions. the aim is to increase numbers and quality of health care workers, retain them where they are most needed and improve locally relevant research capacity. mullan et al. noted that there is a great shortage of faculty in subsaharan african medical schools. this negatively impacts on the training of health professions in the region. 82 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts objective. to establish the number of faculty at the mepi schools, faculty: student ratios, and what the schools are doing to ensure they retain their faculty. method. yearly surveys were sent out to the schools and data analysed. results. there was an average of 204 full-time medical school faculty among the 13 institutions. these ranged from 35 to 795, with an average of 257. the average ratio of full-time faculty to medical students was 1:5.03 and ranged from 1:1.53 to 1:15.98. these numbers indicate that schools varied greatly in the number of full-time medical school faculty and the student faculty ratio. there were many vacancies at most schools. all 13 schools have a focus on faculty development using different strategies, including short and long courses such as masters and phds, mentoring and faculty exchange, and research and medical education support to provide faculty with development programmes, stimulate medical research and ensure the quality of curricula. the challenges of the schools include shortage of faculty; internal and external brain drain; environmental factors, such as poor facilities; remuneration and incentives; and increase in the number of medical schools. conclusion. many of the mepi schools have faculty shortages but are trying to tackle the problem using different useful strategies. promoting scholarship in safri: does it work? j bezuidenhout,* j frantz, j van wyk, d manning, f cilliers, v burch *jbez@sun.ac.za background. ernest boyer describes four types of scholarship: discovery, application, integration and teaching. scholarship can be defined as ‘advancing or transforming knowledge in a discipline through the application of the scholar’s intellect in an informed, disciplined and creative manner’. it is demonstrated by peer-reviewed, publically disseminated output including publications, syllabi, assessment tools, teaching cases, webbased instructional materials, and curriculum change. the sub-saharan faimer regional institute (safri) programme, established in 2008, accepts applicants from the region and, implementing capacity development principles (leadership, project management, research methodology and educational methods), centred around an education innovation project to assist fellows to achieve at least an entry (minimum scholarly) level output of an abstract and a poster presentation at saahe. objective. to compare the education-related scholarship output of applicants prior to and since entering the fellowship. method. a survey was administered to all safri fellows and faculty for the period 2008 2011 (three intakes), focusing on scholarly outputs in health professions education only. results. preliminary data analysis is presented in the form of a table, as the total for the cohort prior to and since entering the fellowship. conclusion. although a causal relationship between the increases in scholarly output since entering the fellowship will be difficult to prove, it is clear that there has been an increase, not only in the number, but also in the scope of scholarly outputs. pique-ing an interest in curriculum development j blitz,* h conradie, n kok, b b van heerden, s van schalkwyk *juliablitz@sun.ac.za background. most medical schools in south africa have as their overall aim for undergraduate medical education, the preparation of graduates for internship. if we are to reach this aim, one of the ways to evaluate this would be to explore whether our graduates indeed feel able to do the things that we think they should, or could, be doing in their internship. objective. to elicit the opinions of first-year interns who graduated from stellenbosch university on the extent to which they felt that their undergraduate education had prepared them for internship. method. the preparedness for internship questionnaire (pique) was designed based on hill’s preparation for hospital practice questionnaire, with additional questions covering graduate attributes and the profile of the stellenbosch doctor. face validity was confirmed by a panel of faculty experts. the questionnaire asked the participant to respond to a series of statements preceded by ‘my undergraduate medical training prepared me to …’ with ‘fully’, ‘well’, ‘fairly well’, ‘little’ or ‘not at all’ prepared. it ended with open-ended questions, which allowed elaboration on other issues. in july prior since peer-reviewed publications 58 87 conference presentations local 38 29 national 41 52 international 23 47 grants obtained 25 22 workshops presented institutional 23 34 national 6 14 international 0 8 reviewer/editorial boards reviewer: national/regional journals 19 32 reviewer: international journals 14 26 editorial board: national/regional journals 4 3 editorial board: international journals 0 2 education-related responsibilities in your faculty 264 385 awards 9 (2 international) 13 (4 international) may 2014, vol. 6, no. 1 ajhpe 83 abstracts 2012 an invitation to participate in the online survey was sent to all the 2011 stellenbosch mb chb graduates. results. there was a 36% return rate. in general graduates felt that they had been well prepared for most mainstream clinical activities. however, there were also a number of areas in which respondents felt they could have been better prepared – largely in the areas of pharmacology, medico-legal work, minor surgery and the non-clinical tasks which an intern encounters. conclusion. using this questionnaire has highlighted areas needing attention within our curriculum. as many of these appear to be in nonclinical areas, it challenges us to look at how faculty can be developed to address these unmet educational needs of our undergraduate students. ‘a system that is constantly trying to shape you in a different way’: students’ perspectives on being a good doctor c naidu,* s reid, v burch *claudia.naidu@uct.ac.za background. there is an ever-increasing awareness of the need for medical schools to train socially accountable health professionals. however, not much is known about students’ perceptions of what a socially accountable doctor is or does. objective. this pilot study aimed to explore student’s perceptions of what a good doctor is as well as their understanding of a doctor’s accountability to society. method. a purposive sample of medical students was invited to participate in this research via e-mail. those who indicated interest and were available to attend were included in a focus group discussion. this data were supplemented by qualitative comments from a pilot questionnaire administered to all 4th-year medical students. results. ten students participated in focus group discussions and qualitative comments from another 20 students who had completed questionnaires were included in the analysis. most students appreciated the psychosocial, patientcentred focus of medicine, and acknowledged their responsibility in improving access and quality of healthcare, particularly to those in need. however, many believed that engaging in ‘socially accountable’ activities are by choice rather than obligation, and felt that responsibilities needed to be prioritised, shared, and was dependent on the context and medical specialty. a few students were resistant to the idea that the medical profession was anything more than a career and felt that they are being unfairly expected to be self-sacrificing. conclusion. the climate of the educational/training environment in which students learn is an important factor affecting the values and behaviours adopted. while the difficulties in teaching and evaluating social accountability are understood, it is imperative to develop tools and to generate knowledge of how students perceive and understand their roles and responsibilities, assess their behaviour and attitudes, and how this changes through the course of their training and practice. medical students’ attitudes towards patient-centredness e archer,* b b van heerden, j bezuidenhout *elizea@sun.ac.za background. the doctor-patient relationship is fundamental to medical care, and several studies have shown that medical students’ attitudes in terms of this relationship deteriorate during their time in medical school. the patient practitioner orientation scale (ppos), an instrument that measures students’ patient-centred beliefs, was used in this study. objective. to examine changes in the attitudes of medical students regarding patient-centredness as they progress through medical school as well as the validation of the ppos as a measuring tool in our context. method. subsequent to validating the ppos for the south african context in october 2011, medical students from year 1 to year 6 (n=1 127) completed the ppos questionnaire in 2012. this was done as a cross-sectional survey. results. the internal reliability of the questionnaire that seemed to be adequate with the pilot group (cronbach’s alpha of 0.627 for caring and 0.67 for sharing) was very low in the final study (cronbach’s alpha of 0.41 for caring and 0.57 for sharing ); therefore interpretations from the questionnaire should be made with caution. however, the mean score of the ppos was much lower for this cohort of medical students compared with some other studies that were done in the rest of the world. suggestions for such low scores could be that the scale should rather be used in qualified doctors as opposed to medical students. other issues that need to be considered are the diversity of our student population, the definition of patient-centred care in our context as well as the interpretation of the ppos questions. conclusion. even when making use of existing well-published questionnaires, the reliability scores still need to be considered. there seems to be a need for a reliable tool to measure patient-centredness in undergraduate medical students. essential steps in the management of obstetrics emergencies (esmoe) n moran,* j moodley, m khan, n nadesan-reddy, m muzigaba *morann2@ukzn.ac.za background. in south africa the current saving mothers report highlights the contribution of preventable causes to maternal deaths. in an effort to reduce such deaths, the essential steps in the management of obstetric emergencies (esmoe) was developed by a team of specialists. objective. to train all midwives and doctors in all state facilities in kzn in esmoe. method. the programme consists of 12 modules of 90 minutes duration covering a range of topics including obstructed labour and maternal and neonatal resuscitation. the current model is a centrally run workshop over three days. each individual module is facilitated by an expert who oversees small groups of trainees. a short lecture, skills demonstration, video, skills practice on a mannequin and role play (fire drills) all constitute a module. a ‘train the trainer’ approach has been adopted with master trainers then tasked with training others at their healthcare facilities. relevant training material to do this is provided at the workshop. results. eight ‘train the trainer’ workshops have been conducted to date, with 190 doctors and nurses trained. every hospital in kzn, several chc/ mous and every district clinical specialist team (dcst) now has master trainers. fire drills have been commenced by the dcst at local sites but have yet to be evaluated. further evaluation of training by the master trainers at facility level is required. a partnership with the department of health has been forged to facilitate expansion of training. conclusion. the esmoe programme is ultimately aimed at reducing preventable maternal deaths; the impact of the training however is difficult to assess and still requires evaluation. 84 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts the transformation of health professions education in south africa b b van heerden,* v burch , m de villiers, s reid, s van schalkwyk *bbvh@ sun.ac.za background. the global impact of work published by the lancet commission (2010), the royal college of physicians and surgeons of canada (canmeds), boelen and woollard, thenet and others on the future education of health professionals cannot be ignored. in south africa, several organisations have embraced international recommendations and are actively working towards transforming health sciences education and training programmes. objective. to describe some of the current national initiatives aimed at transforming health professions education in south africa with a view to informing further work in this regard. method. in 2011 the undergraduate education and training (uet) sub-committee of the medical and dental professions board (mdb) embarked on a strategic planning process to ensure that global and national recommendations regarding transformative learning, interdependence in education, graduate attributes and social accountability are used to guide the revision of health sciences education and accreditation processes in south africa. to date a number of national workshops, including representatives from higher training institutions and the collaboration for health equity through education and research (cheer), have been held to plan the way forward. other important national transformative initiatives include the medical education partnership initiative (mepi), work done by the academy of science for south africa (assaf ), cheer and others. results. a number of processes are underway and some have produced strategic planning documents, peer review processes, research proposals and projects. institutional conversations are increasingly characterised by a discourse of change. specific desired outcomes are: institutions that are socially accountable; faculty who are role models of responsible practice; students who demonstrate social responsibility; graduates who are appropriately skilled for the south african context; and graduates with attitudes of commitment to service. conclusion. several national initiatives, focused on transforming health professions education in south africa, are in place. careful co-ordination of these processes, as well as government involvement, are prerequisites for success. mentoring as social practice c oltmann* *c.oltmann@ru.ac.za background. mentoring has been defined and described in many ways because there is no ‘one size fits all’ model. every mentoring programme has to be designed to meet the needs of the mentees. mentors and mentees form a relationship and together address the issues that the mentee deems as ‘real’. in the faculty of pharmacy at rhodes university we identified the role of mentoring as a strategy for success. mentees benefited directly from the mentoring process and mentors transformed as they constructed mentoring. objective. to determine how mentors constructed mentoring as social practice. method. in trying to determine how mentors constructed mentoring i had to do more than just describe mentoring because social mechanisms are not readily observable; they require theory and abstraction. i therefore used critical realism as my meta-theory, and discourse analysis as the methodology. i interviewed mentors, and analysed field notes of meetings, mentors’ journals, and evaluation data – using the nvivo® software program. results. this research suggests that mentoring is about understanding, empathising, guiding, helping, and providing a shared space that is safe. discourse analysis suggests that mentors require specific knowledge, that mentoring is about social relations and social identities, and that it is important not to abuse the power relations that are at play. conclusion. the strategies that mentors employed changed as the mentors mentored. mentors help make hidden rules and conventions overt during the mentoring process. the epistemological value of physics in medical rescue education and practice: toward a transformative emergency medical rescue curriculum n naidoo, l christopher, m marais, j bosman* *naidoon@cput.ac.za background. physics is fundamental to most natural sciences. the rationale behind the medical rescue content of the bachelor of emergency medical care qualification is poorly defined. medical rescue education in south africa would benefit from contribution to its horizontal and vertical discourse and inform the academic level description  and nqf alignment. objective. to document the principles of physics implicit in the medical rescue curriculum, its implementation and its practice. conceptual/ theoretical physics is critically appraised for alignment or misalignment in the medical rescue curriculum. finally, recommendations of specific theories/principles of physics that may have implications and applications for medical rescue education and practice will be made. method. multiple qualitative approaches are employed. document analysis is used to appraise linkages between physics and rescue inherent in the curricula. the delphi technique is employed to reach expert consensus on the typology of rescue scenarios. using process tracing, the practical components of medical rescue will be deconstructed for underpinning of physics principles. a criterion-referenced gap analysis will enable understanding of what principles and theories of physics are missing, desirable and fundamental to the goal of medical rescue paedagogy and practice. results. there are no texts on medical rescue that address principles of physics and their application. this study informs evidence-informed rescue training and efficient rescue practice. theories and ‘models of competence’ and ‘acting in context’ have relevance for knowledge integration of conceptual physics and medical rescue. this study problematises current medical rescue curricula, critically analyses the conceptual physics upon which medical rescue practice is predicated and provides a transformative approach to curriculum review. conclusion. critical reflection and inquiry into medical rescue practice is central to its professional growth. impediments to learning include knowledge deficiencies and fragmentation, irreconcilable ontologies and pedagogic malpractice. curricula transformation is preceded and proceeded by interrogating explanatory deficiencies and foundational prerequisite knowledge. may 2014, vol. 6, no. 1 ajhpe 85 abstracts use of isizulu videos as a teaching aid in clinical communication teaching in the college of health sciences p diab, m matthews,* r gokool *matthewsm@ukzn.ac.za background. the use of the calgary-cambridge guide in teaching communication skills to medical students is widely used. it has been debated whether such a guide is relevant and useful in multicultural societies. the university of kwazulu-natal finds itself in such a multicultural society with the challenge of equipping students to communicate with patients from different language and cultural backgrounds. objective. to equip students with good isizulu language and communication skills in order to improve student-patient communication and a patientcentred approach, and ultimately enhance retention of doctors in the public service. method. content topics and scenarios from each theme in the preclinical years were chosen. transcripts were developed incorporating aspects such as language accuracy, clinical excellence and cultural sensitivity. simulated patients trained in communication skills as well as doctors experienced in teaching communication skills and the zulu language and culture acted in the videos. editing and production of the videos were done using windows movie maker. results. the four theme-based videos that were developed provide basic and some extended vocabulary around the scenarios. the biomedical content included supports learning within the themes and highlights culturally sensitive topics. in addition to content, process skills in communication, especially those relevant to second-language zulu speakers, are emphasised. conclusion. the development of such videos is a unique and versatile tool that can be utilised in a variety of ways to achieve many different learning outcomes. the use of the videos fills a gap in communication which is vital to bridge language and cultural divides. the videos can be further developed to include a wider range of topics, with extended vocabulary and content. the potential exists for developing content for specialist disciplines and other health professions. establishing an online short-course in clinical immunology w liebrich,* m esser *liebrich@sun.ac.za background. a one-month practical rotation for pathology registrars in the immunology unit nhls tygerberg (division of medical microbiology) was initiated upon their request. in order to address a perceived knowledge gap in applied immunology as reported by the students, we developed an assisted on-line self-study course. objective. to assess students’ perceptions on the use of the on-line course and design and plan improvements based on student feedback and observations. method. structured interviews were applied by an independent third-party observer before and after completion of the self-study course. student progress was tracked on the learning management system (lms). results. in the pre-interviews the students confirmed the impression of shortcomings of immunology teaching in undergraduate training and indicated willingness for self-directed learning on-line. in the post-interviews it emerged that, although students perceived the course as helpful, they did not indicate that their applied clinical immunology knowledge had improved significantly, with comments on the need for more clinical applicability. it was noticed on tracking that almost half the students did not make use of the course, interpreted as lack of motivation. some students reported difficulty in accessing the lms from within their clinical setting. based on these findings, the course was re-designed. clinical cases and pointers to clinical applications were included. copyrighted content was removed to allow all materials to be freely downloadable and usable off-line as well. the course was also given a more formal standing by converting it into a certified short-course, to provide more incentive to partake and complete. the immunology certificate can in future be included in the clinical portfolio. conclusion. when designing an immunology on-line course, the material content for clinical registrars requires significant clinical applicability for motivation to partake in and finish the course. our new short-course in clinical immunology is aimed to address these for the future. an assessment of university of zimbabwe first-year medical students’ experience with information communication technology (ict) v tagwira,* j frantz *vjtagwira@yahoo.co.uk background. it is universally acknowledged that the education of undergraduate medical students will be enhanced through the use of computer-assisted learning. before designing a programme that serves local students’ requirements best, there is a need to establish their access to and experience with ict. objective. to determine the level of ict experience that first-year university of zimbabwe medical students have, and the ict resources that they currently have access to. it also explored their views on integration of ict into medical education. method. a cross-sectional descriptive study was performed using a selfadministered questionnaire that gathered quantitative and qualitative data. the survey population included all first-year medical students (n=286) two months into their degree programme. results. a total of 120 students completed and submitted the questionnaire (42% response rate). almost 12% (n=14) owned a desktop computer, 91.7% (n=110) owned a laptop, and 77.5% (n=93) owned an internet-enabled cellphone. all students owned at least one of the devices. computer skills and experience with application software and the internet varied from no skills to advanced skills, with at least 54% (n=45) reporting basic skills, 42% (n=35) reporting intermediate skills, and 18% (n=15) reporting advanced skills. generally, students felt that there should be greater incorporation of ict and web-based tasks into their learning. some students wanted to learn more about the internet and indicated that internet and social networking sites could be used to improve their communication with lecturers. conclusion. most of the first-year medical students at the university of zimbabwe have a foundation of ict access and skills on which effective use of information and communication technology in medical education can be constructed. understanding the skills that medical students have regarding ict use can possibly influence how educators incorporate ict into medical education. implementation of a podcasting website for undergraduate students w liebrich,* l khoury, s rajah, d pinetown, s walsh *liebrich@sun.ac.za background. we started podcasting lectures for the mb chb ii course in 2012 (see presentation by steve walsh). this has since been extended to 86 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts all mb chb courses. these podcasts were initially uploaded onto various modules of our learning management system for students to view and download. objective. to allow medical students and staff access to all podcasts of all modules of the mb chb curriculum at all times. to this aim we implemented an access-controlled podcasting website in 2013. method. a podcasting site was developed using the dotnetnuke web content management platform as well as gallery server pro. results. the podcasting site allows staff and students password-controlled access to all undergraduate lectures recorded so far. these include at this stage the lecture blocks circulatory system, clinical pharmacology, digestive system, endocrine system, haematological system, health management, intro to clinical medicine 2, musculoskeletal system, neuroscience, reproductive system, respiratory system, and urogenital system. every podcast page contains a treeview menu, but users can also click on the desired album to see its contents. the entire gallery can be searched for keywords contained in the lecture title. entire lecture blocks or single podcasts can be downloaded. the website also gives background information, instructions, and a contact page with a feedback form. facebook and twitter links are provided. conclusion. the podcasting effort at the faculty of medicine and health sciences at stellenbosch university has so far been perceived by the students as a resounding success. we are eagerly awaiting feedback from users on our new podcasting website. safri and capacity building in health professions education j bezuidenhout,* j frantz, v burch *jbez@sun.ac.za background. capacity building in health professions education has been identified as a need in africa. the sub-saharan faimer regional institute (safri) programme, established in 2008, accepts applicants from subsaharan africa and incorporates all of the capacity development principles. this programme focuses on leadership development, education methods, research methods, and implementing an education innovation project. this allows the fellows to apply what they learn in the context of an innovation project in their home institution. scholarly outputs linked to this project include an abstract, a poster presentation and an paper. objective. to demonstrate the reach and capacity building impact of the programme in africa and the type of education innovation project completed. method. a document analysis for the period 2008 2012 was conducted using the safri poster presentation abstract booklet. data were analysed by two reviewers and reported descriptively. results. the safri programme has reached 13 countries in africa with a total of 75 participants. participants were from a range of disciplines, including medicine (40), nursing (11), physiotherapy (7) and dentistry (4). the project emphasis was primarily on undergraduate programmes, with the study population usually undergraduate students (25 projects) and/or faculty (26 projects). forty-two projects included a situational analysis or needs assessment, 21 focused on programme impact and evaluation, and 9 on curriculum development. seventeen of the 75 projects concentrated on capacity building needs or interventions and faculty evaluation. a third of the projects had a community-based focus. conclusion. in only 4 years, safri capacity development initiative in africa has already established a broad geographical footprint with multiprofessional representation and a range of education projects. an evaluation of students’ perceptions of learning in clinical learning centres based at district hospitals s memon, j m louw, m bac, j f m hugo, w n rauf* *nisa.rauf@up.ac.za background. the department of family medicine of the university of pretoria started a new 3-year course for mid-level medical healthcare workers in 2009. most of their training takes place at 17 mostly rural district hospitals in the mpumalanga and gauteng provinces. objective. to measure bcmp ii and iii students’ satisfaction with learning opportunities and their involvement in learning and to assess the functionality of rural clinical learning centres in district hospitals. method. in 2010 and 2011 a survey was done using the med-ed iq questionnaire. results. most students were satisfied with the learning environment and their preceptors as well as learning opportunities in all clinical learning centres. however, final-year students (group 2) were least satisfied with their involvement and they seem to be keen to assume greater responsibility in the care of patients’ with psychosocial and complicated problems. conclusion. on the basis of this feedback from the students, important information was obtained and specific interventions were done which improved the learning environment of the clinical learning centres. the students desired more learner involvement and participation in patient care, with a shared responsibility. student feedback is very important to assess functionality of teaching platform and improve the learning environment. students should be maximally involved in learning and patient care. mapping transformation indicators in allied health sciences education at the university of cape town, south africa – 10 years later (2001 2011) s l amosun,* n hartman *seyi.amosun@uct.ac.za background. a five-year (2002 2006) operational plan was developed for the transformation of allied health sciences education in the department of health and rehabilitation sciences as part of the transformation process in the faculty of health sciences, university of cape town. objective. to carry out a preliminary review of the change processes that have taken place in education, research, and capacity development after the implementation of the operational plan. method. two documents – the annual faculty of health sciences handbook and the research reports – from 2002 to 2010, were perused, and the contents analysed descriptively. results. within the first four years after the implementation of the operational plan, the preliminary outcomes in undergraduate education revealed a widening of access to students, the modularisation of curricula, support for academically under-prepared students, expansion of the teaching platforms in service learning, and development of new multidisciplinary modules. new postgraduate programmes were also developed. the output in postgraduate education and research publication was low, but the proportion of academic staff with doctoral qualifications increased from 16.7% in 2002 to 46.6% in 2010. may 2014, vol. 6, no. 1 ajhpe 87 abstracts conclusion. since all the key purposes of the operation plan are yet to be achieved, the evaluation of the outcomes of the transformation process in the department should be on-going. current challenges in clinical teaching: a situational analysis for evidence-based change z gebremichael,* r weiss *zerihunet@yahoo.com background. in the past few years the medical student intake at hawassa university has quadrupled, while human and material resources have not increased proportionately. a newly established health professions education unit (hpeu) has been tasked with addressing the educational challenges this situation creates. objective. to identify gaps and challenges that the new hpeu must address to improve the quality of medical education. method. a survey using a five-point likert scale (1 being lowest rating and 5 highest) collected students’ opinions about current clinical teaching, learning and assessment practices. four focus group discussions also gave instructors in each department opportunities to provide qualitative feedback on the same issues. results. a total of 137 questionnaires were returned; 34 surgery, 32 internal medicine, 37 paediatrics and 34 gynaecology. the mean values for the summated scales are <3 for almost all thematic areas. the lowest means for all four departments surveyed were for co-ordination between departments and assessment methods. students’ ratings were also unsatisfactory for instructional skills, course relevance and organisation, specific instructional situations, hospital teaching activities and professional ethics and attitudes. the major findings from faculty focus group discussions in four departments are: • training needs at subspecialty level and medical education for staff • inadequate practical exposure for students • lack of innovative and purpose assessment methods • inadequate infrastructure to handle large numbers of students • problems linked to student interest, attendance and discipline • loose interdepartmental co-ordination • lack of appropriate orientation and advice for students • need for curriculum revision. conclusion. the participatory, dual approach of this study enabled both students and faculty to provide valuable inputs that will inform and guide the future work of hpeu in addressing the identified issues, and set the stage for implementing collaborative solutions. technology as a tool to develop a community health model e meyer,* s stolz, j van den heever *ellenoremeyer@hotmail.com background. the presentation describes a case study of a community health model that was developed and piloted at an academic service learning clinic in partnership with the south african department of health. within the health context of developing countries there is a need for an e-health model that is contextually appropriate and supportive of national and international health information management. objective. to strategise, innovate and implement a collaborative care model strengthened by available technological resources that would improve the health and social status of a struggling community. to develop a collaborative care model by using technology as a tool that could practically demonstrate the multidisciplinary team’s participation in service learning. this framework would inform sharing of patient health and social information, synergising of resources and future community development plans. method. the question posed was explored by means of a multidisciplinary literature review and a restricted narrative enquiry of the experiences of the healthcare team. the 5 cs e-health framework for developing countries was applied together with the human resources for health 2030 strategy. results. the world health organization identified five key elements of effective primary health care. in practice this implies reducing social disparities and services orientated around people’s needs, including the integration of health into all sectors and the pursuit of collaborative care with increased stakeholder participation. the daspoort case study indicates that an e-health framework could develop and strengthen a collaborative team approach to integrate healthcare among community role players and increase community involvement to improve the health of society. conclusion. technology as a tool could unlock community development by strengthening collaboration via the delivery of information to enable better individual, stakeholder and community decision-making in health and social issues. getting answers that you can trust – issues in questionnaire design w mcmillan* *wmcmillan@uwc.ac.za background. surveys are commonly used in higher education to gather facts, opinions and attitudes. while survey research has a long history, literature suggests that survey methods are not always well understood or properly executed – especially in educational research. errors in study design, sampling techniques, and instrument design can undermine confidence in the survey results. this poster offers theoretical insights into valid and reliable survey research in health sciences education. objective. to introduce the basic elements of survey research relevant to education and identify common problems in survey research. a study of senior students’ experiences of alienation and engagement in a faculty of dentistry in south africa is used to contextualise the insights. method. the literature was reviewed for texts related to survey research methods. particular attention was paid to accessing relevant literature from health sciences education. results. the literature highlights the importance of: clearly defining the research problem/question, the purpose of the study and the associated research questions prior to questionnaire design • clearly identifying the aspects to be surveyed, and identifying the associated variables • compiling relevant questions associated with the variables • writing ‘good’ questions that are clear and specific • auditing the survey for completeness related to the information desired • selecting scales appropriate to the type of question posed • appropriate and defensible sample selection • piloting the questionnaire to pre-test the survey questions. the poster uses the alienation and engagement student survey to illustrate these key aspects of study design. conclusion. rigour in survey planning, construction and implementation are essential to ensure valid and reliable results. the credibility of educational 88 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts research depends on the alignment of all aspects of the survey. only then can the significance of findings be claimed, and the applicability of findings to classrooms and clinical contexts be justified. a review of university of the witwatersrand medical students’ communitybased health promotion service learning projects in south africa g mothoagae,* j irlam, d prozesky, t hlungwani *gaolatlhe.mothoagae@wits.ac.za background. thirdand fourth-year graduate entry medical programme (gemp) students at the university of the witwatersrand undertake community-based service learning (sl) projects. working with trained facilitators, students are required to identify a priority health problem in the community, and then plan and implement an appropriate project to address the problem. at the end, group presentations are conducted for assessment. objective. to review past sl projects that have been implemented by gemp 1 and 2 students in order to inform the future planning and conduct of the sl programme in the faculty. method. a document review of all available powerpoint presentations for projects implemented from 2006 to 2011 was undertaken, employing content analysis. results. of approximately 286 projects completed, 183 documents were available for review. of the implemented projects, 38.8% were clinic based and 28.4% done in the inner city region of the city of johannesburg municipality. the projects covered a wide range of health issues employing mainly basic health promotion strategies such as health education and distribution of educational posters and pamphlets. four themes on students’ perceptions of the educational worth of the projects were identified: theory comes alive, improved knowledge and understanding of communities and their needs, appreciating the expanded role of a doctor, and personal growth. challenges reported by the students included administrative shortfalls, poor communication and facilitation, lack of students’ participation in project selection and prioritisation as well as limited time allocated to work on the projects. conclusion. these findings indicate that students benefit from participating in the project. however, future planning and co-ordination of these projects need to address the identified loopholes based on students’ concerns. it is recommended that more attention be paid to strengthening the administrative and supervision aspects, making efforts to involve students properly in project selection, improving communication between the university and the community facilitators, and reviewing placement duration. an evaluation of an hiv/aids peer education programme at a higher education institution in the western cape h vember* *vemberh@cput.ac.za background. education seems to be one of the most powerful weapons to fight the hiv/aids pandemic in south africa; hence it is expected of higher education institutions (heis) to respond to this problem in a meaningful manner. higher education hiv and aids programme (heaids) took the initiative to bring all role players in heis together to devise plans to deal with the pandemic. despite the fact that 22 of the 23 heis surveyed by heaids in 2008 were engaged in peer education training programmes, none of them monitored or evaluated these programmes. objective. to evaluate and establish the influence of a peer education programme among students at a selected hei in the western cape. method. an evaluation research design was employed, using a mixed methods approach to collect data. quantitative data were collected by means of a questionaire. qualitative data were collected by means of personal interviews with staff and focus group interviews with student groups. a logic model was developed that assisted with the evaluation design. results. the quantitative data revealed that more work needs to be done with regard to behaviour change among peer educators. it was clear from the data that knowledge does not lead to behaviour change. an example is as follows: despite the fact that students received the same information with regard to safer sex practices, 80% use condoms, but 20% still do not use condoms, and 6% still have multiple partners. however, in this study, the qualitative data showed that peer educators need to develop more skills to empower themselves to facilitate workshops and to enhance their communication skills. a strong emphasis should also be placed on reflection within the programmes. conclusion. if the lifespan of the peer education training programmes on heis is lengthened and more students are engaged in these programmes, it would have the potential to develop staff, students and communities into advocacy-orientated communities that would eventually challenge the hiv/ aids pandemic through united mobilised action. it is important that all peer education training programmes and interventions on all hei campuses become part of a coherent, well-planned and strategic process to include hiv/aids and sti education meaningfully across the curriculum. knowledge of community-oriented primary care among heads of department at makerere university college of health sciences k i besigye,* a barnard *kibesigye@yahoo.co.uk background. in 2003, makerere university college of health sciences (makchs) introduced community-based education to achieve social accountability as one of its core values. a situation analysis of teaching and learning of medicine and nursing students done in 2010 showed that primary care competence was not adequately addressed by the current learning and teaching strategies. community-oriented primary care (copc) training has been documented as a viable educational strategy to improve graduates’ competence in primary care. objective. to establish copc knowledge among heads of department (hods) at makchs and their willingness to train medical students in copc as an additional strategy to community-based education to improve competence in primary care. method. this was an exploratory qualitative study using a purposive sample of 10 hods at makchs. the interviews were transcribed verbatim, transcripts were reviewed and a manual qualitative analysis was performed revealing the emerging themes and sub-themes. data saturation was reached after 10 interviews. results. all hods knew the concepts of copc like students knowing their practice communities and being able to involve communities in their health affairs. all respondents mentioned that community priority health problems should be identified and that students should be able to identify the underserved and disadvantaged populations in communities. all respondents mentioned that students acquire these skills during their community placements. only one respondent had ever heard the term copc, but all were willing to train students in copc. may 2014, vol. 6, no. 1 ajhpe 89 abstracts conclusion. hods at makchs have knowledge of copc and are willing to train students in copc. there is a mismatch between the copc knowledge and understanding of copc training for medical students as there is a belief that placing students in the community is equal to community-oriented medical education. staff need copc training to transform communitybased education at makchs to community-oriented medical education to improve students’ primary care competence. medical students and social accountability c gordon* *chivaugn@gmail.com background. social accountability is a prerequisite for all faculties of health sciences. there is considerable literature acknowledging this and encouraging institutions to increase their practical efforts to implement change that will produce socially responsive graduates. lack of exposure to ‘coal face’ or primary healthcare situations may be restricting students’ growth in developing greater social awareness, and one way to accomplish a change to greater social responsiveness could be through exposure of undergraduates to student-run volunteer clinics. these clinics reflect the shift in students’ training from hospital based to community based as well as epitomising students’ taking responsibility for their own learning. objective. the university of cape town is exploring students’ attitudes to student volunteer-run, after-hours clinics, which take place in underserviced and disadvantaged areas. method. a survey is being undertaken to gauge the motivations of students who volunteer to attend the students health and welfare community organisations (shawco) clinics. these clinics take place in several informal settlements around cape town. focus groups will further explore purposely selected students’ attitudes to this constructivist, and potentially transformative, learning experience. results. the results of the survey of students’ attitudes and perceptions of their personal growth and clinical acumen gained from these clinical experiences will be presented in quantitative and qualitative format. the pilot study indicates a considerable growth in altruistic pride in attendance at the clinics. conclusion. undergraduates who volunteer to serve in clinics set up by their fellow students find the experience formative, and that time spent in this endeavour fulfils a significant role in promoting social accountability in their education. student-run clinics have the potential to promote social accountability in the medical curriculum. a curriculum for the community m s mogodi,* j blitz *mpho910@gmail.com background. when the university of botswana (ub) opened the country’s first school of medicine (som) in 2009, the decision was made that medical students should be introduced to the community from the onset of their medical training. objective. to guide the ub som public health medicine (phm) unit to come up with a curriculum for firstand second-year medical students’ community placement module. method. qualitative research was conducted following ethical clearance. purposively selected key informant interviews were conducted among education experts, health services experts and leaders at the ub’s faculty of health sciences. a semi-structured interview guide was used to elicit the respondents’ understanding and suggestions regarding a rural placement curriculum design. recorded data were transcribed and coded. results. the following themes were identified as required elements of a community placement curriculum: curriculum design that includes spiralling outcomes, clearly aligned outcomes, active learning, integrated multiple forms of assessment, and contextualised learning; course elements that entail community needs assessment, intervention and systems thinking; guiding values that support social accountability, holistic health definition, problem-based learning and systems thinking; logistics to be considered for a rural placement programme including transport, accommodation, nationwide student placement and duration of the placement. in general, there is agreement that the community placement programme should be guided by the philosophy of social accountability. there is continuing support for the ub som medical students to have community placements from the onset of their medical training. conclusion. in order for health professionals to make a difference in their communities they need to work in communities they will serve and find long-lasting solutions to the community’s needs. conducting key informant interviews on the issue of community placement can provide valuable input for the development of a socially accountable community placement curriculum, and provide the groundwork for ensuring co-operation in its implementation. what’s in the knitting? c engelbrecht* *engelbrechtc@ukzn.ac.za background. higher education in the health professions has an important role to play in affecting the community’s health and wellness. education is not merely a tool for personal development and self-actualisation. by participating in community-based education programmes, health educators and their students are providing services to the community that might not have been available owing to lack of resources, assisting a process of transformation in the community towards healing and wellness. kaethe weingarten declared that all of us are subjected to common shock as a result of witnessing violent and violating acts in everyday life. to raise awareness and healing from common shock, weingarten recommended acknowledgement and planned action. she called this compassionate witnessing. objective. a knitting project was used to develop informal social support and compassionate witnessing and the experiences of participating students and community members were explored. method. students in the b. nursing programme at the university of kwazulu-natal were doing mental health promotion in a nearby community known for its violent and criminal acts in the past. a content analysis of two focus groups was done, where the community and student participants were invited to share their experiences and opinions of the project. results. the results were compared with the literature in this field and will be discussed with the audience. by knitting teddy bears in a group, women have the opportunity to stand up against the abuse and violence they are witnessing directly or indirectly. the group provides opportunities for conversations about these acts. as relationships are kindled, an informal compassionate witnessing community is developed. nursing students learn 90 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts how to listen and facilitate this conversation and compassionate witnessing. conclusion. by knitting teddy bears in a trauma care project, community members get an opportunity to ‘do hope’ as a transforming compassionate witnessing act. let us knit! an interprofessional education project – a model for learning in context h talberg,* p gretschel, f walters *heather.talberg@uct.ac.za background. with rehabilitation being seen as an integral component of service delivery plans within the south african healthcare context, promoting the presence and role of rehabilitation professionals in both district and primary healthcare settings has become a necessity. with one of the key mandates of district level service being the of development of a multiprofessional approach to client care, higher education institutions have looked at ways to better prepare their students for this infrastructure. this involves exposing undergraduates to this type of work environment and approach. one such initiative is the inter-professional student learning site at vredenburg in the saldanha bay sub-district of the western cape. here, health and rehabilitation students from the university of cape town’s health sciences faculty, representing the disciplines of audiology, occupational therapy, physiotherapy and speech and language therapy are placed together to engage in practice learning. vredenburg is a semi-rural area in which a shortage of health professionals, limited access to specialist services and a broad client population make it an authentic context in which inter-professional practice can be facilitated. while such practice is strongly encouraged as an effective way in which the complex health needs of individuals and communities can be addressed, the structural and attitudinal barriers to inter-professional practice are well documented. method. this paper describes a pilot course in which inter-professional practice has been extended beyond paper case discussion to practise contexts where students have worked collaboratively with vulnerable children in the context of their home and community. results and conclusion. provisional findings describing the students’ learning about their own and other health professionals’ contributions to care within an interdisciplinary context will be presented, as well as their suggestions of how inter-professional practice can be facilitated in practice learning contexts. views of student nurses regarding implementation of case-based teaching and learning methodology at a higher education institution: a reflection on student perspectives n s linda,* f m daniels, l p fakude, r r modeste *nlinda@uwc.ac.za background. the undergraduate nursing students` enrolments increased from 150 in 2003 to 300 in 2005 in the first year bnurs programme at the university of the western cape (uwc) based on a mandate from the minister of education regarding nursing education in the region. this resulted in three universities collaborating to offer the nursing programme. uwc had to respond to the changes and challenges, among others by reviewing the teaching and learning approaches used at the time, and ensuring more creative approaches that were current and relevant and, in view of large student numbers, would ensure that students’ learning was adequate and high-quality graduates would be produced. casebased education methodology was selected as an overarching innovative teaching and learning approach at the school of nursing at uwc. after more than six years cbe adoption and implementation at son, its inherent value to teaching and learning had not been researched. a need was identified to establish what the experiences of the recipients of cbe are and whether or not it meets the purpose for which it was adopted. objective. to establish what the studens’ experiences are with regard to the use of the cbe methodology for teaching and learning in large student classes. to establish whether or not the cbe method is of benefit to recipients method. a qualitative research approach and case study design were used. inclusion criteria were year 1 and 2 students registered in the bnurs programme at son at uwc. potential participants were purposely selected. the sample consisted of students in year 1 and 2 of the bnurs programme. nursing module evaluations and portfolios were the data collection sources. data were analysed using tesch’s (1992) thematic analysis method. results and conclusion. these indicate that students have mixed experiences about cbe. positive experiences include benefits such as growth in interpersonal skills, problem-solving skills, respect for each other, and teamwork. participants’ negative experiences were challenges with learning process and content, which were overcome over time, and inappropriate distribution of time between theory and practical learning opportunities. evaluation of the palliative training and palliative care provider visits at the university of pretoria a rautenbach,* m van rooyen, e meyer, a reinbrech-schütte *anita.rautenbach@up.ac.za background. in 2011, four palliative training and hospice visits (pthv) were introduced to the fourth-year medical curriculum. the programme was adapted in 2012 to address the challenges identified below: • developing an understanding of hospice in terms of facilities, patients and services. • providing opportunity to experience multidisciplinary, holistic management in various settings. • developing a consultation approach to the patient with a terminal disease. • developing an understanding of pain and symptom management. • developing life skills. • creating awareness of related ethical and professional challenges. objective. • to evaluate the impact of pthv on students in terms of personal, academic and professional growth. • to evaluate the opportunities to experience the holistic, multidisciplinary management of patients and to map the differences in sites. • to evaluate the impact of the changed programme. method. this is a descriptive, qualitative study with a questionnaire to students, hospices and palliative care providers. feedback questionnaires are individually scrutinised for themes by researchers and then compared until consensus is reached. this will continue until saturation is achieved. results. preliminary results show that the new introductory session made a huge difference in terms of the students’ perceptions of their own readiness for the visit. although the programmes and activities at the various sites differ, the potential for learning is universal and transferable. it seems that the challenge that death and dying pose to the students is a good catalysing agent for personal and professional reflection and growth. may 2014, vol. 6, no. 1 ajhpe 91 abstracts conclusion. palliative care exposure is an excellent platform to experience multidisciplinary management of a patient, as well as being exposed to the challenges of dealing with a family. good support and preparation is necessary. this is a learning and growth experience for students. assessing a directed pbl course – pitfalls and solution j wright* *john.wright@mopipi.ub.bw background. the university of botswana school of medicine mb bs course uses a form of directed problem-based learning (pbl) in its two pre-clinical years. some outline lectures, plus practical and workshop classes, support student learning in pbl. a challenge of this system is to ensure that students regard the support class framework as a way of guiding their pbl, and not as the backbone of the course. objective. the concern was that learning around pbl cases and not just learning in formal classes should be assessed in examinations, but standard mcqand emq-type questions can usually be identified as deriving from a particular support class. the aim was to re-focus the exams on pbl cases. method. we have devised a short-answer format in which a clinical scenario derived directly from a pbl case that the students have studied leads to a series of questions. the subject matter of these questions is intentionally diverse and can range from anatomy, through physiology, pathology and pharmacology to clinical skills and public health arising from the same root scenario. examples will be presented. student feedback was collected after every exam and included questions about the way the test balanced pbl and lecture material. results. an analysis will be presented and correlated with the introduction of the case-based questions, which now comprise up to about 50% of the marks of each examination. conclusion. to avoid a directed pbl course being viewed by students as lecture based, it is important that pbl is tested in an obvious way. one way of doing this is to use scenario-based questions that require multi-subjectbased answers. it will further reinforce the importance of pbl if these derive obviously from such cases. developing critical thinking skills through radiography service learning r w botha,* j bezuidenhout, m m nel *rbotha@cut.ac.za background. the literature indicates that service learning assists in the development of critical thinking skills of students engaged in communitybased educational experiences, where critical thinking is defined as a reasoning process that involves reflecting on ideas, actions and decisions. the development of students’ critical thinking skills is the only education that makes good citizens, as individuals educated in it are not easily coerced, but rather seek out and weigh evidence. it is also suggested that service learning helps students to develop as ‘traditional experts’ and as ‘expert learners’. objective. to establish specifically whether service learning cultivates critical thinking in radiography students. method. radiography students were divided into five groups, each with their own identified community. since radiography is a resource-based discipline, learners decided to concentrate on the dissemination of information related to mammography, ultrasound and bone densitometry. each group prepared and executed dramatised presentations. radiography students (n=22) had to complete the watson-glaser critical thinking tool before and after the intervention. the results were averaged and compared to evaluate whether there was development of critical thinking skills or not. results. the watson-glaser critical tool average for the pre-intervention was 75.98% and that of the post-intervention was 80.72%. for the deduction section of the tool it was 68.6% and 72.8%, respectively. for the interpretation section it was 79.46% and 96.6%, respectively. conclusion. overall, the difference in the preliminary results suggests that service learning does promote the development of critical thinking skills. additionally, there is a definitive increase in interpretation and deduction skills among radiography students. clinical training in the discipline of speech language pathology at ukzn: establishing a balance between service and learning p flack* *flackp@ukzn.ac.za background. the discipline of speech language pathology (slp), in line with the ukzn vision, mission and goals, has a strong focus on community engagement that is entrenched in the curriculum. in planning clinical modules, the discipline prioritises service or engagement in under-resourced contexts and/or under-served communities. fourie (2008) suggests that different forms of community engagement activities include volunteerism, internships, experiential education, service learning, community outreach and research. this paper explores what is understood in the discipline of slp as academic service learning (asl), one of the ‘cluster’ of activities of community engagement. objective. asl brings together community service with teaching and learning in official credit-bearing modules. however, it has been recognised that service learning activities may not always result in learning goals being met where service provision becomes the primary goal (furco, 1996). in this paper 10 clinical modules offered in the discipline of slp are interrogated with a view to evaluating whether the focus on service compromises learning and vice versa. method. data are gathered through a modified version of schumer’s assessment of the service learning tool, focus group interviews with staff and students and analysis of curriculum documents such as module guides. results. these suggest that while it is important to establish a balance between service and learning in the professional programmes, the scales may tip in a particular direction as a result of context, of students’ level of competence and independence as well as community needs. conclusion. while it is important to establish a balance between service and learning in the professional programmes, the scales may tip in a particular direction as a result of context, of students’ level of competence and independence as well as community needs. perhaps a balance is not always necessary. the prevalence of burnout among emergency medical care students at the university of johannesburg t sibanda, c stein* *cstein@uj.ac.za background. burnout has been identified as a cause of poor academic performance and an increase in attrition rate in medical students. the 92 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts bachelor’s degree in emergency medical care (emc) is a four-year qualification focusing on pre-hospital emergency care. in addition to academic work, students must complete a significant clinical learning component from year one and are often exposed to very challenging emergency cases during this time. several studies have identified high levels of burnout among qualified paramedics. we thus hypothesised that the combination of a stressful clinical environment and the stresses of academic life may pose a significant risk of burnout to emc students, which may in turn adversely affect their academic performance. objective. to determine the prevalence of burnout, and whether a significant difference existed in burnout scores across the four academic years of study among students at the university of johannesburg’s department of emergency medical care. method. the copenhagen burnout inventory (cbi) was used to assess levels of burnout in the personal, work-related and patient care-related categories. students (n=93) were asked to complete a questionnaire based upon the cbi, but also containing a number of distractor questions. burnout scores were calculated according to the cbi scoring method and these data were analysed descriptively. mean differences in cbi scores over the four academic years of study were assessed using one-way analysis of variance. results. in the first-year group, 35% of students had cbi scores ≥50 (the threshold for falling into the ‘total burnout’ category). between 9% and 19% of students in the remaining academic years were found to fall into the total burnout category, with fourth year containing the greatest proportion and third year containing the smallest proportion. personal burnout was found to be the greatest contributor to the students’ cbi scores in first, second and fourth year, while work-related burnout was the greatest contributor in third year. patient care-related burnout was consistently observed to be the smallest contributor to cbi scores across all academic years. no significant difference was found in cbi scores over the four academic years of study. conclusion. although direct comparison with similar programmes is not possible owing to a lack of published data, the prevalence of total burnout appears to be fairly high, particularly in the first-year group. this result was unexpected, as we hypothesised that the prevalence of burnout would increase with years of academic progression in keeping with the greater academic complexity and responsibility faced by students. results regarding the contribution of different categories of burnout to cbi scores were also contrary to our hypotheses. in particular, burnout arising from patient care (i.e. clinical learning) had the smallest contribution to total burnout, while personal burnout contributed the most. while we did not study the effect of burnout on academic performance, a negative effect is highly likely. a burnout monitoring or surveillance programme should be initiated in order to diagnose this problem early and bring about efficient referral to the appropriate support services. recruiting rural-origin students to health sciences – a 1-year follow-up of top achievers at rural high schools in south africa c pfaff,* l f du toit, i d couper, n o sondzaba *colinpfaff@yahoo.co.uk background. south africa has struggled to attract healthcare professionals to work in rural areas and evidence from many countries suggests that students from rural areas tend to return to rural areas for medical practice. as a result, there has been a call to increase the number of students from rural origin at medical schools. objective. to evaluate the challenges students from rural areas face in accessing tertiary education. method. from march to june 2009, a facilitator from wits conducted a life skills and careers course as part of a project to identify suitable students for the health sciences bursary programme in rural high schools in north west province. a total of 39 schools were invited to send the top grade 12 achievers in maths and science to a 5-day programme. these students were then contacted by telephone after 12 months and a quantitative survey questionnaire was administered. results. of 158 students, 54 could be contacted one year later by telephone; 46 respondents (87%) could not follow through with their original plans for the year following the completion of their grade 12, although 13 (24%) were studying at tertiary institutions with plans other than they had anticipated, mainly at colleges. only 7 (13%) students were able to achieve their original plans of studying at a university. nine (17%) of these top students failed grade 12 and 27 (50%) respondents were at home and not doing anything. reasons for not achieving initial plans were academic (44%), financial (30%) and logistic (26%). thirteen out of 16 students who applied for financial aid received it. information sent by the tertiary institution, career days and friends already at tertiary institution were the most commonly used sources of information to access financial aid. career days, friends already at tertiary level and life orientation classes were the most common sources of help used in choosing which courses to study. conclusion. a minority of top-achieving rural high school students are able to access tertiary institutions in south africa, but many of those who are successful do access financial aid. as open days are an important source of information, universities would be advised to give more resources to these events. an interventional study: assessing knowledge, attitudes and practices regarding mycobacterium tuberculosis infection risk among health science students h van der westhuizen,* k kotze, h narotam, b willems, a dramowski *15635317@sun.ac.za background. south african healthcare workers are at increased risk of contracting tuberculosis (tb), and drug-resistant tb. health science students working in tb-endemic settings require knowledge of tb control measures to reduce their risk of occupationally acquired disease. objective. to determine knowledge, attitudes and practices of health science students regarding mycobacterium tuberculosis and to assess the impact of a structured intervention imparting knowledge and awareness of occupational tb risk and control measures. method. a cross-sectional study of 327 stellenbosch university and health science students using a preand post-intervention questionnaire. the intervention included personal accounts by medical professionals affected by drug-sensitive and -resistant tb and information on how to reduce occupational risk. results. students overestimated their risk of developing tb, but underestimated the mortality associated with the drug-resistant strains. pre-intervention knowledge of using personal protective equipment (ppe) was poor, but was successfully improved by 20% post-intervention (0.575 v. 0.775 out of 1 (p=0.0000)). reported practices at tygerberg hospital (tbh), western cape, showed that 62% (n=182) interacted once a week or more with patients who had defaulted on tb treatment. only 8% reported that may 2014, vol. 6, no. 1 ajhpe 93 abstracts n95 masks were available daily, where needed (n=177). natural ventilation and mechanical ventilation were reportedly not used/functional in clinical areas (60%, n=179 and 55%, n=164, respectively). additional mdr tb control measures, such as airborne precaution signs and a ‘closed door’ policy for tb isolation rooms, were reported to be inadequately utilised. conclusion. health science students lacked knowledge of tb control measures and protective equipment while working in an environment with reportedly poor implementation of infection prevention measures. a structured educational intervention can effectively increase awareness and knowledge pertaining to occupational tb infection risk and control measures. impact of formative assessment on low achievers s r kamath,* s torke, a m ciraj *surekharkamath@yahoo.com background. it is a well-known fact that assessment is an integral part of the curriculum. students seldom have adequate information on the core areas of the curriculum that need detailed study and the nice-to-know areas of the curriculum. so we must ensure that students know the performance expected of them, and the standards against which they will be evaluated. to meet the above-mentioned needs, frequent feedback for enhancing the student learning process should be included among low achievers. objective. to enhance the performance of weaker students in the first year medical students in the subject of physiology. method. based on the performance of the students at the end of first semester weaker students were identified and trained by remedial classes. results. a total of 127 students were in the study group, 28 students were identified as weaker group. of these students 17 (60.7%) were able to pass physiology. in spite of remedial activities the remaining 11 (40%) students were unsuccessful. the incorporation of formative assessment would help the students to reflect on their learning process and help them take adequate remedial measures with the help of faculty. conclusion. by providing a timely feedback on the student learning process and effectively guiding students through the essential elements of learning, performance of students will be enhanced. thus it is important to help low achievers in completing their medical course for serving the community. distraction factors that affect the academic performance of students at the melaka manipal medical college, manipal, india m roche* *mayaroche2011@gmail.com background. academic excellence is what every institution desires from its students. at melaka manipal medical college, manipal india, majority of the mbbs students hail from malaysia with a smattering of students from other countries. in addition to living away from home for the first time, they are exposed to a new culture in india and possibly distracting surroundings. objective. to study the general perception of students regarding the distraction factors that prevail in the student community and what survival strategies they have developed. method. a questionnaire consisting of 9 items pertaining to the factors that distract students from academics was distributed to two batches of students, seniors (n=134) and juniors (n=92) of the mbbs programme. the results were analysed and expressed as a percentage. results. both the batches of students opined that the internet and online games were a major distraction factor (41% to 69%), followed by visual entertainment like movies (18% to 64%). effect of drugs and smoking on academic activities was minimal (2%). however, students minimised the time spent on the distracting activities when their grades suffered. conclusion. the academic programme at mmmc is packed with different activities. avenues for entertainment are limited in the campus. it is but natural that students take refuge in playing online games and watching movies on their computers. it is a relief however, to know that students have stayed away from drugs and smoking. nevertheless, some advice regarding time and resource management through the mentorship programme is in order to further better the academic performance of the students. a progress evaluation of extended degree programme (edp) students at stellenbosch university with the aim to determine the reasons for differences in performance in the years following on the edp programme a j n louw,* a bawoodien, l crous, g young *ajnlouw@sun.ac.za background. students which are selected for the edp programme generally do well during phase 1 of the programme, but the phases following on phase i are experienced as challenging with a number of these students experiencing academic problems. faculty can react to this challenge by determining what could be done in the edp programme to prepare these students adequately for the full academic programme following on phase i. objective. the unsuccessful progress of some edp students in the consecutive years following the edp programme necessitates a systematic investigation to be done to determine the factors contributing to the lack of progress of some of the students, as well as the factors contributing to the successful completion of the programme by their peers. focused and systematic intervention could be launched if such factors could be identified. method. a retrospective quantitative and qualitative study was done. the results and selection data of all edp students since 2007 up to the most recent results (nov. 2012) were analysed. individual in-depth interviews were held with eighteen students – both successful and unsuccessful – in modules of phase ii. interviews were also conducted with relevant advisors of these students. interviews were recorded and transcribed by an independent person. data were thematically analysed. data that were collected from examination results were used to invite students to participate in the interviews. results. five major areas were determined as to be the major problematic areas. the academic and social themes sound self-evident, but the specific factors in these themes provide faculty with food for thought to react upon. other important themes were those of the psyche, residence, and finances. conclusion. scientific research is essential to facilitate the process of determining crucial factors influencing student success in an edp programme. assessment for learning: facing the change, changing the face b subramaniam* *barathi2021@gmail.com background. assessment and learning are intimately intertwined and often indistinguishable from one another. the new reforms introduced by faimer has brought assessment as a lever for educational reforms to the forefront and as an integral part of learning, not as a thing to be done in the last. assessment has to be differentiated and understood in all its intricacy. it is becoming increasingly apparent to redefine assessment and its different approaches. 94 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts objective. the study was done to identify the effect of combining assessment for learning with assessment as learning. method. sixty students of first year mbbs who consented for the study were enrolled. the students were bifurcated into two groups – control and the study group. an environment was created in which students of the study group were exposed to learning purposes, learning outcomes, and were trained in peer assessment and self-assessment using success criteria to reinforce the assessors learning as well as to give constructive criticism, while the control group was not provided any such exposure. in both the groups’ assessment for learning was carried out as per the university guidelines. results. the results show that the performance of study group is better when assessment as learning is combined with assessment for learning. in addition, many nurturing effects of assessment as learning were also observed by the teachers who witnessed the overbrimming joy of the learners’ as they were not the passive receivers but active participants. learners’ motivation and self-esteem apparently sloped high. conclusion. assessment for learning combined with assessment as learning significantly improves the assessment of learning. when adopted for the entire course, this will transform the perspective of formative assessment. the tiny steps travelled together can transform learners and learning. the afem rex: an innovative workplace-based assessment method for emergency care training in africa h geduld,* t reynolds, v burch *heikegeduld@yahoo.com background. the african federation for emergency medicine (afem) is a regional professional and academic organisation representing emergency care providers and trainers from over 20 countries. afem’s scientific agenda includes the development of emergency training programmes for a range of providers and settings. afem has developed a modular emergency care training programme for physicians and non-physicians who provide emergency care. objective. to describe the development and piloting of an innovative workplace-based assessment method for the afem emergency care curriculum. method. we conducted a review of existing workplace-based assessment tools used in the setting of medical training as well as a review of the more specific literature on emergency medicine shift-based feedback. based on our findings, we developed a draft clinical evaluation tool and adapted it to the distinct constraints of the african emergency department work environment via a systematic consensus process. we subsequently conducted a feasibility pilot of the tool in two african emergency departments with post-graduate physician training programmes, and revised the tool to these results. results. we present here the afem rex (rapid evaluation exercise), an assessment method designed to be used in 5 minutes and focus on a single competency domain for each use. we present the results of our initial pilot study and the final version of the tool. conclusion. the afem rex is a useful workplace based evaluation method suited to african emergency care training. what do postgraduate examiners know about, and think of, standard setting in the college of physicians of south africa? s schoeman,* v burch, m m nel *schoemanfhs@ufs.ac.za background. since its inception in 1954, the colleges of medicine of south africa (cmsa) has used a fixed pass mark (cut-score) of 50% for all fellowship examinations in its 29 constituent colleges. from 2011, the college of physicians (cop) introduced standard setting (cohen method) for components of their fellowship examinations. despite an earlier workshop, it seemed that cop examiners had limited knowledge of, and diverse opinions about, standard setting. objective. to conduct a situational analysis of the current cop examiners – to verify knowledge gaps and explore views, attitudes and perceptions towards standard setting. this research would guide the design of a focused workshop for cop examiners about standard setting. method. an anonymous online survey was sent to current (2010 2013) cop examiners (n=51). their knowledge of, and opinions about, standard setting were investigated. results. seventy five per cent of examiners completed the survey. some examiners did not know that standard setting had been introduced; 21% for part i mcq exam and 45% for part ii purpose test. altogether 21% were knowledgeable about, and 55% were familiar with, but not knowledgeable about, standard setting. a number of examiners (29%) had ‘no problem’ with using a fixed 50% pass mark, 32% were concerned about it and 39% rejected the practice. most (63%) endorsed the changes made and 74% supported further implementation of standard setting in other cop examinations. conclusion. although many cop examiners endorsed standard setting, and some rejected the ongoing use of a fixed 50% pass mark, they had very limited knowledge about standard setting. cop examiners, although broadly positive and supportive, need more information about, and a better understanding of, standard setting. assessors in asessment c tan* *tanplchristina@gmail.com background. the assessment of clinical competence is one of the most important tasks facing medical teachers and is usually done at the end of their students’ clinical course to certify a level of achievement. it is also of importance because it is central to public accountability, as medical schools have a responsibility to ensure and demonstrate that a certain level of competency has been achieved in their graduating doctor. much has been described about the tools for assessment, and who requires assessment, but focus should also be applied to the assessors, and how they are trained to assess. observations made during actual purpose structured clinical examinations (osces) in the final-year exit examinations in the faculty of medicine, university of malaya in kuala lumpur, malaysia, noted assessors engaging in inappropriate behaviours, such as prompting, indicating to the candidate how they had performed in the station, and also teaching/ correcting the candidate. there were also apparent differences in the way assessors used the mark sheets their departments had developed. may 2014, vol. 6, no. 1 ajhpe 95 abstracts objective. to evaluate training workshops which have focused on addressing issues of consistency in marking and assessor behaviour. method. training workshops for osce assessors were initiated, focusing on assessor consistency in marking the checklists and assessor behaviour. assessors who had undergone training were followed up in subsequent osce examinations to observe if there was any improvement. observers completed checklists on assessor behaviour during the osces, and their comments were analysed qualitatively. results. trained assessors were on the whole consistent in their behaviour, with minimal or no prompting as compared to untrained assessors. conclusion. training does help assessors become more consistent in their behaviour in osces. improving the reliability in osce assessors may contribute to more accurate assessment of the clinical competence of medical graduates. second-year dental students’ perceptions about a joint medical curriculum l bronkhorst, t c postma* *corne.postma@up.ac.za background. a recent study from australia showed that dental students participating in a joint medical curriculum were being marginalised, which may contribute to unfavourable educational outcomes. objective. given the phenomenon of marginalisation in a joint medical curriculum elsewhere in the world, this study investigates whether there are perceptions among second-year dental students at the university of pretoria, south africa, that they are being marginalised in the joint medical curriculum they are participating in. method. quantitative and qualitative analyses were performed based on anonymous information obtained from 2011 and 2012 second-year dental students’ individual written reflection with regard to their first two years of study. the reflection was open to any comment the student wished to share and specific topics such as marginalisation were not mentioned as part of the instruction. results. a total of 98 students consented to the use of their comments in the study. although there was a fair amount of positive comments about the joint curriculum, 54% of the second-year dental students were of the opinion that the joint curriculum included too much irrelevant information, which contributed little to their skills as future dentists. furthermore, 43% noted that dental students felt excluded during lectures and were disregarded by lecturers, and 42% felt that medical students were treated superiorly by lecturers. conclusion. universities utilising a joint medical curricula to train dental and medical students should be cognizant of the potential marginalisation of dental students. two possible solutions may be to establish a dedicated programme to train dentists, which has the potential to improve the perceived relevance of the training, or to manage the joint curriculum to ensure that marginalisation is eliminated. preparedness of graduates in occupational therapy for clinical practice: perceptions of students and supervisors in a kwazulu-natal case study d naidoo,* j van wyk, r joubert *naidoodes@ukzn.ac.za background. investigating the effect of curricular interventions and fieldwork placement on the competence and confidence of occupational therapists to practise is an emerging field in south african occupational therapy research. it has become essential in educational research, as new graduates are often required to work autonomously during their community service. objective. this study explored the perceptions of the final-year university of kwazulu-natal occupational therapy students and their clinical supervisors regarding their undergraduate education and preparedness for independent clinical practice. method. seventeen final-year students and their clinical supervisors (n=24) participated in focus groups and semi-structured interviews. document analysis was conducted to compare the practice for training and assessment at the local institution with the stipulated guidelines from the guideline of the world federation for medical education and the national accrediting body, i.e. the health professions council of south africa. results. most final-year students and their supervisors indicated that students were only partially prepared and lacked confidence for clinical practice. their confidence was better in areas of occupational therapy training that they enjoyed and experienced in a positive light during fieldwork placements. curriculum review was identified as a priority. conclusion. both the clinical supervisors and the students felt that students would cope as new graduates after training in basic clinical practice. however, aspects of the curriculum could be improved to ensure that newly trained clinicians are more confident about their practice and better equipped to deliver an occupational therapy service specifically for the needs of the diverse african healthcare populations and settings. the home visit: still a feasible teaching tool for medical students? a pilot study for curriculum revision d michaels,* s reid *des.michaels@uct.ac.za background. for experienced family physicians the home visit can often re-connect them with the reasons why they practise medicine, while for students it is the ideal environment to counteract the effects of the ‘hidden curriculum’ in medical education. we conducted a pilot study to determine the logistic and pedagogic implications of home and clinic visits by medical students at the university of cape town. objective. to identify potential obstacles, pedagogic strengths and logistic implications of home visits and patient accompaniment to clinic visits for its proposed inclusion in the curriculum. method. 2ndand 4th-year medical students were invited to participate in the patient follow-up pilot study which was conducted between may and august 2012. quantitative and qualitative data analyses were conducted. results. thirteen (18%) 2nd-year and 4% (n=5) of 4th-year students completed the study. student-initiated patient recruitment proved challenging to the majority (57%, n=8). all found the activity worthwhile. eighty-six per cent (n=12) responded that the learning purposes could not have been attained without the home visit. the clinic visit accompaniment was not feasible, mainly due to the amount of time required. ninety-three per cent (n=13) felt that a home visit experience should be included in the medical curriculum. recommendations were made regarding patient recruitment and selection criteria, duration of follow-up, mentorship, support and assessment. conclusion. the educational value of the home visit was confirmed; however, the clinical link must be made explicit and appropriate resources allocated to enhance the pedagogic value and feasibility of the activity. 96 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts predictors of success for first-year students in health sciences: how useful are secondary school factors? u naidoo,* p flack, s essack *naidoou@ukzn.ac.za background. universities in south africa generally achieve low success rates, which translate to low throughput rates, especially in the first year of study. student dropout in the school of health sciences (shs) at ukzn has a two-fold consequence. it results in the loss of students and the loss of prospective healthcare professionals who are required to address the shortage of skilled healthcare workers in the country. thus the need to determine factors that relate to success and throughput in the first year of study. objective. this paper presents an aspect of a research project which explored factors that could be potential predictors of success in first-year students. the focus is on secondary schooling factors (area and type of schooling, matriculation point scores (aps) and matriculation subjects) in relation to first-year academic success in selected school of health science students over the period 2009 2011. method. a retrospective design with a quantitative approach was used to collect data from 713 student records, from the 2009, 2010 and 2011 intakes. quantitative data were analysed using descriptive and inferential statistic, while the spearman rank correlation test and the mann-whitney test were used to determine differences among variables related to academic success. a p-value of ≤0.05 was considered statistically significant. data were analysed and presented as annual composite results as well as stratified by disciplines as appropriate. results. overall the area of secondary schooling was not statistically significant as a variable that correlated with academic success. in contrast, the type of secondary schooling, matriculation points, and matriculation subjects investigated were statistically significant variables that correlated with academic success in the school of health sciences. at discipline level, physiology showed to have the most consistent correlations among variables, with a moderate correlation with matriculation subjects as well as the aps. conclusion. the results of this study yielded evidence-based admissions criteria for students into the shs at ukzn. evaluation of a dental therapy curriculum using mixed methodology p singh* *kissoonp@ukzn.ac.za background. dental therapists were introduced to the healthcare system to improve access to basic dental services for disadvantaged communities. however, studies have demonstrated that these professionals practise mainly in the private sector, serving a small minority of the population. this has perpetuated the lack of access for disadvantaged communities. objective. to evaluate the dental therapy curriculum offered at a south african university to determine whether it produced appropriately trained graduates to meet the oral health needs of the population. method. this study was conducted in four phases: context, input, product and process, which are analogous with stufflebeam’s cipp evaluation model. a combination of qualitative and quantitative research methods was used; with the hicks curriculum design model serving as the theoretical framework, and pragmatism serving as its philosophical partner. participants were selected by purposive and convenience sampling and included key external stakeholders, students and academics. qualitative data were generated by interviews, focus group discussions and unobtrusive measures and analysed by thematic analysis. quantitative surveys encompassed student module and competency evaluations. this information was analysed by descriptive analysis, which included frequency tables, graphs and percentages. results. the results showed that the dental therapy curriculum followed the traditional subject-centred format, with a lack of integration between the basic, preclinical and clinical sciences. training was based on a hospicentric, urban-based, curative training model, with little focus on primary healthcare. conclusion. in order to develop professionals to meet the health care needs of a country, curricula should be evaluated iteratively, where the cycle of analysis, design and development, evaluation and revision are conducted as an ongoing exercise, using an appropriate evaluation model. findings of this study gave rise to an extension of the hicks model, which focuses on curriculum evaluation of health science programmes in developing countries. assessment of the educational environment perceptions of senior medical students at the university of the free state (ufs) s schoeman,* c ntsere, s phate, l khasoane, r raphuthing *schoemanfhs@ufs.ac.za background. the educational environment (ee) of a medical school plays a critical role in the learning of its students. it is the context or environment within which the students need to learn and master medicine. factors that influence it include, inter alia, the learner, other learners, teachers and the physical environment (campus and hospitals). an accreditation report in 2010 by the hpcsa highlighted some concerns about our clinical training platform, and anecdotal challenges regarding the ee in the clinical departments were also surfacing from staff and senior medical students. this created the need to formally research the ee of the clinical phase of the school of medicine (som) at the ufs, as perceived by the senior medical students (final 2 years – 4th and 5th year). objective. to measure the senior students’ perceptions of the ee in the large clinical departments in the som. the effect of year group, gender, language, age and race were also investigated. method. the internationally recognised and validated dreem questionnaire was used and contextualised for each of the 5 departments included – internal medicine, general surgery, obstetrics and gynaecology, paediatrics, and psychiatry. only departments where 4thand 5th-year students rotated in both years were included. results. overall response rate was 88%. non-parametric tests and indicators were used to analyse the data since the majority of data weres not normally distributed. overall median dreem for the departments combined was 137/200. paediatrics was consistently top rated and obstetrics and gynaecology consistently received the lowest ratings in all domains and subscale analyses. gender had no influence and the other demographic elements had minor influences on the dreem scores. conclusion. the overall ee, as measured in the 5 large clinical departments, was more positive than negative, which is good news for the som. although the subscale analysis largely revealed very positive results, some particular concerns were noted in one department. may 2014, vol. 6, no. 1 ajhpe 97 abstracts does a structured dermatology surgical workshop make a difference in student learning? e smuts,* a de villiers, w visser *estellesm@sun.ac.za background. the formalised exposure of 4th-year mb chb students to dermatology consists of a two-week clinical rotation in wards and outpatient clinics. in january 2011 a small surgical skills workshop was introduced in the first week of the rotation. objective. to determine whether attending a small surgical skills workshop: (i) enhanced student confidence in performing the procedures; (ii) enhanced student competence in performing these procedures; (iii) taught increased student willingness to appropriate practice opportunities in the clinical setting. method. students’ surgical skills competency was assessed using an purpose structured clinical examination (osce). two skills were assessed, namely punch and excisional biopsy. qualitative and quantitative data were obtained by means of questionnaires. the first study group (n=24) completed the dermatology rotation in september 2010 before the introduction of the workshop. osce assessment took place in april 2011. a second study group (n=22) attended the workshop in september 2011. assessment took place in march 2012. time and student availability constraints caused a delay between attendance of the dermatology rotation (first and second study group) and workshop (second study group) and assessment of the students’ skill. knowledge and skill decay were expected. results. the students who attended the workshop demonstrated higher competence in the osce than the non-workshop students. their confidence levels increased compared with the non-workshop group, and they were more willing to perform the procedures in the clinical setting. conclusion. the introduction of the small surgical skills workshop enhanced student learning of the particular skills. the researchers wish to suggest that a student’s request to perform more procedures under direct supervision in the clinic be strongly considered. merit-based redistribution of students in anatomy dissection classes: method revisited b m george,* s nayak, s mishra *bincyrajakumary@yahoo.com background. at melaka manipal medical college (manipal campus) we have adopted merit-based re-arrangement of students in the second term of their anatomy dissection classes in the first year of medical school. this method showed improvement in the individual scores in the subsequent examinations of the second term. objective. the above distribution caused uneasiness, especially to the students who scored least marks in the first term. some among them complained of being depressed after the re-distribution. the purpose of our intervention was to reduce the stress and anxiety, but achieve the same or better improvement in the exam scores. method. the students were redistributed depending on the aggregate of marks of the two exams in the first term, but the groups were not assigned their meritorious ranks. hence, the students were not told to which meritorious group they belonged, whereas the teachers were. this helped the teachers to teach to the groups accordingly. results. the students who scored less were not depressed as their scores were unrevealed to them and to their peers. around 66% of students felt this method of redistribution is satisfactory. conclusion. student redistribution with unrevealed ranking almost erased the earlier uneasiness. most of them were happy and felt that the course was delivered to them at their intellectual level. comparison of effects of paragraph reading and mind mapping on shortterm memory p g r kumari,* m c naing, l a yan, g c ling, j r antony, v raj *grkumari@yahoo.com background. the mind map is an expression of radiant thinking. mind maps can be used as self-learning methods that facilitate understanding of difficult concepts. objective. an attempt was made to compare the effectiveness of mind mapping and paragraph reading on visual short-term memory (vstm) and to find out the most effective way of studying. method. the study was done among the students of melaka manipal medical college (mmmc) so as to enable their study performance and to aid in the effectiveness of teaching of the faculty. students of mbbs phase 1 stage 1 (154 students) and phase 1 stage 2 (132 students) belonging to batches 28, 29 and 30 with a total of 286 students of mmmc were included in this study. the effectiveness of both the presentations on vstm was evaluated by a set of questionnaire. results. the results from both the groups of students were compiled and compared. these were analysed statistically by the chi-squared test. the number of correct answers of students exposed to paragraph format had a median of scoring of 5 10 questions correct, while the students who answered the questionnaire after exposure to mind map presentation had a higher median distribution of correct answers as 8 -13. students would be able to recall more information from the mind maps rather than reading from the paragraph. the majority of the students in our study preferred mind maps to aid their learning process. conclusion. mind mapping has a greater impact on vstm compared with that of paragraph method tool of learning in our study. evolving a training programme for pbl tutors at melaka manipal medical college (mmmc) for enhancing their facilitation skills: students and faculty perceptions a kukkamalla,* k l shobha, a m ciraj, j s d’souza *anandkukkamalla@gmail.com background. problem-based learning (pbl) has been an integral part of our curriculum. pbl fosters students’ independent learning while tutors act as facilitators. new faculty members are naive to the pbl process, are not trained in facilitating it and yet are expected to facilitate the pbl sessions. therefore a structured pbl orientation and facilitation skills module was designed. objective. to create awareness of the pbl process and to design a training module for pbl tutors to enhance their facilitation skills and assess its effectiveness. method. mbbs students (years 1 and 2) and faculty were included. after pbl orientation, preand post-test questionnaires (likert’s scale with 20 items) were administered. pbl tutors later facilitated a pbl session. a pre98 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts intervention questionnaire (likert’s scale with 20 items) on facilitation skills was administered. a one-day activity-based training programme on pbl facilitation skills was conducted for faculty. the same pbl tutors facilitated the next pbl sessions. post-intervention questionnaires (likert’s scale with 20 items) were administered. results. there was a statistical significant difference in the median score for all 4 domains, i.e.: what is pbl?, pbl dynamics, individual roles, general attributes among students and domains 1 and 2 among faculty for pbl orientation. for facilitation skills, year 2 students showed a significant difference in all the 5 domains, i.e. being student-centred (facilitation skills), managing group dynamics, creating a motivating environment, using questions effectively, providing constructive feedback, and evaluation. domain 1 was found to be statistically significant for year 1 students. qualitative analysis of data of the training programme on facilitation skills also yielded significant results. conclusion. pbl orientation and the training programme that was designed were found to be effective. second-year students perceived that the facilitation skills of the tutors were enhanced when compared with the batch of 1st-year students. however, constant review, repeated orientation, implementation of the programme and assessment of skills are imperative. standard setting in purpose-structured clinical examination (osce) in an undergraduate medical school: will it improve the outcome? k l shobha,* k m u anand, m manipal *shobhamicro@yahoo.com background. standard is a conceptual boundary on the true-score scale between acceptable and non-acceptable performance. the outcome of assessment is determined by the standard setting method. objective. since we did not have a valid and reliable osce stations and assessment system, stations were to be set and the standard setting method to be implemented, and outcome was assessed. the purposes were to: (i) develop reliable and valid osce assessment stations in clinical skills related to microbiology; (ii) analyse the scores obtained in osce using modified angoff ’s method and a holistic method; (iii) collect the feedback from the students and faculty regarding the osce. method. four osce stations were developed, and checklists prepared after peer validation. the microbiology faculty and students were orientated regarding conduct and assessment of the osce. the modified angoff ’’s method and holistic method were used for standard setting. feedback on faculty and students’ perceptions regarding the osce was collected. data were analysed using prism software and spss 16. results. cronbach’s alpha was 0.901 for the reliability and validity of osce stations. the p-value was not significant for inter-rater reliability (student t-test). altogether 24.5% of students had failed in the modified angoff ’s method when compared with the holistic method, which had only 14.25% failures. regarding faculty perception, 90.90% of faculty felt that the osce was comprehensive, valid and reliable, while 77% of students felt the purpose of the skills was clearly defined. eighty-nine per cent of students felt that the osce was stressful. conclusion. modified angoff ’s method of standard setting was found to be more reliable and had good interrater reliability than did the holistic method. periodic feedback helps for better conduct of the osce. compilation of a wits-chse database: work in progress s khan,* d prozesky *sayedabanoo.khan@wits.ac.za background. there is currently a large database of multiple choice questions (mcqs) in the wits-chse resource base. unfortunately clinical examiners are reluctant to use the database in its current format because of the system of classification of questions. objective. the project aimed to address the problem by reclassifying the questions using a clinically orientated model. method. a new classification model was compiled and adapted for the first phase of this project. mcqs for the mb bch iii and iv years of study were classified accordingly, spanning a duration of four years. in the original classification items were classified according to system, discipline, process, transition, taxonomy and type, whereas the wits-chse classification system uses the following categories: discipline (29 categories), clinical process (12 categories), pathological process (19 categories), transition, taxonomy, type and statistics. results. all mcqs were classified within the parameters of the original system as well as the wits-chse system. it was found that there is no alignment between the original and wits-chse databases. it is envisaged that the wits-chse system will provide a user-friendly means for potential examiners to identify questions for examination papers. since this is still work in progress, a more sophisticated method could be devised in the future using a computer-based software package. conclusion. the wits-chse database needs to be expanded to include mcqs for the clinical years and its use needs to be monitored. a database of mcqs adapted for the local context is necessary if it is to be useful effectively. building together: inter-faculty collaboration to create innovative learning opportunities and platforms for all involved students r jansen,* j hugo, m van rooyen, a reinbrech-schütte *riaan.jansen@up.ac.za background. the department of construction economics (ce) in collaboration with the department health sciences (hs) provided the opportunity for their students to apply their theoretical knowledge by means of real-life community projects. the purpose of the programme is to provide 80 healthcare centres which will enable students to spend their community work on career-orientated projects. this is done within the sites where re-engineering of phc is done and ward-based outreach teams (wbots) are established in collaboration with the department of health. objective. the programme integrates with the learning outcomes of ce and hs subjects, while also fulfilling the community’s needs and exposing ce and hs students to the latest innovative system; ce students are exposed to the planning, the manufacturing and the erection of the building system, while hs students will be the first to experience the benefits thereof. method. an action research project was initiated, where ce and hs students were selected to participate. the action research include exposing students to concepts of planning, negotiation, networking, manufacturing, and construction in line with subject learning outcomes. results. the year 2011 was spent in planning the best innovative system. continuous assessment in these subjects showed marked improvements in the students’ conceptualisation, marks and overall involvement. may 2014, vol. 6, no. 1 ajhpe 99 abstracts conclusion. enriching the educational experience through the application of this service-learning model and exposing students to other students, the community and industry. hiv exposure incidents: an audit of reported incidents during 2012 to inform the development of a standardised protocol m van rooyen,* t rossouw, k richter *marietjie.vanrooyen@up.ac.za background. medical students of the university of pretoria are exposed to patients presenting with hivand aids-related illnesses as well as hepatits b and c on a daily basis. although there is a protocol for dealing with such incidents it seems that there is room for improvement. the department of family medicine was tasked to set up a protocol and take charge of the care of students presenting with an exposure incident. objective. evaluation of the management of exposure injuries. method. an audit was done on reported exposure incidents in 2012. the results from the audit were triangulated with an anonymous questionnaire administered to all medical students, and compared with data from previous years. results. • 125 exposure injuries reported. • 66.4% related to percutaneous injuries, • most incidents happened in the casualty department and labour ward during or after venesection. • most of the mucocutaneous exposures were related to either suturing or putting up a drip. • in most cases (91/125) the patient’s hepatitis status was unknown. • 29% (36/125) of incidents had a confirmed hiv-positive source. • a wide variety of pep regimens were used. • less than 1% of students followed up after the initial visit. data from the questionnaire still need to be analysed. conclusion. the exposure protocol needs to be revised and amended regularly. innovative ways are discussed to deal with irresponsible practices in work-based situations, low follow-up rates, pep regimens that are less than favourable and the unknown hbv and hcv status of patients. the knowledge and perceptions of pharmacists about the commonly sold herbal mixtures that are used as african traditional medicines in community pharmacies in tshwane townships, gauteng m e mothibe,* d mpe, t malesa, s dipula, b hlongwane, j nabyoma *mamza.mothibe@ul.ac.za background. traditional medicines (tms) continue to play a significant role in the treatment and management of diseases in the developing world. commercialisation and marketing have popularised the herbal mixtures. they are available ready for use from pharmacies, muti-markets and other outlets. the many herbal mixtures sold over the counter in pharmacies have not been tested for efficacy and safety. as such, although they are readily available and used, their effectiveness remain unproven and their safety and toxicity profiles remain unknown. objective. to determine the knowledge and perceptions of pharmacists about the commonly sold herbal medicines used as african tms (atms) in tshwane township pharmacies. method. the study population for this study was the qualified and registered pharmacists working in community pharmacies in tshwane townships. both qualitative and quantitative data were collected by means of self-administered questionnaires. results. most of the participants were aware of the use of atms and the recognition of atms by the national department of health. the majority believed that atms were used owing to their affordability and that the users trusted the medicines as they were considered to be natural products. they perceived it was appropriate for them to dispense atms, yet only 50% of them took safety aspects into consideration during dispensing. although 83% of the participants had no formal teaching or training about tms, the majority knew that the medicines are derived from plants. they knew the indications, routes of administration and storage conditions of most of the 10 commonly sold medicines, but not their safety aspects or interactions. conclusion. the pharmacists perceived that although the safety aspects of the medicines are unknown, some atms are effective and trusted; hence it is appropriate that pharmacists dispense them. there are some knowledge gaps that exist due to unavailability of information about the medicines and their uses. to include aspects of atms in the pharmacy curriculum, as well as to regulate and standardise the tms and their information. prevalence of myopia among students: a cross-sectional study in a south indian medical college s r kamath,* s d jessica *surekharkamath@yahoo.com background. myopia is not only inherited but also caused by excessive reading and other close-up work. generally, myopia first begins in schoolage children, since the eye continues to grow during childhood until about the age of 20. objective. the purpose of the present study was to establish the various genetic and environmental factors contributing to the occurrence of myopia among students. method. the prevalence of myopia among first-year medical students (n=115) of mmmc manipal india was assessed using a questionnaire. these malaysian medical students belonged to different ethnic groups, e.g. chinese, malaysian and indian. results. our survey showed that females had a higher prevalence of myopia when compared with males of the same age group. a higher percentage of chinese medical students were found to have myopia than other malaysian races. the survey of myopia indicated the prevalence of myopia among several of our medical students. it also showed the different hereditary and environmental factors which could have led to the development of myopia in these students. since our students work on computers and read often there is every chance of a non-myopic student developing myopia. conclusion. although there was an association with the level of education, gender, ethnicity and origin with the prevalence of myopia, its occurrence may be reduced by suitable awareness programmes and proper knowledge on development of myopia by environmental factors. awareness about the side-effects of tattoos among medical undergraduate students of melaka manipal medical college (manipal campus), india n nagalakshmi,* a a aaron, d miller, t w yi, d kumaran *nagubrp@gmail.com background. while tattoos have been around for centuries, in recent years they have become increasingly popular, especially among teenagers. 100 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts however, as the popularity grows, so do the concerns over the safety and risks of tattoos. little attention has been directed to the potential latent health effects of tattoos. some of the risks that come with a tattoo are infection at the site of the tattoo, an allergic reaction to the tattoo dye, the spread of disease such as hiv and hepatitis c, granulomas and keloid formation. objective. to investigate the awareness about the side-effects of tattoos among medical undergraduate students of melaka manipal medical college (manipal campus), india. method. a total of 200 students from melaka manipal medical college (manipal campus) participated in this study. awareness about side-effects of tattoos was analysed using pre-set questionnaires. results. of 200 students who responded to questionnaires, we found 11% have a tattoo, 38% are considering getting a tattoo and 70% do not have a tattoo. only 17% of the students were aware of needle sterilisation. altogether 70.5% of students were aware of the hazards of tattoos and diseases transmitted by needle-stick tattoos. from the data obtained, we can come to a firm conclusion that the hypothesis is accepted that 62% of respondents do not have adequate awareness about the side-effects of tattoos. conclusion. different cultures have their own perception regarding tattoos. it’s important to create awareness about side-effects of tattoos among teenagers to prevent transmission of infectious diseases such as human immune deficiency virus, hepatitis b and c virus. international classification of functioning, disability and health (icf): a framework for transformative interprofessional education s snyman,* m clarke, k von pressentin *ssnyman@sun.ac.za background. to promote health equity, a focus is needed on providing patient-centred and community-based care. this is a challenge for health professions educationalists as they advocate for instructional and institutional reform, which includes interprofessional education (ipe). as a solution the who recommends using the icf framework. since 2010 stellenbosch university’s ipe strategy has promoted the icf. clinical training of undergraduate health professions students includes rural placements where students use the icf framework in managing and presenting patients, and are assessed by interprofessional teams of local healthcare professionals. objective. to establish how applying the icf framework as ipe strategy contributed to (i) instructional reform; (ii) institutional reform; (iii) interprofessional practice; and (iv) functioning of health systems. method. associative group analysis – an unstructured method of qualitative research used to reconstruct people’s subjective images from the spontaneous distributions of their free associations – was used to conduct this study. questionnaires were administered to 70 participants: 37 fourth-year students, 18 facilitators of learning, and 15 patients. free word associations were used to reconstruct the internal world and subjective meanings expressed by more direct methods. results. students indicated that they adopted a patient-centred approach which improved patient outcomes and satisfaction. this was confirmed by health professionals, who felt they were indirectly challenged to practise patient-centred, interprofessional care as a result of them assessing students applying the icf. they reported improved interprofessional collaboration, interprofessional practice and job satisfaction as they started applying the icf in clinical practice. patients appreciated the improved quality of care. conclusion. the assessment of student presentations using the icf framework drives interprofessional practice among healthcare students and professionals, facilitates the bio-psycho-social-spiritual approach to patientcentred care and results in improved patient outcomes and strengthened health systems. journey from transformative education to transformational leadership l s mcnamee* *mcnameel@ukzn.ac.za background. transformative education is characterised by a change of ‘habits of the mind and heart’. medical education has been recognised, like other educations and apprenticeships into professions, as a self-altering course of identity construction (and reconstruction). transformational leadership implies that the change within has influenced others and brought about change without. all medical practitioners are arguably leaders in society due to the status and position afforded them by virtue of their qualification. yet the field has generally lagged behind in the adoption of contemporary transformational leadership models which are more likely to effect meaningful change in healthcare systems. objective. the study aimed at better understanding the development of a professional identity as medical students become doctors. various factors that influence aspirations, motivations and trajectories of newly qualified doctors (nqds) are being explored in an on-going study. method. six graduates of a pbl curriculum participated in a narrative study of medical internship experiences. qualitative data in the form of written reflections 3 years post-graduation were analysed using sociolinguistic methods. the same participants were followed up with one-on-one, in-depth interviews 6 years post-graduation. interpretative evaluation enabled insight into their journeys as professionals while reflecting back on internship experiences from a more mature perspective. results. a synopsis of how graduates reached their current professional positions 6 years post-graduation showed that in addition to knowledge, skills and values participants’ experiences relating to ‘life and fate’ have an unexpectedly profound bearing on career choices. relationships to others and to institutions, both preand post-graduation, were found to be a central theme in the trajectories of nqds. in addition, national policies governing post-internship placement of practitioners in community service were a further compounding factor highlighted by participants’ narratives. conclusion. beyond transformative undergraduate medical education lies a liminal space fraught with complexity, unpredictability and uncertainty. nqds should be equipped to deal with contextual and cultural aspects of medical practice in order to develop as transformational leaders. enhancement of postgraduate skills through an educational programme b kotze* *bekotze@cut.ac.za background. all healthcare professionals must be registered with the health professions council of south africa (hpcsa). the council requires healthcare professionals to register as a professional with the required education and training, to conduct themselves in an ethical manner, to continuously develop professional skills (cpd) and to comply to healthcare standards as set out by the health professions act no. 56. may 2014, vol. 6, no. 1 ajhpe 101 abstracts objective. the study, as one of its possible outcomes, evaluated the effectiveness of utilising an educational programme (offered as a cpd event) to enhance a specific professional skill (neonatal chest image quality) of postgraduates (radiographers). method. an essential skill required from all radiographers in clinical practice was evaluated in three institutions. the skill was evaluated by means of an international standardised checklist. areas in need of enhancement, found in the skill, were identified and addressed through an educational programme, offered as a cpd event. the programme consisted of various contact sessions, practical sessions and poster presentations. the effectiveness of the programme was established by re-evaluation of the specific skill of the radiographers found in three institutions, both private and governmental. results. the quantitative and qualitative results indicate that most participants (radiographers) found the educational programme both informative and enlightening. however, quantitative results from the re-evaluation of the skill in clinical practice showed a low percentage of enhancement. this indicates that even though cpd events strive to improve skills and develop professionals, it is not guaranteed to be successful. conclusion. cpd skill development plans through educational programmes should be thoroughly revisited and re-evaluated to establish if it truly can enhance a professional’s skill. collaborative learning as a transformative force for social inclusion v s singaram* *singaram@ukzn.ac.za background. among the challenges faced in south african education is the need to transform its face, its function and its folk, drawing the three aspects away from the divisive apartheid past towards a more inclusive, affirming and enabling future. the thrust of transformation underscores the tension between eliminating the inequities of our past and remaining conscious of our people’s underlying diversity. collaborative learning is ideally suited to helping students mediate and explore the tensions of transformation as well as the discomfort of diversity. objective. to explore the use of collaborative learning as a transformative tool for social cohesion in higher education. method. in this study, data from focus group interviews conducted among a stratified sample of second-year medical students and teachers of problembased learning (pbl) were analysed using mezirow’s first phase of the process of transformation. this phase poses ‘a disorienting dilemma’ – a situation in which new information clashes with past beliefs, leading to self-examination, critical assessment of assumptions and a new perspective. results. four major transformational dilemmas are identified. we show what aspects of diversity are operating in our student population and suggest what may be done to maintain a constructive balance between the polarities. conclusion. we argue that collaborative learning is an effective way of presenting these aspects to a diverse, heterogeneous student population for their reflection towards personal transformation. as highlighted by mezirow (2003), transformative learning involves critical reflection on assumptions that may occur in group interactions. our findings support the role of collaborative learning as a transformative force in higher education. situation analysis of the training of eye healthcare professionals in four african countries g du plessis, d prozesky* *detlef.prozesky@wits.ac.za background. the vision2020 global initiative aims to eliminate avoidable blindness in the world by 2020. one of its three core strategies is human resource development for eye care. objective. the research aimed to assess the educational quality of training programmes for eye care professionals in eritrea, ethiopia, kenya and rwanda. method. all but two of the recognised training programmes were identified and sampled. following negotiations with national bodies and training institutions, on-site visits to each programme were carried out over a period of three months. data collection instruments were developed for interviews with managers, teachers, students and graduates, and structured observation of the training environment and documentation. results. altogether 16 programmes were evaluated: four for ophthalmologists, four for optometrists and eight for mid-level workers. considerable strides have been made in establishing training programmes, often with severe resource limitations. most curricula revealed deficiencies due to not having been derived through a rigorous process of task analysis based on a prepared list of capabilities. the quality of teaching and assisting student learning varied: one-way lectures were commonly used, lesson plans were absent, and support material for knowledge and skills learning was significantly lacking. skills teaching mostly followed a relatively unsystematic apprenticeship model. assessment of learning was problematical in terms of validity, reliability and technical quality for cognitive and skills assessment. explicit educational quality assurance systems were not found. in addition to these educational findings it became clear that training is significantly affected by wider systems issues such as cadre recognition, accreditation, and human and physical resources for training and in the workplace. conclusion. there is a clear need for educational expertise in the programmes. based on the findings of the evaluation, an educational package is being developed. training programmes for health professionals may lack basic educational expertise. peer assessment of quality in teaching and learning f oosthuizen,* j bodenstein, s y essack *oosthuizenf@ukzn.ac.za background. quality teaching is a central tenet to the retention and success of students in higher education, but teaching quality measures and indicators have not enjoyed debate and discourse within the higher education sector as much as research has. quality measures such as pass rates, student and peer evaluations of teaching, moderator and external examiner reports, reports from student support personnel, feedback from experiential learning supervisors and institutional research on teaching and learning may be used to inform quality improvements in teaching and learning. objective. to evaluate the use of peer evaluations of teaching to inform quality improvements in teaching and learning. method. peer evaluations were conducted using a team approach with the team consisting of an internal academic, an academic external to the 102 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts university and a healthcare professional in clinical practice. peers were provided with comprehensive information on the module, including but not limited to content, assessments, notes, practical/experiential learning manuals/log books, past test and examination papers and performance trends prior to conducting evaluations. each peer individually completed a peer evaluation questionnaire after all peers observed teaching practice as a team and submitted a team report. results. academic participants unanimously agreed that qualitative data from peers were best able to highlight strengths and weaknesses as well as assess standard of content at national professional/peer level and qualitative data provided the most useful data to inform changes in teaching practice. the qualitative data engendered and enhanced reflective practice and were of greatest use for teaching portfolios. conclusion. peer evaluation is a suitable tool/indicator/measure for quality teaching as it provides holistic feedback and engenders reflective practice, positively impacting on the quality of teaching. prizes and surprises: evaluation of the safri fellowship programme d manning,* j bezuidenhout, j frantz, v burch, j van wyk, j blitz, s friedman *dianne.manning@up.ac.za background. the sub-saharan africa faimer regional institute (safri) delivers a faculty development fellowship which is aimed at capacity building for educators of health professionals. a traditional approach aligned with kirkpatrick’s four-level model has previously provided a useful framework for evaluating the fellowship. this model interrogates reaction/ experience, learning, behaviour change and results/impact. however, a recent paper by haji et al. (2013) encourages us to rethink evaluation of education programmes by considering whether it worked, how, why and what else happened. objective. to consider how a different approach can be used to rethink evaluation of the safri fellowship. method. a number of different evaluation tools are used, including daily surveys to collect data on reaction and learning, a retro-pre-post survey on perceptions of learning, assessment and evaluation of online distance learning, an online portfolio of professional development for documenting activities, leadership roles, and scholarly achievements. fellows present education intervention projects and share personal and career successes. results. the information gathered provides valuable feedback at all four kirkpatrick levels, strongly indicating that the fellowship ‘works’. how and why it works emerges from the individual stories shared by fellows at the on-site sessions and on the dedicated listserve. their accounts emphasise the important role played by the mentorship and support they receive as part of the community of learners which they have joined. context-related surprises have included the spread of the programme to include fellows from beyond southern africa, necessitating a name change of the institute, and the rapid appointment of a number of fellows to senior leadership positions. conclusion. evolving concepts of evaluation encourage a richer understanding of programme outcomes. transforming the examination process of the examination council of health sciences of the university of zambia school of medicine c marimo,* f m goma *chikacle@gmail.com background. the examination council of health sciences (ecohs) oversees the examination process of affiliated health sciences programmes at colleges in zambia. examination malpractices have been a chronic problem despite the presence of control mechanisms and penalties including prosecution in court. the types and levels of examination malpractices were especially alarming in the december examinations of 2011. an instituted ad-hoc committee found that examination malpractices were rampant with intricate mechanisms of evading identification at the student, trainer levels and possibly the ecohs centre itself. notably, weaknesses were identified in the trainers’ preparation of the examination papers, security in the examination hall and trainers marking schedules. objective. to address the examination malpractices of affiliated health sciences programmes at colleges in zambia. method. prepare examination questions from the prescribed and recommended readings guided by the curricula of each affiliated programme to create a bank of questions in ecohs. one person activates and prepares the examination paper using a specially designed software programme with features that include unique access codes, random selection of examination questions and weighting in terms of difficulty from mild, moderate to difficult. the printing and auto-packaging of the examination paper will be on camera with an inbuilt mechanism of tracking any spoiled papers that have to be signed for and destroyed on camera. the chief invigilator with newly trained personnel secures the examination venue and entrants as well as collecting all answer sheets including spoiled ones and notes for submission to ecohs. correction of answer sheets, compilation and submission of marks will be under supervision at a single venue. results. southernsoft technologies are developing the software programme and ecohs holds the bank of questions. conclusion. security of the examination process has to be equal or better to types of examination malpractices in order to improve or maintain the integrity of the qualification. an assessment of the impact of academic development officers’ interventions in challenging modules in the college of health sciences at the university of kwazulu-natal b mkhonto,* l qulu, c subiah, z ndlazi, p mudaly, n mchunu *mkhontob@ukzn.ac.za background. the college of health sciences comprises four schools (school of clinical medicine, health sciences, laboratory medicine and medical sciences and school of nursing and public health). two core modules, anatomy and physiology, are common to all disciplines within the college. over the years, these modules have proven to be challenging to many students. the poor performance in these modules has impacted negatively on student throughput within the college. may 2014, vol. 6, no. 1 ajhpe 103 abstracts objective. in an effort to combat this poor performance challenge, the college implemented various forms of interventions including the appointment of academic development officers (ados). students who have failed modules, were made aware of the academic development interventions available to them in order to improve their performance. however, students access the ado services on a voluntary basis. method. the performance of students who accessed the ado programme was monitored throughout the semester. a retrospective data review was conducted with regard to midand year-end examination performance of repeat students. results. our findings have shown that students who accessed ado intervention improved their academic performance in physiology and anatomy, in comparison to those who did not make use of the service. conclusion. this finding underscores the importance of providing academic support to students through ados. success v. failure: an evaluation of student success in the emergency medical care programme against the course selection criteria at central university of technology, free state m van eeden,* r g campbell *mveeden@cut.ac.za background. selection of candidates for admission to the national diploma: emergency medical care programme (ndip: emc) at the central university of technology (cut) remains a challenging process. admission criteria provide clear guidelines for school-leaving applicants, but grey areas exist with the selection of mature learners (≥24 years of age) and those between leaving school and the mature category. the use of the matric score (m-score) with prerequisite subjects is standard practice. the general scholastic aptitude test (gsat), considered a valid tool measuring academic potential, is also used. besides academic criteria for admission to the programme, physical fitness and environmental tolerance criteria need to be met. objective. to explore a correlation between student success and academic admission criteria. method. a retrospective analysis of selection results for admitted candidates to the ndip: emc at cut from 2004 to 2010 will be conducted together with an analysis of corresponding graduates from 2006 to 2012. correlation between selection test results and graduate success of students will be identified. results. the hypothesis is that there is a relationship between traditional selection criteria and successful achievement of the qualification. the cohort of students in the mature category who have demonstrated success without having met all the prerequisite admission criteria may point to other characteristics that can be used to predict success in the programme. conclusion. the anticipated outcome of this study is to identify criteria that are predictors of success that can be used when selecting older students for the emergency medical care programme at cut. student support: developing a consultation framework a bawoodien* *azizab@sun.ac.za background. there is mounting pressure on medical schools in south africa to increase the intake of health science students and ensure optimal throughput of its recruits. primary and high school education has undergone many changes over the last decade in the country, causing uncertainty about the preparedness of recruits for tertiary education. additionally constraints in facilities to deal with the numbers and the shrinking base of health science educators call for greater support of the student who may not be adapting. formal or informal accessible student support structures exist at most institutions. at a 2012 saahe workshop it became apparent that a diversity of professionals were involved in student support, viz. lecturers, family physicians, physicians, psychologists, social workers, and educationists. objective. to develop a standardised framework to interview students identified for support. method. reflect retrospectively on students presenting for student support. identify literature to substantiate the reasons for utilisation of support. develop consultation guidelines which can be generalised for use by student supporters. results. students entering health science institutions in south africa are predominantly in the late adolescent stage of emotional development and top performers from an economically stratified range of schools. when they start underperforming they go through a spiral of psychological changes including feelings of embarrassment, social withdrawal and alienation to overindulgence and seeking of power positions in non-academic activities. it is also an age group where there is an increasing incidence of psychiatric morbidity and where they are not forthcoming with the reasons for underperformance. many student supporters work in isolation, sometimes perceived as a threat to students and faculty. conclusion. a standard approach to deal with the complexities that come in the guise of academic underperformance is necessary to implement remediation and exclude pathology. students’ experiences and perceptions of a community-based medical education programme at the university of kwazulu-natal k naidoo,* m muzigaba, p mcneill, m naidoo, r govender, c rangiah, m kendon, s pillay, u g lalloo *naidook7@ukzn.ac.za background. in 2013 the university of kwazulu-natal introduced a community-based education programme for 4th-year medical students in family medicine. the programme involves provision of accommodation, transport, tutors and it facilities by the ukzn medical education partnership initiative (mepi) to enable groups of 30 40 students to conduct clinical rotations in urban and rural primary healthcare centres. objective. a formative evaluation to investigate the students’ experiences and perceived effectiveness of such a programme in achieving predetermined learning purposes. method. all students who completed the rotation in the first 2 quarters of the 2013 programme were invited to complete a survey questionnaire to evaluate their perceptions and experiences of the programme. the main outcome measures were self-assessments of knowledge and skills preand post-introduction of the community-based education programme as well as an evaluation of the teaching methods. results. between january and may 2013, there were 89 students who underwent the rotation (half the class) and completed the evaluation. the overall satisfaction of the students with community-based placements was high (83%). more students felt that small group tutorials (88.9%) and bedside teaching (86.7%) were effective teaching methods compared with 104 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts lectures (70%) and an online platform – moodle (73%). based on the mean difference (md) of preand postperception scores computed on a scale of 1 5, the most significant gain that students perceived was in their understanding of chronic illnesses (md -1.27). the learning purpose of understanding patient context was also well met (md -1.05). however, students’ perceived gain in patient communication only reflected a md of -0.88. more than 80% of respondents indicated that the relationship with their supervisor and facility staff was positive and enhanced the learning experience. conclusion. training health professionals in the community is resourceintensive and requires innovative pedagogy in order to achieve the desired purposes. however, in this family medicine programme at ukzn, attaining specific learning purposes such as understanding patients’ context and chronic diseases has been demonstrated to be effective with communitybased education. further evaluation of community placements and pedagogies required is needed to inform educators of how to best implement community-based education. developing students’ isixhosa and afrikaans communication skills for the clinical consultation: a stellenbosch university faculty of medicine and health sciences initiative m f sikele,* p lewis, m de villiers *fezs@sun.ac.za background. in a multilingual country comprising 11 official languages nationally and at least three in each of the nine provinces, communication (language and cultural) barriers experienced between healthcare professionals and non-language concordant patients are well documented and perceived as a major challenge to quality healthcare in south africa. since 2011, stellenbosch university faculty of medicine and health sciences (sufmhs) embarked on a distinctive roll-out initiative to integrate the teaching and learning of isixhosa and afrikaans communication skills into the clinical consultation. this initiative is being rolled out in all 5 undergraduate programmes at sufmhs. objective. this presentation provides an overview of past trends that have led to the implementation of current as well as future anticipated innovations designed to optimise sufmhs medical and allied trained health professions students’ isixhosa and afrikaans communication skills for the clinical consultation. method. various innovations, ranging from the implementation of communicative-based teaching and learning classroom practices and assessment procedures accompanied by the introduction of two novel technologically based platforms will be reflected upon and discussed as ways to (i) support and reinforce students’ isixhosa and afrikaans communication skills; and to (ii) ultimately optimise students’ isixhosa and afrikaans communicative competency for the clinical consultation. results. the importance of sharing on-going teaching and learning innovations among peers interested in implementing similar related initiatives is expressed and encouraged. to demonstrate the contribution provided by such integral innovations, a video will be presented and briefly discussed to illustrate students’ acquired isixhosa communicative competency while engaging with an isixhosa-speaking simulated patient during a clinical consultation. conclusion. south africa is faced with huge communication barrier challenges in the healthcare sector. faculties of medicine and health sciences are encouraged to be more involved with innovative initiatives that will become integral to the complete training of a health professional in a multilingual society. trends in xhosa language teaching and learning at faculties of medicine and health sciences: findings and new initiatives m du plessis,* m de villiers *mads@sun.ac.za background. communication problems between healthcare workers and patients are perceived as a major barrier to quality healthcare. there are generally very few effective language programmes that equip student professionals with communicative skills in the context of their profession. therefore, the education system produces healthcare professionals who are communicatively incompetent in the languages of their patients. in 2011, stellenbosch university faculty of medicine and health sciences (sufmhs) embarked on a new initiative. this initiative includes the implementation of communicative-based xhosa courses in all undergraduate programmes with the focus on learning how to communicate in a clinical context. objective. this is a comparative study conducted on speech-language and hearing therapy i and ii students to determine their perceptions about their xhosa proficiency in the respective xhosa courses they have received. method. two groups of students are participating in this particular study, i.e. speech-language and hearing therapy i and ii students. each group comprises approximately 30 students. the students participating in this study are not first-language speakers of xhosa and furthermore they have not received the same xhosa course. the study made use of a survey, consisting of open and closed questions, as well as open-ended questions, which determined the perceptions and attitudes of students towards the teaching and learning trends of the respective xhosa courses they attended. a second component comprises students having to express their feelings by the use of drawings on the xhosa course they have received. results. the data will be captured through the specific questionnaire and then be analysed by comparing the responses obtained. the information of the two respective groups will be compared. the results will be finalised in may 2013. conclusion. faculties of medicine and health sciences are encouraged to expose students to communicative-based classroom settings that nurture meaningful and interactive clinical communication skills in order for them to become an integral part of the community. family medicine training as a specialty: the university of limpopo (ul) experience (the new family medicine specialisation training will be discussed with the lessons from this new course) i govender, j tumbo* *tumbo@lantic.net background. the district health system was adapted as the vehicle for healthcare delivery in south africa in 1994. family medicine and primary health care weres identified as a key pillar of the district health system. therefore, the 8 academic departments of family medicine aligned their undergraduate and postgraduate training to this national priority. until 2007, family medicine masters programmes were part-time vocational courses at all universities. in 2008, ul developed a new curriculum based on the outcomes set by the family medicine education consortium (famec) may 2014, vol. 6, no. 1 ajhpe 105 abstracts and a full-time residency programme. provincial departments of health developed training platforms for the universities. within this platform district training complexes were developed. there were joint appointment of trainers between provincial departments of health and universities. results and discussion. the context of training was identified as the district health services. training complexes were accredited by the hpcsa in 3 provinces (gauteng, limpopo, north west). ul prepared for this new course by training 17 family physicians from university of limpopo to become facilitators in the new programme which was conducted with extensive learning from the belgian family medicine training programme. the hpcsa accredited 60 family medicine registrar training positions for the university of limpopo. the curriculum is structured into 36 modules (17 in year 1, 10 in year 2, and 11 in year 3), with 3 training sessions at the university and 3 at a provincial training site per year for 2 days. there was constant supervision by a family physician at the training site and weekly seminars by all registrars at the site. challenges of running the training include a limited number of funded registrar posts by the provincial health authorities (employer), shortage of supervisors to meet the needs, change management in implementing the intensive on-site supervision, limited interest and understanding of family medicine specialisation among generalists lessons learnt: • need for proper planning and marketing of family medicine specialty. • crucial stakeholder buy-in, particularly from the department of health that employs registrars and specialists. • national consensus of medical schools on standardisation of training and outcomes • need to customise the curriculum to address local country needs and improve on retention of specialists conclusion. the university of limpopo has made significant strides in the implementation of training of family medicine as a speciality in the district health context. collaboration between academic institutions and provincial health authorities is crucial in the success of training of family physicians. curriculum issues affecting rural-origin health science students across three south african medical schools p n diab,* p s flack, h mabuza *diabp@ukzn.ac.za background. recruitment and retention of staff to rural health facilities is a global challenge. past research suggests that students from rural backgrounds are more likely to go into rural practice. however, these students face a number of challenges. overcoming those challenges is key to ensuring their retention and success through the academic programme and to increase the likelihood of their subsequent decision to practise in rural communities. objective. this paper examines to what extent the curriculum influences such decisions and interrogates students’ opinions as to their exposure to rural health and the challenges that rural students face during their undergraduate education that may affect their final decision to practise in a rural area. method. a study conducted at three south african medical schools was conducted using a self-administered questionnaire. firstand final-year students from all health science disciplines were sampled. data were entered into epidata and analysed using spss (version 19). chi-square tests were utilised to determine statistical significance of the quantitative data while qualitative data were analysed thematically. results. the majority of students (59.9%) knew of modules exposing them to rural health and believed that this was sufficient. students felt that such modules should be introduced early and sustained throughout the curriculum and that such exposure was important in terms of preparing them for future practice. the biggest challenges for rural students were the language of teaching, technological and financial issues. academic course content, personal challenges or adaptation to urban life were no more challenging for rural than urban students. conclusion. students reflected past research that rural health should be introduced early and sustained throughout the curriculum. language support and technological skills training may be required to assist rural students. seeking ways to alleviate or reduce these stresses may well influence future recruitment of rural students to rural practice. review of final-year medical students’ rural attachment at district hospitals in kzn p n diab,* p d mcneill, a ross *diabp@ukzn.ac.za background. many medical schools utilise community-based training facilities to expose students to undifferentiated patients presenting to primary healthcare facilities within the community. the programme at ukzn has been in existence for some time but no formal evaluation of the programme has yet taken place. objective. in preparation for a new 6-week attachment commencing in 2015, this review aimed to investigate the programme from the viewpoint of the site supervisors and students. method. an exploratory research design was used. purposive sampling of supervisors involved with the training at the time of the review was undertaken and in-depth interviews were conducted using a semistructured interview guide. data were collected from students by means of a self-administered questionnaire at the end of the block. interviews were transcribed and a thematic analysis of the data is presented in this review. quantitative data were analysed using spss (version 19). ethical approval was granted by the ukzn humanities and social science ethics committee (hss/1347/010). results. communication issues, including frequent liaison between academic institutions and hospitals, preparation of supervisors and frequent visits from university staff were highlighted to be of importance. assisting with the structuring of a programme and providing daily rosters and clear lines of delegation of students were also essential. preparation of students was seen to be an essential factor in the overall success of the programme. support structures including accommodation, technical support and recreational opportunities were seen to be important factors to address. conclusion. regular review of such programmes is vital in order to ensure its sustainability and gain the best possible outcome for students, supervisors and institutions to which they belong. the activities performed by the students should be under-pinned by a theoretical perspective and focus not just on skills acquisition but on the broader experience of life and work in a rural district hospital. 106 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts career and practice intentions of health science students across three south african medical schools c naidu,* j irlam, p diab *claudia.naidu@uct.ac.za background. the distribution and accessibility of healthcare professionals as well as the quality of healthcare service are significantly affected by the career choices of health science graduates. objective. this study aimed to provide insight into the future career plans of health science students across three south african medical schools, and to identify some of the factors which most strongly affect these preferences. method. a self-administered survey was conducted of firstand finalyear health science students at the university of cape town, university of kwazulu-natal and university of limpopo. all data were entered into epidata and exported for analysis using spss. results. the overall response rate was 52% (n=1 676). just under half of all respondents (49%, n=771) intend to work after completing their undergraduate studies, 43% (n=333) of whom would like to work in a rural area. the most popular choices of institutions were district hospitals, private hospitals and tertiary hospitals. forty-one per cent (n=654) of respondents intend to further their studies, and for medical students (n=396), the most popular specialties included surgery, paediatrics, cardiology, neurology, obstetrics and gynaecology, and internal medicine. just under half of all respondents intend to work in another country (47%; n=748), primarily motivated by career development, financial reasons and wanting to learn about a new culture. conclusion. the findings demonstrate that students are influenced by a multitude of factors in making their career choices and emphasise the need to design specific strategies to overcome the maldistribution of health professionals across sectors, geographical areas and specialities. why medicine? a survey of medical students at the university of botswana n l badlangana* *nlambiwa@gmail.com background. botswana is a large country with a population of ±2 million. however, the number of doctors is very low. there is no direct entry into the school of medicine (som) and students have to apply for admission. if we can identify early why students choose medicine we hope that they will not only stay in medicine, but will practise anywhere in the country for the benefit of its citizens. objective. to determine the reasons why medical students at the university of botswana som chose medicine as a career. method. an online survey using survey monkey was developed using comments and suggestions from focus group discussions conducted separately with lecturers and students. the survey included questions on influences and reasons to study medicine, alternative career choices (if any), strengths of studying in botswana, expectations for student achievement at the som and expectations on graduation. the 2nd-, 3rdand 4th-year students were invited by e-mail to participate in the online survey. results. forty students responded (response rate = 50%). altogether 74% (n=28) indicated their greatest influence for studying medicine was personal experience rather than parents and relatives (2.6% each), while 28.1% (n=9) indicated their choice of medicine was to have a stable job after graduation. when asked what they would have studied if not medicine, 41.7% (n=15) responded that they would have studied another health sciences field (e.g. dentistry, nursing, pharmacy, physiotherapy). on the choice to study medicine in botswana, 80.6% (n=29) responded that the relevant conditions they might see when they start practising medicine was a strong factor, as they would be familiar with certain conditions that they would have encountered in the course of their studies. conclusion. students are interested in medicine. their experiences play an important role in choosing medicine as a career. challenges faced by rural-origin health science students across three south african medical schools: a focus on support p flack,* v singaram *flackp@ukzn.ac.za background. there is vast body of literature that suggests those students most at risk for drop-out, or non-persistence, are students from disadvantaged backgrounds (braunstein, lesser, and pescatrice, 2008), students whose language for learning is not their mother tongue and students who enter the tertiary education sector ill prepared academically owing to the existing disparities in the primary and secondary levels of education. many of these students who enter the tertiary education sector ill prepared are from rural backgrounds. a student who feels alienated, alone and unsupported is at high risk for ‘non-persistence’ or drop-out (quarterman, 2008). therefore, in order to improve retention it is essential to ensure students feel supported, included and socially integrated at university. objective. the focus of this paper is on the support required and accessed by students from rural backgrounds in particular. method. this study was conducted at three south african universities. health science students in their first and final years of study completed self-administered questionnaires. students identified themselves as either of rural or urban origin in the questionnaires. data were analysed according to those two categories. data were entered into epidata and analysed using spss (version 19). chi-square tests were utilised to determine statistical significance of the quantitative data while qualitative data were analysed thematically. results. rural students report requiring support to overcome the following challenges: the language of teaching and learning, computer literacy and other technological issues, and financial constraints. support is accessed from family and friends, and religious communities, in a similar way to urban students. however, peer mentors were considered less supportive unless they too shared a rural background. rural students also reported teachers as being supportive more frequently than urban students. conclusion. universities should consider ensuring that student support is relevant. results indicate that students from rural backgrounds access academic, financial and social support from various sectors but rely most on peers who know and understand their context, family and the broader community ‘back home’. it is important for universities to consider the type and nature of support that students need in order to address gaps in support programmes. may 2014, vol. 6, no. 1 ajhpe 107 abstracts assessing the efficacy of posters as educational intervention for paediatric sample collection in forensic pathology practice at the tygerberg medicolegal mortuary h la grange,* j verster, a louw, v thompson, j bezuidenhout, j dempers, c de beer *hlg@sun.ac.za background. published literature in south africa focusing on investigations into sudden unexpected death in infants (sudi) is limited. such studies are further restricted by the lack of a universally recognised sudi investigation protocol for south africa. challenges to facilitate training of forensic pathology officers (fpos) in sudi specimen collection to assist sudi investigations include personnel shortage and work rotations. although fpos receive basic training in collection of autopsy specimens, the need was identified for further training in the collection of special swabs for the purposes of an ongoing study of virological infections. as an adjuvant to training, specimen collection procedures were indicated algorithmically on a mini-poster and introduced in the medico-legal mortuary. objective. to determine the efficacy of instructional mini-posters in guiding fpos with sudi autopsy specimen collection procedures. method. this was a qualitative, retrospective, prethen post-assessment study conducted at the tygerberg medico-legal mortuary in cape town, south africa. fpos were evaluated with a questionnaire and focus group session to determine the efficacy of the mini-posters placed at this centre. results. preliminary observations indicated that posters, in isolation, were ineffective in guiding sudi autopsy procedures. continuous verbal guidance was frequently required during the course of the sample collection procedure. therefore it became apparent that different approaches are needed to increase awareness and adherence to the poster content in order to effectively guide sudi specimen collection procedures. conclusion. effective strategies are required to improve awareness of instructional posters to streamline standard sudi autopsy specimen collection procedures. this urges the need for larger follow-up studies to aid in the development of a more structured and feasible forensic pathology service training programme in the western cape. final-year mb chb assessment mapping: what value does this add? c p l tan,* s c van schalkwyk, f j cilliers *tanplchristina@gmail.com background. in high stakes examinations, tests of clinical competence, which allow decisions to be made about medical qualifications and fitness to practise, need to provide reliable and valid measurements of student performance. there is an extensive body of literature devoted to the challenges of clinical assessment. there are also widely accepted criteria for sound assessment. at stellenbosch university, there is also an assessment policy to provide a framework and to bring the assessment practices of the university in line with current, research-based views and standards regarding assessment. an investigation was undertaken to determine what current assessment methods are being used at exit level in the bachelor of medicine and bachelor of surgery (mb chb) programme at stellenbosch university and how these assessment methods are described in official module documents. objective. to map what assessment methods are used and how they are used in the exit level mb chb programme at stellenbosch university, as described to students in relevant documentation. method. document analysis of study guides for exit-level modules was done for information relating to methods of assessment and their use. assessment methods, divided into written and non-written formats, were mapped on an excel spreadsheet against modules to provide an overall view of assessment for all final-year modules. results. assessment practice varied across modules based on (i) the approaches and number of assessments; (ii) weighting of individual components; and (iii) the use of assessment tools. conclusion. mapping the assessments can provide a useful reference overview for module and programme co-ordinators. the next step in this research would be to determine if there is sound assessment taking place and would provide some indication of the degree of alignment with the stellenbosch university assessment policy as well as with international criteria. evaluating the knowledge of clinical teachers required to implement osce as an alternative clinical assessment method at the catholic university of health and allied sciences (cuhas) in mwanza, tanzania r kabangila,* j van wyk *rodking20012000@yahoo.com background. long and short case clinical examinations have been traditionally and widely accepted as a means of clinical skills assessment in various institutions. however, using both methods at cuhas with more than 700 students and only 45 clinical teachers, these methods are usually time intensive to both students and teachers alike. the objective structured clinical examination (osce) which is more objective is not used as a method of assessment at cuhas. objective. to assess the knowledge of osces among clinical teachers required to implement this as an alternative clinical skills assessment method at cuhas. method. we conducted a cross-sectional study among clinical teachers from 4 clinical departments (surgery, gynaecology, paediatrics and internal medicine). data were collected using a pre-tested structured questionnaire. simple analysis of the data was done. results. a total of 34 questionnaires were distributed and there was a return rate of 82%. the majority of respondents (68%) were junior faculty (assistant lecturers and tutorial assistants). median age of the respondents was 35 years (range 28 55 years). although 96% of respondents had heard about osce before and 71% heard about it in the medical school, the proportion of respondents who were able to write in full what the term ‘osce’ stood for was only 58%. sixty-three per cent of the respondents were not able to define basic concepts of assessment, including validity and reliability, and 60% were not able to state the types of skills that oscce can assess. conclusion. clinical teachers require training to use osce effectively as an assessment method. a dashboard for monitoring hospital practice for thirdand fourth-year medical students at wits university d mandić,* d prozesky *ddragan.mandic@wits.ac.za background. following anecdotal reports of problems in programme delivery a comprehensive evaluation of clinical teaching in years 3 and 4 was carried out (cassim, 2009). despite the implementation of improvements many problems still persisted. 108 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts objective. the hospital day dashboard initiative aimed to monitor and improve thirdand fourth-year medical students’ clinical teaching during hospital and community site visits. the strategy was developed by having transparent weekly feedback from students about each clinical site. method. weekly student surveys were carried out over a period of five months. data collection questionnaires were developed, allowing quantitative and qualitative evaluation. the results were analysed and widely distributed weekly in dashboard format. problems identified were individually followed up and rectified. results. the weekly performance reports to all stakeholders resulted in progressive and significant improvement in the educational quality of the events, as well as greater satisfaction among the students. the report format made it possible to identify specific weaknesses and remedy them without delay. some of these weaknesses were found to be administrative, such as poor communication, resulting in students and tutors not meeting as planned, specific transport problems, and monitoring of student attendance. others were educational: unsystematic skills teaching and one-way lecturing, and students not using their initiative and expecting to be spoon-fed. conclusion. there is a clear need for transparent and meticulous weekly follow-up in such programmes. as a result of the ‘dashboard’ system student satisfaction, student attendance and quality of clinical teaching are being advanced. clinical training of thirdand fourth-year medical students benefits by thorough, continuous and transparent weekly surveys. writing and its significance to problem-based learning research: an innovative way of contributing to medical education research k bryant,* m kebaetse, m mpho, o nkomazana *katie.bryant@mopipi.ub.bw background. medical education research illustrates that medical schools experience benefits and challenges in both implementing and using problem-based learning (pbl) curricula. in terms of the challenges, studies tend to highlight one of two themes: those related to teaching and learning or those related to institutional implementation. in the context of developing countries, particularly the context of various african countries, as new medical schools open and implement pbl or hybrid curricula, research is also beginning to emerge on this issue; yet, most of these studies focus on implementation as opposed to teaching and learning-related challenges. interestingly though, the university of botswana’s recently opened school of medicine (ubsom) has identified and started to investigate a teaching and learning challenge potentially connected to its use of a pbl curriculum. this challenge is the difficulties first-year medical students have writing for pbl purposes. objective. to present preliminary findings from this study at ubsom to demonstrate how studying the activity of writing, specifically the writing challenges of first-year medical students, can uncover particular teaching and learning challenges that emerge from using a pbl curriculum method. situated in the qualitative research paradigm, and using a constructivist grounded theory methodology, these findings come from interviews with ubsom’s first-year pbl teaching staff and purposively sampled first-year medical students. the interviews focused on both groups’ perceptions of first-year medical students’ challenges writing for pbl purposes. results. the discussion will focus on overarching themes emerging from interviews with teaching staff and students about the challenges medical students experience writing for pbl purposes. these themes will be connected to larger teaching and learning challenges emerging from the literature about using pbl curriculums in medical schools. conclusion. investigating the writing-related challenges of medical students can highlight important teaching and learning challenges that come from implementing and using pbl curriculums in medical schools. a south-south elective: helping to establish a role for family medicine in rwanda m flinken-flögel,* g a ogunbanjo *maaike.cotc@gmail.com background. postgraduate education in family medicine in rwanda started in 2008. family medicine does not yet have a place in the rwandan healthcare system and residents are therefore unsure about their future professional role. therefore, when offered the opportunity, five out of six rwandan final-year residents selected a 4-week elective in south africa to experience family medicine. objective. to explore how an elective in south africa adds value to the rwandan postgraduate family medicine training. method. an existing bilateral co-operation facilitated the establishment of a 4-week elective at limpopo university, south africa. a qualitative descriptive study was conducted, doing semi-structured individual interviews with all five residents who completed the elective. interviews were transcribed and inductive thematic analysis was undertaken. results. residents’ purposes for the electives were to increase knowledge of and gain practical experience in several areas. these areas were divided into patient care, the south african health are system, family medicine in the south african setting and postgraduate family medicine education in south africa. the last purpose was to identify useful aspects to implement in the new rwandan family medicine context. most knowledge-related purposes were met and the elective was considered to have added good value. however, purposes in practical skills were not met. residents also reflected that due to contextual difference, not everything observed could be applied in the rwandan setting. in addition to residents’ purposes, interviews revealed that the elective increased their confidence as family physicians and enhanced their attitude towards family medicine as a profession in rwanda. conclusion. a south-south elective in an african country with an established role for family medicine can add value to a rwandan family medicine curriculum. experiencing the role of family medicine in the south african healthcare system enhanced rwandan residents’ sense of professional identity. adapting the format of the elective to the rwandan context will further enhance this learning opportunity. quality improvement projects as a way to achieve transformative learning m bac* *jannie.hugo@up.ac.za background. medical and bcmp students at the university of pretoria are required to do a quality improvement project (qip) during their final year of study. every year 200 medical students do their community obstetrics and family medicine rotation in district hospitals and clinics in gauteng and mpumalanga. each group of students is required to do a qip in their clinical learning centre (clc). clinical associate students spend a full may 2014, vol. 6, no. 1 ajhpe 109 abstracts year at a clc, usually in a district hospital, and are also required to write an assignment on the functioning and performance of an aspect of the health services. method. in this way about 250 students are involved in the assessment of the health services and become actively involved in the analysis of the weak and strong points of healthcare delivery. after a study of the relevant literature, an intervention plan is made that has to be presented to the local health team that is responsible for this service and has to implement the recommended improvements. results and conclusion. medical and clinical associate students can be involved in transformative learning by doing qips and become important team members of an on-going quality improvement spiral in district hospitals. in this way learning is no longer informative or formative but transformative and in line with the recommendations of the lancet commission report. designing a faculty development workshop on integrating research into teaching and learning j m frantz,* a rhoda, j de jongh *jfrantz@uwc.ac.za background. a paucity of information regarding the impact of faculty development initiatives to improve the integration of research into teaching and learning exists. many academics do not possess the knowledge and skills to integrate research into teaching and learning, and faculty development in this area is therefore required. workshops can be used to develop academics’ understanding of the strengths and limitations of incorporating research into teaching and learning, as well as to give them an opportunity to apply knowledge gained in their practice of teaching modules. objective. to describe the procedures that were used to plan and implement a faculty workshop related to integrating research into teaching and learning. method. the ‘backwards instructional design’ was used to plan the workshop. this design aims to address three main questions: what does an accomplished learner know?, how does a learner demonstrate their knowledge?, and what activities will provide an opportunity for practice and ‘uncovering’ knowledge? the description of the faculty development programme will be focused on the guiding principles for the backward instructional design and the content. results. backward design uses a question format rather than measurable purposes to identify desired results of the workshop. by answering key questions, participants deepen their learning about the content and experience an enduring understanding. in addition, the facilitators formulated the questions with the desired outcome in mind. during stage 2 in the design process facilitators defined activities that will demonstrate that the participants acquired the knowledge, understanding and skill to answer the questions. finally, stage 3 incorporated planning the learning experience that will equip participants to develop and demonstrate the desired understanding. conclusion. backward design assists facilitators to incorporate research findings in designing learning programmes that have clear goals and purposes and include activities that are aligned to these goals. evaluation of a research capacity intervention for academic staff within the appreciative inquiry framework a rhoda,* j de jongh, j blitz, j frantz *arhoda@uwc.ac.za background. the development of research capacity of health professionals could result in improved provision of healthcare. evaluating interventions aimed at developing research capacity is vital to determine their value and need. as a framework used for organisational change, the appreciative inquiry framework is suitable for the evaluation of research capacity development interventions. objective. to explore academic staff experiences of a research capacity development intervention in the faculty of community and health sciences at the university of the western cape using the appreciative inquiry framework. method. this study used a qualitative contextual exploratory design. all the academics that had completed a research capacity development programme in the preceding year were approached to take part in the study. five academics volunteered to participate in a focus group discussion which explored their experiences of the research capacity intervention. an interview guide was used to collect the data. content analysis using the appreciative inquiry framework was used to analyse the data. ethical clearance was obtained from the university of the western cape’s ethics committee. results. the themes that emerged from the focus group discussions are presented according to the appreciative inquiry phases. within the discovery and description phase were active contextualisation of teaching and learning concepts, emotion-based intrinsic factors related to the intervention, and interaction with facilitators. within the dream phase the participants visualised the need for continued mentorship and support. within the designing and destiny phase were recommendations relating to the content and format of the intervention. conclusion. analysis of the focus group discussion using the appreciative inquiry framework highlighted that while the capacity development intervention had been a very positive experience, there was still room to develop post-intervention support initiatives to help faculty cope with the disablers encountered in their everyday work environment. participating then using: what gets the academic racehorse to the faculty development water trough and what makes it drink? f cilliers,* n herman *francois.cilliers@uct.ac.za background. much advice about faculty development (fd) practice is based on intuition, experience and isolated empirical evidence rather than being grounded in a conceptual framework (cf). to be useful, a cf for fd would need to address human behaviour in a complex social context. health behaviour theory (hbt) does this. eaton et al. (2003) proposed a cf relating inter alia to personal factors, interpersonal factors and organisational factors as influences on behaviour. objective. to explore the utility of a cf drawn from hbt to understand the participation of academics in fd initiatives and their subsequent application of what they learn. 110 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts method. structured interviews were conducted with 14 purposively sampled academics. interview data and concepts from a hbt informed the design of a questionnaire. a total of 495 academics who had participated in an fd retreat over a 12-year period were surveyed using closed-ended and open items. results. a total of 246 academics (49.7%) responded. participation was influenced more strongly by personal and organisational factors than by interpersonal factors. personal factors included intrinsic motivation and perceived utility of activities. organisational factors included workload (administrative and teaching) and pressure to do and reward for research. utilisation was also influenced more by personal and organisational, than interpersonal, factors. utilisation was enabled by intrinsic motivation, perceived utility and feasibility of ideas and a departmental climate supportive of teaching. utilisation was hindered by workload (administrative, undergraduate teaching, research and postgraduate teaching), but not by a lack of either confidence or a sense of self-efficacy. conclusion. while the hbt cf proved useful, qualitative data we collected added dimensions to our results that transcended those of the cf used. our data align better with a recently published refinement of a model of the transfer of training. applying cfs should contribute to the design of conceptually stronger fd programs. time to get online: ibadan postgraduates root for distance learning m d dairo* *drdairo@yahoo.com background. the master of public health (mph) degree is a mandatory requirement for appointment of public health officers in both the private and public health sectors in nigeria. unfortunately, admission has been limited owing to infrastructural constraints. delivery of the mph curriculum as distance learning offers a solution. objective. this study examined the feasibility and acceptability of a distance learning mph programme to applicants as a necessary condition to determine its introduction in the institution. method. a self-administered questionnaire was used to collect data on demographic variables, nature of employment, desirability of a distancelearning module and motivation to enrol for a distance-learning mph programme. results. many applicants (40%) are engaged in paid employment and 67.8% worked 6 8 hours daily. applicants indicate access (96.5) to personal computers, mainly laptops (92.9%). internet access ranges from all day (45.4%) to only 2 3 hours daily (8.5%). most applicants access the internet at home (35.5%), at both home and office (22%) and by mobile telephone devices (24.8%). most considered themselves skilful (95.1%) in its use. about 49.6% of the applicants have previous experience accessing online instruction and are willing (84.4%) and enthusiastic (75.9%) to receive online modules of instruction. about half (53.9%) consider such modules effective and of the same quality (50.4%) as traditional learning. reasons for preferring online instruction include inconveniences of large classes (50.4%), ease of learning (16.3%) and having other commitments (14.9%). blended audiovisuals with written modules (53.9%) is the preferred online mode of course delivery. conclusion. the findings from this study indicate that infrastructural capacity and attitudinal disposition to uptake of online mode of instruction are high among applicants to the mph degree programme. institutional policy change and curriculum development are therefore required to exploit the opportunity. postgraduate students’ perception of online learning in a selected nursing education institution in kwazulu-natal v mdunge, n mtshali, s mthembu* *sindizama@gmail.com background. online learning is becoming an indispensable complementary teaching and learning tool and has been an integral aspect of education in many tertiary institutions around the world. in nurse education and training, online learning, web-based learning or e-learning is a fundamental necessity, especially in the light of the growing shift into information and communication technology (ict). objective. to explore the online learning experiences of postgraduate nursing education students at a selected nursing education institution in kwazulu-natal. method. a qualitative exploratory design was used. data were collected through semi-structured interviews from 16 postgraduate nursing education students and thematic data analysis was used. ethical approval to conduct the study was secured from the university ethics committee. results. themes that emerged focused on specific areas – engaging with information technology, online learning process, facilitator’s role and expertise, knowledge construction process, empowerment personally and academically, challenges and recommendations. the role and expertise of the online facilitator emerged as critical in guiding, supporting the learning process and ensuring that all participants engage in the learning process to facilitate intensive learning. intensive engagement with learning material before the online session, engaging with and critiquing work posted online by peers, the process of generating new knowledge or contextdriven knowledge, easy access, convenience and flexibility in terms of time emerged as benefits associated with online learning. asynchronicity and flexibility regarding time to engage with online content, availability of a facilitator to engage with students online, financial cost and technical expertise emerged as challenges. conclusion. although a large majority of participants had never taken an online class prior to this course, the overall perception of online learning was positive. the positive aspect outweighed the negative aspects. online learning is a worthwhile experience that facilitates personal and academic development. the neglected grass-root adoption of mobile phones as learning tools in resource-limited settings: a study from advanced midwifery education in kwazulu-natal, south africa p brysiewicz,* c pimmer, u gröhbiel, f walters, s linxen, j chipps *brysiewiczp@ukzn.ac.za background. many m-health and m-learning interventions fail, because they adopt a technocentric view and ignore the local context. objective. to address the above, the present study investigated the ‘organic’ adoption and educational usage of mobile phones by health workers in rural health settings. method. a qualitative study was conducted, interviewing nursing/advanced midwifery students, facilitators and nursing managers from rural, resourceconstrained regions in the province of kwazulu-natal, south africa. may 2014, vol. 6, no. 1 ajhpe 111 abstracts content analysis used the concepts of community of inquiry theory as ‘a priori-constructs’. results. the research revealed a number of unexpected learning and teaching practices, based on the grass-root adoption of mobile phone functions and in particular social apps. these practices involved cognitive, teaching and social presence as well as reflective practice and enabled rich educational experiences – according to the community of inquiry theory. theoretical discussion: ‘traditional’ communities of inquiry are based on predetermined online environments. by contrast, learners used bundles of phone-based functions/apps to embed mobile and blended communities and other resources that were fragmented across social, temporal, topical, geographical, digital and ‘real’ spaces in the inquiry process in very dynamic ways. conclusion. in view of future mhealth and mobile learning efforts, mobile phones appear to be particularly suitable to facilitate competence development in the following ways: (a) problem solving and situated co-construction of local knowledge; (b) sociocultural participation – to alleviate professional isolation; (c) connecting learning in workplaces with formal education systems; and (d) addressing unpredictable opportunities and challenges that are typical for the changing and provisional (health) contexts observed. instead of ignoring the revealed practices, health and education institutions are well advised to support learners in media literacy, enabling them to more effectively and critically use existing (mobile) technologies. enhanced video podcasting and its potential for transformative learning s walsh,* m de villiers *walsh@sun.ac.za background. to assist our students with learning, we created enhanced podcasts of all the second-year mb chb lectures during 2012. our study used enhanced non-segmented podcasts with a conceptual focus for receptive viewing. method. the lecturer’s powerpoint slideshow together with the audio of their lecture was converted into an enhanced podcast (video) of the lecture and placed on the blackboard learning management system for the class to view and download. data were collected by means of a questionnaire and a focus group to evaluate the intervention. examination results from 2012 were compared with those of previous classes. results. ninety-five per cent of students rated the podcasts as beneficial or extremely beneficial. our students came up with a novel uses of podcasts: playing the podcast at 1.5 times its normal speed; podcasts benefited with language issues; they could evaluate the quality of the lecture; and object to test questions they felt were unfair because the content was not covered in class. one of the major hurdles we had to overcome was how podcasting impacts on copyright and aspects of this are discussed. feedback from our lecturers and the student’s focus group indicated that podcasts did not result in significant non-attendance of classes. conclusion. the medical curriculum is acknowledged to suffer from information overload. our students mostly found podcasts beneficial for clarifying concepts they did not grasp in class. the feedback provided useful pointers for improving the process and has resulted in all podcasts being made available online to all students and faculty. we see the podcasts as one of the foundational enablers in implementing transformative learning, as podcasts can facilitate the flipped classroom approach. out-of-the-box teaching: teaching for different learning styles d mtyongwe,* k m mpeko, m raphuthing *dmtyongwe@cut.ac.za background. historically, teaching has been left to the interpretation of the respective teacher, creating as many views and methods as there are teachers. traditionally, the way the teacher learns becomes the way they view learning, which impacts on the way they teach. in essence ‘we teach students to receive information, the way we believe information is received’. what determines how information is received is thus influenced by the learning style of the individual. learning styles in this context are referred as classed in the vak learning styles self-assessment questionnaire, viz. visual, auditory and kinesthetic. these learning styles promote successful lifelong learning, as the focus is on how you learn rather than what you learn. there are those students whose learning needs are not met by traditional teaching methods; and this has created the birth of innovative teaching methods. objective. to introduce learning styles in higher education and review the relationship between the application of learning styles in order to address the shortfalls of traditional teaching by introducing innovative teaching methods. method. the study covered two programmes: clinical technology and dental assisting in the faculty of health and environmental sciences. a total of 76 first-year students participated and completed a vak learning styles selfassessment questionnaire which addressed their learning styles. results. the data revealed 28 visual, 15 auditory, 30 kinaesthetic, and one with an equal score in all categories and one who scored equal in auditory and kinaesthetic. conclusion. the majority of the students are kinaesthetic and visual so the teaching elements in both programmes need to consider the needs of these students. it’s important to know learning styles to be able to address student needs and innovative teaching must be introduced for shortfalls discovered. the effect of teaching methods used as experienced and perceived by student nurses at a nursing college in the western cape province l furst,* e stellenberg *lfurst@sun.ac.za background. the 21st century teaching environment is unique in its diversity, and challenges academic staff to create a teaching environment that is conducive to all current learners. various teaching methods are available and affordable, but technology remains an essential investment for the future of higher education institutions. objective. to evaluate the perceptions of student nurses regarding the effectiveness of the teaching methods which they experienced at a nursing college in the western cape province. method. an explorative, descriptive research design with a quantitative approach. the target population of 1 238 nursing students following the r425 programme. stratified random sampling selected the sample of participants (n=267). a self-administered questionnaire with predominantly closed questions was personally administered by researcher. results. results include a significant difference in generation x participants and the green/whiteboard teaching methods (spearman p=0.02) and their preference of the traditional lecture as a teaching method (spearman p<0.01). the perceived effectiveness of the teaching methods on student 112 may 2014, vol. 6, no. 1 ajhpe abstractsabstracts performance varied between very helpful and not helpful. only 49 (19%) of participants experienced the traditional lecture as being very helpful on their general academic performance compared with the effect of group work (n=69; 26%) and self-activity (n=102; 39%). open-ended questions showed that participants regarded the teaching strategies as boring and ancient and that much of the unhappiness expressed stems from the difference in the needs of millennials and the lack of change and obstinacy existing among academics. conclusion. should recommendations be implemented, a complete transformation of the college under study will result. it may force the education institution to move out of complacency, to a more vigorous and dynamic education environment that enables them to emerge as a higher education institution (hei) of good standing. recommendations include an increase in the use of technology, a blended approach to teaching, the re-training of academic staff, and measures in counteracting a boring classroom environment. nursing students’ experiences using simulation as a clinical teaching method in south africa n nel,* e stellenberg *natalievdmerwe@sun.ac.za background. given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the experience students have utilising simulation laboratories. objective. exploring the experience of primary healthcare students utilising simulation laboratories. method. a descriptive qualitative research design was applied. purposive sampling of 10 individual interviews and a focus group of seven participants was drawn from the primary healthcare students who successfully completed the programme the preceding year. data were collected by two trained fieldworkers and transcribed by the researcher. ethics approval was obtained from the stellenbosch university and informed consent from the participants. results. these showed that the students are in favour of simulation as a foundation phase in their programme but preferred to be introduced to an actual human being. ‘ ... it already began laying the foundation to work with the patients and stuff. it gives reassurance that you at least know something.’ students felt more confident and competent after practising on human beings. member checking was done to determine the validity of data analyses. conclusion. simulation as a clinical teaching method ensured a good foundation phase, but students felt more competent and confident after practising on human beings. the use of mannequins for the foundation phase should be maintained. however, the introduction of human beings for students to practise on after practising on a mannequin should become part of the learning opportunities. multidisciplinary learning: joint patient encounters with undergraduate medical and pharmacy students s de johnston, s moch, f oluwafolajimi,* l green-thompson, p mc inerney, p g shiba *oluwafolajimi.fadahun@wits.ac.za background. multidisciplinary approaches in the education of pharmacy and medical students have had reported benefits. medical students are perceived to have stronger diagnostic skills while pharmacy students are seen to have superior medication knowledge. the wits faculty of health sciences offers degrees in both pharmacy and medicine on the same campus and is therefore in an ideal situation to implement and assess interdisciplinary learning encounters between these two groups of students. objective. to, firstly, implement combined clinical learning opportunities where medical and pharmacy students would jointly see patients and, secondly, establish the students’ perceptions of these joint learning opportunities. method. a total of 45 registered students comprising 15 final-year pharmacy students and 30 third-year medical students were invited to participate in the joint patient encounter. fifteen groups were formed from the pool of participants. each group consisted of two medical students paired with one pharmacy student. the students remained in these groups for the 8-week period of the study at charlotte maxeke johannesburg academic hospital. during the study, they jointly assessed patient records and participated in the patient consultation, guided by a supervising doctor. students who participated in the encounter were invited to attend a discipline-specific focus group discussion where they shared their perceptions and experiences. the two discipline-specific focus groups were asked the same primary and probing questions by interviewers. results. three themes were identified: the meeting of professions, the value of the shared experience, and the patient as a source of learning. conclusion. there are potential benefits for both healthcare professionals and patients when adopting multidisciplinary approaches in teaching and learning. introducing a novel assessment instrument designed to address students’ xhosa language skills in the clinical consultation m du plessis,* c tan, p lewis m de villiers *mads@sun.ac.za background. in 2011, stellenbosch university faculty of medicine and health sciences (sufmhs) embarked on a new initiative in teaching students language in communication with patients so as to improve healthcare service delivery. this includes the implementation of xhosa and afrikaans courses in the undergraduate programmes, starting with the bachelor of speech-language and hearing therapy and bachelor of science in dietetics degrees. as the focus for students is on learning how to communicate competently in a clinical context, there is also a need to develop effective and appropriate assessment instruments. objective. to refine an existing assessment instrument in order to make it more appropriate for the purpose of assessing language of communication skills in a clinical context, and implement its use at sufmhs. method. an assessment instrument, with emphasis on assessing a student’s ability to incorporate relevant clinical skills in a communicatively competent manner, was refined and developed jointly by linguists and clinicians. this is used to assess human nutrition students in role plays with simulated patients. simulated patients are also required to assess students on aspects they consider important for improving quality of patient care. students, lecturers and simulated patients are then surveyed on their perceptions of the newly refined assessment instrument to gauge its acceptability. results. this is an ongoing study. the process of refining, developing and implementing the assessment instrument is described. the assessment by the simulated patients, as well as the responses from the survey, will be summarised and documented. may 2014, vol. 6, no. 1 ajhpe 113 abstracts conclusion. this study is striving towards further development of this novel assessment instrument designed to address students’ xhosa language skills in the clinical consultation. interprofessional participation and collaboration has been critical in the refinement and development of this assessment instrument. putting the click into clickers: a novel formative assessment approach developed for isixhosa clinical communication l mhlabeni,* p lewis, m de villiers *lmhlabeni@sun.ac.za background. the necessity to improve the increasing communication challenges experienced among health professionals and patients is a focal point in the south african multilingual society. this predicament is currently being addressed by many universities in the country. stellenbosch university faculty of medicine and health sciences (sufmhs) has embarked on numerous innovative initiatives to develop and improve students’ clinical communication proficiencies with non-language concordant patients. this presentation reflects on the development and application of student response systems (srs) as a formative assessment tool in isixhosa teaching and learning interventions. objective. this presentation aims to demonstrate the design, development and application of this technologically based tool to assist with clinical consultation assessment procedures in learning isixhosa and to prepare students for simulated osces. the implementation is informed by a study designed to investigate students’ user-satisfaction and application of the srs platform for isixhosa. method. experiences with the development and application of srss used in isixhosa formative assessment procedures together with its strengths and challenges are reported by the presenter. this project is also informed by a pilot study focusing on students’ and lecturers’ user-satisfaction views on this alternative assessment approach. results. fifty occupational therapy first-year students have been identified to participate in this pilot study. the findings of the study will be available by october 2013 and will open avenues to further analyses to improve the application of future srs-related developments as well as envisaged endeavours to support and reinforce students’ isixhosa communication skills. conclusion. south africa is faced with huge language barriers in the healthcare sector.  we trust that by developing this novel formative assessment approach for isixhosa teaching and learning we will be able to contribute towards enhancing the learning of an african language for health professionals in order to improve quality patient care in our health services. supervisor-student engagement: do we ask the right questions? h friedrich-nel,* j mac kinnon *hfried@cut.ac.za background. the roles and responsibilities of the research supervisor are not universally agreed upon, and so this is an area that creates active debate in the literature. the function of the research supervisor is to assist the student in completing a script, a dissertation or a thesis and by doing so attain the outcomes of research. the supervisor also has to provide ‘information to transformation’ to support the student in becoming an independent professional researcher and scholar as well as develop critical thinking and problem-solving abilites. objective. the question was if the right questions are asked during research supervision so that outcomes such as critical thinking and problem solving are attained. method. a qualitative study exploring the perceptions of supervisors was conducted at a university of technology as a case study. postgraduate research supervisors in the faculty of health and environmental sciences responded to an e-mail request to provide details of their approaches in postgraduate supervision. content analysis was used to analyse the data. concepts were created and grouped according to sub-themes. results. three themes emerged from the data collected from the supervisors who responded, namely the mechanics of the supervision, the environment in which the supervision was performed, and the attitude of the supervisor. additionally, supervisors indicated a preference for discourse rather than just feedback, a preference for face-to-face meetings and that feedback needs to be regular. conclusion. supervisors were silent about challenging the students to facilitate critical thinking during the feedback sessions. the postgraduate supervision process should aim to transform the student into an independent scholar, attain the research outcomes and encourage critical thinking and problem solving. for this reason the right questions need to be asked. a patient’s experience of critical illness: informing those who cure/care c drenth* *nelia@phca.co.za/neliad@wol.co.za background. critical illness, admission to an intensive care unit and prolonged hospitalisation all impact on the psychosocial functioning of an individual. objective. there is a dearth of qualitative studies on the patient’s psychosocial reactions to critical care. in this presentation i explore my own experience as a critically ill patient (being hospitalised for 127 days) and the recovery from this illness. method. i conducted an auto-ethnographic study to add knowledge to the scarcity of research from the patient’s point of view. in auto-ethnography the researcher draws on his/her own lived experience and makes a connection between the self and others within the same context. results. the following themes were identified from the data: uncertainty and the need to be kept informed, pain and suffering, meaning making and post-loss growth, and a whirlpool of emotions. my experience as a social worker in healthcare for more than 30 years certainly brought with it an understanding of some issues impacting on the patient who experiences a critical illness. being dependent on the doctors’ calls, care of nursing staff and dependency on my husband after discharge influenced my self-image. i feared being alone and was trapped in my own small world of uncertainty. the themes emerging from the data may not be new, but certainly emphasise the importance of this knowledge for the interdisciplinary team engaging in the world of the critically ill patient. conclusion. psychosocial care for patients in intensive care has lagged behind because of physical problems. the importance of monitoring the icu patient’s psychosocial outcome and not just their physical outcome is highlighted by several authors and confirmed by my experience. my experience of critical illness leads to recommendations for care of the patient in icu. 28 may 2014, vol. 6, no. 1 ajhpe research the city of cape town, south africa is home to an estimated population of 3.5 million, >15% of whom live in informal housing or shanty towns.[1] these dwellings often do not have piped water or access to flushing toilets, and many are still dependent on bucket latrines. according to the 2007 south african census, only 20.9% of people living in the cape town area have completed their final year of high school, and there is an unemployment rate of 24.5%. the city faces a quadruple burden of disease, which includes high levels of infectious diseases (hiv/aids/tb and other sexually transmitted infections); a growing prevalence of noncommunicable diseases (diabetes, hypertension); high maternal, infant and child mortality rates; and social conditions linked to excessive levels of interpersonal violence and injuries. volunteers from the students’ health and welfare centres organisation (shawco), based at the university of cape town (uct), run free primary healthcare clinics in the evenings. shawco manages seven weekly student-run primary healthcare clinics in several under-served cape town communities. crèches (day-care facilities) and primary schools are also visited on a weekly basis and provide preventive care to children in under-privileged communities. shawco maintains a close relationship with uct’s faculty of health sciences, and runs clinics in partnership with, among others, the school of child and adolescent health. shawco clinics were started by concerned medical students and faculty members in the early 1940s in response to large numbers of poor migrant labourers seeking work in cape town. the latter were forced to live in rapidly growing shanty towns, without access to basic amenities or healthcare facilities.[2] initially, shawco provided both healthcare and social welfare services. during the apartheid years, shawco continued with its activities in the townships, despite opposition from the state. the clinics were often the only form of healthcare available in these areas. currently, over 500 medical and allied health sciences students continue to deliver free primary healthcare to over 4 000 people in under-resourced and under-served communities throughout cape town annually. during clinic hours, patients are examined and treated by medical students from uct, who are supervised by volunteer doctors from public hospitals and private practices. students in their clinical years (years 4 6) are responsible for clerking and managing patients, while simultaneously training preclinical students (years 1 3). shawco and health sciences education in an article in a 1963 edition of the samj,[3] dr golda selzer, a co-founder of shawco, writes that this organisation provides students with experience in a range of clinical problems and conditions rarely seen in highly specialised teaching hospitals, but that are the mainstay of general practice. the community-based approach of shawco tackles aspects of general medical practice that cannot be dealt with at tertiary hospitals.[2] katz[4] alludes to the multiple educational benefits of shawco, including knowledge gained regarding the manifestations and treatment of common ailments, the application of knowledge gained during formal education in a practical training ground, and the ability to distinguish minor complaints from serious ones. in addition, katz writes that the clinical environment of shawco ‘enables the student to handle a patient with ease, enhancing the doctor-patient relationship’. the article concludes that the knowledge gained and the increased appreciation of patients’ medical and social problems better prepare these students for clinical medicine. background. since 1943, the students’ health and welfare centres organisation (shawco) of the university of cape town has provided voluntary, student-run free clinics in under-served communities in cape town, south africa, filling major gaps in the city’s healthcare services. objective. to determine the role shawco clinics play in medical education. methods.  a mixed-methods study with a predominantly quantitative questionnaire utilising dichotomised likert scales was performed with 110 clinic volunteers. the likert scales were converted to population proportions for quantitative analysis. qualitative data obtained from participants’ comments were analysed thematically. discussion. shawco clinics provide a controlled environment in which to practise skills acquired in medical school. over 98% of students attend clinics to increase their clinical exposure. medical conditions that students encounter are primary care problems, often neglected at tertiary level teaching institutions. the clinics achieve what the formal curriculum struggles to do: humanise medical treatment, allowing one to better understand the socio-economic background of patients. conclusion.  shawco is best suited in its current role of hands-on, community-based learning to augment the training provided in the formal medical curriculum.  ajhpe 2014;6(1):28-32. doi:10.7196/ajhpe.311 student doctors (umfundi wobugqirha): the role of student-run free clinics in medical education in cape town, south africa s c mendelsohn, mb chb rob ferreira hospital, nelspruit, mpumalanga, south africa corresponding author: s c mendelsohn (simonmendelsohn@gmail.com) mailto:simonmendelsohn@gmail.com may 2014, vol. 6, no. 1 ajhpe 29 research role of student-run clinics in medical education a number of studies demonstrate that student-run clinics, in addition to benefiting local under-serviced communities, also play a significant role in medical education, filling the primary healthcare gap not addressed by tertiar y hospitals.[5-8] the autonomous nature of student-run clinics promotes student-directed learning, more humanistic learning and patient care.[8] students learn and practise many skills while working in the clinics, including taking a history, examining patients, formulating assessments and managing, while also gaining an understanding of important biopsychosocial issues.[6,9-11] the clinics also provide students with administrative and health management training – an aspect omitted in their health sciences education.[8,12-14] many student-run clinics offer multidisciplinar y team-based care, which provides an ideal context for fostering a team relationship. some studies conclude that the early clinical experience helps students to develop confidence and a positive attitude towards their medical studies and future careers.[6] students who have had early clinical contact are also more likely to pursue careers in primary care, become more socially responsive and show a greater interest in rural health.[11] there is good evidence that the quality of care delivered at student-run clinics is as good as or better than healthcare managed and delivered by qualified professionals,[8] and that patients are satisfied with the service.[15] the aim of this study was to determine the role of student-run free clinics in medical education at uct. research questions • what are the educational benefits of studentrun free clinics? • what do medical students gain from working in the clinics that they would not gain from their formal medical training? • why do medical students attend the clinics? • what form of educational platform do the clinics provide? methods study design this was a cross-sectional mixed-methods (primarily quantitative) study done by means of a questionnaire and analysis of the shawco patient and student-volunteer databases. ethical considerations ethics approval for use of the shawco databases and questionnaires was obtained from the uct research ethics committee (rec-ref:187/2010). all data were anonymous and informed consent was obtained from all participants. instruments used a standardised quantitative questionnaire with dichotomised likert scales was used, with the option of providing additional comments for each question. some of the questions are the same as or similar to those used by simpson and long,[5] but have been adapted to the south african context. the full questions are provided in the results section of this article. during a pilot study, the questionnaire was administered to 10 regular shawco volunteers. the study appears to have good construct validity: the students all agreed that the questions were clear. reliability was estimated using the ‘test/ re-test’ method, i.e. 3 participants completed the same questionnaire on two different occasions. there was a high positive correlation between original and repeat survey results (r=0.9) and the study was shown to be repeatable and generalisable. the concepts were well defined and explained before being measured. questionnaires were proofread and reworded to make them easy to understand, with no chance of misunderstanding. study population the study population consisted of health science students at uct (n=668) who had volunteered to work in shawco clinics (fig.1). this study population represents approximately 39.1% of the total health sciences campus student population. sample a non-randomised convenience sample of students in all years of study (fig. 2) was obtained, with 110 questionnaires captured from available volunteers at shawco clinics during a 1-month period in 2010. using a 95% confidence interval (ci), the sample population needed to be n>61 to yield results of statistical significance. answer saturation was attained with qualitative questions. data analysis data were cleaned and analysed using microsoft excel 2003 software. results of the dichotomised likert scales were converted to population proportions. the adjusted wald method was used to calculate cis for population proportions. thematic analysis was used for qualitative data obtained from participants’ comments. results shawco patient population the shawco database captured 4 267 patients in 2010, over two-thirds of whom were female. 278; 42% 240; 36% 102; 15% 48; 7% pre-clinical medical students clinical medical students international/visiting medical students allied health professions students fig. 1. total student volunteers. 14 18 8 2 12 56 6th year 5th year 4th year 3rd year 2nd year 1st year clinical pre-clinical fig. 2. student participants by year of study. 30 may 2014, vol. 6, no. 1 ajhpe research the patients ranged from 2 weeks to 91 years of age, with the largest grouping <18 years of age (39.37%). the majority of patients presented with infectious diseases, often associated with poor living conditions, lack of basic services and the hiv/ tb co-epidemic. the six leading diagnoses (fig. 3) were upper respiratory tract infections (20.98% of all patients), backache (5.60%), lower respiratory tract infections (5.48%), suspected or confirmed worm infestations (5.44%), sexually transmitted diseases/infections (5.39%) and acute diarrhoea (4.76%). educational benefits of attending clinics many students learn a variety of new skills for the first time in shawco clinics (table 1), including basic side-room investigations and clerical skills. many skills that are taught as part of the medical curriculum are later practised in shawco clinics (fig. 4), as one respondent wrote: ‘shawco clinics allow me to put into practice the copious amounts of theory being learned and make it more relevant to what i am doing.’ several students also mentioned using clinics as an opportunity to practise their language skills (n=11), specifically afrikaans and isixhosa. tables 2 and 3 summarise what students perceive to be the benefits of attending shawco clinics. teaching whereas pre-clinical students are predominantly taught by students in their clinical years (83.82%), the latter receive more teaching from volunteer doctors (77.50%) and less from their peers (61.54%). one volunteer responded as follows: ‘the clinics allow us as students to assist those in the years below us develop the skills that we were so privileged to learn during our shawco experiences. the whole self teach thing works, if it is voluntary and practical … [and] not in a tutorial room!’ why do students attend shawco clinics? most students attend clinics ‘to serve the poor’ (93.58%) or because of enjoyment (93.64%), as one participant wrote: ‘being a first year, shawco is what brought excitement to my medical school life because we don’t do anything practical … i like them maybe because they’re not compulsory: i go because i want to.’ the majority of students attend clinics to spend time with patients and get hands-on exposure (98.18%): ‘we were actually responsible for the appropriate treatment and management of patients for the first time.’ ‘i want to do primary care when i graduate. we don’t get enough clinical exposure to primary level problems in our curriculum.’ discussion benefits of student-run free clinics shawco clinics have several benefits over government-run clinics. student volunteers identified these benefits, which include more time to address patients’ needs (allowing a higher quality of care), shorter waiting times (resulting in greater patient satisfaction), and free care and treatment. a respondent wrote: fig. 4. patients queue outside a shawco clinic in cape town, south africa. 0 200 400 600 800 1 000 1 200 1 400 1 600 1 800 n o n e c ar d io va sc u la r d en ta l d er m at o lo g ic al en d o cr in e g as tr o in te st in al tr ac t g yn ae co lo g ic al h ae m at o lo g ic al in fe ct io u s d is ea se s n eu ro lo g ic al ps yc h o lo g ic al o p h th al m o lo g ic al o rt h o p ae d ic s/ rh eu m at o lo g y r es p ir at o ry a n d ea r, n o se a n d t h ro at tr au m a u ro lo g ic al /m al e 19 5; 4 .5 7% 11 1; 2 .6 0% 19 ; 0 .4 5% 70 5; 1 6. 52 % 28 ; 0 .6 6% 64 0; 1 5. 00 % 44 8; 1 0. 50 % 14 ; 0 .3 3% 40 ; 0 .9 4% 15 9; 3 .7 3% 52 ; 1 .2 2% 88 ; 2 .0 6% 41 5; 9 .7 3% 1 62 5; 3 8. 09 % 47 ; 1 .1 0% 17 3; 4 .0 5% pa ti en ts , n fig. 3. patient diagnosis statistics. table 1. what skills did you learn for the first time in shawco clinics? skills student volunteers (n=110), % (ci (%)) completing a referral letter or medical certificate 63.64 (54.32 72.04) taking a patient history 58.18 (48.84 66.98) presenting patients to the doctor 57.27 (47.93 66.12) performing physical examinations 56.36 (47.03 65.26) performing a pregnancy test and counselling 56.36 (47.03 65.26) filling in a legal prescription 53.64 (44.35 62.68) managing/treating patients 52.73 (43.46 61.81) performing health promotion/education 42.73 (33.88 52.07) testing blood glucose with a visidex 38.18 (29.64 47.52) using an otoscope or ophthalmoscope 34.55 (26.3 43.83) using a stethoscope, reflex hammer or taking blood pressure 31.82 (23.83 41.03) testing haemoglobin with a haemoglobinometer 24.55 (17.41 33.4) shawco = students’ health and welfare centres organisation of the university of cape town; ci = confidence interval. may 2014, vol. 6, no. 1 ajhpe 31 research ‘we deliver care within the community – we get to know the members of the community within their cultural context – we use what they have taught us to come up with culturally/contextually-appropriate treatment plans. we are given the opportunity of time to address all the patients’ needs.’ situated learning at shawco the leading diagnoses at student-run free clinics in first world countries appear to be diseases of lifestyle and urban environment, i.e. hypertension, diabetes, hyperlipidaemia, depression and asthma.[12,13] this is in contrast to the diagnoses at shawco clinics in the south african context, where infectious diseases (respiratory and gastrointestinal) related to living conditions and the hiv/aids/tb pandemic predominate. despite the majority of patients having primary care problems, medical training is conducted in secondary and tertiary hospitals; consequently, such problems are often neglected. the clinics expose students to appropriate primary healthcare conditions that they will frequently encounter during their internship and community service years. the shawco experience provides hands-on clinical experience that enhances the learning of students, and additional health management/ administrative skills lacking in our healthcare system. although elements of shawco have been incorporated into the uct medical school curriculum, it does not qualify as a service-learning experience, i.e. students do not reflect upon their experiences in the formal clinics and there are no learning outcomes or core competencies. perhaps shawco and other student-run clinics are better suited in their current role of providing a platform for learning situated in the community as an adjunct to formal university medical education. they provide a controlled environment in which to practise skills learned during medical training. this is the concept of situated learning (learning taking place in the same context in which it is applied), first proposed by lave and wenger.[16] the clinics also offer an opportunity to integrate language training into the curriculum (specifically isixhosa and afrikaans), as one respondent wrote: ‘i attend the shawco masiphumelele clinic, and a significant proportion of patients speak isixhosa as a first language, maybe some english. thus, it has impressed upon me the importance of being able to effectively and understandably converse with these patients in isixhosa. shawco always allows me to practise my isixhosa, and my skill in the language has definitely improved as a result of attendance of the clinics.’ why do students attend student-run free clinics? ‘you initially learn clinical skills in the tertiary level teaching hospital where the patients are complicated and are tired of seeing so many students. i used to hate going up to patients as a second or third year where your practicing does nothing to help them and they are irritated because you are the millionth student come to see them. at shawco clinics, you don’t feel bad about practicing your clinical skills on them because you are actually being useful and your examination contributes towards the diagnosis and management of the patient instead of it only benefiting you.’ by attending shawco clinics, students gain clinical exposure and confidence, practise clinical skills, and gain skills that cannot be learnt in a lecture room setting, including administrative and logistics skills. the results indicate that a more hands-on training is more appreciated by students. community of practice the concept of a community of practice, a group that shares a similar occupation and interests, was first postulated by lave and wenger[16] and can be seen in the shawco community. the clinics offer a unique opportunity for senior students to tutor junior students by passing on their knowledge. this peer-to-peer teaching is often easier for students. they may attend clinics, as they feel a sense of belonging or a connection to similar medical professionals who all have similar ideals and interests. this group provides motivation and a sense of importance to the students. some comments by participants illustrate this idea: ‘i really enjoy the interaction with the patients, hearing their stories. i really appreciate that they let us all learn from them, but it seems that they appreciate us too ... it makes me so excited to be doing this course. working at shawco reminds me of the things that make all the theory that we have to slog through worth while!’ table 2. do you feel that attending shawco clinics … student volunteers (n=110), % (ci (%)) allows you to better understand the socioeconomic background of patients in our society? 89.18 (87.39 90.74) makes you more confident in interviewing or examining patients? 88.73 (86.92 90.32 ) shows you the practical relevance of what you are studying and makes it easier to study? 87.06 (85.14 88.76) helps you to learn things that could not be gathered from books? 84.22 (82.16 86.08) humanises the medical treatment of disadvantaged people? 82.87 (80.75 84.80) reminds you why you are studying medicine? 77.99 (75.68 80.13) improves your health management and logistical skills? 76.71 (74.36 78.90) has improved your knowledge of south africa’s medical system? 69.95 (67.43 72.35) promotes the multidisciplinary team relationship? 47.56 (44.89 50.24) table 3. why do i volunteer for shawco clinics? student volunteers (n=110), % (ci (%)) to spend time with patients/get hands-on exposure 98.18 (93.21 99.91) i enjoy myself at clinics 93.64 (87.23 97.1) to serve the poor 93.58 (87.12 97.07) to learn clinical skills 85.45 (7.57 90.95) because i don’t get enough clinical (hands-on) exposure as part of my academic course/these clinics fill this gap in the curriculum 66.06 (56.74 74.28) to spend time with friends 56.36 (47.03 65.26) enhance my resume/curriculum vitae 36.70 (28.23 46.07) to receive rewards/gifts 5.45 (2.28 11.63) 32 may 2014, vol. 6, no. 1 ajhpe research making clinical practice a fun experience: it is also clearly evident from the respondents’ comments that the clinics motivate and encourage them. in short, they are fun. they give students a sense of purpose and achievement, and a desire to persevere with the degree programme. humanistic care and biopsychosocial context the shawco experience makes volunteers feel that they have made a difference and positively reinforces their altruistic reasons for becoming doctors. this is very important as many feel that the medical school experience has become dehumanising for both patient and student. the clinics teach the students an holistic approach to managing patients. as one volunteer wrote: ‘the most important thing i learned from shawco was the influence of social problems on people’s health and well-being. (something that is largely ignored in clinical medicine curriculum).’ ‘it has also opened [my eyes] into other peoples’ worlds and background, which has taught me a lot about how different cultures perceive certain diseases.’ pitfalls of student-run free clinics free clinics are perpetually under-resourced, which creates challenges, i.e. insufficient supervision and under-treatment of patients. as a result of learning from peers and inexperienced physicians, students may also acquire poor clinical practices (‘bad habits’). some weaknesses identified by study participants include a lack of certain essential services at the clinics, insufficient access to psychosocial services, and poor continuity of care (patients are often seen by different students and doctors on a return visit to the shawco clinic, resulting in poorer treatment outcomes). the clinics teach these important realities of healthcare in the south african context to future patient advocates and healthcare leaders. conclusion shawco student-run clinics play an integral role in primary healthcare education at uct’s faculty of health sciences by increasing clinical exposure, confidence, skills and knowledge of medical students. these clinics achieve what the medical curriculum struggles to do: humanise medical treatment, allowing one to better understand the socio-economic background of patients. this author recommends that student-run free clinics at medical schools throughout south africa would serve as ideal platforms for situated learning, while simultaneously fulfilling the social responsibility obligations of the medical institutions. future research opportunities there are several research opportunities available to explore, e.g. how do student-run free clinics influence future career choice: are volunteers more likely to work in rural settings once qualified, or stay in africa? another avenue of research to assess the educational role of student-run free clinics would be to compare the quality of patient care from doctors who attended free clinics with that of colleagues who did not. a future study could also ascertain where students acquired knowledge, confidence and clinical skills, comparing shawco volunteers with other medical students. there are currently no data comparing the quality of care received at student-run to government clinics in south africa and limited research on the quality of care received at student-run clinics in general. acknowledgement. i would like to thank dr george draper for his supervision during this study. references 1. statistics south africa. community survey, 2007. south africa: statistics south africa, 2007. 2. favara dm, mendelsohn sc. the students’ health and welfare centres organisation (shawco) of the university of cape town: a review of the past 69 years. s afr med j 2012;102(6):400-402. 3. selzer g. shawco: the students’ health and welfare centres organisation of the university of cape town. s afr med j 1963;37:58-59. 4. katz d. the students’ health and welfare centre (shawco), university of cape town, south africa. br j med educ 1967;1(3):178-182. 5. simpson sa, long ja. medical student-run health clinics: important contributors to patient care and medical education. j gen intern med 2007;22:352-56. [http://dx.doi.org/10.1007/s11606-006-0073-4] 6. batra p, chertok js, fisher ce, et al. the columbia-harlem homeless medical partnership: a new model for learning in the service of those in medical need. journal of urban health: bull n y acad med 2009;86(5):781790. [http://dx.doi.org/10.1007/s11524-009-9386-z] 7. clark dl, melillo a, wallace d, et al. a multidisciplinary, learner-centered, student-run clinic for the homeless. fam med 2003;35(6):394-397. 8. meah ys, smith el, thomas dc. student-run health clinic: novel arena to educate medical students on systemsbased practice. mt sinai j med 2009;76:344-356. [http://dx.doi.org/10.1002%2fmsj.20128] 9. cooper hc, gibbs tj, brown l. community-orientated medical education: extending the boundaries. med teach 2001;23:295-299. [http://dx.doi.org/10.1080%2f01421590120043071] 10. davenport ba. witnessing and the medical gaze: how medical students learn to see at a free clinic for the homeless. med anthropol q 2000;14:310-327. [http://dx.doi.org/10.1525%2fmaq.2000.14.3.310] 11. littlewood s, ypinazar v, margolis sa, et al. early practical experience and the social responsiveness of clinical education: systematic review. br med j 2005;331:387-391. [http://dx.doi.org/10.1136%2fbmj.331.7513.387] 12. beck e. the ucsd student-run free clinic project: transdisciplinary health professional education. j healthcare poor underserved 2005;16(2):207-219. [http://dx.doi.org/10.1353%2fhpu.2005.0026] 13. jimenez m, tan-billet j, babineau j, et al. the promise clinic. a service learning approach to increasing access to healthcare. j healthcare poor underserved 2008;19:933-943. [http://dx.doi.org/10.1353/hpu.0.0046] 14. o’connell mt, rivo ml, mechaber a, et al. a curriculum in systems-based care; experiential learning changes in student knowledge and attitudes. fam med 2004;36(suppl):s98-s104. 15. ellett jd, campbell ja, gonsalves wc. patient satisfaction in a student-run free medical clinic. fam med 2010;42(1):16-18. 16. lave j, wenger e. situated learning – legitimate peripheral participation. cambridge: cambridge university press, 1991. http://dx.doi.org/10.1007/s11606-006-0073-4] http://dx.doi.org/10.1007/s11524-009-9386-z] http://dx.doi.org/10.1002%2fmsj.20128] http://dx.doi.org/10.1080%2f01421590120043071] http://dx.doi.org/10.1525%2fmaq.2000.14.3.310] http://dx.doi.org/10.1136%2fbmj.331.7513.387] http://dx.doi.org/10.1353%2fhpu.2005.0026] http://dx.doi.org/10.1353/hpu.0.0046] research 180 november 2015, vol. 7, no. 2 ajhpe an assumption that higher moral reasoning is a desirable quality for healthcare providers is supported by research that shows a correlation between moral reasoning ability and good clinical performance.[1] however, moral reasoning (ability to distinguish between right and wrong and good and bad) can only begin, as a cognitive process, once a problem has been identified.[2] this is disconcerting, as a considerable body of evidence indicates that people have little, if any, insight into what constitutes a moral problem and the processes underlying their judgements (mainly evaluations or estimates) and decisions (an intention to pursue a particular course of action), causing their moral behaviour to be based essentially on rationalisation.[3,4] according to kohlberg’s cognitive moral development theory, an individual must first become aware of an ethical issue before ethical judgement processes are likely to be triggered.[5] kohlberg and blatt worked on a theory[6] in which they argue that individuals can only move to higher levels of moral reasoning by reorganising their thinking after they have had the opportunity to grapple independently and actively with moral issues or dilemmas one stage above their current moral development. traditionally, ethics has been taught in the form of didactic lectures in which much information has been given to students, who had to reproduce the facts. the author concurs with rest[7] that this kind of methodology is counterproductive in isolation as a singular teaching technique where only summative assessment is done. rest[7] argues that socratic classroom discussions (smallgroup discussions (usually 5 15 participants) about universal questions) held over several months can produce changes (understanding issues as having a moral base) which, although small, are significantly greater than those found in control groups that have not had this experience. the aim of this study was therefore to conduct a pilot study in a south african (sa) study to test the assertions of rest[7] and investigate whether a combination of didactic and socratic teaching approaches could influence a group of students’ moral reasoning abilities. the aim is furthermore to use the knowledge gained from this study and to conceptualise a next study where suggestions could be tested, such as the integration of moral frameworks and reasoning activities into the general curriculum rather than it being a separate module. a 1-week course was presented to include beauchamp and childress’ four basic principles (autonomy, beneficence, non-maleficence and justice) as well as assisting participants’ growing awareness of one another’s viewpoints on values and also their consciousness of their own personal values. in addition to this information about the legal requirements, the formation of psychological structure in moral reasoning and the implication of one’s actions were also provided to give the students a holistic picture of the effect of decision-making. applying the acquired knowledge and skills through a final grand finale group case study presentation, the students were challenged to overcome their own prejudices and give their objective analysis of a case within their field of study by following the steps of an ethical reasoning. the duration of the intensive course was 1 week, with 8 hours contact per day with a facilitator. the format of the course was both didactic (moral instruction) and socratic (answering questions with questions, where participants were challenged to form their own insights and solutions). the formal tuition (as described above) was supported by multimedia presentations (video-clips and podcasts) of influential case studies, ethical dilemmas and opinion analysis found in the ethical literature. group work, with an average of 5 6 members per group, focused on socratic dialogue and developed students’ reasoning abilities. each group had individual contact time with the facilitator during the day, when everyone had to give his/her opinion about an ethical dilemma to challenge ideas and internalise new constructs. the objective of the research was therefore to measure students’ moral reasoning frameworks before and after the intensive course in medical ethics to address the research question. methods participants and instruments the authors wanted to ascertain whether a 40-hour, week-long course of basic ethics training would influence the moral behaviour, reasoning and judgement of a group of final-year dietetic university students, regardless of whether the influence was only temporary. the aim was to prove that it is possible, and to suggest incorporation over a longer period of time (curriculum integration). to test the research question, 38 fourth-year dietetics students at a tertiary institution in sa were asked to participate voluntarily in the study. the course was part of their degree programme. no student was coerced into completing the questionnaires and all 38 students participated in completing the survey anonymously. ethical clearance background. ethics training at tertiary level is important to facilitate an understanding of patient dignity and respect. traditionally, ethics has been taught in the form of didactic lectures; however, the authors are of the opinion that practical applications are more useful. objective. to measure students’ moral reasoning frameworks before and after an intensive course in medical ethics. methods. the study cohort was given a preand post-test of the moral behaviour scale (mbs). the t-test for matched scores was performed to determine the presence of significant differences between the mean preand post-test scores for the 5 scales of the mbs. results. the study showed that there was a change in the students’ moral behaviour when a specific course structure was evaluated. conclusion. a combination of didactic and socratic methodology of training had some effect on the moral reasoning ability of healthcare students. afr j health professions educ 2015;7(2):180-182. doi:10.7196/ajhpe.385 changing students’ moral reasoning ability – is it at all possible? n nortjé,1 dphil; k g f esterhuyse,2 phd 1 department of dietetics, faculty of community and health sciences, university of the western cape, bellville, south africa 2 department of psychology, faculty of the humanities, university of the free state, bloemfontein, south africa corresponding author: n nortjé (nnortje@uwc.ac.za) research november 2015, vol. 7, no. 2 ajhpe 181 was obtained from the ethics committee of the university of the free state, bloemfontein (ecufs no. 139/2011) to conduct the study. the students were asked to complete a biographical questionnaire. table 1 indicates their gender. although females usually score higher than males in moral behaviour and judgement tests[8] (possibly because of their genderspecific socialisation processes[9]), this variable was not included in the study as the majority of the group was female and only 3 were male. the students were also asked to complete crissman’s moral behaviour scale (mbs) (adapted by rettig and pasamanickas[10]) before class time, and after completion of the course (outside class time). the scale consists of examples of different behaviours, grouped into 5 categories as clustered, and described by gorsuch and smith.[8] the students were asked to judge all 50 items as either moral or immoral. the categories are: 1. misrepresentation, e.g. a student who has been allowed to grade his own paper and reports higher marks than achieved. 2. irreligious hedonism, e.g. falsifying a child’s age to secure a reduced fare. 3. sexual misbehaviour, e.g. a man deserting a girl whom he impregnated without taking responsibility. 4. non-philanthropic behaviour, e.g. not giving to charity when able to. 5. non-conservative marriage pattern, e.g. seeking divorce because of incompatibility when both parties agree to separate. the scale values range between 1 (‘i strongly agree’) and 10 (‘i strongly disagree’). therefore, a higher average score would indicate that the person disagreed more with the specific action/subscale, i.e. a higher score on the misrepresentation subscale would indicate that it is less acceptable. averages per category were calculated and converted to a score out of 100 to simplify statistical analysis. analysis of data to determine the presence of significant differences between the mean preand post-test scores for the 5 scales of the mbs, the t-test for matched scores[11] was performed. this test does not determine whether there is a significant difference in the means of two groups, but rather investigates whether the mean difference equals 0. consequently, the mean scores ( x ), standard deviations (s), mean difference scores (d) and standard error of the mean (sg) for the different dependent variables are reported. to determine the difference scores, the post-scores were subtracted from the prescores. results the descriptive statistics (averages and standard deviations) for the total research group affecting the 5 subscales of the mbs are given in table 2. as shown in table 2, only 2 of the 5 subscales have significant t-values (misrepresentation and sexual misbehaviour), which means that these are the only 2 subscales where a change in the moral reasoning of the total group has taken place. the average post-score for misrepresentation is significantly higher than its average prescore, while sexual misbehaviour is the opposite, i.e. the average post-score is significantly less than the average prescore. the last column indicates, by means of the cohen d-value, that these differences have medium effect sizes, where effect size means the relation the average participant in the study has to the average control group (those not included in the study). this is an indication that the results are of practical significance and should be noted as areas where change has taken place. discussion the study did show that there was a change in the students’ moral behaviour and that the training had some effect. the students started to view the different scenarios in a less rule-orientated fashion (which is synonymous with religiosity) and started to move from kohlberg’s stage 4 (conventional level) to a more principled stage 5, where the individual determines what is right and wrong more autonomously by looking to universally held principles of justice and rights. thereby, the students became aware of and started to identify moral issues. applying an analytical framework (four-quadrant analysis of ethical problems), the students were forced to think more widely than their basic assumptions and incorporate more detail into their moral judgement-making. this stimulated more right-hemisphere thinking, which explains the downward pattern in all the post-test scores of the mbs values. although the changes in the average scores of the post-test are not as large as anticipated, the fact that the course was run over a single week must be taken into consideration. a limitation of the 40-hour programme is that moral development does not take place or change necessarily over a period of a week. however, the aim of the study was not to indicate total moral reasoning change, but rather to illustrate that in the sa student population such training can influence students’ moral reasoning abilities and that this needs to be explored and extrapolated into a greater part of the curricula. therefore, a programme in ethical training should be structured over a longer period, where the students have more time to engage in a socratic dialogue, be challenged to move to a table 1. distribution of total group with regard to gender variable distribution, % female 92 male 8 table 2. mean scores (x ), standard deviations (s), mean difference scores (d) and standard error of the mean (sg) for the matched difference scores dependent variable prescore post-score difference score t-value two-sided p-value dx s x s d sg misrepresentation 60.20 8.22 62.88 8.25 −2.68 1.10 −2.434* 0.023 0.48 irreligious hedonism 13.80 4.83 15.00 5.13 1.20 1.13 1.062 0.299 sexual misbehaviour 25.88 4.39 23.56 5.13 2.32 1.05 2.216* 0.036 0.44 non-philanthropic behaviour 17.28 5.21 16.40 6.52 0.88 1.40 0.627 0.537 non-conservative marriage pattern 4.24 3.33 4.16 2.85 0.08 0.78 0.103 0.919 *p ≤0.05 research 182 november 2015, vol. 7, no. 2 ajhpe cognitive moral stage higher than the present, and have a chance to internalise these opinions and changes. it would be beneficial to the discipline of ethics training to use the data gathered in this pilot study and do a similar study on a course which runs over an entire degree programme (these currently do not exist in sa) to extrapolate the benefit, and then to follow the graduates in a longitudinal study to see whether they genuinely internalised the principles and were able to apply them in specific situations in their professional conduct. references 1. sheenan tj, husted s, candee d, et al. moral judgement as a predictor of clinical performance. evaluating health professionals 1980;3:394-404. 2. green b, miller pd, routh cp. teaching ethics in psychiatry: a one-day workshop for clinical students. j med ethics 1995;21:234-238. 3. hardman d. judgment and decision making – psychological perspectives. chichester, uk: john wiley, 2009. 4. nisbett re, wilson td. telling more than we can know: verbal reports on mental processes. psychol rev 1997;84(3):231-259. 5. treviño lt, weaver g, reynolds sj. behavioral ethics in organisations: a review. j manage 2006;32:951-990. [http://dx.doi.org/10.1177/0149206306294258] 6. crain wc.  theories of development: concepts and applications.  6th ed. new york, usa: prentice-hall, 2010. 7. rest jr. morality. in: mussen ph, ed. handbook of child psychology. 4th ed. new york, usa: john wiley, 1983. 8. gorsuch rl, smith ra. changes in college students’ evaluations of moral behaviour: 1969 versus 1939, 1949, and 1958. journal of personality and social psychology 1972;24(3):381-391. 9. eisenberg n, fabes r, shea c. gender differences in empathy and prosocial moral reasoning: empirical investigations. in: brabeck mm, ed. who cares? theory, research, and educational implications of the ethics of care. new york, usa: praefer, 1989. 10. braithwaite va, scott wa. values. in: robinson jp, shaver pr, wrightman ls, eds. measures of personality and social psychological attitudes, vol. 1. san diego, usa: academic press, 1991. 11. howell dc. statistical methods for psychology, 6th ed. belmont, usa: thomson higher education, 2007. ajhpe issn 0256-9574 2010, vol.2 no.1 african journal of health professions education article 29 december 2010, vol. 2, no. 2 ajhpe many forms of simulation, as a teaching strategy, have been used successfully over the last few decades. some of the advantages thereof in health sciences education are that it is a learner-centered training modality that presents with no risks to patients and allows for facilitated repetition of learning until all students have achieved the required level of proficiency.1 simulation may reduce time spent by students in clinical areas to master the necessary skills and it is therefore perceived as an efficient use of limited resources. utilising the clinical skills centre (csc) for teaching of procedures may therefore facilitate the reduction in time allocated to the clinical areas. critical care (cc)-trained nurses are expected to have the expertise to perform a variety of practical procedures on patients, but even more importantly, they should be able to integrate information about a patient in order to provide holistic and effective care. the practical component of the cc nursing programme at the specific university consists of two parts: the completion of practical procedures and case presentations. some of the challenges associated with the teaching and assessment of these two components are important and will be discussed in this article. background/ literature the practical procedures are activities that are performed on a daily basis by registered nurses caring for critically ill patients. although these practical procedures consist of a cognitive, psychomotor and affective component, they amount to a set of rules for a list of actions, and therefore pose the risk of fragmenting the patient’s care instead of providing holistic care. performing the practical procedures correctly contributes to better and safer nursing care of the critically ill patient, but it does not allow the development of insight and critical thinking skills that are required of cc nursing students by the end of the programme. in order to do case presentations students need to master the skills of integration and critical thinking, which is at a higher cognitive level than simply performing the individual practical procedures. cc nursing students require an integrative type of thinking about physiology, pathophysiology and treatment to be able to grasp the nursing care priorities of a critically ill patient.2 the students have opportunities during the programme to be supervised by a cc nursing tutor in the clinical area. this time should ideally be spent on discussing the critically ill patients and their environments. these structured supervised clinical opportunities are of marked importance. tutors aim to spend at least one hour per week with individual students and during this time students have the opportunity to ask questions and discuss patients with the cc nursing tutor or practise the practical procedures required by the programme. the ineffective use of these clinical contact times is often a problem. during these teaching sessions, the students tend to focus on completing the individual practical procedures and neglect to do case presentations. the result of this is often cc-trained registered nurses who do not possess the skills to integrate knowledge, think critically and manage patients appropriately. the use of simulation in a csc to teach, learn and assess the individual practical procedures allows the cc nursing tutors to use the time in the clinical areas to assist the students in the development of their integrative and critical thinking skills. the questions addressed in this study were the following: • which practical procedures are suitable to be taught with simulation? • how do students and cc tutors perceive the use of simulation? • how do students spend the allocated teaching time at the bedside with the cc nursing tutors? methods ethics permission was received from the research ethics committee for this study and written consent was obtained from all participants. all participants agreed to take part in the study and they remained anonymous throughout. research design a descriptive case study design was used to examine a single nursing department and its cc nursing programme. the aim of the case study was to determine if simulation could be used to teach, learn and assess the practical procedures required in a cc nursing programme. population and sample the study population was all the postgraduate cc nursing students registered at a specific university as well as the cc nursing tutors involved in the clinical education of this group of students during 2007. all students (n=15) and tutors (n=5) volunteered to be part of the study so no samples were drawn. methods and procedures qualitative and quantitative data were used for this study. the qualitative data were generated through semi-structured group interviews as well as questionnaires consisting of open-ended questions. the quantitative data were obtained through a questionnaire making use of a five-point likert-type scale as well as by analysing students’ clinical logbooks. the interviews were conducted by the researcher, who was the manager of the clinical skills centre. in the first semi-structured group interview (with the cc tutors in the programme) consensus was reached about which of the 12 practical procedures required for the programme were most suitable to be taught and assessed in simulation in the csc. by the end of the academic year a follow-up semi-structured group interview was held with the same nursing tutors to gather data on how they had experienced the use of simulation as part of the programme. a questionnaire was used to gather both qualitative and quantitative data from the cc nursing students at the end of the programme. the researcher administered the questionnaire but remained uninvolved. a questionnaire used by freeth and fry3 served as a basis for the questionfresh simulation options in critical care nursing education elize archer, bcur hons (critical care), mphil higher education clinical skills centre, centre of health sciences educaion, university of stellenbosch correspondence to: elize archer (elizea@sun.ac.za) article article 30 december 2010, vol. 2, no. 2 ajhpe naire. the questions mainly focused on themes that emerged as being important from the literature review. two students randomly selected from the participant group were used to pilot the questionnaire in order to identify errors and ambiguous questions. the questionnaires completed by these two students were excluded from the participant group. finally, the clinical logbooks of the students were analysed to gather numeric data on how the teaching time at the bedside was spent. clinical logbooks of students from 2006 (who did not have the benefit of the simulated teaching sessions) as well as 2007 (the students who were exposed to simulation sessions) were analysed to see whether any observable differences existed. data analysis the qualitative information of the group interviews was transcribed and analysed by the researcher. field notes that were taken during the focusgroup interviews were also used to ensure that none of the discussion points were missed. content analysis was used in the analysis of the data. the text was broken down into units for analysis and then coded and categorised according to events and ideas. the categories identified were put together to see which different themes emerged. the quantitative data from the questionnaire as well as the data from the clinical logbooks were captured in ms word and descriptive measures such as averages and tables were used for analysis. results discussion-group interviews with the tutors the cc nursing tutors involved in the programme reached consensus that 10 of the 12 practical procedures would be appropriate to be taught and assessed in simulation in the csc (table i). the two procedures that were identified as not being suitable for assessment in simulation both require the presence of a patient to ensure that the students understand and interpret these procedures adequately. the themes of the focus-group interview at the end of the academic year with the tutors on how they had experienced the use of simulation are reflected in table ii and explained in the discussion section. student questionnaire (n=15) in general the students valued the simulation sessions. table iii is a summary of the perception and attitudes towards the teaching and learning in simulation in the csc. analysis of the clinical logbooks a comparative analysis of the 2006 and 2007 student logbooks was completed in order to investigate how the clinical contact sessions with the cc nursing tutor were spent. these data revealed that more time was spent at the bedside doing discussions or presentations of patients in 2007 than in 2006. there was also a decrease in the number of isolated practical procedures performed at the bedside during 2007, compared with 2006. this could well have been because of the fact that students had the opportunity to practise and complete most of their practical procedures in simulation in the csc and that they could therefore spend more time at the bedside discussing their patients holistically with their cc nursing tutors. discussion most of the reviewed studies found in the literature on the use of simulation discuss this in terms of undergraduate nursing and medical programmes. the results of this study, however, reveal that the practical procedures of a postgraduate cc nursing programme can also be effectively taught through simulation. below is a brief discussion of how the students and cc nursing tutors perceived the use of simulation in the csc. table i. results of the consensus discussion group interview procedures suitable to be taught and assessed in simulation procedures not suitable to be taught and assessed in simulation • assess an abnormal blood gas • assessment of neurological status • assess a chest x-ray • care of a ventilated patient • assess a 12-lead ecg • administer iv medication • perform open et suctioning • extubate a patient • maintain epidural analgesia • maintain haemodynamic monitoring • care of patient with a ventricular drain • care of a patient post-temporary pacemaker insertion table ii. themes identified from the group interview with the tutors concerning their experiences of the use of simulation positive feedback about the simulation sessions issues that needed to be improved • it worked pretty well • due to the sessions in the csc some of the students canceled their appointments with the cc tutors in the clinical areas • students with little practical experience prior to the course benefited most from the sessions • some students had difficulty in performing the procedures in the clinical areas although they have been found competent in the csc • procedures were taught consistently • teaching at the bedside needed to be revisited and structured • assessment was fair, consistent and uniform • the lack of equipment in the csc made some of the clinical scenarios unrealistic • the students’ practical procedures were all completed in time • clinical contact sessions were far more productive than in the past article 31 december 2010, vol. 2, no. 2 ajhpe curriculum integration the cc tutors indicated that they thought simulation was a consistent way to teach the practical procedures. neary4 points out that the use of simulation enables clinical skills to be clearly defined as learning outcomes for each part of the programme and that it can help to bridge the gap between theory and practice by offering opportunities for learning in a risk-free, low-anxiety environment. relying only on the clinical placement can mean that the development of clinical skills is ad hoc and dependent on what a particular unit has to offer. in a simulated environment students can be encouraged to discuss the situation and establish links between theory and practice. different learning and teaching methods small-group teaching and learning another positive comment in this study was that the small-group teaching allowed focused discussion in a non-threatening environment. in a ‘real’ health care setting, learning is in a sense a by-product of care. the clinical needs of the patients must always take priority over the educational needs of the learner. simulation, however, deliberately places the learners’ needs at the centre of attention and provides the opportunity to create conditions of best practice for teaching. 1 self-directed learning students are increasingly being encouraged to take responsibility for their own learning and to develop skills for becoming lifelong learners. the csc provides them with the opportunity to maintain their skills in periods between clinical placements and ‘revise’ them prior to clinical assessments.5 feedback all the students indicated that they valued the assistance and feedback while practising the practical procedures with a cc nursing tutor in the csc. this confirms that feedback on performance is a crucial component of the learning processes associated with simulation. nicol and glen5 explain that provided that there is an adequate level of supervision, mistakes can be used to provide valuable feedback opportunities for the whole group. the additional use of dvds the students indicated in the questionnaire that there is a need for additional teaching and learning material to be available in the csc, e.g. dvds. treadwell and grobler’s6 study about medical students’ perceptions of learning in simulation, recommend the following with regard to the use of videos in the csc: • videos should not take the place of live practical demonstrations. • videos are only appropriate if students watch them before an actual live demonstration. • one should show videos that are relevant to the south african context. controlled and safe environment simulation is a learner-centered modality that presents no risk to patients and facilitates the repetition of particular aspects of tuition. this aspect was greatly valued by the students and they indicated that they welcomed the fact that they could repeat practical procedures in the csc without causing harm to their patients. because the environment is safe, learners have the opportunity to fail and can then learn from their mistakes.7 the transfer of learning the problem of transferring the learning in the csc to the clinical area is always a challenging issue that one has to be aware of. according to kneebone1 procedural interventions are often directed towards taskbased training, whereas clinical practice is artificially broken down into component skills. these are practised and assessed in skills laboratories, isolated from the clinical reality that they are intended to reflect. the assumption that such learning is directly transferable to a clinical context often goes untested. there is a danger that the task-based simulation may become divorced from the wider context of actual clinical practice. unfortunately in the case of the data gathered from this study it was not possible to measure whether students had the ability to perform better in more complex skills expected of them. utilisation of teaching time at the bedside the cc nursing tutors indicated that the csc sessions were of particular benefit to the academically weaker students. because their practical procedures had been completed timeously in simulation, these students, when taught in the clinical areas could proceed to performing case presentations with their cc nursing tutors rather than doing individual practical procedures. conclusions the aim of the study was to investigate whether simulation was suitable to be used to teach and assess the practical procedures required in a cc nursing programme as well as how it was perceived by the students and the tutors. the information obtained from the study indicated that the students and tutors were largely in agreement that simulation was valuable and can be used in a cc nursing programme. the study also revealed that table iii. results of the student questionnaire attitudes and perceptions percentage of agreement with statements • they could repeat practical procedures in the csc without causing harm to their patients 100% • the sessions in the csc assisted them in the process of integrating theory and practice 100% • it added value to have the assistance and feedback of a cc nurse tutor while practising the procedures in the csc 100% • practice in the csc was realistic enough to ensure the transfer of learning to the clinical area 92% • the learning opportunity in the csc helped to make them more confident and competent to perform these same procedures on real patients 92% • learning in groups and from peers was meaningful and enjoyable 75% • the manikins in the csc were sufficiently realistic to help with the development of their clinical skills 75% • students enjoyed the sessions in the csc and learned from them 100% article 32 december 2010, vol. 2, no. 2 ajhpe the way students spent their time in the clinical areas have changed due to the use of simulation opportunities. although this study has shown the benefits of teaching in simulation, it is advisable that each skill should be individually assessed for advantages and disadvantages of teaching in simulation before a general recommendation can be made. limitations: this study was done at one university with one group of critical care nursing students. further studies amongst similar groups are needed to assess the generalisability of this study. funding: none conflicting interests declared: none acknowledgements: the authors wish to acknowledge the students who participated in this study and the nursing tutors involved. references 1. kneebone r. evaluating clinical simulation for learning procedural skills: a theory based approach. academic medicine 2005;80(6):549-552. 2. rauen ca. simulation as a teaching strategy for nursing education and orientation in cardiac surgery. critical care nurse 2004;june:46-51. 3. freeth d, fry h. nursing students’ and tutors’ perceptions of learning and teaching in a clinical skills centre. nurse education today 2005;25:272-282. 4. neary m. project 2000 students’ survival kit: a return to the practical room. nurse education today 1997;17:46-52. 5. nicol n, glen s. clinical skills in nursing. the return of the practical room. ltd, london: macmillan, 1999. 6. treadwell i, grobler s. students’ perceptions on skills training in simulation. medical teacher 2001;23(5):476-482. 7. kneebone r. simulation in surgical training: educational issues and practical implications. medical education 2003;37:267-277. article december 2012, vol. 4, no. 2 ajhpe 123 the university of the western cape (uwc)’s school of dentistry has two training platforms, situated at the mitchell’s plain oral health centre and tygerberg oral health centre. the paediatric dentistry module spans a two-year period during the 4th and 5th years of the undergraduate dentistry programme. three full-time permanent staff members manage the department between the two sites and additional part-time clinical supervisors are employed to assist with supervision of approximately 200 students. part-time staff members with a keen interest in paediatric dentistry are recruited from the private sector to assist with student training in the clinic. the department has a structured teaching protocol with regard to clinical teaching, and guidelines aligned with the clinical outcomes are routinely provided to the staff to standardise what is being taught. yet, from student evaluations of the course, it was evident that part-time staff members do not follow these guidelines and do not engage in chair-side teaching as often as the department would like them to. two interventions were introduced to address these issues ‒ one for staff and one for students. the staff intervention involved a workshop where questionable treatment plans signed off by part-time staff members were used as a departure point to illustrate how they could be improved. this article focuses on student intervention involving the use of an e-learning management platform to impart more detailed information to students to compensate for the lack of chair-side teaching, i.e. a blended learning approach was followed to supplement the department’s traditional teaching methods. introduction there has been a ‘phenomenal uptake of new technologies’ by the younger generation, to the extent that today’s students think and process information differently than their predecessors.1 technology has changed the way students access information.2-4 computers provide easy access to unlimited knowledge and resources in every field and computer literacy is considered to be a priority for student development.2 currently, computers enjoy prominence as a learning tool. integration of technology into academic practice is dependent on how well it fits into existing systems and to what extent it contributes to the generation of knowledge.2 the e-learning platform creates an opportunity to explore unconventional methods of teaching.5 however, computer literacy is vital if this platform is to be used.6 e-learning or ‘technology-enhanced learning’ refers to the transfer of knowledge via the internet, intranet or through other digital means, such as previously recorded audiovisual media or satellite television.4 this wide introducing dental students to e-learning at a south african university n mohamed, f peerbhay department of paediatric dentistry, university of the western cape n mohamed, bchd, bsc hons (paed dent), msc (paed dent), lecturer f peerbhay, bsc, bchd, diploma (paed dent), msc (comm dent), lecturer corresponding author: nadia mohamed (namohamed@uwc.ac.za) background. this article reports on the introduction of an innovative ‘blended learning’ approach in the paediatric dentistry department at the university of the western cape (uwc) in cape town, south africa. this intervention was the first of its kind to be introduced at uwc’s dentistry faculty. methods. educational resources were placed online to supplement didactic and clinical teaching and thus compensate for the lack of chair-side teaching. an online learning platform was therefore provided for students to engage with. results. forty-seven per cent of students accessed the site. the evaluation of the course by these 4thand 5th-year students was mostly positive. students who did not access the site provided a variety of reasons for not doing so, the main reasons being ‘lack of time’ (40%) and ‘lack of it resources’ (41%). conclusion. this intervention highlighted the fact that ‘blended learning’ definitely has its place in the dentistry curriculum, especially if minor issues such as access to resources can be addressed. the paediatric dentistry department at uwc is continually pursuing current trends in teaching to provide an education that is on par with global standards. ajhpe 2012;4(2):123-127. doi:10.7196/ajhpe.179 article 124 december 2012, vol. 4, no. 2 ajhpe article range of online tools enables users to engage with the information on different levels and caters to variations in learning styles.3 in cases where e-learning is used as an adjunct to face-to-face teaching, the term ‘blended learning’ applies. formal lectures provide ‘directed learning’, which is supplemented by online learning resources.7 computer-based activities are thus integrated with traditional teaching methods. teaching methods or tools should enhance student learning.2,4 for the successful implementation of e-learning, the underlying pedagogy must be taken into consideration as to how learning takes place online.8 e-learning cannot exist without a sound foundation of pedagogical theory.8 the e-learning platform should not only be a different means of delivering information but should actively encourage learning.5 this was the motivation for providing an online resource in this study. incorporation of e-learning into university programmes should be a gradual process.2 varying degrees of online resources can be utilised, including the provision of very basic information such as access to module information, course content, suggested reading and lecture content, to the other end of the spectrum where courses are interactive and fully integrated with limited formal contact time.7 some e-learning systems only provide textbased learning materials that do not engage the students adequately for them to gain a good understanding of the topic.9 the current advances in multimedia technology allow for e-learning systems to combine multimedia content to make it interactive and stimulating.9 in the paediatric dentistry course, the first phase of implementation involved creating a basic online module, purely as a means of providing access to additional information. an interactive component, including the use of multimedia technology, will be introduced to the course at a later stage once students have engaged sufficiently with the current material. the ‘phases of engagement framework’ reported by conrad and donaldson10 provides a framework for the instructor to develop appropriate activities for their course and introduce them in an effective sequence. learners can be guided through more advanced activities once they have gained more confidence and expertise.10 the objective of the current intervention was to make additional resources available to students to supplement their lectures and enhance their understanding of the subject matter. a wealth of information on paediatric dentistry is available on the internet, but students at 4thand 5th-year level have yet to develop the skills required to critically appraise the literature. internet resources can be unreliable because their credibility is often not checked.6 lecturers can overcome this problem by screening the content and making relevant, updated, evidence-based information available. providing easily accessible information on an e-learning platform could therefore be a means of ‘quality control’.6 the content on the paediatric dentistry online environment would also be supplemented by in-depth explanations and definitions to clarify concepts and improve students’ understanding of the more challenging sections of the syllabus. this could then provide a means of ‘filling in the gaps’ and help compensate for the lack of clinical teaching. methods the e-learning team created a framework of the paediatric dentistry course online, within uwc’s e-learning/e-teaching management platform. the lecturers who co-ordinated the module then tailored the course to address ‘gaps’. sanders and walsh4 refer to this type of content-specific resource as a ‘quick snack’ which could ‘satisfy a hungry learner’. this was the first phase of implementation and involved the placement of the following resources onto the e-learning management platform: • an overview of the course including assessments, quotas, clinical guidelines and course expectations. • a clinical diagnosis and treatment planning form with detailed explanations. all the relevant information on this form that needed clarification was linked to explanations that would assist students with diagnosis and treatment planning. • lecture notes and presentations. • concept maps to give an overview of lectures and assist with revision. • possible test and exam questions. • additional relevant reading material, e.g. links to journal articles. • a calendar with test dates and assignment due dates. the course was first made available online. students were given training by means of a short power point presentation to acquaint themselves with the e-learning management platform. they did not receive any other formal training but were given the basics on how to navigate through the site. additional training would only be arranged if more than 25% indicated that it was necessary. students were given a two-week period in which to access the online site. thereafter, they had to complete an anonymous evaluation form with regard to their e-learning experience. student evaluation forms provided the data for analysis. responses were analysed by grouping the comments made by the students into themes related to positive and negative aspects of e-learning. results a total of 118 responses were received. of these, only 55 students accessed the module online (fig. 1). students provided a variety of reasons for not accessing these resources (fig. 2). twenty-five per cent claimed not to have access to the internet at home, while others blamed the lack of computer availability for not accessing the site. they claimed that there are not enough computers in the computer lab as well as at the residences. ten per cent of students reported that the computers did not work, and 2% did not have access to the computer lab. the majority (40%) cited the lack of time and huge clinical workload as the main reasons for not accessing the site. website problems were also common with students citing slow internet connection and log-in problems as the main obstacles. sixteen per cent of students complained that the servers were down on numerous occasions (fig. 3). the majority of students found the site easily accessible, easy to navigate and user friendly (fig. 4). no additional training was arranged as only 18% of students felt they needed it. december 2012, vol. 4, no. 2 ajhpe 125 article students were asked what would motivate them to access the module online. their responses (according to their year of study) are given in table 1. more general comments are summarised in table 2. discussion the current body of evidence supports the effectiveness and acceptance of e-learning within the realm of medical/dental education.11 e-learning is enhanced when combined with traditional classroom activities in a blendedlearning approach.11 an advantage of the e-learning platform is that it enables students to learn at their own pace, and information can be accessed at the student’s convenience.3,4,6,7 in this study, however, students claimed not to have had the time to access the resources due to their clinical workload that is spread over two teaching platforms. as is evident from the responses, the junior students had a very different attitude towards accessing the module online. they mostly intended to use the facility to access notes if printed ones were not provided. a possible reason for the lack of interest shown by the junior students is that ‘engagement of e-learning by students requires more maturity than classroom teaching does’.12 the majority of 4th-year students were not open to the idea of accessing these resources online as they felt it was more difficult to learn from a computer screen and they preferred information in the form of printed notes. this invariably means increased cost for the university. peterson et al.3 found that when given a choice between purchasing a traditional textbook and accessing the electronic version of the textbook online, not a single hard copy was sold as the online textbook did not cut into their budget and was more accessible. paediatric dentistry students at the university of washington found value in online resources for lectures, reading, instruction/demonstration, selfassessment and testing.3 students at the university of basel in switzerland also reported that the possibilities offered by e-learning had a positive impact on their studies.13 similar responses were received in the present study but, unlike at the universities of washington and basel, these students were not exposed to interactive assessment. the majority of them did, however, find the possible test and examination questions at the end of each chapter to be very helpful. fig. 1. access to site (n=118). fig. 4. ease of navigation through site. fig. 3. website problems. fig. 2. reasons for not accessing site. table 1. students’ motivation for accessing the online module 4th-year students 5th-year students curiosity to obtain notes only if it will be helpful for exam purposes it encourages more advanced learning good supplement to lectures and tutorials helps with preparation for exams table 2. general comments from students with regard to the online module 4th-year students 5th-year students not a good idea not all students have access not enough working computers do not want to learn from a computer screen good idea interesting broadens knowledge base 126 december 2012, vol. 4, no. 2 ajhpe article the final-year students were generally more positive about their experience and commented that the information provided a good guide for studying purposes and helped them to prepare for theory and clinically based examinations. many students found the information relevant, helpful and informative. it is, however, imperative that the content on these learning platforms is updated regularly.4 in addition to website-related problems, students in this study cited the lack of resources and poor access to computers as the major obstacles. bozalek et al.14 reported that students at uwc generally did not have access to computers and the internet at home, whereas the majority of students at stellenbosch university (su) did. uwc students could only use the computers available at the university.14 the situation at uwc as reported by bozalek et al.14 is in stark contrast with the scenario at the university of basel, where ‘all except one student owned at least one computer or laptop’.13 despite the fact that both uwc and su had computer labs, it appears that the labs at the former were often very full and not readily available to students. this situation was exacerbated by the fact that these labs were closed after hours.14 inability to access resources can become frustrating and could impact negatively on students’ willingness to engage with these online resources.3 the lack of technical resources among the students in this study contributed to their negative attitudes. some students even suggested that making use of the university’s shared drive would be an easier way to access the information. this would, however, negate one of the benefits of creating an online module where public access to the course is limited to students who are registered, thereby also safeguarding original material. the students also found that some documents were difficult to download if their computers did not have the appropriate version of windows. peterson et al.3 experienced similar glitches where students were unable to access certain quizzes from computers that were not equipped with the newer version of the java computer program. downloading information from home can also be problematic owing to the possibility that access to broadband could be limited.4 faster internet connectivity would therefore be a major advantage.3 other barriers to access would include computer failures and viruses.6 recommendations for improvement it-related • improve accessibility to the site. students found it very frustrating that the network was down for long periods of time and they did not have the time to return when the computers were eventually online. • make the downloading of documents easier. documents should be made available in a format that is accessible to all and should be compatible with older versions of windows. • allow students to open more documents simultaneously. the system is very awkward as one has to keep going back. • increase the number of working computers to improve student accessibility. • ban access to social networking sites so that all students can access the computers for legitimate reasons. • send e-mails to students when the site has been updated. module-related • add clinical cases. • combine test and exam questions with a case. • include mock tests with memos. • add all student case presentations to use as mock osces. • include notes on additional topics, e.g. prophylaxis, fluorides, sedation and general anaesthesia, to clear up confusion. • keep updating the site. • include section for ‘suggested reading’. • give more references. with the migration of e-learning to a new e-teaching platform which is more structured, it is envisioned that many of these concerns will be addressed. students may therefore be more inclined to access these resources, thereby encouraging them to take responsibility for their own learning. conclusion a change in mindset needs to occur, especially among the younger dentistry students before they are ready to accept this intervention as an adjunct to traditional teaching methods. final-year students recognised the value of this teaching tool. this study highlights areas where the content of the site could be improved to make it more attractive to students and where problems regarding it support were also brought to light. a good support structure is essential to facilitate a positive e-learning experience and encourage students to routinely use this facility to enhance their learning experience. the success of such an intervention also depends on the student’s willingness to make use of the resources provided. adding an interactive component to this learning platform could be used as an incentive for students to engage more actively with the material. this would be the next phase of implementation for this department and could take the form of interactive self-assessment and discussion boards. weekly questions could be posted and discussed on the discussion boards and incorporation of some of these topics in test and examination questions could be an added incentive. this would shift the focus from the more traditional teacher-centred approach where students take on a passive role in the learning process to a student-centred learning approach where students are encouraged to actively engage with the material and take responsibility for their own learning.15 active learning was shown to develop important ‘graduate capabilities’.15 e-learning definitely has a place in the paediatric dentistry curriculum. studies have shown that technology can be used to enhance student learning.7,16 online resources should not replace lectures but should be used as an adjunct to formal contact sessions.7 it is important that institutions of higher learning move with the times and embrace technology as a teaching tool. references 1. mason r, rennie f. e-learning and social networking handbook. resources for higher education. new york: routledge, 2008:12. 2. goodfellow r, lea mr. challenging e-learning in the university ‒ a literacies perspective. new york: mcgraw hill society for research into higher education and open university press, 2007:12-135. 3. peterson d, kaakko t, smart e, jorgenson m, herzog c. dental students attitudes regarding online education in pediatric dentistry. online journal of dentistry for children 2007:74(1):10-20. december 2012, vol. 4, no. 2 ajhpe 127 article 4. sanders j, walsh k. a consumer guide to the world of e-learning. student british medical journal 2006:14:240-241. 5. herrington j, reeves tc, oliver r. a guide to authentic e-learning. taylor and francis group, new york: routledge, 2010:3. 6. jackson h, ibrahim r, shah s, begum a, brigden d. e-learning: the way forward for medical students. international doctors association news review 2010:5. 7. turney csm, robinson d, lee m, soutar a. using technology to direct learning in higher education: the way forward? active learning in higher education 2009:10:71-83. [http://dx.doi.org/10.1177/1469787408100196] 8. govindsamy t. successful implementation of e-learning pedagogical considerations. the internet and higher education 2002:4:287-299. 9. zhang d, zhao l, zhou l, nunamaker jf. can e-learning replace classroom learning? communications of the acm 2004:47(5):75-79. [http://dx.doi.org/10/1145/986213.986216] 10. conrad rm, donaldson ja. engaging the online learner ‒ activities and resources for creative instruction. 1st ed. san francisco, john wiley & sons inc, 2004:10. 11. ruiz jg, mintzer mj, leipzig rm. the impact of e-learning in medical education. acad med 2006:81(3):207-212. [http://dx.doi.org/10.1097/00001888-200603000-00002] 12. kumar a, kumar p, basu sc. student perceptions of virtual education: an exploratory study. in: mehdi khosrowpour, web-based instructional learning 2001:132-141. http://books.google.co.za/books?hl=en&lr=&id=drnk0p nlkcmc&oi=fnd&pg=pa132&dq=kumar+a,+kumar+p,+basu+sc+%2b+students+perception+of+virtual+ed ucation:+and+exploratory+study&ots=2lpvdxbrca&sig=kdidrdasuxfwvfdsyz6jqm8cyvi#v=onepage&q&f =true (accessed 1 september 2012). 13. neuhaus kw, schegg r, krastl g, amato m, weiger r, walter c. integrated learning in dentistry: baseline data and first evaluation at the dental school basel. european journal of dental education 2008;12:163-169. [http:// dx.doi.org/10.1111/j.1600-0579.2008.00513.x] 14. bozalek v, rohleder p, carolissen r, leibowitz b, nicholls l, swartz l. students learning across differences in a multi-disciplinary virtual learning community. sajhe 2007; 21(7):812-825. 15. kember d. promoting student-centred forms of learning across an entire university. higher education 2009; 58:1-13. [http://dx.doi.org/10.1007/s10734-008-9177-6] 16. sweeney j, o’donoghue t, whitehead c. traditional face-to-face and web-based tutorials: a study of university students’ perspectives on the roles of tutorial participants. teaching in higher education 2004;9(3):311-323. [http://dx.doi.org/10.1080/1356251042000216633] 51 june 2017, vol. 9, no. 2 ajhpe short research report role-play, as a teaching technique, can greatly enhance students’ learning by asking them to enact a specific role that relates to their learning outcomes.[1] it draws on students’ creativity, improves their communication, serves as an effective tool for team building and increases analytical skills.[2] benefits of role-play in medical education have been reported,[3] but the impact of the strategy is yet unreported in the allied health sciences at universities of technology, where there is a need to improve pass rates. role-play, when combined with community engagement, can greatly enhance empathy in issues and challenges relating to the community.[4] the objective of this study was for 2nd-year students enrolled for programmes in the allied health professions at the durban university of technology (dut), south africa (sa), to ascertain the benefits of role-play and community engagement projects (ceps) in the context of understanding the parasitic diseases. this study also explored the benefits of interventions on students’ learning. methods ethical clearance was obtained from the dut research ethics committee (ref. no. irec 030/14). chiropractic and homoeopathy students who register ed in 2014 for the parasitology module in their 2nd year of study (n=58) were given an assignment on arthropod and mammalian parasites. the assignment was presented as a role-play in class and subsequently in a school or children’s home as part of a cep. the assignment required students to work in self-selected groups of 6 8 members. each group performed a play on a different arthropod/ mammalian parasite, which included common community pests such as flies, ticks, bedbugs, mosquitoes, lice, fleas, mites, rats and mice. the groups conducted research in relation to the parasite, including the parasitic life cycle, diseases caused, and prevention and control measures. topics were allocated by a ballot method. student groups prepared a research report that was made available to their peers on the online forum. after delivery and assessment of the assignment, all students were invited to participate in the study; however, participation was voluntary and those who agreed to participate (n=56) signed informed consent prior to answering the research questionnaire, which was adapted from a study by higgins-opitz and tufts.[3] responses required yes/no or degrees of agreement on a likert scale. additional comments were offered in an open-ended section. questionnaires were administered by an independent research assistant. test scores of the students before and after the assignment were compared. data were analysed on spss version 21 (ibm corp., usa). results respondents were mainly english (60%) and isizulu (22%) first-language speakers. the majority (85%) found the topics interesting and relevant. they reported that the topics helped them to understand the parasites’ life cycles (82%) and diseases (84%). the majority of respondents experienced the role-play as beneficial to their learning. they thought that it encouraged and supported further selfstudy. they became more enthusiastic because of the creativity required during the project (73%) and it helped them to understand the relevance of their studies (77%). the majority of respondents (78%) indicated that they learnt more when preparing for the role-play. in addition, participation in background. role-play can enhance students’ learning, improve communication and serve as an effective tool for team building. when combined with community engagement projects (ceps), it can enhance empathy in challenges relating to the community. the benefits of role-play in medical education have been reported, but the impact of the strategy is unknown in the allied health sciences at universities of technology, where there is a need to improve pass rates.  objective. to ascertain the benefits of role-play and ceps in the context of understanding parasitic diseases by students enrolled for programmes in the allied health professions. method. role-play and ceps were used to facilitate students’ learning of parasitic diseases. students’ perceptions of the influence of these strategies on their learning were determined through the use of a semi-structured questionnaire. test scores of the students before and after the assignment were compared. results. the majority of students reported becoming more enthusiastic about their studies. they indicated that role-play with regard to the clinical features of the parasitic diseases added to their improved understanding of the disorders. role-play also made the learning entertaining and informative, and enhanced class camaraderie. an improvement in the students’ test marks and pass rates relating to this section was also observed. students valued the opportunity to teach people in the community, which linked their learning to a community engagement initiative. conclusion. learning through role-play and using a cep to teach about parasites enhanced the quality of student learning in the allied health sciences. afr j health professions educ 2017;9(2):51-53. doi:10.7196/ajhpe.2017.v9i2.673 use of role-play and community engagement to teach parasitic diseases f haffejee,1 phd; j van wyk,2 phd; v hira,1 bsc 1 department of basic medical sciences, faculty of health sciences, durban university of technology, south africa 2 department of clinical and professional practice, nelson r mandela school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: f haffejee (firozah@dut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. june 2017, vol. 9, no. 2 ajhpe 52 the play caused students to engage in additional reading and research of the parasites and parasitic diseases (74% and 78%, respectively; table 1). the respondents agreed that role-play made the presentations more entertaining (82%) and that it helped them to gain an easier and better understanding of the disorder being studied (77%). those who were hesitant to speak in front of a large group indicated that the activity had helped them to overcome their fear of public speaking (58%). the role-play of other groups was equally informative (85%) and easy to follow (63%). students valued the feedback from their peers, which helped them to identify deficiencies in their presentations (64%). some students (34%) were, however, still reluctant to ask questions during the discussion time (table 1). the role-play enhanced class camaraderie (82%). the presentations allowed the majority to integrate new material with previously taught content (76%). despite a small group (44%) indicating that the presentations were more informative than lectures, 78% thought that role-play should be continued in the future. while 71% found the exercise useful, only 56% wanted role-play extended to other parts of the curriculum (table 1). most respondents were pleased to present as part of a cep (80%). the cep component increased their awareness of how education can help others (85%). the majority planned to become more involved in cep in the future (84%). the students obtained a significantly higher mean on their test scores (77.7 (standard deviation 10.9)%; range 53 95%) after the role-play intervention, when their marks were compared with the pre-intervention test (55.2 (17.0)%; range 11 91%; p=0.005). the pre-intervention and postintervention pass rates were 72.4% and 100%, respectively. discussion the intervention promoted active involvement of students in the learning process. it allowed them to be creative and to develop new skills. it had a positive impact on the students’ learning, with the majority becoming more enthusiastic and active in the learning process. students found the topics stimulating and relevant to the course; it also helped in understanding both parasitic lifestyles and diseases. students were very creative in their approach to and presentation of the task. the role-play took the form of short plays, which ranged from patient consultation with health practitioners, school scenarios, such as was seen in a lice presentation, to sa real-life situations, mimicking housing conditions of low-income workers through to taxi drivers. the plays generated a great deal of interest and humour among students and staff. the students indicated that the presentations were informative, enhancing class camaraderie. role-play of clinical features of the parasitic diseases was perceived to improve students’ understanding of the disorders. other studies have similarly found that roleplay increased learning and retention.[3] role-play can serve as an extra strategy to assist weaker students, who generally struggle with abstract concepts.[5] we also noted an improvement in mean test marks and pass rates after the role-play exercise, indicating that weak students, particularly, benefited from the intervention. as higher education institutions are striving to increase higher pass rates, the introduction of this type of intervention will be beneficial to both the students and the institutions. interestingly, only 44% of respondents found role-play more informative than lectures. it is possible that this finding stems from our students’ past, where they relied heavily on teacher-directed instruction, and that these students still need to become confident in their ability to research their own topics. the students could easily follow and understand the peer presentations, indicating that they were able to learn from researching, role-playing and their role as a peer observer and assessor. furthermore, our study indicates that students who were previously hesitant to speak in front of large groups of people now overcame their fear of public speaking. this is supported by a previous study, where role-play was used in the teaching of foreign language education.[1] it has been suggested that role-play boosts self-confidence and raises self-education capabilities.[2] our study was novel in that the students were required to present the role-play at an educational facility, such as a school or a children’s home, as part of a cep. feedback indicated that this part of the project was favourably experienced and enjoyed. the majority intended to maintain their involvement in the community setting. soon after the class activity, two groups of students returned to the respective children’s homes to spend additional time with the children. the activity thus not only created sympathy for those afflicted by parasitic diseases, but created empathy for those less fortunate than themselves. consequently, our students have taken steps to alleviate the plight of disadvantaged individuals. the majority of students wanted the exercise to continue during the course. however, only 58% felt that such an exercise should be extended table 1. benefits of role-play and responses to a community engagement project benefits of role-play in the classroom, % role-play by the other groups were informative 85 role-play made the presentations more entertaining 82 role-play contributed to a more friendly camaraderie atmosphere in the class 82 role-play encouraged further reading on parasitic diseases 78 learn more when having to prepare for the role-play 78 this method of teaching should continue in future 78 role-play helped in understanding the relevance of the study 77 gained an easier and better understanding of the disorder 77 role-play helped to integrate material covered in other parts of the curriculum 76 role-play encouraged further reading on parasites 74 role-play caused more than usual enthusiasm about studying 73  found the exercise useful 71 audience feedback was helpful in identifying deficiencies 64 it was easy to follow the subject matter presented by other groups 63 role-play helped in overcoming the fear of addressing a large group of people 58 would like role-play extended to other courses offered in the 2nd-year programme 56 generally reluctant to speak in front of a large group 56 role-play is more informative than lectures 44 hesitant to ask questions during discussion time 34 responses related to community engagement, % project created awareness of the need to be engaged in communities that need help with education 85 plan to become more involved in community engagement projects in the future 84 happy to present the work as part of a cep 80 short research report 53 june 2017, vol. 9, no. 2 ajhpe to other sections of the curriculum. similarly, a study conducted among sa medical students indicated that students did not want the exercise to continue in other parts of the curriculum, possibly owing to the large volume of work comprising the 2nd-year curriculum and the substantial amount of time required in the preparation of a good role-play.[3] nevertheless, the positive feedback received indicates that the exercise should be continued in future years for this part of the course, as the benefits would outweigh the extra time spent in preparing for the presentation. conclusion this study indicated that the innovative method of teaching through roleplay and a cep was beneficial to students in the allied health sciences. the students felt good about directing their own learning. it allowed them to read around related topics, in addition to the topic of their own presentation. presentation of their work as part of a cep was enjoyable and has made them more aware of issues surrounding those less fortunate than themselves. it was perceived as a positive learning experience and also improved pass rates. 1. haruyama j. effective practice of role play and dramatization in foreign language education. komaba j engl educ 2010;1:31-58. https://doi.org/10.1016/0346-251x(85)90037-5 2. wang j, hu x, xi j. cooperative learning with role play in chinese pharmacology education. ind j pharmacol 2012;44(2):253. https://doi.org/10.4103/0253-7613.93862 3. higgins-opitz sb, tufts m. student perceptions of the use of presentations as a method of learning endocrine and gastrointestinal pathophysiology. adv physiol educ 2010;34(2):75-85. https://doi.org/10.1152/advan.00105.2009 4. illich i. to hell with good intentions. in: kendall j, ed. combining service and learning: a resource book for community and public service. vol. 1. raleigh, nc, usa: national society for internships and experiential education, 1990:314-320. 5. littlefield jh, hahn hb, meyer as. evaluation of a role-play learning exercise in an ambulatory clinic setting. adv health sci educ 1999;4(2):167-173. https://doi.org/10.1023/a:1009789110719 short research report https://doi.org/10.1016/0346-251x(85)90037-5 132 october 2016, vol. 8, no. 2 ajhpe master of public health (mph) students come from a wide range of health professional backgrounds.[1] graduate programmes in public health aim to equip students with critical skills to be able to integrate research into practice and have an analytical but practical approach to addressing current public health issues.[1] schools of public health (sophs) have the responsibility to ensure that graduates will be able to respond to rapidly changing local and global public health problems. south africa (sa) is a country with dynamic demographic and epi­ demiological transitions.[2] there is a growing demand for public health professionals who have an adaptable public health approach; who can solve public health issues; and who can contribute meaningfully to transforming the health sector. the public health sector landscape has changed over the years and the national department of health (ndoh) has adopted a strategic approach that is grounded in a vision for the population’s health, and that embraces re­engineered primary healthcare, strengthened hospital care, and health promotion and protection.[2] effective governance and leadership are necessary to ensure that the strategic goals are achieved. in kwazulu­natal (kzn) province, public health has been taught since the 1940s. through the institute of family and community health at the medical school, university of kwazulu­natal (ukzn), durban, sa, a wide range of professionals were educated using the community­ orientated primary healthcare approach.[3] after the institute was closed, the department of community health was established. during the 1970s, specialist training in public health for medical practitioners was instituted.[3] in an attempt to rationalise and improve public health education, the eastern seaboard association of tertiary institutions (esati), a network of eight apartheid institutions, four universities (durban­westville, natal, zululand, and the university of sa), and four technikons (natal, ml sultan, mangosuthu and technikon sa) was established, which offered public health postgraduate courses from 2001 to 2004. it enabled public health training of all healthcare providers, including medical, nursing, and environmental health. since 2004, ukzn has offered a graduate training programme in public health.[3] the tracking of graduates by institutions is important for higher education development to assess the social accountability, effect and influence of study programmes on the labour market.[4] no undergraduate degree in public health is offered in kzn and students for the postgraduate degree are recruited from diverse professional backgrounds. most of these students comprise clinicians who want to develop a population perspective on health and disease. the role and relevance of public health graduates in the sa health system have not been reported. given the multidisciplinary background of these graduates, it is necessary to establish their role within the health system. the objective of this study was to describe the educational and employment background of graduates and ascertain which skills acquired in the mph programme are applicable in their current work situation. methods an observational cross­sectional survey was conducted between june and october 2013. data were obtained from a self­administered questionnaire sent via email to the 61 contactable alumni who graduated with an mph degree between 2004 and 2013. nine international graduates were not contactable and were excluded from the study population. graduates were sent six weekly email reminders for 4 months to complete the questionnaire and those who did not respond were contacted telephonically. the questionnaire had a total of 23 closed­ and open­ended questions. data were collected on demographic characteristics, educational background and employment history. the questions included a component on the extent to which the mph degree contributed to career progression and the skills background. master of public health (mph) students come from a wide range of health professional backgrounds. graduate programmes in public health should equip alumni with knowledge and skills to analyse and integrate health research findings, and have a practical approach to current public health issues. in south africa (sa), there is a need for health professionals with an adaptable public health approach who can contribute meaningfully to addressing public health problems and transforming the health sector. the role and relevance of graduate public health training in the sa healthcare system have not yet been reported. tracking of graduates is important to assess the effectiveness of study programmes, graduates’ worth for the healthcare labour market, and their contribution towards improving the healthcare system. objective. to describe the professional backgrounds of mph graduates from the university of kwazulu­natal, durban, sa and the role of their learning in their current public health practice. methods. an emailed, self­administered questionnaire survey of graduates (n=61) was conducted in 2013. results. forty­five (73%) of the 61 contactable public health graduates from the past 10 years returned the completed questionnaire; 28 (63%) are working in the public sector and 9 (22%) at academic institutions. graduates reported that research skills, critical analysis, report writing, and leadership and management were acquired in the mph programme. most reported that they were able to integrate the knowledge and skills acquired from the mph degree in their current workplace. conclusion. the mph degree equips graduates with skills that contribute to addressing some of the public health problems in sa. afr j health professions educ 2016;8(2):132­134. doi:10.7196/ajhpe.2016.v8i2.681 tracking master of public health graduates: linking higher education and the labour market t dlungwane, bsc (physio), mph; s knight, bsc, mb bch, fcphm (sa) discipline of public health medicine, school of nursing and public health, university of kwazulu-natal, durban, south africa corresponding author: t dlungwane (dlungwane@ukzn.ac.za) short research report this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 133 acquired in the programme, as well as the graduates’ performance in their current positions. the questions on demographics, educational background and employment history were closed ended and those on skills and competencies were open ended. the data were captured into excel 2003 (microsoft, usa) and exported into the statistical package for the social sciences 15 (spss 15) (spss inc., usa). incomplete and other compromised data were omitted. data were summarised in appropriate frequency distribution tables and then analysed. ethical approval was granted by ukzn human and social sciences research ethics committee (hss/0615/013), and permission to conduct the study on university alumni was granted by the registrar. results of the 61 sa mph graduates, all were contactable and 45 (73%) returned self­completed questionnaires. the age, gender and educational background data for other graduates (non­respondents) were available from the alumni records. the non­respondents comprised females (60%), 40% were aged 30 ­ 39 years and >50 years, and 36% were trained in the social sciences. of the 45 respondents, 26 (58%) were female and 18 (40%) were 40 ­ 49 years old. twenty­one (48%) of the respondents’ first professional degree was in the allied health sciences, 9 (21%) had a medical degree, 8 (18%) were nurses, and 7 (14%) were from the social sciences (table 1). with regard to current employment of the respondents, 28 (63%) are working in the public sector and 9 (22%) at academic institutions. the respondents were asked which skills in their current employment relate to the mph programme. the most popular were research skills (82%), critical analysis (51%), report writing (51%) and leadership and management (49%). discussion seventy mph students have graduated at ukzn in a period of 10 years. the number is low for a province with a population of 10.3 million and the highest hiv, aids, and tuberculosis (tb) disease burden in sa, with an estimated hiv­tb co­infection rate of 70%.[5] the demand for public health graduates should be high, taking into consideration the transformation and development of the healthcare system in sa. the sa human resources for health (hrh) strategy has outlined the need to increase the output of mph graduates from the various schools of public health.[2] a substantial number of the graduates were between the ages 40 and 49 years. generally, public health graduates are older than graduates of other master­level degrees,[6,7] which has added implications for workforce planning and development. the hrh strategy recognises that the ageing healthcare workforce is a concern, as not enough young people are being trained to take over key roles in the health sector.[2] most of the public health graduates in this study were female, which is in line with other studies and is consistent with the feminisation of healthcare workers, particularly in public health globally.[1,7] this study shows a different trend in terms of the educational background of people enrolling for the mph degree. in africa there were traditionally more medical doctors registering for the mph degree than for other disciplines.[8,9] in this study, graduates were from diverse backgrounds such as allied health sciences (physiotherapy, pharmacy, environmental health and medical science) – similar to results reported from six mph programmes in low­ and middle­income countries.[1] most graduates are working in the public sector and 22% are working at academic institutions. they reported using the knowledge and skills acquired in the mph programme, such as report writing, critical analysis, research, and leadership and management skills. sa faces a shortage of highly skilled professionals with sound research skills.[10] the national plan for higher education outlines that universities should produce graduates with skills and competencies to participate in the modern world.[10] the results of the study suggest that the perceived skills and competencies acquired in the mph programme are relevant and adequate for the sa labour market. the public health sector is undergoing a major transformation, including primary healthcare re­engineering and the introduction of the national health insurance. these and other initiatives by the ndoh would increase the demand for appropriately or highly trained public health practitioners. the ndoh has outlined leadership, governance, research and development as key priorities.[2] in our study, the majority of mph graduates who responded work in the sa healthcare system, where they integrate the skills acquired in the programme to improve their workplace. the sophs need to work closely with the ndoh to ensure that public health graduates have appropriate skills and competencies required for the healthcare labour market. study limitations this survey was based on self­reporting by graduates, which is prone to social desirability bias. as a relatively small number of graduates are enrolled in this programme, a further study incorporating mph gradutes from other programmes is recommended. ascertaining employers’ percep­ tions of the mph graduate’s competencies and the relevance of these to the labour market are needed. this study is part of a large reseach project in which, alongside graduates, non­completers were interviewed to establish differences between groups. the results are being analysed. table 1. demographic characteristics of 70 mph graduates characteristics respondents (n=45), n (%) non-respondents (n=25), n (%) age (years) 20 ­ 29 1 (2) ­ 30 ­ 39 12 (27) 10 (40) 40 ­ 49 18 (40) 5 (20) >50 14 (31) 10 (40) gender female 26 (58) 15 (60) male 19 (42) 10 (40) educational background medical 9 (21) 5 (20) nursing 8 (18) 8 (32) social science 7 (14) 9 (36) allied health 21 (48) 3 (12) current employment public sector 28 (63) ­ academic institution 9 (22) ­ research 3 (6) ­ non­governmental organisation 3 (6) ­ self­employed 2 (3) ­ short research report 134 october 2016, vol. 8, no. 2 ajhpe conclusion the mph degree equips graduates with report writing, critical analysis, research, and leadership and management skills, which could contribute to addressing some of the public health problems in the healthcare system in sa. most graduates reported that the skills attained in the mph programme are incorporated at their current workplace. however, the number of public health graduates needs to increase to meet to the hrh demand in sa. this could be achieved by incorporating research training and early exposure of health science undergraduates to population health. references 1. zwanikken pa, huong nt, ying xh, et al. outcomes and impact of master of public health programs across six countries: education for change. hum resource health 2014;12:40. doi:10.1186/1478­4491­12­40 2. national department of health. human resource for health strategy for the health sector. pretoria: ndoh, 2012. http://www.health.gov.za (accessed 15 july 2016). 3. reddy j. regional consortia, partnerships, mergers and their implications for the transformation of the south african higher education system. tertiary education linkages project, 1998. http://www.usaid.gov (accessed 20 july 2016). 4. gaebel m, hauschildt k, muhleck k, smidt h. tracking learners and graduates’ progression paths. european university association, 2012. http://www.eua.be/about.aspx (accessed 15 july 2016). 5. kwazulu­natal department of health. strategic plan 2015 ­ 2019. http://www.kznhealth.gov.za/strategic­ plan­2015­2019.pdf (accessed 15 july 2016). 6. hoffman jc, julie h. the academic transitional experiences of masters’ students at the university of the western cape. curationis 2012;35(1). doi:10.4102/curationis.v35i1.33 7. li iw, awofeso n. labour market outcomes of public health graduates: evidence from australia. perspect public health 2014;134(5):283­288. doi:10.1177/1757913913491864 8. ijsselmuiden cb, nchinda tc, duale s, tumwesigye nm, serwadda d. mapping africa’s advanced public health education capacity – the afrihealth project. bull world health organ 2007;85(12):914­922. doi:10.2471/ blt.07.045526  9. hoffman m, coetzee d, hodes r, london l. from comprehensive medicine to public health at the university of cape town: a 40­year journey. s afr med j 2012;102(6):442­445. 10. department of education. national plan for higher education. pretoria: department of education, 2001. http:// www.education.gov.za (accessed 15 july 2016). short research report http://dx.doi.org/10.1186/1478-4491-12-40 http://dx.doi.org/http://www.health.gov.za http://dx.doi.org/http://www.usaid.gov http://dx.doi.org/http://www.eua.be/about.aspx http://dx.doi.org/http://www.kznhealth.gov.za/strategic-plan-2015-2019.pdf http://dx.doi.org/http://www.kznhealth.gov.za/strategic-plan-2015-2019.pdf http://dx.doi.org/10.4102/curationis.v35i1.33 http://dx.doi.org/10.1177/1757913913491864 http://dx.doi.org/10.2471/blt.07.045526 http://dx.doi.org/10.2471/blt.07.045526 http://dx.doi.org/http://www.education.gov.za http://dx.doi.org/http://www.education.gov.za research 220 november 2015, vol. 7, no. 2 ajhpe mindfulness is moment-to-moment awareness and can be intentionally cultivated by paying attention in a specific way, i.e. in the present moment, non-judgementally, nonreactively and open-heartedly.[1] while mindfulness is a core element of buddhist philosophy, early western psychologists, such as william james, recognised the relevance of mindfulness, although it was not until the 1980s that the academic literature began to earnestly grapple with and fully understand its construct and application.[2] more generally, high mindfulness scores have been shown to predict selfregulated behaviour, positive emotional states and improved psychological wellbeing.[3] high levels of mindfulness have also been shown to correlate inversely with dissociation, alexithymia, and general psychological distress.[4] mindfulness-based interventions (mbis) have been developed to reduce symptoms across a wide range of populations and disorders, such as anxiety and depression, chronic pain, irritable bowel syndrome, hiv/aids and eating disorders.[5] research shows that mindfulness-based approaches induce neuroplastic changes in the brain, especially the frontal-limbic axis,[6] enhance humoral immunity,[7] and may reduce relapse in patients who abuse substances.[8] mbis therefore have a therapeutic place in healthcare services, and healthcare professionals such as psychologists or family physicians have shown interest in learning how to teach mbis to their patients. to deliver mbis to patients, healthcare professionals have to acquire knowledge of the approach and be able to practise mindfulness. the training of professionals to deliver mbis rests on a set of core competencies that are introduced and assessed over the course of the programme. these competencies include guiding formal mindfulness practices, facilitating group processes and having good relational skills, linking one’s direct experience of mindfulness with course themes and embodying the qualities of mindfulness through modelling a particular way of being.[9] the secularisation of mindfulness in the form of mbis and its strong research foundation has led to its growing popularisation. there is a risk that the mainstreaming of mindfulness may lead to a slow dilution in the integrity of the approach. in this context, the effective and ethical training of teachers to deliver mbis in diverse contexts is an important development in the pedagogy of mindfulness. in south africa (sa) it is the motivating principle behind the training programme being offered by the faculty of medicine and health sciences at stellenbosch university in collaboration with the institute for mindfulness sa, a nonprofit organisation committed to the training, research and application of mbis. the certification in mindfulness-based interventions is a 60-credit training, which provides participants with experiential and theoretical exposure to mindfulness and mindfulness-based approaches in a supportive learning environment, with a view to professional application within existing spheres of expertise. the training consists of 4 modules structured as a series of 8 10 week courses. methods of learning combine residential training retreats and distance learning strategies, including online supervision and discussion, self-directed mindfulness practice with formal techniques and integration of mindfulness into daily life, practising and exploring teaching skills background. mindfulness-based interventions (mbis) have been shown to be effective in a wide range of health-related problems. teaching and research with regard to mbis have largely been conducted in the usa and europe. the development of teachers of mbis requires that they embody the practice of mindfulness and acquire pedagogical competencies. stellenbosch university and the institute for mindfulness south africa have launched a new and innovative training programme consisting of 4 modules, with a blend of residential retreats and e-learning. internationally, this is the first study that specifically investigates the effects of mindfulness on the mental state of health professionals being trained to teach mbis in their clinical practice. objectives. to evaluate the first 9-week module in terms of its effect on mindfulness practice, self-determination, self-compassion and perception of stress. methods. this is a before-and-after study of 23 participants, using 4 validated tools: kentucky inventory of mindfulness skills, self-determination scale, self-compassion scale, perceived stress scale. results. there were significantly increased scores (p<0.05) for all 4 aspects of mindfulness practice (observing, describing, acting with awareness and accepting without judgement) and self-compassion. there was also a significant decrease in the perception of stress, but no effect on self-determination scores, which were already high at baseline. conclusion. potential teachers of mbis in south africa demonstrated significant gains in their own mindfulness practice and self-compassion as well as decreased perception of stress during the first module of the training programme. further research will follow as this group completes the entire programme. afr j health professions educ 2015;7(2):220-223. doi:10.7196/ajhpe.460 examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, self-compassion and self-determination s whitesman,1 mb chb; r mash,2 mb chb, drcog, dch, mrcgp, fcfp, phd 1 division of family medicine and primary care, faculty of medicine and health sciences, stellenbosch university and institute for mindfulness south africa, cape town, south africa 2 division of family medicine and primary care, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: s whitesman (simonw@lantic.net) research november 2015, vol. 7, no. 2 ajhpe 221 (such as guiding practices and inquiry), self-reflective journaling, reading and critiquing peer-reviewed literature and writing essays for assessment purposes. the 4 modular themes are as follows: module 1. mindfulness from the inside-out: an introduction to mindfulness and mindfulness-based approaches. the objective of this module is for participants to begin to explore the practice of mindfulness experientially and understand the theoretical basis and clinical context of its application. module 2. blending form and essence: exploring the key elements of a mindfulness-based intervention. the intent of this module is to understand the architecture, essential content and process of an mbi. module 3. the ground beneath our feet: the foundations of mindfulness. the aim of module 3 is for participants to experience the depth of mindfulness practice and the ethos from which it arose, to encounter the framework for exploring suffering and its transformation, and to consider the relationship between the source of these teachings and their contemporary expression. module 4. mindfulness at work: refining the practice, refining the teaching, and the space between. the purpose behind the final module is to translate the theory into practice and to consider how to develop a personal intention and capacity for teaching through intensive exploration of guiding mindfulness practices in a variety of contexts under peer supervision. most of the formal training programmes in mindfulness-based approaches take place in the usa and europe, up to and including master’s level degrees. our training programme is the first of its kind in sa and research into its uptake, effectiveness, applicability and impact on participants and the communities they serve is essential. while mbis are increasingly viewed as structured stepwise approaches to various health-related issues, the ethical debate among those offering university-based training programmes focuses on the centrality of the teachers’ embodiment of the qualities of mindfulness itself (such as presence, centredness, compassion) and the effect of the subjective state of the teacher on the communication and uptake of the curricular elements by the participants.[9] in this context, monitoring and evaluating the inner states of those undergoing teaching training development – and continuing this evaluation process after completion of the training – is potentially an important addition to the growing literature on the pedagogy of mindfulness. the essential quality of mindfulness is a combination of heightened attentional capacity and compassion. the latter is the ability to be receptive to, understanding of and responsive to our suffering and to that of others. in this context, there can be no compassion separate from self-compassion. furthermore, compassion encompasses a softening of the habitual tendency to judge the contents of the present moment in a manner that reduces engagement with the actuality of what is occurring. this attitude of lessening the negating quality of mind is not a loss of discernment. rather, the increase in mindfulness leads to a more refined and accurate perception of what is actually happening to and in an individual in successive moments of awareness, and the capacity to discern reality from reactivity. one of the consequences is to deal with stressful experiences on their own terms rather than from the reflexive overlay of conditioning. such mindfulness becomes a valuable means to reduce the impact of psychological stress – much of which arises from a distorted perception of the present reality – at the same time embedding the capacity to respond rather than react to stressors within an individual’s awareness. this capacity to choose a response to stressors, rather than simply reacting, is referred to as self-determination. effective mindfulness practice, therefore, should lead to enhanced self-compassion and selfdetermination and a reduced perception of stress. there are no studies in the literature that describe changes in levels of mindfulness and other mental capacities (e.g. compassion) as a result of such a professional training programme. the aim of this study was to evaluate the first module of the new short course on mindfulness practice at stellenbosch university. the study evaluated changes in mindfulness practice, self-determination, self-compassion and perception of stress among participants. methods study design we evaluated a short course on mindfulness, using before-and-after quantitative measures of mindfulness, self-determination, self-compassion and perceived stress. setting healthcare professionals participated in a 9-week short course on mindfulness practice at stellenbosch university in collaboration with the institute for mindfulness sa. the short course was the first module in a larger programme on mbis in healthcare that will follow. it consisted of an initial 1-week residential retreat, which intensively focused on the practice of mindfulness. the first day started at the faculty of medicine and health sciences, stellenbosch university, with training in the computer laboratory and an overview of the course. the retreat was followed by 8 weeks of further theory, practice during normal daily living and reflection delivered by an internet-based program. the course was designed for healthcare practitioners, who were assessed on their contributions to online discussions and 2 final written assignments. one of the assignments was a personal narrative on their experience and exploration of mindfulness practice over the previous 8 weeks, and the second was a critique of the theory of mindfulness. the cohort consisted predominantly of medical practitioners and psychologists in clinical practice in private and state sectors. participants enrolled in the training programme with the intention of learning how to teach mindfulness to patients in a secular context through deepening their personal practice while exploring the pedagogical aspects of its application. study population the 23 students registered for the course were invited to participate in the study. data collection data were collected at the start of the course (at the introduction on day 1) and immediately after the end of the course as part of the feedback. the kentucky inventory of mindfulness skills is a validated 39-item self-report tool that was used to measure mindfulness on 4 scales: observing, describing, acting with awareness, and accepting without judgement.[10] the selfdetermination scale, a 10-item tool, assessed differences in people’s selfawareness and the extent to which they feel a sense of choice with regard to their behaviour.[11] the self-compassion scale is a validated 26-item questionnaire that was used to rate how people responded to themselves in difficult times.[12] the perceived stress scale is a validated 10-item questionnaire employed to measure perceived stress over the last month.[13] research 222 november 2015, vol. 7, no. 2 ajhpe data analysis quantitative data from the questionnaires were entered, checked and cleaned in a microsoft excel spreadsheet and analysed (in statistica) with the assistance of the centre for statistical consultation. before-and-after numerical data from paired groups were compared with a nonparametric wilcoxon-signed rank test. ethical considerations the study was approved by the health research ethics committee, stellenbosch university (n13/07/100). results the study population comprised 18 women and 5 men with a mean age of 44.2 (range 32 76) years. the group included 5 psychologists, 5 medical practition ers, 4 counsellors or coaches, 3 nurses, 3 professionals involved in leadership development, 1 social worker, 1 physiotherapist and 1 volunteer working with student groups. eighteen participants had some previous exposure to mindfulness practice, while 5 had no prior exposure. eighteen were self-employed or working in the private sector, 4 worked in the public sector and 1 was doing voluntary work. table 1 presents the results of the questionnaires and shows a statistically significant improvement in the practice of mindfulness. participants showed a significant improvement in all 4 key dimensions of mindfulness: the ability to observe or direct one’s attention to internal and external phenomena; ability to non-judgementally describe thoughts and feelings; ability to act with full awareness of what one is doing in the present moment; and ability to accept or allow what is happening without judging the experience. participants improved despite being a self-selected group, most of whom had some previous exposure to mindfulness practice. participants also improved significantly in all the dimensions of self-compassion, which measure how someone acts towards him/herself while experiencing difficult circumstances: selfkindness, avoiding self-judgement, identification with others, avoiding isolation, practice of mindfulness, and avoiding over-identification with difficulties. participants reported improved mindfulness and self-compassion and a significant decrease in their perception of stress during the previous month. there was no change in the extent to which participants reported functioning in a selfdetermined way. this especially relates to a sense of choice and control over one’s behaviour. the reported self-determination was relatively high at baseline and did not change significantly during the course. discussion internationally, this is the first study that specifically investigates the effects of mindfulness on the mental state of those being trained to become teachers of mindfulness-based approaches. the results suggest that the initial stages of the abovementioned training at stellenbosch university increased levels of self-compassion and mindfulness, which were accompanied by a decrease in the perception of stress. there is an emerging literature on mbi teacher training that focuses on pedagogical elements. this literature speaks in depth to the core competencies required and offers a framework in which professionals training to teach mbis are assessed. assessment focuses on skills development and capacity to communicate the key elements of a curriculum effectively, skillfully, compassionately and in an embodied way.[14] the initial data in this study suggest that compassion, one of the core elements of mindfulness, is enhanced with this training methodology and serves to support one of the key aspects required in teacher development.[14] the complex and multi-levelled challenges in our society demand innovative approaches to integrating mindfulness, without compromising the standards of training, leading to benefit in the therapeutic domain. the course offered at stellenbosch university follows the international trend of combining residential and distance learning elements, although the curriculum structure is unique to this programme, considering cost, context and accessibility to make the training available to healthcare professionals in other african countries. there are a number of potential benefits of training professionals in mindfulness-based approaches. mindfulness and compassion are universal capacities and may potentially be used in diverse contexts. mbis can be delivered in group format at primary care level and at relatively low cost (one only needs a room and teacher fees), is highly participatory and empowering for participants, and the skills acquired may subsequently be developed beyond the conclusion of a programme at no cost. furthermore, mbis are highly adaptable in terms of structure, duration and language without losing the essential elements or thread of the curriculum. research table 1. results of the questionnaires at baseline and follow-up (n=23) item baseline mean (95% ci) follow-up mean (95% ci) p-value kentucky inventory of mindfulness skills (summative score) observe (12 60) 40.9 (37.6 44.2) 47.1 (44.7 49.5) <0.001 describe (8 40) 28.4 (25.5 31.3) 30.3 (28.1 32.6) 0.018 acting with awareness (10 50) 31.4 (28.5 34.3) 34.9 (32.2 37.5) 0.001 accept without judgement (9 45) 32.7 (29.5 35.9) 35.5 (33.0 37.9) 0.016 perceived stress scale (summative score) perceived stress scale (0 40) 16.5 (13.5 19.4) 12.8 (9.8 15.7) 0.012 self-compassion scale (mean score) humanity (1 5) 3.3 (3.0 3.7) 3.8 (3.5 4.1) 0.005 isolation (1 5) 3.4 (3.0 3.8) 3.8 (3.4 4.1) 0.032 judgement (1 5) 3.2 (2.8 3.6) 3.6 (3.3 4.0) 0.012 kindness (1 5) 3.3 (2.9 3.7) 3.8 (3.4 4.1) 0.002 mindful (1 5) 3.4 (3.0 3.9) 3.8 (3.5 4.1) 0.051 over-identified (1 5) 3.1 (2.8 3.5) 3.4 (3.1 3.8) 0.047 total (1 5) 3.3 (3.0 3.6) 3.7 (3.4 3.9) 0.002 self-determination scale (mean score) aware (1 5) 4.0 (3.7 4.3) 4.0 (3.8 4.3) 0.681 choice (1 5) 3.8 (3.5 4.2) 4.0 (3.8 4.3) 0.117 total (1 5) 3.9 (3.7 4.2) 4.0 (3.8 4.2) 0.346 ci = confidence interval. research november 2015, vol. 7, no. 2 ajhpe 223 on the implementation of mbis in the inner cities in the usa supports this adaptability.[15] however, similar contextual adaptations in africa remain to be explored. the lack of a control group, and participants in the training programme having been self-selected, limits the generalisability of these findings. it is possible that unmeasured confounding factors influenced the results, although none were identified. it is also possible that obsequiousness bias could have influenced the responses of the participants to the questionnaires, although the follow-up questionnaire was completed online and not in the presence of the tutor. moreover, this is the first of 4 modules; at this stage conclusions cannot be drawn with regard to the effects on the overall training programme. ongoing research might consider whether the inner state of the teacher correlates with the therapeutic outcome in mbis. there is evidence for this in other contexts, where increased levels of empathy among primary care physicians correlated with a reduction in diabetic complications.[16] high workload, low numbers of healthcare workers, poor infrastructure and an unsupportive organisational culture all contribute to high levels of stress, burnout and depression.[17] quality of care and the ability to care for others diminish with burnout and lower levels of resilience among healthcare professionals. the changes seen in this study in levels of mindfulness, self-compassion and stress may not only help to better prepare healthcare professionals as teachers of mbi but also have a positive impact on their clinical engagement and quality of care due to enhanced wellbeing and resilience.[18] in the sa context, ongoing research into the impact of healthcare professional training programmes, based on the practice of mindfulness, should be explored in educational and clinical settings. conclusion the first module of a training programme in mbis led to significant improvements in mindfulness practice and levels of stress and selfcompassion among participating healthcare professionals. there was no change in the degree of self-determination. such changes may assist healthcare professionals to become teachers of mindfulness practice and be more resilient in the clinical workplace. further research is needed to evaluate the effect of all 4 modules of the training programme. references 1. kabat-zinn j. full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. 15th ed. new york: delta trade paperback/bantam dell, 2005. 2. stanley s. intimate distances: william james’ introspection, buddhist mindfulness, and experiential inquiry. new ideas in psychology 2012;(2):201-211. 3. baer ra, smith gt, lykins e, et al. construct validity of the five facet mindfulness questionnaire in meditating and non-meditating samples. assessment 2008;15(3):329-342. 4. baer ra. mindfulness training as a clinical intervention: a conceptual and empirical review. clinical psychology: science and practice 2003;10(2):125-143. 5. cullen m. mindfulness-based interventions: an emerging phenomenon. mindfulness 2011;2:186-193. 6. hölzel bk, carmody j, vangel m, et al. mindfulness practice leads to increases in regional brain gray matter density. psychiatry res 2011;191(1): 36-43. [http://dx.doi.org/10.1016/j.pscychresns.2010.08.006] 7. davidson rj, kabat-zinn j, schumacher j, et al. alterations in brain and immune function produced by mindfulness meditation. psychosom med 2003;65(4):564-570. 8. britton wb, bootzin rr, cousins jc, hasler bp, peck t, shapiro sl. the contribution of mindfulness practice to a multicomponent behavioral sleep intervention following substance abuse treatment in adolescents: a treatmentdevelopment study. substance abuse 2010;31(2):86-97. 9. crane rs, kuyken w, hastings rp, rothwell n, williams jmg. training teachers to deliver mindfulness-based interventions: learning from the uk experience. mindfulness 2010;1:74-86. 10. baum c, kuyken w, bohus m, heidenreich t, michalak j, steil r. the psychometric properties of the kentucky inventory of mindfulness skills in clinical populations. assessment 2010;17:220-229. 11. sheldon km, ryan rm, reis h. what makes for a good day? competence and autonomy in the day and in the person. personality and social psychology bulletin 1996;22:1270-1279. 12. neff kd. development and validation of a scale to measure self-compassion. self and identity 2003;2:223250. 13. cohen s, kamarck t, mermelstein ra. global measure of perceived stress. j health soc behav 1983;24:385-396. 14. crane rs, kuyken w, williams jmg, hastings rp, cooper l, fennel mjv. competence in teaching mindfulnessbased courses: concepts, development and assessment. mindfulness 2012;3(1):76-84. [http://dx.doi.org/10.1007/ s12671-011-0073-2] 15. roth b, robbins d. mindfuless-based stress reduction and health-related quality of life: findings from a bilingual inner city patient population. psychosom med 2004;66(1):113-123. 16. del canale s, louis dz, maio v, et al. the relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in parma, italy. acad med 2012;87:12431249. 17. rossouw l, seedat s, emsley ra, suliman s, hagemeister d. the prevalence of burnout and depression in medical doctors working in the cape town metropolitan municipality community healthcare clinics and district hospitals of the provincial government of the western cape: a cross-sectional study. s afr fam pract 2013;55(6):567-573. 18. goodman mj, schorling jb. a mindfulnes course decreases burnout and improves well-being among healthcare providers. int j psychiatry med 2012;43:119-128. 184 october 2016, vol. 8, no. 2 ajhpe research the ugandan ministry of health (moh) identified lack of leadership and management skills, rather than lack of resources, as the main reason for poor healthcare delivery in the country.[1] healthcare professionals, as an integral component of uganda’s healthcare system, receive a high level of training to develop technical skills to provide appropriate care to the population. these professionals were, however, often found lacking in critical leadership knowledge and skills.[2-4] because of this deficiency, health workers may fail to deliver quality healthcare services, resulting in patients resorting to unsafe methods of treatment. poor leadership and management skills have led to mishandling of resources, which has also impacted on the health sector.[5] quality healthcare service delivery to the community in uganda continues to be a challenge. the moh responded to the lack of leadership skills by providing in-service training to improve these skills of healthcare workers who are already in service. mbarara university of science and technology (must), uganda responded to the gap by creating a leadership training programme for all undergraduate students pursuing a bachelor’s degree in nursing, medicine and surgery, pharmacy, and medical laboratory science in the faculty of medicine. the objective of the leadership development programme (ldp) was to produce skilled leaders who could confront the healthcare challenges and create a better and healthier community.[6,7] the assumption was that the leadership skills taught during a didactic class could be implemented in the community immediately after the training and then later in practice. in this required leadership and community-based education research and service (cobers), the 242 undergraduate health science students were placed in multidisciplinary teams of 7 10. each of the 32 teams was then assigned to a different rural community, with the purpose of working with the community to identify a significant health-related problem where they could intervene. cobers is a university platform for embedding progressive transformative leadership and research related to healthcare in uganda.[8] prior to the community placements, the health science students were equipped with theoretical knowledge in leadership skills that employed interactive studentbased learning. the study analysed the self-reported perceptions of this training and its effect on students during their community placement. the main objective was to assess the students’ perception of the 1-week precommunity placement ldp at must. the study was specifically carried out to: (i) assess the self-reported students’ leadership skills before and after leadership training; and (ii) assess the self-reported effect of the training on students during and after the community placement. methods study location the study was conducted at must and at 34 community placement sites. the sites reflected the different levels of healthcare delivery, ranging from health facilities where only basic services were provided, to hospitals where more advanced medical procedures were carried out. the health facilities were in rural hard-to-reach communities in southwestern ugandan districts. the students remained at the remote sites for a 5-week experience. background. community-based education research and service (cobers) is a platform for embedding progressive transformative leadership and research-related medical education in uganda. the leadership development programme (ldp) developed at mbarara university of science and technology (must), uganda is a key component of cobers. health science students at must are equipped by means of the ldp with leadership knowledge and skills, and a positive attitude towards leadership and rural communities. the programme involves employing interactive learner-centred education techniques, with the opportunity to implement these skills in a community setting immediately after the training. objective. to assess the students’ self-reported perception and effectiveness of the precommunity placement ldp at must and its impact during the community clinical placement, and to measure the self-reported improvement of students’ knowledge and their application of leadership skills in the community. the results of the evaluation will improve and build on this educational programme. the study also evaluated the effectiveness of the preplacement leadership training course for undergraduates at must, as reported by students. methods. the programme evaluation of the ldp used quantitative pretest and post-test measures and qualitative data from focus group discussions to enrich the evaluation. data were collected from students before and after the 1-week leadership training course using the same self-administered questionnaire. variables were then compared to evaluate the impact of the ldp. results. prior to the intervention, only 14% of the participants had ever attended a leadership training session. there was significant self-reported change in the task accomplishment skills, interpersonal relationship skills and quality of leadership. conclusion. the results suggest that the ldp may increase leadership skills among health science students to improve healthcare in uganda. our study recommends that this leadership programme be considered for use by ugandan medical training faculties and similar environments elsewhere. afr j health professions educ 2016;8(2):184-188. doi:10.7196/ajhpe.2016.v8i2.587 multidisciplinary leadership training for undergraduate health science students may improve ugandan healthcare j n najjuma,1 bnursing science; g ruzaaza,2 med (phc); s groves,1 mph, mns, drph; s maling,3 mb chb, mmed (psychiatry); g mugyenyi,4 mb chb, mmed (o&g) 1 department of nursing, faculty of medicine, mbarara university of science and technology, mbarara, uganda 2 community-based education program, faculty of medicine, mbarara university of science and technology, mbarara, uganda 3 department of psychiatry, faculty of medicine, mbarara university of science and technology, mbarara, uganda 4 department of obstetrics and gynecology, faculty of medicine. mbarara university of science and technology, mbarara, uganda corresponding author: j n najjuma (jnajjuma@must.ac.ug) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 185 research study design and data collection the study was a programme evaluation using quantitative pretest and post-test self-reported measures, and qualitative data from focus groups to enrich the evaluation. the data were used to evaluate the outcomes of the programme. the quantitative data were collected using a pretested leadership assessment tool composed of 49 questions, e.g. qualities of leadership, personal relationship skills, and task accomplishment skills. it was comprised of three sections with likert scales and one section with open-ended questions. this article discusses 26 of the questions in the analysis, i.e. those specific to leadership. six of the questions gathered demographic information. we used a self-administered questionnaire that took ~20 minutes to complete – in a pretest and post-test format. it was administered for the first time 1 week before the training began, and the second time during the last week of the 5-week clinical course at the community placement site. codes instead of names of respondents were used for purposes of confidentiality. the tool was developed by the team, and pretested among students who had the same characteristics as those who were being studied, except that they had not yet participated in cobers and would not take the course in the year of the study. it was administered to 10 students (male and female) from all the health science courses at must. they were asked, while completing the tool, to think out loud for every question they read and answer. notes were taken and the tool was reviewed for errors. the researchers also noted the time taken to complete the tool. the abovementioned information was used to improve the tool. the qualitative data were collected during focus group discussions (fgds). there were four fgds, each attended by 8 12 students. the fgds took place after the students returned from their community placement. the groups were a purposive convenience sample of students who were willing to meet on a saturday for the discussion. the researchers ascertained that someone from every community group (32 sites) was included, with a mix of male and female students. after the sample signed informed consent forms, the fgd leaders used an interview consisting of six open-ended questions, in which the students were asked to share their experiences from the ldp and those related to working as a team. the fgds were tape recorded. analysis quantitative data were analysed using the statistical package for the social sciences 20 (spss 20; ibm corp., usa). quality of leadership, personal relationship skills and task accomplishment skills were examined to measure change of perceptions after the intervention. preand post-intervention scores were matched, means and standard deviations were calculated, and t-tests were used to examine the statistical significance of these changes. qualitative data were transcribed, read and reread by the researchers. themes were identified based on the quantitative data schema. the themes were: quality of leadership, personal relationship skills, and task accomplishment skills. ethical considerations the study protocol was reviewed and approved by the must institutional review committee. permission was obtained from the dean of the faculty of medicine and the co-ordinator of the community-based medical education programme. informed consent was obtained from all respondents. none of the respondents was obligated to participate in the study and lack of participation had no impact on their course grade. the information collected was used only for the intended evaluation and only reported in the aggregate. study limitations although carefully planned, there were limitations to the study. data collected relied on reports given by the study participants. the study would have presented the impact of the course better if we had provided both subjective and objective information. results demographic characteristics of the 242 students participating in the course, 152 (62%) returned both the pretest and post-test. the sample was representative – 72% males and 28% females. of the respondents, 31% were medical students, 37% medical laboratory science students, 14% nursing students, and 18% pharmacy students. thirty-five percent of the respondents had a post-secondary education certificate or diploma. only 14% of the respondents had ever before attended leadership training. qualities of leadership students were asked to rank themselves with regard to specific leadership qualities, such as self-confidence, their vision and extent of understanding implications for the community, importance of coalition building, and listening skills. table 1 shows the results of comparisons between preand table 1. changes in personal perceptions of self for quality of leadership* student quality pre-intervention, mean (sd) post-intervention, mean (sd) t-value p-value 1 i am confident of meeting most challenges and emerging intact and feeling good about myself 3.6250 (0.90696) 4.0938 (0.81752) −2.611 0.014† 2 i have a vision of where we ought to be going as a group, community, society, people 3.0909 (1.23399) 3.8788 (1.05349) −3.116 0.004† 3 i am constantly excited by the learning process, which stretches out before me as far as i can see 3.6875 (1.11984) 3.7500 (1.10760) −0.239 0.813 4 i am constantly amazed at how i pick out the very broadest implications of enterprises and projects that others see in narrow terms 3.3333 (0.95743) 3.8788 (0.96039) −2.796 0.009† 5 i see the way to success is through steady coalition building 3.6452 (1.05035) 4.2581 (0.77321) −2.608 0.014† 6 i see great wisdom in building the capabilities of others, empowering them, and motivating them to do their best 4.0303 (0.98377) 3.9697 (0.98377) 0.297 0.768 7 i am an active, effective listener; people seek me out as a listener 3.4848 (1.00378) 3.9394 (0.93339) −2.390 0.023† 8 i have the courage to take on what is right, regardless of my critics and detractors 4.0312 (0.99950) 4.0625 (0.91361) −0.197 0.845 *using pretest and post-test scores with a range of 1 5 (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). †p<0.050 (primary research data). 186 october 2016, vol. 8, no. 2 ajhpe research post-intervention ratings of participants’ leadership qualities. four of the seven leadership qualities showed statistically significant improvement, while three showed little change. for the latter, the mean was initially high. there was an improvement in participants’ perceptions about the importance of coalition building, with an increase in mean rating from 3.65 preintervention to 4.23 post intervention (statistically significant; t=2.608; p<0.05). at the end of the community placement, a qualitative assessment was undertaken using fgds to better understand how students implemented their leadership. during the fgds the importance of coalition building was described by several of the students: ‘the training also promoted my team, co-operative people, and different work capability as i had to work with different people with different characteristics.’ ‘we saw how much everybody is contributing, and i realised we can’t do medicine alone.’ after the intervention, participants self-reported to have a better vision of where they ought to be going as a group, community, and society. this improvement was shown by the increase in the pre-intervention mean from 3.09 to 3.88 after the intervention (statistically significant; t=3.116; p<0.05). furthermore, participants’ confidence for meeting most of the challenges also increased from 3.63 pre-intervention to 4.09 post intervention (statistically significant; t=2.611; p<0.05). students felt that the course helped to improve their confidence in their ability to work in the community. this argument was reflected in the statement below: ‘it was very helpful to us because actually we learnt very many activities that helped us to carry out analysis in the community. for example, root cause and stakeholder analysis as in all those things we learnt during the workshop they gave us a background knowledge that helped us to carry out our activities in the community successfully.’ personal relationship skills table 2 presents the preand post-intervention ratings of personal relationship skills of the respondents. four of the five ratings were significant and the fifth showed positive change. results indicate an improvement in participants’ perception of the skill of helping groups to maintain discipline and to direct them towards achievement, while suggesting ways in which all members of a group could participate. the mean rating of this participant skill increased from 3.23 to 4.00 after the intervention (statistically significant; t=3.430; p<0.05). the improvement was also depicted in the following statement: ‘i got to know it is not easy for people who have grown up in different families to be brought together, and then you want things to move smoothly.’ there was also improvement in participants’ skills to facilitate interpersonal and group relationships to help the group to be very productive. the students reported to have learnt how to teach by example and how to make these relationships visible. this is shown by the statistically significant increase from a mean of 3.38 to 3.75 after the intervention (t=1.459; p<0.05). in the fgds a student emphasised how the leadership training helped: ‘attitude, that is to say, how to accommodate different people with different personalities and be tolerant, really helped me in my interpersonal relationships.’ they furthermore reported improvement in the skill to mediate for others, and helping to find and reinforce the common ground on which solutions could be built. there was also a statistically significant increase in mean skill from 3.22 to 3.73 after the intervention (t=2.283; p<0.05). a student noted: ‘even when we disagreed, one had a basis of argument, like we learnt from the training. it helped us know what to do in case of breakdowns and was a basis to streamline and check on how to agree and disagree.’ results also showed that the participants’ skills to elicit information and ideas by asking open-ended questions were perceived to have improved significantly, with a mean increase from 3.28 to 3.78 after the intervention (t=2.374; p<0.05). participants also reported an improvement in listening skills after the intervention, with mean pre-intervention and post-intervention skills of 3.48 and 3.94, respectively (t=2.390; p<0.05). task accomplishment skills students also scored themselves in task accomplishment skills before and after the leadership training. these scores are presented in table 3. all eight of the skills showed significant improvement. the results indicate that the participants’ skills of seeking information and clarifications to shed light on ideas and suggestions improved. the difference between the preand post means was statistically significant (3.5 4.07; t=3.138; p<0.05). table 2. changes in personal perceptions with regard to personal relationship skills* student skill pre-intervention, mean (sd) post-intervention, mean (sd) t-value p-value 1 i understand the nature of power; i exercise and respect power 3.5455 (0.93845) 3.8788 (0.85723) −1.727 0.094† 2 i elicit information and ideas by asking open-ended questions 3.2812 (1.11397) 3.7812 (0.83219) −2.374 0.024‡ 3 i provide others with clear feedback, reinforcing positive contributions, clarifying and confronting as is helpful 3.6667 (0.81650) 3.7273 (1.00849) −0.285 0.778 4 i mediate for others, helping them find and reinforce the common ground on which solutions can be built 3.2000 (0.96132) 3.7333 (0.98027) −2.283 0.030‡ 5 i facilitate interpersonal and group relationships, teaching by example, and by making these relationships visible i provide both knowledge and skills about productive behaviour 3.3750 (1.07012) 3.7500 (1.10716) −1.459 0.005‡ *using pretest and post-test scores with a range of 1 5 (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). †p<0.100 (primary research data). ‡p<0.050 (primary research data). october 2016, vol. 8, no. 2 ajhpe 187 research in the fgds the participants communicated their experiences: ‘i also learnt that if you have not involved the community in whatever you implement, they will destroy it. you must bring them on board and they become serious stakeholders. they are the ones suggesting the implementations that will work.’ the students reported that by seeking more information with clarification they had an improved understanding of community health-seeking behaviour, and could work better with the community to identify the correct programmes for implementation: ‘even their health-seeking behaviours were poor as people never sought treatment, and had a perspective that these were spirits cast on them by people who never wished them good; who never wished them well … .’ there was a self-reported statistically significant increase in participants’ skills of effective communication. the mean ratings of communication skills increased from 3.44 to 3.94 after the intervention (t=2.104; p<0.05). during the fgds the students also emphasised that: ‘even communication skills were improved, so now as you communicate with a colleague you know what to say and what not to say.’ participants also reported a statistically significant improvement in idea elaboration, with a pre-intervention mean of 3.44 and post-intervention mean of 4.06 (t=3.215; p<0.05). this is illustrated in statements, such as the following: ‘it was important because the skills and knowledge i acquired, like mobilisation, scanning, aligning, communication skills such things, those are the very things we used when we reached the community.’ furthermore, participants’ reported that their skills of initiating ideas, actions, procedures and solutions had improved. with a pre-intervention mean of 3.38 and post-intervention mean of 4.00, it is statistically significant (t=3.056; p<0.05). as shown in table 3, there was significant change in the participants’ skills with regard to analysing ideas, tasks and processes, represented by the preand post-intervention means of 3.35 and 4.09, respectively (statistically significant; t=4.190; p<0.001). participants’ skills in diagnosing difficulties also improved, with an increase in the mean rating from 3.39 prior to the intervention to that of 4.03 after the intervention (statistically significant; t=3.566; p<0.001). results also indicate an improvement in participants’ management skills, using a combination of planning, task assignment, and guidance to accomplish goals after attending the leadership training, with a pre-intervention mean of 3.25 and a post-interventional mean of 4.22 (statistically significant; t=4.550; p<0.001). in addition, there was a selfreported improvement in evaluating progress, process and products, with a mean of 2.79 before the intervention and 3.76 thereafter (statistically significant; t=4.197; p<0.001). discussion this study found that in all three leadership areas, the participants self-reported statistically significant improvement in their knowledge and application of the knowledge. the results suggest that scholars selfreported a significant improvement in their skill levels in all 15 competency areas examined. the preplacement course taught them useful leadership skills, which they immediately used, having the opportunity to increase their learning through direct application in the community. in 16 of the 20 competency skills examined, there was a statistically significant improvement; in the others they remained the same or showed a slight improvement. research suggests that leadership training among public health officials is essential, given the growing complexity of national healthcare systems.[1,9] however, in most low-resource countries poor leadership remains a challenge and contributes to the failure of the healthcare system. workshops to improve leadership skills were used successfully in nigeria to improve healthcare delivery.[10] for uganda, problems identified in providing quality healthcare included: deficient infrastructure, heavy disease burden, lack of rural health workers, a demanding workload, and a poor ratio of health workers to the population.[1] improving leadership skills among health workers could help to solve many of these different challenges. table 3. changes in personal perceptions for task accomplishment skills* student skills pre-intervention, mean (sd) post-intervention, mean (sd) t-value p-value 1 i initiate ideas, actions, solutions, and procedures 3.3750 (0.90696) 4.0000 (0.84242) −3.056 0.005† 2 i elaborate on ideas, using examples and definitions 3.4375 (0.91361) 4.0625 (1.01401) −3.215 0.003† 3 i communicate ideas effectively 3.4375 (1.04534) 3.9375 (1.01401) −2.104 0.044† 4 i co-ordinate ideas, activities, relationships, making sense out of the piece 3.2500 (0.91581) 4.0938 (0.92838) −4.190 0.000‡ 5 i diagnose the sources of difficulties 3.3939 (0.99810) 4.0303 (0.80951) −3.566 0.001‡ 6 i summarise for the group, restating progress and offering a decision or conclusion for consideration 3.3030 (1.10354) 3.7576 (0.93643) −1.936 0.062§ 7 i evaluate progress, process and products, holding them up to comparison with standards or expectations 2.7931 (0.81851) 3.7586 (1.02313) −4.197 0.000‡ 8 i manage, using a combination of planning, task assignment, and guidance to accomplish goals 3.2500 (1.04727) 4.2188 (0.87009) −4.550 0.000‡ 9 i seek information and clarification to shed light on ideas and suggestions 3.5000 (1.01600) 4.0625 (0.87759) −3.138 0.004† *using pretest and post-test scores with a range of 1 5 (1=poor, 2=fair, 3=good, 4=very good, 5=excellent). †p<0.050 (primary research data). ‡p<0.001 (primary research data). §p<0.100 (primary research data). 188 october 2016, vol. 8, no. 2 ajhpe research sherk et al.[11] found that the development of qualified and able public health leaders using a team approach was a critical step in building the infrastructure to address public health challenges. this applied to all countries, including resource-poor countries, such as uganda. they used a virtual web-based programme and face-to-face interventions that allowed a team to identify and address issues, and then implement what they learnt to successfully create change.[11] results suggest that leadership can improve with knowledge and by implementing it in a multidisciplinary working team. the students were generally successful in creating change in these isolated and very-low-resource communities, which might be attributed to their new leadership skills. these results agree with those of o’neil[12] and saleh et al.[9] that good leadership and management can be learned and practised. o’neil[12] found that, worldwide, the ldp made a profound difference in health managers’ attitudes toward their work. strategies that have been put in place to improve health system challenges included leadership training among healthcare workers in uganda.[9] in a modular work-based training model matovu et al.[2] found that having a programme model that combined both educational and work-based training was very effective in strengthening the capacity and competency of ugandan health workers.[1] must’s approach was unique in that they saw the importance of using the ldp for undergraduate students before these students practised in the community. as with the models of matovu et al.[4] and sherk et al.,[11] they also reinforced learning by having the students implement it immediately in the community with specific projects. medical education for equitable services for all ugandans (mesau) has emphasised the need for leadership skills to be taught to undergraduate students. mesau and the ministries of health and education have designed minimum competencies for medical education, of which leadership and management skills is one of the nine competencies.[8] research has identified that teamwork is one of the most important skills for effective clinical practice, with better clinical outcomes in acute and chronic care settings, and fewer medical errors. successful teams have good leadership.[13,14] o’neil[12] noted that for leadership to be effective it should not use the traditional approach, focusing on top leaders, leadership traits and characteristics, but rather focus on the development of teams that can identify problems, find solutions, and obtain results. this training proposed a response to the identified lack of leadership and management skills recognised by uganda’s moh and the gap identified internationally by the lancet commission in 2010.[15] one action that might improve the quality of healthcare in uganda is the ldp, an important component in molding healthcare graduates. the positive results of this study might be a basis for recommending the leadership course as part of cobers to all medical education partnership initiative (mepi) members, a consortium of health science universities. acknowledgement. this project was supported by the mesau-mepi programmatic award (no. 1r24tw008886) from the fogarty international center. the content is solely the responsibility of the authors and does not necessarily represent the official views of the fogarty international centre or the national institutes of health. we wish to acknowledge the following persons: drs m mutumba and c muchunguzi for supporting the project’s data analysis activities; mr i ddumba, ms l mbabazi, ms o nambusi, mr m barigye, and ms m n mirembe for their contribution to the data collection; and the respondents for participating in the project. references 1. ministry of health. uganda health sector strategic plan (hssp) 2010/11 2014/15, 2010. http://www.health. go.ug/docs/hssp_iii_2010.pdf (accessed 29 july 2016). 2. matovu jk, wanyenze rk, mawemuko s, okui o, bazeyo w, serwadda d. strengthening health workforce capacity through work-based training. bmc int health hum rights 2013;13(1):1-13. doi:10.1186/1472698x-13-8 3. kiguli s, baingana r, paina l, et al. situational analysis of teaching and learning of medicine and nursing students at makerere university college of health sciences. bmc int health hum rights 2011;11(suppl 1):s3. doi:10.1186/1472-698x-11-s1-s3  4. matovu j, wanyenze r, mawemuko s, et al. building capacity for hiv/aids program leadership and management in uganda through mentored fellowships. global health action 2011;4:5815. doi:10.3402/ gha.v4i0.5815 5. gray j, armstrong p. academic health leadership: looking to the future. proceedings of a workshop held at the canadian institute of academic medicine meeting quebec, canada, 25 26 april 2003. clin invest med 2003;26(6):315-326. 6. abhinav s, bharathi p. focusing on leadership development skills among school graduates. basic res j educ res rev 2012;1(3). 7. goldstein ao, calleson d, bearman r, steiner bd, frasier py, slatt l. teaching advanced leadership skills in community service (alscs) to medical students. acad med 2009;84(6):754-764. doi:10.1097/ acm.0b013e3181a40660 8. medical education for equitable services for all ugandans (mesau). mesau consortium defines the minimum competencies for medical education in uganda. mesau news 2011;1(1). 9. saleh s, williams d, balougan m. evaluating the effectiveness of public health leadership training: the nephli experience. am j public health 2004;94(7):1245-1249. 10. uneke s, ezeoha a, ndukwe c, oyibo p, onwe f. enhancing leadership and governance competencies to strengthen health systems in nigeria: assessment of organizational human resources development. healthcare policy 2012;7(3):73-84. doi:10.12927/hcpol.2013.22749  11. sherk k, nauseda f, johnson s, liston d. an experience of virtual leadership development for human resource managers. hum resour health 2009;7:1. doi:10.1186/1478-4491-7-1 12. o’neil m. human resource leadership: the key to improved results in health. hum resour health 2008;6:10. doi:10.1186/1478-4491-6-10 13. bannister s, wickenheiser h, keegan d. key elements of highly effective teams. pediatrics 2014;133(2):184-186. doi:10.1542/peds.2013-3734 14. balasooriya c, olupeliyawa a, iqbal m, et al. a student-led process to enhance the learning and teaching of teamwork skills in medicine. educ health (abingdon) 2013;26(2):78-84. doi:10.4103/1357-6283.120698. 15. frenk j, chen l, zulfiqar ab, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 http://www.health.go.ug/docs/hssp_iii_2010.pdf http://www.health.go.ug/docs/hssp_iii_2010.pdf http://dx.doi.org/10.1186/1472-698x-13-8 http://dx.doi.org/10.1186/1472-698x-13-8 http://dx.doi.org/10.1186/1472-698x-11-s1-s3  http://dx.doi.org/10.3402/gha.v4i0.5815 http://dx.doi.org/10.3402/gha.v4i0.5815 http://dx.doi.org/10.1097/acm.0b013e3181a40660 http://dx.doi.org/10.1097/acm.0b013e3181a40660 http://dx.doi.org/10.12927/hcpol.2013.22749 http://dx.doi.org/10.1186/1478-4491-7-1 http://dx.doi.org/10.1186/1478-4491-6-10 http://dx.doi.org/10.1542/peds.2013-3734 http://dx.doi.org/10.4103/1357-6283.120698. http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 research 180 october 2014, vol. 6, no. 2, suppl 1 ajhpe when revising a curriculum, a common task is identifying a core curriculum.[1,2] curriculum designers are confronted with an array of new things that beg for inclusion in contemporary health professions education curricula.[3,4] an ever-expanding knowledge base provides an enticing and growing menu of content to include. professions, and the health profile of communities they serve, change over time. ideas like graduate attributes, interprofessional education and social accountability are propagated.[5] this places ongoing pressure on those entrusted with managing the curriculum. is the curriculum relevant? can graduates be prepared, in the time available, to tackle the challenges they will face? the expansion of new knowledge and a greater understanding of existing knowledge have characterised the coming of age of physiotherapy as a profession. since first being published online in 1999, the number of randomised controlled trials (rcts) indexed in the physiotherapy evidencebase database (pedro) have doubled every 3 5 years.[6] in 2010 it was calculated that 18  000 rcts and 3  500 systematic reviews of rcts were indexed in pedro. it has been argued that with the expansion of information, knowledge should be greater and practice should be more effective.[7] as regards changing population healthcare needs, the world health organization (who) has highlighted the increased prevalence of lifestyleassociated diseases.[8] within the context of global economic changes the expectation is that the prevalence of these diseases is also likely to increase in the developing world, while the impact of infectious diseases (like hiv infection, tuberculosis and malaria) is still worrying. some have argued that this change in disease profile necessitates a realignment of physiotherapy practice[9] and consequently the education of therapists. these changes are forcing expansion of the scope of physiotherapy practice. however, the time available to teach physiotherapy-specific skills and knowledge at an undergraduate level is limited.[10] the south african qualifications authority (saqa) requires that 4-year bachelor degrees be limited to 480 credits, where one credit equals 10 notional hours. there are thus 1 200 hours available per year for students to attend structured academic activities, study, and complete assignments and assessments. this includes a minimum of 1 000 hours for clinical training that is mandated over the 4-year period. facilitating the development of critical cross-field outcomes in higher education and generic graduate attributes of healthcare professionals is also increasingly being recognised,[5] and therefore requires dedicated time. another challenge faced by physiotherapy curriculum designers in south africa, is that entry-level programmes are required to deliver professionals who can practise as unsupervised first-line practitioners on graduation.[11] this is in contrast to professions like medicine, accountancy and law, where graduates have to complete a supervised internship before assuming an independent professional role. all of the factors outlined above directly challenge curriculum content. one approach to managing these competing demands is the identification of a core curriculum. the concept of a core curriculum is not new.[12,13] various reasons have been advanced for adopting a core curriculum; prime among these is content overload, which has a negative influence on the quality of student learning: ‘students haven’t forgotten, they never learned that which we assumed they had. in demanding coverage of a broad landscape of material, we often win the battle but lose the war. we expose the students to the material and prepare them for the tests, but we don’t allow them to learn the concepts.’[14] background. during curriculum revision, an important task is identifying a core curriculum. deciding what criteria to use to determine core content is crucial and impacts on graduate outcomes and patient care. objective. to identify criteria to apply in order to determine core content. methods. a high engagement process involving eleven staff and two undergraduate student representatives was used. the process consisted of a stimulus question; brainstorming; sharing, clarification and clustering of ideas; second-phase brainstorming, clarification and clustering; prioritisation; and finally vote tally and categorisation. results. the group initially identified 28 criteria to use when deciding on core content. the criteria were reduced stepwise to 15, and finally 3 criteria that enjoyed widespread support were identified. content would be included in the curriculum if: (i) it was relevant to the south african context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. conclusion. the process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. it helps ensure that all voices are heard and ideas included in prioritisation. the process easily manages a multiplicity of ideas; similar ideas are efficiently identified and clustered. finally, the process is time-efficient. ajhpe 2014;6(2 suppl 1):180-184. doi:10.7196/ajhpe.496 deriving criteria by which to determine core curriculum content: a high engagement process s d hanekom,1 msc (physio), phd; m unger,1 msc (physio), phd; f cilliers,2 mb chb, bsc (medsc) hons, mphil (higher education), phd 1 division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 education development unit, faculty of health sciences, university of cape town, south africa corresponding author: s hanekom (sdh@sun.ac.za) research october 2014, vol. 6, no. 2, suppl 1 ajhpe 181 the very idea of ‘core’ implies criteria by which content is determined to be core or not, yet deciding what those criteria are and applying them is not straightforward.[15] various methods have been described to determine core content. these include the use of document analysis,[16] questionnaires,[2,17] the delphi technique[3] and interdisciplinary or inter-institutional working groups.[18,19] given the potential impact on graduates of these judgments, deciding what criteria should be used to determine core content is crucial. furthermore, if the process of determining and applying these criteria is alienating to some lecturers, the likelihood is that the resultant curriculum will not be fully implemented as planned.[1] when the undergraduate physiotherapy curriculum at stellenbosch university (su) was revised, the decision was therefore taken to use a consensus-building process to determine criteria to apply to determine core content. three consensusbuilding processes have been described in the healthcare context. these include the nominal group technique (ngt), the delphi process and a consensus development conference.[20] these structured methodologies attempt to overcome issues associated with group decision-making processes by allowing all participants to contribute to the discussion. the aim of this paper is to describe the high engagement process we used to reach consensus. methods participants all full-time staff members of the physiotherapy division at su in 2006 were invited to participate. in addition two final-year students who were elected members of the undergraduate programme committee were also invited. the reason for limiting participation was twofold: (i) during a major curriculum update in 1999 the structure and content of the physiotherapy curriculum were renewed after consultation with key stakeholders including clinicians, students and multidisciplinary team members; and (ii) time and financial constraints precluded the advocated involvement[1,21] of role players outside of the university. the renewal of the curriculum included an update of the content, and organisation of the curriculum within the existing structure. process an institutional staff member from the university’s centre for teaching and learning facilitated the session. the facilitator holds qualifications in medicine and higher education and was trained in the participlan process.[19] this process was adopted as it allowed full, anonymous participation from all group members. it also allowed visual display of all ideas, thus ensuring that at the stage of prioritisation, all ideas were visible for consideration. power differentials in the group, e.g. between senior and junior staff, and between students and staff, were thus diminished. furthermore, no single member of the group could dominate discussions and steer the outcome in a particular direction. the outcome of the process therefore represented the opinion of the group rather than any one or two persuasive, articulate and powerful members of the group. a six-step process was used. in preparation for the session, large sheets of paper were affixed to the wall of the venue. participant contributions, written on sheets from small note pads, were subsequently attached to these display sheets. step 1. stimulus question the following open-ended question was posed to all participants: which criteria will we use to define the core content of the revised curriculum? the question was posed verbally and a printed version was attached to one of the display sheets against the wall. step 2. brainstorming participants were afforded the opportunity to brainstorm ideas and jot their ideas down on small note pads. this step was completed individually by all participants in silence. participants were instructed to write each idea on a separate page. step 3. sharing, clarification and clustering of ideas participants were each invited to select three ideas they felt particularly strongly about. the selected pages were handed to the facilitator. the facilitator read each idea aloud. participants then guided the placement of the ideas on the display sheets. if an idea was similar to an idea already displayed, it was placed touching that idea. if an idea was new, it was placed separately. table 1. profile of participants area of interest highest qualification experience (clinician, years) experience (academic, years) 1 cardiopulmonary msc 14 9 2 paediatric neurology bsc hons 7 11 3 orthopaedics; sport injuries msc 6 27 4 orthopaedics bsc 10 7 5 orthopaedics; neuro-musculoskeletal m phil 10 7 6 adult neurology diploma 25 12 7 orthopaedics phd 10 7 8 orthopaedics bsc 7 2 9 community health; paediatric neurology msc 13 13 10 paediatric neurology; exercise msc 7 11 11 orthopaedics; biomechanics msc 10 7 student 1 completed fourth year student 2 completed third year mean (sd) 10.82 (5.35) 10.27 (6.36) research 182 october 2014, vol. 6, no. 2, suppl 1 ajhpe participants were invited to comment on or interrogate any ideas that were displayed, as well as question how the clusters of ideas were being developed. in some instances, clusters of ideas were separated into two or more clusters when it became evident that similar but distinct ideas had been incorporated in a cluster. in other instances, two separate clusters were merged when it became apparent that they related to the same idea. during this process, there was no onus on the participant whose idea was under discussion to take ownership of the idea. anonymity of contributions was thus preserved. step 4. second-phase brainstorming, clarification and clustering after all first-round ideas had been placed, participants were afforded the opportunity to select any further ideas they had written down and that were not already represented on the display sheets for discussion and placement. participants could also write down and submit new ideas. step three was then repeated. step 5. prioritisation participants were each given three adhesive dots with which to vote. each cluster of ideas was numbered and participants selected the three clusters they wished to vote for. participants then stuck their dots to the label identifying each cluster they wished to vote for. step 6. vote tally and categorisation votes were tallied to identify the criteria enjoying most support. these criteria were subsequently grouped into categories to yield the final set of criteria to be used for the determination of core content for the revised curriculum. results eleven staff members and two students participated in this process. participants had a mean (standard deviation (sd)) 10.82 (5.35) number of table 2. results of the six-step process* steps 2 4: criteria identified by participants step 5: prioritisation n=13 (%) step 6: categorisation step 6: final tally (total votes) n=39 relevant 7 (53.8) relevant to [sa] context 14 (33.3) appropriate to ... [sa] [sa] context driven by needs → [hpcsa]??? official national health plan requirements of practice 7 (53.8) prevalent pathology 0 patient numbers 0 health structures 0 safe and effective and an adequate amount of techniques to treat a patient appropriately in sa and internationally 7 (53.8) minimum skills needed for effective, safe and relevant physiotherapy practice 13 (33.3) identify the patient that you can help 7 (53.8) evaluate↑↑↑; plan ↑↑; do ↑ (hands-on, or refer) refers to the extent of training: students need to be equipped with skills related to evaluation, planning and management research findings 9 (69.2) evidence-based 8 (20.5) evidence-based ‘evidence’ – knowledge or practical evidence-based techniques evidence-based levels core knowledge on which physiotherapy science is based 5 (38.5) minimum building blocks needed 4 (10.2)basic principles building blocks basic/base concepts and principles definition of physiotherapy: role as described by the hpcsa 0 other clinical value based on expert opinion 0 selected techniques ↑↑↑ – basic knowledge of others. develop other opportunities to expand technique base 0 level of the student 0 international 0 what is needed to reach the newly defined profile of the stellenbosch graduate 0 sa = south africa; hpcsa = health professions council of south africa. *ideas submitted by respondents are reported verbatim. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 183 years’ experience as clinicians and 10.27 (6.36) number of years in academia. the profiles of participants are depicted in table 1. the group initially identified 28 potential criteria to be used when deciding on core content (step 3) (table  2). after step 4, 15 criteria remained. following the voting process (step 5) and categorising of the criteria, 3 criteria were identified to be used to determine the core curriculum (table 2). the process took 2 hours from start to finish. discussion through a high engagement process, we identified 3 essential criteria deemed appropriate for determining the core content of a revised undergraduate physiotherapy curriculum that enjoyed widespread support among participants. content would be included in the curriculum if: (i) it was relevant to the south african context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. the high engagement process we used has not been widely documented in literature, but is similar in some respects to the ngt.[22] the advantages and drawbacks of the process may therefore be similar to those of the ngt. one distinct advantage of the process described here is that it is very efficient. it could be argued that the degree of challenge posed by a process of reaching consensus within one department is insignificant compared with that of reaching consensus across multiple departments as would be the case in, say, a medical curriculum. however, the process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. it helps ensure that all voices are heard and included in prioritisation. we therefore believe that the process would be effective even under more complex circumstances. the generation of too many ideas during the initial process of brainstorming when using the ngt can pose challenges to participants and facilitators.[20,23] in contrast, the participlan process easily manages a multiplicity of ideas, and duplicate ideas are efficiently identified and clustered as part of the process. almost half the ideas generated during the brainstorming phase were duplications. this could be an indication that group members were too similar in their thought processes, although as indicated in table 1, all participants had extensive experience both as clinicians in different fields and as academics. nonetheless, the ideas generated may not represent those of a broader group.[22] on the one hand, this could have been countered by involving physiotherapists from other institutions and stakeholders from outside of physiotherapy. subsequent validation of the results of this process by obtaining feedback from stakeholders like students, clinicians and employers could also have addressed this issue. however, as mentioned, resource limitations precluded this eventuality. furthermore, the goal of this work is to describe the process used. we hope that by publishing our process and outcome we can stimulate conversation and debate around the important question of which criteria should be used to identify core content for undergraduate physiotherapy training. while the ngt has been promoted as a way of reaching consensus, this view is not always supported in the literature.[22] in our case, the process adopted did facilitate attainment of consensus in the group. group members only voted for 6 of the 15 potential criteria during step 5; with 1 criterion receiving majority support (evidence-based). we hypothesise that this was because the group decided to retain some criteria as distinct criteria despite apparent similarities. after voting was completed, the group was happy to group similar criteria during a categorisation process (step 6). this process clarified the various dimensions of each criterion. the process allowed for all views to be considered equally. the 3 criteria that we ultimately decided on received 89.7% (n=39) of all possible votes. given the limitations identified above, what of the validity of the criteria identified? although the purpose of this paper is to describe the process used rather than the results obtained, we believe there is a case to be made for the validity of the criteria identified. firstly, regarding relevance to the local context, the importance of producing therapists who can address the healthcare needs of specific communities is increasingly being recognised and encouraged. physiotherapy is an internationally recognised profession and graduates are encouraged to travel abroad. while there are generic skills that define physiotherapy, the scope of physiotherapy practice varies across contexts. the importance of developing curricula which are relevant to the health and social needs of each particular nation was acknowledged in the world confederation of physical therapy (wcpt) guideline (2012) for physical therapist professional entry-level education.[24] regarding the criterion that core content should ensure safe and effective practice by first-line practitioners, a first-line practitioner within the south african context has been defined as: ‘… a person who can make an independent diagnosis and can treat such a condition, provided it falls within his/her scope of practice. should the condition fall outside of their scope of practice, this practitioner will refer on. this person is autonomous in professional decisionmaking. it is acknowledged that with “first line practitioner status” come accountability and legal responsibilities.’[11] although this definition was only published 6 years after we embarked on identifying core content, the definition validates the group’s decision to ensure that the core curriculum includes knowledge and skills which will enable students to identify patients who would benefit from physiotherapy intervention. in the revised curriculum greater emphasis was thus placed on evaluation techniques and students’ ability to formulate a differential diagnosis, and less on treatment techniques. a number of physiotherapy techniques can be used both for evaluation and management of conditions. however, this is not always the case. the implication of this decision is that students may not always have the necessary skills to address the patients’ problems efficiently and optimally. the decision to equip students with the ability to accurately identify patients’ problems at the expense of optimal management at first contact was regarded as the lesser of two evils. our physiotherapy division is currently consulting with relevant stakeholders (universities, clinicians, employers) regarding our revised curriculum to develop innovative collaborative strategies to address this potential shortcoming in our students’ training. finally, regarding evidence-based practice, in a policy statement the wcpt[25] has endorsed the concept of evidence-based physiotherapy practice. the importance of developing educational strategies which would ensure the development of the necessary skills for evidence-based practice in entry-level practitioners has also been advocated.[7] it is evident from the policies and documents published since we embarked on this process, that the decisions we made find support internationally. we argue that the high engagement process we used to decide on criteria for a core curriculum facilitated the quality of the decisions made. the effect of these decisions on the quality and ability of the therapists produced will need to be investigated. research 184 october 2014, vol. 6, no. 2, suppl 1 ajhpe conclusion through a six-step high engagement process we identified 3 criteria which were used to determine the core content of a revised physiotherapy curriculum. the process lends itself to the participation of multiple stakeholders in an engaging yet anonymous manner. it helps to ensure that all voices are heard and ideas included in prioritisation. the process easily manages a multiplicity of ideas; duplicate ideas are efficiently identified and clustered. finally, the process is time-efficient; the process described above took 2 hours from start to finish. content was included in the curriculum if: (i) it was relevant to the south african context; (ii) it would ensure safe and effective practice by first-line practitioners; and (iii) it was evidence-based. these criteria are offered for critical reflection and as a basis for a national (or international) debate on core content of a physiotherapy curriculum. author contributions. all authors contributed to the conception, design, analysis or interpretation of data. s hanekom drafted the manuscript. all authors provided critical revision and approval of the manuscript version to be published. references 1. bandaranayake r. the concept and practicability of a core curriculum in basic medical education. med teach 2000;22(6):560-563. [http://dx.doi.org/10.1080/01421590050175523] 2. bax nd, godfrey j. identifying core skills for the medical curriculum. med educ 1997;31(5):347-351. [http:// dx.doi.org/10.1046/j.1365-2923.1997.00676.x] 3. syme-grant j, stewart c, ker j. how we developed a core curriculum in clinical skills. med teach 2005;27(2):103106. [http://dx.doi.org/10.1080/01421590500046403] 4. fishman sm, young hm, lucas arwood e, et al. core competencies for pain management: results of an interprofessional consensus summit. pain med 2013;14(7):971-981. [http://dx.doi.org/10.1111/pme.12107] 5. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 6. elkins mr, moseley am, sherrington c, herbert rd, maher cg. growth in the physiotherapy evidence database (pedro) and use of the pedro scale. br j sports med 2013;47(4):188-189. [http://dx.doi.org/10.1136/ bjsports-2012-091804] 7. dawes m, summerskill w, glasziou p, et al. sicily statement on evidence-based practice. bmc med educ 2005;5(1):1. 8. world health statistics. 2013. http://www.who.int/gho/publications/world_health_statistics/en_whs2013_ full.pdf. (accessed 16 september 2014). 9. the first line practitioner status of physiotherapists position paper 2012. http://www.physiosa.org. za/?q=node/161 (accessed 20 february 2014). 10. harden rm, davis mh, crosby jr. the new dundee medical curriculum: a whole that is greater than the sum of the parts. med educ 1997;31(4):264-271. [http://dx.doi.org/10.1111/j.1365-2923.1997.tb02923.x] 11. mcmanus ic, wakeford re. a core medical curriculum. bmj 1989;298(6680):1051. [http://dx.doi.org/10.1136/ bmj.298.6680.1051] 12. harden rm. amee guide no. 21: curriculum mapping: a tool for transparent and authentic teaching and learning. med teach 2001;23(2):123-137. 13. haddad d, robertson kj, cockburn f, helms p, mcintosh n, olver re. what is core? guidelines for the core curriculum in paediatrics. med educ 1997;31(5):354-358. [http://dx.doi.org/10.1046/j.1365-2923.1997.00675.x] 14. verma, s, paterson, m, medves j. core competencies for health care professionals: what medicine, nursing, occupational therapy, and physiotherapy share. journal of allied health 2006;35(2):109-115. 15. rizk de, elzubeir m. identifying core obstetric and gynecologic skills required of, and used by, graduates of the faculty of medicine and health sciences, united arab emirates university. teach learn med 2000;12(2):66-71. [http://dx.doi.org/10.1207/s15328015tlm1202_1] 16. bligh j, brice j. further insights into the roles of the medical educator: the importance of scholarly management. acad med 2009;84(8):1161-1165. [http://dx.doi.org/10.1097/acm.0b013e3181ace633] 17. broberg c, aars m, beckmann k, et al. a conceptual framework for curriculum design in physiotherapy education – an international perspective. advances in physiotherapy 2003;5(4):161. [http://dx.doi. org/10.1080/14038190310017598] 18. o’keefe m, jones a. promoting lay participation in medical school curriculum development: lay and faculty perceptions. med educ 2007;41(2):130-137. [http://dx.doi.org/10.1111/j.1365-2929.2006.02666.x] 19. thomas p. training in the participlan process 2011. http://www.participlan.co.za/business-executive-coachingtraining (accessed 20 february 2014). 20. jones j, hunter d. consensus methods for medical and health services research. bmj 1995;311(7001):376-380. 21. snyman ma. assessment of professional behaviour in occupational therapy education: iinvestigating assessors’ understanding of constructs and expectations of levels of competence.  m phil health sciences education, stellenbosch university, stellenbosch, 2012. 22. lloyd-jones g, ellershaw j, wilkinson s, bligh jg. the use of multidisciplinary consensus groups in the planning phase of an integrated problem-based curriculum. med educ 1998;32(3):278-282. [http://dx.doi.org/10.1046/ j.1365-2923.1998.00221.x] 23. lloyd-jones g, fowell s, bligh jg. the use of the nominal group technique as an evaluative tool in medical undergraduate education. med educ 1999;33(1):8-13. [http://dx.doi.org/10.1046/j.13652923.1999.00288.x] 24. world confederation for physical therapy. wcpt guideline for physical  therapist professional entry  level education 2012. http://www.wcpt.org/guidelines/entry-level-education (accessed 20 february 2014). 25. world confederation for physical therapy. policy statement: evidence based practice 2011. http://www.wcpt.org/ policy/ps-ebp (accessed 20 february 2014). ajhpe is published by the health and medical publishing group (pty) ltd co registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za 28 main road (cnr devonshire hill road), rondebosch, 7700 | +27 (0)21 681 7200 all letters and articles for publication must be submitted online at www.ajhpe.org.za editorial 178 mapping of a curriculum renewal journey: lessons learned s hanekom research 180 deriving criteria by which to determine core curriculum content: a high engagement process s d hanekom, m unger, f cilliers 185 does a problem-based learning approach benefit students as they enter their clinical training years? lecturers’ and students’ perceptions s b statham, g inglis-jassiem, s d hanekom 192 what does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? g inglis-jassiem, s b statham, s d hanekom 198 integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: reflections on a new approach m burger, q a louw 203 teaching my peers: perceptions of tutors in physiotherapy practical skills training m unger, l keiller, g inglis-jassiem, s d hanekom 207 evaluation of clinical sites used for training undergraduate physiotherapy students: factors that may impact on learning l g williams, d v ernstzen, s b statham, s d hanekom 211 learning experiences of physiotherapy students during primary healthcare clinical placements d v ernstzen, s b statham, s d hanekom 217 physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module d v ernstzen, s b statham, s d hanekom 222 benefits of curriculum renewal: the stellenbosch university physiotherapy experience m unger, s d hanekom ajhpe african journal of health professions education | october 2014, vol. 6, no. 2, suppl 1 editorial board editor-in-chief vanessa burch university of cape town supplement editor susan hanekom stellenbosch university international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria ntombifikile mtshali university of kwazulu-natal marietjie nel university of the free state ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state elizabeth wolvaardt university of pretoria hmpg editor janet seggie consulting editor jp de v van niekerk deputy editor bridget farham editorial systems manager melissa raemaekers scientific editor ingrid nye technical editors emma buchanan anne hahn paula van der bijl head of publishing robert arendse production coordinator bronlyne granger art director brent meder dtp & design carl sampson online manager gertrude fani issn 1999-7639 plagiarism is defined as the use of another’s work, words or ideas without attribution or permission, and representation of them as one’s own original work. manuscripts containing plagiarism will not be considered for publication in the ajhpe. for more information on our plagiarism policy, please visit http://www.ajhpe.org.za/ index.php/ajhpe/about/editorialpolicies may 2015, vol. 7, no. 1 ajhpe 39 research ‘health workers need to be educated about how to incorporate human-rights principles into their work.’[1] while teaching human rights to a diverse group of health science students, i felt a need to open a door to turn learning into personal meaning-making beyond the understanding of legal instruments. this shift in teaching objectives, from transmission of knowledge towards transforming attitudes, created an opportunity to try new and alternative approaches that could promote the personal connections needed to motivate individual students to engage in issues of social justice. human rights are defined by london and baldwin-ragaven[2] as ‘universally applicable social or material entitlements, essential to fulfil fundamental needs, which individuals can claim from society on the basis of [their] humanity’. mann[3] argued for the inextricable link between human rights and health to be recognised beyond the health consequences of human rights violations. this broader perspective takes into account the multiple influences that impact on human rights and health, including the promotion and protection of human rights towards human flourishing. london et al.[4] point out that health professionals can be change agents to advance social justice and equity in health; yet, they can also create barriers when they act as gatekeepers who limit access to health. in south africa (sa), a progressive constitution sets norms and standards within a legal framework towards achieving democratic practices; yet, the legacy of apartheid, with growing inequalities and a weak public health system, challenges educators in a health science faculty (hsf) to seek ways to promote students’ social responsiveness towards social justice and equity. a history of complicity by health professionals in human rights abuses is a contributing factor that is driving curricular change.[5] the health professions council of sa (committee on human rights, ethics and professional practice 2006) mandated for human rights (together with professional ethics and medical law) to form a core component of medical undergraduate curricula. in the hsf at the university of cape town (uct) a transformation agenda intends to scaffold human rights as a curricular golden thread throughout the years of undergraduate study. to understand health through a human rights lens it is important to recognise the social, political, cultural and economic factors that contribute towards or limit wellbeing. apart from the structural factors in the health system there are many actors, including medical undergraduate students, who can play a role in mediating the realisation of the rights of others. human rights education (hre) enables the use of critical self-reflection as a process of self-discovery. it fosters a consciousness for each student to acknowledge the realities of difference, and the relationships between the determinants of health, the multiple stakeholders and influences, and the legal instruments. although hre forms part of the life orientation course in sa high school curricula, few students appear to understand the relationship between classroom learning and clinical practice, as is apparent in student feedback. to view health through a multifaceted lens, i propose an ontological approach to teaching, one in which ‘knowing is … situated within a personal, social, historical and cultural setting … a way of thinking, making and acting’.[6 ] in this article i explain the emergence of the human rights key (key) as a tool to equip students and educators to learn and teach human rights issues in an engaging manner. i explain the meanings to be drawn from the metaphor and describe how the key is used in the classroom. it has also been made available as an open educational resource (oer) and shared with the wider educational community. the limitations and transferability of the background. in response to the need for health and human rights education in undergraduate medical curricula, the faculty of health sciences at the university of cape town, south africa, has included human rights learning in its reformed programme. drawing on experiences in several curricular initiatives within the faculty and beyond, i introduce the human rights key as a new heuristic learning tool. objective. to share a teaching innovation in an area of need in medical education. method. the key scaffolds and facilitates students’ learning through a sequential process of guided self-reflection with probing questions. it illuminates the inter-relationship of key human rights concepts, enabling students to create and make connections between human rights principles, legal mechanisms, their own personal realities and their developing clinical practice. discussion. feedback reflects the effectiveness of the human rights key in supporting transformative learning, suggesting that the key will remain prominent in students’ memory. online publication of the key as an open educational resource (oer), with extensions to specific themes, has increased its impact and demonstrated the generalisability of the tool. conclusion. i propose the human rights key as a useful visual communication tool to guide students in connecting their classroom learning with the reality of local, regional and international health and human rights issues. as an oer with a creative commons licence, the key is available online for both educators and students to use as a resource with downloadable components. afr j health professions educ 2015;7(1):39-42. doi:10.7196/ajhpe.366 the human rights key: an innovative tool for teaching health and human rights in the health sciences v a mitchell, bsc (physio), mphil (hes) department of obstetrics and gynaecology, faculty of health sciences, university of cape town, south africa corresponding author: v a mitchell (veronicaannmitchell@gmail.com) 40 may 2015, vol. 7, no. 1 ajhpe research key are explored, including the expansion of its usability through the new opportunities afforded by the internet, leading to my conclusion. emergence of the key beyond the school curriculum, the first year of the reformed uct curriculum in the hsf includes a course ‘becoming a professional’ (bp) – 25% of its content is related to health and human rights. the overriding theme in this multidisciplinary module is the ‘integrated health professional’ (ihp), a model of professional identity constituting the reflective, empathetic and knowledgeable domains.[7] as a facilitator in this course, i felt challenged in engaging students’ interest and commitment to human rights. i wanted to assist them to link their present being to their future practice and to the codified legal human rights instruments. while teaching senior students in their third year, opportunities arose to explore additional ways to promote human rights learning. as i initiated and facilitated human rights workshops in the department of obstetrics and gynaecology, a wheel image became a useful visual model, using the ihp concept from bp as the hub. concentric circles indicated progressively broader influences from the family, community (local) and country (national) to wider international actors. the universal declaration of human rights created the foundation or holding platform (fig. 1). further examination of possibilities led me to develop the wheel into the head of a key. the key was recognised as a symbol for opening and closing doors – as a self-assessed indicator measuring and evaluating students’ own agency. this heuristic key offered a visual model for students to draw on their prior learning and personal experiences. students are able to reflect on their own biographies and frames of reference, shifting from global to closer domestic influences. because of sa’s discriminatory history, many of our students’ lives have been and still are affected by past and present injustices. through the key, each student may recognise the multidimensional aspect of human rights and its relationship with multifaceted developing professionalism. method cutting the key in the classroom i construct the key (fig. 2) piece by piece, using paper templates, guiding students to place their own content into the visual model. probing questions to promote the students’ understanding of health and human rights facilitate their reflection on the state of their own keys within education and awareness obstacles global community country local community family media r e�e ctio n empathy knowledge convention on the rights of the child convention on the elimination of all forms of discrimination against women convention on the rights of persons with disabilities international covenant of economic, social and cultural rights (icescr) international covenant of civil and political rights (iccpr) universal declaration of human rights (udhr) 30 c r c c e d a w c r p d c o n s t i t u t i o n non-governmental organisations fig. 2. the human rights key infographic (by veronica mitchell, uct, 2011). ihp e k r wheel for human rights education global context national local legal instrumentsnational constitution international conventions universal declaration of human rights fig. 1. health and human rights wheel (ihp = integrated health professional; r = reflection; e = empathy; k = knowledge). may 2015, vol. 7, no. 1 ajhpe 41 research a human rights framework, resulting in raising their self-awareness and evolving consciousness. by posing problems related to their future practice as clinicians working within varying spheres of influence in the context of women’s health, students gain a deeper understanding of the complexities of the lived realities of individuals and population groups. a detailed explanation of the key’s components and the method used to facilitate student learning is available on the human rights key website (https://open.uct.ac.za/handle/11427/6599). testing the key feedback from both educators and students has indicated the meaningful contribution that the infographic offers to hre. since its inception in 2008, it has been used in the classroom, with educators from/at other institutions, and presented at both local and international conferences. the key’s visual representation is appealing to students, assisting them to remember the concepts of what they have learnt as well as showing how the many components are integrated. the key provides a summary of previous discussions and learning within the larger context of local and international influences. it illuminates the inter-connectiveness of the elements, demonstrating the enormous value of education and awareness. furthermore, from an educator’s point of view, the key enlightened the students’ understanding by simplifying concepts and clarifying their relevance and relationships by contextualising the complexities. the transformative objective in hre is facilitated by the key, providing a vehicle to value different standpoints. as a tool for critical reflection, it gives students an opportunity to explore their own areas of need. moreover, the model enables students to identify their future professional responsibilities. however, a few students have found the key challenging and confusing. responding to students’ earlier calls for more structure, the method of delivery in presenting the key has changed. initially, i drew the model on a white board, but now i use coloured templates to represent the key’s components to show how they fit together, and refer students to the website for further self-study. the addition of the key as an online resource makes it available to students to revise and reinforce their learning. research is planned into the longitudinal impact of the key on students’ social responsiveness, with an examination of the difficulties that appear to limit a few students’ understanding of the concepts. discussion interpretation of the key the key contributes to substantive understanding of human rights. it offers a visual tool to explore and challenge values and attitudes that ‘truly reflect the underlying principles of human rights: universality, indivisibility, interdependence, equality, human dignity, respect, non-discrimination and social progress’[8] – essential components for the success of hre. turning human rights into personal realities is facilitated by means of the key’s symbolic significance and its individualistic design for each person. a connection between students’ personal experiences and their future professional practice is created. as haidet et al.[9] indicate in their study using life-circle drawings, a visual diagram can be useful in understanding how the webs of relationships in the life-worlds of students may shape and influence their practice. the key metaphor enables ‘us with the capacity as agents to make sense of the universe, sort out perceptions, make evaluations, create an adventure in meaning and guide our purposes’.[10] deshler emphasises the relevance of metaphors for transformative learning,[10] particularly in participatory teaching as a vehicle to promote dialogue and the recognition of new, unexplored perspectives. he argues that metaphors offer a sense of ownership, freedom and liberation, and assist learners to recognise unexamined influences that impact on their lives. generally, keys are personal possessions kept and cared for in a vigilant manner with a sense of responsibility. as key holders and duty bearers, the quality of practitioners’ keys can reflect their own agency. for instance, indifference and complacency imply a key sitting in a lock without being turned. similarly, conformity and acceptance of a status quo could mean a key that is never or seldom used. even when mechanisms are in place, initiative, knowledge, skills and confidence are needed to take up the keys and use them in a meaningful manner. to empower others out of their vulnerability, doctors as agents of change have the opportunity to become champions of equality. london[11] argues that agency is critical to a human rights approach. health professionals, through their position of authority and as community role models, can assist others in finding and turning their keys, acting as mentors in their advocacy roles and more conventional role of monitors. as students gain a critical understanding of their individual human rights values through guided personal reflection in constructing their own keys, an opportunity is created to generate personal and social change. for many marginalised people, their keys can be interpreted as blanks – present, yet indistinct – not fulfilling their purpose of opening doors. in ongoing human rights violations the key can play a protective role in turning against abuse, unlocking the doors to alternative choices or locking doors to oppressive situations. doors tend to be bolted through oppression and ignorance. in such situations, assistance may be needed to unlock potential individual opportunities. developing partnerships with co-operative efforts are key to a human rights approach in health.[12] if health professionals facilitate the opening of channels of communication, the keys held by communities are ‘oiled’ – as with the locks they are used in – which would allow them to be used more easily and freely. such a supportive bridging role is evident in the relationships developed with government, including social services and the local police, and civil society organisations, such as community-based organisations, non-governmental organisations and faith-based groups. networking and collaboration create avenues for support and assistance in promoting fairness in a united democracy. the expansion of the initial classroom key has led to the development of the key website on uct opencontent. expanding themes include the rights of persons with disabilities (disability key) and sexual and gender minorities (lesbian, gay, bisexual, transgender (lgbt) key), demonstrating the generalisability of the model. as an oer it gives permission through a creative commons licence (attribution – non-commercial – sharealike) for others to use, download and adapt for their own context. alongside the barriers to realising rights, is the recognition that when health professionals become human rights defenders, holding both their own keys and those of others, they can become vulnerable. their actions and decisions may be influenced by third parties.[13] in such situations of dual loyalty, value judgements need to be made – knowing which key to hold and how far to turn it. further plans for the key as indicated earlier, research is needed to assess the long-term impact of the key model on individual students’ learning and professional practice. 42 may 2015, vol. 7, no. 1 ajhpe research it will be useful to explore the transformative impact in changing attitudes and collective behaviours towards defending and promoting human rights. furthermore, the key may act as a valuable tool to stimulate institutional discourse and help to build connections between different stakeholders. conclusion in this article i have described the development of an innovative key model for teaching health and human rights. the visual representation reflecting the principles of hre illustrates the inter-relationship between professionalism and legal mechanisms, assisting students in guiding their understanding and personal interpretation of the multidimensional nature of health and human rights. furthermore, the visual medium helps students to self-reflect within their own contexts and experiences, interpreting the broader dynamic of social, cultural, economic and political influences. students gain insight by examining and analysing the components of their own keys. by raising awareness of human rights for individuals and communities, students as future health professionals are able to draw on this reflective tool. in so doing, they may contribute towards the progressive realisation that everyone has the right to the highest attainable standard of health. healthcare through a human rights lens acknowledges and respects varying perspectives. the internet offers new opportunities to strengthen hre. by publishing the key as an oer on uct opencontent, with additional theme topics, it can be used by others beyond one institutional boundary. the increasing views on the website indicate the ongoing interest and value of sharing classroom innovations. unlocking a toolbox of opportunities, the key promotes deep learning, advancing respect for social justice and equity. international, regional and local human rights mechanisms provide the strength and support for each individual’s key – a universal entitlement. acknowledgements. i wish to thank prof. leslie london, dr kevin williams, prof. wendy mcmillan, prof. athol kent, mr james irlam, mr gregory doyle and dr claire mitchell for their inspiration and support in assisting my development of the human rights key. in addition, i thank and acknowledge mrs  denise oldham and volunteers at uct’s disability unit. references 1. gruskin s, mills e, tarantola m. history, principles and practice of health and human rights. lancet 2007;370(9585):449-455. [http://dx.doi.org/10.1016/s0140-6736(07)61200-8] 2. london l, baldwin-ragaven l. human rights obligations in health care. continuing medical education 2006;24(1):20-24. 3. mann j. medicine and public health, ethics and human rights. in: mann jm, gruskin s, grodin ma, annas gj, eds. health and human rights. a reader. new york: routledge, 1999:439-452. 4. london l, fick n, tram kh, stuttaford m. filling the gap: a learning network for health and human rights in the western cape, south africa. 2012. http://www.hhrjournal.org/2013/08/19/filling-the-gap-a-learning-networkfor-health-and-human-rights-in-the-western-cape-south-africa/ (accessed 12 january 2015). 5. baldwin-ragaven l, de gruchy j, london l. an ambulance of the wrong colour. health professionals, human rights and ethics in south africa. rondebosch: university of cape town press, 2009. 6. dall’alba g, barnacle r. an ontological turn for higher education. studies in higher education 2007;32(6):679-691. [http://dx.doi.org/10.1080/03075070701685130] 7. olckers l, gibbs t, duncan m. developing health science students into integrated professionals: a practical tool for learning. bmc med educ 2007;7:45. http://www.biomedcentral.com/content/pdf/1472-6920-7-45.pdf (accessed 12 january 2015). 8. nazzari v, mc adams p, roy d. using transformative learning as a model for human rights education: a case study of the canadian human rights foundation’s international human rights training program. intercult educ 2005;16(2):171-186. [http://dx.doi.org/10.1080/14675980500133614] 9. haidet p, hatem ds, fecile ml, et al. the role of relationships in the professional formation of physicians: case report and illustration of an elicitation technique. patient educ couns 2008;72:382-387. 10. deshler d. metaphor analysis: exorcising social ghosts. in: mezirow j and associates. fostering critical reflection in adulthood. san francisco, calif.: jossey-bass, 1990: 296-313. 11. london l. what is a human-rights based approach to health and does it matter? health hum rights 2008;10:1. 12. london l. can human rights serve as a tool for equity? 2003. http://www.equinetafrica.org/bibl/docs/ pol14rights.pdf (accessed 14 january 2015). 13. rubenstein l, london l, baldwin-ragaven l. dual loyalty and human rights in health professional practice: proposed guidelines and institutional mechanisms. 2003. https://s3.amazonaws.com/phr_reports/dualloyalties2002-report.pdf (accessed 14 january 2015). article 17 december 2010, vol. 2, no. 2 ajhpe introduction generating and disseminating knowledge through publication is generally considered to be one of the core activities of an academic. publication of peer-reviewed articles is one of the primary methods of evaluating academic faculty, programmes and institutions.1 researchers have concluded that the ‘measurement of research output of university academic staff is crucial in determining the contribution of staff to the overall research profile of the university’.2 however, the production of research articles among physiotherapy academics was identified as a cause for concern two decades ago.3 this could have been due to the clinical focus within the physiotherapy profession. there are indications that professions such as physiotherapy were becoming more actively involved in research and evidence-based practice. the past decade has seen considerable growth in physiotherapy schools with regard to research and postgraduate programmes in south africa.4 a literature search indicated that various professions have highlighted the research productivity of their professions and these included professions such as chiropractors,5 pharmacists6 and medicine.7-9 a few international studies assessing physiotherapy productivity were found.3,10 one study assessed the scholarly productivity of 19 physiotherapy programmes in the usa and the other assessed research productivity among physiotherapists in the usa and puerto rico between 1998 and 2002. both studies concluded that research activity among physiotherapy academics was limited and every effort should be made to address this. however, the nature of publication output has not been measured among physiotherapy schools in south africa. research indicated that there is a need to ‘assess the impact of physical therapy education on scholarly productivity’.10 the information of this current study has value for physiotherapy departments because it is the first to provide baseline information of physiotherapy academics research output in south africa. thus the aim of this study was to evaluate the research productivity of the physiotherapy department at a local university in the western cape between 2002 and 2009. in this study scholarly or research productivity is measured by publications, postgraduate student through, research funding and conference presentations. the hierarchy of criteria (fig. 1) was adapted and used as an analytic lens through which to evaluate the research productivity of academics currently employed in the department.2 a factor that the model does not include was also used, namely the amount of research funding generated by academics. background to the study setting the university of the western cape is one of the historically disadvantaged tertiary institutions in south africa. before 1994, higher education institutions were segregated according to the apartheid vision.11 institutions such as the university of the western cape were under-resourced abstract objective: research productivity is an important activity among academics. this study was done to document the research productivity of the academics of a physiotherapy department in south africa. method: an archival research design was used to document the research productivity for the physiotherapy department between 2002 and 2009. data were analysed by two independent reviewers and consensus was reached on the information to be included in the study. results: among the nine academics there were 67 publications, 20 articles in progress, 7 under review and 63 conferences attended. while the overall research productivity of the department seems to be good, the bulk of the productivity rests in the hands of the senior academics. conclusion: there is a need to facilitate the acquisition of research skills in academic staff, particularly in upgrading staff to phd level and improving publication output. research productivity of academics in a physiotherapy department: a case study j m frantz, a rhoda, p struthers, j phillips department of physiotherapy, university of the western cape, bellville, south africa correspondence to: josé frantz (jfrantz@uwc.ac.za)   fig. 1. hierarchy of criteria (adapted from uzoka, 2008).                                        fig. 1. hierarchy of criteria (adapted from uzoka, 2008). article article 18 december 2010, vol. 2, no. 2 ajhpe and offered limited courses. in addition, the research was not uniformly supported across the higher education sector. there are eight physiotherapy schools in south africa and the physiotherapy department at uwc is located within the faculty of community and health sciences. at the end of 2009 the department had nine full-time academic staff members of whom 3 were associate professors, 1 senior lecturer and 5 lecturers. the demographic data of current staff members are presented in table i. research productivity is one of the areas considered for promotion among academics at the university of the western cape. the academic staff at the department is actively engaged in research activities as the promotion of academic staff is partially dependent on academic publications. at the time of the study (2009), the department had 3 academics with phd degrees and 5 with master’s degrees. the department currently offers an undergraduate programme, a 2-year course work master’s programme, master’s by thesis programme and a phd programme. eighty students have graduated from the master’s by thesis and course work programmes and four students have obtained doctoral degrees in physiotherapy. methods an archival research design was used. archival research methods include activities used to facilitate the investigation of documents and textual materials produced by and about organisations. this case study drew on contextual information provided through the analysis of documents relating to data on the master’s and phd graduates between 2002 and 2009 from the archives and the website of a local university in the western cape. research productivity of the academics was determined using document analysis (annual reports, research files, faculty cvs) available at the institution and records indicating research publications. information recorded included the journal, dissertations, year of publication and authors. although every attempt was made to obtain accurate information for this study, the possibility does exist that all information might not have been available as the research design indicates that the original information gathered was not for the purpose of the study. approval was obtained from the ethics committee of the university of the western cape and head of the physiotherapy department. information was recorded on a data capture sheet based on the hierarchy of criteria mentioned earlier. the documents were reviewed independently by two people and consensus was reached on the information to be included in the study and the additional information that needed to be followed up. academics and graduates were followed up via telephone or e-mail to identify any publications or other relevant information that could have been missed in the documents that were analysed. results during the period of assessment, the department had successfully graduated 80 master’s and 4 phd students from various african countries. in addition, two senior academics (2002 2006) left the department and four junior academics joined the department between 2006 and 2007. the document analysis found that the current academics (academics employed in the department at the time of the review) had been fairly productive between 2002 and 2009 in terms of the number of graduated master’s students and publications based on student work (see table ii). a total of 74 articles were published by academics and their master’s or phd students during the identified period. of the articles published (n=74), 34 (46%) were co-authored with master’s or phd student graduates. all of the articles that were published had been submitted to peerreviewed journals and 42 (57%) were published in accredited journals. accredited journals in south africa are journals which the department of education recognises and rewards the university money for any publications in these journals. research productivity as it relates to publications (published, submitted and in progress) of the current staff in the department is reflected in table iii. records reflected that the academics published from their own table i. demographic data of the participants level years in academia highest qualification years on contract at hei years permanent at hei gender race lecturer 1 2 years msc (2008) 2 years none male white lecturer 2 4 years msc (2007) 2 years 2 years female white lecturer 3 4 years msc (2005) none 4 years female black lecturer 4 4 years msc (2005) none 4 years female indian lecturer 5 12 years msc(2005) 6 years 6 years male coloured snr lecturer 9 years msc (2002) 1 year 8 years female coloured ass prof 1 11 years phd (2006) 3 years 8 years female coloured ass prof 2 11 years phd (2006) none 11 years female white ass prof 3 13 years phd (2005) 4 years 9 years female coloured table ii. publication output for the period 2002 2009 of current staff academic master’s students graduated by current staff publications publications from student work lecturers (5) 6 9 3 (33%) senior lecturer (1) 11 10 5 (50%) associate professors (3) 33 55 26 (47%) article 19 december 2010, vol. 2, no. 2 ajhpe research work (postgraduate studies and projects), as well as being second author to publications of their students work. a summary of the research productivity of the department according to uzoka’s (2008) evaluation of research productivity is presented in table iv. the majority of the publications were in local journals, but the academics were also publishing in national and international journals. figs 2 and 3 illustrate the number of articles published for the period 2002 2009 according to academic rank and the journals commonly published in during this period. between 2004 and 2006 there were no associate professors in the department. the 8-year output of the physio therapy department indicates an average of nine articles per year and the increase in seniority of academics increased per year. the most common journals in which publications featured was the faculty’s in-house journal, the journal of community and health sciences (n=35, 47%), south african journal of physiotherapy (n=21, 28%), african journal of physical health, education, recreation and dance (n=10, 14%). the rest were single publications in various journals. of the journals in which the academics published, only one journal was a discipline-specific journal. namely the south african journal of physiotherapy. academics over the last 7 years regularly attended and presented at conferences. of the total number of conferences attended (n=63), 48% were national conferences, 38% were international conferences and 14% were african conferences; 40% of the national conferences were attended by junior lecturers and 96% of the international conferences were attended by the more senior academics. discussion research plays an important role in helping academics to identify the gaps in knowledge through critical appraisal of available literature. the process of publication allows academics to develop as researchers through a peer-review process that scrutinises their work and acceptance for publication acknowledges the value of the research and the contribution to the area. the aim of the current study was to highlight the research productivity of academics in a physiotherapy department in south africa. in the current study there is evidence of a consistent annual publication output within this physiotherapy department. this annual output by academics in the department of physiotherapy could assist in increasing the academic standing of the department in south africa and even africa. the consistent output of this department could possibly be attributed to the existence of the postgraduate programmes within the department which graduates master’s students annually and the commitment to convert these theses into publications. this idea could be supported by the fact that many of the articles published were co-authored by master’s and doctoral graduates and their supervisors. other researchers have highlighted that the presence of doctoral degrees and a thesis component in training programmes assists academics with publication output.12 in a study among academic nurses the lack of scholarly publications among the nurses at a malawian university could be due to the lack of master’s degree programmes at the institution.13 this was confirmed by another study which reported that the strategic recruitment of dedicated phd academics does assist in increasing research productivity.14 it is evident from the current study that the academics who had a phd had an increased number of publications in relation to the more junior academics. thus the presence of postgraduate programmes and staff members with phds seems to have a positive effect on departmental academic research output. another reason for the increased research output in this department could possibly be the availability of a local in-house journal. the limited number of physiotherapy journals in south africa and even africa would fig. 2. publications according to academic level.                                       fig. 2. publications according to academic level. fig. 3. academic level v. publisher.                fig. 3. academic level v. publisher.                     fig. 3. academic level v. publisher. table iii. publications among academics level years in academia highest qualification publications submitted in progress lecturer 1 2 years msc (2008) 3 1 3 lecturer 2 4 years msc (2007) 2 2 1 lecturer 3 4 years msc (2005) 2 2 1 lecturer 4 4 years msc (2005) 0 1 2 lecturer 5 12 years msc(2005) 2 1 1 senior lecturer 9 years msc (2002) 10 2 1 associate prof 1 11 years phd (2006) 15 2 3 associate prof 2 11 years phd (2006) 17 3 5 associate prof 3 13 years phd (2005) 36 5 5 article 20 december 2010, vol. 2, no. 2 ajhpe make it difficult for physiotherapy academics to publish. this could be the reason for the increased number of publications in journals not directly linked to the physiotherapy profession. this idea was supported by other studies which indicated that professional journals did not commonly publish articles from other professions.13 however, the low number of articles published in international journals could be that the research conducted by the academics was not of interest to a global audience. it is however evident from the current study that a higher level of research productivity was more prevalent among senior academics. this is highlighted in the statistics for publication output as well as the conference attendance. studies conducted among chiropractors reported that academics with higher qualifications and also more senior status tended to produce more publications.5 in addition, the average number of articles per staff member per year in this current study is approximately one article, with the average among senior staff members being two articles per year. this was similar to other studies6 which reported an average of two articles per year among only 5% of their staff. it would thus be imperative for this department to ensure that all academics, especially younger academics, obtain doctoral degrees in order to ensure an increase and steady growth in the departmental publication output. ‘success in scholarly productivity is based on a complex interaction between individual faculty members and the departmental culture in the context of the global institution.’10 thus the success within this department could be enhanced by a good interaction between senior and junior staff as well as a culture of research evident from the successful postgraduate programme and publication output. conclusion research productivity among physiotherapy academics is important for the physiotherapy profession. the three pillars of evaluation among academics include teaching, research and administration and it has become imperative that all academics find a balance. if the research productivity among junior academics is to be improved, strategies need to be put in place that will encourage this. strategies that could assist in this process are mentoring of junior academics by senior academics in the form of joint publications, dedicated time for research and writing for publication workshops. references 1. holden g, rosenberg g, barker k. a potential decision making aid in hiring, reappointment, tenure and promotion decisions. social work in health care 2005;41:67-92. 2. uzoka f. a fuzzy-enhanced multicriteria decision analysis model for evaluating university academics’ research output. information knowledge systems management 2008;7:273-299. 3. holcomb j, selkar l, roush r. scholarly productivity: a regional study of physical therapy faculty in schools of allied health. physical therapy 1990;70:66-72. 4. louw q, grimmer-somers k, crous l, marais m, amosun s. framing a vision for physiotherapy research: synthesizing educators view points in cape town. internet journal of allied health sciences and practice 2007;5:2 (issn 1540-580x). 5. hoskins w, pollard h, reggars j, vitiello a, bonello r. journal publications by australian chiropractors: are they enough? chiropractic and osteopathy 2006;14:13 doi:10.1186/1746-1340-14-13. 6. coleman c, schlesselman l, lao e, white c. number and impact of published scholarly works by pharmacy practice faculty members at accredited us colleges and schools of pharmacy (2001-2003). american journal of pharmacy education 2007;71(3):44. 7. han m, lee c. scientific publication productivity of korean medical colleges: an analysis of 1988-1999 medline papers. journal of korean medical school 2000;15:3-12. 8. petrak j, bozikov j. journal publications from zagreb university medical school in 1995-1999. croatian medical school 2003;44:661-669. 9. dakik h, haidbey h, sabra r. research productivity of the medical faculty at the american university of beirut. postgraduate medical journal 2006;82:462-464. 10. richter r, schlomer s, krieger m, siler w. journal publication productivity in academic physical therapy programs in the united states and puerto rico from 1988 – 2002. physical therapy 2008;88:376-386. 11. council on higher education. higher education monitor: access and throughput in south african higher education: three case studies. higher education monitor 2010; no 9. 12. cooper m, turpin g. clinical psychology trainees’ research productivity and publications: an initial survey and contributing factors. clinical psychology and psychotherapy 2007;14:54-62. 13. muula a. status of scholarly productivity among nursing academics in malawi. croatian medical journal 2007;48:568-573. 14. chung s, clifton j, rowe a, finley r, warnock g. strategic faculty recruitment increases research productivity within an academic university division. canadian journal of surgery 2009;52:401-406. table iv. research productivity n reputation of publisher institution based 32 professional society based 21 other (sa/african/international) 21 publication type published journal articles 74 submitted papers 7 papers in progress 20 authorship single author 17 double author 34 triple author 14 multiple authors 9 place of publication local (institution) 32 (published papers) regional (south african) 23 international (african/ international) 19 conference presentations national 30 african 9 international 24 students graduated mini-thesis 50 full master’s thesis 17 research funding generated local university research funding 9 nrf funding 2 mrc funding 2 international funding 2 ajhpe editorial.indd research october 2014, vol.6, no. 2 ajhpe 117 editorial the term ‘simulation’, as it pertains to the training of healthcare professionals, appears in three of the 10 articles selected for publication in this edition of ajhpe.[1-3] this provides an ideal opportunity to pause and reflect on some aspects of this teaching technique in the context of healthcare training in africa, a key mandate of the journal. simulationbased training is not new. the technique, widely known for its use in non-medical industries such as commercial aviation and nuclear power production, was first used to train healthcare professionals more than 40 years ago.[4-6] ‘resusci-annie’ was born in 1960[7,8] and many of us can recall how we carefully wheeled her around the medical school while she patiently endured, and survived, endless resuscitation training sessions on a daily basis. more than 30 years later, a dynamic interactive ‘gentleman’ – ‘simman’[8] – replaced ageing annie. since then, the human body simulation industry has grown in leaps and bounds and clinician educators are now confronted by a bewildering array of equipment designed to teach an everincreasing number of basic and advanced technical and clinical skills.[5] while the applications of human body simulation are diverse[9] and the educational benefits have been documented,[4-6,10,11] the question that needs to be considered is ‘should simulation-based training be an essential, nonnegotiable component of training for a career in healthcare provision?’. many will say that this question has already been answered and provide a list of important reasons why clinical simulation training centres are essential, including: (i) concerns about patient safety; (ii) risk of injury to trainees; (iii) medico-legal consequences of procedural errors; (iv) need for a ‘safe’ learning environment where errors can be made and remediated without dire consequences; (v) reduction in time needed to become proficient in the requisite skills; and most recently (vi) need for additional appropriate training opportunities in circumstances where the clinical teaching platform has become overloaded with both patients and students, and the combined epidemics of tuberculosis, hiv/aids and trauma have inappropriately skewed the case mix from a training perspective.[1] while these reasons are all valid and important, it is somewhat disappointing to learn that robust evidence, demonstrating better health outcomes for patients managed by trainees who have undertaken simulationbased training, compared with those who have not, is still lacking.[6-9,11] okuda et al.[6] made the point quite clearly by stating the following: ‘as simulation becomes increasingly prevalent in medical school and resident education, more studies are needed to see if simulation training improves patient outcomes’. gaba,[9] an internationally respected leader in simulation training, sounded an even sterner warning: ‘the future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality’. one could argue that the need for such data is obsolete because many health sciences faculties worldwide have already spent, and continue to spend, considerable sums of money to set up and run simulation training facilities because ‘simulation is here to stay’. if only the latter assumption was a global reality. while 71% of medical schools that responded to a worldwide survey conducted in 1999 were using some form of manikin or simulator to teach anaesthesia skills to medical students,[12] and one-third of us medical schools were using human patient simulators by 2003,[5] the cost of setting up and maintaining such simulation facilities is prohibitively expensive and beyond the reach of most health sciences training centres in the developing world. in 1997, the start-up and first-year operational costs for a high-fidelity simulation centre in canada was about usd665 000.[13] even in south africa (sa), one of the wealthiest countries in africa, access to simulation-based training facilities at all the local universities was an incremental process that took more than a decade to become a reality. so, if simulation-based training is essential, for the many good reasons we believe, then the question arises, ‘what is the future of health sciences faculties where such training facilities do not exist?’. should wealthy countries provide the equipment needed or should trainees go to wealthy countries, including sa, to undertake simulation-based training? this debate is a double-edged sword because simulation centres, set up by wealthy donors, require ongoing funding to run and maintain/repair/ replace the necessary equipment. unfortunately, these long-term ‘hidden’ costs are not always factored into start-up projects, and ongoing skills training gradually dwindles as equipment/systems failure becomes the order of the day. the alternative approach – sending trainees to centres where simulation-based training is available – is also not as easy as it seems. firstly, it is not a viable option for large numbers of undergraduate students, but seems like an attractive option for postgraduate trainees. the truth, however, is that travel and subsistence costs, even in sa, are beyond the financial means of fellow african trainees, not to mention further afield, and so this option is only available to a tiny proportion of trainees who would benefit from the learning opportunity. if simulation-based training is desirable, and the abovementioned realities are faced on the african continent, how should we proceed? there is no easy answer to address this huge challenge, but part of the answer must reside in the innovative and creative ways in which simulation equipment can, and will need to, be made from affordable, locally available materials. simple examples of cheap innovations include the use of pig cadavers to teach intercostal drain insertion, or wooden boxes with ‘portals’ that provide laparoscopy training. while these models lack the attractive appearance and endless capabilities of expensive high-fidelity equipment, the level of training that can be achieved with them has not been formally documented to determine the size of the residual skills gap deficit, if at all. having developed workable models, we need to share their innovations with our fellow africans, and with others, by means of workshops (virtual or face-to-face), conference presentations (virtual or face-to-face), peerreviewed publications, education clearing houses such as mededportal (https://www.mededportal.org) and social media, as appropriate. this is however not a comprehensive answer to the challenges we face, but we need to systematically address our essential training needs in a feasible, affordable and sustainable way. this area of ‘innovation’ research is largely does simulation-based training have a future in africa? vanessa burch editor-in-chief african journal of health professions education vanessa.burch@uct.ac.za research 118 october 2014, vol.6, no. 2 ajhpe editorial unexplored and ready to be exploited, e.g. which models can be successfully made locally?; how well do locally made models work?; how large is the skills gap deficit of trainees using locally made simulation models compared with trainees using high-fidelity simulation facilities? finally, we should not forget that data demonstrating health outcome benefits of simulation-based training, whether cheap or expensive, are still needed and there is no good reason why africans could not also make a meaningful contribution to answering this question, perhaps the most important one of all. 1. labuschagne mj, nel mm, nel ppc, van zyl gj. recommendations for the establishment of a clinical simulation unit to train south african medical students. ajhpe 2014;6(2):138-142. [http://dx.doi. org/10.7196/ajhpe.345] 2. aldous cm, searle r, clarke dl. an educational programme for error awareness in acute trauma for junior doctors. ajhpe 2014;6(2):161-164. [http://dx.doi.org/10.7196/ajhpe.350] 3. katowa-mukwato p, andrews b, maimbolwa m, et al. medical students’ clerkship experiences and self-perceived competence in clinical skills. ajhpe 2014;6(2):155-160. [http://dx.doi.org/10.7196/ajhpe.358] 4. bradley p. the history of simulation in medical education and possible future directions. med educ 2006;40:254262. [http://dx.doi.org/10.1111/j.1365-2929.2006.02394.x] 5. good ml. patient simulation for training basic and advanced clinical skills. med educ 2003;37(suppl. 1):14-21. 6. okuda y, bryson eo, demaria s, et al. the utility of simulation in medical education: what is the evidence? mt sinai j med 2009;76:330-343. [http://dx.doi.org/10.1002/msj.20127] 7. tjomsland n, baskett p. resuscitation greats: asmund s laerdal. resuscitation 2002;53:115-119. 8. rosen kr. the history of medical simulation. j crit care 2008;23:157-166. [http://dx.doi.org/10.1016/j.jcrc.2007.12.004] 9. gaba dm. the future vision of simulation in health care. qual saf health care 2004;13(suppl. 1):i2-i10. 10. issenberg sb, mcgahhie wc, petrus er, gordon dl, scalese rj. features and uses of high-fidelity medical simulations that lead to effective learning: a beme systematic review. med teach 2005;1:10-28. 11. mcgaghie wc, issenberg sb, petrusa er, scalese rj. a critical review of simulation-based medical education research: 2003-2009. med educ 2010;44:50-63. [http://dx.doi.org/10.1111/j.1365-2923.2009.03547.x] 12. morgan pj, cleave-hogg d. a worldwide survey of the use of simulation in anaesthesia. can j anaesth 2002;49:659-662. 13. kurrek mm, devitt jh. the cost for construction and operation of a simulation centre. can j anaesth 1997;44:1191-1195. ajhpe 2014;6(2):117-118. doi:10.7196/ajhpe.534 march 2017, vol. 9, no. 1 ajhpe 13 research proponents of service learning (sl) state that it is a form of experiential education that combines student learning goals intentionally with service provision to communities.[1-4] the rationale for these sl activities is grounded in educational philosophies that propagate social responsibility as the primary goal of learning.[5] educators who integrate sl into the curriculum hope to develop cultural sensitivity and civic responsibility in students by raising student awareness with regard to the challenges communities experience. this philosophical stance is also reflected in sl definitions formulated by acclaimed us scholars, such as bringle and hatcher,[2] and in south african (sa) higher education policy documents. bringle and hatcher[2] define sl as a ‘course-based, credit-bearing educational experience in which students participate in an organised service activity that meets the identified community needs and reflect on the service activity in such a way to gain further understanding of the course content, a broader appreciation of the discipline and an enhanced sense of personal values and civic responsibility’. in the sa context, the higher education quality committee (heqc) positioned sl as a core function of higher education to advance social development and transformation of disadvantaged communities.[3] to this end, the heqc has formulated criteria for sl as criterion 7 in the framework for institutional audits[6] and in the framework for programme accreditation.[7] in addition, sl provides an opportunity for the students to reflect on the service activity in such a way as to gain further understanding of the course content, a broader appreciation of the discipline, and an enhanced sense of civic responsibility. this is achieved through the introduction of reflection as an assessment strategy. according to elyer and giles,[8] reflection has been identified as a foundational principle of sl and is regarded as the glue that holds service and learning together to provide an optimal educative experience. reflective practice is about acquiring the skills and attitude to inquire continually into one’s own professional practice and into the context in which it is embedded. it can also take place on different levels to which students are exposed in academic practices. bringle and hatcher, as cited by julie et al.,[9] state that sl provides higher education institutions with a strategy to explore ways of incorporating service to extend their mission, enhance student achievement, and engage students in their communities as part of their academic curriculum. problem statement students of dental therapy and oral hygiene, school of oral health sciences, sefako makgatho health sciences university (formerly university of limpopo, medunsa campus), pretoria, sa are trained in predominantly clinical settings. however, these clinical placements are not linked to learning outcomes aimed at developing social responsiveness in the students. likewise, the community site visits for 2nd-year students are not explicitly linked to their learning outcomes – these visits tend to happen randomly. background. service learning (sl) as a pedagogy in higher education must be differentiated from other services with a primarily philanthropic intent. dental therapy and oral hygiene students at sefako makgatho health sciences university, school of oral health sciences, pretoria, south africa visit community sites during their 2nd year of study. however, the current curricula would need restructuring for alignment with the espoused pedagogy and standards of sl. such an sl curriculum design would thus allow for the provision of meaningful services to communities as an integral component of these programmes. objective. to explore (i) perceptions of 2nd-year oral health students; and (ii) opinions of academics with regard to the need for an sl module. methods. purposive sampling was used to conduct two focus group discussions with academics involved in curriculum development (n=11) and students who had previous exposure to communities (n=10). a survey containing open-ended questions was completed by 9 academics, who would implement the proposed sl module. frequencies were calculated and data from the open questions were analysed for emergent themes. results. most academics (89%, n=8) indicated that working effectively with others as members of a team and developing cultural sensitivity were achievable from an sl module. two themes emerged from the focus groups, i.e. (i) enhanced teaching and learning – students could apply theoretical and clinical training in an authentic setting; and (ii) standardisation of training – an sl module would ensure consistency when engaging with communities. conclusion. the needs assessment was valuable to inform the development and implementation of the sl module. afr j health professions educ 2017;9(1):13-16. doi:10.7196/ajhpe.2017.v9i1.597 developing a service-learning module for oral health: a needs assessment r ebrahim,1 msc (dent); h julie,2 mph, mcur, phd 1 extended programme, faculty of natural and agricultural sciences, university of pretoria, south africa 2 school of nursing, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: r ebrahim (ruebecca.ebrahim@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 14 march 2017, vol. 9, no. 1 ajhpe research why a needs assessment? for sl to be institutionalised, standardised and formally structured, an sl component in the curriculum is required. to plan and implement an sl module that will integrate learning in the classroom with practice in the community, it is important to conduct a needs assessment. research has shown that educational activities based on learning needs are more effective in delivering sustainable educational outcomes for participants; therefore, a learning needs assessment should be conducted as the first step in planning an educational activity.[10] the purpose of designing such a module in oral health would be to integrate classroom teaching with meaningful community service activities, designed as an integral feature of the clinical programme. the objectives were to explore: (i) perceptions of 2nd-year oral health students with regard to the need for a structured module for sl; and (ii) opinions of the academics at the school of oral health sciences, sefako makgatho health sciences university regarding the need for an sl module. definition of terms • sl is a course-based, credit-bearing educational experience in which students participate in an organised service activity that meets the identified community needs and reflect on the service activity in such a way as to gain further understanding of the course content, a broader appreciation of the discipline and an enhanced sense of personal values and civic responsibility.[4] • community engagement refers to the interactions and processes through which the expertise of the institution in the areas of teaching, learning and research is applied to develop and sustain society.[5] methods study setting the university of limpopo’s policy on community engagement (ce) identifies sl modules as one of the mandated community engagement activities.[11] the school of oral health sciences, situated in garankuwa, pretoria, comprises the departments of periodontology, oral medicine and community dentistry; maxillo-facial surgery, pathology, radiology and orthodontics; and restorative dentistry, integrated clinical dentistry and prosthodontics. at the time of the study, three academic programmes were offered, i.e. bachelor of dental science, bachelor of dental therapy, and diploma in oral hygiene. not all the aforementioned departments, and therefore not all the academics, are involved in the teaching and training of dental therapy and oral hygiene students, as the scope of their clinical practice is limited compared with that of bachelor of dentistry students. study design the study used an exploratory descriptive design comprising two focus group discussions with academics and students, respectively, and a quantitative survey with academics. population and sample the study population for the qualitative part was selected based on their potential participation in ce activities. purposive sampling was used to select the participants for the two focus group discussions. the first focus group comprised 10 3rd-year bachelor of dental therapy students who had participated in unstructured ce activities during their 2nd year of study. the second focus group comprised 11 academics who were involved in the teaching and training of the abovementioned students and served on the curriculum development committee (cdc); they were therefore involved in curriculum development at the school of oral health sciences, university of limpopo medunsa campus (currently sefako makgatho health sciences university). the study population for the survey comprised an additional 12 academics involved in teaching and training, who were not members of the cdc. allinclusive sampling was used because these 12 academics were involved in the teaching and training of the abovementioned students and hence were potential implementers of the proposed sl module. data collection method and process prior to commencement of the study, ethical approval was granted by the school research and ethics committee and the medunsa research and ethics committee (ref. no. mrec/e/112/2013:pg). informed consent was obtained from participants, who were assured of confidentiality and anonymity. the focus group discussions with the academics and students explored the participants’ understanding of sl, how to structure an sl module and how to identify critical cross-field outcomes that could be attained from an sl module. in addition to these questions, in the focus group discussions the researcher also explored the students’ expectations of an sl module. the focus group discussions were audio recorded, transcribed verbatim and analysed to identify emergent themes. an independent coder validated the findings for correctness after the participants had verified the accuracy of the transcribed data through member checking. the self-developed structured questionnaire comprising three openended questions explored: (i) the academics’ understanding of sl; (ii) critical cross-field outcomes; and (iii) learning outcomes that could potentially be achieved by introducing an sl module in dental therapy and oral hygiene. the frequencies were calculated in microsoft excel (usa) for the nine completed questionnaire received, representing a response rate of 75%. results the results of the survey are presented first, followed by the themes that were identified from the two focus group discussions. survey results the major categories identified from the open-ended questions related to: (i) academics’ understanding of sl; (ii) critical cross-field outcomes; and (iii) potential of an sl module to enhance teaching and learning. academics’ understanding of sl the exploration of this theme reflected that 55% (n=5) of academics regarded sl as a ‘method of teaching’, while 33% (n=3) stated that sl is ‘rendering service to the community’. other responses varied from ‘learning while rendering a community service’ to ‘combines cognitive learning with practice’. critical cross-field outcomes fig. 1 illustrates unanimity among all participants (100%, n=9) that the following two learning outcomes could be achieved: ‘identify and solve problems by using critical and creative thinking’ and ‘diagnose, plan and march 2017, vol. 9, no. 1 ajhpe 15 research implement a community-based programme’. they further indicated that ‘work effectively with others as members of a team’ and developing ‘cultural sensitivity’ were also achievable from such an sl module (89%, n=8). it was also mentioned that ‘interacting and engaging with the community’ would help students to identify the needs of a target population group (78%, n=7). potential of an sl module to enhance teaching and learning the overall responses of academics indicated that an sl module would ‘enhance teaching and learning’ (89%, n=8). responses indicated that an sl module would provide a tool for the site visit; would encourage critical thinking; and that reflection and evaluations would help students to identify strengths and weaknesses and thus enhance learning. the academics also indicated that going out into the community allows students to apply their theoretical knowledge and clinical skills in an environment that differs from the ideal conditions of training institutions. fig. 2 summarises the academics’ responses regarding learning outcomes that may be achieved from an sl module. results emanating from the two focus group discussions the participants’ voices are captured in table 1. two themes emerged from the focus groups, i.e. (i) enhanced teaching and learning – students could apply theoretical and clinical training in an authentic setting; and (ii) standardisation of training – an sl module would ensure consistency when engaging with communities. academic staff and students concurred that students should consult with members of the community before and after the sl activity to identify needs and expectations and obtain feedback. enhanced teaching and learning the academics suggested that an sl module would ‘enhance learning if structured for the reciprocity of needs’. while some academics voiced the opinion that sl offers a learning experience in an authentic setting and allows students to ‘look at patients as a whole’, the students discussed how ‘you get to see different things out there that you don’t see in hospitals’, which provides experience in a real-world setting and often requires students to improvise. standardisation of training the students felt that an sl module would provide standardisation of training, allowing them to ‘perform better’, as ‘we have an idea of what we are going to do’. students’ statements, ‘learning in the process of helping the community’ and ‘i think it’s also about teaching the community’, indicated that interaction with the community is a two-way learning process. one student articulated: ‘we have to know what the community needs, because different communities need different treatment.’ the following observation from the student succinctly summarises the essence of sl in terms of service delivery: ‘with sl there is no imposition, it’s a two-way stream, we go there to learn and they receive service from us, and it’s the service they want, not the service we want to give whether they want it or id en tif y an d so lv e pr ob le m s b y us in g cr iti ca l a nd c re at iv e th in ki ng w or k eff ec tiv el y w ith o th er s a s m em be rs o f a te am , g ro up , or ga ni sa tio n or c om m un ity o rg an ise a nd m an ag e on es el f an d on e' s a ct iv iti es re sp on sib ly an d eff ec tiv el y co lle ct , a na ly se , o rg an ise a nd cr iti ca lly e va lu at e in fo rm at io n co m m un ic at e eff ec tiv el y us in g vi su al , m at he m at ic al a nd la ng ua ge sk ill s u se sc ie nc e an d te ch no lo gy eff ec tiv el y an d cr iti ca lly be c ul tu ra lly a nd a es th et ic al ly se ns iti ve a cr os s a ra ng e of so ci al c on te xt s 120 100 80 60 40 20 0 g at he r a nd a na ly se d at a id en tif y th e ne ed s o f a ta rg et p op ul at io n gr ou p d ia gn os e, p la n an d im pl em en t a co m m un ity -b as ed p ro gr am m e co m pa re th e eff ec tiv en es s, effi ci en cy an d fe as ib ili ty o f d en ta l p ro gr am m es 120 100 80 60 40 20 0 a ca d em ic s' re sp o n se s, % a ca d em ic s' re sp o n se s, % fig. 2. academics’ responses with regard to learning outcomes that may be achieved from an sl module. id en tif y an d so lv e pr ob le m s b y us in g cr iti ca l a nd c re at iv e th in ki ng w or k eff ec tiv el y w ith o th er s a s m em be rs o f a te am , g ro up , or ga ni sa tio n or c om m un ity o rg an ise a nd m an ag e on es el f an d on e' s a ct iv iti es re sp on sib ly an d eff ec tiv el y co lle ct , a na ly se , o rg an ise a nd cr iti ca lly e va lu at e in fo rm at io n co m m un ic at e eff ec tiv el y us in g vi su al , m at he m at ic al a nd la ng ua ge sk ill s u se sc ie nc e an d te ch no lo gy eff ec tiv el y an d cr iti ca lly be c ul tu ra lly a nd a es th et ic al ly se ns iti ve a cr os s a ra ng e of so ci al c on te xt s 120 100 80 60 40 20 0 g at he r a nd a na ly se d at a id en tif y th e ne ed s o f a ta rg et p op ul at io n gr ou p d ia gn os e, p la n an d im pl em en t a co m m un ity -b as ed p ro gr am m e co m pa re th e eff ec tiv en es s, effi ci en cy an d fe as ib ili ty o f d en ta l p ro gr am m es 120 100 80 60 40 20 0 a ca d em ic s' re sp o n se s, % a ca d em ic s' re sp o n se s, % fig. 1. academics’ responses to critical cross-field outcomes that may be achieved from an sl module. table 1. themes and supporting statements enhanced teaching and learning standardisation of training ‘a learning experience in an authentic setting.’ ‘you’ll know what to do when you are there.’ ‘interaction with the community is a two-way learning process.’ ‘we have an idea of what we are going to do.’ ‘consideration of community expectations.’ ‘it has to be comprehensive.’ ‘you get to see different things out there that you don’t see in hospitals.’ ‘people are gonna perform better.’ ‘we have to know what the community needs, because different communities need different treatment.’ ‘maybe you’ll find that the other group did certain things that the other group didn’t do.’ ‘when we go into a community the people are actually learning, it’s not just service rendering.’ ‘people at school a are gonna benefit in a way that people at school b didn’t benefit because the people at school b didn’t do it.’ ‘you learning in the process of helping the community.’ ‘some people, they not doing things – but if it’s in a course then … .’ ‘it’s an opportunity to see more cases.’ ‘so it becomes more uniformed and structured.’ 16 march 2017, vol. 9, no. 1 ajhpe research not.’ the academics also agreed that community needs and expectations are often forgotten, and it is important to determine the community’s values and needs from service providers. this may be achieved by obtaining feedback from the community. they also saw great value in a multidisciplinary module that could be used by all health professionals, illustrated by the following statements: ‘the best way would be an integrated module, not an oral health module’, and ‘… a comprehensive health module that can be used throughout the medunsa campus.’ discussion although the university of limpopo had a policy on community engagement that was approved by the senate in 2008, all the study participants were unaware of its existence. this could explain the differences in the understanding of sl. recommendation 33 of the heqc report[12] suggests that the university of limpopo ‘(1) conduct an institution-wide debate on what community engagement means for the university; (2) develop a framework document that conceptualises community engagement in relation to the core functions of teaching and learning and research; and (3) put in place strategies and mechanisms to monitor and harness the impact of community engagement initiatives on the core functions of the institution’. this further indicates the need for sl to be formally embedded in the curriculum to ensure that teaching and training are in keeping with the national policy for higher education institutions and the university of limpopo’s policy on community engagement. julie et al.[13] reported similar findings at other higher education institutions in sa. this study indicates that sl means different things to different people. some academics were aware that sl involves teaching students while addressing identified community needs, while others knew that sl is pedagogy in health education that combines cognitive learning with practice in the community. it is therefore imperative that academic staff are equipped and developed to provide training to students, as sl is first and foremost an academic endeavour requiring the expertise of academic staff, which provides the essential context linking community service to theoretical texts and principles.[1] students’ understanding of sl was based on their experiences of learning in the process of visiting and helping the community. many failed to mention the significance of reflection in providing a better understanding of the course content and the impact of social, cultural and economic factors on health. it is important to include reflection in the sl framework for dental education, as reflection is a central characteristic of sl and has been called the hyphen that links service and learning.[14] yoder[14] states that some of the most powerful learning experiences occur in a non-clinical setting, where the artificial barriers of the white coat do not interfere with communication. the responses from some academics, indicating that an sl module would provide a tool for the site visit, encourage critical thinking and thus enhance learning, validate this statement. developing a module that incorporates sl in the oral health curriculum will allow students to apply the course content to real-world situations, which often lack the resources available at training institutions. research has shown that courses incorporating sl components generally provide greater learning benefits than those that do not, including a deeper understanding of course material, a better understanding of the complex problems people face, and an ability to apply course material to new situations.[10] a limitation to the results of this study should be noted. choosing a survey for the quantitative is a limitation because the results cannot be generalised. the findings of this study indicate that an sl component in the oral health module will enhance teaching and learning. a further study to develop a framework for the module is recommended. conclusion the findings of this study indicate that an sl module would enhance teaching and learning and would impact on civic responsibility and students’ retention of theoretical and practical course material. exposure and experiences during a curriculum-integrated module would afford students the opportunity to work in a structured manner, while being guided through the dynamics of authentic settings. acknowledgements. the authors gratefully acknowledge the following from the university of limpopo medunsa campus (currently sefako makgatho health sciences university): the cdc members and 3rd-year dental therapy students for their willingness to participate in the focus group discussions; drs a khan, n nzima, and p motloba, and prof. t gugushe for their assistance, and prof. g ogunbanjo for his feedback. the authors also acknowledge the sub-saharan africa-faimer regional institute (safri) for the invaluable mentorship support. 1. bender cjg, daniels p, lazarus j, naude l, sattar k. service learning in the curriculum: a resource for higher education institutions. pretoria: council on higher education and jet/chesp, 2006:40-46. 2. bringle rg, hatcher ja. a service-learning curriculum for faculty. michigan j comm serv learn 1993;(2):112-122. 3. higher education quality committee. service partnerships. service learning in the curriculum: a resource for higher education institutions. pretoria: council on higher education, 2006. 4. hood jg. service-learning in dental education: meeting needs and challenges. j dent educ 2009;73(4):454-463. 5. osman r, petersen n. students’ engagement with engagement: the case of teacher education students in higher education in south africa. br j educ studies 2010;58(4):407-419. http://dx.doi.org/10.1080/00071005.2010.527665 6. higher education quality committee. framework for institutional audits. pretoria: council on higher education, 2004. 7. higher education quality committee. framework for programme accreditation. pretoria: council on higher education, 2004. 8. elyer j, giles dw. where’s the learning in service-learning? san francisco: jossey-bass, 1999. 9. julie h, daniels p, adonis ta. service-learning in nursing: integrating student learning and community-based service experience through reflective practice. health sa gesondheid 2005;10(4):41-54. http://dx.doi.org/10.4102/ hsag.v10i4.206 10. association of reproductive health professionals. conducting a cme activity needs assessment. 2002. http://arhp. org/about-us/joint-sponsorship/needs-assessment (accessed 27 january 2017). 11. university of limpopo. community engagement policy. pretoria: ul, 2008:5. https://ul.ac.za/application/.../ community%20engagement%20policy (accessed 3 february 2017). 12. council on higher education.higher education quality committee. report to the university of limpopo. executive summary. pretoria: che, 2011. http://www.che.ac.za/sites/default/files/institutional_audits/institutional_ audits_2010_lp_executive_summary.pdfwww.che.ac.za/.../institutional_audits_2010_lp_executive_summary (accessed 3 february 2017). 13. julie h, adejumo oa, frantz jm. cracking the nut of service-learning in nursing at a higher educational institution. curationis 2015;38(1). http://dx.doi.org/10.4102/curationis.v38i1.117 14. yoder km. a framework for service-learning in dental education: meeting needs and challenges. j dent educ 2006;70(2):115-123. http://dx.doi.org/10.4102/hsag.v10i4.206 http://dx.doi.org/10.4102/hsag.v10i4.206 http://www.arhp.org/about-us/joint-sponsorship/needs-assessment http://www.arhp.org/about-us/joint-sponsorship/needs-assessment https://www.ul.ac.za/application/.../community%20engagement%20policy https://www.ul.ac.za/application/.../community%20engagement%20policy http://www.che.ac.za/sites/default/files/institutional_audits/institutional_audits_2010_lp_executive http://www.che.ac.za/sites/default/files/institutional_audits/institutional_audits_2010_lp_executive editorial a curriculum is described as an expression of educational ideas in practice.[1] it is a living document which should be adaptable to a changing environment. when faced with specific contextual challenges that required curriculum renewal, we took a phronetic approach. the process was predominantly based on craft knowledge and relied in most part on the insightfulness of staff. the curriculum renewal provided a unique opportunity to evaluate both the content and the mode of delivery. in this edition of ajhpe we share the valuable lessons learned along the journey of curriculum renewal. we started with the end in mind by defining the profile of the stellenbosch university physiotherapy graduate (table 1). the curriculum aimed not only to assist the development of physiotherapy-specific knowledge and psychomotor skills but also to develop generic skills (graduate attributes), which would equip our students to practise as first-line practitioners within the south african healthcare context. this is in line with an editorial in the lancet which states that curricula should be designed to think globally but to act locally.[2] the curriculum is vertically and horizontally aligned (fig. 1). if students can’t learn the way we teach, maybe we should teach the way they learn. (ignacio estrada) mapping of a curriculum renewal journey: lessons learned table 1. profile of the stellenbosch university physiotherapy graduate the recently graduated stellenbosch university physiotherapist will have the basic knowledge and skills to function in the south african health context as a reflective practitioner within the philosophy and values intrinsic to the physiotherapy profession this philosophy and the values of the physiotherapy profession are encapsulated in three domains, namely professional accountability, client management and the organisation of services. the qualities of the recently graduated physiotherapist are reflected as follows within the three domains: professional accountability • be ethically accountable towards the profession, client and community • execute a safe, effective and professional practice • demonstrate a positive attitude in terms of continued professional development • develop interpersonal relationships • comprehend the importance of involvement with professional organisations • communicate appropriately and effectively with clients, family members as well as with other healthcare team members patient management • demonstrate knowledge of the normal and abnormal functioning of the human body and psyche • show insight in terms of the impact of cultural environment on the outcomes of health services • possess the necessary skills to evaluate a client’s status (physical, functional and psychological), to analyse his/her needs and be able to formulate a physiotherapy diagnosis and prognosis • be able to develop an outcomes-based intervention plan and to implement it based on evidence-based practice • should be able to re-evaluate the effectiveness of this intervention and incorporate the findings in future practice organisation of services • should be able to plan, implement and evaluate appropriate, cost-effective physiotherapy services within the south african health context • use appropriate technology to support, analyse and improve physiotherapy services clinical physiotherapy physiotherapy practice research methodology applied physiotherapy physiotherapy science registered physiotherapist real world pathology pharmacology human sciences (psychology; sociology) medical sciences (anatomy; physiology) basic sciences (chemistry; physics; biology) fig. 1. structure of the curriculum. 178 october 2014, vol. 6, no. 2, suppl 1 ajhpe october 2014, vol. 6, no. 2, suppl 1 ajhpe 179 editorial identifying the core content of a curriculum is a daunting task. hanekom et al.[3] describe the use of a high engagement methodology to determine the core content within the context of an expanding professional knowledge base. in addition to defining the content, curriculum designers have lobbied for the inclusion of a variety of didactic strategies to optimise learning and adequately prepare students to function in a dynamic environment.[4] student-centered approaches were explored which could provide learning opportunities to facilitate the development of professional and generic skills. despite a body of work describing the use of problem-based (pb) and enquiry-based (eb) approaches to learning, these two pedagogical approaches remain controversial.[5] statham et al.[6] compare the perceptions of students and staff to the success of a hybrid pb learning module using a theorybased evaluation approach. inglis-jassiem et al.[7] report on the lessons learned when implementing an eb approach to learning. two examples of pedagogical innovation are included in this edition.[8] evidence-based practice (ebp) is widely recognised as a key skill for health professionals. developing competent evidence-based practitioners on entry to the profession is a cornerstone of an undergraduate programme. burger and louw[9] explain the rationale for adopting a secondary research approach as a vehicle to teach the principles of ebp as part of the undergraduate physiotherapy research module. in addition they share implementation strategies and lessons learnt on this path of restructuring. the five-step model has been offered as a simple and an efficient model for clinical skills training.[10] however, increasing student numbers hinder the immediate feedback, correction and reinforcement needed to cement the correct performance. unger et al.[11] describe an innovative strategy using near-peer-assisted tutorials to address this challenge. the data reflect the added value of this strategy to the professional development of tutors. the primary aim of the undergraduate programme is to produce competent physiotherapists who can function as first-line practitioners on entry to the profession. the importance of providing authentic learning opportunities in this process is widely acknowledged. three papers in this edition focus on clinical education. while much has been written about the social aspects of clinical environments there is a paucity of data on the physical requirements of clinical placements.[12] williams et al.[13] describe the clinical sites and exposure of students based on a self-developed site evaluation tool. the importance for academic institutions to develop partnerships with health service providers is evident from the data. they argue for a more active role of universities in the development of clinical education sites. ernstzen et al.[14] explore whether the learning experiences of the primary healthcare clinical rotation was appropriate to enable students to reach the learning outcomes for the rotation. the data highlight the need for programme designers to evaluate and align learning opportunities that are offered at clinical sites. a second paper by ernstzen et al.[15] adds to the conversation around transitional issues experienced by students on entry to the clinical environment.[16] the clinical learning opportunities perceived by learners to assist in the transformation from classroom to clinical practice are presented. while curriculum renewal in health education is not novel, unger and hanekom[17] reflect on the impact of the process. the reflection is based on data comparing the perceptions of students from the ‘old curriculum’ with the revised curriculum. it is hoped that by sharing our experiences of a curriculum renewal process, debate can be stimulated: (i) within the physiotherapy profession regarding future curriculum content and design; and (ii) among educationalists regarding strategies to optimise the training of healthcare professionals in a resourcerestricted environment. susan hanekom supplement editor sdh@sun.ac.za 1. thomas pa, kern de. mph internet resources for curriculum development in medical education: an annotated bibliography. gen intern med 2004;19(5):599-605. [http://dx.doi.org/10.1111/j.1525-1497.2004.99999.x] 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 3. hanekom sd, unger m, cilliers f. deriving criteria by which to determine core curriculum content: a high engagement process. african journal of health professions education 2014;6(2 suppl 1):180-184. [http://dx.doi. org/10.7196/ajhpe.496] 4. abela j. adult learning theories and medical education: a review. malta medical journal 2009;21(1):11-18. 5. colliver ja. effectiveness of problem-based learning curricula: research and theory. acad med 2000;75(3):259-266. [http://dx.doi.org/10.1097/00001888-200003000-00017] 6. statham sb, inglis-jassiem g, hanekom sd. does a problem-based learning approach benefit students as they enter their clinical training years? lecturers’ and students’ perceptions. african journal of health professions education 2014;6(2 suppl 1):185-191. [http://dx.doi.org/10.7196/ajhpe.529] 7. inglis-jassiem g, statham sb, hanekom sd. what does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? african journal of health professions education 2014;6(2 suppl 1):192-197. [http://dx.doi.org/10.7196/ajhpe.532] 8. graffam b. active learning in medical education: strategies for beginning implementation. med teach 2007;29(1):38-42. 9. burger m, louw qa. integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: reflections on a new approach. african journal of health professions education 2014;6(2 suppl 1):198-202. [http://dx.doi.org/10.7196/ajhpe.516] 10. george jh, doto fx. a simple five-step method for teaching clinical skills. fam med 2001;33(8):577-578. 11. unger m, keiller l, inglis-jassiem g, hanekom sd. teaching my peers: perceptions of tutors in physiotherapy practical skills training. african journal of health professions education 2014;6(2 suppl 1):203-206. [http:// dx.doi.org/10.7196/ajhpe.497] 12. mccallum ca, mosher pd, jacobson pj, gallivan sp, giuffre sm. quality in physical therapist clinical education: a systematic review. physical therapy 2013;93(10):1298-1311[http://dx.doi.org/10.2522/ptj.20120410] 13. williams l, ernstzen dv, statham sb, hanekom sd. evaluation of clinical service sites used for training undergraduate physiotherapy students in a resource-restricted environment: identifying factors that may negatively impact on students’ learning. african journal of health professions education 2014;6(2 suppl 1):207-210. [http:// dx.doi.org/10.7196/ajhpe.528] 14. ernstzen dv, statham sb, hanekom sd. learning experiences of physiotherapy students during primary healthcare clinical placements. african journal of health professions education 2014;6(2 suppl 1):211-216. [http://dx.doi.org/10.7196/ajhpe.530] 15. ernstzen dv, statham sb, hanekom sd. physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module. african journal of health professions education 2014;6(2 suppl 1):217-221. [http://dx.doi.org/10.7196/ajhpe.524] 16. le maistre c, pare a. learning in two communities: the challenge for universities and workplaces. journal of workplace learning 2004;16(1/2);44-52. 17. unger m, hanekom sd. benefits of curriculum renewal: the stellenbosch university physiotherapy experience. african journal of health professions education 2014;6(2 suppl 1):222-226. [http://dx.doi.org/10.7196/ ajhpe.519] ajhpe 2014;6(2 suppl 1):178-179. doi:10.7196/ajhpe.527 70 may 2015, vol. 7, no. 1, suppl 1 ajhpe forum in africa the number of doctors and nurses required to provide essential health services will be deficient by an estimated 800 000 in 2015, resulting in the crippling of an already compromised health system.[1] much has been written about the need for adequate numbers of healthcare workers to address the health challenges facing the people of africa.[2,3] at the same time, there is considerable international focus on transforming and scaling up health professionals’ education and training, calling for sustainable and contextual reforms which will strengthen health systems and improve population health outcomes.[4] the world health organization’s building blocks for effective health systems include a well-performing health workforce that is equitably distributed and responsive to the needs of the population.[5] the health workforce will thus need to be not only clinically competent, but hold competencies, skills, knowledge and behaviours on how to function within a resource-constrained environment as socially responsible change agents that make a difference to their communities.[4,6,7] the medical education partnership initiative (mepi) is a us president’s emergency fund for aids relief (pepfar)-funded response to improving human resources for health in africa and focuses on three aims, namely: increasing human resource capacity through enhancing the quality of medical education and quantity of medical graduates; facilitating the retention of medical faculty and graduates; and enhancing locally relevant research.[6] thirteen african medical schools received programmatic awards and an additional 17 african and 18 us medical schools are involved in building communities of practice and creating sustainable solutions. the faculty of medicine and health sciences (fmhs) at stellenbosch university (su) is one of two medical schools in south africa (sa) funded by mepi. sa faces similar human resource challenges to other african countries. between 2002 and 2010, 12  000 doctors graduated nationally with only 4 400 choosing to work in the public sector.[8] the situation is particularly critical in rural areas, where 43.6% of the population reside, but are served by only 12% of doctors and 19% of nurses.[8] this has resulted in poor infant mortality rates in rural areas of 80/1 000 live births compared with 54 in urban areas.[8] mepi at su therefore focuses on improving the human resources for health in rural areas. this article describes the stellenbosch university rural medical education partnership initiative (surmepi) as background to the research articles in this ajhpe edition, and its response to the challenges as outlined above, from the perspective the us president’s emergency fund for aids relief (pepfar) has responded to the need for the upscaling of africa’s health workforce by investing in medical education on the african continent. the medical education partnership initiative (mepi) aims to: enhance the quality of medical education and quantity of medical graduates; facilitate retention of medical faculty and graduates; and enhance locally relevant research. stellenbosch university rural medical education partnership initiative (surmepi) strives to develop, implement and evaluate innovative, workable and effective medical education models, in order to strengthen medical education and health systems within rural and resource-constrained environments. the purpose of this forum piece is to describe the surmepi project as background to the research articles emanating from surmepi in this ajhpe edition. surmepi’s overall focus is on innovations and interventions in high schools, undergraduate medical education, postgraduate and continuing medical education, e-learning and collaborations, of which some highlights and challenges are described here. afr j health professions educ 2015;7(1 suppl 1):70-72. doi 10.7196/ajhpe.503 innovative strategies to improve human resources for health in africa: the surmepi story m de villiers,1 mfammed, phd; k moodley,2 mmed (pub health) 1 department of family medicine, surmepi, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 surmepi, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m de villiers (mrdv@sun.ac.za) high schools: maths and science intervention medical schools: transformative learning for undergraduate students capacity development for faculty and postgraduate students capacity development for rural healthcare workers beyond stellenbosch university: building collaborations in africa fig. 1. the surmepi pipeline. may 2015, vol. 7, no. 1, suppl 1 ajhpe 71 forum of the author and co-author. permission to publish was provided by the funders and project management. addressing the pipeline surmepi vision and focus surmepi strives to develop, implement and evaluate innovative, workable and effective medical education models, in order to strengthen medical education and health systems within rural and resource-constrained environments. this is in keeping with the south african department of health human resources for health strategy 2012/13 2016/17 which seeks to implement a rural health strategy to attract and retain health professionals in rural areas.[8] surmepi addresses the pipeline for developing human resources for health from high (secondary) school learners, undergraduate and postgraduate students, faculty staff, to practising healthcare workers. fig. 1 shows the elements of the pipeline that are addressed by surmepi. strengthening the health system by addressing gaps in the pipeline recruitment of learners selecting medical students from rural and underserved areas is outlined as a strategy to improve human resources for health in rural areas as rural-origin students are more inclined to choose rural careers.[9,10] however, learners from these areas perform poorly in gateway subjects such as mathematics and physical science.[11] the stellenbosch university area health education centres (su-ahec) project focuses on preparing rural school learners from underserved communities for tertiary education in the health professions in these subjects as well as life skills development. it also supports teacher development in mathematics and physical science. the project has enrolled more than 400 learners from grades 7 11 in rural areas of the western cape. undergraduate medical education surmepi embraces the concept of training change agents in order to improve health systems and health outcomes.[2,4,7] for undergraduate students, this is accomplished by changing what, how and where they learn. the curriculum has been revised to include more communitybased education, primary healthcare and public health. students learn to understand their patients’ environments, social determinants of health and the poor functioning of health systems, which adversely affect these same communities. they are encouraged to work towards improving health systems and health outcomes.[12] results from our efforts in changing the context in which students are trained through early and progressive training at district and rural health facilities are yielding evidence of transformative learning experiences for students, staff and the faculty, examples of which are provided in surmepi publications.[12-14] selected medical, occupational therapy, and dietetics students spend a full academic year of their training at the rural clinical school (rcs). students receive early, progressive and longitudinal exposure to rural and underserved communities throughout their training at su.[14,15] surmepi is changing the way students are learning at the fmhs by developing a culture of e-learning. all lectures (approximately 4 000) from mb,chb 1 6 have been podcast. this has proved extremely popular with students, as demonstrated in the research published in this ajhpe edition.[16] some lecturers are moving towards flipped classrooms where students view online pre-recorded lectures followed by in-class discussion and interaction as opposed to the traditional didactic-only lectures. students reported that podcast lectures promoted their active learning as well as being a novel and fresh way to deal with content. the podcasts complement and provide ease of mind in students’ preparation for examinations.[16] our work in e-learning generated interest from mepi schools and other sa universities, leading to the development and implementation of an e-learning strategy at the fmhs. a user-friendly content management system (cms) serves as a repository for the podcasts and other relevant resources for students. secondly, a ‘bring your own device (byod) system’ for examinations was implemented to increase the number of students that can take online exams at the same time. building capacity for faculty, postgraduate students and rural healthcare workers capacity building is an essential part of any strategy to renew and align medical training. to this end surmepi is engaged in a wide variety of capacity-building efforts across a spectrum of activities, including a focus on leadership and management for rural clinical trainers, evidence-based healthcare, infection, prevention and control and research capacity for faculty and health workers. the model of training for healthcare workers employs online learning, as well as mentoring and coaching on site rather than removing staff from their duties. bursaries are awarded to masters and doctoral students to support their studies in relevant rural fields. medical education research e-learning graduate tracking community-based education medical education research monitoring and evaluation • leads twg • leads workshops and webinars for mepi network • assists with the development of medical education units • co-compiled twg action plan • authored medical education biblography for mepi publication • facilitates discussions on twg mailing lists • co-facilitates multi workshop in botswana • shares podcasts with mepi network • capacity building in cms and podcasts • authored article for mepi website • participates in multicountry workshop to develop generic graduate tracking systems • presents sa progress at second tracking planning workshop • participates in cbe education workshop in kampala • co-author in 2 mepi publications on cbe • participated in multicountry workshop on m & e for medical education workshops • shares smartsheet tool with mepi partners fig. 2. surmepi contributions to mepi technical working groups (twgs). (m & e = monitoring and evaluation) 72 may 2015, vol. 7, no. 1, suppl 1 ajhpe forum collaborations and partnerships surmepi is committed to the sharing of our achievements beyond the fmhs not only through publications (31) and conference presentations (98, of which 26 were international presentations), but also through active knowledge and skills transfer. to this end, we have widespread collaboration with other mepi schools including the university of kwazulu-natal, makerere university (uganda), the university of botswana, the university of zimbabwe, the university of zambia, and kenyatta university (kenya). these collaborations include promoting primary healthcare models through the development of family medicine, building competency in biostatistics, evidence-based healthcare and through rural student electives.[17] surmepi is also partnering with the academy of science of south africa (assaf ) in influencing national policy through a consensus study on transformative medical education in sa. being part of the mepi network has been hugely rewarding for su in fostering relationships with colleagues across africa and in the usa. it enabled us to extend and cement our networks, collaborations and partnerships. we learnt from engaging with colleagues in different contexts and settings, and this enhances our work. surmepi’s active engagement in the mepi technical working groups (twgs) is an example of this (fig. 2). the twgs provide forums for development of equal partnerships that could foster the development of an emerging african voice in medical education scholarship. highlights and challenges designing and implementing complex medical education projects requires high-level management, governance and stewardship from the project leadership. recruitment and appointment of the appropriate staff and alignment with funder regulations, processes and procedures was a steep learning curve as donor funding has not traditionally been awarded to medical education initiatives. developing and discovering appropriate tools for monitoring and evaluation such as real-time online systems simplified our task. if there is to be any lasting advantage of this large mepi injection into medical education on the african continent, mepi should be able to optimise impact through catalysing change and building sustainability. in the surmepi experience, curriculum renewal, transformative learning experiences, integration of innovations into the curriculum, e-learning, staff development, research, dissemination of evidence gathered, twg participation and policy influences are all factors that contributed towards leveraging significant change in the fmhs. the sustainability of the surmepi interventions has been supported through the institutionalisation of curriculum changes, a multidisciplinary informed curriculum using faculty across boundaries such as departments and disciplines, health system strengthening activities entrenched into the health services, active collaborations and partnerships in-country and across africa and extensive capacity building. perhaps mepi’s lasting effect lies in our empowerment to change policy, curriculum and actions, actively addressing human resources for health challenges, in our particular context and environment. acknowledgements. we gratefully acknowledge funding from the us president's emergency plan for aids relief (pepfar) through health resources and services administration (hrsa) under the terms of t84ha21652 via the stellenbosch university rural medical education partnership initiative (surmepi). we are also very thankful for the guidance and support we have received from our various programme officers at hrsa, and other hrsa staff. the collaborating centre’s support and leadership, especially during official site visits, are also highly appreciated. none of this would have been possible without the committed and dedicated surmepi team. references 1. scheffler rm, mahoney cb, fulton bd, et al. estimates of health care professional shortages in sub-saharan africa by 2015. health aff 2009;28(5):849-862. [http://dx.doi.org/10.1377/hlthaff.28.5.w849] 2. crisp n, chen l. global supply of health professionals. n engl j med 2014;370(10):950-957. [http://dx.doi. org/10.1056/nejmra1111610] 3. world health organization (who). working together for health: the world health report 2006. geneva: who, 2006. http://www.who.int/whr/2006/whr06_en.pdf (accessed 6 june 2014). 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 5. mullan f, frehywot s, omaswa f, et al. the medical education partnership initiative: pepfar’s effort to boost health worker education to strengthen health systems. health aff 2012;31(7):1-11 [http://dx.doi.org/10.1377/ hlthaff.2012.0219] 6. world health organization (who). transforming and scaling up health professionals' education and training: world health organization guidelines 2013. geneva: who library cataloguing-in-publication data; 2013. 7. world health organization (who). everybody’s business: strengthening health systems to improve outcomes: who’s framework for action. geneva: who, 2007. http://www.who.int/healthsystems/strategy/everybodys_ business.pdf (accessed 6 june 2014). 8. department of health. human resources for health strategy for the health sector 2012/13 2016/17. pretoria: department of health, 2011. 9. de vries e, reid s. do south african medical students of rural origin return to rural practice? s afr med j 2003;93:789-793. 10. eley d, baker p. does recruitment lead to retention? rural clinical school training experiences and subsequent intern choices. rural and remote health 2006;6:511. 11. south african institute of race relations (sairr). fast facts: time to take the shine off the school story. 2013. no. 02/2013, issn 1019-2514. http://www.sairr.org.za (accessed 6 june 2014). 12. van schalkwyk sc, bezuidenhout j, conradie hh, et al. ‘going rural’: driving change through a rural medical education innovation. rural and remote health 2014;14:2493. (online) http://www.rrh.org.au 13. van schalkwyk sc, bezuidenhout j, de villiers m. understanding rural clinical learning spaces: being and becoming a doctor. med teach 2014;1-6, early online. [http://dx.doi.org/10.3109/0142159x2014.956064] 14. blitz j, bezuidenhout j, conradie h, de villiers m, van schalkwyk s. 'i felt colonised': emerging clinical teachers on a new rural teaching platform. rural and remote health 2014;14:2511. (online) http://www.rrh.org.au 15. de villiers m, conradie h, snyman s, van heerden b, van schalkwyk s. experiences in developing and implementing a community-based education strategy – a case study from south africa. in: talaat w, ladhani z, eds. community-based education in health professions: global perspectives. chapter 8:176-206. cairo: world health organization regional office for the eastern mediterranean, 2014. 16. de villiers m, walsh s. how podcasts influence medical students’ learning – a descriptive qualitative study. afr j health professions educ 2015;7(1 suppl 1):130-133. [http://dx.doi.org/10.7196/ajhpe.502] 17. mash rj, de villiers mr, moodley k, nachega jb. guiding the development of family medicine training in africa through collaboration in the medical education partnership initiative. acad med 2014;89(8):s73-s77. [http:// dx.doi.org/10.1097/acm.0000000000000328] research 198 october 2014, vol. 6, no. 2, suppl 1 ajhpe undergraduate education plays an important role in fostering evidence-based practice (ebp) to meet the needs and challenges of the twenty-first century healthcare system.[1] evidence-based care is widely recognised as a key skill for health professionals, and healthcare students are expected to be competent evidence-based practitioners by the time they graduate and embark on their clinical or academic career.[2] the world confederation for physical therapy (wcpt) strongly advocates teaching the principles of ebp in undergraduate physiotherapy curricula.[3] herbert et al.[4] defined physiotherapy ebp as ‘physiotherapy informed by relevant high quality clinical research, patients’ preferences and physiotherapists’ practice knowledge’. ebp facilitates quality healthcare by amalgamating clinical knowledge and expertise with scientific evidence and patients’ preferences.[5] an international consensus statement (the sicily statement on ebp)[6] sets out a five-step approach to ebp and recommends that this approach be incorporated into academic curricula by teaching the following steps: step 1. translation of uncertainty into an answerable question step 2. systematic search for and retrieval of evidence step 3. critical appraisal of evidence for validity and clinical importance step 4. application of appraised evidence to clinical practice step 5. evaluation of performance and thus auditing evidence-based decisions. based on the above model, undergraduate education should provide students with research skills to seek, evaluate and integrate new knowledge to facilitate professional growth and support lifelong learning.[7] because of the time and curricular constraints within professional degree courses, it could be argued that the best place to introduce the principles of ebp is in research methodology modules. the aim of this paper is to explain the rationale for adopting a secondary research approach as a vehicle to teach the principles of ebp as part of the undergraduate physiotherapy research module. implementation strategies and lessons learnt are also outlined. motivation for reviewing the research methodology module and introducing ebp the research methodology module was reviewed as part of the overall revision of the undergraduate physiotherapy curriculum at stellenbosch university (su). this created an ideal opportunity to assess how to introduce and align the principles of ebp with the current mode of teaching research methodology and basic statistics to undergraduate students. the previous research methodology module spanned the final 2 years of the 4-year undergraduate physiotherapy curriculum and was delivered as didactic lectures covering a wide range of research design and statistical concepts. after completing the series of 30 1-hour lectures at the beginning of their third year, students were divided into groups and each group was tasked to conduct a research project. two supervisors (physiotherapy lecturers) were assigned to a research group and mandated to assist the students in conceptualising a project, recruiting subjects, collecting data and writing up the research report. there were no guidelines or boundaries background. the research methodology module was reviewed as part of the overall revision of the undergraduate physiotherapy curriculum of stellenbosch university. this created an ideal platform from which to assess how to align the principles of evidence-based practice (ebp) with research methodology. fostering the principles of ebp provides students with research skills and attributes to be able to seek, evaluate and integrate new knowledge and to apply critical thinking in order to effectively facilitate professional growth and support lifelong learning. objective. to describe the process of changing the undergraduate research methodology module from a primary research to a secondary research approach. methods. we consulted international experts and searched the literature for ideas and concepts of how to incorporate the principles of ebp. the overall objective of the new research module was formulated to provide students with lifelong skills in obtaining, evaluating, synthesising and forming clinical recommendations, as well as applying research evidence to the clinical setting. results. structuring the research methodology module using an ebp teaching framework prepares students to formulate a research question, effectively search for and critically appraise the evidence and formulate clinical recommendations. the barriers and strategies of implementing the new undergraduate research methodology module, as well as lessons learnt, are presented. conclusion. utilising a secondary research approach in the form of a systematic review or meta-analysis in our undergraduate research methodology module provides the opportunity for students, as novice researchers, to be trained in the principles of ebp. ajhpe 2014;6(2 suppl 1):198-202. doi:10.7196/ajhpe.516 integrating evidence-based principles into the undergraduate physiotherapy research methodology curriculum: reflections on a new approach m burger, msc (physio); q a louw, phd (physio) division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m burger (mbu@sun.ac.za) research october 2014, vol. 6, no. 2, suppl 1 ajhpe 199 regarding the type, nature and scope of the research projects, and typically the projects were limited by time and financial constraints only. students were expected to write a primary research protocol, research paper/report and present their research findings at a forum attended by fellow students, clinical supervisors and independent evaluators. although it was not one of the main outcomes of the research methodology module, publication was strongly encouraged. despite this, these research projects yielded only two research publications in accredited journals over four decades. this mode of teaching research methodology was carried out for 40 years until the undergraduate curriculum was reviewed. during the curriculum revision process, all permanent academic staff participated in an in-depth analysis of the former research methodology module. the issues raised are listed below. • the course content focused on epidemiology, research techniques and statistical calculations rather than the application of research to patient care. • design of studies was primarily limited to surveys which limited the ability of undergraduate students to recognise the link between research and clinical practice. • the large number of surveys often duplicated previous research and thereby created research waste.[8] • the types of questions did not address important clinical issues and students could not translate their study findings into clinical practice. • studies were limited to small sample sizes (because of time and financial limitations) and yielded inconclusive results. • students had no exposure to systematic searching and no tools to critically appraise literature, implying that they lacked the core epb skills and attributes for clinical application and lifelong learning. • obtaining ethical approval from the health research ethical committee and relevant institutions imposed further time constraints for completion of the research projects. • no funding or equipment was available for undergraduate research projects. • there were concerns that the course objectives were too broad and did not allow consolidation of research methodology skills. after reviewing the content, mode and outcomes of the research methodology module, it was clear that the module needed substantial revision. table 1. steps followed for teaching the five key principles of evidence-based practice as part of the research methodology module[12-15] step 1 – asking clinically relevant questions by translation of uncertainty into an answerable question • students search for interesting systematic review or meta-analysis topics published in the past 3 5 years • students determine if their chosen topic has not been published in the form of a systematic review/meta-analysis or protocol in the past 12 months • if no similar systematic review has recently been published, students proceed to formulate their pico question and search terms. searches in relevant databases are conducted to ensure that at least three eligible rcts were published following the publication of the previous systematic review or meta-analysis. this does not form part of the primary search, but the purpose is merely to determine if eligible rcts have been published to warrant a new systematic review on their chosen topic • students then need to conceptualise their topic and ideas and write and submit a secondary research protocol step 2 – finding the evidence: systematic search for and retrieval of evidence • in consultation with a librarian, 3 hours of practical small-group library training are allocated to teach students how to conduct effective searches in at least seven different medical databases and how to define mesh terms and boolean operators • a 2-hour library session is allocated to teach students how to utilise reference database software (refworks)[12] to capture, manage, and organise bibliographic citations • after approval of their research protocol, students conduct and tabulate structured searches with relevant search terms in at least seven of the following databases: pubmed, cochrane library, cinahl ebscohost, proquest, science direct, scopus, pedro, sportdiscus – ebscohost, ot seeker and google scholar  step 3 – critically appraising the evidence for validity and clinical importance • the eleven-item pedro scale[13] is utilised to assess the study’s internal validity (criteria 2 9), external validity (criteria 1) and the statistical accuracy for interpretation purposes (criteria 10 11) • students receive extensive training in how to use the pedro scale for critical appraisal and their skills in using the pedro scale are also tested as part of formative and summative assessment step 4 – interpreting the evidence and applying research evidence: application of appraised evidence to clinical practice • the adapted ‘jbi data extraction form’[14] is used to extract the following data from the selected article: reference, type of study, participants, interventions (treatment and control group), outcome measures (including outcome measure tools), results, as well as the clinical status post-intervention and clinical implications thereof • on completion of the data extraction, homogeneous data are combined using the revman review manager software 5.2[15] which pools data statistically in forest plots to determine the superiority of one intervention in comparison with the other. heterogeneous data are summarised in a narrative form • staff members guide and assist the students to extract relevant data and to interpret the data • students are expected to interpret the relevance of the project findings to the local context and present contextualised recommendations for physiotherapists. formal evaluation of their project findings and recommendations for clinical practice is done in presentation format at the physiotherapy division’s research day. they are also strongly encouraged to present at the faculty of medicine and health sciences student academic year day, as well as at the combined university physiotherapy research day research 200 october 2014, vol. 6, no. 2, suppl 1 ajhpe developing an alternative teaching strategy for research methodology one of the main drivers for the new research methodology module was to develop an understanding of the role of scientific research in informing clinical practice. while the previous mode of teaching research methodology was inclined towards equipping students with skills to conduct research, we decided to deviate from this approach and place the emphasis on the acquisition of skills to become efficient users of published research, rather than personally conducting primary research, i.e. being ‘doers of research’.[9] the primary aim of the newly revised undergraduate curriculum was therefore to train effective clinicians who are able to ask clinically relevant questions, find and critically appraise the evidence, and interpret and apply the evidence to their daily practice. methods journey to design a new research methodology module we explored avenues to teach the principles of ebp and developed aims for the new research methodology module. during this process, we consulted international experts and searched the literature for ideas and concepts of how we could design a module which would facilitate the drive to understand scientific evidence and its role in clinical practice. we gained valuable advice from colleagues at the university of south australia’s international centre for allied health evidence (icahe), melbourne university’s department of physiotherapy and the south african cochrane centre. based on discussions and feedback, we proposed secondary research, in the form of evidence syntheses, instead of primary research as our platform to teach the principles of ebp. in an attempt to reduce the variability of the scope and design of the projects, we envisaged only effectiveness reviews based on randomised controlled trials (rcts) aimed to establish the effectiveness of a physiotherapeutic intervention. evidence synthesis/meta-analysis of rcts is viewed as level 1 evidence for effectiveness of interventions on many evidence hierarchies because it presents the least biased approach for the effectiveness of an intervention.[10] therefore, it seemed to be an appropriate approach to assist students in understanding how scientific evidence, generated from research, can be used to inform clinical practice. description of the aim and outcomes of the newly designed research methodology module the overall aim of the module was to provide students with skills in obtaining, evaluating, synthesising and formulating clinical recommendations, as well as applying research evidence to the clinical setting. this module also assists the students to obtain knowledge and develop skills to find and assess evidence to answer a clinically relevant question. moreover, students are required to work both individually and in teams, and this provides students with the opportunity to develop team skills that are a necessary part of effective clinical practice. the key learning outcomes of newly revised research methodology module outcomes of the third and fourth years are to: • design an effectiveness research question, using the pico method (patient or problem, intervention, comparison and outcome);[4] • effectively search for and select the best evidence using all available medical databases via the webpage of su’s medical library; • critically appraise the evidence for validity and clinical importance using a reliable appraisal tool, as well as evaluate and grade the articles’ hierarchical level of evidence; • extract and analyse data from primary research articles and apply basic statistical concepts (meta-analysis); • apply evidence to clinical practice and formulate clinical recommendations; • formulate implications and recommendations for future research. these outcomes concurred with the graduate attributes that are promoted by the faculty of medicine and health sciences, su, and are also in keeping with the work of laidlaw et al.,[11] who used different methodologies to define and rank the most important graduate attributes and skills for undergraduate medical programmes from both a research and a professional perspective. the seven most important graduate attributes and skills were listed as follows: • inquiring mind/curiosity • core knowledge • critical appraisal • understanding of the evidence base for professional practice • understanding of ethics and governance • ability to work in a team • ability to communicate. laidlaw et al.[11] suggested that these core attributes should be mapped to current learning activities to ensure that there are opportunities within the curriculum for students to develop and practise these skills. teaching strategies were set in place, aimed to incorporate at least four of the five-step principles of ebp into the undergraduate research methodology module (table 1) to address some of the graduate attributes and skills as defined by laidlaw et al.[11] a total of 120 hours were allocated in the third year and 110 hours in the fourth year of the physiotherapy curriculum to achieve these outcomes. the course materials included handouts and the textbook by herbert et al.[4] on practical evidence-based physiotherapy. step 1 of the five-step module was accomplished during the second term of the third year when the students were divided into groups of four to six members and had to formulate relevant research questions and complete a systematic literature review protocol. steps 2 to 4 of the five-step module were completed in the first semester of the fourth year, when the students conducted a systematic literature review and wrote a systematic review article. as part of step 4, the students had to deliver a scientific oral report of their research findings at the division of physiotherapy’s annual student research day. action plans to implement ebp within the new research methodology module – barriers and solutions the main barrier was that less than a third of the permanent academic staff who were eligible to supervise undergraduate research groups had been trained in conducting systematic reviews. this barrier was addressed by training staff in conducting systematic reviews using a ‘train the trainer’ approach. staff are required to ‘train/supervise’ students and therefore these skills are needed. the main training event was conducted by an expert from the university of south australia’s icahe. the focus of these training sessions was to equip staff members with the sicily statement’s five-step approach to ebp including question formulation, skills on how to conduct the most effective database searches, critical appraisal of rcts as well as other types of research designs, and applying the evidence to clinical problems. after the initial training, staff members were trained and supported via a peer-mentoring approach by a fellow staff member who already had research october 2014, vol. 6, no. 2, suppl 1 ajhpe 201 a track record of published systematic reviews. subsequently, this staff member (the mentor) attended a 5-day international course on training health professionals to conduct secondary research and on return trained colleagues in these skills. newly appointed staff members supervised research groups with a trained colleague. in this way skills were imparted to new staff members in an experiential manner. another barrier was ensuring that the staff and students were ready to change to the new research approach. at the time when we changed the research methodology module, there was much scepticism as it did not involve any primary data collection and required new methodological and statistical knowledge. this was addressed by the training outlined above, as well as bi-annual sessions with staff to update their knowledge and skills, and thereby improve their confidence and willingness to supervise research groups. a final barrier was to find suitable research topics to formulate an effectiveness question. students often wanted to conduct a research project on a topic that interested them, only to discover after an extensive database search that a systematic review or meta-analysis had recently been published on the topic, or that they could not find any suitable rcts to evaluate and include in their systematic reviews. we addressed this problem by guiding the students to search for interesting systematic review or meta-analysis topics that had been published in the past 3 5 years. students needed to search for rcts on the same topic published after the systematic review of their choice. students could then utilise the recently published rcts for secondary research in the form of evidence synthesis and compare their findings with the previous systematic review(s) on their topic. students were thus encouraged, where possible, to conduct updates of existing systematic reviews or meta-analyses. results and discussion lessons learnt and the way forward we managed to define the core research skills appropriate for undergraduate physiotherapy students, and by integrating ebp principles in the research methodology module we hope to foster important graduate attributes to equip new graduates for their professional career.[11] structuring the research methodology module using an evidence-based teaching framework may successfully prepare our undergraduate students for a postgraduate academic career. we hope that teaching the principles of ebp will have a positive impact on improving clinical practice and their transition to a research career, and the throughput of current and future postgraduate students. from the time we implemented the revised research methodology module we noted a lack of high-quality evidence for many of the physiotherapy interventions which were reviewed by students.[16] consequently rcts of poor methodological quality often had to be included in the systematic reviews. conclusive recommendations to support or refute current practices, as well as the translation of the new-found evidence into their clinical practice, were often impossible. this lack of evidence enhanced the students’ awareness of the need for high-quality research to advance ebp in the physiotherapy profession. it also nurtured and stimulated critical thinking and improved their appraisal skills of the current evidence. similar traits were also reported by seymour et al.,[17] who noted that undergraduate research resulted in a professional and personal growth experience with many transferable benefits such as critical and reflective thinking, problem solving, and an increased confidence in students’ ability to effectively communicate, explain and defend their work to others. since implementing the new research curriculum in 2007, we have published three undergraduate research papers[18-20] and another two are under review in accredited international journals. annually, the best abstracts are also published in the south african physiotherapy forum. we have a much higher publication success rate with systematic reviews and meta-analyses (secondary research) in the revised undergraduate research methodology module as compared with the previous module. supervisors of undergraduate research groups spend on average 100 hours per group assisting them in the research process and writing the scientific protocol and paper. we found that the students and supervisors who published their papers felt a great sense of achievement and that the hours spent synthesising evidence were not wasted. the way forward will be to support and encourage all supervisors of undergraduate research groups to ensure that evidence syntheses are published. limitations of incorporation of ebp principles as part of the research methodology module the key limitation of incorporating ebp principles is that it was not possible to fully incorporate and formally assess all five steps of the sicily five-step approach to ebp,[6] namely the interpretation and application of research evidence into daily clinical practice (step 4) and the evaluation of performance and thus auditing evidence-based decisions (step 5). the best vehicle to fully incorporate steps 4 and 5 of the sicily five-step module should be introduced during the undergraduate clinical training, and this still needs to be investigated. conclusion utilising a secondary research approach, in the form of conducting a systematic review or meta-analysis to teach our new undergraduate research methodology module, provides the opportunity for physiotherapy students, as novice researchers, to acquire basic research skills and become clinicians who provide evidence-based clinical services. we were able to define and align core research skills with the graduate attributes as promoted by the faculty of medicine and health sciences. evidence synthesis in the form of systematic reviews and meta-analyses is a time-efficient and sustainable method, which has led to an increase in undergraduate physiotherapy publication outputs. integrating the principles of ebp into the undergraduate physiotherapy research methodology module may contribute to preparing our students to become healthcare professionals with an interest in ebp and/or researchers who advance the field of physiotherapy. author contributions. both authors contributed to: (i) conception, design, analysis and interpretation of data; (ii) drafting or critical revision for important intellectual content; and (iii) approval of the version to be published. references 1. rudman a, gustavsson p, ehrenberg a, boström am, wallin l. registered nurses’ evidence-based practice: a longitudinal study of the first five years after graduation. int j nurs stud 2012;49(12):1494-1504. [http://dx.doi. org/10.1016/j.ijnurstu.2012.07.007] 2. olsen nr, bradley p, lomborg k, nortvedt mw. evidence based practice in clinical physiotherapy education: a qualitative interpretive description. bmc med educ 2013;13:52. [http://dx.doi.org/10.1186/1472-6920-13-52] 3. world confederation for physical therapy. policy statement: evidence based practice. london: wcpt, 2011. www.wcpt.org/policy/ps-ebp (accessed12 december 2013). 4. herbert rd, jamtvedt g, mead j, hagen kb. practical evidence-based physiotherapy. edinburgh: butterworth heinemann elsevier, 2005. research 202 october 2014, vol. 6, no. 2, suppl 1 ajhpe 5. herbert rd, sherrington c, maher c, moseley am. evidence-based practice – imperfect but necessary. physiotherapy theory & practice 2001;17(3):201-211. [http://dx.doi.org/10.1080/095939801317077650] 6. dawes m, summerskill w, glasziou p, et al. sicily statement on evidence-based practice. bmc med educ 2005;5:1-7. [http://dx.doi.org/10.1186/1472-6920-5-1] 7. laidlaw a, aiton j, struthers j, guild s. developing research skills in medical students: amee guide no. 69. med teach 2012;34(9):754-771. [http://dx.doi.org/10.3109/0142159x.2012.704438] 8. chalmers i, glasziou p. avoidable waste in the production and reporting of research evidence. lancet 2009;374(9683):86-89. [http://dx.doi.org/ 10.1097/aog.0b013e3181c3020d] 9. meats e, heneghan c, crilly m, glasziou p. evidence-based medicine teaching in uk medical schools. med teach 2009;31(4):369-374. [http://dx.doi.org/10.1080/01421590802572791] 10. oxford centre for evidence-based medicine. the oxford levels of evidence 2011. http://www.cebm.net/mod_ product/design/files/cebm-levels-of-evidence-2.1.pdf (accessed 12 april 2014). 11. laidlaw a, guild s, struthers j. graduate attributes in the disciplines of medicine, dentistry and veterinary medicine: a survey of expert opinions. bmc med educ 2009;9:28. [http://dx.doi.org/ 10.1186/1472-6920-9-28] 12. refworks http://www.refworks.com/ (accessed 12 april 2014). 13. pedro. physiotherapy evidence database. pedro scale. http://www.pedro.org.au/english/downloads/pedroscale/ (accessed 12 april 2014). 14. pearson a, field j, jordan z. appendix 3: data extraction tools. in: evidence-based clinical practice in nursing and health care: assimilating research, experience and expertise. oxford: blackwell, 2009. 15. cochrane informatics and knowledge management department http://tech.cochrane.org/revman/download (accessed 12 april 2014). 16. miller pa, mckibbon ka, haynes rb. a quantitative analysis of research publications in physical therapy journals. physical therapy 2003;83(2):123-131. 17. seymour e, hunter a, laursen sl, deantoni t. establishing the benefits of research experiences for undergraduates in the sciences: first findings from a three-year study. science education 2004;88(4):493534. 18. little k, nel n, ortell v, van wyk h, badenhorst m, louw qa. the clinical effect of hippotherapy on gross motor function of children with cerebral palsy. south african journal of physiotherapy 2013;69(2):26-34. 19. du plessis m, eksteen e, jenneker a, et al. the effectiveness of continuous passive motion on range of motion, pain and muscle strength following rotator cuff repair: a systematic review. clin rehabil 2011;25(4):291-302. [http://dx.doi.org/10.1177/0269215510380835] 20. duvenhage l, mushaike t, parker n, et al. a meta-analysis into the effect of lateral-wedged insoles with subtalar strapping versus traditional insoles in adults with medial knee osteoarthritis. south african journal of physiotherapy 2011;67(1):35-43. 144 october 2016, vol. 8, no. 2 ajhpe research clinical teaching, including interpersonal and communication skills, has been known to be more effective when conducted at the bedside.[1,2] osler[3] considered learning in the presence of a patient of the utmost importance, and stated it as a rule to have ‘no teaching without a patient for a text, and the best teaching to consist of lessons taught by the patient himself ’. bedside teaching involves a process where leaners use their senses − hearing, vision, smell and touch − to learn about the patient[4] to enhance their humanistic skills, which are often neglected in classroom settings.[5] the process requires students to spend unsupervised time with patients, from whom they take histories and on whom they perform physical examinations independently.[1] the development of medical students’ clinical competence is a long process and the use of live patients for teaching during this process poses valid ethical concerns with regard to the patient’s welfare. a number of studies have been conducted on the effect of bedside activities on patients.[6-11] some studies explored patients’ perceptions of having students present during bedside teaching sessions;[9] some investigated their perceptions on the effect of bedside v. conference room presentations;[12] while other studies obtained patients’ views on the ability of students to conduct interviews.[7] most studies reported that patients were tolerant towards bedside teaching activities and generally positive towards students.[2,6,8,10,12] however, there was resistance from patients who did not perceive any benefit from being part of the teaching process.[6] cooke et al.’s[6] study reported that differences in patients’ tolerance levels and perceptions are linked to their level of education, i.e. implying that better-educated patients were more tolerant. these authors also reported that differences in patients’ reactions towards bedside teaching activities depended on the patient’s race. the situation in ethiopia is new and needs special attention. driven by the desperate shortage of health personnel and a need to reach the millennium development goals, the ethiopian ministry of health has approved a plan to improve the training of medical and healthcare professionals. this decision led to a drastic increase in training facilities, i.e. from 3 to 32 medical schools in the past 8 years, 438 newly qualified medical doctors per year compared with 90 a decade ago, and the admission of 6 000 6 500 students in 2011.[13] the increased enrolment of students has manifested in much higher ratios of students to medical staff at the patient’s bedside. anecdotal evidence suggests that patients have mixed feelings about the increased presence of students at their bedside, and to date there has not been any research to explore the patient’s view and experience in the context of an ethiopian teaching hospital. this gap is being addressed by the current study. the increased student-to-patient ratio has many consequences. firstly, it impacts on clinical teaching and students’ learning, as they are unlikely to gain adequate experience in the absence of sufficient patients to clerk and perform physical examinations. secondly, the disproportionate ratios have an effect on teaching, as it is becoming increasingly more difficult to teach students how to perform physical examinations correctly and to detect physical findings on fewer patients. patients who are already ill and experiencing discomfort find it annoying and tiring to be clerked repeatedly by different students from various academic years, which undoubtedly has an effect on their assessment of the clinical competence of the students.[10] ethiopia lacks a standardised approach to guide training institutions on an appropriate or approved minimum number of students allowed per patient. it is believed that such a guide would ensure that the patients’ treatment and the students’ learning remain optimal. an example of a background. clinical bedside teaching is more effective when done at the bedside. the number of medical schools in ethiopia has increased tenfold in 8 years to meet the millennium development goals. the increased number of students at the patient’s bedside has been met with mixed feelings by patients. objective. to determine patients’ perceptions of bedside teaching during their admission to the medical and surgical wards at mekelle university hospital, ethiopia. methods. a 32-item questionnaire was used for data collection. patients used a likert scale to rate their perceptions of the quality of their hospital stay with regard to teaching, clerkships and physical examinations. items where respondents scored less than the median of 67 (interquartile range 21) were categorised as displaying a negative attitude. results. patients (60%) did not favour the bedside teaching activities. no significant association was found with age, sex, occupation, literacy level, duration of hospital stay, and ward. patients (>80%) also did not understand the discussions following teaching sessions, and claimed to be unaware of the teaching status of the hospital. patients (>80%) did not understand the role of the students and were anxious when left alone to be examined and clerked by them. conclusion. the rights of patients in medical education should be emphasised. patients should be informed about the role of students at teaching hospitals and about their rights and responsibilities as patients. institutional protocols and country-wide guidelines can help to regulate the number of times that a patient should be clerked and physically examined by students. instructors should ensure that patients understand the purpose of the discussion that follows the examination. afr j health professions educ 2016;8(2):144-147. doi:10.7196/ajhpe.2016.v8i2.520 effect of bedside teaching activities on patients’ experiences at an ethiopian hospital f a gebrekirkos,1 md, fcs-cosecsa; j m van wyk,2 bsc ed, med, phd 1 department of surgery, college of health sciences, and center for health professions education, mekelle university hospital, ethiopia 2 clinical and professional practice, nelson r mandela school of medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: j m van wyk (vanwykj2@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 145 research policy to manage such a process is found in the context of india. an indian admission policy allocates 100 students to a 500-bed healthcare facility, or 200 students for 900 beds per year in facilities with a bed occupancy rate of 75%. this proportion excludes beds reserved for subspecialties.[14] ethiopia, however, does not have an established standard to guide the allocation of students in the medical wards. given the lack of guidelines on the ideal number of students to allocate to the bedside in the african context and the centrality of the patient in the training of clinical competences, our study explored the perceptions and attitudes of patients towards the clinical teaching process. methods this quantitative, cross-sectional study was conducted in october 2013. a 32-item questionnaire (appendix 1) was used to collect data from adult patients (n=256) admitted to the medical and surgical wards during that period. patients were asked to respond to questions enquiring about the effect of bedside teaching activities, student clerkships and physical examinations on their experience in hospital and the quality of their hospital stay. the self-developed questionnaire was designed in english and translated into amharic and tigrigna – the latter is the language spoken by the majority of the people in this region of ethiopia. in the absence of a validated, reliable data collection tool, we developed a questionnaire based on the literature around a number of focal areas of studies on patients’ perceptions of clinical teaching.[9,10] for example, statements such as ‘i have enjoyed bedside teaching’, ‘i felt anxious when clerked by students’, and ‘i have been told that students will be spending some time with me’ were extrapolated from nair et al.’s[9] study. statements such as ‘patients understood what was being discussed’, and ‘comfortable that their case was being discussed’ were obtained from seo et al.’s[12] study. the focal areas included questions exploring patients’ awareness and perceptions of the role of mekelle university hospital as a medical training facility; their perceptions of the discussions during bedside teaching about their illness and the presence of students around them; their level of comfort and/or anxiety at being clerked by unsupervised students; their tolerance and participation in responding to students’ questions; and their perceptions of benefiting and gaining an improved understanding of their illness owing to being treated at a teaching hospital. patients were asked to indicate their responses to each item on a 5-point likert scale. the questionnaires were distributed by ward nurses, who also assisted illiterate patients. data were captured on an excel spreadsheet. the responses were computed using the statistical package for the social sciences 16 (spss 16) (spss inc., usa). the categories ‘strongly agree’ and ‘agree’ were aggregated to indicate a positive score, and the ‘strongly disagree’ and ‘disagree’ were aggregated to obtain a negative score. descriptive statistics were computed on each item. items where respondents scored less than the median of 67 (interquartile range (iqr) 21) were categorised as displaying a negative attitude. the median was used because the mean and standard deviation were found to be 72.0236 and 14.49, respectively. the frequency distribution graph was positively skewed (skewness 1.253). ethical approval for the study was obtained from the health research ethics review committee of the college of health sciences, mekelle university, ethiopia. all the patients who participated in the study signed an informed consent document. a copy of the questionnaire is available from the first author. results a total of 150 questionnaires were distributed, of which 127 (84.7%) were completed and returned. the completed questionnaires were received from 74 and 53 patients who had been admitted to the internal medicine and surgical wards, respectively, during october 2013. eighty-four (61.0%) of the 127 respondents were male. their ages ranged from 16 to 84 years. one hundred and twenty (94.4%) respondents spoke tigrigna, the local language. forty-seven (37.0%) respondents were illiterate at the time of the study, 30 (23.6%) had attended only elementary school, 29 (22.8%) had attended high school, and 21 (16.5%) had attended a higher education institution. eighty-seven percent (n=127) did not understand the discussions during the bedside teaching sessions. before hospitalisation, nearly 87.0% (n=110) were not aware that students would be spending time with them and claimed not to understand the role of the students in the ward. eighty-one percent (n=103) did not see any benefit to being treated at a teaching hospital. eighty-five percent (n=108) of the respondents did not at all understand what was being discussed during the bedside teaching session. patients (86.6%; n=110) indicated feeling uncomfortable in the presence of unsupervised students; 81.1% (n=103) felt anxious when left alone with students for examination and clerking; and 82.2% (n=104) did not like having students around them. seventy-nine percent (n=100) felt uncomfortable when being clerked by students. respondents (70.1%; n=89) thought that bedside teaching may result in a breach of confidentiality, and 65.0% (n=83) were unwilling (would not volunteer) to have their case discussed at the bedside teaching session. only 33.0% (n=42) thought that bedside teaching sessions had assisted them in gaining a better understanding of their illness. sixteen percent were aware that they were being treated at a teaching hospital. in response to the question that explored the patients’ awareness of and attitude towards bedside teaching activities, 48.0% (n=61) were not in favour of such activities, and 48.0% had an attitude score below the median of 67. no significant association was found with age, sex, occupation, address (urban v. rural), literacy level, duration of hospital stay, or the wards to which the patients had been admitted. discussion the ultimate goal of medical education is to improve patient care. this study explored the perceptions of adult patients towards students in the context of an increased student presence in the ward during bedside teaching activities, the patients’ perceptions of the benefit of admission to a teaching hospital, and their role in the training of student doctors. while bedside teaching was meant to be beneficial to learners and patients, findings suggest that patients felt anxious when approached by unsupervised students and that they were ill informed of the reasons for and details of the bedside conversations between the teacher and the student. patients’ reluctance to having their case discussed during bedside sessions also stemmed from concerns about confidentiality. these findings are similar to those of a study in oxford, uk, where patients expressed reservations about being left in the care of student doctors.[6] illiterate patients and those who were not well informed of the reasons for having students at the bedside, were more anxious. a study in belgium similarly cautions clinicians not to increase dosages of hypertensive medication of patients in teaching hospitals, as blood pressure levels of patients became elevated when they were in the presence of student doctors.[15] 146 october 2016, vol. 8, no. 2 ajhpe research patient care also includes the patient’s mental perception of receiving appropriate care. patients at this medical teaching hospital were sceptical of the facility and considered the high student presence untrustworthy. in this regard, the institution has failed to address the psychological needs of the patients. it is obvious that patients need reassurance and that communication should be improved to ensure that bedside teaching sessions become an informative and enjoyable experience to them. senior members of staff will have to play a more supportive role in explaining to patients that their health and participation in the teaching and learning processes are valued and their wellbeing and care are central in the bedside learning process. this lesson is reinforced in suggestions for good practice, requiring teachers to refrain from discussing embarrassing details in the presence of their patients and to display exemplary professional behaviour.[5] some of the ways to convey this message include ensuring that patients leave with a better understanding of their illnesses. it will reassure them and help them to see the benefit of having learned from the discussion of their case. it is also possible that a difference in the language of learning and that of the patient could lead to a misunderstanding in communication. this may have an effect on patients experiencing the bedside teaching sessions as tedious, especially in areas such as ours where the patients’ education levels require more effort in relaying the purpose, process and outcome of the bedside examination. patients should be informed that they are being admitted to a teaching hospital and that it involves some degree of interaction with students who are being trained at the facility. an agreement, perhaps in the form of signed informed consent, may be administered on admission to ensure that patients are informed and agreeable to interact with students. the role of the students and the rights and responsibilities of patients should be better explained. emphasis on this process will address patients’ fears relating to confidentiality, or of being managed by students or incompetent persons. patients can benefit from being educated about the advantages of being treated in a teaching hospital and the value of their contribution in the teaching of future doctors. students’ attitudes towards patients should be monitored to ensure that the former create an environment of trust and professionalism in their interaction with patients. they should display honesty, integrity and confidentiality; clearly communicate their expectations about their capacity and limitations; and explain that they are there to learn and help in every possible way. teachers should instruct students about demonstrating the aforementioned values to co-operate with patients, and to take their time to offer a full explanation of the disease. the rights of patients in medical education should be emphasised. after each teaching session instructors should explain what they were discussing so that patients understand the purpose of the discussion. as almost all patients do not understand the medium of instruction (english), it will have a significant effect on patients’ perceptions of the teaching activities if we can summarise and explain in their own language the proceedings and possible outcomes of the discussion. anecdotal evidence has shown that patient fatigue is definitely a factor in the way they experience their stay at our hospital. the perception of being treated unfairly is enhanced in the absence of clear guidelines on a reasonable number of students allowed per patient for teaching purposes. this can be resolved when medical educators, community stakeholders and the ministry of health collaborate to formulate regulations and guidelines for safe practices in training institutions. study limitations include the design, as this was an explorative quantitative study. some issues to enhance our understanding should be explored more qualitatively. furthermore, the study has been conducted in one region of the country, where a specific language is spoken and where the patients’ education levels are relatively low. we therefore caution that results may not be generalised, but that educators compare their settings to ours and learn from the lessons that we have highlighted. the success of a patient education campaign and effect of the suggested recommendations will be monitored and reported. conclusion bedside teaching affords students the opportunity to understand the context of medicine better and to learn from the clinician as a role-model. it is important to note that it can be a tedious and stressful experience for patients and that those who are poorly informed will have a negative attitude towards the student and be less perceptive to the potential benefit of being part of the learning process. every effort should be made to educate patients about the benefits of visiting a teaching hospital. the teaching institution should also regulate the process to ensure patient confidentiality, comfort and safety, while senior members of staff should become more visible for monitoring and role-modelling. references 1. bell k, boshuizen hpa, scherpbier ajja, dornan tl. when only the real thing will do: junior medical students’ learning from real patients. med educ 2009;43(11):1036-1043. doi:10.1111/j.1365-2923.2009.03508.x 2. olson lg, hill sr, newby da. barriers to student access to patients in a group of teaching hospitals. med j austr 2005;183(9):461. https://www.mja.com.au/system/files/issues/183_09_071105/ols10328_fm.pdf (accessed 26 july 2016). 3. osler w. aequanimitas; with other addresses to medical students, nurses and practitioners of medicine. am j med sci 1905;130(2):337. 4. bekele a, reissig d, loffler s, hinz a. experiences with dissection courses in human anatomy: a comparison between germany and ethopia. ann anat 2011;193(2):163-167. doi:10.1016/j.aanat.2010.10.007 5. ramani s. twelve tips to improve bedside teaching. med teach 2003;25(2):112-115. doi:10.1080/0 1 42159031000092463 6. cooke f, galasko g, ramrakha v, richards d, rose a, watkins j. medical students in general practice: how do patients feel? br j gen pract 1996;46(407):361-362. 7. feletti g, carney s. evaluating patients’ satisfaction with medical students’ interviewing skills. med educ 1984;18(1):15-20. doi:10.1111/j.1365-2923.1984.tb01470.x 8. lehmann ls, brancati fl, chen m-c, roter d, dobs as. the effect of bedside case presentations on patients’ perceptions of their medical care. n engl j med 1997;336(16):1150-1156. doi:10.1056/nejm199704173361606 9. nair b, coughlan j, hensley m. student and patient perspectives on bedside teaching. med educ 1997;31(5):341346. doi:10.1046/j.1365-2923.1997.00673.x 10. nair b, coughlan j, hensley m. impediments to bed-side teaching. med educ 1998;32(2):159-162. doi:10.1046/ j.1365-2923.1998.00185.x 11. spencer j, blackmore d, heard s, et al. patient‐oriented learning: a review of the role of the patient in the education of medical students. med educ 2000;34(10):851-857. doi:10.1046/j.1365-2923.2000.00779.x 12. seo m, tamura k, morioka e, shijo h. impact of medical rounds on patients’ and residents’ perceptions at a university hospital in japan. med educ 2000;34(5):409-411. doi:10.1046/j.1365-2923.2000.00516.x 13. zhao f. health resources for health: the ethiopian success story. ethiopia: human development afdb, 2012. 14. rao m, rao k, kumar a, chatterjee m, sundararaman t. human resources for health in india. lancet 2011;377(9765):587-598. doi:10.1016/s0140-6736(10)61888-0 15. matthys jh. teaching students in general practice can affect patients’ blood pressure. bmj 2005;331(7513):406. doi:10.1136/bmj.331.7513.406-b http://ap.psychiatryonline.org https://www.mja.com.au/system/files/issues/183_09_071105/ols10328_fm.pdf http://dx.doi.org/10.1016/j.aanat.2010.10.007 http://dx.doi.org/10.1111/j.1365-2923.1984.tb01470.x http://dx.doi.org/10.1056/nejm199704173361606 http://dx.doi.org/10.1046/j.1365-2923.1997.00673.x http://dx.doi.org/10.1046/j.1365-2923.1998.00185.x http://dx.doi.org/10.1046/j.1365-2923.1998.00185.x http://dx.doi.org/10.1046/j.1365-2923.2000.00779.x http://dx.doi.org/10.1046/j.1365-2923.2000.00516.x http://dx.doi.org/10.1016/s0140-6736(10)61888-0 http://dx.doi.org/10.1136/bmj.331.7513.406-b october 2016, vol. 8, no. 2 ajhpe 147 research appendix 1. results of the questionnaire variable strongly agree agree never thought about it disagree strongly disagree the role of the students is clearly communicated to me 6 16 102 3 i think there is a benefit to being treated at a teaching hospital 8 13 3 100 3 i was told/informed that this is a teaching hospital 6 7 7 102 5 i am aware that students will be spending time with me 5 9 8 99 6 i clearly understand that my case will be discussed with students and their teachers 7 14 4 100 2 i do not know what the students are talking about at the bedside 8 100 6 11 2 i feel uncomfortable with the presence of students around me 13 97 5 10 2 i like it when there are students around me 3 15 4 101 4 i feel anxious when students and their teachers are talking about me 11 60 11 35 10 i believe students’ involvement can improve my clinical outcome 12 85 3 22 5 i don’t have any clue what the discussion is about in the bedside teachings 17 96 2 10 2 bedside teaching has helped me to understand my illness better 9 29 4 81 4 i have enjoyed being used as an example during bedside teaching 9 34 6 73 5 i think that bedside teaching will lead to a breach of confidentiality 11 78 15 20 3 i can tell the difference between students, instructors, and ward nurses 17 58 14 29 9 i think that i am being managed by students 6 64 12 33 12 i find it uncomfortable when students are checking up on (clerking ) me 12 88 5 19 3 i feel anxious when students visit me without the presence of the instructor 9 94 2 17 5 i like it when young students come and clerk me 7 24 5 85 6 i find it painful when students are doing a physical examination on me 10 74 11 25 7 students have good clinical knowledge 6 35 11 70 5 i will volunteer to be clerked and examined by students next time 10 32 2 78 5 i think i am unnecessarily being asked about my health many times 7 91 10 18 1 i am being asked about my health because the questions are very important for my condition 15 30 20 62 my body part is unnecessarily being touched too many times 13 89 7 12 6 medical students take my time unnecessarily 11 84 6 22 4 the discussion in bedside teaching takes my time unnecessarily 13 78 8 22 6 21 august 2010, vol. 2, no. 1 ajhpe short report there has been an overwhelming explosion in student numbers in higher institutions of learning which has not proportionately corresponded with an increase in recruitment of staff.1 a concern relating to the relevance of the tertiary education curriculum1 to the country’s development needs has been discussed. most programmes offered in uganda’s tertiary education are theoretical with little practical application and hence irrelevant to the job market.1 to implement cost-effective interventions, health workers must have the appropriate skills, competencies and training. underfunding of uganda’s higher institutions is so severe that expenditure per student is declining while enrolments are increasing rapidly in this era of technology and science.2 inadequate funding to train students in experimental sciences results in teaching programmes being dominated by verbal communication, undermining the quality of the technical training.3 insufficient facilities have increased the training of graduates in arts and the humanities, whose fields of study are not critical to priorities of uganda’s development. knowledge and advanced skills are becoming critical determinants of a country’s economic growth and standard of living. the high spread of infection in uganda needs a balanced population of well-trained personnel. science-based institutions needing well-trained microbiologists are rapidly increasing in east africa but well-trained microbiologists are still very few. the efforts by uganda’s education ministry to provide for increasing student numbers entering tertiary education are faced with educational quality challenges. over the recent decades, research output in uganda has ultimately remained static because the shortage of senior academic staff meant that lecturers are overloaded, leaving little time for research.4 this study was designed to assess the stakeholders’ need for an msc degree programme for microbiology in uganda. methods this was a prospective descriptive cross-sectional study. participants included were potential msc microbiology students, members of faculty with a microbiology background and organisations working on infectious disease. standard epidemiological/multistage sampling processes5 were used to select 103 stakeholders. the study included 50 undergraduate students, 10 faculties and 43 potential employers (3 universities, 20 research institutions and 20 non-governmental organisations). data were obtained from a semi-structured, close-ended self-administered questionnaire using on-line software. the questionnaires were piloted for content and face validity. information obtained from participants included demographic data, knowledge about the programme, future potentials of graduates of the programme, the role of the programme in national growth and development and the impact of the programme vis-à-vis containment of an increasing pandemic of tropical infections. ethical approval was obtained from the kampala international university research/ethics committee and participants gave informed consent. data were analysed using statistical package for the social sciences, and the chi-square test (α=0.05) was used to test for statistical significance of the data generated. results a total of 103 questionnaires were administered, of which 49 were returned, yielding a response rate of 47.6%. when focusing on the need for an msc microbiology programme, students (58%) and staff (100%) agreed that there was a definite need for the programme. all of the student participants indicated that they would like to further their studies and 64% want to further their studies outside east africa. of these students, 14% wanted a career path in microbiology and 47% strongly believed that the graduates of the programme have good prospects, would advise others to take it up as a career path and agreed that universities should begin the programme as soon as possible. out of the 8 faculties studied, 6 (75.0%) recommended an urgent and immediate need for the programme because it offers adequate research capacity building, science-based education and hands-on experience. in addition, 85.7% of the faculties strongly recommended the need to allow mostly microbiologists to participate in the programme implementation for quality and professionalism. all the potential employers studied (100%) strongly agreed that there is an urgent need for the programme, are willing to participate in the training and said the graduates are employable both as researchers, health system managers and lecturers. the support for establishment of the programme was significantly (p<0.05) high among old experienced male uganda microbiologists working in the east african region compared with young inexperienced female east african residents with allied science disciplines related to microbiology. knowledge of east african community academia significantly (p<0.05) played a role in participants’ decision to agree or not to agree regarding the establishment of the programme. discussion addressing the health crisis in africa by means of relevant postgraduate modules is essential. the brain drain of health professionals has created a shortage in personnel needed for service delivery in the health care sector; hence the need for trained professionals. the positive response from all the faculty participants and 58% of the students towards the need for this programme is overwhelming as it will assist in capacity building in uganda. the need for a master of science degree programme in microbiology in uganda agwu ezera, phd tropical disease research unit, department of medical microbiology & parasitology, faculty of biomedical sciences, kampala international university, bushenyi, republic of uganda correspondence to: agwu ezera (agwuezera@yahoo.com or agwuezera@gmail.com) short report 22 august 2010, vol. 2, no. 1 ajhpe the challenge that 64% of the students want to further their studies outside east africa points to a known chronic problem of health workers migrating to other african sub-regions.6 establishment and awareness of different career paths such as this programme may be one way to address this migration and it may motivate potential students to enrol for this programme. the fact that 75% of the faculty members supported the need for the programme could indicate a positive attitude towards a likely change in the educational system and curricula. the benefits of the proposed programme, which include adequate research capacity building, sciencebased education and hands-on experience, address the concerns raised by kasozi1 regarding the irrelevance of common theoretically based university curricula to uganda’s development needs. conclusion an msc microbiology programme is urgently needed in uganda in order to facilitate regional research and educational capacity, and this study highlights that key stakeholders support this need. acknowledgement i am grateful to the management and staff of kampala international university for supporting my participation in safri and to professor jose frantze (phd) of the university of the western cape, who personally supervised the writing of this manuscript. i am also grateful to all safri faculties whose assistance made the production of this manuscript possible. references 1. kasozi abk. a proposed quality assurance framework for institutions of higher learning in uganda. a paper presented at the seminar on quality assurance in tertiary education, servres, france, 2006. 2. kasozi abk. the african universities’ capacity to participate in global higher education supply and productions case of uganda. the uganda journal of education 2003; 4: 45-63. 3. castells m. universities as dynamic systems of contradictory functions. in: muller j, cloete n, badat s, eds. challenges of globalisation. south african debates with manuel castells. cape town: maskew miller longman, 2001: 206-224. 4. bakkabulindi f. financing higher education in uganda. nkumba university education journal 2006; vol. 1. 5. grais rf, rose amc, guthmann jp. don’t spin the pen: two alternative methods for second-stage sampling in urban cluster surveys. emerging themes in epidemiology 2007, 4:8 doi:10.1186/1742-7622-4-8. http://www.ete-online.com/ content/4/1/8 6. matsiko cw, kiwanuka j. a review of human resource for health in uganda, health policy and development. umu press, 2003; 1: 15-20. article 9 december 2010, vol. 2, no. 2 ajhpe introduction a chronic wound is defined as any break in skin integrity that persists for longer than 6 weeks or recurs frequently.1 the main causes for these wounds include vascular insufficiency, complications of diabetes, skin damage due to pressure and postoperative complications. chronic wounds affect 2.8 million patients in the usa2 and 4 million in germany,3 the prevalence being 120 per 100 000 between the ages of 45 and 65 years, increasing to more than 800 per 100 000 in patients older than 75.2 years.2 the cost to health care systems is enormous, amounting to billions of dollars. for example, in 1992 treatment of venous leg ulcers accounted for 1.3 2% of the annual health care costs of the uk, france and germany.4 in 2005, the usa spent $2.3 billion on advanced wound care products. this is expected to rise at an annual growth rate of 12.3% to $4.6 billion in 2011.3 in germany, the cost is 5 billion euros annually.3 additionally there are losses to countries’ economies as these lesions are often socially isolating, take years to heal and recur frequently. most important is the reduced quality of life experienced by these patients and their families. in spite of the prevalence of chronic wounds, wound care education is regarded as inadequate in the usa5 and in germany.3 a canadian study reported that most family physicians feel ill-prepared to manage pressure ulcers, suggesting that they do not receive enough training in this disorder.6 canadian nurses express little confidence in the knowledge of physicians who supervise treatment of chronic wounds.7 in south africa, chronic wound care is often left to unsupervised nursing personnel, who may or may not seek help from medical practitioners, especially in primary health care clinics where standards of care may vary. at present many practices are derived from questionable sources such as from company representatives and time-honoured procedures that are conveyed by word of mouth.8 improper wound care leads to prolonged hospital admissions and prolonged healing times that result in wastage of limited resources.3 conversely, it has been shown that wound education campaigns have beneficial effects on the use of resources and on patient outcomes such as duration of hospital stay and time to achieve wound healing.3,9 during 8 years of rural hospital practice one of the authors (fc) has repeatedly been faced with patients who had complicated, non-healing wounds. it became apparent that knowledge in this regard was scanty and that treatment guidelines were not readily available. at present there is no information regarding the adequacy of chronic wound care know ledge in south africa. the purpose of this cross-sectional study was (i) to ascertain how much time is devoted by south african medical schools to formal teaching about chronic wound care; and (ii) to determine the state of knowledge about wound care among general practitioners (gps), surgical registrars and final-year medical students. methods approval for the study was obtained from the health research ethics committee of stellenbosch university. a questionnaire was compiled from evidence-based resources regarding chronic wound treatment.10 the draft was sent to the president of the wound healing association of south africa (whasa), who subjected it to scrutiny by a panel of experts attending the 3rd national conference of whasa (durban, april 2009), abstract chronic wounds afflict millions worldwide, incurring significant health care costs and chronic suffering. clinicians are often unsure about treatment, resulting in poor outcomes. objective. to determine the scope of knowledge possessed by fifthyear medical students, general practitioners (gps) and surgical registrars, concerning chronic wound management. design. cross-sectional study. methods. deans of eight south african medical schools received letters requesting information regarding time devoted to wound-care training. knowledge-based questionnaires were distributed to finalyear students at two universities, surgical registrars at four universities and gps attending refresher courses. results. four medical schools replied, of whom only two offered formal teaching. 162 medical students, 45 gps and 47 surgical registrars completed questionnaires. the overall median (25th 75th percentiles) knowledge scores for registrars, gps and students were 65% (55 70%), 55% (45 65%) and 45% (35 50%) respectively. whereas the scores of registrars and gps did not differ, the student scores were significantly less. only 32% of registrars and 18% of gps attained scores of 70% or more. 96% considered training to be inadequate. interest in wound care was only mild to moderate, with more gps than registrars requesting literature. conclusions. very little, if any, training on chronic wounds is offered in south africa. the levels of knowledge cannot be considered adequate for successful treatment, nor for teaching to undergraduates. this preliminary study cannot reflect the attitudes and knowledge throughout the country. however, it is clear that there is a need for improved education about these conditions that have huge clinical and economic consequences. a survey of wound care knowledge in south africa francois coetzee1, johan coetzee2, dirk hagemeister3 1 department of family medicine, stellenbosch university 2 department of anaesthesiology and critical care, faculty of health sciences, stellenbosch university 3 division family medicine and primary care, stellenbosch university correspondence to: francois coetzee (franna@cornergate.com) article article 10 december 2010, vol. 2, no. 2 ajhpe validated the questions and made recommendations. the final, approved questionnaire comprised two sections. the first included items to identify covariates that may influence wound care knowledge (age group, gender, institution, level of training, qualifications held, professed level of interest in wound care and their opinion of the adequacy of their wound care training). the second consisted of 20 knowledge-related, multiple-choice questions that were grouped into four domains concerning (i) dressings; (ii) diabetic foot ulcers; (iii) stasis ulcers; and (iv) pressure ulcers. to each questionnaire an information leaflet was attached that set out the aims of the study, assuring participants that their contributions were voluntary and anonymous. a copy of the questionnaire and the correct answers can be obtained via e-mail from the corresponding author. letters were sent to the deans of the eight medical schools in south africa explaining the purpose of the study and requesting information with regard to the number of hours of formal instruction that are devoted to teaching wound care to undergraduate medical students, surgical registrars and family medicine registrars. in addition permission was requested from certain universities to distribute the questionnaires to students and registrars. a copy of the ethics committee approval was attached to each letter. on obtaining permission, questionnaires were handed out directly to registrars and final-year students during pre-arranged personal visits to two local institutions and the remainder were mailed to the two distant universities who had responded to the letters. questionnaires were distributed among gps during regional, continued professional development activities and during a gp conference held at the university of cape town (division of family medicine gp conference, 13 15 january 2010). calculation of sample size regarding analysis of variance (anova) of three groups: if a meaningful result is obtained when two score means differ by 33% (standard deviation 40% of the smallest), the required sample size to detect a difference with an alpha value of 0.05 and power of 0.9 is 30 per group. additionally, to detect a difference between the proportions of three groups with a power of 0.8, presupposing an effect size (w) of 0.33, requires a total sample of 89. it was decided to collect a minimum of 30 completed questionnaires from each of the three groups. statistical analysis inter-group comparisons of numerical data were done using anova. if the data did not meet the assumptions for performing parametric tests (gaussian distribution of the underlying population and equal variances), or if the data were ordinal, equivalent, non-parametric, distribution-free tests were performed (kruskal-wallis anova), followed by dunn’s post-hoc multi-comparison tests. proportional data were analysed using chi-square and fisher’s exact tests where appropriate. multiple linear regression with the knowledge scores as the dependent variable was performed to identify covariates that may influence wound-care knowledge. an alpha value of 0.05 was accepted as indicating a significant result. results four deans responded to the letters, of whom only two stated that there was formal wound-care teaching: for undergraduates 2 h and 20 h, for family medicine registrars 3 h and 4½ h, for surgical registrars 0 h and 50 h, respectively. two universities returned questionnaires completed by students, and three universities returned questionnaires from surgical registrars. the response rate was 71%, resulting in 257 questionnaires received, of which three were incomplete. completed questionnaires comprised 45 from general practitioners, 47 from registrars and 162 from students. fig. 1. proportions (%) of participants according to age group. 0.0 20.0 40.0 60.0 80.0 100.0 2130 3140 4150 5160 > 60                    fig. 1. proportions (%) of participants according to age group. 0.0 10.0 20.0 30.0 40.0 50.0 60.0 1 2 3 4 5 6 p er ce n ta g e o f p ar ti ci p an ts level of interest gp's registrars students    1 = not interested 2 = interested but do not read about it 3 = interested and i have read about it 4 = very interested: send me reading material 5 = very interested: send me on a wound care course 6 = very interested: i would like to do research in this area *p<0.001 ( hi-square test).  fig. 2. proportions (%) of participants’ interest in wound care. fig. 2. proportions (%) of participants’ interest in wound care. score 100 80 60 40 20 0 group gp registrar student  fig. 3. notched box and whisker plots of knowledge scores obtained by the various groups. notches = 95% confidence intervals; lines joining notches = median values; horizontal box borders = 25th & 75th percentiles; whiskers = range of values; circles = outliers.  fig. 3. notched box and whisker plots of knowledge scores obtained by the various groups. notches = 95% confidence intervals; lines joining notches = median values; horizontal box borders = 25th & 75th percentiles; whiskers = range of values; circles = outliers. article 11 december 2010, vol. 2, no. 2 ajhpe this response rate is made up out of: 35 out 110 general practitioners attending a gp conference (31%), 10 out 10 general practitioners attending a cpd meeting (100%), 133 fifth-year medical students out of a class of 160 (83%), 29 out of a group of 30 medical students (97%) and 47 out of 47 registrars returned completed questionnaires (100%). the age-group distribution of participants is depicted in fig. 1. all students fell within the age group 21 30 years, while registrars were approximately equally distributed between 21 30 and 31 40 years. most gps were aged 40 60 years. the proportion of males and females was equal (50.4% and 49.6%). postgraduate degrees (mmed or college of medicine fellowship) were held by 7 gps and 4 registrars. one gp had earned a diploma in wound care therapy. participants’ interest in chronic wound care according to a scale of 1 6 is displayed in fig. 2. less than 10% of each group expressed keen interest in wound care (levels 5 & 6). significantly more gps than registrars and students were sufficiently interested to request literature on the subject (level 4) (38% v. 17% and 13%; p<0.001). more registrars than gps and students were only mildly interested (level 3) (49% v. 24% and 22%; p<0.001). the majority of students (54%) professed interest but did not read about the subject (level 2) and this proportion was greater than those of the gps (29%) and registrars (19%); (p<0.001). of registrars and students 4% admitted that they were not interested. median interest levels indicated moderate interest among gps (3[2-4]) and registrars (3[3-4]), but low among students (2[2-3]); (p<0.001). 96% of the 254 participants were of the opinion that the training that they had received regarding chronic wound care was either ‘totally inadequate’ (137) or ‘too basic’ (108). five registrars, 2 gps and 1 student thought that their training was ‘appropriate’ and 1 registrar that it was ‘advanced’. numerical data were not normally distributed; results are reported as median values (25th 75th percentiles) and where appropriate, 95% confidence intervals (95% ci). the highest score (90%) was achieved by a registrar and the lowest score (5%) by a student. details of the results that were achieved by the three groups are presented in table 1 and fig 3. surgical registrars achieved the highest median score (65% [55 70%]) which was not significantly different from that of the gps (55% [45 65%]). the low median score by the students (45% [35 50%]) differed significantly from both practitioner groups. the proportions of the three groups that achieved certain knowledge scores and greater are presented in table ii. in all these analyses, the students’ scores differed significantly from the practitioners (table ii and fig. 4). again, the practitioner groups did not differ from each other. whereas the proportions of students who attained scores above 50%, 60% and 70% differed from the gps and registrars, these proportions did not differ between the two practitioner groups. an analysis by intervals of the scores achieved by the three groups is presented in fig. 4. table iii depicts the scores achieved in the four knowledge categories (dressings, diabetic foot ulcers, stasis ulcers and pressure ulcers). all three groups fared the best in the venous stasis category and worst in the wound dressing selection category. here too, students scored significantly less than the gps and registrars, whose scores did not differ between each other. table iv depicts the scores achieved by the groups from the three medical schools. the students from university b attained slightly higher median scores than those from university c (45% v. 40%; p<0.001). the scores achieved by the three registrar subgroups did not differ. backward stepwise regression indicated three covariates that influenced the knowledge scores, namely the institution attended by the stu0 5 10 15 20 25 30 35 40 70% + 60-69% 50-59% 40-49% 30-39% 20-29% 10 to 19% 0 10%                knowledge scores achieved (%)         *p<0.001 (fisher’s exact test) †p<0.001 (chi-square test) ‡p=0.012 (chi-square test) §p=0.004 (fisher’s exact test) fig. 4. distribution of percentages of correct answers for the three groups. table i. knowledge scores by level of training level n median percentiles (25 75th) 95% ci range gps 45 55* 45 65 50 60 20 75 registrars 47 65* 55 70 50 65 40 90 students 162 45 35 50 40 45 5 75 results are expressed as percentage of correct answers out of a total of 20 questions. n = number of participants. p<0.001 (anova). *gps and registrars differ significantly from students, but not from each other (p<0.05). table ii. proportions of participants who achieved certain knowledge scores and greater knowledge score 70% + 60% + 50% + gps (%) 18* (9 31) 47* (33 61) 69* (54 81) registrars (%) 32* (20 46) 62* (47 74) 85* (72 93) students (%) 3 (1 6) 7 (4 12) 30 (23 37) data are presented as percentages of the total possible score (95% confidence interval). 70% +; 60% +; 50% + = scores of 70% and greater, etc. * gps and registrars differ significantly from students, but not from each other (p<0.05). article article 12 december 2010, vol. 2, no. 2 ajhpe dents and registrars, the level of training (student, gp or registrar) and the age group (r=0.58, r2=0.34, durbin-watson statistic 1.7). the following covariates were rejected from the model: gender, qualifications, and professed interest. discussion the finding that nearly all respondents (96%) regarded their training in wound care as inadequate is in accordance with previous surveys in other countries. over 70% of a sample of 155 family physicians in minnesota felt that they were ill-prepared to manage pressure ulcers.6 in canada only 16% of 107 family physicians felt confident about their ability to manage leg ulcers and 61% reported that they did not know enough about wound-care products.4 in a survey among canadian home-care nurses, nearly half (48%) indicated that although initial treatment planning was usually done by family physicians, they could not rely on them to have up-to-date information on leg-ulcer treatment.7 furthermore, more than half reported receiving patients with less-than-adequate diagnostic workup or stated disease aetiology and that initial treatments ordered by physicians were inappropriate. the 50% response rate by the deans of the eight medical schools is disappointing. taken together with the fact that only two of the respondents stated that wound care was formally taught and then only for a few hours, it is perhaps an indication of how unimportant wound care is perceived to be in south african universities. there appears to be a similar attitude towards wound-care education in the usa, germany and the uk. patel et al.5 reported that in 2005 only 50 of 100 american medical schools documented any educational time dedicated to undergraduate wound care training where the mean was 9.2 hours. in germany and the uk, the hours of wound-care training were 9.0 and 4.9 respectively.3 the vast difference in training offered for surgery registrars at the two medical schools that responded is unusual. one medical school indicated that they offered no training, and the other that they offered 50 hours of training. i suspect both medical schools offered little or no training in the form of lectures. i contacted the person who indicated 50 hours, and he explained that he regarded ward rounds and clinical discussions as their formal training in wound care. to our knowledge this is the first survey to test wound-care know ledge among undergraduate students in south africa. it is not surprising that pre-final-year students scored less than practitioners, considering that their exposure to chronic wound care is short, mainly theoretical and constitutes at best a minor component of a busy, multifaceted curriculum. however, their median score was a poor 45% (95% ci 40 45%), indicating that on leaving medical school they are not equipped with the necessary knowledge to treat chronic wounds and are forced to pick up skills by means of self-instruction. nevertheless 3 out of 162 students achieved scores ≥70% and 7 scored between 60% and 69%. this probably indicates that students learn about wound care in a disorganised manner and that the traditional, discipline-based undergraduate curriculum has resulted in a fragmented approach to wound-care education.11 knowledge scores achieved by students from two of the three participating medical schools differed significantly. whereas the dean of the lower-scoring group did not reply to our letter, the dean of the higher-scoring group indicated that their students received 2 hours of training. the result was that it was not possible to determine whether undergraduate wound-care instruction had any influence on the scores attained by the students. registrars appeared to have scored better than the gps (table i, fig. 2). however, the difference did not achieve statistical significance. the study was probably underpowered to detect a real underlying difference; however, the median difference was only 5% and the confidence interval of the difference between the medians was quite wide (0.00% 10.00%), so that if a real statistically significant difference does exist, it is unlikely to be of practical importance. it is possible that the gp knowledge scores do not reflect the true situation in south africa as there may have been selection bias due to the fact that the gps were all attendees at refresher courses and may represent a group who were particularly enthusiastic about continued professional development (cpd). table iii. correct answers for each category of knowledge by level of training category level n median percentiles (25 75th) p (anova) gps 45 2* 1.75 3 dressings registrars 47 2* 2 3 <0.001 students 162 1 1 2 gps 45 3* 2 3 diabetes registrars 47 3* 3 4 0.003 students 162 3 2 3 gps 45 3* 2 3.25 pressure sores registrars 47 3* 2 4 <0.001 students 162 2 1 3 gps 45 4* 2 4 venous stasis registrars 47 4* 3 4 <0.001 students 162 2 1 3 maximum score per category = 5. *gps and registrars differ from students, but not from each other. table iv. knowledge scores achieved by the groups from the three participating medical schools group university a university b university c p (anova) registrars mean 57.9 66.3 58.5 0.069 (sd) (9.3) (13.4) (11.1) n 21 16 10 students median 45 40 <0.001 (25 75th) (41 55) (35 45) n 31 131 [25 75th] = 25 75th percentiles n = number of participants. article 13 december 2010, vol. 2, no. 2 ajhpe if a knowledge score of 70% is regarded as indicating sufficient knowledge to treat various types of chronic wounds successfully, then only small proportions of practitioners and future practitioners qualify (table ii). by this standard, taking the gps and registrars sampled together, 75% (69/92) (95% ci from 65% to 83%) of gps and trainee surgeons do not possess adequate knowledge to treat chronic wounds. even if a score of 60% is regarded as acceptable, then approximately half of clinicians are probably inadequately trained (46%; 95% ci from 36% to 56%). these findings are alarming, because not only do the large number of wrong answers possibly indicate that practitioners are actually applying potentially harmful treatments, but these practices are probably being taught to students during the little clinical teaching to which they are exposed. gps were more interested in receiving wound-care literature than the registrars. however, the general levels of interest were quite low (38% of gps v. 17% of registrars). these are surprising findings considering that both groups regarded their training as having been inadequate. this may indicate that a greater number of gps have to treat chronic wounds or alternatively that registrars are confident about their wound-care knowledge. on the other hand, it may also reflect a general feeling of apathy towards treatment of chronic wounds. there are some weaknesses to this study. if the authors would have been able to visit each university personally, a better response rate might have been obtained, to gain a more complete picture of the situation in south african medical schools. furthermore, there may have been selection bias with regard to the gp group; therefore the results of this small study cannot be regarded as being a true reflection of the state of knowledge countrywide. this study comprised the thesis for a master’s degree in family medicine (fc); hence for logistical and financial reasons it was not possible to extend it further. secondly, it was not possible to perform an in-depth evaluation of the participants’ knowledge using only 20 multiple-choice questions. nevertheless this limited survey does indicate that there are serious deficiencies in the wound-care knowledge of clinicians as well as, importantly, future practitioners. conclusions in spite of the limitations and weaknesses of this preliminary study, certain conclusions can be made about the care of patients with chronic wounds in south africa. • nearly all students and practitioners regard their training as inadequate. • as in other countries, time allocated to formal teaching varies widely and, in addition, appears to be insufficient. • gps appear to glean knowledge after leaving medical school. the knowledge possessed by most final-year students and a large proportion of practitioners (gps and registrars) appears to be deficient. • despite the huge financial and clinical significance, little importance is attached to teaching about chronic wounds. furthermore, there appears to be a general lack of interest therein. • surgical registrars may possess insufficient knowledge to act as teachers during a wound-care module. in order to obtain a more comprehensive estimate of the extent of the problem a similar study needs to be extended to all medical schools and to include a larger, more representative gp sample as well as the nursing profession. this might eventually lead to a concerted effort to improve wound-care education to be launched by the various role players. guidance from other countries should be sought where various strategies have already been investigated. these include dissemination by telemedicine, website-based courses, consensus guidelines, ward rounds, self-study material and lectures or workshops.11-15 a study of the deficiencies of wound-care training in english medical schools led to recommendations by the general medical council’s committee for undergraduate medical education.11 included were suggestions that wound-care education should be integrated with the basic sciences, it should promote self-learning and it should make use of available technologies to the advantage of learners. some south african medical schools are in the process of revising their curricula and this could present an excellent opportunity to include a formal module on the management of wounds. designing such a module may prove challenging, since there is a wealth of available knowledge and a limited amount of time to be allocated. perhaps the medical schools should attempt to achieve consensus with regard to such content in collaboration with whasa. references 1. fonder ma, lazarus gs, cowan da, aronson-cook b, kohli ar, mamelak aj. treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. j am acad dermatol 2008;58:185-206. 2. page jc, newswander b, schwenke dc, hansen m, ferguson j. retrospective analysis of negative pressure wound therapy in open foot wounds with significant soft tissue defects. adv skin wound care 2004;17:354-364. 3. patel np, granick ms, kanakaris nk, giannoudis pv, werdin f, rennekampff ho. comparison of wound education in medical schools in the united states, united kingdom, and germany. eplasty 2008;8:e8. 4. graham id, harrison mb, shafey m, keast d. knowledge and attitudes regarding care of leg ulcers. survey of family physicians. can fam physician 2003;49:896902. 5. patel np, granick ms. wound education: american medical students are inadequately trained in wound care. ann plast surg 2007;59:53-55. 6. kimura s, pacala jt. pressure ulcers in adults: family physicians’ knowledge, attitudes, practice preferences, and awareness of ahcpr guidelines. j fam pract 1997;44:361-368. 7. graham id, harrison mb, moffat c, franks p. leg ulcer care: nursing attitudes and knowledge. can nurse 2001;97:19-24. 8. ashton j, price p. survey comparing clinicians’ wound healing knowledge and practice. br j nurs 2006;15:s18-s26. 9. schultz gs, sibbald rg, falanga v, et al.wound bed preparation: a systematic approach to wound management. wound repair regen 2003;11(suppl 1):s1-28. 10. jones kr, fennie k, lenihan a. evidence-based management of chronic wounds. adv skin wound care 2007;20:591-600. 11. davis m. wound-care training in medical education. j wound care 1996;5:286287. 12. flanagan m. a contemporary approach to wound care education. education must enable the practitioner to replace traditional and out-dated practices in wound care with research-based practice. j wound care 1995;4:422-424. 13. gottrup f. optimizing wound treatment through health care structuring and professional education. wound repair regen 2004;12:129-133. 14. jones ml. e-learning in wound care: developing pressure ulcer prevention education. br j nurs 2007;16:s26-s31. 15. jones sm, banwell pe, shakespeare pg. telemedicine in wound healing. int wound j 2004;1:225-230. 24 march 2017, vol. 9, no. 1 ajhpe research context of emergency medicine training in sub-saharan africa emergency medicine (em) is a relatively new, but now established and growing medical specialty in sub-saharan africa. according to the african federation of emergency medicine (afem), there are specialist-level graduates of em training programmes from south africa (sa), ghana, tanzania, and ethiopia, with several new programmes with first generations of trainees in rwanda and botswana, among other african nations.[1] now that african em has taken shape as a specialty-level discipline with academic and departmental leadership at major universities, new challenges have emerged for the continued success of the nascent field. a survey among recently graduated em-trained specialists from the aforementioned african training programmes sought to characterise the challenges faced by the growing body of new em practitioners.[2] the largest perceived needs were the lack of leadership development and training, including materials for training and ‘active learning’, the need for improved relationships with faculty mentors, and the need for interprofessional communication training. failure of the em programmes to meet these needs has led to trainees leaving the field, a consequence noted by the first em training programme developed in sa.[3] a follow-up survey from the em programme in ghana highlighted the need for region-specific medical knowledge to enhance training curricula.[4] many of the em curricula used in african training programmes were based on models from prior established residency programmes in north america, europe, and australia. these curricula consisted of multimodal approaches to learning, with the use of small-group learning (sgl), including case-based seminars, simulation training, and procedure-based skills labs to supplement traditional didactic lectures. while there has been evidence supporting the effectiveness and acceptance of such modalities for their countries’ respective learner populations,[5-11] there has been little or no investigation regarding the appropriateness of these modalities in the sub-saharan african context of em training. sgl for em has been favourably accepted by medical students in botswana,[12] but has not yet been explored in the postgraduate context. it cannot be assumed that western-developed educational modalities will be functionally (or culturally) appropriate for african educational norms, and investigations background. emergency medicine (em) is a relatively new, but growing medical specialty in sub-saharan africa. african em training programmes have used small-group learning (sgl) modalities in their curricula. however, there is little knowledge of whether sgl modalities are perceived to be effective in these african em training programmes. objectives. to investigate the acceptability of sgl for physicians’ training in an academic tanzanian emergency department using a novel em curriculum. methods. using responses to a written questionnaire, we explored the perceived effectiveness of sgl compared with traditional didactic lectures among 38 emergency department physician learners in dar es salaam, tanzania. perceptions of sgl were identified from qualitative responses, and regression analyses were used to determine strength of association between quantitative outcomes. results. reported benefits of sgl included team building, simulation training, enhancement of procedural skills, and the opportunity to discuss opinions on clinical management. sgl scored more favourably with regard to improving clinical practice, enjoyment of learning, and building peer-to-peer relations. lectures scored more favourably at improving medical knowledge. preference towards sgl over lectures for overall training increased with years of clinical experience (95% confidence interval (ci) 0.16 0.62, p=0.002, spearman’s rho 0.51), and the perception that sgl reinforces learner-teacher relationships correlated with seniority within residency training (95% ci 0.14 0.86, p=0.007, spearman’s rho 0.47). conclusion. techniques of sgl were perceived as effective at improving clinical practice in the emergency department setting. these modalities may be more favourably accepted by more experienced physician learners – therefore, new em teaching programmes in africa should consider these factors when targeting educational strategies for their respective regions and learner cohorts.  afr j health professions educ 2017;9(1):24-28. doi:10.7196/ajhpe.2017.v9i1.692 pioneering small-group learning in tanzanian emergency medicine: investigating acceptability for physician learners a g lim,1 md, ms; h geduld,2 mb chb, dippec, mmed, fcem; k checkett,3 md; h r sawe,4 md, mba, mmed; t a reynolds,5 md, ms, phd 1 division of emergency medicine, department of medicine, university of washington, seattle, wa, usa 2 education and training, division of emergency medicine, faculty of health sciences, university of cape town, south africa 3 section of emergency medicine, department of medicine, university of chicago, ill, usa 4 emergency medicine, muhimbili national hospital, muhimbili university of health and allied sciences, dar es salaam, tanzania 5 emergency and trauma care programme, world health organization department for management of noncommunicable diseases, disability, violence and injury prevention, geneva, switzerland; and department of emergency medicine, university of california, san francisco, ca, usa corresponding author: a g lim (andrewglim@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2017, vol. 9, no. 1 ajhpe 25 research of learner perspectives would facilitate future programme design and curricular development for em training on the continent. in this study, we explore the acceptability and perceived effectiveness of sgl among physician-learners at the muhimbili university health and allied sciences (muhas) em training programme in dar es salaam, tanzania. these physician-learners include registrars (who have completed internship and have varying years of clinical experience, often transitioning to other specialty training or general practice by working for a limited time in the emergency department (ed)), em residents (who have completed 1 3 years as registrars before joining the 3-year residency programme), and recent residency graduates <1 year out of training (now working as faculty at the ed at muhimbili national hospital (mnh)). we compared the perceived effectiveness of sgl with lecture-based learning to investigate if acceptance correlates with learners’ clinical experience or other demographic factors. our objective was to identify characteristics of the tanzanian physicians’ experience with sgl modalities that could facilitate further development of em residency curricula in other sub-saharan african countries. emergency medicine in tanzania em education was introduced in tanzania in 2010 at mnh and has been challenged by the country’s limited basic healthcare infrastructure and access to training,[13,14] barriers exemplified in other sub-saharan african countries.[15-17] regardless, the demand for improved prehospital and hospitalbased em specialty training in this country continues to grow.[18] despite previous successes of sgl medical education in tanzania, there have been few investigations of sgl acceptability in the region, and none for em education. a recent study showed significant improvement to trauma resuscitation knowledge following implementation of a small-group-based resuscitation simulation course,[19] but researchers have yet to investigate the impact of sgl on other topics within the scope of em postgraduate training. the muhas em curriculum, first introduced in 2010 with a primarily lecture-based format, was redesigned by faculty and residents in 2014 to formally incorporate sgl during educational conferences, comprising ~40% of all conference time; this included case-based small-group seminars, procedure laboratories, and resuscitation simulations. the remaining 60% of conference time consisted of traditional lectures structured around monthly subject-based modules. the new 2014 curriculum provided the first exposure to non-lecture and non-bedside teaching modalities for many of its physician-learners. a core group of 6 10 specialist physician instructors (from tanzanian, the us and sa medical schools) was primarily responsible for both lecture and sgl sessions, although visiting faculty from outside tanzania gave occasional lectures supplemental to the core curriculum. case-based small-group seminars (done on a weekly basis) involved groups of 4 6 physician-learners with a senior resident or faculty facilitator, progressing through a patient presentation with discussions regarding clinical reasoning, diagnostic testing, therapeutic management and disposition decisions. procedure laboratories (roughly once or twice per monthly module) included technical simulation of procedural skills, including diagnostic ultrasound scans, ultrasound-guided peripheral intravenous cannulation, advanced airway management and tracheal intubation. these were typically led by faculty and involved rotating groups of 4 6 physician-learners. resuscitation simulations were also done once or twice per monthly module and involved placing junior physician-learners as resuscitation leaders for management of emergent clinical scenarios (such as anaphylaxis, cardiac arrest, sepsis, trauma, and mass casualty triage) using low-fidelity mannequins, facilitator-controlled vital signs monitors, training cardioverter defibrillators, and other resources to simulate real-time, hands-on patient care. methods we invited 38 physician-learners enrolled in the mnh em training programme to participate in this study, to which all agreed. they represented all learners who had experienced the newly designed sgl curriculum at mnh’s ed at the time of data collection in march 2014 (19 residents, 14 registrars, 5 recent residency graduates). a recent graduate, one of the authors of this study, was excluded. informed consent was obtained for each participant at the time of interview and survey administration, and subjects were not required to participate in the study. ethical approval was granted by respective review boards of muhas and the university of california, san francisco (ucsf), usa. we developed an exploratory survey using a written questionnaire to elicit both quantitative and qualitative responses through closedand open-ended questions regarding the educational techniques used in the muhimbili ed. open-ended questions prompted subjects to characterise their perceptions of strengths and weaknesses of the various modalities of the sgl component of their education. to strengthen content and response process validity, the survey was designed and modified based on key informant interviews with muhimbili ed faculty leadership and 10 of the participants. faculty involved in afem curriculum development, and programme leaders of tanzanian, sa and us em residencies, also provided expert opinion to develop these instruments. the 37-item written survey incorporated free response fields and likertscale questions about physician-learners’ perceptions of sgl within the muhas em curriculum. the first section of the survey comprised openended questions about the effectiveness of sgl for both the acquisition of medical knowledge and improvement of clinical practice in the ed setting (table 1). the second section asked respondents to directly compare sgl with lecture-based learning along several educational dimensions with numerical likert-scale responses (table 2). these educational dimensions were adapted from a study of indian medical students’ perceptions and acceptance of sgl v. lecture-based learning modalities, although this was originally intended for a general medical school curriculum not specific to em education.[20] to investigate whether the acceptance of sgl was associated with learner experience, we collected data on participants’ years of clinical experience (number of years working in clinical settings following medical school), and their current level in the muhas em training programme. regression analyses were used to determine associations between learners’ clinical experience and programme level with their acceptability of sgl based on the likert-scale survey responses. results the majority of the 38 respondents were male (63%) and had 3 6 years of clinical experience (81%). approximately half of respondents had some medically orientated sgl experiences prior to their em education (47% with experience, 45% without experience, 8% no response). respondents 26 march 2017, vol. 9, no. 1 ajhpe research were distributed among varying levels of advancement within the em training programme (table 1). responses to the qualitative section of the survey were categorised into major themes, providing insight into the overall acceptability of small-group education. the most commonly reported benefits of sgl included team building/relationship building in clinical settings (n=13), the opportunity to discuss and interact with other learners (n=10), the ability to simulate clinical scenarios (n=9), the opportunity to clarify gaps in knowledge with faculty mentors (n=7), improving clinical confidence (n=6), and the enhancement of procedural skills (n=6). the summary of these findings is reviewed in table 2. table 3 summarises the likert-scale responses regarding the perceived effectiveness of sgl compared with lectures. the majority of respondents agreed that sgl was both effective at improving medical knowledge (mean (standard deviation (sd) 4.18 (0.63), where a likert response of 1 = strongly disagree and 5 = strongly agree) and clinical practice (4.14 (0.85)). overall, respondents felt that lectures were more effective at developing medical knowledge compared with sgl, but that the latter was comparatively more effective at improving clinical practice. sgl was preferred for enjoyment of learning and building positive peer-to-peer relations. for overall training, small groups and lectures were evenly favoured. there was a significant and positive correlation between clinical experience and preference towards sgl for overall training compared with lectures (coeff 0.39, 95% confidence interval (ci) 0.16 0.62, p=0.002, r2=0.30; spearman’s rho 0.51, p=0.003). there was also a significantly positive correlation between level of em residency training and the perception that sgl reinforces learner-to-teacher relationships (coeff. 0.48, 95% ci 0.14 0.86, p=0.007, r2=0.21; spearman’s rho 0.47, p=0.005). discussion the findings of the study suggest that sgl methods implemented in a novel tanzanian em training curriculum had favourable learner acceptability for improving clinical practice, enhancing enjoyment of learning, and reinforcing peer relations, while lectures were favoured for improving medical knowledge. the following themes emerged in our study with regard to the strengths and weaknesses of sgl compared with lectures: • sgl was preferred over lectures for overall training by participants with more clinical experience. the association between years of clinical experience and preference for sgl was consistent with the literature, showing that physician-learners are more satisfied with learning environments than approximate clinical practice, especially when further removed from the medical school experience.[21] • sgl reinforces learner-to-learner relationships compared with lectures. sgl appeared to reinforce teamwork and relations among learners, especially in clinically applied settings. • sgl reinforces learner-to-teacher relationships for participants in continued residency training. as learners progressed through the residency programme, they identified sgl as more effective at building relations with their teachers. this could be owing to the trust built over time with mentors, along with the camaraderie fostered through residency. additionally, experienced trainees were expected to participate as teachers/leaders in both sgl and lectures, and were therefore more likely to identify with mentorship roles. conversely, registrars and 1st-year residents may have felt more distanced from the small-group experience and hesitant of teacher-learner interactions, perhaps owing to nascent professional relations with their mentors. some younger participants expressed feeling intimidated to speak out in the early years of medical school, a feeling they may have carried over to their postgraduate training. table 1. participants’ gender, clinical experience and training level (n=38) demographics n (%) gender male 24 (63) female 14 (37) clinical experience, post-medical school (years) 3 4 16 (42) 5 6 15 (39) 7 8 7 (18) level of em training registrar 14 (37) resident, year 1 9 (24) resident, year 2 4 (11) resident, year 3 6 (16) new faculty (year 4) 5 (13) table 2. summary of participants’ perceptions of sgl (n=38) effective aspects of sgl teambuilding and peer-relationship building (n=13) opportunities for discussion/interaction with other learners (n=10) opportunities for practising real-life clinical scenarios (n=9) opportunities to clarify gaps in knowledge with mentors (n=7) improves confidence of clinical skills (n=6) interactivity of seminar to learn physical/procedural skills (n=6) improvement of public speaking/communication/presentation skills (n=5) improves critical thinking and medical concepts (n=4) ineffective aspects of sgl small groups can be too much like mini-lectures (n=2) small-group teaching should be divided by trainee level (n=2) table 3. perceived effectiveness of lectures v. sgl (n=38) characteristic of learning modality mean (sd)* improving medical knowledge 2.20 (1.15) improving clinical practice 4.12 (0.86) ability to organise what you’ve learned 3.79 (0.96) defining/clarifying of learning objectives during lesson 2.82 (1.31) developing clinical/diagnostic reasoning 3.24 (1.35) developing independent critical thinking 3.45 (1.42) enjoyment of learning 4.15 (0.87) motivation to learn more on your own 3.27 (1.31) reinforcing learner-to-learner relationship building 4.12 (0.88) reinforcing learner-to-teacher relationship building 3.53 (1.35) overall training 3.45 (1.09) *1 = lectures much more effective; 2 = lectures more effective; 3 = neutral; 4 = small groups more effective; 5 = small groups much more effective. march 2017, vol. 9, no. 1 ajhpe 27 research there were also negative aspects to the sgl modalities that were expressed by the physician-learners. interestingly, small groups were criticised when seminars were too ‘lecture-like’ in quality, i.e. when they failed to retain features unique to sgl. further criticism of small groups occurred when learners were intermixed with those from other training levels. this resulted in decreased ability to form team bonds, given that the experience and knowledge among peers was discordant. study limitations there were significant limitations to this study. it was a single-site study, affecting the generalisability of our findings to other african em training programmes. although we used a total sample of physician-learners with experience in em-specific sgl in the only em specialty training programme in tanzania, the sample size was still small and thus limited in statistical significance. our analyses would benefit further from longitudinal studies of this cohort as they progress through the curriculum. an attempt was made to calculate effect size between the resident and regis trar cohorts for their overall preference of sgl v. lectures (using cohen’s d). however, these calculations showed no significant effect size difference. further, no significant associations were found with gender and other independent variables. despite attempts at ensuring the appropriateness of survey items via key informant interviews and pretesting, the instruments had not been previously validated or standardised, in part due to inability of finding existing instruments suitable for the research objectives. therefore, specific attempts at validity testing for the quantitative portion (such as inter-item reliability) were not pursued. we solicited learner opinions of a better conduit for medical knowledge, and did not seek objective measures of medical knowledge; therefore, participants’ perceptions were undoubtedly influenced by their previous learning experiences. furthermore, some of the participants (senior residents) also had teaching responsibilities, e.g. to lecture or facilitate small groups; this bias could not be further controlled in our analysis. the significance of sgl being associated with improvement of clinical practice and lectures with medical knowledge deserves further exploration. the qualitative data would suggest that clinical practice entails practical skills and the ability to perform patient care at the bedside. it is not entirely clear from the survey data if clinical practice also encompassed provider confidence, team building, communication, critical awareness, or other essential skills related to patient care. likewise, medical knowledge may have meant basic science knowledge, clinical science knowledge, or other fundamentals of medical science; these findings require a more nuanced investigation in future research. conclusion physician-learners with more clinical experience and professional maturity tended to be more accepting of sgl as a learning modality. residency programmes should consider these factors when deciding on which educational modalities to incorporate into their curricula. as em educators in africa tailor their residency programmes’ educational curricula to their regional needs, they should weigh factors such as clinical experience of their trainees and potential benefits to team building and learning enjoyment when deciding how to incorporate sgl modalities. sgl has been a prominent feature of north american, european, and australian em training in recent decades. with the calls toward ‘novel’ forms of education developed in these countries, we must be careful in assuming that these learning methods will be culturally or socially appropriate for a given region’s needs in the african context.[22] if we lack an understanding of the educational context where a new training curriculum is being implemented, the curriculum could easily fail to have its desired effect. we believe that medical practitioners who are not familiar with the relevant country’s educational context must also have a strong understanding of regional educational issues, or must be working in collaboration with educational researchers well versed in the regional context. for example, it is possible that perceptions and acceptability of sgl are different among em residents in the usa, where the average postgraduate time period out of medical school is only 1 2 years. given that the majority of tanzanian physician-learners were in their 5th through 8th postgraduate year, this differential in experience level alone provides evidence that african em curricula need to be designed with its unique learner populations in mind. there are also considerable differences in the nature of clinical experiences between the average tanzanian and us physician-learners entering em training. nonetheless, this research does suggest that sgl may address some of the needs identified by bae et al.[2] in their survey of african em specialists. sgl may be effective in increasing relationship building between learners and mentors, promoting active learning, and building more effective leadership and communication training. however, more targeted research, and programme-specific monitoring and evaluation of the curriculum, will be needed to explore these themes further for the future development and strengthening of em education in sub-saharan africa. acknowledgements. we would like to acknowledge prof. v mwafongo, muhas, and head of em at mnh. we thank all participants, physicians, nurses, and other ed staff who work tirelessly on behalf of their patients, and for the advancement of em in tanzania. 1. african federation of emergency medicine. 2016: http://www.afem.org (accessed 21 december 2016). 2. bae c, geduld h, wallis la, smit dv, reynolds t. professional needs of young emergency medicine specialists in africa: results of a south africa, ethiopia, tanzania, and ghana survey. afr j emerg med 2016; 6(2):94-99. http://dx.doi.org/10.1016/j.afjem.2016.02.005 3. wen ls, geduld hi, nagurney jt, wallis la. africa’s first emergency medicine training program at the university of cape town/stellenbosch university: history, progress, and lessons learned. acad emerg med 2011; 18(8):868871. http://dx.doi.org/10.1111/j.1553-2712.2011.01131.x 4. martel j, oteng r, mould-millman nk, et al. the development of sustainable emergency care in ghana: physician, nursing and prehospital care training initiatives. j emerg med 2014;47(4):462-468. http://dx.doi.org/ 10.1016/j.jemermed.2014.04.041 5. maddry jk, varney sm, sessions d, et al. a comparison of simulation-based education versus lecture-based instruction for toxicology training in emergency medicine residents. j med toxicol 2014;10(4):364-368. http:// dx.doi.org/10.1007/s13181-014-0401-8 6. li ch, kuan ws, mahadevan m, daniel-underwood l, chiu tf, nguyen hb (atlas investigators: asia network to regulate sepsis care). a multinational randomised study comparing didactic lectures with case scenario in a severe sepsis medical simulation course. emerg med j 2012;29(7):559-564. http://dx.doi.org/10.1136/ emermed-2011-200068 7. wang ee, beaumont j, kharasch m, vozenilek ja. resident response to integration of simulation-based education into emergency medicine conference. acad emerg med 2008;15(11):1207-1210. http://dx.doi.org/10.1111/j.15532712.2008.00208.x 8. häske d, beckers sk, hofmann m, et al. the effect of paramedic training on pre-hospital trauma care (epptcstudy): a study protocol for a prospective semi-qualitative observational trial. bmc med educ 2014;14(1):32. http://dx.doi.org/10.1186/1472-6920-14-32 9. chung sp, cho j, park ys, et al. effects of script-based role play in cardiopulmonary resuscitation team training. emerg med j 2011;28(8):690-694. http://dx.doi.org/10.1136/emj.2009.090605 10. park i, gupta a, mandani k, haubner l, peckler b. breaking bad news education for emergency medicine residents: a novel training module using simulation with the spikes protocol. j emerg trauma shock 2010;3(4):385-388. http://dx.doi.org/10.4103/0974-2700.70760 11. mccoy ce, menchine m, anderson c, kollen r, langdorf mi, lotfipour s. prospective randomized crossover study of simulation vs. didactics for teaching medical students the assessment and management of critically ill patients. j emerg med 2011;40(4):448-455. http://dx.doi.org/10.1016/j.jemermed.2010.02.026  12. cox m, chandra a. undergraduate emergency medicine in an african medical school – experiences from botswana. afr j emerg med 2013;3(4):157-163. http://dx.doi.org/10.1016/j.afjem.2013.04.003 http://dx.doi.org/10.1016/j.afjem.2016.02.005 https://dx.doi.org/10.1016/j.jemermed.2014.04.041 http://dx.doi.org/10.1007/s13181-014-0401-8 http://dx.doi.org/10.1007/s13181-014-0401-8 http://dx.doi.org/10.1136/emermed-2011-200068 http://dx.doi.org/10.1136/emermed-2011-200068 http://dx.doi.org/10.1111/j.1553-2712.2008.00208.x http://dx.doi.org/10.1111/j.1553-2712.2008.00208.x http://dx.doi.org/10.1016/j.afjem.2013.04.003 28 march 2017, vol. 9, no. 1 ajhpe research 13. reynolds ta, mfinanga ja, sawe hr, runyon ms, mwafongo v. emergency care capacity in africa: a clinical and educational initiative in tanzania. j public health policy 2012;33(suppl 1):s126-s137. http://dx.doi. org/10.1057/jphp.2012.41 14. hsia ry, mbembati na, macfarlane s, kruk me. access to emergency and surgical care in sub-saharan africa: the infrastructure gap. health policy plan 2012;27(3):234-244. http://dx.doi.org/10.1093/heapol/ czr023 15. caruso n, chandra a, kestler a. development of emergency medicine in botswana. afr j emerg med 2011;1(3):108-112. http://dx.doi.org/10.1016/j.afjem.2011.08.002 16. wachira b, martin ibk. the state of emergency care in the republic of kenya. afr j emerg med 2011;1(4):160165. http://dx.doi.org/10.1016/j.afjem.2011.10.008 17. wallis la, garach sr, kropman a. state of emergency medicine in south africa. int j emerg med 2008;1(2):6971. http://dx.doi.org/10.1007/s12245-008-0033-3 18. celletti f, reynolds ta, wright a, stoertz a, dayrit m. educating a new generation of doctors to improve the health of populations in lowand middle-income countries. plos med 2011;8(10):e1001108. http://dx.doi. org/10.1371/journal.pmed.1001108  19. bergman s, deckelbaum d, lett r, et al. assessing the impact of the trauma team training program in tanzania. j trauma 2008;65(4):879-883. http://dx.doi.org/10.1097/ta.0b013e318184a9fe 20. nanda b, manjunatha s. indian medical students’ perspectives on problem-based learning experiences in the undergraduate curriculum: one size does not fit all. j educ eval health prof 2013;10:11. http://dx.doi. org/10.3352/jeehp.2013.10.11  21. al-azri h, ratnapalan s. problem-based learning in continuing medical education: review of randomized controlled trials. can fam phys 2014;60(2):157-165. 22. bleakley a, brice j, bligh j. thinking the post-colonial in medical education. med educ 2008;42(3):266-270. http://dx.doi.org/10.1111/j.1365-2923.2007.02991.x http://dx.doi.org/10.1016/j.afjem.2011.10.008 ajhpe 524.indd research october 2014, vol. 6, no. 2, suppl 1 ajhpe 217 clinical placements offer a rich opportunity for physiotherapy students to learn while patients are receiving care.[1] they involve situated experiential learning and are an important strategy to facilitate professional socialisation and to integrate knowledge and skills in the developmental pathway towards clinical competence.[2] in the clinical learning environment, students are engaging in a socially authentic workplace environment and these experiences and circumstances shape their learning.[2] learning in this environment is multimodal and complex, and its sociocultural nature may influence learning in several ways.[2] consequently, learning in the classroom differs greatly from learning in the clinical environment. in the classroom, the learning conditions are controlled and learning activities can be planned and structured, while in the clinical environment, unplanned activities often occur and a flexible structure is needed. these two learning environments differ with regard to their distinct objectives, work tasks, rules and codes of conduct, processes, systems, complexity and community of practice.[2,3] it is therefore not surprising that students feel anxious and vulnerable at the start of clinical practice because of uncertainty, variability and unpredictability in the clinical environment.[4-8] the transition of the student into the role of practitioner requires the application of classroom content (e.g. theories, techniques) to the clinical context. while students focused on learning new knowledge and skills in the classroom, in the clinical environment those learnt skills now have to be implemented in practice.[3] moving from being a learner to a novice practitioner creates a challenging experience. novice practitioners become concerned with their level of skill and ability to deliver effective patient care.[9] it is therefore important to ensure that learning opportunities sufficiently address novice practitioners’ needs at the start of clinical practice. introductory clinical placements can reduce students’ anxiety about clinical education and improve their self-confidence.[4,5] the success of these placements lies in the fact that students can learn in a supportive and non-threatening environment where they are not expected to take full responsibility for patient care.[4,5,9] further benefits of an introductory clinical programme include feeling more motivated and enthusiastic about entering the profession,[4] and adapting learning strategies towards a more clinical orientation.[10] while there are benefits to having peer mentoring and support as part of an introductory programme,[4,11] it is unclear which learning opportunities best facilitate the attainment of learning outcomes in an introductory clinical placement. the aim of the study was to determine second-year physiotherapy students’ perceptions about the learning opportunities provided in an introductory clinical module and to determine their perceptions about the attainment of the learning outcomes. context the first 2 years of the 4-year physiotherapy programme, division of physiotherapy, stellenbosch university (su), south africa (sa) are foundational and mainly classroom-based. during third and fourth year, students take responsibility for patient management at clinical placements. the division presents a second-year clinical introductory module, as a transitional strategy between the classroom and the clinical learning environment. this semester course exposes students to clinical practice through visits to different clinical placements, without being responsible for patient management. the learning opportunities background. clinical education forms a core component of physiotherapy training. however, the transition from the classroom to clinical learning environments can be challenging. an introductory clinical placement with appropriate learning opportunities is therefore important to ensure that learning outcomes are reached. objectives. to determine second-year physiotherapy students’ perceptions about the learning opportunities provided in an introductory clinical module and to determine their perception about the attainment of the learning outcomes. methods. a descriptive case study was undertaken, using mixed methodology. all 39 second-year physiotherapy students were invited to participate. data were collected using a self-developed questionnaire which focused on the outcomes of the module and the perceived value of the learning opportunities. a focus group discussion was conducted with a random subset (n=15) of the population. results. the response rate to the questionnaire was 79% (n=31). peer learning by observing senior students, demonstrations by clinical lecturers and the assessment of specific skills were perceived by students to be particularly useful. however, several learning opportunities did not contribute effectively to learning. participants highlighted a transitional process between classroom and clinical environments during which they became aware and could respond mentally to the demands of a clinical placement. conclusions. the clinical education introductory module provided valuable opportunities, where students learnt productively in a non-threatening learning environment. junior students linked theoretical and practical concepts to clinical implementation. peer mentoring and progressive mastering were valuable learning strategies. reflection and students’ emotional adjustment to clinical practice are topics for further investigation. ajhpe 2014;6(2 suppl 1):217-221. doi:10.7196/ajhpe.524 physiotherapy students’ perceptions about the learning opportunities included in an introductory clinical module d v ernstzen, bsc (physio), mphil (higher education); s b statham, msc (physio); s d hanekom, phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: d ernstzen (dd2@sun.ac.za) researchresearch 218 october 2014, vol. 6, no. 2, suppl 1 ajhpe offered to facilitate the attainment of module outcomes are summarised in table 1. assessment tasks include the ability to interview a patient; record key findings; analyse a video of a patient, focusing on listening and observational skills; and a written assignment, on a health condition encountered during clinical practice. methodology ethics the protocol for the study was approved by the health research ethics committee, faculty of medicine and health sciences, su (reference number n05/08/144). permission to undertake the study was obtained from the chairperson of the physiotherapy division. written informed consent was obtained from the participants by the primary author. research design a descriptive case study was undertaken at the physiotherapy division, su. a mixed methodology was used. we employed a survey questionnaire and a focus group discussion in order to generate quantitative and qualitative data, respectively. sample the study population included all second-year physiotherapy students registered for the introductory clinical module during 2006 (n=39). all students were invited to complete the questionnaire. fifteen students were randomly selected (via computed random numbers) and invited to participate in a focus group discussion to explore their perceptions of the learning opportunities provided in the introductory clinical module. instrumentation questionnaire a purposely designed questionnaire was developed by the research team. the questionnaire focused on the learning value which the different learning opportunities presented. it also enquired about the students’ perceptions of knowledge and skills gained. the participants could indicate on a five-point likert scale which learning opportunities they felt they learnt best or least. the participants could also indicate which outcome they felt they had achieved successfully. focus group discussion an interview schedule was developed to ascertain students’ perceptions of the module. the topics discussed in the interview included: experience and opinion about the introductory clinical module; main lessons learnt during the clinical exposure; barriers to learning; experiences with observing the final-year students; view on reflective tasks; suggestions for improvement. probing questions were used to develop a deeper understanding of participants’ accounts of learning. the experienced interviewer ensured that there was no dominance of one participant over the other. data collection the questionnaire was distributed and returned during a rostered contact session. students unwilling to participate were requested to remain in class while completing other tasks. one semi-structured focus group discussion was held at a time convenient for all participants. the discussion was conducted by sbs in english and afrikaans, according to participant preference and was recorded using a digital voice recorder. the interview lasted approximately 50 minutes and took place at the physiotherapy division, su. the recorded interview was transcribed by an independent transcriber. data analysis the quantitative data were recorded on a purpose-built ms excel data sheet. data were analysed using percentages. qualitative data were analysed by an independent research assistant using content analysis.[12] this process included familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising the data; interpreting of data; and checking. final codes were checked and adjusted by the research team to aid validation. results the response rate for the questionnaire was 79% (n=31). table 2 indicates the percentage of participants who indicated that they had learnt most during the provided learning opportunities. peer learning by observing senior students, demonstrations by clinical lecturers and the assessment of interviewing skills were perceived to be particularly useful. fourteen participants (45%) reportedly did not learn from the reflection exercise. participants also reported on the skills developed during the module (table 3). the majority of participants perceived that the provided learning opportunities greatly facilitated the development of three of the eight module outcomes. ta bl e 1. l ea rn in g op po rt un it ie s an d le ar ni ng o ut co m es o f t he in tr od uc to ry c lin ic al m od ul e le ar ni ng o ut co m es fo r m od ul e c on du ct e ff ec ti ve in te rv ie w d ev el op o bs er va ti on sk il ls d ev el op li st en in g sk il ls id en ti fy p re ca ut io ns p la n a ph ys ic al ex am in at io n p la n ba si c pa ti en t m an ag em en t d ev el op c lin ic al re as on in g d ev el op do cu m en ta ti on sk il ls learning opportunities d em on st ra tio ns o f p at ie nt m an ag em en t b y le ct ur er √ √ √ √ √ √ g ro up a nd in di vi du al in te rv ie w s w ith p at ie nt s √ √ √ √ √ √ o bs er vi ng s en io r st ud en ts √ √ √ √ √ √ r ef le ct io n on a ct iv iti es √ √ d oc um en ta tio n √ √ w ri tt en ta sk √ √ v ie w in g pa tie nt in fo rm at io n fo ld er s √ research october 2014, vol. 6, no. 2, suppl 1 ajhpe 219 the qualitative findings indicated that the module was perceived to be a positive learning experience for the participants. four key themes emerged from the data, namely: • bridging experience • role models • emotional implications • reflection is challenging. bridging experience the module provided participants with a bridging strategy to link the classroom to the clinical experience. they reported that observing clinical sessions with facilitators assisted them to put skills they had practised in class into perspective. the module clarified the expectations and requirements that they needed upon entering clinical practice in their third/fourth years of the programme. they were thus introduced to the demands they would face during semi-dependent and independent clinical practice, as evidenced by the following verbatim quotations: ‘you see where the techniques done in class fit into clinical practice.’ ‘some work done in classroom makes more sense now that you have seen it in clinical.’ ‘i am glad we did it – you slowly get used to it … and you don’t feel as if you have been thrown in at the deep end.’ ‘it was really good to give us exposure to an area where we will work in the future.’ ‘if you are in your second year, you can’t do it on your own, so it is good to be with somebody who shows you what you are working towards.’ introducing students to the first step of patient assessment alerted them to the process of conducting the interview, without the added stress of the content of the interview. this process strengthened their confidence. ‘doing the interview helped to familiarise myself with how the interview should be done. so next year i can concentrate on the content of the interview.’ the participants mentioned several bridging experiences related to organisational aspects, which included becoming familiar with the hospital environment and obtaining patient information. interestingly, interdisciplinary learning was facilitated even in this introductory clinical placement, as evident from the following quotation: ‘… this is the one place where you can see and understand the interaction between the different health professionals.’ role models senior students played an important part in the learning experience by serving as role models. learning from senior students depended on their attitude towards the second years. it was clear that senior students could facilitate valuable learning opportunities by being approachable and willing to assist, by involving themselves thoroughly in the process of leading the juniors and by explaining their clinical reasoning during observational sessions. the following quotations confirm this. ‘the fourth years were very helpful, they really went to a lot of trouble and they were nice to us.’ ‘we often worked with the fourth years, and some of them were very good; some students had a better experience because their fourth years were willing and open towards them.’ ‘some fourth years were really good, you could ask them anything. they know their theory well … maybe they were just naturals, or had good training!’ however, not all senior students participated fully in the process, as a participant explained: ‘i don’t know what was communicated to the fourth years beforehand, but some of them did not know what to do, they did not know what to expect, they were a bit confused. maybe they should be informed about our needs and how they can help us. give them an indication of what they should show us.’ the participants offered suggestions on how the learning experience could be improved. these included clarifying expectations with senior students and allocating juniors only to committed senior students: ‘maybe you should enquire which fourth years are willing to accommodate second years, because … if they care about us, they will help us.’ emotional implications participants had to come to terms with patient distress and suffering. it appeared that caring for patients was important to them. viewing patient care assisted them in seeing the person holistically. they also became familiar with an environment where the patients’ needs often take preference over students’ needs. the verbatim quotations below illustrate the emotional challenges faced during the first exposure to clinical work. table 2. percentage of students who reported that they learnt a lot/learnt an extreme amount in specific learning/assessment opportunities provided learning/assessment opportunity percentage observing senior student 76 demonstration by lecturer 71 assessment of interviewing skills 71 conducting an interview with a patient 68 patient information folders 67 assessment of documentation tasks 56 video on listening skills 45 pathology task 41 documentation tasks 32 feedback session 32 reflection 6 table 3. percentage of students who reported that the learning opportunities provided in the introductory clinical module improved the following skills a lot/hugely skill gained percentage interviewing skills 81 observation skills 77 listening skills 68 clinical reasoning 48 scientific documentation 42 application of theory 36 planning of the physical examination 33 researchresearch 220 october 2014, vol. 6, no. 2, suppl 1 ajhpe ‘some of us have never been in such circumstances, and sometimes you see things that are disturbing, and you need to adapt to the situation. so i think the exposure was good to prepare us.’ ‘the other part is also the emotional attachment you get … it is hard. like when you were in the intensive care unit, you see people on machines and lines. and you feel sympathy for them and work with them. it was difficult.’ reflection is challenging participants found reflection challenging as they requested more time and guidance on content and how to reflect. participants requested to be informed of the aims of reflection and guidance on the process of reflection: ‘i need more time to reflect, i need time to think about it …’ ‘give us some guidelines that will force us to think about every aspect.’ ‘is it required to say what we felt, or what we saw happened, or is it required from us to describe the clinical picture? what is required during reflection?’ nonetheless, reflecting with senior students was seen as a collaborative approach towards learning: ‘it was really helpful when we reflected with the fourth years by sitting around the table with them and discussing what happened; they asked us questions and they explained everything to us.’ discussion the aim of the study was to determine second-year physiotherapy students’ perceptions about the learning opportunities provided in the introductory clinical module and to determine their perceived attainment of module outcomes. the main findings show that the learning opportunities facilitated some of the key learning outcomes for this module, but not all. participants benefitted particularly from observation of senior students and lecturers. the findings are congruent with the participants’ self-reports that only three learning outcomes were successfully developed through the learning opportunities provided, namely the ability to observe, listen and to interview a patient. the findings emphasise the value of observation as a non-threatening learning opportunity. learning by observation is a key component of the social cognitive learning theory,[13] and its value in situated learning contexts has been emphasised.[2] the qualitative data indicated that observation of the learning task was a crucial transitional strategy from one learning environment to the other. specific transitional aspects included: putting skills taught into perspective, organisational aspects, mental adjustments and patient care. however, participants, through their feedback (table 2), also confirmed that learning through observation is not enough. learning was facilitated by performing and assessment of the learning task learning was thus optimised when observation of the task was followed by doing of the task, that is ‘learning by doing’, as advocated in social cognitive learning theory.[13] the value of peer mentoring for the development of clinical skills was emphasised in this study, as in other studies.[4,5,11] peer mentoring was enhanced by the personal attributes of the mentor and the mentor’s willingness to provide explanations. a personal, as well as a cognitive, component of peer mentoring was therefore indicated. however, peer mentoring was largely dependent on the mentor as role model. senior students, who were unsure and less confident mentors, were perceived as ineffective mentors. sprengel and job[4] reported similar findings. learning from peer mentors reverberates collaborative learning through the zone of proximal development (zpd). [13] the zdp emphasises learning by socialisation, where learners learn efficiently when interacting with knowledgeable others. the findings of the study confirm the clinical learning environment as authentic and situated, where students can apply their knowledge and skills.[14] spencer[14] and skoien et al.[11] emphasise the authenticity of the clinical learning environment as a strong motivator for learning, which facilitates active participation and the attainment of learning outcomes. in this case, students could apply their novice skills in a non-threatening learning environment. learners were expected to perform small steps of the clinical process congruent with their level of experience and skill. this concept, known as scaffolding or progressive mastery, is described in behaviourist and social cognitive learning theories.[13] progressive mastery was also successfully employed in introductory physiotherapy clinical education by oldmeadow.[8] skoien et al.[11] contend that professional competence develops over time, and that students’ responsibilities should be gradually increased over time in practice. this strategy might enable task attainment by the students which could in return boost self-confidence and the motivation to learn. however, several learning opportunities which had been offered did not contribute effectively to learning, as can be seen in table 2. participants were particularly uncertain about the written reflection exercise. in another study by ernstzen et al.,[1] physiotherapy students also reported not learning efficiently from reflective activities. similarly muir[15] found that medical students and their teachers had an incomplete understanding of reflection. a greater emphasis on reflection may thus be needed in learning, teaching and assessment.[15] in the context of this study, participants requested guidelines on reflective strategies to optimise its learning value. donaghy and morrs[16] also advocate guided reflective practice. they argue that reflection should be closely linked to critical enquiry, problem solving and clinical reasoning in order to develop higher-order cognitive processes. the value of reflection as a meta-cognitive strategy to create meaning from experience is also clear from the literature.[13,15, 16] participants in this case attached more value to verbal reflection (discussion with senior students) than to written reflection. a reflective discussion can be collaborative learning where students gain practice in thinking through problems, organising concepts, and formulating goals. consequently, reflection in this introductory clinical placement needs to be revisited to include structure and support to optimise its learning value. an unexpected finding was that the learning opportunities contributed to a transitional experience with regard to the mental adjustment of the participants in coming to terms with human suffering. skoien et al.[11] and geddes et al.[17] also found this adjustment when developing a patienttherapist relationship[11] and with ethical aspects in the clinical practice context which challenged students’ roles as emerging physiotherapists. the field of novice practitioners’ mental adjustment to clinical practice is relatively unexplored in the literature and warrants further investigation. the findings of the study suggest that an introductory clinical placement needs to be carefully planned to ensure academic and personal development of students. care should also be taken to align learning opportunities and outcomes. while reflection is important for transformative learning, novice learners seemed to require guided and collaborative reflective activities. the learning activities provided did not fully address the development of clinical reasoning, documentation, application of theory and planning skills. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 221 optimal strategies for facilitation of these skills for novice practitioners need to be actively sought. the study offers valuable insights into the introductory physiotherapy clinical placement at one institution. it was clear that both classroom and clinical learning environments are essential to prepare graduates for professional practice. the findings of the study confirmed that entrance to the clinical learning environment can be challenging, and that students need support in the transition from the classroom to the clinical learning environment.[4-8] therefore, careful consideration needs to be given to the content of learning activities and support structures in the classroom and clinical learning environments to optimise learning, and to aid the transition from one context to the other. it is acknowledged that this study sought only the views of the junior students. the perceptions of the senior students who acted as mentors should also be investigated. conclusion an introductory clinical education module was found to provide valuable learning opportunities, where junior students learnt productively in a non-threatening environment. it gave junior students the opportunity to link theoretical and practical concepts to clinical implementation. peer mentoring and progressive mastery were valuable strategies to enhance learning in this context. the study highlights that reflection should receive more attention in teaching and learning applications, and that the mental adjustment to commencing clinical practice should be further investigated. some learning opportunities described in this paper can be included in introductory clinical modules to facilitate content and process learning; however, learning outcomes and opportunities need to be aligned. author contributions. all authors contributed to the conception, design, analysis of data and interpretation of data. d ernstzen drafted the manuscript. all authors provided critical revision and approval of the manuscript version to be published. acknowledgements. the authors would like to thank mrs r bester and mrs r lochner for their involvement in the study. we also thank the participants for their time and input. funding was provided by the fund for innovation and research into teaching and learning, centre for teaching and learning, stellenbosch university, south africa. references 1. ernstzen dv, bitzer em, grimmer-somers k. physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: a case study. medical teacher 2009;31(3):e102-115. 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[http://dx.doi.org/10.1080/01421590902832970] 10. cole b, wessel j. how clinical instructors can enhance the learning experience of physical therapy students in an introductory clinical placement. advances in health sciences education 2008;13:163-179. [http://dx.doi. org/10.1007/s10459-006-9030-6] 11. skoien ak, vagstol u, raaheim a. learning physiotherapy in clinical practice: student interaction in a professional context. physiotherapy theory and practice 2009;25(4):268-278. [http://dx.doi.org/ 10.1080/09593980902782298] 12. creswell jw. research design: qualitative, quantitative and mixed methods approaches. 2nd ed. los angeles: sage, 2003. 13. schunk dh. learning theories: an educational perspective. 4th ed. upper saddle river, nj: pearson education, 2004. 14. spencer j. learning and teaching in the clinical learning environment: abc of learning and teaching in medicine. bmj 2003;326:591-594. [http://dx.doi.org/10.1136/bmj.326.7389.591] 15. muir f. the understanding and experience of students, tutors and educators regarding reflection in medical education: a qualitative study. international journal of medical education 2010;1:61-67. [http://dx.doi. org/10.5116/ijme.4c65.0a0a] 16. donaghy me, morrs k. guided reflection: a framework to facilitate and assess reflective practice within the discipline of physiotherapy. physiotherapy theory and practice 2000;16:3-14. [http://dx.doi. org/10.1080/095939800307566] 17. geddes el, wessel j, williams rm. ethical issues identified by physical therapy students during clinical placements. physiotherapy theory and practice 2004;20(1):17-29. [http://dx.doi.org/10.1080/09593980490425076] ajhpe 404.indd october 2014, vol.6, no. 2 ajhpe 119 research despite the promise of a better life for all made after the first democratic elections in south africa (sa) in 1994, excellent legislation and policy documents, health outcomes in sa are poor and compare unfavourably with other countries at a similar stage of development.[1] in 2009, the district health barometer reported that healthcare indices are generally worse in rural than in urban areas, with a higher burden of infectious diseases, higher under-5 mortality and reduced life expectancy at birth.[2] there are major inequalities between staffing levels at rural and urban hospitals, which contribute to poor health outcomes.[2] these disparities remain, despite the commitment of the national department of health of ‘health for all’ and the prioritisation of recruitment of healthcare professionals (hcps) for rural areas.[1] failure of the health service to deliver on the promises of a better life for all has been attributed to the shortage of well-qualified hcps.[3] increasing the number of healthcare workers in underserved rural areas improves health outcomes in general, and maternal, child and infant mortality indicators specifically.[4] rural-origin hcps are more likely than those from urban origin to work in rural areas and contribute to improved health outcomes in these areas.[5] however, only a small number of rural-origin sa scholars are trained each year as hcps,[6] and staffing of rural hospitals remains an ongoing challenge. absent role models, dysfunctional families, poorly performing schools and inadequate funding make it almost impossible for rural-origin students to gain access to tertiary institutions to train as hcps.[7,8] in view of this, new strategies are necessary if sa rural scholars are to provide a solution to the shortage of hcps in rural areas. since 1999, the umthombo youth development foundation sholarship scheme (uydf ss) has run an innovative scheme in rural kwazulunatal. the uydf ss model includes the selection by rural hospitals of rural students with the potential to train as hcps, comprehensive funding for students, a compulsory mentoring programme and hospital-based experiential vacation work. the annual pass rate of students supported by uydf ss is >85%, and by december 2013, 184 rural-origin hcps supported by uydf ss had graduated from tertiary institutions in sa.[9] all these graduates have returned to rural areas to work there, <10% have bought themselves out of a portion of their work-back contract, and >60% continue to work in rural areas after completing their work-back obligation. the objective of this article is to present the experiences of uydf ss graduates, build on tinto’s model of persistence and engagement, and contribute towards building a theory of success for rural-origin hcps. methods this qualitative study used a life-history methodology to explore the educational experiencs of rural-origin hcps. this methodology enabled participants to tell their life story within a social, historical and cultural context. the meanings that they attached to their experiences and how they made sense of their world as they journeyed from rural scholar to hcp became clear. six rural-origin hcps were purposefully selected from uydf ss graduates. selection criteria included background. major inequalities in staffing levels at rural and urban hospitals contribute to poorer health outcomes in rural areas. local and international studies have shown that healthcare professionals (hcps) of rural origin are more likely than those of urban origin to work in and contribute to improved health outcomes in rural areas. however, absent role models, dysfunctional families, schools that perform poorly and inadequate funding make it almost impossible for rural-origin students to gain access to institutions of higher learning (ihls) to train as hcps. objective. to present the experiences of graduates from the umthombo youth development foundation scholarship scheme, build on tinto’s model of persistence and engagement, and contribute towards the success rates of rural-origin hcps. methods. this qualitative study used a life-history methodology. unstructured interviews, photomemory, artefacts and collage development were used to explore the educational experiences of six rural-origin hcps. data were coded and categorised and themes identified. results. compulsory academic and peer mentoring promoted academic and social engagement, helped students to recognise their pre-university experiences as generative, and contributed to their success. the generative potential of pre-university experiences and compulsory work-based experiential learning were identified as initiatives that could strengthen tinto’s model of persistence and engagement. conclusion. a number of targeted interventions, if introduced at south african ihls, could contribute to improved success rates of rural-origin health science students. ajhpe 2014;6(2):119-123. doi:10.7196/ajhpe.404 building on tinto’s model of engagement and persistence: experiences from the umthombo youth development foundation scholarship scheme a ross, mb chb, dch, mmed (family medicine), fcfp (sa) department of family medicine, faculty of health sciences, university of kwazulu-natal, durban, south africa corresponding author: a ross (rossa@ukzn.ac.za) 120 october 2014, vol.6, no. 2 ajhpe researchresearch that they were (i) willing to participate; (ii) articulate; and (iii) working in a rural environment.[10] to provide a service of excellence at a district hospital, a team of hcps is required. therefore, hcps in a variety of healthcare disciplines were included in the study (table 1). the author collected data using two unstructured interviews, which were supplemented by photomemory, artefacts and construction of a collage. participants were asked, ‘tell me about your educational experiences from rural scholar to healthcare professional’. the first interview provided an overview of their home environment and educational experiences, while the second interview clarified and elaborated on issues previously raised. at a subsequent meeting, participants were asked to bring four photographs and an artefact from different stages of their educational journey and to construct a collage of a day in their lives. they had to explain how the photographs/artefacts/pictures selected for the collage related to their educational experiences. all interviews and discussions were recorded and transcribed verbatim. from the transcripts, a reconstructed story was written and sent to the participants for validation of content.[10] the stories were read and re-read, codes and categories identified, patterns and relationships between categories reviewed and themes developed.[10] ethical approval for the study was obtained from the social science ethics committee of the university of kwazulu-natal, durban, sa (hss/1205/012d). written informed consent, including possible identification, was obtained from all participants after explaining the objective of the study. th eoretical model although there are many theoretical models to study the reasons why students succeed or fail at institutions of higher learning (ihls), tinto’s theory of engagement and persistence has been the major theoretical/explanatory model about student success at ihls since the 1980s.[11,12] tinto’s initial writing focused only on academic and social integration as key factors in determining engagement and persistence at ihls and, finally, success at university. as the model developed, tinto added pre-university factors that may influence students’ ability to engage, persist and ultimately succeed at ihls (fig. 1). tinto’s theoretical model is useful because it recognises factors beyond the control of academic institutions. these may influence retention and success at ihls, including students’ academic abilities, and study and language skills. the acquisition of all these factors is usually the responsibility of the family and school.[13,14] in addition, attitudes towards higher education, such as commitment, motivation, aspirational goals and expectations, influence retention and success at ihls.[13] external commitments such as family table 1. list of healthcare professionals who participated in the study initials current position qualification professional experience professional experience, yrs age gender originally from schooling dg student mentor co-ordinator, mtubatuba bsc physiotherapy (ukzn, 2003) physiotherapist (2004 2008) mentor co-ordinator (2008 ) 11 37 male ingwavuma ingwavuma fn sub-saharan co-ordinator, brian holden eye institute bsc optometry (ukzn, 2003) optometrist, mosvold, phelophepa train (2004 2009) brian holden eye institute (2010 ) 11 34 male ingwavuma ingwavuma sm psychologist, hlabisa hospital msc clinical psychology (uj, 2009) clinical psychologist, hlabisa hospital (2010 ) 4 29 male ingwavuma ingwavuma tm physiotherapist, emmaus hospital bsc physiotherapy (wits, 2004) physiotherapist (2005 ) 10 33 male ingwavuma ingwavuma nm pharmacist, mtubatuba bsc pharmacy (wits, 2004) pharmacist (2005 ) 10 35 female ingwavuma nongoma lh medical officer, mseleni hospital mb chb (ukzn, 2006) intern/community service officer/medical officer (2007 ) 9 30 female ubombo ubombo ukzn = university of kwazulu-natal; uj = university of johannesburg; wits = university of the witwatersrand. institutional commitment abilities, skills preparation attributes attitudes, values, knowledge external commitments feedback support involvement expectational climate learning successquality of e�ort fig. 1. structure of a preliminary model of institutional action.[12] october 2014, vol.6, no. 2 ajhpe 121 research responsibilities and adequate financial support also play a role in whether students complete their degrees. however, while recognising that experiences before entering university may influence student success, tinto’s model focuses on the contribution of institutions to ensure that students complete their courses and graduate. at the core of the model is a need for student engagement with peers and faculty members in a supportive university environment, with high expectations of student success.[15] tinto suggests that student engagement be facilitated by lecturers, primarily in the classroom, to promote academic and social interaction that in turn lead to the development of communities of learning. the latter would ensure student involvement, provide opportunities to develop relationships with peers and faculty members, and provide academic and social support and opportunities for feedback on whether learning has been adequate. student involvement with these communities has been shown to increase the quality of effort put into learning, which in turn contributes to success and graduation.[11,12,16,17] results from the data collected from rural-origin hcps supported by uydf ss, one can add to tinto’s model of persistence and engagement at ihls in three important ways: • introducing compulsory academic and peer mentoring for all students to promote academic and social engagement. • assisting students to recognise pre-university experiences as generative. • strengthening learning at university by introducing compulsory workbased experiential learning. compulsory mentoring, promoting engagement and persistence at university the uydf ss model has a compulsory mentoring programme for all students. it involves regular meetings with a university mentor and the establishment of peer mentorship groups. these proactive meetings with a local mentor ensure that academic problems are identified early. ‘i would get a call from the mentor to find out how i was doing.’ (fn) the mentoring ensured that students recognised academic challenges so that solutions could be identified. ‘you can’t fix a problem unless you are prepared to say, “i failed. i have a problem. i must do something.”’ (dg) these early interventions were initiated by the student and monitored by the mentor and their peers to ensure resolution of the problem. evidence from this study suggests that the early identification of deficiencies and active interventions were key to student retention and success. this problem-focused behaviour to achieve success encouraged students to access academic resources. ‘i approach the physics lecturer to help me pass the course, and to find a tutor for physics and maths.’ (dg) students also worked with like-minded peers and formed study groups, ‘which was a way of cementing my knowledge. i studied by myself first, then when we were in a group, i shared what i had learned.’ (dg) the mentoring process focused on accountability to the funder and to one another. ‘we would be asked, “why didn’t you pass the test?”, and then i needed to know exactly why i didn’t pass the test.’ (tm) mentoring was based on the belief that students had the potential to succeed, and tapped into their hopes, dreams and determination to succeed. ‘i had no option, i had to make it. and if i don’t make it, i’d lose the scholarship and it would just be the end of the world.’ (sm) the uydf ss mentoring was not only academic, as social integration is also important for success at ihls. ‘when other students came to johannesburg for the first time i would tell them, “this place is like this and that and that.” i would tell them, whatever your circumstances, you need to pass, because that’s the only thing that you are at university for. so i would mentor them. not teaching them maths and physics, but i would mentor them in terms of social life, and how to handle the situation, knowing their background.’ (tm) for these students peer mentoring helped with social integration and accountability. it facilitated the development of friendships and helped them to make the most of the academic support available at ihls. ‘the group of friends that i had, we had the same vision, we did not want to fail, we wanted to graduate.’ (fn) the rural community as a generative context in the rural context, these graduates and their families recognised that education was a priority and were prepared to make sacrifices for a good education, because ‘we really wanted to learn. even though our matric maths teacher got sick in february and never came back to school we walked 1 km after school for extra maths lessons.’ (sm) they learnt to work hard and work together to compensate for deficiencies at school by ‘forming study groups where we shared information with each other to ease the pressure’. (dg) ‘our experiences built some personalities within us so as to be able to push even when it was difficult.’ (fn) through the mentoring process, uydf ss students were encouraged to reflect on their rural experiences, learn from these experiences, and apply the learning to new challenges at university. the mentoring encouraged students to draw on previous learning and personal strength, and sought to reframe challenges at university in the light of previous successes in overcoming challenges. this was based on the understanding that if students had overcome challenges in the past, there was no reason why they could not overcome challenges at university. ‘i knew this world where i could do things, and where i was going to do things.’ (sm) in response to challenges that they faced at university, uydf ss students sought lecturers who could help them, asked for tutors and mentors, and formed study groups to help one another. ‘we were willing to learn to study in different ways to ensure that we passed.’ (tm) work-based experiential vacation work rural-origin students supported by uydf ss worked at the hospital closest to their home for at least four weeks per year, alongside qualified colleagues. students recognised the value that this added to their learning, because ‘our vacation work at the hospital made things better for us … we got to know about the drugs … the pharmacist would tell me, every day “i want you to choose three drugs and read about them, know what they are for and why are you using them”’. (nm) in the physiotherapy department, for example, ‘the therapist wanted to see what we had learnt, and that we could apply it, which was also very good and very helpful’. (tm) this work-based experiential learning allowed them to gain experience in a real-life environment and witness role models who were providing a service in rural areas. discussion tinto’s model of institutional action recognises pre-university experiences outside the control of ihls, a sentiment echoed in the recommendations for undergraduate curricula reform recently submitted to the council on researchresearch 122 october 2014, vol.6, no. 2 ajhpe higher education.[18] tinto emphasises the need for social and academic integration if students are to persist at ihls.[19] the uydf ss supports the importance of engagement at ihls as many academic resources are available to help students to succeed, but they can only derive benefit from these resources if they are willing and able to access them. tinto suggests that this engagement should happen primarily in the classroom and be facilitated by academic staff. however, in an sa context of large, diverse classes this may not be effective. a compulsory academic mentoring programme for all students would ensure that they are helped in a proactive manner so that problems are identified early and solutions found. this academic mentoring should tap into the students’ intrinsic motivation, desire for learning and personal gain, and should be provided in a supportive framework. peer mentoring ensures social engagement, which tinto has recognised as contributing to student persistence and success at university. peer support and learning have been shown to increase productivity, the quality of effort put into learning activities, and ultimately success.[12,20] the experiences of uydf ss graduates and the success of the scheme point to the critical role that academic and peer mentoring plays in the success of students at ihls and could be incorporated into such programmes in sa. the uydf ss model recognises the many challenges faced by rural-origin students, e.g. finance, being first-generation students, and poor preparation owing to dysfunctional schools, and adds to tinto’s model by suggesting that these experiences can be generative, dynamic and transformative.[21] the uydf ss encourages students to embrace, not to ignore, these experiences so that these can become the substance on which future solutions are built. many students entering a university in sa, particularly rural, black students, are underprepared both academically and in terms of the skills needed (studying skills and practical laboratory-based skills) to succeed. however, many of them have life experiences that have given them tools to problem solve and find solutions that could be applied to the challenges at ihls. encouraging students to reflect on their experiences and to view these as important life lessons that give them tools and resources to succeed at ihls, are important additions to tinto’s model. career-specific work experience has been recognised as a motivating influence for students at ihls and can contribute to academic success.[22] alignment between training programmes and career aspirations is a powerful motivator for students to persist and succeed at ihls.[22] vacation work provided opportunities for students to study in a supportive environment, practise their skills and view their studies in relation to the working world. the vacation work also exposed them to hcps working in a rural environment and helped them to gain insight into their chosen career. this relevant and focused learning experience contributed to their knowledge and skills, influenced their attitudes and values about working in rural areas, and contributed to their motivation, engagement and success at university. other studies have shown that such exposure contributes towards motivating students to put in the effort required to succeed at ihls. [22] a similar programme could be added to most university programmes in sa (fig. 2). limitations of this study although students supported by the uydf ss have been very successful at ihls over the past 14 years, the number of students in the current study was very small. in similar upscaled projects, similar outcomes cannot be guaranteed. conclusion this study aimed to present the experiences of rural-origin graduates at ihls in sa in order to build on tinto’s model of persistence and engagement. the study analysed participants’ experiences in the uydf ss, which supported them financially, academically and socially in their journey from rural scholar to hcp. tinto’s model promotes student engagement at classroom level, which may not always be possible in an sa context. the model also suggests some limitations to the contribution by universities to facilitate student success by identifying preuniversity experiences beyond their control. the findings of this study have implications for universities that are looking to successfully educate students from rural regions. while tinto’s notion of academic and social integration is essential in the success of students at ihls, the current study suggests that for students of rural origin to succeed at university, a number of targeted interventions are essential: (i) a compulsory structured academic and peer mentoring programme, emphasising student potential; (ii) reframing of academic challenges, thus helping students to recognise the generative nature of pre-university experiences; and (iii) introducing compulsory vacation work. drawing on the success and learning of uydf ss graduates, these additions have the potential to improve persistence and success at ihls in sa. with institutional commitment, the mentoring model and work experience are practical and implementable, and if offered to all students could lead to immediate improved success rates at ihls throughout sa. institutional commitment abilities, skills preparation attributes attitudes, values, knowledge external commitments feedback support involvement expectational climate learning successquality of e�ort workbased learning experiential ihl pre -ih l e xpe rien ces fig. 2. mentoring and work-based experiental work added to tinto’s model of institutional action. (ihl = institution of higher learning.) october 2014, vol.6, no. 2 ajhpe 123 research conflict of interest. the author was the founder of the friends of mosvold scholarship scheme (currently uydf ss). he was intimately involved in running the scheme until 2007 and knows all the participants, as they were supported by the scheme. however, since 2007 he is no longer actively involved in student selection or financial support of the students and serves only as a trustee of the scheme and a mentor at the local university. none of those who participated in the research has any financial or other obligation to or any personal relationship with the author. this research project was supported by a grant from discovery health and conducted during a sabbatical period at the university of kwazulunatal. references 1. department of health. human resources for health for south africa 2030. pretoria: south african national department of health, 2011. 2. health systems trust. the district health barometer 2008/2009. http://www.hst.org.za/publications/districthealth-barometer-200809 (accessed 8 february 2012). 3. world health organization. models and tools for health workforce planning and projects. human resources of health observer 3. geneva: world health organization, 2010:3. 4. world health organization. increasing access to health workers in remote and rural areas through improved retention. 2009. http://www.who.int/hrh/migration/background_paper_draft.pdf (accessed 22 july 2014). 5. wilson nw, couper id, de vries e, reid s, fish t, marais bj. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9(2):1060. 6. tumbo jm, couper id, hugo jf. rural-origin health science students at south african universities. s afr med j 2009;99(1):54-56. 7. adam f, backhouse j, baloyi h, barnes t. access and throughput in south african higher education: three case studies. pretoria: council on higher education, 2010. 8. department of basic education. educational statistics in south africa 2009. pretoria: department of basic education, 2010. 9. mcgregor g. umthombo youth development foundation annual report 2012-13. durban: youth development foundation, 2013. 10. terre blanche m, durrheim k, painter d, eds. research in practice. applied methods for the social sciences. cape town: university of cape town, 2006. 11. tinto v. dropout from higher education: a theoretical synthesis of recent research. review of educational research 1975;45(1):89-125. 12. tinto v, pusser b. moving from theory to action: building a model of institutional action for student success. 2006. http://cpe.ky.gov/nr/rdonlyres/d7ee04d0-ee8c-4acd-90f6-5bb3c8bc8e05/0/ss_related_info_6_22_3_ moving_from_theory_to_action.pdf (accessed 28 june 2012). 13. spady wg. dropouts from higher education: an interdisciplinary review and synthesis. interchange 1970;1(1):64-85. 14. jama mp, mapesela mle, beylefeld aa. theoretical perspectives on factors affecting the academic performance of students. south african journal of higher education 2008;22(special edition 5):992-1005. 15. tinto v. taking student success seriously: rethinking the first year of college. nacada journal 1999;19(2):5-9. [http://dx.doi.org/10.12930/0271-9517-19.2.5] 16. tinto v. learning better together: the impact of leaning communities on student success. higher education monograph series 2003:1-8. 17. tinto v. research and practice of student retention: what next? journal of college student retention 2006;8(1):1-19 . 18. council on higher education. a proposal for undergraduate curriculum reform in south africa: the case for a flexible curriculum structure. pretoria: council on higher education, 2013. 19. tinto v. completing college: rethinking institutional action. chicago: the university of chicago press, 2012. 20. van rheede van oudtshoorn gp, hay d. group work in higher education: a mismanaged evil or a potential good? south african journal of higher education 2004;18(2):131-149. 21. balfour rmm. troubling contexts: towards a generative theory of rurality as education research. journal of rural and community development 2008;3:95-107. 22. lubben f, davidowitz b, buffler a, allie s, scott i. factors influencing access students’ persistence in an undergraduate science programme: a south african case study. international journal of educational development 2010;30(4):351-358. [http://dx.doi.org/10.1016/j.ijedudev.2009.11.009] research november 2015, vol. 7, no. 2 ajhpe 199 globally, medical and dental university students share basic science curricula,[1-6] promoting cost-effectiveness of student training.[7] this strategy ensures that dental students develop a solid medical background. the approach has historical roots,[8] and remains a current teaching and learning requirement for a dentist.[9] the university of pretoria, south africa (sa) utilised a joint basic science curriculum for firstand second-year medical and dental students from the late 1940s to 2014. a recent article by ajjawi et al.[1] identified the marginalisation of dental students in a combined medical curriculum at a university in australia. similarly, a us study showed that dental students felt like ‘second-class citizens’ in their joint curriculum and that its relevance was based on the needs of the medical student; it also contained too much irrelevant information from a dental perspective.[3] ajjawi et al.[1] suggest that prejudice and stereotyping may be prevalent in joint basic science curricula. these factors may possibly be present from a social and psychological perspective,[10] when two distinct groups have to interact in a joint curriculum. medical and dental students sharing a joint curriculum may therefore pose undesired risks with regard to student learning.[1] despite the identification of these problems, no studies or reports could be traced in the literature that describe how such problems are actively being addressed in terms of medical and dental students. there are no studies in sa that investigate dental students’ perceptions of their social and peer relationships with medical students in a shared medical curriculum. with the marginalisation of dental students being reported elsewhere,[1] one should investigate this issue in sa. further evidence in this regard may indicate the need to reconsider the use and management of generic joint programmes locally in terms of the effect on learning and interprofessional collaboration. based on this assessment, our study investigated whether dental students at the university of pretoria perceive the joint curriculum to be relevant and useful and if marginalisation is prevalent. methods ethical approval and permission for the study were obtained. anonymous written student reflections of the 2011 (sample a (n=53)) and 2012 (sample b (n=45)) second-year dental student cohorts from the school of dentistry, university of pretoria regarding their experience in the first 2 years of the medical curriculum were retrospectively analysed using qualitative thematic coding methods.[11] the frequency distributions of the coded themes were subsequently studied to complement the qualitative analysis. the written reflection was open to comments that the students wished to share and specific topics such as marginalisation were not mentioned as part of the instruction, which was as follows: ‘write a one-page reflection about your experience during the first two years of study.’ the feedback session took place without prior announcement and the students were not allowed to interact during this session. they were encouraged to give both ‘positive’ and ‘negative’ feedback. relevant phrases were identified from the responses of the students and were coded, based on the similarity of the comments.[11] ‘relevance’ and ‘marginalisation’ were pre-empted as key themes. similar comments were grouped together based on common themes.[11] provision was made to identify new themes during the course of the analysis, based on the similarity of the students’ responses.[11] background. medical and dental students often participate in joint basic science curricula, such as the basic science curriculum at the university of pretoria, south africa. reports from the usa and australia, however, show that it may be problematic because joint basic science curricula are mostly tailored around the needs of the medical students only, which may lead to prejudice and marginalisation of dental students. there are no local studies to inform decision-making in this regard. objectives. to determine whether dental students perceived the joint basic science curriculum at the university of pretoria to be relevant to their needs and if they felt marginalised. methods. reflective essays with regard to the 2011 and 2012 second-year dental students’ perceptions of the first 2 years of study in the joint curriculum were qualitatively analysed using a thematic approach. frequency distributions of the identified themes were also calculated. results. despite positive comments, the dental students perceived that the joint basic science curriculum at the university of pretoria may not be relevant to their needs and that they are being marginalised in the teaching and learning processes. conclusion. the current study highlights the need for improvements in the manner in which joint basic science curricula are being administered in order to foster interprofessional collaboration. alternatively, dental and medical students should be separated to ensure that the educational objectives of basic science curricula are being met for minority groups, such as dental students. afr j health professions educ 2015;7(2):199-201. doi:10.7196/ajhpe.409 second-year dental students’ perceptions about a joint basic science curriculum t c postma,1 phd; l bronkhorst,2 bchd 1 department of dental management sciences, school of dentistry, faculty of health sciences, university of pretoria, south africa 2 department of dental management sciences, school of dentistry, faculty of health sciences, university of pretoria, south africa (bchd student at the time of the study) corresponding author: t c postma (corne.postma@up.ac.za) research 200 november 2015, vol. 7, no. 2 ajhpe results ninety-eight students representing 80% of the total student population of the 2 second-year cohorts participated in the study. the remaining students in each cohort did not attend the feedback session. the thematic analysis of the students’ comments included ‘relevance’, ‘marginalisation’ and related topics (table 1). qualitative results – what did the students say? a selection of quotes from the students’ reflections is given in table 2. quantitative results – positive comments forty-two per cent of the students commented that the first 2 years of study were enjoyable, 35% described it as an interesting experience, and 26% and 23% mentioned that the joint curriculum was useful and relevant, respectively. a further 23% suggested that the joint curriculum may be advantageous to a dental student, while 15% remarked that it is ‘good’ practice. at least 12% mentioned that they gained numerous friends during this time, while 11% felt that they grew on a personal level. quantitative results – negative comments more than half (54%) of the participating second-year dental students were of the opinion that the joint curriculum contained too much irrelevant information (table  1). forty-three per cent thought that the medical students were treated superiorly by lecturers compared with dental students and 38% felt excluded during the teaching and learning. the students mentioned that the first 2 years of study were challenging, with an intense scope (28%), and contained too much information (27%). twenty-one per cent thought that the head and neck anatomy was neglected during the anatomy block. nearly 1 in 5 students (17%) recommended that dental subjects should be included in the first 2 years of study, while 14% pertinently suggested that the curriculum should be split. some (14%) perceived the first 2 years of study as being overwhelming, difficult and stressful, while 13% mentioned that the curriculum was conducive to a lack of deep and meaningful study. discussion this study investigated the perceptions of dental students with regard to their participation in a joint medical curriculum at the university of pretoria. despite a substantial number of positive comments, it is evident that most of the seemingly negative results of this study correspond to findings of us[3] and australian[1] studies. table 1. thematic analysis of the top 20 comments of dental students with regard to their first 2 years of study at the university of pretoria coded theme (student perception) sample a, n sample b, n % of sample (a + b) positive feedback • enjoyable experience 19 22 42 • interesting experience 14 20 35 • useful experience 6 19 26 • relevant 12 11 23 • professional advantage 11 12 23 • joint curriculum is a good thing 14 1 15 • gained numerous friends 10 2 12 • grew on a personal level 1 10 11 negative feedback • too much irrelevant information 34 20 54 • medical students superiorly treated 19 23 43 • dental students feel excluded 15 22 38 • challenging, with an intense scope 6 21 28 • too much information 4 22 27 • neglect of head and neck anatomy 12 9 21 • dental subjects needed 9 8 17 • overwhelming 5 9 14 • difficult and stressful 3 11 14 • the joint curriculum should be split 12 2 14 • lack of deep, meaningful studying 8 5 13 table 2. perceptions from samples a and b (table 1) with regard to the first 2 years in the joint medical curriculum at the university of pretoria student perception ‘ ... good experience ... ’ ‘ ... enjoyed the joint medical/dental curriculum ... ’ ‘ ... did not seem to give us any information related to the actual dental field ... ’ ‘ ... demotivating to do work that is not applicable ... ’ ‘ ... feel it is a waste of time ... ’ ‘ ... more time should, however, have been given to the head and neck chapter ... ’ ‘ ... learned a lot of unnecessary anatomy ... ’ ‘ … dental students have transferred to medical due to the intimidation we have to live with everyday.’ ‘ ... medical students are treated as if they are superior to us ... ’ ‘ ... we do not have to be in joined field if it does not benefit the group as a whole ... ’ ‘ ... fact that it is more medicine-based than dentistry-based, it does sometimes get you under ... ’ ‘ ... would have been better perceived by us dentistry students if we were taken into account ... ’ ‘ ... if medical and dental students were in different classes, i think it would be easier ... ’ ‘ ...would love to have more hands-on practicals ... just basics so we can feel like dentists ... ’ ‘... enjoyed anatomy ... especially when we did the head and neck anatomy ... ’ ‘... we were able to have a background about the different diseases and the body as a whole ... ’ ‘ ... medical terminology was extremely useful ... ’ ‘ ... maybe one or two dental subjects should be implemented ... ’ ‘ ... help a lot if the dentistry faculty could communicate with our different block chairpersons ... ’ ‘ ... challenging in terms of workload ... ’ ‘ ... both challenging and interesting ... ’ ‘ ... you tend to read to pass instead of reading, understanding and pass ... ’ research november 2015, vol. 7, no. 2 ajhpe 201 the perception of dental students that the joint curriculum contained too much irrelevant information and that they were being marginalised were the two most important findings. it is conceivable in a resource-constrained environment that faculty will design the curriculum to be applicable to the majority of the learners. it is within this paradox that the conflict and prejudice between the two groups arise.[1] as there are usually more medical than dental students, shared curricula are often designed from a pure medical perspective, which may result in a situation where medical students perceive the curriculum to be relevant to them, while dental students perceive the opposite.[3] relevance, however, is a key element in adult learning.[12] adult learners mostly decide what is relevant or not. participation in a joint curriculum, where one group feels that the content is irrelevant, will most likely lead to a breakdown in the learning processes.[12] a lack of relevance may even neutralise the primary intent of a joint curriculum of providing the dental student with a solid medical background.[13] a large percentage of dental students thought that they are being excluded or stereotyped by faculty and that medical students are considered to be superior, which may be detrimental to the learning process and of little value for interdisciplinary co-operation. interdisciplinary co-operation has been propagated recently[2] and is based on three principles: learning ‘together’, ‘from’ and ‘about’ one another to foster collegiality on an equal basis.[2] the last two principles are absent in the current study. the results suggest that sharing a joint curriculum, where one of the groups is given preference, may cause conflict and division among the professions. the relative lack of comment about socialising and collaboration among the group in the written reflections may also suggest that negative perceptions regarding the joint curriculum dominate positive perceptions. two choices exist for addressing the situation. firstly, the dental and medical curricula could take separate routes. such an approach may be costly, as some courses may have to be duplicated. marginalisation and stereotyping will be eliminated to some degree, but possibly at the expense of interdisciplinary collaboration. secondly, being cognizant of the potential threats of a joint curriculum, it could be managed to suit the needs of all parties concerned. consequently, the fundamentals of adult learning should be embraced:[14] prejudice must be reduced through the support of the institution, equal status between the groups should be actively propagated, and positive expectations need to be encouraged. furthermore, common goals should be set for both groups, but differences should be highlighted and respected.[14,15] in practice this means that the basic medical sciences should be made more relevant for dental students within the joint curriculum.[13] such an adjustment will require greater collaboration and communication between the medical and dental schools and may require additional resources.[13] conclusion the findings of this study are particularly relevant in the african context. africa is a developing continent with considerable resource constraints. the establishment of joint basic science curricula may therefore be regarded as the most viable option to train students. the findings of the current study provide evidence – for the first time in africa – that the use of a joint curriculum for medical and dental students may be problematic to facilitate interdisciplinary respect and co-operation, with potentially detrimental consequences from a learning perspective. should a joint curriculum be the only option from a resource perspective, the importance of ‘relevance’ of the content in a joint curriculum – as it relates to all parties concerned and the psychological factors of group interaction – should not be underestimated. ignorance in this regard is likely to result in prejudice[1] and possibly even a breakdown in the learning processes. possible prejudice or a breakdown of learning processes would refute the original intent of a joint basic science curriculum to equip the dentist with more than only ‘superficial’ basic medical science knowledge. acknowledgements. barbara english of the research office at the faculty of health sciences, university of pretoria is thanked for the language editing. references 1. ajjawi r, hyde s, roberts c, nisbet g. marginalisation of dental students in a shared medical and dental education programme. med educ 2009;43:238-245. 2. craddock d, o’halloran c, borthwick a, mcpherson k. interprofessional education in health and social care: fashion or informed practice? learn health soc care 2006;5:220-242. 3. henzi d, davis e, jasinevicius r, hendricson w. in the students’ own words: what are the strengths and weaknesses of the dental school curriculum? j dent educ 2007;71(5):632-645. 4. martinez-alvarez c, sanz m, bertold p. basic sciences education in the dental curriculum in southern europe. eur j dent educ 2001;5:63-66. 5. klineberg i, massey w, thomas m, cockrell d. a new era of dental education at the university of sydney, australia. aust dent j 2002;47:194-201. 6. hammick m, freeth d, koppel i, et al. a best evidence systematic review of interprofessional education: bme guide no. 9. med teach 2007;29:735-751. [http://dx.doi.org/10.1080/01421590701682576] 7. pyle m, andrieu sc, chadwick dg, et al. the case for change in dental education. j dent educ 2006;70:921-924. 8. formicola aj. the relationship between dental and medical education: a perspective for the 1990’s. j dent educ 1995;59:540-545. 9. haden nk, hendricson wd, kassebaum dk, et al. curriculum change in dental education, 2003-09. j dent educ 2010;74(5):539-557. 10. tajfel h, turner t. an integrative theory of intergroup conflict. in: hogg ma, abrams d, eds. intergroup relations: essential readings. philadelphia, pa: psychology press, 2001:94-109. 11. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. 12. ashton s. authenticity in adult learning. int j lifelong educ 2010;29(1):3-19. 13. baum bj. can biomedical science be made relevant in dental education? a north american perspective. eur j dent educ 2003;7(2):49-59. 14. carpenter j, hewstone m. shared learning for doctors and social workers: evaluation of a programme. br j soc work 1996;26(2):239-257. 15. hean s, dickinson c. the contact hypothesis: an exploration of its further potential in interprofessional education. j interprof care 2005;19(5):480-491. article 8 august 2010, vol. 2, no. 1 ajhpe article over the past two decades, all eight south african medical schools (see map (fig. 1) and table i) have undertaken renewal of their mb chb educational programmes. as i write this in mid-2010, all programmes are settled and have been accredited by the undergraduate education and training committee of the health professions council of south africa (hpcsa). nevertheless, the educational leadership at all universities continues to undertake steady evaluation and research with a view to refinement of their educational offerings and assessment strategies. in this paper, i seek to outline the triggers to medical educational transformation in south africa, then to show the options selected, and finally to posit the successes that south african medical schools have achieved, while highlighting the challenges that remain. the main triggers to educational reform were: • the acknowledged ‘ills’ of the so-called ‘traditional’ curricula developed, and hardly modified, over nearly a century ago following the report submitted to the carnegie foundation’s committee on higher education by abraham flexner in 1910.1 • a belated acceptance of the concept of the adult learner and of the importance to that learner of contextualised learning,2 while accepting, nevertheless, that the adult learner of medicine might not be so different from learners in general, and moreover that too much self-direction in the course of training a doctor might actually be undesirable!3 the chief driver of curriculum reform during the late 1990s was the call to all south african medical schools from the hpcsa to modernise their medical curricula. in 1997 the hpcsa issued a discussion document, the final version following in 1999. entitled education and training of doctors in south africa,4 it was along the lines of the general medical council’s tomorrow’s doctors5 delivered to uk medical schools in 1993. continued accreditation, it was made clear, would be dependent upon schools undertaking the broadly stipulated changes. there were three main imperatives: • to mitigate the ‘ills’ of existing curricula which had come to characterise the established programmes (all of which mirrored the so-called ‘flexnerian’ model (see below)) • to acknowledge the realities of so-called adult learning • to produce a graduate fit-for-service in post-apartheid south africa. this latter key reform was consonant with adoption on the part of the new national government that was elected in 1994 of a national health plan6 aimed at strengthening and reinforcing the primary health care (phc) approach to health care delivery. in the words of the education and training of doctors in south africa document, the five-star doctor of boelen (fig. 2) was viewed as likely to provide the ‘best fit’ for delivery of health care to the country’s communities. the then deputy vice-chancellor responsible for the faculty of health sciences’ affairs at the university of cape town (uct) responded by asserting that it would be necessary ‘to find new and innovative ways to sustain the enterprise of medical education and to reform that system so that it produces doctors who are both excellent and relevant, “excellence and relevance” being defined in the context of the present and future south african realities’. in essence curriculum change informed by the phc approach demanded the training of graduates who would combine preventive, promotive, curative and rehabilitative care in their practice and who would demonstrate an understanding of the patterns, aetiology and natural history of common diseases and disabilities in rural and urban south africa. these graduates would acquire knowledge and skills enabling them to practise with confidence at multiple levels (primary, secondary and tertiary) of health care in a restructured south african public health sysmb chb curriculum modernisation in south africa – growing doctors for africa janet l seggie, bsc (hons), md (birm), frcp (lond), fcp (sa) consultant physician and professor of medicine, department of medicine, university of cape town correspondence to: j seggie (janet.seggie@uct.ac.za) fig. 1. map indicating all eight south african medical schools. fig. 2. the five-star doctor. 9 august 2010, vol. 2, no. 1 ajhpe article tem. they would, moreover, acquire an overview of the organisational structure of the national and provincial health systems, while being required to demonstrate an understanding of human rights and ethics as applied to population-orientated health care and research. the medical educational environment with a single exception, all of the medical schools in south africa were established in the last century … that of uct is the oldest and the first of its kind in subsaharan africa, having been established in 1912 (table i). the exception is the walter sisulu school of medicine, established in 1985. during the years of apartheid there were those medical schools that were ‘white’ and english-speaking (uct, wits, and ‘white’ and afrikaans-speaking (us, up, and ufs), and those that were ‘black’, but in which the medium of education was english (ukzn, u limpopo and wsu). owing to apartheid policies in place prior to the 1980s, individual black students were admitted to the mb chb programmes of ‘white’ universities on grounds that the particular medical school was closest to the student’s home and then only with special government dispensation. nevertheless, from the early 1980s onwards, this dispensation did permit the traditionally ‘white’ medical schools to begin to make concerted efforts to recruit black students. what had to be acknowledged, however, were the deprived educational backgrounds – the legacy of apartheid-driven educational policies at school level – from which such black students were recruited. as a consequence, the universities that chose to admit such disadvantaged learners (who were seen to be academically at risk of not succeeding with their training) had to put special academic development strategies in place to facilitate these students’ success. even into the late 1990s, with the exception of the youngest medical school at wsu, the mb chb programmes of all universities were of the traditional kind, reflecting a scottish pedagogy typical of the medical schools founded in british commonwealth countries in the early years of the 20th century. given the dates of establishment of the south african schools, their curricula had developed to reflect the flexnerian model – that inadvertent distortion of flexner’s hopes for medical education (see below) which were contained in his catalytic 1910 report and which sparked medical educational change in the early decades of the 20th century, particularly in the english-speaking world. at this juncture, it is worth reminding ourselves that abraham flex ner (fig. 3), who deserves to be recognised as the world’s first ‘medical educationist’, recommended that all medical school entrants receive a solid training in biology, chemistry and physics, followed by an education in anatomy (including histology and embryology), physiology (including what came to be termed biochemistry), pharmacology, pathology and microbiology, with active use of the laboratory before undertaking clinical training. flexner had believed – mistakenly, as it turned out – that departments of the basic sciences would be led by ‘medical men’. flex ner was not to know that the burgeoning of medical scientific research following the two world wars would leave basic science departments short of ‘medical’ men and necessitating the increasing recruitment of pure scientists. flexner’s insistence1 on the appointment to medical schools of fulltime clinicians as members of faculty, and moreover that medical schools should control hospital beds, was aimed at ensuring the presence of ‘true university teachers’ and at securing authentic clinical training for medical students. i have alluded to the distortion of flexner’s insights and hopes for 20th century medical education. apropos, it is worth noting how prescient flexner was with regard to the mb chb curriculum reforms undertaken around the world to prepare doctors for the 21st century. in his report flexner argued that medical practitioners should be scientists treating each patient encounter as an exercise in scientific enquiry – observation leading to hypothesis leading to action, but also that the physician serve as a ‘social instrument . . . stating that … the physician’s function is fast becoming social and preventive, rather than individual and curative’. he further advised that medical education should be ‘marked by small classes, personal attention, and hands-on teaching’! his views of lectures bordered on the cynical … lectures in his belief enabled colleges ‘to handle cheaply by wholesale a large body of students that would otherwise be unmanageable and thus give the lecturer time for research’.7 table i. list of south african medical schools and year established province university (u) established western cape uct – u of cape town 1912 us – u of stellenbosch 1956 kwazulu-natal ukzn – nelson mandela school of medicine 1947 eastern cape wsu – walter sisulu university (formerly university of the transkei unitra) 1985 free state ufs – u of the free state 1969 gauteng wits – u of the witwatersrand, johannesburg 1919 up – u of pretoria 1943 limpopo u limpopo – medical university of south africa 1976 fig. 3. abraham flexner. article 10 august 2010, vol. 2, no. 1 ajhpe article regrettably, from our current vantage point, the curriculum model that evolved and remained virtually unchanged for nearly a century and that characterised medical education in south africa, as well as throughout most of the western world, was a sorry distortion of flexner’s vision in that: • there developed a clear separation of the basic sciences from the clinical clerkships • there developed a ‘building block’ system of individual courses (fig. 4), the content of which was determined by the scientists who, as stated, were increasingly not ‘medical’ men. this led to the establishment of courses with little reference to adjacent courses and certainly scant reference to what might be necessary for clinical practice. to be fair, it was believed that students must be given a sound foundation in the basic sciences, but there was unfortunately no general consensus about what should be included in this foundation! before too long students were beginning to be overwhelmed with the details and facts required of their basic science courses and were being forced to depend for success upon memory. as tosteson8, dean of harvard, observed: ‘as medical science advanced, adding new knowledge, and new disciplines developed the curriculum was simply added to, to the point of crisis for students whose only way of coping was to become superficial rote learners’. to paraphrase harden,9 ‘ … a curriculum which exposes students first to animals (in biology and physiology), then to dead humans (in anatomy) and parts of humans (in pathology) and only later to humans’ had come to incorporate all the ills to which he drew attention (fig. 5) and was ‘an unsatisfactory preparation for a career in medicine’ . courses tended to be knowledge based and teacher centred and offered in full-class lecture format in both the basic and clinical sciences. clinical training was wholly discipline based with minimal integration. moreover, clinical clerkships were undertaken typically in tertiary referral hospitals with students receiving minimal exposure to patients at primary or secondary levels of care or to patients in ambulatory settings. and • there was no accommodation of the social sciences or of public health or of anything akin to the bio-psychosocial model of patient care or learning about population health, health policy and the organisation of health services. rather, the bio-scientific model of illness prevailed. south african students might have made the claim, as did beeson in 2000 reflecting on his training at mcgill university, that ‘certainly no teacher, at any time, reminded us [he and his fellow students] that patients are people, with differing life situations and backgrounds’10 • as stephen11 observed ‘one error … is common to all countries: no medical school appears to understand, or considers itself res ponsible, for meeting the needs of the health service it is supplying with doctors’. • increasingly, research productivity became the measure by which faculty accomplishment was judged. • teaching, caring for patients, and addressing broader public health issues were viewed as less important activities and teaching became subordinated to research. regarding the last two points, beeson commented that the medical schools of the 1950s and 60s had become submerged in large academic medical centres which he labelled as biomedical factories, incorporating teaching hospitals staffed by clinical faculty, nearly all of whom were specialists and super-specialists who tended to restrict their interests to narrow segments of medicine which related to their research fields. desiderata of curriculum reform with the above as background, three leading educational themes informed the processes of curriculum change: • the introduction of student-centred learning in small groups utilising problem-based strategies • a shift in emphasis from the bio-scientific model of illness to the bio-psychosocial model • an increased exposure to community-based learning opportunities, also encompassing rural settings. it is notable that wsu, perhaps because of its youth, adopted problem-based learning and community-based clinical training soon after its founding in 1985, thanks to the courage and foresight of the founding dean of the medical school, professor marina xaba-mokoena. in addition, it was determined by all medical schools that the new curriculum would, in generic fashion, • be outcomes orientated. fig. 4. a building block system of individual courses. fig. 5. the ills of the ‘traditional’ medical curriculum (drawn from harden9) 11 august 2010, vol. 2, no. 1 ajhpe article a description of what is to be expected of the south african brand of doctor at the end of undergraduate medical education and training was developed as the profile of the graduate or similar. these qualities and skills that define ‘fitness for purpose’ are still being worked on by sub-committees of the hpcsa and committee of south african medical deans. • continue to employ academic support strategies, where necessary, to facilitate success. students who struggle receive additional tuition, provided they continue to meet certain minimum performance criteria, while academically strong students receive additional opportunities to pursue new interests and develop new skills. • offer multidisciplinary and multiprofessional learning opportunities, whenever educationally feasible and appropriate, exploiting the presence in most schools of students pursuing under graduate degrees in physiotherapy, in occupational therapy and in speech therapy and audiology. • employ an integrated, systems-based approach to the study of the sciences basic to medicine, incorporating early clinical contact in the form of clinical scenarios and patients as the focus of learning. thus, case-based learning in a structured problem-based format was introduced with the aim of blurring the pre-clinical/clinical divide which characterised the former ‘traditional’ curriculum. • require students to acquire core knowledge and core skills while also enjoying the opportunity of selecting additional study opportunities through the medium of special study modules or electives or selectives. the integrated systems-based approach and identification of a core of learning, deemed essential to medical practice, benefit the learner by reducing the factual overload that had characterised the former traditional curricula. • make use of computer-based technologies (for learning and assessment) where appropriate, while ensuring continuation of the close tutor/student interaction that has been the great strength of south african medical faculties. • deliver teaching of clinical skills, clinical reasoning and diagnostic and management skills to ensure development of clinical competence. south african institutions have always justly prided themselves on the strong clinical skills acquired by their graduates, culminating in strong diagnostic and patient-management abilities. this has continued and, if anything, been reinforced through the teaching of clinical skills in the early semesters of medical programmes and the development of clinical skills centres. • ensure the acquisition of generic competencies such as study skills, it skills, communication and second language (typically an african language such as xhosa or zulu and afrikaans) skills, interpersonal skills, problem-solving ability and decision-making ability. • maintain a strong commitment to high ethical standards, professional values and human rights to impart the moral and ethical responsibilities carried by those entering the health professions and develop an ethics curriculum which ‘spirals’ through the course. change change did not prove easy to effect … not least because there appeared to be no overt problems with the existing traditional programmes and no apparent shortage of applicants for medical training. and, as has been shown, there existed several compelling barriers to change12 which included: • faculty members’ inertia • lack of leadership • lack of oversight of the educational programme as a whole • limited resources and lack of a defined budget for medical education • the perception that there was no evidence that implementing change would result in the necessary improvements • predominance of the status quo (faculty members who were once students in the traditional system had been conditioned to value that system and to support it) • perceived loss of control on the part of senior staff members • pressure of service delivery on the part of particularly clinical faculty members • perceived lack of rewards for teaching and sense of the importance of research for promotion (and tenure) on the part of faculty (to which may be linked) • lack of staff development. arguably, the two most potent of these barriers, highlighted above, were: • that faculty members who were once students in the traditional system had been conditioned to value that system and to support it. these members could, and did, assert that they had enjoyed professional success, citing also colleagues who had risen into the highest academic positions. • the perceived lack of rewards for teaching and sense of the importance of research for promotion (and tenure) on the part of faculty. this perception – that there is scant academic recognition for participating in policy development and implementation of teaching – remains current, as an international survey of medical educators carried out in 2007 revealed.13 ultimately the ‘big-stick’, in the guise of the threat of loss of accreditation of medical training programmes on the part of the hpcsa, forced curriculum renewal. fortunately, there were several ‘pioneers’ of curriculum reform around the world from whom all south african medical schools could learn – among which were the new medical schools at the universities of mcmaster, limburg in maastricht (the netherlands) and newcastle (australia), those that had adopted problem-based learning such as liverpool, manchester and sydney, those that had community-based curricula such as ben gurion university at ber sheba (israel), university of new mexico and wsu here in south africa, and those that had led the way in educational reform such as harvard where the ‘new pathway’ of problem-based learning was adopted in 1985.8 prompted to change, there was at last an acknowledgement on the part of those concerned with medical education, and who found them article 12 august 2010, vol. 2, no. 1 ajhpe article selves leading the processes of curriculum transformation at their particular medical school, that: • adults do indeed learn differently: the work of cognitive psychologists has shown that adult learners see themselves as selfdirecting and responsible and possess an accumulation of experience as a resource for their own learning … medical students learn best if provided with a clinical context for their learning.14,15 such contact with real patient problems, research has shown, leads to deep levels of processing, and thus memorising of information and the development of concepts in contradistinction to the superficial, even rote, learning resorted to in a largely lecture-based course. there is acceptance of the caution offered by norman,3 a cognitive psychologist/medical educationist based at mcmaster university, who insists that all learners achieve best if provided a context for their learning but warns that, because a degree of mastery of knowledge and skill is demanded of a doctor, medical students deserve a fair level of direction from their tutors throughout their learning and training. underpinning curriculum reform in south african schools, as in those around the world, has been the acknowledgment that … • full-scale mastery of knowledge is beyond anyone, and accepting that much of what is mastered soon becomes obsolete, that there has been the need to define a ‘core’ curriculum with options/special study modules/selectives/electives • the habits and skill of active inquiry, research, and learning must be inculcated for a lifetime • medical education requires the active participation of the student • small groups are more advantageous because they concentrate on the student rather than the faculty member and increase the experience of working together • problem solving should become an essential part of the learning process • basic and clinical sciences must be integrated in order to train students to act scientifically when they practise medicine • medical education should be research based. these important insights have led to the introduction of problemor task-based learning with early clinical contact on the part of even the most junior medical students. and, there are, as federman16 points out, many ‘little heralded benefits’ to problem-based learning, which include person-to-person contact, ‘implied intelligence’ on the part of the student, a focus on patients, opportunity to address moral/ethical issues and the ability of the student to learn to develop hypotheses (a key part of the clinical diagnostic process). mazwai17 (fig. 6), recently-retired dean of wsu, made the signal observation in the south african context that pbl will always take the character of the environment of the people and as an educational strategy will greatly enhance local graduates’ appreciation of the health issues and needs of the populace whom they would serve. no south african medical school has adopted a doctrinaire approach to pbl … rather a ‘mixed economy’ of pbl and lectures has tended to be put in place. students tend to more avidly attend lectures in the course of their pbl, viewing them as a key resource, provided that lectures are crafted in such a way that they offer clarification, correlate with the tutorial components of the patient problem being addressed and provide a general approach. lectures also offer an opportunity for students to meet those members of faculty who, through their academic endeavours, have achieved national and often international profiles; students may then take pride in this and deserve to receive this affirmation of their choice of medical school. given the depredations of the apartheid years of under-resourcing of black education in particular, south african students are variably underprepared for their medical studies; this is particularly true in relation to the sciences and mathematics. unfortunately, this continues to be the case as a result of deteriorating standards of teaching in our secondary schools. south african medical schools have therefore had to respond with a number of interventions which include: • use of alternative tests of a student’s intellectual ability and potential to succeed; these are considered alongside a school leaver’s ‘matriculation’ scores for purposes of deciding selection for admission into the medical programme • academic support strategies of various kinds to assist the student who is identified as being academically at risk of failing his/her course(s) • the reservation of (some) places for graduates, a proven success record at tertiary education level in the view of some medical schools being deemed preferable as a preparation for medical studies. wits reserves up to 25% of its medical places for those students who have obtained a prior (preferably science) degree. if one surveys the educational changes that have been implemented in south african medical schools according to the mandate contained in education and training of doctors in south africa, it is clear that a great deal has been achieved: • the introduction of problem-based learning strategies aimed at reducing the teacher-centredness of learning and demanding a greater student-centredness, while retaining a certain orthodoxy as befits the relative under-preparedness for such learning of our mainly school-leaving medical students. fig. 6. l mazwai. 13 august 2010, vol. 2, no. 1 ajhpe article • apropos, it is reassuring that early research18 carried out at the uct suggests that pbl may be advantaging students who have weaker prior educational preparation; findings, albeit preliminary, indicate higher retention rates and improved clinical clerkship performance in students who have educationally disadvantaged backgrounds. further research is necessary but work from wsu19 does suggest that pbl may benefit disadvantaged students by producing more versatile learners. • the evolution of core basic science and clinical syllabi to achieve unloading of the factual content of the curriculum. • the racial transformation of graduating medical classes at the previously so-called ‘white’ institutions (the traditionally ‘black’ institutions, in their turn, are striving to attract white and indian students to their faculties). • the establishment of academic support strategies to ensure that the traditionally high throughput rates, with regard to graduateness, have been maintained. indeed, south african medical schools continue to boast graduation rates in excess of 95%. • greater integration of the basic and clinical sciences achieved through early clinical contact; students, from the earliest phase of their programme, are presented with real patient problems as the context for learning (this being referred to as vertical integration). • multidisciplinary learning (an example of which is the blending of courses in obstetrics and neonatology) (this being referred to as horizontal integration). • the establishment of computer laboratories to enable student access to a university intranet and the internet, e learning, computerbased assessment, etc. • the establishment of clinical skills laboratories and centres to facilitate students’ learning of skills of procedures (e.g. siting of an intravenous line or achieving endotracheal airway access) and of clinical examination. • multiprofessional learning and practice whenever it has proved educationally sound and practicable in order to exercise medical, physiotherapy, occupational therapy and speech therapy students together in addressing patients’ problems, thus ensuring that students understand the scopes of practice of the different health professions. • greater emphasis on clinical experience gained in communitybased and rural settings, and in ambulatory practice, in contrast to the traditional tertiary teaching hospital setting. this is in line with the ‘new’ health service delivery in south africa. • golden thread status afforded to teaching of issues of professionalism, ethics, human rights and language and culture; such teaching is introduced in the earliest phases of the programme and continues to be addressed, and assessed, throughout the programme. • modernisation of assessment strategies in line with best practice and research, and the alignment of assessment with curriculum content. • the establishment within faculties, and their staffing with specialists in education, of medical education units whose roles are several but are key to the modernisation of health sciences education, viz.: • providing leadership with regard to the choice teaching and assessment strategies, maintaining oversight of the entire programme(s) • undertaking staff development (through provision of ‘scientist-aseducator’ and ‘doctor-as-educator’ short courses) • conducting research which leads in its turn to continuous refinement and improvement of teaching, and finally • preventing reversion for ‘the academic landscape is littered with the skeletal remains of brave curricular innovations’ … and … ‘the half-life of medical educational reform is short, the tendency to revert to type is seemingly irresistible, and human enthusiasm for sustaining change is short-lived’20 • our graduates demonstrate … ‘acquisition of a specific body of knowledge and the ability to move about within it with ease and the confidence to use it in a more patient-driven practice thus to serve as a doctor … but also to have practice in thinking by virtue of his/her university education.’21 despite these obvious successes, it cannot be claimed that curriculum reform is complete. many challenges remain: • teaching ‘generation me’, who, among other characteristics,22 has grown up digital, believing that if the subject matter is not on the internet, it is not real … the textbook may never be read or only be skimmed. this will have to be managed, and as academics we shall have to guide students towards quality resources on the internet. • getting the basic sciences right. weatherall,23 reflecting on basic sciences, states that ‘one of the greatest challenges is to protect unusually gifted young people from the numbing uniformity that some of the reforms in medical education are demanding … given the extraordinary complexities of sick people … we must … influence at least some institutions to train and nurture such gifted young people to ensure that the extraordinary potentials of the current biological sciences become available for the better treatment of our patients’. • getting assessment right and achieving testing of clinical reasoning,24 particularly at the end of the programme. this acknowledges that the south african graduate is ‘special’ and must demonstrate an unusual degree of clinical maturity as s(he) will be required to work in a health system ill-equipped to cope with one of the most severe hiv and tb epidemics in the world together with huge burdens of non-communicable diseases, high rates of maternal and child mortality and soaring rates of violence and injury.25 • teaching the teachers/assessors and ensuring ongoing staff development. • achieving greater opportunities for community-based learning and authentic rural experience. • the possible request that the training of greater numbers of doctors be undertaken in view of the inadequate human resource capacity, especially given the extremely low number of doctors in the public sector26 of the health system. • the feminisation of the profession where graduating classes are now over 60% female and the responses required with regard to systems of postgraduate training to facilitate specialisation and article 14 august 2010, vol. 2, no. 1 ajhpe sub-specialisation of women who choose to marry and raise families. • defining and measuring professionalism. professionalism has been defined in terms of the practice of medicine as a vocation in which knowledge, clinical skills and judgement are put in the service of protecting and restoring human well-being and wherein the attributes of integrity, compassion, altruism, continuous improvement, (striving for) excellence, accountability, and working in partnership with a wider health care team are sought in the medical practitioner.27 it is revealing in this context to read the new tomorrow's doctors,28 recently released to uk medical schools by the general medical council. as expected, standards for delivery of teaching, learning and assessment are highlighted under a series of headings, as are also the desirable outcomes for graduates in terms of the doctor as a scholar and a scientist and as a practitioner. what is particularly notable is the emphasis placed on the professionalism of the graduate and his/her fitness to practise. this – the issue of ensuring professionalism, and all that it stands for, in our medical graduates – i would argue, constitutes the next frontier in medical education. this paper is based on the arthur landau memorial lecture delivered by me at several of our south african medical schools during 2009. the chosen topic arises out of the leadership role i have recently played in medical curriculum reform at my own institution. references 1. beck ah. the flexner report and the standardization of american medical education. jama 2004; 291: 2139-2140. 2. spencer ja, jordan rk. learner centred approaches in medical education. bmj 1999; 318: 1280-1283. 3. norman gr. the adult learner: a mythical species. acad med 1999; 74: 886-889. 4. hpcsa. education and training of doctors in south africa. undergraduate medical education and training. guidelines by the medical and dental professional board. pretoria: health professions council of south africa, 1999. 5. gmc. tomorrow's doctors: recommendations on undergraduate medical education. london: general medical council, 1993. 6. white paper on transformation of the health system. government gazette 1997; 382(17910). 7. wear d. iconoclast: abraham flexner and a life in learning. n engl j med 2002; 347: 2008-2009. 8. tosteson d. new pathways in general medical education. n engl j med 1990; 322: 234-239. 9. harden rmcg. educational strategies in curriculum development: the spices model. med educ 1988; 18: 284-297. 10. lee rv. changing times: reflections on a professional lifetime. an interview with paul beeson. ann intern med 2000; 132: 71-79. 11. stephen wj. primary medical care and the future of the medical profession. world health forum 1981; 2(3): 315-331. 12. bloom sw. structure and ideology in medical education: and analysis of resistance to change. journal of health and social behaviour 1988; 29: 294-306. 13. huwendick s, mennin s, nikendei c. medical education after the flexner report. n engl j med 2007; 356: 90-91. 14. norman gr, schmidt hg. the psychological basis of problem-based learning: a review of the evidence. acad med 1992; 67: 557-565. 15. spencer ja, jordan rk. learner centred approaches in medical education. bmj 1999; 318: 1280-1283. 16. federman dd. little heralded advantages of problem-based learning. acad med 1999; 74: 93-94. 17. mazwai l. an interview with lizo mazwai. educ for hlth 2005: 8995 (http:/www.educationforhealth.net/efharticlearchive/1357-6283_ v18n1s12_713726010.pdf – accessed 20 january 2010). 18. burch vc, sikakana c, seggie jl, et al. performance of academically at-risk medical students in a problem-based learning programme: a preliminary report. adv hlth sci educ 2007; 12: 345-358. 19. iputo je. impact of problem-based curriculum on the learning styles and strategies of medical students at the university of transkei. s afr med j 1999; 89: 50-55. 20. pellagrino ed. medical education: time for change – yes – but… j am board fam pract 1990; 3(suppl): 55-63. 21. horton r. why graduate medical schools make sense. lancet 1998; 351: 826-828. 22. twenge jm. generational changes and their impact in the classroom: teaching generation me. med educ 2009; 43: 398-405. 23. weatherall dj. ruminations of a geriatric emeritus regius professor of medicine. clin med 2009; 9: 104-107. 24. van der vleuten cpm, newble dj. how can we test clinical reasoning? lancet 1995; 345:1032-1034. 25. kleinert s, horton r. south africa’s health: departing for a better future? lancet 2009; 374: 759-760. 26. coovadia h, jewkes r, barron p, et al. the health and health system of south africa: historical roots of current public health challenges. lancet 2009; 374: 817-834. 27. doctors in society. medical professionalism in a changing world. report of a working party of the royal college of physicians. clin med 2005; suppl 1. 28. gmc. tomorrow's doctors 2009 (http://www.gmc.uk.org/education/static/documents/content/tomorrows_doctors_2009.asp – accessed 23 july 2010). research may 2016, vol. 8, no. 1 ajhpe 41 in the 21st century, health science faculties need to be more than institutions of education where health science students develop the knowledge, skills and competencies for becoming health professionals. it is essential that students are equipped to meet global health challenges and that their skills are relevant to the needs of local communities.[1,2] this means working with communities to improve their health and access to health services, especially communities that struggle for health against multiple social and economic barriers.[3] in south africa (sa), poor rural communities have least access to healthcare.[4] doctors are considered the ‘attorneys of the poor’, an advocacy role that requires a strong sense of social responsibility in medical education and practice. according to dharamsi et al.,[5] developing and nurturing a moral sense of responsibility depends largely on the curriculum and the pedagogical approaches adopted by an institution. in striving to entrench these values of social accountability, medical schools should engage with national and regional stakeholders, such as medical educators, health managers, doctors, communities and policy makers.[6] this engagement should inform the educational model, research agenda and health services offered by medical schools in order to align medical education with local health needs. woollard and boelen[6] assert that ‘the medical school must provide ample and appropriate learning opportunities for medical students to grasp the complexity of socioeconomic determinants in health. it must explicitly adopt a preferential model of practice that integrates the biomedical aspects of diseases into a holistic approach to health and wellbeing, and it must offer role models to reinforce this approach.’ developing future medical doctors to be advocates for greater health equity and quality patient care may require health science faculties to re-orientate their educational activities and contexts of learning. traditional curricula have not kept pace with rising inequities in health and emerging health risks and continue to graduate students who lack the competencies to address these challenges.[7] it is therefore essential that medical students learn and practise in settings that provide authentic community exposure, to develop their capacity for social change.[8,9] we define this capacity in terms of transformative education of students as agents of change towards better patient care and greater health equity. student electives can contribute to the development of social conscience and the knowledge, skills and attitudes needed for addressing the health needs of diverse communities.[10] elective students may have opportunities for deeper engagement with community and social structures that allow application of their altruistic ideals.[11] we therefore hypothesised that the more choice that students are given over their learning, the greater is their development of a sense of agency. the faculty of health sciences, university of cape town (uct) aspires to promote quality patient care and social justice within the lead theme of the equitydriven primary healthcare (phc) approach.[12] the 5th-year medical elective, introduced in its present form into the curriculum in 2006, is an opportunity for students to work for 4 weeks in the health system to develop their clinical skills and better understand the principles of the phc approach. the vast majority of students choose clinical electives in general medical practices, community health centres or hospitals in the sa public sector. a minority work in the for-profit and not-for-profit private sector and a handful undertake research electives. background. student electives during the 5th year of the university of cape town (uct) medical curriculum provide a 4-week work experience in the health system. the reflective reports of past students indicate that the electives may significantly shape their developing identities as health professionals and agents of change. objective. to better understand how 5th-year medical elective students perceive themselves as agents of change to strengthen the elective programme in the faculty of health sciences, uct. the hypothesis was that the more choice that students are given over their learning, the greater is their sense of agency. methods. thirteen 5th-year student volunteers participated in four focus group discussions soon after completing their electives in district, regional or tertiary health facilities in the south african health system. thematic analysis of the transcripts was performed independently by two of the authors. results. key themes were the importance of providing holistic patient-centred care, becoming a competent health professional, working within the health team and advocating for a better health system. the elective experience helped students to be more confident in their abilities and to better understand how to effect change at a clinical and health system level. conclusion. this study supported the hypothesis that the more choice students have over their learning, the greater is their sense of agency. the electives are appreciated as opportunities to develop clinical skills and competencies and to better understand the role of future doctors within the health team and health system. the value of the uct elective programme could be enhanced by greater promotion, funding for rural electives, and post-elective peer-topeer feedback sessions. this study will inform planning for an extended 2016 medical elective programme in the faculty. afr j health professions educ 2016;8(1):41-44. doi:10.7196/ajhpe.2016.v8i1.540 on being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences, university of cape town, south africa j irlam,1 bsc, bsc (med) hons, mphil (epidemiology); l pienaar,2 bsc (physio), msc (physio); s reid,1 bsc (med), mb chb, mfammed, phd 1 primary health care directorate, faculty of health sciences, university of cape town, south africa 2 health education development unit, faculty of health sciences, university of cape town, south africa corresponding author: j irlam (james.irlam@uct.ac.za) research 42 may 2016, vol. 8, no. 1 ajhpe the electives are assessed based on a written reflective report by the student, accompanied by a brief evaluation from the elective supervisor on site. students’ clinical elective reports over the past 9 years indicate that the electives raise their awareness of the social determinants of health and may significantly shape their developing identities as health professionals with agency. the purpose of this study is to better understand how 5th-year medical elective students perceive themselves as agents of change, to strengthen the elective programme in the faculty of health sciences, uct. methods fifth-year medical students in four elective rotations of the class of 2014 (76 students of a class total of 184) were invited to participate in the study within 2 months of completing their electives. only those who had completed their electives in district (primary-level care), regional or tertiary health facilities in the sa health system were eligible for inclusion. all those who accepted the invitation were included in the study. one of the authors (lp) facilitated four focus group discussions (fgds) in a private venue in the faculty of health sciences, uct. five questions (table 1) were discussed, which were drafted by ji, based on review of past elective reports. the questions were refined in consultation with colleagues, three of whom teach on the faculty’s medical programme and two on the allied health sciences programme. the questions were pretested by lp on three students, who were also participants in the study, and were well understood. the fgds were recorded by lp and transcribed by a professional transcription agency. ji and lp analysed the transcripts independently without use of a software package and then discussed their analyses to reach consensus on the key themes. ethical approval for the study was obtained from the human research ethics committee (hrec #133/2014) of the faculty. the uct department of student affairs gave permission for student participation and participants signed a standard consent form. results thirteen medical elective students (10 females and 3 males) participated in one of four fgds with their elective peers, averaging three students per fgd. the following key themes arising from the discussions are described: the importance of providing holistic patient-centred care, becoming a competent health professional, working within the health team and advocating for a better health system. providing holistic patient-centred care the phc approach emphasises the principle of holistic patient-centred care, which includes biopsychosocial assessments of patients, good commu nication, effective health promotion, and involvement of families and communities in care. participants reflected on the multiple aspects of this principle and how it strengthens the agency of health professionals in the lives of their patients. the relationships of health professionals with their patients are strengthened by demonstrating concern for the whole person: ‘the [general practitioner] gp was able to actually diagnose and treat the person fully and at the same time he had such a good relationship with his patients because he is their family doctor and he treated their mothers, their grandfathers and their great grandmother … and that connection that you have with your patient is so much better.’ (fgd, 21 may) speaking the language of one’s patient enhances the patient encounter and promotes their health more effectively: ‘i just like the fact that we get taught … different languages during our studies. i realised how important it is … i don’t think i maximise my exposure to the language to the best of my ability, and i think that one thing i would change personally is to be able to speak the language of the people that i’m going to be treating.’ (fgd, 2 june) being a good listener demonstrates humility and empathy towards your patients: ‘… just being kind and listening to people and … getting yourself out of this role and off this pedestal that you’re sitting on and just being human and approaching people on that level.’ (fgd, 31 july) making time to counsel and educate patients about their health is important for early prevention of disease: ‘it made me feel like the simplest things could actually make a difference because i think the way lifestyle conditions have taken over, that our focus shouldn’t be more on treating complications; you should go a few steps back and prevent them from happening in the first place.’ (fgd, 31 july) respecting your patient and the importance of each consultation makes a real difference in their lives: ‘i think it’s about taking responsibility for what you know, and taking responsibility for what you’re learning and making a difference in patient’s lives … that patient made an effort to see you, you should make an equal effort to treat them well and not just see them as like, “oh number three, number four, number five”. realise the importance of each patient encounter.’ (fgd, 31 july) becoming a competent health professional the uct electives are seen as a valuable opportunity to develop clinical skills and competencies and to address one’s deficiencies. having extended responsibilities for patient care develops greater self-confidence and deeper insight into what it means to be an agent of change, but it can also erode one’s empathy: ‘as agents of change, you always need to come back to the reason why you made the decision in the first place. and so when i came into med-school, i think i was possibly a lot more understanding and empathic than i am now.’ (fgd, 2 june) table 1. focus group discussion questions 1. please share what you learnt from your elective about being an agent of change as a student doctor. provide some examples. 2. please tell me how you think you can be an agent of change as a future doctor in the sa healthcare setting. 3. how do you think the elective programme could better prepare you to be an agent of change in the sa healthcare setting? 4. how do you think the faculty could better prepare you to be an agent of change in the sa healthcare setting? 5. what does being an ‘agent of change’ mean to you? research may 2016, vol. 8, no. 1 ajhpe 43 an agent of change is someone who is able to identify problems and find feasible solutions: ‘so it’s someone who is able to identify problems, but also to identify realistic solutions and be able to come up with ways in which to implement those solutions; and more than that it’s someone that is able to network.’ (fgd, 4 june) initiating change requires sharing your ideas and convincing others to participate in what can be a long process: ‘yes, so that excitement again made me realise that you can’t sit back and watch things happen around you. if you identify a problem, take it upon yourself to either speak to other people who can do something about it, or start the process yourself. initiate change because that’s why you studied medicine, to help people and you have the ability to start the process and get everybody involved.’ (fgd, 31 july) ‘… having perseverance and dedication to whatever goals you have, as change usually takes a long time; … to make the changes you need to convince the rest of the team; … to almost prove it, sell your idea, why this needs to happen.’ (fgd, 4 june) having greater clinical responsibility is very motivating for most students and develops a deeper appreciation of what they are able to do in the ‘real world’ of medicine: ‘because i have been in a more practical setting where i was kind of given responsibilities, it makes me appreciate more what i learn now.’ (fgd, 31 july) ‘i feel like studying for 6 years, we kind of lose the reason we signed up for medicine, like it’s just, it’s not really what we thought it was, and then getting this four weeks was a little taste of what life will be like, and that just gives you that light push until the end.’ (fgd, 31 july) the elective is a time for reflection on the medical profession and one’s personal learning experiences and objectives: ‘i’m starting to think more consciously about my profession, like medicine is so broad, there’s so much to know, there’s so much to learn.’ (fgd, 31 july) ‘i only have a year and a half left of purely academic undergraduate time, and i need to make sure that i use it wisely. i want to be able to make sure that i know what i am doing, and i can manage, especially in emergency situations, until someone more senior can get there.’ (fgd, 4 june) ‘it’s just finding that niche and i think the elective helped us realise a little bit more what path we will be going on, and knowing where we will be going.’ (fgd, 31 july) working in the health team after years of being junior members of the health teams in large training hospitals, the elective experience of being respected as equals within the health team is very empowering. respect for each other’s roles builds the confidence of the team, as observed by one student in a rural district hospital: ‘i also think that the sisters there had confidence in their position, they wouldn’t feel like the doctors are looking down on them, or feeling like they are superior; and with everybody understanding that everyone has a different role, you are all contributing very much to the team.’ (fgd, 4 june) a well-functioning health team is essential to improving healthcare and motivating health workers: ‘it’s helpful for the patient if i work well with the team, with the nurses … if you have a good relationship, then our patients tend to get better care.’ (fgd, 4 june) ‘and the way that they used the multidisciplinary team in psych it’s so interesting ... everyone was just discussing how we can make his life better, you know. so if you work like that, eventually everyone will be motivated.’ (fgd, 2 june) rural electives expose students to another important principle of the phc approach, which is collaboration between the hospital-based health team and its community partners. the partnership with a non-profit organisation called mentor mothers to improve neonatal care in a rural district was cited as a good example: ‘the mentor mother will come to the mother’s home, in the middle of the rural community and speak to her, and follow her up, and refer her back to the hospital if there are any problems that the doctors can sort out, or refer them to [occupational therapy] ot if that is needed. and so it’s doing things like that that really require lateral thinking, that really can make a big difference, and it’s not an extra burden on the hospital at all; in fact it’s really helpful because it means you’re not admitting 6-week-old babies that are already malnourished.’ (fgd, 4 june) advocating for a better health system several students felt that their elective experiences helped them to realise the important social determinants of health, to see what may be needed to improve healthcare in the local setting, and to understand how they can advocate for a better health system. careful observation to identify deficiencies in the healthcare setting is seen as an essential first step: ‘… seeing things that hadn’t yet been changed, or seeing difficulties to implement change, i think part of being a student then was bringing up like why … just asking why this is not yet done, and having discussions with the doctors there, which was then finding out difficulties that they’re facing.’ (fgd, 4 june) ‘… it’s so easy for us to judge what’s right or wrong, but the truth is we’re a new set of eyes and we should be the driving force.’ (fgd, 2 june) although the shortage of resources is a common complaint, minimising wastage should be everyone’s responsibility: ‘so i think if you just stop wasting some of our resources and making sure that like you know whatever is done with this patient, because we’re so resource limited, it’s actually needed for that patient’. (fgd, 2 june) one student saw the maldistribution of specialists and the poor living conditions of doctors in many rural areas as important challenges for the sa health system: ‘we need to evaluate how we distribute our specialists, but more than that, we need to look at the living conditions of doctors in rural areas, research 44 may 2016, vol. 8, no. 1 ajhpe because it’s natural for a doctor not to want to go and live somewhere where he can’t send his or her kids to school or where there isn’t a proper house, or there isn’t running water, and it is unfair to send doctors to places like that, if they don’t want to go. so we really need to look at why certain provinces are better than others, and we need to look at fixing that.’ (fgd, 4 june) the challenges of the health system have implications for the type of doctors that should be trained and for where they are trained: ‘the doctors that we need … are actually okay to go and work in a rural area where you don’t have proper referral systems, and the [antiretrovirals] arvs are out of stock occasionally, and where you really have to make a plan.’ (fgd, 4 june) working to change the system can seem overwhelming; some students would rather focus on doing what they can at the individual level: ‘i think it’s absolutely overwhelming, and if you’re that person where you are motivated to make change on a big level, then you have to step out of the hospital to do it. but i think for me that just loves patient contact, i’m going to do what i can for this patient, just this one particular patient. so mine is a personal agent of change.' (fgd, 2 june) working together makes one a more effective agent of change at a health systems level: ‘one person can’t change the whole system nationally; we need to all work together and … fill in the gaps that you can.’ (fgd, 4 june) discussion in this study, we sought to understand medical elective students’ perceptions of themselves as agents of change during their 5th-year electives. we found that the electives are generally perceived as good opportunities to practise holistic patient-centred care, to develop clinical skills and competencies, to work within the health team, to gain first-hand awareness of the determinants of health, and to better understand the role of future doctors within the health system. our findings support the hypothesis that the more choice students have over their learning within the curriculum, the more opportunity they have to develop agency or self-efficacy.[13] this may contribute to a stronger internal locus of control that may result in greater agency and impact as graduate doctors.[14] these findings are consistent with the findings of dharamsi et al.[15] that students became more aware and engaged with the needs of vulnerable communities during international service-learning programmes. smith and weaver[16] found that students became more aware of primary care and public health issues while undertaking their electives. our study participants recommended that the faculty promote the electives more (an extended pre-elective session on the range of elective opportunities was suggested), restore the funding for rural electives (discontinued due to budget constraints), and introduce post-elective peer-to-peer feedback sessions. post-elective workshops with faculty staff and student peers have enhanced the educational value of student electives at newcastle university, uk, and would be feasible within the faculty.[17] offering training opportunities beyond relatively well-resourced teaching hospitals and health centres was seen as essential for ensuring that uct medical graduates are equipped to practise in an under-resourced health system such as that in sa. a limitation of this study is the small group of volunteer participants, whose perceptions about the electives may be more positive than those of their non-participating peers. nevertheless, our findings on the value of the electives are consistent with the vast majority of elective reports assessed by ji since the inception of the elective programme in 2006. we conclude that the uct medical elective programme makes a valuable contribution to the development of agency among students. this study provides timely and relevant evidence for an extended 2016 medical elective programme at uct and indicates the value of health science electives in other faculties. declaration of funding. we received support from the uct internal research award. acknowledgements. we thank our colleagues, c s naidu, h talberg, m setshedi and s amosun, for their assistance in developing the protocol, the 5thyear uct students for their participation in the focus group discussions, ms elloise kennell for administrative support, and on time transcribers for the fgd transcriptions. references 1. mcmenamin r, mcgrath m, cantillon p, macfarlane a. training socially responsive health care graduates: is service learning an effective educational approach? med teach 2014;36(4):291-307. [http://dx.doi.org/10.3109/ 0142159x.2013.873118] 2. world health organization (who). who transformative scale up of health professional education. an effort to increase the numbers of health professionals and to strengthen their impact on population health. geneva: world health organization, 2011. http://whqlibdoc.who.int/hq/2011/who_hss_hrh_hep2011.01_eng.pdf (accessed 16 october 2014). 3. coria a, mckelvey tg, charlton p, woodworth m, lahey t. the design of a medical school social justice curriculum. acad med 2013;88(10):1442-1449. [http://dx.doi.org/10.1097/acm.0b013e3182a325be] 4. harris b, goudge j, ataguba je, et al. inequities in access to health care in south africa. j public health policy 2011;32(suppl 1):s102-s123. [http://dx.doi.org/10.1057/jphp.2011.35] 5. dharamsi s, ho a, spadafora sm, woollard r. the physician as health advocate: translating the quest for social responsibility into medical education and practice. acad med 2011;86(9):1108-1113. [http://dx.doi.org/10.1097/ acm.0b013e318226b43b] 6. woollard b, boelen c. seeking impact of medical schools on health: meeting the challenges of social accountability. med educ 2012;46(1):21-27. [http://dx.doi.org/10.1111/j.1365-2923.2011.04081.x] 7. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/ s0140-6736(10)61854-5] 8. papadimos tj, murray sj. foucault’s ‘fearless speech’ and the transformation and mentoring of medical students. philos ethics humanit med 2008;17(3):12. [http://dx.doi.org/10.1186/1747-5341-3-12] 9. elam cl, sauer mj, stratton td, skelton j, crocker d, musick dw. service learning in the medical curriculum: developing and evaluating an elective experience. teach learn med 2003;15(3):194-203. [http://dx.doi. org/10.1207/s15328015tlm1503_08] 10. murray rb, larkins s, russell h, ewen s, prideaux d. medical schools as agents of change: socially accountable medical education. med j aust 2012;196(10):653. [http://dx.doi.org/10.5694/mja11.11473] 11. meili r, fuller d, lydiate j. teaching social accountability by making the links: qualitative evaluation of student experiences in a service-learning project. med teach 2011;33(8):659-666. [http://dx.doi.org/10.3109/014215 9x.2010.530308] 12. uct faculty of health sciences. vision, mission, values and goals. http://www.health.uct.ac.za/about/mission/ (accessed 18 february 2014). 13. bandura a. self-efficacy: the exercise of control. new york: freeman, 1997:604. 14. rotter jb. generalized expectancies for internal versus external control of reinforcement. psychol monogr 1966;80(1):1-28. 15. dharamsi s, richards m, louie d, et al. enhancing medical students’ conceptions of the canmeds health advocate role through international service-learning and critical reflection: a phenomenological study. med teach 2010;32(12):977-982. [http://dx.doi.org/10.3109/01421590903394579] 16. smith jk, weaver db. capturing medical students’ idealism. ann fam med 2006;4(suppl 1):s32-s37;s58-s60. [http://dx.doi.org/10.1370/afm.543] 17. evans r, dotchin c, walker r. maximising the value from the elective experience: post-elective workshops. clin teach 2013;10(6):362-367. [http://dx.doi.org/10.1111/tct.12033] research 56 may 2016, vol. 8, no. 1 ajhpe drugs play a central role in ensuring the successful health of any population, and this holds equally true for south africa (sa), which is currently grappling with a high burden of disease. since the abolition of apartheid, the sa healthcare system has undergone drastic reform, with one of the main priorities being to ensure the availability and affordability of quality healthcare for all citizens.[1] in 2001, the sa government amended the medicines and related substances act 101 of 1965, obligating pharmacists to inform all patients of the benefits of generic medicine substitution.[2] the shift in legislation to increase the use of generic drugs was primarily instituted as a means of reducing healthcare expenditure for both patients and government. in the discussion over the use of generic medicines, prescriber and dispenser perceptions have often been neglected. several international studies have noted the influence of healthcare professionals on the consumption of generic medicines; however, very little knowledge on the sa perspective has been previously researched.[3,4] generic medicines are the therapeutic equivalents of proprietary, branded or innovator medicines.[5] they are of the same strength and dosage form, and possess the same safety and efficacy profiles, as the equivalent innovator medicines.[3] the primary difference is that generic medicines are much more cost effective than the innovator medicine. the sustainability of the generic medicine sector is vital, to ensure that its role in increasing accessibility and affordability of essential treatments will extend well into the future. multiple factors contribute to generic medicine use, among them providerlevel factors such as pharmacist and prescribing-doctor beliefs or practices. despite the several advantages offered by the use of generic medicines, the perceptions, attitudes and beliefs held by healthcare practitioners have been identified as a potential barrier to the use of generic medicines.[6] furthermore, once practice habits have been embedded, it may prove difficult to change the prescriber and dispensing practices of healthcare providers, which highlights the importance of correcting misconceptions before the commencement of professional practice. based on the nature of their future jobs, healthcare professionals will have an effect on their patients' medication choices. it is, therefore, essential to evaluate future practitioners’ knowledge and perceptions of generic medicines. the findings of this study will help to address any misunderstandings that these students may have about generic medicines at this crucial stage of their professional career, and aid universities in altering curricula to improve student understanding. method study sample a cross-sectional survey was conducted among the final-year audiology, dental therapy, pharmacy, physiotherapy, occupational therapy, optometry, speech-language and sport science students enrolled at the university of kwazulu-natal (ukzn), durban, sa. convenience sampling was adopted to approach potential respondents. ethical considerations gatekeeper permission and ethical approval for this study were obtained from ukzn faculty of health sciences ethics committee (ref. shsec 006/14). written consent was obtained from the respondents who participated in the study. any information disclosing respondent identity was excluded from the tool. data analysis descriptive statistics were completed using spss version 21 (ibm, usa). background. the use of generic medicines to reduce healthcare costs has become a mandated policy in south africa. an increase in the use of generics can be achieved through improved knowledge, attitudes and perceptions of generic medicine among healthcare professionals. objective. to explore knowledge, attitudes and perceptions among final-year health science students on generic medication. methods. a cross-sectional survey was carried out among the final-year audiology, dental therapy, pharmacy, physiotherapy, occupational therapy, optometry, speech-language and sport science students enrolled at the university of kwazulu-natal. a questionnaire was used as the study tool, developed using information adapted from literature reviews. data analysis was completed using statistical package for the social sciences (spss) version 21, and computed using descriptive statistics. results. total number of participants was 211, as follows: audiology (n=14), dental therapy (n=15), pharmacy (n=81), physiotherapy (n=41), occupational therapy (n=6), optometry (n=25), speech-language (n=6) and sport science (n=23). a total of 90.0% of students had heard of generic medicines, with 20.9% of them agreeing that generic medicines are less effective than brand-name medicines. concerning safety, 30.4% believed that brand-name medicines are required to meet higher safety standards than generic medicines. regarding the need for information on issues pertaining to safety and efficacy of medicines, 53.3% of participants felt that this need was not being met. conclusion. all groups had knowledge deficits about the safety, quality and efficacy of generic medicines. the dissemination of information about generic medicines may strengthen future knowledge, attitudes and perceptions. afr j health professions educ 2016;8(1):56-58. doi:10.7196/ajhpe.2016.v8i1.560 exploring knowledge, perceptions and attitudes about generic medicines among final-year health science students v bangalee, bpharm, mpharm; n bassa, bpharm; j padavattan, bpharm; a r soodyal, bpharm; f nhlambo, bpharm; k parhalad, bpharm; d cooppan, bpharm discipline of pharmaceutical sciences, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: v bangalee (bangalee@ukzn.ac.za) research may 2016, vol. 8, no. 1 ajhpe 57 study tool a questionnaire was developed to obtain the objectives of the study. the questionnaire was subdivided into four sections and was developed after reviewing the available published literature in the area. the first section consisted of four demographic questions about age, gender, discipline and work experience. a 5-item likert-type scale was used to record variations in perceptions, attitudes and knowledge, constituting the remaining three sections. the questionnaires were personally distributed and data were collected over a 3-week period. results table 1 illustrates the demographics and general knowledge about generic medications of the respondents in the study. a total of 211 students (52 males and 155 females) completed the survey, with the majority of students (65.0%) aged 21 22 years. of these, 14 (6.6%) were audiology students, 6 (2.8%) were speech-language, 15 (7.1%) were dental therapy, 6 (2.8%) were occupational therapy, 25 (11.8%) were optometry, 81 (38.4%) were pharmacy, 41 (19.4%) were physiotherapy and 23 (10.9%) were sport science students. of the respondents, 68.3% had previous work experience in a hospital or community pharmacy. majorities of 79.4% and 89.5% of students had heard of branded medicines and generic medicines, respectively. with regard to student knowledge on generic medicines (table 2), an overall majority of students knew that generic medicines are interchangeable (74.1%), must be in the same dosage form (58.0%) and are the therapeutic equivalents of brand-name medicines (66.3%). only 42.8% of students were aware that generic medicines are manufactured after patent expiry of originator medicines, with a smaller percentage (19.6%) agreeing that generic medicines produce more side-effects compared with brand-name medicines. for perceptions of quality, safety and efficacy of generic medicines (table 3), the majority of respondents did not associate generic medicines table 1. respondent demographics and general knowledge about generic medications demographics and knowledge frequency, n groups audiology speech-language dental therapy occupational therapy optometry pharmacy physiotherapy sport science 14 6 15 6 25 81 41 23 age (years) 18 20 21 22 23 25 >25 15 133 52 6 gender male female 52 155 work experience in hospital or community pharmacy/job experience yes no 123 88 have you ever heard of branded medicine? yes no 158 53 have you ever heard of generic medicine? yes no 179 32 table 2. knowledge of generic medicines recorded according to the likert scale* survey question/statement 1 2 3 4 5 generic medicines are interchangeable with brand-name/ originator medicines, % 41.6 32.5 19.1 5.3 1.4 a generic medicine must be in the same dosage form (e.g. tablet, capsule) as the brand-name/originator medicine, % 37.2 20.8 23.2 14.5 3.9 generic medicines are therapeutically equivalent to brand-name/ originator medicines, % 38.0 28.3 21.0 9.3 2.4 generic medicines are manufactured after the patent expiry of originator/innovator, % 31.4 11.4 32.4 12.9 11.9 generic medicines produce more side-effects than brand-name medicines, % 4.3 15.3 34.4 22.5 23.4 *1 = strongly agree; 2 = agree; 3 = neither disagree nor agree; 4 = disagree; 5 = strongly disagree. table 3. perceptions of the quality, safety and efficacy of generic medicines versus brand-name medicines recorded according to the likert scale* survey question/statement 1 2 3 4 5 generic medicines are of inferior quality to brand-name medicines, % 4.8 17.2 23.9 25.8 28.2 generic medicines are less effective than brand-name medicines, % 6.3 14.9 26.0 26.4 26.4 generic medicines are less safe than original medicines, % 2.9 11.1 21.3 33.3 31.4 generic medicines are less expensive than brand-name medicines, % 28.2 34.9 16.7 11.0 9.1 brand-name medicines are required to meet higher safety standards than generic medicines, % 11.7 19.4 29.6 16.5 22.8 i believe that generic medicines are only meant for the poor, % 11.5 7.7 17.7 16.3 46.4 *1 = strongly agree; 2 = agree; 3 = neither disagree nor agree; 4 = disagree; 5 = strongly disagree. table 4. perceptions of current university education about generic medicines recorded according to the likert scale* survey question/statement 1 2 3 4 5 i need more information on the issues pertaining to the safety and efficacy of generic medicines, % 26.2 27.1 17.6 14.8 14.3 i find it easier to recall a medicine’s therapeutic class using generic names rather than brand names, % 17.6 18.6 41.0 12.4 10.5 i have been taught how medicines are subsidised in the pharmaceutical benefits scheme, % 10.0 12.4 25.2 20.0 32.4 *1=strongly agree; 2 = agree; 3 = neither disagree nor agree; 4 = disagree; 5 = strongly disagree. research 58 may 2016, vol. 8, no. 1 ajhpe with being of infe rior quality (22.0%), being less effective (21.2%), or being less safe (14.0%) than brand-name medicines. overall, 63.1% of students acknowledged that generic medicines are less expensive than branded medicines. only 31.1% of students believed that brand-name medicines are required to meet higher safety standards and a smaller percentage (19.2%) felt that generic medicines are only meant for the poor. with regard to the perceptions students had of current university education relating to generic medicines (table 4), 53.1% of respondents felt that they required more information on the safety and efficacy of generic medicines, with 36.2% finding it easier to recall a medicine’s therapeutic class using generic names rather than brand names. a small percentage thought that they had been taught how medicines are subsidised in the pharmaceutical benefit scheme. discussion a major responsibility for all educators of health science students is to teach future practitioners about the cost-effective use of medicines. to increase the uptake of generic medicines, it is vital that health science practitioners, in particular pharmacists, have a sound knowledge of the issues surrounding generic medicines. the current study showed that the majority of students surveyed had heard of branded and generic medicines. a similar finding was observed in a study conducted in bangladesh, which sought to explore medical and pharmacy students’ knowledge and perceptions about generic medicines.[5] in our study, however, there was still a significant proportion of students who were unfamiliar with the correct definition of a generic medicine, which came through by incorrect responses to questions on knowledge. despite their lower prices, generic medicines are required to meet the same safety standards as brand-name medicines. a majority of participants agreed that generic medicines cost less than brand-name medicines, which provides some promise for the use of generic medicines by these future healthcare practitioners in curtailing patient medication costs. on perceptions of current university education about generic medicines, a large percentage of students felt that they needed more information on the safety and efficacy of generic medicines, and many students were unfamiliar with the safety standards associated with the regulation of medicines in sa. similarly, respondents to the study conducted in bangladesh also displayed concern about the safely and quality of generic medicines. lack of or incorrect responses to survey questions may reflect nonexposure to generic medicine issues, differences in professional curricula, or a lack of understanding. in general, mean score differences between the groups showed that pharmacy students’ knowledge was better than that of any other group; this probably stems from the limited use and pertinence of medicines in the fields of practice of other students. future practitioners need to be exposed to these issues early in their education, so that they can be confident in counselling and treating patients whenever applicable. limitations to our knowledge, the objectives of this study have not been previously researched, which limits comparison of findings with available published literature. the use of convenience sampling, together with the relatively small sample size, might affect the generalisability of the study to the larger student population in sa. furthermore, the current study did not assess the association between curriculum content and perceptions about the use of generic medicines for each of the chosen disciplines. conclusion although there were some differences in the responses received from the different groups of future practitioners, all groups demonstrated knowledge deficits, especially on specific issues relating to the safety and effectiveness of generic medicines. these areas need to be addressed by educators, to convince students of the value of generic medicines to further strengthen policy initiatives. acknowledgements. the authors would like to acknowledge ms fikile nkwanyana for her assistance with the statistical analysis. references 1. department of health. national drug policy for south africa. pretoria: government printer, 1996. 2. government gazette. general regulations in terms of the medicines and related substances act, 1965, as amended. vol. 432, no. 22235. republic of south africa, 2001. 3. shrank wh, stedman m, ettner sl, et al. patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use. j gen intern med 2007;22(9):1298-1304. [http://dx.doi.org/10.1007/s11606007-0284-3] 4. mott da, cline rr. exploring generic drug use behavior: the role of prescribers and pharmacists in the opportunity for generic drug use and generic substitution. med care 2002;40(8):662-674. [http://dx.doi. org/10.1097/00005650-200208000-00006] 5. siam mks, khan a, khan tm. medical and pharmacy students’ knowledge and perceptions about generic medicines in bangladesh. j pharm health serv res 2013;4(1):57-61. [http://dx.doi.org/10.1111/jphs.12008] 6. patel a, gauld r, norris p, rades t. quality of generic medicines in south africa: perceptions versus reality – a qualitative study. bmc health serv res 2012;12(1):297. [http://dx.doi.org/10.1186/1472-6963-12-297] the ajhpe is published by the health and medical publishing group. ajhpe african journal of health professions education december 2009, vol. 1 no. 1 editor vanessa burch editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk deputy editor nonhlanhla p khumalo assistant editor emma buchanan technical editors marijke maree robert matzdorff paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse clinton griffin online manager gertrude fani hmpg board of directors r e kirsch (chair) m lukhele d j ncayiyana m raff a thulare m veller the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. fax (021) 681-1395. e-mail: publishing@hmpg.co.za contents editorial does africa need another journal? vanessa burch 2 articles a survey of nurses’ basic life support knowledge and training at a tertiary hospital m keenan, g lamacraft, g joubert 3 integrating the primary health care approach into a medical curriculum: a programme logic model james irlam, mpoe johannah keikelame, lauraine vivian 8 correlation between different pbl assessment components and the final mark for mb chb iii at a rural south african university mirta erotida garcia-jardon, ernesto v blanco-blanco, vivek g bhat, sandeep d vasaikar, enoch n kwizera, andrez stepien 12 short report students’ perception of different teaching aids in a medical college s n baxi, c j shah, r d parmar, d parmar, c b tripathi 15 letter information about the mphil in health sciences education at stellenbosch university ben van heerden 17 abstracts south african association for health educationalists 2008 and 2009 congresses, held in cape town 18 cpd 25 166 october 2016, vol. 8, no. 2 ajhpe research clinical teaching is a technique used in the education of nurses. it involves the exposure of students to authentic clinical environments and guiding them to attain specific requirements applicable in that particular environment.[1] the clinical environment is a platform for the application of knowledge and skills that have already been introduced in the classroom. nursing students in the clinical environment integrate knowledge and skills learnt in a contextualised learning environment, which should support them in their educational objectives.[2] competent professional nurses could enhance the quality of the clinical environment as a learning platform. the competency of the professional nurse in the clinical environment is essential for the success of the nursing student. they should possess attributes that enhance clinical teaching.[3] some of the attributes include the ability to identify brief periods during which to teach students, awareness of their own professional role and responsibility, and ability to manage the teaching platform for the development of the nursing student. if professional nurses are aware of their professional role in the clinical environment, it enhances their functionality. a review of the literature highlights that professional nurses are involved in clinical teaching, which is conducted through various models, depending on the context or setting. models used in clinical teaching include: apprenticeship, internship, supervision, and preception.[4] professional nurses tend to move towards the supervisory model of clinical teaching, especially for students in basic nursing or pre-registration programmes. this model involves the allocation of nursing students to a qualified professional nurse who, in the course of clinical practice, shares knowledge and skills with the students. however, while in the clinical area, students are expected to observe and absorb the lessons learnt while participating in activities overseen by a qualified professional nurse. the learning includes knowledge and skills that may be acquired in that context, to aspects of professional practice and organisational culture. the healthcare delivery system in lesotho is led by nurses, and the majority of healthcare professionals trained there are nurses. the number of professional nurses in lesotho is inadequate to meet the burden of disease. the government of lesotho has intervened, through its partners, to increase the number of nurses completing training in the country. this has increased the enrolment of student nurses since 2010. this increased enrolment translates into increased student numbers in the clinical setting at any given time. these increased numbers and the demands of nursing education institutions have led to a degree of role confusion among professional nurses. professional role confusion may be associated with changes in the workplace, and influence regulatory authorities and the nursing education institutions’ expectations of professionals in the clinical environment.[5] professional role confusion may affect the quality of clinical teaching and subsequently student outcomes. this article describes the perceptions of professional nurses with regard to their clinical teaching role at a rural hospital in lesotho. methods this was a descriptive qualitative study and included professional nurses who qualified in general nursing and midwifery at a rural hospital in lesotho. eight professional nurses who had previously worked with student nurses in the clinical environment were purposively selected. data were obtained from semi-structured interviews conducted by one of the researchers, using an interview guide. the interviews explored the professional nurses’ perceptions and experiences of teaching nursing students in the clinical environment. data saturation was reached after eight semi-structured interviews. background. nursing education institutions in lesotho face an increasing number of enrolments owing to a high demand for professional nurses to work in the community. enrolments have doubled during the last 3 years, without an increase in teaching resources or staff. professional nurses in the wards are expected to mentor students and teach the clinical elements of nursing while continuing with their day-to-day clinical duties. furthermore, professional nurses in lesotho have not been trained for this clinical teaching role. objective. to explore the perceptions of professional nurses with regard to their clinical teaching role in the development of competent nurses. methods. a qualitative study was undertaken at a rural hospital in lesotho. data were gathered by conducting semi-structured interviews with professional nurses. interview transcripts were coded and emerging themes identified. data saturation was reached after eight interview transcripts were analysed. results. four themes representing the perceptions of the professional nurses emerged in the analysis: (i) the clinical teaching role; (ii) the complexities of clinical teaching; (iii) learners have their issues; and (iv) making it work. conclusion. professional nurses understand and appreciate their educa tional role in the development of competent nurses. this clinical teaching role is performed in difficult circumstances, including administrative challenges, limited resources and staff shortages, while maintaining clinical responsibilities. despite these challenges, the nurses have remained resilient and solution focused. nursing education institutions should re-orientate professional nurses with regard to current trends and principles of nursing education to enhance their clinical teaching role. afr j health professions educ 2016;8(2):166-168. doi:10.7196/ajhpe.2016.v8i2.557 professional nurses’ perception of their clinical teaching role at a rural hospital in lesotho c n nyoni,1 bsc hons (nursing science), msocsc (nursing); a j barnard,2 mb chb, da (sa), mfgp (sa), mphil (palliative medicine) 1 paray school of nursing, thaba-tseka, lesotho 2 division of family medicine, school of public health and family medicine, faculty of health sciences, university of cape town, south africa corresponding author: c n nyoni (cnyonioffice@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 167 research the audio-recorded interviews were transcribed and coded to display themes that reflected the perceptions of the professional nurses with regard to their clinical teaching role. consensus on the themes that emerged from the data analysis was reached between the researcher and an expert. the trustworthiness of the study was further enhanced by means of member checking. the participants confirmed the accuracy of the results and that these represented their perceptions.[6] ethical approval was granted by the institutional review board of the ministry of health of lesotho (rec 05/2013). access to the rural hospital was granted by the manager, hospital nursing services, on behalf of the hospital board. results analysis of the transcripts of the semi-structured interviews with the professional nurses generated four themes. these include: (i) the clinical teaching role; (ii) the complexities of clinical teaching; (iii) learners have their issues; and (iv) making it work. the description of the results is structured around these themes and is supported by some quotes from the interviews. theme 1: the clinical teaching role professional nurses felt an obligation to teach student nurses in the clinical environment. the former emphasised that they have to interact with students while attending to the day-to-day running of the ward. the following quote demonstrates this dual role: ‘… when students are in the wards, i know it is expected of me to teach them what i know.’ (nf3) this statement shows that the professional nurses understand that their role includes clinical teaching. this is also supported in the literature, which discusses the dual working role of professional nurses as clinical practitioners and clinical teachers in the working environment.[2] even though professional nurses expect that their clinical positions encompass a teaching role, they feel that there is no consultation or preparation for clinical teaching. they complain that they are incorporated into the training of students without their opinions or challenges being taken into consideration. the following quote illustrates the perception of a professional nurse who was propelled into a teaching role in the clinical situation, with insufficient preparation and consequent denial of identification as a teacher: ‘just when i got employed … i see students and i am supposed to teach them … i was reminded that it’s part of my job but i don’t know what and how to teach them … i am not a teacher … .’ (nm1) the expectation that professional nurses facilitate clinical learning of nursing students imposes an added burden on these busy clinical practitioners. this was felt to have been ‘thrust upon them’. one positive response to the added burden was to integrate the clinical teaching role with all their daily tasks. models of clinical teaching that nurses recalled from their own training formed the basis of their clinical teaching practice, as illustrated in the next quote: ‘i recognise that i have an extra load of work when the students are around, we have to be busy and include them in whatever we do but me i just teach them the way we were taught … .’ (nf8) theme 2: the complexities of clinical teaching statements grouped under this theme reflected the complexity of the clinical teaching process in the context of a rural hospital. students should be afforded the best learning opportunities in an authentic environment. the professional nurses highlighted some of the complexities and challenges that hampered the process of clinical teaching: ‘at times i really wish these students could actually practise the real thing … it’s disheartening to always compromise the quality of training because we are out of supplies.’ (nf4) this quote above shows that the unavailability of everyday resources hampers the clinical teaching process.[4] these challenges reduced the effectiveness of professional nurses as clinical teachers. the nurses highlighted that the resource constraints widened the theory-practice gap. it is clear from the literature that the theory-practice gap affects the overall process of learning.[7] this phenomenon may be considered from the point of view of the classroom, where the curriculum is not based on the healthcare delivery system; or from the point of view of the clinical learning site, where the students’ learning experiences are not aligned with the requirements of the curriculum. the following shows that this mismatch is present in practice: ‘… some of the things that they wish to do are not practical here, so we tell them to practise what and how we do it here … [not] as it is demonstrated at school.’ (nf3) the increased student enrolment was challenging and made clinical teaching difficult. however, increased student numbers offered relief from some clinical tasks, as the students would do some of the work in the wards: ‘i am excited when i hear that we are having students here, i know someone has to do some of my work, so i sit back and relax.’ (nm1) theme 3: learners have their issues the trainees, in this case the nursing students in the clinical environment, contribute to the realisation of the clinical teaching role of the professional nurse. the latter explained that a dynamic relationship of trust between trainer and trainee is essential for teaching and learning to be effective, and for the commitment and objectives of the trainees to be demonstrated: ‘these learners have to be treated on an individual basis. after spending a day or two with me, i can tell who is interested in their work or not.’ (nf6) according to the professional nurses, the student nurses did not seem to be aware of their own responsibilities or of the purpose of clinical placement. nursing students failed to identify their own learning needs and had poor levels of self-motivation. the professional nurses indicated that they had limited skills in identifying teaching opportunities. should students fail to take the initiative, they are forgotten in the day-to-day running of the wards. this lack of initiative proved to be a barrier to training. the following quote demonstrates this aspect, but may also indicate that there are further student issues that require investigation: ‘the students that are attached to my ward are usually many and that may lead to over-crowding and it is in this over-crowding that a student who does not talk disappears due to silence, i mean i forget that she is there.’ (nf7) theme 4: making it work it was recognised that clinical teaching is an important activity that has been carried out by professional nurses in the ward for many years. the professional nurses confirmed that they are aware of their role in training and developing students during the time that they are in the wards, despite 168 october 2016, vol. 8, no. 2 ajhpe research operational difficulties. the professional nurses suggested solutions that could enhance their clinical teaching role, including continuing professional development aimed at keeping them up to date with clinical practice: ‘we need to be put in the loop when it comes to [the] latest information with regards to disease and new evidence, … technical assistance and other new information on patient management routinely from the school … .’ (nf5) they suggested that professional development should include academic support and motivation. they would prefer their clinical teaching role to be appreciated more. commitment from stakeholders in nursing education, especially the employers, was mentioned as critical for the effectiveness of professional development aimed at improving their training role: ‘if we are to work together towards these refresher courses, i would like my employer (hospital) to be part of it and support me throughout.’ (nm1) discussion the literature shows that there is a shortage of nursing faculty in many african countries[8] and that professional nurses are the clinical teachers for student nurses in the wards. the findings of this study support those of previous research that explored the experiences and perceptions of healthcare workers in clinical environments about the training of students.[5,9] nursing education institutions use professional nurses working in the clinical environment to train nursing students, particularly in the acquisition of skills and in integrating theory and practice. it is essential that these professional nurses have some degree of experience and an awareness of their clinical teaching role. this is intended to enable authentic and contextual learning, representative of clinical practice in the real world, thereby better preparing the students for practice. professional nurses are expected to adopt both clinical and training roles, despite their relative inexperience in both areas. these findings were consistent with the experience in other rural training institutions in africa.[9] owing to the rural nature of the setting, the more experienced professional nurses moved to urban areas and some leave the country, leaving only young and inexperienced professionals. these novices require further mentorship and guidance.[10] they are expected to work in clinical settings and carry the burden of orientating and training students.[11] the facilitation of skills development, critical thinking and clinical judgement is an important task that requires training. the professional nurses identified the need for training in ‘learning facilitation’ as a critical gap in their preparation for a clinical teaching role. the curriculum for training general nurses and midwives is practice orientated, with no elements of nursing education. the lack of knowledge in the basic principles of clinical teaching reduces the effectiveness of the professional nurse in identifying brief periods for teaching, assessing students fairly and giving feedback and debriefing sessions.[9,12] these aspects of nursing education are critical for all professional nurses, particularly in africa, where they all have a direct clinical teaching role.[9] the professional nurse is expected to provide skilled guidance to students, as they apply classroom theory in practice. this study found that professional nurses perceive themselves as fitting in the educational process of student nurses. the clinical teaching role is performed in the context of operational difficulties, which are either beyond the control of the professional nurse, such as lack of resources, or within the control of the nurse, such as personal interest and a lack of a sense of lifelong learning. lifelong learning is an important attribute of all health professionals that enables them to actively search for information when necessary. the nurses recognised that they have knowledge gaps that often made it difficult for them to teach students. as one of the professional nurses said, ‘… it is very difficult to teach whatever you don’t know’. nursing education institutions have high expectations of professional nurses with regard to their clinical teaching role. despite the limited resources, professional nurses have shown resilience and willingness to find solutions to the problems experienced. the study showed that professional nurses had some suggestions to improve their clinical teaching roles. at the rural hospital they reflected on their strengths and weaknesses and recommended continued professional development in the clinical environment as a strategy to enhance clinical teaching. such a strategy should address the actual and perceived knowledge gaps among practising nurses. the stakeholders of nursing education in lesotho should demonstrate commitment to the continued training and professional development of professional nurses in clinical environments, including their clinical teaching roles. future areas of research should explore the training needs of nurses with regard to clinical teaching and lifelong learning needs. this could inform the development of continuing professional development strategies. this study was carried out at a rural hospital in lesotho and the findings cannot be generalised to the other training hospitals in lesotho or elsewhere. although this may be viewed as a study limitation, the results highlight the perspective of healthcare workers in rural institutions who are expected to perform roles for which they are not suitably trained. conclusion we recommend that nursing education institutions work in collaboration with teaching hospitals to devise and implement continuing professional development programmes to address the nursing education needs of professional nurses. support strategies should be established for newly qualified professional nurses to assist them in their clinical teaching role. this support should be extended to all professional nurses in the hospital. continuing enhancement of skills of professional nurses who are working with students is essential to educate competent nurses. references 1. spencer j. learning and teaching in the clinical environment. bmj 2003;326(7389):591. doi:10.1136/bmj.326.7389.591  2. botma y, herter s, kotze r. responsibilities of nursing schools with regard to peer mentoring. nurse educ today 2013;33(8):808-813. doi:10.1016/j.nedt.2012.02.21 3. jokelainen m, turumenh, tossavainen k, jamookeeah d, coco k. a systematic review of mentoring nursing students in clinical placements. j clin nurs 2011;20(19-20):2854-2867. doi:101111/j.365-2702.2010.03571.x 4. gaberson kb, oermann mh, shellenbarger t. clinical teaching strategies in nursing. 4th ed. new york: springer, 2014. 5. bray l, nettleton p. assessor or mentor: role confusion in professional education. nurse educ today 2007;27(8):848-855. doi:10.1016/j.nedt2006.11006 6. de vos as, strydom h, fouche cb, delport csl. research at grassroots: for the social sciences and human services professions. 4th ed. pretoria: van schaik, 2011. 7. houghton ce, casey d, shaw d, murphy k. students’ experiences of implementing clinical skills in the real world of practice. j clin nurs 2013;22(13-14):1961-1969. doi:10.1111/jocn.12014 8. sherr k, mussa a, chilundo b, et al. brain drain and health workforce distortion in mozambique. plos one 2012;7(4):e35840. doi:10.1371/journal.pone.0035840 9. eta vea, atanga mbs, atashili j, d’cruz g. nurses and challenges faced as clinical educators: a survey of a group of nurses in cameroon. pan afr med j 2011;8(1):28. doi:10.4314/pamj.v8i1.71085 10. benner p. from novice to expert. am j nurs 1982; 2(3):402-407. doi:10.2307/3462928 11. ogochukwu cg, uys lr, karani ak, okoronkwo il, diop bn. roles of nurses in sub-saharan african region. int j nurs midwif 2013;5(7):117-131. doi:10.5897/ijnm2013.0104 12. makhakhe am. nurses’ experience of the transition from student to professional practitioner in a public hospital in lesotho. mcur thesis. potchefstroom: north west university, 2011. http://dx.doi.org/10.1136/bmj.326.7389.591  http://dx.doi.org/10.1016/j.nedt.2012.02.21 http://dx.doi.org/101111/j.365-2702.2010.03571.x http://dx.doi.org/10.1016/j.nedt2006.11006 http://dx.doi.org/10.1111/jocn.12014 http://dx.doi.org/10.1371/journal.pone.0035840 http://dx.doi.org/10.4314/pamj.v8i1.71085 http://dx.doi.org/10.2307/3462928 http://dx.doi.org/10.5897/ijnm2013.0104 research november 2015, vol. 7, no. 2 ajhpe 183 interprofessional education is central to the development of collaborative practice among healthcare professionals.[1] it ‘occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ and includes the training of undergraduate students from different disciplines working together in a learning environment.[2] collaborative learning between healthcare professionals improves the efficiency of the healthcare system through shared integration of skills and knowledge. it also leads to the development of mutual respect and identifies new roles and responsibilities of team members.[3] the promotion of an interprofessional undergraduate learning environment offers health science students an opportunity to work in a collaborative manner early on in their careers. this co-operative setting may prevent stereotyped and negative attitudes that students may develop towards other professions.[4] doctors and pharmacists have specialised knowledge and skills, with the common goal of improving patient care. relationships between these two professions can be strengthened by means of collaboration.[5] studies involving interprofessional education of medical and pharmacy students are limited; however, available outcomes indicate that there are benefits to joint learning opportunities, e.g. learning to work in a team.[6-8] the university of the witwatersrand’s faculty of health sciences, johannesburg, south africa (sa) offers undergraduate degree programmes in six health professions. this provided an opportunity to instigate interprofessional encounters of patient care between pharmacy and medical students to establish students’ perceptions of working together. methods organisation of the patient encounter the study took place at one of the large tertiary teaching hospitals associated with the university. in the current system, the medical students attend weekly clinical practice days while the pharmacy students are assigned to the hospital dispensary. medical students were expected to elicit a patient history and conduct an examination before presenting their findings to the attending doctor during a bedside tutorial. the pharmacy students, however, during their time in the dispensary, participated in stock procurement, extemporaneous compounding, dispensing of medication and patient counselling. for the purpose of this study, all the participating students were registered at the university of the witwatersrand and the supervising staff members were employed jointly by the faculty of health sciences and the department of health. fifteen groups were formed, each consisting of a final-year pharmacy student and 2 third-year medical students, to learn clinical skills, history taking and examination as well as discussing the pharmacological management of the patient. rather than going to the dispensary, the pharmacy students attended medical student clinic rounds and participated in the patient clerking process and ensuing tutorial. the joint clinical groups participated in weekly visits to the wards between may and july 2012. these groups were assigned to wards as per the normal rotation of the medical students involved. working as a group, the students were expected to assess patient records and participate in patient consultation, guided by the supervising doctor. because of the opportunistic background. patient care is significantly affected by doctors and pharmacists, who have specialised knowledge and skills. in establishing an interprofessional undergraduate learning environment, medical and pharmacy students have the opportunity to start working in a collaborative manner early on in their careers. objectives. to implement combined clinical visits, where medical and pharmacy students jointly encounter patients, and to establish the students’ perceptions of working in an interprofessional team. methods. final-year pharmacy students together with third-year medical students at the university of the witwatersrand, johannesburg, south africa were invited to participate in weekly joint patient encounters at a central academic hospital from may to july 2012. students assessed patient records and participated in the patient consultation, guided by the supervising doctor. participants from each discipline were invited to attend a disciplinespecific focus group discussion, where they shared their perceptions and experiences. the discussions were audio-taped and transcribed verbatim. content analysis was used to analyse the transcriptions. ethics approval was obtained from the human research ethics committee of the university. results. four themes were identified: the meeting of professions; shared teaching and learning; reciprocity in teaching and learning; and valuing the experience. it is evident that there was a change in students’ attitudes, and they developed mutual respect and a better understanding of their professional role and that of their peers. they also reported positive experiences in learning from and with one another. conclusion. this study focused on eliciting students’ perceptions and attitudes towards interprofessional teaching and learning. the positive responses to the experiences suggest that further learning opportunities should be created with students from another discipline. afr j health professions educ 2015;7(2):183-186. doi:10.7196/ajhpe.394 experiences of medical and pharmacy students’ learning in a shared environment: a qualitative study d johnston,1 bpharm, mpharm; p a mcinerney,2 phd; o fadahun,2 msc (med), mb bs; l p green-thompson,2 mmed (anaesthesia), mb bch; s moch,1 med, msc (med), bsc (hons), bpharm; p goven shiba,1 mb bch, bsc (hons) pharmacology; a magida,2 bsocsci (hons) 1 department of pharmacy and pharmacology, school of therapeutic sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: d johnston (deanne.johnston@wits.ac.za) research 184 november 2015, vol. 7, no. 2 ajhpe nature of the clinical learning environment, learning outcomes were not specified for each week. focus groups students who participated in the encounter were invited to attend disciplinespecific focus group discussions, where they could share their perceptions and experiences. informed consent was obtained for study participation and audio-recording. the discussions were conducted in a room where privacy could be ensured and the 2 groups were asked the same primary questions (table 1) by the interviewers who probed further, depending on the ideas that emerged. the audio-recordings were transcribed verbatim and checked by the researchers for correctness. tesch’s 8 steps were used to guide the data analysis process[9] and common themes were identified. results fourteen pharmacy students and 13 medical students participated in each discussion, respectively. there were male and female participants in both groups. the size of the groups did not appear to adversely influence participation in the discussion. four themes emerged from the data, i.e. the meeting of professions; shared teaching and learning; reciprocity in teaching and learning; and valuing the experience. the meeting of professions this theme was characterised by descriptions of learning to evaluate other professions and understand their contribution to healthcare. this appreciation of others resulted in a changed perception of roles. one pharmacy student stated ‘it’s like the professions almost don’t meet’, describing the interaction between the pharmacy and medical student before the interprofessional encounter. a medical student intimated that there is a perception that the hospital environment was more their ‘domain’ than that of the pharmacy students. a pharmacy student stated that they felt ‘like parasites to them [medical students]; like they are going [on] with their normal routine and we are just on the side’. the pharmacy students relayed comments made by medical students that ‘[a] pharmacist should become doctors’ secretaries; it’s convenient to have them around’. when the medical students described their initial relationship they indicated that the pharmacy students at first seemed ‘shy’ and that they sensed the pharmacy students may have felt inferior to them. furthermore, a medical student mentioned that ‘medical students sometimes almost tend to give off more superior attitudes’. however, as time progressed, pharmacy students commented that ‘very good relationships’ were formed with the medical students and that ‘mutual respect was a very very important aspect that came to light’. learning professional roles was discussed in a range of thoughts and ideas. gaining understanding of each other’s roles led to a changed perception and was valued: ‘i enjoyed the fact that we gained respect for one another.’ pharmacy students identified their role in the interprofessional encounters as they described two occasions when they had identified an anomaly with the patient’s medication and brought it to the attention of the attending doctor. furthermore, a pharmacy student found an opportunity to counsel a patient on the correct usage of an asthma pump. gaining understanding of each other’s curricula contributed to valuing the other profession – a participating medical student stated: ‘[it showed] me just like how much they are learning as pharmacists. like they were telling us what they actually study in their degree and you know it just made me realise just how much [more] they know, than i thought.’ the medical students thought that it would be a good idea to have learning opportunities with other professionals, such as physiotherapists, occupational therapists and nursing students. taking the shared learning into the postgraduate area, one of the medical students stated that ‘maybe interns could benefit perhaps from a roaming pharmacist, because they have all the pharmacology knowledge and as interns you’re still learning so much ... i don’t know cos i’m not there but i think it could be quite useful to have a pharmacist who could come into [the] wards and help you with the prescribing.’ shared teaching and learning there were mixed views in both focus groups with regard to the level of shared learning and teaching. the most commonly expressed view was that the teaching and learning experiences were shared, and that each group of students contributed to and benefited from the exercise. a medical student’s perspective was that ‘[the pharmacy students] were always willing to learn and always go to the tuts [tutorials] with us, they even wanted to [do] clinical skills with [us] and asked us things. so we were always teaching them and they were teaching us back.’ this perspective was endorsed by some of the pharmacy students, with one stating that ‘i learnt a lot about taking a proper patient history from my colleague who was a medic student, and she learnt from me when i was going through the medication with her, what it’s for and why shouldn’t you give it to this patient’. a minority of students, however, were at variance with this interpretation. the medical students expressed the view that the pharmacy students imparted their knowledge about drugs, but gained little in return. these views were expressed as follows: ‘no, i don’t think i taught them anything or we did. i think they taught us all the drugs.’ and another confirmed that ‘they never once asked us “what is this disease?’’, never once. so for me it was more of a case of they were teaching us, i don’t know what they gained from it.’ this was not the view of all the medical students. one of the pharmacy students expressed her disappointment at the asymmetry of her learning experience compared with that of the medical students, saying ‘i couldn’t wait meeting the medical students but personally i found that they … they learned more. i feel i could have benefited more.’ while many of the pharmacy students were enthusiastic about the opportunities that they were afforded to learn clinical skills, their main dissatisfaction arose from the perception that the focus of the hospital day at third-year level for the medical students was in developing sufficient clinical acumen to be able to correctly diagnose a patient’s ailment. the pharmacy students would have preferred an emphasis on therapeutic management. one of the students felt that ‘the clinical aspect of it was much more dominant and [the] pharmacological side was much less covered’ (referring to the teaching input). table 1. primary questions asked in each of the discipline-specific focus groups 1 from your perspective, describe the experience of multidisciplinary learning 2 what were the benefits of the encounter? 3 what were the disadvantages or problems with this kind of learning? 4 do you feel competent in your professional role to participate in the multidisciplinary encounter? research november 2015, vol. 7, no. 2 ajhpe 185 reciprocity in teaching and learning students acknowledged that the process of teaching assisted them in their own development of knowledge and skills. a medical student stated: ‘i found that the most helpful aspect of this experience for me, was the fact that we were kind of instructing or teaching as it were the pharmacology students in our clinical things that we were doing, and so that obviously helps you to learn quite a lot when you’re instructing someone else. that was probably the most beneficial part that i found.’ the medical students observed that the pharmacy students contributed drug information, specifically with regard to generic drug names, trade names, recognition of adverse effects and sourcing of drug information. they also improved the speed at which the preparation sessions occurred, as they provided a faster source of information than the medical students, who had to refer back to their notes. one medical student reflected that ‘i think the best learning experience for both pharmacy students and medical students was the time we went through the patient files – that whole process was sped up so much. we would have trouble with the drugs, specifically with trade names and they help there by far with the whole experience in those settings.’ the medical students felt that they were able to teach clinical skills to the pharmacy students and explain the background pathology and microbiology to them to assist in developing their understanding of the patients’ problems. this reciprocal teaching was expressed as follows: ‘for me it was pretty helpful because my pharmacy student had an assignment of taking patient history and examination and i had an osce coming up, so i was kind of practising and teaching him and we were helping each other.’ valuing the experience students ascribed value to the experience of peer learning as they felt able to question and argue with their student colleagues in constructing their own understanding. they thought that explanations were less complicated and the whole learning situation was simplified compared with when they were taught about drug therapy by a staff member who was hierarchically superior. this ability to construct knowledge through discussion was described as follows: ‘it’s nice hearing all of this information from someone who is your peer as well, it’s easier too, i don’t know if i’m not sure or disagree, i find it easier to sort of argue with them and then let’s just say come to a conclusion, it’s easier to do that with a peer than someone who is considered your superior.’ another medical student described this benefit, saying that ‘clinicians are really advanced. they just say this is how it works and that is what we expect.’ while the medical students valued the drug information provided by the pharmacy students, they also valued the resources that the pharmacy group provided: ‘my pharmacology student had a samf [south african medicines formulary] – so that was probably the most useful part.’ the long-term value of the experience extended beyond the allocated time period to enrich other learning. this was expressed by a medical student who noted that ‘it was nice to have someone to talk to throughout the block, not necessarily just on hospital days. i had formed quite a good relationship with my student and i was able to ask her questions i had regarding pharmacology we were doing.’ discussion this study was the first of its kind at the university of the witwatersrand, involving undergraduate medical and pharmacy students participating in joint patient encounters. these two professional disciplines traditionally had had little or no student interaction at an undergraduate level. the intervention was largely unstructured, as outcomes were not explicit other than participation in groups in the clinical setting. this may warrant further attention in future efforts in interprofessional learning. the four themes demonstrate positive results. it is evident that there was a change in attitude of the students, the development of mutual respect, a better understanding of their professional role and that of their peers, and positive learning experiences from and with one another. other studies involving interprofessional undergraduate pharmacy and medical students support our findings.[6,8] both groups of students noted attitudes related to superiority and hierarchy. for the pharmacy students this was compounded by the fact that they joined the medical students in their ‘domain’. gilbert[10] notes that competition exists between medical practitioners and pharmacists and suggests that each profession appears to need to protect their individual professional rights to diagnose, prescribe and dispense. this may explain the antagonistic relationships that often exist between these two professional groups, which may, in turn, filter down to the students. however, the students described improved understanding of the other profession, and relationships and friendships formed over the course of the intervention. similarly, o’neill and wyness[8] found that students’ participation in teams led to relationships being formed among students, deepening their understanding of the professions. interprofessional activities could assist to ‘break down unnecessary barriers’ between doctors and pharmacists,[6] as seen in the change of the students’ attitude to one another in our study. mutual respect was formed between the two groups. the pharmacy students described the development of respect over time between them and the medical students, and they felt that the medical students respected them more when they could see the contribution the pharmacy students could make to their learning. the medical students concurred with this perception when they expressed surprise at the extensive content of the pharmacy curriculum. this development of mutual respect is consistent with one of the principles of interprofessional education described by parsell and bligh,[11] i.e. ‘respects the integrity and contribution of others’. participants in this study noted the varying interests between the two student groups, i.e. the medical students were interested in the examination and diagnosis of the patient’s condition, while the pharmacy students were focused on medication. these interests are consistent with how students view their roles in their professions. this concurs with the findings described by greene et al.,[6] who found that medical students were more comfortable with interviewing patients and pharmacy students with drug therapy. the ability to share and gain knowledge and skills in the peer teaching that occurred was clearly described. the medical students found particular value in the pharmacy students’ knowledge of the medications prescribed and therefore viewed the pharmacy students as a useful resource. however, fewer pharmacy students spoke about learning from the medical students with regard to taking a patient’s history and learning clinical skills. hall and weaver[12] note that there is a need for ‘overlapping competencies and share[d] responsibilities’ for interdisciplinary team collaborations to take place. this may explain the asymmetry in learning expressed by some of the pharmacy students, who had anticipated that they would learn more from the medical students. barr et al.[13] describe five levels of educational outcomes that may be identified in interprofessional learning (table 2). research 186 november 2015, vol. 7, no. 2 ajhpe the findings of our study align with levels 1 and 2 of the outcomes (table 2). the interprofessional learning experience that we implemented generated a reaction from students, modifying their perceptions and attitudes. both groups reported to have learnt through the shared experience. the study was initiated to document a shared learning experience between medical and pharmacy students to incorporate interprofessional clinical training in the undergraduate curricula of the two groups. however, several limitations constrain such generalisation. compared with the total class sizes from both student groups, only a small number participated in the learning opportunity. furthermore, as participation in this study was voluntary, students’ contribution and performance were not quantitatively measured through assessment. without placing academic value on participation, students might not place value on the knowledge and skills acquired.[14] difficulties were experienced in communicating with the supervising doctors; this needs to be addressed in future studies. conclusion our study focused on eliciting attitudes and opinions of students to learning through exposure in this interprofessional encounter. we found that students valued this shared experience, which generated a better understanding of each other’s profession and facilitated peer teaching and learning. it has been suggested that to measure effectiveness, students’ attitudes towards interdisciplinary education should be assessed on entry into the programme, after the clinical component, on completion of the course, and when the graduate is practising as a professional.[15] future studies should consider outcomes concerning ‘changes in behaviour’ relating to professional practice, ‘change in organisational practice’ and ‘benefits to patients/clients’.[13] references 1. world health organization study group on interprofessional education and collaborative practice. framework for action on interprofessional education and collaborative practice. 2010. http://whqlibdoc.who.int/hq/2010/ who_hrh_hpn_10.3_eng.pdf (accessed 6 december 2013). 2. centre for the advancement of interprofessional education. interprofessional education. 2013. http://caipe.org. uk/about-us/defining-ipe/ (accessed 6 december 2013). 3. world health organization. learning together to work together for health. 1988. http://whqlibdoc.who.int/trs/ who_trs_769.pdf (accessed 6 december 2013). 4. parsell g, spalding r, bligh j. shared goals, shared learning: evaluation of multiprofessional course for undergraduate students. med educ 1998;32:304-311. [http://dx.doi.org/10.1046/j.1365-2923.1998.00213.x] 5. mcdonough rp, doucette wr. developing collaborative working relationships between pharmacists and physicians. j am pharm assoc (wash) 2001;41:682-692. 6. greene rj, cavell gf, jackson shd. interprofessional clinical education of medical and pharmacy students. med educ 1996;30:129-133. [http://dx.doi.org/10.1111/j.1365-2923.1996.tb00730.x] 7. horsburgh m, lamdin r, williamson e. multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. med educ 2001;34:876-883. [http://dx.doi.org/10.1046/j.1365-2923.2001.00959.x] 8. o’neill bj, wyness ma. student voices on an interprofessional course. med teach 2005;27:433-438. [http:// dx.doi.org/10.1080/01421590500086680] 9. cresswell jw. research design: quantitative, qualitative, and mixed methods approaches. 2nd ed. thousand oaks, ca: sage, 2003. 10. gilbert l. to diagnose, prescribe and dispense: whose right is it? the ongoing struggle between pharmacy and medicine in south africa. current sociology 2001;49:97-118. [http://dx.doi.org/10.1177/0011392101049003007] 11. parsell g, bligh j. interprofessional learning. postgrad med j 1998;74:89-95. [http://dx.doi.org/10.1136/pgmj.74.868.89] 12. hall p, weaver l. interdisciplinary education and teamwork: a long and winding road. med educ 2001;35:867875. [http://dx.doi.org/10.1046/j.1365-2923.2001.00919.x] 13. barr h, freeth d, hammick m, koppel i, reeves s. evaluations of interprofessional education. a united kingdom review for health and social care. the united kingdom centre for the advancement of interprofessional education with the british educational research association. 2000. http://caipe.org.uk/silo/files/evaluations-ofinterprofessional-education.pdf (accessed 28 november 2013). 14. parsell g, bligh j. educational principles underpinning successful shared learning. med teach 1998;20:522-529. [http://dx.doi.org/10.1080/01421599880229] 15. gilbert jhv. interprofessional education for collaborative, patient-centred practice. nursing leadership 2005;18:32-38. table 2. modified levels of educational outcomes that result from interprofessional education[13] level 1: reaction level 2a: modification of perceptions and attitudes level 2b: acquisition of knowledge and skills level 3: behavioural change level 4: change in organisational practice level 5: benefits to patients/clients 15 august 2010, vol. 2, no. 1 ajhpe article the use of portfolios in health professions education has increased dramatically over the years.1-3 the enthusiastic acceptance of this principle is in part born out of the ever-growing interest in outcomes-based education in all divisions of health science.2 portfolios not only stimulate professional development and reflective learning, they also provide opportunity for self-direction, and avenues for faculty feedback.1 portfolios have also been recommended for the assessment of professional development in medical education,3 and several reports document their successful use in the assessment of competence at both undergraduate and postgraduate levels.4 to stimulate engagement and to assess professional development during clinical laboratory training, portfolio development and assessment was proposed for final-year students for the bachelor of medical laboratory sciences and the diploma in medical laboratory technology, kampala international university, uganda, in 2008. this article reports the experience of the use of portfolios to assess professional development in these programmes. methods institutional approval for the study was obtained from the institutional review and ethics committee. eighteen final-year students undergoing clinical laboratory training in the teaching hospitals and participating in routine daily laboratory work were requested to compose and maintain a portfolio detailing their daily experiences, work done, and lessons learnt during their training. their supervisors and programme facilitators provided daily feedback and endorsed all entries. at the end of their training, the portfolios were examined by a team of faculty and an external examiner. the students were also required to make a 15-minute presentation based on their portfolio, and to participate in an interview. a rating rubric (table i) used for the assessment considered the quality of a student’s presentation, portfolio content, demonstration of development over time, and ability to make professional judgement. to obtain a pass, a student is expected to meet all the criteria in the rubric in the collective judgement of the assessors. questionnaires were used to determine the students’ and raters’ views on the usefulness of this method of assessment. the data were analysed quantitatively and qualitatively. results seventy-two per cent of the students and assessors accepted the method as a valid and effective means of assessing professional competence. fifteen of the eighteen students reported that it improved their commitment to laboratory training, and encouraged reflection. both faculty and students were of the opinion that it allowed for frequent feedback and using portfolios to assess professional competence and development in medical laboratory sciences christian c ezeala, phd, msc, micr (uk), csci (uk), aimls, lecturer, department of health sciences, fiji school of medicine, fiji national university, suva, fiji islands; formerly senior lecturer/hod, medical laboratory sciences, kampala international university, uganda mercy o ezeala, ba, ma, faculty of arts and law, university of the south pacific, suva, fiji islands ephraim o dafiewhare, mb bs, mwacfp, senior lecturer, department of medicine, kampala international university, ishaka, uganda correspondence to: christian ezeala (christian40ezeala@yahoo.com) table i. rubric for the assessment of portfolios criteria criterion met criterion not met 1. presentation was complete in 15 minutes (student completed presentation in 15 minutes) 2. quality of presentation (text readable from 2 meters (minimum font size 32); good organisation; student communicated with audience) 3. student showed progressive development over time (portfolio showed student development from dependent trainee to independent professional) 4. student reflected on experiences and could make good professional judgement (student could make decisions relevant to his work) 5. portfolio content was adequate (length and scope of portfolio showed adequate experience) 6. overall assessment pass (all the criteria were met) fail (some or all of the criteria were not met) general comments: article 16 august 2010, vol. 2, no. 1 ajhpe more engagement in the programme. many believed that it was a rational assessment as it captured development over time, but it was time consuming and quite tasking on both students and the staff. eighty-eight per cent were of the view that it should be a supplement and not a substitute for the standard written and practical tests. discussion the evolution of a portfolio as a tool for the assessment of professional competence and development offers several advantages over the traditional standard tests which, to a large extent, are ‘reductionist’ and do not capture progression over time.3 application of portfolio assessment in medical laboratory sciences education is not widespread, and only a few reports are available in the literature.4 this study has demonstrated that portfolio development and assessment is well accepted in the medical laboratory sciences programme. an important aspect of medical education is the matching of assessment methods with learning mode,5 as assessment drives learning. portfolio assessment aligns well with competency-based education. tenets of the latter include learner centredness, formative feedback, developmental process, reflection, and multiple types and sources of assessment.1 this study demonstrated it clearly as it promoted student /staff engagement in the clinical laboratory training programme, students’ ownership of their training, and reflective learning. although its introduction extends the methods of assessment in medical laboratory sciences, the study showed that many of the participants would not welcome it as the only mode of assessment. rather it would be a valuable addition to the traditional methods of assessment of competence. the limitations of this study include the small sample size. it is recommended that a larger sample of students be included in a more elaborate study, possibly over a longer period. to ease the burden of assessment, using a structured interview to assess the portfolio as recommended by burch and seggie,6 could be helpful. references 1. driessen ew, van tartwijk j, overeem k, vermunt jd, van der vleuten cpm. conditions for successful reflective use of portfolios in undergraduate medical education. med educ 2005; 39: 1230-1235. 2. davis mh , amin z , grande jp, et al. case studies in outcome-based education. medical teacher 2007; 29(7): 717-722. 3. friedman bdm, davis mh, harden rm, howie pw, ker j, pippard mj. amee medical education guide no. 24: portfolios as a method of student assessment. medical teacher 2001; 23(6): 535-551. 4. thome g, hovenberg h, edgren g. portfolio as a method for continuous assessment in an undergraduate health education programme. medical teacher 2006; 28(6): e171-e176. 5. segers m, dochy f. introduction enhancing student learning through assessment: alignment between levels of assessment and different effects on learning. studies in educational evaluation 2006; 32(3): 171-179. 6. burch vc, seggie jl. use of a structured interview to assess portfolio-based learning. med educ 2008; 42(9): 894-900. march 2017, vol. 9, no. 1 ajhpe 29 research knowles[1] defined self-directed learning (sdl) as ‘a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes’. this definition is difficult to apply in an institutional setting,[2] and more so in the complex process of imparting the defined knowledge, skills and attitudes required to produce a medical doctor. in formal education, self-regulated learning (srl) is a more feasible framework of a student’s proactive approach to learning.[3] srl ‘describes the proactive, self-directive processes and self-beliefs, by which students become masters of their own learning’.[4] developing skills in srl requires the student’s ‘personal initiative, perseverance and adaptive skill that derives from advantageous motivational feelings and beliefs and metacognitive strategies’.[4] the three skills that comprise srl are metacognition, motivation and cognition.[5] srl expresses a student’s motivation to achieve defined academic goals utilising specific strategies, which leverage on self-efficacy beliefs.[4] therefore, the concepts of being proactive, motivated to learn, and teacher guidance are defined components of srl.[5] the teacher can leverage the cognitive load theory to create a conducive atmosphere for learning. the key concept of the cognitive load theory is that the cognitive load should match the working memory of the learner. cognitive load occurs when several new facts (sensory information) are received without scaffolding.[6] teacher support is needed to provide the scaffolding to help the student ‘make sense’ of the new information.[7] this teacher-directed learning has contextual overtones in the hierarchical culture of many higher education institutions, especially in africa. sdl in a problem-based learning (pbl) curriculum in developing countries reveals difficulties with its implementation owing to high start-up costs and the need for well-trained facilitators. this has been observed, for example, in argentina, south-east asia and sub-saharan africa (mainly in south africa).[8-10] in the west african sub-region and specifically in nigeria, pbl is yet to be established, although the college of medicine, university of ibadan, nigeria has started implementing this programme.[11-13] therefore, it would seem that most learning in nigerian medical schools is not student centred or focused on developing lifelong learning skills. these skills would enhance a professional’s relevance after formal education and thus promote safe, efficient medical care. however, published work on structured medical education in nigeria is scanty; information on types of curricula is mostly not available in public repositories. this study attempts to answer the following question: what is the current state of sdl among the students (as trainees) and its perception among the faculty leadership (as trainers) at a nigerian medical school? it appears to be the first structured assessment of sdl status and perception in a nigerian medical school – its findings are transferable to other medical schools in background. self-directed learning (sdl) is the essential mechanism of lifelong learning, which, in turn, is required for medical professionals to maintain competency because of advancing technology and constantly evolving disease care and contexts. yet, most nigerian medical schools do not actively promote sdl skills for medical students. objective. to evaluate the status of sdl behaviour among final-year students, and the perceptions of faculty leadership towards sdl in a nigerian medical school. methods. a mixed research method was used, with a survey consisting of a validated likert-based self-rating scale for sdl (srssdl) to assess students’ sdl behaviour. focus group discussions with selected faculty leaders were thematically analysed to assess their perceptions of sdl. results. the medical students reported moderate sdl behaviour, contrary to faculty, who considered their students’ sdl behaviour to be low. faculty leadership further defined sdl as the self-motivated student demonstrating initiative in learning under the guidance of teachers, who use interactive forums for teaching. furthermore, teachers and students should partner towards the goal of ensuring that student learning takes place. teachers expressed concerns about sdl methods in medical schools owing to the fear that this will require medical students to teach themselves medicine without expert guidance from teachers. conclusion. this study suggests that final-year students have a low to moderate level of sdl behaviour. the index faculty are willing to develop teacherguided self-motivated learning for their students, rather than strict sdl. faculty should be concerned about this behaviour and should encourage sdl in such a way that students realise its benefits to become lifelong learners. further study of the perceptions about self-regulated learning are recommended. afr j health professions educ 2017;9(1):29-33. doi:10.7196/ajhpe.2017.v9i1.708 self-directed learning: status of final-year students and perceptions of selected faculty leadership in a nigerian medical school – a mixed analysis study t e nottidge,1 mbbs, mphil health sced, fwacs; a j n louw,2 bed, med, phd 1 department of orthopaedics and traumatology, college of health sciences, university of uyo, nigeria 2 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa  corresponding author: t e nottidge (timnottidge@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 30 march 2017, vol. 9, no. 1 ajhpe research the developing world, which are yet to develop sdl and lifelong learning in their curricula. methods a sequential mixed method approach – first quantitative and then qualitative methods – was used to answer the research question of this study.[14] the quantitative data formed part of the material for discussion in the qualitative arm of the study. it therefore follows an explanatory design, where the qualitative findings help to clarify the quantitative findings. therefore, the research followed separate phases – first the quantitative phase, followed by the qualitative phase. a third phase of the study involved reviewing the findings from the focus group discussion with the members of the group on an individual basis, thus providing data triangulation and further enriching the data.[14] the phases of the study were as follows: • phase i (quantitative phase): self-rating scale for sdl (srssdl) administered to the final-year students of the index medical school. • phase ii (qualitative phase): focus group discussion. • phase  iii: member-checking phase; results of phases i and ii discussed with members of the focus group individually. this was done to enhance the validity and trustworthiness of the data. the srssdl was designed by williamson[15] to assess sdl behaviour – the user’s level of self-directedness in learning is graded on an ordinal scale as low, medium or high. the srssdl is a paper questionnaire that has 60 positively worded questions, with answer options on a likert scale. the question domains are: (self ) awareness, learning strategies, learning activities, (self ) evaluation and interpersonal skills. a scoring rubric is embedded after the questions, which allows for self-scoring, although the self-scoring option was not used in this study. low sdl is defined in the srssdl as ‘guidance is definitely needed from the teacher. any specific changes necessary for improvement must be identified and a possible complete re-structuring of the methods of learning.’ in addition, medium sdl is defined as ‘this is half-way to becoming a self-directed learner. areas for improvement must be identified, evaluated and a strategy adopted with teacher guidance when necessary.’ high sdl ‘indicates effective self-directed learning. the goal now is to maintain progress by identifying strengths and methods for consolidation of the students’ effective self-directed learning.’ purposive sampling was used for this study. the choice of faculty was based on the criteria that those chosen would be a head of department, considered likely to attend the event, and also the two deans involved. nine staff members were chosen – 3 of 3 for the basic sciences, 4 of 13 for the clinical sciences, and the 2 deans – all those selected attended or sent a representative for the focus group discussion. the selection of deans and heads of department ensured that the opinion of faculty leadership was engaged, because they play a central role in managing the teaching and learning policies of the medical school. the questionnaires completed during phase i were collected and graded and the scores were captured on a microsoft excel (usa) spreadsheet for analysis. during phase ii, the focus group discussion was recorded on both audio and video devices and a manual transcript of the entire audio recording was made. the feedback obtained in phase iii was worked into and enriched the data analysed in phase ii. non-crossover mixed analysis was used to analyse the data. the quantitative data were captured on a microsoft excel spreadsheet and basic descriptive statistical data of the students’ ages and scores were obtained – frequencies and means, respectively. the overall mean score was used to classify the group into low, medium or high sdl behaviour, using the scoring rubric embedded in the srssdl. ethical approval for this study was obtained from the ethics committee of the faculty of medicine and health sciences, stellenbosch university (ref. no. s14/02/033). permission to carry out the study for the purpose of college development and curriculum review was obtained from the chief executive officer of the medical school. the study was carried out in 2014. results following an explanatory design for the mixed method study, the results are presented accordingly – the quantitative findings are followed by the results of the qualitative phase of the study. students’ self-reported sdl behaviour forty of 43 final-year students participated in this study – a 93% response rate. the 3 students who did not participate were not available at the time. ten of the participants were female and 30 male; 34 were in the 20 29-year age group, while 6 were in the 30 39-year age group. the mean (standard deviation) for self-directed behaviour was 212.3 (21.2) (fig. 1), which is within the medium range of the srssdl scale. faculty’s perception of sdl table 1 is a summary of the results of the qualitative aspect of the focus group discussion. positive concepts at the start of the focus group discussion, faculty observed that the term sdl was new to them. in this first part of the discussion, faculty considered table 1. summary of results of the qualitative aspect of the focus group discussion positive concepts negative concepts self-motivated learning self-decided learning initiative self-teaching task shifting interactive partnership guided learning 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 300 250 200 150 100 50 0 sr ss d l sc o re student serial number fig. 1. the srssdl score against the student’s serial number. most of the students’ scores are in the medium range (141 220), with no score in the low range (60 140). march 2017, vol. 9, no. 1 ajhpe 31 research the term sdl and discussed what it means for learning in the medical school. the categories identified were: • self-motivated learning. the perception of faculty was of a student who is enthusiastic about learning and is determined to learn. the following comment made during the focus group meeting illustrates this: ‘… the main thing is that there is somebody who is trying to have some kind of self-motivation to learn something, hold it, improve on it without really being coerced, pushed, begged, there is self-determination to achieve something.’ (participant 3) • initiative. faculty embraced the idea of students showing some initiative in reading more than the scripted material: ‘… we feel that there could be a room for initiative and also a room to explore other means even at the learning level; the students may be able to discover other things for themselves.’ (participant 7) • task shifting. this was seen as a positive aspect of sdl, as it transferred some responsibility for learning to the student and thus reduced the responsibility and workload of teachers. a statement of one of the participants conveys this: ‘it [sdl] will reduce our [teachers’] work.’ (participant 8) • interactive. this conveyed the sense of being active, involved, talking to each other and changing each other. interactive learning was seen to indicate learning in a group of which the teacher is a part, which was reflected by another teacher’s concept of equality, and in which the traditional hierarchy between teacher and student was de-emphasised. participants’ comments on this in the focus group discussion were, inter alia, the following: ‘… people in groups, making it learning, interacting … .’ (participant 1) ‘… sit, not in a classroom, in a circular form … .’ (participant 1) • partnership. faculty felt that success in the world sometimes hinged on partnerships and the same concept should be leveraged to help students feel more involved with their learning: ‘… many of these companies in the united states succeeded because they made the staff part of the company.’ (participant 8) • guided learning. the teachers seemed to emphasise the importance of guiding the students in the discovery of medical knowledge and to acquire relevant skills while following the prescribed curriculum: ‘it’s more of encouraging participation, that is what we are talking about, but still under, you know, a guide; still under the framework of an institution.’ (participant 4) negative concepts after reviewing the definition of sdl as defined by knowles,[1] faculty members elicited some negative sentiment about it. the following negative categories were identified: • self-directed learning. faculty were not keen on the idea that the students decide what and how to learn, as illustrated by the following quotes: ‘… if you put a medical student to stay on his own and start learning everything by himself, set goals for himself and decide appropriate learning strategies by himself, i don’t think it’s going to be better at the end of the day. he has a curriculum. he has a period of time he needs to learn. he needs to interact with others along the learning process.’ (participant 3) ‘… for medical education, it will be difficult to allow the students to decide how they want to learn and what they want to learn before graduation if they all have to graduate within the same 6 or 7 years.’ (participant 5) • self-teaching (autodidactism). learning by using the curriculum as a guide but without the teacher. this was expressed to question the trend of discussion that seemed to displace the teacher from the centre of the learning process: ‘giving us the impression the student is self-directed, doesn’t need the teachers again.’ (participant 8) faculty’s perception of the srssdl score of the students the faculty unanimously rated the self-directedness in learning of the finalyear medical students at the university as low. they expressed surprise that the students thought of themselves as having moderate sdl behaviour. this was a qualitative overview of the students’ learning behaviour, as they did not go into the detail of reviewing the questionnaire and its various aspects. ‘i would really want to score our student low … but if we … direct them in this self-directed learning focus, i guess from low they can get to high.’ (participant 1) discussion radical sdl is difficult to apply in formal education and is not an appropriate pedestal for teaching and learning in medical education – this summarises the view of the faculty leadership at the index medical school and is not new in the literature.[2,16] this study adds the view of the nigerian faculty about what sdl should entail in medical education, both in its positive and negative aspects, and the application of an sdl self-assessment tool to a group of nigerian medical students. it also adds the results of applying the srssdl to a cohort of medical students, probably for the first time. furthermore, it adds to previous research done in africa and internationally.[10] it is clear that the faculty perception in this study is in tandem with schmidt[16] with regard to the central role of teacher support for the selfmotivated student, but that there should be teacher guidance for those in need. scaffolding is an offshoot of the cognitive load theory of sweller, in which the teacher provides support for the student in a learning task by providing a means of chunking the new information or skill, to more easily engage with working memory.[17,18] the first contact with new information is through the sensory memory, but the individul becomes aware of the data when these move to the working memory, according to the cognitive load theory.[6] learning occurs when this information moves to the longterm memory, which has an infinite number of schematics to store and retrieve information. cognitive overload occurs when the learner meets new information that is not organised into the schemata that allows movement to the long-term memory (usually about seven chunks).[6] sdl needs to be staged according to the capacity of the learner by reducing the amount of scaffolding, as the learner matures in self-learning.[2] task-shifting from teacher to student would certainly make the teacher’s work easier, but the focus should rather be on how it could enhance the 32 march 2017, vol. 9, no. 1 ajhpe research student’s learning. it seems that teachers do not always realise the benefits of self-discovery during the learning process and tend to want to be in charge of students’ learning. however, the faculty in this study laud an interactive model of teaching and learning and, indeed, would be comfortable for students to partner with them in this process. this is reflected in the literature on pbl, which entrenches an interactive partnership model as a means of developing sdl in medical students.[7] from the results of this study, it appears that guided learning seems to be the core of the concept of how medical students can acquire the complex knowledge and skills required of a medical doctor. this is supported by the concept of cognitive load theory. moreover, srl is a teaching and learning method that utilises teacher guidance, which is more appropriate for the high cognitive load in medical education than sdl. faculty was loath to adopt a concept that seemed to do away with the need for teachers. rather, they preferred to shift more of the work of learning to the students in an interactive model, which makes students partners in the task of learning but under the guidance of teachers. in the pbl model of applying sdl, teachers are still necessary as facilitators. however, with the objective of developing sdl in medical students at the index school, faculty’s concerns would have to be addressed. the results of this study also demonstrate that there are some negative perceptions about the concept of sdl. faculty members were concerned about the idea of sdl – this concept was expressed by the faculty as a facet of sdl that was not compatible with medical training, which has a defined curriculum and a fixed time of completion. therefore, the view that a student can independently determine the subjects to study in a medical school (or any school), would be unusual to faculty in most medical schools and be precarious to the stakeholders to whom the school is socially accountable.[19] autodidaxy is a term that has been used synonymously with sdl in the literature;[20] it speaks of self-learning or self-teaching and is considered a process in sdl. however, faculty members in this study seemed to be more concerned about autodidactism, which is self-teaching without formal education.[21] autodidactism is therefore more in tune with the comment of the faculty, who stated that giving the student the curriculum to study without the teachers would not be a reliable way to learn medicine. the difficulty this faculty had with regard to defining sdl is common in the literature, more so with the need to safeguard the core aspects of the curriculum.[22] faculty was unanimous in rating the students in the low range of sdl behaviour and was rather surprised that the students’ self-assessment placed them in the moderate range. this faculty rating can be misleading, as they have not been formally orientated to the workings of sdl, and so may not have the experience to make such a judgement. rather, the general assessment by the faculty is more likely to represent their sense of the students’ level of motivation, initiative and commitment to learning. it is also possible that the faculty have developed more sdl traits in the students than they credit themselves for. this study may be the first where srssdl is being applied to medical students. other studies have shown the application of the sdl readiness scale to medical students – somewhat different from sdl behaviour.[23] the key findings of this study centre on the perceptions of the faculty focus group, which revealed a reluctance to participate in a venture that could make students decide what and when to learn. rather, the group members had expectations about what it would take to produce self-directed learners and are willing to commit to this model, which can be paraphrased as follows: the self-motivated students demonstrating initiative under the guidance of teachers who use interactive forums for teaching. in addition, the teachers and students should partner towards the goal of ensuring that student learning takes place. the modality for practically achieving this objective was not discussed, but the underlying ethos indicates a major need for training and orientation for both faculty and students. this model appears to be similar to srl in the following aspects: student motivation and initiative and teacher guidance in learning, suggesting that the faculty at the medical school would prefer to operate an srl rather than an sdl framework for teaching. nonetheless, sdl is a concept that is probably more relevant to a postgraduate medical doctor, who can use this approach to pursue lifelong learning and thus maintain safe, relevant and efficient practice for the duration of their professional life. in view of the aim of medical schools, i.e. to produce self-directed, lifelong learners, there is a need to determine whether srl would achieve this goal. furthermore, it gives teachers more control and thus would seem more attuned to a hierarchical culture. the first author’s (ten) hierarchical cultural background may be reflected in the predominant teacher-centred culture of this medical school. therefore, he may inadvertently prefer more teacher guidance in the teaching and learning framework in use at the index medical school. it would seem that changes in teaching and learning methods need to work with and leverage upon the background culture. this work serves as a needs analysis with regard to the basic concepts of the faculty at this medical school to develop self-directed lifelong learners. faculty development forums can therefore be designed that will be relevant to their needs. the outcomes of this study are transferable to medical schools, especially in developing economies, which are yet to engage with producing selfdirected life-long learners. study limitations to interpret the students’ level of self-directedness in learning in detail would have required a faculty more conversant with the theories and practice of sdl. more depth of information on student behaviour, their challenges, and successes within the nigerian context could have guided sdl implementation strategies. the sampling of faculty was restricted to make the study ‘doable’, but also limited the conclusions from the study to those involved in the focus group. a systematic sampling of all faculty members would have yielded more valid results. this study was conducted in a medical school that was yet to implement sdl; therefore, the definition of sdl may have been more difficult to grasp fully. conclusion this study suggests that the final-year students have a low to moderate level of sdl behaviour. the index faculty are willing to develop teacher-guided self-motivated learning in their students, rather than strict sdl. faculty should be concerned about this behaviour and should encourage sdl in students, in such a way that they realise its benefits to become lifelong learners. further study on the perceptions about srl are recommended. march 2017, vol. 9, no. 1 ajhpe 33 research author contributions. ten conceived the study. ajnl participated in study conception. ten collected the data and drafted the manuscript. ajnl participated in the drafting of the manuscript. 1. knowles ms. self-directed learning – a guide for learners and teachers. chicago: follett publishing, 1975:18. 2. grow g. teaching learners to be self-directed. adult educ q 1991;41(3):125-149. http://dx.doi.org/10.1177/ 0001 848191041003001 3. loyens s, magda j, rikers r. self-directed learning in problem-based learning and its relationships with selfregulated learning. educ psychol rev 2008;20(4):411-427. http://dx.doi.org/10.1007/s10648-008-9082-7 4. zimmerman bj. investigating self-regulation and motivation: historical background, methodological developments, and future prospects. am educ res j 2008;45(1):166. http://dx.doi.org/10.3102/0002831207312909 5. kistner s, rakoczy k, otto b, dignath-van ewijk c, büttner g, klieme e. promotion of self-regulated learning in classrooms: investigating frequency, quality, and consequences for student performance. metacogn learn 2010;5(2):157-171. http://dx.doi.org/10.1007/s11409-010-9055-3 6. young jq, van merrienboer j, durning s, ten cate o. cognitive load theory: implications for medical education: amee guide no. 86. med teach 2014;36(5):371-384. http://dx.doi.org/10.3109/0142159x.2014.889290 7. miflin bm, campbell cb, price da. a conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula. med educ 2000;34(4):299-306. http://dx.doi.org/10.1046/j.13652923.2000.00564.x 8. carrera li, tellez te, d’ottavio ae. implementing a problem-based learning curriculum in an argentinean medical school: implications for developing countries. acad med 2003;78(8):798-801. http://dx.doi.org/ 10.1097/ 00001 888 200308000-00010 9. amin z, hoon eng k, gwee m, dow rhoon k, chay hoon t. medical education in southeast asia: emerging issues, challenges and opportunities. med educ 2005;39(8):829-832. http://dx.doi.org/10.1111/j.1365-2929.2005. 02229.x 10. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, sewankambo n, mullan f. medical education in sub-saharan africa: a literature review. med educ 2011;45(10):973-986. http://dx.doi.org/10.1111/j.1365-2923.2011.04039.x 11. olapade-olaopa eo, ed. the 2010 mbbs curriculum of the college of medicine, university of ibadan. ibadan: college of medicine, 2010. 12. gukas id. problem-based learning in undergraduate medical education: can we really implement it in the west african subregion? west afr j med 2007;26(2):87-92. 13. olabiyi oo, aiyegbusi ai, noronha cc, okanlawon ao. students’ view of a learning method: opinions of first year medical and dental students in the school of basic medical sciences of university of lagos, nigeria, about problem based learning. nig q j hosp med 2008;18(4):185-190. http://dx.doi.org/10.4314/nqjhm.v18i4.45025 14. creswell jw. research design: qualitative, quantitative, and mixed methods approaches. 2nd ed. thousand oaks: sage, 2003:15-16. 15. williamson sn. development of a self-rating scale of self-directed learning. nurse res 2007;14(2):66-83. http:// dx.doi.org/10.7748/nr2007.01.14.2.66.c6022 16. schmidt hg. assumptions underlying self-directed learning may be false. med educ 2000;34(4):243-245. http:// doi.org/10.1046/j.1365-2923.2000.0656a.x  17. jin j, bridges sm. educational technologies in problem-based learning in health sciences education: a systematic review. j med internet res 2014;16(12):e251. http://dx.doi.org/10.2196/jmir.3240 18. baker rm. examples of scaffolding and chunking in online and blended learning environments, 2010. http:// dx.doi.org/10.2139/ssrn.1608133 19. boelen c, woolard r. social accountability: the extra leap to excellence for educational institutions. med teach 2011;33(8):614-619. http://dx.doi.org/10.3109/0142159x.2011.590248 20. ainoda n, onishi h, yasuda y. definitions and goals of ‘self-directed learning’ in contemporary medical education literature. ann acad med singapore 2005;34(8):515-519. 21. wikipedia. autodidacticism, 2014. http://en.wikipedia.org/wiki/autodidacticism (accessed 5 january 2017). 22. lunyk-child oi, crooks d, ellis pj, ofosu c, o’mara l, rideout e. self-directed learning: faculty and student perceptions. j nurs educ 2001;40(3):116-123. 23. premkumar k, pahwa p, banerjee a, baptiste k, bhatt h, lim hj. does medical training promote or deter self-directed learning? a longitudinal mixed-methods study. acad med 2013;88(11):1754-1764. http://dx.doi. org/10.1097/acm.0b013e3182a9262d http://dx.doi.org/10.1177/--0001-848191041003001 http://dx.doi.org/10.1177/--0001-848191041003001 http://dx.doi.org/10.1046/j.1365-2923.2000.00564.x http://dx.doi.org/10.1046/j.1365-2923.2000.00564.x http://dx.doi.org/-10.1097/-00001-888---200308000-00010 http://dx.doi.org/-10.1097/-00001-888---200308000-00010 http://dx.doi.org/10.1111/j.1365-2929.2005.-02229.x http://dx.doi.org/10.1111/j.1365-2929.2005.-02229.x http://dx.doi.org/10.7748/nr2007.01.14.2.66.c6022 http://dx.doi.org/10.7748/nr2007.01.14.2.66.c6022 http://doi.org/10.1046/j.1365-2923.2000.0656a.x  http://doi.org/10.1046/j.1365-2923.2000.0656a.x  http://dx.doi.org/10.2139/ssrn.1608133 http://dx.doi.org/10.2139/ssrn.1608133 http://dx.doi.org/10.1097/acm.0b013e3182a9262d http://dx.doi.org/10.1097/acm.0b013e3182a9262d 86 may 2016, vol. 8, no. 1, suppl 1 ajhpe guest editorial universal access to healthcare mandates that all people worldwide have access to comprehensive healthcare services, without suffering financial hardship.[1] however, unless the severe shortages and inequitable distribution of healthcare workers, especially in many lowand middle-income countries, are addressed,[2,3] universal access will, similar to ‘health for all by the year 2000’, go down in history as a desirable but unattainable goal. the dearth of healthcare workers follows an ‘inverse care law’,[4] with the direst shortages in areas of greatest need, mostly rural areas.[2,3] in a bid to address the challenge in sub-saharan africa, many new medical schools with larger class sizes have sprung up in the past 20 30 years.[5,6] there is strong evidence, mostly emanating from the usa, australia, the philippines, thailand and canada, linking rural-based training of healthcare workers with increased retention.[7-10] consequently, there has been an increase in curricular innovations to incorporate or strengthen rural and community-based training in sub-saharan africa. recent investments by the us president’s emergency plan for aids relief (pepfar) to support medical and nursing institutions in sub-saharan africa, through the medical education partnership initiative (mepi) and the nursing education partnership initiative (nepi), respectively, have added further impetus to curricular innovations aimed at promoting reten tion of graduates in rural areas and primary care.[11-13] the funding has supported infrastructure development in the form of teaching spaces, hostel accommodation and internet access at rural training sites of a significant number of schools.[14,15] although most of these community-based training programmes have the same primary goal, i.e. increasing the number of healthcare workers in underserved areas, the programmes vary greatly in duration and frequency of exposure. rural contact ranges from single blocks of 6 8 weeks, through multiple exposures of 4 8 weeks, to a 1-year attachment at the ukwanda rural clinical school.[11,13] in this issue of ajhpe, muzigaba et al.[16] describe a pilot community-based programme lasting 10 days. this variability begs the question: is there a threshold length of exposure that will give the desired outcome, i.e. an increased number of healthcare workers in rural areas? is the wetting of toes just as effective as protracted immersion? this is a critical question, considering the substantial cost of setting up and running these programmes and the urgent need to increase the number of healthcare workers in rural areas. mepi and nepi grants have fostered strong north-south and south-south partnerships, creating opportunities for joint learning and relevant research to optimise the programmes. muzigaba et al.[16] introduce a very important concern, i.e. that students of rural origin were more likely to choose primary care exposure in urban centres. this raises two key questions: (i) what proportion of students should participate in rural-based training to achieve a meaningful effect on rural retention? (ii) as rural origin and training in rural areas are independent predictors of rural retention, is the university of kwazulunatal's programme limiting its potential effect by allowing students to elect not to have rural exposure? this elective v. required rural contact characterises a number of programmes.[11-13] stellenbosch university (su) stands out as a trailblazer on the african continent with regard to longitudinal clinical clerkship. nevertheless, only a small, self-selected proportion of medical students rotate through the ukwanda rural clinical school.[13] therefore, institutions that may want to emulate su, need to answer the question: what proportion of students need to participate to realise the desired effect? this is fundamental with regard to cost-effectiveness of interventions in the face of pressing needs and resource constraints. the parallel rural community curriculum of flinders university, adelaide, australia, requires 40% of students to complete 1 year of training in six regions, spanning 3 500 km.[17] however, the northern ontario school of medicine in canada obliges all its medical students to complete a 1-year comprehensive community clerkship in 12 large communities across the vast region.[17] although evaluation has demonstrated comparable health systems and educational value of the australian and canadian programmes, comparative analysis of their cost-effectiveness will be very instructional. rural-based training of healthcare workers, especially doctors, is receiving increasing attention in sub-saharan africa. this has been largely influenced by evidence from resource-rich countries and south-east asia, with the belief that it will similarly increase the number of healthcare workers in rural areas. experience of the walter sisulu university, mthatha has also significantly heightened this expectation of value accrual.[18] nevertheless, the association between rural exposure and rural retention is unlikely to be simple, as context and other known confounders, such as rural recruitment of learners, are likely to affect the correlation.[8] it is therefore imperative that highquality, methodologically rigorous longitudinal studies be conducted to inform the innovations in rural-based training in sub-saharan africa. oathokwa nkomazana guest editor faculty of medicine, university of botswana, gaborone, botswana nkomazanao@mopipi.ub.bw 1. world health organization. health systems financing: the path to universal coverage. geneva: who, 2010. 2. nkomazana o, peersman w, willcox m, mash r, phaladze n. human resources for health in botswana: the results of in-country database and reports analysis. afr j prim health care fam med 2014;6(1):e1-e8. [http:// dx.doi.org/10.4102/phcfm.v6i1.716] 3. world health organization. working together for health. geneva: who, 2006. 4. hart jt. the inverse care law. lancet 1971;1(7696):405-412. 5. derbew m, animut n, talib zm, mehtsun s, hamburger ek. ethiopian medical schools’ rapid scale-up to support the government’s goal of universal coverage. acad med 2014;89(8 suppl):s40-s44. [http://dx.doi. org/10.1097/acm.0000000000000326] 6. monekosso gl. a brief history of medical education in sub-saharan africa. acad med 2014;89(8 suppl):s11-s15. [http://dx.doi.org/10.1097/acm.0000000000000355] 7. wibulpolprasert s, pengpaibon p. integrated strategies to tackle the inequitable distribution of doctors in thailand: four decades of experience. hum resource health 2003;1(1):12. 8. ranmuthugala gi, humphreys j, solarsh b, et al. where is the evidence that rural exposure increases uptake of rural medical practice? aust j rural health 2007;15(5):285-288. 9. dolea c, stormont l, braichet j-m. evaluated strategies to increase attraction and retention of health workers in remote and rural areas. bull world health organ 2010;88(5):379-385. [http://dx.doi.org/10.2471/blt.09.070607] 10. rabinowitz hk, diamond jj, markham fw, et al. medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. acad med 2008;83(3):234-243. [http://dx.doi.org/10.1097/acm.0b013e318163789b] 11. mariam dh, sagay as, arubaku w, et al. community-based education programs in africa: faculty experience within the medical education partnership initiative (mepi) network. acad med 2014;89(8 suppl):s50-s54. [http://dx.doi.org/10.1097/acm.0000000000000330] 12. child mj, kiarie jn, allen sm, et al. expanding clinical medical training opportunities at the university of nairobi: adapting a regional medical education model from the wwami program at the university of washington. acad med 2014;89:s35-s39. [http://dx.doi.org/0.1097/acm.0000000000000350] 13. van schalkwyk sc, bezuidenhout j, conradie hh, et al. ‘going rural’: driving change through a rural medical education innovation. rural remote health 2014;14:2493. 14. ndhlovu ce, nathoo k, borok m, et al. innovations to enhance the quality of health professions education at the university of zimbabwe college of health sciences – nectar program. acad med 2014;89(8 suppl):s88-s92. [http://dx.doi.org/10.1097/acm.0000000000000336] 15. vovides y, chale sb, gadhula r, et al. a systems approach to implementation of elearning in medical education: five mepi schools’ journeys. acad med 2014;89(8 suppl):s102-s106. [http://dx.doi.org/10.1097/ acm.0000000000000347] 16. muzigaba m, naidoo k, ross a, nadesan-reddy n, pillay s. predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south africa. afr j health professions educ 2016;8(1 suppl 1):xx-xx. [http://dx.doi.org/10. 7196/ajhpe.v8i1.741] 17. couper i, worley ps, strasser r. rural longitudinal integrated clerkships: lessons from two programs on different continents. rural remote health 2011;11(2):1665. 18. iputo je. training doctors from and for rural south african communities. medicc review 2008;10(4):25-29. afr j health professions educ 2016;8(1 suppl 1):86. doi:10.7196/ajhpe.2016.v8i1.797 going rural – protracted immersion or toe-wetting: does it matter? research may 2016, vol. 8, no. 1 ajhpe 3 editorial cultural competence has become yet another buzz word in the education of healthcare professionals. according to prasad et al.,[1] ‘culturally competent care assumes that healthcare providers can learn a quantifiable set of attitudes and communication skills that will allow them to work effectively within the cultural context of the patients they come across’. the questions that arise, therefore, are whether clinical trainees are being fully supported to acquire this fundamental skill and whether overloaded curricula can accommodate the ongoing demand for more ‘teaching time’. a recent survey[2] found that two-thirds of us medical schools offer a medical spanish curriculum. these data are very encouraging until the article is read in more detail. most of these curricula are elective, not eligible for course credit, and few schools reported the use of validated instruments to measure language proficiency after completing the curriculum. major barriers to implementing these curricula include lack of time in students’ schedules, overly heterogeneous student language skill levels, and a lack of financial resources. what about other places in the world? for example, are non-english language proficiency skills being taught to medical students in the uk, where english is not the first language of 4 million residents (8% of the population) and the first language of up to 20% of londoners is other than english?[3] given this information, it is easy to argue that the number of languages spoken in the uk precludes the possibility of teaching one other useful language to students. however, according to the census, four of the five major non-english languages spoken in the uk are indian dialects. therefore, this argument does not really hold water and it obfuscates the need for healthcare professionals to learn a quantifiable set of communication skills that will allow them to work effectively within the communities they are mandated to serve. it is clear from the literature that while medical schools have turned their attention to the issue of cultural competence, they have largely failed to address the challenge of non-english language competence of doctors. when this matter is reviewed through the wider lens of health professions education, the literature on non-english language proficiency in other healthcare training programmes is scant, at best. instead, the literature continues to expand with terms such as cultural awareness, cultural sensitivity, cultural diversity and, more recently, cultural humility. surely, the most basic need of a person seeking healthcare is the need to be heard and understood? so, how are we doing in africa? the issue closer to home is vastly different from the language homogeneity of the developed world. africa has the greatest language diversity in the world[4] and most africans speak more than one language – it has been said that ‘multilingualism is the african lingua franca’.[5] south africa, a case in point, has 11 official languages, and several universities offering degree programmes in the health professions include obligatory, credit-bearing courses in a non-english language, e.g. all health sciences students learn afrikaans and isixhosa at the university of cape town,[6] medical students learn isixhosa and afrikaans at stellenbosch university[7] and isizulu at the university of kwazulu-natal,[8] and pharmacy students learn isixhosa at rhodes university.[9] these and other training programmes have given effect to the mandate to equip graduates with a quantifiable set of communication skills that will empower them to enhance the delivery of healthcare to all south africans. the article by diab et al.[10] in this edition of ajhpe describes a language competence course addressing the needs of isizulu-speaking patients. two other articles[11,12] allude to the challenges of delivering healthcare when trainees do not speak the language of the community, and highlight the strategic importance of basic nonenglish competence in multilingual societies. the issue of cultural competence is a long way from being comprehensively addressed. non-english language proficiency of healthcare trainees in multicultural communities needs to be systematically addressed. is this a challenge which the developed world will take on in a significant and meaningful way, or will cultural competence continue to avoid the need for patients to be heard and understood in a language other than english? vanessa burch editor-in-chief department of medicine, faculty of health sciences, university of cape town, south africa vanessa.burch@uct.ac.za 1. prasad sj, nair p, gadhvi k, barai i, danish hs, philip ab. cultural humility: treating the patient, not the illness. med educ online 2016;21:10. [http://dx.doi.org/10.3402/meo.v21.30908] 2. morales r, rodriguez l, singh a, et al. national survey of medical spanish curriculum in us medical schools. j gen intern med 2016;30:1434-1439. [http://dx.doi.org/10.1007/s11606-015-3309-3] 3. evans n. do you speak english? 2011 census shows that 140,000 uk residents cannot speak the national language. the mirror, 30 january 2013. http://www.mirror.co.uk/news/uk-news/2011-census-shows-140000cannot-1563462 (accessed 28 april 2016). 4. atkinson q. phonemic diversity supports a serial founder effect model of language expansion from africa. science 2011;332:346-349. [http://dx.doi.org/10.1126/science.1199295] 5. desai z. the evolution of post-apartheid policy language policy in south africa: an ongoing site of struggle. eur j intercultural studies 1995;5:18-25. 6. hartman n, kathard h, perez g, et al. health sciences undergraduate education at the university of cape town: a story of transformation. s afr med j 2012;102:477-480. 7. khoury lr. an evaluation of the use of an e-learning platform in complementing xhosa language teaching and learning as an additional language. med thesis. pretoria: university of south africa, 2015. 8. matthews m, van wyk j. speaking the language of the patient: indigenous language policy and practice. s afr fam practice 2016;58:30-31. [http://dx.doi.org/10.1080/20786190.2015.1083718] 9. maseko p, kaschula r. vocational language learning and teaching at a south african university: preparing professionals for multilingual contexts. stellenbosch papers in linguistics plus 2009;38:130-142. 10. diab p, matthews m, gokool r. medical students’ views on the use of video technology in the teaching of isizulu communication, language skills and cultural competence. afr j health professions educ 2016;8(1):11-14. [http:// dx.doi.org/10.7196/ajhpe.2016.v8i1.402] 11. parris dl, van schalkwyk sc, ernstzen dv. home-based rehabilitation: physiotherapy student and client perspectives. afr j health professions educ 2016;8(1):59-61. [http://dx.doi.org/10.7196/ajhpe.2016.v8i1.561] 12. matthews mg, diab pn. an exploration into the awareness and perceptions of medical students of the psychosociocultural factors which influence the consultation: implications for teaching and learning of health professionals. afr j health professions educ 2016;8(1):65-68. [http://dx.doi.org/10.7196/ajhpe.2016.v8i1.562] afr j health professions educ 2016;8(1):3. doi:10.7196/ajhpe.2016.v8i1.802 cultural competence or speaking the patient’s language? research may 2016, vol. 8, no. 1 ajhpe 15 in a constantly and rapidly changing environment, the training of competent, caring and committed healthcare professionals requires a continuous cycle of curriculum revision, implementation and evaluation. this is crucial to keep up to date with changes in educational practice and advances in medical knowledge. society expects that medical graduates function as healthcare change agents.[1] there is an increasing awareness of the centrality of generic learning skills underpinning success at university and fostering effective life-long learning.[2] many higher educational courses have introduced explicit generic skills training in their programmes to ensure that these skills are embedded early.[3] globally, school curricula strive to ensure that such skills are introduced. it is recognised that students are most vulnerable during the crucial transition period from high school to university.[4] the skills profiles of medical entrants are not static; whittle et al.[5] identified a changing profile of the key skills that underpin learning. furthermore, a widening access agenda means that students come from a diverse range of educational backgrounds, some of which almost certainly mean that the students are potentially educationally disadvantaged.[6] this necessitates sufficient support within a curriculum designed to ensure knowledge and skills acquisition relevant to the course, and identifies and addresses deficiencies in students’ learning and other generic skills. curricula need to ensure incorporation of opportunities to practise these skills, and importantly for students, to obtain feedback.[2,6] comprehensive evaluation is essential to understand the effect of the curriculum, including aspects introduced specifically for generic learning skills acquisition. these should include review of the needs of students, ensuring that the necessary generic capabilities and sufficient practice are provided.[7] this requires a regular, cyclical process of curriculum evaluation, especially after significant change, to allow embedding and re-evaluation of whether the desired effect has been achieved and further changes are needed. the purpose of this study was to evaluate the effect of a newly revised curriculum, including the acquisition of generic skills underpinning effective learning, on 1st-year students at the faculty of medicine and health sciences (fmhs), stellenbosch university (su), cape town, south africa (sa). methods context the study population consisted of all 1st-year medical students at the fmhs, su from 2007 to 2011. major curriculum revisions were undertaken in the early years of the 6-year mb,chb programme and implemented from the beginning of 2008 (table 1). the main purpose of the revision was to introduce – in the first semester after arrival at university – curriculum elements focusing on a combination of generic skills and basic practice skills integrated within the sciences in an interdisciplinary, sa medical education context. modules emphasised generic skills, i.e. that students need not only succeed in their studies, but also be responsible professionals. these skills comprise inter alia academic literacy, acquisition of an additional language, stress management, study skills, and how these are relevant in the context of ethics, professionalism, biostatistics, epistemology, and interdisciplinary behaviour. background. curriculum review is a dynamic, iterative process, and the effect of change may not always be wholly predictable. at stellenbosch university, cape town, south africa, revision of the mb,chb curriculum was undertaken to meet enhanced and changing educational and medical practice, and to provide opportunities to enhance optimal generic skills underpinning effective learning, implemented in 2008. objective. to determine the extent to which the newly implemented revised curriculum had an effect on experience in necessary generic skills of students in their first year of study. methods. students provided annual formal end-of-module evaluation in addition to focus group interviews. evaluation by teaching staff was conducted by individual in-depth interviews. a validated generic skills questionnaire completed at the end of each academic year monitored the effect on students’ generic learning skills experience. results. feedback from these different evaluation methods identified specific needs in the newly implemented revised curriculum, including contextualisation of interventions, unnecessary duplication of content and malalignment of assessment. this led to minor curriculum changes and an educational capacity-building programme. these responsive curriculum changes after evaluation had the intended positive effect on students’ selfreported acquisition of generic learning skills. conclusion. the objective of the curriculum evaluation was to monitor content output and the acquisition of crucial generic learning skills. implementation of a revised curriculum combined with ongoing responsive changes aligned with careful multimodality evaluation can ensure that, in addition to scientific knowledge and skills, generic learning skills development of students is facilitated. afr j health professions educ 2016;8(1):15-19. doi:10.7196/ajhpe.2016.v8i1.414 effect of curriculum changes to enhance generic skills proficiency of 1st-year medical students d murdoch-eaton,1 mbbs, md, frcpch; a j n louw,2 bed, med, phd; j bezuidenhout,2 mb chb, mmed, phd 1 medical education, medical school, university of sheffield, uk 2 centre for health professions education, stellenbosch university, cape town, south africa corresponding author: a j n louw (ajnlouw@sun.ac.za) research 16 may 2016, vol. 8, no. 1 ajhpe curriculum evaluation formal end-of-module evaluation by students was undertaken using a standard questionnaire, including closed questions (a 3-point likert scale) and open-ended questions. additionally, two focus group discussions (fgds) were conducted annually (end of first and second semesters; 8 10 students per fgd). teaching staff conducted evaluation by individual in-depth interviews (idis). at the end of 2008, an accreditation visit by the health professions council south africa (hpcsa) provided external evaluation. generic skills evaluation the effect of the students’ generic learning skills experience was monitored using a validated generic skills questionnaire completed at the end of each academic year.[8] students rated their frequency of practice (1 = never, to 4 = every week) of 31 key generic skills, grouped into six categories, i.e. information handling, technical and numeracy, information technology (it), time management, managing own learning and presentation skills (table 2). the questionnaire has been validated and shown to be reliable in the sa context, with stability of items within the skills categories verified by factor analysis.[9] data were analysed with the statistical package for the social sciences (spss) 17 (usa), using analysis of variance (anova) to investigate differences between year groups. while the generic skills questionnaire includes evaluation of confidence, for the purpose of this curriculum experience study the emphasis was on practice. the generic skills profile of students entering sa medical schools, including su, over the period of this study, seems according to studies in progress not to be significantly different across and within institutions. ethical approval ethical approval was obtained from the human research ethics committee, fmhs, su (n07/03/05). informed consent was obtained from all the participants before participation in the study. results enrolment ranged from 230 students in 2007 to 264 in 2011 (total number of students over the 5 years: 1 161). eighty-five percent were firsttime students (direct entrants) aged 18 years, the remainder having undertaken prior graduate studies. the ethnic diversity of the population did not alter significantly over the study period. curriculum evaluation and modifications a comprehensive semester evaluation report is compiled annually, including key aspects of good practice, in addition to areas of concern identified from student and staff feedback, and was used to inform minor curriculum interventions in 2009, which required immediate implementation. full impact evaluation over 2 years informed more substantive curricular change, implemented in 2010 (table 1). contextualisation, alignment and assessment from the fgds it emerged that students were not satisfied with the relevance of the modules with regard to their future professions and considered that assessments were not wholly aligned with outcomes. table 1. summary of medical curriculum changes during the study period 2007 2008 2009 2010 2011 first-semester modules chemistry biology data management physics chemistry for health sciences personal and professional development health in context life forms and functions of clinical importance chemistry for health sciences personal and professional development health in context life forms and functions of clinical importance chemistry for health sciences personal and professional development health in context life forms and functions of clinical importance chemistry for health sciences personal and professional development health in context life forms and functions of clinical importance second-semester modules cell and tissue haematology and immunology respiratory system cardiovascular system ethics essentials of disease processes principles of therapy essentials of disease processes principles of therapy essentials of disease processes principles of therapy introduction to clinical medicine essentials of disease processes principles of therapy introduction to clinical medicine significant changes position natural sciences in a health context reduce science content introduce two generic skills modules replace systemic modules in second semester with basic principles of pathological and therapeutic processes reduce content overlap and duplication between modules decrease number of lectures emphasise contextualising of modules within the health sciences improve quality of study guides change to continuous assessment in two of the first-semester modules restructure and contextualise chemistry for health sciences implement computer skills training contextualise assessments across modules (horizontal integration) dedicated time slots for teamwork implement introduction to clinical medicine module staff changes and capacitybuilding short courses minor refinements in all modules research may 2016, vol. 8, no. 1 ajhpe 17 ‘it doesn’t make sense! it feels if we learn nothing, and nothing is applicable to us … the testing is dumb. parrot learning teaches you very little and all these assessments required parrot learning instead of application of knowledge.’ (fgd10b st4 2008) ‘there are too many themes that waste our time’ and ‘… the relevance of some parts of this work was not clear to me.’ (fgd1 st3 2009) ‘… generally it’s been said that they [students] feel like some of the modules are useless because we are focusing on the main thing that we are here for, and that is medicine.’ (fgd10 st5 2008) students’ comments during fgds and the formal module feedback at the end of each module contributed to recognition of a need for several changes. the key interventions focused around improving the contextualising topics, especially chemistry and generic learning skills; alignment of assessment and outcomes; use of integrated single assignments to assess more than one theme; and change from end-of-semester to continuous assessment in two modules. methods for enhanced contextualisation included starting the semester with role-play by teaching staff and senior faculty management demonstrating the relevance of all four modules, followed by small group discussions and a debriefing, an explanation at the start of each theme of the relevance of that specific theme, and the continuous use of real-life examples. curriculum mapping reducing overlap, fostering integration, and eliminating conflicting messages reflected in the study guides were at the heart of curriculum mapping interventions. prior to the curriculum interventions students commented: ‘some content between the modules and different themes overlap and repeats.’ (fgd5 st5 2009) ‘the themes in the module were very random and the information wasn’t continuous and it was frequently repeated and didn’t seem relevant.’ (fgd8 st7 2009) educational capacity development the need for educational capacity development was illustrated by the following quote from a module chair: ‘some lecturers feel overwhelmed by large class groups and experienced it as dominating.’ (idi3) some students felt as follows: ‘… the lecturers i think can still be a bit more interactive with us, and not just stand there and do their lecture slides.’ (fgd1 st4 2009) this was echoed by other teaching staff and resulted in the development and implementation of a very successful short course on interactive teaching, with an emphasis on large classes. hpcsa evaluation in 2008 the external evaluation panel of the hpcsa highlighted a number of positive aspects of the newly implemented 1st-year curriculum: the interdisiplinary nature of this phase was commended, especially as it does not exist elsewhere in sa; the emphasis on teamwork and establishing the concept of a health team in the first year; the development of communications skills, stress management and academic literacy; and the use of case studies on the ‘essentials of disease processes’ module in the second semester. recommendations were made to improve the extent of integration of content in the four modules, align assessment with outcomes, and be vigilent for ‘content overload’. generic skills evaluation responses were obtained from 1 002 students at the end of each academic year over the study period (86.2% response rate). the new curriculum, from implementation in 2008, showed a sustained and positive effect on students’ practice in information handling skills (fig. 1). technical and numeracy skills, however, initially showed a negative effect, with significantly reduced reported practice; curriculum changes implemented in 2010 in response to this led to a reversal. similarly, table 2. thirty-two generic skills evaluated by the questionnaire, grouped into six main categories[8] categories skills information handling researching a new topic using library resources selecting information interpreting information using information to solve problems or answer questions technical and numeracy skills performing laboratory experiments designing your own experiments analysing experimental data, e.g. graphs drawing conclusions from your data calculations statistics it skills word processing spreadsheets databases using the internet to find information using email organisational skills managing your time/meeting deadlines planning tasks thoroughness/accuracy teamwork managing your own learning coping with stress learning from other students receiving feedback positively giving constructive feedback taking responsibility for your own learning evaluating your strengths and weaknesses presentation skills essay writing writing laboratory reports explaining ideas giving oral presentations communicating with other scientists/doctors communicating scientific/medical ideas to non-scientists research 18 may 2016, vol. 8, no. 1 ajhpe significantly enhanced information technology skills, managing own learning skills and organisational skills practice were only reported from 2010 (figs 2 4). no effect was identified with presentation skills practice. interventions in the individual curriculum changes that contributed to enhanced practice are illustrated in table 1. discussion curriculum review is a dynamic, iterative process and the effect of change may not always be entirely predictable. curriculum content and process should be continually reviewed, recognising that the student population changes and that delivery is influenced by a multitude of factors ranging from the educational environment through to teachers. bitzer[10] highlights that a curriculum must maintain relevance in the context of societal, university and student changes, and to improve it must be evaluated regularly. the evaluation process at su is strengthened by a formal annual process of module evaluation, including both student and teaching staff perceptions. this study is additionally strengthened by information provided by the generic skills practice evaluation, which collectively contributed to a responsive curriculum review evaluation, resulting in appropriate and responsive considered interventions.[8] evidence of enhanced skills around ‘managing your own learning’ underpins much of the intended curriculum effect, initially introduced in 2008 and reinforced in 2010. the effect of changes in assessment approach on students’ learning is well recognised.[11] assessment changes in the curriculum review included enhanced alignment with learning outcomes, identifying clearly for students the importance of skills and content, e.g. around application of academic literacy. some significant increases in the generic skills practice level, especially from 2010, indicate the influence of a change to continuous assessment in the modules that particularly require generic learning skills around information handling (academic literacy), technical and numeracy (statistics), it skills (word processing and spreadsheets) and organisational skills. one particularly significant intervention was recognised as being necessary after consideration of the 2008 and 2009 curriculum evaluation results, including feedback from students and review of teaching staff interviews, i.e. the full effect on student learning had not been realised. enhancement of teaching skills was clearly identified as an area of particular need to fully implement the intended curriculum changes. a programme of staff development was therefore implemented before the start of 2010. the subsequent effect on students’ generic learning skills end 2007 end 2008 end 2009 end 2010 end 2011 3.35 3.30 3.05 m ea n r at in g academic year 3.25 3.20 3.15 3.10 fig. 1. information-handling skills (practice). end 2007 end 2008 end 2009 end 2010 end 2011 3.35 3.30 3.25 3.20 3.10 m ea n r at in g academic year 3.15 fig. 2. information technology skills (practice). end 2007 end 2008 end 2009 end 2010 end 2011 3.75 3.70 3.65 3.60 3.55 3.50 3.45 m ea n r at in g academic year fig. 3. organisational skills (practice). end 2007 end 2008 end 2009 end 2010 end 2011 3.45 3.40 3.35 3.30 3.25 m ea n r at in g academic year fig. 4. managing own learning skills (practice). research may 2016, vol. 8, no. 1 ajhpe 19 experience was evidenced by further enhancement of skills practice in 2010 and 2011. the sustained increase in information handling skills practice reflected the new curriculum requirement for participation in ‘research’ from admission. the revised course required students to actively use and identify a range of resources to select, interpret and apply information to problem solving. these include diverse activities ranging from, e.g. interviewing people to gain information, to reading up on topics, through to a more scientific enquiry from conventional written texts. moreover, the increase in experience was also driven by a continuous process of formative and summative assessments and feedback, including assignments, presentations and online quizzes.[7] the initial reported reduction in practice in technical and numeracy skills in 2008 and 2009, followed by an improvement with an increase in experience in these skills in 2010 and 2011, is interesting. this is an example of a potentially unintended consequence of curriculum changes and why monitoring of skills practice crucially contributed to the curriculum evaluation. the changes can be explained by the removal of physics as a pure scientific module in the first year, and the down-scaling of biostatistics in the new revised curriculum. curriculum interventions subsequently introduced included contextualisation and redesign of modules (such as chemistry and biostatistics), which might account for the enhanced reported practice from 2010. no single intervention is likely to wholly account for the enhanced skills, which illustrates the value of integrated, collaborative discussion of multiple sources of evidence and feedback. the world federation for medical education identified a minimum basic standard for effective use of e-learning skills during training. an often-made assumption is that all students have sufficient practice in it skills during their high-school years.[5] in sa, however, it is possible that some students enrolling at universities lack these skills.[12] as part of the curriculum monitoring, students and staff indicated a potential deficiency in it skills in some 1st-year students. the implementation in 2010 of a specific it intervention may be interpreted as the reason for the resulting reported increase in it skills. there has been an increasing trend in the level of experience of students’ organisational skills since 2008, but a definite and significant positive change occurred in 2010 and 2011. organisational skills include aspects of self-management, such as meeting deadlines. to meet deadlines, students have to plan and manage their time. from 2010, two of the modules used continuous assessment, which required students to take responsibility for managing different assignments and tasks on a variety of topics, some involving teamwork and meeting different submission dates. students therefore have to learn to work in a group, and learn from, receive and give feedback to one another. while working in a team, students evaluate their own strengths and weaknesses, and soon realise the important role of each individual group member for the group to function optimally.[13] this method of teaching and assessing students forced them to take responsibility for their own learning, which consequently had an effect on students’ ‘managing your own learning skills’, evidenced by the positive, sustained enhanced practice in this skill. these skills are important for success in high-pressure environments, particularly for later success at university, and subsequent future medical practice. it is also possible that other areas of change management, including enhanced staff communication, engagement with collaborative decisionmaking (at all levels – from administrative support staff to teaching staff ), scrutinising study guides to enhance transparency, and other subtle changes in approach that are difficult to measure and articulate, are almost certainly cumulative and contributory. this approach to curriculum review reinforces the importance of a scholarly approach to all aspects of educational practice, and aligns with van der vleuten’s appeal that educational research, which informs practice, should be evidence based.[14] conclusion contextual skills development in medicine is vital and more effective when embedded in the curriculum. this underpins the approach taken in this curriculum review, ensuring that key generic learning skills are addressed. our study indicates the value of curriculum evaluation that goes beyond monitoring output only in terms of content outcomes. it also evaluated the effect on student learning, specifically how they are equipped with generic learning skills to support their expected success at university. such a comprehensive methodological approach not only takes into account feedback and evaluation from staff and students, but, importantly, evaluates effect, particularly on skills development. this ensures identification of how the curriculum meets the diversity of learning needs and skills present on entry into higher education. practice points • scientific research is a tool to evaluate a curriculum and enhance the validity of the evaluation process, and results in appropriate and responsive considered interventions. • change to the type of assessments results in significant increased changes to the generic skills practice levels of students. • curriculum changes have to be accompanied by the necessary and appropriate staff development initiatives. • key generic skills have to be embedded in a curriculum, and the contributions of the curriculum have to support student success by means of methodological evaluation processes. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 2. murdoch-eaton dg, whittle s. generic skills in medical education: developing the tools for successful lifelong learning. med educ 2012;46:120-128. [http://dx.doi:org/10.1111/j.1365-2923.2011.04065.x] 3. barrie s. a conceptual framework for the teaching and learning of generic graduate attributes. studies in higher education 2007;32:439-458. [http://dx.doi.org/10.1080/03075070701476100] 4. paul g, hinman g, dottl s, passon j. academic development: a survey of academic difficulties experienced by medical students and support services provided. teach learn med 2009;21:254-260. [http://dx.doi. org/10.1080/10401330903021041] 5. whittle sr, pell g, murdoch-eaton dg. recent changes to students’ perceptions of their key skills on entry to higher education. j further higher educ 2010;34:557-570. [http://dx.doi.org/10.1080/030987 7x.2010.512082] 6. burch vc, sikakana cnt, gunston g, shamley dr, murdoch-eaton d. generic learning skills in academicallyat-risk medical students: a development programme bridges the gap. med teach 2013;35:671-677. [http://dx.doi. org/10.3109/0142159x.2013.801551] 7. kember d. 2009. nurturing generic capabilities through a teaching and learning environment which provides practice in their use. higher educ 2009;57:37-55. [http://dx.doi.org/10.1007/s10734-008-9131-7] 8. whittle sr, murdoch-eaton dg. curriculum 2000: have changes in sixth-form curricula affected students’ key skills? j further higher educ 2005;29:61-71. [http://dx.doi.org/10.1080/03098770500037762] 9. murdoch-eaton d, manning d, kwizera e, burch v, pell g whittle s. profiling undergraduates’ generic learning skills on entry to medical school: an international study. med teach 2012;34:1033-1046. [http://dx.doi.org/10.3 109/0142159x.2012.706338] 10. bitzer e. first-year students’ perceptions of generic skills competence and academic performance: a case study at one university. s afr j higher educ 2005;19(3):172-187. [http://dx.doi.org/10.4314/sajhe.v19i3.25512] 11. cilliers fj, schuwirth lwt, herman n, adendorff hj, van der vleuten cpm. a model of the pre-assessment learning effects of summative assessment in medical education. adv health science educ 2012;17:39-53. [http:// dx.doi.org/10.1007/s10459-011-9292-5] 12. boveé c, voogt j, meelissen m. computer attitudes of primary and secondary students in south africa. computers human behav 2007;23:1762-1776. [http://dx.doi.org/10.1016/j.chb.2005.10.004] 13. hrynchak p, batty h. the educational theory basis of team-based learning. med teach 2012;34:796-801. [http:// dx.doi.org/10.3109/0142159x.2012.687120] 14. fincher rme, simpson de, mennin sp, et al. scholarship in teaching: an imperative for the 21st century. acad med 2000;75:887-894. october 2016, vol. 8, no. 2 ajhpe 129 researchshort communication context and setting cuban medical internationalism[1] is a strategy aimed at providing medical personnel to under-resourced countries. to address the severe shortage of medical doctors in rural south africa (sa), our government forged an intergovernmental agreement to train rural and disadvantaged students at tertiary cuban medical facilities. the collaboration students spend a year studying spanish, and then receive an additional 4 years of medical training before returning to sa to complete their 5th and final academic years. they graduate from a local medical school with a view to practise in rural and underserved areas of sa. this report summarises a study that explored the success of the collaboration strategy at a local medical school. why the idea was necessary despite the implementation of a learner support programme, general observations indicate that approximately two-thirds of each returning class (averaging 10 13 students) are unable to complete their training within the dedicated 18 months after returning to sa. generally, the students have difficulty integrating and applying their knowledge and skills on the sa clinical platform; they struggle to translate their knowledge into english; and they have had insufficient exposure to common sa diseases. what was done? to strengthen and support the collaboration students, this quantitative study used questionnaires and interviews to investigate the curricular experience and teaching exposures in clinical skills of the collaboration students before their return to sa. all the students were invited and participated (n=11). institutional ethical approval was obtained. results and impact findings revealed that the cuban curriculum emphasises primary healthcare and training in clinical settings, which focus predominantly on preventive care. the healthcare philosophy also considers the disease profiles prevalent in the cuban setting, thus leaving students inadequately prepared for clinical practice in sa. the majority of students displayed gaps in their knowledge and an inadequate performance of clinical skills.[2] the students found it difficult to translate the concepts learnt in spanish into english medical terminology, and they reported inadequate knowledge of infectious diseases, specifically hiv/aids and tuberculosis. knowledge and understanding of the context of healthcare delivery, including population characteristics and disease profiles, impact on curricular decisions. treating and managing infectious diseases that are prevalent in sa require consideration and communication between participating institutions to ensure adequate exposure and training for practice in sa conditions. sa institutions are socially accountable to train doctors appropriately to respond to the needs of local communities. it is therefore important to support the academic needs and requirements of the collaboration students to ensure their successful education and training. this study identified areas where students lacked knowledge and skills, which informed the design and content of the support programme offered at our institution. conclusion the study has highlighted the need to compare educational exposures and clinical experiences of students at our institution with those of the collaboration students to inform the details required in the support programme. cuban medical internationalism may benefit countries with a similar language, patient profile and health contexts. this strategy, however, has limitations in sa, as it requires schools to allocate additional human and financial resources to support the collaboration students’ adaptation to the local context. references 1. huish r, kirk jm. cuban medical internationalism and the development of the latin american school of medicine. latin am perspect 2007;34(6):77-92. doi:10.1177/0094582x07308119 2. motala m, van wyk j. south african-cuban medical collaboration: students’ perceptions of training and perceived competence in clinical skills at a south african institution. s afr fam pract 2016;1(1):1-6. doi:10.1080/20786190.2015.1120936 afr j health professions educ 2016;8(2):129. doi:10.7196/ajhpe.2016.v8i2.641 cuban medical collaborations: contextual and clinical challenges m motala, mb chb, mmedsci; j m van wyk, bsc (ed), bed, med, phd department of clinical and professional practice, nelson mandela school of medicine, faculty of health sciences, university of kwazulu-natal, durban, south africa corresponding author: j m van wyk (vanwykj2@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://dx.doi.org/10.1177/0094582x07308119 http://dx.doi.org/10.1080/20786190.2015.1120936 editorial 146 november 2015, vol. 7, no. 2 ajhpe one of the key mandates of the 21st century is the provision of comprehensive, integrated healthcare to all members of society. for this to become a reality the training needs of all healthcare professionals must be addressed by the research endeavours of health professions educators. so, the key question is, ‘does the current health professions education research agenda address the training needs of all healthcare professionals?’. a simple ‘dipstick’ test can be used to provide a broad answer to one aspect of this question. i recently paged through the latest editions of 4 prestigious health professions education (hpe) journals, including medical education, medical teacher, academic medicine and advances in health sciences education, and found that only 8 of 51 research reports (16%) focused on the training needs of healthcare professionals other than undergraduate and postgraduate medical trainees. while this crude audit has many limitations, it does suggest that the training of medical doctors continues to dominate the hpe research agenda despite the global call for transformation of the training of health professionals, as outlined in the widely cited lancet commission published in 2010.[1] does the african journal of health professions education (ajhpe) suffer from the same malady or are the education needs of a broader range of health professions being addressed in this journal? the current edition of ajhpe contains only 3 publications of a total of 18 articles (17%) that focus on the training of medical doctors. the other 15 publications (83%) address the education needs of 9 other healthcare professions, including nursing, dentistry, physiotherapy, occupational therapy, emergency medical services, dietetics, psychology, optometry and pharmacy. this finding demonstrates one of the key purposes of the journal – to provide a common platform for the dissemination of information addressing the education needs of all healthcare professionals. another aspect of the question posed at the outset of this editorial is whether the education needs of hpe communities of practice, which vary by geographical location, language of instruction, ethnic traditions and beliefs and many other contextual factors, are being addressed. such factors significantly influence the design and delivery of education programmes for healthcare practitioners. while all these factors are important, the geographical location of the authors and their work is an easy way of obtaining a bird’s eye view of the hpe research landscape. of the 51 pub­ lications included in the 4 journals already mentioned, 37 articles come from north america, 10 from europe and the uk, and 4 from the pacific rim, specifically australia, korea and hong kong. the absence of a single article from any of the brics countries (brazil, russia, india, china, south africa) is striking. once again, a ‘spot check’ has many limitations, but the annual sprinkling of a few articles from 5 countries that account for 40% of the global population of 3 billion people, cover more than a quarter of the world’s land area over 3 continents and 25% of the global gdp,[2] has to raise the level of response – from concern to one of action. this challenge can be addressed by finding ways of supporting the process of hpe research capacity in developing countries rather than trying to establish why these countries have such limited visibility in prestigious journals. a large us­funded hpe capacity development project involving more than 10 hpe institutions in sub­saharan africa, the medical education partnership initiative (mepi),[3] has yielded a number of worthy publications, including a supplement published in academic medicine in 2014.[4] the question, however, is whether the success of these african institutions can be independently sustained and locally replicated in the long term. building long­term hpe research and development partnerships between mepi­funded institutions and the many other unfunded hpe institutions in sub­saharan africa would be an indicator of real success, i.e. large­scale continental transformation initiated by small pockets of excellence. in addition to hpe capacity development projects in africa, journal editors can, and do, play an important role in advancing the scholarship of hpe by providing publication opportunities for emerging researchers. this approach has been adopted by journals such as medical education (see the section ‘really good stuff ’) and academic medicine (see the section ‘short report’). this practice has also been adopted by ajhpe; short reports of <1 500 words, including 1 table or figure and 5 references, appear in this edition of the journal. this category of research publications specifically caters for: (i) work done in single centres; and/or (ii) studies that include a small number of participants; and/or (iii) early innovative work with limited evaluation of impact. this initiative aims to expand the publication footprint of ajhpe by including more work from hpe institutions beyond the borders of south africa. in closing, the editorial team would like to wish all our readers well for 2016 and we look forward to receiving more manuscripts from our colleagues in south africa and those further afield in the rest of sub­ saharan africa. as one of my colleagues would say, ningene kakuhle kunyaka ka – 2016. vanessa burch editor-in-chief african journal of health professions education vanessa.burch@uct.ac.za 1. frenk j, chen l, bhutta z, cohen j, crisp c, evans t. health professions for the new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923­1958. [http://dx.doi. org/10.1016/s0140­6736(10)61854­5] 2. population statistics for brics countries. http://globalsherpa.org/bric­countries­brics/ (accessed 10 november 2015). 3. medical education partnership initiative. http://www.mepinetwork.org (accessed 10 november 2015). 4. association of american medical colleges. the medical education partnership initiative: investing in medical education in sub­saharan africa. academic medicine 2014;89(suppl 8):s1­s116. [http://dx.doi.org/10.1097/acm.0000000000000357] afr j health professions educ 2015;7(2):146. doi:10.7196/ajhpe.704 has the health professions education research agenda changed in the new millennium? ajhpe issn 0256-9574 african journal of health professions education july 2012, vol. 4 no. 1 ajhpe 530.indd research october 2014, vol. 6, no. 2, suppl 1 ajhpe 211 the attainment of clinical competence is a key outcome of physiotherapy programmes worldwide. a goal of the physiotherapy undergraduate programme at stellenbosch university (su) is that new graduates will be able to function as reflective practitioners in the south african (sa) healthcare context. therefore, optimal learning opportunities are crucial for students to develop the necessary skills to attain this outcome. clinical education, a situated learning experience, is acknowledged as a powerful learning experience to develop students’ skills and professional knowledge through social interaction.[1] learning thus occurs within the community of practice (clinical environment) and necessitates participation and engagement to develop competence. market expectations of physiotherapy reflect changing demands in competencies for graduates. a greater focus is now being placed on client centeredness, community-based care and management of chronic diseases.[2] in sa the healthcare context has been reformed to emphasise primary healthcare (phc). phc refers to healthcare that is provided in the community, addressing the health needs of the community within the community.[3] the components of phc include community participation and empowerment while integrating preventive, promotive, curative and rehabilitation services. improving access to healthcare and developing phc has been at the centre of transforming healthcare.[4] to facilitate this transformational process for healthcare providers in sa, the department of health introduced a year-long compulsory community service for all newly qualified healthcare practitioners, including physiotherapists.[4] new physiotherapy graduates are thus placed in rural and under-resourced regions in an attempt to redistribute services to underserved communities. it is imperative that new graduates are equipped with the necessary skills to function in such contexts. therefore, physiotherapy curricula need to include the philosophy of community-based education (cbe) to develop the knowledge, technical and affective skills needed in a phc context. cbe is advocated as necessary to equip health professionals for future and changing healthcare systems, to be responsive to community needs and to prepare students for future professional work at the community level.[5-7] cbe is described as learning activities that occur in the community, through active engagement with community members, while providing healthcare relevant to the community needs. phc placements are thus ideally suited for learning and applying the principles of cbe. cbe has several advantages for the students and the community concerned. for students, the advantages include: opportunities to interact with people from different backgrounds; developing social responsibility; planning and delivery of healthcare interventions with the community; developing appropriate knowledge and skills; deepening understanding of health and social services; promoting client-centered care; enhancing interdisciplinary teamwork; and increased recruitment into phc.[2] for communities, advantages are: improved access to healthcare; the specific needs of the community are considered and addressed; and participation in the care process.[5] cbe thus reinforces a strong social justice ethic, and provides opportunities to develop and use competencies that are needed to improve the health of citizens and society.[8] in the sa context, two studies investigated the perceptions of new physiotherapy graduates about their preparedness for community service.[4,9] two other studies evaluated physiotherapy students’ experiences about their community-based clinical placements,[10,11] while another study involved a document analysis of physiotherapy cbe curricula.[12] these studies found background. primary healthcare (phc) is necessary to address the health needs of communities. it creates the opportunity for the attainment of curricular outcomes through community-based education. appropriate learning opportunities are needed to enable students to develop the necessary skills to attain these outcomes. objectives. to describe the learning opportunities occurring during physiotherapy phc placements and to explore the role the learning environment and learning opportunities played in attaining the outcomes for the placements. methods. a descriptive case study was conducted using different strategies for data collection and analysis. participants completed a record sheet to indicate time spent on different activities. observational site evaluations, individual interviews with site representatives and focus-group discussions with students were conducted to explore their perceptions about phc clinical placements. results. the results indicated that the participants valued phc placements as powerful learning environments. however, students did not have the opportunity to engage satisfactorily in activities that foster the principles of phc. participants acknowledged that several resource constraints existed in this context; however, they identified several potential valuable learning opportunities. students suggested curriculum-specific strategies needed to prepare them for phc, and recognised the need for healthcare services in the communities they served. conclusion. while the phc learning environment was rich and authentic, learning opportunities need to be optimised to enable students to fully reach the outcomes for the placements. learning opportunities need to be crafted to foster collaborative learning, interdisciplinary learning, community engagement and empowerment. ajhpe 2014;6(2 suppl 1):211-216. doi:10.7196/ajhpe.530 learning experiences of physiotherapy students during primary healthcare clinical placements d v ernstzen, bsc (physio), mphil (higher ed); s b statham, msc (physio); s d hanekom, phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: d v ernstzen (dd2@sun.ac.za) researchresearch 212 october 2014, vol. 6, no. 2, suppl 1 ajhpe cbe to be a valuable learning experience which furthered the students’ understanding of social determinants of health.[10,11] however, these studies identified that students needed more preparation to succeed in the complex health environment of community physiotherapy.[4,9] in particular, a focus on the social, political and economic factors that impact health, the local burden of disease and cultural competence was advocated. the need for interdisciplinary collaboration was also highlighted. moreover, ramklass[4] advocates that curriculum design needs to be dynamic and responsive to local and global policies on cbe. the changes in healthcare provision in sa, the complexity of the healthcare system and the su division of physiotherapy’s accountability towards its graduates and the profession, motivated the need to determine if the division’s phc placements offered the necessary cbe components. the objectives of this study were to describe the learning opportunities occurring during physiotherapy phc placements, and to explore the role the learning environment and learning opportunities played in attaining the learning outcomes for the placement. context of the study physiotherapy students at the faculty of medicine and health sciences (fmhs), su, sa, rotate in groups of 2 4 students through a 6-week phc placement in their final year. at the time of the study, four different phc clinical sites were used; one was rural and three were in peri-urban areas. two of the clinical sites were based at community health centres (chcs) and students used the chc as their base. the other two sites lacked a chc and students organised their services from their vehicles. at the latter two sites, the students served as the primary service providers of physiotherapy in the absence of permanently employed physiotherapists. students were supported by a clinical facilitator from su, and where applicable, also by the chc physiotherapist. the outcomes for these placements are summarised in table 1. methods research design a descriptive, situational case study was conducted, to provide an in-depth description of the phc clinical setting.[13] a mixed-method study generated qualitative and quantitative data which obtained input from different stakeholders, using different strategies. population all final-year physiotherapy students completing their phc rotation during 2006 were eligible to participate in the study (n=40), as were all physiotherapy clinical facilitators involved in these placements (n=6). different data collection activities and different sampling strategies were used, as explained below. table 1. the learning outcomes and opportunities for the primary healthcare (phc) placements outcomes learning opportunities home visits occupational visits therapeutic classes educational sessions screening interdisciplinary sessions daily duties community health centre • source appropriate information to plan a client assessment x x x x x x x • conduct an interview with client/carer x x x x • plan, perform and motivate a physical evaluation of a client x x x x x • develop a problem list focused on main problems and rehabilitation needs of the client x x x x x • formulate appropriate rehabilitation goals with the client x x x x x x • select and perform appropriate intervention strategies for optimum rehabilitation x x x x x x x • use appropriate outcome measures x x x x x x • teach clients/carers appropriate home/work interventions x x • advise clients/carers about applicable management x x x x x x x • analyse home/work environments and suggest appropriate recommendations x x • present effective therapeutic classes x x • refer clients appropriately x x • scientifically document all findings x x x x x x • become acquainted with safety and emergency procedures in the phc environment x x x x research october 2014, vol. 6, no. 2, suppl 1 ajhpe 213 data collection and procedures all data were collected during the last two clinical rotations of the year. the data collection activities included: student record sheets; site visits (observation using a site evaluation form); interviews with clinical facilitators; and student focus-group discussions (fgds). student record sheets to determine the type of activities that students were involved in during their phc placement, and how much time they spent on different activities, an activity questionnaire sheet was developed. purposive sampling was used, to include those students who were on the phc placement at that specific time to generate realistic data for the timeframe, and to limit recall bias. students on phc placements (n=16) were invited to complete the two-page record sheet. the record sheet was set up by one member of the research team, and was checked and adapted by two other members. the students were trained in how to complete the data sheet to aid understanding and correct completion. the activities covered in the record sheets included: new patient (evaluation); individual patient treatment; group exercise classes; promotional talks; home visits; screening in clinics; ward rounds; documentation; feedback between team members; academic demonstrations; clinical supervision; and other. participants indicated the time spent on different activities in units of 10 minutes. site visits and interviews with site representatives different observational teams among the research group, including one external auditor, were assembled to visit the different phc sites. a site evaluation form was developed by one member of the research team to guide the observational process. this form focused on facilities, apparatus, safety and security. the procedure for the site visits was as follows: an appointment for a visit was made; the team visited the site, and completed the site evaluation form; following the observation, an interview was conducted with the site representative (physiotherapy clinician and/or clinical supervisor). this interview focused on specific aspects identified on the site evaluation form, namely: staff employed at the site; interdisciplinary activities; community outreach activities; treatment protocols; patient profile; administration and management. these themes were addressed to provide a holistic picture of the healthcare setting. at the end of the visit, the visiting team, together with the site representative, developed a swot (strength, weakness, opportunity and threat) analysis of the site. this unique approach was used to extract the data into the significant swot aspects as relevant for physiotherapy undergraduate training. focus-group discussions with students four semi-structured fgds were conducted by an independent interviewer. all final-year students were invited to participate in fgds about their clinical experiences. fgds were conducted after the final clinical placements. four focus groups, consisting of ten participants per focus group, were invited to participate. topics discussed are listed in table 2. appropriate probing questions were used to develop a deeper understanding of participants’ accounts. fgds were conducted at the division of physiotherapy, su, in english and/or afrikaans according to the choice of the participants, and each lasted approximately 40 minutes. data management and analysis the quantitative data generated by the time sheets were recorded in a purpose-built data collection sheet in ms excel. data were then analysed on a statistical program (statistica 7), using proportions. the qualitative data generated by the site visits, combined with the interview of the site representative, were deductively analysed using the swot analysis as an analytical framework, as explained in the previous section. the qualitative data generated by the students’ fgds were recorded using a digital voice recorder and were downloaded and saved after the fgds. unique serial numbers were given to each data set. the fgds were then transcribed by an independent transcriber, and analysed by an independent and experienced research assistant using content analysis.[13] this process included: familiarising oneself with the data; identifying themes; creating a theme list (codebook); coding and categorising the data; interpretation of data; and checking. the coding and themes were checked by the research team to aid trustworthiness. for the purpose of this manuscript, data pertaining to phc were extracted. data triangulation was done by using various data sources (students and clinical educators), methodological triangulation by using various techniques and instruments of data generation, and investigator triangulation by discussing findings within the research group. triangulation is a valuable means of ensuring the credibility of the research as data are seen from different perspectives, and data may be corroborated.[14] ethical considerations the protocol for the study was approved by the health research ethics committee (number n05/08/144) at fmhs, su, sa. permission to undertake the study was obtained from the division of physiotherapy chairperson. persons eligible to participate in the study were contacted and the aim and procedures of the study were explained. written informed consent was obtained from participants. the following measures were taken to ensure participant confidentiality: no identifying information was expected on the time sheet; the names of the clinical sites are not published; the voice recordings of interviews and the transcripts were coded using non-identifying particulars. results this section elaborates on the main findings gathered through the student record sheets, observational site visits and the fdgs with participants. table 2. main interview schedule for the student focus-group discussions • what is your opinion of the clinical placements you were on? • what aspects of the clinical placements did you enjoy? • what value did the clinical placements add to your learning? • what were the problems that you encountered during clinical placements? • what suggestions do you have to improve the clinical placements? • do you think that interdisciplinary learning takes place during clinical practice placements? • tell me about how you experience the service delivery part of your clinical training? • how did this service delivery impact on your learning experience during the placement? researchresearch 214 october 2014, vol. 6, no. 2, suppl 1 ajhpe student record sheets fourteen of 16 students completed record sheets (88%). the data for all four phc sites had the same pattern, and were therefore combined (fig. 1). students spent most of their time performing individual treatment sessions. this activity communicates a strong focus on the curative/treatment aspect of healthcare service. little time was spent on promotive and preventive strategies such as group classes, educational talks, home visits and occupational (work) visits. this lack of focus on community participation and empowerment was not congruent with the philosophy of phc. observational site visits and site representative interviews table 3 provides the combined swot matrix of the phc sites as constructed from the observational site visits and site representative interviews. the strength of the phc placements was the variety that it offered. staff shortages, as well as the lack of facilities and equipment, were shared weaknesses. the range of learning opportunities was diverse and abundant, ranging from the outright need for the healthcare services, to possibilities of participation in community activities. staff and student burnout, as well as safety concerns, were identified as important threats. fgds with students students’ perceptions of phc clinical placements are summarised in table 4. the main theme, sub-theme and motivating verbatim quotes are provided. for the purpose of this article, some quotations have been translated from afrikaans to english by the primary author. five main themes emerged: • preparation for phc placements. • guidance and supervision is much appreciated, but has not been a priority. • learning opportunities are abundant, but are not always aligned with the outcomes. • interdisciplinary learning advantages and disadvantages. • preparation for the future clinical practice. discussion the main findings of the study are that while the phc learning environment was rich and authentic, the learning opportunities needed to be optimised to enable students to fully reach all outcomes for the placement. the activities that students participated in as part of their placement did not continually reflect a focus on phc, as illustrated by fig. 1 and table 3. it was clear that amendments in learning opportunities would be required to optimise attainment of outcomes. indeed, a revisit of the outcomes of the phc placements was also pertinent. to be aligned with the philosopy of phc, learning activities and outcomes should include a focus on community participation and empowerment through preventive, promotive and rehabilitation activities.[3,4] participants in this study reported feeling unprepared for the activities and challenges that they faced during the phc placements and made suggestions for curriculum content that would aid in their preparation. the following preparatory components were suggested: clarifying expectations for phc; foundational aspects of group therapy and homebased care; social determinants of health; and the contextual factors of the communities being served. these suggestions by participants are congruent with literature about preparation for phc clinical rotations.[2,4,5,8] participants acknowledge the phc placement as an authentic and rich learning environment. this environment was reported to create valuable learning opportunities that transcended personal and professional growth. however, several resource 18 000 16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 ti m e sp en t (1 0/ u n it ) clinical activities ne w pa tie nt ev alu at io n in di vid ua l t re at m en t do cu m en ta tio n cl in ica l s up er vis io n ac ad em ic ot he r pa tie nt de m on str at io n pr og re ss re po rt (fe ed ba ck ) cl as se s ho m e v isi t he alt h t alk s m an ag em en t o th er w ar d r ou nd sc re en in g fig. 1. summary of the time sheets of students on phc placements (10-minute units per day). table 3. combined swot analysis for the four physiotherapy phc placements strength weakness opportunity threat full-time physiotherapist employed (at two sites) multiple professions at the site reasonable teamwork established site variety of clinics strong phc focus (at three sites) variety of activities and classes good referral system in place (one site) no physiotherapist employed (at two sites) insufficient space lack of equipment/lack of suitable facilities insufficient staff to cope with patient numbers, administration and students little guidance and support for students no cardio-pulmonary rehabilitation enough patient numbers diversity of patients presence of volunteer workers interdisciplinary activities community health workers/homebased carers volunteers prospect of establishment of services not yet offered staff need/would like more support from employer multiple locations may lead to fragmentation little focus on phc at one site no central work location (base) for students at the sites where there was no chc safety and security concerns regarding parking research october 2014, vol. 6, no. 2, suppl 1 ajhpe 215 constraints were identified as part of this environment. the infrastructure of all placements was limited, and this influenced learning in positive and negative ways. this finding is in keeping with that of skoien et al.,[1] who found that physical surroundings such as space and materials can either inhibit or facilitate learning. the resource-constrained environment in this study challenged participants’ structured approach to tasks. however, these challenges provided students with the opportunity to think creatively and laterally to solve problems, as reported by taukobong.[11] the challenge of a resource-constrained environment is a recurring theme in the literature regarding physiotherapy phc, and includes (as also identified in this study) lack of equipment, facilities, staff constraints and safety concerns.[4,9,11] despite the abovementioned resource constraints, the information gained from the site visits and interviews emphasised the tangible healthcare needs of the community being served. this need was evident in the sheer number of patients who sought healthcare. clinical staff and students reported feeling overwhelmed by the community needs. as a result, provision of healthcare focused on service delivery in the form of direct clinic-based patient care, and subsequently not on community participation (fig. 1). consequently, several learning opportunities appropriate for students were not identified, optimised or utilised. the tension noted between providing optimal patient care and the creation of sufficient learning opportunities is not unique to this study and is substantiated by other research findings.[15,16] the challenges of high patient volumes and minimal resources, together with need for sufficient physiotherapy staff support and improved management systems at phc level, have been reported in several studies.[4,9] it is therefore not surprising that a lack of staff support was identified as a threat (table 3). table 4. findings from student interviews main theme sub-theme verbatim quotes preparation for phc skills (not) taught in curriculum ‘it is mentioned that primary care is important, but there is not much emphasis on it and what they [educators] want us to do on a primary care block.’ (5.1) translated ‘they want us to present group classes, but we are never reallly taught to do it.’ (5.1) translated guidance and supervision assistance/guidance to students ‘so you get there, and you have your basic theoretical knowledge ... but no guidance.’ (5.1) translated ‘the physiotherapists are very busy on primary care blocks, there are lots of patients. they are often too busy to help students.’ (5.1) translated focus on patient care v. focus on student learning ‘and although they [clinical staff ] want to help and they really want to be accessible, … .’ (5.2) ‘we had the best; you could always go and ask, really. but every now and then you could see there was so much going on that it was just difficult.’ (6.1) work overload ‘i don’t think there’s a lack of understanding on our part that, you know, that this person [clinical staff ] is overloaded.’ (6.1) ‘all our diaries are booked with patients 3 weeks in advance, it is fully booked. i am lucky if i see a patient twice in these 6 weeks. so you can’t see how the patient progresses. at the end of the block you can’t refer the patient, because everybody is fully booked. the patients get angry. it is frustrating.’ (6.1) translated learning opportunities the clinician as a source ‘the other thing is, that even though it’s such a busy place, i’ve had one of the best, i’ve learnt the most from that clinical supervisor. she told us, she’s very busy, but she made time for us.’ (5.2) ‘but for me, what is more valuable is the human resource. the person, be it the clinician who works there, or your supervisor. just that you have somebody that is accessible’ (6.1) alignment with outcomes ‘i never did a home visit on my block at ...’ (5.4) translated ‘if i get a home visit in my final exam, i will not know what is going on. so maybe one should do a complete home visit.’ (5.4) translated interdisciplinary learning formal interdisciplinary sessions are valuable, but can be misused ‘i think it is a showcase for the medical students so that they can see what physiotherapy and occupational therapy are about, and i don’t mind helping other people learn, but for me … i learnt nothing.’ (5.2) informal interdisciplinary discussions are valuable ‘we see a patient and then discuss what each would have done, the occupational therapist, the medical student. so, it was good.’ (5.2) translated ‘this is a problem, as everybody wants us to see the patient in a multidisciplinary team, but nobody really makes time for it in our day.’ (5.2) translated ‘it was nice to talk to the occupational therapist there. we spoke about a patient and could see where we overlap.’ (5.4) translated preparation for community service ‘for next year it is important, because you might be working in a clinic, and would then know how to manage apparatus and do registers.’ (5.3) translated ‘the lack of equipment forces us to be creative. next year or some time we will be working in the community, but is diffucult to say how effective you might be if you don’t have all the equipment.’ (6.1) translated for practice management ‘in primary care it was nice to see how the physiotherapist runs the practice. it was good to see how it works, how to complete the forms, how to order mobility aids, how to organise the practice, how to make posters and so on.’ (6.2) translated research 216 october 2014, vol. 6, no. 2, suppl 1 ajhpe accordingly, boelen and woollard[8] recognise the lack of staff in phc as a global crisis. several positive aspects of the phc placements were acknowledged by participants. these placements prepared future graduates for community service and practice management. preparing for community service has been cited as an important outcome of cbe;[6] however, at the time of the study, it was not an outcome of the phc placement. the phc sites were full of untapped learning opportunities. in particular, the opportunity for formal and informal interdisciplinary learning sessions was identified by students and staff. interdisciplinary collaboration was described as the backbone of community physiotherapy.[9] however, the participants in the aforementioned study stated that in practice, team members are often ignorant about each other’s roles. furthermore, taukobong[11] found a lack of focus on interdisciplinary approaches during cbe in phc. the study findings strengthen the need to include interdisciplinary learning sessions in the curriculum to foster collaboration and patient-centered care.[2] participants in this study warned that careful monitoring of interdisciplinary sessions would be required to ensure benefit for all stakeholders. this study found the phc learning environment to be complex and multimodal, where the situated context influenced learning in multiple ways. several changes are needed to transform phc placements to be able to address learning outcomes and the needs of the students, while considering the needs of the patients and staff. indeed, the learning ecosystem needs to be taken into account when designing a curriculum.[17] the ecosystem approach implies that the needs of the local and broader community should inform curriculum design and implementation to enhance social accountability and holistic patient care. the study provides valuable lessons to be learned from the analysis of learning opportunities in phc placements, although the context investigated in this study was specific and limited to a particular setting. the need for regular curriculum review to ensure that the provided learning opportunities sufficiently address learning outcomes was clear. the phc placement was successful in increasing awareness among students about future professional work at the community level and responsiveness to community needs. these aspects were cited as important outcomes of cbe, and needed to be included in the outcomes of the phc placement.[6,7] although various role players were consulted in the review process, future studies should obtain information from different stakeholders, such as patients, community members and organisations. conclusion the learning opportunities that final-year physiotherapy students experienced as part of their cbe placements needed to be expanded. to optimise phc placements, learning opportunities need to be crafted to foster collaborative learning, interdisciplinary learning, community engagement and empowerment. funding. funding was received from the fund for innovation and research into teaching and learning, centre for teaching and learning, stellenbosch university, south africa. author contributions. all authors contributed to the conception, design, and analysis and interpretation of data. d ernstzen drafted the manuscript. all authors provided critical revision and approval of the manuscript version to be published. acknowledgements. the authors would like to thank mrs ria bester for her involvement in the study. we also thank the participants for their time and input. references 1. skoien ak, vagstol u, raaheim a. learning physiotherapy in clinical practice: student interaction in a professional context. physiotherapy theory and practice 2009;25(4):268-278. [http://dx.doi.org/ 10.1080/09593980902782298] 2. lindquist i, engardt m, garnham l, poland f, richardson b. physiotherapy students’ professional identity on the edge of working life. med teach 2006;28(3):270-276. [http://dx.doi.org/10.1080/01421590600605272] 3. keleher h. why primary health care offers a more comprehensive approach to tackling health inequalities than primary care. australian journal of primary health 2001;7:57-61. [http://dx.doi.org/10.1071/py01035] 4. ramklass ss. physiotherapists in under-resourced south african communities reflect on practice. health soc care community 2009;17(5):522-529. [http://dx.doi.org/10.1111/j.1365-2524.2009.00869.x] 5. world health organisation. primary health care – now more than ever. 2008. http://www.who.int/whr/2008/ en/ (accessed september 2012). 6. okayama m, kajii e. does community-based education increase students’ motivation to practice community health care? a cross sectional study. bmc med educ 2011;11(1):1-6. [http://dx.doi.org/10.1186/1472-6920-11-19] 7. ezzat e. role of the community in contemporary health professions education. med educ 1995;29 suppl 1:44-52. [http://dx.doi.org/10.1111/j.1365-2923.1995.tb02887.x] 8. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43(9):887-894. [http://dx.doi.org/10.1111/j.1365-2923.2009.03413.x] 9. mostert-wentzel k, frantz j, van rooijen aj. a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. african journal of health professions education 2013;5(1):19-25. [http://dx.doi.org/10.7196/ajhpe.203] 10. futter m. developing a curriculum module to prepare students for community-based physiotherapy rehabilitation in south africa. physiotherapy 2003;89(1):13-24. [http://dx.doi.org/10.1016/s0031-9406(05)60665-7] 11. taukobong np. community based clinical program: the medunsa physiotherapy students’ experience. south african journal of physiotherapy 2004;60:7-10. 12. mostert-wentzel k, frantz j, van rooijen aj. status of undergraduate community-based and public health physiotherapy education in south africa. south african journal of physiotherapy 2013;69:1-10. 13. mouton j. how to succeed in your masters and doctoral studies: a south african resource book. pretoria: van schaik publishers, 2001. 14. frambach jm, van der vleuten cpm, durning sj. am last page: quality criteria in qualitative and quantitative research. acad med 2013;88(4):552. 15. ladyshewsky r, barrie sc, drake vm. a comparison of productivity and learning outcome in individual and cooperative physical therapy clinical education models. phys ther 1998;78:1288-1298. 16. currens jb. the 2:1 clinical placement model: review. physiotherapy 2003;89(9):540-554. [http://dx.doi. org/10.1016/s0031-9406(05)60180-0] 17. van schalkwyk s, bezuidenhout j, burch vc, et al. developing an educational research framework for evaluating rural training of health professionals: a case for innovation. med teach 2012;34(12):1064-1069. [http://dx.doi. org/10.3109/0142159x.2012.719652] march 2017, vol. 9, no. 1 ajhpe 39 research patients with neurological dysfunction form a large proportion of the patient population treated in the healthcare system.[1] dysfunction has a large impact on patients’ functioning, which necessitates treatment from an occupational therapist and, therefore, forms a substantial portion of occupational therapists’ workload. patients’ limited access to therapy and the high patient turnover mean that occupational therapists need adequate knowledge, experience and problem-solving skills to enable independent functioning of their patients in the shortest possible time.[2] informal feedback from stakeholders (occupational therapy clinicians, students, and clinical educators) alluded to some discrepancies between the content taught in the stellenbosch university (su) undergraduate curriculum and what is expected within the clinical setting. this raises questions regarding the relevance and applicability of what undergraduate occupational therapists are taught, given the nature and demands of the south african (sa) public health system. it is important that training programmes align with the health needs and available resources, in this case specifically within the sa context. according to freeme,[3] the ideal curriculum should consider the development of knowledge and skills from the latest research, the available resources on the clinical platform, and input from relevant stakeholders. it is essential that the restricted time for the teaching of neurology should be dedicated to the most relevant knowledge and skills needed in practice.[3] mccluskey[4] and unger and hanekom[5] conducted studies in the domain of curriculum development in the health sciences. mccluskey[4] identified the following categories for development of the neurology curriculum: foundation studies; assessment; treatment; and the building of confidence. to encourage confidence in practice, it was suggested that students gain more practical experience in the classroom and clinical setting, and a more sound knowledge of contemporary scientific literature in the field of neurology. the study by unger and hanekom[5] identified three essential criteria deemed appropriate for determining the core content of a revised undergraduate curriculum. content should be included in the curriculum if it: (i) is relevant to the sa context; (ii) ensures safe and effective practice by first-line practitioners; and (iii) is evidence based. studies by chiang et al.[6] and naidoo et al.[7] provide insight on students’ perspectives with regard to their readiness for clinical practice. the findings of the first-mentioned study indicated that a negative clinical experience may cause students to feel overwhelmed. this is often linked to inadequate guidance from clinical supervisors (lack of clear expectations and communication, understanding of students’ learning needs and limited feedback) and inadequate preclinical preparation (limited time to practise techniques and to refresh theoretical knowledge).[6] the latter study found that the students’ level of confidence to practise was directly related to their degree of enjoyment and their fieldwork experience. there were, however, some concerns with regard to the curriculum content, teaching methods, and relationships with the lecturer and clinical supervisors.[7] an important consideration is to include all stakeholders (occupational therapy clinicians, students and educators, client groups, employers, and professional boards) when developing a new curriculum.[8] stakeholders background. the south african (sa) health system is characterised by limited resources, high bed turnover rates and a high therapist-to-patient ratio. patients with neurological dysfunction form a large majority of the caseload of occupational therapists. feedback from stakeholders alluded to some discrepancies between the content taught in the stellenbosch university undergraduate curriculum and what is expected within the clinical setting. this raises questions regarding the relevance and applicability of what undergraduate occupational therapists are taught, given the nature and demands of the sa public health system. objective. to explore the perspectives of final-year occupational therapy students with regard to the core competencies required for optimal preparation of students for practice in the field of neurology. methods. this explorative study used three focus groups to obtain the perspectives of 18 final-year students who had experienced clinical placements in neurology. information from the focus groups was transcribed and analysed thematically to determine the findings. results. analysis of the data revealed four themes, i.e. core knowledge and skills; attitude; resource and time constraints in clinical areas; and factors influencing optimal learning experiences. conclusion. the curriculum should prepare students to be well equipped for the current climate of the profession. while the current neurology curriculum may be viewed as having some positive features, there are some aspects that need to be updated and revised. key considerations to optimise learning include a more regular interface between clinical areas and the university, scheduling of teaching blocks, and applying relevant teaching methods. afr j health professions educ 2017;9(1):39-43. doi:10.7196/ajhpe.2017.v9i1.722 occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology l jacobs-nzuzi khuabi, bsc (occ ther), mph (health economics); j bester, bot, bsc hons (health sciences), mphil (higher education), postgrad dipl (program monitoring and evaluation); k gatley-dewing, bot; s holmes, bot; c jacobs, bot; b sadler, bot; i van der walt, bot division of occupational therapy, department of health and rehabilitation sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: l jacobs-nzuzi khuabi (leeann@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 40 march 2017, vol. 9, no. 1 ajhpe research could aid in developing the content, teaching methods, evaluation requirements, and the delivery of the curriculum. the purpose of this article is to investigate the students’ views on the core competencies needed by final-year occupational therapy students in the field of neurology. competence is defined as a multidimensional and dynamic concept that includes more than knowledge – the understanding of knowledge, interpersonal skills, clinical skills, clinical judgement, problemsolving and technical skills.[9] the students’ views as stakeholders form part of a larger study conducted at su, which furthermore investigates the views of clinicians and academics to inform the revision of the neurology curriculum. methods an explorative approach within a qualitative paradigm was used to explore the perspectives of 4th-year undergraduate occupational therapy students regarding the core competencies needed to work in the field of neurology. total population sampling was used. participants included 18 final-year occupational therapy undergraduate students at su who had placements in neurology in their final clinical block in the 3rd year or first clinical block in the 4th year. the study population was representative of participants who had exposure to neurology within primary, secondary and tertiary levels of healthcare, and learners with special needs from the department of education. table 1 displays each participant’s clinical placement according to the sector, and the diagnosis that they were exposed to. data were gathered through the use of three focus groups discussions (5 7 participants per group), lasting ~1 hour each. the focus groups were conducted by the researchers, using a predetermined question guide. the questions focused on the students’ perspectives of the core knowledge, skills, and attitude required for practising neurology. it also explored the resource constraints they experienced in the clinical placements and aspects they viewed as important in the revision of the neurology curriculum. burnard’s[10] 14-step method of data analysis for semi-structured interviews was used. the audio-recordings from the focus groups were transcribed verbatim. inductive coding was done using the qualitative data analysis (qda) miner 4 analysis program (provalis research, canada).[11] lincoln and guba’s[12] model of trustworthiness for qualitative research was used to ensure rigour. credibility was ensured by acknowledging and analysing the researchers own preconceptions of the topic and their experiences of the neurology curriculum for objectivity. the researchers also used investigator triangulation, member checking and peer checking. transferability was obtained by thick description of procedures for data collection and analysis. for dependability, the data were coded twice, checking that codes correlated. confirmability was ensured through investigator triangulation and reflexivity. ethical clearance was obtained from the su health research ethics committee (ref. no. n14/09/118) and the su institutional research and planning committee, which oversees ethics of research involving the student population. permission was also obtained from the undergraduate programme committee of the division of occupational therapy, su. ethical principles were upheld by giving the participants a choice to participate and respecting their opinions during the focus group discussions. confidentiality was ensured by allocating participants pseudonyms, and all transcribed data were kept on password-protected programs to which only the researchers have access. results analysis of the data revealed four themes that participants felt should be considered for inclusion when revising the curriculum (fig. 1). these themes are: core knowledge and skills; attitude; resource and time constraints in clinical areas; and factors influencing optimal learning experiences. theme 1: core knowledge and skills this theme encompasses core generic knowledge about pathology, anatomy and practice models. it furthermore includes core knowledge and skills pertaining to occupational therapy-specific neurological assessment, treatment and knowledge of own, and other professions’ scope and role within an interdisciplinary team. table 1. participants’ clinical placements according to sector and diagnosis to which they were exposed participant sector list of diagnoses exposed to 1 health: secondary level of care cva, spinal cord injuries 2 health: primary level of care spinal cord injuries, amputations, tb spine 3 education: special needs school cp, neuro-psych 4 health: tertiary level of care paediatric: cp, neuro-psych, tb spine health: secondary level of care cva, spinal cord injuries 5 health: secondary level of care cva, spinal cord injuries, tb meningitis 6 education: special needs school cp 7 health: primary level of care spinal cord injuries, amputations, tb spine 8 health: primary level of care cva, tb spine 9 health: secondary level of care tb meningitis 10 health: secondary level of care cva 11 health: primary level of care cva, tb spine 12 health: secondary level of care cva, cp education: special needs school cp 13 health: secondary level of care cva 14 health: tertiary level of care paediatric: cp, neuro-psych, tb spine 15 health: primary level of care cva 16 health: primary level of care cva 17 health: tertiary level of care paediatric: cp, neuro-psych, tb spine education: special needs school cp 18 health: tertiary level of care cva, tbi cva = cerebrovascular accident; cp = cerebral palsy; tb = tuberculosis; tbi = traumatic brain injury; neuro-psych = neurology psychology. march 2017, vol. 9, no. 1 ajhpe 41 research the majority of the participants felt that in terms of knowledge, the curri culum should include more information on core and trunk stability, spinal cord injury, and paediatrics, and that students need knowledge of models and frames of reference in the 1st year. the majority of the participants said that the current curriculum sufficiently prepares students for assessment, although there could be more focus on test mechanics. participants thought that they should be better prepared for treatment, specifically activity analysis, which includes grading, how to make adaptations and how to integrate it within treatment. participants thought it important to be taught the skill of making good use of time and prioritising intervention, which would help them to prepare for resource constraints of limited time with patients. they also felt that the knowledge of their own role and the scope of other team members’ roles are important for clinical practice: ‘the techniques we learn are good to know but … we want to see how they are applied in the activity.’ ‘in terms of spinal cord, because you have to make so many adaptations, you have to think very creative, to think if your patient can’t supinate, how else is he going to dress himself … .’ ‘communication skills with other professionals, especially, uhm, working with team members. it is really helpful to work with a physio.’ ‘we need to be taught how to do something in an hour, functionally and especially for the high turnover.’ theme 2: attitude this theme alluded to the importance of client centredness, self-directed learning and confidence of the student. participants all agreed that confidence, adaptability and willingness to learn are essential attitudes for students to develop to ensure good clinical practice. it is suspected that having confidence may result in students being more handson in dealing with patients, thus improving the quality of service that they provide. participants thought that the attitude of clinical therapists towards the curriculum and lecturers’ attitudes towards the students are also important aspects to consider in the training of students in the field of neurology: ‘i felt unsure and a little bit anxious, which automatically carries over to the patient and then the patient didn’t want me to touch him and then that was not good at all.’ theme 3: resource and time constraints in clinical areas this theme focused on the availability of resources within the clinical area and the limited time for intervention. the greatest resource constraint identified by participants was limited time spent with patients owing to the high patient turnover, limited funds available to patients to attend outpatient services, and the scheduling of time for treatment, taking into consideration other team members: ‘the reality of the high turnover i think is a very scary thing and it affects your therapy a lot more than you think it does and i didn’t feel like we were equipped for that.’ ‘a resource constraint is, in terms of wheelchairs, a lot of the hospitals have a wheelchair shortage, and even the school i worked at.’ theme 4: factors influencing optimal learning experiences this theme focused on the importance of evidence-based practice, practical exposure, and a closer interface between academics and the clinical areas. the majority of participants felt that it would be beneficial to have neurology lectures scheduled consecutively, i.e. taught in a learning block. this would assist students to link aspects, allowtheme 1: core knowledge and skills theme 2: attitude theme 3: resource and time constraints in clinical areas theme 4: factors in�uencing optimal learning experiences closer interface between academics and the clinical areas practical exposure up-to-date information and evidence-based practice availability of resources limited time for intervention con�dence self-directed learning client centredness team members foundational knowledge assessment treatment pathology anatomy models and frames of reference test mechanics patient and family education activity analysis activities of daily living functional assistive devices selection of appropriate assessments fig. 1. themes and categories that emerged from the data. 42 march 2017, vol. 9, no. 1 ajhpe research ing for better consolidation of the information. the participants alluded to the importance of making use of updated information sources and ensuring that the intervention taught is based on evidence-based practice. participants indicated that using a variety of teaching methods, including case studies, videos and shared experiences, and being given an opportunity to observe the practical application of theory, can help to facilitate transference and application of what is taught from classroom to practice in the clinical setting. participants felt that the opportunity to practise on real patients to develop skills is essential and that the mastering of skills takes place in the clinical setting. participants also thought that there should be ongoing communication between the university, clinical platform, students and supervisors to ensure realistic expectations of students: ‘that they clearly define what is undergraduate stuff and what they expect from us in a block because you come to the block and then they expect you to do postgrad stuff … .’ ‘they give us unattached, separated pieces and they expect that when we get with our real patient all these puzzle pieces are going to come together.’ discussion looking at the knowledge required for treatment, the participants did not feel adequately prepared for implementing appropriate treatment in the clinical setting. this may be because treatment knowledge is taught from the 3rd year when clinical practice has already commenced, while during the assessment of knowledge more time is allowed for learning, consolidation, and application, as it is taught in the 2nd year.[13] the participants also indicated that expectations for clinical practice differ from the theory that is taught in the classroom. it is speculated that this may be a contributing factor to why the participants do not feel adequately prepared for implementing treatment in clinical practice. the prevailing point regarding the skills needed in practice was the participants’ feeling that they did not have adequate opportunity for practising skills on real patients before commencing clinical practice. many of the participants felt that as the mastering of skills occurs in the clinical setting, the opportunity for clinical practice is essential. this point needs to be considered when revising the neurology curriculum. it is important to view the grading of learning opportunities to facilitate the students from classroom experience to clinical practice. a possible grading could be as follows: students learn techniques in the classroom; they practise these on peers under supervision of the lecturer in class; they shadow the lecturer in the clinical field doing the techniques; and they have an opportunity in small groups to practise techniques on patients under supervision of the lecturer – placed in a clinical setting. participants required more knowledge of the starting point for assessment and treatment. they felt it necessary to be skilled in working efficiently and prioritising intervention. considering a change in the clinical picture and resource constraints, it is important for students to be innovative in creating solutions to problems. this raises the question of how to teach students to interpret referrals, taking cognisance of all the factors impacting on a particular patient. the greatest resource constraint experienced is having limited time with patients owing to high patient turnover, limited funds available to patients to attend outpatient services, and scheduling time for treatment, taking into consideration other team members. this is in line with the resource constraints expressed by griffin.[14] it was stated that it is important for clinical supervisors to be understanding and have a positive attitude towards student supervision to improve the students’ clinical experiences. this reflects what was found in the study by chiang et al.,[6] which indicated that inadequate guidance by clinical lecturers often leads to a negative clinical experience. participants thought that being learning orientated will help to ensure that they are better prepared for clinical practice. as in other studies,[4,7] participants in this study unanimously felt that confidence is an essential attitude when going into a clinical placement. the study by naidoo et al.[7] found that students’ experiences of clinical work directly relates to their degree of confidence in neurology practice. participants were of the opinion that transference and application of what is taught from theory to practice in the clinical setting could be facilitated by using teaching methods, such as case studies, videos, and lecturers sharing their clinical experience and demonstrating on real patients. it was suggested that it could be beneficial to teach the occupational therapy neurology curriculum together with the neurology content of preclinical subjects in a learning block, rather than spreading these out. this would allow greater opportunity for the students to be able to link all the aspects of the neurology practice together, allowing for better consolidation of the information. conclusion this research suggests that the neurology curriculum should prepare students to be as well equipped as possible for the current climate of the profession in sa, and therefore should be updated and revised regularly. the majority of the participants recommended that neurology be taught as a learning block and that students should adopt a willingness to learn. participants also felt that educators and therapists should maintain a positive attitude to facilitate the development of the students’ confidence. furthermore, clinical areas and the division of occupational therapy should have clear communication to ensure alignment of what is taught and what is expected in clinical practice. while the current neurology curriculum may be viewed to have some positive features and aspects that need to be updated and revised, it may be valuable to note that, as pointed out by tryssenaar and perkins,[15] that students will always perceive gaps and discrepancies in training, as it is difficult to teach all skills that may be needed in occupational therapy practice. therefore, when revising an undergraduate curriculum, it is important for educators to consider the views of relevant stakeholders to determine the most important aspects for inclusion in the revision of a curriculum. acknowledgements. this research was funded by the fund for innovation and research into learning and teaching (firlt), su. 1. world health organization. the global burden of disease. 2004 update. geneva: who, 2004. 2. wittman pp. the disparity between educational preparation and the expectations of the practice. am j occup ther 1990;44(12):1130-1131. http://dx.doi.org/10.5014/ajot.44.12.1130 3. freeme jd. a proposal for an undergraduate stroke rehabilitation curriculum appropriate for south african occupationl therapy. s afr j occup ther 2014;44(1):69-75. 4. mccluskey a. collaborative curriculum development: clinicians’ views on the neurology content of a new occupational therapy course. aust occup ther j 2000;47(1):1-10. 5. unger m, hanekom sd. benefits of curriculum renewal: the stellenbosch university physiotherapy experience. afr j health professions educ 2014;6(2):222-226. http://dx.doi.org/10.7196/ajhpe.519 6. chiang hya, pang ch, li ws, shih yn, su ct. an investigation of the satisfaction and perception of fieldwork experiences among occupational therapy students. hong kong j occup ther 2012;22(1):9-16. http://dx.doi.org/ 10.1016/j.hkjot.2012.04.001 7. naidoo d, van wyk j, joubert r. are final-year occupational therapy students adequately prepared for clinical practice? a case study in kwazulu-natal. s afr j occup ther 2014;44(3):24-28. http://dx.doi.org/10.7196/ ajhpe.2016.v8i1.536 http://dx.doi.org/-10.1016/j.hkjot.2012.04.001 http://dx.doi.org/-10.1016/j.hkjot.2012.04.001 http://dx.doi.org/10.7196/ajhpe.2016.v8i1.536 http://dx.doi.org/10.7196/ajhpe.2016.v8i1.536 march 2017, vol. 9, no. 1 ajhpe 43 research 8. rodger s, clark m, banks r, o’brien m, martinez k. a national evaluation of the australian occupational therapy competency standards: a multistakeholder perspective. aust occup ther j 2009;56(6):384-392. http:// dx.doi.org/10.1111/j.1440-1630.2009.00794.x 9. verma s, paterson m, medves j. core competencies for health care professionals: what medicine, nursing, occupational therapy, and physiotherapy share. j allied health 2006;35(2):109-115. 10. burnard p. a method of analysing interview transcripts in qualitative research. nurse educ today 1991;11(6):461-466. http://dx.doi.org/10.1016/0260-6917(91)90009-y 11. peledeau n. qda miner: user’s guide. montreal: provalis research, 2004. 12. lincoln y, guba eg. paradigmatic controversies, contradictions and emerging confluences revisited. in: dezin nk, lincoln ys. the sage handbook of qualitative research. 4th ed. thousand oaks, ca: sage, 2011:97-128. 13. stellenbosch university occupational therapy department. occupational therapy neurology outcomes. cape town: stellenbosch university, 2014. 14. griffin sd. short bed stays: their effect on occupational therapy services in teaching hospitals. arch phys med rehabil 1993;74:1087-1090. 15. tryssenaar j, perkins j. from student to therapist: exploring the first year of practice. am j occup ther 2001;55(1):19-27. http://dx.doi.org/10.5014/ajot.55.1.19 http://dx.doi.org/10.1111/j.1440-1630.2009.00794.x http://dx.doi.org/10.1111/j.1440-1630.2009.00794.x research 212 november 2015, vol. 7, no. 2 ajhpe the training of pharmacy students in south africa (sa) takes place through an intensive 4-year programme. there are 5 major subject groups in the baccalaureus pharmaciae (bpharm) curriculum: pharmacology, pharmaceutics, pharmaceutical chemistry, clinical pharmacy and pharmacy practice.[1] pharmacy practice comprises 7 modules related to the practice of a pharmacist, which includes the patient, medicine distribution, health management and good pharmacy practice, communication, financial management, managed healthcare and general management and human resource management. the last-mentioned module was the context for this study. students’ lack of engagement in introductory management modules, especially non-major modules, is a common phenomenon.[2] this was also the case for an introductory management module for pharmacy students. students tend to be negative about the module if they do not perceive the work as valuable or important for their development as future pharmacists. although the exit level outcomes are prescribed by the south african qualifications authority (saqa),[3] most students have difficulty integrating the theory of management with pharmacy practice. it seems as if they do not see the bigger picture and have difficulty understanding where/ how management fits into their everyday life and professional careers. students don’t realise that pharmacists will very likely be appointed as pharmacy managers about 2 years after graduation owing to the shortage of pharmacists in sa.[4] a possible strategy to influence students’ understanding and perception of the importance of a management module is the inclusion of field trips in the curriculum. when planned efficiently, field trips add additional value to and enrich the classroom.[5] such trips can contribute to and complement the textbook used during formal class lectures[6] and even present better learning outcomes than school-based learning.[7] such trips assist students in the development of ideas and a deeper understanding around the field/profession and prevent the straightforward memorisation of facts.[6,7] field trips enhance students’ awareness on a cognitive and an affective level,[8] which often cannot be achieved in the classroom.[9] cognitive learning is achieved when students can make connections among and interpret different aspects of a subject to apply what they have learned in other fields of practice or the profession.[7] field trips also result in increased memory.[8] from the literature reviewed, field trips are commonly included in subjects such as geography and museum studies,[5-9] biology and ecology[10] and law.[11] in this study, we used field trips as a strategy to influence students’ perceptions regarding a management module as part of their training as future pharmacists. the aim of this article is to report, for the first time, on the findings of a research study on the implementation of field trips in a management module in the bpharm curriculum and to conclude whether this intervention changed pharmacy students’ perception of the module. method a mixed-method sequential exploratory research design was followed, where qualitative data were first gathered to explore students’ perceptions of the management module. quantitative data were then gathered to measure the effect of the field trips on the students’ perceptions.[12-14] the qual/quant approach started with written narratives, followed by in-depth focus group interviews and a survey (pre-post questionnaire). the purpose of the study, voluntary participation and anonymous handling of data were explained to students before informed written consent was received. an independent researcher in higher education teaching and learning facilitated the datagathering process to ensure anonymity. the north-west university ethics committee granted permission for the study to be done. background. management training is an important aspect of pharmacy training, as many pharmacists are appointed in management positions early in their careers. however, students struggle to see the importance and relevance of a management module in the final year of the bpharm curriculum and show low levels of motivation and engagement with regard to the module. a possible strategy to change students’ perceptions of the importance of a management module is the inclusion of field trips in the curriculum. objective. to determine whether students’ experience of field trips influenced their perceptions regarding a management module as part of their training as future pharmacists. methods. a mixed-method sequential exploratory research design was used. data were gathered through written narratives and focus group interviews, followed by surveys before and after the field trips. results. the students who participated in the field trips (experimental group) had higher mean scores in the post-test than those who did not participate (control group). the experimental group was more positive about the module than the control group. the field trips improved the perception of students regarding the importance of the management module for future job preparation. conclusion. field trips add value to pharmacy training and should form part of the bpharm curriculum in south africa. afr j health professions educ 2015;7(2):212-215. doi:10.7196/ajhpe.436 field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: a pilot study m j eksteen, mpharm; g m reitsma, phd africa unit for transdisciplinary health research (auther), faculty of health sciences, north-west university, potchefstroom, south africa corresponding author: m j eksteen (mariet.eksteen@nwu.ac.za) research november 2015, vol. 7, no. 2 ajhpe 213 written narratives the first phase of the research included all students who attended the specific management module (n=156) and wrote 1-page qualitative narratives reflecting on the importance and relevance of this module and their expectations of it. the content was analysed to determine trends and patterns,[15] from which specific themes were identified for further investigation through focus group interviews. credibility of this qualitative method was ensured by requesting all students in the class to write the narratives, thus increasing the scope of feedback, providing a safe place and time for students to write anonymous reflections, and explaining the purpose of the process clearly.[16] focus group interviews the second qualitative phase consisted of focus group interviews with the 32 ‘branch managers’ in the class. (all the students who were enrolled for this module formed different groups, referred to as branches, and each group had to appoint a branch manager.) the purpose of the focus group interviews was to explore the themes raised in the written narratives. the independent researcher transcribed the interviews to ensure anonymity, thus conforming to ethical conduct. the transcribed interviews were then analysed[17] through a process of identifying, analysing and reporting patterns in the data.[18] trustworthiness of the qualitative data was ensured by the engagement of the researchers in the field of research for an extended time (at least one semester) and by applying triangulation[12] by using different methods and different data sources to investigate the same phenomena. the data from the narratives were analysed and the themes were used to inform the focus group questions. the written narratives and transcribed focus group interviews were presented as evidence that the findings were from the data and not the ideas or preferences of the researchers, thus ensuring confirmability (neutrality or objectivity).[19] pretest survey the third phase of research started with a pretest questionnaire. the purpose of the questionnaire was to determine the students’ perceptions of the relevance of this module to their current training and their employment after graduation. the questionnaire was compiled based on data gathered from the focus group discussions. content validity was ensured by formulating the questions from the focus group data. face validity was ensured by presenting the draft questionnaire to an independent educational researcher and a statistician to evaluate and refine the questionnaire. nine statements regarding the relevance of the module to practice were formulated. students had to indicate, on a scale of 1 5, their level of agreement with these statements: 1 – do not agree at all, and 5 – agree totally. the quantitative data were analysed using descriptive statistics, e.g. mean and standard deviation (table 1) and independent samples t-test and cohen’s d-value. population and sample for the survey one of the major obstacles in planning a field trip is funding.[21] because this was a pilot study, the sample was limited to a manageable group within the scope of available time and money. the sample was large enough to provide useful information regarding tendencies in the group that can be investigated in future larger-scale studies. a simple random sample (20.6%, n=34) of the total number of students who enrolled for the module (n=165) was selected and invited to attend the three field trips. participation was voluntary and 9 students withdrew. the final experimental group comprised 25 students. the selected students were briefed on what would be required of them during the field trips, the required commitment of attending all three field trips, logistical aspects such as transport and food,[22] and the guarantee that their participation in or withdrawal from this project will in no way influence their marks for the module. those who did not participate in the field trips formed the control group (n=140). field trips the main purpose of the field trips was to expose the experimental group to a diversity of real-life scenarios, where the same management principles discussed in theory were applied in the different sectors of the pharmacy profession. the first field trip focused on pharmacists’ experience as managers. students interacted with guest speakers from academia, the corporate pharmacy community and the government sector. the second field trip was a visit to a large corporate pharmacy with different divisions, e.g. an independent community pharmacy, a wholesaler, courier pharmacy and training academy for pharmacy assistants. the third field trip was an excursion to a mining hospital pharmacy chain group. post-test survey after the intervention, the experimental and control groups completed a post-test questionnaire similar to the pretest one. results the themes identified from the written narratives included the following: place and value of the management module in the curriculum; students’ opinions on the content of the module; possible reasons why students experience this module as a waste of time, their perception being that it is time costly with regard to more important modules; and importance of practical experiences for the students. during the focus group interviews, these themes were further explored and clarified. initially, students did not see or understand the importance of the module for their future professional careers. this was evident from comments made during the focus group interviews, such as, ‘i don’t think we see the value of this module, we have to take it, so we just have to deal with it’, and ‘they don’t see this as important because of their mind set’. students were negative about this module, because ‘... anything other than pharmacology is a waste of time’. this concurs with taylor et al.’s[2] research findings on non-major management modules. the results of the preand post-tests are presented in table 1. questions 1 3 measured students’ perception of the relevance of the management module to practice. the results indicated that the students were positive about the relevance in both the preand post-tests. however, there was a slight decrease in the control group’s perception in the post-test. questions 4 and 5 determined whether students were able to link their own practical experience to the module content and whether they needed more practical exposure. both the experimental and control groups’ agreement decreased slightly in the post-test compared with the pretest. the experimental group, however, felt more strongly in the post-test (d=0.26) that they did not see the need for more exposure to practise compared with the control group, where no practical significant difference was measured between the preand posttests for this statement. questions 6 9 measured the students’ perceptions of how this module prepares them for their future as pharmacists. there was a definite improvement in the experimental group’s perceptions of the value of the module for their future employment, with medium practical research 214 november 2015, vol. 7, no. 2 ajhpe significance measured in question 6 (d=0.59) and question 7 (d=0.62). questions 2, 3, 5 and 9 were stated in a negative sense; therefore, the low means indicate that the students did not agree with the negative statement. discussion the impact of an intervention in the form of field trips on student perceptions was researched through an exploratory mixed-method approach. by increasing student engagement through field trips, the researchers aimed to influence students’ perceptions regarding the value and importance of the module. evidence from the quantitative phase indicated that these field trips did have a positive impact on students’ perceptions. contrary to the findings from the focus groups, the students as a class were not as negative about the management module as first perceived, as is evident from the higher than average pretest means for the experimental and control groups (table 1). the effect sizes indicated no significant difference between the experimental and control groups in the pretest. in the post-test, the mean scores for the experimental group increased for most of the items, indicating a more positive perception of the module. however, the control group’s responses were more negative in the post-test, indicating that they still did not understand the value of the module in preparing them for their future positions. this may be because few students had to apply management knowledge and skills in their previous practical work. they explained this as follows: ‘the younger you are, the less you do in the pharmacy. first you only wash shelves and it is only in your third year that you start with dispensing’ and ‘they [the pharmacy staff ] don’t really give you more to do’. students may have difficulty linking the concepts addressed in the module to practical examples owing to limited exposure to practice. the means of all the questions in the pretest for the experimental and control groups indicate that there was already a positive expectancy towards the importance of this module in the bpharm curriculum before the intervention. this was in contrast to what the lecturer perceived at the beginning of the semester with regard to student comments. overall, the means for the experimental group were higher than those for the control group, although the difference was only practically significant for questions 6 and 7. the field trips as intervention did contribute to the experimental group having a better understanding of the importance of this module towards their future roles as pharmacists. the experimental group better understood that the knowledge and skills taught in this module are important for their future employment. understanding the significance of what they learn, may influence their perceptions positively. marzano[23] explained the importance of assisting students to develop positive attitudes and perceptions about learning, without which they have little chance of learning proficiently, if at all. if students have certain attitudes and perceptions, they have a mental climate conducive to learning. if those attitudes and perceptions do not exist, learners have a mental climate not conducive to learning. conclusion students’ negative perception of introductory non-major management modules is a common phenomenon at universities. in this study, field trips were implemented as an intervention to determine whether students’ table 1. responses of the experimental and control groups regarding relevance of the module to practice before and after the field trips (preand post-test) survey questions group pretest, mean (sd) post-test, mean (sd) effect size t-test between groups e and c for posttest (d-value)† q1: this module would have been of more use to me if i had completed it before i did my practical hours in a pharmacy e 2.80 (1.0) 3.00 (1.2) 0.05 c 2.9 (1.1) 3.06 (1.2) q2:* according to me, the theoretical content of this module is not related to practice e 1.52 (0.5) 1.60 (1.0) 0.14 c 1.70 (0.7) 1.74 (0.8) q3:* the module content is completely unrelated to practice e 1.48 (0.6) 1.48 (0.7) 0.28 c 1.80 (0.9) 1.74 (0.9) q4: i easily understand the work in the module because i can think of practical examples for most of the concepts e 4.16 (0.6) 4.00 (0.9) 0.15 c 4.01 (0.8) 3.86 (0.9) q5:* it isn’t really necessary to add more practical exposure to this module e 2.16 (0.9) 2.48 (1.2) 0.06 c 2.53 (1.1) 2.56 (1.1) q6: i see this module as useful to me as prospective pharmacist e 4.60 (0.5) 4.68 (0.6) 0.59 c 4.42 (0.6) 4.22 (0.8) q7: the knowledge and skills that i am learning in this module are what i will need one day in my job e 4.44 (0.7) 4.56 (0.8) 0.62 c 4.21 (0.7) 4.04 (0.8) q8: to some degree i can understand how this module will help me some day in practice e 4.4 (0.5) 4.36 (0.6) 0.33 c 4.17 (0.7) 4.10 (0.8) q9:* i can’t really see how the knowledge and skills in this module are necessary for my job one day e 1.88 (1.1) 1.52 (0.6) 0.42 c 1.73 (0.8) 1.95 (1.0) e = experimental group (n=25); c = control group (pretest, n=128; post-test, n=108). *questions asked in a negative trend. †an effect size of 0.2 is small, 0.5 medium and 0.8 large.[20] research november 2015, vol. 7, no. 2 ajhpe 215 experience of field trips influence their perceptions regarding a management module as part of their training as future pharmacists. this was motivated by the comments made by students and confirmed during analysis of written narratives and focus group interviews. the survey results showed that the field trips did not have a practically significant effect on students’ overall positive perception of the relevance of this module to practice. this may have been because of high mean scores measured in the pretest, indicating that students were already positive about the module and its relevance to practice. it is, nonetheless, evident that students who did not participate in the field trips did not show the same positive perception of the module as those who did partake in the trips, as there was a clear tendency towards higher mean scores in the post-test results of the experimental group. the field trips influenced students’ perceptions of the importance of the module for their future positions. therefore, it can be concluded that field trips in the management module in the bpharm curriculum changed students’ perception positively towards this module. although the quantitative study did not statistically prove the positive impact of field trips on all the concepts measured, the experimental group gained more from this experience than those students who did not participate in the field trips. field trips may have a positive effect on student perception and it is recommended that such trips should be included in the teaching-learning repertoire of modules in the pharmacy curriculum to expose students to relevant practices. furthermore, this study indicated that student comments and conversations may provide important information regarding teaching and learning that should be taken into consideration in planning and presenting modules. student voices on teaching-learning aspects may provide useful and critical information for lecturers to improve their teaching. lecturers should include more opportunities for conversations through focus group discussions or reflective narrative writing to gain insight into student experiences. the researchers acknowledge that including only a small sample of the students from the same class for the field trips may be a limitation to the study. as there was lack of funding, not all students were invited to attend the field trips. also, possible ‘contamination’ could have taken place as the experimental and control groups were students from the same class and informal discussions could have taken place between students discussing the field trips and their experience thereof. references 1. north-west university. yearbook of the faculty of health sciences, undergraduate. potchefstroom: north-west university, 2014. 2. taylor sa, hunter gl, melton h, goodwin sa. student engagement and marketing classes. journal of marketing education 2011;33(1):73-92. [http://dx.doi.org/10.1177/0273475310392542] 3. south african qualifications authority. registered qualification: bachelor of pharmacy. pretoria: saqa, 2011. http://regqs.saqa.org.za/viewqualifications.php?id=72784 (accessed 11 february 2014). 4. south african pharmacy council. pharmacy human resources in south africa. pretoria: south african pharmacy council, 2011. 5. sturm h, bogner fx. learning at workstations in two different environments: a museum and a classroom. studies in educational evaluation 2010;36(1):14-19. [http://dx.doi.org/10.1016/j.stueduc.2010.09.002] 6. demirkaya h, atayeter y. a study on the experiences of university lecturers and students in the geography field trip. procedia social and behavioural sciences 2011;19:453-461. [http://dx.doi.org/10.1016.j.sbsp ro.2011.05.154] 7. gill n, adams m, eriksen c. engaging with the (un)familiar: field teaching in a multi-campus teaching environment. j geogr higher educ 2012;26(2):259-275. [http://dx.doi.org/10.1080/03098265.2011.619523] 8. falk jh, dierking ld. school field trips: assessing their long-term impact. curator 1997;40(3):211-218. 9. sanders m. planning a fieldtrip to the cradle of humankind: a model of factors affecting the success of educational museum visits. 18th annual meeting of the south african assosiation for research in mathematics, science and technology education, 18 21 january 2010, durban, south africa. http://www.saarmste.org/ conferences (accessed 10 february 2014). 10. lei sa. field trips in college biology and ecology courses: revisiting benefits and drawbacks. j instruct psychol 2010;37(1):42-48. 11. higgins n, dewhurst e, watkins l. field trips as teaching tools in the law curriculum. research in education 2012;88:102-106. 12. creswell jw, plano clark vl. designing and conducting mixed methods research. 2nd ed. california: sage, 2011. 13. macmillan j, schumacher s. research in education. evidence-based inquiry. new york: pearson, 2014. 14. drew cj, hardman ml, hosp jl. designing and conducting research in education. los angeles: sage, 2008. 15. mayring p. qualitative content analysis. forum: qualitative social research, 2000. http://www.qualitativeresearch.net/index.php/fqs/article/view/1089/2385 (accessed 15 april 2014). 16. graneheim uh, lundman b. qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. nurse educ today 2004;24:105-112. [http://dx.doi.org/10.1016/j.nedt.2003.10.001] 17. vaismoradi m, turunen h, bondas t. content analysis and thematic analysis: implications for conducting a qualitative descriptive study. nurs health sci 2013;15:398-405. [http://dx.doi.org/10.1111/nhs.12048] 18. braun v, clarke v. using thematic analysis in psychology. qualitative research in psychology 2006;3(2):77-101. [http://dx.doi.org/10.1191/1478088706qp063oa] 19. tobin ga, begley mc. methodological rigour within a qualitative framework. j adv nurs 2004;48(4):388-396. 20. cohen j. a power primer. psychol bull 1992;112(1):155-159. 21. anderson d, kisiel j, storksdieck m. understanding teachers’ perspectives on field trips: discovering common ground in three countries. curator 2006;49:365-386. 22. kent m, gilbertson dd, hunt co. fieldwork in geography teaching: a critical review of the literature and approaches. j geogr higher educ 1997;21(3):313-332. 23. marzano rj. a different kind of classroom: teaching with dimensions of learning. alexandria, va: association for supervision and curriculum development, 1992. dear cpd client, we wish to take this opportunity to thank you for your continued support through the completion of our online cpd questionnaires as well as to share some exciting news with you. hmpg’s journal cpd questionnaires will be moving to the medical practice consulting (mpc) cpd platform (www.mpconsulting.co.za) as part of a strategy to consolidate all south african medical association (sama) members’ cpd certifi cates and history. all sama cpd certifi cates (whether for annual conferences, branch meetings or workshops) are already available online on the mpc cpd platform and moving all active hmpg online cpd questionnaires to the same platform will mean that all sama member cpd certifi cates will be issued in one central, convenient location – resulting in less admin for our cpd clients. an additional benefi t is that the mpc cpd manager can complete your iar form on your behalf (no more countless hours of reconciling cpd records before a compliance audit) and submit your cpd history to the hpcsa once you have approved it and are happy with the results. all that is required of you, when you are ready, is to click a single button to submit your cpd activity record to the hpcsa. nothing will, of course, ever be submitted without your prior approval and consent. 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that ceus have a 24-month shelf life and expire after 24 months). what happens if i run into technical di� culties? simply complete an online contact form and mpc will assist you with your technical problem. if your sama number for some reason does not match that in the sama membership database, mpc will assist with rectifying the problem. mpc’s contact details are available online: www.mpconsulting.co.za/contact-us sincerely, gert steyn ceo, health and medical publishing group (hmpg) cpd notification http://www.mpconsulting.co.za http://www.mpconsulting.co.za http://www.cpdjournals.co.za http://www.cpdjournals.co.za http://www.cpdjournals.co.za http://www.mpconsulting.co.za/contact-ussincerely http://www.mpconsulting.co.za/contact-ussincerely cpd questionnaire effective in 2014, the cpd programme for ajhpe will be administered by medical practice consulting: cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/016/01/2014 (clinical) a maximum of 3 ceus will be awarded per correctly completed test. may 2014 true (a) or false (b): the effect of an interprofessional clinical simulation on medical students 1. interprofessional education takes place when medical students from different disciplines, for example medicine and psychiatry, participate together in a shared learning activity. 2. good communication skills and teamwork skills are essential in learning activities that involve students from different healthcare professions. are further education opportunities for emergency care technicians needed and do they exist? 3. bridging programmes that address knowledge gaps play an important role by supporting articulation between diploma and degree qualifications in south africa. how we see ‘y’: south african health sciences students’ and lecturers’ perceptions of generation y students 4. generation y students prefer visual rather than text data. do physiotherapy students perceive that they are adequately prepared to enter clinical practice? an empirical study 5. final-year south african physiotherapy students are better prepared for clinical practice from a generic skills, rather than an interventional skills, perspective. pique-ing an interest in curriculum renewal 6. medical graduates in south africa may not be adequately prepared for the non-clinical roles they encounter as interns. student doctors (umfundi wobugqirha): the role of student-run free clinics in medical education in cape town, south africa 7. attendance at student-run clinics, such as shawco, is mainly motivated by a desire to serve the poor rather than the opportunity to obtain ‘hands-on’ experience. 8. more than 80% of students attending student-run clinics, such as shawco, consider the clinics an ideal place to practise their language skills. problem-solving abilities of radiography students at a south african university 9. the key attributes of clinical problem-solving are to: (i) understand the problem; (ii) plan an appropriate solution; (iii) carry out the plan correctly and logically; and (iv) evaluate the result. 10. problem-solving skills may be developed by using role-play, video-taped simulation sessions, case studies and integrated assessments. introduction of a learning management system at the kilimanjaro christian medical university college 11. free learning management systems, such as moodle, may be useful to deliver, assess and evaluate medical curricula. medical and dental students' willingness to administer treatments and procedures for patients living with aids 12. most nigerian dental students (>80%) are willing to do dental extractions on hiv-positive patients. 13. most nigerian medical students (>80%) are willing to assist in surgery performed on hiv-positive patients. understanding the learning styles of undergraduate physiotherapy students 14. it is essential to address the full range of learning styles of students when planning teaching and learning activities. health-promoting schools as a service learning platform for teaching health-promotion skills 15. service learning facilitates students’ learning by participation in random, opportunistic service experiences. 16. service learning requires a structured opportunity for reflection after participating in a service activity. using graduates as key stakeholders to inform training and policy in health professions: the hidden potential of tracer studies 17. tracer studies of graduates may be a useful way of identifying policy needs that can improve healthcare services. the effect of characterisation training on the congruence of standardised patient portrayals 18. for standardised patients to be believable/congruent, real emotions, complementary verbal and non-verbal cues and gestures and appropriate use of voice and facial expression are required. continuous professional training of medical laboratory scientists 19. the delivery of good healthcare in africa is hampered by a lack of high-quality laboratory services owing to the limited availability of welltrained laboratory personnel. physiotherapy clinical students’ perception of their learning environment: a nigerian perspective 20. the provision of learning objectives at the beginning of a course allows students to take responsibility for their learning and become autonomous, self-directed learners. may 2014, vol. 6, no. 1 ajhpe 115 dear cpd client, we wish to take this opportunity to thank you for your continued support through the completion of our online cpd questionnaires as well as to share some exciting news with you. hmpg’s journal cpd questionnaires will be moving to the medical practice consulting (mpc) cpd platform (www.mpconsulting.co.za) as part of a strategy to consolidate all south african medical association (sama) members’ cpd certifi cates and history. all sama cpd certifi cates (whether for annual conferences, branch meetings or workshops) are already available online on the mpc cpd platform and moving all active hmpg online cpd questionnaires to the same platform will mean that all sama member cpd certifi cates will be issued in one central, convenient location – resulting in less admin for our cpd clients. an additional benefi t is that the mpc cpd manager can complete your iar form on your behalf (no more countless hours of reconciling cpd records before a compliance audit) and submit your cpd history to the hpcsa once you have approved it and are happy with the results. all that is required of you, when you are ready, is to click a single button to submit your cpd activity record to the hpcsa. nothing will, of course, ever be submitted without your prior approval and consent. the mpc system also adds additional functionality to the cpd questionnaires and the system has been set up to make the process as easy to follow as possible. the south african medical association (sama) board has concluded that the cpd services associated with the south african medical journal (incorporating continuing medical education) and the south african journal of bioethics and law will only be off ered to registered and fully paid-up sama members, as per the sama member benefi t schedule; therefore, you will be required to register a profi le on the mpc cpd system (if you do not already have one – if you already have one, login as usual) and to supply your sama membership number. you will be required to do this only once. your membership will be validated in real-time and you will be able to access the journal cpd questionnaires. this once-off registration should not take more than 2 minutes and you will be on your way to completing the cpd questionnaires. below are some questions and answers that will assist you in getting started. when will the cpd questionnaires move to mpc? all hmpg-issued journal cpd questionnaires will move to the mpc cpd platform from february 2014 onwards. this will include all prior cpd questionnaires that are still active. what website do i access to complete the hmpg questionnaires? www.mpconsulting.co.za who is mpc? medical practice consulting (mpc) is a group company of sama. mpc has historically hosted cpd at sama’s annual conferences, issued all sama member cpd certifi cates and has hosted sama’s online branch elections. by moving active hmpg journal cpd questionnaires to the mpc system, sama members will have all their cpd certifi cates in one central, convenient location. mpc has also been supplying the foundation for professional development distance learning courses online for the last 2 years and has hosted some of the largest online training initiatives in the south african healthcare industry. what do i need to register a pro� le on the mpc cpd system? mpc does not retain any confi dential information on their database, so you will not be requested to share your telephone number, practice or home address. all that is required for registration is your name, surname, specialty, sama membership number and hpcsa number (which is included on your cpd certifi cate to comply with hpcsa cpd requirements). how long will registration take? completing registration should take no longer than 2 minutes – please remember to have your hpcsa (mp number) and sama membership number at hand. what about my historic cpd certi� cates on the www.cpdjournals.co.za website? if you register on the mpc cpd platform with the same email address as you were using on the www.cpdjournals.co.za website, mpc will import all your cpd certifi cates for the last 36 months into your mpc cpd manager for you. alternatively you can still login to www.cpdjournals.co.za and save any cpd certifi cates that are still valid (remember that ceus have a 24-month shelf life and expire after 24 months). what happens if i run into technical di� culties? simply complete an online contact form and mpc will assist you with your technical problem. if your sama number for some reason does not match that in the sama membership database, mpc will assist with rectifying the problem. mpc’s contact details are available online: www.mpconsulting.co.za/contact-us sincerely, gert steyn ceo, health and medical publishing group (hmpg) cpd notification http://www.mpconsulting.co.za 44 march 2017, vol. 9, no. 1 ajhpe research simulation is the art and science of recreating a clinical scenario in an artificial setting to allow for deliberate teaching and learning of clinical skills.[1] examples of simulation include the use of standardised patients, models and mannequins, which may be low, medium or high fidelity. a high-fidelity simulator, such as a state-of-the-art mannequin, can be programmed to produce physiological functions, such as palpable pulses, voices and abdominal sounds through computer interfaces.[2] changes in training of nurses and the progressive culture of teaching and learning support the use of simulation to maximise and enhance clinical skills training.[2] high-fidelity simulation (hfs) uses advanced technology to produce most human physiological responses in a mannequin, while medium-fidelity simulation provides only basic human responsive functions, with low-fidelity simulation mannequins being static and non-responsive.[2] while there has been an explosion of research on hfs in the developed world, there are relatively few studies emerging from the developing world.[3] current evidence shows that the use of hfs in nurse training institutions has been met with mixed reactions, which has impacted on the use of hfs at these institutions.[4] in cases where hfs has been well received and effectively used, it has resulted in improved learning of clinical skills.[5] it therefore stands to reason that an institution that introduces hfs will benefit from establishing its acceptability among educators. the benefits of knowing how educators perceive the value of hfs will give an indication of the likelihood of it being used in teaching and training. against a background of slowly improving health outcomes, lesotho acquired hfs with the hope of improving the quality of nursing skills training. hfs equipment was distributed to six nursing schools in lesotho. for hfs to facilitate improved clinical skills learning outcomes in these institutions, it has to be accepted and effectively used by nurse educators and students. this study was conducted to explore nurse educators’ perceptions and experiences of using hfs in learning clinical skills in one of the resource-constrained schools of nursing. literature review hfs as a learning pedagogy as a pedagogical strategy, hfs is supported by learning theories, including constructivism, experiential learning and situated cognition. when making use of hfs during learning sessions, students practise skills by means of clinical scenarios, where they construct meaning out of these scenarios through deliberate practice. students need to understand that the practice that takes place in the clinical skills laboratory later needs to be transferred to the clinical area. therefore, theories suggest that hfs as a teaching and learning strategy shifts learning from a predominantly behaviourist pedagogy (teacher centred) towards more student-centred approaches.[2] the student-centred approaches supported by hfs include experiential learning and situated cognition, where hfs allows students to make mistakes in the simulation and then transform and apply the learned experiences to tasks, background. simulations are defined as situations where models are used for practice and to gain experience that will enhance students’ practical skills. the use of simulations in clinical skills training can stimulate deep learning and help students to bridge the gap between theory and practice in nursing. this has been revealed in many studies where simulations positively impacted on clinical decision-making and patient care, and there has been great interest in the use of simulation in nurse training. however, the introduction of technologically driven simulators, especially in resourceconstrained settings, has been met with mixed feelings. objective. to explore the perceptions and experiences of nurse educators in using high-fidelity simulation (hfs) in teaching. methods. a qualitative case study design was utilised. seven educators at a school of nursing, which has hfs, participated in a focus group discussion. data were thematically analysed. results. four themes emerged from the educators’ experiences and perceptions. the use and benefits of hfs were generally accepted by educators. they valued its positive impact on learning outcomes in learners and the ability to simulate more complex scenarios during training. lack of prior planning, inadequate training and lack of resources impacted negatively on the effective use and implementation of hfs. conclusion. the results indicated that nurse educators perceived hfs as a learning pedagogy that can improve students’ learning outcomes if used effectively. they believed that to realise the potential of hfs, more support should be provided through training, the availability of necessary resources, and improved planning and organisation. afr j health professions educ 2017;9(1):44-47. doi:10.7196/ajhpe.2017.v9i1.739 exploration of high-fidelity simulation: nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting t munangatire,1 bscns, mphil (hse); n naidoo,2 mmedsci, med 1 paray school of nursing, thaba tseka, lesotho 2 division of physiotherapy, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa corresponding author: t munangatire (takamunangatire@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2017, vol. 9, no. 1 ajhpe 45 research interactions and cultural dynamics in different situations and contexts, such as various departments of the clinical area.[7,8] theoretical framework the national league of nursing framework (nlnf), developed by jeffries,[1] is important in understanding the concepts that influence the acceptability of hfs.[9] this framework suggests that effective hfs use depends on several factors (fig. 1). jeffries[1] acknowledges the role of the teacher as a designer, supervisor and implementer of simulation in nurse education. to ensure successful use of simulation, the teacher must have a good perception of simulation, be comfortable using the technology, and be a good facilitator and evaluator of the learning process.[1] the nlnf has been endorsed and utilised in evaluating simulation use by several researchers ahead of other models, such as the expert performance approach.[1,10] therefore, the jeffries[1] model remains the most relevant and was used to guide this study. constructs shaping experiences and perceptions using hfs in teaching presents educators with mixed experiences – some exciting and some frustrating. the experiences are shaped by constructs, such as planning for simulation, training on how to use simulation, the availability of resources and motivation for using simu lation.[4] educators’ experiences of using hfs influence their perceptions and adoption of hfs in teaching.[4] adoption of hfs as pedagogy for clinical skills without carefully planning for its use creates a negative perception among educators.[10,11] issenberg et al.[10] contend that hfs is complex, and for effective use it requires excellent planning and organisational contextualisation. furthermore, lack of time, support, appropriate equipment and fear of using hfs simulation as a pedagogy create negative perceptions, and result in underutilisation.[12] findings to date suggest that there are mixed perceptions among lecturers regarding the impact on training of using hfs in teaching.[10] in dowie and phillips’[13] study, 90% of educators were using hfs, although only 35% of them had been trained in its use. however, schlairet’s[14] findings revealed that only 50% of trained educators were using hfs in teaching. this suggests that motivation and the level of support from colleagues and administrative staff influence educators’ use of hfs rather than training alone.[11] in summary, this study explored the perceptions and experiences of nurse educators’ use of hfs in teaching, as its acceptability by educators as a teaching strategy is important for effective use. methods research design a descriptive, qualitative case study design was utilised to explore nursing educators’ perceptions and experiences in a focus group discussion. population and sample all 10 educators who teach at our nursing school were identified as the population for this case study. from this population, a sample of seven educators was purposively selected to participate in the study, based on the inclusion criteria stated above. these seven educators were selected because they were using hfs in their teaching. data collection data were collected during a once-off focus group discussion, which was guided by an interview schedule adapted from krueger and caseys’s[15] guidelines on focus group interviews. adaptations to the guidelines were made based on literature and the opinions of two researchers who validated the semi-structured interview guide. the researcher and the assistant prepared the venues and seating arrangement in a semicircle to promote interaction. the researcher moderated the focus group discussion, while the assistant managed digital voice recorders and took notes. anonymity was ensured by identifying participants by number rather than name. the focus group discussion lasted for 55 minutes. to ensure the credibility of the study, the methods were well described, and the data were recorded and transcribed verbatim by the researcher. the co-researcher and participants checked the transcription for accuracy. data analysis the data recordings were transcribed by the researcher, who organised the data into paper records for ease of thematic analysis. thematic analysis was suitable for this descriptive qualitative study because it is not closely tied to any theory of qualitative research, and allows for flexibility of analysis, resulting in the detailed description of data. data analysis was an iterative and reflexive process to ensure richness of the analysis. it commenced with the coding process, which involved recognising (seeing) an important moment and encoding (seeing it as something) it prior to a process of interpretation. the encoding organised the data in such a way that themes could be identified and developed. the encoding process resulted in the development of a codebook, which served as a data management tool for organising segments of similar or related text to assist in interpretation. as a way of testing the reliability of the codes, the researcher invited the co-researcher to also code the transcripts; the co-researcher’s codes were found to be similar to those of the researcher. results this study explored nursing educators’ experiences and perceptions of using hfs in teaching. participants had positive and negative experiences and perceptions of hfs, which are described under the themes that emerged from the focus group discussion data: planning, training, resources, benefits and limitations (table 1). • demographics • programme • level • age • active learning • feedback • student/faculty interaction • collaboration • high expectations • diverse learning • time on task teac her student educational practices • objectives • fidelity • problem-solving • student support • debrie�ng simulation design characteristics • learning (knowledge) • skill performance • learner satisfaction • critical thinking • self-con�dence outcomes fig. 1. national league of nursing framework.[1] 46 march 2017, vol. 9, no. 1 ajhpe research discussion this study explored nurse educators’ perceptions and experiences of hfs in teaching to establish how acceptable hfs would be in a resource-limited setting. participants perceived hfs to be an important teaching strategy, but pointed out that effective implementation requires careful planning. hyland and hawkins[9] and adamson[11] noted that lack of adequate preparation for the introduction of hfs results in non-use. however, in this study, lack of planning did not impede the use of hfs in teaching clinical skills. lack of training did not discourage the use of hfs for teaching, as educators were highly motivated and willing to teach using hfs. they appreciated the benefits of being able to simulate rare scenarios, teaching problem-solving skills and improving student confidence.[4] there is a need to support this motivation and willingness through formally training educators, which can potentially promote hfs use and destigmatise the educators’ experiences and perceptions of not using or improperly using hfs.[5,7,13] training will capacitate educators to use hfs strategically and to maximise its benefits in teaching.[6,12] despite challenging experiences due to lack of formal training, educators used hfs because they believed it to be a worthwhile investment that could improve student learning outcomes in resource-limited settings. hfss are some of the resources required in teaching clinical skills in nursing, but cannot be used in isolation.[12] additional resources, such as time and appropriate equipment, are needed to facilitate effective teaching using hfs, otherwise educators become frustrated and discouraged from using it.[13] the need for these resources, together with technological support in the simulation room, was clearly verbalised in our study, confirming the need to holistically plan and procure all resources necessary to effectively operationalise hfs in teaching. in this way, nurse educators will have satisfying experiences and consequently readily accept the use of hfs in teaching. table 1. findings theme descriptors quote planning some participants were not pleased with the implementation of hfs at the school and felt that the resource had been provided without giving due recognition to other priority needs. some people were frustrated that hfs had been introduced without consultation. they explained that the frustration was evident in the low use of hfs as a teaching resource ‘it is an excellent teaching device but it is not meeting what we want at that point in time.’ (educator 3) ‘… they suddenly just bring those things [hfs] to us.’ (educator 3) ‘because if really our institutions cried for those simulators, we couldn’t be facing challenges in terms of utilising them.’ (educator 1) training most participants reported that they were excited about the short orientation or ‘training session’ that they were given when hfs was initiated. their excitement turned to disappointment, however, when they realised that they lacked adequate training and were not able to fully use hfs with the initial level of training ‘when we were first oriented on how to use high fidelity simulation, i was so excited and i will believe that i will be able to use it and it will enhance, ahh my teaching … .’ (educator 6) resources the participants perceived hfs use as a demanding pedagogy, requiring technical know-how, careful planning, time, teamwork, and innovation in creating simulation scenarios for effective implementation participants emphasised that there was insufficient equipment, both in quantity and type. additional resources were needed, such as mannequins, part-task trainers, technical support, monitoring cameras and dedicated space for projection, where students may observe demonstrations without being present in the simulation rooms ‘… i might not have the time for preparation and planning because i might have to feed the doll information … .’ (educator 2) ‘my recommendation is as i mention the issue of technical somebody like in a school lab … .’ (educator 5) ‘… high fidelity wouldn’t be part of our high priority needs.’ (educator 4) benefits participants were strongly in favour of the use of hfs because of students’ positive learning outcomes and improved confidence, and because they felt that hfs promoted skills transfer from the lecturer to the students ‘… simulators help build up the confidence and polish up the skill … .’ (educator 3) ‘… simulator helps in the transfer of skill from the instructor to the students.’ (educator 3) some reported that hfs allows simulation of uncommon procedures, facilitating traditionally difficult-to-teach skills, such as problem-solving and critical thinking ‘… the high fidelity ones are more effective in other clinical situations that are rare … .’ (educator 1) limitations participants felt that the ability to transfer skills from the simulation to the clinical area may not be easy ‘… that thing is not a person, when the student is practising on that thing it might be easy.’ (educator 3) some participants noted that there were limitations to the level of fidelity or the extent to which hfs resembles a real human being. hfs was, for example, able to imitate a human being physically, but failed to do so psychologically ‘… they are more effective on the skills part, but the attitudes, nurse-patient relationship, it’s not very effective … .’ (educator 5) ‘it’s like you cannot do everything on high fidelity, there is a limited number, that limitation frustrated me.’ (educator 5) march 2017, vol. 9, no. 1 ajhpe 47 research previous studies have revealed that educators view hfs as an effective teaching strategy, but noted that it has a number of limitations.[13] this resonates well with the findings in our study, where educators perceive hfs as a beneficial teaching strategy, even though it has inherent limitations. our study found that educators believe that hfs improves learning outcomes in simulation, although the nurse educators thought that it is difficult to transfer these skills to actual practice. young and shellenbarger’s[6] findings align with these findings, which showed that nurse educators’ use of hfs depends on whether or not they are comfortable using the technology and believe that hfs promotes learning and improves learning outcomes. however, its use is challenging owing to the complexities associated with working with simulation equipment. nurse educators view hfs as a worthwhile strategy for use in teaching, and the reported benefits of its use act as a motivation for them to adopt it. this suggests that nurse educators are in favour of using hfs in teaching clinical skills. poor utilisation of hfs by educators may stem from negative experiences surrounding the use of simulation. poor planning in introducing hfs, lack of resources to support its use, inadequate training, and the limitations of hfs in teaching result in negative experiences and hence poor utilisation by educators. to have hfs accepted and used effectively, it is essential to create adequate implementation plans, acquire the necessary additional resources, and provide comprehensive training for educators. conclusion hfs is perceived as a valuable teaching strategy that improves students’ competence, motivating educators to use hfs in teaching clinical skills. however, if it is not properly implemented, educators may experience frustration and disappointment, with the result that the benefits of hfs may be diminished, leading to under-utilisation or non-use. therefore, setting up hfs and implementing it should be carefully planned, and educators should be formally trained and given technical support and any additional resources needed for teaching students to use hfs. these measures will increase the adoption of hfs which, in turn, may improve the training of nurses. 1. jeffries pr. a framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. nurs educ perspect 2005;26(2):96-103. 2. bux a. nurses’ perceptions of the usefulness of high fidelity simulation technology in a clinical education program. proquest 2009;503. 3. davies j, alinier g. the growing trend of simulation as a form of clinical education: a global perspective. int para prac 2011:1(2):58-62. http://dx.doi.org/10.12968/ippr.2011.1.2.58 4. reid-searl k, happell b, vieth l, et al. high fidelity patient silicone simulation: a qualitative evaluation of nursing students’ experiences. collegian 2012;19(2):77-83. 5. cooper s, cant r, porter j, et al. simulation based learning in midwifery education: a systematic review. women birth 2012;25(2):64-78. http://dx.doi.org/10.1016/j.wombi.2011.03.004 6. young pk, shellenbarger t. interpreting the nln jeffries framework in the context of nurse educator preparation. j nurs educ 2012;51(8):422-428. http://dx.doi.org/10.3928/01484834-20120523-02 7. paige jb, daley bjo. situated cognition: a learning framework to support and guide high-fidelity simulation. clin simul nurs 2009;5(3):e97-e103. http://dx.doi.org/10.1016/j.ecns.2009.03.120 8. lea sj, stephenson d, troy j. higher education students’ attitudes to student-centred learning: beyond ‘educational bulimia’? studies higher educ 2003;28(3):321-334. http://dx.doi.org/10.1080/03075070309293 9. hyland jr, hawkins mc. high-fidelity human simulation in nursing education: a review of literature and guide for implementation. teach learn nurs 2009;4(1):14-21. http://dx.doi.org/10.1016/j.teln.2008.07.004 10. issenberg bs, mcgaghie wc, petrusa e, et al. features and uses of high-fidelity medical simulations that lead to effective learning: a beme systematic review. med teach 2005;27(1):10-28. http://dx.doi.org/ 10.1080/01421590500046924  11. adamson k. integrating human patient simulation into associate degree nursing curricula: faculty experiences, barriers, and facilitators. clin simul nurs 2010;6(3):e75-e81. http://dx.doi.org/10.1016/j.ecns.2009.06.002 12. garrett b, macphee m, jackson c. high-fidelity patient simulation: considerations for effective learning. nurs educ perspect 2010;31(5):309-313. 13. dowie i, phillips c. supporting the lecturer to deliver high-fidelity simulation. nurs standard 1987;25(49):35-40. http:// dx.doi.org/10.7748/ns2011.08.25.49.35.c8651 14. schlairet mc. simulation in an undergraduate nursing curriculum: implementation and impact evaluation. j nurs educ 2011;50(10):561-568. http://dx.doi.org/10.3928/01484834-20110630-04 15. krueger ra, casey ma. designing and conducting focus group interviews. social anal select tools techn 2002;4(23):4-24. http://researchprofiles.herts.ac.uk/portal/en/persons/guillaume-alinier(679f6dc7-9973-4fb1-b974-3ecbec03e95f).html http://researchprofiles.herts.ac.uk/portal/en/publications/the-growing-trend-of-simulation-as-a-form-of-clinical-education(dc6c26cc-3686-401e-ae1d-d47a481fc886).html http://dx.doi.org/10.1016/j.ecns.2009.03.120 http://dx.doi.org/10.1080/03075070309293 http://dx.doi.org/10.1016/j.teln.2008.07.004 http://dx.doi.org/-10.1080/01421590500046924  http://dx.doi.org/-10.1080/01421590500046924  http://dx.doi.org/10.1016/j.ecns.2009.06.002 http://dx.doi.org/10.7748/ns2011.08.25.49.35.c8651 http://dx.doi.org/10.7748/ns2011.08.25.49.35.c8651 34 march 2017, vol. 9, no. 1 ajhpe research following its initial conception at mcmaster medical school,[1] problem-based learning (pbl) has been adopted by many health professions institutions.[2] pbl is preferred, because it fosters student-centred learning compared with traditional didactic teacher-centred lectures.[3] it allows students to construct new knowledge based on previous knowledge through regulation of their own learning. the focus of pbl is the tutorial process, which allows students to take control of their own learning.[3] during this tutorial process, a small group of students meet and discuss a given learning task, which can take on many forms, such as a written problem, clinical case scenario, or clinical vignette. this task stimulates the students’ discussion, thereby acting as a trigger for learning. during the tutorial process, the lecturer facilitates the students’ discussion to ensure that it is aligned to the institutional learning objectives,[4] ensuring that students understand the concepts of the problem and formulating appropriate learning objectives, which subsequently guide their self-directed independent study. in pbl, therefore, the role of the lecturer (who in the tutorial is called a tutor) is to guide students and promote sharing, interaction and exchange of ideas towards constructing new knowledge.[4] learning in a pbl tutorial group is aimed at enhancing activation of prior knowledge, elaboration of such knowledge, and discovering new knowledge to build on prior knowledge through students’ own self-directed and selfregulated learning processes.[3,4] self-regulated learning has been described as learning where students use various mechanisms to take control of their own learning processes.[5] they are proactive, and they direct and control their own learning. zimmerman[5] reports that students’ achievements cannot only be attributed to abilities, but that skills to participate in self-regulated learning also contribute. zimmerman and schunk[6] as well as zimmerman[5] further report that in self-regulated learning, students should be active participants in learning rather than passive recipients of knowledge, tenets that are evident within a pbl tutorial. other studies have shown that students’ interest in a subject influences their self-regulation.[7,8] for example, students who are highly interest ed in a subject are likely to use efficient self-regulatory strategies to learn independently, even in the absence of tutors. during the process of guiding students in a pbl tutorial, the tutor delivers feedback, identifying strengths, as well as learning gaps that need to be addressed. feedback has been described as the exchange of information by human beings in a problem-solving situation.[9] in the context of this study, it can be viewed as the exchange of information between tutors and students regarding performance during pbl tutorials. feedback acknowledges students’ progress in relation to achieving the intended learning objectives.[9] by providing an opportunity for students to reflect and act upon the received feedback, tutors indirectly facilitate not only students’ learning, but also their self-regulated learning skills.[9] therefore, effective feedback has been defined as being concise, clear, specific and timely and identifies learning strengths and gaps.[9] butler and winne[10] link the concepts of feedback and self-regulation. they described self-regulated learners as those who possess skills of setting goals to acquire knowledge, and discuss strategies to address these goals while monitoring, evaluating and reflecting upon the process, sometimes re-shaping their initial goals to achieve their objectives. during this entire process of self-regulation, butler and winne[10] conclude that ‘feedback is an inherent catalyst’. pintrich[11] further reports that self-regulation is an ‘active constructive process whereby learners set goals for their learning and then attempt to monitor, regulate, and control their cognition, motivation, and behavior, guided by their goals’. the concepts of self-regulation reported by butler and winne[10] and pintrich[11] are evident in a typical pbl tutorial process, where feedback is an integral part. hattie and timperley[12] concur that selfbackground. problem-based learning (pbl) has been adopted across many health professions training institutions. small-group student tutorials are a major component of pbl. facilitator feedback during a tutorial is a key activity to promote self-regulated learning. objective. to explore ways in which students use feedback to promote self-regulated learning in a pbl environment. methods. this was an exploratory qualitative study in which individual interviews and focus group discussions were conducted with health science students who had experience of the tutorial process. data were collected through audio recording and writing of field notes. thematic analysis was employed to generate the reported themes. results. students used feedback in various ways that can lead to self-regulated learning. their experiences were summarised into three themes, i.e. activation of prior knowledge; reflection; and formulation of a personal learning plan. from the findings, a conceptual model linking feedback and selfregulated learning in a pbl context was developed. conclusion. in this study, we propose a conceptual model illustrating how feedback is a major activity in the critical pathway that leads to self-regulated learning. afr j health professions educ 2017;9(1):34-38. doi:10.7196/ajhpe.2017.v9i1.715 self-regulated learning: a key learning effect of feedback in a problem-based learning context a g mubuuke, bsc, msc, mphil, phd fellow; a j n louw, phd; s van schalkwyk, phd centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: a g mubuuke (gmubuuke@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2017, vol. 9, no. 1 ajhpe 35 research regulation is vital to effective learning, and that feedback offers an opportunity to students to practise self-regulated learning. self-regulated learning theory was advanced by pintrich.[11] it comprises four phases of self-regulation, including: (i) forethought, planning and activation; (ii) monitoring; (iii) control; and (iv) reaction and reflection. these phases of self-regulated learning are also evident in a pbl tutorial. the theory emphasises that with self-regulation, learners: (i) should be active participants in the learning process; (ii) have the potential to control key learning activities; (iii) have goals against which to assess progress; and (iv) mediate personal factors and performance outcomes. from the literature, one can identify that self-regulated learning can be achieved within a pbl context, as it is a student-centred instructional approach. one can also identify that feedback of performance with regard to learning tasks has the potential of promoting self-regulated learning. however, a key question arises, i.e. how do students utilise feedback received within the pbl environment to promote self-regulated learning? this question formed the basis of this study. methods study setting the study was conducted at the college of health sciences, makerere university, kampala, uganda. the institution trains undergraduate students across various health disciplines using a pbl approach. small-group tutorials of ~8 10 students are conducted twice a week, facilitated by a tutor, who also delivers feedback to students. research design this was an exploratory qualitative study. this kind of design allowed an in-depth understanding of a subject from the perspective of participants.[13] adopting this study design was aimed at obtaining an in-depth insightful understanding of how students used feedback to engage in self-regulated learning in a pbl tutorial context. study participants purposive sampling was used to select the student participants. these included 3rd-year undergraduate health science students across five disciplines: medicine, dentistry, radiography, pharmacy and nursing. third-year students were chosen because they attend tutorials within their specific professional disciplines and were not integrated. in total, 25 individual interviews and five focus group discussions were conducted. each focus group consisted of 6 8 students. data collection and management data were collected during in-depth individual interviews and focus group discussions. the interview sessions and focus group discussions were conducted in english. questions used to guide the interviews and focus group discussions were open-ended and semi-structured, which allowed participants to freely express their experiences without being directed. the development of these questions was informed by the literature and generally explored ways in which students used feedback to engage in self-regulated learning. the questions for both the individual interviews and focus group discussions were first piloted to assess clarity. using two methods of collecting data was for purposes of triangulation. responses from the participants were audio recorded and later transcribed. the transcribed data were put into electronic format and stored on one computer secured by a password. these data were accessible only to the researchers. data analysis thematic analysis was used. analysis was carried out manually by the researchers. raw data were read and through a series of iterative and inductive open and axial coding, codes were developed. this involved reading through the participants’ responses, identifying common meanings and coding them. specific codes were developed, related to each other to generate broader categories of similar responses. these were also related to each other and to the raw data, subsequently resulting in major themes that were used to report findings. quality assurance participants were invited to validate emerging themes. furthermore, researcher bias was minimised by having more than one researcher; they avoided all preconceived ideas or experiences of the subject under investigation, thus practising reflexivity and bracketing throughout the research process. the researchers engaged in the research process with an open mind and did not impose their own views and ideas on the participants. using more than one data collection method also added rigour to this study, and thus improved quality of the data collected. ethical considerations participants provided written informed consent, and their anonymity and confidentiality were ensured. permission to conduct the study was granted by the health research ethics committee, faculty of medicine and health sciences, stellenbosch university, cape town, south africa, and the research and ethics committee, school of medicine, college of health sciences, makerere university, kampala, uganda (ref. no. s15/04/071). results the purpose of this study was to explore how students used tutor feedback received in a pbl tutorial to engage in self-regulated learning practices. various ways in which students used feedback to become self-regulated learners were identified. these have been grouped into three themes, presented below: theme 1: activation of prior knowledge students used feedback to activate their prior knowledge, recalling what they knew about the learning task from accumulated learning experiences. the following were typical responses: ‘i always used feedback from my tutor to try and link up the concepts that i already knew from my high school to solve the learning tasks given to me … .’ (medicine student) ‘the pbl problems sometimes looked very knew to me and at first, i could not figure out how to tackle them. however, i realised that the tutor feedback reminded me of certain concepts i had learnt from previous problems which i recalled. this helped a lot … to drive my understanding.’ (radiography student) ‘many pbl cases especially in first year were actually related to my high school concepts … even second year cases were related to first year cases. i therefore had to recall most of that data … the tutor feedback was vital in this recall process because the tutor would give us trigger responses and questions which enabled us to recall the already learnt information … .’ (nursing student) ‘the tutor feedback assisted me to recall many concepts i had already learnt. i had forgotten them and yet they were applicable to the new pbl 36 march 2017, vol. 9, no. 1 ajhpe research case … this is why tutors should attend all our tutorials … their feedback helps us a lot.’ (pharmacy student) from the responses above, one can observe that tutor feedback in the form of triggers, challenging observations, comments and questions in a pbl tutorial enabled students to recall information acquired from previous experiences and apply it to solve a current learning task. theme 2: reflection students used feedback to reflect on their own performance. from numerous responses, this reflection seemed to centre around self-appraisal regarding competency, using feedback received, discovering strengths and identifying learning gaps that still needed to be addressed. the following responses were a common thread: ‘the feedback i received from my tutors often helped to critique my own contribution to the tutorial discussion because from this feedback, i would discover where i did best and where i needed to improve. without this feedback … i would not consider some aspects probably.’ (dentistry student) ‘i think the beauty with our pbl tutorial feedback is that it engages one to appraise oneself regarding mastery of the concepts in the tutorial problem. personally, i used to find it hard to internally evaluate myself objectively. with tutor feedback, it is easy for me to use those comments, look at what he said i did well and what i did not do well … and this pushes me to work even harder to cover my gaps.’ (medicine student) ‘the biggest strength of this feedback process in the tutorial is that it teaches you how to self-evaluate your own work. the comments generated by the tutor are so important in guiding us on where we need to maintain and also improve. it teaches us to critically think about our work and gauge our own performance.’ (radiography student) ‘the tutors have always been talking about reflection about our work, but they had failed to teach us how to reflect effectively. the feedback i get from my tutor has actually done the trick. i use the comments from my tutor to evaluate myself and reflect upon my own performance … this helps me a lot … all tutors should give us good feedback. it is better than preparing a power point lecture teaching me how to reflect.’ (pharmacy student) the responses set out above illustrate how tutor feedback enhanced reflective practice. it seemed that feedback played a crucial role in directing the students to practise reflection and self-appraisal regarding their performance, identifying both strengths and areas that needed improve ment. theme 3: formulation of a personal learning plan students used feedback to design their own learning plans. the identified learning gaps became their learning objectives. from the responses obtained, the feedback appeared to assist students to clearly identify and formulate learning objectives that would guide their self-study, organise and plan for adequate time frames to cover objectives, identify key knowledge sources to obtain information that would address the learning objectives, and then apply new knowledge gained to fully solve the learning task. the following responses were typical: ‘the feedback we received in our groups was very instrumental in helping us form our learning objectives. it is these objectives that guided our selfdirected learning.’ (nursing student) ‘to me, the tutor feedback assisted me to identify my knowledge gaps and this gave me an opportunity to plan on how to discover that knowledge and where to get it from. most likely without such feedback, my learning would not have been directed effectively.’ (dentistry student) ‘i think the overall advantage i see with tutor feedback is that it enables students to identify from tutor comments what they have done well and what they need to improve upon. areas that need improvement then become our learning objectives that direct our self-study. with such objectives formulated, i can then draw up my own learning time frames and identify sources of information to cover the objectives.’ (medicine student) discussion the purpose of this study was to explore ways in which students used tutor feedback received within a pbl tutorial to engage in self-regulated learning. there were no major variations in responses received from students across various health science disciplines. the reason for this observation is not clear-cut. a possible explanation could be that the students who participated were drawn from the same pbl environment, where they share the tutors and learning resources. tutor feedback prompted students to utilise key activities identified in this study to engage in self-regulated learning. these included: activation of prior knowledge, reflective practice, and formulation of personal learning plans. these can be linked to self-regulated learning theory, which emphasises activation of what is already known, as well as reflection.[11] therefore, pbl tutors need to be aware that feedback is vital in engaging students into selfregulated learning processes. such feedback should therefore be packaged and delivered efficiently. activation of prior knowledge students in this study used feedback received from tutors to activate prior knowledge. this finding resonates well with what is postulated in self-regulated learning theory, i.e. activating prior knowledge activates self-regulated learning processes.[6,7] therefore, feedback could be one way of achieving this. activation of student prior knowledge to solve pbl learning tasks has also been previously emphasised in the pbl literature.[4] gijbels et al.[2] reported that students possess much knowledge of previous learning experiences, and new learning tasks should build on what students already know. effective pbl tutors should be able to invoke what students already know so that newly acquired knowledge builds on what is already known. good feedback in a pbl tutorial is one way of stimulating students to recall already acquired knowledge to solve new learning tasks.[3] our findings resonate well with these previous findings. it can be discerned from our study that tutor feedback helped students to recall concepts already learnt to solve new pbl learning tasks. the feedback probably also assisted students to place their knowledge in sequence, relating new information to what is already known. therefore, good feedback delivery practice is one way through which tutors can assist students to recall already learnt knowledge, subsequently engaging them in self-regulated learning. this study did not specifically focus on exploring attributes of good feedback. however, one march 2017, vol. 9, no. 1 ajhpe 37 research could notice that students perceived some feedback as beneficial, which implicitly reflected the attributes of good feedback reported in the literature. for example, students expressed that specific, clear and unambiguous feedback was significant in their learning. specificity and clarity of feedback have been reported as some of the good feedback attributes.[12] reflection feedback also assisted students to reflect about performance. this finding is in agreement with what is reported in self-regulated learning theory, i.e. active reflection about performance promotes self-regulated learning.[7,8] the importance of training reflective health professionals has been previously emphasised.[14] this reflective practice is vital, as it helps health professionals to independently appraise their own performance, identifying strengths and areas that need improvement.[14] although the literature emphasises the importance of training students how to engage in reflective practice,[15] there is a dearth of reported literature on how to teach reflection. findings from this study probably contribute to this gap. we identified that good tutor feedback in a pbl context could probably be one way through which students can be trained how to reflect. such feedback should be specific, timely and clear. feedback comments from tutors most likely trigger students to think about the task and their own performance of the task, and identify what they did well and where they need to improve. students therefore engage in a form of self-evaluation, using the feedback received, which enhances their self-regulated learning. formulation of a personal learning plan feedback enabled students to form their personal learning plans. this finding relates well to self-regulated learning theory, which postulates that self-regulated learners always form personal learning goals against which to assess progress.[11] clearly forming a learning plan to address a learning task is a vital step in a pbl tutorial. a learning plan may include aspects such as forming learning objectives (which emanate from initially identified learning gaps) and mapping out key sources of information to address those objectives and subsequently solving the learning task. it is sometimes a challenge for students to suggest a clear learning plan from the tutorial;[1] therefore, the tutor has a role to play by guiding students to create a clear learning plan. while it is standard practice in pbl for students to derive their own learning objectives, they may not be able to satisfactorily achieve this, even when the tutor is present to guide them. sometimes the tutor feedback may be inefficient in guiding students to derive good learning objectives. the key message in this study is that effective feedback from the pbl tutor regarding students’ strengths and learning gaps with regard to the presented task and relating this feedback to the intended learning outcomes make this process easier. therefore, while tutors may deliver feedback, it may not assist students to form their learning objectives. this feedback must follow good feedback principles to achieve this. if tutor feedback is inefficient, even though the tutor is present, students might struggle. feedback that is specific, focused and clear assists students to only focus on those key areas pertinent to the pbl task and not digress into other irrelevant issues. often, students without tutor guidance formulate learning objectives that are skewed away from the intended institutional learning outcomes.[4] feedback and self-regulated learning: a conceptual model from the preceding discussion, one can discern that tutor feedback in a pbl tutorial can probably assist students to take charge of their own learning through activation of prior knowledge, engagement in reflective practice, and formulation of personal learning plans to address any gaps that may exist. all these cognitive activities, driven by feedback, are part of selfregulated learning. based on these findings, a conceptual model has been developed linking feedback and self-regulated learning within a pbl tutorial environment (fig. 1). the model illustrates that good feedback is vital in the critical pathway towards training self-regulated learners. the model postulates that self-regulated learning is central in a pbl tutorial setting, where students direct and plan their own learning. various activities contribute to self-regulated learning. at first, there is an initial learning task, which then triggers active student discussion, activating prior knowledge to solve the task. vital to this process is the feedback students receive from the pbl tutor regarding performance of the task. this feedback, which must follow good feedback principles, such as being timely, unambiguous and specific,[12] then engages students in active reflection about the task and how they have solved it. it is therefore the feedback in the tutorial that initiates this process of reflection. during this reflective process, students identify learning gaps and formulate a learning plan to cover those gaps. the plan might include raising learning objectives, identifying knowledge sources, and putting in place time frames to cover the objectives before a new task is introduced. with a learning plan, students then engage in self-directed study, where they use sources of knowledge already identified and tutor feedback to address the learning objectives of the task. subsequently, students apply this newly acquired knowledge from self-directed study to not only cover the learning gaps of the initial pbl task, but also to solve future learning tasks. from the model one can observe that self-regulated learning within a pbl context involves many activities, of which tutor feedback is very vital. each of these activities, evident within a pbl tutorial, contributes to promote self-regulated learning processes in students. pbl task discussion of task effective feedback knowledge application self-regulated learning self-directed study/learning formulation of learning plan reflection fig. 1. a conceptual model relating feedback and self-regulated learning in a pbl tutorial. 38 march 2017, vol. 9, no. 1 ajhpe research findings from this study are generally in agreement with the literature, which shows that feedback can promote self-regulated learning. what this study adds to the literature is how feedback promotes self-regulated learning in a pbl context. it has been observed from the study that tutor feedback promotes activation of prior knowledge, gives students an opportunity to engage in reflection, and formulate learning objectives that subsequently guide their selfdirected learning. this ultimately leads to self-regulated learning. the study involved small numbers of student participants from one institution. this and the non-probability sampling technique are major study limitations. although the focus was on students from one institution only, it is envisaged that involving many more students and other stakeholders, such as pbl tutors and feedback experts from more than one institution, would probably have added richness to the findings. the conceptual model developed from this study also presents new thinking and gives direction for future research in health professions education. this model was developed from one institution and therefore calls for its testing and validation in other settings, which is likely to give more insight on the issues raised within this framework. conclusion this study demonstrated that tutor feedback assisted students to activate prior knowledge, engage in active reflection, and formulate their own learning plans – processes in self-regulated learning. therefore, pbl tutors should be aware that self-regulated learning, which pbl aims to promote, is a key learning effect of effective feedback. 1. schwartz p, mennin s, webb g. problem-based learning: case studies, experience and practice. london: kogan page, 2001. 2. gijbels d, dochy f, van den bossche p, segers m. effects of problem-based learning: a meta analysis from the angle of assessment. rev educ res 2005;71(1):27-61. http://dx.doi.org/10.3102/00346543075001027 3. gukas id. problem-based learning in undergraduate medical education: can we really implement it in the west african subregion? west afr j med 2007;26(2):87-92. 4. savery jr. overview of problem-based learning: definitions and distinctions. interdisc j problem based learn 2006;1(1):9-20. http://dx.doi.org/10.7771/1541-5015.1002 5. zimmerman bj. theories of self-regulated learning and academic achievement: an overview and analysis. in: zimmerman bj, schunk dh, eds. self-regulated learning and academic achievement: theoretical perspectives. 2nd ed. mahwah, nj: lawrence erlbaum associates, 2001:1-38. 6. zimmerman bj, schunk dh. self-regulated learning and academic achievement: theoretical perspectives. 2nd ed. mahwah, nj: lawrence erlbaum associates, 2001. 7. pintrich pr, zusho a. the development of academic self-regulation: the role of cognitive and motivational factors. in: wigfield a, eccles js, eds. development of achievement motivation. san diego, ca: academic, 2002:249-284. 8. yang m, carless d. the feedback triangle and the enhancement of dialogic feedback processes. teach higher educ 2013;18(3):285-297. 9. orsmond p, maw sj, park jr, gomez s, crook ac. moving feedback forward: theory to practice. assess eval higher educ 2013;38(2):240-252. http://dx.doi.org/10.1080/02602938.2011.625472  10. butler dl, winne ph. feedback and self-regulated learning: a theoretical synthesis. rev educ res 1995;65(3):245-281. http://dx.doi.org/10.3102/00346543065003245 11. pintrich pr. the role of goal orientation in self-regulated learning. in: boekaerts m, pintrich pr, zeidner m, eds. handbook of self-regulation. san diego, ca: academic, 2000:451-502. 12. hattie j, timperley h. the power of feedback. rev educ res 2007;77(1):81-112. http://dx.doi.org/ 10.3102/003465430298487 13. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. http://dx.doi. org/10.1191/1478088706qp063oa 14. mubuuke ag, kiguli-malwadde e, kiguli s, businge f. a student portfolio; the golden key to reflective, experiential and evidence-based learning. j med imaging radiat sci 2010;41(2):72-78. http://dx.doi.org/10.1016/j. jmir.2010.03.001 15. hughes m, heycox k. promoting reflective practice with older people: learning and teaching strategies. austr social work 2005;58(4):344-356. http://dx.doi.org/10.1111/j.1447-0748.2005.00231.x http://www.ncbi.nlm.nih.gov/pubmed/17939306 http://www.ncbi.nlm.nih.gov/pubmed/17939306 http://dx.doi.org/-10.3102/003465430298487 http://dx.doi.org/-10.3102/003465430298487 http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1016/j.jmir.2010.03.001 http://dx.doi.org/10.1016/j.jmir.2010.03.001 research 72 may 2016, vol. 8, no. 1 ajhpe the traditional approach to teaching physiology at our university has been the delivery of a didactic lecture by an expert standing in front of the class. the lecture format usually involves the use of powerpoint slides or chalk and a blackboard to illustrate concepts. after the lecture, students are referred to a recommended non-south african textbook.[1] frequently, especially in large medical student classes, the lecturer may be unavailable on a one-to-one basis for follow-up tuition. therefore, students may find themselves in a situation where misconceptions or poorly received concepts are not easily addressed and corrected. these students may subsequently ignore or discard the information and consequently perform poorly in assessments. they could therefore overlook the relevance of the knowledge, which in the context of medical disciplines, may have an effect on their careers and ability to treat their patients. moreover, diligent students who seek to further investigate a concept, frequently do not know where to find the relevant information in their textbook, the library or even on the internet. a number of different emerging factors have made the challenges of effective teaching of healthcare professionals even more difficult in the local south african (sa) context. these include a changing school education system where disparate pedagogical approaches have been implemented over the last decade;[2] a changing patient population, with the emergence of previously neglected or unknown diseases;[3] and a lack of available resources, making clinical insight even more important as the primary tool available to healthcare workers. consequently, long-established didactic approaches to the teaching of physiology may no longer fully meet the needs of current students or fulfil the demands for effective training of healthcare professionals. the promotion of active and self-directed learning, which may be defined as the process in which students identify their learning niches and strengths and take the initiative to fulfil their learning requirements, may be achieved through an e-learning system[1] that may prove to be a useful aid in supplementing the learning of students. a review article by michael,[4] focusing on physiological education, highlights the evidence that active learning approaches to teaching are more effective than passive methods. the evidence suggests that active learning promotes meaningful learning and performance is improved if these methods are employed. online learning tools, which promote active learning by students, provide a supplemental resource through which students may engage the use of assessment with feedback, which potentially allows for tutoring that may not otherwise have been available. there is evidence to suggest that e-learning tools are an effective method of providing additional teaching aids to students and also improve outcomes on summative test assessments.[5] formative assessment provides immediate feedback to students and promotes student learning, whereas summative assessment is an evaluation of student learning.[6] e-learning systems are largely formative tools employed to assist students in summative assessment tasks.[5] according to velan et al.,[7] the advantages of online formative assessments include ‘immediacy of feedback, flexibility in time and place of undertaking the assessment; feedback can provide links to learning resources, thereby providing motivation to study, opportunity for repetition, and interactivity’.[7] therefore, in our school, we have decided to embrace the technological approach to assist in meeting the needs of current learners. the use of computerised learning methods not only appears to lend themselves to the tech-savvy nature of the new generation of learners, but also allows students background. the didactic approach to teaching physiology in our university has traditionally included the delivery of lectures to large groups, illustrating concepts and referencing recommended textbooks. importantly, at undergraduate level, our assessments demand a level of application of physiological mechanisms to recognised pathophysiological conditions. objective. to bridge the gap between lectured material and the application of physiological concepts to pathophysiological conditions, we developed a technological tool approach that augments traditional teaching. methods. our e-learning initiative, equip, is a custom-built e-learning platform specifically created to align question types included in the program to be similar to those used in current assessments. we describe our formative e-learning system and present preliminary results after the first year of introduction, reporting on the performances and perceptions of 2nd-year physiology students. results. students who made use of equip for at least three of the teaching blocks achieved significantly better results than those who did not use the program (p=0.0032). questionnaire feedback was positive with regard to the administration processes and usefulness of equip. students reported particularly liking the ease of access to information; however, <60% of them felt that equip motivated them to learn. conclusion. these results are consistent with the literature, which shows that students who made use of an online formative assessment tool performed better in summative assessment tasks. despite the improved performance of students, the questionnaire results showed that student motives for using online learning tools indicated that they lack self-directed learning skills and seek easy access to information. afr j health professions educ 2016;8(1):72-76. doi:10.7196/ajhpe.2016.v8i1.581 an online formative assessment tool to prepare students for summative assessment in physiology s kerr,1 phd; d muller,1 phd; w mckinon,1 phd; p mc inerney,2 phd 1 school of physiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: s kerr (samantha.kerr@wits.ac.za) research may 2016, vol. 8, no. 1 ajhpe 73 to learn physiological concepts at their own pace, revisit misunderstood concepts and shift their focus to where they may need the most conceptual support. in this article we assess the results of implementing our new e-learning system, designed as a formative teaching tool with the objective to provide factual knowledge and immediate results of formative assessments to students, including detailed explanations of the correct physiology after each assessment. the system has been designed to provide a student with experience in answering test questions relevant to their discipline, while explaining basic physiological concepts. furthermore, our system is designed to provide sa students with knowledge applicable and relevant to the local population rather than information more relevant to north american or european populations, which are conventionally used. in this study, our objective was to assess the performance of students (summative assessment) after the introduction of an e-learning tool as a supplemental tool for learning and the subjective reactions of students to using such a tool. background students the school of physiology, university of the witwatersrand, johannesburg, sa teaches courses in physiology and medical biochemistry as compulsory components of 2nd-year undergraduate curricula in a range of different medical disciplines. these include pharmacy, physiotherapy, occupational therapy, nursing, dentistry, medicine, health sciences and biomedical engineering. the physiology course is divided into four 8 10-week blocks and is delivered through a series of lectures (5 hours per week), tutorials (3 hours per week) and practical laboratory skill sessions (3 hours per week). all lectures and tutorials are taught by academic staff members and practical sessions are demonstrated by trained postgraduate students under the guidance of academic staff members. the therapeutic health science course is taught to students studying pharmacy, physiotherapy, occupational therapy, nursing and dentistry as one class (n=220). students write a summative test at the end of each of the four teaching blocks (based on the work covered in that quarter) and a final assessment at the end of the year (based on the course content taught throughout the year). the therapeutic health science course material includes the following: test 1: blood, body fluids, immunology, metabolism, autonomic nervous system and excitable tissue; test 2: metabolism, central nervous system and temperature regulation; test 3: cardiovascular system, respiration, kidney, acid-base and gastro-intestinal system; and test 4: liver, endocrine and exercise. equip in addition to lectures, tutorials and laboratory sessions, which were already in place, an e-learning initiative was introduced as a tool to supplement students’ understanding of physiology and the method of assessment. equip (equestions for understanding integrated physiology) is a custom-built e-learning platform to suit the specific needs of the school (developed by the school in collaboration with coding expertise supplied by an external information technology firm (simnat technology pty ltd, johannesburg). the framework for the platform was based on the x-type multiple-choice questions (mcqs) used in our current assessments, developed by mitchell.[8] in our assessment protocol and equip program each mcq statement has five corresponding responses, where each response must be answered as true or false. each mcq therefore contains five questions or statements that require an answer. in the equip program, once a question has been answered (true or false selected), the student is given feedback on whether they were correct or incorrect. additionally, an extensive explanation as to why the statement was true or false is presented to the student. model answers have been researched and validated under the supervision of subject expert academic staff to align the model answers with current course content and objectives. furthermore, images and explanations detailing the underlying mechanisms that explain the reasons for statements being correct or incorrect have been sourced, designed and included, enabling the students to visualise the rationale behind each statement. selected responses also have links to approved internal library e-references or external sites (such as youtube videos) that further clarify concepts. therefore, equip was specifically designed and created to align the question types included in the program to be similar to those used in our current assessment protocols, providing experience in answering x-type mcqs and offering immediate feedback. the equip program draws on kolb’s experiential learning cycle, as it offers students the opportunity for concrete experience and active experimentation; the immediate feedback provides them with an opportunity for reflective observation and abstract conceptualisation.[9] the home page of equip is divided into 16 topics, reflecting the structure of the course topics taught throughout the year. there are approximately 500 mcqs with model answers captured in the system. a unique feature of the system is that many of the questions included are based on diseases or problems prevalent in patients seen in african hospitals. thus, at an early point in their medical career, students are being exposed to problem-solving around problems and diseases such as malaria, hiv and kwashiorkor. methods study design at the start of the academic year all the students who registered for therapeutic health sciences disciplines were given a brief orientation session to familiarise them with equip and encourage them to use the platform. participation was voluntary and no extra credit incentives were offered to encourage use of the program. students accessed equip using their personal student identification username and password. no time limitations were placed on answering the questions, as it was felt that this was a learning platform and students could take as much time as required to interact with the system. because of internet security issues, the site was only accessible from computer laboratories at the university and students could not access the platform off campus. questionnaire a paper-based questionnaire to obtain feedback about equip was administered to the students in the final lecture of the year as part of the department-approved course evaluation. this formed a convenience sample, as not the entire class was present. the students were asked to volunteer to complete the questionnaire and could elect to complete it anonymously. it was made clear to them that there was no obligation to complete the questionnaire and they would not be disadvantaged should they choose not to participate. the questionnaire administrators and e-learning team played no role in the summative assessment process. using a 5-point likert scale, equip-specific questions were answered on ease of access, frequency of usage, relevance of material and whether students were satisfied and would recommend the program. furthermore, based on the questionnaire developed by seluakumaran et al.,[10] students were asked what the most useful features were. research 74 may 2016, vol. 8, no. 1 ajhpe outcomes student logins to equip were tracked throughout the year to determine the percentage use of the program and the number of teaching blocks each student made use of. fisher’s exact 2 × 2 contingency tables were used to assess the relationship between students who passed and those who failed (50% cut-off ) and their equip use per teaching block. year-end grades (average of the results of the test at the end of each of the academic teaching blocks) were compared (using analysis of variance (anova) with a tukey’s posthoc test) according to the number of teaching blocks where the student had made use of equip. results participants the mean (sd) percentage of students who used equip throughout the year was 67 (6.9)%. a statistically significant percentage of students who passed used equip (62%), compared with only 25% of those who failed (p=0.0036). a significantly greater proportion of students who used equip in all four teaching blocks passed compared with those not making use of the program (p=0.0006; table 1). students using equip for at least three academic blocks achieved significantly better year-end results than those who did not make use of the program (fig. 1). students were normally distributed in terms of grades achieved in the group using equip and those not using the program. questionnaire results completed questionnaires were received from 66% (n=146) of the class, and 92% of respondents stated that they had made use of equip at least once (table 2). the students indicated that they made use of the e-learning tool most frequently immediately before tests. although 146 questionnaires were collected from the class, some of the respondents elected not to answer all the statements. accordingly, each of the statements was calculated as a percentage of the responses for that statement (tables 2 and 3). in each case ≤20 students failed to provide an answer to any question posed. overall, feedback from the class was positive with regard to the registration process, access, ease of use, satisfaction and relevance of material on equip. students found the mcq model answers and images particularly useful, but provided mixed reactions about the links to other sites. discussion students who made use of equip achieved significantly better results in their summative tests than those who did not use the program, suggesting that the introduction of the online tool facilitated the learning process for students. this study is congruent with numerous studies focusing on medical education, which have also demonstrated that students who participate in formative online assessments and use supplementary tools performed better in summative tests and assessments.[5-7,10-13] the significant differences in year-end results between the students who consistently used equip and those who did not may be a reflection of the higher percentage of use of the program and that students received greater benefit from the system. kibble[12] noted that students are less likely to participate in formative assessment tasks if participation is voluntary. although the average use of the program throughout the year was >60%, ~13% of the class reported that they had either not heard or made use of it, in the latter case primarily because access was restricted to on-campus use. therefore, it is worthwhile noting that frequent promotion and accessibility are key features in the success of implementing an e-learning program. historically, students have struggled in the first tests in our 2nd-year physiology course, as they are introduced to a new question format and a more challenging course than they experienced during their 1st year of study. by modelling the question type included in the e-learning program on the assessment protocol, students were familiarised with the question format when using the online system before writing the test, which may have assisted them when writing the summative assessments. familiarisation with the question format highlights one of the strengths of equip, which exposes students to the question type and expectations in answering styles, thus providing them with experience with the question type. previous literature has shown formative assessments (such as our equip-based questions) to be most effective if they are similar to the summative assessments that they are supporting.[5,14] features of the equip system that we considered key to the successful implementation of our formative e-learning tool included the creation of a system that encouraged the learning process and provided timely and table 1. students who passed or failed 2nd-year physiology according to the number of teaching blocks for which they used the e-learning program equip number of teaching blocks students used equip, n students who passed, % students who failed, % 0 6 7 1 5 4 2 12 7 3 15 5 4* 31 8 *p=0.0064 v. 0 (fisher’s exact test). g ra d e av er ag e, % number of teaching blocks students used equip * 80 70 60 50 40 30 0 0 1 2 3 4 † fig. 1. comparison between physiology year-end grade averages for therapeutic health science students based on the number of blocks for which the students used the e-learning tool equip (anova, p=0.0032; tukey’s posthoc test, three blocks used v. equip not used (*p<0.05), four blocks used v. equip not used (†p<0.01)). table 2. summary of student feedback with regard to the use of equip did you make use of equip? students, % i looked at it once 5 i used it just before tests 49 i consistently used it 38 i knew about it but i never used it 5 what is equip? i’ve never heard about it or used it 3 research may 2016, vol. 8, no. 1 ajhpe 75 informative feedback. marden et al.[15] reported that formative learning tools were more useful when students were allowed multiple unsupervised and untimed attempts. therefore, another strength of e-quip is that it creates a non-intimidating environment for students to assess and re-assess their knowledge and practise questions. furthermore, to facilitate student understanding and foster a student’s sense of responsibility for their learning, it was seen as beneficial that our formative assessment provides informative and supportive feedback, rather than just a grade, and does so in a timely manner to optimise learning outcomes.[16,17] we cannot definitively state that the higher results obtained by equip users compared with the results of those who did not use the program were because more conscientious students made use of the system and whether they would have obtained such results without the program. however, the distribution curves of the grades for students who used the system and those who did not indicate that there was an even distribution of strong and weak students. two studies by kibble et al.[11,13] demonstrated that students were more likely to participate in formative assessment tasks if there were extra credit incentives. however, as noted by kibble, increasing incentives to participate may result in a disconnect between the final grades and the amount of online participation. if incentives are offered, the motivation for using the program may not be the attainment of knowledge but rather to achieve the necessary grades. in contrast to incentive-driven engagement with a formative assessment tool, voluntary participation in formative assessment tasks is more likely a reflection of self-directed learning. our students had the freedom to access information from a reliable source at their convenience (albeit limited to on-campus access) and they could control the amount of inand output that they obtained, essentially empowering them to take control of their learning. self-directed learners are able to identify their own deficits and make amends. equip lends itself to this, as it allows students to work at their own pace and apply information. this is particularly useful in the local setting, as the majority of the class are second-language learners (not learning in their mother tongue). conversely, it is possible that the easy access to answers on equip may actually facilitate a lack of self-directed learning. the results from the questionnaire indicated that students were motivated to use equip, as the system provided them with easy access to model answers, which the students rated as particularly useful. it is possible that students viewed the system as a means to attaining the correct answers and not as a learning tool. taradi et al.[18] captured this idea by stating ‘the real power of computers to improve education will only be realized when students actively use them as cognitive tools rather than passively perceive them as tutors or repositories of information’. the mixed student reaction to the additional resources supplied supports the notion that students may have used equip merely as an information repository. we expected that the additional resources would guide students to further their knowledge and correct misconceptions through their own learning process. however, <50% of students agreed that the links to other sites were useful. we speculate that the students may have considered it too much effort to access the additional material or that this information was superfluous to the content provided by their lecturers. further investigation into reasons why these resources were not utilised and which resources were used is required. study limitations results from our questionnaire survey found that students complained about access to the system being limited to computer laboratories on campus and felt that they would have used the program more often if they could have accessed it from their home environment, an issue which we have subsequently addressed and rectified. additionally, technical difficulties with access to the system were resolved when students reported such issues. as access to the system is a fundamental requirement for compliance, the provision of technical assistance (in our case, by making the contact details of the system administrator available to students) is vital to its success. the study design could not control for potential confounding variables regarding the study population. we previously stated that the higher grades obtained by equip users could have been because the more conscientious students made use of the system and would, regardless, have obtained higher marks; this should be considered a limitation. moreover, the motivating factors and likelihood to commit to learning in an online environment were not table 3. summary of therapeutic health science students (physiology) feedback with regard to equip, provided by a questionnaire using a condensed likert scale students, % student feedback agree neutral disagree the registration process for equip was easy 87 9 4 equip was easy to access 71 14 16 i was happy and satisfied to use equip 91 5 4 equip was easy to navigate and use 93 4 2 the material on equip was relevant and appropriate 94 5 1 equip helped me to further my understanding about the topic taught in physiology 90 7 2 equip complemented traditional learning through lectures and tutorials 84 14 1 i recommend the school of physiology to continue using equip 96 1 3 i don’t think i learnt much from equip 5 13 82 i like reading notes/textbooks rather than using equip 11 28 60 equip motivated me to learn 61 31 8 the most useful features of equip model answers to each question 97 3 0 the images 84 12 4 that it allowed me to practise mcqs, but wasn’t for marks 92 7 1 easy access to the model answers 91 8 2 links to other sites 47 30 23 research 76 may 2016, vol. 8, no. 1 ajhpe considered in this study, which is a potential limitation and requires further research. conclusion the implementation of a physiological e-learning program was related to improved summative assessment performance in a cohort of undergraduate students; however, improvements are only evident with frequent use. these results are consistent with those in the literature, which recommend the use of active online learning tools to promote educational performance. results from a questionnaire assessing the students’ experiences suggested that the program was found to be a useful and relevant addition to our undergraduate physiology courses. recommendations include further research into the additional resources the students are utilising and motivations behind committing to online learning tools. moreover, encouraging students to frequently use the platform and take responsibility for their learning should further improve performance. acknowledgements. we would like to thank prof. elena libhaber, university of the witwatersrand, for her assistance with the statistical analysis. references 1. gorman pj, meier ah, rawn c, krummel tm. the future of medical education is no longer blood and guts, it is bits and bytes. am j surg 2000;180:353-356. [http://dx.doi.org/10.1016/s0002-9610(00)00514-6] 2. aldridge jm, laugksch rc, fraser bj. school-level environment and outcomes-based education in south africa. learning environments research 2006;9(2):123-147. [http://dx.doi.org/10.1007/s10984-006-9009-5] 3. etyang ao, scott jag. medical causes of admissions to hospital among adults in africa: a systematic review. glob health action 2013;6(1):1-14. [http://dx.doi.org/10.3402/gha.v6i0.19090] 4. michael j. where’s the evidence that active learning works? adv physiol educ 2006;30:159-167. [http://dx.doi. org/10.1152/advan.00053.2006] 5. dobson jl. the use of formative online quizzes to enhance class preparation and scores on summative exams. adv physiol educ 2008;32:297-302. [http://dx.doi.org/10.1152/advan.90162.2008] 6. olson bl, mcdonald jl. influence of online formative assessment upon student learning in biomedical science courses. j dental educ 2004;68:56-65. 7. velan gm, jones p, mcneil hp, kumar rk. integrated online formative assessments in the biomedical sciences for medical students: benefits for learning. bmc med educ 2008;8:52. [http://dx.doi.org/10.1186/1472-6920-8-52] 8. mitchell g. medical physiology: objectives and multiple choice questions. 2nd ed. durban: butterworths, 1986. 9. kaufman dm, mann kv. theory and learning in medical education: how theory can inform practice. in: swanwick t, ed. understanding medical education. evidence, theory and practice. london: wiley blackwell, 2014. 10. seluakumaran k, jusof ff, ismail r, husain r. integrating an open-source course management system (moodle) into the teaching of first-year medical physiology course: a case study. adv physiol educ 2011;35:369-377. [http://dx.doi.org/10.1152/advan.00008.2011] 11. kibble j. use of unsupervised online quizzes as formative assessment in a medical physiology course: effects of incentives on student participation and performance. adv physiol educ 2007;31:253-260. [http://dx.doi. org/10.1152/advan.00027.2007] 12. kibble jd. voluntary participation in online formative quizzes is a sensitive predicator of student success. adv physiol educ 2011;35:95-96. [http://dx.doi.org/10.1152/advan.00053.2010] 13. kibble jd, johnson tr, khalil, mk, et al. insights gained from analysis of performance and participation in online formative assessment. teach learn med 2011;23(2):125-129. [http://dx.doi.org/10.1080/10401334.2011.561687] 14. rolfe i, mcpherson j. formative assessment: how am i doing? lancet 1995;345:837-839. [http://dx.doi. org/10.1016/s0140-6736(95)92968-1] 15. marden ny, ulman lg, wilson fs, velan gm. online feedback assessments in physiology: effects on students’ learning experiences and outcomes. adv physiol educ 2013;37:192-200. [http://dx.doi.org/10.1152/ advan.00092.2012] 16. gipps v. what is the role for ict-based assessment in universities? studies in higher education 2005;30(2):71180. [http://dx.doi.org/10.1152/advan.00092.2012] 17. hattie j, timperley h. the power of feedback. rev educ res 2007;77(1):81-112. [http://dx.doi. org/10.3102/003465430298487] 18. taradi sk, taradi m, radić k, pokrajac n. blending problem-based learning with web technology positively impacts students learning outcomes in acid-base physiology. adv physiol educ 2005;29:35-39. [http://dx.doi. org/10.1152/advan.00026.2004] ajhpe is published by the health and medical publishing group (pty) ltd co registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za suites 9 & 10, lonsdale building, gardener way, pinelands, 7405 tel. 021 532 1281 | cell 072 635 9825 l letters and articles for publication must be submitted online at www.ajhpe.org.za editorial 146 has the health professions education research agenda changed in the new millennium? v burch review 147 optimising cognitive load and usability to improve the impact of e-learning in medical education m r davids, m l halperin, u m e chikte short report 153 rising to the challenge: training the next generation of clinician scientists for south africa b kramer, y veriava, j m pettifor research 155 effect of simulated emergency skills training and assessments on the competence and confidence of medical students i treadwell 158 student compliance with indications for intravenous cannulation during clinical learning c vincent-lambert, b van nugteren 161 implementing and managing community-based education and service learning in undergraduate health sciences programmes: students’ perspectives s b kruger, m m nel, g j van zyl 165 preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation i treadwell 170 a faculty-led solution to transport-related stress among south african medical students s schoeman, g van zyl, r a smego (deceased) 176 nursing students’ perception of simulation as a clinical teaching method in the cape town metropole, south africa n nel, e l stellenberg 180 changing students’ moral reasoning ability – is it at all possible? n nortjé, k g f esterhuyse 183 experiences of medical and pharmacy students’ learning in a shared environment: a qualitative study d johnston, p a mcinerney, o fadahun, l p green-thompson, s moch, p goven shiba, a magida 187 ethical dilemmas experienced by occupational therapy students – the reality n nortjé, j de jongh 190 promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective i ndateba, f mtshali, s z mthembu 194 dental students’ perceptions of practice management and their career aspirations s e van der berg-cloete, l snyman, t c postma, j g white 199 second-year dental students’ perceptions about a joint basic science curriculum t c postma, l bronkhorst 202 self-regulation – the key to progress in clinical reasoning? t c postma 208 the meaning of being a pharmacist: considering the professional identity development of first-year pharmacy students m van huyssteen, a bheekie 212 field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: a pilot study m j eksteen, g m reitsma 216 an exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a south african university j r naidoo, s mthembu 220 examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, selfcompassion and self-determination s whitesman, r mash correspondence 224 it is time to balance communitarianism and individualism in south african medical education l m campbell, a j ross, r g macgregor 226 cpd questionnaire ajhpe african journal of health professions education | november 2015, vol. 7, no. 2 editorial board editor-in-chief vanessa burch university of cape town international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university michael rowe university of the western cape associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannah.k@hmpg.co.za editor-in-chief janet seggie, bsc (hons), md (birm), frcp (lond), fcp (sa) executive editor bridget farham, bsc (hons), phd, mb chb managing editor ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design carl sampson head of sales & marketing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani i tel. 072 463 2159 email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 1999-7639 research 190 november 2015, vol. 7, no. 2 ajhpe the traditional teaching approach has been criticised for not equipping health professionals with the necessary knowledge and skills to work in rural, remote and under-resourced communities.[1,2] the conventional approach focuses on hospital-based, curative-focused teaching, which relies on sophisticated technology. furthermore, upon graduation, many nurses are reluctant to work in rural, underprivileged areas, where resources are scant and the focus is on healthcare and prevention.[2] this instructional approach hinders the equal distribution of health professionals in south africa (sa) and therefore the quality of services provided to its citizens. this, in turn, impedes the promotion of primary healthcare (phc). the world health organization (who) defines phc as ‘essential healthcare based on practical scientifically sound and socially sound acceptable method and technology, universally accessible to all in the community through their full participation; at an affordable cost, and geared toward self-reliance and self-determination’.[3] phc is therefore an approach to healthcare that promotes the attainment by all people of a level of health that will permit them to live socially and economically productive lives. healthcare is essential, practical, socially and scientifically sound (evidence based), ethical, accessible, equitable, affordable, and accountable to the community. furthermore, phc is more than primary medical or curative care or a package of low-cost medical interventions for the poor and marginalised. to address these challenges, the who, international council of nurses (icn) and south african nursing council (sanc) recommended the implementation of a community-based education (cbe) programme as part of the teaching curriculum in the training of nurses.[2,4-6] cbe refers to learning activities that take place in a particular setting, i.e. the community setting.[7] students are allocated to different communities (urban, peri-urban and rural or semi-rural) to undertake activities relevant to community health needs and that address community health-related needs. cbe may contribute to solve the inequity in service delivery by producing healthcare professionals who are willing and able to work in underserved areas, particularly rural communities.[8,9] cbe also offers opportunities for students to learn in situations similar to those in which they might work later in their professional lives. it may equip students with transferable core competencies that they would not learn otherwise, such as leadership skills, the ability to work in teams, and the capability to interact with the community. the south african department of education (doe) and the council on higher education (che) endorse the implementation of cbe as a responsive educational method.[10] furthermore, the department of health (doh) (sa), in the 1997 white paper on the transformation of the health system, highlighted that in order to align nursing education with phc the curriculum should be based on community needs and linked to phc.[11] gumbi and muller[12] and mekwa[6] emphasised that the curriculum of health professionals should be linked to phc. mekwa[6] states that cbe is a tool to foster phc, as it affords students the opportunity to learn by providing services to under-resourced communities. various higher education institutions for health professionals, including background. community-based education (cbe) serves as a primordial instrument in the implementation of primary healthcare (phc). learning experiences in community-based settings provide students with learning opportunities, as they are actively engaged in phc-associated activities in under-resourced communities. many nursing schools in higher education integrated and implemented a cbe programme with an end-goal of becoming healthcare practitioners who are responsive to the needs of the community. objectives. to establish how phc philosophy is promoted through a community-based nursing education programme. methods. the study was non-experimental and cross-sectional with a quantitative approach and was done at a selected higher education institution in kwazulu-natal, south africa. a total of 118 participants were selected using the non-probability convenience sampling technique. a self-report questionnaire was distributed to the participants; 91 questionnaires were completed and returned – a response rate of 73.3%. ethical clearance was obtained from the university of kwazulu-natal ethics review committee. participation was voluntary, informed consent was obtained, and other ethical principles were respected. data were analysed with the statistical package for social sciences (spss). descriptive and analytical analysis was used to analyse the data. results. the participants reported exposure to community-based learning from the first until the fourth year of their study programme. participants (69.9%) indicated that their learning activities had involved members of the community. the community-based learning projects, which mostly promoted a phc philosophy, included prevention of illness, injuries and social problems (90.1%), health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%). conclusion. findings revealed that the community-based learning experiences of students promoted a phc philosophy and that under privileged community settings provided a rich learning environment. afr j health professions educ 2015;7(2):190-193. doi:10.7196/ajhpe.399 promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective i ndateba,1 mn; f mtshali,1 phd; s z mthembu,2 phd 1 school of nursing and public health, university of kwazulu-natal, durban, south africa 2 kwazulu-natal college of nursing, durban, south africa corresponding author: s z mthembu (sindizama@gmail.com) research november 2015, vol. 7, no. 2 ajhpe 191 nursing institutions, have responded positively by allowing students to engage in phc-associated activities.[13] however, little is known about whether this programme promotes the phc approach. this article presents the findings of a study aimed at exploring whether cbe activities promote phc. methods following a quantitative approach and a non-experimental, explorative, descriptive design, a cross-sectional survey was used to explore students’ perspectives of whether cbe promotes phc. non-probability convenience sampling was used to invite 118 students to participate in the study. they included second-, thirdand fourth-year students who were studying for a bachelor in nursing degree at a university-based college of nursing in kwazulu-natal, sa. the students were selected to participate, as they had been exposed to the cbe programme. first-year students were excluded because of the limited exposure to community-based learning at first-year level. permission to conduct the study was obtained from the university of kwazulu-natal ethics review committee. participation was voluntary and informed consent was obtained from participants after the study had been thoroughly explained to them. questionnaires were distributed to the participants; 91 were completed and returned – a response rate of 73.3%. experts in cbe and phc at the university of kwazulu-natal, and the related literature and studies, facilitated the measurement of validity of the instrument. to test the consistency of the measurements, a pilot study was conducted with 6 participants, who were not included in the final analysis. descriptive and analytical statistics were used in the data analysis. cronbach’s α was 0.851 and a p-value ≤0.5 was considered statistically significant. results research setting the selection of clinical training sites in the community is considered an important aspect of cbe for an effective process of knowledge construction. students are placed in urban, suburban and informal settlements and semirural communities. the communities around the university are used extensively as a learning environment to give students an opportunity to understand the capacities and initiatives of the communities they serve. nearby phc clinics, schools and other community centres are used. these communities all provide rich information with regard to the raw content material and a variety of health problems that could be used as a frame of reference for cbe. students are involved in cbe from their first to their fourth year of study and exposed to learning in various community settings, including phc facilities and other community centres. their communitylearning activities were carried out in old-age homes (82.4%), crèches (24.4%), general hospitals (94%), phc clinics (34.4%) and psychiatric settings (36.7%). participants indicated that their cbe activities promoting phc had involved community members from different sectors. the study revealed that 69.9% of respondents indicated that their community-learning activities had involved members of the community and 85.7% had participated in the implementation of community projects. it was found that these activities involved school teachers (95.6%), local leaders (91.2%), church leaders (44%), youth leaders (60.4%), community health workers (89%), nurses (87.95) and community members (94.3%). the student learning experiences also reflect identification of community health problems. the results of this study showed that 97.8% (n=89) of students had participated in family assessment, while 100% (n=91) had conducted epidemiological studies. additionally, the findings indicated that 100% (n=91) had carried out community assessment to identify community health needs, and 95.6% (n=81) had validated needs from the community to identify health need priorities. eighty-nine per cent of participants had been involved in cbe activities that focused on health promotion, 90.1% on prevention of illness, injuries and social problems, 52.7% on treatment of common illnesses and injuries at home, 45.1% on rehabilitative care, which was associated with learning in an informal settlement, and 76.9% on promoting community self-reliance and self-determination. the focus of cbe projects can be seen in table 1. the study indicated that students were exposed to many aspects of phc in various learning environments, such as classrooms, communities, phc facilities and hospitals. in these cbe environments, 71.4% of participants learnt about health education with regard to preventing diseases and promoting health, 52.7% were exposed to learning about oral rehydration for children and 57.1% learnt about breastfeeding. the study also revealed that 62.6% had an opportunity to learn about family planning for males and females and 70.3% learnt about prevention of malnutrition in children. furthermore, 58.2% could familiarise themselves with first-aid measures at home, 52.7% with monitoring the growth of children and 60.4% with immunisation of babies. table 1. focus of community-based learning projects focus of community-based project yes, n (%) no, n (%) total, n (%) promotion of health (health education on nutrition, sexuality, breastfeeding, environmental health, waste disposal, safe and clean water) 81 (89) 10 (11) 91 (100) prevention of illness, injuries and social problems (e.g. immunisations, family planning, health education on prevention of sexually transmitted infections, chronic illnesses (e.g. hypertension) and teenage pregnancy) 82 (90.1) 9 (9.9) 91 (100) treatment of common illnesses and injuries at home (e.g. treatment of lice, diarrhoea and vomiting, flu, minor burn injuries) 48 (52.7) 43 (47.3) 91 (100) rehabilitative care (e.g. home management of patients with deformities, elderly patients with chronic illnesses, and mentally ill clients in the community) 41 (45.1) 50 (54.9) 91 (100) promoting community self-reliance and self-determination (e.g. identifying, accessing and using available resources in the community to address health-related issues) 70 (76.9) 21 (23.1) 91 (100) research 192 november 2015, vol. 7, no. 2 ajhpe the results revealed that cbe had given 70.3% of the participants the opportunity to learn about community involvement in community-based projects, 38.5% had become involved in advocating for vulnerable people and 50.5% learnt about educating the community about waste disposal. the study showed that 56.7% learnt about ways to keep water clean if there is no safe water supply and 51.6% about caring for terminally ill patients at home. moreover, 57.1% acquired knowledge about women empowerment and 59.3% about collaborating with other sectors to address health issues in the community. the findings indicated that 94.3% of the participants had been involved in fundraising for community projects, while 80.2% had participated in helping the community to take responsibility for their health and mobilising resources for promoting community self-determination. the community-based learning projects that participants were exposed to were associated with the promotion of health; prevention of illnesses, injuries and social problems; home treatment of common illnesses and injuries; rehabilitative care and community self-reliance and self-determination. discussion cbe is an approach to teaching and learning that exposes students to community nursing from an early stage of the course until their fourth year. this takes place in a variety of real-world settings, including the community and specialty learning environments as stated by mthembu and mtshali.[7] such early exposure to a community setting aims to familiarise students with phc principles to equip them with the culture of phc practice about health promotion and disease prevention.[5,14] the continuity of community learning is crucial as it helps students to maintain a spirit of community practice, while striving to become competent nurses. ongoing experience of working in phc settings and providing healthcare services to under-served communities not only reinforces internalisation of health promotion and illness prevention throughout the educational programme, but also makes healthcare services more accessible to the community. the current study showed that 97.8% (n=89) of students had participated in family assessment, while 100% (n=91) had conducted epidemiological studies. additionally, the findings indicated that all students (n=91) had carried out community assessment to identify community health needs, and 95.6% (n=81) had validated needs from the community to identify health need priorities. these results are congruent with the findings of various other studies[7,15-17] that students who engaged in cbe learnt to identify community healthcare needs and implement health interventions to address health problems. this enables both students and community members to identify real issues in the community and the available resources.[7] as a result of the experience they gain through community studies, students learn to understand how cultural, socioeconomic and political factors are interrelated and how these factors determine the health status of the population.[1,18] this enables them, as phc practitioners, to implement the necessary measures to affect these determinants of health. this process of identifying community health problems and validating needs is in line with the phc philosophy where community members participate in the identification of their needs and resources.[5] findings showed that the principle of community participation was reflected in this cbe programme, where 70.3% (n=64) of respondents had been exposed to learning about community involvement and 51.6% (n=47) had covered it in the classroom learning environment. furthermore, 69.9% of respondents indicated that their communitylearning activities had involved members of the community and 85.7% had participated in the implementation of community projects. this embraces the phc principle that community members should be involved in the planning, implementation, monitoring and evaluation of communitybased projects aimed at addressing their health needs.[19] the findings are also consistent with recommendations from the who,[5] which state that community members should be involved in students’ educational experiences, not only to provide support to foster learning, but also to ensure that community needs are satisfied. the success of cbe depends on community participation in the educational process. the community helps students by identifying health problems in the community, which forms the curriculum content. in return, they benefit from the services provided by students.[7,14] during the learning experience, students and community members jointly plan and implement community-based learning projects, which enhances closeness between both groups, a sense of belonging for students, ownership of the interventions implemented, and their acceptability for the community.[20] this achieves the main objective, i.e. improving the health of the community being served. the findings indicated that 94.3% of the participants had been involved in fundraising for community projects, while 80.2% had participated in assisting the community to take responsibility for their health. students were also involved in mobilising resources for promoting community self-determination – a principle of phc. the role of phc practitioners involves helping the community through collaboration, partnerships with other sector teams and advocacy to assume control of their lives. according to mtshali,[1] cbe prepares nursing students to fulfil this role, which aims to improve the health of the population through health promotion, disease prevention, and self-reliance and -determination of community members with regard to their health. according to the who and health and welfare canada,[21] health is considered as a resource for community development. the community-based projects of 89% of respondents focused on phc components of health promotion. also, 90.1% of community-based projects focused on prevention of illness, injuries and social problems, and 45.1% of respondents conducted community-based projects focused on rehabilitative care of patients with deformities, elderly patients with chronic illnesses and mentally ill clients. this study revealed that 52.7% of respondents conducted communitybased projects on the treatment of common illnesses and injuries at home, such as treatment of lice, diarrhoea and vomiting, flu and minor burn injuries, and 76.9% carried out projects on promoting community self-reliance and -determination, such as identifying, accessing and using available resources in the community to address health-related issues. the findings are congruent with the results of studies conducted elsewhere,[15, 22-24] which showed that nursing students in cbe implemented various health-promotion and disease-prevention programmes to vulnerable groups, targeting diabetes, heart diseases, safe sexual behaviours and prevention of infectious diseases, such as sexually transmitted infections, tuberculosis, and hiv and aids. the health-promotion and diseaseprevention programmes incorporated immunisation, oral health, infant feeding, hygiene products, transmission of germs, preparation for cold weather, healthy eating, women’s health issues and assessment of blood pressure for adults. these studies revealed that cbe has a positive impact on the lives of target groups, while enabling the learners to become socially research november 2015, vol. 7, no. 2 ajhpe 193 responsible and respond to the needs of the community, especially those who are underserved and vulnerable.[5,25,26] the community-based nursing education programme is in line with recommendations of the doh,[11] doe,[10] sanc and various other international organisations. these institutions stipulate that the education of healthcare professionals should be responsive to community needs in achieving learning objectives by actively involving students in learning experiences that bring about change in the community.[6,7,10,11,27] the literature maintains that this approach provides comprehensive learning experiences that focus on health promotion, illness prevention, treatment, and rehabilitation, and that it promotes self-reliance and -determination of the community.[1,2] education is therefore linked to phc, making phc philosophy a driving force in healthcare in the world and in sa in particular.[1,3,5, 7,13,28] students’ community-based learning projects focused on providing healthcare services according to the needs of the community. as a social justice teaching approach,[29] this enhanced accessibility of the health service to underserved areas, thus promoting equity in healthcare services provision, which is in accordance with the social justice orientation of the phc philosophy. one of the principles of phc is equity in healthcare provision, with the ultimate goal of changing the lives of the population being served. equity in healthcare delivery has been reiterated in the phc declaration of alma-ata.[3] the findings are in line with the recommendations of the lancet report of 2010, stipulating that the curriculum of health professionals should equip them with competencies to practise at community level, where they provide phc services focusing mainly on health promotion and prevention of diseases. it further stipulates that health professionals should learn to work in teams, as maintenance and restoration of health depend on multiskilled professionals.[30] this study shows that the educational experiences of students in the community incorporate the essential elements of phc and are consistent with the aims of the alma-ata declaration,[3] i.e. to address the health problems of a community by making healthcare services accessible to them and by promotive, preventive, curative and rehabilitative healthcare education and services to prevent diseases and improve health. our findings are congruent with the results of the study conducted in sa by mtshali,[1] who found that learning experiences in community-based nursing education exposed students to a number of strategies aimed at promoting and improving the health status of the population, especially those from underserved and poor groups. the strategies included growth monitoring, oral rehydration, breastfeeding, immunisation, female literacy as women empowerment, family planning, food supplementation to prevent malnutrition, and first aid at home, also known as the gobi-ffff strategy by the united nations children’s fund (unicef).[31] the results of this study showed that community-based learning exposes nursing students to educational experiences that prepare them to fulfil the roles of health promoters, health educators, community and vulnerable group advocators, promoters of community self-reliance and -determination, and members of interdisciplinary teams working together to improve the health of individuals and groups, which according to keleher et al.[32] are the roles of nurses in phc settings. the findings revealed that community-based learning activities enhance and promote phc. conclusion community-based nursing education as an educational approach provides students with an opportunity to learn and provide services to communities. the findings show that the students involved community members in their community-based service-learning experience. students engaged in cbe projects that focused on health promotion, prevention of illnesses, injuries and social problems, treatment of minor illnesses, rehabilitative care and promotion of community self-reliance and -determination. these projects and other learning experiences are linked to phc principles, thus providing healthcare services to vulnerable groups and promoting equity in healthcare access. this familiarises students with principles of phc, as these principles were instilled during training and therefore promoted a phc philosophy. this study revealed that a cbe programme promotes phc philosophy. references 1. mtshali ng. implementing community-based education in basic nursing education programs in south africa. curationis 2009;32(1):25-32. 2. world health organization (who). increasing the relevance of education for health professionals. report of who study group on problem solving education for health professionals. geneva: who, 1993. 3. who and united nations children’s fund ( unicef). international conference on primary healthcare. almaata, ussr, 6 12 september 1978. 4. international council of nursing (icn). reducing the gap and improving the interface between education and service: a framework for analysis and solution generation. 2009. http://www.icn.ch/images/stories/documents/ publications/free_publications/reducing_the_rap.pdf (accessed 7 august 2012). 5. who. community-based education of health personnel. report of a who study group. geneva: who, 2012. 6. mekwa j. transformation in nursing education. http://www.healthlink.org.za/uploads/files/chapter13_00.pdf. (accessed 27 may 2014). 7. mthembu sz, mtshali ng. conceptualisation of knowledge construction in community service learning programmes in nursing education. curationis 2013;36(1):69-79. 8. okayama o, kajii e. does community based education increase students’ motivation to practice community health care? a cross sectional study. british medical council medical education 2011;11:19. [http://dx.doi.org/ doi:10.1186/1472 -6920-11-19] 9. kaye dk, mwanika a, sewankambo s. influence of the training experience of makerere university medical and nursing graduates on willingness and competence to work in rural health facilties. rural and remote health 2010;10(1):1-9. 10. department of education, south africa. white paper for the transformation of the health system in south africa. pretoria: department of education, 2013. http://www.healthlink.org.za/pphc/phila/chap01-4.htm (accessed 27 january 2014). 11. department of health, south africa. white paper for the transformation of the health system in south africa. pretoria: department of health, 2012. http://www.info.gov.za/whitepapers/1997/health.htm (accessed 28 march 2012). 12. gumbi rv, muller me. health personnel education in south africa. health sa gesondheid 1996;1(3):36-40. 13. fichard ae, du rand pp. facilitators’ perceptions of problem-based learning and community-based education. health sa gesondheid 2000;5(2):3-10. 14. mtshali ng. developing a community-based nursing education curriculum. in: uys lr, guele ns, eds. curriculum development in nursing process and innovation. new york: routledge, 2005. 15. sullivan ch. educational innovations. partnering with community agencies to provide nursing students with cultural awareness experiences and refugees health promotion access. journal of nursing education 2009;48(9):519-522. 16. lenz bk, warner s. global learning experiences during a domestic community health clinical. nursing education perspectives 2011;32(1):26-29. 17. bentley r, ellison kj. impact of a service learning project on nursing students. nursing education perspectives 2005;26(5):287-290. 18. uys lr, gwele ns. curriculum development in nursing: process and innovation. new york: routledge, 2005. 19. australian capital territory. phc strategy 2011 2014. 2010. http://www.health.act.gov.au/c/health?a=sendfile& ft=p&fid=1299734305&sid (accessed 18 april 2012). 20. institute for sustainable communities. community-based approach to education for sustainability. developing a new generation for leaders through school-based programs linked to community issues. 2011. http://www.iscvt. org/who_we_are/publications/education%20for%20sustainability%20guidebook.pdf (accessed 20 november 2012). 21. who and health and welfare canada. ottawa charter for health promotion. an international conference on health promotion, 17 21 november 1986, ottawa, canada. geneva: who, 1986. 22. reising dl, shea ra, allen pn, et al. using service learning to develop health promotion and research skills in nursing students. international journal of nursing education scholarship 2008;5(1):1-18. 23. eriskson gp. community health nursing in a non-clinical setting: service-learning outcomes of undergraduate students and clients. nurse educator 2004;29(2):54-57. 24. lashley m. nurse on a mission: a professional service learning experience with the inner-city homeless. nursing education perspectives 2007;28(1):24-26. 25. lazarus j, erasmus m, hendricks d, et al. embedding community engagement in south african higher education. education, citizenships and social justice 2008;3(1):57-83. 26. vogt ma, chevez r, schaffner b. baccalaureate nursing student experiences at a camp for children with diabetes: the impact of a service learning model. pediatric nursing 2011;37(2):69-73. 27. whelan j, spencer j, rooney k. a ‘ripper’ project: advancing rural interprofessional health education at the university of tasmania. rural and remote health 2008;8(3):1017-1022. 28. mtshali ng. a grounded theory analysis of the meaning of the community-based education in basic nursing education in south africa. phd thesis. durban: university of kwazulu-natal, 2003. 29. henry j. meaning and practice in experiential learning. in: weill sw, mcgill i, eds. making sense of experiential learning: diversity in theory and practice: buckingham: srhe and open university press, 1993. 30. frenk j, chen l, bhutta za, et al. education of health professionals for 21st century. health professionals for new century: tranforming education to strenghten health systems in an independent world. lancet 2010;376:19231958. [http://dx.doi.org/10.1016/s0140-6736(10)61854-5] 31. who. research for universal health coverage: world health report. geneva: who, 2013. 32. keleher h, parker r, francis k. preparing nurses for primary healthcare futures: how well do australian nursing courses perform? australian journal of primary health 2010;6(3):211-216. 208 october 2016, vol. 8, no. 2 ajhpe research as health systems become more complex and accordingly place a heavier burden on healthcare professionals, it is evident that healthcare education has not kept up with this changing situation. curricula have been described as ‘fragmented, outdated, and static’ and continue to produce graduates who have difficulty coping with the complexity of modern health systems.[1] while the science of medicine has changed significantly in the past few decades, the teaching of medicine has not undergone significant change.[1-2] systemic problems include, e.g. poor alignment between graduate competencies and patient needs, poor teamwork, distracted and over-committed teachers, ossified curricular structures, archaic assessment practices, and a focus on the technical aspects of knowledge and practice without emphasising contextual understanding.[1,3] it has been suggested that healthcare professionals must be more than technically competent. the modern healthcare professional is not necessarily someone who knows all the facts, but is rather able to access knowledge efficiently and when necessary, and is capable of forming conceptual relationships between seemingly unrelated areas.[4] there is evidence to support the use of learning theories to change practice and enhance students’ learning; yet, clinical educators continue to use teaching strategies that ‘knowingly fail to change behaviour’.[2] teachers who solely adopt a transmission-based approach to teaching may encourage the rote learning of facts and a resultant superficial understanding of the topic.[5] many teachers still adopt an almost exclusive emphasis on developing knowledge and technical skills as part of competent practice. however, a focus on competence alone is inadequate to produce graduates who are capable of adapting to the changing needs of health systems. while knowledge and technical skills are essential aspects of clinical education, we must go beyond teaching students what to know and what to do. we must help them to learn how to be by using teaching methods that focus on the process of learning rather than the memorisation of content.[6] we need to create learning spaces where students can be introduced to, and immersed in, the culture of the profession, giving them the feeling of what it is like to be legitimate peripheral participants in a community of practice,[7] i.e. what is learnt should be subordinate to how it is learnt.[8] this study sought to answer the question: what teaching strategies can be used to facilitate a developmental learning process that does not emphasise simply ‘having’ knowledge and skills? the objective of the study was to identify the teaching strategies that could be used to help students to develop a set of attributes that go beyond technical proficiency. methods this study used a nominal group technique (ngt) to gather input from a panel of clinical educators who were experts in different knowledge domains. the ngt is used to gather data from domain experts with the intention of reaching consensus, often around poorly defined topics[9] that would include the development of alternative approaches to a curriculum. the ngt was conducted in 2012 in an online workspace in which panellists shared their responses to guided questions. there were three sessions; after each session the researcher aggregated participant responses and presented additional follow-up questions based on the summarised responses, giving participants further opportunities to clarify their statements and make alternative suggestions. the panel consisted of purposively selected south african and international clinical educators who had experience in the training of healthcare students (table 1). panel participants were conveniently selected from the researcher’s professional network, and therefore included a greater number of physiotherapists. the purpose of the demographic information was to demonstrate the credibility of the panel as a whole, rather than to describe individual qualifications. the main purpose of the discussion was to ask panel members how they would go about creating an environment where students could engage in learning tasks that helped them to develop attributes beyond technical proficiency. data analysis panel members submitted their responses to the questions in an online workspace, which the researcher used to gather and summarise the data. inductive analysis background. clinical educators are being challenged to graduate students who can adapt to complex situations. evidence suggests that one must go beyond teaching students what to know and what to do, and help them learn how to be. objective. to identify teaching strategies that could be used to help develop students beyond technical proficiency. methods. this study used a nominal group technique to gather input from clinical educators, requesting them to identify teaching strategies for developing lifelong learning, emphasising the development of students’ knowledge and skills, and taking into account students’ emotional responses to the clinical context. participant responses were transcribed and analysed thematically. results. participants reported that clinical educators should be role-models to students in a process of lifelong learning, including demonstrating the vulnerability of ‘not knowing’. they also suggested integrating a variety of different teaching methods that aim at achieving the same goal. finally, participants emphasised the importance of intentionally incorporating personal values into reflective learning activities. by creating space for the shared learning experiences of teachers and students, participants high lighted the possibility of helping students to develop the mindset necessary to adapt to complex health systems. conclusion. clinical educators emphasised the developmental nature of the teaching and learning process, highlighting the importance of an authentic interaction between students and teachers. afr j health professions educ 2016;8(2):208-210. doi:10.7196/ajhpe.2016.v8i2.787 beyond the lecture: teaching for professional development m rowe, phd department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: m rowe (mrowe@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 209 research was used to determine themes emerging from the data, rather than using predetermined themes.[10] words and phrases were highlighted as being similar or belonging to the same categories, which were then used to determine the themes. participant responses were analysed thematically until saturation was reached.[11] these emergent themes were then summarised and re-presented to panel members for clarification and further comment. trustworthiness of the analysis was established using a framework for qualitative research that identified the following criteria against which to judge the work: credibility, transferability and dependability.[10] the analysis, emergent themes and subsequent surveys were cross-checked by two other researchers, who provided critical input on the results and analysis. the results in this article are presented as quotes from the original participant responses, providing evidence for the themes that arose. these, together with the critical review of two independent researchers, serve to establish both the credibility and dependability of the claims made in the article. the transferability of the claims is limited, considering the specific context in which this study took place. ethical considerations this study received ethical clearance from the institutional ethics committee (project registration no. 09/8/16). prior to participating in the study, invited panel members received an information sheet and were asked to state their consent to participate. panellists were informed that their participation was voluntary and that non-participation would not affect them negatively. they could withdraw from the study at any stage and have their responses removed. all responses to the questions were anonymous so as to limit the possibility that comments made by panellists with more experience would be referred to. results the results of the discussions are presented below according to the questions that informed the discussion. panellists were asked what teaching strategies they would use to facilitate professional development and lifelong learning among their students, how best to develop the students’ knowledge and skills, and how to support students’ values and emotional responses to the clinical environment. the themes that emerged during the discussion included the following: teachers should model their own approach to continuous learning to students; they should use teaching strategies that are both varied and integrated; and they should include the roles of personal values and emotions in reflective learning activities. demonstrate continuous personal learning panel members were asked how they would facilitate a learning process among students that emphasised continuing professional development and lifelong learning, rather than focusing on only the technical aspects of competent practice. participant responses are presented below and clearly demonstrate an emphasis on educators’ openness to continuous professional development, as well as modelling their approach to students: ‘i encourage [students] to read widely and challenge themselves and others by always asking “why”? i refer to the development of staff in the department, and my own professional and personal development. informing students when i learn something new, when i learn from them, and from patients.’ ‘i mention that i cannot teach them anything, but can only invite them to learn and that the only person who i can guarantee will learn from our [short] time together is myself.’ ‘role-modelling is the way that makes the biggest impact. as often as possible during routine clinical activities i make a point of referring to my own need for learning and development when addressing the students. i often look things up in a book on the ward round to illustrate the need for ongoing learning and the fact that even at a senior clinical level the need for learning is ongoing.’ ‘we are not scared to admit that we do not know all the answers, even to clinical questions and use the same resources we provide for the students to look up the answers. use humour in the learning and teaching room.’ integrate a variety of methods in addition to the development of an approach to lifelong learning, it was clear that having a set of basic knowledge and technical skills were important components of competent practice. these were identified by panellists, and included communication and technical skills, applying knowledge to practice, clinical reasoning, and critical thinking. the teaching strategies they suggested to determine how these aspects of professional practice could be developed are presented below. it is clear that participants recommend the integration of different teaching approaches during the same session: ‘integrating short role-play to teach communication skills (especially how to deal with the emotional content of patient interaction), immediately followed by bedside interview, and then reflection individually and in a safe small group. this followed by a compulsory formative assignment with a reflective component. students comment that the role-play leads into the authentic clinical consultation very well.’ ‘teaching strategies would include: clinical demonstrations on models and patients as well as return demonstrations, working with students through the following steps: observer, assistant, active performer with assistance, and finally active performer with minimal assistance but under supervision.’ ‘theory of the meaning of the practical technique of technical skill, and evidence for it. demonstrate the technique and then let them practice while i correct and explain again what the techniques aim to do. in revision they demonstrate a practical technique and the class critique.’ incorporate values and emotions into reflective learning activities panel members discussed the role that personal, affective components of learning can play in the students’ development and professional practice. they were asked how they could support students’ values and emotional responses table 1. demographic information of panel members demographic information* panel, n=21 occupation professor lecturer clinician other 3 4 3 11 profession physiotherapist physician other 8 3 2 experience, years range average 4 25 14 highest degree obtained bsc msc phd mmed 4 3 4 1 additional qualifications educational clinical other 4 11 1 * not all participants completed every section of the demographic survey; hence, the totals are inconsistent. 210 october 2016, vol. 8, no. 2 ajhpe research to learning experiences in the clinical context. the panel highlighted intentional incorporation of personal values and emotions in students’ reflective learning tasks as important: ‘the nature of the programme allows students to share personal values and experiences when discussing the cases. the students have to develop trust to be able to share in their groups, which improves as they become more comfortable with one another.’ ‘students need opportunities for self-reflection that is structured, is written down and receives developmental feedback; they need to be given opportunities to develop their own sense of agency; if they are always passive in the health system as students then they will always be passive when professional.’ ‘specifically asking students to express and discuss their personal values and emotional responses to patient encounters is a critical part of clinical training. students need to express what they think and feel in the clinical setting so that they learn to deal with value issues and emotional responses to events in clinical practice.’ discussion the overwhelming response from panel members was that there is a need to display an open attitude to their own personal continuous learning, thereby modelling to students what a process of lifelong learning entails. panel members did not believe that clinical educators should have all the answers, and noted that the teachers’ lack of knowledge can be used to drive and motivate student learning. this openness to display vulnerability and uncertainty has been identified as an attribute of positive role-models among clinical teachers.[12] the panel also suggested that educators should model a process of inquiry to stay up to date in their respective fields, noting that role-modelling is an important process through which teachers demonstrate their own continued learning. educators must therefore create safe spaces for students to explore the domain in collaboration with peers and the teacher, rather than simply informing students what to do and what they need to know. we need to help students to ‘create paths to knowledge’ when needed,[13] and to focus on helping them to learn how to learn, a conception of teaching as a process that makes student learning possible.[9,14] however, this approach to teaching and learning requires a cultural change among clinical educators.[4] panel members also suggested that a variety of teaching approaches should be used to develop knowledge and skills, and that these approaches should be integrated. for example, lectures could be used to cover key concepts prior to practical demonstrations, followed by observed practice by the students, and associated feedback. they suggested that teachers make use of tutorials and modelling, either in the classroom or in the clinical context. role-play to explore different aspects of appropriate behaviour, followed by feedback from teachers and peers, was encouraged. again, the concept of feedback was highlighted as an essential aspect of learning that could be used to guide future learning.[15] there is evidence to suggest that, with appropriate guidance, peers are able to provide constructive feedback on performance that can be used to structure changes in future practice.[15] clinical educators should therefore consider the role of peer evaluation and feedback in their teaching sessions. furthermore, reflection in small groups and by individuals immediately after receiving feedback was noted as having the potential to enhance student learning. it was clear that panellists reported using combinations of teaching strategies, rather than suggesting only one approach. these integrated teaching and learning activities emphasised the connection and interaction between people, highlighting the idea that teaching and learning is a process that ‘values human relationships’.[16] this is in stark contrast to a knowledgetransmission form of teaching, where the teacher ‘transmits’ what should be known and the students passively ‘receive’ it, an approach that many clinical educators still subscribe to.[2] panel members reported that educators should encourage the sharing of personal values and experiences among students and clinicians, and evaluate the impact of those experiences on themselves. they should build reflective components into the curriculum, asking students how they feel about, and deal with, their emotional responses to the clinical context. panel members also suggested that students be encouraged to provide evidence of engagement with their own emotional responses through reflective self-reporting, which should include a feedback component from peers and more experienced clinicians. the inclusion of a feedback component highlights the essential role that it plays in the shaping of students’ values.[15,17] however, it is important that this feedback is given in a safe space, as it can be linked to confusion, anxiety, embarrassment and lack of confidence.[14] in some cases the feedback interaction is so negative that it has an emotional impact lasting several years, and can inhibit learning.[18] therefore, the sharing of personal experiences and the emotional response to those experiences, together with feedback from peers and teachers, require a caring and trusting relationship to be effective. conclusion and recommendations to develop learning outcomes that go beyond knowledge and skills, clinical teachers should model an approach to lifelong learning for students, make use of an integrated variety of teaching methods, and intentionally incorporate the role of personal values and emotional response into students’ learning activities. teachers should also understand that these approaches are premised on the existence of a relationship between student and teacher, which encourages both of them to create space for the other to be vulnerable and admit to ‘not knowing’. clinical educators in this study emphasised the developmental nature of the teaching and learning process, highlighting the importance of an authentic interaction between students and teachers. by engaging with shared learning experiences, we may be able to provide students with opportunities to develop the knowledge and mindsets necessary to participate in dynamic and complex health systems. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s0140-6736(10)61854-5 2. graffam b. active learning in medical education: strategies for beginning implementation. med teach 2007;29(1):38-42. doi:10.1080/01421590601176398 3. cooke m, irby dm, sullivan w, ludmerer km. american medical education 100 years after the flexner report. n engl j med 2006;355(13):1339-1344. doi:10.1056/nejmra055445 4. fraser sw, greenhalgh t. coping with complexity: educating for capability. bmj 2001;323(7316):799-803. doi:10.1136/bmj.323.7316.799 5. pratt dd, arseneau r, collins jb. reconsidering ‘good teaching’ across the continuum of medical education. j contin educ health professions 2001;21(2):70-81. doi:10.1002/chp.1340210203 6. jarvis-selinger s, pratt dd, regehr g. competency is not enough: integrating identify formation into the medical education discourse. acad med 2012;87(9):1185-1190. doi:10.1097/acm.0b013e3182604968 7. lombardi mm. authentic learning for the 21st century: an overview. educause learning initiative, may 2007. http://net.educause.edu/ir/library/pdf/eli3009.pdf (accessed 25 july 2016). 8. ovens p, wells f, wallis p, hawkins c. developing inquiry for learning: reflecting collaborative ways to learn how to learn in higher education. london: routledge, 2011. 9. delbecq al, van de ven ah, gustafson dh. group techniques for program planning: a guide to nominal group and delphi processes. glenview, scotland: foresman, 1975. 10. cohen l, manion l, morrison k. research methods in education. 6th ed. london: routledge, 2007. 11. pope c, ziebland s, mays n. qualitative research in health care: analysing qualitative data. bmj 2000;320(7227):114-116. doi:10.1136/bmj.320.7227.114 12. jochemsen-van der leeuw hg, van dijk n, van etten-jamaludin fs, wieringa-de waard m. the attributes of the clinical trainer as a role model. acad med 2012;88(1):1-9. doi:10.1097/acm.0b013e318276d070 13. anderson t. theories for learning with emerging technologies. in: veletsianos g, ed. emerging technologies in distance education. edmonton: athabasca university press, 2011:23-39. 14. ramsden p. learning to teach in higher education. 2nd ed. london: routledge, 2003. 15. boud d, molloy e. feedback in higher and professional education: understanding it and doing it well. london: routledge, 2013. 16. doll we. a post-modern perspective on curriculum. new york: teachers college press, 1993. 17. epstein rm. assessment in medical education. n engl j med 2007;356(4):387-396. doi:10.1056/nejmra054784 18. falchikov n, boud d. assessment and emotion: the impact of being assessed. in: boud d, falchikov n, eds. rethinking assessment in higher education. learning for the longer term. london: routledge, 2007:144-156. http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1080/01421590601176398 http://dx.doi.org/10.1056/nejmra055445 http://dx.doi.org/10.1136/bmj.323.7316.799 http://dx.doi.org/10.1002/chp.1340210203 http://dx.doi.org/10.1097/acm.0b013e3182604968 http://net.educause.edu/ir/library/pdf/eli3009.pdf http://dx.doi.org/10.1136/bmj.320.7227.114 http://dx.doi.org/10.1097/acm.0b013e318276d070 http://dx.doi.org/10.1056/nejmra054784 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 117 the training of novices in medical specialties to achieve the optimum state of cognitive, clinical, technical and professional development requires the use of a variety of teaching methodologies, including the process of feedback. this level of excellence can only be achieved if the gaps between actual and desired performance are reported to the trainee by a more experienced supervisor, together with a plan for improvement.[1] the failure of feedback mechanisms can contribute to incompetent healthcare professionals.[2] this is due to various reasons, including the failure of students to recognise different forms of provision of feedback; when and where feedback is provided; incapacity of the teacher; operational demands of the clinical setting; lack of clearly defined teaching and learning objectives; and inadequate support mechanisms for students not meeting such objectives.[1] training to become a doctor is almost the same as serving an oldfashioned apprenticeship, during which skills from more experienced seniors are passed on to students in an experiential learning setting.[3-5] as training progresses in postgraduate specialisation, the need for constant, highquality feedback from clinical supervisors/mentors to students intensifies to aid in the development of the trainees’ finely honed competencies in their chosen field. it is only through the provision of feedback that strengths can be identified and amplified, and corrective measures can be put in place to overcome deficiencies.[4,6] traditionally, consultants in academic teaching hospitals were held in high esteem for their clinical expertise. students were expected to learn from observation, rather than being taught by consultants competent in the formal art of teaching. this process is often compounded by service delivery, as tending to patients takes precedence over more timeconsuming explanations about details of and reasons for processes followed. however, the failure to provide this essential component of training may contribute to incompetent and poorly trained clinicians, resulting in poor patient outcomes. ende,[6] in his seminal article, defined feedback in clinical medical education as ‘information describing students’ or house officers’ performance in a given activity’. feedback addresses the deficit in meeting a predetermined standard of desired skills by identifying the area of poor performance and devising a means to achieve the standard. it is used to promote the desired, high-quality performance in trainees through raising awareness of current skills in high-level performers.[7] however, to be effective, the process needs to be a formalised assessment of performance, with a corrective plan of action to address deficiencies – a ‘learning through guiding’ process.[5,8,9] in this way, the trainee receives clarification of the process he or she followed compared with what was expected; on how to address the gap between actual and intended performance; and, most importantly, of the consequences for patient outcomes should the current performance go unchecked. ideally, this should prompt a behaviour change in the trainee to achieve the desired standard.[7,8] background. the training of novices, in any field, to achieve the optimum state of cognitive, clinical, technical and professional development requires a variety of teaching methodologies, including the process of feedback. feedback is defined as a process where the desired standard of proficiency in a task has already been established and communicated to the student before gaps in performing the task or in the level of knowledge are identified. the process of feedback has often been evaluated and has consistently revealed students’ dissatisfaction with the amount and type of feedback they receive in their clinical and postgraduate training, as they perceive it to be inadequate, inappropriate or non-existent. objectives. to investigate the perceptions of the quality of feedback received by a diverse, heterogeneous population of registrars in postgraduate training at an academic hospital. methods. a study was conducted using a questionnaire to determine the perceptions of all registrars in the six major clinical training programmes with regard to the quality, efficacy and effectiveness of feedback received during clinical training. descriptive statistics were used to interpret the responses of the registrars, with mean values being calculated. results. perceptions of the quality of feedback received differed across disci plines. overall, the registrars rated the feedback they received as poor. the majority (51.4%) reported that both formal and informal feedback was only sometimes, even rarely, received during all encounters with consult ants. others (51.3%) felt that the feedback received was unacceptable, and did not perceive it to be based on concrete observations of performance. the proficiency of consultants in giving feedback was scored as unacceptable by 64.8% of registrars. conclusion. registrars in training regard feedback as an essential compo nent of their postgraduate medical education and as an important component of achieving clinical competence. more formalised processes need to be implemented. the majority of registrars agreed that consultants required training in providing feedback effectively. afr j health professions educ 2016;8(1 suppl 1):117-120. doi:10.7196/ajhpe.2016.v8i1.768 feedback as a means to improve clinical competencies: registrars’ perceptions of the quality of feedback provided by consultants in an academic hospital setting c i bagwandeen,1 mb chb, dhsm, doh, dip hiv man (sa), fcphm; v s singaram,2 bmedsc, mmedsc, phd 1 discipline of public health, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 2 clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: c i bagwandeen (bagwandeenc@ukzn.ac.za) research 118 may 2016, vol. 8, no. 1, suppl 1 ajhpe the lack of appropriate feedback in guiding students on when and how to change, and taking note of and acknowledging what is being done well, can soon lead to disillusionment of the student.[10] however, excessively praising or complimenting the student, which is not feedback in the true sense, has been shown to be equally unsatisfactory over time.[11] with appropriate feedback, students develop autonomy in implementing suitable corrective mechanisms to achieve the desired standard of competence,[10] and are able to critically self-assess performance.[11] as the student makes the transition from underand postgraduate student to independent practitioner, this skill will prove a valuable resource in the context of an evolving set of compe tencies, as it aids in a positive approach to lifelong learning, which is expected of a competent doctor. therefore, even practising physicians, in whom the art of self-reflection (which should be a component of feedback) has been inculcated in their clinical training, are cognizant of the need for continuous medical education and feedback, leading to improved patient outcomes.[12-14] feedback has often been evaluated, which consistently reveals students’ dissatisfaction with the amount and type of feedback they receive in their clinical and postgraduate training, as they perceive it to be inadequate, inappropriate or non-existent.[14,15] to achieve clinical competence that will result in optimal patient care and outcomes, trainee errors must be rectified and competencies reinforced, especially in the context of workplace ‘experiential’ learning. this study explores registrars’ perceptions of feedback provided by consultants at a teaching hospital across six clinical disciplines, i.e. internal medicine, surgery, obstetrics and gynaecology, paediatrics, psychiatry and family medicine. methods although a mixed methods approach was adopted for this study, this article reports only on the quantitative data collected. the study population comprised all registrars (i.e. qualified doctors undertaking postgraduate specialisation training) employed at a major teaching hospital attached to the nelson r mandela school of medicine (nrmsm), university of kwazulunatal, durban, south africa. all registrars from the disci plines listed above were invited to participate in the study via an online questionnaire. owing to a low response rate, questionnaires were also hand ed out at departmental academic days. thirty-seven out of a total of 60 regis trars consented to participate in the study. questions related to various aspects of how feedback was given, including: when (e.g. ‘feedback is provided in all encounters with a consultant’); where (e.g. ‘feedback is provided in all settings’); type (e.g. ‘feedback is informal’); effect (e.g. ‘the effect of feedback on the registrar is noted’); topic (e.g. ‘feedback is given about clinical skills’ ); and how (e.g. ‘feedback is given in non-emotive, non-judgemental language’). sociodemographic information regarding age, gender, home language, discipline and year of study was also gathered. registrars responded using a 5-point likert scale (1 (never) 5 (always)). a definition of feedback was also included: ‘for the purposes of this study, feedback is defined as: a process whereby the desired standard of proficiency in a task has been clearly established. this standard has been communicated to the student. gaps in performing the task or level of knowledge are identified, based on actual observation of the student, and the student is made aware of his or her shortcomings, together with a plan to improve performance.’ descriptive statistics were used to interpret the responses of the registrars, with mean values being calculated. differences between groups were calculated using pearson’s χ2 test for independent variables, with a p-value of <0.05 regarded as being statistically significant. responses were combined to give an overall negative (1, 2 and 3) and positive (4 and 5) response to certain questions. full ethical approval for the study was received from the humanities and social sciences ethical committee, university of kwazulu-natal (hss/1185/013d). results the mean age of the registrars was 32.3 (range 27 43) years. the majority were female (64.9%) and first-language english speakers (54.1%). only two of the registrars had a postgraduate diploma and one had a master of medicine (mmed), while the remaining 34 had completed only their basic under graduate medical degree. most of the registrars (n=16) were in their 4th year of training, 12 were in their 3rd year, 7 were in their 2nd year, and 2 had just commenced training. the registrars’ specialisations were divided as follows: paediatrics (n=9), obstetrics and gynaecology (n=9), surgery (n=7), internal medicine (n=6), psychiatry (n=3) and family medicine (n=3). overall, registrars rated the feedback they received as poor, as illustrated in fig. 1. the majority of registrars (51.4%) reported that both formal and informal feedback was only sometimes, even rarely, received in all encounters with consultants. the location of formal feedback sessions was perceived as appropriate (59.4%), but the advance scheduling of such sessions was not (62.1%). a total of 48.6% registrars rated equally the provision of standards for assessment being predetermined and communicated in advance. however, 51.3% felt that the feedback received was unacceptable, and did not perceive it to be based on concrete observations of performance. the majority report ed that they did not receive feedback on techniques performed incorrectly (54.0%) or on those performed correctly (67.5%). many registrars (59.4%) perceived that feedback was not being documented. more than half (56.7%) of registrars reported that the intended message was not received and the same percentage perceived insufficient opportunity to respond to the consultant. overall, 54.0% did not agree with the content of the feedback. when formal feedback was given, 64.8% of the registrars believed that a plan for improvement had been given, while 59.5% reported the inclusion of new learning objectives. some 67.6% of registrars positively reported reflecting on previous feedback as a result of current feedback. the language in which feedback was given was perceived to be non-emotive and nonjudgemental by 64.8%. in a similar vein, 56.7% of the registrars believed that the feedback received was not influenced by race, gender or ethnicity. the proficiency of consultants in giving feedback was scored as unacceptable by 64.8% of registrars, while 59.4% perceived that the effect of feedback on them went unnoticed, and 67.5% noted that there were no support structures for students after receiving feedback. other results showed that a majority of the registrars (91.7%) believed that consultants should be trained to provide feedback and all agreed that feedback about registrars’ clinical proficiency was important. the exit examination for specialisation – fellowship of the relevant college of the colleges of medicine of south africa – requires specific preparation in the honing of clinical skills, how to answer written examination questions and make presentations during oral examinations. while 83.3% of registrars agreed that feedback was provided in preparation for these examinations, only 58.8% felt that this feedback was adequate. some 45.7% thought that it research may 2016, vol. 8, no. 1, suppl 1 ajhpe 119 was provided in a timely manner. while 61.1% of the registrars reported that feedback was provided on how to obtain their mmed qualification in terms of the protocol preparation, research and administrative processes, less than half thought the information was provided adequately (44.4%) or timeously (41.7%). the majority (70.6%) believed that the esteem in which they held their consultants influenced the manner in which they received feedback. multiple settings are available for provision of feedback. registrars reported that feedback was provided in various settings: 25.0% during group teaching, 22.0% at the patient’s bedside, 20.0% during academic days, and 17.0% during one-on-one teaching. no feedback was given in side-room settings. a majority (87.1%) thought that feedback provided by consultants differed between academic hospitals in kwazulu-natal. discussion this study explored the perceptions of registrars’ feedback given to them by their consultants at a teaching hospital in six academic disciplines. a fundamental tenet of feedback is the need to improve on performance by identifying the gaps when comparing actual performance with the desired level of competence to be achieved and a previously identified standard. the information with regard to what is missing should be conveyed to the trainee, ideally together with a plan to improve said performance.[4,6] the predetermination of standards to be achieved is a key component.[6] in this study, registrars were divided in their opinions as to whether this fundamental component of feedback was met. the lack of guidelines that delineate the desired standards and learning objectives to be achieved may leave registrars unsure as to how best to acquire competence in areas of deficiency, as feedback given may be misunderstood. a core component of medical education is the transfer of skills from an experienced senior to an inexperienced novice in a workplace. assessing performance and providing timeous feedback at the patient’s bedside or shortly thereafter is a type of brief feedback that forms part of a wider spectrum of types of feedback.[1] it is therefore of concern that this study found that feedback was infrequent and not often given at the bedside of the patient, a prime area for highlighting clinical management.[6,7] this finding highlights the need to encourage consultants to provide more feedback, as the experiential clinical setting is particularly conducive to training.[5] as far back as the ‘apprenticeship’ that medical students served in the days of hippocrates, the importance of feedback has been well documented as a means of ensuring that underperforming students achieve the desired level of competence, informing competent students of the skills that they are using, encouraging increasing use of those skills, and focusing the attention of students on the consequences of not performing optimally.[1,5,7,8,15,16] of grave concern is that the majority of registrars reported that no feedback was given when techniques were performed incorrectly and that opportunities for entrenching good practice were also missed. it is essential for these deficiencies to be addressed to prevent registrars’ clinical competence and training being compromised. 18.9 27.08.18.137.8 18.9 29.7 13.5 10.8 13.5 16.2 10.8 8.1 16.2 29.7 29.7 35.1 35.1 18.9 21.6 21.6 8.1 51.4 29.735.1 10.8 32.4 18.9 18.9 13.5 13.5 51.4 16.2 13.5 29.7 27.0 5.4 43.2 10.8 8.1 48.6 29.7 13.5 24.3 13.5 35.1 18.9 29.7 rarely never sometimes always often 100.0 0.0.080.0 60.0 40.0 20.0 100.080.060.040.020.0 37.8 45.9 16.2 8.129.7 5.4 13.5 13.532.4 2.72.748.6 10.85.440.5 13.52.748.6 29.7 10.8 27.0 10.8 10.8 40.5 32.4 8.1 16.2 2.75.432.4 2.7 5.45.429.7 18.9 35.1 8.1 13.5 10.8 2.75.4 8.18.1 24.3 13.5 16.216.235.1 8.1 5.4 16.2 13.5 13.5 32.4 32.4 13.518.9 5.48.124.3 37.8 13.510.8 8.12.751.4 2.7 8.1 48.6 43.2 i would like to receive peer feedback i would like to receive group feedback i would use these techniques when i have students i agree with the feedback provided my feedback sessions are always successful. i receive the intended message in the intended manner consultants are pro�cient at giving feedback to registrars the e�ect of feedback on me is noted by my consultant formal feedback is documented feedback incorporates new learning objectives i have an opportunity to respond to the feedback given support is available to me from di�erent sources after both formal and informal feedback sessions feedback is in�uenced by my race, gender or ethnicity feedback is given in non-emotive, non-judgemental language formal feedback is provided informal feedback is provided feedback is provided in all encounters with a consultant a component of feedback process is a plan for improvement receiving feedback encourages re�ection about previous feedback feedback is given about procedures and techniques performed correctly feedback is given about procedures and techniques performed incorrectly feedback is based on concrete observations of my performance standards for assessment are predetermined and communicated to me in advance formal feedback sessions are held in an appropriate location formal feedback sessions are scheduled in advance fig. 1. how registrars believe feedback is provided. research 120 may 2016, vol. 8, no. 1, suppl 1 ajhpe in a study comparing the giving of feedback to the process of breaking bad news, emphasis is placed on the importance of the supervisor being fully cognizant of the standards against which performance is assessed, and how these apply to learners at different levels.[8] being able to respond to feedback allows registrars the opportunity to clarify areas of deficiencies and the steps needed to rectify such deficiencies, which increase the possibility of improvement. the majority of registrars reported not receiving the intended message and not agreeing with the feedback. this is further compounded by them reporting that they were not given an opportunity to respond. this is a serious concern, as these findings may have the detrimental effect of causing the registrar to feel the process is unhelpful, with no clear direction of how to improve, leaving him or her inert, demoralised and fearful to proceed in case of erring. worse still, the registrar may come to believe that the consultant is wrong and so may persist with incorrect clinical management.[6] consultants need to be made aware of the effect of feedback on registrars and to ensure that various and appropriate support mechanisms are available to prevent any untoward consequences. registrars must be at ease in seeking such support. an appropriate approach to feedback is essential to ensure that the process attains the desired end result of improving performance. this study found that only a third of registrars felt that consultants were competent in providing feedback. it is in the interaction with patients, under the expert eye of the consultant, that these practical areas, which require a ‘hands-on’ approach and cannot be learnt abstractly or didactically, can be improved, provided feedback is given.[5] hence, it is critical for supervisors and students to be skilled in the process of giving and receiving feedback. the fellowship examination is the exit examination for registrars – an external examination after 4 years of training. the examination has as much to do with being able to present competently and have appropriate examination techniques as with being academically competent. it is disconcerting that, although registrars reported that feedback is provided in preparation for the examination, it is only perceived to be adequate and given timeously half of the time. such preparation should be an integrated and continuous part of a comprehensive training approach, enabling registrars to present with ease and confidence in their final examinations. it should not be a mere add-on during the last weeks before the examination. furthermore, information regarding the timelines, and academic support for attaining the mmed qualification, should be standardised to prevent unnecessary delays and improve throughput time in the registrar programme. our study suggests that a component of the discipline aca demic day be allocated for formal fellowship examination preparation to ensure that essential feedback is provided to registrars timeously to allow for adequate preparation. conclusion good-quality feedback comprising all elements is essential in postgraduate clinical training. while feedback is provided in some meetings with consultants, the essential elements of feedback appear to be missing, i.e. of having predetermined standards to be achieved established and in place, clearly communicated to the registrar beforehand, based on observed performance and incorporating a plan for improvement. provision must be made for the registrar to respond to feedback and clarify areas of possible confusion, especially with regard to the improvement plan. the findings of this study highlight the need for appropriate and continuous training programmes that must be developed and implemented for consultants to provide and for registrars to receive feedback effectively in the postgraduate medical training settings. a limitation of this study was the small sample size and possible female bias, which can be addressed in future studies by including more academic hospitals to increase both sample size and equitable gender representation. acknowledgements. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. we thank dr m muzi gaba for help with the statistical analysis, and the staff and students who participated in this study. references 1. shrivastava sr, shrivastava ps, ramasamy j. effective feedback: an indispensable tool for improvement in quality of medical education. j pedagogic dev 2014;4(1)12-20. 2. iobst wf, sherbino j, ten cate o, et al. competency-based medical education in postgraduate medical education. med teach 2010;32:651-656. [http://dx.doi.org/10.3109/0142159x.2010.500709] 3. rodriguez-paz jm, kennedy e, salas e, et al. beyond ‘see one, do one, teach one': toward a different training paradigm. qual saf health care 2009;18:63-68. [http://dx.doi.org/10.1136/qshc.2007.023903] 4. henderson p, ferguson-smith a, johnson m. developing essential professional skills: a framework for teaching and learning about feedback. bmc med educ 2005;5(1):11. 5. fluit c, bolhuis s, grol r, et al. evaluation and feedback for effective clinical teaching in postgraduate medical education: validation of an assessment instrument incorporating the canmeds roles. med teach 2012;34:893101. 6. ende j. feedback in medical education. jama 1983;250:777-781. 7. delima thomas j, arnold r. giving feedback. j palliat med 2011;14:233-238. [http://dx.doi.org/10.1089/ jpm.2010.0093] 8. bing-you r, trowbridge r. why medical educators may be failing at feedback. jama 2009;32:1330-1331. 9. nicholson s, cook v, naish j, boursicot k. feedback: its importance in developing medical students’ clinical practice. clin teach 2008;5:163-166. 10. jussim l, yen h, aiello j. self-consistency, self-enhancement, and accuracy in reactions to feedback. j exp soc psychol 1995;31:322-356. 11. srinivasan m, hauer k, dder-martirosian c, wilkes m, gesundheit n. does feedback matter? practise-based learning for medical students after a multi-institutional clinical performance exam. med educ 2007;41:857-865. 12. veloski j, boex j, grasberger m, evans a, wolfson d. systematic review of the literature on assessment, feedback and physicians’ clinical performance: beme guide no. 7. med teach 2006;28:117-128. 13. rogers a, boehler m, schwind c, meier a, wall j, brenner m. engaging medical students in the feedback process. am j surg 2012;203:21-25. [http://dx.doi.org/10.1016/j.amjsurg.2011.07.009] 14. mckinley r, williams v, stephenson c. improving the content of feedback. clin teach 2010;7:161-166. 15. hattie j, timperley h. the power of feedback. rev educ res 2007;77:81-112. 16. archer j. state of the science in health professional education: effective feedback. med educ 2010;44:101-108. research 92 may 2016, vol. 8, no. 1, suppl 1 ajhpe there is a maldistribution of the health workforce in favour of urban areas, with fewer medical doctors practising in geographical areas where the need is greatest in south africa (sa).[1] research commissioned by the sa department of labour in 2008 showed that the health workforce shortages are not only geographically defined.[2] in addition to rural and urban disparities, there are recruitment and retention difficulties in the public sector compared with the private sector. over the past decade, canada, australia and the usa have also reported disparities between metropolitan and non-metropolitan areas, despite an increase in the number of medical graduates per capita.[3,4] the shortage of doctors in rural areas has been linked to poor treatment outcomes for diseases such as hiv/aids and other complicated illnesses, when compared with urban areas in sa.[2] the incorporation of primary care or family medicine in the undergraduate medical curriculum and decentralising training outside of large academic complexes are two of 10 evidence-based undergraduate interventions demonstrated to influence medical graduates’ decisions to work in rural areas.[5] this ‘distributed’ approach has become more popular in medical universities with a drive to promote rural health. students spend some time in decentralised training sites with a view to enhancing their experiential learning and increase their chances of eventual career paths and retention in these areas.[6,7] there is also some evidence to show that students from rural origins are more likely to pursue their medical career in rural settings after graduation, compared with those from non-rural origins.[8] to maximise the outcomes of such intervention, particularly those related to experiential learning and desire for a future career in rural settings, it is important to understand what factors influence the choice for training site location, as this may dictate whether an objective approach for student allocation may be necessary. in this study, we evaluated a decentralised training programme which was piloted at the university of kwazulu-natal (ukzn) in 2013 on 4th-year undergraduate medical students as part of their family medicine block. the primary hypothesis was that students’ choice for site location was determined by their gender, race, place where they were raised and where they completed high school. secondly, we tested the hypothesis that learning experiences differed among students depending on the ‘rurality’ of the site where they completed their rotation. this formative evaluation was partly conducted to share lessons learned with the medical education community and to generate information to inform the refinement of this pilot intervention. the ukzn decentralised training programme the ukzn decentralised training programme was piloted in 2013 in sa through a collaboration between ukzn, the medical education partnership initiative (mepi) and the kwazulu-natal (kzn) department of health. as part of the programme implementation plan, students were allowed to self-select in groups of four to six. the resultant groups of students then chose one of six primary healthcare facilities across kzn, where they were attached for 12 consebackground. there is a dire need for medical schools in south africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities, particularly in rural areas. objectives. to assess the effect of students’ gender, race, place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students’ learning experiences relevant to primary care across training sites. methods. a survey design involving six cohorts of 4th-year undergraduate medical students (n=187) who were part of the 2013 family medicine rotation at the nelson r mandela school of medicine. self-administered questionnaires were completed by students at the end of each rotation. data analyses involved descriptive computations and inferential statistical tests, including non-parametric tests for group comparison and generalised polynomial logistic regression. results. students believed that their knowledge and skills relevant to primary care increased after the rotation (p<0.0001). there were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. male students were less likely to choose urban sites. black students were less likely to choose rural sites compared with their white and indian counterparts, as were students who attended rural high schools (odds ratio (or) 9.3; p<0.001). students from a rural upbringing were also less likely to choose rural sites (or 14; p<0.001). conclusion. based on the findings, an objective approach for student allocation that considers students’ background and individual-level characteristics is recommended to maximise learning experiences. afr j health professions educ 2016;8(1 suppl 1):92-98. doi:10.7196/ajhpe.2016.v8i1.741 predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south africa m muzigaba,1 phd, mph, mphil, bsc; k naidoo,2 mb chb, mcfp, mfammed; a ross,2 mb chb, dch, mmed (family medicine), fcfp (sa); n nadesan-reddy,3 mb chb, fcphm, mmed (public health medicine); s pillay,1 mb chb, dom, dip hiv man (sa) 1 medical education partnership initiative, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 department of family medicine, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 3 discipline of public health medicine, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: m muzigaba (mochemoseo@gmail.com) research may 2016, vol. 8, no. 1, suppl 1 ajhpe 93 cutive days. two of the facilities were rural, two peri-urban and two urban. for this programme, an urban area was defined as a geographical location where there is a high population density and economic functioning, such as the city of durban. a rural area was defined as a geographical location with very low population density and little to no economic activity. a peri-urban area was considered to be an area between consolidated urban and rural regions. the students received one week of teaching and skills training prior to the clinical attachment. in the short term, the programme sought to enhance student learning experiences at each of the training sites. the mediumterm outcome following directly from this would have been an increased propensity or willingness to return to such areas after undergraduate training. methods design this study involved cross-sectional surveys with six successive cohorts of 4th-year medical students who benefited from the mepi-ukzn decentralised training programme in 2013. of a total of 187 4th-year students who completed the rotation, 183 consented to participate, giving a response rate of 97%. at the end of each rotation, students were given a structured quantitative questionnaire to complete. the questionnaire was developed mindful of the need to maximise the response rate and to obtain accurate and relevant information for the survey. questions were constructed using short and simple sentences asking one piece of information at a time. with the study being exclusively quantitative, only closed questions were used. this allowed for specific information on dependent and independent variables of interest to be gathered. the independent variables of interest were categorical in nature and included students’ gender, race, geographical areas that best describe where they completed high school and were born, and geographical location of the site where they completed their rotation. the questionnaire also contained questions that were developed against specific learning objectives set out in the primary care/family medicine curriculum. these constituted the dependent variables and were formulated using a 5-point likert scale ranging from 1 (no knowledge or skills) to 5 (no need for supervision). the scale was used to rate each learning objective before and after the rotation, as a subjective measure of the change in knowledge/skills on that learning objective. a number of experiential learning variables on the evaluation of clinical placement programmes which are commonly cited in the literature[6,7] were also included in the questionnaire. students used a 5-point likert scale to rate their experiences during the rotation period, based on these variables. to maximise accuracy of the information gathered, negative questions were avoided as far as possible and questions table 1. distribution of students (n) across cohorts by their demographic characteristics and type of dtc location they selected variable cohort 1 cohort 2 cohort 3 cohort 4 cohort 5 cohort 6 total pearson’s χ2 p-value sex male 11 10 15 11 10 16 72 female 16 19 17 16 22 18 109 total 27 29 32 27 32 34 181 14.28 0.501 ethnicity white 3 5 5 2 4 2 21 black 14 10 13 14 13 15 79 indian 8 15 14 11 15 16 79 coloured 2 0 0 0 1 1 4 total 27 30 32 27 33 34 183 11.47 0.721 type of dtc location rural 12 12 20 13 19 26 102 urban 8 7 8 8 9 0 40 peri-urban 7 6 5 6 4 8 36 total 27 25 33 27 32 34 178 15.74 0.112 area where student completed high school rural 3 8 5 6 8 7 37 urban 16 17 25 16 15 20 109 peri-urban 8 5 3 5 9 7 37 total 27 30 33 27 32 34 183 9.34 0.500 area where student was born rural 5 8 5 9 9 7 43 urban 16 18 21 13 16 21 105 peri-urban 5 4 7 5 8 6 35 total 26 30 33 27 33 34 183 5.14 0.881 dtc = decentralised training centre. research 94 may 2016, vol. 8, no. 1, suppl 1 ajhpe that were likely to induce bias in responses were minimised. imprecise questions were avoided to ensure that there were no differences in how respondents understood the questions. statistical analysis the survey data were first entered into microsoft excel 2010, then imported into stata version 13.0 (statacorp, usa)[9] for cleaning and analyses. descriptive analyses involved computation of summary statistics and graphical presentations based on students’ background characteristics and other survey responses. pearson’s χ2 test with measures of asso ciations was used to compare student cohorts by gender, race and the decentralised training centres (dtcs) where they completed their rotation. the data were not normally distributed and therefore non-parametric tests were used for betweenand within-group comparisons based on participants’ responses. to compare the ‘before’ and ‘after’ perceived knowledge and skills scores, wilcoxon’s signed-rank test was used. the kruskal-wallis test was used to compare different areas of attachment by the perceived quality of the programme delivery and perceptions about the programme in general. to assess the relationship between students’ background characteristics and their choice of location of the dtc where they completed their rotation, a generalised polynomial logistic regression model was used. a p-value of <0.05 was considered statistically significant. ethics approval the study was approved by the ukzn biomedical research ethics committee (ref. no. be046/13) before the study commenced. results of the 183 students surveyed in all six cohorts, 180 satisfactorily completed the questionnaire − a completion rate of 98.3%. sixty percent of these students were female. regarding racial distribution, 79 (43%) were indian, 79 (43%) were black, 20 (11.5%) were white and 4 (2.5%) were coloured. sixty percent of the students completed their clinical rotation in rural dtcs while the rest were attached to peri-urban or urban dtcs in almost equal proportions. more black students (44.30%) had a rural upbringing than an urban or peri-urban upbringing (29.11% and 26.58%, respectively). students who attended rural high schools and those who attended urban high schools were equal in proportion (39.24%), with the rest (21.52%) attending high school in peri-urban areas. there were no statistically significant differ ences between cohorts in terms of sex, race, and chosen dtc, or in geographical area of high school completion and upbringing (table 1). similarly, the differences between cohorts in terms of choice for site location were not statistically significant. students felt that their knowledge of and skills in a variety of subject matters increased following exposure to the clinical rotation. all perceived changes were statistically significant (p<0.001). on a likert scale of 1 5, the median ratings increased from 3 (some knowledge/skills) to 4 (good knowledge/skills but need supervision/ support). the most notable perceived change table 2. students’ ratings of their perceived change in knowledge/skills (wilcoxon signed-rank test) statistic knowledge and skills variable n median z-value p-value* effective communication skills in carrying out a patientcentred interview before 179 3.00 −9.87 <0.001 after 183 4.00 understanding context of the patient before 179 3.00 −10.59 <0.001 after 183 4.00 describing the indication and risks with common investigations and procedures before 177 3.00 −10.24 <0.001 after 180 4.00 clinical problem-solving skills before 177 3.00 −10.33 <0.001 after 181 4.00 formulate a three-stage assessment and manage ment plan before 177 3.00 −10.97 <0.001 after 181 4.00 manage undifferentiated problems before 177 2.00 −10.44 <0.001 after 181 4.00 manage common chronic illnesses before 178 3.00 −10.79 <0.001 after 181 4.00 clinical record keeping before 179 3.00 −10.52 <0.001 after 183 4.00 ethical issues in clinical practice such as confidentiality, consent and patient autonomy before 179 3.00 −8.43 <0.001 after 182 4.00 health promotion and disease prevention before 179 3.00 −10.75 <0.001 after 184 4.00 liaising with other members of the healthcare team before 176 3.00 −10.50 <0.001 after 181 4.00 *asymptotic significance (two-tailed). research may 2016, vol. 8, no. 1, suppl 1 ajhpe 95 in knowledge/skills was observed in the management of undifferentiated problems where the median rating increased from 2 (vague knowledge/skills) to 4 (good knowledge/skills but need supervision/support) (table 2). further post-hoc analyses conducted to compare rural, urban and peri-urban sites revealed that there were no site-specific differences in all 11 items for perceived change. statistically significant differences between rural, urban and peri-urban dtcs were only observed in relation to students’ ratings of their relationship with the clinic staff (p<0.001), their access to materials during the rotation (p<0.05) and the clinical skills/knowledge they gained (p<0.05). shown in table 3, students who were in urban dtcs reported, for the most part, better quality of programme delivery than those in rural and peri-urban dtcs. ratings of other measures such as the relationship with their supervisors, quality of supervision and teaching and the overall content of the training were again better in urban dtcs than in other dtc locations, but these differences were not statistically significant (table 3). despite the dtc-specific differences reported here, the median perception ratings were encouraging overall. they ranged between 3 (good) and 5 (excellent) across the board on a likert scale of 1 (poor) to 5 (excellent). the perceived effect of the decentralised training programme was, for the most part, also rated higher by students who completed their rotation in urban dtcs (table 4). however, these differences were only statistically significant for four subjective indicators of the programme’s effectiveness. for example, although students in urban dtcs reported to be much more motivated to continue with their medical career following their experience at the urban dtcs, this was not statistically different from that reported by students in rural and peri-urban dtcs (p>0.05). the same result was found for the perceived effect of the programme in easing students’ transition to the clinical environment. however, it was encouraging to learn that on a scale of 1 5, the median ratings ranged between 4 and 5 across all indicators of programme effectiveness. table 5 shows results from both the univariable and multivariable analy ses of four predictors of site choice. at univariable level, most odds ratio (or) estimates were statistically significant. the model predicted that male students were less likely to choose urban dtcs than their female classmates. with regard to ethnicity, black students were more likely to choose urban dtcs than their white and indian classmates. the students who attended and completed their high school in rural areas were nine times less likely to select a rural dtc for their rotation compared with those who completed high school in urban and peri-urban areas. the same direction of predictions was also observed for students who were born and raised in rural areas. these students were 14 times less likely to choose the dtcs located in rural areas. although the direction of ors remained similar across all the four predictors after multivariable analyses, the ors became smaller. some predictors also became statistically insignificant. for example, only sex and race remained statistically significant predictors of site choice, with males more likely to choose rural dtcs than their female counterparts, and black students less likely to choose rural dtcs than their white and indian classmates. students’ place of birth and high school completion were not statistically significant predictors of site choice after model adjustment. discussion this pilot study was conducted with a view to documenting some of the factors that influence undergraduate medical students’ choice of site location within the context of the ukzn decentralised training programme. the objective of the study was also to find out whether the site location determined students’ perceptions about the quality of the programme, as well as their perceived learning experience. the purpose of the study was to generate information for future use by the programme developers to craft an intervention that is more context-sensitive and likely to be well received by the actual end users. the programme structure and mode of delivery were, in principle, well aligned with table 3. students’ rating of the quality of programme by dtc locations (kruskal-wallis test) statistic variable n mean rank χ2 df median p-value overall content of the training rural 101 91.08 4.17 2 3.00 0.153 urban 40 92.97 peri-urban 34 73.00 clinical skills/knowledge gained rural 102 90.79 5.88 2 3.00 0.042 urban 39 95.88 peri-urban 34 70.59 quality of supervision and teaching rural 102 86.25 2.03 2 3.00 0.391 urban 40 98.00 peri-urban 34 84.09 relationship with clinic staff rural 102 89.93 12.31 2 4.00 0.000 urban 40 103.25 peri-urban 34 66.87 access to necessary materials rural 100 84.53 7.88 2 3.00 0.021 urban 40 105.19 peri-urban 34 75.44 relationship with the rotation supervisor rural 102 84.92 2.82 2 4.00 0.241 urban 40 99.04 peri-urban 34 86.84 df = degrees of freedom. research 96 may 2016, vol. 8, no. 1, suppl 1 ajhpe novel strategies in medical education,[5-7] which are geared towards enhancing experiential learning among undergraduate medical students during their early years of medical training. indeed, there is ongoing discourse around how training in a variety of clinical teaching facilities correlates with eventual practice locations.[10] some proponents of this approach continue to argue that it results in students entering permanent practice in a location similar to the one in which they trained.[11] this study adds a slightly different but complementary dimension to what already exists in the literature. as the study participants were only recruited in their 4th year of undergraduate medical training, this study was not able examine the effect of the decentralised training programme on eventual practice location. a follow-up study to examine their career paths and practice location after graduation and whether these are influenced by the individual-level characteristics assessed in this study, would be useful. however, our findings begin to show some intricacies of allowing students to self-select in a model that involves one programme and multiple training sites which vary in resources, infrastructure and location. we advance a view that medical educationists with an interest in the distributed approach ought to be more objective in how they allocate students to training sites away from the traditional medical schools to place the ‘right’ candidate in the ‘right’ training location. the study was able to show that students with rural upbringing and rural high school education were less likely than those from urban areas to select rural training sites as part of their family medicine rotation, when these two predictors were considered independently. when combined with sex and race in a multivariable model, the two predictors produced similar results, but with smaller ors. despite the lack of statistical significance in the multivariable model, the direction of predictions reported here should not be overlooked. the univariable analyses tell a story that ought to be explored further in much larger studies within the sa context. a much larger study in sa may use a mixed-effects or multilevel modelling approach to assess the potential effects of additional upstream factors, such as the programme type and name of academic institution, on site choice. this would address the possible influences of curriculum differences within institutions, as well as the kind of students trained at each institution. the same approach can also be used within the context of an international study, by taking into account the country in which the programme was implemented. a large-scale study is therefore recommended, as it is more likely to be able to answer the question around the generalisability of the findings reported here. there is ongoing debate elsewhere that if rural students are selected to enter medical training programmes and are provided with both underand postgraduate training opportunities in rural areas, they are more likely than those selected from urban areas to return to such areas for medical practice.[12] this has been referred to as the ‘pipeline approach’ to rural physician resources.[13,14] the disinclination of students with a rural background to select rural sites as part of their decentralised training begs the question as to whether a targeted approach, with sites selected for students based on student characteristics, may more objectively ensure that the pipeline approach works more effectively. a qualitative study would be valuable to further unpack the table 4. students’ rating of the quality of programme effectiveness by dtc locations (kruskal-wallis test) statistic variable n mean rank χ2 df median p-value will ease my transition to the clinical environment rural 101 90.50 3.88 2 5.00 0.212 urban 39 93.47 peri-urban 35 74.69 motivated me to continue with the medical career rural 101 87.78 2.55 2 5.00 0.382 urban 40 97.01 peri-urban 35 80.84 orientated me towards the social context of practice rural 101 92.57 6.75 2 5.00 0.031 urban 39 89.83 peri-urban 34 69.76 made me more confident to approach patients rural 101 91.02 10.37 2 5.00 <0.001 urban 40 100.26 peri-urban 35 67.77 made me more aware of myself and others on the team rural 101 87.87 9.05 2 4.00 0.025 urban 40 104.26 peri-urban 35 72.30 strengthened my theoretical knowledge rural 101 90.13 3.65 2 4.00 0.213 urban 39 94.14 peri-urban 35 75.01 introduced me to the organisation of the healthcare system and role of various professionals within it rural 100 88.97 9.48 2 4.00 0.022 urban 39 100.82 peri-urban 35 68.46 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 97 underlying constructs of this observation. it may be possible that black students who, within the context of this study, were mostly raised in rural settings, may indeed have chosen to complete their rotation in urban settings but have the desire to go back to rural areas once they have completed their medical training. therefore, one aspect to explore would be whether there is a short-term desire to experience learning in a more urban setting but a long-term career plan in a rural setting, and the reasons for these choices. despite the above findings, it was encouraging to learn that the largest proportion of students, regardless of their sex, ethnicity and background characteristics, selected rural dtcs. this pattern was observed across all six cohorts of students. although not specifically asked, this may be an indication that these students anticipated better learning opportunities in rural health facilities, which are presumed to be more understaffed and student-friendly than facilities in urban areas. our findings also revealed that students in urban areas reported better learning experiences than those in rural areas. this was particularly true with regard to access to necessary hospital resources, their interaction with the clinical team and the clinical skills and knowledge gained. similarly, compared with rural dtcs, students in urban dtcs felt more confident in approaching patients and became more conscious of the organisation of the healthcare system and the role of various professionals within it. however, students from rural dtcs were better orientated towards the social context of practice, meeting the objective of the programme. the last finding mirrors what has been shown elsewhere.[15] these are important issues to consider if rural dtcs are to contribute to the long-term staffing of rural facilities. training institutions therefore need to ensure that resources are equitably provided in both rural and urban training sites. the differences in the students’ learning experiences across the dtcs could be attributed to logistical and operational issues that were encountered during the course of the programme. the programme was not implemented wholly as originally intended owing to delays in the mobilisation of resources, particularly in rural dtcs. this highlights the complexities of the distributed approach in which students are allocated to multiple settings with varying characteristics. the situated learning theory postulates that a training location provides the context within which a student develops his or her professional identity.[16,17] programmes that utilise a distributed design must ensure that adequate resources, both human and material, are available to enhance the personal learning of students in rural areas. this would more likely encourage these students to return to similar settings for future practice. universities and other medical training institutions may not achieve this without supportive policies at macro level, particularly from government structures and other relevant civil society organisations. finally, our study revealed that the students’ knowledge and skills increased across all sites following their exposure to the dtcs. this was based on a number of learning elements posited in the programme. despite table 5. relationship between students’ background characteristics and their choice of dtcs using a polynomial logistic regression model univariable analysis multivariable analysis predictors location of the dtc or 95% ci p-value or 95% ci p-value sex rural * * male v. female urban 0.29 0.12 0.72 0.0076 0.166 0.05 0.53 0.002 male v. female peri-urban 1.57 0.73 3.41 0.2506 1.337 0.54 3.28 0.525 race rural * * white v. black urban 0.04 0.01 0.33 0.0027 0.047 0.01 0.41 0.006 white v. black peri-urban 0.22 0.05 0.87 0.0315 0.154 0.03 0.78 0.024 indian v. black urban 0.03 0.01 0.12 <0.0001 0.047 0.01 0.19 <0.0001 indian v. black peri-urban 0.22 0.10 0.51 0.0005 0.213 0.07 0.62 0.004 area where student completed high school rural * * rural v. urban urban 9.40 3.47 25.45 <0.0001 3.326 0.60 8.30 0.167 rural v. urban peri-urban 5.03 1.81 13.94 0.0019 2.734 0.53 3.99 0.227 peri-urban v. urban urban 2.80 1.07 7.23 0.0358 2.862 0.59 13.78 0.189 peri-urban v. urban peri-urban 1.30 0.45 3.72 0.6269 2.798 0.62 12.45 0.176 area where student was born rural * * rural v. urban urban 14.01 5.08 38.67 <0.0001 1.872 0.35 10.01 0.463 rural v. urban peri-urban 4.20 1.60 10.96 0.0035 0.797 0.15 3.98 0.782 peri-urban v. urban urban 5.40 1.97 14.79 0.0010 1.373 0.27 6.84 0.699 peri-urban v. urban peri-urban 0.85 0.26 2.82 0.7955 0.243 0.04 1.42 0.117 *reference value. research 98 may 2016, vol. 8, no. 1, suppl 1 ajhpe the use of a subjective measure of knowledge and skill gain, this was an encouraging finding which indicates promising effects of the programme in enhancing learning among the students. conclusion students had positive perceptions and experiences about the primary care curriculum and the decentralised training programme, even though these varied depending on the geographical location of the site. the choice for the location of the dtc was dependant on gender, race, and place where the student grew up and completed high school. although this study can be considered a pilot, our findings suggest that students should be allocated to sites based on their individual characteristics to maximise their potential for experiential learning and the likelihood of eventual career paths in areas where they are needed the most. nevertheless, large-scale studies conducted within a much broader context may be required to substantiate the findings reported here. acknowledgements. this work was made possible by grant no. 5r24tw008863 from the us president’s emergency plan for aids relief (pepfar), and the national institutes of health, us department of health and human services. its contents are solely the responsibility of the ukzn mepi programme and do not necessarily represent the official views of the us government. references 1. de vries e, irlam j, couper i, kornik s. career plans of final-year medical students in south africa. s afr med j 2010;100(4):227-228. [http://dx.doi.org/10.7196/samj.3856] 2. research consortium. the shortage of medical doctors in south africa. scarce and critical skills research project. south africa: research consortium, 2008. http://www.labour.gov.za/dol/downloads/documents/ researchdocuments/medical%20doctors dol report.pdf (accessed august 2014). 3. rural health workforce australia. will more medical places result in more rural gps? melbourne: rhwa, 2008. 4. united states general accounting office. physician workforce: physician supply increased in metropolitan and nonmetropolitan areas but geographic disparities persisted. report no. gao-04-124. washington: usgao, 2003. 5. hsueh w, wilkinson t, bills j. what evidence-based undergraduate interventions promote rural health? n z med j 2004;117(1204):u1117. 6. zink t, center b, finstad d, et al. efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of minnesota – duluth and the rural physician associate program. acad med 2010;85(4):599-604. [http://dx.doi.org/10.1097/acm.0b013e3181d2b537] 7. woloschuk w, tarrant m. does a rural educational experience influence students’ likelihood of rural practice? impact of student background and gender. med educ 2002;36(3):241-247. [http://dx.doi.org/10.1046/j.13652923.2002.01143.x] 8. wilson nw, couper id, de vries e, reid s, fish t, marais bj. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9(2):1060-1081. 9. statacorp. stata statistical software: release 13. college station, tx : statacorp lp, 2013. 10. slade s. on the move: a retrospective, longitudinal view of physician migration patterns in canada. paper presentation, 6th annual physician workforce research conference, alexandria, virginia, usa, 6 7 may 2010. 11. strasser r, hogenbirk jc, lewenberg m, story m, kevat a. starting rural, staying rural: how can we strengthen the pathway from rural upbringing to rural practice? aust j rural health 2010;18(6):242-248. [http://dx.doi. org/10.1111/j.1440-1584.2010.01167.x] 12. norris te. education for rural practice: a saga of pipelines and plumbers. j rural health 2000;16(3):208-212. [http://dx.doi.org/10.1111/j.1748-0361.2000.tb00458.x] 13. rabinowitz hk, paynter np. the role of the medical school in rural graduate medical education: pipeline or control valve? j rural health 2000;16(3):249-253. [http://dx.doi.org/10.1111/j.1748-0361.2000.tb00468.x] 14. henry ja, edwards bj, crotty b. why do medical graduates choose rural careers? rural remote health 2009;9(1):1083. www.rrh.org.au (accessed 6 november 2013). 15. dornan t, bundy c. what can experience add to early medical education? consensus survey. bmj 2004;329(7470):834. [http://dx.doi.org/10.1136/bmj.329.7470.83] 16. gray jd, steeves lc, blackburn jw. the dalhousie university experience of training residents in many small communities. acad med 1994;69(10):847-851. [http://dx.doi.org/10.1097/00001888-199410000-00016] 17. norris te, norris sb. the effect of a rural preceptorship during residency on practice site selection and interest in rural practice. j fam pract 1988;27(5):541-544. article 3 june 2011, vol. 3, no. 1 ajhpe introduction during lectures and ward rounds, teaching staff at medical schools repeatedly emphasise to their students the importance of ‘speaking like a professional’ and thus adopting the discourse appropriate to the medical fraternity. events such as clinical case presentations give students the opportunity to demonstrate the degree to which this skill has been developed, and doctors often have high expectations for appropriate discourse use on these occasions. it is our contention, however, that this expectation is not supported when students are assessed. assessment is widely regarded as the activity associated with teaching and learning that has the greatest influence on how students approach their studies.1-3 in this article, we report on a preliminary study conducted to determine the extent to which appropriate discourse is adopted by 9 medical students early in their final year during clinical case presentations, and compare this usage with the students’ final results. these findings may serve to inform future research and practice in this regard. the need for the medical practitioner to communicate effectively and appropriately, not only with patients, but importantly with fellow doctors and other health care professionals, is well documented. often this research has focused on the relationship between the health care professional and the patient.4,5 at least one study has demonstrated that poor communication is linked to poor clinical (although not necessarily academic) performance,6 communication being an important skill for ensuring good patient handover and management. internationally, institutions have addressed the need for such skills through the implementation of extensive communication skills courses.7,8 however, we wish to focus on the more encompassing concept of discourse, rather than purely communication. our understanding of discourse concurs with the work of gee9 who suggests that discourse refers to ‘… a socially accepted association among ways of using language, of thinking, feeling, believing, valuing, and of acting that can be used to identify oneself as a member of a socially meaningful group or ‘’social network’’ or to signal (that one is playing) a socially meaningful role’. in the context of this study the ‘social network’ comprises medical doctors. often there is an implicit expectation that students at university, including students studying towards a professional qualification such as medicine, will through their years of study adopt the ‘way of doing’ that defines the chosen discipline.10,11 to our knowledge, however, no formal research has been conducted to investigate the discourse used by medical students during clinical case presentations and how or whether the level of discourse used may link to performance. our study aims to begin the journey into this uncharted void. methods two members of the research team collected data by observing and recording individual case presentations of 9 final-year students during ward rounds over a period of two weeks, i.e. 9 transcriptions in total. the recordings were done during the general surgery rotation, where students abstract introduction: the need for medical students to adopt a discourse appropriate to the field is repeatedly emphasised by teaching staff during lectures and ward rounds. the acquisition of such discourse is often not assessed, resulting in inconsistency between the levels used among students of similar academic backgrounds. objective: the aim of this study was to determine the extent to which appropriate discourse was adopted by 9 medical students early in their final year during clinical case presentations, and to compare this usage with the students’ final results. methods: transcriptions of recorded case presentations by 9 students were assessed by 2 experts and a peer evaluator, using a rubric which drew on prior research in medical discourse, and included the prominent themes of terminology and thematic staging. these were then compared with their academic results. results: our findings show that most students are able to use the appropriate terminology when they reach their final year of study. however, our data also support the hypothesis that students with similar academic backgrounds may display considerable variation in their level of discourse. although it appears as if the students were all beginning to shift towards a more mature form of medical discourse, the degree to which this occurs is sporadic. the apparent absence of a relationship between discursive competencies and academic achievement may suggest that the ability of assessment to encourage the adoption of disciplinary discourse is perhaps not being optimally applied, although further research is required. discourse of final-year medical students during clinical case presentations h botha,* g i van schalkwyk,* j bezuidenhout,† s c van schalkwyk‡ *medical students (first authors), stellenbosch university, tygerberg, w cape †faculty of health sciences, stellenbosch university, tygerberg, w cape ‡centre for teaching and learning, stellenbosch university, tygerberg, w cape correspondence to: g van schalkwyk (gvs.psych@gmail.com) article 4 june 2011, vol. 3, no. 1 ajhpe are expected to present a case that they have seen in the wards to a consultant – on a weekly basis. this rotation was chosen, as it was one of the few rotations where presentations were made on a regular basis to the same consultant. although no specific format was defined for how the cases needed to be presented, the students were aware that the presentation was to be done as if the consultant had no prior knowledge of the patient; hence a degree of detail was required. convenience sampling was adopted, as the selection of the students was dependent on who was presenting a case on our research days. to support the electronic recordings, we scribed the basic details of each case presentation recording including time, date, place, and a list of those present, including their student numbers – this also to ensure the validity of the data. the recordings were then transcribed. this entire process of data collection was undertaken subsequent to obtaining the necessary ethical clearance as well as written permission from the relevant consultant and the students in advance. the transcriptions were then assessed by 3 evaluators. the first evaluator (the expert) was a consultant surgeon with experience in teaching and assessment of final-year students as well as extensive medical knowledge in the field to which the presentations related. drawing on the work of bazerman, jacobs12 describes the university lecturer as ‘the expert’ – the one who sits at the centre of a particular discipline’s ‘discursive system’, having invested ‘a huge amount of energy, training and social activity within it’. our selection of an expert was framed by this understanding. the second evaluator (a second expert) was an anatomical pathologist and co-author with experience in medical education research, student assessment and curriculum development. in order to maximise perspectives, a volunteering student in the same year group as the subjects was chosen as the third evaluator, thus providing a voice for both the insider and the outsider.12 the evaluators received only basic instruction on how to complete the rubric, so as to not prejudice their opinions regarding what would be considered ‘appropriate’ in each context, and thereby ensured the authenticity of each evaluator’s own voice. the evaluation was conducted according to a rubric that was developed specifically for the study by compiling a set of indicators drawn from previous studies of a similar nature. the first indicator was the appropriate use of medical terminology, one of the primary components of medical discourse.4,13 thematic staging was chosen as the second indicator, based on its use in assessing doctor-patient interaction during osces.4 however, we applied the term in a slightly different manner – in our study it served as an indicator for whether or not the student addressed the most pertinent issues at the appropriate time during their case presentation, which is both a marker of good discourse and clinical reasoning. the third indicator was length of the presentation, which was found to be one of the most important indicators of success in osces in a large study conducted in australia.14 here again, our usage of this indicator was somewhat different, and we sought to determine not the exact length of the presentation, but rather whether or not it was considered to be of appropriate length for the given case. the fourth indicator evaluated the structure of the presentation in accordance with prior research that highlights the degree to which formalised structures are commonplace in case presentations.15 in our rubric, the focus was on whether the format was logical and easy to follow, rather than whether or not a specific formula was followed. the last indicator sought to elicit a phenomenon referred to in prior research,14 whereby students include spurious detail in their case presentations in an effort to prove competence, an important marker of immature discourse that often differentiates the discourse of medical students from that of doctors. an example would be referencing journal articles, facts from textbooks and other resources that are not relevant to the specific case in question. this latter indicator drew us back to the literature on discourse mentioned earlier that refers to students, especially junior students, who in trying to imitate the expert seek to include all the academically appropriate-sounding words in their own texts.16 the entire rubric is included in table i. the decision to include only these indicators was not specifically grounded in established theory, owing to a lack of research in this area. each individual indicator has been used in previous studies, and the decision to combine them in this manner was based on choosing variables that we felt would most appropriately assess discourse as defined in this study. the results obtained from the assessment of the discourse levels according to the rubric were then interpreted by comparing the findings of the various evaluators and highlighting specific examples. they were then compared with the academic achievement of the participants at the end of their fifth-year final examinations (i.e. their previous year). these examinations included both previous clinical clerkships (50%) as well as core theory modules in ethics, health management and community health care (50%), therefore providing a recent and representative sample of a student’s academic achievement. a potential ethical dilemma in our study was that the principal investigators were also peers of those being studied. to address this concern, the handling of sensitive information (e.g. academic records) was conducted by the sub-investigators – both of whom are members of staff at the university – who allocated reference numbers to the different participants that could not be traced back to the individual students. table i. discourse assessment rubric 5 4 3 2 1 does the student display the appropriate use of medical terminology? all of the time most of the time half of the time less than half of the time never does the student address the most pertinent issues at the optimum time? all of the time most of the time half of the time less than half of the time never given the context of the patient and illness, comment on the length of the history the history is excessively long for the given case the history is somewhat lengthy for the given case the history is of appropriate length for the given case the history is a little too short for the given case the history is much too short for the given case how would you rate the structure of this presentation? very good, logical and easy to follow good average, at times illogical and confusing below average poor, illogical and difficult to follow to what extent is the history bolstered by irrelevant medical facts? >4 instances 3 instances 2 instances 1 instance never article 5 june 2011, vol. 3, no. 1 ajhpe results terminology most of the students in the sample displayed appropriate use of medical terminology. in the opinion of the expert evaluators, 7 of the 9 students used the appropriate medical terminology ‘most of the time’. examples of this usage are evident in all of the transcripts, with students using appropriate medical terms, such as ‘comorbidities’, ‘oedema’, ‘odynophagia’. the peer evaluator felt that 5 of the 9 students used the appropriate terminology most of the time, and all of these instances overlapped with those who had scored highly according to the other evaluators. thematic staging the results of the second element of the rubric, which assessed thematic staging, were less positive, and also showed less agreement between the 3 evaluators. the peer evaluator felt that 7 of the 9 students used the correct thematic staging at least half of the time, as did the surgeon, although this did not always apply to the same students. the educational expert considered 8 of the 9 students to have used thematic staging appropriately or better, agreeing with the surgeon in most instances. presentation length with regard to the length of the presentations, the student and surgeon considered the presentations to be generally too short. the peer was most critical in this regard, expressing the opinion that 5 of the 9 presentations were ‘much too short for the given case’. the surgeon was slightly less critical, and in the case of one student felt that the presentation was of appropriate length. the educational expert was far less critical, and considered 5 of the 9 cases to be of an appropriate length or longer. structure and spurious detail the fourth element of the rubric assessed structure. the surgeon gave relatively positive evaluations, regarding 7 of the 9 cases as possessing average structure or better. the opinion of the educational expert was concordant, and the peer evaluator was generally stricter. the phenomenon we attempted to find with element five, i.e. the use of irrelevant detail for the purposes of proving competence, was largely absent in our sample, with only one instance reported by the educational expert and none by either of the other evaluators. academic performance and discourse despite the random nature of the sampling, as described above, the marks of the students were surprisingly homogenous, with a 2% variation in aggregate for theory modules for 7 of the students. the other 2 students had significantly higher marks, especially in the theory modules, for which their aggregates were 8% higher than the mean for the rest of the group. of great interest in our findings is the apparent diversity of discourse use between students of similar academic backgrounds. a pertinent example was the case of students a and b, the top-performing students (who obtained aggregates in their previous years’ final examinations of 68.6% and 71.2%, respectively) in the sample, who scored the lowest and highest scores on the rubric, respectively (figs 1 and 2). the following extracts are particularly illustrative: student a: ‘… she presented with severe abdominal in um, um, left upper quadrant abdominal pain with difficulty swallowing and nausea and um vomiting. um the, um gp um subsequently decided to do a i think a ct scan of the abdomen …. she at that point did not have any, ah jaundice ... no other abnormalities, nothing. clinical examination was ….’ student b: ‘… gives a history of progressive, um dysphagia, first with fluids, now with um solids. also vomiting and hoarseness and later, um, odynophagia. um, the patient has no other comorbidities. according to him he’s non-smoking and not drinking. um, on examination he’s um, extremely wasted …. his last um, hb was, um tested after he received a transfusion.’ both students presented patients with similar histories. however, student a referred to the patients as having ‘difficulty swallowing’, whereas student b used the term ‘dysphagia’ and later ‘odynophagia’. student a also referred to the patient having no other ‘abnormalities’, whereas student b used the term ‘comorbidities’. the differences in thematic staging are also clear -student a mentioned special investigations in the middle of the presentation, followed by rather random detail regarding the examination. student b, by contrast, mentioned the lab results only after completing the report on the history and physical examination. in terms of structure,13 the presentation of student b was neatly segregated into detail obtained from history, physical examination and special investigations, whereas student a mentioned information largely at random. discussion from this preliminary study it would appear that this group of students was able to obtain above-average academic results irrespective of whether or not they displayed appropriate levels of medical discourse during clinical assessments. of further interest is that even students who achieve relatively weaker scores are able to acquire and use the appropriate medical terminology in their final year of study. skills in thematic staging are discourse evaluation of student a (aggregate 68.6%) 5 4 3 2 1 0 peer surgeon educational expert terminology staging length structure spurious detail fig. 1. student a. discourse evaluation of student a (aggregate 68.6%) 5 4 3 2 1 0 peer surgeon educational expert terminology staging length structure spurious detail fig. 2. student b. article 6 june 2011, vol. 3, no. 1 ajhpe less developed, and represent a source of concern as this competency is regarded as important to a good communicative style.4 that the presentations were regarded as too short by the evaluators was an unexpected finding, as it might be surmised that final-year students ought to be aware of how important providing a detailed history is for ensuring success in clinical evaluations14 and, potentially, clinical practice. the educational expert was far less critical in this regard, and a possible explanation is that this assessor had comparatively less exposure to the exact context of the presentation, and was therefore less likely to know what would be considered an appropriate length for a case presentation in this situation. our expectation was that the structure of the presentation would be generally good, as any student, even at the start of their final year, is likely to have had significant practice and tutoring in this regard. the 2 experts agreed with this expectation. however, the peer evaluators’ more negative views suggest that the perceptions regarding the appropriate structure of presentations vary to some extent between students and qualified doctors. a possible reason is that medical students are generally expected to communicate in a more formal manner,15 especially during assessment or when presenting to consultants, whereas qualified professionals are more accustomed to a conversational discourse. lingard et al.13 highlights one of the purposes of the student case presentations as being to ‘prove competence’, compared with presentations by doctors for the purpose of ensuring optimum patient care. this difference will certainly influence the expectations regarding appropriate structure, and one may go so far as to say that as the students received positive evaluation from the doctors, but rather weaker evaluations from their peers, suggests that they are beginning to transition into a more mature form of medical discourse. further evidence for the above hypothesis is the general absence of spurious detail in the case presentations. anecdotal evidence suggests that this is a highly prevalent phenomenon, and is also highlighted by lingard et al.13 as a technique for ‘proving competence’. perhaps its absence is due to it no longer being required by students who have progressed further along the path of discourse development and are becoming ‘socially accepted’ in the sense referred to by gee.9 it appears as if the students in our study were beginning to develop a more mature form of medical discourse. however, the degree to which this occurs appears to be sporadic, both between different students and between different components of discourse within the same student. furthermore, the absence of a relationship between these competencies and academic achievement suggests that the ability of assessment to encourage learning and the adoption of disciplinary discourse is perhaps not being optimally applied. it is interesting that the variation in quality of discourse is much greater than the variation in academic achievement and that the 2 students with the strongest academic background had the highest and lowest scores on the rubric. however, it is important to acknowledge that a limitation of our study was that we only obtained one discourse sample per student, and any findings are therefore preliminary. another limitation of our study was that we were not able to follow up these students until the completion of their final year, at which point their varying discourse skills may have become more relevant given the increased emphasis on clinical assessment. conclusion in closing we acknowledge that strong conclusions cannot be drawn based on this preliminary exploration. the primary value of this research is the manner in which it opens several avenues for further study, both with regard to issues of the assessment of case presentation and the role of developing an appropriate disciplinary discourse, specifically among senior medical students. the rubric that was used in this study provided a unique way to assess this complex concept of discourse, and may be of great value in larger studies. furthermore, we have shown that discourse is a useful construct for assessing communication between doctors, and possesses certain unique properties which provide advantages over traditional communication skills assessment. using these tools on larger samples may help to further establish our findings as well as explore the implications for a student’s eventual success as a medical practitioner and the subsequent effect on patient care. this study presents a preliminary exploration into these important phenomena. references 1. biggs j, tang c. teaching for quality learning at university. buckingham: open university press, 2007. 2. entwistle n. contrasting perspectives on learning. in: entwistle n, marton f, hounsell d, eds. the experience of learning: implications for teaching and studying in higher education. edinburgh: scottish academic press, 1997:3-22. 3. ramsden p. learning to teach in higher education. london: routledge, 2003. 4. roberts c, wass v, jones r, sarangi s, gillett a. a discourse analysis study of ‘good’ and ‘poor’ communication in an osce: a proposed new framework for teaching students. med educ 2003;37(3):192-201. 5. spencer j, silverman j. education for communication: much already known, so much more to understand. med educ 2001;35(3):188-190. 6. taylor g. underperforming doctors: a postal survey of the northern deanery. bmj 1998;316(7146):1705-1708. 7. kurtz sm, silverman jd. the calgary-cambridge referenced observation guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. med educ 1996;30(2):83-89. 8. skochelak s, thaler s, gjerde c. the interdisciplinary generalist curriculum project at the university of wisconsin medical school: the generalist partners program. acad med 2001;76(4 suppl):s131-s3. 9. gee jp. social linguistics and literacies: ideology in discourses. london: routledge, 2008. 10. bourdieu p, passeron j, de saint martin m. academic discourse: linguistic misunderstanding and professorial power. cambridge: polity press, 1994. 11. van schalkwyk sc. crossing discourse boundaries: students diverse realities when negotiating entry into knowledge communities. south african journal of higher education 2007;21(7):954-968. 12. jacobs c. teaching explicitly that which is tacit. in: van schalkwyk sc, leibowitz b, van der merwe a, eds. focus on first-year success: perspectives emerging from south africa and beyond. stellenbosch: sun media, 2009:241-252. 13. lingard l, garwood k, schryer cf, spafford mm. a certain art of uncertainty: case presentation and the development of professional identity. soc sci med 2003;56(3):603-616. 14. mistican m, baldwin t, cordella m, musgrave s. applying discourse analysis and data mining methods to spoken osce assesments. proceedings of the 22nd international conference on computational linguistics 2008:557-584. 15. anspach rr. notes on the sociology of medical discourse: the language of case presentation. j health soc behav 1988;29(4):357-375. 16. van schalkwyk sc. acquiring academic literacy: a case of first-year extended degree programme students at stellenbosch university. phd (curriculum studies), stellenbosch university, 2008. november 2015, vol. 7, no. 2 ajhpe 147 researchreview clinical reasoning ability is central to clinical competence as it allows medical practitioners to evaluate patients and their test results in order to make accurate diagnoses and implement appropriate treatment.[1] the development of expertise in clinical reasoning may be facilitated through active learning and practice with authentic cases. e-learning has the potential to support this process by providing students with interactive learning experiences, exposure to multiple cases, and opportunities for deliberate practice with tailored feedback. creative educators use animation and simulation to build innovative learning resources. the available technology makes it possible to offer personalised instruction, collaboration and an engaging, even immersive, learning experience.[2] simulations allow inexperienced trainees to practise their clinical reasoning skills on virtual patients without exposing real patients to the possibility of harm, and can provide exposure to a variety of clinical presentations and uncommon medical conditions. errors in managing these virtual patients may be allowed and provide valuable learning opportunities. developing innovative e-learning materials can, however, be very time consuming and expensive. for example, a survey published in 2007 on the development of computer-based virtual patients at medical schools in the usa and canada revealed that each took an average of 16.6 months to complete and 85% cost >usd10 000 (zar120 100).[3] this level of investment of time and money needs to be justified by the educational impact of the resources developed, especially in under-resourced environments such as african tertiary education institutions. there are many factors that must be in place to ensure successful e-learning.[4] this article highlights two critically important but under-appreciated factors, i.e. the management of the learner’s cognitive load and the usability of the computer interface. the sections that follow briefly discuss: (i) development of expertise in clinical reasoning; (ii) cognitive load theory and its relevance to e-learning; and (iii) importance of the usability of computer interfaces. developing expertise in clinical reasoning learning requires alterations in long-term memory. the major mechanisms involved are the acquisition and automation of knowledge schemas.[5] in the context of clinical medicine, schemas are sometimes also referred to as ‘illness scripts’.[6] these are cognitive constructs or ‘mental models’ for organising and storing information. the critical role of long-term memory in intellectual performance started emerging with the publication in the 1960s of studies on chess players.[7] after a brief exposure to a typical mid-game position, expert chess players were much better than novices in their ability to recall the exact positions of the pieces. however, when the same pieces were randomly distributed on the board, there was no difference between experts and novices in recalling the positions of the pieces.[8] chess experts do not see a position as isolated pieces, but as configurations of pieces and squares, most of which they have seen many times before. these configurations are stored as ‘chunks’ or e-learning has the potential to support the development of expertise in clinical reasoning by being able to provide students with interactive learning experiences, exposure to multiple cases, and opportunities for deliberate practice with tailored feedback. this review focuses on two important but underappreciated factors necessary for successful e-learning, i.e. the management of the learner’s cognitive load and the usability of the technology interface. cognitive load theory views learning as involving active processing of information by working memory via separate visual and auditory channels. this system is of very limited capacity and any cognitive load that does not directly contribute to learning is considered extraneous and likely to impede learning. researchers in cognitive load theory have provided evidence-based instructional design principles to reduce extraneous cognitive load and better manage the cognitive processing necessary for learning. usability is a concept from the field of human-computer interaction which describes how easy technology interfaces are to use, and is routinely evaluated and optimised in the software development industry. this is seldom the case when e-learning resources are developed, especially in the area of medical education. poor usability limits the potential benefit of educational resources, as learners experience difficulties with the technology interface while simultaneously dealing with the challenges of the content presented. practitioners in the field of human-computer interaction have provided guidelines and methods for evaluating and optimising the usability of e-learning materials. the fields of cognitive load theory and human-computer interaction share a common goal in striving to reduce extraneous cognitive load. the load induced by poor usability of e-learning materials can be viewed as a specific component of extraneous cognitive load, adding to any load resulting from poor instructional design. the guidelines from these two fields are complementary and, if correctly implemented, may substantially improve the impact of our e-learning resources on the development of the clinical reasoning skills of students. afr j health professions educ 2015;7(2):147-152. doi:10.7196/ajhpe.569 optimising cognitive load and usability to improve the impact of e-learning in medical education m r davids,1 mb chb, fcp (sa), mmed (int med), phd; m l halperin,2 bsc (biochemistry), mdcm, frcp(c), md; u m e chikte,3 bchd, dhsm, mdent, msc, phd 1 division of nephrology, department of medicine, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 emeritus professor, division of nephrology, li ka shing knowledge institute, st michael’s hospital and university of toronto, canada 3 department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m r davids (mrd@sun.ac.za) 148 november 2015, vol. 7, no. 2 ajhpe review schemas, and it is estimated that chess experts have between 10 000 and 100 000 such configurations stored in their long-term memory. similarly, medical experts appear to solve most clinical problems by pattern recognition, without resorting to ana lytical, pathophysiological reasoning.[9] they are able to do this, with good diagnostic accuracy, by drawing on an extensive database of schemas or illness scripts stored in their long-term memory. many studies on noviceexpert differences indicate that expertise is the result of the acquisition of a large fund of domainspecific knowledge that is well organised and easily retrieved when needed.[10] deliberate practice over an extended period of time produces a high level of automation of these schemas[11] so that their use no longer requires conscious processing and makes minimal demands on the limited resources of working memory. this is how the expert clinician is able to make diagnoses rapidly, accurately and effortlessly. however, when problems are unusual or complex, the expert is able to shift from pattern recognition to analytical reasoning and bring to bear an extensive store of basic science knowledge to address the problem.[12] this is often required in disciplines such as anaesthesiology, intensive care medicine and nephrology, which are rooted in the basic sciences.[12] expertise in clinical reasoning is very case specific.[13] our challenge as teachers is to help students develop expertise that can be effectively applied to the diagnosis and management of different – but related – cases that they encounter later. such transfer of expertise is very difficult to achieve,[13,14] but may be facilitated by ensuring active learning and creating opportunities for ‘deliberate practice’[11] with carefully selected and sequenced examples. multiple examples of cases or clinical problems allow learners to encounter key concepts in a variety of contexts. this facilitates the abstraction of the underlying concepts rather than merely focusing on the surface features of clinical problems, and improves the transfer of clinical reasoning ability from one problem to another.[1] e-learning offers the possibility of fostering deep learning and the transfer of expertise in clinical reasoning by being able to provide students with interactive learning experiences, exposure to multiple cases, including cases seldom encountered during their clinical rotations, and opportunities for deliberate practice with immediate feedback. there are many factors that must be in place to ensure successful e-learning[4] and exploit the educational potential of innovative e-learning resources. these include ensuring institutional buy-in, ensuring that appropriate hardware and software are available, and providing skills training and technical and administrative support. there must be appropriate integration of e-learning into the curriculum, ensuring that assessments include the e-learning material, and a blended learning approach should be used where possible. the following sections highlight the importance of managing the learner’s cognitive load and optimising the usability of the computer interface when implementing e-learning. these factors may have a major influence on the benefit derived from the e-learning resources we employ to develop the clinical reasoning skills of our students. managing cognitive load to promote learning cognitive load theory builds on well-established models of human memory that include the subsystems of sensory memory, working memory and long-term memory.[15] while long-term memory appears to have an unlimited capacity, working memory has a very limited capacity and can hold and process only a few discrete elements at any given time.[16] sweller’s cognitive load theory[17] and mayer’s cognitive theory of multimedia learning[18] are based on a model of human cognitive architecture that views learning as involving the active processing of information by working memory via separate visual and auditory channels (fig. 1). this system for dealing with new information is of very limited capacity and any cognitive load that does not directly contribute to learning is considered extraneous and likely to impede learning. overloading the limited capacity of working memory is more likely to occur when the content to be learned is difficult and presents a high intrinsic cognitive load.[19] intrinsic cognitive load refers to the essential processing required to understand the learning material. when the material consists of multiple interacting elements of information, the intrinsic cognitive load will be high and learners therefore experience it as difficult. because of the interaction the elements cannot be learned in isolation or sequentially, but must be assimilated simultaneously for learning to occur.[19] the topic of metabolic acidosis, for example, is difficult because there are many interacting elements that operate simultaneously. students have to appreciate that metabolic acidosis may be caused by a gain of acid or the loss of sodium bicarbonate. they must also appreciate the role of the following: the extracellular fluid volume in determining the bicarbonate concentration; buffer systems in ameliorating the effects of an acid load; the kidney in excreting acid and generating new bicarbonate; and the respiratory system, which compensates for the acidosis by increasing ventilation. in contrast to the example of metabolic acidosis, some content may also contain many elements, but because of a low level of interactivity these elements can be learned in isolation or sequentially. the intrinsic cognitive load which it presents is low, and the content is therefore not experienced as difficult. for example, learning where hormones are produced could involve a long list of hormones and their sites of origin, but each of these unrelated hormone-origin pairs has little interaction with the successful learning of any other pair. learning that insulin is produced by the pancreas, for instance, can be done in isolation and without reference to any other hormone and its site of origin. the number of elements and degree of interactivity in a particular piece of learning material can only be an estimate as it varies according to the level of expertise of an individual. words pictures multimedia presentation working memory sensory memory ears eyes selecting selecting organising organising words images words images sound images verbal model pictorial model prior knowledge integrating long-term memory fig. 1. the cognitive theory of multimedia learning. sensory memory holds an exact copy of what was presented for <0.25 second, working memory holds a more processed version for <30 seconds and can process only a few items at any one time, and long-term memory has virtually unlimited capacity, holding an individual’s entire store of knowledge for long periods of time. from mayer re,[20] with permission. november 2015, vol. 7, no. 2 ajhpe 149 researchreview therefore, whether material is experienced as difficult or not depends mainly on the presence, sophistication and automation of pre-existing schemas in the long-term memory of the individual. there is a growing body of evidence supporting the idea that learning materials should be designed consistent with principles of cognitive load theory. research-based design principles have been proposed which are aimed at reducing extraneous cognitive load, managing essential processing, and fostering generative processing during learning. these principles are listed in table 1 and discussed in the sections below. reducing extraneous processing extraneous cognitive load is caused by poor instructional design and results in processing being required that does not contribute to schema acquisition or automation. methods of presentation that reduce extraneous cognitive load free up working memory and facilitate learning. mayer[20] has recommended reducing extraneous load by applying the coherence principle, which states that all irrelevant material should be eliminated; the signalling principle, which involves highlighting essential material; and the spatial contiguity principle, which involves placing printed words near the corresponding graphics. these principles are aimed at minimising the splitting of the learners’ attention between multiple sources of information, and avoiding the presentation of redundant or irrelevant information.[5] for example, if a set of images illustrating the functions of the kidneys is physically separated from the corresponding explanatory text, the learner needs to scan back and forth to mentally integrate these two sources of information. restructuring the information so that the explanatory text is close to, or even inserted into, each image eliminates the need for mental integration and reduces cognitive load. managing essential processing essential processing involves selecting relevant information and representing it in working memory. the complexity of the material and the existing expertise of the learner determine the intrinsic cognitive load related to this part of the learning process. intrinsic cognitive load can be managed by applying research-based design principles. the pretraining principle states that people learn better from a multimedia lesson when they are already familiar with the key components and concepts. novice learners should therefore receive pretraining in the names and functions of each major component of a new lesson. the segmenting principle states that people learn better when a large lesson is broken down into smaller, learner-paced segments. the navigation of the lesson should therefore be under the control of the learner. the modality principle states that the words in a multimedia lesson should be delivered via narration rather than being printed, thereby shifting information from a potentially overloaded visual channel onto the auditory channel. fostering generative processing generative processing is aimed at making sense of the material during learning and involves organising and integrating pictures and words and information from long-term memory. three design principles are helpful for increasing motivation and engagement, thereby promoting generative processing. the multimedia principle is that people learn better from words and pictures than from words alone. for example, instead of only presenting a block of text explaining how the kidney works, add a series of illustrations. the personalisation principle is that people are more engaged and learn better when words are delivered in conversational language rather than in more formal language. for example, it is better to refer to ‘your kidney’ rather than ‘the kidney’. the voice principle is that people learn better from multimedia lessons when the narration uses a human voice rather than a computer-generated one. the advances in cognitive science summarised above provide useful guidance for designing effective e-learning resources that can support the development of students’ clinical reasoning skills. the implementation of these design principles has been tested in multiple experiments and shown to have a significant positive impact on learning, with medium to large effect sizes.[20] improving the usability of computer interfaces usability is a concept from the discipline of human-computer interaction that describes how easy it is to use technology interfaces.[21] interfaces should be designed to be intuitive and self-evident, so that even inexperienced users can accomplish tasks successfully. the international standard, iso 9241-11, formally defines usability as the ‘extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use’.[22] design approaches that evaluate and optimise usability are common in the field of software development, but this is still seldom the case with e-learning, especially in the area of medical education.[23] studies on e-learning interventions in the health sciences rarely describe usability evaluation that has been conducted at an early stage of the development process, and usability is usually not even mentioned as a component of the final evaluation. it has been suggested that journals should encourage the authors of e-learning articles to report on usability and share the important lessons learnt, thereby helping colleagues to avoid costly mistakes in the future.[23] high usability of e-learning materials is required to ensure the maximum educational impact, especially when the material to be learnt is complex.[19] poor usability limits the potential benefit obtained from e-learning resources[23,24] by imposing an extraneous cognitive load, as users struggle with the interface and challenges of the content presented. we observed this with an interactive simulation we developed for improving clinical reasoning in the area of electrolyte table 1. principles for the design of e-learning materials from mayer’s cognitive theory of multimedia learning[20] reducing extraneous processing coherence principle: eliminate all extraneous material signalling principle: highlight essential material contiguity principle: place printed words near corresponding graphics managing essential processing pretraining principle: provide pretraining in the names and characteristics of key concepts segmenting principle: break lessons into learner-controlled segments modality principle: present words in spoken form rather than as text to be read fostering generative processing multimedia principle: use words and pictures rather than words alone personalisation principle: present words in a conversational style voice principle: use a human voice rather than a machine voice 150 november 2015, vol. 7, no. 2 ajhpe review disorders.[25] formal usability evaluation revealed that serious usability problems rendered the resource unusable for many participants.[26] some researchers have found significant learning effects from optimising the usability of learning materials.[27] this is most likely to be seen with novice learners who experience the content as presenting a high intrinsic cognitive load and would therefore be more sensitive to any extraneous load imposed by poor usability.[17] other researchers have reported improvements in efficiency, satisfaction or motivation.[24,28,29] these effects are important in the light of the high dropout rate from e-learning courses.[30] motivated and self-regulated learners are more likely to persist and succeed in e-learning environments, and by optimising usability one can make an important contribution to their satisfaction and motivation. an example of a usability problem and how it might be addressed is presented in fig. 2. the two main approaches to usability evaluation are ‘usability inspection’ and ‘user testing’.[33,34] usability inspection involves a process where experts evaluate the application against established design principles and includes methods such as heuristic evaluation, cognitive walkthroughs, guideline review and consistency inspection.[33] cognitive walkthroughs involve evaluators doing a step-by-step execution of common tasks, taking into account a typical user’s likely goals and knowledge. they focus on the differences between the user’s expectations and likely actions, and the steps required by the interface. guideline reviews check whether an interface conforms to a set of design guidelines, such as an industry standard or corporate style guide. consistency inspection is a methodical review for consistency in design throughout an application, including the graphics, text and the interaction or navigation style. heuristic evaluation is the most widely used inspection method and involves experts evaluating a technology interface against a set of heuristics, or principles of good interface design[35] (table 2). it provides an efficient alternative to testing with representative endusers[31] and can usually be conducted in less time, and at much less expense, than user testing. a group of inspectors is required, as the average problem detection rate of individual inspectors is generally low and each tends to uncover a different set of usability problems.[36] inspectors will usually categorise the problems detected with regard to their severity and may also suggest solutions to the problems identified. empirical user testing involves the recruitment of typical end-users and studying their interaction with the application. this approach is often considered to have better validity and a greater impact on product development than inspection methods.[34,38] evaluations may be conducted in sophisticated usability laboratories and informal settings using paper prototypes and think-aloud protocols. selecting which usability measures to use can be difficult. there is no single global measure of usability. some measures are subjective and others objective; all have their own cost and time requirements, and examine a particular aspect of usability. the objective measures include parameters such as successful task completion and error rates, while subjective measures include parameters such as satisfaction and perceived workload[39] and often make use of standardised questionnaires. recently, there has been an increasing trend to use a broader range of measures to evaluate the user experience. this includes measures such as engagement, motivation, aesthetics, and fun.[29,30] the affective features of instructional messages can influence the level of learner motivation and engagement in deep processing. we should therefore consider incorporating instructional design features aimed at priming motivation, while being careful not to overload the learner’s working memory.[40] our own experience[25,26,31,32] has illustrated how clinician-teachers who are not usability table 2. principles of good interface design. these commonly used heuristics are from nielsen,[35] with the last item from karat et al.[37] heuristic descriptor 1. visibility of system status; feedback keep users informed through timely appropriate feedback. they should always know where they are, which actions can be taken and how these actions can be performed. 2. match with the real world – language, conventions speak the users’ language, with familiar words, phrases and concepts. follow real-world conventions, making information appear in a natural and logical order. 3. consistency and conformity to standards words, situations and actions mean the same thing; application uses commonly accepted platform conventions and conforms to user expectations. 4. minimise memory load; recognition rather than recall make objects, actions, and options visible. the user should not have to remember information from one part of the application to another. instructions should be visible or easily retrievable. 5. aesthetic and minimalistic design no irrelevant information as it competes with relevant information and diminishes its relative visibility. animation and transitions should be used sparingly. 6. help and documentation it is better if the system can be used without documentation. if required it should be concise, easy to search and task centred. 7. user control and freedom the user can control the direction and pace of the application. clearly marked exits are available if they take incorrect options by mistake. the application supports undo and redo. 8. flexibility and efficiency of use users can modify the application to suit their individual capabilities and needs, e.g. by using shortcuts. 9. error prevention and tolerance careful design to prevent errors occurring. despite user errors, the intended result may still be achieved by error correction or good error management. 10. help users recognise, diagnose and recover from errors error messages should be expressed in plain language (no codes), precisely indicate the problem, and constructively suggest a solution. 11. intuitive visual layout position elements on screen to be easily perceived and understood, and visually attractive. november 2015, vol. 7, no. 2 ajhpe 151 researchreview experts can set about improving the usability of the resources they develop and provide a practical example for teachers in medical education and other areas. we developed a multimedia e-learning resource for electrolyte and acid-base disorders,[25] and then conducted a usability evaluation that included testing with end-users[26] and inspection by experts against principles of good design.[31] serious usability problems were identified, which limited the educational impact of the resource. user testing and expert evaluation each detected problems that were missed with the other method. we also observed a striking disconnect between objective usability measures and self-reported data. the usability problems were corrected in a subsequent redesign and resulted in substantial improvements in usability as assessed in a randomised trial that compared the original with the revised version.[32] the question of how many users are required for an evaluation is important because each additional user adds to the cost and the time required. nielsen[41] has suggested that 4 5 users are sufficient, as they will uncover 80% of the usability problems with a technology interface. this well-known ‘five users are enough’ approach assumes that a formative evaluation is being conducted where several iterations of testing and redesign are envisaged. however, when the application is complex or when testing is done after the most obvious problems are already fixed, the probability of detecting each usability problem decreases and more users may be required.[26,42] to date, there has been surprisingly limited interaction between usability practitioners and researchers in the field of cognitive load theory. a recent review[43] reported that cognitive load theory concepts were mentioned in very few of the citations in the guide to computing literature[44] database. the authors of this review point out that the two fields have much in common, notably a strong focus on the reduction of extraneous cognitive load. they propose that the load induced by poor usability of e-learning interfaces be viewed as a specific component of extraneous cognitive load, adding to the load resulting from poor instructional design. conclusions and recommendations for e-learning design the guidelines that the fields of cognitive load theory and humancomputer interaction have provided are complementary. both fields have a strong focus on reducing extraneous cognitive load. applying evidencebased design principles to manage cognitive load and optimising usability is essential to improve the educational impact of our e-learning resources. this is especially relevant with innovative and interactive multimedia resources, which are very costly and time consuming to develop but have great potential in facilitating the development of the clinical reasoning skills of our students. usability evaluation is critical and should form a routine part of the development and implementation of e-learning materials, modules or programmes. failing to do this may result in the implementation of resources that are unusable for many learners. it is advisable to start with the earliest versions of the resource, ideally at the prototype stage, when making changes is easier and much less costly. an iterative approach should be followed, with several cycles of testing and redesign. heuristic evaluation by experts should be used first and, once the obvious problems have been identified and fixed, followed by testing with real users. user testing should always include the study of objective usability measures and not rely only on self-reported measures of user satisfaction. references 1. norman g. research in clinical reasoning: past history and current trends. med educ 2005;39:418-427. 2. ellaway r, masters k. amee guide 32: e-learning in medical education part 1: learning, teaching and assessment. med teach 2008;30:455-473. [http://dx.doi.org/10.1080/01421590802108331] 3. huang g, reynolds r, candler c. virtual patient simulation at us and canadian medical schools. acad med 2007;82:446-451. fig. 2. an example of a usability problem. the ‘hidden’ laboratory data panel displays information essential for the assessment of the case presented. upon clicking the tab at the side of the screen (a, red arrow) it slides open (b). this was completely missed by several users who then entered the treatment simulation which followed and attempted to treat their patient without having accessed this important information. when open, the panel obscures other on-screen information and remains open even when navigating to another slide. the tab has to be clicked again to close the panel. this usability problem was corrected in a subsequent redesign (c). the sliding panel has been completely eliminated and all the information is now in full view in the patient data panel on the left of the slide. from davids mr, et al.[26,31,32] 152 november 2015, vol. 7, no. 2 ajhpe researchreview 4. childs s, blenkinsopp e, hall a, walton g. effective e‐learning for health professionals and students – barriers and their solutions. a systematic review of the literature – findings from the hexl project. health info libr j 2005;22:20-32. 5. sweller j. implications of cognitive load theory for multimedia learning. in: mayer re, ed. the cambridge handbook of multimedia learning. new york, ny: cambridge university press, 2005:19-30. 6. barrows hs, feltovich pj. the clinical reasoning process. med educ 1987;21:86-91. 7. de groot ad. thought and choice in chess. 2nd ed. the hague: mouton publishers, 1978. 8. chase wh, simon ha. perception in chess. cognit psychol 1973;4:55-81. 9. eva kw, norman gr, neville aj, wood tj, brooks lr. expert-novice differences in memory: a reformulation. teach learn med 2002;14:257-263. 10. ericsson ka, kintsch w. long-term working memory. psychol rev 1995;102:211-245. 11. ericsson ka. deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. acad med 2004;79:s70-s81. 12. norman gr, trott al, brooks lr, smith ekm. cognitive differences in clinical reasoning related to postgraduate training. teach learn med 1994;6:114-120. 13. eva kw, neville aj, norman gr. exploring the etiology of content specificity: factors influencing analogic transfer and problem solving. acad med 1998;73:s1-s5. 14. elstein as, shulman ls, sprafka sa. medical problem solving: an analysis of clinical reasoning. cambridge, ma: harvard university press, 1978. 15. young jq, van merrienboer j, durning s, ten cate o. cognitive load theory: implications for medical education: amee guide no. 86. med teach 2014;36:371-384. [http://dx.doi.org/10.3109/0142159x.2014.889290] 16. simon ha. how big is a chunk? science 1974;183:482-488. 17. sweller j, van merrienboer jjg, paas fgwc. cognitive architecture and instructional design. educ psychol rev 1998;10:251-296. 18. mayer re. multimedia learning. cambridge, uk: cambridge university press, 2001. 19. sweller j. cognitive load theory, learning difficulty, and instructional design. learn instr 1994;4:295-312. 20. mayer re. applying the science of learning to medical education. med educ 2010;44:543-549. [http://dx.doi. org/10.1111/j.1365-2923.2010.03624.x] 21. nielsen j. usability 101: introduction to usability. nielsen norman group. 2003. http://www.nngroup.com/ articles/usability-101-introduction-to-usability/ (accessed 31 august 2014). 22. abran a, khelifi a, suryn w, seffah a. usability meanings and interpretations in iso standards. software qual j 2003;11:325-338. 23. sandars j. the importance of usability testing to allow e-learning to reach its potential for medical education. educ prim care 2010;21:6-8. 24. zaharias p. usability in the context of e-learning. int j technol human interact 2009;5:37-59. 25. davids mr, chikte ume, halperin ml. development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders. adv physiol educ 2011;35:295-306. [http://dx.doi.org/10.1152/advan.00127.2010] 26. davids mr, chikte u, grimmer-somers k, halperin ml. usability testing of a multimedia e-learning resource for electrolyte and acid-base disorders. brit j educ technol 2014;45:367-381. 27. avouris nm, dimitracopoulou a, daskalaki s, tselios nk. evaluation of distance-learning environments: impact of usability on student performance. international journal of educational telecommunications 2001;7:355-378. 28. kanuka h, szabo m. conducting research on visual design and learning: pitfalls and promises. can j learn technol 1999;27:105-123. 29. hancock pa, pepe aa, murphy ll. hedonomics: the power of positive and pleasurable ergonomics. ergon des 2005;13:8-14. 30. zaharias p, poylymenakou a. developing a usability evaluation method for e-learning applications: beyond functional usability. int j hum-comput interact 2009;25:75-98. 31. davids mr, chikte ume, halperin ml. an efficient approach to improve the usability of e-learning resources: the role of heuristic evaluation. adv physiol educ 2013;37:242-248. [http://dx.doi.org/10.1152/advan.00043.2013] 32. davids mr, chikte um, halperin ml. effect of improving the usability of an e-learning resource: a randomized trial. adv physiol educ 2014;38:155-160. [http://dx.doi.org/10.1152/advan.00119.2013] 33. nielsen j, mack rl. usability inspection methods. new york: wiley, 1994. 34. dumas js, salzman mc. usability assessment methods. rev hum factors ergon 2006;2:109-140. 35. nielsen j. 10 usability heuristics for user interface design. nielsen norman group. 1995. http://www.nngroup. com/articles/ten-usability-heuristics/ (accessed 14 october 2014). 36. hertzum m, jacobsen ne. the evaluator effect: a chilling fact about usability evaluation methods. int j humcomput interact 2001;13:421-443. 37. karat c-m, campbell r, fiegel t. comparison of empirical testing and walkthrough methods in user interface evaluation. proceedings of the sigchi conference on human factors in computing systems. monterey, ca: acm, 1992:397-404. 38. rosenbaum s, rohn ja, humburg j. a toolkit for strategic usability: results from workshops, panels, and surveys. proceedings of the sigchi conference on human factors in computing systems. the hague, the netherlands: acm, 2000:337-344. 39. hornbæk k. current practice in measuring usability: challenges to usability studies and research. int j humcomput st 2006;64:79-102. 40. mayer re. incorporating motivation into multimedia learning. learn instr 2014;29:171-173. 41. nielsen j. how many test users in a usability study? jakob nielsen’s alertbox. 2012. http://www.nngroup.com/ articles/how-many-test-users/ (accessed 1 april 2015). 42. faulkner l. beyond the five-user assumption: benefits of increased sample sizes in usability testing. behav res meth instrum comput 2003;35:379-383. 43. hollender n, hofmann c, deneke m, schmitz b. integrating cognitive load theory and concepts of humancomputer interaction. comput hum behav 2010;26:1278-1288. 44. association for computing machinery. the acm guide to computing literature. http://librarians.acm.org/ acm‐guide‐computing‐literature (accessed 18 august 2015). research 108 may 2016, vol. 8, no. 1, suppl 1 ajhpe one of the targets of the joint  united nations  programme on hiv and aids (unaids) 2016 2021 plan is the following: ‘90% of young people are empowered with the skills, knowledge and capability to protect themselves from hiv’.[1] therefore, the development of effective hiv prevention programmes is a top public health and policy priority.[2] however, in spite of calls to increase awareness of the high levels of hiv transmission in young women,[3] particularly in southern africa,[4] there is little scientific consensus about how best to prevent hiv infection among the youth. comprehensive sexuality education is considered an important means of addressing adolescent risk behaviours,[5] although little evidence supports its direct effect on biological measures of prevention success, particularly of hiv and other sexually transmitted infections (stis).[5] in sub-saharan africa, experience with youth hiv prevention programmes is limited, with evidence regarding effectiveness still emerging. prior reviews and studies of youth intervention programmes in both developed and developing countries[2,5,6] suggest an important role for education interventions to increase young people’s knowledge of sexuality, reproductive health and hiv prevention, with a majority of interventions leading to reductions in reported risk behaviours. as young people are a target for knowledge and skills development, it is imperative that more hiv/aids prevention and education initiatives are developed that target the nation’s youth. this research addressed the effect of an online hiv/aids course on student knowledge of hiv prevention and transmission and of the science of hiv infection. in the second semester of 2009, the discipline of pharmaceutical sciences, school of health sciences, university of kwazulu-natal, durban, south africa began to test the concept of online aids education by offering an online course on hiv/aids in collaboration with dr sharron jenkins of purdue university, indiana, usa. the sensitivity of the topics related to hiv/aids, such as sexual preferences, practices and behaviours, could be quite uncomfortable for students in the traditional classroom setting. in light of these observations, purdue university began delivering an onlineonly course, providing students the opportunity to have candid, open, and anonymous dialogue about sex and hiv/aids. this approach was also adopted at the university of kwazulu-natal (ukzn). the primary purpose of this article is to present and discuss the results of an anonymous online course, the preand post-confirmation of acceptance for studies (pre-cas and post-cas, respectively), given to students during the first and last weeks of class, respectively. the surveys were designed to assess the overall effect of the aids online international (aoi) course on hiv-related attitudes, beliefs, knowledge and risk behaviours. only the effect on knowledge is presented in this article. methods the aoi course was offered as an 8-credit mandatory pharmacy module in the second semester of the first year at ukzn. the course was given over 17 weeks (including the examination week). ninety-seven students took the course in the first year of its implementation. thereafter, 101 students (2010), 98 students (2011), 113 students (2012) and 104 students (2013) took the course. the aoi course runs online only through a course management system and consists of weekly quizzes, examinations, discussion board activities, animations, and videos/movies to support the learning objectives of the course. in addition, students participate in several online mock activities, including hiv testing, hiv risk assessment, and mandatory online discussions. embedded into the online delivery of the course, the material and assessments are designed to reflect two theories: the health belief model and social cognitive theory – two well-established models that attempt to explain and predict health background. more international hiv/aids intervention initiatives targeting young adults are needed to help reach targets set by the joint  united nations programme on hiv and aids (unaids). objectives. to determine the effect of an online hiv/aids course on 1st-year pharmacy students’ knowledge of hiv prevention and transmission and of the science of hiv infection. methods. online anonymous surveys, the preand post-confirmation of acceptance for studies, were administered by means of an online survey tool, surveymonkey (usa), to 1st-year pharmacy students, from 2009 to 2013. these surveys were adminis tered online during the first and last weeks of class, respectively. results. with regard to hiv prevention and transmission, student knowledge of the manner in which hiv is transmitted improved during the course. overall, students were more confident about their knowledge of hiv prevention. they also indicated that as a direct result of taking the aids online international course they were more reluctant to have unsafe sex and more confident about how to protect themselves against hiv/aids. their scientific knowledge also improved. conclusion. the implementation of an online hiv/aids course has proved to be an effective method of hiv/aids education, and may also be a viable hiv intervention initiative. afr j health professions educ 2016;8(1 suppl 1):108-112. doi:10.7196/ajhpe.2016.v8i1.750 assessing the effect of an online hiv/aids course on 1st-year pharmacy students’ knowledge f suleman,1 bpharm, mpharm, phd; s jenkins,2 phd 1 discipline of pharmaceutical sciences, school of health sciences, university of kwazulu-natal, durban, south africa 2 chemistry department, purdue university northwest, indiana, us corresponding author: f suleman (sulemanf@ukzn.ac.za) research may 2016, vol. 8, no. 1, suppl 1 ajhpe 109 behaviours by focusing on the attitudes and beliefs of individuals, including exploring health behaviours associated with hiv transmission. over a 17-week period, students are given approximately 14 lessons, covering topics such as hiv/aids history/origin, statistics, transmission, prevention, testing, and the science of hiv disease progression/opportu nistic infections, aids diagnosis, vaccines, and antiviral drugs. hiv prevention activities span 2 3 weeks. halfway through the course students participate in a midsemester activity to help them to assess their personal risk of hiv infection. the activity is a 20 -question survey of behaviours that may place the student and his/her partner at risk of contracting hiv. students also watch one movie on aids history and several online animations related to testing hiv-positive and the science of infection. the online animations provide case studies that help students personalise their own risk of hiv infection. by participating in online mock activities, such as hiv testing and risk assessment, students are able to evaluate their sexual practices and their perceived susceptibility and vulnerability to hiv infection. the activities also provide students with skills to practise and negotiate safer sex. to assess the effect of the aoi course on participants, online anonymous surveys, the pre-cas and post-cas, were administered by means of an online survey tool, surveymonkey (usa). the surveys were used to assess the knowledge, attitudes, beliefs, and behavioural practices of course participants. the pre-cas was administered online during the first week of class and the post-cas during the last week of class. approximately 100 questions were posed to students in each of the 5-year periods. pre-cas and post-cas statements discussed here cover four main categories: knowledge of hiv transmission/prevention, attitudes/beliefs regarding aids-related issues, science of hiv infection, and hiv risk behaviours. each survey statement allowed students to respond by selecting one of the following: strongly agree, table 1. demographics of students from 2009 to 2013, % 2009 (n=97) 2010 (n=101) 2011 (n=98) 2012 (n=113) 2013 (n=104) demographics pre-cas post-cas pre-cas post-cas pre-cas post-cas pre-cas post-cas pre-cas post-cas gender female 70.10 60.82 61.39 62.38 76.53 80.61 57.52 59.29 76.00 73.00 male 29.90 25.77 26.73 26.73 13.27 15.31 21.24 23.89 24.00 27.00 age categories, years 15 19 80.41 69.07 76.24 74.26 81.63 84.69 55.75 61.95 77.00 76.00 20 24 19.59 17.53 9.90 12.87 5.10 8.16 20.35 19.47 24.00 22.00 marital status single 69.07 64.95 62.38 69.31 73.47 83.67 58.41 63.72 77.90 77.00 single, but in mono gamous relationship 27.84 17.53 22.77 16.83 13.27 9.18 17.70 18.58 19.20 22.00 single with more than one sex partner 3.09 4.12 1.98 1.98 1.10 0.00 1.90 0.00 1.90 0.00 married 0.00 0.00 1.10 1.10 2.30 3.20 0.00 1.00 1.00 1.00 sexual preference heterosexual male (sex with women only) 26.80 24.74 23.76 23.76 13.27 12.24 22.12 23.89 25.00 27.00 homosexual male (sex with men only) 7.22 2.06 5.94 0.99 6.12 5.10 3.54 2.65 3.80 4.00 bisexual male (sex with both men and women) 1.03 1.03 0.00 0.99 0.00 0.00 0.00 0.00 0.00 0.00 heterosexual female (sex with men only) 58.76 57.73 56.44 62.38 68.37 72.45 51.33 54.87 68.30 67.00 living arrangements renting house/apartment 27.84 27.84 20.79 20.79 11.22 12.24 35.40 36.28 41.30 44.00 own house/apartment 4.10 7.10 9.70 2.20 11.22 10.20 5.80 5.00 5.80 5.00 staying with family/friends who rent house/apartment 12.40 3.60 5.40 14.30 17.35 12.24 8.70 8.00 8.70 8.00 staying with family/friends who own house/apartment 53.61 48.45 50.50 51.49 45.92 58.16 28.32 32.74 41.30 41.00 access to a regular doctor, nurse or health practitioner yes 70.10 64.95 65.35 61.39 69.39 82.65 45.13 51.33 61.50 63.00 research 110 may 2016, vol. 8, no. 1, suppl 1 ajhpe ta bl e 2. k no w le dg e ab ou t h iv /a id s (a s a m ea n sc or e) fr om 2 00 9 to 2 01 3, w it h pva lu es k no w le dg e ab ou t h iv tr an sm is si on /p re ve nt io n 20 09 ( n= 97 ) 20 10 ( n= 10 1) 20 11 ( n= 98 ) 20 12 ( n= 11 3) 20 13 ( n= 10 4) p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e d o yo u ag re e or d is ag re e w ith th e fo llo w in g st at em en ts ? i am c on fid en t t ha t i kn ow th e co rr ec t a nd m os t e ff ec tiv e w ay to u se a co nd om 2. 05 1. 42 0. 00 29 2. 02 1. 30 0. 00 00 2. 39 1. 32 0. 00 00 2. 44 1. 53 0. 00 00 2. 29 1. 44 0. 01 06 i am r el uc ta nt to h av e un sa fe s ex b ec au se o f w ha t i’v e le ar ne d fr om th is co ur se 2. 00 1. 43 0. 00 10 1. 87 1. 40 0. 01 01 2. 06 1. 43 0. 00 05 2. 15 1. 51 0. 00 34 2. 07 1. 64 0. 26 04 * h iv te st s ge ne ra lly te st fo r h iv a nt ib od ie s an d no t fo r th e vi ru s 2. 04 1. 08 0. 00 00 1. 76 1. 17 0. 00 00 1. 71 1. 21 0. 00 04 2. 13 1. 20 0. 00 00 3. 06 3. 46 0. 00 00 a n h iv te st d ur in g th e ‘w in do w p er io d’ c ou ld re su lt in a fa lse -n eg at iv e re su lt 1. 27 1. 03 0. 00 49 1. 28 1. 14 0. 10 17 * 1. 31 1. 14 0. 09 58 * 1. 39 1. 04 0. 00 05 3. 06 3. 46 0. 00 08 i am a w ar e of a t l ea st o ne h iv /a id s su pp or t g ro up in m y ar ea 1. 62 1. 24 0. 00 01 1. 57 1. 23 0. 00 20 1. 73 1. 50 0. 13 99 * 1. 68 1. 44 0. 02 08 3. 06 3. 46 0. 05 05 * is it p os si bl e to c on tr ac t o r tr an sm it h iv th ro ug h th e fo llo w in g w ay s?                               o ra l s ex w ith a n h iv in fe ct ed p er so n 1. 43 1. 09 0. 00 25 1. 40 1. 08 0. 00 22 1. 37 1. 04 0. 00 00 1. 34 1. 11 0. 00 64 3. 06 3. 46 0. 03 04 r ec ei vi ng b re as t m ilk fr om a n h iv -i nf ec te d m ot he r (m ot he rto -c hi ld tr an sm is si on ) 1. 16 1. 05 0. 06 01 * 1. 27 1. 06 0. 00 72 1. 10 1. 02 0. 13 44 * 1. 33 1. 07 0. 00 08 3. 06 3. 46 0. 02 73 d ee p ki ss in g or ‘f re nc h ki ss in g’ a n h iv -i nf ec te d pe rs on 1. 89 1. 38 0. 00 00 1. 99 1. 39 0. 00 00 2. 00 1. 26 0. 00 00 2. 08 1. 40 0. 00 00 3. 06 3. 46 0. 00 52 w hi ch o f t he fo llo w in g gr ou ps o f p eo pl e w ou ld b e at r is k fo r co nt ra ct in g h iv ? c ho os e al l t ha t a pp ly                               m en w ho h av e se x w ith m en ( ho m os ex ua l m en ) 1. 53 1. 00 0. 00 00 1. 24 1. 05 0. 00 86 1. 41 1. 02 0. 00 00 1. 32 1. 04 0. 00 08 3. 06 3. 46 0. 03 95 c on ti nu ed … research may 2016, vol. 8, no. 1, suppl 1 ajhpe 111 ta bl e 2. ( co nt in ue d) k no w le dg e ab ou t h iv /a id s (a s a m ea n sc or e) fr om 2 00 9 to 2 01 3, w it h pva lu es k no w le dg e ab ou t h iv tr an sm is si on /p re ve nt io n 20 09 ( n= 97 ) 20 10 ( n= 10 1) 20 11 ( n= 98 ) 20 12 ( n= 11 3) 20 13 ( n= 10 4) p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e p re -c a s po st -c a s pva lu e pe op le w ho h av e ha d a se xu al ly tr an sm itt ed d is ea se 1. 44 1. 01 0. 00 00 1. 26 1. 03 0. 00 27 1. 18 1. 03 0. 05 50 1. 26 1. 08 0. 02 34 3. 06 3. 46 0. 00 56 pe op le w ho in je ct d ru gs 1. 53 1. 02 0. 00 00 1. 19 1. 06 0. 02 71 1. 21 1. 03 0. 00 69 1. 17 1. 07 0. 32 03 * 3. 06 3. 46 0. 00 46 a p er so n w ho f re nc h ki ss es a pe rs on w ith h iv in fe ct io n 1. 85 1. 38 0. 00 00 1. 93 1. 38 0. 00 00 2. 01 1. 20 0. 00 00 1. 98 1. 38 0. 00 00 3. 06 3. 46 0. 00 03 d o yo u ag re e or d is ag re e w ith th e fo llo w in g st at em en ts ?                               i kn ow a ll th e w ay s to pr ev en t h iv tr an sm is si on 1. 87 1. 19 0. 00 00 1. 62 1. 18 0. 00 05 1. 65 1. 10 0. 00 00 1. 85 1. 36 0. 00 05 3. 06 3. 46 0. 00 35 g lo ba lly , m os t p eo pl e co nt ra ct h iv th ro ug h he te ro se xu al c on ta ct 1. 77 1. 24 0. 00 00 1. 80 1. 14 0. 00 00 1. 92 1. 17 0. 00 00 1. 60 1. 24 0. 00 40 3. 06 3. 46 0. 01 49 d ou ch in g af te r se x ca n pr ev en t h iv tr an sm is si on 2. 48 2. 01 0. 00 00 2. 44 2. 03 0. 00 00 2. 41 2. 04 0. 00 00 2. 30 2. 06 0. 00 40 3. 06 3. 46 0. 00 01 k no w le dg e of th e sc ie nc e of h iv 20 09 ( n= 97 ) 20 10 ( n= 10 1)  2 01 1 (n =9 8)   20 12 ( n= 11 3)    20 13 ( n= 10 4)   p re -c a s po st -c a s pva lu e  p re -c a s  po st -c a s   p -v al ue   p re -c a s  po st -c a s  pva lu e    p re -c a s  po st -c a s  pva lu e    p re -c a s po st -c a s  pva lu e  d o yo u ag re e or d is ag re e w ith th e fo llo w in g st at em en ts ? so m e an tiv ir al d ru gs c an he lp p re ve nt m ot he rto ch ild tr an sm is si on o f h iv 1. 33 1. 08 0. 01 34 1. 47 1. 08 0. 00 01 1. 30 1. 15 0. 04 24 1. 35 1. 12 0. 01 15 3. 06 3. 46 0. 00 95 a p os iti ve h iv te st m ea ns th at th e bo dy is p ro du ci ng an tib od ie s to h iv 1. 66 1. 02 0. 00 00 1. 64 1. 03 0. 00 00 1. 52 1. 12 0. 00 00 1. 66 1. 11 0. 00 00 3. 06 3. 46 0. 00 00 a c d 4 ce ll is an im m un e ce ll 1. 38 1. 01 0. 00 00 1. 42 1. 05 0. 00 05 1. 44 1. 04 0. 00 00 1. 37 1. 06 0. 00 07 3. 06 3. 46 0. 00 89 t he re a re tw o m ai n ty pe s of h iv , t hr ee m ai n gr ou ps , an d se ve ra l s ub ty pe s 2. 47 1. 02 0. 00 00 2. 35 1. 05 0. 00 00 2. 47 1. 08 0. 00 00 2. 23 1. 11 0. 00 00 3. 06 3. 46 0. 00 00 r ev er se tr an sc ri pt io n is a st ep in th e h iv li fe c yc le 1. 44 1. 00 0. 00 00 1. 19 1. 07 0. 09 63 * 1. 21 1. 05 0. 00 30 1. 45 1. 11 0. 00 01 3. 06 3. 46 0. 00 79 in te gr as e, r ev er se tr an sc ri pt as e, a nd p ro te as e ar e h iv e nz ym es 1. 87 1. 01 0. 00 00 1. 51 1. 06 0. 00 01 1. 60 1. 03 0. 00 00 1. 63 1. 07 0. 00 00 3. 06 3. 46 0. 00 06 a nt iv ir al d ru gs su ch a s zi do vu di ne (a zt ) a nd di da no si ne (d di ) a re re ve rs e tr an sc ri pt as e in hi bi to rs 2. 05 1. 16 0. 00 00 2. 11 1. 16 0. 00 00 2. 21 1. 24 0. 00 00 1. 90 1. 33 0. 00 00 3. 06 3. 46 0. 00 26 * n on -s ig ni fic an t p -v al ue s. research 112 may 2016, vol. 8, no. 1, suppl 1 ajhpe agree, not sure, disagree, strongly disagree, or skip the question. paired t-tests were calculated for each year to determine if there were significant differences between the pre-cas and post-cas statements. ethical clearance to administer and analyse the questionnaire was obtained from ukzn. informed consent was obtained from the students, who were aware that they could volunteer for the survey and withdraw from it at any time. anonymity was maintained and no identifying information on the student was obtained (except gender and age). results the data presented in tables 1 and 2 are results of the pre-cas and postcas surveys from 2009 to 2013. table 1 presents the demographics of the students over the 5-year period. the majority of students were female and single. most were in the 15 19-year age group and in most instances stayed with family or friends. most students reported being heterosexual and had access to a regular doctor or nurse. in terms of knowledge of hiv prevention and transmission, student knowledge on the methods of hiv transmission improved during the course (table 2). for instance, correct identification of hiv transmission increased in the post-cas for oral sex, mother-to-child transmission during childbirth, and mother-to-child transmission via breastfeeding. overall, students were more confident in their knowledge of hiv prevention. they also indicated that as a direct result of taking the aoi course they were more reluctant to have unsafe sex and more confident about how to protect themselves. knowledge of the science of the disease and of medication therapy improved. there were some differences in cohort responses over the 5-year period. of concern is the 2013 cohort's response to the course in terms of ‘i am reluctant to have unsafe sex because of what i’ve learned from this course’ (p=0.2604), which might indicate that risky behaviour was being practised. this group also seemed unsure if hiv could be transmitted via breastmilk. they had very different responses from the group of the previous year (in terms of mean scores). as this was an online anonymous survey, further investigation as to the reason for the difference could not be undertaken. discussion although most students were reasonably knowledgeable about hiv transmission and prevention before the course, pre-cas and post-cas data indicate that they were more confident about their knowledge after the course. the aoi course did have a significant effect in helping students to understand the science of hiv disease. it is important, however, to continue to investigate if the 2013 cohort responses were an anomaly or if there are other reasons for youth to respond to the questions in such a manner. it could be that there are now too many messages being provided through different media, which creates confusion. this topic must be further researched. studies found that although students have reasonable knowledge about hiv prevention measures, they do not make behavioural changes because: (i) they lack the technical and/or communication skills to practise safe sex; (ii) they do not personalise the risk by separating themselves from the issue; and (iii) they do not socialise or have discussions about safe sex as there is a homosexual stigma associated with aids.[7,8] therefore, to translate knowledge about hiv into risk-reducing behaviours, prevention initiatives must be able to personalise the risk of hiv infection, the seriousness of becoming infected, the benefits of practising safer sex, and the skills learned so that there is self-efficacy to practise them.[9] the aoi course is designed to reflect these theories by incorporating into the curriculum activities intended to influence specific beliefs towards safer sexual practices. recent studies indicate that computerised, online or internet-based hiv prevention initiatives may be a viable way to promote hiv education, awareness and prevention skills.[10,11] the results of this study suggest that an online course on aids may be a viable and effective way to influence students’ knowledge related to hiv/aids and hiv risk behaviours. furthermore, the aoi course proved to be an effective hiv prevention initiative with the potential to make a significant international contribution to hiv prevention initiatives – educating large numbers of young adults about preventing the spread of hiv. this study had a higher proportion of female than male students, which could have affected the responses to the survey, and might be a limitation of this study. a ghanaian study in 2012,[12] which had a more equitable distribution of male and female students, found that the female students had significantly (p=0.017) more knowledge about hiv/aids than their male counterparts. the results were similar to those of studies conducted in nigeria,[13,14] which found that aids knowledge differs on the basis of gender among university students. conclusion the online hiv/aids course provided a safe and anonymous environment for students to acquire the knowledge necessary to understand the science of the disease and knowledge on hiv prevention and transmission in terms of their own attitude and behaviour. it can be used across disciplines in the health sciences as a way to engage students in discussions on risky behaviours and provide them with information to protect themselves against infection, or on the management of the infection. results from ukzn cohorts will need to be compared with cohorts at other universities across the globe that are teaching the aoi course, and to assess whether a class with more male students would alter these results. however, results suggest that this could be a good intervention for higher education. acknowledgements. this article was made possible by grant no. 5r24tw008863 from the us president’s emergency plan for aids relief (pepfar) and the national institutes of health (nih), us department of health and human services. its contents are solely the responsibility of the author and the ukzn mepi programme and do not necessarily represent the official views of the us government. references 1. joint united nations programme on hiv and aids (unaids). aids by the numbers. geneva: unaids, 2015. http:// www.unaids.org/sites/default/files/media_asset/aids_by_the_numbers_2015_en.pdf (accessed 29 february 2016). 2. ross d, dick b, ferguson j. preventing hiv/aids in young people: a systematic review of the evidence from developing countries. report of the unaids inter-agency task team on young people. world health organization (who) technical report series 938, 2006. geneva: who, 2006. 3. laga m, schwärtlander b, pisani e, sow ps, caraël m. to stem hiv in africa, prevent transmission to young women. aids 2001;15:931-934. 4. stirling m, rees h, kasedde s, hankins c. addressing the vulnerability of young women and girls to stop the hiv epidemic in southern africa. aids 2008;22:s1-s3. [http://dx.doi.org/10.1097/01.aids.0000341772.48382.57] 5. ibrahim n, rampal l, jamil z, zain am. effectiveness of peer-led education on knowledge, attitude and risk behaviour practices related to hiv among students at a malaysian public university – a randomized controlled trial. prev med 2012;55:505-510. 6. oppong ak, oti-boadi m. hiv/aids knowledge among undergraduate university students: implications for health education programs in ghana. afr health sci 2013;13(2):270-277. [http://dx.doi.org/10.4314/ahs.v13i2.11] 7. oakley a, fullerton d, holland j, et al. sexual health education interventions for young people: a methodological review. br med j 1995;310:158-162. 8. mkumboa k. assessment of hiv/aids knowledge, attitudes and behaviours among students in higher education in tanzania. glob public health 2013;8(10):1168-1179. [http://dx.doi.org/10.1080/17441692.2013.837498] 9. heeren ga, jemmott gb iii, ngwane z, mandeya a, tyler jc. a randomized controlled pilot study of an hiv riskreduction intervention for sub-saharan african university students. aids and behaviour 2013;17(3):1105-1115. 10. catalani c, philbrick w, fraser h, mechael p, israelski dm. mhealth for hiv treatment and prevention: a systematic review of the literature. open aids j 2013;7:17-41. [http://dx.doi.org/10.2174/1874613620130812003] 11. schnall r, travers j, rojas m, carballo-diéguez a. ehealth interventions for hiv prevention in high-risk men who have sex with men: a systematic review. j med internet res 2014;16(5):e134. [http://dx.doi.org/10.2196/jmir.3393] 12. oppong asante k, oti-boadi m. hiv/aids knowledge among undergraduate university students: implications for health education programs in ghana. afr health sci 2013;13(2):270-277. [http://dx.doi.org/10.4314/ahs.v13i2.11] 13. aluede o, imhonde h, maliki a, alutu a. assessing nigerian university students' knowledge about hiv/aids. j soc sci 2005;11:207-213. 14. chng l, eke-huber e, eaddy s, collins j. nigerian college students: hiv knowledge, perceived susceptibility for hiv and sexual behaviours. college student journal 2005;39(1):60-71. ajhpe book review.indd 174 october 2014, vol.6, no. 2 ajhpe book review principles of medicine in africa ed. by david mabey, geoffrey gill, eldryd parry, martin w weber and christopher jm whitty. 4th ed. cambridge: cambridge university press, 2013. isbn 978-1-107-00251-7 this is the 4th edition of this important book, which was first published in 1976, and a far thicker tome than the original. as implied by the title, the scope of the publication is huge – medicine in africa, arguably one of the more interesting continents in terms of pathology. and that pathology is not always driven by diseasecausing organisms, as the opening section of the book reminds us, covering people and the environment, food and nutrition, refugees and disasters, and how to manage a health service. mother and child health has a complete section, mirroring the concerns of the millennium development goals – sadly missed in most african countries for myriad reasons, poor health systems being one of the most pertinent. infections come next, with the major infections such as hiv and tuberculosis singled out from the sections on viral, bacterial, protozoal, helminth and fungal infections. non-communicable diseases are of course becoming all too common, even in the developing world, and are covered in detail, along with the diseases of the body systems, cancer and palliative care (the latter poorly provided in most parts of the continent), and venoms and poisons. like all cambridge university press publications the book is laid out well, with easyto-read text, plus text boxes, illustrations, tables and graphs where these add to the text. colour photographs are used to aid understanding and diagnosis, and are of high quality. my only criticism is the make-up of contributors to the book. africa is poorly represented. the sections on hiv and tuberculosis, for example, are provided predominantly by authors from the uk and europe. this is strange when there is such expertise in these common infections right here in africa. i would urge the publishers to look more broadly for authors when putting together the next edition of this excellent textbook. bridget farham deputy editor, samj ugqirha@iafrica.com 6 may 2016, vol. 8, no. 1 ajhpe evidence-based practice (ebp) is positioned as an inherent good in the medical and clinical literature, and not without reason. it relies on the integration of research evidence, clinical expertise and patient preferences,[1] and has become a foundation on which health systems are built and improved. there is however, a growing body of literature that takes a more critical stance towards ebp, especially when practitioners make assumptions about what constitutes ‘the evidence’ and how the data informing that evidence are gathered.[2,3] the evidence upon which ebp is premised is usually derived from experimental research conducted in professional disciplines that are firmly rooted in the positivist paradigm; the research method most closely associated with this is the randomised controlled trial (rct). rcts are quantitative, controlled experiments in which the effect of an intervention can be determined more objectively than by observational studies.[4] there is no doubt that the method has utility in determining cause-effect relationships between medical treatments and patient outcomes, making it a powerful design for intervention studies with the objective of determining the influence of one variable on another.[5] in an educational context it may initially seem reasonable to expect that an experimental design could determine the effect of a teaching intervention that aims to improve student learning. the argument is that by using randomisation to average out the differences between students, one would be able to demonstrate which teaching and learning strategies lead to the largest effect sizes. these data, presumed to be free of subjective interpretation, could then inform policies that drive the implementation of effective teaching interventions.[6] however, if we assume that the evidence gathered via experimental research provides insight into an objective reality, we must take a position on teaching and learning that is at odds with our best explanations for how learning happens. therefore, if we want to use rcts in educational research, we must assume that there is a cause-effect relationship in the teaching and learning interaction that can be objectively measured. in this article we argue that rcts are an inappropriate design choice for educational research because they force one to assume ontological and epistemological positions that are at odds with theoretically informed perspectives of learning. rcts in educational research we begin by highlighting the biased way in which rcts are positioned relative to other forms of research endeavours, explicit in the language employed by rct proponents. goldacre[7] suggests that ‘evidence-based interventions in teaching could … replace the current system where untested methods are passed to teachers through a variety of often dubious outlets’, and ‘we need a slow revolution that puts evidence at the heart of teaching’. torgerson[8] asserts that rcts are the ultimate expression of evaluative research, referring to ‘the importance and supremacy of the rct’, and expresses concern that educational research tends to rely on ‘manifestly inferior’ qualitative methods. it seems clear that those who most strongly advocate the use of rcts in education have an inherent bias against other methods of data collection, strongly positioning themselves within a positivist interpretation of reality. this does not mean that rcts and other forms of experimental research are not valuable tools in the repertoire of the researcher; randomisation is rightly considered an appropriate design choice in clinical trials. by controlling for the influence of all other variables between groups – through the assumed equal distribution of those differences in a large enough randomised sample – any differences in outcome can be more confidently attributed to the intervention.[5] as the rct is a powerful tool successfully used in medical and clinical research, some have suggested that it should therefore underpin all ‘good’ research regardless of context’.[9] however, one cannot assume that rcts can provide more – and better – evidence, which inevitably leads to improvements in education.[6] rct proponents hope that these trials can do for educational researchers what they have done for medical researchers, i.e. provide clear-cut answers around the relative benefits of one intervention over another.[7] rcts are presented as a gold standard, able to determine ‘the truth’ by simplifying and randomised controlled trials (rcts) are a valued research method in evidence-based practice in medical and clinical settings because they are associated with a particular ontological and epistemological perspective that is situated within a positivist world view. it assumes that environments and variables can be controlled to establish cause-effect relationships. however, current theories of learning suggest that knowledge is socially constructed, and that learning occurs in open systems that cannot be controlled and manipulated as would be required in a rct. they recognise the importance and influence of context on learning, which positivist research paradigms specifically aim to counter. we argue that rcts are inappropriate in education research because they force one to take up ontological and epistemological positions in a technical rationalist framework, which is at odds with current learning theory. afr j health professions educ 2016;8(1):6-8. doi:10.7196/ajhpe.2016.v8i1.683 randomised controlled trials in educational research: ontological and epistemological limitations m rowe,1 phd; c oltmann,2 phd 1 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 division of pharmacy practice, faculty of pharmacy, rhodes university, grahamstown, south africa corresponding author: m rowe (michael@realmdigital.co.za) short report may 2016, vol. 8, no. 1 ajhpe 7 generalising the complex social interactions of the educational context.[10] for example, goldacre[7] suggests that by ‘… collecting better evidence about what works best, and establishing a culture where this evidence is used as a matter of routine, we can improve outcomes’. by positioning the rct as the best way to collect ‘better evidence about what works best’, it has been suggested as a means by which educational practice can be improved, as it generates absolute facts about an existing reality that is objectively measured.[10] by choosing the rct as a method of gathering data, the researcher is taking a stance within a framework that describes what they believe about what it means to know something in the world. the way researchers make decisions about which methodologies are useful is determined in part by their ontological and epistemological perspectives. a research methodology is not simply a neutral plan for designing a systematic inquiry, but is instead informed by a theoretical perspective. the selection of a research method is therefore a proxy for expressing a belief about what it means to know and our attempts to better understand what we know.[11] therefore, our beliefs around our ways of knowing in the world influence how we choose to investigate them.[10] according to grix,[12] research is best done by establishing a relationship between what a researcher thinks can be researched (the ontological position), what we believe can be known about it (the epistemological position), and how to go about acquiring it (the methodological approach). thus, the influence of the ontological and epistemological position on what and how a topic is investigated is clear.[12] as researchers we are required to make explicit claims about how we view reality (ontology) and what constitutes knowledge (epistemology),[13] because these perspectives have a significant influence on the methodology chosen and ultimately on the outcomes of the research.[14] educational and clinical contexts differ it may initially seem as if clinical and educational contexts are similar and that the processes in both are therefore susceptible to the same methods of investigation. however, there are fundamental differences that make it difficult to see how experimental methods are appropriate in the process of evaluating learning. while it could be argued that both clinical and educational contexts represent complex (open) systems,[8] this typically conflates the clinical trial, where all variables are carefully controlled, with a health system. while health systems are complex environments, it is clear that rcts are not used to investigate complete health systems. instead, their objective is to achieve generalisable simplicity by holding all else equal and determining the effect of a single variable, the outcome of which is applicable across a variety of contexts.[10] therefore, the rct represents an attempt to create an ‘artificially closed system’[15] whereby the relationships between variables in controlled, non-complex contexts are determined.[10] this is appropriate in the positivist ontology and epistemology and is therefore the reason that the rct is an appropriate method of gathering data in clinical research. however, it is not possible to create controlled, non-complex educational environments that enable cross-context predictions.[10] randomisation does not control for other sources of variation and confounding factors that are likely to be found in educational contexts. these include for example, factors that lead to differences in studying methods, changes in learner motivation, and effects of other, non-intervention experiences that occur during the implementation of the intervention.[5] it is impossible to create a closed education system, even an ‘artificially closed system’,[15] and therefore almost impossible to identify how much of the intervention the learner actually ‘receives’, or to determine what the learner does with what the teacher provides.[6] the factors that influence learning outcomes cannot be recreated in different contexts, or even in the same context at different times.[5] education therefore exists in an open system, and even if we attempt to reduce and limit change and variation – internally and externally – we will not be able to determine causality.[15] rcts assume that every implementation of the intervention is the same, that everyone receiving the intervention will be affected in the same way, and that giving and receiving the intervention is divorced from the reality of the individual personalities and institutional contexts of the participants. in educational research it is difficult to tightly control variables and blind subjects in ways that are ethical or feasible, and one cannot ‘apply curriculum daily’ in the same way that one can prescribe medication.[5] it is therefore impossible to control for confounding variables in learning environments, making the attempt to use rcts in this context ‘hopelessly flawed’.[10] the beliefs of the researcher around the context in which the research will take place clearly inform the choice of method used to gather data, which in turn informs the outcome of the study. by conflating a clinical trial with research that seeks to determine the effectiveness of a teaching intervention on student learning, rct proponents ignore the fact that clinical and educational contexts are fundamentally different and that these differences require different methods of gathering data. we now present an argument demonstrating how beliefs around knowledge and the nature of reality may contradict our understanding of how learning happens. beliefs around reality and knowledge if one believes in an objective reality that is separate from the people conducting research into that reality, one is more likely to view knowledge as a quantity of something that is to be accumulated.[16] the belief that knowledge is separate from knowers and that it can be transmitted to others suggests that a positivist approach to educational research should be considered.[17] the focus is likely to be on using reliable and valid tools to collect quantitative data about the learning intervention that is regarded as value free.[18] positivist research maintains that knowledge is objective, that it involves hypothesis testing and identifies causality.[19] in this understanding of the world, learning is focused on the teacher and concerned largely with the transfer of information to the learner.[11] therefore, a positivist perspective on the nature of reality is most likely associated with a method of teaching and learning that considers knowledge as something that can be transferred between people. an alternative perspective on the nature of reality is that it is interpretive, subjective and different for each person.[20] in this context, knowledge is socially constructed by individuals interacting with each other and the world.[17] thus, interpretive perspectives of reality involve an attempt to understand phenomena from an individual’s perspective,[10] and consequently recognise that in certain contexts it is not possible to determine causality. instead, interpretive research focuses on trying to understand and explain reality from the unique vantage point of individuals.[21] if knowledge is socially constructed and experienced differently by individuals in different contexts, it is a conception of reality that is fundamentally at odds with positivism and therefore unlikely to be explained with positivist research methods. there are many theories that seek to explain how learning happens. regardless of which theory one adopts, they all describe an interpretation and negotiation taking place between an individual and their unique short report 8 may 2016, vol. 8, no. 1 ajhpe short report context. this understanding of learning recognises that it influences and is in turn influenced by the context[22] in a complex relationship between knowledge, the knower and knowing.[23] there is therefore a distinction between con ceptions of research that are atomistic and orientated towards external products with the intention of producing outcomes, and conceptions that are holistic and analytical with an orientation towards internal processes, where the intention is to understand.[11] if the purpose of educational research is to understand learning in a holistic way, rather than to control and predict for certain predetermined outcomes, then interpretive research methodologies may be more appropriate than experimental methods such as rcts.[9] one suggestion to move the discussion forward is for researchers to avoid the ‘methodological tribalism’ that takes up so much of our attention and to embrace a pragmatic approach to research, where we use the tool that is the best fit for the problem we are addressing.[24] conclusion rcts are not neutral methods of gathering unbiased data that describe an objective reality. they are positioned within paradigms that come with certain ontological and epistemological perspectives about the world, which seem to be at odds with ontological and epistemological perspectives of learning. the rct requires the researcher to adopt a particular stance in terms of their beliefs about the world, which is in contrast with our understanding about how learning happens. to use rcts in educational research, we are forced to assume a positivist view of the world in which the learning context must be simplified and controlled, rather than accepting the complexity and inherent subjectivity of the nature of learning, and working in it. the use of the rct in educational research is therefore a flawed design choice, as it betrays a flawed understanding of the nature of learning. it requires us to accept that there exists a set of ‘correct conditions’, and that by controlling for the ‘right’ variables we are able to control learning in the same way that we control clinical trials. the problem with rcts in educational research is therefore not only that they may be ineffective and impractical when determining the value of a learning intervention, but that they also force us to take up ontological and epistemological positions in a technical rationalist framework that perceives the world as having a single truth, which is inconsistent with a real understanding of learning. references 1. sackett dl, rosenberg wmc, gray jam, richardson ws. evidence based medicine: what it is and what it isn’t. bmj 1996;312:71-72. 2. biesta gjj. why ‘what works’ still won’t work: from evidence-based education to value-based education. studies in philosophy and education 2010;29(5):491-503. 3. dimitriadis g. revisiting the question of evidence. cultural studies – critical methodologies 2008;8(1):3-14. 4. chalmers tc, smith h jr, blackburn b, et al. a method for assessing the quality of a randomised control trial. control clin trials 1981;2(1):31-49. 5. sullivan gm. getting off the ‘gold standard’: randomized controlled trials and education research. j grad med educ 2011;3(3):285-289. 6. norman g. rct = results confounded and trivial: the perils of grand educational experiments. med educ 2003;37:582-584. 7. goldacre b. building evidence into education. department for education, london. 2013. https://www.gov.uk/ government/news/building-evidence-into-education (accessed 6 january 2016). 8. torgerson cj. educational research and randomised trials. med educ 2002;36:1002-1003. 9. denzin nk. the elephant in the living room: or extending the conversation about the politics of evidence. qualitative research 2009;9(2):139-160. 10. regehr g. it’s not rocket science: rethinking our metaphors for research in health professions education. med educ 2010;44:31-39. [http://dx.doi.org/10.1111/j.1365-2923.2009.03418.x] 11. brew a. teaching and research: new relationships and their implications for inquiry-based teaching and learning in higher education. higher education research and development 2003;22:3-18. 12. grix j. the foundations of research. london: palgrave macmillan, 2004. 13. maton k, moore r. social realism, knowledge and the sociology of education – coalitions of the mind. london: continuum international publishing group, 2010:1-13. 14. jackson e. choosing a methodology: philosophical underpinning. practitioner research in higher education journal 2013;7(1):49-62. 15. danermark b, ekstrom m, jakobsen l, karlsson jc. explaining society: critical realism in the social sciences. london: routledge, 2002. 16. mourad rp jr. postmodern philosophical critique and the pursuit of knowledge in higher education. westport, ct: bergin and garvey, 1997. 17. crotty m. the foundations of social research. london: sage, 1998. 18. house e. realism in research. educ res 1991;20(6):2-25. 19. creswell jw. research design: qualitative and mixed methods approaches. london: sage, 2009. 20. guba eg, lincoln ys. competing paradigms in qualitative research. in: denzin nk, lincoln ys, eds. handbook of qualitative research. london: sage, 1994;105-117. 21. cohen l, manion l, morrison k. research methods in education. 6th ed. london: routledge, 2007. 22. marton f, hounsell d, entwistle n. the experience of learning, 2nd ed. edinburgh: scottish academic press, 1997. 23. maton k. knowledge-knower structures in intellectual and educational fields. in: christie f, martin j, eds. language, knowledge and pedagogy: functional linguistics and sociological perspectives. london: continuum, 2007:87-108. 24. lamont m, swidler a. methodological pluralism and the possibilities and limits of interviewing. qualitative sociology 2014;37:153-171. research may 2016, vol. 8, no. 1 ajhpe 25 if one can compare deanship to an atom, then the focus in the literature is on the physical manifestations of deanship as a source of support, funding and problem solving rather than the nucleus.[1-3] this article outlines some insights into deanship that emerged as a result of the first author’s exploration of teaching public health in the medical curriculum. in exploring the inclusion of public health, the serendipitous understanding of what it entails to hold a medical curriculum together for a vice dean (vd) of medicine in a south african (sa) university surfaced. at this particular university, the chairperson of the school of medicine (similar to dentistry) also holds the position of the vd of medicine. the two remaining schools, healthcare sciences and public health, do not have vds. it is the second of these two schools that, although a postgraduate school, is responsible for the inclusion of public health in the undergraduate medical curriculum. one consequence of this separation between a school of public health and a school of medicine is that although the responsibility for the inclusion of public health rests with one school, the students and the curriculum in which public health is included are those of another school. the series of interviews with the vd were conducted with the primary intention of better understanding the original curricular intentions, curricular development and current inclusion of the public health curriculum in the medical curriculum. among the journal articles that focus on deans of medicine, the emphasis is on the qualifications, competence, abilities and personal qualities. qualifications and experience deans of medicine are usually described as being medical specialists with a reputation in clinical expertise and research in their field of expertise. deans usually come from mainstream specialties such as internal medicine, surgery, and obstetrics and gynaecology, and are often appointed in their fifties.[2] the professional pathway followed by the dean is immaterial (academic, clinical or administrative).[2] however, the most common criteria used in the selection of deans (excellence in clinical practice and research) are insufficient in themselves to fulfil the leadership role. leadership and management competencies various understandings exist on what constitutes leadership and management practice. the purpose in this article is not to engage in the debate on leadership and management, but rather to highlight how both are considered desirable attributes. the management and leadership competencies described by rich et al.[4] are based on a comprehensive review of 33 sources, but it is the need to create a common vision that is of particular interest.[1,2,4] medicine focuses on decision-making at the individual physician-patient level. leadership necessarily involves stepping away from this relationship and examining problems at a systems level, requiring the ability to view issues broadly and systemically.[5] at the nucleus of systems thinking is the ability ‘to balance the interests of several conflicting interests with an ultimate focus on the benefit of the institution as a whole’.[2] also popular in the literature are the desirable skills and abilities required. skills and abilities the differences between skills or abilities are, again, better debated elsewhere, but what is clear is that a wide range of both is required. the literature suggests that the skills required to create common goals of communal achievement include patience, persuasion, communication and background. the literature on deans of medicine focuses mostly on the qualifications, roles, abilities, management and leadership competence of the deans. the gap between theory and practice is, however, the nucleus of the position. objectives. to describe insights into the educational forces that act on a dean of medicine and the implications for those who wish to bring about change – in this case, changes in the inclusion of public health in the medical curriculum. methods. a series of in-depth interviews of a vice dean (vd) of medicine was conducted over a period of a year. the interviews were transcribed. initial in-depth analysis of the transcriptions was done using open coding, prior to a second round of coding that resulted in themes. results. the interviews revealed a serendipitous aspect, namely the ontological realities of the vd’s practice. this practice is characterised by balancing multiple internal and external forces, such as the breadth and depth of the curriculum that acts on the medical curriculum. conclusion. the ontological realities of the vd bring to life the qualifications and leadership, and management competence, roles and abilities described in the literature. the multiple – often opposing – educational choices that deans face are an inescapable reality of deanship. medical deans must balance these opposing forces to ensure fusion within the curriculum, and those interested in changes, such as strengthening the teaching of public health in this curriculum, need to plan on how to overcome this. afr j health professions educ 2016;8(1):25-29. doi:10.7196/ajhpe.2016.v8i1.474 balancing the educational choices in the decision-making of a dean of medicine: fission or fusion? j e wolvaardt,1 bcur, mph, pgche, phd; b g lindeque,2 mb chb, mmed, md, gkog; p h du toit,3 ba, hed, ba hons, med, dti, phd 1 school of health systems and public health, faculty of health sciences, university of pretoria, south africa 2 school of medicine, faculty of health sciences, university of pretoria, south africa 3 department of humanities education, faculty of education, university of pretoria, south africa corresponding author: j e wolvaardt (liz.wolvaardt@up.ac.za) research 26 may 2016, vol. 8, no. 1 ajhpe interpersonal skills.[2,6] patience is required not only in the act of persuading others, but as a more generic ability to tolerate ambiguity – an inescapable reality of management, but not necessarily of doctors in the diagnostic process.[2] despite working within a management environment that has few diagnostic tests, the dean is nevertheless expected to ‘act decisively, and achieve an appropriate balance between flexibility and assertiveness’.[2] interpersonal skills identified include diplomacy, and communication skills including listening skills, facilitation and spiritual sensitivity.[2] among the professional and technical management skills, fiscal expertise, planning, problem-solving, organising, and administering are just a few.[2] these skills and abilities of the envisaged successful dean overlap with the personal qualities that are needed to fulfil the role(s). roles and personal qualities among the plethora of roles, the primary roles of the dean are to ensure that the medical school flourishes and to foster a deeper understanding of why it is important to flourish.[2] successful deans are described as having high professional competence combined with human relation skills and the ability to administer a complex programme, and personal qualities, such as openness and objectivity.[2,6] the personal qualities of honesty and integrity, and the ability to address conflict of interest so that decisions are fair, consistent and transparent, are valued, as well as ‘tenacity, stamina, longterm wisdom, emotional intelligence … equanimity’.[1] it is surprising that we have any who meet these criteria listed in the literature. the aim of this article is to highlight the often opposing educational choices an experienced dean of medicine faces – a key consideration for those who wish to bring about change in the curriculum. methods a constructive grounded approach using qualitative methods, as described by charmaz,[7] was used. the longitudinal series of interviews formed part of the first author’s action research design,[8] aimed at her professional development. ethical considerations ethical approval for the overarching study of exploring the inclusion of public health in the medical curriculum was granted by the university of pretoria’s faculty of education ethics committee (hs10/05/01). written informed consent for the interviews was obtained from the vd. data gathering qualitative data were obtained through a series of three semistructured in-depth interviews over the period of a year. each interview with the vd started with a trigger question: • interview one: what is the next big idea in medical education? (academic medicine question of the year, 2011) • interview two: the health professions council of south africa (hpcsa) regulations refer to having medical public health as a prominent curriculum theme. so what do you think they envisage/want with this inclusion? • interview three: so what roles (for our medical students) do we consider ideal? the interviews were exploratory and dialectic in nature and were videotaped for transcription by an expert. the transcription was checked by the first author as the interviewer, and member-checked by the vd. an initial in-depth analysis of the transcriptions was done using open coding, and a constant comparative method suggested by tesch[9] was used to form and delineate categories, and to discover patterns in the data. the second round of coding included axial coding that resulted in themes. a software package for qualitative data (nvivo 8) was used for data management. agreement of the themes was reached through discussion between the authors. crystallisation in this research, crystallisation replaced triangulation, as triangulation implies that the outcome is a fixed position. in contrast, crystallisation allows a ‘more complex and deeper understanding of the phenomenon’.[10] crystallisation was ensured by inviting other specialists in deanship in health sciences to peer review this article. these experts were a current dean of medicine from another african university, a vd of research and a director of a school of medicine from two other sa universities, and a senior experienced academic from another institution who had never been a dean or vd. the participants were asked to critically read the article and to reflect whether the account is an authentic reflection of their own reality, and also to identify any additional educational forces that influence their decision-making in education. results the core theme that emerged from the text is that of constant pressure of often-conflicting interests. this main theme is supported by six subthemes: • balancing those who use blocking strokes and those who hit for the boundary in education • balancing the breadth and depth of the curriculum • balancing the interests of the many and the interests of the few • balancing the individual focus and population focus • balancing teaching in the academic complexes and in the field • balancing international and local realities. to represent the complexity of medical education, extensive use is made of verbatim text as the authentic voice of the vd.[11] balancing those who use blocking strokes and those who hit for the boundary in education the profiles of academic staff include those who model their teaching practice on their own experience as undergraduate students so that ‘we still have some people who read from a textbook’. these members of the academic team are ‘just … blocking like we were taught before …’ using predictable serviceable classroom techniques of lecturing. but the milieu has changed and as a result there are those who have been included in the team who are engaged in their educational practice as well as their clinical practice, and who are using educational strategies that, in effect, have changed the game: ‘in the modern game of cricket everything has changed. because i think you are right. i think that some of the people who are out there batting, who are teaching the students, who were taught in a conventional sense and their game … is no longer adequate for the challenges at hand. we have to devise new strokes … .’ but the challenge of combining traditional and modern styles of teaching fades in the face of the major challenge of deciding the breadth and depth of the curriculum. research may 2016, vol. 8, no. 1 ajhpe 27 balancing the breadth and depth of the curriculum each school of medicine has to decide on what must be included in the curriculum, and how much time each inclusion will have. ‘historically, when i was a medical student, um, the curriculum was driven by what the lecturers thought the students should know. so it was totally a lecturercentred thing, giving us a story and, in fact, they dictated so we had to write down. so that has soon been replaced then by a sort of a student-centred thing where we … identify themes and the students must solve problems.’ although the curriculum is no longer characterised by what the academic staff consider important on the day, there is still a balance to be struck between the breadth and the depth. ‘in the us you have all these [clinical] offices next to one another … but here we have hundreds of kilometres between people, so that is quite difficult. so wide, wide knowledge, but not necessarily deep, means that they [the students] must be able to recognise and not necessarily be able to deal with everything … we use what we call the nijmegen criteria.’ the nijmegen criteria that provide a typology for the levels of knowledge and skills required by a student are useful to curtail dominance of any particular academic staff member’s personal research or clinical interest within the curriculum. ‘our motto says, a wide but not necessarily deep … and the depth varies with the different conditions. it’s a bit like the seabed. wide, however, is essential because they are out there in the field. so that is why we expose them to 18 blocks, 13 special activities and 12 exit rotations as a final-year student and that defines the width.’ but this decision also comes at a price: ‘… that means that we spread the marmite very thin on the bread.’ the decision to focus on ‘messages of the reality and not necessarily the messages of complete academic theory’ is not necessarily met with universal approval, in that ‘in most people’s hearts there is a desire to cover everything.’ clearly, these curricular decisions have to be reinforced to work against the desire to have saturation of theory as ‘the not … not covering everything is also a new thing that we have to work on’ and this constant balancing results in a changing stability ‘so there is evolution all the time’. but it is not the constant struggle for balance between breadth and depth of the curriculum alone that is the cause of the vd’s insomnia: ‘my difficulty does not come with the departments or the blocks that have a standardised programme. my difficulty is those who still make use of whatever patient is in the ward.’ the pull of the past curriculum can still be felt in the present curriculum: ‘my personal favourite is that while in this curriculum, we still have one lecture for prostate cancer, which is the leading cancer of men and one lecture of cervix cancer, which is the leading cancer of women and while we have one lecture for heart attack … we spend a week on the krebs cycle, which nobody has actually seen.’ the push and pull continues also with placing blocks within the curriculum, with slots within the senior years more desirable than the early years: ‘not everybody can have the students for the last block … everybody would like that.’ a primary intention of the medical curriculum is that the learning experience will prepare students for professional practice, and while not all can be achieved within the curriculum alone, the curriculum needs to anticipate a future reality. balancing the known with the unknown: ‘… so, the preparing for the hardness of a community service, we expose them to that but in a controlled way and we hope that the concept of width with a varying degree of depth with increasing competencies in the intern year, will allow them to be properly armed for the whole thing.’ balancing the interests of the many and the interests of the few the global consensus on social accountability considers the priority health concerns of the community as the departure point for education, research and service delivery.[12] however, the priority needs of the community (or the many) are not necessarily in line with the scientific interests of the academic staff members (or the few). even within the lecture halls, this tension between what students need to know (the common) v. what is cutting-edge science, is played out: ‘listen, the wheel keeps on turning and … now we know a lot of things. we know about the human genome. we know about multidrug-resistant [tuberculosis] tb. we know about all those things but your training should reflect what’s happening in your community.’ this strain is not felt by academic staff alone: ‘and the student on the other side sits there and i think everything weighs kind of equally. gynaecology – we see one new patient with cervix cancer every day and most days more than one new patient with cervix cancer, which is, which is … a lot. and we see about one patient with cancer of the fallopian tube every third of a year. so we might see three a year. yet the students will take the two chapters in the book as equivalent.’ the central anchoring point is to ensure a ‘new commitment for a gain for relevance [to undergraduates]’ and part of this striving for relevance is the inclusion of public health in the curriculum. balancing the individual focus and population focus the debate surrounding the inclusion of a population focus, such as public health, in the curriculum that focuses on individuals, is well summarised.[13] the decision of the hpcsa to include public health in the medical curriculum renders the decision moot. what remains, however, is not ‘should we’ but questions of ‘how’, ‘when’ and ‘why’? it was this inclusion that was of primary interest for the interviews and it became clear that there has been some evolution in the curriculum: ‘but that is basic sort of old-style public health, where you get health inspectors and that sort of stuff … we have moved on.’ the status of the health of the public now serves to inform the medical curriculum: ‘we have an epidemic of trauma and, uh, violence … that can only be known if you look at what is happening in the community and from there on, the competencies should be designed to deal with crises and so on, uh, with lesser events. which doesn’t mean that we shouldn’t tell them about addison’s disease or something that happens rarely.’ this role of public health, not only to inform, but also to interpret, is elaborated on: research 28 may 2016, vol. 8, no. 1 ajhpe ‘… public health medicine must tell us what is happening, what it’s prioritising and what is the context and hopefully that will lead to a complete understanding of where we are.’ among the myriad decisions that surround the inclusion of public health, none are so central than whether to embed public health in mainstream medical teaching or encapsulate public health in one or more stand-alone modules/blocks/activities. the inclusion to embed public health relies on the academic staff from the school of medicine feeling able to include a population perspective. ‘so if we talk about cervix cancer, i’m supposed to give a public perspective as well as not.’ one negative design effect of embedding public health is that it is then virtually impossible to evaluate the inclusion and this in turn is problematic in an environment that requires evidence of the inclusion for accreditation purposes: ‘on the other hand, one of the things that we have to be comfortable with is whether … it’s … this behind the scenes and visible work … so to be rated on something that is behind the scenes will lead to a limited yield.’ balancing teaching in the academic complexes and in the field in sa, filling clinical posts outside the metropolitan areas is notoriously difficult and finding those who are then also prepared to support students at these teaching sites is a constant headache: ‘so at least there is one teacher per hospital where the students go who have actually said, “i am prepared to take part in this process as a teacher”. better than that in our social economic situation, and our staff situation, is pretty hard to get.’ difficult or not, this imperative of widening the training platforms is unavoidable, and is driven by trends in medical education, rising student numbers and the need to reduce the dominance of hospital-centric training for students. this dispersed model of training brings about an additional tension, that of involving others: ‘ah, the hard thing is that we then delegate our in loco parentis responsibility to people who are very far from us, and who are not necessarily buying into the system of being a teacher.’ in many cases, the health professionals in question are not fellow medical colleagues: ‘… so the sisters in the clinics don’t see these visits that the kids come and do every two weeks and … they say “oh, here they are again and we already have 300 people waiting here.” so that’s a hard match at the moment.’ an additional strain is that of content in the field: ‘community-based teaching, where the students are predominantly trained in the community, depends on a principle that they will see what they need to see because they are there.’ but the ability to handle ambiguity is a key ability for a dean, not the average medical student. the counterweight argument of student support, through guided reflection of these community experiences, is then yet another factor to consider. if support of the students in training is not problematic enough, then preparation of students to cope beyond the reach of support is almost unimaginable. much of the clinical practice and experience required for final professional registration takes place in the community-service years. but reality is somewhat different from expectations in that ‘… they work then in the state sector which was supposed to be a comm[unity] serv[ice] year under supervision but that has been abandoned because there is no supervision. so they now work within the constraints of what they are presented with … and that means that there is not necessarily an expected growth in procedural competencies.’ balancing international and local realities the commissioned lancet article outlined what international authors consider the third reform period in medical education.[14] what is important in the context of this article is not the content of that reform, but the acknowledgement that these sentinel theories expand our local thinking about medical education. one example is the question of whether to make use of interprofessional education: ‘i’m not sure that that’s the ideal myself because … any programme that you enter, you have to have … a prime knowledge. so, if the knowledge base of all the professions is the same, then it’s pretty easy to go into a joint programme. if the knowledge bases are different or if the expectations or the objectives are different, you will have a staggered, non-equal outcome of a joint thing.’ resisting the attraction of opting for the simple adoption of international educational strategies is the messy complexity of our local reality. we are: ‘… still developing [as] an evolutionary system [where] patient numbers is a strength, it is not a problem. we all have our own problems, it is just ours seem less exotic so that it is a dangerous phenomenon to think that if you talk about great things that they see on the tv, then they think that this is the real thing, whereas the rest, the bread and buttery sort of stuff, might not be regarded as important.’ feedback from the critical readers supports this authentic account of the experience of being a dean or vd of medicine, with one respondent who added two additional sources of tension: the demands of the department of health as the employer and the demands of the regulatory bodies. summary this article outlines a complex picture of forces and counterforces on the medical curriculum in general, and the energy required by the vd to bind these forces into a stable whole. there are subthemes of balancing: those who use blocking strokes and those who hit for the boundary in education; the breadth and depth of the curriculum; the interests of the many and the interests of the few; the individual focus and population focus; teaching in the academic complexes and in the field; and international and local realities. these emphasise the required systems thinking ability of the vd, who needs to balance multiple conflicting interests to benefit the institution.[2] the ontological reality of the vd in this research brings to life the qualifications, experience, leadership and management skills, and roles and abilities, described in the literature. while leadership and support of the dean are necessary for enhancing the teaching of public health,[15] the complex forces of often-opposing educational choices is a significant factor to effect change. the literature suggests that within this reality of multiple research may 2016, vol. 8, no. 1 ajhpe 29 educational choices, the development of a common educational vision is fundamental to effecting the required changes.[1,2,4] conclusion this article is an in-depth description of the ontological reality of one vd of medicine at one medical school. through crystallisation, it became apparent that this reality is a common one for those who occupy similar positions. the forces that exert pressure on the curriculum, such as international or local realities, are an inescapable aspect of practice. similarly, deans of medicine have to strike a balance in teaching in the academic complexes and teaching in the field. the debate on the inclusion of a population focus in the individual focus of medicine should never end, and the interests of the many do not have to annihilate the interests of the few. those who wish to bring about change in any medical curriculum – in this case strengthening the teaching of public health – need to be cognizant of the pressure of educational choices that act on the dean and need to be able to create a common educational vision to justify the changes. acknowledgements. the authors would like to acknowledge the contribution of the following critical readers for their valuable input: prof. m. chidzonga, college of health sciences, university of zimbabwe; prof. n. ebrahim, director of the school of medicine, university of limpopo (medunsa), south africa; and prof. j. frantz, deputy dean of research, faculty of community and health sciences, university of the western cape, south africa. references 1. bassaw b. determinants of successful deanship. med teach 2010;32(12):1002-1006. [http://dx.doi.org/10.3109 /0142159x.2010.497821] 2. lee a, hoyle e. who would become a successful dean of faculty of medicine: academic or clinician or administrator? med teach 2002;24(6);637-641. [http://dx.doi.org/10.1080/0142159021000063970] 3. chapman j. reflections on the medical deanship. acad med 1998;73(6):654-656. [http://dx.doi.org/10.1097/00001888199806000-00011] 4. rich e, magrane d, kirch dg. qualities of the medical school dean: insights from the literature. acad med 2008;83(5):483-487. [http://dx.doi.org/10.1097/acm.0b013e31816becc9] 5. collins-nakai r. leadership in medicine. mcgill j med 2006;9(1):68-73. 6. yedidia mj. challenges to effective medical school leadership: perspectives of 22 current and former deans. acad med 1998;73(6):631-639. [http://dx.doi.org/10.1097/00001888-199806000-00007] 7. charmaz k. constructing grounded theory: a practical guide through qualitative analysis. thousand oaks, california: sage publications, 2006:123-150. 8. whitehead j, mcniff j. action research: living theory. london: sage publications, 2006. 9. tesch r. qualitative research. analysis types and software. london: falmer press, 1990. 10. nieuwenhuis j. qualitative research designs and data gathering techniques. in: maree k, ed. first steps in research. pretoria: van schaik publishers, 2007:70-97. 11. regehr g. it’s not rocket science: rethinking our metaphors for research in health professions education. med educ 2010;44(1):31-39. [http://dx.doi.org/10.1111/j.1365-2923.2009.03418.x] 12. global consensus for social accountability of medical schools, 2010. http://my.ibpinitiative.org/community. aspx?c=c5357538-ce2a-4627-94f6-6110addbe047 (accessed 22 april 2013). 13. woodward a. public health has no place in undergraduate medical education. j public health med 2004;16(4):389-392. 14. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 15. johnson i, donovan d, parboosingh j. steps to improve the teaching of public health to undergraduate medical students in canada. acad med 2008;83(4):414-418. [http://dx.doi.org/10.1097/acm.0b013e318166a8e4] research october 2014, vol. 6, no. 2, suppl 1 ajhpe 203 peer-assisted learning (pal) is well described in the literature as an effective collaborative teaching strategy to aid the development of knowledge and skills through deliberate helping and supporting among equals or matched cohorts.[1] one of the main reasons cited for this is that students are perceived as equals and identify more easily with student tutors; this also assists with gaining confidence when engaging in learning material with one another.[2] lockspeiser et al.[3] proposed a ‘cognitive congruence hypothesis’ which states that a teacher with a similar knowledge base to the learner is more effective than one who is an expert in the field but with a disparate knowledge base. a near-peer, a senior student who is one or more years senior in training to more junior students,[4] may better understand the challenges students face, and could therefore explain concepts in a more appropriate manner and offer an alternative method for studying.[5] the described benefits related to pal are, however, not always the primary rationale for implementing this mode of teaching and learning. a study by haist et al.[6] showed that replacing medical faculty teachers with senior medical students did not compromise the learning of the students. similarly, pal of technical skills in a skills laboratory has been shown to be as effective as training provided by experienced faculty.[7] this evidence is frequently used to motivate for introducing pal or peer teaching and learning (ptl) to help lighten teaching workloads for faculty.[5] this is especially true where resources are limited and where there is a growing demand for training more health professionals to deal with the increasing burden of disease.[1,8] the potential benefits of pal for the tutors themselves are also increasingly being reported. consolidating own-learnt knowledge and refining (automating) skills,[1] development of leadership skills, increased social interaction and increased managerial skills[9] have all been reported in the literature. following their review of the medical education literature, ten cate and durning[5] identified that using the analogy of the guild concept, with the intermediate (journeyman) between the student (apprentice) and the health professional (master) is a valuable but underrecognised source of education in medicine. the opportunity to teach others what they have learnt recently consolidates own knowledge and prepares them for further cognitive development. this practice of peer teaching especially prepares students for their role as health educators, a graduate attribute stipulated in most competency charters for health professionals.[11] owing to increasing student numbers and financial constraints, pal tutorials were introduced and implemented as part of a second-year module to assist with practising manual physiotherapy techniques. the tutors (who were in their third year of study) were deemed suitable as they had already begun to use these techniques in clinical practice. tutors were trained prior to the implementation of the tutorial programme by the centre for teaching and learning (ctl) at stellenbosch university (su). their training included cooperative learning principles and facilitation skills. the tutors were also mentored by staff members as an extra strategy to support background. a near-peer tutorial system was introduced and implemented as part of a second-year module to assist physiotherapy students with the practising of manual techniques. although not the primary drive for initiating this system, there are potential added benefits for the tutor reported in the literature. objective. to determine the effect of near-peer teaching on the perceptions undergraduate physiotherapy students have of their own learning. methods. a descriptive study utilising mixed methods was used. a pre-tutorial focus group discussion (fgd) format explored the expectations and perceptions of tutors’ own abilities and the proposed tutorial system. the researchers conducted a post-tutorial fgd to explore the experiences and perceptions of the tutors’ learning experiences. the responses were transcribed and analysed using deductive thematic analysis. a questionnaire was used to quantify which competencies or skills student tutors thought they had obtained through the facilitation of the tutorial sessions. the results were explored using a competency framework. results. all ten tutors in the 2012 programme participated in the study. students moved from unconscious incompetence to conscious incompetence, and seemed to have reached the phase of conscious competence by the end of the programme. unconscious competence was not observed. more than half of the tutors agreed that the programme had a positive impact on their communication, ability to transfer skills and their own understanding of techniques and underlying theory, while two tutors felt that the programme did not improve their own theoretical basis of techniques. conclusion. participating and functioning as near-peer tutors had a positive influence on physiotherapy students’ perceptions of their own learning both in terms of own clinical technique competency, but also as teachers and facilitators of learning. it is hypothesised that these students will transition effectively between clinician and health advocator/teacher. ajhpe 2014;6(2 suppl 1):203-206. doi:10.7196/ajhpe.497 teaching my peers: perceptions of tutors in physiotherapy practical skills training m unger,1 bphyst, msc (physio), phd; l keiller,2 bsc (physio), mphil (hse); g inglis-jassiem,1 bsc (physio), msc (physio); s d hanekom,1 bsc (physio), msc (physio), phd 1 division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 centre for learning technology, stellenbosch university, cape town, south africa corresponding author: m unger (munger@sun.ac.za) research 204 october 2014, vol. 6, no. 2, suppl 1 ajhpe their role as tutors. although the primary drive for this initiative was to guarantee successful student throughput in an undergraduate physiotherapy curriculum, it was hoped that tutors would also benefit in that their own communication, listening, leadership, and skills-transfer abilities would improve. the aim of this paper is to describe the effect of student-facilitated tutorials on tutors’ perception of their own learning. methods this descriptive study utilised both qualitative and quantitative data collection methods. ethical approval was granted by the su health research ethics committee (n12/04/018). informed consent from all 2012 third-year tutors was obtained. data collection and analysis two semi-structured interview schedules were used for focus group discussion (fgd) with the tutors. a pre-tutorial fgd explored the expectations and perceptions of the new format of teaching and tutors’ own abilities. the post-tutorial fgd explored tutors’ experiences and perceptions of their own learning. these fgds were conducted by the same researcher. in addition, a questionnaire was developed by the research team in collaboration with ctl to determine tutors’ perceptions of their own learning, and this was completed at the end of the programme. the questionnaire was piloted for face validity. the self-assessment questionnaire required tutors to indicate which competencies or skills they had developed through facilitation of the tutorial sessions. these skills pertained to communication, listening, leadership, helping, social and skills-transfer abilities. tutors were asked to rate their skills in these domains on a fivepoint likert scale (ranging from strongly disagree to strongly agree). they were also asked to rate whether their own understanding of the practical technique and the theory underpinning these techniques had improved. fgds were audiotaped and transcribed. these transcriptions were deductively analysed independently by two researchers to determine the main themes. the data from the questionnaires were graphically presented and the total number of responses for each category was determined. results all ten tutors in the 2012 programme participated in the study. from the pre-tutorial fgds, three themes emerged. tutors had a tendency to focus on their concerns regarding competence, confidence and the logistics of the programme. they also verbalised their perceptions of how the programme might impact on themselves as well as the tutees. in the post-tutorial fgd, the themes which emerged highlighted the resolution of the concerns regarding competence, and focused more on the impact of the tutorial programme on their own competencies and skills. tutors also identified additional benefits relating to relationship building, leadership skills development and the importance of time management. pre-tutorial fgd there were tutors who perceived themselves to be responsible for the learning of their peers, some of whom were confident that they had the necessary knowledge to do so and some who expressed anxiety at the perceived high level of responsibility. they reported concerns that adaptations in the clinical setting of techniques learnt in the classroom would influence their tutoring. tutors expressed concern that this might confuse the secondyear students not yet exposed to the clinical environment. although tutors expected to function as facilitators and not as teachers of new techniques, they still expressed concern regarding accuracy and consistency across the tutorial groups. with regard to the benefits of the programme, tutors believed that it would benefit their own learning because of the forced revision of the techniques, as well as positively contributing to the tutees through individual attention and immediate feedback. their ability to position these techniques through mentoring, in the context of the broader programme for the tutees, was also seen as a potential benefit. this mentor role within this less intimidating environment would also contribute to relationshipbuilding between year groups. post-tutorial fgd tutors recognised that learning styles of tutees differed and perceived a need to adapt their teaching style to the different needs of their tutees. ‘so there are people like me out there who learn better from having it done on ourselves and there are other people who learn by doing it, and there are other people who learn by watching.’ similarly, students reported that they were able to pass on knowledge and skills in a contextualised manner and that this contributed to more effective learning. tutors realised where they had gaps in their own learning and could address these accordingly while seeing an improvement in their own performance in clinical practice. ‘i remember the next day when i went to clinical, i had a patient that i needed to do that on and we had just done it the day before. i probably wouldn’t have remembered properly if i hadn’t done it again with the second years.’ another comment – ‘i think it helped me in that i could better explain the effect of the techniques to my own patients now’ [translated] – further supports the overflow into their own clinical practice. perceptions of tutors were that this process allowed them to develop deeper relationships with their peers, as well as between year groups, and this allowed them to learn from each other. ‘you feel a deeper connection to students because you have helped them and have seen them more…’ [translated] and ‘but getting to know some of the others, some from the other groups now also stop me in the passage and feel free to ask me questions, they know who we are’ are comments suggesting the value of these relationships. one tutor commented, ‘i would have wanted [liked] someone to talk to at the end of my second year.’ they also identified the improvement of their leadership abilities as the tutorial programme progressed, which included dealing with issues of discipline and seniority. given that participating in this programme would impact on the time that they had available for their own third-year academic programme, the students recognised the importance of time management. the following comment was shared in the focus group: ‘we also have class, we also have tasks, we also have tests, and that needs to be worked out a little bit better.’ post-tutorial questionnaire while the post-tutorial questionnaire required responses to eight items, the responses to the impact on listening, helping and social skills were seemingly misunderstood by participants. fig.1 represents the students’ perceptions of how participating in this tutorial programme impacted on the remaining five items. more than 50% of the tutors agreed that the programme had a positive impact on their communication, ability to transfer skills, and their own understanding of techniques and underlying theory. only two research october 2014, vol. 6, no. 2, suppl 1 ajhpe 205 tutors felt that the programme did not improve their own theoretical basis of techniques. tutors provided comments to support their rating of each item (table 1). discussion the aim of the physiotherapy programme at su is to prepare students to cope with entry into community service. as health promotion and prevention are key aspects of primary healthcare, it is expected of healthcare professionals to spend much of their time in clinical practice as teachers. in addressing the needs of the division and those of the second-year physiotherapy students at su, this near-peer tutorial programme created a space in which students as tutors were able to grow in confidence and increase not only their own clinical skills but their competency as teachers as well. the process by which tutors have benefited from the tutorial programme can be mapped using an adapted competency framework such as the one proposed by taylor. [12] using this framework,[12] once the tutors had begun to prepare for the tutorials through training and using the manual, students moved from a phase of unconscious incompetence to one of conscious incompetence, where they realised that although they were able to adapt their skills in facilitation from a student-patient relationship to a tutor-tutee relationship, there were specific techniques and theoretical concepts that they needed to revise. the revision of techniques and theory, added to the experience they gained in the early tutorial sessions, allowed them to reach a phase of conscious competence, in which they realised that they did have the skills necessary to facilitate and explain the basic concepts and relationships needed to their junior peers. the ultimate aim would be for these students to become unconsciously competent in their teaching skills. this, however, was not yet achieved by the tutors. from the literature it seems plausible, however, that it would be a natural progression for the students to reach this stage as they continue into clinical practice. the reflective competence phase,[12] though not explicit within the process, was apparent during their participation in the study data collection phase and participation in the fgd. it demonstrated that they were able to comment and reflect on their own strengths and weaknesses as facilitators of learning. limitations the study is limited to the experiences of student tutors within our division only. concerns expressed prior to the start of the programme were shared by the full cohort. the perceived benefits of pal on their own learning and development did, however, vary among the students and warrant further investigation. conclusion functioning as near-peer tutors had a positive influence on physiotherapy students’ perceptions table 1. tutor comments supporting their rated perception of the impact of the near-peer tutorial programme communication • ‘i feel more comfortable to talk to strangers.’ [translated] • ‘i had to find new ways to explain concepts in ways that others understand it.’ • ‘i learned how to break things down to basics, to the how and why.’ [translated] leadership • ‘they had respect for me and i could just facilitate.’ [translated] • ‘we had to take charge.’ • ‘learned to take charge in the class and give guidance; it’s rather intimidating when everyone is looking at you at the same time.’ [translated] ability to transfer skills • ‘it was easy to transfer techniques, especially through demonstration.’ [translated] • ‘that you have to explain and demonstrate something and the person has to show you themselves, then you know if they understood.’ [translated] own understanding of techniques • ‘if you can explain something to someone, it means that you understand the concept yourself.’ [translated] • ‘was able to better my clinical evaluation and treatment techniques due to repetition … and explaining to others.’ • ‘was able to … [and] learn … from the students about better positions, etc.’ own understanding of theory • ‘yes; because we had to explain some of the theory behind the techniques to the students if they ask.’ • ‘it resulted in me having to read up on the theory again.’ [translated] own understanding of theory base of techniques own understanding of techniques practised ability to transfer skills leadership communication 0 2 4 6 8 10 n strongly disagree disagree neutral agree strongly agree fig. 1. student perceptions of the impact on their own learning. research 206 october 2014, vol. 6, no. 2, suppl 1 ajhpe of their own learning, both in terms of own clinical technique competency, and as teachers/facilitators of learning. further work is needed to determine whether peer-assisted learning helps graduates transition effectively between clinician and health advocator/teacher. acknowledgements. the authors would like to acknowledge the fund for innovation research in learning and teaching for funding this initiative and research. we wish to thank mrs josephine kotze for her invaluable contribution to the conceptualisation and data collection. references 1. topping kj, ehly sw. peer assisted learning: a framework for consultation. journal of educational and psychological consultation 2001;12(2):113-132. [http://dx.doi.org/10.1207/s1532768xjepc1202_03] 2. secomb j. a systematic review of peer teaching and learning in clinical education. journal of clinical nursing 2008;17(6):703-716. [http://dx.doi.org/10.1111/j.1365-2702.2007.01954.x] 3. lockspeiser tm, o’sullivan p, teherani a, muller j. understanding the experience of being taught by peers: the value of social and cognitive congruence. advances in health sciences education 2008;13(3):361-372. [http:// dx.doi.org/10.1007/s10459-006-9049-8] 4. bulte c, betts a, garner k, durning s. student teaching: views of student near-peer teachers and learners. medical teacher 2007;29(6):583-590. [http://dx.doi.org/10.1080/01421590701583824] 5. ten cate o, durning s. peer teaching in medical education: twelve reasons to move from theory to practice. medical teacher 2007;29(6):591-599. [http://dx.doi.org/10.1080/01421590701606799] 6. haist sa, wilson jf, brigham nl, fosson se, blue av. comparing fourth-year medical students with faculty in the teaching of physical examination skills to first-year students. acad med 1998;73(2):198-200. [http://dx.doi. org/10.1097/00001888-199802000-00020] 7. tolsgaard mg, gustafsson a, rasmussen mb, høiby p, müller cg, ringsted c. student teachers can be as good as associate professors in teaching clinical skills. medical teacher 2007;29(6):553-557. [http://dx.doi. org/10.1080/01421590701682550] 8. burch vc. medical education in south africa: assessment practices in a developing country. erasmus university rotterdam 2007. http://hdl.handle.net/1765/10152 (accessed august 2014). 9. wamsley ma, julian ka, wipf je. a literature review of ‘resident‐as‐teacher’ curricula. j gen intern med 2004;19(5 pt 2):574-581. [http://dx.doi.org/10.1111/j.1525-1497.2004.30116.x] 10. haber rj, bardach ns, vedanthan r, gillum la, haber la, dhaliwal gs. preparing fourth‐year medical students to teach during internship. j gen intern med 2006;21(5):518-520. [http://dx.doi.org/10.1111/j.1525-1497.2006.00441.x] 11. frank jr, snell l. the draft canmeds 2015 physician competency framework http://www.royalcollege.ca/portal/ page/portal/rc/common/documents/canmeds/framework/framework_series_1_e.pdf (accessed august 2014). 12. taylor w. the conscious competence learning model 2007. http://www.businessballs.com/ consciouscompetencelearningmodel.htm (accessed january 2014). march 2017, vol. 9, no. 1 ajhpe 9 research allied health professions programmes, in particular with regard to occupational therapy, physiotherapy, and dietetics and nutrition, share common traits in the structure of their clinical programmes. each requires clinical experience for undergraduate students, which provides valuable hands-on patient care. from an educational viewpoint, the accreditation standards of the professional bodies and institutions of higher learning, to which the clinical training programmes must adhere, are also applicable. acquiring these clinical professional skills needs clinical supervisors who must balance patient care with clinical instruction and supervision of students. one strategy adopted in nursing and medicine to address the teaching of clinical skills is peer-assisted learning (pal), which is well documented in especially nursing training programmes.[1-3] informal pal has been practised for many years among students of all health professions, while formal or planned pal became particularly prominent in medical education in recent years.[1] pal is increasingly being implemented in healthcare education for a variety of reasons, i.e. increased student numbers, teaching professional skills in a clinical setting, increasing focus on group training, and challenges with clinical supervision and placements. the literature indicates that in allied health professions pal is under-researched,[3] a view shared by sevenhuysen et al.[4] martin and edwards[5] added that although the benefits of peer learning have been well documented in the educational literature, it is less so in health professions education. pal in allied health professions is not as well documented as in medicine and nursing, although common principles are relevant for most clinical training courses. the terminology used to describe pal is often submerged under a general label,[2] such as informal teaching by senior students. for the purpose of this literature review, planned pal is defined as peer tutoring and peer learning. boud[6] describes planned pal as ‘a two way reciprocal learning activity and should involve the sharing of knowledge, ideas’. topping[7] added that pal takes place among people of similar social groupings who are not professional teachers, helping each other to learn and learning themselves by teaching. researchers are of the opinion that the benefits of this approach include reinforcement and revision of learning, provision of feedback, role-modelling, communication, appraisal and team-working skills. curriculum developers also increasingly consider pal as a vehicle to help undergraduate healthcare students learn to teach.[3] it is further argued that the peer teachers have ‘cognitive congruence’, which allows these tutors to use language that their tutees understand and to explain concepts at an appropriate level.[6,8] in the usa, a recent study of 130 medical schools indicated that 76% use students in some form of pal, and interest is growing in the field of pal in medical and allied health professions.[8] the reason for this interest is that pal can be considered to address gaps in learning after assessment, and new learning outcomes or drivers from external and political requirements. in the uk, the lack of interest among some health professionals to pursue an academic career may be due to limited teaching skills.[1] an article on the clinical education of physiotherapy students adds that the demand for clinical background. the concept of peer-assisted teaching or peer-assisted learning (pal) has been receiving more attention in the teaching of medical and allied health students. many advantages have been described in the literature, but much more research is needed. challenges with the academic platform at a specific institution of higher learning necessitate investigation into the current literature on pal, which can inform decisions in terms of teaching and learning of allied health professions students. objective. to critically appraise evidence of the effectiveness and implementation of pal during the professional clinical skills training of undergraduate students in allied health professions to make informed future decisions on teaching and learning. methods. a literature search was conducted by an experienced librarian in the faculty of health sciences, university of the free state, bloemfontein, south africa and the researcher in multiple electronic databases (medline, cinahl, africa-wide information, eric and pubmed) published from 2000 to 2014. results. one hundred and seventy-five articles on pal in health professions training were identified. the selected articles (n=20) were independently critically appraised by two researchers by means of the standardised critical appraisal skills programme (casp) and the author manuscript of the national institutes of health on appraising quantitative research in health education. nine articles were identified to be reviewed (two by the same author). conclusion. the findings with regard to the limited number of articles reviewed suggested that pal may address some of the needs of the new generation of students and may be beneficial to the student tutor, student tutee and clinical supervisor. more evidence is needed in terms of the questions arising from the review, especially with regard to occupational therapy, dietetics and nutrition, and optometry, to fully implement pal. afr j health professions educ 2017;9(1):9-12. doi:10.7196/ajhpe.2017.v9i1.588 an integrated literature review of undergraduate peer teaching in allied health professions s van vuuren, bot, mot, phd health professions education school for allied health professions and department of occupational therapy, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: s van vuuren (alliedhealthfhs@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 10 march 2017, vol. 9, no. 1 ajhpe research placements outstrips the supply of facilitators – and pal can support clinical facilitators.[3] the school for allied health professions (sahp), university of the free state, bloemfontein, south africa currently offers four undergraduate programmes, i.e. nutrition and dietetics, occupational therapy, physiotherapy, and optometry. investigation of the possibilities of pal is necessitated by several factors, such as challenges in terms of the current academic platform for different stages of clinical training, the economic advantages for both the teaching institution and clinical fieldwork areas, enhancing the teaching skills of senior students, role-modelling for junior students, and increased collegial behaviour among different groupings of students. planned pal has been implemented as a pilot project in 2013 in the department of occupational therapy as part of revisiting the current undergraduate curriculum and clinical training platforms. another department is also investi gating the possibilities to enhance the quality of teaching and learning owing to increased institutional research, other expectations of staff, and challenges with the availability of clinical supervisors in the public health sector. to assume that pal will add to addressing these challenges, further investigation of the literature is necessary, as the best available evidence will inform/confirm current and future clinical teaching decisions regarding the training programmes in sahp. objective this integrated literature review was done by the researcher to appraise findings of the effectiveness and implementation of pal (peer tutoring and peer learning) during the training of undergraduate students in allied health professions in professional clinical skills, contributing to informed future decisions on teaching and learning. the purpose of the literature review was to identify: (i) pal in allied health profession programmes – professions that adopted pal and level of students involved; (ii) the dimensions of pal, which included training of tutors and tutees; formality of teaching encounter; evaluation of tutor and tutee; group size; outcome related to knowledge, skills and attitudes of tutors and tutees; strategies enabling implementation of pal; and recommendations to improve pal.[1,2,8] methods a literature search was conducted by an experienced librarian in the faculty of health sciences and the researcher in multiple electronic databases (medline, cinahl, africa-wide information, eric and pubmed) from 2000 to 2014. the following keywords and phrases were used: peer-assisted teaching health sciences; pal and undergraduate allied health professions; pal and occupational therapy; pal and physiotherapy; pal and nutrition and dietetics; and pal and optometry. one hundred and seventy-five articles on peer-assisted learning in health professions training were identified. the selection criteria for the final review were as follows: • articles on pal for allied health professions undergraduate students as a group • articles on pal applicable to undergraduate students in nutrition and dietetics, occupational therapy, optometry and physiotherapy • pal teaching clinical professional skills • full-text articles published in english • articles of qualitative and quantitative nature • articles related to undergraduate training. the selected articles (n=20) were independently critically appraised by two researchers by means of the standardised critical appraisal skills programme (casp),[9] and the author manuscript of the national institutes of health on appraising quantitative research in health education.[10] eight articles were identified to be reviewed. these nine articles referred only to occupational therapy and physiotherapy programmes. no research articles on pal in nutrition and dietetics or optometry were retrieved. the other 12 articles were excluded as they described blogging and not person-to-person learning; pal relating to postgraduate students and theory; collaborative learning (group work and problem-based learning); collaborative supervision models that included principles different from those of pal; pal in other professional groups; and peer support, mini literature descriptions and collaborative group support. ethical approval for the study was obtained from the faculty of health sciences ethics committee according to faculty research policy (ref. no. eufs 182/2014). results this review was unable to provide conclusive evidence on pal in allied health professions owing to the small number of relevant articles, lack of articles on nutrition and dietetics and optometry, difference in sample size, study population, and duration of implementation of pal. the majority of the articles reflected pal of physiotherapy undergraduate students. however, the articles reviewed agreed on most of the principles of pal and can be used to guide the planning and implementation of pal. pal in allied health professions programmes two of the articles were related to occupational therapy programmes[11,12] and the remaining six to physiotherapy programmes.[13-18] this indicated that knowledge on pal in the allied health professions is limited. the level of students participating in pal indicated that experienced students mostly help inexperienced ones. using pal during the training of professional skills, the tutors and tutees should be senior students,[11,12,18] but pal could also be implemented during the first year of study in physiotherapy.[14] one article conveyed the opinion that students from the same academic year could also assist.[12] evidence is needed for occupational therapy, dietetics and nutrition, and optometry to determine at what level of their programmes pal will be most beneficial. dimensions of pal in this section the following is addressed: training of tutors and tutees; formality of the teaching encounter; evaluation of tutor and tutee; group size; outcome related to knowledge, skills and attitudes of tutors and tutees; strategies enabling implementation of pal; and recommendations to improve pal. training of tutors and tutees student preparation has frequently been cited as key for a successful pal experience. without training the tutors and tutees may not have the skills to make their collaborative relationship work.[13] it is important to be explicit about what peer learning does/does not entail, and what it intends to achieve.[14] a compulsory 2-hour tutorial session on peer coaching was hosted and students had to read an article on pal in clinical education.[13] in another study an introductory lecture was presented and a hand-out was march 2017, vol. 9, no. 1 ajhpe 11 research given that covered information on the structure, aims, benefits, guidance on the roles of tutor and tutee, and what topics should be dealt with during pal,[14] and also understanding the group process, such as leadership, conflict management, decision-making and adult learning principles.[17] during the preparation sessions, some tutors viewed pal as positive, while others felt there was nothing to gain by helping fellow students and demonstrated resentment in parting with their own knowledge,[15] or the development of competition that could result in disengagement among students.[16] the literature confirms the importance of adequate preparation of students by instructors and students to accept peer tutors.[13,14,17] ladyshewsky[16] proposed an eight-step model for the preparation of peer coaching, starting with assessment of compatibility and trust building; planning; formalising the process; defining the goals; clarifying facts and assumptions; exploring possibilities; gaining commitment to actions; offering support; and accountability. previous research demonstrated that the preparation of students during training is very important and little is known about pal in the training of other allied health professionals. research is needed by these professions to establish whether some clinical skills and fieldwork settings are more appropriate for the implementation of pal; what information should be shared with the clinical supervisors; and/or whether they need any training beforehand. formality of the teaching encounter planned peer teaching indicates that some formality during the planning and execution of formal encounters should be scheduled. findings by hammond et al.[14] showed that pal sessions should be organised and incorporated in the timetable and curriculum of students, and not be seen as an additional task, but enjoyed as self-directed tutoring sessions.[18] adequate preparation of those directly involved is necessary, which means that formal sessions for both the tutors and tutees are required and academic oversight should be maintained to ensure consistency and quality of teaching.[17] students also indicated that they felt that staff should be present at the sessions.[18] formal pal has been demonstrated to reduce demands on clinical supervisors and to improve the overall clinical experience of students.[16] evaluation of tutor and tutee feedback is essential during learning and coaching, and tutors must understand the principles of formative feedback. ladyshewsky[16] was of the opinion that feedback is difficult to administer in pal, as it often becomes evaluative and influences the experience. providing formative feedback through key coaching questions will engage tutees to reflect on their clinical reasoning and practice. this approach preserves the integrity of the relationship and strenghtens it. where pal was used for preparation of formative assessment,[15] a student who failed received immediate feedback and further practice time to rectify mistakes. it has been suggested that most student evaluation forms to be completed during clinical work should have a section on professional behaviour, and that pal of both the tutor and the tutee could be assessed in this section. the following example was given:[16] competency: professional behaviour this demonstrates appropriate commitment to learning by: • demonstrating a positive attitude (motivation) towards learning • welcoming/seeking opportunities to gain new knowledge • reviewing appropriate material related to, e.g. the clinical specialty. limited research has examined the preferences of tutors and tutees for assessment and feedback. therefore, it would be helpful to determine if there should be instances where the tutor and tutees are assessed. however, to create an environment conducive to learning for both, the author is of opinion that it should only be part of the formative assessment. only two of the articles addressed the specific evaluation during pal by means of a quantitative and a qualitative research study.[4,13] both these studies relate to physiotherapy programmes. group size the literature describes a variation in group size of 1:1, 1:2 and 1:3,[11,12,17] although current trends refer to students working in pairs, i.e. a 1:1 learning experience.[6] none of the remaining articles mentioned the group size, but referred to growing confidence of tutees as the session continued, and, taking into consideration that tutees have to master their own clinical skills, a 1:1 group size seems the most realistic.[16] outcomes of pal related to knowledge, skills and attitudes of tutors/tutees tutors peer tutoring provides students with opportunities to develop teaching support skills and enables them to function on a higher cognitive level and transfer learning to new situations.[17] these skills are very important for allied health professionals, as in many instances clients are taught new skills, exercises and precautionary measures, to name a few. understanding the principles of adult learning is also important during professional interventions; pal creates an opportunity to tutees to apply and practise these principles. teaching other students has been reported as positive; it also helped to develop their own learning and reasoning.[11-13,18] added advantages include the promotion of collegial relationships between the students,[17] and facilitating communication skills.[13,18] asghar[15] indicated that students showed sensitivity and empathy with regard to providing feedback to their peers. physiotherapy students were also of the opinion that it was an opportunity to revise their skills and even master skills that they had not mastered in previous years of training.[13,18] this approach provides an added bonus for senior students to do revision during clinical placements, as some of the skills were taught in previous years and the full programme does not have sufficient free time for revision. occupational therapy students reported that they viewed things from a different perspective after the pal sessions and it increased their confidence in their own skills.[11] the challenges described in the literature are clashes of personalities,[12] negative attitudes of tutors related to the sharing of knowledge,[15] and inconsistency in the level of support given.[11] tutees tutees’ experience of pal has been described as positive. pal allowed them to focus on learning without fear of asking basic questions and reduced stress.[12,17,18] some individuals felt more confident approaching a peer leader than a staff member with questions.[18] many of the effects on the skills, knowledge and attitudes of tutors and tutees are similar, such as the mastery of skills; transfer of learning in the classroom; improvement of communication skills and collegial relationships; and facilitation of clinical reasoning.[11-13,18] tutees were also of the opinion that the pal environment had been useful to clarify issues that 12 march 2017, vol. 9, no. 1 ajhpe research they did not understand in the formal teaching sessions, and that it fostered positive attitudes towards the subject matter.[17] challenges during pal were congruent with those experienced by tutors, except that advanced students might dominate the learning environment or competition between tutee and tutor might occur. with no regulation of the content of the sessions, the potential exists for incorrect information to be conveyed.[18] the cohort of students in health sciences are competitive by nature. it should, however, be stressed that competition is frowned upon in the current clinical practice environment, and working together as a team is necessary for today’s health professionals, which should be emphasised during this learning experience.[16] strategies enabling implementation of pal although most articles elucidated the experiences and value of pal, only one article gave a more detailed overview of the process of implementation.[16] aspects to address during implementation are facilitation of a positive interdependence between tutors and tutees; preparation of tutors in understanding adult learning principles and group processes, such as leadership, conflict management, decision-making, giving feedback, how to deliver information in a non-evaluative manner; and reflection on and evaluation of processes. individual accountability should be fostered in both the tutor and tutee. the same article[16] described the different stages and objectives in each stage of implementation. other findings with regard to implementation included compilation of a hand-out for pal,[11] careful incorporation of time in the timetable and curriculum to train and orientate the tutors and tutees,[14] collaboration of students in the writing of pre-placement packs,[12] putting a control system of qualified professionals in place to ensure consistency of dissemination of information, and ensuring a mechanism for debriefing peer tutors and to clarify queries.[17] recommendations to improve pal asking two people to coach each other does not necessarily guarantee success. although all 175 articles reported on the value of pal, more evidence-based practice and research are needed to promote tailor-made pal for a specific programme. questions still unanswered, according to the literature, include how learning is negotiated within pal sessions, and whether pal promotes informal group activities outside the classroom. ongoing investment in student support will be needed and, in addition, strategies (social media such as blogs and facebook) must be investigated to provide equivalent support to students in clinical placements outside the city to ensure parity across the whole student group.[11,14,16] limited literature on the implementation of pal in occupational therapy and other allied health professions warrants more research about the planning and implementation of pal for these programmes. although deemed a positive learning strategy in nursing and medicine with more researched evidence available, allied health professions need their own evidence to inform their decisions on clinical teaching. conclusion since 2000, little has been published on occupational therapy, dietetics and nutrition, and optometry. physiotherapy has investigated pal slightly more often, but most of the research was grounded in the work of one researcher at a specific institution of higher learning. this limited literature acknowledges the need for more research on the topic, as the majority of findings in other health professions[1,2,4-6] and the reviewed articles indicate that the value for staff, clinical placements and students’ positive experiences outweigh the challenges. insufficient clinical placements and supervision for undergraduate students in occupational therapy, physiotherapy and other allied health professions, as well as sufficient time for staff in higher education to adhere to their different roles, are a reality in the south african context. globally, there is a need for more innovative methods to teach professional skills to health professionals, in addition to the need and requirements to also give attention to other skills, such as leadership, communication skills and clinical reasoning. the findings in the limited number of articles reviewed show that pal may address some of the needs of the new generation of students and may be beneficial for the student tutor, student tutee and clinical supervisor. more evidence on the questions that arise from the review, especially with regard to occupational therapy, dietetics and nutrition, and optometry, is needed to fully implement pal. 1. ross mt, cameron hs. peer assisted learning: a planning and implementation framework. amee guide no. 30. med teach 2007;29(6):527-545. http://dx.doi.org/10.1080/01421590701665886 2. field m, burke jm, mcallister d, lloyd dm. peer-assisted learning: a novel approach to clinical skills learning for medical students. med educ 2007;41(4):411-418. http://dx.doi.org/10.1111/j.1365-2929.2007.02713.x 3. secomb j. a systematic review of peer teaching and learning in clinical education. j clin nurs 2008;17(6):703716. http://dx.doi.org/10.1111/j.1365-2702.2007.01954.x 4. sevenhuysen sl, nickson w, farlie mk, raitman l, keating jl. the development of a peer assisted learning model for the clinical education of physiotherapy students. j peer learn 2013;6:30-45. http://ro.uow.edu.au/cgi/ viewcontent.cgi?article=1068&context=ajpl (accessed 15 january 2015). 5. martin m, edwards l. peer learning on fieldwork placements. br j occupational ther 1998;61(6):249-252. http:// dx.doi.org/10.1177/030802269806100603 6. boud d. introduction: making a move to peer learning. in: boud d, cohen r, sampson j, eds. peer learning in higher education: learning from each other. london: kogan page, 2001:1-20. 7. topping kj. the effectiveness of peer tutoring in further and higher education: a typology and review of the literature. high educ 1996;32:321-345. http://dx.doi.org/10.1007/bf00138870 8. burgess a, mcgregor d, mellis c. medical students as peer tutors: a systematic review. bmc med educ 2014;14:115. http://dx.doi.org/10.1186/1472-6920-14-115 9. maden-jenkins m. casp 2006. literature searching for qualitative studies and quality appraisal. lancashire, uk: edge hill university, 2006. 10. jack l jr, hayes sc, scharalda jg, et al. appraising quantitative research in health education: guidelines for public health educators. health promotion practice 2010;11(2):161-165. http://dx.doi.org/10.1177/1524839909353023 11. daniels n. peer interactions and their benefits during occupational therapy practice placement education. br j occupational ther 2010;73(1):21-28. http://dx.doi.org/10.4276/030802210x12629548272664 12. steele-smith s, amstrong m. 'i would take more students but…’: student supervision strategies. br j occupational ther 2001;64(11):549-551. 13. ladyshewsky rk. a quasi-experimental study of the differences in performance and clinical reasoning using individual learning versus reciprocal peer coaching. physiother theory pract 2002;18(1):17-31. http://dx.doi. org/10.1080/095939802753570666 14. hammond ja, bitchell cp, jones l, bidgood p. a first year experience of student-directed peer-assisted learning. active learn high educ 2010;11(3):201-212. http://dx.doi.org/10.1177/1469787410379683 15. asghar a. reciprocal peer coaching and its use as a formative strategy for first-year students. assess eval high educ 2010;35(4):403-417. http://dx.doi.org/10.1080/02602930902862834 16. ladyshewsky rk. building co-operation in peer coaching relationships: understanding the relationships between reward structure, learner preparedness, coaching skill and learner engagement. physiotherapy 2006;92(1):4-10. http://dx.doi.org/10.1016/j.physio.2005.11.005 17. lekkas p, larsen t, kumar s, et al. no model of clinical education for physiotherapy students is superior to another: a systematic review. aust j physiother 2007;53(1):19-28. http://dx.doi.org/10.1016/s0004-9514(07)70058-2 18. sole g, rose a, bennet t, jaques k, rippon z. a student experience of peer assisted study sessions in physiotherapy. j peer learn 2012;5:42-51. http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1042&context=ajpl (accessed 6 january 2016). http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1068&context=ajpl http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1068&context=ajpl http://dx.doi.org/10.1080/095939802753570666 http://dx.doi.org/10.1080/095939802753570666 october 2016, vol. 8, no. 2, suppl 2 ajhpe 229 research interprofessional education (ipe) is a process that prepares professionals, through collaborative learning and diverse fieldwork experiences, to work in partnership with communities to meet the multifaceted needs of society.[1] it is a process that assists in providing the knowledge, skills and values needed by health professionals to collaborate effectively with other health professionals as they serve families and communities. ipe allows health professionals to overcome the lack of knowledge of basic concepts in collaboration and issues facing other professions.[2] preparing future health and social-care professionals to work together with future colleagues would assist in fostering interprofessional collaboration in the clinical setting.[3] ipe is viewed as a collaborative approach to the development of healthcare students as future interprofessional team members, and their viewpoint is based on an understanding that complex health and social challenges are best addressed by interprofessional teams.[4] however, starting an ipe programme poses unique challenges that may not be encountered when starting a more traditional, discipline-specific programme. in south africa (sa), promising developments towards transforming health professionals’ education are taking place, indicating a positive shift to ipe opportunities.[5] these developments include moving away from discipline-focused faculties to health sciences faculties that include at least two or more allied health disciplines; integration of interprofessional core courses in the undergraduate health professions curricula, which are commonly developed around health, primary healthcare, health promotion and ethics; and moving away from the teaching hospital to the teaching platform, which includes hospitals, clinics and communities. in other words, these developments comprise application of this concept to all levels of care and the extension of collaboration among faculties in the provinces, where clinical platforms are shared with provincial health authorities. various strategies are used to implement ipe and practice, including the world café methodology.[4,6] the world café process is based on seven key design principles: setting the context and understanding why groups are being brought together; creating a hospitable space that encourages trust; exploring questions that are relevant to real-life situations faced by the group; encouraging participation and connecting diverse perspectives; collectively considering the different perspectives; and, finally, sharing collective discoveries. thus, the world café can allow the collective intelligence of a group to emerge and increase people’s capacity for effective action in the pursuit of common aims. this approach has been shown to assist students in engaging with ipe.[7] this article describes the views of students with regard to the use of the world café methodology to learn about interprofessionalism in healthcare professionals. methods research setting a world café is conducted once per academic term for all senior students as part of interprofessional activities in the faculty of community and health sciences (fchs), university of the western cape (uwc), cape town, sa. the fchs had revised its undergraduate curriculum by incorporating core interdisciplinary modules into the 4-year undergraduate curriculum of its health professions programmes (physiotherapy, psychology, human ecology, complementary medicine, occupational therapy, social work, sport, recreation and exercise science, dietetics and nursing) in response to the health and social needs of society. background. interprofessional education (ipe) and practice were conceived as a means to improve quality of care by bringing together the health and social professions to learn and work collaboratively in teams. this collaboration in turn would assist in overcoming negative stereotypes, and promote an understanding and value of the roles of the different professions. objective. to highlight a specific methodology to advance the interprofessional learning of senior students across five disciplines. by sharing the views of students engaged in a world café model of ipe, the authors highlight this strategy as a new concept in instilling core competencies in students. this in turn may assist other higher education institutions in their own processes of creating interprofessional curricula opportunities. methods. the participants included senior students from university departments of physiotherapy, oral health, social work, pharmacy and nursing. at the conclusion of the world café sessions, students evaluated the process by means of a questionnaire, using associative group analysis methodology. the responses were analysed into themes according to questions posed to students in an evaluation questionnaire. results. it was evident that students understood the terminology of ipe and learnt from others in terms of their roles and responsibilities within a team. overall, students valued the experience; however, they emphasised the need for additional authentic learning opportunities throughout their student training. conclusion. it is evident that although higher education institutions create opportunities for interprofessional learning, similar opportunities need to be provided in the practice setting. afr j health professions educ 2016;8(2 suppl 2):229-233. doi:10.7196/ajhpe.2016.v8i2.844 students’ views of learning about an interprofessional world café method g c filies,1 mphil; z yassin,2 mcfs; j m frantz,3 phd 1 interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town, south africa 2 child and family studies unit, faculty of community and health sciences, university of the western cape, cape town, south africa 3 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: g c filies (gfilies@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 230 october 2016, vol. 8, no. 2, suppl 2 ajhpe research population and sampling the population consisted of undergraduate students from the fchs. an open invitation was sent to all interprofessional departmental representatives to participate in the world café initiatives. timetable slots were indicated at the beginning of the year by the co-ordinating unit, allowing departments to plan accordingly. departments that responded included nursing, physiotherapy, occupational therapy, social work, oral health, pharmacy, sports management and the school of natural medicine, which amounted to 653 students from the different professions over a 3-year period (2013 2015). not all students participated at the same time, as participation was dependent on student availability. data collection methods this article reports on the data collected through evaluative questionnaires of five disciplines (nursing, physiotherapy, oral health, pharmacy, social work) that have consistently participated in the world cafés over the 3-year period (n=171). at the end of every world café session, students evaluated the process and experience by means of a questionnaire, using the associative group analysis (aga) questionnaire (table 1). the objective of the questionnaire was for students to share what they had learnt from their engagement in the world café education activity. the questions were phrased in such a way that the students listed their responses consecutively. thus, each question would have at least three responses or phrases that were captured per participant. interprofessional world café intervention the interprofessional world café (ipwc) was designed to create an opportunity for students to have a discussion around specific cases, and incorporated the core interprofessional competencies as a measure towards collaborative practice. through brief didactic input, initial theoretical positions were introduced to students in an attempt to raise their awareness of the subject, and initiate reflection opportunities for them to consider the key concepts of ipe.[8] during the small-group discussions the learning experience was, therefore, a shared dialogue between the facilitator and students. the facilitator asked probing questions about the case study to allow student teams to develop an intervention care plan for presentation purposes to the plenary. this allowed the values and beliefs that underpinned the thoughts and statements of the students to emerge. the students could also ask questions of the facilitator and each other. the dialogue progressed interactively and the facilitator was as much a participant as a guide of the discussion.[9] tables were set up, café style, with flip chart paper covering the tables. each table was hosted by a facilitator (staff member) for the duration of the programme. dialogue was facilitated with groups of six to eight students around a specific question that aimed to generate discussion towards the development of an interprofessional care plan. coming from specific departments in the faculty, the students each brought to the table not only their disciplinary expertise but the competencies they had developed through training in their early years in ipe in such areas as collaboration. students spent 20 minutes at a table discussing a specific question, after which they moved on to another table for the next round of discussions. students were not required to remain in the same group, but were required to visit each table with a different question. students could rotate to different tables based on which questions they needed answered in the development of their understanding of interprofessional competence towards collaborative practice. at the end of the session (six 20-minute rounds of dialogue) students convened in their original groups and were given a case study with a set of questions. using all the information they had gathered from the different discussion rounds, the interprofessional student teams were then required to develop a poster presentation based on a case study, and respond to any questions from the plenary following their presentation. faculty members could use this opportunity to evaluate students as part of their clinical practice modules. data analysis this method of analysis offers an opportunity for a greater depth of content analysis.[9] the basic unit of analysis is the stimulus word or theme word.[10] as the study focused on interprofessionalism, the aga methodology aimed to explore thinking patterns and determine how the students perceived and evaluated the concept of interprofessional practice.[10] the responses were in the table 1. key questions a. using an interprofessional approach to patient care: what is the first thing that comes to mind when you think about using an interprofessional approach to patient care? what is the second thing that comes to mind when you think about using an interprofessional approach to patient care? what is the third thing that comes to mind when you think about using an interprofessional approach to patient care? b. with reference to working as part of an interdisciplinary healthcare team during your training: 1. what is the first thing that comes to mind when you think about working in an interdisciplinary team? 2. what is the second thing that comes to mind when you think about working in an interdisciplinary team? 3. what is the third thing that comes to mind when you think about working in an interdisciplinary team? c. with reference to your prior exposure to interprofessional teaching and learning activities, how does this contribute to your development as a healthcare professional? 1. what is the first benefit that comes to mind when you think about your earlier exposure and its contribution to your development as a team member? 2. what is the second benefit that comes to mind when you think about your earlier exposure and its contribution to your development as a team member? 3. what is the third benefit that comes to mind when you think about your earlier exposure and its contribution to your development as a team member? d: criteria to measure the impact of interprofessional health care (iphc). 1. list at least three criteria that should serve as indicators of success when measuring the impact of iphc. october 2016, vol. 8, no. 2, suppl 2 ajhpe 231 research form of one word or short phrases. the data were captured verbatim from the open-ended questions in a microsoft excel (usa) spreadsheet and analysed into themes, and are presented accordingly.[11] ethical clearance for the study was obtained from the uwc ethics committee (project no. 14/9/25). results the questionnaires were completed by 171 3rdand 4th-year students across five different professions, including physiotherapy (n=19), oral health (18), social work (n=24), pharmacy (n=12) and nursing (n=98). the average age of the students was 23.4 years and 84.5% of the 171 students were female. predominant clusters and verbal responses to the interprofessional learning opportunity (world café) are presented in the tables. these tables highlight the key responses, particularly those that were repeated more than once. the sections below present students’ understanding of the interprofessional approach to care – what it entailed, its benefits to the patient and the healthcare professional, and possible criteria to evaluate the impact of ipe and practice. how and what students learnt about interprofessionalism from engaging in the world café activity is also reflected below. interprofessional approach to care in response to the question that explored the students’ understanding about an interprofessional approach to care, seven common responses emerged: communication, collaboration/teamwork, competence, interdisciplinary, multidisciplinary, model of care, and shared responsibility (table 2). several students stated that an interprofessional approach entailed multiple health professionals working together in a team with a common goal to achieve their objectives. participants expressed the benefits of this model of care because it provides holistic care for the patient/family/community, it provides an approach for optimum care, and is a better model of care than the individual professional approach. collaboration and communication were considered the greatest components of an interprofessional approach to patient care. in addition, collaboration allowed for the integration of knowledge and experience of health professionals, leading to combined interventions that promoted a holistic model of care. interprofessional communication was recognised as an essential tool to facilitate discussions and interactions while enhancing team function. effective collaboration and communication were seen as contributing to the competence of health professionals, as they developed a variety of skills and mutual respect for one another while gaining knowledge about the roles and responsibilities of other health professions. competence in the skills related to a health professional was also identified as the attainment of interpersonal skills and understanding aspects such as advocacy, ethics and punctuality. despite the perceived benefits of an interprofessional approach to patient care, multidisciplinary challenges were highlighted by participants. interprofessional collaboration was identified as a challenging process between health professionals as a result of ineffective communication through the use of discipline-specific terminology, the lack of clarity of roles and responsibilities, the feeling of superiority as health professionals dispute which profession is deemed superior or the best, and the belief that effective collaboration is impossible and cannot be achieved. teamwork as part of health professionals’ education training four key themes pertaining to the question about teamwork as part of their health professions education training emerged: collaboration, roles and responsibilities, model of care, and a multidisciplinary approach to care (table 3). collaboration was identified as an essential component in health professionals’ education training, as participants recognised the need for other professionals’ assistance and the promotion of good health. similarly, roles and responsibilities were also deemed pertinent to the theme of teamwork and involved sharing of the responsibilities associated with patient care. each health professional, as part of the interdisciplinary team, is needed, as they play a significant role in patient management and care required for the restoration of optimal health. additionally, each disciplinary expert possesses knowledge and various skills needed for the diagnosis and treatment of a patient. interprofessional teaching and learning activities and their contribution to the development of future healthcare professionals interprofessional teaching and learning activities were identified as contributing to the development of competence and skills, improved understanding and improved knowledge of participants (table 4). participants demonstrated table 2. benefits of using an interprofessional approach of care predominant clusters verbal responses communication communication and respect, teamwork and communication, effective communication, good communication, educating the patients competence respect for other health professionals, variety of skills, integration of skills, responsibility, mutual respect, knowledge of the professions, interpersonal skills, understanding each other, advocacy, ethics, punctuality collaboration/teamwork collaborative input to patient care, collaboration with different disciplines, collaboration of health professionals in the treatment of a patient, teamwork interdisciplinary management of the patient’s condition by getting help from other professions, working towards a common goal – treatment of patient, sharing and working towards a common goal model of care holistic care of patient, the patient will receive holistic care, better model of care, holistic approach, optimum patient care multidisciplinary taking care of the patient’s health needs as a multidisciplinary team, working together as different professionals, working together to promote health shared responsibility each person in a team takes different responsibilities for giving care, different roles and responsibilities of professionals, each person in the team providing their field of expertise, sharing of workload multidisciplinary challenges challenging process between professionals, differences of opinion as to which profession is best, not happening, not possible 232 october 2016, vol. 8, no. 2, suppl 2 ajhpe research enhanced competence and more respect for other disciplines and health professionals as they became more knowledgeable about the scope and practice of other health professions, and acknowledged an increase in the value of the roles and contributions of other healthcare professions. interprofessional training and teaching assisted in the development of interpersonal and professional skills, as participants described effective communication, respect, attentiveness, mutual understanding, active listening, participation, punctuality, passion, unity and ethical practice as a collaborative team. interprofessional teaching and learning activities provided participants with an understanding of the scope and practice of other disciplines and the value and importance of teamwork in rendering effective, efficient and reliable healthcare services. moreover, participants reported being more knowledgeable about the roles and responsibilities of healthcare professionals and how these professionals may contribute to the management and care of a patient. according to participants, an increase in knowledge allows for a more effective model of care as health professionals make appropriate referrals and consult various other health professionals when unable to address or effectively treat a patient. criteria used to measure the impact of interprofessional teaching and learning activities students’ suggestions of the criteria that can serve as indicators to measure the impact of interprofessional teaching and learning included authentic learning opportunities, patient involvement, patient outcomes, improved research, communication and workshops (table  5). participants believed that authentic learning activities or creative measures may promote interprofessional practices in a reallife setting. patient feedback, evaluation of a patient’s health and improvement of a patient’s condition were recognised as good measures of the outcomes of interprofessional teaching and learning activities. communication was identified as a means of measurement, as participants were able to offer constructive criticism, effectively communicate with or within a multidisciplinary team and develop mutual respect for one another. other methods found to measure impact included focus groups, questionnaires, reflective journals, portfolios, social media, videos and observation during clinical practice. discussion according to our findings, the world café is viewed as a distinct model of ipe and practice. the model has been recognised as successfully contributing to a student’s ability to work in a multidisciplinary team, promoting skills for holistic care and aiding the development of health professionals. aligned with the findings of the study, ipwc is an example of authentic learning, as students participate in real-life problems. by engaging in the ipwc, students are taught how to work in interprofessional teams in practical settings. if students are exposed to interprofessional learning opportunities, they are likely to translate these experiences into practice. by doing this, they use their acquired skills and knowledge, which could be needed in the workplace at a future stage.[12] similarly, the world café has been recognised for assisting students in engaging in ipe, which involves professional collaboration by communication or dialogue.[6] the ipwc has created an opportunity for dialogue between students, which equips them with key competencies regarding interprofessional collaboration and care. these competencies include communication, collaboration, team work, identifying roles and responsibilities, planning a holistic model of care, sharing responsibility for patient care and developing health professional competence. the collaboration achieved through ipwc played a significant role in highlighting the importance of promoting a better model of care through the attainment of common goals. table 3. benefits of training in an interdisciplinary team predominant clusters verbal responses collaboration help each other in order to promote good health combined efforts make the objective easier to achieve it was helpful in knowing other groups that we work with in the hospital and sharing ideas every profession contributes to make a change everyone assists in the final outcome model of care patient care was easier we can provide better specialised care for the patient holistic improvement of health skills and patient’s health good approach to treating the patient to manage patients in order to promote their wellbeing makes the case easier and brings about more effective results multidisciplinary we need each other involve everybody but always remain equal all the disciplines connect in a way roles and responsibilities sharing responsibility for a patient each discipline has a role to fulfil in restoring the patient to optimum health playing significant role in patient management each discipline carries weight for diagnoses table 4. value of interprofessional teaching and learning activities predominant clusters verbal responses improved competence and skills improved respect and values, learnt how to master skills, practised ethics together, skills development, interpersonal skills development improved understanding helped understand what other disciplines do better understanding of other disciplines fully understand why each one of us should work as a team understanding the importance of others improved knowledge increased my knowledge of other professions gained information from the different professions of healthcare of the patient gained knowledge of the roles and responsibilities of the different healthcare professionals it opened up my mind to know what the other disciplinary teams do october 2016, vol. 8, no. 2, suppl 2 ajhpe 233 research similarly, d’amor et al.[13] have described the promotion of interprofessional collaboration as an efficient, effective and satisfying way to offer healthcare services. students described their combined efforts to reach a common goal as helpful and promoting a better model of care. similarly, the ipe and dialogue promoted by ipwc allow for specialised and integrated interventions that address the holistic health and wellbeing of a patient. these integrated interventions are recognised for their ability to yield more effective results within a real-life setting.[14,15] therefore, ipwc can be used as an authentic learning experience that facilitates the promotion of ipe and practice in health professional students. conclusion it was evident that students understood the meaning of ipe, even though they used various terms interchangeably. they learnt from other students about their roles and responsibilities and could function as a team to complete the various tasks during the ipwc. the students understood the attributes needed to function within a team and improve their knowledge and skills. students ultimately emphasised the need for authentic learning experiences where two or more disciplines were present in the clinical setting. acknowledgements. the authors thank the departments, students and community stakeholders for their participation in the interprofessional programmes. furthermore, we wish to acknowledge dr f waggie, mrs c fester, mr j appolis, ms a simpson, mrs r hull and mrs i fredericks for their support and assistance in the development of ipe and practice at uwc. references 1. canadian interprofessional health collaborative. a national interprofessional competency framework, 2010. http://www.cihc.ca/ resources/publications (accessed 25 april 2015). 2. mcnair rp. the case for educating health care students in professionalism as the core content of interprofessional education. med educ 2005;39(5):456-464. doi:1111/j.1365-2929.2005.02116.x 3. dumont s, brière n, morin d, houle n, iloko-fundi m. implementing an interfaculty series of courses on interprofessional collaboration in prelicensure health science curriculums. educ health 10 (online) 2010;23(1):395. http://www.educationforhealth.net/article (accessed 27 may 2016). 4. bridges dr, davidson ra, odegard ps, maki iv, tomkowiak  j. interprofessional collaboration: three best practice models of interprofessional education. med educ online 2011;16. doi:10.3402/ meo.v16i0.6035 5. mpofu r. interprofessional education for collaborative health care in south africa. workshop of the south african committee health science deans, 3 july 2012 ukzn. http://shs.ukzn.ac.za/sacohsd/ presentation.aspx (accessed 11 june 2016). 6. brown j, isaacs d. world café community. the world café: shaping our futures through conversations that matter. san francisco: barrettkoehler publishers, 2005. 7. terry j, raithby m, cutter j, murphy f. a menu for learning: a world café approach for user involvement and interprofessional learning on mental health. social work educ 2015;34(4):437-458. doi: 10.1080/02615479.2015.1031651 8. banning m. approaches to teaching: current opinions and related research. nurse educ today 2005;25(7):502-508. doi:10.1016/j.nedt.2005.03.007 9. reich r. the socratic method: what it is and how to use it in the classroom. speaking of teaching 2003;13(1):1-4. 10. zlotnick jl, mccroskey j, gardner s, et al. myths and opportunities: an examination of the impact of discipline-specific accreditation on interprofessional education. alexandria, va: council on social work education, 1999:75,77. 11. peterson m, martin ss. associative group analysis: a tobacco prevention case study. soc mar q 2003;9(2):32-49. doi:10.1080/15245000309100 12. snyman s, von pressentin kb, clarke m. international classification of functioning, disability and health: catalyst for interprofessional education and collaborative practice. j interprof care 2015;29(4):313319. doi:10.3109/13561820.2015.1004041 13. d’amour d, ferrada-videla m, san martin rodriguez l, beaulieu md. the conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. j interprof care 2005;19(suppl 1):116-131. doi:10.1080/13561820500082529 14. cullingham c, scott c, lagendyk l. primary healthcare models through the lens of alma ata. 2008. http://compaircanada.ca/system/ files/phc+models+final+feb+2008.pdf (accessed 17 june 2016). 15. o’daniel m, rosenstein ah. professional communication and team collaboration. in: hughes rg, ed. patient safety and quality: an evidence-based handbook for nurses. rockville, md: agency for health care research and quality, 2008. table 5. criteria to measure interprofessional education activities predominant clusters extracts of verbal responses authentic learning opportunities students to be more creative and go out more to deal with situations are we able to use what we are being taught, in a proper manner and where it counts? activities can be done in order to promote and encourage interpersonal/ multidisciplinary practices in real situations all disciplinary teams must be available in the clinical setting patient involvement feedback from the patients or clients listen to response from the patients get feedback on how the patient made progress with interprofessional care patient outcomes is there a decrease in prevalence of disease burden? evaluating the patient as the bigger role player improvement in the patient. how does it impact on the patient? see if the patient’s condition has improved after meeting with interprofessional team improved communication interact with others in the team constructive criticism and mutual respect should be encouraged make sure that different disciplines do not undermine each other, and communicate well learn to share ideas with other groups make sure all disciplines have adequate training and especially work on developing communication skills research surveys and interviews should be done to measure the impact of the interprofessional teaching and learning activities survey on patients to see whether professions are working together and if this promoted their understanding workshops discussions among different health professionals on a monthly basis through workshops workshops for interdisciplinary teams should take place http://dx.doi.org/http://www.cihc.ca/resources/publications http://dx.doi.org/http://www.cihc.ca/resources/publications http://dx.doi.org/1111/j.1365-2929.2005.02116.x http://www.educationforhealth.net/article http://dx.doi.org/10.3402/meo.v16i0.6035 http://dx.doi.org/10.3402/meo.v16i0.6035 http://dx.doi.org/http://shs.ukzn.ac.za/sacohsd/presentation.aspx http://dx.doi.org/http://shs.ukzn.ac.za/sacohsd/presentation.aspx http://dx.doi.org/10.1080/02615479.2015.1031651 http://dx.doi.org/10.1016/j.nedt.2005.03.007 http://dx.doi.org/10.1080/15245000309100 http://dx.doi.org/10.3109/13561820.2015.1004041 http://dx.doi.org/10.1080/13561820500082529 http://dx.doi.org/http://compaircanada.ca/system/files/phc+models+final+feb+2008.pdf http://dx.doi.org/http://compaircanada.ca/system/files/phc+models+final+feb+2008.pdf october 2016, vol. 8, no. 2 ajhpe 193 research burnout, characterised by the well-described triad of emotional exhaustion, depersonalisation and a decreased sense of personal accomplishment,[1] has been studied in a number of emergency medical services (emss) contexts.[2-5] the prevalence of burnout among paramedics varies, but is generally quite high compared with that in other health professions. in many cases stress from work environment-related factors appears to contribute to the development of burnout more than patient care-related factors.[2-5] while qualified paramedics may draw on coping strategies developed over years of experience to mitigate the effects of work stress and subsequent development of burnout, students typically are not able to do this. students also tend to face a more complex and multifactorial set of stressors, including stress related to the educational environment, the inherently stressful nature of clinical emergency care, and stress related to academic workload and success. by considering maslach’s model of burnout and the typical academic life of medical students, jennings[6] argues that the relationship between academic success and burnout is bidirectional. the stress of academic workload and performance not only influences the development of burnout, but the latter may in turn negatively affect academic performance.[6-9] students therefore appear to have a more complex set of risk factors for the development of burnout and perhaps also have the most to lose when burnout does occur. this study aimed to determine the prevalence of burnout among students in a 4-year paramedic university degree programme and to assess whether there was any significant difference in the prevalence of burnout among students during the 4 years of study. methods we used a cross-sectional survey to assess the prevalence of burnout in this student population. the survey was conducted by using a directly administered questionnaire based on the copenhagen burnout inventory (cbi).[10] the cbi consists of 19 questions in three burnout categories: personal burnout (a state of prolonged physical and psychological exhaustion); work-related burnout (a state of prolonged physical and psychological exhaustion which is perceived as related to the participant’s work or, in this case, academic activities); and patient-related burnout (a state of prolonged physical and psychological exhaustion which is perceived as related to the participant’s work with patients).[10] the term burnout was purposefully avoided anywhere in the questionnaire, i.e. the student wellness questionnaire (swq). cbi questions were interspersed with a number of distractor questions. the cbi questions use a likert-type response scale and a system that assigns a score of between 0 and 100, depending on the response chosen. once the inventory’s scoring system had been applied to all responses, an average burnout score was calculated for each of the individual sections and for all three sections combined, giving a total burnout score, of which ≥50 suggests a diagnosis of burnout.[10] the validity, reliability and internal consistency of the cbi have been previously demonstrated.[10,11] all students who were registered for the emergency medical care (emc) degree programme at the department of emergency medical care, university of johannesburg, south africa (sa) were invited to participate in the survey. the emc programme spans 4 years of full-time study and is structured with a focus on basic sciences and diagnostic skills in the background. burnout has been studied in several emergency medical services contexts and has been found to be high compared with that found in other health professions. although burnout among students has been described in several healthcare disciplines, this has not been done in the field of prehospital emergency care. objectives. to determine the prevalence of burnout among students in a 4-year university paramedic degree programme and to assess whether there was any significant difference in the prevalence of burnout among students during the 4 years of study. methods. in this cross-sectional survey all students enrolled in a 4-year university paramedic degree programme were invited to participate. the questionnaire consisted of 19 questions from the copenhagen burnout inventory (cbi), combined with distractor questions. responses were analysed descriptively and one-way analysis of variance was used to compare cbi scores across the 4 academic years of study. results. an 85% (n=93) response rate was obtained. the overall prevalence of burnout was 31%. mean cbi scores across all academic years of study were highest for personal burnout, followed by work-related burnout and patient care-related burnout. the highest prevalence of students with burnout was in the 4th year, as was the highest prevalence of work-related and personal burnout. the second highest prevalence of students with burnout was in the 1st year, as was the highest prevalence of patient care-related burnout. no significant difference was found in cbi total burnout scores across the 4 years of study. conclusion. although there are no directly comparable data, the prevalence of burnout in this group of students appears to be high, particularly in the 1st and 4th years of study. steps should be taken to ensure access to social and psychological support to avoid a negative impact on academic success and student wellbeing. afr j health professions educ 2016;8(2):193-195. doi:10.7196/ajhpe.2016.v8i2.626 burnout among paramedic students at a university in johannesburg, south africa c stein, phd; t sibanda, btech emc department of emergency medical care, faculty of health sciences, university of johannesburg, south africa corresponding author: c stein (cstein@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 194 october 2016, vol. 8, no. 2 ajhpe research first 2 years, progressing to more advanced and specialised clinical practice in the last 2 years (table 1). students were informed of the survey before or after scheduled lectures at the university campus. those wishing to participate completed a consent form, followed by the swq. data collection was completed between july and august 2012. all completed swqs were collected and data were transcribed to an electronic spreadsheet application for further analysis. transcribed data were checked for correctness. cbi scores for each of the burnout subscales, and the total burnout score, were analysed descriptively. to establish whether a significant difference between cbi scores (subscale and total) existed across the 4 years of academic study, one-way analysis of variance (anova) was used. the statistical package for the social sciences version 20 (spss 20) (ibm corp., usa) was used and p<0.05 was considered significant for all statistical tests. ethical approval for the study was granted by the faculty of health sciences research ethics committee, university of johannesburg (rec01-149-2015). results ninety-three (85%) of a total of 110 students who registered for the emc degree programme consented to participate in the survey. all swqs handed out were completed and returned. descriptive data for each of the burnout categories and for total burnout scores across all academic years of study are given in table 2. on average, students scored highest in the personal burnout category, with work-related burnout and patient care-related burnout categories yielding lower scores. the mean total burnout score was below the threshold value of 50 points. a total of 29 (31%) students across all academic years had a total cbi score of ≥50, the cbi threshold for burnout. descriptive data on burnout scores by academic year of study (table 3) show that the mean work-related burnout score peaked in the 4th-year group, the mean personal burnout score was similar across all academic years of study, the mean patient care-related burnout score was highest in the 1st year, and the mean total burnout score was highest in the 4th year, followed closely by the 1st-year group. results obtained by selecting only students with cbi scores of ≥50 in each burnout category are shown in table 4. first-year students had the highest percentage of burnout scores of ≥50 in the patient care-related burnout category, and slightly more than one-third of this group had total burnout scores of ≥50. with the exception of the 2ndyear group in the work-related burnout category, approximately two-thirds of students in each academic year had work-related and personal burnout scores of ≥50. roughly one-third of students in each academic year had patient care-related burnout scores of ≥50, with the exception of the 2nd-year group, where the prevalence was approximately half of this. the total burnout category showed the greatest variation, with the percentage of students having scores of ≥50 ranging between 18% and almost three times this score. the greatest percentage of students with total burnout scores of ≥50 was in 4th year. anova results indicated that there was no significant difference in mean burnout scores between the 4 academic years of study in the categories of personal burnout (p=0.866), work-related burnout (p=0.245), patient care-related burnout (p=0.079), or total burnout (p=0.456) scores. table 1. summary of academic structure for emergency medical care degree programme academic year of study main academic focus 1 basic sciences (anatomy, physiology, chemistry, physics), fundamental clinical content, limited clinical ems exposure 2 basic supporting sciences (diagnostics, pathology), clinical content, clinical exposure mostly in hospital (operating room, emergency department, obstetrics) 3 pharmacology, advanced adult clinical content, more intensive clinical ems exposure 4 specialised areas (paediatrics, thrombolysis, intensive care transfer), related clinical exposure (paediatrics, intensive care), ongoing clinical ems exposure, and a research project ems = emergency medical service. table 2. descriptive data for cbi burnout scores (n=93) burnout score category mean (sd) work related 49.1 (12.9) personal 53.4 (15.0) patient care related 34.0 (19.5) total 45.2 (11.5) table 4. participants with cbi scores of ≥50 (n=93) cbi burnout scores of ≥50, n (%) burnout score category 1st year 2nd year 3rd year 4th year work related 24 (60) 7 (33) 11 (65) 10 (67) personal 24 (60) 14 (67) 10 (59) 10 (67) patient care related 12 (30) 3 (14) 5 (29) 4 (27) total 14 (35) 5 (24) 3 (18) 7 (47) table 3. descriptive data for cbi burnout scores across 4 years of study cbi burnout scores, mean (sd) burnout score category 1st year 2nd year 3rd year 4th year work related 50.10 (12.92) 44.86 (10.75) 48.76 (14.70) 53.40 (13.01) personal 52.53 (14.50) 52.81 (16.46) 55.06 (16.0) 55.80 (14.17) patient care related 38.63 (21.93) 25.00 (15.81) 33.82 (17.55) 34.33 (16.35) total 46.80 (11.62) 40.38 (10.94) 45.65 (11.72) 47.80 (10.98) october 2016, vol. 8, no. 2 ajhpe 195 research discussion no data currently exist on burnout prevalence among paramedic university students; therefore a direct comparison with a similar cohort is not possible. the 31% prevalence of total burnout, measured with the cbi, is very similar to that found among a group of qualified advanced life support paramedics in johannesburg (30% prevalence) measured with the same instrument.[5] it is higher than the prevalence of burnout identified in a number of other studies investigating this phenomenon among qualified paramedics.[2-4] burnout has been investigated and described in other healthcare student populations. the prevalence among medical students has been found to be comparatively high, with between 45% and 71% of students affected in different studies.[12-15] burnout among nursing students has been shown to be widely prevalent in one study, but at low to moderate levels,[16] and has increased over the duration of educational contact in one population.[17] the use of different scales to measure burnout makes direct comparison difficult, but it appears that the prevalence of burnout in this study was lower than that found in medical students but probably higher than that reported for nursing students.[12-15,16] our results suggest two main focal points of concern at extremes of the student academic experience − 1st year and 4th (final) year. given the increased complexity and volume of academic work (including a research project), and clinical responsibility in the final year of the emc programme, it is perhaps not surprising that the prevalence of work-related burnout, total burnout and personal burnout would be highest or among the highest in this group of students. the 1st-year students’ results were not anticipated, with this group having the highest prevalence of patient care-related burnout and the second highest total burnout prevalence. although the clinical ems exposure in the 1st year is not at an advanced level of care, as a first taste of the real world of ems it may be rather overwhelming to these students, who have no prior experience. in a more general sense, 1st-year students may also find the transition from school to university life quite demanding and thus experience greater stress during their 1st year, giving rise to burnout. the objective of this study did not include an assessment of the effect of burnout on academic performance. studies investigating this relationship in other fields of study and academic environments have provided some evidence that the existence of burnout negatively affects academic performance and success mainly by a decrease in efficiency and productivity of students.[7-9] it is therefore likely that a similar, albeit unquantified, effect may be present in this group of students. the abovementioned burnout prevalence data and evidence linking these to a negative effect on academic performance highlight the need for available and effective social and psychological support referral pathways for emc students, particularly those in 1st and 4th year. even if such support is available and accessible, it could be argued that too much has already been lost in a fast-paced academic environment by the time a student or others recognise the need for referral. prevention of burnout can be attempted through various strategies, including personand organisation-directed interventions, and a combination of both. the vast majority of such interventions have been found to be effective to some degree, with combined interventions having the best results over the longest time period.[18] ultimately, outcomes of even the most effective burnout prevention interventions will lessen over time, highlighting the importance of repeated preventive efforts. it is recommended that institutions offering emc or similar academic programmes introduce ongoing burnout prevention interventions as one important way of contributing to the improved wellbeing of their students. limitations of the study the sample used in this study contained larger student numbers in the 1stand 2nd-year groups than in the 3rdand 4th-year groups (40 and 21 v. 17 and 15, respectively). the smaller 3rdand 4th-year numbers may have increased the risk of a type 2 error in the anova comparison of mean burnout scores across all academic years of study. the educational environment and circumstances at the university of johannesburg, where students experience emergency care, cannot necessarily be compared with those of other universities or geographical areas; therefore the results of this study cannot necessarily be generalised compared with other emc student populations in sa or elsewhere. references 1. schaufeli wb, maslach c, mazek t, eds. professional burnout: recent developments in theory and research. new york: taylor and francis, 1993. 2. neale av. work stress in emergency medical technicians. j occup med 1991;33(9):991-997. 3. chng cl, eaddy s. sensation seeking as it relates to burnout among emergency medical personnel: a texas study. prehosp disaster med 1999;14(4):36-40. doi:10.1017/s1049023x00027709 4. nirel n, goldwag r, feigenberg z, et al. stress, work overload, burnout and satisfaction among paramedics in israel. prehosp disaster med 2008;23(6):537-546. doi:10.1017/s1049023x00006385 5. stassen w, van nugteren b, stein c. burnout among advanced life support paramedics in johannesburg, south africa. emerg med j 2013;30(4):331-334. doi:10.1136/emermed-2011-200920] 6. jennings ml. medical student burnout: interdisciplinary exploration and analysis. j med humanit 2009;30(4):253-269. doi:10.1007/s10912-009-9093-5 7. galbraith cs, merrill gb. academic performance and burnout: an efficient frontier analysis of resource use efficiency among employed university students. j further higher educ 2015;39(2):255-277. doi:10.1080/030 9877x.2013.858673 8. salanova m, schaufeli w, martinez i, breso e. how obstacles and facilitators predict academic performance: the mediating role of study burnout and engagement. anxiety stress coping 2010;23(1):53-70. doi:10.1080/10615800802609965 9. yang h. factors affecting student burnout and academic achievement in multiple enrollment programs in taiwan’s technical-vocational colleges. int j educ dev 2004;24(3):283-301. doi:10.1016/j.ijedudev.2003.12.001 10. kristensen ts, borritz m, villadsen e, et al. the copenhagen burnout inventory: a new tool for the assessment of burnout. work stress 2005;19(3):192-207. doi:10.1080/02678370500297720 11. milfont tl, denny s, ameratunga s, et al. burnout and wellbeing: testing the copenhagen burnout inventory in new zealand teachers. soc indic res 2008;89(1):169-177. doi:10.1007/s11205-007-9229-9 12. dyrbye ln. burnout and suicidal ideation among us medical students. ann intern med 2008;149(5):334-341. doi:10.7326/0003-4819-149-5-200809020-00008 13. dyrbye ln, massie sf, eacker a, et al. relationship between burnout and professional conduct and attitudes among us medical students. jama 2010;304(11):1173-1180. doi:10.1001/jama.2010.1318 14. guthrie e, black d, bagalkote h, et al. psychological stress and burnout in medical students: a five year prospective longitudinal study. j r soc med 1998;91(5):237-243. 15. dyrbye ln, thomas mr, eacker a, et al. race, ethnicity, and medical student well-being in the united states. arch intern med 2007;167(19):2103-2109. doi:10.1001/archinte.167.19.2103 16. michalec b, diefenbeck c, mahoney m. the calm before the storm? burnout and compassion fatigue among undergraduate nursing students. nurse educ today 2013;33(4):314-320. doi:10.1016/j.nedt.2013.01.026 17. deary ij, watson r, hogston r. a longitudinal cohort study of burnout and attrition in nursing students. j adv nurs 2003;43(1):71-81. doi:10.1046/j.1365-2648.2003.02674.x 18. awa wl, plaumann m, walter u. burnout prevention: a review of intervention programs. patient educ couns 2010;78(2):184-190. doi:10.1016/j.pec.2009.04.008 http://dx.doi.org/10.1017/s1049023x00027709 http://dx.doi.org/10.1017/s1049023x00006385 http://dx.doi.org/10.1136/emermed-2011-200920] http://dx.doi.org/10.1007/s10912-009-9093-5 http://dx.doi.org/10.1080/0309877x.2013.858673 http://dx.doi.org/10.1080/0309877x.2013.858673 http://dx.doi.org/10.1080/10615800802609965 http://dx.doi.org/10.1016/j.ijedudev.2003.12.001 http://dx.doi.org/10.1080/02678370500297720 http://dx.doi.org/10.1007/s11205-007-9229-9 http://dx.doi.org/10.7326/0003-4819-149-5-200809020-00008 http://dx.doi.org/10.1001/jama.2010.1318 http://dx.doi.org/10.1001/archinte.167.19.2103 http://dx.doi.org/10.1016/j.nedt.2013.01.026 http://dx.doi.org/1046/j.1365-2648.2003.02674.x http://dx.doi.org/10.1016/j.pec.2009.04.008 76 may 2015, vol. 7, no. 1, suppl 1 ajhpe the discourse surrounding the social accountability of medical schools has gained momentum over the past 20 years. this has been driven by various global initiatives including the world health organization (who)’s early recommendation that medical schools should direct their research, activities and education towards the priority health needs of the population.[1] medical schools therefore have an imperative to produce appropriately trained graduates that are not only academically skilled but socially responsive to the communities they serve.[2] rourke[3] outlines that successful socially accountable medical schools include a selection of medical students who are representative of the nation’s demographic and geographic diversity. such medical schools ensure that the country is served with the most competent doctors that can meet the health needs of the population.[3] however, in south africa (sa), the poorest representation of medical students are from rural and low-economic backgrounds.[4] this is problematic as rural-origin medical graduates are more likely to return and work in rural areas than urban-origin medical graduates.[4] this has negative implications for healthcare in rural and low-economic areas as most medical graduates are concentrated in urban areas.[4] this is evident by the dearth of human resources for health in rural areas and resultant poor health outcomes in these areas.[5] the who outlines that one of the building blocks for effective health systems is an effective health workforce.[6] the recommended physician to population ratio is 100 per 100 000 population.[6] however, in sa the physician to population ratio varies from 11.5 to 39 per 100  000 population in rural and urban areas respectively.[4] the selection of rural-origin students therefore becomes a critical strategy for socially responsive universities, given the evidence that rural-origin students are more likely to return to their area of origin.[4] international strategies and evidence to improve the retention of health workforce in rural areas includes the selection of students from such areas, as they are likely to return there for employment.[4,7] medical graduates selected from rural areas are found to be more socially responsive and are more likely to function as generalists providing essential primary care services to communities.[8] however, as alluded to above, selection of ruralorigin medical students across south african universities is low (27%) when compared with the average rural population of 46%.[4] this is due in part to insufficient rural learners meeting the selection criteria for health sciences tertiary education.[9] generally there is a fair degree of ‘underpreparedness’ among grade 12 learners in sa, and even more so in rural areas.[10] performance in mathematics and science, which serve as gateway subjects for the study of various health sciences disciplines, is much lower in rural than in urban areas.[11] the poor performance is as a result of several factors. schools in rural communities are generally more difficult to reach, lack basic infrastructure for sanitation, water, transport and electricity and have fewer skilled teachers.[12] socioeconomic background is also a strong predictor of performance.[13] poor teaching standards in mathematics and science are also associated with poor learner performance, and are further aggravated by the large number of underqualified teachers who teach in overcrowded and under-resourced classrooms.[14,15] the inefficiencies in educating learners combined with the socioeconomic challenges that exist within rural and underserved areas serve as key barriers to accessing tertiary health sciences education and therefore may influence the output of rural-origin graduates in required fields such as healthcare.[16] stellenbosch university, in response to the inadequate preparation of rural students for university, implemented school interventions to improve learners’ grades in mathematics and science in preparation for tertiary education. in 2012 the faculty of medicine and health sciences acquired a linked award through the us president’s emergency fund for aids relief (pepfar) for school interventions to commence the pipeline of the stellenbosch university rural medical education partnership initiative (surmepi) project and increase the pool of rural-origin medical graduates.[17] pepfar recognises the constraints in learner education and the negative impact these have on human resources for health in south africa. this model of school interventions linked to medical faculties was derived from the usa, called the area health education centres (ahec) project. ahec function as a ‘pipeline’ through the recruitment of youth from underserved communities into the health professions. this article describes the intervention of as rural areas in south africa have a lack of human resources for health, selecting rural-origin learners for health sciences education can serve to improve the number of health sciences graduates choosing to work in these areas. schools within rural areas are however characterised by poor infrastructure, limited access to water and electricity and fewer skilled teachers, resulting in poor performance of learners. the poor performance in mathematics and science is a concern as these serve as gateway subjects to the health sciences. the stellenbosch university area health education centres (su-ahec) focus on interventions in rural and underserved schools with the aim of enhancing learner performance in mathematics and science to improve access to tertiary health professions education. this project is funded by the us president’s emergency fund for aids relief in south africa. afr j health professions educ 2015;7(1 suppl 1):76-78. doi:10.7196/ajhpe.504 the role of socially accountable universities in improving the selection of medical students from rural and underserved areas k moodley,1 mmed (pub health); t fish,2 mba; s naidoo,3 mscmedsc 1 surmepi, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 community service and interaction, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 area health education centres, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: k moodley (moodleyk@sun.ac.za) short report may 2015, vol. 7, no. 1, suppl 1 ajhpe 77 the su-ahec project in the western cape (fig. 1) – a long-term strategy to improve human resources for health in rural and underserved areas. stakeholder collaboration the success and sustainability of such an intervention is dependent on the inclusion of relevant stakeholders. morehouse school of medicine in atlanta have partnered with stellenbosch university on this project as they are currently involved in the implementation of a number of ahec in the usa. the stellenbosch university faculty of medicine and health sciences have collaborated with the faculty of education’s suncep (stellenbosch university centre for pedagogy) project. suncep is a significant stakeholder and partner, as their goals of strengthening mathematics, science and accounting learning in high schools in preparation for tertiary education were closely aligned with those of su-ahec. in addition the western cape department of education, teachers and parents in these communities have been key stakeholders that embraced the project. they recognise the importance of improving access to tertiary education and especially health sciences training. intervention currently suncep offers the hope@maties programme in the western cape, a programme targeted at grade 12 learners to improve mathematics, science and accounting in preparation for tertiary education. learners are recruited into the programme only if their grades in both mathematics and science are above 70% at the end of grade 11. the cohort of selected learners are then encouraged to attend week-long sessions during school holidays. these week-long tuition sessions occur three times during the year and focus on revising the content of mathematics and science according to the set school curriculum. in addition, information is provided on available bursaries and the application processes for university courses. su-ahec has expanded the suncep hope@ maties intervention in three rural districts of the western cape, viz. malmesbury, caledon and worcester, in the following five categories: • expanding the cohort in the general education and training phase to include grades 7 9 learners from each of the three rural districts with 30 learners per district. utilise teachers from each of the three rural areas to function as tutors. conduct bi-weekly sessions after school for 1.5 hours alternating between mathematics and science tuition. • expanding the cohort in the further education and training phase to include learners with a 65% average from grades 10 and 11 with 30 learners per grade from each district. the model of the holiday schools is implemented for this learner group. • providing teacher capacity development for mathematics and science teachers to improve the quality of teaching. • providing life skills interventions and career counselling for learners. this includes understanding the socioeconomic circumstances of learners in these rural areas and providing relevant interventions and psychosocial counselling and support where necessary. su-ahec community engagement & stakeholder collaboration tracking student outcomes using teachers from rural areas capacitating teachers providing life skills interventions speci�c to the learner providing guidance on subject/ career choice fig. 1. contextualising and implementing area health education centres in the western cape, south africa. short-term outcomes long-term outcomes medium-term outcomes • improved learner performance in mathematics and science • increased number of health professionals in rural and underserved areas • increased number of rural origin students accepted for study for professional degrees fig. 2. su-ahec project indicators of success. short report 78 may 2015, vol. 7, no. 1, suppl 1 ajhpe implementing a learner tracking system using smartcard identification to monitor and track the performance and outcomes of the project. the su-ahec project now comprises a cohort of 400 learners and 150 teachers responsible for grades 7 12 in three rural districts of the western cape. outcomes the short-, mediumand long-term outcomes of this project will be measured using the indicators shown in fig.2. conclusion the su-ahec project aims to improve the performance of secondary school rural learners to increase their eligibility to access tertiary health professions education. it is envisaged that this intervention will contribute to an increased pool of rural-origin students. the response and social responsibility from universities to improve selection from rural and underserved areas is critical to increasing the availability of the health workforce in these areas. the injection of funds by universities or nongovernmental organisations into school projects via donor funders such as pepfar will be critical for the expansion of such interventions. the ahec project addresses only one part of the systemic problem that affects the quality of school education in rural areas. the project may represent the start of a harmonising of interventions together with the pooling of resources. acknowledgements. we gratefully acknowledge funding from the us president's emergency plan for aids relief (pepfar) through health resources and services administration (hrsa) under the terms of t84ha21652 via the stellenbosch university rural medical education partnership initiative (surmepi). we are also very thankful to our partners, morehouse school of medicine, atlanta, usa, suncep and the parents and learners of the communities su-ahec works in. references 1. rourke j. how can medical schools contribute to the education, recruitment and retention of rural physicians in their region? bull world health organ 2010;88(5):395-396. [http://dx.doi.org/10.2471/ blt.09.073072] 2. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43(9):887-894. 3. rourke j. social accountability of medical schools. acad med 2013;88(3):430. [http://dx.doi.org/10.1097/ acm.0b013e3182864f8c] 4. tumbo jm, couper id, hugo jfm. rural-origin health science students at south african universities. s afr med j 2009;99(1):54-56. 5. department of health. human resources for health strategy for the health sector 2012/13-2016/17. pretoria: department of health, 2011. 6. world health organization (who). everybody’s business: strengthening health systems to improve outcomes: who’s framework for action. geneva: who, 2007. http://www.who.int/healthsystems/strategy/everybodys_ business.pdf (accessed 8 june 2014). 7. world health organization (who). the universal truth: no health without a workforce. geneva: who, 2013. http:// www.who.int/workforcealliance/knowledge/resources/ghwa_auniversaltruthreport.pdf (accessed 8 june 2014). 8. de vries e, reid s. do south african rural origin medical students return to rural practice? durban: health systems trust, 2003. 9. dunbabin js, levitt l.  rural origin and rural medical exposure: their impact on the rural and remote medical workforce in australia. rural and remote health 2003; 3:212 (online). http://www.rrh.org.au (accessed 17 may 2014). 10. gardiner m. education in rural areas. johannesburg: centre for education policy development, 2008:4. http:// www.cepd.org.za/files/cepd_issues_in_education_education_in_rural_areas.pdf (accessed 30 may 2014). 11. tachie sa, chireshe r. high failure rate in mathematics examinations in rural senior secondary schools in mthatha district, eastern cape: learners’ attributions. stud tribes tribals 2013;11(1):67-73. 12. department of basic education (dobe). quality education for rural schools in south africa – challenges and solutions. south african rural educator 2011;1:8-15. 13. taole m, mncube vs. multi-grade teaching and quality of education in south african rural schools: educators’ experiences. stud tribes tribals 2012;10(2):151-162. 14. department of education (doe). report of the ministerial committee: schools that work. pretoria: doe, 2007. 15. mji a, makgato m. factors associated with high school learners’ poor performance: a spotlight on mathematics and physical science. south african journal of education 2006;26(2):253-266. 16. ross a. building on tinto’s model of engagement and persistence: experiences from the umthombo youth development foundation scholarship scheme. afr j health professions educ 2014;6(2):119-123. [http://dx.doi. org/10.7196/ajhpe.404] 17. de villiers m, moodley k. innovative strategies to improve human resources for health in africa: the surmepi story. afr j health professions educ 2015;7(1 suppl 1):70-72. [http://dx.doi.org/10.7196/ajhpe.503] short report research may 2016, vol. 8, no. 1 ajhpe 37 students who enrol in occupational therapy (ot) at the university of kwa zulu-natal (ukzn), durban, south africa (sa) follow a 4-year degree programme, which includes theoretical and practical components. fieldwork placement constitutes the main practical component of the undergraduate training programme[1] and involves rotation of students in groups of 2 4 through four 6-week placements at government hospitals or non-governmental organisations (ngos). fieldwork placement allows students opportunities for learning by integrating their theory into practice, conceptualising what professionalism entails and providing a chance to practise their professional skills in a supportive environment. furthermore, it affords them the opportunity to engage with members of communities through service delivery.[2] they can also gain knowledge about their profession while learning how to practise as health professionals. in this way they learn to identify the strengths and shortfalls of their interventions, while developing a repertoire of professional practice and clinical reasoning skills.[2] learning during fieldwork encompasses a multimodal and complex experience where students become engaged in socially authentic workplace experiences in environments that shape their learning.[3] generally, on commencing fieldwork practice, they enter a complex and relatively unknown world, with differing social and cultural realities. there is therefore a need not only to prepare students for the variety of contexts where they will work, but also to ensure that they can benefit from the quality of the fieldwork exposures. the latter may include becoming familiar with the disintegrating social systems in primary healthcare settings; exposure to crime; and abuse, poverty and the realities and limitations of resources in their local areas.[4] the transition from student to practitioner requires that the theories and techniques initially acquired in the classroom context be transferred to the clinical context. furthermore, planning and implementing a comprehensive contextualised client treatment programme entails clinical reasoning and decision-making skills. a lack of adequate preparation may render the students’ therapy ineffective. with the entry-level ot practitioners’ learning firmly embedded in their ability to practise effectively in the community, the quest remains for academic institutions to ensure that students make a successful transition to the role of a novice practitioner, notwithstanding the challenging circum stances. in recognising the value of fieldwork for learning, the health professions council of south africa (hpcsa) has mandated that a minimum of 1 000 fieldwork hours be completed by ot students before their graduation.[1] the need to reach consensus on the concept of professional behaviour and for clinicians to guide students to attain the required competencies has been highlighted.[5] clinical supervisors’ personal beliefs and prior experiences have been found to influence their assessment of students’ performance.[5] the need for training to improve the validity of student performance assessments is noted by snyman.[6] incongruence in rating students’ clinical performance is exacerbated in the absence of collaboration between site-based clinical supervisors and university academics. there is therefore a need for academic institutions to review the implementation of fieldwork practice, guidance and assessment of students during this important practical work-based experience. in the discipline of occupational therapy at ukzn, final-year students rotate in groups of 2 4 through four 6-week fieldwork placements in their final year, forming the bulk of the 1 000 hours of clinical practice required for graduation. the sites for the fieldwork include placements at district or tertiary-level hospitals, ngos and one peri-urban site. given the severe staff shortages at a number of placement sites, some students may be expected to perform the duties of a qualified ot while being supervised by the only remaining ot at the hospital. the students are supervised primarily by the ot at the site; however, they receive additional supervision from an allocated academic supervisor once a week. this highlights the need for efficient background. fieldwork practice forms a vital part of occupational therapy (ot) education and contributes significantly to competent practice and students’ clinical reasoning. students’ learning is positively or negatively influenced by their fieldwork experience. objective. to explore the views and experiences of final-year ot students, site-based clinicians and university-based academic supervisors to identify strategies that influenced students’ learning during fieldwork practice. methods. this descriptive qualitative study used a purposeful sampling technique. data collection strategies included focus group discussions with clinical and academic supervisors and semistructured interviews with final-year students. each set of data was analysed according to the research questions. the researcher analysed the data into themes, which were corroborated by a supervisor. data source and analyst triangulation ensured trustworthiness of the study. results. two themes, i.e. difficulties experienced by students during field work and supervision strategies that they found beneficial for learning, are described. guidance and mentoring from experienced therapists helped students to link observations from assessments and intervention plans. observations of treatment sessions, peer learning and practice in the skills laboratories were beneficial for learning, competence and confidence. guided questions from supervisors to enhance reflexive practice and peer learning strengthened the students’ confidence and ability to give feedback to their peers. the students also benefited from sessions that allowed them the freedom and space to work autonomously. conclusion. this study provides insight into the difficulties that students experienced when engaging with fieldwork and offers some strategies that have been found to advance their learning. afr j health professions educ 2016;8(1):37-40. doi:10.7196/ajhpe.2016.v8i1.536 fieldwork practice for learning: lessons from occupational therapy students and their supervisors d naidoo,1 mot; j van wyk,2 phd education 1 discipline of occupational therapy, school of health sciences, university of kwazulu-natal, durban, south africa 2 clinical and professional education, nelson r mandela school of medicine, school of clinical medicine, university of kwazulu-natal, durban, south africa corresponding author: d naidoo (naidoodes@ukzn.ac.za) research 38 may 2016, vol. 8, no. 1 ajhpe supervision strategies to facilitate the student’s acquisition of professional behaviour and learning of practice skills. one of the key challenges for supervisors is fostering and developing professional behaviour of students,[6] which entails introducing new theore tical ideas and knowledge as a necessary foundation for practice. it also comprises experimenting with and evaluating the success of interventions in the practical and clinical context.[7] while authors agree that ethics, cultural competence, empathy and therapeutic use of self are important aspects of professional behaviour, limited literature exists to describe how these attributes can be taught to students. a considerable amount of literature has acknowledged the impact and difficulty brought about by the rapid expansion of tertiary education and the increased diversity of students because of broadened access and redress policies in the sa setting. the changes in students’ preparedness for tertiary training and characteristics of millennial students who seek training have implications for the skills of supervisors and effectiveness of instructional methods for training, including fieldwork.[8] in the absence of theories to explain how ot students negotiate fieldwork and supervision strategies that best assist their learning, this article reports on a study that explored the opinions of final-year ot students and their academic and clinical supervisors on the difficulties that students encounter during their fieldwork experience and the supervision strategies that they found beneficial during their various placements. methods a descriptive qualitative study was used to gain an understanding of the perceptions and concerns of final-year ot students and their academic and clinical supervisors with regard to their fieldwork experience at an sa institution of higher learning.[9] purposeful sampling was used to identify potential participants. all final-year students (n=21) who had studied at ukzn for the full duration of their degree, clinical supervisors (n=7) and academic supervisors (n=5) who supervised for ≥2 years were invited via email to participate in the study. all potential participants were sent information documents and the informed consent letter with a request to volunteer. seventeen final-year students who were in the final semester of their undergraduate programme, 7 of their clinical supervisors and 5 academic supervisors agreed to share their views and experiences about fieldwork. the student sample consisted mainly of females (n=16) aged between 21 and 27 years, from all racial groups. the supervisors in the sample were aged from 25 to 59 years, with clinical supervisory experience from 2 to 36 years. the supervisors were white and indian and only one was a male. there were three data sources, i.e. the students, supervisors and data gained from the curriculum documents. two focus groups (n=13) and four semistructured interviews were conducted with students by two practising experienced ots who were trained as research assistants. (the schedule of questions is given in appendix a.) this allowed for student anonymity and provided greater reliability by reducing potential research bias, as the principal investigator was a member of the academic staff in the discipline of occupational therapy at ukzn, which could have impacted on the veracity and integrity of the feedback. two focus groups were facilitated by the principal investigator to collect data from the clinical supervisors and the academic supervisors, respectively. the focus group sessions and the interviews were audiorecorded and transcribed. each set of data was analysed in answer to the research question. the researcher analysed the data into themes; these were corroborated by a supervisor. triangulation of data collection methods (focus groups, semi structured interviews) and the use of two data analysts enhanced the trustworthiness of the research process and the generated data. informed consent, voluntary withdrawal and potential bias were reduced by an experienced research assistant who is a qualified ot practitioner. ethical clearance was obtained from the ukzn’s health and social sciences ethics committee (hss/0761/012m). results the two themes outlined in this article relate to the difficulties experienced by students during fieldwork, and to the supervision strategies that were identified as beneficial for learning. subthemes are further reported within each respective theme. difficulties experienced by students during fieldwork the difficulties that students encountered during fieldwork practice include anxiety about failing because they are mark driven, a need for clear guidelines, difficulty with clinical reasoning and a lack of understanding of the diverse contexts of their patients. mark driven and anxious about failing both the clinical site-based and academic supervisors identified the students’ desire to obtain high marks and its impact on their motivation to learn. they noted how a desire to score well inspired the students and how fear of failure increased anxiety. the supervisors also noted that students employed very limited initiative and self-directed learning, which increased their dependence on the supervisors. ‘they lack confidence in approaching their supervisor to ask for help and to discuss things … , they expect the supervisor to organise their day and structure supervision times for them which can help.’ (clinical supervisor focus group, participant 6) ‘i think the initiative to go and find out more is lacking … they need to be told what to do.’ (academic supervisors, participant a) need for clear guidelines the students and clinical supervisors reported a need for clear guidelines or expectations to ensure a successful fieldwork experience. one student discussed it in the following way: ‘they must also like, … tell me from the very beginning what they want … and okay, … such as you not doing the right thing and you gonna fail and all … . so that it gives me a chance to improve.’ (student focus group, participant 3) ‘set expectations so student know what you want … so they come into their prac sessions more prepared on a daily basis.’ (clinical supervisor focus group, participant 2) difficulty with clinical reasoning the clinical and academic supervisors reported that students had difficulty linking their observation of a patient to their assessment. moreover, students experienced difficulty when constructing a patient problem list and linking it to appropriate intervention strategies. students requested generic steps (recipes) relating to therapies and experienced difficulty in planning alternative sessions. they also lacked the skills needed to adapt sessions and failed to demonstrate adequate problem-solving during sessions. ‘they can’t interpret it [assessment] and … their observation skills are lacking.’ (academic supervisor focus group, participant d) ‘there’s no link between the assessment to the problem list to the treatment, you don’t see that follow through.’ (clinical supervisor focus group, participant 4) research may 2016, vol. 8, no. 1 ajhpe 39 ‘want to do the treatment based on … the basic recipes that they’ve been taught … so lack of focus of it, difficulty to see that what’s working, what’s not.’ (academic supervisor focus group, participant b) ‘they struggle with the grading and adapting, they’re afraid to change the activity if it’s not working at that point because they plan this and they gonna stick to that. and they don’t have back up plans.’ (clinical supervisor focus group, participant 3) lack of understanding of the diverse contexts of their patients students’ lack of understanding of the diverse contexts of their patients’ lived experiences impacted on their ability to provide effective therapy. ‘most of our students are middle-classed, they don’t have to take the bus and the taxi … how do we then expect them to then problem solve for our clients who live in those circumstance.’ (academic supervisor focus group, participant d) ‘they actually have no idea of the context which the client is … is going back to so it becomes a programme that’s really not of benefit to the client.’ (clinical supervisor focus group, participant 2) supervision strategies found beneficial all participants found guidance and mentoring beneficial for understanding links between observations from assessments and patients’ intervention plans. furthermore, the use of active teaching strategies, such as reflective journals, peer learning and the skills laboratory, enhanced learning. allowing students freedom and autonomy with intervention sessions and ensuring that there was constructive feedback was the final subtheme. guidance and mentoring clinical and academic supervisors found that verbalising and explaining their clinical reasoning process with regard to the problem list was a useful intervention, which seemingly improved students’ professional skills. ‘explaining what’s going on in my mind out loud, i feel that they then latch onto that and they will engage in conversation, will learn from it.’ (academic supervisor focus group, participant a) ‘sit with them … drawing up a problem list … they can start seeing where things [patients problem areas] were clustering and plan intervention from there.’ (academic supervisor focus group, participant c) ‘the supervision and the guidance from a supervisor, it’s really helpful cause it also makes you feel … umm … you going somewhere, like you actually doing something right.’ (student focus group, participant 8) active teaching strategies the use of reflective journals with prompts in the form of questions allowed students to reflect on their clinical reasoning and actions during the fieldwork session. this included observations of the scope of the therapist’s treatment plan, the impact of peer learning on their understanding and skills, and the use of skills laboratories to practise skills in a safe environment. ‘practical sessions, demonstration, watching … watching an experienced therapist handle a situation. uhm, we’re not confident in the way we do it and we need to know that someone else does it that kind of way.’ (students focus group, participant 6) ‘i also found that getting them to sit in on each other’s sessions have helped them inside building for their own activity … umm … also giving positive or negative feedback to their colleague or their friends.’ (clinical supervisor focus group, participant 3) students’ freedom and autonomy, and providing constructive feedback students further benefited from flexible planning during sessions and freedom and space to work autonomously. supervisors found that encouraging students to be flexible in their sessions helped to build their confidence to cope with problems arising in the session. constructive feedback and evaluation of sessions with students were valued. ‘what i’ve asked my students to do is to do their plan session and then do something that they haven’t tried before … so just try another activity, see how it would work.’ (clinical supervisor focus group, participant 5) ‘i’ve had the confidence to … explore. let me do my own thing and then she [supervisor] is there to say, “hey, that didn’t work. this or that worked.” but … you grew in those situations where you were left alone.’ (student focus group, participant 9) ‘you do feel confident … especially once you’ve had feedback on the prac, especially in 4th year. it’s quite nice to hear that you’re doing what’s expected of you, ... it helps if they give constructive feedback.’ (student focus group, participant 1) discussion the literature supports the findings that the students are mark driven and that they fear failure. this behaviour often results in the lack of persistence, as noted with the millennium generation, owing to their need to receive constant praise and being unfamiliar with receiving and/or coping with negative feedback.[8] these students’ unrealistic perceptions of themselves, continuous access to the internet and technology, and need for high marks, which is not always well correlated with their effort, were also noticed by their supervisors. as a result of these peculiar generational characteristics, several authors suggest that millennium students, although being more technologically savvy, have difficulty communicating in traditional formats. they therefore prefer group learning and peer work, where their interactions demonstrate their drive for high achievement. the students’ strategic approaches to studying, linked especially to tasks involving high stakes, necessitate the need to link every learning activity to clear educational goals and outcomes that are directly relevant to their learning.[8] the difficulty with clinical reasoning can partially be explained by the students’ limited experience as novice therapists, who may lack the ability to integrate theory and practice. completing a comprehensive assessment, and creating a prioritised problem list and contextualised client treatment regimen require clinical reasoning and clinical decision-making skills. the view that clinical reasoning skills develop over time is supported by the literature. furthermore, clinical reasoning reportedly improves as students gain experience in the field, which allows them to acquire a repertoire of clinical practice skills to draw on.[9,10] students thus become more confident as they master the clinical decision-making process.[2,11] students’ ability to engage with clinical reasoning is further hindered by a lack of understanding of the diverse contexts of their patients. a possible explanation for the restricted world view may be found in amosun et al.’s[12] observation relating to the predominance of students from middle-class families in health science programmes. in sa this observation is supported research 40 may 2016, vol. 8, no. 1 ajhpe in that these students enjoy greater access, as they are more likely to have studied at better-resourced secondary schools. leibowitz et al.[13] suggest that educators need to be aware of their own assumptions and should create safe spaces and opportunities for students to improve their cultural sensitivity and exposure to lifestyles that differ from their own lived experiences. cultural sensitivity is vital for health professional education, given the diverse nature of the population for whom the graduates would be required to deliver a service.[14] buchanan and cloete[4] indicate that students need to be prepared for the experiences they will face during fieldwork to facilitate more effective planning for patient intervention.[15] as supervisors, we need to ensure that students access psychological services for debriefing and counselling for emotional stress that placements could generate. but how can supervisors and educators assist student learning? the findings suggest that clear guidelines and mentoring were found to be beneficial to learning. students follow rule-based procedural reasoning to guide their actions when implementing an intervention.[10] sinclair’s[10] matrix for clinical reasoning and schell and schell[11] suggest that students straddle the levels from novice to advanced beginner in clinical reasoning upon starting out as therapists. this study found that clinical supervisors can aid students’ learning by verbalising the clinical reasoning processes when treating more complex cases. this practice helps to model more advanced clinical reasoning in context, which illustrates the relevance to the case being discussed. furthermore, feedback from students and supervisors suggests that reflexive practice and peer learning have been noted to start the process of building students’ confidence with regard to their observational skills. these also enhance their ability to give feedback to their peers. this is supported by the literature, which shows that working with peers creates support, as students often experience the same tensions when trying to apply and transfer knowledge to new settings.[7] in this way students are able to explore their professional reasoning and thoughts and evaluate their own interventions. the findings from this study concur with the social constructivist learning experience in which students observe the supervisor providing intervention and improve their repertoire of practice skills though this modelled behaviour.[16] the supervisor and student would then work on an intervention session together, thereby eliciting cognitive changes through guidance and prompting. finally, students would try intervention sessions using prior knowledge and constructing new knowledge for their professional practice through integrating the observed learned experiences with their own experiences gained during fieldwork.[16] this would help them to learn to use client-generated cues to guide intervention, the ability to anticipate and recognise client strengths and weaknesses based on the experience of other clients, and be flexible to alter and adapt their intervention plans.[10] this feedback from the students and supervisors has shown that during fieldwork the latter are better able to facilitate graded learning experiences, which would create a store of professional reasoning and practice experiences for the student to use in future professional practice. conclusion fieldwork is a necessary and essential practical component of the ot undergraduate programme. this study provides insight into the difficulties that students experience when engaging in fieldwork. students benefited from increased guidance and mentoring and the use of active teaching strategies, which allowed them to accept greater responsibility for their learning. both academic and clinical supervisors play a vital role in modelling therapy, demonstrating clinical reasoning and providing structured learning experiences where students can be supported to master concepts and be empowered to practise independently. in the context of the current diverse student intake at tertiary institutions, it is necessary that we acknowledge our cultural identities and be reminded of students’ inexperience in under standing the cultural contexts of their clients. it is therefore advisable for educational programmes to allow opportunities for supervised debriefing after fieldwork experiences for learners and practitioners to learn from one another. references 1. health professions council of south africa (hpcsa). professional board for occupational therapy, medical orthotics and prosthetics and arts therapy. the minimum standards for training of occupational therapists. form123b. hpcsa: pretoria, 2009. 2. gray m, clark m, penman m, et al. new graduate occupational therapists’ feelings of preparedness for practice in australia and aotearoa/new zealand. aust occup ther j 2012;59(6):445-455. 3. billet s, choy s. learning through work: emerging perspectives and new challenges. journal of workplace learning 2013;25(4):264-276. [http://dx.doi.org/10.1108/13665621311316447] 4. buchanan h, cloete l. preparing students for the complexities of practice learning. in: lorenzo t, duncan m, buchanan h, alsop a, eds. practice and service learning in occupational therapy. new york: john wiley, 2006:73-87. 5. emslie b. clinical occupational therapists’ experience of their role as clinical educators during the fieldwork experience of occupational therapy students. mphil. cape town: stellenbosch university, 2012. http//:scholar. sun.ac.za/bitstream/handle/10019/emslie_clinical_2012.pdf (accessed 9 october 2015). 6. snyman ma. assessment of professional behaviour in occupational therapy education: investigating assessors’ understanding of constructs and expectations of levels of competence. mphil. cape town: stellenbosch university, 2012. http://scholar.sun.ac.za/handle/10019.1/20037 (accessed 9 october 2015). 7. rutter l. ‘theory’ and ‘practice’ within he professional courses – integration of academic knowledge and experiential knowledge. 6th ldhen symposium, bournemouth, uk, 2009. http://eprints.bournemouth.ac.uk/10130/2/ldhen_lr_paper.final.pdf (accessed 16 august 2014). 8. hills c, ryan s, smith dr, warren-forward h. the impact of ‘generation y’ occupational therapy students on practice education. aust occup ther j 2012;59(2):156-163. 9. carpenter c, suto m. qualitative research for occupational and physical therapists: a practical guide. uk: blackwell publishing, 2008. 10. sinclair k. exploring the facets of clinical reasoning. in: creek j, lawson-porter a, eds. contemporary issues in occupational therapy: reasoning and reflection. 2nd ed. uk: wiley and sons, 2007:143-160. 11. schell ba, schell j. clinical and professional reasoning in occupational therapy. philadelphia, usa: lippincott williams and wilkins, 2008:1-433. 12. amosun s, hartman n, janse van rensburg v, duncan e, badenhorst e. processes in widening access to undergraduate allied health sciences education in south africa. afr j health professions educ 2012;4(1):34-39. [http://dx.doi.org/10.7196/ajhpe.138] 13. leibowitz b, bozalek v, carollissen r, nicholls n, rohleder p, swartz l. bringing the social into pedagogy: unsafe learning in an uncertain world. teaching in higher education 2010;15(2):123-133. 14. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;6 (9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 15. rodger s, fitzgerald c, davila w, millar f, allison h. what makes a quality occupational therapy practice placement? students and practice educators’ perspectives. aust occup ther j 2011;58:195-202. 16. schunk dh. learning theories: an educational perspective. 6th ed. boston, usa: pearson, 2012. appendix a. schedule of questions for student semistructured interviews 1. describe your experiences of the ot programme during your training. (probe: negative or positive experiences?) 2. do you think that clinical fieldwork placements are valuable and why? (probe: please give examples of positive experiences that contributed to your learning. did you have any negative experiences?) (what do you feel makes a good supervisor?) 3. if you had an opportunity to change anything about fieldwork, what would you change? 4. how do you feel about assessing and treating clients in the various fields of ot? (probe: what do you think helped or would have helped with this?) 5. do you feel prepared for the planning of treatment programmes and sequencing of treatment sessions? what would assist with this? 6. do you feel you are able to evaluate the outcome of your treatment intervention? what helped or would have helped you with this? 7. the purpose of this interview was to explore your perceptions and concerns related to the fieldwork experience. is there anything you anticipated me asking that i did not? please feel free to bring up any topic that might have been missed. march 2017, vol. 9, no. 1 ajhpe 17 research obtaining a professional qualification can be viewed as a starting point that demonstrates the minimum level of competence within a given field of study.[1] the half-life of knowledge varies between 2 and 5 years. therefore, knowledge obtained at the point of professional qualification is insufficient to support an individual throughout a lifetime of professional practice. new learning opportunities that translate into advanced professional competencies should hence be created.[2] professional practitioners should consequently improve their knowledge and skills to stay abreast and meet the demands of the dynamic environment in which they operate. continuous professional development (cpd) evolved from the need for a platform that allows professionals to become lifelong learners and stay up to date with new knowledge, developments and skills. cpd can be defined as ‘the continuous and systematic maintenance, improvement and broadening of knowledge, expertise and skills for the execution of professional duties throughout the practitioners’ working life’.[3] cpd is, therefore, an ongoing process, encompassing formal and informal education, which builds on an initial professional qualification and addresses the learning needs of practitioners in preparation for new responsibilities or extended roles. after the implementation in 2004 of compulsory cpd for kenyan health professionals, the society of radiography in kenya (sork) established cpd guidelines for radiography, in which they undertook to: • ensure that cpd addresses the short-term learning needs of radiographers, while maintaining high competence standards for the profession in the longer term • encourage radiographers to participate in cpd by providing a systematic framework that supports lifelong learning • accredit all cpd activities • promote cpd by working in partnership with employers, academic institutions, government agencies and other relevant bodies. the current cpd requirement for radiographers in kenya is based on the attainment of 40 credits obtained over a 2-year cycle. numerous factors may influence cpd participation among members of a profession. these factors can include professional attitude, work pressure, job satisfaction, organisational culture, dissemination of information, financial or time constraints, or lack of resources, including access to journals or other educational materials. some of these factors are especially detrimental to professionals in rural and remote work environments.[4] as the majority of radiographers (63.6%) work in rural and remote health facilities in kenya, this study was conducted to investigate the barriers experienced by diagnostic radiographers to cpd participation. background. updating knowledge and skills on an ongoing basis is an important requirement if one is to remain professionally relevant. formalised continuous professional development (cpd) is, therefore, essential to stay up to date in a dynamic work environment. the majority of radiographers in kenya work in remote rural health facilities, where cpd activities are limited. the question therefore arose: ‘to what extent are radiographers participating in cpd activities and what constitute barriers to participation?’ objective. to describe the challenges that affect diagnostic radiographers’ participation in cpd activities in kenya. methods. the study targeted radiographers who were registered with the society of radiography in kenya (sork). two hundred and fifty prospective participants were recruited from the sork database, using the fish-bowl sampling method. questionnaires with self-addressed stamped envelopes were posted by ordinary mail to facilitate ease of return, while telephonic follow-up improved the response rate. results. the study revealed that 69% of diagnostic radiographers in kenya were effectively participating in cpd activities. barriers to cpd participation included time constraints (62%), financial constraints (66%), lack of information (54%), organisational culture (47%), paucity of resources (58%), and difficulty in being selected by their organisation to attend cpd activities (42%). conclusion. professional development in a rapidly developing and expanding profession such as radiography is critical for best practice. although the majority of diagnostic radiographers in kenya participate in cpd, a large number do not owing to various challenges. a lack of finances was one of the most significant factors that served as a barrier. sork, employers and institutions of higher education all have a responsibility towards the culture of lifelong learning. as the professional organisation representing radiographers, sork should engage all stakeholders to collectively address the barriers to cpd participation for radiographers in kenya. afr j health professions educ 2017;9(1):17-20. doi:10.7196/ajhpe.2017.v9i1.605 barriers to continuous professional development participation for radiographers in kenya l g kanamu,1 mtech rad, btech rad (d), hdip med ed, dip rad (d); b van dyk,2 mtech rad, btech rad (u/s), ndip rad (t), ndip rad (d); l chipeya,2 mphil he, badmin hons ind psych, badmin, nhd (nm), ndip rad (d & nm); s n kilaha,3 phd, mmed ed, hdip med ed, dip rad (d) 1 department of medical imaging sciences, faculty of diagnostic sciences, kenya medical training college, nairobi campus, kenya 2 department of medical imaging and radiation sciences, faculty of health sciences, university of johannesburg, south africa 3 department of medical imaging sciences, faculty of diagnostic sciences, kenya medical training college, nyeri campus, kenya corresponding author: b van dyk (bvandyk@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 18 march 2017, vol. 9, no. 1 ajhpe research methods this was an empirical study; it therefore relied on perceptions, experiences and observations of participants. a quantitative descriptive survey allowed for the statistical comparison between variables. population and sampling the population comprised ~1 000 diagnostic radiographers, who were registered as members of sork at the time of the study. to calculate the sample size, a confidence level of 95% with a confidence interval (ci) of 5% was set by using the following formula: n=p (100% − p)/(se)2. (n = calculated sample size (296); p = proportion of radiographers (74%) expected to participate in cpd activities, as derived from responses in the pilot study (n=19); se = standard error, calculated by dividing the ci by 1.96 (5/1.96=2.55).)[5] a calculated sample size of 296 participants was ideal, but owing to financial constraints, only 250 questionnaires were dispatched to radiographers, who were randomly selected from the sork database, using the fish-bowl technique.[6] data collection the dependent variable was defined as cpd participation, while the independent variables consisted of a number of factors with the ability to influence participation rate, as identified from the literature.[4] data were collected with the aid of a self-administered questionnaire. content validity of the questionnaire was addressed by providing a set of questions as derived by an extensive literature review.[4] external consistency was pretested by subjecting the questionnaire to a pilot study, allowing for information that was not clearly understood to be addressed before data collection commenced. the pilot study thus measured the reliability of the instrument. questionnaires, including an explanatory letter, were mailed to prospective participants with a stamped self-addressed envelope to facilitate ease of return. questionnaire items targeted information regarding barriers to cpd participation, while questionnaires were completed anonymously. statistical analysis data analysis was performed using spss version 14.0 (spss inc., usa). while descriptive analysis aimed to describe the sample and summarise variables, cross tabulations were employed to demonstrate relationships between variables. pearson’s χ2 test was likewise employed to compare variances between categorical data in non-2 × 2 tables, followed by cramér’s v test, used as a post test to determine the strength of the association, with a value between 0 and 1. (low association <0.3; moderate association 0.3 0.5; high association >0.50.)[6] a p-value of <0.05 indicated that a relationship exists between two variables and the null hypothesis was rejected. ethical considerations participants were safeguarded against ethical misconduct by obtaining permission to collect data from the national council for science and technology (ncst/5/002/r/537/5) in the ministry of higher education, science and technology of the government of kenya. the research was further approved by the higher degrees and research ethics committees of the university of johannesburg, south africa (ref. no. hdc 40/2009). a letter explaining the purpose of the study and giving assurance of anonymity and voluntary participation, accompanied the questionnaires. results of the 250 questionnaires, 162 (65%) were returned and available for analysis. table 1 indicates that just over two-thirds (69%) of diagnostic radiographers, registered with sork, were enrolled in a cpd programme. factors influencing cpd participation in the kenyan context are displayed in fig. 1. financial constraints, time constraints and a paucity of resources were rated as the most significant barriers to cpd participation among radiographers. tables 2 and 3 show the extent to which each of the factors in fig. 1 affected participation in cpd activities. the factors indicate the options selected by each participant in response to a likert scale. the lack of finances, as indicated in table 3, mostly affected participants’ involvement in formal training programmes (p=0.017; cramér’s v=0.302), the acquisition of (p=0.048; phi=0.267) and reading (p=0.036; cramér’s v=0.258) of scientific journals. although time constraints (p=0.576), organisational culture (p=0.341), availability of resources (p=0.46) and difficulty in getting nominated/ selected by the organisation to attend cpd activities (p=0.226) affected cpd participation to some extent, these factors showed no statistical significance. dissemination of cpd information to sork members appeared to be the least significant barrier. however, statistical significance with a weak association was recorded between communication from sork to its members and the regularity with which seminars or workshops were attended. discussion knowledge and skills become obsolete in the absence of efforts to update them on an ongoing basis.[7] however, this study found that diagnostic table 1. overall participation in cpd activities  category n (%) are you enrolled in a cpd programme (n=162)? yes 112 (69) no 49 (30) no response 1 (1) do you work in a rural or urban setting (n=162)? urban 59 (36) rural 103 (64) 80 60 40 20 0 % fin an ce ti m e re so ur ce s in fo rm at io n cu ltu re no m in at io n fig. 1. barriers to cpd participation among diagnostic radiographers in kenya. march 2017, vol. 9, no. 1 ajhpe 19 research radiographers experienced barriers to cpd participation, which need to be addressed. financial constraints a large proportion of radiographers in kenya work in health facilities in rural areas. participants in rural areas generally experience additional infrastructure challenges, such as poorly maintained transport networks, which increase the cost of cpd participation outside their work stations.[8] this may explain why only 34% were not affected by financial constraints. although employers could provide financial support, managers rarely prioritise the need for cpd when allocating resources.[9] as salaries are inadequate, a good incentive or remuneration policy can act as a catalyst for the improvement and broadening of knowledge and skills. [10] this can be achieved by linking remuneration and promotion to minimum educational standards and experience for each professional level. professionals will, therefore, strive to acquire the qualifications and/or competencies required to advance professionally. although not applicable to all radiographers, the remuneration policy in the kenyan public sector makes provision for the acquisition of additional qualifications or specialisation to enhance work performance and facilitate advancement within the profession.[11] it, therefore, seems as if the relatively low salaries prevent radiographers from furthering their studies or subscribing to expensive scientific journals, when they are personally being held responsible for the financial implications. time constraints lack of time to attend cpd activities affected 62% of the diagnostic radiographers in this study. although not investigated in our study, work pressure and family responsibilities were previously found to have an adverse effect on cpd participation.[12] paucity of resources most respondents in our study (58%) were negatively affected by a limitation of resources. lack of access to resources contributes greatly to the challenges facing professionals. this is more obvious in rural settings, where access to resources, such as scientific journals, professional materials, the internet and study clubs, are limited. lack of information and communication competency cannot be separated from effective communication, as good personal relations and communication of information provide a stimulus that enhances participation in cpd.[13] although the communication between sork and its members seems to be good, a lack of information still affects the rate at which radiographers in kenya attend seminars or workshops. as the professional body representing radiographers in kenya, sork has a key role in supporting the education, lifelong learning and professional development of its members. we are, therefore, of the opinion that sork should support members to engage in cpd by creating a platform where diagnostic radiographers can share scientific knowledge – a journal would be ideal for this purpose.[3,15] furthermore, communication with members can be improved by providing the most current information regarding cpd activities on the website and exploring the internet as a means of providing a range of cpd opportunities.[3,15] apart from arranging regular seminars, sork can partner with tertiary institutions or structure the content of cpd activities to address key educational issues to improve professional practice, knowledge, skills and attitudes of radiographers.[3,15] by formulating a cpd policy employers can, additionally, be guided in developing an organisational culture conducive to participation.[8,15] table 2. barriers to cpd participation (n=162) scale used to rate the extent to which cpd participation is affected by each factor financial constraints, % time constraints, % paucity of resources, % organisational culture, % lack of information, % difficulty in getting nominated or selected to attend cpd activities, % not affected (0) 3 7 7 20 15 27 least extent (minimal chance) (1) 7 9 12 14 24 12 some extent (some chance) (2) 25 30 29 25 20 15 great extent (3) 34 23 17 8 10 15 no response 31 31 35 33 31 31 total 100 100 100 100 100 100 table 3. cross tabulations between barriers and cpd participation (n=112) test value p-value effect of financial constraints on cpd participation 1. were you enrolled in any formal train ing programme in the last 12 months? pearson’s χ2 10.240 0.017 cramér’s v 0.302 moderate association 2. how often do you read scientific journals? pearson’s χ2 22.117 0.036 cramér’s v 0.258 weak association 3. do you subscribe to scientific journals? pearson’s χ2 7.894 0.048 cramér’s v 0.267 weak association effect of lack of information on cpd participation at seminars and workshops 1. how regularly do you attend seminars/workshops? pearson’s χ2 18.745 0.027 cramér’s v 0.238 weak association 2. how often do you read scientific journals? pearson’s χ2 18.745 0.027 cramér’s v 0.238 weak association 20 march 2017, vol. 9, no. 1 ajhpe research organisational culture although organisational culture showed no statistically significant association with cpd participation in this study, it is generally believed to contribute to non-participation of diagnostic radiographers in cpd. professionals who work in a supportive environment maintain their motivation and job satisfaction.[14] employers are, therefore, responsible to ensure that their workforce maintain appropriate standards by adopting a pro-cpd culture.[3] in our study, only 20% of participants expressed satisfaction with their organisational culture towards cpd (table 1). this implies that service delivery may be adversely affected, as professionals lack opportunities to update their professional knowledge and skills. organisational support could be achieved by advocating a culture that encourages employees to maintain and improve their professional knowledge and skills for optimal service delivery and personal advancement.[15] support may be in the form of funding or subsidising of formal or informal cpd activities,[8] or by providing learning resources in the workplace, inclusive of current and relevant scientific publications and internet access.[3,15] difficulty in getting nominated or selected to attend cpd activities in our study, 42% of participants encountered difficulties in getting nominated by their employers to attend cpd activities (fig. 1). it seems easier to obtain approval to enrol in distance learning programmes than in formal face-to-face programmes. although not statistically significant (p=0.226), radiographers might feel deprived of formal learning opportunities owing to a lack of goodwill from their employers. study limitations as all legally practising radiographers are not registered members of sork, the sample was restricted to include sork members only. the organisation currently has no power to compel radiographers to become members owing to the lack of a legislative framework. conclusion professional development in a rapidly developing and expanding profession such as medical radiography is critical for best practice. although the majority of diagnostic radiographers in kenya participate in cpd, a large number do not participate owing to various challenges (fig. 1). while organisations need to support cpd activities to optimise the benefit to the organisation, it is problematic that some still value cpd as a cost and not an investment. although the majority of radiographers in our study considered cpd as an investment, the associated cost made it difficult for them to fully engage in cpd activities, which may have a negative impact on the standard of radiological services in kenya. 1. henwood s, edie j, flinton d, simpson r. continued professional development: a re-examination of the facts. radiography 1998;4(1):5-8. http://dx.doi.org/10.1016/s1078-8174(98)80023-0  2. hughes p. evaluating the impact of continual professional education. nurse educ today 1990:10(6):428-436. http:// dx.doi.org/10.1016/0260-6917(90)90105-y  3. henwood sm, taket a. a process model in continuing professional development: exploring diagnostic radiographers’ views. radiography 2008;14(3):206-215. http://dx.doi.org/10.1016/j.radi.2007.03.005  4. brink h. fundamentals of research methodology for health care professional practitioners. 2nd ed. cape town: juta, 2006. 5. fox n, hunn a, mathers n. sampling and sample size calculation. yorkshire: national institute for health research, 2009. 6. kothari cr. research methods, research methodology: methods and techniques. 2nd ed. new delhi: new age international, 2008. 7. chisholm cu, burns gr. the role of work-based and workplace learning in the development of life-long learning for engineers. global j engineer educ 1999;3(3):235. 8. henwood sm, yielder j, flinton d. radiographers’ attitudes to mandatory cpd: a comparative study in the united kingdom and new zealand. radiography 2004;10(4):251-258. http://dx.doi.org/10.1016/j.radi.2004.05.008  9. brown ca. cost effectiveness of continuing professional development in health care: a critical review of the evidence. bmj 2002;324(7338):652-655. http://dx.doi.org/10.1136/bmj.324.7338.652  10. palarm t, jones k, gilchrist m. personal and professional development: a survey of radiographers employed in the south west region. radiography 2001;7(1):43-53. http://dx.doi.org/10.1053/radi.2000.0301  11. directorate of personnel management. scheme of service for radiographers in kenya. nairobi: government printers, 2009. 12. schweitzer dj, krassa tj. deterrents to nurses’ participation in continuing professional development: an integrative literature review. j contin educ nurs 2000;41(10):441-447. http://dx.doi.org/10.3928/00220124-20100601-05  13. groopman j. how doctors think. new york: houghton-mifflin, 2007. 14. broad k, evans m. a review of literature on professional development content and delivery modes for experienced teachers. toronto: university of toronto, 2006. 15. henwood sm. continuing professional development in diagnostic radiography: a grounded theory study. phd thesis. london: south bank university, 2003. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 207 clinical education forms an important and distinct part of all healthcare education.[1] in clinical education the student refines the knowledge, skills, values, attitudes and philosophies of the profession that she/he has learnt in the classroom or skills laboratories.[2] clinical education provides the situation, task and human complexities necessary to integrate prior learning and a context for new learning. clinical education is a multidimensional and complex process whereby students aim to reach entry-level clinical competence in real-time clinical practice.[3] it is reported that in clinical education students come to appreciate their role as healthcare providers with specific roles and responsibilities.[5] this central role as healthcare provider may integrate elements of other roles that form part of graduate attributes, such as collaborator, communicator, health advocate, etc.[5,6] as first-line practitioners it is important that newly qualified physiotherapists can demonstrate general competence and a range of abilities that will allow them to function satisfactorily and safely in their professional role. to reach this goal the health professions council of south africa (hpcsa) requires that students are placed in a variety of clinical areas for a minimum of 1 000 hours over a 4-year training period.[7] at stellenbosch university (su), physiotherapy students gain their first exposure to clinical practice in the second year of the 4-year degree course. from their third year of study they take responsibility for patient management as part of their clinical training. the creation of optimal learning opportunities for students to obtain the necessary clinical skills forms an integral part of the undergraduate programme and can be seen to facilitate the development of graduate attributes.[5] the integration of theory into the real-world environment is recognised as a primary purpose of clinical education.[8] ideally this process should also incorporate an interdisciplinary and holistic approach to healthcare.[9] however, the complexity of healthcare systems, rapid change in service provision, financial constraints and demands of accountability are increasingly being recognised as impacting on the learning opportunities that can be provided.[3] several factors have been identified as playing a role in the clinical learning experience. these include the model of clinical education used,[2] clinical educator attributes,[10] teaching methods used by the clinical educator,[11] student assessment,[11] and the atmosphere, facilities and safety at the healthcare setting.[1] kilminster and jolly[12] found that the environment in which learning takes place profoundly affects what is learned and the students’ responses to learning. as the students’ learning occurs in the context of clinical practice, the clinical environment is also identified as the best area to facilitate the skills and attitudes needed.[3] national core standards for health establishments have been developed by the national department of health in south africa with the aim to optimise the health services provided to patients.[13] similarly there have been suggestions that clinical sites should be credentialed for the purpose of clinical education.[14] in addition, growing tension has been noted among clinicians attempting to provide optimal patient care while creating sufficient learning opportunities for students.[15] the literature is lacking with regard to the physical requirements of clinical training sites for optimal learning. the aim of this study was to evaluate the clinical sites used to train undergraduate physiotherapy students at su and identify factors that may influence the clinical learning experience of these students. context students rotate through three clinical placements during the third year of study. these include orthopaedics, neurology and medical and surgical conditions. a background. clinical education forms an integral part of the training of undergraduate healthcare students. clinical learning and education can be influenced by a number of factors. objectives. to evaluate clinical service sites used to train undergraduate physiotherapy students at stellenbosch university, in terms of: (i) the suitability of the site as a training facility; and (ii) the range of clinical problems students encounter at these clinical service sites. methods. a descriptive study was conducted. data were gathered through structured clinical site visits, staff interviews and student record sheets documenting the number and type of patients students encountered at the clinical service sites. results. seven of the nine clinical sites used for training were evaluated. close proximity to the faculty was an identified strength of three of the sites. there were opportunities for the expansion of multidisciplinary services and group treatment classes. there were safety concerns at most of the sites visited. the number of qualified physiotherapists was low and there was also a lack of basic equipment needed for patient management at more than half of the clinical sites. students’ exposure to the various fields of physiotherapy varied greatly at the tertiary service settings versus primary healthcare settings. on average students saw only two patients per day during a 5-hour clinical day. conclusion. the suitability of healthcare service sites for training undergraduate students should be carefully evaluated prior to commencing training at these sites. the development of good clinical training sites for undergraduate healthcare students requires the availability of adequate resources such as equipment, an adequate complement of clinical staff and effective measures to ensure student and patient safety. ajhpe 2014;6(2 suppl 1):207-210. doi:10.7196/ajhpe.528 evaluation of clinical sites used for training undergraduate physiotherapy students: factors that may impact on learning l g williams, msc (physio); d v ernstzen, msc (physio), mphil; s b statham, msc (physio); s d hanekom, phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: l g williams (leonie@sun.ac.za) research 208 october 2014, vol. 6, no. 2, suppl 1 ajhpe number of clinical service sites are used to provide the specific exposure needed for students to reach the predefined outcomes for the respective placements. students spend 5 weekday mornings for 5 weeks per clinical placement. students are supported in their clinical learning by both the clinician and a clinical educator. the clinician provides the daily physiotherapy service to patients at the clinical site. the clinical educator is employed by su and is responsible for weekly, individualised clinical facilitation sessions with students at the service site. methods this project was registered with the institutional human research ethics committee at su (n06/07/118). all participants provided written informed consent. the study took the form of a mixed-methods observational study design to generate both quantitative and qualitative data. sample during 2006 all third-year physiotherapy students at su (n=40) were invited to participate in the study. during the clinical site visits semistructured interviews were held with a representative at each of the service sites visited. data collection and procedure the data collection activities included student record sheets and clinical site visits. student record sheets a data sheet was developed to record the number of treatment sessions provided per day, time spent on patient care, time spent on documentation, the number of patients treated per day and the pathology involved. students received training on how to complete the data sheet correctly before data collection began. patient statistics and the time spent on specific activities were documented by students for the last two clinical rotations of 2006. data sheets were tracked for the duration of the two clinical rotations. site visits the visit to the clinical site and an interview with a site representative (physiotherapist clinician/ clinical educator) were combined. different observational teams among the research group were assembled to visit the different clinical sites. a site evaluation form (table 1) was created by a research team member after an extensive search of the literature proved fruitless to find a tool to determine the suitability of clinical service sites for student training. the site evaluation tool was based on the minimum standards for clinical sites and focused on gathering information on facilities, apparatus, safety and security.[16] information regarding the level of healthcare provided at the clinical sites, as well as the travelling distance from the faculty of medicine and health sciences (fmhs), was recorded. the researchers evaluating the clinical site had to document the presence or not of specific features, as well as provide additional comments regarding each feature assessed. table 1 provides an illustration of the information gathered during the site visits which were deemed important factors for teaching and learning of undergraduate students. during the visit, the site evaluation form was completed by one of the researchers, while the site representative gave the team a tour of the facilities. thereafter an interview was conducted with the site representative. the interview focused on: staff employed at the clinical site; interdisciplinary activities; community outreach activities; treatment protocols; patient profile; administration; and management. at the end of the visit, the visiting team together with the site representative formulated a summary of the visit by using the framework of a swot (strength, weakness, opportunity and threat) analysis of the site. this approach was used to extract the data into the significant swot aspects as relevant for physiotherapy undergraduate training, while immediately summarising the information. data management and analysis the quantitative data generated by the time sheets were recorded in a purpose-built data collection sheet in ms excel. descriptive data analysis was performed using statistica version 7. the qualitative data generated during the interviews were deductively analysed using the swot analysis as an analytical framework. results summary of site visits seven of the nine clinical service sites used for third-year placements were visited by the research team. two of the sites could not accommodate the research team at the allocated times because of clinical activities. strengths and opportunities identified strengths included the travelling distance to the clinical sites, with three of the sites within close proximity of the fmhs, therefore table 1. site evaluation tool components needed criteria staff • staff available for consultation on the block • staff available for clinical supervision on the block facilities • availability of treatment space/group treatment areas • number of patients attending the facility • equipment availability/electrotherapy, mats appropriate for the block, plinth, telephone, basin, desk and chair • equipment in good working order • laundry services students • number of students on the block • number of patients seen by the students on an average day • number of hours a week that the students receive supervision on the block • student locker facilities • possibility of multidisciplinary work patients • list of most common presenting conditions in the facility, and do they align with the outcomes for the block? • compliance with appointments administration • availability of files and other patient information • availability of administrative staff • availability of support regarding evaluation forms, information sheets • how are bookings made for the students? • referral system • systems for contacting outpatients transport • transport of students to and from the clinical site • patient transport services research october 2014, vol. 6, no. 2, suppl 1 ajhpe 209 reducing the travelling time of students to and from the clinical site. the other clinical areas were located within a 20 45-minute drive from the faculty. a valuable strength of the majority of clinical sites was the large patient numbers available and the variety of conditions the patients presented with that were suitable for third-year physiotherapy students. at three of the clinical sites, the staff were approachable and eager to have students at their facilities. opportunities for development at the clinical site that could impact on the quality of learning of the students included the support and development of clinical physiotherapists at the sites who were eager to learn and grow. two of the clinical physiotherapists were recent graduates themselves (2 years previously). the potential existed for the development and expansion of multidisciplinary services, a variety of group classes and/or factory visits at five of the clinical sites. weaknesses and threats a number of weaknesses and threats were identified at these clinical service sites. one of the weaknesses that could impact on the learning of students was the lack of clinical physiotherapists. more than half the sites (57%, n=4) did not have full physiotherapy staff levels, whereas at one site the clinical physiotherapists had only sessional posts. four of the seven visited sites lacked basic physiotherapy equipment needed for patient management, e.g. exercise equipment, electrotherapy machines, etc. threats at the clinical sites included poor safety and security for patients, students and staff members. six (86%) of the sites evaluated reported concerns relating to safety. safety issues raised included theft of equipment (n=4) and the theft of valuables of staff and students, e.g. cell phones (n=2). at three of the clinical sites concerns related to lack of infection control protocols were also highlighted. table 2 summarises the data relating to site evaluation problems. student record sheets similar patient statistics were recorded for the three clinical placements (orthopaedics, neurology and medical and surgical). because of the small ratio of students versus referred patients at clinical sites, students only recorded an average of two treatment sessions per day. table 3 shows that there was a significant difference in the clinical exposure of students during the respective clinical rotations. students placed at a primary healthcare facility for their clinical placement in orthopaedics were more likely to see patients with cold orthopaedic pathology than students placed at a tertiary facility (p<0.0001). students placed at a tertiary hospital were more likely to see patients suffering from acute neurological conditions when compared with students placed at a primary healthcare facility (p<0.0001). students placed at a tertiary hospital were more likely to treat patients following surgery when compared with students placed at a secondary hospital (p<0.0001). discussion this study identified a number of factors that could negatively impact on the learning of students placed at clinical service sites for practical training experiences. firstly, the clinical sites utilised for the clinical placements offered variable clinical exposure to certain pathologies. secondly, although the majority of clinical sites had large patient numbers, the ratio of patients to physiotherapy students was low at some clinical sites, which curtailed opportunities for students to interact with patients. skoien et al.[1] reported on the value of patient interaction for the development of communication skills, practical skills and clinical reasoning. there have been calls to standardise the breadth of practice settings in clinical education, but further research in this field is required.[14] when students are first exposed to patients, it is very important for them to have sufficient space, time and the necessary equipment available for patient management.[1] in this study we found that space and equipment were limited at some clinical sites. this could be detrimental to students’ ability to develop planning and organisational skills and prioritisation of physiotherapy services. furthermore, patient care is likely to be compromised by the lack of basic equipment in the clinical sites. it has previously been reported that clinical physiotherapists at service sites act as role models and potential mentors for undergraduate students.[11] at more than half of the sites there was a lack of sufficient staff, which could have a negative impact on student learning. table 2. site evaluation problems at seven sites problems identified during evaluation of seven sites n (%) physiotherapy posts not available/sessions 4 (57) insufficient individual treatment space 2 (29) insufficient basic equipment available 4 (57) safety of staff and equipment 6 (86) not enough patients 1 (14) lack of infection control 3 (43) table 3. student exposure to patient care clinical rotation exposure conditions tertiary level placement % (n/n) secondary level placement % (n/n) primary level placement % (n/n) p-value orthopaedics cold 0 (0) 74 (326/440) <0.001 sports injuries 0 (0) 1 (5/440) 0.32 trauma 100 (130/130) 25 (109/440) <0.001 medical and surgical conditions medical surgical burns 8 (22/272) 85 (222/272) 10 (28/272) 52 (146/279) 33 (92/279) 15 (41/279) <0.001 <0.001 0.12 neurological acute 58 (84/145) 45 (47/105) 2 (6/262) 0.04 rehabilitation 41 (60/145) 55 (58/105) 95 (250/262) 0.04 traumatic injuries 0 (1/145) 0 (0) 2 (6/262) 0.42 research 210 october 2014, vol. 6, no. 2, suppl 1 ajhpe safety, for both patients and students, was a big concern at the majority of the clinical sites visited; incidents of petty theft of personal items and physiotherapy equipment were reported. safety of patients at healthcare facilities has been identified as one of the seven key domains of the national core standards for improving healthcare services in south africa.[13] the lack of a safe and secure environment could negatively impact on students’ perceptions of healthcare. furthermore, brown et al.[17] noted that students prefer a more positive and relaxed environment as being conducive to their learning. we acknowledge that the data presented in this paper provide a limited snapshot of the clinical sites used for undergraduate physiotherapy training at one institution only. this aspect limits the generalisability of the specific findings but the data do provide an idea of the key elements of clinical training sites that require careful review before placing students at these sites. based on our findings we propose that when selecting clinical sites for training healthcare students the following should be considered: (i) the physical environment and available facilities and equipment required for student training; (ii) equivalence of the clinical exposure students will have at the various clinical sites; and (iii) development of additional learning opportunities to optimise the clinical exposure in a clinical rotation. the site evaluation tool developed in this study could be useful in this regard. the tool could also be adapted and used by other programmes to investigate the viability of potential clinical service sites for the training of healthcare students. finally, we argue for a more active, participatory role by universities in the clinical training of undergraduate healthcare students and the development of suitable clinical training facilities. the need for academic institutions to develop partnerships with health service providers is evident from the study results. the partnership should seek to inform the development of healthcare services that provide optimal care for the population, while also providing adequate learning facilities and opportunities for students. the development of a socially accountable evaluation framework for the accreditation of medical training programmes by the medical and dental professions board of the hpcsa is an encouraging advance in this direction.[5] it will be valuable for other health professions boards also to align their commitment to meeting these training programme requirements. funding. funding was received from the fund for innovation and research into teaching and learning, centre for teaching and learning, stellenbosch university, south africa. author contributions. all authors were involved in conception, design, analysis or interpretation of data. lw drafted the manuscript. all authors critically reviewed the manuscript and approved the final version. acknowledgements. the authors thank mrs ria bester for her involvement in the study, as well as the participants, for their time and input. references 1. skoien ak, vagstol u, raahiem a. learning physiotherapy in clinical practice: student interaction in a professional context. physiotherapy theory and practice 2009;25(4):268-278. [http://dx.doi.org/10.1080/09593980902782298] 2. lekkas p, larsen t, kumar s, et al. no model of clinical education for physiotherapy students is superior to another: a systematic review. australian journal of physiotherapy 2007;53:19-28. 3. mccallum ca, mosher pd, jacobson pj, gallivan sp, giuffre sm. quality in physical therapist clinical education: a systematic review. phys ther 2013;93(10):1298-1311. [http://dx.doi.org/10.2522/ptj.20120410] 4. higgs j. managing clinical education: the educator manager and the self-directed learner. physiotherapy 1992;78:822-828. 5. van heerden b. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2013;103(1):21-22. [http://dx.doi.org/10.7196/samj.6463] 6. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 7. health professions council of south africa. http://www.hpcsa.co.za (accessed 8 september 2014). 8. rauk rp. knowledge integration: theory and practice in physical therapy education. journal of physiotherapy education 2003;17(1):39-47. 9. higgs j, burns a, jones m. integrating clinical reasoning and evidence-based practice. aacn clinical issues 2001;12(4):482-490. 10. ernstzen dv, bitzer e. the roles and attributes of the clinical teacher that contribute to favourable learning environments: a case study from physiotherapy. south african journal of physiotherapy 2012;68(1):9-14. 11. ernstzen dv, bitzer e, grimmer-somers k. physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: a qualitative study. south african journal of physiotherapy 2010;66(3):25-31. 12. kilminster sm, jolly bc. effective supervision in clinical practice settings: a literature review. med educ 2000;34(10):827-840. [http://dx.doi.org/10.1046/j.1365-2923.2000.00758.x ] 13. national core standards for health establishments in south africa. national department of health 2011. http:// www.sarrahsouthafrica.org/linkclick.aspx?fileticket=ynbshfr8s6q= (accessed 8 september 2014). 14. wetherbee e, peatman n, kenney d, cusson m, appelbaum d. standards for clinical education: a qualitative study. journal of physical therapy education 2010;24(3):35-43. 15. ladyshewsky rk, barrie sc, drake vm. a comparison of productivity and learning outcome in individual and cooperative physical therapy clinical education models. phys ther 1998;78(12):1288-1298; discussion 1299-1301. 16. minimum requirements for equipment and physical facilities for physiotherapy services at all levels of care, 2003. http://saphysio.warpdemo.co.za/docs/default-source/community-service/minimum-standard-for-equipmentand-facilities-jan-2005.pdf ?sfvrsn=2 (accessed 8 september 2014). 17. brown t, williams b, mckenna l, et al. practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students. nurse education today 2011;31:e22-e28 [http://dx.doi.org/10.1016/j.nedt.2010.11.2013] research may 2016, vol. 8, no. 1 ajhpe 33 the creating of clear and accurate patient medical records, and their maintenance and storage, are an important part of the professional training of a dental student. the records of an individual patient in a dental setting constitute the clinical notes, radiographs and plaster models, as well as other information. these records present an in-depth and continuous documentation of the patient’s condition, which helps to contribute to both diagnosis and proper patient care.[1,2] in addition, these records have various other purposes, including research, administration, quality assurance, teaching and learning, and can be used as evidence during legal proceedings.[3,4] patient records have traditionally been paper-based but electronic documentation, in addition to residual paper-based records, is being increasingly used because of the inherent disadvantages of paper-based systems. documented problems of paper-based systems in the literature[5] include difficulty in deciphering clinician handwriting, difficulty in accessing patient information from remote centres, time-consuming patient chart retrieval, and questionable security and confidentiality of records.[6] the other challenge identified with paper-based records is their incompleteness,[6,7] i.e. the omission of vital information, such as laboratory results or radiography reports, from the patient record. missing information has been shown to have consequences, including delays in patient care, repeated laboratory testing and additional patient visits, which also adversely affect the wellbeing of patients. in addition to the pressure to reduce patient length of stay in hospital, this highlights the need for investigation into the use of electronic records. the pace of modern practice dictates the use of technology, but the lack of direct clinical input in the development of information technology is a major factor in the failure of many clinical information systems.[8] replacing paper records with electronic records will assist in changing medical practice, including relationships between doctors and nurses, responsibilities, and work distribution. however, clinicians need to involve themselves in ensuring that software for documenting patient encounters complements the way they work. documentation and note taking continue to be an area of concern because quality documentation is an important aspect of communication by health professionals. the notes of any health professional serve as a window into their thought processes.[9] during student training, communication through note taking is an important aspect of exchange of information with colleagues and patients. therefore, teaching and learning of students in written and verbal communication skills is a key component of health professional curricula. some academics[10] have advocated that it is now more important than ever that education and practice in professional writing and speaking should be included as part of medical training and residency. furthermore, national quality-regulating bodies such as the accreditation council for graduate medical education in the usa, a body that establishes educational standards, have included interpersonal skills and communication as one of six core competencies for all training programmes.[11] at the makerere college of health sciences (makchs), kampala, uganda, teaching and learning in interpersonal and communication skills are included in the undergraduate dental curriculum. these skills are expected to be background. the creating, maintenance and storage of patients’ medical records is an important competence for the professional training of a dental student. objective. owing to the unsatisfactory state of dental records at the students’ clinic, the objective of this study was to obtain information from undergraduate dental students on the factors that affect this process and elicit recommendations for improvement. methods. this qualitative cross-sectional study used focus group discussions with 4thand 5th-year dental students for data collection. data were captured through a written transcript and an audio recorder. the data were transcribed and analysed manually through developing themes, which were compared with the literature and interpreted. results. three themes emerged: (i) poorly designed clerking forms. the clerking forms were deemed to have a poor design with inadequate space for clinical notes. it was recommended that they be redesigned. (ii) inadequate storage space. space for storing patient records was deemed inadequate and a referencing system for file retrieval was lacking. it was recommended that more space be allocated for storage, with a referencing system for easy file retrieval. (iii) poor maintenance of records. patients’ records, especially radiographs, were not well labelled and stored. it was recommended that drug envelopes be utilised to store radiographs. an electronic system was deemed the ultimate solution to this problem. conclusion. the general perception was that the current paper-based record system at the clinic was unsatisfactory. therefore, there is a need to improve the maintenance and storage of records, and to change to a more efficient electronic system. the students’ attitude towards record keeping was found to be questionable, with a need to be addressed as part of teaching and learning in the curriculum. lecturers were deemed to have a bigger role to play in the record-keeping process. afr j health professions educ 2016;8(1):33-36. doi:10.7196/ajhpe.2016.v8i1.521 perceptions of undergraduate dental students at makerere college of health sciences, kampala, uganda towards patient record keeping a m kutesa,1 bds, msc (dent); j frantz,2 phd 1 department of dentistry, college of health sciences, makerere university, kampala, uganda 2 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: a m kutesa (akutesa@chs.mak.ac.ug) research 34 may 2016, vol. 8, no. 1 ajhpe demonstrated by the students, particularly during the clinical years, when they interact with other professionals and patients through record keeping. at makchs dental clinic, the record-keeping system is paper based and patient records have recently had many challenges, which include the loss of patient records, poor status and incomplete records. moreover, the storage of the patient records is inadequate, using cardboard boxes as a filing system, making it difficult to trace patient information when they come for recall visits. these challenges have had an effect on student learning and patient care. despite these concerns, no study has been done among the faculty and students to document their perceptions of the status quo. the objective of this study was to document the perceptions of undergraduate dental students at makchs of factors that affect the keeping of clear and accurate patient records, and their maintenance and storage. it also elicits recommendations to improve the system for better teaching and learning at makchs. methods research setting and design this was a cross-sectional study using descriptive qualitative methodology, conducted at the department of dentistry, makchs. population and sampling the study population comprised 4thand 5th-year dental students (n=20) and faculty members (n=2). fourthand 5th-year students were selected to participate because, at this time, they were in their clinical clerkships and actively used medical records as part of patient care. of the 18 faculty members at the department of dentistry, two were purposefully selected to participate in the study, as they were actively involved in student training for this competence and supervision at the clinic. data collection methods the instrument used for data collection comprised a structured focus group discussion exploring the creating, maintenance and storage of patient records. the interview guide was developed by the authors to ensure that participants were allowed to discuss their perceptions concerning different aspects of patient record-keeping competence, which included knowledge on patient charting, its existence in the curriculum, gaps identified, and recommendations to improve the curriculum. two focus group discussions were conducted. one group comprised 4th-year dental students and the other 5th-year dental students. the dental classes are small, with 10 15 students per year, and thus all students were invited to participate in the study. a total of 10 students per focus group were interviewed, and the discussions took place in a lecture room at the department of dentistry for an hour each. focus group discussions were conducted by one of the researchers (ak) using a structured interview guide. a 5th-year dental student was used as a research assistant and captured the discussions through a written script and a voice recorder. to establish the trustworthiness of this research, the concepts of credibility, transferability, dependability and confirmability were considered as decisive factors for quality, based on guba’s four criteria for trustworthiness.[12] credibility was addressed by describing the methods in detail in the protocol to convey the actual situations that would be investigated. to allow transferability, sufficient detail of the study context has been reported in this article to enable other researchers to decide whether the setting is similar to others and whether the findings can be applied to other settings. dependability has been achieved by describing the methodology clearly to enable a future investigator to repeat the study. to achieve confirmability, the findings that emerged from the data were supported by quoting the participants’ words during the discussions. data analysis after the interviews, the data were transcribed and checked for correctness by cross-checking with the three data sources (the notes of the researcher, the research assistant and the recorder). data were coded by the author using the open code system.[13] coding was done by first using a start list of preset codes. the initial preset codes were three: making, maintenance and storage, which were derived from the study objective. themes were developed from the coded data with the help of an expert in qualitative analysis, and the emerging themes were compared with the data and finally interpreted. the participants’ quotes were identified and labelled using a method devised by the authors. as an example, a quote would be labelled with the year of study as the first digit and the participant number as the second digit. y3p1 would signify a 3rd-year student, participant 1. the emerging themes were checked by one of the authors (jf). ethical considerations ethical clearance to carry out the study was obtained from the school of medicine review and ethics committee. prior to commencement, gatekeeper permission was obtained from the department of dentistry and the faculty. written consent was obtained from the selected participants in accordance with the helsinki declaration. the investigators informed the participants of the procedure, its objectives and benefits, and any possible risks involved. confidentiality was ensured by avoiding the use of any person identifiers. results the two focus group discussions consisted of a total of 20 participants, of whom 10 were female and 10 were male. the 5th-year group had 7 females and 3 males, and the 4th-year group had 4 females and 6 males. the transcribed data from the interviews produced three themes: poorly designed clerking forms, inadequate storage space and poor maintenance of records. the following issues within the themes were highlighted: inadequacy of the currently used clerking forms, patient files, labelling and the electronic system. poorly designed clerking forms it emerged that the current clerking forms were in need of a redesign as they have insufficient space to make clinical notes, and seemed disorganised in design. in addition, owing to the texture of the paper used, they were not easy to store. ‘clerk forms do not have enough space for patient recall notes.’ (y5p2) ‘the clerk form is disorganised, they need to be re-designed.’ (y5p1) ‘record keeping should be improved.’ (y4p6) inadequate storage space the participants felt that the current space for storing patient records was inadequate. in addition, referencing to facilitate patient file retrieval needed updating. it was recommended that management use box files to store research may 2016, vol. 8, no. 1 ajhpe 35 patient records and provide a bigger storage area with a reference system for ease of file retrieval. ‘we need more room to store the patient records, our lockers are too small.’ (y5p3) ‘we need a reference system to be able to retrieve old patient records.’ (y4p9) ‘we don’t know how to get the records, apart from using patient names.’ (y4p9) ‘sometimes we end up reclerking or asking the patient their previous treatment.’ (y4p9) maintenance it emerged that patient records, especially radiographs, were not well labelled. furthermore, their storage was poor. it was unanimously recommended that drug-dispensing envelopes should be labelled and used to store patient radiographs; the introduction of an electronic system to improve storage was also recommended. ‘x-rays should be kept in labelled envelopes and stored in files.’ (y5p6) ‘we need the electronic system for better storage.’ (y5p7) the consensus was that there was an urgent need to introduce an electronic system for better record keeping. respondents also felt that the lecturers had a bigger role to play in record keeping but had not emphasised the aspects of maintenance and storage of patient records. the students also felt that they needed more training in record keeping and guidance from the supervisors. ‘all lecturers at the clinic should emphasise record keeping.’ (y5p1) ‘supervisors at the clinic do not put in enough.’ (y4p2) the recommendations that were given were practical and easy to implement. the students also thought that the responsibility of good record keeping lay with their supervisors and not with themselves. ‘x-rays should be kept in labelled envelopes and stored in files.’ (y5p6) ‘provide box files for each of us to keep the patient records.’ (y4p2) ‘someone should be hired for record keeping.’ (y4p2) ‘lecturers have a bigger role to play in record keeping but they have not put a lot of emphasis on it.’ (y4p1) discussion record keeping is an important competence that, as a key responsibility of the dentist in clinical practice, must be developed during the professional training of a dental student. a dentist is obliged, ethically and legally, to keep patient records that are accurate, legible, comprehensive and organised because appropriate decisions are based on accurate and complete facts retrievable from a patient’s record.[14] this is emphasised through various guidelines from medical and dental councils internationally,[15-17] which state that patient records must be clear and accessible. according to these guidelines, records must formally record patient details, clinical findings and treatment given, among other details. these records should be kept securely and in line with dataprotection requirements of the institution for a period of not less than 10 years from when the patient last attended the clinic for treatment.[17] owing to the inadequacies observed by the authors with patient records at makchs dental school clinic, the next step was to obtain information and create awareness among the undergraduate dental students and the faculty of the factors that affect this process, with the overall objective of improving the quality of service rendered by dental professionals. in view of the international guidelines discussed above,[15,16] we found that the students felt that the dental records were being inadequately stored and maintained at the clinic. we thought this was unfortunate because accurate records, in part, are considered important for good clinical decisions[13] and, therefore, better treatment outcomes. the students expressed the need for more training in record keeping and guidance from the supervisors. this information was beneficial to educators and will guide us in improving student training at the clinic, especially supervision. this finding is corroborated elsewhere, where students have been found to be a source of information that can provide formative feedback to faculty for improving teaching, course content and structure.[18] we also found that the students were able to give recommendations that are practical and easy to implement. as an example, they suggested the use of drug envelopes and box files to store patient radiographs and records. these recommendations we believe will be taken into consideration as we plan to improve patient record storage and maintenance. the reaction of the students in this study was interesting, showing that they expected the challenges to be solved by someone else. they felt that the responsibility for good record keeping lay entirely with others rather than with the students. they commented that someone should be hired for record keeping and that lecturers had a bigger role to play in record keeping. this showed us that the students were aware of inadequate recordkeeping practices at the clinic, but that they took no initiative to effect change to improve the situation. this implies that the students cannot easily show initiative to change challenging situations, even when they are aware of them, expecting others to take the lead. therefore, we realise that students need to be taught to be agents of change, and advocate change in their work environment to improve practice.[19] this remains a challenge, as the problem will not be solved if students do not accept this responsibility during their training. educators will need to ensure that this aspect in the curriculum is highlighted and receives the attention it deserves. conclusion the general perception was that the current paper-based record system at the clinic was unsatisfactory. therefore, there is a need to improve the storage of records and their maintenance, and to change to a more efficient electronic system. the students’ attitude to record keeping was also found to be questionable, emphasising a need to be addressed as part of teaching and learning in the curriculum. supervisors need to take on a more supportive role and guide the students towards good record-keeping practices. medical record-keeping clinical skills are a core part of the training of a dental student and should be given the platform they deserve in the curriculum. acknowledgements. we highly appreciate the support of both the medical edu cational partnership initiative/medical education for equitable services for all ugandans (mepi/mesau) and the sub-saharan africa-faimer regional institute (safri) accorded during the course of this study. research 36 may 2016, vol. 8, no. 1 ajhpe references 1. cole a, mcmichael a. audit of dental practice record-keeping: a pct-coordinated clinical audit by worcestershire dentists. prim dent care 2009;16(3):85-93. [http://dx.doi.org/10.1308/135576109788634296] 2. osborn jb, stoltenberg jl, newell kj, osborn sc. adequacy of dental records in clinical practice: a survey of dentists. j dent hyg 2000;74(4):297-306. 3. charangowda bk. dental records: an overview. j forensic dent sci 2010;2(1):5-10. [http://dx.doi. org/10.4103/0974-2948.71050] 4. soisson el, van de creek l, knapp s. thorough record keeping: a good defense in a litigious era. professional psychology: research and practice 1987;18(5):498. 5. zandieh so, yoon-flannery k, kuperman gj, langsam dj, hyman d, kaushal r. challenges to ehr implementation in electronic versus paper-based office practices. j gen intern med 2008;23(6):755-761. [http:// dx.doi.org/10.1007/s11606-008-0573-5] 6. hersh wr. the electronic medical record: promises and problems. j am soc inf sci 1995;46(10):772-776. 7. smith pc, araya-guerra r, bublitz c, et al. missing clinical information during primary care visits. j am med ass 2005;293(5):565-571. [http://dx.doi.org/10.1001/jama.293.5.565] 8. walsh s. the clinician’s perspective on electronic health records and how they can affect patient care. br med j 2004;328(7449):1184-1187. [http://dx.doi.org/10.1136/bmj.328.7449.1184] 9. cegala dj, broz sl. physician communication skills training: a review of theoretical backgrounds, objectives and skills. med educ 2002;36(11):1004-1016. 10. simonson ja. why we must teach written and verbal communication skills to medical students and residents. acad med 2013;88(4):435. [http://dx.doi.org/10.1097/acm.0b013e3182854f57] 11. accreditation council for graduate medical education (acgme). core competences. 2003. http://www.ecfmg. org/echo/acgme-core-competencies.html (accessed 14 july 2014). 12. guba eg. criteria for assessing the trustworthiness of naturalistic inquiries. educ commun tech j 1981;29(2):75-91. 13. lofland j, lofland lh. analyzing social settings: a guide to qualitative observation and analysis. belmont, usa: wadsworth publishing company, 1995. 14. record keeping outline – oregon.gov. www.oregon.gov/obce/publications/record_keeping_ch_final_jan06. pdf (accessed 14 july 2014). 15. the guidelines of the royal college of dental surgeons, may 2008. www.rcdso.org (accessed 8 july 2014). 16. good medical practice. 2013. http://www.gmc-uk.org/guidance/ (accessed 14 july 2014). 17. record keeping in the uk. 2012. http://www.dentalprotection.org/uk/riskmanagement/recordkeeping/ (accessed 8 july 2014). 18. marsh hw, roche l. the use of students’ evaluations and an individually structured intervention to enhance university teaching effectiveness. am educ res j 1993;30(1):217-251. [http://dx.doi.org/10.3102/00028312030001217] 19. dunne e, roos z, tony brown t, nurser t. students as change agents: new ways of engaging with learning and teaching in higher education. york, uk: escalate/higher education academy publication, 2011. 130 october 2016, vol. 8, no. 2 ajhpe short research report many african countries are involved in complex plans to improve medical education as part of health sector strengthening. several governments in sub-saharan africa are investing heavily in human resources for health in response to this urgent need.[1] the 2010 united nations report projects the establishment of numerous new medical schools in the sub-saharan region by 2020.[1] in 2007, boulet et al.[2] reported that 16 of 57 african nations did not have a medical school; many of the southern african countries were among these. in southern africa, the botswana and lesotho governments have established their first medical schools in their countries. these countries and swaziland have a long history of partnership through the university of botswana, lesotho and swaziland (ubls) system. this is a derivative of what was commonly known as the boleswa partnership. swaziland, however, has a newly founded private medical school.[3] the ubls was established in lesotho in 1964 by a royal charter, two years before botswana, lesotho and swaziland attained independence.[4,5] it was founded to address manpower constraints in the face of the soon-to-be newly independent countries that needed to ‘sustain [their] existence’.[4,5] the ubls was based between the main campus in lesotho and the evolving campuses in botswana and swaziland. the countries had agreed to concentrate on different professional trainings: botswana in engineering, swaziland in agriculture, and lesotho in medicine.[4,5] the three governments were not able to achieve their goal of establishing a medical school in lesotho owing to the collapse of the ubls. the three countries ultimately established their own separate universities. the university of botswana school of medicine before the establishment of the university of botswana school of medicine (ubsom), botswana placed >500 students in >15 partner medical schools. the training of students outside botswana cost the government more than usd500 million in tuition and living expenses. unfortunately, too few students return to botswana upon completion of their training. those who do return are not retained owing to their inadequate adaptation on the botswana healthcare environment; this continued to put strain the system. this model of training medical doctors proved to be financially unsustainable. the number of batswana doctors remains too low to meet the increasing population and demand for improved healthcare service delivery. in 1995, the government commissioned a feasibility study to explore the notion of starting a medical school. this was followed in 1998 by a presidential directive to establish a medical school in phases. the first phase involved training selected students in botswana for two years of a bsc degree before sending them to various partner medical schools in south africa, australia, europe and the caribbean. in august 2009, the ubsom accepted its first medical students, who completed their training locally. this marked the final phase in the establishment of a medical school. the first cohort of botswana-trained doctors graduated in october 2014 and the second in 2015. the lesotho medical school several efforts were made since 1974 to establish a medical school in lesotho. while preparing for this, lesotho – as botswana – trained its students in other countries and faced similar financial and human resource losses. the last effort was made in 2010. it was preceded by a positive feasibility study and a roadmap for the project. because of the urgency of the project, the university of zimbabwe assisted lesotho by training three cohorts of students in biomedical sciences and preclinical work. the first cohort will complete their training in 2016, their degrees being awarded in southern africa, former members of the botswana-lesotho-swaziland (boleswa) partnership, botswana and lesotho, have established their first and only publicly funded medical schools in their countries. swaziland has a private medical school. the three countries have a long history of partnership through the university of botswana, lesotho and swaziland (ubls) system − a derivative of boleswa. botswana and lesotho are also members of a newly founded consortium of new southern african medical schools (consams). the ubls was established in lesotho in 1964 by a royal charter, two years before the three countries gained independence. it was founded to address manpower constraints in anticipation of their independence. the three countries had agreed to concentrate on different professional trainings, as follows: botswana in engineering, swaziland in agriculture, and lesotho in medicine. consams was established as a unique collaborative approach involving south-south networks, which included south-north partnerships. this created an opportunity to strengthen medical education in the region. the boleswa partnership is further strengthened by participation in consams by two of the five founding members. other members include mozambique, namibia and zambia. a sharing of resources through regional and international partnerships has been established. the sub-saharan african medical school study has examined the challenges, innovations, and emerging trends in medical education in the region and has made recommendations on how to better share resources. consams is one innovative way of addressing these issues. partnerships between the boleswa countries have been strengthened through consams. this has afforded the new medical schools sharing of their limited resources. afr j health professions educ 2016;8(2):130-131. doi:10.7196/ajhpe.2016.v8i2.525 remembering old partnerships: networking as new medical schools within boleswa countries l badlangana,1 phd; k matlhagela,1 phd; n tlale,2 mb chb, mmed (o&g) 1 department of biomedical sciences, faculty of medicine, university of botswana, gaborone, botswana 2 medical school of lesotho, ministry of health, maseru, lesotho corresponding author: l badlangana (ludo.badlangana@mopipi.ub.bw) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 131 by the university of zimbabwe until the lesotho medical school (lms) becomes fully operational. a consortium of new medical schools, the consortium of new southern african medical schools (consams),[6,7] has been formed and includes botswana and lesotho as founding members. this new partnership has resuscitated the old relationship of boleswa between the two countries. it was established as a unique collaborative approach involving south-south networks, which include a north-south partnership.[7] the network creates a unique opportunity to strengthen medical education in the region.[7] southern africa has an extremely low physician to high population ratio, as is the case throughout sub-saharan africa. a number of reports and recommendations have been published advising policy makers and medical schools on medical education in the region, such as the sub-saharan african medical school study (samss). samss examined the challenges and emerging trends in medical education in the region.[8] in southern africa, there is an effort by consams to address such challenges through the collaboration of new medical schools by sharing and exchanging resources via a well-planned platform. hosting a consams meeting to capacitate the newly formed schools and to ensure that consams objectives are carried forward, partners communicate frequently to exchange ideas and report on the progress of key objectives by various means, including annual meetings. the consams schools alternately host the meetings, which assist the schools to attract key stakeholders to continue their support, as they share and appreciate the successes and challenges experienced by such schools. consams has held six meetings since its inception in 2010. the ubsom hosted the third meeting in november 2012 and the lms the fourth meeting in october 2013. a number of funders have assisted in the running costs of consams and annual meetings and workshops that are regularly held. the partners include consams medical education partnership initiative (consamsmepi), the world health organization (who), and the global health through education, training and service (ghets).[9] our unique network forms a common medical training ground for our students. this has become invaluable to tackle our healthcare challenges. we have the flexibility to standardise our individual curricula according to our local contexts, e.g. we have facilitated faculty exchanges, external examiners, and student exchanges. the students are able to complete electives across varying environments without loss of time and finances. conclusion consams has facilitated the revival of the next era in the boleswa partnership, going beyond politics and investing in a healthier southern africa. references 1. joint learning initiative. human resources for health. overcoming the crisis. cambridge, ma: harvard, 2005. 2. boulet j, bede c, mckinley d, norcini j. an overview of the world’s medical schools. med teach 2007;29(1):20-26. doi:10.1080/01421590601131823 3. magadza m. swaziland: first school of medicine to be built. university world news, 3 july 2011. http://www. universityworldnews.com/article.php?story=20110701161600103 (accessed 5 july 2016). 4. mokopakgosi bt. why the university of botswana, lesotho and swaziland failed: lessons from the brief history of a regional university in southern africa. j southern african studies 2013;39(2):465-480. doi:10.1080/03057070.2013.796737 5. vernon-jackson hoh. creating a new university campus: the university of botswana, lesotho and swaziland. mcgill j educ 1973;8(2):198-207. 6. magadza m. africa: new medical schools seek strength in numbers. university world news, 20 november 2011. http://www.universityworldnews.com/article.php?story=20111118205356486 (accessed 5 july 2016). 7. eichbaum q, nyarango p, bowa k, et al. global networks, alliances and consortia in global health education − the case for south-to-south partnerships. j acquir immune defic syndr 2012;61(3):263-264. doi:10.1097/ qai.0b013e31826bf957 8. mullan f, frehywot s, chen c, et al. the sub-saharan african medical school study (samss): data, observation, and opportunity, 2010. https://smhs.gwu.edu/medicine/sites/medicine/files/125.pdf (accessed 5 july 2016). 9. global health through education, training and service. local knowledge, global health. www.ghets.org/ (accessed 5 july 2016). short research report http://dx.doi.org/10.1080/01421590601131823 http://dx.doi.org/http://www.universityworldnews.com/article.php?story=20110701161600103 http://dx.doi.org/http://www.universityworldnews.com/article.php?story=20110701161600103 http://dx.doi.org/10.1080/03057070.2013.796737 http://www.universityworldnews.com/article.php?story=20111118205356486 http://dx.doi.org/10.1097/qai.0b013e31826bf957 http://dx.doi.org/10.1097/qai.0b013e31826bf957 http://dx.doi.org/https://smhs.gwu.edu/medicine/sites/medicine/files/125.pdf http://dx.doi.org/www.ghets.org/ research 222 october 2014, vol. 6, no. 2, suppl 1 ajhpe curriculum renewal in health education is not novel. educational institutions have an ethical obligation to produce quality graduates capable of addressing their communities’ healthcare needs. however, a worldwide ongoing change in the profile of disease with resultant increase in burden on personal and government resources means that health education programmes need to change. these programme changes should not just occur at content level but should also consider the changing profile of the undergraduate student which is affecting their readiness for tertiary level education.[1] programme evaluation is therefore essential not just for ensuring effective and fiscally responsible use of government resources, but should also evaluate the impact change on the student stemming from this curriculum renewal. background in 2007 a renewed physiotherapy curriculum was implemented at stellenbosch university (su) which aimed to meet these multiple challenges but still produce graduates capable of independent practice in a community setting. although the scope of physiotherapy practice is rapidly expanding, the undergraduate programme was forced to cut back on content and students’ critical reasoning, problem-solving and managerial skills needed to improve. the profile of an su physiotherapy graduate was revisited, and a new, more appropriate and flexible curriculum was developed which aimed to assist the development of manual skills while developing skills of reflection, communication, information gathering and critical analysis, safety, group work (team, organisation and community), evidence-based practice, professionalism, problem solving, ethical practice and lifelong learning. this skills set was aligned with the graduate attributes identified by the faculty of medicine and health sciences (fmhs), su. a phronetic approach was taken in that the process followed for curriculum renewal was predominantly based on craft knowledge[2] and relied in most part on the intuitiveness of the current staff, none of whom had a formal background nestled in education. the framework that guided the process closely follows that of an instructional systems design using the addie model (analysis, design, develop, implement/delivery & evaluation).[3] a swot analysis was used to identify the strengths, weaknesses, threats and opportunities of the changing learning and healthcare environment; a nominal group technique[4] was used to identify core content; and a survey of the literature guided decisions regarding best practice methods of teaching and learning. the end product the end product of the above process was a newly constructed physiotherapy undergraduate curriculum. the curriculum consists of four phases: phase 1. this forms the scientific foundation for the practice of physiotherapy which is laid down in the first 18 months of the programme (years 1 and 2). phase 2. over the next 12 months there is a gradual integration of pathology and environmental factors into the science of physiotherapy and the early development of clinical reasoning skills (years 2 and 3). background. driven by a changing healthcare environment, the division of physiotherapy (stellenbosch university) reduced core content and adopted a multimodal approach to teaching and learning. the benefits of curriculum renewal, however, are seldom investigated despite ongoing internal appraisal. evaluation of the bsc physiotherapy programme was considered incomplete without determining the worth of the programme. objectives. to determine whether there was a change in students’ perception of the impact of the programme on personal development; and whether the programme prepared them for community service. methods. a descriptive comparative desktop analysis was conducted in which the data from the faculty’s programme evaluation process were compared between students enrolled in the old curriculum (2006) and students enrolled in the new curriculum (2011) using pooled data and t-tests to compare responses between the two groups. a level of significance was set at p<0.05. results. a significant increase in scores was noted for various graduate attributes developed as a result of the programme, such as critical thinking, clinical reasoning, communication and sourcing information (p<0.01). similarly, students scored their perceptions related to programme structure significantly higher (p<0.01). no change was reported regarding students’ ability to maintain a balance between studies and other activities. scores pertaining to their perception of readiness for community service or professional practice remained the same with both cohorts believing they were well prepared. conclusion. the renewed format seemed to benefit students greatly in assisting the development of graduate attributes. students were significantly more satisfied with the structure of the renewed curriculum and – despite extensive changes – the principles-based multimodal approach to teaching and learning was perceived as effective for preparing students for community service. programmes undertaking curriculum renewal should not only focus on the curriculum content but also develop a variety of learning opportunities to facilitate the development of graduate attributes. the next cycle of evaluation should however reflect on clinical practice. ajhpe 2014;6(2 suppl 1):222-226. doi:10.7196/ajhpe.519 benefits of curriculum renewal: the stellenbosch university physiotherapy experience m unger, bphyst, msc (physio), phd; s d hanekom, bsc (physio), msc (physio), phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: m unger (munger@sun.ac.za) research october 2014, vol. 6, no. 2, suppl 1 ajhpe 223 phase 3. this phase is focused on refining clinical reasoning skills (years 3 and 4). phase 4. this phase can be viewed as pre-profession entry with increasing emphasis on autonomy and reflection (year 4). the learning opportunities and teaching methods used were aligned with the outcomes of each module. a wide variety of formats for the presentation of content were selected. these included lectures, discussions, group work, self-study and experiential learning.[5] didactic (lectures), small-group table 1. summary of teaching and learning events: a comparison between the old and new curricula year old curriculum new curriculum anticipated benefitslearning events assessment learning events assessment 1 lectures theory paper (short qs) lectures theory paper (short qs) ↑ knowledge base practical skills training ospe practical skills training ospe 2 lectures theory paper (short qs) lectures written integrated theory tests (basic level – body areas and systems based) ↑ knowledge integration practical skills training practical tests (1 hr) case-based practical skills training ospe wpbl nursing elective wpbl clinical patient interviews; nursing elective, task: ethics and understanding health services; observational review ↑ communication; collect, analyse and organise information; be culturally sensitive 3 lectures theory paper (short qs); development of a research proposal pbl mcqs; written integrated theory tests; development of a research (systematic review) proposal ↑ clinical reasoning ↑ awareness for evidence-based practice ↑ patient-centeredness ↑ multidisciplinary approach think critically practical skills training practical tests (1 hr) case-based practical skills training and case-based skills training (skills lab) dops progressive mastery of technical skills wpbl treatment of a known patient and evaluation of an unknown patient, block reports wpbl treatment of known and evaluation of unseen patients; block reports; dops community re-integration communication ↑ clinical reasoning work within a multi-professional team think critically 4 lectures theory paper (short and long qs) ebl tasks (case-based); self-development of an evaluation form; presentations; mcqs; written integrated theory tests promote clinical reasoning source relevant evidence-based literature wpbl treatment of a known patient and evaluation of an unknown patient wpbl treatment of known and evaluation of unseen patients; block reports; dops; tasks (management, human rights, reflection and referral letter) and submit a portfolio; service learning project presentations source relevant literature ↑ critical thinking ↑ health advocacy teacher primary research project mini-thesis systematic review article critical appraisal of the literature q = question; ospe = objective structured practical exams; wpbl = workplace-based learning; pbl = problem-based learning; mcqs = multiple choice questions; dops = direct observational procedural skills; ebl= enquiry-based learning. research 224 october 2014, vol. 6, no. 2, suppl 1 ajhpe problem-based (pbl)[6] and enquiry-based (ebl)[7] learning approaches are used to deliver prescribed knowledge; practical training sessions and a nearpeer tutorial system[8] are used to teach and practise manual evaluation and treatment techniques prior to entering the clinical ‘real world’ setting for continuous experiential learning. both horizontal and vertical scaffolding of complexity in theory training was achieved by gradually progressing from basic knowledge related to a singular body structure to integrated theory and complex pathology case presentations to workplace-based learning (wpbl)[9] opportunities. assessment should be constructively aligned with the teaching and learning opportunities and so a similar multimodal approach to assessment was adopted (table 1). practical skills development progresses from training and objective structured practical exams (ospes) performed on peers[10] to technique tests (direct observational procedural skills (dops)[11] performed on patients; to patient evaluation and treatment in the clinical environment (table 1). a method of continuous assessment was employed. this bold change to the traditional format of teaching and learning employed by most of the eight physiotherapy programmes offered in south africa (sa) required careful and close monitoring to ensure successful delivery, as well as ensuring ongoing development of this curriculum. to this end several internal audits by module coordinators (lecturers) were conducted to determine effect and perceptions of selected aspects of the 4-year degree programme. these allowed for identification of problem areas; amendments, where necessary, were made. reports from the su centre for teaching and learning (ctl)[12] regarding lecturer, module and (at the end of their degree programme) programme evaluation, together with the internal audits, provided information as to content, presentation and perceived enjoyment. it was important to ensure that the division’s throughput rate of 98% was maintained. the question remained, however, as to whether the renewed curriculum, regardless of reduced core content, which has a strong selfdirected learning focus, would be perceived by students to have a significant effect on personal development and still be effective for preparing students for professional practice within the sa context. methods a descriptive comparative desktop analysis was conducted in which the data from the faculty of medicine and health sciences programme evaluation process were compared for two bsc physiotherapy cohorts. responses from students enrolled in the old curriculum (2006) were compared with responses from students enrolled in the new curriculum (2011). ctl annually invites all final-year physiotherapy students to anonymously complete a paper-based programme evaluation feedback questionnaire at the end of their final academic year before their results are made known. the questionnaire has three sections aimed at obtaining information on: the extent to which the programme outcomes have been achieved; programme architecture; and programme (physiotherapy)-specific outcomes (table 2). all 30 questions require response on a five-point likert scale ranging from strongly disagree (1) to strongly agree (5). the first 10 questions assess whether the students feel that the programme empowered them across a wide range of generic skills including critical thinking, problem solving, taking responsibility for learning, working in a team, etc. the next 10 questions pertain to programme architecture in terms of communication, appropriateness of evaluation methods, structure, etc. the last 10 questions were more specifically related to physiotherapy; however, the responses to only two of these questions were deemed appropriate for analysis in this study, and pertained to whether the programme encouraged evidence-based practice and whether the programme prepared them sufficiently for their compulsory community service year. the questionnaire is handed out by an independent member from ctl to all students at the end of their last contact session with lecturers. all assessments, including the final professional clinical entry examination, have been completed by then. statistical analysis for each of the 22 selected questions, ctl reports the feedback as an average mark for the year group on a continuum of 1 5 which varies between ‘strongly disagree’ to ‘strongly agree’. these data were then analysed in statistica (version 11) in consultation with a statistician using pooled data and t-tests to compare responses between the two groups. a level of significance was set at p<0.05. as this was an internal audit, ethical approval was not required. individual questionnaires were not reviewed and students could therefore not be identified. results responses from 36/41 (87.7%) graduates enrolled in the old curriculum (2006) were compared with responses from all 38 (100%) graduates enrolled in the new curriculum. responses differed significantly between the two groups, with the students following the new curriculum reporting higher mean values for most of the questions or statements (table 2). this was so for perceptions related to personal gain/development, as well as those regarding the quality of the programme. no improvement in their ability to balance their studies and other activities (q7, table 2) was noted. questions 19 and 21 are similar and relate to students’ readiness for future professional practice; no differences in scores between the two groups were found. for the 2011 cohort an average score of 4 is reported compared with an average score of 3.8 for the 2006 cohort. regarding the statement ‘if i were to start again i would follow the same programme’, no improved rating was found. discussion within our division we view programme evaluation as crucial for both accountability and development of learning. the findings of this desktop analysis suggest that the renewed curriculum was successful in maintaining students’ perception of their readiness for professional practice. the improved rating scores relating to perceptions of graduate attributes and programme design were very encouraging. the renewed curriculum produced students who rated themselves significantly higher than students enrolled in the old curriculum, especially those scores related to critical thinking (q1) and clinical reasoning (q2, 3 & 5), communication (q6) and self-directed learning (q8). students also seemed more aware of the principle of evidence-based practice (q21) and were able to function effectively as part of a multidisciplinary team (q4). similarly, various aspects of the programme architecture (q11 18) were more positively rated by students in the new curriculum. to qualify as programme evaluation, it is argued that the programme must focus on either outcome (in this case, did students perceive the programme to have an impact on personal development and their perception of research october 2014, vol. 6, no. 2, suppl 1 ajhpe 225 readiness for independent practice?), outputs (student grades or number of students graduating) or administration[13] (effect of processes followed). it is however our opinion that all three aspects are important for ensuring client satisfaction while maintaining standards and producing effective, independent first-line practitioners. while the primary focus of this paper is to describe the outcome related to students’ perceptions of self-development and readiness, throughput rate and students’ final marks were also observed and evaluated. there was no significant change in the distribution of marks. the throughput rate for the 2006 cohort was 100% and the throughput rate has since been maintained at 98%. it was our assumption that potentially negative effects of reducing core content and changing the approach to teaching this core content would become evident during the clinical rotations. although the structure and format of student supervision and support had to change, it was the opinion of the external examiners following the clinical physiotherapy exit exam that utilising a wide range of assessment methods contributed not only to patient evaluation and treatment skills, but also to producing critical thinkers and innovative students. the relatively low and unchanged score relating to the question: ‘would you follow the same programme’ was disappointing. it was hypothesised that the multimodal approach[14] would be welcomed by students, and with the increasing number of assessment opportunities students would perceive the system to be more reflective of their potential.[15] potential contributing factors such as personal factors including career choice, individual learning style and personality factors were not investigated. post hoc subgroup analysis of individual responses may have identified relationships between these factors and perceived ‘likeness’ of the renewed teaching and learning approach. although not evident from the above results, the programme is extremely busy and despite the nature of problem-based and enquiry-based learning allowing for many non-contact hours, students still find it difficult to table 2. analysis of responses to centre for teaching and learning's programme evaluation questionnaire (su bsc physiotherapy 2006 v. 2011) questions 2006 average* (sd) 2011 average* (sd) pooled sd t p a. the programme empowered me to: 1.think critically 3.92 (0.72) 4.68 (0.52) 0.1467 -5.181 <0.001 2. solve problems reasonably 4.03 (0.64) 4.66 (0.53) 0.1370 -4.598 <0.001 3. keep the bigger picture in mind when solving problems 3.97 (0.6) 4.61 (0.54) 0.1329 -4.814 <0.001 4. work effectively with others as a member of the team 4.03 (0.83) 4.68 (0.46) 0.1572 -4.135 <0.001 5. collect, analyse, organise and evaluate information 3.83 (0.76) 4.53 (0.6) 0.1597 -4.382 <0.001 6. communicate effectively using language skills (orally & in writing) 3.78 (0.89) 4.63 (0.58) 0.1757 -4.839 <0.001 7. manage myself and my activities effectively in such a way that i maintain a good balance between my studies and other activities 3.36 (1.06) 3.39 (1.14) 0.2558 -0.117 0.45 8. take responsibility to acquire knowledge and skills 4.17 (0.7) 4.5 (0.72) 0.1651 -1.999 0.02 9. be culturally sensitive 3.82 (0.78) 4.55 (0.59) 0.1614 -4.522 <0.001 10. identify and explore opportunities in educational, career and business world 3.31 (0.84) 3.68 (0.65) 0.1753 -2.111 0.02 b. state whether you agree with the following statements: 11. programme outcomes were communicated to me clearly 3.17 (0.73) 4.13 (0.86) 0.1851 -5.186 <0.001 12. i achieved the programme outcomes 3.5 (0.55) 4.24 (0.7) 0.1460 -5.071 <0.001 13. the assessment methods and criteria are appropriate and match the programme outcomes 3.0 (0.94) 3.68 (1.08) 0.2351 -2.894 <0.001 14. the content of the programme is clearly aimed at a clearly identifiable profession 3.81 (0.74) 4.21 (0.92) 0.1936 -2.066 0.02 15. the modules in the programme form a meaningful unit 3.42 (0.86) 4.16 (0.63) 0.1760 -4.204 <0.001 16. the programme is organised in such a way that knowledge and understanding have deepened from the first to the final year 4.36 (0.71) 4.58 (0.59) 0.1522 -1.446 0.08 17. little unnecessary duplication occurs between modules 3.67 (0.85) 3.87 (0.77) 0.1889 -1.059 0.15 18. the programme is in line with contemporary knowledge 3.89 (0.92) 4.32 (0.61) 0.1825 -2.357 <0.001 19. the programme prepared me for the working environment 3.91 (0.650 4.11 (0.79) 0.1678 -1.192 0.12 20. if i were to start again i would follow the same programme 3.31 (1.09) 3.43 (1.39) 0.2896 -0.414 0.34 c. physiotherapy-specific questions. state whether you agree with the following statements: 21. the curriculum enhances the importance of science as support for the practice of the profession 3.76 (0.84) 4.39 (0.71) 0.1813 -3.475 <0.001 22. i feel adequately prepared for my community year 3.74 (0.6) 3.89 (0.75) 0.1575 -0.952 0.17 * pooled statistics from a 5-point likert scale rating where 1 = strongly disagree to 5 = strongly agree. degree of freedom (df ) = 72. research 226 october 2014, vol. 6, no. 2, suppl 1 ajhpe balance their studies with other activities. participation in extracurricular activities is promoted at tertiary institutions and colleges in order to develop leadership, communication and time-management skills;[16] however, the physiotherapy students at su seem to continue to struggle with time management and effective study methods. the ‘i can do it all’ mentality of peak performing students who embark on multiple academic, sport and social activities but have poor personal time management and inability to prioritise may be reasons for this. this was however not explored in this paper. this study has several limitations, ranging from questionable timing to appropriateness of the group data analysis. it is clear from the group sd that there was wide variable response to some of the questions/statements and a more in-depth subgroup analysis of individual responses may have provided opportunity for investigating factors other than curricular influences. ethically, however, access to individual responses was not possible. another limitation is that this paper reports on the outcome of the ctl programme evaluation of the first cohort of physiotherapy students only. comparison with more recent cohorts will provide more reliable interpretation of the outcome of the renewed curriculum. the invitation to participate was issued prior to obtaining their results, which may have influenced their scoring; however, as this effect could have gone both ways, in that students typically either underor overestimate their performance, it was considered a negligible effect. to accurately be able to judge whether this curriculum was effective in preparing students for their role as independent practitioners ready for community service, remains difficult. follow-up 6 or 8 months into their community service year is recommended. conclusion changing the content and the teaching and learning events had a significant impact on students’ perception of their ability to: evaluate and treat clients; work effectively within a team; source information; and identify and explore opportunities in education, career and in business. students felt prepared and ready for community and professional practice. programmes undertaking curriculum renewal should not only focus on the curriculum content, but also develop a variety of learning opportunities to facilitate the development of graduate attributes. ongoing evaluation and increasing student support regarding time management and study methods is recommended. the next cycle following graduation should reflect on clinical practice. references 1. dell s. south africa: universities face more under-prepared students. university world news, 17 january 2010. http://www.universityworldnews.com/article.php?story=20100114190733824 (accessed august 2014). 2. flyvbjerg b. phronetic planning research: theoretical and methodological reflections. planning theory & practice 2004;5(3):283-306. [http://dx.doi.org/10.1080/1464935042000250195] 3. castagnolo c. the addie model why use it. ezine articles 2007. [http://ezinearticles.com/?the‐addie‐ model‐‐‐why‐use‐it?&id=859615] (accessed february 2007). 4. lloyd-jones g, fowell s, bligh jg. the use of the nominal group technique as an evaluative tool in medical undergraduate education. med educ 1999;33(1):8-13. [http://dx.doi.org/10.1046/j.1365-2923.1999.00288.x] 5. carl ae. course notes: an introduction to curriculum development. course: netact west africa curriculum workshop, 2011 (accessed december 2013). 6. norman gr, schmidt hg. effectiveness of problem‐based learning curricula: theory, practice and paper darts. med educ 2000;34(9):721-728. [http://dx.doi.org/10.1046/j.1365-2923.2000.00749.x] 7. kahn p, o’rourke k. understanding enquiry-based learning. in: barrett t, mac labhrainn i, fallon h, eds. handbook of enquiry and problem based learning. galway: celt, 2005. 8. ten cate o, durning s. peer teaching in medical education: twelve reasons to move from theory to practice. medical teacher 2007;29(6):591-599. [http://dx.doi.org/10.1080/01421590701606799] 9. richardson b. professional development: 2. professional knowledge and situated learning in the workplace. physiotherapy 1999;85(9):467-474. [http://dx.doi.org/10.1016/s0031-9406(05)65471-5] 10. miller g. the assessment of clinical skills/competence/performance. acad med 1990;65(suppl 9):s63-s67. [http://dx.doi.org/10.1097/00001888-199009000-00045] 11. kneebone r, nestel d, yadollahi f, et al. assessing procedural skills in context: exploring the feasibility of an integrated procedural performance instrument (ippi). med educ 2006;40(11):1105-1114. [http://dx.doi. org/10.1111/j.1365-2929.2006.02612.x] 12. centre for teaching and learning services. policy with regard to student feedback on modules, lecturers and programmes, 2013. http://sun025.sun.ac.za/portal/page/portal/administrativedivisions/sol/ctl%20home%20 page/ctlservices/student%20feedback/policy/sf_policy.pdf (accessed august 2013). 13. vedung e. public policy and program evaluation. new brunswick, nj: transaction publishers, 2008. 14. kerby j, shukur zn, shalhoub j. the relationships between learning outcomes and methods of teaching anatomy as perceived by medical students. clin anat 2011;24(4):489-497. [http://dx.doi.org/10.1002/ca.21059] 15. newfield d, andrew d, stein p, maungedzo r. ‘no number can describe how good it was’: assessment issues in the multimodal classroom. assessment in education: principles, policy & practice 2003;10(1):61-81. [http:// dx.doi.org/10.1080/09695940301695] 16. eggleston t. balancing academics with co-curricular activities, 2009. https://www.mckendree.edu/newsarchive/2009/balancing-academics-with-co-curricular-activities.php (accessed february 2014).  october 2016, vol. 8, no. 2, suppl 2 ajhpe 213 editorial engaging across professions in teaching and practice facilitates improved abilities by students to address the health needs of society.[1] universities worldwide have therefore integrated learning outcomes and teaching acti­ vities related to interprofessional education (ipe) into their curricula.[2,3] to this end, the faculty of community and health sciences (fchs) at the university of the western cape has introduced a scaffolded approach, where ipe and collaborative practice (cp) learning activities are presented in the curriculum, as well as co­curricular activities, from first to final year. in addition to the curricular considerations, the faculty has presented a number of development activities to ensure that academics are equipped with the knowledge and skills to act as facilitators in ipe and cp student activities.[4] a successful grant from the national research foundation facilitated the implementation of an interdisciplinary community­engaged research project, which explored the needs of a rural community. in this ajhpe supplement on ipe and interprofessional practice and research, we share the experiences of both academics and students, with ipe and cp interventions implemented in the fchs. the experiences of applying a community­based participatory research approach are also presented in this supplement. thus, a holistic approach to scholarship is presented that integrates teaching, research and community engagement. julie et al.[5] explored academics’ knowledge and experiences with ipe and cp. while it became clear that academics were knowledgeable of the concepts related to ipe and cp, they recommended the use of a framework to facilitate further understanding of the process. it became evident that the use of frameworks is beneficial, assisting students to identify community needs and thus plan collaborative projects to address these needs, as highlighted in the short report by rhoda et al.[6] although the students supported the use of frameworks, they requested earlier exposure to them before entering the clinical setting.[7] senior students from the various departments in the fchs engage in a co­curricular interprofessional learning activity on campus, namely a world café teaching strategy, to facilitate development of ipe competencies. in the exploration of the students’ views on world cafés, filies et al.[8] found they facilitated students’ knowledge about the roles of the different professionals as well as what working in interprofessional teams entails. the students who attended the world cafés also mentioned that the use of authentic learning activities would assist in the development of the skills needed to function in the clinical setting. the ipe activities, which were provided across departments in the fchs, focused on facilitating the development of core competencies among students. manilall and rowe[9] report on the development of collaboration as a competency as part of the physiotherapy curriculum. these authors found that although lecturers and students had a good understanding of collaboration, there were gaps in the curriculum in both classroom and clinical setting activities related to this concept. in addition to engaging in interprofessional teaching and learning activities, fchs academics also engaged in interprofessional research. using the principles of community­based participatory research, it was evident that clear aims and implementation strategies are important considerations when implementing this type of research, as reported by frantz et al.[10] capacity development of both community members and academics also emerged from this study as an important consideration. therefore, it is evident that strategies exist that higher education institutions can use to drive the implementation of ipe and interprofessional practice and research, as functioning collaboratively in interprofessional teams is beneficial. findings from our studies will be used to further inform ipe and interprofessional research activities in the fchs. we hope that the findings generate further discussion on this topic and contribute to additional innovations in this field. anthea rhoda guest editor department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa arhoda@uwc.ac.za 1. interprofessional education collaborative. connecting health professionals for better life. core competencies for interprofessional collaborative practice 2016 – update. http://www.aacn.nche.edu/education­resources/ (accessed september 2016). 2. snyman s, von pressentin k, clarke m. international classification of functioning, disability and health: catalyst for interprofessional education and collaborative practice. j interprof care 2015;29(4):313. doi:10.31 09/13561820.2015.1004041 3. bondevick b, haugaland m. interprofessional workplace learning in primary care: students from different health professions work in teams in real­life settings. int j teach learn higher educ 2015;27(2):175­182. 4. mclean m, cilliers f, van wyk j. faculty development: yesterday, today and tomorrow. med teach 2008;30:555­ 584. doi:10.1080/01421590802109834 5. julie h, hess­april l, wilkenson j, cassiem w, rhoda a. academics’ knowledge and experiences of interprofessional education and practice. afr j health professions educ 2016;8(2 suppl 2):222­224. doi:10.7196/ ajhpe.2016.v8i2.845 6. rhoda a, waggie f, filies gc, frantz jm. using operative models (icf and cbr) within an interprofessional context to address community needs: a short report. afr j health professions educ 2016;8(2 suppl 2):214­216. doi:10.7196/ajhpe.2016.v8i2.850 7. rhoda a, laattoe n, smithdorf g, roman n, frantz j. facilitating community­based interprofessional education and collaborative practice in a health sciences faculty: student perceptions and experiences. afr j health professions educ 2016;8(2 suppl 2):225­228. doi:10.7196/ajhpe.2016.v8i2.846 8. filies g, yassen z, frantz j. students’ views of learning about an interprofessional world café method. afr j health professions educ 2016;8(2 suppl 2):229­233. doi:10.7196/ajhpe.2016.v8i2.844 9. manilall j, rowe m. collaborative competency in physiotherapy students: implications for interprofessional education. afr j health professions educ 2016;8(2 suppl 2):217­221. doi:10.7196/ajhpe.2016.v8i2.841 10. frantz j, filies g, jooste k, et al. reflection on an interprofessional community­based participatory research project. afr j health professions educ 2016;8(2 suppl 2):234­237. doi:10.7196/ajhpe.2016.v8i2.851 afr j health professions educ 2016;8(2 suppl 2):213. doi:10.7196/ajhpe.2016.v8i2.861 introducing interprofessional education, practice and research in a higher education setting this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://www.aacn.nche.edu/education-resources/ http://dx.doi.org/10.3109/13561820.2015.1004041 http://dx.doi.org/10.3109/13561820.2015.1004041 http://dx.doi.org/10.1080/01421590802109834 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.845 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.845 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.850 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.846 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.844 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.841 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.851 214 october 2016, vol. 8, no. 2, suppl 2 ajhpe short report identifying educational strategies to assess and address the health needs of communities is a high priority, both nationally and internationally.[1] clinical training of healthcare professionals occurs in different settings using different learning strategies and activities. one such setting is the community, as community-based education (cbe). according to villani and atkins,[2] ‘cbe is centred on the student’s ability to recognise and support the needs of the surrounding community. in this way, students become accountable for providing values which stem from their freedom to express, develop, and solve the inherent problems or concerns they have for their community.’ community members, lecturers and individuals from different sectors are all involved in this learning process, which is primarily based on the needs of the community. as interprofessional education (ipe) occurs among students from more than one profession,[3] interprofessional cbe could be considered as an educational approach, where learning strongly occurs within communities and with consideration of the needs of communities, with two or more professional groups of students. when implementing community-based ipe initiatives, the use of frameworks has been found beneficial[4,5] and may facilitate the development of ipe competencies such as communication and student learning.[6] in the context of ipe, the international classification of functioning, disability and health (icf) may assist students in identifying the needs or challenges experienced by individuals and communities.[7] the icf[8] conceptualises functioning in terms of activities and participation, and considers contextual factors, such as environmental and personal factors. the icf can therefore be used as a tool to assess functioning.[8] communitybased rehabilitation (cbr), which is encompassed within community development, facilitates the rehabilitation, equalisation of opportunities and social inclusion of persons with disabilities, and can be used to address the needs of communities. the cbr matrix provides a visual illustration of cbr and consists of five components (health, education, livelihood, social and empowerment), each consisting of five elements. the elements of the different components are as follows: health – prevention, promotion, medical care, rehabilitation and assistive devices; education – early childhood, primary, secondary and higher, non-formal and life-long learning; livelihood – skills development, self-employment, financial services, wage employment and social protection; social – relationships, marriage and family, personal assistance, culture and arts, recreation, leisure and sports, and access to justice; and empowerment – communication, social mobilisation, political participation, self-help groups and disabled people’s organisations.[5] this short report highlights how a group of interprofessional students can collaboratively identify the needs of individuals and communitybased groups using the icf, and also highlights possible interventions conceptualised within the cbr matrix. methods the study sample consisted of a convenient cohort of 30 students from the departments of physiotherapy, nursing and biokinetics at the university of the western cape (uwc), cape town, south africa, who participated in an ipe activity while rotating through a community-based clinical practice placement in 2013. as part of the activity, the students were placed in groups, and engaged with specific community-based organisations (cbos). the cbos consisted of a day-care centre for children without disabilities, background. the use of conceptual frameworks has been advocated when implementing interprofessional initiatives. objective. to present the use of the international classification of functioning disability and health (icf) and the community-based rehabilitation (cbr) matrix for identifying and addressing the health needs of the community. methods. the icf care plan and the cbr matrix were used to conduct a retrospective document analysis. the documents were completed by interprofessional groups of students who were involved in an interprofessional community-based intervention. data were captured on a sheet and analysed descriptively using the domains of the icf and the cbr matrix. ethical clearance was obtained from the university of the western cape, cape town, south africa. results. a total of 30 senior nursing, physiotherapy and biokinetics students were divided into groups and interacted with five community-based groups. each group of students completed one icf care plan and one cbr matrix. the needs documented in the icf care plans included impairments, activity limitations, participation restrictions and environmental challenges. impairments included sensory, motor and psychological impairments, while activity limitations included limitations in activities of daily living and mobility. limited social interaction and physical environment were identified as experienced environmental challenges. the interventions documented to address these needs included health promotion, prevention, medical care, skills development and facilitation of access to justice. conclusion. the icf and cbr matrix can be used to facilitate students’ identification of the needs of communities and the implementation of interventions to address these needs in an interprofessional manner. afr j health professions educ 2016;8(2 suppl 2):214-216. doi:10.7196/ajhpe.2016.v8i2.850 using operative models (icf and cbr) within an interprofessional context to address community needs a rhoda,1 phd; f waggie,2 phd; g c filies,2 mphil; j m frantz,1 phd 1 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town south africa corresponding author: a rhoda (arhoda@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2, suppl 2 ajhpe 215 short report a day-care centre for children with disabilities, a frail-care centre, a homebased care organisation, and a community-based skills development group. the students used the icf care plan[9] to document the needs of individuals who were part of these organisations. additionally, the students indicated on the cbr matrix which components and elements were relevant when addressing the identified needs. a document analysis was, therefore, used table 1. icf domains, cbr domains and cbr elements cbo/group needs of cbo/group icf domains cbr component (cbr elements) assessment intervention day-care centre for children without disabilities developmental screening stimulation of children impairments none identified activity limitations none identified participation restrictions none identified environmental factors facilitators supportive principal and family barriers physical environmental – limited space attitudinal limited space and unfriendly (space and location) health promotion prevention medical care education early childhood livelihoods skills development day-care centre for children with disabilities constant care of children increased resources qualified staff impairments sensory motor psychological activity limitations limitations in activities of daily living and mobility participation restrictions limited social interaction environmental factors barriers lack of social support limited physical space lack of trained healthcare workers health promotion prevention rehabilitation education primary life-long learning livelihoods skills development social recreation leisure sport personal assistance empowerment communication frail-care centre (carers) understanding conditions of the elderly training impairments none activity limitations none participation restrictions none environmental factors barriers caregiver knowledge of conditions health promotion prevention empowerment communication home-based carers access to information access to health professional team impairments none activity limitations none participation restrictions none environmental factors facilitators building barriers language health promotion prevention education life-long learning skills development livelihoods self-employment social culture and arts empowerment access to justice continued ... 216 october 2016, vol. 8, no. 2, suppl 2 ajhpe short report to determine both the identified community needs and the interventions suggested by the students. the documents were reviewed by one of the authors (ar) and peer reviewed by another author (jf). the information collected from the documents was captured on a data sheet. captured data included the cbo needs of the organisations, the icf domains, the cbr domains and the cbr elements. names of students and institutions were not identified during the analysis and presentation of the data. ethical clearance was obtained from uwc (ethics no. 13/3/9). results the sample of 30 students consisted of 22 nursing, 4 physiotherapy and 4 biokinetics students who had the opportunity to collectively interact with five different community-based groups. when documenting the needs according to the icf, the students identified mainly environmental barriers experienced by the organisations or groups. within the context of the cbr matrix, the students highlighted a need for access to justice for the homebased care group that was not documented for the other community-based groups. the icf domains, cbr domains and cbr elements, as documented by the students, are presented in table 1. discussion the use of frameworks and models is recommended to facilitate student interaction regarding management during ipe initiatives.[6] the icf and cbr matrix, both developed by the world health organization, are two such models. these frameworks were used to facilitate the students’ identification of community needs and the suggested interventions to address these needs. when contextualised within the icf, the students identified limitations that went beyond identification of impairments. environmental barriers, which included a lack of physical space and finances, were identified. lack of skills and social interaction was also highlighted a limitation.[8] to address these challenges, the students highlighted the need for life-long learning, skills development and the facilitation of access to justice.[4] conclusion the icf and cbr matrix can be used to facilitate students’ identification of the needs of communities and the implementation of interventions that are appropriately based on these needs, in an interprofessional manner. references 1. salvatori ps, berry sc, eva kw. implementation and evaluation of an interprofessional education initiative for students in the health professions. learn health soc care 2007;6(2):72-82. doi:10.1111/j.1473-6861.2007.00152.x 2. villani cj, atkins d. community-based education. school comm j 2000;10(1):39-44. 3. world health organization. transforming and scaling up health professionals’ 4. education and training: world health organization guidelines, 2013. geneva: who, 2013. http://apps.who.int/ iris/handle/10665/93635 (accessed 25 july 2016). 5. tartavoulle tm, english r, gunaldo t, et al. using the idea framework in an interprofessional didactic elective course to facilitate positive changes in the roles and responsibility competency. j interprof educ prac 2016;2:21e-24e. http://www.jieponline.com (accessed june 2016). 6. world health organization. community-based rehabilitation. http://www.who.int/disabilities/cbr/en/ (accessed 17 august 2016). 7. allan ca, campbell wn, guptill ca , stephenson ff, campbell ke. a conceptual model for interprofessional education: the international classification of functioning, disability and health (icf). j interprof care 2006;20(3):235-245. doi:10.1080/13561820600718139 8. schneider m, hartley s. international classification of functioning, disability and health (icf) and cbr. in: hartley s, ed. cbr as a part of community development: a poverty reduction strategy. london: university college, london centre for international child health, 2006. 9. world health organization. international classification of functioning, disability and health. geneva: who, 2001. www.who.int/classifications/icf/en/ (accessed july 2016). 10. snyman s, von pressentin kb, clarke m. international classification of functioning, disability and health: catalyst for interprofessional education and collaborative practice. j interprof care 2015;29(4):313-319. doi: 10.3109/13561820.2015.1004041 table 1. (continued) icf domains, cbr domains and cbr elements cbo/group needs of cbo/group icf domains cbr component (cbr elements) assessment intervention skills development group financial support biokinetics input impairments blindness muscle pain activity limitations none participation restrictions none environmental factors barriers language financial transport health promotion prevention medical care education life-long learning skills development livelihoods self-employment social culture and arts empowerment access to justice http://dx.doi.org/10.1111/j.1473-6861.2007.00152.x http://apps.who.int/iris/handle/10665/93635 http://apps.who.int/iris/handle/10665/93635 http://www.jieponline.com http://www.who.int/disabilities/cbr/en/ http://dx.doi.org/10.1080/13561820600718139 http://www.who.int/classifications/icf/en/ http://dx.doi.org/10.3109/13561820.2015.1004041 march 2017, vol. 9, no. 1 ajhpe 21 research there is a persistent shortage and an unequal distribution of workforce across the dental specialties in nigeria.[1-3] this has been attributed to biased levels of interest by dental graduates towards all dental specialties, as a few specialties are preferred above others.[1] oral and maxillofacial surgery (oms) has been reported as the most preferred specialty among the majority of nigerian dental graduates, while prosthetic dentistry (pros) is the least preferred.[1] this is a significant problem, as some dental specialties persistently have greater manpower than other dental specialties, which hinders the adequate delivery of holistic oral healthcare to the nigerian population.[1-3] dental students’ and graduates’ choice of a dental specialty is determined by many factors, including potential financial income, self-employability, personal interest, job security, fear of litigation, and prestige.[4,5] the trend of specialty choice among dental students at the university of ibadan, nigeria has yet to be determined. the objective of this study was to determine the most preferred dental specialties among these dental students, and also to explore the factors that inform their choice. our findings try to provide solutions to the problem of unequal preference of dental specialties. methods ethical approval to carry out this study was obtained from the oyo state ministry of education, nigeria. the study population comprised dental students in the faculty of dentistry, university of ibadan. only students who rotated through all the academic departments within the faculty were considered eligible to participate in the study. based on this criterion, only students in their final year were able to participate. the study tool was a 34-item questionnaire that was self-administered to the participants after obtaining verbal informed consent. twenty-seven final-year dental students, of a total of 35 eligible students, volunteered to participate in the study. the questionnaire had three sections: • section a obtained information on the sociodemographic data of the participants. • section b obtained information on the choice of dental specialties being considered by participants for a residency programme. • section c obtained information on the factors that informed participants’ choice of a dental specialty. collected data were statistically analysed using spss version 16.0 (spss inc., usa). the frequencies, proportions, arithmetic means, and standard deviations of variables were determined and are illustrated using a table and a chart. tests of association between qualitative variables were done using the χ2 test; p<0.05 was considered statistically significant. results the response rate was 77.1% (27/35). the mean age of the respondents was 22.6 years, and the gender distribution was fairly even, with 13 males (48%) and 14 females (52%) participating. background. the unequal distribution of workforce across dental specialties in nigeria poses a significant problem in the delivery of specialists’ oral healthcare to the nigerian population. objectives. to determine dental specialties preferences among dental students at the university of ibadan, nigeria, and to explore the factors that influence their choices. methods. we obtained ethical approval to conduct this study. only the dental students who rotated through all the dental specialties were selected to participate in this questionnaire-based study. data were analysed using spss version 16 (spss inc., usa). results. the majority of dental students at the university of ibadan preferred the oral and maxillofacial surgery (oms) specialty above all other dental specialties, while prosthetic dentistry was least preferred. of all the factors to take into consideration when choosing a dental specialty, personal interest was the only factor considered by nearly all respondents. only male respondents considered prestige as an influencing factor in their choice of a specialty. lifestyle and job description were factors considered by a higher proportion of the male respondents (10/13) than females (5/14). the mean age of the 27 respondents who participated in this study was 22.6 years, 52% of whom were females. conclusion. oms was the most preferred specialty among our respondents (n=8). nearly all dental students chose residency training in the specialty that most appealed to them. the interest of dental students towards the least appealing dental specialties needs to be developed to solve the problem of skewed distribution of the dental workforce in nigeria. our findings suggest that this may be accomplished by changing dental students’ perceptions of certain specialties, building on male students’ interests in job security and private practice potential, and the female students’ interests in family-friendly specialties and increasing flexibility in dental residency programmes. afr j health professions educ 2017;9(1):21-23. doi:10.7196/ajhpe.2017.v9i1.670 specialty choice among dental students in ibadan, nigeria k k kanmodi,1 dental student; a i badru,2 mbbs, fmca; a g akinloye,3 bed, med; w a wegscheider,4 md 1 faculty of dentistry, university of ibadan, ibadan, nigeria 2 department of anaesthesia, faculty of clinical sciences, olabisi onabanjo university, sagamu, nigeria 3 department of mathematics and statistics, faculty of science, osun state college of technology, esa oke, nigeria 4 department of dentistry and maxillofacial surgery, medical university of graz, graz, austria corresponding author: k k kanmodi (kanmodikehinde@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 22 march 2017, vol. 9, no. 1 ajhpe research oms was the specialty with the highest frequency of being the first choice (8/27 (29.6%)) of the respondents, all of whom were considering a residency training programme after graduation. oral pathology (orp), oms, and orthodontics (ort) were the top three 1st and 2nd choice specialties. the least popular specialty choices, placed 7th, 8th, and 9th, were pros, community dentistry (cd), and oral radiology (orr) (fig. 1). table 1 shows the comparison between gender and factors influencing the choice of our respondents for any dental specialty. more than half of the male respondents chose a specialty based on the prestige associated with it, while none of the female respondents made a choice based on that factor (7/13 v. 0/14, p=0.001). a higher proportion of the male respondents compared with the female respondents considered lifestyle (including job description) as a factor (10/13 v. 5/14, p=0.031). further comparisons of association between gender of respondents and other influencing factors were not statistically significant (table 1). for men, the top influential factors were personal interest (100%), lifestyle/job description (76.9%), and job security/potential for advancement and opportunity for private practice (61.5% each). for women, the top influential factor, as with men, was personal interest (85.7%), which was the only factor chosen by more than half of the women. the next highest influencing factors for women were easy compatibility with having a family and enough time for leisure activity (42.9% each). all the males and females indicated that ease of entry into the residency programme and gender distribution within the specialty had no influence on their decision-making. prestige, others’ perception of the job, and low risk of litigation were also chosen by all female participants (100%) as having no influence on their choices. 100 90 80 70 60 50 40 30 20 10 0 cd oms ort peri pros cons orp orr pd 9th choice 8th choice 7th choice 6th choice 5th choice 4th choice 3rd choice 2nd choice 1st choice % fig. 1. the percentage distribution of specialty choices (in ranking) among respondents. (cd = community dentistry; oms = oral and maxillofacial surgery; ort = orthodontics; peri = periodontology; pros = prosthetic dentistry; cons = conservative dentistry; orp = oral pathology; orr = oral radiology; pd = paediatric dentistry.) table 1. comparison between gender distribution and factors influencing specialty choice among respondents male (n=13) female (n=14) influencing factors yes, n (%) no, n (%) yes, n (%) no, n (%) χ2 (p-value) personal interest in the specialty 13 (100) 0 (0) 12 (85.7) 2 (14.3) 0.157 job security/advancement prospects 8 (61.5) 5 (38.5) 5 (35.7) 9 (64.3) 0.180 ease of entry into the residency programme of the specialty 0 (0) 13 (100) 0 (0) 14 (100) * lifestyle and job description 10 (76.9) 3 (23.1) 5 (35.7) 9 (64.3) 0.031 prestige 7 (53.8) 6 (46.2) 0 (0) 14 (100) 0.001 close relation with other specialties 5 (38.5) 8 (61.5) 2 (14.3) 12 (85.7) 0.152 positive influence during the posting in the specialty 7 (53.8) 6 (46.2) 5 (35.7) 9 (64.3) 0.343 opportunity to conduct research 5 (38.5) 8 (61.5) 2 (14.3) 12 (85.7) 0.152 flexibility with training 7 (53.8) 6 (46.2) 4 (28.6) 10 (71.4) 0.182 amount of patient contact 5 (38.5) 8 (61.5) 1 (7.1) 13 (92.9) 0.050 technically challenging specialty 2 (15.4) 11(84.6) 4 (28.6) 10 (71.4) 0.410 high wages 6 (46.2) 7 (53.8) 4 (28.6) 10 (71.4) 0.345 opportunity for private practice 8 (61.5) 5 (38.5) 4 (28.6) 10 (71.4) 0.085 easy compatibility with having a family 4 (30.8) 9 (69.2) 6 (42.9) 8 (57.1) 0.516 inclination of specialty before entering dental school 1 (7.7) 12 (92.3) 4 (28.6) 10 (71.4) 0.163 a wide variety of caseload 3 (23.1) 10 (76.9) 2 (14.3) 12 (85.7) 0.557 influence from a mentor 6 (46.2) 7 (53.8) 3 (21.4) 11 (78.6) 0.173 enough time left for leisure activity 4 (30.8) 9 (69.2) 6 (42.9) 8 (57.1) 0.516 influence of family or relative 1 (7.7) 12 (92.3) 1 (7.1) 13 (92.9) 0.957 other people’s perception of the job 1 (7.7) 12 (92.3) 0 (0) 14 (100) 0.290 little on-call commitment 2 (15.4) 11 (84.6) 1 (7.1) 13 (92.9) 0.496 low risk of litigation 3 (23.1) 10 (76.9) 0 (0) 14 (100) 0.057 gender distribution in the specialty 0 (0) 13 (100) 0 (0) 14 (100) * *no statistics were computed because variables were constant. march 2017, vol. 9, no. 1 ajhpe 23 research discussion oms is known to be one of the most preferred specialties among dental students and graduates.[1,4] this specialty was also the most appealing specialty among our study population. our respondents showed little interest in specialising in pros, cd, and orr. this indicates a high possibility that the number of prosthetic dental specialists, community dentists and oral radiologists will remain lower than all other dental specialists in the country. there were different factors that informed our respondents’ choice of a dental specialty (table 1). we noticed that personal interest played an important role, as almost all of our respondents selected it as a major factor in their selection of a specialty. personal interest had also been reported as a major influential factor with regard to the choice of a medical specialty among some final-year medical students at the university of calabar, nigeria.[6] this reveals that most students prefer the residency training programmes that are most appealing to them, but it would be helpful to know how these personal interests are formed and how they could be influenced. prestige, lifestyle/job description, and low risk of litigation were more commonly considered among males than females. addressing potential misconceptions about each dental speciality during student rotations may contribute to a broader range of acceptable choices for male dental students and may change personal interests for both genders. job security and potential for private practice were also important factors for male students. both of these factors are strongest in specialties with fewer competitors. pointing out that the less desirable specialties may have the highest job security and private practice potential might influence male students to consider specialities they might have otherwise overlooked. combining a residency training programme with family life was a more common concern among female dental trainees. the creation of residency programmes with a more flexible family-friendly structure may encourage female dental graduates to go into specialties where females tend to be under-represented or where there are shortages. furthermore, the gender distribution of existing specialists in a dental specialty, call duties, technicalities associated with specialist training, perception of people about a specialty, and ease of admission into the residency programme of a specialty, among others (table 1), did not seem to have much influence on dental students’ choice of a specialty. changes made to these factors would have less impact in attracting male or female residents to specialties. conclusion we found that the majority of ibadan dental students want to specialise in oms, ort, or orp because these specialties appeal most to their personal interests. many dental students were least interested in becoming a prosthetic dental specialist, community dentist or oral radiologist. we conclude that there is still a strong likelihood that pros and other less appealing specialties may remain under-staffed in the future. to prevent this, dental students’ interest must be stimulated by changing their perceptions of certain specialties, building on their interests in job security and potential for private practice and, particularly for female dentists, by increasing flexibility in dental residency programmes. acknowledgement. the authors appreciate the assistance of dr k e shields, shields medical writing, greater philadelphia area, usa, for her in-depth review of this research and manuscript. the principal investigator (kkk) also thanks miss o m familoni and mr m a owadokun for their inspiration and support. 1. arowojolu om, aderinokun ga, arotiba jy, dosumu oo. choice of specialty training among nigerian graduates. odonto-stomatologie tropicale 1997;77:21-24. 2. adeniyi aa, sofola oo, kalliecharan rv. an appraisal of the oral health care system in nigeria. int dent j 2012;62(6):292-300. http://dx.doi.org/10.1111/j.1875-595x.2012.00122.x 3. nwhator so, olatosi o, ashiwaju mo, isiekwe gi. emerging trends in dental specialty choice in nigeria. int dent j 2013;63(2):91-96. http://dx.doi.org/10.1111/idj.12019 4. halawany hs. career motivations, perceptions of the future of dentistry and preferred dental specialties among saudi dental students. open dent j 2014;8:129-135. 5. arora r, panwar nk, dhar v. reason for choosing paediatric dentistry as career-survey among postgraduate dental students. j oral health comm dent 2011;5(2):86-89. 6. oku oo, oku ao, edentekhe t, kalu q, edem be. specialty choices among graduating medical students in university of calabar, nigeria: implications for anesthesia practice. ain-shams j anesthesiol 2014;7(4):485-490. http://dx.doi.org/10.4103/1687-7934.145673 research 57 june 2017, vol. 9, no. 2 ajhpe abstract-driven scientific conferences are expensive and little has been written on their benefits – if any – beyond the possible improvement in the knowledge of the participants. articles that report on health conferences focus on the clinical advancements,[1-3] the ethical issues surrounding hiv,[1] or the political arena of hiv in south africa (sa).[4] one article focused on the benefits (including improved knowledge) experienced by the participants.[5] healthcare conferences in developing countries have an additional obligation of ensuring societal benefit beyond the knowledge acquisition of delegates, as these conferences are often supported by donors who speculate whether the funding could not be better spent elsewhere. one area of donor funding is that of sponsoring scholarship programmes so that access to information presented at the conference is not a barrier for those without financial means. the question is whether scientific health conferences influence the actions of the delegates after the conference. lalonde et al.[5] reported that the majority of survey respondents indicated that they would change their behaviour after attending the 15th international aids conference, bangkok, thailand, 2004, and 80% of survey respondents who had attended one or more previous international aids conferences reported that they had changed their behaviour after attending. the international conference on aids and sexually transmitted infections in africa (icasa) is the most important international aids conference in africa and receives donor funding. its current biennial hosting alternates between anglophone and francophone african countries and draws together african scientists, leaders, communities, organisations and individuals who share experiences and update their responses to the hiv/aids epidemic. sa was selected to host the 17th icasa – held in cape town from 7 to 11 december 2013 (icasa 2013). the conference theme, ‘now more than ever: targeting zero’, highlighted the need to ‘now more than ever’ maintain the commitment to ensure access to treatment for everyone in africa, irrespective of their ability to pay for such treatment. the hosting of this icasa conference in sa was symbolic, as it was in our country that, during the 13th international aids conference in 2000, a turning point was reached in breaking the silence around aids in africa. this conference was a catalyst for the unprecedented commitment by donors, government and civil society to increase access to treatment in an attempt to turn the tide of this epidemic. icasa 2013 was an opportunity to renew the global commitment by drawing the world’s attention to the legacy of aids 2000 being under threat as a result of the worldwide economic downturn. the conference was an opportunity for the world’s leading scientists, policy makers, activists, people living with hiv (plhiv), and government leaders to promote intersectoral achievements in the aids response and to strengthen partnerships. the swedish international development cooperation agency (sida) and the us president’s emergency plan for aids relief (pepfar) made funding available for a scholarship programme, which enabled individuals to attend, participate or present at the conference. there were several categories for scholarship applicants, i.e. plhiv, community-based organisations, women, youth, least-developed countries, media, students, and community influencers. sida provided funding for 97 full scholarships, which included travel, accommodation, per diems and conference registration fees. sida further funded 138 partial scholarships, which included conference registration fees background. although abstract-driven scientific conferences are expensive, little has been written about their benefits and whether attendance influences delegates’ actions. objective. to explore possible benefits of conference attendance among 97 scholarship recipients at the international conference on aids and sexually transmitted infections in africa (icasa) 2013. methods. a cross-sectional study was conducted. data were collected via an online survey before the start and on the last day of the conference, and 5 months after the conference. results. scholarship recipients represented 27 countries and were between 20 and >60 years of age. the majority of respondents were between 26 and 40 years old, were male, and were researchers/scientists or advocates/activists. respondents reported that they attended icasa 2013 to learn more about tuberculosis/hiv/aids/sexually transmitted infections and networking opportunities. the majority reported that they gained professionally from attending icasa 2013 and made ‘new contacts and opportunities for partnership and collaboration’ and ‘new ideas/directions for new project(s)’. respondents identified ways in which they intended to use what they had learnt at the conference. five months later respondents reported that they, their colleagues, managers and/or partners were motivated with regard to their hiv work and had shared information, best practices and/or skills gained. the majority had implemented best practices or innovations and retained professional contact with someone they met at icasa 2013. conclusion. conference scholarship programmes provide opportunities for learning and networking and may translate into partnerships or joint ventures, which may result in the implementation of innovations and best practices. such programmes may also lead to skills transfer, which could strengthen workforce capacity and health systems. afr j health professions educ 2017;9(2):57-61. doi:10.7196/ajhpe.2017.v9i2.693 the health system benefits of attending an hiv/aids conference a bosman,1 bcom (fin man), hed, bcom hons (acc), achm; j e wolvaardt,2 bcur, mph, pgche, phd 1 foundation for professional development, pretoria, south africa 2 school of health systems and public health, faculty of health sciences, university of pretoria, south africa corresponding author: a bosman (aletb@foundation.co.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research june 2017, vol. 9, no. 2 ajhpe 58 only. the pepfar scholarship was reserved for delegates ˂30 years of age. this article reports on the experience and effects of the conference on the sida fully-funded scholars. methods this was a cross-sectional study of a cohort of scholarship recipients. a purposive sampling technique was used, and those who met the inclusion criteria (fully-funded sida scholarship) were invited to participate. participation was voluntary and commenced after the scholarship was accepted and participants had arrived at the conference. data were collected by means of three self-completed anonymous surveys, which were available in english and french. the survey questions were translated from english to french by a french mother-tongue speaker and checked by another french mother-tongue speaker. data were collected at three points in time: • pre-conference. fully-funded scholarship recipients were requested to complete the pre-conference survey on arrival and registration at the conference. the survey comprised 10 questions, including closedand open-ended questions focused on the planning and organisation of icasa 2013 and the scholarship programme. a total of 97 pre-conference evaluation surveys were completed in hard-copy format (english, n=87; french, n=10). • last day of conference. fully-funded scholarship recipients were requested to complete a reaction evaluation survey on the last day of the conference. it consisted of 18 closedand open-ended questions, which focused on the programme, what the attendees intended to do with what they gained at the conference, and the effects of having attended previous icasa conferences. the surveys were completed either in hard copy or online on limesurvey (limesurvey gmbh, germany). a total of 65 surveys were completed (english, n=44; french, n=21). • five months after the conference. an online survey was e-mailed to all fully-funded scholarship recipients on 1 may 2014. the survey focused on the benefits of attending the conference. a total of 63 surveys were completed (english, n=45; french, n=18). all hard-copy questionnaires were captured on limesurvey by a volunteer who could speak both english and french. the captured data were checked for correctness by the evaluation project manager. the online data were exported to microsoft excel 2007 (usa), which was used for data cleaning, coding and analysis. once exported, the data were cleaned. during the cleaning process duplicate responses were deleted and spelling errors were corrected to facilitate sorting. permission to use the data was granted by the society for aids in africa. scholarship recipients entered into an agreement between themselves and the icasa 2013 organiser, whereby they agreed to participate in all three surveys. results the response rate was 100% in round 1 of data collection, 67% in round 2 and 65% in round 3. demographic profile of the respondents the scholarship recipients represented 27 countries, based on their nationality, and 29 countries, based on their country of residence/work (fig. 1). only 1% (n=1) of scholarship recipients was not originally from africa and 3% (n=3) did not reside or work in africa. the majority of respondents were from sub-saharan africa (92%, n=89). the minority (3%, n=3) of scholarship recipients were between 20 and 25 years old; 58% (n=56) were between 26 and 40 of age; 35% (n=34) were between 41 and 60 of age; and 3% (n=3) were >60 years old. one respondent did not answer the question with regard to age. although the options of female, male, transgender and do not want to disclose were provided, all classified themselves as male (57%, n=55) or female (43%, n=42). when asked to select their occupation/profession from a list of 12 options, fig. 1. african scholarship recipients’ nationality (n=97). 1 1 2 2 4 4 6 8 13 17 20 22 0 5 10 15 20 25 lawyer teacher/educator/trainer community/religious/traditional leader policy/administration media representative other student other healthcare worker/social services provider advocate/activist clinician/physician researcher/scientist programme/facility manager or administrator occupation/profession, % fig. 2. scholarship recipients’ main occupation/profession (n=96). fig. 3. scholarship recipients’ reasons for attending icasa 2013 (n=267). i have always wanted to visit cape town 4 18 21 22 29 0 5 10 15 20 25 30 35 i was required/recommended by my employer other i was recommend by a peer/colleague networking opportunities i want to learn more about tb/hiv/aids/stis i am a conference speaker, facilitator or presenter (abstract accepted) i received a scholarship 2 2 2 reasons for attending icasa 2013, % research 59 june 2017, vol. 9, no. 2 ajhpe 22% (n=21) of the scholarship recipients selected researcher/scientist (fig. 2). the second-largest groups of respondents were clinician/physicians and advocate/activist, both at 20% (n=19) each. reasons for conference attendance the reasons to attend the conference were explored; 267 responses were received from the 97 respondents (fig. 3). the four most cited reasons were receiving a scholarship (29%, n=76), acceptance of an abstract (22%, n=58), wanting to learn more about tuberculosis (tb)/hiv/aids/sexually transmitted infections (stis) (21%, n=55), and networking opportunities (18%, n=49). perceived value of attending the conference the majority (95%, n=62) of respondents in the second round of data collection reported that they did gain professionally from attending the conference and identified their gains. the largest proportion (78%, n=51) reported that they had made ‘new contacts and opportunities for partnership and collaboration’, while 77% (n=50) reported that they developed ‘ideas/ directions for new project(s)’, and 75% (n=49) indicated that they ‘increased understanding of the challenges to achieving treatment access in africa’. almost all (98%, n=64) of the respondents in the second round reported that they had the opportunity to build a professional relationship with other delegates and speakers, which underlines the networking opportunities that conferences offer. at the end of the conference, scholarship recipients were asked how they intend to use what they had gained at the conference (from a list of 14 potential intentions). sixty-five respondents reported a total of 480 intentions. the responses from the 14 potential intentions were combined after the analysis into seven thematic areas. five months after attending the conference, respondents were asked to report on the effect of their conference attendance on their work and their organisation. respondents could choose from a list of 10 items; 63 respondents selected a total of 351 effects. the responses from the 10 potential effects were combined post analysis into four thematic areas (table 1). attendance of previous icasas fewer than half (41%, n=26) of the respondents indicated they had attended previous icasas. the majority (77%, n=20) of those who had attended a previous conference reported that attendance had had an influence both on their work and their organisation. the most frequently cited influences were: • adjusted/changed work focus, direction or approach (77%, n=20) • improved/refined work practices and/or methodologies, including manage ment (73%, n=19) • created new partnerships (69%, n=18) • motivated self, colleagues, managers, and/or partners with regard to hiv work (69%, n=18) • shared information with colleagues, peers and/or partner organisations (65%, n=17). nearly all (92%, n=24) of the respondents who had attended previous icasas reported that they continue to have contact with someone they had met for the first time at a previous conference. a large percentage (69%, n=18) indicated that they had entered into a partnership or a joint venture with someone whom they had met for the first time at a previous icasa conference. effects of conference attendance at 5 months in addition to the self-reported effects at 5 months after the conference (table 1), almost all of the respondents (98%, n=61) indicated that they still have contact with someone whom they met for the first time at icasa 2013, and 68% (n=42) entered into a partnership or joint venture with someone they had met at icasa 2013 for the first time. respondents were asked how many media articles related to or inspired by icasa 2013 they had published after attending the conference. nonmedia scholarship respondents (n=34) had the option to indicate that they were not from the media. nine respondents answered this question and 15 articles were published: 6 respondents published 1 article each, 2 respond ents published 2 articles each, and 1 respondent published 5 articles. the target audiences of the articles varied, i.e. special interest groups, organisations with activities similar to those of the authors’ oganisations, scientists, policy makers and the general public. a large majority (84%, n=52) of respondents indicated that in the 5 months since attending icasa 2013, they had implemented a ‘best practice’ or ‘innovation’ in their work, community and/or research environment. respondents were also asked to summarise the action steps that they had undertaken and/or what they had done differently as a result of attending icasa 2013. the descriptions of the best practices or innovations and the responses regarding action steps were analysed, and themes were allocated and combined according to the main themes. the following main themes were identified and are illustrated by some of the respondents’ quotes: collaboration and fundraising ‘ after the icasa conference i used the experience to write a combination prevention project and we received funding worth 250 000 dollars to implement combination hiv/aids.’ ‘we are conducting a study on hiv and disabilities, which is first of its kind in nigeria. the idea sprang from icasa 2013 experience and we hope the findings will stimulate donors towards this direction.’ research ‘i have been able to redirect the focus of our organisation to start researching unique phenotypes of hiv infection.’ table 1. respondents’ intention to use what was gained and achieved from the conference intentions/effect intention to use what was gained at end of conference, n (%) (n=480) self-reported effect of attendance 5 months after conference, n (%) (n=351) strengthen and expand efforts 203 (42.3) 115 (32.8) create new collaborations and projects 93 (19.4) 101 (28.8) influence and motivate others 91 (19.0) 83 (23.6) share information and raise awareness 88 (18.3) 52 (14.8) i am unsure 2 (0.4) i will not do anything differently 2 (0.4) other 1 (0.2) research june 2017, vol. 9, no. 2 ajhpe 60 ‘i have written three articles for conferences awaiting response. i am trying to ensure that partners were co-operating into responding to the global hiv response. i aim to support building the capacity of [community service organisations] csos partners to write and present scientific papers based on evidence.’ ‘i have changed the methodology of my research based on the best practices that i learnt at the conference.’ outreach/linkage to care ‘commercial sex workers hiv outreaches.’ ‘i conducted a community dialogue with women in the church to discuss about issues of gender-based violence and intimate partner violence, which make women vulnerable to hiv and aids.’ ‘i have developed new strategies for tracing people who do not come back into care, based on models that have worked in other countries and in special populations, such as displaced people, people with a lot of stigma.’ ‘created awareness on regular and consistent use of condoms and lubricants.’ key populations ‘condom promotion and integrating female condoms into our hiv prevention strategies. we have also established more male and female condom community outlets to increase access.’ ‘gender sensitive advocacy on preventing discrimination against the mostat-risk population – [men having sex with men] msm, [injecting drug users] idus.’ ‘new approaches in handling the key populations. addressing gender issues in fighting against hiv.’ ‘intervention strategies to close referral for targeting high-risk groups.’ policy ‘supported the [international conference on population and development] icpd process as part of a government delegation. info from icasa helped earmark priorities that icpd should incorporate.’ ‘in implementing prevention program [minimum prevention package inter vention] mppi used.’ service uptake ‘forming a network for all [non-governmental organisations] ngos working with [most at risk populations] marps in egypt.’ ‘using expert patient to strengthen linkage of hiv-positive to care and treatment.’ improvement and innovation ‘information sharing through restitution and monitoring for better implementation.’ ‘systematic screening of tb patient[s]. i am determined to speak strongly in [favour of screening of ] immunocompromised [patients].’ strategy ‘discussing experiences and new lessons learnt in sa with the three major networks on the need to involve [knowledge attitude and practices] kap … in our implementation. this has led to redirecting our project through the involvement of two of the organisations in our pilot project.’ ‘i disseminated the key lessons and new innovations that i learnt from the conference that enabled my technical support unit to generate a new project that actually got funded. hence developing a new partnership.’ advocacy ‘i have created a mailing list where i have shared several abstracts that pertain to women and health presented at icasa. i created a whatsapp group where we continue to discuss issues that came from icasa. i was on a radio programme where i spoke on the various issues that a diverse group of people spoke about at icasa; in particular, issues around hiv prevention, treatment care and support.’ ‘encouraging msm/idu to open up. sensitising on the danger of sexual risky behaviour. creating awareness on the regular and consistent use of condoms and lubricants.’ discussion the majority (59%, n=60) of the scholarship recipients were between the ages of 26 and 40 and two-thirds were a combination of researchers/ scientists, clinicians/physicians and advocates/activists. this demographic profile is characteristic of earlyto mid-career health professionals. the three most-cited reasons for attending the conference were practical (receiving a scholarship) or educational (acceptance of abstract and wanting to learn more about tb/hiv/aids/stis). the fourth cited reason – networking opportunities – proved to be durable, as these new contacts and opportunities for partnership and collaboration were the most cited in terms of perceived value of the conference. also, almost all of the respondents reported that they had the opportunity to build a professional relationship with other delegates and speakers during the conference. this level of networking can be considered to be sustainable after the conference, as nearly all (92%, n=24) of the respondents who had attended previous icasa conferences reported that they still had contact with somebody they had met for the first time at a previous icasa conference. this finding held true, as 5 months after the icasa 2013 conference almost all (98%, n=61) of the respondents still had contact with somebody they had met for the first time at icasa 2013. the networking opportunity also translated into concrete partnerships or joint ventures with somebody they had met at icasa 2013 for the first time for more than two-thirds (68%, n=42) of the respondents. this finding is consistent with that of 69% (n=18) of respondents from the second round of data collection, who reported that they had entered into a partnership or a joint venture with somebody they had met for the first time at a previous icasa conference. the findings regarding the network opportunities support the findings of wiessner et al.,[6] who reported that the focus of conferences extend beyond opportunities for learning, as the delegates have other expectations and needs that include making contacts and building relationships. the stimulation of ideas for new projects and an increased understanding of the challenges to achieving treatment access in africa were also cited as being perceived of value as a result of conference attendance, and 31 new projects were listed by the respondents 5 months after the conference. at the conclusion of the conference, the respondents committed to strengthen and expand efforts within their organisations/networks, create new collaborations and projects, influence and motivate colleagues, peers and/or partners, and share information and raise awareness when they returned to their workplaces. the third round of data collection at 5 months after the conference suggested that the respondents did indeed strengthen and expand their efforts, create new collaborations and partnerships, influence and motivate their colleagues, managers and/or partners, share information, and raise awareness. this finding is supported by the theory of reasoned action described by fishbein and middlestadt.[7] capacity was built by research 61 june 2017, vol. 9, no. 2 ajhpe sharing the information, best practices and/or skills gained with colleagues, managers and/or partners. this skills transfer included improved/refined work practices and/or methodologies, including management practices. the majority of the activities described by the participants after the conference are health-system strengthening activities. this vigorous post-conference activity is not surprising, as lalonde et al.[5] reported that ‘significantly more delegates from developing versus developed countries reported an intended behaviour change’ after the conference. the survey 5 months after the conference may have been too soon to determine with absolute certainty the impact of attending the conference. in particular, creating new collaborations and projects and influencing and motivating others would need more time to take full effect. in contrast, strengthening and expanding efforts and sharing and raising awareness could be more rapidly achieved. this post-conference survey was, however, an opportunity for participants to reflect on conference experiences that could have an impact on their scholarship and practice.[6] the post-conference survey did give a good indication of some of the outcomes. ninety-eight percent (n=61) of the respondents in round 3 of data collection indicated that they still have contact with somebody they had met for the first time at icasa 2013, and 68% (n=42) reported that they had entered into a partnership or joint venture with someone they had met for the first time at icasa 2013, suggesting the value of conferences for networking and possible partnerships. according to wiessner et al.,[6] this kind of reflective learning is a return on a conference investment. the conference also served as an impetus for the implementation of best practices or innovations in the workplace, community and research environment. these improvement and innovation activities included research reports, outreach, work with key populations, policy work and improving service uptake. what is now needed is confirmation of this impact through another study. study limitations the timing of the questionnaire 5 months after the conference is a limitation, as it is likely that some of the effects (such as developing new projects) might require more time. also, the use of anecdotal data is not sufficiently strong evidence of the impact of the conference. finally, the use of self-reported data is a limitation, as participants might have provided socially desirable responses as scholarship recipients. conclusion from the respondents’ reports 5 months after the conference it is clear that the scholarship programme contributed to the strengthening of health systems. in the case of icasa 2013, the benefits are retained in africa, as the majority of scholarship recipients work in africa. as the majority (59%) of scholarship recipients were between 26 and 40 years old, it implies that they will be able to continue to strengthen health systems for several decades to come. conference scholarship programmes, therefore, arguably provide the opportunities to create partnerships and strengthen health systems in africa, and answer the question whether this kind of activity is worthy of donor support. the finding by lalonde et al.[5] suggests, however, that the maximum benefit would be achieved by ensuring that scholarships are awarded to those who are new to the conference, as respondents who had attended only one previous international aids conference were ‘[statistically] significantly more likely to report making a change in their hiv/aids work as a result of attending a past [aids conference] than those who attended more than one’. funding. this study was made possible by icasa and the professional conference organisers, dira sengwe conferences. the icasa scholarship project was funded by sida. according to the agreement with sida, it was not necessary to obtain approval from sida to write this article. sida did not contribute to the writing of this article and does not vouch for the content. conflict of interest. ms a bosman is a technical advisor in evaluation in the programme evaluation unit of the foundation for professional development and the company secretary of dira sengwe conferences. 1. fuller j, keenan jf. the international aids conference in bangkok: two views. america (ny) 2004;191(5):13-15. 2. mukherjee js. the international aids conferences from vancouver to bangkok: how far have we come in eight years? pan am j public health 2004;16(2):75-77. http://dx.doi.org/10.1590/s1020-49892004000800001 3. brannon pm, yetley ea, bailey rl, picciano mf. vitamin d and health in the 21st century: an update. am j clin nutr 2008;88(suppl 2):s483-s490. 4. horton r. politicisation of debate on hiv care in south africa. lancet 2000;355(9214):1473. http://dx.doi. org/10.1016/s0140-6736(00)02154-1 5. lalonde b, wolvaardt je, webb em, et al. a process and outcomes evaluation of the international aids conference: who attends? who benefits most? j int aids soc 2007;9:6. http://dx.doi.org/10.1186/1758-2652-9-1 6. wiessner ca, hatcher t, chapman d, et al. creating new learning at professional conferences: an innovative approach to conference learning, knowledge construction and programme evaluation. hum res dev int 2008;11(4):367-383. http://dx.doi.org/10.1080/13678860802261488 7. fishbein m, middlestadt se. using the theory of reasoned action as a framework for understanding and changing aids-related behaviours. in: mays vm, albee gw, schneider sf, eds. primary prevention of aids: psychological approaches. newbury park, ca: sage, 1989. http://dx.doi.org/10.1016/s0140-6736(00)02154-1 http://dx.doi.org/10.1016/s0140-6736(00)02154-1 article 3 august 2010, vol. 2, no. 1 ajhpe it has been said that how you study the world determines what you learn about it.1 the purpose of health science education research is to understand teaching and learning so as to improve the quality of both. this endeavour is based on the assumption that better teaching will lead to better learning, and that better learning will result in a more clinically competent graduate. the emphasis in such research is therefore on creating explanations of teaching and learning, and then using these explanations to inform ‘best practice’ with regard to teaching and learning. however, much of the health sciences education research showcased at national and international conferences falls short of generating explanations that have practical applicability because the reported studies do not move beyond description. while description may be interesting, it fails to generate the kind of information that health professions educators need to understand, and thereafter improve, teaching and learning. this paper suggests ways in which health professions educators might move beyond description in order to generate explanations that have educational significance and applicability. the paper commences with a discussion of the role of theory in education research. three forms of theory are identified – personal theoretical assumptions, theory from literature, and generation of theory from research. the paper highlights the limitation of research without theory and the role that theory might play in generating understandings of teaching and learning. thereafter practical ways to ensure theoretical rigor in education research are discussed. hypothetical examples of qualitative research on assessment will be used to illustrate pertinent issues. the role of theory in education research generating explanations of human activity research that sets out to understand and generate explanations of human activity (such as teaching and learning) is usually qualitative.2-4 qualitative research aims to generate an ‘interpreted understanding’ (p. xii) of people’s social world through learning about people’s experiences and their interpretations of these experiences.5 thus a qualitative study of assessment might set out to understand how students experience assessment, and how assessment (including its content, strategies and timing) influences what students take seriously and what they consider less important about their curriculum. the findings could be used to plan assessment that helps students focus on all the aspects required to be competent health professionals. without an in-depth understanding of how students interpret assessment such planning would be based on teachers’ assumptions and conjecture. by understanding the students’ experiences and how these shape students’ learning behaviour, the planning of assessment as part of the teaching and learning process can be evidence-based. much qualitative research, however, fails to contribute to such insight because data analysis remains as surface description of what people said and did.2 a qualitative study of assessment might use focus group interviews to elicit students’ opinions of assessment. questions might even ask students to reflect on how assessment influences what and how they learn. however, such a study design will not automatically lead to the insights required to design assessment to shape students’ learning. it is the way in which the data are analysed that will determine whether the study generates explanations that have educational significance and applicability. from the research study suggested above, students’ responses could be categorised, using thematic analysis. for example, from a conscientious reading of the various interview transcripts it may, hypothetically, become evident that students understand assessment in three broad ways – for passing, as a hurdle, or as related to clinical competence. this finding may be presented by illustrating the three broad categories with quotations from the interviews, or in tabular form, or even statistically (i.e. how many students fall into each category). however, the insight that students have three broad interpretations of assessment falls short of an explanation of students’ understanding of assessment. rather, it describes what students assume but does not explain their understanding – and as such, has limited potential for influencing teaching and learning. the insights from such a study cannot yet be used to design assessment that influences learning. kelly2 notes that analysis that remains at the level of ‘thematic’ involves a relatively surface-level description of the data. as such this analysis represents a preliminary exercise to gain a general overview of the issue under investigation,2 and falls short of generating theory beabstract this paper is premised on the assumption that education research, in order to be relevant, needs to generate explanations that have educational significance and applicability. it argues that much of the health sciences education research showcased at conferences falls short of generating explanations that have practical applicability because the reported studies do not move beyond description. the paper suggests ways in which health professions educators might move beyond description in order to generate explanations of teaching and learning that can be used to inform ‘best practice’ in education. the paper commences with a discussion of the role of theory in education research. three forms of theory are identified – personal theoretical assumptions, theory from literature, and generation of theory from research. the paper highlights the limitations of research without theory and the role that theory might play in generating understandings of teaching and learning. practical ways to ensure theoretical rigor in education research are suggested. moving beyond description: research that helps improve teaching and learning wendy mcmillan professor and education advisor, faculty of dentistry, university of the western cape correspondence to: wendy mcmillan (wmcmillan@uwc.ac.za) article 4 august 2010, vol. 2, no. 1 ajhpe article cause it does not attempt to stand back from the data in order to undertake more detailed interpretation.2,6 theories arrange sets of concepts to define and explain phenomena,7 and thus allow movement beyond description to interpretation and explanation.2 using literature to generate explanations of human activity according to mcmillan and schumacher,8 a theory should be consistent with both the observed phenomenon and an already established body of knowledge. the assessment study discussed earlier neglects to draw on existing theory and literature. it fails to locate the study against the backdrop of what is already known about assessment and thus ignores potential lenses9 for interpreting the data and understanding the findings. engagement with existing theory and literature in the field of study2,10 facilitates research in two ways. firstly, it allows a greater range of questions to be asked of the data set.2 it allows the researcher to use the literature as a lens to interpret data by aiding him/her in recognising and interpreting patterns beyond the surface level of the data.2 secondly, it ensures that explanations generated from the study build upon what is already known.2 in the case of the assessment research, existing literature has the potential to suggest a variety of lenses for interpreting these patterns – for example, literature suggests variously that assessment drives learning,11 that assessment needs to be ‘authentic’ to be effective,12 that ‘good’ assessment should promote ‘deep’ learning,13 that assessment needs to be ‘aligned’ with outcomes and teaching strategies to be effective,14 and/ or that assessment provides teachers with feedback regarding the effectiveness of their teaching.13 these lenses could be used to categorise and interpret the data in ways which would allow an explanation of assessment. for example, if the researcher draws on the extant literature regarding the role that assessment plays in driving learning,11 a study might be designed that elicits the ways in which assessment drives learning, that explicates the kinds of learning that different assessment techniques drive, and that elucidates how students work with assumptions about assessment and learning when they prepare for assessment activities. data from this study would be analysed through the lens of existing understandings of the role that assessment plays in driving learning (i.e. concepts from the literature would be used to sort, categorise, interpret and understand the data). however, the purpose of such research would not be to repeat an existing study or to confirm the literature. rather, the study would be intended to examine, in the specific context in which it was conducted (i.e. in the researcher’s institution, faculty, field of health sciences education), how assessment drives learning for his/her students. the question might be, for example, ‘how does the use of four objective structured clinical examinations (osces) as high stakes assessment in the final year of the dentistry programme at my institution influence students’ learning in their final academic year?’. clearly the purpose of this study would be to ascertain whether the osces helped students to focus on the kinds of knowledge, skills and dispositions that will make them competent clinicians on graduation. findings from the study would be used to plan appropriate assessment. if the osce assessments were found to drive learning that was clinically orientated in the fullest understanding of that concept (i.e. psychomotor, cognitive and normative) then use of the osces could be strengthened. if, however, evidence from the study suggested that the students learnt only to pass the osces and that they failed to integrate the learning from the osces into their clinical practice, then alternative exit assessments would need to be explored. it is thus evident that the specific context of a study is important because the study is initiated to improve the quality of learning in a specific context. this is not to say that the findings may not be generalisable to other contexts – to other dental schools or, more broadly, to other fields of health sciences education. the presentation of such findings at conferences and in journals suggests that there is an assumption that findings from a specific context will have more general applicability. indeed, ‘transferability’ (or applicability) of concepts and theories generated from localised qualitative research to other contexts is often considered a criterion of valid15 or relevant research.16 however, in order for the findings to be transferable, the contexts must be similar. lincoln and guba16 suggest that the role of the researcher is to identify key aspects of the context from which the findings emerge and the extent to which they may be applicable to other contexts.(i) the preceding discussion has highlighted the significant role that theory plays in generating understandings of teaching and learning. firstly, through existing literature, theory informs study design and analysis. secondly, theory is also the product of the research process. there is a further way in which theory influences the nature of qualitative research, although not explicitly in its potential to generate understanding. however, this aspect of theory will influence the kinds of understandings that are generated, and is thus pertinent to the current discussion. personal theoretical assumptions much analysis, including the examples illustrated earlier, fails to acknowledge the way in which theoretical assumptions, often implicit, influence how studies are designed, how analysis is completed, and what conclusions are considered appropriate. for example, drawing on existing literature, the researcher may assume that students experience assessment in terms of reward and punishment. this assumption would influence what the researcher asked the research participants, and how the participants’ responses were interpreted. the emphasis in study design and analysis would be on how students experience assessment as reward or punishment, and how this influences their learning practices. however, what the researcher may neglect to do – and this is a common shortcoming in current qualitative research2,18-20 – is to make explicit the roots of this assumption which are based in the behaviourist tradition of learning. behaviourism assumes that learning is achieved through stimulus-response,21 and this conclusion about the nature of learning is based on classic maze studies with rats. it is unlikely that the researcher in the assessment study will problematise the applicability to health science students’ behaviour of a theory of learning that is based on rat studies. similarly, if the researcher assumed a constructivist understanding of learning, s/he would premise the study design on the assumption that students are active participants in their own learning and constantly trying to make meaning of their learning experiences.21 in designing the interview questions and interpreting the data, such a researcher would look for evidence of how students used assessment opportunities to assist them to make meaning. however, it is possible to present the findings from this study without ‘owning up’ to the hidden assumptions about learning that framed the study design, analysis and conclusions. these two studies might have the same research question and the same students. to some extent, the same data might be generated for each study. however, how the data are interpreted and how the explanation that is given of the data will differ, will be strongly influenced by the initial assumptions about learning that the two different researchers held. their theory of the nature of reality (in this case, of assessment) (i.e. their ontology) and their theory of what counts as knowledge and what passes for justification of knowledge claims (in this case, what conclusions can be made about assessment, and what conclusions are ‘true’) (i.e. their epistemology) influenced, albeit implicitly, all aspects of the study. merriam22 argues that this kind of theory (i.e. ontological and epistemo5 august 2010, vol. 2, no. 1 ajhpe article logical assumptions) shapes every aspect of the study, from determining how to frame the purpose and problem, to what to look at and for, to how to make sense of the data that are collected. the preceding discussion has highlighted three aspects of the importance of theory in education research. if the purpose of education research it to create explanations of teaching and learning that can inform ‘best practice’, then the research ‘product’ needs to be an applicable explanation. in fact, the product needs to be a theory about the meaning of the research findings that can eventually be applied in the teaching and learning context. theory is thus, firstly, the product of the education research process. secondly, theory needs to inform the research process. in other words, theoretical insight (and the literature that frames it) is an essential prerequisite to educational research design(ii) if the study is to be located within, and is intended to make a contribution to, what is already known about the subject. thirdly, the theoretical assumptions that framed the study (the epistemology and ontology) need to be made explicit as these will determine what kinds of conclusions, understandings or theoretical insights can be drawn from the study. in the section that follows, discussion will highlight practical ways of ensuring rigor for each of these three aspects of theory. ensuring theoretical rigor ‘owning up’ to theoretical assumptions theoretical rigor requires that the researcher ‘owns up’ to the set of ideas (i.e. the assumptions) that s/he started out with when designing the study.26 the researcher, thus, needs to explicitly disclose, when presenting research findings at conferences or through academic papers, the presuppositions and values that guided his/her research design, analysis and conclusions.24 such disclosure may be a challenge because assumptions about the world are so often ‘taken for granted’, and it may be difficult for a researcher to recognise and name his/her own assumptions. parse et al.26 suggest that this disclosure might be achieved through description – the researcher describes the personal meaning of the subject under study, and includes his/her beliefs about the subject by drawing on theoretical and experiential frames of reference. these beliefs may be drawn from named and formally labelled theoretical perspectives (such as positivism,27 interpretivism,27 critical inquiry,27 postmodernism,27 objectivism,28 constructivism,28 subjectivism28), from the researcher’s professional discipline (for example, nursing theories of care),20,24 from concepts, models, and theories of a particular literature base and disciplinary orientation,9 from personal values, biases and culture,2,9,20 and from personal experiences.9 the assumptions that the researcher has about how the world operates also influence the choice of methodology.28 methodology is the theory that underpins the research design,2 for example the selection of experimental research, survey, ethnography, phenomenology, grounded theory, or action research. the methodology provides the rationale for how a study will be conducted, how the analysis will be done, and how meaning of the findings will be made.2 methodology influences selection of objectives, research questions, research strategy and implementation of the study,19 as well as determines the choice of methods9 (for example, observation, focus group interview, statistical analysis, documentary analysis). methodology affects the kinds of things that can be found and the conclusions that can be drawn – as carter and little19 note, ‘a grounded theory study is likely to produce a theory, a narrative study a detailed analysis of life stories, and an ethnography a detailed description and/or interpretation of a culture. a successful action research project might produce teen anti-smoking activists and anti-smoking activities on school premises’ (p. 1323). what is taken for granted by the researcher at the commencement of the study thus affects not only how the study is conducted and what conclusions can be drawn (i.e. what theory might be generated), but also how the findings might be used. it is arguable that there can be no study without what is taken for granted at the moment of conception of the study. the disclosure of these assumptions is therefore essential in order to support and elucidate any claims that the researcher might want to make about the relevance, validity, or transferability of the study findings. in making his/her research preconceptions explicit, the researcher provides the reader with a basis for evaluating the study.24 the reader may agree or disagree with the initial assumption, but is, at least, able to evaluate the study from within the paradigm (or perspective) that the researcher designed it.24 theory to inform research it has already been argued that research needs to be located in relation to current understandings of a topic.2,10 thomas17 suggests that this access to theory and literature provides ‘tools for thinking’ (p. 422). the purpose of referring to existing literature and theory is to inform the study design and the analytical framework. charmaz29 suggests that locating a study within extant theory allows the researcher to set the scene for the study, to justify the focus of and techniques used to conduct the study, and to organise, analyse, interpret and provide a context for the data that is collected. in qualitative research, a preliminary literature review is usually conducted at the planning stage.2 theory in qualitative research frequently provides an organisational framework (or even a comparative context) for interpreting the data and for ways in which to represent the data after initial analysis.20 sandelowski20 suggests that a theoretical framework drawn from the literature ‘fits’ (p. 216) the data well when it easily permits comparison (i.e. when there are common characteristics in the theoretical framework and the data set), when it provides a useful framework for organising the data for representation (i.e. when it provides conceptual tools that can be used to organise and analyse the data – for example, the concepts of ‘deep’,30 ‘surface’30 and ‘strategic’13 approaches to learning may help analyse data that emerges from focus group interviews with students in a study of how assessment influences learning), and when it does not distort the meaning of the data (i.e. the data should not be ‘massaged’ to fit the theory – rather the theory should help explain the phenomenon under scrutiny). the role of theory varies depending on the study design.31 case study design needs identification of the theoretical perspective at the beginning of the study because that perspective affects the design of the research questions and the analytical framework for interpreting the findings.32 this theoretical perspective is generated from the existing knowledge base accessed during the preliminary literature study.18 similarly, ethnography, although initially descriptive, is ‘guided’ (p. 574) by the available knowledge related to the field of study.18 even for study designs such as grounded theory and phenomenology, where pre-conceptions are ‘bracketed out’ so as not to interfere with the theoretical perspective that should emerge from the study,33 prior familiarity with the relevant theory and literature is pertinent – ‘theory plainly becomes functional for the background of the research and is a strategy for literature review research’ (p. 574).18 grounded theory and phenomenology study designs balance the generation of new theory with recognition of what already exists in the field.18 however, for grounded theory and phenomenology, the literature is not used as a lens for designing the study and interpreting the data.18 article 6 august 2010, vol. 2, no. 1 ajhpe article the relationship between literature and analysis is often iterative in qualitative research. thus further literature, possibly even on a slightly different aspect of the topic, might need to be reviewed during the analysis and writing up phases of the research when the data analysis highlights the relevance of new or unexpected issues.2 kelly2 notes that the researcher may go backwards and forwards between the literature and the research question during the course of the study. finally, onwuegbuzie and leech34 remind, and warn, that the selection and review of the literature and the theoretical perspectives within that literature is not a neutral process. it, like all other aspects of the research process, is influenced by the researcher’s view of the world – as dellinger35 puts it, ‘review of the literature is inherently an interpretive and value driven process … (influenced by) the researcher’s own story about what is deemed valid, worthwhile, meaningful and valuable in a set of studies’ (p. 4). generating theory from research this paper commenced with the argument that education research, in order to be relevant, needs to generate explanations that have educational significance and applicability. this is the third aspect of theory in education research, and is the ultimate purpose of such research. the first, ‘owning up’ to theoretical assumptions, provides the broad parameters within which the study will be conceptualised. the second, surveying the current literature and relevant theories, provides the lens for understanding the field of research and analysing and interpreting the data. the first and second aspects of theory provide the context for the third. they determine what is scrutinised, how it is scrutinised, and how findings are interpreted. however, without the third aspect of theory – the generation of theory as provisional end-product36 – educational research cannot have practical applicability. glaser and strauss25 suggest that theory can be ‘discovered’ (p. 1) from the data, and although their methodology is specific to ‘grounded theory’, this suggestion has applicability to other qualitative methodologies. to generate theory, data analysis moves beyond surface-level description, and this process requires time and training.2 data analysis usually proceeds from the identification of patterns present in the data to explorations of the meanings and processes associated with the observed categories or patterns of behaviour.2 if the study is to move beyond description and an explanation is to be generated, then even a systematic analysis of the data leading to the identification of key themes will not be enough.2 in order to undertake a more detailed interpretation that may lead to explanation or theory, the researcher is required to ‘stand back’ (p. 287) from the data.2 the meaning associated with the categories identified in the initial analysis needs to be explored before an explanation can be generated.2 except in the specific methodologies of phenomenology(iii) and grounded theory(iv), extant literature informs the construction of this meaning. kelly2 argues that quality theory must build upon what is already known. such theory should be clear, have structure, coherence, scope, generalisability and pragmatic application.37,38 in the context of education research, understandings and theoretical insights generated have to, ultimately, be ‘usable’ in the context of teaching and learning. they need to be able to inform ‘best practice’. conclusion this paper commenced with a call for research that generates the kind of information that health professions educators need to understand, and thereafter improve, the quality of their teaching and the learning of their students. in the ensuing discussion, the significance of theory in explanations that have educational significance and applicability was highlighted. three aspects of theory were identified – theory as the product of education research, theory to inform the research process, and theory as the assumptions that frame the study. their inter-relationship was explicated, echoing sandelowski’s20 observation that ‘(t)heory in qualitative research is produced from inside and also enters from outside the boundaries of any research project’ (p. 214). qualitative research has the potential to generate theory ‘from inside’ a data set, but the nature of that theory is determined ‘from outside’ by the assumptions of the researcher, including what s/he reads, or neglects to read, in preparation for the study. in elucidating the characteristics of qualitative research, hammersley39 offers a checklist that ensures that all three kinds of theory are taken into account. the characteristics serve as a useful guideline to determine theoretical rigor in education research. quality qualitative research should generate substantive and formal theory, be empirically grounded and scientifically credible, produce findings that can be generalised or transferred to other settings, and be internally reflexive in terms of taking account of the effects of the researcher and his/her research strategy on the findings that have been produced.39 manuscript status the manuscript has not been published and is not under consideration in the same or similar form in any other journal. references 1. patton mq. qualitative valuation and research methods. newbury park, ca: sage, 1990. 2. kelly m. the role of theory in qualitative health research. family practice 2010; 27: 285-290. 3. mcleod j. qualitative research in counseling and psychotherapy. london: sage, 2001. 4. czarniawska-joerges b. exploring complex organizations. beverley hills, ca: sage, 1992. 5. ritchie j, lewis j. qualitative research practice. london: sage, 2003. 6. ahrens t, chapman cs. doing qualitative field research in management accounting: positioning data to contribute to theory. accounting, organizations and society 2006; 31(8): 819-841. 7. silverman d. interpreting qualitative data: methods for analyzing talk. london: sage, 2001. 8. mcmillan jh, schumacher s. research in education: a conceptual introduction. new york: longman, 2001. 9. anfara va, mertz nt. introduction. in: anfara va, mertz nt, eds. theoretical frameworks in qualitative research. thousand oaks, usa: sage, 2006: xii-xxxii. 10. whitley r. introducing psychiatrists to qualitative research: a guide to instructors. academic psychiatry 2009; 33(3): 252-255. available: http://ap.psychiatryonline. org (accessed 9 june 2010). 11. biggs j. teaching for quality learning at university. berkshire, uk: the society for research into higher education & open university press, 2003. 12. darling-hammond l, snyder j. authentic assessment of teaching in context. teaching and teacher education 2000; 16(5/6): 523-545. 13. canon r, newble d. a handbook for teachers in universities and colleges. london: kogan page, 2000. 14. butcher c, davies c, highton m. designing learning: from module outline to effective teaching. oxford: routledge, 2006. 15. devers kj. how will we know ‘good’ research when we see it? beginning the dialogue in health services research. health services research 1999; 34(5): 1153. available: http://www.umdnj.edu/idsweb/shared/how_know_good_qual_research. htm (accessed 8 june 2010). 16. lincoln ys, guba eg. ethics: the failure of positivist science. review of higher education 1998; 12(3): 221-240. 7 august 2010, vol. 2, no. 1 ajhpe article 17. thomas g. theory’s spell – on qualitative inquiry and education research. british educational research journal 2002; 28(3): 419-434. 18. tavallaei m, abu talib m. a general perspective on role of theory in qualitative research. journal of international social research 2010; 3(11): 570-577. 19. carter sm, little m. justifying knowledge, justifying method, taking action: epistemologies, methodologies, and methods in qualitative research. qualitative health research 2007; 17(10): 1316-1328. 20. sandelowski m. theory unmasked: the uses and guises of theory in qualitative research. research in nursing and health 1993; 16: 213-218. 21. conole g, dyke m, oliver m, seale j. mapping pedagogy and tools for effective learning design. computers and education 2004; 43: 17-33. 22. merriam sb. qualitative research and case study applications in education. san francisco: jossey-bass, 1998. 23. mills ge. levels of abstraction in a case study of education change. in: flinders dj, mills ge, eds. theory and concepts in qualitative research: perceptions from the field. newbury park, ca: sage, 1993: 103-116. 24. mitchell gj, cody wk. the role of theory in qualitative research. nursing science quarterly 1993; 6(4): 170-178. 25. glaser bg, strauss al. the discovery of grounded theory. new york: aldine de gruter, 1967. 26. parse rr, coyne ab, smith mj. nursing research: qualitative methods. bowie, md: brady, 1985. 27. denzin nk, lincoln ys. the landscape of qualitative research. thousand oaks, ca: sage, 2003. 28. crotty m. the foundations of social research. london: sage, 1998. 29. charmaz k. ‘discovering’ chronic illness: using grounded theory. social science and medicine 1990; 30: 1161-1172. 30. saljo r. qualitative differences in learning as a function of the learner’s conception of the task. gothenburg: acta universitatis gothoburgensis, 1975. 31. creswell jw. qualitative inquiry research design: choosing among five approaches. thousand oaks, ca: sage, 2007. 32. yin rk. case study research: design and methods. california: sage, 2008 33. husserl e. ideas: general introduction to pure phenomenology. new york: coller, 1962 (original published 1913). 34. onwuegbuzie aj, leech nl. a typology of errors and myths perpetuated in educational research textbooks. current issues in education (online) 2005, 8(7). available: http://cie.ed.asu.edu/volume8/number7/ (accessed 1 june 2010). 35. dellinger ab. exploring the relationship between validity and the review of literature. paper presented at the annual meeting of the southwestern educational research association, san antonia, tx, february 2003. 36. althusser l. from marx. london: allen lane, 1969. 37. morse j. considering theory derived from qualitative research. in: morse j, ed. completing a qualitative project: details and dialogue. thousand oaks, ca: sage, 1997: 163-190. 38. dey i. grounded theory. in: seale c, gobo g, gubrium j, silverman d, eds. qualitative research practice. thousand oaks, ca: sage. 2004: 80-93. 39. hammersley m. what is wrong with ethnography? methodological explorations. london: routledge, 1992. footnotes (i) this suggestion is not uncontested. thomas17 argues strongly that it is not the purpose of qualitative research to use ‘local interpretation (for) informing global interpretation’ (p. 427), and that ‘qualitative inquiry can’t do that and … that it doesn’t pretend to be able to’ (p. 427). whether findings from qualitative studies can, or should, be generalisable is a strongly contested proposition and persuasive arguments are presented for both sides. (ii) a note for those concerned about the relationship between this claim and qualitative research methodologies such as grounded theory and phenomenology. mills23 argues that ontological (theoretical perspectives on the nature of reality) and epistemological assumptions (theories for knowledge justification) shape how all research is conceptualised. these implicit and explicit theories underlie the beliefs, propositions, and theoretical conceptions that frame studies and their analysis, even when the theory is purported to be emergent. mills23 suggests that these theories ‘provide the researcher with a framework for the problem and questions to be addressed in the study’ (p. 114). mitchell & cody24 go further, suggesting that grounded theory methodology and phenomenology are in themselves theoretical locations that influence the study design and findings. further, while these methodologies recommend researchers to suspend any prior theoretical commitments or to bracket their assumptions concerning their field of study25 (which the preceding discussion suggests may, in fact, be impossible), they do not ‘mandate ignorance of relevant scholarship in an area nor do they excuse the failure to develop the theoretical sophistication required to do good qualitative research’ (p. 213).20 indeed, glaser and strauss25 called for a sociological ‘perspective’ and ‘theoretical sensitivity’ which mitchell and cody24 suggest is achievable only through theoretical knowledge. theory thus arguably remains significant to study design and analysis even for those methodologies that claim to generate rather than rely on theory. (iii) for a detailed discussion of the methodology of phenomenology see husserl e. ideas: general introduction to pure phenomenology. new york: coller, 1962 (original published 1913). (iv) for a detailed discussion of the methodology of grounded theory see strauss al. qualitative analysis for social scientists. cambridge: cambridge university press, 1987. ajhpe cover.indd ajhpe issn 0256-9574 african journal of health professions education sponsored by www.foundation.co.za october 2014, vol. 6, no. 2 152 october 2016, vol. 8, no. 2 ajhpe research a lack of democratic governance and failure to respect human rights contribute to persistent food insecurity and malnutrition in many african countries.[1] health professionals need to make concerted efforts to change the current prevalence of malnutrition and alleviate its long-term consequences. to strengthen the link between human rights and nutrition, tertiary education institutions need to provide human rights-orientated education to equip graduates to operationalise the concepts, standards and principles of human rights.[2-7] scholars at the university of oslo, norway; oslo and akershus university college for applied sciences, norway; stellenbosch university, south africa (sa); and makerere university, uganda proposed to develop and deliver a transnational and interdisciplinary track module (henceforth referred to as ‘the module’) focusing on these links. funding was obtained from the norwegian government under the norway masters (noma) programme, through the centre of international cooperation in education (siu), to strengthen universities in the south, supporting two cohorts of students from the universities in africa, each for a period of 2 years (2011 2012 and 2012 2013).[8] norwegian students were also accepted for the module but they supported themselves financially. the module was approved by all four institutions for incorporation into their respective master of nutrition curricula for the participating students. the module was presented through a 6-week study unit in each country, the content of each building upon the others, totalling 18 weeks (april august). participating students from all three countries attended every study unit in each country, first in norway, followed by sa and lastly uganda. the focus was on the theoretical and institutional background to international human rights, and the responsibilities of state and civil society to implement, through democratic governance, measures towards enjoyment of the rights of all to adequate food and nutritional health and to be free from hunger (fig. 1). an additional objective was to provide a model that could raise the interest of other universities in africa. to introduce a transnational module posed challenges to the institutions, given several seemingly incompatible administrative differences (table 1). through close collaboration and good will, some compromises regarding academic calendars and accreditation systems were accommodated. the objective of this article is to document the perceptions of the students enrolled in the module. understanding how students experienced the module could inform future efforts to embed a human rights-based approach (hrba) into nutrition curricula. methods the sampling frame consisted of all students (n=22) participating in the two cohorts of the module (2011 2012 and 2012 2013). data were collected during october and november 2012, using a mixed methods approach. firstly, data were extracted from a quantitative evaluation by students for each study unit. the evaluation form consisted of eight categories of statements investigating various aspects of the module. students anonymously responded to statements relevant to each category by using a 7-point likert-type scale, ranging from ‘strongly disagree’ to ‘strongly agree’. for reporting the results, positive or negative responses were added together for ease of reading. secondly, an interpretative methodological approach was used to elicit narrative accounts of students’ perceptions of the module through in-depth background. a module on nutrition, human rights and governance was developed and presented jointly by academic institutions in norway, south africa and uganda, under the norway masters (noma) programme, for their respective master’s degree programmes in nutrition. consisting of three study units, it was presented consecutively in the three countries, with each study unit building on the previous one. objectives. to document the perceptions of participating students on various aspects of the module, informing future curriculum endeavours. methods. a mixed methods approach was followed. a module evaluation form completed by students for each study unit was analysed. in-depth telephonic interviews were voice recorded and transcribed. through an inductive process, emerging themes were used to compile a code list and content analysis of the unstructured data. results. an overall positive module evaluation by 20 participants (91% response rate) can be ascribed to the module content, enlightening study visits, expertise of lecturers and an interactive teaching style. logistical issues regarding time management and administrative differences among the academic institutions caused some concerns. students experienced some resistance against qualitative research in natural science faculties. students benefited from being exposed to different teaching styles and education systems at universities in different countries. constructive alignment of teaching and learning activities could be optimised through involvement and empowerment of all relevant lecturers. conclusion. successful implementation of the module not only provides nutrition master’s students with knowledge to operationalise a human rights-based approach during future interactions in their professional practice, but also serves as an example of the benefits and challenges of interdisciplinary and transnational collaboration in module development. afr j health professions educ 2016;8(2):152-159. doi:10.7196/ajhpe.2016.v8i2.553 the noma track module on nutrition, human rights and governance: part 1. perceptions held by master's students m l marais,1 bsc dietetics, dipl hospital dietetics, m nutrition; m h mclachlan,1 phd; w b eide,2 cand.real (oslo), dipl nutrition (london) 1 division of human nutrition, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 department of nutrition, faculty of medicine, university of oslo, norway corresponding author: m l marais (mlm@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 153 research interviews. two research assistants conducted the research to minimise potential bias, as the researcher was also the study co-ordinator in sa. as students resided in different countries, the assistants conducted interviews (35 125 minutes) telephonically. interviews were conducted in english using a discussion guide based on probes relevant to the module, e.g. positive and negative aspects of the module as well as students’ view on the incorporation of an hrba in nutrition curricula. interviews were transcribed and checked to ensure accuracy. a systematic approach was used to analyse unstructured data, and constant comparison of texts ensured that the themes reflected the original data. through an inductive process, a code list was compiled from emerging themes and used to code the transcribed text, using a text analysis computer programme (atlas.ti version 6, germany). to ensure that all emerging themes were identified and to check for inconsistencies and contradictions, the text was reread several times. one set of themes emerged related to the categories used in the evaluation form and are presented as such. ethics and legal aspects approval for the research project was obtained from the health research ethics committee of the faculty of medicine and health sciences, stellenbosch university (ref. no. n12/08/044). informed written consent for both voluntary participation and voice recording of interviews was obtained from all participants. each participant received a signed electronic copy of the completed consent form. anonymity and confidentiality was maintained by assigning participant codes during the transcription of interviews and whenever direct quotes were used. all transcripts and voice recordings were stored in protected files and the voice recordings were destroyed. results background information about participants twenty noma students (16 female and 4 male), enrolled at the different universities, with a mean (standard deviation (sd)) age of 30.2 (6.0) years, provided consent to participate in the study (91% response rate). some participants had no work experience and had only been registered students; others had between 1 and 18 years experience in various professions (including community dietitian, nutritionist, research scientist and cook (table 2)). participants’ curiosity was raised by the unique content and nature of the module. the noma scholarship not only enabled students to register for a master’s degree in nutrition, but also provided them with the opportunity to study abroad. there were some logistical issues pertaining to the conditions of the scholarship, which was a cause of concern for some students, but these were mostly due to different administrative systems at the universities and were largely resolved during the first cohort. despite careful planning, students were concerned that the difference between the various universities’ credit allocations was to the disadvantage of some students as the workload was not always aligned with the number of credits (table 1). data from the quantitative module evaluation indicated that, overall, students were very positive about the module (98% of respondents agreed and strongly agreed). students were impressed with the planning and content of the module as well as the choice of lecturers (85% agreed and strongly agreed). the largest variation in responses was with regard to the organisation and time allocation (67% agreed and strongly agreed; 15% disagreed and strongly disagreed (fig. 2)). reasons for this variation became apparent during the in-depth interviews, which revealed nuances of students’ perceptions about the module (table 3). emerging themes from the in-depth interviews are presented according to the categories in the evaluation form. general assessment of the noma track module ‘i was so glad that they set up the noma track module, if i jumped out of the programme right now, i can never remain the same person … .’ (male student, uganda) module: nutrition, human rights and governance study unit 1 in norway theoretical basis and principles subunit 1 the historical background and conceptual basis for international human rights and good governance subunit 2 the structure and function of the international human rights systems study unit 2 in sa the sa case: application study unit 3 in uganda the uganda case: application subunit 3 the right to adequate food and nutritional health in international law subunit 4 the politics of human rights and democratic governance in global and development initiatives subunit 5 empirical dimensions and indicators of governance and human rights−based approach to planning and development subunit 1 historical background of nutrition, human rights and governance in sa subunit 2 implementation of the right to adequate food and nutritional health at national and provincial level in sa subunit 3 current events in sa that may a�ect the protection and promotion of human rights and governance subunit 1 historical background of nutrition, human rights and governance in uganda subunit 2 implementation of the right to adequate food and nutritional health in uganda: rati�cation process, mechanisms, institutions and monitoring in africa subunit 3 current events that may e�ect the realisation and promotion of human rights and governance in uganda, including millennium development goals and regional issues • poverty and vulnerability • gender and lifecycle interventions • regional distribution • emergency feeding • indigenous groups subunit 4 achievements and prospects subunit 4 achievements and prospects • poverty and vulnerability • gender and lifecycle interventions • regional distribution • communicable and non-communicable chronic diseases fig. 1. framework for the noma track module on nutrition, human rights and governance (2011 2012 and 2012 2013). 154 october 2016, vol. 8, no. 2 ajhpe research the experience was described as an emotional roller coaster because students were exposed to so many different areas, issues and solutions.[9] as much as students benefited from physically being in a developed country (norway), going to different developing countries provided the opportunity to grapple with issues regarding the implementation of the right to food within the context of a specific country’s situation. the sequence in which countries were visited was regarded as optimal. for example, the rights-based sa constitution is widely acclaimed and the implementation thereof illustrated theoretical principles studied in norway. one student remarked that ‘if we did not go to sa first, if we went directly to uganda, we would not have known how to implement the international human rights’. (male student, uganda) r es p o n se s, % strongly agree st ud y v isi ts (n =1 10 ) 100 90 80 70 60 50 40 30 20 10 0 agree agree a little neutral disagree a little disagree strongly disagree ho lis tic as se ss m en t ( n= 22 0) pl an ni ng co nt en t ( n= 22 0) w or kin g m et ho ds (n =1 76 ) co nd uc t o f m od ul e ( n= 26 4) or ga ni sa tio n an d tim e ( n= 26 4) le ct ur er s ( n= 88 ) lit er at ur e ( n= 22 0) fig. 2. summary of students’ quantitative evaluation of the noma track module according to the number of responses per category. table 1. summary of relevant academic information pertaining to the noma track module presented by universities in norway, sa and uganda[8] norway sa uganda institutional information participating university and department department of nutrition, faculty of medicine and centre for human rights, faculty of law, university of oslo (m nutrition) oslo and akershus university college of applied sciences (m food, nutrition and health) division of human nutrition, faculty of health sciences, stellenbosch university school of food technology, nutrition and bio-engineering; faculty of agriculture – applied nutrition programme; together with human rights programme, department of philosophy, faculty of arts, makerere university master’s programme offered m nutrition m food, nutrition and health m nutrition msc applied human nutrition noma module’s contribution to credits 8.33% contribution to master’s programme 25% contribution to master’s programme 4.5% contribution to master’s programme academic year january november january november august may module organisation number of contact sessions 3 afternoons per week 2 3 full days per week 5 full days per week duration of contact sessions per day 3 sessions of 45 minutes 15-minute breaks 6 7 sessions of 45 minutes 15-minute breaks 1 hour lunch 6 sessions of 1 hour 2 hours lunch field trips none 1 day per week and 1 week of visits only 2 field trips of 1 day each module conduct teaching style lectures informal and flexible time schedule some lectures informal, mostly inflexible time schedule lectures formal and inflexible time schedule presenters of lectures lecturers with expertise in human rights, nutrition and/or governance, (n=4) various presenters from different departments and institutions (n=28) various presenters from different departments and institutions (n=25) presenters’ place of employment university departments (n=3) university departments (n=3) government (n=15) non-governmental (n=10) university departments (n=12) government (n=9) non-governmental (n=4) format of literature printed core documents electronic links textbook printed core documents electronic links articles relevant to sa on cd printed core documents electronic links reading lists october 2016, vol. 8, no. 2 ajhpe 155 research matters relating to the content of the module ‘… nutrition alone is not complete without human rights. nutrition involves other issues like the way people grow the food, the environment and all the other factors, they all affect nutrition. to look at nutrition as only one component is not complete but if you integrate with human rights, then it brings in the other aspects like water, land, production … .’ (female student, uganda) over-arching outcomes for the module were formulated during the development of the module. students appreciated having specific study objectives for study units offered in norway and sa, as the outcomes provided an overview and guided them during their studies. participants regarded the opportunity to learn about the theoretical and institutional background to international human rights in norway as a highlight of the module. building on the theoretical principles, a variety of topics was included in sa and uganda to illustrate the practical application of human rights principles (fig. 1). a holistic approach to the incorporation of an hrba into food and nutrition was nurtured as students came to a deeper understanding of the complexity of issues, ‘that human rights are not just about poverty but about the whole aspect of human beings’. (female student, norway) one student disagreed and was uncomfortable with the impression that an hrba should be the only way nutrition can be strengthened. she believed that any approach based on strong moral values would make an equally valuable contribution to the attainment of nutritional health and food security for all. regarding the study units in sa and uganda, students from both cohorts identified the limitations of focusing on one province/region only. they suggested that different provinces should be compared to obtian a better perspective of the national situation. as uganda was the third country to present a study unit, students found some repetition of the theory and it was suggested that lecturers should ensure that the content of study units remains country specific. students from outside uganda regretted not being exposed to the positive contributions of ugandan non-government organisations (ngos) and civil society (fig. 1 and table 1). through critical observations in the foreign countries, students also became aware of various aspects pertaining to the right to food in their own country, ‘learning about where we are, what has been our past, how we have gotten to where we are now’. (female student, sa) some felt honoured to visit places they had never been to before and being allowed to go into people’s houses: ‘whatever could have been covered, was covered as much as possible in the module in a very short format.’ (female student, sa) students from the second cohort thoroughly enjoyed an introductory lecture about the political history of sa and uganda and how it has impacted on the right to food. notwithstanding this, students requested more information about the governmental structure in each country, including norway. one student confessed that the course was ‘definitely emotionally draining when it comes to the history … [it] is something that i wished we did not have to go through’. (female student, sa) one of the conditions of participating in the module was the inclusion of an hrba in students’ research design. co-ordinators tried to encourage students to start with ideas for their theses as early as the first study unit. table 2. demographic information of participants in the noma track module (2011 2012 and 2012 2013) country gender age (yrs)* marital status highest qualification occupation experience (yrs)† norway f 49.3 married b public health nutrition cook 18 f 30.3 single b nutrition student 0 f 27.2 single b nutrition student 0 f 26.0 single b public nutrition student 0 sa f 30.8 single bsc med hons nutrition and dietetics dietitian 6 f 28.3 single bsc dietetics dietitian 3 f 25.5 single bsc dietetics dietitian 0 f 30.6 single bsc human nutrition, dipl community nutrition nutritionist 9 f 26.3 single bsc dietetics dietitian 3 f 25.7 single bsc dietetics dietitian 2 f 42.9 married bsc med hons in dietetics dietitian 15 uganda f 26.9 single bsc food science and technology research scientist 1.5 f 29.7 single bsc food science and technology nutritionist 3 f 33.8 single bsc food science and technology dietitian 8 f 27.7 married bsc food science and technology research scientist 3 f 25.9 single bsc human nutrition and dietetics assistant nutritionist 1.25 m 30.5 single bsc food science and technology dietitian 6 m 25.6 single bsc human nutrition and dietetics dietitian 1 m 29.6 single bsc human nutrition and dietetics nutritionist 4 m 30.9 married bsc in human nutrition and dietetics dietitian 6 f = female; m = male. *mean (sd) = 30.2 (6.0) years. †mean years work experience = 4.5 years. 156 october 2016, vol. 8, no. 2 ajhpe research at the time, students thought that this was too far in advance. eventually, students realised that research is a time-consuming process. thinking back to discussions about research ideas held in norway and again in sa, students remembered the challenges faced by everyone in this regard. because students were continually receiving new information about human rights in each study unit, they felt they had to complete the full module before they had the ‘big picture’. only then did they feel equipped to ‘cement a research topic’. other students found it difficult to focus on research per se, and preferred to focus on the information relevant to each country and the subsequent examinations: ‘during the module there was no time to even consider working on a literature review or anything … other than just thinking about it.’ (female student, sa) another example of the challenges emanating from interdisciplinary collaboration was the discrepancy between the expectations of a science faculty and the noma module requirements regarding interdisciplinary research combining human rights and the right to adequate food and nutrition. on presentation of the research protocol using an hrba, some table 3. quotes from master of nutrition students describing various aspects of the noma track module, grouped according to the categories in the quantitative questionnaire category quotes an overall assessment of noma track module ‘i was so glad that they set up the noma track module, if i jumped out of the programme right now, i can never remain the same person … that can be attributed to the programme.’ (male student, uganda) ‘i don’t think any of us could have done it if it wasn’t funded.’ (female student, sa) ‘it has been wonderful in general and it was more than what i expected it to be. it has been beyond my expectations in every way.’ (female student, norway) ‘it was generally a good course, especially the exposure i got to the different countries: norway, uganda and sa … i’m finding it quite hard to really bring out one particular highlight.’ (male student, uganda) ‘the best part was that we moved from country to country. you could see the differences in economic status, culture … just how different the country had developed … you could see, this is a country that’s just beginning, like uganda … then you had sa, which is somewhere in between. it’s like … a midway transition from being a developing country, to being a developed country. then you had norway, which is the most developed of the three. it was nice to see that unfold, as you moved from country to country. you could also identify negatives about this development.’ (female student, sa) ‘when you have been away and then at home again and knowing you need to catch up and you have a certain amount of time and get ready to go away again. it was actually very hard to have the dual studying and getting ready for exams and try and catch up and being home … that was hard.’ (female student, sa) ‘of course i missed my family and friends … but i did not work with that in my mind. i was trying very hard to learn. i thought of them after studying.’ (female student, uganda) matters relating to the planning and content of the module ‘i feel that since this was the very first time that the course was run, this was a fantastic effort, and i feel that not much could have been changed or improved. it was obvious that a lot of hard work, preparation and consideration went into the planning of this module, and i think that every one of the students would have benefited from this. thank you very much for a very stimulating, challenging and well-organised course.’ (female student, sa) ‘whatever could have been covered, was covered as much as possible in the module in a very short format.’ (female student, sa) ‘[the module] should be planned with a collective mind. the module was incorporated into ongoing master's programmes but when you go back [to your country], you get into the master's programme and then there is no mention of human rights; and until you get to your research, you will not find it anywhere. i think in the future they need to streamline the programme to become uniform across the three countries and we get the same qualifications to do that … because now after studying that long, i get a transcript from the university for three credit units.’ (male student, uganda) ‘the noma team has the regulation that we are supposed to do research on human rights and the right to food. and then you choose this supervisor and you draw up your proposal on the thing which suits the context very well and how you are incorporating it into your proposal. personally, i have changed my entire topic [after working on it for a year] because of the department saying you are doing a master's of science in applied human nutrition ... so they are saying, issues of human rights shouldn’t be the one to dominate in your proposal. of course i am saying, it is issues of human rights, so there is this kind of confusion. so how do i meet the expectations of the university and the requirements of human rights?’ (male student, uganda) ‘the noma course increased my understanding of the world and especially with sa and its history and the problems and, hopefully, how to increase, improve the situation there and the same with uganda. it has just been excellent.’ (female student, norway) ‘we had a chance to analyse the politics of the three different countries. in that, i found a good basis for comparison, and generally understood the world, and how it is. the interactions between the three different countries were good.’ (male student, uganda) matters relating to working methods in the module ‘you don’t just get knowledge about things … you see what you are learning.’ (female student, sa) ‘these universities, they have their way of learning and teaching that was unique.’ (male student, uganda) ‘i think, that the three universities involved gave it a different character, i would say. i found norway was a new experience … in oslo. then when we go to stellenbosch – it was a different environment … method of lecturing and teaching … and come to uganda it was a different thing. it gave us insight, an idea of how different products from different universities was.’ (male student, uganda) ‘it has so many different dimensions and it is also a very individualistic way of experiencing learning, what i hear is different from what someone else hears; and what i understand is not the same as what other people understands; so it is just a mixture and you must really be ready to engage.’ (female student, sa) continued … october 2016, vol. 8, no. 2 ajhpe 157 research students were instructed to change their topic, as an hrba was not deemed appropriate for a research proposal in a natural science faculty (table 3). matters relating to working methods used in the module students benefited from being exposed to different teaching styles and education systems at universities in different countries. they enjoyed the interaction with foreign students and learnt from one another. overall, students were very positive about the participative nature of the module: ‘you don’t just get knowledge about things … you see what you are learning.’ (female student, sa) students rated highly the integrated and reflective assignments that were compiled on all field trips, as they needed to ‘incorporate their knowledge and all [they] had been learning’. (female student, uganda) it is important for a module of this integrated nature to allow students enough time for self-study. students found it challenging at times to balance everything, i.e. completing assignments, studying for the examinations and, also, visiting tourist attractions. in norway, students were grateful that the lectures and workload were timetabled to provide adequate time to read and study for the examination. table 3. (continued) quotes from master of nutrition students describing various aspects of the noma track module, grouped according to the categories in the quantitative questionnaire category quotes matters relating to the conduct of the module ‘i was probably expressing things that i only express to people that i was close with. i do hope it means something to someone because i don’t want it to just be feedback and then it sits on a piece of paper somewhere. it is nice to do a post mortem of what you have been through.’ (female student, sa) ‘i think the evaluation was good … it was good to explain how you experienced the situations. and in sa, because we had different lecturers and we could get the evaluation directly after the lecture. it was good to say how you see the lecturer, his method of teaching. and for them to ask us how we feel about the course and the modules and how we experienced it, so evaluation was good.’ (female student, sa) it [the module] was good, because it was interactive and basically it was good that it was put together by three different universities; because by interacting and exposure to the outside – we were able to meet different people, different cultures and different norms. the course basically, was so good, because like these people of norway – is from a developed country … and how the situation is in this underdeveloped country. because of that, and also because we are from different regions, the focus of facilitators were interesting to understand basically what the norms are and how things are and why the evaluation is from country to country.’ (male student, uganda) ‘in sa … just to see what we do right … it was not just the theory but we had to apply the practical part also. what and how can i apply what i learned in the workplace, what can i do to incorporate human rights. the practical application … that was a big positive.’ (female student, sa) assessment of the lecturers ‘in sa i think it was extremely important that we also evaluated every lecturer and lecture, which we did not do either in norway nor uganda, so that is actually something i think should have been done also in the other two countries. this interview here, maybe for me it would have been better to have it written, as it is very difficult with the poor line, but i think it is extremely important because i want the noma course to continue.’ (female student, sa) [students valued the input of experts with practical experience]: ‘… people who can think on ground level … are involved in integration, implementation, monitoring and evaluation. they understand it very well and bring it in a way that is very relevant to the students. they see it every day in their lives, and they appreciate it.’ (male student, uganda) ‘we had great lecturers and it was very good because we had different lectures from different fields and we got different perspectives of things. i really loved the visiting of institutions and we had lectures there as well which was great.’ (female student, norway) matters relating to organisation of the module and allocation of time ‘there was quite a lot happening around that time … we were travelling back, we had written exam in norway, came back [to sa], wrote an exam here, started lectures, and all of that.’ (female student, sa) ‘it was difficult, it was too close. we were flying from norway to sa, you did not have time to settle in; and from sa to uganda. you fall in there, you begin with classes. the time was so, so, so close to each other.’ (male student, uganda) ‘i mean we did not get the information until the very last minute, in all three countries … we are used to getting the information about a course at least one month before.’ (female student, norway) ‘as soon as we arrived, for example in sa, everything was sort of already organised. the whole program was all in place, we did not have any difficulties, all we had to do was get down and study and work and so on.’ (female student, norway) ‘for us, we never used to take time seriously, but we also learnt through norway, because everything was on schedule … so you agree on a time and you keep within that time [limit].’ (male student, uganda) matters relating to the literature ‘the other positive was the resources, that we got exposed to, and we got textbooks, readings, articles that i hadn’t seen before, websites.’ (female student, sa) ‘the readings also … the fact that we couldn’t get to all of them. i still got them as resources. i could still go and use them if i wanted to. i don’t think the readings should have necessarily been cut down … .’ (female student, sa) matters relating to the study visits ‘we saw with our own eyes what the situation is, what is being done about it and then discussed how those situations could be remedied, looking at how the country is progressing towards realisation of the right to food.’ (male student, uganda) ‘if you read about it in a book you don’t get the same as if you see it with your own eyes … like the field trips.’ (female student, norway) ‘we heard from people who were directly involved in the actual activities regarding the right to food, that also was a new experience. we went directly to the fields talking to the different farmers and people who are suffering and people that were currently misplaced and talking about it.’ (female student, uganda) 158 october 2016, vol. 8, no. 2 ajhpe research matters relating to the conduct of the module in spite of the overall positive response to the module, some issues were raised that could have negatively affected students’ learning experiences. it was felt that some lecturers discussed irrelevant information, didn’t pitch their lectures at an appropriate level or did not adequately link nutrition and human rights. it was suggested that lecturers should receive adequate orientation regarding the objective of the module and the content of all study units. the reason why the teaching style in uganda was perceived as less interactive than in norway could be ascribed to the perception of lecturers as elders/authority figures and ‘… in our african culture you don’t talk back to your elders … and in terms of educational qualifications, it is sort of like a parent-child relationship’. (female student, sa) students found ‘it was so inclusive’ to evaluate each study unit and make recommendations for improvement: ‘[giving feedback] felt good … people in charge will know what went wrong.’ (male student, uganda) one student was concerned about the confidentiality of the interviews due to the sensitive nature of the information conveyed. assessment of lecturers one of the main themes that emerged was the appreciation students expressed for the privilege of learning from people who were experts in their fields of practice. the lecturers in norway in particular were acclaimed for their patience, and ability to explain unfamiliar human rights concepts clearly and incorporate legal terminology. it was very beneficial to have a variety of presenters sourced from different institutions and departments: ‘one person wouldn’t have all the knowledge that those people had.’ (female student, sa) it provided students with a broader understanding of the implementation of human rights instruments and violations of the right to food. matters relating to the organisation of the module and allocation of time with the invaluable assistance of resident students in norway and the international office at the host universities, foreign students were able to settle in within a few days: ‘we did not worry about general arrangements.’ (female student, sa) students were appreciative because the module was well co-ordinated and they were timeously informed about changes in the programme, although they requested that they might receive information concerning a study unit earlier than a week before the time. the way lectures were scheduled in norway allowed for time to reflect and ask questions; however, students would have preferred longer lectures. some students found the schedule in sa and uganda (table 1) overwhelming and inflexible, with students needing more time to interact with lecturers. the long days with inadequate breaks were tiring and affected their studies, as they had little time to process information. this was considered unnecessary at a master’s level. despite the full schedule, students still enjoyed it ‘because we learned so much and we were exposed to so much … it was great’. (female student, sa) matters relating to the literature mastering unfamiliar concepts such as human rights principles, meant that students immersed themselves in literature provided in print, on cd or as internet sources. comprehensive reading lists were provided in the relevant countries’ study guide, yet much of the literature was not country specific. students struggled to obtain access to some of the recommended sources due to poor internet connectivity and unstable electricity supply, and in some instances documents were only available as hard copies, thus difficult to obtain. students were concerned about the amount of reading material as the sheer volume encouraged superficial reading. others regarded it in a positive light: ‘we got textbooks, articles and websites that i hadn’t seen before … and i could keep it for future reference.’ (female student, sa) matters relating to the study visits ‘if you read about it in a book you don’t get the same as if you see it with your own eyes … like [during] the field trips.’ (female student, norway) the highlights of the module were the study visits to various government departments, and to national and international organisations in the two african countries (table 1). the study visits necessitated a substantial amount of travelling that required ‘early mornings’ to ensure arrival in good time at the relevant institutions. on the positive side, students used the time spent in the buses to reflect and debrief. not all the expectations of students were met in sa, as some wanted to observe the implementation of programmes in deeper rural areas. students also expressed their regret that ‘we did not really see the aspects of those living at the grassroots [in norway]’. (female student, uganda) the two field trips in uganda were valued as unique opportunities that should be extended and combined with lectures presented at these sites. students’ opinions of the incorporation of a human rightsbased approach in curricula even though both nutrition and human rights principles form part of a holistic approach to client care, students were aware that very few lecturers in nutrition currently have training in human rights. they felt that incorporation of an hrba in a holistic manner from an early point in one’s academic career should be encouraged in all academic institutions to empower graduates to use an hrba should they become involved in policymaking and programming: ‘it is not an add-on – it is more a way of doing things … it is not only for the community dietitians or government dietitians or ngo dietitians.’ (female student, sa) students argued that the integration of an hrba could be achieved if nutrition departments adopt the principles of an hrba and understand the links to health and nutrition. it will then become easier for lecturers to incorporate human rights principles where relevant. discussion ‘human rights education and training is a lifelong process.’[4] globally, the need for more fully comprehensive courses in human rights has been identified by academics,[4] as short courses and seminars are regarded as inadequate in equipping healthcare professionals to operationalise the hrba in all spheres of their individual professions.[9] although these courses should be based on human rights law, procedures and principles, they should be responsive to the context within which they are offered october 2016, vol. 8, no. 2 ajhpe 159 research and according to various societies’ own ideals.[4,10] the interactive and participative approach followed in the noma track module offered this group of nutrition professionals the unique opportunity to learn how they, as health professionals, could use an hrba to make a contribution to the realisation of the human right to be free from hunger and achieve nutritional health for all. the way the module affected students’ professional competence was reported by marais et al.[9] and indicated an enhanced awareness of their roles as nutrition practitioners. lessons learnt from this experience are applicable at both undergraduate and postgraduate level and are useful during the development of transnational and/or interdisciplinary modules. to create successful modules, it is crucial to follow all steps of curriculum development,[12] from the needs assessment to feedback and critical reflection upon completion of the module. commitment from all partners and thorough planning during the initial phases are essential, as the academic and institutional requirements must be reconciled. participants expressed great appreciation for the way that the module was structured, the sequence in which countries were visited and the content of the curriculum. suggestions for improvement mainly focused on logistical issues, with some additional lecture themes. comments on the differences between various academic institutions firstly concerned the individual systems of awarding credits to a module and the corresponding workload. the substantial differences in the approach to the concept of credits was also a major hurdle during the development phase of the module. even though the negotiated solution to the problem was acceptable to the postgraduate committees and senates of the participating universities, the unequal credit load caused some friction and students requested that the matter be reassessed in future. secondly, students perceived prejudice against qualitative research methods in natural science faculties, which according to the literature have been only recently introduced in the health sciences.[13] students were faced with this dilemma and needed to defend or even change their research proposals, after spending several months on planning research topics to which qualitative research was better suited. limitations of the module were identified by students. specific learning outcomes were sometimes lacking, the relevance, amount and availability of reading material was questioned, and there was some unnecessary repetition of information. constructive alignment of the curriculum objectives as well as the teaching and learning activities is of paramount importance for facilitating students’ performance at the desired cognitive level.[14,15] it is of even greater importance when using an interdisciplinary approach[16] and when different parts of the same module are developed and presented in different countries. to ensure that all lecturers from the different institutions and departments are fully aware of the predefined scope of the lectures and to minimise repetition, it is recommended that several workshops, dedicated to the alignment of module objectives and content, are presented by the collaborating institutions and/or departments. evaluation and feedback is an essential part of the curriculum development cycle.[14] it was encouraging to see students keen to participate in the evaluation, and their input will be invaluable during future development of transnational and interdisciplinary modules. conclusion the noma track module succeeded in providing a group of nutrition professionals with the knowledge to operationalise the principles of an hrba in an appropriate manner. the interactive teaching style proved effective in enhancing students’ comprehension of unfamiliar human rights concepts. the module serves as an example of transnational and interdisciplinary collaboration in module development, which requires commitment to the cause and a willingness to share expertise. references 1. united nations children’s emergency fund (unicef). implementing the millennium development goals: health inequality and the role of global health partnerships. new york: un, 2009. http://www.unicef.org/health/ files/mdg_and_health_inequalities_un_2009.pdf (accessed 2 july 2014). 2. nixon s, forman l. exploring the synergies between human rights and public health ethics: a whole greater than the sum of its parts. bmc int health hum rights 2008;8(2):207-209. doi:10.1186/1472-698x-8-2 3. food and agriculture organization of the united nations. right to food unit. rome: fao, 2006. http://www.fao. org/righttofood (accessed 2 july 2014). 4. united nations general assembly. united nations declaration on human rights education and training (a/ res/66/137). geneva: un, 2012. http://www.un.org/docs/asp/ws.asp?m=a/res/66/137 (accessed 29 july 2016). 5. eide wb. enhancing cross-disciplinary skills to analyse and promote food and nutrition as human rights – the role of academic insitutions. in: eide wb, kracht u, eds. food and human rights in development. volume ii: evolving issues and emerging applications. antwerpen: intersentia, 2007:513-543. 6. forman l. making the case for human rights in global health education, research and policy. can j public health 2011;102(3):207-209. 7. maunder e, khoza s. a case for national training in nutrition and human rights in south africa. in: eide wb, kracht u, eds. food and human rights in development. volume ii: evolving issues and emerging applications. antwerpen: intersentia, 2007:547-562. 8. iverson po, kikafunda j. application to siu for noma funding for the programme: develop and deliver cooperative regional masters programmes in ‘nutrition, human rights and governance’. oslo: university of oslo, 2009. 9. marais ml, eide wb, mclachlan mh. the noma track module on nutrition, human rights and governance: part 2. a transnational curriculum using a human rights-based approach to foster key competencies in nutrition professionals. afr j health professions educ 2016;8(2):160-165. doi:10.7196/ajhpe.2016.v8i2.554 10. jonsson u. the need for masters-level training in human rights. paper presented at the federation of african nutrition societies (fanus) congress, 2nd meeting, abuja, nigeria: 15 september 2011. 11. conteh mb. human rights teaching in africa, the socio-economic and cultural context. secur dialogue 1983;14(1):53. doi:10.1177/096701068301400107 12. kern d, thomas p, howard d, bass e. curriculum development for medical education: a six-step approach. baltimore: johns hopkins university press, 1998:1-11. 13. tavakol m, sandras j. quantitative and qualitative methods in medical education research: amee guide no 90: part 1. med teach 2014;36(9):746-756. doi:10.3109/0142159x.2014.915298 14. mclean m, gibbs t. twelve tips to designing and implementing a learner-centred curriculum: prevention is better than cure. med teach 2010;32(3):225-230. doi:10.3109/01421591003621663 15. biggs j. enhancing teaching through constructive alignment. high educ 1996;32:347-364. doi:10.1007/ bf00138871 16. kezar a, elrod s. facilitating interdisciplinary learning: lessons from project kaleidoscope. change: magazine high learn 2012;44(1):16-25. doi:10.1080/00091383.2012.635999 http://www.unicef.org/health/files/mdg_and_health_inequalities_un_2009.pdf http://www.unicef.org/health/files/mdg_and_health_inequalities_un_2009.pdf http://dx.doi.org/10.1186/1472-698x-8-2 http://www.un.org/docs/asp/ws.asp?m=a/res/66/137 http://dx.doi.org/10.7196/ajhpe.2016.v8i2.554 http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1177/096701068301400107 http://dx.doi.org/10.1080/00091383.2012.635999 ajhpe african journal of health professions education sponsored by www.foundation.co.za issn 2078-5127 october 2016, vol. 8, no. 2 the ajhpe is published by the health and medical publishing group. ajhpe african journal of health professions education august 2010, vol. 2 no. 1 editor vanessa burch editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk assistant editor emma buchanan technical editors marijke maree robert matzdorff paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse clinton griffin online manager gertrude fani hmpg board of directors m raff (chair) r abbas m lukhele d j ncayiyana t terblanche m veller issn 1999-7639 the ajhpe is published by the health and medical publishing group (pty) ltd, co registration 2004/0220 32/07, a subsidiary of sama. 28 main road (cnr devonshire hill road), rondebosch, 7700 all letters and articles for publication must be submitted online at www.ajhpe.org.za tel. (021) 681-7200. fax (021) 681-1395. e-mail: publishing@hmpg.co.za contents editorial educating health professionals to meet africa’s needs vanessa burch 2 articles moving beyond description: research that helps improve teaching and learning wendy mcmillan 3 mb chb curriculum modernisation in south africa – growing doctors for africa janet l seggie 8 using portfolios to assess professional competence and developement in medical laboratory science christian c ezeala, mercy o ezeala, ephraim o dafiewhare 15 is temperament a key to the success of teaching innovation? j j blitz, m r van rooyen, d a cameron, g p pickworth, p h du toit 17 short report the need for a master of science degree programme in microbiology in uganda agwu ezera 22 abstracts south african faimer regional institute poster day, held in cape town 23 cpd 25 ajhpe issn 0256-9574 african journal of health professions education sponsored by www.foundation.co.za may 2016, vol. 8 no. 1 ajhpe is published by the health and medical publishing group (pty) ltd co. registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za suites 9 & 10, lonsdale building, gardener way, pinelands, 7405 tel. 021 532 1281 | cell 072 635 9825 l letters and articles for publication must be submitted online at www.ajhpe.org.za guest editorial 86 going rural – protracted immersion or toe-wetting: does it matter? o nkomazana research 87 implementation and outcome evaluation of the medical education partnership initiative biostatistical reasoning workshops for faculty and postgraduate students at the university of kwazulu-natal, durban, south africa m muzigaba, m l thompson, b sartorius, g matthews, n nadesan-reddy, s pillay, u lalloo 92 predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south africa m muzigaba, k naidoo, a ross, n nadesan-reddy, s pillay 99 exploring the relationship between demographic factors, performance and fortitude in a group of diverse 1st-year medical students s hamid, v s singaram 104 motivated strategies for learning and their association with academic performance of a diverse group of 1st-year medical students s hamid, v s singaram 108 assessing the effect of an online hiv/aids course on 1st-year pharmacy students’ knowledge f suleman 113 feedback as a means to improve clinical competencies: consultants’ perceptions of the quality of feedback given to registrars c i bagwandeen, v s singaram 117 feedback as a means to improve clinical competencies: registrars’ perceptions of the quality of feedback provided by consultants in an academic hospital setting c i bagwandeen, v s singaram 121 third-year medical students’ and clinical teachers’ perceptions of formative assessment feedback in the simulated clinical setting r m abraham, v s singaram ajhpe african journal of health professions education | may 2016, vol. 8, no. 1, suppl 1 editorial board editor-in-chief vanessa burch university of cape town supplement editor oathokwa nkomazana university of botswana international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university michael rowe university of the western cape elizabeth wolvaardt university of pretoria associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design carl sampson head of sales & marketing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani i tel. 072 463 2159 email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 editorial 213 introducing interprofessional education, practice and research in a higher education setting a rhoda short report 214 using operative models (icf and cbr) within an interprofessional context to address community needs a rhoda, f waggie, g c filies, j m frantz research 217 collaborative competency in physiotherapy students: implications for interprofessional education j manilall, m rowe 222 academics’ knowledge and experiences of interprofessional education and practice h julie, l hess-april, j wilkenson, w cassiem, a rhoda 225 facilitating community-based interprofessional education and collaborative practice in a health sciences faculty: student perceptions and experiences a rhoda, n laattoe, g smithdorf, n roman, j frantz 229 students’ views of learning about an interprofessional world café method g c filies, z yassin, j m frantz 234 reflection on an interprofessional community-based participatory research project j frantz, g filies, k jooste, m keim, n mlenzana, n laattoe, n roman, c schenck, f waggie, a rhoda ajhpe african journal of health professions education | october 2016, vol. 8, no. 2, suppl 2 editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors julia blitz stellenbosch university jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria lionel green-thompson university of the witwatersrand patricia mcinerney university of the witwatersrand sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wasserman stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design clinton griffin head of sales & marketing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405, tel. 021 532 1281 | cell 072 635 9825 please submit letters and articles for publication online at www.ajhpe.org.za 54 june 2017, vol. 9, no. 2 ajhpe short research report professional development is a process entered into by professional practition­ ers to maintain, enhance and broaden professional and reflective practice. reflective portfolios in physiotherapy have predominantly been used as part of professional practice and to a lesser extent in undergraduate training.[1] there is considerable variation in the definitions of reflection and the criteria used to assess it. definitions have common threads of experience, a process of introspection, analysing knowledge and taking action on the learning or practice needs of the learner.[2,3] recognition of experiential learning in the curriculum is acknowledged if learning is clearly demonstrated in a written form.[4,5] the use of the written portfolio as an alternative form of assessment provides a means to evaluate students’ growth, maturity and achievement over time. final­year students at the university of the witwatersrand, johannesburg, south africa are exposed to knowledge and skills that prepare them for the practice of physiotherapy in a public health and rural community setting prior to embarking on this clinical experience. a reflective diary, as part of a portfolio, is used to assess the level of reflection undertaken by students during their rural experience. students write their reflective diaries daily during their 3­week rural community placement. the aim of this study was to analyse the level of reflective practice attained by final­year physiotherapy students. methods this study used a qualitative approach and directed content analysis to evaluate the reflective diaries. the definitions used are based on an integration of brookfield’s work on reflective practice that makes use of primary work by mann et al.,[3] schön,[6] mezirow,[7] johns,[8] gibbs[9] and kolb.[10] our study followed the vertical dimension model of reflective practice (table 1). a framework was derived from the literature on the process of reflection. forty­eight portfolios with reflective diaries were available for analysis. each researcher was initially allocated two randomly selected diaries to read and code. further allocation of diaries was planned until data saturation was attained. codes were identified from the students’ write­up and a constant comparison method was applied. on completion of the first iteration of coding, the portfolios were exchanged. then the second coder checked and read the diary, and looked for alignment of codes to the specific reflective category and possible fitting of reflective statements that may have been overlooked. after the second iteration of coding, the diaries were exchanged between coders. this provided a means of verification, conformability and peer debriefing.[12] a fifth category was added to the framework, i.e. level 5, which ‘shows evidence of reflective practice’. after the coding of eight portfolios, saturation of data was achieved. ethical approval was obtained from the human research ethics committee of the university of the witwatersrand (ref. no. m120360). permission was obtained from students to use their portfolios for research purposes. results in the eight diaries reviewed, the full range of levels of reflective practice was found. three of the eight diaries showed growth in reflective practice over background. the department of physiotherapy at the university of the witwatersrand, johannesburg, south africa has a programme that allows 4th­year physiotherapy students to experience learning about public health in a rural setting. this experience is assessed using a portfolio. to date, the portfolios have only been assessed in terms of the students achieving the learning objectives. the process has not been evaluated for its effectiveness in promoting a reflective learner. a reflective learner is considered as one who will develop critical thinking and better accountability for their own learning. objective. to analyse the level of reflective practice attained by the students. methods. a qualitative approach was used to analyse evidence of reflective practice in student reflective diaries. guided content analysis, using a framework compiled from the literature, was used to code the data. the coding framework outlined the levels of reflective practice – from the lowest level, identifying learning outcomes, to the highest level, i.e. abstract concept formation. results. forty­eight portfolios with reflective diaries were available for analysis. data saturation was obtained after eight reflective diaries were analysed. the majority of the student diaries (6 of 8) reflected a low level of reflective practice, with only a few attaining a high level. conclusion. this study showed that physiotherapy students who experienced learning in a rural setting achieved low levels of reflective practice. a minority of students were able to progress in their reflection to reveal elements of critical thought, reflective thinking and, further still, abstract concept formation. afr j health professions educ 2017;9(2):54­56. doi:10.7196/ajhpe.2017.v9i2.888 ‘he has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: the role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement h myezwa,1 phd; d maleka,1 phd; p mcinerney,2 phd; j potterton,2 phd; b watt,1 bsc 1 department of physiotherapy, school of therapeutic sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 centre for health sciences education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: h myezwa (hellen.myezwa@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. june 2017, vol. 9, no. 2 ajhpe 55 the 3­week period, with levels 4 and 5 being more evident in the second half of the students’ clinical rotation. the majority (108 of 283) of the entries were categorised as level 1a. twelve examples could be classified as level 1b. the example in table 2 reflects one student referring to a forgotten consideration of ensuring that a screening tool was reliable and valid. there were fewer reflections (n=27) at level 2. the majority of the entries were at level 2a, where students referred to actual achievements experienced. there were only four entries at level 2b. at level 3a, students (n=16) demonstrated a deep understanding of the learning outcome. there were a greater number of entries at level 3b (n=42), where students demonstrated insight into their own learning processes. the reflections at level 3 were in the limitations of self, others and the system. problems related to communication and language barriers were often mentioned in relation to the self. in reflecting on others in level 3, students frequently mentioned the role of family members. sometimes students described an incident in which self, others and the system were linked. level 4 reflections demonstrated students’ experience of growth. there were a total of 74 reflections across the four sub­levels. four out of the eight diaries showed a greater progression to levels 4 and 5. the importance of context (level 4b) was recognised frequently as an important factor in healthcare. students (n=2) recounted events with reflective scepticism, as reflected in the quote in level 4b. not all diaries (2 of 5) displayed evidence of level 5 reflections. students often reflected on what they had seen and how they would have managed a situation. discussion the results of this study revealed that all student entries demonstrated a low level of reflection. there were not many self­examination entries showing insight, self­awareness and recognition of own and others’ limitations. a higher level of reflection (level 4) was evident in 50% of the diaries, with 2 of 8 diaries progressing to abstract formation (level 5). similar findings have been reported in the literature, where low levels of reflective practice have been attained when student journals were assessed.[13,14] learning and practice issues, such as ethical concerns, questioning one’s profession and questioning student supervisor behaviours, emerged from the results of the analysis. these findings may have been influenced by confounding factors such as trust between student and educator, clarity of instruction, type of feedback, grading, number of entries and training. the rural block is unique in our physiotherapy curriculum. reflection occurs when a situation does not suit normal practice. hallett[15] found that the practical element and exposure to a community setting were crucial for developing critical thought. students should be encouraged to interrogate limitations of themselves, others and the system. no gold standard on how best to assess the levels of reflection exists.[6] the knowledge that the reflective journals would be read by examiners and assigned a mark may have affected the levels of reflection. the study used eight reflective diaries and attained saturation. this may be owing to the study being in a single institution; future studies may include diaries from other institutions. conclusion our study demonstrated that physiotherapy students in a rural placement achieve low levels of reflection involving factual, cognitive and competency­ related thinking. a minority were able to expand this to reflection that involved elements of critical thought, reflective thinking and reflective practice. strategies need to be developed to enhance the quality of reflective practice among students. acknowledgements. the authors acknowledge the final­year students of 2011 for giving permission to use their written portfolios, including their reflective diaries, in this study. we further acknowledge the staff and patients at the clinical placement sites, whose participation made this experience possible. 1. buckley s, coleman j, davison i, et al. the educational effects of portfolios on undergraduate student learning: a best evidence medical education (beme) systematic review. beme guide no. 11. med teach 2009;31(4):282­ 298. http://dx.doi.org/10.1080/01421590902889897 2. boud d, walker d. promoting reflection in professional courses: the challenge of context. stud higher educ 1998;23(2):191­206. http://dx.doi.org/10.1080/03075079812331380384 3. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. adv health sci educ 2009;14(4):595­621. http://dx.doi.org/10.1007/s10459­007­9090­2 4. cross v. the professional development diary: a case study of one cohort of physiotherapy students. physiotherapy 1997;83(7):375­383. http://dx.doi.org/10.1016/s0031­9406(05)65791­4 5. alsop a. competence unfurled: developing portfolio practice. occup ther int 2001;8(2):126­131. http://dx.doi. org/10.1002/oti.139 6. schön da. the reflective practitioner: how professionals think in action. 6th ed. new york: basic books, 1983:1­8. 7. mezirow j. learning as transformation: critical perspectives on a theory in progress. san francisco, ca: jossey­ bass, 2000:1­300. 8. johns c. framing learning through reflection within carper’s fundamental ways of knowing in nursing. j adv nurs 1995;22(2):226­234. http://dx.doi.org/10.1046/j.1365­2648.1995.22020226.x 9. gibbs g. learning by doing: a guide to teaching and learning methods. oxford: oxford brookes university, 1988:27­30. 10. kolb da. experiential learning: experience as the source of learning and development. vol. 1. englewood cliffs: prentice‐hall, 1984:20­38. 11. brookfield s. developing critical thinkers. milton keynes: open university press, 1987:1­67. 12. lincoln ys, guba eg. naturalistic inquiry. beverly hills: sage, 1985:1­416. 13. williams rm, wessel j. reflective journal writing to obtain student feedback about their learning during the study of chronic musculoskeletal conditions. j allied health 2004;33(1):17­23. 14. kember d. determining the level of reflective thinking from students’ written journals using a coding scheme based on the work of mezirow. int j lifelong educ 1999;18(1):18­30. http://dx.doi.org/10.1080/026013799293928 15. hallett ce. learning through reflection in the community: the relevance of schön’s theories of coaching to nursing education. int j nurs stud 1997;34(2):103­110. http://dx.doi.org/10.1016/s0020­7489(97)00001­1 short research report table 1. coding framework[6-11] level of reflection description 1a the student refers to a particular activity/task  1b the student demonstrates the process of acquiring an understanding of the task 2a the student refers to achievements experienced 2b the student has applied a methodical approach using a standard procedure to complete the task, and the detail of the description should be to the level provided in the rubric for the entire portfolio 3a the student demonstrates an accurate and deep understanding 3b the student demonstrates insight into his/her own learning process 3c acknowledgement of limitations of: 3ci self 3cii others 3ciii system 4a identifies and challenges assumptions  4b understands the importance of context 4c explores and imagines alternatives 4d reflective scepticism 5 direct experience, reflection on action and reflection with abstract concept formation http://dx.doi.org/10.1002/oti.139 http://dx.doi.org/10.1002/oti.139 56 june 2017, vol. 9, no. 2 ajhpe short research report table 2. results of level of reflection level of reflection entries, n quotes illustrating level of reflective practice 1a: the student refers to a particular activity/task 1b: the student demonstrates the process of acquiring an understanding of the task 1a: 108 ‘i really should have checked, and this is so basic, how could i have forgotten?’ (pf 7) 1b: 12 ‘of all the questions covered in the denver screening tool, our chosen outcome measure, the children here seemed to struggle the most with colours, adjectives and opposites.’ (pf 1) 2a and b: achievements and methods used in the task 2a: 23 ‘we finally had a meeting with the manager of the sewing room. i am overjoyed at the response – he agreed with all our suggestions and it would seem that he is willing to implement the necessary changes to help improve the working environment of the seamstresses. i have a deep feeling of satisfaction – at last, something is making a difference.’ (pf 8) 2b: 4 ‘i walked away from the home visit feeling proud of the work i do and the potential impact we can have on community such as this one.’ (pf 3) 3a, b and c: insight, under­ standing and acknowledge­ ment of limitation of self, others and the system 3a:16 ‘these figures showed the need for an intervention to impede the increasing prevalence of hypertension and arising complication(s) among the health staff as well as to intervene in empowering those who are already hypertensive to take control and improve their lifestyles.’ (pf 3) 3b: 42 ‘the best i could do was be compassionate and educate him on his condition and what he has the potential to become if he continues with rehabilitation.’ (pf 2) 3c: 22 ‘this is when i realised that sometimes this job is not about what you do for the patient alone but also for the people around them.’ (pf 1) ‘with so many patients to see i must admit that short cuts were taken, which i didn’t feel comfortable with.’ (pf 8) ‘when we went to [a particular] clinic, there were no patients booked for us. this happens so often that [it] really annoys me how the few resources that are available to the clinic are not utilised!’ (pf 4) sometimes students described an incident in which self, other and the system were linked.’ (pf 7) ‘throughout the morning, i was increasingly aware of a sub­standard level of treatment given to the patients and was also told that i should not try to learn from what i was seeing because this is community – and things are done differently in community compared to theory. i did not pursue that as i wanted to avoid any conflict (it’s only my second day!!!) but felt very disappointed that patients are receiving such poor rehabilitation. i hope that this is not a true reflection of the care being given at the hospital and that today was just a once off !’ (pf 7) 4a, b, c and d: identifying challenges, importance of context and exploring alter ­ natives 4a: 27 ‘home­based care seems to bring back the sensitivity to healthcare, he is no longer a cerebrovascular accident covered by sheets. he is a man, who has a family and a community who bear him on their shoulders. he has a life, a soul, a meaning that extends far deeper than his medical assessment. and it is only in this setting that these things come together.’ (pf 8) 4b: 22 ‘… it is important to them, the patients travel so far just for the treatment they seek and it’s our responsibility to make the most of the time we have with them!’ (pf 1) 4c: 16 ‘although we wanted to help him for his painful hand, there was a possibility there was an undiagnosed fracture. therefore we advised him to go to siloam hospital for x­ray.’ (pf 1) 4d: 18 ‘when the children have to write, they have to kneel on the cold and dirty concrete floor and write on their benches. how can this still be happening in a country that is striving to promote equality among its citizens!?’ (pf 3) 5: reflection and abstract formation 5: 4 ‘i don’t think that my siblings, or myself, would give up our dreams in order to look after a parent after a stroke.’ (pf 4) ‘i learned again how courtesy goes so far. just simple greeting in your patients’ mother tongue, ensures, that they will try to co­operate as much as possible.’ (pf 4) pf = portfolio. research 20 may 2016, vol. 8, no. 1 ajhpe stress is part of daily life and may be the stimulus for individual achievement. therefore, stress can serve as a motivational factor for students to perform at their peak or reduce their level of effectiveness.[1] individuals experience stress to a greater or lesser degree, depending on their perception of the demands in their environment and the resources to cope with these demands.[2] university entry for students is a transitional period, as they are exposed to a multitude of changes in their personal, social and academic environment. conditions and events inherent to university life induce experiences of stress, which may lead to difficulty in adjusting to this new environment.[3] the health sciences educational milieu is unique, as students are exposed to further stressors such as early engagement with patients and communities. stress among students in various disciplines in the health sciences is well documented.[1,4-21] however, the literature on stressors among students and qualified dental hygienists is sparse.[7,14,20-22] sources of environmental stress among dental students have been identified and quantified by means of the dental environment stress (des) questionnaire.[4,5] stressors identified include the learning environment, fear of failure, heavy workload, difficulty in dealing with patients, performing non-reversible procedures in a confined space, difficulty in dealing with transitions in curricula and difficult relationships with academic staff. gorter et al.[11] suggested that stress among dental students has been reported at length and that it would currently be more useful to focus on interventions to address this concern. long-term exposure to stress in the learning and working environment may result in burnout,[23] also referred to as a syndrome found among professionals doing ‘service work’.[24] burnout includes the domains of emotional exhaustion (ee), becoming emotionally exhausted; depersonalisation (dp), the development of a negative, cynical attitude to patients; and a sense of diminished personal accomplishment (pa), evaluating oneself and one’s own accomplishments negatively. roberts and ellingson[20] reported that signs and symptoms of burnout include ‘emotional, cognitive, behavioural and physical aspects’. these may be seen as loss of humour, a persistent sense of failure, anger, resentment and bitterness, postponement of contact with patients, constant feeling of tiredness, increased use of sick leave, rigid thinking, and difficulty concentrating.[25] although burnout has not been reported as being prevalent, ee, the key dimension of burnout, has been reported among students and professionals in the dental field.[7,11,14,15,23,26] there are no published reports on stress among south african (sa) oral hygiene students. as qualifications in both oral hygiene and dentistry are offered at the faculty of dentistry, university of the western cape (uwc), cape town, sa, it would be premature to develop student interventions without identifying the stressors and their effect. the objective of this study was to determine perceived stressors and the level of burnout among oral hygiene students at uwc. background. university students are exposed to a multitude of stressors that may impact on their performance. the nature of health sciences education generally involves early engagement with patients and communities, which may add to the stressors inherent to university life. there is sparse information on stressors in the oral hygiene educational environment. objective. to determine perceived stressors and the level of burnout among oral hygiene students at the university of the western cape, cape town, south africa. method. a descriptive, cross-sectional study design was used. the study sample included all students in the bachelor of oral health (boh) degree during 2012 (n=89). a self-administered questionnaire was used to gather data. three parameters were measured, i.e. (i) demographic characteristics; (ii) perceived sources of stress, using a modified dental environment stress (des) questionnaire; and (iii) burnout, using the maslach burnout inventory (mbi). results. respondents were mostly female (74%) and primarily in the 18 25-year age group (92%). firstand 2nd-year students identified fear of failing and study load as major stressors. stressors related to a lack of basic needs were identified as major stressors by 25% of 1st-year students. third-year students identified clinical quotas, supervision and patients being late as major stressors. mbi scores indicated that students were not at risk for burnout; however, most students (66.2%) scored high on emotional exhaustion (ee). conclusion. oral hygiene students identified stressors in their learning environment. there was a progressive increase in ee across academic years. the results suggest that interventions should be tailored for specific academic year groups. afr j health professions educ 2016;8(1):20-24. doi:10.7196/ajhpe.2016.v8i1.422 perceived stressors of oral hygiene students in the dental environment n a gordon,1 dipoh, ba, mph, dip adult education; c a rayner,1 dipoh, ba hons, ma; v j wilson,2 bchd, mchd; k crombie,3 dip diagnostic radiography, hde, msc dent; a b shaikh,4 bchd, msc dent, mchd; s yasin-harnekar,5 bchd, msc dent, pdd 1 department of oral hygiene, faculty of dentistry, university of the western cape, cape town, south africa 2 department of restorative dentistry, faculty of dentistry, university of the western cape, cape town, south africa 3 department of diagnostics and radiology, faculty of dentistry, university of the western cape, cape town, south africa 4 department of orthodontics, faculty of dentistry, university of the western cape, cape town, south africa 5 department of paediatric dentistry, faculty of dentistry, university of the western cape, cape town, south africa corresponding author: c a rayner (crayner@uwc.ac.za) research may 2016, vol. 8, no. 1 ajhpe 21 methods study design a descriptive, cross-sectional study design was used. study population all students registered for the 3-year bachelor of oral health (boh) programme during 2012 were included (n=89). instrument and data collection data were collected by means of a self-administered questionnaire. the following three parameters were measured: (i) demographic characteristics; (ii) perceived sources of stress, using a modified des questionnaire; and (iii) burnout, using the maslach burnout inventory (mbi). the des[4] and mbi[24] questionnaires are validated instruments. demographic characteristics included home language as a proxy of ethnicity, in view of the 11 official languages in sa. the des consisted of 79 statements categorised into the following areas of study: study environment (n=27), theoretical aspects (n=14), preclinical aspects (n=13), and clinical aspects (n=25). students were asked to respond to each statement by indicating whether it posed ‘no problem’, ‘a small problem’ or ‘a huge problem’ that might interfere with their studies. the following statements were added to suit the local context: discrimination due to race, nationality, gender or social class; transport to the university; accommodation; safety; and having enough food to eat. the mbi consisted of 22 statements. each statement was scored on a 7-point likert scale ranging from 0 (‘never’ experienced) to 6 (experienced ‘every day’). the mbi was divided into three subscales, i.e. ee, pa and dp. statements in the mbi were adapted to include ‘other students or people’. this was in view of the teaching methodologies that encompass engagement with students and communities throughout the programme. the questionnaire was piloted with 10 students to assure validity, and modified accordingly. it was distributed to students for completion in their classrooms. completed questionnaires were submitted to the researchers. the study was conducted at the end of the first semester. data analysis data were entered and analysed using descriptive statistics (ibm spss statistics for windows, version 21.0, usa: ibm corp.). frequency distributions were used to identify stressors posing a ‘huge problem’ to students. the mbi manual[24] was used to categorise the student groups into high, average and low risk for burnout. burnout is indicated in high scores of ee (≥27) and dp (≥10) and low scores of pa (≥40) in the human services survey (mbi hss).[24] ethical considerations ethical approval was obtained from the faculty of dentistry and university research and ethics committees, uwc. prior to distributing the questionnaires, students were informed verbally and in writing of the purpose of the study. informed consent was obtained. results demographics the response rate was 85%. respondents were mostly female (74%) and primarily in the 18 25-year age group (92%). six of the 11 official languages were reported as home languages, with 38% having english, the medium of education at the university, as their home language. more than half (58%) resided in the western cape – the province where uwc is located; 76% had attended public schools and 24% private schools; 47% lived with families and the remainder stayed in university residences (30%) or private residences (17%). student response to the des statements table 1 illustrates the top five stressors reported as a ‘huge problem’ for each category of the des. the ‘study environment’ scored lowest overall of the four categories. only 3rd-year students completed the clinical category and the majority experienced this as a ‘huge problem’. table 2 illustrates the top five stressors by year group, indicating that stressors vary across the academic years. firstand 2nd-year students identified the theoretical aspect of their studies as most stressful, whereas the 3rd-year group reported the clinical category as most stressful. table 1. the top five perceived stressors in each category of the des perceived stressors responses to a ‘huge problem’, % study environment 1. fear of being unemployed in future 48 2. lack of time for relaxation 37 3. neglect of personal life 36 4. treated as being immature 36 5. lack of confidence to be a successful hygienist 34 theoretical problems 1. heavy study load 65 2. fear of failing a module or year 64 3. overloaded feeling due to the large number of modules in the programme 61 4. having a lecture or clinic before a scheduled assessment 52 5. lack of self-motivation to study 36 preclinical problems (boh ii and iii) 1. fear of making mistakes 61 2. lack of time to practise preclinical procedures 59 3. limited co-operation from laboratory technicians/staff 54 4. meeting preclinical requirements 51 5. number of supervisors in relation to students; inconsistency between supervisors 46 clinical problems (boh iii only) 1. number of assigned quotas 95 2. number of clinical supervisors in relation to number of students 74 3. fear of being criticised 74 4. patients being late/missing appointment 74 5. fear of being unable to catch up with clinical requirements 74 research 22 may 2016, vol. 8, no. 1 ajhpe although not in the top five stressors, the statements added to the des questionnaire to suit the local context indicated the following: 1st-year students reported transport (29%) and safety (27%) to and from the university, accommodation (29%), not being able to study in their living environment (24%) and not having enough to eat (24%) as a ‘huge problem’. discrimination due to race, nationality, gender or social class was reported as a ‘huge problem’ by 2nd-year (32%) and 3rd-year (37%) students. student response to the mbi table 3 shows overall means and standard deviations for ee, pa and dp. the mean and standard deviations for individual statements were ranked in descending order. statements referring to ‘self ’ were reportedly experienced more frequently in ee (‘i feel used up at the end of my day at university’) and dp (‘i worry that my studies are hardening me emotionally’) subscales. table 4 shows the categorisation of year groups according to their risk for burnout. the means and standard deviations of the mbi score for each subscale and the percentage of students in the respective year group are indicated. most (66.2%) students scored high on ee, the key dimension for burnout. however, there were significant differences between the three year groups (p=0.039). in terms of burnout, 1st-year scores were seen as ‘indicative of engagement with work’, with 76.5% of the class scoring high on pa and 14.7% scoring average on ee. second-year scores were high on ee and dp but average on pa, suggesting a risk for burnout. third-year scores showed a reversal on the dp and pa scores; yet, ee remained high. there was no significance in student demographics and ee, dp and pa. there was considerable variation in student experiences in the academic year groups, as seen by the percentage of students in each category. discussion demographic characteristics oral hygiene is a predominantly female-orientated profession globally.[27] the gender distribution in this study is indicative of a changing student profile, with more males entering the profession. further diversity of the study population is evident in the home language distribution and schooling background. bojuwoye[3] reported that factors associated with financial difficulties, demands of the university environment and administrative processes were experienced as stressful by 1st-year university students. the current study suggests that 1st-year oral hygiene students may experience similar stressors. reports of discrimination due to race, nationality or gender as a ‘huge problem’ are cause for concern and warrant further enquiry. the decision to include additional stressors to the des was supported by the results, suggesting that a validated tool should be adapted to the local context to accommodate the social, cultural, economic and historical factors. table 2. top five perceived stressors of the des per year group study year potential stressor frequency, % boh i fear of failing a module overloaded feeling due to large number of modules heavy study load fear of being unemployed in the future having financial responsibilities 61 55 52 44 38 boh ii heavy study load overloaded feeling due to large number of modules fear of failing a module or year having a lecture before an assessment fear of making mistakes 91 82 77 68 66 boh iii number of assigned clinical quotas number of clinical supervisors in relation to students fear of being criticised by supervisors patients being late/missing appointments fear of being unable to catch up with clinical requirements 95 74 74 74 74 table 3. the maslach burnout inventory statements describing student feelings mean (sd) emotional exhaustion 3.28 (1.75) 1. i feel used up/worn out at the end of a day at university 4.25 (1.53) 2. i feel emotionally drained/exhausted from my studies 4.24 (1.56) 3. i feel fatigued/tired when i get up in the morning and have to face another day at university 4.11 (1.63) 4. i feel frustrated by my studies 3.96 (1.65) 5. i feel burnt out from my studies 3.86 (1.65) 6. i feel that i am working too hard on my studies 3.01 (1.94) 7. i feel that i am at the end of my rope 2.32 (2.23) 8. interacting with people all day is really a strain for me 1.96 (1.84) 9. interacting with people directly puts too much stress on me 1.85 (1.74) depersonalisation 1.29 (1.58) 1. i worry that my studies are hardening me emotionally 2.53 (2.19) 2. i have become more callous/uncaring towards people since i started my studies 1.35 (1.82) 3. i feel that i treat some patients and other students as if they were impersonal objects 0.99 (1.35) 4. i don’t really care what happens to some patients and other students 0.93 (1.44) 5. i feel that patients and other students blame me for some of their problems 0.65 (1.12) personal achievement 3.71 (1.66) 1. i feel i’m positively influencing other people’s lives through my studies 4.18 (1.46) 2. i can easily create a relaxed atmosphere with my patients and other students 4.17 (1.63) 3. i can easily understand how my patients and other students feel about things 3.93 (1.67) 4. i feel exhilarated/inspired after working closely with my patients and other students 3.77 (1.68) 5. i deal very effectively with the problems of my patients and other students 3.70 (1.73) 6. i have accomplished many worthwhile things in my studies 3.68 (1.70) 7. in my studies, i deal with emotional problems very calmly 3.47 (1.74) 8. i feel very energetic 2.85 (1.70) research may 2016, vol. 8, no. 1 ajhpe 23 student response to the des statements there were a number of similarities between the top stressors identified in this study and those in the international literature.[1,3-5,9,10,12,13,16,17] the study load, financial responsibilities, patients being late or missing appointments, and fear of being unable to catch up with clinical requirements were also noted among us dental hygiene students.[20] at least two stressors in the top five of each component of the des questionnaire posing a ‘huge problem’ in this study were also reported by saudi arabian dental students.[4] these stressors were: lack of time for relaxation, being treated as immature, study load, feeling overloaded due to the large number of modules in the programme, lack of time to practise a preclinical procedure, number of supervisors in relation to students, inconsistency between supervisors, fear of being criticised, and patients being late or missing appointments (table 1). fijian dental students also reported the following stressors: feeling overloaded, fear of failure, criticism from clinical supervisors in the presence of patients, amount of assigned work, financial resources, and fear of unemployment after graduation.[12] of concern is that stressors identified by garbee et al.[1] in 1980 are still reported in the current literature and were also found in our study. considering that the stressors were known, the authors questioned whether demands by departments were realistic and in the interest of students or whether departments competed for students’ time.[1] stressors in the abovementioned studies could be categorised as student, staff, curriculum and/or educational system related. it may be expedient to use categories to guide universities to the type and level of intervention required for a less stressful dental environment. final-year oral hygiene students reported significantly higher (p<0.01) stress levels than 1st-year students in three des items, i.e. atmos phere created by clinical faculty, lack of input into decisionmaking processes at the faculty and inconsistency of feedback between different instructors.[20] a number of items identified were also noted by students in the current study. the authors questioned whether different experiences to stressors between class years were a result of changing demands of the programme or the unique personality of a class.[20] the results of this study did not indicate a lack of input into decision-making processes at university as a ‘huge problem’, contrary to those reported by roberts and ellingson.[20] a possible explanation is that uwc students have representation on faculty structures. the manner in which stress is defined by the researcher informs the research approach and ultimately the answers gained. hamill,[28] in a qualitative study of student nurses’ perceptions of stress, used cox’s interactionist model of stress. this model advocates that ‘stress should not be seen as either a stimulus or a set of responses but rather a person’s interpretation of the significance of a threatening event (the stimulus) and his or her resources to cope with it (the response)’. the des and mbi questionnaires are quantitative instruments and may not be useful on their own. future studies using these instruments should consider using a mixed-method approach, where qualitative aspects are included to allow for clarification and elaboration of student experiences. polychronopoulou and divaris[16] grouped stressors into seven categories to facilitate targeted interventions. these are self-efficacy beliefs, faculty and administration, workload, patient treatment, clinical training, performance pressure, and other. a substantial number of stressors identified by students in this study were in the ‘self-efficacy beliefs’ category, suggesting that further enquiry may be needed. in considering interventions, programmes may also have limited control over stressors, such as patient co-operation,[20] also identified as a stressor in this study. in such instances student stress can be reduced through training to develop interpersonal relationships with patients to foster understanding of the patient’s life context and so improve co-operation.[20] longitudinal studies have been suggested to better the understanding of stressors identified and to monitor at-risk students to inform appropriate interventions.[11,12,21,23,29] this position is supported by the current study in view of stressors appearing to vary across the academic years. response to the mbi the scores for each subscale of the mbi show a trend (table 3), with statements referring to ‘engagement with others’ reported at a lower frequency on the ee and dp subscales and at a higher frequency on the pa subscales. this observation suggests that students may feel better about themselves when interacting with others, which supports the view that early engagement with patients is ‘protective’ in terms of stress and burnout.[19] the opposite, where engagement with ‘self ’ was reported at a higher frequency on ee and a lower frequency on pa, may indicate that students are challenged to cope in an academic environment. this finding may be consistent with the fact that a number of stressors noted in the des were located in the ‘self-efficacy beliefs’ category.[16] the overall scores (table 4) indicate that the group is not at risk of burnout. although the mean scores for the programme may be favourable, considerable variations across the academic years were noted. the 1st-year class started off positively, showing ‘engagement with work’, the 2nd-year class appeared to be at risk of burnout, and at the 3rd-year level students appeared to be coping better. of concern is that ee, the key dimension of burnout, increased progressively over the 3 academic years, with 62% of students falling into the ‘high’ category in the 3rd year. dimensions of burnout were also found among qualified dental hygienists, with high levels of ee (14%) and dp (15%) and high levels of diminished pa (29%).[14] hinshaw et al.[7] reported on stress and burnout experienced by dental hygiene educators. the authors highlighted institutional responsibility to reduce stress experienced as a result of educators’ roles and responsibilities. the results of this study cannot be generalised with regard to the broader oral hygiene student table 4. categorisation of mbi subscales by student year group, boh mbi subscales overall score 1st year 2nd year 3rd year ee category ee score % within group high 29.04 (11.00) 66.2 average 25.79 (10.56) 14.7 high 33.09 (10.10) 81 high 30.16 (11.51) 63.2 dp category dp score % within group average 6.28 (5.24) 27.8 low 5.14 (4.97) 56.3 high 8.13 (4.86) 36.4 average 6.15 (5.77) 27.8 pa category pa score % within group high 28.89 (8.23) 76 high 29.02 (10.05) 76.5 average 26.44 (6.35) 13.6 high 31.47 (5.66) 63.2 research 24 may 2016, vol. 8, no. 1 ajhpe population. however, the findings provide insight into the perceptions and experiences of uwc oral hygiene students. conclusion this study found that stressors were identified within the oral hygiene student population. stressors were generally similar to those reported by dental hygiene and dental students in the international literature. the fact that ee increased progressively across the 3 years indicated a need for intervention to improve the experiences of students in the dental learning environment. the results suggest that interventions should address student stressors at a generic student level and at the level of the academic year. references 1. garbee wh, zucker sb, selby gr. perceived sources of stress among dental students. j am dent assoc 1980;100:853-857. [http://dx.doi.org/10.14219/jada.archive.1980.0279] 2. taylor se. health psychology. 3rd ed. new york: mcgraw-hill, 1995. 3. bojuwoye o. stressful experiences of first year students of selected universities in south africa. counselling psychology quarterly 2002;15(3):277-290. 4. al-saleh sa, al-madi em, al-angari ns, al-shehri ha, shukri mm. survey of perceived stress-inducing problems among dental students, saudi arabia. saudi dent j 2010;22:83-88. [http://dx.doi.org/10.1016/j.sdentj.2010.02.007] 5. alzahem am, van der molen ht, alaujan ah, schmidt g, zamakhshary mh. stress amongst dental students: a systematic review. eur j dent educ 2011;15:8-18. [http://dx.doi.org/10.1111/j.1600-0579.2010.00640.x] 6. dahan h, bedos c. a typology of dental students according to their experience of stress: a qualitative study. j dent educ 2010;74(2):95-103. 7. hinshaw kj, richter lt, kramer ga. stress, burnout, and renewal activities of dental hygiene education administrators in six us midwestern states. j dent educ 2010;74(3):235-250. 8. silverstein st, kritz-silverstein d. a longitudinal study of stress in first-year dental students. j dent educ 2010;74(8):836-848. 9. kumar s, dagli rj, mathur a, jain m, prabu d, kulkarni s. perceived sources of stress among indian dental students. eur j dent educ 2009;13:39-45. [http://dx.doi.org/10.1111/j.1600-0579.2008.00535.x] 10. polychronopoulou a, divaris k. dental students’ perceived sources of stress: a multi-country study. j dent educ 2009;73(5):631-639. 11. gorter r, freeman r, hammen s, murtomaa h, blinkhorn a, humphris g. psychological stress and health in undergraduate dental students: fifth year outcomes compared with first year baseline results from five european dental schools. eur j dent educ 2008;12:61-68. [http://dx.doi.org/10.1111/j.1600-0579.2008.00468.x] 12. morse z, dravo u. stress levels of dental students at the fiji school of medicine. eur j dent educ 2007;11:99-103. [http://dx.doi.org/10.1111/j.1600-0579.2007.00435.x] 13. sofola oo, jeboda so. perceived sources of stress in nigerian dental students. eur j dent educ 2006;10:20-23. [http://dx.doi.org/10.1111/j.1600-0579.2006.00391.x] 14. gorter rc. work stress and burnout among dental hygienists. int j dent hyg 2005;3(2):88-92. [http://dx.doi. org/10.1111/j.1601-5037.2005.00130.x] 15. pohlmann k, jonas i, ruf s, harzer w. stress, burnout and health in the clinical period of dental education. eur j dent educ 2005;9(2):78-84.[http://dx.doi.org/10.1111/j.1600-0579.2004.00359.x] 16. polychronopoulou a, divaris k. perceived sources of stress among greek dental students. j dent educ 2005;69(6):687-692. 17. naidu rs, adams js, simeon d, persad s. sources of stress and psychological disturbance among dental students in the west indies. j dent educ 2002;66(9):1021-1030. 18. sanders e, lushington k. effect of perceived stress on student performance in dental school. j dent educ 2002;66(1):75-81. 19. heath jr, macfarlane tv, umar ms. perceived sources of stress in dental students. dent update 1999;26:94-100. 20. roberts ra, ellingson pl. perceived environmental stressors for dental hygiene students. j dent educ 1996;60(10):836-841. 21. hendricks sjh, joshi a, crombie k, moola mh. perceived sources of stress among black dental students in south africa. j dent educ 1994;58(6):406-410. 22. lopresti s. stress and the oral hygiene profession. can j dent hyg 2014;48(2): 63-69. 23. humphris g, blinkhorn a, freeman r, et al. psychological stress in undergraduate dental students: baseline results from seven european dental schools. eur j dent educ 2002;6:22-29. [http://dx.doi.org/10.1034/j.1600-0579.2002.060105.x] 24. maslach c, jackson se, leiter mp. maslach burnout inventory manual. 3rd ed. palo alto, ca: consulting psychologists press, 1996. 25. scutter s, goold m. burnout in recently qualified physiotherapists in south australia. austr physiother 1995;41(2):115-118. [http://dx.doi.org/10.1016/s0004-9514(14)60425-6] 26. gorter rc, storm mk, te brake jhm, kersten hw, eijkman maj. outcome of career expectancies and early professional burnout among newly qualified dentists. int dent j 2007;57(4):279-285. 27. johnson pm. international profiles of dental hygiene 1987 2006: a 21-nation comparative study. int dent j 2009;59:63-77. 28. hamill c. the phenomenon of stress as perceived by project 2000 student nurses: a case study. j adv nursing 1995;21:528-536. [http://dx.doi.org/10.1111/j.1365-2648.1995.tb02737.x] 29. burk dt, bender dj. use and perceived effectiveness of student support services in a first-year dental student population. j dent educ 2005;69(10):1148-1160. research may 2016, vol. 8, no. 1 ajhpe 59 south africa (sa)’s health system places the focus on primary healthcare (phc),[1] which deals with the health needs of a population in the communities where they live.[1] phc policy incorporates community-based rehabilitation as part of continuity of care and includes interventions in a client’s home.[1] physiotherapy education should produce graduates who are competent in addressing the health needs of the people within the community context.[2] graduates need to serve as health advocates and be accountable for making informed decisions to improve healthcare.[3] to enable them to be more effective in this regard, graduates need exposure to the realities of the healthcare system, socioeconomic health determinants, and clients’ real-life situations through phc. to train students effectively, authentic learning opportunities are necessary in the communities they will ultimately serve, particularly during their compulsory community service year.[2,4] these communities are often situated in under-resourced areas. experiencing the real-life context of clients is vital for students so that they will ultimately provide effective interventions and develop social responsibility.[2] students witness the roles of poverty and society in health first-hand during home-based rehabilitation (hbr). students report feeling overwhelmed when witnessing the realities of life in poor households.[4-6] factors such as diverse socioeconomic, racial, language and cultural backgrounds may affect healthcare interventions. developing cultural competency, i.e. the ability to treat people from a culture different to one’s own with respect and as equals, has become critical in physiotherapy training.[7] culturally competent and effective client-centred communication leads to improved client satisfaction, outcomes and compliance.[8] different skills and clinical reasoning processes are required for physiotherapeutic rehabilitation in a home context compared with clinicor hospitalbased interventions. tasker et al.[9] report that during hbr, clinical reasoning should primarily consider the client and family needs within the home setting. students need to be able to adjust the goal and process of the intervention to ensure efficacy and relevance to the clients’ context.[7] listening attentively to clients can increase the students’ understanding of all factors affecting clients’ health, goals and quality of life and thereby improve client satisfaction.[8] other skills students may develop in this context include: increased insight, coping with complexity, ability to think on one’s feet, assertiveness, building rapport, empowering others, enhanced observation skills, functioning in someone else’s space, consideration of quality of life and function as applicable to the client, knowing when to discontinue treatment, integration of services, and ability to function as a professional with limited resources.[4,9,10] the theory of situated learning, i.e. learning through active participation within a community of practice, underpins the educational experience of hbr.[11] authentic exposure in a client’s home environment can result in experiential learning, thereby promoting transformative learning.[11] transformative learning, i.e. learning that changes one’s view of the world, is a desired outcome of health professional education.[12] hbr leads not only to academic learning and personal development, but also to an understanding of social accountability and responsibility.[2,3] however, to gain maximum benefit from the learning opportunities available, students should be prepared effectively before exposure to hbr.[4] there is a scarcity of literature on hbr in the physiotherapy context, specifically with regard to the students’ or clients’ perceptions. this study sought to discover the perceptions of final-year physiotherapy students background. home-based rehabilitation (hbr) in under-resourced areas in a primary healthcare (phc) context exposes students to the real-life situations of their clients. there is a scarcity of literature on student and client experiences of hbr in the physiotherapy context. increased knowledge of hbr could result in an enhanced experience for both student and client. this study sought to discover the perceptions of final-year physiotherapy students and their clients relating to their experiences of hbr during a phc placement in a resource-constrained setting. objectives. to explore the experiences and perceptions of physiotherapy students and their clients regarding hbr as part of clinical training in resource-constrained settings. to discover the barriers to and facilitators of effective hbr. methods. an exploratory case study was performed. a qualitative pheno menological research design in the interpretivist paradigm was used. semistructured interviews were conducted with clients (n=7) living in an under-resourced setting, who had received hbr from physiotherapy students. paired interviews were conducted with final-year physiotherapy students (n=6) after their hbr placement. results. clients appreciated the students’ services; however, data revealed communication barriers and unmet expectations. students reported struggling to adapt to the context, resulting in interventions not being sufficiently client-centred. they voiced a need for language competency and earlier exposure to such contexts. conclusion. exposure to real-life situations in under-resourced settings in hbr provides valuable situated and authentic learning opportunities for physiotherapy students. the experience can be useful in preparing graduates to address the needs of the populations they serve during community service. afr j health professions educ 2016;8(1):59-64. doi:10.7196/ajhpe.2016.v8i1.561 home-based rehabilitation: physiotherapy student and client perspectives d parris,1 bsc (physio), mphil (hse); s c van schalkwyk,2 phd; d v ernstzen,1 bsc (physio), mphil (higher ed) 1 division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa  2 centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa  corresponding author: d parris (dparris@sun.ac.za) research 60 may 2016, vol. 8, no. 1 ajhpe and their clients regarding their experiences of hbr during a phc clinical training placement in resource-constrained and diverse settings. increased knowledge of hbr could improve the preparation of students for the placement, resulting in an enhanced experience for both students and clients. method research design an exploratory case study was conducted, focusing on the phenomenon of hbr in an educational context. the phenomenological enquiry allowed an understanding of the real-life experiences and feelings of the participants.[13] in-depth interviews generated qualitative data in an interpretivist paradigm, taking the clients’ and students’ perceptions as their reality.[14] research context at stellenbosch university (su), cape town, sa, final-year physiotherapy students each spend 6 weeks at a community site learning to integrate and apply the principles of phc and communitybased rehabilitation. approximately 5 10 clients are seen in their homes per week. one of the assessed outcomes of this placement is that the students will be able to effectively evaluate and treat clients in their own homes. before this placement, the students mostly treated clients in community health centres or hospital settings, which are more structured and better-equipped environments. students receive 1 hour of supervision per week from their clinical supervisor; therefore, they mostly conduct hbr on their own. they have the assistance of a community member as a chaperone and translator one afternoon per week. the research was conducted at a community placement site in an under-resourced community in the western cape, sa. the majority of residents are isixhosa speaking and live in informal housing with minimal resources.[15] students provide the only physiotherapy service in the area. the clients receive hbr in their homes, as they are unable to access or afford transport to the nearest physiotherapy department. participants purposive sampling was used to invite participants who could share their experiences of hbr.[14] final-year physiotherapy students from su were invited to participate in the study after they had completed their rotation in the area. clients who had received treatment in their homes by these students were approached to participate. data collection single, face-to-face, semistructured interviews with individual clients were conducted in their homes. the student interviews comprised a reflective conversation between pairs of students who had conducted hbr together, as required by su safety guidelines.[14] the interviews were conducted in the home language (english, afrikaans or isixhosa) of each participant to enable more fluent answers and were recorded with their permission. open-ended questions regarding their perceptions and experiences of hbr were used to stimulate conversation. the participants were asked about their perceptions about the barriers to and facilitators of effective hbr. obtaining both groups’ perceptions assisted in data triangulation.[16] students were also asked for their perspectives on the preparation for phc and hbr. to minimise potential bias, the interviews were conducted by trained research assistants who were not associated with the su division of physiotherapy. data analysis the isixhosa interviews with clients were independently translated into english and transcribed. to improve rigour, the transcriptions were checked for accuracy by an isixhosa-speaking assistant. member checking by clients was not feasible owing to low literacy levels. the researcher – the students’ clinical supervisor – checked the transcriptions of the students’ interviews. the data were subjected to inductive thematic analysis by the researcher.[14] codes were manually assigned to themes identified in the data and categorised accordingly. iterative data analysis occurred to increase the dependability of the study.[16] to ensure credibility, member checking of a transcript and data coding by a student assisted in data verification.[16] the researcher acknowledged that her role as an instrument in the study may have affected student data. to minimise this, she made use of peer debriefing with the co-authors at different points in the study to enhance the confirmability and trustworthiness of the data.[16] ethical considerations approval for the study was obtained from the su health research ethics committee (s13/10/180) and the western cape department of health (rp032/2014). signed informed consent was obtained from all participants. participation was entirely voluntary and did not affect services to clients or influence student assessment. the interviews were conducted after the students’ examination papers had been marked and feedback given in order to minimise any potential bias. confidentiality was maintained during the process, with no identifying particulars of individual clients or students being kept. results participants seven clients, of a potential 12, were interviewed. three clients were exclu ded owing to their inability to converse, 1 client was not traceable and 1 had died. all 6 students who had completed their hbr placement at the time of the study participated. the students and clients had different socioeconomic, racial, cultural and language backgrounds. the data obtained from the interviews were analysed to identify themes and categories to promote understanding of hbr. the major themes and associated categories emerging from the client and student interviews are presented separately with supporting quotations. client perspectives the major themes of appreciation and clientcentredness emerged from the client interviews. the main theme related to their appreciation of the treatment received, being treated in their home and attention paid to their goals (table 1). categories under the theme of clientcentredness (table 2) related to communication, table 1. clients’ appreciation of students category supporting quotations impact of treatment ‘there is a difference since; i now am able to do things independently.’ (cl2) ‘since they came, i can do so many things that i was not able to do before.’ (cl2) treatment at home ‘i appreciate the fact that students come to the house for therapy; it’s expensive to hire a car. due to the location of my house it’s too difficult for the car to get there.’ (cl1) treatment goals ‘they would ask what they could do to help me.’ (cl1) ‘i do want them to give me the exercises as is supposed to be.’ (cl2) research may 2016, vol. 8, no. 1 ajhpe 61 home programmes and client expectations. clients perceived communication from students as inadequate. clarity and under standing were factors deemed to be important in the writtten home exercise programme the students give the client to continue with on their own. there was an expectation that the students would provide medication. clients also expected to improve after treatment, seeing the attention by students as a source of hope and motivation. clients wanted to know what to expect from the students, particulary with regard to regular treatment. more frequent interventions were also desired. student perspectives data obtained from student interviews produced three main themes: differences, preparation for hbr, and learning. differences noted in socioeconomic, cultural and language domains were repeatedly mentioned in the student interviews (table 3). although the students experienced culture and language as difficult areas for them, clients did not mention these issues. differences between providing interventions in formal and informal treatment contexts were also frequently mentioned. there was a realisation that the usual physiotherapeutic interventions, which they would provide in a formal setting, were not necessarily appropriate in the home environment. the experience of seeing how clients function in their own environment was regarded as important in understanding the meaning of holistic intervention. they realised that there is more to treatment than merely the physical techniques they employ. the theme of preparation for hbr was divided into the preparation the students required from the division of physiotherapy and the advice they felt would be helpful to give to future students (table 4). the categories were subdivided to facilitate understanding of the data. the students thought that earlier exposure to resourceconstrained settings would be beneficial preparation for hbr. they pointed out, however, that a powerpoint presentation at the beginning of the 4th year was not helpful. all students interviewed desired more language competency in isixhosa. handover of clients to new students was suggested to help to prepare them for what to expect and to assist with logistics and strategies for overcoming barriers. apart from preparation by the division, the students had plenty of advice to give to future students, particularly with regard to setting specific client-centred goals and being adaptable and organised (table 5). the last major theme emerging from the student data related to their learning (table 6). underlying the situated learning experience, various other learning theories were evident in students’ comments. the need to adapt knowledge gained in the classroom and in other settings was sometimes a challenge in hbr. the students valued the learning opportunities afforded by working in pairs. the importance of learning from clients was also noted. transformative learning experiences occurred from the experience of having to adapt to real-life situations, including in one instance dealing with the death of a client. in summary, clients were grateful for the interventions received. there were, however, concerns regarding communication and unmet expectations. the students observed many differences between clients’ socioeconomic contexts, culture and language, and their own. differences in interventions in hbr compared with a formal setting were noted. preparation desired in the curriculum included early exposure to communities and better language competency. assistance was required with management and strategies for dealing with problems encountered. preparation for hbr was preferred just before entering the community – not in advance. discussion this article contributes to the understanding of physiotherapy students’ and clients’ experiences of hbr in an educational context. the need for improved client-centred communication was highlighted in both client and student data. table 2. client-centredness category supporting quotations communication ‘i wondered when they were coming back, or are they going away for good, so there was no communication.’ (cl5) ‘i was surprised that they didn’t come back again. i didn’t know what happened.’ (cl3) ‘how did they know about me?’ (cl3) home programme ‘the student that drew the pictures really helped me a lot.’ (cl2) ‘the student made sure to show me until i understood.’ (cl6) expectations of physiotherapy ‘[i thought] they would come with tablets or something.’ (cl3) ‘the experience of standing up with them makes me believe i can walk again.’ (cl7) ‘i’m happy to see them because i want to be better.’ (cl3) frequency of treatment ‘if people come back, to know when and how many times.’ (cl3) ‘please come twice a week.’ (cl7) table 3. differences noted by students category supporting quotations location ‘what could this patient’s home environment actually be like, because sometimes you can’t even imagine.’ (st1) ‘you have to walk in between some interesting areas to get to your patient’s house.’ (st6) culture ‘completely different cultural setting, socioeconomic problems are completely different.’ (st1) ‘it gives you a culture shock; you do not expect what you see.’ (st6) informal compared with formal treatment settings ‘just because your patient can walk a little bit wobbly on tiles [in a clinic] doesn’t mean they are going to cope at home.’ (st6) ‘techniques that we learn that would be good in the clinics, it literally does not work in the community.’ (st4) ‘the success has almost got to do with more personal things than it has to do with exactly what you’re going to do.’ (st1) ‘it’s actually more the talking, the social and psychological part that for them is more important than the physical treatment.’ (st2) language ‘there was a serious communication barrier. getting them to understand that you need them to tell you what they’re struggling with is a thing all on its own.’ (st6) ‘even with my translator, it’s difficult understanding them and getting my own point across.’ (st3) research 62 may 2016, vol. 8, no. 1 ajhpe students identified early exposure to underresourced and culturally diverse settings as a prerequisite. clients’ appreciation of hbr suggests that it is an important aspect of healthcare, providing treatment to clients who may otherwise not be able to access physiotherapeutic rehabilitation. however, clients seemed uncertain of the students’ plans for their rehabilitation, particularly regarding the frequency of visits and termination of treatment, and were left wondering if the students would return. this suggests a lack of effective client-centred communication and planning. stainsby and bannigan[10] regard the making of decisions on frequency and cessation of interventions as a skill; it appears that students need assistance with this aspect. the need for an in-depth and relevant subjective assessment to allow for appropriate collaborative goal setting with the client cannot be underestimated. mindful communication with clients and carers, reported by tasker et al.,[9] is highlighted in the home environment to ensure relevant interventions. the differences in socioeconomic, racial, cultural and language backgrounds of these su physiotherapy students compared with those of their clients may have decreased the efficacy of hbr. communication and goal setting were most affected, as evidenced by students’ comments on initial culture shock and the difficulty in client and therapist understanding each other. development of the students’ cultural competency and communication skills could enable the clients’ understanding of the intervention and allow their desires to be heard. reflection with peers and supervisors to address these issues should form an integral part of the placement. although the clients did not comment that the students could not speak their language, this may have contributed to ineffective communication and management. language is an integral aspect of communication, and hbr highlights its significance in healthcare.[2,4,6] the students stated that being proficient in isixhosa would have helped in hbr to minimise the verbal communication barrier. they reported that an introductory isixhosa course in their 1st year seemed irrelevant to them at the time. once they started treating clients they realised the importance of learning the language. therefore, agreeing with prose et al.,[8] the possibility of a more timely course, which also promotes cultural competence, should be investigated. we agree with mbalinda et al.[6] that a translator, who could also aid cultural understanding, can be a valuable communica tion tool. although an interpreter accompanied the participants in this study on their home visits, there was still a barrier in communication with the client. this suggests that students should be taught how to facilitate better communication with clients through an interpreter or that a lack of language competency was not the only communication barrier. clients’ lack of knowledge regarding physiotherapy may have contributed to communication barriers and unmet expectations, as seen in the common assumption that the students would provide medication. therefore, client education is another aspect of client-centred communication. another factor may be the rotation of different students through the placement, which may affect the consistency of treatment and progress table 4. preparation for home-based rehabilitation category sub-category supporting quotations student suggestions for preparation by the division of physiotherapy early exposure ‘i don’t know if this would be viable at all, but to almost have a job-shadowing of a home visit [in 3rd year].’ (st1) ‘having been exposed to it before you’re very able to put the new setting and culture shock at the back of your mind and get on with why you were there.’ (st3) language ‘being able to speak xhosa would’ve made a very big difference.’ (st6) ‘in 1st year, even though you’re learning the words, you don’t realise why [isixhosa is] so important. once you see a patient you understand. more exposure to xhosa in our 3rd year would also be best.’ (st1) advance preparation ‘it’s difficult to prepare someone a hundred percent for something they’ve never seen before. a photo only says so much. the actual area of the house is completely different.’ (st2) ‘[a lecture early in year] you forget or don’t really take it in because it is so long until then.’ (st2) handover ‘so that they know more or less what they can expect ... they can be better prepared and know more than absolutely nothing.’ (st6) ‘new students don’t need to figure out all the barriers for themselves from scratch.’ (st1) strategies ‘strategies to overcome the problem, because you see the problem but you don’t know [what to do].’ (st1) table 5. preparation for home-based rehabilitation: advice to future students category sub-category supporting quotations advice to future students professionalism ‘make yourself comfortable in someone else’s house whether it’s a mansion or a shack. be respectful of their environment.’ (st2) goal setting ‘just being goal specific.’ (st4) ‘put your patient’s needs first.’ (st3) ‘do a really in-depth subjective [evaluation] and get to know them and find out their goals etc.’ (st5) adaptability ‘don’t be so eager to try to teach patients what you are taught in class perfectly step by step; not be so technique driven in the community because that’s not going to get you anywhere, it doesn’t work.’ (st3) ‘the plan is never set in stone so don’t forget that it should always have room to be adapted.’ (st5) communication ‘discuss why we’re only seeing you say once every two weeks.’ (st1) organisational skills ‘just organising your patients better, making sure when to see who, and making sure you have everything with you that you need.’ (st6) research may 2016, vol. 8, no. 1 ajhpe 63 towards goals. as noted in a study on educa tion in a community, collaboration with peers in the form of more comprehensive handover is necessary to build on what previous students achieved.[6] early exposure to the clinical environment as part of an integrated curriculum has been shown to increase student motivation and lead to deeper learning.[3,4] students suggested that earlier exposure may assist in overcoming the initial ‘culture shock’. experience of under-resourced environments and seeing clients in their own contexts will also help to situate physiotherapy practice from the beginning of the students’ clinical training. providing hbr is complex, requiring the integration of many different skills.[4,9,10] the students seemed to feel that they had adequate physiotherapy skills to conduct an intervention, but required greater adaptability in the hbr situation. a level of maturity is required to enable students to cope with the sometimes challenging real-life situations they experience. therefore, hbr is better suited to the final year of study. however, facilitated exposure at the beginning of the clinical phase could be considered. in this study, students suggested that earlier exposure would assist in preparing them for the hbr context and help to minimise the reported culture shock. collaborative learning from accompanying final-year students on home visits could be an option. having a background of the clients’ context may facilitate construction of more relevant knowledge at all the levels of care to which a student is exposed. students remarked on the differences between interventions in formal and informal settings. there is a paradigm shift in planning treatment from a purely physiotherapeutic approach to one that considers the client’s context as paramount. this realisation of the need for a more holistic approach was also noted in other studies.[2,9] grappling with these adjustments leads to constructive and even transformative learning, as the students begin to think beyond the application of learned techniques to solving a client’s problem. students reported using their experience of the realities clients face to influence interventions in other contexts. students were silent on the issues of social accountability and responsibility, as well as the need for change in healthcare service delivery and their potential involvement in these areas. although they were not specifically questioned on these aspects, it was hoped that a realisation of the place of hbr in the context of healthcare would emerge. this omission could indicate that clinical training in this context should specifically address the notion of social accountability. students expressed a need for assistance in strategies to cope with the physical barriers they experienced in these settings. however, support is needed to assist them to recognise and deal with issues beyond the normal individualised intervention. adopting a more reflective practice could, as part of this placement, facilitate transformative thinking, stimulating students to embrace the bigger picture and view their role as future agents of change.[2,3] in summary, to ensure that students are able to gain full benefit from the exposure to hbr as a learning environment, they need effective and timely preparation just prior to entering the placement and continuous support to cope with the day-to-day challenges. communication competence and specifically isixhosa instruction are also needed. facilitated early expo sure to under-resourced communities should be considered. effective prepara tion and support will assist the students to overcome the challenges of hbr and enhance the experience for clients. this study cannot be generalised, as it focuses on the perspectives of a small sample in a specific setting.[14] the use of research assistants may have limited the depth of probing during interviews; therefore, some comments may not have been explored sufficiently. translation can result in some meaning being lost during interpretation. further investigation into the client and student experience in other community settings is required to achieve more in-depth information on the learning possibilities imbedded in the hbr experience. the effects of earlier exposure to underserved areas should be investigated in future to assess how this affects students’ learning and practice. follow-up of su graduates to explore whether their hbr experience prepared them effectively for community service should be considered and the findings compared with those in previous similar studies.[2,4] conclusion exposure to real-life situations in underresourced settings in the form of hbr provides valuable situated and authentic learning opportunities for physiotherapy students. clientcentredness, cultural competence, communication and adap tability are just some of the skills that students can develop and which will ultimately lead to enhanced client experiences. the hbr experience can be used to prepare graduates to address the needs of the populations they will serve during community service in sa. acknowledgements. this research has been suppor ted by the president’s emergency plan for aids relief (pepfar) through health resources and services administration under the terms of t84ha21652, stellenbosch university rural medical education partnership initiative. table 6. learning facilitated by home-based rehabilitation category supporting quotations authentic learning ‘in class you don’t think of those kinds of things – an uneven path or it’s steep.’ (st1) ‘think bigger with your treatment.’ (st3) social constructive learning ‘they always talk about tools in our toolkit, things that we’ve learnt and things that we can then apply to a patient, and that was sometimes a challenge.’ (st1) ‘it’s not outputs and techniques that we learn that would be good in the clinics. it literally does not work in the community. use your initiative and be creative.’ (st3) ‘had to think out of the box a lot more. you learn to adapt – there were many life skills that you develop.’ (st1) collaborative learning ‘we helped each other a lot and discussed situations.’ (st1) ‘your patients come up with the most interesting ways to do something.’ (st6) transformative learning ‘so you had to adapt to what the patient had. and it doesn’t necessarily mean that your treatment is then poorer, it just means we had to think out of the box a lot more.’ (st1) ‘my biggest lesson from those weeks spent in the community – you must remember where your patients are going once they leave you. it’s made me treat my patients more holistically in an acute setting because i know some of the areas they are going back to and that it’s not ideal, you have to aim your treatment that way.’ (st3) ‘the patient passed away very unexpectedly, we knew the story, we knew she had children; we had been in her home, so it’s very different, like when you get into someone’s living space. we learnt so much out of that.’ (st1) research 64 may 2016, vol. 8, no. 1 ajhpe references 1. western cape government: health. healthcare 2030. the road to wellness. draft. 2013. http:www.westerncape. gov.za/health (accessed 7 may 2014). 2. mostert-wentzel k, frantz j, van rooijen aj. a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. afr j health professions educ 2013;5(1):1925. [http://dx.doi.org/10.7196/ajhpe.203] 3. boelen c, woollard b. social accountability and accreditation: a new frontier for educational institutions. med educ 2009;43:887-894. [http://dx.doi.org/10.1111/j.13652923.2009.03413.x] 4. ramklass s. physiotherapists in under-resourced south african communities reflect on practice. health soc care community 2009;17(5):522-529. [http://dx.doi.org/10.1111/j.1365-2524.2009.00869.x] 5. cameron d. community-based education in a south african context: was socrates right? s afr fam pract 2000;22(2):17-20. 6. mbalinda s, plover c, burnham g, et al. assessing community perspectives of the community-based education and service model at makerere university, uganda: a qualitative evaluation. int health hum rights 2011;11(suppl 1):s6. 7. chang w. cultural competence of international humanitarian workers. adult educ quart 2007;57(3):187-204. [http://dx.doi.org/10.1l77/o741713606296755] 8. prose n, diab p, matthews m. experiential learning outside the comfort zone: taking medical students to downtown durban, south africa. afr j health professions educ 2013;5(2):98-99. [http://dx.doi.org/10.7196/ajhpe.256] 9. tasker d, loftus s, higgs, j. head, heart and hands: creating mindful dialogues in community-based physiotherapy. n z j physiother 2012;40(1):5-12. 10. stainsby k, bannigan k. reviewing work-based learning opportunities in the community for physiotherapy students: an action research study. j further and higher educ 2012;36(4):459-476. [http://dx.doi.org/10.1080/0309877x.2011.643769] 11. mann k. theoretical perspectives in medical education: past experience and future possibilities. med educ 2011;45:60-68. [http://dx.doi.org/10.1111/j.1365-2923.2010.03757.x] 12. van schalkwyk s, bezuidenhout j, burch v, et al. developing an educational research framework for evaluating rural training of health professionals: a case for innovation. med teach 2012;34(12):1064-1069. [http://dx.doi.org/10.3109/0 142159x.2012.719652] 13. somekh b, lewin c. research methods social sciences. london: sage, 2005. 14. silverman d, ed. qualitative research. london: sage, 2011. 15. du plessis j, heinecken l, olivier d. community needs assessment and asset mapping profile of kyamandi. 2012. http:// admin.sun.ac.za/ci/asset%20mapping%20report%20kayamandi%202012%20phase%201.pdf (accessed 22 december 2015). 16. frambach j, van der vleuten c, durning s. quality criteria in qualitative and quantitative research. acad med 2013;88(4):552. march 2017, vol. 9, no. 1 ajhpe 3 review international aid can take on a number of forms. traditionally, official development aid via governments and global institutions is provided by members of the development assistance committee (dac) of the organisation for economic cooperation and development (oecd). funding through these channels is commonly referred to as dac funding. it is, however, important to note that various other players are also active in the global aid arena, such as international foundations, non-governmental organisations (ngos), inter-governmental organisations (ingos) and private funders.[1,2] there is a global debate on the effectiveness of different implementation models of aid and the eventual measurement of impacts and outcomes on recipient countries and populations. there is much theorising over the intended outcomes of development and, therefore, by implication, what aid aims to achieve. the current focus in discussions around development shows a relatively holistic conception of wellbeing and quality of life, rather than narrowly defined economic measures.[3] there is furthermore an expressed need to understand the desires and intentions of all the parties involved in the aid relationship, from the political/foreign policy intentions of donors to the goals of recipients, and how these intentions and the consequent relationships were formed historically.[4] in the literature on the evolution of approaches to funding there is a trend towards criticism of traditional funding modalities and the promotion rather of more inclusive models of aid, such as south-south cooperation (ssc), comprising collaboration between partners in the global south, and triangular models, involving development partners supporting southern collaborations.[1,5] the latter models are thought to have advantages,[6] notably a greater focus on partnerships and co-operation. this article has four broad aims: firstly, to present the evolution of southern approaches to development co-operation. ssc will be situated historically against the backdrop of aid generally in the post-world war ii period. there is a particular theoretical background to the concept of ssc, which is importantly derived from the post-colonial experience of africa, latin america and asia, loosely referred to as the developing world in current discourse. this historical positioning gives rise to a number of criticisms of traditional aid models, from terminology to practice. secondly, it aims to indicate examples of current co-operative programmes in health and health science education in africa, which are based on the principles of ssc and triangular aid. some of these programmes (notably the united states  president’s emergency plan for aids relief (pepfar)) have evolved away from strategies based on vertical interventions, and at the time of writing were active in the brokering of co-operative partnerships and the facilitation of ‘twinning’ relationships.[7] the latter approach is in line with those typical of ssc and triangular models. in a policy document on approaches to collaborative projects, rosseel et al.[8] mention a number of approaches combining northern and southern partners. the document makes specific reference to the social role of universities, and the role of higher education in human development, emphasising the role of institutions in promoting and supporting training that is beneficial to various communities, not only those communities in which they are based. important to note is the key advantage of universities as co-creators of knowledge and facilitators of participation, producing types of science that are socially relevant to the needs of people. this is even more relevant in the area of health professions education. in the literature on the evolution of funding approaches there is criticism of traditional funding strategies and the promotion of inclusive models, such as south-south cooperation (ssc) and triangular models. the latter are felt to have a number of advantages. this article has four broad objectives: (i) to present a literature review on the evolution of southern approaches to development co-operation; (ii) to indicate examples of current co-operative programmes in health and health professional education in africa; (iii) to assess the advantages and disadvantages of these models; and (iv) to mention some emerging issues in monitoring and evaluation. the boolean logic approach was used to search for applicable literature within three topic layers. searches were conducted using pubmed, plos and other accessible databases. an initial draft of the article was presented to a group of academics and researchers at the flemish inter-university council (vlir-uos) primafamed annual workshop held in august 2010 in swaziland. comments and suggestions from the group were included in later versions of the article. it is important to note that the existence of various funding models implemented by a variety of actors makes it difficult to measure their effects. in health and health professional education, however, ssc and triangular models of aid provide conditions for more effective programming through their focus on participation and long-term involvement. with an eye towards evaluating programmes, a number of salient issues are emerging. the importance of context is highlighted. afr j health professions educ 2017;9(1):3-8. doi:10.7196/ajhpe.2017.v9i1.541 south-south cooperation in health professional education: a literature review l du toit,1 ba hons, ma (development studies); i couper,2 ba, mb bch, mfammed, fcfp (sa); w peersman,3 ma, phd; j de maeseneer,3 md, phd 1 centre for rural health, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 ukwanda centre for rural health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 department of family medicine and primary health care, faculty of medicine and health sciences, ghent university, belgium corresponding author: i couper (icouper@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 4 march 2017, vol. 9, no. 1 ajhpe review the third aim is to note the advantages of these funding models as policy responses to the criticisms levelled against traditional funding arrangements. it is important to note that one cannot postulate a blanket assumption about the effectiveness of a funding model for all contexts. an understanding of the context where a programme is being implemented is of paramount importance in the decision on the funding model and definition of goals. these southern models have particular relevance in the field of health and health science education. health and education have been identified as the main drivers of ssc; yet, they have been given little attention. there is a need, therefore, to focus on these because of the long-lasting benefits; health professional education has particularly long-term outcomes. finally, there is a discussion on some issues that are indicated as having particular relevance in the process of monitoring and evaluating these programmes. some suggestions of future areas that may be important in research are made. it is felt that there is a strong need for monitoring and evaluating data that move beyond financial and logistical reporting. research that produces information on qualitative issues, such as buy-in and participation among partners, programme evolution over the long term, and contextual factors of programme design, is felt to be of importance when describing programme impacts and outcomes. methods literature searches for this article included those within three interlocking ‘layers’ of the topic, i.e.: • examples of and literature on ssc in the field of health science education • examples of and literature on ssc in the field of health • examples of and literature on ssc in education. most information retrieval systems used on the web use boolean logic when searching.[9] in this review, the boolean logic approach was used to search for applicable literature within the three topic layers described above. databases searched included pubmed, plos (public library of science) and bmj. searches were also done using google scholar. searches were conducted using different combinations of keywords, including: southsouth cooperation, funding, health, education, health science, health science education, and africa. key literature sources were identified and their lists of references were reviewed to identify particular literature trails on the topic. criteria for the selection of literature included: (i) reference to international aid or co-operation in the field of education, and more specifically health science education; (ii) reference to aid and co-operation in the field of health; (iii) human resources for health; (iv) specific reference to ssc and/or triangular models of aid; and (v) focus on programmes in africa. peer-reviewed books and journal articles were included, along with reports (not necessarily peer reviewed) from institutions and organisations. content was scanned using the criteria listed above. those selected for analysis were then reviewed and their content tabulated, categorised in relation to the four aims. it is noted that there is a dearth of literature on programmes that focus on health professional education specifically, which was the key area of interest in the current study. there was much to be found on ssc and triangular models in health on the african continent, and furthermore very broadly on programmes in education. the review strategy was therefore to start with the broader literature on ssc and triangular models in education, progressively narrowing down to literature on health, and then further narrowing down to health science education. as a final stage in the process, an initial draft of the article was presented to a group of academics and researchers involved in health and health science education (from europe and africa) at the flemish inter-university council (vlir-uos) primafamed annual workshop held in august 2010 in swaziland. comments and suggestions from the group were included in later versions of the article. results historical positioning of aid and global presence of the south criticism of international development aid and different funding models begin by pointing out the conceptual problems with the terms associated with the field (such as global south), and the very idea of development itself.[10] reference is made to the roots of the idea of development in western, positivist ways of thought. it is posited that use of the concept and term has essentially disguised a close relationship between funding/aid, colonialism and the workings of global capitalism.[10] critics of the concepts encapsulated in the traditional aid paradigm point out that the use of these discursive constructs in essence describes a relationship of inequality between the global north and south, between the first world and the third world.[11] the term third world as a concept emerged in 1952 in an article entitled trois mondes, une planète by french demographer, historian and anthropologist, alfred sauvy. this article described the ideological division of the world during the cold war, the term itself referring to countries, particularly those in the middle east, south asia, latin america, africa, and oceania, that were not aligned with either the communist soviet bloc or the capitalist north atlantic treaty organization (nato) bloc.[10] the original meaning of the concept therefore refers more pertinently to political alignment rather than to economic and social realities in these countries. the cold war had a particular impact on the implementation of aid for large parts of the 20th century. this conflict dominated the international policy stances of the then hegemonic states, i.e. the usa and what was then the union of soviet socialist republics (ussr), during the 1950s, with the two superpowers vying for ideological control over newly decolonised states in africa, asia and latin america. partly in reaction to the experience of the cold war in developing countries, and the perceived neocolonialist movement of international aid, ssc became prominent in development circles when asian-african leaders met at the bandung conference, indonesia, in 1955. the purpose of this meeting was to forge links in cultural and economic areas by and for the global south. the bandung conference paved the way for the eventual establishment of the non-aligned movement (nam) in 1962, and finally the group of 77 (g77) in 1964. the g77 issued a joint declaration at the conclusion to the united nations (un) conference on trade and development in 1964. this declaration was based on the realisation that newly decolonised countries were at a disadvantage when it came to global trade and development, and that this disadvantage was endemic to the process of decolonisation. the vulnerabilities of the developing world in terms of international trade and labour division indicated the need to co-operate in leveraging international influence. key in this era is the perception among countries of the global south that the funding flows of international aid were determining the march 2017, vol. 9, no. 1 ajhpe 5 review development agendas of recipient countries, more in line with the interests of donor countries than those of developing countries.[12] the collaboration of nam therefore strongly reflected a desire among newly decolonised countries to participate in global trade and investment on equal terms. there is furthermore strong reference in the joint declaration of this conference to the need to address issues around development and living standards of developing world populations.[12] ssc as distinct funding model it is important to point out that the ssc and triangular models of aid form a specific type of funding model among various different types. some authors[2,13] identify the funding community as comprising donors that do not form part of dac, oecd and the organization of the petroleum exporting countries (opec). there is further grouping of these ‘others’ into the categories: emerging donors, ssc and arab donors.[2] three distinct funding models become apparent: the dac model, the arab model and the southern model. ssc and triangular models therefore fall under the southern group of funding modalities.[1] in terms of defining ssc, sa e silva[5] notes that ssc has probably existed since the very first independence movements in colonised nations. however, only in the 1940s did it acquire an institutionalised character. for the purposes of this article, and in line with the reference to the bandung conference, ssc is defined similarly to the view espoused by sa e silva. we will therefore demarcate our discussion to those initiatives displaying an institutionalised character, which fall under the banner of ssc. evolution of ssc sa e silva[5] describes a very useful division of the three eras of ssc in the 20th century. it is interesting that this three-phase process mirrors the evolution of the development paradigm through its modernist, marxist and postmodernist phases. phase 1. self-reliance and political strengthening (1949 1979) the colonial period in many ways represents the modernist era of development, with its hallmarks of positivist thinking, and the belief in a linear, almost natural developmental process. this way of thinking implies that all countries are at a certain stage on one, single development continuum, and that underdeveloped countries therefore need to follow the path that has been followed by the ex-colonial powers. the modernist era of development, which characterises the period immediately after world war ii, was facilitated by technical consultants and multilateral agencies, with the rise of the influence of multinational corporations furthermore being an identifying characteristic of this phase.[14] this history of colonialism and neocolonialism provides the backdrop to the start of various independence movements, and ideas around self-reliance (often referred to as de-linking from the world system), with widespread acknowledgement among newly decolonised states that the world economic system is exploitative of the global south. the idea of ssc in this context arose out of calls for collective action, presented as an ‘alternative to the traditional path of development’.[5] the g77 was interestingly referred to by tanzanian president, julius nyerere, as ‘the trade union of the poor’.[15] the cold war backdrop to this phase provides a certain ‘flavour’ to the development discourse at the time: dependency theory and world systems theory emphasise the vagaries of capitalism and espouse values of socialism, communalism and human need over market processes. this background therefore lent itself to the structuring of exchanges and co-operative agreements, especially between countries that promoted socialist ideals.[14] phase 2. demobilisation (1980 1998) the second definable phase of ssc was characterised by a certain sense of disillusionment, with the promises of socialist economics, self-reliance and the new international economic order. during these two decades, a number of countries in the global south faced similar domestic difficulties, i.e. high levels of foreign debt, high levels of domestic inflation, and economic recession. a decision by the usa in 1980 to increase interest rates by ~20% resulted in what is commonly referred to as the debt crisis for developing countries.[5] the demise of the soviet block and the end of the cold war during this period furthermore appeared to confirm the superiority of market-based economies over what seemed like the obvious failure of socialist systems. this circumstantial evidence of the need to follow neoliberal economic policies can be seen at work in the implementation of structural adjustment programmes of the international monetary fund (imf) and the world bank; the programmes involved austere economic policy measures that were required to be implemented by a country seeking financial assistance from these bodies. during the 1990s, the net result of these structural adjustment programmes was to drastically cut government spending on social services, notably health, education and social assistance, in both the north and the south, but with particularly negative consequences in the global south, especially in africa.[10] during this phase of development aid, there emerged a realisation among those in the global south (but certainly also visible in the aftermath of various movements around human and civil rights in the global north) that the goals of development have systematically been shown to be more about economics than social change.[16] phase 3. best practice transfer (1999 present) as the developing world went through a phase of disillusionment with socialism, so there was also a stage of disillusionment with the ‘gospel’ of free market economics. the results of attempts by southern countries to adopt the doctrines of the washington consensus (i.e. structural adjustment programmes) were far removed from the prosperity promised by neoliberal ideology. high levels of unemployment and poverty, coupled with less access to education and healthcare, saw the re-emergence of the situation that originally inspired ssc.[5] ssc increasingly became an official part of the foreign policies of various developing nations, with a number of trade agreements emerging between 2003 and 2004. examples are the india-brazil-south africa (ibsa) trilateral forum and the brazil-russia-india-china-south africa (brics) forum.[5,17,18] in this current era of ssc, there is an emphasis on the transfer of best practice policies and programmes. therefore, the experiences of the developing world in terms of policy and programming are useful for discussion among other developing nations, as there is a sharing of similar domestic situations, problems and possible advantages. the approach of a linear development path so characteristic of modernist views earlier in the 20th century is replaced with a sense of exchange and co-operation around multiple experiences of development and social change. the current era furthermore expresses dissatisfaction among developing countries of the traditional development aid paradigm: strong criticisms emerged of the work 6 march 2017, vol. 9, no. 1 ajhpe review developed by international agencies, highlighting their ineffectiveness in producing positive change in the south by means of development projects.[5] in the current phase of ssc the concept has increasingly been adopted as a co-operation tool rather than a political movement. its politically correct character makes it an appealing tool for international agencies, which have increasingly changed their involvement in aid to the facilitation of south-south agreements and co-operative arrangements (as opposed to the sponsoring of projects).[5] health and health science education in africa in an era where southern governments were dealing with the fall-out of structural adjustment programmes of the early 1990s, the cuban healthcare model, focused on primary, community-based care, promised to be a particularly relevant approach in the developing world. the principles of community-orientated primary care emphasise the role of the social determinants of health (e.g. sanitation, education, housing, nutrition).[19] this model is different to the curative model that is largely associated with the colonial system in africa, being more focused on preventive strategies. the primary care model furthermore has a particular focus on equity in access to care.[20] the understanding of the interaction between social realities and the health and wellbeing of people and communities, provides a unique vantage point from which to do research, to advocate and to design programming.[21] the impact of attention to the primary healthcare needs of populations in developing countries provides a unique lens through which to view larger processes aimed at human development. there are therefore a number of good reasons for promoting the primary care approach in healthcare and health science education for developing countries. a health system based on the primary care approach has been shown in a number of studies (in the developed and developing world) to have the greatest impact on public health as measured, for example, by maternal and infant mortality rates.[22-24] in relation to the primary healthcare focus and ssc associated with healthcare and the training of health professionals, one cannot fail to mention the example of cuban medical professionals in other parts of the developing world. cuban involvement in co-operation around healthcare, specifically in africa, can be traced back to the 1960s and the first era of southern mobilisation focused on self-reliance.[20] an article in the economist[25] noted that one in three cuban doctors work abroad (mainly in other developing countries) at any given time. the cuban model of co-operation in africa has focused more on the building of capacity than on the provision of infrastructure, which is an approach characteristic of ssc programmes. the co-operative initiatives around health and health science education mentioned in this article have very real intentions around the promotion of primary healthcare in developing countries in africa. this is done mainly through the support of training, which promotes the recruitment and retention of relevant, effective medical professionals for the diverse settings in africa. a number of current examples of ssc and triangular programmes in health science education in africa are described. chestrad: southern civil society dialogue on health and accountability the centre for health sciences training, research and development (chestrad) international is an african-based non-profit organisation with support from donors in the uk and usa. the organisation’s main aim is to support dialogue and co-operation among various actors involved in health and health systems in africa (and beyond) through advocacy activities based on reliable research. chestrad is active in a number of initiatives on the african continent aimed at health system strengthening and human resources for health. a number of initiatives, declarations and documents actively refer to the need to address human resource shortages in healthcare in africa, including the global health workforce alliance, international health partnership, the united nations action plan on maternal and child health, the millennium development goals and the african health workforce and systems strengthening solidarity programme.[26] pepfar initiatives in africa pepfar is a broad programme aimed at addressing some of the health system problems on the african continent by supporting (through funding and technical assistance) programmes that are related to health and healthcare delivery, health systems and human resources for health. important to this initiative are the brokering of partnerships and ‘twinning’ agreements between health science education institutions in the global north and south. the twinning programmes are based more on the best practice model of co-operation, illustrating a general shift in approach between the initial pepfar programme (characterised by vertical programme delivery) and the second phase (focus on system strengthening and support). mepi and nepi: medical and nursing education partnership initiatives the medical education partnership initiative (mepi) and nursing education partnership initiative (nepi) programmes represent major collaboration between pepfar and its partner agencies, i.e. health resources and services administration (hrsa), the us agency for international development (usaid), and the pepfar country teams with a number of partner organisations. external partners included the world health organization (who) and a number of usand africa-based funding, teaching and research organisations. the programme aimed at encouraging partnerships in africa, supporting the development of skills and research capacity. there was a focus on collecting quality information on the health needs of countries on the african continent, system challenges and opportunities, as well as the production of health professionals in africa. a further aim was to support the development of health education programmes in institutions in africa, with the ultimate objective of increasing the production and retention of health professionals in africa. samss: sub-saharan medical schools study and african medical education symposium the objective of the sub-saharan african medical schools study (samss) was to promote knowledge and dialogue among key stakeholders in africa by sourcing and collating quality research and information on health and health systems. the study furthermore collected information on medical education programmes in africa and co-operative arrangements (often called twinning agreements) among health science education institutions in africa.[27] the promotion and development of national and global policies around human resources for health is increasingly being debated and discussed march 2017, vol. 9, no. 1 ajhpe 7 review in international forums, an example being the african medical education symposium (ames) held in dar es salaam, tanzania.[28] family medicine educational consortium the family medicine educational consortium (famec) worked in supporting the development of family medicine training, focusing on primary healthcare in southern africa since 2003. this co-operative model had as its later focus the building of partnerships between african countries in the development and establishment of training for family medicine in the framework of the primafamed-network (www. primafamed.ugent.be). this phase supported the twinning of established family medicine programmes in south africa (sa) with other countries in southern africa, with the purpose of developing training and assessment methods. this programme had at its core a belief that the experiences of southern partners are sufficiently different from the experiences of the global north to create the understanding that ‘all the expertise was in the south’.[29] discussion the literature describes the primary advantage of ssc and triangular approaches as being the increase in a sense of ownership among beneficiaries of aid. the major criticism against traditional funding relationships between north and south was that the lack of ownership and input in the process among the beneficiaries seriously affected the sustainability and costeffective ness of programmes.[6] it is also felt that the south shares many common problems and issues, and can therefore provide more contextually appropriate experience and assistance.[6,11,12] the major criticism against traditional aid relationships was that it often introduced inappropriate technology and technical skills that did not match the environment in which these were supposed to work. this led to higher costs and serious concerns around sustainability, as the recipients of the assistance could often not maintain the technology.[6,10,30] a number of salient issues are emerging in health and health science education. these issues are often, but not always, quite distinctive of the african context. variability of socioeconomic and sociocultural life worlds cultural understandings of health and medicine can be highly variable. primary care that focuses on the individual rather than the illness, can garner great synergy and impact when it is cognisant of traditional indigenous knowledge systems.[31] there is much opportunity to combine social teaching and research in health science education to make professionals more responsive to the needs of communities, and to promote and facilitate participation in the definition of health needs. cultural competence of learners and teachers related to the above, healthcare that is orientated around communities and sensitive to the contextual realities of people’s lives needs to take cognisance of socially and culturally defined ways of thinking about health, illness and healing. such a cultural competence is more representative of a set of intellectual skills (such as the ability to conduct a community assessment by using different data collection methods) than a particular type of course content. related to this issue is the need to produce skilled professionals who are well suited to the social and economic context of the many different settings in the developing world, and furthermore to define clearly what those skills and professional attributes are.[32] the use of information and communication teaching technology across vast distances and in resource-poor settings a practical issue in teaching and skills development in southern africa (and of course, further afield) relates to the use of technology that can bridge the vast distances between community-based health services and often urbanbased centres of teaching and research.[33] thinking about the development path with reference to the discussion above on the evolution of development aid away from linear conceptions of development and growth, it is important to mention that the current paradigm of ssc and triangular aid does not easily escape these tensions. when it comes to training, research and engagement at a community level, there is often conflict between the ‘modern’ and the ‘traditional’, and the power relations associated with each. it is important to consider the ability of teaching and training institutions to transcend these tensions, and a tendency among populations to classify the ‘modern’ with ‘imperialist’. critical in this discussion is the use of language (as a medium of instruction, or to communicate with patients), how it relates to tensions and power struggles, and how it enables or disables the health professional and the patient. hountondji[34] refers to the process of grappling with the ‘colonial roots of science’ and the status of african countries on the ‘scientific periphery’. he advocates the need for african institutions to own their own scientific traditions; this can only be achieved by the development of high-quality research and teaching on the continent, which forms the basis of a socially relevant tradition of research, teaching and practice. forces influencing the migration of medical professionals a major field of research relates to the forces impacting on the supply of suitably qualified medical practitioners, especially for rural africa. the well-known process whereby medical professionals are trained in the developing world, only to then leave their countries of origin for better working and living conditions in the developed world, is described in the literature.[35] an increasing trend worth noting in this regard is the migration of professionals between different african countries, also with the idea of better living and working conditions in certain places, notably sa. this process results in acute losses in the developing world: not only does the provision of health services in the developing world suffer, the migration of a trained professional represents a significant loss in terms of training investment. describing and evaluating innovative programmes there are a number of existing health science training programmes in the south that are truly innovative in terms of supporting students’ knowledge of social realities, community-based teaching, and community-based care. many southern countries boast a long history of grappling with the social determinants of health, multiple policy reforms and varying success in either creating new approaches, or adapting old approaches to teaching for their contexts.[36] a large gap in knowledge currently refers to the lack of studies that evaluate the impact of existing programmes under current ssc and triangular co-operation models, especially over a significant period of time, producing longitudinal data. here it is important to provide information on the quality of curricula, training methods, and the co-operative agreements themselves. beyond these issues, however, is a much larger question on the human impact of such initiatives, and how a programme affects the provision of services over 8 march 2017, vol. 9, no. 1 ajhpe review a particular period of time. this broader impact needs to be described more effectively for the initiatives that are already in existence. harris and tanner[30] highlight the need in this regard to strengthen structures in the global south that can produce quality ‘southern knowledge’. betancourt and schulz[37] point out the need for such evaluation work to help define what should be regarded as good practice or best practice, and what such initiatives should deliver. conclusion ssc and triangular models reflect the historical situation of funding from the colonial era to the current era of co-operation. a number of current co-operative agreements in health and health professional education in africa follow the ssc and/or triangular models of aid, which are thought to be advantageous in the field of health and health professional education. with regard to these two aspects, ssc and triangular models of aid provide conditions for more effective programming through their focus on participation and long-term involvement. the need for ongoing funding for these kinds of initiatives remains, and they appear to provide the greatest opportunity for long-term developmental impact. the existence of various funding models implemented by a variety of actors makes it difficult to measure their impact, but it is important to do so, with a broad development perspective. while context is important in evaluating programmes, common tools that monitor both outcomes and the extent of south-south collaboration, with the long-term benefits that accrue for all partners, are needed. acknowledgements. this work was supported by the flemish inter-university council (vlir-uos) primafamed project through direct funding of the centre for rural health, university of the witwatersrand, johannesburg, where the research was based. a scholarship of short duration for the first author (ldt) was also provided for travel and accommodation in ghent, belgium, during the drafting of the article. 1. walz j, ramachandran v. brave new world: a literature review of emerging donors and the changing nature of foreing assistance. centre for global development. 2010. http://cgdev.org (accessed 16 january 2017). 2. zimmerman f, smith k. more actors, more money, more ideas for international development co-operation. j int dev 2011;23(5):722-738. http://dx.doi.org/10.1002/jid.1796 3. united nations development programme. human development report 2010. the real wealth of nations: pathways to human development. geneva: undp, 2010. http://hdr.undp.org/en/content/human-developmentreport-2010 (accessed 16 january 2017). 4. schraeder pj, hook sw, taylor b. clarifying the foreign aid puzzle: a comparison of american, japanese, french and swedish aid flows. world politics 1998;50(2):294-323. 5. sa e silva mm. 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2000;321(7264):817-820. http://dx.doi.org/10.1136/ bmj.321.7264.817 31. germond p, cochrane jr. healthworlds: conceptualising landscapes of health and healing. sociology 2010;44:307-324. http://dx.doi.org/10.1177/0038038509357202 32. mash r, downing r, moosa s, de maeseneer j. exploring the key principles of family medicine in sub-saharan africa: international delphi consensus process. s afr fam pract 2008;50(3):60-65. 33. geissbuhler a, bagayoko co, ly o. the raft network: five years of distance continuing medical education and tele-consultations over the internet in french-speaking africa. int j med inform 2007;76(5-6):351-356. http:// dx.doi.org/10.1016/j.ijmedinf.2007.01.012 34. hountondji p. scientific dependence in africa today. res afr lit 1990;21(3):5-15. 35. bundred pe, levitt c. medical migration: who are the real losers? lancet 2000;356(9225):234-236. http://dx.doi. org/10.1016/s0140-6736(00)02492-2 36. lehmann u, andrews g, sanders d. change and innovation at south african medical schools: an investigation of student demographics, student support and curriculum innovation. pretoria: health systems trust, 2000. 37. betancourt mc, schulz ns. south-south cooperation in latin america and the caribbean: ways ahead following accra: fride 2009. http://fride.org/descarga/com_sur_sur3_eng_mar09.pdf (accessed 11 january 2017). http://hdr.undp.org/en/content/human-development-report-2010 http://hdr.undp.org/en/content/human-development-report-2010 http://handbook.southsouthconference.org http://handbook.southsouthconference.org https://lirias.kuleuven.be/bitstream/123456789/229636/1/policy_paper_vlir_uwc__nss.pdf https://lirias.kuleuven.be/bitstream/123456789/229636/1/policy_paper_vlir_uwc__nss.pdf http://infed.org/mobi/julius-nyerere-lifelong-learning-and-education/ http://infed.org/mobi/julius-nyerere-lifelong-learning-and-education/ http://dx.doi.org/10.1093/ije/30.4.720 http://dx.doi.org/10.1093/ije/30.4.720 http://www.economist.com/node/8597159 http://www.economist.com/node/8597159 http://dx.doi.org/10.1136/bmj.321.7264.817 http://dx.doi.org/10.1136/bmj.321.7264.817 http://dx.doi.org/10.1016/j.ijmedinf.2007.01.012 http://dx.doi.org/10.1016/j.ijmedinf.2007.01.012 http://dx.doi.org/10.1016/s0140-6736(00)02492-2 http://dx.doi.org/10.1016/s0140-6736(00)02492-2 research may 2016, vol. 8, no. 1 ajhpe 81 background the criteria and processes to select students for the mb chb course have been the subject of much controversy and debate over the past 20 years, as these represent the main mechanisms by which racial and gender imbalan ces in student profiles can be rectified.[1-4] consequently, all medical schools have in recent years evaluated and adapted their selection criteria and processes.[5,6] most south african (sa) medical schools use academic and non-academic criteria to select students, the former accounting for 70 80% of admission requirements.[5] some authors suggest that previous academic performances alone are not a fair reflection of some other very important characteristics required to be successful at medical school.[5] academic criteria emphasise an overall matriculation (matric) pass rate (the m-score) and subject choices; recently, the national benchmark test (nbt) was also introduced.[5,7,8] the national senior certificate (nsc) is the school-leaving certificate in sa and replaced the senior certificate in 2008. pupils study at least six subjects from six different groups, including two compulsory official sa languages – a first and second language – and four selected subjects. requirements for matric pass rates vary, as do those for subject choices. most medical schools require matric physical science and mathematics, and in some cases life science, while some also have language requirements.[5] the nbt was a 3-year project commissioned by higher education sa, designed as an instrument to assess the nsc system, and calibrated against the previous matric system. a second and equally important goal of the nbt was to help to assess the validity of the ncs results as a predictor of success in university studies. the nbt provides information about the competence of students with regard to three core domains of knowledge and skills, i.e. academic literacy (al), quantitative literacy (ql) and mathematics (ma). the tests are written during the year before university entry or at the beginning of the year of entry. research indicated that many students lack quantitative concepts and techniques that medical courses appear to assume students have.[6] although all medical students have studied ma at school, it does not necessarily mean that they are prepared for the ql demands of the curriculum. school ma does not include applying the mathematical techniques in real contexts and the statistical content of the school ma curriculum is very limited.[7] problem setting during recent years, more applicants at sefako makgatho health sciences university, pretoria, sa have come from diverse educational, linguistic, cultural and socio economic backgrounds. at this university, admission to medical studies is primarily based on the academic abilities of the student and determined by the student’s matric results. lately, the students have also written the nbt, but it is not currently used in the selection process. an average student pass rate of 80.1% in physiology (mb chb ii) in the past 13 years compelled the institution to investigate which factors are predictors of success or failure in this subject. failure to pass physiology often prevents students from continuing their medical studies. the information obtained by means of this study can be used to identify factors that place students at risk of failure. objectives the objectives of the study were to analyse existing data (matric and nbt results) of the 2011 mb chb ii group; to compile profiles of successful students and those who failed physiology; and to identify predictors for success in physiology. methods sampling of specific target groups although the study included data from all 2011 2nd-year medical students (n=228), two specific target groups were identified for comparison, i.e. background. admission to sefako makgatho health sciences university, pretoria, south africa is determined by the student’s matriculation (matric) results, while the writing of the national benchmark test (nbt) is not compulsory. an average student pass rate of 80.1% in physiology (mb chb ii) in the past 13 years compelled this institution to investigate which criteria in the selection process could be predictors for success in physiology, a fundamental discipline for medical studies. objectives. to compile a profile of very successful physiology students and those who failed the subject, and to identify predictors for success in physiology. methods. a quantitative study, using matric and available nbt results, was conducted among the mb chb ii group (n=228) of 2011. two target groups were identified: highly successful students in physiology (n=37) and those who failed (n=46). statistical analysis of the results was performed on sas 9.2, microsoft windows (sas institute inc., usa) (p-values ≤0.05 are significant) using the t-test, fisher’s exact test and the simple linear regression test. results. these indicated that a good matric symbol (≥5) in english and life science and a good performance in the quantitative literacy domain of the nbt were statistically significant predictors for success in physiology. conclusion. this preliminary study indicates the need for our institution to rethink the effectiveness of the selection criteria, redesign the selection process of students for the mb chb course, and consider making use of the nbt. afr j health professions educ 2016;8(1):81-83. doi:10.7196/ajhpe.2016.v8i1.647 preliminary study: predictors for success in an important premedical subject at a south african medical school n j allers, msc, phd, bed; l hay, msc, phd; r c janse van rensburg, bsc, ba hons department of human physiology, sefako makgatho health sciences university, pretoria, south africa corresponding author: n j allers (nico.allers14@gmail.com) research 82 may 2016, vol. 8, no. 1 ajhpe highly successful students in physiology, with a final mark of ≥65% (n=36; group 1), and those who failed physiology, with a final mark of <50% (n=45; group 2). the performance of these two groups was compared with regard to the four matric subjects that were used for their selection, i.e. ma, english, life science and physical science, and also for the nbt results. time schedule data were analysed after the final physiology results became available. data analysis statistical analysis of the quantitative results was done by the statistical consultation service of the university of limpopo, medunsa campus. all statistical procedures were performed on sas 9.2, microsoft windows (sas institute inc., usa) (p-values ≤0.05 are significant) using the t-test, fisher’s exact test and the linear regression test. the last test was used to determine the extent to which there is a linear relationship between the dependent variable (final mark in physiology) and ≥1 independent variables. results scores for the subjects that were used in the selection process (ma, physical science, life science and english) were taken in consideration. the grading systems for the subjects were between level 5 and 7 – level 5 was the cut-off point. for level 5 a student has to obtain 60 69% in a subject, which was regarded as an aboveaverage achievement. the matric and nbt results for the two groups are presented in table 1. discussion matric results as students were selected on the basis of their performance in only four of their matric subjects, one has to assume that they performed relatively well in these subjects. the overall combined mark also plays a role in the selection; therefore, it does not necessarily mean that they achieved high marks in all four of the subjects. our study objective was to establish whether performing better in one or more of these subjects could be to the student’s advantage while studying physiology. higher education institutions in sa mainly use english as the language of preference. at our institution, english is not the mother tongue of the majority of students. the language issue might be more unique to sa, as minority groups from disadvantaged backgrounds in countries such as the usa and uk are more likely to have been exposed to the language of tuition. at our institution the majority of students come from disadvantaged backgrounds, with little exposure to english. the significance of language is highlighted by the results, which indicated that the successful group had significantly higher marks for english in matric than their counterparts who failed physiology. a similar tendency was seen for students with english as a home language, but it was not statistically significant, probably due to the low number of students in this category. the other subject in which the successful group showed significantly better results, was life science. the results were supported by the linear regression test. linear regression analysis for the entire group of students (n=228) showed that of the four matric subjects, life science was the only statistically significant predictor of the final mark in physiology (p=0.0006). this result was not completely unexpected, as the school syllabus for life science provides a good foundation for physiology. similar observations were made in both the usa and uk.[9,10] in these countries, chemistry also correlated well with a good performance in medical studies. in sa, however, chemistry is part of physical science, which includes physics. a surprising finding in our study was that there was no difference between the performances of the two groups for ma and physical science. therefore, these subjects were found not to be good predictors of success. similar observations with regard to ma have been made elsewhere in the world.[9] these findings are significant and somewhat ironic as, for many years (before 2008), our institution selected students solely on the basis of their performance in these two subjects, and they were not required to have life science (formerly biology) as a matric subject. nbt results even though our results and those of others suggest that ma was not a good predictor of success, it is interesting that when applying mathematical skills in problem-solving, as tested by the ql of the nbt, the successful group performed significantly better. this is supported by both the t-test (table 1) and linear regression analysis. the latter showed that of al, ma and ql, the last was the only statistically significant predictor of the final mark in physiology (p=0.001). this correlates with the pilot tests of the nbt project in 2009, which indicated that only onequarter of all students tested were classified as ‘proficient’ in ql.[11] the performance of the table 1. matric and nbt results matric: students with a ≥ level 5 gradation* in the four essential matric subjects (fisher’s exact test) group 1: students highly successful in physiology (n=36) group 2: students who failed physiology (n=45) matric subject n (%) n (%) p-value english (home language) 10 (80.0) 6 (66.7) 0.60 english (first additional language) 26 (84.6) 39 (61.5) 0.05* life science 36 (91.7) 45 (62.2) 0.004* physical science 36 (86.1) 45 (86.7) 1.00 mathematics 36 (91.7) 45 (95.6) 0.65 nbt: average percentage obtained by students in the three nbt domains (t-test) nbt domain group 1: students highly successful in physiology (n=29)† group 2: students who failed physiology (n=21)† average % average % p-value academic literacy 53.97 48.24 0.15 quantitative literacy 52.28 37.05 0.0006* mathematics 47.35 43.05 0.22 *p≤0.05 statistically significant. †students who wrote the nbt, where the results were available. research may 2016, vol. 8, no. 1 ajhpe 83 group that failed tended to be weaker for both al and ma, but this is not supported by the statistical analysis. our results therefore suggest that the nbt could have some value in predicting the success of candidates in their 2nd year of study. conclusion the results suggest that a good performance in matric english, the ql of the nbt, and excellent results in life science increase a student’s chances of success in physiology in mb chb ii. this study will be repeated for the following two consecutive years to ensure reliability. recommendations institutions should investigate different parameters to be used in the selection process of medical students, of which the matric performance in life science should be one of the factors. this preliminary study indicates the need to rethink the effectiveness of our selection criteria, redesign our selection process for mb chb, and consider using the nbt. it will be desirable to seek to integrate the ql provision into the students’ experience of the contexts studied in the physiology curriculum. ideally, this could be done by ensuring that the lecturers in physiology are fully aware of the quantitative demands made by their curricula, the possible difficulties that students could experience, and knowing how to address these difficulties. references 1. mitchell kj. traditional predictors of performance in medical school. acad med 1990;65(3):149-158. 2. de silva nr, pathmeswaran a, de silva n, et al. admission to medical schools in sri lanka: predictive validity of selection criteria. ceylon med j 2006;51(1):17-21. 3. ramos sm, croen l, haddow s. predictors of preclinical and clinical performance of minority medical students. j natl med assoc 1986;78(7): 601-607. 4. reede jy. predictors of success in medicine. clin orthop relat res 1999;362:72-77. 5. lehmann u, andrews g, sanders d. change and innovation at south african medical schools. durban: health systems trust, 2000. 6. frith v. quantitative literacy interventions at university of cape town: effects of separation from academic disciplines. numeracy 2012;5(1):article 3. [http://dx.doi.org/10.5038/1936-4660.5.1.3] 7. foxcroft cd, stumpf r. matric: what is to be done? chet: pretoria, 2005. 8. du plessis l, gerber d. academic preparedness of students – an exploratory study. journal for transdisciplinary research in southern africa 2012;8(1):81-94. 9. montague w, odds fc. academic selection criteria and subsequent performance. med educ 1990;24(2):151-157. 10. jones rf, thomae-forgues m. validity of the mcat in predicting performance in the first two years of medical school. j med educ 1984;59(6):455-464. 11. yeld, n. the national benchmark tests project: addressing student educational needs in the tertiary education system. in: hofmeyer j, ed. recession and recovery. cape town: institute for justice and reconciliation, 2009:76-83. ajhpe african journal of health professions education sponsored by www.foundation.co.za issn 2078-5127 march 2017, vol. 9, no. 1 editorial 2 march 2017, vol. 9, no. 1 ajhpe the challenges of healthcare provision in south africa have led to initiatives to strengthen the public sector,[1] increase the number of healthcare workers,[2] improve the relevance of training programmes,[3] and develop leadership capacity[4] to enable more positive health outcomes in communities. these initiatives in health have been implemented concurrently with developments in education with the hope to improve the quality of, and to transform, learning for the very diverse student population enrolled at institutions of higher learning. in this context, faculty development is offered to staff to stay abreast of pedagogical and disciplinary developments. faculty development essentially includes efforts at individual, institutional or system level to capacitate staff with knowledge and skills in areas considered essential for their function as faculty members. healthcare educators generally become aware of the limitations in their educational understanding and practice when called on to teach students and junior members of staff. although there is widespread agreement regarding the need to stay abreast with developments in one’s area of expertise, it is believed that additional reflective learning and educational skills are needed for optimal functioning across the sectors in which staff offer their clinical and educational services. facilitating learning for millennial students requires more active and interactive learning strategies; the appropriate use of technology to advance understanding; improved communication and learning support; and a greater willingness to engage with students and collaborators across space and time. much has been written about professional learning and the conditions necessary for effective lifelong and reflective practice.[5] while methods to facilitate faculty development have changed with time, the reason for doing so has remained to improve the quality of the learning experience. it is also widely known that a lifelong commitment to and investment in personal and professional development is needed. it is, however, possible that some members of staff and health professionals are not always able to identify their own learning needs[6] or prioritise time to engage in developmental activities. in discipline-specific settings, provisions have been made for members to engage in continuous professional development, such as reported in this edition of ajhpe.[7] while efforts in low-income countries are severely hamstrung by the availability of training and resources,[8] it is believed that the lack of training in integrated teams continues to perpetuate the professional silos that are detrimental to the development of the competencies as needed for collective teamwork and effective leadership.[9] while some higher education institutions have implemented mandatory educational training modules for employees, the complexity of staffing of most health programmes results in only a fraction of teaching actually being done by trained educators. the absence of equal training demands for all who work in the sector thus simply increases the existing knowledge and training gap between university staff and their department of health counterparts, for whom compulsory training has not been mandated. the latter category of staff are, however, not exempted from teaching. in fact, the initiative to use a primary healthcare approach has seen more vociferous calls for education and training to be offered on distant and peripheral platforms. these discrepancies demand even greater collaboration among community-based practitioners and university stakeholders. while faculty development initiatives have a better chance of success if implemented across longitudinal institutionalised frameworks,[10] providers are often met with resistance from those who seemingly ‘go through the motions’ to satisfy institutional regulations. these participants, while physically present, choose to engage only superficially with training, thus defeating its purpose. it is therefore desirable that academics and clinical teachers alike become motivated to engage in ongoing training and educational debates, as they understand its inherent benefits for improved interactions with students and patients. institutions should also recognise and value the impact of training in translating knowledge to practice and ultimately on improving health outcomes.[9] despite technological developments in modes to deliver training, users in lowand middle-income countries are still affected by resource limitations and poor connectivity. training will therefore need to be designed in consultation with stakeholders, with the methods of delivery being greatly dependent on the infrastructure and resource allocation of local settings. while it is anticipated that the faculty development flame may initially be ignited through external drivers, such as legislative requirements, it is hoped that individual professional gains and an enhanced educational climate will fan the flame for sustained internal motivation to stay the course. jacqueline van wyk department of clinical and professional practice, nelson r mandela school of clinical medicine, college of health sciences, university of kwazulunatal, durban, south africa vanwykj2@ukzn.ac.za 1. matsoso mp, fryatt r. national health insurance: the first 18 months. s afr med j 2013;103(3):154-155. http:// dx.doi.org/10.7196/samj.6601 2. motala m, van wyk j. cuban medical collaborations: contextual and clinical challenges. afr j health professions educ 2016;8(2):129. http://dx.doi.org/10.7196/ajhpe.2016.v8i2.641 3. naidoo d, van wyk j, joubert rw. exploring the occupational therapist’s role in primary health care: listening to voices of stakeholders. afr j prim health care fam med 2016;8(1):1-9. http://dx.doi.org//10.4102/phcfm. v8i1.1139 4. frantz jm, bezuidenhout j, burch vc, et al. the impact of an educational faculty development programme for health professionals in sub-saharan africa: an archival study. bmc med educ 2015;15(28):3-9. http://dx.doi. org/10.1186/s12909-015-0320-7 5. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. adv health sci educ 2009;14(4):595-621. http://dx.doi.org/10.1007/s10459-007-9090-2 6. davids jm. continuing professional development in nursing. mphil thesis. stellenbosch: stellenbosch university, 2006. http://hdl.handle.net/10019.1/2816 (accessed 13 march 2017). 7. kanamu lg, van dyk b, chipeya l, kilaha sn. barriers to continuous professional development participation for radiographers in kenya. afr j health professions educ 2017;9(1):17-20. http://dx.doi.org/10.7196/ajhpe.2017. v9i1.605 8. munangatire t, naidoo n. exploration of high-fidelity simulation: nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting. afr j health professions educ 2017;9(1):44-47. http://dx.doi. org/10.7196/ajhpe.2017.v9i1.739 9. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. http://dx.doi.org/10.1016/s01406736(10)61854-5 10. mclean m, cilliers f, van wyk j. faculty development: yesterday, today and tomorrow. amee guide no. 3. med teach 2008;30(6):555-584. http://dx.doi.org/10.1080/01421590802109834 afr j health professions educ 2017;9(1):2. doi:10.7196/ajhpe.2017.v9i1.913 this open-access article is distributed under creative commons licence cc-by-nc 4.0. fanning and refuelling the flickering flame of faculty development http://dx.doi.org/10.7196/samj.6601 http://dx.doi.org/10.7196/samj.6601 http://dx.doi.org//10.4102/phcfm.v8i1.1139 http://dx.doi.org//10.4102/phcfm.v8i1.1139 http://dx.doi.org/10.1186/s12909-015-0320-7 http://dx.doi.org/10.1186/s12909-015-0320-7 http://dx.doi.org/10.7196/ajhpe.2017.v9i1.605 http://dx.doi.org/10.7196/ajhpe.2017.v9i1.605 http://dx.doi.org/10.7196/ajhpe.2017.v9i1.739 http://dx.doi.org/10.7196/ajhpe.2017.v9i1.739 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 editorial 50 authorship: lone wolf or wolf pack? j e wolvaardt short research reports 51 use of role-play and community engagement to teach parasitic diseases f haffejee, j van wyk, v hira 54 ‘he has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: the role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement h myezwa, d maleka, p mcinerney, j potterton, b watt research 57 the health system benefits of attending an hiv/aids conference a bosman, j e wolvaardt 62 a learning development module to support academically unsuccessful 1st-year medical students c a kridiotis, s swart 67 depression, anxiety, stress and substance use in medical students in a 5-year curriculum p m van zyl, g joubert, e bowen, f du plooy, c francis, s jadhunandan, f fredericks, l metz 73 developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings m van rooyen, a reinbrech-schütte, j f m hugo, t s marcus 78 reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education h pandya, w slemming, h saloojee 83 dental undergraduate students’ knowledge, attitudes and practices in oral health self-care: a survey from a south african university s singh, s pottapinjara cpd questionnaire ajhpe african journal of health professions education june 2017, vol. 9, no. 2 editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors julia blitz stellenbosch university jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wasserman stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens dtp & design clinton griffin travis arendse chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 | cell 072 635 9825 please submit letters and articles for publication online at www.ajhpe.org.za 25 august 2010, vol. 2, no. 1 ajhpe cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can checkthe answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/010/01/2010 (clinical) cpd august 2010 1. true (a) or false (b) – click on the correct answer: portfolios are a useful way of assessing reflective learning and providing student feedback. 2. true (a) or false (b) – click on the correct answer: portfolios provide a cross-sectional view of student learning and are not useful in assessing longitudinal learning. 3. true (a) or false (b) – click on the correct answer: procedural competence can be evaluated by video-based review of postgraduate trainees. 4. true (a) or false (b) – click on the correct answer: nurses with comprehensive multidisciplinary skills are a great need in african countries such as uganda. 5. true (a) or false (b) – click on the correct answer: intercalated degree programmes for medical students are not considered a priority health educational need by african medical students. 6. true (a) or false (b) – click on the correct answer: postgraduate courses in laboratory-based disciplines such as microbiology do not address the priority health needs of africa. 7. true (a) or false (b) – click on the correct answer: health professions educators demonstrate a preferred teaching method based on their temperament. 8. true (a) or false (b) – click on the correct answer: health professions educators’ perceptions of their teaching styles match their observed teaching styles. 9. true (a) or false (b) – click on the correct answer: academic faculty who have predominantly ‘abstract thinkers’ tend to have a concept-changing student-orientated approach to teaching. 10. true (a) or false (b) – click on the correct answer: in terms of teaching, ‘concrete thinkers’ have a tendency to use an information transfer style of teaching. 11. true (a) or false (b) – click on the correct answer: people who observe the world through their senses tend to explore concepts and provide students with a ‘big picture’ view of the topic being discussed. 12. true (a) or false (b) – click on the correct answer: abstract thinkers talk about ideas and concrete thinkers talk about reality. 13. true (a) or false (b) – click on the correct answer: concrete thinkers are slow to adopt innovations and curriculum changes. 14. true (a) or false (b) – click on the correct answer: the concept of the ‘five star´ doctor was developed by charles boelen. 15. true (a) or false (b) – click on the correct answer: much of south african health sciences education pedagogy was based on the scottish education system adopted in the 19th century. 16. true (a) or false (b) – click on the correct answer: abraham flexner wrote a report on the state of medical education in north america and europe in 1910. 17. true (a) or false (b) – click on the correct answer: adult learners require real life-based learning experiences to facilitate their learning. 18. true (a) or false (b) – click on the correct answer: problem-based learning takes on the character of the environment of the people, which facilitates learning of local health care needs of communities. 19. true (a) or false (b) – click on the correct answer: medical education research generally focuses on providing evidence for teaching practice. 20. true (a) or false (b) – click on the correct answer: health sciences education should be theory driven. scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa september 2017, vol. 9, no. 3 issn 2078 5127 african journal of health professions education editorial 3 cultural competence or speaking the patient’s language? v burch short reports 4 the development of a reflective vascular training portfolio: using a country-specific infrastructure j pillai, t b rangaka, c yazicioglu, t monareng, m g veller 6 randomised controlled trials in educational research: ontological and epistemological limitations m rowe, c oltmann 9 standard setting and quality of assessment: a conceptual approach s s banda research 11 medical students’ views on the use of video technology in the teaching of isizulu communication, language skills and cultural competence p diab, m matthews, r gokool 15 impact of curricular changes to enhance generic skills proficiency of 1st-year medical students d murdoch-eaton, a j n louw, j bezuidenhout 20 perceived stressors of oral hygiene students in the dental environment n a gordon, c a rayner, v j wilson, k crombie, a b shaikh, s yasin-harnekar 25 balancing the educational choices in the decision-making of a dean of medicine: fission or fusion? j e wolvaardt, b g lindeque, p h du toit 30 relationship between student preparedness, learning experiences and agency: perspectives from a south african university n v roman, s titus, a dison 33 perceptions of undergraduate dental students at makerere college of health sciences, kampala, uganda towards patient record keeping a m kutesa, j frantz 37 fieldwork practice for learning: lessons from occupational therapy students and their supervisors d naidoo, j van wyk 41 on being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences, university of cape town, south africa j irlam, l pienaar, s reid 45 mapping undergraduate exit-level assessment in a medical programme: a blueprint for clinical competence? c p l tan, s c van schalkwyk, j bezuidenhout, f cilliers 50 the umthombo youth development foundation, south africa: lessons towards community involvement in health professional education l m campbell, a j ross, r g macgregor 56 exploring knowledge, perceptions and attitudes about generic medicines among final-year health science students v bangalee, n bassa, j padavattan, a r soodyal, f nhlambo, k parhalad, d cooppan 59 home-based rehabilitation: physiotherapy student and client perspectives d parris, s c van schalkwyk, d v ernstzen ajhpe african journal of health professions education | may 2016, vol. 8, no. 1 editorial board editor-in-chief vanessa burch university of cape town international advisors deborah murdoch-eaton sheffield university, uk michelle mclean bond university, ql, australia senior deputy editors juanita bezuidenhout stellenbosch university jose frantz university of the western cape deputy editors jacqueline van wyk university of kwazulu-natal julia blitz stellenbosch university michael rowe university of the western cape elizabeth wolvaardt university of pretoria associate editors francois cilliers university of cape town lionel green-thompson university of the witwatersrand dianne manning university of pretoria sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape ben van heerden stellenbosch university marietjie van rooyen university of pretoria gert van zyl university of the free state hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design carl sampson head of sales & marketing diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani i tel. 072 463 2159 email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 65 an exploration into the awareness and perceptions of medical students of the psychosociocultural factors which influence the consultation: implications for teaching and learning of health professionals m g matthews, p n diab 69 the way forward with dental student communication at the university of the western cape, cape town, south africa r maart, k mostert-wentzel 72 an online formative assessment tool to prepare students for summative assessment in physiology s kerr, d muller, w mckinon, p mc inerney 77 the forensic autopsy as a teaching tool: attitudes and perceptions of undergraduate medical students at the university of pretoria, south africa l du toit-prinsloo, g pickworth, g saayman 81 preliminary study: predictors for success in an important premedical subject at a south african medical school n j allers, l hay, r c janse van rensburg 84 cpd questionnaire supplement 85 health professions education and research capacity building in africa: opportunities and challenges, from the medical education partnership initiative at the university of kwazulunatal, durban, south africa ajhpe is published by the health and medical publishing group (pty) ltd co. registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za suites 9 & 10, lonsdale building, gardener way, pinelands, 7405 tel. 021 532 1281 | cell 072 635 9825 l letters and articles for publication must be submitted online at www.ajhpe.org.za research 73 june 2017, vol. 9, no. 2 ajhpe the longitudinal community attachment programme for students (l-cas) is an undergraduate education initiative of the school of medicine, university of pretoria (up), south africa (sa). by means of this programme each student is exposed to primary healthcare learning and practice. first initiated in 2008, l-cas is a formal module (longitudinal community programme (lcp)) in the curriculum from years 1 to 4 across all mb chb blocks. through this programme students participate in ~13 000 community contacts per annum. in keeping with health education reform, advocated by the 2010 lancet commission on the education of health professionals for the 21st century, l-cas brings together three intersecting educational dimensions, i.e. the importance of the learning setting (curriculum context), a capability approach to learning (the process), and the production of expert generalists (the outcome) (fig. 1). together, these are designed to ensure that health professionals are ‘educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patientand population-centred health systems as members of locally responsive and globally connected teams’.[1] communities are the primary context of health. there is, therefore, a need for students to learn and practise primary healthcare in communities rather than in hospitals. over the years, l-cas has been adjusted and refined in response to changes within the primary care setting and the university. it started as a clinic visit programme (2008 2010). subsequently, it developed into a community-orientated primary care approach to support primary care re-engineering in tshwane district, where students were linked to community health workers (chws) in community ward-based outreach teams (wbots), accompanying them to schools, crèches, shelters and oldage facilities, and into people’s homes.[2] in 2014, the school of medicine, up, discontinued home visits, restricting medical student community visits to clearly defined institutional learning platforms, such as health posts (where chws meet), paediatric institutions, district hospitals, old-age homes, interprofessional clinics, and shelters. background. the longitudinal community attachment programme for students (l-cas) is an activity by means of which each student is exposed to primary healthcare learning and practice in communities. capability has been described as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively … but in response to new and changing circumstances’. within this paradigm, peer-assisted learning (pal) has been used to support the development of student capability during l-cas activities. objective. to evaluate the impact of pal sessions on student and community health worker (chw) capability development. methods. study participants comprised 4th-year medical students and chws. student data were drawn from the rotation reflective reports (rrrs) and chw data from semi-structured interviews. results. the main themes that emerged from the rrrs and interviews were the impact on the personal and professional development of participants; the creation of awareness and understanding of the context of the communities; relationship building; and the impact of peer learning activities on the knowledge, skills and attitudes of participants. conclusion. in the process of addressing the challenge of preparing capable professionals, pal was found to be a very effective way of positioning peers in relation to each other as resources. pal activities enhanced the abilities of students and chws to learn from experience and to achieve the goals of critical reflection and experiential learning. afr j health professions educ 2017;9(2):73-77. doi:10.7196/ajhpe.2017.v9i2.723 developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings m van rooyen, mmed (fammed), mb chb; a reinbrech-schütte, mmed (fammed), mb chb; j f m hugo, mb chb, mpraxmed; t s marcus, phd department of family medicine, school of medicine, faculty of health sciences, university of pretoria, south africa corresponding author: m van rooyen (marietjie.vanrooyen@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. context of the curriculum process of learning outcome health knowing doing people students sta� fig. 1. intersection of educational dimensions. research june 2017, vol. 9, no. 2 ajhpe 74 there is considerable literature on capability as an approach to human economic and social development, including education. in terms of the process of learning, saunders and hart[3] argue for the potential of the capability approach as ‘a creative way for changing and evaluating curricula’. for us, the project team, capability is relevant to both the what and the how of learning. capability has been simply and precisely articulated by stephenson and weil,[4] as ‘an integration of knowledge, skills, personal qualities and understanding used appropriately and effectively – not just in familiar and highly focused specialist contexts, but in response to new and changing circumstances’. capability can be observed when ‘people with justified confidence in their ability [t]ake effective and appropriate action; [e]xplain what they are about; [l]ive and work effectively with others; and continue to learn from their experiences as individuals and in association with others, in a diverse and changing society’. capability not only involves skills, but also qualities, such as judgement and the commitment to learn from experience, as well as ethics, including the virtue of moral excellence through practical wisdom. while capability incorporates notions of competence, the capability approach to learning makes competence a dynamic rather than a static state of being. therefore, it combines the ability to perform effectively at any one point in time (competence) with an individual’s capacity to envisage and realise their own and others’ potential to do and be in the future (capability) (fig. 2). it includes ongoing reflection and adaptation of action with the view to constant improvement.[5] within this paradigm of learning, to be capable in the communityorientated primary care (copc) context, peer-assisted learning (pal) has been used to support the development of student capability during l-cas activities. pal is known to contribute to a number of essential competencies, including communication, learning transfer, teamwork, self-confidence, and reciprocal and effective practice.[6-8] research also shows that pal provides a safe and alternative way of learning, motivates ongoing learning and helps to prepare clinicians for their future roles as educators and mentors.[9] pal is also an essential route to developing chw competency. given their current and potentially significant future contribution to primary health, it is a way of enhancing their ability to deliver quality communitybased primary healthcare.[10-12] throughout the evolution of l-cas practice, the focus of learning content has been on primary health, with special attention to health and disease prevention, early detection and management, and their relation to both the social determinants of health and best healthcare practice, as articulated in the principles of copc.[13] reflection is an essential part of capability that involves understanding the self, others and situations to prepare and plan future action.[14] as one of the l-cas deliverables, medical students are required to submit a rotation reflective report (rrr) after each community visit. it is structured to guide students through a process of reflection that focuses on the assessment and plan for the person with whom they are interacting, their most significant learning experiences, the learning that still needs to take place, and the resources needed to accomplish the learning. objective the objective of this study was to evaluate the impact of pal sessions on student and chw capability development. the article focuses specifically on students’ professional and personal development and their perceptions of behaviour change that resulted from new knowledge, skills and attitudes learnt during the pal sessions. methods the study was conducted with two groups of participants: • the entire 2015 4th-year medical student cohort (n=242) • all chws (n=50) of three purposefully selected wbots. two wbots fig. 2. the capability approach to learning.     the  capability  approach  to  learning     (jfm  hugo,  t  marcus  and  n  honniball)         research 75 june 2017, vol. 9, no. 2 ajhpe had minimal reported problems and were known to be student friendly, and one wbot was known to have problems with student visits and organisation. all respondents in both groups agreed to participate in the study, with the exception of one chw. student data were drawn from the rrrs. chw data were generated through semi-structured interviews conducted by trained independent interviewers from the same culture and language backgrounds as the chws. the researchers individually scrutinised the data for themes and then compared their findings until consensus and saturation were reached. anonymised quotations were identified to support or substantiate each theme. results and discussion the main themes that emerged from the rrrs and interviews are presented and discussed, and supported by quotes from the students and chws. impact of pal on personal development the strength of any activity lies in the development of the participants to become more capable. if one can challenge anyone to change, you have had an impact on the person. both the medical students and the chws said they experienced personal growth through their interaction with each other. chws reported direct personal health benefits from pal. chws felt their own lifestyles and habits improved and they could apply new knowledge to their own families and in the community: ‘to try to live a healthy lifestyle and to promote a healthy lifestyle to my friends and family.’ (chw-s11) in some, illnesses and problems were discovered or diagnosed and could be addressed: ‘… i once felt sick and went to the clinic but the information i got regarding hypertension was not helpful but after the sessions i know what i need to reduce to get my blood pressure to the correct level.’ (chw-d2) some of the medical students also saw the value and impact of the principles of primary care. impact of pal on professional development students presenting information to the chws, led to knowledge sharing with the community: ‘what we learn from the students we can teach the community so that they know how to prevent certain illnesses.’ (chw-d7) chws described a perceived improvement in lifestyle, health promotion, screening and prevention of diseases in the community: ‘we take services to their door and they benefit from our health talks.’ (chw-s22) this, however, was not always successful. chws reported that some community members did not trust chw competency: ‘they didn’t benefit much from the sessions because they feel as though the information we give them is lies. they want us to be accompanied by the students.’ (chw-s10) most chws felt that their knowledge and various practical and communication skills improved as a result of the pal sessions: ‘i know how to check diabetes and blood pressure. i can do pregnancy tests and screen tb and hiv.’ (chw-s19) ‘i have more confidence when i do my work and i fear nothing.’ (chw-s6) ‘… it gave me the ability to express myself easier because i had more skills.’ (chw-d5) ‘my listening skill has improved a lot as a result of these sessions.’ (chwp2) ‘the session expanded my vocabulary when it comes to health terms.’ (chw-p5) creating awareness and understanding as a health professional, greater understanding of the context of the person with whom you deal leads to greater capability, because it improves your understanding of where the person comes from and enables you to negotiate an appropriate management plan. many of our students are far removed from the daily realities of the majority of our patients. it is very important for the learning programme that students gain understanding and knowledge of the patient context. as chws are from that community, they represent the patients that wbots and students serve. students were able to recognise the value of this in their interactions with chws: ‘you get to really interact with the chws and they have so much to teach you about the people’s culture and why people do the things they do.’ (std-32) from their responses, it was apparent that pal created awareness of the social gap between the students and the people they are seeing: ‘i learned a lot about walking in the shoes of those that are less fortunate than me.’ (std-22) they learnt about the importance of social issues in healthcare: ‘as medical practitioners we are very much focused on the discovery of pathology and disease. sometimes it’s more a social thing than a medical thing.’ (std-19) they were made acutely aware of the linguistic and conceptual issues of translating biomedical ideas into everyday intelligible language: ‘i think these visits have helped us to become aware of the fact that our patients will not always understand exactly what we are saying and will require us to be able to simplify concepts for their understanding.’ (std-1) language and culture form an integral part of the context of a person. although all of the chws understand english, they felt that when students explained something in their language, they could understand better: ‘i liked that there is not only white students, because the black students used a language that we can understand better.’ (chw-s1) they appreciated students’ efforts to speak and learn their language. it created a sense of being respected: ‘… they respect our culture. they were actually interested in learning our languages.’ (chw-s5) they also felt they benefited from peer language learning: ‘… we sometimes teach each other words (medical terms) in different languages. they teach us afrikaans and we teach them sepedi.’ (chw-p8) research june 2017, vol. 9, no. 2 ajhpe 76 interaction with a traditional healer was a culturally enriching experience for both sets of learners: ‘… it showed ways in which traditional and western medicine can work together.’ (chw-p3) building relationships to develop capability and enhance learning relationships are one of the three essential components of learning in the capability model. as professionals, the backbone of our interactions with patients and colleagues is our interpersonal relationships. with enough time spent together, relationships and even friendships can be formed. good relationships are also an integral part of developing capability and being an effective peer learner. pal is a well-described tool to enhance self-development and relationship building. with pal, the curriculum extends beyond prescribed work to include language, cross-cultural learning and ethics. furthermore, literature reports on the benefits of peer learning in terms of creating a sense of closeness and co-operation as individuals encourage and facilitate each other’s development.[6] chws seemed to have enjoyed these repeated interactions and learning opportunities. because students were friendly and open, chws felt free to ask questions and felt as though they were part of the learning process: ‘i formed a relationship with them and felt free to ask questions. they were not intimidating and they spoke in simple english. we felt part of a team because they can also learn something from us.’ (chw-s5) ‘… some of them come back to work at the clinic and i am able to ask them anything because they are friendly.’ (chw-d7) it is important to note that relationships need to be honed and developed, and often there are challenges that need to be addressed to facilitate relationship formation and learning. these challenges can include logistics, such as student numbers and continuity: ‘no, there is no relationship between us because they come in large numbers. i don’t feel part of the learning process because they are there for a short period of time.’ (chw-s27) peer learning experience students prepared and presented topics related to their blocks. however, they also had to address topics and learning needs communicated by team leaders and chws. this was particularly significant, given the limited and varying training that chws undergo before they commence their work in the households. the students’ role was therefore to enhance and expand chw knowledge and skill to equip them adequately for their work. the experience of peer learning was novel to students, as their only previous experience was a 2-hour introductory training session. students were surprised about their own teaching skills, their enjoyment of the sessions, and the participation and interaction of the chws: ‘we made our session very interactive … to get a basic understanding of their knowledge. to our surprise they knew quite a lot.’ (std-27) most students understood that chws learnt more when the presentation was creative and entertaining: ‘yes, it was so much fun. some students would do role-plays, it makes the content more understandable than when they are just standing in front and talking. they also leave us with pictures and information of what they were presenting.’ (chw-p8) chws were encouraged to participate actively and share their knowledge with the students. in this way, true reciprocal learning took place and collaboration was honed: ‘i asked questions and would not be satisfied if i left without clarity.’ (chw-s24) ‘when some of the information we were taught was inaccurate, i was able to make corrections to the students.’ (chw-d9) ‘… by informing the students about the challenges we experience in the community.’ (chw-p8) chws had much to offer in terms of experience, knowledge and skills. a study looking at the impact of chws on patients with diabetes mellitus showed an improvement in patient knowledge and behaviour when they were in contact with a chw.[12,15] most students found chws to be worthy pal partners, noting the value of the contribution they made to their communities and to their own learning: ‘they clearly were of benefit to the community, but while so they also benefited us by making us do research and revise sections of work.’ (std-38) this was especially so in terms of student understanding of non-academic aspects of medicine: ‘it was so lovely to see how passionate they are about taking care of the people and trying their best to make a difference in their lives.’ (std-31) some students, however, didn’t realise that pal provided them with an opportunity for reciprocal learning: ‘this [peer learning] wasn’t applicable to our visits as we were the ones teaching the chws.’ (std-12) conclusion and take-home message consolidation of knowledge and cognitive development is enhanced when you teach someone else that which you have only recently learnt. it may, therefore, be a positive experience to entrust intermediate trainees with teaching responsibilities, as it may also accelerate their own learning.[6,9] by interacting with chws, through the methodology of pal, students were provided with an alternative contextual learning opportunity without having to do home visits. chws formed a direct link between students and the community. the pal interactions impacted on a professional and personal level on the students and the chws. the findings give some insight into the value and challenges of pal activity to support capability. they also highlight the need to deepen and expand participants’ awareness of capability as a learning approach to selfdevelopment, personal awareness and understanding, and perceptions of acquiring new knowledge, skills and attitudes. capability is an approach to learning that enables people at all levels of qualification and practice to be competent in unpredictable circumstances in an on-going and cumulative way. as lizzio and wilson[16] observe, ‘… professional or work-place relevant learning is rarely developed through formal or didactic means, but in informal, reflective and interactive episodic contexts’. in the process of addressing the challenge of preparing competent professionals, students need to be involved in activities that enhance their ability to learn in context and from experience. pal positions peers in relation to each other as learning resources and support.[6] it also aids research 77 june 2017, vol. 9, no. 2 ajhpe collaborative practice, an essential part of capability in holistic, patientcentred healthcare. pal activities furthermore provided students the opportunity to experience collaborative practice within the copc context, where teamwork is integral to individual and family health. students had the opportunity to form a better understanding of the scope of practice, challenges and opportunities for the chws, and how they can support and empower them to make a difference within their communities. although they did not go to people’s homes, they could obain a better understanding of the context of patient and community life through the eyes and experiences of the chws. acknowledgement. we thank drs j f m hugo, t s marcus and n honniball for providing fig. 2. 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. http://dx.doi.org/10.1016/s01406736(10)61854-5 2. national department of health. guidelines for the implementation of the three streams of phc. pretoria: ndoh, 2011. 3. saunders j, hart cs. the capability approach for medical education. amee guide no. 97. med teach 2015;37(6):510-520. http://dx.doi.org/10.3109/0142159x.2015.1013927 4. stephenson j, weil sw. quality in learning: a capability approach in higher education. london: kogan page, 1992. 5. marcus t, hugo j. community orientated primary care. in: mash b, ed. handbook of family medicine. 4th ed. cape town: oxford university press, 2016. 6. glynn lg, macfarlane a, kelly m, cantillon p, murphy aw. helping each other to learn – a process evaluation of peer assisted learning. bcm med educ 2006;6(1):18. http://dx.doi.org/10.1186/1472-6920-6-18 7. field m, burke jm, mcallister d, lloyd dm. peer-assisted learning: a novel approach to clinical skills learning for medical students. med educ 2007;41(4):411-418. http://dx.doi.org/101111/j1365-2929.2007.02713.x 8. yu tc, wilson nc, sing pp, lemanu dp, hawken sj, hill ag. medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. adv med educ pract 2011;2:157-172. http://dx.doi.org/10.2147/ amep.514383 9. ten cate o, durning s. peer teaching in medical education: twelve reasons to move from theory to practice. med teach 2007;29(6):591-599. http://dx.doi.org/10.1080/01421590701606799 10. tice m. building collaboration and competence: peer assisted learning and the interprofessional education of allied health students. master of arts/science in nursing scholarly projects. paper 75. sophia, bulgaria: st catherine university, 2014. 11. witmer a, seifer sd, finnocchio l, leslie j, o’neil eh. community health workers: integral members of the health care work force. am j public health 1995;85(8):1055-1058. 12. national center for chronic disease prevention and health promotion. addressing chronic disease through community health workers: a policy and systems-level approach. cdc 2nd ed. cdc: atlanta, ga, usa, 2015. https://www.cdc.gov/dhdsp/docs/chw_brief.pdf (accessed 28 april 2017). 13. marcus ts. community oriented primary care l2: primary health. series: pathways. cape town: pearson, 2013. 14. sandars j. the use of reflection in medical education. amee guide no. 44. med teach 2009;31(8):685-695. http:// dx.doi.org/10.1080/01421590903050374 15. ross mt, cameron hs. peer assisted learning: a planning and implementation framework. amee guide no. 30. med teach 2007;29(6):527-545. http://dx.doi.org/10.1080/01421590701665886 16. lizzio a, wilson k. action learning in higher education: an investigation of its potential to develop professional capability. studies higher educ 2004;29(4):469-488. http://dx.doi.org/10.1080/0307507042000236371 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.2147/amep.514383 http://dx.doi.org/10.2147/amep.514383 http://dx.doi.org/10.1080/01421590903050374 http://dx.doi.org/10.1080/01421590903050374 200 october 2016, vol. 8, no. 2 ajhpe research research has shown that academic stressors, living circumstances, working conditions and where students undertake their leisure activities affect their academic performance, capabilities and functionings. at a tertiary educational level, individuals are exposed to academic material and activities that should promote basic capabilities and functionings as well as academic achievement.[1] amartya sen proposed the capability approach, which is a philosophical perspective that has grown into an interdisciplinary paradigm for development and wellbeing on an educational, personal and social level.[2] the capability approach is a multifactorial concept that reflects on people’s capabilities and functionings. this concept supports the ideas of people and the scope of their abilities to achieve, while successes are the actual achievements they accomplish. human advancement and development can only occur when capabilities and achievements are realistic and attainable.[3] the term capability can encompass skills, attributes and competences. stephenson and yorke[4] define capability as ‘an integration of knowledge, skills, personal qualities and understanding, used appropriately and effectively in response to new and changing circumstances’. capability can be observed while watching people act with confidence in their ability to: (i) explain what they stand for; (ii) live and work effectively with others; (iii) take effective and appropriate action; and (iv) continue to learn from their experiences as individuals and in association with others in a diverse and changing society. each of these four abilities is a complex integration of different skills and qualities. capable people are not only proficient in their areas of specialty, but also have the confidence to apply their knowledge and skills in varied and changing situations, and continue to develop their specialist knowledge and skills long after they have left formal education. capability connotes integration, lifelong learning and the confidence to realise future potential in a developmental and self-managed way.[4] it has been suggested that a beneficial advancement of personal abilities and achievements occur through education and learning.[5,6] according to saito,[7] there is a potentially strong and mutually enhancing relationship between the capability approach and education. these capabilities and functionings include happiness, satisfying social relations, personal integrity and a healthy life that needs to be advanced to create a successful learning environment.[5,6] it would be reasonable to assume that the edu cational process leads to heightened consciousness, self-enhancement, empowerment and informed choices in both academic and personal life.[6,8] the strength of the capability approach lies in its capacity to provide sensible tools and frameworks, within which literacy, competencies and other educational aspects might be conceptualised and evaluated using a validated questionnaire. objective our study focused on the academic capabilities and achievements of 1st-year medical and nursing students. we investigated how students perceived their personal scope of abilities (capabilities) compared with background. research indicates that academic stressors, living circumstances, working conditions and where students undertake leisure activities affect academic performance, capabilities and achievements (functionings). objective. to investigate how 1st-year medical and nursing students perceived their own capabilities compared with their actual achievements (functionings). the article focuses on the achievements (functionings), as these students were admitted through a selection process, indicating their potential capability to succeed. methods. in this descriptive, comparative study, all 1st-year medical and nursing students at the university of the free state, bloemfontein, south africa were invited to complete a validated questionnaire to reflect their capabilities (scope) and achievements (outcomes). the questionnaire incorporated seven domains: happiness, achievements, health, intellect, social relations, environment and integrity. data were analysed using descriptive statistics (frequencies, medians, means, standard deviations and standard errors). results. all respondents valued the domains positively with regard to the outcomes (functionings). on average, nursing students valued the domains 17.4% lower than the medical students. integrity was valued the highest by all. health scored the lowest in the medical group, and environment (where students study and undertake leisure activities) the lowest in the nursing group. conclusions. medical schools should include wellness in their curricula, limit the degree of physical and emotional exhaustion associated with training, and have realistic expectations of students. programmes should allocate enough time for students to manage their time well to take part in physical activity and eat healthy foods. nursing students’ work environment should improve. more time should be made available for leisure activities and improvement to students’ study environment. afr j health professions educ 2016;8(2):200-202. doi:10.7196/ajhpe.2016.v8i2.719 an inferential comparison between the capabilities and achievements of 1st-year medical and nursing students at the university of the free state, bloemfontein, south africa a m gerber,1 phd; r botes,2 msc; a vorster,1 mb chb 1 department of basic medical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of clinical epidemiology, university medical center groningen, university of groningen, the netherlands corresponding author: a gerber (gerberam@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 201 research their successes (functionings) in the different domains. the article focuses on the achievements of students, based on admission to a tertiary institution by means of a selection process, who were expected to have the ability to succeed and achieve more compared with the general students admitted to tertiary institutions. methods this was a descriptive, comparative study with quantitative elements. all 1st-year medical and nursing students at the university of the free state, bloemfontein, south africa were invited to complete a validated questionnaire to reflect their capabilities (scope) and achievements (outcomes). questionnaires were distributed during lectures. participation was voluntary and, as no identifiable information was captured, anonymity was ensured. students were informed about the context of the study and that completion of the questionnaire would take ~15 minutes. the questionnaire the standardised capabilities and achievements questionnaire, validated by anand, was select ed for this study.[5] seven different domains were identified and include happiness, achievements, health, intellect, social relations, environment and integrity. respondents were able to give their perceptions of their personal successes by guided options in the questionnaire. the first section investigated the scope of abilities (capabilities) each respondent felt that they were capable of achieving, by rating their abilities on a likert scale from 1 (very good) to 7 (very inade quate). the next section required the respondents to reflect on the outcomes (successes) they were able to achieve in their lives. they had to rate the outcomes on a likert scale from 1 (strongly agree) to 7 (strongly disagree). ethical considerations a protocol was approved by the ethics committee, faculty of health sciences, university of the free state (ecufs 105/2011). permission to perform the survey was obtained from the vice-rector: academic planning, and the dean of the faculty of health sciences, university of the free state. data management and statistical analysis the data were analysed and interpreted by the inves tigators and a statistician. data are presented by standard descriptive statistics (frequencies, medians, means, standard deviations and standard errors). trends, correlations and meaningful differences were noted, from which consequential conclusions were drawn. as the students would reflect their perceptions/opinions with regard to their own functionings, as defined by the questionnaire, implicit weight was attributed to each of the domains. the results of the seven domains regarding scope of abilities and outcomes were grouped together according to the responses: positive (1 3), neutral (4), or negative (5 7). results respondents (n=148; 68 medical and 80 nursing students) completed the questionnaire. fig. 1 shows the results of the different domains when comparing the two groups. both the medical and nursing students rated the domains on integrity and intellect the highest. the medical students valued all the domains positively (>60%) in terms of the outcomes. on average, the nursing students valued all the outcomes 17.4% lower than the medical students, the greatest difference (30%) being for the environment domain. medical students rated achievement (75%) and health (69%) as the domains they were least satisfied with. nursing students indicated that they were least satisfied with their environment (48%) and health (53%). the medical students’ academic performance indicated that 32% achieved marks between 51% and 60%, and 66% achieved >60% in their respective tests for the semester in which the survey was done. nursing students achieved a pass rate of 34%, with marks between 51% and 60%, while 53% attained a >60% mark. discussion our findings indicate that the 1st-year medical and nursing students valued integrity and intellectual outcomes the highest. this might in part be owing to these students being in an intellectually stimulating and challenging environment, with extensive focus on integrity and ethical behaviour. as for the health domain − rated worst by the medical group and second worst by the nursing group − it is clear that both groups were not satisfied with factors regarding their personal health. insufficient sleep, mild exhaustion, poor eating habits and little time to exercise may be contributing factors. the results further showed that medical students rated their achievements notably higher than nursing students. however, the achievement domain was still rated second lowest in the medical group, reflecting their opinion that they should perform better, which could be a stressor in their lives. even though they value achievement, they are not satisfied with their personal level of achieving success. this may also contribute to their poor validation of personal health due to stress with regard to successful outcomes. for the nursing students, time management could have been a contributing factor to their poorer academic achievements, as they have to work 440 clinical hours per year as part of their training. the nursing students indicated their environment domain as the worst. they rated their living circumstances, working conditions and where they undertake leisure activities as unsatisfactory or not ideal. comparing our nursing group results with findings reported by pryjmachuk and richards,[9] the three main group stressors that they identified medical, % di�erence, % nursing, % % environmenthappiness health intellect social integrityachievement 100 90 80 70 60 50 40 30 20 10 0 75 58 1716 62 78 16 53 69 78 57 2115 69 84 30 48 78 7 80 87 fig. 1. the percentage of 1st-year medical and nursing students that rated each of the seven domains as positive. 202 october 2016, vol. 8, no. 2 ajhpe research were similar to our results. these include: (i) acade mic stressors (testing and evaluation, fear of failure with regard to training, workload); (ii) clinical stressors (work, fear of making mistakes, negative responses to death or patients’ suffering); and (iii) personal/social stressors (economic problems, imbalance between household and academic work).[9] a similar study also reported a diversity of stress sources, and that high levels of stress were associated with poor academic performance. these stressors were identified as normal stressors in day-to-day living, additional stress of the course workload, lack of leisure time, material to be learnt, and frequent academic examinations in a competitive environment.[10] our results were similar to these. the capability approach has many facets, which reflect upon people’s capabilities and functionings. human advancement is needed to develop ability and achieve successes. students need self-discipline, support from home, ability to work independently, resilience, and relevance of their skills to future work, i.e. characteristics a 1st-year student needs to be successful in life. some of these characteristics are not evident in all 1st-year students and need to be developed and improved.[11] conclusions the students in both groups indicated integrity and intellect as the domains with which they were most satisfied. both the medical and nursing students indicated a negative response in the health domain. they were concerned about their eating habits and time spent on physical activities. the achievement domain was perceived unsatisfactorily among the medical students. they were of the opinion that they could achieve better academically and perform better. the nursing students experienced their working environment, where they undertake social activities, and study environment as unsatisfactory. to address these challenges, it is suggested that faculties of health sciences should introduce wellness curricula, set realistic expectations for the workload, and limit the degree of physical and emotional exhaustion associated with training. successful role-models or mentors should be provided to assist students. giving students the opportunity to be responsible and accountable for their own learning may result in better performance in their working and personal lives. this would promote a deeper understanding of their course content, build confidence in their ability to learn, and develop better skills across various functional, personal, social and professional platforms. tertiary institutions should direct more effort towards creating circumstances where students can experience joy and satisfaction. this could include conditions that promote studying in a pleasant environment, provision of financial aid, if necessary, provision of adequate resources, and general support. time management also includes time set aside for satisfying social relationships and extramural physical activities. supporting students on an academic and personal developmental level may result in a better quality of life with improved academic performance and a more capable student, which translates into more competent and capable doctors and nurses for the future. capabilities and achievements questionnaire. this questionnaire is available from the corresponding author on request. acknowledgement. we thank ms t mulder, medical editor, school of medicine, university of the free state, for technical and editorial preparation of the manuscript. references 1. dyrbye ln, west cp, satele d, et al. burnout among us medical students, residents, and early career physicians relative to the general us population. acad med 2014;89(3):443-451. doi:10.1097/acm.0000000000000134  2. martinetti e. a multidimensional assessment of well-being based on sen’s functioning approach. http://www-3unipvit/cds/userfiles/file/papers/paper_chiappero_1 pdf (accessed 24 june 2016). 3. krishnakumar j. going beyond functionings to capabilities: an econometric model to explain and estimate capabilities. j hum dev 2007;8(1):39-63. doi:10.1080/14649880601101408 4. stephenson j, yorke m. capability and quality in higher education. london: kogan page, 1998. 5. anand p, van hees m. capabilities and achievements: an empirical study. j socio-economics 2006;35(2):268284. doi:10.1016/j.socec.2005.11.003 6. young m. basic capabilities, basic learning outcomes and thresholds of learning. j hum dev capab 2009;10(2):259-277. doi:10.1080/19452820902941206 7. saito m. amartya sen’s capability approach to education: a critical exploration. j philos educ 2003;37(1):17-33. doi:10.1111/1467-9752.3701002 8. robeyns i. the capability approach: a theoretical survey. j hum dev 2005;6(1):93-117. doi:10.1080/146498805200034266 9. pryjmachuk s, richards da. mental health nursing students differ from other nursing students: some observations from a study on stress and coping. int j ment health nurs 2007;16(6):390-402. doi:10.1111/j.14470349.2007.00494.x 10. sohail n. stress and academic performance among medical students. j coll physicians surg pak 2013;23(1):67-71. 11. naong n, zwane g, mogashoa g, fleischmann e. challenges of teaching first-year students at institutions of higher learning. http://www.ccsenet.org/journal/index.php/ies/article/view/1719 (accessed 24 june 2016).. http://dx.doi.org/10.1097/acm.0000000000000134 http://www-3-unipvit/cds/userfiles/file/papers/paper_chiappero_1 pdf http://www-3-unipvit/cds/userfiles/file/papers/paper_chiappero_1 pdf http://dx.doi.org/10.1080/14649880601101408 http://dx.doi.org/10.1016/j.socec.2005.11.003 http://dx.doi.org/10.1080/19452820902941206 http://dx.doi.org/10.1111/1467-9752.3701002 http://dx.doi.org/10.1111/j.1447-0349.2007.00494.x http://dx.doi.org/10.1111/j.1447-0349.2007.00494.x http://www.ccsenet.org/journal/index.php/ies/article/view/1719 cpd questionnaire 226 november 2015, vol. 7, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting: cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/163/02/2015 (clinical) a maximum of 3 ceus will be awarded per correctly completed test. true (a) or false (b): optimising cognitive load and usability to improve the impact of e-learning in medical education 1. usability is a concept from the field of human-computer interaction, which describes how easy technology interfaces are to use, and is routinely evaluated and optimised in the software development industry. rising to the challenge: training the next generation of clinician scientists for south africa 2. applicants to this fellowship programme need only have a medical degree. effect of simulated emergency skills training and assessments on the competence and confidence of medical students 3. clinical experience and the level of confidence have some predictive value in performance assessments when using standardised simulated scenarios. student compliance with indications for intravenous cannulation during clinical learning 4. one recommendation by the authors of this study is that medical educators should consider recent evidence and research in the area of simulation-based learning, as this appears to be an under-used didactic approach. implementing and managing community-based education and service learning in undergraduate health sciences programmes: students’ perspectives 5. the authors propose 3 steps that can potentially enhance students’ communitybased education (cbe) and service learning (sl) experiences. evaluating whether module outcomes have been met is part of the ‘actions during cbe and sl’ step. preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation 6. in this article, the authors refer to neal et al., who demonstrated that trainees provided with a checklist beforehand performed just as well in their medical management and non-technical performance during a simulated episode. a faculty-led solution to transport-related stress among sa medical students 7. the student transport project was found to alleviate financial but not emotional pressures for most students. nursing students’ perception of simulation as a clinical teaching method in the cape town metropole, south africa 8. bloom’s taxonomy has only recently been adopted as a popular framework for designing learning experiences, and to help educators to clarify their proposed objectives and to design suitable education and assessment methods. changing students’ moral reasoning ability – is it at all possible? 9. research has supported a correlation between moral reasoning ability and good clinical performance. experiences of medical and pharmacy students’ learning in a shared environment: a qualitative study 10. only the medical students of this study noted attitudes related to superiority and hierarchy. ethical dilemmas experienced by occupational therapy students – the reality 11. the authors of this study identified inconsistencies in the students’ understanding of privacy and confidentiality. they clarified that ‘privacy’ refers to the notion of access to others, whereas ‘confidentiality' is restricted to information, how it relates to accessing such information and how it is applied. promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective 12. the traditional teaching approach has been criticised for not equipping health professionals with the necessary knowledge and skills to work in rural, remote and under-resourced communities. dental students’ perceptions of practice management and their career aspirations 13. similar to results from other studies on dental students, this study highlights that leadership and management were considered to be the most important skills to acquire other than clinical skills. second-year dental students’ perceptions about a joint basic science curriculum 14. the perception of dental students that the joint curriculum was too difficult and stressful was the most important finding of this study. self-regulation – the key to progress in clinical reasoning? 15. a model of self-regulated learning was described in this study as consisting of three phases, i.e. the planning phase, performance phase, self-reflection phase. the meaning of being a pharmacist: considering the professional identity development of first-year pharmacy students 16. the ‘development of a professional identity’ is primarily concerned with the process of integrating a new social identity into an individual’s self-identity. field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: a pilot study 17. the survey results showed that the field trips did not have a practically significant effect on students’ overall positive perception of the relevance of this module to practice. an exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a south african university 18. email correspondence was found to be the most common mode of supervision in this study. examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, self-compassion and self-determination 19. this is the first study that specifically investigates the effects of mindfulness on the mental state of those being trained to become teachers of mindfulnessbased approaches, both locally and internationally. 20. this research showed that there were significant changes in the degree of self-determination. november 2015 scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa december 2017, vol. 9, no. 4 issn 2078 5127 african journal of health professions education research 67 june 2017, vol. 9, no. 2 ajhpe psychological distress is prominent in medical students, and it has been shown that members of this group are more prone to depression, anxiety and stress than comparable populations.[1] yet, some studies found that these indicators of psychological distress are not unique to medical students.[2,3] being a student, irrespective of whether a medical student, is stressful and associated with depression and anxiety. ibrahim et al.[4] reviewed articles published on the prevalence of depression among university students in all disciplines, using a variety of measuring instruments, and found a range of 10 85%, with a weighted prevalence of 30.6%. medical students, however, consistently obtain higher scores for depression, anxiety and stress than the general population.[1] dyrbye et al.[1] performed a systematic review of studies published between 1980 and 2005 reporting on depression, anxiety and other indicators of psychological distress among medical students. two main schools of thought exist on the reason for medical students being so vulnerable. on the one hand, it is proposed that personality traits such as conscientiousness, that enhance academic performance and therefore a student’s chances for selection, may also render them vulnerable to self-criticism in an environment of high academic or occupational demand. on the other hand, medical training itself has been described as a major psychological stressor. while the results on higher depression scores at entry into medical school are not consistent, there are numerous replications of the observation that medical students eventually have higher depression scores than comparable agematched groups.[1] yusoff et al.[5] even expressed concern that medical training causes mental health problems in medical students. students themselves perceive curricular factors, such as examinations, high volume of work and time constraints, as the major factors contributing to high levels of stress in medical school.[5] a prospective longitudinal study by zoccolillo et al.[6] used the diagnostic interview schedule (dis) to screen for possible depression in 1stand 2nd-year medical students, followed by an interview to confirm the diagnosis. they found an upward trend over time, and estimated a projected lifetime prevalence for depression in this cohort at three times that of their peers. the authors postulated that student selection seemed to contribute more to the findings than exposure to medical training. a particular concern is the risk of substance use and abuse as a possible consequence of high levels of depression, anxiety and stress in this population group.[1] baldwin et al.[7] completed a large alcohol and drug use survey at 23 medical schools in the usa, and reported past month use of alcohol of 87.5%, marijuana use of 10.0%, and nicotine use of 10.0%, with the corresponding figures for cocaine at 2.8% and tranquillisers at 2.3%, among the 2 046 participants. background. the mental health of medical students is a global concern, and medical training has been described by some as being detrimental to the health of medical students, affecting both their student experience and professional life. objectives. to determine the prevalence of depression, anxiety, stress and substance use among preclinical students in a 5-year outcomes-based medical curriculum. the study also investigated the association of selected demographic factors with these outcomes. methods. all university of the free state medical students in semesters 3 (n=164) and 5 (n=131) during 2015 were included in this cross-sectional study. depression, anxiety and stress levels were measured by means of the depression anxiety stress scales (dass-21). demographic questions were included in an anonymous self-administered questionnaire. lifetime and past month substance use were determined. results. a prevalence of 26.5% for moderate to extremely severe depression, 26.5% for moderate to extremely severe anxiety, and 29.5% for moderate to extremely severe stress was recorded. female students had significantly higher stress levels, but not increased anxiety. relationship status and accommodation were not associated with these outcomes. lifetime use of methylphenidate, lifetime use of alcohol, and past month use of alcohol were associated with depression. conclusion. the study revealed high levels of depression, anxiety and stress in 2ndand 3rd-year medical students compared with the general population, but the levels were comparable to those of medical students elsewhere in the world. past month substance use of alcohol and cannabis was lower than in international studies, but nicotine use was higher. afr j health professions educ 2017;9(2):67-72. doi:10.7196/ajhpe.2017.v9i2.705 depression, anxiety, stress and substance use in medical students in a 5-year curriculum p m van zyl,1 mb chb, mmedsc, phd; g joubert,2 ba, msc; e bowen,3 mb chb student; f du plooy,3 mb chb student; c francis,3 mb chb student; s jadhunandan,3 mb chb student; f fredericks,3 mb chb student; l metz,3 mb chb student 1 department of pharmacology, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa 3 school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: p m van zyl (vzylpm@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research june 2017, vol. 9, no. 2 ajhpe 68 the university of the free state (ufs) is situated in the province with the third highest occurrence of alcohol use disorders in south africa (sa), where alcohol abuse causes extensive harm to the population as a whole.[8] a recent study involving hostel-dwelling students on the campus of ufs showed a combined prevalence of hazardous, harmful and dependent drinking of 25.3%.[9] the medical curriculum at the faculty of health sciences, ufs, is unique in that it is the only 5-year (10 semester) medical curriculum in sa. five semesters each are dedicated to preclinical and clinical training, respectively. the programme is outcomes based and accredited by the health professions council of south africa (hpcsa), which has recently commended the programme for its innovative integrated assessments, quality of teaching material, and resources to facilitate self-directed learning.[10] at the time of the study, students were selected for medical training at the institution primarily on academic merit, yet geographical origin and leadership qualities were also taken into account. all lectures are presented in afrikaans and english. academic support is provided according to the initiative of the module leader or session presenters, and may take the form of continuous assessment, revision sessions or individual counselling. some modules make use of tutorials presented by student tutors. the faculty of health sciences also hosts a formal academic development plan that identifies and supports students who lag academically.[10] a perception of common occurrence of psychiatric diagnoses among local medical students gave rise to the question to what extent students in this 5-year curriculum experience depression, anxiety and stress; and whether these are associated with substance use. the aim of the study was to assess the prevalence of depression, anxiety, stress and substance use among preclinical medical students. associations between these outcomes and selected demographic factors were also investigated. methods a group of 2nd-year students compiled the research proposal and questionnaire under the guidance of the supervisor and the department of biostatistics. the protocol was approved by the ethics committee of the faculty of health sciences, ufs (ref. no. ufs-hsd 2014/0156). permission was obtained from the relevant ufs authorities: the head of the school of medicine, the dean of the faculty of health sciences, the vice-rector: research, and the dean: student affairs. a quantitative cross-sectional study design was used, with convenience sampling. the inclusion criteria were medical students in semester 3 (n=164) and semester 5 (n=131), who were registered at the school of medicine of the faculty of health sciences, ufs, during the first half of 2015. these two groups were selected for inclusion in the study, as semes ter 3 students had not been exposed to clinical environments yet, whereas semester 5 students had been exposed. the date of the investigation was selected so that no major tests or examinations were scheduled to take place in that particular week. the questionnaire consisted of demographic questions, questions to determine depression, anxiety and stress levels according to the depression anxiety stress scales (dass-21),[11] and questions on alcohol and drug use. dass-21 distinguishes between depression, anxiety and stress as distinct manifestations of psychological distress, and assigns a value on a scale ranging from normal to severely affected. depression is defined as a range of scores on dass that indicates the presence of self-blame, pessimism and loss of enjoyment. anxiety is defined as a range of scores that indicates a state of persistent apprehension and worry, accompanied by physical symptoms of sympathetic activation. stress is defined as a range of scores that indicates a state of over-arousal, tenseness and the inability to relax. the scales are purely for screening purposes and do not provide a definitive diagnosis. as described in the dass guidelines, the categories moderate, severe and extremely severe are applied to indicate the degree of each of the respective conditions.[11] for purposes of this study, substance use is defined as medicinal or recreational use of selected psychoactive substances, as selected by the researchers. substance use was determined for the periods lifetime (ever), past month and past week. some questions of the drug abuse screening test (dast)[12] were also included, which are not reported here. the questionnaire was tested in a pilot study that included six physiotherapy students, equally representing the two language groups, to test the clarity of questions and practical aspects, such as the time to complete. translation errors were corrected. formal translation-back translation methods were not utilised, but it must be noted that the majority of the research team were fluent in both english and afrikaans. the research was introduced by the student researchers to each class directly following a normally scheduled compulsory contact session. the voluntariness and anonymity of participation were explained before the questionnaires were handed out to all students present, excluding the researchers themselves. the anonymous self-administered questionnaire was available in afrikaans or english and was accompanied by an information document. non-respondents were students absent on the day of questionnaire distribution, and students who did not wish to complete the questionnaire. the students performing the research formed part of the study population, but were excluded from participation. to maintain anonymity, participants were requested to place the completed questionnaires in a box. results are reported by frequencies and percentages. subgroups were compared using χ2 or fisher’s exact tests, as appropriate. a p-value <0.05 was considered statistically significant, and 95% confidence intervals (cis) were calculated for differences between percentages. all analyses were performed using sas version 9.2 (sas institute, usa). results a total number of 295 students were registered in 2015 for semesters 3 and 5. a total of 257 questionnaires were returned, of which 14 were excluded owing to a number of incomplete items on the dass-21 section. another two questionnaires that contained inconsistent and erratic responses were excluded from the analysis. therefore, 241 questionnaires could be analysed. the response rate was 81.7% (137/164 (83.5%) for semester 3, and 104/131 (79.4%) for semester 5). semester 3 participants were mainly in the age group 18 20 years (75.9%) and semester 5 participants mainly in the age group 21 23 years (51.9%). female students were in the majority in both semesters: 52.6% of semester 3 students and 56.7% of semester 5 students. the most common depression category, apart from normal/mild, in both semesters was moderate (table 1), whereas for anxiety it was extremely severe in both semesters. for stress the most common categories, apart from normal/mild, were moderate for semester 3 and severe for semester 5. in both semesters seven students each reached severe or extremely severe for all three conditions. table 2 shows a comparison between students of semesters 3 and 5. there was a statistically significant higher percentage of anxiety (p=0.01, 95% ci 3.8 25.5) and stress (p=0.03, 95% ci 1.6 24.2) in semester 3 students. significantly more semester 5 students had none of the three conditions (p=0.05, 95% ci 0.4 research 69 june 2017, vol. 9, no. 2 ajhpe 25.3). the most common combination of conditions in each semester, other than all three or none, was anxiety and stress in 10.3% of semester 3 students, and depression only in 9.7% of semes ter 5 students. an upward trend was seen for the diagnosis of depression and anxiety and current use of antidepressants progressing from semesters 3 to 5, yet the differences are not statistically significant (table 3). female students were statistically significantly more likely to report stress (table 4, p<0.01, 95% ci for difference between female students and male students: 6.3 28.6), yet only marginally more likely to report anxiety or depression (p=0.32 and p=0.52, respectively). no significant associations were found between relationship status or housing arrangement and any of the conditions. the highest prevalence of past month substance use was found for alcohol (71.0%, table 5), followed by nicotine (19.1%) and codeine (9.5%). lifetime use of marijuana was relatively high at 22.8%, but past month use dropped to 5.4%. there were low numbers of lifetime use of cocaine, methcathinone (cat), methylenedioxy-n-methylamphe tamine (mdma) (ecstasy) and lysergic acid diethylamide (lsd), with no past month use of these substances reported. no lifetime use or past month use of crystal methamphetamine (tik) or heroin was reported. table 6 shows a statistically significant association between lifetime methylphenidate use and depression when comparing lifetime users and never users (p<0.01, 95% ci 10.7 41.8). likewise, a statistically significant association between lifetime methylphenidate use and stress was found when the same groups were compared (p<0.01, 95% ci 7.0 38.4). past month use of methylphenidate was substantially less than lifetime use and no association was demon strated with depression (p=0.11), anxiety (p=0.34) or stress (p=0.53), possibly owing to small numbers. depression was significantly more common in lifetime alcohol users compared with never users (p=0.01, 95% ci 9.3 32.0), and past month alcohol users compared with non-users (p=0.01, 95% ci 5.4 27.2). anxiety was statistically significantly more common in past month users of alcohol compared with non-users (p=0.04, 95% ci 1.7 24.6). depression was also statistically significantly more likely in past month nicotine users compared with non-users (p=0.03, 95% ci 0.2 30.9). there were no significant associations between codeine or marijuana use and depression, anxiety or stress. discussion the current study is limited by its cross-sectional design and because a wide range of measuring instruments are used in reported studies. however, it provides a useful baseline for further investigations, e.g. the effect of major transitions in terms of implementation of the english-only language policy and demographic changes in selection criteria in the immediate future. the study showed a prevalence of 26.6% for depression, 26.6% for anxiety and 29.5% for stress, as defined by the dass-21 screening tool, in the preclinical medical student cohort at ufs for 2015. it is important to note that 12.9% of the study cohort had a lifetime diagnosis of depression and 11.6% a lifetime diagnosis of an anxiety disorder. these findings should be interpreted against the background of the high levels of anxiety and depression in the general population of the free state and findings among similar study populations done on similar populations using the same measuring instrument. the sa stress and health (sash) study[8] reported a prevalence of lifetime diagnosis of mood disorders of 9.8% and anxiety of 15.8% for the free state population table 1. degree of depression, anxiety and stress (n=241) degree of psycholo gical distress normal, n (%) mild, n (%) moderate, n (%) severe, n (%) extremely severe, n (%) depression total 144 (59.8) 33 (13.7) 32 (13.3) 16 (6.6) 16 (6.6) semester 3 78 (56.9) 22 (16.1) 19 (13.9) 11 (8.0) 7 (5.1) semester 5 66 (63.4) 11 (10.6) 13 (12.5) 5 (4.8) 9 (8.7) anxiety* total 130 (53.9) 45 (18.7) 21 (8.7) 15 (6.2) 28 (11.6) semester 3 70 (51.5) 21 (15.4) 16 (11.8) 10 (7.4) 19 (14.0) semester 5 60 (58.3) 24 (23.3) 5 (4.9) 5 (4.9) 9 (8.7) stress total 142 (58.9) 28 (11.6) 32 (13.3) 28 (11.6) 11 (4.6) semester 3 72 (52.6) 17 (12.4) 23 (16.8) 18 (13.1) 7 (5.1) semester 5 70 (67.3) 11 (10.6) 9 (8.7) 10 (9.6) 4 (3.9) *semester 3: n=136; semester 5: n=103; total: n=239. table 2. positive screening for depression, anxiety and stress screening semester 3, n (%) (n=137) semester 5, n (%) (n=104) p-value total, n (%) (n=241) depression (dass-21 >6) 37 (27.0) 27 (26.0) 0.86 64 (26.6) anxiety (dass-21 >5)* 45 (33.1) 19 (18.5) 0.01 64 (26.6) stress (dass-21 >9) 48 (35.0) 23 (22.1) 0.03 71 (29.5) depression, anxiety and stress* 19 (14.0) 14 (13.6) 0.93 33 (13.8) none of the abovementioned three* 71 (52.2) 67 (65.1) 0.05 138 (57.7) *semester 3: n=136; semester 5: n=103; total: n=239, as two participants did not complete the anxiety items fully. table 3. previous diagnosis and current medication for depression and anxiety diagnosis and medication semester 3, n (%) (n=137) semester 5, n (%) (n=104) p-value total, n (%) (n=241) previously diagnosed with depression 16 (11.7) 15 (14.4) 0.53 31 (12.9) previously diagnosed with anxiety 14 (10.2) 14 (13.5) 0.44 28 (11.6) current medication for depression 8 (5.8) 8 (7.8) 0.55 16 (6.6) current medication for anxiety 11 (8.0) 8 (7.7) 0.92 19 (7.9) research june 2017, vol. 9, no. 2 ajhpe 70 using the composite international diagnostic interview (cidi) as measuring instrument. both these figures were statistically significantly higher than the corresponding figures for the country as a whole. owing to the difference in the measuring instruments and definition of outcomes measured, the current study results cannot be directly related to these figures, yet the results seem high if one considers the relatively young age of the study population. with regard to comparability, findings of the studies mentioned below, which also used dass-21 or dass-42 and categorised the results in a similar manner, are of value. a study of 575 medical students at the alfaisal university in riyadh, saudi arabia,[13] using dass21, showed a fluctuation of depression, anxiety and stress scores before and after examinations: between 43% and 30% for moderate or more severe depression, between 63% and 47% for moderate or more severe anxiety, and between 41% and 30% for moderate or more severe stress. the results of the current study therefore correspond with their postexamination measurements, with a notable lower level of moderate to extremely severe anxiety. another study using dass-21 in a group of 508 undergraduate college students at a university in the usa[14] reported a prevalence of 29% for depression, 27% for anxiety and 24% for stress. these results are closely comparable with the results of the current study. however, the authors did not explicitly indicate whether they grouped normal and mild categories together. it is therefore possible that the figures for positive cases appear higher than their actual value because they included mild cases, whereas in the current study mild cases were grouped together with the normal category. the instructions for dass-21 indicate that the mild category refers to a group of individuals who experience symptoms that are not yet so severe as to prompt the person to seek treatment. a similar study was done in a population of 1 617 tur kish undergraduate students using dass-42, which is an extended version of dass-21.[15] the authors found a prevalence of 27% for moderate or more severe depression, 47% for moderate or more severe anxiety, and 27% for moderate or more severe stress. medical students did not attain higher scores in this particular group. the current study shows scores of stress and depression comparable to those found in studies on general student populations, performed with the same or similar test instruments, but the levels of anxiety measured tended to be lower. this trend coincides with a lower than expected level of anxiety in female students. according to the literature, female students are more likely to report anxiety and stress.[1,4,12-14] in the current study, female students showed a significantly higher tendency for stress (p<0.01) than male students, yet there were no significant differences with regard to depression or anxiety. in line with the reported literature,[1] semester 3 students showed statistically significant higher levels of anxiety and stress than semester 5 students. nonetheless, the prevalence of depression did not differ significantly between the two year groups. past month alcohol use in the study population (71.0%) compares favourably with that among us medical students, which ranges from 79% to 84%[16] and the 87% of alcohol use during the past two months reported among 1st-year psychology students from the university of limpopo.[17] the sa youth risk survey of 2011 reported past month alcohol use of 32.3% among high school learners in sa and 46.2% for the free state.[18] the current study found past month cigarette smoking of 19.1% among the study population, while us studies showed figures of 10 12% for daily or regular use of nicotine.[16] the corresponding figures for sa schoolchildren were 17.6% for the country and 24.9% for the free state.[18] while cigarette smoking was more common among the current study population compared with similar us populations, past month use of cannabis was found to be 5.4% compared with the corresponding figures for us studies ranging between 1% and 28%.[16] past month use for school learners in sa was 9.2% and 12.4% for the free state.[18] the finding of 22.8% for lifetime use of cannabis was low compared with studies reporting lifetime use of cannabis among us medical students from 1973 to 2013, reporting figures between 47% and 74%.[16] the figure for lifetime use of cannabis among high school children in sa was 12.8% and for the free state 13.5%.[18] cannabis was the only illicit drug used during the 30 days preceding the current study. low figures were recorded for lifetime exposure to other illicit drugs: cocaine (1.7%), cat (1.2%), ecstasy (3.3%) and lsd (1.2%). lifetime use for cocaine in the us review ranged from 20% to 39%, and for stimulants between 20% and 27%.[16] there is no literature available on the use of illicit drugs among university students or medical students in sa. the sa youth risk survey of 2011[18] reported the lifetime use of cocaine among high school learners as 4.9% nationally and 7.2% for the free state. a recent survey by jain et al.[19] showed that 11% of undergraduate medical students at ufs use methylphenidate. the lower figure of 5.3% found for past month use of methylphenidate in a proportion of the same population in the current study could reflect the timing of the investigation in relation to major assessments. no national figures are available for comparison in this regard. in a recent comprehensive meta-analysis of studies on methylphenidate use in medical students, finger et al.[20] reported lifetime use of 8.3 9% and past year use of 3 16%. most of these students used methylphenidate intermittently for performance enhancement. table 4. influence of demographic factors on depression, anxiety and stress demographic factors depression (dass-21 >6) anxiety (dass-21 >5) stress (dass-21 >9) sex female, n (%) (n=131) 37 (28.2) 38 (29.0) 49 (37.4) male, n (%) (n=110) 27 (24.6) 26 (24.1) 22 (20.0) p-value 0.52 0.39 <0.01 relationship status* single, n (%) (n=148) 40 (27.0) 37 (25.0) 42 (28.4) married or in a relationship, n (%) (n=92) 23 (25.0) 26 (28.9) 28 (30.4) p-value 0.73 0.51 0.73 housing arrangement with family, n (%) (n=40) 13 (32.5) 12 (30.0) 14 (35.0) hostel on campus, n (%) (n=66) 15 (22.7) 16 (24.2) 18 (27.3) private accommodation, n (%) (n=135) 36 (26.7) 36 (27.1) 39 (28.9) p-value 0.54 0.81 0.68 *missing data: 1. research 71 june 2017, vol. 9, no. 2 ajhpe the current study also showed past month use of codeine of 9.5% and benzodiazepines of 1.7%. interestingly, semester 5 students had a statistically significant higher lifetime use of benzodiazepines (p=0.03), lifetime use of codeine (p<0.0001), and past month use of codeine (p=0.01). the study found an association between lifetime use of methylphenidate and depression, lifetime use of nicotine and depression, and lifetime use of alcohol and depression. these results need to be explored in further studies. medical students at ufs suffer near identical levels of depression and stress, and similar or lower levels of anxiety than their peers in institutions where comparable measuring instruments were used. the shorter 5-year medical curriculum at ufs, therefore, does not seem to contribute to these conditions, yet shows a positive association with lower levels of anxiety, especially in female students. several curriculum-specific factors may be responsible for this tendency, e.g. that expectations are well described in the outcomes-based model and the emphasis given to academic and psychological support in the curriculum. the authors recommend that aspiring medical students should be made aware of the potential risk to their mental health posed by their career choice. likewise, academic institutions should take cognisance of the tendency of medical students to fall prey to psychological distress under academic pressure. the medical curriculum should also contain instruction on resilient behaviour and healthy responses to stress during the introductory phase. the associations between alcohol use and depression and anxiety, and nicotine use and depression, need to be incorporated in such instruction. conclusion medical curricula in general are challenging in terms of volume and complexity, which create an environment where stress vulnerability and resilience are tested. the current study supports a widely reported phenomenon of higher levels of depression, anxiety and stress in medical students compared with the surrounding population. acknowledgement. we thank ms t mulder, medical editor, school of medicine, ufs, for technical and editorial preparation of the manuscript. 1. dyrbye ln, thomas mr, shanafelt td. systematic review of depression, anxiety, and other indicators of psychological distress among us and canadian medical students. acad med 2006;81(4):354-373. http://dx.doi. org/10.1097/00001888-200604000-00009 2. bunevicius a, katkute a, bunevicius r. symptoms of anxiety and depression in medical students and in humanities students: relationship with big-five personality dimensions and vulnerability to stress. int j soc psychiatry 2008;54(6):494-501. http://dx.doi. org/10.1177/0020764008090843 3. mahajan as. stress in medical education: a global issue or much ado about nothing specific? southeast asian j med educ 2010;4(2):9-13. http://dx.doi.org/10.4103/0253-7176.122235 4. ibrahim ak, kelly sj, adams ce, glazebrook c. a systematic review of studies of depression prevalence in university students. j psychiatr res 2013;47(3):391-400. http://dx.doi.org/10.1016/j.jpsychires 5. yusoff ms, abdul rahim af, yaacob mj. prevalence and sources of stress among universiti sains malaysia medical students. malays j med sci 2010;17(1):30-37. 6. zoccolillo m, murphy ge, wetzel rd. depression among medical students. j affect disord 1986;11(1):91-96. http://dx.doi. org/10.1016/0165-0327(86)90065-0 7. baldwin dc jr, hughes ph, conard se, storr cl, sheehan dv. substance use among senior medical students: a survey of 23 medical schools. jama 1991;265(16):2074-2078. http://dx.doi.org/10.1001/ jama.1991.03460160052028 8. herman aa, stein dj, seedat s, heeringa sg, moomal h, williams dr. the south african stress and health (sash) study: 12-month and lifetime prevalence of common mental disorders. s afr med j 2009;99(5):339-344. 9. van zyl p, botha j, van wyk m, et al. hazardous, harmful and dependent drinking in hostel-dwelling students at the university of the free state, bloemfontein: a cross-sectional study. j child adolesc ment health 2015;27(2):125-133. http://dx.doi.org/10.2989/17280583.2015.1084310 10. health professions council of south africa. accreditation of undergraduate medical education and training, school of medicine, faculty of health sciences, university of the free state. pretoria: hpcsa, 2010. 11. lovibond pf, lovibond, sh. the structure of negative emotional states: comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories. behav res ther 1995;33(3):335-343. http://dx.doi.org/10.1016/0005-7967(94)00075-u 12. skinner ha. the drug abuse screening test. addict behav 1982;7(4):363371. http://dx.doi.org/10.1016/0306-4603(82)90005-3 13. kulsoom b, afsar na. stress, anxiety, and depression among medical students in a multiethnic setting. neuropsychiatr dis treat 2015;11:17131722. http://dx.doi.org/10.2147/ndt.s83577 14. mahmoud js, staten r, hall la, lennie ta. the relationship among young adult college students’ depression, anxiety, stress, demographics, life satisfaction, and coping styles. issues ment health nurs 2012;33(3):149-156. http://dx.doi.org/0.3109/01612840.2011.632708 15. bayram n, bilgel n. the prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. soc psychiatry psychiatr epidemiol 2008;43(8):667-672. http://dx.doi. org/10.1007/s00127-008-0345-x 16. dumitrascu ci, mannes pz, gamble lj, selzer ja. substance use among physicians and medical students. med student res j 2014;3:27-35. 17. mogotsi m, nel k, basson w, tebele c. alcohol use by students at an emerging uni versity in south africa. j sociol soc anthropol 2014;5(2):187-195. 18. reddy sp, james s, sewpaul r, et al. umthente uhlaba usamila: the 3rd south african national youth risk behaviour survey 2011. cape town: south african medical research council, 2013. 19. jain r, chang c, koto m, geldenhuys a, nichol r, joubert g. nonmedical use of methylphenidate among medical students of the university of the free state. s afr j psychiatry 2016;22(1):a1006. http:// dx.doi.org/10.4102/sajpsychiatry 20. finger g, silva er, falavigna a. use of methylphenidate among medical students: a systematic review. rev assoc med bras 2013;59(3):285-289. http://dx.doi.org/10.1016/j.ramb.2012.10.007 table 5. substance use substance semester 3, n (%) (n=137) semester 5, n (%) (n=104) p-value total, n (%) (n=241) methylphenidate lifetime use 26 (18.9) 20 (19.2) 0.96 46 (19.1) past month use 9 (6.6) 4 (3.9) 0.35 13 (5.3) alcohol lifetime use 116 (84.7) 91 (87.5) 0.53 207 (85.9) past month use 98 (72.6) 73 (70.2) 0.68 171 (71.0) nicotine lifetime use 33 (24.1) 33 (31.7) 0.19 66 (27.4) past month use 22 (16.1) 24 (23.1) 0.17 46 (19.1) marijuana lifetime use 30 (21.9) 25 (24.0) 0.69 55 (22.8) past month use 9 (6.6) 4 (3.9) 0.35 13 (5.4) codeine lifetime use 9 (6.6) 33 (31.7) <0.0001 42 (17.4) past month use 7 (5.1) 16 (15.4) 0.01 23 (9.5) benzodiazepine lifetime use 5 (3.7) 11 (10.6) 0.03 16 (6.6) past month use 3 (2.2) 1 (1.0) 0.64 4 (1.7) cocaine lifetime use 3 (2.2) 1 (1.0) 0.64 4 (1.7) past month use 0 (0) 0 (0) 0 (0) cat lifetime use 0 (0) 3 (2.9) 0.08 3 (1.2) past month use 0 (0) 0 (0) 0 (0) mdma (ecstasy) lifetime use 3 (2.2) 5 (4.8) 0.30 8 (3.3) past month use 0 (0) 0 (0) 0 (0) lsd lifetime use 1 (0.7) 2 (1.9) 0.58 3 (1.2) past month use 0 (0) 0 (0) 0 (0) http://dx.doi.org/10.1097/00001888-200604000-00009 http://dx.doi.org/10.1097/00001888-200604000-00009 http://dx.doi.org/10.1177/0020764008090843 http://dx.doi.org/10.1177/0020764008090843 http://dx.doi.org/10.1016/0165-0327(86)90065-0 http://dx.doi.org/10.1016/0165-0327(86)90065-0 http://dx.doi.org/10.1001/jama.1991.03460160052028 http://dx.doi.org/10.1001/jama.1991.03460160052028 http://dx.doi.org/10.1016/0005-7967(94)00075-u http://dx.doi.org/10.1016/0306-4603(82)90005-3 http://dx.doi.org/10.1007/s00127-008-0345-x http://dx.doi.org/10.1007/s00127-008-0345-x http://dx.doi.org/10.4102/sajpsychiatry http://dx.doi.org/10.4102/sajpsychiatry research june 2017, vol. 9, no. 2 ajhpe 72 table 6. association between substance use and depression, anxiety and stress substance substance use depression, n (%) anxiety, n (%) stress, n (%) methylphenidate lifetime yes (n=46) 22 (47.8) 17 (37.0) 22 (47.8) no (n=195) 42 (21.5) 47 (24.4) 49 (25.1) p-value <0.01 0.08 <0.01 past month yes (n=13) 6 (46.2) 5 (38.5) 5 (38.5) no (n=227) 57 (25.1) 59 (26.2) 65 (28.6) p-value 0.11 0.34 0.53 alcohol lifetime yes (n=207) 61 (29.5) 58 (28.3) 65 (31.4) no (n=34) 3 (8.8) 6 (17.7) 6 (17.7) p-value 0.01 0.19 0.10 past month yes (n=171) 53 (31.0) 52 (30.8) 54 (31.6) no (n=68) 10 (14.7) 12 (17.7) 16 (23.5) p-value 0.01 0.04 0.22 nicotine lifetime yes (n=66) 23 (34.9) 21 (32.3) 22 (33.3) no (n=175) 41 (23.4) 43 (24.7) 49 (28.0) p-value 0.07 0.24 0.42 past month yes (n=46) 18 (39.1) 15 (33.3) 16 (34.8) no (n=195) 46 (23.6) 49 (25.3) 55 (28.2) p-value 0.03 0.27 0.38 marijuana lifetime yes (n=55) 14 (25.5) 15 (27.3) 17 (30.9) no (n=186) 50 (26.9) 49 (26.6) 54 (29.0) p-value 0.83 0.92 0.79 past month yes (n=13) 1 (7.7) 2 (15.4) 3 (23.1) no (n=228) 63 (27.6) 62 (27.4) 68 (29.8) p-value 0.19 0.52 0.76 codeine lifetime yes (n=42) 14 (33.3) 11 (26.2) 13 (31.0) no (n=199) 59 (25.1) 53 (26.9) 58 (29.2) p-value 0.27 0.92 0.82 past month yes (n=23) 6 (26.1) 6 (26.1) 7 (30.4) no (n=218) 58 (26.6) 58 (26.9) 64 (29.4) p-value 0.96 0.94 0.91 editorial v burch short communication cuban medical collaborations: contextual and clinical challenges m motala, j m van wyk short research reports remembering old partnerships: networking as new medical schools within boleswa countries l badlangana, k matlhagela, n tlale tracking master of public health graduates: linking higher education and the labour market t dlungwane, s knight research research supervision: perceptions of postgraduate nursing students at a higher education institution in kwazulu-natal, south africa c muraraneza, f mtshali, s z mthembu the electrocardiogram made (really) easy: using small-group tutorials to teach electrocardiogram interpretation to final-year medical students m p jama, j a coetser effect of bedside teaching activities on patients’ experiences at an ethiopian hospital f a gebrekirkos, j m van wyk student feedback on an adapted appraisal model in resource-limited settings l arnold the noma track module on nutrition, human rights and governance: part 1. perceptions held by master's students m l marais, m h mclachlan, w b eide the noma track module on nutrition, human rights and governance: part 2. a transnational curriculum using a human rights-based approach to foster key competencies in nutrition professionals m l marais, m h mclachlan, w b eide professional nurses’ perception of their clinical teaching role at a rural hospital in lesotho c n nyoni, a j barnard allied health professional rural education: stellenbosch university learners’ experiences m pillay, j bester, r blaauw, a harper, a msindwana, j muller, l philips self-assessment of final-year undergraduate physiotherapy students’ literature-searching behaviour, self-perceived knowledge of their own critical appraisal skills and evidence-based practice beliefs d a hess, j frantz the usefulness of a tool to assess reflection in a service-learning experience a-m wium, s du plessis multidisciplinary leadership training for undergraduate health science students may improve ugandan healthcare j n najjuma, g ruzaaza, s groves, s maling, g mugyenyi ajhpe african journal of health professions education | october 2016, vol. 8, no. 2 editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors julia blitz stellenbosch university jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria lionel green-thompson university of the witwatersrand patricia mcinerney university of the witwatersrand sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wasserman stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design carl sampson chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani i tel. 072 463 2159 email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 exploring occupational therapy graduates’ conceptualisations of occupational justice in practice: curriculum implications l a hess-april, j smith, j de jongh burnout among paramedic students at a university in johannesburg, south africa c stein, t sibanda registrars teaching undergraduate medical students: a pilot study at the university of pretoria, south africa l du toit-prinsloo, n k morris, m lee, g pickworth an inferential comparison between the capabilities and achievements of 1st-year medical and nursing students at the university of the free state, bloemfontein, south africa a m gerber, r botes, a vorster developing social accountability in 1st-year medical students: a case study from the nelson r mandela school of medicine, durban, south africa j m van wyk, s e knight, t dlungwane, s glajchen beyond the lecture: teaching for professional development m rowe cpd questionnaire supplement interprofessional education, practice and research ajhpe is published by the health and medical publishing group (pty) ltd co. registration 2004/0220 32/07, a subsidiary of sama | publishing@hmpg.co.za suite 11, lonsdale building, lonsdale way, pinelands, 7405 tel. 021 532 1281 | cell 072 635 9825 l letters and articles for publication must be submitted online at www.ajhpe.org.za 68 may 2015, vol. 7, no. 1, suppl 1 ajhpe editorial the announcement of the medical education partnership initiative (mepi) that committed more than usd132 million to medical schools in sub-saharan africa (ssa) over a 5-year period coincided with the publication of a seminal article in the lancet[1] that called for the strengthening of health systems through transformative education. the significance of these two events has been considerable for the faculty of medicine and health sciences (fmhs) at stellenbosch university (su). while mepi was to provide substantial resources that would lead to the establishment of the stellenbosch university rural medical education partnership initiative (surmepi), frenk et al.’s[1] work would offer a theoretical premise for our thinking and a model for our practice. in this edition of the ajhpe we endeavour to showcase some of the work and research that has emanated from the initiative. the articles provide a snapshot in time, reflecting activities that characterised the first few years of surmepi. ‘the surmepi story’[2] highlights how the project seeks to adopt innovative strategies to improve human resources for health in africa – particularly focusing on the pipeline that commences already at secondaryschool level. in describing this entry point, moodley et al.[3] introduce a key philosophical construct that provides significant direction for our work, namely social accountability and the importance of ensuring medical graduates are both academically sound and responsive to the needs of the communities they serve. community-based education (cbe) activities run by the fmhs are based on this founding principle. another key component of cbe is the fostering of relationships with communities such that the engagement is mutually enabling and focused on strengthening both the educational experience and the community. creating learning centres in community nodes, therefore, provides a place where cbe can be optimised. fish et al.[4] offer a synopsis of a purposeful intervention in this regard in the ‘avian park service learning centre story’. the establishment of surmepi further coincided with the implementation of the ukwanda rural clinical school (rcs) and the project has been instrumental in supporting activities on this platform. the potential for enhancing retention in rural areas and heightening student awareness of the public health system has been well documented.[5] a cluster of articles present a series of evaluative research that has been undertaken at the rcs. these include a focus on what influences students’ decisions to go to the rcs;[6] how rcs students following the longitudinal integrated model cope with being in a district hospital for their entire final year;[7] and what the implications are for academic success when students do opt to attend the rcs.[8] however, simply changing the place where learning happens will not be sufficient to shift behaviour among our medical graduates. and, of course, only a relatively small percentage of our students have the opportunity to spend more than 4 6 weeks a year at a rural or community site. if we wish to ensure that all of our graduates emerge as agents for change, equipped to strengthen our health system, then we recognise the need to critically consider what it is that they are being taught. a comprehensive review of the medical curriculum[9] was, therefore, undertaken with surmepi, specifically focusing on aspects of: public health; health systems research;[10] evidencebased healthcare;[11] and infection prevention control.[12] importantly, this study, with its series of substudies, has already impacted on the curriculum in significant ways, ensuring exposure of all medical students to these key issues. surmepi has also been active within communities to advance health systems and outcomes. dramowski et al.[13] describe a quality improvement project to strengthen infection prevention control, while goliath and colleagues[14] focus on an assessment of capacity-building needs among rural health managers. the role of technology in all of our activities has been key. reaching both students and communities through the electronic communication systems that are now available to us will be essential to ensuring a health system that is stable. an additional focus in this special edition, therefore, is on the role and uptake of podcasting among our student population.[15,16] as this tenure of mepi draws to a close, there is strong focus among the 13 medical schools in ssa that received awards, as well as their african and us partners, to provide an account of how the funding has been utilised and what the outputs have been. the two final articles in this edition provide insight into this work, drawing in voices from the broader mepi community, specifically focusing on evaluating cbe activities and offering thoughts on how this might best be done.[17,18] it is now time to ask critical questions, and for those of us within mepi to reflect on whether or not we have been good custodians of that which has been granted. what have we learnt as a result of having access to resources that have enabled us to enhance our educational practices? to what extent has this strengthened the health systems within which our graduates must function? how do we ensure better patient outcomes for all? most importantly, how do we share what has been learnt in a scholarly, evidencebased manner? in 2011, greysen et al.[19] published a review of medical education in ssa, in which they acknowledged the significant developments in the field, also identifying a number of challenges within the system, and the need for more targeted research, particularly in certain neglected areas. while we recognise that this edition does not address all of the issues raised in that article, we do believe that this work will contribute to strengthening medical education as a field of inquiry. acknowledgements. funding from the stellenbosch university rural medical education partnership initiative (surmepi), which is supported by the us president’s emergency plan for aids relief (pepfar) through health resources and services administration (hrsa) under the terms of t84ha21652, is gratefully acknowledged. susan van schalkwyk guest editor: surmepi supplement african journal of health professions education scvs@sun.ac.za medical education to strengthen health systems in africa: mepi as a catalyst for change may 2015, vol. 7, no. 1, suppl 1 ajhpe 69 references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/s01406736(10)61854-5] 2. de villiers m, moodley k. innovative strategies to improve human resources for health in africa: the surmepi story. afr j health professions educ 2015;7(1 suppl 1):70-72. [http:/dx.doi.org/10.7196/ajhpe.503] 3. moodley k, fish t, naidoo s. the role of socially accountable universities in improving the selection of medical students from rural and underserved areas. afr j health professions educ 2015;7(1 suppl 1):76-78. [http:/dx.doi. org/10.7196/ajhpe.504] 4. fish t, lourens g, meyer l, muller j, conradie h. when the clinic is not yet built ... the avian park service learning centre story. afr j health professions educ 2015;7(1 suppl 1):79-80. [http:/dx.doi.org/10.7196/ ajhpe.506] 5. van schalkwyk s, bezuidenhout j, conradie h, et al. ‘going rural’: driving change through a rural medical education innovation. rural and remote health 2014;14(2493). 6. daniels-felix d, conradie h, voss m. choosing final-year placement: why students decide not to go rural. afr j health professions educ 2015;7(1 suppl 1):111-114. [http:/dx.doi.org/10.7196/ajhpe.508] 7. voss m, coetzee j, conradie h, van schalkwyk s. ‘we have to flap our wings or fall to the ground.’ the experiences of medical students on a longitudinal integrated clinical model. afr j health professions educ 2015;7(1 suppl 1):119-124. [http:/dx.doi.org/10.7196/ajhpe.507] 8. van schalkwyk s, kok n, conradie h, van heerden b. academic achievement of final-year medical students on a rural clinical platform: can we dispel the myths? afr j health professions educ 2015;7(1 suppl 1):115-118. [http:/dx.doi.org/10.7196/ajhpe.513] 9. dudley l, young t, rohwer a, et al. fit for purpose? a review of a medical curriculum and its contribution to strengthening health systems in south africa. afr j health professions educ 2015;7(1 suppl 1):81-85. [http:/ dx.doi.org/10.7196/ajhpe.512] 10. mukinda f, goliath c, willemse b, dudley l. equipping medical graduates to address health system challenges in south africa: an expressed need for curriculum change. afr j health professions educ 2015;7(1 suppl 1):86-91. [http:/dx.doi.org/10.7196/ajhpe.511] 11. rowher a, willems b, young t. taking stock of evidence-based healthcare in the undergraduate medical curriculum at stellenbosch university: combining a review of curriculum documents and input from recent graduates. afr j health professions educ 2015;7(1 suppl 1):98-104. [http:/dx.doi.org/10.7196/ajhpe.501] 12. dramowski a, marais f, willems b, mehtar s. does undergraduate teaching of infection prevention and control adequately equip graduates for medical practice? afr j health professions educ 2015;7(1 suppl 1):105-110. [http:/ dx.doi.org/10.7196/ajhpe.500] 13. dramowski a, marais f, goliath c, mehtar s. impact of a quality improvement project to strengthen infection prevention and control training at rural healthcare facilities. afr j health professions educ 2015;7(1 suppl 1):7379. [http:/dx.doi.org/10.7196/ajhpe.499] 14. goliath c, mukinda f, dudley l. capacity-building needs assessment of rural health managers: the what and the how ... afr j health professions educ 2015;7(1 suppl 1):92-97. [http:/dx.doi.org/10.7196/ajhpe.510] 15. walsh s, de villiers m. enhanced podcasting for medical students: progression from pilot to e-learning resource. afr j health professions educ 2015;7(1 suppl 1):125-129. [http:/dx.doi.org/10.7196/ajhpe.505] 16. de villiers m, walsh s. how podcasts influence medical students’ learning: a descriptive qualitative study. afr j health professions educ 2015;7(1 suppl 1):130-133. [http:/dx.doi.org/10.7196/ajhpe.502] 17. bailey r, baingana rk, couper id, et al. evaluating community-based medical education programmes in africa: a workshop report. afr j health professions educ 2015;7(1 suppl 1):140-144. [http:/dx.doi.org/10.7196/ajhpe.475] 18. dreyer a, couper i, bailey r, talib z, ross h, sagay as. identifying approaches and tools for evaluating community-based medical education programmes in africa. afr j health professions educ 2015;7(1 suppl 1);134-139. [http:/dx.doi.org/10.7196/ajhpe.568] 19. greysen sr, dela dovlo e, olapade‐olaopa o, jacobs m, sewankambo n, mullan f. medical education in sub‐saharan africa: a literature review. med educ 2011;45(10):973-986. [http://dx.doi.org/10.1111/j.13652923.2011.04039.x] afr j health professions educ 2015;7(1 suppl 1):68-69. doi:10.7196/ajhpe.628 editorial research 192 october 2014, vol. 6, no. 2, suppl 1 ajhpe khan and o’rourke[1] consider enquiry-based learning (ebl), sometimes called inquiry-based learning (ibl), as a broad overarching term used to describe studentcentred learning approaches driven by enquiry. ebl forms part of a family of approaches such as case-based and problem-based learning (pbl).[2,3] these approaches, especially pbl, are widely used in medical and allied health curricula to enhance problem solving, critical thinking and self-directed learning skills in both undergraduate and postgraduate students.[4,5] pbl has been widely used in undergraduate physiotherapy programmes,[6] but the utilisation of ebl is less documented.[1,7] ebl is a learning approach that inspires students to be self-directed learners engaged in problem solving of realistic scenarios and often complex problems.[2,4,5] it may entail small-scale investigations, projects that result in products for industry or research-based projects which are assessed.[1] it may be used to facilitate learning and completion of a singular task, as an approach for a module, or incorporated into traditional curricula, and therefore be referred to as hybrid ebl. this approach has been reported in different fields such as engineering, nursing and dentistry.[5] hutchings[8] encourages the use of ebl approaches if a deep level of engagement with complex problems is required. it has been hypothesised that multifaceted problems will force students to work creatively, to grapple with differing views and find novel solutions, or to come to the realisation that the loop of enquiry remains ongoing and solutions are often elusive.[1,8] jackson[9] considers ebl a vehicle to prepare graduates for continually expanding and changing information by teaching them skills on how to acquire and appraise knowledge for a particular purpose rather than content only. although pbl and ebl have similar attributes, ebl is considered more advanced where students are empowered to take ownership of their learning, thereby fostering a deeper level of engagement.[2] in contrast with pbl, there has been no structured process described for ebl.[3] similarities have been noted in the roles of lecturers that facilitate learning rather than the source of knowledge.[7] in ebl an enquiry begins with a general theme to trigger learning and may take the form of a reallife scenario or stimulus question, for which there is usually no known answer.[10] students have to identify what resources they need to solve the problem and embark on a journey of constant questioning, problem solving and seeking evidence-based and relevant solutions.[6] facilitators in ebl provide guidance to students on the learning process rather than content knowledge. this may take the form of coaching students on how to pose researchable questions, how to access and critically appraise information, and how to reflect on the progressive development of the students’ own enquiry skills.[1,10] facilitators are encouraged to model effective enquiry themselves and promote opportunities for reflection on learning.[10] student engagement is further enhanced in ebl by the synthesis and creation of new knowledge.[1] it has been hypothesised that the synthesis of new information results in deeper learning.[2] group work is the mainstay of enquiry-driven approaches, but students may also do self-directed background. physiotherapy students in their final year at stellenbosch university (su) complete a module that follows an enquiry-based learning (ebl) approach. this module exposes them to higher-order problem solving and was developed to facilitate independent self-directed learning and improved higher-order thinking skills. objective. to describe the perceptions of undergraduate physiotherapy students on the impact of this ebl approach on their learning. methods. a cross-sectional descriptive study was conducted with three consecutive cohorts of final-year undergraduate physiotherapy students. a questionnaire was used to obtain information related to the students’ perception of this module. coding and identification of themes were done independently using an inductive approach. initial themes were compared and discussed to achieve consensus regarding the final themes reported. results. students reported the development of skills such as the ability to source relevant information and problem-solving abilities. students attributed improvements in their clinical reasoning and performance during clinical work to the skills they developed during this module. the main themes identified as barriers to learning during this module were availability of learning materials, quality assurance and time constraints. group work was identified as both a facilitator and a barrier to their learning. conclusion. physiotherapy students at su perceived the introduction of a module following an ebl approach positively. they developed skills such as sourcing information and problem-solving, which they perceived improved their clinical work. the main barriers to learning were time constraints and concerns regarding quality assurance of learning material. group work was regarded as both facilitatory and a barrier to learning. programmes considering the implementation of ebl should ensure sufficient resource material and that quality assurance mechanisms are in place to address students’ anxiety regarding learning material. guidance and support to students during the initial implementation phase of an ebl approach are necessary to allay fears and frustrations. ajhpe 2014;6(2 suppl 1):192-197. doi:10.7196/ajhpe.532 what does an enquiry-based approach offer undergraduate physiotherapy students in their final year of study? g inglis-jassiem, msc (physio); s b statham, msc (physio); s d hanekom, phd division of physiotherapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: g inglis-jassiem (gakeemah@sun.ac.za) research october 2014, vol. 6, no. 2, suppl 1 ajhpe 193 individual study and utilise a wide range of information sources to tackle the problems, such as research articles and web-based information sources.[1] assessment in ebl could be formative or summative in nature and might be completed by facilitators and/or peers. facilitators may provide feedback on the quality of questions, the depth of study or nature of information sourced. peer feedback may be useful to identify problems in collaborative learning and communication within groups.[10] summative assessment could entail a research report or product for industry. palmer[11] reports on the successful use of written and oral presentations where psychology students presented their research of self-selected topics to the class. students following an ebl approach report satisfaction with their training, better retention of knowledge, deeper understanding of subject matter and the ability to apply their skills in solving new and complex scenarios.[7,12] the collaborative nature of small-group learning in ebl facilitates the development of teamwork, communication and leadership skills. it has been reported that an ebl approach is suited to the development of interpersonal and social skills.[13] cairncross[14] considers these transferable skills prerequisites for successful professional careers. in addition, kahn and o’rourke[1] highlight the many advantages that ebl poses for contemporary issues in higher education related to the goals for student learning. some of these include preparing graduates for employability, and the development of skills and personal attributes to ensure lifelong learning. small-group teaching approaches are often staff, resource and time intensive.[7] the literature recommends that staff and students should be supported when embarking on ebl, especially during the transition phase between other more traditional pedagogies.[1] the complexity of the clinical scenarios faced by physiotherapy students in the real world necessitates higher-order problem solving and clinical reasoning. students are required to work as first-line practitioners on graduation. the ability to solve complex problems and develop new understanding of an ever-changing multidimensional healthcare context are necessary skills to help students to function independently as healthcare practitioners on entry to the physiotherapy profession. ebl – as progression to pbl – has been identified as a strategy that could facilitate students’ transition to this higher-order thinking and level of functioning. the aim of this paper is to describe the perceptions of undergraduate physiotherapy students on the impact of this ebl approach on their learning. context a hybrid curriculum was implemented in 2007 in the division of physiotherapy, stellenbosch university (su). the curriculum consists of 2 years of didactic teaching in basic sciences and physiotherapy modules followed by a pbl approach in the third year and ebl in the final year. the aim of these two modules is to provide students with the opportunity to integrate knowledge, techniques and concepts covered during the two foundational years within the context of pathology, personal circumstances of patients and healthcare structures. this level of integration is essential for clinical reasoning. the ebl module consists of five complex cases spread over the academic year. these cases are facilitated by academic staff over a 3-week period with contact sessions once per week. students work clinically for the rest of the week. the whole class or smaller groups may attend contact sessions. various stimulus activities are used at the start of cases, e.g. clinical guidelines, videos or clinical records of patients. students complete self-directed research and/or group work to source, appraise and synthesise information in an attempt to solve the complex ebl case scenarios. assessments entail individual and group tasks. the final product may be a pamphlet or an educational talk in a community setting. tables 1 and 2 provide information regarding the various cases and how each was assessed. methods a cross-sectional descriptive study was conducted. ethical clearance was obtained from the su health research ethics committee (n08/10/301). participants were assured of confidentiality and all provided written informed consent. the project was conducted with three consecutive cohorts of final-year physiotherapy students from 2008 to 2010. a questionnaire was designed to obtain information on the perception of students of the ebl approach. this paper reports on the two open-ended questions students were posed regarding facilitators to their learning and barriers to their learning. all the data were collected after implementation of the module. the questionnaire was completed during scheduled class time before the final assessment opportunity. responses were typed in microsoft word (ss) and coded by the research team (ss, sh, gij). coding and identification of themes were done independently by two researchers in the team using an inductive approach. initial themes were compared and discussed to achieve consensus regarding the final themes. table 1. outcome of fourth-year module following an ebl approach by the end of this module, the student will be able to: • integrate the theoretical concepts and principles of the biomedical sciences (e.g. pharmacology, pathology); social sciences (psychology, sociology) within the concept of physiotherapy practice (client management) • have a sound knowledge of the medical and surgical management of the client, as well as disease processes applicable to physiotherapy intervention • understand the role of the other team members in the total management of the patient • have basic knowledge of diagnostic tests (e.g. chest x-ray, mri, blood gases, etc.) and understand their impact on patient management • execute evaluation techniques skilfully, with the necessary adaptations, on a model • interpret the findings of an evaluation, formulate a physiotherapeutic diagnosis/hypothesis and prioritise problems • motivate the choice of selected physiotherapeutic interventions and/or the different approaches that can be followed in the management of patients • execute physiotherapeutic interventions skilfully, with the necessary adaptations, on a model • set specific, measurable, realistic aims that are attached to a time scale • source and critically appraise relevant subject literature pbl = problem-based learning; ebl = enquiry-based learning; mri = magnetic resonance imaging. research 194 october 2014, vol. 6, no. 2, suppl 1 ajhpe results all final-year students were invited to participate over the 3-year period of this study. questionnaire response rates were 85% (n=35/41) in 2008, 86% (n=37/43) in 2009 and 89% (n=41/46) in 2010. facilitators to learning the main themes identified in this category were skills development, collaborative learning, impact on clinical reasoning, and integration across modules. all three cohorts commented on the development of additional skills with the new learning approach (table 3). feedback centred on the ability to source relevant information, solve clinical problems and critical appraisal of literature. students attributed improvements in their clinical reasoning and performance in clinical work to skills developed during the ebl module. comments reflected an improved ability to problem solve with patients. they felt empowered to source information and follow similar steps in critical appraisal of information. improved patient outcomes were attributed to their ability to assess patients more holistically and develop relevant management plans. a few comments described how this module facilitated integration of theoretical and practical components across modules. some students found the collaborative learning of group work enjoyable and insightful in terms of self-knowledge and getting to know their peers. they appreciated peers as colleagues and sources of knowledge with new insights. they enjoyed working together and learned to value different opinions. however, there were students who experienced group work as a barrier. barriers to learning the barriers to learning were availability of learning materials, concerns regarding the quality of sourced information, time constraints and group work (table 4). some students experienced difficulty in sourcing relevant literature. students were particularly concerned about the quality of information and felt insecure about the accuracy and relevance of information received from peers. lack of lecturer-developed hand-outs remained a source of anxiety for students and left many frustrated. preparation for assessments was particularly daunting. table 2. ebl module content – information related to cases diagnosis or clinical context stimulus given at start of case assessment (final product) head injuries (hi) direct observation of patients with hi (different clinical presentations) scientific written task on evidence-based physiotherapy management of patients with hi intensive care unit (icu) records of patients admitted and managed in icu development of a patient assessment form to facilitate evidence-based practice in icu whiplash clinical guidelines for the management of whiplash-associated disorders (wad) group presentations on evidence-based physiotherapy management of wad headaches evidence-based physiotherapy management of headaches educational talk at community health centre on prevalence, pathogenesis and physiotherapy management of headaches guillain-barré syndrome (gbs) video of patients with gbs (psychosocial impact and prognosis) educational pamphlet on role of physiotherapy in gbs ebl = enquiry-based learning. table 3. student feedback related to additional skills development with implementation of ebl approach sub-theme quotes source information ‘improved my ability to research for evidence based information & my ability to interpret that information.’ ‘this module, as difficult as it was to adapt to, gave us the skills to problem solve and find resources by ourselves to find out more about things.’ problem solving/clinical reasoning ‘we learnt a lot about research & how to base your rx (treatment) on evidence, this enables you to ensure that you are effective.’ ‘i learnt to think more practically and to research and have evidence-based arguments/knowledge with treatment of my patients. clinical reasoning rather than “parrot learning” of theory is more important.’ life skills ‘learnt to be strong.’ ‘achieving knowledge and practical skills. learned how to be responsible when made student facilitator.’ ‘taught me not only physiotherapy skills but life skills as well.’ critical appraisal of information ‘helped me to source appropriate information and analyse information.’ ‘criticising research.’ independent learning ‘learn to help yourself and source information on your own.’ ‘was responsible for own progress.’ scientific writing skills ‘improved scientific writing.’ ebl = enquiry-based learning. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 195 there were many comments related to time management. students indicated not having sufficient time to prepare for contact sessions, to source and appraise information, or to study and consolidate learning. they ascribed it to a full academic programme and commitments to other modules, especially clinical work. some students focused more on assessment activities such as the completion of the final product than the process of learning. dysfunctional groups with diverse personalities or lacking in cooperation reported more negative comments related to group work. some students were unhappy if group members delivered poor quality work and did not meet agreed expectations. discussion we found that three cohorts of final-year physiotherapy students consistently reported the development of skills, such as enhanced clinical reasoning, integration across modules, and collaborative learning as facilitators to learning attributed to an ebl approach. barriers to learning included time constraints, group work and anxiety due to the lack of lecturer-developed learning material. ebl has become increasingly popular as a teaching and learning approach in health education in recent years.[5] the reported benefits of an ebl approach are many and include improved understanding of evidence-based practice, use of information resources, and enhanced critical thinking skills and clinical reasoning.[2,5] koh et al.[13] believe that an enquirydriven approach to learning results in the development of interpersonal and life skills. improvement in transferable skills such as interpersonal communication skills and holistic patient management was observed in physiotherapy students exposed to ebl.[4] the students in our study reported similar development in skills related to research, as well as personal growth. khan and o’rourke[1] advocate ebl as an approach to develop many key transferable skills needed for lifelong learning. the inclusion of an ebl module in our final year of the physiotherapy programme at su offers unique opportunities to hone these skills in a classroom environment and could extend to clinical placements. it has been reported that, although students enjoy ebl,[15] these approaches do not directly lead to improved management of clinical cases in comparison to conventional curricula.[7,12] gunn et al.[4] reported that physiotherapy students exposed to this approach demonstrated increased knowledge and client-centeredness which correlated with positive selfdirected learning behaviours. the student’s level of maturity, learning approach and motivation were key factors that influenced how different individuals performed and coped.[4] although the students in our cohort partly ascribed their improved clinical reasoning to the new ebl module, it needs to be corroborated by other sources such as the clinical supervisors who facilitate their learning on clinical placements. understanding why certain students in our cohort found an ebl approach challenging needs table 4. student feedback related to facilitators of and barriers to learning facilitators of learning quotes clinical reasoning ‘i found it easier to get a holistic picture of the patient and as a result plan and implement a treatment plan for the patient.’ ‘you had a much better ability to adapt in the clinical setting as the cases were focused but you had to adapt what you had to your own patients.’ ‘my clinical reasoning and skills improved a lot and by the end of the year problem solving was much easier. this will help me in future with patient management.’ group work ‘it was fun to consult with colleagues and challenge the ideas to ultimately get to the best solution.’ ‘we learnt a lot from each other and got to know each other at other levels.’ barriers to learning quotes availability of learning materials ‘was sometimes difficult to source the correct references.’ ‘everything must be evidence based, but for certain topics no best evidence articles could be found (pubmed).’ ‘not getting info from other groups regarding the topic being researched; only researching a small aspect of the topic.’ ‘the information you receive depends on other students. everyone is not as motivated to perform well.’ ‘we did not receive well-compiled information sheets or learning material.’ ‘there were no notes provided which was a barrier to the learning process.’ quality assurance of learning materials ‘we did not receive feedback on the information we sourced, so we did not know whether what we read and what we are supposed to do is the same.’ ‘no real control over the correlation of information between groups.’ ‘everyone’s information was not necessarily the same.’ time constraints ‘sometimes time (clinical, research, social, sport) was limited.' ‘time management of clinical and applied physiotherapy cases, as well as researching the first semester.’ ‘spending too much time at individual task and none at understanding cases as a whole.’ ‘it feels as if i spent 80% of my time sourcing literature instead of learning.’ group work ‘not always easy to work in groups with diverse personalities.’ ‘group members not doing their work/not supplying enough information.’ ‘lack of enthusiasm from some group members.’ research 196 october 2014, vol. 6, no. 2, suppl 1 ajhpe further study. we are in agreement with gunn et al.[4] that mechanisms should be implemented to identify and support students who have difficulty applying ebl principles during clinical work, and therefore we need to investigate what strategies might be best suited to our context. the implementation of the ebl approach at su was not without challenges and student feedback has highlighted areas that need further consideration. our students’ perception that the open-ended nature of the enquiry cycle was daunting and anxiety-provoking is well documented in the literature. we reflected on whether students were adequately prepared for independent study and if they had received the necessary guidance to develop these skills. simons and ertmer[16] highlight that students who are supported through scaffolding and preparation tend to perform better and are able to transfer their problem-solving strategies more effectively. one could argue that students in the final year have skills and experience to deal with ebl as a result of the third-year pbl module. training students to source literature coincided with the start of pbl and research methodology modules, where critical appraisal was a key learning outcome. we anticipated that the pbl module would facilitate collaborative learning and the skills needed for more complex scenarios. pbl supporters argue that students familiar with pbl who are exposed to a novel problem, are often better problem solvers because of their experience with the steps involved. in contrast, kirwan and adams[5] found that students exposed to ebl for the first time, found it challenging to adjust and had to adapt learning styles and time management. srinivasan et al.[7] argue that senior students who have developed some context for their work would cope better with open enquiry. however, the more structured and guided enquiry in our pbl module may still provide insufficient preparation for advanced independent enquiry. dahlgren and dahlgren[15] reported that preprofessional students engaged in pbl were especially frustrated by the ambiguity of facilitation and unsure of the correct amount of information to source. it could be argued that our cohort were exposed to pbl in their third year and should have grappled and subsequently resolved some of these issues. based on the findings of this study, our students continue to experience similar frustrations with the ebl module, especially with the lack of resources and not trusting the quality of information gathered by peers. bruder and prescott[17] are adamant that students’ prior knowledge and understanding influence their performance in ebl. preconditions such as personality and learning style, exposure to group and independent work, and experiences with different learning strategies influence the success of learning situations.[15] this could explain why some of our students, who were grappling with basic concepts and knowledge gaps, coped less well with ebl, since it requires flexible application of prior knowledge and personal learning strategies. students who perform poorly in foundation courses, especially the pbl module, might experience the ebl module as more challenging. one could argue that management of time to source, appraise and synthesise appropriate information would be challenging for these students too; this is an additional motivation for students seeking lecturerdeveloped notes or reassurance about the quality of information. srinivasan et al.[7] see feedback on the process of enquiry as essential to the development of higher-order reasoning skills. an ebl approach becomes less effective when facilitators are inflexible and do not model enquiry behaviour during contact sessions.[17] according to ashby et al.,[2] students new to ebl tend to have difficulty with the transition from traditional teaching and learning to a more self-directed approach to learning. this experience could be ascribed to the preparedness and willingness to change, of both lecturers and students. ebl facilitators are encouraged to create a safe space for peer interaction, to probe skilfully and make sense of students’ ideas, and to guide and support students to question assumptions and challenge one another’s viewpoints.[15] students need to receive feedback on their progress during an ebl module to progressively develop these enquiry skills. to optimise the learning experience during our ebl module, one needs to reflect on how students may gain abilities in self-regulation to work successfully as individuals and in groups.[15] ashby et al.[2] warn faculty wishing to adopt ebl to plan well, consider logistical management (especially resources like time) and to support students during the transition phase. our advice to prospective users of this approach is to encourage students to set ground rules, to manage group dynamics proactively and timeously, to facilitate enquiry in terms of how to phrase questions, and offer support to students in information appraisal. the challenge remains as to the most suitable support to offer in the learning process. academic staff requires support through professional development to hone facilitation skills and enhance feeling comfortable with the open-ended nature of ebl.[15] student feedback was collected prior to the final assessment to obtain more objective reflection of the module and its impact on learning. another strength is that the data were collected for three cohorts of students. the data only reflect the perceptions of students at a single institution and this can limit the generalisability of findings. however, the data provide some insight into students’ perceptions of ebl. programmes considering the implementation of ebl should ensure sufficient resource material and time for students to engage in group discussion to enhance understanding and synthesis. quality assurance mechanisms should be implemented to address students’ anxiety about learning material. student preparation for the module should include reflection on learning strategies. support during the initial implementation phase of an ebl approach is necessary to allay fears and frustrations of both staff and students. conclusion based on findings of this study we conclude that physiotherapy students responded positively to ebl. they developed skills such as sourcing information and problem solving which they perceived improved their clinical work. the main barriers to learning were time constraints and concerns regarding quality assurance of learning material. group work was regarded as both facilitatory and a barrier to learning. programme designers could use perceptions of our cohorts when planning an ebl module. whether this approach is more effective in developing self-directed learners with higher-order thinking skills than other learning approaches will need to be established. author contributions. gij, sdh and sbs were all part of the original project team. sbs developed the questionnaire as part of the su physiotherapy programme monitoring and evaluation project and gij administered the questionnaires to students. gij drafted this manuscript but all authors consent to the publication and contributed to: (i) conception, design, analysis and interpretation of data; (ii) drafting or critical revision for important intellectual content; and (iii) approval of the version to be published. acknowledgements. we would like to thank the final-year physiotherapy students who contributed to this project for their active participation in the module and for sharing their experiences. research october 2014, vol. 6, no. 2, suppl 1 ajhpe 197 references 1. kahn p, o’rourke k, eds. understanding enquiry-based learning. in: handbook of enquiry and problem based learning. galway: celt; 2005. www.aishe.org/readings/2005-2/chapter1.pdf (accessed october 2014) 2. ashby j, hubbert v, cotrel-gibbons l, et al. the enquiry-based learning experience: an evaluation project. nurse educ pract 2006;6(1):22-30. [http://dx.doi.org/10.1016/j.nepr.2005.05.008] 3. mahony mj, wozniak h, everingham f, reid b, poulos a. inquiry based teaching and learning: what’s in a name? in: learning for an unknown future. proceedings of the 26th herdsa annual conference, christchurch, new zealand, 6-9 july 2003: http://www.herdsa.org.au/wp-content/uploads/conference/2003/papers/herdsa34.pdf (accessed october 2014). 4. gunn h, hunter h, haas b. problem based learning in physiotherapy education: a practice perspective. physiotherapy 2012;98(4):335-340. [http://dx.doi.org/10.1016/j.physio.2011.05.005] 5. kirwan a, adams j. students’ views of enquiry-based learning in a continuing professional development module. nurse educ today 2009;29(4):448-455. [http://dx.doi.org/10.1016/j.nedt.2008.09.003] 6. morris j. how strong is the case for the adoption of problem-based learning in physiotherapy education in the united kingdom? med teach 2003;25(1):24-31. 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[http://dx.doi.org/10.2304/plat.2002.2.2.82] 12. castro-sánchez am, encarnación m, aguilar-ferrándiz me, et al. problem based learning approaches to the technology education of physical therapy students. med teach 2012;34(1):e29-e45. [http://dx.doi.org/10.3109/0142 159x.2012.638011] 13. koh gc, khoo he, wong ml, koh d. the effects of problem-based learning during medical school on physician competency: a systematic review. cmaj 2008;178(1):34-41. [http://dx.doi.org/10.1503/ cmaj.070565] 14. cairncross s. special session enhancing graduate attributes through research-teaching linkages. 39th annual frontiers in education conference: imagining and engineering future cset education, fie 2009, 18 21 october 2009. [http://dx.doi.org/10.1109/fie.2009.5350783] 15. dahlgren ma, dahlgren l. portraits of pbl: students’ experiences of the characteristics of problem-based learning in physiotherapy, computer engineering and psychology. instructional science 2002;30(2):111-127. [http://dx.doi.org/10.1023/a:1014819418051] 16. simons kd, ertmer pa. scaffolding disciplined inquiry in problem-based learning environments. international journal of learning 2005;12(6). www.edci.purdue.edu/ertmer/docs/simons_lc05.pdf (accessed 10 october 2014). 17. bruder r, prescott a. research evidence on the benefits of ibl. zdm int j math educ 2013;45(6):811-822. [http://dx.doi.org/10.1007/s11858-013-0542-2] editorial december 2017, vol. 9, no. 4 ajhpe 161 in her 2009 inaugural editorial for ajhpe, vanessa burch[1] described the status of healthcare in africa as being in a ‘desperate situation’ and argued that a response would be the strengthening and extending of existing training platforms, which, among others, would facilitate the emergence of a cadre of high-quality educators for the continent. it was into this space that she and her editorial team at the time envisaged a journal that would provide exposure for scholarship being produced in africa. such scholarship would speak to our unique context and challenges, and offer opportunities for both experienced and emerging educators to contribute to building a body of literature in health professions education (hpe). as i engaged with the different articles that comprise the final 2017 edition of ajhpe, 8 years after the first edition, i was struck by the depth and breadth of the work that is being showcased. it bears testimony to the way in which the journal has indeed become an important platform for scholarly endeavour in the field, and there is much to celebrate. it is clear that our research is not only keeping abreast of global trends, including innovative approaches to teaching with technology, strengthening assessment practices, and encouraging interprofessional approaches to education and collaborative care, but it is also responding to local imperatives in resourceconstrained contexts, often in creative ways. the student voice emerges strongly in these articles, and there is an interesting mix of methodologies being employed. the publications emanate from scholars located in both rural and urban contexts in botswana, ghana, south africa, uganda and zimbabwe, and speak to undergraduate and postgraduate work, in the fields of human nutrition, medicine, nursing, occupational therapy, physiotherapy and radiography. notwithstanding this positive picture, critical reflection as to the extent to which our work is influencing both our practice and thinking, and possibly also practice and thinking elsewhere in the developing world, is important. how has the scholarship that has been published in ajhpe over the past years contributed to transforming hpe, and to what extent has it been responsive to the challenges that burch[1] posed for us at the genesis of the journal’s existence? are we building on what others have done before us, and is this work finding traction in our classrooms and in our teaching? of course, these questions are pertinent far beyond ajhpe. van der vleuten and driessen[2] have previously challenged the sector to consider what hpe would look like if the evidence that is currently being generated was ‘taken seriously’. would this be reflected in how we teach and how learning happens? in this edition of ajhpe, the evidence on offer takes various forms. increasingly, for example, there have been calls to extend clinical training platforms beyond the traditional academic hospital. joubert and louw[3] describe how clinicians at these sites are experiencing and responding to this shift in practice. the distributed approach is also mirrored in many community-based education (cbe) initiatives. ndlovu et al.[4] place the spotlight on opportunities for learning during a cbe attachment for occupational therapy and physiotherapy students in zimbabwe. another key theme from maree et al.[5] relates to enhancing collaborative approaches to care, as curriculum developers grapple with designing responsive interventions. continuity of care is the educational principle underpinning a course requirement for nursing science students, investigated by modiba.[6] jooste and frantz[7] explore the importance of academic leadership, particularly self-leadership, from the perspective of a group of senior academics from within and outside hpe. their article offers insights into a complex set of preferred competencies for such leadership. the medical elective features twice in this edition. while caldwell et al.[8] discuss the elective as an opportunity for a unique educational experience, danso-bamfo and a group of international colleagues[9] qualitatively explore the experiences of ghanaian students on an elective abroad. several articles offer practical guidance for enhancing educational practices. the importance of reliability and validity in the assessment of student learning is addressed by mubuuke et al.[10] mwandri et al.[11] and siwela and mawera[12] employ statistical analyses to motivate for the use of a ‘low-cost’ approach to simulation-based training and innovative approaches to teaching anatomy, respectively. pillay[13] picks up the potential of current technology and the use of ‘selfies’ to foster student engagement. finally, current debates with regard to the need for radical curriculum transformation are problematised by witthuhn and le roux,[14] specifically in the context of postgraduate studies in the arena of public health. indeed, a rich matrix of perspectives and insights. earlier this year, ajhpe changed its look and added the tagline: ‘scholarship of africa for africa’. it is exciting to see how the research included in this edition embodies this ideal. our ongoing endeavour should be to generate ever-more robust evidence to strengthen what we do. either way, let’s be sure to take our work seriously. s van schalkwyk centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa scvs@sun.ac.za 1. burch vc. does africa need another journal? afr j health professions educ 2009;1(1):2. 2. van der vleuten cpm, driessen ew. what would happen to education if we take education evidence seriously? perspect med educ 2014;3(3):222-232. https://doi.org/10.1007/s40037-014-0129-9 3. joubert s, louw vj. clinical undergraduate medical student training at kimberley hospital, northern cape, south africa: ‘a test of fire’. afr j health professions educ 2017;9(4):180-184. https://doi.org/10.7196/ajhpe.2017.v9i4.836 4. ndlovu t, chikwanha tm, munambah n. learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment. afr j health professions educ 2017;9(4):189-193. https://doi.org/10.7196/ajhpe.2017.v9i4.958 5. maree c, bresser p, yazbek m, et al. designing interprofessional modules for undergraduate healthcare learners. afr j health professions educ 2017;9(4):185-188. https://doi.org/10.7196/ajhpe.2017.v9i4.853 6. modiba lm. experiences of south african student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery. afr j health professions educ 2017;9(4):194-198. https://doi. org/10.7196/ajhpe.2017.v9i4.730 7. jooste k, frantz j. self-leadership traits of academics to conform to a changing higher-education environment. afr j health professions educ 2017;9(4):199-202. https://doi.org/10.7196/ajhpe.2017.v9i4.823 8. caldwell ri, inglis ac, morgan m, rasmussen k, aldous c. the medical elective: a unique educational opportunity. afr j health professions educ 2017;9(4):162-163. https://doi.org/10.7196/ajhpe.2017.v9i4.883 9. danso-bamfo s, abedini na, mäkiharju h, et al. clinical  electives at the university of michigan from the perspective of ghanaian medical students: a qualitative study. afr j health professions educ 2017;9(4):203-207. https://doi.org/10.7196/ajhpe.2017.v9i4.827 10. mubuuke ag, mwesigwa c, kiguli s. implementing the angoff method of standard setting using postgraduate students: practical and affordable in resource-limited settings. afr j health professions educ 2017;9(4):171-175. https://doi.org/10.7196/ajhpe.2017.v9i4.631 11. mwandri m, walsh m, frantz j, delport r. the use of low-cost simulation in a resource-constrained teaching environment. afr j health professions educ 2017;9(4):168-170. https://doi.org/10.7196/ajhpe.2017.v9i4.829 12. siwela r, mawera g. medical students’ perspectives on the anatomy course at the university of zimbabwe. afr j health professions educ 2017;9(4):176-179. https://doi.org/10.7196/ajhpe.2017.v9i4.822 13. pillay jd. selfies 2015: peer teaching in medical sciences through video clips – a case study. afr j health professions educ 2017;9(4):164-167. https://doi.org/10.7196/ajhpe.2017.v9i4.803 14. witthuhn j, le roux cs. factors that enable and constrain the internationalisation and africanisation of master of public health programmes in south african higher education institutions. afr j health professions educ 2017;9(4):208-211. https://doi.org/10.7196/ajhpe.2017.v9i4.839 afr j health professions educ 2017;9(4):161. doi:10.7196/ajhpe.2017.v9i4.1033 scholarship for africa: are we taking it seriously enough? this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:scvs@sun.ac.za https://doi.org/10.1007/s40037-014-0129-9 https://doi.org/10.7196/ajhpe.2017.v9i4.836 https://doi.org/10.7196/ajhpe.2017.v9i4.958 https://doi.org/10.7196/ajhpe.2017.v9i4.853 https://doi.org/10.7196/ajhpe.2017.v9i4.730 https://doi.org/10.7196/ajhpe.2017.v9i4.730 https://doi.org/10.7196/ajhpe.2017.v9i4.823 https://doi.org/10.7196/ajhpe.2017.v9i4.883 https://doi.org/10.7196/ajhpe.2017.v9i4.827 https://doi.org/10.7196/ajhpe.2017.v9i4.631 https://doi.org/10.7196/ajhpe.2017.v9i4.829 https://doi.org/10.7196/ajhpe.2017.v9i4.822 https://doi.org/10.7196/ajhpe.2017.v9i4.803 https://doi.org/10.7196/ajhpe.2017.v9i4.839 research may 2016, vol. 8, no. 1 ajhpe 69 clinical, scientific and interpersonal skills have been recognised as important components of the dental curriculum. good interpersonal skills enhance studentto-patient relationships.[1,2] communication is one of the salient skills in clinicians’ relationship with patients. it is an element that is often overlooked and underemphasised, both at dental school and in continuing education.[3] dental students at the university of the western cape (uwc), cape town, south africa (sa) are thoroughly trained to provide dental treatment to their patients during their undergraduate programme; however, little time is spent on teaching and learning basic communication skills. at this institution the emphasis is directed towards ensuring that students are competent clinicians. however, the literature shows that the ability to communicate effectively with patients is crucial; the better communicators we are, the better clinicians we will become.[2,3] a communication course for dental students at uwc would be necessary to improve dental student communication. the inclusion of a communication course has human resource implications; the course has to be designed, taught, assessed and evaluated. the success of curricular change requires faculty buy-in and consensus.[3] being confronted with a paradigm shift in dental education can create uncertainty and resistance among faculty.[4] embedding a communication course in the undergraduate dental curriculum at the uwc dental school would require the support of all teaching staff and clinical teachers. therefore, the purpose of this research was twofold: (i) to explore perceptions; and (ii) to create awareness among clinical teachers with regard to dental student communication. methods ethical clearance for the research was obtained from the dental faculty ethics committee, uwc (reference 13/4/36). written consent was obtained from all participants. a sequential mixed-methods research design was chosen. this research was conducted at the uwc dental faculty in 2013. first, qualitative data were collected from a focus group discussion with dental clinical teachers (n=5). during this discussion, the clinical teachers were asked to give their opinions on how students communicate and empathise with patients; if and how a communication skills course should be included in the undergraduate curriculum; possible education strategies to improve dental communication between students and patients; and involvement of faculty in future communication education. data from the interview guided the development of the questionnaire used in the second phase of the survey. quantitative data were collected from this phase of the survey. surveymonkey, an  online cloud-based survey tool (usa), was used to distribute the survey to all fulland part-time clinical teachers (n=57). closed and open-ended questions were used in the survey. data were entered on a microsoft office excel 2010 spreadsheet, descriptive data analysis was applied to the closed-ended questions, and common themes were identified. results thirty-five percent of clinical teachers (n=20) completed the questionnaire. thirty-seven percent of the respondents had 11 15 years of clinical teaching experience, 58% were female and 79% were full-time employees at uwc. forty-two percent were between the ages of 31 and 40 years, 26% between 51 and 60 years, and only 11% <30 years. background. dental students are extensively trained to provide dental treatment to their patients during the undergraduate programme. however, no or little time is spent on the training of basic communication skills. embedding a communication course in the curriculum would require support of the teaching staff and clinical teachers. objective. to explore the perceptions of the clinical teachers with regard to the teaching and learning of dental student communication. methods. the study had a two-phase, sequential, exploratory, mixed-methods research design. the first phase explored the lecturers’ perceptions of dental student-patient communication by means of a focus group interview (n=5). findings were used to develop the questionnaire for the second phase. the survey was distributed to 57 clinical teachers using the online surveymonkey system (usa). results. sixty-three percent rated dental student-patient communication as good. all the respondents thought communication skills should be included in the dental curriculum. of the total, 47% strongly agreed that students wish to continue with their work and not attend to communication. of the clinical teachers, 47% strongly agreed that they need training on how to communicate and assess communication skills. sixty-eight percent strongly agreed that developing and teaching a communication module should be shared among faculty staff. conclusion. clinical teachers agreed that communication skills training and clinical assessment in the dental curriculum are important. the study raised awareness among faculty members about the importance of communication skills and ensured initial buy-in for the development of such a course. afr j health professions educ 2016;8(1):69-71. doi:10.7196/ajhpe.2016.v8i1.571 the way forward with dental student communication at the university of the western cape, cape town, south africa r maart,1 bchd, mphil (higher education); k mostert-wentzel,2 mphyst, mba, phd 1 department of prosthetics, faculty of dentistry, university of the western cape, cape town, south africa 2 department of physiotherapy, faculty of health sciences, university of pretoria, south africa corresponding author: r maart (rmaart@uwc.ac.za) research 70 may 2016, vol. 8, no. 1 ajhpe sixty-three percent rated dental student communication with patients as good, although 47% strongly agreed that students just want to ‘get on with the work’ and that they see patients as quotas; a definite lack of empathy with patients was observed. although only 53% strongly agreed that communication skills can be taught, 63% often commented on the student-to-patient communication during clinical supervision of students. forty-seven percent strongly agreed that communication skills with patients should form part of the education of the clinical assessment. all of the respondents indicated that communication skills should be included in the dental curriculum in future. sixty-four percent suggested that communication skills should be taught during the 2nd and 3rd years, while 26% suggested that these skills should be taught throughout the 5-year dental curriculum (fig. 1). the majority of respondents (84%) agreed that video-recording of student-topatient communication and case discussions should be included as teaching methods in the communication skills course. the recommended education strategies are shown in fig. 2. forty-seven percent of clinical teachers agreed that they need training on how to communicate and assess communication skills effectively. furthermore, 68% strongly agreed that developing and teaching a communication module should be shared among faculty members and not become the responsibility of one department only. the findings need to be interpreted with caution, in light of the limited participation of departments in the focus group discussion and the low response rate for the questionnaire. discussion the objective of this study was to explore the perceptions of clinical teachers with regard to dental student communication and its teaching and learning. the sample included clinical teachers with regard to years of experience, clinical field of interest, gender, and age, and working mostly full time. from the findings of the survey it is clear that the clinical teachers agree that dental student-to-patient communication is important. although the majority were of the opinion that students already demon strate good communication skills, a lack of empathy with patients was observed. the ability to convey messages clearly to patients, listen, be observant and respond to patients’ needs, empathise, understand and carry out consultations in an organised and a professional manner are considered basic requirements of a competent dentist.[1] the clinical teachers agreed that a communication skills module should be included in the future dental curriculum. they suggested that such a course be embedded throughout the curriculum; the objective of this strategy would be to align what is taught and assessed. the inclusion of communication-related topics in a dental curriculum was also favoured in a study by woelber et al.[5] and cannick et al.[6] the integration ladder in curriculum planning has been accepted as an important educational strategy in medical education and can be used as an aid to planning, implementing and evaluating the medical curriculum.[7] the higher one is on the integration ladder, the more important communication and joint planning between teachers become, requiring greater participation by staff.[7] the results have suggested video-recordings and case discussions as educational strategies to teach communication in the dental curriculum. educational strategies tend to vary in type and duration between studies, but those used appear to be similar, involving a mixture of didactic episodes and clinical scenarios.[8] if the purpose of education is to provide students with appropriate skills, the lecture-only approach in many dental schools is not sufficient. active practice is necessary to learn communication skills.[9] role-playing was highlighted as a possible teaching strategy, which corresponds to findings from woelber et al.[5] and rider and keefer.[10] the latter suggest rolemodelling as a teaching strategy to be explored formally in the communication skills of modules and informally by all clinical teachers. the use of simulated patients who are skilled at presenting complex clinical conditions, monitoring students’ performance, and delivering specific feedback are components of a communication skills course.[11] clinically relevant scenarios enable students to develop skills such as problem-solving, increased knowledge of referral processes, and awareness of ethical/legal issues.[11] evidence from studies that used video-reviewing for learning and assessment supported its use, and it was well received by the majority of students. only the student and patient need to be present for the consultation, which might minimise the feeling of ‘unreality’ of scenarios when one is simultaneously observed by peers, as reported by some students.[8] in addition to including such a course, clinical teachers have nevertheless admitted that they require training in teaching and assessing communication skills. faculty development can be a powerful tool in initiating and setting the direction for curricular change.[3] bylund et al.[12] showed that teaching and encouraging facilitators can lead to positive outcomes when training students in communication skills. a foundation for future staff participation during curriculum develop ment and integration was established by engaging clinical teachers during the focus group interviews and participating in the questionnaire. faculty buyin and participation in curricular change are essential in any academic context and therefore need to be prioritised. curriculum planners often initiate and plan curriculum changes without consultation with the faculty members responsible for the implementation. this topdown approach is frequently met by faculty resistance; therefore, we recommended that faculty buy-in and participation in curriculum change are considered as viable alternative strategies. embedding communication into the undergraduate curriculum has an effect on human resources. faculty members developing the course need to include teaching and assessment of this aspect, as a new course adds to the work load. human resource planning needs to form part of the curriculum planning process to ensure that the desired educational outcome is achieved. fig. 1. participants’ response with regard to where in the curriculum communication skills should be taught. 1st year 2nd year 3rd year other 11% 32% 32% 26% 90 80 70 60 50 40 30 20 10 0 vi de o r ec or di ng s ro le -p lay in g ca se d isc us sio ns le ct ur es sh ow -d ote ll ot he r % fig. 2. participants’ response (%) with regard to which teaching methods should be included in the teaching of communication skills. research may 2016, vol. 8, no. 1 ajhpe 71 conclusion from the results of this study it is apparent that the clinical teachers agree that effective communication skills are important in dental student training and should be included in the curriculum. the study demonstrated a way of raising awareness in the faculty about the importance of communication skills and ensured initial buy-in for the development and integration of such a communication course. after this study, embedding communication throughout the dental undergraduate curriculum, and implementation and evaluation thereof, are recommended. acknowledgements. the authors thank mrs y erasmus for her assistance with the data collection. we also acknowledge the sub-saharan african foundation for advancement of international medical education and research (faimer) regional institute (safri) for its support. references 1. gonzalez m, abu kasim n, naimie z. soft skills and dental education. eur j dent educ 2013;17(2):73-82. [http:// dx.doi.org.10.1111/eje.12017] 2. abu kasim nh, abu kassim nl, razak aa, et al. pairing as an instructional strategy to promote soft skills amongst clinical dental students. eur j dent educ 2014;18(1):51-57. [http://dx.doi.org/10.1111/eje.12058] 3. steinert y, cruess s, cruess r, et al. faculty development for teaching and evaluating professionalism: from programme design to curriculum change. med educ 2005;39:27-136. 4. spallek h, o’donnell j, yoo y. preparing faculty members for significant curricular revisions in a school of dental medicine. j dent educ 2010;74(3):75-288. 5. woelber j, deimling d, langenbach d, et al. the importance of teaching communication in dental education: a survey amongst dentists, students and patients. eur j dent educ 2012;16(1):e200-e204. 6. cannick f, horowitz a, garr d, et al. use of the osce to evaluate brief communication skills training for dental students. j dent educ 2007;71(9):1203-1209. 7. harden r. the integration ladder: a tool for curriculum planning and evaluation. med educ 2000;34:551-557. 8. carey j, madill a, manogue m. communications skills in dental education: a systemic research review. eur j dent educ 2010;14:69-78. [http://dx.doi.org.10.1111/j.1600-0579.2009.00586.x] 9. yoshida t, milgrom p, coldwell s. how do us and canadian dental schools teach interpersonal communication skills? j dent educ 2002;66(11):1281-1288. 10. rider e, keefer c. communication skills competences: definitions and a teaching toolbox. med educ 2006;40:624-629. [http://dx.doi.org/10.1111/j.1365-2929.2006.02500.x] 11. hannah a, millicahamp j, ayers k. a communication course for undergraduate dental students. j dent educ 2004;68(9):970-977. 12. bylund c, brown r, lubrano di ciccone b, et al. training faculty to facilitate communication skills training: development and evaluation of a workshop. patient educ couns 2008;70:430-436. [http://dx.doi.org.10.1016/j.pec.2007.11.024] article 6 december 2011, vol. 3, no. 2 ajhpe introduction the faculty of health sciences (fhs) at stellenbosch university (su) offers undergraduate programmes for several disciplines. all these programmes need clinical supervisors to teach undergraduate students in the clinical settings. although most clinical teachers are enthusiastic and take their role as teachers of future generations of healthcare professionals seriously, they often lack knowledge of educational principles and teaching strategies and thus may be inadequately prepared for this additional professional role.1,2 according to the literature it is clear that clinicians do not become teachers by virtue of their medical expertise, but a reflective approach to teaching and professional development can foster excellence in clinical teaching.3 due to new methods of teaching and learning, a more student-centred approach to teaching, competency-based assessment and emphasis on aspects such as professionalism, educators today are required to have an expanded toolkit of teaching skills and clinical experience.4 staff development can provide clinicians with new knowledge and skills about teaching and learning and it can also reinforce or alter attitudes or beliefs about education.3,5 increasingly educational providers require their clinical teachers to undertake some form of basic teacher training.2 these training programmes might differ from informal short courses to master’s or doctoral degrees in health sciences education. research shows that the act of teaching facilitates an improved level of knowledge for the teacher compared to self-study or lecture attendance. furthermore, it revealed that residents’ job satisfaction is augmented by teaching duties.6 a short course in clinical supervision was designed and implemented at the faculty of health sciences as an attempt to increase the standard of clinical supervision of undergraduate students. the faculty does not have the resources to present different clinical supervision courses for each discipline; therefore a short course with an interdisciplinary focus was designed. the course consists of one contact session of 8 hours where a study guide is provided for self-study. within 6 weeks of attending this contact session students have to submit an assignment reflecting on a recently performed clinical supervision session. a certificate is awarded after the completion of the course. the awarding of continuous professional development (cpd) points on completion of the course serves as an additional incentive. the course covers topics such as the roles of the clinical educator; how adults learn; learning in a clinical environment; techniques of facilitating learning, assessment and feedback to students. after the first course was presented a qualitative study was done to determine the strengths and weaknesses of the course in order to re-curriculate if deemed necessary. methods semi-structured individual interviews were held with 10 (n=16) course participants (supervisors) as well as the five lecturers involved in the development of the course. the course participants that were interviewed were purposively sampled with reference to the clinical sites where they worked; e.g. hospitals, private practices or community health centres, their years of experience, professions as well as their availability. none of the participants has done any formal courses in education before. amongst them were five occupational therapists (n=6), four physiotherapists (9) and one medical doctor (n=1). the years of teaching students in the clinical areas ranged between 1 and 21 years, with most of them less than 3 years. the semi-structured interviews were done by an independent person at the clinical sites of the course participants and lasted about 1 hour each. some of the questions that were explored during the interviews were participants’ motivation to do the course; whether the assignment was relevant; use of new teaching skills after the course and confidence when teaching. the interviews were recorded and the transcribed data were improving undergraduate clinical supervision in a south african context e archer faculty of health sciences, university of stellenbosch correspondence to: elize archer (elizea@sun.ac.za) abstract objectives: the faculty of health sciences, stellenbosch university, has undergraduate programmes for several disciplines; these programmes need clinical supervisors to teach their students in the clinical settings. the faculty does not have the resources to present different clinical supervision courses for each discipline; therefore a short course with an interprofessional focus was designed. design: a qualitative study was done to determine the strengths and weaknesses of the course in order to re-curriculate as deemed necessary. semi-structured individual interviews were held with 10 (n=18) course participants as well as the tutors involved in the development of the course. ethical approval was obtained. participation was voluntary and anonymity was guaranteed. the recorded and transcribed data were analysed. setting: the health professionals acting as supervisors may be the experts in their fields, but they do not always have the necessary teaching skills. the centre for health sciences education (chse) at the faculty has developed a generic short course in undergraduate clinical supervision to address the above issue. results and conclusion: the data were used to inform restructuring of the short course for the following year. the impact of this short course on clinical supervisors was that their interaction with students in the clinical setting improved. there was unanimous support for extending the short course to all clinical supervisors. the lecturers involved in developing the course were positive about the interprofessional cooperation among colleagues and students. they emphasised that the faculty of health sciences has an obligation to provide opportunities for clinical supervisors to improve their skills to supervise students. article analysed by the researcher as well as a second health sciences educator. the data were coded and recurring themes were identified. ethical approval was obtained for the study. participation was voluntary and anonymity was guaranteed. results key themes that emerged from the interviews are presented below. (some of the quotations from participants that are used in the section below were translated from afrikaans to english.) motivation to attend the short course supervisors attended the course for various reasons, for example they felt inadequately equipped when they had to supervise students. felt lost when supervising the students. some of them were new to student supervision while one was interested in furthering an academic career. the motivational impact of cpd points can also not be disregarded. the cpd points were a good motivator to work through the course. applicability of the course to the clinical context the content of the course seemed to be appropriate to the needs of the course participants. their confidence to transfer the new teaching skills varied from being ready to implement new teaching techniques immediately to a more cautious approach where more information was required. especially the teaching techniques that were discussed were valuable, i think i can use them next time. usefulness of the short course’s study guide supervisors reported that they have read almost all the prescribed articles, which they found sufficient. only two participants read some of the recommended literature. most of them agreed that they preferred a hard copy study guide with all the notes and articles rather than electronic access to the same. i like to make notes on the hard copies. relevance of the assignment all the participants reported the relevance of the assignment with reference to their context and that completing the assignment assisted them in thinking clearly about how they were fulfilling their role as supervisors. i thought the assignment was relevant; it made you think a bit outside the box and what other teaching methods i could also use. some supervisors felt encouraged in realising that their teaching skills were often in line with recommended strategies. improved interaction with students interaction with the students and insight into the student/supervisor relationship were markedly improved. it was clear that some of the supervisors did not always follow a structured approach to clinical teaching. i use to wing things as i went along, but now i have a structured plan for the clinical rotation. almost all of the supervisors indicated that they now make use of teaching strategies that they have never used before. re-currriculation the half-day course was changed to a full day after the participants recommended that they would have preferred more time for the discussion of the topics. detailed guidelines for the assignment were included in the study guide after the participants requested more specific instructions. did not completely understand what was needed for the assignment. lecturers’ general opinions the lecturers involved in the design and presentation of the course were very enthusiastic about the course. they were all positive about the interdisciplinary cooperation amongst colleagues and students. they emphasised that the faculty has an obligation to provide opportunities for clinical supervisors to improve their skills to supervise students and to have a better understanding of adult learning. i think it is very unfair of universities to expect outside people to assist with the teaching of students without assisting them. discussion the participants who attended the course were of the opinion that this short course is vitally important in our institution if we want the quality of clinical supervision to improve in the clinical areas. this opinion is in line with other studies done with healthcare providers.6 the participants’ motivation to attend the short course was mainly intrinsic; supervisors who have a passion for their work were keen to attend and further their knowledge. as far as faculty development is concerned, the challenge lies in the process of convincing all clinical supervisors of undergraduate students to attend this course. for teachers to succeed at their teaching tasks, faculty development is essential.4 although cpd points can be an added motivator, ironically most of the motivated supervisors seem to have earned their quota of cpd points even before they attended the course. there could have been a degree of bias in the study group firstly because they do not represent all professions, and secondly because it could be that those who attended the course may be more enthusiastic about teaching than those who did not attend the course. the technique used in this study to evaluate the course participants’ improvement in teaching skills, namely self-reflection, is not regarded as a very rigorous evaluation method, according to post et al.,7 and future studies looking at this same issue would attempt to use more rigorous methods such as direct observation and videotape of the participants before and after the course. the majority of participants who were interviewed for the research had less than 3 years’ teaching experience. one could therefore argue that young clinical supervisors still have a lot to learn. it would be recommended that in a next research study more senior lecturers/clinicians be interviewed and asked the same questions. in a critical review of residents-as-teachers curricula it is suggested that a study population of 40 residents from all training years should be used to give a study enough power to show a significant effect of the teaching intervention.7 according to bursari et al.8 the development of teacher-training programmes is a rather complicated issue, mainly because of logistical problems such as irregular working hours, and the support of important stakeholders such as training boards and cooperation of staff. when designing such a course it is vital to ensure that the content and length of the course are very specific to the needs of the supervisors. in a critical review that was done to determine the most evidence-based curricula and 7 december 2011, vol. 3, no. 2 ajhpe article 8 june 2011, vol. 3, no. 1 ajhpe8 december 2011, vol. 3, no. 2 ajhpe evaluation strategy used in residents’ curricula it was found that the mean length of the teaching courses was 7.6 hours and that the most common intervention was based on the one-minute preceptor.8 in our course we included the one-minute preceptor9 as well as other teaching methods/ techniques to address the teaching needs of the variety of professions all attending the same course. course participants reported in their feedback that the interprofessional nature of the course was refreshing and that the teaching strategies that were discussed would be applicable to their different contexts. due to the fact that the course consists only of one contact day it seems very important that the study guide has to provide the course participants with all the relevant information. the assignment at the end of the course needs to have clear instructions and be relevant in order to empower the supervisors for their clinical teaching opportunities. some of the course participants reported that having to do reflection about a teaching intervention in to write up the assignment was valuable in the sense that they had to stop and think what they were doing. the presentation of the course in an interprofessional manner seems to have many advantages, amongst others the realisation that supervisors from different professions share common challenges and frustrations regarding the teaching of students. conclusions demonstrating that a particular supervisory intervention has a direct effect on patient/client care is extremely difficult. consequently researchers have attempted to examine the effects of supervisor on the trainee/ student.10 our study is an example of the perceptions of supervisors about their teaching skills and behaviours after attending a short course in clinical supervision. some of the pronounced quantitative evidence in the literature shows that supervision can have an effect on patient outcome and that the lack of supervision is harmful to patients. clinical supervision with input from a supervisor seems to facilitate skills development more rapidly than unsupervised clinical sessions.7 there was unanimous support from all the course participants to extend the short course to all clinical supervisors. if this is not done supervisors could be inclined to apply the same teaching methods which they experienced when they were undergraduate students. however, teaching workshops can provide clinicians with new knowledge and skills about teaching and learning .3,4 this study adds to the body of knowledge in this field by confirming the need for faculty development of clinical supervisors in our south african context. a follow-up study that is currently being undertaken is looking at the impact of the course, including supervisors’ behaviour before and after the course as well as students’ feedback regarding the teaching strategies of the clinical supervisors. acknowledgements a word of appreciation to the interdisciplinary course development team as well as to m van heusden for conducting the interviews and proofreading this article. the research was funded by the fund for innovation and research into learning and teaching (firlt) stellenbosch university, south africa. references 1. wilkerson l, irby dm. strategies for improving teaching practices: a comprehensive approach to faculty development. acad med 1998;73:387-396. 2. steinert y. staff development for clinical teachers. clinical teacher 2005;2:104110. 3. godfrey j, dennick r, welsh c. training the trainers: do teaching courses develop teaching skills? med educ 2004;38:844-847. 4. ramani s, leinster s. amee guide nr 34: teaching in the clinical environment. medical teacher 2008;30:347-364. 5. hays r. developing as a health professional educator: pathways and choices. the clinical teacher 2007;4:46-50. 6. skeff km, stratos ga, mygdal w, et al. faculty development: a resource for clinical teachers. j gen intern med 1997:12: s56-s63. 7. post re, quattlebaum rg, benich jj. residents-as-teachers curricula: a critical review. acad med 2009;84(3):374-380. 8. bursari jo, scherpbier ajja, van der vleuten cpm, essed ggm. a two-day teacher training programme for medical residents: investigating the impact on teaching ability. adv health sci educ 2006:11:133-144. 9. neher j, gordon, kc, meyer b, stevens n. a five steps ‘microskills’ model of clinical teaching. j am board fam pract 1992;5:419-424. 10. weiss v, needlman r. to teach is to learn twice: residents teachers learn more. arch pediatr adolesc med 1998:152:190-192. editorial september 2017, vol. 9, no. 3 ajhpe 91 health professions are anchored in the education and training that underpin them; such training continues to evolve with support from the growing evidence base.[1] health professions education (hpe) focuses on the theories, principles, concepts, methods, skills and attitudes specifically required for the education and training of health professionals within the specific learning environment of hospitals or communities. hpe also aims at encouraging the application of educational principles in the unique context of health professions and healthcare settings. the aforementioned reasons typically differentiate hpe from more general educational training. in developed and developing countries, greater variety in skills within health professions is needed if healthcare is to be made accessible to all.[1] furthermore, to be able to contribute to the advancement of the different health professions, today’s health professionals have to be highly skilled and knowledgeable in a number of competencies.[2] this implies that health professionals must be educated and trained to the required high standards to address the ever-dynamic community health needs. improving the quality of training is, therefore, an important contribution to strengthening health systems.[3] however, such improvement in training needs to be supported by good evidence-based practices that are feasible, especially in institutions with limited resources. there is a global drive to expand the numbers and competencies of health professionals being trained in response to societal needs.[4] in addition, major reforms and innovations are taking shape in the field of hpe.[1] such reforms include student-centred learning, interprofessional education, community-based education, competency-based education, e-learning and service-learning.[5,6] to implement these reforms, faculty in health professions training institutions not only need to improve the existing training methods, but also innovate other feasible methods to improve training by means of evidence-based scholarly approaches. ajhpe has had a strong tradition of publishing scholarly original research and reviews related to improving the training and performance of health professionals, using evidence-based practices. in this issue, the use of scholarly evidence to improve the education and training of health professionals as well as strengthening existing systems resonates through all the articles, which can generally be grouped into three over-arching themes. the first theme is about enhancing the learning environment, which is reflected in a number of articles. for example, the article by westmore land et al.[7] examines the improvement of the learning environment and wellness of trainee regis trars to prevent burnout and exhaustion, while urimubenshi et al.[8] explore solutions from students’ perceptions on how to improve their learning environment. the article by jacobs and venter[9] speaks to improving the clinical learning environment using standardised patient simulation. dlungwane et al.[10] and idon et al.[11] explore means of improving the learning environment of post graduate trainees. the important idea of using feedback to improve the clinical learning environment of students is also discussed in this issue. the second theme relates to improving skills and competencies of student trainees to address the prevailing needs. a key factor is the need to identify gaps within the skills and competencies of health professionals and design appropriate training interventions using an evidence-based approach. for example, the articles by van der merwe et al.,[12] sanders et al.[13] and koch et al.[14] indicate skills gaps and appropriate training interventions to enhance trainee skills. the last theme in the current issue is the value attached to community-based education, which in hpe has been reported to be an excellent mechanism of promoting service-learning[15] and stimulating the interest of students to work in rural and under-served areas.[16] this is reflected through aspects of community-based training and how it can be improved to promote a more positive student experience. therefore, the scholarly research work in this edition of ajhpe demonstrates that improving the training of health professionals can indeed be fanned by an evidence-based foundation. in africa, many institutions have adopted and adapted teaching and learning approaches from europe and the usa. taking on these approaches, as a whole, has proved to be a challenge owing to our own systemic and contextual differences. therefore, while external forces may drive evidence-based practice in hpe, there is a need for individual institutions to generate local evidence of what works best through scholarly and empirical inquiry. this will fuel and sustain innovations in hpe in africa. g mubuuke school of medicine, college of health sciences, makerere university, kampala, uganda gmubuuke@gmail.com 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 2. bhutta za, lassi z, pariyo g, huicho l. global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. geneva: global health workforce alliance, 2010. 3. hung w. all pbl starts here: the problem. interdiscipl j problem-based learn 2016;10(2). https://doi. org/10.7771/1541-5015.1604 4. xue h, qian j,  wang l,  et al. 3c3r modified pbl pediatric teaching of chinese medical students. plos one 2013;8(5):1-9. https://doi.org/10.1371/journal.pone.0063412 5. amoako-sakyi d, amonoo-kuofi h. problem-based learning in resource-poor settings: lessons from a medical school in ghana. bmc med educ 2015;15:221. https://doi.org/10.1186/s12909-015-0501-4 6. burch vc, sikakana cnt, yeld n, seggie jl, schmidt hg. performance of academically at-risk medical students in a problem-based learning programme: a preliminary report. adv health sci educ 2007;12(3):345-358. https://doi. org/10.1007/s10459-006-9006-6 7. westmoreland kd, lowenthal erd, finalle r, et al. registrar wellness in botswana: measuring burnout and identifying ways to improve wellness. afr j health professions educ 2017;9(3):98-102. https://doi.org/10.7196/ ajhpe.2017.v9i3.881 8. urimubenshi g, songa j, kandekwe f. assessment of the education environment of physiotherapy students at the university of rwanda using the dundee ready educational environment measure (dreem). afr j health professions educ 2017;9(3):103-106. https://doi.org/10.7196/ajhpe.2017.v9i3.828 9. jacobs a, venter i. standardised patient-simulated practice learning: a rich pedagogical environment for psychiatric nursing education. afr j health professions educ 2017;9(3):107-110. https://doi.org/10.7196/ajhpe.2017.v9i3.806 10. dlungwane t, voce a, searle r, wassermann j. understanding student early departure from a master of public health programme in south africa. afr j health professions educ 2017;9(3):111-115. https://doi.org/10.7196/ajhpe.2017. v9i3.793 11. idon pi, suleiman ki, olasoji ho, mustapha z, abba hm. postgraduate trainees’ perceptions of the learning environment in a nigerian teaching hospital. afr j health professions educ 2017;9(3):116-122. https://doi. org/10.7196/ajhpe.2017.v9i3.786 12. van der merwe b, kruger sb, nel mm. radiation safety requirements for training of users of diagnostic x-ray equipment in south africa. afr j health professions educ 2017;9(3):123-127. https://doi.org/10.7196/ajhpe.2017.v9i3.691 13. sanders j, makasa m, goma f, kafumukache e, ngoma ms, nzala s. a quick needs assessment of key stakeholder groups on the role of family medicine in zambia. afr j health professions educ 2017;9(3):94-97. https://doi. org/10.7196/ajhpe.2017.v9i3.831 14. koch ggv, swindon ld, pillay jd. training requirements for the administration of intravenous contrast media by radiographers: radiologists’ perspective. afr j health professions educ 2017;9(3):128-132. https://doi.org/10.7196/ ajhpe.2017.v9i3.809 15. mubuuke ag, oria h, dhabangi a, kiguli s, sewankambo nk. an exploration of undergraduate medical students’ satisfaction with faculty support supervision during community placements in uganda. rural remote health 2015;15(4):3591. 16. crampton pes, mclachlan jc, illing jc. a systematic literature review of undergraduate clinical placements in underserved areas. med educ 2013;47(10):969-978. https://doi.org/10.1111/medu.12215 afr j health professions educ 2017;9(3):91. doi:10.7196/ajhpe.2017.v9i3.1002 strengthening health professions education and training: the power of evidence-based approaches this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.7771/1541-5015.1604 https://doi.org/10.7771/1541-5015.1604 https://doi.org/10.1371/journal.pone.0063412 https://doi.org/10.1186/s12909-015-0501-4 https://doi.org/10.1007/s10459-006-9006-6 https://doi.org/10.1007/s10459-006-9006-6 https://doi.org/10.7196/ajhpe.2017.v9i3.881 https://doi.org/10.7196/ajhpe.2017.v9i3.881 https://doi.org/10.7196/ajhpe.2017.v9i3.828 https://doi.org/10.7196/ajhpe.2017.v9i3.806 https://doi.org/10.7196/ajhpe.2017.v9i3.793 https://doi.org/10.7196/ajhpe.2017.v9i3.793 https://doi.org/10.7196/ajhpe.2017.v9i3.786 https://doi.org/10.7196/ajhpe.2017.v9i3.786 https://doi.org/10.7196/ajhpe.2017.v9i3.691 https://doi.org/10.7196/ajhpe.2017.v9i3.831 https://doi.org/10.7196/ajhpe.2017.v9i3.831 https://doi.org/10.7196/ajhpe.2017.v9i3.809 https://doi.org/10.7196/ajhpe.2017.v9i3.809 https://doi.org/10.1111/medu.12215 research 104 may 2016, vol. 8, no. 1, suppl 1 ajhpe poor learning strategies are among the factors responsible for the high failure rate of 1st-year students.[1] non-cognitive factors must be taken into account to facilitate academic success.[2] motivation is a prominent factor, which is linked to positive academic outcomes and associated with psychological wellbeing.[3] motivation is one of the central constructs in understanding academic performance and influencing learning strategies. students with higher motivation levels are more attentive and engaged in their learning than those with lower levels of motivation.[4] the former may be viewed as self-regulated students with a higher degree of independent engagement in their learning processes. self-regulation has been defined as the ‘mindful capacity to plan, guide and monitor one’s behaviour flexibly according to changing circumstances and is considered as vital for autonomous and adaptive functioning’.[5] therefore, self-regulated learners tend to be cognitively, emotionally and behaviourally involved in their learning processes.[6] among medical students, high motivation was linked to high academic performance in both the preclinical and clinical years and to health-related extracurricular activities.[7] although these results are supported by other studies,[8-10] contradictory findings, related to lack of association between academic performance and motivation, have also been published.[11] lack of motivation or amotivation has also been found to be one of the important barriers to learner achievement and performance.[12] therefore, factors that enhance motivation need to be investigated. motivation is understood to be triggered by intrinsic or extrinsic factors. intrinsic motivation refers to a person’s actions being influenced by an internal state – a self-determined form of motivation.[13] external motivation, in contrast, is influenced by external sources, e.g. an anticipated reward. both intrinsic and extrinsic forms of motivation have been found to be positively associated with adjustment to university.[13] consequently, students who are well adjusted experienced a sense of belonging within the university, did not feel overwhelmed by the amount of work, and performed well academically.[7] much research on motivation has been done in general education, but in medical education such research has been limited.[7] while there are many instruments to measure motivation and learning strategies, most of these, including the well-known motivated strategies for learning questionnaire (mslq),[14] have been designed in settings in western countries. use of the mslq in health professions education is also limited. hence, the objective of this study was to assess the mslq and its association with the academic performance of a diverse group of 1st-year medical students. methods all 1st-year medical students at the nelson r mandela school of medicine (nrmsm), university of kwazulu-natal (ukzn), durban, south africa were invited to participate. a total of 200 questionnaires were distributed; 165 students (83%) consented to completing the questionnaire. the summative end of semester academic results of the only two compulsory academic modules involving all 1st-year students (becoming a professional and basic science) were obtained from the faculty of medicine. ethics approval and gatekeeper permission were obtained from ukzn’s human social sciences research ethics committee (hss/0119/013d). instrument the research instrument contained 95 items, with nominal and ordinal levels of measurement. it comprised two sections, i.e. a demographic section and the mslq.[7] the demographic section consisted of 14 items related to gender, age, type of school (urban v. rural), attendance of peer-mentoring background. most instruments, including the well-known motivated strategies for learning questionnaire (mslq), have been designed in western homogeneous settings. use of the mslq in health professions education is limited. objective. to assess the mslq and its association with the academic performance of a heterogeneous group of 1st-year medical students. methods. eighty-three percent of 1st-year medical students consented to participate in this quantitative study. the mslq consisted of a motivation strategies component with six subscales, while the learning strategies component had nine subscales. demographic and academic achievement information of the students was also collected. stata version 13 (statacorp lp, usa) was used for the statistical analyses of all data. results. female students displayed significantly higher motivational scores. students with prior educational experience and those who attended peermentoring sessions had significantly higher learning strategy scores. significant but moderate relationships were found between academic performance and the motivation strategies subsumed within the categories ‘task value’ and ‘self-efficacy for learning performance’. in terms of the ‘learning strategy component’, ‘critical thinking’, and ‘time and study environment’, the composite score was significantly but poorly correlated to academic performance. conclusion. overall, limited correlations were found between the mslq scores and academic performance. further investigation of the use of the mslq and its association with academic achievement is recommended, with greater focus on specific learning events than on course outcomes. this study highlights the importance of evaluating an instrument in a specific context before accepting the findings of others with regard to the use of the instrument and its correlation with academic performance. afr j health professions educ 2016;8(1 suppl 1):104-107. doi:10.7196/ajhpe.2016.v8i1.757 motivated strategies for learning and their association with academic performance of a diverse group of 1st-year medical students s hamid, bsocsc, bsocsc hons, ma, phd; v s singaram, bmedsc, mmedsc, phd clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: s hamid (shaista.saib@gmail.com) research may 2016, vol. 8, no. 1, suppl 1 ajhpe 105 sessions, attendance of study skills sessions and degree choice. the mslq had 81 items.[14] this validated scale assesses motivation and self-regulated learning strategies, as illustrated in table 1. data analysis stata version 13 (statacorp lp, usa) was used for analysis of all the data.[15] reliabi lity was measured using cronbach’s α, which determines the internal consistency or average correlation of items in a survey instrument to gauge its internal validity. continuous variables were first inspected using the shapirowilk and shapiro-francia tests for normality to determine which statistical tests were appropriate for the data. the data that were found to be normally distributed were analysed using parametric tests. non-parametric tests were employed for data that were not normally distributed. for normally distributed data, the two independent samples t-test was used to compare mean composite scores for two independent groups. a one-way analysis of variance (anova) was used for categorical independent variables (three or more categories) and a normally distributed interval-dependent variable (composite scores of learning strategy) to test for differences in the means of the dependent variable broken down by the levels of the independent variable. otherwise, non-parametric equivalent tests were used. with regard to scoring of the mslq, students rated themselves on a 7-point likert scale from 1 (not at all true of me) to 7 (very true of me). scales were constructed by taking the mean of the items that comprise that scale, e.g. intrinsic goal orientation (igo) has four items. an individual’s score for igo was computed by adding the four items and dividing the total by the number of items to obtain an average score. results table 1 depicts the reliability and descriptive sta tistics obtained for the mslq. the reliability statistics for the mslq displayed fair to good internal validity. most of the sections have a reliability score that is close to or exceeds the recommended value of 0.7. this indicates an overall degree of acceptable, consistent scoring of items within each construct. analyses of relationship between demographic characteristics, academic performance and motivation as illustrated in table 2, statistically significant differences were found between male and female students in the composite score for motivation (p=0.03). based on the rank sum (7 814) and expected rank sum (8 466) scores, female students had much higher scores than males. no other statistically significant relationships were found between student characteristics and motivation. task value, self-efficacy for learning perfor mance and test anxiety (inversely) correlated significantly with both modules (table 3). igo and control of learning beliefs correlated significantly but poorly with the becoming a professional module. the composite score for motivation and other subscales had limited correlation with the academic performance in both modules. table 1. reliability and descriptive statistics for the mslq (n=165) mslq scales mean (sd) cronbach’s α motivation strategies intrinsic goal orientation (4 items ) 5.01 (1.07) 0.60 extrinsic goal orientation (4 items) 5.75 (1.04) 0.62 task value (6 items) 5.71 (0.97) 0.80 control of learning beliefs (4 items) 5.44 (1.03) 0.51 self-efficacy for learning and performance (8 items) 5.22 (1.04) 0.88 test anxiety (5 items) 4.42 (1.32) 0.68 learning strategies rehearsal (4 items) 5.01 (1.22) 0.64 elaboration (6 items) 5.12 (1.14) 0.80 organisation (4 items) 5.16 (1.28) 0.71 peer learning (3 items) 3.98 (1.61) 0.72 critical thinking (5 items) 4.26 (1.30) 0.77 metacognitive self-regulation (12 items) 4.67 (0.97) 0.77 time and study environment (8 items) 4.53 (0.96) 0.55 effort regulation (4 items) 4.97 (1.27) 0.58 help-seeking (4 items) 3.87 (1.27) 0.56 sd = standard deviation. table 2. comparison between composite score for motivation and demographics: mann-whitney u-test (n=165)* test statistics student characteristics n rank sum expected rank sum z-score p-value gender male 63 5 881 5 229 2.190 0.03 female 103 7 814 8 466 geographical area of high school urban 92 7 481 7 636 −0.509 0.61 rural 73 6 214 6 059 medical degree first or second choice first 142 11 710 11 786 0.358 0.72 second 23 1 985 1 909 satisfied with the current degree choice yes 159 13 210.5 13 117.5 0.891 0.37 no 5 319.5 412.5 student has a previous degree yes 21 1 944.5 1 732.5 1.045 0.3 no 143 11 585.5 11 797.5 attended study skills sessions yes 36 2 959 2 970 −0.044 0.97 no 128 10 571 10 560 attended peermentoring sessions yes 135 11 551 11 205 1.464 0.14 no 30 2 144 2 490 *the n-score will vary, depending on the number of responses received for each factor. research 106 may 2016, vol. 8, no. 1, suppl 1 ajhpe correlational analyses of learning strategies independent sample t-test results in table 4 depict that having obtained a previous degree and attending peer-mentoring sessions were found to be statistically significantly correlated with the learning strategies adopted. no significant associations were found between learning strategies and other demographic variables or student characteristics. the time and study environment subscale was moderately significantly correlated with both academic modules (table 5). the composite score for the learning strategies and the rest of the eight subscales significantly correlated poorly with academic performance in both academic modules. discussion this study explored the motivated strategies for learning and their association with the academic performances of a diverse group of 1st-year medical students. the mslq instrument was found to be reliable, as there was an overall degree of acceptable, consistent scoring of items within the different categories. statistically significant differences were found between gender and the composite score for motivation. similar to sikhwari’s[16] results, it was found that females had higher scores then males. these studies revealed that females generally engage more with academic activities than males and are consequently higher achievers academically. by comparison, men are reported to place less value on engaging with academic activities. although urban students had higher scores than their rural counterparts, the differences, such as those between the other characteristics and demographic factors, were not significant. significant moderate relationships were found between academic performance and the motivation strategies subsumed within task value and self-efficacy for learning performance. task value refers to students’ perceptions of how important they believe the subject matter is. it is also associated with higher engagement in learning. these students may be more likely to put in greater effort if they appraise academic content as meaningful and relevant. increased effort and engagement with the subject matter could contribute positively to academic performance. self-efficacy for learning performance relates to the students’ sense of confidence in their ability to achieve their goals. the influence of self-efficacy on motivation is often ignored in research; yet students’ beliefs in their own ability are important and merit attention.[17] self-efficacy and academic performance are interlinked and can be mutually beneficial, as was found previously.[17] conversely, unlike results of other studies,[18] intrinsic and extrinsic goal orientation correlated poorly with one academic performance in this study. table 3. correlations between six subscales of motivation and academic performance with regard to two modules in 1st year of medical school becoming a professional (n=158) basic science (n=152) subscales r* r* intrinsic goal orientation (average subscore) 0.1864† 0.13 extrinsic goal orientation (average subscore) −0.0016 −0.07 task value (average subscore) 0.2533† 0.19† control of learning beliefs (average subscore) 0.1777† 0.13 self-efficacy for learning performance (average subscore) 0.3672† 0.27§ test anxiety (average subscore) −0.3379§ −0.21‡ composite score for motivation (combining the above average subscores)‡ 0.1382 0.09 *pearson’s product moment correlation coefficient. †correlation at p<0.05 (two-tailed). ‡correlation at p<0.01 (two-tailed). §correlation at p<0.001 (two-tailed). table 4. comparison of students’ characteristics by their mean composite scores for learning strategy – independent sample t-test (n=165)* test statistics student characteristics n mean (sd) 95% ci p-value gender male 63 4.85 (0.76) 4.66 5.05 0.11 female 101 4.65 (0.81) 4.49 4.81 geographical area where high school was completed urban 92 4.67 (0.83) 4.49 4.84 0.25 rural 72 4.81 (0.75) 4.63 4.98 medical degree first or second choice first 141 4.75 (0.76) 4.62 5.07 5.07 second 23 4.63 (0.99) 4.21 satisfied with the current degree choice yes 158 4.75 (0.78) 4.62 4.88 0.11 no 5 4.18 (0.98) 2.96 5.39 previous degree yes 21 5.05 (0.94) 4.63 5.46 0.05 no 142 4.73 (0.79) 4.61 4.81 attended study skills sessions yes 36 4.76 (0.73) 4.51 5.01 0.82 no 127 0.79 (0.79) 4.61 4.85 attended mentoring sessions yes 135 4.80 (0.82) 4.66 4.94 0.01 no 29 4.41 (0.79) 4.61 4.85 ci = confidence interval. *the n-score will vary, depending on the number of responses received for each factor. research may 2016, vol. 8, no. 1, suppl 1 ajhpe 107 in our study, test anxiety was found to have a significantly inverse relationship to academic performance. opateye[8] also found a significant negative relationship between test anxiety and academic performance. the results of this article suggest that students with high task value and high self-efficacy may present with lower test anxiety, as they may be more likely to feel better equipped to deal with the examinations and would probably judge themselves as prepared for the task at hand. performing well academically further reinforces these feelings and motivation, which may become a cyclical process of continued engagement and motivation. this is supported by previous studies on self-efficacy and its relationship with test anxiety.[9,10] however, our study found that the majority of the six subscales of motivation and academic performance were poorly correlated, although some significant associations were noted. in the ‘learning strategies’ section, stu dents who had prior higher education qualifications obtained higher scores than those who entered medical school without post-school qualifications. students with existing qualifications are referred to as mature students and their higher scores may be due to their increased tertiary experience. students who attended mentoring sessions also had significantly higher scores for learning strategies. this is a positive finding, as attending mentoring sessions is currently compulsory at nrmsm. this could act as a source of continuous external motivation and engagement with the learning process in a supportive context. this finding highlights the importance of peer-mentorship programmes for developing the student on a personal and academic level, as reported in other studies.[14] with regard to the learning strategies, only the ‘time and study environment’ subscale showed some significant moderate correlation with academic performance. the significant though weak correlation between critical thinking and academic performance is contrary to findings in other studies, as critical thinking is expected to be positively associated with academic performance. this factor is indicative of deeper engagement with the academic content compared with rote learning.[18] overall, this study found limited correlations between the majority of the nine subscales of the learning strategy component of the mslq and academic performance. a limitation of the study may be the correlation of once-off self-reported scores to end-of-year summative results. future studies should perhaps be more focused by correlating the mslq to specific learning events. additionally, several measurements throughout the year may address the possible bias attributed to self-reporting in studies investigating course or curriculum achievement outcomes. conclusion female students reported more positively on motivation strategies than males. first-year medical students with prior educational experience and those who attended the peer-mentoring sessions reported more positively on learning strategies that they adopted. this study found limited though significant correlations between the mslq self-reported scores and academic performance at ukzn. overall, the study highlights the importance of evaluating an instrument in a specific context before accepting the findings of others with regard to the use of the instrument and its correlation with academic performance. these findings warrant further investigation of the use of the mslq in health professions education. acknowledgements. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. we thank the medical students for their participation in the study and dr m muzigaba for statistical guidance and analysis. references 1. maree cm, van rensburg gh. reflective learning in higher education: application to clinical nursing. afr j phys health educ recreation dance 2013;19:44-55. [http://dx.doi.org/10.hdl.handle.net/2263/32417] 2. munteanu a, costea j, palos r. relationships between academic achievement and personality dynamics during adolescence. s afr j psychol 2011;41(4):552-561. [http://dx.doi.org/10.1177/008124631104100413] 3. pajares p. toward a positive psychology of academic motivation. j educ res 2001;95(1):27-35. [http://dx.doi. org/10.1080/00220670109598780] 4. schunk dh, meece jl, pintrich pr. motivation in education: theory, research and applications. 4th ed. boston: pearson, 2014. 5. wissing mp, ed. well-being research in south africa. new york: springer, 2013. 6. artino ar, hemmer pa, durning sj. using self-regulated learning theory to understand the beliefs, emotions, and behaviours of struggling medical students acad med 2011;86:s35-s38. [http://dx.doi.org/10.1097/ acm.0b013e31822a603d] 7. kusurkar ra, ten cate thj, van asperen m, croiset m. motivation as an independent and a dependent variable in medical education: a review of the literature. med teach 2011;33:e242-e262. [http://dx.doi.org/10.3109/014 2159x.2011.558539] 8. opateye ja. the relationship between emotional intelligence, test anxiety, stress, academic success and attitudes of high school students towards electrochemistry. ife psychologia 2014;22(1):239-249. 9. richardson m, abraham c, bond r. psychological correlates of university students’ academic performance: a systematic review and meta-analysis. psychol bull 2012;138(2):353-387. [http://dx.doi.org/10.1037/a0026838] 10. bertrams a, englert c, dickhauser o, baumeister rf. role of self-control strength in the relation between anxiety and cognitive performance. emotion 2013;13(4):668-680. [http://dx.doi.org/10.1037/a0031921] 11. petersen i, louw l, dumont k. adjustment to university and academic performance among disadvantaged students in south africa. educ psychol 2009;29(1):99-115. [http://dx.doi.org/10.1080/01443410802521066] 12. goodman s, jaffer t, keresztesi m, et al. an investigation of the relationship between students’ motivation and academic performance as mediated by effort. s afr j psychol 2011;41(3):373-385. [http://dx.doi. org/10.1177/008124631104100311] 13. sommer m, dumont k. psychosocial factors predicting academic performance of students at a historically disadvantaged university. s afr j psychol 2011;41(3):386-395. [http://dx.doi.org/10.1177/008124631104100312] 14. pintrich pr, smith daf, garcia t, mckeachie wj. a manual for the use of the motivated strategies for learning questionnaire (mslq). ann arbor, michigan: national centre for research to improve post-secondary teaching and learning, 1991. 15. statacorp. stata statistical software: release 13. college station, tx: statacorp lp, 2013. 16. sikhwari td. a study of the relationship between motivation, self-concept and academic achievement of students at a university in limpopo province, south africa. int j edu sci 2014;6(1):19-25. 17. javanmard a, hoshmandja m, ahmadzade l. investigating the relationship between self-efficacy, cognitive and metacognitive strategies, and academic self-handicapping with academic achievement in male high school students in the tribes of fars province. j life sci biomed 2013;3(1):27-34. 18. karbalaei a. critical thinking and academic achievement. medellin–colombia 2012;17(2):121-128. table 5. correlations between nine subscales of the learning strategy scale and academic performance with regard to two modules in 1st year of medical school (n=157) becoming a professional basic science subscales r* r* rehearsal (average subscore) 0.0397 −0.01 elaboration (average subscore) 0.1407 0.09 organisation (average subscore) 0.0766 0.01 peer learning (average subscore) 0.0753 0.01 critical thinking (average subscore) 0.1862† 0.16† metacognitive self-regulation (average subscore) 0.2082‡ 0.09 time and study environment (average subscore) 0.3041§ 0.25‡ effort regulation (average subscore) 0.2098‡ 0.10 help seeking (average subscore) 0.0658 0.01 composite score for learning strategy (combining the above average subscores) 0.2125‡ 0.11 *pearson’s product moment correlation coefficient. †correlation at p<0.05 (two-tailed). ‡correlation at p<0.01 (two-tailed). §correlation at p<0.001 (two-tailed). forum 162 december 2017, vol. 9, no. 4 ajhpe elective medical student (ems) programmes have existed worldwide for half a century and are voluntary placements undertaken as part of a medical degree, in a setting different from that to which the students are accustomed.[1,2] electives take place at an early professional age, and provide in-depth experiences, including the core values of service learning. the community, students and medical schools should all benefit from this arrangement. foreign students may choose south africa (sa) for an international health elective (ihe) when their university affords them a period away from formal studies. the process involves advance paperwork and funding, whether through saving or by sponsorship.[3] the student applies via the recipient website, or directly to a particular consultant. registration with the health professions council of sa (hpcsa) is crucial, requiring confirmation of eligibility from the student’s own medical school and from the recipient sa school. immunisation certificates, medical insurance, and provincial department of health indemnities are further necessities. once fees are paid, the university will send a letter of acceptance. a tourist visa suffices if the visit is shorter than 3 months; otherwise, a study visa is required. word-of-mouth information can result in a succession of ihes to specific departments. when sa students, already hpcsa registered, seek electives at other sa hospitals, parent institutions only require an appropriate supervisor rather than acceptance by another medical school. there are also ‘non-elective’ applicants, i.e. sa citizens who, having not gained admission to a local medical school, are studying abroad. their parent medical school requires a year’s clinical tuition in another country, including detailed documentation thereof. this is not a voluntary ihe, which merely requires a certificate of attendance. benefits of medical electives the student and the community ihe students experience a different system of medicine in exotic surroundings, and are taken out of their comfort zones, observing the advantages and disadvantages of the foreign training. sa has patients with a wide range of illnesses that students overseas may not be exposed to. ems programmes, embodying the concepts of person-centred and communityorientated care, allow these students to expand their knowledge base and skills under supervision. emss from sa universities will be able to observe how other medical professionals in the public health service deal with similar problems, thus acquiring a different approach to working in the developing world. the recipient institution and medicine medicine is globalised, and therefore any gains to a student are to the credit of the recipient medical school.[4] this ‘bigger picture’ fits the mantra: ‘think globally, act locally’. ihe students, observing what developing countries deal with, may in time influence policymakers. they may provide insight into management of similar conditions in their own countries. research is also a possibility. emss are popular with other medical personnel, as was obvious on rural outreach visits. there is evidence, both published and gained in person by three of the authors during outreach visits, suggesting that staffing of rural hospitals by foreign junior doctors is in accordance with ihes.[5,6] these doctors, or their colleagues, had been emss as undergraduates, recommending hospitals noted for sound clinical experience under good supervision. no student should act unethically, e.g. by undertaking unsupervised clinical responsibilities beyond their level of capability.[7] sa medical school emss undertaking an elective elsewhere in sa might well consider internship, community service and beyond in the centre visited – a win-win outcome. drawbacks of ihes/emss there may be concern that emss could make undue demands on recipient consultants. however, the relevant department accepts such students only when it has the space and time for them. ‘medical tourism’ has been criticised, as the net gain favours the trainee participant and insufficient consideration is given to the needs of the host country.[8] nevertheless, the same authors acknowledge that even medical tourism increases involvement in global medicine.[8] emss come with a set of socially responsible objectives from their university. in our experience, most of them exceed the requirements and are anything but medical tourists. designing an ems programme while it is important not to over-regulate this fragile asset, administration needs to be efficient and user friendly. the following suggestions may be useful to institutions offering ems and/or ihe programmes: • the elective experience should be based on international professional and ethical standards. • potential emss should include a cv and details regarding their expectations from the elective. preferred dates may be requested, up to a maximum of 16 weeks’ duration. • applications should not proceed without a department’s acceptance of the ems (automatically governing saturation). • university ‘processing’ should ensure that hpcsa registration takes priority; 3 4 months should suffice, with the onus on the student to complete the paperwork promptly. • emss from sa medical schools should not pay a fee, other than for accommodation. • occupational health risks are real. an induction course in the first week is advisable, emphasising hivand tuberculosis-related issues. the medical elective: a unique educational opportunity r i caldwell,1 bsc (med), mb chb, fcp (sa), frcp (lond); a c inglis,1,2 facem, fcem (uk), mb chb, dip soc admin (oxon), dtm&h (liverpool), dip paed (akl), dip o&g (akl), dip med sci (dive&hyperbaric med) (akl); m morgan,1,3 mb bch, fcpaed (sa), cert critical care (sa) paed; k rasmussen,1,3 fcp (sa), fcch (sa), dhsm, dtm&h, doh; c aldous,1 phd 1 school of clinical medicine, university of kwazulu-natal, pietermaritzburg, south africa 2 kwazulu-natal department of health, edendale hospital, pietermaritzburg, south africa 3 kwazulu-natal department of health, grey’s hospital, pietermaritzburg, south africa corresponding author: r i caldwell (ric@caldwells.co.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. forum december 2017, vol. 9, no. 4 ajhpe 163 • the funds generated through ihes could be used to enhance the programme, including sponsorship of local students for their own electives. encouragement should be given to the institution’s own students towards undertaking elective periods, either as an ihe student or elsewhere in sa. conclusion this article supports medical electives that benefit the community, the student and higher educational institutions. it identifies a ‘non-elective’ group, which needs attention. the objective is to provide an elective opportunity that will help to create 21st-century health professionals, including clinical involvement and encouragement towards enjoyment and appreciation of sa. acknowledgements. none. author contributions. all the authors complied with the international committee of medical journal editors' rules of authorship and were part of formulating and conceptualising the article. although the initial draft was prepared by the first author, subsequent work on the manuscript included inputs from all authors. funding. none. conflicts of interest. none. 1. edwards r, piachaud j, rowson m, miranda j. understanding global health issues: are international medical electives the answer? med educ 2004;38(7):688-690. https://doi.org/10.1046/j.1365-2929.2004.01849.x 2. o’donnell p, mcauliffe e, o’donovan d. unchallenged good intentions: a qualitative study of the experiences of medical students on international health electives to developing countries. hum resource health 2014;12(1):49. https://doi.org/10.1186/1478-4491-12-49 3. gulsin gs, johnston pw. funding your elective. student bmj. http://student.bmj.com/student/view-article. html?id=sbmj.d5851 (accessed 4 october 2017). 4. jeffrey j, dumont ra, kim gy, kuo t. effects of international health elec tives on medical student learning and career choice: results of a systematic literature review. fam med 2011;43(1):21-28. 5. dolea c, stormont l, braichet j-m. evaluated strategies to increase attraction and retention of health workers in remote and rural areas. bull world health organ 2010;88(5):379-385. https://doi.org/10.2471/blt.09.070607 6. thompson mj, huntington mk, hunt d, pinsky le, brodie jj. educational effects of international health electives on us and canadian medical students and residents: a literature review. acad med 2003;78(3):342-347. https://doi.org/10.1097/00001888-200303000-00023  7. elit l, hunt m, redwood-campbell l, ranford j, adelson n, schwartz l. ethical issues encountered by medical students during international health electives. med educ 2011;45(7):704-711. https://doi.org/10.1111/j.13652923.2011.03936.x 8. petrosoniak a, mccarthy a, varpio l. international health electives: thematic results of student and professional interviews. med educ 2010;44(7):683-689. https://doi.org/10.1111/j.1365-2923.2010.03688.x accepted 9 may 2017. afr j health professions educ 2017;9(4):162-163. doi:10.7196/ajhpe.2017.v9i4.883 https://doi.org/10.1046/j.1365-2929.2004.01849.x https://doi.org/10.1186/1478-4491-12-49 http://student.bmj.com/student/view-article.html?id=sbmj.d5851 http://student.bmj.com/student/view-article.html?id=sbmj.d5851 https://doi.org/10.2471/blt.09.070607 https://doi.org/10.1097/00001888-200303000-00023 https://doi.org/10.1111/j.1365-2923.2011.03936.x https://doi.org/10.1111/j.1365-2923.2011.03936.x https://doi.org/10.1111/j.1365-2923.2010.03688.x research may 2016, vol. 8, no. 1, suppl 1 ajhpe 121 a key component of undergraduate medical education is feedback, which is considered the ‘lifeblood of learning’.[1] several definitions for feedback exist, but all suggest that feedback is an interactive process with the objective of giving students constructive input into their work.[2] feedback in the context of behavioural science is defined as the ‘provision of information about the gap between the actual level and the reference level of learning that is used to alter the gap in some way’.[3] in medical education, feedback is defined as ‘specific information about the comparison between trainees’ observed performance and a standard, given with the intent to improve the trainee’s performance’.[4] feedback can be either formative or summative. formative feedback in clinical assessment may occur during the theme/module or clinical placement. the objective here is to enhance students’ learning ability by informing them of the strong and weak aspects of their clinical performance, and providing suggestions for improvement in preparation for their summative examination. it does not include the rating of clinical skills performance but intends to shape the students’ responses to the task being worked on. summative feedback takes place at the end of a theme/module to determine whether or not overall goals have been achieved and includes explicit feedback with rating of clinical skills performance. it may help to shape the next performance or task but is often received too late to have an effect on the task being evaluated.[5] formative assessment, through the provision of feedback and debriefing in the simulated clinical setting, is important to support student learning and clinical skills development. feedback is considered effective when it is: provided soon after task performance; is presented in a manner sensitive to students’ learning style; clearly identifies strengths and weaknesses; includes suggestions for improvement; and is constructive, motivating and able to ‘feed-forward’.[6] students are aware of its importance in improving learning outcomes and value a balanced and structured feedback approach as effective to meet individual needs.[7] however, concerns about the quality of feedback received by medical students have been highlighted.[8] clinical skills laboratories (csls) are educational facilities that provide medical students with opportunities during the preclinical years to learn and practise clinical skills before using them in real clinical settings. patient history-taking, performing a physical examination and then analysing and presenting this information involve psychomotor and cognitive skills, as well as behaviour acquired through repetitive and systematic training, and depends upon effective teaching, assessment and feedback[9] in the csl setting. these skills are better demonstrated than described. unfortunately, a widely reported deficiency is the lack of dynamic assessment, which involves direct observation and immediate feedback given to medical students’ performing these skills.[10] without feedback on observation, errors go uncorrected, good performance is not reinforced and clinical competence is achieved only minimally. as evidenced from empirical research, students need adequate motivation and belief in their abilities to be able to satisfactorily decode feedback messages to self-regulate their clinical performance.[11] the importance of feedback is also widely acknowledged by clini cal teachers. although they believe they give regular and sufficient feedback, this is often not the perception of learners.[8] in a study conducted to assess the students’ voice, students rated assessment feedback as an aspect in need of improvement across 14 universities in australia.[12] even though giving feedback to learners on their clinical performance has been identified as background. clinical skills training in the clinical skills laboratory (csl) environment forms an important part of the undergraduate medical curriculum. these skills are better demonstrated than described. a lack of direct observation and feedback given to medical students performing these skills has been reported. without feedback, errors are uncorrected, good performance is not reinforced and clinical competence is minimally achieved. objectives. to explore the perceptions of 3rd-year medical students and their clinical teachers about formative clinical assessment feedback in the csl setting. methods. questionnaires with openand closed-ended questions were administered to 3rd-year medical students and their clinical skills teachers. quantitative data were statistically analysed while qualitative data were thematically analysed. results. five clinical teachers and 183 medical students participated. average scores for the items varied between 1.87 and 5.00 (1: negative to 5: positive). the majority of students reported that feedback informed them of their competence level and learning needs, and motivated them to improve their skills and participation in patient-centred learning activities. teachers believed that they provided sufficient and balanced feedback. some students were concerned about the lack of standardised and structured assessment criteria and variation in teacher feedback. no statistical difference (p<0.05) was found between the mean item ratings based on demographic and academic background. conclusion. most teachers and students were satisfied with the feedback given and received, respectively. structured and balanced criterion-referenced feedback processes, together with feedback training workshops for staff and students, are recommended to enhance feedback practice quality in the csl. limited clinical staff in the csl was noted as a concern. afr j health professions educ 2016;8(1 suppl 1):121-125. doi:10.7196/ajhpe.2016.v8i1.769 third-year medical students’ and clinical teachers’ perceptions of formative assessment feedback in the simulated clinical setting r m abraham, mbbs, pgdip (anaesthesia), pgdip (public health), mmedsc; v s singaram, bmedsc, mmedsc, phd clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: r m abraham (abrahamr@ukzn.ac.za) research 122 may 2016, vol. 8, no. 1, suppl 1 ajhpe a major approach to academic teaching and learning in clinical education, it needs to be monitored.[8] the objective of this study was to survey medical students’ and clinical teachers’ perceptions of formative assessment feedback on direct observation of clinical examination skills performed in the csl. method context the nelson r mandela school of medicine (nrmsm) at the university of kwazulu-natal (ukzn), durban, south africa has adopted a 6-year hybrid problem-based learning (pbl) medical curriculum. clinical skills teaching forms a part of each of the theme-based pbl modules during the first three preclinical years taught in the medical school csl, using simulated patients. the clinical skills mini-logbook formative assessment session occurs before the summative assessments at the end of each 6to 8-week theme-based module. during the formative assessment sessions, each student is given 8 minutes to systematically demonstrate examination skills on a simulated patient. the teacher observes each student and rates the performance in the mini-logbook, based on the minimum requirements for the skill to be deemed satisfactory. performances are rated as ‘inadequate’, ‘satisfactory’ or ‘exceeded expectation’ and verbal and written feedback are provided. study design this mixed methods observational study was conducted with the 2014 cohort of 3rd-year medical students and their clinical skills teachers at the nrmsm. ethical approval was granted by the ukzn humanities and social sciences research ethics committee (hss/0084/014m). third-year medical students (n=183) and clinical teachers (n=5) consented to completing the questionnaires. the research design involved mixing both qualitative and quantitative research data to provide a more comprehensive understanding of the perceptions of both the students and teachers. instrument two questionnaires, consisting of closedand open-ended questions, were designed. one questionnaire was designed to explore the teachers’ perceptions of the feedback. the other questionnaire explored students’ responses to the mini-logbook formative assessment feedback received with regard to the value of feedback, preferences for feedback and suggestions to improve feedback. each instrument consisted of the following components, which formed the different sections of the questionnaire: (i) demo graphic data; (ii) perceptions of feedback; (iii) value of feedback; (iv) preferences for feedback; and (v) suggestions for feedback. sections (ii), (iii) and (iv) included closed questions that required students and clinical teachers to indicate their level of agreement with a series of statements on a 5-point likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’. there were two open-ended questions on the general perceptions of feedback (section (iii)) and suggestions to improve it (section (v)). minor modifications were made after questionnaires were piloted. data analysis quantitative data were analysed statistically using the statistical package for the social sciences (spss) (version 21) (ibm, usa) and reported anonymously. student independent t-tests and analysis of variance (anova) statistical tests were employed to ascertain specific age, gender, language, enrolment status and academic performance differences between the demographic groups. confidence intervals (cis) were set at 95% and statistical significance at p<0.05. the qualitative data were read and reread for familiarity with what it entailed, paying specific attention to patterns that occurred. the pattern of responses was used to identify emergent themes, with consensus from both authors. the student and teacher responses were then clustered according to the emergent themes and categorised according to the degree of support that a particular response represented in terms of the total sample. the qualitative data gathered from the students’ and clinical teachers’ responses to the open-ended questions were thematically analysed and will be reported in more detail in a follow-up study.[13] specific quotations were selected to support or extend the quantitative data that are the focus of this article. results the student sample consisted of 115 (68%) females. the majority (96%) were between 18 and 25 years of age. the teachers consisted of 1 (20%) female and 4 (80%) male clinicians. the students and teachers came from diverse multicultural, language and academic backgrounds. students’ responses to feedback received illustrated in table 1, most students believed that receiving feedback had a positive effect on their learning by informing them of what was needed to improve their performance (94%), explaining the performance rating received (90%) and providing an evaluation of their strengths and weaknesses in clinical skills (96%). they also appreciated feedback as it informed them of the teachers’ expectations with regard to the skill table 1. clinical skills logbook assessment feedback: impact of feedback on academic performance (n=183) statement response positive response, % neutral response, % negative response, % feedback informs me what i need to do to improve my performance in clinical skills 94 4 1 feedback explains the performance rating i received in the logbook 90 9 1 feedback is an evaluation of my strengths and weaknesses in the skill performed 96 3 1 feedback informs me what the expectations of the lecturer/teacher are regarding clinical skills performance 93 5 2 i use feedback to try to improve my performance in future logbook assessments and end-of-semester objective structured clinical examinations 93 6 2 feedback is only useful when i receive a bad performance rating in the logbook 12 5 82 feedback is only useful when it is positive 7 7 86 getting a performance rating is more important to my learning than feedback 23 35 42 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 123 performed (93%) and was useful and relevant to their goals as a student to feed-forward (93%): ‘i really appreciated the fact that we have logbook sessions before the actual exam … it helps me to see my weak points.’ although feedback was valued, the students did not think feedback was useful if it only reported a bad performance (82%) or a good performance (86%). they were more likely to value balanced feedback with positive reinforcement and constructive criticism indicative of an understanding of their performance: ‘teachers must give us feedback that is truly indicative of our performance. they must not focus only on the wrong things but also explain how we can improve the things that we did well.’ students reported that they valued the feedback received (99%) and always ensured they read the feedback provided in the logbook (98%) (table 2). they believed that they deserved to receive feedback, especially after putting effort into practising clinical skills (96%), as it encouraged (92%) and motivated them to study (93%). students felt that their teachers’ feedback was a demonstration of them caring about a student’s work (78%). they suggested ways to improve their feedback experience and requested feedback as a tool to gauge their knowledge in summative assessments: ‘we don’t receive feedback for our [objective structured clinical examinations] osces. i believe to improve we should be given this feedback as it is an indication of how much more work you need to put towards your clinical skills.’ an important issue raised was teacher variability when delivering feedback (60%) and the need for more clarity when providing feedback. the criteria with which feedback was provided were of concern. students linked feedback variation to lack of use of standardised and structured assessment criteria by the teachers. when prompted for recommendations for improving clinical skills logbook assessment feedback they suggested standardisation: ‘logbook sessions are useful in assessing our skills. however, i feel that teachers should use the same methods of testing to make things fair for all students. assessment criteria must be available to students as a form of learning objectives and goals.’ students were satisfied with the timely delivery of feedback (85%). they valued some general feedback (51%) as it gave them an idea about whether other students in the class experienced similar problems (table 3). one suggestion made was the need for the following: ‘… a little more group feedback to judge where i am in the class and whether or not i am putting enough effort into my learning.’ the students acknowledged individual feedback (88%) as more personal and fitting for clarifying issues with teachers as an important part of their learning: ‘it is always better for one-on-one feedback that focuses on individual needs and allows students table 2. clinical skills logbook assessment feedback: impact of feedback on personal motivation to learn (n=183) statement response positive response, % neutral response, % negative response, % feedback is important to me 99 1 0 i always read the feedback on my logbook 98 1 1 i deserve feedback when i put a concerted effort into practising my clinical skills 96 3 1 when i receive substantial feedback i feel encouraged 92 7 1 teachers who provide feedback care about what the students generally think 78 15 6 feedback motivates me to study 93 7 0 when i don’t receive feedback i feel that the teacher does not respect me 44 34 22 all the clinical skills teachers follow a similar style and criteria of providing feedback 16 24 60 an important part of learning is being able to discuss the subject with my teacher 92 7 1 i learn more when my teacher focuses on what i did wrong 63 15 22 table 3. clinical skills logbook assessment feedback: references for feedback (n=183) statement response positive response, % neutral response, % negative response, % feedback on clinical skills logbook assessments is generally provided immediately 85 5 10 general feedback provided in class helps me learn independently 62 23 15 individual feedback is better because i can clarify any issues with the teacher or lecturer 88 8 4 verbal feedback is easier to understand 76 19 6 specific feedback is better because it helps me understand what i did right and wrong in the logbook session 96 3 2 it is boring when lecturers provide general feedback to the class 27 39 34 i prefer general feedback in class because it is not personal 8 26 66 i prefer verbal feedback because i can communicate with the teacher and clarify information 75 21 4 group feedback is best because i can see where other students have experienced similar problems 51 25 24 teachers’ written comments are often difficult to read and inadequately explained 21 27 53 written feedback is better because i can refer to it much later 69 19 12 research 124 may 2016, vol. 8, no. 1, suppl 1 ajhpe to interact with the facilitator easily, ask questions and receive clarification when necessary.’ the students preferred verbal feedback (75%) specific to their work, including both positives and negatives in the skill demonstrated: ‘more emphasis on verbal individual feedback for me … because it focuses specifically on my performance and accounts not only for the things i got wrong but the things i got right and what i need to improve on.’ clinical teachers’ perceptions of giving feedback as illustrated in table 4, teachers were comfortable with providing feedback, and agreed that effective performance feedback improved students’ learning and required their engagement with and necessary skill in the feedback provision process. they all reported providing individual and verbal feedback, while some amount of written and group feedback was also given. three teachers indicated that the setting in which feedback was provided in the csl was private; one was neutral regarding this, while another did not think the setting was private enough. three teachers provided feedback that reflects more general information on the students’ performance. three teachers allowed the students to self-assess and reflect on their performance to confirm if they agreed or disagreed with the feedback information provided. most teachers disagreed that the culture and language background of students determined the feedback they give: ‘i do not really take account of culture and background because i am only focused on the topic, the technique and documentation of clinical skills.’ however, one teacher considered language and culture to be an important factor while providing feedback: ‘for second-language students the delivery of feedback is important. also, from a cultural perspective students may see me as a figure of authority and misconstrue my feedback as “scolding”.’ the majority of teachers felt that staff development is crucial for increasing teachers’ confidence and skill in this area of giving feedback: ‘a workshop on feedback in clinical skills is very important. it will allow all teachers to harmonise the way they have to improve and deliver the feedback.’ teachers also indicated some barriers and suggestions to improve feedback in clinical skills: ‘regular student and staff evaluations and increase time for feedback. these approaches are limited by time and staffing resource constraints.’ discussion lack of effective feedback is considered a serious deficiency in medical education.[7] it is therefore positive to note that the current study found that most students and teachers were satisfied with the mini-logbook formative assessment feedback in the csl. similar to previous studies, students valued the feedback received during clinical skills sessions as most of them requested personalised, frequent, immediate and clear feedback linked to specific learning outcomes as a tool to gauge their knowledge relevant to their goals.[14] they confirmed that receiving timely feedback had a positive effect on their learning and clinical performance and hence their future practice. the students preferred balanced feedback as an evaluation of their strengths and weaknesses essential for their growth as a student, to boost their confidence and self-esteem, to increase their motivation to study and to provide them table 4. clinical teachers’ perceptions of feedback provided during a logbook session (n=5) statement response positive response, % neutral response, % negative response, % provision of effective performance feedback to medical students improves learning outcomes 100 0 0 provision of clearly effective feedback would require engagement and skill 100 0 0 i often provide the following types of feedback to my students (verbal) 100 0 0 i often provide the following types of feedback to my students (written) 40 0 60 i often provide the following types of feedback to my students (group) 60 0 40 i often provide the following types of feedback to my students (individual) 100 0 0 the students are aware that they would be receiving feedback after the clinical performance 100 0 0 feedback is often provided in a confidential setting 60 20 20 the feedback i provide only reflects what the student did satisfactorily 20 0 80 the feedback i provide only reflects what the student did unsatisfactorily 40 0 60 the feedback i provide is usually a balance between what the student did well and what areas require improvement 100 0 0 the feedback i provide reflects more specific information about the student’s clinical performance 100 0 0 the feedback i provide reflects more general aspects of the student’s clinical performance 60 20 20 immediately after providing the feedback i would allow the students to self-assess and reflect on their performance to confirm if they agree or disagree with the feedback 60 20 20 i am comfortable providing feedback to students 100 0 0 the culture and language background of the students is an important factor when giving feedback 60 20 20 i feel there should be formal training to improve and enhance my feedback skills as an academic 60 20 20 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 125 with some direction for learning. this may have a positive effect on their subsequent clinical performance and the development of their clinical competence.[2] although there were a wide variety of feedback preferences, the medical students who took part in the study preferred personal, individual and verbal feedback. this afforded them an opportunity to communicate with the teacher and clarify information – an important part of learning.[15] some group feedback was favoured, as it gave students an idea about whether other students in the class experienced similar problems. while some found general comments uninformative, this method of feedback must not be dismissed as students should be able to probe feedback by asking specific questions.[16] the clinical skills teachers in this study all agreed that providing directly observed immediate formative feedback improved students’ learning and allowed enough time for students to make changes to their performance before examinations.[17] some teachers allowed students to reflect on their performance, providing them with insight into the students’ ability to self-assess and reflect.[6] although teachers were aware that providing regular, balanced feedback with clear guidelines for improvement is essential and the teachers believed they provided this most of the time, this is not how the students perceived the situation. one of the reasons that may explain deficiency in the delivery of negative feedback in this setting may be the teachers’ desire to avoid upsetting students, leading to ‘vanishing feedback’ and subsequent avoidance in giving any feedback. even though cultural and linguistic differences did not seem to influence the feedback process, a concern regarding misconceptions was attributed to different cultural and language backgrounds. staff development workshops on the provision of negative feedback[18] and diversity training to bridge language and cultural differences is recommended to address these challenges. there were other concerns raised by the clinical teachers with regard to the effective delivery of feedback. these included the challenges of teaching and assessing large groups of students within a short time period in an environment that is not adequately private, as well as limited space and time for recording feedback in the mini-logbook. moreover, a greater emphasis on assessment, as opposed to giving feedback, was noted, together with a request from teachers for training to enhance their skills in giving feedback. the limited clinical staffing was raised as a barrier to providing effective feedback, highlighting the need for more clinical teachers in the csl. some students commented on teacher variability and inconsistency in the quality of feedback delivered during clinical skills mini-logbook sessions. these findings are similar to those of other studies revealing that learners often do not feel they receive enough feedback and if they do, they feel that the process is not effective most of the time.[7] students attributed this variability to the lack of standardised and structured feedback assessment criteria. another reason contributing to the discounting of feedback by the students may be their unfamiliarity with a particular teacher and their assessment style. connecting with teachers to create a positive and healthy environment will enhance the feedback process and eliminate barriers to the use of feedback as a tool for self-improvement and development.[19] this will further help students recognise areas for clinical skills development by assisting them to self-regulate and self-monitor their learning processes.[20] conclusion the students recognised the transferable value of the learning skills developed as a result of an effective feedback for processing new learning. hence, they valued the effect of feedback as an instrument to guide and regulate their learning. based on information from this study on students’ varied and inconsistent experiences with receiving feedback, feedback briefing or training sessions, together with the development of an appropriate feedback strategy, are recommended for students and teachers. a structured and balanced criterion-referenced feedback process is also recommended to enhance the consistency of feedback practice and provide fair assessment. moreover, establishing an instructional system and revising the clinical skills mini-logbook to a more specific criterion-based, standardised and structured feedback instrument, as well as extending it to other clinical disciplines, are suggested. further regular evaluation of the feedback process in the csl would help to maintain and enhance clinical skills core competencies and provide direction to address any deficiencies in the clinical skills teaching programme. acknowledgements. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health. its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. the staff and students who participated in the study are also acknowledged. references 1. rowntree d. assessing students: how shall we know them? 2nd ed. london: kogan, 1987:86. [http://dx.doi. org/10.2307/1981340] 2. eraut m. feedback. learn health soc care 2006;5(3):111-118. [http://dx.doi.org/10.1111/j.1473-6861.2006.00129.x] 3. ramprasad a. on the definition of feedback. behav sci 1983;28(1):4-13. [http://dx.doi.org/10.1002/bs.3830280103] 4. van de ridder jm. what is feedback in clinical education? med educ 2008;42(2):189-197. [http://dx.doi. org/10.1111/j.1365-2923.2007.02973.x] 5. wiggins g. feedback: how learning occurs. in: chaffee ee, ed. assessing impact: evidence and action. washington, dc: american association for higher education, 1997:31-39. 6. hattie ja, timperley h. the power of feedback. rev educ res 2007;77(1):81-112. [http://dx.doi. org/10.3102/003465430298487] 7. weinstein df. feedback in clinical education: untying the gordian knot. acad med 2015;90(5):559-561. [http:// dx.doi.org/10.1097/acm.0000000000000559] 8. edgren g, haffling ac, jakobsson u, et al. comparing the educational environment (as measured by dreem) at two different stages of curriculum reform. med teach 2010;32(6):e233-e238. [http://dx.doi. org/10.3109/01421591003706282] 9. association of american medical colleges. recommendations for clinical skills curricula for undergraduate medical education. washington, dc: aamc, 2005. https://www.aamc.org/download/130608/data/clinicalskills_ oct09.qxd.pdf.pdf (accessed 22 may 2014). 10. association of american medical colleges.  medical school graduation questionnaire. 2012. all school summary report.  washington, dc: aamc, 2014. https://www.aamc.org/data/gq/allschoolsreports (accessed 17 february 2015). 11. wright k. student nurses’ perceptions of how they learn drug calculation skills. nurse educ today 2012;32(6):721726. [http://dx.doi.org/10.1016/j.nedt.2011.09.014] 12. scott g. assessing the student voice: a higher education innovation program project. canberra: department of education, science and training, 2006:8-10. 13. krippendorff k. content analysis: an introduction to its methodology. 2nd ed. thousand oaks, ca: sage publications, 2004:413. [http://dx.doi.org/10.1177/1094428108324513] 14. hounsell d. towards more sustainable feedback to students. in: boud d, falchikov n, eds. rethinking assessment in higher education. london: routledge, 2007:101-113. 15. parikh a, mcreelis k, hodges b. student feedback in problem-based learning: a survey of 103 final year students across five ontario medical schools. med educ 2001;35(7):632-636. [http://dx.doi.org/10.1046/j.13652923.2001.00994.x] 16. dent j, harden rm. a practical guide for medical teachers. 4th ed. new york: elsevier health sciences, 2013:273-275. [http://dx.doi.org/10.1136/pmj.78.916.125] 17. krackov sk. expanding the horizon for feedback. med teach 2011;33(7):570-575. [http://dx.doi.org/10.3109/0 142159x.2011.617797] 18. ende j. feedback in clinical medical education. jama 1983;250(6):777-781. [http://dx.doi.org/10.1001/ jama.250.6.777] 19. watling c, driessen e, van der vleuten cp, lingard l. learning from clinical work: the roles of learning cues and credibility judgements. med educ 2012;46(2):192-200. [http://dx.doi.org/10.1111/j.1365-2923.2012.04126.x] 20. raftery s. feedback: an essential element of student learning in clinical practice. nurse educ pract 2008;8(6):405411. [http://dx.doi.org/10.1016/j.nepr.2008.02.003] october 2016, vol. 8, no. 2 ajhpe 203 research south africa (sa)’s racially divided past is evident in the inequitable delivery of health services, which still reflects in inferior care to the poor and those living in underserved communities. apart from the disparity between healthcare delivery in the public and private sectors, the country faces a quadruple burden of disease that includes the hiv, aids and tuberculosis epidemics, non-communicable diseases, injury and violence, as well as the silent epidemic of maternal, neonatal and child mortality. the frenk report[1] indicts medical schools for having failed disadvantaged communities, as health services, research and education offered by these institutions have not translated into actions to address the health needs of these communities. while the problems are complex and multisectoral, medical education should incorporate community-based learning in decentralised training platforms to create awareness of inequities in health provision and to prepare graduates more appropriately for the needs of the disadvantaged communities they will serve.[2] community-orientated education requires a review of the roles and responsibilities of all stakeholders, access to resources and innovative use of teaching methodologies to maximise learning. creating opportunities for greater community participation by medical students will culminate in professional behaviour and learning that cannot be simulated in the classroom. early exposure to experiential learning for medical students enhances their understanding of the social determinants of health and the needs of a population, helping them in the development of the interpersonal skills that facilitate empathetic attitudes towards their patients.[3] early experiences also nurture professional identities and promote social responsiveness among medical students; responsiveness, in turn, fosters doctors’ accountability to the communities they serve.[4] socially accountable medical schools are required to direct their education, research and service activities to address priority health concerns in collaboration with stakeholders of the communities they serve.[5] the challenge for sa health educators is to make learning meaningful and ensure that students become socially responsible, responsive and accountable in the ailing healthcare system. medical students, however, may become alienated and disengaged during their extended study away from their own communities.with students often burdened with informative learning and regarded as not sufficiently knowledgeable to make substantial service contributions, the making a difference group community service activity (mad) was conceived to facilitate greater involvement of 1st-year students with organisations that serve local disadvantaged communities. early community and clinical exposures also aid students’ learning, increase the recruitment of graduates to work in underserved primary healthcare settings and impact on graduates’ competencies as health advocates through the development of appropriate knowledge and attitudes.[6] boelen et al.[7,8] define a socially accountable medical school as demonstrating the most desirable level of social obligation by using education, research and service to address priority health needs. in collaboration with government and other health service organisations, they should influence people’s health positively at a local level. social obligation, through its component parts – responsibility, responsiveness and accountability – can increase the relevance of medical education. therefore, these programmes should adhere to principles that anticipate society’s health needs, and include education that fosters an understanding of the social context and background. medical schools need to be more socially accountable. the making a difference group community service activity (mad), which is part of the 1st-year medical curriculum at the university of kwazulu-natal, durban, south africa, aims to make students more responsible, responsive and accountable to community needs. small groups of students engage with an organisation of their choice that works with a disadvantaged community. they spend 16 hours in appropriate community service, which includes an hiv and aids education activity. objective. to describe and categorise the mad process of developing social accountability in medical students. methods. this case study draws on routinely collected administrative and qualitative data obtained from reflective journals kept by each student. a document analysis was undertaken of the posters produced by each group that described their reciprocal learning from this experience. ethical approval for the ongoing evaluation of the undergraduate programme was obtained. results. the mad gave students exposure to authentic experiences through socially accountable activities. enabled by the structured and stepwise mad approach, groups demonstrated responsibility in identifying and engaging a local community. they developed a simple plan of action that was responsive to community needs. at each stage, they demonstrated accountability to the various stakeholders. students reflected on the social determinants of health and disease and described mad as a ‘humbling and huge learning experience’. conclusion. through mad, 1st-year medical students engaged in practical, socially accountable activities with members of disadvantaged communities. they developed some understanding of a population perspective on health and the social determinants that influence health and disease in a community. afr j health professions educ 2016;8(2):203-207. doi:10.7196/ajhpe.2016.v8i2.745 developing social accountability in 1st-year medical students: a case study from the nelson r mandela school of medicine, durban, south africa j m van wyk,1 bsc ed, med, phd; s e knight,2 mb bch, fccm (sa); t dlungwane,2 bsc (physio), mph; s glajchen,2 bsc (ot), mph 1 clinical and professional practice, nelson r mandela school of medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: s e knight (knights@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 204 october 2016, vol. 8, no. 2 ajhpe research partners with stakeholders in the health system.[7,9] medical graduates, as competent and capable clinicians, should be willing change agents in contributing to and improving the health system in which they work.[2] the mad at the university of kwazulu-natal (ukzn), durban, sa requires groups consisting of three or four students to identify and perform 16 hours of a group community service with a local organisation dedicated to serving a disadvantaged community (fig. 1). this educational activity forms part of the becoming a professional module offered in the 1st year of the 6-year undergraduate medical programme and is preceded by a series of workshops called ‘hiv and me’. for the mad to be completed during term time, the identified community must be within the ethekwini municipal area and close to students’ termtime residence. each group must initiate and organise their own mad with the host organisation. the students are allocated an afternoon per week of curriculum time over a 3-month period to complete the activity. groups have four meetings with a trained faculty member who facilitates the process, assists with planning and debriefing and supports reflection on challenges encountered during the implementation of the educational activity. the nature of the service activities that groups undertake in mad is planned in consultation with the host organisation and depends on the needs of the hosts. for the final activity, each group has to deliver an appropriate hiv prevention session in the selected community. each student keeps a diary and log of the time and activity at the organisation, and completes a set of structured reflective learning entries on an electronic journal. their first journal entry describes their chosen disadvantaged community and reasons for selecting the site. the second journal entry comprises a reflection on the meaning of health, after discussion with community members. the final journal entry involves a structured reflection on their reciprocal learning during the entire mad experience. at completion of the mad, each group prepares and presents a poster to their peers, community stakeholders and faculty academics at a ‘poster day’ session. the poster demonstrates reciprocal learning as a group and the goals achieved during mad, and the presentation reflects their individual and collective learning. each step (fig. 1) of the process is assessed, with greater weighting allocated to the third reflective journal entry and the poster presentation. in this article, we use boelen’s[10] social accountability framework to describe a case study of the development of social accountability in 1st-year learners at ukzn. the article reports on a document analysis undertaken to identify the type of sites chosen by student groups, scope of activities undertaken and challenges encountered during the mad experience. we also provide an overview of the steps and process (fig. 1) that guide and support the 1st-year cohort towards demonstrating responsibility, responsiveness and accountability in a community setting. methods origin of the study the study was conceived in response to the need for educators from the school of nursing and public health, ukzn to evaluate students’ learning group/ individual activity social accountability category accountable accountable accountable responsible responsive accountable accountable responsive responsive responsive accountable responsive responsive responsible accountable accountable responsible individual group group group individual individual group individual group group group individual group group group individual individual facilitator meeting register on-site register and photo of poster at site poster presentation submission of poster for printing journalling/re�ection 03 journalling/diary group meeting 04 with facilitator journalling/re�ection 02 final plan of action draft activity plan for 16 hours of community service group meeting 02 with facilitator journalling/re�ection 01 introductory site visit and obtain signed permission from organisation identify two possible making a di�erence sites group meeting 01 with facilitator plagiarism and collusion declaration form introduction to making a di�erence: a group community service activity step 17 step 16 step 15 step 14 step 13 step 12 step 11 step 10 step 9 step 8 step 7 step 6 step 5 step 4 step 3 step 2 step 1 fig. 1. steps in mad that foster the development of responsibility, responsiveness and accountability. october 2016, vol. 8, no. 2 ajhpe 205 research from the mad. it had already been established that students’ knowledge had increased from the exposure and a decision was taken to explore the extent to which the mad had contributed towards achieving the school’s mission of increasing social accountability among students. in this observational, descriptive case study, both quantitative and qualitative data were collected from the 2013 1st-year mb chb student cohort (n=249) enrolled at the nelson r mandela school of medicine, ukzn. each step in the mad process (fig.1) was analysed and categorised with reference to boelen’s[10] social accountability framework to determine how each component aided the development of students’ sense of responsibility, responsiveness or accountability. in addition, we collected basic quantitative demographic information including schooling, home location and mad site data from each student as part of the first journal entry. students used the gibbs[11] reflective cycle to reflect on positive and negative disorientating experiences encountered during mad. finally, an audit of the 63 posters and students’ final reflective journal entries was undertaken. the analysis sought the reasons why students had chosen a specific site, as well as information on the nature of the activities performed by the student groups. all the posters and reflective journals were analysed to ensure trustworthiness. students are routinely invited to evaluate educational activities such as the mad. the documents used to extract the data were collected throughout the year, which served to triangulate the data sources.[12] approval to conduct ongoing evaluation of specific educational exposure, including the mad of the mb chb degree, was sought and received from the biomedical research ethics committee at ukzn (ref. no. brec 201/04). results demographic student profile most (77%) 1st-year medical students at ukzn in 2013 were black and 58% were female. the average age of the cohort was 20 years. eighty percent had entered the medical programme straight from school and 13% had completed a prior tertiary qualification in a science discipline. nearly half (40%) were from quintile 1 and 2 (non-fee-paying) schools. types of services and reasons for selecting a site the types of services performed by the student group are represented in fig. 2. most groups chose to work with organisations that provided services to children. these included orphanages, children’s homes, places of safety, street children’s shelters, and organisations working with aids orphans and children living with disabilities. the reasons for choosing the selected sites included that students ‘liked working with children’. some thought that children were ‘more vulnerable to abuse and neglect’, and that the ‘impact of hiv is greatest in this age group’. homes for the aged and the mentally and physically challenged were also identified as sites where students preferred to spend their mad time. other organisations included those that worked with communities of refugees, the homeless, and people living with hiv/aids. the reasons for selecting these sites were pragmatic in that they were easy to travel to, or students thought that these organisations were not well supported: ‘it is close to where i live so i’m making a difference in my community. charity begins at home … they need as much help as they can get as they are shorthanded.’ ‘… there are less people who volunteer in that place [children’s home] without wanting money … .’ ‘this school is for the mentally challenged children that cannot cope in mainstream schools. the students come from poor backgrounds and are subjected to various challenges within the community such as drugs, alcohol, unsafe sex.’ ‘they come from poor homes and many have weak support systems.’ types of activities and challenges the activities undertaken by students at the mad sites included assisting with homework; feeding and caring for the disabled; occupational therapy activities; appropriate educational activities (e.g. tooth brushing, basic hygiene, back exercises); career guidance and motivation for senior pupils; reading and playing games with children; artwork; collecting books for a children’s library; planting vegetable gardens and basic facility maintenance. one of the challenges experienced by the groups included finding appropriate, common time to travel to sites. as students fund the activity themselves, some mentioned travel costs and obtaining resources for educational and other activities as a challenge. some students found it difficult to connect with learners who were not as trusting: ‘[it was difficult] getting pupils to be open with us during group work.’ ‘some did not participate eagerly, especially girls in sporting activities.’ 2 3 4 6 6 2 9 10 11 27 11 15 18 number of groups (n=63) type of service relief refugee rehabilitation place of safety special school orphanage youth/resource centre hiv care old-age home children's home funding source state church/religious non-governmental 0 5 10 15 20 25 30 fig. 2. types of communities served by 1st-year medical students during the 2013 ukzn mad. 206 october 2016, vol. 8, no. 2 ajhpe research students’ overall learning during mad despite the challenges, many reported enjoyment during the mad. they found that it was ‘… a humbling and huge learning experience’ and that they could ‘… see children find happiness in life’s simplest gifts’. the experience fostered team spirit among the students, who may have only known each other for a brief period. they reported being ‘… able to work together successfully and … sharing responsibility to work with multiple personalities’. some students’ interactions during the activity left a lasting impression. some captured the ways in which they learned in the following entries: ‘you learn to discover things by yourself, it opens [a] window of discovery – from the day we started looking for sites. also teaches us – no situation is the same. can’t expect same results in every situation … make the most of that situation.’ another reflected on his/her personal development in taking responsibility during mad: ‘it promotes creative thinking – no one tells you what to do – put in [the] ocean and develop own skills – does not let you relax – there is no-one else to blame.’ the involvement in the community led some students to decisions to continue their participation at the chosen site beyond the initially stipulated period: ‘personally, i will continue to help out at this organisation in future because it is close to home and it provides self-fulfillment to know that you are making a difference in someone else’s life.’ some students realised the relevance of public health and how the experience had helped to value the perspectives of others: ‘the public health lectures started to become real for me – the upstream and downstream factors.’ ‘we have views that are not always right, till we go and see for ourselves. “go and see” and we can relate better to what they [are] going through.’ discussion this article was conceived in an attempt to explore the development of social accountability in a cohort of 1st-year medical students through engagement in an experiential learning activity. through the various component steps of the mad, students demonstrated an increase in responsibility, responsiveness and accountability for their own learning and the plight of people in a disadvantaged community. students took responsibility for themselves and others through the setting of high expectations to ‘make a difference’. group members combined their strengths to gain and negotiate entry to an organisation of their choice where they planned appropriate activities in response to needs identified by community stakeholders.[13] they identified the sites, made contact and were involved in age-appropriate activities, including hiv/aids education in a community setting. their engagement in early authentic community-based exposures increased the relevance of their learning, as these settings reflected a realistic picture of their future work environment.[13] many students were not residents of the city and were initially unfamiliar with the environment in which they were to live and work for the duration of their medical education. the mad allowed students opportunities to work in small but diverse groups of peers who were not known to each other at first. the common experiences, however, facilitated the formation of strong bonds among peers as a result of mutual dependence on the strengths and skills of the diverse group. the students also learned from real first-hand experiences and reflected on the social determinants of health and disease, especially hiv/aids, in the supportive group environments. the support of the peer group, as reported by kubo et al.,[14] can greatly assist collaborative learning; this has been demonstrated in this case study where students gained insight into both the subject matter and how their course was preparing them in a relevant manner for their future career. medical student educators find it challenging to guide the development of professionalism during medical students’ lengthy period of training. this time-tabled activity helped students improve their communication with community stakeholders and understand their role as responsible caregivers. this educational experience facilitates early exposure to a community setting, which provided the experiences and foundations for learning and reflection on which to build in subsequent years. it also served as an important motivator to instil empathy in medical students in preparation for the future.[15] various steps in the process encouraged responsiveness. groups developed their service action plans in response to an identified need and in collaboration with their chosen organisation. reflection on the planned activities occurred in group meetings and through journalling. the effectiveness of the plans and the relationship of these plans to the expected outcomes and challenges experienced enabled reflection on the outcomes, and the modification needed during the process. responsive community engagement reinforces the real benefits to the communities and lends authenticity to students’ learning in the setting.[4] the mad boosted students’ accountability (steps 2, 3, 7, 11, 12, 15, 16 and 17 – fig. 1). they set and attended group meetings with their facilitators, kept a diary of time spent on mad, submitted formal documents as evidence of the agreements made, kept registers of visits, showed evidence that the poster had been displayed at the site, and presented the poster to their peers, stakeholders and examiners. finally, the programme emphasised commitment to public service, showing that students were starting on a journey towards transformation, with many making commitments to maintain their contact, even after the completion of the project. while many made strides in understanding their own learning, others became aware of their future responsibilities and the needs of marginalised communities. conclusion this case study demonstrated the guidance provided to 1st-year medical students to engage them in socially accountable service learning activities. authentic early community-based experiences were offered in curriculum time and involved all students enrolled in the medical programme. through the activity, the institution was able to engage communities in low-resource settings and at minimal cost to the faculty. the mad boosted students’ sense of responsibility and their responsiveness, and they learned aspects of accountability through engagement in the community. the students’ awareness of disadvantaged communities and the social determinants of health increased and they committed to playing a more active role in making a difference in local communities. october 2016, vol. 8, no. 2 ajhpe 207 research acknowledgements. the authors wish to thank the students who participated in this programme, the mad facilitators, site facilitators and the ukzn medical education partnership initiative (mepi). funding. this research and publication was made possible by the office of the global aids coordinator and the us department of health and human services, national institutes of health, grant no. 5r24tw008863. authors' contributions. sk co-ordinates the mad activity and prepared the article. jvw holds the ethical approval and contributed substantially to the writing of the article. td and sg co-ordinated and contributed substantially to the development and running of the mad in 2013 and 2014 and contributed to the article. references 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 2. starfield b, shi l, macinko j. contribution of primary care to health systems and health. milbank q 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x 3. littlewood s, ypinazar v, margolis sa, scherpbier a, spencer j, dornan t. early practical experience and the social responsiveness of clinical education: systematic review. bmj 2005;331(7513):387-391. doi:10.1136/ bmj.331.7513.387 4. medical professionalism project. medical professionalism in the new millennium: a physicians’ charter. lancet 2002;359(9305):520-522. doi:10.1016/s0140-6736(02)07684-5 5. world health organization. transforming and scaling up health professionals’ education and training. in: world health organization guidelines. geneva: who, 2013. 6. dornan t, littlewood s, margolis sa, scherpbier a, spencer j, ypinazar v. how can experience in clinical and community settings contribute to early medical education? a beme systematic review. med teach 2006;28(1):3-18. doi:10.1080/01421590500410971 7. boelen c, dharamsi s, gibbs t. the social accountability of medical schools and its indicators. educ health 2012;25(3):180. doi:10.4103/1357-6283.109785 8. boelen c, heck j. defining and measuring the social accountability of medical schools. geneva: who, 1995. 9. thenet.training for health equity network, 2015. thenetcommunity.org (accessed 23 february 2016). 10. boelen c. adapting health care institutions and medical schools to societies’ needs. acad med 1999;74(8 suppl):s11-s20. 11. gibbs g. learning by doing: a guide to teaching and learning methods. oxford: centre for staff and learning development, oxford brookes university, 1988. 12. shenton ak. strategies for ensuring trustworthiness in qualitative research projects. educ inf 2004;22(2):63-75. 13. boelen c, woollard r. social accountability: the extra leap to excellence for educational institutions. med teach 2011;33(8):614-619. doi:10.3109/0142159x.2011.590248 14. kubo k, okazaki h, ichikawa h, et al. usefulness of group work as a teaching strategy for long-term practical training in the 6-year pharmaceutical education. j pharm soc jpn 2011;132(12):1467-1476. doi:10.1248/ yakushi.12-00080 15. hojat m, vergare mj, maxwell k, et al. the devil is in the third year: a longitudinal study of erosion of empathy in medical school. acad med 2009;84(9):1182-1191. doi:10.1097/acm.0b013e3181b17e55 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1111/j.1468-0009.2005.00409.x http://dx.doi.org/10.1136/bmj.331.7513.387 http://dx.doi.org/10.1136/bmj.331.7513.387 http://dx.doi.org/10.1016/s0140-6736(02)07684-5 http://dx.doi.org/10.1080/01421590500410971 http://dx.doi.org/10.1080/01421590500410971 http://dx.doi.org/10.3109/0142159x.2011.590248 http://dx.doi.org/10.3109/0142159x.2011.590248 http://dx.doi.org/10.3109/0142159x.2011.590248 http://dx.doi.org/10.1097/acm.0b013e3181b17e55 research may 2016, vol. 8, no. 1 ajhpe 77 the use of the autopsy in teaching undergraduate medical students is a well-known worldwide practice.[1,2] autopsies are used for teaching anatomical and forensic pathology to underand postgraduate students. harris et al.[3] reported that general practitioners regard autopsies as ‘being of benefit to education and research’. their study excluded coroners’ cases and was published as part of the first publication of the uk general medical council’s tomorrow’s doctors.[3] burton[4] conducted a qualitative study on the use of the autopsy and the curriculum, indicating that the role of the former is multifactorial and can aid in teaching anatomy and clinicopathological correlations, can be a form of clinical audit and, in the forensic medicine setting, can aid in death certification. burton included structured interviews with teachers of undergraduate medical students, including histopathologists, non-pathologists, general practitioners, surgeons and physicians. (no forensic pathologists were interviewed.) the participants in burton’s study indicated that although it is strongly advised that students be exposed to autopsies, they did not feel that it should be compulsory. a number of articles have been written on the perceptions, views and attitudes of students after attending autopsies. in germany, tschernig et al.[5] reiterated that the medical student’s first encounter with corpses is usually during anatomy training. these authors indicate that even for the purpose of attending autopsies for anatomy training, students need to be prepared both psychologically and physically. benbow,[6] from the division of histopathology, department of pathological services, university of manchester, uk, distributed questionnaires to 2nd and 3rd-year undergraduate medical students, reviewing personal details and experiences as well as general questions about autopsies. the study indicated that medical students viewed the autopsies as useful, although some indicated that the only use is to determine the cause of death. the psychological effects indicated that some students could come to terms with death, while others found it ‘difficult’. physical symptoms included the worrisome smell, palpitations and tears. bataineh et al.,[7] from the department of anatomy at the jordan university of science and technology, reviewed questionnaires from preclinical medical students, which indicated that 28.9% expressed a degree of fear before entering the autopsy room, 19.3% had palpitations and 50.3% were concerned about an infection risk. it would appear that there is very little literature that reviews the perceptions of medical students who attend forensic pathology autopsies. at the university of athens, greece, papadodima et al.[8] indicated that 50% of students who attended forensic autopsies were fearful and anxious, with some experiencing physical symptoms such as nausea. sergentanis et al.[9] did a follow-up study with the objective of identifying risk factors for the psychological reactions experienced during the forensic medical practical rotation. the authors identified the following risk factors: female gender and ‘stereotypic beliefs about forensic pathologists, a more emotional frame of mind with regard to forensic dissection, more passive coping strategies, and greater fear of death’. he et al.,[10] from the department of pathology, shanghai hospital, second military medical university, china, reviewed the perceptions of medical students who attended autopsies on individuals who had died from unnatural causes. the students were enrolled voluntarily and divided into groups to view the autopsies from behind a glass partition on television screens linked to a camera, or stood next to the autopsy table. they indicated the advantages of attending the autopsies, e.g. with regard to anatomy teaching: ‘the autopsy is a valuable tool to clinical practice and analysis of background. numerous articles have been published on the use of autopsies in training medical students in anatomy and different branches of pathology. some authors have described the emotional response of students who attend such postmortem sessions. forensic pathology is an important subdivision of pathology. in some countries undergraduate medical students are expected to attend postmortem examinations on persons who died from traumatic causes. objective. to determine the attitudes and perceptions of 5th-year medical students with regard to forensic postmortem examinations at the university of pretoria, south africa. methods. a questionnaire was voluntarily completed by medical students on the last day of the practical rotation. results. the overall rating of the practical rotation was 82%. the strengths, weaknesses, opportunities and threats (swot) analysis indicated the following as strengths: record keeping, legislation review and traumatology description; as weaknesses: emotional trauma and nightmares; as opportunities: the attendance of autopsies; and as threats: physical dangers. conclusion. the current study was similar to international studies with regard to students’ emotional response to attending autopsies. the autopsy remains a valuable teaching tool for undergraduate students. emotional support is currently available for all students to assist them in overcoming their fear of attending forensic autopsy sessions. afr j health professions educ 2016;8(1):77-80. doi:10.7196/ajhpe.2016.v8i1.589 the forensic autopsy as a teaching tool: attitudes and perceptions of undergraduate medical students at the university of pretoria, south africa l du toit-prinsloo,1 mb chb, dipformed (sa) path, fcforpath (sa), mmed (path) (forens); g pickworth,2 bsc, bsc hons (psych), med (psych), dphil (psych); g saayman,1 mb chb, mmed (medforens), fcforpath (sa) 1 department of forensic medicine, faculty of health sciences, university of pretoria, south africa 2 department of education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: l du toit-prinsloo (lorraine.dutoit@up.ac.za) research 78 may 2016, vol. 8, no. 1 ajhpe wound condition and wound rescue in future work’; a method to ‘correlate information from different sources’; and ‘the autopsy is the epitome of problem-based learning’.[10] disadvantages included that it was physically ‘unpleasant and frightening’ and also ‘an autopsy in human terms is a horrendous thing to do … the mortuary room is a dangerous place’.[10] the authors indicated that the primary objective of the autopsy is to teach pathology; yet, most students indicated its helpfulness in teaching anatomy. the concluding remarks include that the students had a positive attitude towards autopsy (despite discomfort) and its multifactorial role. in south africa (sa), a study by de villiers and ruhaya [11] from the department of paediatrics at the university of limpopo (medunsa campus) (currently sefako makgatho health sciences university, pretoria) reviewed questionnaires completed by final-year medical students after autopsies conducted in anatomical pathology. twenty-two percent of students indicated that they felt that the corpses were handled disrespectfully, 58% that the first autopsy attendance was rewarding, and most (it is not exactly quantified) felt uncomfortable, with some experiencing nightmares. in forensic pathology training in sa, many of the medical schools require that undergraduate medical students attend forensic postmortem examinations. in a study by mcnamee et al.,[12] from the department of forensic medicine, nelson r mandela school of medicine, university of kwazulu-natal, durban, 10 students took part in semistructured interviews after completion of the forensic medicine practical rotation. all students experienced a degree of discomfort, 70% indicated that they had a better understanding of the mechanism of death and could better differentiate between natural and unnatural causes of death, and 80% indicated that the description of trauma aided a great deal. the current study was undertaken in the department of forensic medicine, university of pretoria, where 5th-year medical students voluntarily completed a questionnaire after completing a 2-week practical rotation in forensic pathology. the objective was to review perceptions and attitudes of students towards the practical rotation. methods at the university of pretoria, 5th-year medical students attend a 2-week practical rotation in the department of forensic medicine (8 consecutive groups). the facility at the forensic pathology service, medico-legal laboratory, pretoria consists of a large dissection hall with three dissection stations, where the bodies are placed next to each other and opened; organs are eviscerated in the hall and dissected at the dissection stations. adjacent to the large dissection hall is an autopsy amphitheatre, with a door opening into the large hall. in the autopsy theatre the students have a direct view of the dissection station. the bodies are brought into the theatre in order that an external examination can be performed, but the physical opening of the bodies and evisceration of the organs are conducted in the large dissection hall (behind the door). the students in the theatre view the organ dissection. each student rotation consisted of ~30 students who were divided into two groups − a large group of ~20, who were seated in the theatre and observed the postmortem examinations, and a smaller group of ~10, who stood in the dissecting room. during the 2 weeks, the students were rotated between the large and small groups. each student therefore attended ~10 postmortem examination sessions (each session lasted ~90 minutes). of special note is that the daily cases are viewed prior to the arrival of the students and severely mutilated or decomposed bodies are not shown to the students. after the practical postmortem sessions, the students attended tutorial sessions in a lecture room at the mortuary. these lasted up to 2 hours each and were conducted as powerpoint presentations, providing information on topical issues, such as death notification and legislation, which are not taught in formal lectures. in 2011, the year of the current study, no specific emotional support or preparation was provided to students before commencement of the rotation. at the end of the 2-week rotation, the students were asked to voluntarily complete a questionnaire. the questionnaire was divided into four parts: • part a (quantitative): 10 general questions regarding the information provided to students, expectations and organisation. students indicated their response on a scale of 1 (strongly disagree) 5 (strongly agree). • part b (quantitative): the students provided an overall rating of the practical rotation on a scale of 1 10. • part c (qualitative): the so-called strengths, weaknesses, opportunities and threats (swot) analysis was used and the students could write their responses under each component. • part d (qualitative): space was provided for the students to write recommendations. results in 2011, 220 students were enrolled for the 5th-year of the mb chb degree. a total of 212 (96%) students completed the voluntary questionnaire at the end of the forensic medicine practical rotation. part a. general information: quantitative table 1 summarises the average obtained for each of the questions. part b. overall rating of the rotation: quantitative all eight groups indicated a score of >8/10 as a general impression of the rotation (with an average of 82%). table 1. general information question average, % we were well informed where we had to be on the first day of the rotation 93 we received sufficient information on what would be expected of us in the rotation 86 the outcomes and objectives of the rotation, as well as the way in which we would be evaluated, were clearly communicated to us 83 we had sufficient exposure to forensic postmortem examinations (variety of cases) and the medicolegal investigation of death 92 our time was used very effectively 92 the tutorial sessions were well presented and informative 91 the evaluation assessed what we had learned in the rotation 84 the consultants and registrars made positive inputs towards our training 90 the personal protective equipment in the mortuary was up to standard 85 the rotation was well organised 92 research may 2016, vol. 8, no. 1 ajhpe 79 part c. swot analyses: qualitative strengths several of the students indicated the following as strengths: • the emphasis on applicable legislation pertaining to medical practitioners • the practical exposure and opportunity to attend autopsies • the importance of proper record-keeping • recognising the different aspects of death • how to deal with death (‘how to cope with dramatic deaths and injuries’) • differentiating between deaths due to natural and unnatural causes • the nature of injuries and the terminology of trauma, which were explained • how to determine the cause of death • revision of anatomy. weaknesses students indicated that: • they experienced the rotation as emotionally traumatising (n=64) • the rotation showed ‘too much death and dying’ and they were ‘being exposed to death in such a brutal manner’ • the smell was worrisome (n=4), and he/she experienced nightmares (n=1) • he/she could not continue the rotation after 3 days of exposure (owing to nightmares) (n=1) • there had been no debriefing (n=2) • the rotation was too short (n=4). opportunities students indicated that: • a wide variety of cases were seen (n=35) • the attendance of autopsies was an opportunity to learn pathology and anatomy, as normal and abnormal findings were seen (n=15) • the attendance taught them the procedure being followed and what to expect during an autopsy (n=8) • information regarding medical negligence was provided (n=7) • the rotation was a ‘good learning opportunity’, but they did not elaborate on the statement (n=5) • they learned a lot about the common causes of death in the medicolegal environment in sa (n=3) • one can ‘overcome fear of death’ (n=1) • he/she would consider forensic pathology as a specialty (n=1). threats students indicated that: • personal protective equipment was insufficient (n=6) • they were worried about the risk of infections, specifically tuber culosis (n=2) • the bodies or organs were handled dis respectfully (n=2) • awareness of medical negligence was high lighted (n=4). part d. recommendations students recommended that: • attendance should not be compulsory (n=2) • there should be fewer postmortem sessions (n=2) • the practical rotation should be longer (n=5) • a debriefing session/better emotional preparation is needed prior to commencement of the practical session (n=5). discussion the training of undergraduate medical students differs worldwide. in sa, the health professions council of south africa (hpcsa) is the governing body for healthcare practitioners and prescribes the clear minimum standards of training for medical students. in the core competency lists provided by the hpcsa, the exact curriculum and expectations for forensic medicine/pathology are not clearly stipulated.[13] the autopsy is a valuable tool when teaching several important branches of medicine to undergraduate students, such as anatomy and pathology.[1,2] undergraduate students are exposed to different forms of learning with regard to the deceased. at most institutions, anatomy teaching exposes students to embalmed bodies, where they often perform the dissections. attending postmortem examinations in pathology – anatomical as well as forensic – entails viewing a non-embalmed body (in the majority of cases). at the university of pretoria, medical students attend most of the anatomy dissections in the 2nd year of study, anatomical pathology in the 3rd year and the forensic pathology practical rotation in the 5th year (the undergraduate degree comprises 6 years of study at our institution). the difference in the type of body seen and the expected teaching and learning outcomes makes it difficult to compare studies on the role of the autopsy as a teaching tool. tschering et al.[5] pointed out that the first encounter with human bodies is usually in the anatomy dissection hall and they refer to the provocative question posed by lippert in 1985: ‘how humane is human anatomy and to what extent will the behaviour of a medical student during dissection influence his/her future attitude to patients?’ the current study was smilar to other international studies with regard to students’ emotional responses to attending forensic autopsies.[8-10] it would appear that there is a degree of ambiguity in their response to the practical rotation, as the sessions were generally regarded as a positive learning experience, with the overall impression receiving a score of >8/10; yet, 30% of the students indicated an emotional aspect (seeing too much of death). an explanation for this discrepancy could be that most of the questions in part a relate to the administration of the rotation (time management, tutorial sessions and assessments), with one question phrased as ‘we had sufficient exposure to forensic postmortem examinations (variety of cases) and the medicolegal investigation of death’. the students scored the latter question 92%, and it could be that even those who found the rotation emotionally distressing agreed that they had ‘sufficient exposure’. a second reason could be that the swot analysis might not have been the best tool with which to evaluate the perceptions of students. the study also reiterated the findings of mcnamee et al.[12] regarding the emotional aspect surrounding the attendance of forensic autopsies, indicating that the autopsy aided in the description of trauma and differentiated between natural and unnatural causes of death. statistics sa[14] specified that in 2010, 543 856 people died in sa, a country with an estimated population of ~50 million. of these deaths, 48 377 were due to unnatural causes. this indicates and emphasises the importance of training undergraduate medical students in the legislation pertaining to registering deaths correctly and how to recognise a death as being due to an unnatural cause. furthermore, there are only 50 forensic pathologists in sa. this implies that a large number of medicolegal postmortem examinations are being conducted by general practitioners – a reality that further emphasises the importance of training undergraduate medical students in the field. at the university of pretoria, student feedback confirmed that some students experience emotional distress relating to forensic autopsy sessions. research 80 may 2016, vol. 8, no. 1 ajhpe this highlights the need to address both the educational goals and emotional impact for students. emotional support has been introduced, with clinical psychologists being available to students who find it difficult to cope with the forensic autopsy sessions. currently, a clinical psychologist addresses the entire group at the mortuary after the first postmortem session (due to other clinical engagements this was the only feasible session) and on the last thursday of the 2-week rotation. during the first session, the clinical psychologist provides a contact number to initiate further emotional support, should the individual need arise. the feedback forms pointed out that all applicable sa legislation is made available to students, and the emphasis of the practical session is on teaching what a generalist medical practitioner should know. conclusion the autopsy as part of the undergraduate training of medical students remains an invaluable tool. in a country with a high number of violent and unnatural deaths, appropriate teaching regarding legislation and management of victims (especially appropriate referral for medicolegal investigation in cases of death) cannot be neglected. provision needs to be made to support medical students who experience the rotation as emotional. the current study only reflects the opinions of medical trainees and does not represent objective measuring of the evidence of the learning of these students. acknowledgements. the authors would like to thank mmes v tredoux and h malherbe from the department of education innovation at the faculty of health sciences, university of pretoria for capturing the data onto the system. special thanks also to ms b english from the faculty of health sciences for the language editing of the article. references 1. deroy ak. the autopsy as a teaching-learning tool for medical undergraduates. j med educ 1976;51:1016-1018. [http://dx.doi.org/10.1097/00001888-197612000-00011] 2. hill rb, anderson re. the uses and value of autopsy in medical education as seen by pathology educators. acad med 1991;66:97-100. [http://dx.doi.org/10.1097/00001888-199102000-00011] 3. harris a, ismail i, dilly s, maxwell jd. physicians’ attitudes to the autopsy. j r coll physicians lond 1993;27:116-118. 4. burton jl. the autopsy in modern undergraduate medical education: a qualitative study of uses and curriculum considerations. med educ 2003;37:1071-1081. [http://dx.doi.org/10.1046/j.1365-2923.2003.01710.x] 5. tschernig t, schilaud m, pabst r. emotional reactions of medical students to dissecting human bodies: a conceptual approach and its evaluation. anat rec 2000;261(1):11-13. 6. benbow ew. medical students’ views on necropsies. j clin pathol 1990;43:969-976. [http://dx.doi.org/10.1136/jcp.43.12.969] 7. bataineh zm, hijazi ta, hijleh mf. attitudes and reactions of jordanian medical students to the dissecting room. surg radiol anat 2006;28(4):416-421. [http://dx.doi.org/10.1007/s00276-006-0101-4] 8. papadodima sa, sergentanis tn, illiaki rg, sotiropoulos kc, spiliopoulou ca. students who wish to specialize in forensic medicine vs. their fellow students: motivations, attitudes and reactions during autopsy practice. adv health sci educ theory pract 2008;13:535-546. [http://dx.doi.org/10.1007/s10459-007-9065-3] 9. sergentanis tn, papadodima sa, evaggelakos ci, mytilinaios dg, goutas nd, spiliopoulou ca. students’ physical and psychological reactions to forensic dissection: are there risk factors? anat sci educ 2010;3(6):287294. [http://dx.doi.org/10.1002/ase.182] 10. he m, wang j, zhu z, et al. a survey study of military medical students to autopsy in modern medical education. scientific research and essays 2011;6(32):6666-6670. [http://dx.doi.org/10.5897/sre11.1197] 11. de villiers fpr, ruhaya m. students’ opinions on autopsy and death. sa fam pract 2005;47(1):47-50. [http:// dx.doi.org/10.1080/20786204.2005.10873172] 12. mcnamee ls, o’brien fy, botha jh. student perceptions of medico-legal autopsy demonstrations in a studentcentred curriculum. med educ 2009;43:66-73. [http://dx.doi.org/10.1111/j.1365-2923.2008.03248.x] 13. health professions council of south africa. www.hpcsa.co.za (accessed 14 december 2015). 14. statistics south africa. mortality and causes of death in south africa, 2010: findings from death notification. http://www.statssa.gov.za/publications/p03093/p030932010.pdf (accessed 16 march 2014). ajhpe issn 0256-9574 african journal of health professions education 2010, vol.2 no.2 short research report 168 december 2017, vol. 9, no. 4 ajhpe chest trauma is one of the most common surgical conditions seen in our teaching hospital at the university of botswana and in the southern african region.[1] therefore, intercostal chest drain (icd) insertion is regarded as a core skill in the medical curriculum. during surgical rotations and assessments we observed varying exposure of students to surgical conditions, despite the high surgical disease burden, and also varying levels of competence in managing chest injuries. simulation-based training plays a significant role in current surgical training practice,[2] and we hypothesised that chest trauma management, knowledge and skills may be improved by employing low-cost task trainers. simulation describes a full-range use of physical objects (task trainers) or situations for mimicking real-life scenarios or functions during training. it plays a significant role in current health professions education, and was introduced to address the decreasing exposure to real patients in surgery[2,3] and improve teaching and assessment in medicine.[4] simulation-based training and its assessment for both cognitive and psychomotor learning domains have been studied extensively.[5] this study employs a preand post-test design[6] to assess an educational intervention based on the kirkpatrick evaluation model for training.[7] the kirkpatrick model defines four evaluation levels. levels 1 and 2 evaluate short-term outcomes, such as acceptability and change in level of knowledge and skills, while levels 3 and 4 evaluate behavioural change associated with training and the organisation’s ultimate gain. we hypothesised that chest trauma management, knowledge and skills may be improved by employing simulation in the form of locally made lowcost task trainers. the overall purpose of this pilot study was to improve management of chest trauma. we included simulation in the previously theory-based chest trauma training module and thereafter tested trainees’ knowledge and skills with regard to the effectiveness of the intervention. we also tested acceptance of this new simulation-based module. methods research setting the study was conducted at the university of botswana’s new faculty of medicine, where the competence-based curriculum employs a problembased learning approach and traditional patient encounters. research design this study employed a quantitative preand post-test design. population and sampling all medical students (n=41) were invited to take part in the study after their last surgical rotation and newer intern doctors (n=20) during their initial rotation – before being deployed to the surgical rotation. using convenience sampling we included 35 medical students and 14 interns. there were 39 participants in the pre-test assessment and training; 14 completed all three sessions, i.e. the pre-test assessment, training and post-test assessment. data collection instrument a checklist developed for the module was used for the pre-test and post-test assessments. thirteen content-based items (total score of 22) evaluated the students’ knowledge relating to the diagnosis and management of a chest injury (cognitive domain) and one item (total score of 3) evaluated their ability to perform the procedure correctly (psychomotor domain). a rating background. to improve the management of chest trauma at the university of botswana, gaborone, botswana, we incorporated simulation into a theorybased chest trauma module by developing procedural guides, checklists and low-cost simulation. objectives. to assess the suitability of low-cost simulation-based training and its impact on students’ proficiency, as well as its general acceptability. methods. a total of 39 medical students who completed their surgical rotation and 20 intern doctors in their first clinical rotation participated. a checklist was used in a preand post-test design to assess procedural proficiency, and a rating system categorised scores. thirteen content-based items assessed the students’ knowledge relating to the diagnosis and management of a chest injury and one item assessed their ability to perform the procedure correctly. a questionnaire was administered after the second assessment to evaluate the acceptability of the training module. findings were summarised by median, proportion and range, and preand post-test outcomes were compared by student’s paired t-test. results. preand post-test assessment scores differed significantly (median (range) 11.3 (4.5 21.0) and 19.5 (15.5 23.0), respectively (p<0.001)). the proportions of participants’ scores categorised as ‘full proficiency’ rose from 7% to 42%, and ‘reasonable proficiency’ from 30% to 60%, while both ‘some proficiency’ and ‘poor proficiency’ decreased from 50% and 20% to 0%. most (93%) participants ‘strongly agreed’ that the training module was acceptable. conclusion. our results demonstrate the suitability of low-cost simulation for training and assessment in resource-constrained settings. afr j health professions educ 2017;9(4):168-170. doi:10.7196/ajhpe.2017.v9i4.829 the use of low-cost simulation in a resource-constrained teaching environment m mwandri,1 md, mmed (surgery); m walsh,1 bsc, mbbs, ms, frcs (gen); j frantz,2 bsc, msc, phd; r delport,3 msc, med, phd 1 department of surgery, school of medicine, university of botswana, gaborone, botswana 2 faculty of community and health sciences, university of the western cape, cape town, south africa 3 skills laboratory, faculty of health sciences, university of pretoria, south africa corresponding author: r delport (rhena.delport@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. december 2017, vol. 9, no. 4 ajhpe 169 scale was developed to describe their performance scores, and a survey based on kirkpatrick’s model was used to assess the trainees’ acceptability of the module by trainees. data collection and procedure management of chest trauma was assessed before and after a training intervention. the training module comprised theoretical and practical sections. the theoretical component covered the clinical presentation, chest radiograph interpretation and management of chest trauma. the practical component was taught in a simulated environment using task trainers as low-cost simulation for the insertion of icds. the task trainers were built from affordable material and comprised a suture trainer and icd-insertion trainer, respectively (fig. 1a and b). knowledge and understanding (cognitive assessment) and procedural proficiency (psychomotor ability) were evaluated using a checklist that was developed in accordance with the advanced trauma life support programme founded by the american college of surgeons. the assessment was designed to evaluate suitability and acceptability of the proposed module – not for summative assessment purposes. the checklist evaluated students’ knowledge and understanding of indications for chest drain insertion, which included the use of diagnostic criteria for chest radiograph interpretations, anatomical considerations in icd insertion, indications for referral for surgery, maintenance of icd patency and monitoring for abnormalities regarding drainage. there were multiple possibly correct responses for each item and a mark of 0.5 was allocated for each correct response. the psychomotor section of the checklist assessed appropriate handling of instruments, economy of movements during a procedure, correct forming of knots, and correct suturing. a mark of 0.5 was awarded for each correctly performed step. if students demonstrated smooth forward progression of the procedure (incision and insertion of the drain, suturing to control leakage, anchoring of the drain), they were awarded 1 mark, as it closely demonstrates mastering of psychomotor skills and not merely observing how to perform a task. the pre-test assessment and training were performed on the same day. the post-test assessment employed the same checklist as the pre-test and was conducted 2 weeks after the training session. the scores obtained from the assessments were converted to percentages and a rating system was designed to categorise scores, ranging from ‘poor proficiency’, ‘some proficiency’, ‘reasonable proficiency’ and ‘full proficiency’ for percentage scores of <40, 40 59, 60 79, and 80 100, respectively. after the training session, a course evaluation survey employed likert scales to assess acceptance of the model as formal training for chest trauma, clarity of the content, and relevance of the content to practise, as perceived by participants who completed preand post-training assessments.[8] data analysis collated information was analysed using spss 16 (spss inc, usa). mean, median, frequency and proportion were summarised to describe the pre and post-training test assessment scores. student’s paired t-test was used to compare preand post-test performance. a p˂0.05 value indicated a statistically significant change. scores were graded using the described rating system. ethical approval ethical approval for this study was granted by the university of botswana (ref. no. x-ref:ubr/ethi/21). written informed consent was obtained from each of the participants. results thirty-nine participants took the pre-test and underwent training. fourteen (36%) participants completed all planned sessions, completing the pre-test, training and post-test assessments. the analysis comparing the preand post-training tests was performed on the 14 participants who completed all the planned sessions. the median (range) scores for preand posttest assessments were 11.3 (4.5 21.0) and 19.5 (15.5 23.0), respectively (p<0.001). the median scores for the psychomotor assessment (chest drain insertion skill) improved from 1.0 (0 3.0) to 2.5 (1.5 3.0) of a possible score of 3 in the pre-test and post-test assessments, respectively. six (42%) participants attained ‘full proficiency’ grades in the post-test assessment compared with 1 (7%) in the pre-test. participants in the ‘reasonable short research report fig. 1. (a) step-wise illustration of creating a suture trainer. (b) intercostal chest drain-insertion trainer. 170 december 2017, vol. 9, no. 4 ajhpe profi ciency’ grade rose from 4 (30%) to 8 (60%) in pre-test and post-test assessments, respectively. participants in the ‘some proficiency’ and ‘poor proficiency’ grades in the pre-test decreased from 6 (50%) and 3 (20%), respectively, to 0% in the post-test. the majority of participants (93%) strongly agreed that they would accept this module as their formal training for chest trauma. discussion this study evaluated the usefulness and acceptability of low-cost simulation in a resource-limited environment. the process undertaken represents the initial two levels of the kirkpatrick model: change of knowledge following the training and reaction from the trainees.[7,8] several previous studies have demonstrated the effectiveness of simulation in assessment.[2-4] at our university and other universities in developing countries, medical training has not fully exploited the use of simulation for training and assessment.[3] despite the demonstrated advantages of simulation in surgical training, the literature on this topic in sub-saharan africa is scarce – probably because of the limited use of simulation.[2,3] among the possible reasons for these low usages are: high cost of purchasing simulation models and lack of logistical and organisational initiatives.[2,3] although there is an abundance of patient encounters for trainees and a high disease burden in many developing countries, simulation may still form an important part of training and assessment of critical skills. in comparable situations, simulations have been used for the initial training of novices, e.g. in the military and aviation industries.[2,4] study limitations the main limitations of this study were: (i) loss to follow-up of participants in the post-test assessment, which may affect the generalisability of our findings; and (ii) ethical issues that restricted the use of control groups in this pilot study, leading to the use of single-group preand post-test designs, which are known to have variations in estimations of the effect size of outcomes. conclusion the results of this study indicated that low-cost simulation can be a useful and readily available aid for training and assessment in a resourceconstrained environment. if used in conjunction with the existing surgical curriculum, low-cost simulation appears to contribute to the knowledge and skills of our students and trainees. low-cost task trainers, as described in this study, are an effective option for training and assessment. we would recommend an extension of this type of model to the rest of the curriculum. we also recommend that further studies should be done to evaluate the long-term impact of low-cost simulation on trainees’ behavioural change and patients’ outcome. acknowledgements. we acknowledge the contributions of drs s kuskov, m kwati and k mmalane from princes marina hospital, gaborone, botswana, and the 2014 sub-saharan africa-faimer regional institute (safri) faculty and fellows for their support and contributions. author contributions. mm: conception, design, analysis, data interpretation and writing of the manuscript; rd: conception, design, data interpretation and critical revision of intellectual content; jf: conception, design, data interpretation and critical revision of intellectual content; and mw: data interpretation and critical revision of intellectual content. all the above-named authors approved publication of this manuscript. funding. none. conflicts of interest. none. 1. clarke dl, quazi ma, reddy k, et al. emergency operation for penetrating thoracic trauma in a metropolitan surgical service in south africa. j thorac cardiovasc surg 2011;142(3):563-568. https://doi.org/10.1016/j. jtcvs.2011.03.034 2. raison n, ahmed k, dasgupta p. role of simulation in surgical training. eur urol focus 2016;2(1):63-64. https:// doi.org/10.1038/nrurol.2016.147 3. taché s, mbembati n, marshall n, et al. addressing gaps in surgical skills training by means of low-cost simulation at muhimbili university in tanzania. hum resour health 2009;7:64. https://doi.org/10.1186/14784491-7-64 4. scalese rj, obeso vt, issenberg sb. simulation technology for skills training and competency assessment in medical education. j gen intern med 2008;23(1):46-49. https://doi.org/10.1007/s11606-007-0283-4 5. kardong-edgren s, adamson ka, fitzgerald c. a review of currently published evaluation instruments for human patient simulation. clin simul nurs 2010;6(1):e25-e35. https://doi.org/10.1016/j.ecns.2009.08.004 6. maier-riehle b, zwingmann c. effect strength variation in the single group pre-post study design: a critical review. die rehabilitation 2000;39(4):189-199. https://doi.org/10.1055/s-2000-12042 7. kirkpatrick d, kirkpatrick j. evaluating training programs: the four levels. 3rd ed. california: berrett-koehler, 2006. 8. allen ie, seaman ca. likert scales and data analyses. qual progress 2007;40(7):64-65. accepted 15 june 2017. short research report https://doi.org/10.1016/j.jtcvs.2011.03.034 https://doi.org/10.1016/j.jtcvs.2011.03.034 https://doi.org/10.1038/nrurol.2016.147 https://doi.org/10.1038/nrurol.2016.147 https://doi.org/10.1186/1478-4491-7-64 https://doi.org/10.1186/1478-4491-7-64 https://doi.org/10.1007/s11606-007-0283-4 https://doi.org/10.1016/j.ecns.2009.08.004 https://doi.org/10.1055/s-2000-12042 november 2015, vol. 7, no. 2 ajhpe 153 short report in africa we are faced with enormous challenges in healthcare that require intensive and high-quality research; yet, there is a lack of clinically trained research scientists and of support for those who do exist. if south africa (sa) in particular and africa in general are going to tackle their huge healthcare burdens appropriately, we need well-trained scientists with clinical expertise to lead research endeavours and to train our future clinical researchers. because of the ‘serious decline in clinical research activity and capacity’, the academy of science of south africa (assaf) examined the state of clinical research and related training in south africa. in 2009, the report published by assaf recommended, among others, ‘stimulating phd degrees for professional graduates through the widening of the necessary opportunity and support mechanisms’.[1] the recommended target was 500 phds to be produced in the clinical research field over the next 10 years.[1] in the usa the md-phd pathway appears to be the most prevalent way of training clinician scientists.[2] the federal government through the national institutes of health (nih) is the major funder of such programmes.[3] while the md-phd programme has been successful, the postgraduate training of clinicians in research is also showing promising outcomes.[4] a similar programme was established in the uk in 2000 following reports from the royal college of physicians and the academy of medical sciences of the united kingdom.[5] however, this process, while well funded and highly competitive, has had low phd completion rates.[3] the importance of investment in the development of clinician scientists cannot be overestimated. however, not all governments invest or invest sufficiently in this area. while the assaf report[1] recommended ‘raising the research and development budget to 2% of the gross domestic product (gdp), of which 20% should be allocated to health research’, as well as other measures, to date this is only slowly translating into funding for capacity development in the clinical sciences in sa. in 2009, the faculty of health sciences, university of the witwatersrand, johannesburg, sa, supported by the carnegie corporation of new york, chose to initiate a programme around the development of appropriately skilled academic clinicians, of which the clinician scientist was an integral part. this article describes the setting up of the programme, the aim of which is to provide opportunities for young clinicians to develop research skills through enrolling for a phd. methods on the basis of funding from the carnegie corporation of new york, the faculty of health sciences formalised the ‘academic medicine clinician scientist phd programme’ within the health sciences research office and appointed a director of the programme to provide oversight and mentorship to the fellows. applicants are required to have a medical degree and a specialist qualification (mmed degree). the fellowship is of 2 years’ duration (restricted owing to funding), during which period fellows are expected to complete their phd − ready for submission for examination. fellows select their own field of research and supervisor/s in one of the well-established research niches in the faculty. as part of the fellowship the candidates have to attend courses, e.g. on research methodology, biostatistics, scientific writing, research ethics, curriculum design and student assessment. so as to allow for full-time research activities, the fellows do not participate in routine clinical service delivery. once the phd degree has been attained, funding is also provided towards running expenses for postdoctoral research activities to encourage the setting up of a research niche by the fellow. background. a shortage of clinician scientists globally, particularly in the developing world, including africa and south africa (sa), is well known and was recently highlighted in a consensus report by the academy of science of south africa. there is a need to find innovative ways to develop and advance clinician scientists in sa. objective. to provide opportunities for young clinicians to develop research skills through enrolling for a phd. method. to address this need in sa, we developed an innovative programme over 2 years in collaboration with the carnegie corporation of new york to support and train young specialist clinicians in research as the next generation of clinician scientists, through a full-time phd programme. results. since initiation of the programme in march 2011, 16 such specialists have been enrolled at intervals in the fellowship programme, 5 have qualified with phds, while a further 3 are expected to qualify shortly. publications and presentations at congresses have been recorded as well as grant applications. discussion. although the programme is seen as an important initial step in addressing the shortage of clinician scientists, its dependence on donor funding and the lack of a secure career path for clinicians wishing to spend more of their career in research pose problems for the programme’s sustainability. it is hoped that the positive outcomes of this experience will initiate further programmes of this kind at academic institutions and attract the attention of funders and universities in order to sustain and enlarge this initiative. afr j health professions educ 2015;7(2):153-154. doi:10.7196/ajhpe.671 rising to the challenge: training the next generation of clinician scientists for south africa b kramer,1 bsc, bsc hons, phd; y veriava,2 mb bch, fcp (sa), frcp (lond), dsc (honoris causa); j m pettifor,1 mb bch, phd (med), fcpaed (sa), massaf 1 health sciences research office, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 school of clinical medicine, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: b kramer (beverley.kramer@wits.ac.za) 154 november 2015, vol. 7, no. 2 ajhpe it is critical to adequately support the fellows financially during the 2-year period of their fellowship. therefore, each fellow is provided with a tax-free stipend approximately equivalent to that which they would have earned in their clinical post, but without overtime remuneration, medical aid and pension contributions. as most sa academic clinicians are employed by the provincial government, it has been important to negotiate with the authorities to allow the relevant fellow/s to take a 2-year leave of absence from their posts to allow them to return to their clinical position on completion of their fellowships. results to date we have enrolled 16 fellows into the programme in 4 cohorts of 4 fellows each per annum. the 16 fellows were ethnically diverse − 7 black, 6 indian, 2 white and 1 coloured. fellows accepted into the programme were mainly of sa origin (14 out of 16). thirteen of the 16 fellows were females. fields of research have been generally well distributed over the disciplines within clinical medicine, thus establishing niche areas where research in these specific fields can grow in the future. while the programme is in its infancy, we believe the outcomes have been substantial. the first cohort of 4 fellows completed their fellowships in 2013 and graduated in the same year, thus completing their degree in the minimum 2-year time period. all 4 graduates have returned to their clinical departments in the academic hospitals. the second cohort of 4 fellows was due to complete in july 2014 (only 1 has graduated within the 2 years, the others should be submitting their theses shortly), while the third and fourth cohorts are still in the early stages of their research. publication outputs with regard to cohort 1 have been very encouraging (11 publications), as well as several presentations at local and international congresses. publication output from the second cohort has been less substantial to date. in addition, 3 of the fellows from cohort 1 were awarded a total of 4 awards for their presentations at national congresses, and thus far 1 fellow from cohort 2 has been awarded for a presentation at a congress. one fellow from cohort 2 was appointed as assistant dean for teaching and learning. two of the fellows have been awarded substantial grants by an external/corporate foundation. a total of 81 research courses have been attended by the first 8 fellows, indicating the perceived need for such formal training during the phd programme. discussion although in its infancy in comparison with programmes in the usa and uk, the wits academic medicine clinician scientist programme was successfully initiated to meet the need voiced by the sa minister of health, the sa medical research council and assaf[1] to increase the number of clinician scientists in the country. the programme has demonstrated the possibility of training qualified medical specialists in research and academic skills, with the outcome of a completed phd in a minimum of 2 years. we acknowledge, however, that this period is extremely demanding and inappropriately short when compared with other programmes such as the nih mentored research scientists development award (k01) programme, which provides protected time of 3 5 years for career development in clinical sciences.[6] kosik et al.[4] undertook a systematic review of the literature to identify the best models for clinician scientist training. using outcome measures such as publications and/or awarding of grants, the authors identified 13 programmes in 9 studies. of the programmes surveyed, the medical scientist training programme in the usa proved to be the most successful model, with 83% of graduates entering a career in academia and 78% receiving major grants,[4] although this positive assessment is not shared by all. kosik et al.[4] also suggest that training following specialisation through postgraduate programmes showed promising outcomes. the average time to complete the md-phd in 24 programmes in the usa was 8.0±0.4 years.[2] in the sa context, as in other developing countries, where doctors are sorely needed following graduation, training clinician scientists at the postgraduate level is the financially more viable and faster option. the gains already experienced from this new programme have been substantial. it has firmly established the opportunity in the faculty for young clinicians wishing to obtain a phd. furthermore, clinical publications and conference proceedings have emanated from the programme. we hope the programme will have a positive effect on the retention of young staff, as on completion of their fellowships the fellows are expected to return to their original departments and are given research funding for a year postphd to encourage the development of a research nidus in their disciplines. the sustainability of this programme is of concern. the funding required to maintain it is higher than that of the average phd programme, as it has to provide a stipend which is commensurate with the age and qualifications of the fellows. the lack of suitable funders locally may be a barrier to continuing and extending the programme. in addition, the lack of a defined clinician researcher career path in academic medicine in sa is an additional barrier to continuance of the programme. in this regard, there is a need for the university to accept that it has the responsibility to fund research and support staff positions in the clinical disciplines. while it is premature to assess the impact of this programme, its influence will be tracked over time. the challenges faced by clinicians in an african setting, through our quadruple burden of disease and the resulting heavy clinical service loads, are very different from those faced by clinicians in developed countries, and impact on the training of our young clinicians. therefore, to enable our clinician scientists to achieve the relevant research training in this difficult arena, a structured programme ensuring protected time is imperative. conclusion an innovative, structured programme that ensures protected time for undertaking research has been set up for the training of clinician scientists at our institution. this programme shows promising outcomes, which may lead to the training of a pool of clinician scientists for africa. acknowledgements. the authors wish to acknowledge the support of the carnegie corporation of new york, without which the initiation of this programme would not have been possible. in addition, two past deputy vice-chancellors, profs bellinda bozzoli and helen laburn at our institution, must be acknowledged for their contributions and valuable insight into the initiation of this programme. ethics clearance for undertaking this study was approved by the human research ethics committee of the university of the witwatersrand (hrec m140701). conflict of interest. the authors declare that funding was received for the programme from the carnegie corporation of new york. references 1. mayosi bm, dhai a, folb p, et al. revitalising clinical research in south africa: a study on clinical research and related training. pretoria: academy of science of south africa, 2009. 2. brass lf, akabas mh, burnley ld, et al. are md-ph.d programs meeting their goals? an analysis of career choices made by graduates of 24 md-phd programs. acad med 2010;85(4):692-701. [http://dx.doi.org/10.1097/ acm.0b013e3181d3ca17] 3. stewart gw. an mbphd programme in the uk: the ucl experience. clin med 2012;12(6):526-529. [http:// dx.doi.org/10.7861clinmedicine,12-6-526] 4. kosik ro, tran dt, pei-chen fan a, et al. physician scientist training in the united states: a survey of the current literature. eval health prof 2014;1-18. [http://dx.doi.org/10.1177/0163278714527290] 5. turnbridge m. monitoring the clinicain scientist scheme. clin med 2004;4(2):141-143. [http://dx.doi.org/10.7861/ clinmedicine.4-2-141] 6. juve am, kirsch jr, swide c. training intensivists and clinician-scientists for the 21st century: the oregon scholars program. j grad med educ 2010;2(4):585-588. [http://dx.doi.org/10.4300/jgme-d-10-000871] short report research 144 september 2017, vol. 9, no. 3 ajhpe many medical schools currently offer medical students the opportunity to spend time in rural settings as part of their education.. the expectation is that such experience will encourage future interest in rural practice. this approach is supported by studies showing that rural experiences during training can increase the likelihood of students choosing to practise in rural areas after graduation.[1-3] the first medical school in botswana opened at the university of botswana in 2009 and the first cohort of students graduated in 2014. the school trains doctors in gaborone, an urban setting, with rural clinical placements in serowe, molepolole, mahalapye and maun. the teaching curriculum emphasises that the training should take place at all levels of the health system; therefore, the curriculum includes rural training to enhance students’ learning and experiences. the curriculum includes exposure to rural healthcare in various formats throughout the 5-year programme. the places where students do rural training are highlighted in fig. 1. during each of the 1st and 2nd years students complete 4 weeks’ training in a public health community, in each of the 3rd and 5th years they complete 8 weeks of family medicine, and in the 4th year they complete 8 weeks of public health. this gives a total of 32 weeks of rural exposure throughout the 5 years. as an example, the curriculum for the family medicine rotation involves problem-based learning sessions, ward rounds and outpatient care, as well as attendance at continuing medical education lectures. tutorials and practicals focus on patient-centred consultations, the doctor, the patient and environmental factors in consultation, communication skills (e.g. breaking bad news), motivational interviewing and counselling skills. although the medical students in botswana are exposed to rural training at different levels, their perceptions of the current rural training are unknown. exploring students’ rural experiences and perceptions of the clinical rural training relevance is important to a newly established school. understanding their experiences and perceptions can help the faculty of medicine to improve future rural development and maximise background. the curriculum of the faculty of medicine at the university of botswana includes rural community exposure for students throughout their 5 years of training. in addition to community exposure during the first 2 years, students complete 16 weeks of family medicine and 8 weeks of public health medicine. however, as a new faculty, students’ experiences and perceptions regarding rural clinical training are not yet known. objective. to describe the experiences and perceptions of the 5th-year medical students during their rural training and solicit their recommendations for improvement. methods. this qualitative study used face-to-face interviews with 5th-year undergraduate medical students (n=36) at the end of their family medicine rotation in mahalapye and maun villages. we used a phenomenological paradigm to underpin the study. voice-recorded interviews were transcribed and analysed using atlas ti version 7 software (usa). results. three main themes were identified: (i) experiences and perceptions of the rural training environment; (ii) perceptions of the staff at rural sites; and (iii) perceptions of clinical benefits and relevance during rural training. while the majority of students perceived rural training as beneficial and valuable, a few felt that learning was compromised by limited resources and processes, such as medical equipment, internet connectivity and inadequate supervision. conclusion. while the majority of students perceived rural training as beneficial, students identified limitations in both resources and supervision that need to be improved. understanding students’ rural training experiences and perceptions can help the faculty of medicine, stakeholders and site facilitators to guide future rural training implementation. afr j health professions educ 2017;9(3):144-147. doi:10.7196/ajhpe.2017.v9i3.738 fifth-year medical students’ perspectives on rural training in botswana: a qualitative approach p kebaabetswe,1 phd, mph; t arscott-mills,2,3,4 md, mph; k sebina,1 bsc; m b kebaetse,1,5 phd; o makgabana-dintwa,1 mph; l mokgatlhe,6 phd; g tawana,1 bsc; d o mbuka,7 md, mmed fam med; o nkomazana,1,8 mb chb, fcophth, msc ceh 1 medical education partnership initiative (mepi), faculty of medicine, university of botswana, gaborone, botswana 2 botswana-university of pennsylvania (botswana-upenn) partnership, gaborone, botswana 3 department of pediatrics, perelman school of medicine, university of pennsylvania, pa, usa 4 department of paediatrics, faculty of medicine, university of botswana, gaborone, botswana 5 department of medical education, faculty of medicine, university of botswana, gaborone, botswana 6 department of statistics, faculty of social sciences, university of botswana, gaborone, botswana 7 department of family medicine, faculty of medicine, university of botswana, gaborone, botswana 8 department of surgery, faculty of medicine, university of botswana, gaborone, botswana corresponding author: t arscott-mills (tonyaarscottmillsbup@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research september 2017, vol. 9, no. 3 ajhpe 145 students’ learning experiences. this article focuses on the experiences and perceptions of 5th-year medical students after completion of the 32 weeks of their rural exposure. the specific objective of the study was to describe the experiences and perceptions of 5th-year medical students during their rural training and solicit their recommendations for improvement. methods between october 2013 and june 2014, we conducted an open-ended interview qualitative study among 5th-year medical students after their 8-week family medicine rotation. interviews were conducted at the training sites of the faculty of medicine, university of botswana, in mahalapye, maun and gaborone. we used the phenomenological paradigm to underpin the study, as this approach is relevant for formulating the experiences and perceptions of individuals from their own perspectives.[5] participants’ recruitment all 36 (16 female, 20 male) 5th-year undergraduate medical students were invited to participate in the study during the last week of their 8-week family medicine rotation. criteria included having completed the 5th-year rural training rotation at one of the four rural clinical placement sites. recruitment was done by email; all 5th-year students were informed of the study and were followed up by means of telephone calls inviting them to take part. of 36 potential 5th-year students recruited, 15 accepted the invitation and 21 declined, citing a busy schedule. data collection data were collected from the 15 students who volunteered to take part in the study. after informed consent was obtained, they participated in a face-toface interview at a place and time convenient to them. the interviews were conducted in either maun or mahalapye during the last week of the rotation, or in gaborone after they returned from the rural rotation sites. although all medical students were fluent in both setswana and english, they had the right to be interviewed in either of the two languages. most preferred to mix setswana and english. the data collection tool included demographic information and a structured open-ended interview guide (table 1). although the questions were not piloted with students, they were reviewed by independent persons, who provided feedback on understanding. data were collected by three researchers (omd, gt and ks), with no teaching or clinical interactions with students. participants were encouraged to openly express their views about rural training. to facilitate data capturing, the interviews were audio recorded after consent had been obtained. the duration of an interview was up to 1.5 hours. although data saturation was reached after 12 interviews, all 15 interviews with individual participants were included in the analysis. following data collection, interviews were transcribed and translated by two independent professional transcribers. data analysis content data analysis was performed by three researchers (pk, omd and gt). the team thoroughly read and re-read each transcript, and listened back to the audio-recorded interviews to become familiar with the data and to check all transcripts for errors. the team used the atlas ti version 7 software (usa) to code and identify common themes and subthemes independently. they discussed their analysis and reached a consensus on the key themes and interpretations. ethical considerations ethical approval was obtained from the ethics committees of the university of botswana (ref. no. ubr/irb/1454), the ministry of health, botswana (ref. no. ppme 18/8/1 viii (303), and the university of pennsylvania, pa, usa (ref. no. 81944). because of confidentiality, the names of the participants were not written on the interview guide and not used during audio recordings. the tape recordings were locked and kept by the principal investigator. signed consent was kept locked separately from the data and recordings. results three main themes were identified: (i) experiences and perceptions of the rural training environment; (ii) perceptions of the staff at rural sites; and (iii) perceptions of clinical benefits and relevance during rural training. experiences and perceptions of the rural training environment students expressed mixed views about the rural training environment. while some claimed that, in general, the rural environment was more relaxed, less hectic and less conducive to learning, others felt that rural areas lacked resources such as simple medical equipment and internet connectivity and were therefore not conducive to learning. presented below are examples of both positive and negative perceptions. fig. 1. map of rural training sites. legend: rural training site rural training site table 1. interview guide demographic information • please tell me about your rural training experiences. probe for: rural training environment, the staff and facilities • in your opinion, was the rural training or exposure during your medical school training beneficial/valuable or not? please explain your answer • what challenges, if any, did you encounter during your rural training? how do you think they can be improved? what are your recommendations? research 146 september 2017, vol. 9, no. 3 ajhpe positive perceptions ‘i got to see something different from what i was used to seeing at princes marina in gaborone. for the first time i got to work where it wasn’t really, really busy, so there was time to focus on one patient at a time and just learn from that and establish a working relationship, so that was good.’ (participant 3) ‘i enjoy the rural environment to some degree; enjoy the relaxed nature of most of the places. also just being in a different environment is something that i have also enjoyed. i tend to have time to even study for other things, yes. it’s not very hectic like when i’m in gaborone.’ (participant 13) negative perceptions ‘when you have no equipment, no basic things like an ecg machine and you have a patient who has arrhythmias and you don’t have an ecg machine you end up compromising medical. if you need to do a ct on a patient you don’t need to send the cts or the samples anywhere further, you get the results as soon as possible.’ (participant 4) ‘i think rural environment kind of delays professional growth because if there are no supplies and no equipment then i won’t be able to help as much as i know i could help. but having been placed here for the past seven weeks, i don’t think i have learnt as much as i would have learnt when i was in gabs. i want a place where i can be challenged every day and that will help me grow professionally.’ (participant 10) perceptions of the staff and community at rural sites generally, almost all the students felt that people in the rural sites were welcoming and supportive, including those at the hospitals, at the clinics and in the community. ‘generally the people were very welcoming. they respected us more and appreciated us more and they welcomed us more than in the urban setting and even in the hospital people work together and respect each other. even the community members they respect us, they really appreciate us and welcomed us here and even appreciate us as batswana doctors.’ (participant 1) ‘generally the people were very welcoming. it was, it felt … warm to be there. the people in the hospitals … the people just in the town … yeah, cause i was in maun. they were very excited, very happy and helpful. i thought that was nice, yes. it would definitely be good to work in that kind of environment, everyone was helpful, even in the hospital.’ (participant 11) perceptions of clinical benefits and relevance during rural training students had different views about clinical benefits and the relevance of rural exposure. the majority of students described the rural training as clinically beneficial and valuable, as it offered them the opportunity to apply theoretical knowledge, gain practical skills, learn new cases in a relaxed environment, and appreciate cultural influences on diseases. students with negative experiences felt that there were fewer opportunities for learning. they only saw uncomplicated cases because serious ones were referred to city hospitals. others expressed concerns that there were fewer opportunities for professional growth, as there were few specialists to learn from and shortages of equipment to provide quality care, as well inadequate supervision. positive perceptions ‘rural training is advantageous for me because it widens my scope of learning. i think i learnt much more … varied content of stuff in a rural setting than … in a referral hospital where i just focused on surgical cases, but in rural areas there are different things that come on the same day, and its better … .’ (participant 8) ‘i think rural rotations are beneficial in the sense that you really get to see different things … you get to see different … ways that could work and you get to be in a different setting and you get experience. it was a nice experience because i managed to see how culture actually influences diseases so it was nice to see how their culture influences their health around there.’ (participant 13) ‘in the rural areas, there are opportunities to practise procedures. so there is not much competition in terms of procedures here. but you go to marina you compete with third-year medical students, fourth-year and interns that’s the problem. i have learnt a lot. even my experience to actually assist in an operation was in a rural environment which i enjoyed very much.’ (participant 15) negative perceptions ‘having been exposed to a rural area i realised that actually being in an urban area is way better because there you have all the equipment that you need. you know if you need to do a ct on a patient you don’t need to send the patient out of the city.’ (participant 4) ‘… having been placed here for the past seven weeks, i don’t think i have learnt as much as i would have learnt when i was in gaborone; the quality is low. actually i think rural areas kind of delayed my professional growth.’ (participant 10) ‘there was no teaching during the rural/family medicine rotation; everyone was on their own, unlike in marina where there are many mentors. i do not think it was beneficial to learning, we just go to hospitals, little learning during morning rounds, then morning meetings, rest of the day you are on your own.’ (participant 1) discussion rural training has been found to provide a valuable opportunity to develop skills, competencies and confidence in the management of patients with various conditions.[6-8] the literature also suggests that rural training programmes can have a positive effect on patient care.[9] additionally, smith[10] indicates that rural training can have a positive influence and impact on medical students and residents and dispel misconceptions of rural healthcare practices. consistent with the literature, our findings showed that the majority of students had positive experiences during rural training. they claimed that their learning was enhanced by a relaxed and less hectic rural work environment. in view of the benefits of rural exposure, students’ supervision during rural training is important to maximise positive experiences. the quality of students’ supervision during field placements is related to overall student satisfaction.[11,12] in a study to explore undergraduate medical students’ satisfaction with faculty support supervision during community placements in uganda, mubuuke et al.[13] noted that lack of resources to manage frequent super vision visits to the students while they were in the communities and few available faculty supervisors were key challenges to students. similarly, our study showed that students experienced inadequate supervision owing to a shortage of clinical staff, which affected learning. as a solution they recommended that rural medical doctors be empowered to supervise undergraduate students during rural training. this model has been supported in the literature.[13] limited resources can contribute to a dislike of rural exposure.[14] although rural training is usually done in places with limited resources, research september 2017, vol. 9, no. 3 ajhpe 147 absence of the internet and web-based support has been found to increase students’ perception of academic isolation.[15] our results showed that limited resources contributed to negative rural experiences. students recommended that in future rural training sites should be equipped with adequate resources and facilities, such as electricity, water, television and internet. although students decried limited resources at rural training sites, interestingly, some felt that the rural areas were not rural enough and they would have preferred exposure to the most remote areas to prepare them for worse experiences in their medical career. when selecting rural training sites it is important to select those that could maximise experiences, while ensuring that the learning environment is optimised. conclusion the general experiences and perceptions of 5th-year medical students were positive. while the majority perceived rural training as beneficial, students also identified barriers related to both resources and supervision that need to be improved. these results can be used by the university, stakeholders and site facilitators to enhance students’ rural experiences and guide future rural training implementation. study limitations although issues raised in our study are consistent with findings in other studies, the results are specific to botswana students. they cannot be generalised to all medical students and it is possible that the students who did not participate would have different views. however, recommendations could be applicable to other similar settings in the region. although the interviews were conducted by staff not directly involved with the students, it is possible that some students declined to participate because all the interviewers were university staff. acknowledgements. the information, content and conclusions presented in the article are those of the authors and should not be construed as the official position or policy of, and endorsements should not be inferred by, the health resources and services administration (hrsa), us department of health and human services (hhs), or us government. author contributions. pk: planning, design of data analysis, and writing of the manuscript. tam: planning, design and implementation of the study, and editing of the manuscript. omd: planning, design and data collection, data analysis, and editing of the manuscript. gt: data collection and editing of the manuscript. ks, mbk, dom, lm and on: planning and editing of the manuscript. all authors approved the final version of the manuscript. funding. this study was supported by the hrsa, and the us department of hhs, grant t84ha22125 (medical education partnership initiative, us$10 000 000). conflicts of interest. none. 1. tate rb, aoki fy. rural practice and the personal and educational characteristics of medical students: survey of 1 279 graduates of the university of manitoba. can fam phys 2012;58(11):e641-e648. 2. farmer j, kenny a, mckinstry c, huysmans rd. a scoping review of the association between rural medical education and rural practice location. hum resource health 2015;6(13):27. https://doi.org/10.1186/s12960-0150017-3 3. holst j, normann o, herrmann m. strengthening training in rural practice in germany: new approach for undergraduate medical curriculum towards sustaining rural health care. rural remote health 2015;15:3563. 4. botswana villages. https://www.google.co.bw (accessed 20 october 2016). 5. davidsen as. phenomenological approaches in psychology and health sciences. qual res psychol 2013;10(3):318339. https://doi.org/10.1080/14780887.2011.608466 6. irlam j, pienaar l, reid s. on being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences, university of cape town, south africa. afr j health professions educ 2016;8(1):41-44. https://doi.org/10.7196/ajhpe.2016.v8i1.540 7. van schalkwyk sc, bezuidenhout j, conradie hh, et al. ‘going rural’: driving change through a rural medical education innovation. rural remote health 2014;14:2493. 8. kibore mw, daniels ja, child mj, et al. kenyan medical student and consultant experiences in a pilot decentralised training program at the university of nairobi. educ health (abingdon) 2014;27(2):170-176. https://doi.org/10.4103/1357-6283.143778 9. liskowich s, walker k, beatty n, kapusta p, mckays, ramsden vr. rural family medicine training site: proposed framework. can fam phys 2015;61(7):e324-e330. 10. smith cc. investigating a rural immersion experience in medical education utilizing narrative inquiry. narrative inquiry bioethics 2012;2(1):55-64. https://doi.org/10.1353/nib.2012.0005 11. barrett fa, lipsky ms, lutfiyya mn. the impact of rural training experiences on medical students: a critical review. acad med 2011;86(2):259-263. https://doi.org/10.1097/acm.0b013e3182046387 12. roberts c, daly m, kumar k, perkins d, richards d, garne d. a longitudinal integrated placement and medical students’ intentions to practise rurally. med educ 2012;46(2):179-191. https://doi.org/10.1111/j.13652923.2011.04102.x 13. mubuuke ag, oria h, dhabangi a, kiguli s, sewankambo nk. an exploration of undergraduate medical students’ satisfaction with faculty support supervision during community placements in uganda. rural remote health 2015;15:3591. 14. kapanda ge, muiruri c, kulanga at, et al. enhancing future acceptance of rural placement in tanzania through peripheral hospital rotations for medical students. bmc med educ 2016;16(1):51. https://doi.org/10.1186/ s12909-016-0582 15. isaac v, watts l, forster l, mclachlab cs. the influence of rural clinical school experiences on medical students’ levels of interest in rural careers. hum resource health 2014;12:48. https://doi.org/10.1186/1478-4491-12-48 accepted 16 november 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3498038/ http://www.ncbi.nlm.nih.gov/pubmed/25943870 https://doi.org/10.1186/s12960-015-0017-3 https://doi.org/10.1186/s12960-015-0017-3 https://www.google.co.bw http://www.ncbi.nlm.nih.gov/pubmed/?term=davidsen as%5bauthor%5d&cauthor=true&cauthor_uid=23606810 http://www.ncbi.nlm.nih.gov/pubmed/23606810 https://doi.org/10.1080/14780887.2011.608466 https://doi.org/10.7196/ajhpe.2016.v8i1.540 http://www.ncbi.nlm.nih.gov/pubmed/?term=van schalkwyk sc%5bauthor%5d&cauthor=true&cauthor_uid=24803108 http://www.ncbi.nlm.nih.gov/pubmed/?term=bezuidenhout j%5bauthor%5d&cauthor=true&cauthor_uid=24803108 http://www.ncbi.nlm.nih.gov/pubmed/?term=conradie hh%5bauthor%5d&cauthor=true&cauthor_uid=24803108 http://www.ncbi.nlm.nih.gov/pubmed/24803108 https://doi.org/10.4103/1357-6283.143778 http://www.ncbi.nlm.nih.gov/pubmed/?term=liskowich s%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pubmed/?term=walker k%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pubmed/?term=beatty n%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pubmed/?term=kapusta p%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pubmed/?term=mckay s%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pubmed/?term=ramsden vr%5bauthor%5d&cauthor=true&cauthor_uid=26380856 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4501623/ https://doi.org/10.1353/nib.2012.0005 https://doi.org/10.1097/acm.0b013e3182046387. https://doi.org/10.1111/j.1365-2923.2011.04102.x. https://doi.org/10.1111/j.1365-2923.2011.04102.x. https://doi.org/10.1186/s12909-016-0582 https://doi.org/10.1186/s12909-016-0582 https://doi.org/10.1186/1478-4491-12-48 short research report 94 september 2017, vol. 9, no. 3 ajhpe general practitioners (gps) have long been important for the delivery of healthcare services in zambia, and they currently represent the largest class of physicians in the country. however, as the health needs of the zambian population have become more complex, the training of the gp has not been able to keep pace. as a result, zambia’s healthcare workforce has been challenged to keep up with the country’s increasingly complex health service demands. zambia is not alone in being confronted with a mismatch between the competencies of its healthcare workforce and the needs of the population. many countries in the region face a similar set of issues, and have looked to family medicine as a strategy to improve their country’s health outcomes.[1,2] family medicine is seen by the region’s healthcare planners and administrators as an attractive solution to addressing some of the region’s health needs, because it offers a broad scope of advanced medical competencies within the embodiment of a single practising physician. from the mid-1960s until 2012, zambia only had one medical school, which was situated in the country’s capital, lusaka. initially, the educational focus was on training physicians to a gp’s level. training to a more advanced clinical level, such as adult medicine, paediatrics, general surgery and obstetrics and gynaecology, did not begin until the 1990s. other speciality postgraduate programmes have been recently introduced, and now include orthopaedics, ophthalmology, anaesthesiology, psychiatry and infectious diseases. ironically, one of the consequences of training to a speciality level has been the diminished capacity of the zambian health sector’s ability to consistently provide full-service care to its patients. this is because medical specialists tend to aggregate towards more tertiary healthcare settings, making them less accessible to the general population. it is also true that in zambia it is rare to find enough specialists in any one location to meet the needs of the presenting patients.[3-5] this is especially so for the majority of zambians, who live outside of large city centres.[6] in 2011, the university of zambia’s school of medicine committed itself to begin a postgraduate training programme in family medicine, with special focus on alleviating the shortage of specialist doctors at the district level. a 5-year grant from the us government, the medical education partnership initiative, supported this commitment. in a country with no tradition of family medicine as a medical speciality, it was not self-evident that a unipolar plan of action from the university of zambia’s school of medicine would be sufficient for success. accordingly, we undertook a needs assessment of different stakeholder groups within the country’s healthcare landscape to better understand how family medicine might be received. a medline search using the key words ‘survey’, ‘needs assessment’, ‘family medicine’ and ‘africa’ yielded only one published report for comparison.[7,8] to our knowledge, however, our study is the first a priori needs assessment in sub-saharan africa to critically examine the receptivity background. zambia is a nation of nine million people, and has too few physicians to meet the country’s health needs. following the strategy of other subsaharan countries, zambia has developed a training programme in family medicine to help improve the medical competencies of its physician workforce. a needs assessment was undertaken to better understand the landscape into which zambian family medicine is being placed. methods. in 2014, a nine-question survey in likert-scale format was developed, validated, and then delivered to four stakeholder groups: (i) practicing clinical physicians, (ii) the general public, (iii) the university of zambia’s school of medicine’s academic faculty and (iv) medical students. the needs assessment was delivered through several different mechanisms: via web-based service, to respondents’ email addresses; in paper form, to population samples of convenience; and verbally, through face-to-face encounters. results. the number of stakeholders from each group who responded to the needs assessment were: clinical physicians, 27; general public, 15; academic faculty, 14; and medical students, 31. five of the nine survey statements achieved super-majority consensus, with >66% of stakeholders in each group agreeing. two additional statements achieved a simple-majority consensus with >50% agreement within each stakeholder group. conclusion. this survey suggests that there is a broad-based a priori understanding of family medicine in zambia, and general agreement that its presence would be valuable to zambia’s healthcare system. afr j health professions educ 2017;9(3):94-97. doi:10.7196/ajhpe.2017.v9i3.831 a quick needs assessment of key stakeholder groups on the role of family medicine in zambia j sanders,1 md; m makasa,2 md; f goma,3 phd; e kafumukache,4 mmedsci; m s ngoma,5 mrcp; s nzala,6 md 1 department of family and community medicine, faculty in the school of medicine, medical college of wisconsin, milwaukee, usa 2 department of community and family medicine, faculty in the school of public health, university of zambia, lusaka 3 centre for primary care research, faculty in the school of medicine, university of zambia, lusaka 4 department of anatomy, faculty in the school of medicine, university of zambia, lusaka 5 department of paediatrics and child health, faculty in the school of medicine, university of zambia, lusaka 6 department of medical education development, faculty in the school of medicine, university of zambia, lusaka corresponding author: j sanders (jsanders@mcw.edu) this open-access article is distributed under creative commons licence cc-by-nc 4.0. september 2017, vol. 9, no. 3 ajhpe 95 to family medicine within major stakeholder groups before any educational efforts were begun. methods in 2014, an anonymous nine-question survey was developed using a common five-point likert scale for answers. items were scored ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5) (table 1). the survey was validated for content by having the six members of the university of zambia’s school of medicine’s working group on family medicine review each statement and answer the survey for themselves. each of the workinggroup members critically appraised the survey’s statements for accuracy and validity. additionally, representatives from each stakeholder group were approached in an ad hoc manner and were led through a facilitated process of progressive inquiry around each of the survey’s statements. the iterative process continued until each statement was refined and considered valid for all target stakeholder groups. four key stakeholder groups were identified and targeted for solicitation about their participation in family medicine’s future: faculty at the medical school who would have the responsibility to teach this new kind of postgraduate learner; medical students who would need to be attracted to this area of medicine and see a professional future for themselves within it; practising physicians who would need to make room within their ranks for graduates of family medicine; and the public at large, who, by being the end consumer of family medicine, would need to ‘buy’ what family medicine was ‘selling’ if there was going to be longterm sustainability. criteria for inclusion included being >18 years of age and able to speak english. three out of the four stakeholder groups speak english as a matter of their daily professional lives, and it is also the most widely spoken second language in zambia, with even higher prevalence in the larger cities. at the time of the survey distribution, english was the exclusive language of instruction for all zambian public schools.[9] respondents were drawn mostly from populations of convenience, such as the university of zambia’s school of medicine faculty, who had come together for the purpose of another meeting, or a group of medical students between lectures. the academic faculty and the medical students were given paper-based surveys to fill out. clinical physicians were contacted via a web-based software platform that delivered the survey to the email addresses of the physician members of the zambian medical association. members of the general public were approached in public areas of lusaka, and the survey was delivered to them by face-to-face interviews. the method of convenience sampling was chosen as a compromise to expedite this a priori study, because other higher-profile efforts to organise family medicine within the country were on the verge of being rolled out, and news of these efforts might have biased respondents. the same interviewer was used for all face-to-face interviews, so as to improve the reliability and accuracy of the reported results. the sample size was considered sufficient to detect differences among responses, with a total of at least 80 respondents. this research was approved for human research by the university of zambia’s research ethics committee (ref. no. fwa00000338/ir800001 131 of iorg0000774). results the number of respondents from each subgroup was: clinical physicians, 27; general public, 15; academic faculty, 14; and medical students, 31. response rates were not calculated. average scores for each question from each stakeholder group were calculated (fig. 1). additionally, an inter-stakeholder group comparison was done on a question-by-question basis. responses have been collapsed so table 1. the survey instrument using a scale of 1 5, please respond to the following statements: 1 2 3 4 5 strongly disagree strongly agree i am familiar with family medicine as a medical speciality. i know a family physician who practises in zambia. there is a need for training family physicians in zambia. family medicine is important to zambia’s health. family medicine is well understood as a speciality. family medicine will be welcome within the zambian medical profession. family-medicine physicians can be leaders in clinical care. family-medicine physicians are best suited for district healthcare. family-medicine physicians are best suited for district health officer positions. a ve ra g e sc o re p er s ta te m en t 5 4.5 4 3.5 3 2.5 2 1.5 1 statement no. 1 2 3 4 5 6 7 8 9 practitioners students public academics 100 90 80 70 60 50 40 30 20 10 0 % of respondents neutral % of respondents agreeing with statement % of respondents disagreeing with statement 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 20 5 8 5 21 17 20 22 23 46 29 91 93 15 78 70 62 48 34 66 1 2 64 5 10 16 29 % of respondents neutral % of respondents agreeing with statement % of respondents disagreeing with statement fig. 1. average numerical score for each statement by stakeholder grouping. a ve ra g e sc o re p er s ta te m en t 5 4.5 4 3.5 3 2.5 2 1.5 1 statement no. 1 2 3 4 5 6 7 8 9 practitioners students public academics 100 90 80 70 60 50 40 30 20 10 0 % of respondents neutral % of respondents agreeing with statement % of respondents disagreeing with statement 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 20 5 8 5 21 17 20 22 23 46 29 91 93 15 78 70 62 48 34 66 1 2 64 5 10 16 29 % of respondents neutral % of respondents agreeing with statement % of respondents disagreeing with statement fig. 2. family medicine in zambia: aggregated results. short research report 96 september 2017, vol. 9, no. 3 ajhpe that ‘disagree’ and ‘strongly disagree’ are coupled, as are ‘agree’ and ‘strongly agree’ (fig. 2). there is wide-based concordance between the different stakeholder groups. more than 66% of each stakeholder population agreed that there is: • a lack of family medicine physicians currently in zambia • the desire for zambia to have a training programme for family medicine physicians • a recognition of the role that family medicine physicians can play in improving zambia’s health landscape • a sense that family medicine will be welcome within the professional ranks of medical specialists • an acknowledgement of the central roles within the zambian health system that family medicine physicians might inhabit. in addition, >50% of each stakeholder population agreed that: • family medicine physicians would be well-suited to care for patients at the district level of health services. • there is a need to educate the country at large about the speciality of family medicine. discussion there was a broad-based consensus among the respondents from each of the four stakeholder groups, despite the disparity in their make-up. the respondents were made up of taxi drivers, bureaucrats, shopkeepers, students, restaurant patrons, academics, clinicians and a variety of others. all seemed to speak with one mind. for seven of the nine statements, more respondents answered in agreement with one another than in disagreement, and the two remaining statements that did not meet majority consensus failed to do so by less than 5% each. one possible explanation for this general agreement across most statements is the simple nature of some of them. for example, the statement ‘family medicine is important to zambia’s health’ sounds very much like ‘rain is important for zambia’s crops’: it is hard to disagree with a statement having such an obvious answer. yet this idea belies the deeper complexities of the survey's other statements, which were also answered with a high degree of intergroup correlation. statements 1, 2 and 5 all dealt with the respondents’ familiarity with family medicine. fig. 1 shows that there was fairly high congruency across all four of the respondent groups on this topic. fig. 1 also shows that across all respondent groups, there was a high degree of intergroup congruency on what they all thought about the development of family medicine in zambia (questions 3, 4, and 6). it is interesting to note that despite a general unfamiliarity with the speciality, there is a general recognition that family medicine can play a central role in zambia’s healthcare landscape. furthermore, respondents also noted the speciality’s innate capacity to train physicians to become leaders within zambia’s healthcare hierarchy. one possible explanation for the high intergroup congruency is that the idea of family medicine has already arrived in zambia, even if its actual physical embodiment has yet to materialise. after all, at the end of the day, stakeholders from each group are, in some aspect, all consumers of the zambian health system. the respondents might have intuitively recognised what other research has shown: a family-medicine physician represents a very efficient way to bring competent human resources to the clinical and managerial challenges facing stressed health systems. [10,11] this survey and its results proved to be highly beneficial to the momentum of garnering stakeholder buy-in for family medicine’s continued development in zambia. the details of the evolution of family medicine in zambia, and the road ahead, are described elsewhere, and are outside of the scope of this article.[12,13] there are some structural limitations to our survey. our survey was limited in that it only included speakers of english. the vast majority of zambians speak a mother tongue other than english. as a result, there might have been some misunderstandings of the survey’s statements, despite our pre-testing validation, and the respondents might have been skewed towards those belonging to a more educated or merchant class. additionally, the ‘general public’ group was drawn solely from the capital city of lusaka. the rural inhabitants of zambia, for whom family medicine is being expressly developed, were not consulted, and might have opinions significantly different from their urban-dwelling countrymen. nonetheless, the survey’s findings are interesting and give us an indication of attitudes and knowledge about family medicine in zambia. however, due to the limited sample size, these findings cannot be generalised. conclusion our survey demonstrated that the idea of family medicine was broadly recognised by the population sampled, and that there was wide-based receptivity to its local development. these findings could be used as a basis for developing family medicine programmes in zambia. further, other academic medical centres looking to begin family medicine might also use these results as a basis for their own stakeholder inquiries. acknowledgements. none. author contributions. js was responsible for study design, oversight of study activity, data analysis and development of the manuscript. mm was responsible for data collection, data analysis and development of the manuscript. fg was responsible for the development of the manuscript. ek was responsible for study design and the development of the manuscript. sn was responsible for study design, human ethics committee application and development of the manuscript. msn was responsible for the development of the manuscript. funding. there was no external funding for this study. conflicts of interest. none. 1. flinkenflogel m, essuman a, chege p, ayankogbe o, maeseneer j. family medicine training in subsaharan africa: south-south cooperation in the primafamed project as strategy for development. fam pract 2014;31(4):427-436. https://doi.org/10.1093/fampra/cmu014 2. hellenberg d, gibbs t. developing family medicine in south africa: a new and important step for medical education. med teach 2007;29(9-10):897-900. https://doi.org/10.1080/01421590701827890 3. atkinson s, ngwengwe a, macwan’gi m, ngulube t, harpham t, o’connell a. the referral process and urban healthcare in sub-saharan africa: the case of lusaka, zambia. soc sci med 1999;49(1):27-38. https://doi. org/10.1016/s0277-9536(99)00072-6 4. few r, harpham t, atkinson s. urban primary healthcare in africa: a comparative analysis of city-wide public sector projects in lusaka and dar es salaam. health place 2003;9(1):45-53. https://doi.org/10.1016/s13538292(02)00029-1 5. zulu j, michelo c, msoni c, hurtig a, byskov j, blystad a. increased fairness in priority setting processes within the health sector: the case of kapiri-mposhi district, zambia. bmc health serv res 2014;14:75. https://doi. org/10.1186/1472-6963-14-75 6. ferrinho p, siziya s, goma f, dussault g. the human resource for health situation in zambia: deficit and maldistribution. hum resour health 2011;9:30. https://doi.org/10.1186/1478-4491-9-30 short research report https://doi.org/10.1093/fampra/cmu014 https://doi.org/10.1080/01421590701827890 https://doi.org/10.1016/s0277-9536(99)00072-6 https://doi.org/10.1016/s0277-9536(99)00072-6 https://doi.org/10.1016/s1353-8292(02)00029-1 https://doi.org/10.1016/s1353-8292(02)00029-1 https://doi.org/10.1186/1472-6963-14-75 https://doi.org/10.1186/1472-6963-14-75 https://doi.org/10.1186/1478-4491-9-30 september 2017, vol. 9, no. 3 ajhpe 97 7. gossa w, wondimagegn d, mekonnen d, eshetu w, abebe z, fetters m. key informants’ perspectives on development of family medicine training programs in ethiopia. adv med educ pract 2016;7:261-269. https:// doi.org/10.2147/amep.s94522 8. essuman a, anthony-krueger c, ndanu ta. perceptions of medical students about family medicine in ghana. ghana med j 2013;47(4):178-184. 9. lusaka times. use of local language as a medium of instruction to be implemented next year. 18 january 2013. https://www.lusakatimes.com/2013/01/18/use-of-local-languages-as-media-of-instruction-to-be-implementednext-year-for-pre-grade-4/ (accessed 2 august 2017). 10. starfield b. is primary care essential? lancet 1994;344(8930):1129-1133. https://doi.org/10.1016/s01406736(94)90634-3 11. starfield b, leiyu s, macinko j. contribution of primary care to health systems and health. milbank q 2005;83(3):457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x 12. makasa m, nzala s, sanders j. developing family medicine in zambia. afr j prm health care fam med 2015;7(1). https://doi.org/10.4102/phcfm.v7i1.909 13. sanders j, makasa m, goma f, kafumukache e, ngoma m, nzala s. developing a family medicine post-graduate training program in zambia. fam med 2016;48(7):517-522. https://doi.org/10.4102/phcfm.v7i1.909 accepted 3 november 2016. short research report https://doi.org/10.2147/amep.s94522 https://doi.org/10.2147/amep.s94522 https://www.lusakatimes.com/2013/01/18/use-of-local-languages-as-media-of-instruction-to-be-implemen https://www.lusakatimes.com/2013/01/18/use-of-local-languages-as-media-of-instruction-to-be-implemen https://doi.org/10.1016/s0140-6736(94)90634-3 https://doi.org/10.1016/s0140-6736(94)90634-3 https://doi.org/10.1111/j.1468-0009.2005.00409.x https://doi.org/10.4102/phcfm.v7i1.909 https://doi.org/10.4102/phcfm.v7i1.909 research september 2017, vol. 9, no. 3 ajhpe 107 quality nursing education must go beyond the imparting of information. teaching strategies must link theory to practice, foster critical thinking, be relevant and stimulate students. the strength of a pedagogical approach is the intentional integration of knowledge, clinical reasoning, skills practice and ethical comportment across the nursing curriculum.[1] when students implement their skills and knowledge, they become aware of the professional role their career entails. professional nursing, through the action of its members, demonstrates accountability and responsibility towards society.[2] psychiatric nursing practice is a complex interpersonal process that requires a professional nurse to be interpersonally competent. this competence needs to be incorporated into a systematic process of care, which demands not only integration of theory and practice, but also an in-depth understanding of the complexity of human interaction. therefore, it is important to thoroughly prepare psychiatric nursing students before their first encounter with a real patient. nursing simulations using standardised patients (sps) have proven effective in creating realistic learning opportunities to enhance the students’ competencies necessary for mental health clinical practice.[3] increasingly, simulation is being seen as a way to support the transfer of theory to practice and there is evidence that simulated contextual practice can prepare professionals for safe practice. furthermore, evidence suggests that exposure to simulation decreases anxiety towards clinical practice among student nurses.[4] the process of simulated practice learning can help students to develop confidence, professional aptitude and competence before they deliver nursing care to a real patient.[5] psychiatric nursing is often not the ultimate goal of students when enrolling in a nursing course and they may experience more anxiety due to their unfamiliarity with the psychiatric setting.[6] sp simulation can assist these students by decreasing their anxiety and increasing their confidence. an sp is a person who acts as a patient in a standardised manner. not only do sps present the specified healthcare scenario, they also give constructive feedback to the students. sps can teach student nurses to take a patient history, perform a mental status examination, practise psychiatric interventions and develop communication skills.[7] several challenges in psychiatric nursing education can be addressed with sp simulation. one can ensure that all students are exposed to the same clinical situation or experience, and a specific situation or diagnosis is available on demand without having to wait for it. students receive realistic feedback from a simulated patient in an honest and objective way, which is not easily available in the clinical practice situation.[8] simulation as a learning strategy is new to south african (sa) nursing education, and therefore scenarios need to be developed to be aligned with learning needs. research in the use of sps in undergraduate nursing in sa, especially in psychiatric nursing, is sparse, but evidence suggests that it is an effective learning strategy.[9] the question is whether the scenarios for psychiatric nursing that we develop address the student nurses’ learning needs. objective it was deemed necessary to investigate the undergraduate student nurses’ learning experiences after sp simulation. the purpose of this study was to explore and describe undergraduate nursing students’ experiences of conducting a psychiatric assessment on an sp presenting with a mental health problem. background. nursing education needs to adapt to be relevant to student nurses’ learning needs. this study investigates the use of standardised patients (sps) in a simulated patient interview as a learning strategy to bridge the theory-practice gap. simulation helps students to develop skills such as communication, higher cognitive thinking, decision-making and problem-solving. there is evidence to support the use of sp case scenarios to enable students to develop their clinical and interpersonal skills in a controlled environment before encountering patients in a clinical setting. objective. to explore and describe students’ experiences of the developed sp scenario for the mental health nursing interview. methods. a qualitative approach was taken and data were gathered using structured open-ended questions to gather information from 33 undergraduate nursing students after they encountered the sp simulation. participants’ responses were thematically analysed. results. nursing students experienced the simulation as challenging, but felt that being able to practise their skills within a safe simulated environment built confidence. they indicated that the experience was not only enjoyable, but that it helped them to integrate theory with practice, develop communication skills and feel professional. conclusion. sp-simulated practice combined with classroom teaching is important in improving nurses’ professed ability to respond to patients’ needs. nursing students need to be interpersonally competent before engaging with mental health users. sp-simulated learning helps student nurses to participate actively in a positive learning process; they then begin to understand the need for linking theory with practice. afr j health professions educ 2017;9(3):107-110. doi:10.7196/ajhpe.2017.v9i3.806 standardised patient-simulated practice learning: a rich pedagogical environment for psychiatric nursing education a jacobs, msocsc nursing; i venter, phd (nursing) school of nursing, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a jacobs (jacobsac@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 108 september 2017, vol. 9, no. 3 ajhpe methods this is a qualitative descriptive study that explored nursing students’ experiences. an open-ended questionnaire consisting of five questions aimed to explore student nurses’ learning experiences. an explorative interview that acted as a pilot study was conducted with students who had participated in an sp simulation earlier in the year. this was to ensure that the questions were formulated in a manner that was clear and would elicit the appropriate responses. the questions were refined after the interview. population and sampling the study population comprised 34 fourth-year student nurses registered in the baccalaureate nursing programme. a purposive sampling technique was used and 33 student nurses, who signed informed consent forms, comprised the unit of analysis. the inclusion criteria were registration in the psychiatric nursing module and having participated in the sp simulation. sp-simulated learning process as soon as possible after the procedure of conducting a psychiatric assessment had been taught, the students were exposed to an sp learning experience related to the theory. the simulation laboratory has individual interview rooms, allowing for 7 students to be accommodated simultaneously. on arrival, small groups of 7 students were briefed on the scenario and the outcomes, after which they participated in the sp simulation. directly after the conclusion of the simulation, students were given feedback by the sps on how they experienced the nursing care (from a patient’s point of view), which was followed by a debriefing session led by an experienced facilitator. the debriefing questions were based on pendleton’s method, which assists the students as a peer group to reflect on their own learning while exploring the link between theory and practice.[10] for simulation to be effective, its authenticity must reflect the clinical situation as well as possible.[11] we use senior drama students of the department of drama and fine arts, who have been briefed on and trained in the scenario. in the case reported here the nursing students had to assess sps who portrayed a student suffering from depression. they were given the following written instructions and objectives that had to be achieved: do a psychiatric assessment of a mental healthcare user in this clinic by means of: • an interview (structured and unstructured) • observation • demonstrating interpersonal skills to lay the foundation of a relationship of trust • completing the psychiatric assessment form (included). after receiving the instructions and having had an opportunity to ask for clarification, the students interviewed the sps. data collection directly after the debriefing session the students were asked to complete the following open-ended questionnaire: • how did you emotionally (personal and professional) experience the participation in the sp scenario? • what in the scenario did you experience as most valuable and what can you do differently next time? please motivate your answer. • how did the sp experience help you in closing the gap between theory and practice and in which area in this learning experience did you benefit most? please explain your answer. • how will this sp experience help you in the working environment? please explain your answer. • what suggestions can you make in order for us to give you a better learning experience? data analysis as this was a qualitative study, the authors adhered to the acknowledged inductive data analysis as described by creswell,[12] according to the following steps: examining the patterns of meaning; categories and themes; and working back and forth between the themes and the data. trustworthiness trustworthiness is addressed by adhering to the principles of credibility, dependability, confirmability and transferability, according to creswell.[12] by describing the stated parameters, using purposive sampling and an explorative interview, credibility was enhanced. triangulation of data from all the groups increased the confirmability of the results, and an independent co-coder corroborated the trustworthiness of the study. finally, a literature search was conducted as a basis for comparing, contrasting and contextualising the findings of the data. ethical principles the researchers adhered to the ethical principles of beneficence, respect for human dignity and justice. the participants were informed about the study and asked to sign a document indicating that they participated voluntarily and that they had been informed about the nature of the research.[12] the questionnaire was completed anonymously. the necessary institutional permission (ref. no. ecufs nr 34/2011) was obtained to conduct this research. results and discussion six themes emerged from the participants’ responses, i.e. positive learning experience, realistic and safe environment, integrating theory with practice, professionalism, confidence and processing skills in communication. theme 1: positive learning experience many of the participants stated that they remembered more from a simulation session than from a lecture. in the process they found learning to be enjoyable, exciting and motivating. the following responses are evidence of this: ‘best way of education.’ ‘i learned more in this situation than just sitting in a class listening to people talking about the work.’ ‘learned more in one hour in the lab than three hours of lecture, because you’re having fun.’ ‘i really enjoyed it, i felt emotionally calm and content; a little bit of stress but it went away quickly.’ ‘it was great and motivating.’ a recurring theme was that the participants wanted more time in the simulation suite because it was challenging and pleasant: ‘it was challenging but joyful. it was good to have practical experience.’ ‘very exciting to be in a new situation not knowing what to do or what to expect.’ research september 2017, vol. 9, no. 3 ajhpe 109 ‘wonderful experience. allow us to evaluate our competence.’ ‘the experience was really exciting and good. it really made me put myself in the situation and it also helped trigger my mind.’ shawler[13] describes sp simulation as a creative teaching strategy for psychiatric nursing and proclaims simulation use as important to ensure competency and quality nursing education. functioning at a high cognitive level is required from students, as they learn to elicit information from patients with mental disorders in a controlled, realistic and safe environment. theme 2: realistic and safe environment to comply with the requirements of an sp learning experience it is important to create a realistic but safe environment. campbell and daley[14] describe three levels of enacting a reality-based simulation. first, the simulation must seem credible to the students. they need to feel the responsibility of a nurse providing nursing care to the patient and acknowledge their actions in this regard. second, the simulation must address the teaching outcomes of the module; and third, the simulation must help the student nurse to retrieve the theory and to integrate it into practice. the participants commented on the realism of the situation and also stated that they felt free to develop their skills: ‘the fact that the patient was real. i got a chance to like really put my skills into practice, my communication skills and i also liked the environmental setting. it really ensured privacy and it instilled confidence in me.’ ‘the experience was realistic enough to implement all the aspects of theory. very good!!’ the feedback from the ‘patient’ (sp) had a definite impact on the students’ learning. the students learned how the sps experienced the encounter from a patient’s point of view and the sp made suggestions to help the student to be more competent in the future: ‘the chance to be me in the scenario and to deal with the patient in the same way as i would in practice and the honest feedback given after the session.’ obtaining insight into how one is perceived by the patient is invaluable. patients often do not know what the correct actions are – they only know how they experience the nurse. this kind of feedback is special because it rarely occurs in clinical practice. it is awkward to ask for this kind of feedback, as patients might not be able to or be too intimidated to convey their perceptions clearly and openly. sp feedback is a powerful teaching strategy to change students’ behaviour.[15] theme 3: integrating theory with practice through integration of theory and practice, student nurses’ skills in health promotion, counselling, empathetic communication, and health screening improve, and they will adhere to practice guidelines.[13] the theory made more sense when they could apply their knowledge in a practical session. it is a way of cementing the theory and ingraining the knowledge and skills. the essentiality of a thorough theoretical grounding for skills is instilled in the students’ understanding and approach to practice: ‘making the knowledge and skill your own.’ ‘it was of great value. it lets you think out of the box and generate your own way of approaching a patient and what you want to achieve.’ ‘it really helped me link what i learned during the week in class into practice now (today).’ ‘with the theory you learn more of what may be but with the practical part you get to bring what theory taught you and do it practically.’ the participants found they could link theory and practice. theme 4: professionalism mccormack and mccance[1] describe a professionally competent person as one who has skills that reflect a holistic approach, demonstrating knowledge and attitudes in a person-centred manner. one of the principles of practice in simulation is to encourage professional behaviour.[9] the sp learning situation gave the participants the opportunity to build a therapeutic relationship with the patient – experiencing themselves as professional nurses. the following responses indicated that the participants had started the process of building a therapeutic relationship with the patient, managing the patient’s emotions as well as their own: ‘fact that the patient acted the scenario out, really is valuable because you feel you are with a real patient, which then automatically changes your perception with [sic] the whole scenario. you then start being serious and do your optimum best in bringing out the professionalism in you.’ ‘in the practical part i gained a lot and in learning the standards of professionalism.’ ‘it was really nice because the patient (actor) really looked real. that showed me the manner of professionalism i should have.’ many participants commented on nursing being a hands-on profession, with one respondent suggesting: ‘i know i will not forget now as practice makes perfect.’ milisen et al.[16] indicate that a person’s self-image and self-respect influence his or her professional aptitude. student nurses will move towards independence and then gain experience, confidence and autonomy. theme 5: confidence as stated above, confidence is very important for the development of skills, and the sp experience gave the students just that: ‘it showed me where i should do more reading and practice. but gave me confidence to do it.’ ‘the feedback from the patient gave me confidence in doing the same in practice and to correct my mistakes.’ ‘it helped me build more confidence practising what i have learned in almost a real situation.’ ‘i felt more comfortable in doing this and the teaching method is more relevant to the subject, it also brings confidence.’ ‘i learn self-confidence, interpersonal skills, and patient-interaction skills.’ students who were exposed to a simulation learning approach found that their learning needs were met and they experienced increased confidence; in the process the safe practices of individuals were improved. confidence is closely linked to independence and the motivation to learn. sp-simulated learning ensures an interactive, safe and productive learning environment that fosters student nurses’ security and confidence.[14] theme 6: processing skills in communication student nurses need to practise their verbal communication in a nurse-patient relationship for them to grow and develop from novice to expert. they need to be aware of how their own behaviour affects the patient and that research 110 september 2017, vol. 9, no. 3 ajhpe communication is essential to understand the patients’ needs with regard to providing effective nursing care.[2] the importance of communication skills in nursing, and especially in psychiatric nursing, is critical. the participants reflected on their own skills and limitations, gaining an understanding of their abilities. in the process they discovered the value of empathy and listening skills: ‘being an active listener is very important. even hearing what is not being said.’ ‘next time i will try to not repeat questions and give more attention or active listening to my patient in order to create trust between us.’ ‘active listening to the patient such that i got absorbed in her story and went beneath just her answers but what she was communicating to me as well on a deep personal level.’ the value of therapeutic communication is a key component in a therapeutic relationship. shawler[13] advises students to examine their own verbal and non-verbal communication. conclusion nursing educators need to be aware of their students’ learning needs and that the use of different learning strategies will help the students to gain knowledge and master skills. the integration of nursing theory with practice is crucial for becoming independent, autonomous registered nurses. sp-simulated learning helps student nurses to participate actively in a positive learning process and to understand the need for linking theory with practice. nursing students need to be well grounded in therapeutic communication before engaging with mental health users. by providing a realistic, true-to-life experience for the development of competence in clinical skills, students are assisted to understand how they need to function in clinical practice. this allows them to acquire and process skills in communication and gain confidence in a safe environment in which they can learn by making mistakes, thus enhancing patient safety. the learning experience should include opportunities to question personal frames of reference that could hinder therapeutic engagement. considering the limited research on the use of sps in mental health nursing, especially in africa, it was important to know whether the scenario resulted in effective learning. we can be cautiously confident that the scenario rendered a useful learning experience, as the students clearly stated that they found the experience very useful to master the skills necessary for a clinical situation. further research should be done on the transfer of sp-simulated learning to clinical practice. recommendations future studies should encompass the views of more training schools regarding the use of simulation as a learning strategy. the perceptions of nursing educators and staff in clinical practice, who interact with student nurses, should be ascertained so that potential shortcomings can be identified and addressed. study limitations the data are closely bound to the context and are therefore not generalisable. only students of one institution in a single study year were involved. this limits the broader applicability of the results even further. acknowledgements. we wish to thank the school of nursing, university of the free state, for financial and logistical support, as well as the students who participated in the study. author contributions. aj: primary researcher, pilot study for a phd dissertation. iv: supervisor, co-coding and co-author of article. funding. none. conflicts of interest. none. 1. mccormack b, mccance t. person centred nursing: theory and practice. oxford: wiley-blackwell, 2010:41-84. 2. benner p, sutphen n, leonard v, day l. educating nurses: a call for radical transformation. san francisco, ca: jossey-bass, 2010:155-167. 3. jacobs ac, van jaarsveldt de. ‘the character rests heavily within me’: drama students as standardized patients in mental health nursing education. j psychiat mental health nursing 2016;23(3-4):198-206. https://doi. org/10.1111/jpm.12302 4. lehr st, kaplan b. a mental health simulation experience for baccalaureate student nurses. clin simulation nursing 2013;9(10):e425-e431. https://doi.org/10.1016/j.ecns.2012.12.003 5. berragan l. conceptualising learning through simulation: an expansive approach for professional and personal learning. nurse educ pract 2013;13(4):250-255. https://doi.org/10.1016/j.nepr.2013.01.004 6. jansen r, venter i. psychiatric nursing: an unpopular choice. j psychiat mental health nursing 2015;22(2):142-148. https://doi.org/10.1111/jpm.12138 7. szpak jl, kameg km. simulation decreases nursing student anxiety prior to communication with mentally ill patients. clin simulation nursing 2013;9(1):e13-e19. https://doi.org/10.1016/j.ecns.2011.07.003 8. anderson m, holmes tl, leflore jl, nelson ka, jenkins t. standardized patients in educating student nurses: one school’s experience. clin simulation nursing 2010;6(2):e61-e66. https://doi.org/10.1016/j.nedt.2015.03.004 9. doolen j, giddings m, johnson m, de nathan g, badia ol. an evaluation of mental health simulation with standardized patients. int j nursing educ schol 2014;11(1):1-8. https://doi.org/10.1515/ijnes-2013-0075 10. timmis c, speirs k. student perspectives on post-simulation debriefing. clin teach 2015;12(6):418-422. https:// doi.org/10.1111/tct.12369 11. davis s, josephsen j, macy r. implementation of mental health simulations: challenges and lessons learned. clin simulation nursing 2013;9(5):e157-e162. https://doi.org/10.1016/j.ecns.2011.11.011 12. creswell jw. research design. 4th ed. london: sage, 2014:183-213. 13. shawler c. standardized patients: a creative teaching strategy for psychiatric-mental health nurse practitioner students. j educ 2008;47(11):528-531. https://doi.org/10.3928/01484834-20081101-08  14. campbell sh, daley km. simulation scenarios for nurse educators. new york: springer, 2009:8-10. 15. wallace p. coaching standardized patients for use in the assessment of clinical competence. new york: springer, 2007:216-218. 16. milisen k, de busser t, kayaert a, abraham i, de casterlé bd. the evolving professional nursing self-image of students in baccalaureate programs: a cross-sectional survey. int j nursing studies 2010;47(6):688-698. https:// doi.org/10.1016/j.ijnurstu.2009.11.008  accepted 13 december 2016. https://doi.org/10.1111/jpm.12302 https://doi.org/10.1111/jpm.12302 https://doi.org/10.1016/j.ecns.2012.12.003 https://doi.org/10.1016/j.nepr.2013.01.004 https://doi.org/10.1111/jpm.12138 https://doi.org/10.1016/j.ecns.2011.07.003 https://doi.org/10.1016/j.nedt.2015.03.004 https://doi.org/10.1515/ijnes-2013-0075 https://doi.org/10.1111/tct.12369 https://doi.org/10.1111/tct.12369 https://doi.org/10.1016/j.ecns.2011.11.011 https://doi.org/10.3928/01484834-20081101-08 https://doi.org/10.1016/j.ijnurstu.2009.11.008 https://doi.org/10.1016/j.ijnurstu.2009.11.008 article 23 december 2010, vol. 2, no. 2 ajhpe introduction the need for physicians to recognise the importance of behavioural and social factors in human health and illness is not disputed.1 engel’s pioneering work on the biopsychosocial model of illness challenged us to ‘see our patients as united, biopsychosocial persons rather than biomedical persons divorced from their psychological and social dimensions’.2 in 1978 an international conference on phc in alma-ata described a health care approach aimed at protecting and promoting ‘the health of all people of the world’; this was reinforced by the world health report 2008.3,4 over the past three decades these two key developments have led to an international recognition of the critical elements of holistic health care and an acquired state of fluency which draws upon appropriate knowledge, skills and attitudes enabling practitioners to offer culturally responsive care.5-7 statutory bodies regulating the training of health professionals in the usa and canada (liaison committee on medical education) and the uk (general medical council) now require cultural competence teaching in medical training programmes, and guidelines have been developed in the usa to facilitate this process (association of american medical colleges).8-10 despite the importance of this key component of physician education, health sciences faculties are still grappling with the challenges of developing teaching pedagogies that address these issues in the clinical teaching context. a recent paper from the usa provided an excellent outline of a preclinical curriculum that teaches students about social and behavioural factors that influence health care delivery, but a teaching model for the clinical years was not mentioned.11 the lack of biopsychosocial competence teaching in the clinical setting was highlighted by a us report in which senior medical students and postgraduate trainees indicated that they recognised the need for a biopsychosocial approach to patient care, but lacked effective training in this approach. of most concern was the observation that few students indicated an interest in receiving further training in the psychosocial aspects of clinical practice.1 the need to address the challenges faced when teaching a biopsychosocial approach to illness in real clinical practice is apparent. there is limited literature about the factors that constrain the teaching of psychosocial determinants of health and illness at the bedside. a recent paper identified three key barriers to implementing a biopsychosocial approach to patient care when teaching medical students and postgraduate trainees: a lack of time to explore psychosocial determinants of health and illness; physicians’ lack of expertise in teaching this approach; and discomfort with the feelings of uncertainty that arise when addressing psychosocial factors in the clinical setting.1,12,13 an interesting approach to teaching biopsychosocial competency at the bedside has been suggested by kleinman and benson (2006). they suggested that an ethnographic approach in the use of mini-ethnographies could bridge the divide between the biomedical model of illness and the psychosocial determinants of illness and health. the core feature of an ethnographic approach is that it attempts to describe ‘what life is like in the world of the patient’.14 for physicians with limited experience in the use of this anthropological method, kleinman and benson recommended that patient interviews should focus on five psychosocial aspects: the patient’s ethnic identity; what is at stake for the patient and their family as they face the current illness; what the illness means to the patient, including its cultural meaning; psychosocial stressors associated with the illness and its treatment; and the impact of culture on the clinical relationship with the patient, as perceived by the physician. in so doing this approach blends the biopsychosocial approach with the philosophy of phc as iterated in the alma-ata declaration 1978.3 abstract the importance of behavioural and social determinants in health was recognised long ago, yet we still grapple with the challenges of developing appropriate teaching pedagogies to bring these principles into routine clinical practice. a teaching pedagogy blending the biopsychosocial approach and the principles of primary health care (phc), as expressed in the alma-ata declaration of 1978, is lacking in the literature. this report hopes to address this need. in 1994 the university of cape town (uct), south africa, adopted a phc-based approach to health sciences education to equip its graduates with the necessary knowledge, skills and attributes required to meet the challenges of providing health care in a country with vast socio-political inequalities. this paper describes an educational pedagogy which weaves these principles into clinical practice in an undergraduate medical clerkship. the methodology uses real patient encounters linked to an interactive seminar and a portfolio of case studies. students described the teaching pedagogy as interesting and informative. they recognised the importance of holistic, patient-centered care based on a biopsychosocial approach and the importance of the phc principles. barriers to implementing this approach were also highlighted. the pedagogy, in use for four years, is being adopted by another department, indicating the sustainability and success of the course. teaching biopsychosocial competence and the principles of primary health care (phc) at the patient’s bedside lauraine vivian1, sean mclaughlin2, charles swanepoel3, vanessa burch3 1primary health care directorate, faculty of health sciences, university of cape town 2south african national bio-informatics institute, university of the western cape 3department of medicine, faculty of health sciences, university of cape town correspondence to: lauraine vivian (lauraine.vivian@uct.ac.za) article article 24 december 2010, vol. 2, no. 2 ajhpe in this paper we describe an educational strategy in which an anthropologist facilitates the use of the biopsychosocial model as expressed in mini-ethnographies to teach medical students a comprehensive and holistic approach to patient care at the bedside. we chose this setting because ‘novices learn best to apply technical knowledge within skilled actions in rich, relevant contexts’.15 this context also reinforces the development of the professional identity of the student. background in 1994, when the first democratic government of south africa was elected, apartheid was abolished and the new government pledged itself to an equity-driven approach to health care. the foundations of this approach were embedded in the principles of phc as laid out in the declaration of alma-ata in 1978. with the advent of the new government in south africa, the faculty of health sciences at the university of cape town adopted a phc-based approach to education in order to equip its graduates with the knowledge, skills and values necessary to meet the changing demands of health care in a country with vast social, political and economic inequalities. the faculty adopted a single definition of phc as ‘an approach to health care that promotes the attainment by all people of a level of health that will permit them to live socially and economically productive lives. phc is health care that is essential; scientifically sound (evidence-based); ethical; accessible; equitable; affordable; and accountable to the community’.16 nine key principles outlining the phc approach, shown in table i, were used to design a cross-disciplinary phc theme spanning all six years of the mb chb programme.17 within the phc theme, three sub-themes were identified: • culture, psyche and illness • health promotion • evidence-based practice. the biopsychosocial model is the paradigm that ‘enfolds’ knowledge from different disciplines, and the ethnographic model has been incorporated into this approach to teach students a multidisciplinary approach to patient care. the purpose of the paper is to demonstrate how the bio psychosocial model has been interleaved in the teaching of phc principles. we understand phc to be a philosophy and approach, rooted in the mandate given in the alma-ata declaration. rather than phc being a public health approach to medicine, the faculty embraces phc as an interdisciplinary approach which should be implemented and function at all levels of the health system as an integrated approach. table ii shows how these sub-themes were integrated into the preclinical and clinical courses offered in the programme. for the purpose of this paper we will restrict our focus to the ‘culture, psyche and illness’ sub-theme and describe how clinical teaching around this sub-theme was developed and integrated into a fourth-year medical clerkship at the university of cape town. course design the ‘culture, psyche and illness’ component of the phc theme specifically focuses on four phc principles: cultural sensitivity and the biopsychosocial model of illness; the role of multi-professional teams; intersectoral collaboration in health care provision; and pathways to care. in the first three years of the mb chb programme the disciplines of psychology and anthropology teach students ‘psychosocial’ theory; this is integrated into the cases used in the problem-based learning curriculum adopted by the faculty in 2001. at this early stage students learn about the biopsychosocial model of illness and how to develop biographies drawn from mini-ethnographies and psychological narratives. all summative assessments in the preclinical years focus on learning objectives derived from both the basic sciences as well as the social sciences components of the integrated courses offered. fourth-year students rotate through a 12-week general medicine clerkship and are required to develop a portfolio of 32 patient encounters which must include mini-ethnographies for at least 15 patients interviewed. the ethnographies need to provide a description of the patient’s experience of the illness from a personal and cultural perspective, the impact of the illness on their family, any psychosocial stressors related to the illness and any other points raised by the patient during the interview. the case histories also need to reflect on any other phc principles relevant to the patient’s health care experience. students learn to construct these mini-ethnographies based on their prior learning and active participation in a 2-hour seminar centered on real patient encounters in a busy district hospital.18 the pedagogy, developed in 2005, commences with a ward round jointly conducted by a senior physician (vb) and a medical anthropologist (lv), who review newly admitted patients and select those who best demonstrate psychosocial and/or ethnocultural issues relevant to their illness experience and/or demonstrate other phc principles important to their care. the anthropologist notes down the patient’s details, the biomedical diagnosis, psychosocial and/or ethnocultural issues relevant to the illness presentation and other phc principles relevant to the case. medical students attending the ward round are then sent, in pairs, to interview the selected patients and any family present at the bedside. in a 20-minute interview they are expected to develop a mini-ethnography using the three-stage approach. students are specifically instructed not to focus on the biomedical diagnosis, and an observational, empathic approach to the interview is stressed. an example of mini-ethnography is shown in box 1. after completing the patient interviews students participate in a seminar (8 10 students) in which the patient ethnographies are presented and the anthropologist uses ‘trigger questions’ to focus the discussion on the phc principles relevant to the patients interviewed. during the seminar particular emphasis is placed on the importance of a psychosocial, including ethnocultural, interpretation of illness from the patient’s perspective. course assessment each portfolio of fifteen ethnographies is assessed using a structured interview in which two cases are selected for discussion, focusing specifically table i. principles of primary health care • promote equity and human rights in health care • display biopsychosocial and cultural sensitivity towards the patient • practise health promotion at the individual and population level • promote evidence-based health care • treat patients at the appropriate level of care • promote multiprofessional health care • promote broad intersectoral collaboration • encourage communities to assert their rights and interests • monitor and evaluate the efficacy, efficiency and equity of health services article 25 december 2010, vol. 2, no. 2 ajhpe on psychosocial and/or ethnocultural issues relevant to the presenting illness and health care-seeking behaviour as well as other phc principles demonstrated by the patient’s health care experience. this portfoliobased interview forms part of a series of four portfolio interviews, each of 15 minutes’ duration, in which a panel of examiners discusses cases from the portfolio relevant to primary health care, internal medicine, psychiatry and obstetrics. each station uses it own scoring method based on the original model described by burch and seggie.19 the scores achieved at the medicine station and the phc station both contribute to the final course mark for internal medicine in the fourth year. course requirements the course requires three core elements: • a medical anthropologist who has sufficient social science expertise to critically analyse a patient’s place in his/her larger community’s social and cultural framework, its belief systems and biases. s/he needs to be able to make inferences about psychosocial factors relevant to the illness based on astute observation and verbal and non-verbal communication. the anthropologist should also be comfortable working in a busy clinical setting and must be able to probe prior knowledge and facilitate analytical thinking. • students who have sufficient social science and psychology theory to participate in a discussion of illness experiences, health-seeking behaviour and beliefs that are culturally bound. they also need to be familiar with the nine phc principles described in the university of cape town curriculum, be able to perform a three-stage (biopsychosocial) patient assessment and have a broad overview of the socioeconomic and political determinants of health and illness in south africa. • a clinician who is familiar with the concept of ethnography and a three-stage patient assessment as well as the phc principles described by the faculty. in addition, time needs to be apportioned to case identification on busy ward rounds. the latter is a particular challenge but the provision of holistic patient care informed by the phc principles, as endorsed by the faculty, constitutes an essential part of student education at the university of cape town. course evaluation by 2009, a total of 590 students had participated in the course. we selected a convenience sample of 73 students in 2009 to provide anonymous written feedback about their experience of the interactive seminar sessions. students are randomly assigned to groups in the fourth year of table ii. components of the primary health care theme in the mb chb programme at the university of cape town, south africa year of programme course name phc theme focus within the course 1st year becoming a health professional part ia the principles of phc and the concept of a district health system 2nd year integrated health systems part 1a biopsychosocial and cultural issues; relevant phc principles becoming a doctor part ia phc and equity in global health; introduction to evidence-based medicine becoming a doctor part ia health promotion and the principles of developing health education messages becoming a doctor part 1b introduction to health promotion approaches and behaviour, and health promotion ethics special study modules • alternative medical practices, e.g. acupuncture • medical anthropology methods • bringing medical practice to students • collaborative role of traditional healers in health care, cultural beliefs and folk illnesses 3rd year integrated health systems part 2 biopsychosocial and cultural issues; relevant phc principles becoming a doctor part 2a causation and evidence 4th year public health introduction to phc principles, specifically equity, evidence-based practice and human rights primary health care/health promotion ethics of health promotion, including community participation and partnerships; behaviour change theories and health promotion approaches, planning cycle process (models) medicine teaching biopsychosocial competence and phc principles at the bedside 5th year primary health care elective all phc principles relevant to the setting of the clinical attachment 6th year family medicine evidence-based practice, health promotion, culture psyche and illness article article 26 december 2010, vol. 2, no. 2 ajhpe study and there was no reason to consider an element of systematic bias in the groups surveyed. the research ethics committee of the university of cape town granted approval for this aspect of the project. two open-ended questions were used to prompt student responses: (1) did you benefit from the teaching methodology; and (2) what did you learn from the process? the written responses were reviewed by applying the principles of thematic analysis.20 an open coding process was used to identify key responses and develop themes. the codes were reviewed and grouped into 21 themes. the raw data were then reviewed to ensure that no emerging themes were missed during the initial coding process. the coding process was verified by another researcher. the themes were then arranged into five categories empirically derived from the data. the five categories were: • the educational value of the case-based seminars • personal benefits derived from participation in the case-based seminars • the importance of a biopsychosocial approach to patient care • the importance of phc principles in clinical practice table iii. results of student evaluation of the interactive casebased seminars categories themes educational value of seminars • based on real patient encounters • made learning more interesting • reinforced prior learning • learnt from peers • showed how to integrate phc principles and biopsychosocial approach • challenged perceptions and perspectives personal benefits derived from seminars • importance of good communication skills • holistic approach to taking a history • improved critical thinking skills • improved observation skills importance of biopsychosocial approach to patient care • patient-centered • holistic patient care • improve patient care • does not take too much time importance of phc principles in clinical practice • applicable at all levels of care • does not take too much time • easily integrated into clinical practice • phc principles not practiced by doctors challenges to implementing phc principles in clinical practice • resource constraints limit holistic care • doctors don’t know about phc principles • a negative attitude to phc box 1. mini-ethnography based on a patient interview biomedical diagnosis provided by the senior clinician a 28-year-old xhosa-speaking black african female presents with a crusting skin rash covering her entire body except her face. skin scrapings confirm a diagnosis of norwegian scabies. she also has a right pleural effusion due to active pulmonary tuberculosis (tb). her previous medical history includes an episode of pulmonary tuberculosis in 2004 at which time she was told that she was hiv-positive. she has never attended an hiv clinic, does not know her cd4 count and is not receiving antiretroviral therapy. personal context derived from the student interview she lives with her mother and brother and ‘they don’t know i am hiv’. she had two children but one was taken away by a traditional healer at the age of seven and the other child ‘died from hiv’ in 2004. she also says that she was raped by her stepfather when she was younger and says ‘i tried to kill myself’ three years ago. for the past three years she has been too weak to work and stays at home most of the day. she cannot apply for a disability grant because she does not have a birth certificate. social context derived from the student interview she says that she has been too frightened to tell anyone ‘about my hiv’ because she is scared that her family will ‘throw her out of the house’. she says she does not want to visit an hiv clinic because ‘then everyone will know that i have hiv’. phc principles relevant to the case discussion equity the hiv pandemic in south africa raises major issues about equitable care for all infected patients. public sector budgetary constraints and the scale of service required limit access for the poorest to basic primary care, which is overburdened and overcrowded. in this setting confidentiality is difficult to maintain and patients with hiv infection are often required to attend an ‘hiv clinic’, which automatically discloses their status to the broader community. in contrast, patients with health insurance have access to the best available care and confidentiality is easy to maintain. intersectoral collaboration this patient needs a birth certificate so that she can apply for a temporary disability grant because she is not fit to work in her current state. since she is only barely literate, the doctor looking after her in hospital will need to help her apply for the birth certificate from the department of home affairs. once she has a birth certificate she will be able to apply for a disability grant from the department of social services. once again she will require medical assistance with this application process. multiprofessional health care this patient requires intensive counselling by an hiv counsellor to bring her to a point where she can accept her hiv status and seek appropriate health care. ideally she should also be seen by a community psychiatry liaison nurse to determine whether she is still clinically depressed (previous suicide attempt) and whether she requires therapy for depression. she also needs to be seen by a doctor to be assessed for antiretroviral therapy and she needs to attend the local tb clinic for the next six months. article 27 december 2010, vol. 2, no. 2 ajhpe • challenges to implementing phc principles in clinical practice. the results are shown in table iii and some examples of students’ comments are listed in box 2. the feedback demonstrated that students enjoyed the interactive learning activity centered on real patient encounters. their prior know ledge was reinforced and this also facilitated peer teaching. an unanticipated positive outcome of the seminars was a perception on the part of the students that other skills were also improved; these included communication, critical thinking and direct observation of the patient. the feedback received from the students made it clear that minimal extra time was required to apply the biopsychosocial model of illness to patient assessment and that the model was applicable at all levels of care, i.e. not only at the primary care clinics in the community. the students also felt that a patient-centered holistic approach was likely to improve patient care. aside from all the positive comments, students also pointed out that there were challenges to implementing the phc principles in clinical practice. these included the observation that clinicians did not routinely apply phc principles to clinical practice in the teaching environment; resource constraints appeared to limit implementation of holistic care; a lack of understanding of phc principles by clinicians and a negative attitude towards phc by some clinicians and students. sustainability this project, in place since 2005, demonstrates the feasibility of using a combined approach of case-based seminars and a portfolio of patient ethnographies to teach biopsychosocial competence at the bedside. based on the current success of the course it is being extended to include a paediatric clerkship in the fifth year of the mb chb programme, thereby further increasing student exposure to key principles of phc and a biopsychosocial approach to health care. this will reinforce transfer of these skills to other clinical settings. furthermore, the education development unit in the faculty has recognised the need to teach clinician educators about the principles of phc, including a biopsychosocial approach to clinical care. a teaching module focusing on these aspects has been included in the faculty development programme for clinician educators working in the university of cape town-affiliated teaching hospitals. conclusion this paper demonstrates that the principles of phc and a biopsychosocial approach to patient care can be taught at the bedside using ethnographic methods. not only is the method feasible and sustainable, but the students readily perceived the educational benefits and broader implications of the skills learnt. the integrated approach described in this paper casts the net much wider than cultural competence since it also incorporates the relevant phc principles contained in the declaration of alma-ata. these principles have not received enough emphasis in the current literature, which mostly focuses on ethnocultural competence and to some extent on socioeconomic and political factors as relevant to developing country immigrants living in developed world countries – so-called transnational competence.5,21 the benefit of bringing a medical anthropologist to the bedside to teach medical students about the broader aspects of health care that lie outside the strict biomedical approach is not widely appreciated. as can be seen from our work, clinicians and anthropologists can bring complementary aspects of health care together in a seamlessly integrated manner without the need for clinicians to learn about the finer details of anthropology or for anthropologists to learn about biomedical diagnoses. indeed, the combined approach led by a clinician emphasises the importance of a holistic approach to patient care and directly addresses the misconception that learning about the psychosocial components of a patient’s illness is ‘soft science’. this addresses astin et al.’s three barriers to implementing the biopsychosocial approach by allocating dedicated time in clinical settings where students and clinicians have to engage in an often uncomfortable discourse on holistic care.1 our feedback data show that students recognised the importance of the comprehensive model of health and illness. as one student commented: ‘i think this method is more practical, less “airy-fairy” and less idealistic (my early perception of phc)’. the major limitation of this study is that it only reports student perceptions about the educational value of this approach to bedside teaching. a study is being designed to evaluate the impact of this learning experience on the routine clinical practice of students in subsequent years of study. the relationship between the latter and student performance in the final examination will also be evaluated. we do not report the summative assessment results of student performance in the oral assessment (osce). the need to take the biopsychosocial model of patient assessment and a phc-driven approach to treatment plans to the bedside is long overdue. this paper makes a contribution to the literature by describing a simple strategy which advances interdisciplinary and complementary approaches to health care and provides students with authentic learning box 2. quotes from student feedback educational value of seminars: ‘yes, the approach of letting students go to the ward and practise and actually bring back the information puts the student in the situation of actually taking into consideration not only the history and diagnosis but also the family and social situation, including education and doctor-patient relationships.’ importance of biopsychosocial approach to clinical care: ‘lots of issues have to be considered when seeing a patient. it is very important to look at the biopsychosocial circumstances of a person so that the best possible treatment can be given. phc is very important in assessing the patient completely and ensuring that we do our jobs efficiently.’ importance of biopsychosocial approach to clinical care: ‘culture and psyche play an important role in illness and the outcomes thereof; therefore we as health practitioners need to pay special attention to these issues. also how the system operates plays an important role. it can assist or hinder the process.’ importance of phc principles in clinical practice: ‘i learned that phc principles are actually quite easily integrated into general medicine – it really takes only a few minutes to ask them phc-related questions that are extremely essential in the diagnosis, and probably the treatment of the patient as well.’ importance of phc principles in clinical practice: ‘i learnt that phc principles apply to all patients in some way; that dealing with the primary health care issues at hand can actually help in the recovery process of patients and assist in health promotion.’ challenges to implementing phc principles in clinical practice: ‘it is very easy to do the medical approach to the patient, as we learn from our superiors. we need to remind ourselves that we are treating patients and not diseases. it would be nice to have a way of reminding students of this on a regular basis.’ personal benefits derived from seminars: ‘i learnt that taking a few minutes in a history-taking consultation to ask some important questions can give imperative insight into the patient and their needs.’ article 28 december 2010, vol. 2, no. 2 ajhpe opportunities which facilitate their learning of the fundamental principles of holistic patient care, perhaps the most important learning outcome of any medical training programme offered across the globe. declaration of interest the study was reviewed and passed by the human research ethics committee at the university of cape town. the authors report no conflicts of interest. the authors alone are responsible for the content and writing of the paper. funding no external funding was received to write this paper. references 1. astin ja, sierpina vs, forys k, clarridge b. integration of the biopsychosocial model: perspectives of medical students and residents. acad med 2008;83:20-27. 2. engel gl. the need for a new medical model: a challenge for biomedicine. science 1977;196:129-136. 3. world health organization. declaration of alma-ata. international conference on primary health care, alma-ata, ussr, 6-12 september 1978. geneva: who. available at http://www.who.int/hpr/nph/docs/declaration_almaata.pdf accessed 10 march 2010. 4. world health organization. the world health report 2008. primary health care. now more than ever. geneva, switzerland: who press. 5. betancourt jr, green ar, carrillo je, ananeh-firempong o. defining cultural competence: a practical framework for addressing racial /ethnic disparities in health and health care. public health rep 2003;118:293-302. 6. kai j, spencer j, wilkes m, gill p. learning to value ethnic diversity – what why and how? med educ 1999;33:616-623. 7. roberts jh. cultural competence in the clinical setting. the clinical teacher 2006;3:97-102. 8. liaison committee for medical education (lcme). accreditation standards. available at http://www.lcme.org/standard.htm accessed 17 march 2010. 9. general medical council (gmc). tomorrow’s doctors. london: general medical council, 2009. http://www.gmc-uk.org/static/documents/content/ tomorrowsdoctors_2009.pdf accessed 17 march 2010. 10. association of american medical colleges (aamc). cultural competence education for medical students: tool for assessing cultural competence training (tacct). http://www.aamc.org/meded/tacct/start.htm accessed 17 march 2010. 11. post dm, stone lc, knuston dj, gutierrez tl, sari f, hudson wa. enhancing behavioural science education at the ohio state university college of medicine. acad med 2008;83:28-36. 12. fehrsen g, henbest r. in search of excellence: expanding the patient-centred clinical method: a three-stage assessment. fam pract 1993;10:49-54. 13. jacobson ld, edwards agk, granier sk, butler cc. evidence-based medicine and general practice. br j gen pract 1997;47:449-452. 14. kleinman a, benson p. anthropology in the clinic: the problem of cultural competency and how to fix it. plos medicine 2006; 3:10. http://plosmedicine.org accessed 29 november 2010. 15. maudsley g, strivens j. promoting professional knowledge, experiential learning and critical thinking for medical students. med educ 2000;34:535-544. 16. university of cape town. faculty of health sciences. the primary health care approach. http://www.primaryhealthcare.uct.ac.za accessed 17 march 2010. 17. irlam j, kiekelame mj, vivian l. integrating the primary health care approach into a medical curriculum: a programme logic model. african journal of health professions education 2009;1:1. http://www.ajhpe.org.za accessed 10 march 2010. 18. burch vc, benatar sr. rational planning for health care based on observed needs. s afr med j 2006;96(9):796-802. 19. burch vc, seggie jl. use of a structured interview to assess portfolio-based learning. med educ 2008;42:894-900. 20. bowling a. research methods in health. investigating health and health services. buckingham: open university press, 1997:336-357. 21. koehn ph, swick hm. medical education for a changing world: moving beyond cultural competence into transnational competence. acad med 2006;81:548-556. 234 october 2016, vol. 8, no. 2, suppl 2 ajhpe research community engagement has become a key aspect of higher education initiatives. to drive this agenda, higher education institutions, specifically health and social faculties, need to find opportunities in communities for health professional student engagement. to accomplish this goal, a potential strategy is to link community engagement activities with community-based participatory research. universities have a unique role in this partnership as creators and sharers of knowledge. communities provide the reality of social and health challenges and therefore provide the platform for learning and exploring their authentic challenges.[1] community-university partnerships are thus intended to bring together academic researchers and communities, share power, establish trust, foster co-learning, enhance strengths and resources, build community capacity, and address community-identified needs and health problems.[2] community-based participatory research (cbpr) is a model used to strengthen communities and universities through the application of research. cbpr principles[3] include trust based on communication, collaboration involving shared responsibility, excellence in science through training, monitoring and strict adherence to protocol, and ethics or strict guidelines and agreement on the handling of confidential information. interprofessional collaboration initiatives place greater emphasis on interprofessional education and practice and less emphasis on interprofessional research. the latter involves the collaboration of two or more health professionals in the research process. for practitioners or professionals to connect more effectively with the general public to better ascertain a given society’s actual needs and concerns, there is also a need to learn cbpr approaches. it is agreed that future healthcare providers require excellent clinical knowledge, a solid grounding in health promotion and disease prevention, the ability to use evidence-based guidelines, and the competencies for practice in interprofessional teams.[4] higher education institutions (hei) therefore play a vital role in formulating the pedagogical transition from a single-disciplined to a more integrated approach in research. however, this transition is challenging and complex, and an understanding of the benefits and possible challenges is required. to link cbpr and interprofessional education and practice (ipep), we need to understand how we create authentic universitycommunity partnerships that are beneficial to all stakeholders. although cbpr may employ a wide range of methodologies, the key principles remain the same.[5] academic researchers may experience challenges[6] in the implementation of cbpr, but these can be minimised if an awareness of potential barriers and upfront communication is shared. this article draws upon the experiences of academics, relating to their involvement in an interprofessional cbpr project. background. a collaborative interprofessional research project that involved community members was beneficial to community development. objective. to draw upon the experiences of academics relating to their involvement in an interprofessional community-based participatory research (cbpr) project. methods. a delphi study was applied as a self-reflective evaluation process to reach consensus on the lessons learnt from participation in a cbpr project. round one of the delphi employed closed-ended questions and the responses were analysed descriptively using microsoft excel (usa). the second round consisted mainly of open-ended questions and responses, and was analysed qualitatively. ethical clearance was obtained from the university of the western cape research committee. results. based on round one of the delphi study, it became evident that recognition of the community as a unit of identity, addressing health from physical, emotional and social perspectives and formation of long-term commitments were the cbpr principles most applied. disseminating information to all partners and facilitation of the collaborative equitable involvement of all partners in all phases of the research were the principles least applied. themes that emerged from the second round of the delphi included the identification of clear objectives based on the needs of the community, a shift from identification of the needs of the community to the implementation of strategies, and the creation of capacity-building opportunities for all stakeholders. conclusion. in a reflection on the research process, the interprofessional team of academics found that the basics of cbpr should be attended to first. a focus on clear objectives, implementation strategies and capacity building is important in cbpr. afr j health professions educ 2016;8(2 suppl 2):234-237. doi:10.7196/ajhpe.2016.v8i2.851 reflection on an interprofessional community-based participatory research project j m frantz,1 phd; g filies,2 mphil; k jooste,3 phd; m keim,4 phd; n mlenzana,1 phd; n laattoe,4 mphil; n roman,5 phd; c schenck,6 phd; f waggie,2 phd; a rhoda,1 phd 1 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 interprofessional education unit, faculty of community and health sciences, university of the western cape, cape town, south africa 3 school of nursing, faculty of community and health sciences, university of the western cape, cape town, south africa 4 interdisciplinary centre for sport science and development, faculty of community and health sciences, university of the western cape, cape town, south africa 5 child and family studies unit, faculty of community and health sciences, university of the western cape, cape town, south africa 6 department of social work, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: j m frantz (jfrantz@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2, suppl 2 ajhpe 235 research method research setting and context the faculty of community and health sciences, university of the western cape (uwc), cape town, south africa (sa) participates in various servicelearning activities at designated rural sites to promote interprofessional education, practice and research based on boyer’s model of scholarship. this model includes the scholarship of discovery, teaching and learning application, and integration. the scholarship of discovery includes interprofessional and collaborative research projects. research design a delphi study was used as part of a self-reflective evaluation process to identify barriers, as well as facilitating factors, in cbpr from a researcher’s perspective. delphi studies are used most often to gather data from domain experts, with the intention of coming to consensus, often around poorly defined topics such as the development of programme alternatives.[7] participants in the current study, the purposively selected delphi participants were the researchers who engaged in various aspects of the community engagement project. participants represented disciplines such as psychology, physiotherapy, social work, occupational therapy, nursing, education and sports science, thus highlighting an interdisciplinary approach to research. data collection methods prior to commencement of the study, ethics clearance was obtained from the uwc research ethics committee (project no. 13/2/3). during the first round of the delphi study, the participants were provided with the principles of cbpr and asked to rate the application of the principles during cbpr. the first round would thus identify the aspects that researchers were able to apply in their project and determine the overall extent to which a university-community partnership can implement cbpr principles. the data were then ranked according to the most commonly used principles and distributed for round two. during round two of the delphi, the participants were informed of the commonly used principles identified by all the participants in the previous round and were then asked to explain, in ≤250 words, the benefits, barriers and facilitators of the identified principles according to their experience with cbpr projects. the data were then analysed, and categorised into common themes. data analysis round one consisted of closed-ended question responses that were analysed descriptively using microsoft excel (usa). the second round consisted mainly of open-ended question responses and was, therefore, analysed qualitatively. participant responses were analysed thematically until saturation was reached.[8] the analysis, emergent themes and subsequent surveys were cross-checked by two other researchers, who provided critical input to the results and analysis. results sociodemographic data nine participants, 1 male and 8 females, responded to round one of the delphi. experience in academia ranged from 7 to 35 years, with a median of 17 years. experience with engagement in community-engaged research ranged from 3 to 25 years, with a median of 5 years. during round one of the delphi, the participants ranked the application of the principles of cbpr as these applied to their project (summarised in table 1). when looking at the application of key cbpr principles in an interdisciplinary project, the main themes that emerged were the importance of identifying clear objectives for the collaborative project based on the needs of the community, a shift from identifying the needs of the community to implementing strategies, and finally the creation of capacity-building opportunities for all stakeholders. theme 1: identifying clear aims and objectives setting of clear objectives was identified as a key consideration in driving cbpr. this is reflected in the following quotes: ‘the objectives of the study were based on the needs of the community so the community was involved in needs analysis.’ (p3) ‘if all parties are clear of the concept then collaboration will flow easily.’ (p4) ‘clear role clarity and an orientation session in the beginning of the project as departure could be useful.’ (p1) table 1. application of principles of cbpr item never applied: 0 sometimes applied: 1 often applied: 2 always applied: 3 mode recognising the community as a unit of identity 0 1 1 7 3 building on strengths and resources in the community 0 1 3 5 3 facilitating collaborative equitable involvement of all partners in all phases of research 1 3 3 2 1, 2 integrating knowledge and interventions for mutual benefits of all partners 2 1 3 3 2, 3 promoting a co-learning and empowering process 1 2 3 3 2, 3 addressing health from physical, emotional and social perspectives 0 0 3 6 3 finding a balance between research and interventions 2 2 2 3 3 disseminating information to all partners 0 1 6 2 2 forming long-term commitments 1 1 1 6 3 236 october 2016, vol. 8, no. 2, suppl 2 ajhpe research however, it was highlighted that we need to be conscious of the challenges, which could include the lack of involvement of a dedicated community member and limited time among stakeholders dedicated to the project, as illustrated in the following quotations: ‘we could have invited a community member to be part of the research team.’ (p3) ‘one of the challenges with doing this is time. time is needed to identify champions in the community who can be trained and then train them.’ (p3) ‘much more time should have been spent befriending them and gaining their trust.’ (p2) theme 2: shifting from identifying the needs of the community to implementing the strategies involving the community members as part of the team when shifting from needs to implementation creates a sense of pride and trust, as solutions are collectively found: ‘as the project was interdisciplinary the different domains of the person’s health were investigated, also looking beyond the individual to the family and environment.’ (p1) ‘a sense of community and pride was established by revisiting their stories; it assisted them to think afresh about the community and its worth.’ (p1) ‘the research process on its own created a space for the community members to reflect on their own context and issues (awareness).’ (p2) a barrier highlighted with shifting from needs to intervention included the additional workload for all stakeholders: ‘[stakeholders] have indicated that they have an overload of current work already and it would be additional work if they have to implement additional programmes.’ (p2) ‘one would have to integrate outcomes of the research programme within current community programmes.’ (p3) theme 3: creating capacity-building opportunities as empowerment is a key feature of cbpr, three clear themes emerged: commitment from partners, creation of learning opportunities and sharing of ideas to build capacity. if an interdisciplinary project is to be successful, all stakeholders should declare their commitment to the project from the onset: ‘a commitment to be part of a team should be given in the beginning and clear expectations and an agreement set with all stakeholders.’ (p1) ‘i think in principle much more time should have been spent collaborating with the community and the co-researchers.’ (p2) participants were very clear that cbpr must provide opportunities for capacity development: ‘… important part of ce research is capacity development …’ (p3) ‘i think what worked well was the effort made to create opportunities for people to meet and discuss about the project.’ (p4) ‘open discussion between stakeholders creates an awareness of challenges to be addressed and things to be avoided.’ (p1) discussion the four pillars of learning that have been articulated in the literature are ‘learning to know’, ‘learning to do’, ‘learning to live together’ and ‘learning to be’.[9] universities are increasingly viewed as agents of change and no longer as ivory towers. cbpr, in addition to traditional research, is seen as one way of facilitating change, closing disparities in communities and achieving ‘learning to know, learning to do, learning to live together and learning to be’.[9] in particular, we cannot underscore the value of cbpr as a way of researching and learning together with community members and community stakeholders within the sa context. the objective of the study was to reflect on the cbpr process to identify the lessons learnt and make recommendations for the way forward. cbpr practitioners may experience many challenges with implementing it; these could be minimised if an awareness of potential barriers is shared and communication is upfront. there are numerous challenges and barriers to conducting cbpr, as well as facilitating factors, as highlighted in literature.[10] we list four recommendations, based on the reflections of the participants of an interdisciplinary cbpr project. recommendation 1: cbpr requires a people-centred and critical approach that focuses on empowerment within cbpr, community members are viewed as participants in the research and as knowledgeable partners in the research process. cbpr is not seen as a once-off event but rather a process of conducting research, resulting from the ongoing action-reflection process between the university, community and stakeholders.[10] differing from traditional research, where the researchers move in and out of the community, cbpr is a facilitated collaborative process benefitting both researchers and community.[10] therefore, before embarking on the cbpr process, teams should clarify their knowledge and perceptions of cbpr as different from traditional research. the application of cbpr requires a fundamental shift in academics’ views of people in communities from one of subjects who are beneficiaries to a perception of them as invaluable partners and experts who can galvanise their communities in the development of effective, novel and sustainable interventions. recommendation 2: time spent in the community and within the team the community development resource association[11] regards time spent with the people in the community and the team as ‘getting the basics right’. ‘if you want to enter into a venture with people, you have to know them ‒ you have to know what is in their souls.’ this is important if we aim to create authentic partnerships where community capacity-building occurs and learning opportunities for students are created. the literature highlights that if insufficient time is spent in the community, community capacity-building may be limited to individuals only and not occur in communities and organisations.[12] similarly, a need was expressed by the research team for more time to interact with each other and thus be able to attend meetings, share thoughts, build capacity, share experiences and build support structures. to spend time with the community and the team brings a debate to the table relating to the workload of the academics and researchers who will take part in cbpr processes. these are conversations that should be facilitated with the university management structures.[13] recommendation 3: build relationships relationship-building with and within the community and within the team is a key aspect of cbpr. cbpr is dependent on good and growing relationships with the community and between team members.[10] it is only when a good relationship exists that cbpr can be sustainable. implied in the building of relationships in cbpr work are the values of mutual integrity, humility and respect.[6] october 2016, vol. 8, no. 2, suppl 2 ajhpe 237 research recommendation 4: building capacity in the community and the team participants in the research referred to the need and importance of building capacity of the people in the community, but in particular for the members of the interprofessional team. sustainability of the cbpr process can only be ensured when research teams and community members are capacitated and mentored to take the process forward.[10] implicitly, cbpr is about human development and, thus, building capacity within individuals to manage their own lives, and within the team, is important to ensure sustainability. capacity-building elements should include the cultivation of self-knowledge and self-reflection, as well as the ability to observe, interview and learn to listen, and the facilitation of respect and flexibility.[14] we need to continually maintain opportunities for self-reflection with ourselves, in the team and with the community and research partners, about ourselves, our institutions, power relations and cultures.[14] conclusion cbpr aims to facilitate sustainable change through research and create longterm relationships with community members and stakeholders as research partners. from this reflection on the research process, we concluded that the basics of cbpr should be attended to first. a changed research paradigm, spending time building relationships and capacitating staff and community members, should be facilitated. getting this right will then assist the universities and communities to learn to know, learn to do, live together and learn to be. all of the above should be applied in an interprofessional and collaborative manner, as the researchers embark on the scholarship of discovery suggested by boyer’s model. acknowledgement. the authors thank the national research foundation for the funding that made this research project possible. references 1. allison j, khan t, reese e, dobias bs, struna j. lessons from the labor organising community and health project: meeting the challenges of student engagement in community based participatory research. j public scholarship higher educ 2015;5. 2. mthembu sz, mtshali fg. conceptualisation of knowledge construction in community service-learning programmes in nursing education. curationis 2013;36(1):e1-e10. doi:10.4102/curationis.v36i1.69 3. watterson n, dunbar d, terlecki m, et al. interdisciplinary community-based research: a sum of disparate parts. j community engagement higher educ 2011;3(1):1-10. 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 5. savage cl, xu y, lee r, et al. a case study in the use of community-based participatory research in public health nursing. public health nurs 2006;23(5):472-478. doi:10.1111/j.1525-1446.2006.00585.x 6. ahmed sm, beck b, maurana ca, newton g. overcoming barriers to effective community-based participatory research in united states medical schools. educ health 2004;17(2):141-151. doi:10.1080/1357628041000171 0969 7. hsu cc, sandford ba. the delphi technique: making sense of consensus. pract assess res eval 2007;12(10):1-8. 8. elo s, kyngas h. the qualitative content analysis process. j adv nurs 2008;62(1):107-115. doi:10.1111/j.13652648.2007.04569.x 9. higgs p, moeketsi rmh. the africanisation of academic development programs: a case study. indilinga: afr j indigenous knowledge syst 2012;11(2):146-159. 10. horowitz cr, robinson m, seifer s. community-based participatory research: from the margin to the mainstream. circulation 2009;119(19):2633-2642. doi:10.1161/circulationaha.107.729863 11. taylor j. emergence: from the inside out. community development resource association 2003/2004 annual report. cape town: cdra, 2004. 12. soal s. measuring development: holding infinity. community development resource association 2000/2001 annual report. cape town: cdra, 2001. 13. mosavel m, simon c, van stade d, et al. community-based participatory research (cbpr) in south africa: engaging multiple constituents to shape the research question. soc sci med 2005;61(12):2577-2587. doi:10.1016/j.socscimed.2005.04.041 14. wallerstein nb, duran b. using community-based participatory research to address health disparities. health promot pract 2006;7(3):312-323. doi:10.1177/1524839906289376 http://dx.doi.org/10.4102/curationis.v36i1.69 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1111/j.1525-1446.2006.00585.x http://dx.doi.org/10.1080/13576280410001710969 http://dx.doi.org/10.1080/13576280410001710969 http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x http://dx.doi.org/10.1161/circulationaha.107.729863 http://dx.doi.org/10.1016%2fj.socscimed.2005.04.041 http://dx.doi.org/10.1177/1524839906289376 178 october 2016, vol. 8, no. 2 ajhpe research bringle and hatcher[1] described service-learning as a ‘course-based, creditbearing education experience in which students participate in an organized service activity that meets identified community needs, and reflect on the service activity in such a way as to gain further understanding of course content, a broader appreciation for the discipline, and an enhanced sense of civic responsibility’. eyler et al.[2] defined reflection as ‘the hyphen between service-learning’. however, the way in which reflection is conducted should be carefully considered, as it may not necessarily result in deep learning or may lead to learning the incorrect information. it is therefore important to ensure good-quality reflection on experiences where students articulately express the essence of their learning.[3] these authors also found a correlation between meeting deeper learning outcomes and how rigorous the reflection opportunity is presented, and the quantity and quality of the reflections. as students learn from and through experience in service-learning modules, reflection becomes an integral part of the learning process. in this article, we first describe reflection and its role in service-learning. subsequently, an overview of previous research on the measurement of reflection in service-learning is provided, and, lastly, the use of rubrics in the measurement of reflection is discussed. reflection and its role in service-learning reflection allows one to think critically about successes and failures, develop concepts that are based on ideas and information from multiple sources, and apply such knowledge in future.[4] currently, reflection is regarded as an integral part of the learning process. there are various types of reflection journals for service learning,[5] including key-phrase journals, double-entry journals, critical incident journals, directed writings and three-part journals. the last was applicable to this research, as students had to respond to guided questions addressing three separate aspects: (i) to describe what happened in the service experience with regard to what was successful or not; (ii) to provide possible reasons for this and to analyse how the course content relates to the service experience; and (iii) to apply the service experience to how they see the world (e.g. goals, values, attitudes, beliefs and philosophy). the benefits of reflection are numerous: it allows one to make better choices or to take more appropriate actions in future, which result in greater effectiveness;[6] students develop a deeper and more sustainable knowledge of curricular content, skills, and increased understanding of self, others and the community;[7] and they develop a critical understanding of their theoretical modules and foster an ability to consider their own progress, values and goals. reflection activities must allow students to discover the value of dialogue, embrace the importance of perpetuity in the learning process, and develop the ability to consider the meaning of personal experience. reflection should start on a contextual level (a holistic view of the situation) and move towards a dialectical level (to question the value of knowledge systems, moral and ethical issues).[8] effective reflection should firstly link the service experience to the course content and be structured. it should also ensure regular provision of feedback from the instructor so that students learn how to improve their reflective practices, and provide the opportunity for students to discover, refine or adjust their values and opinions.[1] facilitators need to help students to link their experiences to the course material and to challenge their beliefs to deepen their learning.[3] one of the challenges of facilitators in service-learning is to determine how reflection contributes to the students’ professional and personal growth. according to bender et al.[9] it is essential that the outcomes of servicelearning activities be assessed to measure learning and growth. students do not encounter reflection similarly and also differ in how quickly they mature in their ability to learn from reflection.[1] background. during a service-learning module, the focus is on the development of reflective competence, which is part of professional competence. the students have to reflect in a structured manner on the service-learning experience to understand and appreciate not only the module and discipline, but also their sense of personal value and social responsibility. by providing structured opportunities for reflection, deeper learning can be facilitated, which enhances competence. do students benefit from the process of reflection and how should it be measured? objective. to determine the usefulness of an assessment tool. methods. a documented review of reflection journals made use of a rubric to score the structured reflection of students at a particular service-learning site. descriptive statistics were used to analyse the data. results. the results showed positive changes in terms of analysis, critical thinking, emotive aspects, social responsibility and self-confidence. conclusion. specific factors were identified that could have affected the reflections, and recommendations are made to increase the effectiveness of the assessment tool and the process of reflection. afr j health professions educ 2016;8(2):178-183. doi:10.7196/ajhpe.2016.v8i2.586 the usefulness of a tool to assess reflection in a service-learning experience a-m wium, ba logopaedics, m communnication pathology, dphil, pgche, pgd (ethics); s du plessis, ba logopaedics, m communnication pathology, dphil, pgche discipline of speech-language pathology and audiology, school of health care sciences, sefako makgatho health sciences university, pretoria, south africa corresponding author: a-m wium (anna-marie.wium@smu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 179 research measuring reflection: previous studies most previous assessments of reflection relied on self-reported measures of outcomes, but did not assess student learning.[10] there seems to be a gap in the literature on how to determine professional and personal growth, or how the amount and type of reflection activity relate to student outcomes.[1] this can most probably be ascribed to limited assessment procedures or tools. bender et al.[9] recommended that rubrics be created as scoring tools of reflection, in which the specific expectations and acceptable and unacceptable levels of performance are stipulated. critical reflection is the process that transforms the service to the ideas and understanding of the learning experience. this study developed a rubric to assess the reflective competence of students. the objective was to determine the usefulness of an assessment tool that measures change in students’ personal and professional growth. methods this was a retrospective study using document review.[11] once ethical clearance had been obtained (mrec/h/170/2012:ir), qualitative data were collected from reflection journals that were previously completed by each student. the data were analysed qualitatively and quantitatively. the journal entries were obtained from three different occasions over a period of 1 year and were scored retrospectively; the scores were compared to measure change.[10] these reflections were scored using a rubric to increase reliability and validity. a sampling design was not used, as all the journals compiled by an entire group of eight students at a particular service-learning site were analysed. the reflection journals consisted of structured questions. as a rule, the journal entries were made on a weekly basis for 30 minutes during the service-learning programme. students reflected on their experiences without consulting peers and completed their reflection sheets on site after the service had been provided. at the time of the reflection, the students congregated in a communal meeting room in the presence of a 4th-year student (programme manager) and their two facilitators. the individual reflection was then followed by a discussion led by the programme manager, during which students shared with each other their experiences during the day in terms of planning, implementation and future planning, and their feelings. this procedure was repeated on a weekly basis during the academic calendar. because the research focused on the individual reflection of each student, as documented in the reflection journals, it indicates the changes in professional and personal competence (including knowledge, skills and attitude/emotive components) over the course of the year. the reflection journals consisted of 10 questions to guide students and were graded according to a coding scheme using a 3-point scale (1 – no reflection; 2 – inadequate response; 3 – adequate/ positive response with rationale). the journal entries documented throughout a period of 1 year were obtained; three specific entries made at the beginning of the year, during the middle of the year, and towards the end of the year were analysed and compared to determine whether any change had occurred in the students’ thinking (knowledge), skills, and attitudes (including confidence) over time. the rubric was pilot tested before use. two researchers independently reviewed the data and obtained 80% agreement with regard to coding to increase trustworthiness. marks assigned to each criterion were automatically calculated as percentages in excel and an average of total scores was calculated from the three measurements taken over the year. descriptive statistics were used to describe, summarise, and interpret the data.[12] the linear regression facility of the analysis tool pack in excel (microsoft, usa) was used for the analyses to measure growth across time. growth was depicted by the slope in the graph and displayed by a change in colours ranging from red (poor), yellow (average/limited) to green (growth) on the excel spreadsheet where the data were entered. the statistical results were supported by specific verbatim quotes. the use of a rubric allowed the data to be compared across time and among various participants. results change related to professional growth the results in fig. 1 show that the reflections documented at the beginning of the academic year differed from those obtained towards the middle and end of the year. the graph depicts three measurements. linear regression was used to fit a curve to the experimental data. a slope of the regression line signifies the degree of improvement from one phase to the next. in this case, the statistical analysis indicates that the slope of the regression line is >0% at a confidence level of 95%, i.e. even in this limited sample size a steady improvement has been noted. with reference to the structured questions in the reflection journal depicted in section a of table 1, results show a change over time in critical thinking and emotive (attitude) aspects in terms of all the questions in the analyses. the limited change observed in problemsolving skills addressed in questions 9 and 10 in section a could be attributed to these questions being the last two to be completed in the journals. time constraints in the completion of the reflection could influence the results. the results show an increase in students’ sense of social responsibility. an awareness of the needs of the community increased from 42% at the beginning of the year to 100% towards the end of the year. at the beginning of the year, only 38% of the students indicated that they would stay in the a ve ra g e sc o re fo r ea ch d at e, % 100 90 95 80 85 70 75 60 65 50 55 1 2 3 4 5 6 7 8 9 10 question feb. 2012 oct. 2012 june 2012 fig. 1. average score per question. 180 october 2016, vol. 8, no. 2 ajhpe research ta bl e 1. m at ri x fo r re fl ec ti on se ct io ns le ve l o f r ef le ct io n st ud en t 1 st ud en t 2 st ud en t 3 st ud en t 4 st ud en t 5 st ud en t 6 st ud en t 7 st ud en t 8 fe br ua ry , % ju ne , % o ct ob er , % g ro w th se ct io n a le ve l 1 ‘a na ly se s’: ‘w ha t? ’ w ha t k in d of ac tiv ity d id y ou en ga ge in to da y? 3 2 3 3 2 3 2 3 88 10 0 96 1 w ha t d id y ou le ar n to da y? 3 1 2 3 2 2 2 2 71 92 88 1 le ve l 2 c ri tic al th in ki ng ‘s o w ha t? ’ w ha t d id y ou d o th at w as s uc ce ss fu l? w hy w as it su cc es sf ul ? 3 3 3 3 2 3 2 2 88 83 10 0 1 w ha t d id y ou do th at w as n ot su cc es sf ul ? w hy w as it n ot ? 3 3 3 2 2 3 2 2 83 83 92 1 w ha t d id y ou d o to co m pe ns at e fo r th e ab ov e? 2 3 3 2 2 2 2 2 75 79 83 1 d id th e co m pe ns at or y st ra te gy w or k? w hy ? 2 3 3 2 2 2 2 2 75 83 83 1 le ve l 3 em ot iv e as pe ct s w ha t a re y ou r fe el in gs r e th e se rv ic ele ar ni ng ex pe ri en ce ? 2 3 2 3 2 2 3 2 79 88 10 0 1 w ha t a re y ou r fe el in gs r e yo ur se rv ic e de liv er y? 3 3 2 3 2 3 3 1 83 88 10 0 1 le ve l 4 pr ob le m so lv in g: ‘n ow w ha t? ’ w ha t w ill y ou d o di ff er en tly n ex t tim e? 3 3 3 2 2 2 2 2 79 92 79 2 w ha t i s th e re le va nc e of th e in te nd ed a ct io n pl an ne d? 3 3 2 2 2 2 2 2 75 92 79 1 fe br ua ry , % 90 90 87 83 67 80 73 67 ju ne , % 10 0 97 90 90 10 0 83 63 80 o ct ob er , % 97 63 10 0 87 10 0 97 83 93 g ro w th 1 3 1 1 1 1 1 1 co nt in ue d … october 2016, vol. 8, no. 2 ajhpe 181 research ta bl e 1. (c on ti nu ed ) m at ri x fo r re fl ec ti on se ct io ns le ve l o f r ef le ct io n st ud en t 1 st ud en t 2 st ud en t 3 st ud en t 4 st ud en t 5 st ud en t 6 st ud en t 7 st ud en t 8 fe br ua ry , % ju ne , % o ct ob er , % g ro w th se ct io n b d ev el op m en t of s oc ia l re sp on si bi lit y d oe s st ud en t s ho w an a w ar en es s fo r th e ne ed s of th e co m m un ity ? 1 3 1 1 1 1 1 1 42 33 10 0 1 d oe s st ud en t s ho w / ex pr es s a ne ed to st ay in vo lv ed in th e co m m un ity ? 1 2 1 1 1 1 1 1 38 38 96 1 d oe s st ud en t s ho w an u nd er st an di ng o f hi s/ he r co nt ri bu tio n to s oc ia l c ha ng e? 2 3 1 2 1 2 1 1 54 46 10 0 1 fe br ua ry , % 43 90 33 43 33 43 33 33 ju ne , % 67 33 33 43 33 33 33 33 o ct ob er , % 90 10 0 10 0 10 0 10 0 10 0 10 0 10 0 g ro w th 1 1 1 1 1 1 1 1 se ct io n c su m m ar y of p er ce iv ed co m pe te nc e pe rc ei ve d un de rs ta nd in g of w ha t h e/ sh e ha s be en d oi ng m at ch es th e cu rr ic ul um ou tc om es 1 1 1 1 1 2 1 2 42 50 88 1 pe rc ei ve d su cc es s w ith im pl em en ta tio n 3 2 2 2 2 2 2 2 71 83 10 0 1 st ud en t’s a tt itu de to s er vi ce -l ea rn in g ex pe ri en ce 3 3 2 2 2 3 3 2 83 79 10 0 1 fe br ua ry , % 77 67 57 57 57 77 67 67 ju ne , % 90 10 0 67 77 57 43 67 67 o ct ob er , % 77 10 0 10 0 10 0 10 0 90 10 0 10 0 g ro w th 2 1 1 1 1 1 1 1 182 october 2016, vol. 8, no. 2 ajhpe research community, but their views changed over the course of the year, as 96% were positive after working in this community for the entire year. their work in the community for an extended period also made them understand how they could contribute to social change, as shown in the results that changed from 54% to 100% towards the end of the year. considering that community awareness is an integral part of service learning, it is important that facilitators guide their students in this regard.[3] in this study professional services were provided to young learners at a rural preschool, and although the circumstances in which they worked were dire, not all sessions were particularly aimed at increasing community awareness. an increase in social responsibility could only be noted once the students were escorted walking through the village to visit clients in their homes. in these cases the specific opportunity allowed them to look beyond the boundaries of providing their professional services and to see the needs of the wider community. only then did they comprehend how they fit into the bigger picture and could they challenge their own beliefs and value systems. the goal of reflection is to think about the larger social issues behind the needs for which the service is provided. these issues include the social, cultural, economic, and political context of the needs to be addressed.[13] the traditional roles of lecturer and student are challenged in service learning, as the lecturer is no longer the sole expert contributing to the training, but fellow students and community members (even if uneducated) can contribute to the students’ education and knowledge acquisition.[8] the following quotes emphasise how the students have developed a sense of social responsibility and valued their service-learning experience: ‘it is important to be a helper of people and as a person try to help where you can because as a community we all stand together and there are a lot of people that are not identified that need help.’ ‘this experience has taught me to strive to make a difference.’ ‘it is important to stay involved in this community – because the need for education and special services are very high and i know i can make a difference by helping these children.’ the results obtained in section c of table 1 indicate the change in the students’ perceived self-confidence. all students were of the opinion that they have become clinically competent in their service provision at the site, as these scores increased from 71% to 100%. the following demonstrates their attitudes at the end of the year: ‘i will be more able to communicate with others who can’t speak my language and collaborate with teachers to make a change. i can work better in a team when helping a client. i have more self-confidence when doing therapy and working with children. it makes me more positive about the future.’ some students did not understand how their service-learning experience related to the curriculum outcomes. despite having received learning guides in which the relevance is explained, students tend not to read them. although change did occur for the group (42 88%) in terms of whether their actions matched the curriculum outcomes, it is possible that some degree of uncertainty remained. it is therefore important that facilitators continuously make students aware of their curriculum outcomes at the service-learning site. overall, the students were positive about their experience at the end of the year compared with the beginning of the year. the results show that the students were pushed beyond superficial interpretations and that their reflective competence contributed to personal growth, civic responsiveness, and critical thinking. evaluating the usefulness of the assessment tool the strength of the assessment tool was that it provided answers for programme evaluation (quality control). the tool indicates change and was relatively quick and easy to use once the scorers were familiar with the procedure. reliability therefore depends on how familiar the scorer is with the rubric, which is determined by the frequency of the measurements. once the scorers had familiarised themselves with the tool, there was an increase in reliability. the 3-point scoring matrix used in this study was adequate for providing a general indication of whether change had occurred. future research may opt for a 5-point scale to obtain a better understanding of a student’s reflective competence (e.g. surface to moderately deep reflection to depict a student not looking beyond the particular experience, and a moderate to deep reflection for the student who looks at how the process has helped him/ her to plan for the near future).[14] although this study focused on the use of the rubric as a tool to assess whether there was any professional and personal growth, the particular reflection practice used at this site also came under scrutiny. criticism from the literature clearly indicates that individual student reflection may be inadequate and one-sided, because students’ established thoughts are not challenged and they are not stimulated to think beyond their original viewpoints. reflective journal notes in individual reflection may, however, be judgemental as opposed to a wider understanding and a rethinking of ideas, as evident in reflective interaction with other students.[8] when reflection takes place in small groups, ideas may be generated by the sharing of different perspectives. at our specific site, the individual reflection is followed by small-group reflection, with verbal feedback by the facilitators to the entire group. the research emphasised the need for facilitators to also provide individual feedback on the students’ written reflections to further guide them on how to critically reflect. it is therefore suggested that such feedback be provided during supervisor feedback sessions when students are assessed on their clinical skills. the use of the rubric for multiple measurements over time to assess written journal entries was time consuming for the facilitators. dalal et al.[14] found the use of a rubric in peer assessment of e-portfolios to be effective, which is a possibility that should be investigated for future use. this implies that journal entries will be completed after the service-learning experience when the students access their computers. it also implies that students would have had the opportunity to reflect as a group before they are allowed to reflect individually, which may contribute to their growth. factors affecting reflection and completion of the journals specific factors emerged from analysing the journal entries that could have affected the manner in which the students interpreted their practical experiences or documented their impressions. some students were succinct when writing their reflections, while others expanded and expressed themselves more eloquently. for some students the writing exercises were easy, while others wrote more laboriously and required more time to formulate their thoughts.[8] language proficiency (english is not the students’ first language, but an additional language) may therefore also be a factor to consider when analysing reflection. the structure provided by the 10 questions, however, made the writing experience easier. the october 2016, vol. 8, no. 2 ajhpe 183 research questions made them describe their experiences, consider the needs of the community, and relate the experiences to themselves. guided reflection therefore contributed to their professional and personal growth. it became evident from reading the journal entries that diversity is related to the manner in which students reflect. students of different cultures, race, and socioeconomic backgrounds work together at practical sites, which has an effect on how they construct meaning from their practical experiences.[8] from scrutinising and relating the reflections to the individual students, it appears as if those from disadvantaged backgrounds were less affected by poverty in this specific community than their peers from more affluent circumstances, who were in the same group. from this limited sample it seems as if the background of the students and the context in which the service is provided influence the manner in which the students reflect. the individual reflections portrayed how the students felt directly after their experience. the following quotes show how their feelings were largely influenced by how well they were prepared for providing the service, as those who were well prepared reflected a more positive attitude, and vice versa: ‘be more prepared and not look like a fool again. need to pick-up my sox. i can do better than this.’ ‘not being totally prepared is a waste of time to yourself and others that you are helping. life is knocking.’ whenever students embarked on a new task, they often felt unsure and anxious, which reflected in their journals. at the beginning of the year most 2nd-year students have not acquired the clinical skills to meet the learning outcomes, but they developed these over the course of the year. furthermore, their reflections were related to real-life experiences, which is why they experienced some days to be better than others. their reflections when describing the activity therefore changed as they became more competent and gained more clinical skills. further limitations were time-related factors, which led to no response to some of the journal questions. students were allowed 30 minutes for their reflection, but as they were dependent on communal transport leaving at a specific time, those who started late tended to omit certain questions. to increase the response rate it is important that all students simultaneously and strictly keep to the time restrictions. the data showed a discrepancy between the different students, as some performed better than others. not all students develop at the same pace and development can therefore be placed on a continuum. this is probably because reflection skills develop slowly over time from adolescence to adulthood.[15] when a task was new or difficult to perform (e.g. assessment), students responded less positively in their reflection, and some reflected negatively because of their incompetence at the time. once they became more skilled in that task, they became more confident, which was reflected in their journal entries. unfortunately, the nature of the service-learning experience allowed for some tasks to be performed only at the onset of the year, when students still felt unsure about their competence. it is therefore recommended that the researchers compare results obtained at the start of the year over several years and not only across time for a specific year to obtain more reliable results. recommendations the two facilitators refrained from allocating marks for the reflections to avoid the hawthorne effect[11] (i.e. students trying to impress the supervisor). however, it is recommended that such reflections be used by facilitators in their feedback to students, which could ultimately affect the final mark for practical work, and could also contribute towards formative assessment. assessment of reflection in supervisor feedback should be conducted on a regular basis.[10] although this rubric shows potential for use in determining professional growth at a service-learning site, it should be further developed. it is recommended that a larger sample be selected, and that the study be implemented at various sites to increase the dependability of the research. it is suggested that it should also be compared with other tools and across different cohorts. references 1. bringle rg, hatcher ja. introduction to service-learning toolkit: reading and resources for faculty. providence, ri: campus compact, 2003. 2. eyler j, giles de, schmiede aa. a practitioner’s guide to reflection in service-learning. nashville, tn: vanderbilt university, 1996. 3. ash sl, clayton ph. the articulated learning: an approach to guided reflection and assessment. innovative higher educ 2004;29(2):137-154. doi:10.1023/b:ihie.0000048795.84634.4a  4. hopkins d. improving the quality of teaching and learning. support for learning 1997;12(4):162-165. doi:10.1111/1467-9604.00038  5. hatcher ja, bringle rg. reflections: bridging the gap between service and learning. j coll teach 1997;45:153. doi:10.1080/87567559709596221 6. rogers r. reflection in higher education: a concept analysis. innovative higher educ 2001;26(1):37-57. doi:10.1023/a:1010986404527 7. rice k. engaging all partners in reflection: designing and implementing integrative reflection opporunities, 2010. suu.edu/servelearn/pdf/ricereflectionpacket.pdf (accessed 11 july 2016). 8. petersen n, osman r. an introduction to service learning in south africa. in: osman r, petersen n, eds. service learning in south africa. cape town: oxford, 2013. 9. bender g, daniels p, lazarus j, naude l, kalawathie s. service-learning in the curriculum: a resource for higher education institutions. pretoria: council on higher education, 2006. 10. molee lm, henry me, sessa vi, mckinney-prupis er. assessing learning in service-learning courses through critical reflection. j experiential educ 2010;33(3):239-257. doi:10.5193/jee33.3.239 11. leedy pd, ormrod je. practical research: planning and design. 9th ed. boston: pearson, 2010. 12. johnson rb, christensen lb. educational research: quantitative, qualitative, and mixed approaches. 2nd ed. boston, ma: allyn and bacon, 2004. 13. tsang e. use assessment to develop service-learning reflection course materials. 32nd asee/ieee frontiers in eduation conference, boston, ma, 2002. doi:10.1109/fie.2002.1158150 14. dalal dk, hakel mt, sliter mt, kirkendall sr. analysis of a rubric for assessing depth of classroom reflections. int j eportfolio 2012;2(1):75-85. www.theijep.com/pdf/ijep115.pdf (accessed 11 july 2016). 15. king pm, kitchener ks. reflective judgment: theory and research on the development of epistemic assumptions through adulthood. educ psychol 2004;39(1):5-18. doi:10.1207/s15326985ep3901_2 http://dx.doi.org/10.1023/b:ihie.0000048795.84634.4a http://dx.doi.org/10.1111/1467-9604.00038 http://dx.doi.org/10.1080/87567559709596221 http://dx.doi.org/10.1023/a:1010986404527 http://dx.doi.org/10.5193/jee33.3.239 http://dx.doi.org/10.1109/fie.2002.1158150 www.theijep.com/pdf/ijep115.pdf http://dx.doi.org/10.1207/s15326985ep3901_2 october 2016, vol. 8, no. 2 ajhpe 189 research in the past decade, developments within the occupational therapy profession led to a critique of reductionist approaches that retained practice in traditional biomedical settings and the adoption of knowledge frameworks responsive to community needs. it was acknowledged that as a basic human need occupation is crucial for health and wellbeing.[1] accordingly, the concept of occupation, as understood in the profession, evolved from therapeutic activity (within a medical model approach) to occupational enablement as a principle of occupational justice (within a sociopolitical approach). considering that some people are privileged to choose what they do, while others are deprived of occupational choice, the central point in the theoretical construct of occupational justice is that injustice results when people are restricted from engaging in occupation.[2] an occupationally just society is therefore viewed as one in which people’s occupational rights are met, and in which they are empowered to choose and perform occupations according to their own needs or wants.[2] consequently, there were calls for occupational therapy education programmes to become more responsive to the local context, and to facilitate graduate attributes such as resilience[3] and critical reflexivity.[4] this resulted in a global reorientation of the profession that, coupled with health and education reform in south africa (sa), gave momentum to the development of the university of the western cape (uwc) occupational therapy curriculum to one with a critical orientation.[5] a number of factors may inhibit occupational therapists’ ability to promote occupational justice in everyday practice. méthot[6] is of the opinion that the occupational therapy profession’s emphasis on the promotion of occupational justice may be at odds with the curative approach of the medical model that, in some instances, is still dominant in healthcare. likewise, wilding’s[7] study on occupational therapists’ experiences in a hospital setting showed that the dominant discourse of medical epistemology acted as a form of hegemony that manifested in the therapists’ unconscious compliance with the protocols of the hospital, thus hindering occupation-based practice. with regard to practice context, newton and fuller[8] identified that occupational therapists who work in rural and remote areas may encounter challenges, such as professional isolation, as interprofessional networks may be non-existent and they therefore may not be able to form collaborations and alliances to support their practice. it has been suggested that occupational therapy education programmes facilitate students’ ability to examine institutional systems that hinder occupational justice, and their ability to advocate for systemic and structural changes that would facilitate it,[9] highlighting the importance of critical consciousness.[5] one teaching and learning approach that has been singled out as a doorway to critical consciousness is transformative learning.[10] the facilitation of critical reflexivity as a teaching and learning approach is central to transformative learning, as it entails a process by which assumptions are brought to light, clarified and challenged to generate beliefs to guide action.[10] julio et al.[11] describe the essence of transformative learning as developing students’ leadership attributes and producing enlightened change agents. in addition to transformative learning, they emphasise the importance of interprofessional education in fostering joint solutions to health issues and the transformation of health systems. the influence of a truly critical curriculum would be exhibited by its graduates through their own empowerment beyond the confines of the university.[12] uncovering graduates’ conceptualisations of occupational justice and its translation into practice could therefore illuminate developments in the curriculum that may be required to address the critical competencies of students. this article reports on a broader study that aimed to explore how background. the concept of occupational justice was derived from a social justice perspective in response to a renewed commitment by the occupational therapy profession to address the occupational needs of individuals, groups and communities who experience social injustice. accordingly, it is acknowledged that education with regard to occupational justice has the deliberate intention of preparing graduates, who would be change agents as critical practitioners. nonetheless, while occupational therapy education programmes may seek to instil broader professional values, theory covered in the curriculum may not always assure congruent practice. objective. to explore how occupational therapy graduates’ conceptualisations of occupational justice, as instilled by the occupational therapy curriculum of the university of the western cape, south africa, manifested in their practice while undergoing community service. methods. seven occupational therapy graduates were selected to participate in the study through purposive sampling. a descriptive case study of their practice was generated through qualitative methods. semi-structured interviews, document review and participant observation were used as data collection methods, analysed through a process of inductive thematic analysis. results. the findings revealed that while the participants conceptualised occupational justice as broader social change through occupational enablement, they encountered several constraints related to structural and systemic power issues in their practice contexts. conclusion. the study supports the utilisation of transformative learning and inter-professional education in developing critical competencies such as agency and political proficiency to assist graduates in dealing with the complexities of practice during community service. afr j health professions educ 2016;8(2):189-192. doi:10.7196/ajhpe.2016.v8i2.609 exploring occupational therapy graduates’ conceptualisations of occupational justice in practice: curriculum implications l a hess-april,1 phd; j smith,2 phd; j de jongh,1 phd 1 department of occupational therapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 department of educational studies, faculty of education, university of the western cape, cape town, south africa corresponding author: l a hess-april (lhess@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 190 october 2016, vol. 8, no. 2 ajhpe research uwc occupational therapy graduates’ conceptualisations of occupational justice manifest in their practice. in particular, we discuss one of the objectives of the study, i.e. to reflect on strategies that could be employed to address constraints faced by uwc community service occupational therapy graduates in incorporating occupational justice into their practice. methods a qualitative research approach was adopted to generate a case study of the practice of a group of uwc graduates who were performing community service. qualitative research is fundamentally interpretive, with the primary objective of comprising in-depth description and understanding.[13] the objective of the study was to explore how uwc occupational therapy graduates’ conceptualisations of occupational justice manifest in their practice. a descriptive case study design was therefore appropriate. data collection and procedures purposive sampling was used to recruit seven graduates who had at least 6 months of community service experience in 2010. graduates in underresourced, rural practice contexts were selected in line with the purpose of the community service policy to increase availability and access to health services in these contexts. selection was further based on the service level where they were placed for community service. data collection methods included document review that provided background information on the participants’ practice; participant observation that was utilised to gain an understanding of their practice contexts; and semi-structured interviews that allowed them to reflect on their understanding and enactment of occupational justice in practice and on the influence of their education on their practice. initial interviews, between 45 minutes and 1 hour in duration, were conducted during the period of participant observation, while follow-up interviews that lasted for ~1 hour were conducted after the completion of data analysis to allow for a deeper probing of the research issues. to prompt reflection, a set of predetermined questions was developed as a guide (table 1) and used in a flexible manner. inductive thematic data analysis was used to analyse the data. trustworthiness was ensured through triangulation, a detailed description of the research context and process, peer examination, and maintaining a reflective journal. once the data were transcribed and analysed, the participants had an opportunity to check the accuracy of the findings, engage with the analysis, and further reflect on the curriculum in relation to its tenet of occupational justice. ethical clearance was obtained from the uwc research committee (no. 10/4/25) and the respective provincial health research ethics committees. informed written consent was obtained from all participants. they could withdraw their participation at any stage without being penalised, and issues of confidentiality and anonymity were adhered to. in conducting participant observation, informed consent was obtained from all persons with whom the participants interacted at that particular time. results the participants practised in settings where health problems were described as typical of a developing context, as these were characterised by poor socioeconomic conditions. six of the seven participants were placed at district hospitals. the primary responsibility of the participants was to provide clinical occupational therapy services, with individual interventions as the focal mode of practice. only two participants were involved in community projects, while the others engaged in community activities on their own initiative, as it was not expected of them. table 2 provides a description of the participants’ practice contexts, settings and roles. table 1. interview guide questions can you describe the kind of ot you are, or that you identify with? why are you thinking in this way? what is the role of the ot in this setting? what is your particular vision for the role of ot in the setting? how have you come to this vision? how do you understand occupational justice and how have you incorporated it into your practice? what have been some constraints or challenges, if any, you experience in practising in this setting? how have you responded to these constraints/challenges? can you describe some interventions you’ve participated in that you would say exemplify how you integrate your education about ot with what you do in practice? ot = occupational therapist. table 2. participants’ practice contexts, settings and roles participant province practice setting primary roles 1 northern cape department of health district office clinic/hospital individual consultations health-promotion groups home visits 2 western cape community health centre individual consultations weekly clinics health-promotion groups home visits health forum meetings community outreach and support 3 eastern cape district hospital individual consultations disability grant assessments rehabilitation meetings cerebral palsy groups 4 eastern cape district hospital individual consultations disability grant assessments rehabilitation meetings 5 northern cape district hospital individual consultations 6 northern cape district hospital individual consultations 7 western cape regional hospital individual consultations in-patient groups rehabilitation meetings october 2016, vol. 8, no. 2 ajhpe 191 research two themes that illustrate how the participants conceptualised occupational justice and the factors that curtailed their efforts to promote it in practice emerged from the findings: (i) the meaning of occupational justice; and (ii) contextual constraints to occupational justice (table 3). theme 1 the meaning of occupational justice captures the participants’ understanding of it as broader social change and an outcome of people’s occupational enablement. it is supported by two categories, i.e. health and wellbeing through social change, and social change through occupational enablement. health and wellbeing through social change illustrates that the extent to which people have opportunities, resources and skills for occupational engagement informed the participants’ conceptualisations of occupational justice. the interviews illuminated an understanding that occupation, e.g. play in children, was important for their health and wellbeing. therefore, in addition to addressing biological problems, the occupational therapy role also entailed addressing social issues that affect people’s occupational performance. social change through occupational enablement points to the value that the participants assigned to taking cognisance of the influence of context on occupational participation. hence, their reflections revealed insight into the conditions of people’s lives and the understanding that occupational enablement needs to extend beyond hospital borders. theme 2 contextual constraints to occupational justice capture systemic and educational factors that influenced the participants’ practice. it is supported by four categories, i.e. occupational therapy vision does not fit the system; resource constraints; complex process of bureaucracy; and practice-education gaps (table 4). that the occupational therapy vision does not fit the system illustrates that the participants perceived the medical model to be dominant in their practice settings and that other health professionals lacked awareness of occupational therapy. consequently, they felt that the health system did not accommodate their vision of occupational enablement. resource constraints capture constraints to practise encountered by the participants, such as a lack of resources for materials to assist clients to practise their occupations, and a lack of transport for community outreach. the participants, however, articulated that they used personal resources and were determined to succeed. the complex process of bureaucracy shows that the participants perceived issues of bureaucracy to hinder their efforts at providing community practice and to prohibit the accurate recording of statistics for services provided through community outreach. lastly, practice-education gaps point to the participants’ articulated feelings of despondency that resulted in a lowered sense of morale because of a perceived lack of ability and confidence to engage in interprofessional practice, build collaborations, and practise occupational therapy according to the way in which they were educated, indicating an apparent gap between their practice and their education. discussion with the purpose of generating an understanding of the graduates’ perspectives and practice experiences with regard to occupational justice to inform the undergraduate curriculum, this study explored new occupational therapy graduates’ conceptualisations and enactments of occupational justice while undergoing compulsory community service. the participants shared a knowledge base by virtue of their status as uwc graduates and by being guided by the philosophies of the occupational therapy profession. this was evident in the manner in which they held the belief that there is a relationship between table 3. quotations in support of the categories of theme 1: meaning of occupational justice category quotations health and wellbeing through social change ‘we saw that the kids did not engage in any occupational activities, we explained to them [the caregivers] the importance of occupation … that the occupations of the children are play and education and we reflected on how we could make a difference.’ ‘children play as their primary occupation so it’s equipping the teachers with skills … developing personal skills so that they can deliver a better service to the children.’ social change through occupational enablement ‘the medical is obviously important … but you can’t send patients back to the community without considering if they will be able to perform their occupations at home.’ ‘when i have a session with the client i ask if the wheelchair will fit through the door … is it possible to make a path or a ramp … the question is: can it [the wheelchair] really be used … can it be used in the context?’ table 4. quotations in support of the categories of theme 2: contextual constraints to occupational justice category quotations occupational therapy vision does not fit the system ‘it is very medically orientated … very clinical … they expect you to only work with kids who have learning problems or you work with hands or strokes … .’ ‘they [staff ] have poor understanding of the service that we provide … that is … very big barrier for us.’ resource constraints ‘you aim to restore occupation in the end but to use it as a means is very difficult … it’s about resources, because sometimes you just don’t have any resources to work with.’ ‘we use our own money. the other day, we were in this mobile … [giggles] … just said … as long as it takes us from point a to point b we will sit at the back.’ complex process of bureaucracy ‘there’s that barrier between the health and the education department … you don’t have connections with each other … we went to the schools and were told that we are not allowed to.’ ‘if i must ask where this workshop fits in she [senior ot] will say admin and it is not really admin because it is community outreach but at the end of the day the [management] want statistics.’ practice-education gaps ‘as professionals we should be confident in building collaboration and build alliances with the most influential groups in the community who can support us.’ ‘i’ve gone through a little depression because i was thinking of everything that we were taught and how passionate we were at university … i feel that i am not doing enough.’ 192 october 2016, vol. 8, no. 2 ajhpe research health, wellbeing and occupational engagement, and that occupational participation is contextual.[1] informed by this belief, they worked to advance occupational justice, which they conceptualised as enhanced wellbeing and broader social change as outcomes of occupational enablement.[2] however, the participants experienced many constraints to practise, including a lack of occupational therapy awareness, difficulty collaborating with other professionals, and systemic factors such as medical model dominance, lack of resources and a complex system of bureaucracy. the challenges encountered concur with those identified by occupational therapists who practise in rural contexts[8] and settings where the medical model dominates.[6,7] the participants did not appear to be able to effectively address these challenges, thus alerting to a lack of agency and ability to respond to the complexities of community service practice. it appears that they may have experienced a sense of powerlessness, evident in their low sense of morale due to their inability to bring their occupational therapy vision to reality. although they may have had similar educational experiences, the interpretation of these constraints would be different for each participant owing to their individual life experiences and variations in their own world. furthermore, as novice practitioners they left behind the educational setting in which their particular occupational therapy knowledge was constructed and entered a health service that portrayed its own socially constructed knowledge. consequently, it appears that the participants experienced value discrepancies between the knowledge constructed by means of their education and the knowledge system they encountered in their practice contexts. this dissonance left them with a sense of despondency towards the constraints they encountered. it is important to consider to what extent the findings illustrate competencies, such as political proficiency[4] and critical reflexivity,[5,10] in judging to what extent the participants were able to work towards occupational justice. while the participants were critical about systemic factors that impacted people’s occupational wellbeing, they seemed unable to engage in actions to address these factors. the complexities of community service practice require graduates to recognise the dynamics that operate within this context and to identify and implement strategies to work proactively within the limitations or opportunities imposed by these dynamics. inferred here is the importance of critical reflexivity to stimulate awareness of self and contexts, which in turn foster critical consciousness, thereby motivating critical or transformative action.[5] a lack of critical reflexivity regarding power dynamics could therefore have led to participants’ failure to actively address occupational justice. curriculum implications transformative learning[10] could provide students with a more in-depth approach to critical reflection and develop their critical consciousness. educators would have to facilitate a level of reflexivity that interrogates questions such as: how do different forms of power in my practice context influence me and my practice?; and what strategies could i use to challenge power dynamics? through the use of this critical lens, visions of possibilities for change,[5] supporting the development and implementation of critical actions towards realising these possibilities could be identified. to further students’ ability to engage in a possibilities-based practice, griffin[14] suggests the development of skills such as negotiation and conflict resolution, and those influencing decision-making within the healthcare system. similarly, kronenberg et al.[9] name skills such as creative networking, writing proposals and political lobbying as requisites for occupational therapists to shape and influence the face of healthcare in sa. other examples might be teaching students how to write submissions for change or conduct action research projects that deal with occupational justice issues.[9] the importance of interprofessional practice is also highlighted by this study. the findings support the importance of collaborative practice in increasing the relevance of healthcare services.[15] accordingly, the integration of interprofessional education in occupational therapy curricula may facilitate health professions graduates’ understanding of the role of occupational therapists and other team members, and facilitate the development of positive attitudes towards collaboration. study limitations it is a limitation of this study that formal feedback regarding the participants’ role in practice was not sought from their respective employers, managers, colleagues and users of occupational therapy services. such feedback is indeed worthy of future research. conclusion this study highlights that for occupational therapy graduates to influence the contexts in which they practise in sa, occupational therapy education must ensure that students not only accumulate core occupational therapy knowledge, but are equipped to advance occupational justice in challenging practice environments. to reach this goal, transformational learning as pedagogical practice could be instrumental, as it frames student preparation not just as learning but as a process that equips students to intervene in matters of social and occupational justice as active agents of change. it is furthermore imperative that occupational therapy curricula facilitate interprofessional education and practice to develop graduates’ competencies in forming alliances and collaborations in addressing health outcomes. acknowledgement. the national research foundation financially supported this study, but did not influence the research process or this article. references 1. wilcock a. an occupational perspective of health. 2nd ed. thorofare, nj: slack, 2006. 2. townsend e, wilcock a. occupational justice and client-centered practice: a dialogue in progress. can j occup ther 2004;71(2):75-87. doi:10.1177/000841740407100203 3. buchanan h, cloete l. preparing students for the complexities of practice learning. in: lorenzo t, duncan m, buchanan h, alsop a, eds. practice and service learning in occupational therapy: enhancing potential in context. london: john wiley, 2006;71-87. 4. duncan m, mcmillan w. a responsive curriculum for new forms of practice, education and learning. in: lorenzo t, duncan m, buchanan h, alsop a, eds. practice and service learning in occupational therapy: enhancing potential in context. london: john wiley, 2006:7-19. 5. freire p. pedagogy of the oppressed. london: penguin, 1996. 6. méthot d. capacity and competency, collaboration and communication: a road map for the future. can j occup ther 2004;71(4):197-201. doi:10.1177/000841740407100402 7. wilding c. raising awareness of hegemony in occupational therapy: the value of action research for improving practice. aust occup ther j 2011;58(4):293-299. doi:10.1111/j.1440-1630.2010.00910.x 8. newton e, fuller b. the occupational therapy international outreach network supporting occupational therapists working without borders. in: kronenberg f, algado s, pollard n, eds. occupational therapy without borders: learning from the spirit of survivors. edinburgh: churchill livingstone, 2005:361-373. 9. kronenberg f, pollard n, ramugondo e. introduction: courage to dance politics. in: kronenberg f, pollard n, sakellariou d, eds. occupational therapies without borders, vol. 2: towards ecology of occupation-based practices. edinburgh: churchill livingstone, 2011:1-16. 10. mezirow j. transformative dimensions of adult learning. san francisco, ca: jossey-bass, 1991. 11. julio f, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s0140-6736(10)61854-5  12. freire p, shor i. a pedagogy for liberation: dialogues for transforming education. south hadley, ma: bergin and garvey, 1987. 13. babbie e, mouton j. qualitative studies. in: babbie e, mouton j, eds. the practice of social research. cape town: oxford university press, 2001:269-312. 14. griffin s. occupational therapists and the concept of power: a review of the literature. aust occup ther j 2001;48(1):24-34. doi:10.1111/j.1440-1630.2001.00231.x 15. world health organization. transforming and scaling up health professionals’ education and training. geneva: who, 2013. http://dx.doi.org/10.1177/000841740407100203 http://dx.doi.org/10.1177/000841740407100402 http://dx.doi.org/10.1111/j.1440-1630.2010.00910.x http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1111/j.1440-1630.2001.00231.x 222 october 2016, vol. 8, no. 2, suppl 2 ajhpe research in the context of socially responsive and politically relevant inter­ professional education (ipe), the need for educators to engage more seriously with ipe has been highlighted. the underlying assumption to ipe is that enhanced collaboration between professionals will lead to better use of scarce resources and a more effective response to complex health needs. ipe is not a new concept – the centre for the advancement of interprofessional education (caipe)[1] in 1987 defined ipe as occurring ‘when two or more professions learn with, from and about each other to improve collaboration and the quality of care’. the world health organization (who) recently published the framework for action on interprofessional education and collaborative practice.[2] collaborative practice can improve access to and co­ordination of health services, appropriate use of specialist clinical resources, and health outcomes.[3] a global, independent lancet commission stated that professional education has not kept up with contemporary health challenges.[4] they attribute this to five factors: (i) fragmented, outdated curricula and static pedagogy that produce ill­equipped graduates; (ii) a mismatch of competencies to population needs; (iii) insufficient adaptation of education to local contexts; (iv) professions operating in silos; and (v) tribalism and a lack of team spirit among professionals. the commission asserts that as a result of these factors, professionals have become mere managers of technology and are reluctant to serve marginalised communities. at the same time, they are not able to exercise effective leadership to transform health systems. the who[5] therefore calls for the education of health professionals to be redesigned as ipe to facilitate the breaking down of professional silos while enhancing collaborative practice. the underlying assumption to ipe is that enhanced collaboration between professionals will lead to better use of scarce resources and a more effective response to complex health needs. ipecp are thus regarded as strategies to transform health systems globally.[2] according to the lancet commission,[4] the realisation of enhanced collaboration between professionals requires instructional and institutional reforms, which should be guided by two proposed outcomes: transformative learning and interdependence in education.[4] they describe the essence of transformative learning as developing leadership attributes and producing enlightened change agents. interdependence in education involves a shift from isolated to harmonised education and health systems, as well as a shift from stand­alone institutions to networks and alliances that harness educational content, teaching resources and innovations. to facilitate this shift, the who highlights that educators of outstanding quality are needed to transform and upscale health professionals’ education.[5] hence, continuous professional development initiatives, based on the principles of ipe and the healthcare needs[2] of communities, are required to transform health professional education. principles of ipe that should be highlighted during these ipe initiatives include values that need to be addressed when engaging in ipe, processes involved in ipe and specific ipe­related outcomes.[1] to equip academics in ipe, educational institutions need to develop ipe communities of practice in order to champion ipecp in their respective health professional programmes. background. interprofessional education (ipe) can be seen as the vehicle to address the health and social problems of society through collaborative approaches. since ipe should be facilitated by educators who are skilled in this area, faculty development initiatives should be based on the principles of ipe and collaborative practice (ipecp). objective. to explore academics’ knowledge and experiences of ipecp. methods. the study used an exploratory descriptive design and the appreciative inquiry framework underpinned data gathering and analysis. the data were collected using workshops, and the participants of the workshops shared their knowledge and experiences of ipecp, which were audio­recorded and analysed using thematic analysis. ethical clearance was obtained from the university of the western cape, cape town, south africa. results. the analysis revealed three themes: knowledge of ipe; experiences of ipecp; and enablers of ipecp aligned to the dream and discovery phases of appreciative inquiry. the findings revealed that academics were knowledgeable about the concept of ipe and that their experiences with ipecp ranged from clinical supervision to research. regarding enablers of ipecp, they provided important input, which could facilitate ipecp in a university faculty. these included competencies for ipecp, professional development and a common practice framework. conclusion. the academics who attended the faculty development workshops were knowledgeable about the concepts of ipecp. they concluded that for ipe to be effective, a common practice framework should be adopted in the faculty to inform specific teaching and learning strategies and outcomes. afr j health professions educ 2016;8(2 suppl 2):222­224. doi:10.7196/ajhpe.2016.v8i2.845 academics’ knowledge and experiences of interprofessional education and practice h julie,1 phd; l hess-april,2 phd; j wilkenson,3 msc; w cassiem,4 phd; a rhoda,5 phd 1 school of nursing, faculty of community and health sciences, university of the western cape, cape town, south africa 2 department of occupational therapy, faculty of community and health sciences, university of the western cape, cape town, south africa 3 department of dietetics and nutrition, faculty of community and health sciences, university of the western cape, cape town, south africa 4 school of natural medicine, faculty of community and health sciences, university of the western cape, cape town, south africa 5 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: h julie (hjulie@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2, suppl 2 ajhpe 223 research problem statement the faculty of community and health sciences (hereafter referred to as the faculty) at the university of the western cape (uwc), cape town, south africa has identified ipecp as a priority area for its 2015 ­ 2019 strategic plan. the intended outcome is to prepare health professional graduates as change agents, able to competently intervene in health issues relevant for the 21st century. given the strategic direction of uwc and the faculty, it is therefore important that ipecp be integrated in the academic curricula of the 10 professional disciplines located in the faculty. a critical mass of academics (lecturers and clinical supervisors) is therefore needed to drive the process of this strategic initiative. in response to this, the faculty implemented initiatives to: (i) develop knowledge and skills in ipe; (ii) facilitate the development of ipe communities of practice to achieve the relevant student outcomes; (iii) engage interprofessional communities to develop the skills needed to promote and facilitate collaborative leadership, ipe and team­based practice; and (iv) use innovative curricula, high­quality experiential learning and coaching (personal communication, dr f waggie, ipe unit, uwc, 2015). it was therefore imperative to assess the progress the faculty has made in terms of these ipe initiatives. the purpose of this article is to present academics’ knowledge and experiences of ipecp as explored during an ipe faculty development initiative. methods study setting the faculty offers education programmes in physiotherapy, occupational therapy, nursing, dietetics, psychology, social work, sport, recreation and exercise science, public health, and natural medicine. all departments provide 3­ or 5­year professional degree programmes at undergraduate level with a focus on primary healthcare (phc) and community development. the ipe unit presents interprofessional courses that form part of the curriculum of all disciplines and all year levels in the faculty. apart from the undergraduate degree programmes, the faculty offers a range of postgraduate qualifications such as certificates, diplomas, master’s and doctoral degrees. usually, dentistry is considered part of a health sciences faculty, but at uwc dentistry forms its own a faculty. study design the study used an exploratory descriptive research design.[6] appreciative inquiry was the philosophical stance that underpinned the methodological processes of data gathering and analysis.[7] the appreciative inquiry process[8] involves four movements: (i) discovery (i.e. defining the concept and discovering what has worked); (ii) dreaming (i.e. envisioning what could be); (iii) design (i.e. prioritising and planning what should be); and (iv) destiny (i.e. developing a model based on identified priorities). inviting faculty members to collaborate within an appreciative inquiry framework in a workshop setting, where participants inquire into a specific topic or issue in which they have some vested ownership, can result in transformational changes in very short time frames.[9] the objective of the study was to explore the academics’ knowledge of the ipe concept and their ipe experiences. this exploration was conducted through an appreciative lens in that the positive aspects of ipe­related activities of the faculty were highlighted. these baseline data were needed to facilitate the design and development of a faculty ipecp model by engaging academics in the ‘discovery’ and ‘dreaming’ cycles of appreciative inquiry. population and sample the study population comprised the academics (lecturers and clinical supervisors) from the 11 departments and schools that constitute the faculty at uwc. the population also included academics from the faculty of dentistry, school of pharmacy and other higher education institutions who expressed prior interest in ipe. data were collected from a convenience sample of 30 participants from the different health science disciplines who participated in faculty development workshops (table 1). data collection method and process this study forms part of a larger study that received ethical clearance from the uwc research ethics committee (no. 13/3/9). two faculty development workshops, offered on 4 june and 18 sep­ tember 2015 at the uwc campus, were used for the purpose of data collection. the stated purpose of these workshops was to contribute to strengthening and refining the ongoing discourse among academics on ipecp in the faculty. the workshops consisted of a number of presentations by keynote speakers. after the didactic input, the workshop participants were divided into smaller interprofessional groups and were asked to share their understanding and experiences of ipe. two main issues were probed by facilitators during the group discussions: (i) participants’ understanding of ipe; and (ii) participants experiences of ipecp. the presentations on these issues from the small­group work and subsequent plenary workshop discussions were audio­recorded and transcribed verbatim. sensitised by the principles of appreciative inquiry, we conducted data analysis of these transcripts, following an inductive process of thematic analysis, where data were read and reread, coded and categorised into themes.[7] as proposed by braun and clarke,[10] thematic analysis, which involves the identification of themes or intersecting patterns in qualitative data, was used to analyse the data. this allowed for in­depth and direct data examination and consideration of the different meanings of participants’ experiences and perspectives, from which emerging patterns and themes could be generated.[7] the initial themes and codes were validated by three independent coders and consensus was reached regarding the analysis. table 1. representatives attending the faculty academic development workshops on 4 june and 18 september 2015 constituency representatives, n deanery of the faculty of community health sciences 2 dietetics 2 dentistry and oral health 2 external higher education institutions 2 interdisciplinary teaching and learning unit 2 nursing 2 natural medicine 8 occupational therapy 2 pharmacy 2 physiotherapy 2 social work 3 teaching and learning specialist 1 total 30 224 october 2016, vol. 8, no. 2, suppl 2 ajhpe research results the results of the first two steps of the appreciative inquiry framework that highlighted the participants’ conceptual understanding of the concept and previous experiences with ipe (discovery), and their suggestions for what could be (dreaming), are presented. the data analysis revealed three major themes and related categories: (i) knowledge of ipe; (ii) experiences of ipecp; and (iii) enablers of ipecp (summarised in table 2). theme 1: knowledge of ipe in probing the issue of the participants’ knowledge of ipe, their conceptual understanding of the concept and previous experiences with ipe emerged. they alluded to the principles and value of ipe. principles of ipe in relation to principles of ipe, collaborative teamwork and common client outcomes were foregrounded: ‘working together as a team of health professionals to solve a problem or develop common client­centred outcomes.’ ‘learning with, from and about each other, and putting this new knowledge into practice.’ values of ipe by referring to a collapsing of professional and territorial hierarchies, the participants appeared to be cognizant of the values of ipe: ‘having a basic understanding of various healthcare disciplines with joint intervention adopting a holistic approach to the management of a patient, without prejudice towards the next discipline or reluctance to refer.’ theme 2: experiences of ipecp from the participants’ responses, it was clear that they had diverse experiences with ipecp. these experiences included those encountered during joint teaching and learning, clinical practice and research. teaching and learning participants highlighted their involvement in the faculty­based interprofessional modules and interprofessional community­based projects: ‘i have been involved directly in teaching inter­ disciplinary modules and supervising students in the interprofessional community­based programmes … facilitating interdisciplinary principles and practice.’ most participants also participated in the planned interprofessional teaching and learning activities co­ordinated by the ipe unit on campus: ‘i attended the world café last year and this year with my students.’ clinical practice the participants experienced ipecp in different practice settings. hospitals were highlighted as an example where ipe was experienced in an institution: ‘we have monthly [multidisciplinary team] mdt meetings, experienced it at … hospital with medical doctors, a case would be discussed and input from various professionals given.’ interprofessional community­based practice experiences were also highlighted: ‘i experienced it in [the community], with natural medicine practitioners and nurses and community health workers.’ research in addition, the participants referred to the inter­ professional research projects they engaged in: ‘we also conduct collaborative research in different specialisations … .’ theme 3: enablers of ipecp enablers of ipecp appeared to be a natural out­ flow from the participants’ reflections regarding their experiences of ipecp. they highlighted that for ipe to be effective, enablers such as competencies for ipecp and the professional development of academics and clinical educators, as well as a common practice framework, are needed. competencies for ipecp with regard to facilitation of competencies, participants articulated that these competencies need to be explicit: ‘competencies for [interprofessional practice] ipp need to be explicit … maybe, there is a competency to be able to work as a team … there definitely needs to be competencies that are explicit about working with other healthcare professionals.’ professional development the participants also expressed the need for continuous professional development in the area of ipecp. they stressed that competencies need to be facilitated through appropriate teaching and learning strategies, where ipe outcomes are included in the planning of curricula: ‘there is a need for an ipe and ipp induction course just to bring everybody [on board] … to create awareness and [shared] understanding of ipe [and for] … capacity building of academics [lecturers] and clinical supervisors.’ participants identified that there are opportunities for collaborative practice to be role­modelled at certain clinical placements but academics need to work with clinical supervisors to harness these opportunities: ‘for instance at hospital … nursing, [occu­ pational therapy] ot and [physiotherapy] physio students could use the opportunities for ipe … in this way our supervisors could be trained to drive the agenda so that in our thinking, planning and practice we get it right … to design ipe opportunities [that are] authentic [in] clinical learning environments [to allow for] interprofessional role modelling.’ common practice framework participants further identified the need to adopt a common language and practice framework for ipecp to be successful. two frameworks mentioned were the international classification of functioning, disability and health (icf) and phc: ‘the one thing that we need to be common is the language, and that is the aim of the icf, so that we speak and understand the common language of the framework within all the professions.’ ‘if we look at phc … we speak about the district health system, we meet individual need, we need to meet population need as well … it is about looking at something [a framework] that we can develop that is common for us, for our faculty.’ table 2. summary of themes and categories theme 1: knowledge of ipe theme 2: experiences of ipecp theme 3: enablers of ipecp principles of ipe value of ipe teaching and learning clinical practice research competencies for ipecp professional development common practice framework october 2016, vol. 8, no. 2, suppl 2 ajhpe 225 research the participants further related the use of a common practice framework to specific outcomes for ipecp: ‘there must be outcomes phrased around ipe and ipp, that need to be explicit, so we need to write that as part of our [curriculum] … our training for our students’. it was also highlighted that buy­in from service partners would be crucial to the successful facilitation of ipecp competencies: ‘people need to understand how ipp can benefit the community at large, so yes, we will have to engage with the management of these services where our students practise and get ipp on their agenda.’ in discussing the relevance of the icf and phc frameworks, the participants articulated that competencies related to the ethos of uwc need to be incorporated into ipecp and the specific teaching and learning strategies adopted: ‘a shortcoming of both frameworks is the issue of power … where you have to deal with structural and systemic barriers to social justice … should political adeptness and understanding power dynamics be competencies that we want our students to develop through ipe?’ discussion within an appreciative inquiry framework, this article aimed to present the experiences of academics regarding ipecp. the motivation for the study was the ever­expanding evidence that exists on the value of ipe in improving attitudes and perceptions, as well as knowledge and skills, collaboratively. in exploring participants’ knowledge and experiences of ipe (discovery), their knowledge of the principles of ipe,[2] such as responsiveness to clients’ needs, as well as the use of each profession’s distinctive contributions to learning and practice, were highlighted in the findings. it further emerged that the academics were knowledgeable about values of ipe, such as respect for diversity and the setting aside of differences in power and status between professions. if academics are knowledgeable, or at least aware, of the principles and values of ipe, it could provide momentum to its implementation.[11] in addition to this, the facilitation of collaborative practice actions towards the delivery of healthcare services could also be enhanced.[12] while the participants’ experiences of ipecp ranged from educating students, both as supervisors and academics, to joint clinical practice at both a community­ and institution­based level, to collaborative research, they did not elaborate on the actual quality of these experiences, but appeared to be more focused on reflecting on how ipecp could be enhanced. hence, in their expression of what could be (dreaming), the participants offered suggestions for the enablement of ipecp in the faculty. they indicated that competencies for ipecp need to be clearly defined. they further suggested that capacity development of academics (both lecturers and supervisors), and role­modelling of interprofessional collaborative practice behaviours, would benefit the faculty ipe strategy. furthermore, the need for a common faculty model or practice framework to drive ipe was identified. these strategies are corroborated by the findings of a systematic review, which identified that curriculum, leadership, resources, student diversity, teaching and accreditation are important challenges for ipe in developing and developed countries.[13] implementing a competency framework, based on the competencies of teamwork, responsibilities, communication, learning, patient focus and ethics, could assist the faculty in setting explicit competencies for the implementation of ipecp.[11] easing the framework into the curriculum by capitalising on what already exists, effective communication, respect for others and shared decision­making, as well as collaborative leadership, problem­solving and conflict resolution, are also important considerations.[11] practical suggestions for the enablement of ipe in the faculty included providing students with authentic learning environments, evident in suggestions for the inclusion of collaborative practice outcomes for community­based clinical placements, and for the buy­in of ipecp from the management teams of these placements. these enablers are imperative, as the task of the educator is to create a natural learning environment, where the critical thinking skills and desired outcomes[14] related to critical practice skills are embedded into authentic learning tasks.[14] hence, through implementation of interprofessional learning opportunities and assessment in ipe,[14] authentic learning experiences for producing desired student outcomes are increased[14] and interprofessional readiness addressed.[13] students are expected to function in teams, help one another learn, and be self­directed, meaning that students become active participants in their own process of learning.[13] in further elaborating on what could be, the findings also highlighted that the participants perceived transformative learning as central to ipe. in relation to this, the facilitation of graduate competencies and attributes with regard to social justice and being agents of change were also highlighted. this concurs with the views of the lancet commission,[4] which proposed not only authentic practice experiences in ipp but also transformative learning as important teaching and learning approaches in ipe. conclusion the exploration of academics’ knowledge and experiences of ipe generated an understanding of important considerations for the development and progression of ipecp in the faculty. they concluded that for ipe to be effective, the outcomes and competencies for ipecp need to be clear and that a common practice framework should be adopted within the faculty to inform specific teaching and learning strategies and outcomes. references 1. iroku­malize t, matson c, freeman j, mcgrew m, david a. interprofessional education. ann fam med 2013;11(2):188­189. doi:10.1370/afm.1523 2. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. http://www.who.int/hrh/nursing_midwifery/en/ (accessed 19 july 2016). 3. interprofessional ambulatory care unit, edith cowan university. interprofessional learning. impact of health care teams on patient outcomes. iacu, edith cowan university, 2012:1­30. https://www.ecu.edu.au/community­ engagement/health­advancement/interprofessional­ambulatory­care­program/interprofessional­learning/ipl­ through­simulation/impact­of­health­care­teams­on­patient­outcomes (accessed 21 july 2016). 4. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923­1958. doi:10.1016/s0140­ 6736(10)61854­5 5. world health organization. transforming and scaling up health professionals’ education and training: world health organization guidelines 2013. geneva: who, 2013. http://apps.who.int/iris/handle/10665/93635 (accessed 19 july 2016). 6. lambert v, lambert c. qualitative descriptive research: an acceptable design. pac rim int j nurs res thail 2012;16(4):255­256. 7. naude l, van den bergh tj, kruger is. ‘learning to like learning’: an appreciative inquiry into emotions in education. soc psychol educ 2014;17(2):211­228. doi:10.1007/s11218­014­9247­9 8. cooperrider dl. a contemporary commentary on appreciative inquiry in organizational life. adv appreciative inq 1987;1:129­169. 9. shuayb m, sharp c, judkins m, hetherington m. using appreciative inquiry in educational research: possibilities and limitations. berkshire: national foundation for educational research, 2009:1­8. http://www. nfer.ac.uk/publications/aen01/aen01.pdf (accessed 19 july 2016). 10. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77­101. doi:10.1191/1478088706qp063oa 11. kwan d, barker kk, austin z, et al. effectiveness of a faculty development program on interprofessional education: a randomized control trial. j interprof care 2006;20(3):314­316. doi:10.1080/13561820500518712 12. reeves s, fletcher s, barr h, et al. a beme systematic review of the effects of interprofessional education: beme guide no. 39. med teach 2016;38(7):656­668. doi:10.3109/0142159x.2016.1173663 13. sungunya bf, hinthong w, jimba m, yasuoka j. interprofessional education for whom? – challenges and lessons learned from its implementation in developed countries and their application to developing countries: a systematic review. plos one 2014;9(5):e96724. doi:10.1371/journal.pone.0096724 14. fain ea, kennel b. authentic learning and multifaceted assessment utilizing interprofessional collaborative learning events. world fed occup ther bull 2016;8:1­5. doi:10.1080/14473828.2016.1152730 http://dx.doi.org/10.1370/afm.1523 http://www.who.int/hrh/nursing_midwifery/en/ https://www.ecu.edu.au/community-engagement/health-advancement/interprofessional-ambulatory-care-program/interprofessional-learning/ipl-through-simulation/impact-of-health-care-teams-on-patient-outcomes https://www.ecu.edu.au/community-engagement/health-advancement/interprofessional-ambulatory-care-program/interprofessional-learning/ipl-through-simulation/impact-of-health-care-teams-on-patient-outcomes https://www.ecu.edu.au/community-engagement/health-advancement/interprofessional-ambulatory-care-program/interprofessional-learning/ipl-through-simulation/impact-of-health-care-teams-on-patient-outcomes http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://apps.who.int/iris/handle/10665/93635 http://dx.doi.org/10.1007/s11218-014-9247-9 http://www.nfer.ac.uk/publications/aen01/aen01.pdf http://www.nfer.ac.uk/publications/aen01/aen01.pdf http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1080/13561820500518712 http://dx.doi.org/10.3109/0142159x.2016.1173663 http://dx.doi.org/10.1371/journal.pone.0096724 http://dx.doi.org/10.1080/14473828.2016.1152730 research the teaching of anatomy has been one of the cornerstones of medical education for centuries.[1,2] knowledge of anatomy assists a physician in examining a patient, determining a diagnosis, and communicating these findings to the patient and other medical professionals.[2] traditionally, anatomy has been learnt using didactic lectures and practical cadaver dissections.[1,2] anatomy lectures have been an efficient way of introducing basic concepts and conveying basic knowledge to medical students.[3] cadaver dissection, on the other hand, has been used to impart an appreciation of 3d anatomy and to familiarise students with the human body.[4] nonetheless, these methods have been criticised for their inability to convey long-term knowledge, their propensity to overload students with information that may not be necessary for clinical practice, and the associated large expenses for storage, maintenance and disposal of human cadavers.[2,3,5] therefore, the years spent learning anatomy are seen to be largely labour and resource intensive, but potentially not useful.[2] to counteract the abovementioned pitfalls, the teaching of anatomy has been modified to be less reliant on academic-led teaching, instead emphasising student-led learning, using methods such as problem-based learning (pbl) and team-based learning (tbl).[6] pbl at its most basic level is a teaching method that uses patient problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical sciences.[7] tbl, however, is a small-group learning method during which students are guided to apply conceptual knowledge through activities that involve individual work, teamwork and immediate feedback.[8] the rationale behind these methods has been that they create a more usable body of knowledge and that the most important medical skills for treating patients are the solving of problems rather than memorising of information.[4,5] these new student-led methods of teaching and their variations are being increasingly embraced by medical schools in developed countries, as they are in line with educational theory.[1] despite the adoption of these student-orientated methods, there is still widespread debate on their pedagogical advantages.[2,9] the small-group sessions in pbl have been shown to suffer from poor attendance, variable student preparation and inconsistent group problem-solving achievement.[10] furthermore, few students come truly prepared to engage in active discourse and too much time is spent on covering basic factual material rather than applied problem solving.[10] in africa, there are a few studies on the teaching of anatomy and the modes of instruction. a continental survey of anatomy teaching and the changes in the curricula showed that modern methods of teaching anatomy are being used by a substantial number of medical schools in africa.[11] eleven of the 19 african departments that responded were using pbl and had converted to this mode of teaching before 2000.[11] in contrast, a review article on anatomy teaching in africa concluded that ‘socioeconomic and political instability, failure to rapidly overcome the inertia for change by substituting the old curriculum with a more problem-based system and student-based one and redefining the goals of medical education are some of the issues of concern for africa, and its ability to keep up in the dynamic world of medical education’.[12] in line with current modifications in the teaching and assessing of anatomy in medical schools globally, the department of anatomy, university background. traditional academic-led anatomy teaching methods, such as didactic lectures and cadaver dissections, are on the decline, as more student-led teaching methods are being adopted. objectives. to assess medical students’ perspectives on the teaching objectives achieved by traditional teaching methods (lectures, cadaver dissections and tutorials) used in the anatomy course. methods. a cross-sectional survey comprising a matrix questionnaire was performed among selected 1st-year 5th-year medical students, using stratified random sampling. the students were requested to select a score between 0 and 5 to represent the fit between the learning outcome and the teaching method, with 0 being no fit and 5 representing a perfect fit. results. lectures had the highest mean score of 3.871 for the ability to provide medical vocabulary. cadaver dissection had the highest mean score of 3.488 for its ability to develop team skills. the highest mean score of 3.415 for all three teaching methods combined was recorded for the learning outcome relating to imparting an anatomical foundation, while the lowest mean score of 2.731 was recorded for the development of skills in order to follow complicated instructions. however, no teaching method had an excellent fit (mean ≥4.5) with any of the teaching objectives. conclusion. the study showed that the three teaching methods being used in the anatomy course were, to a great extent, useful to impart the skills and content base. however, other teaching methods, such as problem-based and team-based learning, have to be considered to achieve the other important learning outcomes. afr j health professions educ 2017;9(4):176-179. doi:10.7196/ajhpe.2017.v9i4.822 medical students’ perspectives on the anatomy course at the university of zimbabwe r siwela, msc; g mawera, dphil department of anatomy, college of health sciences, university of zimbabwe, harare, zimbabwe corresponding author: r siwela (rudosiwela@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 176 december 2017, vol. 9, no. 4 ajhpe research of zimbabwe needs to make relevant changes to the anatomy course. to improve existing structures and make relevant reforms, a needs assessment has to be done. this will assist in obtaining feedback from students on the strengths and weaknesses of traditional teaching methods, and the learning outcomes that such methods fail to meet. this study, therefore, serves to assess medical students’ perspectives on the learning outcomes of the teaching and assessment methods used in the anatomy course at the university of zimbabwe. this will help in guiding the revision of its anatomy curriculum. methods local context the university of zimbabwe medical school was established in 1963 as an affiliate of the university of birmingham, uk. the university’s anatomy course is taught in three semesters during the first two preclinical years by the department of anatomy. teaching is done by traditional didactic lectures, practical cadaver dissections, and group tutorials, while in the past 15 years the assessment has been done by multiple-choice-based end-ofregion tests and a final professional multiple-choice question examination at the end of the 2nd year. the curriculum has remained largely unchanged since the establishment of the medical school, despite major curriculum changes elsewhere in the world. a cross-sectional survey was carried out at the college of health sciences, university of zimbabwe, harare, zimbabwe between august and september 2014. a total of 1 063 medical students were registered with the college in the 2014 academic year – 208 students in the 1st year, 303 in the 2nd year, 225 in the 3rd year, 212 in the 4th year, and 115 in the 5th year. stratified random sampling was used to choose the students who took part in the study to ensure that they were equitably distributed in accordance with the total number in each class relative to the total number of all students from the 1st to the 5th year of study. questionnaires (n=750) were distributed to the selected 1st-, 2nd-, 3rd-, 4thand 5th-year medical students. the study instrument was a matrix questionnaire, which was divided into two sections. section a elicited students’ year of study and gender. section b assessed how well the three teaching methods (didactic lectures, cadaver dissections and tutorials) used in the anatomy course fitted a variety of teaching aims according to moxham and moxham.[6] the students were asked to choose a score between 0 and 5, where 0 represented no fit between the teaching method and the teaching aim and 5 represented a perfect fit (table 1). data were collected and entered into a computer. it was cleaned and analysed using the stata statistical package version 13.0 (statacorp., usa). means and standard deviations (sds) for the scores of each teaching objective for the three teaching techniques were calculated. the criteria designed by moxham and moxham,[6] shown in table 2, were then used to assess the fitness for purpose of the mean scores between the teaching method and teaching aims. the mean scores for each teaching method were calculated for each teaching aim and the result was compared with the ratings (table 2)[6] before a decision of whether the fit was excellent, good, moderate or poor was made and entered into a table. ethical approval ethical approval to conduct the study was obtained from the joint parirenyatwa hospital and college of health sciences research ethics committee, university of zimbabwe (ref. no. jrec 172/14). each participating student signed an informed consent form that outlined the objectives of the study, emphasising that participation was voluntary. table 1. blank matrix questionnaire teaching methods teaching aim dissection by students didactic teaching only tutorials 1. to impart an anatomical foundation 2. to provide background for clinical disciplines 3. to provide medical vocabulary 4. to appreciate anatomical variation 5. to relate structure to pathology 6. to provide student-directed learning 7. to develop team skills 8. to develop the ability to think and solve problems 9. to develop skills of following complicated instructions table 2. fitness-for-purpose ratings fitness for purpose rating excellent fit mean ≥4.5 good fit 3.4≤ mean ˂4.5 moderate fit 2.5≤ mean ˂3.4 poor fit mean ˂2.5 table 3. demographic data of study participants mb chb, year questionnaires distributed, n questionnaires returned, n (%) questionnaires disregarded, n questionnaires used, n 1 150 119 (79.4) 0 119 2 210 149 (71.0) 2 147 3 160 129 (80.6) 5 124 4 150 81 (54.0) 14 67 5 80 46 (57.5) 1 45 total 750 524 (69.9) 22 502 december 2017, vol. 9, no. 4 ajhpe 177 research 178 december 2017, vol. 9, no. 4 ajhpe results of the 750 questionnaires distributed to the study participants, 524 were returned, giving a response rate of 70%. twenty-two of the questionnaires were disregarded because they were incompletely filled out or the participants failed to follow the instructions. only 502 questionnaires were used in the final analysis (table 3). table 4 shows the mean scores and sds for the three teaching methods (lectures, cadaver dissections and tutorials) for the nine different teaching aims. the results of the fitness for purpose between the three teaching methods and the nine teaching aims are shown in table 5. discussion the results of this study showed that none of the three teaching methods had an excellent fit (mean >4.5) with the nine teaching aims. cadaver dissection had a good fit with the teaching aims to develop team skills and to appreciate anatomical variation. in addition, it had a moderate fit with all the teaching aims, suggesting that this teaching method had the greatest ability to fulfil all the teaching aims. this supported earlier observations that cadaver dissection was the teaching method that could best achieve most learning outcomes desired in the anatomy course,[6] the reason being that cadaver dissection is able to build both the skills base and content base of students, both of which are important in anatomy.[4] however, the primary concern with cadaver-based learning is the difficulty in acquiring and maintaining enough cadavers.[5] this is notable in zimbabwe, where the body donor programme has had a low uptake among black zimbabweans. furthermore, unclaimed bodies, a main source for anatomy cadavers, are usually decomposed when available for collection by the anatomy department. this is further compounded by the ethical and emotional worries associated with the use of human specimens for teaching purposes and the cultural implications of donating one’s body for anatomy teaching.[5] when the individual learning outcomes were analysed, results indicated that lectures had a good fit with teaching aims related to content base, such as imparting an anatomical foundation and providing medical vocabulary. this is explained by the previous observations that didactic lectures are a good platform for teaching the basic language of anatomy to students.[3] our results are also similar to those of a study of the perspectives of medical students on the relationship between course aims or learning outcomes and teaching methods.[6] several teaching aims, however, were shown not to have a good fit with any of the teaching methods. these included provision of background for clinical disciplines, ability to relate structure to pathology, provision of student-directed learning, ability to think and solve problems, and acquisition of skills of being able to follow complicated instructions. the latter two teaching aims were shown to have the lowest mean scores of all the teaching aims. this can be explained by observations made in earlier studies, which showed that teaching of students using traditional methods was weak in integrating basic anatomy knowledge and practical situations in the clinic.[13,14] moreover, basic science subjects were reported to be effective only to prepare students for assessments.[14] in addition, the students were reported to be passive learners, lacking initiative with regard to learning and applying anatomy knowledge.[13] table 4. a completed matrix questionnaire teaching methods teaching aim lectures, mean (sd) cadaver dissections, mean (sd) tutorials, mean (sd) all three methods, mean (sd) 1. to impart an anatomical foundation 3. 606 (1.180) 3.486 (1.319) 3.153 (1.575) 3.415 (1.380) 2. to provide background for clinical disciplines 3.337 (1.129) 3.078 (1.337) 3.088 (1.552) 3.167 (1.355) 3. to provide medical vocabulary 3.871 (1.078) 2.944 (1.373) 3.225 (1.504) 3.347 (1.385) 4. to appreciate anatomical variation 3.363 (1.212) 3.408 (1.435) 2.873 (1.535) 3.214 (1.420) 5. to relate structure to pathology 3.082 (1.257) 2.902 (1.427) 2.815 (1.540) 2.932 (1.416) 6. to provide student-directed learning 2.735 (1.424) 3.219 (1.446) 3.066 (1.638) 3.001 (1.518) 7. to develop team skills 2.339 (1.464) 3.488 (1.415) 2.735 (1.738) 2.854 (1.617) 8. to develop the ability to think and solve problems 2.616 (1.396) 2.735 (1.417) 2.978 (1.605) 2.776 (1.482) 9. to develop skills of following complicated instructions 2.719 (1.371) 2.898 (1.457) 2.416 (1.563) 2.731 (1.471) sd = standard deviation. table 5. results of fitness for purpose of the three teaching methods and the nine teaching aims rating teaching aim cadaver dissections lectures tutorials 1. to impart an anatomical foundation moderate good moderate 2. to provide background for clinical disciplines moderate moderate moderate 3. to provide medical vocabulary moderate good moderate 4. to appreciate anatomical variation good moderate moderate 5. to relate structure to pathology moderate moderate moderate 6. to provide student-directed learning moderate moderate moderate 7. to develop team skills good poor moderate 8. to develop the ability to think and solve problems moderate moderate moderate 9. to develop skills of following complicated instructions moderate moderate moderate research december 2017, vol. 9, no. 4 ajhpe 179 conclusion and recommendations the study indicated that traditional teaching methods are useful in imparting the content and skills base required in the anatomy course. however, there are some important teaching aims that are not being achieved by the methods used in the anatomy course at the university of zimbabwe. these are mostly related to the ability to apply anatomy knowledge to clinical scenarios and to enhance the potential to think and solve problems. therefore, modern teaching methods, such as pbl and tbl, should be incorporated in anatomy teaching to address these observed deficits. this combined approach to teaching and increased co-ordination among different basic and clinical departments might be the answer to a better understanding and application of anatomy knowledge in medical practice in zimbabwe for the betterment of the health of the society. acknowledgements. we would like to thank all the students who participated in the study. author contributions. rs was involved in the conceptualisation, design, analysis and interpretation of the data. gm was involved in the design, analysis and interpretation of the data. rs drafted the initial version, and gm critically revised the content. rs and gm both approved the version submitted for publication. funding. the southern africa consortium for research excellence (sacore). conflicts of interest. none. 1. papa v, vaccarezza m. teaching anatomy in the xxi century: new aspects and pitfalls. sci world j 2013;31:348. https://doi.org/10.1155/2013/310348  2. turney bw. anatomy in a modern medical curriculum. ann r coll surg engl 2007;89(2):104-107. https://doi. org/10.1308/003588407x168244 3. nagar sk. newer approaches in anatomy teaching. natl j med res 2012;2(1):17-23. 4. granger na. dissection laboratory is vital to medical gross anatomy education. anat rec (new anat) 2004;281b(1):6-8. https://doi.org/10.1002/ar.b.20039  5. habbal o. the state of human anatomy teaching in the medical schools of gulf co-operation council countries. squ med j 2009;9(1):24-31. 6. moxham bj, moxham sa. the relationship between attitudes, course aims and teaching methods for the teaching of gross anatomy in the medical curriculum. eur j anat 2007;11(s1):19-30. 7. albanese ma, mitchell s. problem based learning: a review of literature on its outcomes and implementation issues. acad med 1993;68(1):52-81. https://doi.org/10.1097/00001888-199301000-00012  8. kibble jd, bellew c, asmar a, barkley l. team based learning in large enrolment classes. adv physiol edu 2016;40(4):435-442. https://doi.org/10.1152/advan.00095.2016  9. thistlethwaite jei, davies d, ekeocha s, et al. the effectiveness of case-based learning in health professional education. a beme systematic review. beme guide no. 23. med teach 2012;34(6):e421-e444. https://doi.org/10.3109/014215 9x.2012.680939  10. nieder gl, parmelee dx, stolfi a, hudes pd. team based learning in a medical gross anatomy and embryology course. clin anat 2005;18(1):56-63. https://doi.org/10.1002/ca.20040  11. kramer b, pather n, ihunwo a. anatomy: spotlight on africa. anat sci edu 2008;1(3):111-118. https://doi. org/10.1002/ase.28  12. gukas id. global paradigm shift in medical education issues: issues of concern for africa. med teach 2007;29(9):887-892. https://doi.org/10.1080/01421590701814286  13. schimdt hg, dauphinee wd, patel vl. comparing effects of problem based and conventional curricula in an international sample. j med educ 1987;62(4):305-315. https://doi.org/10.1097/00001888-198704000-00002  14. gupta s, gupta ak, verma m, kaur h, kaur a, singh k. the attitudes and perceptions of medical students towards basic science subjects during their clinical years: a cross sectional survey. int j appl basic med res 2014;4(1):16-19. https://doi.org/10.4103/2229-516x.125675  accepted 4 may 2017. https://doi.org/10.1155/2013/310348 https://doi.org/10.1308/003588407x168244 https://doi.org/10.1002/ar.b.20039 https://doi.org/10.1097/00001888-199301000-00012 https://doi.org/10.1152/advan.00095.2016 https://doi.org/10.3109/0142159x.2012.680939 https://doi.org/10.3109/0142159x.2012.680939 https://doi.org/10.1002/ca.20040 https://doi.org/10.1002/ase.28 https://doi.org/10.1002/ase.28 https://doi.org/10.1080/01421590701814286 https://doi.org/10.1097/00001888-198704000-00002 https://doi.org/10.4103/2229-516x.125675 research september 2017, vol. 9, no. 3 ajhpe 123 the importance of radiation safety training was reiterated by the world health organization (who). in 2007, world health assembly (wha) resolution 60.29 urged the who to ‘draw up guidelines to ensure the quality, safety and efficacy of medical devices’.[1] annually, millions of x-ray examinations are done worldwide and, therefore, the benefit/risk balance of every examination should always be considered. the education of radiation workers has the potential to change behaviour to implement a culture of safe patient care. it is important that procedures and requirements are easily understood by health professionals.[1] not complying with the regulations of safety has often been observed by the principal researcher (bvdm) in clinical practice and is increasingly a matter of great concern. to comply with minimum safety regulation criteria, the entry-level radiography student, placed in clinical practice during the first weeks of training, needs education regarding the safety requirements before being occupationally exposed to radiation. the same applies to radiography students in their 2nd 4th year, whose safety is the responsibility of the licence holder of medical x-ray equipment. one should also take into consideration that the radiography student may apply to procure x-ray equipment upon graduation, which emphasises the imperative for a training model that will ensure 100% compliance to international standards. recently, the international atomic energy agency (iaea) made important international recommendations to promote a safety culture by motivating commitment to protection and safety at all levels. radiation safety participation must be encouraged and accountability ensured, which implies that a learning attitude should be promoted to carry out tasks safely.[2] the international commission on radiological protection (icrp) is the primary body for protection against ionising radiation, created by the 1928 international congress of radiology to promote radiological protection as a public interest. the icrp publishes quarterly recommendations on and guidance in protection against the risks associated with ionising radiation in annals of the icrp. each issue provides in-depth coverage of a specific subject area.[3] the commission has made basic recommendations for education and training of medical staff in icrp publications 103 and 105.[4] publication 113 provides guidance regarding the necessary radiological protection education and training for use by regulators, industry and institutions educating professionals involved in radiation in healthcare.[3] in the context of the icrp publication,[5] the term ‘education’ refers to imparting knowledge and understanding of radiation health effects, regulation, and factors in practice affecting patient and staff doses. it has been suggested that the education should be part of the curriculum of medical, dental, radiography and other healthcare specialists, such as radiologists and medical physicists. the term ‘training’ is defined as coaching with regard to radiological protection for the justified application of modalities (e.g. computed tomography (ct), fluoroscopy) that a healthcare worker uses in medical practice.[5] having provided an international perspective, it is important to consider the local scenario. the south african (sa) department of health (doh) accepted the recommendations of the icrp and regulates radiation protection within the framework of the hazardous substances act no. 15 background. globally, the aim of requirements regarding the use and ownership of diagnostic medical x-ray equipment is to limit radiation by abiding by the ‘as low as reasonably achievable’ (alara) principle. the ignorance of radiographers with regard to radiation safety requirements, however, is currently a cause of concern. the enhancement of the 4-year radiography curriculum leading to a bachelor’s qualification provides an opportunity to explore the training and assessment to meet, among others, the alara principle, which addresses national and international concerns and criteria. healthcare workers outside the scope of radiography, who are also considered radiation workers, may be even more ignorant and are therefore also implicated. the process of investigation included a contextualisation of the available regulation documents, the delphi technique to determine the content of the training, and a questionnaire to test students’ knowledge before and after training. objectives. to determine the content of the radiation safety requirements training and assessment to implement standardised teaching, learning activities and assessment to prepare radiographers as radiation workers well trained for practice. methods. the content of the radiation safety requirements training was determined with the delphi technique. results. consensus regarding the content of the radiography students’ training was reached and implemented. furthermore, it guided the development of teaching and learning activities complemented by aligned assessment. conclusion. standardised education and assessment for radiation safety requirements have the potential to ensure that radiation safety regulations are implemented optimally in diagnostic imaging. afr j health professions educ 2017;9(3):123-127. doi:10.7196/ajhpe.2017.v9i3.691 radiation safety requirements for training of users of diagnostic x-ray equipment in south africa b van der merwe,1 phd; s b kruger,2 phd; m m nel,2 phd 1 department of clinical sciences, central university of technology, bloemfontein, south africa 2 division of health sciences education, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: b van der merwe (bevdmerwe@cut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 124 september 2017, vol. 9, no. 3 ajhpe of 1973.[4] this act stipulates that the minister of health, and specifically the director-general of health, may issue licences to manufacturers, importers and users of electromedical (x-ray) equipment. x-ray equipment comprises electronic products (x-rays) and is considered a group iii hazardous substance. group iii hazardous substances are regulated by regulation 1332 (regulations concerning the control of electronic products).[6] the sa doh applies international standards as requirements and guidelines through the directorate radiation control (drc). the drc issues a licence if the product and usage comply with the legislative and international requirements for safety and performance.[4] two documents are effective when a licence is issued, i.e.: (i) ‘code of practice for users of medical x-ray equipment’;[7] and (ii) ‘requirements for licence holders with respect to quality-control tests for diagnostic x-ray imaging systems’.[8] the requirements in these two documents were contextualised as criteria in the delphi document to determine the content of the training for radiography students. it is important that radiographers as radiation workers and users of x-ray equipment are aware of the legislation and regulations underpinning the use of the equipment. they must therefore be informed that the documents exist and consequently be educated in the regulations before applying them. standardised training of radiation safety regulations in sa the responsibilities of licence holders of medical x-ray equipment are listed in the ‘code of practice for users of medical x-ray equipment’.[7] apart from equipment requirements, the licence holder and responsible person must ensure that those who are occupationally exposed to ionising radiation (radiation workers) are identified and issued with personal radiation monitoring devices (prmds). diagnostic radiographers employed in radiography departments and radiography students in training, who are occupationally exposed to radiation, are therefore radiation workers.[4] the code further mandates that every radiation worker receives ‘education regarding the risks and safety rules of ionising radiation; that protective clothing, devices and equipment are provided and properly used; radiation safety rules are communicated to and followed by all personnel; operational procedures are established and maintained to ensure that the radiation exposure to workers, patients and public is kept [as low as reasonably achievable] alara without compromising the diagnostic efficiency of the result; and lastly, that workers are educated in the hazards and risks of ionising radiation’.[7] entry-level radiation workers, e.g. 1st-year radiography students, are legally required to be monitored and issued with prmds (commonly referred to as dosimeters) as soon as they are placed in clinical practice. no standardised monitoring of the required education is currently in place. the dosimeter can be ordered from the radiation protection service (rps) of the sa bureau of standards (sabs). the only drc requirement before registration as a radiation worker and subsequent issuing of the dosimeter, is that a new radiation worker must undergo a medical examination to determine fitness to work.[7] this implies that a licence holder may order dosimeters without submitting proof of education of radiation workers regarding ionising radiation safety. the concern is that the responsibility of the training institution is not signified, which may be the reason for the lack of vigilance observed in clinical practice in terms of the application of certain radiation safety principles. radiography training institutions have different policies regarding the training and issuing of dosimeters to 1st-year radiography students. as a rule, the department in which the student is placed for clinical practice is responsible to register the radiation worker and order the dosimeters. the status quo at one training institution may be that the clinical department issues the dosimeters, while the training institution in due course incorporates the radiation safety lectures combined with a radiation protection test. in another setting, dosimeters may be issued within the first week of clinical practice, only to lecture on the academic aspects of dosimeters and radiation risks over the course of a year. these varying procedures result in an unfavourable situation, where the training institution places the radiation safety responsibility of the radiation worker solely on the hospital or practice where the 1st-year student is assigned to for workplace learning. the education of these members of staff regarding radiation is not formally monitored in most hospitals.[9] the researcher observed ignorance regarding the wearing of dosimeters, confirming that human error must be considered.[10] the responsibilities of licence holders of x-ray equipment are further outlined in the ‘requirements for licence holders with respect to qualitycontrol tests for diagnostic x-ray imaging systems’.[8] this document emphasises the acceptance and quality-control tests of diagnostic x-ray equipment. since 31 march 2009, an inspection body, approved by the doh or an appropriately trained professional registered with the health professions council of south africa (hpcsa) as a medical physicist, must perform all the acceptance and routine tests. radiographers, however, are responsible for the routine tests; it is important that they are not only familiar with the requirements, but also equipped to perform thse tests, interpret the tests and adjust necessary parameters to maintain safety on a daily basis. the training must therefore include quality testing of x-ray equipment. the central university of technology (cut) in bloemfontein, sa, had the privilege to engage in a curriculum review process that led to cut being one of the first training institutions for radiography in the country to implement a 4-year qualification in radiography in 2014. the curriculum development process provided an opportunity to determine appropriate content for the radiation safety and quality-control requirements training module. by using the delphi technique, content was confirmed for basic outcomes for 1st-year radiography students (representing the entry-level radiation worker issued with a dosimeter), and advanced outcomes for 3rdyear radiography students (representing the licence holder, responsible person and qualified radiographer). the development of teaching and learning activities and assessment strategies for radiography radiation safety based on the findings of the delphi survey will be reported in separate publications. the delphi technique in this study, the delphi technique was used to reach consensus[11] on the content of the radiation safety regulations training course. the technique differs from other methods of gathering data from a group of people, as it involves a research team, who are involved collectively with the goal of enhancing the quality and utilisation of the research.[11] the delphi technique is a decision-making process that has been used for planning and collective decision-making, not only in the field of technology, but also in healthcare and education.[12] in the decision to use the delphi technique, we took cognisance of two inferences, i.e. that decisions are more valid if the judgement of a group of people is involved, and the possibility that the group members may be influenced by one another if decisionmaking occurs in the presence of the group.[13] a study by skulmoski et al.[14] indicates that because of the flexibility of the delphi process, the method may be adapted creatively for most studies. their study provides proof of numerous three-round studies with successful research september 2017, vol. 9, no. 3 ajhpe 125 effects. the current study, however, required four rounds. in the fourth round, the panellists were informed that if they wished they could change their opinion. stability in this study was declared when participants did not change the selection in more than one round.[15] the delphi technique was used in this study to establish a set of criteria needed for the development and implementation of a training course for diagnostic radiography students. the process involved a quantitative approach that was appropriate for determining the objectives for the radiation safety training course. on the delphi questionnaire the participants had to respond by making choices between various statements; they were granted opportunities to add comments or suggestions. the latter gave the panellists an opportunity for inductive reasoning and to make unique contributions.[16] the questionnaire encouraged expression of the expert opinion of the panellists by indicating in the information document that the responses would be incorporated in follow-up rounds. the controlled anony mous feedback is a positive characteristic of the process, rendering it suitable to receive feedback from individuals who are physically separated.[17] method data collection entailed a delphi process that was mainly quantitative, with an invitation to panellists to add comments or suggestions. the qualitative findings were reported by incorporating the comments in the follow-up rounds of the delphi process. the research was aimed at improving the current practice of radiation safety training of radiographers and was, therefore, considered action research.[18] the processes of action and research was integrated because the teaching activities and assessment were developed after the delphi survey and aligned with the criteria accepted through the delphi process.[18] participants in the delphi questionnaire the 10 participants in the delphi questionnaire were experts in the field of diagnostic imaging. the panel included lecturers at higher education institutions involved in radiography training, medical physicists involved in quality tests in diagnostic departments, diagnostic radiography managers of radiography departments and the drc. the researcher selected the delphi participants based on the expected value they would add to the study.[18] the sample consisted of 10 individuals from several institutions that consented to participate in the delphi process, including male and female participants considered knowledgeable in the code of practice for users of medical x-ray equipment and the doh requirements for licence holders of diagnostic imaging systems. the lecturers were involved in the modules pertaining to radiation protection, and the radiography managers were involved in quality control of medical imaging systems. ethical approval ethical approval for this project (ref. no. ecufs 74/2013) was obtained from the ethics committee, faculty of health sciences, university of the free state (ufs). the delphi procedure was commenced with an invitation letter regarding the purpose of the study, the process and the duration of the study; the participants gave written consent upon receipt of the invitation.[18] each participant’s response was colour coded to reflect anonymity. compilation of the delphi questionnaire the sa doh requirement statements for licence holders of medical x-ray equipment, contained in the ‘code of practice for users of medical x-ray equipment’[7] and ‘requirements for licence holders with respect to quality control tests for diagnostic x-ray imaging systems’[8] were presented as 418 criteria in the delphi questionnaire. each statement had to be evaluated for inclusion in a basic training course before dosimeters could be issued to the beginner radiation worker, or the advanced training course for the potential licence holder of x-ray equipment. the options were stated on a 4-point likert scale. these points were defined as follows: 1 = both courses; 2 = basic only; 3 = advanced only; and 4 = none. the layout of the questionnaire was divided into the following sections: 1. general definitions and licensing conditions (n=84) 2. responsibilities of licence holders/responsible person (n=18) 3. operators of equipment and radiation workers (n=38) 4. radiation protection of patients (n=81) 5. radiation protection for the radiation worker (n=77) 6. quality-control tests for diagnostic medical systems (n=94) 7. the training course (n=26). space was provided for comments for each specific statement and at the end of the section for additional comments deemed necessary by the panellists. section 1. general definitions and licensing conditions this section dealt with the requirements and recommendation documents for radiation safety associated with the use of medical diagnostic x-ray equipment. it also dealt with the licensing conditions for medical x-ray equipment, with specific reference to the requirements of the apparatus for diagnostic use. the adherence to specific conditions for premises of x-ray equipment was stated in detail. this section was divided into three subsections , each containing various statements (n=84). section 2. responsibilities of licence holders/responsible person this section dealt with the responsibilities of licence holders or appointed responsible persons. it contained various statements (n=18). section 3. operators of equipment and radiation workers this section dealt with the operators of diagnostic x-ray equipment, with specifics on the application and monitoring aspects of radiation workers. the issuing of the personal monitoring device with the detailed threshold dose limits for radiation workers received attention in this section. it was divided into two subsections, each containing various statements (n=38). section 4. radiation protection of patients this section dealt with the basic radiation principles for the public. the importance of justification, optimisation and limitation in managing ionising radiation was stated in order to adhere to the alara principle. this section was divided into four subsections, each containing various statements (n=81). the statements referred to general radiography, fluoroscopy and ct. section 5. radiation protection for the radiation worker this section dealt with the basic radiation principles and personal monitoring devices for the worker. the statements dealt with the identification and application of principles and techniques to lower the radiation dose to staff in the healthcare environment. the care of the monitoring device with regard to optimal use was also specifically stated. this section was divided into two subsections, each containing various statements (n=77). research 126 september 2017, vol. 9, no. 3 ajhpe section 6. quality-control tests for diagnostic medical systems this section dealt with the requirements for licence holders with regard to quality-control tests for diagnostic imaging systems. the recording, interpretation and management of the results of the tests received meticulous focus. the frequencies of the tests were listed for diagnostic, ct and mammography equipment. this section was divided into four subsections, each containing various statements (n=94). section 7. the training course* this section dealt with the training course presentation and assessment. the statements dealt with the learning and teaching activities for the basic and advanced courses in terms of the presentation, either online or in a classroom setting. this section contained various statements (n=26). the percentage of participants making a specific choice on the likert scale is indicated as selecting either ‘strongly agree’, ‘agree’, ‘disagree’ or ‘strongly disagree’; e.g. 1 = 80%; 2 = 0%; 3 = 20%; 4 = 0%, with 1, 2, 3 and 4 referring to the respective terms on the scale in the order mentioned above. results the researcher manually prepared the analysis of the various rounds of the delphi process. the researcher also entered all quantitative responses in microsoft excel (usa) for calculation of consensus and stability and the development of the questions for the next round. the qualitative data were categorised into themes to make an identifying summary. these common themes were added in the next round as additional criteria items. the new items were incorporated in the following round and communicated as such to the panellists. every round served to refine the results of the previous rounds.[11] a response rate of 100% was obtained in all four rounds of the delphi process. consensus was reached when 80% of the panellists agreed on a certain criterion.[19] consensus was reached on 309/418 (74%) statements in the questionnaire. among the 418 statements, consensus was reached on 13 selections for both basic and advanced training and assessment, 131 select ions for basic training and assessment, and 137 selections for advanced training and assessment, with no exclusion of any statements from the training and assessment. stability was determined on completion of the fourth round. linstone and turoff[15] describe stability as the tendency of expert opinions to merge when there is stability in the movement of the group’s responses. stability, which may be declared when movement of opinion of the group as a whole has reached stability, was acquired with regard to the remaining 26% of statements. discussion and recommendations the relatively high degree of consensus and stability, combined with no statements being excluded from the training and assessment by a diverse group of panellists, support the appropriateness of the conclusions drawn from these data. the comments from the delphi panellists regarding the content of radiation safety and assessment provided insight that guided the researcher to consider important aspects, e.g. the basic training must address the awareness of principles, and the advanced training must engage the student in more in-depth training. section 7 of the delphi questionnaire dealt with the presentation of the training and the panellists’ opinions on the assessment of radiation safety. the panellists strongly agreed that all the criteria on which consensus was reached in the survey had to be included in both the basic and advanced assessment. they also agreed that the delphi questionnaire covered all the aspects required to use diagnostic x-ray equipment safely, with the comment that it was comprehensive without the guarantee of completeness. the panellists strongly agreed that successful completion of the basic and advanced training should be confirmed by assessment, and that the score to indicate successful completion of both assessments should be a minimum of 75%. the panel disagreed that distance learning was appropriate for basic training, as students need hands-on training. the panel did not reach consen sus on the appropriateness of distance learning for advanced training. they disagreed that the student would master the content of the training by self-learning and added specifically that there was a need to execute the tests, and that evidence should be recorded for the advanced students. the panellists strongly agreed that content on risks of radiation and interaction of radiation and tissue had to be included in the basic training. further comments from the panellists included that insight in the workload should be evenly distributed between the training, and that the advanced training should build on criteria for the basic training. the information contained in the training was regarded as necessary for different reasons, including professional, clinical, or compliance. repetition of the content, according to the panellists, would ensure a high degree of understanding and recollection. information was allocated to the basic training, which the students could use immediately, but information on technical equipment and structural specifications was recommended for the advanced training. the concluding comments addressed the need for supervision and monitoring for both trainings to ensure that correct quality tests were carried out and that candidates gained understanding of acceptable limits of the tests. flexibility was reiterated in terms of the offering and assessment owing to the reality of scarce resources in sa. the comments from the panellists provided insight in and guidance for the final list of criteria to be included in either the basic or advanced training and assessment. the comments were incorporated in the teaching and learning activities. conclusion by involving a panel of experts to determine the content of radiation safety training and the criteria and methods for assessment, the study can make a contribution to the existing body of knowledge in the field of radiography. furthermore, the training programme has already been found to deliver a better-trained 1st-year student to the radiography profession and practice. to equip the radiation worker with standardised knowledge and expect from the student to provide standardised evidence of mastery of radiation safety principles and requirements, is a major step to optimally apply the currently neglected alara principle in practice. *supplementary information. an appendix is available from the corresponding author on request. acknowledgements. the authors wish to thank the health and welfare sector education and training authority  (hwseta) for funding, prof. driekie hayswemmer for assistance with the preparation of the article, and dr daleen struwig for final technical and editorial preparation of the manuscript. author contributions. bvdm was responsible for the literature search, conceptualisation, design of the training and assessment, and drafting of the manuscript. sk, as the study leader, and mmn, as the co-study leader, revised the manuscript critically. all three authors approved the final version of the manuscript submitted for publication. funding. funding was provided by hwseta. conflicts of interest. none. research september 2017, vol. 9, no. 3 ajhpe 127 1. perez m. enhancing radiation safety and quality in healthcare. proceedings of the 18th isrrt world congress, 12 15 june 2014, helsinki, finland. http://portfolio-web.ess.fi/www/suomenrontgenhoitajat/2014_isrrt/#/1/ (accessed 23 june 2017). 2. international atomic energy agency. radiation protection and safety of radiation sources: international basic safety standards. iaea safety standards series gsr part 3. vienna: iaea, 2014. http://www-pub.iaea.org/books/ iaeabooks/8930/radiation-protection-and-safety-of-radiation-sources-international-basic-safety-standards (accessed 23 june 2017). 3. vaño e, rosenstein m, liniecki j, rehani m, martin cj, vetter rj. education and training in radiological protection for diagnostic and interventional procedures. icrp publication 113. ann icrp 2009; 39(5). http:// www.icrp.org/publication.asp?id=icrp%20publication%20113 (accessed 20 june 2017). 4. south african government. hazardous substances act, 1973 (act no. 15 of 1973). government gazette no. 3834:550. 1973. 5. international commission on radiological protection. the 2007 recommendations of the international commission on radiological protection. icrp publication 103. ann icrp 2007;37(2-4). 6. south africa. regulations: control of electronic products. government gazette no. 3991, 1973. (published under government notice r1332.) https://docs.google.com/file/d/0b5d_i5llohwtyzzjy2i1zdetowqwmy00yju5ltg1zdqtnznmmtkznzdkzju4/edit?pli=1 (accessed 20 june 2017). 7. department of health. directorate: radiation control. code of practice for users of medical x-ray equipment. 2011. http://www.scribd.com/doc/33826566/department-of-health#scribd (accessed 23 june 2017). 8. department of health. directorate: radiation control. requirements for licence holders with respect to quality control tests for diagnostic x-ray imaging systems. 2012. http://rssa.co.za/alerts/department-of-healthdiagnostic-quality-control.html (accessed 23 june 2017). 9. van der merwe b. radiation distribution in a private neurological theatre during invasive back pain management procedures. mhpe. bloemfontein: central university of technology, 2008. 10. herbst cp, fick gh. radiation protection and the safe use of x-ray equipment: laws, regulations and responsibilities. s afr j radiol 2012;16(2):50-54. https://doi.org/10.4102/sajr.v16i2.306 11. du plessis e, human s. the art of the delphi technique: highlighting its scientific merit. health sa gesondheid 2007;12(4):13-24. https://doi.org/10.4102/hsag.v12i4.268 12. loo r. the delphi method: a powerful tool for strategic management. policing. int j police strat manage 2002;25(4):762-769. https://doi.org/10.1108/13639510210450677 13. murray jw jr, hammons jo. delphi: a versatile methodology for conducting qualitative research. rev higher educ 1995;18(4):423-436. https://doi.org/10.1353/rhe.1995.0008 14. skulmoski gj, hartman ft, krahn j. the delphi method for graduate research. j inform technol educ 2007;6:1-21. 15. linstone ha, turoff m. the delphi method: technique and application. london: addison-wesley, 1979. 16. cottrell rr, mckenzie jf. health promotion and education research methods. sudbury: jones and bartlett, 2011. 17. nel cpg. a framework for achieving excellence as a clinical educator in the school of medicine, university of the free state. mhpe. bloemfontein, university of the free state, 2007. 18. denscombe m. the good research guide. 3rd ed. maidenhead, uk: open university press, 2007. 19. larson e, wissman j. critical academic skills for kansas community college graduates: a delphi study. commun coll rev 2000;28(2):43-56. https://doi.org/10.1177/009155210002800203 accepted 21 february 2017. http://portfolio-web.ess.fi/www/suomenrontgenhoitajat/2014_isrrt/#/1/ http://www-pub.iaea.org/books/iaeabooks/8930/radiation-protection-and-safety-of-radiation-sources-international-basic-safety-standards http://www-pub.iaea.org/books/iaeabooks/8930/radiation-protection-and-safety-of-radiation-sources-international-basic-safety-standards http://www.icrp.org/publication.asp?id=icrp publication 113 http://www.icrp.org/publication.asp?id=icrp publication 113 https://docs.google.com/file/d/0b5d_i5llohwtyzzjy2i1zdetowqwmy00yju5ltg1zdqtnznmmtkznzdkzju4/edit?pl https://docs.google.com/file/d/0b5d_i5llohwtyzzjy2i1zdetowqwmy00yju5ltg1zdqtnznmmtkznzdkzju4/edit?pl http://www.scribd.com/doc/33826566/department-of-health#scribd http://rssa.co.za/alerts/department-of-health-diagnostic-quality-control.html http://rssa.co.za/alerts/department-of-health-diagnostic-quality-control.html https://doi.org/10.4102/sajr.v16i2.306 https://doi.org/10.4102/hsag.v12i4.268 https://doi.org/10.1108/13639510210450677 https://doi.org/10.1353/rhe.1995.0008 https://doi.org/10.1177/009155210002800203 196 october 2016, vol. 8, no. 2 ajhpe research the health professions council of south africa (hpcsa) is the overall governing body of the medical and dental profession in sa. the vision of the hpcsa is ‘to enhance the quality of health by developing strategic policy frameworks for effective co-ordination and guidance of our twelve professional boards in: setting healthcare standards for training and discipline in the professionals registered with the hpcsa’.[1] the hpsca, in conjunction with the sa government, set high standards and rules with regard to the training of undergraduate (ug) medical students. the sa medical and dental council regulations relating to the registration of students, minimum curricula and professional examinations in medicine and dentistry (r652, may 1995) clearly stipulate the minimum curriculum requirements for medical studies in part ii of the regulations.[1] it is well known that at different medical schools in sa, registrars (also known as residents in other countries) are involved in the training of ug medical students.[2] the hpsca, however, does not indicate the role of the registrar as teacher. there seems to be a paucity of literature pertaining to the exact extent of ug training that registrars conduct.[2] the majority of studies relating to the role of registrars as teachers have been conducted in the northern hemisphere. registrars play a vital role in teaching ug medical students. a review article by post et al.[3] specifically researched the role of registrars in teaching clinical skills. it is stated that registrars contribute to as much as 30% of medical students’ knowledge, and studies indicate that up to 20% of a registrar’s time is spent on teaching ug medical students.[4-8] the benefits of teaching medical students are also seen in the knowledge acquired by registrars. a study by weiss and needlman[9] showed that by teaching ug students residents improved their own knowledge and understanding of the topic. the knowledge obtained from teaching outweighed that obtained by self-study or attendance of lectures.[9] the association for medical education in europe (amee) guide no. 20 defines 12 roles of a teacher, which include a teacher being someone who provides information, and who is a role-model, facilitator, assessor and planner.[10] the section on a role-model specifically refers to an on-thejob model during contact sessions with students.[10] this is applicable to registrars, as they spend much of their time with the ug students during ward rounds and on-call sessions. mentorship is regarded as part of the role of facilitator, and the role of mentor is inevitable.[10] clinical and practical training form part of providing information.[10] norcini and burch[11] emphasised the importance of assessment in the workplace, including presentation of clinical findings after students conducted the physical examination of patients. this is also applicable to registrars, as ug students present their findings after examination of the patient. the article also stresses the importance of providing feedback to students after the assessment.[11] the international literature indicates that, until recently, residents were not offered a formal programme in teaching. morrison et al.,[12] in the usa, background. registrars play a vital role in teaching undergraduate (ug) medical students. previous studies indicate that registrars contribute as much as 30% of medical students’ knowledge and that up to 20% of a registrar’s time is spent on teaching ug medical students. the association for medical education in europe (amee) guide no. 20 defines 12 roles of a teacher, including an on-the-job role-model. objective. to evaluate the perception and attitudes of registrars with regard to their role as teachers of ug medical students.  methods. a questionnaire-based study with qualitative and quantitative aspects was conducted at the faculty of health sciences, university of pretoria, south africa. results. despite numerous attempts, the response rate to the study was very poor, with only 25 registrars participating. this pilot study indicated that registrars were mostly involved with on-the-job training, followed by ward rounds and practical sessions. the attitudes towards teaching included that registrars deemed teaching as beneficial, with only three indicating that it should not be done by registrars. advantages of teaching included own learning opportunities and gaining confidence in teaching. registrars’ own workload and lack of time hampered teaching. the majority of registrars indicated that receiving training with regard to teaching would be useful. conclusion. our pilot study concurs with international studies, indicating that the benefits of teaching medical students include knowledge acquired by registrars. studies showed that the knowledge obtained in this manner outweighed that obtained by self-study/attendance of lectures. the on-the-job role-model as part of teaching is applicable to registrars. the international literature indicates that until recently registrars were not offered a formal teaching programme. our study echoed this, with only one student indicating that it is not necessary, as registrars should not be expected to teach. afr j health professions educ 2016;8(2):196-199. doi:10.7196/ajhpe.2016.v8i2.660 registrars teaching undergraduate medical students: a pilot study at the university of pretoria, south africa l du toit-prinsloo,1 mb chb, dipformed (sa) path, fcforpath (sa), mmed (path) (forens); n k morris,1 bsc, bsc hons, msc (medical criminalistics); m lee,2 bbibl hons; g pickworth,3 bsc, bsc hons (psych), med (psych), dphil (psych) 1 department of forensic medicine, faculty of health sciences, university of pretoria, south africa 2 department of library services, faculty of health sciences, university of pretoria, south africa 3 department of education innovation, faculty of health sciences, university of pretoria, south africa corresponding author: l du toit-prinsloo (lorrainedutoitprinsloo@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. october 2016, vol. 8, no. 2 ajhpe 197 research indicated that ‘by 2000, 55% of us residencies provided instruction on teaching’, but those who provided such instruction only did so for 11 hours per resident for the entire residency. smit[2] conducted a study at stellenbosch university, sa, reviewing the role of the registraras-a-teacher. her findings indicated that registrars spent 40% of their time teaching ug medical students and that only one of the registrars had received formal training in teaching. at the university of pretoria (up), sa, registrars play a vital role in teaching ug medical students. no research has been done at our university to indicate the extent and type of training, involvement of registrars in the assessment of ug students, and the registrars’ perceptions about their role as teachers. up provides a medical education orientation programme (meop), which assists in equipping teachers with basic knowledge to teach ug students. this programme is, however, not compulsory for registrars. the objective of this study was to evaluate the current involvement of registrars as teachers of ug medical students, including reviewing how much time a registrar spends on teaching such students, the type (and duration) of teaching being done, involvement in assessment of students, their perceptions regarding their role as teachers, and whether a need exists for training registrars as teachers. methods a questionnaire-based study with qualitative and quantitative aspects was conducted at the faculty of health sciences, up. all registrars enrolled at up were identified and the questionnaires were distributed with the help of the secretary of the head of the department. the data collected included the following: • demographic details (age, gender) • type of discipline (surgery/medicine/pathology) • current year as registrar • indication of the average working hours per week • different types of teaching provided and time spent on teaching • attitude towards teaching medical students • constraints in teaching medical students • need for a formal teaching course • involvement in assessing ug medical students • competency table. the study was approved by the faculty of health sciences research ethics committee, up. data were analysed using epi info 7 (cdc, usa). results despite numerous reminders and resending of the questionnaires, only 25 of the initial 280 questionnaires distributed were returned (response rate 9%). these results are therefore only a pilot study of the attitudes of registrars. demographic details registrars were aged between 28 and 44 years, with the majority (n=18; 72%) between 30 and 35 years. there were 15 females and 8 males (2 did not indicate gender). eight registrars (35%) were in a surgical discipline, 4 (17%) in a medical discipline, 7 (31%) in pathology, and 4 (17%) in dentistry. the average number of hours worked per week was stated as 54. teaching done by registrars table 1 indicates the type of teaching done by registrars and the average time spent on teaching. most of the registrars’ teaching was so-called on-the-job training (5 hours 4 minutes per week). views/attitudes of registrars towards teaching the registrars indicated the following views/ attitudes towards their role as teachers of ug medical students: • enjoy teaching (n=9) • it is a duty (n=5) • day-time teaching should be done by consultants and after-hours teaching by registrars (n=1) • it is important and refreshes one’s knowledge (n=5) • negative feeling (n=4) • should not be done by registrars (n=1) • stressed out (n=1). benefits of teaching the benefits of teaching are the following (from most recorded to least recorded): • learning and revision – improves knowledge (n=15) • improves own skills (n=5) • better patient care (n=1) • increases experience (n=1) • no benefits (n=5). what hampers teaching? the registrars indicated the following as factors that hamper their teaching of ug students (from most recorded to least recorded): • own workload (n=10) • attitudes of students towards registrars (n=7) • time constraints (n=6) • anxiety and lack of training to teach (n=3) • inexperience with regard to teaching (n=2). registrars’ opinions regarding developing teaching skills not one of the 25 registrars received any formal training in teaching. the majority (n=23; 92%) indicated that they deemed formal training in teaching necessary. twenty-four registrars responded to the question as to whether they would be interested in a computer-based (e-learning-type training), with 16 (67%) indicating ‘yes’. table 2 indicates the year of the registrarship in which the teaching should take place, and table 3 depicts the time when the training should take place (as indicated by the registrars). registrars assessment of students table 4 indicates the involvement of registrars in the different methods of assessment. the majority of registrars are involved in more than one type of assessment (n=16; 70%) (the table 1. type of teaching and time spent on teaching by registrars type of teaching time spent per week yes, n (%) no, n (%) not applicable, n (%) respondents, n formal lectures 1 h 9 min 11 (46) 12 (50) 1 (4) 24 tutorials 1 h 45 min 14 (56) 10 (40) 1 (4) 25 ward rounds 2 h 40 min 16 (64) 8 (32) 1 (4) 25 practical sessions 1 h 52 min 12 (48) 12 (48) 1 (4) 25 on-the-job training 5 h 4 min 12 (48) 12 (48) 2 (8) 25 table 2. year of registrarship in which training should take place (n=23) year of registrarship respondents, n (%) 1 16 (70) 2 5 (22) 3 2 (8) 198 october 2016, vol. 8, no. 2 ajhpe research registrars marked more than one option in the table). competencies necessary for registrars as teachers ten competencies were included in a table; the registrars had to indicate their perceptions on the importance of the competency and rate themselves using the self-rated category with each of the competencies. this is summarised in table 5. values of 5 (high) to 1 (low) were indicated and the table summarises the score that the majority of the respondents indicated. all the registrars rated all the competencies as 5, with the importance of professionalism being the one most indicated. not one self-rated ability obtained a score of 5. discussion the world health report of 2006[13] emphasised the importance of training the correct number of quality healthcare workers; the quality of training medical practitioners in sa is clearly prescribed by the hpcsa.[1] essack,[14] in sa, reported that there is a severe shortfall in the existing and future personnel. a lay publication[15] revealed that there must be an increase in the number of medical students to help to alleviate the shortage of doctors. however, who would ultimately be responsible for the added burden of teaching these students? our study, albeit a small pilot study, indicates that registrars do participate in the training of ug medical students, which concurs with the study conducted by post et al.[3] that showed registrars as having an important role in teaching clinical skills to students. in our study, most of the time spent on teaching was done during on-the-job and ward-round teaching. we could not accurately draw conclusions to the exact time registrars spend on teaching. they indicated that, on average, they worked 45 hours per week and all different types of teaching combined comprised 12.5 hours per week, i.e. nearly 30% of the work hours per week were spent on teaching – slightly more than the average of 20% reported by other authors,[4-8] but less than the 40% reported by smit.[2] our study also indicated that registrars generally have a positive attitude towards teaching. only one registrar indicated that registrars should not teach, and another indicated that consultants should teach during the day and registrars after hours, during the on-call sessions. in our study, the perceived benefits of teaching were improving one’s own knowledge and understanding of the topic. this was also reported by weiss and needlman,[9] who stated that the knowledge obtained from teaching outweighed that acquired by self-study or attendance of lectures. the amee guide no. 20 includes on-thejob training as being part of a role-model.[10] in our questionnaire, registrars indicated that they are occupied for ~5 hours 4 minutes per week with on-the-job-training. this type of training is generally done during on-call sessions (after hours training). although all competencies were regarded as important, teaching of clinical skills and professionalism received the highest ratings (table 5). many of the registrars in our study take part in assessment of students. norcini and burch[11] emphasised the importance of assessment in the workplace and the significance of providing feedback to students after the assessment to support learning. the registrars perceived providing feedback as important, but their self-rating on feedback received an average score of 3. this suggests that they are of the opinion that they do not provide adequate feedback (the objective of the study was not to evaluate the quality of the feedback to ug students). not one of the registrars received formal training in teaching or assessment of ug students. in the usa, morrison et al.[12] indicated that by 2000 already 55% of residents were provided with instruction on teaching, although this was only 11 hours per resident for the entire residency. only one registrar in our study indicated that no training in teaching is necessary. all the others indicated the need for training and that this should take part in the first year of the registrar training programme, preferably during a morning. the meop currently offered at up is a 4-day course (4 afternoon sessions) and is not compulsory. the need for such training indicated by the small pilot study might motivate changing the current course and giving it during morning sessions, applicable specifically to registrars. the major limitation of our study was the very small number of participants and that some did not respond to all the questions. conclusion our pilot study indicates that most of the registrars have a positive attitude towards teaching and that they spend approximately a third of their time on teaching ug students. studies have shown that the knowledge obtained by teaching outweighs that obtained by selftable 5. competencies with perceived importance and self-rated ability competency perceived importance, score (n (%)) self-rated ability, score (n (%)) importance of being taught how to give a lecture 5 (10 (44)) 3 (11 (46)) teaching diagnostic skills 5 (18 (79)) 4 (9 (38)) teaching clinical procedures 5 (8 (67)) 4 (11 (92)) teaching patient management skills 5 (6 (70)) 4 (10 (42)) importance of providing feedback to students 5 (10 (44)) 3 (10 (42)) importance of assessment of students 5 (12 (52)) 3 (12 (50)) importance of attitudes and ethical values 5 (18 (78)) 4 (15 (63)) importance of professionalism 5 (18 (82)) 4 (13 (54)) importance of being a role-model 5 (17 (74)) 4 (16 (67)) ability of managing own stress 5 (15 (75)) 4 (17 (74)) table 4. registrars’ involvement in assessment type of assessment respondents, n (%) marking of written examinations 1 (4) objective structured clinical examination 2 (9) signing off of logbooks 4 (17) multiple methods 16 (70) table 3. time when training should take place, as suggested by registrars (n=22) time/day of training respondents, n (%) one morning 9 (42) one afternoon 6 (28) lunchtime 2 (10) evening 2 (10) saturday 2 (10) october 2016, vol. 8, no. 2 ajhpe 199 research study/attendance of lectures. an on-the-job role-model as part of teaching is very applicable to registrars; they can benefit from the teaching and assist in alleviating the teaching burden with the increase in medical students. the international literature indicates that, until recently, registrars were not offered a formal programme in teaching. our study echoed this, and we suggest adapting such a programme to fulfil the needs of registrars. our study comprised a very small number of registrars, and it would be beneficial to repeat the study at a forum, such as interdepartmental meetings, to attempt to obtain a better response rate. acknowledgement. the authors wish to express a special thank you to all the secretaries from the heads of department for the distribution of the questionnaires. references 1. health professions council of south africa. vision and mission. pretoria: hpcsa, 2013. http://www.hpcsa.co.za/ about/visionmission (accessed 25 july 2016). 2. smit ej. evaluation of a pilot ‘registrar-as-a-teacher’ faculty development program at stellenbosch university. mphil thesis. stellenbosch: stellenbosch university, 2014. http://scholar.sun.ac.za/handle/10019.1/96044 (accessed 11 august 2016). 3. post re, quattlebaum rg, benich jj. residents-as-teachers curricula: a critical review. acad med 2009;84(3):374-380. doi:10.1097/acm.0b013e3181971ffe 4. bing-you rg, sproul wb. medical students’ perceptions of themselves and residents as teachers. med teach 1992;14(2-3):133-138. doi:10.3109/01421599209079479  5. morrison eh, hollingshead j, hubbell a, hitchcock ma, rucker l, prislin md. reach out and teach someone: generalist residents’ needs for teaching skills development. fam med 2002;34(6):445-450. 6. greenberg lw, goldberg rm, jewett ls. teaching in the clinical setting: factors influencing residents’ perceptions, confidence and behaviour. med educ 1984;18(5):360-365. doi:10.1111/j.1365-2923.1984. tb01283.x 7. schenk tl, sheets kj, marquez jt, whitman na, davis we, mcclure cl. where, how and from whom do family practice residents learn? a multi-centre analysis. fam med 1987;19(4):265-268. 8. tremonti lp, biddle wb. teaching behaviours of residents and faculty members.acad med 1982;57(11):854-859. doi:10.1097/00001888-198211000-00006  9. weiss v, needlman r. to teach is to learn twice: resident teachers learn more. arch pediatr adolesc med 1998;152(2):190-192. doi:10.1001/archpedi.152.2.190 10. harden rm, crossby j. amee guide no. 20: the good teacher is more than a lecturer – the twelve roles of the teacher. med teach 2000;22(4):334-337. doi:10.1080/014215900409429  11. norcini j, burch v. amee guide no. 31: workplace-based assessment as an educational tool. med teach 2007;29(9):855-871. doi:10.1080/01421590701775453 12. morrison eh, friedland ja, boker j, rucker i, hollingshead j, murata p. residents-as-teachers training in us residency programs and offices of graduate medical education. acad med 2001;76(10 suppl):s1-s4. doi:10.1097/00001888-200110001-00002  13. world health organization. report. working together for health. geneva: who, 2006. http://www.who.int/ whr/2006/whr06_en.pdf (accessed 25 july 2016). 14. essack sy. models for increasing the health workforce. s afr med j 2012;102(11 pt 1):830-832. doi:10.7196/samj.5779 15. rondganger l. sa needs 14 351 doctors, 44 780 nurses. iol news. http://www.iol.co.za/dailynews/sa-needs-14351-doctors-44-780-nurses-1.1456417 (accessed 25 january 2016). http://www.hpcsa.co.za/about/visionmission http://www.hpcsa.co.za/about/visionmission http://scholar.sun.ac.za/handle/10019.1/96044 http://dx.doi.org/10.1097/acm.0b013e3181971ffe http://dx.doi.org/10.3109/01421599209079479 http://dx.doi.org/10.1111/j.1365-2923.1984.tb01283.x http://dx.doi.org/10.1111/j.1365-2923.1984.tb01283.x http://dx.doi.org/10.1097/00001888-198211000-00006 http://dx.doi.org/10.1001/archpedi.152.2.190 http://dx.doi.org/10.1080/014215900409429 http://dx.doi.org/10.1080/01421590701775453 http://dx.doi.org/10.1097/00001888-200110001-00002 http://www.who.int/whr/2006/whr06_en.pdf http://www.who.int/whr/2006/whr06_en.pdf http://dx.doi.org/10.7196/samj.5779 http://www.iol.co.za/dailynews/sa-needs-14-351-doctors-44-780-nurses-1.1456417 http://www.iol.co.za/dailynews/sa-needs-14-351-doctors-44-780-nurses-1.1456417 true (a) or false (b): the development of a reflective vascular training portfolio: using a countryspecific infrastructure 1. training portfolios cannot be used to provide direction and standardisation of educational activities. randomised controlled trials in educational research: ontological and epistemological limitations 2. the positivist perspectives of reality involve an attempt to understand pheno­ mena from an individual’s perspective, and consequently recognise that in certain contexts it is not possible to determine causality. standard setting and quality of assessment: a conceptual approach 3. the effect of assessment outcomes extends to political, economic, social and policy domains. medical students’ views on the use of video technology in the teaching of isizulu communciation, language skills and cultural competence 4. teaching communication skills through videos has generally been found to be unsuccessful. effect of curriculum changes to enhance generic skills proficiency of 1st-year medical students 5. as a result of the interventions introduced, students’ information technology skills, presentation skills and organisational skills practice were enhanced. perceived stressors of oral hygiene students in the dental environment 6. emotional exhaustion rather than burnout has been reported by dental students and professionals. balancing the educational choices in the decision-making of a dean of medicine: fission or fusion? 7. leadership was understood to involve the stepping away from the individual patient relationship. relationship between student preparedness, learning experiences and agency: perspectives from a south african university 8. students who have a better learning experience take more responsibility for their own learning. perceptions of undergraduate dental students at makerere college of health sciences, kampala, uganda towards patient record keeping 9. medical record­keeping clinical skills are a core part of the training of a dental student and should be given the platform they deserve in the curriculum. fieldwork practice for learning: lessons from occupational therapy students and their supervisors 10. clinical reasoning improves over time and as students gain experience in the clinical field. on being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences, university of cape town, south africa 11. students agreed that having extended responsibilities for patient care prevents against erosion of empathy. mapping undergraduate exit-level assessment in a medical programme: a blue print for clinical competence? 12. multiple­choice questions were the least common format of written assess­ ments, and short answers the most common. the umthombo youth development foundation (uydf), south africa: lessons towards community involvement in health professional education 13. community involvement was an explicit intention when the uydf was initiated in 1999. exploring knowledge, perceptions and attitudes about generic medicines among final-year health science students 14. the beliefs of pharmacists and prescribing doctors are examples of factors that contribute to generic medicine use. home-based rehabilitation: physiotherapy student and client perspectives 15. although an interpreter accompanied students on their home visits, the students still felt a barrier in communication with the client, suggesting that a lack of language competency was not the only communication barrier. an exploration into the awareness and perceptions of medical students of the psychosociocultural factors which influence the consultation: implications for teaching and learning of health professionals 16. exposure to patients from various cultures, particularly in the rural setting, had raised awareness of the challenges of cultural diversity, with several participants observing behaviours that demonstrated insufficient knowledge of cultural practices. the way forward with dental student communication at the university of the western cape, cape town, south africa 17. clinical teachers agree that dental student­to­patient communication is important and that they have the skills to teach and assess communication skills. an online formative assessment tool to prepare students for summative assessment in physiology 18. despite <50% of students accessing the additional resources available in feedback on the answer to a multiple­choice question, those who made use of the testing programme achieved significantly better results in their summative tests than those who did not use the programme. the forensic autopsy as a teaching tool: attitudes and perceptions of undergraduate medical students at the university of pretoria, south africa 19. he et al. (2011) from the department of pathology, shanghai hospital, second military medical university, china, indicated that the primary objective of the autopsy is to teach anatomy; yet, most students indicated its helpfulness in teaching pathology. preliminary study: predictors for success in an important premedical subject at a south african medical school 20. good performance in matric english, the quantitative literacy of the national benchmark test, and excellent results in life science, increase a student’s chances of success in physiology in mb chb ii. cpd questionnaire 84 may 2016, vol. 8, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/175/02/2016 a maximum of 3 ceus will be awarded per correctly completed test. may 2016 research december 2017, vol. 9, no. 4 ajhpe 171 during curriculum development, teachers adopt various criteria to assess the students’ level of competence. these are put in practice during tests and examinations. ideally, examiners need an educational method to determine cut scores to distinguish non-competent from competent students. the practice of determining cut scores is called standard setting.[1,2] a cut score is a point on a scale that separates one performance standard from another. the traditional arbitrary methods used to define cut scores, such as responding correctly to 50% of the test items, cannot provide robust and valid evidence to judge student performance. therefore, the use of these methods may be difficult to justify. consequently, there is a need to set cut scores using methods that are robust, valid, and provide a fair judgement of student performance. although no method has been identified as the benchmark for setting cut scores, the use of scientific methods with a systematic approach provides a balanced judgement of student performance.[3-5] there are two broad categories of standard setting: (i) the criterion or absolute method, where setting a cut score is independent of test results;[6-9] and (ii) the norm-referenced or relative method, where cut scores are set depending on test results.[6-9] norm-referenced methods are generally used to rank students, while criterion-referenced methods are used to judge student performance against a set benchmark.[7-9] the criterion-referenced methods for setting cut scores in health professions education usually involve a number of subject experts making judgements about test items and proposing a final cut score; this is labour intensive, costly and subjective. the current study focused on a feasible way of using the angoff method of setting cut scores in resource-limited settings with few experts. the original angoff and modified angoff methods have been widely used in setting cut scores.[8] the original method requires a panel of subject experts to determine the probability of a minimally competent student answering a test item correctly. it requires each expert to estimate the probability of each test question. the final cut score becomes the average of the sums of different probabilities from all experts.[10] in the original angoff method, experts determine the probabilities, i.e. they can select any probability ranging from 0 to 1 (0.90, 0.44, 0.56, etc.). the modified angoff method restricts the probabilities to eight choices (0.2, 0.4, 0.5, 0.6, 0.75, 0.90, 0.95, ‘do not know’).[7, 11] the angoff method of setting cut scores is resource intensive and requires many well-qualified experts in the test domain. in many institutions, there are not enough qualified experts to form a reliable panel in any one particular field. the few available have to divide their time between many tasks other than student assessment.[12,13] one needs to find a way of effectively using the available resources to implement the angoff method in a resource-limited context. this study had two purposes: (i) to explore the knowledge and practices of faculty about standard setting and the use of the angoff method; and (ii) to explore the feasibility of using postgraduate students as panel members when implementing the angoff method of standard setting. methods study setting the study took place in uganda and involved faculty from five medical schools: makerere university college of health sciences (makchs), kampala; mbarara university of science and technology; gulu university; busitema university; and kampala international university. under the auspices of the medical education partnership initiative (mepi), the five ugandan medical schools formed a consortium – the medical education for background. cut scores for students’ assessments have always been arbitrarily determined in many institutions. some institutions have adopted reliable methods of determining cut scores, such as the angoff method. however, use of this method requires many experts, making it difficult to implement in resource-limited settings. the possibility of involving postgraduate students in implementing the angoff method of setting cut scores could be the solution to this problem. objectives. to explore the knowledge and practices of faculty regarding standard setting and the feasibility of using postgraduate students when implementing the angoff method. methods. this was an exploratory operations research study in which data were collected during focus group discussions. students were trained to use the angoff method, i.e. a previous examination, in which the pass mark was 50%, was used to evaluate the method. results. initial findings showed that faculty in the consortia of schools did not know what standard setting and the angoff method entailed and had never used this approach. the postgraduate students involved in implementing the angoff method of setting cut scores were excited and interested in engaging in the exercise; the pass mark they arrived at was 61.21%. conclusion. the study demonstrated that it is feasible to use the angoff method of determining pass marks, even in resource-limited settings. this can be made possible by involving postgraduate students in the absence of enough faculty experts. afr j health professions educ 2017;9(4):171-175. doi:10.7196/ajhpe.2017.v9i4.631 implementing the angoff method of standard setting using postgraduate students: practical and affordable in resource-limited settings a g mubuuke, bsc, msc, mphil, phd fellow; c mwesigwa, bds, msc; s kiguli, mb chb, mmed, mhpe college of health sciences, makerere university, kampala, uganda corresponding author: a g mubuuke (gmubuuke@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 172 december 2017, vol. 9, no. 4 ajhpe equitable services for all ugandans (mesau) – to have one unified voice aimed at improving the training of health professionals in the country. this consortium developed common competencies and suggested the adoption of common assessment practices. study design this was a hands-on research study in which knowledge and practices of lecturers regarding standard setting and the angoff method were initially explored across the mesau schools during focus group discussions. after conducting a baseline exploration of lecturers’ knowledge and practices of standard setting, we investigated the feasibility of using postgraduate students as part of the panel of experts to set cut scores for undergraduate students, employing the original angoff method. this was done as a pilot study in the radiology department of one of the mesau schools. six postgraduate students in this department and two faculty members were recruited through convenience sampling to participate in the scoring of examination questions. before the scoring exercise, three short training sessions, one per day, were organised for the relevant students and faculty. each training session lasted ~25 minutes and focused on the meaning of standard, advantages and using the original angoff method to set cut scores. scheduling of the training sessions into three short sessions allowed the postgraduate students time for other learning activities. in the last session, the 6 postgraduate students and 2 faculty members were briefed about the exercise and possible issues were clarified. the following day, the relevant postgraduate students and faculty members were invited to form a panel of experts (also referred to as judges), who would score the test questions and provide a final pass mark. a previously written test for undergraduate students was used for the exercise. this test had 30 questions; a student had to circle one single-best correct option. to avoid bias, the correct answer was not shown to the judges. the key guiding question for the panel during the exercise was: what is the percentage chance of a borderline student answering this question correctly? the researchers carefully formulated the question using simple language. they avoided educational terminologies because the intended audience comprised non-educational experts. therefore, the researchers further defined a borderline student as one who spends a minimum of time studying, is good enough to pass the examination and often finds it difficult to score above the pass mark. each judge was then requested to note down any percentage chance for each test question for all 30 questions. after the initial round of scoring, the judges discussed the scores among themselves. the facilitator also afforded each group the opportunity to express their opinions. subsequently, a second round of scoring was done, the various average scores from the 8 judges were compiled, and a final cut score for the test was determined. after setting the cut score for the test, the 6 postgraduate students who participated in the exercise were invited to participate in a 30-minute focus group discussion the following day to share their experiences. one key assumption was that a postgraduate student in radiology had the required competency to determine whether a borderline undergraduate medical student can answer a given radiology question correctly. data collection and analysis focus group discussion was the primary method of collecting data in each mesau school. two focus group discussions, which included the lecturers, were conducted in each school, giving a total of 10 focus group discussions conducted across the 5 mesau schools. each focus group comprised 6 partici pants. the researchers audio recorded and later transcribed the responses from these discussions. two of the researchers then read through the data. thematic analysis was used,[14] and the researchers analysed the data manually. during this process, raw data were read, and through a series of iterative and inductive open and axial coding, codes and themes were developed manually.[15] quality assurance the researchers stored the data electronically and secured these with a password. participants were invited to validate the emerging themes to ensure credibility of the data. additionally, researcher bias was minimised by the researchers, avoiding all preconceived ideas or experiences on the subject being investigated and practising reflexivity and bracketing throughout the research process. ethical considerations participants provided written informed consent. they were not identified by name and their responses were kept anonymous and confidential. permission to conduct this study was granted by the research and ethics committee, school of health sciences, makchs (ref. no. 2014-045). results the lecturers generally had limited knowledge of standard setting and mostly did not practise it. one major theme arose from the analysis, with key representative responses, as indicated below. knowledge and practices of lecturers regarding standard setting the lecturers who participated in the focus group discussions lacked knowledge of standard setting in assessment, almost all of them agreeing that they did not know what it means. a few had heard about the concept, but did not know what it entailed. some typical responses are given below: ‘i have not heard about standard setting and cannot tell what it exactly means.’ ‘i have heard about standard setting from a few seminars and workshops i have attended – that it involves setting pass marks. however, i feel am not competent enough to explain what it is.’ ‘i am not an education expert and therefore i cannot commit myself to offer an explanation as to what standard setting means.’ from the responses listed above and many more that echoed a similar interpretation, it is clear that lecturers involved in student assessment lacked knowledge of standard setting. moreover, the lecturers had never practised standard setting in their institutions during assessment: ‘why should i practise what i do not know?’ ‘we cannot practise standard setting unless someone teaches us what it is and how it should be done.’ ‘although i have a little knowledge about standard setting, i have never practised it myself.’ from the responses it was therefore clear that the faculty members who participated did not know what standard setting is, and had never practised it. additionally, none of the lecturers had ever heard about the angoff method of setting a cut score: ‘we have never heard about that terminology and do not know what it means.’ using postgraduate students, it was observed that the final cut score determined from the scoring was 61.21%. table 1 illustrates how each test question was scored by each judge, the various averages of the raters, as research december 2017, vol. 9, no. 4 ajhpe 173 well as the standard deviations (sds) from the mean scores. from the sds, it can be observed that across the test items, there was generally no large dispersion of scores from the mean. also, the final cut score fell within the mean cut score of each judge for the 30 questions. the entire exercise of setting the cut score lasted 90 minutes. having participated in the exercise, a focus group discussion was conducted with the postgraduate students to explore their experiences. the findings are presented below. experiences of postgraduate students after the scoring exercise the focus group discussion conducted with postgraduate students after the standard-setting exercise revealed interesting and encouraging experiences. all postgraduate students who participated expressed excitement about becoming involved, as can be observed in the following responses: ‘this was a whole new experience to me. it was indeed interesting for me to get involved in determining other students’ pass marks. i wish ours were determined like this before.’ ‘this is the best way to go and i thank our teachers for getting us this opportunity. i feel that this system is fair to students and will be welcomed if implemented fully.’ ‘we enjoyed the whole exercise. this method of determining pass marks where people follow a systematic process is not only fair, but also acceptable. just saying that the pass mark is 50% does not make sense.’ from such responses, it appears that the graduate students enjoyed the exercise and supported setting a pass mark using the relevant steps. table 1. scores (%) from each judge and final cut-score judge and score, % question 1 2 3 4 5 6 7 8 cut score, mean (sd) 1 50 55 61 60 58 50 49 55 54.75 (4.71) 2 60 60 55 60 58 57 60 55 58.12 (2.23) 3 54 58 60 50 55 55 50 50 54.00 (3.82) 4 50 50 52 53 58 60 60 55 54.75 (4.17) 5 50 45 50 55 55 57 60 60 54.00 (5.29) 6 50 50 50 56 53 54 60 60 54.12 (4.22) 7 55 60 60 60 55 50 50 50 55.00 (4.63) 8 54 56 55 55 60 60 60 55 56.88 (2.64) 9 55 55 50 50 60 65 65 70 58.75 (7.44) 10 52 53 55 55 60 60 50 56 55.13 (3.56) 11 65 60 60 70 65 65 60 60 63.13 (4.58) 12 50 50 48 50 52 50 50 52 50.25 (1.28) 13 65 58 60 65 60 55 60 60 60.38 (3.34) 14 60 60 54 55 53 60 65 70 59.63 (5.78) 15 90 80 80 75 85 80 80 75 80.63 (4.96) 16 70 75 70 65 70 78 80 65 71.63 (6.58) 17 60 57 65 60 70 65 60 55 61.50 (4.87) 18 85 80 78 80 90 75 85 80 81.63 (4.75) 19 100 85 88 95 90 85 80 80 87.88 (7.00) 20 56 50 49 55 50 50 55 50 51.88 (2.90) 21 60 58 65 60 60 50 55 55 57.88 (4.52) 22 70 67 65 60 75 65 65 70 67.13 (4.52) 23 56 55 60 50 50 55 52 60 54.75 (3.96) 24 70 65 60 75 60 60 58 60 63.50 (6.05) 25 85 80 80 75 80 85 80 78 80.38 (3.34) 26 55 60 53 50 51 50 55 50 53.00 (3.55) 27 65 60 58 55 60 64 60 60 60.25 (3.15) 28 70 65 75 60 60 70 65 60 65.63 (5.63) 29 55 58 70 54 56 60 60 55 58.50 (5.18) 30 55 58 50 49 45 48 51 55 51.38 (4.31) final average cut score for minimum competency 62.40 60.77 61.20 60.40 61.80 61.27 61.33 60.53 61.21 (9.88) sd = standard deviation. research 174 december 2017, vol. 9, no. 4 ajhpe although they generally accepted the method, the graduate students expressed some concerns: ‘this is very good. however, i have seen that one needs several lecturers to do it.’ ‘the exercise of setting the pass mark required some time. in my opinion, time considerations need to be put in place before carrying out the exercise, like setting exams early enough and determining the pass mark before students sit for the exam.’ ‘availability of time is the most crucial thing here. do lecturers have enough time to carry out this exercise?’ the abovementioned responses single out the factor of time, which should be considered when planning implementation of this exercise. however, the graduate students had a solution to mitigate this: ‘like we sometimes do participate in teaching of undergraduates, we can also participate in determining a pass mark alongside our lecturers. if this exercise is carried out early enough before exams commence, the time factor can be fairly addressed.’ ‘we can dedicate some time on our timetables to participate in determining a pass mark for our undergraduate fellows. at least, if it is time tabled, there should be no problem. indeed, reserving a little time to participate also refreshes our memories of what we learned earlier.’ from the responses, it appears that graduate students were eager to participate and allow some time for this exercise. discussion this study explored lecturers’ knowledge and practices of standard setting across mesau schools and the possibility of using postgraduate students in the standard-setting process. knowledge and practices of lecturers regarding standard setting findings of the current study illustrated that the lecturers lacked adequate knowledge of standard setting, specifically of the angoff method, which they did not practise before. while this was a significant observation, it may not be surprising. many lecturers in these medical schools lack formal training in medical education and are not very conversant with issues of standard setting. the majority are recruited into teaching owing to excellent grades in their professional disciplines, which do not involve educational issues. this probably explains the observation that they lacked knowledge about standard setting. our study also points to a lack of adequate faculty-development programmes in standard setting in these mesau institutions. many lecturers in medical schools lack educational knowledge and skills; this is not unique to the mesau schools, but has been widely reported elsewhere.[7] many institutions have taken on the initiative to design and implement facultydevelopment programmes, targeting specific faculty needs to improve teaching, learning and assessment.[13] feasibility of employing postgraduate students in the standard-setting process the study also explored the feasibility of implementing the original angoff method using postgraduate students. findings indicated that they fully participated in and were very excited about the exercise. one would have expected these students to complain about the additional workload alongside their usual learning activities. it is, however, not clear why postgraduate students were excited and found the exercise interesting. one can argue that it probably benefited them educationally, as it allowed them to revise and refresh their memories with regard to previous learning material. one can also argue that as their own cut scores were predetermined when they were students, they were eager to participate in the process of determining cut scores for their colleagues. moreover, it appears as if the standard-setting process provided what could be deemed a credible cut score for the test, despite the participation of postgraduate students as judges. the final cut score for the test used in this study was 61.21%, whereas a cut score of 50% had previously been used for this test. the cut score of 61.21%, as determined by the panel of judges, seems a fair, valid and reliable representation of the difficulty of the test compared with the 50% score. this can be supported by previous records, which show that the lowest-scoring student in this particular test achieved 63%, which is above our cut score of 61.21%, determined by the angoff method. this vindicates our exercise and suggests that the angoff method had some degree of reliability and credibility. this observation is in agreement with findings from verhoeven et al.,[1] who reported that using recent graduates as judges when implementing the angoff method can be credible and reliable. one could argue that postgraduate students are not subject experts. however, all such students have studied the undergraduate curriculum and should have the minimum competency to offer an opinion regarding the probability of an average undergraduate student answering a question correctly. the advantage of the angoff method is that judges can initially score the questions and then discuss their scores before continuing with another round of scoring. with the exercise taking place in the presence of two faculty members, the discussion most probably offered valuable insights, which encouraged the participating postgraduate students to reflect on and think carefully about their initial scores and the test items before the second round of scoring. to tap into the advantages of the angoff method while simultaneously not overburdening the few available academic staff, this study proposes involving postgraduate students in various departments to become part of the panels, together with some faculty members, as a way of implementing the angoff method in the context of limited human resources. however, the postgraduate students need to be trained alongside faculty so that they know what is expected of them. the issue of time, as observed from the responses, should not be overlooked, as the exercise can appear as an additional workload to the already busy students. it is suggested that faculty need to take into consideration postgraduate students’ time. it was feasible to divide the training into three short sessions of 25 minutes per day for 3 days, instead of a 2-hour session for 1 day. the suggestion from the participating students that examinations be set early and the exercise be time tabled is another way of addressing the time factor. furthermore, postgraduate students could receive an assessment mark for participating in this exercise as a way of motivating them. without proper scheduling of time, taking into consideration postgraduate students’ learning periods, their involvement is not likely to succeed. from the literature, it appears that there are no studies exploring the possibility of postgraduate students as judges when setting cut scores, using the original angoff method, in the event of limited academic staff. although verhoeven et al.[1] studied this aspect using recent graduates on progress tests, they employed the modified angoff method and provided research december 2017, vol. 9, no. 4 ajhpe 175 correct answers to the judges before the scoring exercise, an observation that arguably creates bias. by providing the correct answer, the mind of the judge is influenced and a seemingly difficult question might be viewed as easy, and vice versa, which creates some degree of bias. we decided not to provide answers to the judges to avoid such a scenario. additionally, the modified angoff method that verhoeven et al.[1] used also restricts judges to specific scores.[7] the disadvantage is that judges are limited to the use of predetermined scores, which can be viewed as a way of influencing their decision. we left the scoring open, so that the judges could carefully consider the question and provide an appropriate score from a very wide range of possible scores. therefore, the contribution of this study is worth noting and building on. our approach of training the judges before the exercise most probably eliminated all uncertainties in the minds of the judges; therefore, it was clear what was expected of them. this eliminated issues of providing correct answers to the judges, which could lead to bias. nonetheless, findings from our study generally concur with those of verhoeven et al.[1] and further illustrate that postgraduate students can be judges when using the angoff method. in our study, short training sessions for the student judges possibly eliminated the requirement of providing correct answers to them when scoring. simple, short training sessions, e.g. half a day, are specifically encouraged. because of these observations, we suggest using postgraduate students as part of the panel that determines cut scores for undergraduate students in situations where there are not enough subject experts to form such a panel in a resource-limited setting. study limitations we used postgraduate students in only one department, a major limitation of the study. it is difficult to recommend a major roll-out using data from only one department. we therefore suggest that such an exercise be tried and evaluated in other departments, and incremental implementation be carried out rather than a major roll-out at the mesau schools and other schools. however, the information gathered provides a foundation on which this exercise can be applied elsewhere and findings compared. further research a major focus of this study was addressing the human resource gap when using the angoff method; it did not specifically focus on how time can be used optimally when involving postgraduate students. this provides a direction for future research. conclusion our study has demonstrated that postgraduate students can be efficiently used as a cost-effective measure to address the human resource gap when employing the angoff method of setting cut scores. there is also a need for faculty-development programmes in assessment and standard setting, so that faculty can have a basic knowledge of what these programmes entail. in this manner, the advantages of introducing innovations, such as standard setting, are most likely to be reasonably well accepted instead of being completely rejected. acknowledgements. we acknowledge support from the medical education for equitable services for all ugandans-medical education partnership initiative (mesau-mepi). the content is solely the responsibility of the authors and does not necessarily represent the official views of the fogarty international center or the national institutes of health. author contributions. agm: conceived the idea, drafted the protocols for ethical reviews, participated in designing the study tools and in data collection and analysis, and wrote the initial draft; cm: refined the idea, participated in designing the study tools and in data collection, and reviewed the initial draft; sk: guided the team during the process and reviewed the final draft. funding. this study was funded by the mesau-mepi programmatic award (ref. no. 1r24tw008886) from the fogarty international center. conflicts of interest. none. 1. verhoeven bh, van der steeg afw, scherpbier ajja, muijtjens amm, verwijnen gm, van der vleuten cpm. reliability and credibility of an angoff standard setting procedure in progress testing using recent graduates as judges. med educ 1999;33(11):832-837. https://doi.org/10.1046/j.1365-2923.1999.00487.x 2. muijtjens amm, schuwirth lwt, cohen-schotanus j, thoben ajnm, van der vleuten cpm. benchmarking by cross-institutional comparison of student achievement in a progress test. med educ 2008;42(1):82-88. https://doi. org/10.1111/j.1365-2923.2007.02896.x 3. friedman b-d m. amee guide no. 18: standard setting in student assessment. med teach 2000;22(2):120-130. https://doi.org/10.1080/01421590078526 4. taylor ca. development of a modified cohen method of standard setting. med teach 2011;33(12):e678-e682. https://doi.org/10.3109/0142159x.2011.611192 5. mcharg j, bradley p, chamberlain s, ricketts c, searle j, mclachlan j. assessment of progress tests. med educ 2005;39(2):221-227. https://doi.org/10.1111/j.1365-2929.2004.02060.x 6. norcini j, guille r. combining tests and setting standards. in: norman gr, van der vleuten cpm, newble di, eds. international handbook of research in medical education. dordrecht, the netherlands: kluwer academic publishers, 2002. 7. norcini j. setting standards on educational tests. med educ 2003;37(5):464-469. https://doi.org/10.1046/j.13652923.2003.01495.x 8. bandaranayake rc. setting and maintaining standards in multiple choice examinations: amee guide no. 37. med teach 2008;30(9):836-845. https://doi.org/10.1080/01421590802402247 9. george s, sayeed haque m, oyebode f. standard setting: comparison of two methods. bmc med educ 2006;6:46. https://doi.org/10.1186/1472-6920-6-46 10. angoff wh. scales, norms, and equivalent scores. in: thorndike rl, ed. educational measurement. 2nd ed. washington, dc: american council on education, 1971:508-600. 11. gagnon r, charlin b, coletti m, sauvé e, van der vleuten cpm. assessment in the context of uncertainty: how many members are needed on the panel of reference of a script concordance test? med educ 2005;39(3):284-291. https://doi.org/10.1080/10401334.2010.488197 12. verhoeven bh, verwijnen gm, muijtjens amm, scherpbier ajja, van der vleuten cpm. panel expertise for an angoff standard setting procedure in progress testing: item writers compared to recently graduated students. med educ 2002;36(9):860-867. https://doi.org/10.1046/j.1365-2923.2002.01301.x 13. prince kjah, scherpbier ajaa, van mameren h, drukker j, van der vleuten cpm. do students have sufficient knowledge of clinical anatomy? med educ 2005;39(3):326-332. https://doi.org/10.1111/j.1365-2929.2005.02096.x 14. thomas j, harden a. methods for the thematic synthesis of qualitative research in systematic reviews. bmc med res methodol 2008;8:45. https://doi.org/10.1186/1471-2288-8-45 15. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa accepted 13 june 2017. https://doi.org/10.1046/j.1365-2923.1999.00487.x https://doi.org/10.1111/j.1365-2923.2007.02896.x https://doi.org/10.1111/j.1365-2923.2007.02896.x https://doi.org/10.1080/01421590078526 https://doi.org/10.3109/0142159x.2011.611192 https://doi.org/10.1111/j.1365-2929.2004.02060.x https://doi.org/10.1046/j.1365-2923.2003.01495.x https://doi.org/10.1046/j.1365-2923.2003.01495.x https://doi.org/10.1080/01421590802402247 https://doi.org/10.1186/1472-6920-6-46 https://doi.org/10.1080/10401334.2010.488197 https://doi.org/10.1046/j.1365-2923.2002.01301.x https://doi.org/10.1111/j.1365-2929.2005.02096.x https://doi.org/10.1186/1471-2288-8-45 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa may 2016, vol. 8, no. 1 ajhpe 9 the practice of deciding the pass/fail cut-off point is commonly referred to as standard setting.[1] however, many standard-setting practices, e.g. the historical 50% pass/fail cut-off point, can be difficult to defend psychometrically, yet they continue to be used despite rational disapproval in the literature.[2-7] demands for accountability by means of defensible, valid, reliable and robust assessment policies and practices, including pass/fail decisions, are increasingly becoming important.[5,8] discussions are being held on credible and defensible standard-setting practices[6,7] for high-stakes examinations. this debate presents a vehicle to discuss quality of assessment, which has a crucial role in promoting the quality of health professions education (hpe) institutions.[9] this conceptual review considers how standard setting can be placed strategically within the quality dialogue arena to ensure that appropriate action is taken to address concerns about credibility and defensibility in the literature. the medical education communities in african countries are small and need to join forces to contribute to the dialogue on standard setting and its potential to improve the quality of hpe. this article also provides the background to the purpose of assessments and sources of common standard-setting procedures. the last section gives a conceptual framework to embed standard setting in the hpe quality discourse. assessment purpose assessment categorises examinees into two groups – those who pass and those who fail – with regard to curriculum objectives, content and skills.[5] the final mark represents an examinee’s attainment on the performance continuum implied by proficiency levels[5] and is represented on a test score range from 0% to 100%. this process means that standard setting is the embodiment of the attainment of learning objectives[10] and the pass mark is the operationalisation of the performance standard.[11] a decision has to be made whether the cut-off marks and the resulting pass/fail results are sufficiently valid and accurately representative of the intended interpretations assigned to them. for specific information about the technical process and in-depth review of each method, several publications may be consulted.[1-3] there are ~50 standard-setting methods reported in the literature.[7] some of the well-known methods include the angoff method;[2,4,8,10] ebel method;[1,2,10] bookmark method;[12,13] borderline-group method and contrasts by group approach.[4,6,7,10] a conceptual approach plain, fair and valid standard setting cannot result from unfair and invalid assessments.[7] validity, reliability, educational effect, feasibility and acceptability frequently constitute the criteria used to select assessment methods.[14] primarily, validity and reliability have been central to decisions about the assessment methods used in different hpe settings. validity focuses on whether a test succeeds in testing the competencies for which it was designed.[1,4] reliability or generalisability is a measure of the relative size of variability in scores due to error, with the objective of reaching a desired level of measurement accuracy across different tasks.[14] acceptability is the extent to which many stakeholders endorse the measure and interpretation of scores.[14] blueprinting, which requires test content to be carefully planned against learning objectives,[1,5] has also been advocated. the focus should be on psychometric rigour.[14] because test theory, e.g. classic test theory, item response theory, generalisability theory,[1] informs psychometrics, it must be a critical consideration in the assessment of planning, analyses and interpretation, especially with regard to reliability. the abovementioned considerations can be grouped into ‘assessment technical sufficiency’ matters. however, an important result of the standard-setting process is the pass/ failure rate, which directly or indirectly implicates the quality of instruction, instructors and graduates. the reason is that assessment is the symbolic measure of confirming achievement of the prescribed performance standard. together, these can be considered ‘impact of assessment outcomes’. educational tension, therefore, arises between the expectations of quality of assessment, performance standards and impact of assessment outcomes.[7] accordingly, technical sufficiency of assessment practices is not enough – impact considerations are as important. the close relationship between quality of assessment and standard-setting practices and their effect on hpe accountabilities is neglected, poorly understood and underdeveloped at many hpe the debate with regard to standard setting continues among scholars, but the perfect method remains elusive. nonetheless, resolute demands for accountability by means of defensible, valid and reliable practices, including pass or fail decisions, provide an opportune vehicle for scholars to consider the quality of assessments and ramifications on standard setting. this conceptual review considers how standard setting can be placed strategically in the quality dialogue space to address concerns about credibility and defensibility in the literature. quality performance standards and the effect of assessment outcomes are important in the educational milieu, as assessment remains the representative measure of achievement of the prescribed performance standard but also includes the quality of health professions education (hpe). the author suggests that standard setting can be a pivotal focus for technical and psychometric sufficiency of assessments and accountability of hpe institutions towards stakeholders. standard setting should not be seen as a methodological process of setting pass/fail cut-off points only, but as a powerful catalyst for quality improvements in hpe by promoting excellence in assessments. afr j health professions educ 2016;8(1):9-10. doi:10.7196/ajhpe.2016.v8i1.712 standard setting and quality of assessment: a conceptual approach s s banda, mb chb (unza), msc (glasgow), mmed (dundee), phd (unza), facadmed (uk) department of medical education development, school of medicine, university of zambia, lusaka; and school of medicine, cavendish university, lusaka, zambia corresponding author: s s banda (ssbanda2007@gmail.com) short report research 10 may 2016, vol. 8, no. 1 ajhpe institutions. the ultimate key determinants of pass rates are the quality of the assessments and the pass/fail standard-setting practices and decisions. in the context of their validity, educators must be aware of this relationship as they plan, implement and interpret assessment outcomes. consequently, this article proposes that standard setting should be seen as a critical aspect of the assessment structures and processes. it is dependent on assessment quality, as a test that does not cover appropriate content is not at the appropriate level of difficulty, is not reliable, and will not lead to appropriate decisions, regardless of the standard-setting methods employed.[11] however, educational assessments not only comprise technical sufficiency; attention must also be paid to the accountability of the hpe institution to various stakeholders. the holistic representation is captured in the conceptual approach (fig. 1), summarising key principles and concepts in a relational method. standard setting can be a pivotal focus to attend to technical and psychometric sufficiency of assessments as well as accountability responsi bilities of hpe institutions to stakeholders. although standard setting is an important psychometric problem, it is not solely a technical issue.[1,11] the consequences of appropriate or inappropriate standards for society, institutions and individuals must be considered.[1] crocker and zieky[7] noted that because of the judgemental nature of standards, validity was dependent on how sensible the standard-setting process and its outcome were, together with the consequences of pass rates and possible classification errors. the effect of assessment outcomes therefore extends to political, economic, social and policy domains.[1,7,11] notably, decisions about the effect of assessments on accountability have to depend on the decision-making theory[7] or alternative decision theories. conclusion standard setting should not be seen as a methodological process of setting the pass/fail cut-off point only, but as a powerful catalyst for quality improvement in hpe by promoting assessment excellence. while medical education departments can be important catalysts with regard to capacity and quality, in africa, for example, their development remains basic. therefore, numerous academic staff and policy makers should join the standard-setting dialogue and in particular its potential to improve the quality of hpe. references 1. crocker l, algina j. introduction to classical and modern test theory. boston, ms: wadsworth, 2006. 2. cizek gj. setting performance standards: foundations, methods, and innovations. london, uk: routledge, 2012. 3. cizek gj, bunch mb. standard setting: a guide to establishing and evaluating performance standards on tests. thousand oaks, ca: sage, 2007. 4. ben-david mf. standard setting in student assessment. med teach 2000;22(2):120-130. 5. hambleton rk. setting performance standards on educational assessments and criteria for evaluating process. in: cizek gj, ed. setting performance standards: concepts, methods, and perspectives. mahwah, nj: lawrence erlbaum, 2001:89-116. 6. zieky mj, piere m, livingston s. cutscores: a manual for setting standards of performance on educational and occupational tests. 2008. http://www.amazon.com/cutscores-standards-performance-educationaloccupational/dp/1438250304 (accessed 4 july 2015). 7. crocker l, zieky m. proceedings of the joint conference on standard setting for large-scale assessment, washington, dc, 5 7 october 1994. washington, dc: national center for education statistics, 1995. 8. kilminster s, roberts t. standard setting for osces: trial of borderline approach. adv health sci educ theory pract 2004;9:201-209. 9. barman a. standard setting in student assessment: is a defensible method yet to come? ann acad med singapore 2008;37:957-963. 10. ricker k. setting cut scores: critical review of angoff and modifiedangoff methods. alberta journal of educational research 2006;52(1):53-64. 11. norcini jj, banda ss. increasing the quality and capacity of education: the challenge for 21st century. med educ 2011;45:81-86. [http://dx.doi. org/10.1111/j.1365-2923.2010.03738.x] 12. karantonis a, sireci sg. the bookmark standard setting method: a literature review. educational measurement: issues and practice 2006:4‐12.   13. buckendahl c, smith r, impara j, plake b. a comparison of angoff and bookmark standard setting methods. journal of educational measurement 2002;39(3):253-263. 14. norcini jj, mckinley dw. assessment methods in medical education. teaching and teacher education 2007;23:239-250. test theory validity reliability educational e�ect acceptability feasibility framework for selection of assessment methods political economical social quality assurance equity assessments purpose of assessment standard setting assessment outcomes formative summative failure rates grade point average pro�ciency standards pass/fail cut-o� marks e�ect accountability to stakeholders social constructivism measurement error decision theory item response theory classic test theory generalisability theory fig. 1. conceptual framework of standard setting as quality assurance catalyst. short report 128 october 2016, vol. 8, no. 2 ajhpe editorial health and education systems are increasingly recognised as complex adaptive systems, characterised by high levels of uncertainty and constant change as a result of rich, non-linear interactions that cannot all be tracked.[1,2] this means that complex systems are inherently ambiguous and uncertain, and that they lack predictable outcomes or clear boundaries. as systems have become more complex and integrated at the beginning of the 21st century, it is no longer possible for individuals or even single disciplines to work effectively within them.[3] the problems generated by complex systems have been called wicked problems and are not simply difficult, but impossible to solve.[4,5] these are the kinds of problems where different stakeholders have different frameworks for even trying to describe a problem, and where the constraints and resources necessary to work on the problem change over time.[4] they are ‘messy, devious, and they fight back when you try to deal with them’.[5] wicked problems are also about people, vested interests and politics, making them very subjective, which is why they do not have stable problem formulations and predefined solution concepts, and why their outcomes are unpredictable.[5] the uncertainty of complex systems is therefore something that we need to be comfortable with, learn to engage with, be curious about and be sceptical of. in other words, wicked problems can’t be managed or studied with formal, structured methods; we must adapt to working within them. even though we cannot solve wicked problems, we can move them forward by learning how to adapt to change, generate new knowledge, and continue to improve performance.[1] interprofessional education may be a possible strategy to develop the requisite competencies necessary for health practictioners to work within complex systems. these competencies include, among others, the ability to develop relationships, emotional intelligence, group work, communication and self-management, all of which are difficult to develop and assess with students.[6] the ability to drive progress in complex systems depends on the ability to generate and connect ideas, and to implement new processes based on them. not only do these activities take time, but they are also highly social, as success often depends on who we work with.[7] therefore, teams are not only important for effective work but also for the kinds of generative, creative work that 21st-century problems require. the knowledge, skills and attributes required to work with wicked problems in complex systems are so diverse that it is impossible for a single individual or profession to make any appreciable impact. the ability to work in effective, interdisciplinary and creative teams is essential if we are to address the health problems of the future. however, higher education is not well positioned to help students develop the competencies needed to work with wicked problems in complex social systems. social learning theories can help practitioners to work more effectively in non-linear, dynamic systems through interprofessionalism and shared tolerance of ambiguity.[2] however, adopting these approaches at the programme level in health professions education requires a significant change in curriculum and practice – one that traditional health and education systems are highly resistant to.[3] if we want to make any real progress in improving health and education outcomes in an increasingly complex world, we must start taking seriously the idea that radical curriculum reform is not only indicated, but required. michael rowe department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa mrowe@uwc.ac.za 1. fraser sw, greenhalgh t. coping with complexity: educating for capability. bmj 2001;323(7316):799-803. doi:10.1136/bmj.323.7316.799  2. bleakley a. blunting occam’s razor: aligning medical education with studies of complexity. j eval clin pract 2010;16(4):849-855. doi:10.1111/j.1365-2753.2010.01498.x 3. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s0140-6736 4. conklin j. wicked problems and social complexity. cognexus institute. 2001. http://cognexus.org/wpf/ wickedproblems.pdf (accessed 29 september 2016). 5. ritchey t. wicked problems: modelling social messes with morphological analysis. acta morphologica generalis 2013;2(1):2013. 6. knight pt, page a. the assessment of ‘wicked’ competences: a report to the practice-based professional learning centre for excellence in teaching and learning in the open university. 2007. www.open.ac.uk/cetl-workspace/ cetlcontent/.../460d21bd645f8.pdf (accessed 29 september 2016). 7. jarche h. valued work is not standardized. 2016. http://jarche.com/2016/09/valued-work-is-not-standardized/ (accessed 29 september 2016). afr j health professions educ 2016;8(2):128. doi:10.7196/ajhpe.2016.v8i2.889 this open-access article is distributed under creative commons licence cc-by-nc 4.0. the future of education in complex systems http://dx.doi.org/10.1136/bmj.323.7316.799  http://dx.doi.org/10.1111/j.1365-2753.2010.01498.x http://dx.doi.org/10.1016/s0140-6736 http://cognexus.org/wpf/wickedproblems.pdf http://cognexus.org/wpf/wickedproblems.pdf www.open.ac.uk/cetl-workspace/cetlcontent/.../460d21bd645f8.pdf www.open.ac.uk/cetl-workspace/cetlcontent/.../460d21bd645f8.pdf http://jarche.com/2016/09/valued-work-is-not-standardized/ editorial 2 clinical education and training: have we sufficiently shifted our paradigm? a rhoda forum 3 adopting a role: a performance art in the practice of medicine l schweickerdt 5 medical education units: a necessity for quality assurance in health professions education in nigeria a o adefuye, h a adeola, j bezuidenhout short research report 10 a survey of radiation safety training among south african interventionalists a rose, w i d rae research 13 physiotherapy clinical education at a south african university v chetty, s maddocks, s cobbing, n pefile, t govender, s shah, h kaja, r chetty, m naidoo, s mabika, n mnguni, t ngubane, f mthethwa 19 creating opportunities for interprofessional, community-based education for the undergraduate dental therapy degree in the school of health sciences, university of kwazulu-natal, south africa: academics’ perspectives i moodley, s singh 26 health education on diabetes at a south african national science festival m mhlongo, p marara, k bradshaw, s c srinivas 31 engagement of dietetic students and students with hearing loss: experiences and perceptions of both groups y smit, m marais, l philips, h donald, e joubert 38 the perspectives of south african academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training s m govender, m mars 44 comparing international and south african work-based assessment of medical interns’ practice k l naidoo, j van wyk, m adhikari 50 ‘sense of belonging’: the influence of individual factors in the learning environment of south african interns k l naidoo, j van wyk, m adhikari 56 the effect of undergraduate students on district health services delivery in the western cape province, south africa s reid, h conradie, d daniels-felix 61 a new way of teaching an old subject: pharmacy law and ethics s chetty, v bangalee, f oosthuizen 66 transition-to-practice guidelines: enhancing the quality of nursing education t bvumbwe, n mtshali cpd questionnaire ajhpe african journal of health professions education march 2018, vol. 10, no. 1 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens dtp & design clinton griffin chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, mrs h kikaya, dr m mbokota, dr g wolvaardt issn 2078-5127 research 62 june 2017, vol. 9, no. 2 ajhpe not all 1st-year students who enter the medical programme in the faculty of health sciences at the university of the free state (ufs) in bloemfontein, south africa, are successful, despite the application of strict selection and admission criteria. selection criteria include high academic scores in school-leaving examinations and achievement according to national benchmark tests (nbts). furthermore, applicants may have held secondary school leadership roles, as well as achieving in both sport and cultural activities, for which additional admission points are allocated. across all institutional faculties, research has shown that student success is ‘a complex phenomenon with many influencing factors’,[1] which include cognitive, motivational, dispositional, sociocultural and economic variables.[2] while acknowledging that complex factors contribute to entry-level student unpreparedness for higher education, institutional support is considered vital for students struggling academically in their 1st year of study. international research has shown that faculties can contribute to student support by using strategies to enhance self-efficacy in students in all disciplines.[3] in the ufs undergraduate medical programme, early monitoring of assessment results and student academic support and development are in place.[4] the identification of effective strategies for medical student remediation has been investigated, which include providing at-risk students with an alternative learning environment, teaching to smaller groups of students and improving students’ generic skills.[5,6] results show that mandatory remedial courses offered to small groups of medical students have proved successful.[6,7] in line with the international trend of providing remediation programmes,[6,7] ufs medical students who fail one or more of their first-semester modules for the first time, are given the opportunity to join a 6-month learning development programme (ldp) during the second semester. academic success in the ldp allows students a second opportunity to re-enter the mainstream medical programme at the start of the following academic year. theoretical underpinnings of a remediation course include mindful design of the syllabus to include aspects of active learning and carefully selected course content, with the aim to promote student self-regulation and self-reflection.[7] the theory behind successful remediation includes the three key steps of diagnosis, use of remedial activities, and subsequent re-testing.[8]  additionally, according to hommes et al.,[9] collaboration between students benefits their performance and influences their learning, over a number of years, the focus of the ldp for ufs medical students has been on modules providing additional content knowledge, i.e. medical terminology, language skills, medical physics, basic biochemistry and physiology, and integrated anatomy and physiology. since 2013, the ldp curriculum also includes a new generic skills module – lifelong learning skills (llls). the rationale behind this revised curriculum was that recent international research has indicated that key generic learning skills were contributing factors in the academic success of medical students.[5,7] these generic skills include information literacy, data handling, information and computer technology, problem-solving, self-management and teamwork.[5] critical thinking skills are also considered to be a key generic skill, specifically for medical education.[7] according to murdoch-eaton and whittle,[5] the challenge for medical educators is to train healthcare professionals to recognise ‘unstated assumptions, values or prejudices, to evaluate evidence, interpret data and inspect arguments using discrimination, accuracy and judgement’. the focus of the llls module is on developing generic skills in students, and introducing them to professional conduct, ethics, and critical thinking in healthcare. motivation, learning styles and study techniques, time management, communication skills, problem-solving and professional behaviour in the health sciences are all key learning areas in the module. international research has shown that curricula for medical education may undervalue student motivation, and ways to stimulate intrinsic motivation may improve the manner in which future medical education is planned and background. students who fail the first semester in an undergraduate medical programme at the university of the free state may join a learning development programme (ldp) in the second semester. a new generic skills module, lifelong learning skills (llls), was added to the curriculum in 2013. objective. to ascertain whether the llls module helped to improve the generic learning skills of ldp students. methods. student reflections and a self-administered questionnaire with open-ended questions were used to obtain feedback. results. students believed that the llls module enhanced their generic skills, and that it was beneficial to them. aspects such as motivation, time management and critical thinking improved. furthermore, they indicated that the skills mastered during the module continued to be useful in the subsequent academic year. conclusion. the students’ reflections made a valuable contribution to understanding ways in which they can be supported. through student insights, future presentation of the llls module can be enhanced. afr j health professions educ 2017;9(2):62-66. doi:10.7196/ajhpe.2017.v9i2.694 a learning development module to support academically unsuccessful 1st-year medical students c a kridiotis, ma (health professions education), btech, bcom; s swart, phd (health professions education), ma (industrial psychology) division of health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: c a kridiotis (c.kridiotis@intekom.co.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research june 2017, vol. 9, no. 2 ajhpe 63 delivered.[10] when studying students’ wellbeing, motivational strategies and ‘approaches to learning and their perception of their learning environment’, it was found that the same learning environment may not be perceived in the same way by all students.[11] the ldp provides unsuccessful students with an alternative learning environment. in a large-scale study conducted in the usa across various institutions, booth et al.[12] researched factors that students thought had supported their educational success, in an attempt to understand how institutions could deliver support to students, both inside and outside the classroom. feedback from the study showed that students regarded ‘being directed’ and working towards a goal as important, and that being focused and aiming to succeed were equally important. it was also reported that if students felt that they were nurtured and valued, and that there was someone who encouraged them to succeed, it had a positive impact on their studies. when students were actively engaged, and when they participated in lectures and felt that they were connected with the institutional community, these factors contributed to student success.[13] international results highlight that collecting data on self-regulated learning among medical students and on student participation in learning activities, may ‘help medical schools to identify students who are at risk for poor performance early in their training’.[13] students’ confidence in their individual academic-related skills plays a role in their motivation to achieve, and although student perceptions may be self-reported, there is an association between level of practice of a skill and confidence to use the skill.[14] the newly developed llls module in the ldp at the faculty of health sciences, ufs, is aligned with the abovementioned research findings, and aims to help students to address their goals, function in a small and nurtured environment, and overcome their academic shortcomings in positive ways. the current research sought to gauge student perceptions regarding the new llls module. the objectives of the study were: • to ascertain whether there was a student perception that the introduction of the llls module within the ldp of the faculty of health sciences, ufs, helped to improve their generic learning skills • to ascertain whether there was a student perception that the llls module made a difference to the way they approached their studies, and whether the module could be improved in future • to determine whether the module was perceived by students to have had an ongoing impact not only on their generic skills, but also on their attitudes, professional conduct, group skills, and overall academic success. methods the study used a qualitative methodology, with some quantitative elements. student academic statistics were used as an overview to determine the number of students who passed and failed. the qualitative methodology included student reflections on the llls module. these reflections were documented and reviewed by the researchers over a period of two years. ten medical students were in the ldp in 2013, and 15 in 2014. in the second part of the research, a self-administered questionnaire with open-ended questions was used to gain information from the first group of students (n=7), who had successfully progressed through the ldp in 2013, re-entered the second-opportunity mainstream programme and successfully completed semesters 1 and 2 in the mainstream. students were asked to reflect on the benefits of the llls module in particular and the ldp in general, a year after completion of the programme, and subsequent academic success in the mainstream programme. by analysing academic achievements and student self-reflection, triangulation was used as a validity process. the data were edited, categorised and summarised by both researchers, and thematical analysis was used to identify common themes in the responses. ethical approval to conduct the study was obtained from the ethics committee of the faculty of health sciences, ufs (ecufs ref. no. 112/ 2014). permission was obtained from the dean of the faculty of health sciences, head of the school of medicine and vice-rector: teaching and learning, ufs. results during 2013, 158 1st-year students enrolled in the first semester of the medical programme at the faculty of health sciences at ufs. of these students, 144 (91.1%) passed the first semester, 12 (7.6%) failed the first semester and 2 (1.2%) voluntarily discontinued their studies. of the 12 students who failed the first semester, 10 (6.3%) were placed in the ldp for the second semester. one of the students had already obtained a qualification before being selected for the medical programme and, according to regulations, was not allowed into the ldp. at the end of the second semester ldp, 7 of the medical students in the ldp achieved an overall average mark of 75% for all the modules in the programme and were readmitted to the first semester of the mainstream medical programme in 2014. two students were unsuccessful in the ldp, as shown in table 1. one student discontinued his studies. in 2014, 149 1st-year medical students were enrolled for the first semester of the medical programme. of the total group, 131 (87.9%) passed the first semester, 17 (11.4%) failed the first semester and 1 student (0.7%) voluntarily discontinued his/her studies. fifteen students (10.1%) were admitted to the ldp for the second semester, of whom 12 obtained the required minimum of 75% average for all modules and were readmitted to the first semester of the mainstream medical programme for 2015. three students were unsuccessful in the ldp (table 1). key reflections of the 2013 ldp students included that many expressed the feeling that they had lost a degree of self-confidence after failing the first semester. most students viewed their experience of the llls module as very beneficial, and the small size of the group promoted mutual support among the group members. during the llls module they were given the opportunity to express their opinions and interact with each other. the facilitators of the llls module positively reinforced the students, further ensuring that they felt connected and nurtured. the facilitators also ascertained that the students were made aware that, with the right table 1. statistics of 1st-year medical students at the end of the first semester of 2013 and 2014 outcome 2013, n (%) (n=158) 2014, n (%) (n=149) successful (passed first or second examination opportunity) 144 (91.1) 131 (87.9) unsuccessful (no admission to write examination, or failed examination) 12 (7.6) 17 (11.4) dropped out of the medical programme 2 (1.3) 1 (0.7) admitted to lpd 10 (6.3) 15 (10.1) successful in lpd 7 (4.4) 12 (8.1) unsuccessful in lpd 2 (1.3) 3 (2.0) research 64 june 2017, vol. 9, no. 2 ajhpe approach to their studies, academic success was within their reach. essential reflections of students regarding the most beneficial aspects of the generic skills learned in the llls module during 2013 are shown in table 2. some students indicated that they would like more information on applying new learning styles, and also that more help was needed in applying study techniques, and test and examination management. these shortcomings, having been identified, were addressed in subsequent facilitation of the llls module. the comments of the 15 medical students in the ldp during the second semester of 2014 included reflections, e.g. that they found the module insightful and beneficial, as they reassessed the way in which they learnt and applied knowledge. the llls module encouraged the students and made them approach the future positively, despite the fact that they had failed. they reported having acquired skills in writing scientific reports, presenting and critical reflection, which they did not have before. the module also brought about an improvement in attitudes and perspectives, preparing students to become academically and socially better prepared for the challenges of medical education. further reflections of the 2014 ldp students included comments that although some of the module content was similar to what they were taught in semester 1 in the mainstream, the attention to foundational knowledge in this module made the understanding and retention of the study material more manageable. the underlying support provided to the students in the ldp course enabled them to grasp concepts they had previously found challenging. the module was considered by one student ‘to have made a huge impact on my studies and the way i look at university life’. one effective and beneficial skill acquired by students was improved time management. their reflections regarding the generic skills learned in the llls module are shown in table 3. quantitative data were used to track the academic progress of the students in the year following the ldp, to ascertain whether students maintained their level of academic success. the students who had passed the ldp in 2013 and re-entered the mainstream medical programme (n=7) had all been academically successful. these students indicated that they had learnt better time management during their llls module, which was very beneficial. the students also indicated that the ldp in general had motivated them to study consistently and consequently and to prepare ahead of their classes in the mainstream programme. students were asked a year after completing the ldp which module(s) they considered to have been the most beneficial during the programme. student perceptions on the efficacy of the ldp in general, as well as the contributing factors to their initial academic failure and subsequent academic success, were documented by the researchers. the students cited the modules of integrated anatomy and physiology, medical terminology, and basic biochemistry and physiology as being the most helpful. the consolidation of core knowledge during ‘the slower pace’ of the ldp modules was cited as very beneficial to the students after they had re-entered and were successful in the mainstream programme. when asked to comment on factors that contributed to their subsequent success in the mainstream programme, students indicated that during the second opportunity, they were more aware of the way in which they would be assessed. by being familiar with the assessment methods, they could adjust their learning. in the mainstream, integrated assessment methods are used, which require deep learning and challenge students to apply critical thinking. the llls module had informed students of assessment principles and key action words, as well as giving them the opportunity to practise the use of study techniques, learning skills such as effective summarising and ways to maximise retention of study material. the students also indicated that timeous feedback on the results of assessment helped them to plan for the next test. when students were part of the ldp, their progress was carefully monitored and they became familiar with the support services at the division of health sciences education, which also played a role, as the students were comfortable with asking for assistance when they needed it. additionally, the second-opportunity students indicated that the student mentors who had been appointed during 2014 to guide mainstream students also played an important supportive role, and that this contributed to their academic success. table 2. most beneficial aspects of the key generic skills taught in the llls module, 2013 learning unit students’ reflection on beneficial aspects motivation and selfmanagement ‘helped build up confidence after failing first semester.’ ‘helped build a constructive, positive attitude.’ ‘discovered other students faced the same challenges as i did.’ learning styles and study techniques ‘discovered how best to study using my personal learning style.’ ‘helped me study large amounts of work.’ ‘assisted with becoming more effective while studying.’ time management ‘helped to discover how to make an effective study timetable.’ ‘helped to avoid procrastination by using a study timetable.’ ‘managing study time by writing it down in the form of a schedule made a huge difference.’ communication skills and critical thinking skills ‘the oral presentation was a very good exercise.’ ‘i was apprehensive about giving the oral presentation, but felt confident afterwards.’ ‘built confidence and helped the group to bond.’ group work, problem-solving and conflict management ‘helped me realise i must take the viewpoints of others into consideration.’ ‘made it easier to function in a group.’ ‘helpful – being more considerate and mindful of the opinions of others.’ stress management ‘helped me identify my stressors and helped me cope better with stress.’ ‘discovered techniques to help me deal with stress.’ ‘helped, i had been very stressed out when i failed.’ ‘realised i could ask for help.’ test and examination management ‘was useful to discover techniques to approach tests and examinations.’ ‘learning key action words to identify what examiner is asking for was useful.’ ‘helpful, we could have spent even more time on this.’ research june 2017, vol. 9, no. 2 ajhpe 65 discussion in the first part of the survey, students indicated that the skills they had learnt during the llls module helped them regain their confidence after a demoralising failure in semester 1. students learnt to plan and apply time management and effective study techniques. they concluded that the following factors played a role in increased levels of confidence: (i) the small-group approach with supportive facilitators; (ii) interaction with peers; (iii) class discussions; and (iv) oral presentations within the small-group setting of the llls module. stegers jager et al.[15] reported that participation by students in scheduled learning activities was strongly related to academic performance in the first year. a similar trend was found in the llls module. students who were more conscientious regarding attendance outperformed those with poor session attendance. this trend was in line with a recent study among medical students in china, which showed that student engagement in lectures and recognition that effort needed to be put into studies, directly contributed to achievement.[16] in the second part of the survey, students indicated the generic skills development continued to be useful in the academic year that followed, as they studied timeously and more effectively. the slower pace at which the academic modules within the ldp were presented, was perceived as beneficial to students, and they felt their core knowledge in modules such as anatomy and physiology had been consolidated during the ldp. former ldp students reported that, once they were back in the mainstream programme, their core knowledge of anatomy and physiology compared favourably with the levels of knowledge demonstrated by their peers. this insight is a topic to be considered in further research, and would justify research into the short-, mediumand long-term effects of a short, integrated programme on study skills and learning development of 1st-year medical students. the ldp students of 2013, who were the first group to take the llls module, were positive about its benefits, and indicated that the skills they had learnt during the module had continued to be useful in the subsequent academic year. the group of students were aware of the academic challenges they had to face in their continued studies, but were more equipped on a personal level to deal with the challenges, as they had acquired techniques to deal with the academic workload and the accompanying stress. using the table 3. beneficial aspects of the key generic skills taught in the llls module, 2014 learning unit students’ reflection on beneficial aspects motivation and self-management ‘learned about goal setting, to keep being motivated.’ ‘helped benchmark my needs, identified lack of resources.’ ‘made me realise what went wrong last semester.’ learning styles and study techniques ‘practical application methods of learning strategies extremely valuable.’ ‘i realised i have below average self-acceptance, and am critical of others – things i have to work on.’ ‘i learned to improve, implement deep learning, being more effective while studying.’ ‘i learned to summarise, formulate questions while learning.’ ‘helped me understand the preparation-teaching-learning-assessment and reflection cycle.’ ‘i am more accommodative of people than i was previously.’ time management ‘i organised my study space, used tips to study more effectively.’ ‘i realised how much i procrastinate and how to avoid this.’ ‘managing my study time by planning a schedule.’ ‘i learnt that working continuously is better than cramming.’ ‘making a weekly, daily and semester planner helped me to record and plan for tests and assignments, very helpful.’ communication skills and critical thinking skills ‘i learned about written academic submissions, which was worthwhile.’ ‘the chance to give an oral presentation in front of a smaller audience was beneficial, and will prepare me for giving a presentation in front of a larger audience.’ ‘i benefited from having to write a scientific essay and reference it correctly.’ ‘i benefited by having some classes with other allied health professionals, such as nurses. this gave me understanding and insight.’ group work, problem-solving and conflict management ‘this module’s focus was on the social aspects of ethical dilemmas.’ ‘the focus on group work is something i appreciated, i saw how my behaviour affects the other members of the group.’ ‘i do not enjoy group work, but because of this learning unit, i now know how to take part in group work and discussions in a responsible and accountable manner.’ ‘helped me to think outside the box.’ ‘i realised that in the medical profession we will be faced with dilemmas, which will need critical thinking.’ ‘i found it hard to critically reflect on an article, which worries me. i need to improve this skill.’ stress management ‘stress is a constant and chronic problem throughout the medical field and i believe this unit approached it in the right way.’ ‘i was able to identify how my stress is manifested.’ ‘although this learning unit did help me identify stressors and the symptoms of stress, i still do not know how to manage my stress.’ test and examination management ‘i found that reflecting on a test helped me to prepare for the next test.’ ‘it was useful to learn about different kinds of questions and how to approach them.’ ‘good techniques during the test, such as reading the question analytically and identifying the action words, is useful.’ research 66 june 2017, vol. 9, no. 2 ajhpe goal-orientation theory to design an intervention to reinforce mastering goals as a successful outcome, ‘may enhance the effectiveness of medical student training’.[17] as indicated earlier by hommes et al.,[9] collaboration between students benefits their performance and influences learning, which was also found in the current research, as frequent collaboration between the same group of students in the llls module strengthened the bond between them, and had a positive influence on their confidence and performance. after an unsuccessful first semester, students may also have had a better understanding of how to avoid pitfalls during assessment at university, which may also have played a role in their subsequent academic success. conclusion the students noted the benefits of the remedial ldp, with support from facilitators and interaction with their peers within the small group. they considered that the slower pace at which the academic modules within the ldp were presented had helped them to consolidate core knowledge, which became apparent once they were back in the mainstream medical programme. the rationale behind the development and introduction of the new llls module was that recent research, both nationally and internationally, indicated that key generic learning skills were contributing factors in the academic success of health sciences students. the llls module was found to have addressed the need for enhanced key generic skills among 1st-year medical students who had initially been unsuccessful, in line with findings by burch et al.,[6] who stress that ‘the importance of generic skills in underpinning effective learning is increasingly appreciated’.[6] the reflections of students made a valuable contribution to understanding how the key generic skills can be useful to medical students. the generic skills taught were found to supplement the core knowledge component of the ldp and promote lifelong learning skills in medical students in their subsequent years of study. acknowledgements. dr daleen struwig, faculty of health sciences, ufs, for technical and editorial preparation of the manuscript. 1. wilson-strydom m. a framework for facilitating the transition from school to university in south africa: a capabilities approach. phd thesis. bloemfontein, university of the free state, 2012. http://scholar.ufs. ac.za:8080/xmlui/handle/11660/1935 (accessed 21 april 2017). 2. cliff a, ramaboa k, pearce c. the assessment of entry-level students’ academic literacy: does it matter? ensovoort 2007;11(2):33-48. http://www.academia.edu/7958363/the_assessment_of_entry-level_students_academic_literacy_does_it_matter (accessed 11 april 2017). 3. krumrei-mancuso ej, newton fb, kim e, wilcox d. psychosocial factors predicting first-year college student success. j coll stud dev 2013;54(3):247-266. http://dx.doi.org/10.1353/csd.2013.0034 4. university of the free state. student academic support and development. bloemfontein: ufs, 2014. 5. murdoch-eaton d, whittle s. generic skills in medical education: developing the tools for successful lifelong learning. med educ 2012;46(1):120-128. http://dx.doi.org/10.1111/j.1365-2923.2011.04065.x 6. burch v, sikakana cnt, gunston gd, shamley dr, murdoch-eaton d. generic learning skills in academicallyat-risk medical students: a development programme bridges the gap. med teach 2013;35(8):671-677. http:// dx.doi.org/10.3109/0142159x.2013.801551 7. winston ka, van der vleuten cpm, scherpbier aj. the role of the teacher in remediating at-risk medical students. med teach 2012;34(11):e732-e742. http://dx.doi.org/10.3109/0142159x.2012.689447 8. cleland j, mackenzie rk, ross s, sinclair hk, lee aj. a remedial intervention linked to a formative assessment is effective in terms of improving student performance in subsequent degree examinations. med teach 2010;32(4):e185-e190. http://dx.doi.org/10.3109/01421591003657485 9. hommes j, rienties b, de grave w, bos g, schuwirth l, scherpbier a. visualising the invisible: a network approach to reveal the informal side of student learning. adv health sci educ theory pract 2012;17(5):743-757. http://dx.doi.org/10.1007/s10459-012-9349-0 10. kusurkar ra, croiset g, mann kv, custers e, ten cate o. have motivation theories guided the development and reform of medical education curricula? a review of the literature. acad med 2012;87(6):735-742. http://dx.doi. org/10.1097/acm.0b013e318253cc0e 11. lonka k, sharafi p, karlgren k, et al. med nord – a tool for measuring medical students’ well-being and study orientations. med teach 2008;30(1):72-79. http://dx.doi.org/10.1080/01421590701769555 12. booth k, cooper d, karandjeff k, purnell r, schiorring e, willett t. student support (re)defined: what students say they need to succeed. key themes from a study of student support. http://archive.rpgroup.org/sites/default/ files/studentperspectivesresearchbriefjan2013.pdf (accessed 21 april, 2017). 13. stegers-jager km, cohen-schotanus j, themmen ap. motivation, learning strategies, participation and medical school performance. med educ 2012;46(7):678-688. http://dx.doi.org/10.1111/j.1365-2923.2012.04284.x 14. murdoch-eaton d, manning d, kwizera e, burch v, pell g,whittle s. profiling undergraduates’ generic learning skills on entry to medical school; an international study. med teach 2012;34(12):1033-1046. http://dx.doi.org/10.3109/104 2159x.2012.706338 15. stegers-jager km, cohen-schotanus j, themmen ap. the effect of a short integrated study skills programme for first-year medical students at risk of failure: a randomised control trial. med teach 2013;35(2):120-126. http:// dx.doi.org/10.3109/0142159x.2012.733836 16. zhou yx, ou cq, zhao zt, et al. the impact of self-concept and college involvement on the first-year success of medical students in china. adv health sci educ theory pract 2015;20(1):163-179. http://dx.doi.org/10.1007/ s10459-014-9515-7 17. madjar n, bachner yg, kushni t. can achievement goal theory provide a useful motivational perspective for explaining psychosocial attributes of medical students? bmc med educ 2012;12(1):4. http://dx.doi.org/10.1186/1472-6920-12-4 http://scholar.ufs.ac.za:8080/xmlui/handle/11660/1935 http://scholar.ufs.ac.za:8080/xmlui/handle/11660/1935 http://dx.doi.org/10.3109/0142159x.2013.801551 http://dx.doi.org/10.3109/0142159x.2013.801551 http://dx.doi.org/10.1097/acm.0b013e318253cc0e http://dx.doi.org/10.1097/acm.0b013e318253cc0e http://archive.rpgroup.org/sites/default/files/studentperspectivesresearchbriefjan2013.pdf http://archive.rpgroup.org/sites/default/files/studentperspectivesresearchbriefjan2013.pdf http://dx.doi.org/10.3109/1042159x.2012.706338 http://dx.doi.org/10.3109/1042159x.2012.706338 http://dx.doi.org/10.3109/0142159x.2012.733836 http://dx.doi.org/10.3109/0142159x.2012.733836 http://dx.doi.org/10.1007/s10459-014-9515-7 http://dx.doi.org/10.1007/s10459-014-9515-7 editorial 2 fanning and refuelling the flickering flame of faculty development j van wyk review 3 south-south cooperation in health professional education: a literature review l du toit, i couper, w peersman, j de maeseneer research 9 an integrated literature review of undergraduate peer teaching in allied health professions s van vuuren 13 developing a service-learning module for oral health: a needs assessment r ebrahim, h julie 17 barriers to continuous professional development participation for radiographers in kenya l g kanamu, b van dyk, l chipeya, s n kilaha 21 specialty choice among dental students in ibadan, nigeria k k kanmodi, a i badru, a g akinloye, w a wegscheider 24 pioneering small-group learning in tanzanian emergency medicine: investigating acceptability for physician learners a g lim, h geduld, k checkett, h r sawe, t a reynolds 29 self-directed learning: status of final-year students and perceptions of selected faculty leadership in a nigerian medical school – a mixed analysis study t e nottidge, a j n louw 34 self-regulated learning: a key learning effect of feedback in a problem-based learning context a g mubuuke, a j n louw, s van schalkwyk 39 occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology l jacobs-nzuzi khuabi, j bester, k gatley-dewing, s holmes, c jacobs, b sadler, i van der walt 44 exploration of high-fidelity simulation: nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting t munangatire, n naidoo 48 cpd questionnaire ajhpe african journal of health professions education | march 2017, vol. 9, no. 1 editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors julia blitz stellenbosch university jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria lionel green-thompson university of the witwatersrand patricia mcinerney university of the witwatersrand sindiswe mthembu university of the western cape ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wasserman stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu ingrid nye technical editors emma buchanan paula van der bijl production manager emma jane couzens dtp & design clinton griffin travis arendse chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m j grootboom, mrs h kikaya, prof. e l mazwai, dr m mbokota, dr g wolvaardt issn 2078-5127 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405, tel. 021 532 1281 | cell 072 635 9825 please submit letters and articles for publication online at www.ajhpe.org.za a maximum of 3 ceus will be awarded per correctly completed test. june 2017, vol. 9, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/170/02/2017 (clinical) cpd questionnaire june 2017 true (a) or false (b): use of role-play and community engagement to teach parasitic diseases 1. role-play, when combined with community engagement, can greatly enhance empathy in issues and challenges relating to the community. 2. there was no significant difference in mean test scores before and after the role-play intervention. ‘he has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: the role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement 3. reflective portfolios in physiotherapy have been used to a large extent in undergraduate training. 4. the results of this study revealed that student entries demonstrated a low level of reflection, with very few students showing insight, self-awareness and recognition of own and others’ limitations. the health system benefits of attending an hiv/aids conference 5. based on the respondent data collected 5 months after the conference, the scholarship programme appears to have made no contribution to the strengthening of health systems. 6. the three most cited reasons for attending the conference were practical (receiving a scholarship) or educational (acceptance of abstract and wanting to learn more about tb/hiv/aids/stis). a learning development module to support academically unsuccessful 1st-year medical students 7. research has shown that student success is ‘a complex phenomenon with many influencing factors’, which include cognitive, motivational, dispositional, sociocultural and economic variables. 8. feedback by students of a large-scale study conducted in the usa showed that students regarded ‘being directed’ as less important than working towards a goal. 9. the following factors were said to play a role in students regaining their confidence after a failure in their first semester: (i) the small-group approach with supportive facilitators; (ii) interaction with peers; (iii) class discussions; and (iv) oral presentations within the small-group setting. depression, anxiety, stress and substance use in medical students in a 5-year curriculum 10. research has shown that medical school students are no more prone to depression, anxiety and stress than students in other faculties/departments. 11. there is a concerning association between stress and anxiety and substance abuse by medical students. 12. rates of depression, anxiety and stress were found to be higher in the semester 5 students than their semester 3 counterparts. developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings 13. the longitudinal community attachment programme for students (l-cas) is an activity by means of which each student is exposed to primary healthcare learning and practice in communities. 14. peer-assisted learning is known to contribute to a number of essential competencies, including communication, learning transfer, teamwork, self-confidence, and reciprocal and effective practice. 15. there is very little literature on capability as an approach to human economic and social development, including education. reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education 16. according to the authors, portfolios are an under-utilised assessment and self-development tool in postgraduate training. 17. the authors report that there is strong evidence as to whether portfolios aid or hinder reflection in postgraduate education. 18. as this qualitative study is based on narratives reported in portfolios, it limits the generalisability of the results. dental undergraduate students’ knowledge, attitudes and practices in oral health self-care: a survey from a south african university 19. at the institution where this study was based, 2nd-year students are less involved in preventive care than those in their 3rd year. 20. the implications of the findings in this study suggest that students need sustained exposure to preventive care in their undergraduate training to maximise greater awareness of positive self-care practices. cpd questionnaire september 2017, vol. 9, no. 3 ajhpe september 2017 true (a) or false (b): health sciences students’ contribution to human resources for health strategy: a rural health careers day for grade 12 learners in the north west province of south africa 1. the participating learners reported that while they found the funding station informative, additional information on funding was needed. a quick needs assessment of key stakeholder groups on the role of family medicine in zambia 2. there was general consensus among all respondents that there is a need for more family medicine physicians in zambia. registrar wellness in botswana: measuring burnout and identifying ways to improve wellness 3. according to the job demand-control-support model, employees who work in jobs with high demands, low control, and low social support experience the highest level of psychological and physical wellbeing. 4. the results showed that 75% of registrars had a high level of burnout, which is in the upper range of normal for registrars internationally. assessment of the educational environment of physiotherapy students at the university of rwanda using dreem 5. the highest score was in the domain of ‘students’ perceptions of learning’. standardised patient-simulated practice learning: a rich pedagogical environment for psychiatric nursing education 6. the researchers noted that there is no evidence that using standardised patients decreases student anxiety and increases confidence. understanding student early departure from a master of public health programme in south africa 7. stress and demands of the mph programme emerged as one of the main themes. postgraduate trainees’ perceptions of the learning environment in a nigerian teaching hospital 8. pheem has not been validated and is therefore not a reliable instrument. 9. results showed no significant differences in scores across gender or specialty. radiation safety requirements for training of users of diagnostic x-ray equipment in south africa 10. according to the icrp, the term training refers to imparting knowledge and understanding radiation health effects. 11. the delphi technique involves a research team, who are involved collec tively with the goal of enhancing the quality and utilisation of the research. training requirements for the administration of intravenous contrast media by radiographers: radiologists’ perspective 12. in south africa, radiographers perform the task of administering intravenous contrast media as per their legal scope of practice. perceptions of the impact of an advanced training programme on the management skills of health professionals in gauteng, south africa 13. training of managers is not prioritised by the sa national strategic plan. 14. respondents in this study scored poorly in the creation of a marketing plan and its implementation. a peer evaluation of the community-based education programme for medical students at the university of zimbabwe college of health sciences (uzchs): a southern african medical education partnership initiative (mepi) collaboration 15. one of the strengths of the uzchs curriculum is the consistent exposure of students to community-based education. 16. the entire process of peer evaluation happens over a short period of time and requires minimal commitment from hosts and reviewers. fifth-year medical students’ perspectives on rural training in botswana: a qualitative approach 17. this study was conducted using a survey to quantitatively analyse students’ perceptions of their rural training. 18. consistent with other literature, the students in this study identified barriers of rural training relating to resources and supervision. quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-cex assessment form 19. the results of this study showed that the use of mini-cex forms had no effect on the quantity and quality of teachers’ written feedback. upskilling nursing students and nurse practitioners to initiate and manage patients on art: an outcome evaluation of the ukzn nimart course 20. results showed that trainees from urban and peri-urban facilities report less knowledge gain than their counterparts in rural areas. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/170/02/2017 (clinical) a maximum of 3 ceus will be awarded per correctly completed test. 23 august 2010, vol. 2, no. 1 ajhpe abstracts needs assessment for the introduction of intercalated degrees at the college of medicine of the university of malawi nyengo chiswakhata mkandawire, mwapatsa mipando, carrie kollias correspondence to: nyengo mkandawire(nmkandawire @medcol.mw) context and setting malawi has a critical shortage of medical graduates, researchers and academics. the college of medicine, together with affiliated research units which include malawi-liverpool-wellcome trust, johns hopkins university, the malaria alert centre and blantyre malaria project-michigan university, has the potential to offer intercalated degrees, such as bachelor of science honours, by adding an extra year during the undergraduate medical programme. why the idea was necessary the main objectives were to assess medical students’ interest in undertaking intercalated degrees and the capacity of the college of medicine and its affiliated research units to offer the degrees, with a secondary aim of encouraging careers in health sciences education and research. what was done an electronic survey evaluating student and faculty views, both qualitatively and quantitatively, was distributed between july and september 2009 to all undergraduate medical students and the medical faculty of the college of medicine and affiliated research units. ethics approval was obtained for this survey. evaluation of results and impact seventy-seven of 250 students (31%) and 46 of 100 faculty members (46%) responded. the proportions of students in relation to year of study for years 1 5 were 25%, 22%, 16%, 29% and 8%, respectively. among the student respondents 58% knew about intercalated degrees prior to the survey. eighty-five per cent were in favour of introducing intercalated degrees, believing it would encourage pursuit of careers in medical academia and research; 67% would consider doing a degree and 34% (26 students) were very strongly in agreement. the choice study areas were histopathology (33%), anatomy (21%), physiology (14%) and microbiology (14%). other perceived benefits included acquiring research skills and widened career and job opportunities. two students believed the degree would cause an unnecessary delay in graduating from medical school. of the faculty respondents 64% knew about intercalated degrees prior to the survey. eighty-five per cent agreed that the college of medicine should introduce the degrees, believing this would encourage medical graduates to pursue careers in medical academia and research, enhance research and human resource capacity as well as collaboration between institutions, resulting in better utilisation of existing facilities. thirty per cent and 50% felt that they had adequate non-human and human resources, respectively, to offer degrees. the college and the research units combined felt they could offer 24 intercalated degrees per year in microbiology, statistics and epidemiology, histopathology, immunology, anatomy, physiology, haematology, biochemistry, management and pharmacology. twenty-six students were very interested in doing an intercalated degree, matching well with the 24 slots that can be offered per year. students’ interest and departmental capacity corresponded well for micro biology and statistics/epidemiology, but a very strong interest in histo pathology resulted in a mismatch with the capacity of the department to accommodate the students. there is a strong enthusiasm among students and faculty for intercalated degrees. although limited human and non-human resources are seen as a major challenge, the faculty is keen to start the programmes, and plans are underway to develop curricula. capacity of nursing training institutions to implement comprehensive nursing curricula in uganda safinah kisu museene correspondence to: safinah museene (safinahm2002@hotmail.com) context and setting in uganda there are 32 nursing training institutions that implemented single non-comprehensive nursing programmes (general nursing/midwifery/ mental health). because of increasing pressure to achieve the millennium development goals (mdgs), a government policy was passed to train comprehensive nurses instead of single-specialty nurses. the capacity in terms of tutors, management skills, accommodation, classroom space and other resources required for the two strategies is not the same. comprehensive nursing training demands training in the four main domains of nursing (midwifery, community health, mental health and general nursing). it is therefore evident that comprehensive training will require more resources than the monovalent training. why the idea was necessary determining the capacity of nursing training institutions in uganda is a very important first step in managing health training institutions. the findings of the study provided useful information for the ministry of education, business, technical vocational training (btvet) department, ministry of health and other policy makers to use in the process of planning, supervision and evaluation of comprehensive nursing programmes. this same knowledge is also being used by health tutors in the planning, implementation and evaluation of nursing programmes and for accreditation purposes. what was done the data were collected using pre-tested structured and unstructured questionnaires. the researcher and trained research assistant distributed the questionnaire to the principals of the 7 schools. in turn the principals distributed the questionnaires to all the teaching staff, at least 2 governing council members and 2 guild council members. using a structured observational checklist the researcher determined the availability, presence and suitability of ward allocation, vision mission, organogram, work plans, certificates of merits, presence of teaching staff, infrastructure vehicles, southern african faimer regional institute poster day, held in cape town on 8 march 2010 abstracts 24 august 2010, vol. 2, no. 1 ajhpe and evidence of recent text books in the library. student enrolment and success rates as recorded in the last 2 years were also registered. i also reviewed the relevant records in relation to the above information. results and impact the findings of the study indicate that the human resources, especially the teaching staff, were qualified for the job but inadequate in numbers compared with the student population. the average tutor:student ratio was 1:76 and 1:40 in public and private not-for-profit nursing institutions, respectively (set standards in uganda is 1:20). the number of textbooks in libraries did not meet the set ratio standards (directorate of education standards in uganda) of 1 textbook to 4 learners. this was an indication of resource constraint, especially in the areas of tutors, teaching and learning materials. these results are useful for improvement. the results have been communicated to concerned stakeholders (ministry of education and nursing council). the tutors college’s curriculum is under review, processes are underway for equipping schools with the necessary teaching and learning material and even distribution of tutors according to their skills is being emphasised. can video-based material validate learning experiences in postgraduate forensic pathology training? johan dempers, michèle janse van rensburg, janette verster, juanita bezuidenhout correspondence to: johan dempers (jd2@sun.ac.za) context and setting along with the move to establishing the colleges of medicine of south africa as the unitary specialist exit examination body for all postgraduate students, has come the requirement by the college of forensic pathologists for all students to submit logbooks of practical work and a portfolio of learning providing details of practical learning experiences in topics such as anthropology, odontology, blood splatter analysis, firearms/ballistics/tool marks, and autopsy technique. no specifications exist for the format of the logbook and portfolio, but these are currently presented in a paper-based format. why the idea was necessary in a practically orientated discipline such as forensic pathology (autopsy techniques, death scene investigation, etc.), the objectivity and validity of a paper-based logbook and portfolio system are questionable. this study was designed to determine the feasibility of developing a studentgenerated, video-based portfolio for the assessment of practical skills in forensic pathology. what was done? questionnaires were sent to all actively practising consultants and registrars in forensic pathology in south africa. two themes were addressed in the questionnaire: (i) the characteristics of individual postgraduate education programmes with a focus on assessment and the use of a portfolio; and (ii) the skill of individuals to use technology to produce studentgenerated videos as part of the portfolio compilation. evaluation of results and impact • most forensic pathologists in south africa (83%) play an active role in undergraduate and postgraduate education. this includes traditional ‘classroom’ training and practical instruction. • while 65% of consultants indicated that a paper-based portfolio was an adequate way of assessing the practical conduct of candidates, only 42% of registrars agreed with this opinion. many respondents (62%) viewed the concept of a video-based portfolio with cautious optimism, and were supportive of integrating video material into the portfolio. • wide-scale implementation of a video-based system may be constrained by limited technical expertise on the part of consultant staff; only 29% of consultants felt able to advise registrars on the development of video material suitable for inclusion in a portfolio. however, 64% of registrars indicated that they would be able to compile video clips as would be required for portfolio purposes. • this study lays the groundwork for the development and piloting of an audiovisual-based portfolio system in forensic pathology. article 7 june 2011, vol. 3, no. 1 ajhpe introduction the measurement of research output is common practice among public institutions internationally. although controversial and often contested, such measurement is regarded as the most important indication of research productivity by academic staff.1 producing adequate research outputs is influenced by various personal and institutional factors which include finding time to write,2 lack of skills in identifying appropriate journals,3 and fear and anxiety in sharing ideas with others.4 institutional inhibiting factors include limited research funding support and increased workload.5 because of these inhibiting factors, various support strategies for academics have been attempted and documented in the literature. the support strategies can take various forms, ranging from providing academics with time off from job responsibilities, to access to staff in senior mentoring, peer mentoring or writing support groups. in most countries, the higher education institutions produce the bulk of health research in terms of publications. a decade ago, the health research community in south africa was producing approximately 3 000 publications in national and international health and related publications annually, of which about 1 500 were peer-reviewed, index-linked publications.6 less than 5 years ago it was still reported that the proportion of publications by authors in health and rehabilitation sciences was assumed to be insignificant.7 for the purpose of this article, health and rehabilitation sciences include all health care professions except medicine. there are currently 22 tertiary institutions in south africa, consisting of 11 traditional universities, 6 comprehensive universities and 6 universities of technology.8 ten of the traditional universities, 3 of the comprehensive universities and 1 of the universities of technology have courses in health and rehabilitation sciences. there are multiple opportunities for academic staff in these institutions to be involved in research activities. based on the opinion of ncayiyana,7 it seems there is little evidence of the research engagements of these academic staff in terms of publication output. in medical and nursing education, these publications are clearly documented and the dearth of information in the area of health and rehabilitation sciences needs to be addressed. therefore, the aim of this paper was to review published literature reporting on strategies designed to promote research publication among academics and clinicians in health and rehabilitation sciences programmes to inform strategies to increase the proportion of publications in health and rehabilitation sciences in the health research community in south africa. methods literature search strategy a systematic search of electronic databases such as medline, cinahl, and ebscohost from 2000 to 2010 was performed. the criteria for inclusion of articles into the study were: (i) publication in the english language; (ii) access to full text publication data between 2000 and 2010; (iii) target population included academics and/or clinicians; and (iv) publication writing interventions. search terms were constructed after some review of the relevant literature. combinations of the following terms were used in all databases: publication, writing, intervention, support, clinicians and academics. the reference lists of all retrieved articles were examined to identify additional relevant studies. the initial search yielded titles and abstracts, which were then reviewed by the two reviewers for: sample population (academics, clinicians, and postgraduate students), type of intervention (e.g. courses, support groups, mentoring, workshops) and outcome (improved publication rate). a total of 481 published articles were identified based on our search criteria. abstract the health research community in south africa annually produces a fair number of research papers in national and international health and related journals. unfortunately, the proportion of papers produced by authors in health and rehabilitation sciences is insignificant compared with other disciplines. to identify strategies to increase the number of publications in south africa, this article reports on a review of published papers into the effectiveness of interventions designed to promote research publications among academics and clinicians in health and rehabilitation sciences programmes. seven of the papers reported on interventions for academics, and six reported on the interventions for academics in the nursing profession. the most common interventions were ‘writing support groups’, ‘writing retreats’, and ‘writing courses’ that lasted from 3 days to 5 years. the interventions were designed to meet the needs of the participants for structured time, motivation, improved writing skills and peer support. all the interventions produced significant research output relating to submission or publication of academic papers. the implementation of these interventions by south african tertiary institutions where health and rehabilitation sciences are offered may improve the number of papers published by the health research community. identifying strategies to improve research publication output in health and rehabilitation sciences: a review of the literature j m frantz department of physiotherapy, university of the western cape s l amosun division of physiotherapy, school of health and rehabilitation sciences, university of cape town correspondence to: j m frantz (jfrantz@uwc.ac.za) article 8 june 2011, vol. 3, no. 1 ajhpe table i. summary of the studies included for review no. author(s) and titles intervention duration and programme components targeted population outcome 1 mentoring and coaching for publication10 writing for publication support group 10 weeks 9 physiotherapy academics in south africa all participants submitted a paper for publication. 4 were published and 2 were asked to revise, with 1 rejected 2 mentored residential retreats: a leadership strategy to develop skills and generate outcomes in writing for publication11 writing retreats 3 days and 2 nights – scheduled work time from 07h00 to 21h00, with two 1-hour breaks 2005: 20 nursing participants 2007: 15 nursing participants 2007: 14 nursing participants, australia 2005: 16 papers submitted, 15 published and 1 in revision 2007: 12 papers submitted, 10 currently under review and 2 published 2007: 9 papers submitted and currently under review 3 building research capacity: through a hospital-based clinical school of nursing12 clinical school 3-year period • joint research • development of clinicians and academics nursing clinicians and academics, australia 11 articles published additional research projects 4 facilitating writing for publication13 writing course 6-month course • six 3-hour meetings • programme included writing, discussion and planning time 14 health and rehabilitation sciences professionals, glasgow. 6 physiotherapists 2 occupational therapists 3 speech and language therapists 3 podiatrists 7 submitted articles, of which 6 were accepted for publication 2 had submitted and received reviewer feedback 5 supporting academic publication: evaluation of a writing course combined with writers’ support group14 writing for publication course and support group 5-day writing for publication course • how to write for publication • group discussions • editing guidance writing support was provided over a 2-year period 8 academics from disciplines such as nursing, social science, science and humanities, australia publication increased to 33 articles in a period of 2 years 6 conquering the publishing silences of black academic women15 support group monthly meetings over 1 year • 1-hour session • support and encouragement 4 academics, in south africa: 2 physiotherapists, 1 educationalist, 1 human ecologist 2 group articles published 7 writing for publication: a new skill for nurses16 writing course 4 separate half-day workshops over a 6-month period • 2-hour sessions • strategies for successful writing • structuring a paper 17 nurses participated, uk 14 articles submitted 11 articles published 8 peer mentoring for tenuretrack faculty17 support group 2 years • meetings every second week • discussions 4 nursing academics, usa 10 articles submitted and 5 accepted 9 improving faculty publication output: the role of a writing coach18 writing coach 13 months • part-time hired coach • 21 hours/month for academic support 16 nursing academics, usa 21 articles submitted, 5 rejected, 1 under review and 15 published article 9 june 2011, vol. 3, no. 1 ajhpe methods of the review the search produced 481 hits and, after a review of the abstracts, we retrieved the full text of 30 articles and assessed them for information on writing for publication strategies among academics and clinicians, with specific emphasis on health and rehabilitation sciences professionals. after further review of the 30 articles, 9 were finally selected for inclusion in the current evaluation. the articles were appraised for quality using the guidelines for critical review, developed by the occupational therapy evidence-based practice research group at mcmaster university.9 each article was given a score based on the criteria, e.g. aim of the study, literature, study design, methods. a maximum score of 15 could be achieved. given the paucity of work in this area, papers were not excluded on the grounds of methodological weakness. authors also followed up outputs with original authors if outputs were not indicated. articles were excluded mainly based on the population addressed in the article and when the focus of the research capacity development initiative was not on publications. a data sheet was then designed (table i) to capture the relevant information, such as author, date, type of intervention, population and outcomes. major themes were identified in each paper by the authors, a consensus approach was used to identify the relevant quotes, and an analytical framework was developed. results several interventions were being used to support academics and clinicians within the health and rehabilitation sciences discipline to improve their publication writing. in addition, most of the articles included in the review highlighted academics as participants involved in writing for publication interventions (7/9 studies). various terminologies are used to describe interventions with similar goals and outcomes. the most common terminologies used are ‘writing support groups’, ‘writing retreats’, and ‘writing courses’. most of the studies were conducted in developed countries such as the usa and australia. the reasons given by the participants for attending included the need for structured time, to improve writing skills, for motivation, and for peer support. all the interventions produced significant output relating to submission or publication of academic papers. the duration of the interventions ranged from 3 days to 5 years. the duration did not seem to affect the outcomes as all interventions had positive outcomes. the experiences of the participants in different interventions are similar. they reported that the group format intervention enhanced positive interpersonal relationships and mentoring: ● ‘the shared sense of achievement amongst the group was an extremely positive aspect.’14 ● ‘i found it useful to be part of a group in which all members submitted themselves to the process of reading, writing and being read.’10 the participants also reported that they improved their knowledge and skills relating to writing and submitting articles: ● ‘i have never before had this sort of attention and i feel privileged and have a real sense of achievement.’11 ● ‘it’s less scary, now i believe i can write.’13 the various formats also allowed the participants to appreciate the value of feedback. ● ‘it was an opportunity to “try” your writing on others.’14 ● ‘i was able to take on board comments from peer review with more understanding.’13 discussion much has been said about the need, purpose and benefits of research publication,19,20 and about it being the natural conclusion in the research and discovery journey, allowing new findings and ideas to be shared, challenged and verified before adoption. research and publication are essential factors in the survival of the education of health care professionals. publications are a major element in the transfer of knowledge from clinicians and academics to potential users that could ultimately assist in saving lives and improve health care and delivery. this review therefore focuses on intervention strategies aimed at improving research publication outcomes. although there are only a few studies focusing on strategies for health and rehabilitation sciences professionals, the literature suggests positive outcomes relating to publication. the strategies are recommended to improve research publication output in health and rehabilitation sciences in south africa. from the review, interventions would obviously vary according to target groups (academics v. clinicians), but the basic framework of interventions should comprise interactive sessions where participants are allowed opportunities to write and receive feedback from others. the sharing and critiquing process in writing for publication interventions allows for participants to bring forward the realisation that there can be many ways of presenting a finding or expressing an idea. it also prepares writers for the process of reviewing, but some are more effective than others. in addition, as in interdisciplinary clinical goal, interdisciplinary research goals and groups can positively impact on health care and delivery among health and rehabilitation sciences professionals. in addition, it seemed that the outcomes for clinicians14 and academics10 can be the same with a structured intervention. thus we can create synergy between clinicians and academics using structured writing for publication workshops. conclusion the review is encouraging in that the strategies identified in the 9 reviewed articles have resulted in improvement in publication counts among health and rehabilitation sciences professionals. however, studies tended not to report on the status of the participants before the intervention so as to be able to measure whether there had been an increase in publication. if implemented, these strategies may contribute to increasing the research publication output among health and rehabilitation professionals in south africa. references 1. pouris a. assessing scientific strengths of academic institutions: the example of the university of pretoria. south african journal of science 2006;102:23-28. 2. emden c. establishing a ‘track record’: research productivity and nursing academe. australian journal of advanced nursing 1998;16(1):29-33. 3. keen a. writing for publication: pressures, barriers and support strategies. nurse education today 2007;27:382-388. article 10 june 2011, vol. 3, no. 1 ajhpe 4. lee a, boud d. writing groups, change and academic identity: research development as local practice. studies in higher education 2003;28(2): 87-200. 5. wheeler e, hardie t, schell k, plowfield l. symbiosis – undergraduate research mentoring and faculty scholarship in nursing. nursing outlook 2008;56:9-15. 6. mbewu a, mngomezulu k. health research in south africa. in: the south african health review. durban: health systems trust, 1999. 7. ncayiyana d. academy of science survey of research publishing in sa the samj streaks ahead. samj 2006;96(8):659. 8. fourie m, hay d. preparing the way for mergers in south african higher and further education institutions: an investigation into staff perceptions. higher education 2002;44:115-131. 9. law m, stewart d, pollock n, letts l, bosch j, westmorland m. critical guidelines for critical review form – quantitative studies. mcmaster university occupational therapy evidence-based practice research group, 1998. 10. frantz j, rhoda a, rowe m, et al. mentoring and coaching in promoting publications in the department of physiotherapy at a local university in south africa. south african journal of physiotherapy 2010;66(2):33-36. 11. jackson d. mentored residential writing retreats: a leadership strategy to develop skills and generate outcomes in writing for publication. nurse education today 2009;29:9-15. 12. lee g, metcalf s. building research capacity: through a hospital based clinical school of nursing. nurse education today 2009;29:350-356. 13. murray r, newton m. facilitating writing for publication. physiotherapy 2008;94:29-34. 14. rickard c, mcgrail m, jones r, et al. supporting academic publication: evaluation of a writing course combined with a writers’ support group. nurse education today 2008 doi:10.1016/j.nedt.2008.11.005 15. rhoda a, maurtin-cairncross a, phillips j, witbooi s. conquering the publishing silences of black academic women. journal of community and health sciences 2006;1(2):70-77. 16. taylor j, lyon p, harris j. writing for publication: a new skill for nurses? nurse education in practice 2005;5:91-96. 17. jacelon c, zucker d, staccarini j, henneman e. peer mentoring for tenure-track faculty. journal of professional nursing 2003;19(6):335-338. 18. baldwin c, chandler g. improving faculty publication output: the role of a writing coach. journal of professional nursing 2002;18(1):8-15. 19. pololi l, knight s, dunn k. facilitating scholarly writing in academic medicine. journal of general internal medicine 2004;19:64-68. 20. mcgrail m, rickard c, jones r. publish or perish: a systematic review of intervention to increase academic publication rates. higher education research and development 2006;25(1):19-35. scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa march 2018, vol. 10, no. 1 issn 2078 5127 african journal of health professions education march 2018, vol. 10, no. 1 ajhpe 5 forum as reported in the edinburgh declaration on medical education of 1988,[1] the main goal of any medical education programme is to produce clinicians who will promote the health and well-being of all people adequately, and not merely deliver curative medical services. therefore, quality assurance in health professions education and social accountability should be part of every country’s ethical responsibility.[2] physicians graduating from medical colleges must be competent clinicians, clinical thinkers, critical thinkers, self-directed learners, team players, effective communicators, problemsolvers and collaborators if they are to provide high-quality medical care within clearly defined criteria of minimally accepted standards.[3] however, many middleto low-income nations, including nigeria, have failed to achieve this goal, and are not aligned with the enormous advances in biomedical sciences that are taking place elsewhere. of great concern is the claim that graduates of medical colleges in nigeria who trained under the present curriculum may lack the skills and aptitude required for success in the changing practice environment of the 21st century.[4] in response, the nigerian federal ministry of health, in conjunction with the medical and dental council of nigeria (mdcn) and the national university commission (nuc) have, on several occasions, set up committees in an attempt to review the medical and dental education curricula in the country.[4] this has, however, not yielded any favourable results.[5,6] the failure of these committees/meetings therefore necessitates a new approach to improving the quality of medical education in nigeria. there is an urgent need to pay particular attention to matters of medical education and educator training. medical practice and medical education in nigeria the mdcn remains the main regulatory body for medical and dental practice in nigeria. it was established by the medical and dental practitioners’ act of 28 june 1988 (cap m8 lfn 2004) to replace the nigerian medical council established by the medical and dental practitioners’ act of 18 december 1963.[7] the mandates of the mdcn are to regulate training and practices in medicine, dentistry and alternative medicine in nigeria; determine the knowledge and skills of health professionals; and to regulate and control laboratory medicine in nigeria.[7] while the various universities/colleges of health sciences are at liberty to establish academic/medical education programmes at undergraduate level, the mdcn remains the only authority empowered to approve courses, institutions and qualifications intended for persons seeking to be registered as health professionals. medical curricula and pedagogical methods of medical education in nigeria according to the mdcn, there are 31 fully accredited and 6 partially accredited medical schools in nigeria. nine of the 31 fully accredited nigerian medical schools have dental schools, of which 7 are fully accredited and 2 have partial accreditation. while the development of medical curricula remains the sole responsibility of the senates of the individual universities, the mdcn and the nuc are mandated to determine the minimum standards of these curricula. historically, the mdcn and nuc employ dissimilar approaches to medical education, owing to differences in in recent years, curricula and pedagogical methods in medical education have undergone rapid and unprecedented changes globally. the emphasis has shifted from traditional, teacher-centred learning, characterised by the accumulation of non-integrated volumes of knowledge, to active, student-centred learning. the medical and dental council of nigeria (mdcn) reports that there are 31 fully accredited and 6 partially accredited medical schools in nigeria. the majority of these medical schools still offer undergraduate medical training based on a curriculum characterised by a distinct separation of preclinical and clinical training, with minimal or no integration. this approach is coupled with low-quality teaching by medical educators, as many medical colleges in nigeria presently use specialists as lecturers who have little or no training in higher education practices; their only exposure to teaching is that obtained during their postgraduate specialty training. similarly, very few medical schools in nigeria have established medical education units (meus), as recommended by the world health organization and the world federation for medical education. we discuss the shortcomings of the present medical education system in nigeria and suggest ways to improve the quality of pedagogy among nigerian medical educators, such as the establishment of clinical-skills centres and meus at nigerian medical schools. in addition, this review highlights the role and importance of meus in facilitating quality assurance in health professions education, and the urgent need for more medical schools in nigeria to establish meus to promote, co-ordinate and evaluate medical education reforms based on needs assessments and within the confines of mdcn standards. afr j health professions educ 2018;10(1):5-9. doi:10.7196/ajhpe.2018.v10i1.966 medical education units: a necessity for quality assurance in health professions education in nigeria a o adefuye,1 mb chb, msc, phd (med); h a adeola,2,3 dds, phd (med); j bezuidenhout,1 ba (ed), med, dtech (ed), pgd (hpe) 1 division of health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of oral and maxillofacial pathology, faculty of dentistry, university of the western cape, cape town, south africa, and tygerberg hospital, cape town, south africa 3 division of dermatology, department of medicine, faculty of health sciences, university of cape town, and groote schuur hospital, south africa corresponding author: a o adefuye (adefuyeao@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 6 march 2018, vol. 10, no. 1 ajhpe forum their targets and priorities. these contrasting interests, as presented below, of the dual monitoring bodies for medical education in nigeria present a dilemma (table 1). the expected learning activities during a programme of study or a course that results in the acquisition of knowledge and skills is known as a curriculum.[9] some of the capacities enabled by the design of a curriculum include determining professional and educational context for programme development and delivery; aligning the needs of learners and the expectations of professional bodies; determining learning outcomes; recognising constraints; determining the areas of learning and teaching; reviewing the modules based on feedback; and determining the topic sequence and key examinations.[9] over the years, emphasis and trends in planning and design of the medical curriculum and pedagogical methods in medical education have shifted, from traditional passive (teacher-centred) learning, characterised by the accumulation of non-integrated volumes of knowledge, to an active (self-directed/student-centred), systematic approach.[10-13] though nigeria is the most populous nation in africa and has four generations of medical schools, not much has changed in the blueprint of the medical education curriculum since the inception of the first medical school in 1948.[5] there has not been any systematic training pathway for medical educators; nor has there been significant curriculum review or planning. although, on paper, regulatory bodies such as the nuc and mdcn have proposed modifications of the traditional medical education curriculum in line with regional and global standards, there has been a varying degree of response towards medical curriculum review.[5] the federal ministry of health of nigeria, supported by the united states agency for international development (usaid), under the flagship of the health 20/20 project, developed the nigeria undergraduate medical and dental curriculum template, 2012, from which individual schools could develop their own curriculum de novo.[14] this curriculum template boasts being a home-grown, needs-assessment-based, integrated, systembased, person-centred, community-oriented and competency-driven model, meant to provide medical students with the best possible learning opportunities and to produce competent medical graduates. major revision of medical/dental curricula is recommended every 5 years, owing to the diminishing lifespan of useful medical information and the increasing complexity of medical practice.[15] reviewing a medical curriculum is a complex process that involves human, capital and time resources.[16] for example, the revision of the traditional bachelor of medicine and bachelor of surgery (mbbs) curriculum to a competency-based curriculum (cbme; competency-based medical education) at the college of medicine, university of ibadan, took approximately 12 years (2001 2012), in a series of overlapping processes.[15] few medical colleges in nigeria have access to the necessary resources (human, capital and time), which causes curriculum stagnation.[6] the current medical education curriculum in use at most medical colleges in nigeria involves 2 and 4 years of preclinical and clinical training, respectively. each of these stages is followed by an examination in the form of written, practical/clinical and oral (viva voce) exams. some medical schools have introduced objective structured clinical exams or objective structured practical exams into their student assessment, which improve objective evaluation of students, compared to long and short cases methods of assessment. there is a lack of integration between the preclinical and clinical curricula in most medical schools, making it difficult to harness the skills and experience acquired at both levels of training.[5] this lack of integration is exacerbated by the fact that the medical educators are specialists with little or no training in higher education practices,[17] and whose only exposure to teaching is that obtained during their postgraduate training.[6] most lecturers lack training in modern educational methods, and therefore cannot improve their teaching output, leading to poor student outcomes.[6] there is therefore an urgent need for compliance with global shifts in medical curricula, in order to improve the training and evaluation of medical doctors and dentists in nigeria. shortfalls of the present system and suggested solutions the shortfalls of the present medical education system in nigeria are outlined below. (i) medical curricula and pedagogical methods: these still follow an opportunistic approach, leading to curriculum overload and atrophy.[15] (ii) staff quality: this is not optimal, and there is a paucity of systematic training programmes for medical educators. the only requirement of the current system is that doctors who train medical students possess medical specialist qualifications, irrespective of whether these educators are wellequipped or even willing to train undergraduates. (iii) quality of medical doctors: this is not consistent, owing to the lack of standards vis-à-vis medical curriculum approval and medical school accreditation, and the quality of medical doctors produced by the different medical schools.[5] institutions in the medical sector lack adequate and modern learning and evaluation facilities.[6] (iv) unreliable forms of assessment: the viva voce examination has been used subjectively as a victimisation tool to punish students perceived to be disrespectful to their teachers.[18] furthermore, oral examinations have been demonstrated to have low reliability as an assessment tool for clinical competence.[19] another inconsistency relates to the fact that some examiners are generous when marking oral exams, while others are not.[19] although it table 1. contrasting interests of the dual monitoring bodies for medical education in nigeria national university commission (nuc) medical and dental council of nigeria (mdcn) prefers a course credit system and wants all medical teachers to be in possession of a phd before promotion into senior academic positions. does not support these requirements.[6] would like to grow the quota intake of medical students per year. wishes to ensure that the available facilities are able to accommodate such increases without compromising the quality of graduating doctors.[6] prescribes minimum academic standards, and ensures, through periodic monitoring, that training institutions adhere to these minimum standards. minimum requirements have been set by the mdcn in terms of student intake, minimum physical facilities, learning resources, administrative facilities and teaching staff requirements.[8] march 2018, vol. 10, no. 1 ajhpe 7 forum has been postulated that the use of long case/short case as a form of assessment appears to be suitable for situations where resources are limited,[14] its subjectivity makes it highly unreliable as an assessment tool. considering that professional development progress depends on a grounded relationship between continued educational activity and performance, a practical framework that could be used for evaluating competencies/skills at nigerian medical schools is miller’s pyramid, which employs multilevel achievement steps, starting with knowledge at the bottom and ending with competence at the top.[20] to tackle these problems, renewed efforts should be made to achieve greater synergy between the nuc and mdcn, medical educators should be mandated to undergo training in educational methods, and more medical colleges in the country should be supported to undertake curriculum reviews that reflect modern trends in medical education. the need for medical education units at medical schools in nigeria the cape town declaration of 1995, which was the outcome of the african regional conference of the world health organization and the world federation for medical education, states that medical (health sciences) education units (meus) should be established at every medical school, and that mechanisms should be put in place for promoting, co-ordinating and evaluating medical education reforms. since then, independent meus or similar bodies have been established at medical schools across the african continent.[21, 22] titles commonly given to these units include office, division, department, centre and unit.[23] however, very few medical schools in nigeria have established meus.[21] this deficiency is evident from a 2007 study carried out by ofeogbu and ozumba,[21] which surveyed 26 accredited medical schools in nigeria to determine whether they had independent meus. of the 14 respondents, only 1 had a designated meu. by 2017, the number of accredited medical schools in nigeria had grown to 31 fully accredited medical and 7 dental schools.[7] however, a comprehensive online literature search for ‘medical education department or health science education unit or office or centre or division’ at medical schools in nigeria, undertaken in the course of this review, revealed that only two medical schools, the college of medicine, university of nigeria, enugu[21] and the college of medicine, university of ibadan, nigeria,[24] have established meus. the activities of meus transcend educational levels, and encompass undergraduate, postgraduate and continuing medical education.[25] the roles of meus include teaching, programme evaluation, facilitating the use of educational technologies, planning, implementing and promoting educational (teaching and learning) development and  supporting medical education research.[26] it has been suggested that establishing meus at medical schools in nigeria will be a good starting point to stimulate strategy for curriculum transformation in order to improve the quality of health professions education.[24] on the basis of needs assessment, meus at individual medical schools can determine their training needs through constant curriculum reform and evaluation processes within the specified standards of the mdcn.[27] the purpose of medical education at all levels is to prepare knowledgeable and highly skilled healthcare professionals taxed with delivering safe and effective patient care.[28] the traditional learning model of medical education is undergoing a pedagogical shift, to a simulation-based medical education (sbme) learning model.[28] not all medical educators in nigeria are aware of the minimum standards for teaching and learning at both undergraduate and postgraduate levels, including educational technologies that can be utilised.[29] sbme is an effective pedagogical tool that can be used to develop new skills, identify knowledge gaps, reduce medical errors and maintain infrequently used clinical skills, even among experienced clinical teams, with the overall goal of improving patient care.[28] planning and establishing a simulation/clinical-skill centre that can train staff on the basic pedagogical principles of sbme and deliver it effectively will be the core role of the professional team situated at an meu. however, the human, time and, particularly, the financial resources required to set up a dedicated simulation/clinical-skill centre might prove to be a challenge for most medical colleges in nigeria. nevertheless, overcoming these challenges will yield a rich return. in the area of research, meus can support health professionals/medical educators to conduct research in the field of medical education in their respective fields of practice.[30] steps toward establishing meus in nigeria taking into consideration the variability in culture, geographical location and available resources, approaches to setting up meus at individual medical colleges across nigeria may vary considerably. however, we suggest key steps and methods for setting up successful meus at medical schools in nigeria.[29] (i) conduct a needs assessment: the opinions of the various stakeholders in medical education (college executives, teaching and non-teaching staff, medical/dental students, employers of doctors and members of the public) of the individual medical college should be sought. the needs assessment could probe into the kind of health professionals (doctors, dentists, nurses or physiotherapists, for instance) needed by modern medical practice, the curricula required to produce the desired health professionals, the pedagogical methods in which the curriculum will be presented and the support needed to improve the quality of pedagogy among medical educators. (ii) solicit appropriate administrative support: in the academic environment, establishing a new unit/division such as an meu would generally require a great deal of administrative support from the dean and other powerful advocates within the medical school, such as the faculty management/board and university senate committee. approaching a newly appointed dean for support might yield a positive result, as studies have shown that newly appointed organisational heads are keen to effect organisational change, and are receptive to implementing new innovations.[31] lobbying for a dean’s support may involve presenting the results of the needs assessment study that justifies the establishment of an meu, and making the necessary recommendations. data can be gathered through questionnaire surveys, interviews (semi-structured or structured), focus group discussions, nominal group discussions and an expert delphi survey, to attain consensus on salient topics. a thorough review of the existing literature, discussing the current strengths and weaknesses of current medical education systems and demonstrating practical ways in which establishing an meu will benefit a department, could also be part of the needs assessment process. recommendations should be made and reports produced on the way in which an established meu can help attain anticipated goals, namely enhancing curriculum reform, improving staff skills regarding medical education and producing exceptional medical graduates who will meet the needs of society. 8 march 2018, vol. 10, no. 1 ajhpe forum (iii) nominate a technical working group (twg): nominating a twg that will be taxed with working on various aspects of the project will be essential at the onset. members of the twg may include academic staff from the various departments within the faculty, and an education expert. (iv) train staff and build capacity: several members of the twg may need to undertake formal training in medical education, both locally and internationally. training could take the form of visits to other institutions with established meus, both locally and internationally. such visits will enable networking that can lead to personnel development, academic stimulation, mutual support and practical demonstrations of what should be done and how it can be done.[29] (v) conduct preliminary discussions with relevant regulatory bodies: these discussions on the role an meu will play in the medical education arena, e.g. health professions education, staff development and research should be held with the mdcn and the nuc. (vi) staff the meu: the staff size and staff profile of an meu will vary according to the unit’s roles in each institution.[26] on average, meus employ five or more academic staff with professional qualifications such as a phd, ded or mbbs/mb chb and three or more support/administrative staff.[30] (vii) obtain a mandate for funding for a few years before becoming selfsupporting: this mandate should be obtained from the governing body of the institution.[29] (viii) attract financial resources: resources could be obtained through grant incomes that can be used to support the activities of the unit, which could include multicentre research on medical education. (ix) establish networks with other meus: these networks should be established both nationally and internationally. (x) ensure a non-judgemental approach to members of the faculty: creating a supportive, encouraging and facilitating approach will ensure acceptance of the newly created meu.[29] factors hindering the establishment of meus at medical schools in nigeria, and suggestions for solutions the challenges hindering the establishing medical education units at medical at medical schools in nigerian are summarised below. (i) financial hurdles: to create meus of uniform standard, quality and efficacy at nigerian medical schools, the co-operation of the government, university, hospitals and private and international organisations to support the project financially is very important. public-private support partnerships could be established by medical school authorities to reduce the financial burden of setting up and staffing an meu. in addition, the financial burden can be defrayed by innovation and by improvising with resources already available at the respective medical schools. for example, mobile devices and newly emerging apps can be used for the dissemination of information to healthcare professionals, and for training medical educators and students.[32] as explained by ofoegbu and ozomba,[21] existing faculty members could be allowed to spend a percentage of their working time as ad hoc staff in the meu. because financial hurdles can constitute an impediment to setting up an meu, the judicious use of existing resources is key. (ii) mdcn and nuc bureaucracy: a practical suggestion for overcoming nuc and mdcn bureaucracy is to establish a mutually agreed-upon minimum requirement for medical education and medical educators in nigeria. a major contributing factor to the lack of progress in this regard is the dearth of qualified medical educators with appropriate training and qualifications in medical education. the dual authority of the nuc and mdcn should be actively directed towards establishing health professionals’ education units across the country. as it is sometimes the same individuals who perform accreditation for both mdcn and nuc,[6] these individuals should carry out these duties in a manner that harmonises the mandates of the two bodies. (iii) lack of willingness to change: medical educators are sometimes sceptical of the drastic changes that a revision of the curriculum by meus might cause, and fear that such changes would erode their busy clinical schedules. if this scepticism is prevalent at a medical school, the leadership of the school could engage meu advocates to systematically engage faculty members on the benefits of having an independent meu at the university. (iv) sustainability: once an meu has been established, its success depends on the willingness of the institution and faculty members to sustain its existence and efficacy.[21] an independent evaluation of the efficacy of the meu must be carried out periodically, possibly by the mdcn and/or nuc, and each meu must strive to achieve excellence. (v) leadership: to establish lasting reform in medical education via meus, a strong leadership structure is an essential requirement.[26] meus should be directed by leaders who are good role models and are able to motivate members of the meu. in addition, such leaders should be visionaries, and remain professionally aligned to the development initiative of the meu of the medical school. they should also be able to create good mentorship and collaborative research networks across the medical school. (vi) research and service focus: meus should not only be dedicated to providing medical education services to the medical community, but also be constantly engaged in research.[26] a lack of research by an meu could result in diminished innovation, and lead to the complete loss of its function. conclusion this review highlights the role of and importance of meus in facilitating quality assurance in health professions education, and the urgent need for more medical schools across nigeria to establish such meus to promote, co-ordinate and evaluate medical education reforms on the basis of needs assessment, and within the confines of mdcn standards. medical curriculum and course design must be built on the premises of modern-day educational theories; this would promote the production of a communityoriented and competent health workforce,[33] and expand the learning and teaching experience of both the student and the medical teacher. medical curricula should be designed to accommodate dynamic learning and teaching strategies, to produce customised medical practitioners who can maximise the resources available in order to serve in their own local environments. [33] acknowledgements. none author contributions. aoa conceptualised, designed, prepared and critically revised the manuscript, and haa and jb were involved in the design and critical intellectual revision of the article. all authors read and approved the final manuscript submitted for publication. funding. the health and welfare sector education and training authority (hwseta), sa. conflicts of interest. none. 1. walton hj. edinburgh declaration and medical education. lancet 1989;333(8629):105. https://doi.org/10.1016/ s0140-6736(89)91466-9 https://doi.org/10.1016/s0140-6736(89)91466-9. https://doi.org/10.1016/s0140-6736(89)91466-9. march 2018, vol. 10, no. 1 ajhpe 9 forum 2. woollard rf. caring for a common future: medical schools’ social accountability. med educ 2006;40(4):301-313. https://doi.org/10.1111/j.1365-2929.2006.02416.x 3. boelen c. building a socially accountable health professions school: towards unity for health. educ health 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https://doi.org/10.1111/j.1365-2923.2007.02931.x 31. entwistle n. handbook of educational ideas and practices (routledge revivals). oxon: taylor & francis, 2015. 32. ventola cl. mobile devices and apps for health care professionals: uses and benefits. pharm ther 2014;39(5): 356-364. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4029126/ (accessed 3 september 2017). 33. barrow mmj, samarasekera dd. strategies for planning and designing medical curricula and clinical teaching. south east asian j med educ 2010;4(1):2-8. http://seajme.md.chula.ac.th/articlevol4no1/mededp1_mark%20 barrow.pdf (accessed 3 september 2017). accepted 5 october 2017. https://doi.org/10.1111/j.1365-2929.2006.02416.x https://pdfs.semanticscholar.org/2d85/83f69aa6e7a54702578d22c87a2223d4a7f9.pdf https://doi.org/10.1080/01421590701832130 https://doi.org/10.1080/01421590701832130 http://www.nigeriamedj.com/text.asp?2010/51/2/84/71004 http://www.nigeriamedj.com/text.asp?2010/51/2/84/71004 http://www.mdcnigeria.org/downloads/cap%20m8.pdf http://www.mdcnigeria.org/downloads/cap%20m8.pdf https://doi.org/10.12968/hmed.2009.70.12.45510 https://doi.org/10.12968/hmed.2009.70.12.45510 https://doi.org/10.1111/j.1365 2923.1984.tb01024.x https://doi.org/10.1046/j.1365-2923.2000.00607.x https://doi.org/10.1007/s40037-012-0002-7 https://doi.org/10.1007/s40037-012-0002-7 https://doi.org/10.4103/1119-3077.127576 https://doi.org/10.4103%2f0300-1652.122330 https://doi.org/10.4103%2f0300-1652.122330 https://doi.org/10.1097/ceh.0000000000000117 https://doi.org/10.1097/ceh.0000000000000117 https://doi.org/10.1111/j.1365-2929.2007.02730.x https://doi.org/10.1186/s12909-015-0398-y https://doi.org/10.1046/j.1365-2923.2002.01152.x https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3074823/ https://doi.org/10.1111/j.1365-2929.2004.01811.x https://doi.org/10.1007/s13312-015-0565-6 https://doi.org/10.1111/j.1365-2923.2007.02931.x http://seajme.md.chula.ac.th/articlevol4no1/mededp1_mark%20barrow.pdf http://seajme.md.chula.ac.th/articlevol4no1/mededp1_mark%20barrow.pdf article 3 december 2010, vol. 2, no. 2 ajhpe introduction the number of older adults (oas) is increasing worldwide, and as the life expectancy in developing countries improves their populations will grow faster than in developed countries. worldwide there are approximately 600 million oas, of whom 370 million (60%) live in developing countries. by 2050, this proportion is estimated to increase to 80%.1 in uganda, the population of oas (people ≥65 years) was estimated at 5% of the country’s population of 30 million in 2002.2 this has been brought about by the increase in life expectancy from 46.5 years to 48.1 years to the current 51 52 years for men and women, respectively.3 although the current life expectancy in uganda is still below 65 years, projections indicate that in the next five decades the number of oas and therefore potential geriatric patients in uganda will be nine times greater than currently.2 the demographic transition from a young to an older population is usually accompanied by increased prevalence of chronic diseases, both physical and psychological.4,5 reports from developed countries show that as people become older, they experience more chronic and multiple health problems due to lowered immunity, existing medical conditions and difficulty in accessing health care services.6 other risks include accidents such as falls and fractures.7 the increased risk of health problems is also associated with an increased risk of disability among oas. in uganda, 40% of oas have a disability and as a group they are among those most affected by poverty, malaria, hiv/aids, poor housing, malnutrition, and poor access to health care and water.8,9 the two trends of increasing numbers of oas and increased chronic health problems or disability are enormous challenges to health care systems, health professional training institutions and policy makers who are required to meet the changing and complex needs of oas. the response to the challenges has generally been minimal because in developing countries the focus is mostly on infectious diseases, paediatrics and maternal health, and most curricula to train and educate health professionals currently do not include geriatrics.1 as a result most health professionals are not formally trained to address health care problems specific to oas.10 training in geriatrics (scientific study of the effects of ageing and age-related diseases on humans, including the biological, physiological, psychosocial, and spiritual aspects of ageing) is essential to address the health care needs of oas. lack of geriatric knowledge and skills has significant implications for health care providers (hcps) working in rural areas of developing countries because this is where most aos live. additionally, these areas are characterised by poor access to health care services and a wide gap between the health care needs of oas and treatment skills of hcps who serve them.11 some of the strategies suggested to address the lack of geriatric skills among hcps include integration of geriatric content in training curricula and geriatrics continuing education programmes.11,12 however, before undertaking curricula revisions or continuing education programmes it is important to establish existing geriatric knowledge and attitudes of currently practising hcps. negative attitudes towards oas are one of the critical factors that impede provision of proper health care by health professionals.12 abstract population trends in developing countries show an increasing population of older adults (oas), especially in rural areas. the purpose of this study was to explore the geriatrics continuing education needs of health care providers (hcps) working in rural uganda. the study employed a descriptive design to collect data from hcps working in apac district, a rural district in northern uganda. the 240 hcps (mean age 33.8±10.5 years) from whom data were collected were nurses (52%), physician assistants (17%), social workers (12%), laboratory technologists (10%) and physicians (10%). self-administered questionnaires composed of the palmore’s facts on aging quiz (faq1) and kogan’s attitude towards old people (kaop) scale were used for data collection. results. most hcps (63%) regularly cared for oas but their professional education did not include geriatric-specific courses (69%). the majority of hcps had a poor or fair geriatric knowledge (88%) (faq1 mean score 11.6±2.3), but had a positive attitude towards oas (80%) (koap mean score 115.9±11.5). positive attitude was associated with personal experiences with oas and a desire for a future career in geriatrics (p≤0.05). conclusion. in uganda training curricula for health professionals have not evolved to address the changing demographic trends showing increasing numbers of oas. consequently, there is a significant knowledge gap in certain aspects of health care, such as geriatrics, among currently practising hcps. there is need for tailored geriatrics continuing education programmes to bridge the knowledge and skill gaps to ensure quality health care for oas. continuing education in geriatrics for rural health care providers in uganda: a needs assessment mary ajwang, bsn, rn nursing officer, continuing professional development, mulago national referral and teaching hospital, uganda joshua k muliira, dnp, msn, ma, bsn, rn lecturer of nursing and geriatric nurse practitioner, department of nursing, college of health sciences, makerere university, kampala, uganda ziadah nankinga, msc, bsn, rn lecturer of nursing and clinical epidemiology, department of nursing, college of health sciences, makerere university, kampala, uganda correspondence to: j k muliira (jkmuliira@gmail.com) article article 4 december 2010, vol. 2, no. 2 ajhpe oas in developing countries are at a disadvantage because as urbanisation and modernisation set in they become more socially isolated and economically vulnerable.13 in developed countries other concerns such as abuse and neglect have also been highlighted as major problems, with health implications among oas.14 a combination of diminished vitality due to ageing, increased risk of poor health, and social and economic deprivation means that when oas seek health care they present with more than one health problem. therefore, if hcps are not specifically trained in caring for geriatric patients, they are bound to face a major challenge and eventually provide inadequate care.15 the unique characteristics and health care needs of oas have to be specifically addressed to optimise health outcomes and quality of life.16 therefore, to achieve optimal health and quality of life for oas, the hcps must be knowledgeable and skilled in geriatrics.17 in several countries geriatrics or gerontological content is not emphasised in entry-level training programmes for health professionals,18 and this gap in the curricula can lead to negative attitudes towards ageing and geriatrics by hcps.19 the attitudes of hcps are important because unfavourable attitudes hinder delivery of quality health care.20 studies of students in health care disciplines, such as physiotherapy, have also shown that they often lack geriatric knowledge and require planned learning opportunities to develop positive attitudes towards oas.21 training in geriatrics has also been shown to be the most effective approach to changing hcps attitudes towards oas.22,23 the purpose of this study was to explore geriatrics continuing education needs of hcps working in rural areas of uganda. study setting the study was conducted among hcps working in rural health facilities in apac, a rural district in northern uganda. the two health facilities (apac hospital and aduku health center) are both in apac district. according to uganda’s 2002 population census, apac district is estimated to have a population of 12 400. apac hospital, the only hospital in the district, is staffed by 264 health professionals (nurses, physicians, physician assistants, social workers, laboratory technologists, dentists, dental assistants, physiotherapists and occupational therapists), and has a capacity of 120 beds. aduku health center is a 50-bed facility located 25 miles from apac hospital and is staffed by 48 health professionals, including physicians, nurses, laboratory technologists, optometrists and dental assistants. the health centre provides mostly primary care services and in-patient care for patients with uncomplicated conditions. apac hospital and aduku health center were selected because they are the largest health facilities in the district and regularly receive geriatric patients, both as in-patients and out-patients. methods a descriptive quantitative design was used to explore the need for geriatrics continuing education among hcps working in rural health facilities. after obtaining approval from the institutional review board of the college of health sciences at makerere university, meetings were held with administrators of apac hospital and aduku health center. at the two facilities the study was publicised and advertised on notice boards, by word of mouth, and during meetings a week before data collection. to participate in the study, participants had to be qualified health professionals registered by their relevant professional bodies, legally employed by the health facility, directly involved in patient care and not currently a student in any health profession training institution or programme. a convenience sampling technique was used to access the 257 participants in apac hospital and 48 participants at aduku health center. the investigators went to each clinical unit or ward in the two facilities during day, evening and night shifts to explain the study purpose to hcps on duty. the hcps were approached during their shift break in the break room. those who agreed to participate in the study signed a consent form before they were given self-administered questionnaires in english, the official language in uganda. participants were given 2 hours to complete the questionnaire and to drop it off in the receiving box in the break room or lobby of the unit. data were collected over 3 weeks in april 2010. of the 305 participants who consented and received a self-administered questionnaire at the two facilities, 240 returned the completed form at the designated centres. therefore the response rate for this study was 79%. instruments the self-administered questionnaire used for data collection had four sections, i.e. demographic characteristics, experiences with oas, geriatric knowledge and geriatric attitude. in this study the need for geriatrics continuing education was determined by measuring rural hcps’ geriatric knowledge and attitude towards oas. the section on experience with oas generated data about prior personal and clinical experiences with oas and was comprised of items such as: ‘have you ever lived with a relative of age 65 years and above?’; ‘how often do you take care of patients older than 65 years?’; ‘how comfortable are you with the knowledge and skills required to take care of oas?’ living with a relative of age 65 years and above was emphasised because such experience gives a person close interaction with oas, and an understanding of lifestyles and the social aspects of ageing. the section on geriatric knowledge was composed of a standardised scale called the palmore’s facts on aging quiz (faq1). the faq1 was developed by erdman palmore in 197724 and has been found to be a reliable measure of geriatric knowledge in a variety of cultures.25 the faq1 has reliability values ranging from cronbach’s alpha of 0.66 0.68 and content validity of up to 0.82.26,27 the faq1 is composed of 25 statements focusing on different aspects of ageing and oas. the participants responded by stating whether a statement is true (t) or false (f). the faq1 include statements such as: ‘old people tend to react slower than young people’; and ‘lung vital capacity tends to decline with old age’. the statements that are answered correctly are assigned a score of 1 and the wrong ones a score of 0. the final scores for each participant are interpreted as follows: poor knowledge for scores of less than 10; fair knowledge for scores of 10 14; good knowledge for scores of 15 19; very good knowledge for scores of 20 24; and excellent knowledge for scores of 25. the section on attitude towards oas was composed of the kogan’s attitude towards old people (koap) scale. the koap measures attitude towards geriatric patients and has been used in several studies.28 the reliability of the koap has been reported at cronbach’s alpha ranging from 0.79 to 0.82.29,30 the koap is a 34-item tool with a 6-point likert scale (strongly disagree = 1, disagree = 2, slightly disagree = 3, slightly agree = 5, and strongly agree = 6). the tool contains 17 positively rated and 17 negatively rated statements about oas. for instance, the participants responded to items such as: ‘most oas get set in their ways and are unable to change’; and ‘most oas tend to let their homes become shabby and unattractive’. the range of scores for the koap is from 34 to 204, with higher scores representing positive attitude. the participants’ scores on the koap are categorised as: poor attitude for a score of less than 103; neutral attitude for a score of 104; and positive attitude for scores greater than 105. the two standardised scales (koap and faq1) are tested and proven measures that have been used in several cultures, and when closely examined by the researchers their items were found to be culturally neutral and focused on general aspects of ageing and oas. the details of the two scales are published in other studies.24-30 article 5 december 2010, vol. 2, no. 2 ajhpe although this is the first time the koap and faq1 are being used in uganda, considering the above characteristics and that they were to be used to collect data from english-speaking participants, pilot testing was done on only six hcps working in another rural health centre (nurse, doctor, dental assistant, social worker, laboratory technologist and dentist). the results of the pilot testing showed that the questionnaire was understandable, with no cultural biases or ambiguities, and required on average 60 minutes to complete because the hcp stayed on the ward/unit performing other routine duties. results demographic characteristics of participants the sample was composed of 240 participants representing five different health professions. as shown in table i, 51% of participants were male, and 43% qualified with associate degrees and 42% with professional certificate-level education. the mean (+sd) age and years of clinical experience for the sample was 32 (±10.5) and 4 (±1.9) years, respectively. participants’ experience with oas during professional practice as shown in table ii, most participants had lived with a relative of age 65 years or older (85%), and during clinical practice they took care of oas every day or regularly (63%). when participants were asked to list the five most common health problems among oas, they reported depression (58%), hypertension and cardiovascular diseases (54%), diabetes (38%), arthritis (28%) and dementia (28%). most participants (71%) agreed that they needed training in geriatrics to provide better care to oas. table i. demographic characteristics of participants variable frequency (n=240) percentage (%) gender male 122 (50.8) female 118 (49.2) age (yrs) (m=33.8, sd=10.5) 20 30 132 (55.0) 31 40 54 (22.5) 41 50 32 (13.3) 51 60 20 (8.4) ≥60 2 (0.8) profession of health care provider doctor or physician 24 (10.0) nurse 124 (51.7) laboratory technologist 24 (10.0) physician assistant 40 (16.7) social worker 28 (11.7) years of clinical experience (m=4.0, sd=1.9) <1 20 (8.3) 1 3 92 (38.3) 4 5 34 (14.2) ≥5 94 (39.2) level of education certificate 100 (41.7) diploma level or associate degree 104 (43.3) bachelor’s degree 30 (12.5) master’s degree 6 (2.5) table ii. participants’ personal and professional experience with oas variable frequency (n=240) percentage (%) experience with oas in personal life has ever lived with a relative of ≥65 years 204 (85.0) has never lived with a relative of ≥65 years 36 (15.0) takes care of patients of ≥65 years during clinical practice every day 64 (26.7) regularly 88 (36.7) rarely 76 (31.6) not at all 12 (5.0) five most common health conditions seen among patients of ≥65 years (multiple responses from health care providers) hypertension and other heart diseases 130 (54.2) diabetes mellitus 90 (37.5) arthritis 68 (28.3) dementia 68 (28.3) cataracts 36 (15.0) deafness 10 (4.2) depression 140 (58.3) fractures 16 (6.7) cancer 44 (22.0) benign prostatic hyperplasia 24 (10.0) i need special training in geriatrics to provide better care strongly agree 50 (20.8) agree 120 (50.0) neutral 46 (19.2) disagree 18 (7.5) strongly disagree 6 (2.5) article article 6 december 2010, vol. 2, no. 2 ajhpe participants’ geriatric knowledge the knowledge of participants about geriatrics and care of oas was measured using the faq1. results presented in fig. 1 and table iii show that most participants (88%) scored below 14. the majority of hcps (69%) were in the score range of 10 14, while others (19%) had scores of less than 10, representing fair and poor geriatric knowledge, respectively. the mean score for the sample on the faq1 was 11.6 (±2.3), which indicates poor knowledge. results in table iii also show that the majority of participants (69%) reported that they were educated and trained on curricula that did not include geriatric-specific content or courses. however, despite the poor scores on the faq1 and lack of formal professional education focusing on geriatrics, some participants felt very confident (26%) or somewhat confident (46%) about their geriatric skills and knowledge levels. participants’ attitude towards oas the attitude of rural hcps towards oas was measured using the koap and results in table iii show that a significant percentage (80%) of partici pants attained scores representing a positive attitude. the highest score attained by participants was 145 out of 170 and the mean for the sample score was 115.9 (±11.5). results in table iv highlight some of the factors associated with hcps’ attitude towards oas. the findings show that a positive attitude towards oas is significantly associated with having lived with an oa relative (r=0.207, p≤0.05), desire for a future career in geriatrics (r=0.206, p≤0.05) and feeling comfortable with current geriatric knowledge and skills (r=0.207, p≤0.05). on the other hand, as years of clinical experience increase among rural hcps their participation in caring for oas diminishes (r=-0.416, p≤ 0.01) and the desire for a career in geriatrics depreciates (r=-0.286, p≤0.01). these factors are important to consider when planning implementation of tailored geriatrics continuing education programmes for rural hcps. hcps’ geriatric knowledge was not significantly associated with any factors. discussion the participants in this study were mostly mid-career health professionals as indicated by the mean age (33.8±10.5 years) and years of clinical experience (4±1.9 years). the findings show that they had very good personal and professional experience with oas, and therefore were able to identify the common medical problems that affect oas. the common health problems identified, such as hypertension and heart diseases, diatable iii. geriatric knowledge and attitudes of rural health care providers in uganda variable frequency (n=120) percentage (%) underwent professional training curriculum that included geriatric-specific courses yes 60 (25.0) no 166 (69.0) don’t remember 14 (6.0) confident about knowledge and skills necessary for quality care of geriatric patients very confident 62 (25.8) somewhat confident 102 (42.5) not confident 76 (31.7) definition of a person considered an oa person of ≥45 years 20 (8.3) person of ≥50 years 38 (15.8) person of ≥65 yars 128 (53.3) person of ≥75 years 54 (25.5) health care providers’ knowledge about geriatric care as measured by faq1 (m=11.6, sd=2.3) poor knowledge (score of <10) 46 (19.2) fair knowledge (scores = 10 14) 166 (69.1) good knowledge (scores = 15 19) 28 (11.7) health care providers’ attitudes towards oas as measured by kogan’s attitude towards old people (koap) scale (m=115.9, sd=11.5) 91 99 14 (5.8) 100 109 66 (27.5) 110 119 68 (28.4) 120 129 64 (26.6) 130 139 26 (10.9) ≥145 2 (0.8) categorisation of participants’ attitudes poor attitude (koap score <103) 36 (15.0) neutral attitude (koap score = 104) 12 (5.0) positive attitude (koap score ≥105) 192 (80.0) fig. 1. bar graph showing distribution of participants by scores on the faq1. article 7 december 2010, vol. 2, no. 2 ajhpe betes mellitus, arthritis, dementia, cataracts, deafness, cancer, and benign prostatic hyperplasia, are all chronic and, without adequate care, may lead to other chronic complications and disability. when complications and disability occur there is a need for interdisciplinary teams of hcps who are knowledgeable and skilled in geriatrics to provide quality health care. similar health problems are common among oas in kenya and the rest of sub-saharan africa.31,32 currently, good health care for oas living in rural uganda is difficult to achieve because, as shown by the findings of this study, the majority of hcps who take care of oas have a poor or fair geriatric knowledge and were educated on curricula that did not include geriatric content. however, the future is promising because most hcps recognise their geriatric knowledge and skills deficits and are interested in attaining special training in geriatrics to provide better care to oas. the lack of geriatric knowledge and skills is not unique to hcps in uganda. other studies in countries such as australia and saudi arabia show that hcps in rural settings commonly have significant deficits in geriatric knowledge and skills.33,34 the geriatric knowledge and skills deficits have been mostly blamed on lack of geriatric content in curricula to train and educate health professionals before they enter into professional practice. the response to this problem has been mainly inclusion of geriatric content in training curricula for future health professionals. although this is important in ensuring geriatric competencies of future health professionals, it is a partial response to the problem and only caters for the geriatric knowledge and skills of those who are yet to join professional practice, and neglects the needs of those who are already in clinical practice. in this study we have been able to emphasise the extent of the geriatric knowledge and skills gaps of hcps working in a rural health facility in uganda. these results will be used to inform the planning and implementation of a pilot programme to enhance geriatric competencies through a tailored continuing education programme. the costs and details will be developed by a team of local and international experts in geriatrics and continuing education for health professionals. however, even before implementation of the pilot programme, in this study there are significant results which show that the continuing education programme has a very good chance of being successful. for instance, the majority of rural hcps had a positive attitude towards oas. this study also revealed that in rural areas of developing countries like uganda there are still some competent health professionals with good clinical experience (mid-career) who can be trained through continuing education to improve their care of geriatric patients. the viability of a continuing education programme in geriatrics is also further enhanced by the fact that most of the participants had personal experiences with oas. this is very important, especially for adult learners, because it facilitates easy understanding of psychosocial problems of oas. the other geriatric competencies commonly recommended for all health care disciplines include understanding age-related changes, risk assessment and health promotion, and mental, physical, affective, psychosocial and environmental aspects of health problems experienced by oas.12 all these aspects are easier to understand when you have lived with and later alone taken care of oas.35,36 another general but important lesson from this study is that as years of clinical experience increase, hcps become less interested in geriatrics as a specialty and are less likely to be working in clinical units where oas are admitted. this finding suggests a need for balance when recruiting participants in continuing education programmes in geriatrics to ensure that there is good representation of junior to mid-career hcps. the factors highlighted above and the other findings of this study provide some baseline information on which to build a continuing education programme in geriatrics in a country where there are no data on geriatric competencies and where geriatrics has not yet been introduced as a specialty. in the immediate term a tailored continuing education programme in geriatrics is the most cost-effective approach to ensuring knowledge and skills acquisition by rural hcps, because they are able to enhance their competencies without leaving the work station. this point is especially important in uganda and other sub-saharan countries which are currently experiencing shortages and migration of hcps to developed countries. limitations the sample for this study was recruited using a convenience sampling technique from a rural district in uganda which is mostly settled by people with limited incomes. this decision was taken because the current study was undertaken as a baseline assessment in preparation for the implementation of the pilot continuing education programme. therefore, as the results are based on a sample obtained from a specific setting, the findings have limited generalisability. however, despite its limitations, this study is the first to focus on geriatrics and health professionals in uganda and it highlights the gaps in geriatric knowledge and skills among rural hcps. furthermore, the results of this study have the potential to stimulate debate about curriculum revision in health professional training institutions to address the geriatric knowledge and skills gaps in preparation for the changing health care needs of the population of uganda and other countries with similar characteristics. table iv. factors associated with participants’ attitude towards oas factor (n=240) atoas lived care gero comf exp attitude towards older adults (atoas) 1 ever lived with relative of ≥65 years (lived) 0.207* 1 cares for patients ≥65 years (care) 0.058 0.302† 1 would like a future career in geriatrics (gero) 0.206* 0.205* 0.430† 1 comfortable with current geriatric knowledge and skills (comf) 0.207* 0.287† 0.286† -0.059 1 years of clinical experience (exp) 0.114 -0.206* 0.416† -0.286† -0.149 1 * correlation is significant at the 0.05 level (2-tailed). † correlation is significant at the 0.01 level (2-tailed). article 8 december 2010, vol. 2, no. 2 ajhpe conclusion hcps working in the rural apac district of uganda have deficits in geriatric knowledge and skills, and underwent professional training that did not emphasise geriatrics. the hcps recognise this knowledge and skills gap and voiced a need for tailored continuing education programmes to be able to provide quality health care to oas. the challenge of enhancing geriatric knowledge and skills may be easier to address, as most hcps have positive attitudes, and professional and personal experiences with oas, and are interested in attaining geriatric-related knowledge and skills. to ensure quality health care and health outcomes for aos in rural areas of developing countries there is a need to address the geriatric knowledge and skills gap of practising hcps, and one of the most cost-effective strategies that can be used to achieve this goal is tailored continuing education programmes in geriatrics. references 1. united nations population division. world population report 2009. available at www.unpopulation.org (accessed 10 march 2009). 2. uganda population census report 2002. kampala: uganda bureau of statistics, 2002. 3. uganda demographic and health survey (udhs). the uganda demographic and health survey report 2006. kampala: uganda bureau of statistics, 2006. 4. weiss co, boyd cm, wolff jl, leff b. patterns of prevalent major chronic disease among older adults in the united states. jama 2007;298:1160-1162. 5. schoenberg en, kim h, edwards w, fleming st. burden of common multiplemorbidity constellation on out-of-pocket medical expenditures among older adults. gerontologist 2007;47(4):432-437. 6. van sant c. preparing your office and team for the care of geriatric patients. dent today 2009;5(2):86-89. 7. vu qm, weintraub n, rubenstein zl. falls in the nursing home: are they preventable? j am med dir assoc 2006;7(3):53-58. 8. nankwanga a, philips j, neema s. exploring and curbing the effects of hiv/ aids on elderly people in uganda. j comm & health sci 2009;4(2):19-30. 9. nkoyoyo ml. poverty and the elderly in uganda: cause and effect. global action on aging, 1995. 10. burbank m, dowling-castronovo a, crowther r, capezuli e. improving knowledge and attitude toward older adults through innovative educational strategies. j prof nurs 2006;22(2):91-97. 11. toner ja, ferguson kd, sokal rd. continuing interprofessional education in geriatrics and gerontology in medically underserved areas. j contin educ health prof 2009;29(3):157-160. 12. mezy m, mitty e, burger sg, mccallion p. healthcare professional training: a comparison of geriatric competencies. j am geriatr soc 2008;56(9):1724-1729. 13. king sv. introduction to the journal of cross-cultural gerontology, special issue on aging and social change in africa. j cross cult gerontol 2008;23(2):107-110. 14. lee a, wong a, loh e. score in the palmore’s aging quiz, knowledge of community resources and working preferences of undergraduate nursing students toward the elderly in hong kong. nurs educ today 2006;26(4):269-276. 15. kumar v. aging in india -an overview. indian j med res 1997:106:257-264. 16. halphen jm, varas gm, sadowsky jm. recognizing and reporting elder abuse neglect. geriatrics 2009;64(7):13-18. 17. karlamangla a, tinetti m, guralnik j, studenski s, wetle t, reuben d. comorbidity in older adults: nosology of impairment, diseases and conditions. j gerontol a biol sci med sci 2007;62(3): 296-300. 18. fuhram mp. home care for the elderly. nutr clin pract 2009;24(2):196-205. 19. miller ek, zylstr gr, standridge bj. the geriatric patient: a systematic approach to maintaining health. am fam physician 2000;61(4):1-5. 20. unwin kb, unwin gc, olsen c, wilson c. a new-look at an old quiz: palmore’s facts on aging quiz turns 30. j am geriatr soc 2008;56(11):2162-2164. 21. hobbs c, dean cm, higgs j, adamson b. physiotherapy students’ attitudes towards and knowledge of older people. aust j physiother 2006;52(8):25-28. 22. ryan m, mccauley d. we built it and they did not come: knowledge and attitude of baccalaureate nursing students toward the elderly. j ny state nurses assoc 2004;35(2):5-9. 23. glaister aj, blair c. improved education and training for nursing assistants: keys to promoting the mental health of nursing home residents. issues ment health nurs 2008;29(8):863-872. 24. mezey m, mittly e, burger gs, mccallion p. health care professional training: a comparison of geriatric competencies. j am geriatr soc 2008;56(9):1724-1729. 25. seufert lr, carrozza am. a test of palmore’s facts on aging quizzes as alternate measures. j aging stud 2002;16(3):279-294. 26. norris e, tindale a, matthews ma.the factor structure of the facts on aging quiz. gerontologist 1987;27(5):673-676. 27. duerson mc, thomas wj, chang j, benjamin c. medical students’ knowledge and misconceptions about aging: responses to palmore’s facts on aging quizzes. gerontologist 1992;32(2):171-174. 28. cheng-ching w, wen-chun l, pi-chao k, et al. the chinese version of the facts on aging quiz scale: reliability and validity assessment. int j nurs stud 2010;47(6):742-752. 29. kearney n, miller m, smith k.oncology health care professionals’ attitudes toward older people. ann oncol 2000;11(2):599-601. 30. soderham o, gustavsson sm, lindencrona c. reliability and validity of a swedish version of kogan’s old people’s scale. scand j caring sci 2000;14(4): 211-215. 31. chi-hua y, wen-chun l, yu-ru c, min-chen k, meng-chih l, cheng-ching w. a chinese version of kogan’s attitude toward older people scale: reliability and validity assessment. int j nurs stud 2009;46(1):38-44. 32. waweru ml, kabiru ew, mbithi jn, some es. health status and health seeking behaviors of the elderly persons in dagoretti division, nairobi. east afr med j 2003;80(2):63-67. 33. nordberg e. health and the elderly in developing countries with special reference to sub-saharan africa. east afr med j 1997;74(10):629-633. 34. mellor p, chew d, greenhill j. nurse’s attitudes towards elderly people and knowledge of gerontic care in a multi-purpose health service. aust j adv nurs 2007;24(3):37-41. 35. cankurtaran m, halil m, ulger z, et al. influence of medical education on student’s attitudes towards the elderly. j natl med assoc 2006;98(9):1518-1522. 36. fitzgerald tj, wray al, halter bj, williams cb, supiano a. relating medical students’ knowledge, attitudes and experience to an interest in geriatric medicine. gerontologist 2003;43:849-855. a maximum of 3 ceus will be awarded per correctly completed test. december 2017, vol. 9, no. 4 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/170/02/2017 (clinical) cpd questionnaire december 2017 true (a) or false (b): selfies 2015: peer teaching in medical sciences through video clips – a case study 1. the purpose of the class activity described in this study was to integrate the hard and soft skills, a requirement of most curricula. the use of low-cost simulation in a resource-constrained teaching environment 2. the literature suggests that the high cost of simulation models and the lack of organisational initiatives are possible reasons for the low usage of simulation in surgical training. implementing the angoff method of standard setting using postgraduate students: practical and affordable in resource-limited settings 3. the angoff method of setting cut scores typically requires minimal resources and few well-qualified experts in the test domain. 4. to avoid the bias that emerged in similar studies, the researchers in this study chose not to provide correct answers to the judges before the scoring exercises. medical students’ perspectives on the anatomy course at the university of zimbabwe 5. student-led learning of anatomy has been emphasised as a method to overcome the labourand resource-intensive pitfalls of the traditional didactic training and practical cadaver dissection. 6. the results of the study showed that lectures had a poor fit with teaching aims related to content base. clinical undergraduate medical student training at kimberley hospital, northern cape, south africa: ‘a test of fire’ 7. expansion of the clinical training programme has no impact on clinicians’ health service delivery responsibilities. 8. specialists who participated in this study considered good teaching to entail the appropriate skills, knowledge and attitudes. designing interprofessional modules for undergraduate healthcare learners 9. traditionally, undergraduate medical education has offered many opportunities for exposure to teamwork between healthcare professionals. 10. the steps involved in the development of interprofessional modules described in this article included: knowledge enquiry (identify problem), synthesis (review knowledge), and product tools (adapt knowledge to local context). learning outcomes of occupational therapy and physiotherapy students during their community-based education (cbe) attachment 11. the goals of cbe ultimately increase health professionals’ willingness to work in underserved areas. 12. the unavailability of supervisors during cbe activities has been frequently cited as a challenge hindering effective learning during attachments. experiences of south african student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery 13. difficulties in recruitment, poor support and financial constraints were reported to be some of the main challenges associated with the followup experience. 14. based on the literature, it is unclear whether follow-up experiences result in any new learning. self-leadership traits of academics to conform to a changing highereducation environment 15. self-leadership of academics fundamentally refers to being driven by motivation and self-influence to direct oneself towards achieving optimum performance in a situation. 16. factors such as relationships with peers and peer support are not considered to have any influence on leadership. clinical  electives at the university of michigan from the perspective of ghanaian medical students: a qualitative study 17. most international electives are skewed towards students from the lowincome nations to resource-rich countries. 18. a common theme that emerged was ‘translation’ and included paying more attention to infection control, improving ‘system factors’, and being more empathetic towards patients. factors that enable and constrain the internationalisation and africanisation of master of public health programmes in south african higher education institutions 19. with the increasing internationalisation and globalisation, endeavours to establish and maintain an african character of higher education in south africa are irrelevant. 20. according to the respondents in this study, there is no clear understanding of or working definition for concepts and processes such as internationalisation and africanisation as they apply to their professional contexts. editorial 91 strengthening health professions education and training: the power of evidence-based approaches g mubuuke short communication 92 health sciences students’ contribution to human resources for health strategy: a rural health careers day for grade 12 learners in the north west province of south africa n o mapukata, i d couper, a r dreyer, m mlambo short research report 94 a quick needs assessment of key stakeholder groups on the role of family medicine in zambia j sanders, m makasa, f goma, e kafumukache, m s ngoma, s nzala research 98 registrar wellness in botswana: measuring burnout and identifying ways to improve wellness k d westmoreland, e d lowenthal, r finalle, l mazhani, m cox, j c mwita, s b mphele, c e turner, a p steenhoff 103 assessment of the educational environment of physiotherapy students at the university of rwanda using the dundee ready educational environment measure (dreem) g urimubenshi, j songa, f kandekwe 107 standardised patient-simulated practice learning: a rich pedagogical environment for psychiatric nursing education a jacobs, i venter 111 understanding student early departure from a master of public health programme in south africa t dlungwane, a voce, r searle, j wassermann 116 postgraduate trainees’ perceptions of the learning environment in a nigerian teaching hospital p i idon, i k suleiman, h o olasoji, z mustapha, h m abba 123 radiation safety requirements for training of users of diagnostic x-ray equipment in south africa b van der merwe, s b kruger, m m nel 128 training requirements for the administration of intravenous contrast media by radiographers: radiologists’ perspective g g v koch, l d swindon, j d pillay 133 perceptions of the impact of an advanced training programme on the management skills of health professionals in gauteng, south africa j mutyabule, f senkubuge, d cameron, v pillay, p petrucka 138 a peer evaluation of the community-based education programme for medical students at the university of zimbabwe college of health sciences: a southern african medical education partnership initiative (mepi) collaboration d michaels, i couper, m s mogodi, j g hakim, z talib, m h mipando, m m chidzonga, a matsika, m simuyemba ajhpe african journal of health professions education september 2017, vol. 9, no. 3 editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens dtp & design clinton griffin travis arendse chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, mrs h kikaya, dr m mbokota, dr g wolvaardt issn 2078-5127 144 fifth-year medical students’ perspectives on rural training in botswana: a qualitative approach p kebaabetswe, t arscott-mills, k sebina, m b kebaetse, o makgabana-dintwa, l mokgatlhe, g tawana, d o mbuka, o nkomazana 148 quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-cex assessment form r m djajadi, m claramita, g r rahayu 153 upskilling nursing students and nurse practitioners to initiate and manage patients on art: an outcome evaluation of the ukzn nimart course r mngqibisa, m muzigaba, b p ncama, s pillay, n nadesan-reddy cpd questionnaire ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za 211 october 2016, vol. 8, no. 2 ajhpe cuban medical collaborations: contextual and clinical challenges 1. with its strong emphasis on primary healthcare, the results of the study show that the cuban medical curriculum was adequately preparing students for the south african context. remembering old partnerships: networking as new medical schools within boleswa countries 2. prior to the establishment of the university of botswana school of medicine, botswana had been placing students in more than 15 of their partner medical schools. tracking master of public health graduates: linking higher education and the labour market 3. as elsewhere in africa, this study showed that public health graduates were mostly medical doctors. research supervision: perceptions of postgraduate nursing students at a higher education institution in kwazulu-natal, south africa 4. the literature shows a very weak association between the quality of supervision and the capacity of academic staff. the electrocardiogram made (really) easy: using small-group tutorials to teach electrocardiogram interpretation to final-year medical students 5. the need for an earlier introduction and more tutorials on electrocardiogram interpretation was one of the major findings of the study. effect of bedside teaching activities on patients’ experiences at an ethiopian hospital 6. confidentiality was not raised as a concern by the patients included in this study. student feedback on an adapted appraisal model in resource-limited settings 7. approximately half of the students who participated in the study felt uncomfortable talking about their personal problems with their appraiser. the noma track module on nutrition, human rights and governance: part 1. perceptions held by master’s students 8. a highlight of the module for students was the opportunity to learn about the background to international rights in norway. the noma track module on nutrition, human rights and governance: part 2. a transnational curriculum using a human rights-based approach to foster key competencies in nutrition professionals 9. the principles of the human rights-based approach emphasise participation, transparency, sustainability, and comprehensiveness. professional nurses’ perception of their clinical teaching role at a rural hospital in lesotho 10. the findings of this study demonstrate that skills development, critical thinking and clinical judgement in the clinical environment are important tasks that require training. allied health professional rural education: stellenbosch university learners’ experiences 11. context, educators, and time were identified as the three core themes of professional education curricula. self-assessment of final-year undergraduate physiotherapy students’ literature-searching behaviour, self-perceived knowledge of their own critical appraisal skills and evidence-based practice beliefs 12. inadequate access to the internet and to medical literature was noted as a challenge by the students in this study. the usefulness of a tool to assess reflection in a service-learning experience 13. petersen and osman (2013), cited in this article, suggest that reflection should start on a dialectical level and move towards a contextual holistic view of the situation. multidisciplinary leadership training for undergraduate health science students may improve ugandan healthcare 14. students who participated in the multidisciplinary leadership training programme showed minimal improvement in the competencies examined. exploring occupational therapy graduates’ conceptualisations of occupational justice in practice: curriculum implications 15. the challenges reported by the participants in the study concur with those identified by occupational therapists who practise in rural contexts and settings where the biomedical model dominates. burnout among paramedic students at a university in johannesburg, south africa 16. the prevalence of burnout among the cohort of students in this study was greater than that found in studies on medical students. registrars teaching undergraduate medical students: a pilot study at the university of pretoria, south africa 17. a review study quoted in this article reported that 20% of a registrar’s time is spent on teaching undergraduate medical students. an inferential comparison between the capabilities and achievements of 1st-year medical and nursing students at the university of the free state, bloemfontein, south africa 18. the three main stressors identified by the authors of the study were academic stressors, clinical stressors and personal/social stressors. developing social accountability in 1st-year medical students: a case study from the nelson r mandela school of medicine, durban, south africa 19. the nature of the service activities that groups undertake in the making a difference programme is decided by the course convenor in consultation with the student groups. beyond the lecture: teaching for professional development 20. panel members who participated in this study felt that a teacher’s lack of knowledge can be used to motivate student learning. cpd questionnaire the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/175/02/2016 a maximum of 3 ceus will be awarded per correctly completed test. october 2016 true (a) or false (b): research 83 june 2017, vol. 9, no. 2 ajhpe the attitudes and behaviours of oral health service providers towards their own oral health practices could reflect their understanding of the importance of oral health-promotive procedures and, in turn, play a role in improving the oral health of the population.[1-2] dental undergraduate students are seen as role-models for good oral health behaviour among other university students, patients and the community at large.[3-5] these students are uniquely placed in the academic learning environment to motivate individuals and communities on optimal oral health self-care.[6] taylor et al.[7] further add that to provide students with more information regarding their own health, will allow them to learn more experientially about health parameters, as opposed to theoretical, textbook-based learning. there is little published research evidence in south africa (sa) to suggest that sufficient focus is placed on understanding undergraduate students’ perceptions and attitudes towards their own self-care practices. in this context, there is a need to describe dental therapy and oral hygiene students’ knowledge, attitudes and practices towards oral health self-care and the perceived influence of the dental curriculum on these practices. undergraduate training in prevention the oral disease profile, potential burden of oral diseases and oral consequences of health problems in sa suggest that interventions need to be addressed at various levels of care, such as promotion, prevention, and therapeutic and curative measures.[8] dental therapists and oral hygienists are an important cadre of oral health workers ideally placed to provide primary preventive and curative oral healthcare in urban and rural settings. to this effect, the university of kwazulu-natal, durban, sa has offered dental therapy and oral hygiene undergraduate training since the late 1970s. both these programmes have a strong emphasis on preventive primary oral healthcare, and students registered for these programmes have historically had the same theory and clinical exposure in prevention and oral health promotion. in terms of the university’s commitment to community upliftment, these programmes are marketed to increase access for students from historically disadvantaged and rural areas in kwazulunatal.[9] although the diploma in oral health was phased out in 2015, the new proposed bachelor’s degree in oral hygiene will continue to be closely aligned to the dental therapy degree in relation to teaching and learning with regard to prevention. the students in these programmes are introduced to preventive dentistry early in the 1st year through an engagement with classroom-based theoretical principles and concepts in prevention, followed by skills development on the phantom head in the dental preclinical laboratory. this knowledge acquisition and the skills are further built in the 2nd year, where the student is systematically introduced into the clinical and community environment. both training programmes are offered on a full-time basis. oral health self-care practices the measures for oral health self-care practices have evolved over time, but mechanical plaque control remains the primary method for controlling supra-gingival accumulations.[10] the most common method of mechanical plaque control is tooth brushing. for enamel caries prevention, the combination of fluoride dentifrice with other topical fluoride treatments has shown some possible additive effect, mainly in patients at high risk of caries.[11] tooth brushing alone, however, does not reach the interproximal areas of the dentition, leaving part of the dentition unclean. a wide variety background. dental students are seen as role-models for promoting good oral health behaviour, yet there is little published evidence in south africa (sa) that describes student knowledge and attitudes towards their own oral healthcare. objective. to investigate undergraduate dental therapy and oral hygiene students’ knowledge and attitudes towards their self-care practices and the perceived influence of the dental curriculum on these practices. methods. this was a descriptive survey of 64 undergraduate dental students at the university of kwazulu-natal, durban, sa. a self-administered questionnaire was used for data collection. results. fifty-two respondents returned the completed questionnaires, yielding an 81% response rate. almost all respondents (n=30; 96.8% (2nd-year students), and n=21; 100% (3rd-year students)) indicated the use of toothpaste and toothbrush to clean their teeth. most respondents reported cleaning their teeth from 1 to 5 minutes, with 52% (n=27) reporting 1 2 minutes and 42% (n=22) 3 5 minutes. only three respondents reported cleaning their teeth for >5 minutes (n=3; 6%). other practices included the use of toothpicks (n=12; 23%), dental floss (n=42; 81%), and interdental brushes (n=5; 10%). almost all respondents (n=50; 96%) indicated the use of commercially available mouth rinses. all 2nd-year students (n=30) and 90% of 3rd-year students (n=18) agreed that exposure to clinical training increased their awareness of self-care practices. conclusion. respondents reported good knowledge and practice of oral health self-care, but there were inconsistencies in these practices. respondents also agreed that the dental undergraduate curriculum did influence their knowledge and oral health self-care practices. afr j health professions educ 2017;9(2):83-87. doi:10.7196/ajhpe.2017.v9i2.800 dental undergraduate students’ knowledge, attitudes and practices in oral health self-care: a survey from a south african university s singh, boh, msc (dent), phd, postgrad dip health res ethics; s pottapinjara, b dent surg, mmed (dent) discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: s singh (singhshen@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research june 2017, vol. 9, no. 2 ajhpe 84 of interdental cleaning devices are available. as a method to remove interproximal biofilm (commonly known as dental plaque), flossing has received the most attention. it has been generally accepted that dental floss has a positive effect on removing dental biofilm.[12] the use of antimicrobial agents such as stannous fluoride and amine fluoride, tin, zinc and copper has demonstrated antimicrobial effects, but there is little evidence of demonstrated anticaries effectiveness. similarly, triclosan and essential oils (a mixture of thymol, eucalyptol, methyl salicylate and menthol) have demonstrated effectiveness in reducing plaque and gingivitis, but have also failed in reducing dental caries rates.[13,14] dental students are exposed to these various measures in oral health individual self-care practices in the undergraduate training programme. it would be interesting to note the extent to which the students are able to engage with these practices and the possible influence on their own self-care practices. methods this was a descriptive quantitative survey to determine undergraduate dental students’ knowledge and attitudes towards the use of dental biofilms and self-care practices in relation to their exposure to undergraduate learning in oral disease prevention. the total study population comprised 64 undergraduate dental therapy students in their 2nd and 3rd year of study, and oral hygiene students in their 2nd year of study, in the discipline of dentistry, university of kwazulu-natal. the study focused on these students because of their exposure to the clinical and community training environment. students in the 1st year of study were excluded because they are only exposed to preclinical laboratory-based training. the research instrument comprised a self-administered questionnaire that was based on a previously developed questionnaire by oberoi et al.[15] permission was obtained from the authors to use and adapt the questionnaire for this study. the questionnaire included 20 items designed to assess students’ oral health knowledge, attitudes and self-care practices. the first part of the questionnaire consisted of sociodemographic data, such as age, sex, year of study, knowledge of dental biofilms, and understanding of the relationship between oral health and general health. the second part of the questionnaire included variables, such as frequency of toothbrushing, interval for replacement of toothbrushes, and use of mouth rinses, dental floss and interdental aids. the questionnaire also included questions on dental visits, barriers in accessing dental care, and perceptions of selfreported dental health status. the last part of the questionnaire focused on the perceived impact or influence of the curriculum on self-care practices. a likert scale format with responses such as 1 (strongly agree), 2 (agree), 3 (not sure), 4 (disagree), and 5 (strongly disagree) was used to elicit respondents’ perceptions on whether the theory taught in the classroom, practical lessons in the laboratory, or exposure in the clinical/community environment were perceived to be contributing factors to self-oral hygiene practices. the questionnaire comprised openand closed-ended responses. the study was granted ethical clearance by the humanities and social sciences research ethics committee at the university of kwazulu-natal (ref. no. hss/1539/015).written informed consent was obtained from all participants. students were made aware that the study was voluntary and that participants were free to withdraw from the study at any stage, without any negative consequences. the questionnaire was administered in the english language after confirming that all the participants were comfortable with the language. all other ethical issues, such as confidentiality and anonymity, were maintained. data were analysed using spss version 23.0 (ibm corp., usa). univariate descriptive statistics, such as frequency and mean distribution, were conducted for all variables. the responses to the open-ended questions were grouped and emergent themes were examined and compared for possible associations. inferential techniques included pearson’s χ2 test to assess a possible relationship between the independent variables (age, sex, and year of study) and the dependent variables (toothbrushing frequency, and use of dental floss and mouth rinses). a p<0.05 level was established as being significant. results in total, 64 questionnaires were distributed among 2ndand 3rd-year dental therapy and 2nd-year oral hygiene students and 52 were returned, yielding an 81% response rate. the response rate was in proportion to the population total (i.e. 28 students in the 3rd year of study and 36 in the 2nd year, with a ratio of 2:3). the sample comprised 21 respondents in their 3rd year and 31 in their 2nd year. the majority of respondents from the 2nd year were female (n=26; 84%) compared with those in the 3rd year of study (n=11; 52%) (table 1). overall, the ratio of male to female was ~1:3 (28.8:71.2; p<0.01). the mean (standard deviation) age for 2nd-year and 3rd-year students was 20 and 21.6 (1.59) years, respectively. attitudes towards dental health forty-four respondents (84.6%) perceived their own dental health to be good (n=27; 87.1% (2nd-year students), and n=17; 81.0% (3rd-year students)). however, a third of respondents (n=18; 32.0%) indicated that their gingiva bled during dental flossing. all respondents (n=52) agreed that oral hygiene was important for the overall health of the body. knowledge of dental self-care practice respondents provided the following responses to their understanding of oral biofilms: a combination of bacteria, saliva and food debris that adheres to the tooth surface (n=24; 46.0%); accumulation of plaque (n=12; 23.0%); accumulation of debris caused by food and worsened by not brushing and flossing teeth (n=2; 4.0%). oral health self-care practices the majority of respondents (n=30; 96.8% (2nd-year students), and n=21; 100% (3rd-year students)) indicated the use of toothpaste and toothbrush to clean their teeth. the time taken to clean teeth varied from 1 to 2 minutes (n=27; 51.9%) to 3 5 minutes (n=22; 42.3%) to >5 minutes (n=3; 5.8%) (table 2). most respondents (n=44; 84.6%) indicated that they brushed their teeth twice daily. almost all respondents (n=47; 92.0%) indicated that brushing the tongue was part of the oral healthcare regimen. respondents in the 2ndand 3rd-year programmes indicated similar responses with reference to the replacement of toothbrushes. the majority of 2nd-year students (n=26; 83.9%) and two-thirds of 3rd-year students (n=15; 71.4%) indicated that toothbrushes were replaced after 3 months. more than half of the responses in the 3rd year were by female students (n=9; 60.0%). only 12% (n=6) of respondents indicated that toothbrushes were replaced after 6 months and only 3.8% (n=2) replaced their toothbrushes on an annual basis. table 1. gender distribution of students gender 2nd year, n (%) 3rd year, n (%) total, n (%) male 5 (16.1) 10 (47.6) 15 (28.8) female 26 (83.9) 11 (52.4) 37 (71.2) total 31 (100) 21 (100) 52 (100) pearson χ2 test: 6.048; p<0.01. research 85 june 2017, vol. 9, no. 2 ajhpe table 2. respondents’ reported knowledge, attitudes and practices questions response 2nd-year students, n (%) 3rd-year students, n (%) total, n (%) χ2 p-values how would you describe your present state of dental health? excellent good fair 6 (19.4) 21 (67.7) 4 (12.9) 6 (28.6) 11 (52.4) 4 (19.0) 12 (23.1) 32 (61.5) 8 (15.4) 1.248 0.60 do you think oral hygiene is important for overall health of the body? yes no don’t know 31 (100) 0 0 21 (100) 0 0 52 (100) 0 0 which of the following do you use to clean your teeth? toothpaste and toothbrush other 30 (96.8) 1 (3.2) 21 (100) 0 52 (100) 0 0.691 0.41 how much time do you take for cleaning your teeth? 1 2 minutes 3 5 minutes >5 minutes 18 (58.1) 11 (35.5) 2 (6.5) 9 (42.9) 11 (52.4) 1 (4.8) 27 (51.9) 22 (42.3) 3 (5.8) 1.464 0.54 how often do you clean your teeth? once daily twice daily thrice or more 4 (12.9) 27 (87.1) 0 2 (9.5) 17 (81.0) 2 (9.5) 6 (11.5) 44 (84.6) 2 (3.9) 3.132 0.21 how often do you change your toothbrush? once every month once in 3 months once in 6 months once every year 1 (3.2) 26 (83.9) 4 (12.9) 0 2 (9.5) 15 (71.4) 2 (9.5) 2 (9.5) 3 (5.8) 41 (78.8) 6 (11.5) 2 (3.8) 4.183 0.24 do you use commercially available mouth washes? yes no 30 (96.8) 1 (3.2) 20 (95.2) 1 (4.8) 50 (96.2) 2 (3.8) 0.080 0.77 how often have you visited a dentist/dental clinic in the past 12 months? once twice more than twice never 8 (25.8) 18 (58.1) 4 (12.9) 1 (3.2) 2 (9.5) 13 (61.9) 4 (19.0) 2 (9.5) 10 (19.2) 31 (59.6) 8 (15.4) 3 (5.8) 2.925 0.40 do you seek a routine dental visit for oral hygiene maintenance? once in a year twice in a year only if a problem occurs 9 (29.0) 14 (45.2) 8 (25.8) 5 (23.8) 9 (42.9) 7 (33.3) 14 (26.9) 23 (44.2) 15 (28.8) 0.388 0.82 what are the potential barriers for avoiding a routine visit to a dentist/dental clinic for oral hygiene maintenance? cost time fear other 10 (32.3) 17 (54.8) 3 (9.7) 1 (3.2) 8 (38.1) 10 (47.6) 1 (4.8) 2 (9.5) 18 (34.6) 27 (51.9) 4 (7.7) 3 (5.8) 1.503 0.68 has the dental curriculum influenced your daily self-care practices? yes no/not sure 29 (93.5) 2 (6.5) 18 (90.0) 2 (10.0) 47 (92.2) 4 (7.8) 0.212 0.65 which components of the curriculum have assisted you in understanding oral hygiene self-care practices? theory taught in the classroom strongly agree agree disagree 14 (45.2) 16 (51.6) 1 (3.2) 13 (65.0) 7 (35.0) 0 27 (52.9) 23 (45.1) 1 (2.0) 2.293 0.32 practical lessons in the laboratory strongly agree agree not sure disagree 20 (66.7) 7 (23.3) 2 (6.7) 1 (3.3) 12 (60.0) 5 (25.0) 3 (15.0) 0 32 (64.0) 12 (24.0) 5 (10.0) 1 (2.0) 1.597 0.67 exposure in the clinical environment strongly agree agree not sure 21 (67.7) 10 (32.3) 0 17 (85.0) 1 (5.0) 2 (10.0) 38 (74.5) 11 (21.6) 2 (3.9) 7.774 0.02 exposure in community-based interventions strongly agree agree not sure disagree 9 (31.0) 7 (24.1) 10 (34.5) 3 (10.3) 10 (52.6) 8 (42.1) 1 (5.3) 0 19 (39.6) 15 (31.3) 11 (22.9) 3 (6.3) 8.781 0.32 research june 2017, vol. 9, no. 2 ajhpe 86 with reference to the use of dental aids, 23% of respondents (n=12) used toothpicks, 81% (n=42) used dental floss, and 10% (n=5) used interdental brushes. about 56% of respondents (n=29) indicated that they always rinsed their mouths with plain water after meals. thirty-one percent of respondents (n=16) indicated that they rinsed their mouths once in the morning. almost all respondents (n=50; 96.2%) indicated the use of commercially available mouth rinses. more than half of the study population (n=31; 59.6%) mentioned that they visited the dental clinic twice a year for their own treatment. however, respondents provided varied responses to whether they would seek routine dental care for oral hygiene maintenance. about 45% of respondents (n=23) indicated that they would visit the dental clinic twice a year to seek routine dental treatment, while 27% (n=14) stated that they would visit the dental clinic once a year. a significant number of respondents (n=15; 28.8%) indicated that they would seek dental care only if a problem occurred (table 2). more than half of the study population (n=27; 51.9%) noted time as a potential barrier for seeking routine dental visits for oral hygiene maintenance. similarly, the cost of dental treatment (n=18; 34.6%) was also shown as a potential barrier. linking oral health self-practices to the curriculum the majority of respondents (n=29; 93.5% (2nd-year students), and n=18; 90.0% (3rd-year students)) agreed that the dental curriculum influenced their daily self-care practices. respondents were further asked to identify aspects of the curriculum that were seen as being valuable in their understanding of oral hygiene self-care practices. almost all respondents (n=30; 96.8% (2nd year), and n=20; 100% (3rd year)) agreed that the theory taught in the classroom contributed to their understanding of oral health self-care practices. ninety percent of respondents in the 2nd year (n=27) and 85% in the 3rd year (n=17) agreed that the practical lessons learnt in the laboratory also contributed to their self-care practices. although all respondents in the 2nd year of study (n=31) agreed that the clinical environment did have an influence on understanding oral health selfcare, some differences were noted among respondents in the 3rd year. only two respondents (10%) were unsure of this perceived influence. while the majority of respondents in the 3rd year (n=18; 94.7%) agreed that their exposure to community-based activities did contribute to their understanding of oral health self-care practices, a number of respondents in the 2nd year (n=13; 44.8%) disagreed or were unsure. some of the perceived influences of the curriculum included understanding the significance of good oral hygiene and ensuring optimal oral hygiene care (n=21; 40%); use of interdental aids, additional fluoride uptake and mouth rinses (n=10; 19%); correct toothbrushing practices (n=5; 10%); flossing practices (n=7; 14%); and change in dietary practices (n=2; 3.8%). discussion the results indicated that both 2ndand 3rd-year dental students generally had good knowledge of the nature and formation of dental biofilms. the perceived influence of the undergraduate curriculum included an understanding of the significance of good oral hygiene and ensuring optimal oral hygiene care; use of interdental aids, additional fluoride uptake and use of mouth rinses; correct toothbrushing practices; and flossing. mathur et al.,[16] however, point out that students’ understanding and conceptualisation of oral disease processes could affect daily practice, but that the opposite also holds true. existing social practices may also affect concepts of the disease process. this study investigated the concept of dental biofilm only from a theoretical perspective. a more detailed assessment of this learning process is required in future studies to unpack the complex realities in understanding health and oral disease processes.[16] given that the study population comprised 2ndand 3rd-year under graduate dental students, it was assumed that they would have adequate theoretical knowledge of the nature and formation of dental biofilms in addition to the measures to ensure plaque control. however, knowledge of theoretical concepts and principles does not necessarily translate into positive self-care practices.[17] some inconsistencies were noted in the respondents’ reported self-care practices, such as time taken to clean teeth, replacement of toothbrushes and dietary practices. similar inconsistencies were also reported by gopinath,[18] i.e. less than two-thirds of dentists in their study (55.9%) indicated that they brushed twice a day with fluoridated toothpaste (55.1%), despite their awareness of plaque control measures. although the majority of respondents in this study used toothpaste and toothbrushes to clean their teeth, 13% of 2nd-year students (n=4) and 19% of 3rd-year students (n=4) did not replace their toothbrushes after a 3-month period. more female respondents in the 3rd year (60%) reported replacement of their toothbrushes after a 3-month period than male students. oberoi et al.[15] further noted significant gender differences in their study. this study, however, did not observe any other marked gender difference in the reported knowledge, practices and attitudes, except the replacement of toothbrushes. there is little evidence-based data to guide the replacement of toothbrushes, with the average period recommended being between 2 and 6 months. the literature is also inconsistent with regard to the effectiveness of new and worn toothbrushes for optimal plaque removal;[19,20] however, tangade et al.[21] suggest that the design of the toothbrush bristles should be considered for efficacy in toothbrushing. over half of the respondents (56%) indicated that they rinsed their mouths regularly with plain water after meals. reinforcement of correct toothbrushing, flossing and dietary advice forms part of the core of oral hygiene counselling that dental students are expected to conduct as part of patient/client management. mechanical oral hygiene measures (toothbrushing and flossing) could be complemented by chemotherapeutic agents (broadspectrum antiseptics, antibiotics aimed at specific bacteria, combinations of enzymes that could modify plaque structure or activity, and non-enzymaticdispersing or non-enzymatic-modifying agents).[12-14] furthermore, there is no scientific basis for the recommended 6-monthly dental check-up. dental recall systems should be based on individual risk assessment profiles.[2] while toothbrushing and flossing have been highlighted, very little mention was made of dietary practices. this is of particular interest given that diet, specifically the consumption of refined sugars, is an integral component of oral health education.[7] dogan and gokalp[22] reported that snacking between meals and consumption of sugary foods were observed among dental students in their study. folayan et al.[23] also observed an association between students’ oral health behaviour, gender, age, knowledge of preventive care, and attitudes towards preventive dentistry. the authors concluded that older students were more likely to follow the recommended oral self-care measures, while younger students could have good knowledge of preventive dental care yet were more likely to consume sugary snacks. our study did not observe a marked difference in the reported oral health knowledge and self-care practices between 2ndand 3rd-year dental students. this could possibly be attributed to the curriculum’s structure. students acquire the core skills in preventive dentistry in the 2nd year of study. the 3rd year of dental therapy training focuses mainly on building clinical skills in the area of relief of pain, sepsis (extractions), and restorative dentistry (fillings). there is no additional acquisition of knowledge and skills in preventive dentistry research 87 june 2017, vol. 9, no. 2 ajhpe in the 3rd year. hence, both 2ndand 3rd-year students would have similar levels of knowledge and skills in preventive dentistry. second-year students, however, are more involved in preventive care than those in their 3rd year, which could have probably contributed to the slightly higher response scores for the former. the implications of these findings suggest that students need sustained exposure to preventive care in their undergraduate training to maximise greater awareness of positive self-care practices. therefore, there is a need for a curriculum review to ensure that 3rd-year students are more exposed to prevention strategies in the final-year programme. time and the costs of dental treatment were also identified as potential barriers for students seeking routine dental visits for oral hygiene maintenance. more effort needs to be made to address these barriers through a curriculum review process. moreover, more research is required to examine the undergraduate dental students’ dietary practices in relation to their oral health self-care. it is further noted that almost a third of the 2nd-year students (44.8%) did not perceive community engagement to influence their understanding of oral health selfcare practices. more research is required to unpack students’ understanding of the role of community engagement in relation to self-care practices. although the results indicate that dental students had positive perceptions towards the influence of the curriculum on self-care practices, there is a need to reiterate comprehensive coverage in prevention in under graduate dental curricula. kawamura et al.[24] suggest that undergraduate dental education should include comprehensive programmes in preventive care that empower dentists/oral health workers to motivate patients’ self-care practices, in addition to programmes that ensure dental students also institute their own oral self-care regimens. such educational effort should enable dental students to develop stable oral health behaviours and practices. therefore, curriculum planning needs to take into account that undergraduate learning is not simply an acquisition of knowledge and clinical skills but that students’ self-awareness and self-reflection should be integrated into the learning process.[25] study limitations the study provided valuable insight into dental undergraduate students’ oral health knowledge and self-care practices, but some limitations were noted. the study focused exclusively on students’ perspectives of the influence of the curriculum on self-care practice. more research is required to further explore the learning environment, taking into account the attitudes and perceptions of educators, patients and other stakeholders. the interplay between the learnt experience (dental curriculum) and the social and cultural norms that influence students’ attitudes and oral health practices, is an important consideration.[3] as this study relied on self-report, there could have possibly been over-reporting with regard to students’ oral health self-practices. this observation is consistent with ahamed et al.’s[6] findings that self-reported data could be overor under-reported owing to social desirability. more research is required to correlate students’ reported self-care practices to their oral health clinical status (state of the oral cavity). conclusion the results indicated that dental undergraduate students generally reported having good knowledge and practice of oral health self-care, but there were inconsistencies in these practices. respondents also agreed that the dental undergraduate curriculum did influence their knowledge and oral health self-care practices. dental undergraduate student training is pivotal in producing oral health graduates who can adopt leadership roles in oral health promotion. it cannot, however, be assumed that exposure to dental knowledge and skills will automatically result in a graduate with meticulous oral health self-care practice/habits. curriculum planning needs to take into account the pre-existing attitudes and oral health practices that students bring into the training programme, and appropriate strategies need to be devised to reinforce/modify positive oral healthcare practices that can be sustained through the life-cycle. 1. vangipuram s, rekha r, radha g, pallavi sk. assessment of oral health attitudes and behavior among undergraduate dental students using hiroshima university-dental behavioral inventory hu-dbi. j indian assoc public heal dent 2015;13(1):52-57. https://doi.org/10.4103/2319-5932.147645 2. halawany hs, abraham nb, jacob v, al-maflehi n. the perceived concepts of oral health attitudes and behaviors of dental students from four asian countries. saudi j dent res 2015;6(2):79-85. https://doi.org/10.1016/j. sjdr.2014.09.002 3. jaramillo ja, jaramillo f, kador i, et al. a comparative study of oral health attitudes and behavior using the hiroshima university-dental behavioral inventory (hu-dbi) between dental and civil engineering students in colombia. j oral sci 2013;55(1):23-28. https://doi.org/10.2334/josnusd.55.23 4. sudhanshu s, shashikiran nd. oral self-care behaviors among future dental professionals in central india. int j curr res aca rev 2016;4(3):189-196. https://doi.org/10.20546/ijcrar.2016.403.021 5. tanalp j, guven ep, oktay i. evaluation of dental students’ perception and self-confidence levels regarding endodontic treatment. eur j dent 2013;7(2):218-224. https://doi.org/10.4103/1305-7456.110189 6. ahamed s, moyin s, punathil s, patil na, kale vt, pawar g. evaluation of the oral health knowledge, attitude and behavior of the preclinical and clinical dental students. j int oral health 2015;7:65-70. 7. taylor gw, stumpos ml, kerschbaum w, inglehart mr. educating dental students about diet-related behavior change: does experiential learning work? j dent educ 2014;78(1):64-74. 8. singh s. dental caries rates in south africa: implications for oral health planning. s afr j epidemiol infect 2011;26:259-261. 9. university of kwazulu-natal. vision and mission statement. http://www.ukzn.ac.za/ (accessed 18 april 2017). 10. berchier ce, slot de, haps s, van der weijden ga. the efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: a systematic review. int j dent hygiene 2008;6(4):265-279. https://doi.org/10.1111/j.1601-5037.2008.00336.x 11. zimmer s, strauss j, bizhang m, krage t, raab wh, barthel c. efficacy of the cybersonic in comparison with the braun 3d excel and a manual toothbrush. j clin periodontol 2005;32(4):306-363. https://doi.org/10.1111/j.1600051x.2005.00683.x 12. gaffar a, afflitto j, nabi n. chemical agents for the control of plaque and plaque microflora: an overview. eur j oral sci 1997;105(5):502-507. https://doi.org/10.1111/j.1600-0722.1997.tb00237.x 13. wolff ms, larson c. the cariogenic dental biofilm: good, bad or just something to control? braz oral res 2009;23(1):31-38. https://doi.org/10.1590/s1806-83242009000500006 14. ribeiro lg, hashizume ln, maltz m. the effect of different formulations of chlorhexidine in reducing levels of mutant streptococci in the oral cavity: a systematic review of the literature. j dent 2007;35(5):359-370. https:// doi.org/10.1016/j.jdent.2007.01.007 15. oberoi ss, mohanty v, mahajan a, oberoi a. evaluating awareness regarding oral hygiene practices and exploring gender differences among patients attending for oral prophylaxis. j indian soc periodontol 2014;18(3):369-374. https:// doi.org/10.4103/0972-124x.134580 16. mathur a, batra m, makkar dk, dileep cl, kaur p, goyal n. exploration of different school of thoughts among undergraduate dental students regarding dental caries and periodontal diseases. j indian assoc public health dent 2015;13(4):454-458. https://doi.org/10.4103/2319-5932.171177 17. madan c, arora k, chadha vs, manjunath bc, chandrashekar br, moorthy vrr. a knowledge, attitude, and practices study regarding dental floss among dentists in india. j indian soc periodontol 2014;18(3):361-368. https://doi.org/10.4103/0972-124x.134578 18. gopinath v. oral hygiene practices and habits among dental professionals in chennai. indian j dent res 2010;21(2):195-200. https://doi.org/10.4103/0970-9290.66636 19. daly c, marshall r. attitudes to toothbrush renewal: a survey of australian periodontists and dental hygienists. periodontol 1996;17:118-121. 20. daly cg, chapple cc, cameron ac. effect of toothbrush wear on plaque control. j clin periodontol 1996;23(1):45-49. 21. tangade ps, shah af, ravishankar tl, tirth a, pal s. is plaque removal efficacy of toothbrush related to bristle flaring? a 3-month prospective parallel experimental study. ethiop j health sci 2013;23(3):255-264. 22. dogan bg, gokalp s. self-assessed dental status of the first year students of health related faculties of a university in turkey. j res pract dent 2015;2(3):1778-1812. https://doi.org/10.5171/2014.269657 23. folayan mo, khami mr, folaranmi n, et al. determinants of preventive oral health behaviour among senior dental students in nigeria. bmc oral health 2013;13:1-8. https://doi.org/10.1186/1472-6831-13-28 24. kawamura m, yip hk, hu dy, komabayashi t. a cross-cultural comparison of dental health attitudes and behaviour among freshman dental students in japan, hong kong and west china. int dent j 2001;51(3):159163. https://doi.org/10.1002/j.1875-595x.2001.tb00833.x 25. kerdijk w, snoek jw, van hell ea, cohen-schotanus j. the effect of implementing undergraduate competencybased medical education on students’ knowledge acquisition, clinical performance and perceived preparedness for practice: a comparative study. bmc med educ 2013;13:1-9. https://doi.org/10.1186/1472-6920-13-76 https://doi.org/10.1016/j.sjdr.2014.09.002 https://doi.org/10.1016/j.sjdr.2014.09.002 https://doi.org/10.2334/josnusd.55.23 https://doi.org/10.1111/j.1600-051x.2005.00683.x https://doi.org/10.1111/j.1600-051x.2005.00683.x https://doi.org/10.1111/j.1600-0722.1997.tb00237.x https://doi.org/10.1590/s1806-83242009000500006 https://doi.org/10.1016/j.jdent.2007.01.007 https://doi.org/10.1016/j.jdent.2007.01.007 https://doi.org/10.4103/0972-124x.134580 https://doi.org/10.4103/0972-124x.134580 https://doi.org/10.4103/0970-9290.66636 https://doi.org/10.1002/j.1875-595x.2001.tb00833.x 2 march 2018, vol. 10, no. 1 ajhpe editorial in 2010, almost a decade ago, frenk et al.[1] reported that health professions education needs to be transformed to appropriately address the health needs of the population in the 21st century. the authors further suggested that a competency-based curriculum would facilitate this transformation process.[1] the competencies that should be facilitated in such a curriculum should be aligned with the roles that health professionals need to fulfil to respond to the population’s health needs. these above-mentioned roles include being a collaborator, manager, health advocate, good communicator, professional and scholar.[2] it is therefore important that the clinical education and training component of health professions education programmes includes learning outcomes, teaching and learning activities, as well as assessment tasks that would facilitate the development of these competencies. the articles in this edition of ajhpe report on a number of aspects related to clinical education and training. the papers provide insights into approaches and models of clinical education, as well as the different learning activities students engage in as they become competent practioners. the aspects of an integrated model of clinical education are explored by chetty et al.,[3] while additional perspectives about interprofessional education and practice are provided by moodley and singh.[4] data relating to effectiveness and experiences of students acting as advocators of good health are reported on by mhlongo et al.[5] and smit et al.[6] the exploration of teaching and learning activities, such as telehealth[7] and performance art,[8] demonstrates that educators continue to examine different innovative methods to develop competencies of health professions students. using both qualitative and quantitative methodologies, the samples reported on in the published articles include a variety of professions, such as pharmacy, dentistry, physiotherapy and dietetics. the inclusion of studies related to interns by naidoo et al.[9,10] indicates that research in the field of health professions education extends beyond undergraduate programmes. even though the main objective of clinical education and training, which involves placing students on varied clinical platforms, is to develop specific clinical competencies in students, the positive impact of having students on a specific clinical platform is reported on by reid et al.[11] this is an important aspect to consider in settings where human resources for health are limited. as we read the information shared with us in this edition of ajhpe and reflect on initiatives implemented by health professions educators, such as interprofessional education and collaborative practice,[12] we need to ask how far we have come with training students who can address the health needs of the population in the 21st century, and, moreover, if graduates are equipped with skills to address the existing healthcare disparities.[13] if we are serious about the competencies needed by health professions graduates to meet the needs of communities in the 21st century, we need to continually review how we design and implement clinical education and training programmes. we might need to further shift our paradigms with regard to the manner in which we view clinical education and training. information provided by articles in this edition of ajhpe could contribute to this paradigm shift. anthea rhoda faculty of community and health sciences, university of the western cape, cape town, south africa arhoda@uwc.ac.za 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(4):1958-1923. https://doi.org/10.1016/s01406736(10)61854-5 2. frank jr, snell l, sherbino j, eds. canmeds 2015 physician competency framework. ottawa: royal college of physicians and surgeons of canada, 2015. 3. chetty v, maddocks s, cobbing s, et al. physiotherapy clinical education at a south african university. afr j health professions educ 2018;10(1):13-18. https://doi.org/10.7196/ajhpe.2018.v10i1.987 4. moodley i, singh s. creating opportunities for interprofessional, community-based education for undergraduate dental students within the school of health sciences at the university of kwazulu-natal, durban, south africa: academics’ perspectives. afr j health professions educ 2018;10(1):19-25. https//:doi.org/10.7196/ajhpe.2018. v10i1.974 5. mhlongo m, marara p, bradshaw k, srinivas sc. health education on diabetes at a south african national science festival. afr j health professions educ 2018;10(1):26-30. https://doi.org/10.7196/ajhpe.2018.v10i1.887 6. smit y, marais m, philips l, donald h, joubert e. engagement of dietetic students and students with hearing loss: experiences and perceptions of both groups. afr j health professions educ 2018;10(1):31-37. https://doi. org/10.7196/ajhpe.2018.v10i1.901 7. govender sm, mars m. the perspectives of south african academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training. afr j health professions educ 2018;10(1):3843. https://doi.org/10.7196/ajhpe.2018.v10i1.957 8. schweickerdt l. adopting a role: a performance art in the practice of medicine. afr j health professions educ 2018;10(1):3-4. https://doi.org/10.7196/ajhpe.2018.v10i1.950 9. naidoo kl, van wyk j, adhikari m. comparing international and south african work-based assessment of medical interns’ practice. afr j health professions educ 2018;10(1):44-49. https://doi.org/10.7196/ajhpe.2018. v10i1.955 10. naidoo kl, van wyk j, adhikari m. ‘sense of belonging’: the influence of individual factors in the learning environment of south african interns. afr j health professions educ 2018;10(1):50-55. https://doi.org/10.7196/ ajhpe.2018.v10i1.953 11. reid s, conradie h, daniels-felix d. the effect of undergraduate students on district health services delivery in the western cape province, south africa. afr j health professions educ 2018;10(1):56-60. https://doi. org/10.7196/ajhpe.2018.v10i1.959 12. frantz jm, rhoda aj. implementing interprofessional education and practice: lessons from a resourceconstrained university. j interprof care 2017;31(2):180-183. https://doi.org/10.1080/13561820.2016.1261097 13. mayosi bm, benatar sr. health and health care in south africa – 20 years after mandela. n engl j med 2014;371:13441353. https://doi.org/10.1056/nejmsr1405012 afr j health professions educ 2018;10(1):2. doi:10.7196/ajhpe.2018.v10i1.1080 clinical education and training: have we sufficiently shifted our paradigm? this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 http://https//:doi.org/10.7196/ajhpe.2018.v10i1.974 http://https//:doi.org/10.7196/ajhpe.2018.v10i1.974 https://doi.org/10.7196/ajhpe.2018.v10i1.901 https://doi.org/10.7196/ajhpe.2018.v10i1.901 https://doi.org/10.7196/ajhpe.2018.v10i1.957 https://doi.org/10.7196/ajhpe.2018.v10i1.955 https://doi.org/10.7196/ajhpe.2018.v10i1.955 https://doi.org/10.7196/ajhpe.2018.v10i1.953 https://doi.org/10.7196/ajhpe.2018.v10i1.953 https://doi.org/10.7196/ajhpe.2018.v10i1.959 https://doi.org/10.7196/ajhpe.2018.v10i1.959 https://doi.org/10.1080/13561820.2016.1261097 june 2018, vol. 10, no. 2 ajhpe 75 short communication context and setting in nigerian medical schools, lecturing is the dominant mode of delivering education during the preclinical years. the school of medicine, university of benin (uniben), nigeria, a first-generation institution, provided the stage for the intervention described in this report. why the idea was necessary the traditional lecture is fraught with pitfalls, such as cognitive overload and low engagement between students and faculty.[1] these problems can potentially be tackled by social media.[2] scholars in europe and the usa have described the innovative use of social media in medical education, but little documented evidence exists to suggest that african educators are up to date with this trend. we designed and implemented an intervention to complement face-to-face lectures. what was done the presence and activity of students on social networking sites during their pathology year was determined using a pre-intervention survey. facebook and the photo-sharing application, instagram, had the most users. respondents accessed these sites predominantly via smart phones. content derived from the medical microbiology curriculum was posted on a dedicated facebook page and instagram account throughout the semester. typical posts representing independent units of instruction consisted of an image accompanied by a concise descriptive text. a picture puzzle was also posted weekly. students were provided with the account handles to voluntarily follow and engage on any or both social media platforms. an end-of-semester post-intervention survey was conducted. results and impact there was a high level of satisfaction among participants; 91.6% agreed that the intervention enhanced learning. specifically, posts allowed convenient, asynchronous access to content in manageable chunks (87.5%), addressed gaps in knowledge (66.7%) and afforded students opportunities to engage with their peers and facilitator (50%). participation and engagement were higher on instagram than facebook (70 v.14 followers; 2 students followed both). furthermore, 85% of respondents reported deliberately using the platform as a mobile reference and 79.2% used it as a study tool during downtime, usually between lectures and while commuting. accessing bite-sized content via mobile technology as and when required, whether for deliberate reference or opportunistic studying, has been described as ‘microlearning’.[3] coincidentally, these microlearning activities were reported exclusively by instagram users. our take-home message from the intervention was twofold. first, the success of social media interventions is dependent on the students being positively motivated to use the selected platform. our students possessed both facebook and instagram accounts, but had a greater affinity for the latter. therefore, a thorough analysis of students’ perceptions is vital before adopting any strategy. secondly, the outcomes suggest that instagram is more suitable for microlearning than facebook. we attribute this to the succinct nature of the descriptive texts and the layout of the instagram account, which allows images to function as bookmarks for posts of interest. this intervention’s highest contribution to scholarship in medical education lies in the new questions posed: what is the impact of microlearning as a pedagogical approach?; and is instagram a more suitable vehicle than facebook and other social media platforms for such an approach? our future research will be directed at providing answers. acknowledgements. none. author contributions. iio was responsible for the concept, implementation, acquisition and analysis of the data, and writing of the draft. cfi was responsible for the concept, revision of the draft and intellectual content. funding. none. conflicts of interest. none. 1. frederick p. the lively lecture – 8 variations. coll teach 1986;34(2):43-50. https://doi.org/10.1080/87567555.1 986.9926766 2. orsini c, evans p. social media as a teaching strategy: opportunities and barriers. adv j health professions educ 2015;1(1):44-46. 3. hug t. mobile learning as microlearning: conceptual considerations towards enhancements of didactic thinking. int j mobile blend learn 2010;2(4):47-57. https://doi.org/10.4018/jmbl.2010100104 accepted 16 january 2018. afr j health professions educ 2018;10(2):75. doi:10.7196/ajhpe.2018.v10i2.1057 instagram: a niche for microlearning of undergraduate medical microbiology i i osaigbovo,1,2 mbbs, fmcpath; c f iwegim,2 mbbs, mhpm 1 department of medical microbiology, school of medicine, college of medical sciences, university of benin, nigeria 2 department of medical microbiology, university of benin teaching hospital, nigeria corresponding author: i i osaigbovo (zephyreternal@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1080/87567555.1986.9926766 https://doi.org/10.1080/87567555.1986.9926766 https://doi.org/10.4018/jmbl.2010100104 mailto:zephyreternal@yahoo.com a maximum of 3 ceus will be awarded per correctly completed test. june 2018, vol. 10, no. 2 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/029/01/2018 (clinical) cpd questionnaire june 2018 true (a) or false (b) aimed at itchedd: a proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting 1. the respondents in this study found the mnemonic useful in guiding students through the critical thinking and decision-making processes. association between personality factors and consulting specialty of practice of doctors at an academic hospital in bloemfontein, south africa 2. a previous study using the cloninger inventory found that those students choosing internal medicine had lower harm-avoidance scores than those choosing surgery and emergency medicine. 3. the five personality factors that were explored in this study include impulsive sensation seeking, neuroticism-anxiety, aggression-hostility, sociability and activity. optometry students’ attitudes towards research at undergraduate level 4. the negative statements of respondents related mostly to group work. 5. the tripartite attitude model comprises an affective/emotive, behavioural and cognitive component. factors causing stress among first-year students attending a nursing college in kwazulu-natal, south africa 6. research has shown that self-concept positively affects the success of nursing students’ ability to manage anxiety and stress related to studying. 7. it is well known that stress factors that affect students attending a large university are different from those of students who attend smaller tertiary institutions. ‘pain and stress are part of my profession’: using dental practitioners’ views of occupation-related factors to inform dental training 8. dental training in the south african context, occupational health experiences, self-care and burnout, coping strategies and dental education were the main themes identified in this research. 9. one of the stressors that was strongly recognised in this study was the challenges of teamwork. occupational therapy students’ use of social media for professional practice 10. there is a growing trend of incorporating social media for professional purposes into health professions education. 11. in our study, there was an incline in the frequency of youtube use as students progressed to their final year. establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in nigeria: a delphi study 12. preparedness of students was one of the main reasons cited by stakeholders as to why gender-based violence should be taught at medical school. self-reported generic learning skills proficiency: another measure of medical school preparedness 13. research has shown that students experiencing academic difficulties in their first year at medical school report problems with information handling, problem-solving, critical thinking and time management. 14. this study showed that the self-reported confidence in generic learning skills proficiency of first-year medical students was related to three objective measures of performance: pre-university admission aptitude test scores, information technology proficiency on entry to university and early academic performance at university. integrating critical cross-field outcomes in an anatomy course at a university of technology: a reflective perspective 15. contemporary studies suggest that to improve and promote student learning, current curricula must explore and maximise the benefits of different teaching methods. 16. studies have shown that peer learning has a minimal effect on the development of collaboration and communication skills. strengths and challenges of community-based clinical training as viewed by academics at the university of kwazulu-natal, durban, south africa 17. community-based clinical training is seen as a valuable tool for transforming health professions education to meet graduate competencies and the needs of the health system. 18. improved service delivery was found to be the primary benefit of community-based education to communities in this study. a support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: a pilot study 19. a comprehensive diagnostic evaluation of autism spectrum disorders involves a multidisciplinary team comprised of a paediatric nurse, psychiatrist, psychologist, neurologist, speech-language therapist and occupational therapist. 20. a comparison of preand post-training scores showed a minimal increase in the level of understanding of specific problems associated with autism. editorial 161 scholarship for africa: are we taking it seriously enough? s van schalkwyk forum 162 the medical elective: a unique educational opportunity r i caldwell, a c inglis, m morgan, k rasmussen, c aldous short research report 164 selfies 2015: peer teaching in medical sciences through video clips – a case study j d pillay 168 the use of low-cost simulation in a resource-constrained teaching environment m mwandri, m walsh, j frantz, r delport research 171 implementing the angoff method of standard setting using postgraduate students: practical and affordable in resource-limited settings a g mubuuke, c mwesigwa, s kiguli 176 medical students’ perspectives on the anatomy course at the university of zimbabwe r siwela, g mawera 180 clinical undergraduate medical student training at kimberley hospital, northern cape, south africa: ‘a test of fire’ s joubert, v j louw 185 designing interprofessional modules for undergraduate healthcare learners c maree, p bresser, m yazbek, l engelbrecht, k mostert, c viviers, m kekana 189 learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment t ndlovu, t m chikwanha, n munambah 194 experiences of south african student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery l m modiba 199 self-leadership traits of academics to conform to a changing higher-education environment k jooste, j frantz 203 clinical electives at the university of michigan from the perspective of ghanaian medical students: a qualitative study s danso-bamfo, n a abedini, h mäkiharju, k a danso, t r b johnson, j kolars, c a moyer 208 factors that enable and constrain the internationalisation and africanisation of master of public health programmes in south african higher education institutions j witthuhn, c s le roux cpd questionnaire ajhpe african journal of health professions education december 2017, vol. 9, no. 4 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens dtp & design clinton griffin travis arendse chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, mrs h kikaya, dr m mbokota, dr g wolvaardt issn 2078-5127 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 87 the university of kwazulu-natal (ukzn), durban, south africa (sa) was formed in january 2004 as a result of a merger of the former universities of natal and durban-westville.[1] it has ~44 000 students, which makes it the largest residential university in sa; 26% of the students are in postgraduate programmes.[2] the university sees its research enterprise as fundamental to the initiative of significantly increasing its output of doctoral graduates. biostatistics is the application of statistics to questions about human health.[3] biostatistical considerations inform the design of medical research studies, their analysis and the interpretation of the conclusions. it is an inherently collaborative discipline that is essential in advancing and integrating biomedical, genomic and clinical research. in the kwazulunatal region of sa there is a wide and growing range of medical research activities, the majority of which have a biostatistical component. there is, however, a serious shortage of biostatisticians in sa and in the broader african region.[4] the shortage of expertise manifests itself not only in concrete problems such as difficulty in recruiting suitable biostatisticians for medical research collaboration, but also in less tangible ways affecting quality of research.[5] in an effort to build research capacity in the college of health sciences (chs) at ukzn, a research methodology project (remeth) was developed by ukzn in partnership with the medical education partnership initiative (mepi). the goal of remeth was to improve the research methodology skills of faculties from the schools of medicine, nursing, pharmacy and pharmacology. the mepi biostatistics initiative was conceived in 2011 to support the development of the discipline of biostatistics at ukzn and to strengthen biostatistics skills among researchers and postgraduate students in the chs. the initiative arose over several years of stakeholder engagement and is a collaborative effort between the department of biostatistics at the university of washington, seattle, usa and the ukzn discipline of statistics (in the college of agriculture, engineering and science), as well as disciplines in the chs, including public health medicine and occupational and environmental health. background. there is a shortage of biostatistics expertise at the university of kwazulu-natal (ukzn), durban, south africa and in the african region. this constrains the ability to carry out high-quality health research in the region. objectives. to quantitatively and qualitatively evaluate a programme designed to improve the conceptual and critical understanding of bio statistical concepts of ukzn health researchers. methods. a 40-hour workshop in biostatistical reasoning was conducted annually between 2012 and 2015. the workshops were structured around interpretation and critical assessment of nine articles from the medical literature, with a mix of in-class sessions and small group discussions. quantitative evaluation of the knowledge gained from the workshops was carried out using a preand post-workshop quiz, and qualitative evaluation of the workshop process was done using a mid-workshop questionnaire and focus group discussions. results. for each year that the workshop was conducted, post-workshop quiz scores were significantly higher than pre-workshop scores. when quiz assessments from all 4 years of training were combined, the pretest median score was 55% (interquartile range (iqr) 40 62%) and the posttest median score was 68% (iqr 62 76%), with p<0.0001 for the overall comparison of prev. post-scores. there was a general consensus among participants that the workshop improved their reasoning skills in biostatistics. participants also recognised the value of the workshop in building biostatical capacity at ukzn. conclusion. the workshops were well received and improved the critical and conceptual understanding of the participants. this education mode offers the opportunity for health researchers to advance their knowledge in settings where there are few professional biostatistician collaborators. afr j health professions educ 2016;8(1 suppl 1):87-91. doi:10.7196/ajhpe.2016.v8i1.740 implementation and outcome evaluation of the medical education partnership initiative biostatistical reasoning workshops for faculty and postgraduate students at the university of kwazulu-natal, durban, south africa m muzigaba,1 phd, mph, mphil, bsc; m l thompson,2 phd, bsc hons; b sartorius,3 bsc, bsc hons, msc, epiet, phd; g matthews,4 phd (mathematical statistics); n nadesan-reddy,3 mb chb, fcphm, mmed (public health medicine); s pillay,1 mb chb, dom, dip hiv man (sa); u lalloo,5 mb chb, frcp, doh, phd 1 medical education partnership initiative, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa 2 department of biostatistics, university of washington, seattle, usa 3 discipline of public health medicine, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 4 school of mathematics, statistics and computer science, college of agriculture, engineering and science, university of kwazulu-natal, durban, south africa 5 faculty of health sciences, durban university of technology, south africa corresponding author: m muzigaba (mochemoseo@gmail.com) research 88 may 2016, vol. 8, no. 1, suppl 1 ajhpe in this article, we describe one component of that strategy, a workshop in biostatistical reasoning, and we present an assessment of the workshop over the 4 years of its implementation. as part of the project description, we present the context and rationale of the project, describe the project structure and delivery mechanism, and outline the implementation process. the outcomes evaluation assessed the actual and perceived knowledge gain in biostatistical reasoning among workshop attendees. the process evaluation focused on the perceptions of the workshop attendees regarding the implementation and value of the workshops. project description context and rationale the majority of phd candidates in the ukzn chs have not had any formal biostatistics training during their underand postgraduate years. they are reliant on the few biostatisticians in the chs, who, in addition to being few in number, have many competing demands on their time. this places these candidates at a disadvantage when conducting their research, particularly in critically reading the relevant literature, developing their study design, assessing its validity and generalisability and developing an appropriate statistical analysis plan. while recognising the need for a greater number of professional biostatisticians at ukzn, it was concluded by the biostatistics initiative that one approach to advancing research capacity in a setting with limited biostatistics expertise would be to offer workshops in biostatistical reasoning to chs researchers themselves to improve their understanding of biostatistics concepts. complementary approaches, also undertaken as part of the initiative, include the development of online asynchronous biostatistics modules, which offer the opportunity for hands-on acquisition of biostatistics analysis skills, biostatistics software tutorials, protocol development workshops and one-on-one consultations with remeth candidates. workshop structure and delivery as part of the mepi biostatistics initiative, a 40-hour biostatistical reasoning workshop was offered annually to ukzn chs researchers from 2012 to 2015. this workshop was intended to provide a broad overview of biostatistics methods relevant to the health sciences, emphasising interpretation and concepts rather than computation or mathematical details. topics covered include data description, study design, sampling variability, statistical inference and regression (linear, logistic, poisson and cox). the workshop was built around nine articles from the medical literature. consequently, the material development was not linear, but addressed topics as they arose in each of the articles, with each article advancing the complexity of the concepts covered. this may be considered a variant of case-based learning, which has been shown to overcome many of the limitations of a traditional lecture-based mode of instruction.[6] after the material necessary to understand a particular article had been covered in class, participants broke into small groups to review the article, with a list of questions aimed at guiding the discussion. each group then reported back to the class as a whole and there was further discussion. the in-class sessions were designed to be participatory, with ample opportunity for participants to raise questions or discussion points. upon completion of the workshop, participants should have been able to recognise relevant study design features and explain how they affect interpretation of results, interpret key data displays and statistical results commonly found in medical research reports, and judge whether the conclusions drawn from a study are justified. the workshop learning objectives are outlined below: • interpret and critique graphical displays of data (e.g. box plots, scatter plots, kaplan-meier curves). • interpret and critique numerical summaries of data. • translate scientific questions into measurable outcomes and associated statistical goals. • explain the difference between observational and experimental studies. • identify and describe the key features of different study designs (e.g. randomised trials, cohort, case-control and cross-sectional studies). • explain the concept of bias and how a given study design does or does not control for types of bias. • identify sources of random variation for a given study. • explain how sample size, variability and effect size interact to determine the power of a study. • explain the concepts of confounding and effect modification. • explain the distinction between association and causation. • explain the key elements of statistical hypothesis testing. • identify common statistical tests that might be applied to specific research questions. • explain and interpret p-values and confidence intervals and their implications for the research question under consideration. • explain the distinction between statistical significance and practical significance. • identify questions that can be addressed with regression models and interpret regression coefficients in different settings (linear, logistic, cox proportional hazards). • identify common abuses of statistical methods in the literature. workshop implementation the workshop was held for the first time in 2012, over 14 successive 3-hour afternoon sessions. it was found that this scheduling made it difficult for clinicians among the participants to attend regularly, as they often had clinics and patients to attend to. irregular attendance then possibly contributed towards difficulty in grasping all the material. from 2013, the workshop was offered over 8 full days, which improved attendance, but with disadvantages in terms of participant ability to absorb and process the material. the in-class sessions were a few hours’ duration each, with breaks between sessions. after requests from 2012 participants, supplementary exercises, which participants could work on in their own time, were also provided, with further questions relating to interpretation of biostatistics concepts that had been covered in the workshop in-class sessions. the 2012 workshop was conducted by a faculty member (mlt) from the department of biostatistics at the university of washington in seattle, usa. with a view to sustainability, from 2013 there was increasing participation in facilitating the small group discussions from the three biostatisticians in chs and two members of the ukzn discipline of statistics, and in 2014 and 2015 they participated as co-instructors. project evaluation an evaluation was conducted to assess whether participants’ understanding of biostatistical concepts improved following the training. this also explored participant expectations of the workshop before attending and the extent to which these expectations had been met throughout the workshop. of additional interest were the participants’ perceptions of the strengths and limitations of the workshop, the perceived effectiveness of the workshop in increasing knowresearch may 2016, vol. 8, no. 1, suppl 1 ajhpe 89 ledge and skills in biostatistics, and the value of the workshop in increasing biostatistics capacity at faculty and postgraduate levels. the evaluation was approved by the ukzn biomedical research ethics committee (ethics ref. no. be035/15). methods evaluation components the objective of the evaluation was to assess the knowledge gained as well as workshop process and included both quantitative and qualitative components: (i) quantitative preand postworkshop assessments; (ii) a brief qualitative midworkshop questionnaire; and (iii) focus group discussions (fgds). population and sampling the target population comprised current and future health researchers at ukzn. for the quantitative evaluation of postv. preworkshop knowledge gain, and the mid-workshop qualitative evaluation, the sample comprised all 2012 2015 workshop participants. these participants were regarded as representative of current and future ukzn health researchers who require skills in biostatistical reasoning. participants for the fgds were randomly selected from the 2014 and 2015 workshop participants. each fgd comprised seven to eight participants and, in total, three fgds were conducted. data collection the same knowledge assessment quiz was used with all available participants in each annual cohort, before and after the workshop, to quantify participants’ change in knowledge following the training. box 1 provides an example of one of the questions used for preand post-test assessments. the anonymous mid-workshop questionnaire enquired about the pace of the workshop and participants were asked to describe in one sentence something that they really liked about the workshop and to make a constructive suggestion to improve it. fgds were conducted by a single interviewer (mm), during which information about the objectives of the fgd and the overall study was provided. each participant was asked to provide informed consent to participate and to be recorded using a tape recorder. a structured discussion guide was used to facilitate the fgds. saturation was allowed to be reached during the three fgds conducted. data analysis quantitative data were cleaned and analysed using microsoft excel and stata version 13 (statacorp lp, usa). the distribution of preand post-scores by cohort was graphically assessed using box plots, and the change in knowledge based on the pre and post-test scores was assessed for each year of training using the wilcoxon signed-rank test. the raw audio data from fgds were first carefully reviewed and then transcribed verbatim into microsoft word in english, the language of the interview. the audio transcriber (mm) was familiar with the theoretical perspectives of the study and was able to ensure that these were reflected in the approach to transcriptions, which was interpretative, to ensure that the views and representations of the participants in the fgds were fully conveyed.[7] the framework analysis technique[8] was then used to analyse the transcribed data. this technique was chosen as it has been shown to preserve the integrity of individual responses throughout the analytical process, thereby providing a platform for reconsidering and reworking of ideas where more clarity is needed. to ensure trustworthiness of the qualitative data, respondent validation (cross-checking interim findings) was conducted by means of reflection to ensure that information reported by participants had been accurately understood. the data were collected and transcribed by one interviewer (mm), thereby minimising inter-investigator bias. the same interviewer also carried out the coding and analysis to ensure internal consistency. furthermore, a peer-review process was undertaken whereby a fellow senior researcher reviewed the steps taken to analyse and interpret data as a way of improving the inter-rater reliability of the study findings.[9] results quantitative findings the number of workshop participants in each year was 20, 17, 22 and 19 for 2012 2015, respecresearchers obtained birth weights for a random sample of 1 500 infants. the mean birth weight was 3 250 g and the standard deviation was 550 g. the 95% con�dence interval (ci) for the mean was 3 221 3 278 g. which one of the following statements best describes the information given by the 95% ci? (i) 95% of babies in the sample had a birth weight between 3 221 and 3 278 g (ii) there was a probability of 0.95 that the sample mean birth weight would be between 3 221 and 3 278 g (iii) there was a probability of 0.95 that the 95% ci will contain the mean birth weight for infants in this population (iv) 95% of babies in this population had a birth weight between 3 221 and 3 278 g. box 1. sample quiz question. 2012 (n=18) 2013 (n=13) 2014 (n=21) 2015 (n=14) 80 70 60 50 40 30 20 10 0 q u iz s co re , % wilcoxon signed-rank test, p=0.016 wilcoxon signed-rank test, p=0.007 wilcoxon signed-rank test, p=0.001 wilcoxon signed-rank test, p=0.001 pretest post-test fig. 1. box plots of the participants’ quiz scores before and after the workshop. research 90 may 2016, vol. 8, no. 1, suppl 1 ajhpe tively. in total, 78 postgraduate students and faculty members were trained over this period, the majority of whom were from the school of clinical medicine (33%), with the remainder from the school of nursing and public health (27%), laboratory medicine and medical sciences (13%) and other disciplines in health sciences (13%). the preand post-workshop assessment achieved a response rate of 84.6% (n=66). the 15.4% non-respondents included participants who were not available at either time of testing as well as those who only took part in one test and not the other. fig. 1 shows, for each year, box plots of the participants’ quiz scores (%) before and after the workshop and whether there was a statistically significant change in score, prev. post-workshop. the median post-test scores were higher than the median pretest scores across all 4 years of training; these differences were statistically significant, based on the wilcoxon signed-rank test. when data from all 4 years of training were combined, the results were as follows: pretest median score 55%, interquartile range (iqr) 40 62%; post-test median score 68%, iqr 62 76%; and p<0.0001, for the prev. post-workshop comparison. qualitative findings feedback on the mid-workshop questionnaire regarding the workshop process was generally positive. with very few exceptions, participants found the pace ‘about right’. comments regarding aspects of the workshop that participants really liked included ‘good technique re. learning concepts rather than calculations’, and ‘the fact that it emphasises intuitive understanding of concepts’. comments regarding possible improvement often included requests for consideration of the biostatistics regarding participants’ own research studies. prior expectations v. actual satisfaction participants attended with many expectations about the workshop and it was encouraging to learn from the fgd analysis that the majority were satisfied with the material delivered: ‘generally the pre-course expectations were quite high … but i felt the course has met those expectations in terms of practically understanding biostatistics. it has taken our interpretation of medical literature to another level.’ ‘we are not exposed to basic [statistics] stats on a regular basis. our training too hasn’t equipped us with this knowledge. our knowledge is limited by what we read. coming here, my expectation was to attain the skills to do equations and how to do stats and i have achieved more than what i have expected.’ ‘i have come here to get to know how to do statistical testing for my research purposes. but what we got was more than that, which increased my understanding … .’ perceptions about course delivery participants were also particularly impressed with the way the course was delivered and the approach used by the workshop facilitator: ‘when i first did stats 30 years ago it was manually done. i had various attempts to gain this knowledge and this is the first time we had a person like [name of facilitator] who made it easy to understand the concepts … the effectiveness of this method of teaching made us understand the concepts. that is what we found as beneficial … .’ ‘so she has a nice way of breaking it down to useable chunks, so that you can get a good grasp. she takes you from where you are and your level and builds on that potential.’ ‘the way she brings the message home she is a very good teacher. we had people here like he said … people who are intelligent don’t know how to transfer knowledge to other people [and] that becomes a problem. you ask her a question and she will be able to bring it down to the level of your understanding. that makes it wonderful.’ perceived improvement in the subject matter the workshop also boosted the participants’ ability to engage with the literature. the general sense from those who took part in fgds was that the biostatistical aspect of the literature had been a no-go area and they were grateful for the opportunity to learn how to critically interpret the statistics reported in biomedical and public health literature: ‘it has broadened our understanding because i didn’t have a background in statistics, for example when reading articles i would just rely on the discussion to understand but now i have a clue on how to interpret it.’ ‘i often skip over the stats-based concepts and proceed to the discussion, not knowing whether the study was reliable and valid. this has given me the tools to understand study design, the terminology and the concepts that we use.’ ‘… personally i also feel the same way, my knowledge has gone up by 50 to 60 percent … .’ value of the workshop participants also recommended that the workshop continues as it holds the promise of narrowing the skills gap in biostatistics in the school: ‘personally i think it’s a course that should continue, i think it actually is increasing our appetites in terms of how we look at papers, and the advice it gives to students is incredible … .’ ‘i think most of us are teachers and supervisors so when we are supervising we can also consider this as a master trainer kind of course, where this information is just not going to remain among the participants. we are supervising other students at different levels, so obviously the level and intensity of supervision will also improve as opposed to sending the student to the biostatistician to be assisted.’ ‘ … we are just masters students, it is a good course and maybe more of the students should have an opportunity to be a part of this, because we don’t know anything about statistics so we rely on the supervisor who will refer us to someone else.’ nevertheless, some respondents felt that the workshop was too compressed and could benefit from a more extended timetable to accommodate busy candidates: ‘i think this is a valuable course. however, i think [in] its current form, where it is compressed over 2 weeks, we have difficulty in keeping the commitment of being here the whole day over the 2 weeks. it’s going to be difficult. also this is intensive information which you need some time to process and to practise. they have provided all the building blocks, research may 2016, vol. 8, no. 1, suppl 1 ajhpe 91 they provide us with articles to read, they ask us questions to ensure we understand the concepts being taught, and they also provide us with supplementary exercises to go over. all of these resources are very helpful but at the same time it is very tiring. i think it needs to be changed from the current format and perhaps done over a longer period of time.’ discussion this article was written to share a possible model for improving biostatistical reasoning capacity among health researchers in academic institutions with a shortage of biostatistical expertise, and to demonstrate some of the lessons learned and the outcomes realised during a 4-year implementation period. there are unique needs for health research in the african region, but the ability to carry out this research is limited by the shortage of biostatistical expertise.[4] consequently, africa is often a source of data collection, but studies are designed and analysed elsewhere.[4] the ukzn biostatistics initiative envisaged a range of strategies to address this problem, one of which was a workshop in biostatistical reasoning for ukzn health researchers. the intention of the workshop was to improve the ability of participants to critically interpret the biostatistical components of the literature in their field and for them to be better able to assess the reports and proposals that they are responsible for reviewing. it was also hoped that the knowledge gained by individual participants would be shared with others within their own disciplines. a case-discussion approach to teaching biostatistics has been found to be successful with medical students in terms of both learning and student evaluation,[10] which is consistent with our experience with these workshops. the workshops were well received and there was both quantitative and qualitative evidence of participants achieving some level of learning. the evaluation of preand post-test scores demonstrated quantitative improvement in understanding, and in the fgds the participants indicated that they felt that they had indeed gained knowledge. the opportunity for small group discussions and in-class participation was considered by both instructors and participants to be an important component towards this success. this type of learning platform has been shown to lead to positive perceptions about knowledge gain.[11] some education researchers have advanced a view that to maximise learning outcomes, there is a need to consider group composition, to ensure homogeneity of expertise and seniority.[12] in this project, there was considerable heterogeneity in the seniority and experience of participants. the senior faculty among the participants often raised insightful points for discussion in class, arising from their own experience in their area of specialisation. the challenge for the facilitators was then to address these questions in a way that made them relevant for the broader workshop audience. another challenge for the facilitators was the diverse backgrounds of the participants, ranging from junior researchers, working on master’s-level projects, to heads of departments. however, it was felt that this diversity allowed the opportunity for improvement in biostatistical understanding throughout the spectrum of chs researchers and hence possibly longer-term effect. these pedagogic challenges are most readily met by biostatisticians with a depth of experience in the field, which, of course, presents a ‘catch-22’ challenge in a setting where this expertise is uncommon and, when present, often newly acquired. leading a workshop such as this is very different from teaching a more conventional biostatistics course and, as has been observed in other comparable settings, the choice of instructors is crucial to its success.[13] it is noteworthy that the biostatistical understanding of participants in the 2012 2015 workshops was typically poor to modest before the workshops. this is not surprising, as the dearth of biostatistical expertise in the subsaharan region has been widely recognised,[4,14] but it confirms the need for educational initiatives such as this. while the workshops increased quiz scores by an average of 13% overall, the understanding of many participants, post workshop, was still modest. scheduling the workshop over 8 full days improved participation, but was not ideal from a knowledge-processing perspective. this constraint is reflected in some of the comments from the fgds. this study does not assess to what extent the knowledge of biostatistical concepts was retained in the longer term. refresher sessions might be one way of maintaining and improving knowledge. it is further hoped that the knowledge gained from the workshops would better enable participants to engage with the hands-on online material which has also been developed as part of the biostatistics initiative. conclusion while the workshops were successful, there were limitations. the full-day condensed format, while improving attendance, was not ideal for learning. the concepts covered were increasingly complex and a gestation time to process the ideas would have been preferable. there is clearly a need for ukzn health researchers to also develop some analytic biostatistics skills, given the local shortage of professional biostatisticians for collaboration. acknowledgement. this work was made possible by grant no. 5r24tw008863 from the us president’s emergency plan for aids relief (pepfar), and the national institutes of health, us department of health and human services. its contents are solely the responsibility of the ukzn mepi programme and do not necessarily represent the official views of the us government. references 1. university of kwazulu-natal. the history. university of kwazulu-natal, 2016. http://www.ukzn.ac.za/aboutukzn/history (accessed 29 january 2016). 2. university of kwazulu-natal. the ukzn institutional intelligence report. university of kwazulu-natal, 2016. https://ii.ukzn.ac.za (accessed 11 february 2016). 3. winner l. introduction to biostatistics. department of statistics, university of florida, 2004. http://www.stat.ufl. edu/~winner/sta6934/st4170_int.pdf (accessed 6 february2016). 4. gezmu m, degruttola v, dixon d, et al. strengthening biostatistics resources in sub-saharan africa: research collaborations through us partnerships. stat med 2011;30(7):695-708. [http://dx.doi.org/10.1002/sim.4144] 5. mandala wl, cowan fm, lalloo dg. southern africa consortium for research excellence (sacore): successes and challenges. lancet glob health 2014;2(12):e691-e692. [http://dx.doi.org/10.1016/s2214-109x(14)70321-3] 6. bolt b. encouraging cognitive growth through case discussions. j teach phys educ 1998;18(1):90-102. 7. chandler cir, reynolds j. act consortium guidance: qualitative research protocol template with example tools and sops. london: london school of hygiene and tropical medicine, 2013:21-26. 8. bryman a, burgess r. qualitative data analysis for applied policy research. in: analyzing qualitative data. new york: routledge, 1994:173-194. 9. daly j, mcdonald i, willis e. why don’t you ask them? a qualitative research framework for investigating the diagnosis of cardiac normality. in: daly j, mcdonald i, willis e, eds. researching health care: designs, dilemmas, and disciplines. london: routledge, 1992:189 206. 10. marantz p, burton w, steiner-grossman p. using the case‐discussion method to teach epidemiology and biostatistics. acad med 2003;78(4):365-371. [http://dx.doi.org/10.1097/00001888-200304000-00008] 11. flosason to. evaluating the impact of small-group discussion on learning in an organizational psychology class utilizing a classroom response system.  dissertations 2011; paper 406. http://scholarworks.wmich.edu/ dissertations/406 (accessed 28 march 2016). 12. bennett j, lubben f, hogarth s, campbell b. a systematic review of the use of small-group discussions in science teaching with students aged 11-18, and their effects on students’ understanding in science or attitude to science. in: research evidence in education library. london: eppi centre, university of london, 2004. 13. ambrosius wt, manatunga ak. intensive short courses in biostatistics for fellows and physicians. stat med 2002;21:2739-2756. [http://dx.doi.org/10.1002/sim.1212] 14. fegan g, moulsdale m, todd j. the potential of internet-based technologies for sharing data of public health importance. bull world health organ 2011;89(2):82. [http://dx.doi.org/10.2471/blt.11.085910] editorial 2 august 2010, vol. 2, no. 1 ajhpe vanessa burch editor educating health professionals to meet africa’s needs vanessa burch e-mail: vanessa.burch@uct.ac.za this edition of the african journal of health professions education delves into the educational needs of health sciences training in africa. professor janet seggie provides an overview of the process of curriculum revitalisation in south africa. she follows the sociopolitical and educational currents that led to change over the past three decades and describes the modern tenets of education that have guided curriculum reform across the country. finally, she closes her paper off with a description of the challenges that we currently face in health sciences education and the priorities we need to focus on in the coming decade. five short reports are written by health professions educators who have recently completed a fellowship programme in health professions education, leadership and research offered by the southern africa faimer regional institute (safri). this gives me an ideal opportunity to introduce our readers to the foundation for advancement of international medical education and research (faimer), a usa-based non-profit organisation aimed at improving the health of communities by advancing health sciences education and research in developing countries.1,2 faimer was founded in 2000, and in 2001 i had the privilege of being selected as one of 16 international fellows who participated in the first round of the two-year part-time programme. the organisation focuses on faculty development by providing interactive on-site contact teaching sessions, electronic-based distance learning opportunities and an education research project which addresses a key need of the home institutions of participating fellows. a key element of the programme is the focus on improving education in institutions in developing countries with a strong emphasis on faculty retention in the developing world. about six years ago, faimer recognised the need to expand the programme by several fold and set about establishing regional institutes in india, brazil and south africa. to date there are more than 450 faimer fellows worldwide, including fellows from the five regional institutes. the regional institute established in south africa initially planned to focus on the educational needs of southern africa, hence the name, but it soon became clear that the demand was great throughout sub-saharan africa and we now have fellows all the way from sudan to cape town! so, as director of the safri programme, it is with a good measure of pride that i reflect upon the submissions of our new fellows. the report by ezeala and colleagues describes the use of portfolios in a clinical laboratory sciences training programme in uganda. the paper expands the educational platform suited to portfolio-based learning. ezera highlights the need in uganda for higher degree programmes in laboratory-based disciplines such as microbiology. mkandawire and colleagues from malawi explore the interest and need for an intercalated laboratory sciences degree in the mb chb programme offered in malawi. this triad of papers speaks of the urgent need for laboratory sciences expertise in africa. mkandawire’s paper also highlights the need for growing local research expertise in africa, a well-recognised need if africa is to develop the answers to research questions relevant to african priority health issues. museene describes the infrastructural and human resource needs required to roll out a programme of comprehensive nurse training in uganda. she makes the point that comprehensive training spanning the major disciplines in nursing is needed. our colonial silo-based programmes do not address the greater needs of africa and this abstract signals attempts to address this gap in the health workforce cadre on the continent. the final abstract addresses the need for novel assessment methods to assess competence in disciplines that require practical procedural competence. it is increasingly recognised that postgraduate specialist training programmes certify practitioners who have not necessarily objectively demonstrated competence in procedures germane to the discipline. dempers and colleagues explore the use of video material to demonstrate competence in postmortem examination and show that trainees are more adept than senior colleagues at the use of such modalities. technologybased assessment is increasingly becoming part of assessment processes and educators need to develop skills in the technology required to evaluate material submitted in an electronic format. blitz and colleagues explore a fascinating dimension of teaching: the impact of temperament on teaching. the paper makes the point that temperament and preferred approaches to teaching and actual teaching practices are not necessarily aligned and that faculty development may need to focus on improving the spectrum of teaching modalities of educators or that teams of teachers with different temperaments may need to be put in place to provide a range of teaching style preferences to address student learning needs. finally, mcmillan’s paper suggests ways in which health professions might move beyond description to generate explanations of teaching and learning that can be used to inform ‘best practice’. as with the paper by blitz et al., this paper seeks to enhance teaching practices by providing evidence that seeks to improve teaching. the papers in this edition speak to educational revitalisation, discipline-specific health workforce needs and teaching practices in africa. i think it is fair to say that this journal is providing a forum for discussing africa’s health professions educational needs. 1. burdick wp, morahan ps, norcini jj. slowing the brain drain: faimer education programs. medical teacher 2006; 28: 631-634. 2. burdick wp, morahan ps, norcini jj. capacity building in medical education and health outcomes in developing countries: the missing link. education for health 2007; 20: 3 (http://www.educationfor health.net/). article 21 december 2010, vol. 2, no. 2 ajhpe introduction open educational resources (oer) are learning materials that are freely available and openly licensed so that they can be used, copied, adapted, integrated, and shared.1 oer has the potential to advance the delivery of health education by increasing the availability of relevant learning materials, reducing the cost of accessing educational materials, and stimulating the active engagement of teaching staff and students in creating learning resources. inspired by these potential benefits of oer, in mid2009, over 40 faculty and staff representing 11 health science institutions from across africa came together to discuss the formation of a network to share openly licensed health educational materials developed by and targeted toward their african colleagues. at the meeting, participants jointly developed a vision for health oer network in africa,2 which envisions a network of african institutions that would harness oer to share know ledge, address curriculum gaps, and build communities of practice around health care education. following the meeting, oer africa, an initiative of the south african institute for distance education (saide), a consortium of african health institutions, the kwame nkrumah university of science and technology (knust), university of ghana, university of the western cape, university of cape town and university of michigan submitted a successful 2-year grant proposal to the william and flora hewlett foundation in late 2009, which launched the african health oer network. this report provides a summary of the african health oer network, focusing on the value proposition for the network, our target audience, services offered, content developed by participants, participant motivations for creating oer, and a call to join the network. value proposition for the african health oer network the network provides participants and institutions the following benefits: • global visibility for faculty and the university: participation represents an opportunity for faculty to showcase their expertise on an international level. the network has built relationships with well-known global oer repositories such as connexions, oer commons and mededportal. • integration into a community of educators: participants in the network join a community of health educators. furthermore, oer africa has partnerships with universities across the continent and can introduce members to other relevant continental and global networks. • assistance in finding relevant oer: oer africa is currently developing an oer request facility, which will create an opportunity to request materials that you have a specific need for, as well as to respond to specific requests for content should this material be available. target audience participation in the african health oer network is open to all. the network includes individuals, health faculty, non-governmental organisations, project teams, associations and consortia, among others. there is no obligation to sign or contribute financially to the network, but all participating individuals and organisations are encouraged to contribute oer as well and to add their electronic signatures to a declaration of support for the vision statement.3 as of this writing, 73 individuals and 14 organisations have added their signatures to the declaration. our objective is to systematically draw in more african and, eventually, global participants to create, adapt, share, and use oer to the benefit of health education in africa, while developing models of collaboration and sustainability that can be replicated in other regions of the world. contributing institutions currently include oer africa, university of michigan, knust, university of ghana, university of cape town, university of the western cape, university of malawi, university of botswana, and the health education and training in africa (heat) project of the open university and university of nairobi. services depending on need, network participants provide the following services to each other and new joiners: • training and workshops • mentoring and consulting • reference services for finding oer on a given health topic • reviewing content for copyright, privacy, and endorsement considerations4 • content production and distribution • content evaluation and assessment. content developed motivated by the lack of relevant existing materials and crowded ward rounds at the university hospital, a professor from the university of ghana created an interactive oer for caesarean section procedures. the learning module comprises narrated surgery videos including the seven main steps of the procedure, interactive case studies, and a selfassessment quiz. this module has already been shared with students at the university of ghana. another professor from the university of cape town, frustrated by the ‘horrifically expensive’ cost of textbooks, designed a comprehensive web-based course on occupational health. educators and learners on three continents now use this open course. the african health oer network: advancing health education in africa through open educational resources sarah hoosen1, kathleen ludewig omollo2 1 oer africa 2 university of michigan correspondence to: sarah hoosen (healthoer@oerafrica.org) article 22 december 2010, vol. 2, no. 2 ajhpe thus far, participants have created and shared 24 new oer modules, which are available on the oer africa website.5 disciplines currently represented include internal medicine, obstetrics and gynaecology, basic sciences and laboratory medicine, behavioural sciences, occupational therapy, public health, otorhinolaryngology and family medicine. participant motivations faculty involved in oer production at our partner institutions reaffirm the positive benefits of using oer, for example: african universities struggle to have access to information. if we have information, why do we not also share it as part of a pool of universities? using oer, our institutions are prepared to exchange information for the purpose of improved learning. (peter donkor, provost of the college of health sciences, knust.) you ought to maximise the use of your resources. if you are in a country and there are things unique to your country, then create oer. i really don’t believe in every single institution creating a full set of oer [modules]… i think people should do as best as they can to collaborate. (nii armah adu-aryee, general surgeon and clinical instructor, university of ghana.) join the african health oer network participation is open to all health sciences academics and professionals. with your help, we aim to build the network to include additional educators and institutions to increase development and circulation of healthrelated educational materials. we invite you to sign the declaration and to use the network to share and access teaching materials. we encourage you to experiment with creating open content6 and to share it with us at healthoer@oerafrica.org. references 1. http://www.oerafrica.org/understandingoer/understandingoer/whatisoer/ tabid/1097/default.aspx 2. http://www.oerafrica.org/healthoer/africanhealthoervisionstatement/tabid/955/ default.aspx 3. http://www.oerafrica.org/healthoer/healthoerhome/signdeclaration/tabid/1330/ default.aspx 4. http://open.umich.edu/dscribe 5. http://www.oerafrica.org/healthoer/ 6. http://open.umich.edu/share research 78 june 2017, vol. 9, no. 2 ajhpe reflective portfolios are a collection of evidence that attests to achievement as well as personal and professional development through critical analysis and self-reflection.[1] professional portfolios may be required for purposes such as seeking promotion and documenting continuing professional development, and for accreditation. in health professional education, portfolios have been used to support reflective practice, summative assessment, critical thinking, self-growth, learning and professionalism. in addition, they have been effective in aiding knowledge management processes and in bridging the gap between learning and practice.[2-4] perceived benefits to students include greater learning autonomy and heightened understanding of exit learning outcomes.[5] although portfolios have demonstrated positive effects in undergraduate programmes, evaluations of its use in postgraduate education have shown mixed results.[6] there is limited description of the contribution of portfolios to postgraduate health professional education, particularly within specialised public health programmes, such as maternal and child health (mch) and in african and south african (sa) settings. the master’s degree in child health (msc) and master’s degree in public health (mph (mch)) at the university of the witwatersrand, johannesburg, sa incorporated reflective portfolios as a course activity and assessment tool in 2010. we conducted this study to analyse the contribution of academic portfolios in the development of students’ reflective and critical thinking abilities, and its utility in assisting faculty to monitor and influence students’ learning and attainment of key competencies. methods the university of the witwatersrand offers two part-time 2-year master’s programmes related to mch; one in child health (msc) and another in mch (mph). both programmes are designed to prepare health professionals working in government departments, non-profit organisations, the private sector and at academic institutions for leadership positions in the field of mch. a combination of lectures, student-led seminars and discussions, online learning, group work sessions and site visits are employed across the 8 12-course modules to achieve course competencies. in 2010, portfolios were introduced as an additional strategy for students to reflect on their learning experiences. students are encouraged to review their engagement with course material and activities, and to showcase their academic, professional and personal growth. creative presentation of ideas and learning constructs is promoted. students submit an individual portfolio after each course module and an integrated portfolio at the end of each of the 2 years of study. each portfolio is marked by two or three staff members to enhance reliability. a marking rubric is used to provide grades and feedback to students (appendix 1). this study involved a qualitative, retrospective record review of postgraduate student portfolios submitted as part of their msc/mph coursework. we analysed all 35 integrated portfolios available since 2010 (when they were introduced) until 2014 (three cohorts of students). the final integrated, rather than individual module, portfolios were selected because they better reflected students’ overall experience. narratives/text segments were analysed qualitatively by thematic content analysis, a method used to identify, analyse and report patterns (themes) within data.[7] analysis was supported by maxqda version 11 (verbi soft ware gmbh, germany).[8] deductive and inductive codes were used. we identified deductive codes by reviewing literature on the role of portfolios in health professional education, realising codes such as ‘achievement of background. portfolios are increasingly used across a range of disciplines in health professional education to support reflective practice and to help assess students’ academic and professional development. however, their value in postgraduate education is uncertain. objectives. to identify the role of portfolios in the development and assessment of professional competencies in postgraduate maternal and child public health education. methods. a qualitative retrospective review of 35 student portfolios was conducted. thematic content analysis of portfolios was done, identifying emerging themes and analysing patterns. results. two major themes were explored – the benefit of the portfolio to the student and to faculty. for students, portfolios promoted reflective abilities and critical thinking and assisted them in planning learning needs. for faculty, the portfolios assisted in monitoring students’ growth over time, identified learning gaps, helped to establish if expected learning outcomes were being attained and provided feedback on students’ application of academic learning to professional practice. portfolios also offered students an opportunity to provide critical feedback on curricula content and course pedagogic activities. conclusion. portfolios are an under-utilised assessment and self-development tool in postgraduate training. they allow students to self-assess their attainment of personal learning needs, professional growth and competency achievement and provide faculty with useful feedback on curriculum content, educational activities and competency attainment. afr j health professions educ 2017;9(2):78-82. doi:10.7196/ajhpe.2017.v9i2.796 reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education h pandya, bds, mph; w slemming, bsc (physiotherapy), mph; h saloojee, mb chb, fcpaed (sa), msc division of community paediatrics, department of paediatrics and child health, faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: h pandya (drhimanip@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research june 2017, vol. 9, no. 2 ajhpe 79 learning outcomes’, ‘reflective and critical thinking ability’ and ‘application of learning to practice’. new inductive codes such as ‘feedback on pedagogic techniques’ and ‘plan learning needs’ emerged while analysing the portfolio scripts. finally, all codes were collated to develop two overarching themes, i.e. student benefits and faculty benefits. ethical clearance for the study was obtained from the human research ethics committee (medical) of the university of the witwatersrand (ref. no. m150750). results findings are presented under two major headings: the benefit of portfolios to students and to faculty. portfolios substantially contributed to enhancing students’ critical thinking and reflective abilities and in planning their learning needs during the course of the degree. portfolios assisted the faculty in assessing gaps in students’ learning, and in monitoring and appreciating their personal growth, achievement of learning outcomes and application of learning to professional practice. fig.1 presents a framework that summarises the contribution of portfolios to both students and faculty in postgraduate public health education. it depicts the relationship between major themes and codes, with relevant examples for each code. student benefits of developing a portfolio portfolios promote students’ reflective abilities and stimulate critical thinking students began relating topics and issues covered in modules to events in their daily lives and workplace and utilised the portfolio to reflect on this: ‘i was impressed most by the psychiatric disorder session; i could link this to street children in the democratic republic of congo (where resided). most of them were soldiers and rejected by their family by mothers saying they are not normal, they are sorcerers. the life in the street is very difficult and i cannot imagine the life of girls begging and sleeping on the street and how fragile girls are in the street.’ (mph, 2011) ‘i wrote an assignment on mental health of south african children with a new found understanding of and respect for the field. i always thought mental health services were for the most severe cases and the others would simply sort themselves out over time. however, millions of children throughout south africa and the world suffer in silence from the myriad challenges, i.e. poverty, parental loss, abuse, etc., they are forced to face every day.’ (mph, 2011) students were exposed to mch programmes and policies, and controversial issues, such as hiv infant feeding, abortion and reproductive health, were debated during modules. portfolios contained evidence that students re-examined their own biases and pre-existing notions based on exposure to this additional knowledge and exposure: ‘there is a notice on the entrance to the family planning section of the clinic we visited that says: no male allowed. the lack of men’s participation in reproductive health services and family planning means that they do not benefit from any information given by heath providers regarding sexuality, pregnancy and their roles in these.’ (msc, 2011) ‘on that day, only 20 people came for family planning services. again i started asking myself. why is it that there are so many people seeking termination of pregnancy (top) services and not family planning services? are people using top as family planning method? this made me realise that designing interventions for public health problems is not easy, it needs careful planning, involvement of stakeholders and beneficiaries and there is need to constantly assess the impact of the designed intervention.’ (mph, 2011) portfolios help students to plan their learning needs and reflect on performance through portfolio writing, students systematically compared their learning with explicit mch competencies they were expected to attain, assessed fig. 1. framework showing contribution of a portfolio in postgraduate public health education. to students to faculty promote re�ective abilities and critical thinking plan learning needs assess gaps in student learning assess students’ growth assess application of learning in professional practice feedback on curricula content and pedagogic activities – course subject matter – gaps in public health policies and programmes – attainment of competencies – modi�cation of learning approaches – research design – presentation skills – data interpretation – budgeting – improved communication, leadership and management – professional goal attainment – change management at work place – feedback on group work and experiential visits to clinics assessment feedback from students examples research 80 june 2017, vol. 9, no. 2 ajhpe gaps and indicated how they planned to modify their learning approaches. they also reflected on their performance in assignments and examinations during the modules, analysed reasons for poor performance and developed strategies to improve their performance: ‘i have compared my learning to the mch competency framework for those areas relevant to all modules. i have decided to do this on an ongoing basis … since i will need to pursue a certain amount of selfdirected learning to ensure that i am up to speed in all areas of my studies.’ (msc, 2010) ‘i realise that information comes from reading or seeking to know more. i will need to increase my level of reading of academic papers as well as challenge myself to think critically.’ (mph, 2011) students did not report any negative perceptions about the portfolio, such as fear of confidentiality being breached, distraction from other coursework activities or the repercussions of expressing negative views. many students found the activity quite challenging at first, because it forced them to think creatively and critically, which deviated from their previous academic experiences. however, this challenge was overcome as more portfolio entries were completed and as they received positive feedback. confidence in the lack of negative consequences grew as students recognised that unfavourable reflections on course activities were viewed positively rather than being discouraged by staff: ‘i was introduced to the concept of the “portfolio” – this filled me with a real sense of dread. it encouraged us to “think out of the box” and be creative. for scientifically-minded and very right-brained individuals, “creative” is often something that does not come easily! as more modules rolled around, i think that i understood the portfolio-thing a bit better and felt that i was synthesising many of the concepts learnt during the lecture block weeks.’ (mph, 2013) benefits of the portfolio to faculty portfolios help faculty to assess gaps in students’ learning student portfolios helped us, as faculty members/course organisers, to identify gaps in our students’ academic and professional knowledge and skills. common gaps reported by students included poor epidemiology, research, health budgeting and strategic planning skills and inadequate knowledge of socioeconomic and community components of public health (specifically reported by clinician students): ‘as a clinician, i am able to perform exceptionally well. as a leader, a researcher, a manager and analyser of systems, i found myself in an uncomfortable place where i could understand what was needed to be done but felt lacking in terms of the knowledge and tools to reach my goals.’ (msc, 2012) ‘i must admit that working out budgets was never one of my strong points. i always thought as a public health manager, i will just employ someone qualified to deal with that part. during the discussion session, it became clearer to me that as a leader it is wiser to be involved and understand the financial aspect of any mch programme implemented.’ (msc, 2010) portfolios demonstrate students’ growth and achievement of learning outcomes students used portfolios to reflect on ways in which they matured over the 2 years of the master’s programme. they reported an improvement in their knowledge of mch topics, communication skills (oral presentation and writing) and leadership/management skills. some explained how their newly acquired competencies improved their performance as health professionals: ‘after this module, i had learned a lot about programme planning and managing. all my life i have been taught to implement, not to plan, the experience that i gained over the years, to sit in the consultation room and see patients. at the end of the month i would write reports as part of my responsibility, not knowing that programme planning is based on numbers.’ (mph, 2011) ‘during the course i was exposed to group presentations due to which my communication skills have improved and facing an audience is no longer as frightening as before. i conduct most of the mortality and morbidity meetings in my department and there is no doubt now that a big stage will be next.’ (msc, 2011) portfolios display how students apply learning to professional practice portfolios offered a platform for students to identify and reflect on their professional goals and objectives and to indicate how they transferred their academic learning to professional practice. students outlined their immediate and longer-term goals and described how they would achieve these. students reflected on changes they implemented in their professional practice as a result of their learning: ‘i took back to hospital the use of zinc as one step to improve the outcome of diarrhoea in our ward and now all doctors prescribe it. the pharmacy has joined us in an effort to have zinc available all the time. we have already seen a change in the duration of paediatric patients’ stay in hospital in the last few weeks.’ (msc, 2011) ‘by the time i wrote my third and fourth portfolio, it was great work. i drew up my personal experience and all the principles of writing which i learnt a long time ago and this really helped me. currently, the reports that i write for my work look much better than before.’ (mph, 2011) portfolios provide feedback on curricula content and pedagogic activities students reflected on various teaching and learning techniques experienced in the programme. portfolios captured critical feedback from students not often acquired through other feedback mechanisms. further, portfolios fostered the development of a professional identity: ‘it came to me as a pleasant surprise to find engagement, interrogation and stern but helpful questions and advice employed as tools of learning. as i already understood, this was just one of the skills that would be necessary for me to be successful as not only a master’s candidate but also as a leader, researcher and public health professional.’ (msc, 2014) ‘i was looking forward to the group work sessions, as these were important highlights for me during this module. the group work sessions were slowly training me to be the leader or manager i had in mind.’ (msc, 2010) discussion this study demonstrates that reflective portfolios can substantially contribute to postgraduate and public health education. while the study echoes many of the findings from the existing literature on the benefits of portfolios in health professional education, it is the first to do so specifically in the context of maternal and child public health education and in an african setting. key findings emanating from this study include the following: • portfolios are similarly useful in postgraduate public health education, specifically mch, as in other disciplines of health professional education. research june 2017, vol. 9, no. 2 ajhpe 81 • portfolios can assess students’ learning needs, growth and competency achievement and provide useful feedback on pedagogic activities and curriculum content. • portfolio guidelines and marking rubrics can contribute greatly in directing students’ reflections and ensuring that a full range of activities and developmental areas are considered. • portfolios of postgraduate public health students working within health systems while studying contain crucial evidence of ways in which academic learning is applied in professional practice. with the complexity of emerging public health issues, it is imperative that master’s graduates not only demonstrate mastery of theoretical content, but also critical thinking and application in practice. they are expected to function as reflective practitioners capable of evaluating policies and programmes and fixing gaps in the public health system. we believe that portfolio writing enhanced students’ reflective ability and critical thinking skills. this conclusion concurs with that in a study indicating that portfolios contributed substantially in stimulating critical thinking in social work education.[9] there is mixed evidence as to whether portfolios aid or hinder reflection in postgraduate education, as it depends on individual learning preferences.[2] we found that writing a portfolio generally enabled students to relate the knowledge gained during the coursework to their real life experiences and to reflect on an ongoing basis. we identified no demographic, cultural or learning traits that restricted this conclusion being drawn. we established that students utilised the portfolio as a platform to identify their learning gaps, plan learning needs and organise their academic journey during the course of a master’s programme. in a systematic review of the effectiveness of portfolios for postgraduate assessment and education, portfolio users were shown to take increased responsibility for their own learning and be less passive learners.[2] keim et al.[10] showed that, compared with a control group, portfolio users produced more learning needs assessments and learning plans. portfolios have been recognised as useful tools for faculty to conduct students’ assessments and identify gaps in their learning. however, there is wide variation in the literature in the level of reliability of portfolios for assessment. it is recommended that portfolios should not be used for summative judgements but for more qualitative and less structured student assessments.[2] we assigned summative judgements (20% of the year mark) to our portfolios, primarily to ensure that the task was taken seriously. the study was not designed to test the reliability of our assessment, but we noted good congruence between the three evaluators. portfolio reflections influenced various curriculum change decisions in our programme, including the delivery and structure of curriculum content, facilitator changes and a greater focus on pedagogic techniques preferred by students, such as experiential site visits. massive open online courses (moocs) were introduced as core ‘pre-readings’ based on portfolio comments suggesting that non-clinician students were struggling with basic clinical concepts during modules. comments also directed course co-ordinators to the type of changes needed in student assessment and course evaluation tools. portfolio reflections provided qualitative or descriptive insight into intangible aspects of students’ growth, which could not be assessed by conventional modes of assessment, such as written examinations and assignments. portfolio entries demonstrated ways in which students grew and evolved over the duration of the msc/mph programme. the portfolio guidelines (and assessment rubric) also demanded student engagement with activities that may otherwise have been ignored, such as continuous reflection on, and self-evaluation of, course competency achievement. lastly, a particular strength of the portfolio was the students’ reflection on the transfer of academic learning to their respective workplaces. literature suggests that portfolios support application of learning to practice in health professional education, especially if their use is continued at the workplace.[2] a portfolio can promote holistic learning by serving as a reflective bridge between the student, the workplace and the academy.[11] our study expands this evidence base with a specific focus on postgraduate public health education in mch. as this was a qualitative study based on narratives reported in portfolios, we cannot quantify the proportion of students to whom the positive findings were applicable. this limits the generalisability of the results. we acknowledge that some students had better reflective abilities than others. students’ claims could not be verified by using other evaluative methods. further, as the study did not follow up students after they graduated, we cannot verify if the students’ intentions and self-reported competencies were actually realised or put into practice after degree completion. as the portfolio contributed to summative assessment, students may have presented undue positive or favourable comments to curry favour from staff. to dissuade students’ from doing this, we rewarded critical, rather than overly positive comments. we believe this approach was successful. future research should explore if there is a gap between self-reported learning, competency achievement and actual practice. it would be worthwhile ascertaining if graduates continue reflective activities, such as diaries, blogs or similar activities, in a professional setting when portfolio writing is no longer a compulsory course activity. conclusion the continuing development and improvisation of higher education in specialised fields of health, such as mch, demand more valid and reliable assessment of knowledge, competency and skill attainment, as well as attitude and behaviour assessment. a reflective portfolio can successfully serve this purpose for both students and faculty. portfolios written by msc/ mph students contained crucial evidence of reflective practice, critical thinking, self-growth, professionalism, knowledge management processes and heightened appreciation of exit competency outcomes. the portfolio also enabled us, as faculty, to attain a better understanding of student experiences and exit outcomes accomplishment. acknowledgement. we thank our students who agreed to have their portfolio entries analysed and publically shared on the promise of anonymity. 1. mcmullan m, endacott r, gray ma, et al. portfolios and assessment of competence: a review of the literature. j adv nurs 2003;41(3):283-294. http://dx.doi.org/10.1046/j.1365-2648.2003.02528.x 2. tochel c, haig a, hesketh a, et al. the effectiveness of portfolios for post-graduate assessment and education: beme guide no. 12. med teach 2009;31(4):299-318. http://dx.doi.org/10.1080/01421590902883056 3. sauer ka. use of reflective portfolios in health sciences education. am j pharm educ 2007;71(2):1. http://dx.doi. org/10.5688/aj710234 4. david mfb, davis m, harden r, howie p, ker j, pippard m. amee guide no. 24: portfolios as a method of student assessment. med teach 2001;23(6):535-551. http://dx.doi.org/10.1080/01421590120090952 5. davis mh, ponnamperuma gg, ker js. student perceptions of a portfolio assessment process. med educ 2009;43(1):89-98. http://dx.doi.org/10.1111/j.1365-2923.2008.03250.x 6. driessen e, van tartwijk j, van der vleuten c, wass v. portfolios in medical education: why do they meet with mixed success? a systematic review. med educ 2007;41(12):1224-1233. http://dx.doi.org/10.1111/j.13652923.2007.02944.x 7. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. http://dx.doi. org/10.1191/1478088706qp063oa 8. maxqda. the art of data analysis. 2016. http://maxqda.com/legalinfo (accessed 4 april 2016). 9. coleman h, rogers g, king j. using portfolios to stimulate critical thinking in social work education. social work educ 2002;21(5):583-595. http://dx.doi.org/10.1080/0261547022000015258 10. keim ks, gates ge, johnson ca. dietetics professionals have a positive perception of professional development. j am diet assoc 2001;101(7):820-824. http://dx.doi.org/10.1016/s0002-8223(01)00202-4 11. brown jo. the portfolio: a reflective bridge connecting the learner, higher education, and the workplace. j contin higher educ 2001;49(2):2-13. http://dx.doi.org/10.1080/07377366.2001.10400426 http://dx.doi.org/10.5688/aj710234 http://dx.doi.org/10.5688/aj710234 http://dx.doi.org/10.1111/j.1365-2923.2007.02944.x http://dx.doi.org/10.1111/j.1365-2923.2007.02944.x http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1016/s0002-8223(01)00202-4 research 82 june 2017, vol. 9, no. 2 ajhpe appendix 1. marking rubric for msc/mph portfolios student detail name module characterisation of dimensions of portfolio design style descriptive ٱ ٱ ٱ ٱ ٱ reflective structure informal ٱ ٱ ٱ ٱ ٱ formal confidentiality personal ٱ ٱ ٱ ٱ ٱ public (closed) (open) content focused ٱ ٱ ٱ ٱ ٱ comprehensive (e.g. critical incidents) (e.g. range of activities) presentation grade comment • evidence of guidance framework (index, conclusion, captions, etc.) • organisation • visual appeal • spelling/grammar • referencing content grade comment • conciseness/length • creativity • effort • professionalism • additions (e.g. articles) reflection on grade comment • critical incidents • educational activities • programme objectives • response or solutions to issues • competencies achieved • self growth (e.g. leadership, embracing diversity, communication, etc.) evaluator’s comments • overall decision: (%) • most enjoyed or impressed by: • could have been improved by: • general comment/s evaluator’s name date grading percent category a+ > 80 exceptional a 76 80 excellent b 70 75 superior c+ 65 69 good c 60 64 satisfactory d 50 59 minor deficiencies f < 50 major deficiencies (fail) n not done march 2018, vol. 10, no. 1 ajhpe 13 research physiotherapy is a health profession that is focused on the rehabilitation of individuals faced with impairments, activity limitations and/or disabilities that affect daily life. furthermore, physiotherapists promote quality of life through identification of environmental and social barriers and promotion of health and wellbeing.[1] becoming a registered physiotherapist in south africa (sa) requires graduating from an undergraduate training programme at one of eight universities and successfully completing 1 year as a remunerated supervised community-service physiotherapist.[2] the duration of the sa undergraduate physiotherapy programme is 4 years, leading to a bachelor of science in physiotherapy degree.[2] the university where this study took place offers a physiotherapy programme with an intake of ~50 students in the first year. in the second year of undergraduate training, students are exposed to clinical learning platforms, but are merely observers at this level. in the third year, students begin clinical rotations in groups of 6 or 7 for periods of 5 weeks – 4 blocks per year. the clinical blocks cover cardiopulmonary, neurological and neuromuscular conditions and community rehabilitation, including health promotion and awareness. during the third year, students assess and treat patients individually under the supervision of clinical supervisors and physiotherapists employed at clinical sites. students are subjected to both formative and summative assessments, including bedside clinical examinations at the culmination of each block. the final year of the programme is a reflection of the third-level framework but evolves into specific areas of practice, such as intensive care rehabilitation and orthopaedic mobilisation.[3] students are also expected to manage patients independently and demonstrate clinical reasoning, including diagnosis and prognosis of patients’ conditions to optimise rehabilitation. during their final year, students undergo a summative externally moderated examination at the clinical placement areas. students in their third and fourth years are exposed to clinical practice in primary healthcare settings, as well as various public healthcare contexts, spanning quaternary-, tertiaryand district-level hospitals. these students are supervised and assessed by clinical educators, who are academic staff or university-employed physiotherapy clinicians. they are referred to as clinical supervisors for the purpose of this article. two or sometimes three clinical supervisors are responsible for clinical training of physiotherapy students per clinical block. supervisors facilitate group work through case presentations and problem-based learning and use individual bedside teaching as core strategies of learning. there is at least one clinical supervisor per day to supervise the 6 or 7 students per clinical block. supervision time varies from 1 hour of case presentations with all students to supervising students managing patients for 45 minutes 1 hour at least once during a block. the nature of clinical supervision is consistent throughout the clinical blocks. the role of clinical supervisors is essential in the co-creation of knowledge and facilitation of learning within the physiotherapy programme.[4] clinical education is essential to prepare undergraduate physiotherapy students to gain profession-specific knowledge, develop technical skills and become socially and ethically competent to practise independently.[5-8] in sa, these are governed by the universities’ graduate competencies framework. health science students should demonstrate adeptness in seven key roles, i.e. as practitioner, communicator, collaborator, leader, scholar, health advocate and professional.[9] although clinical education is fundamental for the preparation of students to practise autonomously, little evidence exists on the approaches to deliver an ideal model for training of the physiotherapy background. clinical education for physiotherapists forms a vital part of undergraduate programmes and equips students with competencies to practise autonomously as qualified health practitioners. however, disparities are evident in approaches to clinical education. objective. to explore the perceptions of physiotherapy students, community-service physiotherapists and physiotherapy clinical supervisors regarding the clinical education framework at a tertiary institution in south africa in order to understand preparedness of students for practice. methods. a case study approach with two focus group discussions with students and interviews with community physiotherapists and clinical supervisors was employed. data were analysed and categorised into key themes and sub-themes. results. five themes emerged from triangulation of data from the three groups: preparedness for professional practice, institutional barriers, curriculum disputes, personal factors and recommendations for physiotherapy clinical education. students felt inadequately prepared owing to a perceived lack of exposure to certain aspects of physiotherapy, while community therapists believed that reflection on the undergraduate programme after qualifying contributed to their adequate preparation. clinical supervisors supposed that students would benefit from actively engaging with teaching and learning opportunities, and clinical personnel collaboration was seen as key to facilitate a continuum in clinical education from classroom to healthcare setting. conclusion. participants reported that the existing curriculum structure may need to be revisited to address various issues, while holistic collaboration between students, supervisors and clinical personnel is imperative to create a cohesive learning environment. afr j health professions educ 2018;10(1):13-18. doi:10.7196/ajhpe.2018.v10i1.987 physiotherapy clinical education at a south african university v chetty, phd; s maddocks, mphysio; s cobbing, phd; n pefile, msc, medsc (rehabilitation); t govender, bphysio; s shah, bphysio; h kaja, bphysio; r chetty, bphysio; m naidoo, bphysio; s mabika, bphysio; n mnguni, bphysio; t ngubane, bphysio; f mthethwa, bphysio discipline of physiotherapy, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: v chetty (chettyve@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 14 march 2018, vol. 10, no. 1 ajhpe research student.[5] a review of clinical education models was conducted in 2007, which analysed a milieu of models in global contexts.[7] these included the one-educator-to-one-student model, one-educator-to-multiple-students model, multiple-educators-to-one-student model, multiple-educators-tomultiple-students and/or non-discipline-specific-educator model, and finally student-as-educator model. the review found that no model proved to be superior to another and that benefits and inhibitors influencing the various models were used internationally in tertiary institutions.[7] furthermore, a gap exists regarding a model to guide clinical education in the current sa context and approaches to address discrepancies in tertiary clinical training. this study aimed to explore the views of current students, past students who were in their community-service year of practice, as well as clinical supervisors – to understand the landscape for co-operative construction of the clinical education platform at the tertiary institution of research interest in this study. another objective was to contribute to the development of an integrated teaching and learning model of clinical education within the current study context to inform further enquiry and have a positive influence on the sa health science education. methods a qualitative explorative case study approach allowed for investigation of the clinical education component of a physiotherapy programme at a tertiary institution in sa.[10] with this approach, real-life phenomena could be studied, as experienced by students, community-service physiotherapists and clinical supervisors in a resource-limited higher education context.[10,11] an holistic single case study with triangulation of data from the students, community physiotherapists and clinical supervisors was used to understand the clinical education experience at the university and its collaborating clinical learning platforms.[11] ethical approval the study was approved by the humanities and social sciences research ethics committee at the university of kwazulu-natal in sa (ref. no. hss/1124/016u). permission was also obtained from all designated authorities, including the academic leader of the university’s physiotherapy department. participant enlistment the following were recruited through purposive maximum variation sampling: 22 final-year physiotherapy students from a class of 50; 9 community-service physiotherapists from various clinical settings, including rural, urban and semi-rural settings; and 9 of 12 physiotherapy clinical supervisors responsible for clinical education and supervision of students. maximum variation sampling for the current case study approach allowed for a wide range of views, including current students, communityservice physiotherapists, i.e. physiotherapy students who completed their undergraduate degree at the study setting the previous year, as well as clinical supervisors.[12] all participants signed informed consent forms to participate voluntarily in the study. no incentives were offered. pseudonyms were used to annotate quotes from participants. data collection two focus group (n=12 and n=10) discussions were conducted with the final-year students at the institution to allow an open discussion with each other and to develop thinking. the focus groups remained open and flexible and allowed researchers who were part of the physiotherapy student body to delve into experiences and develop themes. an independent researcher and registered physiotherapist interviewed the clinical supervisors and community-service therapists using semi-structured interview guides, as it was challenging to co-ordinate focus groups with the professionals in the respective groups (community-service physiotherapists and clinical supervisors). the relevant literature was reviewed and feedback from a pilot interview, as well as discussions with two experts in qualitative research methodology at the university, guided the process. a tape-recorder was used to capture narratives, while verbal nuances were recorded manually. the raw data were transcribed verbatim immediately after discussions and shared with the participants for verification. data analysis transcribed data were entered into nvivo 9 software (nvivo, usa) and read independently several times by researchers. two teams of researchers derived themes and sub-themes. two experts in qualitative methodology assisted in facilitating discussion around data and in attaining consensus among the researchers regarding themes and sub-themes. methodological rigour was maintained through triangulation of data sources, member checking for veracity, peer debriefing and use of thick, rich descriptions. furthermore, researcher bias was minimised by interviews conducted by peers, adding valued prompts by means of the data gathering.[11,13] results five overarching themes, i.e. preparedness for professional practice, institutional barriers, curriculum discrepancies, personal factors and recommendations for physiotherapy clinical education, were identified. sub-themes were also derived from the triangulated data from the students, community-service physiotherapists and clinical supervisors. table 1 reflects the data of each group of participants, including age and gender. the community-service therapists worked in environments spanning rural, urban and semi-rural settings. five supervisors had >5 years of experience, 3 clinical supervisors had 1 5 years of experience, and 1 clinical supervisor had >10 years of experience. table 2 displays the themes and sub-themes that emerged from triangulation of the data. themes 1. preparedness for professional practice and associated sub-themes, as well as perceived lack of graduate attributes for clinical practice, are described in the following narratives, together with illustrative quotes. some of the final-year students in this study felt unprepared to face clinical practice in their upcoming community-service year and thought that they were not sufficiently equipped to manage patients within certain fields of physiotherapy, such as paediatric care: ‘we do get exposure but not in all areas … other universities cover blocks like paediatrics.’ (student, kaitlin) some students and the majority of the community-service physiotherapists believed that undergraduate clinical training provided a suitable foundation for clinical practice, patient care and clinical reasoning: march 2018, vol. 10, no. 1 ajhpe 15 research ‘it was a little difficult at first but i adapted quickly, physio knowledge [referring to undergraduate training] serves as a fair foundation.’ (community-service physiotherapist, anele) the perceived lack of professional attributes, such as communication, was highlighted in the voices of the clinical supervisors: ‘the dedication and calibre of students have changed and evolved in the past few years; students have a sense of entitlement and don’t communicate properly.’ (clinical supervisor, refilwe) 2. institutional barriers. the quotes below reflect the barriers experienced by participants. the students reported that they were adequately supervised, but could benefit from smaller numbers of students per clinical supervisor: ‘compared to last year, it is now better to have smaller groups [referring to decreased number of students in blocks from 13 14 to 6 7] … i feel the smaller the number of students, the easier it is to supervise and i wish we had even fewer ... [giggles].’ (student, sandy) work overload, time constraints and other site barriers posed further challenges to the clinical training platform, as mentioned by students and clinical supervisors: ‘i feel like the qualifieds [physiotherapists at the hospitals] on clinical sites give us all too much work; it is because they have too much work to do.’ (student, chris) ‘time is always a challenge, there is so much to learn and very little time to teach it all.’ (clinical supervisor, angelique) ‘limited resources at the clinical sites like equipment is always a challenge, also sometimes you go through periods of insufficient patients on site.’ (clinical supervisor, oupaman) 3. curriculum discrepancies are reflected in illustrative quotes from the participants. the disparity in the curriculum design of the undergraduate programme is evident in echoed voices of students: ‘well, theory-wise i think for us zulu-speaking students they should change that module to an english module … irrelevant modules covered in first and second year.’ (student, melusi) students indicated that some of the theoretical content taught in the programme was irrelevant: ‘there are some theoretical parts [referring to the basic sciences] that we barely actually do apply!’ (student, chante) cohesive agreement between theory and practical sessions seemed to be something students thought was neglected. they believed that there was a gap between what they were learning in the classroom and what they were expected to apply clinically at the healthcare settings when managing patients: ‘i feel that sometimes they don’t correlate what we learnt in class with what is expected in hospital; i couldn’t apply it at the hospital.’ (student, annie) table 2. summary of categories and themes themes sub-themes preparedness for professional practice perceived unpreparedness in exit year reflective preparedness for community service perceived lack of graduate attributes institutional barriers student/supervision ratio work overload time constraints site barriers curriculum discrepancies disparity in curriculum design irrelevant theoretical content cohesive learning personal factors student/educator relationship personal perceptions student engagement communication breakdown recommendations for physiotherapy clinical education theoretical bedside approach improved inclusive educational content improved curriculum design communication between stakeholders collaboration with clinicians table 1. biographical data and characteristics of participants (n=40) gender age group, years participants male female 20 29 30 39 40 49 50 59 final-year students 6 16 22 community-service physiotherapists 3 6 9 clinical supervisors 3 6 2 6 1 16 march 2018, vol. 10, no. 1 ajhpe research 4. personal factors are illustrated by the quotes below. the relationship between student and educator seemed to be ill-defined and posed challenges to clinical education: ‘students feel we owe it to them to hand over all the information; it is not the norm but there is a trend to ask for things at any time and they don’t want to meet you half way.’ (clinical supervisor, chloe) perceptions, such as favouritism, seemed to be a challenge that faced students and hindered learning: ‘we need to be treated fairly and equally. supervisors need to stop this habit of having favourites, and level with us all.’ (student, thomas) student engagement as active learners on the teaching platforms seemed to be another inhibitor in optimum clinical education: ‘students are not active participants of their own learning outcomes.’ (clinical supervisor, refilwe) communication breakdown between stakeholders, e.g. clinical supervisors and clinical placement staff, posed a barrier to optimal learning: ‘we would like the supervisors and the hospital physiotherapists to have the same stories … during exam time we get so confused because of their contradicting ideas.’ (student, xolani) 5. recommendations for physiotherapy clinical education is the final reflection of the study results. a theoretical bedside approach was suggested as a way forward for students to bridge the gap between theory and clinical practice: ‘it will also be nicer if the clinical supervisors would treat patients in front of you at the hospital.’ (community-service therapist, nasreen) students echoed that a more comprehensive and inclusive undergraduate programme, including different aspects of physiotherapy, would benefit them: ‘we need to have a sports block because the whole aspect of us choosing physiotherapy is to have different options when working, and more blocks to touch on paediatrics and strapping should be done in a module as well.’ (student, andiswa) students felt that the curriculum design could be improved by rearranging modules for fluidity, which would have a positive impact on clinical education and patient management: ‘some of the modules should be rearranged to help you, e.g. isizulu should be brought into second or even third year to help us communicate better with our patients.’ (student, thobile) students believed that the communication between stakeholders could be improved by tutorials to have a positive impact on clinical education: ‘the lecturers (academic) should give the supervisors (clinical) tutorials about what we are learning so it [clinical education] will fit what we are learning in the classroom.’ (student, moses) clinical supervisors were convinced that collaboration with clinicians on site would improve the clinical education framework: ‘there needs to be buy-in and greater involvement with the clinicians (at placement sites), as they should be more involved in clinical education.’ (clinical supervisor, africa) discussion clinical education is essential for the training of physiotherapists to prepare them for autonomous practice in their future careers as healthcare professionals. the evidence in a sa context is scarce – insight was gleaned from a broader international framework of the literature regarding various approaches to and perceptions of clinical education for physiotherapy students and their clinical training. it is believed that students learn the technical skills, as well as social and attitudinal competencies, to manage patients in their communities during their clinical education in undergraduate programmes.[5,6] final-year physiotherapy students who participated in the focus group discussions felt unprepared to manage patients and apprehensive to start their communityservice practice year. according to roman and dison,[14] sa universities are currently facing a lack of student preparedness, which is attributed to an array of factors, including the multilingual needs of the students and the large intake of students into university programmes. however, according to ramli et al.,[15] students experienced anxiety towards initial exposure during clinical placements, but later developed a sense of confidence in their professional competencies. interviews with community-service therapists revealed that they only experienced retrospectively that the undergraduate training adequately prepared them for community service. students’ undergraduate education must equip them with skills for continuous reflective practice.[16] mostert-wentzel et al.,[17] in an appreciative inquiry into experiences of community-service physiotherapists in sa, advocated for reflection with regard to clinical learning in undergraduate training that could enhance clinical practice. if students were to critically reflect on the clinical education experienced during their placements, this should impact on their learning and the actions that emanate from it, which will contribute to deepened learning.[15] clinical supervisors need strategies to stimulate reflection on learning at an undergraduate level to enhance clinical education and learning in graduate programmes.[5] reflective diaries and learning contracts are means used to enhance reflective practice, aid in developing thought and create change in students’ personal learning methodologies.[15,18] mostert-wentzel et al.[17] suggested that discussions and presentations could form part of reflections for clinical education. blended learning and online and face-to-face teaching are also reported to improve reflective skills of physiotherapy students.[16] the healthcare system in sa is faced with resource constraints, which often inhibit the implementation of models of healthcare that address the burden of disease in the country.[19] these constraints include healthcare staff shortages and infrastructural limitations.[20] similar constraints have hindered teaching and learning as perceived by participants in the study, as they felt that the shortage of staff, time constraints and lack of equipment influenced their clinical learning experience. congruently, parry and brown,[21] in their study set at physiotherapy teaching institutions in the uk, stated that challenges for both teaching and assessment in communication strategies for physiotherapy students were a lack of resources, time, staffing and expertise. stiller et al.,[8] seeking insight into clinical education models in australia, agreed that healthcare staff are also faced with patient demands, administration and other clinical duties. students further emphasised that their large numbers compared with those of clinical supervisors at clinical settings impacted on their learning. they believed that fewer students in clinical placements were preferable, as it improved their learning. a study conducted at the same setting revealed that a large number of students being march 2018, vol. 10, no. 1 ajhpe 17 research supervised by a limited number of clinical supervisors posed challenges to clinical feedback and supervision within clinical education platforms.[22] however, a study by sevenhuysen et al.,[23] comparing traditional clinical education (similar to the context of the current study) with a peer-assisted learning model of allied health science students in australia, found that although the latter model diminished the clinical supervisors’ workload, students and educators preferred the traditional approach. participants in this study echoed that the curriculum needs to be reviewed owing to disparities, such as irrelevant content and lack of fluidity in the design. it is imperative for students to transform theory into practice. ramklass,[22] in her study at the same setting, found that the design influences the delivery and quality of the undergraduate physiotherapy programme. another health sciences study at the same institute found that harmonious theoretically and clinically based teaching is vital for adequate clinical preparation of undergraduate health professions students.[24] students in this study agreed that there should be more cohesive learning and fluidity in the curriculum design, which is in keeping with a study involving physiotherapists graduating from the same university, who indicated that the absence of theoretical knowledge prior to clinical practice was perceived as a negative attribute of the programme.[22] physiotherapy students at a university in the western cape, sa, felt adequately prepared for clinical practice, which was attributed to a thorough review and alignment of the physiotherapy curriculum.[25] health science curricula necessitate review and revision to accommodate the dynamic climate of healthcare in sa.[6] the relationship between all stakeholders in the learning process in clinical education approaches needs to be collaborative to achieve success. the students in the study perceived that favouritism was inhibiting their learning process. students believed that clinical supervisors were paying more attention to some of their peers, which needs to change for improved learning. students also believed that communication between stakeholders, i.e. clinical supervisors and hospital clinical staff, was lacking. a study in ireland on barriers and facilitators to a physiotherapy education approach supported collaboration between all stakeholders in the education framework, which facilitated learning and contributed to adequately prepared students.[26] according to lo et al.,[27] the partnership and working together of the healthcare student and the clinical supervisor are essential to offer an environment of effective learning of technical skills, core competencies and ethical and social integration into clinical practice. furthermore, olsen et al.[28] indicated that clinical supervisors are role models and responsible for the students in clinical placement areas; they are also the main information source for students. there was inconsistency in what was taught in the classroom and what clinical staff at healthcare settings communicated. in a study by de witt et al.,[29] clinicians involved in education of occupational therapy students felt that they were not adequately prepared to teach undergraduate students and feared judgement by the students. talberg and scott[25] conceded that lack of preparedness emerges when what is taught in the classroom does not translate into clinical practice. the ongoing communication between the academic institution and the clinical placement area offers an enabling environment for students’ clinical education.[26] the clinical supervisors in this study were challenged by their perception of students, who they believed were not playing a pivotal active role in their learning and placed gratuitous pressure and demands on the supervisors. strohschein et al.[30] stated that both students and educators should engage in an ‘intentional, structured process of changing roles during the course of the clinical education process’, meaning a deliberate change in roles to facilitate understanding and improve learning. they also believed that the core competencies, such as communication, collaboration and reflection, formed an integral part of effective learning in clinical education frameworks. rowe et al.[16] found that a ‘mutually beneficial’ relationship between students and clinical supervisors should be sought to improve learning. the success of the current education platform, as recommended by participants, hinged on improved teaching strategies, such as more bedside tutorials, improved curriculum design and better communication and collaboration among stakeholders, including clinical site staff and clinical supervisors. in ernstzen et al.’s[5] article, valuable learning opportunities as perceived by physiotherapy students in clinical settings included demonstration of management of patients, discussion, feedback and assessment (both formative and summative). however, the demonstrations of student-led patient management were more valuable than those that were teacher led, as students believed they were central and actively engaged. this paradigm shift is essential for clinical education as the student takes ‘centre stage’. the student-centred strategy leads to learning by discovery, co-creation of knowledge, and direct and reflective learning.[5] furthermore, as highlighted in the recommendations, communication is a key competency for graduates. it is not merely fundamental for clinical practice and patient management,[31] but also integral for effective team collaboration and a holistic approach to rehabilitation.[25] conclusion clinical education frameworks are dependent on stakeholder involvement and collaboration, teaching and learning opportunities experienced by students, as well as culture at the clinical placement area.[5,31] a deeper understanding of how students and educators interpret the clinical education framework is important in the delivery of education and how to improve it to address the needs of a diverse healthcare context.[31,32] this study aimed to understand the perspectives of students, past students who were doing community service at the time of the study and clinical supervisors of a physiotherapy clinical education framework at a university in sa. the study yielded results that support the ongoing review and alignment of the physiotherapy curriculum, as well as improved collaboration between all stakeholders. moreover, the transformative learning shift needs to be in the forefront, as students move to the focal point of their own learning. in a lancet[33] article, a commission of 20 professional and academic leaders from various countries rallied together to develop a common vision for health science, leaving the issues of tribalism and national boundaries aside. the collaborators advocated for a generation of graduates who are ‘systems based’, who should influence health systems and have core competencies that are locally driven but have global relevance.[33] the commission also acknowledged that specific institutional and instructional reforms are necessary and could be led by transformative learning.[33] the adoption and shift toward transformative learning in physiotherapy curricula across sa could enhance socialisation of students around values and core competencies, resulting in leaders who are critical engagers and creative thinkers.[33] further discussions and research are recommended to begin institutional debate on feasible approaches to incorporate transformative learning into our education systems. 18 march 2018, vol. 10, no. 1 ajhpe research acknowledgements. the authors would like to thank the participants for their time and valuable input with regard to the article. we also thank the participating students for their honest responses and contribution to the study. author contributions. vc, sm, sc and np: conceptualised the study and recruited the research students to assist with the project. vc and sm: collected the data together with the students. vc, sm, sc and np: reviewed, analysed and wrote the article. funding. none. conflicts of interest. none. 1. world confederation for physical therapists. http://www.wcpt.org/search/node/role%20of%20physiotherapy (accessed 15 may 2017). 2. health professions council of south africa. http://www.hpcsa.co.za/pbphysiotherapy (accessed 15 may 2017). 3. university of kwazulu-natal. http://physiotherapy.ukzn.ac.za/homepage.aspx (accessed 15 may 2017). 4. moore a, morris j, crouch v, martin m. evaluation of physiotherapy clinical educational models: comparing 1: 1, 2: 1 and 3: 1 placements. physiotherapy 2003;89(8):489-501. https://doi.org/10.1016/s0031-9406(05)60007-7 5. ernstzen dv, bitzer e, grimmer-somers k. physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: a case study. med teach 2009;(3):e102-e105. https://doi.org/10.1080/01421590802512870 6. krause mw, viljoen mj, nel mm, joubert g. development of a framework with specific reference to exit-level outcomes for the education and training of south african undergraduate physiotherapy students. health policy 2006;77(1):37-42. https://doi.org/10.1016/j.healthpol.2005.07.015 7. lekkas p, larsen t, kumar s, et al. no model of clinical education for physiotherapy students is superior to another: a systematic review. austr j physio 2007;53(1):19-28. https://doi.org/10.1016/s0004-9514(07)70058-2 8. stiller k, lynch e, phillips ac, lambert p. clinical education of physiotherapy students in australia: perceptions of current models. austr j physio 2004;50(4):243-247. https://doi.org/10.1016/s0004-9514(14)60114-8 9. govender p, chetty v, naidoo d, pefile n. integrated decentralized training for health professions education at the university of kwazulu-natal, south africa: protocol for the i-dect project. jmir res protoc 2018;7(1):e19. https://doi.org/10.2196/resprot.7551 10. aberdeen t, yin rk. case study research: design and methods. can j action res 2013;14(1):69-71. 11. baxter p, jack s. qualitative case study methodology: study design and implementation for novice researchers. qual rep 2008;13(4):544-559. 12. patton mq. qual res. online library: john wiley, 2005. https://doi.org/10.1002/0470013192.bsa514 13. creswell jw, miller dl. determining validity in qualitative inquiry. theory pract 2000;39(3):124-130. https:// doi.org/10.1207/s15430421tip3903_2 14. roman nv, dison a. relationship between student preparedness, learning experiences and agency: perspectives from a south african university. afr j health professions educ 2016;8(1):30-32. https://doi.org/10.7196/ajhpe.2016. v8i1.490 15. ramli a, ruslan as, sukiman ns. reflection of physiotherapy students in clinical placement: a qualitative study. sains malaysiana 2012;41(6):787-793. 16. rowe m, frantz j, bozalek v. the role of blended learning in the clinical education of healthcare students: a systematic review. med teach 2012;34(4):e216-e221. https://doi.org/10.3109/0142159x.2012.642831 17. mostert-wentzel k, frantz j, van rooijen aj. a model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. afr j health professions educ 2013;5(1):19-25. https://doi.org/10.7196/ajhpe.203 18. ramli a, joseph l, lee sw. learning pathways during clinical placement of physiotherapy students: a malaysian experience of using learning contracts and reflective diaries. j educ eval health prof 2013;10:6. https://doi. org/10.3352/jeehp.2013.10.6 19. chetty v, hanass-hancock j. the need for a rehabilitation model to address the disparities of public healthcare for people living with hiv in south africa: opinion papers. afr j disabil 2015;4(1):1-6. https://doi.org/10.4102/ ajod.v4i1.137 20. cobbing s, chetty v, hanass-hancock j, jelsma j, myezwa h, nixon sa. the essential role of physiotherapists in providing rehabilitation services to people living with hiv in south africa. s afr j physio 2013;69(1):22-25. https://doi.org/10.4102/sajp.v69i1.368 21. parry rh, brown k. teaching and learning communication skills in physiotherapy: what is done and how should it be done? physiotherapy 2009;95(4):294-301. https://doi.org/10.1016/j.physio.2009.05.003 22. ramklass s. the clinical education experience of student-physiotherapists within a transformed model of healthcare. internet j allied health sci pract 2013;11(2):4. 23. sevenhuysen s, skinner eh, farlie mk, et al. educators and students prefer traditional clinical education to a peer-assisted learning model, despite similar student performance outcomes: a randomised trial. j physio 2014;60(4):209-216. https://doi.org/10.1016/j.jphys.2014.09.004 24. naidoo d, van wyk j. fieldwork practice for learning: lessons from occupational therapy students and their supervisors. afr j health professions educ 2016;8(1):37-40. https://doi.org/10.7196/ajhpe.2016.v8i1.536 25. talberg h, scott d. do physiotherapy students perceive that they are adequately prepared to enter clinical practice? an empirical study. afr j health professions educ 2014;6(1):17-22. https://doi.org/10.7196/ajhpe.219 26. mcmahon s, cusack t, o’donoghue g. barriers and facilitators to providing undergraduate physiotherapy clinical education in the primary care setting: a three-round delphi study. physiotherapy 2014;100(1):14-19. https://doi.org/10.1016/j.physio.2013.04.006 27. lo k, osadnik c, leonard m, maloney s. differences in student and clinician perceptions of clinical competency in undergraduate physiotherapy. nzj physio 2015;43(1):11-15. https://doi.org/10.15619/nzjp/43.1.02 28. olsen nr, bradley p, lomborg k, nortvedt mw. evidence based practice in clinical physiotherapy education: a qualitative interpretive description. bmc med educ 2013;13(1):52. https://doi.org/10.1186/1472-6920-13-52 29. de witt p, rothberg a, bruce j. clinical education of occupational therapy students: reluctant clinical educators. s afr j occupational ther 2015;45(3):28-33. https://doi.org/10.17159/2310-3833/2015/v45n3/a6 30. strohschein j, hagler p, may l. assessing the need for change in clinical education practices. phys ther 2002;82(2):160-172. https://doi.org/10.1093/ptj/82.2.160 31. ernstzen dv, bitzer e, grimmer-somers k. physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: a qualitative study. s afr j physio 2010;66(3):25-31. https://doi.org/10.4102/ sajp.v66i3.70 32. chan ds. combining qualitative and quantitative methods in assessing hospital learning environments. int j nurs stud 2001;38(4):447-459. https://doi.org/10.1016/s0020-7489(00)00082-1 33. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 accepted 29 august 2017. https://doi.org/10.1016/s0031-9406(05)60007-7 https://doi.org/10.1080/01421590802512870 https://doi.org/10.1016/j.healthpol.2005.07.015 https://doi.org/10.1016/s0004-9514(07)70058-2 https://doi.org/10.1016/s0004-9514(14)60114-8 https://doi.org/10.2196/resprot.7551 https://doi.org/10.1002/0470013192.bsa514 https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.1207/s15430421tip3903_2 https://doi.org/10.7196/ajhpe.2016.v8i1.490 https://doi.org/10.7196/ajhpe.2016.v8i1.490 https://doi.org/10.3109/0142159x.2012.642831 https://doi.org/10.3352/jeehp.2013.10.6 https://doi.org/10.3352/jeehp.2013.10.6 https://doi.org/10.4102/ajod.v4i1.137 https://doi.org/10.4102/ajod.v4i1.137 https://doi.org/10.4102/sajp.v69i1.368 https://doi.org/10.1016/j.physio.2009.05.003 https://doi.org/10.1016/j.jphys.2014.09.004 https://doi.org/10.7196/ajhpe.2016.v8i1.536 https://doi.org/10.7196/ajhpe.219 https://doi.org/10.1016/j.physio.2013.04.006 https://doi.org/10.15619/nzjp/43.1.02 https://doi.org/10.1186/1472-6920-13-52 https://doi.org/10.17159/2310-3833/2015/v45n3/a6 https://doi.org/10.1093/ptj/82.2.160 https://doi.org/10.4102/sajp.v66i3.70 https://doi.org/10.4102/sajp.v66i3.70 https://doi.org/10.1016/s0020-7489(00)00082-1 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 the ajhpe is published by the health and medical publishing group. ajhpe african journal of health professions education december 2010, vol. 2 no. 2 editor vanessa burch deputy editor juanita bezuidenhout editorial board adri beylefeld, university of the free state juanita bezuidenhout, stellenbosch university vanessa burch, university of cape town enoch n kwizera, walter sisulu university patricia mcinerney, university of the witwatersrand jacqueline van wyk, university of kwazulu-natal hmpg editor daniel j ncayiyana managing editor j p de v van niekerk assistant editor emma buchanan technical editors marijke maree robert matzdorff paula van der bijl head of publishing robert arendse production co-ordinator emma couzens art director siobhan tillemans dtp & design travis arendse clinton griffin online manager gertrude fani hmpg board of directors m raff (chair) r abbas m lukhele d j ncayiyana t 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(021) 681-7200. fax (021) 681-1395. e-mail: publishing@hmpg.co.za contents editorial collaboration: hope for the future juanita bezuidenhout 2 articles continuing education in geriatrics for rural health care providers in uganda: a needs assessment mary ajwang, joshua k muliira, ziadah nankinga 3 a survey of wound care knowledge in south africa francois coetzee, johan coetzee, dirk hagemeister 9 evaluation of the parallel rural community curriculum at flinders university, south australia: lessons learnt for africa i d couper, p s worley 14 research productivity of academics in a physiotherapy department: a case study jm frantz, a rhoda, p struthers, j phillips 17 the african health oer network: advancing health education in africa through open educational resources sarah hoosen, kathleen ludewig omollo 21 teaching biopsychosocial competence and the principles of the primary health care (phc) at the patient’s bedside lauraine vivian, sean mclaughlin, charles swanepoel, vanessa burch 23 fresh simulation options in critical care nursing education elize archer 29 cpd 33 scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education 66 march 2018, vol. 10, no. 1 ajhpe research there is global consensus that the performance of a healthcare system largely depends on a competent nursing and midwifery workforce. nurses form the backbone of the healthcare system and are a universal access point for almost 80% of healthcare users, especially in primary healthcare settings. however, nurses continue to face challenges in the 21st century, which are more complex and have changed healthcare delivery, especially in poorresource settings. globally, there is an increased demand for an efficient and effective nursing workforce. evidence shows that, despite the increasing complexity of nursing practice, there is a wide gap between theory and practice.[1] clinical education remains central to the nursing curriculum and forms the foundation for bridging the gap between theory and practice. clinical education prepares nurses for skills and competences to effectively provide safe, quality care in complex settings.[2] in malawi, there are reports of poor competences and negative attitudes of nurses towards patients and nursing care. therefore, nursing education falls short of the expectation to produce sufficient and well-trained nurses.[3] missen et al.[4] reported that inadequacy in the preparation of nurses for practice is a worldwide problem. a de-link between initial training and transition to practice has been reported in many setting.[5] effective transition to practice enhances socialisation, and improves competences[6] and confidence among nurses. spector et al.[7] indicated that hospitals that use established transition programmes reported higher retention rates. nurses also reported fewer patient errors, employed fewer negative safety practices, and had lower stress levels and better job satisfaction. it is against this background that we developed transition-topractice guidelines in nursing. assumption underlying the guidelines the transition-to-practice guidelines are built on the assumption that training of nurses is a complex process. its outcome is based on an interactive relationship between academic theory and practice, which is well regulated at all stages. the task to narrow the theory-practice gap requires a co-ordinated process between academic and practice settings, which strengthens the ability of newly graduated nurses to perfect what they have learnt in training institutions in complex practice settings. purpose of the guidelines transition to practice of new graduates forms a critical component of the overall nursing education process. well-developed transition-to-practice programmes ensure a competent nursing workforce that is adequately prepared to deliver within a complex healthcare system. transition guidelines will help to increase nurses’ confidence and competences, increase patient safety and improve overall quality of nursing care in malawi. the guidelines will support formal programmes that are designed to assist progression of newly graduated nurses from training to practice. the purpose of this work was therefore to develop guidelines for transition to practice as a tool to complement nursing education in malawi. background. a de-link between initial training and transition to practice has been reported. effective transitioning to practice enhances competences and confidence among newly graduated nurses. objectives. to develop transition-to-practice guidelines as a tool to complement efforts to improve nursing education in malawi. methods. a multi-method design was used within the framework of the stufflebeam context, input, process, product (cipp) model. analysis of reports from a nursing conference derived four core concepts, highlighting the context within which goals for transition-to-practice guidelines needed to be focused on. a panel discussion suggested guidelines based on these concepts. review meetings and a review of the literature, local policies and standards were conducted to provide input to enhance credibility and reproducibility of the proposed guidelines. consensus workshops involving nurse educators, nursing clinical preceptors, nurse practitioners and policymakers were conducted as a process evaluation for the guidelines. results. four core concepts emerged from the process of guideline development. eleven guideline statements were formulated as a product of the guideline development process. although newly graduated nurses are exposed to various clinical settings during college training, nurses’ skills and clinical judgement are still rather weak and need more formal support. the guidelines provide assistance for transition to practice among newly graduated nurses. conclusion. nursing education is a complex process that starts at student recruitment and should effectively progress until transition to practice. transition-to-practice guidelines to complement other guidelines in nursing education are timely in malawi. afr j health professions educ 2018;10(1):66-71. doi:10.7196/ajhpe.2018.v10i1.898 transition-to-practice guidelines: enhancing the quality of nursing education t bvumbwe,1 phd; n mtshali,2 phd 1 department of nursing and midwifery, faculty of health sciences, mzuzu university, luwinga, malawi 2 school of nursing and public health, university of kwazulu-natal, durban, south africa corresponding author: t bvumbwe (bvumbwe.tm@mzuni.ac.mw) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 67 research guidelines stakeholders the training of nurses is a complex process that starts at recruitment into a nursing programme and progresses to continued professional development throughout their working life. this complex process overlaps with various environments and various stakeholders. the latter are individuals who take a participatory role in the training of nurses and include the student, nurse educator, regulatory body and healthcare institution. nursing educator nurse educators align nursing curricula to the practising needs of the nursing students. the nurse educator imparts knowledge to nursing students, who use it to perfect their practising skills and competences. regulatory body the regulatory body stipulates various scopes of practice and expected competency levels that a newly graduated nurse should achieve to be certified as safe and competent to practise. this body regulates nurse education and practice, and both have to be aligned in the preparation of the new nurse. healthcare institution healthcare institutions have a unique culture in which the new graduate has to adapt to ensure efficiency and effectiveness in delivery of quality services. the nurse manager’s task is to ensure that new graduates increase their performance to achieve health goals for healthcare users. newly graduated nurses a newly graduated nurse is a key stakeholder at the centre of an interactional relationship among healthcare institution, regulatory body and nurse educator. guidelines development process a multi-method design was used for the development of the transition-to-practice guidelines (fig. 1). initially, reports from a national nursing education research conference in 2015 were analysed using thematic analysis to propose core concepts. table 1 summarises research reports that were presented during the conference. four core concepts were derived from analysis of the reports. on the last day of the conference, 8 nursing experts were invited to a panel discussion based on their specific expertise in nursing education and clinical practice to discuss the reports. table 2 presents demographic characteristics of participants during the expert discussion. the discussion was open and guided by two questions followed by probes: ‘what is your comment about the quality of nursing education in malawi based on the research reports presented during the conference?’ and ‘what recommendations would you give to improve nursing education?’. context evaluation by means of the panel discussion determined goals that would be addressed by the transition-to-practice guidelines. context evaluation described the current state of the nursing education gap. a nursing education partnership initiative (nepi) project gathered members of the nepi technical working group (n=4), nurse educators (n=12), nursing managers (n=8) and nursing clinical preceptors (n=8) from teaching hospitals to review strategies being implemented to improve nursing education in malawi in view of the outcome of the expert discussion. the panel of experts and those at the review meetings discussed the core concepts derived from the nursing education conference. key points were summarised and draft transition-to-practice guidelines in nursing education were formulated. the draft guidelines then guided a review of local policies and nursing education standards. a review of the literature and a descriptive exploratory study were conducted to contribute towards an input evaluation to enhance credibility and reproducibility of the proposed guidelines. the guidelines were then discussed national nursing education research dissemination conference – research report analysis expert discussion – academia (n=3); practice (n=3); policymakers (n=2); regulatory bodies (n=1) nepi review meeting – national technical group (n=4); nurse educators (n=12); nurse managers (n=8); clinical preceptors (n=8) draft guidelines formulation – guidelines (n=15) literature review, review of local policies/ standards, descriptive and exploratory studies review and revise draft guidelines 2nd nepi review meeting – nurse educators (n=13); policymakers (n=5); clinical preceptors (n=8); practitioners (n=15) delphi 1st round – nurse educators (n=10); nurse practitioners (n=10) review and revise delphi 2nd round review and revise delphi 3rd round review and �nal guidelines draft final review and endorsement 4 core concepts 11 guidelines review and revise draft guidelines fig. 1. process of guidelines development for transition to practice. (nepi = nursing education partnership initiative.) 68 march 2018, vol. 10, no. 1 ajhpe research and reviewed in a consensus workshop. nurse educators (n=13), nursing clinical preceptors (n=8), nurse practitioners (n=15) and policymakers (n=5) participated in the workshop to provide information that can be used to guide the implementation of the guidelines, procedures and activities, as well as being a means to identify successes and failures. consensus procedure followed the reviews and involved three rounds of delphi stages. first, delphi involved nurse educators (n=10) and nurse practitioners (n=10) to explore their opinions on the guidelines. results from the first round of the discussion informed a questionnaire for the last two delphi stages. the researcher (tb) reviewed and produced a final draft of the guidelines, which was presented to an education committee for approval as the final product of the guideline-development process. table 3 presents final transition-to-practice guidelines that were developed by means of the abovementioned process. table 1. summary of research reports for the nursing education research conference core concepts research report key findings academic clinical collaboration where is the grade coming from? problems and challenges in evaluating the clinical performance of nursing students evaluation of students’ clinical performance is a vital component of nursing education; it should be conducted in a manner that effectively determines students’ clinical proficiency. students become preoccupied with building relationships with clinical nurses to obtain good grades registered nurses’ experiences with the clinical teaching environment in malawi clinical teaching and learning inadequately prepares students for practice owing to challenges of inadequate faculty support, poor clinical learning environment, poor competence among nurses and unsupportive working conditions can research improve nursing and midwifery education in malawi? (keynote address) evidence-based practice requires that both nurse educators and nurse practitioners engage in collaborative research. research builds on knowledge for nurses evidencedbased practice strengthening patient-centred care in nursing and midwifery education quality of nursing care improves when care is based on objective assessment of patients’ needs. nursing education emphasises evidencebased provision of nursing care strategies for the implementation of clinical practice guidelines in intensive care: a systematic review practice guidelines strengthen provision of quality care to the patient in the intensive care unit theory-practice gap reduction involvement of registered nurses in clinical teaching of nursing students in central hospitals in malawi registered nurses possess adequate experience regarding practice. their involvement increases changes for narrowing a theory-practice gap that exists owing to lack of integration between what students learn in class and what happens in practice settings assessing quality of the clinical learning environment for nursing and midwifery students in northern malawi the nature of the clinical learning environment has a direct impact on the achievements of the clinical learning outcomes. however, the clinical learning environment is characterised by a lack of resources, poor faculty support, and a lack of collaboration between academia and practice in training students clinical teaching in clinical situations students learn better in clinical situations that provide adequate support from clinical personnel an investigation of stressors among malawian nursing and midwifery students clinical learning is stressful for students owing to the nature of the clinical learning environment, especially for newer students. with time, students adapt to the challenges of the clinical environment innovations in nursing training enhancing students’ moral competence in practice: challenges experienced by malawian nurse teachers a less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. students develop moral competence when they are given an opportunity to reflect exploring knowledge and perceptions of tutors of the use of a problem-based learning approach in christian health association of malawi nursing colleges nurse educators need capacity building in teaching approaches to promote achievement of learning outcomes among students factors affecting clinical performance of nursing and midwifery technician students at three nursing colleges in southern malawi students’ clinical performance is affected by a poor clinical learning environment. nurses’ attitude towards students, availability of faculty support during clinical practice and lack of resources are important aspects of a clinical learning environment teaching and learning methodology in nurse/midwife education use of various methods in teaching enhances acquisition of knowledge and skills by nurses. clinical mentorship increases the chance for students to learn during practice   knowledge and attitudes of nursing and midwifery learners and educators towards self-directed learning in malawi adequate orientation of students towards teaching approaches increases their positive attitude towards these approaches march 2018, vol. 10, no. 1 ajhpe 69 research guidelines development process: outcome and discussion the national nursing education research conference comprised 18 research reports and 1 keynote speech. before the conference, abstracts were independently assessed for inclusion by a norwegian church aid conference committee. four core concepts within the context evaluation of the research reports emerged and included academic and practice collaboration, evidence-based practice strengthening, theory-practice gap reduction and innovations in the approach to the training of nurses, derived from analysis of the reports. draft guidelines for transition to practice were developed from these four core concepts. core concept 1: academic and practice collaboration the nursing curriculum needs to be aligned to the clinical setting to ensure table 2. characteristics of panel discussion experts characteristics nurse educators nurse practitioners policymakers regulatory bodies gender male 1 female 2 3 2 1 age, years ≤30 31 40 1 2 ≥41 2 1 2 1 education qualification bachelor 1 master 3 2 2 1 phd length of service, years ≤5 6 15 1 ≥16 2 3 2 1 publications, n 0 1 ≤2 1 2 1 1 ≥3 2  1  table 3. guidelines for transition to practice in nursing education core concept 1: academic clinical collaboration transition-to-practice programmes should show evidence of collaboration between training and practice institutions transition-to-practice programmes should be implemented in liaison between co-ordinators of the transition programme from both training and practice institutions core concept 2: evidence-based practice strengthening academic and practice settings should mutually engage to develop innovative ways to support transition of newly graduated nurses newly graduated nurses should undergo a formal performance appraisal by responsible mentors from the hosting practice institution and nurses’ training or linked college core concept 3: theory-practice gap reduction a formal transition-to-practice programme that meets the expected learning outcomes of new graduates should be approved by the nurses and midwives council of malawi all students entering the transition-to-practice programme should show evidence of fulfilling minimum requirements for completion of the nursing training programme transition to practice should be done at health institutions that meet the minimum set standards for clinical training placement newly graduated nurses should be engaged within the first 6 months after graduation, as this is considered a critical period that needs transition support for nurses to consolidate what they learnt while in college core concept 4: innovation in nursing training approaches all registered nurses should be trained as clinical preceptors to support clinical mentorship of newly graduated nurses transition to practice should be done under supervision of a trained preceptor transition to practice is considered as a period for orientation, preceptorship and specific professional development that allows personal and professional growth 70 march 2018, vol. 10, no. 1 ajhpe research that graduates are equipped to face the challenges of a complex and dynamic healthcare delivery system. greenwood[8] argued that the effectiveness of qualified nursing graduates should become the responsibility of both the training institutions and clinical practice. expert review revealed that preparing a sustainable, competent nursing and midwifery workforce is a shared responsibility between academia and the practice setting. some participants highlighted the following: ‘… a nurse will never be fully produced by training institutions without practice institutions.’ (ac, nurse educator) ‘training for practice requires that those trained should practise within the practice settings that embrace theory and practice integration.’ (tl, nurse regulator) academic-practice collaboration is an important mechanism for strengthening nursing education, practice and research. despite the increasing effort to bridge the theory-practice gap, the lack of formal partnerships between academia and practice leads to disintegrated efforts in the improvement of nursing education in malawi. data collected from consensus meetings indicated that the guidelines that were developed put in place measures to ensure that academic and practice settings work collaboratively towards a competent and efficient nursing graduate (table 1). there is hope for an improved nursing education system in malawi if nurse educators and practitioners understand and appreciate the academicpractice partnership, its benefits, elements and challenges. lack of a transition-practice programme exposes new nurses to the loss of the nursing education support system. during guideline review meetings, participants highlighted the importance of maintaining college support during the transition period. duchscher[9] reported that if new nurses do not have immediate access to previous educators to provide intellectual counsel, emotional support, practice consultation and feedback, feelings of isolation and self-doubt increase. access to support from peers and colleagues is reported to be an important link for nurses’ development. a participant indicated that: ‘… the mentorship programme will expose newly graduated nurses to an environment with appropriate support from experienced nurses.’ (gc, policymaker) nurse educators could take a leading role in designing curricula for transition programmes. core concept 2: evidence-based practice strengthening evidence-based nursing promotes the use of contemporaneous recent research findings as the basis for clinical decisions.[10] the newly graduated nurse must develop cognitive and emotional knowledge and technical skills and be able to apply this knowledge in practice. this will help nurses to make well-grounded decisions and deliver evidence-based nursing. findings of this study highlight that new nurses must be able to synthesise evidence-based information with critical thinking skills. transition-topractice programmes should support an understanding of the importance of quality care and of their role in the continuum of care among new nurses. for quality care provision, newly graduated nurses have to develop the clinical judgement that experienced nurses possess: ‘… the process of transition exposes the newly graduated nurses to practice culture that the newly graduated gets socialised into.’ (et, nurse educator) opinions from consensus discussions showed that newly graduated nurses discover the practical knowledge that is necessary for clinical judgement as they undergo transition programmes. expert discussion revealed that clinical decisions should be evidence based and that an understanding of the knowledge sources that newly graduated nurses use is important to safeguard quality of care. voldbjerg et al.[11] argued that, during the transition phase, feelings of confidence and ability to use critical thinking and reflection have a great impact on knowledge sources incorporated in clinical decisions. core concept 3: theory-practice gap reduction the literature shows a mismatch between nursing theory and practice.[12] differing perspectives exist between nurses in the practice sector and those in the education sector with regard to the practice readiness of new graduates. wolff et al.[13] recommended a shift in the discourse around practice readiness, whereby nurses from all sectors should focus on unique, innovative and co-operative solutions to ensure the effective transition of all nursing graduates in the 21st century healthcare system. wide gaps in theory and practice among new nurses are being reported.[14] consensus discussion pointed out that transition-to-practice programmes help to reduce the gap between what students learn in class and what is expected of them in practice: ‘newly graduated nurses need a period of orientation to real practice. this helps them integrate into practice what they learn during training.’ (tn, nurse practitioner) core concept 4: innovations in the training of nurses there was strong argument from the consensus discussions that initial experiences of graduates can shape the development of nurses during their careers. findings of the study indicated the critical importance of welcoming the new nurse into an inquisitive, supportive environment, where good staff relationships flourished. this is consistent with spector et al.’s[7] report, which highlighted that transition-to-practice programmes that included patient-centred care, communication and networking, quality improvement, evidence-based practice, informatics, safety, clinical reasoning, feedback, reflections and specialty knowledge in an area of practice provided better support for newly graduated nurses. data from a panel of experts indicated that preceptorship proved to be an essential and possible way to start as a new nurse. there was a general understanding in the consensus meetings that preceptors provide a supportive environment for new nurses to develop their confidence as independent professionals and refine their skills, values and behaviours. matua et al.[15] noted that having expert support and learning from best practice give new nurses a foundation for lifelong learning through professional feedback. studies showed that supportive behaviour and constructive feedback from qualified nurses and involvement of newly graduated nurses in all aspects of decision-making during care provision are important features that assist in developing the new nurse. newly qualified nurses become well aware of their inexperience. general feedback from the data showed that the guidelines therefore highlight the need for effective preparation of preceptors to fill this important role and help new graduates develop their skills and competences: ‘… registered nurses need to be equipped with knowledge and skills to take newly graduated nurses through a transition process that allows innovation and creativity. (gc, policymaker)’ march 2018, vol. 10, no. 1 ajhpe 71 research conclusion and implications for nursing education nursing education prepares a sufficient number of highly qualified nurses, who are necessary for the complex healthcare demands. a key concern of nurse educators is preparing graduates for practice. findings of our study showed that transition to practice has not been adequately addressed in malawi. new nurses require adequate support because they face a new environment, new expectations and new roles when they join a practice. these guidelines offer a direction on how transition to practice could be conducted in malawi to ensure effective preparation of newly graduated nurses for practice. the guidelines complement the existing standards in guiding nursing education practice. proper transition-to-practice programmes are significant for new graduates’ professional growth. study limitation there is one limitation to this study that needs to be addressed. malawi plans to introduce an internship programme for nursing training programmes. these guidelines may serve the same purpose. consensus should be reached to have either a transition-to-practice programme or an internship programme. one general name needs to be adopted for the programme. acknowledgements. thanks to all nurses who participated in the study. author contributions. tb conceptualised the study and collected the data. tb and nm analaysed the data and drafted and approved the final manuscript. funding. the study was supported by icap through a nepi. conflicts of interest. none. 1. ajani k, moez s. third world conference on educational sciences – 2011 gap between knowledge and practice in nursing. procedia soc behav sci 2011;15:3927-3931. https://doi.org/10.1016/j.sbspro.2011.04.396 2. wells l, mcloughlin m. fitness to practice and feedback to students: a literature review. nurse educ pract 2014;14(2):137-141. https://doi.org/10.1016/j.nepr.2013.08.006 3. msiska g, smith p, fawcett t. the ‘lifeworld’ of malawian undergraduate student nurses: the challenge of learning in resource poor clinical settings. int j afr nurs sci 2014;1:35-42. https://doi.org/10.1016/j.ijans.2014.06.003 4. missen k, mckenna l, beauchamp a. work readiness of nursing graduates: current perspectives of graduate nurse program coordinators. contemp nurse 2015;51(1):27-38. https://doi.org/10.1080/10376178.2015.1095054 5. hofler l, thomas k. transition of new graduate nurses to the workforce challenges and solutions in the changing health care environment. north carolina med j 2016;77(2):133-136. https://doi.org/10.18043/ncm.77.2.133 6. komaratat s, oumtanee a. using a mentorship model to prepare newly-graduated nurses for competency. j contin educ nurs 2009;40(10):475-480. https://doi.org/10.3928/00220124-20090923-02 7. spector n, blegen m, silvestre j, et al. transition-to-practice study in hospital settings. j nurs educ 2012;5(4):24-38. https://doi.org/10.1016/s2155-8256(15)30031-4 8. greenwood j. critique of the graduate nurse: an international perspective. nurse educ today 2000;20(1):17-23. https://doi.org/10.1054/nedt.2000.0424 9. duchscher je. transition shock: the initial stage of role adaptation for newly-graduated registered nurses. j adv nurs 2009;65(5):1103-1113. https://doi.org/10.1111/j.1365-2648.2008.04898.x 10. rosenberg w, donald a. evidence based medicine: an approach to clinical problem-solving. bmj 1995;310(6987):1122-1126. https://doi.org/10.1136/bmj.310.6987.1122 11. voldbjerg sl, gronkjaer m, sorensen ee, hall eo. newly-graduated nurses’ use of knowledge sources: a metaethnography. j adv nurs 2016;72(8):1751-1765. https://doi.org/10.1111/jan.12914 12. rich kl, nugent ke. a united states perspective on the challenges in nursing education. nurse educ today 2010;30(3):228-232. https://doi.org/10.1016/j.nedt.2009.10.015 13. wolff ac, pesut b, regan s. new graduate nurse practice readiness: perspectives on the context shaping our understanding and expectations. nurse educ today 2010;30(2):187-191. https://doi.org/10.1016/j.nedt.2009.07.011 14. monaghan t. a critical analysis of the literature and theoretical perspectives on theory and practice gap amongst newly-qualified nurses within the united kingdom. nurse educ today 2015;35(8):e1-e7. https://doi. org/10.1016/j.nedt.2015.03.006 15. matua g, seshan v, akintola a, thanka a. strategies for providing effective feedback during preceptorship: perspectives from an omani hospital. j nurs educ pract 2014;4(10):24-31. https://doi.org/10.5430/jnep.v4n10p24 accepted 14 september 2017. https://doi.org/10.1016/j.ijans.2014.06.003 https://doi.org/10.1080/10376178.2015.1095054 https://doi.org/10.18043/ncm.77.2.133 https://doi.org/10.3928/00220124-20090923-02 https://doi.org/10.1016/s2155-8256(15)30031-4 https://doi.org/10.1111/j.1365-2648.2008.04898.x https://doi.org/10.1136/bmj.310.6987.1122 https://doi.org/10.1016/j.nedt.2015.03.006 https://doi.org/10.1016/j.nedt.2015.03.006 https://doi.org/10.5430/jnep.v4n10p24 editorial 143 professor bongani mayosi: a legend in our time n ntusi forum 145 speech-language therapy consultation practices in multilingual and multicultural healthcare contexts: current training in south africa m mophosho research 148 interprofessional knowledge and perceptions of selected south african healthcare practitioners towards each other t j ellapen, m swanepoel, b t qumbu, g l strydom, y paul 153 checklist of cognitive contributions to diagnostic errors: a tool for clinician-educators j m naude, v c burch 159 the effectiveness of an online, distance-learning master’s in surgical sciences programme in malawi p j w smith, o j garden, s j wigmore, e borgstein, d dewhurst 166 peer helpers’ construction of their role in an open distance-learning institution s e mabizela 171 interventions aimed towards the development of patient-centredness in undergraduate medical curricula: a scoping review e archer, i meyer 176 exploring community-based training opportunities for dental therapy students in nongovernmental and private sectors in kwazulu-natal province, south africa i moodley, s singh 183 perspectives of advanced life support paramedics on clinical simulation for summative assessment in south africa: is it time for change? r g campbell, m j labuschagne, j bezuidenhout cpd questionnaire ajhpe african journal of health professions education september 2018, vol. 10, no. 3 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria hmpg acting ceo dr manivasan thandrayen executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens senior designer clinton griffin chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, dr m mbokota, dr g wolvaardt , company secretary: adv. y lemmer issn 2078-5127 48 march 2017, vol. 9, no. 1 ajhpe a maximum of 3 ceus will be awarded per correctly completed test. the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/170/02/2017 (clinical) cpd questionnaire true (a) or false (b): south-south cooperation in health professional education: a literature review 1. globally, there is consensus on the effectiveness of different implementation models of aid. 2. the authors acknowledge three distinct funding models: the development assistance committee (dac) model, the arab model and the southern model. an integrated literature review of undergraduate peer teaching in allied health professions 3. despite the small number of relevant articles included in the review, there was clear consensus on the principles of peer-assisted learning (pal). 4. findings by hammond et al. showed that pal sessions should be informally organised and not incorporated in the timetable and curriculum of students. developing a service-learning module for oral health: a needs assessment 5. reflection has been identified as a key principle of service learning (sl) and is considered as the glue that holds service and learning together. 6. the authors define sl as ‘refers to the interactions and processes through which the expertise of the institution in the areas of teaching, learning and research are applied to develop and sustain society’. barriers to continuous professional development participation for radiographers in kenya 7. in this research, it was found that a minority of diagnostic radiographers who were registered with the society of radiography in kenya (sork) were enrolled in a cpd programme. 8. time constraints were not identified by participants as major barriers to cpd participation. specialty choice among dental students in ibadan, nigeria 9. job security is not one of the factors identified as influencing dental students’ and graduates’ choice of dental specialty. 10. personal interest was the major influential factor of career choice for both men and women. pioneering small-group learning in tanzanian emergency medicine: investigating acceptability for physician learners 11. the finding of this research revealed that students preferred lectures as a teaching method for improving medical knowledge. 12. ‘interactivity of seminar to learn physical/procedural skills’ was found to be an ineffective aspect of small-group learning. self-directed learning: status of final-year students and perceptions of selected faculty leadership in a nigerian medical school – a mixed analysis study 13. the three skills considered integral to self-regulated learning include metacognition, self-teaching and cognition. 14. a key concept of cognitive load theory is that the cognitive load should match the working memory of the learner. self-regulated learning: a key learning effect of feedback in a problembased learning context 15. this study noted that students’ interest in a subject influences their selfregulation. 16. the role of the lecturer in problem-based learning (pbl) is to guide students and promote sharing, interaction and exchange of ideas towards constructing new knowledge. occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology 17. participants in this study felt adequately prepared for implementing the appropriate treatment while in their clinical setting. 18. previous research has shown that inadequate guidance from clinical supervisors is linked to negative clinical experiences. exploration of high-fidelity simulation: nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting 19. time and appropriate equipment were acknowledged as important to effective teaching using high-fidelity simulation (hfs). 20. there have been relatively few studies on hfs emerging from the developing world. march 2017 scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa june 2018, vol. 10, no. 2 issn 2078 5127 african journal of health professions education abstracts 24 august 2010, vol. 2, no. 1 ajhpe influence of confidence and experience on the competency of junior medical students in performing basic procedural skills adele de villiers, elize archer correspondence to: adele de villiers (adeledev@sun.ac.za) context and setting studies, mostly done with final-year medical students and doctors, show that the confidence level with which a clinical skill is performed is not a reliable benchmark of actual clinical competence. this inaccurate selfevaluation of proficiency has far-reaching implications, e.g. the inability to identify learning deficiencies and consequently to manage learning – both essential components of self-directed learning programmes. why the idea was necessary the purpose of this study in comparing self-reported competence and actual competence was threefold, i.e. to discover students’ perceptions concerning their competence of specific procedural skills; to establish what the actual competence level of junior medical students were with regard to these skills; and to raise student awareness of the value of accurate self-evaluation. what was done third-year medical students at the faculty of health sciences, stellenbosch university, attended a training session in the clinical skills centre (csc) at the beginning of a year. supervised by clinical tutors, they practised three basic procedural skills on part-task trainers/bench-top manikins, i.e. commencing an intravenous infusion; performing simple wound closure (suturing); and administering an intramuscular injection. during the remainder of the year, they returned in smaller groups in their family medicine rotation for formative assessment of these skills, using an osce. before performing the clinical procedures, students had to rate their perceived competence. clinical tutors then used checklists to rate actual student competence when performing these three skills. evaluation of results and impact in accordance with similar studies, there was poor correlation between selfreported and actual competence regarding the performance of procedural skills. there were, however, significant correlations between self-reported competence and clinical experience (r=0.49, p=0.00) as well as between experience and actual competence (r=0.36, p=0.00). it seems that junior students lack the necessary critical self-assessment skills to accurately evaluate their performance of certain basic procedural skills. however, frequently performing these skills in the clinical setting (or elsewhere) increased both self-reported and actual competence in these students. before this study, junior medical students had limited formal clinical skills teaching in the csc and, because of the already overloaded curriculum, were not assessed with regard to such skills. as a result, the onus rested on the student to gain these and other, often ill-defined, skills in the clinical setting. since the completion of this study, a logbook system has been introduced to encourage students to make the most of the opportunities in the clinical setting to practise the skills taught in the csc. furthermore, a core clinical skills curriculum was compiled, indicating which skills should be taught in simulation and which in the clinical setting, as well as the competency levels (based on miller’s framework for clinical assessment) at which these skills should be performed. from 2011 students will be subjected to a summative osce to assess their clinical skills competency. cracking the nut of service learning in nursing hester julie correspondence to: hester julie (hesjulie@gmail.com) context and setting higher education institutions (heis) worldwide are being held more accountable for the effectiveness and relevance of their educational programmes and are being challenged to ‘reinsert the public good into higher education’. these reasons have contributed to the development of the service learning movement globally. in south africa service learning became entrenched in hei policy documents less than a decade ago. although there are national policy guidelines for community engagement and service learning as a particular type of community engagement, the implementation of service learning has occurred sporadically as heis are struggling with the many changes at all societal levels. purpose while the school of nursing at the university of the western cape is cognizant of this national policy imperative as stipulated in the guidelines of the higher education quality committee, how these statements will be operationalised within the undergraduate nursing programme has not been addressed. the question that therefore needs to be asked is what teaching staff perceive to be the enablers and challenges for institutionalising service learning in the programme by exploring the perceptions of those involved in teaching on the programme. what was done an exploratory, descriptive, contextual design was used. participants, who included academics (n=18) and clinical supervisors (n=18) employed at the school of nursing, completed a selfadministered, structured questionnaire, adapted from furco’s self-assessment rubric for the institutionalisation of service learning in higher education. results of results and impact the preliminary results reported here are part of a wider investigation into the implementation of service learning in selected modules in the undergraduate nursing programme. the findings reveal that the school of nursing has to engage in critical mass building activities because none of the respondents was aware of the higher education quality committee’s assessment criteria for service learning. approximately 9% indicated awareness that the institution has an official definition of service learning that is used consistently to operationalise most aspects of service learning on campus. however, the majority (91%) reported on the absence of a campus-wide definition of service learning, the inconsistent use of service learning to describe a variety of experiential and service activisouthern african faimer regional institute (safri) poster day, cape town, march 2011 and sa association of health educationalists (saahe) conference, johannesburg, july 2010 24 june 2011, vol. 3, no. 1 ajhpe 44 march 2018, vol. 10, no. 1 ajhpe research internship following graduation is an essential period for junior doctors to develop their skills and apply their knowledge in the context of the local health system. newly qualified medical doctors in south africa (sa) enter a supervised 2-year internship period requiring learning and service delivery to occur concurrently in a work-based setting. work-based assessment (wba) during internship is integral to identifying underperformance and to informing decisions regarding certification for independent, unsupervised practice.[1] wba is a complex process that should include the assessment of multiple competencies using validated methods and tools that accurately reflect performance. the assessment process aims to ensure that doctors perform as competent, ethical practitioners who have ‘globally connected, locally responsive attributes that are population and patient-centred’.[2] research into effective wba practices has led to advances in understanding the optimal ways to assess interns.[3] many of these innovations in wba have, however, not yet been translated into practice in many lower-middleincome countries (lmics) such as sa.[4] internship training in sa, as in many other lmics, occurs within a resource-constrained workplace setting where high patient-doctor ratios are the norm.[2] the high rate of needlestick injuries in an hiv-burdened context, coupled with long working hours, has resulted in high levels of stress and burnout among interns in sa.[5] additional factors impacting negatively on intern training include poor institutional leadership and an inability to recruit, retain and develop appropriate staff.[6,7] there is an increasing number of reports of overburdened and inadequately experienced supervisors, which also influences the quality of internship training across institutions in sa.[8,9] the concurrent impact of inadequate supervision within poor working conditions has raised concerns about the quality of assessments of interns in this context.[5,8] the health professionals council of sa (hpcsa) is the regulatory body responsible for the accreditation of institutions, supervisors, curricula and intern-assessment practice.[1] the hpcsa undertakes biannual accreditation visits to each institution to evaluate and ensure adherence to the mandated requirements for adequate training.[1] while a graduate competency framework derived from the royal college of physicians and surgeons of canada physician competency framework (canmeds) has been adopted by most undergraduate and many postgraduate medical training programmes in sa, this has not been rigorously applied to the internship period.[10] wba in internship in sa is based around a logbook that includes discipline-specific competencies focusing on procedural skills and some non-procedural skills, including medical ethics. checklists that rely on self-assessment by interns and inputs from their supervisors with regard to performance are included in the logbook for each discipline.[1] this study was conducted to analyse assessment practices within a competency-based framework in a resource-limited environment. this process can help to identify weaknesses, benchmark practices and inform decisions, in improving the assessment of interns in sa and in other lmics. background. resource constraints and a high disease burden impact on the work-based assessment (wba) of medical interns in south africa (sa). objectives. to review the use of workplace-based assessment frameworks in intern practice in sa and to compare these with international practices. methods. a systematic review using a thematic analysis was performed to analyse 97 articles selected from an initial scoping of 360 sources of evidence on wba in internship between 2000 and 2017. this process informed a synthesis of descriptive and analytic themes related to competency-based assessment practices relevant to internship in sa. results. there was an overall dearth of studies on assessment of medical interns in lower-middle-income countries (lmics). the context in which the assessment of interns in sa occurs has many challenges related to resources, workload and supervision. sa intern assessment is largely focused on core clinical competency, and this occurs without using competency-based frameworks. this focus was reflected in the finding that most studies in sa have dealt with the assessment of core procedural skills related to acute clinical care, while the assessment of non-clinical competencies and non-procedural skills was poorly addressed. self-assessment by interns was the predominant strategy used in the sa context. the review revealed limitations in the use of multiple assessment strategies and direct observation in the local context, in contrast to practices in most high-income countries. conclusions. a shift in focus to assess both procedural and non-procedural skills within a competency-based framework is advocated for sa internship, together with the use of multiple assessment tools and strategies that rely on direct observation of performance. afr j health professions educ 2018;10(1):44-49. doi:10.7196/ajhpe.2018.v10i1.955 comparing international and south african work-based assessment of medical interns’ practice k l naidoo,1,2 mb chb, dch, fcpaed; j van wyk,3 bsc ed, bed, med, phd; m adhikari,2 mb chb, fcpaed, phd 1 king edward viii hospital, kwazulu-natal department of health, durban, south africa 2 department of paediatrics and child health, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 department of clinical and professional practice, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: k naidoo (naidook9@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 45 research methodology the literature review used a thematic analysis to synthesise findings on assessment practices within a competency-based framework among interns in sa, compared with international practice. thematic analysis is often used to analyse data in primary qualitative research and can be used in systematic reviews to bring together and integrate the findings of multiple qualitative studies.[11] a thematic analysis was undertaken to review the studies, which included many diverse approaches to research. the aim of this research synthesis was to identify and highlight key concepts from literature sources and to recognise and compare the use of the same concepts in other studies.[12] search strategy the initial scoping of the literature involved searches on electronic databases by the primary author and an assistant. the databases searched included: ebsco host; medline; pubmed; eric (education resources information centre); sabinet (sa bibliographic information network) and education source. the terminology to describe a medical intern, i.e. a doctor in the first 2 years following undergraduate medical qualification, varies greatly. the terms commonly used include ‘medical intern’; ‘foundation year doctor’; ‘pre-registration house officer’ and ‘junior doctor’. in all databases searched, these terms were used as the primary search terms. the key words ‘assessment’, ‘assessment tools’, ‘competency’ and ‘competency framework’ were used in conjunction with the primary search terms. in addition to the articles obtained through various databases, articles were selected based on manual searches of references cited in key articles. policy reviews, reports relating to assessment and evaluation of national intern programmes, stakeholder analyses, theses and conference proceedings were included in the secondary search. fig. 1 indicates the process followed in the systematic literature review. english-language articles published between 2000 and 2017 were included for review. the last search was conducted at the end of january 2017. the articles selected for inclusion focused only on the wba of junior doctors in their first 2  years post qualification (interns). literature that included undergraduate medical students was excluded. articles describing the assessment of first-year residents in specialty programmes in the usa were included, while those that focused on specialty programmes whose participants were in the later years of specialisation (secondyear residents onwards) were excluded. quality criteria assessing the quality of the largely qualitative research studies that were identified was necessary to avoid drawing unreliable conclusions.[11] in our review, we assessed studies according to seven broad criteria:[13,14] the relevance of the study to the review question; the appropriateness of study design; transferability of the conclusions drawn; the use of context to enable comparability of the findings to interns in sa; data collection; analysis; and finally, an account of reflexivity, in terms of recognising personal biases.[14] data extraction all articles identified from the initial scoping of the literature were reviewed by the main author using the inclusion criteria stipulated.* those studies identified after this process were subjected to a quality assessment, as indicated. those studies that were identified following the quality assessment were scanned for key concepts, which were inductively coded and tabulated. a second independent investigator, a professional health educator, then reviewed the inductive codes to ensure concordance with the primary sources. the individually derived codes were subsequently discussed between the researchers to reach consensus on the final descriptive themes. data synthesis the synthesis took the form of three stages: line-by-line coding of the findings of primary studies; organisation of these ‘free codes’ into related areas to construct descriptive themes; and the development of analytical themes. a multidisciplinary review team consisting of the main author (an intern supervisor and clinician), the second author (the professional health educationist) and the third author (an academic experienced in postgraduate training) reviewed the data obtained to ensure its relevance and robustness in fulfilling the objectives of the review. the analytical themes were refined through a cyclical process with the primary author developing the first draft of inductive codes and two co-authors contributing to the refining and identification of the final themes. the final themes, chosen by consensus, were sufficiently comprehensive to describe the categories and to meet the primary objective of the review.[11,12] results the results from the literature searches indicated that the number and quality of research evidence on wba during internship differed significantly between international and sa sources. a total of scoping use search terms only inclusion/exclusion criteria only studies on interns in �rst 2 years of training quality criteria 1. relevance 2. design 3. transferability 4. context 5. data collection/ sample 6. analysis 7. re�exivity ebscohost, medline, pubmed, eric, sabinet, education source (n=360) high-income countries (usa, canada, uk, nz, australia), n=241 lmics, n=119 (inc. 19 from sa) total, n=182 sa, n=36 international, n=146 included, n=97 sa, n=19 high-income countries, n=78 excluded, n=178 focused on undergraduate or postgraduate programmes excluded, n=85 focused on learning environment thematic analysis 1. descriptive themes 2. analytical themes fig. 1. inclusion and exclusion criteria. (sabinet = south african bibliographic information network; eric = education resources information centre; nz = new zealand; lmics = lower-middle-income countries; inc. = including; sa = south africa.) 46 march 2018, vol. 10, no. 1 ajhpe research 67% percent of the initial 360 articles sourced from the primary searches were from high-income countries, i.e. the uk, north america (usa and canada), western europe, australia and new zealand. using the inclusion and exclusion criteria – selecting only studies involving newly qualified doctors in their first 2 years following graduation (interns) –182 articles were selected. of these, 146 were from high-income countries, and 36 from sa. an application of the quality criteria revealed a large number of studies that did not meet the criteria, as they were not relevant to the research question.[13,14] as indicated in fig. 1, many studies identified in our search on assessment among interns dealt largely with environmental factors, and not assessment within a competency framework. only 19 sa articles had a primary focus on wba in interns, while 78 articles from high-income countries focused on the objectives of the review. ninety-seven articles were thus finally included for analysis to identify definitive themes (fig. 1). the review aimed to extract and synthesise findings relating to the use of competency-based assessment frameworks among interns in sa. there was a paucity of studies on competency-based assessment among interns in sa in comparison with the studies from high-income countries. the aim of the study was therefore to compare and report on similarities and differences in the wba of medical interns across the two contexts. tables 1 4 depict the major descriptive themes identified from the inductive codes, which were derived from the primary sources of literature, and the four analytical themes developed. these themes are ‘lack of competency-based frameworks in accrediting interns in sa’, ‘emphasis on assessing only clinical procedural skills instead of both clinical and table 1. analytical theme 1: lack of competency-based frameworks inductive codes from primary sources major descriptive themes analytical themes 1. defining competency-based systems 2. reasons for shifting towards a competency-based system 3. validation of competency tools using factor analysis and other methods 4. defining specific competencies required by junior doctors 5. limitations in competency-based assessments 6. a shift to the use of entrustable professional activities and milestones the use of a competency-based framework lack of competency-based frameworks 7. rates of underperformance 8. factors affecting underperformance among interns 9. innovative and new methods of assessing ‘at-risk’ interns recognition of underperformance table 2. analytical theme 2: emphasis on assessing clinical procedural skills inductive codes from primary sources major descriptive themes analytical themes 1. procedural skills assessed: • resuscitation • obstetric and anaesthetic skills • paediatrics • surgical and related disciplines skills 2. non-procedural skills: • prescribing skills • documentation of clinical events and procedures • radiological assessment • mental-state examinations type of skills being assessed emphasis on assessing clinical procedural skills table 3. analytical theme 3: self-assessment instead of direct observed assessment inductive codes from primary sources major descriptive themes analytical themes • evidence of the poor reliability of self-assessment tools • poorly performing interns have poor ability in self -assessment • aggregate self-assessment valid for programme evaluation • the use of log books or tick lists not a reliable tool for assessment • portfolios are useful in assessing interns the use of self-assessment self-assessment instead of direct observed assessment • multisource feedback tools used successfully among interns • the use of mini-cex (clinical evaluation exercise) • the use of the mini-pat (peer assessment tool) • the use of the dops (directly observed procedural skills) • the use of peer review tools the use of directly observed assessments march 2018, vol. 10, no. 1 ajhpe 47 research non-procedural skills’, ‘use of self-assessment instead of direct observed assessment’ and the ‘influence of the learning environment on internship’. discussion clear differences were identified in various aspects of wba between the international and sa settings. the first and most obvious difference was noticeable in the number of studies and research articles reporting on issues relating to wba during internship. the second difference related to the dearth of studies conducted in the field of medical and health professions education in lmics and in sa. the limited number of reported research projects in medical education from sub-saharan african countries has been documented before.[15-17] this review confirms the previous observation and confirms the discrepancy in literature relating to research on wba among interns. the review of the literature relating to wba in high-income countries showed a clear focus on assessing the knowledge, skills and attitudes of interns by using a competency-based assessment framework. the two broad areas of competency focused on the assessment of core clinical skills and nonclinical competencies, including communication and professionalism.[18,19] the analysis of the international literature also indicated a shift towards the use of ‘entrustable professional activities (epas)’ as a possible framework for measuring activities of trainees in specific workplace settings. the use of these ‘concrete critical activities which infer the presence of multiple competencies help[s] bridge the gap between the theories of competencybased education and clinical practice. these epas should be ‘independently executable, observable and measurable’; an example of such an activity is executing a patient handover.[21] the concept of milestones, as introduced in best-evidence international practice, provides greater clarity and understanding of the incremental development of competencies in junior doctors over time.[20-22] sa studies, however, did not report on the use of competency-based frameworks, epas or any other time-based indicators (milestones) to measure progress of interns in the work-based setting.[20] the main focus in the sa literature was the assessment of core procedural skills in acute emergency and clinical situations. sa studies indicated the suboptimal performance of interns in paediatric resuscitation, obstetric practice, anaesthesia, orthopedics, intubation, circumcision and appendectomies.[9,15,23,24] the emphasis on procedural skills in acute emergencies possibly reflects the narrow interpretation of the role sa interns are expected to play within institutional hierarchical systems, and disregard for assessing their competence in knowledge, attitudes and non-clinical functions. this lack of studies on non-procedural skills in sa identifies clear gaps in the assessment methods of interns in sa. gaps in the assessment of non-procedural skills such as prescribing medication, communication and mental-state examinations were also identified in a systematic review of non-technical skills in lmics that highlighted the lack of tools to assess non-procedural skills.[16] this gap indicates a need for sa to align intern training and assessment frameworks with undergraduate and postgraduate practice, which frame curricula and assessment practices within frameworks such as canmeds.[25] the use and benefits of epas specific to each discipline may make the acceptance of their use for assessment, and the measuring of competencies, much easier.[19] the literature from high-income countries reflected a trend away from relying on self-assessment as the sole means of determining intern performance. self-assessment is shown to have a poor correlation with other modes of evaluation.[26-28] interns were unable to judge their own performance.[29] the least-skilled intern seems to have the poorest ability to self-assess, which they are often unable to correct even with support.[26] table 4. analytical theme 4: impact of the learning environment inductive codes from primary sources major descriptive themes analytical themes • constant change as a norm of the intern working environment • disease burdens of lmics • burnout • workload as an aggravating factor in internship • workhours in internship • availability of resources in internship learning environment • reliability and relevance of measuring intern preparedness challenges in the learning environment impact of the learning environment • trends in preparedness across disciplines and institutions • factors influencing preparedness of interns • linkages of preparedness with undergraduate training preparedness • critical gaps in supervisor interaction • duration and engagement of supervision • quality of supervision • subjectivity of supervision • training of supervisors • support provided for supervisors supervisor interaction • duration of feedback to interns • quality of feedback to interns • benefits of feedback during internship feedback lmics = lower-middle-income countries. 48 march 2018, vol. 10, no. 1 ajhpe research aggregated self-assessment was more useful for tracking cohorts and for programme evaluation.[30] sa practice largely emphasises self-reported assessments of interns.[1] some sa studies have also indicated that poorly skilled interns were unduly optimistic about their own performance,[31] and that interns’ perceptions of competence were unrelated to the assessments by others of their performance.[32] this may strengthen the argument for the use of multiple methods of assessment, instead of the reliance on self-assessment. innovations in wba from developed countries feature the use and validation of tools that use direct observation. these tools, used either alone or in combination with other modes of assessment, are often centrally developed for a country or district and require significant human resources and administration. the use of mini cex (clinical evaluation exercise), mini pat (peer assessment tool) and dops (directly observed procedural skills) systems was reported in the international literature, reflecting the use of multiple tools of assessment of interns in high-income countries. the 360-degree multisource feedback (msf) assessment process was found to have robustness and feasibility in the first year of internship.[33] msf tools were well received and well aligned to the job, and improvements became evident owing to the use of the msf strategy.[34] the msf process was regarded as a viable strategy to assess a large number of doctors.[35] sa literature did not feature articles on the use of directly observed tools for wba, reflecting a major gap in the reporting, validation and use of efficient assessment tools among interns. in sa it is likely that inclusion of all categories of staff, including middle-grade medical, allied health professionals and nursing staff, in assessments could promote integration, teamwork and the assessment of non-core skills such as communication and professionalism that is currently missing from the assessment system. the lack of multiple directly observed tools of assessment for interns in sa reflects the current status of assessment, the challenges and the shortage of sufficiently experienced supervisors.[7,8] various factors were documented in the literature to indicate the challenges faced by internship training in sa and other lmics. this context is noted for having high workloads, resource limitations and inadequate supervisor support and training. the consequence of this constrained environment of suboptimal supervision is compromising of patient safety, especially due to poorly skilled and trained interns. international research among interns reflects on the assessment of practices to ensure that patient safety is prioritised.[36] in sa hospitals, there is a lack of emphasis on assessing interns on practices that ensure patient safety, despite identification of the fact that their excessive workload and long work hours compromise patient care.[8,37] despite the challenges involved, proven innovations and developments in assessment processes from high-income countries need to be adapted and explored within the context of sa and lmics to optimise the training of interns. recommendations the wba of interns in south africa needs to adopt a broad competencybased framework that encompasses the assessment of knowledge, skills and attitudes. linking internship with the graduate competency-based frameworks of undergraduate and postgraduate courses will assist in this. both procedural and non-procedural skills need to be assessed. nonprocedural skills in internship, including skills in communication, prescribing, mental-state evaluations and documentation, among other ‘soft skills’, need to be given adequate place in the assessment of interns in sa. there is a need to recognise the ‘novice-to-expert’ trajectory among interns over a 2-year period. the use of milestones should be incorporated within this framework, as well as the use of clearly defined disciplinespecific epas that can be easily measured to determine competencies. multiple tools of assessment need to be used that focus on direct observation as well as elements of self-assessment. intern assessment needs to include tools that focus on patient safety. the msf tool is practical, usable for large numbers and will enable teamwork. this process will enable an equitable emphasis on skills such as communication and professionalism, which are currently neglected. further research on the use of directly observed tools of assessment that assess all types of skills and competencies within a resource-challenged context needs to be done. strengths and limitations despite the differences in the quantity of studies emanating from lmics as compared with high-income countries, this review attempted to identify significant differences in assessment practice and propose recommendations to improve wba. this review was restricted to articles published in english over the last 17 years. literature included reports, guidelines theses, policy reviews and stakeholder analyses. abstracts presented at conferences relating to the assessment of medical interns were not included for analysis, if they could not be found via an electronic database. studies of first-year residents in the us context were included whilst studies with defined internship periods elsewhere were focused on. conclusions in sa, the focus in wba among interns is on assessing core procedural skills without a competency-based framework. this occurs to the detriment of assessing non-procedural skills and non-clinical competencies, and fails to consider milestones in this process. self-assessment methodologies, which have proved to be inadequate in assessing interns, predominate in sa. the use of multiple methods of assessment for interns, including tools that incorporate direct observation, is being implemented in most highincome countries, and needs to be evaluated for use in sa. the use of msf is proving efficient for large numbers of doctors. many developments in wba within high-income countries are relevant to the sa context, and their adaptation or adoption within a resource-constrained context should be explored to overcome gaps identified in intern training. *the datasets extracted and analysed in this study are available from the corresponding author on reasonable request. acknowledgements. mrs. leora sewnarain for assistance with typesetting and ms rani moodley for assistance with the database searches. author contributions. kln was responsible for study design, data collection, data analysis and drafting the manuscript. jvw was responsible for supervision of the entire project, study design and manuscript review. ma was responsible for supervision of the entire project and manuscript review. funding. mepi funding: this publication was made possible by grant number march 2018, vol. 10, no. 1 ajhpe 49 research r24tw008863 from the office of the us global aids co-ordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. conflicts of interest. none. 1. medical and dental professions board, health professions council of south africa. handbook on internship training. guidelines for interns, accredited facilities and health authorities. pretoria: hpcsa, 2016. 2. frenk j, chen l, bhutta z, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 3. norcini j, burch v. workplace-based assessment as an educational tool: amee guide no. 31. med teach 2007;29(9-10):855-871. https://doi.org/10.1080/01421590701775453 4. burch v. portfolios for assessment and learning: guide supplement 45.1 – viewpoint. med teach 2011;33(12):1029-1031. https://doi.org/10.3109/0142159x.2011.596589 5. bateman c. system burning out our doctors – study. s afr med j 2012;102(7):593-594. https://doi.org/10.7196/ samj.6040 6. ibeziako o, chabikuli o, olorunju s. hospital reform and staff morale in south africa: a case study of dr yusuf dadoo hospital. s afr fam pract 2013;55(2):180-185. https://doi.org/10.1080/20786204.2013.10874330 7. tumbo j, sein nn. determinants of effective medical intern training at a training hospital in north west province, south africa afr j health professions ecuc 2012;4(1):10-14. https://doi.org/10.7196/ajhpe.100 8. bola s, trollip e, parkinson f. the state of south african internships: a national survey against hpcsa guidelines. s afr med j 2015;105(7):535-539. https://doi.org/10.7196/samjnew.7923 9. peters f, van wyk j, van rooyen m. intern to independent doctor: basic surgical skills required for south african practice and interns’ reports on their competence. s afr fam pract 2015;57(4):261-266. https://doi.org/10.1080 /20786190.2014.976954 10. van heerden, bb. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2012;103(1):21-22. https://doi.org/10.7196/samj.6463 11. thomas j, harden a. methods for the thematic synthesis of qualitative research in systematic reviews. bmc med res methodol 2008;8(1):45. https://doi.org/10.1186/1471-2288-8-45 12. thomas j, harden a, oakley a, et al. integrating qualitative research with trials in systematic reviews. bmj 2004;328(7446):1010. https://doi.org/10.1136/bmj.328.7446.1010 13. mays n, pope c. assessing quality in qualitative research. bmj 2000;320(7226):50. https://doi.org/10.1136/ bmj.320.7226.50 14. kuper a, lingard l, levinson w. critically appraising qualitative research. bmj 2008:337(3):a1035-a1035. https://doi.org/10.1136/bmj.a1035 15. burch v, van heerden b. are community service doctors equipped to address priority health needs in south africa? s afr med j 2013;103(12):905. https://doi.org/10.7196/samj.7198 16. scott j, revera morales d, mcritchie a, et al. non-technical skills and healthcare provision in lowand middleincome countries: a systematic review. med educ 2016;50(4):441-455. https://doi.org/10.1111/medu.12939 17. tutarel o. geographical distribution of publications in the field of medical education. bmc med educ 2002;2(1):1-7. https://doi.org/10.1186/1472-6920-2-3 18. carr s, celenza a, lake f. assessment of junior doctor performance: a validation study. bmc med educ 2013;13(1):1-6. https://doi.org/10.1186/1472-6920-13-129 19. archer j, norcini j, southgate l, heard s, davies h. mini-pat (peer assessment tool): a valid component of a national assessment programme in the uk? adv health sci educ 2006;13(2):181-192. https://doi.org/10.1007/ s10459-006-9033-3 20. hicks pj, schumacher dj, benson bj, et al. the pediatrics milestones: conceptual framework, guiding principles, and approach to development. j grad med educ 2010;2(3):410-418. https://doi.org/10.4300/jgme-d-10-00126.1 21. ten cate o, scheele f. viewpoint: competency-based postgraduate training: can we bridge the gap between theory and clinical practice? acad med 2007;82(6):542-547. https://doi.org/10.1097/acm.0b013e31805559c7 22. gardner a, scott d, choti m, mansour j. developing a comprehensive resident education evaluation system in the era of milestone assessment. j surg educ 2015;72(4):618-624. https://doi.org/10.1016/j.jsurg.2014.12.007 23. ash s. a comparison of two months versus two weeks of internship anaesthesia training. s afr j anaesth analg 2009;15(1):23. https://doi.org/10.1080/22201173.2009.10872583 24. nkabinde t, ross a, reid s, nkwanyana n. internship training adequately prepares south african medical graduates for community service – with exceptions. s afr med j 2013;103(12):930-934. https://doi.org/10.7196/ samj.6702 25. binnendyk j, watling c. canmeds in context: a transition to residency innovation. med educ 2015;49(11):11501151. https://doi.org/10.1111/medu.12862 26. davis d, mazmanian p, fordis m, et al. accuracy of physician self-assessment compared with observed measures of competence. jama 2006;296(9):1094. https://doi.org/10.1001/jama.296.9.1094 27. mckenzie s, burgess a, chapman r, mellis c. pre-interns: ready to perform? clin teach 2015;12(2):109-114. https://doi.org/10.1111/tct.12254 28. barnsley l, lyon p, ralston s, et al. clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence. med educ 2004;38(4):358-367. https://doi.org/10.1046/j.13652923.2004.01773.x 29. ibrahim j, macphail a, chadwick l, jeffcott s. interns’ perceptions of performance feedback. med educ 2014;48(4):417-429. https://doi.org/10.1046/j.1365-2923.2004.01773.x 30. d’eon m, trinder k. evidence for the validity of grouped self-assessments in measuring the outcomes of educational programs. eval health prof 2013; 37(4):457-469. https://doi.org/10.1177/0163278713475868 31. burch v, nash r, zabow t, et al. a structured assessment of newly qualified medical graduates. med educ 2005;39(7):723-731. https://doi.org/10.1111/j.1365-2929.2005.02192.x 32. kusel b, farina z, aldous c. anaesthesia training for interns at a metropolitan training complex: does it make the grade? s afr fam pract 2014;56(3):201-205. https://doi.org/10.1080/20786204.2014.936664 33. hesketh e, anderson f, bagnall g, et al. using a 360° diagnostic screening tool to provide an evidence trail of junior doctor performance throughout their first postgraduate year. med teach 2005;27(3):219-233. https://doi. org/10.1080/01421590500098776 34. miller a, archer j. impact of workplace based assessment on doctors’ education and performance: a systematic review. bmj 2010;341:(1-6). https://doi.org/10.1136/bmj.c5064 35. wilkinson j, crossley j, wragg a, et al. implementing workplace-based assessment across the medical specialties in the united kingdom. med educ 2008;42(4):364-373. https://doi.org/10.1111/j.1365-2923.2008.03010.x 36. fletcher ke, davis sq, underwood w, mangrulkar rs, mcmahon lf, saint s. systematic review: effects of resident work hours on patient safety. ann intern med 2004;141(11):851-857. https://doi.org/10.7326/00034819-141-11-200412070-00009 37. erasmus n. slaves of the state – medical internship and community service in south africa. s afr med j 2012;102(8):655-658. https://doi.org/10.7196/samj.5987 accepted 15 august 2017. https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.7196/samj.6040 https://doi.org/10.7196/samj.6040 https://doi.org/10.1080/20786190.2014.976954 https://doi.org/10.1080/20786190.2014.976954 https://doi.org/10.1186/1471-2288-8-45 https://doi.org/10.1136/bmj.320.7226.50 https://doi.org/10.1136/bmj.320.7226.50 https://doi.org/10.1186/1472-6920-2-3 https://doi.org/10.1186/1472-6920-13-129 https://doi.org/10.1007/s10459-006-9033-3 https://doi.org/10.1007/s10459-006-9033-3 https://doi.org/10.4300/jgme-d-10-00126.1 https://doi.org/10.7196/samj.6702 https://doi.org/10.7196/samj.6702 https://doi.org/10.1046/j.1365-2923.2004.01773.x https://doi.org/10.1046/j.1365-2923.2004.01773.x https://doi.org/10.1046/j.1365-2923.2004.01773.x https://doi.org/10.1111/j.1365-2929.2005.02192.x https://doi.org/10.1080/01421590500098776 https://doi.org/10.1080/01421590500098776 https://doi.org/10.1111/j.1365-2923.2008.03010.x https://doi.org/10.7326/0003-4819-141-11-200412070-00009 https://doi.org/10.7326/0003-4819-141-11-200412070-00009 march 2018, vol. 10, no. 1 ajhpe 3 forum in ancient greece, where western medicine originated, rituals of healing took place in the form of performances – with an observing audience.[1] greek physicians believed in the importance of the role of theatre in the treatment of illness.[2] the connection between the art of healing and the art of performance, which was formed in ancient greece, still exists,[3-5] as also becomes apparent when considering that an operating theatre and a performance theatre are both still referred to as ‘theatres’. however, modern healthcare training focuses predominantly on clinical features and the treatment thereof, which is one of the reasons why students of medicine lose their empathy during their training.[4,5] the acquisition of tools to step in and out of the role of a healthcare practitioner (hcp), could equip students of medicine with the ability to ‘reflect on their own thoughts, feelings, inclinations, practice and expe rience’.[6] this could be regarded as a process of debriefing, as it will allow them to reconnect with their ‘inner selves’ outside the scope of their role as hcps. by drawing attention to aspects of the art of performance in relation to healthcare training, this article explores the notion that, if students of medicine are trained in a way that enables them to reconnect with the art of performance, they could learn to adopt a role that will equip them with the necessary tools to cope with the emotional labour that their training requires.[3,5] adopting a role in the presentation of self in everyday life, goffman[3] investigates the concept of roles that human beings adopt, specifically when they need to adhere to a social structure confined to a building or a space. goffman refers to white coats as creating the impression that the manner in which tasks ‘performed’ by persons wearing such coats are standardised, clinical and confidential.[3] donning a white coat, adding a stethoscope and other features of medical care, could afford students of medicine the possibility of stepping into the role of a hcp while simultaneously stepping away from the self – just as an actor’s costume and make-up assist in transforming them into the character to be portrayed. goffman[3] also refers to a ‘setting’, which is a space that includes ‘furniture, décor, physical layout and other background items which supply the scenery and stage props for the spate of human action played out before, within or upon it’. this setting might refer to a set on stage that allows the actor to believe in the world of the drama that is about to unfold, as his visual perception contributes to the belief in his surroundings. medical students might learn to adapt to the setting in a hospital or consultation room in a similar manner: a setting reminding them that they are surrounded by an environment that offers certain prerequisites for them to take on the role of a hcp. sinclair,[4] a medical  doctor  and anthropologist who returned to medical school to observe how students are trained, draws detailed similarities between the art of performance and that of medicine. according to him, a strong connection between healthcare and the art of performance is suggested in the theatrical setting of ward rounds. students learn to present their patients before the ears and eyes of an audience.[4] apart from the performance aspect that sinclair[4] refers to, the acquisition of medical terminology corresponds to the actor’s internalisation of a stage script. neither the medical student nor the actor uses their own words. their inner selves can hide behind medical terminology or script. the revolutionary director of the russian stage, constantin stanislavski,[7] dealt at length with the notion of the ‘magic if ’. the actor must remain authentic by acting ‘as if ’ he found himself in the situation that the character is in. stanislavski’s ‘system’ – or representational acting – stands in strong contrast to the strasberg[8] ‘method acting’. in strasberg’s method, the actor immerses his entire being into the character he is portraying. the line between the character and the actor’s psyche becomes inextricably intertwined until it eventually dissolves and the actor is left in a state of confusion, with little or no connection to their own personal feelings. a comparison may be drawn between ‘method’ actors and students of the practice of medicine has evolved a long way from its origin, where healing was practised as an art in ancient greece. in current healthcare training, the focus is on clinical features and the treatment thereof. the connection to the arts in the practice of medicine has been lost – one of the reasons why students of medicine lose their empathy during their years of training. in this article, i explore the correlations between the art of performance and medicine, with particular focus on the training of students of medicine. the notion is investigated that if medical students learn to adopt a professional role by incorporating certain non-assuming facets of the art of performance into their training, they could learn to step in and out of the role of healthcare practitioner (hcp). this action could assist them not only in reflecting on their practice as hcps, but could also afford them the opportunity of debriefing, as they are equipped with the tools to view their role as hcps more objectively. the acquisition of tools to step in and out of the role of hcp, complemented by the process of debriefing through reflection, could afford students of medicine the ability to deal with the emotional labour that training to become a future hcp brings. in turn, this may empower them to retain the empathy that they inherently possessed when they enrolled as students. afr j health professions educ 2018;10(1):3-4. doi:10.7196/ajhpe.2018.v10i1.950 adopting a role: a performance art in the practice of medicine l schweickerdt, ba drama hons skills centre, school of medicine, sefako makgatho health sciences university, pretoria, south africa corresponding author: l schweickerdt (louise.schweickerdt@smu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:louise.schweickerdt@smu.ac.za 4 march 2018, vol. 10, no. 1 ajhpe forum medicine who lose touch with their inner selves in an attempt to immerse themselves into their medical identities as hcps. a strong correlation can also be drawn between stanislavski’s system and strasberg’s method and the role that students of medicine could adopt. instead of immersing themselves into the world of their training, such as a method actor would do, students of medicine could be trained to adopt a role such as explained by goffman[3] or stanislavski’s ‘magic if ’. in turn, this could afford medical students the possibility of stripping the role when they leave work to return to an area that goffman[3] refers to as ‘outside’ and sinclair[4] refers to as the ‘lay world’. these are areas that bear no connection to any areas or settings where a professional role needs to be adopted.[3,4] in theatrical terms, it could be the space that an actor returns to after having performed a role. these areas could offer the actor or students of medicine the possibility of rehabilitating the self through reflection as a means of debriefing.[6] here, students of medicine could internalise the experience, incorporating it as part of who they are when they do not need to adopt or portray the role of a hcp. hence, this could assist them not to become overwhelmed by unresolved emotions so that the emotional labour required to be trained as a future hcp does not become too much to bear, with the loss of empathy as consequence.[4,5] conclusion the practice of medicine has evolved from its origin, where healing was practised solely as an art in ancient greece. currently, healthcare training focuses predominantly on clinical features and the treatment thereof. students of medicine could benefit if they are given the tools to adopt a role as hcp instead of attempting to immerse themselves in the medical identity of a hcp.[3,4] incorporating some non-assuming facets of the art of performance into the training of medical students could assist them with the ability to step in and out of the role of hcp, which could afford them the opportunity to reflect on their actions to gain new insights into the strengths and weaknesses of their own practices.[6] the process of reflection could be regarded as a strategy to debrief, which could provide them with the tools to deal with the emotional labour that the work demands.[5] this could enable them to retain the empathy they inherently possessed when they enrolled as students of medicine. acknowledgements. i am deeply indebted to prof. ina treadwell, without whose insight and strong support none of this work would have been possible. i would also like to express immense gratitude towards dr champak barua for believing in the concept and his selfless sharing of knowledge throughout the process. author contributions. sole author. funding. none. conflicts of interest. none. 1. clift s, camic pm, eds. oxford textbook of creative arts, health and wellbeing. oxford: oxford university press, 2016. 2. christos fk, sfakianakis c, papathanasiou iv. health care practices in ancient greece: the hippocratic ideal. j med ethics hist med 2016;7(6):1-6. 3. goffman e. the presentation of self in everyday life. new york: random house, 1959. 4. sinclair s. making doctors: an institutional apprenticeship. oxford: berg publishers, 1997. 5. riley r, weiss mc. a qualitative thematic review: emotional labour in healthcare settings. j adv nurs 2015;72(1):6-17. https://doi.org/10.1111/jan.12738 6. kirklin d. humanities in medical training and education. clin med 2001;1(1):25-27. https://doi.org/10.7861/ clinmedicine.1-1-25 7. stanislavski c. an actor prepares. new york: routledge, 1964. 8. strasberg l. a dream of passion: the development of the method. boston: little, brown, 1987. accepted 16 august 2017. https://doi.org/10.1111/j.1553-2712.2012.01354.x https://doi.org/10.7861/clinmedicine.1-1-25 https://doi.org/10.7861/clinmedicine.1-1-25 article 15 june 2011, vol. 3, no. 1 ajhpe introduction the need to develop reflective practitioners in physiotherapy should in part be the role of higher education institutions. various methods of learning can be used to promote this. according to merrill1 there are four distinct phases of learning for a student that are evident in all methods of learning and these include ‘activation of prior experience, demonstration of skills, application of skills, and the integration of these skills into realworld activities’. as part of the constructivist perspective of learning, more emphasis should be placed on the learner, thus allowing knowledge to be built by the learner and not only given by the instructor. self-directed learning (sdl) is a method of instruction used increasingly in adult education within higher education institutions.2 the authors define self-directed learning in terms of ‘the amount of responsibility the learner accepts for his or her own learning’. however, within this current era, there is another challenge for the educator. the generational differences will definitely influence the approach to learning. the development of ict has allowed for new approaches for delivering instruction in institutions of higher education. thus we need to consider opportunities for learning using social media and e-learning. students also demand that our teaching presentations have structure and that the content being taught is evidence based. within the broad definition of self-directed learning, the self-directed learner needs to take control and accept the freedom to learn what they view as important for themselves. the degree of control the learner is willing to take over their own learning will depend on their attitude, abilities and personality characteristics.2 postgraduate students are considered adult learners and should be encouraged to become self-directed learners as part of their training. this active guided learning tends to remain in memory and can be more easily recalled by the learner.3 however, in becoming self-directed learners, there is a need to understand the role of the facilitator as well as the role of the learner. various studies have indicated the use of self-directed learning and education among health professionals such as doctors,4 dentists and nurses.5 in order to implement a programme or module using the selfdirected learning framework one needs to understand the role of the facilitator. literature has highlighted the role of a facilitator in education and clearly identified that one of the six main roles of the teacher is to be a facilitator.6 according to schwartz,7 a facilitator’s purpose is to abstract the use of information and communications technology (ict) has become integral to health professions education worldwide. the incorporation of online facilities and maintaining of the face-to-face element make blended learning the ‘best of both worlds’. blogs can be used to create a relatively learner-centred environment that allows students to learn at their own pace. though blended learning has been proved to be appropriate in higher learning institutions, it comes with challenges and opportunities. our study intended to highlight the challenges and identify opportunities encountered by an evidencebased practice (ebp) postgraduate class who used the blended learning model of learning. an action-based research methodology was utilised in this study. this involved data gathering, action planning, action taking and action evaluation. data were gathered through the use of a blog that was accessed by all participants. they made comments which were reflecting their perceptions on the model that was used for the course. the students gave consent to participate while permission from the physiotherapy head of department was also acquired. deductive analysis was used for data analysis. the information from the blog was extracted and converted into text files. coding and analysis into opportunities and challenges as expressed by the participants was performed. theoretical saturation through every reviewer’s agreement and satisfaction about the information was included. the data consisted of 94 postings made of primary postings (22) and responses (72). all the authors acted as reviewers. certainty was achieved by discussing any ambiguity in coding. any necessary amendments were made. the participants reported to have experienced some challenges pertaining to blended learning. the blog that was used as a media between students and the facilitator was inefficient in some way. some students could not access it when required and some resources in the blog were inaccessible. the wireless internet connection mainly used in this model was not reliable. however, there were opportunities experienced by the learners. these included easy interaction between the learners and the facilitator at any time. the model also reduced instructor dependence and made the learners more responsible of their work. the blog appeared as a resource base for skills development. timely feedback involving solving the problems students encountered during the course improved the communication skills between the students and the facilitator. however, technology constraints involving the blog and the internet connection were overwhelming among the students while writing up the tasks allocated to them. despite the fact that students faced some challenges, facilitators of blended learning such as the interaction between the students and the facilitator of the course were motivating to keep the course interesting. while students experienced some opportunities about blended learning, its future rests on averting the challenges associated with it more, especially in developing countries. if the challenges reported would be addressed in developing countries, blended learning can be effective in building students’ engagement and relieving of overcrowded classrooms in higher learning institutions. challenges and opportunities related to postgraduate evidence-based practice module using blended learning jm frantz, s himalowa, w karuguti, a kumurenzi, d mulenga, m sakala department of physiotherapy, univeristy of the western cape correspondence to: professor jm frantz (jfrantz@uwc.ac.za) article 16 june 2011, vol. 3, no. 1 ajhpe increase a group’s effectiveness by helping it to improve its processes and structures. the facilitator assists the learning process of the student and the experience is intended to be collaborative. with the facilitator, learning shifts from ‘passive’ learning to ‘active’ learning. the facilitator must understand that the student comes with prior knowledge and the method of instruction by the facilitator should guide the student to ‘the goal of interdependence’.8 in addition, the facilitator realises that ‘effective learning is possible when the role of the teacher is not that of a controller and deliverer of pre-packed knowledge’.9 thus the shift from the teacher-centred to student-centred instruction is being encouraged. the challenge that arises is: what are the guidelines for the shift from lecturing to facilitating learning? even though university requirements at postgraduate level allows for learning to exist, actual personal learning is controlled by, and dependent on the individual according to adult learning principles.10 these principles highlight that real learning occurs in self-directed and problem-oriented processes for adults, and each individual has to realise a ‘need to know’ and be intrinsically motivated to learn. this motivation needs to be nurtured, and knowles10 highlights six factors as sources of motivation; these include social relationships, external expectations, social welfare, personal advancement, stimulation and cognitive interest. to be a life-long learning health professional, self-directed learning should be an essential factor for effective learning. in self-directed learning the individual’s practical experience motivates and stimulates learning and can be linked to the process of evidence-based practice. this poses a challenge to the facilitator in ensuring that the four critical elements of learning are adequately incorporated. these elements include motivation, reinforcement, retention and transference. limited information could be found linking self-directed learning, evidence-based practice and physiotherapists. a postgraduate course in evidence-based practice was revised from the use of face-to-face instruction to a more blended learning approach which utilised face-to-face instruction, online discussions as well as other social media technologies. a blog was used to allow students to share knowledge, reflect and debate. blogs can be used to facilitate ‘small virtual groupings of individuals interested in co-constructing knowledge around a common topic within a community of practice’.11 refshauge & higgs12 describe an experiential learning framework that employs peer-assisted learning as one that allows the learners to relay their experiences, discuss their reflections and make conclusions after considering their own and their peers’ inputs before finally forming an improved view of the experience. thus the aim of this study was to highlight the challenges and opportunities experienced by the students regarding the incorporation selfdirected learning as a framework for learning the skills and methods of collecting and analysing the best evidence available to support practice. methods the study involved five full-time msc students undertaking an evidencebased practice (ebp) module as part of their degree programme. all students registered for the module participated in the study, and the lecturer acted as a facilitator. the students involved in the study were adult learners, with a bsc honours in physiotherapy, and who had returned to higher education after having had a gap of at least 2 years of physiotherapy practice. the mean years of clinical experience in the group were 6 years. this study was a cross-sectional qualitative study. the comments on the blog served as a reflective journal throughout the module. the data consisted of 22 blogs (primary postings) and 72 blog comments (responses to primary postings); these were added together to represent a total of 94 blog postings. although the course was designed to make use of didactic teaching, a blended learning approach was used which included didactic teaching, group discussions and online activities. this was a small-scale study with a qualitative approach because the aim was to gather rich, detailed information reflecting the participants’ viewpoints. this can be compared with the personal diary mode of data gathering in qualitative studies. informed verbal consent of willingness to participate in the study was obtained. permission was obtained from the head of department in which the students were registered and the registrar of the training institution. liberty to withdraw from the study by not contributing to the blog activities was not granted but contributions of those individuals would be excluded if so desired. however, in the current study, all blog posts were made available for use in the publication. data analysis deductive analysis was chosen to analyse the data obtained from the blog. the blogs were extracted from the web and converted into text files. according to tere,13 for an appropriate data analysis, one has to put the data in a format that will be easily analysed. coding and analysis of the blog continued according to the challenges and opportunities mentioned by the participants. theoretical saturation was achieved after every reviewer was satisfied with what he/she had included and agreed on by the other reviewers. all the authors acted as reviewers and any ambiguities in coding between investigators were discussed, reviewed and amended where necessary till certainty was achieved. results the aim of this study was to highlight the challenges and opportunities experienced by postgraduate students in incorporating self-directed learning as a framework for learning the skills and methods of collecting and analysing the best evidence available to support practice. the information in the blog focused on various tasks and the results will be presented according to themes guided by the conceptual model of understanding self-directed learning. according to song & hill,14 ‘the online learning context impacts on self-directed learning personal attributes of resource use, strategy use, and motivation’. within all of this there are opportunities and challenges as highlighted by the following quotes. skills development ebp module has allowed me to develop skills regarding the process of evidence-based practice as well as reflecting on what i do and how i do it. (opportunity) blended learning has been very interesting to me at the same time challenging. for me it is the ultimate learning process in the 21st century. while i appreciate the research skills that i’ve learnt through blended learning, the question that i keep on asking myself is: how are we going to transform this beautiful learning process back home? (challenge) improved learning this course (ebp) came at a time when our knowledge on research was a key higher. however, our writing knowledge has been refined; our aspiration for further writing has been inspired ... i was able to learn, read and contribute at my own pace. (opportunity) article 17 june 2011, vol. 3, no. 1 ajhpe understanding and finding the correct tools to score the methodological quality [of an article] was another challenge as most of the tools aimed at assessing rcts though there are limited tools that critically appraise other study designs which is commonly found in health professionals research … others found this task easier and i felt pressured to complete the task in order to contribute. (challenge) resources the students were able to access each other’s ideas and perspectives on various topics through the blog. however, the blog had both challenges and opportunities as a resource. to my utter disappointment, it wasn’t to be because i was never able to log in. this was at times devastating because i was not able to post anything i wanted to share ‘my experiences’ with my colleagues. it made me trail behind sometimes and this was never good at all. (challenge) the fact that we could share our ideas, opinions, challenges, information and knowledge made it far more important and worthwhile than what i see on facebook ... i could refer back to the comments and additional resources place on the blog. (opportunity) strategies students made use of the blog as well as face to face discussions to improve their skills. in addition the importance of the facilitator and feedback was also highlighted. this process was somehow challenging, where sometimes i would write up any part of the article and feel i have done great but the facilitation and feedback from the lecturer really helped a lot. this assisted me in understanding immediately where necessary. (opportunity) i also like the fact that we had to share our challenges throughout the way because one would feel that he/she is not the only one facing the challenges. support from others helped me cope with the challenges. (opportunity) the blog could at times keep the posted comments pending and therefore denying the bloggers the opportunity to read and respond on time. this was frustrating as i wanted immediate responses. (challenge) task context students reported challenges and opportunities within the process of evidence-based practice and finding information supporting their research question. very little literature around africa was found. this hampered my progress regarding the desired tasks. (challenge) some articles were difficult to review since there was a limitation in drawing out the specific conclusions of the study and research design. i struggled with this. (challenge) the methodology phase has made me realise that teaching the theory relating to tools and techniques is not as effective as providing the students with the opportunity to apply the tools themselves. (opportunity) i found being able to refer to the outline of the tasks on the blog and the comments from others associated with it good as i could go back all the time when i did not understand. (opportunity) discussion blended learning is a combination of any form of technology-facilitated learning and face-to-face instructor-led training.15 the traditional models of learning are being replaced by the emergence of new advanced technologies that provide the facilitators with an exceptional opportunity, creating blended learning environments that are highly interactive, meaningful and learner-centred.16 ebp is a movement within health professions education that allows professionals to identify, disseminate and promote the adoption of practices based on research. designing a postgraduate ebp module is challenging, as it would be expected that the evidence base expands from pure intervention studies and rcts to including evidence on contextual factors using qualitative research. how to best teach ebp has become a major point of discussion in many health professions but teaching concepts of ebp remains a challenge in professional education.13 in exploring effective pedagogies, educators have emphasised the benefits of applying the principles of adult learning theory to ebp modules. in the current study students highlighted the challenges and opportunities faced when allowed to incorporate the principles of self-directed learning in a module. the use of information and communications technology (ict) has become integral to health professions education worldwide. blogs can be used to create a relatively learner-centred environment that allows students to learn at their own pace. this was evident in the current study when participants reflected on their experiences and indicated that they could continuously refer back to comments and tasks on the blog. in addition, participants also indicated that they could ‘learn, read and respond’ at their own pace. however, research has highlighted that there are concerns that developing countries lack the relevant infrastructure and skill base to effectively incorporate ict in education.17 although learners of today have tried to embrace technologies like blogging to enhance their learning in institutions, the students in the current study also highlighted their concern of how they would be able to effectively implement this method of teaching and learning in their home countries in africa. currently this challenge is also being highlighted in medical education in africa.18 conclusion although blended learning can be used to adjust to the essential learning methods and overall learning environment of the student, it is still evident that challenges do exist with this method. the challenges related to blended learning that arose during the course include, but not limited to, technology constraints involving the blog and the internet connection. despite the fact that students faced some challenges, the facilitators such as the interaction of the students and the facilitator providing feedback on students’ progress were motivating to keep the course interesting. the blog allowed a greater and timely feedback such as solving the problems the students encountered during the course and improved the communication and it skills between the students and the facilitator. if the challenges reported would be addressed in developing countries, this type of learning can be effective in building students’ engagement in learning, relieving overcrowded classrooms found in most african countries. in all, there was a multitude of success to both the facilitator and students during this course. implications for practice incorporation of blended learning in physiotherapy will lead to enhancement of learning due to access to literature and reduction of dependency on facilitators, which is a characteristic of didactic learning and improved responsibility and autonomy over the learners’ work. article 18 june 2011, vol. 3, no. 1 ajhpe references 1. merrill d. first principles of instruction. educational technology research and development 2002;50(3):43-59. 2. fisher m, king j, tague g. development of a self-directed learning readiness scale for nursing education. nurse education today 2001;21:516-525. 3. ryan g. student perceptions about self-directed learning in a professional course implementing problem based learning. studies in higher education 1993;18(1):53-63. 4. tagawa m. physician self-directed learning and education. kaohsiung journal of medical science 2008;24(7):380-385. 5. murad mh, varkey p. self-directed learning in health professions education. ann acad med singapore 2008;37:580-590. 6. harden rm, crosby j. the good teacher is more than a lecturer -the twelve roles of the teacher. amee guide no 20: medical teacher 2000;22(4): 334-347. 7. schwarz r. using facilitative skills in different roles. in r. schwarz, a. davidson, p. carlson, & s. mckinney (eds.), the skilled facilitator fieldbook: tips, tools, and tested methods for consultants, facilitators, managers, trainers, and coaches. san francisco, ca. jossey-bass 2005; 27-32. 8. musinski b. the educator as facilitator. a new kind of leadership. nursing forum 1999;34(1):23-29. 9. kwan c. learning a medical pharmacology via innovation: a personal experience at mcmaster and in asia. acta pharmacologica 2004;25(9):1186-1194. 10. johnston ak, tinning rs. meeting the challenge of problem-based learning. developing the facilitators. nurse education today 2001;21:161-169. 11. boulos mnk, maramba i, wheeler s. wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. biomed central medical education 2006;6:41. 12. refshauge k higgs j. teaching clinical reasoning. in: j. higgs & m jones (eds) clinical reasoning in the health professions. oxford: butterworth-heinemann, 2000. 2nd edition, pp141-147. 13. portney lg. evidence based practice and clinical decision making: it’s not just the research course anymore. journal of physical therapy education 2004;18:46-51. 14. song l, hill jr. a conceptual model for understanding self-directed learning in online environments. journal of interactive online learning 2007;6(1):27-42. 15. moeb s, weibelzahl, s, dowling na. supporting facilitators of blended learning with guidebooks 2007; eighth annual irish educational technology users’ conference, dublin, ireland national college of ireland. http://www.easy-hub.org/ stephan/moebs-edtech2007.pdf (accessed 3 september 2010) 16. kirkley se, kirkley jr. creating next generation blended learning generation environments using mixed reality, video games and simulations. tech trends 2005;9(3):42-54. 17. chandrasekhar cp, ghosh j. information and communication technologies and health in low income countries: the potential and the constraints. bulletin of world organization 2001;79(9):850-855. 18. williams c, pitchforth e, o’callaghan c. computers: the internet and medical education in africa. medical education 2010;44:485-488. short communicationshort communication 92 september 2017, vol. 9, no. 3 ajhpe context and setting south africa (sa) has made significant strides towards ensuring that the profile of learners admitted to its eight medical schools reflects the demographics of the country. yet, despite these efforts, sa is still plagued by human-resource challenges within the health sector, with the majority of healthcare professionals preferring to work in urban areas.[1] the wits initiative for rural health education (wirhe) scholarship is one of the programmes that was established by the centre for rural health (crh) as a response to the workforce challenges facing rural areas of sa. this programme provides opportunities to students from previously disadvantaged rural communities to register for professional degrees offered by the faculties of health sciences at any of the three medical schools in gauteng province: the universities of the witwatersrand, pretoria and sefako makgatho (previously medunsa).[2] as such, the launching of the first rural careers day in the north west province was informed by the experiences of managing the wirhe scholarship programme, which highlighted the challenges faced by students from rural communities who try to gain access to institutions of higher education.[3] this report describes the wits crh experience of organising a student-led rural health careers day as a pilot project, and an evaluation thereof based on the experiences of the participating students and learners. why the idea was necessary we recognised the effectiveness of student-learner mentorship based on previous experiences where wits medical students were required to provide input about careers in rural high schools in the bojanala district of the north west province. health sciences students are seldom given the opportunity to engage with high school learners in a structured programme. the hosting of a careers day in a rural district was initiated to create and strengthen an awareness of and enthusiasm for careers in the health sciences among grade 12 rural high school learners. what was done twenty-four senior health sciences students volunteered to facilitate a series of mini-workshops on career options, funding opportunities and healthpromotion topics for learners from 85 high schools in ngaka modiri molema district in the north west province. a total of 224 top-five rural learners completed a self-administered questionnaire once they had completed their rotation through all the stations to evaluate their views of the day. results and impact feedback from the high school learners demonstrated that they became better informed about career options in the health sciences fields (93%). most learners indicated that they would recommend the day’s activities to their peers (97%). the highest career preference score was for medicine (94%) (fig. 1). of the health-promotion stations, substance abuse received the highest ranking (80%) compared with the other topics, including hiv/ aids, sexually transmitted infections and teenage pregnancy. learners perceived the applications and funding station to be ‘informative’ (80%), although they indicated a need for additional information on funding. by engaging learners on health-promotion topics related to their sexual health and life choices, they may have benefited from the exposure and may even develop an appreciation for primary healthcare-intervention strategies and the role of universities at the community level. through designing and implementing programmes that link students to communities, universities have the potential to contribute positively to the realisation of healthcare goals in rural communities. acknowledgements. we would like to extend our appreciation to the wits students who joined us as volunteers, many of whom have completed their studies, and the ngaka modiri molema district for its role and contribution on the rural careers day. author contributions. nm: project director and prepared the initial draft; idc, ard, mm: contributed to the project design, participated in the review and contributed to the final draft. funding. partial funding was received from the csi division: toyota south africa. conflicts of interest. none. health sciences students’ contribution to human resources for health strategy: a rural health careers day for grade 12 learners in the north west province of south africa n o mapukata,1 msc (health care management), msc (med); i d couper,2 mb bch, mfammed, fcfp (sa); a r dreyer,1 mph; m mlambo,1 phd 1 centre for rural health, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 2 ukwanda centre for rural health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: n mapukata (ntsiki.mapukata@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. fig. 1. learners’ rating of the relevance of each career choice station. (q = question; ot = occupational therapy; clin as = clinical associate.) 80 77 82 84 84 71 94 82 0 10 20 30 40 50 60 70 80 90 100 q4a clin as (n=184) q4b ot (n=200) q4c pharmacy (n=194) q4f dentistry (n=160) q4g medicine (n=190) q4h radiography (n=195) learners, n q4e physiotherapy (n=188) q4d physiology (n=207) short communication september 2017, vol. 9, no. 3 ajhpe 93 1. khan t, thomas ls, naidoo s. analysing post-apartheid gender and racial transformation in medical education in a south african province. global health action 2013;(6)10. https://doi.org/10.3402/gha.v6i0.19810 2. ross aj, couper id. rural scholarship schemes: a solution to the human resource crisis in rural district hospitals. s afr fam pract 2004;46(1):5. https://doi.org/10.1080/20786204.2004.10873025 3. sondzaba n, couper i. wirhe scholarship – a case study of recruitment, support and retention of a rural workforce in north west. in: conference proceedings: celebrating innovative health management conference, cape town, 20 30 june 2011. https://uct-heu.s3.amazonaws.com/wp-content/.../2011/.../health-managementreport_final.p (accessed 17 august 2017). accepted 11 january 2017. afr j health professions educ 2017;9(3):92-93. doi:10.7196/ajhpe.2017.v9i3.856 https://doi.org/10.3402/gha.v6i0.19810 https://doi.org/10.1080/20786204.2004.10873025 https://uct-heu.s3.amazonaws.com/wp-content/.../2011/.../health-management-report_final.p https://uct-heu.s3.amazonaws.com/wp-content/.../2011/.../health-management-report_final.p 33 december 2010, vol. 2, no. 2 ajhpe cpd questionnaires must be completed online via www.cpdjournals.org.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb001/010/01/2010 (clinical) cpd december 2010 1. true (a) or false (b) – click on the correct answer: integration into a community of educators is one of the benefits of the network. 2. true (a) or false (b) – click on the correct answer: services that the network provide include reviewing content for copyright. 3. true (a) or false (b) – click on the correct answer: research indicated that there is a need to assess the impact of physical therapy education on scholarly productivity. 4. true (a) or false (b) – click on the correct answer: the lack of scholarly publications among the nurses at a malawian university could be due to the lack of master’s degree programmes at the institution. 5. true (a) or false (b) – click on the correct answer: internationally there has been a move to more communitybased training to ensure appropriate training. 6. true (a) or false (b) – click on the correct answer: a key element of the parallel rural community curriculum (prcc) is the focus on the undifferentiated patient as the basis for learning. 7. true (a) or false (b) – click on the correct answer: in the flinders prcc programme integration of knowledge happens through practice and under the guidance of mentors. 8. true (a) or false (b) – click on the correct answer: the presence of students and academics in rural areas leads to the development of a learning culture. 9. true (a) or false (b) – click on the correct answer: a lack of time to explore psychosocial determinants of health and illness is a key barrier to implementing a bio psychosocial approach to patient care. 10. true (a) or false (b) – click on the correct answer: the biopsychosocial model is the paradigm that ‘enfolds’ knowledge from different disciplines. 11. true (a) or false (b) – click on the correct answer: the principles of primary health care encourage communities to assert their rights and interests. 12. true (a) or false (b) – click on the correct answer: clinicians and anthropologists can bring complementary aspects of health care together in an integrated manner. 13. true (a) or false (b) – click on the correct answer: lack of geriatric knowledge and skills has significant implications for health care providers working in rural areas. 14. true (a) or false (b) – click on the correct answer: the faq1, developed by erdman palmore, is a reliable measure of geriatric knowledge in a variety of cultures. 15. true (a) or false (b) – click on the correct answer: a positive attitude towards older adults (oas) is significantly associated with having lived with an oa relative. 16. true (a) or false (b) – click on the correct answer: geriatric competencies commonly recommended for all health care disciplines include understanding risk assessment and health promotion and mental, physical, affective, psychosocial and environmental aspects. 17. true (a) or false (b) – click on the correct answer: chronic wounds affect 2.8 million patients in the usa. 18. true (a) or false (b) – click on the correct answer: a knowledge score of 70% is regarded as indicating sufficient knowledge to treat various types of chronic wounds successfully. 19. true (a) or false (b) – click on the correct answer: gps are more interested than registrars in receiving wound-care literature. 20. true (a) or false (b) – click on the correct answer: surgical registrars may possess insufficient knowledge to act as teachers during a wound-care module. editorial collaboration: hope for the future juanita bezuidenhout e-mail: jbez@sun.ac.za i recently attended a colloquium at stellenbosch university about the pedagogies of hope, a project launched by the vice-chancellor, russel botman, based on the writings of freire.1-3 at this colloquium i was struck by the openness and directness of the discussion. there was no hiding behind double entendres and subtleties that could be misunderstood. the language was strong, candid and challenging. what is the essence of freire’s writings? jane tobbell summarised freire’s philosophy well: ‘he argues that education is not about knowledge per se but is about ideas, it is about engaging in dialogue to generate thought, explanations and understanding. he rejects the status of the “expert” and instead argues for an exchange of ideas in which both parties benefit and develop. education is expressed as a mutuality.’4 the hope project may have been initiated by stellenbosch university, but we all have the right to hope. as health science educators in the developing world we are particularly responsible for engendering hope. there are many ways in which we accomplish this already, but one of the ways in which we need to be more successful is collaboration, especially in research. in the december 2010 issue of medical education, patricia o’sullivan makes a strong case for collaborative research and argues that the research questions we address are often interdisciplinary in nature, and therefore collaboration should cross the boundaries to other academic fields. properly applied, this will facilitate connection between the abstract nature of theory generation and the concrete nature of addressing practical needs. the collaboration will therefore go beyond only obtaining a larger study sample or enhancing generalisability, to a shared intellectual process.5 we may argue that by the nature of what we do, we collaborate already, but that is often only within our institutions. we infrequently cross the boundaries to other institutions and countries to work on truly collaborative research. in the previous issue of ajhpe, wendy mcmillan argued that we need our research to move beyond description to the realm of explanation.6 she states that this will allow us to inform best practice in education and generate theory. she provides us with a discussion on the role of theory in education research and also with practical ways to ensure theoretical rigour in our research. therefore, on the one hand mcmillan adds her voice to others who argue that we must move from description and justification to clarification and generating theory.7 on the other hand o’sullivan argues for collaboration to generate theory and apply it. i want to reason that it is clear from these two arguments that we need to fearlessly cross the boundaries and engage in collaborative clarification research that could possibly be our best contribution towards engendering hope. i am not suggesting that currently we do not collaborate or perform clarification research; i am proposing that we should be more intentional. where do we start? we could follow a model where one individual initiates the collaboration and subsequently expands, but that would be like an inverse triangle that pivots on one individual. a more sustainable way is to create numerous interlocking networks. this creates a much stronger system that does not depend on a single individual and is therefore more sustainable. networks already exist. there are the institutional networks in faculties, but also across faculties, especially with academic education departments and education units; there are regional and national networks like saahe and heltasa, and then there are continental and global networks such as safri/faimer, the network, and amee, to mention a few. i think we also need to identify key areas for collaboration. there will always be certain aspects that are institution specific, but other aspects with much wider implications, and we need to identify these and develop large collaborative research projects that will substantively contribute not only to the body of knowledge but to engendering hope. ‘as the editor i wish to develop an academic platform which will allow experienced health professions educators to share their work and develop the scholarship of teaching and learning as relevant to our needs. i would also like to see the work of emerging educators published so as to advance their careers and promote educational research. … the challenge to put an african footprint on the map of academic discourse relevant to health sciences education is, i believe, long overdue.’8 these were vanessa burch’s closing words in the first editorial of this journal. three issues down the line the question arises – have we achieved anything during this period? looking at the past three issues of this journal i already see glimmers of hope and i can only say: ‘i believe so’. it is you, the reader and the contributor, who has the final say. do you read the articles? do you submit manuscripts? is it of value to you? as with any newborn, it will take a while for this journal to walk and talk. we are still taking baby steps, but once we have matured, the hope will be a bright shining light. 1. htpps://blogs.sun.ac.za/hopefulpedagoggiessu/. 2. freire p. pedagogy of the oppressed. new york: herder and herder, 1970. 3. freire p. pedagogy of hope. reliving pedagogy of the oppressed. new york: continuum, 1995. 4. tobell j. the oppressive curriculum: viewing the national curriculum through the freirean lens. annual review of critical psychology 2000;2:204-205. 5. o’sullivan p, stoddard h, kalishman s. collaborative research in medical education: a discussion of theory and practice. med educ 2010:44:1175-1184. 6. mcmillan w. moving beyond description: research that helps improve teaching and learning. ajhpe 2010;2:3-7. 7. cook da, bordage g, schmidt hg. description, justification and clarification: a framework for classifying the purposes of research in medical education. med educ 2008;42(2):128-133. 8. burch v. editorial. ajhpe 2009;1:2. 2 december 2010, vol. 2, no. 2 ajhpe juanita bezuidenhout deputy editor a maximum of 3 ceus will be awarded per correctly completed test. march 2018, vol. 10, no. 1 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/029/01/2018 (clinical) cpd questionnaire march 2018 true (a) or false (b) adopting a role: a performance art in the practice of medicine 1. literature suggests that the loss of empathy during training is attributed to a focus on the clinical features and treatment thereof by modern healthcare training. medical education units: a necessity for quality assurance in health professions education in nigeria 2. according to the 1998 edinburgh declaration, the main goal of any medical education programme is to deliver curative medical services. 3. one of the shortfalls of the nigerian medical education system identified by the authors is the unreliable forms of assessment. a survey of radiation safety training among south african inter­ ventionalists 4. in this study, radiologists and cardiologists rated an equal level of training in radiation safety. physiotherapy clinical education at a south african university 5. a 2007 review of clinical education models found that no model proved to be superior to another. 6. work overload, time constraints and other site barriers were some of the institutional barriers identified by respondents in this study. creating opportunities for interprofessional, community­based education for the undergraduate dental therapy degree in the school of health sciences, university of kwazulu­natal, south africa: academics’ perspectives 7. finding a common time for the students from the different disciplines to participate in interprofessional education activities was identified as the main barrier. 8. the study findings revealed that there are very few opportunities for interprofessional community-based education for dental therapy students. health education on diabetes at a south african national science festival 9. the results indicated significant gender differences in the preand postintervention mean percentage scores. engagement of dietetic students and students with hearing loss: experiences and perceptions of both groups 10. this study is the first to explore the experiences of dietetic students in providing health-promotion sessions to deaf students. the perspectives of south african academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training 11. telehealth and telemedicine are synonymous. 12. the academics’ lack of knowledge about telehealth makes it difficult for them to teach in this area. comparing international and south african work­based assessment of medical interns’ practice 13. the aim of the work-based assessment (wba) process is to ensure that doctors are performing as competent, ethical practitioners who have ‘globally connected, locally responsive attributes that are population and patient-centred’. 14. the review of the literature relating to wba in high-income countries showed minimal focus on assessing the knowledge, skills and attitudes of interns by using a competency-based assessment framework. ‘sense of belonging’: the influence of individual factors in the learning environment of south african interns 15. ethnicity, language and urban/rural status were identified as factors that are significantly associated with the lower perceptions of the learning environment in internship. the effect of undergraduate students on district health services delivery in the western cape province, south africa 16. international evidence shows that over the long term, the health service benefits of hosting students in practices and hospitals do not outweigh the demands that they place on the system. a new way of teaching an old subject: pharmacy law and ethics 17. research suggests that students involved in case-based learning (cbl) tend to be more confident in practising the skills learnt during the process. 18. a majority of the students agreed that participation in the cbl exercise helped to improve their understanding of law concepts. transition-to-practice guidelines: enhancing the quality of nursing education 19. effective transition to practice has not been found to enhance socialisation and confidence among nurses. 20. as a result of the guideline development process, 11 guideline statements were formulated. research december 2017, vol. 9, no. 4 ajhpe 199 leaders in higher education are required to address the imperatives for change that come from extrinsic sources, as well as from intrinsic pressure that results from the growth of knowledge itself. academics need to have the confidence to exert their power and be at the forefront of leading other people towards the actualisation of the objectives of a team.[1] in the highereducation sector, visible leadership is usually expected both from people in formal roles, such as heads of school, departmental chairpersons or deans, and those in informal roles, such as postgraduate-degree supervisors who are beginning to master self-leadership. persons engaging in self-leadership frequently cultivate a sense of ownership in terms of their tasks and work processes. as a result, self-leading individuals may demonstrate higher levels of commitment to their tasks, goals, teams, or organisations than individuals who do not engage in self-leadership.[1] in order to understand self-leadership, one needs to have insight into how one is classified as a leader in higher education, whether the role is formal or informal, whether the leader exerts an intentional influence or is it determined by context, and how leadership is embodied in individuals.[2] one must first be able to lead oneself before leading others. perceptions of who leads, and why they lead, are as important as what they do and how and where they do it. now, perhaps more than ever, leadership is seen to be associated with those who manage to create and promote a compelling and meaningful sense of their own values and identity. this is nothing unique to higher education, but the way in which it must be accomplished is highly context-specific.[3] self-leadership of academics fundamentally refers to being driven by motivation and self-influence to direct oneself towards achieving optimum performance in a situation.[1] leadership should be from within, and can thus be defined as ‘authentic self-expression that creates value’.[4] this form of leadership can thus be identified at all levels of an organisation. leadership cannot be removed from the culture of an organisation. the philosophy of the faculty of community and health sciences at a higher-education institution in south africa (sa) focuses on developing leaders at all levels who are able to adapt, collaborate and work within diversity, and who can lead themselves. as it had not been previously studied, it was unclear how academics experienced their selfleadership in their day-to-day challenges as senior academics. thus the aim of this study was to explore experiences of academics in a highereducation institution of their self-leadership traits in an educational environment. the study was conducted within cashman’s[4] theoretical framework of seven pathways for an academic, as it was considered relevant to the specific concept of self-leadership and to the context of academics in this study, focusing on leading from the inside out. methods study design this study used a qualitative, exploratory, descriptive and contextual research design. this design provided insight into the experiences of academic self-leaders in a changing higher-education environment, obtaining rich data and an in-depth understanding of the phenomenon, namely self-leadership. background. now, perhaps more than ever, leadership is seen to be associated with those who manage to create and promote a compelling and meaningful sense of their own values and identity that is demonstrated in the traits they portray to followers. in higher-education sectors, ‘leadership at all levels’ refers to both those in formal roles, such as departmental chairpersons, and those in informal roles, such as postgraduate-degree supervisors or mentors. objectives. to explore academics’ experiences of their self-leadership traits in a higher-education institution in a changing educational environment. methods. a qualitative, exploratory, descriptive and contextual research design was followed. the study population consisted of senior academics in departments in the faculty of community and health sciences at a residential university in south africa. purposive convenience sampling was used to include 10 available participants, all vice deans or heads of department, after which data saturation occurred. individual interviews were conducted that lasted around approximately 45 minutes. the data were analysed using open coding. results. five themes emerged around leadership: its development over time; that it can be earned though different means; that it is influenced through personal experience; the role of role models; and environmental encouragement. conclusion. the study findings indicated different views on the development of leadership skills. participants commented on the importance of a complex blend of competencies needed by leaders. a number of suggestions were put forth on how to develop leadership skills. afr j health professions educ 2017;9(4):199-202. doi:10.7196/ajhpe.2017.v9i4.823 self-leadership traits of academics to conform to a changing highereducation environment k jooste,1 phd; j frantz,2 phd 1 department of nursing science, faculty of health and wellness, cape peninsula university of technology, cape town, south africa 2 department of physiotherapy, faculty of community health, university of the western cape, cape town, south africa corresponding author: j frantz (jfrantz@uwc.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 200 december 2017, vol. 9, no. 4 ajhpe setting and study population the study population consisted of all senior academic leaders in the faculty of community and health sciences at a residential university, in the disciplines of physiotherapy, occupational therapy, dietetics, psychology, social work, sport, recreation and exercise science, natural medicine, nursing and public health. purposive convenience sampling was used, and 10 participants, occupying the roles of deans, heads of department (hods) and directors of schools and academic units, were selected until data saturation occurred, when no new data emerged. data collection individual semi-structured interviews were conducted that lasted approximately 45 minutes. the interviews were tape-recorded and held in a private room. data analysis the data were analysed through open coding, to identify themes and categories. the authors and independent coder reached consensus on the themes that emerged from the data. ethical considerations this study received ethics clearance (ref. no. 23/4/2015) from the senate research and ethics committee at a university in the western cape, sa. all participants signed a written consent form after receiving information on the purpose of the study. they could withdraw from the study at any stage. the interviews conducted were confidential, and names did not appear on the transcripts. results seven themes emerged that corresponded to the self-leadership skills outlined by cashman:[4] developing awareness and mindfulness of character and personality (personal mastery) self-awareness can be described as adopting a strong orientation toward achievement, holding high expectations for yourself and others and pushing yourself and others to achieve at high levels.[5] one participant mentioned that he focused on discovering himself while being mindful of his abilities: ‘we can be aware of what is a leader, a leader should do, should do this, and this, and this, you should manage, you should do this, you should manage time, you should […] but i think leadership is also discovering of yourself, and your abilities.’ another participant was aware of his inner self (inner consciousness), which he said contributed to his leading of others: ‘so i think a lot of my drive and a lot of my work starts with my inner work and i do believe that things work from the inside out, and if i’m on top of my game my inner world then the outer world follows, then i’m able to provide the leadership, then i’m able to be the role model.’ one of the participants also mentioned that leadership characteristics should be developed within a person, and that this development takes time: ‘so i think there are certain skills that, or values that [are] inbred in the person that makes them a leader, but there are also certain skills that need to be developed within a person.’ another participant indicated that the changes in personality and characteristics of a developing leader were bound by the environment or context: ‘that people can learn those skills and that quite often what emerges as leadership qualities is dependent on the environment in the context in which the individual finds themselves.’ the importance of actions having a purpose (purpose mastery) purpose mastery acknowledges creating a vision and figuring out where the organisation is heading, and getting people moving in that direction.[5] an hod mentioned having a vision, with a clear plan of the actions that were needed to move forward: ‘on the one hand, is that the person should have a vision. he should know where he takes the people to, and then of course you should have an idea how to get there […] the vision is to make this department the best department […] but should be realistic […] you should have a clear path on how you can get there, and all the things you should put in place to get there.’ another participant mentioned setting clear goals (purpose) through mentorship and coaching: ‘so i think that mentorship and coaching is very important. i think that peer networks, sharing, getting people doing similar things. setting goals, goal setting, you know.’ from problem focus to opportunity (change mastery) effective leaders should not lose sight of their long-term vision in the midst of change.[4] one participant realised that in the past there were limitations in the higher-education sector, and mentioned that changing oneself to act as a leader was better for the future: ‘i think everybody is protecting their own territory […] it comes from the past where they needed to do that and if we are able to move outside of our silos and move into, if everybody realises that they are a leader and they are promoting, for example, the faculty […] then we would start moving better.’ also, being aware of change, and able to adapt, is needed on different levels, and it was mentioned that: ‘you need to be in touch with what is going on, the changes. things are rapidly changing, so you need to be aware of what’s going on in education and in health, and politically, on education, on a whole lot of levels.’ recognising that there are contributing factors that make leaders successful (interpersonal mastery) another contributing factor in becoming a successful leader is interpersonal mastery, where people learn from each other.[4] a need was identified for interpersonal sharing of ideas through peer support: ‘i think peer support is a very important thing, because i think at the moment you come into the position, and you have to deliver, but there’s actually not a place where you can really go and create ideas and things like that’. a participant stated that a two-way relationship is essential: ‘i think also being in leadership the relationships are always bidirectional, it can never just come from one side’. research december 2017, vol. 9, no. 4 ajhpe 201 taking your own journey into being (being mastery) self-leaders should take time to realise who they are, by reflecting on their life experience, where they have been and where they might go.[4] one participant was of the opinion that to achieve more as a leader, one first needs to understand oneself and one’s own potential as an individual: ‘myself, i think it started off with me and engaging in processes with myself to get to a point where i could understand myself. i don’t think one could be an effective leader if you haven’t done the work on yourself. it’s like i always start my courses and say research and know thyself. because one can never go out and know something or somebody else if you don’t know yourself, so i think a lot of my drive comes from that.’ it was also mentioned that self-confidence was needed: ‘i think part of leadership is about confidence within yourself and if you … if you are solidly grounded within yourself and you confident in terms of who you are and it doesn’t require somebody with a big voice.’ making choices wisely, to be effective (balance mastery) mastering balance refers to recognising that every choice we make potentially also affects our work balance to survive.[4] one participant highlighted her own role in empowerment and choices in self-development: ‘i know that my opinion is that i will go ahead and empower and build my knowledge and get the books and everything, my growth is in my hands. so i’m going to do it irrespectively whether someone else does it or not.’ another participant mentioned his own role in taking wise and accountable decisions and actions: ‘they should be able to take up initiatives, if nothing is happening, say at a certain level as the job’s got to be done. we can’t all wait for something to happen, we’ve got to actually, sometimes say, this is the situation, i’m accountable to staff and students and everything; if no one else is guiding me, i go out and find it.’ the importance of sharing experiences with other people also came to the fore: ‘as leaders we are not prepared for all circumstances in life but if we are given an opportunity to share and in a safe space, then i feel that people will grow, because i find that i learn a lot from sharing, talking to others.’ taking actions connected to purpose and vision (action mastery) our inner resources and values shape our actions and behaviour in the world. personal values shape decisions and behaviour, and are drivers in creating organisational values.[6] the process of drawing others into a common vision was outlined: ‘what comes to mind is vision […] it’s around knowing long-term where your department is heading, and how it should get there. and then, to facilitate a group of people to buy into that vision, share that vision, and be moving towards that vision.’ one participant expressed how her experiences in life had developed her as a leader: ‘i think you […] leadership skills one develops, your personal experiences in life is definitely one of the things that contribute to the development of leadership skills. your values, and your beliefs in life also contributes to the type of leadership and then the opportunities that you have had, to be in a leadership role.’ discussion personal mastery is considered to be achieved when one comes to see life from a new perspective, while following the principles of having purpose, vision, belief and commitment, and knowing oneself.[7] it seemed that through self-awareness, the participants sought new ways of doing things and shaping their environment, while encouraging their followers to be a part of the changing process. under the mentorship model, a more experienced person provides advice and serves as a partner in developing the mentee’s skills, so as to become more self-aware in situations in which leadership should be shown, and also as part of developing him/her for future leadership succession. the participants highlighted the importance of having a vision or purpose for the future. leadership was shown in that participants indicated that they moved from problems to opportunities, that their workplace was always changing and they needed to accept this, and that they needed to adapt to change. participants understood that to create change, it is important to have a clear vision of the future within an organisation that benefits the community it serves. participants saw the need to create an organisational culture where people work together toward success, and this indicated their awareness of the importance of adaptability in change. this requires transformational leadership that involves the enactment of behaviours that inspire followers to perform beyond expectations.[8] participants found that having a vision helped leaders and their teams to become inspired and committed to a shared goal of quality education. effective leadership is an essential attribute for the provision of professional and high-quality education. certain factors contribute to effective leadership, and the findings indicated that a leader cannot exist in isolation, as effective interpersonal relationships are needed. some of these relationships are with peers, and participants mentioned that peer support could provide opportunities to develop teamwork that could enhance the quality of services rendered in the university setting. a study in ireland[9] also confirmed that having peers support one another, especially during challenging times, is very valuable. support can also be seen in a two-way relationship, which could be established through consultation. consultation is bidirectional, and provides individuals with a voice to openly exchange information, which leads to development within a group.[10] the participants experienced their own unique journey while working in different departments as they used their intuition to lead themselves. the intuition of man informs him of the existence of ‘something within’ which transcends all intellectual knowledge and reasoning processes, but which is perceived to be ever-present at the very heart of one’s being.[11] one should make wise choices in an academic environment. professional and personal development originates from one’s own personal skills and expertise.[10] people need to be encouraged to develop the skills and competencies they require to become better workers, managers, entrepreneurs and innovators, who make wise decisions. in this study, the findings indicated that ‘making sense of things’ was part of selfleadership that shaped how academics understood themselves and their competencies. a leader’s abilities and values are related to how they structure tasks and manage the interpersonal relationships between other members of their department, which could impact the processes and ultimately the performance of a team[10] or faculty. conclusion leadership is no longer to be found only among organisational leaders, but also among academics. all the characteristics (masteries) of self-leadership research 202 december 2017, vol. 9, no. 4 ajhpe described in cashman’s[4] theoretical framework were mentioned by participants. participants were self-aware of their leadership roles, and as leaders expressed who they were as individuals, and discussed their diverse leadership experiences in the different departments. the experiences that the participants shared demonstrated a clear philosophy in the faculty of community and health sciences of focusing on leadership development and the succession of academics. acknowledgements. the authors would like to express gratitude to the staff members who participated in this study. author contributions. kj was the main author, with creative input from jf on the theoretical framework implemented. funding. none. conflicts of interest. none. 1. jooste k, ahanohuo l, arunachallam s, et al. the meaning of self-leadership for nursing academics of a research programme in the context of a higher education institution in the western cape. afr j nurs midwifery 2015;17(1):122-133. https://doi.org/10.25159/2520-5293/238 2. grint k. leadership: limits and possibilities. basingstoke: palgrave macmillan, 2005. 3. bolden r, gosling j, o’brien a, et al. academic leadership: changing conceptions, identities and experiences in uk higher education. london: leadership foundation for higher education, 2012. 4. cashman k. leadership from the inside out. provo: executive excellence publishing, 1998:1-7. 5. gerstberger rl, gromala ka. how effective is utility leadership? j am water works assoc 2010;102(1):46-55. 6. lichtenstein s. the role of values in leadership: how leaders’ values shape value creation. integral leadership review. http://integralleadershipreview.com/6176-the-role-of-values-in-leadership-how-leadersvalues-shape-value-creation/ (accessed 1 june 2016). 7. baker b. what is personal mastery – a look into personal development from a new perspective. http:// www.startofhappiness.com/what-is-personal-mastery (accessed 2 april 2016). 8. walsh m, dupré k, arnold ka. processes through which transformational leaders affect employee psychological health. ger j resear hum resour manage 2014;28(1-2):162-172. https://doi.org/10.1177/239700221402800109 9. browne p. bi-directional work to life conflict: an investigation of work life balance for nurses in acute public hospital settings in ireland. doctoral thesis. galway: national university of ireland, galway, 2015. 10. friedrich tm, vessey wb, schuelke mj. a framework for understanding collective leadership: the selective utilization of leader and team expertise within networks. leadersh q 2009;20(6):933-958. https:// doi.org/10.1016/j.leaqua.2009.09.008 11. parkinson s. the learning organisation as a model for rural development. dev pract 2010;20(3):329-341. https://doi.org/10.1080/09614521003709957 accepted 7 september 2016. https://doi.org/10.25159/2520-5293/238 http://integralleadershipreview.com/6176-the-role-of-values-in-leadership-how-leaders-values-shape-v http://integralleadershipreview.com/6176-the-role-of-values-in-leadership-how-leaders-values-shape-v http://www.startofhappiness.com/what-is-personal-mastery http://www.startofhappiness.com/what-is-personal-mastery https://doi.org/10.1177/239700221402800109 https://doi.org/10.1016/j.leaqua.2009.09.008 https://doi.org/10.1016/j.leaqua.2009.09.008 https://doi.org/10.1080/09614521003709957 june 2018, vol. 10, no. 2 ajhpe 74 editorial welcome to the winter 2018 issue of ajhpe. both the quantitative and qualitative research paradigms are represented; therefore, there is something for everyone. what struck me was how reflective of society this issue is, as it contains articles on stress, gender-based violence and use of social media. it was also interesting to note that several topics seem to be in pairs – i am sure it was not intentional! the topic of research in undergraduate curricula is addressed from two different perspectives, but both relate to students. in an undergraduate student study by van aswegen et al.,[1] the association between personality factors and chosen area of specialty of medical practitioners was explored. the authors identified personality types in some specialties and differences between characteristics of local specialists; these were compared with findings from other studies. in contrast, the second study that involved students sought to determine optometry students’ attitudes towards research. coetzee and kruger[2] report that, while students recognised several benefits to undertaking research, the time-consuming nature of conducting research and the administrative processes associated with obtaining ethical approval were viewed negatively. these findings reflect the reality of conducting research. langtree et al.[3] report on factors contributing to stress in nursing students, whereas moodley et al.[4] address stress in the dental profession. while the causes of stress were different in these two study cohorts, both studies recommend the inclusion of stress management programmes in undergraduate curricula. the use of social media in learning is addressed in another pair of articles. naidoo et al.[5] found that most students in their occupational therapy sample used some form of social media and that participants were aware of the ethical dilemmas inherent in using these media. osaigbovo and iwegim[6] report on the use of instagram and facebook to complement lectures in the teaching of medical microbiology in nigeria. their post-intervention survey showed that engagement with material and postings were higher in instagram. using the delphi technique, fawole et al.[7] sought to obtain consensus from teachers on a gender-based violence curriculum for medical schools in nigeria. the study identified topics for inclusion, level of study at which the curriculum should be taught, methods of teaching and who should teach. interestingly, the written examination ranked highest as the method of assessment. using the mnemonic aimed at itchedd, makkink and vincent-lambert[8] conducted a survey to determine teachers’ and students’ opinions on the use of the mnemonic in teaching and learning critical thinking and decision-making in patient management. the mnemonic was generally well perceived by teachers and students alike. the article by burch et al.[9] reminded me of paulo freire’s[10] work, pedagogy of the oppressed. freire believed that learners do not enter tertiary institutions as blank slates. burch et al.[9] studied the self-reported proficiency levels of medical students in six categories of generic learning skills and found a significant relationship with pre-university admission aptitude test scores, information technology proficiency on entry to university and early academic performance at university. furthermore, academically weak students did not overestimate their skills proficiency. pillay et al.[11] compared teaching methods used in an anatomy course with the critical cross-field outcomes specified by the south african qualifications authority. this form of reviewing the curriculum led to changes in teaching methods that enabled better alignment of achievement of the cross-field outcomes. i hope this brief summary of some of the contents of this issue of ajhpe piques your interest and motivates you to read this edition from cover to cover. patricia mcinerney centre for health science education, faculty of health sciences, university of the witwatersrand, johannesburg, south africa patricia.mcinerney@wits.ac.za 1. van aswegen r, ravgee a, connellan g, et al. association between personality factors and consulting specialty of practice of doctors at an academic hospital in bloemfontein, south africa. afr j health professions educ 2018;10(2):79-84. https://doi.org/10.7196/ajhpe.2018.v10i2.997 2. coetzee l, kruger sb. optometry students’ attitudes towards research at undergraduate level. afr j health professions educ 2018;10(2):85-89. https://doi.org/10.7196/ajhpe.2018.v10i2.728 3. langtree em, razak a, haffejee f. factors causing stress among first-year students attending a nursing college in kwazulu-natal, south africa. afr j health professions educ 2018;10(2):90-95. https://doi.org/10.7196/ ajhpe.2018.v10i2.993 4. moodley r, naidoo s, van wyk j. ‘pain and stress are part of my profession’: using dental practitioners’ views of occupation-related factors to inform dental training. afr j health professions educ 2018;10(2):96-100. https:// doi.org/10.7196/ajhpe.2018.v10i2.1005 5. naidoo d, govender p, stead m, mohangi u, zulu f, mbele m. occupational therapy students’ use of social media for professional practice. afr j health professions educ 2018;10(2):101-105. https://doi.org/10.7196/ ajhpe.2018.v10i2.980 6. osaigbovo ii, iwegim cf. instagram: a niche for microlearning of undergraduate medical microbiology. afr j health professions educ 2018;10(2):75. https://doi.org/10.7196/ajhpe.2018.v10i2.1057 7. fawole oi, van wyk j, adejimi aa, akinsola oj, balogun o. establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in nigeria: a delphi study. afr j health professions educ 2018;10(2):106-113. https://doi.org/10.7196/ajhpe.2018.v10i2.988 8. makkink a, vincent-lambert c. aimed at itchedd: a proof-of-concept study to evaluate a mnemonicbased approach to clinical reasoning in the emergency medical care educational setting. afr j health professions educ 2018;10(2):76-78. https://doi.org/10.7196/ajhpe.2018.v10i2.543 9. burch vc, sikakana cnt, gunston gd, murdoch-eaton d. self-reported generic learning skills proficiency: another measure of medical school preparedness. afr j health professions educ 2018;10(2):114-123. https://doi. org/10.7196/ajhpe.2018.v10i2.971 10. freire p. pedagogy of the oppressed. london: penguin books, 1972. 11. pillay jd, govender n, lachman n. integrating critical cross-field outcomes in an anatomy course at a university of technology: a reflective perspective. afr j health professions educ 2018;10(2):xxx. https://doi.org/10.7196/ ajhpe.2018.v10i2.960 afr j health professions educ 2018;10(2):74. doi:10.7196/ajhpe.2018.v10i2.1108 reflecting on our society? this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.7196/ajhpe.2018.v10i2.993 https://doi.org/10.7196/ajhpe.2018.v10i2.993 https://doi.org/10.7196/ajhpe.2018.v10i2.1005 https://doi.org/10.7196/ajhpe.2018.v10i2.1005 https://doi.org/10.7196/ajhpe.2018.v10i2.980 https://doi.org/10.7196/ajhpe.2018.v10i2.980 https://doi.org/10.7196/ajhpe.2018.v10i2.971 https://doi.org/10.7196/ajhpe.2018.v10i2.971 https://doi.org/10.7196/ajhpe.2018.v10i2.960 https://doi.org/10.7196/ajhpe.2018.v10i2.960 editorial 50 june 2017, vol. 9, no. 2 ajhpe publications are essential for promotion and for establishing the professional profile of academics, who can then in turn build national and international collaborations and secure research funding.[1-5] these publications are often equated with subsidy income for universities and improved prestige in the various university ranking systems. therefore, ‘publish or perish’ is an unofficial hashtag in academia. no surprise then that the trend is one of increasing numbers of authors on manuscripts. a review of four prestigious medical journals saw a substantive increase over all four journals in the 20-year period reviewed: from 4.5 authors in 1980 to 6.9 authors in 2000.[6] a partial explanation is that the number of manuscripts authored by study groups is also on the increase.[7] in 1991, only 6% of the 172 research articles published in the journal of the american medi­ cal association involved a study group. ten years later, 22% of the 185 research articles were published by study groups.[7] study groups are common in large clinical or observational studies and the number of authors can be substantial, with the highest number recorded at 5 154 authors.[8] with the increase in the number of authors per manuscript, disputes about authorship follow the same trajectory. little is written about the magnitude of such disputes, but one article reports that from a single faculty the disputes that were referred to the ombudsman increased from 2.3% (1991 1992) to 10.7% (1996 1997). also worth noting is not only the percentage increase, but an overall increase in the number of issues referred to the office of the ombudsman – from 355 to 551 for the same 2-year period.[5] some of the reasons for articles having multiple authors are the complexity, the inherent collaborative nature of research and the emergence of research questions, such as global or multisite questions, which need multidisciplinary or interdisciplinary participation.[1,6] however, when authorship holds academic benefits other than the expansion of knowledge, questions are raised whether multiple-authored articles reflect true collaboration or if they are artefacts of institutional pressure or gaming of the system.[4] editors caution against three particular types of authorship: ghost, guest and gift authors. the ghost author, often a student, who although having contributed substantially, is excluded.[2] guest authors are those who are listed with the hope of increasing the chance of publication. finally, there is the gift author, whose affiliation with the study is symbolic and whose addition is often due to institutional pressure.[4] factors such as power relations (gender, race and sexual orientation) and power differentials in lowand high-income country collaborations have been cited as contributing to these problematic exclusions or inclusions of authorship.[3] this trend of increasing numbers of authors has resulted in guidelines being developed for the allocation of authorship credit. some examples are the international committee of medical journal editors (icmje), the world association of medical educators (wame), and the committee on publication ethics (cope), which have all published comprehensive guidelines. even though these are useful when applied, the guidelines do not assist in guiding authors on the order in which authors’ names are listed. the interpretation of the position also varies: some may interpret the last author as the most senior, but to others the decreasing position is a reflection of a decrease in contribution and the risk of becoming an et al.[1,2] despite all the challenges surrounding multiple authorship, single authorship has almost disappeared in medical journals.[6] however, is it any different in medical education journals? a cursory review of the latest editions (may or june 2017) of three prestigious international medical education journals revealed that none of the original articles was a singleauthored manuscript; this edition of ajhpe is no different. the manuscripts by kridiotis and swart;[9] pandya, slemming and saloojee;[10] van rooyen, reinbrech-schütte,  hugo and marcus;[11] and singh and pottapinjara[12] are all prime examples of the benefit of collaborative – sometimes interdisciplinary – research done within a single department. the manuscript ‘use of role-play and community engagement to teach parasitic diseases’ by haffejee, van wyk and hira,[13] demonstrates the benefits of interdepartmental collaboration within a single institution. the short report by myezwa, maleka, mcinerney, potterton and watt[14] is also an interdepartmental contribution, and another manuscript (bosman and wolvaardt[15]) is a reflection of interinstitutional authorship. a particularly exciting inclusion in this edition is the manuscript by van zyl, joubert, bowen, du plooy, francis, jadhunandan, fredericks and metz.[16] their article, ‘depression, anxiety, stress and substance use in medical students in a 5-year curriculum’, is co-authored by six medical students. if researching and writing for publication – i.e. authorship – is a learning experience, then no better examples can be found than in this edition of ajhpe. however, if we want to solve the problems of africa, should we not lead the pack for multisite or multinational collaborations? j e wolvaardt school of health systems and public health, faculty of health sciences, university of pretoria, south africa liz.wolvaardt@up.ac.za 1. smith e, williams-jones b. authorship and responsibility in health sciences research: a review of procedures for fairly allocating authorship in multi-author studies. sci eng ethics 2012;18:199-212. https://doi.org/10.1007/ s11948-011-9263-5 2. marusic a, bosnjak l, jeroncic a. a systematic review of research on the meaning, ethics and practices of authorship across scholarly disciplines. plos one 2011;6(9):e23477. https://doi.org/10.1371/journal.pone.0023477 3. smith e, hunt m, master z. authorship ethics in global health research partnerships between researchers from low or middle income countries and high income countries. bmc med ethics 2014;15:42. https://doi. org/10.1186/1472-6939-15-42 4. street jm, rogers wa, israel m, braunack-mayer aj. credit where credit is due? regulation, research integrity and the attribution of authorship in the health sciences. soc sci med 2010;70(9):1458-1465. https://doi. org/10.1016/j.socscimed.2010.01.013 5. wilcox lj. authorship. the coin of the realm, the source of complaints. jama 1998;280(3):216-217. 6. weeks wb, wallace ae, kimberley bcs. changes in authorship patterns in prestigious us medical journals. soc sci med 2004;59:1949-1954. https://doi.org/10.1016/j.socscimed.2004.02.029 7. flanagin a, fontanarosa pb, deangelis cd. authorship for research groups. jama 2002;288(24):3166-3168. https://doi.org/10.1001/jama.288.24.3166 8. atlas  and  cms  collaborations. combined measurement of the higgs boson mass in  pp  collisions at s√=7 and 8 tev with the atlas and cms experiments. phys rev lett 2015; 114:191803. https://doi.org/10.1103/ physrevlett.114.191803 9. kridiotis ca, swart s. a learning development module to support academically unsuccessful 1st-year medical students. afr j health professions educ 2017;9(2):62-66. https://doi.org/10.7196/ajhpe.2017.v9i2.694 10. pandya h, slemming w, saloojee h. reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education. afr j health professions educ 2017;9(2):78-82. https://doi. org/10.7196/ajhpe.2017.v9i2.796 11. van rooyen m, reinbrech-schütte a, hugo jfm, marcus ts. developing capability through peer-assisted learning activities among 4th-year medical students and community health workers in community settings. afr j health professions educ 2017;9(2):73-77. https://doi.org/10.7196/ajhpe.2017.v9i2.723 12. singh s, pottapinjara s. dental undergraduate students’ knowledge, attitudes and practices in oral health selfcare: a survey from a south african university. afr j health professions educ 2017;9(2):83-87. https://doi. org/10.7196/ajhpe.2017.v9i2.800 13. haffejee f, van wyk j, hira v. use of role-play and community engagement to teach parasitic diseases. afr j health professions educ 2017;9(2):51-53. https://doi.org/10.7196/ajhpe.2017.v9i2.673 14. myezwa h, maleka d, mcinerney p, potterton j, watt b. he has a life, a soul, a meaning that extends far deeper than his medical assessment … .’: the role of reflective diaries in enhancing reflective practice during a rural community physiotherapy placement. afr j health professions educ 2017;9(2):54-56. https://doi.org/10.7196/ ajhpe.2017.v9i2.888. 15. bosman a, wolvaardt je. the health system benefits of attending an hiv/aids conference. afr j health professions educ 2017;9(2):57-61. https://doi.org/10.7196/ajhpe.2017.v9i2.693 16. van zyl pm, joubert g, bowen e, et al. depression, anxiety, stress and substance use in medical students in a 5-year curriculum. afr j health professions educ 2017;9(2):67-72. https://doi.org/10.7196/ajhpe.2017.v9i2.705 afr j health professions educ 2017;9(2):50. doi:10.7196/ajhpe.2017.v9i2.985 authorship: lone wolf or wolf pack? this open-access article is distributed under creative commons licence cc-by-nc 4.0. https://doi.org/10.1007/s11948-011-9263-5 https://doi.org/10.1007/s11948-011-9263-5 https://doi.org/10.1186/1472-6939-15-42 https://doi.org/10.1186/1472-6939-15-42 https://doi.org/10.1016/j.socscimed.2010.01.013 https://doi.org/10.1016/j.socscimed.2010.01.013 https://doi.org/10.1103/physrevlett.114.191803 https://doi.org/10.1103/physrevlett.114.191803 https://doi.org/10.7196/ajhpe.2017.v9i2.796 https://doi.org/10.7196/ajhpe.2017.v9i2.796 https://doi.org/10.7196/ajhpe.2017.v9i2.800 https://doi.org/10.7196/ajhpe.2017.v9i2.800 https://doi.org/10.7196/ajhpe.2017.v9i2.888. https://doi.org/10.7196/ajhpe.2017.v9i2.888. research 180 december 2017, vol. 9, no. 4 ajhpe medical schools in south africa (sa) are challenged to recommend innovative cost-effective strategies to honour the ministerial directive of increasing the annual number of doctors trained in the country.[1] the intention is to address the disparity in healthcare services between urban and rural areas and, more explicitly, its associated morbidity and mortality.[2] one approach is to establish satellite medical training campuses at rural public health facilities to expand the undergraduate clinical training platform.[3] kimberley hospital complex is a 657-bed tertiary healthcare facility in the northern cape, sa. the hospital employs 39 medical specialists, 14 of whom are foreign-qualified professionals. the available specialties are internal medicine, oncology, paediatrics, dermatology, emergency medicine, family medicine, radiology, intensive care, general surgery, obstetrics and gynaecology, anaesthesiology, orthopaedics, otorhinolaryngology, ophthalmology, urology, plastic surgery and burn unit, and cardiothoracic surgery. clinicians are committed to continuous professional development, and structured academic programmes are followed in each clinical department. the hospital is affiliated to the university of the free state, bloemfontein, sa and is a health professions council of south africa (hpcsa)-accredited training institution. it hosts internship and registrar training programmes in several clinical departments. the faculty of health sciences, university of the free state, has earmarked kimberley hospital as a satellite clinical undergraduate medical student training site and spearheaded the facility’s hpcsa accreditation for undergraduate training. the first group of undergraduate students started their clinical rotation early in 2016. one of the major challenges facing institutions envisaging a new medical school is building a relationship with clinicians to ensure the provision of suitable clinical tutoring experiences for students.[4] the availability of the required range of clinical departments within potential healthcare facilities, and the aptitude and willingness to accommodate medical students in each of the required clinical domains, are equally important.[4] expansion of the training platform also expects clinicians to perform the additional task of clinical student teaching over and above their health service delivery responsibilities.[5] during the 2014/2015 financial year, kimberley hospital served a total of 382 740 new patients at the specialised outpatient clinics, attended to 96 018 patients presenting to the casualty department, and managed 24 687 in-patients and 7 165 theatre cases (ms thembi magabane – personal communication). blitz et al.[6] retrospectively described the experience of emerging clinician educators at a local rural clinical school as a journey: starting from cautious optimism, through a period of uncertainty and insecurity as teachers, to fully fledged trainers enjoying the teaching experience and taking responsibility for their students’ successes. students’ prior knowledge, how they organise knowledge, and their personal motivation influence what they learn, as well as how they apply and continuously practise acquired knowledge and skills. through goaldirected practices and specific feedback, students become self-directed learners integrating their learning approaches with the intellectual, social and emotional aspects of an inclusive teaching environment.[7] the specialists at kimberley hospital are a diverse group of professionals with variable levels of clinical teaching experience. the specialist pool also comprises a mixture of saand foreign-trained professionals. it is therefore imperative to obtain a baseline profile of the potential clinician teachers at the institution. background. medical schools in south africa (sa) are challenged to increase the annual output of medical doctors. satellite medical training campuses at remote public health facilities to expand the undergraduate clinical training platform may be a solution. kimberley hospital, northern cape, sa has been identified as a remote training site affiliated to the university of the free state, bloemfontein, sa. objectives. to profile the clinicians at kimberley hospital complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training prior to the launch of the proposed undergraduate student rotations. methods. the study followed a qualitative research design using semi-structured interviews with full-time saor foreign-qualified specialists at kimberley hospital complex. results. we identified the strengths and weaknesses of kimberley hospital, opportunities created for local healthcare providers, kimberley town and the northern cape province, and threats to the success of the programme. overall, responses were optimistic and depicted excitement about the new challenge. conclusion. the perspectives of emerging clinician teachers at kimberley hospital complex may serve as a point of reference for preparation of both clinician educators and programme administrators at the complex and other emerging satellite medical schools in the sa setting. afr j health professions educ 2017;9(4):180-184. doi:10.7196/ajhpe.2017.v9i4.836 clinical undergraduate medical student training at kimberley hospital, northern cape, south africa: ‘a test of fire’ s joubert, mb chb, mmed (int); v j louw, mb chb, mmed (int), phd (hpe) department of internal medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: s joubert (joubertsunette@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research december 2017, vol. 9, no. 4 ajhpe 181 this study aimed to profile the clinicians at kimberley hospital complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training before the launch of the proposed undergraduate student rotations in 2016. the results may serve as a point of reference for the preparation of clinician educators at kimberley hospital complex and other emerging satellite medical campuses in the sa setting. methods the study followed a qualitative research design and comprised semistructured interviews with full-time saor foreign-qualified specialists at kimberley hospital complex. written informed consent was obtained from participants prior to the interviews. participants received the interview guide in advance to allow preparation for the interview. discussions were digitally recorded, transcribed, coded and organised into broader themes pertaining to the perspectives of the upcoming clinician teachers at the institution. ethical approval the study was conducted with the ethical approval of the ethics committee of the faculty of health sciences, university of the free state (ref. no. ecufs 102/2015) and the northern cape provincial health ethics review committee (ref. no. nc2015/0021). results the number in brackets next to the quotes given below refers to the respondent and ‘t’ indicates that the quote was translated from the original afrikaans. demographic profile of interviewees twenty-seven of the 39 full-time specialists at kimberley hospital were interviewed during a 6-week period from september to october 2015. interviews continued until data saturation was reached (i.e. no new information would be gathered by continuing interviews) and included at least one consultant of every discipline proposed to be involved in clinical student training. community-based education relies heavily on family medicine; hence, all of the family medicine specialists were interviewed. table 1 describes the demographic profile of the interviewees. foreign qualifications were obtained in cuba (n=5), pakistan (n=3), brazil, ghana, nigeria, zimbabwe and northern ireland (n=1 each). foreign-qualified specialists have a higher number of years of postgraduate experience. all but 2 sa interviewees spent their entire career in the public sector. the average number of weekly hours spent on undergraduate student training before employment at kimberley hospital ranged from 1 to 15 clinical bedside teaching hours per week. only 2 of the 27 interviewees (7.4%) had experience in student assessment. results of the qualitative interviews the overall perspective on the proposed undergraduate training programme in kimberley hospital was positive: ‘i am very excited. it is a good opportunity to influence the quality of doctors produced.’ (s9) ‘we have a good reputation, good potential trainers; it is doable, we can perform.’ (f3) twenty-two (81.5%) and 5 (18.5%) participants displayed overall positive and negative perspectives, respectively, on the proposed programme. all 5 interviewees who displayed apprehension towards the project were from one clinical department: ‘i’m not thrilled with the idea.’ (s3t) ‘i am not interested; i do not think we are ready for students.’ (s5) ‘it has no real benefit; you are taking time away from our patients.’ (c5) strengths of the institution interviewees expressed several strengths of kimberley hospital complex. the hospital has an outstanding reputation and the specialist team is focused on quality, evidence-based patient care. every department has an established academic and bedside clinical training programme. students will receive ample exposure to pathology, personal attention and additional opportunities to develop clinical and practical problem-solving skills. overall, the specialists find teaching rewarding: ‘it is rewarding if someone with no self-confidence develops into a doctor who can work independently in paediatrics. the day they start questioning my opinion, then i know i taught them to practise evidencebased medicine, to develop their own opinion and challenge current thinking.’ (s8t) ‘we can teach them the family medicine way of doing things. we see a lot of patients, if we do all the examinations in the department, it will increase our expense tremendously. you teach them to save costs. if you work in the primary healthcare setting, you need to know these things. you cannot go to the clinic and do a lot of special examinations; you will deplete the budget in no time. you need to decide what you are going to need to make a decision whether you must refer the patient at a certain stage. it is a skill you only learn when you pay attention in the department. the best place to learn is at the bedside; a student should see the patient, read up and come back to teach the entire group the next day.’ (c3) ‘we can teach them and show them the reality of casualties being overcrowded, bed management, theatre time, waiting times, overcrowded clinics. we can teach them to be proactive in problem-solving to improve the service.’ (f3) table 1. demographic profile of interviewees (n=27) demographic parameter interviewees, n (%) respondent codes gender male female 20 (74) 7 (26) country where qualifications were obtained south african foreign south african and foreign 14 (52) 6 (22) 7 (26) s1 s14 f1 f6 c1 c7 postgraduate experience, years <5 5 10 11 20 >20 11 (41) 5 (18) 5 (18) 6 (22) s = 8, c = 3 s = 3, c = 2 s = 2, c = 2, f = 1 s = 1, f = 5 s = undergraduate and postgraduate qualifications were obtained locally; f = undergraduate and postgraduate qualifications were obtained abroad; c = undergraduate or postgraduate qualifications were obtained locally and abroad. research 182 december 2017, vol. 9, no. 4 ajhpe ‘students will be drawn into the team to teach them that everybody must work together to reduce hospital stay and get the patient back into the community.’ (s2t) fig. 1 summarises the local specialists’ grasp of what good teaching entails. weaknesses of the institution it became apparent that the interviewees were concerned about potential institutional weaknesses. although the institution has a strong corps of specialists, the numbers of experienced medical officers and registrars are limited. patient care relies heavily on interns, community-service doctors and medical officers in their first year after community service. specialists have to be actively involved in service delivery to patients with tertiarylevel medical conditions. our referral centre recently experienced severe financial and human resource constraints, reducing the number of patients our facility could refer for higher levels of medical care and hindering the referral centre’s outreach programme to kimberley hospital: ‘there must be enough people in the collective pool of consultants and permanent medical officers and time to teach. service delivery will always take preference, but students cannot be neglected – you cannot miss a lecture. if some mishap happens it will be a problem; you cannot say you were busy teaching. teaching as part of service delivery is fine for doctors, but students are a sacred, special group. the concept you teach them now must be correct – they will remember it for the rest of their lives. their base should be sound and strong.’(c5) only 6 of the 27 interviewees admitted to having formal teaching qualifications and experience. they are foreign-trained specialists from cuba and brazil. six other specialists indicated that they attended a recent short course for lecturers at the university of the free state: ‘teaching is an art, a skill; you need to be taught how to do it.’ (c3) none of the specialists has training in assessment methods: ‘we must initially observe assessments at the university. the university compares students; we will compare them to the interns in the ward when giving them ward marks. we may be too strict. our measure will be whether they will be safe doctors if they return to kimberley hospital.’ (s1t) other healthcare professionals, especially nursing staff, play a vital role in student teaching: ‘our nurses are overworked and short staffed. nowadays, it is difficult to get the nurses to join a ward round. it is not a good example to students; they learn you just go on with your round, write down and tell the nurse afterward what she must do.’ (f3) opportunities the general opinion is that an academic environment, research and up-todate evidence-based medicine underscore service delivery: ‘students are going to challenge us academically, ethically, in terms of work environment, the quality of what we are doing. you have to think twice about what you are doing because what i am doing is what i am teaching.’ (f3) specialists will have the opportunity to gain teaching and assessment training and experience over and above their clinical expertise: ‘skills to manage different varieties of students with different levels of academic performance and attitudes.’ (c3) training sessions should preferably be periodic short courses presented in kimberley by facilitators with undergraduate medical student training experience. topics suggested were: the background to the current sa and cuban student curricula, generic and medical teaching, and assessment techniques. facilitators could also attend the local departmental academic sessions and ward rounds to give feedback about the quality to the consultants at kimberley hospital. this venture is the first step towards a medical school in the northern cape. the vision is to recruit specialists and registrars, train our own doctors, retain them in the province and ultimately enhance the accessibility of medical care in the northern cape: ‘i see it as a way to awaken interest in younger colleagues to offer their future services to our communities.’ (f2) ‘it will be a socioeconomic injection into kimberley. students drive smaller towns like stellenbosch.’ (s6t) threats to the programme interviewees expressed their concern about threats to the proposed undergraduate programme. the main threat identified was balancing fig. 1. summary of specialists’ grasp of what good teaching entails. knowledge • up-to-date academic knowledge • preventive medicine • patient safety • research and publishing • generic teaching and assessment • clinical teaching and assessment • students’ baseline academic knowledge, performance and skills • financial implications of medical care • information technology • equipment • factors in�uencing student motivation • public transport • student accommodation • recreational activities • students’emotional readiness to become a doctor • students’ personal and �nancial challenges skill • hands-on clinical skills • probing and thorough; ‘there is always more than meets the eye’ (s8) • focused, interesting, up-to-date clinical teaching skills • integrate prior knowledge and skills • immediate, constructive, goal-directed feedback • fair and transparent assessment • motivational skills • clinical and organisational problem solving skills • structured and ideological communication skills • breaking bad news • inter-disciplinary teamwork • cost-e�ectiveness • time management • emotional intelligence • cultivate orderly, structured, well-equipped environment • leadership attitude • ‘you need to feel it, you are here to save lives’ (f2) • cultivates trust personally and academically, a mentor • general conduct in life: honest, ethical, respectful, humble, balanced, open minded, sincere, calm, fair • approachable, patient, empathetic, sense of humour • passionate, dedicated, dynamic, inspiring • open to feedback and the students’ opinions • teach by example • interested in students’ backgrounds, know their names, empower them • professional, punctual • assertiveness and accountability • dedicated, responsible, interested, curious and motivated students research december 2017, vol. 9, no. 4 ajhpe 183 quality patient care with quality student training, specifically pertaining to time and human resources. the hospital has a high turnover of medical officers, mostly because they move into registrar posts elsewhere in the country. the core workforce remains inexperienced, demanding continuous consultant supervision and involvement to ensure quality tertiary service delivery. some departments have only one consultant; the programme may be jeopardised if the specialist resigns. it is very difficult to compete with academic institutions, the private sector and other more popular provinces in terms of recruitment and retention of specialists. furthermore, financial pressures in the public sector preclude the creation and funding of additional senior medical officer and specialist posts: ‘i will have less time with my patients and it may compromise patient care. we need registrars to assist with the workload and service delivery. we need more subspecialists to assist with training.’ (s5) ‘you have to look for patients with clinical signs; this takes time.’ (c5) active clinical and academic support from our referral hospital and specialists at the main campus through outreach and in-reach programmes is imperative: ‘we are not an island; we are an extension of their academic departments.’ (s6t) the venture demands strong leadership and continuous buy-in of stakeholders in the free state and northern cape departments of health, the university of the free state and the kimberley satellite campus. our specialists’ motivation to invest teaching time relies heavily on the baseline standard of clinical knowledge, skills and attitude of the students rotating at kimberley for their clinical training: ‘it is better to teach someone with sound baseline knowledge than a student who doesn’t know anything. i am worried about the cubantrained students. they need special attention. we do not have time to motivate and support struggling students. the pace is too fast here; they will fall behind.’ (s1t) some junior doctors’ attitudes towards patients, colleagues, nursing staff and the profession are occasionally disrespectful and unprofessional: ‘their etiquette, they are role models.’ (f3) student selection although student participation is voluntary, certain minimum selection criteria are important. a student’s motive for choosing the satellite campus must ideally be determined by an interview process. the ideal student is independent, self-disciplined, resilient, committed, responsible, hardworking and reliable: ‘if we take the top students, obviously they will do well and we did not actually achieve that much because we started with the best. achievement would be if you take the average student, say 60% to 65%, and try to mould him into a top achiever or over 70%. the group must be small. a guy who has the ability to the top might have a better chance when he is part of a small group. the top achiever’s chance to return to the northern cape is slim; they specialise and super-specialise and stay in the main hubs.’ (s10) students must be prepared to accept foreign-trained specialists as teachers and english as the language of tuition: ‘i am worried that students will not accept me as a foreign-qualified specialist.’ (f3) in terms of demographics, ‘rural origin’ should not be a selection criterion. students from the northern cape, especially kimberley, have a logistical and financial advantage, but allowing students from other provinces into the programme may be a marketing strategy to recruit future doctors into the province. other considerations findings show that piloting of the project in the family medicine department is the ideal objective: ‘piloting the project will make us more comfortable with the expectations and give us opportunities for feedback on the logistical abilities of our clinics; how much time and resources are necessary.’ (c4) transport of students to and from clinics, the psychiatric unit, kimberley hospital, and the student residence must be well co-ordinated: ‘administrative office space for specialists and secretarial support with internet connectivity to prepare assessments, load marks, making sure it is correct is crucial’. (s7) end-of-block assessments should take place in kimberley, but the final exit examination must still be hosted at the main campus. the kimberley consultants must have the opportunity to submit questions for the written examination papers: ‘people must feel they are part of this new challenge and new way of doing things.’ (s11) ‘briefing of all medical personnel at kimberley hospital and the district clinics is very important. the nurses at clinics must also give feedback on the number of students they can accommodate.’ (c4) discussion medical schools in sa are challenged to recommend cost-effective strategies to increase the annual number of doctors trained in the country.[1] the intention is to address the disparity in healthcare services between urban and rural areas and its associated morbidity and mortality.[2] one approach is to establish satellite medical training campuses at rural public health facilities.[3] a major challenge is building a relationship with clinicians to ensure the provision of suitable clinical tutoring experiences for students.[4] the availability of a range of clinical departments within potential healthcare facilities, and an aptitude and willingness to accommodate medical students, are important.[4] this study aimed to profile the clinicians at kimberley hospital complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training. the overall perspective on the proposed undergraduate training programme at kimberley hospital was positive. the apprehensive clinicians were from one department, their main concern being the lack of senior medical officer and registrar support in the particular department. study strengths strengths identified were: academically inclined clinicians motivated to teach students the realities of clinical medicine, teamwork, critical thinking and problem-solving skills. they have strong opinions about the concept of good research 184 december 2017, vol. 9, no. 4 ajhpe teaching. the limited number of senior healthcare professionals draws specialists and nurses into front-line service delivery; hence, the added responsibility of student training and assessment will be a challenging balancing act. study limitations the relative inexperience of the respondents regarding this particular subject may be seen as a limitation to the study. one must keep in mind that the study aimed to assess the clinicians’ knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training. moreover, at the time of the study, the specific semester or year of clinical study was not yet finalised. this information could potentially have influenced the interviewees’ responses. conclusion this venture was the first step towards a northern cape-based medical school that trains healthcare professionals from the province and for the province. ultimately, it should improve accessibility to quality medical care and provide a socioeconomic injection into kimberley and the province. it is also a personal and professional career opportunity for local specialists to become more proficient in teaching and assessment methods and may be an important recruitment and retention strategy. if the teaching of medical students is instituted in a rural area, it may also be an alternative option and perhaps a drawcard for specialists who are interested in teaching and would like to live and work in a more rural environment. the success of the proposed satellite medical campus relies heavily on buy-in from key role-players in kimberley hospital, the northern cape districts, the university of the free state, as well as national and provincial executive and financial stakeholders. the perspectives of emerging clinician teachers at kimberley hospital complex may serve as a point of reference for preparation of clinician educators and programme administrators at kimberley hospital complex and other emerging satellite medical schools in the sa setting. as one of the respondents indicated, ‘the first group will be the most difficult: a test of fire. we must work on our mistakes and prepare for the next group. we will get better and better.’ acknowledgements. the authors acknowledge prof. g j van zyl, dean of the faculty of health sciences, university of the free state, for his valuable inputs in the writing of the manuscript. author contributions. sj and vjl: cultivated the idea and methodology of the research; sj: performed the data processing and wrote the article; and vjl: conducted the final checking, inputs and improvement of the discussion section. funding. none. conflicts of interest. none. 1. health-e news. motsoaledi shares his plans. south african health news service, 5 october 2012. http://www. health-e.org.za/2012/10/05/motsoaledi-shares-his-plans (accessed 29 september 2017). 2. harris b, goudge j, ataguba je, et al. inequities in access to health care in south africa. j publ health pol 2011;32:s102-s123. https://doi.org/10.1057/jphp.2011.35 3. bateman c. academics appeal to state: ‘help us train where the needs are’. s afr med j 2011;101(8):498-500. https://doi.org/10.7196/samj.5121 4. whitcomb me. new and developing medical schools: motivating factors, major challenges, planning strategies. new york: josiah macy jr foundation, 2009:1-84. 5. levinson w, branch wt, kroenke k. clinician-educators in academic medical centers: a two-part challenge. ann intern med 1998;129(1):59-64. https://doi.org/10.7326/0003-4819-129-1-199807010-00013 6. blitz j, bezuidenhout j, conradie h, de villiers m, van schalkwyk s. ‘i felt colonised’: emerging clinical teachers on a new rural teaching platform. rural remote health 2014;14:2511. 7. ambrose sa, bridges mw, dipietro m, lovett mc, norman mk. how learning works: 7 research-based principles for smart teaching. san francisco: jossey-bass, 2010:1-6. accepted 3 may 2017. http://www.health-e.org.za/2012/10/05/motsoaledi-shares-his-plans http://www.health-e.org.za/2012/10/05/motsoaledi-shares-his-plans https://doi.org/10.1057/jphp.2011.35 https://doi.org/10.7196/samj.5121 https://doi.org/10.7326/0003-4819-129-1-199807010-00013 research may 2016, vol. 8, no. 1, suppl 1 ajhpe 113 effective supervision in postgraduate medical education involves the process of feedback, which may – in practice – be ineffective or inconsistent.[1] based on the literature,[2–6] this study defines feedback as ‘a process whereby the desired standard of proficiency in a task has been clearly established. this standard has been communicated to the student. gaps in performing the task or level of knowledge are identified, and the student is made aware of his or her shortcomings, together with a plan to improve performance.’ as medical education has moved beyond the paradigm of ‘see one, do one, teach one’,[7] consultants need to be capable of providing suitable training guidance to ensure that graduates are clinically and otherwise competent. this should have a positive effect on patient outcomes, foster a life-long love of learning and the process of reflection, and promote good ethical practice. this process involves more than didactic input. it includes suitable feedback, so that competencies may be enhanced and improved and deficiencies corrected.[8] it might be argued that if some (or all) of the elements contained in the definition are missing, feedback is not being adequately provided in clinical settings, thus affecting the calibre of specialists subsequently produced. feedback has been well recognised as an important component of education and can have an extremely powerful and positive effect on learning.[2,8,9] it is regarded as integral and essential to postgraduate medical education,[4] a concept that is similar to that of serving an old-fashioned apprenticeship in an experiential learning setting. without feedback, poor performance is not corrected, good performance is not entrenched and magnified, and no plans for improvement are implemented.[10,11] feedback that meets all the defined criteria can positively influence the performance of doctors.[12] the importance of suitable external feedback by consultants to registrars becomes critical when there is no self-assessment by registrars or if the feedback is inaccurate.[13] giving feedback may be challenging for consultants who have no formal training in the process, which may be further compounded in heterogeneous settings involving students of different gender, ethnicity, race, socioeconomic backgrounds, educational levels and home or first languages.[14] consultants need to be sensitive to the different dynamics at play to ensure that the same message ‘transmitted is received and understood’[15] by the different groups in the same way. furthermore, several authors have reported that consultants often believe that they provide adequate, timeous and sufficient quality feedback, despite evidence from registrars indicating the contrary.[4,8,10,13] given the importance of feedback as an essential component of medical education, this discrepancy is of great concern and needs to be monitored. hence, this study was undertaken to explore the consultants’ and registrars’ perceptions of feedback given and received. the study focuses on the perceptions of consultants with regard to the quality of feedback they provided to registrars employed at an academic hospital. methods a questionnaire was designed to ascertain the consultants’ perceptions on what, when, where, how often, and how feedback was provided, as well as on the type and effect of feedback to registrars. sociodemographic information (age, gender, home language, discipline and years of specialisation) was also gathered. a definition of feedback, as discussed above, was also included in the questionnaire to try to prevent any misconceptions with regard to the basic tenets of this process. responses were reported on a 5-point likert scale (figs 1 and 2). although this observational study adopted a mixed-methods approach, this article focuses on the quantitative data used to survey the overall perceptions of the consultants. the qualitative investigation of these perceptions will be reported in a follow-up study. background. effective supervision by consultants in postgraduate medical education involves the process of feedback. giving feedback may be challenging for consultants who have no formal training in this process, which may be further compounded in heterogeneous diverse settings. objective. to explore consultants’ perceptions of feedback to registrars in a multicultural, multilingual diverse academic hospital setting. methods. thirty-seven consultants consented to completing a questionnaire on what, when, where, how often, and how feedback was provided, as well as on the type and effect of feedback to registrars. descriptive statistics were used to analyse the data. differences between groups were calculated using pearson’s χ² test for independent variables, with a p-value of <0.05 regarded as being statistically significant. results. only 40% of consultants reported that they provided feedback often or always and 62.2% reported that standards were not predetermined and communicated to registrars. when feedback was provided, it was based on concrete observations of performance (78.4%), it incorporated a plan for improvement (72.9%) and it supplied information on techniques performed incorrectly (72.9%). only 40.5% of consultants provided feedback on procedures performed correctly. moreover, only half of the consultants believed they were proficient at giving feedback. conclusion. consultants need to develop the art of giving feedback through appropriate training so that they are more comfortable and proficient with the various aspects of feedback, leading to a positive effect on enhancing registrar training. afr j health professions educ 2016;8(1 suppl 1):113-116. doi:10.7196/ajhpe.2016.v8i1.758 feedback as a means to improve clinical competencies: consultants’ perceptions of the quality of feedback given to registrars c i bagwandeen,1 mb chb, dhsm, doh, dip hiv man (sa), fcphm; v s singaram,2 bmedsc, mmedsc, phd 1 discipline of public health, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 2 clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: c i bagwandeen (bagwandeenc@ukzn.ac.za) research 114 may 2016, vol. 8, no. 1, suppl 1 ajhpe all consultants from the disciplines of surgery, internal medicine, obstetrics and gynaecology, paediatrics, psychiatry and family medicine were invited to participate. because of a 0% response rate to the online questionnaire, hard copies were distributed at academic day meetings; 62% (n=37) were returned anonymously with informed consent. descriptive statistics were used to inter pret the responses of the registrars, with mean values calculated. differences between groups were calculated using pearson’s χ² test for independent variables, with a p-value of <0.05 regarded as statistically significant. ethical approval for the study was granted by the humanities and social sciences ethical committee, university of kwazulu-natal, durban, south africa (hss/1185/013d). results the mean age of the consultants was 37.8 (range 31 55) years. fifty-four percent were female. english was the first language for the majority of consultants (n=31), while six spoke another language. six consultants had qualifications other than the colleges of medicine of south africa fellowship in their respective fields: 1 had a phd in surgery, while the other 5 had postgraduate certificates in their respective fields. thirteen consultants from paediatrics, 9 from internal medicine, 8 from obstetrics and gynaecology, 3 from surgery and 2 each from psychiatry and family medicine responded. as illustrated in fig. 1, 62.2% of consultants reported that standards for assessment were not predetermined and communicated to registrars in advance – always or often. all consultants reported that they provided feedback, but only rarely never sometimes always often 100.0 0.0.0 100.050.0 50.0 45.927.02.724.3 8.1 16.2 64.9 8.1 48.6 13.5 13.5 40.5 37.8 2.7 29.7 8.1 10.8 13.5 40.5 27.043.2 5.4 54.1 45.9 18.9 27.0 43.2 29.7 45.9 51.4 21.6 13.5 10.8 27.0 27.0 16.2 24.3 27.0 27.0 21.6 21.6 48.610.8 32.462.2 40.5 16.2 27.0 27.0 43.2 37.8 5.4 29.7 16.2 5.4 5.4 10.85.4 5.4 75.7 43.2 24.3 2.7 40.537.8 37.8 24.3 24.3 18.9 10.8 10.8 32.4 2.745.9 2.72.721.6 2.718.9 18.92.740.5 18.929.7 27.05.424.3 13.52.756.8 2.7 5.432.4 i would like to receive peer feedback i prefer giving group feedback the registrar agrees with the feedback provided my feedback sessions are always successful − the registrar receives the intended message in the intended manner i am pro�cient at giving feedback to my registrars the e�ect of feedback on the registrar noted feedback is documented support is available to the registrar from di�erent sources after both formal and informal feedback sessions formal feedback incorporates new learning objectives the registrar has an opportunity to respond to the feedback given feedback is in�uenced by race, gender or ethnicity of the registrar feedback is given in non-emotive, non-judgemental language feedback incorporates a plan of improvement feedback encourages re�ection about previous feedback feedback is given about procedures and techniques performed correctly feedback is given about procedures and techniques performed incorrectly feedback is based on concrete observations of the performance of the registrar formal feedback sessions are held in an appropriate location formal feedback sessions are clearly scheduled in advance feedback is formal feedback is informal standards for assessment are predetermined and communicated to the registrar in advance feedback is provided in all encounters with a registrar fig. 1. a divergent stacked bar graph showing consultants’ perceptions on the feedback they give to registrars. 2.7 2.7 43.216.2 2.7 2.7 2.7 37.8 32.4 24.3 21.6 32.4 35.1 2.78.1 2.7 8.129.7 48.6 2.745.9 16.2 10.843.2 21.6 21.6 16.2 10.813.5 5.4 5.4 48.6 43.2 32.4 100.0 100.080.0 60.0 80.060.040.0 20.0 20.0 40.0 rarely never sometimes always often feedback is given about how to be a professional feedback is given about how to be a scholar feedback is given about how to be a health advocate feedback is given about how to be a manager feedback is given about how to be a collaborator feedback is given about how to be a communicator feedback is given about how to be a medical expert 0.0.0 fig. 2. a divergent stacked bar graph showing consultants’ perceptions on the feedback they give to registrars with regard to graduate attributes. research may 2016, vol. 8, no. 1, suppl 1 ajhpe 115 ~40% provided feedback always or often. the majority of consultants based their feedback on concrete observations of registrar performance (78.4%), incorporated a plan for improvement in their feed back (72.9%), or provided feedback on techniques performed incorrectly (72.9%). however, only 40.5% provided feedback on procedures performed correctly, while 56.7% thought that feedback encouraged reflection about previous feedback. the vast majority gave informal feedback (94.6%). only 27% gave formal feedback that was clearly scheduled in advance, given in an appropriate location and that incorporated new learning objectives – only half of the time. feedback given was influenced by race, gender or ethnicity of the registrars – sometimes (10.8%) and often (5.4%). seventy-three percent reported that feedback was given using non-emotive, non-judgemental language, and 70.2% of consultants gave registrars an opportunity to respond to feedback, but only 32.4% noted the effect of feedback on the registrar. a total of 51.3% reported that support for registrars was available after feedback. while 73% of the consultants felt that the registrar agreed with the feedback, 54% reported that they were proficient at giving feedback and believed that their intended message was received. most consultants (83.7%) preferred giving feedback one on one, and would have liked to receive peer feedback (72.9%). registrars need feedback on both technical and other specific skills and on graduate attributes to improve outcomes. with regard to technical skills, feedback on how to be a professional was provided always or often (59.4%), while the specifics around being a medical expert (56.7%), communicator (64.8%), collaborator (75.6%), manager (75.6%), health advocate (64.8%), and scholar (59.4%) were neglected. sixty-two percent of consultants believed that they always or often provided feedback about clinical skills, technical skills and evidence-based practice, but feedback about interpersonal skills (67.6%), communication skills (59.5%) and ethics (54%) was rarely or never provided. this study found that consultants delivered feedback in a variety of settings. while no consultants provided feedback during group teaching, 84% gave feedback during academic days, 62% made use of side-room settings, 50% provided one-on-one feedback, and 32% gave feedback at the bedside. no statistically significant relationship was observed between the age of consultants and how they perceived feedback to be provided. with regard to gender, male consultants believed that they were proficient at giving feedback, significantly more than their female counterparts (p=0.041, mean 21.91). consultants whose mother tongue was english showed significant differences compared with other language speakers, as they gave more feedback about how to be a communicator (p=0.031, mean 20.58), a collaborator (p=0.017, mean 20.74) and a manager (p=0.052, mean 20.44). provision of feedback was significantly influenced by race, gender and ethnicity of registrars, more so in consultants who were english secondlanguage speakers (p=0.05, mean 27.58) than english first-language speakers. discussion the importance of providing feedback in registrar training has been well documented.[1-5] a good approach to feedback is essential and several necessary elements have been identified for successful feedback to occur and ensure that the process attains the desired end result of improving performance.[2,4,16,17] two of the fundamental requirements for an appropriate and adequate feedback process involve: (i) the development of the desired standards to be obtained, and for these standards to be clearly communicated to the registrar in advance; and (ii) that the consultant’s feedback be based on direct observation of the registrar’s performance and compared with the desired standard to be achieved. such feedback must include an improvement plan to overcome any deficiencies between actual and desired performance.[3,4] the majority of consultants did not communicate such desired ‘gold standards’ to the registrars. furthermore, more than one-quarter did not base their observations on direct observation of performance or provide a plan for improvement in the feedback given. therefore, registrars did not always have a clearly defined set of rules as a benchmark. these findings highlight essential fundamental flaws in the current practice of feedback across the disciplines at our academic hospital. this study suggests that each department should develop a set of guidelines that should be given to registrars at the beginning of a rotation, and consultants should be made aware that the feedback process hinges on direct observation of performance and incorporates improvement plans. moreover, while feedback is used to correct deficiencies, it should also enhance good performance. the majority of consultants did not give feedback on procedures performed correctly, hence missing the opportunity to cement good practice.[5] all consultants reported that they provided feedback, but the majority provided it infrequently and informally. with this approach, registrars will not always recognise feedback as feedback, and may not pay as much attention to it as when it is formally scheduled in advance.[1] owing to the experiential nature of the clinical teaching setting, it is of concern that consultants do not optimise all opportunities with the registrar to provide feedback. this is an indication that many teaching opportunities are being lost. many consultants provided teaching at the bedside, a valuable setting for practical demonstration of clinical skills. however, academic days, which could be the best time for emphasising ‘softer’ skills, including graduate attributes, professionalism and ethics, were not maximised. a specific time should be set aside for discussions around such aspects on these days. also, care should be taken to highlight the relevant application of such tenets during case presentations or didactic lectures on the effect that key areas have on clinical care to ensure that graduates are equipped with more than clinical competencies.[17] as feedback has been likened to giving bad news, the effect of the message on the recipient cannot be ignored.[5] this is particularly important in the diverse multicultural setting of this study. of note, the majority of consultants were not influenced by the race, gender or ethnicity of the registrar. however, this issue needs to be addressed, as not all consultants reported that feedback was given in a non-emotive and non-judgemental way. this is a major concern and counteracts the purpose of giving feedback – to improve performance – as registrars should not be in a position of reacting to how something was being said, rather than what was being said, and so losing the intended message.[5] similarly, not noting the effect of consultants’ feedback on registrars, could have a harmful result. in the face of negative criticism, some registrars lack the emotional capacity to recover from this and may flounder in their attempts to improve on their performance.[5,18] conversely, others, particularly those with strong personalities, may choose to believe that their consultants are incorrect and persist in their chosen behaviour.[18] it is therefore vital not only to be cognizant of the effect of both formal and informal feedback, but also to ensure referral to appropriate support structures should these be required; however, only 45.9% of consultants were aware of the support structures that registrars could access or be research 116 may 2016, vol. 8, no. 1, suppl 1 ajhpe referred to. while the majority of consultants gave registrars an opportunity to respond to feedback, when this did not occur misunderstandings and misconceptions were not clarified. consultants and students need to be skilled in the art of giving feedback.[2,4,6] only half of the consultants felt that they were proficient in providing feedback and gave feedback often. also, less than a third gave feedback about technical skills. as providing feedback is key to improving academic outcomes and clinical proficiency, inadequacies in being able to provide feedback generally and about essential competencies highlight a gap in the key performance areas of consultants and indicate the need for staff development, in addition to a possible postgraduate clinical qualification for employment in an academic teaching hospital. it is encouraging that all consultants agreed that feedback was essential to registrar training and the vast majority felt that they should be trained to give feedback. consultants are aware of the importance of feedback in honing relevant skills and of their own deficiencies and the need to rectify these through appropriate training. the race, gender and ethnicity of the registrars affected the provision of feedback significantly more for english second-language consultants than for english first-language speakers. the latter consultants were probably more aware of the barriers that non-proficiency in the medium of instruction could pose and took care to overcome them. conversely, given that all communication between registrar and consultant is in english, the consultants for whom english was their home language believed that they were skilled in providing feedback, possibly because of their ease of use of the language. consequently, they did not pay as much attention to ensuring that feedback was as successful as it should be, especially for registrars who were not as proficient in english as they were. however, regardless of race or language, generally male consultants believed that they were more proficient at providing feedback than female consultants. conclusion the study found that the art of giving and receiving feedback has to be nurtured so that consultants are more comfortable with and proficient in the process, not only in specific skills, but also with regard to essential graduate outcomes. to train consultants in this process would entail a form of continuing professional development, especially as they are recruited on their clinical skills and the assumption that knowing how to do a procedure equates to being able to communicate it well, without any formal exposure to didactic instruction. this would encourage a process of reflection and seeking feedback from registrars, starting in the preclinical years. an integral component of this training would have to be recognising the effect of feedback on registrars, so that any undesirable outcomes could be appropriately dealt with, be it refusal to accept the feedback or negative emotional reactions. support structures and mechanisms must be developed internally by disciplines and the university at large, and referral pathways must be developed and communicated to consultants and registrars so that they are able to access these quickly and confidentially if and when required. while it is gratifying that most consultants were able to embrace the multicultural and diverse setting, a small majority appeared to be affected by race, gender and ethnicity. we recommend that appropriate programmes addressing diversity issues be implemented so that no-one is prejudiced by these apparent biases. acknowledgements. this article was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health (nih oar and nih orwh). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. we wish to thank dr m muzigaba for help with statistical analysis, and the staff and students who participated in this study. references 1. busari jo, weggelaar n, knottnerus ac, greidanus p, scherpbier ajja. how medical residents perceive the quality of supervision provided by attending doctors in the clinical setting. med educ 2005;39:696-703. 2. hattie j, timperley h. the power of feedback. rev educ res 2007;77:81-112. 3. van de ridder jm, stokking k, mcgaghie w, ten cate o. what is feedback in clinical education? med educ 2008;42:189-197. [http://dx.doi.org/10.1111/j.1365-2923.2007.02973.x] 4. ende j. feedback in medical education. jama 1983;250:777-781. 5. delima tj, arnold r. giving feedback. j palliat med 2011;14(2):233-239. [http://dx.doi.org/10.1089/ jpm.2010.0093] 6. shrivastava sr, shrivastava ps, ramasamy j. effective feedback: an indispensable tool for improvement in quality of medical education. j pedagog dev 2014;4(1):12-20. 7. rodriguez-paz jm, kennedy e, salas e, et al. beyond ‘see one, do one, teach one’: toward a different training paradigm. qual saf health care 2009;18:63-68. [http://dx.doi.org/10.1136/qshc.2007.023903] 8. menachery ep, knight am, kolodner k, wright sm. physician characteristics associated with proficiency in feedback skills. j gen intern med 2006;21:440-446. 9. norcini j. the power of feedback. med educ 2010;44:16-17. [http://dx.doi.org/10.1111/j.1365-2923.2009.03542.x] 10. lieberman a, lieberman m, steinert y, mcleod p, meterissian s. surgery residents and attending surgeons have different perceptions of feedback. med teach 2005;27:470-472. 11. cantillion p. giving feedback in clinical settings. bmj 2008;337:a1961. [http://dx.doi.org/10.1136/bmj.a1961] 12. veloski j, boex j, grasberger m, evans a, wolfson d. systematic review of the literature on assessment, feedback and physicians’ clinical performance: beme guide no. 7. med teach 2006;28:117-128. 13. kogan j, conforti ln, bernabeo ec, durning sj, hauer ke, holmboe es. faculty staff perceptions of feedback to residents after direct observation of clinical skills. med educ 2012;46:201-245. [http://dx.doi.org/10.1111/j.13652923.2011.04137.x] 14. holen a. the pbl group: self-reflections and feedback for improved learning and growth. med teach 2000;22:485-488. 15. murdoch-eaton d. feedback: the complexity of self-perception and the transition from ‘transmit’ to ‘received and understood’. med educ 2012;46:538-540. [http://dx.doi.org/10.1111/j.1365-2923.2012.04278.x] 16. bing-you r, trowbridge r. why medical educators may be failing at feedback. jama 2009;32:1330-1331. [http:// dx.doi.org/10.1001/jama.2009.1393] 17. fluit c, bolhuis s, grol r, et al. evaluation and feedback for effective clinical teaching in postgraduate medical education: validation of an assessment instrument incorporating the canmeds roles. med teach 2012;34:893-101. 18. archer j. state of the science in health professional education: effective feedback. med educ 2010;44:101-108. [http://dx.doi.org/10.1111/j.1365-2923.2009.03546] research may 2016, vol. 8, no. 1, suppl 1 ajhpe 99 the majority of 1st-year students are ill-equipped for university life and academia. this under-preparedness is accentuated by literacy issues, socioeconomic factors and lack of resilience.[1] these issues heighten stress levels, which affect academic performance and personal wellbeing.[2] although psychological morbidity may be high among university students, it is often neglected in educational settings. emotions are the primary forces driving motivation, and poor control and understanding of one’s own or others’ emotions may result in flawed social interactions.[3] for health practitioners, this finding is crucial, as it may not only potentially compromise academic functioning and their personal wellbeing, but may also, in the long term, affect patient care. it has been reported that there is a paucity of research on the coping and adjustment of medical professionals, particularly in the south african (sa) context.[4] this view is reiterated by o’rourke et al.[5] and greysen et al.[6] with regard to medical students. the former authors note that although medical students’ distress is acknowledged, more research into causes and intervention strategies is needed. the latter asserts that the dramatic changes in sub-saharan africa over the past few decades necessitate a greater diversity of research into the perspectives and experiences of and within medical education. barriers to student success that compound adjustment issues affect throughput and retention rates at sa universities, accounting to a large degree for high dropout rates.[7] despite these findings, it appears that tertiary institutions still place primary emphasis on intellectual/cognitive factors, ultimately overlooking the possibility of non-cognitive factors as significant role players in student success. the study of positive psychology concerns itself with all aspects of positive living, and the fostering of interand intrapersonal resources for personal development and happiness. positive psychology adopts a strengths-based perspective (i.e. factors which contribute to things going right, such as ‘mental health’ as opposed to ‘mental illness’) in understanding and enhancing wellbeing. extending the salutogenic perspective, strümpher,[8] a pioneer in the field of psychofortology, theorised that fortitude resulted in psychological coping, emotional stability and stress tolerance. following strümpher’s theory, pretorius[9] expanded on the concept of fortitude within the sa context. he hypothesised that there are three main constructs that contribute to fortitude. they are an evaluative awareness of the self (self-appraisal), an evaluative awareness of family (family appraisal) and an evaluative awareness of social support (support appraisal). pretorius proposed that fortitude was derived and shaped from the construction of self and world and that these constructions were shaped from our appraisal of ourselves and our perceived sense of family and social support.[9] he further described that a person with low fortitude would be more prone to self-doubt, impaired perception of personal competency in coping with stressors and a disengagement from active coping efforts. however, a person with high fortitude would be more confident and would adopt more problem-focused styles of coping. there is limited research in the field of fortitude focusing on medical students. a previous study, which researched salutogenic factors among sa community-service doctors, recommended that it would be beneficial to investigate fortitude, as opposed to salutogenic factors, as fortitude is more holistic and all-encompassing.[10] equipping students to recognise their inner strengths and resources may assist them in coping with stress and adversity and could result in empowered, confident and well-adjusted individuals. the objective of this article is to explore the relationships between the three background. the majority of 1st-year students are ill-equipped for university life. this heightens stress levels, which are accentuated by a lack of resilience and impact negatively on academic performance and personal wellbeing. objectives. to explore, within the paradigm of positive psychology, the relationship between the self, family and support constructs of fortitude, and academic performance of 1st-year medical students. method. first-year medical students completed a fortitude questionnaire and their academic performances in two academic modules were collated. mann-whitney and kruskal-wallis tests were employed for statistical analysis of the variables. pearson correlation coefficients were calculated to assess the relationship between academic performance and fortitude subscales, as well as the fortitude composite score. results. the student population was multicultural, multilingual and had different educational and residential backgrounds. the fortitude instrument was found to be reliable and correlated significantly with student academic performance. male students had significantly higher fortitude scores than female students. students who had attended state/government schools had significantly lower fortitude than those who had attended private and ex-model c schools. students with prior degrees had higher fortitude than matriculants. conclusion. the significant, albeit moderate, positive correlation between fortitude and academic performance highlights the need for further exploration of wellbeing and holistic development of medical students. support programmes are recommended to bridge the gap related to gender and educational background. low and fair levels of fortitude indicate a need for corrective measures. these could include consulting relevant support networks such as student counsellors, mentors and academic development personnel. afr j health profession educ 2016;8(1 suppl 1):99-103. doi:10.7196/ajhpe.2016.v8i1.748 exploring the relationship between demographic factors, performance and fortitude in a group of diverse 1st-year medical students s hamid, bsocsc, bsocsc hons, ma, phd; v s singaram, bmedsc, mmedsc, phd clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: s hamid (shaista.saib@gmail.com) research 100 may 2016, vol. 8, no. 1, suppl 1 ajhpe constructs of fortitude,[9] academic performance and demographic factors in a diverse group of 1st-year medical students. methods ethical clearance and gatekeeper approval were obtained from the human and social sciences ethics committee at the university of kwazulunatal (ukzn), durban, sa (hss/0119/013d). a quantitative correlational research design was adopted using convenience sampling. the study was conducted at the nelson r mandela school of medicine at ukzn. all 1st-year medical students in the 2013 cohort were invited to complete the questionnaire adopted for use in the study. a total of 200 questionnaires were distributed, and 165 students consented to participate. students’ end-of-semester academic results from two academic modules, becoming a professional (36-credit bearing) and basic science (96-credit bearing), were obtained from the faculty of medicine. these are the only two academic modules that all 1st-year students participate in – the other three modules (8-credit bearing), english, isizulu and computer skills, are based on an entrance examination. instrument the research instrument consisted of 34 questions, to which the students responded using either a nominal or an ordinal scale. the questionnaire was divided into a demographic and fortitude component. demographic data were collected on gender, race, age, type of school (urban v. rural), sources of funding, and attendance at peer-mentoring and study skills sessions. the fortitude questionnaire (forq) was used to assess the fortitude component, adopted from pretorius and heyns[11] with permission from the authors. it comprises 20 items aimed at measuring the theoretical construct of fortitude. it has three subscales described below: • the self-appraisal scale comprises seven items related to the global appraisal of the self, as well as more specific appraisals such as problemsolving efficacy and mastery or competence (e.g. ‘i take a positive attitude towards myself ’). • the family-appraisal scale has seven items regarding the evaluative awareness of the family environment, such as support from family, level of conflict, cohesiveness in the family and family values (e.g. ‘there is plenty of attention for everyone in my family’). • the support-appraisal scale is an evaluative awareness of the support from others. these six items also included beliefs about the efficacy of using such support resources (e.g. ‘i am very satisfied with the comfort and support i get from others’). data analysis the data were analysed using stata/ic 13.0 (statacorp lp, usa).[12] descriptive analyses involved computation of summary statistics using frequencies and graphs, based on survey responses. continuous data were tested for normality using the one-sample kolmogorovsmirnov test. the results of this test revealed that the p-values were statistically significant (p=0.000), implying that distribution of the data was not normal. hence, for inferential statistical analyses, the non-parametric mannwhitney u-test was used to test whether the medians of the continuous variables between two independent groups were statistically different at p<0.05, and the kruskal-wallis test was employed to test the statistical significance of the differences between three or more groups. where possible, box plots were constructed to show the difference in medians and interquartile ranges of continuous variables across groups. pearson correlation coefficients were calculated to assess the relationship between academic performance on the two subjects and fortitude subscales, as well as the fortitude composite score. reliability of the instrument was assessed using cronbach’s α. results the sample was predominantly female (62%). according to racial background, the sample consisted of black (77%), indian (13%), white (4%) and coloured (7%) students. ages ranged between 18 and 21 years (78%). seventy-five percent of participants had attended a state/government school (i.e. poorly resourced), 7% had attended a private school and 18% had attended an ex-model c school (i.e. well resourced). forty-five percent of participants completed their schooling in a rural area. the majority lived in a university residence (61%), 29% lived with family or friends and 10% lived in a private residence. twenty-two percent of the students had attended some form of study skills session and 82% had attended peer-mentoring sessions. cronbach’s α coefficients were 0.77 for selfappraisal, 0.88 for family-appraisal and 0.82 for support-appraisal scales. this shows a high internal consistency of the items for all three constructs. a comparison of the medians of the fortitude subscales showed that self-appraisal (20.79), with a range of 8 28, had the highest median, while support appraisal (16.73), with a range of 2 24, had the lowest (table 1). the overall median table 1. descriptive statistics for fortitude and its subscales scale median (sd) items per subscale, n minimum scored maximum scored iep (a b) self-appraisal 20.79 (4.23) 7 8 28 (8.20) family appraisal 19.50 (6.50) 7 0 28 (0.28) support appraisal 16.73 (4.26) 6 2 24 (2.24) fortitude 57.01 (11.44) 20 20 80 (20.80) sd = standard deviation; iep = interval endpoints for each score. table 2. correlations between fortitude and academic performance self-appraisal score familyappraisal score supportappraisal score fortitude composite score module completed n r* n r* n r* n r* becoming a professional 158 0.23† 158 0.20‡ 158 0.25† 158 0.28§ basic science 152 0.09 152 0.17‡ 152 0.22† 152 0.20‡ average of the two assessment scores 135 0.16‡ 135 0.21§ 135 0.29§ 135 0.29§ *pearson’s product moment correlation coefficient. †correlation at p<0.01 (two-tailed). ‡correlation at p<0.05 (two-tailed). §correlation at p<0.001 (two-tailed). research may 2016, vol. 8, no. 1, suppl 1 ajhpe 101 for the composite score of fortitude was 57.01 (table 1). fig. 1 shows the distribution of fortitude scores across the 20 different measures posited in the study questionnaire. as illustrated, the majority of the students felt strongly that these statements applied to them. this implies that, with regard to the family-appraisal subscale, students believed that they had strong levels of family support; the self-appraisal subscale revealed that they felt positive about themselves, and the support-appraisal subscale indicated that they were satisfied with the support they received from others. no statistical differences were found between the race groups for all three subscales and the overall fortitude scores. median scores for the family-appraisal subscale, the support-appraisal subscale and the fortitude composite score were not statistically different between male and female students (p>0.05; fig. 2). however, male students had a significantly higher median score than their female counterparts on the self-appraisal subscale (p<0.0001). the kruskal-wallis test revealed statistically significant differences in the composite fortitude scores of students who had attended different types of schools (p<0.05). those students who had attended state/government schools had the lowest composite median score (fig. 3). fig. 4 illustrates that students with other higher educational experience, such as the completion of another degree, prior to doing medicine, had significantly higher median scores across all three fortitude subscales compared with those without such experience. these differences were statistically significant (p<0.05 for the family-appraisal, supportappraisal and self-appraisal subscales; p<0.001 for the fortitude composite score). the results shown in table 2 indicate that there was a weak but statistically significant correlation between the self, family and support subscales and performance in the becoming a professional and basic science academic modules. when the three subscales were combined, the resultant fortitude composite score was significantly but moderately correlated with the academic scores of the becoming a professional module. furthermore, the composite score of fortitude was also significantly moderately correlated with the average score for both academic modules. discussion three main constructs that contribute to fortitude are the evaluative awareness of the self (self-appraisal), an evaluative awareness of family (family appraisal) and an evaluative awareness of social support (support appraisal).[11] high internal consistency of the items in all three constructs supports the reliability of the instrument used in this study. we found that the majority of the participants had high levels of fortitude in all three constructs. this implies that this cohort of medical students had positive perceptions or appraisals of themselves, their families and their social supports. the self-appraisal scale presented with the highest mean scores overall for this group of students. this may be due to the finding that, compared with other university students, medical students were ‘known to be highly motivated students’.[13] also, being selected from a massive pool of applicants, these students are constantly reminded that they are the ‘cream of the crop’. women generally present with greater psychological distress[14] and hence may have lower fortitude scores, as we have found in this study. when comparing mean scores, males had higher fortitude and significantly different scores for self-appraisal than females. although rahim[15] did not find any significant relationship between fortitude and gender, roothman et al.[16] found that men presented with higher fortitude levels than females. the finding in this study reflects that male students have a higher sense of self, i.e. they are more certain of themselves, have more positive attitudes about themselves, have less trouble making up their minds and trust their abilities to solve problems. dhaniram[10] also found, in her research of stress levels among sa community-service doctors, that female students and female physicians showed higher stress levels. these findings highlight the need 6.0 3.0 4.0 1.0 14.0 20.3 26.4 38.0 40.0 41.0 39.4 53.3 17.0 30.0 36.2 32.2 3.0 16.0 9.2 14.0 4.0 7.0 8.0 22.0 28.3 25.1 30.0 24.3 26.0 20.3 45.4 28.0 47.0 31.0 37.0 33.0 34.0 30.3 28.2 19.0 26.3 35.0 35.0 38.1 3.0 3.0 9.0 10.0 5.0 1.3 7.0 4.0 5.0 45.0 45.0 3.030.0 17.0 12.0 13.4 28.0 31.3 18.4 38.1 38.0 41.3 32.0 48.0 41.0 41.0 44.3 27.0 43.0 19.3 37.0 41.0 45.0 19.132.0 0 10 20 30 40 50 60 70 80 90 100 % does not apply applies very strongly friends often have good advice to give my friends give me the moral support i need se lf -a p p ra is al fa m ily s u p p o rt su p p o rt a p p ra is al i know that someone will always be around if i need assistance i am very satis�ed with the help and support that i get from those that i can count on i am very satis�ed with the comfort and support that i get from others in general, there are more than �ve people that i could really count on to be dependable when i need help activities in our family are pretty carefully planned in my family we tell each other about our personal problems members of my family are good at helping me solve problems i have a deep sharing relationship with a number of members of my family i rely on my family for emotional support there is plenty of time and attention for everyone in our family learning about new and di�erent things is very important in our family at times i think i am no good at all when making a decision, i weigh the consequences of each alternative and compare them with each other on the whole i am satis�ed with myself i trust my ability to solve new and di�cult problems i have no trouble making up my mind i take a positive attitude towards myself i always feel pretty sure of myself fig. 1. the distribution of fortitude scores across the 20 different measures of fortitude: analysis disaggregated by fortitude subscale. research 102 may 2016, vol. 8, no. 1, suppl 1 ajhpe for wellbeing programmes that target females, although not to the exclusion of male students. the underlying reasons for this finding should also be explored further using interviews or focus groups. students who had acquired other educational experiences or degrees prior to studying medicine had significantly higher median scores across all three fortitude subscales compared with those who had not. these findings may be attributed to the increased experience and level of maturity of these students, compared with those pursuing their first degree directly after high school.[10] students who had attended state/government schools had significantly lower fortitude than those who had attended private or ex-model c schools. the type of school attended has been found to influence academic scores.[17] these findings may be attributed to the fact that private and ex-model c schools have greater infrastructure, resources and much lower teacher-to-student ratios than state schools. they also highlight the need for support programmes to bridge this gap in higher education. this study contributes to the body of knowledge regarding the association between non-cognitive predictors, such as student psychological wellness on academic performance.[18-20] a moderately statistically significant relationship was found between fortitude and academic performance. this finding highlights the need to investigate confounding variables that may influence academic performance. hence, further research in this area, preferably with a larger sample, is needed. furthermore, the weak but statistically significant findings of this study suggest an association between psychological wellbeing and academic performance.[13] developing fortitude in medical students and fostering an environment of positive social and academic support could have positive implications for academic success. these findings support the need for further exploration of self-development and wellness programmes at medical schools. such programmes could serve as buffers against medical school stressors and could contribute to enhancing and sustaining fortitude. as the study was limited to 1st-year students only, sampling across all years of medical study is recommended for future studies to investigate the effect of year of study on fortitude. it is also recommended that longitudinal studies be used to assess the fortitude of students as they progress through their years of study. further validation of the instrument is recommended in other health science settings. this study was dependent on self-reported information and perceptions from the participant. however, the fortitude instrument used was found to be reliable. it is suggested that further study includes other health science students, such as those from nursing and pharmacy, to gain a more extensive view of the levels of fortitude. this would enable comparison of curriculum and academic environment influences in health science education. conclusion male students had significantly higher fortitude scores than females. students who had attended state/government schools had significantly lower fortitude than those who had attended private or ex-model c schools. students with prior degrees had higher fortitude than matriculants. low and fair levels of fortitude are indicative of a need for corrective measures. these could include consulting the relevant support networks, such as student counsellors, mentors and academic development personnel. the significant, albeit moderate, correlation between fortitude and academic performance highlights the need for further investigation of the fortitude instrument. r aw s co re self-appraisal subscale support-appraisal subscale family-appraisal subscale composite score for fortitude male female 60 50 40 30 20 70 80 10 0 fig. 2. distribution of the three fortitude subscale scores by gender. r aw s co re self-appraisal subscale support-appraisal subscale family-appraisal subscale composite score for fortitude private school 60 50 40 30 20 70 80 10 0 ex-model c schoolstate/government school fig. 3. distribution of the three fortitude subscale scores by type of school where student matriculated. r aw s co re self-appraisal subscale support-appraisal subscale family-appraisal subscale composite score for fortitude second degree 60 50 40 30 20 70 80 10 0 first degree fig. 4. distribution of the three fortitude subscale scores by whether student acquired a previous degree. research may 2016, vol. 8, no. 1, suppl 1 ajhpe 103 acknowledgements. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the us department of health and human services, national institutes of health. its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. the medical students are acknowledged for their participation, and dr m muzigaba for statistical guidance and analysis. references 1. nel bp. academic advising as intervention for enhancing the academic success of ‘at-risk students’ at a comprehensive university in south africa. mediterr j soc sci 2014;5(27):732-739. [http://dx.doi.org/10.5901/ mjss.2014.v5n27p732] 2. pillay al, ngcobo hsb. sources of stress and support among rural-based first-year university students: an exploratory study. s afr j psychol 2010;40(3):234-240. [http://dx.doi.org/10.1177/008124631004000302] 3. ahammed s, abdullah as, hassane sh. the role of emotional intelligence in the academic success of united arab emirates university students. int educ 2011;41(1):7-21. 4. brown-baatjies o, fouché p, watson m, povey jl. the biopsychosocial coping and adjustment of female medical professionals. s afr j psychol 2006;36(1):126-143. [http://dx.doi.org/10.1177/008124630603600108] 5. o’rourke m, hammond s, o’flynn s, boylan g. the medical student stress profile: a tool for stress audit in medical training. med educ 2010;44(10):1027-1037. [http://dx.doi.org/10.1111/j.1365-2923.2010.03734] 6. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, sewankambo n, mullan f. medical education in subsaharan africa: a literature review. med educ 2011;45(10):973-986. [http://dx.doi.org/10.1111/j.13652923.2011.04039.x] 7. kelly-laubscher rf, van der merwe m. an intervention to improve academic literacies in a first year university biology course. crit stud teach learn 2014;2(2):1-23. [http://dx.doi.org/10.14426/cristal.v2i2.23] 8. strümpher djw. the origins of health and stress. from ‘salutogenesis’ to ‘fortigenesis’. s afr j psychol 1995;25(2):81-89. [http://dx.doi.org/10.1177/008124639502500203] 9. loots t, ebersohn l, ferreira r, eloff i. teachers addressing hiv and aids-related challenges resourcefully. southern afr rev educ 2012;18(1):56-84. 10. dhaniram n. stress, burnout and salutogenic functioning amongst community service doctors in kwazulunatal. ma thesis. pretoria: university of south africa, 2003. http://hdl.handle.net/10500/1526 (accessed 19 april 2016). 11. pretorius tb, heyns pm. fortitude as stress-resistance: development and validation of the fortitude questionnaire (forq). 2005. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.464.1299&rep=rep1& type=pdf (accessed 15 june 2012). 12. statacorp. stata statistical software: release 13. college station, tx: statacorp lp, 2013. 13. jafari n, loghmani a, montazeri a. mental health of medical students in different levels of training. int j prev med 2012;3(suppl 1):s107-s112. 14. akhlaq ba, arouj k. study on the self-esteem and strength of motivation of medical students. int j bus humanit technol 2014;4(5):58-63. 15. rahim mz. investigating the relationship between fortitude and academic achievement in students from historically disadvantaged backgrounds. mpsych thesis. cape town: university of the western cape, 2007. http:// hdl.handle.net/11394/2762 (accessed 19 april 2016). 16. roothman b, kirsten dk, wissing mp. gender differences in psychological well-being. s afr j psychol 2003;33(4):212-218. 17. sommerville t, singaram vs. the whole is greater than the sum: a longitudinal study of demographic influences on medical student assessment scores. alternation 2015;17:28-53. 18. singaram vs, van der vleuten cp, muijtjens am, dolmans dh. relationships between language background, secondary school scores, tutorial group processes and students’ academic achievement in pbl: testing a causal model. interdiscip j probl based learn 2012;6(1):153-164. [http://dx.doi.org/10.7771/1541-5015.1316] 19. sommer m, dumont k. psychosocial factors predicting academic performance of students at a historically disadvantaged university. s afr j psychol 2011;41(3):386-395. [http://dx.doi.org/10.1177/008124631104100312] 20. van lingen jm, douman dl, wannenburg i. a cross-sectional exploration of the relationship between undergraduate nursing student wellness and academic outcomes at a south african higher education institution. s afr j psychol 2011;41(3):396-408. [http://dx.doi.org/10.1177/008124631104100313] june 2018, vol. 10, no. 2 ajhpe 79 research the concept of personality as a measurable trait is hindered by the lack of consensus in the field of psychology on the appropriate model of personality. personality psychologists have attempted to attach biological functions to traits and the diversity of traits, and proposed numerous models.[1,2] the alternative five factorial model of personality claims that human personality can be explained by five broad factors[3] that have a strong biologicalevolutionary basis.[4] these five factors are:[3] • impulsive sensation seeking: ‘the tendency to act quickly on impulse without planning, often in response to a need for thrills and excitement, change and novelty.’ • neuroticism-anxiety: ‘the tendency to be tense and worry, overly sensitive to criticism, easily upset, and obsessively indecisive.’ • aggression-hostility: ‘the tendency to express verbal aggression and show rudeness, thoughtlessness, vengefulness, spitefulness, a quick temper and impatient behaviour.’ • sociability: ‘tendencies to interact with others, enjoyment in being with others, and intolerance for social isolation.’ • activity: ‘the tendency to be active, to prefer challenging work, and being impatient or restless when there is nothing to do.’ numerous studies have attempted to classify underand postgraduate medical students and specialists into personality categories.[4-10] a study[5] published in 2004 used the cloninger inventory to identify the influence of temperament on medical students’ choice of specialty. they distributed the questionnaire to 682 medical students with a choice of preference from procedure-orientated specialties (surgery, obstetrics and gynaecology) and primary care specialties (family medicine, internal medicine, paediatrics). procedure-orientated specialties had higher novelty-seeking scores and scored high on co-operativeness and self-directedness. those interested in emergency medicine scored high on novelty-seeking and low on harmavoidance scales, similar to surgeons, but higher in reward dependence than surgeons. students choosing primary care specialties, especially paediatrics, had the highest reward-dependence scores. those choosing internal medicine had higher harm-avoidance scores than those choosing surgery and emergency medicine. hojat and zuckerman[3] tested the personalities of 1 076 medical students at jefferson medical college, philadelphia, usa, between 2002 and 2006, according to specialty interest. the study used the zuckerman-kuhlman personality questionnaire (zkpq) measuring the five personality factors background. studies found an association between personality types and field of specialty. the current study could assist aspiring specialists in deciding which specialty they are best suited for by comparing their own personalities with the results. objectives. to explore the personality characteristics of doctors in three consulting and four surgical specialties at an academic hospital in bloemfontein, south africa. methods. in this analytical cross-sectional study, questionnaires, including the zuckerman-kuhlman personality questionnaire, were handed out. overall, 58 consultants and senior registrars from the departments of family medicine, paediatrics and internal medicine (response rate 71.6%) and 70 consult ants and senior registrars from surgical specialties (response rate 60.3%) participated. results. family medicine had the lowest median score for impulsive sensation seeking (21.1%) and aggression-hostility (11.8%), and highest for parties and friends (33.3%). paediatrics scored highest for neuroticism-anxiety (44.7%) and aggression-hostility (23.5%). internal medicine scored highest for sociability (25.0%) and isolation intolerance (37.8%), and lowest for neuroticism-anxiety (36.8%) and activity (47.1%). overall, the consulting group scored lower than the surgical group for impulsive sensation seeking, aggression-hostility, sociability and activity, and higher for neuroticism-anxiety. conclusion. the study identified personality types of some specialties, and revealed differences between characteristics of local specialists compared with findings from studies elsewhere. afr j health professions educ 2018;10(2):79-84. doi:10.7196/ajhpe.2018.v10i2.997 association between personality factors and consulting specialty of practice of doctors at an academic hospital in bloemfontein, south africa r van aswegen,1 undergraduate medical student; a ravgee,1 undergraduate medical student; g connellan,1 undergraduate medical student; c strydom,1 undergraduate medical student; j t kuzhivelil,1 undergraduate medical student; g joubert,2 ba, msc; w j steinberg,3 mb bch, dtm&h, dph, dipl obst (sa), mfammed, fcfp (sa) 1 school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of biostatistics, faculty of health sciences, university of the free state, bloemfontein, south africa 3 department of family medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: w j steinberg (steinbergwj@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:teinbergwj@ufs.ac.za 80 june 2018, vol. 10, no. 2 ajhpe research mentioned above. it showed that those interested in surgical specialties had higher than average scores for impulsive sensation-seeking and aggressionhostility factors, and lower scores in the neuroticism-anxiety scale. those interested in obstetrics and gynaecology were more often females and scored highest in neuroticism-anxiety. those interested in hospital care scored lower on the sociability scale, while those interested in emergency medicine and surgery had high activity scores, especially compared with psychiatry students. many doctors and medical students are faced with the dilemma of whether to specialise. to specialise in a field of medicine is often a lifelong commitment – one that requires careful consideration. we believe that perceptions of the type of personalities of individuals in a specific specialty may influence the choice of specialty, and many of these perceptions may be based on stereotypes. the current study could assist aspiring specialists in deciding which specialty they are best suited for by comparing their own personalities with the results. objectives the aim of the study was to explore any association between the personality factors and consulting specialty of practice of doctors at an academic hospital in south africa (sa) in 2014. furthermore, to provide a broader context, the overall results for consulting and surgical groups are provided. methods design and setting this was an analytical cross-sectional study conducted over 4 months, from august to november 2014, at an academic hospital in bloemfontein, sa. population and sampling strategy the target population consisted of 197 doctors working as senior registrars or consultants at 7 specialty departments at the academic hospital. the specialties were assigned to the ‘consulting group’ (family medicine, internal medicine and paediatrics) or the ‘surgical group’ (anaesthesiology, obstetrics and gynaecology, orthopaedic surgery and surgery). this article focuses mainly on the consulting group, which consisted of 81 doctors. inclusion criteria senior registrars (in their third or fourth year of the mmed degree) and specialist consultants, of all ages, who practised at the academic hospital were included. there were no exclusion criteria. method of sample selection convenience sampling of all consultants and senior registrars present at departmental meetings was performed, unless they declined. completed questionnaires were retrieved at the meeting or from the departmental secretary if these were not completed at the meeting. data collection the psychometric tool used in this study was the zkpq.[11] it measures five factors of personality: (i) impulsive sensation seeking; (ii) neuroticismanxiety; (iii) aggression-hostility; (iv) sociability; and (v) activity. impulsive sensation seeking is subdivided into impulsivity and sensation seeking. sociability is subdivided into parties and friends, and isolation intolerance, and activity is subdivided into work effort and general activity. the zkpq, a valid self-report measure,[12] consists of 99 items in true/ false format. in addition to the zkpq, a section was added to the study questionnaire to capture demographic data such as age, gender and years in field of specialty. the questionnaire was available only in english. pilot study eight medical interns training at the academic hospital were included in the pilot study. a few minor adjustments were made to the questionnaire. the data collected were not included in the study. data analysis data were analysed by the department of biostatistics, faculty of health sciences, university of the free state (ufs), bloemfontein. results are presented as median percentages of the maximum result for each specific scale because of skew data distributions. for each scale, the score obtained was expressed as a percentage of the maximum total score applicable for that scale. if >20% of the questions for a specific scale were not answered, the participant’s result for that scale was excluded from the results. the zkpq includes a sixth scale, i.e. infrequency, which identifies participants who provide invalid test results by selecting responses that are unlikely to be true.[3] a comparison was made between results that excluded questionnaires with scores >30% on the infrequency scale and results that did not exclude questionnaires with scores >30%. a few differences were noted, but these were not significant enough to warrant the use of the results that excluded questionnaires. statistical analysis was performed using the non-parametric mannwhitney test, and 95% confidence intervals (cis) for the median differences were calculated. values p<0.05 were considered statistically significant. ethical approval the protocol was approved by the ethics committee of the faculty of health sciences, ufs (ref. no. stud no 28/2014). permission to conduct the study was obtained from the heads of the academic departments, as well as from the head of clinical services at the academic hospital. permission to use the zkpq in the study was given via email by prof. marvin zuckerman (co-creator), along with the manual that was used to score each individual’s results. results the response rates from each consulting specialty and the overall consulting and surgical groups are shown in table 1. family medicine was the consulting specialty with the highest median age (54 years) and duration of practice (14.5 years) (table 2). all consulting specialties had higher medians than the surgical group (age: p<0.01; table 1. sample and population sizes specialty sample size, n population size, n response rate, % family medicine 13 16 81.3 internal medicine 25 37 67.6 paediatrics 20 28 71.4 consulting group, all 58 81 71.6 surgical group, all 70 116 60.3 june 2018, vol. 10, no. 2 ajhpe 81 research 95% ci 2 10 years; duration of practice: p<0.01; 95% ci 1 6 years). all consulting specialties had a larger percentage of females than the surgical specialties (p=0.03). impulsive sensation seeking family medicine had the lowest median score (21.1%) for impulsive sensation seeking (fig. 1). all three consulting specialties had medians of 36.4% for the subscale sensation seeking. family medicine and paediatrics both had medians of 0 for the subscale impulsivity. all three consulting specialties had lower medians than the overall surgical group for impulsive sensation seeking (p<0.01; 95% ci ˗25.8%; ˗5.3%) and the subscale sensation seeking (p=0.01; 95% ci ˗27.3%; ˗3.6%). the subscale sensation seeking scored higher than impulsivity across consulting and surgical groups. neuroticism-anxiety paediatrics scored the highest (44.7%) and internal medicine the lowest (36.8%) for neuroticism-anxiety. the consulting group scored higher than the surgical group (p=0.06; 95% ci 0; 15.8%) (fig. 2). aggression-hostility paediatrics scored the highest (23.5%) and family medicine the lowest (11.8%) for aggression-hostility (fig. 3). there was a strong distinction between the two major groups, with the consulting group scoring much lower than the surgical group (p<0.01; 95% ci 11.8%; 23.5%). sociability internal medicine had the highest score for sociability (25.0%) and the subscale isolation intolerance (37.8%) (fig. 4). family medicine scored the highest for the subscale parties and friends (33.3%). the consulting group scored lower than the surgical group for sociability (p=0.01; 95% ci ˗11.8%; 0). activity internal medicine scored the lowest on the scale for activity (47.1%), as well as for the subscale general activity (33.3%) (fig. 5). paediatrics had table 2. demographic data of specialties demographic data family medicine internal medicine paediatrics consulting, all surgical, all median age, years 54.0 36.5 40.5 42.0 35.0 range, years 32 65 29 64 30 63 29 65 28 78 median duration of practice, years 14.5 8.0 9.5 10.0 4.0 range, years 4 32 2 30 1 30 1 32 1 50 gender* male, n (%) 9 (69.2) 12 (50.0) 9 (56.3) 30 (56.6) 49 (75.4) female, n (%) 4 (30.8) 12 (50.0) 7 (43.7) 23 (43.4) 16 (24.6) ratio 2.25:1 1:1 1.3:1 1.3:1 3.1:1 *gender missing: internal medicine (n=1); paediatrics (n=4); consulting, all (n=5); surgical, all (n=5). 21.1 31.6 26.3 29.0 36.8 36.4 36.4 36.4 36.4 45.5 0 12.5 0 12.5 12.5 sc o re , % specialty impulsive sensation seeking (main) sensation seeking (subscale) impulsivity (subscale) 50 40 30 20 10 0 fa mi ly me dic ine in ter na l m ed ici ne pa ed iat ric s co ns ult ing , a ll su rg ica l, a ll fig. 1. median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor impulsive sensation seeking. 42.1 36.8 44.7 36.8 26.3 su rgi ca l, a ll specialty 50 40 30 20 10 0 sc o re , % fa mi ly me dic ine in ter na l m ed ici ne pa ed iat ric s co ns ult ing , a ll fig. 2. median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor neuroticism-anxiety. 82 june 2018, vol. 10, no. 2 ajhpe research the highest score for the subscale work effort (68.8%). the consulting group scored significantly lower than the surgical group for activity (p<0.01; 95% ci ˗17.6%; ˗5.9%), as well as for the subscales general activity (p=0.06) and work effort (p=0.01). discussion this study was conducted among specialist doctors working at an academic hospital in bloemfontein. they are therefore either in an academic position or pursuing academic studies. to evaluate a more homogenous group, it was decided that only doctors in the academic setting would be included. doctors drawn to academics may have a different personality type with different aims in life, compared with doctors in private practice. family medicine family medicine scored the lowest for the factor aggression-hostility. a possible explanation could be the higher median age of this group, causing aggression and hostility to decrease with increasing maturity and experience, while the patient-orientated nature of the practice necessitates non-aggressive behaviour. family medicine also had the lowest impulsive sensation-seeking scores. the results suggest that family medicine specialists are in general not risktaking or novelty-seeking individuals. this may again be owing to the higher median age, or the broader scope of the specialty, making it less exciting to the more adrenaline-driven individuals. however, one would expect that a specialty with a broad scope would allow for greater diversity, which is an archetypical need for impulsive and sensation-seeking individuals. impulsivity was very low across all the specialties. this may be because of high expectations of professional conduct and intolerance to impulsivity in the work environment of medical specialists. sociability is ‘the tendency to interact with others, enjoyment in being with others, and apparent intolerance for social isolation’. although sociability may not be a crucial aspect of an effective doctor’s personality, proficiency in interpersonal and communication skills is highly regarded by patients, according to a study on patient perspectives on physician behaviour.[13] for the sociability scale, family medicine had the lowest score for isolation intolerance (25.0%) and the highest for parties and friends (33.3%). the reverse is true for the other two specialties. it appears, therefore, that family medicine specialists may not so much be asocial as being highly tolerant of social isolation. an example of a statement from the zkpq for work effort is: ‘i like a challenging task much more than a routine one’, and for general activity: ‘i like to be doing things all of the time.’ although family medicine scored lowest of all specialties in the subscale work effort (50.0%), it scored highest 11.8 17.7 23.5 17.7 40.6 specialty sc o re , % 50 40 30 20 10 0 fam ily m ed icin e in ter na l m ed icin e pa ed iat ric s co ns ult ing , al l su rgi ca l, a ll fig 3. median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor aggression-hostility. 23.5 25.0 17.7 23.5 29.4 33.3 11.1 11.1 16.7 25.0 25.0 37.8 25.0 22.2 37.5 sc o re , % specialty sociability (main) parties and friends (subscale) isolation intolerance (subscale) 50 40 30 20 10 0 fa mi ly me dic ine in ter na l m ed ici ne pa ed iat ric s co ns ult ing , a ll su rg ica l, a ll fig. 4. median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor sociability. 64.7 47.1 61.8 54.6 70.6 55.6 33.3 61.1 55.6 66.7 50.0 62.5 68.8 62.5 75.0 specialty sc o re , % activity (main) general activity (subscale) work e�ort (subscale) 80 70 60 50 40 30 20 10 0 fam ily me dic ine inte rna l m edi cin e pae dia tric s con sul ting , al l sur gic al, all fig. 5. median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor activity. june 2018, vol. 10, no. 2 ajhpe 83 research in the activity (64.7%) scale. this may indicate that these specialists prefer being busy with multiple activities than focusing on a single challenging task. internal medicine internal medicine recorded scores with the widest difference between two subscales: work effort (62.5%) and general activity (33.3%). this could reflect a penchant for hard and challenging work, but not a busy lifestyle. internal medicine also had the lowest score of the consulting specialties for neuroticism-anxiety and the highest score for sociability, although only marginally in both scales. under isolation intolerance, internal medicine had a higher score than the overall score for consulting and surgical groups. paediatrics the highest score for neuroticism-anxiety was observed in this specialty. the researchers hypothesise that paediatricians’ preference for caring for and interacting with children may correspond with greater sensitivity and anxiety. in other words, the specialty draws more sensitive and concerned individuals who tend to be more anxious themselves. hojat and zuckerman[3] showed that there was a greater need in childcare for ‘harm avoidance’, a trait that they found to correlate with high neuroticism and anxiety. paediatrics scored the lowest in sociability. this was surprising, as the authors believed that interaction with children would be associated with a sociable disposition. an aversion to social pressure may be associated with high neuroticism-anxiety, low sociability and a preference for interacting with children and mothers. furthermore, social interaction with children is different from interacting with peers. it may be that the lack of ‘typical’ socialising with patients causes a decrease in sociability over time. even though paediatrics had low aggression-hostility scores (23.5%), these were still higher than those of the other two consulting specialties. this was surprising, as it was assumed that people who interact with children would be the least aggressive. consulting group v. surgical group the surgical group was found to have higher impulsive sensation-seeking scores than the consulting group. this may be attributed to the physically stimulating nature of surgical procedures that attracts ‘novelty-seeking’ individuals. the consulting group had higher neuroticism-anxiety, which may be due to differences in the doctor-patient relationship. the consulting group was much less aggressive. this may also be attributed to a difference in patient interaction, with consulting specialists needing to be approachable, as their work is centred on consultations, not procedures. the consulting group had a lower sociability score than the surgical group. one explanation for this is the higher neuroticism-anxiety of this group, which implies more sensitivity to criticism. moreover, the need for teamwork during surgical procedures, greater academic emphasis of consulting specialties, higher median age of consulting specialists (42 v. 35 years), and difference in role models may have played a part. the zkpq study[3] among medical students found that sociability correlated positively with aggression-hostility. however, it was expected that these two factors would be inversely related to each other. rudeness, impatient behaviour and a quick temper would not normally be associated with good interpersonal relationships. it may be that a limited amount of aggression-hostility could be perceived as social ‘dominance’, and therefore greater success in socialising with others. the zkpq study[3] showed no statistically significant difference in sociability between the medical student groups tested. a study of 590 medical students in saudi arabia,[14] using the zkpq, found that those interested in surgical specialties scored higher than all other specialty choice groups on all factors, including neuroticism-anxiety, except for activity. study limitations the small population and sample sizes for each specialty made generalisation and comparison difficult, and prevented more in-depth analysis into the influence of gender, age and years in field of specialty on personality factors. the study only comprised doctors at an academic hospital, and may not fully reflect the personality types of doctors working in the greater private and public sectors. sampling bias was also of concern, as the completion of the questionnaires depended on the availability of doctors. gender and age were measured, but due to limited sample size, it was not possible to correct for these biases. recruiting of participants at meetings may have systematically excluded doctors with specific personalities, who do not attend meetings. the zkpq does not exhaust the entire range of personality characteristics that any person can possess, and it is emphasised that the results merely provide indications and suggestions and should not be used to place any individuals into ‘boxes’. however, all the specialties had a great range in the minimum and maximum values, demonstrating that specialties are not exclusive of any personality types, but that there may be specialties that are more suited to a person’s personality than others. although published research generally agrees regarding the grouping of family medicine, internal medicine and paediatrics specialties as primary care/people-orientated/consulting, comparison with other studies are hampered by some differences in categorisation of specialties, e.g. meh mood et al.[14] grouped anaesthesiology with hospital-based procedures, whereas we grouped it with surgical specialties. conclusion the study helped to characterise the personalities of doctors in some specialties, as demonstrated in bloemfontein, and revealed some of the differences between findings regarding local specialists and results from studies elsewhere. recommendations potential future research efforts that we recommend include: (i) a comparison of personality factors, such as sociability for different professions; (ii) a study comparing the personalities of consulting specialists with correction for gender; and (iii) a study on the level of neuroticism-anxiety of south africans in general. it could not be confidently ascertained whether choice of specialty was a product of personality, or whether personality was a product of specialty. a study on whether conforming to the personality norm of one’s profession has an impact on career satisfaction will substantiate research on personalities and professions. it is known that certain personality traits impact on career satisfaction,[15-17] but it is not known whether conforming to the norm is related to career satisfaction. 84 june 2018, vol. 10, no. 2 ajhpe research acknowledgements. the researchers would like to acknowledge the following people for their assistance, guidance and suggestions: dr chris snowdowne, the initial study leader, who formulated the idea for the study and guided the researchers throughout the planning phase; prof. marvin zuckerman, from the university of delaware, usa, for generously providing the zkpq free of charge for use in the study; mr jacques le roux, a colleague of the researchers, for suggesting the recommendation of investigating whether matching the personality norm of one’s field is associated with career satisfaction; the research committee of the school of medicine, ufs, for providing funding for printing; and ms t mulder, medical editor, school of medicine, ufs, for technical and editorial preparation of the manuscript. author contributions. rva, ar, gc, cs and jtk developed the protocol, designed the questionnaire, performed the data collection and coding of questionnaires and wrote a draft report as part of an undergraduate research module. wjs was the supervisor of this study, contributing to the planning, interpretation of results and writing of the manuscript. gj assisted with the planning of the project, performed the analysis of the data, and assisted with the interpretation of the data and the writing of the manuscript. funding. none. conflicts of interest. none. 1. hall cs, lindzey g. theories of personality. new york: john wiley, 1957. 2. lewin k. a dynamic theory of personality. new york: mcgraw-hill, 1935. 3. hojat m, zuckerman m. personality and specialty interest in medical students. med teach 2008;30(4):400-406. https://doi.org/10.1080/01421590802043835 4. zuckerman m. zuckerman-kuhlman personality questionnaire. in: de raad b, perugini m, eds. big five assessment (zkpq), and alternative five-factorial model. seattle: hogrefe & huber, 2002:377-396. 5. vaidya na, sierles fs, raida md, fakhoury fj, przybeck tr, cloninger cr. relationship between specialty choice and medical student temperament and character assessed with cloninger inventory. teach learn med 2004;16(2):150-156. https://doi.org/10.1207/s15328015tlm1602_6 6. rathi aa, prabhugaonkar sv, jadhav bs, shanker s, dhavale he. study of personality factors in postgraduate medical students. bombay hosp j 2008;50(2):245-249. 7. freeman b. the ultimate guide to choosing a medical specialty. 3rd ed. new york: mcgraw-hill medical, 2012. 8. coombs rh, fawzy fi, daniels ml. surgeons’ specialities: the influence of medical school. med educ 1993;27(4):337-343. 9. zimet cn, held ml. the development of views of specialties during four years of medical school. j med educ 1975;50(2):156-166. 10. linn bs, zeppa r. does surgery attract students who are more resistant to stress? ann surg 1984;200(5):638-643. https://doi.org/10.1097/00000658-198411000-00014 11. zuckerman m, kuhlman md, thornquist m, kiers h. five (or three) robust questionnaire scale factors of personality without culture. personal individ diff 1991;12(9):929-941. https://doi.org/10.1016/0191-8869(91)90182-b 12. gomà-i-freixanet m, wismeijer aa, valero s. consensual validity parameters of the zuckerman-kuhlman personality questionnaire: evidence from self-reports and spouse reports. j personal assess 2005;84(3):279-286. https://doi.org/10.1207/s15327752jpa8403_07 13. bendapudi nm, berry ll, frey ka, parish jt, rayburn wl. patients’ perspectives on ideal physician behaviors. mayo clin proc 2006;81(3):338-344. https://doi.org/10.4065/81.3.338 14. mehmood si, khan ma, walsh km, borleffs jc. personality types and specialist choices in medical students. med teach 2012;35(1):63-68. https://doi.org/10.3109/0142159x.2012.731104 15. lounsbury jw, loveland jm, sundstrom ed, gibson lw, drost aw, hamrick fl. an investigation of personality traits in relation to career satisfaction. j career assess 2003;11(3):287-307. https://doi.org/10.1177/ 10690 72703254501 16. levy jj, richardson jd, lounsbury jw, stewart d, gibson lw, drost aw. personality traits and career satisfaction of accounting professionals. individ diff res 2011;9(4):238-249. 17. judge ta, heller d, mount mk. five-factor model of personality and job satisfaction: a meta-analysis. j appl psychol 2002;87(3):530-541. https://doi.org/10.1037/0021-9010.87.3.530 accepted 9 november 2017. https://doi.org/10.1080/01421590802043835 https://doi.org/10.1207/s15328015tlm1602_6 https://doi.org/10.1097/00000658-198411000-00014 https://doi.org/10.1016/0191-8869(91)90182-b https://doi.org/10.1016/0191-8869(91)90182-b http://dx.doi.org/10.1207/s15327752jpa8403_07 https://doi.org/10.4065/81.3.338 https://doi.org/10.3109/0142159x.2012.731104 https://doi.org/10.1177/1069072703254501 https://doi.org/10.1177/1069072703254501 https://doi.org/10.1037/0021-9010.87.3.530 october 2016, vol. 8, no. 2, suppl 2 ajhpe 217 research while advances in healthcare have led to an increase in life expectancy in the global population,[1] it is evident that health systems are under pressure to address additional challenges such as globalisation, the emergence of new infections, and an increase in chronic disease, poverty and inequity.[2,3] with the healthcare needs of the world becoming increasingly complex, new, sustainable and dynamic approaches to healthcare are necessary if we are to improve global health outcomes.[4] the development of core competencies in health professions education, aligned with global health needs,[2] has been suggested as one way in which health outcomes may be improved.[1,2,5] however, professional education is struggling because of poor teamwork, as well as a mismatch between health professionals’ competencies and the needs of the patient and the population.[2] the ability to collaborate as part of a team is a core professional competency that produces positive health outcomes for patients,[6,7] as no single discipline can meet all patient and population needs in a complex health system.[8] furthermore, collaboration is an essential component of safe, high-quality patient care.[9] this suggests that health professions education must ensure that the ability to collaborate is intentionally developed in undergraduate students and that we must move away from professional silos to work effectively together.[2,10] health professionals must therefore understand each other’s roles and responsibilities, share knowledge, work together in interdependent teams[6,9] and communicate effectively with each other, their patients, their patients’ families and their communities.[6,8] to effectively address the health needs of the population, the medical and dental board (mdb) in south africa (sa) has adopted a modified version of the canmeds physician competency framework[9] to inform the training and education of medical doctors, dentists and clinical associates in the sa context.[11] the mdb has highlighted the development of the following roles in clinical practice: health practitioner, communicator, collaborator, leader and manager, health advocate, scholar and professional.[12] the framework also suggests that clinicians should possess a set of key competencies that outline the behaviours and skills that graduates should display.[13] in developing the role of collaborator in the mdb framework, the following key competencies were identified: (i) the ability to participate effectively and appropriately in multicultural, interprofessional and transprofessional teams as well as teams in other contexts (the community included); and (ii) the ability to work effectively with other healthcare professionals to promote positive relationships and prevent, negotiate and resolve interpersonal conflict.[12] there is consensus that the ability to collaborate across professional boundaries is therefore an important core competency for health professionals.[10] however, the education of health professionals is traditionally conducted in silos, with each profession developing its own set of competencies in relative isolation from others. interprofessional education (ipe) must therefore be considered as part of a collaborative practice model of care.[10] in this process, students from different professional programmes learn together, with a view to enhancing collaboration and teamwork to improve patient care. this requires all members of the team to understand each other’s roles and core competencies, and that they develop attitudes and behaviours that facilitate collaboration. therefore, ipe must be considered as an essential step in the development of a collaborative health workforce.[10] health professions education provides the foundation for the development of any profession, with training institutes bearing the primary responsibility for the development of core competencies, which includes the ability to collaborate.[6] however, there is no clear understanding of how health professions educators can develop or assess collaborative competency in undergraduate healthcare students. there have been calls for educational reforms to produce graduates with appropriate professional competencies,[2,14] as healthcare education has not kept pace in meeting the demands of struggling health systems.[2,10] this is evident by the fact that these professions do not effectively work well together,[10] possibly as a result of poor development of core competencies in undergraduate education. background. it has been suggested that improved collaborative competency in multidisciplinary teams may help understand how health professionals can address problems that no single-disciplinary expert can manage independently. objective. to describe the development of the ability to collaborate in a south african university physiotherapy department. methods. focus group discussions and interviews were conducted with 3rdand 4th-year physiotherapy students and lecturers, respectively. participant responses were analysed thematically and evaluated against a self-developed framework that described the key and enabling competencies in collaboration. results. the study found that students and lecturers had a basic understanding of collaboration, but lacked a more comprehensive perspective. students and lecturers suggested that group work had the potential to develop collaborative competency, but expressed concerns about task design and implementation. while interprofessional education was a required component of the curriculum, both students and lecturers questioned the value of the module as it related to collaboration. finally, challenges to the development of collaborative competency in the clinical context were highlighted. conclusion. the study found that the development of collaborative competency, while recognised as important for addressing complex health needs, had several challenges that need to be addressed in order to be effective. recommendations are provided for curriculum developers. afr j health professions educ 2016;8(2 suppl 2):217-221. doi:10.7196/ajhpe.2016.v8i2.841 collaborative competency in physiotherapy students: implications for interprofessional education j manilall, msc (physiotherapy); m rowe, phd (physiotherapy) department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: m rowe (mrowedr@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 218 october 2016, vol. 8, no. 2, suppl 2 ajhpe research if healthcare professionals are to address the increasingly complex health needs of their client populations, it appears that the ability to collaborate effectively must be intentionally developed in undergraduate health pro fessions curricula. in addition, it seems evident that ipe is an appropriate space within the curriculum in which to embed the development of collaboration as a core competency. however, there is limited research on the ways in which this important competency is developed in sa health professions students. the objective of this study was therefore to determine how students and lecturers in a physiotherapy department perceive the development of collaborative competency in the undergraduate curriculum. methods the study made use of a descriptive, qualitative research design to gain insight into the learning and teaching experiences of students and lecturers in the department of physiotherapy, university of the western cape (uwc), as they related to the development of collaborative competency. the researcher (jm) used focus group discussions with undergraduate students and semi-structured interviews with lecturers to develop an understanding of how students in the department were being prepared for collaborative practice.[15,16] all lecturers and all 3rdand 4th-year undergraduate students were invited to participate in the study and the focus group participants were selected purposively. the 3rdand 4th-year focus group discussions each included six students and were conducted by mr and jm respectively in june and july 2015. to define the concept of collaboration for this study, the authors combined several competency frameworks: the canmeds physician framework,[9] the essential competency profile for canadian physiotherapists,[17] and the mdb competency profile[12] to develop a single framework against which to evaluate student and staff responses. the framework used to describe collaborative competency in the context of this study is presented in table 1. semi-structured interviews with seven lecturers from the department were conducted by jm in person or telephonically, with one follow-up interview conducted to obtain additional clarity from one participant. the data from the focus groups and interviews were audio recorded and transcribed verbatim, and then sent to participants for member checking to confirm their accuracy. the transcripts were initially read through several times by jm for familiarisation with the content.[18] participant responses to questions related to the development of collaborative competencies were then openly coded to create themes, providing the authors with a formal system for organising the data from each group.[19] themes from both groups were then compared to identify any links and relationships between them. finally, the participant responses were evaluated against the key and enabling competencies in the framework presented in table 1 to determine if collaboration as a core competency was being effectively developed in this group of students. permission to conduct the study was obtained from the registrar of uwc, the research ethics committee (registration no. 15/4/34), and the head of the physiotherapy department. the identities of the participants were removed from the transcripts and all information remained confidential. participants were provided with an information sheet describing the context for the study, and could withdraw at any stage without negative consequences. results and discussion the results present the findings on students’ and lecturers’ perceptions of the development of collaborative competency in the physiotherapy department. participant responses to questions are presented in sections, along with a discussion of the responses and emergent themes in relation to the framework presented in table 1. the questions posed to students and lecturers included the following: what is your understanding of collaboration? how is collaboration developed in the classroom? what are your perceptions of the ipe modules in your course? what are your perceptions of collaboration in the clinical context? question: what is your understanding of collaboration? all participants were asked what they understood collaboration to mean in the context of professional education, to determine if they could identify the activities that were linked to its development. the theme that emerged from the responses was that participants had a basic understanding of collaboration as working together, although the students’ discussion seemed to indicate deeper insight. two lecturer responses are presented: ‘… individuals who work together around a specific subject or topic with a common goal or outcome.’ (lecturer) ‘collaboration for me means working with another team or another set of people on a specific goal … collaboration is a big aspect of teamwork.’ (lecturer) however, students’ responses seemed to suggest that they thought of collaboration as being something beyond simply working together: ‘putting ideas together to get to the best achievement [with the] specific goal to take care of this patient.’ (student) ‘usually when people collaborate, they bring their own unique ideas or they impart a bit of themselves into the project they are working along with others.’ (student) table 1. framework describing collaboration as a competency key competency enabling competency establishes and maintains interprofessional relationships, which foster effective clientcentred collaboration respecting and understanding the roles and responsibilities of other healthcare professionals towards patientcentred care fostering collaboration with other relevant stakeholders in patient care[9,12,16] collaborates with others to prevent, manage and resolve conflict identifying issues that may result in conflict and employing collaborative skills to resolve them demonstrating a respectful attitude towards colleagues and the interprofessional team to foster positive relationships[9,12,16] reflecting on improving the functioning of the interprofessional team[12] effectively and safely transfers care to another health professional being able to assess when the patient should be transferred to another healthcare provider demonstrating the use of written and verbal communication for safe transfer[12] october 2016, vol. 8, no. 2, suppl 2 ajhpe 219 research student participants were able to express the concept that collaboration included the use of knowledge and ideas to achieve a shared goal, while lecturers described it simply in the context of physically working together. [9,12] some students were also more expressive in their understanding of collaboration, including the idea that collaboration involves working with others to achieve a shared goal, but also including the integration of different ideas and of investing themselves in the work. both groups were therefore able to articulate a coherent and accurate description of what collaboration meant, which aligned with the first key competency in our description of collaboration in table 1. in other words, this group understood that collaboration was about establishing and maintaining professional relationships that revolved around patient-centred care. however, in the context of the other key competencies presented in table 1, neither students nor lecturers expressed an understanding of collaboration that went beyond ‘working with others’. neither group discussed the importance of being able to resolve conflict as part of a collaborative process, nor did they discuss the role of referral as a collaborative activity, highlighting a limited understanding of collaboration as a core competency for professional practice. question: how is collaboration developed in the classroom? both lecturers and students in this study emphasised the use of group work in classroom activities as being the primary means by which collaborative competency was developed. within the classroom, group work was viewed by both students and lecturers as a means to develop collaboration, but the theme that emerged from these responses was that there was some uncertainty about specific aspects of group work. lecturers in general seemed confident about their use of group work in the classroom, as expressed by the following participant: ‘we do a lot of group work, we do a lot of group assignments as well and especially in the 1st and 2nd years we do encourage them to work together in groups … .’ (lecturer) however, one lecturer suggested that the structure of the group work determines how well students collaborate. furthermore, the lecturer also expressed uncertainty about how to develop collaboration, questioning whether group work necessarily leads to collaboration: ‘… i think in the classroom, if you want to develop collaboration you do need to be … a little careful about what tasks you’re going to give them … i actually can’t think of what tasks we’d give them to assist them with collaboration.’ (lecturer) the following two responses, the first from a student and the second from a lecturer, highlight a major concern with group work, namely that co-operation is usually the default mode of work, instead of collaboration: ‘they [the lecturers] don’t say, hang on … it’s important that if you are not working together then this is useless … i think we are taught in a way of co-operation … instead of collaboration.’ (student) ‘i’ll break them [the students] up into groups and i’ll give them a task to work on. and then i always ask them to divide themselves in terms of who will do what … .’ (lecturer) one student suggested a particular approach to group work that included the use of clinical case scenarios as part of the structure: ‘i think it starts from case-based learning, that’s how we started collaboration and group work … .’ (student) there was also a concern, expressed by both students and lecturers, that some students would not make a fair contribution to the activity, which influenced how enthusiastic they were about working in groups: ‘you choose them for either how well they work in a group or they’re not lazy or they play their part and you know that they’re going to do the work.’ (student) ‘… what tends to happen when you’re in a group, you get one or two people that slack off.’ (student) in terms of the development of collaboration in the classroom, both lecturers and students in this study identified group work as the only developmental activity that could lead to collaborative competency. however, there was some uncertainty about how the structure of the task within the activity determines how well students actually work together. true collaborative activity requires individuals to work together on a shared goal, where the work is characterised by a low division of labour, synchronous communication and negotiability.[20] in this study, it was clear that while group work was identified by participants as a standard for developing collaborative competency, there were some concerns raised about how well this worked in practice. if the task in the group work activity is not well designed, it leads to a high division of labour, where tasks are split among students and completed individually, rather than working together. finally, if students and lecturers are not convinced that group work is an effective means of developing collaborative competency because not all members contribute equally, they may not engage with the activity at an appropriate level. in terms of the framework (table 1), the students and lecturers were aware that group work may involve conflict between individuals if some students do not contribute to the activity, but neither group expressed any concern about how to manage this conflict, or that teaching students the skills required for conflict management should form part of the activity. in this sense they were lacking both key and enabling competencies that determine if collaboration will be effective. question: what are your perceptions of the ipe modules in your course? students in this course were required to attend interprofessional education modules and activities where they engaged with students from other health professions. students presented contrasting views on the value of these ipe opportunities, especially in terms of developing collaborative competency. the theme that emerged from responses to this question was that students were frustrated with their lack of understanding of the roles of other health professionals. as seen in the example response below, some students did find an opportunity to engage with and learn from other healthcare students: ‘… we obviously have to focus on the subject but we also get talking about your profession, my profession; what you do, what i do. and there we build up an understanding of each other and what we do.’ (student) but these students were in the minority and most others in the focus group discussions reported that the ipe modules did not add to their understanding of the roles of other health professionals, as highlighted in the quotes below: ‘in our 1st and 2nd years they focused a lot on integrating us as disciplines, but they didn’t actually focus on getting each discipline to understand the roles of the [other] disciplines they’re working with.’ (student) 220 october 2016, vol. 8, no. 2, suppl 2 ajhpe research ‘no. i feel like i don’t know everything about what exactly a speech therapist does or what exactly an ot [occupational therapist] does. i vaguely have learned through experience in the last 2 years.’ (student) ‘somewhere along the line we’ve got some form of a definition of each role of different professionals … a definition is not exactly the same thing as describing roles.’ (student) one of the lecturers also remarked on the lack of perceived value by the students in the ipe modules: ‘when i talk to the students they actually just view the module as a waste of time; they don’t view the module as something that they need … .’ (lecturer) several students believed that the ipe modules had limited value for their training which, considering the important position of role understanding in effective collaboration, suggests that these students were not well prepared to work together with other health professions. while the clinical setting provides opportunities for students to collaborate within interdisciplinary teams, it also requires an understanding of the roles and responsibilities of all team members to be effective.[6,9] ipe has been suggested as an approach to developing students’ ability to collaborate so that they become more effective members of interprofessional teams.[21] however, the theme that emerged from responses to this question was that many students were not sure if the ipe modules had any value with regard to their development; this is a concern because if students are not familiar with the roles of other members of the team, it influences how well they work together. when evaluating this theme against the description of collaboration (table 1), we see that an understanding of the role of other health professionals is an important enabling competency that underpins the ability to work effectively together. it would also affect students’ ability to refer appropriately to other professionals, which is another key competency in the ability to collaborate. the students believed that they were not benefitting from the learning opportunities available in the ipe modules, especially in the context of role understanding for effective collaboration. if collaboration requires that health professionals understand each other’s roles, there is a concern that this enabling competency was lacking in many students in this sample. question: what are your perceptions of collaboration in the clinical context? participant responses to this question were categorised into a theme of concern, with the lack of modelling of collaborative practice in the clinical context. while ward round attendance for students on clinical rotations were encouraged by clinicians, students were frustrated with the process. the students highlighted a lack of inclusion, which was perceived as a barrier to their learning and to developing collaborative competency. ‘when the doctors do ward rounds and you are there, they speak to themselves and their students – like they don’t involve anybody else, they don’t even involve the patients.’ (student) ‘they [the doctors] were running the show, talking, but within themselves about themselves.’ (student) ‘when they did ward rounds in the icu [intensive care unit], we kind of just walked with, but it felt like we were sneaking in to hear, i didn’t feel like we were actually invited to be part of it, we were just there, we weren’t part of it.’ (student) even though inclusion in ward rounds provides opportunities to develop interprofessional collaboration and teamwork,[22] the students expressed a sense of exclusion as other healthcare professionals spoke among themselves, ignoring the students and therefore creating a barrier to interprofessional communication and teamwork.[6] moreover, the impact of clinicians’ role-modelling in the development of collaboration among students was highlighted by students. clinicians who modelled the ability to collaborate with other health professionals and who encouraged students to do likewise, promoted the development of collaboration: ‘in my 3rd year i was encouraged by the clinician at the placement. she told me that if i needed to speak to anyone or any of the health disciplines, then i could pick up the phone and i could always phone them and ask them about my patients.’ (student) in contrast, when a clinician wasn’t confident enough to collaborate with others in the team, it influenced the student’s perceptions of collaboration: ‘if the clinician is also too scared to say something then you’re like, “what are we going to do now?” so if she was more like, “you’re right, as physios this is our right to speak ...”. she was just too scared to say something.’ (student) lecturers agreed that clinicians had an influence as role-models in terms of showing students how to collaborate with others: ‘the clinicians are working in silos when they are in hospitals or in the clinics, they are working separately. so it’s difficult to say they would be pushing for collaboration in a clinical setting.’ (lecturer) ‘some clinicians at certain placements can actually be quite good [at rolemodelling collaboration]. but then i also think that some clinicians at other placements are not that good.’ (lecturer) it seemed that if students perceived that a clinician’s self-confidence within the team was low and that they were fearful of contributing to team discussions, this behaviour could be learned by the student. there is therefore a need for all healthcare professionals to be aware of their own behaviour as collaborators because students learn from observation. besides interprofessional interactions, students also learn about collaboration through observation in the clinical environment,[23,24] in particular via the role-modelling of clinicians.[22,24] confidence is an important precursor to interprofessional collaboration,[25] influencing one’s ability to communicate and collaborate within teams.[26] recommendations it appears that deeper insight into a more comprehensive understanding of collaboration was lacking in both students and lecturers in the department, and that there is a need for changes to conceptual understanding and curriculum activities. in terms of the group work activities used to develop collaborative competency, lecturers should pay more attention to task design, ensuring that students do not simply co-operate and work on tasks separately as individuals. in addition, peer evaluations may be one way of motivating and assessing collaborative capabilities in group work to address concerns about some students not contributing. however, lecturers must inform students about the rationale for its use and familiarise them with the process for it to be effective.[20] while students in this department experience their ipe modules in the classroom or campus context, there is evidence to suggest that ipe october 2016, vol. 8, no. 2, suppl 2 ajhpe 221 research learning opportunities may have greater perceived value if they are conducted in the clinical setting.[25,26] in this context, it may also improve students’ understanding of the roles and responsibilities of fellow healthcare professionals.[25,26] the physiotherapy department should therefore consider the integration of ipe activities into the clinical platform in addition to the campus-based modules that students currently attend. and, while logistically challenging because of timetable differences, students from different disciplines should be required to complete collaborative activities within a problem-based learning context[10] over longer periods of time, as opposed to meeting for single-day seminars. the concern about students’ relative exclusion from ward rounds in clinical practice and its influence on their perception of collaborating in a team are suggestive of a larger issue. changes to the social and organisational norms of institutions are not easily addressed owing to long-standing professional hierarchies that create a barrier to effective collaboration within healthcare teams.[6,23] increasing student awareness on how organisational systems influence interprofessional collaboration should also be an objective of the ipe programme.[23] finally, an innovation in teaching and learning strategy that could be considered for the development of collaborative competency in the ipe curriculum is to integrate e-learning into the programme.[10,27] the integration of technology into the classroom is possible in resourceconstrained countries and may serve as a tool for enhancing ipe, particularly if delivered in an open-access environment.[10] however, online tools for collaborative group work must be implemented with care, and student support is an essential component.[27] conclusion this study provides insight into the development of collaboration among undergraduate students at an sa university physiotherapy department. although students and lecturers have a basic understanding of the concept of collaboration, there are gaps in their deeper development, demonstrated by the lack of key and enabling competencies that were articulated by the group. while both lecturers and students recognised the value of group work as an opportunity to develop collaborative competency, there was uncertainty from both groups about specific aspects of its implementation. it was evident that the ability to collaborate, while articulated by both lecturers and students, was not intentionally developed in the programme. the clinical environment and ipe modules are potentially important avenues to developing interprofessional collaborative abilities in physiotherapy graduates, but these aspects of the curriculum should be integrated more effectively. in particular, the use of group work to develop collaborative competency must include activities that help students develop skills in conflict resolution. the findings of this study have relevance for curriculum development in health professional courses, and the recommendations may help to graduate students with the key and enabling competencies to collaborate effectively between professions, within healthcare teams. references 1. chen l, evans t, anand s, et al. human resources for health: overcoming the crisis. lancet 2004;364(9449):19841990. doi:10.1016/s0140-6736(04)17482-5 2. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 3. labonté r, mohindra k, schrecker t. the growing impact of globalization for health and public health practice. annu rev public health 2011;32:263-283. doi:10.1146/annurev-publhealth-031210-101225 4. fried lp, piot p, frenk jj, flahault a, parker r. global public health leadership for the twenty-first century: towards improved health of all populations. glob public health 2012;7(suppl1):s5-s15. doi:10.1080/174416 92.2012.702118 5. crosbie j, gass e, jull g, et al. sustainable undergraduate education and professional competency. aust j physiother 2002;48(1):5-7. doi:10.1016/s0004-9514(14)60276-2 6. interprofessional education collaborative expert panel. core competencies for interprofessional collaborative practice: report of an expert panel. acad med 2011;86(11):1351. doi:10.1097/acm.0b013e3182308e39 7. suter e, deutschlander s, mickelson g, et al. can interprofessional collaboration provide health human resources solutions? a knowledge synthesis. j interprof care 2012;26(4):261-268. doi:10.3109/13561820.2012.663014 8. suter e, arndt j, arthur n, parbhoosingh j, taylor ed, siegrid d. role understanding and effective communication as core competencies for collaborative practice. j interprof care 2009;23(1):41-51. doi:10.1080/13561820802338579 9. frank jr, snell ls, sherbino j. the draft canmeds 2015 physician competency framework – series iii. ottawa: the royal college of physicians and surgeons of canada, 2014. 10. world health organization. transforming and scaling up health professionals’ education and training: world health organization guidelines 2013. geneva: who, 2013. 11. van heerden b. effectively addressing the health needs of south africa’s population: the role of health professions education in the 21st century. s afr med j 2013;103(1):21-22. doi:10.7196/samj.6463 12. medical and dental board of the health professions council of south africa. core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2014. 13. the royal college of physicians and surgeons of canada. canmeds role: collaborator. 2016. http://www. royalcollege.ca/rcsite/canmeds/framework/canmeds-role-collaborator-e (accessed 15 february 2016). 14. senkubuge f, modisenyane m, bishaw t. strengthening health systems by health sector reforms. glob health action 2014;1(8):1-7. doi:10.3402/gha.v7.23568 15. kemparaj u, chavan s. qualitative research: a brief description. indian j med sci 2013;67(3-4):89-98. doi:10.4103/0019-5359.121127 16. mcmillan w. moving beyond description: research that helps improve teaching and learning. afr j health professions educ 2010;2(1):3-7. 17. national physiotherapy advisory group. essential competency profile for physiotherapists in canada. 2009. http://www.physiotherapyeducation.ca/resources/essential%20comp%20pt%20profile%202009.pdf (accessed 15 january 2015). 18. elo s, kyngäs h. the qualitative content analysis process. j adv nursing 2007;62(1):107-115. doi:10.1111/ j.1365-2648.2007.04569.x 19. bradley eh, curry la, devers kj. qualitative data analysis for health services research: developing taxonomy, themes and theory. health serv res 2007;42(2):1758-1772. doi:10.1111/j.1475-6773.2006.00684.x 20. dillenbourg p. what do you mean by ‘collaborative learning?’ in: dillenbourg p, ed. collaborative learning: cognitive and computational approaches. oxford: elsevier, 1999:1-19. 21. bridges dr, davidson ra, odegard ps, maki iv, tomkowiak j. interprofessional collaboration: three best practice models of interprofessional education. med educ online 2011;16:1-11. doi:10.3402/meo.v16i0.6035 22. morris r, hilton j. student placements – is there evidence supporting team skill development in clinical practice settings? j interprof care 2001;15(2):171-183. doi:10.1080/13561820120039892 23. pollard kc. non-formal learning and interprofessional collaboration in health and social care: the influence of the quality of staff interaction on student learning about collaborative behaviour in practice placements. learn health soc care 2008;7(1):12-26. doi:10.1111/j.1473-6861.2008.00169.x 24. sheldon m, cavanaugh jt, croninger w, et al. preparing rehabilitation healthcare providers in the 21st century: implementation of interprofessional education through an academic-clinical site partnership. work 2012;41(3):269-275. doi:10.3233/wor-2012-1299 25. mellor r, cottrel n, moran m. ‘just working in a team was a great experience…’ – student perspectives on the learning experiences of an interprofessional education program. j interprof care 2013;27(1):292-297. doi:10.3 109/13561820.2013.769093 26. o’carroll v, braid m, ker j, jackson c. how can student experience enhance the development of a model of interprofessional clinical skills education in the practice placement setting? j interprof care 2012;26(6):508-510. doi:10.3109/13561820.2012.70920 27. rowe m. the use of a wiki to facilitate collaborative learning in a south african physiotherapy department. s afr j physiother 2012;68(2):11-16. http://dx.doi.org/10.1016/s0140-6736(04)17482-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1080/17441692.2012.702118 http://dx.doi.org/10.1080/17441692.2012.702118 http://dx.doi.org/10.1016/s0004-9514(14)60276-2 http://dx.doi.org/10.1097/acm.0b013e3182308e39 http://dx.doi.org/10.3109/13561820.2012.663014 http://dx.doi.org/10.1080/13561820802338579 http://dx.doi.org/10.7196/samj.6463 http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-collaborator-e http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-collaborator-e http://dx.doi.org/10.3402/gha.v7.23568 http://dx.doi.org/10.4103/0019-5359.121127 http://www.physiotherapyeducation.ca/resources/essential%20comp%20pt%20profile%202009.pdf http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x http://dx.doi.org/10.1111/j.1475-6773.2006.00684.x http://dx.doi.org/10.3402/meo.v16i0.6035 http://dx.doi.org/10.1080/13561820120039892 http://dx.doi.org/10.1111/j.1473-6861.2008.00169.x http://dx.doi.org/10.3233/wor-2012-1299 http://dx.doi.org/10.3109/13561820.2013.769093 http://dx.doi.org/10.3109/13561820.2013.769093 http://dx.doi.org/10.3109/13561820.2012.70920 research 128 september 2017, vol. 9, no. 3 ajhpe the healthcare system is driven by rapidly advancing technologies and international trends. in view of this, healthcare needs are constantly evolving. to meet these needs, the scope of practice of healthcare professionals requires regular re-evaluation. this is achieved through transforming higher education (he) and training and obtaining approval and accreditation from the relevant professional boards. it is important that the input for transforming he and training and expanding the scope of practice is based on scientific evidence that has been obtained through local research. this is necessary for he and training to be contextualised, while remaining aligned with international trends. radiography is a vital component in the medical field; however, the roles and responsibilities of radiographers and radiologists are often misunderstood. radiologists are medical physicians specialised in radiology and responsible for diagnosing and managing patients, whereas radiographers are healthcare professionals responsible for producing the medical images needed by radiologists to make an accurate diagnosis.[1] although radiographers and radiologists work in close collaboration, their roles, responsibilities and professional scopes of practice are different, and are determined by the scope of their relevant professions and training.[2] radiographers, globally, have significantly different scopes of practice. in ireland, canada and europe they are permitted to administer intravenous contrast media (ivcm) after having completed advanced training.[3-5] ivcm can be defined as imaging agents administered to a patient during specialised radiographic investigations to enhance the visibility of the internal anatomical structures.[6] radiographers practising in the usa may also administer ivcm after certification by either the american registry of radiologic technologists (arrt) or the american registry of magnetic resonance imaging technologists (armrit).[7] similarly, radiographers in the uk are able to advance to the levels of ‘consultant’ and ‘advanced practice’ radiographers.[8,9] the scopes of radiographers in these countries are defined by their training, which may differ between countries. radiographers in south africa (sa) have been found to perform, illegally, the task of ivcm administration, which currently falls within the scope of radiologists.[10] this practice may be motivated by the national shortage of radiologists and subsequent service delivery constraints.[11,12] in sa, the radiologist-to-patient ratio is in the region of 1:57 937.[11] radiographers in sa are not legally permitted to administer ivcm, as no formal health professions council of sa (hpcsa)-accredited training is currently offered.[13] they are, therefore, performing a criminal act and may be penalised accordingly. radiologists in sa have agreed in principle with the idea of having the radiographers’ professional scope of practice expanded to include the administration of ivcm, provided the necessary further training is formalised and undertaken.[14] as the administration of ivcm currently falls within the legal scope of practice of radiologists, it is logical that radiologists would be able to provide valuable information in this regard. possible advantages of role extension may include an improvement in the delivery of radiology services and the alignment of radiography with international standards.[10] background. the administration of intravenous contrast media (ivcm) is one of the key areas currently under investigation for inclusion in the south african (sa) radiographers’ scope of practice. however, for the radiographers to legally administer ivcm, training guidelines must first be identified, developed and accredited by the health professions council of sa. objective. to investigate the radiologists’ perspective of the knowledge, skills and medicolegal training required of radiographers for the administration of ivcm to provide input for the development of national training guidelines. methods. a quantitative, cross-sectional research study using an online survey, administered by surveymonkey, was conducted. the target population included all radiologists residing and practising in the province of kwazulu-natal, sa. results. fifty-nine participants (60.8%) completed the online survey. twelve were excluded owing to incomplete surveys, resulting in a final response rate of 48.5% (n=47). the study revealed that various theoretical, clinical/practical and medicolegal study units should be included in the training, i.e. the study of the pharmacology of contrast media, practical training on cardiopulmonary resuscitation and basic life support, as well as the rights and responsibilities of a healthcare professional. in addition, both theory and practical/clinical assessments need to be included. conclusion. key data have been provided for the development of national training guidelines for radiographers to administer ivcm, based on scientific evidence that is relevant to the sa context. the study may be of value to other related health professions where scopes of practice are expanded through transforming the education and training curricula. afr j health professions educ 2017;9(3):128-132. doi:10.7196/ajhpe.2017.v9i3.809 training requirements for the administration of intravenous contrast media by radiographers: radiologists’ perspective g g v koch,1 mhsc: radiography (d); l d swindon,1 med (he), btech: radiography (d); j d pillay,2 phd (physiology) 1 department of radiography, faculty of health sciences, durban university of technology, south africa 2 department of basic medical sciences, faculty of health sciences, durban university of technology, south africa corresponding author: g g v koch (erhardkoch9@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research september 2017, vol. 9, no. 3 ajhpe 129 the professional board for radiography and clinical technology (pbrct) is currently addressing role extension for radiographers, and research studies conducted locally have identified the need for the further training of radiographers to administer ivcm.[10,12] our research study, therefore, hopes to provide input for the hpcsa for the development of national training guidelines that are based on local scientific evidence. methods research design and study participants a quantitative, cross-sectional survey was conducted in the province of kwazulu-natal (kzn), sa. the study was limited to radiologists who were registered with the hpcsa and who were practising and residing in kzn. the target population was identified by means of the hpcsa’s online register, which is available to the public. in addition, the researcher identified participants by word of mouth and social media, i.e. facebook and linkedin. the hpcsa register listed a total of 104 radiologists and, using a confidence level of 95%, it was found that a minimum of 87 responses were needed. however, the exact number of radiologists living and/or practising in kzn could not be determined, as some members who appear ‘active’ on the register could be deceased or have relocated. therefore, as the total population was unknown, a 60% response rate was deemed to be statistically acceptable. sampling a purposive (non-probability) sampling technique was used, which was selected to provide input on a distinct research topic, the administration of ivcm by radiographers. the total target population was used in an attempt to obtain the minimum response rate. ethical considerations ethical clearance for the study was obtained from the institutional research and ethics committee, durban university of technology (ref. no. rec 18/15). a letter of information was included in the email communication sent to the participants, providing them with an outline of the research study and stating that the results may be published in a suitable journal. consent was assumed when participants completed the survey. no identifiable details were requested from the participants, thus ensuring confidentiality and anonymity. the participants were free to exit the survey at any time. research tool and data collection an online survey administered by surveymonkey was used to collect data. the participants were emailed a web link for the survey and a request for participation. the survey included questions and statements relating to the knowledge, skills and medicolegal training required by radiographers to administer ivcm. the content of the survey was benchmarked against international practice standards and training requirements of the radiography profession. the questions and statements in the survey were reviewed by a focus group prior to the data collection process to ensure validity and reliability. the structure of the survey was altered to follow the practical sequence of contrast media administration, i.e. placement of aspects related to patient preparation before those related to administration of the contrast media. the focus group consisted of the authors, a radiologist and two radiographers. they were selected based on their experience in the field of this research study. data analysis the data obtained from this research study were analysed using the statistical package for the social sciences (spss), version 23.0 (ibm corp., usa). descriptive and inferential statistics were applied. factor analysis and reliability testing using cronbach’s alpha were included. statistical significance was set at p<0.05. results fifty-nine participants (60.8%) completed the online survey. twelve were excluded owing to incomplete surveys, resulting in a final response rate of 48.5% (n=47). the majority of respondents were practising in the private sector (68.1%), 98.0% had been qualified as radiologists between 0 and 29 years, the majority were males (78.7%) and more than half (51.1%) were between 40 and 49 years of age. agreement on knowledge components table 1 provides the level of agreement (represented as a percentage) among the respondents for the inclusion of the anatomy, physiology and pathology of the cardiovascular, urinary and nervous system and the upper and lower limbs. the level of agreement was significantly high among the respondents with regard to the inclusion of basic anatomy, physiology and pathology of the cardiovascular, urinary and nervous system and the upper and lower limbs. however, the level of agreement for including the physiology component of the upper and lower limbs was lower compared with that for the inclusion of anatomy and pathology. although the respiratory system was not included in the survey, the study respondents identified it as being necessary for inclusion in the further training. the respiratory system was considered important, based on the possibility of complications and adverse reactions occurring owing to the administration of ivcm. therefore, it is necessary to be able to recognise the signs and symptoms associated with respiratory distress. table 2 provides information based on the need for further training in areas/systems related to contrast media and possible reactions. the level of agreement related to the knowledge components of contrast media and possible reactions was >85% in all instances. the results, therefore, suggest that these components are essential for inclusion in the training requirements for radiographers to administer ivcm. in addition to the results presented in table 2, the theory of cardiopulmonary resuscitation (cpr) and basic life support (bls) was considered important for further training, with agreement levels of 95.74% and 100.00%, respectively. the study of the pharmacology of emergency medicines and the administration thereof, however, indicated lower levels of agreement (68.09% and 65.96%, respectively). the majority of respondents (87.20%) were of the opinion that a theoretical assessment should be conducted towards the end of the training and should contribute a minimum weighting of 0.25 towards the final mark. agreement on skills components fig. 1 presents information pertaining to the technique/s for administering ivcm. all the skills components demonstrate a high level of agreement (95%), apart from the component related to observations of ivcm administration, which indicated an average level of agreement of 85%. notwithstanding this, the results demonstrate high levels of agreement among the majority of research 130 september 2017, vol. 9, no. 3 ajhpe respondents with regard to the observation of needle placement and ivcm administration, as well as the unassisted practice of these two skills. the respondents further agreed that a minimum of 10 needle placements be observed and a minimum of 20 unassisted, independent needle placements should be recorded. it is felt that the radiographers should observe a minimum of 20 ivcm administrations and also record a minimum of 20 un assisted, independent ivcm administrations. there is agreement that the radiographer should seek assistance after two failed attempts at placing the needle. fig. 2 presents information pertaining to the clinical/practical components for inclusion in the further training of radiographers to administer ivcm. patient preparation, management and aftercare, infection control, and cpr and bls practical training were agreed upon by the majority of respondents for inclusion in the further training of radiographers to administer ivcm. more than 55% of the respondents felt that practical training regarding the administration of emergency medicines and record keeping of observational hours of ivcm administrations (40 hours) should be included in the further training. it is noted, however, that of all the clinical/practical components presented in fig. 2, practical training regarding the administration of emergency medicines received the highest level of disagreement (12.77%). the majority of respondents (93.6%) were of the opinion that a clinical assessment be conducted towards the end of the training, which should contribute a minimum weighting of 0.25 towards the final mark. in addition, the results reveal that the students should keep a record of clinical competencies, which should be used as an assessment, with a minimum weighting of 0.25 towards the final mark. agreement on medicolegal components table 3 provides information based on the medicolegal study units to be included as part of the further training for radiographers to administer ivcm. high levels of agreement (>80%) were indicated for the study of basic patient rights and ethics, the rights and responsibilities of a 0 20 40 60 80 100 le ve l o f a g re em en t, % 2.13 4.26 93.62 95.74 2.13 2.13 2.13 12.77 85.11 93.62 0.00 6.38 2.13 4.26 93.62 ob se rv at io n of ne ed le pl ac em en ts un na ss ist ed iv ne ed le pl ac em en ts ob se rv at io ns iv cm ad m in ist ra tio ns un as sis te d iv cm ad m in ist ra tio ns se ek as sis ta nc e a fte r a f ail ed at te m pt skills component disagree neutral agree fig. 1. technique/s. (iv = intravenous; ivcm = intravenous contrast media.) table 1. level of agreement on knowledge components in anatomy, physiology and pathology component level disagree, % neutral, % agree, % anatomy cardiovascular system basic advanced 2.13 38.30 0.00 42.55 97.87 19.15 urinary system basic advanced 6.38 36.17 6.38 34.04 87.23 29.79 nervous system basic advanced 10.64 48.94 2.13 29.79 87.23 21.3 upper limb basic advanced 4.26 25.53 2.13 38.30 93.62 36.17 lower limb basic advanced 4.26 31.91 4.26 44.68 91.49 23.40 physiology cardiovascular system basic advanced 4.26 44.68 17.02 44.68 78.72 10.64 urinary system basic advanced 8.51 46.81 12.77 38.30 78.72 14.89 nervous system basic advanced 10.64 53.19 19.15 38.30 70.21 8.51 upper limb basic advanced 12.77 53.19 21.28 38.30 65.96 8.51 lower limb basic advanced 12.77 53.19 25.53 42.55 61.70 4.26 pathology cardiovascular system basic advanced 6.38 53.19 10.64 42.55 82.98 4.26 urinary system basic advanced 8.51 48.94 6.38 36.17 85.11 14.89 nervous system basic advanced 8.51 53.19 4.26 34.04 87.23 12.77 upper limb basic advanced 6.38 55.32 10.64 34.04 82.98 10.64 lower limb basic advanced 6.38 57.45 10.64 38.30 82.98 4.26 table 2. level of agreement on knowledge components in contrast media and possible reactions study unit disagree, % neutral, % agree, % pharmacology 2.13 2.13 95.74 preparation 4.26 4.26 91.49 type and dose administered for the adult and paediatric patient 0.00 2.13 97.87 clinical/biomedical indications and contraindications 0.00 2.13 97.87 types of needles and accessories 0.00 2.13 97.87 techniques for needle placement 0.00 10.64 89.36 methods of maintaining intravenous access 0.00 2.13 97.87 infection control 0.00 4.26 95.74 complications and adverse reactions 0.00 0.00 100.00 treatment of complications and adverse reactions 0.00 8.51 91.49 research september 2017, vol. 9, no. 3 ajhpe 131 healthcare professional, quality assurance, and patient management and communication. in contrast, the study of basic medical law, designing medical policies and procedural protocols, and cultural diversity collectively received lower levels of agreement (˂60%) and higher levels of neutrality (>35%), indicating that these were possibly not critical areas for training. discussion trends in he and training, coupled with the changing needs of healthcare service delivery, are well documented. the integration of he and training with the professional needs of the radiography profession is of vital importance, as the profession is changing and expanding globally.[15] it is important to investigate, compare and reflect on the training that other countries have in place so that the quality of the training guidelines for health professionals in sa can be improved through benchmarking, while still maintaining a local context. the need for scientific (local) research to be conducted, is deemed particularly important for addressing the specific healthcare needs of sa. the level and duration of the training of sa radiographers can only be established once the national training guidelines have been identified and approved by the pbrct. only then can educational institutions offer training that extends the scope of practice and raises the status of the profession. this research study revealed that both a theoretical and skills component of training should be included for radiographers to administer ivcm. this is similar to the training offered in southern europe at the university of malta and in the uk.[5,16] for example, the theoretical components offered at the university of malta and in the uk include the study of the anatomy of the upper and lower limbs, general physiology, contrast media, patient parameters (e.g. blood pressure), emergency medicines and equipment, infection control, technique associated with needle placements and ivcm administrations, as well as the study of medicolegal issues and legislation.[5,16] with regard to the skills component, the training offered at the university of malta requires that radiographers need to observe a minimum of five ivcm administrations and to record a minimum of 50 unassisted, independent ivcm administrations. the radiographers are also expected to seek assistance after two failed attempts at placing the needle.[5] the results from this research study revealed a similar pattern regarding the minimum number of failed attempts at placing the needle; however, there is agreement regarding the minimum number of 20 unassisted, independent ivcm administrations included in the training guidelines for uk radiographers.[16] international training standards state that the practical cpr training must be updated annually.[5,17,18] the competency profile for further training issued by the ontario association of medical radiation sciences (oamrs) in canada, recommends that in addition to this, an annual clinical competency assessment should be conducted.[18] this, however, requires further investigation, as the research tool for our study did not include the relevant questions. with regard to medicolegal training, the results are in favour of the study units included internationally. both theoretical and clinical assessments are conducted internationally and are in line with the recommendations of this study. our study indicated that the assessments should contribute a minimum weighting of 0.25 towards the final mark. the weightings of the assessments internationally, however, are different. the theoretical assessment at the university of malta contributes a weighting of 0.60 towards the final mark and the remaining weighting of 0.40 is calculated from clinical practice, which includes a record of clinical competencies.[5] fig. 2. clinical/practical component. (cpr = cardiopulmonary resuscitation; bls = basic life support; ivcm = intravenous contrast media.) 0 20 40 60 80 100 le ve l o f a g re em en t, % 2.13 6.38 91.49 93.62 93.62 95.74 59.57 63.83 0.00 6.38 2.13 4.26 2.13 2.13 12.77 27.66 2.13 34.04 skills component disagree neutral agree pr op er p at ien t p re pa ra tio n, m an ag em en t a nd af te rc ar e in fe ct io n co nt ro l m ea su re s a nd p re ca ut io ns pr ac tic al tra in in g on c pr pr ac tic al tra in in g on bl s pr ac tic al tra in in g on th e a dm in ist ra tio n of em er ge nc y m ed ici ne s a nd th e k ee pi ng of a re co rd of ob se rv at io na l ho ur s o f iv cm ad m in ist ra tio ns re co rd of ob se rv at io na l h ou rs table 3. level of agreement on medicolegal study units study unit level disagree, % neutral, % agree, % medical law basic advanced 12.77 70.21 36.17 27.66 51.06 2.13 patient rights and ethics basic advanced 2.13 46.81 12.77 44.68 85.11 8.51 rights and responsibilities of a healthcare professional 2.13 14.89 82.89 designing medical policies and procedural protocols 10.64 44.68 44.68 quality assurance 0.00 12.77 87.23 cultural diversity 4.26 40.43 55.32 patient management and communication 2.13 10.64 87.23 research 132 september 2017, vol. 9, no. 3 ajhpe summary of recommendations with regard to training guidelines the findings of this study highlight the need for theoretical, clinical/practical and medicolegal elements forming essential components of training, and the assessment thereof. theoretical components • basic anatomy, physiology and pathology of the cardiovascular, urinary, nervous and respiratory system and of the upper and lower limbs. • the preparation and pharmacology of ivcm, as well as clinical and biomedical indications and contraindications. • infection control, the different types of needles and accessories, as well as the technique/s for placing the needle and how to maintain iv access. • the different types and dose of ivcm administered for adult and paediatric patients. • the possible complications of and adverse reactions to ivcm and the treatment/management thereof. • cpr, bls, the pharmacology of emergency medicines and drugs, as well as the administration thereof. clinical/practical components • observation of 10 needle placements and a record of 20 unassisted, independent needle placements. • observation of 20 ivcm administrations and a record 20 unassisted, independent ivcm administrations. • patient preparation, management and after-care, as well as practical training regarding infection control, cpr and bls. • practical training on the administration of emergency medicines and drugs. • observation of 40 hours of studies involving contrast media. medicolegal components • the study of basic medical law, basic patient rights and ethics, as well as the rights and responsibilities of a healthcare professional. • quality assurance, cultural diversity, patient management and communication. assessments • a theoretical assessment, contributing a minimum weighting of 0.25 towards the final course mark. • a clinical assessment, contributing a minimum weighting of 0.25 towards the final course mark. • a record of clinical competencies, contributing a minimum weighting of 0.25 towards the final course mark. conclusion the study, in providing key data for the development of training guidelines for radiographers to administer ivcm, demonstrates the importance of he and training in addressing transformation in health services, with particular reference to the professional scope of practice. furthermore, it reinforces the need for local research that will inform he and training and hence a scope of practice that meets local needs. acknowledgements. the author would like to thank the co-authors for their guidance while writing this article, and the study participants for their input. author contributions. ggvk, lds: contributed substantially towards the conceptualisation of this study. ggvk, lds, jdp: contributed towards the design, analysis and interpretation of data, as well as the final approval of the article. funding. financial assistance was received from the faculty of health sciences, durban university of technology. conflicts of interest. none. 1. o’sullivan b, goergen s. x-ray. 2009. http://www.focusradiology.com.au/services/x-ray/ (accessed 13 august 2017). 2. etheredge hr. an opinion on radiography, ethics and the law in south africa. s afr radiographer 2011;49(1):9-12. 3. the irish institute of radiography and radiation therapy. intravenous administration by radiographers – guidelines on best practice. 2nd ed. dublin, ireland: iirrt, 2007. 4. the michener institute for applied health sciences. contrast injection for radiological technologist. 2013. http:// www.michener.ca/ce/course_info.php?course_group_id=4 (accessed 15 august 2017). 5. university of malta. administration of prescribed medicinals by radiographers. 2010. https://www.um.edu.mt/__ data/assets/pdf_file/0005/85568/intravenousinjectionslogbookjuly2010new.pdf (accessed 15 august 2017). 6. koch ggv, robbs jv. carbon dioxide angiography for peripheral vascular intervention. s afr radiographer 2016;54(1):9-11. 7. american college of radiology. acr-spr practice parameter for the use of intravascular contrast media. 2014. http://www.acr.org/~/media/536212d711524da5a4532407082c89ba.pdf (accessed 31 august 2017). 8. price rc, edwards hm. harnessing competence and confidence: dimensions in education and development for advanced and consultant practice. radiography 2008;14(suppl 1):e65-e70. https://doi.org/10.1016/j.radi.2008.11.005 9. kelly j, piper k, nightingdale j. factors influencing the development and implementation of advanced and consultant radiographer practice – a review of the literature. radiography 2008;14(suppl 1):e71-e78. https://doi. org/10.1016/j.radi.2008.11.002 10. munro l, isaacs f, friedrich-nel h, swindon l. an analysis of the need for accredited training on the administration of intravenous contrast media by radiographers: results of an online survey. s afr radiographer 2012;50(2):27-34. 11. gqweta n. knowledge, skills and perceptions of diagnostic radiographers in image interpretation of chest diseases in ethekwini public hospitals. mtech. durban: durban university of technology, 2014. http://ir.dut. ac.za/handle/10321/1003 (accessed 31 august 2017). 12. kekana rm, swindon ld, mathobisa j. a survey of south african radiographers’ and radiologists’ opinions on role extension for radiographers. afr j phys health educ recreat dance 2015;21(4):1114-1125. https://doi. org/10.20151864907 13. koch ggv. the need for qualified diagnostic radiographers to do additional first aid and emergency procedures training. s afr radiographer 2014;52(2):26-28. 14. radiological society of south africa. rssa position statement on the injection of contrast. south africa, 2011. http://rssa.co.za/downloads/doc_download/1240-rssa-position-statement-on-the-injecting-of-contrast (accessed 1 september 2017). 15. cowling c. a global overview of the changing roles of radiographers. radiography 2008;14(1):e28-e32. https:// doi.org/10.1016/j.radi.2008.06.001 16. college of radiographers. course of study for the certification of competence in administering intravenous injection. 2011. http://www.sor.org/system/files/article/201202/sor_iv_document_proof3.pdf (accessed 31 august 2017). 17. royal australian and new zealand college of radiologists. 2016. iodinated contrast media guideline. https:// www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsak hqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinatedcontrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpg rw (accessed 231 august 2017). 18. ontario association of medical radiation sciences. intravenous injection of contrast media – competency profile. 2010. https://www.regonline.ca/custimages/300000/305453/ivinjection_competencyprofile.pdf (accessed 23 april 2016). accepted 9 november 2016. http://www.focusradiology.com.au/services/x-ray/ http://www.michener.ca/ce/course_info.php?course_group_id=4 http://www.michener.ca/ce/course_info.php?course_group_id=4 https://www.um.edu.mt/__data/assets/pdf_file/0005/85568/intravenousinjectionslogbookjuly2010new.pdf https://www.um.edu.mt/__data/assets/pdf_file/0005/85568/intravenousinjectionslogbookjuly2010new.pdf http://www.acr.org/~/media/536212d711524da5a4532407082c89ba.pdf https://doi.org/10.1016/j.radi.2008.11.005 https://doi.org/10.1016/j.radi.2008.11.002 https://doi.org/10.1016/j.radi.2008.11.002 http://ir.dut.ac.za/handle/10321/1003 http://ir.dut.ac.za/handle/10321/1003 https://doi.org/10.20151864907 https://doi.org/10.20151864907 http://rssa.co.za/downloads/doc_download/1240-rssa-position-statement-on-the-injecting-of-contrast http://rssa.co.za/downloads/doc_download/1240-rssa-position-statement-on-the-injecting-of-contrast https://doi.org/10.1016/j.radi.2008.06.001 https://doi.org/10.1016/j.radi.2008.06.001 http://www.sor.org/system/files/article/201202/sor_iv_document_proof3.pdf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsakhqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinated-contrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpgrw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsakhqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinated-contrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpgrw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsakhqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinated-contrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpgrw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsakhqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinated-contrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpgrw https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahukewjmyuyz49pvahujdsakhqm5cj4qfggtmae&url=https%3a%2f%2fwww.ranzcr.com%2fdocuments%2f4108-ranzcr-iodinated-contrast-media-guideline-2016-recommendations%2ffile&usg=afqjcnhpwc5arria7oqrs0u8qvvtddpgrw https://www.regonline.ca/custimages/300000/305453/ivinjection_competencyprofile.pdf a maximum of 3 ceus will be awarded per correctly completed test. september 2018, vol. 10, no. 3 ajhpe the cpd programme for ajhpe is administered by medical practice consulting. cpd questionnaires must be completed online at www.mpconsulting.co.za after submission you can check the answers and print your certificate. questions may be answered up to 6 months after publication of each issue. accreditation number: mdb015/029/01/2018 (clinical) cpd questionnaire september 2018 true (a) or false (b): speech-language therapy consultation practices in multilingual and multicultural healthcare contexts: current training in south africa 1. one of the consequences of problematic communication cited by the author is poor compliance by patients. interprofessional knowledge and perceptions of selected south african healthcare practitioners towards each other 2. the author argues that interprofessional collaboration leads to antagonism and competition between healthcare practitioners. checklist of cognitive contributions to diagnostic errors: a tool for clinicianeducators 3. no fault, system, and personal are the three types of cognitive errors identified by graber et al., mentioned in this study. 4. history and physical examination-related errors accounted for a majority of the top 5 cognitive contributions to diagnostic errors (ccdes) identified in this study. the effectiveness of an online, distance-learning master’s in surgical sciences programme in malawi 5. the most common positive theme to emerge from the research was that students benefited from engaging with peers from other countries in the online discussion boards. peer helpers’ construction of their role in an open distance-learning institution 6. the peer-helper role as a personal eye-opener was not one of the main themes that emerged from this study. interventions aimed towards the development of patient-centredness in undergraduate medical curricula: a scoping review 7. time, pressure and fatigue are some of the reasons for decrease in patient-centredness in healthcare. exploring community-based training opportunities for dental therapy students in non-governmental and private sectors in kwazulu-natal province, south africa 8. concerns about student capabilities did not emerge as a perceived barrier to their community-based training. perspectives of advanced life support paramedics on clinical simulation for summative assessment in south africa: is it time for change? 9. research has shown that simulation remains underutilised, with the two main barriers to effective use being lack of staff training in facilitating simulation and the writing of scenarios. 10. the education regulators provide assessment criteria and guidelines for emergency care educators to fulfil the requirements for simulation assessment, as listed in this article. research september 2017, vol. 9, no. 3 ajhpe 133 few medical and nursing professionals are formally trained to be leaders and managers; yet, such individuals are often called upon to assume these roles.[1-3] traditionally, health professionals assumed managerial or leadership positions based on their clinical and scientific merits; attributes that do not necessarily equate to competency or aptitude as a leader or manager.[4] consequently, there is frequently a perceived failure to perform or significant discontent with role fulfilment. health providers generally expect straightforward, logical answers to every problem. these qualities may be appropriate for a clinical leader, but not so for a leader in the high-pressure business environment of healthcare, which is unpredictable, competitive and imbued with interdisciplinary conflicts, possibly making such leader incompetent. an incompetent leader often has an impact on subordinates by creating a stressful working environment and by the inability to achieve organisational objectives.[2,3,5,6] thus, health managers/leaders experience poor job satisfaction and poor retention, impacting negatively on an organisation in terms of fiscal and human resources and organisational history.[7] previously, health professionals moved from being a practitioner to a leader by virtue of clinical seniority – an approach that no longer reflects the realities of the health sector. ‘with the increasing complexity of health systems, the diversity of the roles and responsibilities that befall a medical manager subsequently have broadened, requiring the individual with a wider range of training and expertise than just seniority.’[8] there is growing evidence of the positive impact of formal training of health professionals in management and leadership.[9] south africa (sa) has prioritised healthcare management capacity building by enacting a skills development plan, as deficiencies in managerial capacity, especially in the public sector, have been identified as a risk. a survey of all managers in registered public and private hospitals in sa, found that 94.9% of public and 80.5% of private sector managers identified a need for further training in management skills development.[10] the sa national strategic plan prioritises the training of managers (i.e. chief executive officers, senior/district managers) to be based on a proposed assessment and gap analysis of competencies of current managers in healthcare.[11] competency is defined as a cluster of related knowledge, skills, and attitudes that can be: (i) measured; (ii) compared with known standards; (iii) correlated with job performance; and (iv) improved by education and training.[11] a call for competency-based education in health management has emanated from professional practitioner groups, researchers, educators, and accreditation bodies.[12] the foundation for professional development (fpd) offers an accredited short course – the certificate in advanced health management (cahm). this 1-year course links course modules and assignments to participants’ work environments to optimise practical and reflective opportunities. the exit learning outcome of the cahm is to enable participants to apply management principles at a strategic level within the healthcare environment to optimise healthcare in sa.[12] the cohort for 2009 completed their training in 2010. this study investigated the impact of the cahm course ~18 months after training. background. south africa’s health sector spans the private and the public sectors. within the sectors, health managers take on strategic leadership roles without formal training in management or leadership – a trend more common in the public sector than the private sector. health managers are selected based on their clinical skills rather than their leadership or management skills. objective. to compare self-rated competencies in management and leadership before and after training of the participants; to assess participants’ experience of the training programme; and to evaluate the management and leadership skills of the participants after training. methods. a cross-sectional, descriptive analytical method and 360° interviewing were used in this study. participants were evaluated ~18 months after completion of the training programme. a 360° evaluation (360° e) of six of the 12 leadership/management competencies was done with the supervisors, colleagues, and subordinates of the participants. results. all participants rated themselves as improved in 12 managerial and leadership competencies. the 360° e affirmed five of these competencies as improved, with the ability to create and implement a marketing plan rating poorly. conclusion. training in management leads to improvement in both leadership and managerial skills of health professionals. afr j health professions educ 2017;9(3):133-137. doi:10.7196/ajhpe.2017.v9i3.696 perceptions of the impact of an advanced training programme on the management skills of health professionals in gauteng, south africa j mutyabule,1,2 rn, mph; f senkubuge,2 mb chb, mmed; d cameron,3 mb chb, mpraxmed, mphil; v pillay,4 mba, pgche; p petrucka,5 rn, phd 1 school of nursing and midwifery, aga khan university, kampala, uganda 2 school of health systems and public health, faculty of health sciences, university of pretoria, south africa 3 department of family medicine, faculty of health sciences, university of pretoria; and foundation for professional development, pretoria, south africa 4 foundation for professional development, pretoria, south africa 5 college of nursing, university of saskatchewan, canada; and academics without borders (east africa), canada corresponding author: p petrucka (pammla.petrucka@usask.ca) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:pammla.petrucka@usask.ca research 134 september 2017, vol. 9, no. 3 ajhpe methods study design and sample size this was a cross-sectional, descriptive analytical study of those who completed the 2009 cahm. data were collected using self-administered electronic questionnaires comprised of both multiple-choice and open-ended questions; the responses where deductively analysed. the questionnaire was developed by the researcher (jm) and piloted among her colleagues at fpd who had completed the cahm. a 360° evaluation (360° e) was conducted with supervisors, colleagues and subordinates as assessors. it is now popular for assessing employee performance in the private and public sectors, as it involves seeking opinions from a spectrum of stakeholders well positioned to reflect on the employee’s job performance and effectiveness. the 360° e gathers perceptions, from those directly affected, about an employee’s behaviour and the impact of his/her behaviour on job effectiveness. the advantages of the 360° e include minimising performance-appraisal errors, and providing a broad-scoped assessment and improved assessment reliability. the questionnaire was sent electronically to all cahm-qualified doctors and nurses (n=17) and participants’ assessors (n=51). although the cahm participant intake was 44, only 17 were health professionals. sixty-eight participants were surveyed, with 40 responses (59% response rate), of whom 10 (25%) were cahm trainees and 30 (75%) assessors. data collection and measurement the questionnaire assessed 12 self-rated competencies across 11 domains of leadership and management (table 1). the 11 domains reflect emotional intelligence, and interpersonal, technical and conceptual/analytical abilities of the participants. data collection included demographic information, number of staff supervised, annual operating budget for which they are responsible, and if the participants received management training before cahm. data relevant to the cahm course were also collected, such as the participants’ personal highlights, relevance to their work, recommendation to other managers in the health sector, influence on achieving organisational strategic objectives, impact of training on their work, and any changes with regard to salary, job promotion, and/or increase in responsibilities. data analysis data were entered into epi info (centers for disease control and prevention, usa) and then exported to stata 11 (statacorp., usa) for analysis. frequencies calculated for categorical variables reflected association of the training course with change in management practices. fisher’s χ2 tests to compare preand post-training competencies addressed the small sample size. statistical significance was set as p<0.05. open-ended questions were transcribed and thematically analysed. results quantitative results sample demographics a range of demographic/supervisory characteristics are reflected in table 2. of note, public-private participation was equal. most participants were female (80%) and nurses (60%), half were in managerial positions for <2 years, and 70% reported no prior management training. reflecting on managerial roles (table 3), the training was highly influential in areas of relevance to job roles (100%), actions impacting on strategic achievements (80%), and job augmentation (60%). competency self-assessment by cahm graduates in preand post-training self-ratings of the 12 competencies (fig. 1a and b), cahm participants indicated considerable improvement in leadership and managerial skills after training. areas of significant growth between pre-periods (t1) and post-periods (t2) were writing and evaluating strategic plans (t1 – 0%; t2 – 90%), assessing organisational design choices (t1 – 0%; t2 – 90%), and obtaining funding for the organisation (t1 – 0%; t2 – 90%). competencies, such as creating and implementing monitoring and evaluation plans, or creating budgets and performing budget variance analysis, were rated by participants as areas of significant growth. all competencies showed improvement after the course in self-rating (fig. 1a and b). the smallest shift from preto post-training occurred in managing time effectively and leading individuals and teams. stakeholder 360° evaluations the 360° e by the supervisors, colleagues, and subordinates assessed 6 of 12 core competencies (fig. 2). agreement by two or more assessors on a particular skill is interpreted as competence in that skill; conversely, if only one assessor rates a participant as competent then the health manager is assumed to be incompetent in that skill. the 360° e affirmed that 80% of cahm graduates were seen as competent to write and evaluate strategic plans; manage time effectively; lead individuals and teams; and develop and implement monitoring and evaluation plans after training. additionally, 30 40 40 50 10 50 10 30 10 70 10 60 10 30 30 50 20 70 10 90 90 30 100 20 90 70 80 0 20 40 60 80 100 120 t1 t2 t1 t2 t1 t2 t1 t2 t1 t2 t1 t2 write and evaluate strategic plans assess organisational design choices create gantt charts create a marketing plan perform �nancial statement analysis create budgets and perform budget variance analysis pa rt ic ip an ts , % not sure needs help can do management skills 60 40 20 10 10 40 10 40 10 90 20 70 10 20 40 20 90 20 90 10 80 10 90 80 100 50 70 0 20 40 60 80 100 120 t1 t2 t1 t2 t1 t2 t1 t2 t1 t2 t1 t2 obtain funding for the organisation perform qualityimprovement analysis analyse the organisation's operations strategy develop m and e indicators lead individuals and teams manage time e�ectively pa rt ic ip an ts , % not s ure needs help can do management skills a b fig. 1. (a and b) self-rated competencies in select management and leadership skills before and after training. (t = time; cahm = certificate in advanced health management; m = monitoring; e = evaluation.) research september 2017, vol. 9, no. 3 ajhpe 135 70% of respondents felt that the participants were competent in financial management. a negative difference occurred between the 360o e and selfrated levels of creating and implementing a marketing plan competency. statistical significance it is possible that the small number of participants in the study affected the lack of statistical significance in comparing competencies at t1 and t2 (table 4). qualitative results both cahm participants and stakeholders provided feedback on their perceptions and experiences with the course. for the graduates, these comments aligned mainly with the impact on their work and use of action research as a tool. stakeholder comments aligned with the impact of training on participants and potential recommendations of cahm for future health managers. impact on cahm participants’ work reflection by cahm participants on how the course affected their work was captured under three themes: successful programme implementation; job promotion; and work relationships. five participants indicated that the skills learned through cahm had practical implications for their ability to act and successfully implement a programme. the course enabled application of management skills in their work environments and projects such as skills-enabling proposal writing, improving approvals, and project implementation. one participant stated: table 1. domains for self-assessment domains understanding of a healthcare environment managing yourself leadership strategic and operational management project management managing information resource mobilisation and donor relations financial management human resource management strategic marketing and customer relations action research table 2. demographic information for cahm participants (n=10) characteristic n (%) organisation type private 5 (50) public 5 (50) gender   male 2 (20) female 8 (80) highest qualification   diploma 1 (10) bachelor’s degree 5 (50) master’s degree 4 (40) profession   nursing 6 (60) medicine 4 (40) prior management training   yes 3 (30) no 7 (70) management role (years)   <1 1 (10) 1 2 4 (40) >2 5 1 (10) >5 4 (40) budget oversight (zar) >1 000 000 5 (50) 500 000 1 000 000 1 (10) 100 000 500 000 4 (40) cahm = certificate in advanced health management. table 3. participants’ perspectives on cahm outcomes (n=10) perspectives n (%) recommend yes 10 (100) no 0 (0) relevance to work   relevant 3 (30) very relevant 7 (70) achievement of strategic targets   yes 8 (80) no 2 (20) impact on current position   better job offer/promotion 1 (10) promotion and increase in responsibilities 1 (10) increase in responsibilities 4 (40) no change in job profile 4 (40) cahm = certificate in advanced health management. table 4. fisher’s χ2 comparative test for management competencies (preand post-training) competency p-value write and evaluate strategic plans 1.00 assess organisational design choices 0.40 create gantt charts 0.40 create a marketing plan 1.00 perform financial statement analysis 0.40 create budgets and perform budget variance analysis 0.60 obtain funding for the organisation 1.00 perform quality improvement analysis 1.00 analyse organisation’s operative strategy 0.80 develop monitoring and evaluation indicators for projects 1.00 lead teams and individuals 0.40 manage your time effectively 0.11 research 136 september 2017, vol. 9, no. 3 ajhpe ‘ i was able to submit my mentorship project to my organisation’s top management in a more structured and comprehensive way and it was approved. the mentorship is actually happening … .’ within the theme of job promotion, skills learned were very relevant and practical for health managers, making them more dynamic and effective change agents. therefore, a competently skilled health manager is beneficial, as described by one graduate: ‘i used the analytical methods of the cahm to do strategic planning for the organisation and this resulted in a change for the organisation. and therefore i was given a new position.’ four respondents’ contributions informed the third theme, ‘better workplace relationships’, highlighting participants’ capacities to manage diverse people and situations. one participant observed: ‘dealing with and managing people is not an easy task … i now possess people skills … .’ through cahm, participants first understand themselves and how their presence has an impact, both negative and positive, on colleagues and subordinates, thereafter increasing awareness of relationships. use of action research and problem-solving action research is a practical tool that a manager can apply to identify and also solve a problem and prevent it from re-occurring. not only does this approach improve the use and creation of evidence, but it also promotes dissemination of evidence within the workplace and beyond. three themes were derived from the participant contributions related to the uptake and utilisation of action research: self-improvement; programme improvement; and work environment improvement. within the first theme (self-improvement), participants referred to the potential of using action research as part of one’s career development, including dissemination of ‘action research results to both national and international conferences’. with regard to the second theme (programme improvement), participants indicated that this ‘tool’ was invaluable to their organisations’ development. one participant stated: ‘through action research we have come up with better ways to control stock. a stock audit was performed at all sites and more than zar500 000 was saved through this exercise.’ as for the final theme (improving the workplace environment), action research can have an immediate effect and increase personnel involvement, as indicated in the following comment: ‘action research was used to improve the absenteeism rates in my workplace.’ impact of training on cahm participants through 360o e, one recurring theme regarding the effect of the cahm programme on participants was ‘improved management and leadership skills’. the course increased participants’ scope of management skills and extension of responsibilities, catalysing their visibility as leaders in their organisations and healthcare networks. supervisors indicated that these individuals were now able to influence programmes within and beyond their own workplace by ‘effectively leading a team of peer educators … [and] successfully networking with partners’. colleagues indicated that cahm graduates have garnered increased respect owing to improved quality of work (e.g. being very professional and very thorough) and increased levels of confidence in their work. this was evidenced as follows: ‘the cahm sharpened and enhanced the participant’s managerial skills in general … added more substance to the content of his knowledge on the principles of leadership and management.’ subordinates indicated that cahm graduates improved the work environment, impacting on the quality and levels of team participation. subordinates also found evidence of application of technical skills after the cahm course in areas such as development of practical organisational strategic plans. a respondent described this as follows: ‘the strategic plan she has developed and uses was much needed by the company and the community. she has involved the entire team in the project and everyone is given a chance to contribute their thoughts.’ assessors’ perspectives on recommending cahm in stakeholder recommendations on cahm for future candidates, two key themes emerged: positive impact due to training; and need for training in management. supervisors and colleagues recommended cahm, as it contributed to significant growth in skills and capacities of the graduates. one of the supervisors stated: ‘the impact and change the course has brought to those exposed to it is of great value.’ regarding the second theme (need for training for managers), both colleagues and subordinates commented on the positive impact of the training on the wider workforce. according to one respondent: ‘the cahm unfolds your potential. all managers need it.’ discussion the key result from participants’ self-rated competencies and the 360o e is that participation in cahm led to improvement in graduates’ leadership and managerial skills. self-rated competencies indicate that, after training, ≥70% of participants were competent in each of the 12 management skills. similarly, the 360o e confirmed competency in five of the six explored management skills, with an evaluated competency level of ≥70%. fig. 2. assessment (360°) on select competencies in leadership and management (post training). (cahm = certificate in advanced health management; m = monitoring; e = evaluation.) 10 60 30 10 0 20 90 40 70 90 100 80 0 20 40 60 80 100 120 ability to write and use strategic plans ability to create and implement a marketing plan possession of �nancial management skills ability to develop m and e indicators and an m and e plan ability to lead individuals and teams ability to manage time e�ectively management skills incompetent competent c a h m p ar ti ci p an ts , % research september 2017, vol. 9, no. 3 ajhpe 137 self-rated competency on finances was low, possibly attributed to gender differences in self-ratings. female self-rated competencies were lower than those of males in several areas. furthermore, organisations do not focus sufficiently on health managers having skills to manage business complexities of client care, such as budget management.[9] the 360o e compared perceptions of stakeholders to provide the assessed individual with a clearer picture of strengths and weaknesses, and to clarify expectations. it increases reliability of individual self-ratings. the 360o e monitors progress, with identification of training priorities and coaching interventions.[13] in this assessment, participants scored poorly in the creation of a marketing plan and its implementation. study limitations in terms of study limitations, 44 individuals participated in the cahm; however, only 17 were health professionals and met our inclusion/exclusion criteria. the small number of participants had an impact on statistical significance and limited generalisability of results. furthermore, this study involved primary collection of data through self-administered questionnaires; therefore, the data were subject to recall information bias. conclusion and recommendations graduates and key stakeholders perceived training in an advanced management course, such as cahm, as beneficial to health professionals in gauteng. our data indicate improvement in areas of leadership, financial management, monitoring and evaluation, strategic planning, and time management. competency to develop a marketing plan was positively self-rated by health managers, but was not viewed as a realised competency by the 360o e. all trained health managers indicated that the course was relevant or very relevant to their work and highly recommended it for other health managers. this was mirrored by stakeholder comments, which also recognised the positive impact of the cahm on health managers and recommended it to other managers in the health sector. further research is needed with a larger sample to address statistical significance and generalisability. this study only considered six of 12 management skills in the 360o e and should be expanded to all 12 in a future study iteration. the 360° assessment tool was considered a strength in this study; hence, future use and implications of this approach should be further explored. finally, the potential to compare impacts and implications with management/leadership across sectors is possible given the mix of participants in the cahm programme. acknowledgements. we thank the following contributors to the study: profs s manda, a mcintyre, t mampe and b english. we also thank the foundation for professional development (fpd) for their permission to conduct the study at their institution. author contributions. jm: involved in all aspects of this project from inception through publication; fs, dc, vp: supervised tool development and the research process; and pp: involved in the analysis and dissemination phase. all authors contributed to the final publication and editing. funding. none. conflicts of interest. the researcher (jm) was employed by the fpd at the time of the study. the fdp supports this journal. 1. strack van schijndel rj, burchardi h. bench-to-bedside review: leadership and conflict management in the intensive care unit. crit care 2007;11(6):234. https://doi.org/10.1186/cc6108 2. green tp. management skills of intensivists influence outcomes in pediatric intensive care units. pediatr crit care med 2007;8(6):587. https://doi.org/10.1097/01.pcc.0000288707.41243.f1 3. harrison t, gray aj. leadership, complexity and the mental health professional. a report on some approaches to leadership training. j ment health 2003;12(2):153-159. https://doi.org/10.1080/0963823031000103461  4. ersson a, chew m. evidence-based approach to intensive care unit management: need for improvement. crit care 2008;12(1):404. https://doi.org/10.1186/cc6763  5. nielsen k, yarker j, brenner so, randall r, borg v. the importance of transformational leadership style for the well-being of employees working with older people. j adv nurs 2008;63(5):465-475. https://doi.org/10.1111/ j.1365-2648.2008.04701.x 6. mclarty j, mccartney d. the nurse manager: the neglected middle. healthcare finan manage 2009;63(8):74-78. 7. reed s. ward management: education for senior staff nurses. paediatr nurs 2008;20(3):27-31. https://doi.org/10.7748/ paed2008.04.20.3.27.c6518 8. dwyer aj. medical managers in contemporary healthcare organisations: a consideration of the literature. aust health rev 2010;34(4):514-522. https://doi.org/10.1071/ah09736 9. dierckx de casterle b, willemse a, verschueren m, milisen k. impact of clinical leadership development on the clinical leader, nursing team and care-giving process: a case study. j nurs manage 2008;16(6):753-763. https:// doi.org/10.1111/j.1365-2834.2008.00930.x 10. pillay r. managerial competencies of hospital managers in south africa: a survey of managers in the public and private sectors. hum res health 2008;6(4). https://doi.org/10.1186/1478-4491-6-4 11. national department of health. strategic plan 2010/11 2012/13. pretoria: ndoh, 2014. 12. foundation for professional development. certificate in advanced health management. study guide. pretoria: fpd, 2009. 13. kim ps. utilising 360-degree feedback in the public sector: a case study of the korean central government. asian j pol sci 2001;9(2):95-105. https://doi.org/10.1080/02185370108434193 accepted 11 july 2016. http://dx.doi.org/10.1186/cc6108 http://dx.doi.org/10.1097/01.pcc.0000288707.41243.f1 http://dx.doi.org/10.1080/0963823031000103461† http://dx.doi.org/10.1186/cc6763† http://dx.doi.org/10.1111/j.1365-2648.2008.04701.x http://dx.doi.org/10.1111/j.1365-2648.2008.04701.x http://dx.doi.org/10.7748/paed2008.04.20.3.27.c6518 http://dx.doi.org/10.7748/paed2008.04.20.3.27.c6518 http://dx.doi.org/10.1071/ah09736 http://dx.doi.org/10.1111/j.1365-2834.2008.00930.x http://dx.doi.org/10.1111/j.1365-2834.2008.00930.x https://doi.org/10.1186/1478-4491-6-4 http://dx.doi.org/10.1080/02185370108434193 research december 2017, vol. 9, no. 4 ajhpe 185 globally, interprofessional education is lauded for its potential to improve the quality of healthcare and healthcare outcomes by teamwork between professionals from various health-related disciplines.[1] furthermore, healthcare professionals need to meet the demands of the community and the country, which are caused by the burden of complicated disease.[2] in south africa (sa), the department of health is re-engineering primary healthcare, advocating a strategy of multidisciplinary teamwork in the community.[3] healthcare professionals from different disciplines or professions work together to achieve a common goal within a multidisciplinary team, sharing some common roles, e.g. professionalism, leadership and advocacy.[4] interprofessional education may address the lack of multidisciplinary teamwork in healthcare settings. traditionally, undergraduate education has focused on a professional specialty, with limited exposure to teamwork between healthcare professionals. interprofessional education therefore aims to prepare learners to collaborate across specialties to provide high-quality healthcare.[5] the school of health care sciences at the university of pretoria, sa has traditionally followed a uniprofessional educational approach. the emerging need for interprofessional healthcare education was identified as a gap in the undergraduate education programme. as part of mandatory curriculum revision, the departments of human nutrition, nursing science, occupational therapy, physiotherapy and radiography identified the opportunity to incorporate interprofessional education as part of their programmes. the school of health care sciences identified two areas with potential for interprofessional education, i.e. research and integrated healthcare leadership. the objective of this article is to describe the approach and process followed in developing integrated healthcare leadership modules for interprofessional education that benefit the community and to achieve the educational outcomes of the five undergraduate healthcare programmes. methods and results we used the knowledge-to-action cycle (fig. 1) to guide and focus important tasks associated with designing and implementing the interprofessional module.[6] the knowledge-to-action framework incorporated information from individuals or teams from diverse contexts. this framework permitted focusing on local context and practice when adapting and implementing the interprofessional module; it fragmented the process from inception to implementation into manageable components and provided a structure and rationale for the activities involved in each phase of development.[ 6] we report on phase 1 of the knowledge-to-action model, which encompasses the planning phase (fig. 1). we describe the process of identification background. interprofessional education aims to prepare learners to collaborate across specialties to provide high-quality healthcare. internationally and nationally, the emerging need for integrated healthcare and education has been emphasised. the current education programme at the school of health care sciences, university of pretoria, south africa primarily follows a uniprofessional approach. objectives. to describe the development of interprofessional modules over 4 years between the departments of human nutrition, nursing science, occupational therapy, physiotherapy and radiography. methods. the knowledge-to-action model guided the module development process. the planning phase comprised three steps: (i) problem identification (e.g. national and international policy focus on interprofessional education); (ii) review of existing knowledge (e.g. common learning outcomes); and (iii) adaptation of knowledge to the local context (e.g. syllabi and logistics). results. the development of interprofessional modules can be guided by the above-mentioned model to meet the needs of the faculty, departments, students and community and to contribute to interprofessional education, while overcoming the associated challenges. conclusion. challenges included clashes in timetable schedules, financial constraints, administrative support, logistical issues and resistance to change. the designing and implementing of new modules were intense and time consuming, and required commitment. the development of the modules was an excellent example of interprofessional teamwork that needs to be transferred to the implementation and role modelling of interprofessional education. afr j health professions educ 2017;9(4):185-188. doi:10.7196/ajhpe.2017.v9i4.853 designing interprofessional modules for undergraduate healthcare learners c maree,1 phd; p bresser,2 mrad; m yazbek,1 dcur; l engelbrecht,3 moccther; k mostert,4 phd; c viviers,5 mdiet; m kekana,2 mtech (ed) 1 department of nursing science, school of health care sciences, faculty of health sciences, university of pretoria, south africa 2 department of radiography, school of health care sciences, faculty of health sciences, university of pretoria, south africa 3 department of occupational therapy, school of health care sciences, faculty of health sciences, university of pretoria, south africa 4 department of physiotherapy, school of health care sciences, faculty of health sciences, university of pretoria, south africa 5 department of human nutrition, school of health care sciences, faculty of health sciences, university of pretoria, south africa corresponding author: c maree (carin.maree@up.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 186 december 2017, vol. 9, no. 4 ajhpe of problems, review of existing knowledge and adaptation of the knowledge to the local context. the results of each phase are integrated in the description of each respective phase. knowledge enquiry: identify need the need for interprofessional education was identified at the strategic planning session of the school of health care sciences. we identified the opportunity to revise undergraduate curricula to meet important healthcare needs. the teaching and learning committee was mandated to establish a task team(s) with representation from all five departments aimed at determining the potential of such modules and the way forward. two task teams were established, focusing on research and integrated healthcare leadership. (the process followed for the research module will be reported in a separate article.) synthesis: review knowledge the task team for integrated healthcare leadership used the knowledgeto-action model to guide the process. the initial team consisted of six members, with an additional member added soon after initiation (table 1). the curricula and professional board regulations of the five professions were included in the knowledge review. content was systematically unpacked to identify common exit-level outcomes and graduate attributes. the common exit-level outcomes were consolidated in table format to facilitate comparison of different professions. potential learning outcomes for interprofessional modules were synthesised and captured. product tools: adapt knowledge to local context the proposed interprofessional modules were presented to the school of health care sciences’ executive management and academic staff; discussions focused on content, and financial and logistical implications. a proposal outlining the implementation and incorporation of the interprofessional modules was drafted for submission to the academic advisory committee and faculty board of the faculty of health sciences. on approval of the submission, two sub-committees were established (table 1) that were tasked with collating and designing learning material and learner guides for the respective interprofessional modules. these modules are incorporated in the first 3 years of undergraduate training of healthcare professionals, with complementary profession-specific modules in alternate semesters (table 2) and the final year of undergraduate training. the interprofessional healthcare leadership modules were first introduced in 2015 at 1st-year undergraduate level – to be offered over consecutive years. discussion interprofessional education is aimed at creating an environment where future healthcare professionals can learn to collaborate, improving knowledge, skills and attitudes that will increase the wellbeing of patients and clients.[5] it can either commence early in professional training or after the unique aspects of professional training have been completed.[5] often students complete their studies independently and shared learning only takes place during clinical exposure. where education occurs in isolation, healthcare students may develop preconceived ideas and biases towards other professions before entering a multidisciplinary clinical environment.[7] it was therefore decided that the integrated healthcare leadership module be introduced from the 1st year to the 3rd year of study (tables 1 and 2). interprofessional education promotes competent and responsible collaborative teamwork. members need to understand ethics, roles and responsibilities of team members and communication.[8] interprofessional education in the school of health care sciences started with collaboration among the academic staff members from the five different professions, and this may build confidence in a personal and professional capacity. the task team experienced increased collaboration and collegiality, which is in line with the report from pirrie et al.[9] that group work may lead to improved task achievement as a team and develop critical reflective practice. the impact will be monitored and reported on in due course. as these modules were new in our school, we had to consider educational design before implementing a shared education programme. we included a needs assessment; clear measurable learning objectives; outcomesbased curriculum design; interactive teaching methods; and an evaluation typology. the task team had to consider individual context, environment and university systems. it also had to incorporate the requirements of professional bodies that uphold standards and unique cultures of the respective professions, while simultaneously promoting interprofessional health team concepts.[9] during programme development we had to ensure that the interprofessional team was able to deal with resistance to implementation of the programme.[10] our group included a front-line healthcare team, health professional educators, administrators, managers and policymakers. interprofessional education is challenging and a prepared team of educators is scarce.[2] our strategic mission had to be all embracing and relied on educators committed to identifying learning opportunities. we faced logistical problems, including clashes in timetable schedules, financial constraints, and lack of administrative support and role models. we also experienced an inability to recognise the value of interprofessional education, resistance to change and an inflexible curriculum.[7,8] we took the theory of constructive alignment into consideration to ensure that there is alignment between the outcomes, assessments and learning activities, as described by biggs and tang.[11] authentic learning, as set out by leppisaari et al.,[12] was also kept in mind, especially the emphasis on the need for a supportive collaborative construction of knowledge. in developing the interprofessional modules, the emphasis on integrated teams was ensured through group projects that are undertaken by students from different professional groups. • need for undergraduate ipe • evaluate common elos and graduate attributes • consolidation to de�ne learning outcomes • synthesis into interprofessional module kn ow le dg e en qu ir y sy nt h es is • evaluate logistic implications • proposal for academic planning • incorporation into revised curricula product tools identify problem review knowledge adapt knowledge to local context phase 1 – planning 1. assess barriers and supports 2. select, tailor and implement interventions 1. identify problem 2. review knowledge 3. adapt knowledge to local content 1. monitor knowledge use 2. evaluate outcomes 3. sustain knowledge use knowledge enquiry synthesis product tools ta ilo rin g kn ow le dg e phase 2 – preand post implementation ph a se 1 – pla n n in g ph a se 3 – e va lu at io n fig. 1. knowledge-to-action cycle. (ipe = interprofessional education; elo = exitlevel outcome.) research december 2017, vol. 9, no. 4 ajhpe 187 table 1. process of development of interprofessional modules steps key activities reality of process knowledge enquiry: identify problem need for undergraduate ipe identified at strategic planning session of the sohcs the need to incorporate interprofessional modules (also referred to as ‘shared modules’) in undergraduate healthcare education and training was identified at a strategic planning session of the sohcs. the teaching and learning committee had to explore the potential of implementing interprofessional modules. two streams were identified for possible interprofessional teaching and learning through discussion and debate of potential themes, and task teams were identified as follows: (i) the task team for development of an integrated healthcare leadership module(s) consisted of members from all departments: department of human nutrition – 1 representative department of nursing science – 1 (chairperson) + 1 representative department of occupational therapy – 1 representative department of physiotherapy – 1 representative department of radiography – 2 representatives (ii) a separate task team was identified for development of an interprofessional module(s) in research, which is not reported on in this article. choice of representatives for the task teams was informed by members’ various roles within departments and expertise in specific subject areas or their roles in the curriculum review process of their department. synthesis: review knowledge evaluate common elos and graduate attributes the task team met on scheduled dates. first meeting: the ground rules and approach to be taken in developing the modules were determined. decisions included that the shared modules should be presented as core modules in all academic years; there should be team teaching; and the focus should be on community-based healthcare. second meeting: members from the respective departments each compiled a list of elos and graduate attributes that might be of generic nature for each profession. the elos and graduate attributes were retrieved from the profession’s regulatory bodies. data were collated and presented in table format to make comparison between professions easier. consolidate to define learning outcomes for ipe third and fourth meetings: the elos were discussed until consensus on the potential generic outcomes was reached and the profession-specific outcomes were eliminated. a decision was made to have profession-specific and interprofessional modules in alternate semesters for each year (table 2). fifth and sixth meetings: possible study themes were informed by the generic profession outcomes, and attributes were identified for scaffolding over the different academic years. product tools: adapt knowledge to local context evaluate logistical implications seventh meeting: a layout of the modules over the consecutive academic years was presented to the executive committee and staff members of the sohcs. logistical implications were discussed, including human resources, timetable and venue implications, and administrative aspects. two sub-committees were established, with representation from all departments, to develop the details of the learning material for the 1st-year module for 2015 (10 lecturers) and 2nd-year module for 2016 (10 lecturers). the third sub-committee was established in 2016 to develop details of the learning material for the 3rd year to be rolled out in 2017 (6 lecturers). the initial task team members formed part of the sub-committees. proposal for academic planning eighth meeting: refinement was made to proposed modules as suggested and decisions were made regarding the writing of the proposed regulation changes. two task team members wrote the proposed regulation changes and distributed the document to the other task team members and the executive committee. the proposed regulation changes then followed the process according to internal policy: head of student administration, academic planning department, academic advisory committee, and faculty board and senate. incorporation into revised curricula once the regulation changes had been approved, the respective departments incorporated the new modules as a core subject in their curricula. the first introduction of the modules took place in 2015 in the departments of human nutrition, occupational therapy and physiotherapy. the departments of nursing science and radiography will introduce them with the roll-out of their new curricula. monthly: 2-monthly meetings followed to discuss challenges, achievements and logistics. an additional outcome was that the department of speech and language pathology joined the process in 2016, with their first group of students enrolling for the modules in 2017. ipe = interprofessional education; sohcs = school of health care sciences; elo = exit-level outcome. research 188 december 2017, vol. 9, no. 4 ajhpe conclusion effective interprofessional healthcare may alleviate service duplication, mini mise interventions and reduce healthcare costs. educators need to work together to create opportunities for shared learning to improve interprofessional teamwork. designing and implementing new modules is intense and time consuming and requires commitment. although various models of interprofessional education in the community have been reported, this article focuses on the application of a structured framework to describe the process followed in the development of interprofessional healthcare modules at undergraduate level. the process was an excellent example of interprofessional teamwork, which needs to be transferred to implementation and role modelling with regard to the designing of interprofessional education opportunities for the healthcare professions. acknowledgements. the authors wish to extend their appreciation to the following individuals for their contribution to the development of the modules: prof. m mulaudzi, drs v bhana-pema, z white, s mataboge, r ngunyulu, s phiri, mmes g lovric, m sethole, ms h van wyk, and mrs m cochrane-booyens. the authors also acknowledge dr c tosh for editing this manuscript. author contributions. all authors contributed to the conceptualisation and writing of the publication. pb did the technical editing. funding. all costs were absorbed by the operational budgets of the departments. conflicts of interest. none. 1. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 2. world health organization. framework for action on interprofessional education and collaborative practice. geneva: who, 2010. 3. pillay y, barron p. the implementation of primary healthcare re-engineering in south africa. 2011. http://www. phasa.org.za/the-implementation-of-phc-re-engineering-in-south-africa/ (accessed 10 october 2017). 4. rawson d. models of interprofessional work: likely theories and possibilities. in: leathard a, ed. going interprofessional. working together for health and welfare. london: routledge, 1994. 5. reeves s, perrier l, goldman j, freeth d, zwarenstein m. interprofessional education: effects on professional practice and healthcare outcomes (update). cochrane database syst rev 2013;(3):cd002213. https://doi. org/10.1002/14651858.cd002213.pub3 6. graham id, tetroe jm. the knowledge to action framework. in: rycroft-malone j, bucknall t, eds. models and frameworks for implementing evidence-based practice: linking evidence to action. west-sussex: wileyblackwell, 2010:207-221. 7. dufrene c. health care partnerships: a literature review of interdisciplinary education. j nurs educ 2012;51(4):212-216. https://doi.org/10.3928/01484834-20120224-01 8. murphy sa. interdisciplinary education in the addictions: a commentary on the current status. j addict nurs 2013;24(1):4-7. https://doi.org/10.1097/jan.0b013e31828767b7 9. pirrie a, wilson v, harden rm, elsegood j. promoting cohesive practice in health care. amee guide no. 12: effective multiprofessional education – a three dimensional perspective. multiprof educ 2000:14-22. 10. waggie f, laattoe n. interprofessional education and practice: two community-based models. in: tolken as, ed. service learning across the globe: from local to transnational. proceedings of the 5th international symposium of service-learning, 20 22 november 2013, stellenbosch, south africa. https://www.sun.ac.za/english/ci/ service-learning/issl (accessed 10 october 2017). 11. biggs j, tang c. teaching for quality learning at university. what the student does. 3rd ed. london: society for research into higher education and open university press, 2007. 12. leppisaari i, herrington j, vainio l, im y. authentic e-learning in a multicultural context: virtual benchmarking cases from five countries. j interact learn res 2013;24(1):53-73. accepted 4 april 2017. table 2. locating the interprofessional modules within curricula year semester 1 semester 2 1st, nqf level 5 uniprofessional module: introduction to respective professions* interprofessional health leadership i: teamwork and communication in the community health setting (8 credits) 2nd, nqf level 6 interprofessional health leadership ii: principles of community health project development and health literacy (8 credits) uniprofessional module: complementary content determined by each discipline* 3rd, nqf level 7 interprofessional health leadership iii: community-based project (8 credits) uniprofessional module: complementary content determined by each discipline* interprofessional healthcare research iii: proposal development (30 credits) 4th, nqf level 8 uniprofessional module: content determined by each discipline* uniprofessional module: content determined by each discipline* interprofessional healthcare research iv: research project (10 credits) nqf = national qualifications framework. *credits differ for respective disciplines. http://www.phasa.org.za/the-implementation-of-phc-re-engineering-in-south-africa/ http://www.phasa.org.za/the-implementation-of-phc-re-engineering-in-south-africa/ https://doi.org/10.1002/14651858.cd002213.pub3 https://doi.org/10.1002/14651858.cd002213.pub3 https://doi.org/10.3928/01484834-20120224-01 https://doi.org/10.1097/jan.0b013e31828767b7 https://www.sun.ac.za/english/ci/service-learning/issl https://www.sun.ac.za/english/ci/service-learning/issl june 2018, vol. 10, no. 2 ajhpe 101 research internet-based applications are changing the manner in which we communicate and circulate professional and personal information.[1] improved connectivity and access to the internet have enabled people to instantaneously share ideas and interact with others on a global scale.[2,3] ventola[4] highlighted the potential use of social media to foster understanding of the occupational therapy (ot) profession and to promote various health behaviours or fund-raising opportunities.[4] for the purpose of this study, social media are defined as ‘digital technologies and practices that enable people to use, create and share content, opinions, insights, experiences and perspectives, build relationships and promote discussion’.[5] this includes the use of discussion groups using messaging software, such as whatsapp. the world federation of occupational therapy (wfot) position paper[6] on social media use highlights the role that social media can play in continuing professional development and enhancing networking within ot. the paper cites gathering information, improving practice and networking for knowledge development as examples of acceptable professional practice use of social media.[6] there is a growing trend of incorporating social media for professional purposes into health professions education. snyman and visser,[7] in a south african (sa) study comprising 344 dentists, established that social media are being used as a marketing tool. pearson et al.[8] used an online survey to explore the use of social media among emergency medicine residents and faculty members at various sites.[8] potential threats cited included ‘breaches of professionalism’, which included online disclosure of private information.[7] variability in the usage trends of social media and concerns about students maintaining clients’ privacy were also cited.[7] despite this article referring to older, qualified professionals, the data highlight potential issues that may arise among students. given the millennium students’ familiarity with social media and technology, there is concern that some of the threats mentioned (breach of professionalism, confidentiality) may be more evident. in contrast, some of the benefits of social media use included more effective communication and interaction among peers,[8] which could have potential positive implications for teaching and student support. many universities, including the university of kwazulu-natal (ukzn), durban, sa, are moving toward blended learning, which implies the need to explore how students use social media for educational purposes. the absence of literature relating to how ot students use social media during their undergraduate education, highlighted the need for greater insight into how social media can potentially be used to improve learning. many policies and guidelines on how to use social media appropriately are still being developed,[5,9] as these have to be adapted to include recent advances in technology.[9,10] pempek et al.[10] suggest that healthcare students and clinicians have difficulty in maintaining a professional persona in the more relaxed setting of social media. despite the presence of definitions or descriptions for the use of social media in the literature,[6,,9,11] there is limited evidence on ot students’ views regarding ethical practice during social media use. this article aims to describe the nature of social media usage by undergraduate ot students at ukzn, emphasising the benefits of social media for professional purposes and students’ knowledge of ethical considerations when using various social media sites for professional practice. background. the use of social media for professional practice is an emerging trend for healthcare professionals; however, limited literature exists on the phenomenon. social media usage is prevalent among students, as it is incorporated into many health professions education curricula. this poses potential ethical dilemmas. objective. to examine the nature of social media usage and knowledge of ethical considerations by occupational therapy (ot) students for professional purposes. methods. a quantitative, cross-sectional survey was administered to the entire cohort of ot students (n=128) enrolled at the university of kwazulunatal, durban, south africa in 2016. data were analysed descriptively using microsoft excel 2013 (microsoft, usa). results. the most commonly used device to access social media was mobile phones, with whatsapp and youtube frequently used for both general and professional purposes. uses included accessing social media for developing professional skills and knowledge, and in fulfilling academic requirements. ethical dilemmas were evident among students, who indicated that social media ethical considerations should be incorporated into the curriculum. conclusion. the study highlighted that most students use some form of social media as part of their professional practice, which has the potential to be used effectively to enhance learning opportunities. future studies of a qualitative nature could shed light on students’ perceptions of social media and practical implications for practice. afr j health professions educ 2018;10(2):101-105. doi:10.7196/ajhpe.2018.v10i2.980 occupational therapy students’ use of social media for professional practice d naidoo, phd; p govender, phd; m stead, bot; u mohangi, bot; f zulu, bot; m mbele, 4th-year ot student discipline of occupational therapy, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: d naidoo (naidoodes@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 102 june 2018, vol. 10, no. 2 ajhpe research methods a cross-sectional survey design was employed.[12] the target population comprised all undergraduate ot students (n=128), through four levels of study, registered in 2016 in the school of health sciences at ukzn. a survey was designed through exploration of the current literature and consultation with a biostatistician. the questionnaire comprised four sections, i.e. (i) demo graphics (including age, gender, level of study, level of information and communication technology (ict), knowledge and devices on which social media are accessed); (ii) social media use (type of media and frequency of use); (iii) general and professional use of social media; and (iv) ethical considerations regarding the use of social media. the questions were fixed to ensure consistency and reliability. the questionnaire was appraised by a biostatistician, supervisors of the study and a data scientist and matched against the research questions for the study to ensure face and content validity. a pilot study was completed with 34 students (mean age 19.6 years) currently enrolled in the discipline of physiotherapy at ukzn. a number of questions were revised after the pilot study to reduce ambiguity. data were collected over 2 months. students were invited to participate during an allocated period. the authors were not present in the session and an academic development officer facilitated administration and collection of the questionnaires. this prevented the influence of possible power differentials. descriptive statistics were employed to analyse the data with the use of microsoft excel 2013 (microsoft, usa). ethical approval ethical clearance was obtained from the human and social sciences ethics committee (ref. no. hss/1117/016u), including gatekeeper permission from the relevant academic leaders. written informed consent was obtained from students prior to initiating the study. principles of autonomy and anonymity and the right to withdraw were observed.[13] the study only explored the use of social media among ot students at ukzn. furthermore, the survey design did not allow researchers to explore reasons for the use of social media sites. results the response rate was 83%, with 106 of the 128 questionnaires distributed returned. the sample comprised 90% females (n=95) and 10% males (n=11), with a mean age of 22.5 (range 17 30) years. the study included 1st-year (n=31; 29%), 2nd-year (n=34; 32%), 3rd-year (n=17;16%) and 4th-year (n=24; 23%) ot students. more than half of the students (n=62; 59%) had a school level of training in ict, while 34% (n=36) had no such previous training and 4% (n=4) had advanced-level training. the same social media account was used for both general and professional purposes by 77% (n=82) of the students. mobile phones (n=102; 96%), laptops (n=91; 86%) and desktop computers (n=57; 53.8%) were the most commonly used devices to access social media. tablets were used by 50% (n=53) of the students. social media for professional use social media were reported to be an important aspect of students’ professional lives. eightythree percent of 4th-year, 42% of 3rd-year, 75% of 2nd-year and 74% of 1st-year students agreed that social media are an important aspect of professional life. fig. 1 highlights the various sites used across the four levels of study. whatsapp, youtube, pinterest, facebook and blogs were used by the majority of students for professional purposes. there were similar whatsapp and youtube usage trends across the years for professional use (fig. 1). there was a greater use of blogs for professional use by 3rd-year (71%) and 4th-year (74%) students than by 1st-year (13%) and 2nd-year (22%) students. there was an increase in professional use of pinterest from the 1st (6%) to the 4th (77%) years. thirty-nine percent of 1st-year, 39% of 2nd-year, 47% of 3rd-year and 1st 2nd 3rd 4th 6 64 8 39 39 47 10 13 29 26 31 18 74 13 22 71 90 87 90 88 90 84 84 88 77 6 53 76 52 10 47 12 6 6 3 3 32 19 6 21 100 90 80 70 60 50 40 30 20 10 0 st u d en ts u si n g s it e, % facebook twitter instagram blogs whatsapp youtube pinterest tumbler reddit myspace snapchat discussion groups other social media sites fig. 1. social media use for professional purposes (n=106). june 2018, vol. 10, no. 2 ajhpe 103 research 64% of 4th-year students used facebook professionally. despite none of the 1st years using tumbler professionally, 52% of the 4th years used this site professionally. interestingly, 1st years (32%) used discussion groups professionally, which was more so than students in any other year. a small percentage of students (6%) used other social media for professional use, which included flickr, vine, blackberry messenger and linkedin (fig. 1). frequency of social media use for professional purposes youtube and pinterest had the highest frequency of daily use. blogs, whatsapp and facebook were accessed for professional use at least once a day. students in all 4 years used whatsapp most frequently in their daily professional use, with 4th-year students having the highest frequency of use (table 1). professional purpose of social media use fig. 2 highlights the main purposes of social media for professional use by students in this study. these included for academic purposes (78%), developing skills and knowledge (59%), improving clinical practice (53%) and discussion with other professionals (37%). general v. professional social media use when comparing various social media sites, it appears that students use these more often for general than professional purposes, with facebook, instagram and snapchat showing the greatest difference between general and professional use (fig. 3). snapchat was used by 38% of students generally, whereas only 2% of students used it professionally. discussion groups were used by 21% of students generally and by 21% professionally. blogs were used by 44% of students generally and by 39% professionally. whatsapp was used by 94% of students generally and by 86% professionally (fig. 3). ethical considerations in social media use interestingly, 96% of students agreed that it is important to consider ethics online when using social media professionally, with 90% agreeing that poor behaviour online can have an impact on the reputation of the profession. however, only 14% of students believed that ethical behaviour online is good. fig. 4 illustrates students’ awareness of ethics in this study. despite 48% of students being fully aware of ethics and 42% agreeing that they have been taught about ethics in their studies, 66% believed that ethics on social media needs to be covered in lectures, especially 3rd years (77%) and 4th table 1. frequency of social media use for professional purposes (n=106) student, year frequency facebook, % blogs, % whatsapp, % youtube, % pinterest, % 1st rarely 16 6 0 10 0 monthly 10 3 6 13 3 weekly 10 3 23 19 0 daily 3 0 58 42 3 2nd rarely 13 13 3 3 3 monthly 10 3 3 16 19 weekly 6 3 30 25 22 daily 10 3 53 41 9 3rd rarely 18 12 0 0 0 monthly 0 53 12 35 41 weekly 18 6 12 29 24 daily 12 0 65 24 12 4th rarely 9 9 0 10 9 monthly 14 30 0 43 27 weekly 32 35 5 24 32 daily 9 0 85 14 9 none developing skills and knowledge promoting skills and abilities disscussion with other professionals providing others with advice improving clinical practice university requirements raise awareness about profession 5 34 78 53 28 37 22 59 pr o fe ss io n al u se s o f s o ci al m ed ia 0 20 40 60 80 100 students, % fig. 2. professional purpose of social media use by students (n=106). 21 21 100 90 80 70 60 50 40 30 20 10 0 83 44 36 8 75 26 44 39 94 86 96 84 69 48 32 23 7 4 4 2 38 2 1 0 11 0 st u d en ts , % fa ce bo ok tw itt er in sta gr am blo gs w ha tsa pp yo ut ub e pin te re st tu m bl er re dd it m ys pa ce sn ap ch at fli ck r vin e di sc us sio n gr ou ps general use professional use fig. 3. general v. professional uses of social media sites (n=106). 104 june 2018, vol. 10, no. 2 ajhpe research years (76%). distinctively, 4th-year students (17%) reported feeling the least aware of ethics (fig. 4). discussion the sa internet user population reached 20 million in 2016.[14] gikas and grant[15] found that 67% of 10  000 students used their mobile phones for the majority of their academic activities. similarly, goldstuck’s[16] sa study found that students felt that social media enhance their academic and social lives. ot students at ukzn use social media for both general and professional purposes. as noted in the literature,[17-20] whatsapp, facebook and instagram were the most commonly used social media sites in this study. whatsapp, youtube, facebook and pinterest were all commonly used by the students for professional purposes. whatsapp appears to be popular owing to the speed of communication, which includes the ability to share text messages, pictures and voice notes rapidly.[16] mohapatra et al.[21] identified that the use of software applications, such as whatsapp, has the potential to enhance communication in healthcare and medical education. there is evidence that students use social media for educational purposes, which corresponds with that in the current literature.[2,7,9,10] lui et al.’s[22] systematic review highlighted that blended learning (face-toface and e-learning) has a positive effect on learning in higher education.[22] the participants noted that fulfilling university requirements, developing skills and knowledge and improving clinical practice were the main reasons for professional social media use. gikas and grant[15] described social media as an open environment where ideas can grow online. youtube and facebook have both been found to be useful sites for content sharing within academic institutions.[23] for example, facebook has been used to start health science special interest/discussion groups, while youtube enhances learning by providing additional content from an outsider’s perspective.[23] in our study, there was a decline in the frequency of youtube use as students progressed to their final year. the highest frequency of usage occurred in 1st and 2nd years. this finding could be owing to 1stand 2nd-year students still seeking foundational knowledge. additionally, youtube videos have been used to enhance clarification of difficult concepts, especially in subjects such as anatomy and physiology. jaffar et al.[24] found that 98% of students used youtube as an online information resource to enhance their understanding of human anatomy. pinterest, a digital pinboard, has gained rapid popularity. wfot acknowledged pinterest in their position statement on social media usage.[6] despite pinterest mainly being used as a social tool, business and education have shown much interest in it.[21] the social and visual aspects of pinterest make it extremely appealing to educators, as it has the potential to provide learning opportunities for students.[25] the current study noted an increase in the frequency of pinterest use, as students progressed from 1st to final year. this could be attributed to the increase in students’ exposure to service-learning settings; hence the need to generate creative ideas when planning intervention sessions. blogs have been used for teaching and learning purposes and to share lessons with colleagues.[2,26] in this study, the higher usage of blogs by 3rdand 4th-year students could be accredited to these students needing to complete a blog as part of their service-learning modules. the reflective practice inherent in writing blogs serves to deepen students’ experiences during professional practice. discussion groups appeared to be more common among 1st-year students than students in any other year. this could be because younger generations are interested in gaining knowledge from online sources. despite the benefits gained through the use social media, there is a risk of unethical practice. some risks include the blurring of professional and social boundaries, breaching patients’ privacy and confidentiality (especially with taking or sharing pictures or information) and damaging the public image of the profession.[27,28] students reported that even though ethics is covered in lectures, ethics specifically focusing on social media use requires further input. despite wfot recently introducing a position statement on the principles of good practice when engaging in social media for professional practice,[6] ethics in social media has been largely neglected. even the health professions council of sa has not included online ethics in their ethical guidelines.[29] wfot guidelines include the setting of a clear boundary when individuals speak for themselves and when they speak for the profession, understanding that the image presented online represents both the individual and the profession and therefore treating others on a public platform with consideration.[6] although this position paper provides individuals in the ot profession with good social media principles, there is lack of detail as what exactly good ethical conduct online constitutes, especially around what can be shared on social media. the current cohort of ot students have been accustomed to social media use in their personal capacity (59% used social media in school) and may not be cognisant of what constitutes a breach of confidentiality or privacy with regard to patients. ethical considerations are fundamental concepts that students must learn, as they need to be accountable for their online posts and can be legally bound to uphold standards of professional practice.[28,30] at ukzn, final-year ot students use social media to convey information to patients and their caregivers about home programmes and reflect on their practice in blogs. however, they reported feeling less aware of ethics than the 1stand 2nd-year students, which may be attributed to 4th-year students experiencing ethical dilemmas in real-life situations during service-learning placements and feeling inadequately equipped to translate the theory they learnt during their 1st year into practice. students need to have a wellestablished understanding of the ethical practice around social media use to prevent breaches of confidentiality or blurring of professional and personal boundaries. chretien and kind[31] described the inability to maintain a professional persona in the more relaxed setting of social media. st u d en ts , % 48 42 66 64 80 37 15 34 13 18 24 21 18 14 6 100 90 80 70 60 50 40 30 20 10 0 fu lly aw ar e of et hi cs ta ug ht ab ou t et hi cs in st ud ie s le ct ur es sh ou ld co ve r s oc ial m ed ia et hi cs co nt en t c an be ed ite d pu bl ic in fo rm at io n ca n be u se d by an yo ne disagree neutral agree fig. 4. students’ awareness of ethics (n=106). june 2018, vol. 10, no. 2 ajhpe 105 research in ventola’s[4] study, 68% of both practising and student physicians felt it was ethically problematic to interact with patients on social networks for either personal or professional reasons. however, 56% of patients wanted their physicians to use social media for activities such as scheduling appointments and answering general questions about their conditions.[5] this highlights the challenge of negotiating between meeting patients’ needs and following ethical guidelines. there is a need for the establishment of clear ethical guidelines from professional bodies to protect both the healthcare practitioner and patient and for health professions programmes to ensure that 2nd 4th-year students have sufficient opportunities for lectures and discussions on social media ethics. conclusion this quantitative, cross-sectional study was conducted to determine the nature of social media usage and ethical awareness among a cohort of ot students. sites such as whatsapp, youtube and facebook appeared to be more popular in this particular context. the study has highlighted the important role that social media play in many students’ professional lives, with a variety of sites being used for fulfilling university requirements and improving clinical practice. another vital area highlighted was the challenges of ethical practice and social media use. students appeared to have some awareness of ethical considerations. however, many students lacked awareness of policies, guidelines and legislation that relate to their online usage, thereby placing them at risk of overstepping boundaries and incurring legal implications. the authors therefore believe that social media need to be covered in ethics lectures and measures have to be put in place to ensure that policies, procedures and guidelines are adhered to. we therefore suggest that this study be used as a starting point for further studies into the extent of the benefits of social media for professional practice. acknowledgements. the authors would like to acknowledge the participants in the study. author contributions. dn and pg were responsible for the conceptualisation and supervision of the study, as well as for the drafting and revision of the manuscript. ms, um, fz and mm were involved in the execution of the study and the analysis and drafting of the manuscript. funding. none. conflicts of interest. none. 1. dieleman c, duncan eas. investigating the purpose of an online discussion group for health professionals: a case example from forensic occupational therapy. bmc health serv res 2013;13(1):253. https://doi.org/10.1186/14726963-13-253 2. ezzamel s. blogging in occupational therapy; knowledge sharing, professional development, and ethical dilemmas. br j occup ther 2013;76(11):515-517. https://doi.org/10.4276/030802213x13833255804711 3. sau k. netiquette: a modern day essential for occupational therapists. ind j occup ther 2013;45(3):26. 4. ventola cl. social media and health-care professionals: benefits, risks and best practices. pharm ther 2014;39(7):491-520. 5. college of occupational therapists of ontario. practice guideline: using social media. http://www.coto.org/pdf/ guidelines_useofsocialmedia.pdf (accessed 2 august 2017). 6. world federation of occupational therapy. position paper: use of social media. 2016. http://www.wfot.org/ resourcecentre.aspx (accessed 2 may 2017). 7. snyman l, visser jh. the adoption of social media and social media marketing by dentists in south africa. s afr dent j 2014;69(6):258-264. 8. pearson d, bond mc, kegg j, et al. evaluation of social media use by emergency medicine residents and faculty. west j emerg med 2015;16(5):715. https://doi.org/10.5811/westjem.2015.7.26128 9. landman mp, shelton j, kauffmann rm, dattilo jb. guidelines for maintaining a professional compass in the era of social networking. j surg educ 2010;67(6):381-386. https://doi.org/10.1016/j.jsurg.2010.07.006 10. pempek ta, yermolayeva ya, calvert sl. college students’ social networking experiences on facebook. j appl develop psychol 2009;30(3):227-238. https://doi.org/10.1016/j.appdev.2008.12.010 11. wu wh, wu yc, chen cy, kao hy, lin ch, huang sh. review of trends from mobile learning studies: a metaanalysis. comput educ 2012;59(2):817-827. 12. lavrakas pj. encyclopedia of survey research methods. thousand oaks, ca: sage, 2008. 13. world medical association. declaration of helsinki. ethical principles for medical research involving human subjects. 2008. http://www.wma.net/e/policy/b3.htm (accessed 23 march 2018). 14. goldstuck a. sa internet penetration to reach 40% in 2017. https://www.worldwideworx.com (accessed 23 march 2018). 15. gikas j, grant mm. mobile computing devices in higher education: student perspectives on learning with cell-phones, smartphones and social media. internet high educ 2013;1(19):18-26. https://doi.org/10.1016/j.iheduc.2013.06.002 16. goldstuck a. sa high-tech student. 2013. https://www.worldwideworx.com/hightech-student (accessed 6 septem ber 2017). 17. snyman a. social media – the latest south african stats. 2016. https://www.webafrica.co.za/blog/social-media-2/ social-media-latest-south-african-stats/ (23 september 2016). 18. sponcil m, gitimu p. use of social media by college students: relationship to communication and self-concept. j technol res 2013;1(4):1. 19. verdonck mc, ryan s. mainstream technology as an occupational therapy tool: technophobe or technogeek? br j occup ther 2008;71(6):253-256. 20. gilbert s. learning in a twitter-based community of practice: an exploration of knowledge exchange as a motivation for participation in #hcsmca. inform commun soc 2016;19(9):1214-1232. https://doi.org/10.1080/ 1369118x.2016.1186715 21. mohapatra dp, mohapatra mm, chittoria rk, friji mt, kumar sd. the scope of mobile devices in health care and medical education. int j adv med health res 2015;2(1):3. 22. lui q, peng w, zhang f, hu r, li y, yan w. the effectiveness of blended learning in health professions: systematic review and meta-analysis. j med internet res 2016;18(1):e2. https://doi.org/10.2196/jmir.4807 23. george dr, dellasega c. use of social media in graduate-level medical humanities education: two pilot studies from penn state college of medicine. med teach 2011;33(8):e429-e434. https://doi.org/10.3109/01421 59x.2011.586749 24. jaffar aa. youtube: an emerging tool in anatomy education. anat sci educ 2012;5(3):158-164. https://doi. org/10.1002/ase.1268 25. hansen k, nowlan g, winter c. pinterest as a tool: applications in academic libraries and higher education. can j libr inform pract res 2012;7(2). https://doi.org/10.21083/partnership.v7i2.2011 26. cain j, scott dr, tiemeier am, akers p, metzger ah. social media use by pharmacy faculty: student friending, e-professionalism, and professional use. curr pharm teach learn 2013;5:2-8. 27. nyangeni t, du rand s, van rooyen d. perceptions of nursing students regrading responsible use of social media in eastern cape. curatonis 2015;38(2). https://doi.org/10.4102/curationis.v38i2.1496 28. grobler c, dhai a. social media in healthcare context: ethical challenges and recommendations. s afr j bioethics law 2016;9(1):22-25. https://doi.org/10.7196/sajbl.2016.v9i1.464  29. health professions council of south africa. guidelines for good practice in the healthcare professions: general ethical guidelines for the healthcare professions. http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/ conduct_ethics/booklet%201.pdf (accessed 8 march 2016). 30. helm j. ethical and legal issues related to blogging and social media. j acad nutr diet 2013;113(5):688-690. 31. chretien kc, kind t. social media and clinical care. circulation 2013;127(13):1413-1421. https://doi.org/10.1161/ circulationaha.112.128017 accepted 12 october 2017. https://doi.org/10.1186/1472-6963-13-253 https://doi.org/10.1186/1472-6963-13-253 http://www.coto.org/pdf/guidelines_useofsocialmedia.pdf http://www.coto.org/pdf/guidelines_useofsocialmedia.pdf http://www.wfot.org/resourcecentre.aspx http://www.wfot.org/resourcecentre.aspx https://doi.org/10.5811/westjem.2015.7.26128 https://doi.org/10.1016/j.iheduc.2013.06.002 https://www.worldwideworx.com/hightech-student https://www.webafrica.co.za/blog/social-media-2/social-media-latest-south-african-stats/ https://www.webafrica.co.za/blog/social-media-2/social-media-latest-south-african-stats/ https://doi.org/10.1080/1369118x.2016.1186715 https://doi.org/10.1080/1369118x.2016.1186715 https://doi.org/10.3109/0142159x.2011.586749 https://doi.org/10.3109/0142159x.2011.586749 https://doi.org/10.1002/ase.1268 https://doi.org/10.1002/ase.1268 http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/conduct_ethics/booklet%201.pdf http://www.hpcsa.co.za/uploads/editor/userfiles/downloads/conduct_ethics/booklet%201.pdf https://doi.org/10.1161/circulationaha.112.128017 https://doi.org/10.1161/circulationaha.112.128017 september 2018, vol. 10, no. 3 ajhpe 171 research undergraduate medical curricula have undergone important transformations over the last two decades. medical education curricula have emphasised – among other changes – a shift away from approaching patients in paternalistic ways, to rendering a more patient-centred approach and, therefore, including more structured communication skills training.[1] patient-centred medical care is important for various reasons: it can assist in the building of caring relationships among healthcare providers and patients, improve health outcomes and reduce costs,[2] while also improving patients’ levels of quality of life.[3] furthermore, there is evidence that a patient-centred approach can increase doctor and patient satisfaction and reduce anxiety in patients.[4,5] while it would seem that most people agree that including the teaching and learning of patient-centredness into the undergraduate medical curricula is vital, the implementation thereof is complicated by the term patient-centredness being neither clearly defined nor easy to measure.[6] one of the seminal definitions of patient-centredness in medicine is that of stewart,[5] who, in 2003, viewed patient-centredness as an approach that embraces two aspects, i.e. a perspective change from a disease focus to a holistic view that includes the patient’s feelings and experience and a shift away from the medical practitioner controlling the relationship, communication and decision-making to one that involves the patient. in krupat et al.’s[7] definition of patient-centredness, they acknowledge these same two aspects. they label them as a ‘caring’ and a ‘sharing’ construct. according to these authors, caring, differentiates between a patient-centred style and a disease-centred style and relates to the degree to which medical practitioners understand the perspectives of their patients and explore patients’ feelings and expectations. the second construct, sharing, relates to the notion that power should be shared between the medical practitioner and the patient. this is not often the case in traditional doctor-patient interactions, where the medical practitioner controls the consultation with only limited involvement by the patient with regard to decision-making.[7] developing educational approaches and interventions that enhance or sustain the constructs of patient-centredness has shown to be a serious challenge in modern medicine and medical training.[8] international research over the last decade has shown that medical students tend to become more cynical and less patient-centred and empathetic towards patients during their training.[9-12] this trend has also been confirmed by local researchers.[13-15] the reasons for this decrease in patient-centredness seem to relate to universal factors, such as time, pressure and fatigue,[16] the negative influences of the unintended curriculum,[17] poor role models,[18] as well as assessment practices that value biomedical aspects over the so-called ‘softer skills’ related to patient-centredness.[19,15] background. patient-centredness has been identified by most medical schools worldwide as a desired core graduate competence. patient-centredness positions the patient at the centre of the consultation and, therefore, focuses on the patient instead of on the disease. the concept of patient-centredness is, however, multifaceted. the choice and development of approaches and interventions that can enhance or sustain the various dimensions of patientcentredness are challenges for undergraduate medical curriculum developers. objectives. to determine what the extent and nature of published scientific literature on implemented interventions are and how these could assist in fostering the various constructs of patient-centredness in undergraduate medical curricula. furthermore, to determine which of these interventions could potentially be applied and incorporated in the context of the undergraduate medical curriculum at the faculty of medicine and health sciences, stellenbosch university, cape town, south africa. methods. the study followed the 6-step scoping review methodology framework. four electronic databases were searched. two independent reviewers screened citations for inclusion and performed the data abstraction. results. articles (n=581) were eligible for inclusion in this study. information captured in the excel spreadsheets resulted in 9 categories of teaching interventions, which could lead to the various constructs of patient-centredness. these included didactic sessions and workshops, simulated patients, reflection, small-group discussions, e-learning, peer role-play/drama/surrogate, narratives/storytelling/art, clinical experiences and mindfulness training. conclusions. it is important to acknowledge that the development of patient-centredness in medical students is more than just a set of communication skills. curricula need to provide learning opportunities for students to enhance knowledge, skills and attitudes related to patient-centredness to develop it as a strong competence. furthermore, students need to be placed in clinical learning environments that foster a patient-centred approach, providing various opportunities where they can reflect on their learning, be more mindful of the needs of their patients and build caring relationships with them. afr j health professions educ 2018;10(3):171-175. doi:10.7196/ajhpe.2018.v10i3.1040 interventions aimed towards the development of patient-centredness in undergraduate medical curricula: a scoping review e archer, bsocsc (nursing), bcur hons (icu), mphil (higher education), phd (health professions education); i meyer, bsc (physiotherapy), mphil (health professions education) centre for health professions education, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: e archer (elizea@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 172 september 2018, vol. 10, no. 3 ajhpe research medical programmes have attempted to address the challenges of developing patient-centredness in medical graduates by either designing new curricula or supplementing existing ones with additional courses and experiences. many of these initiatives seem to centre on the teaching and learning of communication skills.[10,20,21] while communication skills are acknowledged as one of the key enablers for patient-centredness, one should be careful not to reduce this complex construct to a set of communication skills only.[22] the curriculum, in its broadest terms, needs to be considered when teaching interventions are planned, as single interventions in the formal curriculum can easily be undermined by social processes and messages that underplay the learning and practice of patient-centred care.[23] students are often taught one approach to patients in medical school, while they observe other, less patient-centred approaches in practice, where the hidden curriculum is prevalent.[1] the teaching and learning of patient-centredness seem to encompass various factors, such as attitudinal factors, acquired skills and knowledge, subjective norms, student self-efficacy, assessment of learning and the environment or context within which patient-centredness is taught.[15] many authors have written about teaching and learning interventions that could be used to cultivate patient-centredness in medical graduates. this scoping review was undertaken to summarise this body of literature. the intention was to provide us, as curriculum developers, with a solid knowledge base to support our decisions regarding which strategies and interventions would be most appropriate to incorporate into our resourceconstrained, undergraduate medical curriculum. methods the way medical students acquire patient-centredness during their training remains a challenge for curriculum developers. therefore, the purpose of this review was to determine how the constructs of patient-centredness could be taught and learnt within the undergraduate medical curricula. the methods used for this review were based on the 6-step scoping review methodology framework, proposed by arksey and o’mally,[24] and the methodology enhancement, described by levac et al.[25] the 6-step process includes: (i) identifying a research question as a roadmap; (ii) identifying relevant studies; (iii) selecting studies; (iv) charting the data; (v) collating, summarising and reporting the results; and (vi) consulting with key stakeholders. this scoping review sought to answer the following two questions: • what is the extent and nature of the published scientific literature on implemented interventions that can assist with the fostering of the various constructs of patient-centredness in undergraduate medical curricula? • which of these interventions could potentially be applied and incorporated in the context of the undergraduate medical curriculum at the faculty of medicine and health sciences, stellenbosch university? search strategy and eligibility criteria four databases (pubmed, sciencedirect, cinahl (medline and eric), proquest) were searched for studies on how the various constructs of patient-centredness are facilitated in undergraduate medical curricula. the eligibility criteria included articles in english, published between january 2000 and may 2017. the search strategy was determined with input from research collaborators and outlined three themes, i.e. patient-centredness, undergraduate medical students and teaching and learning interventions. to ensure that we did not exclude any potential articles, we had to consider aspects such as the spelling of patient-centredness, as well as the various constructs that underpin patient-centredness as identified as part of the definition clarification (box 1). by making use of the eligibility criteria, the two reviewers (im and ea), who worked independently of each other, screened the titles and abstracts of articles and generated themes. thereafter, all the articles that were representative of the inclusion criteria were independently read by the same two reviewers. articles were eligible for inclusion in this review if they described any of the predetermined constructs of patient-centredness that applied to undergraduate medical curricula (box 1). articles that explored interventions that provided communication skills training programmes for undergraduate medical students, with emphasis on patient-centredness, caring and empathy, were also included. furthermore, only articles with available abstracts were selected. duplicates were eliminated. charting pdf versions of all the articles were searched, collected and analysed. the relevant information was extracted in duplicate by each reviewer and displayed on an excel spreadsheet. the titles and authors, journals, interventions and key findings were recorded. the information was then compared and discussed by the two reviewers to ensure consistency and to reach consensus. results the search strategy resulted in a hit of 581 articles (fig. 1). after reading the articles’ titles and abstracts, 398 were excluded. of the remaining 183, 94 duplicates were eliminated. reviewing the full text of 89 articles, the reviewers excluded a further 38. thus, 49 articles met the inclusion criteria, 6 of which were systematic/literature reviews. during the final stage, 16 additional studies, obtained from the reference lists of these systematic/literature reviews, were added. analysis of the data the information captured in the excel spreadsheets was analysed using content analysis and categories were determined. nine categories (teaching interventions) that could possibly lead to the development of patientcentredness were identified. these were: reflection, small-group discussions, use of didactic interventions, simulated and standardised patient (sp) interventions, e-learning, clinical experiences and role-modelling, peer role-playing/drama/surrogate situations, narratives/storytelling/art, and mindfulness training. a diagrammatic display of the frequency in which these categories were referred to in the selected articles is given in fig. 2. in the 58 articles that were reviewed, we found evidence of various interventions that could lead to the development of patient-centredness or aspects thereof. fig. 1 portrays a condensed summary of the results of the box 1. search terms related to the teaching of patient-centredness in an undergraduate medical curriculum ‘patient-centred*’ or ‘patient-centered*’ or ‘patient centred*’ or ‘patient centered*’ or ‘compassion’ or ‘empathy’ or ‘communication skill*’ or ‘shared decision making’ or ‘self-awareness’ and ‘undergraduate medical student*’ or ‘medical student*’ or ‘undergraduate medical curriculum’ or ‘medical curriculum’ and ‘teaching method*’ or ‘intervention*’ or ‘teaching strategy’. september 2018, vol. 10, no. 3 ajhpe 173 research identified 9 categories. in the following section, the essence of the various interventions is discussed, beginning with the interventions that were used most frequently in undergraduate medical curricula. reflection the opportunity for students to reflect on their learning was found to be a valuable teaching strategy, as described by 33 authors. reflection was mostly used in conjunction with other teaching and learning interventions and authors described it as being effective to develop important aspects, such as compassion, empathy and social awareness, in undergraduate medical students.[26-32] such reflective opportunities can create a platform for the discussion of ethical matters in realistic situations and lead to students developing new skills, specifically decision-making practices.[33] students perceived the opportunity to reflect as a positive enabler to enhance their patient-centredness and to gain insight into addressing patients with empathy. loss of compassion, which often occurs because of early burnout during medical training, could be prevented.[34-36] small-group discussions small-group discussions were mentioned in 31 of the articles as a teaching intervention, as they provide opportunities for students to interact, share and verbalise their feelings. one article reported that students who were given the opportunity to take part in small-group discussions related to their frustrations and feelings of anger and resentment towards patients, developed group cohesion among themselves. students could discuss challenging or frustrating patient interactions, and how the use of empathy could have been applied to the situation.[37] small-group discussions could be directly beneficial to clinical practice, especially if group characteristics and different learning styles are considered.[38] didactic interventions didactic interventions and workshops remain efficient throughout the preclinical years.[39] many of the included studies highlighted the importance of didactic interventions to foster the construct of cognitive empathy (n=24).[29,40] these intervention opportunities introduced students to concepts, while engaging in discussions and opportunities to ask questions about components that needed clarification.[37] the theoretical knowledge helped students to understand the patient’s experience and perspective and to communicate this understanding to the patient. didactic interventions, which are often used as part of basic communication programmes, included lectures, powerpoint presentations, literature-based reading, hand-outs, workshops, problemand case-based seminars.[35,41,42] simulated and standardised patient interventions several articles (n=22) described the incorporation of sps as educational interventions, which provided students with realistic situations and a safe environment to practise empathetic responses. sps refer to both simulated patients, trained to simulate a patient’s illness, and actual patients, trained to present their own illness, both in a standardised way to role-play clinical and biopsychosocial scenarios for experiential learning.[41,42] sps provided opportunities for students to observe and discuss their own and others’ performances in the classroom. rehearsing with simulated actors articles initially searched (n=581) pubmed (n=42) cinahl (n=249) sciencedirect (n=20) proquest (n=270) articles (n=398) excluded at title and abstract review level articles (n=183) included for further review duplicates removed (n=94) full-text articles (n=89) assessed for eligibility articles (n=47) (including 6 systematic/literature reviews) excluded for failing to meet inclusion criteria after full reading full-text articles (n=42) met the inclusive criteria articles (n=16) included from 6 systematic/literature reviews final articles (n=58) included in review (42 articles and 16 articles from references) fig. 1. scoping review process and results. didactic e-learning peer role-play small-group discussion mindfulness standardised patients narrative/storytelling/art clinical experience/role-modelling re�ection 4 24 22 22 7 14 19 31 33 fig. 2. pie chart to illustrate the frequency of various interventions to teach patientcentredness. 174 september 2018, vol. 10, no. 3 ajhpe research playing the roles of challenging patients allowed students to become more confident in these types of scenarios, prior to clinical placements.[27] students could improve their communicative skills with patients and patients’ families.[43,44] sp interventions can increase medical students’ awareness of non-verbal communication skills.[46] some authors reported that, while sps are low-technology instruments, they are expensive tools for training communication skills.[44] use of e-learning several useful e-learning interventions were identified in the 22 articles reviewed. there are many opportunities to incorporate e-learning into a curriculum so that students can acquire the concepts of patientcentredness, e.g. reviewing and analysis of audioor video-recording of patient encounters, with doctors as role models to identify positive and negative interviewing factors,[29] as well as prerecorded videos and role-play to demonstrate counselling skills to medical students.[27,45] in one example, videos and role-play were used for an ageing game, simulating specific ageing characteristics,[46] which were explored as effective interventions to increase the levels of empathy and attitudes towards caring for the elderly. virtual patients (vps) is a recently developed technology that is employed to enhance empathy.[50] video-recording remains a valuable tool for communication skills training that is relatively simple, easily replicable, cost effective and powerful to use for self-reflection and awareness of one’s own biases and attitudes.[47] clinical experience and role-modelling in this review, 19 articles mentioned that clinical learning exercises present students with opportunities to learn about patient-centredness. real-life situations allow medical students to observe and reflect on communications between doctors and patients. during these encounters, biopsychosocial issues become clearer to students, while they could also develop empathy, compassion and social awareness.[26] clinical experiences enable students to draw on the role-modelling of doctors as supervisors and develop conceptualisations of good medical practice. role-modelling and exposure to patient experiences are perceived as crucial mechanisms for learning a patient-centred approach and, according to some authors, it is the most effective approach to teach empathy.[31] peer role-playing, drama and surrogate situations some studies (n=14) pointed out that peer-role scenarios create opportunities for experiential learning in which students can act as a patient, doctor or family member, thus allowing them the experience of both physician and patient perspectives. these interventions can be offered in a safe environment for students to practise.[37,46] participants can also receive direct feedback from their peers, which is an essential part of learning skills, as feedback can improve students’ self-confidence and enhance the understanding of the dimensions of diversity, as stated by chunharas et al.[52] peer role-play can be equally effective, is relatively easy to implement and is a low-cost tool, as it requires less resources compared with training with simulated patients.[46] narratives, storytelling and art interventions making use of creative writing, blogging, drama, poetry, fiction and film were described in 7 articles. these interventions fit into the affective domain of empathy and help students to understand patients’ experiences and appreciation for the value of patients in medical education.[53] a significant improvement was noticed in medical students’ empathy and attitudes towards patients after participating in a short course in reading and discussion of poetry and short stories.[54] mindfulness training consistent with the shift to patient-centred medical care, mindfulness training was regarded in 4 reviewed articles as a core component, as it offers a means of sustaining and enhancing compassion among medical professionals.[28,30,55,56] mindfulness training can lessen physician burnout,[30] prevent physicians’ diagnostic errors[57] and play an important role in increasing physician-patient relationships.[30] it appeared that medical students with low self-compassion could benefit from the inclusion of mindfulness training into undergraduate medical education. these mindfulness training interventions could encourage a more positive attitude towards difficult patients, as well as assist students to develop the resilience needed to improve their own mental health and well-being.[28,58] discussion this scoping review provides a summary of teaching interventions that have been used to enhance patient-centredness in undergraduate medical students. previous reviews have focused on interventions that cultivate empathy in medical students[32,44,59] and communication skills training,[37,42] which are both important components of patient-centredness. however, this study specifically focused on the teaching and learning of patientcentredness. recognising that patient-centredness is a multidimensional construct, the reviewers were encouraged to observe the variety of teaching interventions identified in the articles. the interventions comprised clinical experience and role-modelling, peer role-play, drama, surrogate situations, as well as narratives, storytelling and arts-based interventions. the theoretical components of patient-centredness can be taught through didactic interventions, such as workshops and small-group discussions, while effective communication skills can be taught through simulated and sp interventions, as well as e-learning and small-group discussions. reflection, which formed part of most teaching and learning interventions reviewed, is the process of debriefing and making meaning out of any learning experience. this process of reflection was supported by general literature on effective learning. mindfulness, which among other benefits, enables one to become more aware of one’s own mental processes, judgements and distractions, is currently being taught at several medical schools. mindfulness training is gaining momentum, as it has the potential to prevent compassion fatigue and burnout and increase levels of empathy.[60] conclusion the reported challenges that exist for medical programmes to assist graduates to maintain their patient-centredness and foster it as a strong competence, can only be achieved if carefully planned interventions are included in the curriculum. for these interventions to build on one another, they need to be spaced throughout the curriculum as longitudinal, crosscutting themes and not only as an once-off intervention. it is important for curriculum planners to acknowledge that for students to become patientseptember 2018, vol. 10, no. 3 ajhpe 175 research centred doctors they need more than only a set of communication skills. attention needs to be given, not only to teaching interventions that can address attitude changes, knowledge and skills development, but also to the student as a person and the environment where he/she is placed for clinical training. with regard to the results of this study, we are now in a process of consulting with the key stakeholders to start incorporating some of the findings in our current undergraduate medical curriculum. acknowledgements. we acknowledge the help of several colleagues who 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https://doi.org/10.1002/14651858.cd003267 https://doi.org/10.1016/s0140-6736(02)07959-x https://doi.org/10.1016/s0140-6736(02)07959-x https://doi.org/10.1016/s0738-3991(99)00090-7 https://doi.org/10.1097/acm.0b013e31819fa92d https://doi.org/10.1097/acm.0b013e31819fa92d https://doi.org/10.3109/01421591003657451 https://doi.org/10.3109/01421591003657451 https://doi.org/10.1111/j.1365-2923.2010.03627.x https://doi.org/10.1111/j.1365-2923.2010.03627.x https://doi.org/10.1097/acm.0b013e31819fba36 https://doi.org/10.1097/acm.0b013e31819fba36 https://doi.org/10.1186/1447-056x-10-4 https://doi.org/10.1111/j.1365-2929.2007.02704.x https://doi.org/10.1111/j.1365-2929.2007.02704.x https://doi.org/10.1186/1748-5908-5-69 https://doi.org/10.1001/jama.2009.1384 https://doi.org/10.1001/jama.2009.1384 https://doi.org/10.1080/01421590600568348 https://doi.org.ez.sun.ac.za/10.1080/10401334.2016.1146600 https://doi.org.ez.sun.ac.za/10.1080/10401334.2016.1146600 https://doi.org/10.1016/s0002-9610(02)00867-x https://doi.org/10.1016/s0002-9610(02)00867-x https://doi.org/ 10.1016/j.pec.2008.09.007 https://doi.org/ 10.1016/j.pec.2008.09.007 https://doi.org/10.1186/1472-6920-9-11 https://doi.org/10.1186/1472-6920-9-11 https://doi.org/10.1111/j.1365-2923.2011.04015.x https://doi.org/10.1097/sih.0000000000000142 https://doi.org/10.1097/sih.0000000000000142 https://doi.org/10.1186/1472-6920-10-7 https://doi.org/10.1186/1472-6920-10-7 https://doi.org/10.1007/s11606-015-3211-z https://doi.org/10.1007/s12671-016-0598-5 https://doi.org/10.1080/0142159x.2017.1309374 https://doi.org/10.1080/0142159x.2017.1309374 october 2016, vol. 8, no. 2, suppl 2 ajhp 225 research the world health organization[1] advocates the promotion of social accountability in professional education, with close collaboration with communities. this advocacy for social accountability is important and needs fostering during student training. in health professions education, social accountability means that students must have the ability to adjust to the needs of patients and communities. one of the vehicles identified to achieve this is the ability to address the needs of patients and communities in an interprofessional manner; this requires the training of health professional students in an interprofessional manner to gain skills in aspects such as collaborative practice. health science faculties implement various interventions to facilitate the development of interprofessional core competencies, which include the identification of roles and responsibilities, patient-centred care, professional ethics and interprofessional communication.[2] one key competency and domain of interprofessional education (ipe) and practice is collaborative practice. interventions used to promote collaborative education and practice include the integration of strategies into existing curricula[3] and the placement of interprofessional students at the same clinical sites.[4] the literature mentions a number of positive outcomes with regard to facilitation and/or implementation of ipe strategies. it has been suggested that interprofessional learning facilitates the ability to work together as qualified professionals, while positively affecting service delivery to communities.[5] the value of providing students with interprofessional clinical practice experience is also highlighted, as it enhances respect for other professionals and provides insight into the value of interprofessional care for effective healthcare delivery.[6] the concept of appreciating and valuing the role of other professions has also been expressed by doctors.[7] primary care settings have been identified as providing opportunities for learning in an interprofessional manner.[4] it is, therefore, clear that ipe and collaborative practice interventions could facilitate the development of competencies of students, which they could apply as graduates to enhance the health of the population. the application of interprofessional activities in community settings thus may assist in improving the patient experience by providing holistic care and assisting in improving the health of the community. the objective of this article is to present the findings of a study that explored the experiences of health science students who engaged collaboratively when addressing the needs of communities. methods research setting the faculty of community and health sciences at the university of the western cape (uwc), south africa, comprises nine entities, including departments and schools. undergraduate students from the faculty rotate through a number of community-based settings as part of their clinical practice modules. one such setting is a rehabilitation project based in background. interprofessional education (ipe) aims at facilitating the collaborative practice of healthcare professionals. however, students have varied experiences with ipe and the collaborative practice initiatives implemented by universities. objective. to explore the experiences and perceptions of health science students of an ipe collaborative practice (ipecp) intervention they had engaged in. methods. this qualitative study used two focus group discussions with a conveniently selected group of students who had been part of the intervention. two researchers who were not part of the intervention conducted the interviews. the audiotaped interviews were analysed using thematic analysis. ethical clearance for the study was received from the university of the western cape. results. three main themes emerged from the data: the usefulness of the framework introduced as part of the intervention; engaging in interprofessional groups; and the overall impact of the intervention. the students reported that they needed introduction to the framework earlier for it to be useful. it became apparent that students need to be prepared to work in interprofessional groups. the overall intervention was perceived positively, allowing students to become aware of other students’ roles. conclusion. the students experienced a lack of knowledge and therefore struggled with the applications of the international classification of functioning disability and health as a framework to facilitate ipecp. however, they experienced the ipecp intervention as providing structure to the clinical placements, making it a more positive experience. afr j health professions educ 2016;8(2 suppl 2):225-228. doi:10.7196/ajhpe.2016.v8i2.846 facilitating community-based interprofessional education and collaborative practice in a health sciences faculty: student perceptions and experiences a rhoda,1 phd; n laattoe,2 mphil; g smithdorf,3 bsc; n roman,4 phd; j frantz,5 phd 1 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa 2 interdisciplinary centre for sport science and development, faculty of community and health sciences, university of the western cape, cape town, south africa 3 sport, recreation and exercise science department, faculty of community and health sciences, university of the western cape, cape town, south africa 4 child and family studies unit, faculty of community and health sciences, university of the western cape, cape town, south africa 5 department of physiotherapy, faculty of community and health sciences, university of the western cape, cape town, south africa corresponding author: a rhoda (arhoda@uwc.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 226 october 2016, vol. 8, no. 2, suppl 2 ajhpe research mitchell’s plain, a semi-urban community. to facilitate community-based interprofessional practice, a 7-week programme was implemented. students placed at the project during the programme implementation met once a week for a 2-hour session. these sessions were co-ordinated by a facilitator, who was part of an interprofessional unit based within the faculty. the sessions introduced the students to concepts such as the international classification of functioning disability and health (icf), and were further used to facilitate the ipe core competencies. for the interprofessional practice interventions, students were divided into interprofessional groups, where each group had to engage with a specific community facility or group. research design a qualitative approach was chosen to explore the students’ experiences of the programme. population and sampling to obtain information about students’ experiences of the intervention, a convenience sample of students (interprofessional group) participated in two focus group discussions. a total of 12 participants, comprising physiotherapy, biokinetics and nursing students, formed the focus groups. data collection a researcher not involved in the implementation of the programme conducted the focus group discussions. an interview schedule was designed, with open-ended questions intended to elicit qualitative information. the questions related to students’ experience of the intervention. the focus group discussions were conducted at the end of the rotation and were audiotaped and transcribed verbatim. the data were then analysed thematically.[8] progressing through this process, the use of colour coding led to the checking of the emergent themes and patterns against the categorised data. the checking cross-validated the data sources and findings, and created links between the different parts of the data and the emergent dimensions of the analysis. to facilitate trustworthiness, one of the researchers (nr) confirmed the emergent themes and categories. ethical clearance was obtained from uwc (ethics number 13/3/9). results and discussion during the focus group discussions, the students were asked about their experiences as these related to the intervention. the objective of the intervention was twofold, including the use of the icf framework as well as the development of ipe core competencies, which included role clarification, ethical behaviour and professional communication. themes that arose on the use of the icf as a framework included knowledge about the framework, and its applications and usefulness. the theme that arose with regard to core competencies was students’ experiences of working in interprofessional teams, focusing primarily on role clarification. knowledge of the icf from the participants’ responses, it became evident that there was a difference in the knowledge base of the students with regard to the icf and its use in the clinical setting. some students had only been introduced to the icf on the community-based clinical rotation, while others had received theoretical input about it during lectures on campus: ‘so i feel it’s just something that you must incorporate from the very, very beginning … .’ ‘… we started three weeks ago here, that’s when i first heard about it for the first time … .’ ‘i heard about it [before] but i did not actually know it.’ one student in particular provided a very detailed description of the icf framework: ‘it’s basically like to identify the different needs of the patient … we had to identify what was our purpose, how we’re going to change, do the people need psychological, do they need motor skills where a physio can come in, are there biokinetics students that need to come in. it’s basically how to identify and classify their needs, what they need in different aspects of that, like with your environment, with them alone, abilities, disabilities, things like that.’ one student was also very positive about the icf framework: ‘also this icf thing, we got introduced to it a couple of weeks ago, it was quite interesting. i’d say it was more constructive in that there was an aim and a point and direction in the programme that we’re following … i’d say now than before, i’ve learnt more … so, i’d say it’s a good programme.’ the responses from the students highlighted that although some of them were introduced to the icf earlier in their programmes, they still had a problem applying the framework in the clinical setting: ‘it’s something you should maybe incorporate from the 1st year, because i spoke to some of the [students who had been introduced to the framework in theory lecture] … frankly and quite not even they could help … .’ some students did not experience their engagement with the framework as positive and a learning experience but as something forced upon them: ‘… because it’s not a module that we have taken through, it’s just thrown at you, “there, you must use it”.’ application of the icf in terms of how the icf was applied, students highlighted the usefulness of the framework and the length of time required to apply it. furthermore, the students were contradictory in the application of the icf. this contradiction was expressed by the way they felt about the icf and their experiences, as well as their attitudes towards its use: ‘i think the icf … has its perks and its disadvantages but i think you need a person that’s seen more over a longer period of time … .’ it was clear that students did not always find it useful and could not see the relevance of applying the framework, given the length of time they spent at the clinical rotation and the type of rotation. students indicated that for the icf to be effective in the clinical setting, they need access to patients for a longer period to see the impact: ‘i don’t see the point of doing it for a patient i’m seeing for 4 weeks once off. it becomes very boring and i think that’s where people lose interest in it. it’s a different story, however, if i’m seeing a patient over a course of 4 to 6 months.’ however, the application of the framework became clearer as the weeks progressed and students could apply it further to their clients: ‘so each week it became better, because you literally have to, like … see what it is this week what he [the facilitator] wants this week in the october 2016, vol. 8, no. 2, suppl 2 ajhp 227 research beginning it was … why do i have to do this … so i think that’s why?’ ‘i wanted to say that, the icf, like, it helps us also as among the things that we contribute to … home bases, yes, to the site …what we contributed, the things that we’ve done because they’ll ask us if we communicated with the group, about things like that … .’ the findings clearly indicate a need to introduce a framework to students before expecting its application during a clinical setting. the use of authentic learning activities may have addressed the challenges experienced with engagement of a framework for the first time during a clinical rotation. authentic learning could involve collaborative learning activities, where students engage with cases that mimic real-life cases and therefore prepare students for clinical placements.[9] the use of facilitators who could accompany students to the clients could also have assisted in promoting a better understanding and application of the framework.[3] students seemed only to find the tool useful if they could actually see a change in the domains or constructs identified by the icf. the students viewed the framework as an instrument that measured outcomes and not as one that conceptualises the functioning of individuals or groups of individuals. there was, therefore, a misinterpretation of the use of the framework, which led to students’ lack of understanding of its relevance. students often struggle to understand the relevance of aspects of a curriculum, and the use of case-based and problem-based learning approaches could assist with increasing the relevance of curricula.[10] experiences of working with students from other professions the study highlighted a number of experiences regarding how the students worked with others; these included understanding one’s own role and that of others, and group dynamics. role clarification during the focus group discussions, the students highlighted that they learnt a great deal about the roles of other professionals. however, some students did not have a solid understanding of their own roles. this highlights the concept of ‘t-shaped graduates’, i.e. graduates who are deeply knowledgeable about their own field of specialisation, yet are capable and willing to learn other skills and explore fields that may become part of their work/study for various reasons. previous exposure to other groups of students provided students with some idea of the other professions but not an in-depth knowledge. the students also distinguished between working with and simply being in a class together with other students (ipe): ‘when it came to a stroke patient i know the basics of what [occupational therapy] ot is about but i don’t know the depth.’ ‘not actually working with them, we were just in the class together.’ although students were unclear about the roles of the members of the team, they indicated that a combined effort by more than one team member improves patients care: ‘… if we’re all on the same page and we’re all working together on one patient we can actually get the patients to a higher level … .’ ‘… as to literally see the patient walk out, obtaining their health status and that’s what we are all there to do.’ with certain community-based groups, the students were, at times, confused about what their specific role was: ‘i just don’t know what to do with them … two times i took them to the park, they were just playing … .’ the students highlighted that this problem could be solved with the guidance of facilitators. role clarification and teamwork are two important competencies of ipe.[11] it emerged from the study that students either struggled with the role of their team members or only had a superficial understanding of their role. previous engagement with students from the same profession assisted them in gaining an idea of the role of others. collaborative practice, which is facilitated by ipe activities, is needed to address the health needs of individuals.[11] therefore, it is important for health professionals to understand the roles of their team members. although students lacked an understanding of these roles, the ipe collaborative practice (ipecp) intervention explored in this study provided students with the opportunity to think about the role of others, thereby creating an awareness that could be deepened through other educational activities in the various programmes.[1] in the context of roles and responsibilities, students were very clear about the role of the facilitators. students indicated that the facilitators should guide the process of interacting with other professions and focusing on the tasks. they should provide clarity on roles and responsibilities. if this is not provided, confusion prevails: ‘with our group in the beginning of the term, you had the skills and honestly, we had no idea why we were even there … there was no direction and i think, not to sound horrible, but i think it comes a lot in with the facilitator … besides them planning it, we can also plan it but we’re new to the situation, we come and we’re basically thrown into the deep end and we don’t know anything. i think the facilitators are actually supposed to be there to sort of put you in the right direction … .’ ‘i think the facilitators are supposed to be there to guide one in the right the direction.’ it is important that facilitators of ipe are skilled and knowledgeable. this is important so that skill and knowledge development, as related to competencies and other aspects of ipe, enable or facilitate collaborative practice. the facilitators must be able to facilitate students from various professional groups and believe in and be motivated towards the transformative teaching and learning initiatives that accompany ipe.[12] group dynamics in the context of socially responsive and politically relevant professional education, the need for the education sector to engage more seriously with ipe has been highlighted. the underlying assumption of ipe is that enhanced collaboration between professionals will lead to better use of scarce resources and a more effective response to complex health needs.[13] the students found that members of other groups of students were not always open to sharing and engaging in a group or in teams – an important ipe component. there was a sense that certain students could not confidently engage when in groups: ‘the second time, one guy [student] just stood there and watched … .’ ‘… but otherwise the other students sort of sat in the corner and said nothing … .’ the students indicated that some lacked confidence and did not contribute when working in interprofessional teams: 228 october 2016, vol. 8, no. 2, suppl 2 ajhpe research ‘… i think they know what they[’re] suppose to do … but they’re not confident to speak about it … .’ ‘… i think if you can almost simplify it, would be that they’re not confident enough to tell you what they’re doing.’ ‘it’s not a lack of knowledge, it’s more a lack of being able to express yourself or being afraid to … .’ in ipe, groups of students from different professions work together to address the health needs of individuals or communities.[1] the dynamics of working together in these interprofessional groups need to be considered and facilitated, as it cannot be assumed that students will boldly engage with those from other professions. the students in this study perceived other students as lacking confidence and, therefore, would not engage freely. this could affect the team approach, which is important in the context of ipecp.[11] students’ experiences with the ipe intervention the students struggled with the use of a framework to facilitate ipe in the setting, but they found the ipecp intervention useful in providing structure to the community placement. although students struggled with some aspects of working in an interprofessional team, they expressed that the experience was positive. the students highlighted that the ipecp session assisted with learning about one’s role and the role of others: ‘there’s a focus and there’s something we[’re] actually looking for … and what we[’re] doing and why we[’re] actually doing it … .’ ‘i learnt more in this short period of time than what i learnt in the 10 weeks that i was here before.’ ‘i think any [inter]disciplinary programme is great as you get to know your scope of practice and everybody else’s scope of practice and it has to be done in an educational setting i think … .’ because of their experiences, students were able to describe the ipe process or participation: ‘obviously you would first sort of meet up with the group of people that you’re working with and find out what exactly do they need to know … what you don’t know that, they could probably tell you more. but, so you actually meet up with these people first and find out, okay, what do you want to know and what do you need to know, and next week you can be prepared for it.’ overall, students indicated that communication is very important and central to ensuring the success of ipe: ‘i think it goes even for hospital, because like in the hospital, it’s a normal thing for a student doctor to just come, make the notes and then leave, you know. there’s never a communication, it’s not even there, you know, and someday i would like to see it change.’ ‘before we even come here, they should at least let us know, you’re not only going to be a nursing student, you’re going to be dealing with other professional students, you’re going to mix and you’re going to have, you know, to work together.’ although the students had negative perceptions about certain aspects of the ipe intervention, they had a positive experience overall, especially in relation to the structure that the ipe intervention provided to the clinical placement. the ipe intervention somehow enforced a level of communication between students from different professions that often did not occur during other clinical placements. students have indicated positive responses to ipe interventions, both locally[3] and internationally.[4] as ipecp does not occur in isolation but needs facilitation, the academic or programme co-ordinators need to be sure that certain structures are in place to ensure its success. students have experienced this positively. conclusion the students experienced a lack of knowledge and, in turn, struggled with the applications of the icf as a framework for the facilitation of ipecp. however, the ipecp intervention appeared to provide structure to the clinical placements, making the experience more positive. our findings suggest that students need familiarity with frameworks or models applied during ipecp initiatives. students also need to be prepared to work in groups with students from other disciplines. in addition, facilitators need to be sufficiently equipped and skilled to facilitate the outcomes of the intervention. references 1. world health organization. transforming and scaling up health professionals’ education and training: world health organization guidelines 2013. geneva: who, 2013. 2. frank jr. the canmeds physician competency framework. better standards, better physicians, better care. ottawa, canada: the royal college of physicians and surgeons of canada, 2005. 3. snyman s, von pressentin kb, clarke m. international classification of functioning, disability and health: catalyst for interprofessional education and collaborative practice. j interprof care 2015;29(4):313-319. doi: 10.3109/13561820.2015.1004041 4. bondevik gt, holst l, haugland m, baerheim a, raaheim a. interprofessional workplace learning in primary care: students from different health professions work in teams in real-life settings. int j teach learn higher educ 2015;27(2):175-182. 5. pollard kc, miers me, rickaby c. ‘oh why didn’t i take more notice?’ professionals’ views and perceptions of pre-qualifying preparation for interprofessional working in practice. j interprof care 2012;26(5):355-361. doi: 10.3109/13561820.2012.689785 6. pinto a, lee s, lombardo s, et al. the impact of structured inter-professional education on health care professional students’ perceptions of collaboration in a clinical setting. physiother can 2012;64(2):145-156. doi:10.3138/ptc.2010-52 7. stein-parbury j, liaschenko j. understanding collaboration between nurses and physicians as knowledge at work. am j crit care 2007;16(5):470-477. 8. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. doi:10.1191/1478088706qp063oa 9. rowe m, bozalek v, frantz j. using google drive to facilitate a blended approach to authentic learning. br j educ technol 2013;44(4):594-606. doi:10.1111/bjet.12063 10. evans j, henderson aj, sun j, et al. the value of inter-professional education: a comparative study of dental technology students’ perceptions across four countries. br dent j 2015;218(8):481-487. doi:10.1038/ sj.bdj.2015.296 11. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. doi:10.1016/s01406736(10)61854-5 12. treadwell i, havenga hs. ten key elements for implementing interprofessional learning in clinical simulations. afr j health professions educ 2013;5(2):80-83. doi:10.7196/ajhpe.233  13. reeves s. community‐based interprofessional education for medical, nursing and dental students. health soc care community 2000;8(4):269-276. doi:10.1046/j.1365-2524.2000.00251.x  http://dx.doi.org/10.3109/13561820.2015.1004041 http://dx.doi.org/10.3109/13561820.2012.689785 http://dx.doi.org/10.3138/ptc.2010-52 http://dx.doi.org/10.1191/1478088706qp063oa http://dx.doi.org/10.1111/bjet.12063 http://dx.doi.org/10.1038/sj.bdj.2015.296 http://dx.doi.org/10.1038/sj.bdj.2015.296 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.1016/s0140-6736(10)61854-5 http://dx.doi.org/10.7196/ajhpe.233  http://dx.doi.org/10.1046/j.1365-2524.2000.00251.x research 194 december 2017, vol. 9, no. 4 ajhpe childbirth is a unique and special experience for every woman. unfortunately, however, some would argue that it is increasingly becoming a ‘medicalised’ experience, in which women lose their rights and their control over their own bodies. studies such as that of spurgeon et al.[1] have found that this medicalisation leaves women feeling helpless, and with no freedom of choice. the medicalisation of women’s bodies has led to widespread perceptions of childbirth as a specialist field in which only doctors have appropriate knowledge. however, it can be argued that the care that can be provided by midwives around the time of childbirth can contribute to a good start for the baby and parents during this critical period of human life. as fraser and cooper[2] highlight, a midwife meets a woman at the beginning of her pregnancy and provides care throughout it. if the woman has a low-risk pregnancy, the midwife works with the medical team, but (s)he is still responsible for all the midwifery care. in south africa (sa), the midwife carries out his/her functions based on the scope of practice of a midwife,[3] keeping in mind the code of conduct and making ethical decisions regarding the care of mother and child. all midwives must realise that they are able to make independent judgments regarding the care of a patient according to their knowledge, qualification and skills. the follow-up experience is an innovation on the part of the university of the witwatersrand (wits) in gauteng province, sa. the experience provides the student midwives with the opportunity to form extended relationships with the women who they have been with during pregnancy, labour and birth, and 6 weeks after delivery. this project had been in place for 7 years prior to the time of this study. the nursing department and all institutions in which student midwives are placed for clinical education, e.g. community-service clinics, are aware of the follow-up programme, and work with students to assist and enable them to undertake the follow-up experience. all 21 student midwives who were enrolled for midwifery in the years 2009 and 2010 were given guidelines specified by the nursing department, according to which a student must: • choose one pregnant woman in her first trimester of pregnancy, and give her support throughout pregnancy, birth and postpartum until 6 weeks after delivery – i.e. (s)he will be on call throughout the woman’s journey • choose a woman perceived to be in the ‘low-risk’ category, to allow them good exposure without involving obstetricians • keep records of all their contact hours, as these would be added to their training hours as required by the sa nursing council regulation (r425) • keep anecdotal notes, e.g. pictures • keep journals • write narratives as (s)he continues to support the woman • exchange contact details with the woman, for communication • when visiting the woman at home, be accompanied by one of their colleagues, as some areas are dangerous to visit • by the completion of the project, have written down this experience, and must submit it for marking by the lecturer. the process of recruiting the women varied, sometimes being undertaken at the antenatal clinic of a public hospital, or at a church, or via family and friends. the follow-up experience has the potential to contribute quite significantly to the midwifery practice of students, as the time spent in these experiences is additional to their standard clinical placement. background. in the department of nursing at the university of the witwatersrand, south africa, one of the requirements for students to complete their bachelor of nursing science degree is to choose a pregnant woman and follow up on her care, through pregnancy, during birth and up to 6 weeks after delivery. objective. to explore and describe student midwives’ experiences in the follow-up of a woman through pregnancy, birth, postpartum and until 6 weeks after delivery. methods. the research design was qualitative, descriptive, exploratory and contextual. purposive sampling was used, and 21 student midwives consented to be part of the study. semi-structured face-to-face interviews were conducted with the student midwives after they completed the follow-up project. these interviews were tape-recorded and transcribed verbatim by an independent transcribing service. results. the findings in relation to the research question were synthesised under three themes: building relationships with the women; challenges associated with the follow-up experience; and positive aspects of this experience. conclusion. the follow-up experience provided midwifery students with unique and important learning opportunities that they would not have experienced in standard or hospital-based clinical placements alone. afr j health professions educ 2017;9(4):194-198. doi:10.7196/ajhpe.2017.v9i4.730 experiences of south african student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery l m modiba, d cur department of health studies, college of health sciences, university of south africa, pretoria, south africa corresponding author: l m modiba (modiblm@unisa.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research december 2017, vol. 9, no. 4 ajhpe 195 problem statement i have observed that student midwives in sa believe that their prior learning in nursing education causes them to focus on task performance rather than on interaction and on offering support during midwifery training. as a new learning activity, there is no current research that indicates whether any learning actually arises from this experience, and if there is any learning, what is learnt and how this learning occurs. little has been written about the experiences of offering continuous support during pregnancy in the sa setting. the current evaluations of the follow-up experience in the literature (brook and barnes[5] and davis and mcintosh[6]) do not explore whether learning occurs as a result of this experience. from this problem, the following questions arose: • what are the personal experiences of student midwives on the follow-up of a pregnant woman from pregnancy until 6 weeks after delivery? • what are the learning experiences of student midwives when caring for a pregnant woman from pregnancy until 6 weeks after delivery? • what are the challenges associated with this follow-up experience? purpose the purpose of this research was to determine the student midwives’ personal learning experiences in the follow-up of a pregnant woman until 6 weeks after delivery. to achieve the purpose, the following objectives were set: • to explore and describe student midwives’ personal experiences in the follow-up of a pregnant woman until 6 weeks after delivery • to identify and describe learning experiences associated with the followup experience • to identify and describe the challenges associated with the follow-up experience. methodology a qualitative, exploratory, descriptive and contextual phenomenological study was undertaken to examine student midwives’ learning experiences of a follow-up of pregnant women to 6 weeks after delivery. burns and grove[7] have defined qualitative study design as taking a systematic, subjective approach in describing life experiences (in this study, the experiences of the student midwives) and giving them meaning. descriptive and explorative methods are used interchangeably to gain information and to provide a picture of a situation as it naturally occurs, while contextual aspects are vital in considering the setting of the study, e.g. hospital or home.[8] this study was conducted within witsand in a public hospital, the charlotte maxeke johannesburg academic hospital, in gauteng province, sa, over a period of 2 years (2009 2010). annually, the labour ward takes in about 5 000 women, who may either have uncomplicated deliveries or experience complications. in this ward, 10 student midwives from other nursing/midwifery colleges and from the university receive their clinical training. ten qualified midwives, five doctors and six staff nurses work in this labour ward. a total of 21 student midwives were enrolled in the midwifery programme for 2 years. in the first year, they dealt with ‘normal’ midwifery, and in the second year, ‘abnormal’. through purposive sampling, all students who were registered for midwifery volunteered to participate in this study, and signed informed consent forms in which its purpose and objectives were clearly explained. they were informed about their right to withdraw their participation at any time. confidentiality and anonymity were maintained by not using their real names, and they were guaranteed that their names would not be given to any other person. ethical clearance (ref. no. m10342) was received from the wits human research ethics committee. the students were aged between 21 and 26 years old, and only four had had personal experience of childbearing. at the antenatal clinic of the public hospital, the pregnant women were informed by the qualified midwives about the need for student midwives to gain follow-up experience of pregnant women; therefore, when the student midwives came to recruit them, they were already aware of the programme. the student midwives chose women they were comfortable with, according to either language or culture. on orientation in class, students were also informed that they could choose to follow up a family member, friend or fellow congregant, as long as they received the individual’s permission. data collection semi-structured face-to-face interviews were conducted with the student midwives after completing this project. in order to manage the issue of potential intimidation, as i was their lecturer, i asked a midwifery colleague who also has experience with qualitative interviews to conduct the interviews. i then provided the interviewer with an overview of the research and the interview questions, and introduced her to the students after informing them that they would be interviewed. these interviews were tape-recorded and transcribed verbatim by an independent transcribing service. student midwives were asked to keep journals and to write narratives throughout the experience, which also formed part of the data collected. the purpose was to assist the student midwives to reflect on and evaluate their experiences in offering continuous support. the students were asked to describe their experiences of the followup of the pregnant women. data analysis a qualitative content analysis was used to allow me to interpret the underlying meanings of the texts, as suggested in the literature by graneheim and lundman.[9] as i was also these students’ lecturer, and involved in marking their portfolios, the experiences and narratives documented were read, and meaningful units were identified. these units consisted of text from a few words up to several sentences, the meanings of which were interpreted. during the interpretation, subthemes were identified, and a main theme emerged at the end of this process. the findings in relation to the research questions can be synthesised under three themes: personal experiences associated with follow-up; learning experiences associated with follow-up; and challenges associated with the follow-up experience. the results of the analysis are presented below under these headings. personal experiences associated with follow-up under this theme, three subthemes emerged: ‘getting to know what makes the woman tick’; ‘the woman’s care is in your hands’; and feeling under a lot of pressure. ‘getting to know what makes the woman tick’ students perceived the follow-up experience to be focused on the woman, rather than anything else. getting to know the woman was more than a simple social activity. it involved a deeper relationship that led to the research 196 december 2017, vol. 9, no. 4 ajhpe midwifery student learning about the woman’s wider environment and personal circumstances. one participant explained: ‘you really get to know, especially with home visits, what her home environment is like and how that’s impacting on the person that she is and the choices that she is going to make.’ this theme shows the student becoming deeply involved in the follow-up experience and learning from it. this relationship is built on important facets such as the relationship with her family or partner, demonstrating that this is more than a simple social interaction. ‘the woman’s care is in your hands’ the theme involves the student learning from engaging with the woman and feeling that this puts the woman’s care in their hands. this was described by one student as follows: ‘you actually get to speak to a real person rather than just reading books or just practising on dolls. it is a lot different in the real world than sitting and reading a textbook. you learn that not every labour is like a textbook labour.’ feeling under a lot of pressure students felt under a lot of pressure because of the overload of work from other subjects, e.g. community-health nursing sciences, while they could also be interrupted by their follow-up woman at any time. this was articulated as follows: ‘i will be sleeping and when a phone rang would say dear god, i hope this is not my follow-up woman. i had a young child and still married, and if called at that time it is really a difficult time. it was gruelling!’ in summarising this theme, most of the participants felt that this experience exposed them to getting to know the woman better, so that the care they were providing was centred on trust. the experience clearly identified interaction where a significant relationship was built. some participants articulated the difficulties they were exposed to when they were having family problems. learning associated with experiences under this theme, three subthemes also emerged: ‘being there in the moment’; relationship-building with the woman; and the uniqueness of each woman’s journey. ‘being there in the moment’ this illustrates how learning took place, and it was described by one participant as: ‘what i have learned through this experience is more than what i have learned in class.’ another participant said ‘it has been a deep learning experience because one gets to see the transformation that pregnancy, birth and motherhood brings and what impacts on this. not just fragments of this from the textbooks, it has taught me about taking personal responsibility as a midwife.’ relationship-building with the woman student midwives in this study stressed that the relationships they formed with these women during this time were important for a number of reasons – they knew about the woman, her wishes, her past experiences and her personal circumstances, and they came to understand what impact these had on her experience of pregnancy, labour and early parenting. these relationships meant that the students were able to provide care that was personal and tailored for that particular woman. they described how they came to realise that being able to get to know the woman was a valuable opportunity: one student midwife said ‘it has given me a “bigger picture” approach – holistic care as well as teaching me that my beliefs really have little relevance and it comes about to the woman’s own choices that matters.’ the experience provided student midwives with an opportunity to form extended relationships with the women. being present students reported that the women did not want to be left alone during labour. the presence of the student helped the women to relax and feel more secure. the student’s presence was expressed by touch or talking, as one participant described: ‘the woman wanted me to hold my hand on her belly at every contraction. at first i found it odd. i wondered how it could help her, but then i saw that it really did. to her it was probably important to feel that i was actually there. it seemed it made her to relax.’ another said: ‘i learned that one sometimes does not have to do so much for the woman, it can be enough just to be there for her and to listen.’ according to hunter,[10] ‘presence’ involves a willing interaction between the midwife and the woman, which requires trust on the part of the woman, and the giving of self (engagement, attentiveness, time and awareness of the encounter) by the midwife. this has also been recognised by kennedy et al.,[11] who consider the art of midwifery as being present without interfering; as long as the process is working as it should, midwifery is the art of ‘doing “nothing” well’. feeling of trust student midwives also felt that the women trusted them because they knew them, and that this trust was significant for the women. they recognised the value of having an existing relationship prior to labour and birth, as identified by participants: ‘there’s a better trust there, and it feels a bit more like almost a friendship or a partnership with the woman.’ ‘it is so much easier and rewarding to care for women in a continuity of care. the birth experience in particular becomes so less scary for women when they feel well supported by a known and trusted person.’ the uniqueness of each woman’s journey some participants described how they learnt about how women experience their journey. one participant said: ‘i have learned that pregnancy and birth is a different experience for all women and one should not make any assumptions about how women experience it.’ another one explained: ‘they have all been different so far and each and every one had something special. the issues that came up woke my curiosity and got me reading more.’ in summarising this theme, student midwives recognised that the development of a relationship and a commitment to the woman allowed them to provide her with the type of care that they knew was appropriate for her, particularly during her labour and birth. midwifery literature (kirkham[4] and hunter[12]) has previously shown that midwives experience work differently when they are able to build relationships with women. according to fraser et al.,[13] it is through the development of relationships between caregivers and childbearing women and their families that we make the change from ‘faceless institution’ to ‘humanistic supportive care’. challenges associated with the follow-up experience while student midwives spoke of their experiences of being able to develop relationships with women, they also articulated aspects of the followresearch december 2017, vol. 9, no. 4 ajhpe 197 up experience that were difficult: recruiting; poor support; conflicting priorities; finances; and intimidation. recruiting the student midwives described the recruitment of a woman for follow-up as a difficult and challenging experience, and it was explained as awkward and sometimes time-consuming, as indicated in the following statements: ‘i was frustrated because she couldn’t understand me well. i spoke too quickly for her but i corrected myself and the communication between us grew. my first feeling was that she would be just another attempt, soon she would not come for the visits any longer and i would be sitting in looking for a new woman.’ ‘at the start of the project i wanted to quit because of fear of rejection, but because time was running out i had to do it. it is also a very confronting experience to have to ask a woman if you can be a part of this very intimate time of her life.’ in summarising this theme, it was clear that there were difficulties associated with recruiting women, e.g. it was awkward, and it sometimes took a long time as the participants were also supposed to study and manage work and family life. poor support student midwives received some support from the university, midwives, doctors and their colleagues, but it was not always sufficient, and this was reaffirmed by a student midwife who described how midwives did not ring her for the labour and birth: ‘my follow-up woman asked the midwife to call me as soon as she was admitted but the midwife did not do it. so, i missed out on being at the birth.’ another student explained: ‘after my follow-up woman lost her child, i walked to an empty room and i sat alone and cried. i was interrupted when a nursing sister walked in the room and began shouting at me, saying that is her room, at least she stopped when she saw my puffy eyes, and she asked me and i told her that i was crying because my baby died to which she replied ‘oh!’ and she continued to read her newspaper. i asked myself where her compassion was!’ this showed poor professional support from qualified midwives. one participant explained that sometimes one develops an emotional attachment and this becomes difficult: ‘you can never predict how a birth will end up, i also found the woman to be more trusting and confident in labour. i actually preferred not to know them well as it interfered with my clinical judgement. i was too emotionally involved.’ conflicting priorities one concern was about the difficulties associated with trying to balance university requirements with the follow-up experience. this was revealed in the following comment: ‘i had to miss the appointment with my follow-up woman as i was on the train for community clinical placement in another province.’ this illustrates that although this project was supported by the university, there were clashes as students were also registered for other courses than midwifery, e.g. psychiatry and community-health nursing. finances although the university recognises the follow-up project, difficulties were encountered when student midwives needed to spend money on things such as purchasing cellphone credit in order to call their follow-up woman, and paying for transport when visiting the woman at home. this was illustrated by the following statement: ‘i had to purchase phone credit in order to communicate with the woman. and when i went to visit her at home i bought fruits for her other kids and at the same time had to pay transport money.’ in summary, the student midwives explained that although students are required to commit time, other resources are also needed, such as travel expenses to visit the women at home. intimidation students had to follow up some of the women at home in order to get to know them as members of their families, and to understand the environment in which they were living. the general experience was found to be intimidating, especially if the woman was not at home. this was described by one participant: ‘when i arrived there i found the partner who welcomed me and as i was asking as to where ms x was, he mentioned that she is gone to the homestead, but surprisingly he start to flirt with me and i had to go out of that place running.’ the student midwives, in summary, mentioned that it was not always safe to travel alone, as sometimes they would be faced with awkward situations at the homes of the women, or risked being robbed. discussion the research showed that the implementation of a follow-up woman programme has many benefits to both student midwives and women during their pregnancy, delivery and postnatal period. if care is appropriately organised, and midwives gain interpersonal and clinical skills and knowledge, it is more likely to be successful. the way care is organised, including the pattern and culture of practice, is probably one of the most important factors in creating effective, sensitive and individual care.[13] it is important that midwives ensure continuity of care to mothers and babies throughout pregnancy, the birth experience and the puerperium. ‘continuity of care’ refers to the follow-up of a woman to ensure that her needs – both physical and psychological – are met in each consultation, and that the same midwife continues to care for her throughout the period from early pregnancy to after birth. in this way, in any given encounter with the maternity services, a woman can feel confident that her caregiver will know what has gone before, so that she will not have to repeat her story yet again. equally, decisions about her care will have been made as a result of policies that are shared by all her caregivers and to which all are willing to adhere, so that she will not be given conflicting advice. this is further articulated by homer et al.,[14] who argue that continuity of the carer refers to care by a midwife whom the woman has met previously and feels that she knows. a lot is gained through continuity of care, such as the trust and co-operation of the patient in solving issues at any time in pregnancy and labour. this is supported by pairman,[14] who refers to the woman-student relationship, and the learning that the student gains from this experience, as powerful. it also increases the quality of care of the woman in the sense that the midwife has the opportunity to understand her background and culture, to get to know her more deeply and to allow the establishment of a relationship between them. when in labour, the woman will have support from someone whom she already knows and has a trusting relationship with. this is confirmed by fraser et al.:[13] women identified good communication skills to be of primary importance, although some women also wanted more than this and expected midwives to have a special relationship with them. the pregnant woman may also come to research 198 december 2017, vol. 9, no. 4 ajhpe feel comfortable enough to question the midwife and to participate in any decision-making. each labour is a unique experience, and greater experience with diverse labours means midwives will experience fewer caesarean-section cases and more successful second stages of labour, in terms of a shorter second stage and intact perineum.[16] midwifery offers the possibility of making the childbirth experience of a woman special and unique, and the experience can also end up being just as unique to the midwife, because with each woman, the midwife is able to create a different and personal bond. as midwives, we can empower women and make a difference for them, at the same time creating a learning opportunity for ourselves.[17] conclusions the follow-up experience provided a significant learning environment for midwifery students. students identified the learning they received from the experience as uniquely individual. they articulated that they learned through interaction with each woman, and their ability to be hands-on with her. the follow-up experience provided midwifery students with unique and important learning opportunities that they would not experience in standard or hospital-based clinical placements alone. these learning experiences occur primarily because students are paired with individual women. it is this relationship that provides serendipitous learning, in which learning is informal, the knowledge gained is high and motivation remains with the learner. students are likely to learn more from these experiences if they are embedded within courses, where support is provided for reflection, and where they are not forced to take a superficial approach to care as a result of an excessive workload. acknowledgements. i would like to thank the students who agreed to participate in this study. author contributions. sole author. funding. none conflicts of interest. none 1. spurgeon p, hicks c, barwell f. antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot changing childbirth schemes compared with a traditional model of care. midwifery 2001;17(2):123-132. https://doi.org/10.1054/midw.2001.0255 2. fraser md, cooper is. myles textbook for midwives, 14th ed. new york: churchill livingstone, 2003. 3. south african nursing council. scope of practice of a registered midwife. no: r2488. pretoria: sanc, 1990. 4. kirkham m. the midwife-mother relationship. basingstoke: macmillan, 2000. 5. brooks c, barnes m. experience-based educational strategies to promote woman-cantered midwifery practice. aust j midwifery 2001;14(1):22-26. https://doi.org/10.1016/s1445-4386(01)80031-8 6. davis d, mcintosh c. partnership in education: the involvement of service users in one midwifery program in new zealand. nurs educ pract 2005;5,274-280. https://doi.org/10.1016/j.nepr.2005.02.002 7. burns n, grove sk. the practice of nursing research: conduct, critique and utilization, 5th ed. st louis: elsevier/saunders, 2007. 8. lobiondo-wood g. nursing research methods: clinical appraisal for evidenced-based practice, 6th ed. st louis: mosby, 2006. 9. graneheim up, lundman e. qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. nurs educ today 2004;24(2):105-112. https://doi.org/10.1016/j.nedt.2003.10.001 10. hunter b. the importance of reciprocity in relationships between community-based midwives and mothers. midwifery 2006;22(4):308-328. https://doi.org/10.1016/j.midw.2005.11.002 11. kennedy h, shannon u, chuahorm u, kravetz m. the landscape of caring for women: a narrative study of midwifery practice. j midwifery womens health 2004;49(1):14-23. https://doi.org/10.1111/j.1542-2011.2004. tb04403.x 12. hunter lp. being with woman: a guiding concept for the care of labouring women. j obstetric gynecol neonatal nurs 2002;31(6):650-657. https://doi.org/10.1177/088421702129005281 13. fraser md, cooper am, nolte agw. myles textbook for midwives, african edition. edinburgh: churchill livingstone, 2006. 14. homer cs, davis gk, cooke m, barclay l. women’s experiences of continuity of midwifery care in a randomised controlled trial in australia. midwifery 2002;18(2):102-112. https://doi.org/10.1054/midw.2002.0298 15. pairman s, massey s. where do all the midwives go? a report on the practice choices made by bachelor of midwifery graduates. n z coll midwives j 2001;25:16-22. 16. halldorsdottir s, karlsdottir si. journeying through labour and delivery: perceptions of women who have given birth. midwifery 1996;12(2):48-61. https://doi.org/10.1016/s0266-6138(96)90002-9 17. lavender t, walkinshaw sa, walton i. a prospective study of women’s views of factors contributing to a positive birth experience. midwifery 1999;15(1):40-46. https://doi.org/10.1016/s0266-6138(99)90036-0 accepted 27 march 2017. https://doi.org/10.1054/midw.2001.0255 https://doi.org/10.1016/s1445-4386(01)80031-8 https://doi.org/10.1016/j.nepr.2005.02.002 https://doi.org/10.1016/j.nedt.2003.10.001 https://doi.org/10.1016/j.midw.2005.11.002 https://doi.org/10.1111/j.1542-2011.2004.tb04403.x https://doi.org/10.1111/j.1542-2011.2004.tb04403.x https://doi.org/10.1177/088421702129005281 https://doi.org/10.1054/midw.2002.0298 https://doi.org/10.1016/s0266-6138(96)90002-9 https://doi.org/10.1016/s0266-6138(99)90036-0 research 148 september 2017, vol. 9, no. 3 ajhpe background the mini-clinical-evaluation exercise (mini-cex) is a way of assessing the clinical performance of medical students.[1] the mini-cex consists of three basic elements: a direct observation of the clinical performance of students; an assessment of clinical performance, based on components of competence; and a feedback session immediately after the observation.[1] assessment based on direct observation of clinical performance, with feedback, has a strong impact on student behaviour and learning processes.[2,3] however, studies have found that the feedback given to students is inadequate.[4] factors that have influenced the lack of provision of feedback are the ability of the teacher to provide feedback, the format of the assessment form (for written feedback) and the process of assessing and giving feedback.[3,5,6] since the original emergence of the mini-cex assessment, the form has included spaces to write feedback and an action plan for further learning.[1] the space for writing feedback is divided into two sections: areas that are positive (strengths), and areas that need to be improved (weaknesses). these spaces are found to be mostly unutilised.[7] the provision of written feedback and an action plan on the mini-cex form is not satisfactory owing to the use of unspecific language, the format of the assessment form and uncertainty around the assessment process.[5] moreover, the assessment process provides little ‘dialogue’ space between the teacher and the student. efforts to use a modified mini-cex form were therefore made to stimulate the provision of written feedback and reflection.[5] unwritten or unspecific written feedback and action plan on the minicex form leaves unanswered questions as to how the feedback session went, and whether it really benefited the student’s learning process. the use of written feedback is important for evaluating the progress of a student based on written records/documents, and in the preparation of his/her portfolio.[8] against this background, we tested whether a modified mini-cex form, with the addition of specific spaces on separate sheets for feedback and action plan, and of a new section for written reflection, would improve the quantity and quality of the written feedback, action plan and student reflection in the mini-cex assessment. ethical approval for this study was obtained from the medical health research and ethics committee (mhrec) at gadjah mada university (ref. no. ke/fk/953/ec). methods design this was a single-group pre-test-post-test quantitative study, comparing the data from previous mini-cex forms and the data collected over 3 months after the introduction of the modified mini-cex forms. the analysis was done by means of comparing the quantity and quality of the written feedback, action plan, and student reflection before and after the use of a modified form. background. mini-clinical-evaluation exercise (mini-cex) assessment forms that have been modified with the addition of specific spaces on separate sheets are expected to improve the quantity and quality of written feedback and the action plan for further learning which is agreed upon, and to encourage written reflection. objective. to test whether the modified mini-cex assessment forms improve the quantity and quality of the written feedback, action plan and student reflection in the mini-cex assessment process. methods. data collection was conducted over 3 months. data analysis used the c2 test to compare the quantity and quality of written feedback, action plans, and reflections before and after the introduction of a modified mini-cex assessment form. results. twenty-four clinical teachers and 44 clinical students participated in this study. the percentage of written feedback increased by 39%, and the specificity increased by 30.1% (p=0.001). the percentage of written action plans increased by 37%, and the specificity increased by 17.7% (p=0.001). the percentage of written reflection in the new spaces on the modified forms reached 73%, and 49.2% were classified as ‘specific’. conclusion. the use of modified mini-cex assessment forms, with the addition of extra spaces on separate sheets, improved the quantity and quality of written feedback and action plans, and encouraged written reflection. afr j health professions educ 2017;9(3):148-152. doi:10.7196/ajhpe.2017.v9i3.804 quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-cex assessment form r m djajadi,1 md, mmeded; m claramita,2 md, mhpe, phd; g r rahayu,2 md, mmeded, phd 1 medical education unit, faculty of medicine and health sciences, warmadewa university, bali, indonesia 2 department of medical education, faculty of medicine, universitas gadjah mada, yogyakarta, indonesia corresponding author: r m djajadi (robinmartilo@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research september 2017, vol. 9, no. 3 ajhpe 149 participants the participants were 24 clinical teachers and 44 undergraduate clerkship students who were on duty between 16 september and 15 december 2014 in the departments of obstetrics and gynecology, surgery, internal medicine and paediatrics in sanjiwani hospital, indonesia. in order to gain as much collectable data in the form of the mini-cex sheets as possible, we purposely chose participants from those departments which had the longest period of rotation (3 months), and the highest number of students assigned at the time. instrument the instrument used for collecting data was a modified mini-cex form.[7] the original unmodified form was the regularly used mini-cex form adapted from norcini’s.[1] we then modified the mini-cex form by adding specific spaces for feedback and reflection on each component of competence that was assessed. this modification was adapted from pelgrim et al.’s[5] work on the mini-cex form. the components of competence assessed in the mini-cex form are as follows: (i) history taking; (ii) physical examination; (iii) professionalism; (iv) clinical judgement/diagnosis; (v) patient management; (vi) communication skills; (vii) organisation/ efficiency; and (viii) overall clinical care. our modification was to include separate sheets for writing feedback, an action plan and student reflection. sheet a, which refers to the components of competence assessed, is used for assessing student clinical performance. sheet b, which contains specific feedback spaces for each component of competence, is used for writing feedback, and sheet c, which contains specific reflection spaces on each component of competence and space for an action plan, is a student reflection sheet. the modified mini-cex form was then validated by two experts in medical education. the process of using the modified mini-cex form was conducted based on the ‘reflective-feedback dialogue’ principle, as follows:[9] (i)  students undertake clinical performances for the purposes of the mini-cex, accompanied by a teacher; (ii) the teacher directly observes and assesses the student’s performance using sheet a; (iii) during the observation of the student’s performance, the teacher can write a short and specific feedback section on sheet b; (iv) after finishing the clinical performance, the student is given the opportunity to write a brief reflection on sheet c; (v) the teacher asks the student to present his/her reflection; (vi) the teacher provides oral feedback based on the feedback that has been written and based on student reflection; (vii) the teacher and student agree on an action plan based on learning goals, and the student writes this down briefly and specifically in the action plan space on sheet c; (viii) a follow-up should be planned to evaluate the achievements of the action plan at the next meeting; and (ix) the form is collected and placed in the portfolio document. procedures students are required to undergo mini-cex assessments as a prerequisite for their being permitted to take the final examination on each departmental rotation. each departmental rotation has a different schedule and different requirements about the number of mini-cex assessments which must be performed. at the department of obstetrics and gynecology, students must do two mini-cex assessments, in weeks 5 and 7. the department of surgery requires three mini-cex assessments, in weeks 3, 5 and 7. one mini-cex is required in the rotation of the department of paediatrics, in the last week before the final examination (week 12). the rotation in the department of internal medicine also requires one mini-cex assessment, which is conducted between weeks 8 and 10. the teachers who assess the mini-cexes are decided on according to a fixed schedule, and cannot be specifically requested by students. before data collection was carried out, we met all clinical teachers and undergraduate clerkship students to introduce the modified mini-cex form. the length of the introduction session was ~20 30 minutes. it consisted of a brief description of the modified mini-cex forms, and the steps to be taken to use them. we collected all unmodified mini-cex forms from the mini-cex assessments that had been done in the 3 months before the study began. then we collected all of the modified mini-cex forms used over the next 3 months. once all the forms had been collected, the data transcription was carried out. data analysis the amounts of written feedback, action plan and reflection were calculated by using the number of filled spaces on the form for each category as a percentage of the number of mini-cex forms collected. the quality of the written feedback, action plan and reflection was determined according to specificity, where each variable was classified as belonging to one of three categories: specific, quite specific, or not specific. the specificity criterion for written feedback and written reflection was defined using the classification of pelgrim et al.[5] the written material was classified ‘specific’ if it was clear which component was being referred to, which aspects of it were already positive v. which needed improvement, and why they were either considered good or needed to be improved. it was ‘quite specific’ if it only indicated which component was being referred to and what was already good about it v. what still needed to be improved. it was ‘not specific’ if only general aspects of the overall student clinical performance were covered, without indicating which components were really referred to in terms of what was already good and what needed to be improved. similarly, the written action plans were classified using pelgrim et al.’s [5] criteria as ‘specific’ if they showed explicitly which aspects of their clinical performance should be studied further; ‘quite specific’ if they only listed the components that should be corrected without giving further details; and ‘not specific’ when only general statements were made. inter-rater reliability was tested with three other raters, who were students of a master’s programme in medical education, using cohen’s kappa test to ensure the validity of the classification made by the researcher. the raters were chosen based on their knowledge of mini-cex assessments and feedback. the cohen kappa-test results for the specificity classification of the written feedback, action plan and reflection between researchers indicated that there was agreement on the analysed variables (kappa values >0.6). p-values were calculated using the c2 test. the test was considered significant when p<0.05. results the total number of unmodified mini-cex forms collected between 16 june 2014 and 15 september 2014 was 78. the total number of the modified mini-cex forms collected between 16 september and 15 december 2014 was 63. research 150 september 2017, vol. 9, no. 3 ajhpe written feedback the amount of written feedback increased by 39.0%, and the amount of specific feedback by 30.1% (p=0.001), when the modified forms were used (table 1). on the modified mini-cex form, there are feedback spaces that are specific to each component assessed. if there was only one feedback comment on the assessed component that corresponded to the ‘specific’ criteria, then the overall feedback was classified as ‘specific’. an example of specific written feedback on the modified mini-cex form is: the format of the interview already met/preparation of the patient prior to the interview should be considered; ‘generally good/observe patient reaction during examination; already greets the patient and introduced himself/maintain friendliness with the patient; already good/(blank); (blank)/need to understand again about termination of pregnancy; already good/(blank); (blank)/ (blank); (blank)/(blank). (sheet ob1b1).’ in this example, statements on the left of the ‘/’ indicate aspects of the clinical performance, such as history taking, physical examination, professionalism, patient management, communication skills, that are listed as strengths, while those to the right are aspects still considered deficient. it also considers what is good v. what is still lacking, and/or why it is good or still lacking, in ‘interview format (already met), the patient's reaction (during examination), (already) greets the patient, (maintain) friendliness, (need to understand again about) termination of pregnancy’. action plans the percentage of written action plans increased on the modified forms by 37.0%, and specific action plans increased by 17.7% (p=0.001) (table 2). in the example of a specific action plan, below, it is made explicit which aspects of clinical performance should be studied further: ‘review the reason for induction in cases of oligohydramnion, the plan of putting a patient on a drip in the case of oligohydramnion; re-evaluate how to perform a physical examination of the leopold manoeuver and vt [vaginal toucher] and how to calculate fhr [fetal heart rate].’ (sheet ob6b3) written reflection a total of 73% of the written reflection sheets had been used by the students to write reflections, while specific reflections made up 49.2% of the written reflection on the modified forms (table 3). an example of a specific written reflection, again with strengths listed on the left and weaknesses on the right, is as follows: detailed history/(blank); (blank)/leopold examination, vt examination; greetings/(blank); (blank)/indications for administration of oxytocin drip; comprehensive/(blank); good/(blank); good/(blank); good/(blank). (sheet ob6b3) this example states which components are already good, and which are still deficient, such as history taking, physical examination, profession alism, patient management, communication skills. it also shows what is good v. lacking, and/or why this is so, in ‘detailed (history), leopold (examination), vt (examination), greetings, indication for giving oxytocin drip’. discussion the results of this study showed that the use of a modified mini-cex form may increase the quantity and quality of teachers’ written feedback. the modified mini-cex forms have spaces next to each component of competence to write feedback. these spaces can be used to capture written feedback, either specific or not. in the written feedback it can be assumed that the more specific the feedback, the more concerned the teacher was about this component. the mini-cex was constructed to take into account the limited time that clinical teachers have while teaching and assessing students at the clinical bedside.[1] at first, after the introduction, most of the clinical teachers who participated in this study were reluctant to engage in the intervention because of the impression that it would give them more tasks and take up more of their time. however, we tried to reassure them that based on the process of using the modified mini-cex form, the writing of feedback would be part of the student performance observation, which required no additional amount of time. the teacher would write table 1. the amount and quality of written feedback quality of feedback mini-cex form type unmodified (n=78), modified (n=63), n (%) n (%) blank 49 (62.8) 15 (23.8) filled 29 (37.2) 48 (76.2) not specific 21 (27) 14 (22.2) quite specific 3 (3.8) 11 (17.5) specific 5 (6.4) 23 (36.5) p=0.001, significant if p<0.05. table 2. action plan specificity in modified v. unmodified forms specificity mini-cex form unmodified (n=78), modified (n=63), n (%) n (%) blank 71 (91) 34 (54) filled 7 (9) 29 (46) not specific 1 (1.3) 5 (8) quite specific 5 (6.4) 12 (19) specific 1 (1.3) 12 (19) p=0.001, significant if p<0.05. table 3. the specificity of written reflection reflection modified mini-cex form (n=63), n (%) blank 17 (27) filled 46 (73) not specific 3 (4.8) quite specific 12 (19) specific 31 (49.2) research september 2017, vol. 9, no. 3 ajhpe 151 the feedback while doing the observation as part of usual procedure. therefore, the modified mini-cex form was not meant to be a burden, but should help the teachers remind themselves of their feedback statements that would be delivered at the end of the assessment. this written feedback could benefit the teacher as a reminder, if they had no time available to deliver the feedback right away. they could do the feedback session later based on the written feedback note. the results of this study also showed that the use of the modified minicex form increased the quantity and quality of the written action plans. these results are in accord with those of haffling et al.,[6] who used the reflective-feedback dialogue principle in a structured assessment form. this study adapted the steps appropriate to the reflective-feedback dialogue principle, which require teacher and student to interact in order to reach conclusions, and thereby develop the action plan. the existence of this written action plan showed that there was interaction between teacher and student, resulting in agreement. therefore, it can be concluded that the increase in the number of action plans developed that was seen in this study occurred because the steps used on the modified mini-cex form can encourage teacher and student to interact better and to create a more specific action plan. this result proved that the use of the reflective-feedback dialogue principle on the mini-cex assessment process was beneficial for encouraging interaction and thus improving the quality of the action plans developed. the modified mini-cex form used in this study also includes a separate student reflection sheet that contains spaces to reflect on each component of competence. this reflection sheet serves to remind students to reflect after the clinical performance is complete. in addition, it also serves to remind them that there are things that must be communicated between student and teacher. the filled spaces for written reflections were used in 73% (n=63) of the forms, and 67% of these written reflections were classified as specific (31/46). this result is satisfactory, considering that the writing of reflections on the mini-cex form was a first-time experience for the clinical students in this study. note that reflection takes practice to make it a habit, which the use of these forms encourages. there was a possibility that the reflection data collected were written after performing the steps, i.e. outside of the mini-cex duration, or after receiving feedback. this may have affected the result. however, according to sargeant et al.,[10] reflection after receiving feedback can help a person in the process of deciding to accept or to reject the feedback. therefore, despite this possibility of having written the reflections outside of the mini-cex duration, it can still be concluded that in this study the use of the modified form encouraged and trained students to write reflections on their minicex assessment form. in the process of formative assessment, there are two aspects that may be reflected on: the performance itself, and the feedback provided after the performance.[11,12] either reflection on the performance[13] or reflection on the feedback given[10] can be beneficial to the learning process. therefore, it should be a point of consideration in the future in determining the use of the reflection sheet: that is to say, whether the reflection should be made only after receiving feedback, or before or after receiving feedback. the nature of the reflection that happened can be seen from the contents of the written reflections, which are able to demonstrate the strengths (aspects already good) and the weaknesses (things that need to be improved) of students’ performance, and possible things that can be improved after the mini-cex assessment. the existence of this reflection on experience indicates that there has been a deep learning process.[12,14] we suggest that future research should elaborate on this issue of reflection. in this study, the use of a modified form led to an increase in the quantity and quality of the feedback and the action plans. however, it still can be questioned why the results have not been closer to 100%. there are several factors that affect the quantity and quality of the feedback and the action plans: factors involving the research subjects (communication skills and understanding of the feedback and the action plan) and factors related to conditions in the field (especially the duration of the mini-cex). the research-subject factors play a more important role in determining the quantity and quality of the feedback and the action plan.[5] the mini-cex duration factor also affects the quantity and quality of the feedback and the action plan. presumably, the longer the duration of the mini-cex assessment and feedback session, the greater the likelihood of having better quantity and quality of feedback and action plan. in this study, the mini-cex duration factor was not controlled. data were captured in real conditions that occur in the field, in terms of variations in the duration of the mini-cex. this study may have been affected by the hawthorne effect bias, in that the research subjects felt that they were being observed, inducing them to improve their performance. however, data on some subjects that undertook mini-cex assessments several times within the 3 months showed that there were variations in the quantity and quality of the feedback. some of the subjects remained consistent in providing written feedback, and some did not. this shows that the effect of an improvement in performance due to being observed was minimal. the long data collection period (3 months) also minimises this effect of being observed. this study used a small sample, but if we consider the proportion of the sample to the total population of teachers and students in the hospital, the sample is large. the number of research subjects in the clinical-teacher sample was 24 people, or 63% of the population (38 people). the number of research subjects in the clinical student sample was 44 people, or 38% of the population (115 people). the sample of clinical students in this study was not randomised, because we used the convenient sampling method, but considering that the distribution of the clinical rotation schedule for every department was already done randomly, this implies that the clinical students had already undergone a randomisation process. this study only considered four departments/laboratories, namely, obstetrics and gynaecology, surgery, internal medicine and paediatrics. this may affect the generalisability of the result to the whole undergraduate clerkship. the number of mini-cex assessments performed in each rotation also varies, so that the amount of data collected from each research subject differed. efforts to control the number of mini-cex assessments conducted for research subjects in order for them to each have the same number is technically not feasible, and therefore we selected a period for comparison, i.e. 3 months before and after the intervention. we suggest that further research on these modified mini-cex forms be carried out in different locations and settings. conclusions from these results it can be concluded that the use of the modified minicex form, with the addition of specific spaces on separate sheets, improved the quantity and quality of written feedback and written action plans. it could also encourage and train students to write reflections on their clinical performance. educational institutions could apply the use of the modified research 152 september 2017, vol. 9, no. 3 ajhpe mini-cex form to support the learning process of mini-cex assessments. data from the modified mini-cex forms could be used for student portfolios, to monitor the development of the clinical-student learning process. future studies are needed to assess user perceptions of using the modified mini-cex form, and its relationship to the results of the next mini-cex assessment or examination. acknowledgements. the authors would like to thank the following individuals for their feedback on the article: dr efrayim suryadi, dr yoyo suhoyo and dr ova emilia. author contributions. rmd contributed to the design and implementation of the research, data collection, to the analysis and interpretation of the results and to the writing of the manuscript. both mr and grr supervised the project, gave feedback to the design and implementation of the research, interpretation of results and contributed to the final version of the manuscript. all authors provided critical feedback and helped shape the research, analysis and manuscript. funding. this research received no grant from any funding agency in the public, commercial, or not-for-profit sectors. conflicts of interest. the authors report no conflict of interest. the authors alone are responsible for the content and writing of the article. 1. norcini j. the mini clinical evaluation exercise. clin teach 2005;2:25-30. https://doi.org/10.1111/j.1743498x.2005.00060.x 2. norcini j, burch v. workplace-based assessment as an educational tool: amee guide no. 31. med teach 2007;29:855-871. https://doi.org/10.1080/01421590701775453 3. burch vc, seggie jl, gary ne. formative assessment promotes learning in undergraduate clinical clerkships. s afr med j 2006;96:430-433. 4. daelmans hem, overmeer rm, van der hem-stokroos hh, et al. in-training assessment: qualitative study of effects on supervision and feedback in an undergraduate clinical rotation. med educ 2006;40:51-58. https://doi.org/ 10.1111/j.1365-2929.2005.02358.x 5. pelgrim eam, kramer awm, mokkink hga, van der vleuten cpm. quality of written narrative feedback and reflection in a modified mini-clinical evaluation exercise: an observational study. bmc med educ 2012;12:97. https://doi.org/ 10.1186/1472-6920-12-97 6. haffling ac, beckman a, edgren g. structured feedback to undergraduate medical student: 3 years’ experience of an assessment tool. med educ 2011;33:e349-e357. https://doi.org/10.3109/0142159x.2011.577466 7. djajadi rm. jumlah dan kualitas umpan balik dan rencana aksi secara tertulis sebelum dan sesudah penggunaan lembar penilaian mini-cex dengan penambahan ruang spesifik umpan balik dan refleksi. master’s thesis. yogyakarta: universitas gadjah mada, 2015. 8. haffling ac, beckman a, pahlmblad a, edgren g. students’ reflections in a portfolio pilot: highlighting professional issues. med teach 2010;32:e532-e540. https://doi.org/ 10.3109/0142159x.2010.509420 9. cantillon p, sargeant j. giving feedback in clinical settings. bmj 2008;337:1292-1294. https://doi.org/ 10.1136/bmj.a1961 10. sargeant jm, mann kv, van der vleuten, cp, metsemakers jf. reflection: a link between receiving and using assessment feedback. adv in health sci educ 2009;14:399-410. https://doi.org/ 10.1007/s10459-008-9124-4 11. archer jc. state of the science in health professional education: effective feedback. med educ 2010;44:101-108. https://doi.org/ 10.1111/j.1365-2923.2009.03546.x 12. mann k, gordon j, macleod a. reflection and reflective practice in health professions education: a systematic review. adv health sci educ 2009;14:595-621. https://doi.org/ 10.1007/s10459-007-9090-2 13. pelgrim eam, kramer awm, mokkink hga, et al. reflection as a component of formative assessment appears to be instrumental in promoting the use of feedback: an observational study. med teach 2013;35:772-778. https://doi. org/10.3109/0142159x.2013.801939 14. loughran j. effective reflective practice: in search of meaning in learning about teaching. j teach educ 2002; 53:33-43. https://doi.org/10.1177/0022487102053001004 accepted 5 march 2017. https://doi.org/10.1111/j.1743-498x.2005.00060.x https://doi.org/10.1111/j.1743-498x.2005.00060.x https://doi.org/10.1080/01421590701775453 https://doi.org/ 10.1111/j.1365-2929.2005.02358.x https://doi.org/ 10.1111/j.1365-2929.2005.02358.x https://doi.org/ 10.1186/1472-6920-12-97 https://doi.org/10.3109/0142159x.2011.577466 https://doi.org/10.3109/0142159x.2010.509420 https://doi.org/ 10.1136/bmj.a1961 https://doi.org/ 10.1007/s10459-008-9124-4 https://doi.org/ 10.1111/j.1365-2923.2009.03546.x https://doi.org/ 10.1007/s10459-007-9090-2 https://doi.org/10.3109/0142159x.2013.801939 https://doi.org/10.3109/0142159x.2013.801939 https://doi.org/10.1177/0022487102053001004 research 116 september 2017, vol. 9, no. 3 ajhpe the west african college of surgeons (wacs), west african college of physicians (wacp) and the national postgraduate medical college of nigeria (npmcn) regulate the postgraduate medical and dental education in the west african region and nigeria, respectively. [1,2] currently, progress report forms are completed annually by the trainers, i.e. specialist physicians and surgeons in the various teaching hospitals, to assess the progress of postgraduate training of junior doctors. at regular intervals, the colleges visit these hospitals to assess the facilities for postgraduate training for the purpose of maintaining the standard of training and re-accreditation of the institution for continued training of junior doctors. the term junior doctor in this regard refers to all cadres of doctors, except specialist physicians or surgeons who are fellows of any of the postgraduate medical colleges. these include senior resident doctors, junior resident doctors, medical officers, senior house officers and house officers. the resident doctors are those undergoing the residency training programme in various specialties to become specialist physicians or surgeons under the supervision of consultants. medical officers, although not enrolled in the residency training programme, also work under and learn from the specialists. the senior house officers and house officers are junior doctors at different stages of their pre-registration and compulsory supervised training after graduation from medical school. the specialist physicians and surgeons are appointed as consultants in the teaching hospitals to consult and oversee the training of junior doctors. to date, these assessments only focused on the trainees’ progress and did not take into consideration their perceptions of the trainers and other components in the environment in which they work, and how these affect their learning. the learning environment or educational environment has been considered to encompass physical (safety, food, shelter, comfort), emotional (security, feedback from trainers, absence of bullying and harassment) and intellectual (learning with patients, relevance to practice, evidence-based, active participation by learners) aspects. [3] working and learning in a clinical environment represent a challenging phase for doctors in training. junior doctors in this environment have to achieve a balance between a myriad of things, including care for their patients, adhering to their work schedules, dealing with the loss of a patient, and continuing with their academic pursuits, along with an obligation to their family, and their personal life. [4] the type or quality of the learning environment in a teaching hospital affects the motivation for clinical background. the learning environment represents various factors that describe the learner’s experiences in that setting. the learning environment of junior doctors undergoing training programmes in hospitals is considered a major factor determining both academic success and health service delivery performance. increased performance in both areas requires routine assessment of the learning environment to identify components that need attention. objective. to evaluate the perception of junior doctors undergoing specialist training regarding the learning environment in a teaching hospital. methods. this was a single-centre, cross-sectional study, using the postgraduate hospital educational environment measure (pheem). the questionnaire was used to collect data on the learning environment of junior doctors in all 10 clinical departments at the university of maiduguri teaching hospital, nigeria. all of the junior doctors (n=148) in the hospital at the time of the study received the questionnaire; they constituted the sample size for the survey. data collected were analysed to assess junior doctors’ perceptions of the overall learning environment and of the individual factors in the learning environment as measured by the individual items of pheem. results. the hospital educational environment was rated high, with a score of 98.25. the domains of the environment measure also showed positive perceptions, but revealed specific areas in need of attention as measured by the items of the questionnaire. significant (p<0.05) differences were noted in the perceptions of some items of the environment in the clinical departments. conclusions. the junior doctors’ perceptions of their educational environment were positive. the study was able to identify areas of strengths and weaknesses in the overall hospital learning environment and the specialty departments. overall, it identified the absence of an informative handbook for junior doctors and quality accommodation and catering facilities when the doctors were on call, as well as excess workload and lack of counselling services as areas that require the most attention to improve the learning environment. afr j health professions educ 2017;9(3):116-122. doi:10.7196/ajhpe.2017.v9i3.786 postgraduate trainees’ perceptions of the learning environment in a nigerian teaching hospital p i idon,1 bds, fmcds; i k suleiman,1 bds; h o olasoji,1,2 bsc, bchd, fmcds, fwacs, msc med educ (uk); z mustapha,3 mbbs, fwacs; h m abba,1 bds 1 department of dental surgery, university of maiduguri teaching hospital, nigeria 2 department of oral and maxillofacial surgery and oral pathology, faculty of dentistry, college of medical sciences, university of maiduguri, nigeria 3 department of radiology, college of medical sciences, university of maiduguri teaching hospital, nigeria corresponding author: p i idon (idonp85@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:idonp85@gmail.com research september 2017, vol. 9, no. 3 ajhpe 117 training, knowledge base and performance of junior doctors. [5,6] the teaching hospital has the responsibility of providing satisfactory education for its junior doctors, with the aim of improving the services they render to the public. [7] since recognising the importance of the quality of the learning environment of teaching hospitals in postgraduate medical education, the topic has received increased attention in the literature. [8-10] problems of junior doctors in the learning environment have been noted to include lack of clear objectives regarding the curriculum and its scope. the focus has been on knowledge acquisition, with little emphasis on problem-solving skills. other problems noted have included high workload, leaving little time for academic activities, as well as the more talked-about teaching-byhumiliation method employed by trainers. [11] roff [12] constructed and validated the postgraduate hospital educational environment measure (pheem) for hospital-based junior doctors in the uk. this tool is considered reliable for evaluating the quality of the educational environment of teaching hospitals, and has been used to measure the educational environment for junior doctors in several countries. [5,6,12,13] the lack of empirical data means that little is known about the way junior doctors perceive their learning environment. also, it provides an additional needed input on facilities and learning environment as perceived by the trainees. postgraduate regulatory bodies may use this as part of the assessment tools for the accreditation and re-accreditation of teaching hospitals for the training of junior doctors. the aim of this study was therefore to evaluate the perceptions of junior doctors regarding the learning environment at the university of maiduguri teaching hospital (umth), nigeria, by using pheem. the results of this study can serve as a basis for improvement and for future evaluation/comparison of trainees’ perceptions of nigerian postgraduate medical and dental education. the study therefore set out to determine: • the junior doctors’ perceptions of the hospital learning environment at umth • the effect of area of specialty on the perceptions of the learning environment • the effect of gender on the perceptions of the learning environment. methods study setting the study was conducted at umth, which is the main tertiary health centre in north-eastern nigeria. it is located in maiduguri, a semi-urban settlement and the capital of borno state. the hospital serves as a major referral centre for the north-eastern states and as a training centre for junior doctors in several specialties. currently, the hospital carries out training of junior doctors in 10 specialty departments: dental surgery, general outpatients, ophthalmology, ear nose and throat, internal medicine, obstetrics and gynaecology, paediatrics, pathology, radiology and surgery. study design and recruitment of participants the study employed a cross-sectional research approach in assessing the perceptions of the participants with regard to the hospital learning environment. employing a census survey method of sampling, all doctors below the grade rank of consultant in the various hospital departments and specialties at the time of the study in 2014 were included and constituted the study population. these included the resident doctors, medical officers, senior house officers and house officers. the participants were recruited individually into the study in their departments following an introduction of the objective of the study. data collection method the study used two self-administered questionnaires to collect data from the participants. the first consisted of short structured questions constructed to collect demographical information, such as the participant’s gender, age group, training grade, year in current grade and specialty. information on the participant’s perception of the hospital’s learning environment was collected with the pheem questionnaire. the researchers distributed questionnaires to all the participants by hand and retrieved the completed questionnaires in the same way. to achieve confidentiality, the data obtained from the participants did not include their names and therefore cannot be linked to any individual participant. pheem, as an assessment tool for the learning environment, is simple and practical, taking ˂5 minutes to complete, and has been validated in several studies, with reliability values of 0.92 and 0.93 using cronbach’s alpha.[6,12,13] the questionnaire consists of 40 items with regard to learning environment, divided into three subscales, i.e. perception of role autonomy; perception of teaching; and perception of social support. responses to each statement were indicated on a 5-point likert scale as follows: 0 for strongly disagree, 1 for disagree, 2 for uncertain, 3 for agree and 4 for strongly agree. the maximum possible score is 4 or 160 and the minimum is 0 for item score and overall scores, respectively, with higher scores indicating a better educational environment. four of the 40 items (items 7, 8, 11 and 13) are negative statements and were scored in reverse. three of the items were modified to suit the context in which the study was being carried out. item 7 (‘there is racism in this post’) was not applicable, as most of the junior doctors are nigerians, but of different tribes. the item was therefore modified to read, ‘there is racism/tribalism in this post’. item 11 (‘i am bleeped inappropriately’) was also modified because junior doctors are either required to stay in the emergency department or call rooms when on duty, or are fetched at their residence in the hospital quarters when the need arises. this was modified to read, ‘i am called inappropriately’. also, item 17 was modified to read, ‘my hours of work conform to the civil service rule’, as applicable in the country. data analysis analysis of the data obtained was performed using the statistical package for social sciences (spss) version 17.0 (spss inc., usa). descriptive statistics were reported in the form of frequencies, percentages, means, and standard deviations (sds). student’s t-test was used to compare the item mean and overall pheem scores between the genders, while analysis of variance (anova) statistics was used to analyse mean scores of items and overall scores among the training grades and specialties. statistical significance was inferred at p<0.05. ethical approval the research and ethical committee of the hospital approved the study (ref. no. umth/rec/17/0089) before commencement. a detailed explanation was given to each participant, with assurance of confidentiality regarding data collection and analysis. to achieve such confidentiality, names of participants were not included in the data collected. in data analysis, participants were assured that information provided will be deidentified by aggregating responses of individuals into groups and reporting them as means and sds. participation was voluntary, with consent sought and obtained from each participant included in the study. results of the 148 participants, 108 (66 males and 42 females) completed and returned the questionnaires – a response rate of 73%. data were received research 118 september 2017, vol. 9, no. 3 ajhpe from all 10 specialty departments of the hospital. the highest response rates were recorded from the ophthalmology, radiology and dental specialties, and the lowest rate (50%) from the surgery specialty. the number of junior doctors in the specialty areas ranged from 2 to 17, distributed among the various cadres of junior doctors, house officers, senior house officers, medical officers, junior registrars and senior registrars (table 1). the mean scores and sds of the 40 items of the pheem questionnaire are shown in table 2. the lowest item score was 1.08 for item 26 (‘there are adequate catering facilities when i’m on call’), while the highest was 3.16 (‘i have good collaboration with other doctors in my grade’). items 9 and 32 were scored less than average (2.0) in the perception of the autonomy domain. items 20, 26 and 38, relating to social support, were also ˂2.0. these items indicate problem areas in the learning environment. all other items had scores within the range of 2 3 (‘a more supportive/suitable educational environment, but with need for enhancement’), while only item 29 (‘i feel part of a team working here’) in the autonomy section and items 7, 13 and 16 in the social support section had scores >3.0. an overall score of 98.25 was obtained, with a score of 34.52 for perception of autonomy, 37.91 for perception of teaching and 25.76 for perception of social support (table 3). also shown in table 3 are the various domain scores and overall scores for the different specialties. more items were reported with below-average scores in the obstetrics and gynaecology and paediatrics specialties, while dental surgery and ophthalmology did not score less than average for any of the items (table 4). using kruskal-wallis (data normally distributed) one-way analysis of variance (anova), comparison of these scores among the specialties and the training grades did not show any statistically significant difference, with p=0.055 and p=0.478, respectively. the mann-whitney u-test for domain (perception of role autonomy, p=0.796; perception of teaching, p=0.186; perception of social support, p=0.867) and overall scores between the genders also did not show statistically significant differences (p=0.592). however, differences were noticed using one-way anova in item scores among the specialties (table 5). post-hoc analysis using the tukey honest significance difference (hsd) (equal variance assumed) and games-howell (equal variance assumption not met) statistics revealed the specialties with significant differences. junior doctors in radiology had a significantly better perception (mean 3.29 (sd 0.47)) of the appropriate level of responsibility (item 5) compared with those in internal medicine (2.14 (1.01)). dental surgery (1.19 (0.98)) and internal medicine (1.21 (1.12)) specialties rated item 9 significantly lower than obstetrics and gynaecology (2.80 (0.92)). the doctors in radiology (3.07 (0.73)) and obstetrics and gynaecology (3.50 (0.71)) gave significantly better ratings to item 14 than respondents from internal medicine (1.86 (1.09)), dental surgery (2.19 (1.11)) and paediatrics (2.12 (0.93). the perceptions of junior doctors in ophthalmology (3.00 (0.00)) and radiology (3.14 (0.77)) about their hours of work conforming to the civil service rule were significantly better than those of their colleagues in internal medicine (2.00 (0.96)) and surgery (1.10 (0.88)). item 26 revealed a statistically significant difference among the specialties (p=0.013). a posthoc tukey hsd test revealed a significant difference between respondents in radiology (2.00 (1.24)) and those in obstetrics and gynaecology (0.50 (0.71)) and surgery (0.60 (0.52)) regarding the quality of the catering service while on call. paediatric (1.29 (1.21)) and obstetrics and gynaecology (0.60 (1.00)) specialties had a greater level of disagreement with item 32 (‘my workload in this job is fine’) compared with the response from dental surgery (2.81 (1.05)), pathology (2.78 (0.67)), radiology (2.79 (0.80)) and ophthalmology (3.00 (0.00)). respondents from ophthalmology (3.00 (0.00)) rated the mentoring skills of their teachers significantly higher than the junior doctors in paediatrics (2.00 (1.06)) and there was also better feedback from them than from junior doctors in the general outpatient department (gopd) (1.85 (0.99)). discussion this study used pheem to assess the educational environment of junior doctors in a teaching hospital setting involving all the specialty departments. it also included junior doctors who are not yet in the residency programme, e.g. medical officers, senior house officers and house officers. from the results it was evident that pheem is a reliable tool for assessing the strengths and weaknesses of the postgraduate hospital training environment. [14] the learning environment in the hospital was valued fairly well by the junior doctors, but with room for improvement, as shown by a score of 98.25, corresponding to the ‘more positive than negative environment’ according to the criteria proposed by pheem. [12] the three subscale scores also revealed that there was a more positive perception towards the role of autonomy, and that the perceptions of teaching were moving in the right direction. furthermore, it was found that the perceptions of social support had more positives than negatives. the lowest recorded item score was 1.08 (item 26: ‘there are adequate catering facilities when i am on call’) and the highest was 3.16 (item 16: ‘i table 1. demographic distribution of the participants (n=108) demographic distribution frequency (%) gender male 66 (61.1) female 42 (38.9) total 108 (100) training level house officer 26 (24.1) senior house officer 5 (4.6) medical officer 22 (20.4) junior registrar 36 (33.3) senior registrar 19 (17.6) total 108 (100) specialty dental surgery 16 (14.8) medicine 14 (13.0) obstetrics and gynaecology 10 (9.3) pathology 9 (8.3) paediatrics 17 (15.7) surgery 10 (9.3) radiology 14 (13.0) ophthalmology 2 (1.9) ear, nose and throat 3 (2.8) general outpatient department 13 (12.0) total 108 (100) research september 2017, vol. 9, no. 3 ajhpe 119 table 2. mean scores of each item of the pheem questionnaire item domain mean (sd) perception of role of autonomy 1 i have a contract of employment that provides information about hours of work 2.20 (1.17) 4 i had an informative induction programme 2.07 (1.13) 5 i have the appropriate level of responsibility in this post 2.81 (0.98) 8 i have to perform inappropriate tasks 2.38 (1.15) 9 there is an informative junior doctors’ handbook 1.75 (1.08) 11 i am called inappropriately 2.56 (1.05) 14 there are clear clinical protocols in this post 2.44 (1.00) 17 my hours of work conform to the civil service rule 2.19 (1.22) 18 i have the opportunity to provide continuity of care 2.86 (0.63) 29 i feel part of a team working here 3.01 (0.83) 30 i have opportunities to acquire appropriate practical procedures for my grade 2.81 (0.83) 32 my workload in this job is fine 1.96 (1.30) 34 the training in this post makes me feel ready to be a senior registrar/consultant 2.62 (0.92) 40 my clinical teachers promote an atmosphere of mutual respect 2.82 (0.98) perception of teaching 2 my clinical teachers set clear expectations 2.73 (1.01) 3 i have protected educational time in this post 2.21 (1.11) 6 i have good clinical supervision at all times 2.28 (1.11) 10 my clinical teachers have good communication skills 2.94 (0.86) 12 i am able to participate actively in educational events 2.82 (0.91) 15 my clinical teachers are enthusiastic 2.80 (0.83) 21 there is access to an educational programme relevant to my needs 2.16 (1.06) 22 i get regular feedback from seniors 2.48 (0.89) 23 my clinical teachers are well organised 2.51 (1.05) 27 i have enough clinical learning opportunities for my needs 2.03 (1.13) 28 my clinical teachers have good teaching skills 2.91 (0.76) 31 my clinical teachers are accessible 2.77 (0.97) 33 senior staff utilise learning opportunities effectively 2.25 (0.93) 37 my clinical teachers encourage me to be an independent learner 2.74 (0.97) 39 my clinical teachers provide me with good feedback on my strengths and weaknesses 2.28 (1.05) perception of social support 7 there is racism/ tribalism in this post 3.03 (1.02) 13 there is sex discrimination in this post 3.07 (1.04) 16 i have good collaboration with other doctors in my grade 3.16 (0.63) 19 i have suitable access to careers advice 2.25 (1.09) 20 this hospital has good-quality accommodation for junior doctors, especially when on call 1.79 (1.24) 24 i feel physically safe within the hospital environment 2.69 (0.98) 25 there is a no-blame culture in this post 2.06 (1.09) 26 there are adequate catering facilities when i am on call 1.08 (1.09) 35 my clinical teachers have good mentoring skills 2.53 (0.97) 36 i get a lot of enjoyment out of my present job 2.29 (1.00) 38 there are good counselling opportunities for junior doctors who fail to complete their training satisfactorily 1.90 (1.18) pheem = postgraduate hospital educational environment measure; sd = standard deviation. research 120 september 2017, vol. 9, no. 3 ajhpe have good collaboration with other junior doctors’). the majority of the items (31 of 40) had mean scores between 2 and 3, with only four items scoring >3 (7, 13, 16 and 29). these results highlight that the majority of the areas in the learning environment need improvement. however, it is also good to know that the areas where the junior doctors were most satisfied with their environment border on racism and tribalism, sex discrimination, collaboration with other junior doctors and sense of belonging to a team. in a study by vieira, [15] it was noted that the residents also had a positive perception of the learning environment in terms of gender and racism. clapham et al. [16] reported similar findings in a small sample of intensivecare residents in a hospital in the uk. weaknesses identified in the environment, as indicated by a mean score of ˂2, appeared in five items (9, 20, 26, 32 and 38). this signifies that there was no information booklet available for junior doctors to orientate them with regard to the postgraduate programme. moreover, other weaknesses table 3. subscale and overall pheem scores of the different specialties score assessment dental surgery medicine o & g pathology paediatrics surgery radiology ophthalmology ent gopd mean (sd) perception of role of autonomy 0 14 very poor 35.1 30.4 36.0 38.1 32.2 32.2 40.6 36.5 32.7 32.9 34.5 (7.3) 15 28 a negative view of one’s role 29 42 a more positive perception of one’s job 43 56 excellent perception of one’s job perception of teaching 0 15 very poor 16 30 in need of some training 31 45 moving in the right direction 38.3 34.0 39.4 40.9 33.8 40.4 44.2 41.0 40.3 33.9 37.9 (8.8) 46 60 model teachers perception of social support 0 11 not existent 26.9 24.4 24.2 25.1 24.1 26.6 30.3 27.5 29.0 23.8 25.8 (5.6) 12 22 not a pleasant place 23 33 more pros than cons 34 44 a good supportive environment overall 0 40 very poor 41 80 plenty of problems 80 120 more positive than negative 100.3 88.8 99.6 104.1 90.1 99.2 115.1 105 102 90.6 98.3 (20.0) 121 160 excellent pheem = postgraduate hospital educational environment measure; o & g = obstetrics and gynaecology; ent = ear, nose and throat; gopd = general outpatient department; sd = standard deviation. table 4. items rated below average by the different specialties specialty items with scores ˂2.0 dental surgery ear, nose and throat 17, 20 general outpatient department 20 medicine 20, 25 obstetrics and gynaecology 17, 19, 20, 32 ophthalmology paediatrics 20, 23, 25, 36 pathology 20, 25 radiology 20 surgery 17 research september 2017, vol. 9, no. 3 ajhpe 121 were: inadequate accommodation and catering facilities when on call, excessive workload and absence of good counselling opportunities. vieira [15] reported low scores in four of these areas, suggesting lack of professional and personal support in the learning environment. similarly, al-sheikh et al. [14] reported the lowest scores for catering, housing, information and guidance. the absence of adequate orientation of junior doctors at the beginning of their training, as seen with the low score for item 9, may have an effect on their learning, as this could result in difficulties in making informed choices in career paths from peculiarities of the different clinical rotations. an information handbook detailing the job description for every member of the health team could reduce the possibility of exploitation. [14] it is interesting to note that three of these items (20, 26 and 38) are in the domain of the perception of social support. the results of these items revealed that the educational environment is weak in the area of social support. there was general agreement among the departments with regard to item 20 (‘this hospital has good-quality accommodation for junior doctors, especially when on call’) as 9 of the 10 specialties scored it ˂2.0 (table 4). these three items in the social support domain, and the low score for item 32 (‘my workload in this job is fine’), may support the association between the residency training programme and stress, depression and burnout, which are thought to be mainly due to excessive working hours, sleep deprivation, challenging patients and an aggressive and challenging work environment. [17-19] to improve the learning environment of the doctors in this study, attention should be given to the following focus areas: developing and providing the junior doctors with an information handbook, improving the quality of the accommodation, improving the catering facilities, finding a way to reduce the workload, and providing counselling for the junior doctors if needed. lleras and durante, [20] in a recent study, found a significant negative correlation between the educational environment and burnout among resident doctors, using pheem and maslach burnout inventory questionnaires. the approach to reducing burnout in residents should include other components of the working environment, as a reduction in the workload alone has been found to be unsuccessful. [21] analysis of the overall scores and subscale scores for level of training, gender and specialty department revealed no significant difference in the overall and subscale scores. khoja [22] reported a significantly better perception of the learning environment by the junior doctors in their last year of training compared with those in the first 3 years. possible reasons were reduced workload, greater contact time with their trainers, and increased supervision and feedback from their trainers. however, clapham et al. [16] found that senior house officers scored the learning environment better than other junior doctors who are ahead of them in training. boor et al., [6] with similar results as clapham et al., [16] explained that the house officers and senior house officers may have a better perception of the learning environment, as they have lesser responsibilities and stress compared with those faced by other junior doctors who are ahead of them in training. the differences noted in the results of the abovementioned studies may be due to varying regulations regarding duties and workload for the levels of trainees in different institutions. kanashiro et al., [23] as in the current study, did not find significant differences in the perception of the learning environment among the house officers, senior house officers and the other junior doctors who are ahead of them in training level. however, the authors noted significant gender differences in the scores. our study and other studies [12-14] did not find significant gender differences in pheem scores. although all the specialties or departments were in the same hospital, there was a significant difference in their perceptions of some aspects of the learning environment, as seen, for example, with items 9, 17, and 32, where the junior doctors in dental surgery, internal medicine, ophthalmology, radiology, paediatrics and obstetrics and gynaecology had significantly different perceptions, respectively, than their counterparts in other specialties. these differences may reflect variations in the organisation and use of set protocols in the departments, as well as staff strength and workload assigned to individuals. some specialties may make increased demands on the time of the junior doctors. this may explain why junior doctors in paediatrics and obstetrics and gynaecology reported a significantly greater level of disagreement with their workload. algaidi [24] also noted differences in the perceptions of the learning environment among specialties in the same hospital, where he reported a significantly better perception of the learning environment by the junior doctors in general surgery compared with those in internal medicine. according to algaidi,[24] this is an indication that the learning environment in each department is as important as the general hospital environment, which may have significant effects on the quality of the learning environment. conclusion this study has identified areas of strengths and weaknesses in the hospital educational environment and the 10 individual specialty departments in the same hospital. interventions in the areas of weaknesses identified should be implemented and followed up with regular assessments of the educational environment using pheem as a means of quality control. although this study presented findings from only one hospital, the results could assist other curriculum developers in the country’s postgraduate medical training programmes in assessing their learning environment, making comparisons table 5. analysis of the differences in item scores among the specialties item number statement f-value p-value 5 i have the appropriate level of responsibility in this post 2.545 0.011 9 there is an informative junior doctors’ handbook 3.096 0.003 14 there are clear clinical protocols in this post 3.551 0.001 17 my hours of work conform to the civil service rule 3.023 0.003 26 there are adequate catering facilities when i am on call 2.498 0.013 32 my workload in this job is fine 5.559 <0.001 35 my clinical teachers have good mentoring skills 2.489 0.013 39 my clinical teachers provide me with good feedback on my strengths and weaknesses 1.999 0.047 research 122 september 2017, vol. 9, no. 3 ajhpe and introducing measures to improve the environment for the training of junior doctors. this is important, as the quality of the junior doctors’ experiences in the learning environment relates to the quality of training and therefore the quality of care received by the patients they care for. acknowledgements. none. author contributions. pii: study idea, development of the study idea, experimental design, and preparation of the manuscript; kis: collected data, evaluated statistics and contributed to discussion; hoo: further development of the study idea, development of experimental design and proofreading of the manuscript; zm: proofreading of the manuscript and development of experimental design; and hma: collected data, prepared results from statistical evaluation and contributed to manuscript preparation. funding. none. conflicts of interest. none. 1. west african postgraduate medical college. profile of the college. http://www.wapmc.org/about (accessed 18 february 2016). 2. national postgraduate medical college of nigeria. president’s speeches: welcome npmcn. http://www.npmcn. edu.ng/welcome-to-npmcn (accessed 18 february 2016). 3. chambers r, wall d. teaching made easy: a manual for health professionals. abingdon, uk: radcliffe 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learning environment for junior doctor training – what hinders, what helps. med teach 2005;27(7):619-624. https://doi.org/10.1080/01421590500069710 9. cross v, hicks c, parle j, field s. perceptions of the learning environment in higher specialist training of doctors: implications for recruitment and retention. med educ 2006;40(2):121-128. https://doi.org/10.1111/j.13652929.2005.02382.x 10. wall d, clapham m, riquelme a, et al. is pheem a multi-dimensional instrument? an international perspective. med teach 2009;31(11):e521-e527. https://doi.org/10.3109/01421590903095528 11. rotem a, bloomfield l, southon g. the clinical learning environment. isr j med sci 1996;32(9):705-710. 12. roff s, mcaleer s, skinner a. development and validation of an instrument to measure the postgraduate clinical learning and teaching environment for hospital-based junior doctors in the uk. med teach 2005;27(4):326-331. https://doi.org/10.1080/01421590500150874 13. aspegren k, bastholt l, bested km, et al. validation of the pheem instrument in a danish hospital setting. med teach 2007;29(5):498-500. https://doi.org/10.1080/01421590701477357 14. al-sheikh mh, ismail mh, al-khater sa. validation of the postgraduate hospital educational environment measure at a saudi university medical school. saudi med j 2014;35(7):734-738. 15. vieira je. the postgraduate hospital educational environment measure (pheem) questionnaire identifies quality of instruction as a key factor predicting academic achievement. clinics 2008;63(6):741-746. https://doi. org/10.1590/s1807-59322008000600006 16. clapham m, wall d, batchelor a. educational environment in intensive care medicine: use of postgraduate hospital educational environment measure (pheem). med teach 2007;29(6):184-191. https://doi. org/10.1080/01421590701288580 17. al-marshad s, alotaibi g. evaluation of clinical education environment at king fahad hospital of dammam university using the postgraduate hospital education environment measure (pheem) inventory. educ med j 2011;3(2):e6-e14. https://doi.org/10.5959/eimj.3.2.2011.or1 18. collier vu, mccue jd, markus a, smith l. stress in medical residency: status quo after a decade of reform? ann intern med 2002;136(5):384-390. https://doi.org/10.7326/0003-4819-136-5-200203050-00011 19. peterlini m, tiberio if, saadeh a, pereira jc, martins ma. anxiety and depression in the first year of medical residency training. med educ 2002;36(1):66-72. https://doi.org/10.1046/j.1365-2923.2002.01104.x 20. lleras j, durante e. correlation between the educational environment and burn-out syndrome in residency programs at a university hospital. arch argent pediatr 2014;112(1):e6-e11. https://doi.org/10.5546/aap.2014.eng.6 21. celfand dv, podnos yd, carmichael jc, saltzman dj, wilson se, williams ra. effect of the 80-hour workweek on resident burnout. arch surg 2004;139(9):933-938. https://doi.org/10.1001/archsurg.139.9.933 22. khoja at. evaluation of the educational environment of the saudi family medicine residency training program. j fam community med 2015;22(1):49‐56. https://doi.org/10.4103/2230-8229.149591 23. kanashiro j, mcaleer s, roff s. assessing the educational environment in the operating room – a measure of resident perception at one canadian institution. surgery 2006;139(2):150-158. https://doi.org/10.1016/j. surg.2005.07.005 24. algaidi sa. assessment of educational environment for interns using postgraduate hospital educational environment measure (pheem). j t u: med sci 2010;5(1):1-12. https://doi.org/10.1016/s1658-3612(10)70118-9 accepted 22 october 2016. http://www.wapmc.org/about http://www.wapmc.org/about http://www.npmcn.edu.ng/welcome-to-npmcn http://www.npmcn.edu.ng/welcome-to-npmcn https://doi.org/10.1001/jama.279.15.1194 https://doi.org/10.2147/ijgm.s45336 https://doi.org/10.1111/j.1365-2929.2006.02651.x https://doi.org/10.1111/j.1365-2929.2006.02651.x https://doi.org/10.1097/00001888-200406000-00007 https://doi.org/10.1080/01421590500069710 https://doi.org/10.1111/j.1365-2929.2005.02382.x https://doi.org/10.1111/j.1365-2929.2005.02382.x https://doi.org/10.3109/01421590903095528 https://doi.org/10.1080/01421590500150874 https://doi.org/10.1080/01421590701477357 https://doi.org/10.1590/s1807-59322008000600006 https://doi.org/10.1590/s1807-59322008000600006 https://doi.org/10.1080/01421590701288580 https://doi.org/10.1080/01421590701288580 https://doi.org/10.5959/eimj.3.2.2011.or1 https://doi.org/10.7326/0003-4819-136-5-200203050-00011 https://doi.org/10.1046/j.1365-2923.2002.01104.x https://doi.org/10.5546/aap.2014.eng.6 https://doi.org/10.1001/archsurg.139.9.933 https://doi.org/10.4103/2230-8229.149591 https://doi.org/10.1016/j.surg.2005.07.005 https://doi.org/10.1016/j.surg.2005.07.005 https://doi.org/10.1016/s1658-3612(10)70118-9 research 98 september 2017, vol. 9, no. 3 ajhpe a registrar is a medical doctor undergoing training to become a specialist. registrars frequently feel exhausted because of long working hours, overwhelmed by having a large body of clinical knowledge to master, stressed because of patients who depend on them for survival, financially burdened owing to an insufficient salary, and challenged with balancing the demands of professional and personal life.[1,2] registrars often have tremendous responsibilities at work; yet, they have very little autonomy. according to the job demand-control-support model, employees who work in jobs with high demands, low control, and low social support experience the lowest level of psychological and physical wellbeing.[3] therefore, registrars are at high risk of developing burnout.[4] burnout has been defined as a three-dimensional syndrome that includes emotional exhaustion, depersonalisation and reduced personal accomplishment.[5] emotional exhaustion is a depletion of emotional resources. depersonalisation is a negative and cynical attitude towards others. reduced personal accomplishment is a negative and dissatisfied evaluation of oneself. unlike major depressive disorder, which affects all aspects of a person’s life, burnout is a distinct work-related syndrome.[5] globally, research has shown that burnout rates among doctors range from 25% to 76%.[1,4,6] burnout has been correlated with various physical symptoms, including fatigue, insomnia, headaches and gastrointestinal distress.[1,4,5] potential consequences of burnout include an increase in alcohol and drug use, a higher rate of depression, and an increased incidence of marital and family problems.[1,4,5] doctors who are burnt out are more likely to self-report suboptimal patient care and medical errors.[6,7] burnout often decreases empathy, compassion, and availability of doctors for their patients, which leads to lower patient satisfaction.[8] overall, burnout can negatively impact a registrar’s quality of life and the ability to provide sustainable, safe, and empathetic patient care, simultaneously weakening the morale of registrars in training programmes.[1,4,6,8] in resource-limited settings, work-related stresses are amplified compared with those of doctors working in resource-rich settings.[9,10] registrars in resource-limited settings often work in overcrowded hospitals with inadequate medical supplies and equipment, have fewer mentoring and career-building opportunities, are paid less, and are faced with high patient mortality rates. in sub-saharan africa, hiv has added to the workload, with background. burnout during registrar training is high, especially in resource-limited settings where stressors are intensified. burnout leads to decreased quality of life for doctors, poor job and patient satisfaction, and difficulty retaining doctors. objectives. primary: to measure burnout among registrars working at princess marina hospital in gaborone, botswana. secondary: to determine factors contributing to burnout and identify potential wellness interventions. methods. the validated maslach burnout inventory was used to measure the degree of emotional exhaustion, depersonalisation and personal accomplishment. work-related difficulties and potential wellness interventions were explored through multiple-choice and open-ended questions. results. of 40 eligible registrars, 20 (50%) completed the survey. high levels of burnout were reported for emotional exhaustion in 65% (13/20), depersonalisation in 45% (9/20), and personal accomplishment in 35% (7/20) of registrars. a high degree of burnout was reported by 75% (15/20) of registrars in one or more domains. in the previous 7 days, registrars worked an average of 77 hours, took 1.5 overnight calls, slept 5.7 hours per night, and 53% (10/19) had ≥1 of their patients die. five (25%) registrars considered leaving botswana to work in another country, which correlated with those with the highest degree of burnout. the most common frustrations included insufficient salary and limited medical resources. suggested interventions included improved mentorship and wellness lectures. conclusions. there is a high degree of burnout, especially emotional exhaustion, among registrars. encouragingly, most registrars have a desire to work in botswana after training. future research on improving registrar wellness in low-resource settings is urgently needed. afr j health professions educ 2017;9(3):98-102. doi:10.7196/ajhpe.2017.v9i3.881 registrar wellness in botswana: measuring burnout and identifying ways to improve wellness k d westmoreland,1,2,3 md; e d lowenthal,1,3,4 md, msce; r finalle,1,4 md; l mazhani,2 md; m cox,5 md; j c mwita,6 md; s b mphele,7 psyd; c e turner,1 md; a p steenhoff,1,2,3,4 mb bch, dch 1 global health center and department of pediatrics, the children’s hospital of philadelphia, pa, usa 2 department of paediatric and adolescent health, faculty of medicine, university of botswana, gaborone, botswana 3 botswana-university of pennsylvania (botswana-upenn) partnership, gaborone, botswana 4 university of pennsylvania perelman school of medicine, pa, usa 5 department of emergency medicine, faculty of medicine, university of botswana, gaborone, botswana 6 department of internal medicine, faculty of medicine, university of botswana, gaborone, botswana 7 department of psychology, faculty of medicine, university of botswana, gaborone, botswana corresponding author: k d westmoreland (katewestmoreland@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research september 2017, vol. 9, no. 3 ajhpe 99 a higher burden, acuity, and complexity of disease, and has increased the number of patient deaths.[10,11] these added stressors of doctors working in resource-limited settings may lead to higher rates of burnout.[9,10] there are only a few published reports on registrar burnout from subsaharan africa, with the majority from south africa (sa). one study of 22 junior doctors in cape town, sa, described that 100% experienced a high degree of burnout, and all but one expressed the intention to leave the public hospital where they were working after completing training.[10] a second study from sa found that 26% of registrars and medical officers working at a public healthcare facility experienced a high degree of burnout.[12] a third study in sa reported that 27% of anaesthesia registrars experienced a high degree of burnout, which was significantly higher when compared with the consultants.[13] outside of sa, there was only a single study from kenya describing that 82% of registrars self-reported being moderately affected by burnout, but this was not formally evaluated with a standardised burnout inventory.[11] currently, there are no available data on burnout rates among doctors in botswana, a setting with a new medical school, high population prevalence of hiv, and a number of new registrar training programmes. the primary objective of this study was to measure burnout among registrars working at princess marina hospital (pmh) in gaborone, botswana. the secondary objectives were to determine possible factors associated with or protective against burnout and to identify possible wellness interventions that could be implemented in this resource-limited setting to prevent and minimise burnout. methods study setting pmh is a 525-bed tertiary referral hospital in gaborone. it is the largest hospital in botswana and serves the southern half of the country, as well as selected referrals from the north. in 2009, the university of botswana opened the country’s first medical school, and it remains the only medical school in the country. pmh is the academic teaching hospital and site for clinical rotations for medical students at the university of botswana. the university has registrars in paediatrics, internal medicine, emergency medicine, family medicine, pathology and public health. the registrar training programme spans 4 years, with clinical rotations in both botswana and sa. the 5th year is a chief resident or senior registrar year in botswana, during which registrars complete both their master in medicine research thesis and, for those who have not yet done so, their respective south african colleges of medicine final specialist examinations. study design and instruments all registrars in botswana who provide direct patient care at pmh were invited to participate in this study, which used a two-part survey questionnaire. the first part of the questionnaire used the maslach burnout inventory (mbi) for health service workers to measure the level of burnout experienced by the registrars. the mbi, first formulated in 1981, was designed for and validated in all categories of human service.[5] it consists of 22 items that measure emotional exhaustion, depersonalisation and diminished feelings of personal accomplishment through 7-point likert scales, indicating the frequency of characteristic symptoms.[5] the mbi has established construct, and discriminant and convergent validity.[5] it is valid, reliable and consistent, having been used to study burnout across professions, countries, languages and cultures.[5] the mbi has been tested extensively and has become the gold standard for identifying burnout in the medical research literature.[4] it has been validated and used across africa to measure burnout in healthcare workers, including registrars, with most extensive use in sa.[10,12-14] the second part of the questionnaire included demographic information, work and wellness-related questions, questions to assess potential factors associated with and protective from burnout, and questions to assist in developing a future wellness programme. the questions were in multiplechoice and open-ended free-text format. enrolment of participants the questionnaire was administered using research electronic data capture (redcap) software (usa).[15] the questionnaire link was emailed to all university of botswana registrars who were providing direct patient care at pmh: 20 paediatric, 16 internal medicine, and 4 emergency medicine registrars. pathology and public health registrars were excluded, as they do not provide direct patient care. family medicine registrars were also excluded, as they provide the majority of their clinical care outside of pmh in the district hospitals. prior to initiation of the study, it was explained in person during academic meetings to all eligible registrars by the study’s principal investigator (kw). further study information was provided electronically via email using redcap, and informed consent was obtained. all responses were de-identified through redcap to ensure respondent confidentiality. as recommended in the mbi manual, the questionnaire was presented as a survey on registrar wellness and job-related attitudes and did not mention burnout – to ensure that the respondents were not sensitised to the concept of burnout and did not tailor their responses in that regard.[5] we aimed for a response rate of at least 50%, allowing for a margin of error of ±15% around the 95% confidence level. requests to complete the questionnaire were re-sent to qualifying registrars until a 50% response rate was reached. analysis the mbi scores were calculated and classified based on the recommended normative values.[5] a high degree of burnout is reflected by high scores on emotional exhaustion and depersonalisation subscales and low scores on the personal accomplishment subscale, which is protective against burnout.[5] each of the three dimensions of burnout is categorised as high, moderate, and low, using standardised numerical cut-off points provided by the mbi manual for medical providers (table 1).[5] the scores are considered high if they are in the upper third of normative distribution, average if they are in the middle third, and low if they are in the lower third.[5] as set out in the manual, we described each of the three dimensions of burnout separately, and not as a single combined score.[5] the median and interquartile range (iqr) were provided for each dimension of burnout (emotional exhaustion, depersonalisation and personal accomplishment). scores in our population were compared with those for the 1 104 normative medical professionals provided in the mbi manual for each dimension of burnout.[5] normality of our samples was tested using the shapiro-wilk test, and then either one sample t-test or the wilcoxon signed-rank test was used, as appropriate, based on the distribution of data. table 1. classification of the three dimensions of burnout for medical professionals as defined by the maslach burnout inventory dimensions of burnout low moderate high emotional exhaustion ≤18 19 26 ≥27 depersonalisation ≤5 6 9 ≥10 personal accomplishment ≥40 39 34 ≤33 research 100 september 2017, vol. 9, no. 3 ajhpe demographic data and multiple-choice responses were described using median, iqr, ratio and percentages. the free-text answers were descriptively summarised. ethical approval each registrar programme director from paediatric, emergency and internal medicine individually approved this study. the study was reviewed and approved by the institutional review boards of the botswana ministry of health (ref. no. 13181), the university of botswana (ref. no. 1475), and the university of pennsylvania, usa (ref. no. 820222). the validated mbi instrument was purchased from mind garden, inc. (usa)[5] and permission and a licence were obtained to use the questionnaires for this research project. results of 40 eligible registrars, 20 (50%) completed the survey: 11/20 (55%) paediatric registrars, 2/4 (50%) emergency medicine registrars, 6/16 (38%) internal medicine registrars and 1 unknown. of the 20 respondents, 19 completed the entire survey, and 1 completed the mbi portion only, but not the demographic, workand wellness-related questionnaire portion. the median age of the 19 respondents who completed the entire survey was 32 (iqr 31 34) years, with 11/19 (58%) male. nine of 19 (47%) were married and 14/19 (74%) had children. respondents had a median of 3 (iqr 2 4) years of postgraduate work experience prior to registrar training. in the previous 7 days, registrars worked an average of 77 (iqr 67 85) hours, took 1.5 (iqr 1 2) overnight calls, slept 5.7 (iqr 5 6) hours per day, and exercised 1.3 (iqr 0 2) hours per week. in 53% (10/19) of registrars, ≥1 of their patients died in the previous week. burnout a high degree of burnout was reported by 75% (15/20) of registrars in ≥1 domains, 55% (11/20) in 2 3 domains, and 15% (3/20) in all 3 domains of burnout. twenty-five percent (5/20) of registrars did not experience a high degree of burnout in any domain. fig. 1 depicts the degree of burnout for each domain reported among registrars. emotional exhaustion burnout scores for emotional exhaustion were found to be high for 65% (13/20), moderate for 20% (4/20), and low for 15% (3/20) of respondents. our pmh cohort had a median emotional exhaustion of 35.5 (iqr 23.5 41.0), which was significantly higher than the normative sample (mean emotional exhaustion score of 22.19 (standard deviation (sd) 9.53), t-test p=0.0011). depersonalisation burnout scores for depersonalisation were found to be high for 45% (9/20), moderate for 5% (1/20), and low for 50% (10/20) of respondents. our pmh cohort had a median depersonalisation score of 5.5 (2.0 14.5), which was not significantly different than the mean of the normative sample (mean depersonalisation score of 7.12 (sd 5.22), wilcoxon signed-rank test p=0.60). personal accomplishment burnout scores for personal accomplishment were found to be high for 35% (7/20), moderate for 30% (6/20), and low for 35% (7/20) of respondents. fig. 1. burnout experienced by clinical registrars working at the princess marina hospital in gaborone, botswana (n=20). 0 2 4 6 8 10 12 14 16 18 emotional exhaustion depersonalisation personal accomplishment re g is tr ar s, n burnout domains high moderate low 65% 20% 45% 5% 35% 30% 15% 50% 35% 20 table 2. factors leading to burnout as identified by clinical registrars working at princess marina hospital in gaborone, botswana (n=18) factor leading to burnout n (%) insufficient salary 17 (94) limited resources 16 (89) long working hours 13 (72) overnight calls 13 (72) insufficient support from ancillary staff 11 (61) work-life balance 9 (50) overwhelmed by too many patients 9 (50) insufficient support from administration 8 (44) insufficient support from consultants 6 (33) inadequate knowledge base 5 (28) medical complexity of patients 2 (11) difficulties coping emotionally with death of patients 2 (11) table 3. stress reduction techniques practised by clinical registrars working at princess marina hospital in gaborone, botswana (n=18) stress reduction technique n (%) spending time with family and friends 13 (72) alone time 11 (61) entertainment events 10 (56) exercise and sports 9 (50) sleeping 9 (50) church 9 (50) taking holiday 8 (44) shopping 6 (33) cooking 4 (22) listening to or playing music 3 (17) hobby 2 (11) going out partying 2 (11) being outdoors 2 (11) drinking alcohol 1 (6) using drugs 1 (6) research september 2017, vol. 9, no. 3 ajhpe 101 our pmh cohort had a median personal accomplishment score of 36.0 (iqr 28.5 40.2), which was not significantly different than the mean of the normative sample (mean personal accomplishment score 36.53 (sd 7.34), wilcoxon signed-rank test p=0.35). future plans and retention after registrar training, 58% (11/19) planned to seek sub-specialty training. twenty-six percent (5/19) intended to leave botswana after training to work in another country as a doctor, and 5% (1/19) of participants intended to leave the field of medicine after training. sixty-seven percent (4/6) of registrars with the most severe emotional exhaustion on the mbi indicated their intention to leave botswana. all registrars (3/3) with high levels in all three domains of burnout on the mbi indicated their intention to leave botswana. factors leading to burnout table 2 summarises the job-related frustrations and difficulties that led to burnout. the most common were insufficient salary, limited resources, long working hours, and overnight calls. stress reduction table 3 summarises the most common stress-relieving activities that registrars practised. the most common were spending time with family and friends, alone time, and entertainment events. wellness interventions table 4 summarises wellness activities suggested by the registrars. the most frequently proposed included lectures (wellness, stress reduction, work-life balance and career development), improved mentorship and registrar social events. there was an emphasis on improving the overnight on-call experience, including improved support from consultants, protected time off post-call, access to a cafeteria at the hospital, an on-call room for sleeping, and an on-call break room with access to a refrigerator and microwave. other items that the registrars requested included improved salary, especially when rotating in sa, team building for the department, and protected non-clinical time to work on their master in medicine research project. discussion decreasing registrar burnout and improving quality of life and wellness are key to improving patient care, job satisfaction and retaining doctors in the public sector. the development and implementation of wellness programmes into registrar training are both essential and urgently needed.[8,16] the first step towards addressing this problem is to describe the magnitude of registrar burnout. we describe a high degree of burnout, with statistically significant high levels of emotional exhaustion among clinical registrars training at pmh in gaborone. it is encouraging, however, that most of the registrars continue to have a positive sense of personal accomplishment and expressed a desire to work in botswana after training. we found that 75% of registrars had a high level of burnout in at least one domain. these results are in the upper range of normal for registrars internationally, with reports of burnout ranging from 25% to 76%.[1,4,6] a rate of high emotional exhaustion (65%) was similar to that described in studies from sa, where the level was 46 90%.[10,12] twenty-six percent of the registrars reported the intention to leave botswana to work in another country. a similar publication from sa reported that 95% of junior doctors expressed an intention to leave the public hospital where they were training, but the study did not evaluate the doctors’ intention to leave the country.[10] in our study, the registrars with a high level of burnout in all three domains and those with the highest scores of emotional exhaustion were over-represented among those who expressed a desire to leave botswana to practise medicine elsewhere. it is therefore essential to prioritise the introduction of wellness interventions to decrease burnout and emotional exhaustion, as this will likely promote retention of newly trained specialists. from 1990 to 2009, the botswana ministry of education trained ~1 000 doctors in foreign medical schools, of whom only 10% have returned home to work in botswana.[17] in 2009, the university of botswana opened botswana’s first medical school and established registrar training programmes in an attempt to increase the number of doctors in botswana and improve the overall healthcare system.[17] the majority of sub-saharan african countries have a critical shortage of healthcare providers, despite their high burden of disease. as a response, sub-saharan african governments, with the assistance of the medical education partnership initiative (mepi), have opened new medical schools throughout the region.[17] as new medical schools open across africa, it is essential to study and better understand burnout among registrars in resource-limited settings to improve patient care, job satisfaction and retention of doctors in their home country. we found that the most common factors leading to burnout were insufficient salary, limited resources, long working hours and overnight calls, which are similar to factors reported in other studies.[4,10,18,19] the most frequently proposed wellness interventions by the botswanan registrars included wellness lectures, improved mentorship and registrar social events. these requests are in line with the views of global experts, who are focusing on improving wellness of registrars-in-training, where both individually focused and organisational strategies have been found to decrease burnout among physicians.[4,16,19,20] the results from this study have led to the initiation of wellness activities for registrars at the university of botswana, including wellness lecture series, access to free individual psychotherapy through the department of psychology and registrar social activities, including an annual appreciation luncheon. these activities have been well received by the registrars, but a continued focus on improving the wellness of registrars working in botswana and across sub-saharan africa is urgently needed. study limitations the limitations of our study include a relatively small sample size and 50% response rate. multiple attempts were made to encourage responses from table 4. wellness interventions suggested by clinical registrars working at princess marina hospital in gaborone, botswana (n=18) suggested wellness intervention n (%) lectures on wellness, stress reduction and work-life balance 9 (50) lectures on career development 8 (44) improved mentorship 8 (44) registrar social events 7 (39) annual registrar overnight retreat 6 (33) psychologist offering individual psychotherapy 5 (28) support group during lunch 4 (22) stress reduction during lunch 3 (17) lecture on coping with patient death 2 (11) research 102 september 2017, vol. 9, no. 3 ajhpe all registrars. it is unclear whether those who did not complete the study suffer to a greater or lesser degree from burnout than those who completed the study. it is difficult to get overworked registrars to fill out surveys, and other regional studies from sa report only a slightly higher response rate of 60 68%.[10,12,13] the strengths of this study include the use of a validated survey to measure burnout. the questionnaire was delivered electronically and completed on a voluntary and private basis, thereby minimising response bias.[5] most importantly, this is the first study of registrar wellness in botswana. future studies with a larger sample size and in more countries throughout sub-saharan africa are needed to better understand burnout among registrars in resource-limited settings. additionally, further research will provide more insight into ways to prevent burnout, improve wellness and retain doctors in high-need, low-resource settings. acknowledgements. the authors would like to thank all the registrars at the university of botswana for their hard work, dedication to their patients, and commitment to serving those in need. we would especially like to thank the registrars who took the time to complete the survey for this project. we are grateful to the leadership of the university of botswana, princess marina hospital, botswana ministries of health and education, children’s hospital of philadelphia, botswana-university of pennsylvania (botswana-upenn) partnership, and pincus family foundation (usa). author contributions. kdw: led study conception and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, editing and revising of the manuscript, and final approval of the version to be published; edl, aps: assisted with study conception and design, analysis and interpretation of data, editing and revising of the manuscript, and final approval of the version to be published; rf, lm, mc, jcm, sbm, cet: assisted with study conception and design, editing and revising of the manuscript, and final approval of the version to be published. funding. funding for this project was provided by the pincus family foundation (usa). conflicts of interest. none. 1. ishak ww, lederer s, mandili c, et al. burnout during residency training: a literature review. j grad med educ 2009;1(2):236-242. https://doi.org/10.4300/jgme-d-09-00054.1 2. mccray lw, cronholm pf, bogner hr, gallo jj, neill ra. resident physician burnout: is there 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iwegim short research report 76 aimed at itchedd: a proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting a makkink, c vincent-lambert research 79 association between personality factors and consulting specialty of practice of doctors at an academic hospital in bloemfontein, south africa r van aswegen, a ravgee, g connellan, c strydom, j t kuzhivelil, g joubert, w j steinberg 85 optometry students’ attitudes towards research at undergraduate level l coetzee, s b kruger 90 factors causing stress among first-year students attending a nursing college in kwazulu-natal, south africa e m langtree, a razak, f haffejee 96 ‘pain and stress are part of my profession’: using dental practitioners’ views of occupation-related factors to inform dental training r moodley, s naidoo, j van wyk 101 occupational therapy students’ use of social media for professional practice d naidoo, p govender, m stead, u mohangi, f zulu, m mbele 106 establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in nigeria: a delphi study o i fawole, j van wyk, a a adejimi, o j akinsola, o balogun 114 self-reported generic learning skills proficiency: another measure of medical school preparedness v c burch, c n t sikakana, g d gunston, d murdoch-eaton 124 integrating critical cross-field outcomes in an anatomy course at a university of technology: a reflective perspective j d pillay, n govender, n lachman 129 strengths and challenges of community-based clinical training as viewed by academics at the university of kwazulu-natal, durban, south africa i moodley, s singh 136 a support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: a pilot study a-m wium, m de jongh cpd questionnaire ajhpe african journal of health professions education june 2018, vol. 10, no. 2 ajhpe is published by the health and medical publishing group (pty) ltd, co. registration 2004/0220 32/07, a subsidiary of sama head office: block f, castle walk corporate park, nossob street, erasmuskloof ext. 3, pretoria, 0181 editorial office: suite 11, lonsdale building, lonsdale way, pinelands, 7405. tel. 021 532 1281 please submit letters and articles for publication online at www.ajhpe.org.za editorial board editor-in-chief vanessa burch university of cape town international advisors michelle mclean bond university, ql, australia deborah murdoch-eaton sheffield university, uk deputy editors jose frantz university of the western cape jacqueline van wyk university of kwazulu-natal associate editors francois cilliers university of cape town rhena delport university of pretoria patricia mcinerney university of the witwatersrand ntombifikile mtshali university of kwazulu-natal anthea rhoda university of the western cape michael rowe university of the western cape marietjie van rooyen university of pretoria susan van schalkwyk stellenbosch university elizabeth wolvaardt university of pretoria hmpg ceo and publisher hannah kikaya email: hannahk@hmpg.co.za executive editor bridget farham managing editors claudia naidu naadia van der bergh technical editors emma buchanan kirsten morreira paula van der bijl production manager emma jane couzens senior designer clinton griffin chief operating officer diane smith i tel. 012 481 2069 email: dianes@hmpg.co.za online support gertrude fani email: publishing@hmpg.co.za finance tshepiso mokoena hmpg board of directors prof. m lukhele (chair), dr m r abbas, mrs h kikaya, dr m mbokota, dr g wolvaardt issn 2078-5127 research december 2017, vol. 9, no. 4 ajhpe 189 community-based education (cbe) is a learning approach that enables students to acquire skills by means of applied learning in the community.[1] this learning approach includes elements of primary healthcare, health promotion and disease prevention, and allows students to acquire clinical, research, communication and other professional competencies in a commu nity setting.[2] the goals of cbe include creating knowledge, skills and attitudes among students to ensure the provision of efficient health services to marginalised communities, often in rural areas and communities with significant resource constraints.[3] these goals ultimately increase health professionals’ willingness to work in underserved areas.[4] cbe provides opportunities to acquire research, clinical and public health skills through applied learning in a community setting.[1] the objective of cbe is to direct health professionals towards the most important health problems of the community.[5] despite the several challenges that may affect cbe, lower attrition rates, a greater perceived ability to function in rural communities and high satisfaction, as indicated by students and community members, have been noted as advantages of cbe.[6] other beneficial aspects of cbe include early contact with the community, improved teamwork of trainees, and improved interpersonal relationships and communication skills.[6] the physiotherapy and occupational therapy students at the university of zimbabwe, harare, have been part of cbe attachments since the inception of the programmes in 1987. the university of zimbabwe has 12 cbe attachment sites, which are shared by all the programmes of the college of health sciences. the activities at each of the cbe sites differ, depending on available resources. these activities are mainly sponsored by the ministry of health and child care and its partners. the university of zimbabwe provides transport for the students during the cbe attachment. each of the attachment sites can accommodate a maximum of 10 students; therefore, the number of attachment sites per given year is determined by the number of students registered for their 3rd year in both physiotherapy and occupational therapy. the students who participated in this study had been attached to 5 of these 12 sites. before their cbe attachment, the students in the department of rehabilitation at the university of zimbabwe receive lectures to prepare them for the attachment. some of the content covered during the lectures includes the role of rehabilitation professionals in the community, developing, monitoring and evaluating community-based rehabilitation programmes, as well as managing and administering rehabilitation units. these lectures provide the students with the theoretical learning experience, while the cbe attachments provide a practical learning experience. the students are placed at cbe attachment sites for 6 weeks in teams comprising occupational therapy and physiotherapy students. as part of the attachment, the students are expected to visit the local leadership, such as chiefs, headmen, councillors and traditional healers, before conducting any rehabilitation intervention in the community. they are also background. community-based education (cbe) is a learning approach that enables students to acquire skills by means of applied learning in the community. the goals of cbe include creating adequate knowledge, skills and attitudes that facilitate service delivery in communities. these goals ensure the provision of efficient health services to marginalised communities with significant resource constraints. the department of rehabilitation at the university of zimbabwe, harare, has adopted cbe as one of the learning approaches that enables students to acquire comprehensive skills for future service provision in the community. objectives. to determine the learning outcomes of rehabilitation students at the university of zimbabwe and to identify factors affecting learning during the cbe attachments. methods. a descriptive cross-sectional survey was conducted at the university of zimbabwe. thirty-five final-year occupational therapy and physiotherapy students responded to a self-administered questionnaire. data were analysed using microsoft excel 2013 (usa) and spss version 21 (ibm corp., usa). results. all the students reported that the cbe attachment improved their community-engagement skills, professional skills and personal growth. barriers to effective learning included inadequate transport (100%), poor internet connectivity (82%), lack of research-related objectives (74%) and inadequate resources for cbe activities (60%). conclusion. the cbe attachment enabled students to gain skills in community engagement, professionalism and personal growth. however, more funding directed towards cbe activities and introducing objectives related to research, are some of the strategies that might improve the students’ learning outcomes during the attachments. afr j health professions educ 2017;9(4):189-193. doi:10.7196/ajhpe.2017.v9i4.958 learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment t ndlovu, bsc, hpt; t m chikwanha, mph, bsc (hot); n munambah, msc (ot), bsc (hot) department of rehabilitation, college of health sciences, university of zimbabwe, harare, zimbabwe corresponding author: t m chikwanha (middychiky@yahoo.co.uk) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 190 december 2017, vol. 9, no. 4 ajhpe expected to participate in management and administration activities in the rehabilitation departments. the students are supervised by rehabilitation staff in the districts where they are attached. in addition, the faculty from the department of rehabilitation conduct a once-off mid-attachment evaluation for each of the sites. for the training curriculum to remain relevant in the context of cbe, there is a need to continuously evaluate learning outcomes for students. this study was conducted to determine the learning outcomes, barriers and facilitators to effective learning of physiotherapy and occupational therapy students at the university of zimbabwe during their cbe attachment. methods a descriptive cross-sectional study was conducted in the department of rehabilitation, college of health sciences, university of zimbabwe. the university is currently the only institution that trains physiotherapists and occupational therapists in zimbabwe, with an average enrolment of 40 per year for both. guided by the objectives of the cbe attachment and insights from the literature, the researchers developed a self-administered questionnaire that was used in the study. this questionnaire had three sections. section a collected demographic information. section b consisted of 20 questions related to students’ learning outcomes during the cbe attachment. these questions were further divided into three subsections, i.e. community engagement, professional skills and personal growth. community engagement was defined as the cognitive, affective and behavioural outcomes related to community participation.[7] professional skills were described as techniques, behaviours and attitudes that enhance efficacy in the workplace.[7] personal growth was defined as affective outcomes related to understanding oneself.[7] community engagement was assessed using 6 questions, professional skills were assessed using 10 questions and personal growth was assessed using 4 questions. the responses to the questions that assessed the learning outcomes were rated on a 4-point scale: 1 = not at all, 2 = minimally, 3 = moderately, and 4 = extensively. section c assessed the barriers to cbe and the possible strategies for improving learning experiences during the attachment. this section had closed-ended questions with ‘yes’ or ‘no’ responses. validation of the questionnaire was done in two stages. firstly, the questionnaire was given to a panel of experts who included physiotherapy and occupational therapy lecturers responsible for the cbe programme. after revising the questionnaire based on the feedback from the panel of experts, a pilot study was conducted with 20 of the physiotherapy and occupational therapy students who had graduated from the university of zimbabwe in 2015. the data from the pilot study were then analysed and redundant questions were removed. the study sample comprised 35 occupational therapy and physiotherapy students who had just started the first semester of their final year. an overview of the study and its objectives was presented to these students before the self-administered questionnaires and consent forms were distributed. students who were willing to participate were asked to sign the consent forms first and complete the questionnaire, which they had to drop into a box in their lecture room within 1 week. no names or student identification numbers were recorded on the questionnaires. data were entered into microsoft excel 2013 (usa) and analysed using spss version 21 (ibm corp., usa). sociodemographic characteristics were analysed for means and frequencies. students’ level of community engagement was scored out of a maximum possible score of 24 and a minimum possible score of 6. professional skills were scored out of a maximum possible total of 40 and minimum possible score of 10. personal growth was scored out of a maximum possible score of 16 and a minimum possible score of 4. total expected scores on community engagement (24), professional skills (40) and personal growth (16) were added to give the expected overall learning outcome score of 80. the overall learning outcome score for each of the students was obtained by expressing the total scores from each of the three subsections as a percentage of the overall expected learning outcome score. perceived barriers were grouped into three categories, i.e. administrative challenges, personal barriers and financial challenges, and were presented as frequencies. strategies to facilitate students’ learning during the cbe attachment were also expressed as frequencies. ethical approval permission to carry out the study was requested from the dean, college of health sciences, university of zimbabwe. ethical approval was sought from the joint research ethics committee (ref. no. jrec/253/15) and from the medical research council of zimbabwe (ref. no. mrcz/b997). results all 35 final-year students participated in the study. the mean age of participants was 22 (standard deviation (sd) 0.97) years. twenty-three (65%) of the participants were female and 12 (34%) were male. twenty-one (60%) participants were physiotherapy students and 14 (40%) occupational therapy students. six (17%) students were attached in district 1; 7 (20%) in district 2; 8 (23%) in district 3; 7 (20%) in district 4; and 7 (20%) in district 5. (note that the actual names for the districts were replaced with numbers for confidentiality purposes.) students’ self-reported learning outcomes of the cbe attachments are given in table 1. community engagement all students had an opportunity to learn about community engagement during their cbe attachment (table 1). all of them reported that the cbe attachment had enhanced their understanding of community issues pertaining to rehabilitation, facilitated their understanding of clients in need of rehabilitation services, and improved their understanding of the organisation of rehabilitation services at community level. they also learnt how to conduct health education talks and provide outreach services. professional skills development the students generally reported that the cbe attachment had given them an opportunity to improve their professional skills (table 1). the majority (97%) reported that their learning experiences had helped them to interact with other health professionals in patient care and enhanced their conflict-resolution skills. all the students reported that the attachment had improved their public speaking skills and their ability to work as part of a team. the attachment also improved the ability of 24 (68%) students to work independently. with regard to the development of management skills, most (91%) of the students reported that the cbe attachment had improved their ability to run meetings, delegate tasks and respect the opinions of others when working as a team. nineteen (54%) of the students indicated that the cbe experience extensively improved their understanding of the roles of other rehabilitation staff. twelve (34%) of the participants indicated that the cbe experience extensively improved their understanding of how to manage a rehabilitation department. research december 2017, vol. 9, no. 4 ajhpe 191 personal growth all the students reported that the attachment provided an opportunity to gain skills with regard to personal growth. these included clarification of values, personal professional growth, and understanding of self and others. learning outcome scores students attached to different cbe sites presented with varying scores for community engagement, professional skills and personal growth (fig. 1). generally, all the students indicated the most improvement in community engagement skills and the least improvement in their personal skills. the mean overall learning outcome score was 65 (sd 7.0)%. students placed in district 2 had the highest overall learning outcome score, while those in district 1 had the lowest score (fig. 2). barriers to effective cbe the barriers reported by students included unavailability of internet connectivity (82%), unavailability of supervisors during some of the activities (57%), lack of clarity in the objectives given to students (60%) and lack of objectives related to research (74%). seventeen (48%) participants identified the attachment period as being inadequate to cover all the learning table 1. students’ learning outcomes of the cbe attachment learning attribute not at all, n (%) minimally, n (%) moderately, n (%) extensively, n (%) community engagement enhanced my understanding of community issues 0 (0) 3 (9) 13 (37) 19 (54) will likely enhance my future community engagement 2 (6) 2 (6) 13 (37) 18 (51) facilitated my understanding of clients in need of rehabilitation services 1 (3) 2 (6) 13 (37) 19 (54) helped me to understand the organisation of rehabilitation services at community level 0 (0) 5 (14) 15 (43) 15 (43) deepened my understanding of educational talks 1 (3) 0 (0) 17 (48.5) 17 (48.5) enhanced my ability to conduct outreaches to the community 0 (0) 1 (3) 14 (40) 20 (57) professional skills helped me to interact with other disciplines in patient care 1 (3) 8 (23) 19 (54) 7 (20) improved my public speaking skills 0 (0) 7 (20) 19 (54) 9 (26) improved my ability to work as part of a team 0 (0) 2 (6) 13 (37) 20 (57) improved my ability to work independently 4 (12) 6 (17) 18 (51) 7 (20) improved my skills with regard to conflict resolution 1 (3) 8 (23) 16 (46) 10 (28) improved my ability to run meetings 3 (9) 6 (17) 17 (48) 9 (26) improved my ability to delegate 3 (9) 3 (8) 16 (46) 13 (37) improved my ability to listen to others 0 (0) 1 (3) 12 (34) 22 (63) improved my understanding of the roles of other rehabilitation staff 1 (3) 2 (6) 13 (37) 19 (54) improved my understanding of how to manage a rehabilitation department 1 (3) 2 (6) 20 (57) 12 (34) personal growth helped to clarify my values 0 (0) 7 (20) 16 (46) 12 (34) helped to improve my personal qualities 1 (3) 2 (6) 19 (54) 13 (37) improved my ability to consider the perspectives of others 0 (0) 1 (3) 11 (31) 23 (66) deepened my understanding of myself 2 (6) 7 (20) 13 (37) 13 (37) cbe = community-based education. 0 5 10 15 20 25 30 35 1 2 3 4 5 to ta l s co re , m ea n professional skills community engagement personal growth cbe attachment site, district fig. 1. learning outcome scores by attachment site. (cbe = community-based education.) fig. 2. overall learning outcome scores. (cbe = community-based education.) 61 62 63 64 65 66 67 68 69 70 cbe attachment site, district o ve ra ll le ar n in g o u tc o m e sc o re , % 1 2 3 4 5 research 192 december 2017, vol. 9, no. 4 ajhpe objectives. all the students in districts 1, 2 and 3 reported a low standard of accommodation at their attachment sites. limited access to transport to conduct cbe activities and lack of funding for cbe activities were also identified as barriers to effective learning. failure to communicate using a local language was the only personal barrier to effective learning reported by 13 (37%) participants. proposed strategies for promoting learning strategies that were proposed to improve the students’ learning outcomes during cbe attachments included revising the objectives (94%), increasing faculty involvement (97%), providing of transport by the university throughout the attachment period (97%), improving the state of the accommodation facilities (60%) and introducing funds directed towards the cbe activities (19%). discussion the development of competence and confidence of students is one of the benefits of cbe experience.[5,8] in our study, the cbe experience offered students an opportunity to improve their skills in community engagement, and develop their professional and personal skills needed to effectively provide rehabilitation services to communities. the cbe attachment enhanced the students’ understanding of clients in need of rehabilitation services. in a hospital setting, students often miss the opportunity to interact with people with disabilities in the commu nity.[8] cbe affords students an opportunity to interact with individuals from different backgrounds and with different abilities.[9] such interactions enable students to develop in aspects of client centredness and gain a better understanding of the clients’ rehabilitation needs outside the hospital setting.[9] in our study, the participants reported that the cbe attachment had enhanced their future engagement with the community. they also indicated improvements in their professional skills, including interpersonal skills and their ability to work as part of a team. the interaction with the community allows students an opportunity to acquire more knowledge and skills, and attitudes necessary for practice in the community.[6] cbe therefore positively impacts on the students’ understanding of community issues, as it complements classroom learning.[10] the cbe experience equipped the students with skills needed to educate the community on health-related issues, enhanced their ability to conduct outreaches in the community, and improved their public speaking skills. several authors have reported that cbe offers students a chance to acquire skills in public health services and health promotion.[1-3,5] such exposure affords students an opportunity to learn about health services within the community. generally, all students improved in professional skills, including interpersonal skills and their ability to work as part of a team. interprofessional learning helps students to gain the skills necessary to promote teamwork, communication and collaborative learning.[3,11] such interactions provide them with opportunities to interact with a multidisciplinary team and, as such, they will have an appreciation of the roles of each of the team members. the students also reported that the attachment had improved their ability to work independently, as well as their skills with regard to conflict resolution. practice placements, such as cbe, develop students’ self-confidence, thereby facilitating their ability to work independently. such learning experiences also develop their professional skills, including conflict management.[6,9] from the researchers’ personal experience, for students to fulfil the cbe attachment objectives, they have to work together as a team. conflicts usually arise when tasks have to be shared and they do not agree on how it should be done. conflict resolution skills will then develop, as students learn to negotiate and agree on how tasks should be shared within the team. several authors have identified the unavailability of supervisors during some of the cbe activities as a challenge hindering effective learning during attachments.[3,4,6,12] as noted in the current study, despite all occupational therapy and physiotherapy students being attached at district level, there was a variation in overall learning outcome scores based on different attachment sites. this indicates that students had different learning experiences based on the site to which they were attached. therefore, there is a need to train supervisors and to agree on a model of providing supervision and support services to the students. the introduction of an efficient internet service that facilitates access to e-learning resources may also assist in overcoming the issue of inadequate supervision. to promote effective cbe programmes, e-learning is important, as it permits real-time communication between faculty and students during their attachment, which can help in the daily supervision of students.[4] unavailability of transport was reported to be a major barrier to effective learning, possibly resulting in clients living in very remote areas not receiving the necessary community rehabilitation services. additional resources, including transport, are essential in facilitating the effectiveness of cbe programmes.[12,13] identifying alternative ways of ensuring that transport is available throughout the duration of the placement and introducing funds directed towards cbe, are strategies that can be employed to address transport problems in order to improve students’ learning outcomes. inadequate time and lack of clear objectives related to research were also reported as barriers to effective learning. the tendency to underestimate the amount of time needed by students for their cbe attachments has been linked to lack of clear objectives in various settings.[3,5,14] having clear and specific learning objectives enables the students to know exactly what is expected of them;[4,13] therefore, they are able to allocate adequate time for all their cbe activities. periodically revising the cbe objectives may assist in ensuring that these remain feasible and contextually relevant. low-standard accommodation was perceived as a barrier to effective learning by the physiotherapy and occupational therapy students who participated in this study. unavailability of internet access, poor water and electricity supplies, outdated room appliances and poor security are some of the issues that negatively contribute to accommodation standards.[3,4] currently, the maintenance for most of the hostels used by students during the cbe attachment is the responsibility of the hospitals where these hostels are built. with the prevailing economic hardships in zimbabwe and the recent freezing of posts by the ministry of health and child care, most hospitals have shortages of cleaning staff. cleaning of the students’ accommodation may not even be on the list of cleaning priorities for the hospitals. study limitations this study was conducted to determine the learning outcomes of rehabilitation students at the university of zimbabwe and to identify factors affecting learning during the cbe attachments. it would have been ideal to establish the consistency of the study instrument before conducting the research. however, the data collection instrument did not undergo reliability testing, and the authors acknowledge this omission as a limitation of the study. research december 2017, vol. 9, no. 4 ajhpe 193 conclusion experiential learning during the cbe attachment for occupational therapy and physiotherapy students offered them an opportunity to apply theoretical knowledge to practise and develop personal, professional and community engagement skills. however, barriers, including lack of clear research-related objectives, limited resources for cbe activities, inadequate supervision and limited exposure to communities in terms of time allocated for the attachment, negatively affected the learning experiences. the availability of more resources for cbe activities may improve the overall learning experiences of students. acknowledgements. our most sincere gratitude is extended to lecturers at the department of rehabilitation, college of health sciences, university of zimbabwe, for their assistance and guidance throughout the research project; the joint research ethics committee of the college of health sciences; the medical research council of zimbabwe for reviewing the study protocol; the dean of the college of health sciences for granting permission to carry out this study; to the physiotherapy and occupational therapy students at the university of zimbabwe, who participated in the study; and to the physiotherapists and occupational therapists who participated in the pilot study. author contributions. tn: developed the research protocol, collected and analysed the data, and contributed to writing the manuscript; tmc: developed the research protocol, collected and analysed the data, and contributed to writing the manuscript; nm: analysed the data and contributed to writing the manuscript. funding. none. conflicts of interest. none. 1. dreyer a, couper i, bailey r, talib z, ross h, sagay a. identifying approaches and tools for evaluating community-based medical education programmes in africa. afr j health professions educ 2015;7(1):134-139. https://doi.org/10.7196/ajhpe.568 2. bailey rj, baingana rk, couper id, et al. evaluating community-based medical education programmes in africa: a workshop report. afr j health professions educ 2015;7(1 suppl 1):140-144. https://doi.org/10.7196/ ajhpe.475 3. kaye d, mwanika a, burnham g, et al. the organization and implementation of community-based education programs for health worker training institutions in uganda. bmc int health hum 2011;11(1):1. https://doi. org/10.1186/1472-698x-11-s1-s4 4. mariam dh, sagay as, arubaku w, et al. community-based education programs in africa: faculty experience within the medical education partnership initiative (mepi) network. acad med 2014;89(8):s50-s54. https://doi. org/10.1097/acm.0000000000000330 5. kaye dk, muhwezi ww, kasozi an, et al. lessons learnt from comprehensive evaluation of community-based education in uganda: a proposal for an ideal model community-based education for health professional training institutions. bmc med 2011;11(1):1. https://doi.org/10.1186/1472-6920-11-7 6. wald hs, davis sw, reis sp, monroe ad, borkan jm. reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. acad med 2009;84(7):830-837. https:// doi.org/10.1097/acm.0b013e3181a8592f 7. lichtenstein g, tombari m, thorme t, cutforth n. development of a national survey to assess student learning outcomes of community-based research. j high educ outreach engage 2011;15(2):7-34. 8. shields n, taylor nf. physiotherapy students’ self-reported assessment of professional behaviours and skills while working with young people with disability. disabil rehabil 2014;36(21):1834-1839. https://doi.org/10.3109/096 38288.2013.871355  9. yorio pl, ye f. a meta-analysis on the effects of service-learning on the social, personal, and cognitive outcomes of learning. acad manag learn educ 2012;11(1):9-27. https://doi.org/10.5465/amle.2010.0072 10. davies k, harrison k, clouder d, gilchrist m, mcfarland l, earland j. making the transition from physiotherapy student to interprofessional team member. physiotherapy 2011;97(2):139-144. https://doi. org/10.1016/j.physio.2010.08.00 11. rodger s, fitzgerald c, davila w, millar f, allison h. what makes a quality occupational therapy practice placement? students’ and practice educators’ perspectives. aust occup ther j 2011;58(3):195-202. https://doi. org/10.1111/j.1440-1630.2010.00903.x 12. burggraaf a, bourke-taylor h. occupational therapy students’ fieldwork placement: institutional and community based rehabilitation models in the solomon islands. n z occup ther j 2008;55(2):25. 13. okayama m, kajii e. does community-based education increase students’ motivation to practice community health care? a cross sectional study. bmc med 2011;11(1):1. https://doi.org/10.1186/1472-6920-11-19 14. kristina tn, majoor gd, van der vleuten cp. defining generic objectives for community‐based education in undergraduate medical programmes. med educ 2004;38(5):510-521. https://doi.org/10.1046/j.1365-2929.2004.01819.x accepted 23 may 2017. https://doi.org/10.7196/ajhpe.568 https://doi.org/10.7196/ajhpe.475 https://doi.org/10.7196/ajhpe.475 https://doi.org/10.1186/1472-698x-11-s1-s4 https://doi.org/10.1186/1472-698x-11-s1-s4 https://doi.org/10.1097/acm.0000000000000330 https://doi.org/10.1097/acm.0000000000000330 https://doi.org/10.1186/1472-6920-11-7 https://doi.org/10.1097/acm.0b013e3181a8592f https://doi.org/10.1097/acm.0b013e3181a8592f https://doi.org/10.3109/09638288.2013.871355 https://doi.org/10.3109/09638288.2013.871355 https://doi.org/10.5465/amle.2010.0072 https://doi.org/10.1016/j.physio.2010.08.00 https://doi.org/10.1016/j.physio.2010.08.00 https://doi.org/10.1111/j.1440-1630.2010.00903.x https://doi.org/10.1111/j.1440-1630.2010.00903.x https://doi.org/10.1186/1472-6920-11-19 https://doi.org/10.1046/j.1365-2929.2004.01819.x september 2018, vol. 10, no. 3 ajhpe 159 research less than half of the world’s population has access to safe, affordable and timely surgical care.[1,2] in 2010, 30% of all deaths (16.9 million) worldwide resulted from conditions requiring surgical care; this number surpassed that of hiv/aids, tuberculosis and malaria combined.[3] the lancet commission on global surgery identified that the unmet need is greatest in sub-saharan africa, where 90% of the population do not have access to basic surgical procedures.[2] the development of surgical care in these regions has halted or even regressed over the past two decades, often owing to the loss of young surgeons whose personal training needs are not met locally, resulting in ongoing migration to developed countries, the so-called brain drain. major limiting factors in the development of surgical services are a lack of surgeons on the ground and of specialist surgical expertise and training in healthcare systems.[2] malawi, a landlocked country in sub-saharan africa, has the lowest physician-to-patient ratio in the world, where 1 doctor is responsible for 50 000 patients.[4] this shortage is particularly acute in surgery; in 2007, it was reported that 15 surgeons served this country, which has a population of 12 million people,[5] and more recent data suggest that this alarming ratio remains unchanged.[6] the malawi ministry of health acknowledges that medical training institutions are not producing adequate numbers of graduates to meet the country’s healthcare needs, and aims to address the critical staff shortages by piloting cost-effective higher-qualification training methods, such as e-learning, distance learning, applied and parttime learning.[7] our partner institutions have developed a pioneering approach to the delivery of vocational, academic training to the surgical profession in malawi through an innovative, online master’s programme. the msc in surgical sciences was established in 2007 by the university of edinburgh and the royal college of surgeons of edinburgh, and is designed to support trainees in the early years of surgical training.[8] this 3-year, part-time programme uses a bespoke e-learning platform, hosting virtual case scenarios based on the most common surgical condi tions, and a range of assessment activities, culminating in submission of a research dissertation (fig. 1). all students enrolled on the msc programme are in full-time employ as surgical trainees. their parttime online learning activities are underpinned by in-the-workplace training, where they gain direct practical skills in surgery that, in turn, can be discussed and reflected upon in the virtual learning environment (vle). establishing what garrison and anderson[9] term a ‘community of inquiry’, is central to the success of the students’ educational experiences, and their model is shared with all of the e-tutors at the start of their teaching block. by delivering core academic content online, handson surgical training can be augmented without the need to remove trainees from their own country. crucially, this transnational education has a minimal disruptive impact on surgical service delivery during the period of further study. a number of successful educational programmes in surgery have been launched in african countries in recent years. most notably, the royal background. postgraduate surgical training is limited in malawi, one of the world’s poorest countries, and doctors who pursue further training abroad may fail to return. one solution is to deliver education online, allowing trainees to complement their in-the-workplace learning. objective. to evaluate the perceived effectiveness of an online msc in surgical sciences programme for trainees continuing to train and work full time in their malawian clinical environment. methods. twenty-four malawian surgical trainees enrolled on the programme since 2010. students’ perspectives regarding the msc were explored by questionnaires, and malawian student performance was measured using a variety of metrics and compared with that of other students in their year. training programme supervisors in malawi were surveyed on their opinions of the effectiveness of the programme. results. feedback revealed that students valued the structured presentation of the basic sciences integrated into interactive virtual patients, the access to e-journals and the opportunity for discussion with international surgical colleagues. academic performance of malawian trainees was comparable with that of the cohort average in the first 2 years of the programme. attitudes of students and supervisors regarding the educational benefits of the programme were positive. conclusions. the msc in surgical sciences provides a culture of studying and sharing knowledge with peers and mentors globally, and has increased the academic support network for malawian trainees from a few dedicated surgeons in the country to an international network. this innovative approach can serve as a model in other developing countries with critical shortages of healthcare workers. afr j health professions educ 2018;10(3):159-165. doi:10.7196/ajhpe.2018.v10i3.1020 the effectiveness of an online, distance-learning master’s in surgical sciences programme in malawi p j w smith,1 phd; o j garden,1 md; s j wigmore,1 md; e borgstein,2 md; d dewhurst,3 phd 1 department of clinical surgery, college of medicine and veterinary medicine, university of edinburgh, uk 2 department of surgery, queen elizabeth central hospital, blantyre, malawi 3 learning technology section, college of medicine and veterinary medicine, university of edinburgh, uk corresponding author: p j w smith (paula.smith@ed.ac.uk) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 160 september 2018, vol. 10, no. 3 ajhpe research college of surgeons in ireland (rcsi) and the college of surgeons of east, central and southern africa (cosecsa) have partnered to deliver a series of blended face-to-face and online programmes in surgical skills and pedagogical training of surgical trainers (http://www.rcsi.ie/cosecsa). o’flynn et al.[10] identified some of the challenges of these blended approaches, e.g. poor internet connectivity and the large distances between training facilities, making equity in participation potentially problematic. in the current study, we addressed the research question, ‘what is the perceived effectiveness of the fully online msc in surgical sciences by students and training program supervisors?’. through sponsored ventures (johnson and johnson citizenship trust, scottish government international development fund, physicians for peace, commonwealth scholarship commission in the uk, and royal college of surgeons of edinburgh), a number of scholarships are awarded annually to surgical trainees in malawi to cover tuition fees in full. understanding how the msc programme has benefited the malawian trainees will assist us in refining the online content and delivery, and will help us to secure future scholarship funding. methods to evaluate the perceived educational effectiveness of the online msc for malawian students, a web-based anonymous survey (appendices*) was issued to current students and graduates of the programme (distributed by pjws), as well as training programme supervisors working in teaching hospitals in malawi (distributed by eb). a 5-point likert scale (strongly disagree, disagree, neither disagree nor agree, agree, strongly agree) was used for scoring purposes. the survey consisted of the same set of questions in two versions, one for supervisors and one for students, and focused around the potential and actual effectiveness of the programme (table 1). the first question was designed to assess general attitudes on the use of online postgraduate surgical science programmes. only supervisors whose trainees were current or former msc students were invited to table 1. mean likert-scaled survey responses of clinical supervisors and master’s students, where 1 = strongly disagree and 5 = strongly agree question mean sd n online postgraduate programmes in surgical sciences can improve the current surgical training programme in malawi supervisor student 4.27* 4.71* 1.27 0.47 11 17 the case-based scenarios in the msc in surgical sciences can improve patient safety by providing a way to apply knowledge virtually before practising in reality supervisor student 4.40* 4.29* 0.70 0.47 10 14 the case-based scenarios in the msc in surgical sciences can improve decision-making skills supervisor student 4.40* 4.43* 0.70 0.51 10 14 the online, asynchronous discussion boards in the msc in surgical sciences can improve communication skills supervisor student 4.10* 3.93* 0.88 0.62 10 11 trainees’/my knowledge of the science underpinning surgery has improved since they/i have been on the msc in surgical sciences supervisor student 3.80 4.36* 1.23 0.63 10 14 trainees’/my clinical decision-making skills have improved since they/i have been on the msc in surgical sciences supervisor student 3.60 4.50*† 1.17 0.65 10 14 trainees’/my communication skills have improved since they/i have been on the msc in surgical sciences supervisor student 3.30 3.64* 1.16 0.74 10 14 you would recommend the msc in surgical sciences programme to all junior surgical trainees in malawi supervisor student 4.30* 4.93* 0.95 0.27 10 14 sd = standard deviation. *mean response significantly differs from test value of 3, i.e. respondents agree with these statements (p<0.01, one-sample t-test). †significant difference between supervisor and student responses (p<0.05, two-sample t-test). year 1 applied anatomy, radiology, physiology, pathology and bacteriology certi�cate diploma master of science year 2 assessment and care of the surgical patient, research and communication skills year 3 research dissertation case scenarios multiple-choice questions discussion boards end-of-year examination case scenarios multiple-choice questions discussion boards mini-essays end-of-year examination project proposal project summary e-poster e-dissertation fig. 1. programme structure of the msc in surgical sciences. students are required to pass a variety of in-course and summative assessment tasks (right-hand column) to progress and attain a qualification. september 2018, vol. 10, no. 3 ajhpe 161 research complete the full survey beyond question 1. the survey ran for 3 weeks in semester 1 of the academic year 2017/2018, and excluded year-1 students because, as new intakes, they had only experienced 2 months of being on the programme. furthermore, email questionnaires comprising free-text-style questions, collected since 2013 from malawian students for scholarship quality assurance, were anonymised and re-purposed for analysis in the current study. two reviewers (pjws and dd) independently screened these student responses to identify common themes. ethics approval, while sought from the academic and clinical central office for research and development (accord) at the university of edinburgh, was not required owing to the anonymous nature of the survey instruments. a one-sample t-test (spss version 24.0, ibm corp., usa) was used to identify whether responses to questions differed significantly from a neutral stance, i.e. agreed or disagreed. differences between supervisor and student responses were compared using student’s t-test, assuming unequal variances (microsoft excel 2010, microsoft corp., usa). malawian student performance was measured using two main metrics (in-course assessment and examination scores) and compared with that of other students in the same academic year. differences between group means were identified using student’s t-test, assuming unequal variances (microsoft excel 2010, usa). statistical significance was accepted when p<0.05. data are expressed as mean (standard deviation) (sd). results a total of 24 surgical trainees from malawi have been admitted to the msc programme since 2010, with 22 progressing to date (fig. 2). this number represents 90% of the surgical trainees each year in malawi. the first master’s student from malawi graduated in november 2013. there have been 11 further successful graduates between 2014 and 2017, and 10 other students are currently on the programme. the demographics of malawian students are similar to our international student cohort with regard to age (28 (3) v. 26 (3) years), but the majority of malawian students are female (13:11) compared with the full msc student cohort enrolled between 2010/2011 and 2017/2018, in which over two-thirds are male (n=654/936). seventeen students (of 19 surveyed; 89%) and 11 training programme supervisors (of 16 surveyed; 69%) responded to the web-based, likertscale surveys. eleven student respondents are graduates and 6 are current students. of the supervisors who responded, 10 have supervised current or former msc students, and 1 has not. responses were scaled from 1 (strongly disagree) to 5 (strongly agree). table 1 shows that all student survey questions generated a positive response (p<0.01). student respondents had greater positive attitudes to the effectiveness of the online master’s programme compared with their clinical supervisors. all of the supervisor survey questions relating to the potential benefit of the msc generated a positive response (p<0.01), but supervisors’ opinions on an actual improvement in their trainees’ skills were not significantly different from neutral. the majority of students felt that the msc had improved their knowledge of the science underpinning surgery (93% agree or strongly agree) and clinical decision-making skills (93% agree or strongly agree), but were more neutral with regard to an improvement in their communication skills (50% agree or strongly agree). students and supervisors would recommend the msc to junior surgical trainees in malawi. of the 19 malawi-based students enrolled between 2010/2011 and 2016/2017, 15 (79%) completed the free-text question-style written questionnaire. eight key themes around the benefits/disadvantages of the msc in surgical sciences programme were identified (table 2). discussion boards questionnaire feedback indicated that students appreciated the opportunity for discussion with surgical colleagues from other parts of the world. students identified as a major advantage that the discussion boards allowed geographical differences in surgical practice to be explored, and encouraged students from the developed world to consider options available to surgeons from less-privileged areas. on this theme, a student noted: ‘regardless of where you are from, we are all exposed to the same material, which is very important for our profession because a doctor is supposed to be universal.’ (year 1 malawian student) the students stated that they enjoyed reading through the fellow students’ posted discussions and that these stimulated them to try to read more widely on the issues raised. one student described feeling overwhelmed and experiencing a slight ‘cultural shock’ in the discussion boards in year 1. for example, the student had rarely seen obese patients, and it was the first time she had ever heard the term ‘bariatric (weight-loss) surgery’. another student claimed: ‘i have had a lot of “aha! so this can be done!” moments.’ (year 2 malawian student) currently in year 1 n=3 currently in year 2 n=3 currently in year 3 n=4 completed year 3 and graduated with a master's n=12 malawian students enrolling for the msc between 2010/2011 and 2017/2018 n=24 withdrew during year 1 n=1* left malawi after year 1 n=1† *changed career, no longer pursuing surgical training †relocated to south africa to take up training post fig. 2. flowchart showing status and numbers of malawian surgical trainees studying for the msc in surgical sciences (november 2017). 162 september 2018, vol. 10, no. 3 ajhpe research it is clear that students consider themselves as part of an online community in which they learn from tutors and each other, as one student observed: ‘the discussion boards are very helpful and i am comfortable making comment. there is so much that i am learning from the responses of trainees in other parts of the world and i am encouraged to read more when i see how much my fellow trainees know and post. the tutors are great; they really follow up our posts and correct us when we are not completely right.’ (year 1 malawian student) the only disadvantage relating to the feedback of the discussion boards was that malawian students sometimes found it difficult to relate to clinical guidelines for procedures that are currently not conducted at their hospitals in malawi, e.g. transplant, bariatric or laparoscopic surgery. access to online content and virtual patient scenarios the structured presentation of the basic sciences integrated into interactive virtual patients was well received by students. the interactive model is provided by labyrinth (http://labyrinth.mvm.ed.ac.uk), a tool for authoring and delivering case narratives that was developed at the university of edinburgh. labyrinth was created with the goal of supporting development of richly engaging, narrative medical cases that invites users to take control of their own decisions – and, by extension, their own learning – and develop the critical analytical skills to effectively face the consequences of those decisions.[11] trainees stated that they particularly valued access to electronic material. students and e-tutors on the msc programme receive access to an extensive university of edinburgh e-library consisting of >250 surgical journals and textbooks, allowing surgeons from lowand middle-income countries (lmics) to keep up to date with the latest medical advances. previously, acquisition of knowledge was book-based, but the msc programme encourages students to research web-based material, as one student explained: ‘you get the opportunity to read all sorts of research papers, giving an update on certain conditions. i have learnt how to critically appraise an article and not just read a research paper as a “novel”.’ (year 3 malawian student) internet issues perhaps not surprisingly, a major limitation of the programme related to information technology (it) issues. while the vle that was used to deliver the msc in surgical sciences is accessible via smartphone, tablet and computer, the majority of students do not have good access to the internet at home and are reliant on often unreliable connections from the hospital where they work. the cost of installing broadband at home is prohibitive for most students, and speeds are often slow, which reduces the flexibility of our intended programme delivery. in 2016/2017, the costs of internet provision for the malawian students – typically ~20% of a trainee surgeon’s monthly salary – were met by the msc programme, and will continue so going forward. continuous assessment students reported that they felt encouraged to study regularly throughout the year because assessment comprised both in-course assessment and summative examination components, in contrast to their professional member ship examinations that do not include continuous assessment. such a course structure helps to provide the necessary motivation to students, while acknowledging the time constraints of part-time study alongside fulltime clinical commitments. notably, the majority of respondents cited these time constraints, something that is routinely expressed by their international peers on the msc programme. international network of expert tutors from the feedback received, we know that interaction between tutors and fellow students on the discussion boards plays a key role in maintaining the malawian students’ engagement in the programme. the interconnected approach of the msc in surgical sciences allows the sharing of knowledge between hundreds of international surgeons and trainees from up to 60 different countries. malawian students praised the supportive online environment created by our tutors. relevance to professional examinations students considered course content to be useful in helping to prepare for other postgraduate training, such as the mmed in surgery and the cosecsa membership examination, which share a similar curriculum to the first 2 years of the edinburgh online master’s programme. student performance encouragingly, end-of-year performance (combined examinations and in-course assessment comprising discussion boards, multiple-choice questions, mini-essays) of malawian trainees was not significantly different from that of the cohort average in the first 2 years of the programme (year 1: 58 table 2. major themes relating to the msc in surgical sciences identified from anonymised student questionnaire responses benefits %* disadvantages %* interaction with international trainees, gaining different perspectives, through discussion boards 53 sometimes difficult to relate uk-based clinical guidelines (e.g. transplant surgery) 13 access to e-books/journals/course content and virtual patient scenarios 27 internet provision slow/unreliable and costly 40 continuous assessment encourages regular study 20 time constraints on part-time study alongside full-time clinical commitments 53 being taught by an international network of expert tutors 47 relevant to professional examinations (e.g. mmed and cosecsa) 20 cosecsa = college of surgeons of east, central and southern africa. *percentages indicate response rate (total number of respondents: n=15). http://labyrinth.mvm.ed.ac.uk/ http://labyrinth.mvm.ed.ac.uk/ september 2018, vol. 10, no. 3 ajhpe 163 research (17)% v. 60 (11)%; p=0.60; and year 2: 59 (6)% v. 62 (13)%; p=0.36) (fig. 3a). however, data for the master’s year show that malawian trainees scored less well than the cohort average when conducting a research project and producing an e-poster and research dissertation (59 (11)% v. 68 (10)%; p<0.01) (fig. 3a). analysis of discussion board posts revealed that students from malawi were more likely to post on weekly tutorial group discussions than their international peers (participation rate, i.e. number of discussion boards they were active in out of a total of 25, was 90 (10)% v. 69 (6)%; p<0.01) (fig. 3b). the marks for student activity in the asynchronous discussion boards – assigned by the tutor(s) who facilitated each board, based on quality and timeliness of posts – only comprise 15% and 10% of final marks in year 1 and year 2, respectively, accounting for the similarity of marks overall. discussion this study describes the perceived educational effectiveness of the university of edinburgh’s pioneering online master’s programme in surgical sciences in one of the world’s poorest countries. there was general agreement between students and trainee programme supervisors in malawi that the msc is a potentially useful educational resource. however, students were more positive about the potential and perceived impact of the programme on their development than supervisors’ opinions of trainees enrolled for the msc, but this is anticipated given students’ personal expectations and inherent familiarity with the course content. interestingly, in response to the statement, ‘online postgraduate programmes in surgical sciences can improve the current surgical training programme in malawi’, only one respondent disagreed, disclosing that no trainees working under their supervision are current or former students of the msc programme. this suggests that there may be a bias against fully online educational resources for trainees unless surgeons have direct experience of such a programme. it should be emphasised that the msc programme covers the academic science underpinning surgery, and is intended to complement the practical surgical skills gained from full-time, supervised surgical training posts. the most common positive theme to emerge from the student free-text questionnaires was the beneficial nature of engaging with students and staff from other countries in the online discussion boards. these create an interactive online community that can reduce feelings of isolation associated with distance learning,[12,13] and contribute to increased learning and student satisfaction.[14,15] the msc in surgical sciences encourages students to critically reflect on their day-to-day surgical practice in the context of recent advances, and engage in critical dialogue with peers and tutors. malawian students were more likely to post on the boards than others in their cohort; this may be due to a sense of obligation as recipients of full-fee scholarship funding, as well as an appreciation of the interactions between fellow students and tutors. feedback from the malawian students revealed a certain ambivalence to the international nature of the discussion boards; all were interested to learn about clinical practice in other parts of the world, but they sometimes found it difficult to relate to clinical guidelines for surgical procedures they are not familiar with. although students may not be able to apply their own empirical evidence in discussions, such topics do challenge and extend their existing knowledge, and may prove relevant to future healthcare needs of lmics. equally, anecdotal feedback from our international student cohorts suggests that trainees from developed countries enjoy reading about the resourceful nature of peers in lmics. indeed, students can benefit from contextualising the online content to their local practice.[16] the online nature of the programme is especially important for trainees based in remote and rural areas, where interaction with peers from across the globe can ameliorate professional and social isolation.[2] limited internet and study time are clearly problematic for online students in malawi. msc content authors need to be mindful of limited bandwidths in lmics when including video content or media requiring fast internet speeds. as such, any video content should provide standard, written transcripts. high costs of international bandwidth and limited availability mean broadband can be prohibitively expensive for students in malawi. however, costs are expected to fall in the near future owing to completion of a national fibre-optic backbone that will provide global connectivity en d -o fye ar m ar k, % d is cu ss io n b o ar d p ar ti ci p at io n , % * 100 90 80 70 60 50 40 30 20 10 0 full student cohort malawian students full cohort malawian students year 1 year 2 year 3 100 80 60 40 20 0 a b fig. 3. (a) comparison of academic performance between students enrolled for the msc in surgical sciences from malawi v. the cohort average, from 2010 to 2017. average final percentage marks (mean (standard deviation (sd))) shown for students completing the course at the end of year 1 (n=694, full cohort; n=20, malawian); year 2 (n=463; n=16); and year 3 (n=282; n=12), reveal that there is only a significant difference between malawian students and their respective cohorts in year 3 (59 (11)% v. 68 (10)%; p<0.01, unpaired student’s t-test assuming unequal variances). (b) student level of participation on weekly, asynchronous, online discussion boards from 2010 to 2017. percentage of boards active in (mean (sd)) shown for the full cohort (n=694) and malawian students during years 1 and 2 (n=19) (*p<0.01, unpaired student’s t-test assuming unequal variances). 164 september 2018, vol. 10, no. 3 ajhpe research through a high-speed internet service.[17] by meeting the costs of internet provision at a programme level, malawian students have been able to study more flexibly, i.e. from home as opposed to remaining in their hospital workplace after hours to access the internet. over half of malawian respondents cited time constraints on part-time study alongside full-time clinical commitments. every student is appointed a personal tutor to provide academic and pastoral support throughout the year. this, together with the vocationally relevant course curriculum, helps students to manage their time effectively and view the msc as a continuation of their in-the-workplace learning. this has ensured a high retention and success rate across all 3 years of the taught master’s.[8] malawian graduates of the msc in surgical sciences have been invited to return to the programme as e-tutors and receive online training from the msc team to assist them in this role. they subsequently play an important part in teaching some of the basic sciences to students (n ~50) on the bsc general surgery for clinical officers (cos) (non-medically qualified) in malawi, as well teaching co students (n >100 annually) who are pursuing their diploma in clinical medicine.  malawian undergraduate mbbs students (n ~80 annually) are also beneficiaries of the knowledge imparted by msc in surgical sciences graduates. these educational outcomes, along with research outputs generated from master’s dissertations, demonstrate the synergy of the online surgical sciences programme. indeed, vogt and wang[18] highlight the benefits of training local staff teaching to enhance the long-term impact and sustainability of educational initiatives in lmics. the number of cos in malawi far exceeds the number of doctors, and they provide most of the healthcare in the country. post-basic education and training of this cadre of healthcare professionals have always been challenging, and the hope was that graduates of the online msc would be equipped with the required qualifications and skills to teach those who provide the mainstay of clinical care in the district hospitals of malawi. this hope has been realised, with the first graduate from the online msc successfully organising and delivering anatomy training to first-year bsc general surgery for cos in the college of medicine, blantyre, from 2013. this, in conjunction with larger student intakes to malawi medical training institutions proposed by the ministry of health, will help to address the shortage of healthcare workers. scale-up of doctors in lmics requires initiatives to address both quantity and quality of the healthcare workforce. frambach et al.[19] describe how education programmes in sub-saharan africa should impart lifelong learning skills and equip learners with the motivation for self-directed development if the quality of healthcare professionals is to improve. we consider our online master’s programme as effectively encouraging students to engage in continuing professional development (cpd) through critical appraisal of the research literature, current clinical guidelines, opinions of peers and self-reflection to practise safe, evidence-based medicine. although the malawian students studying for the edinburgh msc achieved slightly lower marks in their research year than our international cohorts, each successfully conducted and completed their master’s dissertation and they are now equipped with the skills to pursue future research in their respective departments. initiatives such as the global surgical outcomes collaboration (http://globalsurg.org/), which fosters regional, national and international surgical networks, will help surgeons from lmics to become involved in global research projects. the global health workforce alliance, launched in 2006 as a response to the global shortage of healthcare workers, is committed to greater access to and improved performance of the health workforce in lmics. the alliance has identified several key strategies that include developing innovative approaches to teaching in lmics with state-of-the art teaching materials and continuing education through information and communications technology, and nurturing a new generation of academic leaders in lmics with the support of experts from industrialised countries.[20] our innovative approach to educating surgeons in malawi meets exactly these strategies, and can serve as a model for other lmics. qureshi et al.[6] emphasised how postgraduate education, through online distance learning, can complement initiatives such as the surgical academic partnership between local hospitals in malawi and international institutions, where collaboration is the key factor.[6] using an approach of collaborative training provided by clinicians from developing and industrialised countries means that trainee surgeons can remain in their home country as they attain their professional and academic milestones. this aspect is highlighted in the student feedback of our programme: ‘i have been able to remain in malawi to learn, while continuing to treat those who need me most.’ (malawian msc graduate) next steps since the launch of our first online surgical postgraduate programme (msc surgical sciences), a further 6 master’s programmes have been developed with the aim of supporting advanced surgical trainees in their intended specialty (http://www.essqchm.rcsed.ac.uk/), and it is likely that similar scholarship schemes to those running in the msc surgical sciences will be initiated to support students from lmics to study on the chm programmes. under the commonwealth scholarship scheme, students receive both full tuition fee funding and the participation costs of an outreach summer school to be held in africa, aimed at supporting leadership and advocacy development. our university is currently in discussion over widening access to some of the msc content to meet educational and training needs. one possibility is to offer online surgical cpd opportunities to senior cos in malawi to help to improve standards of healthcare in that country, with the potential to roll out similar models tailored to other under-privileged countries. conclusions the master’s programme in surgical sciences has demonstrated its quality, relevance and global appeal by being taken up by >1 000 trainees in 60 different countries worldwide. the growth in international recruitment, both in student numbers and international e-tutors employed, and the direct support offered by scholarships to students from lmics, should improve surgical education in some of the poorest countries, including malawi, over the coming years. by delivering this training while trainees stay in their own country, there is minimal impact on surgical service delivery. at the same time, it allows the sharing of knowledge among colleagues. furthermore, this transnational approach prevents the brain drain that can occur when trainees travel abroad and fail to return. by training the msc graduates to be effective teachers in their own countries, and encouraging them to pursue research activities, the impact of this education will spread far beyond enrolled students. our online master’s programme will ultimately improve patient care in lmics, as today’s trainees become tomorrow’s surgeons. *appendices available from the corresponding author on request. september 2018, vol. 10, no. 3 ajhpe 165 research acknowledgements. the authors wish to thank johnson and johnson citizenship trust, the scottish government international development fund, physicians for peace, the commonwealth scholarship commission in the uk, and the royal college of surgeons of edinburgh for their sponsorship of student bursaries, and the clinical supervisors and surgical trainees for their insightful feedback on the msc programme, including dr lughano kalongolera, who provided details on the teaching activities delivered by msc graduates in malawi. author contributions. pjws: supervisor of the study, contributing to the planning, interpretation of results and writing of the manuscript; pjws, dd: designed the questionnaire; pjws, eb: distributed the questionnaire; and pjws, dd: performed the data collection and reviewed students’ responses. all authors contributed to the review of the literature, discussion of results and writing of the article. funding. none. conflicts of interest. none. 1. alkire bc, raykar np, shrime mg, et al. global access to surgical care: a modelling study. lancet global health 2015;3:e316-e323. https://doi.org/10.1016/s2214-109x(15)70115-4  2. meara jg, leather aj, hagander l, 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http://www.aho.afro.who.int/profiles_information/images/d/d8/malawi-statistical_factsheet.pdf http://www.aho.afro.who.int/profiles_information/images/d/d8/malawi-statistical_factsheet.pdf https://doi.org/10.1308/003588407x209329 https://doi.org/10.1016/j.surg.2012.08.004 https://doi.org/10.1016/j.jsurg.2016.10.013 https://doi.org/10.1080/01421590701874041 https://doi.org/10.1080/01421590701874041 https://doi.org/10.5539/ies.v7n13p61 https://doi.org/10.1007/s40670-017-0380-x https://doi.org/10.1016/s1096-7516(02)00102-1 https://doi.org/10.11120/jebe.2010.05010027 http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.6.352&rep=rep1&type=pdf https://www.budde.com.au/research/malawi-telecoms-mobile-and-broadband-statistics-and-analyses https://www.budde.com.au/research/malawi-telecoms-mobile-and-broadband-statistics-and-analyses http://dx.doi.org/10.1080/0142159x.2017.1327041 https://doi.org/10.3109/0142159x.2014.920490 https://doi.org/10.3109/0142159x.2014.920490 http://www.who.int/workforcealliance/knowledge/resources/ghwastrat20132016/en/ http://www.who.int/workforcealliance/knowledge/resources/ghwastrat20132016/en/ september 2018, vol. 10, no. 3 ajhpe 148 research international academic and professional healthcare fraternities share a common vision of interprofessional collaboration among the medicine, nursing and social sciences, and rehabilitation and paramedical professions.[1] interprofessional collaboration among healthcare practitioners stems from interprofessional education.[1-3] reeves et al.[1] state that interprofessional education occurs when medical, rehabilitative, nursing and social science professions study interactively for the primary purposes of improving interprofessional collaboration and enhancing the health and wellbeing of patients. interprofessional education, research and collaboration among academics and practitioners break down the barriers of professional individualism, antagonism and competition, allowing a more holistic and multivalent approach to patient care ˗ thereby responding to the needs of the patient in a more dynamic manner.[1] global advocacy for the adoption of interprofessional collaboration is based on the following validated claims: (i) respect for each other’s profession; (ii) enhanced patient management; (iii) optimal use of each healthcare team member’s skills; and (iv) provision of better healthcare to patients.[1] interprofessional collaboration has been shown to enhance patient wellbeing and reduce the medical expense of noncommunicable diseases (ncds) and orthopaedic injuries.[3] unfortunately, not all medical, rehabilitative, nursing and social science practitioners support interprofessional collaboration.[4-6] the opposite of interprofessional collaboration is professional individualism, which leads to antagonism and competition, with both national and international concerns being frequently brought to the surface regarding an individual discipline’s scope of profession (sop) and the issue of sop trespassing among various medical, social science and rehabilitation practitioners, thereby inhibiting the progress of interprofessional healthcare collaboration.[1] south africa (sa) has a long history of professional individualism and opposition to interprofessional collaboration among healthcare practitioners.[4-6] naidoo and buhler,[4] as well as keyter,[5] reported that the alleged trespassing of the chiropractic profession on the sop of physiotherapy and occupational therapy resulted in chiropractic therapy’s deregistration from the health professions council of south africa (hpcsa). recently, allegations regarding the profession of biokinetics, accused of trespassing onto the sop of physiotherapy, have adversely affected the former.[6] professional individualism and separation have an adverse effect on the quality of available healthcare.[3] the lack of interprofessional knowledge regarding healthcare leads to incorrect perceptions and professional individualism, which result in a dearth of patient referrals to applicable healthcare practitioners.[4,5] however, there is still hope that the sa healthcare fraternity will adopt the concept of interprofessional collaboration. felsher and ross[7] background. interprofessional collaboration is internationally and popularly envisioned as a successful paradigm for the management of disease, disabilities and injuries. despite this, the opinion of south african (sa) healthcare practitioners towards this idea is incoherent; this division of opinion needs to be changed to serve the common goal of better patient care. objective. to provide a narrative overview of literature-based evidence of interprofessional knowledge and perceptions of sa doctors, nurses, physiotherapists, occupational therapists, dieticians, speech and hearing therapists, as well as biokineticists regarding interprofessional collaboration. methods. an electronic search of google scholar, crossref, pubmed and sabinet databases identified 701 records, which were synthesised to 11 articles that were published during 2005 2016. individual article quality was appraised using the modified downs and black scale. results. of the 11 records, 3 were master’s theses reviewing the interprofessional knowledge and perceptions of doctors, physiotherapists and biokineticists towards the profession of chiropractic therapy; 3 examined the perceptions of chiropractic therapy, occupational therapy, speech and hearing therapy and biokinetics towards physiotherapy and chiropractic therapy; while the remaining 5 were supportive of interprofessional collaboration. the nature of the research designs of the selected studies were: survey (n=6), short communication (n=1), clinical commentary (n=1), randomised controlled trial (n=1) and focus group interview (n=2). an incoherence underlies the perceptions of the abovementioned practitioners regarding interprofessional collaboration owing to lack of interprofessional knowledge regarding each given discipline’s scope of profession (sop). this is compounded by uneasiness with regard to patient competition. some physiotherapists are against collaborative relationships, while occupational therapists, biokineticists and chiropractors are inclined to support the notion of a multidisciplinary physical rehabilitation team. there is a paucity of literature-based evidence reviewing the knowledge and perceptions of medical doctors, nurses and physiotherapists with regard to the sop of occupational therapists, speech and hearing therapists, biokineticists, dieticians and chiropractors, thereby warranting future investigation. conclusions. there are mixed perceptions of interprofessional collaboration among the selected healthcare practitioners owing to negative perceptions. afr j health professions educ 2018;10(3):148-152. doi:10.7196/ajhpe.2018.v10i3.951 interprofessional knowledge and perceptions of selected south african healthcare practitioners towards each other t j ellapen,1 phd; m swanepoel,1 phd; b t qumbu,1 ba hons; g l strydom,1 phd; y paul,2 phd 1 phasrec, faculty of health sciences, north-west university, potchefstroom campus, south africa 2 department of sport, rehabilitation and dental science, faculty of science, tshwane university of technology, south africa corresponding author: t j ellapen (tellapen1@yahoo.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 149 september 2018, vol. 10, no. 3 ajhpe research reported that interdisciplinary collaboration among sa physiotherapists, occupational therapists and speech and hearing therapists is important during the rehabilitation of stroke patients. according to booysen et al.,[8] however, despite the encouragement of interprofessional knowledge and collaboration among sa dietetic, occupational therapy, physiotherapy and medical students at tertiary educational institutions, this does not carry over into practice, adversely affecting the quality of sa healthcare. nonetheless, the idea of interprofessional collaboration among sa healthcare practitioners has existed for ~100 years. the earliest recorded idea regarding the development of an sa multidisciplinary medical rehabilitation team can be traced to 1920, when a medical report surfaced identifying the poor fitness condition of young sa men who wanted to join the military.[9-11] in 1934, this culminated in the establishment of the physical training brigade, a specialised unit of the sa national defence force aimed at rehabilitating boys with various medical and psychological illnesses, musculoskeletal injuries and disabilities.[11] this multidisciplinary medical rehabilitation team included physical education instructors, medical doctors, dentists, psychologists, physiotherapists, occupational therapists and social scientists. sa is experiencing an upsurge in the incidence of ncds, which is further increased by inept knowledge of prudent interprofessional healthcare.[12] ncds are non-infectious, non-transferable chronic diseases, which inter alia include cancer, diabetes mellitus and cardiorespiratory diseases.[12] the sa national healthcare plan should consider the strategy of a multidisciplinary medical rehabilitation team to manage, educate and prevent ncds and orthopaedic injuries. such strategies have been adopted internationally, earning great success.[3,13,14] collaborative interaction within a multidisciplinary medical rehabilitation team has been identified as the most effective method of delivering quality healthcare.[13,14] international healthcare trends show a decrease in the number of general hospitals and an increase in multidisciplinary hospitals (encouraging interprofessional co-operation).[13,14] this effort has led to shorter inpatient hospital stays and consequently decreased medical costs, while improving healthcare.[3,13,14] the success of these international multidisciplinary medical rehabilitation teams is dependent on the positive perceptions of their individual practitioners towards each other, as influenced by their interprofessional knowledge regarding each practitioner’s sop.[1-3,13,14] where knowledge is the mindfulness or comprehension of a person, profession or function learnt through discovery and/or education,[15] perception is the manner an individual thinks or understands another person, function or profession with/without knowledge.[15] the positive perceptions shared by these international practitioners are developed during their formal academic training through interprofessional education regarding the specific sop of each discipline.[2,3,13,14] three cochrane systematic reviews pertaining to interprofessional collaboration among international healthcare practitioners have been published, indicating the importance of this global concept;[1] their findings were supportive of interprofessional global healthcare collaboration.[1] there has, however, been no narrative overview of the status of sa healthcare practitioners’ knowledge and perceptions regarding the concept of interprofessional collaboration. the objective of this article is to provide a narrative overview of the literature evidence of interprofessional knowledge and perceptions shared by sa doctors, nurses, occupational therapists, physiotherapists, speech and hearing therapists, biokineticists and dieticians. methods the authors followed the standard practices for systematic reviews, known as preferred reporting items for systematic reviews and meta-analyses (prisma). the definitions were guided by the prisma checklist for participants, interventions, comparisons, outcomes and study designs (picos). information sources and searches a literature search of peer-reviewed, accredited journal publications and records was conducted in the following search engines: crossref metadata base, an academic metadata base comprised of pubmed, medline, sciencedirect, ebscohost, cinahl, sabinet and google scholar search engines (fig. 1). the keywords used were ‘knowledge’, ‘perceptions’, ‘medical doctors’, ‘nurses’, ‘physiotherapists’, ‘chiropractors’, ‘occupational therapists’, ‘speech and hearing therapist’, ‘dieticians’ and ‘biokineticists’. the screening eligibility of articles was performed in the following three steps: (i) title screen; (ii) abstract screen; and (iii) full text screen. the articles were screened by tje, btq, ms and gls. eligibility criteria the participants in this study reflected the interprofessional knowledge and perceptions within the sa medical rehabilitation community; the intervention was not necessarily a therapeutic one, but was interpreted as an exposure, i.e. the knowledge and perceptions of selected sa medical rehabilitation practitioners towards each other. the outcomes of interest were: (i) interprofessional knowledge among selected sa medical rehabilitation practitioners; and (ii) interprofessional perceptions of selected sa medical rehabilitation practitioners towards each other. the exclusion total number of records identi�ed (n=701) keywords: knowledge, perceptions, medical doctors, nurses, physiotherapists, chiropractors, occupational therapists, speech and hearing therapists, biokineticists, dieticians time frame: 2005 2016 application of exclusion criteria 1. title review 2. abstract review 3. removal of duplicate records 4. removal of non-english records 5. removal of records before 2005 6. removal of records other than the practitioners of nursing, doctors, physiotherapists, occupational therapists, chiropractors, speech and hearing therapists, biokineticists, dieticians full-text records eligible to be included in the review (n=11) survey (n=6), short communication (n=1), clinical commentary (n=1), randomised controlled trial (n=1) and focus group interview (n=2) fig. 1. conceptualisation of the review process. september 2018, vol. 10, no. 3 ajhpe 150 research criteria were: (i) publications before 2005; (ii) non-english articles; (iii) inter professional knowledge and perceptions of sa medical rehabilitation practitioners other than those in the abovementioned list; and (iv) nonpeer-reviewed articles. study selection: appraisal of evidence and quality of studies the hierarchy of evidence was appraised by the tool adopted from abdullah et al.[16] (table 1). all publications were filtered, based on the appropriateness of the title and whether they met the inclusion criteria. the authors included all levels of evidence owing to the limited literature available, provided the publications met the inclusion criteria. the quality of individual articles was analysed by adopting the modified downs and black appraisal scale, which examines the quality of randomised controlled trials and non-randomised articles.[17] the downs and black checklist was modified because not all items on the original checklist related to this article; the modified checklist consisted of 12 questions with a maximum of 12 points. answers were scored as either 0 (no) or 1 (yes). the questions adopted were 1, 2, 3, 6, 10, 11, 12, 13, 15, 18, 20 and 27, and these assessed each study’s reporting prowess (n=5), external validity (n=3), internal validity (n=3) and power of significance (n=1) (table 2). the sum of these scores was then expressed as a percentage of the overall estimation of the quality of the article, where the overall quality was graded as: <50% (weak), 50 69% (fair), 70 79% (good) and ≥80% (very good), as per the grading criteria adopted by li et al.[18] table 1 describes the appraisal methods and characteristics of each study. results the electronic literature survey identified 701 records, which were reduced to 11 publications after stringent application of exclusion criteria (fig. 1). table 1 apprises the hierarchy of the records as per the guidelines laid out by abdullah et al.,[16] describing the type of research design adopted by the respective authors. table 2 evaluates each study according to the modified downs and black appraisal scale.[17] a descriptive overview of the characteristics and findings of the studies is given in table 3. of the 11 records, 3 were master’s theses reviewing the interprofessional knowledge and perceptions of doctors, physiotherapists and biokineticists towards the profession of chiropractic therapy; 3 examined the perceptions of chiropractic therapy, occupational therapy, speech and hearing therapy and biokinetics towards physiotherapy and chiropractic therapy; while the remaining 5 were supportive of interprofessional collaboration. there were 1 053 participants across the 11 studies, with sample sizes varying from 8 to 449. the professions involved were medicine, nursing science, physiotherapy, occupational therapy, dietetics, biokinetics and speech and hearing therapy. the nature of the research designs of the selected studies were: survey (n=6), short communication (n=1), clinical commentary (n=1), randomised controlled trial (n=1) and focus group interview (n=2). the overall quality of the studies rated as very good (80%) (table 2). records are arranged chronologically and then alphabetically. discussion the discussion presents the status of the abovementioned sa healthcare practitioners towards interprofessional collaboration, as well as current table 1. appraisal of the hierarchy of records as per abdullah et al.[16] level record type record, n authors i systematic review 0 none ii-1 randomised controlled trial 0 none iii-1 pseudo-randomised controlled trial 0 none iii-2 comparative study with concurrent controls 3 naidoo and buhler (2009),[4] booysen et al. (2012),[8] chetty et al. (2014)[26] iii-3 comparative study without concurrent controls 8 louw (2005),[20] naidoo (2008),[21] keyter (2010),[5] puckree et al. (2011),[22] van staden et al. (2011),[19] ellapen et al. (2016),[25] manillal and rowe (2016),[24] rowe (2016)[23] iv case series/studies with either post-test or pretest/ post-test outcomes 0 none table 2. appraisal of records according to the modified downs and black appraisal scale[17] authors downs and black appraisal scale reported (n=5) external validity (n=3) internal validity (n=3) power (n=1) total (n=12) grading % = x/12 × 100 louw (2005)[20] 5 3 2 1 11 91.6 naidoo (2008)[21] 5 3 2 1 11 91.6 naidoo and buhler (2009)[4] 5 3 2 1 11 91.6 keyter (2010)[5] 5 3 2 1 11 91.6 puckree et al. (2011)[22] 5 3 2 1 11 91.6 van staden et al. (2011)[19] 5 3 3 3 12 100 booysen et al. (2012)[8] 5 2 2 1 10 83.3 chetty et al. (2014)[26] 4 3 2 1 10 83.3 ellapen et al. (2016)[25] 4 1 0 1 6 50.0 manillal and rowe (2016)[24] 4 3 2 1 10 83.3 rowe (2016)[23] 2 0 0 1 3 25.0 151 september 2018, vol. 10, no. 3 ajhpe research ta bl e 3. c hr on ol og ic al o ve rv ie w o f c ha ra ct er is ti cs a nd fi nd in gs o f t he st ud ie s ( n =1 1) a ut ho rs c ha ra ct er is ti cs o f t he s tu dy st ud y ty pe a nd s am pl e ch ar ac te ri st ic s p ro fe ss io n be in g st ud ie d pe rc ep ti on o f t he pr of es si on in te rp ro fe ss io na l kn ow le dg e of sc op e pe rc ep ti on fi nd in gs lo uw ( 20 05 )[2 0] su rv ey : m ed ic al d oc to rs ( n= 82 ) c hi ro pr ac tic th er ap y m ed ic in e   m ed ic al d oc to rs h av e in ad eq ua te k no w le dg e of th e so p of c hi ro pr ac to rs n ai do o (2 00 8) [2 1] su rv ey : b io ki ne tic is ts ( n= 78 ) c hi ro pr ac tic th er ap y bi ok in et ic s   bi ok in et ic is ts a re k no w le dg ea bl e re ga rd in g th e so p of c hi ro pr ac to rs , p er ce iv in g th em as v al ue d m em be rs o f t he m ul tid is ci pl in ar y ph ys ic al r eh ab ili ta tio n te am n ai do o an d bu hl er ( 20 09 )[4 ] su rv ey : s tu de nt p hy si ot he ra pi st s (n =7 2) an d ch ir op ra ct or s (n =4 9) c hi ro pr ac tic th er ap y ph ys io th er ap y c hi ro pr ac tic th er ap y   ph ys io th er ap y st ud en ts h av e ne ga tiv e pe rc ep tio ns o f c hi ro pr ac to rs , t he re by re si st an t t o in te rp ro fe ss io na l c ol la bo ra tio ns , un lik e ch ir op ra ct ic s tu de nt s k ey te r (2 01 0) [5 ] su rv ey : c hi ro pr ac to rs ( n= 12 0) c hi ro pr ac tic th er ap y ph ys io th er ap y m ed ic in e   m ed ic al d oc to rs a nd p hy si ot he ra pi st s ha ve in ad eq ua te k no w le dg e of th e so p of ch ir op ra ct or s pu ck re e et a l. (2 01 1) [2 2] su rv ey : m ed ic al s tu de nt s (n =7 1) , oc cu pa tio na l t he ra py s tu de nt s (n =8 ), sp or ts s ci en ce s tu de nt s (n =4 5) ph ys io th er ap y o cc up at io na l t he ra py sp or ts s ci en ce m ed ic in e   m ed ic al s tu de nt s ha ve p oo r kn ow le dg e of th e so p of p hy si ot he ra py v . t he k no w le dg e of s po rt s sc ie nc e an d oc cu pa tio na l t he ra py st ud en ts v an s ta de n et a l. (2 01 1) [1 9] r an do m is ed c on tr ol le d tr ia l ex pe ri m en ta l g ro up : p at ie nt s w ho re ce iv ed m ul tid is ci pl in ar y re ha bi lit at io n (n =3 0) ; c on tr ol : p at ie nt s w ho d id n ot re ce iv e m ul tid is ci pl in ar y re ha bi lit at io n (n =2 0) o cc up at io na l th er ap y m ed ic in e n ur si ng s ci en ce ph ys io th er ap y bi ok in et ic s   t he re is a n ee d to e st ab lis h an in te rp ro fe ss io na l t ea m a pp ro ac h am on g do ct or s, n ur se s, p hy si ot he ra pi st s, oc cu pa tio na l t he ra pi st s an d bi ok in et ic is ts to he lp e m pl oy ee s to r et ur n to w or k b oo ys en e t a l. (2 01 2) [8 ] su rv ey : m ed ic al d oc to rs ( n= 20 3) , di et ic ia ns ( n= 58 ), oc cu pa tio na l th er ap is ts ( n= 74 ), ph ys io th er ap is ts (n =6 8) , s pe ec h, la ng ua ge a nd h ea ri ng th er ap is ts ( n= 46 ) in te rd is ci pl in ar y he al th ca re te am m ed ic in e d ie te tic s o cc up at io na l t he ra py ph ys io th er ap y sp ee ch , l an gu ag e an d he ar in g th er ap y   d es pi te th e en co ur ag em en t o f in te rp ro fe ss io na l c ol la bo ra tio n at a ca de m ic tr ai ni ng in st itu tio ns , t he e nc ou ra ge d co lla bo ra tio n do es n ot e ff ec tiv el y tr an sl at e in to p ro fe ss io na l p ra ct ic e c he tt y et a l. (2 01 4) [2 6] fo cu s gr ou p in te rv ie w : p hy si ot he ra pi st s (n =8 ), bi ok in et ic is ts ( n= 9) ph ys io th er ap y an d bi ok in et ic s ph ys io th er ap y bi ok in et ic s   t he re is a n ee d fo r co lla bo ra tio n be tw ee n ph ys io th er ap is ts a nd b io ki ne tic is ts , b ut th er e is ig no ra nc e of in te rp ro fe ss io na l s op ; p at ie nt co m pe tit io n in hi bi ts th is el la pe n et a l. (2 01 6) [2 5] c lin ic al c om m en ta ry in te rpr of es si on al co lla bo ra tio n in th e m d pr t bi ok in et ic s   t he re is a n ee d fo r m ul tid is ci pl in ar y ph ys ic al te am r eh ab ili ta tio n to h el p re so lv e lo w er ba ck p ai n m an ill al a nd r ow e (2 01 6) [2 4] fo cu s gr ou p in te rv ie w : p hy si ot he ra py st ud en ts ( n= 12 ) in te rpr of es si on al co lla bo ra tio n in th e m d pr t ph ys io th er ap y   ph ys io th er ap y st ud en ts a nd le ct ur er s ar e re si st an t t o th e id ea o f i nt er pr of es si on al co lla bo ra tio n r ow e (2 01 6) [2 3] sh or t c om m un ic at io n in te rpr of es si on al co lla bo ra tio n in th e m d pr t ph ys io th er ap y   t he re is n ee d fo r co lla bo ra tiv e in te ra ct io n am on g so ut h a fr ic an m ul tid is ci pl in ar y ph ys ic al r eh ab ili ta tio n pr ac tit io ne rs so p = sc op e of p ro fe ss io n; m d pr t = m ul tid is ci pl in ar y ph ys ic al re ha bi lit at io n te am . september 2018, vol. 10, no. 3 ajhpe 152 research plausible solutions to counter the resistance to interprofessional collaboration. the initial findings identified the visible paucity of literature-based evidence regarding interprofessional sop knowledge, perceptions and collaboration among sa healthcare practitioners, which warrants further research. the literature-based evidence presents a disjointed consensus towards the formulation of an sa multidisciplinary medical rehabilitation team. the disjointed nature of the consensus is primarily due to a lack of interprofessional knowledge, which is coupled with certain negative perceptions among the various abovementioned disciplines.[5,20-22] the profession of physiotherapy is generally negative towards the establishment of collaborative relationships with chiropractors and biokineticists owing to their perception that these professionals are trespassing on their sop and pilfering their patients.[22,24] medical doctors and students are not generally mindful and appreciative of the individual sop of physiotherapists and chiropractors; this has produced animosity between these professions, thereby creating obstacles to the formulation of a multidisciplinary medical rehabilitation team.[22,24] chiropractors, speech and hearing therapists, dieticians, biokineticists and occupational therapists are favourably inclined to interprofessional collaboration owing to their sound interprofessional knowledge of each other’s sop.[4,8,19,21] the literature presents no evidence of the interprofessional knowledge and perceptions that medical doctors, nurses and physiotherapists may have regarding biokineticists and occupational therapists. this gap in the literature requires future investigation. one solution to the resistance expressed regarding interprofessional collaboration is the persistent encouragement and institutionalisation of tertiary interprofessional education among all healthcare students.[1,8,23,24] international healthcare academic fraternities have integrated interprofessional healthcare education into their teaching curriculum, which has translated into interprofessional collaboration.[1-3,13,14] there is literaturebased evidence that interprofessional healthcare collaboration provides the best level of healthcare, which should encourage sa healthcare practitioners to put aside their differences to collaboratively strive for improvement of healthcare.[13,14] it is recommended that the hpcsa – the national statutory body for healthcare – institute quarterly roadshows and workshops to encourage interprofessional healthcare collaboration among all healthcare professions and practitioners. it is further recommended that the hpcsa prescribe a multidisciplinary medical rehabilitation team, including all healthcare practitioners, to manage, educate and prevent injuries, illnesses and disabilities among the sa population. this team should form part of the sa national healthcare plan to combat disease, disabilities and injuries. it is postulated that the abovementioned recommendations may encourage collaborative relationships among sa healthcare professionals. conclusions a diverse range of perceptions regarding interprofessional healthcare collaboration exists owing in no small part to a lack of interprofessional knowledge of the individual sop across the various medical and healthcare disciplines. the institutionalisation of interprofessional healthcare education among all relevant universities and colleges, as well as the persistent encouragement from the hpcsa, supporting interprofessional co-operation, should be undertaken to create a collaborative environment that will improve healthcare outcomes for patients. acknowledgements. none. author contributions. tje: conceptualisation of the idea, screening of records, drafting and revision of manuscript; btq: screening of records, drafting of manuscript; ms: screening of records, drafting of manuscript; gls: screening of records, drafting and revision of manuscript; and yp: drafting of manuscript. funding. none. conflicts of interest. none. 1. reeves s, perrier l, goldman j, freeth d, zwarenstein m. interprofessional education: effects on professional practise and healthcare outcomes. cochrane database syst rev 2013;(3):cd002213. https://doi. org/10.1002/14651858.cd002213.pub3 2. bridges dr, davidson ra, odegard sp, maki iv, tomkowiak j. interprofessional collaboration: three best practice models of interprofessional education. med educ 2011;16: 6035. https://doi.org/10.3402/meo.v16i0.6035 3. mcpherson k, headrick l, moss f. working and learning together: good quality care depends on it, but how can we achieve it? qual health care 2001;10(suppl ii):ii446-ii453. https://doi.org/10.1136/qhc.0100046 4. naidoo n, buhler l. the perceptions, attitudes and knowledge of physiotherapy and chiropractic students regarding each other’s professional practise. s afr j physiother 2009;65(2):32-38. https://doi.org/10.4102/sajp. v65i2.85 5. keyter k. the perceptions of the south african chiropractors regarding their professional identity. mtech thesis. durban: durban university of technology, 2010. 6. nhlapho s. advisory letter to the stakeholders. health professions council of south africa, pretoria. 2016. http:// www.hpcsa.ac.za (accessed 26 july 2016). 7. felsher l, ross e. the knowledge and attitudes of occupational therapy, physiotherapy and speech language therapy students regarding the speech language therapist’s role in the hospital stroke rehabilitation team. s afr j commun disord 1994;41:49-56. 8. booysen n, lake j, webb j, van niekerk w, schubl c. the knowledge, attitudes and perceptions of healthcare students and professionals regarding the interdisciplinary health worker team at stellenbosch university and tygerberg academic hospital. s afr j clin nutr 2012;25(4):192-196. https://doi.org/10.1080/16070658.2012.1 1734427 9. geyer gj. liggaamlike opleiding in die unie-verdedigingsmag (1912 1946). ma thesis. pretoria: university of pretoria, 1969. 10. cilliers jj. die bydrae van geprogrammeerde inoefening in na-mediese fisieke rehabilitasie van beseerdes uit die miltêre operasionele gebied. phd thesis. potchefstroom: potchefstroom university for christian higher education, 1985. 11. malan ddj, strydom gl. the evolution of physical education at the north-west university – a multifaceted historical development. afr j phys health educ recreat dance 2007;(suppl):1-22. 12. national planning commission. national development plan: promoting health. 2017. http://www. nationalplanningcommission.org.za (accessed 4 august 2017). 13. vincent-onabajo go, mustapha a, oyeyemi ay. medical students’ awareness of the role of physiotherapy in multi-disciplinary healthcare. physiother theory pract 2014;30(5):338-344. https://doi.org/10.3109/09593985.2 013.871765 14. momsen a, rasmussen jo, nielsen cu, iversen md, lund h. multi-disciplinary team care in rehabilitation: an overview of reviews. j rehab med 2012;44:901-912. https://doi.org/10.2340/16501977-1040 15. stevenson a, lindberg ca. new oxford american dictionary. 3rd ed. oxford: oxford university press, 2010. 16. abdullah am, mcdonald r, jaberzadeh s. the effects of backpack load and placement on postural deviation in healthy students: a systematic review. int j engineer res appl 2012;2(6):466-481. 17. downs sh, black n. the feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. j epidemil commun health 1998;52(6):377-384. https://doi.org/10.1136/jech.52.6.377 18. li c, khoo s, adnan a. effects of aquatic exercise on physical function and fitness among people with spinal cord injury: a systematic review. medicine 2017;96(11):e6328. https://doi.org/10.1097/md.0000000000006328 19. van staden h, kemp r, beukes s. return to work of patients after lumbar surgery. s afr j occup ther 2011;41(3):1-9. 20. louw jd. the knowledge of general practitioners about chiropractics as a factor that may influence health care integration in south africa. mtech thesis. durban: durban institute of technology, 2005. 21. naidoo m. a survey to determine the knowledge and perceptions of biokineticists with respect to the chiropractic profession. mtech thesis. durban: durban institute of technology, 2008. 22. puckree t, harinarain r, ramdath r, singh rb, ras j. knowledge, perceptions and attitudes of final year medical, occupational therapy and sports science students regarding physiotherapy, in kwazulu natal. s afr j physiother 2011;67(3):19-26. https://doi.org/10.4102/sajp.v67i3.50 23. rowe m. the future of education in complex systems. afr j health professions educ 2016;8(2):128. https://doi. org/10.7196/ajhpe.2016.v8i2.889 24. manillal j, rowe m. collaborative competency in physiotherapy students: implications for interprofessional education. afr j health professions educ 2016;8(2):217-221. https://doi.org/10.7196/ajhpe.2016.v8i2.841 25. ellapen tj, swanepoel m, strydom gl. a comparative review of the rehabilitative professions assisting patients with lower back pain in south africa. s afr j res sport, phys educ recreat 2016;39(3):1-14. 26. chetty v, dunpath t, bhagwandin r, et al. collaboration between physiotherapists and biokineticists in managing low back pain in an urban setting in south africa. afr j phys health educ recreat dance 2014;20(4.2):1587-1597. accepted 24 january 2018. https://doi.org/10.1002/14651858.cd002213.pub3 https://doi.org/10.1002/14651858.cd002213.pub3 http://www.doi:10.3402/meo.v16i0.6035 https://doi.org/10.1136/qhc.0100046 https://doi.org/10.4102/sajp.v65i2.85 https://doi.org/10.4102/sajp.v65i2.85 http://www.hpcsa.ac.za http://www.hpcsa.ac.za https://doi.org/10.1080/16070658.2012.11734427 https://doi.org/10.1080/16070658.2012.11734427 http://www.nationalplanningcommission.org.za http://www.nationalplanningcommission.org.za https://doi.org/10.3109/09593985.2013.871765 https://doi.org/10.3109/09593985.2013.871765 https://doi.org/10.2340/16501977-1040 https://doi.org/10.1136/jech.52.6.377 https://doi.org/10.4102/sajp.v67i3.50 https://doi.org/10.7196/ajhpe.2016.v8i2.889 https://doi.org/10.7196/ajhpe.2016.v8i2.889 https://doi.org/10.7196/ajhpe.2016.v8i2.841 march 2018, vol. 10, no. 1 ajhpe 61 research the status of pharmacy practice as a profession is governed by its laws and ethics, which underpin the role of pharmacists and confer upon them the exclusive authority to conduct certain activities that are restricted and unique to the profession. knowledge and understanding of ethical issues and resolutions serve to guide decisions and behaviours inherent to a pharmacist’s practice. however, teaching pharmacy law has become increasingly challenging, as educators are constantly encouraged to find and implement innovative ways of teaching that will promote higher-order, critical thinking and collaborative learning, coupled with the need to increase student motivation.[1] instruction in the main acts and regulations that govern the practice of pharmacy in south africa (sa) are presented in a format that is outdated and difficult to interpret, which makes comprehension of the basic concepts challenging. experience in teaching the module has revealed that the language or legalese in which pharmacy law policy is written is unfamiliar to pharmacy students, and is more suitable to law students. in addition, the acts are fragmented, creating further difficulty for students to draw on the different aspects of the law for rational decision-making, and for its application to real-life circumstances. this situation requires considerable effort and skill from the educator to teach students how to discern reasonable solutions to problems that they may encounter in practice. previously, the various acts and regulations were taught to students in isolation via a predominantly didactic lecturebased format. this teaching method is often disconnected, and although lecturers try to link theory to application, it is difficult to do so by use of mere examples to illustrate the text. it also relies on the skills and expertise of the lecturer to maintain student attention for the duration of the lecture. students at the university of kwazulu-natal (ukzn), durban, sa, are drawn from diverse backgrounds, bringing with them educational, communication and language barriers. in teaching this course, it became clear that students found the language of the law texts difficult to comprehend, interpret and apply. this created a fair amount of anxiety among learners, and called for the use of alternative teaching methods to enhance learning. however, no standardised strategies have been designed to effectively educate students and address the challenges in this area of instruction. one method could be to supplement traditional didactic lecture-based teaching with the development and implementation of case-based learning (cbl). cbl has been defined as an innovative, discussion-based teaching method[2] that is student centred, and encourages learners to interactively explore complex, realistic and specific situation scenarios.[3] cbl allows students to develop critical skills and reflective judgement through reading and discussing complex, real-life scenarios. it also promotes learner-centred small-group interactive learning experiences, as opposed to large-group didactic lecture-based teacher-centred instruction.[1] as a result, students involved in cbl tend to be more confident in practising the skills learnt during the process.[4] a further benefit that makes this method suitable for teaching in healthcare education is that it encourages students to view all aspects of a patient’s situation while handling a real case.[5] there are various types of cbl, which include seminars, standardised patient events, web situations, medical teaching rounds, mini scenarios and directed case studies.[4] the type of case study used depends on the aim of the course, the discipline being taught and the skills needed to be nurtured. background. pharmacy educators are responsible for ensuring that students are equipped with the necessary regulatory knowledge required to deal with ethical challenges that arise in practice. teaching methods have a strong impact on student learning, making it essential to determine how learning is influenced when changing pedagogy. objective. to describe students’ experience and perceptions of the use of a case-based learning (cbl) activity as an adjunctive method to didactic teaching of pharmacy law and ethics. method. a survey was conducted among 3rd-year pharmacy students enrolled for a pharmacy law and ethics course at the university of kwazulunatal, durban, south africa. the course content was delivered didactically, followed by a cbl activity for which the students were divided into groups and assigned various real-life case studies. results. most of the 74 respondents (66%) agreed that the activity was enjoyable and metacognitively useful. a majority (77%) found the activity interactive, and 92% agreed that it enhanced their understanding of pharmacy law concepts. eighty percent agreed that it facilitated their understanding of law and ethics concepts, and their application to real-life situations. conclusion. the use of cbl was beneficial to both the individual student’s learning experience and the overall class learning process. more importantly, the exercise improved their metacognitive awareness, and suggests the need to consider this method of teaching as part of the formal curriculum to better equip students to deal with ethical issues that will arise in practice. afr j health professions educ 2018;10(1):61-65. doi:10.7196/ajhpe.2018.v10i1.714 a new way of teaching an old subject: pharmacy law and ethics s chetty, bpharm, msc, phd; v bangalee, bpharm, mpharm, phd; f oosthuizen, bpharm, msc, phd discipline of pharmaceutical sciences, school of health sciences, westville campus, university of kwazulu-natal, durban, south africa corresponding author: v bangalee (bangalee@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 62 march 2018, vol. 10, no. 1 ajhpe research at ukzn, a cbl activity was used to supplement the pharmacy law and ethics course, which consisted of a series of didactic lectures. the study aimed to establish the usefulness of the exercise through a number of objectives, these being to explore the student’s experience and perceptions of the use of cbl, its perceived effectiveness for learning, aspects that they enjoyed/did not enjoy about the activity, benefits of the activity on learning, and finally, to obtain suggestions on how the activity could be improved. significance of the study the requirement for an adjunct to routine didactic lectures has long been appreciated by higher education institutions. this stems from growing concerns that didactic teaching alone does not encourage the right student qualities, nor does it impart lifelong respect for learning.[6] in teaching pharmacy law and ethics, educators are challenged to create an interesting and engaging method of educating students about a subject that is potentially considered to have little clinical relevance.[7] while cbl has been proven to have some success in meeting this challenge in other health professions courses,[6] there is a lack of documented data on its use in teaching pharmacy law and ethics in sa, and at ukzn specifically. early evaluation of the usefulness of and learner experience with cbl is therefore important to modify and enrich the current teaching methods, and to form a better learning approach with the active participation of students. methods context the study involved all 3rd-year pharmacy students enrolled for the course entitled pharmacy law and ethics (phrm 355) at ukzn in 2015. students enrolled in the course have limited exposure to pharmacy laws (they are introduced to the legal framework of the sa healthcare system in their 1st year of study), and generally have no previous exposure to ethical issues. students registered for the course come from diverse backgrounds in terms of religion, language, ethnicity and self-directed learning skills. the course was developed to inform students of relevant legislation governing the practice of pharmacy. the regulatory content covered includes the pharmacy act 53 of 1974 and the medicines and related substances control act (1963). in addition to law, students were introduced to good pharmacy practice (gpp) standards; ethical principles, such as biomedical ethics; professional ethics; code of conduct; rules pertaining to the scope of practice of pharmacy personnel; and principles of medication scheduling. ethical approval ethical approval was obtained from the ukzn humanities and social sciences research ethics committee (ref. no. hss/0354/015). student consent was obtained prior to administering the questionnaire, with participation being voluntary and anonymity being maintained. current teaching method the course has traditionally been taught via didactic lectures that introduce students to concepts, principles and their application. this has been an attractive approach for ease of information dissemination to increasingly large classes, as it allows for the economical use of staff time. however, this approach is largely teacher-centred, with minimal active interaction between lecturer and students, and between the students themselves.[6] it further places the burden of promoting learning almost entirely on the lecturer, and thus fails to develop opportunities to develop critical thinking among learners. intervention the course content was first taught didactically and then supplemented by a cbl activity session. in this study, the 95 students were randomly divided into 11 groups of 8 or 9 students. the rationale behind the random placement of students into groups was to ensure that they mixed and shared ideas with their peers, irrespective of whether they had previously worked together. each group was assigned a case study that reflected ‘real world’ ethical dilemmas that are seen in pharmacy practice. each case included a brief overview that both established a context for the problem and identified major decisions that needed to be made. the cases required students to consider the problems from a perspective that necessitated analysis, with them being guided to suitable references to consult to solve the problem. an additional reason for modifying the structure of the course was to reinforce concepts covered in the didactic portion of the course with their application to real-practice situations. groups were allocated 3 weeks to discuss and analyse the assigned cases, the activity being designed to encourage communication among the group members, while promoting engagement with the theory of pharmacy law. it was hoped that this type of interactive teaching would stimulate and maintain students’ interest, thereby allowing for greater participation of students in their own teaching programme. students were required to search for relevant information to solve the case, provide supporting evidence and develop a 10 15-minute presentation to be delivered to the rest of the class during a tutorial session. during the presentations, the other groups were encouraged to ask questions, with discussions being concluded by the lecturer who confirmed correct answers or corrected group misconceptions. overall group performance was assessed by the lecturer, and individual marks were adjusted based on the peer assessment of their individual contributions by their own group members. study design this was a descriptive, observational study designed to report on students’ experience of the use of cbl as a teaching method. data were collected through self-administered questionnaires that were manually distributed by the educator at the end of the day of group presentations. the structured questionnaire consisted of three sections, the first being demographic details (age, gender, highest qualification). section 2 contained 9 closedended questions that were designed to establish their perceived value of the activity on improving comprehension, application to real-life situations, as well as metacognitive abilities. it consisted of likert-scale questions focused on the following: (i) the student’s experience and perceptions of the activity; and (ii) its perceived effectiveness for learning. section 3 consisted of open-ended questions that were thematically analysed and the responses aggregated to determine: (iii) what aspects students enjoyed or (iv) did not enjoy about the activity; (v) benefits of the activity on their learning; and (vi) suggestions for improvement. data analysis data were collected, captured electronically and processed using microsoft excel 2013 (microsoft, usa). descriptive statistics were generated and responses were tabled for the closed-ended questions, while the responses march 2018, vol. 10, no. 1 ajhpe 63 research for the open-ended questions were grouped in order of prevalence. the frequency count for common comments was determined and all the repeated responses (>10%) are reported. results a total of 74 respondents (26 male, 48 female) from a class of 95 students completed the survey. the majority of students (64%) were between 21 and 22 years of age, and 71 (96%) indicated that a high school matric was their highest previous education. table 1 reflects responses to the closed-ended likert-scale questions. regarding the student responses to section 2 pertaining to experience and perceptions of the cbl activity, two-thirds (66%) agreed that they found the activity enjoyable, with 92% noting that it helped to improve their understanding of the law concepts. eighty percent indicated that the activity helped them to understand and apply the concepts to real-life situations, while the majority (77%) agreed it was interactive, with many students (69%) reporting increased classroom involvement. regarding the student responses to section 2, pertaining to its perceived effectiveness for learning, just over half (59%) of the respondents agreed that they would rate learning high from this type of activity; however, less than half (46%) indicated that the activity kept them focused and motivated to learn more. seventy-three percent agreed that the activity helped to validate their own learning, while 54% felt that the activity helped them to prepare for the examinations. the open-ended questions were analysed and separated into themes that were developed from the most frequent (>10%) responses (table 2). discussion the responsibility that pharmacy educators face in equipping graduates with enhanced communication skills, greater problem-solving capabilities, effective critical thinking abilities, and sound decision-making skills has become increasingly important.[8] this activity requires the use of innovative and pedagogically sound instructional strategies to facilitate the learning outcomes needed to practise in all aspects of the pharmaceutical profession. to the best of our knowledge, this study represents the first documented research into students’ perspectives on the use of cbl in the teaching of pharmacy law and ethics at ukzn. student feedback regarding section 2 on the experience and perceptions of the cbl activity and its perceived effectiveness for learning was generally positive. significantly, the majority (92%) of the students agreed that participation in the exercise helped to improve their understanding of law concepts, and many indicated that it helped them to appreciate how the various law and ethics concepts applied to real-life situations. this is encouraging, as the ability of students to attach a tangible value to the application of these scenarios to real-life situations is pertinent to the practice of pharmacy in sa. most of the students agreed that the activity was interactive. the last four questions of the closed-ended questions explored the metacognitive responses of the students’ individual learning processes. the term metacognition was first used by flavell, and means ‘thinking about thinking’.[9] metacognition consists of two parts: knowledge of cognition and metacognitive regulation. the first part is the individual’s awareness of table 1. section 2: closed-ended questions questions agree, % neutral, % disagree, % skipped question, % 1. experiences and perceptions of the activity i found this activity enjoyable 66 31 3 0 this activity helped improve my understanding of different law concepts 92 7 1 0 the activity helped in my understanding of the application of various concepts in law and ethics to real-life situations 80 15 1 4 i found this activity interactive 77 20 1 2 this activity increased my involvement in the classroom 69 24 7 0 2. perceived effectiveness for learning i would rate my learning high from this type of activity 59 35 4 2 this activity helped me stay focused and motivated me to learn more 46 46 8 0 this activity helped me validate my own learning 73 27 0 0 the activity helped in preparation for my examination 54 39 6 1 table 2. section 3: open-ended questions questions responses, % 3. aspects enjoyed about the activity the activity was interactive and they learnt from the discussions 31 students found the activity enjoyable 23 students perceived value to it relating to real-life situations 19 it promoted team activity and working together in a group 13.5 4. aspects least enjoyed about the activity nothing to report 22 working in groups and some members of the group did not contribute 22 the presentations were too long 9.5 5. benefits of case-based learning it promoted retention of information 41 application to real-life situations increased comprehension and understanding of the law concepts 38 it promoted learning in a different way 12 6. students’ suggestions to improve the activity students should be allowed to choose their own groups 28 students would like more examples and scenarios 26 no suggestions 15 64 march 2018, vol. 10, no. 1 ajhpe research themselves as a learner and which study method would make them more productive. the second part refers to strategies that the student employs to monitor and enhance their own learning.[10,11] the questions in the survey probed the students’ self-awareness of the activity and their perceived impact on individual learning and preparation for examinations, with two-thirds enjoying the use of this type of activity to aid their learning process. more than half of the students were cognisant that they found learning high from this type of activity. the neutral numbers were quite high in this section, which could mean that people have different ways of learning, but that with this way at least there are more opportunities for learning than the traditional way, and more students will graduate with improved understanding. section 3 consisted of four components, aspects they most and least enjoyed, their opinions of the benefits of cbl, and suggestions for improving this method of learning, all of which were thematically analysed owing to the nature of the open-ended questions. this feedback was valuable for future modification and tailoring of the activity to suit the targeted students and course. regarding issues relating to their enjoyment, a common response was that they found the activity enjoyable and interactive, working together in a group and benefited from the discussions. from an educator’s perspective, group work also encourages co-operative learning, where the educator becomes the facilitator rather than the expert, their role being to guide learners towards achieving their goals.[12] one of the fundamental aspects of teaching in the pharmacy discipline is to ensure that students achieve certain core graduate competencies, one of these importantly being the ability to collaborate and communicate in a group or team. as future healthcare practitioners, their ability to function professionally, inter-professionally and in trans-professional teams will be essential. ideally, students upon graduation from ukzn should be respectful of individual and cultural differences, backgrounds and orientations. they should also possess the ability to prevent, negotiate and resolve interpersonal conflicts.[13] this exercise afforded students this opportunity, to work in teams and be sensitised to the implications of working with different personalities and dynamics. it was envisaged that working in randomly selected groups would facilitate discussion, debate and the sharing of ideas to solve a problem. during case analysis, students work together to discover what they know, as well as what they needed to know about the case, thus leading to more creative resolutions. in addition, students are more open to the ideas of their fellow peers during a cbl discussion.[14] as indicated in tables 1 and 2, a number of students found group work and learning from others enjoyable. contrary to the above, group work was also found to be a theme that students did not enjoy about the activity. as in any group, friction and frustration are bound to arise when individuals are required to work together, particularly when they are randomly assigned. some students voiced concerns about fairness, and complained about being awarded the same mark, as members of the group did not contribute equally to the activity. the use of peer assessment of their group members was used in an effort to counter this bias.[15] in hindsight, this activity would benefit from developing a set of initial ground rules and perhaps appointing a group leader to ensure that these rules are adhered to with regard to student contribution, attendance of meetings and completion of allocated member activities.[16] a suggestion that also emerged from the open-ended questions on how to improve the activity focused on dissatisfaction with the groups, where students suggested choosing their own groups. another factor that hindered student enjoyment of the task was the lengthy nature of the presentations. although students were given a stipulated time of 10 15 minutes per presentation, many groups exceeded this, which created the problem of poor concentration. to overcome this in the future, more stringent time-keeping will be applied, and students will be provided with instruction on how to estimate and prepare for presentations with time limits. responses to the open-ended question that probed the benefits of the activity for learning, included that it promoted greater retention of knowledge. the literature has shown that the process of cbl allows the student to build new knowledge based on what they have previously learnt, meaning that they can access previous knowledge related to the case and, with further effort, find the answer.[2] this self-discovery improves their retention, as opposed to them memorising facts or lecture notes.[2] in addition, the students felt that they learnt from the discussions that were generated on the topic. they also perceived value in the application of the law to real-life situations, indicating that case studies based on real-life situations also promote the use of course content knowledge, and improve decision-making and knowledge retention. the activity was also intended to make learning enjoyable and interactive, thereby allowing students to take more ownership for their own learning and not merely be passive participants. from edgar dale’s[17] cone-ofexperience model, it is theorised that people tend to retain knowledge more productively if they were contributors rather than mere observers. according to dale’s model, in a lecture, people tend to recollect ~10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they see and hear, 70% of what they say and write, and 90% of what they do, i.e. actively participate.[17] one of the themes that emerged from the openended section relates to the value of the activity for learning, as it promoted learning in a different way, using visual and verbal methods and not only reading. active learning is a process by which students are participants in their own learning process. different approaches to active learning include co-operative, problem-based, team-based, case-based, ability-based and assessment-based learning.[18] dividing students into groups and assigning them real-life problems to solve and to present to the class tap into the teambased learning and cbl approaches.[18] although not one of the core objectives of the study, it was ascertained that an additional core competency that was gained in the study was communication skills. developing communication competencies in the pharmacy curriculum should not be limited to teaching counselling and interpersonal skills, but should also enable students to foster confidence in developing public speaking. presenting their findings to their peers provided students with the opportunity to practise their public-speaking skills in a safe and supportive setting.[19] at a national level, accreditation bodies have recommended a paradigm shift from instructional to learning-based teaching.[13] the ‘instructional paradigm’ or ‘talk to chalk’ is primarily a lecture-based one-way flow of information, whereas in the ‘learning paradigm’, students partner in the creation of learning. it facilitates students taking responsibility for their own learning and makes them more independent thinkers.[20] sa pharmacy law entails the teaching of a large subject content, with the acts and regulations often being written in isolation, which makes it difficult to understand their march 2018, vol. 10, no. 1 ajhpe 65 research application. during this exercise, students were encouraged to engage with the literature to find plausible solutions from within sa law texts. students’ responses revealed that the use of the case studies made them search for answers, and in so doing, research a topic further. study limitations the study reported on student experience of cbl to teach the 3rd-year pharmacy law and ethics course module; hence, the true appropriateness of incorporating cbl either as a replacement or in conjunction with didactic lecture-based teaching for other modules remains unclear. the second limitation was that the study did not assess the effectiveness of using cbl as a supplement to didactic teaching. this would have helped to ascertain if this blend of teaching would enhance learning outcomes appropriate for this particular institution in terms of subject matter and student composition. recommendations this research would benefit from further studies exploring the relationship between the use of cbl and results from student assessment grades to better determine the impact of this teaching strategy. in addition, exploring the reasons for those who did not find it beneficial needs to be established in terms of school background and preparedness of independent and critical thinking. conclusion the results of the study regarding the experience of using a cbl activity to teach an aspect of pharmacy law and ethics reveal that this teaching strategy is perceived as a useful adjunct to the traditional didactic teaching of this subject. the student feedback suggests that cbl has a role to play in enhancing learning, and that understanding the reasons for some students not feeling that it added to their learning experience would be a valuable tool to teaching law and ethics to future pharmacy students, this being essential to prepare them to deal with ethical challenges that arise in practice. acknowledgements. the authors are thankful to ms carin martin for all her invaluable advice and editorial support. author contributions. sc was responsible for the conceptualisation, data collection and write-up of the article. vb and fo assisted in data analysis and the final write-up of the manuscript. funding. the research reported in this publication was supported by the fogarty international center (fic), national institutes of health (nih) common fund, office of strategic coordination, office of the director (od/osc/cf/nih), office of aids research, office of the director (oar/nih), and national institute of mental health (nimh/nih) of the nih under award number d43tw010131. the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. conflicts of interest. none. 1. jesus a, cruz a, gomes mj. case based, learner centered approach to pharmacotherapy. proceedings from edulearn11 conference, 4 6 july 2011, barcelona, spain. https://repositorium.sdum.uminho.pt/ bitstream/1822/12772/1/edulearn11-2.pdf (accessed 9 november 2017). 2. hale s. politics and the real world: a case study in developing case-based learning. eur polit sci 2006;5(1):8496. https://doi.org/10.1057/palgrave.eps.2210060 3. chi-wan ly, lopez-nerney s. using case-based learning to enhance awareness of communication principles: an exploratory study. reflect engl lang teach 2005;4:47-65. 4. thistlethwaite je, davies d, ekeocha s, et al. the effectiveness of case-based learning in health professional education. a beme systematic review: beme guide no. 23. med teach 2012;34(6):e421-e444. 5. richards ps, inglehart mr. an interdisciplinary approach to case-based teaching: does it create patient-centered and culturally sensitive providers? j dent educ 2006;70(3):284-291. 6. osinubi aa, ailoje-ibru ko. a paradigm shift in medical, dental, nursing, physiotherapy and pharmacy education: from traditional method of teaching to case-based method of learning – a review. ann res rev biol 2014;4(13):2053-2072. https://doi.org/10.9734/arrb/2014/9053 7. bess dt, taylor j, schwab ca, wang j, carter ja. an innovative approach to pharmacy law education utilizing a mock board of pharmacy meeting. innovations pharm 2016;7(1):9. https://doi.org/10.24926/iip.v7i1.419 8. fisher rc. the potential for problem-based learning in pharmacy education: a clinical therapeutics course in diabetes. am j pharm educ 1994;58(2):183-189. 9. flavell jh. metacognition and cognitive monitoring: a new area of cognitive-developmental inquiry. am psychol 1979;34(10):906-911. https://doi.org/10.1037//0003-066x.34.10.906 10. lai er. metacognition: a literature review. 2011. images.pearsonassessments.com/images/tmrs/metacognition_ literature_review_final.pdf (accessed 9 november 2017). 11. livingston ja. metacognition: an overview. 1997. http://www.gse.buffalo.edu/fas/shuell/cep564/metacog.htm (accessed 9 november 2017). 12. bitzer e. cooperative learning. in: gravetts s, geyser h, eds. teaching and learning in higher education. pretoria: van schaik, 2004. 13. health professionals council of south africa. core competencies for undergraduate students in clinical associate, dentistry, and medical teaching and learning programmes in south africa. pretoria: hpcsa, 2014. 14. waterman ma, stanley ed. investigative case-based learning: teaching scientifically while connecting science to society. invention and impact: building excellence in undergraduate science, technology, engineering and mathematics (stem) education, successful pedagogies. am ass adv sci 2004:55-60. 15. tollefson e. evaluating peer contributions to group work. ma thesis. new york: west point, center for faculty excellence, us military academy, 2015:1-11. http://www.usma.edu/cfe/literature/tollefson_15.pdf (accessed 8 february 2018). 16. haworth is, eriksen sp, chmait sh, et al. a problem based learning, case study approach to pharmaceutics: faculty and student perspectives. am j pharm educ 1998;62(4):398-405. 17. dale e. audio-visual methods in teaching. new york: dryden press, 1946. 18. gleason bl, peeters mj, resman-targoff bh, et al. an active-learning strategies primer for achieving abilitybased educational outcomes. am j pharm educ 2011;75(9):186. https://doi.org/10.5688/ajpe759186 19. luiz aja, zeszotarski p, ma c. developing pharmacy student communication skills through role-playing and active learning. am j pharm educ 2015;79(3):44. https://doi.org/10.5688/ajpe79344 20. barr r, tagg j. from teaching to learning: a new paradigm for undergraduate education. change 1995;27(6):13-26. https://doi.org/10.1080/00091383.1995.10544672 accepted 12 september 2017. https://repositorium.sdum.uminho.pt/bitstream/1822/12772/1/edulearn11-2.pdf https://repositorium.sdum.uminho.pt/bitstream/1822/12772/1/edulearn11-2.pdf https://doi.org/10.1037//0003-066x.34.10.906 images.pearsonassessments.com/images/tmrs/metacognition_literature_review_final.pdf images.pearsonassessments.com/images/tmrs/metacognition_literature_review_final.pdf article 11 june 2011, vol. 3, no. 1 ajhpe introduction communication difficulties between health care workers (hcws) and non-language-concordant patients are well documented all over the world. the importance of good communication between hcws and patients cannot be over-emphasised. patients with limited english proficiency have been shown to be less satisfied with their clinician’s communication and with their overall health care.1 a literature review on the impact of language barriers to health care by timmins2 showed that 86% of studies evaluating quality of care found a significant detrimental effect due to language barriers. in addition, adverse events suffered by patients with limited english proficiency are more severe than those suffered by english speaking patients3 and more likely to be due to communication errors. in south africa, language barriers have been cited as reasons for poor adherence to antiretroviral therapy,4 for hcws not initiating the treatment of insulin on patients who need it5 and for poor asthma care.6 in south africa, eleven official languages are spoken. in the western cape there are three official languages: afrikaans, xhosa and english. according to the language policy of the western cape government, any of these languages may be used in a person’s communication with any institution of the provincial or local government.7 the majority of patients seen in the public health sector of the western cape are black african xhosa-speakers, many of whom are educated to primary or secondary school level and do not speak english or afrikaans.8 most hcws in the public health service in the western cape do not speak an indigenous african language and interpreters are not employed in primary health care centres. this leads to language barriers to effective communication, particularly between hcws and xhosaspeaking patients.8 south africa has eight medical schools. language and communication courses form part of the curriculum in four medical schools – the universities of cape town and stellenbosch teaching xhosa, university of kwazulu-natal teaching zulu and the universities of pretoria and the free state teaching sesotho. however, the first of these courses was only introduced in 2003, thus most practising doctors in south africa have not had any formal language or communication training. a number of surveys conducted in south africa have recommended that practising hcws should be taught language skills in the spoken languages of the population where they are working and trained in communication.9,10 however, these recommendations have not been based on any empirical intervention studies and it is unknown whether implementing these recommendations would have an effect at all, and if so whether the magnitude of the effect would warrant large-scale implementation of language training. few intervention studies for hcws and non-language-concordant patients have been previously performed around the world. teaching spanish to hcws in the usa has shown significant improvements in communication with hispanic patients and in-patient satisfaction.11,12 multifaceted interventions targeting staff-patient communication have been shown to improve patient satisfaction in emergency room settings in australia.13 a study of ‘short course’ focused language interventions abstract most research into medical communication has been in a western setting. communication between non-language-concordant health care workers (hcws) and patients adversely affects patient and staff satisfaction. to the best of our knowledge, no intervention studies have been conducted in africa. objective. to determine whether teaching xhosa language skills and cultural understanding to hcws affects patient satisfaction, hcws’ ability to communicate effectively with xhosa-speaking patients and hcws’ job satisfaction levels. design and setting. a before-and-after interventional study was performed at two community health centres and a district hospital in the western cape province of south africa. participants. fifty-four randomly selected patients (27 pre and 27 post intervention) assessed communication with hcws and rated their satisfaction. six non-xhosa-speaking hcw participants completed preand post-intervention questionnaires. intervention. hcws completed a ten week basic language course comprising ten 120 minute interactive contact sessions developing basic xhosa speaking and listening skills and cultural competence. outcome measures. questionnaires used a likert scale to rate degrees of agreement or disagreement with statements. patients assessed communication with hcws, quality of care and rated their satisfaction. hcw questions were grouped according to themes, including ability to communicate, job satisfaction and staff interpersonal relationships. results. patient satisfaction showed significant improvements. patients perceived hcws to be more understanding, respectful and concerned, and to show better listening skills, after the intervention. patients were better able to understand hcws and their instructions. hcws’ ability to communicate improved and hcws experienced decreased frustration levels. conclusions. teaching language skills and cultural sensitivity to nonxhosa-speaking hcws in south africa improves ability to communicate, increases patient satisfaction and decreases misunderstandings and frustration. effects on quality of care and health care worker satisfaction of language training for health care workers in south africa michael e levin division of allergy, department of paediatrics and child health, university of cape town correspondence to: michael levin (michael.levin@uct.ac.za) article 12 june 2011, vol. 3, no. 1 ajhpe in honduras,14 a developing country, resulted in a larger amount and better quality of medical counselling after the intervention. however, no intervention study has previously been attempted in an african setting, where language barriers may be greater than in any of the previously described studies. in addition, cultural competence, or the ability of individuals to establish effective relationships despite cultural differences, has been shown to be an important determinant, independently of language skill, of effective communication and patient satisfaction.15,16,17 cultural differences may be present between many hcws and patients, but are especially marked in the south african public health service, where many patients are poor and do not have a high degree of education, most doctors do not speak an indigenous african language and there are differences in socio-economic class and cultural background. although some studies in western settings have shown that culture-specific models of disease are not common reasons for misunderstandings in the primary care setting,18 differing explanatory models of disease have been shown to be a significant barrier to communication and satisfaction in the south african setting.19 this study aimed to determine whether teaching basic xhosa-language skills and cultural understanding to non-xhosa-speaking hcws had an effect on patient satisfaction, on hcws’ perceived ability to communicate effectively with xhosa-speaking patients and hcws’ job satisfaction levels. methods a before-and-after interventional study was performed at two community health centres and a district hospital in the western cape. six non-xhosaspeaking hcws (4 doctors, 1 physiotherapist and 1 dietician) completed a 10-week basic xhosa course (the intervention). the course was run by a private company and was aimed at employees working in the health sector. ten 120-minute interactive contact sessions aimed to develop basic speaking and listening skills in xhosa and cultural competence. hcws participating in the research completed preand post-intervention questionnaires measuring their self-assessment of communication with xhosa-speaking patients and their job satisfaction related to communication. the hcw participants were not informed either before or after which of their patients had been interviewed. patients who had consulted the hcw were offered the option to participate in the study if their self-rated english proficiency was poor (1 3 on a 5-point likert scale). fifty-four patients completed a questionnaire to determine their perceptions of their communication with the hcw and their satisfaction, 27 before and 27 after the intervention. between 3 and 6 patients completed the questionnaires per participating hcw. the patients being interviewed were not told whether the hcw had completed the language course or not. post-intervention questionnaires were administered between 2 and 4 weeks after the hcws intervention. the questionnaires were designed using a likert scale to rate degrees of agreement or disagreement with statements. the patient questionnaires were translated into xhosa and back-translated into english to determine accuracy of translation. the questionnaires were piloted and adapted according to recommendations made during the piloting process and both the respondents’ understanding and the questionnaire’s length were confirmed as being appropriate. for the patient responses the two-sample wilcoxon rank-sum test for independent samples (mann-whitney test) was used to determine whether there were statistically significant differences in these responses. the wilcoxon signed rank test for paired observations was used to analyse the preand post-intervention responses of the hcws. hcw questions were grouped according to themes, including perceived ability to communicate, job satisfaction and staff interpersonal relationships. for each theme the total of the scores of all the hcws was summed and compared pre and post intervention but for questions phrased in the negative, ‘reverse’ allocation of values was applied to the likert scores. ethical approval was received from the ethics committee of the health sciences faculty of the university of cape town, the provincial department of health and from all facilities where research was conducted. all health care and patient participants completed informed consent statements. results fifty-four randomly selected patients (27 pre and 27 post intervention) assessed communication with hcws and rated their satisfaction. the two samples of patients used did not significantly differ in terms of their self-assessed ability to speak and understand english or afrikaans, age or gender. seven questions were used to assess the patients’ satisfaction with and perceptions of the hcw’s communication with them before and after the course. six of the 7 showed a significant improvement in the patients’ responses after the hcw had completed the course. all of the areas showed an improvement. fig. 1 demonstrates the percentages of patients who agreed with statements assessing the perceived quality of care they received relating to communication with the hcw before and after the intervention. questions showing significant improvement after completion of the course included whether the hcw was concerned about him/ her (p<0.01), whether the hcw understood his/her problem (p<0.01), whether the hcw respected him/her (p=0.02), whether the hcw listened to him/her (p=0.02), whether the patient understood what the hcw said (p<0.01) and whether the instructions given to the patient by the hcw were clear (p<0.01). the only question which did not show a significant improvement after the intervention asked whether the hcw made the patient feel comfortable (p=0.055). six non-xhosa-speaking hcw participants completed preand postintervention questionnaires. the questions for hcws were grouped ac7 percentage of respondents who agree with questions reflecting quality of care 22 26 41 41 44 19 19 78 59 74 67 70 41 44 0 20 40 60 80 100 co nc er n st af f u nd er sto od re sp ec t co mf or ta ble lis te ne d pa tie nt un de rs to od cl ea r i ns tru cti on s pre-intervention post-intervention fig.1. percentage of respondents who agree with questions regarding quality of care. fig.1. percentage of respondents who agree with questions regarding quality of care. article 13 june 2011, vol. 3, no. 1 ajhpe cording to themes, including ability to communicate, job satisfaction and interpersonal relationships between staff members. the group of three questions assessing the ability to communicate showed a significant improvement between the preand post-course responses (p=0.02). significant improvements were shown in the hcw’s perceived ability to speak xhosa (p=0.03), in their perceived ability to communicate with xhosa-speaking patients (p=0.03) and in their selfassessment of being able to fully understand xhosa-speaking patients (p=0.03). fig. 2 shows the percentage of hcws agreeing with statements related to their ability to communicate with xhosa-speaking patients pre and post intervention. the group of four questions assessing effects on job satisfaction did not show a significant difference as a group (p=0.20). within this group, however, the question asking the hcw whether it is frustrating to communicate with xhosa-speaking patients showed a significant improvement, i.e. a decrease in frustration levels (p=0.0495). fig. 3 shows the percentage of hcws agreeing with statements related to job satisfaction preand post-intervention. two questions assessed the effects of completing the course on interpersonal relationships with xhosa-speaking staff members. these did not show a significant difference (p=0.90). two questions asked the hcws for their perceptions on the effectiveness of communicating via an interpreter. these showed a lower percentage of agreement with the statements after the course than before, i.e. the hcws perceived that communication via an interpreter was less effective after they had completed the course. these results were not statistically significant. fig. 4 shows the percentage of hcws agreeing with statements regarding the use of interpreters pre and post intervention. discussion a 10-week basic xhosa language and cultural competency course improved outcomes significantly, from both the hcws’ and the patients’ perspectives. patient satisfaction showed significant improvements. the patients perceived the hcws to be more understanding, respectful and concerned, and to show better listening skills. the patients also stated they were better able to understand the hcws and the instructions given by the hcws after the intervention. the hcws experienced improvements in their ability to communicate with xhosa-speaking patients, as shown by significant improvement in their self-rated ability to speak xhosa, their perceived ability to communicate with xhosa-speaking patients adequately and their perceived ability to understand what xhosa-speaking patients are saying. in addition to improved communication, hcws experienced decreased frustration levels related to communication with xhosa-speaking patients. other assessments of hcw job satisfaction did not show significant improvements. this could be attributed to the fact that job satisfaction is derived from a large number of factors, not only through the quality of hcw-patient interactions. the hcws assessed communication via interpreters as being less effective after the course. this probably reflects their increased awareness of interpreter errors after learning some basic language skills, rather than a worsening of their skills in using interpreters following the course. interpreter errors are common and important causes of miscommunication in medical encounters.20,21 using interpreters is a skill that needs to be learned and should be included in all courses where cross-cultural and cross-language communication is being taught. post-intervention questionnaires were administered between 2 and 4 weeks after the hcws intervention. it is unknown whether the shortterm effects would be followed by equally good improvements in outcome over the medium and long term. despite the small sample size in this study, the magnitude of the effect of the intervention on patient satisfaction was great enough for it to fig. 2. perceived communication ability of hcws. 9 perceived communication ability of hcws 100 17 0 67 83 33 0 20 40 60 80 100 weak at speaking xhosa able to communicate able to understand patient pre-intervention post-intervention fig. 2. perceived communication ability of hcws. fig. 3. job satisfaction. job satisfaction 0 20 40 60 80 100 communicating with patients is frustrating lack of job enjoyment because of language difficulty pre-intervention post-intervention fig. 3. job satisfaction. fig. 4. communicating via an interpreter. communicating via an interpreter 100 33 67 17 0 20 40 60 80 100 using an interpreter is as good as speaking to patients directly i am able to effectively communicate with patients via an interpreter pre intervention post intervention fig. 4. communicating via an interpreter. article 14 june 2011, vol. 3, no. 1 ajhpe be seen easily, indicating that it was not only a statistically but also clinically significant effect. statistical power was lower in the assessment of effects on hcws than on patients’ satisfaction. there was a trend towards better job satisfaction after the intervention. the participating hcws signed up for the language course voluntarily. this might imply that they were pre-selected as persons interested in issues of language and culture. this could contribute towards their successful completion of the course, the marked improvements in communication ability and the resultant improvement in patient satisfaction. the results might not be as marked if a similar study was done on hcws required to learn xhosa mandatorily as part of their undergraduate or postgraduate education curriculum. hcw language skills were assessed after the course by self-assessment and patient assessment rather than through direct observation. conclusion teaching language skills and cultural sensitivity to hcws improves patient satisfaction and decreases misunderstandings and frustration levels. courses in language skills, effective interpreter use and cultural sensitivity should be considered for all south african medical curricula and postgraduate training encouraged for all practising hcws and made available in public health care facilities. references 1. carrasquillo o, orav ej, brennan ta, burstin hr. impact of language barriers on patient satisfaction in an emergency department. j gen intern med 1999;14:82-87. 2. timmins cl. the impact of language barriers on the health care of latinos in the united states: a review of the literature and guidelines for practice. j midwifery women’s health 2002;47:80-96. 3. divi c, koss rg, schmaltz sp, loeb jm. language proficiency and adverse events in us hospitals: a pilot study. int j qual health care 2007; 19(2):60-67. 4. dahab m, charalambous s, hamilton r, et al. ‘that is why i stopped the art’: patients’ & providers’ perspectives on barriers to and enablers of hiv treatment adherence in a south african workplace programme. bmc public health 2008;8:63-69. 5. haque m, hayden emerson s, dennison c, navsa m, levitt n. barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public sector primary health care centers in cape town. s afr med j 2005;95:798-802. 6. levin me. the importance of language and culture in paediatric asthma care. curr allerg clin immunol 2005;18(1):8-12. 7. western cape language policy document 2004. available from http://www.capegateway.gov.za/eng/publications/policies/w/99328 (accessed august 2008). 8. levin me. language as a barrier to care for xhosa-speaking patients at a south african paediatric teaching hospital. s afr med j 2006;96:1076-1079. 9. schlemmer a, mash b. the effects of a language barrier in a south african district hospital. s afr med j 2006;96:1084-1087. 10. saohatse mc. solving communication problems in medical institutions. s afr j afr lang 2000;20(1):95-102. 11. mazor ss, hampers lc, chande tv, krug se. teaching spanish to pediatric emergency physicians. arch pediatr adolesc med 2002;156:693-695. 12. binder l, nelson b, smith d. development, implementation and evaluation of a medical spanish curriculum for an emergency medicine training program. j emerg med 1998;6:439-441. 13. taylor d, kennedy mp, virtue e, mcdonald g. a multifaceted intervention improves patient satisfaction and perceptions of emergency department care. int j qual health care 2006;18(3):238-245. 14. brown ld, de negri b, hernandez o, dominguez l, sanchack jh, roter d. an evaluation of the impact of training honduran health care providers in interpersonal communication. int j qual health care 2000;12(6):495-501. 15. fernandez a, schillinger d, grumbach k, et al. physician language ability and cultural competence. an exploratory study of communication with spanishspeaking patients. j gen intern med 2004;19:167-174. 16. hudelson p. improving patient–provider communication: insights from interpreters. family practice 2005;22:311-316. 17. beach mc, price eg, gary tl, et al. cultural competence: a systematic review of health care provider educational interventions. med care 2005;43:356-373. 18. roberts c, moss b, wass v, sarangi s, jones r. misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications. medical education 2005;39:465-475. 19. levin me. different use of medical terminology and culture-specific models of disease affecting communication between xhosa-speaking patients and englishspeaking doctors at a south african paediatric teaching hospital. s afr med j 2006;96:1080-1084. 20. flores g, laws mb, mayo sj, et al. errors in medical interpretation and their potential clinical consequences in pediatric encounters. pediatrics 2003;111(1):6-14. 21. vasquez c. the problem with interpreters: communicating with spanish speaking patients. hospital and community psychiatry 1991;42(2):163-165. june 2018, vol. 10, no. 2 ajhpe 129 research community-based education (cbe) is a pedagogical approach that allows a student to develop professional skills in a community setting and gain a deeper understanding of patients in varied social and cultural contexts.[1] from the literature, cbe is shown to be beneficial to students in various ways, including improved practical skills and clinical reasoning, increased self-confidence and development of a positive attitude toward patients.[2-5] by experiencing real work situations, students develop a greater awareness of the responsibilities they have as health professionals.[4] through student placements in community-based settings, cbe is equally beneficial to communities, leading to improved access to healthcare and improved quality of care owing to the use of current practice techniques.[4,6] communities also benefit through home visits and health promotion activities that students undertake.[4] health systems have been noted to benefit from cbe, as students are seen to expand the workforce, especially in rural areas, where there is a scarcity of healthcare workers.[6] moreover, student cbe placements in rural areas have the potential to influence students’ responsiveness to community needs and their future decisions to work in these areas.[4] this can contribute to long-term benefits for the health system. institutions of higher education that implement cbe programmes are viewed as demonstrating social accountability.[7] health professions education is undergoing major reform owing to two main external influences: (i) the council for higher education (che) that advocates the integration of community engagement into curricula in the south african (sa) context;[8] and (ii) the lancet commission that called for health professionals to graduate with appropriate competencies to be fully functional in a patientand population-centred health system.[9] given this context, the university of kwazulu-natal (ukzn), durban, sa strives for reform through its goal of responsible community engagement as outlined in its vision and mission statement. this goal aims to transform health professions education from one with a traditionally structured basis to one with a more competency-based focus that adds value to the communities it serves.[10] to achieve this goal, the college of health sciences (chs) at ukzn embarked on a business plan to adopt a primary healthcare curriculum (phcc) to address service delivery and health professions training.[11] the business plan proposes that a primary healthcare (phc) approach be followed for all programmes offered by the chs.[11] in line with this approach, the chs seeks to produce socially accountable, competent and relevant healthcare professionals with discipline-specific technical skills and generic higher education competencies and attributes. in this way, graduates become more responsive to provincial and national health priorities, the burden of disease and the health system. the chs is therefore committed to offering community-based underand postgraduate education.[11] community-based clinical training is seen as a valuable tool for transforming health professions education to meet graduate competencies and the needs of the health system.[9] therefore, to foster these competencies, ukzn creates learning opportunities for health professions students to engage in activities that can enable them to acquire these skills and values in community-based settings. in the literature, there are many studies highlighting students’ experiences and views of cbe, but there is a paucity of background. community-based education (cbe) is seen as a valuable tool in transforming health professions education by aligning clinical training with graduate competencies and needs of the health system. however, academics involved in the implementation have varied views. objectives. to explore the experiences and views of academics involved in community-based training in the college of health sciences at the university of kwazulu-natal, durban, south africa. methods. this qualitative study used interviews and focus group discussions consisting of a purposively selected sample of academics. the interviews were audio taped, transcribed and analysed using thematic analysis. results. three main themes emerged from the data analysis: the strengths of cbe, challenges experienced in implementation and academics’ suggestions concerning challenges. the strengths included benefits to the institution, students, health system and communities. the main challenges experienced were insufficient support from the institution and the department of health (doh). suggestions were made by academics to overcome these challenges. conclusion. the study indicates that cbe is perceived as an important pedagogical approach in transforming health professions education, as it can align clinical training with the business plan of the university and the needs of the health system. however, for the successful implementation of cbe, full support from the university and the doh is required. afr j health professions educ 2018;10(2):129-135. doi:10.7196/ajhpe.2018.v10i2.954 strengths and challenges of community-based clinical training as viewed by academics at the university of kwazulu-natal, durban, south africa i moodley, msc (dent); s singh, phd discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: i moodley (moodleyil@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 130 june 2018, vol. 10, no. 2 ajhpe research studies on the views of academics directly involved with the implementation of cbe. the objective of this study is to present the experiences and views of academics currently implementing community-based training in the chs, ukzn. methods research setting and context the chs, ukzn comprises four schools: clinical medicine, laboratory medicine and medical sciences, nursing and public health, and health sciences. the school of health sciences has eight disciplines: audiology, biokinetics, exercise and leisure sciences, dentistry, occupational therapy, optometry, pharmaceutical sciences, physiotherapy and speech-language pathology. clinical training in these disciplines is done at campus clinics and designated off-campus sites. cbe is a prominent feature across all disciplines, but the level of participation differs. moreover, as part of the business plan, disciplines are expected to send students to decentralised training sites, i.e. regional and district hospitals and community healthcare centres around these hospitals. research design this was a descriptive, qualitative explorative study in which the intended role of community-based clinical training in the chs was explored and the views of academics involved with cbe were described. participants a purposive sampling method was used to select the study sample. the participants selected for the interviews included the college dean of teaching and learning, the academic leader of teaching and learning and the head of the department of family medicine/rural medicine. they were selected for their expert opinion. one academic from each discipline in the school of health sciences was purposively selected for the focus group discussions. the researcher (im) sent an invitational email to each participant. a total of 11 participants (a1 a11) gave written informed consent to participate in the study. data collection data were collected by using a combination of interviews and focus group discussions. firstly, the researcher conducted in-depth individual interviews with the dean and academic leader to gain a better understanding of the role of cbe and how it should be rolled out at discipline level. the researcher developed a set of leading questions to provide a relevant structure to the interviews (table 1). the interviews focused on the policies and procedures for implementing cbe, support and mechanisms for cbe and funding. secondly, a separate face-to-face interview was held with an academic from the school of clinical medicine (the head of the department of family medicine/rural medicine). the purpose of this interview was to obtain a better understanding of cbe experiences in other schools within the chs. the interviews were scheduled at the interviewees’ convenience and lasted ~30 minutes. lastly, the researcher facilitated focus group discussions with academics representing each discipline. as all academics were not available simultaneously, two focus group discussions were held. the researcher developed a set of open-ended questions to guide the focus group discussions (table 2). the discussions were related to their current cbe projects and how these added value to their clinical training practice, as well as the challenges experienced with implementation. the focus group discussions lasted ~65 minutes. the researcher audio taped the interviews and focus group discussions. a research assistant transcribed the recordings verbatim and then performed table 1. interviews with the dean and academic leader interview with dean interview with academic leader what is your view of community-based clinical training in the education process of health professionals within the school of health sciences? what is your view of community-based clinical training in the education process of health professionals within the school of health sciences? in your opinion, how will this add value to current teaching strategies for clinical training in terms of meeting graduate competencies and meeting needs of the health system? in your opinion, how will this add value to current teaching strategies for clinical training in terms of meeting graduate competencies and needs of the health system? what policies and procedures are in place for community-based clinical training? what is the strategic operational plan present/envisioned by the school regarding community-based training of health professionals? what mechanisms and support can the school provide for community-based clinical training? how can disciplines within the school align to this plan? how will community-based clinical training be funded? how should community-based training be integrated into the current curriculum? table 2. focus group discussions with academics kindly share your thoughts on the university’s goal of community engagement and community-based education for health sciences students. what are your views of how this can be implemented at discipline-specific level? what is the current practice of community-based training in your discipline? in your view, how does community-based teaching and learning add value to your current clinical training strategies? in your opinion, how can community-based clinical training align with the primary health care curriculum model that aims to address service delivery and training of healthcare professionals? in your view, how can community-based teaching align with the health professional graduate attributes in the various roles of healthcare practitioner, who is compassionate and culturally sensitive, communicator, collaborator, leader, scholar and advocator as envisioned by the college of health sciences? from your experience, what are some of the challenges experienced in implementing community-based training? june 2018, vol. 10, no. 2 ajhpe 131 research a data clean-up process. the researcher engaged the services of a research consultant to assist with the data analysis process. this consisted of data coding to identify particular features of the data set and sorting of the data, allowing themes and sub-themes to emerge from the respondents’ statements according to braun and clarke’s[12] guide to thematic analysis. credibility was established by the use of varied research methods, i.e. interviews and focus group discussions to obtain the data as well as peer debriefing. another member of the research team conducted the peer debriefing by examining the data collection methods, processes, transcripts and data analysis procedures, and provided guidance to enhance the quality of the research findings.[13] transferability was facilitated by detailed description of the enquiry and purposive sampling.[14] transferability was further enhanced by comparing research findings with the current literature. dependability was achieved by the use of a co-coder (research consultant) and confirmability was established through the direct quotation of interviewees. participant confidentiality and anonymity were maintained. ethical approval this study was part of a larger study conducted on cbe in the school of health sciences. ethical clearance was obtained from the humanities and social sciences research committee, ukzn (ref. no. hss/1060/015d). results and discussion based on the responses of participants in the interviews and focus group discussions, three main themes emerged from the data analysis process: strengths of the community-based clinical training, challenges experienced and suggestions by academics. strengths of community-based education this study revealed that academics viewed cbe as beneficial at multiple levels. the following section contains a selection of illustrative quotations of the benefits of community-based clinical training. the quotes are displayed on an institutional, student, health system and community level. benefits to institution an academic reported that through cbe the institution could achieve its goal of responsible community engagement by producing socially accountable health professionals. it could create a platform for the institution to implement its policies and teaching strategies, as illustrated by the quotes in table 3. related to its mission and vision statement, ukzn set out goals of being an academic institution actively engaged in redressing the disadvantages and imbalances of the past.[10] the goal of responsible community engagement can be driven through cbe initiatives. by integrating cbe into the curriculum, the university is showing social accountability. this can contribute to the upliftment of the province by producing socially accountable health professionals and serving under-resourced communities. the literature also shows that higher education institutions with a socially accountable mandate can have a positive influence – not only on students but also on surrounding disadvantaged communities, leading to better health outcomes.[15] through implementation of policies and teaching strategies related to cbe, the institution can be seen as facilitating the transition of traditional approaches of teaching to competency-based approaches that align training with the health needs of communities and the health system.[9] benefits to students academics believed that cbe could allow students to develop professionally. students could improve clinical skills, proficiency and critical reasoning by being exposed to many patients. they could also learn by working closely with experienced colleagues in different clinical settings. at a deeper level, it could help them to relate theory to practice and acquire graduate competencies, such as compassion, better communication and leadership skills. these skills are not necessarily obtained in the classroom (table 4). it is well documented in the literature that cbe has been shown to enhance students’ self-development, improving competence and confidence levels through increased patient exposure in community settings.[1] graduate competency can be defined as the acquisition and application of knowledge, clinical skills and values to provide effective care to patients.[11] this study showed that cbe could create learning opportunities for students to acquire these attributes. these findings were similar to those of mabuza et al.,[16] who indicated that the main focus of cbe was the learning of practical skills, professional behaviour and relating theory to practice. however, ferris and o’flynn[17] argue that for cbe to be more meaningful, students should not be left at these sites to acquire practical skills only; they should be given opportunities to self-reflect and self-assess, which can contribute to lifelong learning. benefits to the health system according to academics, the health system could also be strengthened through cbe initiatives. benefits included building sustainable partnertable 3. benefits to the institution benefits participants’ quotes meaningful community engagement ‘we are trying to train competent, relevant, socially accountable health professionals. what better way than to let them go into the community… so we are giving back as a university and, as existing and potential healthcare professionals equally, we are gaining by being trained and fulfilling our criteria for our degree to practise as healthcare professionals.’ (a1) implementation of policies ‘it allows us to implement the policy frameworks of the department of health provincially, as well as nationally, and it allows us as a college to really give effect to our own vision and mission whether it is the teaching and learning office and teaching and learning related to research to general university vision and mission and goals. i think we are in the right place at the right time.’ (a1) facilitating implementation of various teaching strategies ‘community-based training requires a certain type of pedagogy of interactive participative learning. there are frameworks and pedagogies that have been implemented in different programmes … but i think we have got some excellent examples of good practice that we can learn from each other and implement.’ (a1) 132 june 2018, vol. 10, no. 2 ajhpe research ships, making healthcare more accessible to communities and aligning health professionals’ training with the needs of the health system, which could make them easily employable (table 5). by collaborating with the department of health (doh), a mutually beneficial relationship can be developed. the university will benefit, as their clinical training platforms could be significantly expanded. the doh will benefit, as students could complement the current workforce in under-resourced areas, improving access to healthcare. this is further supported by mabuza et al.[17] – students are viewed as important members of the health team and appreciated and welcomed by communities. students exposed to cbe in rural areas could gain better insight to inequalities of healthcare and be motivated to return to these areas to seek employment. a study by kaye[6] shows that community-based clinical training changes students’ attitudes towards rural practice and plays an important role in influencing graduates to work in underserved areas. furthermore, students could have first-hand experience of how the health systems operate, facilitating their transition to the work environment. this finding is further supported by knight,[18] who found that students gained a better understanding of the policies and politics of clinics while in training. table 4. benefits to students benefits participants’ quotes improving clinical skills ‘our students get to attend to more patients in the same time they attend to one patient at the clinical training site.’ (a6) acquiring critical reasoning ‘they also do not come in with a ready-made diagnosis … here they just have to think on their feet and problem solve on site.’ (a5) learning from mentors ‘they are also exposed to different supervisors with their own clinical expertise.’ (a6) adapting to different work environment ‘working within the communities prepare the students for when they qualified … they learn to work with what they have available.’ (a6) relating theory to practice ‘the students will provide a service that they have already demonstrated theoretically that they have the knowledge and through the provision of the service they will develop the clinical competencies.’ (a4) applying primary healthcare principles ‘students do a lot of broad-base promotive and preventive work throughout the communities.’ (a7) providing appropriate care ‘… it is also looking at what is relevant and appropriate for this context, not only socioeconomically but geographically. there is a focus on bringing in the family and the broader community where possible. where there is somebody isolated at home, the rehab is focusing on the families sometimes, even the neighbours or community caregivers and using the resources that are in the community.’ (a4) achieving non-technical competencies ‘it is kind of startling to realise that the patient is a person who has a family and if they understand where the patient comes from they will treat them completely differently. there is a potential for a much deeper, nearly like an ontological shift that takes place.’ (a3) ‘… it is also adding value in terms of the non-clinical aspects. all those things like teaching them how to be leaders in an under-resourced environment, to communicate better when there is a language divide. we find that the campus-based, more resourced training environments were just letting them think in that sort of clinical, mechanical fashion, but now they are forced to be able to apply other skills in that context.’ (a8) ‘i do not think the university sufficiently teaches these competencies or tries to shift thinking in any way possible, we just want to get through the content of the curriculum. this is the right environment where we shift their thinking, where we mould them into what we would like them to be.’ (a5) opportunities for postgraduate studies ‘there are some postgrad projects at master’s and phd levels where research is done in communities.’ (a11) table 5. benefits to the health system benefits participants’ quotes building sustainable partnerships ‘the business plan of community-based training and the primary healthcare model was developed in conjunction with the provincial department of health so it has the endorsement and support from key role players in terms of implementing it. so we will have the clinical training platforms with the department and hopefully we will have the staff to assist us in doing that.’ (a1) making healthcare more accessible ‘the focus is ideally on taking rehab services into the underserved. for example, for a mum with cerebral palsy child … she might only get therapy once a month … she might have to make two taxi trips to get there [local hospital]. if she is taking her child, that will be two taxi fares and if he is on a wheelchair that is a third fare. it is not about not having access, it is about the reality of that access … .’ (a4) learning how the health system operates ‘they are actively going out and we have made an attempt to get them right down to clinic level and not just hospital level, so they understand how the health system works right from the start.’ (a8) producing work-ready graduates ‘… with community-based training, we are trying to implement the policy frameworks and train our students such that they are capable of working in the primary healthcare environment equally well as they will be working in tertiary services for them to be proficient across the continuum.’ (a1) june 2018, vol. 10, no. 2 ajhpe 133 research benefits to communities our study revealed that communities could benefit greatly from cbe initiatives. most disciplines chose underserved communities to undertake their projects to provide or improve access and affordability to healthcare services (table 6). our findings of benefits to communities were similar to those of diab and flack,[4] who found that the primary benefit to communities was improved service delivery. by living in communities, students can become immersed with the realities of the communities.[7] they can develop a better understanding of the disease burden and the social and cultural aspects that impact on health. kelly et al.[5] supported this finding that learning is developed by rich relationships with community members. doherty and couper[7] indicated that through interaction with patient, family and community, students learn by exposure to an integrated primary healthcare experience. however, diab and flack[4] argued that communities receive maximum benefits if the cbe initiatives are aligned with community needs. they also showed that it is important to engage community leaders before student placements to explain their function, as communities feel undermined if not informed of students’ presence. challenges this study shows that although academics embraced the pedagogical approach of community-based clinical training, they experienced challenges that could hinder implementation. the following section contains a selection of illustrative quotations of the challenges of community-based clinical training. the quotes below relate to challenges at university and doh levels. challenges at the university the challenges at the university included not having a clear operational plan, co-operation of all academics, support from the university and logistical issues. no clear operational plan. at the university, the organisational structures are three-tiered: the college level, school level and discipline level. although the business plan was being rolled out at college level, there seemed to be no clear operational plans or communication on how this had to be filtered down to individual disciplines in the school. while academics from individual disciplines believed that there should have been direction from college and school levels, academics from these levels believed that it should be driven by academics in individual disciplines, as illustrated by the following conflicting quotes: ‘this clinical training model was conceptualised, and while it was good and we all supported it on theory, there was no situational analysis, … no plan as to how we are going to roll it out based on the situational analysis; we cannot just say we have this plan … the doh needs help where our students get exposed. let us just go and do it.’ (a8) academics from college and school level firmly believed that: ‘it is people from the ground, from various disciplines who are very passionate about this and who are committed people who will investigate it thoroughly, come out strategically, logistically, resourcefully draw up their own mandates with their own roles and responsibilities. so it is more bottom up. it will never be top down. it will be you having to push from the bottom and finding the ways of making things happen.’ (a1) co-operation of all academics. academics who represented individual disciplines in the focus group discussions believed that they were the only ones in their respective disciplines who were responsible for cbe. other staff members seemed disinterested and if they were to leave, the cbe initiatives would fall apart: ‘if i go, the project from my discipline will fall apart, that is unfortunate. we have become the face of the community … if there is not a voice to speak for it, it falls apart because it is not entrenched in the curriculum. it is hard work and it is time consuming – that is why nobody wants to do it.’ (a4) support from the university. there seemed to be a mismatch between the support given by the college and that received by academics. while academics at college and school level endorsed and supported cbe, academics involved in implementation thought otherwise: ‘there needs to be supporting structures in place as much as they are saying the community outreach should have things in place for us, because lots of things we start and have to stop because of resources, etc.’ (a4) the study also highlighted that there were no incentives for staff participating in community engagement: ‘do we get rewarded for community engagement? is there any structure for community engagement? we have got a research office; we have got a teaching and learning office. is there an office for community engagement? ... it needs to be taken seriously.’ (a3) logistical issues. the results of the study showed that many challenges were logistical in nature, including funding, limiting timetables, cbe being timeconsuming and community issues: table 6. benefits to the community benefits participants’ quotes improving service delivery ‘the priority is to offer a service to the underserved … focus particularly on people, children largely with disability, who either are unable to or have enormous challenges accessing the services that are available.’ (a4) committing to sustainable services ‘it is important that we need continuity in a community. if you start providing a service, you must commit to it. we cannot use the community only to take the students there, they start something and then we take them out. it is also not fair to the community.’ (a2) promoting health in the communities ‘students engage directly with the community, determine their needs and do promotive and preventive work outside of the clinic base.’ (a7) interacting with communities ‘with the community home-stay project where for the rural block we offer some students to live in the community … students engage with host mothers … they are quite motherly.’ (a3) 134 june 2018, vol. 10, no. 2 ajhpe research funding ‘we have costs to consider when going out to communities. the main reasons we were pulled out of a very effective and established project was the cost to transport the students.’ (a4) ‘even with us, the consumables that we require, the cost factor. a lot of our projects have a problem to sustain themselves because we do not have resources.’ (a6) timetables ‘we have a university timetable that does not allow for an integration of disciplines.’ (a4) time consuming ‘i had a student 2 weeks ago who wanted to go and do a follow-up assessment on a child. she cannot do that independently and the home visit is way into the community. the time now for me to go and observe and check on her means a whole morning.’ (a4) community, political and safety issues ‘we had followed everything in the book, the gatekeeper introduced us to everyone and the next thing, we got kicked out from our placement site which was a high school because of the political nature of the community. they thought we were aligned to someone who they were in conflict with. it was the gatekeeper himself. although we were independent from him and he introduced us, but we got parcelled with him … .’ (a7) challenges at the university stem mainly from a lack of support from school and college level: support in the sense of effective communication down to discipline level, guidelines on how cbe programmes should be implemented, expectations and roles of academic staff and financial support. these challenges are not unique to this institution – similar challenges were noted in previous studies, with the main challenges being leadership support, funding and academics not willing to participate in the programme.[19] doherty and couper[7] found that cbe programmes are complex and time-consuming and require sustained hard work by committed academics. cbe is viewed as a mechanism for the university to demonstrate social accountability. the university should therefore provide the structure and support for successful implementation of this programme. it should also be supported by more academics within disciplines – not only those who have an interest in cbe. challenges with the department of health the challenges experienced with the doh were mainly due to clinical staff not clearly understanding their role in community-based training of students or not being aware of it. academics were dependent on doh staff for supervision of students, monitoring their attendance and writing reports on them at decentralised sites. however, there appears to be a lack of commitment from some clinical staff, and students were sometimes seen as a burden and impeding their work: ‘there are perceptions from the doh that this is an outside programme or an outside responsibility that is being imposed on them. there was no plan that was filtered down to the ground. there was this memorandum of understanding between the doh and ukzn, but the people on the ground are not really aware of it.’ (a8) ‘we made arrangements with the head of department to supervise our students. he was very enthusiastic; however, other personnel were not so eager to supervise, as they felt that students slowed down their work pace.’ (a6) the challenges with the doh were similar to those of the university in the sense of not having any guidance from higher authorities. this lack of support for clinical staff can be viewed as a missed opportunity for shared responsibility of this programme. this can hinder student learning at doh sites, as it has been shown that staff enthusiasm for student supervision enhances student learning.[16] it is important for academic staff to provide support for clinical staff in orientation and training of student supervision, as archer[20] noted that clinical supervisors changed their perceptions about student supervision after a short course designed by the university. suggestions by academics the study revealed that academics viewed cbe as being extremely valuable and were eager to make it work, despite many challenges. the following are illustrative quotations of solutions they offered: no clear operational plan ‘there needs to be a core team. we need to sit together and come up with objectives for cbe training; this is the output and this is what we expect of the staff and students.’ ‘without leadership, there is nobody steering the ship. leadership is critical to develop or put together this framework so we can roll out this community-based teaching they expect from us.’ (a10) challenges with doh ‘the one solution that we had was train the trainer. we bring all the clinical staff into the university, we get a workshop going and then we do programmes with them and then we do sessions at the end, where we get them to watch. we were thinking of getting videos and getting them to watch and assess so there is inter-reliability.’ (a10) ‘maybe those trainers should be given some sort of honorary appointment or incentive for them being involved in the training of our students because they will tell you that look, i have queues to push … .’ (a9) communication issues ‘there should also be good, open communication within the institutions and between the institutions, especially with the people on the ground who are directly involved with cbe programmes.’ (a6) this study shows that academics have the enthusiasm to drive the community-based clinical training agenda. sa health professions education is transforming[17] and cbe is certainly a mechanism of change toward this transformation in making clinical training more meaningful in the sa context. transformation is an ongoing process and academics should seize the opportunity for academic autonomy and control over cbe, as it has been shown to have great value in the education process of students in the health sciences. this is further supported by doherty and couper,[7] who state that cbe programmes should be driven by champions within disciplines, especially if there is resistance from other staff. while there are committed academics from the institution, there should also be committed june 2018, vol. 10, no. 2 ajhpe 135 research health professionals from the doh supervising students at the teaching sites. cbe should be regarded as a shared responsibility of the collaborating institutions to ensure success and sustainability. study limitations it is acknowledged that this study is limited to only one university and that the findings related to the views and opinions of academics who participated in the study are limited owing to their generalisability. therefore, more research is required at other universities in sa to obtain wider, broad-based opinions of academics regarding cbe. conclusion the study indicates that cbe is perceived as an important pedagogical approach in transforming health professions education, as it can align clinical training with the business plan of the institution and the needs of the health system. academics play a pivotal role and are seen as drivers of cbe. however, for the successful implementation of cbe, there needs to be full support from the university and doh to overcome any challenges that may arise. acknowledgements. none. author contributions. im was responsible for data collection, data analysis and conceptualisation. ss was responsible for refining the methodology and overseeing the write-up. funding. none. conflicts of interest. none. 1. skelton j, raynor mr, kaplan al, et al. university of kentucky community-based field experience: program description. j dent educ 2001;65:1238-1242. 2. eaton ka, de vries j, widstrom e, et al. ‘schools without walls?’ developments and challenges in dental outreach teaching – report of a recent symposium. eur j dent educ 2006;10(4):186-191. https://doi.org/10.1111/j.1600-05 79.2006.00411.x 3. piskorowski wa, stefanac s, fitzgerald m, green tg, krell r. influence of community-based dental education on dental students’ preparation and intent to treat underserved populations. dent educ 2012;76:534-539. 4. diab p, flack p. benefits of community-based education to the community in southern african health science facilities. afr j prim health care fam med 2013;5(1). https://doi.org/10.4102/phcfm.5i1.474 5. kelly l,walters l, rosenthal d. medical education: is success a result of meaningful personal learning experiences? educ health 2014;27(1):47-50. https://doi.org/10.4103/1357-6283.134311 6. kaye dk, mwanika a, sewankombo n. influence of the training experience of makerere university medical and nursing graduates on willingness and competence to work in rural health facilities. rural remote health 2010;10:1372. 7. doherty je, couper i. strengthening rural health placement for medical students: lessons for south africa from international experiences. s afr med j 2016;6(5):524-527. https://doi.org/10.7196/samj./2016.v106i5 8. centre for higher education, higher education quality committee, south africa. criteria for institutional audits. pretoria: chw, 2004. 9. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 10. university of kwazulu-natal. vision and mission statement. durban, south africa. http://www.ukzn.ac.za (accessed 13 april 2018). 11. essack s. draft business plan: community based training in primary health care model in school of health science. durban: ukzn, 2014. 12. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https:/doi. org/10.1191/1478088706qp063oa 13. pitney wa, parker j. qualitative research in physical activity and the health professions. auckland, new zealand: human kinetics, 2009. 14. bitsch v. qualitative research: a grounded theory example and evaluation criteria. j agribus 2005;23(1):75-91. 15. reeve c, woolley t, ross sj, et al. the impact of socially-accountable health professional education: a systematic review of the literature. med teach 2017;39(1):67-73. https://doi.org/10.1080/0142159x.2016.1231914 16. mabuza lh, diab p, reid sj, et al. communities’ views, attitudes and recommendations on community-based education of undergraduate health sciences students in south africa: a qualitative study. afr j prim health care fam med 2013;5(1). https://doi.org/10.4102/phcfm.v5i1.456 17. ferris h, o’flynn d. assessment in medical education. what are we trying to achieve? intern j high educ 2015;4(2):139-144. https://doi.org/10.5430/ijhe.v4n2p139 18. knight gw. community-based dental education of university of illinois, chicago. j dent educ 2011;75(10) (suppl):s14-s20. 19. abu-rish e, kim s, choe l, et al. current trends in interprofessional education of health sciences students: a literature review. j interprof care 2012;6(6):444-451. https://doi.org/10.3109/13561820.2012.715604 20. archer e. improving undergraduate clinical supervision in a south african context. afr j health professions educ 2011;3(2):6-8. accepted 5 october 2017. https://doi.org/10.1111/j.1600-05 79.2006.00411.x https://doi.org/10.1111/j.1600-05 79.2006.00411.x https://doi.org/10.4102/phcfm.5i1.474 https://doi.org/10.4103/1357-6283.134311 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 http://www.ukzn.ac.za https://dx.doi.org/10.1191/1478088706qp063oa https://dx.doi.org/10.1191/1478088706qp063oa https://doi.org/10.1080/0142159x.2016.1231914 https://doi.org/10.4102/phcfm.v5i1.456 https://doi.org/10.5430/ijhe.v4n2p139 https://doi.org/10.3109/13561820.2012.715604 september 2018, vol. 10, no. 3 ajhpe 143 editorial bongani mawethu mayosi was born on 28 january 1967 in mthatha, eastern cape, the second son of dr george sikhumbuzo mayosi and mrs nontle mayosi. he attended primary school in upper ngculu village, ngqamakhwe, eastern cape. he completed his secondary schooling at the age of fifteen, matriculating from st john’s college, mthatha, and passing six subjects with distinction. his first two degrees were a bmedsci completed in 1986 and concurrently an mb chb completed in 1989 at the university of kwazulunatal, both obtained cum laude and at the top of his class. he worked as an intern at livingstone hospital in port elizabeth, then moved to cape town the following year to work as a senior house officer and later join the medical registrar rotation at groote schuur hospital (gsh) and the university of cape town (uct). within three years he had been admitted to the fellowship of the college of physicians of south africa. immediately after this, he was awarded the prestigious oxford nuffield medical scholarship, allowing him to read for a dphil in cardiovascular medicine on a project on cardiovascular genetics at the university of oxford, under the supervision of prof. hugh watkins. he returned from oxford to complete his clinical training in cardiology at gsh and uct. thereafter, he worked as a consultant in the cardiac clinic. he was appointed as the seventh chair and head of the department of medicine at uct and gsh in 2006. following an illustrious tenure, during which he transformed the department of medicine, growing it to be the largest and leading medicine department on the african continent, in 2016 he was appointed as the dean of the faculty of health sciences at uct and occupied this position until his untimely death on friday 27 july 2018. his enduring legacy will be one of research excellence, academic development and the transforming effect he had on individual lives, institutions and countries, particularly on the african continent. his research focused on non-communicable diseases. he believed in a diversified portfolio of research, and proj ects of varying risk. for him, that portfolio included research on the epidemiology and genetics of heart muscle disease; heart failure; pathophysiology, clinical outcomes and genetics of rheumatic heart disease; tuberculous infections of the heart; hiv infection as it involves the heart; rare genetic disorders among africans; and strengthening of health systems in south africa and on the african continent. when criticised by many that his research focus was too divergent, he always emphasised the important thematic linkage: he studied cardiovascular diseases of the poor – as he called them, ‘the afflictions of the wretched of the earth’. it was his firm belief that by studying these diseases of pestilence, he could make his greatest contribution to the world. during his career, he made seminal contributions to all these seven areas. he was considered the doyen of heart muscle disease on the african continent and has clarified the clinical profile, epidemiology and genetic basis of cardiomyopathies in africans. through this process he was involved in the discovery of many novel genes that cause sudden cardiac death and heart failure in africans. in cardiovascular genetics, prof. mayosi’s discoveries included genes causing dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmo genic cardiomyopathy, coronary artery disease and hypertension. he established an internationally renowned laboratory at uct, which at the time of his death was leading unique studies of the genetics of rheumatic heart disease and congenital heart disease in africa. among his contributions to knowledge in single-gene disorders, his discovery in 2017 of a new gene for arrhythmogenic cardiomyopathy was recognised as one of the most important medical advances made by a south african scientific team since the first human heart transplant. he has also provided the most complete investigation of the contemporaneous causes, clinical profile and optimal approaches to management of heart failure among africans. he has advanced our understanding of the biology of rheumatic heart disease, the role of screening and the employment of a strategy of syndromic treatment of pharyngitis to prevent this disease in children. his research has influenced policy and guidelines on the management of this disease globally, and these have been adopted by the african union, the world heart federation, the world health organization and the world health assembly. more recently, he advocated for the widespread availability of penicillin for the eradication of rheumatic heart disease in the global south. through his investigation of tuberculosis in the heart, he clarified the appropriate diagnostic strategy and role of adjunctive steroids in tuberculous pericarditis. he showed that unstimulated interferon gamma is the most sensitive and specific screening test for tuberculous pericarditis. in addition, his impi trial showed that adjunctive steroids cause cancer in hiv-infected individuals but reduce constrictive pericarditis and hospitalisations in all patients. this has led to the recommendation for the selective use of adjunctive steroids in hiv-negative individuals alone. these findings resulted in the revision of clinical practice guidelines for tuberculous pericarditis. he reviewed the state of healthcare in south africa and on the continent and made important recommendations on how health systems could be strengthened to improve the health of all africans, in particular those in rural and under-served areas. while the contributions he has made will influence the outcomes of future generations, i believe that his academic career will be remembered most for the relationships he built. he made friends everywhere he went. he recognised potential and invested substantially in the development of human capacity as part of the academic project. prof. mayosi used research to advance his dream of ‘1 000 phds’. he wanted to undertake research that would answer the prevailing fundamental questions on african cardiovascular health, and to answer these questions definitively. professor bongani mayosi: a legend in our time this open-access article is distributed under creative commons licence cc-by-nc 4.0. 144 september 2018, vol. 10, no. 3 ajhpe editorial he embarked on building research capacity on the african continent and went into countries with no existing research management infrastructure or ethics committees and helped to set these up ab initio. his professional achievements and accolades are too many to list, but include the order of mapungubwe (silver) in 2009 and an a-rating by the national research foundation. he was a member of the academy of science of south africa and a former president of the college of physicians of south africa. in 2017 he was elected to the us national academy of medicine (arguably one of the highest honours in the fields of health and medicine, which recognises individuals who have demonstrated outstanding professional achievement and commitment to service). he was instrumental in securing dedicated funding for clinicians from organisations such as netcare, for the hamilton naki scholarship and the discovery academic fellowships. this culminated in the ‘1 000 phds in 10 years project’ (also known as the national health scholars programme), in collaboration with the department of health, the national health research committee, the public health enhancement fund and the south african medical research council. as a clinician, he was second to none. he was loved by his patients, who remembered his gentle and impeccable bedside manner. he had a fascination for the understanding of the mechanisms of physical signs, and an encyclopaedic knowledge of clinical medicine. as a researcher, he was a global leader in his field. he published over 350 peer-reviewed articles and book chapters. he had an h-index of 67 and over 40 000 citations. he is one of only a handful of a-rated scientists in south africa. as a teacher, he was legendary. his knowledge of the cardiovascular system was outstanding. but he was revered by undergraduate students for his approach to his teaching of neurology. he graduated over 30 master’s and doctoral students for whom he had provided supervision. all of them will remember him as a caring supervisor who invested substantially in them and created opportunities that have defined their careers. many of his students have gone on to be leaders in academia, industry and government in this country, on the continent and throughout the world. as a leader, he was awesome. his brand of leadership was honest, full of integrity and characterised by creativity and innovation. his commitment and passion were evident at all times. he is one of the most inspiring people i will ever know. he believed that there was no problem that could not be solved, and his work ethic was unquestionable. he played the long game, and always reminded me: ‘a  journey of a thousand miles begins with a few steps.’ as an advocate, he made seminal contributions to health policy and practice in several important areas. following appointment by the academy of science of south africa to chair a consensus panel on the revitalisation of clinical research and related training in south africa, he published a report in 2009 that has significantly shaped the policy framework on the revitalisation of health research in south africa. this formed the blueprint of the approach adopted by the government. how will i remember prof. mayosi? i will remember him as a dear friend, mentor and confidant. i will remember him for tireless dedication to advance a great cause. i salute him for a life of integrity, his humility, his outstanding intelligence and his absolute pursuit of knowledge and truth. how will the faculty of health sciences at uct and gsh remember him? he will be remembered as the consummate professional and the epitome of hard work. a leader who was exemplary in every fashion. a man with immense dignity and an infectious optimism. a visionary who imagined an africa capable of driving its own agenda and using science to improve the health of its nations. he will be remembered for his absolute love of the uct students. his fundamental drive was the transformation of society through investment in future generations of scientists, physicians and future leaders. he will be remembered for his absolute love of the hospital, the department of medicine, the faculty and the university. both those who knew him well and those who hardly knew him spoke of their absolute love of the man, and their sense of his apparent and evident affection for them. he will be remembered for his unwaver ing belief in the potential of others and for his excellence in research, and translation of that research into work with a meaningful impact. his ultimate belief was that science should be a vehicle for social and political change, and ultimately a vehicle for economic upliftment. as he often reminded us, ‘health comes before wealth’. but, above all, he will be remembered for his absolute love of his family. he was a devoted husband and father and never missed an opportunity to share how much his family meant to him. he spoke often of his gratitude for the support of his wife, and the love he received from his daughters, who he constantly referred to as his ‘pride and joy’. he is survived by his wife, nonhlanhla, and three daughters, nosipho, sivuyile and camagu (and many other ‘daughters’ raised in his home). he also leaves behind his mother, nontle, eldest brother, sipho, and two sisters, khuthala and ncumisa. he will be dearly missed by his family, friends and colleagues. may his soul rest in peace. lala ngoxolo rhadebe. phumla ngoxolo qhawe lamaqhawe. oko ubuthunywe nguthixo ukugqibile. umzamo omhle uwenzile. ugqatso ulifezile! rhadebe! bhungane! mashwabada! mthimkhulu! ndleb’entle zombini! acknowledgement. republished with permission from the south african medical journal, the primary source of publication and with which copyright resides.[1] ntobeko ntusi department of medicine, groote schuur hospital and faculty of health sciences, university of cape town, south africa ntobeko.ntusi@uct.ac.za 1. ntusi n. professor bongani mayosi: a legend in our time. s afr med j 2018;108(9):695-696. https://doi. org/10.7196/samj.2018.v108i9.13584 afr j health professions educ 2018;10(3):143-144. doi:10.7196/ajhpe.2018.v10i3.1151 https://doi.org/10.7196/samj.2018.v108i9.13584 https://doi.org/10.7196/samj.2018.v108i9.13584 june 2018, vol. 10, no. 2 ajhpe 76 short research report mnemonic teaching and learning strategies have been described as syste­ matic procedures aimed at enhancing memory and making information more meaningful.[1] a mnemonic is an acronym created by taking the first letters of a list of words and using these to form a memorable phrase. it is thought that the use of mnemonics may develop and improve ways in which information is encoded, thereby making it easier to retrieve at a later stage.[1] two basic types of mnemonics exist: those focused on remembering facts (fact mnemonics) and those focused on remembering rules and procedures (process mnemonics).[2] examples of medical mnemonics include history­ taking and handover mnemonics, such as ample, demist,[3] ashice,[4] sbar[5] and cuban.[3] similarly, the dissect mnemonic represents a classification system that has been described as easy to assimilate and a memorable method of accounting for the critically important factors that influence contemporary decision­making for the management of aortic dissection.[6] clinical assessment and decision­making remain arguably two of the most important skills for all clinicians, and both involve complex abstract processes. this poses a challenge for health professions educators to teach and for students to master. the objective of the aimed at itchedd mnemonic is to guide the student towards gathering, analysing, interpreting and acting on appropriate clinical information in a logical fashion. development of aimed at itchedd development of the mnemonic followed a process of careful consideration and inclusion of the desirable characteristics of an ideal mnemonic: ease of memorisation, logical progression through steps or stages, guidance of decision­making to ensure completion of process and ease of assimilation. aimed at itchedd requires envisaging a chief complaint as an ‘itch’ that needs to be alleviated. interventions are therefore aimed at adequately managing the chief complaint (an itch), leading to the complaint being resolved. hence, the itch becomes ‘itched’. the mnemonic has been designed to create novel and logical links that the student or practitioner can associate with and apply during the management of a clinical case. the aimed at itchedd mnemonic is summarised in table 1. the aimed component focuses on initiating a process of clinical reasoning, which has been described as gathering and comprehending data while recalling knowledge, skills and attitudes about situations as they unfold.[7] the at and itchedd components of the mnemonic expand upon the initial phase of clinical reasoning. after analysis, information is put into a meaningful whole and applied to the new situation presented by the patient and their response to the treatment that is administered.[7] the mnemonic was introduced in the first year of the bachelor of health sciences in emergency medical care programme at the university of johannes ­ burg, south africa, in 2014. method study design a cross­sectional, purposive design made use of an online questionnaire to gather data. a total of 47 responses were received, comprising 26 emergency medical care educators and 21 students. ethical approval ethical approval for the study was obtained from the university of johannesburg’s faculty of health sciences research ethics committee (ref. no. rec­01­125­2014). background. mnemonics are used as memory aids for teaching, learning and practice in a variety of educational contexts and domains. mnemonics are commonly used to assist in the recall of critical components of complex or important clinical processes. the aimed at itchedd mnemonic was designed to assist students to recall and apply steps associated with a structured clinical decision­making process. objective. to obtain the views and opinions of a sample of educators and students regarding the perceived value of aimed at itchedd. method. a prospective, purposive design was followed, making use of an online questionnaire that consisted of 18 likert­type questions, together with areas allowing for open, written comments. a total of 47 responses were received. quantitative data from the closed questions were descriptively analysed. thematic analysis was conducted on the narratives provided to determine emerging themes. results. despite concerns being raised relating to its length, aimed at itchedd was seen as a valuable tool for clinical teaching, learning and practice by the majority of respondents. conclusion. as a process mnemonic, aimed at itchedd is perceived as having the potential to guide both students and practitioners with the critical thinking and decision­making processes associated with patient assessment, diagnosis and management. further research is required to assess and quantify the extent to which the application of aimed at itchedd improves clinical performance. afr j health professions educ 2018;10(2):76­78. doi:10.7196/ajhpe.2018.v10i2.543 aimed at itchedd: a proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting a makkink, nd msrv, nd emc, btech emc, pdte; c vincent-lambert, nd aet, nhd pse, nhd fst, btech emc, mtech ed, phd hpe department of emergency medical care, faculty of health sciences, university of johannesburg, doornfontein campus, south africa corresponding author: a makkink (amakkink@uj.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 77 june 2018, vol. 10, no. 2 ajhpe short research report instrument data were collected using a purpose­compiled questionnaire that used the sogosurvey (sogosurvey inc., usa; www.sogosurvey.com) online plat­ form. it consisted of 18 likert­type, restricted­response questions. the survey also afforded respondents an opportunity to provide additional information at the conclusion of the structured question responses. data analysis quantitative data were analysed and reported descriptively. open­ended questions were read and reread by the investigators to familarise themselves with the content. thematic analysis formed the cornerstone of the analysis and specific attention was given to patterns and emerging themes. results educator responses opinions of the educators who took part in the survy were generally positive with regard to aimed at itchedd. almost all respondents (96%; n=25) considered a mnemonic to be a useful memory aid and indicated that a process mnemonic could be of assistance in the practical environment (92%; n=24). most respondents (92%; n=24) considered the mnemonic logical and 62% (n=16) felt that it was easily remembered, while 84% (n=19) believed that the mnemonic was easy to learn and apply. the mnemonic was perceived as having the potential to improve the structure of task performance in both the simulated (84%; n=22) and clinical (81%; n=21) domains. the mnemonic was also perceived as having the potential to provide a foundation for adaption by the individual (92%; n=24), as well as being able to be used in the clinical environment by qualified practitioners to improve their practice (92%; n=24). analysis of the comments from the open­ended questions indicated two main themes. the first focused on the length of the mnemonic, with a number of respondents who felt that it was quite lengthy: ‘… too many letters … .’ ‘… it is a long mnemonic … .’ we agree that aimed at itchedd is longer than mnemonics that focus on specific components or associated steps in the patient management process. its length reflects the difference from simple process mnemonics, as it encompasses multiple components of the entire patient management process. the second theme focused on the potential value of aimed at itchedd. a number of respondents provided positive comments on its potential: ‘… i am keen to give this one a go … .’ ‘… the system really looks good … .’ student responses similar to the educators’ responses mentioned above, those of the students were generally positive regarding aimed at itchedd. all respondents (100%; n=21) considered a mnemonic a useful memory aid and felt that a process mnemonic could be of assistance in the practical environment (100%; n=21). the mnemonic was considered logical by most respondents (95%; n=20), 86% (n=15) felt that it was easily remembered, and 86% (n=15) believed that it was easy to learn and apply. the mnemonic was seen as having potential to improve the structure of task performance in both the simulation (100%; n=21) and clinical (95%; n=20) learning environments. it was also perceived as having the potential to provide a foundation for adaption by the individual (100%; n=21), as well as being able to be used in the clinical environment by qualified practitioners to improve their practice (100%; n=21). it was interesting that 48% (n=10) indicated that the mnemonic might be difficult to remember. analysis of the comments from the open­ended questions heralded two themes that were identical to those of the educators’ respondents. these were its usefulness and length, and included: ‘… very helpful and logical but somewhat long … .’ ‘… this mnemonic is a great tool [to assist me] in a simulation assessment … .’ ‘… the mnemonic has helped me develop my own structure … .’ discussion many of the respondents in this study felt that mnemonics were useful aids within the clinical practice domain. as a process mnemonic, aimed at itchedd was seen as having the potential to guide both student and practitioner through critical thinking and decision­making processes associated with patient assessment, diagnosis and management. aimed at itchedd was acknowledged as being valuable and useful in guiding students through the critical thinking and decision­making processes. however, it was perceived as being relatively lengthy. the length of a mnemonic is often indicative of the complexity of the processes that table 1. summary of the aimed at itchedd mnemonic letter definition explanation a assess assess the patient and system/organ related to the chief complaint i identify identify the potential cause for the chief complaint m make sure confirm your provisional diagnosis using other tests e evaluate evaluate all potential therapeutic and adverse effects of available options d decide decide on the most appropriate treatment and rule out contraindications a appropriate equipment ensure that you have all the appropriate equipment for the intervention t time to prepare take time to prepare and set out all equipment for the intervention i intervention performed carry out the intervention in a ‘best practice’ manner t time to work give the intervention/treatment appropriate time to work c check result perform an appropriate test to determine whether or not your intervention is having the desired effect h happy or not are you satisfied that the intervention/treatment has had the desired effect? e explore other options if the result is unsatisfactory, what other options are available? d decide decide which option is the most appropriate and start again d don’t forget don’t forget to consider other potential causes or incorrect technique http://www.sogosurvey.com june 2018, vol. 10, no. 2 ajhpe 78 short research report it aims to guide. some mnemonics advocated in other domains are also considered lengthy; examples include fasthug­maidens[8] and a­a­ b­b­c­c­d­d­e­e.[9] we argue that aimed at itchedd, although perceived as lengthy, is comprised of three words – each representing a ‘bite­sized chunk’. we concede that there remain a number of factors that have the potential to influence clinical decision­making. these include the individual’s previous experiences, problem­solving, critical thinking and clinical reasoning abilities.[7] the intention is that the maturing practitioner will not robotically follow aimed at itchedd ad infinitum, but will over time adapt the mnemonic to best suit their own context and practice. study limitations and future research the online survey evinced 47 responses from the emergency medical care domain, and as such the generalisability of these results and findings to the wider health science educator and population cannot be determined. the importance of clinical reasoning in the healthcare education sphere must not be under­emphasised. it is important to ascertain whether this method has the potential to develop critical thinking across other healthcare disciplines. the questionnaire did not assess whether use of aimed at itchedd improved performance during simulated or actual patient assessment and management. this remains an area for future research, where the effectiveness of the mnemonic can be tested. acknowledgements. none. author contributions. am conceptualised the mnemonic. am and cv­l designed the study and managed the data collection, analysis and write­up. funding. none. conflicts of interest. none. 1. bakken jp, simpson cg. mnemonic strategies: success for the young­adult learner. j hum resour adult learn 2011;7(2):79­85. 2. manalo e. uses of mnemonics in educational settings: a brief review of selected research. psychologia 2002;45:69­79. https://doi.org/10.2117/psysoc.2002.69  3. bost n, crilly j, wallis m, patterson e, chaboyer w. clinical handover of patients arriving by ambulance to the emergency department – a literature review. int emerg nurs 2010;18(4):210­220. https://doi.org/10.1016/j. ienj.2009.11.006 4. budd hr, almond lm, porter k. a survey of trauma alert criteria and handover practice in england and wales. emerg med j 2007;24(4):302­304. https://doi.org/10.1136/emj.2006.038323 5. randmaa m, mårtensson g, leo swenne c, engström m. sbar improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. bmj open 2014;4:e004268. https://doi.org/10.1136/bmjopen­2013­004268 6. dake md, thompson m, van sambeek m, vermassen f, morales j. a new mnemonic­based approach to the categorization of aortic dissection. eur j vasc endovasc surg 2013;46(2):175­190. https://doi.org/10.1016/j. ejvs.2013.04.029 7. ackermann a, gore t, hewett b, et al. standards of best practice: simulation. clin simul nurs 2013;9(suppl 6):s3­ s11. https://doi.org/10.1016/j.ecns.2013.05.008 8. masson sc, mabasa vh, malyuk dl, perrott jl. validity evidence for fasthug­maidens, a mnemonic for identifying drug­related problems in the intensive care unit. can j hosp pharm 2013;66(3):157­162. https://doi. org/10.4212/cjhp.v66i3.1252  9. baugher km, mattu a. ten rules to assess and manage the acutely deteriorating patient: a practical mnemonic. patient saf surg 2011;5(1):29. https://doi.org/10.1186/1754­9493­5­29 accepted 23 october 2017. https://doi.org/10.2117/psysoc.2002.69 https://doi.org/10.1016/j.ienj.2009.11.006 https://doi.org/10.1016/j.ienj.2009.11.006 https://doi.org/10.1136/bmjopen-2013-004268 https://doi.org/10.1016/j.ejvs.2013.04.029 https://doi.org/10.1016/j.ejvs.2013.04.029 https://doi.org/10.4212/cjhp.v66i3.1252 https://doi.org/10.4212/cjhp.v66i3.1252 https://doi.org/10.1186/1754-9493-5-29 june 2018, vol. 10, no. 2 ajhpe 96 research stress is prevalent among both dental workers and students. a study conducted among dental students in malaysia found a 100% prevalence of stress.[1] dental students’ stress relates to their expectations of high academic achievements and excellence based on their previous academic records at school. the 5-year curriculum is stressful, with each successive year of study having a significant impact on the stress levels of students. this high level of stress in dental students calls for the implementation of stress management programmes in dental education.[2] dental education should serve as the starting point for the establishment of a healthy workplace that is free of stress. a healthy work environment is a valuable asset to a worker. it can sustain a healthy and productive work life, lowering incidences of work-based injuries and stress. occupational health is not just an important factor in the personal health of the worker; if all principles are followed, it will improve productivity and work quality, increase work motivation, improve job satisfaction and improve the overall quality of life of the individual.[3] the dental workforce involved with treating patients directly in south africa (sa) is comprised of dentists, dental therapists, oral hygienists and specialists. for the purposes of this article, they will collectively be referred to as dental practitioners. dental practitioners provide oral healthcare services in both the public and private sectors in sa. a study conducted at an sa dental school revealed that most of the students experienced stress, with 45% showing signs of moderate stress and 42% severe stress. nearly a quarter (25%) of the respondents wanted to quit or change courses, and a significant 3% (n=6) wanted to commit suicide. the researchers recommended that stress management be included early in the curriculum to equip students to deal with stress.[4] this is supported by research among newly qualified dentists in hong kong. the authors recommended that stress management be added to the curriculum, and stress management updates held for newly qualified dentists.[5] the purpose of the present study was to establish how the current cohort of dental practitioners incorporate occupational health and self-care principles into professional practice, and their relevance to curriculum design. the objective of this study was to gain input from participants regarding stress and burnout – causes, implications and prevention measures – linked to their practice in dentistry. methods this was a qualitative study conducted among dental practitioners in various fields, regarding their occupational health. the study was conducted in kwazulu-natal (kzn), sa. a purposive sampling technique was used to identify participants. data were collected background. stress is prevalent among dental workers and students. a possible means to address this would be to include stress management programmes in undergraduate dental programmes. the purpose of this study was to establish how the current cohort of dental practitioners incorporate occupational health and self-care principles into professional practice, and their potential relevance to future curriculum design. objectives. to gain input from participants regarding stress and burnout – their causes, implications and prevention – as linked to their practice in dentistry. methods. a qualitative research design was used, with a purposive sampling technique. the study population consisted of dentists, dental therapists, hygienists and specialists. a total of 36 participants participated in four focus-group discussions to explore dental education, occupational health, stress and self-care. the data were thematically analysed. results. dental training in the south african context, occupational health experiences, self-care, coping strategies and education were the main themes that emerged. dental services in the public sector were reported to be overwhelmed by high patient volumes and shortages of staff and resources, which added to these stressors. the coping strategies adopted were exercise, stretching, reducing workload and encouraging teamwork. the participants believed that the causes of musculoskeletal disorders, and their impact, should be taught in dental training, as students do not perceive this as a potential problem. a multidisciplinary approach and teamwork training are the recommendations for curricula. conclusion. stress management techniques and workplace posture assessment should be taught in preclinical training to make students aware of managing stress and correct working postures. a multidisciplinary approach should be used. dental curricula should include occupational health safety principles. afr j health professions educ 2018;10(2):96-100. doi:10.7196/ajhpe.2018.v10i2.1005 ‘pain and stress are part of my profession’: using dental practitioners’ views of occupation-related factors to inform dental training r moodley,1 b dent ther, msc dent pub health; s naidoo,2 mb chb, phd; j van wyk,3 bsc (ed), med, phd 1 discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa 2 discipline of public health medicine, school of nursing and public health, university of kwazulu-natal, durban, south africa 3 discipline of clinical and professional practice, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: r moodley (moodleyra@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 97 june 2018, vol. 10, no. 2 ajhpe research through focus-group discussions with dental practitioners. four focusgroup discussions were conducted between may and june 2017. a total of 36 dental practitioners participated in these focus-group discussions, which were conducted by the researcher (the first author). the focus-group discussions explored dental education, occupational health, stress and selfcare. each session lasted between 60 and 90 minutes. this study forms part of a larger project. ethical clearance was obtained from the humanities and social sciences research ethics committee of the university of kzn (ref. no. hss/1490/015d). written informed consent was obtained from all participants, who were informed of their right to withdraw from the study at any stage. all participants agreed to participate and to have an audio recording made of the interview. anonymity of participants was maintained throughout the study by using participant codes instead of names. the participants filled out an anonymous demographic information sheet. the audio recordings were transcribed verbatim, and the transcripts checked for accuracy. member check, or respondent validation, was conducted to establish validity. the data were then analysed thematically. broad themes were identified, according to the main aim, and then further refined and coded until the final analysis was complete.[6] the themes identified were analysed in line with the objectives of this study. results five main themes were identified, based on the questions that were explored. the themes were identified, refined and grouped. dental training in the sa context, occupational health experiences, self-care and burnout, coping strategies and dental education were the main themes identified. dental training is hindered by lack of resources, lack of staff, focus on curative work and a lack of teamwork, all of which impact on the stress levels of staff and students. a brief description of each theme is given, followed by illustrative quotes (tables 1 5). discussion dental practice in the current sa healthcare system is hindered by shortages of resources and staff, and equipment in facilities, and by malfunctioning dental chairs. the poor conditions in the clinical context are exacerbated by high volumes of patients. when dental staff are pressured into working long hours owing to high patient volumes, it impacts on their health, with repetitive tasks exacerbating the situation. occupational stresses place the workers at risk of musculoskeletal disorders (msds). repetitive tasks cause muscle fatigue and increase the use of joints, predisposing dental workers to joint injuries.[7,8] comments from the practitioners showed that the development of a healthy workplace environment and practice should be prioritised to prevent work-based injuries. poor working conditions, staffing problems and time pressures are common stressors. in a poorly resourced dental clinic, the stressors are greater, as is their impact on health.[9] improving the work environment, supplemented by increasing access to resources, can improve morale and dedication among dentists. job-enrichment strategies can be used to improve communication and facilitate contact among colleagues. hakanen et al.[10] suggest promoting an increased variability of skills, which is unfortunately not the case among practitioners in kzn, as many of them perform mainly curative tasks. early retirement of staff, long-term sick leave, loss in productivity, loss of income and increased need for medical care are some of the implications of occupational health-related conditions.[11] one of the stressors that was strongly recognised in this study was lack of teamwork. teamwork skills should be taught, and assessed as one of the core competencies to achieve during dental training; moreover, these skills should be learnt and practised during training. working in a team reduces stress and creates a sense of value for workers. ‘learning together’ for all oral healthcare students would foster teamwork.[12] dental training occurs at various clinics in kzn. dental practitioners are not trained together table 1. dental work in the south african context subtheme quotes public sector dental services are overwhelmed by high patient volumes, compounded by a shortage of staff. ‘like in our place, you’re looking at the public sector and we are short-staffed. so the number of patients is a problem. so you haven’t got time for quality work.’ (focus group 1, participant 3) ‘i think the whole structure of the oral health system – it really needs to be shaken up. why are we seeing so many extractions?’ (focus group 1, participant 1) the public sector is hindered by a lack of structural resources. ‘also at our place we are having a problem with the aircon. and all the windows are sealed in the hospital … there are days when it’s extremely hot.’ (focus group 1, participant 3) there is a marked divide between the services offered in the public and private sector in terms of patient numbers, resources and patient care, which affects service delivery. ‘so the profile of the patient dictates in some way … it means you have to adhere to their requests and prioritise them. and that is in private. but in public, you still have the larger numbers.’ (focus group 1, participant 6) resource constraints affect service delivery and practitioner wellbeing ‘in the current institute where i am, we have two chairs but they are not fully equipped. so we can do crowns, but we cannot do scaling so we only doing extractions. i worked there in a 7-month period and i ended up hurting my arm because of the repetitive nature. i went from working properly to doing no extractions at all.’ (focus group 1, participant 4) ‘healthy operator equals healthy economy. an operator is more useful to government working throughout their career.’ (focus group 1, participant 6) dental staff were disillusioned, as there was a lack of upward employment mobility. ‘there is no growth once you enter the public sector, there is no room for growth.’ (focus group 3, participant 2) ‘so no upward mobility as such even if you’re kind of looking with binoculars.’ (focus group 3, participant 8). aircon = air conditioning. june 2018, vol. 10, no. 2 ajhpe 98 research as a healthcare team at ukzn, since the institution currently only offers two programmes – dental therapy and oral hygiene. while the therapists and oral hygienists seemed to get along, this was not the case with dentists who may have trained at various other institutions in the country. in a study by rafeek et al.,[13] students were prepared for and seemed confident in restorative and preventive dentistry, but not in practice management and teamwork. dental curriculum development should focus more on the affective skills that are required after graduation. a study on teamwork in the uk showed that dental therapists felt valued, supported and consulted as part of a full dental team. however, in some cases, dental therapists felt that dentists were not listening to them, and that as therapists, they were given more preventive than restorative tasks. the dentists did not know the scope of dental therapy practice.[14] caring for patients was a priority for dental practitioners in the present study, and they treated patients who were experiencing pain. the dental practitioners in this focus group prioritised the health of the patients over their own, and this caused them further injury. self-recognition and recognition of health problems should therefore be added to undergraduate training. the caregiver’s role was investigated in a study by leka and jain,[15] and it was found that dentists idealised caring for and healing others. job content, lack of variety of work, underuse of skills and uncertainty of work conditions were identified as psychosocial risk hazards associated with table 2. occupational health experiences in dental work description quotes individual experiences as practitioners lead to various experiences with respect to the diagnosis of their occupational health disorders. ‘i worked for 20 years before i started experiencing my problems. and i think i worked myself to such a point where i couldn’t do it anymore. so i ignored the physical symptoms until i realised it was affecting the quality of my work. it did impact on the quality of my life.’ (focus group 1, participant 4) ‘and this is after 19 years and i kept telling my colleague that i had pain. i couldn’t move my shoulder. i just couldn’t move. every time i did, there was pain … but i started getting pain going down my arm, so i went for physio[therapy] and to see an orthopaedic. i told him about the extractions i do, so he put me off for a month.’ (focus group 1, participant 3) ‘dr a ended up with a musculoskeletal problem. 2014/15 she was doing her community service; she left after completion. luckily, she was able to get permission to do a maximum of 40 per day before she left. dr b – shoulder is compromised resulting in her being unable to do extractions! dr c also suffers from wrist problems. there were days when we were tasked to do 90-odd patients.’ (focus group 1, participant 6) table 3. self-care and burnout description quotes lack of collegiality and teamwork was an issue that had an impact on stress levels. ‘you work with people who know you for who you are and they start questioning you. that was very disappointing.’ (focus group 1, participant 4) ‘i think when you’re working, each one must give their pound of flesh kind of thing. so it’s kind of why am i doing your work kind of thing. (focus group 1, participant 4) ‘you feel like you not pulling your weight. because when you want to do something but your hands are shaking like that, you feel like you can’t do it, but you’ll still do it anyway because you don’t want to feel like you’re not doing your job. so i think i will change my career, definitely. i have to change, because i have seen it. my uncle who’s a maxillofacial surgeon also had to stop work. so it’s scary for me.’ (focus group 1, participant 2) table 4. coping strategies description quote(s) self-adopted coping strategies ‘now when i wake up, i stretch in the morning and it really has made a big difference, so we need to educate the students about this.’ (focus group 1, participant 3) ‘i saw my 15, you must see your 15. so that’s fair. we must share the workload, that’s our motto.’ (focus group 1, participant 3) ‘i was just doing scripts when i was in pain. i saw a physiotherapist, orthopaedic and a chiropractor.’ (focus group 3, participant 9) ‘without the swimming, without the pilates, without physiotherapy, without lumbar corsets being put on myself, i would not be sitting here working. i would not be sitting here right now.’ (focus group 4, participant 4) 99 june 2018, vol. 10, no. 2 ajhpe research the practice of dentistry in kzn. furthermore, the lack of control over one’s workload exacerbates the situation, causing physical and mental strain. the participants in focus group 1 reported that they lacked variety in their work, as they focused mainly on curative work and performing extractions. they wanted to do preventive work, but the clinics lacked the resources. added stressors mentioned included the environment and equipment, e.g. heat in clinics, noise and lack of space. poor organisational structure and communication in/by management, lack of support for problems and lack of personal development were also challenges reported by dental practitioners in kwazulu-natal. career development in the public sector is another factor that causes stress among dental practitioners – there is no career pathway for dental staff to progress along. postgraduate studies are not incentivised, and there are no specialist programmes within the department for dental practitioners to move on to. career progression strategies are required in the public sector. burnout is commonly seen in the ‘caring professions’, i.e. dentists, nurses, doctors, teachers and social workers.[10,15] in a finnish study investigating coping strategies, the dentists felt dedicated to their work despite high job demands, emotional ‘dissonance’ and changes in the law regarding the worksite and one’s work.[10] the study found that dentists with greater control over their job tasks, and those who try to improve themselves, are best equipped to deal with job demands. hakanen et al.[10] concluded that by improving the work environment, we can enhance dentists’ feelings of vigour and dedication through job enrichment approaches. the researchers in the present study found that dentists in the public sector perceived their dental practice as more demanding than service in private practices. more qualitative studies are needed of the psychosocial aspects of dentistry as experienced among private and public sector dentists in sa. the practitioners in this study reported experiencing muscle pain, but continued their work despite these symptoms. some received support in this issue from management, while others did not. their quality of life was affected: some participants had problems sleeping, or could not play with their children, and simple chores at home were a problem. some became physically ill, and opted to change careers. dentistry is a 5-year course, and dental therapy and oral hygiene are each 3-year courses. preclinical and clinical training are covered in these years for all three courses, together with clinical practice and a large volume of lectures. this can be stressful for students, and although burnout is mainly seen among dental professionals, many researchers have seen it among dental students.[16] acharya[17] found that the major causes of stress among newly qualified dentists and students in his study were practice-management issues, treating children, time pressure and fear of failure. fear of facing one’s parents after failure, followed by fear of failure itself, were the greatest stressors. stress is commonly seen in dental practitioners and undergraduates, and it is proposed that the ability to identify, perceive and manage it is an important attribute for health workers.[18] burnout has been described as professional exhaustion,[19] and it is characterised by a loss of enthusiasm for work and a low sense of personal accomplishment.[16] both the personal and educational environments can contribute to stress, but students perceived that workload and a sense of self-efficacy influenced burnout, as seen in a columbian study where 7% (n=394) of students experienced burnout.[20] the participants in this study also found that students were stressed in clinics due to workloads and patient care. clinical supervisors reported that their students were not keen to correct their posture, as they did not experience pain. there is a need for change in this attitude, or these bad habits will be carried into professional practice. students in clinical training benefit from feedback and demonstration. in daily feedback, it would help students if posture and ergonomics, as well as the specific clinical procedures, were discussed. demonstrations of proper posture should be included in all clinical years of training, and not just preclinical. prevention of percutaneous injuries should also be taught and assessed throughout training as these injuries were mentioned as a cause of stress. the inclusion of occupational health and ergonomics training in dental curricula has been suggested by many studies.[21,22] injury prevention and dental ergonomics should be taught to dental practitioners, as these skills and knowledge are required to practice in an ergonomically correct position.[21,23-25] a limitation of the present study was that it was confined to kzn, and did not cover the whole of sa. the study population does not represent all dental practitioners, but it nevertheless allowed the researcher to probe areas that could not be investigated in a cross-sectional study. multiple focus groups were conducted to reduce bias, and the results and conclusions from all four focus groups were very similar. conclusion the reported causes of stress and burnout among this cohort arose from lack of teamwork, high patient numbers, lack of job variation and poor table 5. dental education subtheme quote(s) students were actively discouraged from the profession ‘when the students come in, we literally scare them away from the profession because they look at me and i tell them what happened to me and they then think, should i be doing this?’ (focus group 1, participant 4) participants made suggestions about dental training ‘a physical stretching session, get staff from various disciplines to assist.’ (focus group 1, participant 4) ‘we need to talk about assertiveness training, like how do you assert your own limitations.’ (focus group 1, participant 6) ‘teach the causes of the msd and its impact.’ (focus group 4, participant 1) students were seen as not interested in their own health and showing a lack of interest in self-care; they did not understand the implications of occupational hazards ‘i have seen a lot of times that the students just don’t stand in the right positions. i go to them and i tell them how to stand and what happens if you don’t stand the right way. so i keep correcting them. the students say they want to sit where they can visually see everything, but the body posture is wrong.’ (focus group 1, participant 3) msd = musculoskeletal disorder. june 2018, vol. 10, no. 2 ajhpe 100 research equipment. these dental practitioners incorporate exercise into their routines, seek professional help, lower patient load and share workload to cope with their professional practice. the participants recommended that clinical practice supervision should include a score for posture assessment in the daily assessment rubric. students should also be taught to assess the arrangement of their equipment within the workplace in order to prevent harmful practice habits. stress management techniques and workplace posture assessment should be added to the curriculum, especially in preclinical training, to make students aware of managing stress and correct working postures. a multidisciplinary approach should be used when teaching dental students about occupational health issues. dental curricula, while overloaded in the second-last and final year, need to include occupational health safety principles and training. an interesting point that the participants raised is the lack of preventative dentistry in the public sector; while this is an issue for patient care, it also contributes to the rise in msds, as it means there is a lack of variation in dental work. further research into delivery of patient care, via preventive dentistry service delivery, is required in sa. as an offshoot to this study, participants also recommended that a support group for dental practitioners be formed, as those who experienced pain stated that they felt a degree of isolation. this would create dialogue, to prevent self-isolation. it would be an opportunity to share experiences and to learn. acknowledgements. the authors would like to thank the participants for their valuable input. author contributions. rm: phd student, all literature reviews, data collection and data analysis, interpretation of the results as well as manuscript preparation and writing. sn: phd supervisor. jvw: phd supervisor. funding. department of higher education and training research development grant. conflicts of interest. none. 1. ahmad ms, yusoff mmm, razak ia. stress and its relief among undergraduate dental students in malaysia. southeast asian j trop med public health 2011;42(4):996-1004. 2. alzahem am, van der molen ht, alaujan ah, de boer bj. stress management in dental students: a systematic review. adv med educ pract 2014;5:167. https://doi.org/10.2147/amep.s46211 3. world health organization. global strategy on occupational health for all: the way to health at work. recommendation of the second meeting of the who collaborating centres in occupational health, 11 14 october 1994, beijing, china. who: geneva, 1995. http://apps.who.int/iris/handle/10665/36845 (accessed 22 august 2017). 4. bhayat a, madiba tk. the self-perceived sources of stress among dental students at a south african dental school and their methods of coping. s afr dent j 2017;72(1):6-10. 5. choy h, wong m. occupational stress and burnout among hong kong dentists. j dent res 2017;23(5):480-488. https://doi.org/10.12809/hkmj166143 6. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 7. garstang sv, stitik tp. osteoarthritis: epidemiology, risk factors, and pathophysiology. am  j phys  med  rehabil 2006;85(suppl):s2-s11. https://doi.org/10.1097/01.phm.0000245568.69434.1a 8. rabiei m, shakiba m, dehgan-shahreza h, talebzadeh m. musculoskeletal disorders in dentists. intern j occup hyg 2015;4(1):36-40. 9. hashim r, al‐ali k. health of dentists in united arab emirates. inter dent j 2013;63(1):26-29. https://doi. org/10.1111/idj.12000 10. hakanen jj, bakker ab, demerouti e. how dentists cope with their job demands and stay engaged: the moderating role of job resources. eur j oral sci 2005;113(6):479-487. https://doi.org/10.1111/j.1600-0722.2005.00250.x 11. bhattacharya a. costs of occupational musculoskeletal disorders (msds) in the united states. int j ind ergon 2014;44(3):448-454. https://doi.org/10.1016/j.ergon.2014.01.008 12. evans j, henderson a, johnson n. the future of education and training in dental technology: designing a dental curriculum that facilitates teamwork across the oral health professions. brit dent j 2010;208(5):227-230. https://doi. org/10.1038/sj.bdj.2010.208 13. rafeek rn, marchan sm, naidu rs, carrotte pv. perceived competency at graduation among dental alumni of the university of the west indies. j dent edu 2004;68(1):81-88. 14. csikar j, bradley s, williams s, godson j, rowbotham j. dental therapy in the united kingdom: part 4. teamwork – is it working for dental therapists? brit dent j 2009;207(11):529-36. https://doi.org/10.1038/sj.bdj.2009.1104 15. leka s, jain a. health impact of psychosocial hazards at work: an overview. geneva: who, 2010. 16. eren h, huri m, bagis n, et al. burnout and occupational participation among turkish dental students. southeast asian j trop med public health 2016;47(6):1343-1352. 17. acharya s. factors affecting stress among indian dental students. j dent edu 2003;67(10):1140-1148. 18. pau a, croucher r, sohanpal r, muirhead v, seymour k. emotional intelligence and stress coping in dental undergraduates – a qualitative study. brit dent j 2004;197(4):205-209. https://doi.org/10.1038/sj.bdj.4811573 19. campos jadb, jordani pc, zucoloto ml, bonafé fss, maroco j. burnout syndrome among dental students. rev bras epidemiol 2012;15(1):155-165. 20. mafla a, villa‐torres l, polychronopoulou a, et al. burnout prevalence and correlates amongst colombian dental students: the stresscode study. europ j dent edu 2015;19(4):242-250. https://doi.org/10.1111/eje.12128 21. yamalik n. musculoskeletal disorders (msds) and dental practice part 2. risk factors for dentistry, magnitude of the problem, prevention, and dental ergonomics. intern dent j 2007;57(1):45-54. https://doi.org/10.1111/j.1875595x.2007.tb00117.x 22. morse t, bruneau h, michalak-turcotte c, et al. musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students. j dent hyg 2007;81(1):16. 23. bhandari s, bhandari r, uppal r, grover d. musculoskeletal disorders in clinical dentistry and their prevention. j orofac res 2013;3(2):106-114. 24. biswas r, sachdev v, jindal v, ralhan s. musculoskeletal disorders and ergonomic risk factors in dental practice. indian j dent pract 2012;4(1):70-74. 25. tezel a, kavrut f, tezel a, kara c, demir t, rabia k. musculoskeletal disorders in leftand right-handed turkish dental students. intern j neuroscience 2005;115:255-266. https://doi.org/10.1080/00207450590519517 accepted 21 december 2017. https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1111/idj.12000 https://doi.org/10.1111/idj.12000 https://doi.org/10.1111/j.1600-0722.2005.00250.x https://doi.org/10.1038/sj.bdj.2010.208 https://doi.org/10.1038/sj.bdj.2010.208 https://doi.org/10.1111/j.1875-595x.2007.tb00117.x https://doi.org/10.1111/j.1875-595x.2007.tb00117.x june 2018, vol. 10, no. 2 ajhpe 136 research autism spectrum disorders (asds) encompass a wide spectrum of symptoms and levels of impairment in the social, communicative and behavioural domains.[1] there has been limited research with a focus on interprofessional collaboration regarding asds in the local context. the intention of the present research was to develop a support programme that would allow registered nurses in primary healthcare (phc) to identify the characteristics of children with asds and to recognise possible risk factors. this practice would allow nurses to refer such children to appropriate healthcare services, and to provide parents with essential information when there is reason for concern. phc is the first level of contact between the general population and the health system.[2] patients are referred to healthcare services at secondary and tertiary hospitals.[3] nurses in phc often have to consult with the families of children with disabilities.[4] as registered nurses interact with mothers about the welfare of their children, and become aware of their concerns, they require unique knowledge, competencies and skills.[3] it is therefore important that nurses in phc are made aware of the characteristics and risk factors associated with asds (e.g. social, communicative and behavioural problems, and learning characteristics) in order for them to refer children as soon as possible.[5] early diagnosis provides an opportunity for early intervention, which improves the prognosis of the child in terms of linguistic, cognitive, social and motor abilities.[6] in rural contexts, asds are often only diagnosed many years after the onset of symptoms, or misdiagnosed, possibly as a result of a lack of knowledge.[7] awareness and knowledge of autism is very limited among healthcare workers in sub-saharan african countries;[6] early diagnosis and intervention occur more often in developed countries.[8] because of this situation, the diagnosis and detection of asds often occurs too late. valuable time is lost in which intervention and education could have occurred. in some african countries, the proportion of children with asds receiving an education can be as low as 1 3%.[9] early identification is crucial for the development, education and functioning of the child, and should occur before the age of 3.[10] registered nurses in phc clinics spend most of their time treating and diagnosing common childhood diseases (e.g. diarrhoea, nutritional deficits, hiv/aids) that are related to the national burdens of disease, and are less focused on behavioural difficulties in young children.[3] in addition, registered nurses receive limited information on the topic of asds in their professional training. lack of knowledge about asds presents barriers to early identification of and intervention for such children.[5] previous research has shown that there is a critical need to train healthcare workers in recognising asds, especially in underserved communities.[7,11] early intervention can significantly improve the quality of life of children with asds[3] and prevent further delays.[10] registered nurses should be supported in order to become familiar with the characteristics and risk factors associated with asds, and to understand the impact of asds on children and their families. signs of asds often appear at the age of 12 18 months.[12] children are usually seen at clinics at regular intervals (6, 12, 18, 24 and 30 months) for immunisation, and on such occasions parents may want to discuss their concerns with the nurse. it is important that registered background. registered nurses in south africa often work in community clinics in primary healthcare (phc), where they are first in line to be consulted by families with children with disabilities. there has been limited research with a focus on interprofessional collaboration regarding autism spectrum disorders (asds) in the local context. a support programme was developed to inform registered nurses in phc of the symptoms and characteristics of asds in order to increase the number of referrals to specialists for early diagnosis. objectives. to determine the effectiveness of a support programme for registered nurses in phc clinics, and to raise awareness of asds. methods. two phc clinics in a semirural area in gauteng province, sa, were included in the study, in which 10 registered nurses participated. a descriptive, quantitative approach was used, and data were collected by means of self-administered questionnaires. results. the results confirmed that the support was effective, as participants showed an increase in knowledge and understanding of asds. poor attendance and the limited sample size affected the outcomes. conclusion. a multidisciplinary approach to the early identification and referral of children with possible asds is important to improve the quality of life of these children and prevent further delays. speech-language therapists should provide support to registered nurses in phc, and training should be repeated on a continual basis to facilitate long-term retention and to accommodate shift changes within clinics. afr j health professions educ 2018;10(2):136-140. doi:10.7196/ajhpe.2018.v10i2.963 a support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: a pilot study a-m wium, dphil (commun pathol); m de jongh, phd (psychol) department of speech-language pathology and audiology, school of health sciences, sefako makgatho health sciences university, ga-rankuwa, south africa corresponding author: m de jongh (marguerite.dejongh@smu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 137 june 2018, vol. 10, no. 2 ajhpe research nurses at clinics are aware of the characteristics of asds and the possible risk factors, so that they can refer a child with suspected asd to a specialist physician for early diagnosis and intervention.[12,13] a comprehensive diagnostic evaluation of asds involves a multidisciplinary team comprised of a paediatric nurse, psychiatrist, psychologist, neurologist, speech-language therapist and occupational therapist.[14] in reality, many children with asd are diagnosed too late to obtain optimum benefit from early intervention services. it is estimated that <50% of children with asds are diagnosed before the age of 3 6 years, and that black children are diagnosed much later than white children.[7] this might be a result of inadequate screening practices, slow responses to parental concerns, or a failure to recognise symptoms early in life. the findings suggest that there may be differences in recognition of symptoms and diagnosis across racial and ethnic groups. it may also be a result of differences in accessing information about asds and lack of continuity in the provision of healthcare services. in the south african (sa) context, these differences might be attributable to geography rather than simply race, because of a history of racial segregation. the legislative blue ribbon commission on autism revealed that in general, children with asds might also experience a 13-month delay between the initial evaluation and actual diagnosis.[15] when parents of a child with asd consult a registered nurse at a phc clinic, they expect answers to their questions on how to manage their child. suitable guidance would allow both the family and the child the best quality of life.[14] early intervention through the use of screening, psychological support and education on asds can enable the family to cope and adjust to the necessary changes related to the child’s diagnosis.[16] the present study focused on training registered nurses in phc clinics in a semirural context on asd in children. methods two phc clinics in a semirural area in gauteng province, sa, were included in the study, and 10 registered nurses participated. in this specific context, referrals are made from primary to tertiary level, as there are no secondary hospitals in close proximity to the clinics. the aim of the study was to determine the effectiveness of the support provided in terms of (i)  the training process, and (ii) the knowledge gained about asds. the study was designed as intervention research (fig. 1), using a quantitative approach with a pretest post-test design in the evaluation phase. a questionnaire designed for the study purposes was used, which consisted of mostly closed-ended questions, expanded on by a limited number of open-ended questions. the pre-test questionnaire also included questions about demographic information. the questionnaires collected information on the participants’ knowledge of asds preand post-training, to determine the effectiveness of the support provided. the workshops were evaluated on a rating scale from 1  -  4. the content and clarity of the questions as well as the face validity in the questionnaires was confirmed prior to the study by obtaining the opinions of three volunteers in the nursing department who were experts in the field of phc. a pilot study was conducted with three registered nurses at a clinic that was not included in the study, to test the training and instructions. bias was minimised by not asking sensitive questions of a personal nature, and numbering the questionnaires to ensure anonymity. the questions were based on findings from the literature review and the objectives of the study. ethical clearance for the research was obtained from sefako makgatho health sciences university’s research and ethics committee (ref. no. mrec/h/78/2012: ug), and the gauteng department of health. all ethical principles were adhered to in the design of the study. the researchers conducted a briefing session at the two clinics to explain the rationale for the study and what would be expected from the participants, before obtaining informed consent. arrangements were made for the training sessions. the gauteng department of health determined the particular dates for training in accordance with their continuing professional development schedule. the workshops were designed according to adult learning principles, and were facilitated by the researchers. the participants were registered nurses with a 4-year qualification, who had not obtained any additional specialised qualification (e.g. in psychiatry or paediatrics). the two phc clinics were purposively selected as they were at a reasonable distance from the tertiary institution. the two training sessions of 1 hour each were scheduled over 2 consecutive weeks at each of the clinics. the first session focused on defining and describing the characteristics, prevalence and causes of asds, as well as associated risk factors. the second addressed the role of registered nurses in the identification of asds, parent education and the available resources for children with asds. although a large number of registered nurses (n=21) initially provided informed consent to set goals and objectives identify key elements of successful models specify procedural elements of training apply design criteria to preliminary programme re�ne the programme vi. disseminate information i. problem analysis and project planning identify and involve role players gain entry and co-operation from settings identify population's concerns analyse concerns identi�ed ii. information gathering and synthesis use existing information sources study natural examples iii. design design an observational system iv. early development and pilot testing develop prototype conduct pilot test v. evaluation and advanced development design the research methodology collect and analyse data replicate programme under �eld conditions needs assessment assess e�ectiveness assess e�ect (referral rate) fig. 1. framework for intervention research.[17] june 2018, vol. 10, no. 2 ajhpe 138 research participate in the research at the initial briefing sessions and attended at least one of the workshops, only those who attended both workshops and completed both the questionnaires were included in the research (n=10). the high attrition rate (52%) was due to shift changes and availability on the prearranged days of the workshops. the researchers, who were independent from the clinics, distributed and collected the questionnaires by hand. baseline knowledge had been determined by completing the questionnaire prior to the workshops, and was then compared with the post-training results to obtain knowledge gains. following each workshop, the participants rated the presentation. the quantitative data were entered into an excel (microsoft, usa) spreadsheet to be analysed descriptively. results are presented as percentages (table 1). qualitative answers were listed in a table format and quantified on a threepoint scale as either correct (2), partially correct (1), or incorrect (0), according to a memorandum. knowledge gains were based on a comparison between pre-and post-training scores. results the effectiveness of the support provided was determined by participants’ ratings of the length of the presentation, the language used, the preparedness of the presenters, the style and format of the presentations and the value of the support provided. the majority (90%) regarded the length of the workshops (1 hour) as being adequate. all the participants (n=10) viewed the language used to conduct the workshops as adequate and easy to understand. the presentations were conducted in an explanatory manner in english, which is the language of higher education and training in sa.[20] all the participants (n=10) considered the researchers to have been adequately prepared for the workshops. the style and format of the presentations were considered to be ‘interesting’ by all the participants. the workshop format, using powerpoint (microsoft, usa) together with discussions, appealed to the participants. these results confirm that the presentations and information were valued and interesting, because the content was new but relevant to the participants. the participants also asked several questions and made comments that elicited discussion during the presentations. fig. 2 shows participants’ perceptions of benefits obtained from the training. of those participants who gained (100%) in knowledge, 90% indicated that they gained significantly. these results were confirmed by comparing the preand post-training questionnaires (table 1). this comparison showed definite gains in knowledge, as only 50% (n=5) of participants could explain the concept of asd to some extent prior to training, while all (100%) could do so after training. there is, however, room for improvement and a need for further training, as 70% could still only partially explain what asd entails (table 2)[13] following training. such results imply an emergent understanding of the concept. the ideal would be to provide the participants with additional support, to generate a full understanding of the concept by all the participants. there appears to have been an increase in the level of understanding of specific problems associated with autism, as 90% of the participants had only limited knowledge pre-training (partially correct or incorrect responses), in contrast to 50% post-training, though this still leaves room for improvement. similar knowledge gains can be seen in participants’ understanding of the age at which autism appears, as only 50% of the participants described it correctly prior to the support provided, in contrast to 90% after the training. asds appear during the first 36 months of life,[5] fig. 2. participant rating of benefits of the presentation (n=10). pa rt ic ip an t re sp o n se , % 100 90 80 70 60 50 40 30 20 10 0 0 knowledge increase no ga in lim ite d g ain sig ni� can t g ain no co mm en t 0 10 90 table 1. comparison of preand post-training knowledge/understanding of autism spectrum disorders (n=10) pre-test questionnaire answers, % post-test questionnaire answers, % correct partially correct incorrect correct partially correct incorrect what do you consider autism to be? 0 50 50 30 70 0 autism is characterised by specific problems. please list. 10 50 40 50 40 10 at what age does autism usually appear? 40 10 50 90 0 10 what are the educational alternatives/options for a child with autism? 40 0 60 50 0 50 which other problems can be associated with autism? 20 20 60 60 30 10 is autism hereditary? 40 30 30 50 20 30 who is responsible for the diagnosis of autism? 10 70 20 40 50 10 what are the causes of autism? 30 20 50 70 30 0 where do you refer a child when you suspect an autism spectrum disorder? 0 80 20 90 0 10 what are the treatment approaches for a child with an autism spectrum disorder? 10 20 70 50 10 40 139 june 2018, vol. 10, no. 2 ajhpe research and it is during this period that parents usually consult phc clinics and express their concerns. registered nurses should be vigilant and able to identify the risk factors and symptoms of asds, which include social, communicative and learning characteristics, as well as behavioural problems.[5] there was also an increase in the proportion of participants (30%) who understood who the professionals were to refer patients to for diagnosis of asds. less improvement (10%) was seen in their knowledge about the availability of schools and resources for children with asds. however, the participants asked the facilitators after the workshops for an information leaflet on this, so that they could make proper referrals. a 50% increase in knowledge was seen with regards to the conditions comorbid with asds (e.g. mental illnesses such as attention deficit hyperactivity disorder and anxiety disorder). with regards to the causes of asds, all participants (n=10) provided either a partially correct (30%) or correct (70%) answer after the workshops, in contrast to the 50% of participants who were completely wrong before training. the majority of participants (90%) knew which facility to refer children with asds to after the training, which shows an increase of 10%. it could therefore be expected that the registered nurses who took part in this training would refer children for diagnosis to the tertiary hospital.[4] a more significant improvement was seen in their knowledge of treatment approaches for asds. prior to training, only 30% of the registered nurses had some idea of the different treatment approaches, compared to 60% following the training. these registered nurses had received general training that did not include specialised training in psychiatrics or paediatrics, and they had no prior knowledge of asds. it is therefore suggested that registered nurses collaborate with other members of health teams in order to meet the healthcare needs of the public.[11] discussion based on the overall results, it can be seen that participants’ knowledge improved and that they developed a better understanding of the condition. the information leaflet that we provided upon request, with contact numbers of appropriate schools, was considered helpful in advising parents on educational options. these workshops raised awareness of asds among the participants, but there remains a need for added support. registered nurses in phc clinics are not expected to diagnose asds, but they should be made aware of the risk factors and associated characteristics. they should additionally be able to refer parents to specialists and schools for learners with special educational needs. support should ideally be provided on a continual basis, to refresh their knowledge and to accommodate colleagues who could not attend the original presentations. it was found to be valuable to have discussion groups following training, because the nurses showed a need to discuss the relevant issues pertaining to the topic. the limitations of the study were the low attendance and small sample size. the low attendance (high attrition rate) of the nurses at the two clinics can be attributed to the nature of their work, as shift schedules complicated this matter. as the specific dates for training were predetermined by the gauteng department of health for staff development purposes, no flexibility was possible, and so we could not accommodate all the registered nurses. in addition, this project allowed only two clinics to be included in the research. future support programmes should be conducted in all clinics in the catchment area of the hospital, before an increased referral rate to specialists for early diagnosis of asds is likely to be seen. the results of this study should be interpreted with regards to the limited sample size. purposive sampling further limits the generalisation of these results to other contexts. conclusion the programme was presented in an effective manner, and participants gained knowledge about asds. this condition remains a challenge, owing to the global increase in its prevalence.[20] asds should be addressed in nurses’ professional training, so that they can identify behaviour, symptoms and risk factors, in order to refer these children for diagnosis at an early age, which will improve the prognosis of the condition. a multidisciplinary approach where speechlanguage therapists (slts) and registered nurses work together in the early identification and referral of children with possible asds is needed. in accordance with their scope of practice, slts should provide support to registered nurses in phc to enhance their knowledge of asds. effective support by slts should be based on interprofessional teamwork, and on encouraging adequate attendance of workshops. however, shift schedules are not necessarily flexible, and it may be necessary to repeat workshops to accommodate more registered nurses. the scheduling of table 2. characteristics of autism spectrum disorders[12] social characteristics communication characteristics behavioural problems learning characteristics poor pretend play skills poor eye contact inappropriate display of emotions limited interest in social interaction inability to understand gestures, social cues and facial expressions difficulty reading and expressing emotions inability to babble or coo language delay echolalia limited imitation difficulty using gestures and facial expression and understanding social language limited vocabulary inadequate use of grammatical structures, intonation, pitch, rhythm and stress short attention span disorganised dislike touch do not always respond to auditory stimuli show a lack of fear for danger avoid eye contact are preoccupied with own thoughts are less flexible in adapting to changing routines focus on one activity at a time explore the environment inappropriately, e.g. licking, smelling, handling of objects injure themselves by banging head against table, etc. hypersensitivity or hyposensitivity to sensory stimuli such as textures, taste, smells, sounds, visual input, pain poor fine motor skills, e.g. difficulty holding a pencil, drawing or writing, etc. gross motor difficulties, e.g. coordination and balance problems, etc. easily frustrated june 2018, vol. 10, no. 2 ajhpe 140 research workshops for continuing professional development is an administrative matter that needs to be negotiated with the department of health. acknowledgements. we wish to acknowlege the following students for the data collection: caley-jade selepe, duduzile nhlapo, glen shivambu and kgaugelo tema. author contributions. equal contributions. funding. none. conflicts of interest. none. 1. newschaffer cj, croen la, daniels j, et al. the epidemiology of autism spectrum disorders. annu rev public health 2007;28(1):235-258. https://doi.org/10.1146/annurev.publhealth.28.021406.144007 2. thema lk, singh s. integrated primary oral health services in south africa: the role of the phc nurse in providing oral health examination and education. afr j prim health care fam med 2013;5(1):1-4. https://doi. org/10.4102/phcfm.v5i1.413 3. karande s. autism: a review for family physicians. indian j med sci 2006;60(5):205-215. https://doi. org/10.4103/0019-5359.25683 4. bonis s. stress and  parents of  children with autism: a review of the literature. issues ment health nurs 2016;37(3):153-163. https://doi.org/10.3109/01612840.2015.1116030 5. boyd ba, odom sl, humphreys bp, sam am. infants and toddlers with autism spectrum disorder: early identification and early intervention. j early interv 20101;32(2):75-98. https://doi. org/10.1177%2f1053815110362690 6. bakare mo, ebigbo po, agomoh ao, et al. knowledge about childhood autism and opinion among healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders in nigeria. bmc pediatr 2009;9(1):12. https://doi.org/10.1186/1471-2431-9-12 7. mandell ds, wiggins ld, carpenter la, et al. racial/ethnic disparities in the identification of children with autism spectrum disorders. am j public health 2009;99(3):493-498. https://doi.org/10.2105/ajph.2007.131243 8. bakare mo, munir km. autism spectrum disorders (asd) in africa: a perspective. afr j psychiatry 2011;14(3):208-210. https://doi.org/10.4314/ajpsy.v14i3.3 9. bowker a, d’angelo nm, hicks r, wells k. treatments for autism: parental choices and perceptions of change. j autism dev disord 2011;41(10):1373-1382. https://doi.org/10.1007/s10803-010-1164-y 10. beukelman d, mirenda p. augmentative and alternative communication: supporting children and adults with complex communication needs. baltimore: paul brooks, 2012. 11. van der linde j, kritzinger a. perceptions of rural primary healthcare personnel about expansion of early communication intervention: original research. afr j prim health care fam med 2013;5(1):1-11. https://doi. org/10.4102%2fphcfm.v5i1.553 12. weissman l, bridgemohan c. autism spectrum disorder in children and adolescents: overview of management. uptodate, 2018. https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescentsoverview-of-management (accessed 13 may 2018). 13. christensen dl, bilder da, zahorodny w, et al. prevalence and characteristics of autism spectrum disorder among 4-year-old children in the autism and developmental disabilities monitoring network. j dev behav pediatr 2016;37(1):1-8. https://doi.org/10.1097/dbp.0000000000000235 14. elder jh, d’alessandro t. supporting families of children with autism spectrum disorders: questions parents ask and what nurses need to know. pediatr nurs 2009;35(4):240. 15. henderson k. policies and practices used by states to serve children with autism spectrum disorders. j disabil policy stud 2011;22(2):106-115. https://doi.org/10.1177/1044207310396210 16. hall hr, graff jc. the relationships among adaptive behaviors of children with autism, family support, parenting stress, and coping. issues compr pediatr nurs 2011;34(1):4-25. https://doi.org/10.3109/01460862.2011.555270 17. thomas ej, rothman j. intervention research: design and development for human service. haworth: boston, 1994. 18. matson jl, kozlowski am. the increasing prevalence of autism spectrum disorders. res autism spectr disord 2011;5(1):418-425. https://doi.org/10.1016/j.rasd.2010.06.004 accepted 10 october 2017. https://doi.org/10.4102/phcfm.v5i1.413 https://doi.org/10.4102/phcfm.v5i1.413 https://doi.org/10.4103/0019-5359.25683 https://doi.org/10.4103/0019-5359.25683 https://doi.org/10.1177%2f1053815110362690 https://doi.org/10.1177%2f1053815110362690 https://doi.org/10.1186/1471-2431-9-12 https://doi.org/10.1007/s10803-010-1164-y https://doi.org/10.4102%2fphcfm.v5i1.553 https://doi.org/10.4102%2fphcfm.v5i1.553 https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management/contributors https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management https://journals.lww.com/jrnldbp/toc/2016/01000 march 2018, vol. 10, no. 1 ajhpe 19 research health professionals’ education is currently undergoing a major transformation, in which community-based and interprofessional education (ipe) are being integrated into curricula, to align student training to meet the needs of the communities they are likely to serve and the health systems within which they will work.[1] ipe is an innovative learning strategy that breaks down the professional silos that commonly exist in training institutions.[2] this strategy provides opportunities for students from two or more health profession disciplines to learn with, from and about each other, or to collaborate to provide promotive, preventive, curative and rehabilitative services to patients, in an attempt to enable students to work effectively in healthcare teams upon graduation.[2,3] there are many documented examples of ipe being practised among student health professionals in various institutions, both in south africa (sa) and internationally. however, participation by students in the field of dentistry has been minimal or non-existent.[4] students in the dentistry field include dentists, dental therapists and oral hygienists in training, and their omission from interprofessional learning activities is based on the presumption that oral health is separate from general health,[4] although it is integral to general health and wellbeing.[5] routine dental examinations can result in the early detection of certain systemic diseases that manifest in the oral cavity, making dental personnel important members of a team that manages the overall health of a patient through screening, diagnosis and referral.[4] although highly prevalent, oral diseases are largely preventable, and share common risk factors, including an unhealthy diet, excessive tobacco use and harmful alcohol consumption, with other leading non-communicable diseases (ncds) such as diabetes, cardiovascular diseases, respiratory diseases and certain forms of cancer.[5,6] integrating oral health-promotion strategies and programmes with broader programmes in preventing and controlling ncds can lead to better health outcomes.[7] therefore, collaborating and networking with other healthcare professionals is essential for dental personnel, and should begin in their training, to develop the skills of collaborative practice and holistic patient management. moreover, sa, specifically kwazulu-natal province, has a considerable burden of disease, including oral conditions, which impacts on the under-resourced health system.[8] the university of kwazulu-natal (ukzn) is responsible for training health professionals in the province, and contributes significantly to a workforce that meets the healthcare needs of communities. this is ensured by producing graduates with the key competencies of being compassionate healthcare workers who communicate well with patients from various cultural backgrounds, being able to collaborate with other health professionals in patient management, and being leaders as agents of change. undergraduate student health professionals from multiple disciplines can improve the health outcomes of communities through contextualised health-promotion initiatives, by collaborating with each other in an interprofessional team approach. background. interprofessional education (ipe) provides opportunities for students from two or more health profession disciplines to learn with, from and about each other, to foster collaborative practice in the future, when health professionals are expected to work in healthcare teams. while there are many documented examples of ipe among student health professionals in the literature, dental therapy student participation in ipe has been excluded. objectives. to explore the opportunities for dental therapy students to participate in collaborative interprofessional, community-based initiatives by engaging with academics in the school of health sciences at the university of kwazulu-natal. methods. this qualitative study used audiotaped interviews and focus-group discussions with a purposively selected sample of academics, and the results were thematically analysed. results. the academics noted several opportunities for dental therapy students to participate in interprofessional, community-based education on various platforms, including school, primary healthcare and other community-based settings. barriers that may hamper implementation include finding a common time for ipe in the uniprofessional curricula, matching student numbers and lack of staff support. conclusion. the study findings revealed that opportunities exist for community-based ipe interventions for dental therapy students. however, both the creation and implementation of interprofessional interventions require individual lecturers to act as drivers across all disciplines. afr j health professions educ 2018;10(1):19-25. doi:10.7196/ajhpe.2018.v10i1.974 creating opportunities for interprofessional, community-based education for the undergraduate dental therapy degree in the school of health sciences, university of kwazulu-natal, south africa: academics’ perspectives i moodley, b dent ther, msc (dent); s singh, phd discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: i moodley (moodleyil@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 20 march 2018, vol. 10, no. 1 ajhpe research the discipline of dentistry in the ukzn school of health sciences offers a 3-year degree in dental therapy and a 2-year diploma in oral hygiene, which is currently being replaced with a 3-year oral hygiene degree. the scope of practice for a dental therapist is preventive and curative oral healthcare, by means of various procedures such as dental examinations, diagnosis of common oral diseases, scaling and polishing, placement of direct restorations and tooth extractions. the dental therapist is well suited to meet the oral health needs of the population in both the public and private sectors and in urban and rural communities. in the public sector, the dental therapist can contribute significantly to improved oral healthcare in primary healthcare settings through oral health education and promotion, and managing oral diseases. by collaborating with other health professionals, (s)he can contribute to improved overall health outcomes in communities, through joint oral health and general health education and promotion, referrals, responding to treatment requests, teaching people about precautions and early detection of oral and systemic diseases.[4] this collaboration needs to be fostered while the dental therapy student is in training, emphasising the need for ipe. this study aims to explore opportunities for dental therapy students’ participation in collaborative interprofessional, community-based initiatives within the school of health sciences, ukzn. methods research setting and context the college of health sciences at ukzn has four schools: clinical medicine, laboratory medicine and medical sciences, health sciences, and nursing and public health. the school of health sciences is made up of eight disciplines: audiology; biokinetics, exercise and leisure sciences; dentistry; occupational therapy; optometry; pharmaceutical sciences; physiotherapy; and speech language pathology. clinical training in these disciplines occurs at campus clinics and designated off-campus sites, such as the oral and dental training site in a local hospital. community-based education (cbe) at undergraduate level is a prominent feature across all the disciplines, although levels of participation vary. cbe activities include health awareness programmes, screenings and service delivery under supervision at local primary healthcare centres and hospitals, as well as clinical training at decentralised training sites such as regional and district hospitals. at the decentralised sites, students have an extended stay, providing a continuum of care to patients over a period of 2 6 weeks, depending on the requirements of each discipline. interprofessional community-based activities occur through collaboration between some disciplines, but have thus far excluded the discipline of dentistry. research design this was a qualitative exploratory study in which opportunities for interprofessional community-based initiatives for dental therapy students in the ukzn school of health sciences were investigated by engaging with academics involved with cbe. this study was part of a larger research project conducted on cbe in the school of health sciences. ethical approval was obtained from the humanities and social sciences research ethics committee, ukzn (ref. no. hss/1060/015d). participants the researcher used a purposive sampling method to select the study sample of academics, who were selected for their expert opinions. they included the college dean of teaching and learning, the school’s academic leader: teaching and learning, an academic from family medicine/rural medicine who is involved in the community-based training of medical students and an academic from the discipline of dentistry who is the head of the professional board for dental therapists and oral hygienists in the health professions council of sa. an email invitation was sent to each person to request their participation in the study, by interview. in addition, emails were sent to the academic leaders of each of the eight health sciences programmes, requesting that they nominate one academic currently involved with cbe to participate in a focus-group discussion. individual emails were sent to the nominated academics requesting their participation. thus a total of twelve respondents (a1 a12) agreed to participate in the study (table 1). all provided written informed consent. data collection the data were collected using both face-to-face individual interviews lasting ~30 minutes, and focus-group discussions. the researcher conducted interviews with the dean and academic leader to gain a deeper understanding of how interprofessional cbe could be implemented within the school, using a set of mainly open-ended questions to elicit qualitative information. the questions related to the policies and procedures for implementing interprofessional cbe, associated support and mechanisms and funding for interprofessional projects. an interview was held with an academic from the department of family medicine to learn how cbe was conducted in other schools within the college of health sciences. the researcher conducted the final interview with the academic who heads the professional board for dental therapy and oral hygiene on the hpcsa to gain insight into the hpcsa guidelines regarding interprofessional training for dental therapy. these four interviews were scheduled at the interviewees’ convenience. in addition, the researcher facilitated two focus-group discussions with the academics representing each of the eight disciplines, with four participants in each group, as all academics could not avail themselves at once. the researcher developed a set of questions on participants’ views regarding interprofessional cbe to guide the focus-group discussions. sample questions included: ‘what are some of the interdisciplinary collaborative activities that you are aware of that are being conducted within the school of health sciences?’ ‘what are the opportunities for dental therapy students working collaboratively with other student health professionals to enhance student training within the school?’ and ‘what are the possible barriers perceived to this collaboration?’ the interviews and focus-group discussions were audiotaped, and a research assistant transcribed them verbatim and then edited the language. table 1. study population participant role in academia research method a1 dean of teaching and learning in college interview a2 academic leader: teaching and learning in school interview a3 academic from family medicine interview a4 hpcsa representative interview a5-a12 focus-group participants from school of health sciences two focus groups hpcsa = health professions council of south africa. march 2018, vol. 10, no. 1 ajhpe 21 research the researcher engaged the services of a research consultant to assist with the data analysis process. data coding was done by both the researcher and the research consultant to identify particular features of the data, which were then sorted, allowing themes and subthemes to emerge from the respondents’ statements, in accordance with braun and clarke’s guide to thematic analysis.[9] credibility is a form of internal validity in qualitative research that establishes whether the research findings are genuine and are indeed a true reflection of the participants’ original views.[10] in this study, credibility was established through the use of varied research methods, namely interviews and focus-group discussions, to collect the data. three of the interviewees (a1, a2 and a3) were asked the same questions, while a4 was asked about the hpcsa guidelines, and a5 a12 were asked questions about opportunities for and possible barriers to ipe implementation. credibility was further established through peer debriefing, which was undertaken by another member of the research team, who reviewed the data collection methods and processes, transcripts and data analysis procedures, and provided guidance to enhance the quality of the research findings.[10] transferability relates to external validity in qualitative research, which determines the degree to which the research findings can be transferred to other contexts and other respondents.[10] this was facilitated through the use of purposive sampling and by providing a thick description of the context of the enquiry.[10] transferability was further enhanced by comparing the research findings with the current literature. dependability is used to determine whether the same research findings would be achieved consistently if the same participants had been used in the same context.[10] this was achieved through the use of member checks, where the analysed data were sent to a few participants to evaluate the interpretations made by the researcher. dependability was further enhanced by both the researcher and the research consultant, as a co-coder, analysing the same data and comparing their results. establishing confirmability means checking that the findings are derived solely from data from participants, and not just made up by the researcher.[10] this was established through using direct quotations of the interviewees’ actual dialogue. participant confidentiality and anonymity were maintained through the use of codenames to protect the identity of each participant (a1 a12). results based on the responses of the interviewees, and the focus group discussions, four main themes emerged from the data analysis process: implementing ipe; the benefits of ipe; opportunities for dental therapy students’ participation; and barriers to implementation. theme 1: implementing ipe under this theme, three issues arose: the need for ipe; how ipe should be implemented; and when ipe should be implemented. the need for ipe implementation the focus group participants reported that they only knew of one interprofessional collaboration within the school, which involved occupational therapy, audiology, speech language pathology, physiotherapy and biokinetics. this project was initiated through a collaboration of academics from the respective disciplines. given this context, all respondents agreed that there was a definite need for interdisciplinary education in the school (table 2). how ipe implementation should occur some of the respondents’ ideas on how ipe should be implemented are given in table 3. when ipe should be implemented the academics believed that ipe should have a strategic entry point, as illustrated by the quote: ‘i think level one; if you do it as early as possible, then students get to know and to learn.’ (a2) theme 2: benefits of ipe respondents from the focus group recognised the value of different disciplines working together. the academics stated that ipe not only exposes students to the knowledge and skills of their own profession, but also those of others, and that by understanding the scope of practice of other professionals, they could learn to refer patients appropriately in the future (table 4). theme 3: opportunities for dental therapy student participation in ipe the respondents indicated that there were many opportunities for dental student participation in cbe projects, including integrating oral health into general health-promotion strategies in schools and at primary healthcare centres (table 5). theme 4: barriers to collaboration in implementing ipe academics noted a number of barriers to implementing ipe (table 6). discussion this section discusses the findings for each of the four themes: implementing ipe, benefits of collaboration, opportunities for dental therapy students’ participation and barriers to implementing ipe. table 2. the need for ipe implementation in the school of health sciences subtheme participant’s response inclusive planning for service-based learning ‘i think that there is a need for a definite school strategy to come to the fore.’ (a2) student training aligned to graduate competency ‘if we want to work in inter-, multior transdisciplinary teams later, we need to train in that, you need to have experiences as part of your training as how you work so you get the skills.’ (a3) learning as contextualised in real-world settings ‘there is a demand out there and sometimes you are left alone to manage an array of conditions of patients and sometimes there [are] no occupational therapists, for instance. i feel we need to do enough to be able to do the basics or refer at the right point in time.’ (a11) ipe = interprofessional education. 22 march 2018, vol. 10, no. 1 ajhpe research table 3. how ipe implementation should occur idea response integration into existing timetables ‘i think in health sciences it is very easy to integrate it because we already do clinical placements in all of our programmes. it is not like we have to go and reinvent, getting placements fitting it into the timetable, the structure is there, we basically have it.’ (a1) mobile services ‘the ideal would be to have a mobile clinic or a clinic unit where students are actually able to rotate with the patient. the patient walks in, is assessed in an assessment room by a number of practitioners at the same time, so you will have for example your speech and hearing person, eye specialists, your dental person all assessing the patient in the presence of each other and thereafter referring the patient to the specialist discipline that the patient requires.’ (a4) interdisciplinary service delivery on campus ‘having an interdisciplinary clinic on campus. we can have a clinic where we all have sessions on a friday from 08h00 to 13h00 where each discipline is represented. a patient can go through a system having being exposed to the different disciplines in one healthcare setting. that becomes our own campus training model and when they go out there they know how to work together.’ (a9) ipe = interprofessional education. table 4. benefits of ipe benefit response peer-assisted learning ‘the students learn so much from each other, about each other and about the professions and that is a model for how they are going to be working out there.’ (a5) ‘sharing of knowledge and skills and also they start to treat the patients as a whole, not in parts.’ (a6) knowledge of referral patterns ‘students are aware of the capabilities of the tasks of the scopes of practice of other types of practitioners so that they are able to refer patients and that actually leads to the holistic treatment of patients.’ (a4) access to healthcare ‘it will contribute immensely to community upliftment – this will improve access to different aspects of healthcare that they were not introduced to previously.’ (a8) acquisition of non-technical skills ‘sharing of resources.’ (a6) ‘problem-solving is much better with the team.’ (a6) ipe = interprofessional education. table 5. opportunities for dental therapy student participation in ipe subtheme response integrating oral health into general health ‘oral health is really very well placed. it actually fits in very well with the primary healthcare, re-engineering primary healthcare and community-based training because especially if it is primary care and preventative and promotion with the school health programme, it actually fits in very well, so it resonates with the national health insurance.’ (a1) joining existing cbe programmes ‘dental therapy can definitely play an important role as i have noticed a lot of children have dental problems, but we see you as a consultant for education events, not on an ongoing basis.’ (a8) student-initiated ipe projects ‘it allows for student networking – the students do the inviting. they are the agents of action. they analysed the need and approached the various disciplines to send their students.’ (a8) participation in school programmes ‘the school-based team, the dental therapy students could easily come in really effectively with the speech and audio students. it is about looking at where we can come together.’ (a5) ‘going to a school, working with younger kids and saying we are looking at screening, we can do vision, oral and eye maintenance together. we can look at what services are needed and then manage it so it does not become too overwhelming for patients. if we had projects like this it would be really good. we could also educate teachers on how to pick up on hearing loss and tooth problems.’ (a6) health education and promotion activities ‘the clinic sites that we go to, we go into the queues, while the moms are there for the immunisation for their babies, go through these are the risk factors, we give them pamphlets. you could do that in their space. it is a captive audience there; basically they do not want to leave the queues to come for the actual testing. we say to students, they make these huge posters and they go and stand in the front, while you are waiting, nobody has to move.’ (a6). being part of a rehabilitation team ‘they also have support groups and they put people together either with different disabilities or stroke groups. so it is beyond the prevention and promotion, it is also towards development, collaboration.’ (a6) ‘rehab and long term, at the moment we are seeing a lot of stroke patients, there’s pooling of food, poor dentition, etc., so there is a role for dental therapy.’ (a8) ipe = interprofessional education. march 2018, vol. 10, no. 1 ajhpe 23 research theme 1: implementing ipe given the context of needing to produce more socially accountable and relevant healthcare workers, the participants indicated their support for disciplines to create interprofessional learning opportunities for students. the experience of working together with other student health professionals while in training will prepare them for more effective collaborative practice in response to health needs when they graduate. such initiatives are expected to be driven by interested academics from various disciplines, with no formal mandates from the school of health sciences to ensure that this takes place as a learning opportunity. the current ipe project was initiated by lecturers who are drivers in their disciplines, being motivated to transform health professionals’ education and ensure that their students are equipped for various work environments. these lecturers serve as bottom-up drivers for change, having identified a need to make their teaching relevant, which should be noted by management structures that give direction in preparing the school’s graduates. drivers may be either top-down or bottom-up.[11] top-down drivers refers to people with the highest rank in an organisational structure directing the change. this includes leaders at universities, such as deans. bottom-up drivers are interested academics from across multiple disciplines engaged in co-operative creating, planning and implementation to bring about transformation.[11] in the literature, treadwell and havenga[12] also note that in the absence of top-down drivers for the implementation of ipe, lecturers interested in transforming health professionals’ education must serve as bottom-up drivers for change. moreover, documented examples exist where students have identified the need to create collaborative interprofessional learning environments for themselves, having recognised that this was lacking in their education.[13] the study showed that academics had a number of ideas of how ipe could be implemented in the school, one being to integrate ipe into the current curriculum and time-tables. however, integrating ipe into an existing curriculum can be challenging with the selection of disciplines to collaborate with being a complex process.[12] purden et al.[14] in treadwell note the complexities of such initiatives, and advocate the collaboration of not more than four disciplines.[12] academics believe that ipe should be implemented early in the academic programme. this is supported by vanderwielden,[13] who recommends exposing students to ipe early in their education and training, as it offers increased opportunities for student interaction and collaboration with other emerging health professionals. its early introduction is recommended as it takes a long time to develop the necessary skills and professional competence and to learn how to work with each other, and reap the benefits of a team approach. theme 2: benefits of collaboration the respondents reported that there were many advantages to ipe, including the fact that it exposes students to the knowledge and skills not only of their own profession, but other professions too. the respondents stated that this fosters mutual respect, trust and appreciation for other health professionals, and reduces stereotyping and assumptions about others’ roles. the benefits of ipe, such as creating learning opportunities for student health professionals to acquire non-technical skills, teamwork, leadership and social accountability, are well documented in the literature.[12-14] another benefit is ensuring continuous, reliable and integrated care for patients.[13] theme 3: opportunities for dental therapy students’ participation according to the academics in the study, there are many ipe opportunities for dental therapy students. those involved in the existing interprofessional project were willing to allow dental therapy students to join their project for health education activities, where they could contribute significantly in terms of oral health education for children in the community, as well as offer preventive measures such as fissure sealants and tooth-brushing programmes. this can be seen as an opportunity to screen children for dental problems, offer advice and refer them to the nearest clinic for the management of serious oral conditions. in situations where ‘students are doing the inviting’, dental therapy students could become proactive and liaise with students from other disciplines involved with the project, and also become ‘agents of action’. this is supported by the literature, which draws attention to student-led ipe programmes among student health professionals in the usa, where they recognised interprofessional training as a valuable, but missing, learning strategy in their education.[13] this fostered networking, which is a key component of interprofessional collaboration and developing relationships table 6. barriers to implementation of ipe theme response silo teaching ‘there is no overall curriculum design that allows you to co-ordinate time when students are able to spend time together. some disciplines have this block system of 2 weeks and others blocks of 5 weeks and other blocks of 6 weeks so the timing of us all going together to do [an] activity, which would need to be continuous over time, does not fit into every curriculum.’ (a3) mismatch in student numbers ‘if we have 400 medical students and we want every single one of them to have a meaningful experience with a physio, ot, speech therapist, the dentist but you have only got 30 dental therapists. how do you match the numbers?’ (a3) non-compliance of staff ‘a lot of people are just happy to sit in their offices and keep doing what they have been doing for the past 15 -2 0 years, because they do not see the value. to them it is just a complication, everything is working. we have been doing it this way and it is working, now why are you coming to change things?’ (a9) lack of academic transformation ‘it is like you want to protect your own territory, you do not realise you can learn from each other and that there is so much growth. we need to transform … it has been a culture of this university that everybody stays in their silos, we need to start working together. (a11) community acceptance ‘suddenly they see this team working but they are used to seeing the doctor on their own. it causes a lot of mistrust.’ (a6) ipe = interprofessional education; ot = occupational therapy. 24 march 2018, vol. 10, no. 1 ajhpe research that could benefit current education and future patient care.[13] the literature shows that because oral diseases and other ncds share common risk factors, integrating oral health promotion strategies and programmes with programmes in the prevention and control of ncds can lead to better health outcomes.[8] this can be implemented using the settings approach. the settings approach the settings approach used in health-promotion initiatives creates opportunities to address relevant health issues in the contexts in which people live, work and play.[15] this approach is widely advocated and yields considerable success, as it organises health-promotion interventions to target specific health problems relevant to specific communities.[15] in this study, the respondents agreed that this approach can be used for collaborative initiatives, and identified two relevant settings – the school and the primary healthcare setting. school setting: the academics in the focus groups suggested that dental therapy students could fit into an interprofessional team that could go to schools where joint oral health and health education programmes, health promotion and screenings could be conducted. such activities conducted in the school setting have been identified as the most creative and cost-effective way to improve general health, oral health and quality of life.[16] reddy and singh[17] noted an increased awareness among learners and educators of the importance of daily tooth brushing and adopting the correct tooth-brushing techniques following oral health education interventions conducted in schools, especially in rural areas. it was further noted that following oral health promotion interventions, learners realised the importance of correct eating habits that could inform their choice of purchases from tuck shops and vendors.[17] primary healthcare setting: the academics cited primary healthcare settings as another opportunity for interprofessional collaboration for combined oral health and general health promotion initiatives. these could take the form of health education talks, as suggested by the academics, while patients are waiting to be treated. dental therapy students working together with other health professional students would foster the integration of oral health into general health more effectively, and improve oral healthcare in communities.[18] treadwell and havenga[12] have noted that setting the scene and creating the situation is crucial in the actual learning that takes place. thus, by using the settings approach, students would be exposed to real world settings in which they learn to contextualise, design and implement promotion inventions within resource and funding constraints, this being different from when they will do so at the ideal training sites of their institution. the team approach for rehabilitation besides collaborating in prevention and promotion activities, opportunities also exist for dental therapy students to participate collaboratively with other health professional students in the rehabilitation of patients with physical disabilities, and stroke patients. a stroke can have major effects on oral and facial soft tissues, and can affect simple oral functions such as chewing, drinking and swallowing.[19] in addition, moving the tongue towards the affected side results in food pooling in that side of the mouth and reduces oral clearance, which increases the risk of dental caries, periodontal diseases and halitosis.[19] moreover, medications used to treat stroke patients can result in xerostomia (dry mouth), which further increases the risk of dental caries.[19] oral healthcare is therefore important for stroke patients, but is often overlooked during the rehabilitation phase. the team that manages a stroke patient usually consists of physiotherapists, occupational therapists and speech language therapists, with dental personnel not included. in order for changes to occur in the healthcare workplace regarding professional collaboration, transformation must occur at the level of training. student health professionals from these disciplines, together with dental therapy students, should be given learning opportunities to work together in the rehabilitation of stroke patients. this could lead to better health outcomes for the patient, as well as encouraging the general inclusion of dental therapists in the rehabilitation team. in a systematic review of strategies used for ipe activities, it was observed that the most common strategy used by universities was holding small group discussions, followed by caseor problem-based learning, clinical teaching or direct interaction with patients, simulations, community-based education projects and e-learning.[20] it is clear from the focus-group discussions that there are diverse interprofessional learning opportunities for dental therapy students. these opportunities include joint oral and general health education and promotion activities, screening programmes, diagnosis and referral of patients and rehabilitating patients with stroke and physical disabilities. these opportunities resonate with the principles of primary healthcare, namely prevention, promotion, curative care and rehabilitation, thus establishing a link between ipe and phc and providing the most appropriate mode for facilitating ipe for dental therapy students. theme 4: barriers to ipe the main barriers to ipe identified in this study were finding a common time for the students from the different disciplines to participate in ipe activities, matching the numbers of students and a lack of staff co-operation. abu-rish et al.,[20] in a systematic review of ipe, also reported similar barriers across 65 studies, such as scheduling a common time for ipe implementation, difficulties in matching numbers of students with similar backgrounds, skills and levels of clinical knowledge, funding, and staff and leadership buy-in. to overcome some of the barriers experienced at ukzn, the academics made the following recommendations: ‘we can start by aligning the sites, opening up communication and start talking to each other.’ (a11) ‘there is huge opportunity to sit and develop either a common module or say these are going to be the common times for all of us even if you keep your own separate modules.’ (a5) ‘you need a phased-in approach to implement such a programme. just getting the buy-in from everybody that will be involved at every stage in the academic progress.’ (a11) ‘we should bring innovation and change and ourselves be trained in the very same field. we do not know it at all so we should be open to get more knowledge about what is happening elsewhere.’ (a10) getting the co-operation of staff is challenging; however, treadwell and havenga[12] recommend that staff engage in collaborative discussions to develop a shared understanding of the purpose and goals of ipe, to bring about changes in thinking and acceptance. the way forward the study findings indicate that dental therapy students are well suited march 2018, vol. 10, no. 1 ajhpe 25 research to collaborate with those from the other disciplines. the ipe strategy best suited for their inclusion is engaging in community-based disease prevention and health-promotion interventions, as oral health is related to general health and wellbeing. as a suggestion, it may be a good idea to start a collaboration with one other discipline initially, by integrating oral health promotion into general health-promotion programmes, which can be presented together in primary healthcare settings or school settings. once the basic logistics have been addressed, other disciplines can be incorporated, depending on how the dental therapy student participation integrates with their curricula and clinical placements. most of the disciplines in the ukzn school of health sciences send students to decentralised sites for work experience, which is an untapped opportunity for student health professionals to engage with each other, network, collaborate and conduct contextualised health-promotion interventions with patients throughout the hospital while patients are waiting to be attended to. a programme could be devised whereby the students start off their day by working collaboratively, after which they work in their respective departments attending to their patients. ipe is an effective pedagogical approach that allows health professions students to gain a better understanding of the roles of other professions, as well as collaborative skills.[21] universities have an important role to play in creating such learning opportunities, their implementation requiring motivated drivers of change who can initiate this process of transformation. in this study, it was noted that academics from the various disciplines were the drivers in creating and implementing ipe interventions. academics should embrace this opportunity to meet, collaborate and plan ipe activities for student health professionals. however, successful implementation requires more than just drivers – it requires supportive leadership, committed academics and student compliance. study limitations it is acknowledged that this study was limited to a single university, making the findings and their context limited in their generalisability. more research is therefore required at other universities in sa that train dentistry, dental therapy and oral hygiene students, to obtain a better understanding of how ipe opportunities could be created and incorporated into their programmes. conclusion the study findings revealed that opportunities do exist for interprofessional community-based education for dental therapy students. using the settings approach, the discipline of dentistry undergraduates, in collaboration with other student health professionals, can conduct health-promotion interventions that are contextualised for specific communities, depending on their needs and the available resources, in school, primary healthcare and other community-based settings. using a team approach, they can be included in student healthcare teams that are involved with screening, diagnosis and referral systems, as well as in rehabilitating patients. however, the creation of interprofessional interventions requires individual lecturers from the various disciplines to act as drivers in consultation with each other, with support from programme managers to support curriculum changes and resource allocations. to ensure that the students are equipped to participate in team collaborations once they enter the work environment, the school also needs to support and motivate for such collaborations during training. acknowledgements. none. author contributions. im was responsible for data collection, data analysis and conceptualisation. ss was responsible for refining the methodology and overseeing the write-up. funding. none. conflicts of interest. none. 1. frenk j, lincoln c, zulfiqar a, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010; 376(9756): 1923-1958. https://doi.org/10.1016/s01406736(11)(60492) 2. world health organization. report on a who study group on multiprofessional education of health personnel: the team approach. technical report series 769. geneva: who, 1988. http://apps.who.int/iris/ handle/10665/37411 (accessed 10 september 2014). 3. barr h, koppel i, reeves s, et al. effective interprofessional education: argument, assumption and evidence. oxford: blackwell publishing, 2005. 4. wilder rs, o’donnell ja, barry jm et al. is dentistry at risk? a case for interprofessional education. j dental educ 2008;72(11):1231-1237. 5. petersen pe. the world oral health report 2003: continuous improvement of oral health in the 21st century – the approach of the who global oral health programme. geneva: world health organization, 2003. 6. sheiham a, watt r. the common risk factor approach: a rational basis for promoting oral health. community dent oral epidemiol 2000;28(6):399-406. https:/doi.org/10.1034/j.1600-05 28,2000.028006399.x 7. global action plan for the prevention and control of non-communicable diseases. 2013-2020. geneva: world health organization, 2013. www.who.int/iris/bitstream/10665/943384/1/9789241506236 (accessed 4 september 2014). 8. department of health, south africa. annual health report 2013/2014. pretoria: ndoh, 2014. 9. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 10. anney, vn. ensuring the quality of the findings of qualitative research: looking at trustworthiness criteria. journal of emerging trends in educational research and policy studies 2014;5(2):272-281. 11. vanderwielen lm, do ek, diallo hi et al. interprofessional collaboration led by health professional students: a case study of the inter health professional alliance of virginia commonwealth university. j res interprof pract educ 2014;3(3):1-13. https://doi.org/10.22230/jripe.2014v3n3a132 12. treadwell i, havenga hs. ten key elements for implementing interprofessional learning in clinical simulations. afr j health professions educ 2013;5(2):80-83. https://doi.org/10.7196/ajhpe.233 13. vanderwielen l, enurah a, osburn i. the development of student-led interprofessional education and collaboration. j interprof care 2013;(0):1-2. https://doi.org/10.3109/13561820.2013.790882 14. purden m, fletscher d, ezer h, et al. the mcgill educational initiative on interprofessional collaboration: partnerships for patient and family-centred practice.http://wwwinterprofessionalcare.mcgill.ca/projectoverview. htm (accessed 21 march 2018). 15. poland b, krupa g, mccall d. settings for health promotion: an analytic framework to guide interventions design and implementation. health promotion pract 2009;10(4):505-516. https://doi.org/10.1177/1524839909341025 16. petersen p. challenges to improvement of oral health in the 21st century – the approach of the who global oral health programme. internat dental j 2004;54(s6):s329-s343. https://doi.org/10.1111/j.1875-595x.2004. tb00009.x 17. reddy m, singh s. the promotion of oral health in health-promoting schools in kwazulu-natal, south africa. s afr j child health 2017;11(1):16-20. https://doi.org/10.7196/sajch.2017.v11i1.1132 18. rhoda a, lattoe n, smithdorf g, et al. facilitating community-based interprofessional education and collaborative practice in a health science faculty: student perceptions and experiences. afr j health professions educ 2016;8(s2):s225-s228. 19. fatahzadeh m, glick m. stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management. oral surg oral med oral pathol oral radiol 2006;102(2):180-191. https:// doi.org/10.1016/j.tripleo.2005.07.031 20. abu-rish e, kim s, choe l, et al. current trends in interprofessional education of health sciences students: a literature review. j interprof care 2012;26(6):444-451. https://doi.org/10.3109/13561820.2012.715604 21. hammick m, freeth d, koppel i, et al. a best evidence systematic review of interprofessional education: beme guide no. 9. med teach 2007;29(8):735-751. https://doi.org/10.1080/01421590701682576 accepted 15 august 2017. https://doi.org/10.1016/s0140-6736(11)(60492) https://doi.org/10.1016/s0140-6736(11)(60492) http://apps.who.int/iris/handle/10665/37411 http://apps.who.int/iris/handle/10665/37411 https:/doi.org/10.1034/j.1600-05 28,2000.028006399.x https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa http://wwwinterprofessionalcare.mcgill.ca/projectoverview.htm http://wwwinterprofessionalcare.mcgill.ca/projectoverview.htm https://doi.org/10.1111/j.1875-595x.2004.tb00009.x https://doi.org/10.1111/j.1875-595x.2004.tb00009.x https://doi.org/10.1016/j.tripleo.2005.07.031 https://doi.org/10.1016/j.tripleo.2005.07.031 50 march 2018, vol. 10, no. 1 ajhpe research the learning environment (le) refers to a ‘set of factors’ that describes the experiences of the trainee within an organisation.[1] these factors can be divided into three components. the first is the ‘physical environment’ (facilities, comfort, safety and food), which are the organisational aspects. work load and work hours would also relate to this aspect.[2] the second component is the ‘intellectual environment’, which includes support provided for scholarly activities during training, learning with patients and using evidence-based knowledge and skills.[2] the third component is the ‘emotional environment’, referring to the social support provided, the levels of harassment experienced by the trainee and the trainee’s characteristics that may facilitate or hinder access to support, including that offered by a supervisor.[2] the effect of the le appears to be mediated by the trainees’ own perceptions thereof, and this has been shown to be an important determinant of attitude, satisfaction and achievements.[3,4] an optimally functioning clinical le, where medical interns perceive it as such, is important for successful training in any platform to develop competent physicians.[5] emphasis has previously been placed on evaluating the organisational aspects of these training platforms.[6,7] the environment in which south african (sa) medical interns train has been associated with excessive workloads, long hours, high stress levels, burnout and reports of suboptimal supervision.[8-10] while these organisational aspects form a significant segment of the factors affecting perceptions of the le, the influence of individual demographic factors also needs to be explored and understood.[11] the legacy of apartheid policies and persistent social inequity in sa has continued to manifest in society, including in education.[12] the characteristics linked to social inequity, such as gender, ethnicity and socioeconomic status, have persisted, and remain useful as criteria to measure previous disadvantage. urban/rural status still reflects racial and socioeconomic divisions, and plays an important role in access to and success in higher education.[12] previous educational experiences are considered important contextual factors in learning and in the sa context; huge disparities exist between the education offered by fee-paying compared with non-fee-paying schools.[13] in the higher-education climate, including health professions education in sa, calls are being made to challenge and dismantle the colonial curricula mindsets that perpetuate the ideological framework that allows one culture to dominate others.[14] while these calls for ‘decolonisation’ include aspirations for the ‘creation of a humanising culture of practice that is not at odds with lived practice’, education processes are still noted to have a ‘mandated ignorance’, with les seemingly blind to issues of race and difference.[15] background. the focus is usually on organisational issues when reporting factors influencing the perceptions of south african (sa) medical interns regarding their learning environment (le). individual demographic factors are now being recognised as equally important in influencing these perceptions. objective. to determine whether individual demographic factors influence interns’ perceptions of the le during their paediatrics rotation in hospitals burdened with high disease in sa. methods. perceptions of the le among interns in kwazulu-natal, sa, were assessed in december 2015, using a validated version of the postgraduate hospital educational environmental measure (pheem). overall and subscale pheem scores were calculated using likert scales. the association of these scores with various sociocultural factors relevant to the sa context, previous educational exposure and year of internship were examined using anova or student t-tests. results. a total of 209 interns (59.3%) was sampled. the ethnic breakdown of sampled interns reflected the changing demographic profile of sa junior doctors. statistically significant associations of overall and teaching subscale pheem scores were found with ethnicity (p=0.024), urban/rural status (p=0.023), year of internship (p=0.0047) and university origin (p=0.015). these factors corroborated characteristics that reflect both past disadvantage in the sa context, and those of being an ‘outsider’ in an established group. conclusions. intern training programmes in sa need to recognise that individual demographic factors influence interns’ perceptions in the context of teaching and mentoring in a discipline. with rapid changes in the demographic profiles of junior doctors, sa intern trainers need to enable a ‘sense of belonging’ in les. afr j health professions educ 2018;10(1):50-55. doi:10.7196/ajhpe.2018.v10i1.953 ‘sense of belonging’: the influence of individual factors in the learning environment of south african interns k l naidoo,1,2 mb chb, dch, fcpaed; j van wyk,3 bsc ed, bed, med, phd; m adhikari,2 mb chb, fcpaed, phd 1 king edward viii hospital, kwazulu-natal department of health, durban, south africa 2 department of paediatrics and child health, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 department of clinical and professional practice, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: k naidoo (naidook9@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 51 research demographic factors are being recognised as important indicators of inequity that can be used for its redress, and most sa medical schools have amended their undergraduate selection criteria towards transformation norms.[13] this has seen a rapid change in the demographic composition of the intern population in sa. as a result of these changes, interns of differing socioeconomic and educational backgrounds are allocated to work and learn together in regional hospitals throughout the country for a 2-year internship. the internship programme includes all major medical specialties, including paediatrics.[16] it is not clear how the changes in the composition of the group of newly qualified doctors have influenced their perceptions of the le, especially in paediatrics. an improved understanding of these changes would facilitate the improvement of training for junior doctors. the postgraduate hospital educational environmental measure (pheem) is a well-recognised instrument used internationally to assess the le in postgraduate medicine.[17-19] a local sa version of the pheem instrument was validated among a cohort of paediatric interns in four hospital complexes in durban and pietermaritzburg, kwazulu-natal (kzn).[18] while organisational and institutional factors were identified as obstacles to creating an ideal le, significant differences were noted in the way interns and their supervisors perceived the le, especially with regard to supervision and mentoring.[18] in this study, we report on the influence of individual demographic factors on perceptions of the le among this cohort. this study was thus conducted to: (i) determine whether individual demographic factors influence interns’ perceptions of their experiences in the le in paediatrics; (ii) compare the perceptions of firstand second-year interns of the le in the paediatric rotation; and (iii) determine the influence of previous educational experiences on paediatric interns’ perceptions of their le. methods research design and ethics approval this was an observational, cross-sectional cohort study. ethical approval for the study was obtained from the university of kzn biomedical research ethics committee (ref. no. be 177/15), and gatekeepers’ permission was granted from the various institutions, as well as the health research and knowledge management subcomponent of the department of health in the province of kzn. the study population consisted of all eligible interns, who were informed of the study and invited to participate. participants were informed of their rights, and could withdraw at any stage. participation in the study was voluntary, and the anonymity and confidentiality of respondents were assured. the surveys were group-administered at preexisting intern meetings, and the primary researcher was blinded to the individual responses as no identifying details were required. the instrument the pheem has been used to assess the le among interns throughout the world.[17] the pheem used in our study had eight minor changes made to the original 40 items to accommodate terminology relevant to the sa and paediatric setting.[18] each item was scored by participants on a fivepoint likert scale, where 1 indicated ‘strongly disagree’ and 5 represented a ‘strongly agree’ response. the original questionnaire used a 0 4 scale, while we followed a more conventional scale of 1 5, as used by some authors in clinical settings.[3] procedure the sample population included all interns who had completed a paediatrics rotation at four hospital complexes (comprising eight hospitals) in both major cities of the kzn province in december 2015. demographic data, including gender, ethnicity, home language, urban/rural status and the highest educational level of a ‘parental figure’ were obtained. three categories of urban/rural status were recognised, namely urban (mainly city and suburban neighbourhoods), semi-urban (reflecting mainly ‘township’ neighbourhoods) and rural (mainly outside of an urban or semi-urban area). these distinctly different area types reflect significant racial and socioeconomic divisions in the sa context.[12] data on prior educational exposure were also solicited, on the type of high school attended (whether fee-paying or non-fee-paying) and university origin (whether the intern graduated from the local university (university of kwazulu-natal) or from another university in a different province or country), and on interns’ finalyear undergraduate paediatric performance. sample size a sample-size calculation was based on the comparison of the pheem scores between the intern group and various demographic variables. using a one-way anova with up to four groups, the sample size of 209 interns was found to be adequate, as a sample of 180 was required to achieve 80% power at a 5% significance level.[20] data analysis the overall pheem scale and subscale scores were calculated for each participant. where there were missing data, means were computed based on data for available items, provided this did not exceed 20% of the items. the overall score was computed as the average of all 40 items. the negatively worded items 7, 8, 11 and 13 were reverse-scored. for the descriptive analysis, categorical variables were summarised by frequency and percentage tabulation. continuous variables were summarised by mean, standard deviation, median and interquartile range. the association between the various demographic variables, year of internship and the factors associated with previous educational experiences, with overall pheem score as well as the three subscale pheem scores, was determined by the t-test or anova (for more than two categories). the strength of the association was measured by cohen’s d. the following scale of interpretation was used: ≥0.8 = large effect; 0.5 0.79 = moderate effect; and 0.2 0.49 = small effect. data analysis was carried out using sas version 9.4 for windows (sas, usa). the 5% significance level was used throughout. results a response rate of 59.3% was achieved, as 209 completed questionnaires were returned from a potential pool of 352 interns. of these, 35.8% of the interns assessed were in their first year and 63.8% in their second year of internship, and 55% were female. the mean age of the whole group was 26.2 years (standard deviation (sd) 2.6; range 20 37 years). a number of factors were examined to investigate the influence of previous disadvantage on perceptions. table 1 presents the sociocultural characteristics of the sampled interns. table 2 shows the composition of sampled interns with regard to variables indicating previous educational experiences. an examination of the influence of various demographic factors on the overall pheem scores indicated a number of significant findings. table 3 depicts the 52 march 2018, vol. 10, no. 1 ajhpe research relationship between all the individual demographic variables, including sociocultural factors, factors indicating previous educational experience and internship year, and the overall pheem score. sociocultural variables there was a significant association between ethnicity and the overall pheem score. interns who had self-identified as black african had lower table 2. previous educational experience of sampled interns (n=209) variable n (%) high school type non-fee-paying government fee-paying government fee-paying private 87 (43.50) 63 (31.50) 50 (25.00) university origin: local (ukzn) v. non-local (all other) local non-local 60 (29.56) 143 (70.44) university origin: sa v. non-sa sa non-sa 162 (81.00) 38 (19.00) undergraduate paediatrics performance <60% pass 60% 70% pass >70% pass 19 (9.45) 112 (55.72) 70 (34.83) ukzn = university of kwazulu-natal. table 1. sociocultural characteristics of sampled interns (n=209) variable n (%) gender male 91 (45.05) female 111 (54.95) ethnicity white 53 (27.89) indian 64 (33.68) black african 60 (31.58) coloured 13 (6.84) home province kzn 112 (66.67) gauteng 27 (16.07) western cape 23 (13.69) eastern cape 6 (3.57) urban/rural status urban 119 (58.91) semi-urban (township) 63 (31.19) rural 20 (9.90) home language* english 105 (62.87) afrikaans 29 (17.37) zulu 25 (14.97) xhosa 8 (4.79) highest achieved educational level of parent/caregiver less than high school completion 15 (7.54) completed high school 17 (8.54) non-university tertiary 33 (16.58) university 134 (67.34) kzn = kwazulu-natal. *other home languages were insignificantly represented, so excluded from the table/analysis. table 3. comparisons of the overall mean pheem scores with all demographic variables sociocultural factors n, mean (sd) p-value* gender male 90, 3.48 (0.48) 0.59 female 109, 3.52 (0.52) ethnicity white 53, 3.57 (0.36) indian 64, 3.55 (0.55) 0.024black african 57, 3.37 (0.55) coloured 13, 3.78 (0.27) home province kzn 11, 3.52 (0.54) gauteng 26, 3.64 (0.26) 0.68western cape 23, 3.50 (0.38) eastern cape 6, 3.46 (0.34) urban/rural status urban 117, 3.59 (0.45) 0.023semi-urban (township) 62, 3.37 (0.60) rural 20, 3.50 (0.44) home language† english 105, 3.55 (0.48) 0.16 afrikaans 29, 3.64 (0.35) zulu 24, 3.40 (0.59) xhosa 8, 3.29 (0.48) highest level of education of parent/caregiver less than high school completion 15, 3.43 (0.81) 0.66 completed high school 17, 3.40 (0.50) non-university tertiary 32, 3.51 (0.50) university 133 3.54 (0.48) internship year first year 72, 3.37 (0.56) 0.0047 second year 126, 3.58 (0.47) high school attended non-fee-paying government 85, 3.49 (0.55) 0.61fee-paying government 62, 3.49 (0.51) fee-paying private 50, 3.57 (0.48) university origin: local (ukzn) v. non-local local (ukzn) 59, 3.64 (0.56) non-local 141, 3.45 (0.49) university origin: sa v. non-sa sa 160, 3.54 (0.50) 0.094 non-sa 37, 3.38 (0.53) undergraduate paediatric pass mark >70% 69, 3.51 (0.45) 0.9960% 70% 110, 3.50 (0.55) <60% 19, 3.50 (0.54) pheem = postgraduate hospital educational environmental measure; ukzn = university of kwazulu-natal. *statistical significance was indicated at p<0.05. †other home languages were insignificantly represented, so excluded from the table/analysis. march 2018, vol. 10, no. 1 ajhpe 53 research mean pheem scores than their white, indian or coloured colleagues. this finding was reiterated when comparing ethnicity with pheem scores on the teaching subscale (p=0.0026) (table 4). the effect size was large when comparing the scores of coloured (d=0.88) and indian (d=0.5) with black african interns. there was a significant association between the mean pheem score and urban/rural status, with those who indicated that they came from a semiurban (mainly referring to a ‘township’ area) environment having a lower overall pheem score than those from urban (city or suburbs) rural areas table 4. comparison of pheem teaching subscale scores with all demographic variables sociocultural factors n mean sd p-value gender male 90 3.56 0.55 0.91 female 110 3.57 0.62 ethnicity white 53 3.62 0.38 0.0026 indian 64 3.68 0.65 black african 58 3.36 0.66 coloured 13 3.89 0.30 home province kzn 110 3.60 0.64 0.81 gauteng 27 3.67 0.29 western cape 23 3.55 0.42 eastern cape 6 3.47 0.51 urban/rural status urban 117 3.65 0.53 0.032*semi-urban (township) 63 3.42 0.68 rural 20 3.52 0.52 home language english 105 3.65 0.57 0.032 afrikaans 29 3.69 0.33 zulu 24 3.38 0.70 xhosa 8 3.22 0.61 highest level of education of parental figure less than high school completion 15 3.35 0.94 0.32 completed high school 17 3.42 0.53 non-university tertiary 33 3.58 0.58 university 133 3.61 0.57 year paediatrics rotation done first year 72 3.41 0.64 0.0083† second year 127 3.64 0.56 high school attended non-fee-paying government 86 3.54 0.66 0.30fee-paying government 62 3.51 0.57 fee-paying private 50 3.68 0.54 university origin: local (ukzn) v. non-local local (ukzn) 59 3.74 0.67 0.0068 non-local 142 3.49 0.56 university origin: sa v. non-sa university qualified* sa 161 3.59 0.59 0.19‡ non-sa 37 3.45 0.60 undergraduate paediatric pass mark >70% 70 3.56 0.55 >0.99 60% 70% 110 3.56 0.63 <60% 19 3.56 0.67 *on role autonomy subscale p=0.013. †on role autonomy subscale p=0.00089. ‡on social subscale p=0.047. 54 march 2018, vol. 10, no. 1 ajhpe research (table 3). there were statistically significant associations between urban/ rural status and the mean pheem score on the teaching subscale (p=0.032) and the pheem score on the role-autonomy subscale (p=0.013) (table 4). table 4 shows the mean pheem teaching subscale scores compared with the major languages spoken by interns, which also showed a significant association (p=0.032). we found no statistically significant relationship with gender, home province or the highest educational level of an intern’s parental figure, when comparing overall pheem scores and all subscale scores with these sociocultural variables. there were no significant associations when we compared the pheem subscale scores on the social-support scales with all sociocultural variables. internship year the mean pheem score for interns in their first year was significantly lower than that of interns in their second year of internship. this significant difference between year 1 and 2 interns was seen when comparing pheem scores on the teaching subscale (p=0.0083) (table 4), as well as on the pheem role-autonomy subscale scores (p=0.0089). prior educational exposure table 4 indicates that interns who had graduated from the local university had significantly higher perceptions of the le than interns who had graduated outside the province. there was a significant association between the mean pheem scores of interns who studied overseas, and sa-trained interns, on the social support subscale score. neither the type of high school attended nor undergraduate performance in paediatrics showed any statistically significant relationship with overall pheem score or with the pheem scores on the teaching, role-autonomy and social support subscales. discussion in this study, individual demographic factors are shown to have a major impact in influencing interns’ perceptions of the le. these characteristics have been largely neglected as factors to consider in influencing internship, while organisational factors such as work-hours and the state of the physical infrastructure of the le have been focused on. the good response rate in our sample was in keeping with surveys using the pheem instrument elsewhere,[17] and the distribution of sampled interns closely represented the allocation of interns across the hospital complexes. the 2015 cohort shows an increasing representation of female and black african newly qualified doctors compared with previous years, and is beginning to reflect the implementation of amended selection criteria at sa medical schools.[13] however, evaluating the demographic characteristics of the sampled interns revealed that the newly qualified doctors are still largely drawn from middle-class backgrounds, with nearly 60% of interns originating from urban areas, 56.5% attending fee-paying schools and over 60% from homes with at least one parental figure having obtained a university qualification. in this study, ethnicity, language and urban/rural status were identified as factors that are significantly associated with lower perceptions of the le in internship. these relationships corroborate the notion that interns from previously disadvantaged communities have poorer perceptions of the le than most of their peers in internship. gender was not identified as a factor influencing perceptions of the le. paediatrics is generally a discipline with a larger female composition, and thus probably reflects a more gendersensitive environnment. various other studies have shown the influence of gender on the overall pheem scores, especially in disciplines with an underrepresentation of female doctors such as general surgery and intensive care.[21,22] this study showed a clear difference in the perceptions of interns who were in their first year as compared with those in the second year of internship. various studies internationally corroborate this finding, with juniors having less positive perceptions of the le than senior trainees.[23] interns who did not graduate from the university supporting the internship training platform, and those who graduated outside sa, also displayed poorer perceptions of the le. these findings are consistent with the findings of studies that reported higher levels of stress among interns at hospitals in sa who graduated from non-local universities.[9] the findings show that while indices of socioeconomic disadvantage, especially ethnicity and urban/rural status, did influence interns’ perceptions of the le, these were not the only factors. the combination of factors that significantly influenced the perceptions of the le relate to characteristics of being ‘new’ or ‘different’ to the established norms or ‘culture’. the factors can furthermore be categorised as individual characteristics that seemingly add to perceptions of marginalisation or ‘alienation’ in interns who experienced their training as ‘being isolated from a group activity in which they should be involved’.[24] this difficulty in developing a ‘sense of belonging’ is of concern, especially as learning within the clinical environment relies heavily on participation within a ‘community of practice’ that is provided by the authentic work environment. learning in internship occurs within the context of ‘legitimate, peripheral participation’ within a social context, and is an increasingly communal and negotiated contract.[25,26] this learning, while understood at an individual level, occurs at group level, and involves the acquisition of knowledge, skills, attributes, values and competencies and ‘participation in social processes’ where learning is inextricably linked to and embedded in its context.[27] the interaction between supervisors and interns occurs within a historic context, and reflects a ‘colonised’ culture where the relationship of dominance creates the concept of the ‘outsider’,[28] and in new incumbents, a notion of being the ‘other’ or not being welcome in an already established setting that does not recognise his/her presence. these unequal power relations and marginalisation may contribute to a failure to ensure that all interns are brought into full participation.[14] the learning climate, in this context, may thus be difficult for interns who experience it from the position of ‘outsiders’ or ‘others’, and they are unlikely to seek or initiate a search for effective mentorship, a situation that further compromises the supervision opportunity. these findings, which are of relevance to all health professionals and to undergraduate universities, indicate the need for efforts to ensure that all interns develop a ‘sense of belonging’ in their training platform. the impact of the findings on policy includes the recognition by intern accreditation bodies of the role of individual intern characteristics as important factors to consider when developing intern training curricula and oversight frameworks. this can translate into processes to mandate the development of welcoming environments that facilitate the integration of interns from the start, so that they commence as a team respecting and appreciating each other’s contexts and diversity. the calls to work as a collective to ‘decolonise’ and humanise training have resonance here.[14] intern programmes and curricula need to change to evaluate intern and supervisor interactions, to ensure that all interns experience optimal supervision and that individual demographic factors are taken into consideration. march 2018, vol. 10, no. 1 ajhpe 55 research as the sa medical community transforms to reflect the true demographics of the country, efforts should be made to ensure the inclusion of and support for ‘engagement’ of junior doctors within hierarchical and ‘established’ communities of practice. individual demographic factors in the le can no longer be regarded as minor factors in the learning process, and more work is needed to understand how they impact on successful orientation and learning, especially in the formative period of internship. limitations the sample only included interns linked to hospitals in one province, and the possibility exists that the findings could reflect a regional bias. however, the large number of interns sampled, the good response rate and the choice of large hospitals with known high disease burdens is thought to be adequately representative of the sa internship programme, and adds confidence that the findings would probably represent those of others, including other health professionals, in the sa setting. the pheem instrument was originally created for postgraduate registrars; however, we believe that the le of interns’ work resembles that of the postgraduate registrar trainees, and pheem is therefore highly relevant. this study did not explore the training received or the previous clinical experience of supervisors, which would influence the mentorship relationship in this setting. this study used quantitative methods to assess the le and to fully understand the le in depth; a qualitative evaluation of interns’ perceptions of the le is also needed. conclusion while organisational factors have been noted to affect the le of interns in sa, our research indicates that individual demographic factors are important. perceptions of the le, as measured by validated and reliable tools like the pheem, are influenced by various demographic and individual factors. first-year interns who have not graduated from the local university and who are from previously disadvantaged socioeconomic groups in sa are more likely to perceive a poorer le than their peers. these factors affecting a ‘sense of belonging’ will become apparent in challenged situations where there is inadequate supervision and mentoring, and within the rapidly transforming demographic environment in sa as it attempts to ‘decolonise’ its practices. efforts must be made to ensure that medical-intern and all healthprofessional training policies and practices recognise that these factors must be considered during teaching, mentoring and supervision. further qualitative studies into these relationships are needed to improve our understanding in clinical settings as we aim to train competent health professionals for effective practice in transformed settings. acknowledgements. the authors would like to express their gratitude to the interns and intern supervisors in the kzn hospitals who participated in this study, dr petra gaylard (dmsa) for assistance with the statistical analyses and mrs leora sewnarain for assistance with typesetting and formatting. author contributions. kln was responsible for study design, data collection, data analysis and drafting the manuscript. jvw was responsible for supervision of the entire work, study design and manuscript review. ma was responsible for supervision of the entire work and manuscript review. funding. mepi funding: this publication was made possible by grant number r24tw008863 from the office of the us global aids co-ordinator and the us department of health and human services, national institutes of health (office of aids research and office of research on women’s health). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the us government. conflicts of interest. none. 1. wall d, clapham m, riquelme a, et al. is pheem a multi-dimensional instrument? an international perspective. med teach 2009;31:e521-e527. https://doi.org10.1186/1472-6920-14-226 2. mohanna k, cottrell e, wall d, chambers r. teaching made easy: a manual for health professionals. 1st ed. boca raton: crc press, 2010. 3. boor k, scheele f, van der vleuten c, et al. psychometric properties of an instrument to measure the clinical learning environment. med educ 2007;41(1):92-99. https://doi.org/10.1111/j.1365-2929.2006.02651.x 4. genn, j. amee medical education guide no. 23 (part 1): curriculum, environment, climate, quality and change in medical ducation a unifying perspective. med teach 2001;23(4):337-344. https://doi. org/10.1080/01421590120063330 5. hoff t, pohl h, bartfield j. creating a learning environment to produce competent residents: the roles of culture and context. acad med 2004;79(6):532-540. https://doi.org/10.1097/00001888-200406000-00007 6. sein n, tumbo j. determinants of effective medical intern training at a training hospital in north west province, south africa. afr j health professions educ 2012;4(1):10-14. 7. hospital reform and staff morale in south africa: a case study of dr yusuf dadoo hospital. s afr fam pract 2013;55(2):180-185. https://doi.org/10.1080/20786204.2013.10874330 8. erasmus n. slaves of the state – medical internship and community service in south africa. s afr med j 2012;102(8):655-658. https://doi.org/10.7196/samj.5987 9. sun gr, saloojee h, jansen van rensburg m, manning d. stress during internship at three johannesburg hospitals. s afr med j 2008;98(1):33-35. 10. bateman c. system burning out our doctors – study. s afr med j 2012;102(7):593-594. 11. tyssen r, vaglum p, grønvold n, ekeberg ø. the relative importance of individual and organisational factors for the prevention of job stress during internship: a nationwide and prospective study. med teach 2005;27(8):726-731. https://doi.org/10.1080/01421590500314561 12. statistics south africa. census 2011 statistical release. pretoria: statssa, 2012. http://www.statssa.gov.za/ publications/p03014/p030142011.pdf (accessed 23 january 2017). 13. van der merwe l, van zyl g, st clair gibson a, et al. south african medical schools: current state of selection criteria and medical students’ demographic profile. s afr med j 2016;106(1):76-81. https://doi.org/10.7196%2fsamj.2016. v106i1.9913 14. pillay m, kathard h. decolonising health professionals’ education: audiology and speech therapy in south africa. afr j rhetoric 2015;7(1):193-227. 15. brydon d, dvořák m. crosstalk: canadian and global imaginaries in dialogue. waterloo: wilfrid laurier university press, 2012. 16. medical and dental professions board, health professions council of south africa. handbook on internship training: guidelines for interns, accredited facilities and health authorities. pretoria: hpcsa, 2016. 17. soemantri d, herrera c, riquelme a. measuring the educational environment in health professions studies: a systematic review. med teach 2010; 32(12):947-952. https://doi.org/10.3109/01421591003686229 18. naidoo kl, van wyk jm, adhikari m. the learning environment of paediatric interns in south africa. bmc med educ 2017;17(1): 235. https://doi.org/10.1186/s12909-017-1080-3 19. roff s, mcaleer s, skinner a. development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the uk. med teach 2005;27(4):326-331. https://doi.org/10.1080/01421590500150874 20. faul f, erdfelder e, lang a, buchner a. g*power 3: a flexible statistical power analysis programme for the social, behavioral, and biomedical sciences. behav res methods 2007;39(2):175-191. https://doi.org/10.3758/bf03193146 21. kanashiro j, mcaleer s, roff s. assessing the educational environment in the operating room – a measure of resident perception at one canadian institution. surgery 2006;139(2):150-158. https://doi.org/10.1016/j.surg.2005.07.005 22. clapham m, wall d, batchelor a. educational environment in intensive care medicine – use of postgraduate hospital educational environment measure (pheem). med teach 2007;29(6):e184-e191. https://doi. org/10.1080/01421590701288580 23. pinnock r, reed p, wright m. the learning environment of paediatric trainees in new zealand. j paediatr child health 2009;45(9):529-534. https://doi.org/10.1111/j.1440-1754.2009.01553.x 24. mann s. alternative perspectives on the student experience: alienation and engagement. stud high educ 2001;26(1):7-19. https://doi.org/10.1080/03075070020030689 25. lave j, wenger e. legitimate peripheral participation in communities of practice. in: cross rl, israelit sb, eds. strategic learning in a knowledge economy. boston: butterworth-heinemann, 2000:167-182. 26. mann k. theoretical perspectives in medical education: past experience and future possibilities. med educ 2010;45(1):60-68. https://doi.org/10.1111/j.1365-2923.2010.03757.x 27. yardley s, teunissen p, dornan t. experiential learning: amee guide no. 63. med teach 2012;34(2):e102-e115. https://doi.org/10.3109/0142159x.2012.650741 28. spivak gc. a critique of postcolonial reason. harvard: harvard university press, 1999. accepted 16 august 2017. https://doi.org10.1186/1472-6920-14-226 https://doi.org/10.1111/j.1365-2929.2006.02651.x https://doi.org/10.1080/01421590120063330 https://doi.org/10.1080/01421590120063330 https://doi.org/10.1097/00001888-200406000-00007 http://www.statssa.gov.za/publications/p03014/p030142011.pdf http://www.statssa.gov.za/publications/p03014/p030142011.pdf https://doi.org/10.7196%2fsamj.2016.v106i1.9913 https://doi.org/10.7196%2fsamj.2016.v106i1.9913 https://doi.org/10.1186/s12909-017-1080-3 https://doi.org/10.1080/01421590701288580 https://doi.org/10.1080/01421590701288580 https://doi.org/10.1111/j.1440-1754.2009.01553.x https://doi.org/10.1111/j.1365-2923.2010.03757.x https://doi.org/10.3109/0142159x.2012.650741 research globalisation and internationalisation are unquestionably processes that are part of the twenty-first century. their influence has been particularly felt, inter alia, in higher education (he), and the demand for globally competent graduates who are sensitive and responsive to both local and international contexts and cultures has increased. higher-education institutions (heis) are striving to meet these demands to remain current.[1] changes in the management and administration of he, and the presence of a more diverse student population attending he institutions, have necessitated changes in and differentiation within curricula.[2] the impact of the trend towards internationalisation and globalisation has also been felt in africa and south africa (sa).[3] initially, it was only evident in a small way, but its considerable effect is evident in the increasing number of foreign students and academic staff who study and teach at heis in sa. considering the impact of globalisation and internationalisation on he in africa and sa, we cannot ignore the influence of ‘africanisation’ in the he context. knight[4] describes africanisation as encompassing all the dimensions of a process whereby a university endeavours to establish and maintain an african character, to achieve certain academic, economic, political and cultural aims. given such a context, the call for the africanisation of the curriculum in heis in sa has become inescapable. the need for an african approach to the internationalisation of he is illustrated by what kotecha[5] refers to as the responsible approach ‘that aligns the international dimension of the sector to the enhancement of the national, regional and continental development imperatives’. it is therefore important for heis on the african continent, including sa, to find a balance between the processes of internationalisation and africanisation within their own institutions and organisations.[6] to gain a deeper understanding of how internationalisation and africanisation impact he in sa, and in particular in master of public health programmes (mphps) offered at sa heis, it was decided to undertake this study, which aimed to determine which factors enable and constrain the processes of developing, implementing, and evaluating the internationalisation and africanisation of the curricula of mphps within the heis selected for this study. methods ethical clearance (ref. no. 2014march/05951321/mc) as required by the hei through which the research was undertaken was obtained prior to the research being conducted. ethical clearance requires that all data be collected and used in an ethical way. participants’ signed consent to voluntarily participate in the study was obtained after the researcher had fully explained the nature and purpose of the research, and the role that participants would play therein. participants were also informed of their right to withdraw from the study at any time without fear of reprisal. the researchers were obliged to maintain research-participant and institutional anonymity and confidentiality. the study utilised a multiple-case-study design. the heis that were identified to participate in the study were required to offer an mphp and to have a cohort of international students. the research sample was drawn from institutions that met these criteria. of the 23 registered universities in background. higher education worldwide is currently shaped by globalisation and internationalisation, while african and south african (sa) highereducation institutions (heis) are required to africanise their curricula to equip students to become effective and responsive global citizens, with globally and locally relevant knowledge and skills. objectives. to establish the extent to which curricula for master of public health programmes (mphps) within schools of public health or faculties of health sciences in selected heis in sa are currently internationalised and africanised. methods. the study followed a multiple-case-study design. semi-structured and focus-group interviews with course co-ordinators, lecturers and students provided data. the study was conducted at three heis in sa that offer an mphp. tesch’s interactive process of qualitative data coding and analysis was used. results. according to academics, there is no clear understanding or working definition of concepts and processes such as internationalisation and africanisation as they apply to their professional contexts. the institutions do not subscribe to policies regarding internationalisation and africanisation either. academics are uncertain whether curricula meet the requirements of internationalisation and africanisation, while students consider the curricula to be internationalised and africanised to the best of their institutions’ and lecturers’ abilities. conclusion. there is an urgent need for curriculum transformation in sa, to ensure that the internationalisation and africanisation of curricula occur. curriculum transformation and the formalisation of the processes of internationalisation and africanisation through policy changes and capacity building need to be forefronted. afr j health professions educ 2017;9(4):208-211. doi:10.7196/ajhpe.2017.v9i4.839 factors that enable and constrain the internationalisation and africanisation of master of public health programmes in south african higher-education institutions j witthuhn,1 d ed; c s le roux,2 d ed 1 programme leader – public health, faculty of social and health sciences, monash south africa, roodepoort, south africa 2 department of educational foundations, college of education, university of south africa, pretoria, south africa corresponding author: j witthuhn (jacqueline.witthuhn@monash.edu) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 208 december 2017, vol. 9, no. 4 ajhpe research sa, six met these requirements. through convenience sampling based on proximity to the workplace of the researchers, three of these six institutions were selected for study. the research participants consisted of lecturers and course co-ordinators involved in the design and teaching of mphd programmes within faculties of health sciences or schools of public health, and students who were enrolled in these programmes. course co-ordinators were chosen as it was presumed that they would have a sound knowledge and understanding of the design and presentation of the modules within the mphp offered at their institution. they could therefore provide a comprehensive response to research questions about the degree at their institutions, and its internationalisation and africanisation in general. lecturers teaching specific units or modules within the programme that particularly lend themselves to internationalisation or africanisation, and who could provide insight into the processes of internationalisation and africanisation, were purposively selected for participation. in total, 10 lecturers at the three institutions participated in the study, while five course co-ordinators were included. since students are the main beneficiaries of the programmes, students in the mphps were asked to participate in the study and share their perceptions and insights. a total of 36 students volunteered to participate in the study. initially, the sample size of the research participants was provisional, since the researchers decided that if required, the sample size could be extended until data saturation was reached. prior to data collection, an in-depth literature review of the key underlying concepts of globalisation, internationalisation and africanisation, and how they apply in he locally and internationally, was undertaken. the purpose of the literature review was to establish a sound basis and theoretical framework for the study. the literature reveals no consistent definition of the key concepts or how they apply to he. it seems that the definition of globalisation varies according to the context of analysis. the definition generally refers to increasing levels of interaction across national boundaries, which affects many aspects of life: economic, social, cultural and political.[7] according to knight[8] and fourie,[9] internationalisation in the context of he is understood as the process of integrating an international/intercultural dimension into the teaching, research and service functions of the institution. as far as the curriculum is concerned, africanisation implies an attempt to move away from colonial or apartheid systems.[9] it goes far beyond a simple adaptation to include transformation and innovation, in the sense that the curricula should respond to the needs of the people and help them in their fight against underdevelopment, poverty, wars, diseases, unemployment and illiteracy. data from the research participants were collected through semistructured interviews with course co-ordinators and lecturers, and focusgroup interviews with students from each of the participating heis. the interview schedules for each of the three categories of participants were designed to meet a specific research purpose. the interview schedules were pilot tested with relevant individuals from an hei that met the research requirements, but that was not included in the research sample. the primary focus of the interviews with course co-ordinators and lecturers was to establish their current understanding, status, principles, rationales and processes, as well as the enabling and constraining factors associated with the internationalisation and africanisation of the mphps. the primary purpose of the focus-group interviews with the students was to establish their general understanding of the concepts of internationalisation and africanisation, the importance of both an international and africanised curriculum and the current status of their institutions in relation to both concepts. the interviews were recorded, with the signed consent of the research participants. the interviews were transcribed to facilitate data analysis. tesch’s[10] eight-step approach to the coding of qualitative data was used. the process included reading through the data and identifying and clustering topics that emerged from them. the data were then coded, and the coded topics grouped into categories, each with related subcategories or themes. this iterative process is by nature reflexive, and key to gaining insight into the research question and developing meaning. the process culminated in the reporting of the research findings based on the iterative data-analysis process followed. results it emerged from participants’ responses that there are no formal processes that mandate or facilitate the internationalisation and africanisation of master of public health curricula. academics and students struggled to articulate or identify factors that enabled the process of internationalisation or africanisation, since institutionally, these processes are not established or enforced. however, students were of the opinion that as far as they were concerned, the institutions and their lecturers did strive to ensure that the curriculum they studied met what they understood as international and africanised principles and standards. when reflecting on the process that could be said to facilitate the actual promotion of internationalisation and africanisation, respondents were only able to speculate on what they thought were processes that could enable the process of implementing new programmes and initiatives that address and make provision for internationalisation and africanisation. participants’ responses were related to their daily experiences and general assumptions linked to their involvement in teaching or studying the programmes. synthesis of perceptions regarding possible factors that could enable the processes of internationalising and africanising master of public health curricula possible factors which could facilitate internationalisation and africanisation were identified mainly by academics, with students largely alluding to the fact that the student cohort was international in composition, and that this fact consequently necessitated lecturers providing international and african examples and case studies in the learning content, thereby internationalising and africanising the programme. academics noted that the active links and collaboration with and between professional associations, for example, the public health association of sa and the african public health association, have the potential to be supportive of internationalisation and africanisation endeavours. these collaborative efforts promote and encourage the discussion of international and africanbased public-health initiatives, which contributes to the internationalisation and africanisation of curricula. furthermore, academics are able to attend international and local multinational conferences, where typically, papers are presented that provide insight into issues from an international point of view. depending on the nature and thrust of the conference, africanisation processes were also sometimes addressed during conferences. an added advantage of attending such conferences is that networking opportunities arise, and delegates are able to discuss international and african trends and developments that could be transferred to their own contexts. generally, academics acknowledged that they have access to african educational resources relevant to mphps, which would support africanisation processes. furthermore, existing international public-health frameworks, standards and tools are recognised and utilised by the december 2017, vol. 9, no. 4 ajhpe 209 research heis that participated in the study, and these have paved the way for internationalisation. the presence of international students and academic personnel from other parts of africa could potentially further advance and support attempts to internationalise and africanise the curricula – an observation that was also commented on by students. respondents also identified factors that, although not currently in place, they believed would contribute to the internationalisation and africanisation of the curricula, and facilitate the necessary processes. respondents argued that it is essential that institutional vision and mission statements calling for an international or african approach to doing business should be instituted in their heis. furthermore, institutional leadership that is committed to an international and african vision, which could contribute to establishing policy, research and training initiatives for the internationalisation and africanisation of the curricula of the programmes on offer at the institution, is seen as an imperative. respondents also suggested that funds be allocated to review current programmes (including the mphps) to determine their current level and status of africanisation and internationalisation. in relation to the mphps, determining students’ efficacy and ability to apply their public-health knowledge in local and international contexts was imperative, as this would serve to indicate whether africanisation and internationalisation were indeed in place. the need for the facilitation of seamless access to the internet and social-media platforms that would allow academics and students to readily obtain local and international information relevant to the programmes was also forefronted by respondents. since formal processes are not in place to promote and implement the internationalisation and africanisation of the curriculum in heis, these factors can only be viewed as potentially enabling, as anticipated by the respondents. however, the researchers are of the opinion that the respondents have adequate working experience to equip them to successfully identify potentially enabling (as well as constraining) factors. following the identification of enabling factors, it was important to establish factors which respondents anticipated would either inhibit or aid the development and provision of an internationalised and africanised curriculum. synthesis of perceptions regarding possible factors constraining the processes of internationalising and africanising mph curricula factors that possibly constrain the processes of internationalising and africanising the mph curricula offered at the heis in question are elaborated on according to respondents’ points of view. inhibiting factors would be those that prevent heis from developing and providing internationalised and africanised curricula. again, owing to the lack of formal processes for the internationalisation or africanisation of curricula, responses related to respondents’ daily experiences and their personal views on what could inhibit these processes. the most obvious inhibiting factor was considered to be the lack of institutional vision and policy regarding internationalisation or africanisation, and the consequent fact that academics themselves lack clarity on the meaning of and rationale for the internationalisation or africanisation of curricula.[11] this lack of policy indicates that both these processes are seen as having low priority. funding is consequently not made available, and neither is time or expertise devoted to the process. collaboration with international bodies with the express purpose of promoting internationalisation and africanisation is non-existent. despite the abovementioned factors, respondents identified a variety of constraining factors that could potentially inhibit the internationalisation and africanisation of programmes in general and mph curricula in particular. according to respondents, there is a shortage of adequately trained and experienced personnel, especially international staff, to successfully develop and implement new initiatives that incorporate internationalisation and africanisation principles. in addition to this, there is also a shortage of the appropriation of funding to equip personnel with the required experience and skills through training and exposure in relation to internationalisation and africanisation. an established means of enabling and promoting international exposure and expertise is through affording academics the opportunity to attend international conferences. although heis fund deserving academics to attend conferences, conference attendance is dependent on incumbents presenting a paper at that conference and producing research output, to allow their attendance. attendance for the purpose of attendance only is not permitted, but it is argued that academics could fruitfully open up networking opportunities and gain international exposure if they were able to attend relevant events without the requirement to present a paper. networking could therefore be the main purpose for attending such conferences, but current policy does not allow for this. the diversity of the student body, sometimes representing more than 40 countries in the research sample, represents a challenge when it comes to ensuring that the content concerning public health is relevant for various contexts and cultures. academics are ill-equipped to develop and implement appropriate learning opportunities that meet this need. apart from the lack of expertise to effect appropriate learning, the various public-health modules are generally co-ordinated by different lecturers, leading to inconsistency in the general objective of the modules in the programme, the teaching approach and the content. it is also believed that the current content lacks evidence-based, relevant and contextually germane public-health readings and case studies essential for providing content for an internationalised and africanised context. it should also be taken into account that the scope of public-health issues faced in different parts of the world, including africa, is vast, and appropriate readings on how to address these issues effectively need to be included in the curriculum. intercultural communication in the context of public-health issues and designing public-health interventions in different cultural contexts is another aspect that needs to be factored into any curriculum that is appropriately internationalised and africanised. historical inequities related to education were also cited as a constraining factor. to support affected learners, academics are required to devote additional time to assisting learners in bridging this gap. this significantly impacts lecturers’ workload. excessive workload and additional work pressure negatively impact on academics’ ability to devote time to additional activities such as the internationalisation and africanisation of the curriculum. a further aspect that also needs to be considered when contemplating factors that inhibit the internationalisation and africanisation of mphps is that overseas donors seem to lack trust in african institutions, and this limits the possibilities of heis in africa taking a lead in public-health research, publications and projects. conclusion since there are no formalised policies in place at the heis that participated in the study to ensure the internationalisation and africanisation of 210 december 2017, vol. 9, no. 4 ajhpe research curricula in general, and mphps in particular, there are no review processes in place to determine the extent to which existing curricula are indeed internationalised or africanised. respondents had difficulties identifying prevailing factors that either enable or constrain the internationalisation or africanisation of curricula, and were only able to suggest factors that they, through their experience in the field, anticipated could enable or inhibit the processes in question. collaboration with professional bodies, access to a wide range of international and african resources and exposure to international researchers and experts were suggested as factors that would promote the internationalisation and africanisation of curricula. however, it was pointed out that owing to the lack of formal internationalisation or africanisation policies, there is no drive to recruit international or african experts as faculty staff, nor is there emphasis on promoting international or african collaboration. there is also no concerted effort to support current staff in gaining the necessary expertise to internationalise or africanise their programmes, nor is funding for this purpose made available. regarding factors enabling the internationalisation and africanisation of the mphp curricula, it is recommended that the supporting factors that are currently evident should be endorsed, extended and utilised more effectively by heis to actively promote the internationalisation and africanisation of the curricula in the various schools of public health, and within professional bodies associated with public health. these factors include, for example, certifying committed leadership and ongoing strategic collaboration, and promoting access to resources and expertise that advance internationalisation and africanisation. regarding the factors that constrain the processes of internationalisation and africanisation, it is recommended that these factors should be identified and addressed by the relevant heis, to ensure that the processes are not inhibited. dedicated research on the subject needs to be undertaken as a priority in these heis. some of the constraining factors evidenced by the research that need to be addressed include instituting clear policies for internationalisation and africanisation processes, dedicating funding to monitor and review the status of the internationalisation and the africanisation of programmes within the various heis, ensuring consistency and continuity in relation to programme delivery, appointing and retaining appropriate staff and providing relevant in-service training to enhance expertise among current staff. accelerated global changes in social, economic, and environmental conditions require he graduates to be adept at intercultural relationships as well as being internationally competent in the workplace. twenty-first century heis should acknowledge the importance of adapting to both the international and intercultural dimensions of the local, national and global contexts in their curricula. within the context of this research, there is thus an urgent need for curriculum transformation in sa, and in the curricula of mphps. curriculum transformation and the formalisation of the processes of internationalisation and africanisation through policy changes, information transfer and capacity building need to be forefronted. acknowledgements. none. author contributions. equal contributions. funding. none. conflicts of interest. none. 1. connor g. internationalisation of general education curriculum: missouri community colleges: a faculty perspective. phd thesis. st. louis: university of missouri, 2001. 2. altbach pg, reisberg l, rumble l. trends in global higher education: tracking an academic revolution. a report prepared for the united nations educational, scientific and cultural organization 2009 world conference on higher education. paris: unesco, 2009. 3. botha m. africanising the curriculum: an exploratory study. s afr j high educ 2007;21(2):202-216. https://doi. org/10.4314/sajhe.v21i2.25630 4. knight j. internationalisation elements and checkpoints. canadian bureau for international education. research monograph no. 7. ottawa: canadian bureau for international education, 1994. 5. kotecha p. determining a sectoral approach to internationalisation. izwi: voice he leadership 2004;3rd quarter(3):11. https://doi.org/10.18820/9781920338183/08 6. botha mm. compatibility between internationalising and africanising higher education in south africa. j stud int educ 2010;14(2):200-213. https://doi.org/10.1136/bmj.320.7240.1017 7. united nations poverty and development division. economic and social survey of asia and the pacific. new york: un, 1999. http://www.unescap.org/drpad/publication/survey1999/svy4a.htm (accessed 19 september 2013). 8. knight j. higher education in turmoil: the changing world of internationalisation. rotterdam: sense publishers, 2008. 9. fourie pj. the last word: the ‘africanisation’ of communication studies. where do we stand with the ‘africanisation’ of communication studies? communicare 2005:24(1):171-176. 10. tesch r. qualitative research. new york: falmer press, 1990. 11. leask b. questionnaire on internationalisation of the curriculum: a stimulus for reflection and discussion. university of south australia: australian learning and teaching council national teaching fellowship: internationalisation of the curriculum in action, 2012. http://www.ioc.net.au/main/course/view.php?id=2 (accessed 1 february 2014). accepted 27 march 2017. december 2017, vol. 9, no. 4 ajhpe 211 https://doi.org/10.4314/sajhe.v21i2.25630 https://doi.org/10.4314/sajhe.v21i2.25630 https://doi.org/10.18820/9781920338183/08 https://doi.org/10.1136/bmj.320.7240.1017 http://www.unescap.org/drpad/publication/survey1999/svy4a.htm http://www.ioc.net.au/main/course/view.php?id=2 research september 2017, vol. 9, no. 3 ajhpe 103 an educational environment (ee) is made up of three major compo­ nents: the physical environment, the emotional climate and the intellectual climate.[1] the ee of professional health training is mainly determined by the interactions between different stakeholder groups and the organisational structures of the environment.[2] ideally, the ee should foster intellectual activities and academic progression, while simultaneously encouraging friendliness, co­operation and support. it is important to get students’ feedback on how they experience their ee.[3] different studies aiming to assess medical or health sciences students’ perceptions of their learning environment have been conducted in many developed and developing countries, such as the uk, saudi arabia, canada, india and malaysia.[4] there is only one programme of physiotherapy education in rwanda. this programme is hosted by the university of rwanda (ur), and began in december 1996 with the vision of becoming a centre of excellence in training physiotherapy professionals in rwanda and the whole east african region. despite anecdotal feedback through informal conversations between the students and their lecturers, however, the ee as perceived by the ur physiotherapy students has never been formally assessed. this study aimed to explore how physiotherapy students at ur feel about their ee, to identify domains of strength and weakness, and to suggest ways to improve the students’ experience. methods study design a descriptive cross­sectional study design was used. materials and subjects the dundee ready education environment measure (dreem) was developed by roff et al.[5] as a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. it was administered to collect this data and information on characteristics, including age, gender and year of study. the dreem instrument consists of 50 statements, and gives a universal score of a maximum of 200. it is capable of mea suring five separate elements directly relevant to the educational environment: students’ perception of learning (spol), students’ perception of teachers (spot), students’ academic self­perceptions (sasp), students’ perception of atmosphere (spoa) and students’ social self­perceptions (sssp).[5] the dreem questionnaire has been successfully tested for its internal validity and reliability.[6] the study population consisted of all 82 registered physiotherapy students at the college of medicine and health sciences (cmhs) for the academic year 2014 ­ 2015. a census sampling strategy was used, but four students who assisted in data collection were excluded, and one student was not available during the data­collection period. therefore, the study sample consisted of 77 participants. background. getting students’ feedback regarding their experience of their educational environment (ee) is important. objectives. to explore how physiotherapy students at the university of rwanda (ur) feel about their ee. methods. a descriptive quantitative cross­sectional study design with a census sampling strategy involving all physiotherapy students at ur was used. the dundee ready edu cational environment measure was administered to 77 physiotherapy students in march 2015, to collect data that were analysed using the statistical package for the social sciences version 20 (ibm corp., usa). the frequency distribution, mean, standard deviation and percentages were calculated, and the χ2 test was performed to assess whether responses showed significant vari ance according to level of study and gender. the level of significance (p­value) was set at 0.05. results. the overall mean score on the 50 items was 62.20%. students’ perception of learning scored the highest, with 66.58%, followed by students’ perception of atmosphere with 65.08%, students’ perception of teachers with 61.11% and students’ academic self­perception with 57.78%. the domain of students’ social self­perception scored the least, with 56.50%. all the domains scored positively toward the ee. there was no significant difference between male and female students, or between first­, second­, third­ and fourth­year students regarding their perceptions of the ee. conclusion. the physiotherapy students perceived ur as providing a sound ee. however, the data showed that there is a need for improvement in all five subscales of the learning environment at ur. similar studies from other academic programmes at ur and other academic institutions in rwanda are encouraged. afr j health professions educ 2017;9(3):103­106. doi:10.7196/ajhpe.2017.v9i3.828 assessment of the educational environment of physiotherapy students at the university of rwanda using the dundee ready educational environment measure (dreem) g urimubenshi, mscpt; j songa, bscpt; f kandekwe, bscpt department of physiotherapy, college of medicine and health sciences, university of rwanda, kigali, rwanda corresponding author: g urimubenshi (ugerardus@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 104 september 2017, vol. 9, no. 3 ajhpe data collection procedure the dreem questionnaire was administered to physiotherapy students at ur in march 2015, and scored according to standard guide lines.[7] the dreem questionnaire consists of five­point likert­scale responses to statements, as follows: strongly agree (4), agree (3), neutral (2), disagree (1) and strongly disagree (0). the score is reversed for negatively oriented statements. items with a mean score greater than 3 represent strong areas; items with a mean score of less than 2 indicate problematic areas; and items with mean scores between 2 and 3 indicate areas that could be improved. data analysis the statistical package for the social sciences (ibm corp., usa) version 20 was used to analyse the data. the frequency distribution, mean and standard deviation (sd) were calculated, and the χ2 test was performed to assess whether responses showed significant vari ance according to level of study and gender (p=0.05). the mean score of each domain and the overall mean were calculated, and interpreted using the methods of roff[7] as follows: 0 ­ 50 (0 ­ 25%) = very poor environment; 51 ­ 100 (26 ­ 50%) = multiple problems in the environment; 101 ­ 150 (51 ­ 75%) = more positive than negative environment; and 151 ­ 200 (76 ­ 100%) = excellent environment. ethics approval ethical clearance and permission to conduct the study were respectively granted by the cmhs institutional review board (ref. no. cmhs/ irb/010/2015) and the principal of cmhs (ref. no. 641/ur­cmhs/15). the students were formally briefed about the study and the questionnaire in their class rooms, and were informed that participation was voluntary and that they had the right to withdraw from the study at any time. in addition to this, the questionnaire was anonymous. all the students who were contacted consented to take part in the study, and they were requested to provide their demographic details and to respond to each of the 50 statements. results characteristics of participants questionnaires were administered to 77 physiotherapy students, and all returned the questionnaires completed, corresponding to a response rate of 100%. table 1 reflects the distribution of the students across the 4 years of training. table 2 describes the overall dreem score and mean score for each domain. the total mean scores across the five domains vary between 56.50% (sssp) and 66.58% (spol). the overall score is 124.4/200 (62.20%) (sd 4.40), meaning that the participants perceive their ee more positively than negatively. the study also aimed to test if the responses varied according to the level of study or the gender of the participants. as shown by tables 3 and 4 below, no association was found (p>0.05). discussion to the best of our knowledge, this is the first study providing information on the perceptions of physiotherapy students at ur of their ee. this study used a standardised questionnaire and a census sampling method. the results reflect the ee as experienced by physiotherapy students at ur, and may help different policy makers and physiotherapy lecturers at ur to generate responses for improvement. with an overall dreem score of 124.4/200 (62.2%), the students rated the ee at ur as ‘more positive than negative’. this study also indicated that the students perceived each of the five ee domains more positively than negatively. it is not appropriate to fully compare this study with others, because of contextual dissimilarities and different sample sizes used. however, while contrasting and interpreting the scores against the guidelines proposed by the developers of the dreem instrument, it emerged that this study has a common main finding with other similar studies conducted elsewhere, such as in india,[8] malaysia,[9] nigeria[10] and sweden,[2] for example. all these studies reported that students view their ee in general as more positive than negative, thereby having an optimistic view of their learning situation, lecturers, educational atmosphere and academic and social life. the overall score (124.4/200) for the current study setting, which uses a student­centred learning approach, was higher than those found in saudi arabia (89/200),[11] canada (97/200),[12] bangladesh (110/200),[13] india (117/200)[8] and malaysia (118/200).[14] it has been observed that students involved with innovative curricula (innovative in terms of providing a student­centred approach to education) tend to show more satisfaction with their learning environments, compared with students experiencing traditional curricula.[15] it is likely that the institutions that were studied in these countries offer conventional learning approaches. for instance, in one of the institutions, the college of medicine at king saud university, saudi arabia, the curriculum was reported as overcrowded and teacher centred.[11] table 1. distribution of respondents by gender and level of study (n=77) variable n (%) gender male 53 (68.83) female 24 (31.17) level year 1 14 (18.18) year 2 18 (23.38) year 3 21 (27.27) year 4 24 (31.17) table 2. dreem mean score for all study participants (n=77) dreem domain maximum score mean (%) sd students’ perceptions of learning (spol) 48 31.96 (66.58) 0.30 students’ perceptions of teachers (spot ) 44 26.89 (61.11) 1.42 students’ academic self­perceptions (sasp) 32 18.49 (57.78) 0.36 students’ perceptions of atmosphere (spoa) 48 31.24 (65.08) 0.72 students’ social self­perceptions (sssp) 28 15.82 (56.50) 0.16 overall dreem score 200 124.4 (62.20) 4.40 dreem = dundee ready educational environment measure. research september 2017, vol. 9, no. 3 ajhpe 105 however, the score found in the current study was lower than those found in nigeria (131/200),[10] malaysia (133/200),[9] sri lanka (141/200)[16] and sweden (150/200).[2] this may reflect that these institutions are fairly innovative in terms of providing a student­centred approach to education,[17] and the physiotherapy lecturers at ur should explore how they can learn from good practices in those countries. the highest score in this study was found in the domain of spol. several factors could have contributed to this spol score. the physiotherapy curriculum in rwanda adheres to the standards of the world confederation of physical therapy, the rwanda allied health professions council and the higher education council of rwanda. in addition, physiotherapy education in rwanda emphasises a competence­based and student­centred learning approach. the lowest mean score was found in the domain of sssp. this finding is not surprising, as the majority of the physiotherapy students at ur do not have university accommodation, and live off­campus. this is a call to the ur administration to look for ways that the social welfare of the students can be improved. in contrast with some others,[8,18] this study revealed that there are no differences in the perceptions of ee between male and female students, or between first­, second­, third­ and fourth­year students. not having perception differences among the groups of students may indicate that the ee at ur is equally friendly to all students, and this may be a positive aspect of physiotherapy education in rwanda. study limitations the study has some limitations. the quantitative descriptive study design that was used does not provide participants with opportunities to tell their stories outside the boundaries of structured measurement scales, and therefore to bring depth and clarity to the understanding of experiences of ee. a mixed­method design would be better for such studies to evaluate ee. conclusion the results of this study provide valuable clues as to how undergraduate physiotherapy students perceive their ee. students were positive about teaching, their lecturers and educational atmosphere and their academic success, and had a good overall feeling regarding their social situation. overall, students perceived that the institution provided a sound ee. however, the overall score of 62.20% indicates that there is a need for improvement of the learning environment of physiotherapy education at ur. similar studies from other academic programmes at ur and other academic institutions in rwanda using mixed­method designs are encouraged. acknowledgements. the authors wish to express their gratitude to all physiotherapy students at ur who devoted their time to participate in the study. author contributions. all authors conceived the study, analysed data, reviewed the manuscript and approved the final version of the manuscript. js and fk collected data, and gu wrote the first draft of the manuscript and edited the final version. funding. none conflicts of interest. the authors declare that they have no conflict of interest. 1. clapham m, wall d, batchelor a. educational environment in intensive care medicine ­ use of postgraduate hospital ee measure (pheem). med teach 2007;29(6):184­191. https://doi.org/10.1080/01421590701288580 2. palmgren pj, lindquist i, sundberg t, nilsson gh, laksov kb. exploring perceptions of the educational environment among undergraduate physiotherapy students. int j med educ 2014;5:135­146. https://doi. org/10.5116/ijme.53a5.7457 3. abraham r, ramnarayan k, vinod p, torke s. students’ perceptions of learning environment in indian medical school. bmc med educ 2008;8(3):20­24. https://doi.org/10.1186/1472­6920­8­20 4. al­rukban mo, khalil ms, al­zalabani a. learning environment in medical schools adopting different educational strategies. educ res rev 2010;5(3):126­129. 5. roff s, mcaleer s, harden rm, et al. development and validation of the dundee ready education environment measure (dreem). med teach 1997;19(4):295­299. https://doi.org/10.3109/01421599709034208 6. koohpayehzadeh j, hashemi a, soltani arabshahi k, et al. assessing validity and reliability of dundee ready educational environment measure (dreem) in iran. med j islam repub iran 2014;28:60­68. 7. roff s. the dundee ready educational environment measure (dreem), a generic instrument for measuring students' perceptions of undergraduate health professions curricula. med teach 2005;27(4):322­325. https://doi. org/10.1080/01421590500151054 8. sunkad am, javali s, shivapur y, wantamutte a. health sciences students’ perception of the educational environment of kle university, india as measured with the dundee ready educational environment measure (dreem). j educ eval health prof 2015;12:37­40. https://doi.org/10.3352/jeehp.2015.12.37 9. veasuvalingam b, arzuman h. physiotherapy students’ perception of their educational environment: a study to identify the areas of concern for remedial measures at two schools of physiotherapy in malaysia. educ in med j 2014;6(3):30­39. https://doi.org/10.5959/eimj.v6i3.233 10. odole ac, oyewole oo, ogunmola ot. nigerian physiotherapy clinical students’ perception of their learning environment measured by the dundee ready education environment measure inventory. int j high ed 2014;3(2):83­91. https://doi.org/10.5430/ijhe.v3n2p83 11. al­ayed ih, sheikh sa. assessment of educational environment at the college of medicine of king saud university, riyadh. east mediterr health j 2008;14(4):953­959. 12. audinet k, davy j, barkham m. university quality of life and learning (uniqoll): an approach to student wellbeing, satisfaction and institutional change. j further high educ 2003;27(4):365­382. https://doi. org/10.1080/0309877032000128073 table 3. perception differences on ee in dreem mean scores across years of study (n=77) domains year 1 mean (%) sd year 2 mean (%) sd year 3 mean (%) sd year 4 mean (%) sd p-value spol 32.08 (66.83) 3.61 32.02 (66.71) 4.156 31.62 (65.88) 3.89 31.47 (65.56) 3.87 0.970 spot 25.95 (58.98) 3.121 25.57 (58.11) 3.44 27.34 (62.14) 2.86 28.68 (65.18) 3.00 0.912 sasp 18.72 (58.50) 2.68 18.84 (58.88) 2.80 18.06 (56.44) 2.74 18.35 (57.34) 2.78 0.486 spoa 30.59 (63.73) 3.80 30.67 (63.90) 4.95 31.73 (66.10) 4.37 31.98 (66.63) 4.40 0.47 sssp 15.97 (54.04) 2.57 15.75 (56.25) 2.85 15.63 (55.82) 3.06 15.94 (56.93) 3.12 0.73 p≤0.05 is considered significant. dreem = dundee ready educational environment measure; ee = educational environment; spol = students’ perceptions of learning; spot = students’ perceptions of teachers; sasp = students’ academic self­ perceptions; spoa = students’ perceptions of atmosphere; sssp = students’ social self­perceptions. table 4. perception differences on ee in dreem mean scores according to gender (n=77) domains males mean (%) sd females mean (%) sd p-value spol 30.72 (64.00) 3.35 33.20 (69.17) 3.18 0.83 spot 26.34 (59.86) 3.71 27.44 (62.36) 4.22 0.25 sasp 19.01 (59.41) 4.30 17.97 (56.16) 4.12 0.88 spoa 30.78 (64.13) 3.64 31.70 (66.04) 2.93 0.73 sssp 15.72 (56.14) 3.35 15.92 (56.86) 3.44 0.16 p≤0.05 is considered significant. dreem = dundee ready educational environment measure; ee = educational environment; spol = students’ perceptions of learning; spot = students’ perceptions of teachers; sasp = students’ academic self­perceptions; spoa = students’ perceptions of atmosphere; sssp = students’ social self­perceptions. http://dx.doi.org/10.1080/01421590701288580 https://doi.org/10.5116/ijme.53a5.7457 https://doi.org/10.5116/ijme.53a5.7457 https://doi.org/10.1186/1472-6920-8-20 https://doi.org/10.3109/01421599709034208 http://www.ncbi.nlm.nih.gov/pubmed/?term=soltani arabshahi k%5bauthor%5d&cauthor=true&cauthor_uid=25405126 http://dx.doi.org/10.1080/01421590500151054 https://doi.org/10.3352/jeehp.2015.12.37 https://doi.org/10.5959/eimj.v6i3.233 https://doi.org/10.5430/ijhe.v3n2p83 https://doi.org/10.1080/0309877032000128073 https://doi.org/10.1080/0309877032000128073 research 106 september 2017, vol. 9, no. 3 ajhpe 13. nahar n, talukder hk, khan th, mohammad s, nargis t. students’ perception of educational environment of medical colleges in bangladesh. bsmmu j 2010;3(2):97­102. https://doi.org/10.3329/bsmmuj.v3i2.7060 14. arzuman h, yusoff msb, chit sp. . big sib students' perceptions of the educational environment at the school of medical sciences, universiti sains malaysia, using dundee ready educational environment measure (dreem) inventory. malays j med sci 2010;17(3):40­47. 15. said nm, rogayah j, hafizah a. a study of learning environments in the kulliyyah (faculty) of nursing, international islamic university malaysia. malays j med sci 2009;16(4):15­24. 16. perera d. the assessment of undergraduate physiotherapy education in sri lanka. int j sci res pub 2016;6(4):329­332. 17. brown t, williams b, lynch m. the australian dreem: evaluating student perceptions of academic learning environments within eight health science courses. int j med educ 2011;2(2):94­101. https://doi.org/10.5116/ ijme.4e66.1b37 18. al­naggar ra, abdulghani m, osman mt, et al. the malaysia dreem: perceptions of medical students about the learning environment in a medical school in malaysia. adv med educ pract 2014;5:177­184. accepted 14 december 2016. https://doi.org/10.3329/bsmmuj.v3i2.7060 https://doi.org/10.5116/ijme.4e66.1b37 https://doi.org/10.5116/ijme.4e66.1b37 research december 2017, vol. 9, no. 4 ajhpe 203 over the past few decades, the field of medicine has changed dramatically, reflecting changing disease patterns, increased ease of travel and growing interest in international health. medical-school curricula have evolved accordingly, to include more international health experiences, in the form of electives, as a key feature for trainees.[1] however, most of these international electives are skewed towards students from the resource-rich nations of the global north travelling to low-income countries.[2,3] the exact number of international opportunities available is unknown, but a clear disparity exists,[2] with very few opportunities for students from low-income countries to undertake international electives in resource-rich countries, particularly the usa. this inequality has raised concerns and led to an increased push for academic medical centres in high-income countries to become more involved in collaborative partnerships with medical centres in low-income countries.[3] further concerns raised about the effect international health experiences have on host communities include students practising beyond their medical competence,[4] perpetrating a hero model in the host population[5,6] and working outside of national policies or priorities.[5] however, international medical experiences have also been shown to lead to the participants being more inclined to specialise in public health or primary-care related fields, and students who have completed international clinical rotations often report a greater ability to recognise disease presentations, more comprehensive physical-examination skills with less reliance on expensive imaging, and greater cultural sensitivity.[6,7] unfortunately, very little literature addresses the design and structure of international rotations for students from the global south, and literature that examines the benefits for these students is almost non-existent. based on the results of our previous quantitative analysis, where 97% of participants deemed their university of michigan medical school (umms) rotation as valuable to their medical training, and 90% reported changes in how they approach patient care, the investigators deemed it prudent to conduct a qualitative analysis of in-depth interviews to elucidate exactly what these changes were.[8] history of the ghana-michigan medicalstudent exchange the university of michigan department of obstetrics and gynecology has had a long-term partnership with the university of ghana medical school (ugms), the kwame nkrumah university of science and technology background. participation in international electives is an integral part of medical training for many medical students, yet little research explores the experiences of students from low-income countries who travel to high-income countries for medical electives. methods. one hundred and two ghanaian medical students who participated in 3 4-week clinical rotations at the university of michigan between january 2008 and december 2011 were invited to participate in a mixed-methods study. face-to-face, semi-structured interviews were conducted with 15 respondents from the larger group who agreed to take part in follow-up interviews. the 60to 90-minute interviews were audio-recorded and transcribed verbatim, and transcripts were coded by three investigators in an iterative process of thematic identification, codebook generation and revision and consensus discussions. results. respondents described perceived differences between ghana and the usa, including: exposure to ‘new’ aspects of medicine; differences between ghanaian and us patients, healthcare workers, and patient-provider relationships; and aspects of the us system that they would like to see emulated in ghana. conclusion. this preliminary study suggests that international bilateral exchange programmes have lasting value for participants from low-income nations. further research is needed to determine if the different types of experiences yield measurably different benefits. afr j health professions educ 2017;9(4):203-207. doi:10.7196/ajhpe.2017.v9i4.827 clinical electives at the university of michigan from the perspective of ghanaian medical students: a qualitative study s danso-bamfo,1,2 mb chb, mph; n a abedini,2 md; h mäkiharju,3 ma; k a danso,4 mb chb; t r b johnson,5 md; j kolars,6 md; c a moyer,6 mph, phd 1 harvard t h chan school of public health, boston, mass., usa; and department of emergency medicine, massachusetts general hospital, boston, mass., usa 2 division of hospital medicine, department of internal medicine, university of washington, seattle, wash., usa 3 hematology and oncology division, department of internal medicine, university of michigan medical school, ann arbor, usa 4 school of medical sciences, college of health sciences, kwame nkrumah university of science and technology, kumasi, ghana 5 department of obstetrics and gynaecology, university of michigan medical school, ann arbor, usa 6 departments of learning health sciences and obstetrics and gynaecology, university of michigan medical school, ann arbor, usa; global reach, university of michigan medical school, ann arbor, usa corresponding author: s danso-bamfo (sdbamfo@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 204 december 2017, vol. 9, no. 4 ajhpe school of medical sciences (knust-sms), and ghana’s ministry of health. it started through a carnegie foundation-funded programme, in partnership with universities and colleges of obstetricians and gynaecologists in the usa and the uk. the programme assisted in the development of postgraduate training in obstetrics and gynaecology in ghana,[9] and the resulting partnership has provided opportunities for bilateral student and faculty exchanges, and created a platform for ongoing training, research and collaborative endeavours .[10] the programme has seen more than 80 students from ghana rotate at umms between 2007 and 2011, and has expanded to include the university of development studies school of medicine and health sciences (uds-smhs) and the university of cape coast school of medical sciences. structure of the ghana-michigan medicalstudent exchange ghanaian students typically spend 3 4 weeks in ann arbor, michigan, participating in direct patient care and observation of clinical activities through rotations that are similar to those experienced by umms thirdand fourth-year students, including the umms simulation centre. students receive an orientation to the clinical environment, with topics such as utilisation of electronic medical records, sterile technique protocols and searching medical literature. similarly, umms students undertake clinical electives at ugms, knust-sms or uds-smhs, commonly for a period of 4 weeks. methods this study was reviewed and performed under an exemption granted by both the ethical and protocol review committee of ugms (ref. no. ms-et/ m.11-p.4.6/2010-11) and the university of michigan institutional review board (ref. no. hum00048221). all participants gave electronic consent prior to participation. data collection in late 2011, all 73 ghanaian medical students from ugms and knustsms who had participated in 1-month rotations between january 2008 and december 2010 were contacted via email and asked to complete a survey,[8] at the end of which, participants were given the option to be contacted for a follow up-interview. in mid-2012, invitations for interviews were also extended to a wider pool that included students who had subsequently completed rotations by august 2011, and students from uds-smhs. the 15 respondents who agreed to the follow-up were interviewed face-to-face for 60 90 minutes using a study-specific semi-structured interview tool and an audio recorder. to maintain anonymity, the interviewees’ names were not mentioned during the interview, and audio recordings were labelled anonymously and uploaded to a cloud-based file-sharing platform (dropbox), from which they were accessed and transcribed by another member of the research team (hm). data analysis the audio recordings of the interviews were transcribed verbatim, and transcripts were coded by three separate investigators (sdb, nca, and cam), as described by charmaz.[11] open codes were discussed and harmonised among the investigators, and a codebook was created to describe the codes. transcripts were then coded using the identified coding schema, allowing room for further themes to emerge during the coding process. when additional codes arose, the team discussed the additional code and either amended the definition of an existing code or added a new code category to the codebook. two of the investigators (sdb and cam) discussed the hierarchy of codes, as well as any overarching themes. results in-depth interviews with the 15 former medical students were completed in 2012, between 8 and 40 months after their rotation (mean = 16.7 months). this diverse group of eight women and seven men comprised five graduates of ugms, six graduates of knust-sms, and four graduates of uds-smhs, whose ages ranged from 24 to 29 years old, and was highly representative of the gender, age and medical-school affiliation of the general cohort of participants.[8] respondents described perceived differences between ghana and the usa with regard to the practice of medicine and the behaviours that they wished to emulate. the strongest themes identified in the data included: exposure to ‘new’ aspects of medicine; differences between ghanaian and american patients; differences in the relationships and interactions between healthcare providers and patients, as well as among healthcare providers; and aspects of the us system that they would like to see emulated in ghana. exposure to ‘new’ aspects of medicine many of the respondents described being exposed to new opportunities for further training that they had not been aware of before rotating in the usa. they also learned about subspecialties as well as new and emerging fields in medicine: ‘before i went there i actually didn’t know there were so many specialties. i thought every obstetrics and gynaecology specialist was supposed to do everything […] i didn’t know that gynaecology was on its own, obstetrics was on it its own. i didn’t even know that infertility was on its own as a specialty, so yeah […] i [now] know there are more subspecialties around i can explore.’ (25-year-old female, uds-smhs) differences regarding patients, healthcare workers and their interrelationships respondents described noticeable differences between ghana and the usa regarding patient and provider demographics, the relationships between providers and their patients, and also between providers and trainees. they commented that some patients had done research on their illnesses and came to see the doctor ready with questions – something that would be uncommon in ghana: ‘it’s a more literate community [in the usa] and so patients come knowing more about their condition, asking more questions and expecting to receive more response from the doctor. doctors don’t impose too much of the decisions on patients, and patients form a very important part of the … clinical practice.’ (25-year-old male, ugms) respondents also commented on resident demographics, indicating that many of the residents and faculty in the usa were female, which is not the case in ghana. ‘i was amazed that most of their residents [at michigan] were females … even their chief resident was a female. i was very impressed because i want to do obstetrics and gynaecology but … not a lot of women rotate through that in ghana and everybody says it’s quite difficult. but i was happy to see so many women doing the surgeries.’ (25-year-old female, knust-sms) research december 2017, vol. 9, no. 4 ajhpe 205 one of the most common observations made by visiting trainees related to the differences between how medical students and faculty interacted in usa and ghana. respondents found that the relationship between ‘teacher’ and ‘student’ was less formal in the usa, and faculty were very accessible and approachable: ‘i didn’t expect them [the attendings] to be as eager and willing to help us as they were. they were very open, very ready to teach any opportunity they had. they were gentler if you made a mistake.’ (27-year-old female, knust-sms) respondents noted that this difference in interaction style had a significant effect on them as learners: ‘personally … i think it boosted my self-esteem. it was like, “oh so you can approach people like this and then talk freely?”’ (28-year-old male, ugms) differences in learning environment respondents spoke about differences in the physical learning environment, particularly, the speed and efficiency with which procedures were done and the state-of-the-art machines that were in use, including automated dictation: ‘you got the history on a sheet of paper, nicely typed, you know, printed out. and to me i think it was nice. it was a way of making things more efficient so that i don’t waste time.’ (28-year-old male, ugms) trainees also commented on the speed with which laboratory results were available, and the advantages of having a computerised medical-records system: ‘in ghana [in the morning] we have to go and see the patient immediately to open the folders, to see what the doctors have written … but there you can easily go back and look at their various investigation, labs, and consultations that have been done, and then you just go to the patient and ask a few pertinent questions, then just put your findings together and then just present it to the fellow or the attendant. i find that really as a step beyond what i find in ghana here.’ (24-year-old male, ugms) areas for improvement some respondents also mentioned certain aspects of their experience as less than desirable. the most common complaints were about the amount of hands-on clinical engagement they had, as well as limited contact with local medical students: ‘when we had our letters, it said we were coming mainly in an observatory capacity, but for some reason i thought i would get to do more than i got to do … so for me that was kind of, like, a disappointment because it gets boring when you are only watching people all the time, you’re not really doing much.’ (25-year-old female, uds-smhs) trainees also mentioned organisational lapses as one area of potential improvement. in particular, students reported variability in terms of expectations: ‘sometimes it’s like ok, you get there today, but it’s like quite undefined. you don’t really know whether today you should be going here or be going there. you know sometimes, but i think … those things should be streamlined properly.’ (28-year-old male, ugms) potential applications at home overall, respondents reported learning behaviours that they felt were worth emulating. this included paying more attention to infection control, punctuality, improving the way they relate to patients and being more mindful of how they as individuals can improve the health outcomes of their patients. infection control interviewees reported the desire to improve certain aspects of the hospital setup in ghana that were related to controlling the spread of infections. these included: hand-washing, the use of antibacterial solutions to disinfect hands and limiting the number of people allowed into the theatre to watch surgeries: ‘i don’t think it will cost much for the hospital to provide sanitisers all around … so i think it is a very achievable thing that we can use to prevent infection control … it is something we can apply without spending money.’ (24-year old-male, ugms) punctuality the interviewees reported that punctuality is highly regarded in the usa and they desired to emulate such ideals in ghana: ‘that is one thing that i think i’ve gotten to appreciate. that if you have, if you work within the time that you have, as timely as you can, then you would be able to actually achieve everything that you are trying to do.’ (26-year-old female, knust-sms) empathy another area that trainees repeatedly mentioned was witnessing providers’ empathy and kindness toward patients and wanting to be sure to do that more in ghana: ‘what i saw from the interaction between workers, health workers and patients was a certain level of respect … you wouldn’t see a doctor or a nurse being rude to a patient or shouting at him. i really hope to put this into practice because a lot of times our patients just come and they need someone to be nice to them.’ (25-year-old male, knust-sms) discussion the majority of ghanaian trainees who completed rotations at umms and participated in this study deemed the experience of their overseas rotation valuable. few other studies have explored international health experiences from the perspective of students from the global south, which is one of the main strengths of this study. our interviewees formed a balanced sample, with both male and female students from three different participating schools. furthermore, we conducted follow-up interviews as long as 2 3 years after trainees’ international health experiences, and in this regard, our study was able to solicit the views of students who had recently returned from the exchange as well as those who had undertaken it several years before. we were therefore able to see both the shortand medium-term impacts of the experience, particularly with regard to the influence it has had on the final leg of their medical training, their professional lives and postgraduate plans. one common theme that arose was of potential application of the lessons learned at home, which we termed ‘translation’. it describes the desire several students expressed of wanting to import certain aspects of what they had learned at umms and apply it at their home institution. the theme of research 206 december 2017, vol. 9, no. 4 ajhpe translation included: paying more attention to infection control; improving ‘system factors’ such as orderliness and punctuality; and being more empathetic toward patients. we found that while there are many advantages to a truly bilateral exchange relationship for trainees from under-resourced settings, the design of such a programme is critical to its success. apart from a few articles, such as those by crump and sugarman[12] and bishop and litch,[13] little attention has been paid to the ethical considerations necessary to ensure that north-south training or education initiatives have minimal undesirable effects on the relatively disadvantaged partner. additionally, to help guide the design of ethically sound north-south medical partnerships, crump and sugarman,[14] as part of the working group on ethics guidelines for global health training (weight), have developed a set of guidelines for institutions, trainees and sponsors of field-based global health training on ethics and best practices (table 1) that we believe is a laudable starting point for any institution that is already engaged in or considering engaging in medical exchanges. while the ghana-michigan exchange programme has been beneficial, it is not without its challenge, one of which is the trainee’s level of engagement in clinical care while rotating in the usa. improving efforts to genuinely integrate visiting trainees into patient management is an important learning point for those developing exchange programmes, especially in the face of regulatory and medicolegal challenges that may limit what visitors are allowed to do. while such integration may be difficult in some situations, it is undoubtedly the best way for trainees to maximise their learning. another challenge relates to the organisational structure, and the need to ensure that all participating attending faculty and residents understand the programme and the role of the visiting trainees. study limitations as with all studies, we recognise that our study had some limitations, namely the small sample size and the possibility of people being predisposed to give positive answers when being interviewed face-to-face. we attempted to mitigate the risk of social desirability bias by using a ghanaian interviewer who was also a part of the larger ghana-michigan exchange cohort. given the balance of positive and negative comments recorded, we believe that this strategy was successful in limiting potential biases. we also recognise that our study could be strengthened if we could link participants to their ultimate residency training choice or specialty area of practice; however none of the participants interviewed had entered residency programmes at the time of data collection and as such our study can yield only a relationship between participation in the exchange programme and plans (or the lack thereof ) for specialisation and not the participants’ ultimate specialisation choice. it is also possible that the study design – qualitative interviews with a small subset of the participants within a few years of the experience – precludes the observation of other potential outcomes associated with the exchange programme, for example, an exploration of the effects of an increased desire for subspecialisation among exchange participants. it could spark the development of additional in-country training programmes – as we have seen with the addition of the reproductive health and family planning table 1. selected guidelines proposed by the working group on ethics guidelines for global health training (weight)[14] trainees host/sending institutions sponsors recognise that the primary purpose of the experience is global health learning and appropriately supervised service. the duration of the training experience should be tailored so that the burden to the host is minimised develop well-structured programmes so that host and sender as well as other stakeholders derive mutual, equitable benefit consider local needs and priorities, reciprocity and sustainability of programmes learn appropriate language skills relevant to the host’s locale as well as sociocultural, political and historical aspects of the host community clarify goals, expectations and responsibilities through explicit agreements and periodic review ensure that true costs are recognised and supported seek to acquire knowledge and learn new skills with appropriate training and supervision, but be cognisant and respectful of their current capability and level of training clarify the trainees’ level of training and experience for the host institution so that appropriate activities are assigned and patient care and community wellbeing is not compromised aim to select trainees who are adaptable, motivated to address global health issues, sensitive to local priorities, willing to learn, whose abilities and experience match the expectation of the position and who will be a good representative of their home institution recognise and respect divergent diagnostic and treatment paradigms select trainees who are adaptable, motivated to address global health issues, sensitive to local priorities, willing to listen and learn, whose abilities and experience matches the expectations of the position, and who will be good representatives of their home institution and country promote safety of trainees to the furthest extent possible when requested, be willing to share feedback on the training experience and follow-up information on career progression establish methods to solicit feedback from the trainees both during and on completion of the programme, including exit interviews, and track the participants post training to evaluate the impact of the experience encourage effective supervision and mentorship by the host and sending institutions research december 2017, vol. 9, no. 4 ajhpe 207 fellowship to the postgraduate training programmes in the ghana college within the past few years. however, it could also increase the number of trainees who leave ghana to seek training elsewhere. additionally, seeing more women in positions of leadership during an exchange programme may have lasting effects on trainees – both male and female – in terms of their views on the potential of female physicians to rise to positions of leadership in ghana. furthermore, it would have been of added benefit to measure the systems-level changes (punctuality, infection control, empathy), if any, that occurred in the participants’ home institutions as a result of the participation. however, these outcomes are beyond the scope of the current study, and warrant future research to explore the longer-term outputs of the exchange programme, in terms of its effect on the individual, the profession and society as a whole. furthermore, given the highly regarded nature of the exchange programme and the non-random means of selection (academic merit, interest in participating, access to financial support), we did not compare the participants of the ghana-michigan exchange with non-participants, and this is perhaps another warranted direction for further research. finally, while these trainees participated in an exchange programme in which ghanaian students travel to michigan and michigan students travel to ghana, the focus of this research was on the ghanaian students only. additional work comparing the impact on ghanaian students v. us students is warranted. conclusion we hope the findings of this study will encourage other medical schools and hospitals in the global north to form partnerships with schools in the global south in which there can be a mutual transfer of knowledge through student exchanges. this study suggests that medical trainees from under-resourced countries who complete clinical electives in high-resource settings stand to gain a great deal, not only from exposure to the technology and specialisation that are hallmarks of western medicine, but also from the more oftenoverlooked differences in the practice of medicine between highand lowresource settings, such as the teaching methods employed; relationships and interaction between trainer and trainee and patient and provider; and systems management. it is this exposure to new ideas and behaviours, leading to rethinking and challenging the status quo of medical training in the delivery of care, that we have found to be the most useful change. acknowledgements. the authors would like to acknowledge the significant contributions of the late dr christine ntim-amponsah, professor of ophthalmology and former dean at ugms, to the conceptualisation and design of this study. the authors would also like to thank jennifer jones and carrie ashton for providing valuable insights into the background of the exchange programme. author contributions. cam led and sdb, na, trbj and jck assisted in the conceptualisation of this study. kad, trbj and jck provided feedback on the coding schema and reviewed early drafts of the manuscript. na also provided feedback on the qualitative interviews and assisted in the coding and analysis. hm transcribed the qualitative interviews and provided input on coding schema and worked on data analysis. sdb conducted all qualitative interviews, led the coding and analysis, completed the first draft of the manuscript, and conducted final manuscript revisions, while cam assisted in manuscript drafting. all authors contributed to the final manuscript revisions, and have approved the final manuscript. funding. this work was supported by national institutes of health (nih) research training grant r25 tw009345, funded by the fogarty international center, the national institute of mental health and the nih office of the director, office of research on women’s health and the office of aids research. conflicts of interest. none. 1. mckinley dw, williams sr, norcini jj, anderson mb. international exchange programmes and us medical schools. acad med 2008;83:suppl 10:s53-s57. https://doi.org/10.1097/acm.0b013e318183e351 2. thompson mj, huntington mk, hunt dd, pinsky le, brodie jj. educational effects of international health electives on us and canadian medical students and residents: a literature review. acad med 2003;78(3):342-347. http://doi.org/10.1097/00001888-200303000-00023 3. kolars jc, cahill k, donkor p, et al. perspective: partnering for medical education in sub-saharan africa: seeking the evidence for effective collaborations. acad med 2012;87(2):216-220. https://doi.org/10.1097/ acm.0b013e31823ede39 4. niemantsverdriet s, majoor gd, van det vleuten cp, scherpbier aj. ‘i found myself to be a down to earth dutch girl’: a qualitative study into learning outcomes from international traineeships. med educ 2004;38(7):749-757. https://doi.org/10.1111/j.1365-2929.2004.01843.x 5. anderson wj, wansom t. beyond medical tourism: authentic engagement in global health. virtual mentor 2009;11(7):506-510. https://doi.org/10.1001/virtualmentor.2009.11.7.medu1-0907 6. drain pk, primack a, hunt dd, fawzi ww, holmes kk , gardner p. global health in medical education: a call for more training and opportunities. acad med 2007;82(3):226-230. 7. jeffery j, dumont r, kim g, kuo t. effects of international health electives on medical student learning and career choice: results of a systematic literature review. fam med 2011;43(1):21-28. 8. abedini nc, danso-bamfo s, moyer ca, et al. perceptions of ghanaian medical students completing a clinical elective at the university of michigan medical school. acad med 2014;89(7):1014-1017. https://doi.org/10.1097/ acm.0000000000000291 9. klufio ca, kwawukume ey, danso k, sciarra jj, johnson t. ghana postgraduate obstetrics/gynecology collaborative residency training programme: success story and model for africa. am j obstet gynecol 2003;189(3):692-696. 10. anderson fw, mutchnick i, kwawukume ey, et al. who will be there when women deliver? assuring retention of obstetric providers. obstet gynecol 2007;110(5):1012-1016. https://doi.org/10.1097/01.aog.0000287064.63051.1c 11. charmaz k. constructing grounded theory: a practical guide through qualitative analysis. london: sage publications ltd, 2006. 12. crump ja, sugarman j. ethical considerations for short-term experiences by trainees in global health. j am med assoc 2008;300(12):1456-1458. https://doi.org/10.1001/jama.300.12.1456 13. bishop r, litch ja. medical tourism can do harm. bmj 2000;320(7240):1017. 14. crump ja, sugarman j. ethics and best practice guidelines for training experiences in global health. am j trop med hyg 2010;83(6):1178-1182. https://doi.org/10.4269/ajtmh.2010.10-0527 accepted 17 january 2017. https://doi.org/10.1097/acm.0b013e318183e351 http://doi.org/10.1097/00001888-200303000-00023 https://doi.org/10.1097/acm.0b013e31823ede39 https://doi.org/10.1097/acm.0b013e31823ede39 https://doi.org/10.1111/j.1365-2929.2004.01843.x https://doi.org/10.1001/virtualmentor.2009.11.7.medu1-0907 https://doi.org/10.1097/acm.0000000000000291 https://doi.org/10.1097/acm.0000000000000291 https://doi.org/10.1097/01.aog.0000287064.63051.1c https://doi.org/10.1001/jama.300.12.1456 https://doi.org/10.4269/ajtmh.2010.10-0527 short research report 164 december 2017, vol. 9, no. 4 ajhpe teaching and assessment strategies require constant personal reflection as to whether these approaches adequately prepare students to meet the discipline-specific knowledge base of the profession (‘hard skills’), while simultaneously developing behavioural and attitudinal skills that empower them to become more socially aware and responsible citizens (‘soft skills’).[1] integrating soft skills with hard skills is a conceptual principle that higher education promotes and requires, more recently popularised as ‘graduate attributes’.[2] adapting teaching and assessment practices towards addressing this need from a basic medical science and clinically applied perspective, creates the opportunity and platform to be innovative in identifying new strategies and expanding on conventional practices. consequently, team learning has become popular in many medical training institutions. in anatomy, the limited dissection potential of the cadaveric brain, and the complexity of the three-dimensional stuctures within it, further creates a substrate for innovative learning. this case study highlights the effectiveness of a team project that embraces the elements of hard and soft skills, team learning and self-directed learning. topics provided required the preparation and presentation of models through a video clip as a newly created art form, so as to adopt the contemporary social theme: selfies 2015. as it was an innovative curricular activity, it was considered giving specific attention to and evaluating the project from a student’s perspective. more importantly, the project provided a simple strategy that can be used to integrate hard and soft skills, as has become a requirement of most curricula. objectives a class activity has been used as a strategy to integrate hard and soft skills through the concept of a popular social theme related to the creation of an art form, and to evaluate the students’ perception of the project in terms of expanding subject knowledge, personal appeal and enjoyment, and future considerations. methods each team, comprising 5 6 students, was allocated a topic in neuroanatomy and was required to prepare a model to demonstrate a particular aspect. each of the three topics formed part of the neuroanatomy syllabus, but was not taught through formal lectures and practicals. for these topics, student teams were required to prepare a model relevant to the topic and produce a 15-minute video clip incorporating the model as a class presentation. typically, each of these topics, as in previous years, would have been taught by the lecturer and, as such, contributed substantively to the subject matter. the topics, however, comprised only three of nine key topics of this section of the course and included: • the ventricles of the brain and the flow and circulation of cerebrospinal fluid • the arterial blood supply and venous drainage of the brain and spinal cord • specialised grey matter within the substance of the cerebrum, with particular reference to location, structure and function. there were no specific guidelines for the model preparation or for the presentation of the video clip. in this way, latitude was allowed among students in terms of innovation and team preferences. students were, however, referred to the subject guide for a clear set of stipulated outcomes to be achieved for each topic in terms of the content that would need to be covered and the appropriate level of detail required. a specific time frame background. anecdotally, 2015 was declared the year of the selfie. the theme of selfies is used as an opportunity to engage neuroanatomy students by drawing from it as a newly created art form by means of models and video clips. objectives. to provide a synopsis of student perceptions of a team project to inform further project development and refinement. methods. topics were allocated to teams of 5 6 students, constituting a class of 27. teams were required to prepare a model that would demonstrate a topic, which would be used to produce a video clip presented as a teaching tool. three focus groups comprising 6 8 students subsequently held discussions to determine student perspectives of the project. results. students viewed the project as a means of facilitating teamwork and peer learning and of enhancing presentation skills. while all the teams enjoyed the project and found it to be beneficial, students preferred making the model rather than producing the video clip. nonetheless, students felt particularly accomplished on seeing the completed video clip. a dominant view was that the project provided enhancement of the subject content, pertaining largely to the team’s project, while the knowledge gained of other topics was limited. some students preferred conventional teaching and found the synopsis provided by the lecturer at the end of each presentation to be particularly useful. conclusion. this case study provides evidence to support simple strategies of integrating discipline-specific content (‘hard skills’) with general education (‘soft skills’), as required of higher education. afr j health professions educ 2017;9(4):164-167. doi:10.7196/ajhpe.2017.v9i4.803 selfies 2015: peer teaching in medical sciences through video clips – a case study j d pillay, phd department of basic medical sciences, faculty of health sciences, durban university of technology, south africa corresponding author: j d pillay (pillayjd@dut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. december 2017, vol. 9, no. 4 ajhpe 165 for completion of the project was also clarified. the teams were assessed equally on the model and the video clip, and a questioning session was held, where team members were questioned on relevant aspects of the topic. the allocation of marks regarding the model focused on key aspects, such as appearance and functionality, and its relationship to other relevant structures in the brain and spinal cord (where applicable). for the video clip, marks were allocated on the basis of presentation aspects, such as voice projection, clarity, engagement with and reference to the model, and pace and level of ease with which the topic content was highlighted. during the question-and-answer session marks were allocated based on how accurately students responded to questions and how well they could explain their responses, as well as the level of participation of all team members. students were subsequently invited to a focus group interview to document their opinions of the project. the interviews were conducted independently by an external facilitator to limit the bias of the lecturer requesting feedback from students on a teaching event facilitated by the same lecturer. furthermore, the interviews had taken place after final course assessments were completed so that students felt comfortable during their participation or non-participation, and in providing honest feedback. as these interviews were voluntary, some students chose not to participate or were unavailable owing to the course having been completed by this time. nevertheless, the focus group discussions were used as an opportunity to establish some awareness of student perceptions of the project and to help to engage academics in reflective practice using student feedback as a reliable source. the questions used for the focus group discussions were based on the principle of reflective practice, which pivots on the ability and need to reflect on what, why and how we do things and to adapt and develop our practice during lifelong learning.[3,4] this has been promoted by and required of higher education teaching. it is usually complemented by regular subject evaluations and subsequent adaptations to teaching and assessment, based on the views of students. as such, basic questions were posed to the focus groups, relating to what students enjoyed about the project, what students did not like about the project and, more importantly, how the project could be enhanced if used for future teaching, learning and assessment. consequently, the conceptual framework of the study reporting was based on the questions used for the focus group discussions and key themes that emerged from the interviews. focus group discussions were audio recorded and transcribed by an independent transcriptionist. thematic analyses were used to analyse the transcripts using the nvivo qualitative data analysis software, version 10.[5] themes and sub-themes were created, based in part on the guided questions and data from the transcripts. ethical approval permission to obtain student feedback was obtained from the research ethics committee, durban university of technology (ref. no. 122/15). results three focus group interviews comprising 21 of a class of 27 students (78% response rate), revealed the following key themes: the project a dominant view was that the project integrated theory and practical aspects of the topic, which was found to be enjoyable. students appreciated working as a team, learning from each other and sharing knowledge. a further view that was often highlighted was the technical challenges faced in making the video clip. consequently, many students preferred making the model rather than producing the video clip. there was general agreement that, despite the challenges faced during the process of completing this project, the end product and the experience gained from the endeavour were well worth the effort. perceptions of reasons for engagement in the project students viewed the project as a means of facilitating and ensuring teamwork and peer learning and as a vehicle for the enhancement of presentation skills: ‘we learn it practically instead of theoretically.’ ‘video method was entertaining and increased our concentration; it helped us to learn how to make a video that we can use one day when we qualify.’ ‘we understand better when other students teach us rather than only learning from the lecturer.’ enjoyment of the project while all the teams enjoyed the project, few took pleasure in making the video. it was noted that the more enjoyable part of the project was related to making the model: ‘making the model was nice and enjoyable. the video only tested our skills on how to video it. we found making the video stressful.’ nonetheless, students found the project to be an enjoyable experience, particularly on seeing and presenting the end product (i.e. the video clip): ‘we had a lovely group and we all worked well together and enjoyed working in the group. seeing our work in the end gave us great satisfaction.’ less enjoyable aspects of the project students experienced challenges in making the video and therefore found this to be a less gratifying experience than making the model. some teams also encountered problems getting the entire group together for the video clip and experienced some technical challenges: ‘we struggled with making the video, we had problems with the sound – it was “hazy”. we also had problems, while presenting, with the timing (delayed) so information did not correspond with what was presented. getting all the team members together in the limited time available was a problem, so this delayed the making of the video.’ subject content collective enhancement of knowledge and its application there was general consensus that the project provided good enhancement of the subject matter, but that this pertained largely to a particular team’s project, while knowledge obtained of other topics of the section relied on the presentations and a brief synopsis by the lecturer: ‘we covered the content extensively. however, the areas covered by the other teams – we had limited knowledge of these in the short presentation.’ despite this limitation, students agreed that the exercise was fruitful in enhancing the anatomy learning experience: ‘making it, seeing the video and presenting it helps to remember better. anatomy is good when looking at pictures – you better understand it and this helps to remember it better. doing it yourself enhances memory because you correct it over and over again.’ short research report 166 december 2017, vol. 9, no. 4 ajhpe the project as an alternative to conventional teaching while most students indicated that the experience was exciting and beneficial, some still preferred conventional teaching and found the lecturer’s synopsis at the end of each presentation very useful: ‘yes, it was better, as the way it was explained was not the standard form – the video was attention grasping and fun with humour, despite challenges.’ ‘the lecturer provided important information after the presentation. those areas that we did not do were difficult to understand through the video clip alone, but the lecturer explained it to us after the presentation and this was beneficial.’ some students were of the view that the experience was not beneficial: ‘the making of the model and the video was a like a repetition and you stop paying attention.’ ‘the entire process of making the model and video – we were not learning but we were stressing about what we are presenting rather than what we are supposed to know.’ there were some students who did not consider the project to be a better alternative to conventional teaching, but indicated that ‘it can be improved on’. future recommendations suggested areas for improvement of this learning experience a dominant view that emerged from the discussions was that although this method of learning was beneficial, enhancement was needed in the form of technical assistance, especially for making the video: ‘technical assistance (a tutor) on video making must be made available to us. also to make some kind of software available in the computer lab. this will help, as making the video can be done on the campus by all rather than at somebody’s house, for example.’ some students felt that the video clip could be replaced altogether or supplemented by a conventional power-point presentation. students proposed that a more formative approach to the assessment should be used so that work in progress could be reviewed, with recommendations for improvement. there were also suggestions that more detailed assessment criteria should be outlined. some indicated that before the allocation of team projects, the lecturer should, as an example, do a similar project with the entire class, which includes dissection of an area, development of a video clip and the presentation thereof. discussion in the past, most medical training institutions taught students by means of curricula that were based on the traditional model of teaching, primarily relying on the transfer of information from teacher to student.[6] consequently, students relied on memorisation and largely focused on shortterm recall.[6] the transformation in higher education towards supporting more active student engagement, complemented by the changing needs and interests of students, has warranted more interactive and self-directed learning. furthermore, there is a growing emphasis on the nature of competencies with which students leave university, which go beyond disciplinary expertise or technical knowledge, to producing generic skills, such as the ability to communicate effectively, work as a team and demonstrate responsibility.[7,8] in this regard, the term ‘graduate attributes’ appears to have achieved fairly widespread acceptance in the most recent literature and is commonly used in the south african context.[9] the focus of this study has been on transforming a conventional teaching and assessment tool (i.e. project/assignment) into an endeavour that integrates hard skills, in a self-directed and interactive manner, with soft skills, which contribute towards attaining generic capabilities emphasised in most institutional mandates emanating from the national plan in higher education, 2001.[10] more so, an attempt to incorporate the application of ‘graduate attributes’ in an otherwise content-based task, is inherent in this endeavour. the use of a theme relevant to current social interest provides a stimulating and contemporary appoach. in summary, the following benefits were identified: • the idea of the project was exciting and enjoyable. • the project promoted and enhanced working together as a team. • most of the learning took place in a self-directed manner and pivoted on peer teaching and learning. • active engagement in the project and with the subject content promoted a deeper understanding of and more confidence in knowledge of the topic. • the project required expansion in technical skills and abilities. • great satisfaction/accomplishment was felt upon completion of the project and presentation to the class. the following key aspects were not enjoyed: • there were technical challenges, resulting in difficulties and disappointments in terms of envisaged plans. • the notion of a presentation and questioning session in an auditorium setting was daunting and created anxiety. • there was limited time to work on the project as a team, which became complicated with regard to co-ordinating team meetings outside of formal contact time. • while a high level of mastery was obtained in the topic presented by a team, there were knowledge gaps in the other two topics presented by other groups. relying on the video clip might not have been adequate. suggested improvements: • the primary recommendation was that an experienced person who could provide technical assistance for the project was needed. • formative feedback by a tutor or lecturer would assist in directing students during the process of the project development. • an environment more conducive to video recording would limit the need for teams to co-ordinate meeting outside the university campus. • more clarity on the specifics of mark allocation would provide better direction and focus. while pertinent suggestions were made for future development of the project, the task was recognised as offering an engaging, constructive and exciting space for learning beyond the limits of content-specific theory and practicals. study limitations as each topic covered by the project was not covered during formal lectures, it was not possible to provide information on preand postintervention knowledge. for future studies it might be useful to compare student assessment performance (e.g. in a test or examination) on aspects related to these topics with other topics covered by conventional teaching within the same, if not similar, section. nonetheless, an opportunity for reflection on student experience and insight informs future practice. short research report december 2017, vol. 9, no. 4 ajhpe 167 conclusion allied health and medical students require active learning engagement that will allow them to move beyond the primary concern of ‘content presentation and assessment’ towards revisiting and improving ways of thinking and connecting information.[11,12] the content developed in this study is recognised as being relevant, as the project involved the development of skills and processes appropriate for life beyond the context of medical science. acknowledgements. the author wishes to thank miss sara cassim motala for her valued input and assistance in conducting the qualitative component of the study. author contributions. jdp was responsible for conceptualising, conducting and reporting the study. funding. the study was made possible through personal research funds of the author. conflicts of interest. none. 1. south african qualifications authority. saqa bulletin 1997;1(1). 2. andrews j, higson h. graduate employability, ‘soft skills’ versus ‘hard’ business knowledge: a european study. high educ europe 2008;33(4):411-422. https://doi.org/10.1080/03797720802522627 3. moon j. guide for busy academics no. 4: learning through reflection. 2005. https://nursing-midwifery.tcd. ie/assets/director-staff-edu-dev/pdf/guide-for-busy-academics-no1-4-hea.pdf (accessed 18 september 2017). 4. munby h, russell t. educating the reflective teacher: an essay review of two books by donald schon. j curriculum stud 1989;21(1):71-80. https://doi.org/10.1080/0022027890210106 5. nvivo qualitative data analysis software. qsr international pty ltd, version 10, 2012. http://www.qsrinternational. com/products_nvivo.aspx (accessed 18 september 2017). 6. lachman n, pawlina w. integrating professionalism in early medical education: the theory and application of reflective practice in the anatomy curriculum. clin anat 2006;19(5):456-460. https://doi.org/10.1002/ca.20344 7. barrie sc. a conceptual framework for the teaching and learning of generic graduate attributes. stud high educ 2007;32(4):439-458. https://doi.org/10.1080/03075070701476100 8. kember d, leung d. the influence of active learning experiences on the development of graduate capabilities. stud high educ 2005;30(2):155-170. https://doi.org/10.1080/03075070500043127 9. griessel h, parker b. graduate attributes: a baseline study on south african graduates from the perspective of employers. pretoria: higher education south africa (hesa) and the south african qualifications authority (saqa), 2009. 10. department of education. national plan for higher education in south africa. pretoria: doe, 2001. 11. gibbs g, coffey m. the impact of training of university educators on their teaching skills, their apporach to teaching and the approach to learning of their learners. active learn high educ 2004;5(1):87-100. https://doi. org/10.1177/1469787404040463 12. van amburgh ja, devlin jw, kirwin jl, qualters dm. a tool for measuring active learning in the classroom. am j pharm educ 2007;71(5):85-97. https://doi.org/10.5688/aj710585 accepted 30 march 2017. short research report https://doi.org/10.1080/03797720802522627 https://nursing-midwifery.tcd.ie/assets/director-staff-edu-dev/pdf/guide-for-busy-academics-no1-4-he https://nursing-midwifery.tcd.ie/assets/director-staff-edu-dev/pdf/guide-for-busy-academics-no1-4-he https://doi.org/10.1080/0022027890210106 http://www.qsrinternational.com/products_nvivo.aspx http://www.qsrinternational.com/products_nvivo.aspx https://doi.org/10.1002/ca.20344 https://doi.org/10.1080/03075070701476100 https://doi.org/10.1080/03075070500043127 https://doi.org/10.1177/1469787404040463 https://doi.org/10.1177/1469787404040463 https://doi.org/10.5688/aj710585 september 2018, vol. 10, no. 3 ajhpe 145 forum in a world where language is important for self-understanding and relating, the work of a multilingual speech-language therapist (slt) can bring a person from the margin into the community and from silence to communication. in south africa (sa), where language was a means for structural exclusion under apartheid, the work of an slt supports empowerment for clients. however, in a context where many slts do not speak the language of their clients, their work might be limited. the paradox remains a structural mechanism in contemporary sa public health that does not respond to citizens’ needs. communication across cultures and languages in hospital settings remains a challenge.[1] slts working in sa state hospitals find themselves in challenging cultural and language contexts, where therapists and clients often do not speak the same language. the context is further limited by existing interpreter resource challenges. as communication disorder professionals, their scope of practice requires that they be clinically and culturally sensitive and competent. however, it appears that training institutions might not be preparing them fully for the type of situations and scenarios that they encounter as part of their lived experiences within their profession.[2] according to penn et al.,[2] this lack of preparedness for the sa public health context includes challenges with professional, technical, systemic, managerial, interpersonal and ethical issues. these can be attributed to a variety of complex factors – key being gaps in resources, including research, culturally appropriate intervention tools and relevant human resources. the link between culture and language cannot be overemphasised. health professions council of south africa (hpcsa) regulations relating to the undergraduate curricula and professional examinations in speechlanguage therapy[3] state that ‘the curriculum (academic and clinical) must be consistent with exit level outcomes of the professional board. education and training must: • be relevant to the needs of south africa; • ensure that provision of services to clients/patients is not compromised where the clinician does not speak the client’s/patient’s language.’[3] however, numerous local studies have shown that despite this regulation, many slts employed in the public and private sectors still do not have culturally and contextually relevant intervention tools.[4-8] some authors found that slts not competent in african languages assess non-englishspeaking adults and children in english or afrikaans. annual evidence from the national forum (department of health grouping of all slts nationally) confirms findings from these studies directly from practising clinicians who service 80% of the population, who make use of public health facilities (k khoza-shangase – personal communication, 30 january 2018). slts remain unaware of cultural implications and clients are compromised when assessed in a language that they are not proficient in, indicating that more transformative training and cultural competence skills for the current workforce are pivotal. curricula for undergraduates appear limited in linguistic and cultural diversity training for effective preparation of slts. state hospitals are multilingual and multicultural platforms where slts implement their practical professional training. trainee slts are required by the hpcsa to take the hippocratic oath – a mandate guiding the physicianpatient relationship. the oath is taken at the beginning and the end of their training and is based on the premise that they will treat and serve their patients to the best of their ability, upholding principles, such as confidentiality and the ethics of social justice.[9] despite this professional training context and individual responsibility, evidence suggests that many slts qualify without the requisite cultural competence and critical diversity literacy. however, this cannot be generalised, as there are graduates from one predominantly black institution that has been training slts since the early 1990s.[10] patients who do not speak the same language as their healthcare professional receive limited health services compared with those who do, which may result in poor health outcomes. speech-language therapists in multilingual and multicultural hospital settings often face these challenges. language and translation issues have a marked impact on information received by patients and their families or caregivers. despite clinicians’ challenges experienced in multilingual settings, they seem to find that their working experience is an important leveller when there is an interpreter present during consultations. human or linguistic rights-based teaching frameworks should include how to work with interpreters and be a culturally competent clinician. evidence suggests a slowly increasing number of african language-speaking speech and hearing therapists. there is evidence that some of the existing workforce in the public and private sectors are not culturally competent, as required by the health professions council of south africa (hpcsa). academic curricula and the clinical practice of speech-language and audiology students and professionals should transform application of theoretical knowledge when treating speech and hearing disorders in a multilingual and multicultural context, enhancing the efficacy of management of communication disorders. furthermore, the profession needs to work on developing culturally and linguistically relevant intervention tools. afr j health professions educ 2018;10(3):145-147. doi:10.7196/ajhpe.2018.v10i3.1045 speech-language therapy consultation practices in multilingual and multicultural healthcare contexts: current training in south africa m mophosho, phd department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa corresponding author: m mophosho (munyane.mophosho@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 146 september 2018, vol. 10, no. 3 ajhpe forum this opinion piece was motivated by my exposure and experience as a clinical educator in the department of speech-language pathology and audiology at the university of the witwatersrand, johannesburg, sa. this encompassed observing challenges faced by slts during consultations with caregivers seeking help for their children who have communication disabilities. communication difficulties encountered by both slts and caregivers in these multicultural and multilingual contexts resulted in limited understanding on both sides and rendered the intervention process ineffective. i could empathise with the caregivers’ discomfort when they were treated by medical professionals from a different cultural background, particularly when due consideration is given to the power dynamics created by sa’s sociopolitical history. failed communication and ineffective interventions in multicultural and multilingual contexts raise several pertinent questions for researchers in speech-language therapy. how does a mother cope with her disabled child when she cannot understand that her child has a severe intellectual and/ or physical disability? how does a practitioner function effectively when overwhelmed by the inability to speak informatively with patients/caregivers? how do practitioners operate in the context of laws related to language and human rights? interestingly, in a national study by southwood and van dulm,[7] slts with less experience claimed that they could provide services for diverse clients, including african-language speakers. this is potentially problematic, as they might be unaware of their bias and lack of skills. this article is particularly important in the context of post-apartheid expectations for human rights and service delivery. sa is reputed to have a most progressive constitution, including socioeconomic rights, yet inequities in access to and utilisation of health services continue.[11,12] as part of the problem and possible champions of the solution, slts must first examine their own practices to find solutions across the public health system. studies of doctor-patient communication reported that problematic communication leads to reduced health outcomes, poor compliance by patients, and patients’ poor commitment to the intervention and treatment regimens.[13-15] thomas[16] posits that the communication challenge across all healthcare practitioners comprises unequal encounters in doctor-patient communication. research on interpretation is also challenging, because it cuts across diverse areas of practice, encompassing spoken and unspoken language. consequently, documentation of challenges related to interpretation and effective work between practitioners and interpreters is limited.[17] professionally, speech-language therapists face similar challenges to those of other healthcare practitioners in attempts to communicate with their clients.[18] yet, the use of language and speech lies at the core of slt service delivery: the tools of diagnosis and intervention for slts are mainly centred on communication methods and approaches. executing slt service delivery can be hindered by cultural and linguistic differences between clinicians and clients, thus having an effect on communication. in post-apartheid sa, such differences replicate historical power dynamics, rendering clients even more silent, particularly as the language of practice for many slts is english, which is not the first or second language of many clients. without clear demand-driven engagement, slts cannot provide effective interventions. this in effect creates a cycle of exclusion of patients/ clients entering the healthcare system, but exiting without receiving effective treatment or care, as language remains a barrier. speech-language therapy thus creates a unique and communication-focused context within which to examine the challenges of healthcare communication in a multilingual and multicultural setting. challenges research has shown that interpretation may not necessarily address challenges of multilingualism and multiculturalism in contexts such as international conferences, court interpretation and, to some extent, medical interpretation.[17] yet, knowledge production in the field of interpretation is in its infancy.[17] it is challenging because it cuts across diverse areas of practice, encompassing spoken and unspoken language. therefore, documentation of challenges related to interpretation and how practitioners could work effectively with interpreters in the clinical fields of speech pathology and audiology has been limited.[17] given that cultural and linguistic diversity profoundly affects how families and professionals interrelate cross-culturally and participate together in treatment programmes,[19] the department of health should invest in recruiting trained interpreters to assist healthcare providers and patients in the public service. in public settings where there are no mediated/interpreter services, the objectives of the national language policy framework[20] are contravened. publications on interpreting in sa healthcare establishments are lacking. existing studies have looked at mediation in different languages and at factors contributing to facilitating/inhibiting interpretations.[1,13,15] as noted in my observations and research, most of the slts working in sa hospitals are not trained in critical diversity literacy and power dynamics, and therefore have a limited understanding of patients’ multicultural and linguistic needs. limited knowledge of clients’ culture is not conducive to collaboration with diverse families. for communication intervention to be successful, it should be culturally and linguistically appropriate. culture and language can be a barrier in working collaboratively when parties do not understand each other in a multicultural and multilingual setting. working from a human rights perspective is also imperative. recommendations to be successful as slts in providing quality rehabilitation, we need culturally appropriate resources (e.g. assessment and treatment tools) and to work in ways that do not distance our clients culturally. this is important for ethical and professional behaviour and is to our clients’ benefit. i recommend the following based on my experience as a clinical educator and researcher: • transformation of admission criteria of trainee slts in undergraduate programmes in historically privileged institutions to increase accessibility to african language-speaking students. this will transform and redress practice and balance of power of the workforce in public hospitals. • curricula should comprehensively include cultural competency skills. extensive training is necessary. it would be important to incorporate teaching on the effect of race, ethnicity and culture on clinical decisionmaking. the effect of stereotyping, for example, can be addressed by training slts to be aware of stereotypes. • training institutions should enact language policies that bring redress. this will translate to trainee slts studying at least one sa language or having a basic or introductory knowledge it. • the integration of service learning in the curriculum to inculcate the importance of social justice and human rights of citizens. slts are bound by the ethical principles of justice, beneficence and human rights. according to the sa speech-language hearing association (saslha), slts should ‘ensure that services are made available and accessible and that these services are appropriate to particular individual and september 2018, vol. 10, no. 3 ajhpe 147 forum community needs’. this could be conducted by using formal, informal and in-service training of qualified slts on cultural competence. • training institutions should encourage students to conduct and disseminate action and emancipatory critical research that can guide the regulatory body, such as the hpcsa, in drafting position statements on language, culture and codes of conduct for slts. conclusion the solution to this problem lies in understanding how we can work effectively with interpreters in a multilingual and multicultural society. for this, an overhaul of the training of slts is required, including an understanding of diversity and human rights regarding patients. fortunately, with increasing numbers of graduates who speak african languages, the majority of whom are trained by one institution, service delivery to the multilingual and multicultural population might be improved. acknowledgements. none. author contributions. sole author. funding. diversifying the academy programme in the faculty of humanities, university of the witwatersrand, johannesburg, sa. conflicts of interest. none. 1. penn c. factors affecting the success of mediated medical interviews in south africa. curr allergy clinical immunol 2007;20(2):66-72. 2. penn c, mupawose a, stein j. from pillar to posts: some reflections on community service six years on. s afr j commun disord 2009;56:8-16. 3. national department of health, south africa. health professions council south africa: regulations relating to the undergraduate curricula and professional examinations in speech-language therapy. government gazette no. 35351, 2012. (published under government notice r388.) 4. pascoe m, maphalala z, ebrahim a, et al. children with speech difficulties: an exploratory survey of clinical practice in the western cape. s afr j commun disord 2010;57(1):13-17. https://doi.org/10.4102/sajcd.v57i1.51  5. jordaan h, yelland a. intervention with multilingual language impaired children by south african slts. j multilingual commun disord 2003;1(1):13-33. https://doi.org/10.1080/1476967031000102959  6. barratt j, khoza-shangase k, msimang k. speech-language assessment in a linguistically diverse setting: preliminary exploration of possible impact of informal ‘solutions’ within the south african context. s afr j commun disord 2012;59(1):34-44. https://doi.org/10.7196/sajcd.51 7. southwood f, van dulm o. the challenge of linguistic and cultural diversity: does length of experience affect south african speech-language therapists’ management of children with language impairment? s afr j commun disord 2015;62(1):14. https://doi.org/10.4102/sajcd.v62i1.71 8. mdlalo t, flack p, joubert r. are south african speech-language therapists adequately equipped to assess english additional language (eal) speakers who are from an indigenous linguistic and cultural background? a profile and exploration of the current situation. s afr j commun disord 2016;63(1):1-5. https://doi.org/10.4102/ sajcd.v63i1.130 9. ogubanjo ga, knapp van bogaert d. the hippocratic oath: revisited. s afr fam pract 2009;51(1):31-33. 10. moonsamy s, mupawose a, seedat j, mophosho m, pillay d. speech-language pathology and audiology practice in south africa: reflections on transformation in professional practice since the end of apartheid. perspective, sig 2017;17(2). 11. kale  r.  impressions of health in the new south africa: a period of convalescence.  bmj 1995;310(6987):11191122. https://doi.org/10.1136/bmj.310.6987.1119 12. harris b, goudge j, ataguba j, et al. inequities in access to health care in south africa. j publ health policy 2011;32(s1):s102-s123. https://doi.org/10.1057/jphp.2011.35  13. levin m. the importance of language and culture in paediatric asthma care: communication problems between doctors and xhosa speaking parents of children at a paediatric teaching hospital. curr allergy clin immunol 2005;18(1):8-12. 14. macdonald me, carnevale fa, razack s. understanding what residents want and what residents need: the challenge of cultural training in paediatrics. med teach 2007;29(5):464-471. https://doi.org/10.1080/01421590701509639  15. hussey n. the language barrier: the overlooked challenge to equitable health care. in: padarath a, english r, eds. south african health review 2012/2013. durban: health systems trust, 2013. 16. thomas rk. health communication. new york: springer science and business media, 2006. 17. langdon hw, cheng l. collaborating with interpreters and translators in communication disorders field. eau claire, wi: thinking publications, 2002. 18. ferguson a, armstrong e. reflections on slt’s talk: implications for clinical practice and education. int j language commun disord 2004;39(4):469-507. https://doi.org/10.1080/1368282042000226879  19. centeno jg. serving bilingual patients with aphasia: challenges, foundations, and procedures. revista de logopedia, foniatría y audiología 2009;29(1):30-36. https://doi.org/10.1016/s0214-4603(09)70141-x 20. national department of arts and culture. national language policy framework, 2003. http://www.dac.gov.za/ sites/default/files/lpd_language%20policy%20framework_english_0.pdf (accessed 16 august 2018). accepted 5 march 2018. https://doi.org/10.4102/sajcd.v57i1.51 https://doi.org/10.1080/1476967031000102959 https://doi.org/10.7196/sajcd.51 https://doi.org/10.4102/sajcd.v62i1.71 https://doi.org/10.4102/sajcd.v63i1.130 https://doi.org/10.4102/sajcd.v63i1.130 http://dx.doi.org/10.1136/bmj.310.6987.1119 https://doi.org/10.1057/jphp.2011.35 https://doi.org/10.1080/01421590701509639 https://doi.org/10.1080/1368282042000226879 https://doi.org/10.1016/s0214-4603(09)70141-x http://www.dac.gov.za/sites/default/files/lpd_language%20policy%20framework_english_0.pdf http://www.dac.gov.za/sites/default/files/lpd_language%20policy%20framework_english_0.pdf 38 march 2018, vol. 10, no. 1 ajhpe research the words telemedicine and telehealth are used synonymously by some. telemedicine refers to the use of information and communication technologies for clinical diagnosis and monitoring and the provision of healthcare over distance, but telehealth is a broader concept. telehealth is defined by the health resources and services administration[1] as ‘the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration’. telehealth has been viewed as a promising method of addressing the current health challenges surrounding service delivery to remote and rural areas. it can be used to alleviate the shortage of healthcare practitioners; improve access to specialist physicians; reduce the costs of accessing healthcare services by reducing the need to travel for consultation; and provide support to rural general practitioners and community service therapists, thereby improving retention in rural communities.[2-6] one of the suggested strategies to promote telehealth at a national level within developing countries is to introduce telehealth into the education and training programmes of healthcare professionals, both undergraduate and postgraduate, so that they are aware of, and can use, telehealth methods to provide healthcare to their patients.[7] the benefits associated with telehealth provide impetus for student and professional training across the healthcare disciplines. as students receive their training from academics at tertiary institutions, trained faculty with relevant content knowledge[8,9] and research experience in the field[10] should be available to disseminate this information and to demonstrate how telehealth can be used to provide and improve patient care. a lack of skilled personnel to facilitate training of healthcare professionals is a barrier to sustaining telehealth models of service delivery.[11] a study on telehealth in primary care found that telehealth could support the primary healthcare approach, as its inclusion into student training can be used to connect students with patients from remote and rural areas, allowing them access to diverse communities, but also that insufficient training and exposure during undergraduate training contributed to a limited uptake of this technology.[12] these results are especially relevant in south africa (sa), where almost 50% of the population lives in rural areas.[13] there is sufficient evidence supporting the use of telehealth services to improve patient care across many disciplines of health, including medicine, physiotherapy, nursing, audiology and speech-language pathology.[6,14-19] however, there is a paucity of literature pertaining to the training and education of students in using and implementing telehealth services. a systematic review conducted by edirippulige and armfield[20] found no record of education and training programmes on telehealth in africa. this the professional training and development of healthcare professionals in the area of telehealth is important to ensure the sustainability of this service delivery model. tertiary institutions are among the key constituents involved in telehealth education, training and development. academics within the healthcare sciences should therefore have the necessary experience and knowledge in this area to support the education and training of students. the objectives of this study were to determine the perspectives, experiences and attitudes of south african academics within various disciplines of health sciences regarding telehealth, as well as their views on suitable content areas for a telehealth module. a descriptive survey design was implemented. sixtysix fulltime employed academic staff from five universities participated. the majority of participants were familiar with the terms telehealth/electronic health (ehealth), while 59% were unfamiliar with terms such as synchronous and asynchronous services. eighty percent of respondents felt it necessary to include telehealth in the curriculum. the majority (89%) did not conduct research in telehealth. seventy-one percent felt positive that telehealth could benefit the profession, and 30% stated that lack of standards creates a negative attitude toward the area and its sustainability. the majority of participants (77%) felt that their final-year students knew very little about telehealth upon exiting their study programme. almost half (45%) of the participants felt that ethical issues were the most important aspect that needed to be included in a telehealth module, while data management was ranked as being least important (49%). the correlation between the perspectives on ethical issues and limitations to telehealth was statistically significant (p=0.007), implying that participants saw lack of ethical considerations as a limitation to the uptake of telehealth practice. while attitudes regarding telehealth were positive, concerns were raised around the lack of standards and guidelines. opportunities for professional development in telehealth need to be created through continued professional development (cpd) workshops and training. this in turn may provide more skilled faculty to teach in this area, allowing students to receive better instruction on telehealth service delivery models. afr j health professions educ 2018;10(1):38-43. doi:10.7196/ajhpe.2018.v10i1.957 the perspectives of south african academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training s m govender, mcomm path (ukzn), m mars, mb chb (uct) department of telehealth, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: s m govender (samantha.govender@smu.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 39 research is of concern, as the importance of telemedicine has long been recognised by the sa government. the first phase of the sa national telemedicine system was implemented in 1999, but was not successfully sustained.[21] healthcare acts and policies within sa recognise the value of information and communication technology (ict) in health, and support the use of telehealth applications and technology within the healthcare service delivery model.[22-24] the national department of health outlines 10 priorities (the 10-point plan) within the national service delivery agreement, one of which is the need to improve health infrastructure, including the use of ict and sophisticated technology to advance patient care, and has developed a national ehealth strategy.[22] one aspect identified within the strategic objectives is the need to improve telehealth capacity building. the strategy notes that educational opportunities in telehealth are limited, and government therefore aims to promote capacity development in telehealth through education and research. universities, through their academic staff, have been identified as key role-players to facilitate this process. related to this is the development of education and training courses that are well structured, to provide the theoretical and practical competencies required for administering clinical and educational services via a telehealth model. in order to capacitate academics to teach and train students in this area, key aspects relating to telehealth need to be understood. a review of the literature identified key knowledge areas required for effective telehealth practice that should be included in a telehealth course: computer competence and literacy;[3,25,26] understanding of ethical and legal issues;[25-29] understanding of the protocols and standards that guide good practice;[30] and data management, specifically relating to online transmission, retrieval and storage of data.[29] it is important to put these issues into the sa context in view of current healthcare constraints, service delivery issues and the infrastructure requirements of a telehealth service. early literature from the developed world found that some disciplines of healthcare reported limited or no exposure to telehealth during their undergraduate training. in 2002, the american speech and health association found that only 11% of the 1 667 american speech language pathologists and audiologists used telehealth in their practice. lack of theoretical and clinical exposure to telehealth at undergraduate level, lack of guidelines and insufficient clinical evidence were cited as the primary reasons for non-use by over three-quarters of respondents.[31] the current situation in sa is believed to be similar. the perspectives, practices and overall attitudes of academics toward education and training in telehealth is considered a key enabler of sustainable development of telehealth.[32] the aim of this study was to determine the perspectives, attitudes and exposure of academics within the various disciplines of the health sciences to telehealth and its inclusion in student training. the study further aimed to identify telehealth information that exists within the current curricula as well as to understand which areas of telehealth academics consider important when designing a telehealth course. methods ethical approval to conduct the study was obtained from the university of kwazulu-natal ethics committee (ref. no. hss/0335/014d). a descriptive survey design was implemented, with quantitative methods of analysis. the questionnaire developed by the american speech and hearing association[31] was adapted to include questions relevant to the sa context. the questionnaire comprised 30 questions across four domains linked to the objectives of the study, which were to determine sa academics’: (i) experiences (in teaching, learning and research) with telehealth; (ii) attitudes about telehealth; and (iii) perspectives on what they considered would be most valuable for inclusion in a telehealth course, based on six key areas provided. the questionnaire was circulated electronically via google forms. questions and statements were multiple choice, yes-or-no responses or open-ended, allowing participants to explain their responses. letters requesting participation were sent to the seven sa universities offering health sciences programmes, of which five consented to participate in the study. once institutional permission from the university was granted, permission from heads of department (hods) of the various disciplines was requested. some hods failed to respond to the request, and this contributed to a low response rate. invitations to participate in the study could only be sent to the list of email addresses that could be obtained from the hods who furnished this information. an information letter together with a consent form and a link to the questionnaire was emailed to 170 academic staff members within health sciences departments from the five participating universities. the online survey system allowed the participants 3 weeks to respond. in addition to basing our questionnaire on one that had already been developed and used, other measures to ensure the validity of our questionnaire included a pilot study. ten part-time employed academics were asked to complete the questionnaire to discover whether they experienced any problems answering any of the questions. they were required to complete a response form giving feedback on the clarity of questions, language and grammar, as well as on the length of the questionnaire. no-one experienced any challenges, and no changes were made to the questionnaire. the data were analysed using descriptive and inferential statistics. for the 6-point likert-scale questions on key areas that could be included into a telehealth module, spearman’s correlation coefficient was calculated. the mean square contingency coefficient, the phi coefficient, was used to determine the degree of association between the binary variables (yes-or-no responses). alpha was set at 5%. results a total of 66 academics completed the questionnaire, a response rate of 39%. the distribution of participants across the various health science disciplines is shown in fig. 1. twenty-nine of the academics (44%) had >10 years of teaching experience, 19 had <5 years of experience (29%) and the remaining 18 had between 5 and 10 years of experience (27%). experience with and exposure to telehealth (teaching, learning and research) participants were asked about their experiences with, and exposure to, telehealth. the questions related to their understanding of key definitions and operation and familiarity with telehealth equipment, and their involvement in teaching and research within these areas. regarding how they were first introduced to telehealth, 51 respondents (77%) indicated that they had read about it, while 9 (14%) had heard about it during a conference presentation. the remainder were introduced to it by colleagues 40 march 2018, vol. 10, no. 1 ajhpe research and demonstrations conducted by suppliers. responses to the yes-or-no options are shown in table 1. the majority of the academics did not teach (79%) or research (89%) telehealth. there was a statistically significant relationship between teaching and research (p=0.001), as those who were teaching telehealth were also conducting research in the area. the majority (80%) of participants indicated that they felt it is necessary to include telehealth in the curriculum, while some were either unsure or disagreed. an open-ended question asked them to support their response. most attributed their reasoning to meeting the needs of communities through the use of telehealth services, and 35 (53%) participants stated that students need to have knowledge, exposure and competence in this area so that it is sustainable. one participant stated: ‘the times that we live in are changing and platforms for service delivery are also changing. students should be able to function in various contexts and use various platforms to offer services to patients. i think understanding tele-audiology will be beneficial to students, especially taking into consideration the shortage of professionals in sa’ (audiologist and speech-language pathologist, 8 years’ experience). the importance of using internet-based services was emphasised: ‘telehealth is a collection of means or methods for enhancing healthcare, public health, and health education delivery and support using telecommunications technologies. telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health and education services. i believe that content is freely available to all via the internet and it is best to incorporate it into teaching rather than avoid it’ (physiotherapist, 5 years’ experience). one person who felt that it was unnecessary to include telehealth in the curriculum, however, added: ‘our students are being trained to be clinicians and not academics, the use of telehealth between client and clinician is not relevant in our underresourced areas … among clinicians it is used, and can be learnt in the field at the particular venue, and hence does not to be included in the curriculum’ (occupational therapist, 7 years’ experience). with regard to devices and technology, all institutions had some form of telehealth equipment across the various disciplines. the three disciplines reporting the most access to technology and devices were audiology, physiotherapy and nursing. three of the five institutions owned a kudu-wave 5 000 tele-audiology device. one institution is involved in mhealth (mobile health) and has developed a smartphone application for hearing screening. the discipline of nursing across two institutions reported management of rural community patients via telehealth services. attitudes towards and perspectives on telehealth a total of 47 (71%) respondents indicated that they felt that telehealth could positively benefit their profession, and 47 (71%) stated that it has the potential to address service delivery barriers. twenty (30%) stated that the lack of standards for telehealth practice creates a negative attitude towards the area, while 11 (17%) had a negative attitude regarding the sustainability of telehealth practices even though they felt positive about the benefits. a total of 46 (70%) felt that introducing content on telehealth-based teaching resources could improve overall teaching and learning. however, 18 (27%) did not feel that introducing it would improve learning outcomes for their respective degrees. the responses to the other statements are shown in table 2. there was no correlation between responses to the question, ‘can telehealth positively impact the profession?’ and the question on lack of standards (p=0.369). this implies that not all participants who felt that the lack of standards, guidelines and policy makes it difficult to implement telehealth thought that this would interfere with the positive impact that telehealth could make on their profession. additional comments regarding their attitudes towards telehealth were sought, and included the following: ‘more information and practical demonstrations may change negative views of most audiologists, including academics, toward tele-audiology’ (audiologist, 20 years’ experience). ‘i don’t know much about tele-audiology currently and would benefit from knowing more’ (audiologist and speech-language pathologist, 8 years’ experience). 27% 12% 15% 14% 9% 8% 4% 11% audiology speech language pathology occupational therapy physiotherapy human nutrition and dietetics public health and nursing unknown medicine fig. 1. distribution of participants by discipline, %. table 1. experiences with and exposure to telehealth (teaching, learning and research) (n=66) yes, n (%) no, n (%) unsure familiarity with basic telehealth terminology 59 (89) 7 (11) familiarity with synchronous v. asynchronous telehealth services 27 (41) 39 (59) attended a cpd-related activity on telehealth 18 (27) 48 (73) experience with operating a telehealth device 26 (39) 40 (61) researching telehealth 7 (11) 59 (89) teaching telehealth 14 (21) 52 (79) do you think telehealth should be included in the curriculum? 53 (80) 10 (15) 3 (5) cpd = continuing professional development. march 2018, vol. 10, no. 1 ajhpe 41 research ‘it is unrealistic at most district-level facilities around our country, and so will students actually be able to use or benefit from this while studying or when qualified?’ (occupational therapist, 1 year’s experience). ‘i believe in its potential to resolve many of the practical issues we experience in training interns (human nutrition and dietetics, 20 years’ experience). respondents were asked whether they thought that telehealth-based services would be a feasible way of ensuring that students have adequate exposure to a maximum number and variety of patients, of whom 55 (83%) agreed. when asked whether their students were knowledgeable about telehealth services, 51 (77%) felt that their students knew very little about them. only 14 (21%) indicated that the introduction of telehealth modules was discussed in curriculum planning meetings. finally, academics were asked to rank, in order of importance from most important to least important, the six content areas considered relevant for a telehealth module identified from the literature. these were: standards and protocols; ethical issues; computer literacy and understanding of computers and technology; limitations of telepractice; telepractice as it relates to the sa and african context; and data management as it relates to online service delivery. only 54 participants responded to this question in full (fig. 2). a significant correlation was noted between the variables ‘ethical issues’ and ‘limitations of telehealth services’ (p=0.007). respondents who regarded ethical issues as most or very important also regarded limitations of telehealth services to be very important or important. the correlation between individuals’ responses to the question regarding how face-to-face contact is central to their profession and their selection of ethical issues as most relevant was also significant (p=0.04). discussion telehealth can improve service delivery to remote and rural areas, reduce health service disparities that exist between socioeconomic groups and reduce health costs. education and training in this area would strengthen the health system’s capacity to deliver and sustain these services.[20] academics are central in facilitating the education and training of undergraduate healthcare professionals. the key findings of this study are that the majority of participants do not have much experience with or knowledge about telehealth, do not include any telehealth content in their teaching, have not used a telehealth device and do not have any current research interests in this area. this relationship between teaching and research in telehealth was significant, implying that those participants who were teaching in the area were also engaged in research, possibly as a way to advance their knowledge. the academics’ lack of knowledge about telehealth makes it difficult for them to teach in table 2. attitudes regarding telehealth (n=66) statement yes, n (%) no, n (%) telehealth can positively impact our profession 47 (71) 19 (29) lack of standards, guidelines and policy makes it difficult to implement such practice 20 (30) 46 (70) face-to-face contact is central to our professional interaction, making tele-audiology inappropriate 10 (15) 56 (85) telehealth can address the barriers to services related to access and language between clinician and patient 47 (71) 19 (71) telehealth can improve health service delivery in sa 47 (71) 19 (71) telehealth is a promising concept, provided that a structured curriculum is designed to train students appropriately 50 (76) 16 (24) i think that telehealth is sustainable within the sa context 32 (48) 34 (52) introducing telehealth into clinical training would improve learning outcomes by increasing exposure to more diverse patients 48 (73) 18 (27) sa = south africa. 26 51 5 8 5 5 45 21 13 13 5 3 23 5 38 21 3 10 0 8 18 31 25 18 5 10 8 13 49 15 0 5 18 15 13 49 60 50 40 30 20 10 0 pa rt ic ip an ts w h o c h o se ra n ki n g , % content areas st an da rd s a nd pr ot oc ol s et hi ca l is su es co m pu te r l ite ra cy an d te ch . c om pe te nc e lim ita tio ns o f te le he alt h se rv ice s ap pl ica bi lit y t o sa co nt ex t da ta m an ag em en t most imp. for me very imp. imp. good to include include if there's time least imp. to me fig. 2. participant rankings of importance (imp.) of six content areas for a telehealth module (6-point likert scale). 42 march 2018, vol. 10, no. 1 ajhpe research this area. this finding supports a recent study by grogan-johnson et al.,[29] who surveyed telepractice training in graduate speech-language pathology and audiology programmes. the barriers to adopting telepractice in graduate programmes were related to, among others, a lack of trained faculty to provide instruction. ehnfors and grobe[33] describe this as a real challenge facing healthcare professionals who may find themselves in the future working in a technologically driven healthcare system without the necessary competencies. these studies provide strong motivation for education and training, and demonstrate the need for certification programmes for both academics and healthcare professionals, so that students can also be the recipients of this information. although the majority of academics displayed a positive attitude towards the impact that telehealth can make on the profession, and on the improvement of service delivery, the lack of available standards and guidelines created a negative attitude towards it. picot[25] emphasises the need for guidelines and standards to be developed across all professions that intend using telehealth systems and methods, and further recommends that education and training standards be developed so that suitable knowledge and skills can be obtained. a systematic review by molini-avejonas et al.[34] identified the barriers to the use of telehealth in the speech, language and hearing sciences as the lack of training, regulation of practice and acceptance and recognition of telehealth benefits by both the public and professionals. these findings further support the need for training and development in the area of telehealth. in an article by frenk et al.[35] on transforming education for health professionals to strengthen health systems, it was emphasised that ict is important for transformative learning in terms of exposing undergraduates to telehealth models of service delivery. the authors state that ‘an exciting area of development is the application of ict to build global consortia of education and institutions to leverage their resources, realise synergies and transform educational opportunity into a global public good’. a survey of the attitudes of 202 audiologists toward tele-audiology identified interest in using internet-based facilities to provide patient support. however, participants had concerns regarding their lack of knowledge of and exposure to technologically based services during their undergraduate years.[36] the literature also shows that a lack of user acceptance of technology is a primary reason for the poor uptake of telehealth.[37,38] other studies suggest that exposure to and experience with telehealth increases positivity.[36,39] the present study reflects an overall lack of experience with and exposure to telehealth in sa academics. in addition, participants demonstrated varied attitudes regarding the feasibility and sustainability of telehealth within their contexts. this attitudinal disposition could shape learners’ interest and practice within the area. the majority of participants did not feel confident in the subject matter, owing to their lack of exposure to it. a way forward in addressing this would be to promote professional development activities in the area of telehealth. various systematic reviews indicate that across the different health science disciplines, there are needs for protocol and guideline development, increasing confidence and competence, and the development of training standards.[25,29,40,41] this is in keeping with the strategic priorities of the sa government, in terms of the ehealth strategy for sa.[22] according to the world health organization,[42] health professionals and academic institutions are among the key constituents involved in addressing the health needs of communities, through evidencebased teaching and the development of new and improved methods of service delivery.[42] for the purposes of the study, six key areas were suggested as potential content areas for a telehealth module. protocol and standards development was ranked as the most important area by participants. this was seen to be one of the key strategies necessary for promoting the advancement of telehealth in various health disciplines, as well as for interprofessional collaboration.[43] wade et al.[44] have also identified the development of protocols as one of the key components of sustainable practice. contextual relevance is important within healthcare, especially when one considers establishing infrastructure and rolling out technology to promote health services. in a context where social determinants of health have contributed to the inequitable distribution of health resources and access,[45] and to failure in redressing the injustices of the past, careful consideration must be taken to ensure that these service delivery models are both feasible and sustainable. respondents did not feel that contextual relevance was an important component of a telehealth module, with 49% stating that it can be included if there is time. data management was viewed as the least important subject to be included in a telehealth module. however, data management is a very important part of telehealth services, especially when one considers the intricacies involved in the storage, retrieval and transmission of patient information. failure to adequately manage patient data could result in malpractice. data management was, however, ranked as the least important component by 49% of respondents. an understanding of the legal and ethical issues related to telehealth service delivery is crucial for effective practice.[27] ethical practice guides professional behaviour, and is central to service delivery. its importance was reflected in the responses, with 45% rating it as the most important component of a telehealth module, and 21% as very important. a significant correlation was noted between the variables ‘ethical issues’ and ‘limitations’, as well as between face-to face-contact and ethical practice. this implies that participants considered the limitations of telehealth practice and face-toface contact with patients as important ethical considerations. according to hebert et al.,[46] an understanding of technology, together with its advancement and development, is absolutely integral in promoting the progression of the science behind telehealth. they emphasise that it is important to also understand how the patient views technology and its ability to assist them in healthcare. this understanding is largely developed from the information imparted by a knowledgeable healthcare provider. understanding how technology works is important, considering that telehealth technology can range from simple videoconferencing technology to sophisticated computer programs and virtual environments.[47] jobson[48] mentions that while the government in the usa has significantly progressed in providing medical technology and information systems to support the healthcare system, a lack of trained professionals has resulted in its underutilisation. computer literacy and competence in using technology was ranked third of the six components. the limitations of this study were the refusal of two universities to participate, and the small sample size, representing less than 50% of medical staff at the five participating universities, therefore limiting the generalisability of study findings. the requirement to rank the six content areas on an ordinal scale of importance may give a skewed impression of the overall view of the respondents. the relative differences in importance are not known. some respondents, for example, may have considered two or more components to be of very similar importance, but were obliged to rank them. march 2018, vol. 10, no. 1 ajhpe 43 research conclusion the role of academia within telehealth education and training is emphasised in the literature, and relates to the need for its inclusion in teaching and clinical training for its sustainability. academics in this study shared the view that the inclusion of telehealth in the curriculum could be beneficial for students, and for their own development. they also considered the development of standards and protocols and legal and ethical issues as the most important areas to include in a telehealth course, while applicability to the sa and african context and data management were viewed as the least important considerations. a dialogue needs to begin among the various disciplines on how to integrate telehealth knowledge and clinical training into their curricula. academics are at the forefront of providing knowledge to students, but can only do so if they are knowledgeable themselves. it would also be valuable for more research to be conducted within individual health professions regarding the clinical implications of introducing telehealth into curricula. this will increase knowledge production, which could lead to knowledge translation, thus ultimately addressing the knowledge-to-action gap. this study also highlights the need to develop training standards and guidelines for telehealth. guidelines – clinical, technical, operational and ethical – are required to ensure quality of care and to overcome current negative perceptions of telehealth. professional development in the area of telehealth for academics is also required, and can be facilitated through more workshops, conference presentations given by experts in the field and demonstrations by companies selling telehealth systems. the future of telehealth services depends largely on the pursuit of high-quality training and development, as it is difficult to envisage the use of technologically based healthcare without 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https://doi.org/10.1016/j.ijmedinf.2006.05.041 47. karr s. getting to know telepractice. the asha leader. 2012;17(30):30-30. https://doi.org/10.1044/leader. scm.17122012.30 48. jobson m. structure of the health system in south africa. khulumani support group, 2015. https://webcache. googleusercontent.com/search?q=cache:ovsla4becq0j:https://www.khulumani.net/active (accessed 2 august 2016). accepted 15 august 2017. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2015-telehealth.pdf https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/publications/2015-telehealth.pdf https://doi.org/10.1258/jtt.2012.gth107 https://doi.org/10.1258/jtt.2012.gth107 https://www.ncbi.nlm.nih.gov/pubmed/?term=hall rw%5bauthor%5d&cauthor=true&cauthor_uid=20155874 https://www.ncbi.nlm.nih.gov/pubmed/?term=johansen e%5bauthor%5d&cauthor=true&cauthor_uid=20155874 https://www.ncbi.nlm.nih.gov/pubmed/?term=meglan d%5bauthor%5d&cauthor=true&cauthor_uid=20155874 https://www.ncbi.nlm.nih.gov/pubmed/?term=peng gc%5bauthor%5d&cauthor=true&cauthor_uid=20155874 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2937346/ https://doi.org/10.1089/15305620252933365 https://doi.org/10.1089/15305620252933365 https://www.ncbi.nlm.nih.gov/pubmed/?term=singh s%5bauthor%5d&cauthor=true&cauthor_uid=22067879 https://www.ncbi.nlm.nih.gov/pubmed/?term=terblanche m%5bauthor%5d&cauthor=true&cauthor_uid=22067879 https://www.ncbi.nlm.nih.gov/pubmed/?term=widdicombe n%5bauthor%5d&cauthor=true&cauthor_uid=22067879 https://www.ncbi.nlm.nih.gov/pubmed/?term=lipman j%5bauthor%5d&cauthor=true&cauthor_uid=22067879 https://doi.org/10.1089/tmj.2010.0198 https://doi.org/10.1089/tmj.2010.0198 https://doi.org/10.3928/19404921-20080101-01 https://doi.org/10.3389/fpubh.2014.00173 https://doi.org/10.3389/fpubh.2014.00173 http://www.health-e.org.za/wp-content/uploads/2014/08/south-africa-ehealth-strategy-2012-2017.2012.pdf http://www.health-e.org.za/wp-content/uploads/2014/08/south-africa-ehealth-strategy-2012-2017.2012.pdf http://doi.org/10.1258/135763306776084437 http://doi.org/10.1258/135763306776084437 https://doi.org/10.1089/tmj.2009.0035 https://doi.org/10.1089/tmj.2009.0035 http://doi: 1092-5171/15/4201-0122 https://doi.org/10.1016/s0140-6736(03)14546-1 https://www.asha.org/uploadedfiles/practice/telepractice/surveyoftelepractice.pdf http://scholar.google.co.za/citations?user=pbx9dwcaaaaj&hl=en&oi=sra http://scholar.google.co.za/citations?user=m39bqmwaaaaj&hl=en&oi=sra https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 http://www.ncbi.nlm.nih.gov/pubmed/?term=singh g%5bauthor%5d&cauthor=true&cauthor_uid=25017424 http://www.ncbi.nlm.nih.gov/pubmed/?term=pichora-fuller mk%5bauthor%5d&cauthor=true&cauthor_uid=25017424 http://www.ncbi.nlm.nih.gov/pubmed/?term=malkowski m%5bauthor%5d&cauthor=true&cauthor_uid=25017424 http://www.ncbi.nlm.nih.gov/pubmed/?term=boretzki m%5bauthor%5d&cauthor=true&cauthor_uid=25017424 http://www.ncbi.nlm.nih.gov/pubmed/?term=launer s%5bauthor%5d&cauthor=true&cauthor_uid=25017424 http://www.who.int/goe/publications/goe_telemedicine_2010.pdf http://www.who.int/goe/publications/goe_telemedicine_2010.pdf https://doi.org/10.1089/tmj.2007.0108 https://doi.org/10.1089/tmj.2007.0108 https://doi.org/10.1044/leader.scm.17122012.30 https://doi.org/10.1044/leader.scm.17122012.30 https://webcache.googleusercontent.com/search?q=cache:ovsla4becq0j:https://www.khulumani.net/active https://webcache.googleusercontent.com/search?q=cache:ovsla4becq0j:https://www.khulumani.net/active research 138 september 2017, vol. 9, no. 3 ajhpe the medical education partnership initiative (mepi) was a large-scale, us government investment in strengthening the health workforce in africa by providing medical schools with funding to implement activities based on local needs and priorities. schools that were awarded the grant chose to invest in strengthening community-based education (cbe) and formed a technical working group convened by the coordinating centre of mepi (a partnership of institutions also funded by the mepi grant). the technical working group collaborated with capacityplus (a us agency for international development (usaid)-supported programme with funding specifically allocated to work with the mepi schools) to strengthen their cbe programmes.[1] within this context, the university of zimbabwe college of health sciences (uzchs) requested a peer review of its cbe programme. the evaluation served as a learning exercise for both uzchs and other medical schools in the mepi network in applying the peer-review process while evaluating the uzchs cbe programme. cbe is increasingly included as part of health sciences curricula across the globe. it forms part of an educational strategy to address the worldwide inequities in human resources for health by preparing graduates for service to rural and under-served populations.[2] the protocol developed by the collaboration for health equity through education and research (cheer) was adapted for use by uzchs to evaluate its cbe programme. cheer was formed in south africa (sa) during 2003 to examine strategies that would increase the likelihood of health professional graduates choosing to practise in rural and under-served areas.[3,4] since then, the cheer model has demonstrated effectiveness in examining complex outcomes in medical education in countries other than sa, as reported by s reid on the university of cape town’s primary health care directorate website (www. primaryhealthcare.uct.ac.za/). the medical school in harare, zimbabwe was established in 1963 and runs a 5-year undergraduate medical programme (mb chb). the unibackground. the university of zimbabwe college of health sciences (uzchs), harare, which has a long tradition of community-based education (cbe), has not been evaluated since 1991. an innovative approach was used to evaluate the programme during 2015. objectives. to evaluate the cbe programme, using a peer-review model of evaluation and simultaneously introducing and orientating participating colleagues from other medical schools in southern africa to this review process. methods. an international team of medical educators, convened through the medical education partnership initiative, worked collaboratively to modify an existing peer-review assessment method. data collection took the form of pre-visit surveys, on-site and field-visit interviews with key informants, a review of supporting documentation and a post-review visit. results. all 5 years of the medical education curriculum at uzchs included some form of cbe that ranged from community exposure in the 1st year to district hospital-based clinical rotations during the clinical years. several strengths, including the diversity of community-based activities and the availability of a large teaching platform, were identified. however, despite the expression of satisfaction with the programme, the majority of students indicated that they do not plan to work in rural areas in zimbabwe. several key recommendations were offered, central to which was strengthening the academic co-ordination of the programme and curriculum renewal in the context of the overall mb chb curriculum. conclusion. this evaluation demonstrated the value of peer review to bring a multidimensional, objective assessment to a cbe programme. afr j health professions educ 2017;9(3):138-143. doi:10.7196/ajhpe.2017.v9i3.733 a peer evaluation of the community-based education programme for medical students at the university of zimbabwe college of health sciences: a southern african medical education partnership initiative (mepi) collaboration d michaels,1 bsocsc, mphil (maternal and child health), msc (epidemiology), phd; i couper,2 mb bch, mfammed; m s mogodi,3 mb chb, mph; j g hakim,4 mb chb, mmed (internal medicine), mmedsci (clinical epidemiology); z talib,5 md (internal medicine); m h mipando,6 bed, msc; m m chidzonga,4 bds, ffdrcsi, mmedsci (clinical epidemiology), pgd intresethics; a matsika,4 bbs, mba; m simuyemba,7 bsc, mb chb, mph 1 school of public health, faculty of health sciences, university of cape town, south africa 2 ukwanda centre for rural health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 3 faculty of medicine, university of botswana, gaborone, botswana 4 university of zimbabwe college of health sciences, harare, zimbabwe 5 medical education partnership initiative (mepi) co-ordinating centre, george washington university, washington dc, usa 6 college of medicine, university of malawi, blantyre, malawi 7 medical education partnership initiative (mepi), university of zambia, lusaka, zambia corresponding author: d michaels (desireclas@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. http://www.primaryhealthcare.uct.ac.za/ http://www.primaryhealthcare.uct.ac.za/ research september 2017, vol. 9, no. 3 ajhpe 139 versity’s intention to expose students to cbe originated with the idea of a ‘village family scheme’, whereby students were attached to families in rural areas.[5] the evaluated format of the cbe programme was formally launched in 1987. at the time of the peer review, 22 academic departments and 67 clinical teaching sites contributed to the implementation of the programme. objective the aim of the review was to train colleagues from the network of mepi schools in using the cheer approach (fig. 1) and to conduct an evaluation of how the medical school’s cbe programme served to encourage future rural practice. the specific objectives were: (i) to identify gaps between theory and practice in education and training; (ii) to provide a report for ongoing curricular review; and (iii) to share best practices regarding preparation of students for practice in rural and under-served areas. methods a descriptive study design, using mainly qualitative methods that focused primarily on semi-structured interviews and review of supporting documentation, was employed. in addition, a pre-visit questionnaire was distributed to faculty and students for completion from september to december 2014 to serve as baseline data prior to the review visit. all respondents for pre-visit questionnaires were identified by representatives of uzchs using convenience sampling, whereby as many students and appropriate staff as were available were invited to complete the forms. purposive sampling was done for the on-site face-to-face interviews in february 2015 through the identification of appropriate key faculty members and students, as well as graduates and clinical preceptors at two district hospitals. during the visit, an initial presentation of the findings and recommendations was made to the faculty to corroborate and supplement the findings. a follow-up visit to present final key findings and recommendations was conducted during may 2015; this meeting was also used to further validate the findings prior to drafting a final written report. two facilitators from sa (ic and dm), who were experienced in the cheer peer-review approach, led a team of representatives from the medical schools in botswana, zambia and malawi, who served as peer reviewers while being orientated to the evaluation process. representatives of uzchs were involved in the process, which commenced ~7 months prior to the visit and involved protocol adaptation and questionnaire distribution. during the visit in february 2015, the reviewers divided into two subteams and conducted interviews of ~1 hour. written notes were taken during the interviews, which were conducted with individual faculty members or pairs from the same department. written, informed consent was obtained from each interviewee prior to commencement of the interview. students presented in two large groups of ~50 students each. each group was seen separately but in parallel. due to the large numbers of students, a paper response method was used to encourage response, whereby each student was handed a slip of paper on which to write their answer. following each response, the paper was handed in and a brief discussion ensued to identify common issues. analysis analysis of pre-visit staff questionnaires was done using a grid to summarise answers to the questions as a result of a paucity of responses. the responses to the pre-visit student questionnaires were captured at uzchs using the redcap (usa) database. the descriptive analysis was conducted by members of the peer-review team in sa, with online access to the database. thematic analysis was conducted on the qualitative aspects of the survey. all data from on-site interviews were analysed using recursive abstraction and summarised along broad themes outlined in the interview schedule based on the cheer evaluation framework (table 1), including the nature of involvement of each department in cbe (table 2). the results were discussed by the review team, with consensus being reached on themes within and across the interviews. the students’ paper responses to the structured questions were analysed using a thematic approach. research ethical approval was granted by the medical research council of zimbabwe (mrcz) on 9 june 2014 (ref. no. mrcz/a/1841). results the cbe programme at uzchs was found to be constrained by a number of remote and recent pressures, including the financial crisis in zimbabwe, increasing staff shortages, increased student numbers, and deteriorating infrastructure. despite these pressures, which had evolved over time, the programme had expanded from 10 purpose-built sites in eight provinces to more than 60 sites across all provinces, with positive relationships between the university, the ministry of health and child care, mission hospitals and private medical care providers in the mining industry. pre-visit survey results the pre-visit surveys conducted from november to december 2014 resulted in a low response rate, with 5% (n=54/1 164) and 26% (n= 5/19) of students and faculty responding, respectively. key findings from the student survey were as follows: the majority (94%) did not plan to practise in rural or underserved areas upon graduation; community health workers were perceived as the most significant ‘teachers’ not employed by the university; and half of the respondents were in contact with graduates. the low response from faculty resulted in inadequate baseline data being available to reviewers. faculty respondents were mainly involved with the clinical years (years 3 5), and none reported being involved in the cbe programme. all indicated that there was no policy that specified student recruitment from rural or underserved areas. post-review consultative workshop and �nal report peer-review visit pre-visit desktop review and surveys invite peer reviewers invite participants pre-visit student and faculty surveys and analysis review institutional documentation prepare interview guides one-hour focus group discussions with students remote mentorship institutional agreement on need for evaluation of cbe pre-visit preparation obtain stakeholder buy-in for review protocol development and approval one-hour interviews with individuals/pairs of faculty members, deans and hods analysis, preliminary report workshop final report field visits with clinical preceptors presenting of preliminary results fig. 1. the collaboration for health equity through education and research (cheer) peer-review process at the university of zimbabwe college of health sciences. (cbe = community-based education; hods = heads of department.) research 140 september 2017, vol. 9, no. 3 ajhpe review visit results face-to-face interviews were conducted with the dean, 23 faculty members in preclinical and clinical departments, four recent graduates and two off-site clinical preceptors. modified group interviews were conducted with 3rd-year (n=69) and 4th-year (n=52) students. several strengths and challenges were identified using the cheer evaluation framework, as illustrated in table 1. the faculty mission statement does not overtly mention rural and under-served populations, but states that the institution strives for ‘community oriented and community driven training and learning’. the length of exposure to field attachments was estimated to be ~5% per year on average, with time spent ranging between 1 and 5 days per week for 4 8 weeks within one study year (table 2). the community medicine curriculum provides theoretical input regarding healthcare in rural or under-served areas. staff who supervise the preclinical and clinical field attachments are mostly non-clinicians and often work under difficult circumstances; yet, the programme boasts a large teaching platform (in excess of 67 sites across all provinces and districts in zimbabwe), providing various exposure options. table 1. adapted cheer evaluation framework score criterion number evaluation criteria less than expected adequate better than expected 1 faculty mission statement r/u not mentioned* some mention or indirect reference explicitly supportive stated: ‘community-orientated and community-driven training and learning’† issue of social accountability – where graduates go not addressed† 2 resource allocation none† some staff and funding, but not enough* sufficient staff and funding for sustainability biggest constraint. worked well with external funding. the financial crisis had a major negative effect† 3 student selection no policy with regard to r/u* some policy with regard to r/u >25% rural origin none† reported that most students come from lower ses backgrounds† 4 first exposure final year, if at all middle years 1st year* behavioural sciences convene 1st-year exposure† exposure in every subsequent year† 5 length of exposure none† <5%* >25% of practical in r/u areas 4 8 weeks/year (1 5 days/week for the duration of attachment)† 6 practical experience none† students watch and listen to others students hands-on and contributing* develops over the years; 5th year very hands-on† 7 theoretical input none† r/u mentioned* critical reflection on r/u issues mainly in community medicine; some reference in other disciplines† 8 involvement with community tourism-type exposure* engagement or intervention ongoing joint reflection learn from the community, but don’t contribute to it; unlike the rehabilitation sciences students† 9 relationship with health service students are a drain/burden students are tolerated students’ input is welcomed and used* very positive (especially senior years)† 10 assessment of students no formal assessment for rural learning assessment was done, but not pass/fail* pass/fail contribution from rural component reports and presentations compulsory, but no rigorous assessment of knowledge and skills acquired during cbe† 11 research and programme evaluation no programme evaluation or reflection* evaluation is done, but not specific to r/u current educational research with regard to r/u none† 12 programme oversight and co-ordination no academic co-ordination; administrative co-ordination only* some academic oversight at departmental level; some academic co-ordination good co-ordination with seniorlevel support and academic oversight there was good administrative co-ordination from the dean’s office† cheer = collaboration for health equity through education and research; r/u = rural/under-served; ses = socioeconomic status. *reviewers’ score. †reviewers’ explanatory comments for choosing the score. research september 2017, vol. 9, no. 3 ajhpe 141 strengths there are a number of areas where uzchs performed better than expected using the peer-review tool: early exposure to rural and under-served communities occurs from the 1st year onwards; cbe occurs in every year of study; practical experience is afforded to students during community-based activities (although the extent depends on their year of study, with more senior students having more ‘hands-on’ clinical experience); and a good relationship with health service personnel and the ministry of health. the establishment of a health professions education department in 2014 was intended to encourage and facilitate the training of clinicians and other academics in educational approaches and skills. accommodation at two field sites was upgraded in 2014/2015 and internet facilities were expanded, including a repository for textbooks and assignments. students value and enjoy the cbe experience, despite the poor living conditions at some sites due to lack of adequate maintenance, oversight and funding. they reported that the experiences impacted positively on their personal growth, empathic skills and professionalism. challenges a number of limitations and challenges emerged. the institutional oversight and investment was limited, evidenced by the last mb chb curriculum having been reviewed in the 1980s and the last substantial amendments to the field attachment programme made in the 1990s. the relationship between the medical school and the community leans towards a ‘tourismtype’ exposure, with no evidence of a partnership with the community, especially during the non-clinical years. the dean has provided high-level support and visibility for the programme and administrative oversight for the 2nd-, 3rdand 5th-year table 2. summary of student exposure to community-based education year site duration department focus 1 epworth (peri-urban) fridays: 2 × 8 weeks behavioural sciences (psychiatry) health-seeking behaviour; family health study 2 communities around district sites: variable numbers 4-week block community medicine focus; all departments involved community characteristics, needs and structure 3 district hospitals in various towns 4-week block ‘field attachment office’ (deanery); all departments involved the health system; clinical skills (ward rounds, patient clerking) 4 urban clinics 4-week practicum community medicine maternal and child health focus; general primary care medicine 5 district hospitals in various towns 4-week block ‘field attachment office’ (deanery); all clinical departments involved core clinical disciplines; audit (ward rounds, patient clerking and ongoing patient management) table 3. key recommendations key recommendations (presented) key recommendations (adopted) identify academic co-ordinator for cbe identify academic management structure for cbe monitoring and evaluation revise cbe programme based on review results revise field attachment programme* to evolve into cbe based on results of review integrate cbe programme across medical departments integrate the mb chb cbe programme across all teaching departments align learning objectives with the overall medical curriculum align cbe learning objectives with the overall medical curriculum launch a parallel medical curriculum revision process align teaching platform to learning outcomes align teaching platform to learning outcomes increase cbe exposure time across the years increase cbe exposure time across the years improve student supervision improve student supervision attend to student accommodation, transport, maintenance and resources issues attend to student accommodation, transport, maintenance and resources issues cbe = community-based education. *university of zimbabwe college of health sciences referred to existing cbe activities as the field attachment programme. note: the column on the left indicates recommendations made by the peer-review team, while the column on the right indicates the consensus reached by the university representatives, including the dean. table 4. post-review visit: key outcomes • the establishment of a working committee for cbe revision. the first meeting of the committee was planned for 2 weeks from the date of the post-review meeting. the dean called the meeting and confirmed the convenor of the committee. • the appointment of a convenor of this working group, who was nominated by the dean (the head of the hpe unit). • the inclusion of cbe in the staff development programme originally planned to focus on mb chb curriculum planning. • the agreement that the cbe curriculum review would take place in the context of the overall mb chb curriculum revision. • the agreement that student supervision will be revised and improved to include an academic component. the hpe unit will develop an orientation programme for all supervisors to support the strengthening of cbe. this orientation will include a revision of the guidelines for supervision as per the new goals set for competencies that students should achieve during the field attachment. • the agreement that healz graduates from uzchs would be co-opted to assist the hpe unit and the cbe curriculum committee with the curriculum revision of the cbe programme. • it was agreed that uzchs will explore the implementation of innovative funding strategies for the cbe programme. cbe = community-based education; hpe = health professions education; uzch = university of zimbabwe college of health sciences; healz = health education and advanced leadership for zimbabwe. research 142 september 2017, vol. 9, no. 3 ajhpe cbe programmes, but the transfer of the programme to his office appears to have created a gap in the day-to-day academic oversight and co-ordination of the programme. faculty and students report ‘silo’ learning or a lack of integration between disciplines, and perceive a disconnect between the objectives of the cbe programme and the overall mb chb curriculum. supervisors and clinical preceptors reported a poor understanding of the specific objectives of the cbe programme, particularly in the clinical years, as well as dissatisfaction with some of the infrastructure, support materials and resources available to implement the programme. students reported inadequate supervision from medical professionals during communitybased activities. the various teaching departments reported that they do not have any overt teaching and learning outcomes for the cbe placement, and while there is some assessment of students’ cbe experience in the form of reports and presentations and during the behavioural sciences course examinations in the 1st year, it is not rigorously assessed throughout the study years. clinical skills proficiency was identified by preceptors as a major gap in students’ capacity during field placements. senior students reported that they were not adequately prepared to practise in rural areas, which lacked adequate nearby referral networks and required them to perform clinical skills they were not comfortable with. despite their generally positive cbe experiences, most students reported that they have no intention of practising in rural or under-served areas when they qualify. key recommendations for uzchs the recommendations presented by the review team were generally well received and feasible, with some modifications (table 3). the central recommendation was that uzchs needed to strengthen the structures for curriculum review and academic co-ordination of the cbe programme and assign a person or group to the academic co-ordination of the programme. other key recommendations included: (i) to convert the current ‘field attachment’ into a formal cbe programme, ensuring that there is a spiral of learning that links cbe activities from one year to the next with increasing levels of competency; (ii) to align learning objectives of the cbe programme with the overall medical curriculum, leveraging international guidelines, such as the global consensus on the social accountability of medical schools,[6] the lancet commission report,[7] the world health organization’s transformation of health professions education, 2013,[8] and the approach of evidence-based medical education;[9,10] (iii) to improve student supervision and set clear learning objectives and outcomes, thereby integrating knowledge across disciplines and ensuring skills proficiency; and (iv) to consider the introduction of family medicine to strengthen the provision of primary care, while post graduate trainees in family medicine could potentially provide supervisory support to undergraduate students during cbe placements. other recommendations included reviewing the existing teaching sites to ensure they each provide appropriate learning opportunities, strengthening inter-professional learning through the cbe experience and improving the infrastructure (of accommodation and the health facilities), recognising that the latter will require political will and innovative income-generating strategies. post-review visit results a 2-day meeting reviewing the recommendations with the dean, heads of department, and key faculty led to several main decisions and plans for improvement of the cbe programme (table 4). one of the key decisions, taken in the absence of available funding for an academic co-ordinator, was to convene a working committee chaired by the head of the health professions education department to provide academic oversight of the cbe programme. remote support was provided to the institution by the review team to facilitate implementation of adopted recommendations. discussion peer review is not an accreditation process but rather focuses on providing health sciences schools with organising principles and an opportunity to reflect on the institutional standards and curriculum, which will help them become more accountable in addressing some of the health inequities and improvements to the health system. the process of the review supported peer reviewers to learn from each other and share their experiences, similar to the in-country consortia of medical schools that formed within the mepi network.[11] medical schools in the region share common constraints of limited resources and infrastructure[12,13] and many face the challenge of finding funding for objective programme evaluations. the peer-review approach therefore affords a cost-effective mechanism to provide valuable feedback. the post-visit support was a modification of the cheer model and may well be a feature that others can incorporate in the future. common challenges shared with other mepi schools uzchs has several challenges in common with other mepi partners regarding the cbe programme, such as inadequate clinical preceptorship at cbe sites, increasing admission numbers and limitations of infrastructure and logistics, which include inadequate internet connectivity for online technology expansion, accommodation and transport.[1] other key areas needing attention relate to the cbe curriculum, appropriate course materials, textbook availability and alignment with the central curriculum. these challenges may undermine a major aim of cbe, which seeks to expose students to rural and under-served communities with the objective of encouraging future practice in these areas. despite the positive sentiments expressed about the cbe experience, most students at uzchs would not choose to practise in rural areas in future. this does not bode well for zimbabwe, considering that the majority of the population (67%) live in rural areas and are dependent on government health services.[14] this finding contradicts previous findings that the exposure to cbe in medical curricula increases the likelihood of graduates choosing to work in rural and under-served areas.[1,15] perhaps it is not just exposure to cbe (which in practice spans each year at uzchs), but the quality and nature of that exposure which impacts positively on graduate choice. studies have shown that three main factors influence choice of rural practice by medical graduates, i.e.: (i) rural origin; (ii) positive clinical and educational experience in rural placements during undergraduate medical training; and (iii) targeted postgraduate training for rural practice.[16,17] there is no explicit student recruitment and selection policy aimed at students from rural origin at uzchs, with the majority reporting being of urban origin, and no postgraduate rural training is offered. therefore, all three factors may be linked to graduate choices at uzchs. key lessons while the on-site review occurs within a relatively short space of time (3 5 days), the entire process takes several months.[18] hosts and reviewers must therefore be committed to participation throughout the entire process. buy-in from key stakeholders is important to gather meaningful information and to implement recommendations. the purpose of evaluation is to identify whether a programme meets its objectives. without clearly articulated programme goals, evaluation is challenging. research september 2017, vol. 9, no. 3 ajhpe 143 a specific area of focus for the review is important, as there is a danger of covering too much (depth v. breadth). external peers can offer safe, empowering and multifaceted support to improve and evolve educational programmes within institutions, while enjoying a mutual learning experience. peer review is a fluid process and the approach is one of a conversation with supportive peers, with openness to adaptation. the protocol should, therefore, not be rigidly adhered to if it is not effective in a particular context. in this instance, the addition of the 12th criterion to the evaluation framework was deemed an important adaptation for the uzchs context, and probably also for other cbe programmes. study limitations data collection of pre-review-supporting documentation and completion of course curriculum spreadsheets was unsuccessful owing to the very poor response from faculty. this led to interviews being focused mainly on gathering general information without adequate time for in-depth probing. daily debriefing sessions of the reviewer team with the host institution’s academic representatives would have been very helpful in clarifying issues as they arose. incorporating such meetings into the daily schedule would be best. only two community-based sites were selected because of their proxi mity to the university. thus, the reviewers relied on the two preceptors to relate their experiences and perceptions rather than gaining first-hand information and observations beyond the two sites visited. conclusion this evaluation demonstrated the value of a peer-review process to offer a multidimensional, external but friendly assessment of a cbe programme. the process provided valuable insight and triggered institutional commitment and motivation to revise and align the curriculum with the intended goals. regular evaluation of cbe activities is critical to ensure that educational goals are being met and that limited resources for medical education are being used effectively to train a relevant workforce. acknowledgements. we wish to acknowledge ms rebecca bailey  and the  capacityplus  team at intrahealth international,  who supported the planning and  co-ordination of  the peer-review visit and  were part of  the initial conceptualisation of the project. we thank the staff, students and clinical preceptors of the university of zimbabwe  for their participation in the peerreview process. author contributions. dm: co-facilitated the peer-review project, contributed to the analysis, conducted the write-up of the project results and wrote the manuscript. ic: facilitated the peer-review project, was involved in the concept and design of the process, contributed to the data analysis and made substantial critical revisions to all drafts of the manuscript. msm: peer reviewed the project, contributed to the data analysis and  made  critical revisions  of the manuscript. jgh: principal  investigator on the  uzchs mepi  project,  and involved in the conception and design  of the process,  as well as critical evaluation  of  the draft manuscript. zt: member of the project management team and made substantial contributions to the interpretation of the data, as well as editorial revision of the manuscript. mhm: peer reviewed the project, and contributed to the data analysis and critical evaluation of the draft manuscript. mmc: principal investigator of the project, involved in its conception and design, as well as in critical evaluation of the draft manuscript. am: on-site project co-ordinator and responsible for pre-visit data collection, as well as contributing to the review of the manuscript. ms: peer reviewed the project, and contributed to the data analysis and critical evaluation of the manuscript. all authors approved the final submitted version of the article. funding. funding was received from the capacityplus project within intrahealth international. conflicts of interest. none. 1. mariam dh, sagay as, arubaku w, et al. community-based education programs in africa: faculty experience within the medical education partnership initiative (mepi) network. acad med 2014;89(8):s50-s54. https://doi. org/10.1097/acm.0000000000000330 2. chen l, evans t, anand s, et al. human resources for health: overcoming the crisis. lancet 2004;364(9449):19841990. https://doi.org/10.1016/s0140-6736(04)17482-5 3. reid s, cakwe m; on behalf of collaboration for health equity through education and research (cheer). the contribution of south african curricula to prepare health professionals for working in rural or underserved areas in south africa: a peer review evaluation. s afr med j 2011;101(1):34-38. https://doi.org/10.7196/ samj.4526 4. michaels dc, reid sj, naidu cs. peer review for social accountability of health sciences education: a model from south africa. educ health 2014;27(2):127. https://doi.org/10.4103/1357-6283.143728 5. tsikirayi cmr, todd ch. community-based medical education and curriculum change: the field attachment programme of the school of medicine of the university of zimbabwe. ann comm-oriented educ 1992;6:4-52. 6. boelen c, woollard r. global consensus for social accountability of medical schools. 2010. http://healthsocialaccountability.org/ (accessed 26 july 2017). 7. frenk j, chen l, bhutta za, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 8. couper i, sen gupta t, mcinerney p, larkins s, evans r. transforming and scaling up health professional education and training: policy brief on faculty development. http://whoeducationguidelines.org./sites/default/ files/uploads/whoeduguidelines_policybrief_facultydevelopment.pdf (accessed 26 july 2017). 9. mayer re. applying the science of learning to medical education. med educ 2010;44(6):543-549. https://doi. org/10.1111/j.1365-2923.2010.03624.x 10. levinson aj. where is evidence-based instructional design in medical education curriculum development? med educ 2010;44(6):536-537. https://doi.org/10.1111/j.1365-2923.2010.03715.x 11. talib z, kiguli-malwadde e, wohltjen h, derbew m, mulla y. transforming health professions’ education through in-country collaboration: examining the consortia between african medical schools catalyzed by the medical education partnership initiative. hum resources health 2014;13(1):1. https://doi.org/10.1186/14784491-13-1 12. chen c, buch e, wassermann t, et al. a survey of sub-saharan african medical schools. hum resources health 2012;10(1):4. https://doi.org/10.1186/1478-4491-10-4 13. greysen sr, dovlo d, olapade-olaopa eo, jacobs m, sewankambo n, mullan f. medical education in sub-saharan africa: a literature review. med educ 2011;45(10):973-986. https://doi.org/10.1111/j.1365-2923.2011.04039.x 14. zimbabwe national statistics agency. census 2012 report, zimstat, harare, zimbabwe. 2013. www.zimstat. co.zw/ (accessed 26 july 2017). 15. wilson nw, couper id, de vries e, reid s, fish t, marais bj. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9(2):1060. 16. strasser rp. community engagement: a key to successful rural clinical education. rural remote health 2010;10(1543):1-8. 17. couper i, hugo j, conradie h, mfenyana k. influences on the choice of health professionals to practise in rural areas. s afr med j 2007;97(11):1082-1086. 18. michaels d, couper i. guide for conducting peer reviews of community-based health sciences education programs: capacityplus. 2015. https://www.capacityplus.org/files/resources/cbe-peer-review-guide-final.pdf (accessed 26 july 2017). accepted 5 march 2017. https://doi.org/10.1097/acm.0000000000000330 https://doi.org/10.1097/acm.0000000000000330 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https://www.capacityplus.org/files/resources/cbe-peer-review-guide-final.pdf research september 2017, vol. 9, no. 3 ajhpe 111 student departure from universities without completing a qualification is a major concern for higher-education institutions.[1] three-quarters of undergraduate students who terminate their studies prematurely leave during the first year, and most of those who depart do so during the first 6 weeks of the first semester.[2] higher education south africa reported in 2009 that in undergraduate studies 35% of students depart after the first year and that only 15% of students who enrol complete their degrees within the minimum permissible time.[3] at postgraduate level, the rate of premature departure from masters programmes in south africa (sa) was estimated at 46% in 2013.[4] premature departure varies across fields of study, and is higher for science and lower for arts, social science and legal studies.[5] the high number of students prematurely departing from higher education has a major impact on national resources and robs the labour market of highly skilled personnel.[6] in sa, a 20% premature departure rate for both undergraduate and postgraduate students costs the government zar1.3 billion each year. [6] premature departure costs are not only borne by institutions, society and professions but also by students, who suffer financial, emotional and psychological consequences.[6] despite the post1994 increase in access to higher education in sa, premature departure remains a critical issue for postgraduate programmes.[6] the process of premature departure from higher education is complex, and factors and reasons vary from student to student and from institution to institution.[2,3] furthermore, factors contributing to student departure during the first semester are different from factors associated with students leaving in the later years.[1,2,7] leaving an academic programme before completing the first semester of study is referred to as ‘early departure’. factors reported to influence early departure include financial constraints, poor academic progress, and incompatibility between the student and the institution.[2,7] persistence and resilience during the first semester of the first year are viewed as crucial for students to succeed in higher education. [2,3,7] this article will examine early departure from the master of public health (mph) programme offered at one higher-education institution in kwazulunatal province, sa. mph programmes are structured to cater for a diverse, multidisciplinary and multiprofessional range of students. the programmes are aimed at equipping public health practitioners with collaborative strategies to address major risk factors contributing to the global and national burden of disease. the mph under investigation comprises a 50% coursework and 50% research component. the qualification is offered only part-time over a period of 2 years, on a flexible modular system basis, with each module requiring an initial 2 3 days’ face-to-face contact at the beginning of the semester, and a subsequent 2 3 days’ face-to-face session later in the same semester. students are expected to complete five core modules and one elective, of which four core modules should be completed background. student departure from university without completing a qualification is a major concern in higher education. higher education south africa reported that in undergraduate studies, 35% of students depart after the first year and only 15% of students who enrol complete their degree within the minimum permissible time. at postgraduate level, the departure from masters programmes in south africa (sa) ranged from 30% to 67% in 2010. early departure refers to students who leave an academic programme within the first semester of commencing their studies. at one sa university, there were a total of 109 first-time master of public health (mph) student registrations in 2013 and 2014. by the end of the first semester in the respective years, a total of 27 students actively deregistered from the programme and 11 students did not sit the first-semester examinations, representing an aggregate 35% rate of early departure. the factors associated with early departure at the university of kwazulu-natal are not well understood. objective. to understand factors associated with early departure in the mph programme at the university of kwazulu-natal. method. a mixed-methods design was implemented. students who departed within the first semester of commencing the mph programme in 2013/2014 were followed up. data were collected using self-administered questionnaires and in-depth interviews. results. failure to balance work and academic obligations with poor time management, stress and academic demands related to the programme, and insufficient academic progress were found to be associated with student early departure from the mph programme. conclusion. student early departure from the mph programme was influenced by multifaceted factors. senior students can mentor new students as early as possible in their programme. the orientation block should include development activities such as time management, stress management and effective study skills to assist mature students to cope with the demands of part-time postgraduate studies. afr j health professions educ 2017;9(3):111-115. doi:10.7196/ajhpe.2017.v9i3.793 understanding student early departure from a master of public health programme in south africa t dlungwane,1 bsc (physio), mph; a voce,1 phd; r searle,2 ma, msc; j wassermann,3 phd 1 discipline of public health medicine, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 2 department of higher education studies, school of education, university of kwazulu-natal, durban, south africa 3 discipline of history education, school of education, university of kwazulu-natal, durban, south africa corresponding author: t dlungwane (dlungwane@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 112 september 2017, vol. 9, no. 3 ajhpe within the first year. ongoing interaction and module-related support are provided between contact sessions through the on-line learning system of the institution. in 2013 and 2014, 109 first-time mph students were registered. by the end of the first semester in the respective years, a total of 27 students actively deregistered from the programme, while a total of 11 students did not sit the first-semester examinations. this represents an aggregate 35% early-departure rate. understanding the reasons for the early departures will assist the programme in developing appropriate strategies to ensure greater student retention and throughput. objective to investigate the factors contributing to early departure of students in the mph programme at the university of kwazulu-natal in 2013 and 2014. methods this was an exploratory study to describe the features of early-departure students. a mixed-methods research design was applied. all 38 students who were registered for first-year mph studies in 2013 and 2014 and departed in the first semester were invited to participate in the study via email. early-departure students were sent weekly reminders to complete the questionnaire by email for a period of 8 months, and those who had not responded were contacted by telephone. firstly, data were collected using self-administered questionnaires electronically distributed to all early-departure students. the questionnaire consisted of closed-ended questions. data were collected on demographics, educational and employment background, and programme-related, institutional and personal reasons for leaving the programme. the data were captured into microsoft excel 2003 (microsoft, usa), and then exported into spss 15 (microsoft, usa). the data were analysed using descriptive summary statistics. secondly, from early-departure students who completed the selfadministered questionnaire, a convenience sample for in-depth interviews was drawn of respondents within reach and available and who responded positively to the invitation to be interviewed. an interview guide approach was implemented in face-to-face in-depth interviews until saturation was reached. a total of eight in-depth interviews were conducted. the purpose of the interviews was to gain further insights into the responses emanating from the self-administered questionnaires. the respondents were asked open-ended questions about their experiences as mph students with regard to programme, institutional and personal characteristics. in addition, the interviewer sensitively enquired about the reasons that had influenced their departure from the programme. the interviews took about 30 minutes each, and were tape recorded and transcribed verbatim. thematic analysis was used to analyse transcriptions. coding was done and then emergent themes were identified. trustworthiness of the findings was achieved through: (i) dependability; and (ii) triangulation. dependability of the data collected was ensured through an audit trail. the main researcher and supervisor served as peer reviewers of the individual in-depth interviews, the level of probing, and the sequence in terms of how the data were collected. triangulation of data was achieved through the use of individual in-depth interviews, field notes during the interviews and a self-administered questionnaire. ethical approval was granted by the university of kwazulu-natal human and social sciences research ethics committee (ref. no. hss/0561/014d), and permission to conduct the study was granted by the registrar. results of the 38 early-departure students who were invited to participate, 25 (66%) returned the questionnaire. of the 25 respondents, 19 (76%) were female and 14 (56%) were between the ages of 30 and 39 years. twenty (80%) were employed in the public sector and 11 (44%) were clinicians (table 1). all were in full-time employment. the age, gender and education background data for other graduates (non-responders) were available from the alumni records: females comprised 62%, 38% were aged 40 49 years, and 77% were clinicians. the profile of the respondents is in line with the report by the council of graduate schools, which revealed a shift in the age distribution of postgraduate students in sa.[8] in 2007, 22% of all postgraduate students were ≥40 years of age, compared with 18% in 1987. projections suggest that the number of mature students will continue to increase.[8] reasons provided for early departure from the mph programme respondents were asked what had influenced their decision to leave the programme. the most cited reason was heavy workload on the programme table 1. demographic and social characteristics of earlydeparture students (n=25) categories respondents, n (%) age (yr) 20 29 3 (12) 30 39 14 (56) 40 49 6 (24) ≥50 2 (8) gender female 19 (76) marital status married 17 (68) single 6 (24) widowed 1 (4) living with partner 1 (1) educational background medical 8 (32) nursing 7 (28) allied science 8 (32) social science 2 (8) current position programme manager 6 (24) middle manager 3 (12) medical manager 1 (4) researcher 1 (4) clinician 11 (44) academic 3 (12) current employment public sector 20 (80) ngo 1 (4) research 1 (4) academic 2 (12) research september 2017, vol. 9, no. 3 ajhpe 113 (76%), stress related to the demands of the programme (64%), demands of employment while studying (60%), not enough time spent on studies outside face-to-face sessions (56%), the difficulty of the programme (52%) and insufficient academic progress (44%) (table 2). analysis of the self-administered questionnaires and interviews with the early departures revealed three main and strongly inter-related reasons provided for withdrawing from the programme. the themes identified were balancing responsibilities and time management, stress and the demands of the mph programme, and insufficient academic progress. balancing responsibilities and time management respondents reported that the decision to depart was influenced by not having enough time outside the face-to-face sessions to commit to their studies, within the context of heavy job demands. conflicting demands, work/life balance, time management and student preparedness for postgraduate studies were additonal factors that led to some respondents' decision to leave. ‘my job has timelines. also, whatever assignment the lecturer gives you it has got timelines and all these people need you. also at church there are timelines, you know. i was failing to balance all these three aspects in my life.’ (r2) ‘… it came to a point where, you know you get so exhausted at the end of the day working and then you get back home and then having to fit in time to go over your work and so i felt that was a challenge for me. i was not able to balance it, and i think i needed to have some skills development on how to have managed it [studying]. so perhaps the balancing act was not well done because of the lack of structured plan on how to go about it [managing the studies].’ (r4) ‘and to have time actually to do the assignments was quite difficult for me.’ (r3) stress and the demands of the mph programme the academic demands of the mph programme were reported to cause stress and to contribute to early departure. aggravating the inherently demanding academic programme were poorly managed peer-learning activities, personal factors, and anxieties about academic performance, particularly in the case of students who had been absent from higher education for some time. ‘… it was quite heavy for me because there were lots of assignments to be done within a very short period, and also we have to work in groups and you find that people are not pulling their weight and you do more of the work and i was pregnant and was mindful that i do not want to be too stressed …’ (r3) ‘it was hectic and was actually stressing me and draining me. i did not think with that workload and the amount of work that i have to do i will be able to get the mark that they require for me to proceed.’ (r5) ‘i had not been studying for about 14 years, it was really difficult. it was like i am in a new land. i was struggling.’ (r2) insufficient academic progress fear of failure and insufficient academic progress were highlighted as contributing to early departure, exacerbated by unfamiliar subject matter and a lack of clarity regarding academic expectations. ‘… when it came to me having to prepare for my exam, i just felt lost. so i said to myself, there is no use in continuing with something that i do not understand now and do the next module. what if it happens again? it was actually the fear of failure again, i failed, and then what if i fail again? i have never failed in my life.’ (r8) ‘… i could not even pass and i think it discouraged me and yet i had made a good effort. i was trying my level best to get to there [passing], but when i tried so badly then i realised i have not even passed and yet i think i take out all my energy to go for it [studying].’ (r6) discussion the characteristics of the sample of early-departure students indicate a profile of part-time mature, married women working as clinicians and managers in the public sector. mature part-time postgraduate students are faced with numerous challenges such as adjusting to postgraduate demands when returning to higher education many years after obtaining an undergraduate qualification.[9,10] four inter-related factors were foregrounded by the respondents as contributing to early departure in the mph programme: a struggle on how table 2. reasons provided by students for early departure from the master of public health programme (n=25) importance of reason, n (%) not at all a little moderately/very the difficulty of the programme 6 (24) 6 (24) 13 (52) the programme was not what i expected 11 (44) 5 (20) 9 (36) the way the programme was taught did not suit me 9 (36) 6 (24) 10 (40) the overall organisation of the programme 9 (36) 7 (28) 9 (36) the timetabling of the programme did not suit my needs 9 (36) 6 (24) 10 (40) too heavy a workload on the programme 4 (16) 2 (8) 19 (76) i felt i was making insufficient academic progress 7 (28) 7 (28) 11 (44) not enough time spent on studying outside timetabled sessions 8 (32) 3 (12) 14 (56) stress related to the demands of the programme 5 (20) 4 (16) 16 (64) lack of personal support from colleagues 12 (48) 3 (12) 10 (40) the needs of dependants (e.g. family, partner) 13 (52) 4 (16) 8 (32) emotional difficulties involving others (e.g. family, partner, friend) 17 (68) 3 (12) 1 (4) the demands of employment while studying 8 (32) 2 (8) 15 (60) research 114 september 2017, vol. 9, no. 3 ajhpe to balance the demands of complex academic, personal and professional worlds, with competing demands on time, stress brought about by the academic demands of the mph programme, and insufficient academic progress. the reasons cited for early departure are not unique to the respondents in this study.[7,10] the complex competing roles resulting from enrolling for a master’s degree contributed to their decision to depart. the transition into postgraduate education brought about additional stress and time pressures that competed with existing personal and professional roles for time, space and mental energy.[11] schlossberg[12] defines transition as an event that results in changed routine and roles. the change has a potential to cause stress and anxiety.[12] for mature students, the transition to postgraduate education usually brings conflict with existing roles and could lead to a questioning of the roles.[12] the process of adjustment to the new role of being a student requires appropriate preparation, support and a strong sense of self-belief.[12] the study participants were overwhelmed by the workload and the demands of the mph programme. for many, failure to negotiate the learning demands and volume of work in the programme owing to lack of structured planning, time constraints, lack of preparedness and stresses led to a decision to leave the programme. mature part-time students need structured support systems commencing at the pre-enrolment phase to ensure that they are socially and academically integrated into highereducation institutions and improve their persistence. moreover, for students to be adequately integrated, mentoring by faculty staff and senior students coupled with academic and peer-support structures help students see beyond the immediate stresses to the future benefits studying will bring by identifying achievable goals.[13-15] some participants in this study reported that inability to achieve satisfactory results to progress academically, coupled with difficulty in understanding the course material, resulted in their decision to leave the programme. they displayed an inability to overcome the academic setbacks and study pressure that tend to be associated with part-time mature students. the ability to overcome challenging circumstances and bounce back after experiencing failure requires a certain degree of academic resilience.[16] a growing body of research reports that students with high academic resilience and self-efficacy are more likely than those without to persist when confronted with difficult academic material, and that they perceive negative performance evaluations as challenges to overcome and as signposts indicating where learning needs to be deepened rather than as threats to avoid.[13,14,16] most revealing from the data was that student departure is influenced by multifaceted factors. while 35% of students departed in the first semester, students with presumably equally pressing demands completed the degree. further research must focus on a more nuanced understanding of the differences in characteristics between early-departure students, students who leave after the first semester but before completion, and completers. moreover, an investigation of the influence of resilience and self-efficacy on the persistence of mph students needs to be conducted. although financial constraints and incompatibility between the student and the institution have been reported in the literature as factors that influence early departure, these factors did not surface in this study. study limitations this study was conducted in a single mph programme, and results cannot be generalisable to students in other mph programmes, although they may be transferrable to mph programmes with part-time mature students in sa. further research of a similar nature that compares early-departure students across different programmes in the country is recommended. the non-respondents may have had different reasons for early departure from the mph programme. conclusion this study sought to understand early departure in an mph programme. student early departure in the programme was seen to be influenced by four interrelated factors contributing to early departure: balancing the world of work and academics and poor time management, stress and academic demands related to the programme, and insufficient academic progress. further research needs to focus on student transition into postgraduate education, approaches implemented to help students cope with academic workload, and methods employed to help students deal with insufficient academic progress experienced once they are registered. furthermore, research is needed to understand the coping mechanisms used by parttime mature students at the commencement of their studies. strategies to assist students to cope with the challenges that they encounter need to be structured within the mph programme. orientation and induction should include students’ development activities such as time management, stress management and effective study skills. creating structured supportive systems, and providing mentorship by senior students as an ongoing process, could assist mature students in dealing with the life changes that studying brings. this can be accomplished using a number of methods, such as inviting faculty staff and past students who struggled initially and eventually completed the mph programme to serve as mentors to students registering for the first time. acknowledgements. the authors thank the mph students for participating in the study. author contributions. td had the primary responsibility for the drafting of the manuscript. td, av, rs and jw all contributed substantially to the intellectual content and finalisation of the manuscript. all the authors read and approved the final manuscript. funding. this publication was made possible by grant no. r24tw008863 from the office of the us global aids coordinator and the national institutes of health (nih), us department of health and human services (nih office of aids research and nih office of research on women’s health). its contents are solely the responsibility of the authors and do not necessarily represent the official views of the usa government. conflicts of interest. none. 1. hovdhaugen e. transfer and dropout: different forms of student departure in norway. stud high educ 2009;34(1):1-17. 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/media_and_publications/higher-education-monitor/higher-education-monitor-8-sta http://www.che.ac.za /media_and_publications/.../vitalstats-public-higher-education-2013 http://www.che.ac.za /media_and_publications/.../vitalstats-public-higher-education-2013 http:// files.eric.ed.gov/fulltext/ej1055597 http:/ https://www.dhet.gov.za/hed/policies/national plan on higher education http://www.academia.edu http://cgsnet.org/ckfinder/userfiles/files/datasources_2009_12.pdf http://cgsnet.org/ckfinder/userfiles/files/datasources_2009_12.pdf https://eric.ed.gov/?id=ej936979 research september 2017, vol. 9, no. 3 ajhpe 115 10. koen c. postgraduate student retention and success: a south african case study. phd thesis. cape town: university of western cape, 2007. 11. abrahams ma. making sense of part-time students’ transition into higher education: recognising the self, family and work. int j humanit soc sci 2013;3(21):201-211. 12. schlossberg nk. counseling adults in transition: linking practice with theory. baltimore: springer publishing company, 2005. 13. wilks se. resilience amid academic stress: the moderating impact of social support among social work students. adv soc work 2008;9(2):106-125. 14. culpepper as. women graduates academic resilience and their personal strategies for doctoral success. florida international university, 2004. http://digitalcommons.fiu.edu/dissertations/aai3165156 (accessed 21 june 2017). 15. martin aj. motivation and academic resilience: developing a model for student enhancement. aust j educ 2002;46(1):34-49. https://doi.org/10.1177/000494410204600104 16. taylor h, reyes h. self-efficacy and resilience in baccalaureate nursing students. int j nurs educ scholarsh 2012;9(1):1-13. https://doi.org/10.1515/1548-923x.2218 accepted 21 february 2017. http://digitalcommons.fiu.edu/dissertations/aai3165156 http://digitalcommons.fiu.edu/dissertations/aai3165156 https://doi.org/10.1177/000494410204600104 https://doi.org/10.1515/1548-923x.2218 research september 2017, vol. 9, no. 3 ajhpe 153 hiv/aids continues to be a global public-health problem. globally, there are 36.7 million people living with hiv, 25.8 million of whom live in subsaharan africa (ssa).[1] as of june 2015, 17 million people living with hiv were accessing antiretroviral therapy (art), with 10.3 million of these accessing antiretroviral treatment in ssa. this is 54% of all people living with hiv in the region.[1] hiv/aids is also responsible for a large percentage of morbidity and mortality, especially in settings that have limited resources.[2] of further concern is the fact that ssa was also home to 70% of all new hiv infections in 2012.[3] compared with other countries in the world, south africa (sa) has the highest number of people living with hiv and aids, and currently, the country has the largest public health antiretroviral therapy (art) programme, which began in 2004[4,5] and is being received by about 3.4 million people.[1] with an estimated 6.4 million people living with hiv (plhiv) in sa by mid-2012,[6] and increasing numbers of people requiring art, treatment services need to be decentralised to ensure access and expansion of art services. barriers for the majority of south africans needing healthcare, such as poverty and the inability to travel long distances to access healthcare facilities, add to the critical need to decentralise hiv and aids care to primary healthcare settings.[7] additionally, with the recent changes in eligibility criteria for art initiation, and the resultant increase in the number of patients requiring antiretroviral (arv) medication, a large pool of trained nurses will be required to initiate and manage patients requiring art. in a recent media release published by the kwazulu-natal department of health (kzn doh), the provincial health member of the executive committee in kzn, minister dr sibongiseni dhlomo, announced that ‘the kzn doh must urgently train many more nurses in the administering of antiretroviral treatment as sa adopts the world health organization’s progressive “test and treat” hiv guidelines.’[8] according to the same report, at the beginning of 2016, more than 1 700 nurses had been trained in nurseinitiated management of art (nimart) – a task-shifting strategy put in place in 2010 by the sa government to enhance care for plhiv – but there remained a need to double this number by the end of 2016.[8] the nimart strategy involves nurses initiating patients on art, providing repeat prescriptions for patients stable on art and appropriate background. currently, there is a need in south africa to implement strategies to upskill nurses in the clinical management of hiv and aids, for effective and efficient management of people living with hiv. one such strategy is the nurse-initiated management of antiretroviral therapy (nimart) course. objectives. to evaluate the effectiveness of the nimart course in increasing the knowledge of trainees in select clinical competencies, to assess whether perceived knowledge gain varied according to individual-level characteristics of trainees, and to determine trainee perceptions of the value and delivery of the course. methods. a 5-day training course focusing on various areas of hiv was developed and delivered by experts in the field of hiv to multiple cohorts of fourth-year nursing students at the university of kwazulu-natal, and to post-basic nursing practitioners, over a 5-year period. a single-group preand post-quasi-experimental design was used to assess knowledge change and perceptions about the course among 1 369 trainees who had benefitted from the course during the implementation period. results. post-workshop test scores were significantly higher than pre-workshop scores (p<0.0001), based on both pooled and cohort-specific data. for pooled analysis, the pre-test median score was 67% (interquartile range (iqr) = 60% 73%) and the post-test median score was 77% (iqr = 70% 80%), with p<0.0001. the knowledge gain was the highest in respect of hiv prevention, followed by prevention of mother-to-child transmission, then hiv treatment and lastly, general knowledge of hiv. the vast majority were very satisfied with the content of the training, although 31.3% strongly disagreed that they were ready to apply the knowledge they had learned in their workplace. conclusion. the training was generally well received, and improved the knowledge of participants in hiv and its management. however, this outcome represents short-term benefits of the programme, and there is a need for on-the-job mentorship and support in order to maximise on clinical outcomes related to hiv. afr j health professions educ 2017;9(3):153-158. doi:10.7196/ajhpe.2017.v9i3.879 upskilling nursing students and nurse practitioners to initiate and manage patients on art: an outcome evaluation of the ukzn nimart course r mngqibisa,1 mb chb, mph; m muzigaba,1 phd, mph, mphil, bsc; b p ncama,2 bcur, mcur, mba, phd;  s pillay,1 mb chb, dom, dip hiv man; n nadesan-reddy,1 mb chb, fcphm, mmed (public health med) 1 medical education partnership initiative, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban, south africa   2 school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa corresponding author: r mngqibisa (rmngqibisa@gmail.com)  this open-access article is distributed under creative commons licence cc-by-nc 4.0. research 154 september 2017, vol. 9, no. 3 ajhpe referral to physicians as required.[9] although there were still concerns about the ability of nurses to prescribe art, some studies have reported equivalent treatment outcomes for patients treated by nurses to those managed by doctors.[10-13] studies in sa have also reported similar outcomes, although some of these findings do not represent standard practice, as they are from sites/clinics heavily supported by non-governmental organisations and where intensive training and ongoing support of nurses was implemented.[11-14] a study from cape town showed that the responses of nurses to taskshifting varied from embracing it as a challenge capable of making their work more interesting, and increasing their knowledge and skills, to resisting it because of the additional workload without adequate support and training.[15] koome et al., [16] in their study in kenya, showed that the majority of nurses (70%, n=162) understood and supported task-shifting. support for task-shifting increased with increased years of experience, and was strongly correlated to knowledge,[16] while support, supervision and training were seen by study participants as requirements for effective task-shifting.[17] educational and occupational healthcare-worker training programmes have been shown to decrease fear and improve knowledge regarding hiv and aids transmission, and have led to the overcoming of negative attitudes and increased confidence and ability to care for plhiv.[16] this article outlines the university of kwazulu-natal’s (ukzn’s) nimart training model, designed to contribute towards the task-shifting and task-sharing strategy for better hiv treatment outcomes in sa. the article also presents results from a summative evaluation of the nimart course, with a particular focus on the number and background of trainees who benefitted from the course from 2011 to 2015, and an assessment of the extent to which the course has improved the knowledge of trainees in the management of hiv-positive people. trainee characteristics associated with knowledge change, and their perceptions about the delivery of the course, are also presented in this report. the nimart course at ukzn was led by the enhancing care initiative, and supported by a medical education partnership initiative (mepi) grant. the course was launched at ukzn in 2011, and between 2011 and 2015, at least three separate courses were delivered each year. each course lasted 5 days, and targeted both the fourth-year undergraduate nursing students and registered nurses who were already practising and doing post-basic and postgraduate programmes. the course focused on a number of topics related to the management of art, and was taught by experts in the field of hiv and aids. the content covered during the 5-day course was complementary to the hiv content integrated into the curriculum. the course covered: (i) the basic science of hiv infection, including epidemiology, immunology and virology, and clinical aspects of hiv infection and aids; (ii) hiv management in adults and children, which includes opportunistic infections and their presentation and management; (iii) art in adults and children, which includes classes of drugs and their modes of action; (iv) latest sa guidelines; (v) drug-related toxicities and their management, including treatment failure; (vi) hiv in women; (vii) hiv and tb comorbidity; (viii) ethics related to hiv and aids; and (ix) palliative care for plhiv. methods setting this evaluation involved data collected at ukzn from nimart participants who benefitted from the course during the period 2011 2015. design a single-group preand post-test quasi-experimental design was used to evaluate the extent to which training participants from different cohorts gained knowledge related to hiv clinical management. this type of study design has been widely used in estimating the effect of interventions on short-term outcomes, such as knowledge and attitudes, despite its limitations in alleviating a number of internal-validity threats such as selection bias and subject regression to the mean.[18] change in knowledge was assessed by comparing preand post-test scores of nimart trainees who received the training between 2012 and 2015. the data used for this analysis were therefore secondary data collected as part of outcome and process monitoring and scheduled evaluations of the nimart course during this period. the assessment of trainee perceptions of the delivery and value of the nimart course, as well as factors associated with perceived knowledge gain, involved cross-sectional analysis of pooled data collected from 2011 to 2015. ethical considerations the dataset used for this evaluation was collected for the purposes of quality assurance for the mepi programme. the dataset was obtained and used in robustly anonymised form, with all the identifying information removed. as the assessment of knowledge gain required paired analysis, preand post-test scores for individual trainees were supplied without names or unique identifiers which could be linked to participants’ details. a complete application for ethics approval was submitted to the ukzn biomedical research ethics committee, which granted ethics approval for this evaluation to be conducted (ref. no. be035/15). participants a non-probability sample that consisted of all 615 undergraduate nursing students, as well as 754 practising and post-basic nursing students, who benefitted from the nimart course during the 2011 2015 course rollout period, was used. in total, 1 369 nimart trainees were involved in this evaluation. all participants whose anonymised data were available in the programme monitoring records spanning the evaluation period (2011 2015) were considered for this evaluation. data collection the data were collected from successive cohorts of learners who attended the nimart course between 2011 and 2015. three data-collection tools were used to collect these data. the first tool was a structured participantregistration form, which was used to collect information on the demographic and professional characteristics of nimart trainees. the second tool was an anonymous knowledge-assessment questionnaire, which was completed by trainees before and after the course. this tool consisted of 30 ‘true or false’and ‘don’t know’-type questions that represented key competencies for nimart, including general knowledge of hiv/aids, knowledge of hiv treatment, hiv prevention and prevention of mother-to-child transmission (pmtct) of hiv, to mention but a few. this tool was piloted in a sample of 15 participants, and evaluated for internal consistency using cronbach’s alpha. both positively and negatively worded questions were used, and the tool was given to all participants in each cohort of trainees to quantify their change in knowledge following the course. the third tool was a course-evaluation questionnaire, which collected information research september 2017, vol. 9, no. 3 ajhpe 155 on participants’ perceptions of the value and delivery of the course, their readiness for nimart, their perceived knowledge change following the course and their satisfaction with the content of different nimart thematic areas of training. this tool was also assessed for internal consistency using the cronbach alpha test. the same three research instruments were used over the course of the evaluation period to ensure that measurements across cohorts of learners were standardised. data analysis all the data were firstly processed in excel 2010 (microsoft, usa) and exported to stata/ic 13.0 (statacorp llc, usa) and tableau version 9.3 (tableau software, usa) for analysis. trainee demographic and professional characteristics were summarised using frequency tables. the preand post-test scores and the score for perceived knowledge change were first inspected for normality using the shapiro-wilk and shapiro-francia tests. the distributions of the scores for perceived knowledge change across trainee demographic and processional characteristics were displayed using forest plots, with mean scores per group and 95% confidence intervals. the preand post-test scores were not normally distributed, and therefore the change in knowledge was assessed using the wilcoxon signed-rank test for matched pairs. the distribution of scores before and after the training was displayed per cohort using a box plot with quantile plot overlays. this plot was chosen so as to show side-by-side quantile plots of cumulative distribution of preand post-test scores and their median, as well as the 25th and 75th percentiles. trainees’ satisfaction with the content of different nimart thematic areas of training, as well as their perceptions of the value and delivery of the training, were summarised using a divergent bar graph. a p-value <0.05 was considered statistically significant. results the cronbach alpha tests carried out to assess the internal consistency of the study instrument revealed that the scales used in the instrument were reliable. the alpha coefficients for different sets of questions ranged between 0.78 and 0.86. a descriptive analysis of trainee characteristics revealed that by the year 2015, a total of 1 369 trainees from across the kzn province had benefitted from the programme, 87% of whom were female and 61% were working in healthcare facilities in rural kzn. the course uptake was highest among registered nurses (76.05%), compared with student nurses (12.37%), clinical nurse practitioners (8.68%), professional nurses (0.79%) and other nursing categories (2.11%). assessment of perceived knowledge change from the mean percent scores presented in fig. 1, it can be seen that indian and white nimart trainees believed that they gained relatively less knowledge than their coloured and black counterparts (p=0.084). however, these differences were not statistically significant. candidates who came from facilities based in urban and peri-urban areas also believed that they gained relatively less knowledge from the training than their counterparts from rural areas (p=0.045), and male candidates believed that they learned more than females (p=0.726), as did professional nurses compared with student nurses (p=0.025). similarly, participants who were in the last cohort believed they learned a lot more from the training compared with their colleagues in the preceding years (p=0.002). the mean score (89%) was relatively high, which indicates that, on average, trainees believed they learned something from the training. assessment of actual knowledge change fig. 2 illustrates overall knowledge change among participants, across a number of competencies related to nimart. based on the median scores, it can be seen that the knowledge increase was consistent and statistically significant across all four training periods (p<0.0001). the median preand post-test scores were the highest in year 4 of the training programme. fig. 3 depicts the changes in knowledge in four broad areas of the training course. the knowledge gain was the highest in respect of hiv prevention, followed by pmtct, then hiv treatment, and lastly, general knowledge of hiv. perceptions of the course participants’ perceptions of the course were assessed based on 25 questions that represented different thematic learning areas of the course. the results from this assessment are presented in fig. 4. fig. 1. a forest plot showing trainee perceived knowledge change in the management of art following the training. profession geographical area where employed gender cohort race subgroup overall student nurses registered professional nurses peri-urban rural urban male female 2015 2014 2013 2012 white other indian coloured black pts no. 874 48 195 87 307 122 106 710 283 320 263 8 14 10 46 19 774 effect (95% ci) 89.01 (88.16, 89.86) 83.33 (78.65, 88.01) 87.59 (85.83, 89.35) 85.80 (82.60, 89.01) 88.34 (86.95, 89.73) 86.15 (83.78, 88.51) 89.25 (86.78, 91.71) 88.44 (87.49, 89.38) 93.20 (91.92, 94.48) 86.31 (84.90, 87.73) 88.02 (86.44, 89.60) 81.25 (67.67, 94.83) 86.43 (77.33, 95.53) 93.00 (87.90, 98.10) 85.65 (81.91, 89.39) 93.16 (88.90, 97.41) 89.08 (88.17, 89.98) .....n 80 85 90 95 100 mean score for perceived knowledge gain (%) p-value 0.025 0.045 0.726 0.003 0.084 fig. 2. strip plot showing the cumulative distribution of test scores and median test scores before and after the training with significant tests: pooled data by year of training. median = 63 median = 73 median = 67 median = 77 median = 67 median = 77 median = 70 median = 80 0 10 20 30 40 50 60 70 80 90 100 pre-test post-test pre-test post-test pre-test post-test pre-test post-test year 1 (n=283) year 2 (n=281) year 3 (n=358) year 4 (n=209) te st s co re (% ) wilcoxon p<0.0001 wilcoxon p<0.0001 wilcoxon p<0.0001 wilcoxon p<0.0001 research 156 september 2017, vol. 9, no. 3 ajhpe fig. 4. shows that, based on the pooled data, the vast majority of trainees who received nimart training were very satisfied, or just satisfied, with the content of the training across all the 25 thematic areas of learning that they were asked to evaluate. a shown in fig. 5, 31.3% of the nimart trainees strongly disagreed that they would be able to apply the knowledge and skills that they had learned from the training to their job upon returning to their workplace. furthermore, 31% of trainees were not sure whether the use of case studies during their training was useful to their learning. however, the vast majority believed that the handouts given would be useful to them, and that the use of the examples during the training contributed to their understanding of the training content. discussion key findings this evaluation indicated an overall improvement of knowledge regarding all aspects of hiv management among nursing students and postbasic and working nurses who attended the nimart training between 2012 and 2015. when looking at specific thematic areas of learning, the preand post-knowledge scores were highest for pmtct and hiv prevention, which might be due to the fact that nurses have been expected to demonstrate competencies around pmtct and hiv prevention since the beginning of the art programme in sa.[18,19] therefore, their knowledge in these two thematic areas would be expected to be relatively high. the scores were lower with respect to general hiv knowledge and hiv treatment, which contrasts with the findings from a study conducted in india that showed high baseline and follow-up knowledge of hiv and its treatment.[20] pooled results revealed relatively poor baseline knowledge (mean = 67). this may be related to inadequate learning among some trainees during their formative years, and limited exposure to the management of hiv-positive patients. although not assessed in this evaluation – because the data were not available in the dataset used – it is hypothesised that baseline scores on objective measures of knowledge would have varied by professional characteristics and years of experience in the field. however, the evaluation focused on differences in knowledge according to when trainees received the training, and it was shown that both the baseline and post-test knowledge levels were better in the last group that benefitted from the training. this could be ascribed to the fact that by 2015, the majority of the nursing students were already benefitting from a curriculum which incorporated hiv, and the nurses were mostly from the facilities where nimart was already being practised. in addition to the objectively measured knowledge gain, trainees were also asked to indicate the extent to which the course had benefitted them in terms of knowledge shift. the question asked them to rate, on a scale of 1% 100%, how much they believed that their knowledge about hiv and its management had been impacted as a result of the nimart course. based on this assessment, it was determined whether their perception of the magnitude of knowledge change depended on their professional and demographic characteristics. fig. 3. knowledge gain in specific thematic areas of learning related to nurse-initiated management of antiretroviral therapy competencies, pooled analysis (2012 2015). the pooled analysis, which combined data from all 4 years of assessment without considering different thematic areas of learning, also showed that knowledge increased significantly, with a baseline median score of 67%, which increased to 77% after the training (p<0.0001). the circles demarcate mean scores. pmtct = prevention of mother-to-child transmission. 0 10 20 30 40 50 60 70 80 90 100 te st s co re (% ) pre-test post-test general knowledge of hiv wilcoxon p<0.0001 0 10 20 30 40 50 60 70 80 90 100 te st s co re (% ) pre-test post-test knowledge of hiv treatment wilcoxon p<0.0001 0 10 20 30 40 50 60 70 80 90 100 te st s co re (% ) pre-test post-test pmtct knowledge wilcoxon p<0.0001 0 10 20 30 40 50 60 70 80 90 100 te st s co re (% ) pre-test post-test knowledge of hiv prevention wilcoxon p<0.0001 n=1133 fig. 4. divergent bar graph showing trainees’ satisfaction with the content of different thematic training areas of the nurse-initiated management of antiretroviral therapy course: pooled analysis (2011 2015). each thematic area of learning was measured on a 5-point likert scale with values 1 5. hiv and nutrition 4.5 virology of hiv 4.6 ethics and hiv con�dentiality 4.6 nurse practitioner assessment of the hiv-positive patient 4.6 ethics and hiv informed consent 4.7 monitoring for art and treatment failure 4.7 immune reconstitution in�ammatory syndrome (iris) 4.7 hiv and tb 4.7 common arv drug toxicities 4.7 palliative medicine in hiv and aids 4.7 family planning 4.7 screening for cervical cancer – pap smear 4.7 department of health guidelines on hiv counselling and testing 4.7 adherence strategies 4.7 prevention of mother-to-child transmission guidelines 4.7 hiv and women 4.7 hiv infection in children 4.7 new sexually transmitted infection (sti) guidelines 4.7 transmission dynamics, epidemiology and preventions, including stis 4.8 paediatric antiretroviral therapy treatment guidelines 4.8 natural history and pathenogenesis of acute and chronic hiv 4.9 adult antiretroviral therapy 4.9 ethics and hiv 4.9 staging of hiv 4.9 opportunistic infections in adults 4.9 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 9 9 11 11 12 14 17 17 17 18 19 20 21 21 21 19 22 23 19 22 17 27 18 27 26 65 67 73 68 75 73 74 72 73 75 73 74 75 76 78 78 79 79 80 82 87 88 88 90 90 7 6 7 5 7 4 5 4 4 5 5 3 3 3 3 3 3 4 3 4 1 1 1 1 1 -10 -5 0 very unsatisfactory unsatisfactory neutral satisfactory very satisfactory 0 2 0 1 0 2 0 0 0 1 1 1 1 1 1 0 1 1 0 2 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 item average score % research september 2017, vol. 9, no. 3 ajhpe 157 trainees from facilities based in urban and periurban areas reported less knowledge gain than their counterparts based in rural areas. this may be a proxy for superiority of knowledge at baseline, and may possibly be related to the fact that trainees in urban and peri-urban areas have better exposure to the management of hiv and possibly mentoring. it is therefore to be expected that they are likely to report less knowledge gain from the training compared with those in rural areas, who most likely have fewer support mechanisms around them to promote learning. thus it may be correct to assume that more nimart training is offered in urban/peri-urban areas than in rural areas, while the need for information may be greatest in the latter. recommendations pooled analysis also revealed that the median post-training score was 77%. for hiv treatment it was 75%, and 78% for pmtct. it may be argued that these scores are not sufficient within the context of effective treatment of plhiv and may suggest that didactic training alone is not adequate to capacitate or improve the ability of nurses to manage hiv. training needs to be supported with continuous and ongoing mentoring, especially since only 63% of nurses felt confident enough to apply the knowledge and skills gained to manage plhiv post training. this argument is supported by a study in limpopo province, sa, which showed that better knowledge was associated with frequency of training.[21] another study by cameron et al.[22] also argues that expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating more hiv-positive patients on art. the baseline results on hiv clinical knowledge also highlight the need to create a strong foundation for nurses during their formative years, so that they are equipped with the requisite competencies to effectively manage plhiv. the nursing curricula in the various training institutions that are producing the next generation of nurses need to be structured to ensure that there is sufficient coverage of the essential elements of management of hiv, coupled with ongoing in-service training of nurses in the management of hiv, such as the nimart programme. it is also recommended that a much more extensive study be carried out, to not only focus on the shift in knowledge related to hiv and its management, but also to track and trace nimart trainees to establish whether they have implemented this knowledge in their workplaces, and to determine whether such an intervention has had an impact on an array of health outcomes. in sa, there is still a dearth of literature around the effectiveness of nimart training in improving clinical outcomes. one study has, however, demonstrated that nimart training can increase art uptake and reduce workload at referral facilities, enabling doctors to concentrate on more complicated cases.[23] in their survey conducted in sa to assess whether nurses in primary-care clinics were initiating art after attending nimart training, cameron et al.[22] showed that of the nurses surveyed, 62% (79/126) had started initiating new adult patients on art, but only 7% (9/126) were initiating art in children. the main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages. limitations one of the limitations of this evaluation relates to the generalisability of the study findings. this is primarily because the study used a convenient sample of nurse practitioners and post-basic nurses who attended the nimart training course at ukzn during a specific period of time. however, the study does account for all the nursing students who were trained at ukzn during the evaluation period. another limitation is that the study did not assess whether there were any differences between the nursing students and post-basic nurses and practising nurses in respect of baseline knowledge gain as well as actual knowledge shift. it would also have been valuable to show whether knowledge differed among practising nurses according to their level of experience in the clinical setting. this evaluation used secondary data, and these variables were not captured as part of primary data collection, and therefore could not be used in this study. conclusion the ukzn nimart training course has played a significant role in capacitating more than 1  300 nurses in kzn province with nimart skills, against the provincial target to double the number of nimart-trained nurses from 1 600 by the end of 2016. this evaluation showed that the nimart training programme can significantly increase knowledge of hiv and its clinical management among nursing students and nursing practitioners pursuing their post-basic training in the nursing field. the study showed that their baseline knowledge was low, and that perceptions about learning varied among trainees depending on their demographic and professional characteristics. based on participants’ perceptions of how much knowledge shift they experienced from the course, it was evident that nurses from rural areas had the greatest need for the course. despite the observed increase in knowledge, however, a certain proportion of trainees did not feel ready to implement the knowledge gained in their workplace, which suggests a need for an ‘on-thei will be able to apply the knowledge and skills learned in this class to my job the case studies added value to my learning the scope of the material used in the training was appropriate to meet my needs the examples presented helped me to understand the content of the training the handouts will be useful on the job 3.7 4.2 4.8 4.9 4.9 31 11 4 63 61 85 90 92 6 11 8 6 31 3 1 2 1 2 0 00 0 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 -35 -30 -25 -20 -15 -10 -5 0 strongly disagree (1) disagree (2) neutral (3) agree (4) strongly agree (5) item average score % fig. 5. divergent bar graph showing trainees’ perceived value of the nurse-initiated management of antiretroviral therapy training programme in their workplace: pooled analysis (2012 2 015). research 158 september 2017, vol. 9, no. 3 ajhpe job’ mentorship programme if the benefits of the programme are to be carried forward and be translated into positive health outcomes. acknowledgements. this work was made possible by grant no. 5r24tw008863 from the president’s emergency plan for aids relief (pepfar) and the national institutes of health, us department of health and human services. its contents are solely the responsibility of the ukzn mepi programme, and do not necessarily represent the official views of the government. the kzn department of health is also acknowledged for making the nimart programme successful. author contributions. rm, bn, sp and nn were involved in the development and roll out of the ukzn-nimart programme, rm and bn led the implementation of the programme, mm and rm conceived the evaluation, mm conducted the study, and analysed the data, and mm, rm and bn drafted the manuscript for all co-authors to edit and sign off. funding. this work was made possible by grant no. 5r24tw008863 from pepfar and the national institutes of health, us department of health and human services. conflicts of interest. the authors declare no conflict of interest related to this work. 1. united nations programme on hiv/aids. global aids update. geneva: un, 2016. http://www.unaids.org/ sites/default/files/media_asset/global-aids-update-2016_en.pdf (accessed 12 july 2016). 2. world health organization. millennium development goals (mdgs). fact sheet no. 290. new york: united nations, 2015. http://www.who.int/mediacentre/factsheets/fs290/en/ (accessed 14 august 2016). 3. united nations programme on hiv/aids. joint united nations programme on hiv/aids: unaids partnership with the global coalition on women and aids (gcwa). geneva: unaids, 2010. http://www. womenandaids.net/about-gcwa/partners-and-members/joint-united-nations-programme-on-hiv-aids%28unaids.aspx (accessed 14 august 2016). 4. health systems trust. public haart projects in south africa – progress to november 2004. durban: health systems trust, 2005. http://www.hst.org.za/publications/public-haart-projects-south-africa-progressnovember-2004 (accessed 14 august 2016). 5. uebel ke, timmerman v, ingle sm, j van rensburg dhc, mollentze wf. towards universal arv access: achievements and challenges in free state province, south africa. s afr med j 2010;100(9):589-593. https:// doi.org/10.7196/samj.3897 6. republic of south africa. national strategic plan on hiv/sti and tb 2012 2016. pretoria: south african national aids council, 2011. https://www.health-e.org.za/wp-content/uploads/2014/12/sanac-nsp-progressreport-2014.pdf (accessed 2 september 2016). 7. doshi rk, del rio c, marconi vc. social determinants of hiv healthcare: a tale of two cities. in: kasenga fy, ed. understanding hiv/aids management and care – pandemic approaches in the 21st century. atlanta: emory university school of medicine and rollins school of public health, 2011:34-58. 8. kwazulu-natal department of health. more nurses to be trained on nurse-initiated management of antiretroviral treatment (nimart) programme to meet the expected high demand, following the adoption of new hiv ‘test and treat’ guidelines. media release: kzn doh. pietermaritzburg: kzn doh, 2016. http://www.kznhealth.gov. za/mediarelease/2016/nimart-test-treat-guidelines-17052016.htm (accessed 1 december 2016). 9. zuma j. address by president jacob zuma on the occasion of world aids day, pretoria showgrounds, 1 december 2009. http://www.info.gov.za/speeches/2009/09120112151001.htm (accessed 17 march 2016). 10. georgeu d, colvin cj, lewin s, et al. implementing nurse-initiated and managed antiretroviral treatment (nimart) in south africa: a qualitative process evaluation of the stretch trial. implement sci 2012; 7(66). https://doi.org/10.1186/1748-5908-7-66 11. callaghan m, ford n, schneider h. a systematic review of task-shifting for hiv treatment and care in africa. hum resour health 2010;8(8):1-9. https://doi.org/10.1186/1478-4491-8-8  12. shumbusho f, van griensven j, lowrance d, et al. task shifting for scale-up of hiv care: evaluation of nursecentered antiretroviral treatment at rural health centers in rwanda. plos med 2009;6(10):e1000163. https://doi. org/10.1371/journal.pmed.1000163 13. cohen r, lynch s, bygrave h, et al. antiretroviral treatment outcomes from a nurse-driven, communitysupported hiv/aids treatment program in rural lesotho: observational cohort assessment at two years. j int aids soc 2009;12(1):23. https://doi.org/10.1186/1758-2652-12-23 14. uebel ke, lombard c, joubert g, et al. integration of hiv care into primary care in south africa: effect on survival of patients needing antiretroviral treatment. j acquir immune defic syndr 2013;63(3):94100. https:// doi.org/10.1097/qai.0b013e318291cd08  15. colvin cj, fairall l, lewin s, et al. expanding access to art in south africa: the role of nurse initiated treatment. s afr med j 2010;100(4):210-212. https://doi.org/10.7196/samj.4124  16. centers for disease control. recommended prevention services. atlanta: centers for disease control and prevention, 2013. http://www.cdc.gov/hiv/prevention/programs/pwp/risk.html (accessed 10 august 2016). 17. koome di. feasibility of task shifting in nursing practice: a case study of two level five public hospitals in kenya. kenya: university of nairobi, 2012. http://erepository.uonbi.ac.ke/handle/11295/9328 (accessed 10 august 2016). 18. shadish rw, cook dt, campbell dt. experimental and quasi experimental designs for generalized causal inference. boston: houghton mifflin company, 2002. 19. phetlhu dr, watson mj. perceptions and attitudes of health workers towards patients co-infected with hiv and tuberculosis. j soc sci 2011;29(1):23-7. 20. dicicco-bloom b, crabtree b. the qualitative research interview. med educ 2006;40(4):314-321. 21. mulaudzi mv, pengpid s, peltzer k. nurses’ knowledge, attitudes, and coping related to hiv and aids in a rural hospital in south africa. ethno med 2011;5(1):25-32. 22. cameron d. nurse initiation and maintenance of patients on antiretroviral therapy: are nurses in primary care clinics initiating art after attending nimart training? s afr med j 2012;102(2):98-100. https://doi. org/10.7196/samj.5195  23. nyasulu jcy, muchiri e, mazwi s, ratshefola m. nimart rollout to primary healthcare facilities increases access to antiretrovirals in johannesburg: an interrupted time series analysis. s afr med j 2013;103(4):232-236. https://doi.org/10.7196/samj.6380 accepted 15 november 2016. http://www.unaids.org/sites/default/files/media_asset/global-aids-update-2016_en.pdf http://www.unaids.org/sites/default/files/media_asset/global-aids-update-2016_en.pdf http://www.who.int/mediacentre/factsheets/fs290/en/ http://www.womenandaids.net/about-gcwa/partners-and-members/joint-united-nations-programme-on-hiv-ai http://www.womenandaids.net/about-gcwa/partners-and-members/joint-united-nations-programme-on-hiv-ai http://www.womenandaids.net/about-gcwa/partners-and-members/joint-united-nations-programme-on-hiv-ai http://www.hst.org.za/publications/public-haart-projects-south-africa-progress-november-2004 http://www.hst.org.za/publications/public-haart-projects-south-africa-progress-november-2004 https://doi.org/10.7196/samj.3897 https://doi.org/10.7196/samj.3897 https://www.health-e.org.za/wp-content/uploads/2014/12/sanac-nsp-progress-report-2014.pdf https://www.health-e.org.za/wp-content/uploads/2014/12/sanac-nsp-progress-report-2014.pdf http://www.kznhealth.gov.za/mediarelease/2016/nimart-test-treat-guidelines-17052016.htm http://www.kznhealth.gov.za/mediarelease/2016/nimart-test-treat-guidelines-17052016.htm http://www.info.gov.za/speeches/2009/09120112151001.htm https://doi.org/10.1186/1748-5908-7-66 https://doi.org/10.1186/1478-4491-8-8 https://doi.org/10.1371/journal.pmed.1000163 https://doi.org/10.1371/journal.pmed.1000163 https://doi.org/10.1186/1758-2652-12-23 https://doi.org/10.1097/qai.0b013e318291cd08 https://doi.org/10.1097/qai.0b013e318291cd08 https://doi.org/10.7196/samj.4124 http://www.cdc.gov/hiv/prevention/programs/pwp/risk.html http://erepository.uonbi.ac.ke/handle/11295/9328 https://doi.org/10.7196/samj.5195 https://doi.org/10.7196/samj.5195 https://doi.org/10.7196/samj.6380 june 2018, vol. 10, no. 2 ajhpe 106 research there is growing international consensus that health services need to respond to the needs of those experiencing abuse.[1] there is also an increasing recognition of the need to equip medical practitioners with the appropriate knowledge, attitudes and skills to care for victims of intimate partner violence (ipv). concerns have been raised that faculty possibly neglect teaching of the topic, as it is not included in medical curricula.[2] it is therefore imperative to address this shortcoming in medical curricula, especially in low-income countries where traditions have supported and condoned levels of ipv.[3] different specialised groups of physicians are needed to care for women who have experienced ipv, when managing complications linked to abuse.[3] education about gender-based violence (gbv) in general offers a logical solution in addressing the problem of ignorance.[4] education about violence has been integrated into medical schools, and is being taught by a variety of faculty in many high-income countries.[5,6] evaluations show that training on gbv and ipv generally improves the knowledge, attitudes and skills of students and clinicians.[4] however, medical faculty in many middleand low-income countries are apprehensive about the complexities of addressing the topic. apart from concerns over content and training methods, there is also a lack of agreement on the faculty best positioned to offer such training.[7,8] therefore these issues need consideration, to prepare a range of medical faculty to teach, serve and practise effectively in this area. the present study was conducted to obtain consensus among interprofessional stakeholders on the content, methods and faculty to involve in educating and training medical students on gbv in south-west nigeria. the study also explored reasons why stakeholders thought the teaching was necessary; it identified the stage in the curriculum best suited to teach the topic, and how to assess the effectiveness of training. methods study design the delphi technique[9] was used to obtain consensus among experts on issues relating to the design of a gbv curriculum. three rounds background. gender-based violence (gbv), as a topic of medical study and practice, is an integral component of medical education in many developed countries. there is an increasing need to equip medical practitioners with appropriate knowledge, attitudes and skills to care for victims of gbv. objectives. to obtain consensus among stakeholders on content, the members of faculty who should teach the subject and the methods of training relating to gbv curricula in three medical schools in south-west nigeria. methods. three rounds of the delphi technique involving 52 experts from among academics, medical practitioners, government and non-governmental organisations were conducted. the first round (rd 1) was open-ended, while subsequent rounds were structured. consensus was defined as a gathering around mean (>3.5) responses with minimal divergence (standard deviation (sd) <1.5) to the rd 2 questionnaire; strong consensus was >4.0. for the rd 3, consensus was regarded as >50% satisfaction with the rankings from rd 2. a strong consensus was taken as >60% satisfaction. results. themes identified in rd 1 were: reasons for teaching gbv; teaching methods, strategies needed and departments best positioned to teach it; professions to involve in training; academic level to offer training; and strategies to assess effective training. from rd 2, the topics ranked highest for inclusion in training were (mean (sd)): complications of gbv, 4.44 (0.63); and safety plan, 4.44 (0.51). offering training to final-year medical students was most preferred, at 4.25 (1.13); for teaching methods, using videos for training, at 4.63 (0.89), was ranked highest, followed by information, education and communication materials, at 4.50 (0.82). discussion with victims ranked highest as the most preferred format for teaching, followed by didactic lectures, at 4.06 (0.93) and 4.00 (0.89), respectively. the departments selected to teach gbv were public health, at 4.19 (0.91); accidents and emergency, 4.06 (0.85); family medicine, 3.81 (1.05); and obstetrics and gynaecology, 3.81 (0.89). other professionals suggested were psychologists, social workers and lawyers. with regards to assessment, written examination ranked highest, at 4.06 (0.85). rd 3 confirmed the rankings of rd 2 on all themes, and sought additional suggestions for the training. most (82.9%) respondents had no additional suggestions; the few elicited included clarifying cultural misconceptions around gbv, involving religious leaders and psychologists, and the recommendation that the teaching should be sustained. conclusion. these results will inform the development of evidence-based competencies relevant to healthcare providers in the african context. the need for periodic review of the curricula of medical schools to ensure that they address patient and societal needs is highlighted. afr j health professions educ 2018;10(2):106-113. doi:10.7196/ajhpe.2018.v10i2.988 establishing consensus among interprofessional faculty on a genderbased violence curriculum in medical schools in nigeria: a delphi study o i fawole,1 mbbs, msc, fnmc (ph), fwacp; j van wyk,2 phd; a a adejimi,3 mbbs, mph, fwacp; o j akinsola,4 bsc, msc, mphil; o balogun,5 mbbs, mph 1 department of epidemiology and medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria 2 department of clinical and professional practice, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa 3 department of community medicine, college of medicine, ladoke akintola university of technology, osogbo, nigeria 4 department of community medicine and primary health care, college of medicine, university of lagos, nigeria 5 department of community medicine, college of medicine, university of ibadan, nigeria corresponding author: o i fawole (fawoleo@ymail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 107 june 2018, vol. 10, no. 2 ajhpe research of questionnaires were circulated. the first round (rd 1) used openended questions; the next two rounds (rd 2 and 3) were structured. the responses from each round were summarised and reported to the stakeholders, who were then given an opportunity to respond in the subsequent round. the questions in rd 1 asked whether gbv should be included in the curriculum. the questionnaire also explored the potential content and methods to be used, and asked experts about their previous training. the focus of rd 2 was to consolidate and validate suggestions on the content and methods generated by the rd 1 questionnaire. stakeholders prioritised their responses by ranking each suggestion according to importance. study setting the study was conducted in lagos, oyo and osun states of south-west nigeria in the medical schools of the university of ibadan, the university of lagos and the ladoke akintola university of technology. in addition, relevant officials from the ministries of health and women affairs in the three states were invited as stakeholders. the three universities are public institutions, and all are affiliated to a teaching hospital. selection of expert panel an expert was defined as a person with relevant knowledge of and experience in teaching about issues relating to gbv, with experience regarded as useful to inform the education of medical students. four categories of experts were identified, and one academic, two medical practitioners, three government officials and four representatives of non-governmental organisations were included in the study. the research team of two academic researchers and three medical practitioners, all familiar with issues relating to gbv in nigeria, generated a list of nominees. they brainstormed and identified the most appropriate disciplines, organisations and literature to be used in identifying the categories of experts.[3,10] invitation of experts experts were contacted by telephone or in person and invited to participate. a detailed information sheet explaining the study purpose and procedures, including the level of commitment required, accompanied the rd 1 questionnaire. the participants were asked to complete and return the questionnaire within 5 days, but some had to be reminded repeatedly. seeking consensus consensus was defined as a gathering around mean responses with minimal divergence, which was taken as a mean score >3.5, with a standard deviation of 1.5 or less, and consensus issues were included in the rd2 questionnaire. very strong consensus was set at a mean >4.0. for the rd 3 questionnaire, consensus was regarded as >50% satisfaction with the rankings from rd 2. a strong consensus was taken as 60% satisfaction with results from rd2, and very strong as >70%. sample size the target was to obtain responses from 10 20 health professional experts from each site. a total of 52 experts participated in rd 1, 51 in rd 2 and 47 in rd 3 (table 1). table 1. sociodemographic characteristics of participants variable rd 1 (n=52), n (%) rd 2 (n=51), n (%) rd 3 (n=47), n (%) medical school ibadan 11 (21.2) 11 (21.5) 10 (21.3) lagos 14 (26.9) 14 (27.5) 10 (21.3) osogbo 27 (51.9) 26 (51.0) 27 (57.4) age (years)     20 29 1 (2.0) 1 (2.0) 1 (2.1) 30 39 15 (28.8) 18 (35.3) 14 (29.8) 40 49 28 (53.8) 27 (52.9) 23 (48.9) 50 59 8 (15.4) 5 (9.8) 9 (19.2) sex     male 22 (42.3) 23 (45.1) 2 (44.7) female 30 (57.7) 28 (52.9) 26 (55.3) organisation     academics/practitioners 42 (80.8) 42 (82.4) 41 (87.2) ministry of health/women affairs 6 (11.5) 5 (9.8) 4 (8.5) non-governmental organisation 4 (7.7) 4 (7.8) 2 (4.3) medical specialty (n=48) (n=47) (n=47 ) accidents and emergency 4 (8.3) 5 (10.6) 4 (8.5) dental surgery 3 (6.3) 3 (6.4) 3 (6.4) family medicine 5 (10.4) 5 (10.6) 5 (10.6) obstetrics and gynaecology 7 (14.6) 8 (17.0) 7 (14.9) paediatrics 4 (8.3) 4 (8.5) 2 (4.3) public health/ community medicine 12 (25.0) 11 (23.4) 6 (12.8) psychiatry 3 (6.3) 3 (6.4) 4 (8.5) other* 10 (20.8) 8 (17.1) 16 (34.0) *ophthalmology, pathology, internal medicine, surgery. june 2018, vol. 10, no. 2 ajhpe 108 research questionnaire development rd 1: the rd 1 questionnaire was developed after an extensive literature review[5-11] based on the results of our previous study with medical students and faculty in one of the institutions.[2] the questionnaire consisted of 11 items, and was open-ended. it solicited information on reasons why courses on gbv issues should be taught (table 2); the academic level at which they should be taught; the content to be covered (table 3); teaching methods and strategies; contact hours; duration; format; which medical department(s) should do the teaching; other health professionals to involve in teaching; and suitable teaching platforms to explore. the experts were also asked if they had prior experience in teaching and/or managing patients/victims of gbv, and whether they would share their material. rd 2: the rd 2 questionnaire was developed after analysis of the rd 1 results. the rd 2 questionnaire ranked the 12 themes identified from the rd 1 questionnaire on a 5-point scale, in order of importance, from 5 as most important to 1 as least important. the themes were summarised as follows: the reasons why gbv issues should be taught; medical/clinical and other professionals to include in the training; content and teaching strategies to use; and the academic levels at which to offer training. the results of the ranking are shown in table 4. rd 3: the rd 3 questionnaire informed participants of the results received on each variable of the 12 themes in rd 2. stakeholders were asked to comment on the results, and to suggest additional items that they might not have considered initially, and/or make changes to earlier responses. data collection data collection was preceded by telephone calls to the experts by the principal investigator; next, a member of the research team made physical visits to the table 2. reasons for gbv issues to be taught at medical schools area of concern quote participant characteristics students ‘to prepare them to recognise and handle gbv cases.’ 40 49 years, male, lagos, community medicine, 0 9 ywe ‘to empower them to recognise potential victims.’ 50 50 years, male, ibadan, o&g, consultant/lecturer, ≥20 ywe ‘to create awareness of gbv among medical students.’ 40 49 years, male, lagos, ophthalmology, senior lecturer, 10 19 ywe gbv as a problem ‘to promote enlightenment for prevention of gbv.’ 40 49 years, male, ibadan, family medicine, consultant, 10 19 ywe ‘it makes them know what constitutes gbv as some of them perpetrate without knowing.’ 40 49 years, male, lagos, public health, consultant/lecturer, 10 19 ywe community ‘most people don’t really know what gbv is.’ 20 29 years, female, lagos, accidents and emergency, medical officer, 0 9 ywe ‘it’s the paradigm shift all over the world, it will ensure a better nation.’ 30 39 years, female, osogbo, dentist, dental officer, 0 9 ywe victims ‘to break [the] culture of silence on the issue. silence by female victims [is] common.’ 30 39 years, female, osogbo, ministry of women affairs, gender officer, 0 9 ywe ‘they will be able to do some counselling of the victims.’ 40 49 years, male, lagos, family medicine, consultant, ≥20 ywe gbv = gender-based violence; o&g = obstetrics and gynaecology; ywe = years of work experience. table 3. topics to include in a gbv training programme topic participant characteristics ‘epidemiology of gbv; identification and understanding signs of gbv’ 40 49 years, female, lagos, community medicine, senior lecturer, 0 9 ywe ‘causes of gbv; types of gbv; medico-legal view of gbv’ 40 49 years, male, ibadan, family medicine, consultant, >20 ywe ‘types of gbv; prevalence of gbv; identification of victims of gbv’ 50 59 years, female, ibadan, community medicine, senior lecturer, 10 19 ywe ‘risk factors, causes, management of gbv and the local and national laws on gbv’ 40 49 years, female, osogbo, paediatrics, consultant, 10 19 ywe ‘gbv and culture; societal responsibilities to gbv victims' 40 49 ywe, female, osogbo, family medicine, consultant/ lecturer, 0 9 ywe ‘female genital cutting and widow inheritance’ 20 29 years, female, lagos, paediatrician, consultant, 0 9 ywe ‘ethics of managing gbv and policy issues around gbv’ 50 59 years, male, ibadan, community medicine, lecturer/ public health physician, 10 19 ywe ‘measurement issues in gbv’ 50 59 years, male, lagos, o&g, senior lecturer, 10 19 ywe ‘understanding the mind of perpetrators, including forensics and jurisprudence of gbv’ 40 49 years, male, ibadan, oral pathology, lecturer/ consultant, 10 19 ywe gbv = gender-based violence; ywe = years of work experience; o&g = obstetrics and gynaecology. 109 june 2018, vol. 10, no. 2 ajhpe research table 4. ranking of categories for the training curriculum by participants categories responses received mean (sd) reasons why gbv should be taught       awareness of gbv 4.56 (0.63)   prevention and control 4.44 (0.81)   support or counsel victims 4.44 (0.81)   refer to where to seek help 4.44 (0.81)   identify/screen gbv cases 4.19 (1.05)   preparedness to treat gbv cases 4.13 (1.09) content of gbv training for the students     prevention and safety 4.44 (0.51)   complications 4.44 ( 0.63) medical/legal aspect of violence 4.38 ( 0.60) signs and symptoms 4.38 (0.72)   role of physicians in gbv control 4.38 (0.80) risk factors of gbv 4.31 (0.70)   causes of gbv 4.31 (0.79)   types of gbv 4.31 (0.95)   ethical issues, e.g. confidentiality etc. 4.25 (0.93)   management of victims 4.19 (0.66) gender equality 4.19 (1.17)   definition of gbv 4.13 (0.89) prevalence/epidemiology 4.13 (0.19)   identification of victims 4.13 (1.03) strategies for teaching gbv       video – documentaries, clips 4.63 (0.89)   iec material – posters, flyers, charts 4.50 (0.82)   powerpoint presentation 4.19 (0.98)   web-based/internet 4.06 (0.85)   skills training 3.94 (0.93)   case-based learning 3.94 (1.06)   role play 3.75 (1.13) didactic lectures 3.75 (1.54) level/year gbv should be taught 600 4.25 (1.13) 500 3.88 (1.09) 400 3.44 (1.03) 300 3.13 (1.26) 200 2.69 (1.54) 100 2.69 (1.54) duration of gbv training       longitudinal 3.88 (1.26)   periodic 3.81 ( 1.17)   once 2.19 ( 1.22) contact hours 4 hours 3.25 (1.4) 2 hours 3.19 (1.8) >4 hours 2.94 (1.6) formats for teaching       discussion with victims 4.06 ( 0.89)   didactic lectures 4.00 ( 0.93)   bedside teaching 3.69 ( 1.49)   case study/presentation report 3.88 ( 1.26) departments well positioned to teach       community medicine 4.19 (0.91)   accidents and emergency 4.06 ( 0.85)   public health 4.06 ( 0.93) continued... june 2018, vol. 10, no. 2 ajhpe 110 research experts to distribute the information sheet and questionnaire. the study instruments and information sheets were pretested on five resident doctors from the university college hospital, ibadan, and necessary adjustments were made before data collection commenced. the delphi questionnaires were hand-delivered to participants, and collected a few days later by a research assistant. each round was accompanied by an information sheet, which in rd 1 introduced and explained the study to respondents under the following subheadings: what is a delphi study? what is the purpose of the study? why have i been invited to take part? what will i be asked to do if i take part? who is organising the research? how will confidentiality be maintained? what do i do now? how do i contact the principal investigator? the information sheet used in rd 2 provided feedback on the results of the previous rd, and it was modified to suit rd 3 of the study. rd 1 data collection occurred between june and july 2016. the rd  1 questionnaire took approximately 30 minutes to complete. rd 2 data collection took place between august and october 2016, while rd 3 commenced in november 2016 and ended in january 2017. rd 2 took about 15 minutes to complete, and rd 3, 20 minutes. the data collection was conducted by three trained resident doctors, who were assisted with retrieval of the completed questionnaires by a research assistant. data analysis the three rounds were analysed using different methods. rd 1: the data generated from the open-ended questions in rd 1 were coded. data were entered into statistical package for social sciences (spss; ibm corp., usa) version 16 and analysed using excel (microsoft, usa). these open-ended, qualitative data were coded and categorised in response to each research question. rd 2: the data were entered and analysed using spss version 16. means and standard deviations (sds) were calculated for all responses. each mean was used to obtain a numerical indication of the overall support for a statement, where the responses to the statements were measured on a scale from 1 (least important) to 5 (most important). mean values between 2 and 3 were interpreted as uncertainty or indicating no consensus, while >3.5 and <1 indicated clear positive and negative consensus, respectively. the sd provided a measure of the dispersion of the responses. a small sd between 0.1 and 1.5 was interpreted as indicating greater certainty and consensus on the item being measured. rd 3: the data obtained were coded and entered into spss version 16, and analysed using excel. respondents’ level of satisfaction with the results generated was described in percentages, while quotes on suggestions were collected. ethical considerations the study was a low-risk project; however, ethical clearance was obtained from the ethical review committee of the oyo state ministry of health (ref. no. ad13/479/165) and the university college hospital institutional review board (ref. no. ui/ec/15/03/11). the purpose of the study was explained to participants, and verbal informed consent obtained. stakeholders were assured of confidentiality and anonymity, and identifying details were not recorded on the questionnaires. responses were kept confidential. the table 4. (continued) ranking of categories for the training curriculum by participants categories responses received mean (sd) obstetrics and gynaecology 3.81 ( 0.89)   family medicine 3.81 (1.05)   psychiatry 3.56 (1.21)   dentistry 3.19 (1.42) other professionals who can teach       psychologist 4.19 (0.98)   social worker 4.13 (1.02)   nurse 3.94 (0.99) lawyer 3.81 (0.83)   counsellor 3.81 (1.11)   sociologist 3.81 (1.11)   paediatrician 3.44 (1.41) why other professionals should teach multidisciplinary 4.38 (0.81) intersectoral 4.31 (0.79) social problem 4.23 ( 0.86) venue to teach gbv hospital 4.38 (0.95) community 4.38 (0.96) classroom 4.31 (0.79) assessment methods on gbv written examination 4.06 (0.85)   term paper (assignment) 3.75 (1.07)   oral examination 3.63 (1.03)   clinical examination 3.56 (0.89) gbv = gender-based violence; iec = information, education and communication. 111 june 2018, vol. 10, no. 2 ajhpe research completed questionnaires were kept in a secure compartment in the custody of the main investigator. the investigators had no conflict of interest and the results did not influence their work in any way. data were entered into a password-protected computer. results round 1 results sociodemographic characteristics of experts a total of 52 expert participants participated in rd 1. a little over half (53.8%) of the experts were between 40 and 49 years of age. there was a slight female preponderance (57.7%). most (80.8%) participants were from a university or hospital, while the others represented government ministries and nongovernmental organisations. the medical specialties of those from training institutions cut across 11 disciplines, including preventive medicine (25.0%), obstetrics and gynaecology (14.6%), paediatrics (8.3%) and accident and emergency (8.3%). regarding years of work experience, 44.2% had worked for between 10 and 19 years (table 1). categories generated in response to rd 1, eight categories were identified for teaching about gbv issues. these were regrouped into five categories (a e). a. reasons why gbv issues should be taught at medical schools: stakeholders gave reasons why gbv should be included in the medical undergraduate curriculum. the responses, as illustrated by the quotes in table 2, focused mainly on four areas of concern, namely preparedness of students, the effect of gbv on health, and its effects on the community and on the victims. concern was expressed that students should become knowledgeable and skilled. there was also concern to improve awareness of gbv as a public health problem, as it was believed that its inclusion in medical curricula would reduce its prevalence in the community, and providing training to students would improve the protection and treatment for victims. b. teaching methods, strategies/resources needed and department best positioned: b1. topics to include in a gbv training programme: stakeholders proposed several topics to include in the curriculum, namely causes of gbv, signs and symptoms, complications, types of gbv, and management of gbv cases (table 3). some experts proposed the inclusion of contemporary and culture-specific topics. b2. teaching strategies for gbv: the strategies identified as most useful included didactic lectures, seminar/small group discussions, case studies, students’ presentations of group work and student-driven research projects on gbv. according to some participants: ‘didactic lectures, discussion format, group work for presentation and research’ (30 39 years, female, lecturer/public health physician, lagos: 10 19 ywe) ‘topics can be incorporated into core lectures, followed by case studies and group discussions, clinical clue ship, observer ship, and term paper/ essay’ (40 49 years, female, emergency medicine, consultant physician, ibadan, 10 19 ywe) b3. format for teaching: stakeholders suggested using didactic lectures, supplemented by video documentaries, information, education and communication materials and case studies, as a possible teaching format: ‘didactic lectures, true cases, case studies, skills training’ (40 49 years, female, clinical pathology, consultant pathologist, ibadan, 0 9 ywe) ‘didactic lectures, true cases, case studies’ (30 39 years, male, obstetrics and gynaecology, senior registrar, osogbo, 0 9 ywe). c. teachers: c1. other professionals who can teach on gbv: apart from medical practitioners, other professionals suggested who could teach on gbv included psychologists, sociologists, lawyers, nurses and social workers. for example, some participants suggested: ‘psychologist’ (30 39 years, female, internal medicine, consultant physician, lagos, 10 19 ywe) ‘sociologist’ (40 49 years, male, community health, senior lecturer, lagos, 10 19 ywe) ‘social workers’ (30 39 years, female, dental surgery, dental officer, osogbo, 0 9 ywe). c2. reasons why other professionals should teach gbv: the experts motivated for teaching by other health professionals, describing gbv as a social, multidisciplinary and multidimensional problem. according to these stakeholders: ‘there are various aspects to gbv, it requires multidisciplinary approach’ (40 49 years, male, oral pathology, lecturer/consultant, ibadan, 10 19 ywe) ‘gbv is a social problem that needs to be tackled by all’ (30 39 years, female, women department official, gender officer, osogbo, 0 9 ywe) c3. previous teaching experience on gbv ten experts (19.2%) had prior teaching experience in gbv and had taught medical students on managing patients/victims of gbv. seven (70%) of these experts were willing to share their materials with other teachers. d. academic level(s) of medical students to whom training should be offered, and number of contact hours suggested by experts: the experts had various suggestions on year of schooling. these included: ‘clinical years’ (30 39 years, female, consultant, obstetrics and gynaecology, osogbo, 10 19 ywe) ‘400 600 levels’ (30 39 years, male, senior registrar, psychiatry, lagos, 1 9 ywe) on the number of contact hours, one participant (40 49 years, female, community health, lecturer i, lagos, 10 19 ywe) suggested two, while another (40 49 years, male, institute of child health, senior research fellow, ibadan, 0 9 ywe) suggested four. e. strategies to assess the impact and effectiveness of the training: written examinations were recommended by one participant (40 49 years, female, clinical pathology, consultant, lagos, 0 9 ywe), while another (60 years, male, surgery, senior lecturer, lagos, 10 19 ywe) suggested clinical examination. round 2 results the highest-ranked reason for implementing teaching on gbv (4.56 (0.63)) was to increase awareness. additional reasons selected were to provide support to victims; to prevent and control violence; and to appropriately june 2018, vol. 10, no. 2 ajhpe 112 research refer patients for care (4.44 (0.81 each)). as shown in table 4, the 14 suggested topics for content of the gbv programme all ranked above 4.00. the highest-ranked topics were complications of gbv (4.44 (0.63)) and safety plans (4.44 (0.51)), and the least the definition (4.13 (0.89)), prevalence (4.13 (0.19)) and identification of victims (4.13 (1.03)). stakeholders preferred training to be offered to the most mature students, i.e. at final-year level (4.25 (1.13)). the preferred teaching strategies included videos (documentaries and clips; 4.63(0.89)) and the use of information, education and communication materials (4.50 (0.82)). allocating 4 contact hours to teaching was the most preferred option (3.25 (1.4)) among the experts. a longitudinal training programme was preferred over once-off training (3.88 (1.26) v. 2.19 (1.22)). the experts ranked discussions with victims as the most preferred strategy, followed by didactic lectures and case studies (4.06 (0.93), 4.00 (0.89) and 3.88 (1.26), respectively (table 4). the medical departments considered best positioned to teach gbv were those dealing with community medicine (4.19 (0.91)), public health (4.06 (0.93)), accidents and emergency (4.06 (0.85)), family medicine (3.81 (1.05)), obstetrics and gynaecology (3.81 (0.89)), and psychiatry (3.56 (1.21)). dentistry was the least preferred (3.19 (1.42)). the multidimensional nature of gbv was the main reason (4.38 (0.81)) for including other professionals in the teaching, followed by ‘it is a social problem’ (4.23 (0.86)). other professionals identified included psychologists (4.19 (0.98)), social workers (4.13 (1.02)) and nurses (3.94 (0.99)). teaching platforms included hospitals (wards and clinics, 4.38 (0.96)), community (4.38 (0.96)) and classrooms (4.31 (0.79)). a written examination ranked highest (4.06 (0.85)) as the preferred method to assess students’ learning on gbv. round 3 results most (>60%, depending on the theme) stakeholders were satisfied with the rankings from rd 2. there was consensus (table 5) on the strategies for teaching on gbv (83.0%) and reasons why it should be taught (89.3%). most disagreement related to the ‘format’ (23.4%), ‘venue’ for teaching (23.4%) and the ‘duration of the training’ (34.0%). the comments were, however, positive and affirmed a need for continuous and synchronised training, rather than irregular sessions, with preference shown for 2 contact hours per module. the department of public health was indicated as being the best positioned to offer a course (table 5). the majority of all the stakeholders (82.9%) offered no suggestions on how to improve training on gbv. however, some respondents suggested clarifying cultural misconceptions around gbv (4.3%); the involvement of religious leaders (4.3%) and psychologists in teaching (2.1%); using mid and end-of-term assessments (2.1%); and that training should be sustained (4.3%). discussion this study was conducted to obtain consensus among stakeholders on the necessary content and teaching methods for a gbv curriculum at 3 medical schools in nigeria. most of the experts surveyed, representing the 3 states, were based at training institutions. however, they represented various disciplines, indicating some consensus on the multidisciplinary nature of the problem and interdisciplinary dimensions needed to address ipv as a curricular topic. only a few participants represented the relevant government ministries and non-governmental organisations. this is not surprising, as gbv has only recently started to receive government attention in nigeria, despite the country having been a signatory to international treaties and declarations on women’s rights for more than a decade.[12] ipv in particular in many lowand middle-income countries is often shrouded in secrecy, which inhibits victims from open discussions of abuse.[13] most of the reasons for introducing gbv into the medical curriculum centred on students’ training needs, and an awareness of the need to address the issue in the community and to help victims of gbv. the benefit of improved awareness created by training on gbv was highly favoured. participants preferred a structured curriculum for its ability to provide evidence-based and scientific information,[14] which is more likely to be factual, comprehensive and acceptable to healthcare practitioners and students.[15] training on the prevention and complications of gbv were considered important, to enable students, as practitioners, to identify and manage victims appropriately. training on the signs and symptoms of gbv, with the appropriate knowledge and skills to identify victims, was also considered important. several instruments are used by healthcare providers to identify victims of gbv in healthcare settings. the instruments target different categories of victims, such as women, men, pregnant women or women attending special clinics, and paediatric patients. the instruments also cater for self-reporting, while clinician-administered or computer-based instruments are also used.[16] stand-alone didactic lectures were not the most table 5. consensus on content and methods of a gbv curriculum theme satisfied with ranking, frequency (%) gave some other options, frequency (%) no response, frequency (%) total, frequency (%) reason why gbv should be taught 42 (89.3) 1 (2.1) 4 (8.5) 47 (100.0) strategies for teaching gbv 39 (83.0) 2 (4.3) 6 (12.8) 47 (100.0) content of gbv training for student 37 (78.7) 4 (8.5) 6 (12.8) 47 (100.0) other professionals who can teach gbv 32 (68.1) 5 (10.6) 10 (21.3) 47 (100.0) level/year gbv should be taught 30 (63.8) 11 (23.4) 6 (12.8) 47 (100.0) format for teaching 30 (63.8) 6 (12.8) 11 (23.4) 47 (100.0) reasons other professionals should teach gbv 31 (66.0) 7 (14.9) 9 (19.1) 47 (100.0) venue to teach gbv 31 (66.0) 5 (10.6) 11 (23.4) 47 (100.0) how training should be assessed 29 (61.7) 9 (19.1) 9 (19.1) 47 (100.0) department in best position to teach 28 (59.6) 11 (23.4) 8 (17.0) 47 (100.0) contact hours 24 (51.1) 15 (31.9) 8 (17.0) 47 (100.0) duration of gbv training 22 (46.8) 16 (34.0) 9 (19.2) 47 (100.0) gbv = gender-based violence. 113 june 2018, vol. 10, no. 2 ajhpe research preferred format for training, but the experts in our study recognised their value in complementing visual materials to enhance learning, as has been reported in a previous study.[17] the experts did not reach a clear consensus on the duration of training necessary, possibly owing to the varying lengths of medical degrees at the three medical schools, and the variable ability to accommodate curricular additions.[1] it is also possible that experts differ across the disciplines on the number of hours necessary to dedicate to the topic, and that these decisions require further discussions before the start of a programme. there was strong consensus and agreement on the departments that should offer the training. the departments of community medicine and public health were preferred, suggesting a recognition of gbv as a major public health concern.[18] the department of accidents and emergency was preferred over obstetrics and gynaecology, which is surprising considering that gbv can result in a number of reproductive health complications in women. studies have been conducted on gbv among physicians in both these specialties.[19,20] many stakeholders appreciated the emotional problems that may arise following an episode of violence, and recommended the inclusion of a psychologist on the training team. mental health complications following abuse, including anxiety disorders, depression, low self-esteem, posttraumatic stress and substance abuse have been reported previously.[21,22] stakeholders considered the social constructs surrounding gbv, and the need for practical safety plans for victims and their children, including support from social services. involving social-work practice in student training on gbv would provide comprehensive services to promote women’s health and safety, and to foster social principles of meeting clients at their points of need.[23 as found in our study, prior studies have also identified the teaching role of nurses. tuft et al.[24] similarly recommended the training of nurses as educators on gbv, while legal practitioners can advise on laws to protect victims.[25] assessment is crucial, as it drives learning,[26] and the training institutions agreed that they needed further in-house deliberations on the best assessment practices, for consideration at each university. the strength of this study lies in the use of the delphi technique, which allows for repeated iterations on the content and format with the experts. the main limitations related to the fact that most experts represented academia, and to the attrition in later rounds. despite attempts, few experts were available to participate from government and non-governmental organisations, owing to industrial action in two states at the time of study. secondly, there was no response or consensus to some themes presented in rd 3, which could be viewed as indicating either satisfaction with or a lack of interest in the theme. despite this shortcoming, the results still provide information useful for the development of a curriculum on gbv in the medical schools. it may also be possible to generalise the findings to other medical schools in nigeria. it is recommended that an interdisciplinary and transdisciplinary approach be followed, to design a gbv curriculum to address issues relating to gbv in medical schools in the region. conclusion consensus was reached on the content, methods and faculty necessary for training medical students on gbv in south-west nigeria. there was agreement on the disciplines best suited to teach such a programme, and the need to assess the training. further discussions are needed per institution on the appropriate contact hours, duration of training and particular disciplines to involve in the training. the results will inform the development of evidencebased competencies relevant to healthcare providers in the african context. acknowledgements. we thank the gbv experts for their time and responses. author contributions. conception and design: oif, jvw; administrative support: oif; data collection: bob, aa, oja; data analysis and interpretation: oif, jvw; manuscript writing: oif, jvw. all authors read and approved the final manuscript. funding. data collection was funded by the university of kwazulu-natal, durban, south africa. conflicts of interest. none. 1. world health organization. responding to intimate partner violence and sexual violence against women: who clinical and policy guidelines. geneva: who, 2013. 2. fawole oi, van wyk j, adejimi a. training needs on violence against women in the medical curriculum at the university of ibadan, nigeria. afr j health professions educ 2013;5(2):75-79. https://doi.org/10.7196/ajhpe.222 3. mork t, andersen pt, taket a. barriers among danish women and general practitioners to raising the issue of intimate partner violence in general practice: a qualitative study. bmc women’s health 2014;14:74. https://doi. org/10.1186/1472-6874-14-74 4. hamberger lk. preparing the next generation of physicians: medical school and residency-based intimate partner violence curriculum and evaluation. tva 2007;8(2):214-225. https://doi.org/10.1177/1524838007301163 5. connor pd, nouer ss, mackey sn, banet ms, tipton ng. intimate partner violence education for medical students: toward a comprehensive curriculum revision. south med j 2012;105(4):211-215. https://doi. org/10.1097/smj.0b013e31824f8b01 6. hussain n, sprague s, madden k, hussain fn, pindiprolu b, bhandari m. a comparison of the types of screening tool administration methods used for the detection of intimate partner violence: a systematic review and metaanalysis. trauma violence abuse 2015;16(1):60-69. https://doi.org/10.1177/1524838013515759 7. hossain n, khan s. domestic abuse and the duties of physicians: a case report. indian j med ethics 2015;12(4):248-250. https://doi.org/10.20529/ijme.2015.066 8. kamimura a, al-obaydi s, nguyen h, et al. intimate partner violence education for medical students in the usa, vietnam and china. public health 2015;129(11):1452-1458. https://doi.org/10.1016/j.puhe.2015.04.022 9. okoli c, pawlowski sd. the delphi method as a research tool: an example, design considerations and applications. inf manag 2004;42(2):15-29. https://doi.org/10.1016/j.im.2003.11.002 10. rasoulian m, shirazi m, nojomi m. primary health care physicians’ approach toward domestic violence in tehran, iran. med j islam repub iran 2014;28(148):1-8. 11. usta j, hlais s, farhat ha, romani m, bzeih h, abdo l. lebanese medical students’ exposure to domestic violence: does it affect helping survivors? fam med 2014;46(2):112-119. 12. federal republic of nigeria. national gender policy: situation analysis/framework. abuja: federal republic of nigeria, 2006. 13. world health organization. preventing intimate partner and sexual violence against women: taking action and generating evidence. geneva: who, 2010. https://doi.org/10.1136/ip.2010.029629 14. feder gs, hutson m, ramsay j, taket ar. women exposed to intimate partner violence. expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. arch intern med 2006;166(1):22-37. https://doi.org/10.1001/archinte.166.1.22  15. wathen cn, tanaka m, catallo c, et al. are clinicians being prepared to care for abused women? a survey of health professional education in ontario, canada. bmc med educ 2009;9(34). https://doi.org/10.1186/14726920-9-34 16. basile kc, hertz mf, back se. intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings: version 1. atlanta (ga): centers for disease control and prevention, national center for injury prevention and control, 2007. 17. buranosky r, hess r, mcneil ma, aiken am, chang jc. once is not enough: effective strategies for medical student education on intimate partner violence. violence against women 2012;18(10):1192-1212. https://doi. org/10.1177/1077801212465154 18. centers for disease control. intimate partner violence: fact sheet, 2006. atlanta: cdc, 2006. http:/www.cdc.gov/ ncipc/factsheets/ipvfacts.html (accessed 29 september 2015). 19. ball ca, kurtz am, reed t. evaluating violent person management training for medical students in an emergency medicine clerkship. south med j 2015;108(9):520-3. https://doi.org/10.14423/smj.0000000000000337 20. farchi s, polo a, asole s, ruggieri mp, di lallo d. use of emergency department services by women victims of violence in lazio region, italy. bmc women’s health 2013;13:31. https://doi.org/10.1186/1472-6874-13-31 21. fawole oi, abass lw, fawole ao. prevalence of violence against pregnant women in ibadan, nigeria. afr j med med sci 2010;39(4):293-303. 22. fawole oi, aderonmu al, fawole ao. intimate partner abuse: wife beating among civil servants in ibadan, nigeria. afr j reprod health 2005:54-64. 23. petrosky m, colaruotolo la, billings rj, meyerowitz c. the integration of social work into a postgraduate dental training program: a fifteen-year perspective. j dental educ 2009;73(6):656-664. 24. tufts ka, clements pt, karlowicz ka. integrating intimate partner violence content across curricula: developing a new generation of nurse educators. nurse educ today 2009;29(1):40-47. https://doi.org/10.1016/j. nedt.2008.06.005 25. fawole oi, ajuwon aj, osungbade ko. evaluation of interventions to prevent gender-based violence among young female apprentices in ibadan, nigeria. health educ 2005;105(3):186-203. https://doi.org/ 10.1108/09654280510595254 26. glick s. domestic violence simulated patient case. mededportal 2007;3:624. https://doi.org/10.15766/ mep_2374-8265.624 accepted 15 january 2018. https://doi.org/10.1186/1472-6874-14-74 https://doi.org/10.1186/1472-6874-14-74 https://doi.org/10.1097/smj.0b013e31824f8b01 https://doi.org/10.1097/smj.0b013e31824f8b01 https://doi.org/10.1016/j.im.2003.11.002 https://doi.org/10.1136/ip.2010.029629 https://doi.org/10.1186/1472-6920-9-34 https://doi.org/10.1186/1472-6920-9-34 https://doi.org/10.1177/1077801212465154 https://doi.org/10.1177/1077801212465154 http:/www.cdc.gov/ncipc/factsheets/ipvfacts.html http:/www.cdc.gov/ncipc/factsheets/ipvfacts.html https://doi.org/10.1186/1472-6874-13-31 https://doi.org/10.1016/j.nedt.2008.06.005. https://doi.org/10.1016/j.nedt.2008.06.005. https://doi.org/ 10.1108/09654280510595254 https://doi.org/ 10.1108/09654280510595254 https://doi.org/10.15766/mep_2374-8265.624 https://doi.org/10.15766/mep_2374-8265.624 june 2018, vol. 10, no. 2 ajhpe 85 research during the past decade, increasing pressure has been placed on universities to emphasise research outputs, as it is acknowledged that higher education and the resultant research innovation accomplishments are strategically interwoven.[1] through research findings, resources can be utilised more effectively and solutions for local health-based problems can be implemented. optometry is a primary healthcare profession and often the first point of contact for many patients. the use of best practice through evidence-based medicine is a trend in many higher education departments.[2] this is equally true for departments of optometry at institutions of higher education in south africa (sa). by identifying factors that contribute towards undergraduate students’ attitudes to research, it is argued that a more positive attitude can be developed if positive factors are enhanced and negative factors are rectified. the resultant research may then lead to the advancement of optometric knowledge that could translate into better-skilled practitioners, who may consequently implement better patient care. patient care is a focus point of the intended implementation of the national health insurance (nhi) in sa. this will result in an increase in the number of optometrists trained, with the ability to use the latest patient care procedures. there is therefore a need for optometric education to evolve through research and evidence-based healthcare methodologies. consequently, a strong research culture in departments of optometry is imperative. there is limited information on optometry students’ attitudes towards research. despite similar studies having been undertaken with medical, nursing, chiropractic and social work students in sa,[2-4] this is the first sa study to address the knowledge gap of optometry students. students are the future of the profession, and inculcation of a research culture in these students could promote lifelong learning. krech and crutchfield[5] emphasise the importance of knowing the beliefs and attitudes of people, as it is possible to predict and influence their behaviour. also, by identifying the attitude towards research, findings can influence how educators teach research, as attitudes cannot be directly observed but can be inferred from individuals’ self-reports and behaviour.[6] attitude theory historically, the most prominent of the attitude theories has been the tripartite approach, which encompasses emotion, cognition and behaviour. cognitive origins[7] encompass processes such as a person developing positive or negative connotations about an object through gaining knowledge. attitudes may also be formed from the emotional reactions are experienced when exposed to an object. in this model, attitude is manifested as beliefs, feelings and actions.[8] the cognitive aspect relates to students needing to know and understand the possibilities of conducting research and its use. the affective aspect is equally important, as students need to feel optimistic about and enjoy doing research. the behavioural aspect refers to students attempting to carry out or plan to learn more about research. with these three aspects as the theoretical foundation, the objective of the study was to identify the factors contributing to final-year students’ attitudes towards research in the department of optometry, university of the free state, bloemfontein, sa. methods nominal group technique (ngt) discussion sessions were held with students under the supervision of an experienced facilitator. in this study, as per the ngt process, data gathering and analysis took place simultaneously while the participants prioritised the data.[8] the researcher (lc) used van background. universities worldwide are required to increase their levels of research productivity. objective. to bring about positive changes in research perspectives if the factors contributing to the attitude of undergraduate optometry students can be identified, enhanced and rectified. methods. three nominal group technique (ngt) discussions were conducted with 22 final-year (4th-year) optometry students in central south africa (sa) to reach consensus on the most important factors that students regarded as influencing their undergraduate research experiences. data gathering and analysis took place simultaneously, while participants prioritised the data. data were analysed by in vivo coding, and categories were grouped according to themes that emerged from the codes. results. ranking and content analysis of coded statements yielded positive and negative categories, as well as categories with mixed codes. the major factor influencing students’ attitudes towards research was administration and the time-consuming nature of their research projects. recommendations for more effective administration are given. conclusions. it was concluded that active steps should be taken by the department of optometry, university of the free state, bloemfontein, sa, to alter and minimise negative aspects encountered by the students, which could assist future students’ experiences of research at undergraduate level. afr j health professions educ 2018;10(2):85-89. doi:10.7196/ajhpe.2018.v10i2.728 optometry students’ attitudes towards research at undergraduate level l coetzee,1 mhpe; s b kruger,2 phd, hpe 1 department of optometry, faculty of health sciences, university of the free state, bloemfontein, south africa 2 division health sciences education, office of the dean, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: l coetzee (coetzeels@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 86 june 2018, vol. 10, no. 2 ajhpe research breda’s[8] guidelines, which recommend a method to analyse multiple ngt sessions and combine the results of these sessions as outlined below. van breda’s guidelines are well accepted in sa, and follow a step-by-step process, creating clear instructions for repeatability. step 1 the facilitator welcomed all the participants. the question was posed to the group, and the facilitator provided brief information about the topic. step 2 the participants spent a few minutes writing down their views on the topic or question, and were encouraged to note as many ideas as possible. this was done in silence and had a time limit of 10 minutes. step 3 each participant in turn contributed an idea, which the facilitator recorded on the flip chart. similar suggestions were grouped together where appropriate. partici pants were allowed to skip a turn and then take part again during a later round. step 4 the group discussed each of the contributions for clarification. none of the ideas was allowed to be omitted. the discussion proceeded with one item at a time and one person speaking at a time. step 5 participants ranked the ideas by voting for five statements, prioritising their opinions. students prioritised the different statements they recorded during the ngt interviews by identifying and scoring the five most important ones, giving a value of 5 to the most important statement and a value of 1 to the statement they regarded as the least important. the votes were summated to obtain the five most important statements. the statement that received the highest score was then ranked number 1, continuing in this way. consensus was reached in this manner. when combining the topmost five positive statements from the three groups, the statements mostly related to knowledge gain, the process of research, communicating research results or findings to participants, and aspects of organising and planning the research project. these responses were grouped according to the similarity of the context of the statements. each of the statements from the three groups was given a stand-alone code. these codes were then grouped according to their similarity to form a theme. the categories were identified in this way. this technique gives all participants a chance to voice their opinions. the participants are viewed as experts, as they are expert on how they perceive their experiences. harvey and holmes[9] confirmed the ngt as a reliable method to deter mine priorities and considered it valid and effective for problem identification. sampling all final-year students were invited to participate. the researcher holds a relativist view and acknowledges that each student might have a different experience of the exposure to research in the department of optometry, and might interpret it in a personal manner, which could influence their attitude towards research. for these reasons, the sample size was viewed as sufficient. purposeful sampling was used to recruit 22 of the 23 registered final-year (4th-year) optometry students, who were in the process of completing a research project in 2014. informed consent was obtained through distributing information leaflets regarding the study. participants had the right to withdraw before they signed letters of consent. data collection broad questions, typically used in the ngt, were formulated. the questions were constructed to probe any research-related experience of a student. the facilitator took a few minutes before each session to ensure that the students understood the scope of the questions. these were piloted at the first nominal group session to ensure that there was no ambivalence regarding the questions. three nominal group sessions were completed (n=8, n=6, n=7). the questions, which were not altered, were as follows: • what are the positive experiences related to research? • what are the negative experiences related to research? as the participating students were required to continue adding statements until all opinions or experiences were listed, completeness/saturation of the data was achieved. this study also used descriptive coding, which provides the substance of the data, in vivo coding that uses verbatim statements, as well as emotion coding. results of the 22 final-year optometry students who participated in the study, the majority were female (n=19; 86.4%), and the mean age of this group was 22 (range 21 31) years. among the positive statement categories, the following emerged: benefits of research, research process, reflection, group work, gaining information, skills development, participants, supervision and emotion. statements centred mostly on skill gains; the participants felt they had improved their communication and time management skills, as well as learning to plan and organise themselves. the statements in table 1 are the verbatim responses that were recorded from the three groups (indicated by i, ii and iii). the prioritisation is also reflected (1 for the most important), and if one statement received the same number of votes, the numbering was indicated as 4a, 4b, etc. the negative statements (table 2) related mostly to the time-consuming nature of conducting research, administrative guidelines or processes in the different departments, resources and the research process itself, emotions elicited and level of satisfaction (or dissatisfaction) with regard to their experiences. students were aware of the overall emotional and exertional input, and that the return on their investment was negative. a unique finding was the time-consuming nature of obtaining permission from various offices to gain ethical clearance. different ethical procedures are required when using patients, students or individuals from the public in research projects. with the tripartite model of attitude as a reference point, fig. 1 indicates how each of the categories compiled from the data aligns with one or more of the components of this seminal model of attitude. the overlap of some categories emphasises the complex nature of attitude. these combined valences show that within the affective domain, should the resources in the department of optometry improve, the overwhelming feeling of the students would be more positive. june 2018, vol. 10, no. 2 ajhpe 87 research the behavioural component demonstrates how the students developed and matured. participants acknowledged a broad range of skills that they felt had improved, including learning to deal with difficult interpersonal situations with group members and participants. the cognitive aspect specifies the higher-order thinking of linking theory to practice, understanding the limitations of the study and the benefits of what research could mean to them as individuals, the profession and their patients. the category of reflection spanned all three components of the tripartite model of attitude, from having a humble outlook, to altering behaviour, to co-operating with each other for the greater good of the team. discussion this study revealed a cluster of negative statements related to the administrative concerns of the students. this finding has resulted in recommendations being made to the department (table 3). similar results were found in previous studies,[10-14] whereby benefits that accrued to students who performed research had a positive effect on their view of research in general. these benefits included a more positive attitude towards research,[10,12] increased interest in research,[10,12] a better understanding of research design[11] and being more curious about research.[12] research-related activities were also improved, such as the students’ skill level at library research skills development of research questions and hypotheses,[12] a greater understanding of data interpretation and the use of statistics in research,[11,12] as well as a better grasp of referencing.[12] students perceived improved abilities in workplace skills. participants mentioned creative thinking skills, application of ethical principles, computerbased knowledge and skills,[12] oral presentation skills, organisational skills and time management skills.[12,13] during the research process, students realised the importance of good time management, as well as learning to communicate well with others and share the workload. all of these skills lean towards flexibility, which is a sought-after quality in the working environment. the main negative aspect reported was the time-consuming nature of the research project owing to students being in different clinic groups. in 2015, the students were deliberately placed into clinic groups that matched their research project group. this allowed the students to have more time together to collate data. there were aspects where the department of optometry was perceived by the students as faring well: • presentations at annual faculty conferences • group work for research assignments • exposure to new equipment • earning credits towards one’s degree upon completion of the project • exposure to the literature as a source of learning • having an online arena for student discussions. therefore, there are a number of aspects of the optometry programme that are being implemented correctly. the ngt discussions yielded valuable recommendations that, if implemented, would have the ability to instil a stronger research culture in the department. table 1. the five topmost positive statements from the three nominal group technique groups with regard to their experiences of research category statement group final ranking in group benefits of research/ reflection/research process gaining more information that could possibly help in the future i 1 gaining information getting more knowledge about the research subject i 2 more knowledge related to the study topic ii 3 more knowledge about a specific topic iii 1 group work group work makes the workload during the research process easier ii 1 participants/skills development personal relationships with participants during the study ii 4 research process/skills development improving research techniques and methods i 3 how to format a research question i 5b research process knowledge about the research process iii 2 understanding the concepts of what research is all about iii 4 skills development/resources where to find accurate information i 4a skills development improvement of communication skills i 4b teaches you to organise and plan information iii 3 learn to plan time more effectively iii 5 teach others the new information found i 4c skills development/participants positive experience to convey knowledge to participants ii 5 supervision good guidance of a study leader/supervisor ii 2 emotions feeling valuable i 5a build up confidence i 5c a�ective or emotive • emotions • re�ection • time-related factors • resources behavioural • skills development • group work • participants • supervision • re�ection • emotions cognitive • skills development • re�ection • administration • bene�ts of research • resources • research process fig. 1. categories identified in the nominal group technique discussions aligned with the tripartite model of attitude. 88 june 2018, vol. 10, no. 2 ajhpe research conclusion the key recommendations resulting from the findings of the study were to implement policies in the department of optometry for better communication with students. recommended strategies include the following: • allow students to choose their own groups within their clinic schedule • more dedicated research time in the schedule • provide guidelines that require the project to meet technical aspects of publication standards • quality assurance policy on supervision • workshops on writing for students to learn to compose research articles • share supervision with a senior researcher from a different department • allow staff to attend supervision workshops. the new research module comprises eight credits. the outcomes provide a platform for greater emphasis on and importance of exit-level requirements. this study identified various factors that final-year students in the department of optometry, university of the free state, experienced positively and negatively in relation to the contribution of their attitude towards research. acknowledgements. the authors would like to acknowledge the health and welfare sector education and training authority (hwseta) for funding. dr daleen struwig, faculty of health sciences, university of the free state, is acknowledged for technical and editorial preparation of the manuscript. author contributions. sbk contributed to the study design and methodology, and lc conducted the study and compiled the manuscript. table 2. the five topmost negative statements from the three nominal group technique groups with regard to their experiences of research category statement group final ranking in group time related time consuming i 1 time consuming ii 2 time consuming iii 4 time related/administrative the process to obtain permission is time consuming ii 2 resources lack of resources i 2 use of university of the free state facilities increases the costs iii 3 administrative ignorance relating to the administrative process during the research process ii 3 poor guidelines relating to the module ii 4 no allocated time for research in the programme iii 1 uncertainty about the administrative processes iii 5b administrative/time related the length of time the module takes (2 years) iii 5a reflection missing data make analysis difficult i 4 too complicated research question i 5b participants subjects unwilling to participate i 5a participants/emotions unwillingness of participants during the selection process ii 5 emotions stressful i 3 what you put in is more than you get out ii 1 table 3. recommendations: modification of current status current status statement proposed change possible benefits no protocol of communication between the departments involved in the research project poor guidelines relating to the module; uncertainty about the administrative processes formalised line of communication drafting of rubrics for the presentation and the article to be submitted; these are to be included in the module guide minimise time delays, reduce confusion and ambiguity of assessment smoother planning for meeting outcomes no formal schedule or responsibilities of team members delineated ignorance relating to the administrative process during the research process clear guidelines on deadlines and meetings with the supervisor a timeline for the study is to be included in the supervisor-student contract and responsibilities made transparent in this agreement leadership and commitment from both parties accountability from members research performed throughout the final year, as it suits the group members no allocated time for research in the programme allocated week to perform research groups for the research project share the same practical schedules shorter time span concentrated effort allows for continuity of the research mindset fewer clashes in the timetable, which allows for passive group members students from various practical groups in the research group less hassle for students to meet fewer delays in the implementation of the research project june 2018, vol. 10, no. 2 ajhpe 89 research funding. funding was granted by hwseta. conflicts of interest. none. 1. den hartigh w. research output rises, papers double. 2012. www.mediaclubsouthafrica.com/tech/3038-sasresearch-output (accessed 10 february 2016). 2. grossman es, naidoo s. final-year south african dental student attitudes toward a research component in the curriculum. j dent educ 2009;73(11):1306-1312. 3. chireshe r. research supervision: postgraduate students’ experiences in south africa. j soc sci 2012;31(2):229234. https://doi.org/10.1080/09718923.2012.11893032  4. portnoi l. to be or not to be an academic: south african graduate students. int j educ dev 2009;29(4):406-414. https://doi.org/10.1016/j.ijedudev.2009.01.005 5. krech d, crutchfield rs. perceiving the world in theory and problems of social psychology. new york: mcgraw-hill, 1948. 6. schwarz n, bohner g. construction of attitudes. in: tesser a, schwarz n, eds. blackwell handbook of social psychology. oxford, uk: blackwell, 2001:436-457. 7. olson ma, kendrick rv. attitude formation. in: ramachandran vs, ed. encyclopedia of human behavior. 2nd ed. new york: elsevier, 2012:230-235. 8. van breda ad. steps to analysing multi-group ngt data. soc work pract res 2005;17(1):1-14. 9. harvey n, holmes ca. nominal group technique: an effective method for obtaining group consensus. int j nurs pract 2012;18(2):186-194. https://doi.org/10.1111/j.1440-172x.2012.02017.x 10. mccoy m. professional attitudes regarding research – changing the culture one student at a time. j can chiropr assoc 2008;52(3):143-148. 11. lei sa. factors changing attitudes of graduate school students toward an introductory research methodology course. education 2008;128(4):667-685. 12. lei sa, chuang nk. undergraduate research assistantship: a comparison of benefits and costs from faculty and students’ perspectives. education 2009;130(2):232-240. 13. seymour e, hunter ab, laursen sl, deantoni t. establishing the benefits of research experiences of undergraduates in the sciences: first findings in a three year study. sci educ 2004;88(4):493-594. https://doi. org/ 10.1002/sce.10131 14. john j, creighton j. researcher development: the impact of undergraduate research opportunity programmes on students in the uk. stud higher educ 2011;36(7):781-797. https://doi.org/10.1080/03075071003777708 accepted 21 december 2017. http://www.mediaclubsouthafrica.com/tech/3038-sas-research-output http://www.mediaclubsouthafrica.com/tech/3038-sas-research-output https://doi.org/10.1080/09718923.2012.11893032 https://doi.org/10.1016/j.ijedudev.2009.01.005 https://doi.org/10.1111/j.1440-172x.2012.02017.x https://doi.org/10.1002/sce.10131 https://doi.org/10.1002/sce.10131 https://doi.org/10.1080/03075071003777708 september 2018, vol. 10, no. 3 ajhpe 183 research the emergency care profession in south africa (sa) is regulated by the health professions council of sa: professional board for emergency care (hpcsa: pbec).[1] one of the mandates of the pbec is to provide quality assurance of emergency care education programmes. the pbec advocates integrated clinical simulation, using a full-body mannequin, as a summative assessment instrument for all registered emergency care qualifications.[1] concurrently, the pbec is subject to compliance with assessment guidelines outlined by the sa qualifications authority (saqa). these guidelines clarify assessment criteria and integrated assessment and promote the evaluation of applied competence using work-relevant activities (box 1).[2-4] saqa identifies simulation and role-play in its list of assessment instruments.[3,4] role-play in clinical simulation occurs when students assume the roles of qualified practitioners in the context of ‘a situation, a problem or an incident, to which they have to respond’.[3] the conditions suggested as suitable for using simulation include: ‘where demonstrations and observation will provide reliable and valid results, but where, for a number of reasons, it is difficult or not practicable to assess under actual conditions’.[3] the assessment principles of transparency, fairness, validity and reliability, outlined by saqa, are assumed to apply to integrated clinical simulation for summative assessment.[1,3,4] saqa states that the validity of assessment involves ‘setting authentic or applied tasks in the learning programme that closely simulate real world contexts’.[4] by applying the principle of validity to the simulation assessment, the following assumptions can be made: (i) actions by students in simulation are assumed to replicate what they would do in a similar clinical case in practice; and (ii) competence in simulation infers competence in practice. the pbec requires assessments that lead to an advanced life support (als) qualification to be moderated (box 1).[1] the pbec provides guidelines for moderators to report on the simulation assessments with regard to:[5] • design, structure and facilitation of the simulation • authenticity and realism of the event • adherence to the principles of fairness, validity, reliability and practicality. despite these reporting requirements for moderators, the education regulators provide neither assessment criteria nor guidelines for emergency care educators to fulfil such requirements. in the absence of such guidelines, how clinical simulations are assessed is left to the discretion of assessors background. the professional board for emergency care (pbec), the statutory body regulating the quality of emergency care education programmes in south africa, has mandated these programmes to use integrated clinical simulation as an instrument for authentic assessment. in support of the validity of this instrument, actions by students during simulation are assumed to replicate what they would do in similar circumstances in practice. objectives. to present and discuss perspectives of advanced life support (als) paramedics on the use of integrated clinical simulation as a summative assessment instrument, offer a critique of assumptions regarding the use of this assessment instrument, and recommend improvements for its use. methods. a qualitative, single, embedded case study design was used to address assessment criteria and case types for integrated clinical simulation as a summative assessment instrument. qualitative data were collected by means of focus group interviews. perspectives of als paramedics emerged from the results of this study. results. participants agreed that integrated clinical simulation was an appropriate assessment instrument if assessment principles were adhered to. accurate replication of the contextual elements of emergency care practice was perceived as central for eliciting authentic responses associated with als paramedic practice. the conditions, context and range of life-threatening conditions across medical disciplines challenged the idea that a single, once-off assessment event could be a valid reflection of competence. conclusion. to elicit authentic responses, the design of integrated clinical simulation events for summative assessment should include relevant clinical, environmental and social-professional elements of als paramedic practice. more than one assessment should be done, and should address the range and complexity of medical and trauma emergencies, thereby assessing the true competence of als paramedic students. assessors should acquire the requisite skills to assess simulation effectively. afr j health professions educ 2018;10(3):183-188. doi:10.7196/ajhpe.2018.v10i3.962 perspectives of advanced life support paramedics on clinical simulation for summative assessment in south africa: is it time for change? r g campbell,1 btech (emc), mhpe; m j labuschagne,2 mb chb, mmed (ophth), phd (hpe); j bezuidenhout,1 ba ed, hdiped, pgdiphpe, ba hons psych, med (psych of ed), dtech (ed) 1 division of health sciences education, office of the dean: health sciences, faculty of health sciences, university of the free state, bloemfontein, south africa 2 clinical simulation and skills unit, support school of medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: r g campbell (phdhpe@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:phdhpe@gmail.com 184 september 2018, vol. 10, no. 3 ajhpe research and moderators, who may rely on traditional practices rather than current best practice in simulation. a qualitative study was conducted by the primary author in fulfilment of a master’s in health professions education to identify assessment criteria for integrated clinical simulation for emergency care education programmes in sa. perspectives of als paramedics on the use of this instrument for summative assessment were captured in theme 1 of the results, as set out below. the objective of this article was to present and discuss these perspectives, offer a critique of assumptions regarding the use of this assessment instrument, and recommend improvements for its use. methods a qualitative, single, embedded case study design was used. the main unit of analysis was integrated clinical simulation as a summative assessment instrument, and the two subunits of analysis were assessment criteria and case types. the experiences and perceptions of als paramedics as students and their post-qualification encounters with life-threatening emergencies in clinical practice were identified as valuable sources of data for populating the units of analysis. these qualitative data were collected by means of four focus group interviews. this type of interview was chosen as the method of data collection, based on the expectation that information would be enhanced through group interaction.[6] a non-random sampling method, using both convenience and purposive sampling, was employed. the survey population included all als paramedics in the bloemfontein area in the free state, sa, who had at least 2 years’ clinical experience at als level and had obtained their qualification in sa. a total of 42 als paramedics were identified and invited to participate in the study, of whom 28 volunteered to participate in the focus group interviews. before the interviews commenced, participants signed consent forms and were informed that the interview session would be audio-taped. confidentiality was ensured by concealing the identities of the participants to people outside the group. participant response references were omitted in this article to achieve anonymity. ethical approval (ref. no. ecufs 204/2013) for the study was obtained from the ethics committee, faculty of health sciences, university of the free state, bloemfontein. an independent, experienced facilitator conducted all four focus group interviews. the number of participants in each focus group was 10, 7, 5 and 6, respectively. the interview guide was standardised for all four groups to enable comparison of responses across the different groups. questions focused on the following areas: • the behaviours and attitudes required of als paramedics to effectively manage a critical patient in the out-of-hospital context • competencies that should be assessed when using integrated clinical simulation • case types or scenarios that present the best opportunities to determine the ability of an als paramedic to deal with a life-threatening condition effectively, and which are essential for simulations • factors that should be included in the design of integrated clinical simulations for summative assessment. the audio-taped interviews were transcribed by the primary author and verified by the focus group facilitator and group members. open-coding analysis of transcriptions was used to link participant perspectives to elements of assessment criteria in the relevant categories. inductive and deductive processes of interpreting results were used in the context of the literature review, experience of the primary author and voices of participants to form thick descriptions.[7] the themes and categories into which descriptive data were placed were derived from the elements of assessment criteria clarified by saqa (box 1). the co-authors verified the coding process and thematic analysis. as this is a descriptive study, the results may support analytical generalisation, where the logic of results and discussion can be applied to other similar situations.[8] results and discussion of the focus group participants, 4 (14%) had the minimum of 2 years’ clinical experience, 8 (29%) had 3 4 years’ clinical experience, 13 (46%) had 5 10 years’ clinical experience and 3 (11%) had >10 years’ clinical experience. box 1. clarification of terms als paramedic: someone registered with the hpcsa and qualified to render als in a specified scope of practice. als qualifications include critical care assistant (cca), emergency care technician (ect), national diploma: emergency medical care (ndip: emc), bachelor of technology: emergency medical care (btech: emc) and the bachelor degree: emergency medical care (professional degree). integrated clinical simulation: the holistic process of assessing and managing a simulated patient in a realistic clinical setting using a full-body mannequin; during this process, appropriate medical procedures can be performed and appropriate physiological responses to management can be portrayed. this is also known as ‘full-scale, scenario-based simulation’ or ‘full-mission simulation’.[5] assessment criteria: defined by saqa as ‘the standards used to guide learning and assess learner achievement and/or evaluate and certify competence’, and include ‘statements that describe the standard to which learners must perform the actions, roles, knowledge, understanding, skills, values and attitudes stated in the outcomes’.[2] they are a clear and transparent expression of requirements against which successful (or unsuccessful) performance is assessed.[3] the assessment criteria should stipulate: • ‘the knowledge, understanding, action(s), roles, skills, values and attitudes that a learner has to display in order to provide evidence that outcomes and competence have been achieved • the level of complexity and quality of these • the context of and conditions under which demonstrations should occur.’[3] summative assessment: ‘assessment conducted at the end of sections of learning or at the end of a whole learning programme, to evaluate learning achievements related to a particular qualification, part-qualification, or professional designation’.[2] integrated assessment: a ‘form of assessment which permits the learner to demonstrate applied competence and which uses a range of formative and summative assessment methods’.[4] applied competence: defined by saqa as a ‘learner’s ability to integrate concepts, ideas and actions in authentic, real-life contexts’.[3] hpcsa = health professions council of south africa; als = advanced life support; saqa = south african qualifications authority. september 2018, vol. 10, no. 3 ajhpe 185 research some participants had obtained more than one als qualification. the als qualifications were represented as follows: 7 (25%) critical care assistant, 24 (85%) national diploma: emergency medical care (ndip: emc) and 13 (46%) bachelor of technology: emergency medical care (btech: emc). there were no emergency care technicians who met the inclusion criteria. the critical care assistant training institutions included netcare 911 school of emergency and critical care, and the provincial colleges of emergency care situated in durban, pietermaritzburg and cape town. the ndip: emc training institution included the former technikon natal, the current durban university of technology, cape peninsula university of technology and central university of technology, bloemfontein. the btech: emc training institution included the durban and cape peninsula universities of technology. participants also had experience of teaching the various levels of qualifications in emergency care. of the 28 participants, 5 (18%) had experience teaching at basic life support level, 9 (32%) at intermediate life support level, and 17 (61%) at als level. some had taught more than one level. regarding simulation, 18 (64%) had some experience with designing simulations, 21 (75%) with presenting simulations and 21 (75%) with assessing simulations. from an analysis of the participant group, the range of experience in clinical practice and involvement in simulation together with representation across the als qualifications suggest that this group was well suited to render valuable perspectives on the research questions. theme 1 addressed perspectives of participants on clinical simulation as an integrated summative assessment instrument (table 1). focus group participants were in favour of assessing student performance in authentic situations (table 2). the authentic situation was identified as the real patient, real-time interaction and real conditions.[1,4] assessment in the clinical practice setting, although seen as ideal, was identified as impractical and unreliable owing to inconsistent case presentation (type and severity) and unpredictable occurrence of cases suitable for assessment. focus group participants highlighted the need for patient simulations to replicate the clinical setting as realistically as possible (table 2). objective aspects of a real clinical case in out-of-hospital emergency care includes the context, environment, clinical expression, response to interventions, use of technology and realism with the tasks and procedures that should be performed. this prerequisite for realism underpins a belief that student performance in clinical simulation should correlate with student performance in clinical practice. in contradiction to the support given by participants to the ideals of using clinical simulation for assessment, the experience-based perspectives of participants expressed the opposite, i.e. that the integrated clinical simulation lacks the validity, reliability and generalisability subsumed in its practice. the following reasons were identified for this paradox in performance between the simulation setting and clinical practice (table 3): • unrealistic or inadequate representation of als paramedic practice in simulation • focusing simulation use on summative assessment. unrealistic aspects of the clinical simulation experience include limitations of the simulator, insufficient replication of environmental conditions, poor translation of clinical cases through simulation that causes confusion and misinterpretation by students, and inadequate assessment across the range and complexity of clinical emergencies. the unrealistic and limited features of full-body mannequins for replicating human anatomy and physiology were perceived to undermine true performance in clinical simulation for assessment. how physical and pathophysiological features of the patient’s condition are represented and obtained in simulation may conflict with how such information is gathered table 1. summary of theme 1 theme 1 category clinical simulation as an integrated summative assessment instrument 1. assessment in the authentic situation 2. fictional features of clinical simulation confounding true student performance 3. influence of assessment on true student performance in clinical simulation 4. assessment principles and the integrated clinical simulation table 2. qualitative responses reflecting perspectives of using integrated clinical simulation for summative assessment in emergency care education in south africa[11] 2.1 support for assessment in the authentic situation ‘i mean if you really want to assess somebody on patient management and identification of underlying illnesses it should actually be on real patients with real conditions.’ ‘taking them out and assessing them on the road, the fairness of it i don’t see because you cannot be consistent in what you are assessing because each student is going to be getting a different patient every time.’ ‘but if we can get that student to believe that is the real thing, then you are going to get the demonstration hopefully as close as possible to what they would do in real life.’ 2.2 concerns about the validity, reliability and generalisability subsumed in the historical use of the integrated clinical simulation ‘in my experience we have had cases where there’s been a clear difference between the way the student paramedic performs in a simulated environment as compared to the way they perform in real life … and we’ve had confident students who excel at the roadside under real circumstances and then fall to pieces in a simulation laboratory kind of situation, and then quite the opposite where others have excelled in the laboratory and yet when it comes to the real thing they are not able to deal with it.’ ‘people find it difficult to take something that’s fiction and you have to treat it as if it’s reality.’ 186 september 2018, vol. 10, no. 3 ajhpe research in clinical practice settings. verbally transmitting information, which would normally be obtained through observation, inspection, auscultation and palpation, leads to misinterpretation and may confound information gathering. reliance on memory and imagination may present a barrier to engaging realistically in a stressful situation. additional factors confounding realistic experience in simulation include: • fast-tracking participant actions, such as being told the intravenous line is sited, when it has not been physically performed • fast-tracking patient progress (improvement or deterioration) and response to intervention into the time limit given for the assessment. environmental and contextual factors in paramedic practice were seen to influence performance. poor lighting and noise may hinder obtaining clinical information through observation, inspection and auscultation. interference or distractions by family members or bystanders adds to the challenges of patient assessment and treatment. the quality of interprofessional interaction at the scene and at the medical facility contributes to patient care efforts. when these variables are excluded from the integrated clinical simulation, assessing applied competence is confounded. the range of possible life-threatening emergencies in clinical practice spans medical disciplines, age groups and unique patient categories often complicated by environmental factors. given that the integrated clinical table 3. qualitative responses reflecting reasons for the paradox of performance between the simulation setting and that expected in clinical practice 3.1 unrealistic or inadequate representation of als paramedic practice in simulation 3.1.1 limitations of patient simulators ‘you know the dolls that we are getting … they are making it close to reality, it is still not reality … it is not a human being.’ ‘the differences between a simulation and reality is that reality is a person who can either talk to you, you can see and you can visualise what is actually wrong with the patient.’ 3.1.2 inadequate representation of the clinical case ‘if you are told the patient has a femur fracture when you walk in there and you don’t even see any fracture … you can even miss the fracture and treat everything else and even forget that.’ ‘there is always somebody that interprets everything for you – so there’s always somebody, you are asking somebody a question; is he pale, is he fat?’ ‘the time that is spent in a simulation is not the same as the time it would take in real life, but you are forever compressing certain aspects to say, ok, we consider that as done although it is not yet done … it’s unrealistic.’ 3.1.3 inadequate representation of the conditions and context of als paramedic practice ‘being in a simulation environment, you walk in – it’s quiet – you’ve got the simulator, you basically do what you see there. once you get on the road there’s a difference there, because there’s traffic, there’s noise, it’s raining – the students start reacting differently – their thought process is different – what they might have passed here – they forget the stuff they have to do on the road – there are dogs barking, there’s family fighting – all those kind of things that you don’t find when doing a simulation.’ 3.1.4 insufficient representation of range and complexity of clinical emergencies ‘the problem is this shot in the dark with one or two simulations that then represent what that person can do for all aspects and all categories – a little bit hit and miss – you might have got them on a good day or on a bad day … if there are no limitations then the ideal situation would be to test in each category – in other words, a paediatric simulation, a maternity simulation, a peri-arrest cardiac patient, a trauma patient.’ 3.2 simulation use for summative assessment 3.2.1 the problem with the once-off nature of the simulation assessment ‘not by putting the poor fellow or lady at the end of the year into a situation where this is your be-all and end-all … you’ve wasted your whole year if you do not pass today’s assessment!’ 3.2.2 stress of once-off assessment confounds student performance ‘if he walks in the room and he is all sweaty and trembling … so there’s a psychological aspect, how he presents himself and carries himself inside the plastic environment.’ ‘your whole cca depends on one sim and you get in that room and there’s 7 or 8 doctors, professors and paramedics, so it really intimidates you and even some of the best students failed the sim.’ 3.2.3 factors influencing objectivity and quality of assessment ‘with the evaluator, his knowledge, skills and experience will also determine the way he’s going to evaluate the specific student.’ ‘in some cases i think it is more the fault of the assessors who are not properly assessing people – letting them through the system just to fulfil the number of people to go through the system instead of quality assessment on those students.’ ‘but how harsh is that to the evaluator or assessor because now you are sitting with 5 or 10 or 20 or whatsoever assessments during that specific day – you also get exhausted, you are also getting tired.’ 3.2.4 extent of student adaptation to simulation for assessment ‘ya, they’ve got to imagine it, but if the simulation isn’t close to reality and the student fails to pick up the guy is not breathing because it’s not set as it would be in reality, then i mean there’s no fairness towards the student.’ ‘you are looking at the narrator … looking at your facial expressions, i mean it’s not natural because you are trying to fish for things there; clues or voice tones and stuff like that which are actually not giving you that realistic environment … some individuals … they are not actors and you have to have a sense of acting or role-play in a simulation.’ als = advanced life support; cca = critical care assistant. september 2018, vol. 10, no. 3 ajhpe 187 research simulation summative assessment has traditionally been conducted as a once-off evaluation, means there is an under-representation in assessment of the range of medical and trauma emergencies. when replication of the conditions, context and scope of clinical practice is inadequate, then true performance is confounded and the authentic situation for summative assessment is questionable. within the context of this complex array of factors affecting student performance, participants also expressed concern about the unfair risk to student success by using the integrated clinical simulation as a once-off assessment. specifically, the stress associated with this manner of assessment was reflected as a factor confounding authentic student performance. factors cited as exacerbating the stress of this assessment were the presence and number of assessors, perceived bias and unpreparedness of assessors to judge performance in simulation, and assessor fatigue during lengthy assessments. student success in simulation assessment may result from students adapting to this artificial context by developing skills to cope with stress and navigate fictional aspects of the simulation event. students who cannot cope or make this adaptation, risk underperforming in the assessment. the authors suggest that this coping and adaptive behaviour renders true performance in assessment difficult or impossible and prevents translation to clinical practice. this is prevalent where: (i) rules that convert a clinical case into a clinical simulation are not explicit;[9] (ii) rules that address how inconsistencies between the clinical simulation and the real clinical case will be managed are hidden or change constantly; (iii) there is dissonance in constructive alignment, with differing standards for formative and summative simulation events with regard to design, facilitation and assessment practices;[10] and (iv) the assessment criteria and performance standards are unclear. furthermore, the focus of a formative simulation experience may be on how many simulation events can be offered in preparation for assessment, without attention to quality feedback, debriefing and translation to clinical practice. a signature component of als paramedic practice is the unique context of infinite variations and combinations of environments, socioeconomic conditions and patient profiles.[11,12] bland et al.[13] argue that realistic representation of real-life situations by simulation is central to engaging learners in authentic responses. for example, mills et al.[14] demonstrated that inadequate environmental realism in clinical simulation impeded paramedic student performance, with increased levels of anxiety. bland et al.[13] further contend that, although objective reality is essential to simulation, the students’ subjective interpretation of the simulation experience influences how realistically they engage in simulation. together with engineered realism, authentic clinical experiences in simulation are an integrated function of participant perceptions of reality and willingness to engage realistically.[13] rudolph et al.[15] argue for a psychologically safe environment for learners to engage realistically in a simulation event. psychological safety is a state where learners feel safe enough to accept the discomfort that accompanies performance in front of lecturers, examiners and/or peers. clarifying expectations, instituting a ‘fiction contract’ and consistently applying simulation rules and rituals (governing how clinical cases are converted to hypothetical simulated cases, how fictional elements are addressed and how simulation events are facilitated) are necessary elements of a psychologically safe environment.[9,10,13] preparing learners for participation in simulation for learning and assessment is therefore crucial to ensure fairness and validity of simulation as an authentic assessment. the threat associated with summative assessment can be mitigated through effective formative development and trust in a robust and consistently applied simulation process. barr et al.,[10] for example, demonstrated improved benefits of clinical simulation to paramedic students by: (i) shifting the focus from summative assessment to learning through simulation; (ii) making assessment criteria explicit; and (iii) applying these criteria to both formative and summative simulation assessments. mckenna et al.[12] suggest that the three essential ingredients for effective employment of simulation in emergency care education are simulation facilities, training of educators in the use of simulation, and resources to integrate simulation in the curriculum. in clarifying the reliability of assessment, saqa states that ‘assessors should be trained and competent in administering assessments’.[3] topping et al.[16] argue that educators using simulation ‘should have a minimum skill set [to] integrate simulation appropriately into program delivery’. a recent consensus survey of simulation use in accredited paramedic programmes across the usa revealed underutilisation of simulation.[12] the two main barriers to using simulation effectively were lack of staff training in facilitating simulation, and the writing of scenarios. lack of training in debriefing was sixth on the list. in their updated policy on assessment, saqa states that ‘assessment is used to facilitate learning. this kind of assessment – assessment with instruction, engagement and feedback – is adopted wherever feasible and appropriate.’[2] simulation is a complex educational methodology that blends educational and clinical practice elements. medical simulators are becoming more technologically complex, and educators are expected to use simulators to engage students in authentic learning and assessment. mckenna et al.[12] highlight the complex array of factors involved in using simulation, and suggest that ‘effective instruction using technology requires that educators have adequate knowledge about content, pedagogy, when to select a particular method to teach specific content, and the technology being used’. recommendations for change the following recommendations from findings are offered to employ clinical simulation more effectively in the context of emergency care education in sa: • simulation design, facilitation and feedback strategies used for teaching, learning and assessment should be evidence based, replicate essential features of the clinical practice environment, demand real-world actions and responses from students and support a longitudinal approach to measuring performance across the range of emergencies and medical disciplines. • students need to be prepared effectively to learn and be assessed through simulation, where such learning and assessment are focused on clinical practice realities and achievement of qualification outcomes. such preparation includes clarity on the rules of simulation that address the discrepancies between the simulation and real clinical context. • simulation should first be employed to facilitate learning prior to its use for summative assessment. the formative use of simulation should apply the same assessment principles and criteria employed in the summative assessment process to ensure alignment between assessment for learning and assessment of learning. • since simulation-based learning and assessment require a specific skill set, facilitator and examiner training is required to use this specific instrument effectively. 188 september 2018, vol. 10, no. 3 ajhpe research • the pbec as the regulatory body for emergency care education, in conjunction with emergency care education providers, should develop and promote best-practice guidelines and assessment criteria for using integrated clinical simulation as an assessment instrument. conclusion achievement of qualification outcomes and appropriate preparation of newly qualified als paramedics for clinical practice are the prerogative of emergency care education programmes. to accomplish this, simulation has been promulgated as a valuable instrument for assessing applied competence. the ideals of simulation address the range of medical and trauma emergencies, with transfer of knowledge and skills to clinical practice. by means of this study, however, perspectives of participating als paramedics on their experience with simulation for summative assessment shed doubt on whether these ideals are being achieved. the issues raised challenge the credibility and assumptions of simulation as a summative assessment instrument, yet offer education regulators and emergency care education providers an opportunity to develop evidence-based guidelines and practices for employing simulation for teaching, learning and assessment. having such guidelines, together with trained facilitators and assessors, is likely to promote strategies for authentic student engagement, design and facilitation of simulation that foster realism and immersion, and constructive alignment of simulation for formative and summative assessment across the scope of als paramedic practice. with developments in simulation technology, the challenge remains for emergency care educators to remain up to date in the selection and use of the most appropriate simulators that enable learning, achievement and assessment of qualification outcomes in conjunction with other facilitation and assessment modalities. innovative approaches to accurately replicate pertinent clinical, environmental and social-professional elements of als paramedic practice in simulation are required. important elements for eliciting true performance and influencing performance, and methods of reliably assessing the spectrum of simulation in emergency care, are subjects for further research. this study did not compare simulation with other integrated assessment instruments or other platforms, such as workplace assessment. using simulation as a learning-centred instructional methodology was not addressed in this study. the use of other types of simulators by emergency care education programmes in sa was not discussed and requires additional research. the design of a simulation-based programme for emergency care education, incorporating the range of simulation activities and best use of simulators, needs further investigation for optimising programme delivery. the results of this study can be applied in similar settings in southern africa. acknowledgements. we acknowledge the focus group participants for their valuable contribution to the study. author contributions. rgc: conducted the study in fulfilment of a master’s degree in health professions education from the university of the free state, bloemfontein, and subsequently prepared the manuscript. mjl: study leader, and gave guidance and expertise in the field of simulation. jb: co-study leader, and provided input on technical detail and research aspects. both co-authors assisted with verifying the coding of data, with development of themes and categories, and provided a critical review of the content and technical aspects of the manuscript. funding. the health and welfare sector education and training authority (hwseta) provided funding for the study. conflicts of interest. at the time of preparing the manuscript, the primary author was in the employ of a private company promoting and conducting healthcare simulation training. 1. health professions council of south africa. professional board for emergency care. guidelines for the completion of the portfolio for institutions wishing to offer the emergency care assistant (eca), emergency care technician (ect) and emergency care practitioner (ecp) programmes. pretoria: hpcsa, 2015. 2. south african qualifications authority. national policy and criteria for designing and implementing assessment for nqf qualifications and part-qualifications and professional designations in south africa. pretoria: saqa, 2015. 3. south african qualifications authority. criteria and guidelines for the assessment of nqf registered unit standards and qualifications. pretoria: saqa, 2001. 4. south african qualifications authority. guidelines for integrated assessment. pretoria: saqa, 2005. 5. health professions council of south africa. professional board for emergency care. template and guidelines for the completion of the external moderator’s report. pretoria: hpcsa, 2014. 6. bender de, ewbank d. the focus group as a tool for health research: issues in design and analysis. health transit rev 1994;4(1):63-80. 7. ponterotto jg. brief note on the origins, evolution, and meaning of the qualitative research concept thick description. qual rep 2006;11(3):538-549. 8. yin rk. applications of case study research. 3rd ed. los angeles: sage publications, 2012:18-19. 9. dieckmann p, gaba d, rall m. deepening the theoretical foundations of patient simulation as social practice. sim healthcare 2007;2(3):183-193. https://doi.org/10.1097/sih.0b013e3180f637f5 10. barr n, readman k, dunn p. simulation-based clinical assessment: redesigning a signature assessment into a teaching strategy. australas j paramed 2014;11(6). 11. smith a, andersen p. proven effective: simulation-based assessment facilitates learning and enhances clinical judgment. j emerg med serv 2014:3-8. 12. mckenna kd, carhart e, bercher d, spain a, freel j. simulation in ems education: charting the future. association of ems educators (naemse). 2015. https://c.ymcdn.com/sites/naemse.site-ym.com/resource/ resmgr/docs/simpressrelease15.pdf (accessed 13 july 2018). 13. bland aj, topping a, tobbell j. time to unravel the conceptual confusion of authenticity and fidelity and their contribution to learning within simulation-based nurse education. nurse educ today 2014;34(7):1112-1118. https://doi.org/10.1016/j.nedt.2014.03.009 14. mills bw, carter ob-j, rudd cj, claxton la, ross np, strobel na. effects of lowversus high-fidelity simulations on the cognitive burden and performance of entry-level paramedicine students: a mixed-methods comparison trial using eye-tracking, continuous heart rate, difficulty rating scales, video observation and interviews. sim healthcare 2016;11(1):10-18. https://doi.org/10.1097/sih.0000000000000119 15. rudolph jw, raemer db, simon r. establishing a safe container for learning in simulation: the role of the presimulation briefing. sim healthcare 2014;9(6):339-349. https://doi.org/10.1097/sih.0000000000000047 16. topping a, bøje rb, rekola l, et al. towards identifying nurse educator competencies required for simulationbased learning: a systemised rapid review and synthesis. nurse educ today 2015;35(11):1108-1113. https://doi. org/10.1016/j.nedt.2015.06.003 accepted 22 january 2018. https://c.ymcdn.com/sites/naemse.site-ym.com/resource/resmgr/docs/simpressrelease15.pdf https://c.ymcdn.com/sites/naemse.site-ym.com/resource/resmgr/docs/simpressrelease15.pdf https://doi.org/10.1016/j.nedt.2014.03.009 https://doi.org/10.1016/j.nedt.2015.06.003 https://doi.org/10.1016/j.nedt.2015.06.003 10 march 2018, vol. 10, no. 1 ajhpe short research report interventionalists are highly specialised doctors who undergo rigorous training. the use of ionising radiation is an integral part of their medical practice and potentially poses major occupational health risks, such as skin damage, genetic and chromosomal aberrations, carcinomas and cataract formation.[1] the use of this modality for diagnostic, treatment and interventional procedures has increased substantially, posing greater occupational risks.[2] in medicine, occupational radiation protection is challenging and increased vigilance is required to protect radiation healthcare workers (hcws).[1] ionising radiation places patients at risk of developing skin reactions and alopecia, malaise, gastrointestinal problems, damage to heart and lungs, and primary and secondary carcinomas.[3] patients may receive an increased radiation dose owing to over-investigation, because of the complexity and duration of procedures or poor radiation safety practices by operators.[3] improved knowledge of radiation safety for patients may assist in reducing these complications and thus improve the quality of care.[4] specialists require dedicated training in radiation safety, as it effectively reduces radiation risk and optimises radiation safety practices.[5] there is a need to elevate the level of training received by interventional cardiologists to that of interventional radiologists.[6] this may be challenging, as the cardiologists’ curriculum already comprises an enormous volume of work, but it is important that professional and regulatory bodies find a way to implement and foster these changes in the interest of interventionalists and their patients.[6] developing a culture of learning will assist in developing a culture of radiation protection (crp), which is essential to lessen radiation exposure. a crp is a combination of the knowledge, beliefs and practices in an organisation that promotes radiation safety in the workplace.[7] creating and sustaining a crp is the responsibility of the catheterisation laboratory team (doctors, nurses and radiographers) and managers.[8] the latter are responsible for ensuring that the equipment is functional and maintained and for providing sufficient and correct personal protective equipment (ppe).[8] a crp creates awareness of the risks of radiation injury to patients and operators and facilitates improved compliance with ppe use.[7] this culture can be stimulated by including radiation safety training in the formal curriculum of all interventionalists.[9] the objective of this article is to present the findings of the perceptions of south african (sa) interventionalists on the radiation safety training they received and to offer insights into the importance of developing and promoting such training programmes for all interventionalists in sa. methods in this cross-sectional study, we collected data by means of a structured survey. the study forms part of a larger multiple-methods study, which is described elsewhere.[10] the study population consisted of sa radiologists, adult cardiologists and paediatric cardiologists. data were collected at cardiology and radiology conferences between may 2015 and september 2016 by an electronic survey background. ionising radiation is increasingly being used in modern medicine for diagnostic, interventional and therapeutic purposes. there has been an improvement in technology, resulting in lower doses being emitted. however, an increase in the number of procedures has led to a greater cumulative dose for patients and operators, which places them at increased risk of the effects of ionising radiation. radiation safety training is key to optimising medical practice. objective. to present the perceptions of south african interventionalists on the radiation safety training they received and to offer insights into the importance of developing and promoting such training programmes for all interventionalists. methods. in this cross-sectional study, we collected data from interventionalists (n=108) using a structured questionnaire. results. all groups indicated that radiation exposure in the workplace is important (97.2%). of the participants, the radiologists received the most training (65.7%). some participants (44.1%) thought that their radiation safety training was adequate. most participants (95.4%) indicated that radiation safety should be part of their training curriculum. few (34.3%) had received instruction on radiation safety when they commenced work. only 62% had been trained on how to protect patients from ionising radiation exposure. conclusion. radiation safety training should be formalised in the curriculum of interventionalists’ training programmes, as this will assist in stimulating a culture of radiation protection, which in turn will improve patient safety and improve quality of care. afr j health professions educ 2018;10(1):10-12. doi:10.7196/ajhpe.2018.v10i1.981 a survey of radiation safety training among south african interventionalists a rose,1 mb bch, mmed (community health); w i d rae,2 mb bch, phd 1 department of community health, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of medical physics, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: a rose (roseas@ufs.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 11 short research report system (evasys, uk) (www.evasys.co.uk) and hard copy. the hyperlink to the survey was emailed to delegates at the conferences and workshops and to academic departments in sa. hard copies of the survey were handed out at the scientific meetings. there was no randomisation and all eligible interventionalists willing to participate were included in the study. the data were captured electronically, exported to stata version 14 (statacorp., usa), and a descriptive analysis was done. ethical approval ethical approval was granted by the human research ethics committee of the faculty of health sciences, university of the free state, bloemfontein, sa (ref. no. ecufs 44/2015). participants provided written informed consent, and consent was assumed if participants proceeded with the online survey. results a total of 108 interventionalists completed the survey. table 1 presents a descriptive analysis of this group, which illustrates their demographic characteristics and the radiation safety training they received. discussion interventional procedures place patients and operating staff in the catheterisation laboratory at increased risk of adverse health effects owing to radiation exposure.[1,3] most participants (97.2%) ranked occupational radiation exposure as an important consideration (table 1), which suggests that they were aware that ionising radiation is an occupational risk. it is, however, important to explore their understanding of the risk and its sequelae. despite technological improvements, resulting in equipment emitting lower doses, low-dose radiation may still have detrimental effects on health.[3] therefore, training in radiation safety is imperative and essential for protecting staff in the radiation workplace.[11] overall, participants reported receiving low levels (35.2%) of training in radiation safety. radiologists reported higher levels (65.7%) of training than cardiologists. these results are similar to those of other studies, where radiologists demonstrated higher levels of knowledge of radiation safety.[9] the median duration of time worked for all participants was 10 (interquartile range 5 20) years; participants might therefore have had difficulty recalling their training, which might have introduced bias. even though radiobiology and radiation physics are included in the part i examination for the fellowship of the college of diagnostic radiologists of south africa, not all the radiologists reported having received training in radiation safety.[12] it is unclear why, despite their training for the part i examination, radiologists did not report having received training in radiation safety. it is concerning that there is a difference in training between radiologists and cardiologists, as the interventional procedures performed by these two groups result in similar radiation exposure – placing them at similar table 1. radiation-safety training among south african interventionalists demographic characteristics radiologists, n=35 adult cardiologists, n=41 paediatric cardiologists, n=32 total, n=108 age, years median 43 48 43 44 iqr 36 49 41 59 39 53 39 53 range 30 60 31 69 32 59 31 69 sex, n (%) male 17 (48.6) 37 (90.2) 20 (62.5) 74 (68.5) female 18 (51.4) 4 (9.8) 12 (37.5) 34 (31.5) worked, years median 11 11 9 10 iqr 5 16 5 21 5 14 5 20 range 2 32 1 40 1 28 1 40 sector, n (%) public 14 (40.0) 11 (26.8) 22 (68.7) 47 (43.5) private 15 (42.9) 23 (56.1) 2 (6.3) 40 (37.1) both 6 (17.1) 7 (17.1) 8 (25.0) 21 (19.4) perception of occupational radiation exposure, n (%) important 35 (100) 39 (95.1) 31 (96.9) 105 (97.2) somewhat important 0 2 (4.9) 1 (3.1) 3 (2.8) received radiation safety training, n (%) 23 (65.7) 10 (24.4) 5 (15.6) 38 (35.2) training should be part of the curriculum, n (%) 34 (97.1) 39 (95.1) 30 (93.8) 103 (95.4) received radiation safety induction on commencing work, n (%) 19 (54.3) 14 (34.2) 4 (12.5) 37 (34.3) received at least one talk on radiation safety, n (%) 21 (60.0) 25 (60.9) 7 (21.9) 53 (49.1) trained on how to protect patients from radiation, n (%) 28 (80.0) 25 (60.9) 14 (43.8) 67 (62.0) trained on how to use x-ray equipment, n (%) 24 (68.6) 20 (48.8) 8 (25.0) 52 (48.2) n=31 n=24 n=13 n=68 considered training adequate, n (%) 19 (61.3) 8 (33.3) 3 (23.1) 30 (44.1) iqr = interquartile range. http://www.evasys.co.uk 12 march 2018, vol. 10, no. 1 ajhpe short research report risk.[6] it is important that different specialties employing radiation receive dedicated instruction and training in radiation safety to optimise their medical practice.[13] most participants (95.4%) indicated that it was necessary to include radiation safety in the curriculum. overall, participants indicated low levels of satisfaction (44.1%) with the level of radiation safety training they had received. the combination of these two factors should encourage the curriculum developers for these two groups to investigate and address this omission, especially for cardiology training.[13] one study indicated that implementation of a training programme resulted in a significant shortand long-term reduction in radiation dose to patients and radiation hcws.[14] advocating small behavioural changes among interventionalists reduces radiation during procedures, but requires educating them, especially cardiologists.[15] encouraging more optimal radiation practices is very difficult and necessitates proactive training strategies.[16] training in radiation safety greatly improves reduction in radiation dose to patients and operators.[16] training programmes, however, cannot be a once-off event. in a study by georges et al.[16] it was found that the duration of the impact of training was up to a maximum of 3 months and then tended to decrease.[16] this suggests that there needs to be continuing reinforcement and training in this field. we suggest that the topic should be part of continuing medical education programmes and incorporated into radiology and cardiology conferences. training of interventionalists in radiation safety may have two very important consequences. firstly, it may increase awareness of ionising radiation as an unseen occupational hazard and facilitate utilisation of ppe to mitigate the effects of radiation. this protects an already scarce and highly skilled healthcare workforce. secondly, radiation hcws may become more vigilant when considering the dose administered, thus protecting the patient. patient safety is the keystone of quality care.[4] study limitations this study did not explore participants’ understanding of specific health risks related to ionising radiation. it also did not investigate the participants’ thoughts with regard to the content and depth of a radiation safety curriculum. there may be recall bias from participants in reporting the training they received. it should be investigated why all the radiologists did not report having received training in radiation safety. a culture of radiation protection is discussed in an article linked to this study.[17] conclusion establishing and maintaining an adequate radiation safety training programme is crucial to instilling and sustaining a culture of radiation protection, which can protect radiation workers and patients and improve the quality of care. radiation safety training should be part of formal training programmes and its importance emphasised for it to be effective. further research is necessary to determine the areas of deficit in radiation safety among interventionalists and how these can be addressed. acknowledgements. none. author contributions. ar conceptualised the study, developed the protocol, collected and analysed the data, and wrote the first and final draft of the manuscript. widr conceptualised the study and contributed to the final draft of the manuscript. funding. the phd from which this study emanated was funded by the south african medical research council (samrc) under the samrc clinician researcher programme. ar received the discovery foundation scholarship, which funded the data collection of this project. sa heart (free state branch) partially funded data collection for the project. widr is a recipient of a national research foundation incentive grant. conflicts of interest. none. 1. smilowitz nr, balter s, weisz g. occupational hazards of interventional cardiology. cardiovasc revasc med 2013;14(4):223-228. https://doi.org/10.1016/j.carrev.2013.05.002 2. le heron j, padovani r, smith i, czarwinski r. radiation protection of medical staff. eur j radiol 2010;76(1):2023. https://doi.org/10.1016/j.ejrad.2010.06.034 3. stewart f, akleyev a, hauer-jensen m, et al. icrp statement on tissue reactions and early and late effects of radiation in normal tissues and organs – threshold doses for tissue reactions in a radiation protection context. ann icrp 2012;41(1-2):1-322. https://doi.org/10.1016/j.icrp.2012.02.001 4. mitchell ph. defining patient safety and quality care. in: hughes rg, ed. patient safety and quality: an evidence based handbook for nurses. rockville, md: agency for healthcare research and quality (us), 2008. 5. sheyn dd, racadio jm, ying j, patel mn, racadio jm, johnson nd. efficacy of a radiation safety education initiative in reducing radiation exposure in the pediatric ir suite. pediatr radiol 2008;38(6):669-674. https://doi. org/10.1007/s00247-008-0826-9 6. rehani mm. training of interventional cardiologists in radiation protection – the iaea’s initiatives. int j cardiol 2007;114(2):256-260. https://doi.org/10.1016/j.ijcard.2005.11.061 7. fridell k, ekberg j. making the invisible visible: a qualitative study of the values, attitudes and norms of radiologists relating to radiation safety. j radiol protect 2016;36(2):200-214. https://doi.org/10.1088/09524746/36/2/200 8. cole p, hallard r, broughton j, et al. developing the radiation protection safety culture in the uk. j radiol protect 2014;34(2):469-484. https://doi.org/10.1088/0952-4746/34/2/469 9. sadigh g, khan r, kassin mt, applegate ke. radiation safety knowledge and perceptions among residents: a potential improvement opportunity for graduate medical education in the united states. acad radiol 2014;21(7):869-878. https://doi.org/10.1016/j.acra.2014.01.016 10. rose a, rae w, chikobvu p, marais w. a multiple methods approach: radiation associated cataracts and occupational radiation safety practices in interventionalists in south africa. j radiol protect 2017;2(37):329-339. https://doi.org/ 10.1088/1361-6498/aa5eee 11. cousins c, sharp c. medical interventional procedures – reducing the radiation risks. clin radiol 2004;59(6):468473. https://doi.org/10.1016/j.crad.2003.11.014 12. colleges of medicine of south africa. https://www.cmsa.co.za/default.aspx (accessed 13 october 2017). 13. rose a, rae wid. perceptions of radiation safety training among interventionalists in south africa. cardiovasc j afr 2017;28(3):196-200. https://doi.org/10.5830/cvja-2017-028 14. kuon e, weitmann k, hoffmann w, et al. multicenter long-term validation of a minicourse in radiation-reducing techniques in the catheterization laboratory. am j cardiol 2015;115(3):367-373. https://doi.org/10.1016/j. amjcard.2014.10.043 15. azpiri-lópez jr, assad-morell jl, gonzález-gonzález jg, et al. effect of physician training on the x-ray dose delivered during coronary angioplasty. j invasive cardiol 2013;25(3):109-113. 16. georges j, livarek b, gibault-genty g, et al. reduction of radiation delivered to patients undergoing invasive coronary procedures. effect of a programme for dose reduction based on radiation-protection training. arch cardiovasc dis 2009;102(12):821-827. https://doi.org/10.1016/j.acvd.2009.09.007 17. rose a, uebel k, rae w. interventionalist perception on a culture of radiation protection. s afr j rad 2018;22(1):a1285. https://doi.org/10.4102/sajr.v22i1.1285 accepted 24 july 2017. https://doi.org/10.1007/s00247-008-0826-9 https://doi.org/10.1007/s00247-008-0826-9 https://doi.org/10.1016/j.ijcard.-2005.11.061 https://doi.org/10.1016/j.ijcard.-2005.11.061 https://doi.org/10.1088/0952-4746/34/2/469 https://doi.org/ 10.1088/1361-6498/aa5eee https://doi.org/10.5830/cvja-2017-028 https://doi.org/10.1016/j.amjcard.2014.10.043 https://doi.org/10.1016/j.amjcard.2014.10.043 https://doi.org/10.1016/j.acvd.2009.09.007 september 2018, vol. 10, no. 3 ajhpe 166 research the university of south africa (unisa) is an open distance-learning (odl) institution, and most undergraduate programmes are offered through the distance-learning model. because of unisa’s elasticity and institutional character, the unisa peer help volunteer programme (uphvp) was developed to expand the range of support to students, to render careerguidance services to schools and the surrounding communities and to create a conducive environment for peer helpers to generate personal and professional growth (van schoor and mill – unpublished information, 1998). unisa peer helpers are senior students majoring in psychology, who volunteered to join the peer-help programme to assist other students. in brief, peer helpers are trained to expand the network of support for unisa’s student population, to broaden the range of guidance services to the school and the community and to empower peer helpers to acquire valuable personal and employment skills and abilities (van schoor and mill – unpublished information, 1998). the uphvp was initiated in 1996 at unisa’s pretoria main campus and the cape town regional campus. its success has led to its expansion to other regional campuses across the country. unisa’s institutional character encapsulates, among other matters, reasonable, lower study fees and flexible tuition methods that offer opportunities for students to study and work simultaneously. as a result, unisa is a melting pot where diverse students from various socioeconomic statuses, age groups and areas pursue different careers. in the realm of that context, subotzky and prinsloo[1] argued that most unisa students are not orientated to the challenges of higher learning, which is attributable to the lasting legacy of apartheid and substandard schooling systems. moreover, the majority of unisa students study in isolation, some study part-time while employed full-time, and some are full-time students who are underprepared for distance education (van schoor and mill – unpublished information, 1998). the uphvp falls under the directorate for counselling and career development (dccd), which seeks to support prospective and registered students before, during and after registration. the uphvp was established for the realisation of three specific goals, i.e. to expand the network of support for unisa’s student population, to widen the range of guidance services to schools and the community and to empower peer helpers to develop critical personal and employability skills and abilities (van schoor and mill – unpublished information, 1998). these goals were and are being achieved through the utilisation of peer helpers who act as first contacts in their individual capacity to assist others (mabizela – unpublished information, 2015). the peer helpers are volunteer, senior students majoring in psychology, who are committed to helping others.[2] the core responsibilities of peer helpers were mapped out (van schoor and mill – unpublished information, 1998). unisa peer-help roles and responsibilities • make the student population and the university environment aware of the availability of the uphvp and promote the role of peer help in general. • assist in the day-to-day running of the peer help office by ensuring that it is part of the attendant roster for service delivery. • provide a service to fellow students by staffing the peer help office, answering telephones and replying to internet requests for help. • establish positive helping relationships with all fellow students by attending to them, listening empathically and responding skilfully during interviews. • actively participate in the expansion of their individual knowledge bases about academic, personal and career matters by regularly attending supervision sessions and completing assignments aimed at empowering the peer-help volunteers. background. the university of south africa (unisa) offers educational programmes through distance learning. because of the institution’s elasticity and character, the unisa peer help volunteer programme was developed to extend support to students, to disseminate educational information to schools and the surrounding communities and to engender personal and professional growth of peer helpers. objectives. to explore the modalities used by peer helpers to construct their roles as sources of support at the university. methods. a qualitative approach was used, underpinned by the social constructionist paradigm as an epistemological position. the sample consisted of 6 peer helpers. data were analysed using thematic analysis. results. three themes were identified, i.e. peers as distributors of information, the peer-help role as an opportunity to integrate theory and practice and the peer-help role as a personal eye-opener. conclusion. the findings showed that peer helpers understand the challenges faced by other students and the institutional character of the university and were able to use their experiences in conjunction with available resources to assist their fellow students and to reach out to disseminate educational information to communities. afr j health professions educ 2018;10(3):166-170. doi:10.7196/ajhpe.2018.v10i3.1029 peer helpers’ construction of their role in an open distance-learning institution s e mabizela, ma psychology centre for health science education, university of the witwatersrand, johannesburg, south africa corresponding author: s e mabizela (sfiso.mabizela@wits.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 167 september 2018, vol. 10, no. 3 ajhpe research • work effectively with fellow students by providing information about careers, subjects and study possibilities. • at all times be aware of administrative procedures and deadlines, including registration dates, cancellations and examination procedures. • be familiar with the location of academic and administrative departments and support structures on the campus to promote effective referrals. • at all times be aware of their personal limitations and recognised boundaries of individual competencies, training and experience. the peer helpers should be sensitised to be aware of the risks of transgressing boundaries. • understand what an emergency entails and be familiar with the referral procedures to expedite these to professional counsellors. • manage voluntary activities and maintain records of all contacts (van schoor and mill – unpublished information, 1998). the tendency of students to turn to their fellow students for help during difficult circumstances is a well-noted phenomenon in the literature of peer-help programmes.[3-5] fellow students do not only play a vital role in supporting other students,[6] but they also help their peers in meeting the human, psychological needs, such as love, belonging and freedom.[7] furthermore, by sharing common values, similar experiences and lifestyles, students feel comfortable in sharing their frustration with their fellow students.[8] varenhorst[9] argued that an individual sense of uniqueness, secure membership in one’s group of choice and a sense of contributing significantly to other peoples’ lives are possible through peer help. based on these premises, the peer-help programmes in higher education are foregrounded. according to varenhorst,[9] the peer-help concept is an overarching term used to refer to various support services and activities that take place in different contexts. the possibilities of using peer-help programmes in many settings have produced various terms, ranging from, e.g. peer tutoring, peer helpers, peer counselling, mentors and peer leaders.[10] universities, community centres, organisations and schools are some of the settings with peer helpers. despite the diversity of terms and settings, the descriptions of the peer helpers’ roles are strongly connected with the types of services peer helpers are trained to offer.[11] most importantly, as downe et al.[12] argued, the content of services rendered by peer helpers is of more importance than the term assigned to them. there are conspicuous overlaps in how researchers construct peer help, and it is worth exploring how these constructions are presented through the lens of researchers. gray and tindall[8] conceived peer counselling as forms of interpersonal helping behaviours undertaken by non-professional persons. for salovey and d’andrea[13] active listening and problem-solving coupled with knowledge of human growth and mental health are critical features essential for peer helpers. in some instances, peer help is configured as a form of psychological education intervention, which serves to enhance the psychological and healthy functioning of individuals.[14,15] taking this further, varenhorst[9] configured peer help in a tertiary environment as encapsulating various forms of support and assisting interventions offered by trained peer counsellors in a student-to-student encounter. in summary, the rendering of helpful services to fellow peers by a trained and skilful peer helper is the central theme in the construction of peer help. according to simons and cleary,[16] students who participate in peerhelp programmes demonstrate a sense of civic responsibility and develop professional ethics by giving back to the community. at university level, peer helpers are known to play a pivotal role in motivating their fellow students to be open, and to develop and exhibit responsible attitudes and lifestyles.[17] gould and lomax[18] have strongly argued that peer helpers are capable of communicating with their fellow students in ways better than faculty and administrators. being in a position of providing a broad range of helpful services, it cultivates a belief on the part of peer helpers that they are actively shaping their future and contributing significantly to that of other people.[19] in some instances, the peer-help programmes are configured as the service-learning programmes within the psychology discipline and are critical for educational and personal purposes. according to racz and lacko,[20] students who joined the peer-help programme usually aspire to pursue psychology as a career. for such students, peer-help programmes allow them to integrate theoretical knowledge and practical experience and create opportunities for reflection.[21] moreover, simons and cleary[16] found that practical exposure in peer-help programmes assisted undergraduate psychology students in gaining a broader understanding of the study course and produced notable positive results on students’ personal and interpersonal levels. although there is sufficient practical exposure at postgraduate psychology level, there is little emphasis on practical learning at an undergraduate level.[22] the dearth of practical learning in the undergraduate years could be attributed to the psychology curriculum being structured in such a manner as to open possibilities for different career paths.[22] the peer-help programmes have well-recognised benefits, not only for the recipients of peer-help services but also for the peer helpers themselves. odirile[23] stated that students’ study skills and academic performance improved as a result of joining the programme. aladağ and tezer[7] indicated that peer-help programmes developed students’ ability to demonstrate empathy and reflective skills. brammer and macdonald[24] stressed that the prestige of being selected as a peer helper brings the satisfaction of being involved in the needs of others and of contributing to another person’s wellbeing. lastly, taking part in peer-help programmes assists peer helpers in developing insights and acquiring skills such as leadership, interpersonal communication, self-knowledge and a higher level of self-esteem, and demonstrating positive personal health behaviours.[25,26] notwithstanding the vast spectrum of positive aspects of peer-counselling programmes, there is a marked paucity of literature on the modalities that peer helpers use to construct their roles. in a study by marks et al.[27] on paraprofessional experiences in inclusive education, the paraprofessionals constructed their roles as the bearers of success for the students they were assigned to help. likewise, patterson[28] found that the paraprofessionals’ construction of their roles reflected a sense of taking responsibility for handling the behavioural and academic issues of other students and themselves. however, there has never been a study that looked at the strategies used by unisa peer helpers to construct their roles. methods a qualitative approach was used to elicit the strategies that unisa peer helpers used to construct their roles. the social constructionist approach that embraces the notion of multiple versions of reality and involves explaining and describing the processes people use to construct their realities, was employed as an epistemological stance.[29] the purpose was to take peer helpers’ constructions of their roles as a reflection of their september 2018, vol. 10, no. 3 ajhpe 168 research realities. the sample consisted of 6 peer helpers who were interviewed at a time convenient to them. there were 11 peer helpers who volunteered to participate in the study. however, saturation was reached after four interviews. a further two interviews were conducted to ensure that no new information was forthcoming. all participants were undergraduate psychology students – 2 males and 4 females. a semi-structured interview schedule, which focused on 4 questions, was employed to collect data. the interviews were tape-recorded, transcribed and saved in a passwordprotected sound cloud to ensure confidentiality. after the transcriptions were completed, they were returned to participants for further verification and additional information. the data were analysed using a thematic method. the purpose was to inductively identify the patterns in the data and use codes to develop patterns into themes that encapsulated participants’ constructions.[30] ethical clearance was issued by the department of psychology, unisa. results the participants’ constructions of their roles revealed three overarching inductive themes. the themes that emerged from the findings were organised and lodged into three broad categories: peers as distributors of information, peer-help roles as an opportunity to integrate theory and practice, and peer-help roles as a personal eye-opener. these themes are discussed individually below and are illustrated by the participants’ voices. peers as distributors of information the participants pointed out that the role of being a peer helper offers them the opportunity to disseminate educational information to students and the broader community. in that way, participants’ constructions reveal modalities by which the distribution of information is enacted in the peerhelper role. educational information is distributed to assist students to make informed decisions when selecting career paths, as well as when compiling a curriculum for any field of study where there are many elective modules to select from. this emerged as one of the ways in which educational information is shared. to qualify this position, one of the participants compared the role of the peer helper with that of a doctor: ‘i would like to compare it to a doctor where you have people’s lives in your hands. when people come in here with difficult questions regarding their careers, they are trying to find who they can talk to, where they fit in, in terms of their careers, in terms of studying, and you are that person who can actually in a way guide them.’ (p4) constructing the peer-helper role in that way reveals the seriousness and mechanism of helping one to select a good career path. besides, there is a sense of care and patience in how the peer helpers orientate themselves in facilitating career and decision-making processes that are done to maximise the possibilities for self-directed decision-making: ‘a unisa peer helper is more of a mentor, is more of a satellite for the community out there.’ (p2) the abovementioned extract shows the role of the peer helper as someone in service of the university student population and the broader community. constructing the peer-helper role as a satellite implies that peer helpers are accessible and intricately connected to the needs of the current students and prospective students in communities. furthermore, the actual interactions between peer helpers and clients – unisa students or prospective students – are the core element of peer helping. the quote below describes a participant’s feelings resulting from interactions with clients: ‘it makes me feel complete and happy to hear someone appreciating what you have done, and in that way, it shows that you are playing a part at the university.’ (p1) in making sense of the peer-helper role, the abovementioned participant views the role as a means of giving back to the university, which brings satisfaction. in keeping with the theme being discussed, the participant mentioned below mapped out some of the key characteristics of what constitutes unisa peer helpers as distributors of educational information: ‘being a peer helper is to help students in choosing careers, modules, explain the unisa system, application, registration and what else. we help students with study skills.’ (p6) in synthesising this theme, the participants’ constructions reveal the elasticity, sensitiveness and key elements underpinning unisa peer helpers’ roles and responsibilities. in so far as making a suitable career choice is concerned, the participants’ constructions show the strategies peer helpers used to construct their roles as distributors of educational information and facilitators of career-decision processes. the peer-helper role as an opportunity to integrate theory and practice the role of the peer helper is also constructed as an opportunity to acquire practical knowledge and experience in counselling. this theme is best explained by framing it against the curriculum structure of the undergraduate psychology programme. undergraduate psychology programmes at unisa concentrate largely on theoretical knowledge and few practical opportunities are offered. the onus therefore rests on students to seek opportunities where they can integrate theoretical and practical knowledge. the uphvp offers psychology students opportunities for practical experience. based on the findings, the participants strongly emphasised that within the peer-helper role there are opportunities to apply theoretical knowledge that could not be applied outside the context of the programme. in the quote below, the participants’ constructions reveal how being a peer helper enabled them to apply accumulated theoretical psychology knowledge in practice: ‘to put what i have been studying into action, that is why i joined the peer help programme.’ (p3) ‘i thought it would help to do what i am studying practically; you know its counselling, studying psychology and doing it practically.’ (p6) furthermore, the peer-helper role is not only constructed to offer practical opportunities in counselling, but as a role that simplifies theoretical knowledge in ways that enhance understanding and application of that knowledge. it became apparent that the peer-helper role paved ways for the integration of knowledge acquisition and its application. the opportunity to work as a peer helper also assisted the participants in making informed career decisions. such decisions were made early in their careers as a result of helping other students; this encouraged participants to consider postgraduate programmes in psychology or to contemplate changing to other study programmes. the quotes from the participants below describe how becoming peer helpers enabled them to strike a balance between knowledge acquisition and application: 169 september 2018, vol. 10, no. 3 ajhpe research ‘a lot of things are very abstract when you are studying, they are very abstract. so, one can make sense but one can make more sense if it was practical; so what i thought about this is that if i could get an environment whereby i could put into practice what i have learned, things would make more sense.’ (p2) ‘i wanted an environment where i can put theory into practice because i felt that yes i am studying psychology but i am not really combining or i am not really integrating. what i am learning in the book to actually practise it and see whether i can do it or not.’ (p5) encapsulated in this theme are subjective constructions illustrating selfinitiated attempts to look for an environment that allows the integration of theoretical knowledge with practice. furthermore, peer helpers’ constructions show that they have mastered psychological literacy, which entails the ability to adapt and use psychological knowledge to satisfy personal, professional and societal needs.[14,31] the uphvp is configured as the site that offered practical opportunities for participants and contributed significantly to their learning and personal development. the peer-helper role as a personal eye-opener lastly, this theme is constructed as a personal eye-opener because the findings show that the participants have developed a deeper level of self-insight since joining the uphvp. the self-insight, as shared by the participants, seems to have occurred at two levels, i.e. a personal and career level. at a personal level, the participants stressed aspects related to self-knowledge in a sense that they have symbolised certain aspects of their personalities into themselves. they were not aware of these before they were helpers. below are some of the discoveries pointed out by the participants: ‘i have figured out myself, my journey, my study journey.’ (p3) ‘meeting new people with different personalities on a daily basis, i also got to discover that i am not introverted as i thought i am.’ (p6) at a career level, the findings show that the participants constructed the peer-helper role as one where they were exposed to different career paths within the field of psychology. having such exposure enabled the participants to map out their career paths with regard to postgraduate programmes: ‘one thing is that i now have a clear career knowledge; there were a lot of things that i did not know before coming to this environment. so from working here i realise that i always have a clear picture of what i wanted to be, but i now have a direction to follow in order to get there.’ (p5) ‘it’s a great experience because it helps you to discover yourself as an individual, and also to learn more about these career fields in psychology, as you know that careers evolve now and then; however, with this programme, it exposes you to things like careers research.’ (p1) for one participant the exposure obtained from being a peer helper assisted her to decide that psychology was not her field of interest: ‘when i registered for the psychology qualification, i knew that i wanted to be a psychologist. i was not aware about other career options that are offered in the psychology department. so being at the peer-helper programme has helped me to decide that psychology is not my field of interest.’ (p2) in the abovementioned quote, there is a shift away in thinking about career choices. the participant was certain that the psychology programme was her field of interest; however, after the uphvp, she started to re-evaluate her career choice. it seems that being in the uphvp, where she was exposed to information, helped her to decide that psychology was not her field of interest. summary of the findings in constructing the peer-helper role, the participants’ constructions show the wealth of professional and personal benefits for them as peer helpers. furthermore, there are tangible and intangible benefits for unisa students and the broader community regarding information and guidance services offered by peer helpers. however, findings pose a challenge to the university to enhance the altruistic capacity inherent in students, and to consider infusing practical components in the undergraduate psychology programmes. these two elements are discussed further below. discussion the participants’ constructions have to a greater extent depicted the students’ capacity to utilise the university resources to share valuable information with their fellow students. the students’ ability to help their fellow students is not limited to unisa, but something that is also evident in other institutions of higher education.[32] the body of literature, along with the research conducted in this study, demonstrated that peer helpers are better equipped to assist their fellow students.[18,33] in the current study, the participants state ways in which they expand their help services not only to their fellow students but also to reach prospective students in different communities. this shows the extent to which students are capable of contributing in shaping their future and that of other students.[19] the sentiments shared by the participants concur with the premises guiding the formation of the uphvp, i.e. to expand the range of counselling services to students and the broader community (van schoor and mill – unpublished information, 1998). peer helpers have similar experiences, values and lifestyles as their fellow students,[34] which ease help-seeking behaviours and counselling relationships. one participant perceived the peer-helper role as a satellite; this indicates the extent to which peer helpers are able and open to use their skills to cultivate change in the lives of others.[35] these sentiments tap into students’ inherent resources to play a fundamental role in the lives of other students.[17] despite the peer helpers’ contribution towards helping their fellow students, there is still a paucity of research on peer-help programmes at tertiary level.[7] this is alarming, as the need for research-guided, peer-help programmes is critical for stable programmes and enhanced services. arising from this study is the need to infuse a practical component in the undergraduate psychology degrees. the role of peer help is constructed as one that offers opportunities for the acquisition of practical experience and further learning which, according to the peer helpers, ties in well with their studies. according to racz and lacko,[20] joining a peer-help programme was a motivating factor for students who wanted to pursue studies in psychology. in this study, the participants actively expressed the need to integrate theoretical knowledge with practical experience. because the undergraduate psychology programme at unisa is theoretically saturated, the participants have been seeking an environment where the application of theoretically acquired knowledge could be implemented and tested. this opportunity for the practical implementation of knowledge september 2018, vol. 10, no. 3 ajhpe 170 research and skills is essential in preparing students for postgraduate studies. the entrance pool at undergraduate level is large and very few students are accepted into postgraduate psychology programmes owing to limited spaces available. this leaves many students with few choices, not only regarding the application of theoretical knowledge but also opportunities for further studies.[22] there is, therefore, a strong need to create multiple, practical opportunities for undergraduate psychology students so that they can utilise theoretical knowledge in planning their future careers if they are not accepted into postgraduate programmes. another benefit of practical exposure is the need to reconsider one’s own career options, which was impossible prior to exposure through the peer-help programme. thus, the findings present concrete dimensions of integrated learning within the uphvp that do not only orientate students towards their prospective career goals, but further assist them in re-evaluating their career choices. practical exposure is configured as critical in enhancing students’ understanding of the course and in developing their personal and interpersonal skills.[21] although it may not be an achievable intervention to infuse a substantial component of practical exposure that can accommodate all students through the peer-help programmes, the benefits of practical exposure outside the university need to be considered. conclusion this article explored the strategies used by peer helpers to construct their roles at an odl institution. the findings used by peer helpers show that the participants have an enormous capacity to assist, motivate and guide their fellow students towards the realisation of their goals. it became apparent that students have a strong understanding of the challenges faced by other students and the institutional character of the university, and that they can use their experiences in conjunction with the available resources – not only to assist their fellow students but to reach out to the community and distribute information. the second essential element observed in this study was that students who participate in university activities increase their opportunities for learning and acquiring practical knowledge. lastly, the uphvp has enabled peer helpers to get to know themselves and chisel their path towards self-determined career goals. acknowledgements. i acknowledge johan kruger, supervisor of my master’s degree. author contributions. sole author. funding. none. conflicts of interest. none. 1. subotzky g, prinsloo p. turning the tide: a socio-critical model and framework for improving student success in open distance learning at the university of south africa. dist educ 2011;32(2):177-193. https://doi.org/10.1080/0 1587919.2011.584846 2. barnard se, deyzel l, lephondo mj, et al. adapted unisa peer help training manual. pretoria: university of south africa, 2003. 3. cole ga. personnel and human resource management. 5th ed. london: continuum, 2002:385. 4. myrick rd, highland wh, sabella ra. peer helpers and perceived effectiveness. element school guidance counseling 1995;29(4):278-288. 5. pritchard me, wilson gs, yamnitz b. what predicts adjustment among college students? a longitudinal panel study. j am coll health 2007;56(1):15-22. https://doi.org/10.3200/jach.56.1.15-22 6. robinson se, morrow s, kigin t, lindeman m. peer counsellors in a high school setting: evaluation of training and impact on students. school counselor 1991;39(1):35-40. 7. aladağ m, tezer e. effects of a peer helping training program on helping skills and self-growth of peer helpers. int j advance counsel 2009;31(4):255-269. https://doi.org/10.1007/s10447-009-9082-4 8. gray hd, tindall ja. peer counselling. an in-depth look at training peer helpers. accel develop 1979;30(5):49. https://doi.org/10.1177/002248717903000523 9. varenhorst bb.tapping the power of peer helping. reclaim child youth 2004;13(3):130-133. 10. myrick rd, bowman rp. becoming a friendly helper: a handbook for student facilitators. a leadership training program for young students. minneapolis: educational media corporation,1981. 11. morey re, miller cd, rosén la, fulton r. high school peer counselling: the relationship between student satisfaction and peer counsellors’ style of helping. school counselor 1993;40(4):293-300. 12. downe ag, altman ha, nysevold i. peer counselling: more on an emerging strategy. school counsel 1986;33(5):355-364. https://www.jstor.org/stable/23901264 13. salovey p, d’andrea vj. a survey of campus peer counselling activities. j am college health 1984;32(6):262-265. https://doi.org/10.1080/07448481.1984.9939581 14. cranney j,  dunn ds. psychological literacy and the psychologically literate citizen. new frontiers for a global discipline. in: cranney j, dunn d, eds. the psychologically literate citizen: foundations and global perspectives. new york: oxford university press, 2011:3-15. 15. foster-harrison es. peer helping in the elementary and middle grades: a developmental perspective. element school guidance counselor 1995;30(2):94. 16. simons l, cleary b. the influence of service learning on students’ personal and social development.  college teach 2006;54(4):307-319. https://doi.org/10.3200/ctch.54.4.307-319 17. pascarella et, terenzini pt. how college affects students: a third decade of research. san francisco: josseybass, 2005. 18. gould j, lomax a. the evolution of peer education: where do we go from here? j am college health 1993;41(6):235-240. https://doi.org/10.1080/07448481.1993.9936333 19. carter k, mcneill j. coping with the darkness of transition: students as the leading lights of guidance at induction to higher education. br j guidance counsel 1998;26(3):399-415. https://doi.org/10.1080/03069889808253852 20. racz j, lacko z. peer helpers in hungary: a qualitative analysis. int j advance counsel 2008;30(1):1-14. 21. roos v, temane qm, davis l, et al. service learning in a community context: learners’ perceptions of a challenging training paradigm. s afr j psychol 2005;35(4):703-716. https://doi.org/10.1177/008124630503500406 22. bryan j, ranzijn r, balfour c, et al. increasing the work readiness of australian psychology undergraduates through an experiential learning placement. int j psychol  2012;47(1):164-179. https://doi.org/00011205201201001-04467 23. odirile l. the role of peer counselling in a university setting: the university of botswana. paper presented at the 20th anniversary summit of the african educational research network at north carolina state university raleigh, usa, 19 may 2012. 24. brammer lm, macdonald g. the helping relationship: process and skills. boston: allyn, bacon, 2003. 25. brack ab, millard m, shah k. are peer educators really peers? j am coll health 2008;56(5):566-568. https://doi. org/10.3200/jach.56.5.566-568 26. good jm, halpin g, halpin g. a promising prospect for minority retention: students becoming peer mentors. j negro educ 2000;69(4):375-383. 27. marks su, schrader c, levine m. paraeducator experiences in inclusive settings: helping, hovering, or holding their own? except child 1999;65(3):315-328. https://doi.org/10.1177/001440299906500303 28. patterson kb. roles and responsibilities of paraprofessionals: in their own words.  teach except child plus 2006;2(5):1-13. 29. gergen kj. the social constructionist movement in modern psychology. am psych 1985;40(3):266-275. http:// dx.doi.org/10.1037/0003-066x.40.3.266 30. braun v, clarke v. using thematic analysis in psychology. qual resource psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 31. morris s,  cranney j,  jeong jm,  mellish l. developing psychological literacy: student perceptions of graduate attributes. austr j psychol 2013;65(1):54-62. https://doi.org/10.1111/ajpy.12010 32. naicker m, boshoff n, maritz g, fourie a. the development of a comprehensive peer buddies program in a merged tertiary institution: the university of johannesburg. j counsel develop high educ south afr 2014;1(1):12-29. 33. burton lj, mcdonald k. introductory psychology and psychological literacy. in: cranney j, dunn d, eds. the psychologically literate citizen: foundations and global perspectives. new york: oxford university press, 2011:91-103. 34. tindall, ja. peer programmes: an in depth look at peer helping: planning, implementation, and administration. bristol: accelerated development, 1995. 35. chester a, burton lj, xenos s, elgar k. peer mentoring: supporting successful transition for first year undergraduate psychology students. austr j psychol 2013;65(1):30-37. https://doi.org/10.1111/ajpy.12006 accepted 22 january 2018. https://doi.org/10.1080/01587919.2011.584846 https://doi.org/10.1080/01587919.2011.584846 https://doi.org/10.3200/jach.56.1.15-22 https://doi.org/10.1007/s10447-009-9082-4 https://doi.org/10.1177/002248717903000523 https://www.jstor.org/stable/23901264 https://doi.org/10.1080/07448481.1984.9939581 https://doi.org/10.3200/ctch.54.4.307-319 https://doi.org/10.1080/07448481.1993.9936333 https://doi.org/10.1080/03069889808253852 https://link.springer.com/journal/10447 https://doi.org/10.1177%2f008124630503500406 https://doi.org/00011205-201201001-04467 https://doi.org/00011205-201201001-04467 https://doi.org/10.3200/jach.56.5.566-568 https://doi.org/10.3200/jach.56.5.566-568 https://doi.org/10.1177%2f001440299906500303 http://psycnet.apa.org/doi/10.1037/0003-066x.40.3.266 http://psycnet.apa.org/doi/10.1037/0003-066x.40.3.266 https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1191/1478088706qp063oa https://doi.org/10.1111/ajpy.12010 https://doi.org/10.1111/ajpy.12006 june 2018, vol. 10, no. 2 ajhpe 124 research south african (sa) higher education institutions are aligned to the higher education qualifications framework (heqf), which is committed towards creating discipline-specific learning programmes that underpin the critical cross-field outcomes (ccfos).[1] these outcomes, gazetted by the sa qualification authority (saqa),[2,3] are defined as generic outcomes directed towards stimulating a critical social conscience among students. these embrace the concept of ‘life-long learning, personal growth, honest business acumen, critical thinking and aesthetic appreciation’,[4] and form standard competencies that are intended to underpin all qualifications registered on the national qualifications framework (nqf).[4] split into seven critical and five developmental outcomes, the ccfos include: the identification and solving of problems using critical and creative thinking; the use of effective teamwork within study groups, organisations and communities; organising and managing oneself and one’s activities conscientiously; collecting, analysing, organising and critically evaluating information; communicating effectively using visual or language skills via oral and/or written presentations; using science and technology effectively and successfully demonstrating an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation.[5] recently popularised as graduate attributes, the ccfos contribute soft skills towards empowering students to become more socially aware and responsible citizens.[6] the aspiration to develop graduate attributes at an institution forms part of the drivers’ encompassing innovation towards quality enhancement and improving the student experience, as well as creating a well-rounded graduate (k sattar and l cook – unpublished data, 2014). teaching strategies therefore require reflection and consequent adaptation in an attempt to integrate discipline-specific knowledge with graduate attributes, as is promoted and required of the institution and higher education (he). contemporary studies suggest that to improve and promote student learning, current curricula must explore and maximise the benefits of different teaching methods.[7,8] a popularised approach in engaging academics towards exploring changes in teaching strategies pivots around theories on reflective practice. one of the more commonly referenced models of reflective practice is provided by kolb,[9] who identifies four learning stages and cycles, i.e. the concrete experience (a new experience of a situation that is encountered or a re-interprtetation of an existing experience); reflective observation (of the new experience); abstract conceptualisation (reflection giving rise to a new idea or the modification of an existing concept); and active experimentation (applying the experience globally). according to kolb, teachers could use this framework to critically evaluate a learning provision typically available to students and to develop more appropriate teaching/learning approaches. academic and clinical components of formal training of most medical training programmes include anatomy as an integral component of the programme, particularly taught during the first 2 years of the academic course. consequently, an attempt towards integrating graduate attributes in the anatomy course provides an early opportunity to exercise awareness of the ccfos that can contribute towards such an application becoming instrinsic in the learning experience over subsequent academic years. while human dissection supplemented by formal lectures forms the basis of most background. recent trends in higher education have become particularly directed towards incorporating elements of general education in professionspecific training. consequently, the inclusion of critical cross-field outcomes (ccfos) – a set of generic outcomes gazetted by the south african qualification authority – in curricula, is directed towards stimulating a critical social conscience among students. this embraces the concept of education, more than simply certification, in embedding underlying principles that foster lifelong learning, critical thinking and social responsibility, and provides an opportune platform to examine our teaching strategies in the context of reflective practice. objectives. this article demonstrates an application of the theory of reflective practice in the modification of teaching strategies and the integration of the ccfos in a human anatomy course at a university of technology. methods. we present the different teaching strategies that were applied, and highlight the ccfos embodied in each approach. results. in so doing, we demonstrate how the integration of underpinning general education principles and discipline-specific core competencies can be easily attained through simple modifications of conventional teaching practices. conclusion. the teaching methods highlighted attempt to encourage and ensure that students evaluate, understand and apply their knowledge in an integrated and shared manner, as embraced by the ccfos. afr j health professions educ 2018;10(2):124-128. doi:10.7196/ajhpe.2018.v10i2.960 integrating critical cross-field outcomes in an anatomy course at a university of technology: a reflective perspective j d pillay,1 phd; n govender,1 phd; n lachman,2 phd 1 department of basic medical sciences, faculty of health sciences, durban university of technology, durban, south africa 2 department of anatomy, faculty of health sciences, mayo clinic, rochester, mn, usa corresponding author: n govender (nalinip@dut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 125 june 2018, vol. 10, no. 2 ajhpe research anatomy courses, learning, both in the dissection laboratory and outside the classroom/laboratory setting, can be achieved by different teaching and learning strategies that embrace the ccfos. this article demonstrates an application of the theory of reflective practice in the modification of teaching strategies and the integration of the ccfos in a human anatomy course at a university of technology. a synopsis of teaching practices that have been introduced/modified in the course to integrate the ccfos into subject-specific content, is presented. methods the anatomy ii course that is taught to allied health students within the homoeopathy and chiropractic second-year programme is primarily dissection based and includes didactic teaching (two 1-hour theory sessions per week) and practicals/dissections (three 1-hour sessions twice a week) over a 32-week year. the course is taught in the second academic year of the programme, with students having completed a similarly structured anatomy i course during the first yearof the programme. as a follow-on from anatomy i, the anatomy ii course includes limb and back anatomy, neuroanatomy and head and neck anatomy. as such, the anatomy of the entire human body is completed by the end of the second academic year. in highlighting some of the changes in teaching approaches within this course, the different components of the theory of reflective practice and the methodological approaches applied within each cycle of the theoretical model are summarised. conceptual model for reflective thinking/practice this article highlights the application of kolb’s[9] model on the theory of reflective practice, which identifies four learning stages/cycles that form the basis of reflective practice, i.e. the concrete experience; reflective observation; abstract conceptualisation; and active experimentation. in the context of our study, the concrete experience relates to the introduction of innovative teaching and assessment approaches and forms the basis of this article. much of this application relates to the fourth phase of reflective practice, i.e. active experimentation, as being the impetus for initiating the concrete experience. this is based on previous/conventional teaching and learning practices, lecturer and subject evaluations by students and consequent self-reflection in terms of ‘how we do what we do’ and more importantly, ‘how can we effect change to improve teaching and learning?’. there are also secondary aspects that may prompt reasons for innovative teaching. in the case of this course in human anatomy, one such reason relates to the diverse learning abilities and learning styles of students in a class. a further intrinsic motivation pivots around the need to integrate the ccfos into teaching and learning. reflective observation centres on thinking about the experience, while abstract conceptualisation is based on the notion of learning from the experience.[9] much of these two phases are unravelled in our article, collectively through the viewpoints of the lecturer and highlighted in the discussion. the changes in teaching strategies implemented in the course are outlined in table 1. the different modes of teaching strategies implemented included assignments and projects, integrated theory and practical sessions and team teaching through dissection projects. assignments and projects the traditional approach included individual written assignments, e.g. to provide an account on the brachial plexus and its contributions toward the movement of the upper limb. the modified approach in this strategy was the allocation of task-specific team assignments that involved model construction related to specific body systems and their functional demonstration. examples of such task-specific assignments included either the design of a model of the upper limb to illustrate the muscle compartments of each region, and the demonstration of its functionality as a system of levers, or the design of a three-dimensional model of the head and neck region, demonstrating the dural venous sinuses of the brain. theory and practical sessions traditionally, this approach involved independent didactic lectures, followed by dissection sessions, which were modified by integrating both lectures and practical sessions, coupled with the demonstration of models and prosected specimens that enabled immediate integration of both theoretical and practical elements. cadaveric dissections during practical sessions traditionally, formal lectures on specific anatomical areas were conducted by an academic. students were then assigned to dissection teams that worked on an allocated cadaver. the extent of learning and personal accountability was variable and depended on the extent of involvment of each team member and their ability/interest to work together. the modified approach included team teaching through the introduction of dissection projects during the practical sessions. teams comprised 5 6 students, who were allocated specific dissection areas of their cadaver. each team was required to present the specific topic/area and demonstrate their dissection area to the class in formats such as video clips, practical demonstrations, posters, powerpoint presentations, traditional didactic teaching or a combination of one or more of these methods. completion of this activity as a learning table 1. traditional and modified approaches to teaching and learning mode of teaching traditional approach modified approach assignment/project written assignment task-specific assignment, which involves model construction related to specific body systems and their functional demonstration integrated theory/practical sessions powerpoint lecture and separate practical/dissection sessions combined lectures with the demonstration of models/ prosected specimens team teaching by means of dissection projects delivery (by lecturer) of formal lectures on specific anatomical areas dissection teams work together in dissecting the allocated cadaver team teaching through dissection projects review of learnt content by viva voce (oral assessment) and an assessment mark determined by the entire team june 2018, vol. 10, no. 2 ajhpe 126 research outcome was achieved by engaging students in collective learning, even outside time-tabled sessions. team members were therefore required to strategise conducive ways of working together, such as convenient meeting times, dates, venues or allocation of tasks within the project. post-practical sessions were also included to recapitulate key concepts and assist with any challenges experienced. this strategy included oral and post-dissection assessments as a tool to determine the level of learning achieved and the quality of dissection conducted. the final assessment mark was agreed upon by all team members; teams were thus accountable for both the learning and assessment outcomes of the exercise. results the modified teaching strategies implemented in relation to the seven ccfos are shown in table 2. our results highlight the changes made to the anatomy curriculum in the context of integrating the ccfos. details of the modifications are presented in the methods section of this article. discussion allied health professionals, regardless of their occupational role, career stage or employment status, are required to be professionally competent when they exit he institutions[10] and enter the workforce. therefore, he training needs to provide professional competence that embraces the graduates’ attributes. studies conducted in the uk corroborate this need by highlighting a professional competence framework essential for enhancing the productivity of allied health professionals.[10] these studies concluded that allied health professionals will only be able to face the forthcoming challenges if they are open to opportunities to develop reflective thinking skills that foster useful engagement and support continued professional development.[10] recent studies highlighted the need for educators to be more reflective about their teaching approaches towards critical thinking and clinical reasoning.[11,12] while clinical reasoning is a key aspect of medical practice, the complexity linked to teaching and learning is most difficult owing to its invisibility to students.[12] some investigators explored the use of action research,[13] in which participant engagement is promoted within a structured means of reflection regarding their teaching practices.[14] the study explored the use of the making-thinking-visible approach and highlighted two themes, i.e. the students’ understanding of the reasoning process and the increased knowledge of individual teaching approaches to demonstrating clinical reasoning.[12] the study concluded that the makingthinking-visible approach may support educators in articulating their own expert reasoning, as well as being a potential mechanism for personal reflection.[12] in our study, teamwork formed the basis of all the approaches used and required an effective, responsible and interactive collaboration of all team members, with the intent of enhancing personal reflection and critical thinking. team assignments/projects model construction required the interactive engagement of students to generate a functional anatomical form of the upper limb, whose functionality was determined by its movement and biomechanics. this strategy improved student creativity and problem-solving skills linked to model functionality in relation to limb anatomy. all the required ccfos (i.e. ccfos 1 7) were achieved as an otcome of this strategy. similarly, other studies using strategies such as casts,[14] body painting,[15] clay modelling[16] and construction of three-dimensional models[17] highlight the potential value of their use as a supplement to teaching standard anatomical principles. the use of model construction in our study required extensive planning, creativity and preparation, which subsequently developed problem-solving skills to produce an aesthetically appealing, scientifically relevant and mechanically functional product. lefroy et al.[17] reinforced teaching of the brachial plexus using three-dimensional pipe models. these investigators showed that the use of such models improved students’ understanding of specific areas of the plexus. the combination of knowledge-based and skills-based teaching, its application and assessment, are demonstrated in the achievement of ccfo 7. this ccfo highlighted the inter-relatedness of systems, processes and effects, and enabled multidisciplinary engagement of disciplines such as physics (through the system of levers that bring about movement), chemistry (through the chemical reactions responsible for muscle contraction and consequent movement) and biomechanics (through the application of concepts around synergism and antagonism). this was similar to the learning activity in which the dural venous sinuses of the table 2. teaching strategies applied to integrate the critical cross-field outcomes critical cross-field outcome modified teaching strategies assignment integrated theory/ practical sessions team teaching through dissection projects 1. identifying and solving problems in which responses demonstrate that responsible decisions using critical and creative thinking have been made √ √ 2. working effectively with others as a member of a team, group, organisation or community √ √ √ 3. organising and managing oneself and one’s activities responsibly and effectively √ √ √ 4. collecting, analysing, organising and critically evaluating information, integrating teaching and learning √ √ √ 5. communicating effectively using visual or language skills in modes of oral and/or written presentation √ √ 6. using science and technology effectively and critically √ 7. demonstrating an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation √ √ √ 127 june 2018, vol. 10, no. 2 ajhpe research brain were demonstrated. the application of knowledge of concepts such as volume, density and flow, acquired through multidisciplinary integration of knowledge, demonstrated their inter-relatedness. the teamwork underlying these activities supports peer learning and promotes independent and critical analyses and review of all information provided by each team member, thereby enhancing the skill of being able to distinguish between relevant and irrelevant information. this outcome supported the acquisition of ccfo 4, in which skills appropriate to collecting and organising relevant information are achieved. this further promoted the conscious awareness of having a critical and analytical approach to gathering, analysing and evaluating information. integrated theory and practical sessions integrating anatomy lectures and practicals can be applied to foster selfdirected learning and reflective practice.[18] combining several teaching approaches, such as traditional didactic teaching, cadaveric dissections, prosections, plastination and medical imaging, complements each other and benefits the learning experience.[18] critical and creative thinking is therefore achieved as students develop unique ways of linking the dissected areas with theoretical background. this strategy promotes personal understanding, application and retention of key facts, as well as fostering the development of learning and recall as part of the learning experience. the strategy also encouraged the gathering of subject-relevant information and its evaluation, and consequently promoted the application of ccfos 1, 3, 4, 5 and 7. collecting, analysing and critically evaluating information therefore becomes an active component of the learning experience and students are expected to use the information provided, engage in and enhance further application. in some instances, formal lectures have been completely eliminated and primarily adopted as an integrated lecture and practical session within a practical setting. the assumption that students have engaged with the lecture material prior to the learning session, provides an expectation that they have some knowledge of the relevant topic. the ideal of students collecting, organising and critically analysing information is a desired outcome during teaching. thus, the integrated nature of the practical component of this strategy lends itself to the application of various learning resources. similarly, the integration of discipline-specific content, such as radiological techniques[19] and co-ordinated anatomy and physiology teaching[20] with anatomical teaching, improves the clinical student interest and the application of anatomy. team teaching through dissection projects this strategy allowed the achievement of ccfos 2, 5 and 6. the dissection experience supports group engagement/peer learning and working effectively with others as team members. strategies employing the use of body painting were similarly reported to be successful in improving the learning experience for medical students using a team-learning approach.[15] these studies corroborate its value as an adjunct to support the learning of human anatomy. more recently, the construction of anatomical casts was employed to improve the acquisition of anatomical knowledge.[14] these studies have shown to improve the collaborative and problem-solving outcomes necessary to produce professional medical graduates. thus, the teaching and learning strategy implemented in our study fosters and stimulates self-directed learning through an active (hands-on) approach. peer learning and the use of team assignments strengthen teamwork and improve personal and peer learning through shared accountability. teamwork is thus enhanced during the practical sessions through the introduction of combined group assessments. this increases student engagement, sharing of knowledge/learning styles and accountability. moreover, outcomes such as problem-solving and creative thinking are achieved by means of student-directed initiatives to enhance learning, e.g. the use of diagrams, mind-maps, flowcharts and pneumonics. studies have shown that peer learning encourages the development of collaboration and communication skills and provides a conducive learning community that prepares students for project planning.[21,22] this engagement empowered students to communicate their knowledge and to have it peer reviewed.[21] furthermore, students become accountable for recognising their own learning needs, thereby ensuring that these needs are met. peer learning fosters a learning-how-to-learn skill, which prepares students for the co-operative interacting skills necessary to be functional employed citizens.[21] this improves communication and self-confidence.[22] an underlying outcome of the dissection experience, by nature of its team approach and active participation, requires the ability to communicate effectively with each other. similarly, peer learning and group assessments/ assignments provide a need for peers to communicate effectively and develop effective language skills in written and oral forms. this approach also supports extensive student engagement as a result of their oral delivery with regard to the specific dissected regions to the class. therefore, the achievement of ccfo 6 was improved owing to the use of various innovative and technological approaches in delivering and communicating the acquired knowledge. the extensive creativity and innovative modes of presentation, such as video recordings, interactive three-dimensional models and posters, were examples of team decisions. thus, the team dissections and projects provided a medium for the extensive use of science and technology as an adjunct to the conventional use of the e-learning interface. conclusion the value of graduate attributes in he has gained international recognition, particularly in universities of technology where vocational needs have formed the basis of academic training. the challenge, however, is in trying to integrate qualities such as accountability and shared responsibility into programmes that have traditionally focused solely on self-betterment and professional needs. to our knowledge, this is the first study that presents information of modified teaching methods within the context of human anatomy and in relation to the ccfos. the teaching methods highlighted in our study attempt to encourage and ensure that students evaluate, understand and apply their knowledge in an integrated and shared manner, as embraced by the ccfos. we also demonstrated how the application of the theory of reflective practice, coupled with the drive for change by institutional and he recommendations, can stimulate academics to consider simple ways of applying innovative teaching approaches. studies that evaluate student perceptions regarding the teaching modifications would further support the reflective practice approach to teaching. a more objective evaluation of the benefits of change (e.g. through assessment performance) would provide useful information and direction for further application. acknowledgements. the authors wish to thank mr r maharaj for his administrative assistance during submission of the manuscript. june 2018, vol. 10, no. 2 ajhpe 128 research author contributions. jdp drafted and conceptualised the article. ng and nl contributed conceptually to the development of the manuscript. all authors approved the final document. funding. none. 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https://doi.org/10.1155/2013/930901  accepted 21 november 2017. www.saqa.org.za/docs/pol/2015/national%20policy%20for%20assessment.pdf www.saqa.org.za/docs/pol/2015/national%20policy%20for%20assessment.pdf https://doi.org/10.1080/03797720802522627 https://doi.org/10.1002/ase.99  https://doi.org/10.1002/ase.99  https://doi.org/10.1002/ase.1296 https://doi.org/10.1080/1462394032000169938 http://www.che.ac.za/documents/d000196 https://doi.org/10.1186/1472-6920-14-20 https://doi.org/10.1002/ase.206 https://doi.org/10.1002/ase.32 https://doi.org/10.1002/ase.32 https://doi.org/10.1002/ase.92 https://doi.org/10.1111/j.1743-498x.2011.00448.x https://doi.org/10.1016/j.aanat.2016.02.010 https://doi.org/10.1016/j.aanat.2016.02.010 https://doi.org/10.1016/j.acra.2015.12.010 https://doi.org/10.1007/s12576-015-0428-x https://doi.org/10.1080/0260293990240405 https://doi.org/10.1080/0260293990240405 https://doi.org/10.1155/2013/930901 26 march 2018, vol. 10, no. 1 ajhpe research non-communicable diseases (ncds) are the leading cause of death worldwide. although ncds are on the rise in both developed and developing countries, they affect lowand middle-income countries (lmics) inordinately.[1] evidence shows that ncds continue to rise owing to the prevalence of unhealthy diets, excessive alcohol consumption, smoking and lack of physical activity.[2,3] such behavioural and lifestyle risk factors can be addressed by increasing primary prevention, public awareness and understanding of ncds.[4] health education initiatives and improved health literacy have been shown to be important to improve primary prevention and reduce ncd-related disparities in lmics.[5] according to the world health organization (who), diabetes contributes 6% to the mortality rate in south africa (sa).[6] the international diabetes federation (idf) projects that these statistics will double by 2040.[7] according to the idf, sa reported 2.28 million cases of diabetes in 2015.[7] this has a negative effect on the health status of sa citizens, given that sa has moved to a quadruple burden of disease according to the statistics south africa report.[8] diabetes is a significant contributor to this burden[9,10] and, with other ncds, has serious financial implications, particularly on the national government and people of productive age (15 64 years).[10,11] sustainable development goal 3 and health education are important tools to achieve sustainable health development in lmics.[12] the role of healthcare professionals in empowering the public with regard to health matters is vital.[13,14] pharmacists play an important role in public health, and hands-on health promotion training is therefore essential for pharmacy students.[10] the focal point of competency-based training is to improve pharmacists’ knowledge and communication skills with regard to ncds such as diabetes, so that tailor-made and culturally appropriate information is conveyed to patients and the general public.[10] healthcare empowerment is key to the prevention of diabetes[15,16] and should be implemented by an interdisciplinary team. it provides an effective means of conducting public health education, as it allows the use of technology-based interventions to positively influence health behaviour outcomes.[17] healthcare empowerment can be achieved by health education, and it is a vital rudimentary intervention strategy in which learning goals and community service are combined in ways that allow both the student and community to benefit.[18,19] health education outside the classroom facilitates meaningful learning by enabling pharmacy students to transpose[20] course content into real-life scenarios, which may be difficult to achieve in any other way for the analysis and understanding of their experience with the community.[21] this article reports on the effect of a pharmacy student-developed public health education exhibit at a national science festival (nsf) on the understanding of diabetes, its causes and prevention, among a group of school learner attendees. method research design a descriptive cross-sectional study was conducted. quantitative data were collected preand post-intervention via a computer-based quiz. background. diabetes is one of the non-communicable diseases with a major negative impact on the health and development of south africans. empowering the population’s understanding of the condition, with health-literacy appropriate approaches, is one of the interventions that allows discussions around the prevention of diabetes. objective. to determine the effects of a health education programme on increasing knowledge about diabetes and encouraging preventive measures. method. a public health education exhibition was held by a pharmacy student at a national science festival. it incorporated presentations, posters, health models, word-search games, information leaflets and a computer-based quiz consisting of preand post-intervention questions. results. junior and senior school learners participated in the computer-based quiz. results from the junior school pre-intervention phase showed that learners had a fair prior knowledge of diabetes, with an overall score of 52.8%. improvement in their overall mean score at the 5% significance level was noted (p=0.020). there was a significant difference in the mean score after the intervention at the 1% level (government schools: 65.5 (standard error (se) 3.1)%, independent schools: 45.9 (6.2)%; p=0.006). of the senior learners 53.7% (n=137) indicated that they use computers at school, while 118 (46.3%) did not have access to computers. the improvement in overall knowledge of the senior participants after the intervention was significant at the 0.1% level (p<0.001). conclusion. the health education offered by the pharmacy student's project was interactive and used an interdisciplinary approach to improve health literacy and raise awareness of diabetes. this is a tested intervention that may be adopted for improving health literacy among schoolchildren. afr j health professions educ 2018;10(1):26-30. doi:10.7196/ajhpe.2018.v10i1.887 health education on diabetes at a south african national science festival m mhlongo,1 bpharm; p marara,1 bpharm; k bradshaw,2 phd; s c srinivas,1 phd, pgdhe 1 faculty of pharmacy, rhodes university, grahamstown, south africa 2 department of computer science, rhodes university, grahamstown, south africa corresponding author: s c srinivas (s.srinivas@ru.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. mailto:s.srinivas@ru.ac.za march 2018, vol. 10, no. 1 ajhpe 27 research research procedure pilot study the pharmacy student first conducted a pilot test using a quiz for senior learners (grade 8 12) and one for junior learners (grade 1 7). learners from a mathematics and science club for disadvantaged local schools in the eastern cape assisted during this phase. names of the participants were not collected to preserve anonymity and confidentiality. participants provided feedback for acceptability of the quiz on diabetes. a presentation on diabetes was delivered in isixhosa and english. it used posters, games and health models to clarify its content. changes to the quiz were implemented based on feedback obtained during the pilot study. data collection an interdisciplinary collaboration with the department of computer science at rhodes university, grahamstown, resulted in the design of the computerbased quiz software using microsoft powerpoint (microsoft, usa), and known as the bknow program, to collect preand post-intervention data, while participants attempted to answer the computer-based quiz. school learners needed to use only three buttons on the computer keyboard while answering the quiz. pharmacy students manning the exhibit instructed participants on how to operate the computer, as most of the schoolchildren who attended the nsf were from rural and township schools, and had little or no prior experience of using a computer.[22] senior and junior students had separate quizzes. the pre-intervention questionnaire was followed by the intervention slide show on the computer. immediately thereafter, the post-intervention questionnaire was made available. intervention in addition to the interactive computer-based quiz, participants received an interactive presentation on diabetes, which included a model to demonstrate the benefits of a healthy diet and the consequences of an unhealthy one; a poster; an anatomical model of the alimentary system; a word search game; and a practical demonstration of the measuring tools for body mass index (bmi) and blood pressure. the anatomy board of the alimentary tract was used to show the organs affected by diabetes, and the interactive model on making healthy dietary lifestyle choices showed which choices predispose patients to diabetes. the poster was used to visualise and summarise information, and was presented to enhance the learning experience. bilingual take-home leaflets (available in isixhosa and english) were given to participants who attended the pharmacy health exhibition after the presentation. thus they could take home basic information on diabetes to share with their families or community members. schoolchildren received a word-search game, allowing interactive learning. the game reinforced key concepts associated with diabetes. the interactive presentation created a learning atmosphere for participants, which included schoolchildren, their parents and their teachers. the option to measure blood pressure and bmi was only available after receiving informed consent from volunteering participants. data analysis to assess whether the intervention made a difference in the understanding of diabetes, its causes and treatment, dependent t-tests on percentage scores for the junior and senior quizzes and mcnemar χ2 tests on the percentage of correct answers obtained for each question before and after the intervention were conducted. individual t-tests and analysis of variance (anova) procedures were performed to test the effects of age, gender and type of school (independent or government-funded) on quiz percentage scores before and after the intervention. mean and standard error (se) were calculated for preand post-intervention scores. all tests were performed using the statistical programming language r, with significance set at the 5% level. separate analyses were performed on the junior and senior learners’ quiz results. ethical approval the project was approved by the rhodes university pharmacy ethics committee (ref. no. pharm 2016-6). results junior learners demographics of the participants (age, grade, school and province of residence) were captured by the first 5 questions of the quiz, in which 113 learners took part. data obtained show that 51 participants (45.1%) were ≤7 years of age, 23 (20.4%) were between 8 and 10 years, 27 (23.9%) between 11 and 13 years, and 12 (10.6%) were ≥14 years. of the total, 65 (57.5%) were female and 48 (42.5%) male. regional distribution showed that 102 (90.3%) were from the eastern cape, and the remainder were based in the other sa provinces. demographics further showed that 88 (77.9%) participants attended government schools, while the remaining 25 (22.1%) attended private or independent schools. the numbers of learners who made use of or did not use computers at school were almost equal: 56 (49.6%) and 57 (50.4%), respectively. pre-intervention results results from the pre-intervention questions, presented in table 1, showed that learners had fair prior knowledge of diabetes, its effects, and how the disease can be prevented (overall mean score 52.8%). questions 4 and 5 had the lowest correct percentage scores: ‘why is insulin produced by the body?’ and ‘a person can prevent getting diabetes by eating what?' – for which 40.7% and 35.4% of the participants, respectively, provided correct answers. conversely, questions 2 and 7 had the highest correct scores: ‘can uncontrolled diabetes cause death?’ and ‘if diabetes is uncontrolled, it leads to what?’ – for which 71.7% and 62.0% of the participants, respectively, answered correctly (table 1). comparison of preand post-intervention results of the 113 learners who answered the pre-intervention questions, 72 (64%) advanced to the post-intervention questions. to analyse the change in learners’ knowledge after the intervention, one-sided mcnemar dependent χ2 tests were used. these results are presented in table 1. the intervention resulted in a significant increase (p<0.05) in correct responses to question 3, relating to what life would be like for children with diabetes (p=0.012). no significant improvement was observed in the number of correct answers given to any of the other questions. however, an improvement in the participants’ overall percentage score at the 5% significance level was noted (p=0.020). results showed no significant gender differences for either the preor post-intervention mean (se) percentage scores (pre-intervention, male: 54.0 (3.8)%, female: 53.6 (3.4)%; p=0.930; post-intervention, male: 61.1 (3.9)%, female: 62.5 (4.4)%; p=0.809). no significant difference in mean percentage score between participants from government and independent schools was 28 march 2018, vol. 10, no. 1 ajhpe research noted before the intervention (pre-intervention, government: 55.2 (2.8)%, independent: 48.0 (5.7)%; p=0.257). however, after the intervention there was a significant difference at the 1% level (post-intervention, government: 65.5 (3.1)%, independent: 45.9 (6.2)%; p=0.006). no significant difference (p>0.05) was observed between the age groups for the pre-intervention mean percentage scores. however, a significant difference at the 5% level was noted for post-intervention scores (p<0.05) (table 2). significant differences were also noted between preand post-intervention scores for the following groups: (at the 0.1% significance level) for learners from government schools (p<0.001); (at the 0.1% significance level) for participants in the 11 13 age category (p=0.009); and (at the 5% significance level) for male participants (p=0.018) and participants in the ≤7-year age category (p=0.027). senior learners as in the junior school quiz, the demographics of the 255 participants in the senior quiz were captured by questions 1 5. data show that 62 partici pants (24.3%) were ≤12 years old, 84 (32.95%) were 13 15 years, 84 (32.95%) were between 16 and 19 years, and 25 (9.8%) were ≥20 years. of the total, 141 (55.3%) were female and 114 (44.7%) were male. regional distribution indicated that 235 (92.2%) attended or had attended a school in the eastern cape, while the remaining 20 (7.8%) were schooled elsewhere in sa. demographics also showed that 232 (91.0%) and 23 (9.0%) participants attended government and independent schools, respectively. some learners (n=137; 53.7%) responded that they had used computers at school before, while 118 (46.3%) had not. pre-intervention results results from the pre-intervention questions are shown in table 3. based on the results of the pre-intervention study, learners had fair prior knowledge of diabetes, its effects, and how it could be prevented (overall score 59.1%). questions 9, 4 and 7 had the lowest correct scores. these were: table 1. junior school quiz results question correct answers (n=113), n (%) correct responses for pre-intervention scores (n=72), mean (%) correct responses for post-intervention scores (n=72), mean (%) p-value (one-sided) 1. diabetes is when your body has? 66 (58.4) 40 (55.6) 43 (59.7) 0.677 2. can uncontrolled diabetes cause death? 81 (71.7) 51 (70.8) 51 (70.8) 1 3. which of these statements is correct? 60 (53.1) 41 (57.0) 54 (75.0) 0.012* 4. why is insulin produced by the body? 46 (40.7) 27 (37.5) 30 (41.7) 0.719 5. a person can prevent getting diabetes by eating what? 40 (35.4) 29 (40.3) 33 (45.8) 0.387 6. which of the following statements is incorrect? 55 (48.7) 39 (54.2) 47 (65.3) 0.186 7. if diabetes is uncontrolled, it leads to: 70 (62.0) 44 (61.1) 53 (73.6) 0.066 overall mean (%) 53.8 (5.0) 61.7 (5.8) 0.020* *p<0.05. table 2. preand post-intervention scores for different age groups (junior quiz) age group, years pre-intervention score, mean (%) post-intervention score, mean (%) ≤7 51.1 (6.1) 59.0 (7.1) 8 10 63.4 (7.1) 66.1 (8.3) 11 13 51.1 (4.8) 67.0 (5.6) ≥14 50.0 (9.8) 47.6 (11.4) analysis of variance, pre-intervention: f=1.439; df =3, 68; p=0.239; post-intervention: f=1.255; df =3, 68; p=0.297. table 3. senior school quiz results question correct answers (n=255), n (%) correct responses for pre-intervention scores (n=139), mean (%) correct responses for post-intervention scores (n=139), mean (%) p-value (one-sided) 1. what is diabetes? 189 (74.1) 114 (82.0) 113 (81.3) 1 2. how does someone get diabetes? 200 (78.4) 113 (81.3) 115 (82.7) 0.860 3. how does someone get to know if they have diabetes? 183 (71.7) 101 (72.7) 113 (81.3) 0.074 4. what is insulin? 88 (34.5) 48 (34.5) 58 (41.7) 0.175 5. uncontrolled diabetes is a disease that may cause damage to what? 134 (52.6) 78 (56.1) 93 (66.9) 0.041* 6. the onset of diabetes can be delayed or prevented by? 172 (67.5) 99 (71.2) 108 (77.7) 0.151 7. which of the following is least likely to cause diabetes? 117 (45.9) 66 (47.5) 87 (62.6) 0.001** 8. why do we need to avoid obesity? 135 (52.9) 83 (59.7) 90 (64.8) 0.391 9. true or false: uncontrolled diabetes can cause high blood pressure 86 (33.7) 44 (31.7) 75 (54.0) <0.001*** 10. which of the following statements is incorrect? 179 (70.2) 98 (70.5) 104 (74.8) 0.440 11. which of the following statements is correct? 174 (68.2) 99 (71.2) 113 (81.3) 0.014* overall mean (%) 61.7 (3.5) 69.9 (3.8) <0.001*** *p<0.05; **p<0.01; ***p<0.001. march 2018, vol. 10, no. 1 ajhpe 29 research ‘true or false: uncontrolled diabetes causes high blood pressure’, ‘what is insulin?’ and ‘which of the following is least likely to cause diabetes?’. results showed that only 33.7%, 34.5% and 45.9% of the participants answered the respective questions correctly. questions 2 and 1, ‘how does someone get diabetes?’ and ‘what is diabetes?’, had the highest correct scores with 78.4% and 74.1% correct answers, respectively (table 3). comparison of preand post-intervention results of the 255 senior school participants who answered the pre-intervention questions, 139 (55%) continued to the post-intervention ones. mcnemar’s dependent one-sided χ2 test was used to analyse each question; the results are shown in table 3. the intervention resulted in a significant increase in correct responses to four of the questions. question 9 showed improvement at the 0.1% significance level (p<0.001), while question 7 showed improvement at the 1% significance level (p=0.001). furthermore, questions 5 and 11 showed improvement at the 5% significance level (p=0.041 and 0.014, respectively). improvement in the overall knowledge of participants after the intervention was significant at the 0.1% significance level (p<0.001). results indicated no significant gender differences for either the pre or post-intervention mean percentage scores (pre-intervention, male: 60.7 (2.5)%, female: 62.7 (2.5)%; p=0.582; post-intervention, male: 68.3 (2.7)%, female: 71.6 (2.8)%; p=0.389). no significant differences in mean percentage scores were found between participants from government and independent schools (pre-intervention, government: 62.5 (1.8)%, independent: 53.1 (5.70)%; p=0.121; post-intervention, government: 71.3 (2.0)%, independent: 56.6 (6.2)%; p=0.123). there were no significant agerelated differences in either the preor post-intervention mean percentage scores. the mean (se)% scores of the participants in the age groups are shown in table 4. overall, significant differences were noted between preand postintervention mean percentage scores for the following groups: for participants in the 16 19-year age group, male participants, and learners from government schools (at the 0.1% significance level) (p<0.001 for each); and for female participants (at the 1% significance level) (p=0.002) and participants in the 13 15-year age group (at the 1% significance level) (p=0.002). it is interesting to note that no change took place in the mean percentage scores of the ≥20-year age group. discussion the computer-based quiz was used for health education and as a mechanism for raising awareness and encouraging healthier lifestyle decisions, particularly among the young attendees at the nsf. this project targeted schoolchildren, as the health education they received could assist them in understanding aspects related to the prevention of diabetes. this approach is important, as it keeps a healthy population healthy. evidence shows that more children are becoming obese and are thus increasingly prone to developing ncds.[5] therefore, the results are encouraging, as the majority (45.1%) of the junior school quiz participants were ≤7 years old. child health education is important to address health literacy, especially in rural communities, where access to information is limited. interestingly, demographic results obtained indicate that 90% of the junior and 92% of the senior school participants were from the eastern cape, the second poorest province in sa.[23] diabetes is one of the major diseases contributing to the rise of ncds, and the resulting mortality in the productive age group has a negative economic impact on individuals, families and governments in lmics.[10,24] this further decreases the gross domestic product (gdp) of lmics, where >75% of ncd-related mortality occurs.[25] the quadruple burden of diseases in sa[8,26] means that the poorest provinces, such as the eastern cape,[23] will be inordinately affected as the global burden of disease rises. by working towards the global goal of reducing ncd mortality rates by 2% yearly, significant improvements to the gdp and health coverage can be achieved,[25] along with a cost-effective health education tool. both junior and senior school participants had fair prior knowledge of diabetes, according to pre-intervention quiz results. only 64% of the junior and 55% of the senior school quiz participants in the pre-intervention questions advanced to the post-intervention ones. as most participants attended rural government schools, where the english language acts as a barrier to effective learning, lack of understanding of the questions might have been a factor that led to the participants not continuing to the postintervention questions. moreover, as a significant improvement on the postintervention results was only observable for question 3 for the junior school quiz, with no significant improvement with regard to other questions, it shows the need for more community engagement from pharmacy students as an intervention to promote health education and learning. senior school participants’ overall knowledge on diabetes improved in the postintervention section. demographics show that there were more female participants in both the senior and junior phase quizzes. a focus on female participants is important, as 42% of women in sa are obese.[27,28] food companies, manufacturers and multinationals are profit centred, which has a detrimental effect on the population, because these stakeholders seek to influence who guidelines on sugar restrictions in favour of maximised profits.[29] world health day 2016 focused on diabetes mellitus; this health education was aligned to it.[30] opportunities to design a poster, a bilingual information leaflet, a word-search game and a health model to explain healthy lifestyle choices, in addition to the interactive computer-based quiz, could have made this project unique for pharmacy students in developing a deeper understanding of the benefits of hands-on interactive health education. use of multiple materials to focus on preventing and reducing ncds offered an exciting and creative way of broadening the horizon of young participants. conclusion the public health education exhibit on diabetes demonstrated the role of a cost-effective approach to reach out to the attendees and the broader community during an nsf. it accommodated learners from public and private schools, and illustrated ways in which health education aimed at children could lead to dissemination of health information for improved health literacy and disease prevention. table 4. preand post-intervention scores for different age groups (senior quiz) age groups, years pre-intervention score, mean (%) post-intervention score, mean (%) ≤12 61.4 (4.3) 68.9 (4.6) 13 15 61.7 (5.3) 70.4 (5.7) 16 19 62.5 (5.1) 72.4 (5.6) ≥20 58.3 (7.4) 58.3 (8.0) analysis of variance, pre-intervention: f=0.129; df =3, 135; p=0.943; post-intervention: f=1.287; df =3, 135; p=0.282. 30 march 2018, vol. 10, no. 1 ajhpe research acknowledgements. the authors wish to thank the facilitators and students of the khanya maths and science club for their participation in pilot testing the quizzes. mr n borland is kindly acknowledged for his technical and logistics assistance. drs r tandlich and s khamanga are acknowledged for their support. author contributions. this health promotion project was carried out as a part of mr m mhlongo’s final-year bpharm research project. he manned the health promotion exhibit during the scifest and was assisted adequately to write the first draft of the manuscript. ms p marara, a master’s student working with prof. s c srinivas, was a mentor to mr mhlongo during the scifest project and also assisted with manning the exhibit when mr mhlongo had to attend his practical or other academic commitments at the university. ms marara was also a mentor during the manuscript-writing phase. dr k bradshaw provided technical support related to the capture of the data during the scifest and in analysing the data. dr bradshaw wrote the results section of the manuscrip. she edited the final version of the manuscript before submission and also when the reviewers’ feedback was received. prof. srinivas conceptualised and supervised the scifest health promotion project. she also co-ordinated all the logistics required at various stages of the scifest, such as pilot testing, setting up the exhibit and schedules of manning the exhibit, and edited the various drafts of the manuscript until completion. funding. the faculty of pharmacy, rhodes university, is gratefully acknowledged for the funding of this project. funds from rhodes university’s inaugural distinguished vice-chancellor’s community engagement award made to prof. srinivas and ms w wrench are acknowledged. these funds supported the language-editing costs of this manuscript. conflicts of interest. none. 1. world health organization. 2008 2013 action plan for the global strategy for the prevention and control of noncommunicable diseases. geneva: who, 2008. 2. raal fj. the cardioprotective diet – carbohydrates versus fat. s afr j diabetes vasc dis 2015;12(1):4. 3. stuckler d, mckee m, ebrahim s, basu s. manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. plos med 2012;9(6):e1001235. https://doi.org/10.1371/journal.pmed.1001235 4. ahmed msam. lifestyle measures for primary prevention of t2 diabetes mellitus (t2dm). ind j comm health 2014;26(4):450. 5. taggart j, williams a, dennis s, et al. a systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. bmc fam pract 2012;13:49. https://doi.org/10.1186/14712296-13-49 6. world health organization. noncomunicable diseases: country profiles 2014. geneva: who, 2014. http:// www.who.int/nmh/countries/zaf_en.pdf ?ua=1 (accessed 20 march 2016). 7. international diabetes federation. idf africa members. 2015. http://www.idf.org/membership/afr/south-africa (accessed 20 march 2016). 8. bradshaw d, groenewald p, laubscher r, et al. mrc policy brief: initial estimates from the south african national burden of disease study, 2000. cape town: mrc, 2003. http://www.mrc.ac.za/policybriefs/ initialestimates.pdf (accessed 20 march 2016). 9. mayosi bm, flisher aj, lalloo ug, sitas f, tollman sm, bradshaw d. the burden of non-communicable diseases in south africa. lancet 2009;374(9693):934-947. https://doi.org/10.1016/s0140-6736(09)61087-4 10. tasic l, pesic v. identification of risk factors for diabetes type 2 and components of pharmacists’ interventions in community pharmacy setting: a serbian pilot study. indian j pharm educ res 2016;50(1):90-102. https://doi. org/10.5530/ijper.50.1.12 11. world bank. world bank open data: population ages 15 64 (% of total). 2017. http://data.worldbank.org/ indicator/sp.pop.1564.to.zs (accessed 18 march 2016). 12. united nations development program. sustainable development goals. 2016. http://www.undp.org/content/ undp/en/home/sdgoverview/post-2015-development-agenda.html (accessed 2 may 2016). 13. blom l, krass i. introduction: the role of pharmacy in patient education and counselling. patient educ couns 2011;83(3):285-287. https://doi.org/10.1016/j.pec.2011.05.021 14. irlam j, pienaar l, reid s. on being agents of change: a qualitative study of elective experiences of medical students at the faculty of sciences, university of cape town, south africa. afr j health professions educ 2016;8(1):41-44. https://doi.org/10.7196%2fajhpe.2016.v8i1.540 15. mitchell b, armour c, lee m, et al. diabetes medication assistance service: the pharmacist’s role in supporting patient self-management of type 2 diabetes (t2dm) in australia. patient educ couns 2011;83(3):288-294. https://doi.org/10.1016/j.pec.2011.04.027 16. healthcare information for all. about hifa. 2015. http://www.hifa2015.org/about/hifa2015-in-context/ (accessed 21 march 2016). 17. sawesi s, rashrash m, phalakornkule k, carpenter js, jones jf. the impact of information technology on patient engagement and health behavior change: a systematic review of the literature. jmir med inform 2016;4(1):e1. https://doi.org/10.2196/medinform.4514 18. bandy j. what is service learning or community engagement. 2016. https://cft.vanderbilt.edu/guides-sub-pages/ teaching-through-community-engagement/ (accessed 20 march 2016). 19. kruger sb, nel mm, van zyl gj. implementing and managing community-based education and service learning in undergraduate health sciences programmes: students’ perspectives. afr j health professions educ 2015;7(2):161-164. https://doi.org/10.7196%2fajhpe.333 20. hamner j, wilder b, byrd l. lessons learned: integrating a service learning community-based partnership into the curriculum. nurs outlook 2007;55(2):106-110. https://doi.org/10.1016/j.outlook.2007.01.008 21. mouton j, wildschut l. service learning in south africa: lessons learnt through systematic evaluation. acta acad suppl 2005(3):116-150. 22. srinivas sc, wrench wm, bradshaw k, dukhi n. diabetes mellitus: preliminary health-promotion activity based on service-learning principles at a south african national science festival. j endocrinol metab diabetes s afr 2011;16(2):101-106. 23. lehohla p. poverty profile of south africa: application of the poverty lines in the lcs 2008/2009. pretoria: statistics south africa, 2012. 24. horton r. chronic diseases: the cause for urgent global action. lancet 2007;370(9603):1881-1882. https://doi. org/10.1016/s0140-6736(07)61701-2 25. abegunde d, mathers cd, adam t, ortegon m, strong k. the burden and cost of chronic diseases in low-income and middle-income countries. lancet 2007;370(9603):1929-1938. https://doi.org/10.1016/s0140-6736(07)61696-1 26. perez am, ayo-yusuf o a, hofman k, et al. establishing a health promotion and development foundation in south africa. s afr med j 2013;103(3):147-149. https://doi.org/10.7196%2fsamj.6281 27. south african medical research council. south african women show high levels of obesity and overweight. 2014. http://www.mrc.ac.za/media/2014/14press2014.htm (accessed 29 may 2014). 28. ng m, fleming t, robinson m, et al. global, regional, and national prevalence of overweight and obesity in children and adults during 1980 2013: a systematic analysis for the global burden of disease study 2013. lancet 2014;384(9945):766-781. https://doi.org/10.1016/s0140-6736(14)60460-8 29. stuckler d, reeves a, loopstra r, mckee m. textual analysis of sugar industry influence on the who's sugars intake guideline. bull world health organ 2016;94(8):566-573. https://doi.org/10.2471/blt.15.165852 30. world health organization. world health day 2016: beat diabetes. 2016. http://www.who.int/campaigns/worldhealth-day/2016/en/ (accessed 9 march 2018). accepted 14 september 2017. https://doi.org/10.1186/1471-2296-13-49 https://doi.org/10.1186/1471-2296-13-49 http://www.who.int/nmh/countries/zaf_en.pdf?ua=1 http://www.who.int/nmh/countries/zaf_en.pdf?ua=1 http://www.idf.org/membership/afr/south-africa http://www.mrc.ac.za/policybriefs/initialestimates.pdf http://www.mrc.ac.za/policybriefs/initialestimates.pdf https://doi.org/10.1016/s0140-6736(09)61087-4 https://doi.org/10.5530/ijper.50.1.12 https://doi.org/10.5530/ijper.50.1.12 http://data.worldbank.org/indicator/sp.pop.1564.to.zs http://data.worldbank.org/indicator/sp.pop.1564.to.zs http://www.undp.org/content/undp/en/home/sdgoverview/post-2015-development-agenda.html http://www.undp.org/content/undp/en/home/sdgoverview/post-2015-development-agenda.html http://www.hifa2015.org/about/hifa2015-in-context/ https://cft.vanderbilt.edu/guides-sub-pages/teaching-through-community-engagement/ https://cft.vanderbilt.edu/guides-sub-pages/teaching-through-community-engagement/ https://doi.org/10.1016/s0140-6736(07)61701-2 https://doi.org/10.1016/s0140-6736(07)61701-2 https://doi.org/10.1016/s0140-6736(07)61696-1 https://doi.org/10.1016/s0140-6736(14)60460-8 http://www.who.int/campaigns/world-health-day/2016/en/ http://www.who.int/campaigns/world-health-day/2016/en/ march 2018, vol. 10, no. 1 ajhpe 31 research when referring to the audiological condition of deafened individuals, ‘deaf ’ is used. an uppercase d is used when writing about deaf culture, a group with which many prelingually deaf individuals affiliate themselves. culturally deaf individuals have their own language, specific customs and ways of behaving.[1] the deaf and persons with hearing loss (d/hl) are a minority group worldwide that faces challenges to achieve optimal health owing to various factors,[1-4] such as inequities in accessing healthcare, low reading levels, writing levels that often do not exceed those of 6th-grade english pupils,[3,5] not understanding health-related terminology, with a resultant inability to interpret written prescriptions,[5] missed appointments and misunderstood diagnoses.[1] d/hl find the attitude of healthcare professionals (hcps) patronising, creating a barrier between them and hcps in general. due to poor communication, there is very little transfer of information, leading to inaccurate interpretations by d/hl, which may negatively affect health outcomes.[1,2,5] there is a need to educate hcps about the unique problems faced by d/hl,[2,4] as even well-educated deaf individuals may have difficulty understanding written english. mastering of basic sign language by hcps could help to build trust during consultations, as the use of interpreters could lead to fear of being judged by the interpreters[1] and has the potential of breaching confidentiality[5] and privacy. enhancing these communication skills among hcps will comply with the development of professional competencies that extend beyond disciplinary expertise or technical knowledge, such as those of communicator, collaborator, scholar, health advocate, manager and leader.[6] the rural clinical school (rcs) of the faculty of medicine and health sciences (fmhs) of stellenbosch university (su) is based in worcester, western cape province, south africa (sa). the rcs provides students from fmhs with exposure to rural community health, allowing for reallife experiences during their placement at the rcs and rendering services in a rural community setting.[7] it further promotes community-orientated education and training through engagement of students via a multitude of learning activities in under-served areas.[7] final-year dietetic students complete a 6-week rotation at the rcs as part of their internship, thereby providing services at various facilities in the worcester district. rcs facilitators affiliated to the division of human nutrition, su, have fostered relationships with several community partners (box 1). one of these partners is the national institute for the deaf (nid), a private training institution registered with the department of higher education and training (dhet) that caters for specific training needs of deaf students. the nid offers hospitality courses, one of which is professional cookery (pc). the main aim of these courses is to increase employability of these special needs students.[8] the nid employs a multidisciplinary approach to their teaching to meet the diverse needs of their students.[8] ‘deaf students are not simply hearing students who cannot hear’,[9] is a message continually emphasised by numerous researchers in the field of d/hl education.[1,2,5,9-11] the literature reports that the cognitive functioning of d/hl differs background. final-year dietetic students from stellenbosch university (su) present selected training sessions during their rural clinical school (rcs) rotation to professional cookery students of the national institute for the deaf (nid). objective. to describe experiences and perceptions of dietetic students and nid students before and after training sessions. methods. a descriptive, phenomenological approach was followed. su students (n=23) reflected on experiences before and after providing training to nid students. two focus group discussions were conducted with nid students (n=19) after training to explore their experiences related to the training. an experienced interpreter facilitated discussion topics using south african sign language (sasl). voice recordings were transcribed verbatim and thematic content analysis was performed manually. results. nid students described feelings of uncertainty and fear of the unknown prior to the training. these feelings turned to excitement and curiosity as the presentations continued. they were positive about the learning experience and described it as wonderful and interesting. su students described it as challenging, but valuable in gaining insight into living with deafness. the experience positively influenced their professional and personal development. students were appreciative of and grateful for the opportunity to engage with and learn from each other. suggestions were made to improve future training sessions based on identified barriers, such as overcoming communication challenges and clarifying reciprocal misperceptions. perceptions changed when similarities between student groups were realised. conclusion. the overwhelmingly positive experience of both groups is a strong motivation to continue with this initiative. su students recognised the importance of health promotion to persons with impairments. afr j health professions educ 2018;10(1):31-37. doi:10.7196/ajhpe.2018.v10i1.901 engagement of dietetic students and students with hearing loss: experiences and perceptions of both groups y smit, bsc diet, m nutrition; m marais, bsc diet, m nutrition; l philips, bsc diet, m nutrition; h donald, bsc diet; e joubert, bsc diet division of human nutrition, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: y smit (yolandes@sun.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 32 march 2018, vol. 10, no. 1 ajhpe research from that of hearing learners and may possibly affect learning, language comprehension and literacy.[1,2,5,11,12] contact with nid students provides an opportunity to raise awareness among su students of the unique needs of the d/hl.[2,11] currently, the literature on the experience of hcps providing services to d/hl relates to medical, nursing, occupational therapy and speech therapy professionals or students.[14] this study is the first to explore the experiences of dietetic students in providing health-promotion sessions to deaf students, a vulnerable group,[4] who have the right to health and to be informed.[4] they are more likely to be forgotten in healthcare programmes owing to language differences, health knowledge limitations and cross-cultural differences.[4,11.15] the literature reports that hcps expressed feelings of fear, anxiety and discomfort when dealing with d/hl patients,[11,14] as well as lack of knowledge and experience in counselling them.[14] for hcps to communicate effectively[11] and build a relationship of trust[4,5,11] with d/hl, they need the knowledge and skills to adapt to the special needs and preferred way of communication of this group.[1,5,11] satchidanand et al.[14] report that previous training and experience in treating persons with physical disabilities furnish hcps with more favourable attitudes. as su dietetic students have the unique opportunity to interact with deaf students, this article reports the experiences and perceptions of both groups of students after four training sessions, including perceived barriers to successful training. methods study participants a qualitative, descriptive phenomenological approach (fig. 1) was followed to describe the lived experiences of the study participants.[16] all nid students (n=19) registered for the professional cookery module and finalyear dietetic students (n=23) provided consent and were included in the study. all nid students included in this study were fluent in sa sign language (sasl). data collection data were collected in 2015 in worcester using structured reflections of the su students and focus group (fg) discussions with the nid students. su students (n=23) completed two separate structured written reflections based on their experiences preand post-training. students have been guided in the skill of reflecting since their 2nd year of study. the threestage model of reflection guided students to capture the ‘what’ (describe experience and emotions), ‘so what’ (describe importance) and ‘what now’ (describe influence on professional development).[17] according to the literature, fg discussions are regarded as a more suitable research method to elicit responses from the pc students,[15,18] as sasl is the preferred means of communication for the deaf.[11,15,19] in the deaf culture, people share information and openly discuss even sensitive topics in groups.[4,19] furthermore, it is possible that reflections and questionnaires would not be a reliable method of obtaining data in this group of students, as vocabulary and sentence construction are different when using sasl.[15] a fg discussion guide compiled by the researchers consisted of questions and probes to investigate nid students’ perceptions of being trained by dietetic students, learning experiences, as well as barriers to successful training and suggestions for improvement. the fg discussion guide was sent to two nid lecturers before the fg discussions to evaluate the validity of its content. the face validity was also assessed by nid lecturers to ensure that the questions and probes were phrased correctly to optimise the use of sasl by the interpreters. two fg discussions (n=10, n=9) with the nid students, guided by the fg discussion guide, were conducted by an su lecturer after their fourth training session. the rcs facilitator(s) assisted with obtaining informed consent, managed the voice recordings and acted as an observer. the fg discussions were held at the nid college, and were conducted in a classroom that was familiar to the nid students and the interpreter. nid students were seated facing the interpreter to ensure that the facial expressions and hand signs of the interpreter were clearly visible.[5] a trusting relationship between an interpreter and the deaf is deemed important to optimise the dynamics of the discussions.[20] an interpreter with 32 years of experience facilitated communication using sasl. fortunately, after 10 years of employment at the nid, the interpreter was familiar with the different dialects used by nid students. the interpreter signed the questions asked by the su lecturer and verbalised the responses given by the nid students for voice-recording purposes. probes were used to encourage further input from nid students, and the su lecturer had an opportunity to ask for clarification or restating box 1. context the rcs rotation allows students the opportunity to experience how different dietetic subjects link with one another and where the translation of theoretical knowledge into practical skills is practised through appropriate responses to the health needs of community members.[13] an assignment introduced in 2014 involved dietetic students who had to give presentations to nid students on nutrition-related topics not covered in the nid professional cookery curriculum. this assignment contributed to the enhancement of professional competencies of su students in more than one way. after consultation with the nid co-ordinator, topics for four training sessions were identified: (i) healthy eating; (ii) healthy cooking methods; (iii) meal planning; and (iv) menu planning. training material developed by the su students was evaluated prior to the training sessions by two lecturers from su and one lecturer from the nid for conciseness, accuracy and suitability for the target group. training sessions were limited to 3 hours and comprised two components: a theoretical component presented in a classroom and a practical session in a wellequipped kitchen. the ratio of the su:nid students was 4:10. in preparation for their duties during the rcs rotation, dietetic students attended an introductory session of one of the nid lecturers regarding the skills necessary to communicate with persons with hearing loss. dietetic students (su: n=23) re�ections (pre/post) descriptive phenomenological approach professional cookery students (nid: n=19) focus group discussions (using sasl) inductive content analysis fig. 1. study design and population (n=42). (sasl = south african sign language; nid = national institute for the deaf; su = stellenbosch university.) march 2018, vol. 10, no. 1 ajhpe 33 research of the issue if misunderstanding arose. the duration of the fg discussions was 45 minutes, by which time data saturation was reached, as discussions started to deviate from the topic. data analysis voice recordings of the fg discussions were transcribed verbatim. transcriptions were checked to ensure that the text was a true reflection of the recorded interviews. a systematic approach was used to do content analysis. an inductive process was followed, as common themes emerging from the text were used to compile a code list and themes were grouped into categories.[21] to enhance validity and limit possible inconsistencies, the text was independently re-read by two researchers. a third researcher was consulted if there was uncertainty, which allowed consensus to be reached before the findings were reported. the same content analysis process was performed for the written reflections and the voice recordings. the reflections and fg discussions were analysed separately using the same framework, but reported simultaneously. the findings were reviewed by the nid co-ordinator to verify accuracy and ascertain that the information was disseminated appropriately. ethical approval and legal aspects approval to perform the study was granted by the health research ethics committee of the fmhs, su (ref. no. s13/10/210), and permission to conduct research on students was subsequently obtained from the division of institutional planning, su, as well as the nid college co-ordinator. all participants in the study provided written informed consent in their language of choice (afrikaans or english). consent forms for nid students were amended using simplified terminology. the forms included a separate section for voice recording of the fg discussions. the consent forms were explained by the nid co-ordinator and all students were provided with an opportunity to clarify queries before signing the forms. voice recordings were password-protected and destroyed after completion of the research, while interview data and reflections were stored separately from the consent forms. anonymity and confidentiality were ensured, as it was not expected of participants to identify themselves at any point. the information will be disseminated by sending copies of the final article to all participants to assure them that their participation made a contribution to the education of hcps.[5] results sociodemographic information the study participants were mostly female and <24 years of age (table 1). students’ responses before training the main themes identified before training were emotions, expectations and insight. emotions su students felt positive and optimistic about the assignment that they had received. although many conveyed mixed feelings at the onset, these were mainly due to excitement at the challenge ahead of them, combined with the uncertainty of exploring relatively unknown territory. this uncertainty stemmed largely from ‘having no previous experience communicating personally with hearing-impaired persons’: ‘receiving the task of presenting to the nid students, strengthening their knowledge on healthy eating and healthy lifestyle choices was very exciting, as this is a challenge i have never been confronted with, and an important skill for me to develop to grow best as a holistic professional.’ (su student) nid students shared comparable sentiments, as they were positive about the learning experience, described varying emotions when they learnt of the training sessions and wondered ‘who these people were’. nid students were initially apprehensive, ‘scared and shocked’ when they were informed about the purpose of the presentations by the su students. expectations su students realised the possibility of not only teaching the nid students, but at the same time benefiting from their time together as ‘… there is no better way to learn how to work with people that are different to you than to spend time with them’. they regarded this as a unique opportunity that would afford them the chance to interact with deaf students, instil confidence, encourage ‘out of the box’ thinking and experience overall growth as hcps: ‘being exposed to as many different target audiences as possible will expand our skill levels and adaptability as professionals, and working with hearingimpaired students will allow us to develop a sense of understanding and respect which would not be achieved otherwise.’ (su student) ‘i think there is so much they can share with us that we would never have known before had we not been put in this situation.’ (su student) nid students were also positively curious and expressed hope for developing reciprocal relationships. students admitted to ‘not knowing what to expect’ and not knowing what the sessions would entail. insight su students admitted to ‘not knowing what to expect’ before the training. they had a preconceived idea that they would need to move out of their ‘comfort zones’ to adapt to the needs of deaf students, which led some to experience feelings of doubt, pessimism and discomfort. su students expressed anxiety and perceived intimidation on presenting food preparation techniques to culinary students owing to an apparent threat of prior above-average knowledge of nid students in this field. students’ responses after training the main themes identified after completion of the training were insight, communication, impact of training and barriers to optimal learning. insight the su student group recounted feelings of admiration and respect for their fellow nid students. although the nid students were initially perceived as table 1. demographic information of students su students (n=23) nid students (n=19) male, n (%) 0 (0) 8 (42.1) female, n (%) 23 (100) 11 (57.9) age (yrs), mean (sd) 22 (0.99) 24.15 (3.59) su = stellenbosch university; nid = national institute for the deaf. 34 march 2018, vol. 10, no. 1 ajhpe research being shy, the increasing time spent together allowed students to relax. as time wore on, the nid students became more animated and were actively engaging in the training sessions. su students appreciated the friendliness and positive attitude of the nid students. several students noted the absence of self-pity of the nid students, and were subsequently motivated and inspired by their empowering attitudes, passionate communication and teamwork. their prowess and knowledge in the kitchen were admired by the su students, as was their thirst for knowledge and active participation during the sessions. su students came to realise that, despite previous misconceptions about students with hearing loss, their affective abilities were no different from those of other students, such as thinking, interaction or possessing an enquiring mind: ‘a perception that definitely changed during the activity was the realisation that hearing-impaired students are just like any other students in their interaction with each other and within the learning environment.’ (su student) the overall sentiment of su students on completion of the training sessions was one of appreciation and gratitude. they were overwhelmingly positive about the experience and described it as being ‘rewarding’, ‘enriching’, ‘inspiring’, ‘indispensable, ‘an eye-opener’ and ‘better than i could ever have anticipated’. similarly, nid students felt it was ‘wonderful’ and ‘interesting’: ‘i was surprised at one point when a student [nid] burst into laughter for some or other reason. the outburst of delight among a room full of quiet reminded me that these students with such a disability as deafness, still experience laughter and pain.’ (su student) value of communication despite some frustrations, the end-goal was ultimately achieved as su students began to realise the importance of communication in their everyday lives, both personally and professionally. with time, su students adapted their approach and began to modify rate and tone of speech, sentence structure and complexity of messages to facilitate easier translation. su students also realised the need to talk directly to the deaf students (as they tended to address the interpreter) and not use confusing hand gestures, which resulted in greater confidence in speaking to this particular target population: ‘i found it extremely rewarding and amazing to see the [nid] students’ facial expressions and realise that they understood what i was saying through the interpreter.’ (su student) working with an interpreter was a challenging but enlightening experience for the su students. they were positive about the presence of the interpreter, but at times felt uncomfortable with longer periods of silence or talking slowly. they realised later that the deaf students did not perceive this as uncomfortable because it is their ‘normal’. even in situations where the interpreter was not available on a one-onone basis, su students were able to improvise and make use of simple visual and non-verbal cues to communicate on a basic level with the nid students. ‘this made me realise how we actually don’t realise how easy it is for us to communicate with one another.’ this fostered a feeling of accomplishment among the su students. the majority of su students were grateful for this opportunity to rethink the value of conveying simple, yet effective, messages to their audiences. although the su students might have felt initial trepidation with regard to interacting with nid students, the latter group was grateful for the attempts made to communicate, be it via simple hand gestures or writing messages to one another: ‘it stretched the abilities i thought i had and showed me that with a bit of confidence and a good attitude, i can talk to anyone – even if they can’t hear me.’ (su student) impact of learning activity su students were appreciative of skills gained and commented on improved confidence levels, being less apprehensive in new environments, being able to ‘think on their feet’, as well as gaining invaluable practical experience in dealing with diverse target audiences. ‘i understand how this task can help us to grow as dietitians – it broadens our scope, our knowledge.’ their role as health professionals became clearer in terms of seeing how working with individuals with any form of disability would affect them in their future professions: ‘everyone has the right to education, no matter their background or disability and we need to all respect everyone and be aware of what is going on around us.’ (su student) su students also expressed personal anecdotes of how the experience had strengthened their levels of gratitude at being blessed with the ability to hear, becoming more patient and respectful of those with disabilities and to be more open-minded when faced with new experiences: ‘i personally feel that engaging with people/patients with disabilities is often overlooked, despite the fact that there is a large population of south africans who are living with disabilities, and require dietetic services/ health knowledge.’ (su student) nid students realised the potential impact of pooling resources and learning from one another. ‘we can also teach them what we know. so we can teach each other.’ nid students expressed a deep desire for more intricate and in-depth learning opportunities. they wanted to know more about healthy eating and the role of the dietitian in the greater community. ‘they teach us the basics, but we want to learn something a little bit more difficult; what dietitians can do; things dietitians do.’ nid students were also thankful to have benefited from knowledge dissemination, and mentioned that ‘it was something new to learn’ and that they had ‘heard some information for the first time’. the students particularly enjoyed the practical sessions more than the theoretical presentations and described them as being ‘nice’. ‘they didn’t complain when we made mistakes, they just encouraged us to work on our future.’ on a personal level, the su students motivated the nid students to ‘eat healthy’ and the nid students felt that ‘without the training, if people had asked about healthy food, we never would have known about it, so this [the training] was good’. barriers su students described occasional frustration at not being able to communicate optimally with the nid students. the desire to be able to interact with the deaf was often overshadowed by feelings of helplessness, as they needed to rely on the interpreter to facilitate an interactive conversation: ‘there were so many occasions where i just wanted to talk to them and get to know them but because i was unable to communicate in a way that they march 2018, vol. 10, no. 1 ajhpe 35 research would understand, this was impossible. it was such a frustrating feeling that i have never experienced before.’ (su student) despite planning the sessions in advance, su students discovered that the actual training was a lengthier process than they had anticipated, given the need for interpretation, which often relied on greater concentration and adaptability on their part. they also expressed concerns that nid students would perceive them as being ‘condescending’, given the need to speak more slowly than they would usually do. on occasion, some su students left immediately after the training was concluded owing to commitments elsewhere and several nid students considered this as being rude. the perceived apprehension of the su students towards the nid group was seen as a barrier. a lack of confidence in communication skills and discomfort on the part of the su students could have been erroneously interpreted by the nid students as a lack of interest in communicating with them, when it could rather be explained by a feeling of uncertainty or difficulty adapting to a new environment: ‘so are they scared of deaf people? are they scared to talk to us? what is the problem … why are they never communicating with us?’ (nid student) the curiosity regarding the dietetic students distracted nid students from focusing on the discussion topics. nid students expressed a need to learn more about the su students on a personal level by spending more time with them on an informal basis. to summarise, feelings of discomfort and uncertainty soon eased when the su students were welcomed on the nid campus, where an atmosphere of calm, peace and hospitality prevailed. a few su students admitted to feeling slightly uncomfortable at the difference in communication techniques and felt fortunate at being blessed with the gift of hearing. nid students expressed feelings of appreciation towards the su students for trying to forge relationships with them, despite communication barriers. the experience was insightful and changed the reciprocal perceptions of both groups. it is important that su students are equipped with the skills necessary to facilitate communication with persons with hearing loss. maintaining collaboration with the nid college serves as an opportunity to facilitate the translation of knowledge to students with hearing loss. discussion positive feedback from dietetic students who completed the assignment during previous years led to the question of whether the nid students had the same experience and whether the assignment should be repeated. recommendations could be made to improve training sessions for the benefit of persons with hearing loss. deaf students are more heterogeneous than their hearing-abled peers and vary in their cognitive abilities and knowledge.[4,11,12,22] the unique study population facilitated an enriching experience embraced by both groups of students. even so, it is crucial to bear in mind that the majority of participants were female, which could have influenced the finer nuances of the discussions and reflections as female hcps have more favourable attitudes towards persons with physical disabilities.[14] experiences and insight su students admired the absence of self-pity on the part of the nid students, and were subsequently motivated by their empowering attitudes, passionate communication and teamwork. it was inspiring that this group of students with hearing loss were very positive and appreciative of the efforts of su students, not only in conveying new knowledge, but also in engaging with them. these findings contradict findings of furnham et al.,[23] who reported that deaf students had the perception that hearing individuals have more negative attitudes to deafness than they actually have. it could possibly be explained by nid students being unaware that dietetic students form part of hcps, and therefore did not project the mistrust or anger towards hcps as reported elsewhere.[5,11,19] su students learnt not to underestimate the abilities of students with hearing loss purely on the basis of their living with a disability. as a communicator, an hcp needs to have the ability to develop rapport, trust and ethical therapeutic relationships with clients from different backgrounds, having distinct skills and competencies.[6] this role of communicator links strongly to the required graduate attributes that have been widely embraced by the health science curricula of su.[24] the invaluable role of communication, not only in day-to-day existence, but also in the essential role of fostering optimal healthcare, was realised by the students. nid students responded well to the effort of the su students to communicate, which may be due to deaf students’ ability to make inferences and connections with world knowledge associated with incidental learning, enabling them to react appropriately.[11,25] the active engagement of d/hl students proves that even with linguistic difficulties it is both important and feasible for them to participate in research.[15] hcps need to be educated with regard to the barriers experienced by individuals from the deaf culture relating to access to healthcare.[1,3,4,11] effective communication can be improved via frequent contact of students with the deaf culture during their training.[14] the experience of interacting with the deaf contributed to the professional and personal development of final-year dietetic students and added to a deeper understanding of the different dimensions of their role as healthcare advocates.[6] su students’ ability to recognise the importance of health promotion to individuals with disabilities and not limiting valuable health-promotion messages to only hearing-abled individuals exemplifies their role as scholar[6] to disseminate and translate nutrition knowledge to the broader community.[5,19] as d/hl students have different backgrounds and experiences than hearing-abled students, both their knowledge and learning strategies differ. marschark[9] describes deaf learners as ‘visual-learners’, which explains why nid students clearly enjoyed the practical part of the training sessions the most.[3] the literature advises the use of visual aids[19] and a variety of media, including videos using sub-titles.[5] deaf learners fluent in sign language have the ability to generate complex visual images.[9,12] it was therefore deemed appropriate to conduct fg discussions, facilitated by an interpreter fluent in sasl, to gain insight into the way the nid students experienced the training provided by hearing students.[18] theoretically, it would have been ideal to obtain written reflections from the nid students, but this was not practical. most d/hl display lower vocabulary levels compared with hearing peers owing to their limited access to full, fluent language.[3,10,26,27] having smaller fgs might be considered in future, as 5 8 participants per group are advised for the deaf.[20] fluency in a sign language is a predictor of reading level, as research shows that those most proficient in a sign language were better readers. recent literature found that post-secondary students learned just as much from text as they did from sign language, despite the reading difficulties they experienced.[10] therefore, printed information leaflets to 36 march 2018, vol. 10, no. 1 ajhpe research support the messages conveyed during practical training sessions can be beneficial, provided the necessary modifications of materials are made to accommodate their needs,[20,28] such as using an easy handwriting/font type and basic vocabulary that does not exceed 6th grade reading level.[5] deaf learners can learn as much as their hearing peers when taught by skilled teachers of the deaf.[9] a clear understanding of the content of previous modules and the level of knowledge are crucial when developing new training material.[9] prior knowledge of the curriculum enables su students to build on the existing knowledge of the nid students to open up a world of new information to them. training sessions presented by the su students successfully complemented the pc course. future collaboration between the two parties should therefore be encouraged, as nid students requested more information. perceived barriers experienced during the training the desire to be able to interact with the hearing-impaired group was often overshadowed by feelings of helplessness, as su students needed to rely on the interpreter to facilitate an interactive conversation. uncertainty surrounding the role and competencies of each group was explicitly expressed by both groups. su students were afraid of being viewed as condescending, whereas the nid students perceived them to be rude owing to su students’ seeming inability to reach out. meador and zazove[5] report that in the deaf culture, it is considered rude to be excluded from any conversation, which easily happened when su students had private discussions among themselves or had to leave suddenly at the end of a contact session. helen keller is quoted as saying that ‘being deaf isolates one from people’.[5] spending more time together on an informal level[1] could help to diffuse the tension, as both groups tended to relax after a while and adopt a reciprocal attitude of tolerance and appreciation. sarchet et al.[10] conclude that ‘differences between students with hearing loss and hearing students do not necessarily reflect unsurmountable challenges but they do need to be acknowledged by students, instructors, and institutions if all are to succeed in the educational endeavour’. research shows undeniably that hcps lack the knowledge and skills to communicate effectively with the d/hl, as very few acquire sasl skills[2] and would benefit from having more opportunities to serve individuals with physical disabilities.[4,14] the need expressed by the nid students for healthcare students to learn at least a few signs[3] corresponds with the current literature.[2,11] healthcare students need to be sensitised and encouraged to make a concerted effort to be cognisant of the deaf culture and values.[1,2] healthcare information disseminated in an appropriate manner could help this minority group receive quality healthcare, participate and feel valued as persons[5,20] and decrease anxiety and fear of hcps.[1] study limitations the researchers were cognisant of the limitations of analysing the englishlanguage translations of sasl conversations. the richness of emotions of nid students, as evident by sentiments such as being ‘shocked’ in anticipation of the training session, was probably limited by using sasl. the literature shows that students with hearing loss tend to overestimate their understanding and learning from reading and lectures.[10] the question arises as to how accurate the nid students’ expression of emotions was, despite the prompting by an experienced sasl interpreter. greenbaum[18] suggests using two interpreters, as often one will be able to understand something the other could not. recommendations to build trust and understanding, facilitators are encouraged to arrange additional contact sessions in the form of visits to both campuses and social interaction prior to the academic sessions. using smaller groups for discussion with deaf students could potentially provide greater insight regarding their perceptions and specific needs. hearing students should ideally develop a clear understanding of the context of the proposed module content and the knowledge level of the persons with hearing loss to apply the correct context and enable the ‘training’ students to build on the existing knowledge of the hearingimpaired students. communicating with individuals with hearing loss can also be strengthened to establish a trust relationship and encourage participation by acquiring basic sign-language skills, specific presentation proficiencies and communicating via a trained sasl interpreter. practical sessions that allow for hands-on demonstrations and greater communication between groups should be prioritised, as well as the importance of relaying feedback during and after each training session. the provision of hand-outs tailored to the linguistic needs of individuals with hearing loss is essential. deaf students should ideally also be provided with some background information regarding the dietetic students before the training sessions commence. this information could include snippets on the dietetic profession and curriculum to ease anxiety before the training. a desire for a deeper level of learning about healthy eating was also expressed, and could perhaps be incorporated into the pc curriculum in the near future. conclusion findings of this research provide some understanding of the way deaf students experienced training sessions provided by dietetic students. su students were challenged to perform an assignment that required them to think and act innovatively, which appears to have been a valued experience in empowering them to effectively fulfil their role as hcps. su students were apprehensive prior to training commencement, but these emotions changed during the presentation of the training. su students agreed that the assignment helped them to better understand the challenges that deaf persons face every day and subsequently gained respect for them. preconceived ideas that nid students might not understand their training messages or that they were very different to the su students were altered. the activity had a positive impact on both their personal and professional growth and development, as they gained increased confidence in working with individuals with disabilities. as evidenced by the mutually beneficial outcome of this project and the overwhelmingly positive experience from both student groups, it is suggested that the collaboration between the nid and division of human nutrition, su, be continued and strengthened in the future. nid students were appreciative of the efforts to reach out to them and were keen to acquire new knowledge, which they claim to also utilise in their private lives. acknowledgements. we express our gratitude towards the nid co-ordinator and lecturers, nid students and sasl interpreter for inviting us into their deaf world. the contributions of the bsc dietetics final-year students (2015) were invaluable. march 2018, vol. 10, no. 1 ajhpe 37 research author contributions. ys, mm, ej: study completion and design; ys, hd, ej: data collection; ys, mm, lp: data analysis and interpretation; ys, mm, lp, hd: conceptualising and writing the manuscript. funding. financial support was provided by the su fund for innovation and research in rural health (firrh) and the su rural medical education partnership initiative (surmepi). conflicts of interest. none. 1. scheier db. barriers to health care for people with hearing loss: a review of the literature. j new york nurses ass 2009:4-10. https://doi.org/10.1097/phm.0b013e3182555ea4 2. sadler gr, huang jt, padden ca, et al. bringing health care information to the deaf community. j cancer educ 2001;16:105-108. https://doi.org/10.80/08858190109528742 3. barnett s. deaf sign language users, health inequities and public health: opportunity for social justice. http:// blogs.cdc.gov/pcd/2011/02/15/ (accessed 14 february 2017). 4. munoz-baell im, ruiz mt. empowering the deaf. let the deaf be deaf. j epidemiol comm 2000;54:40-44. https:// doi.org/10.1136/jech.54.1.40 5. meador he, zazove p. health care interactions with deaf culture. j am board fam prac 2005;18(3):218-222. https://doi.org/10.3122/jabfm.183218 6. frank jr, ed. the canmeds 2005 physician competency framework. better standards. better physicians. better care. ottawa: the royal college of physicians and surgeons of canada, 2005. 7. stellenbosch university, faculty of medicine and health sciences. faculty home/about us. 2016. http://blogs. sun.ac.za/ukwanda/ukwanda-rural-clinical-school/why-a-rural-clinical-school/ (accessed 17 november 2016). 8. national institute for the deaf. http://www.nid.otg.za/college/about.html 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intern med 2006;21:260-266. https://doi.org/10.1111/j.1525-1497.2006.00340.x 20. fraser m, fraser a. are people with learning disabilities able to contribute to focus groups on health promotion? j adv nurs 2001;33(2):225-233. https://doi.org/10 1111/j.1365-2648.2001.01657x 21. skinner d. qualitative research methodology: an introduction. in: joubert g, ehrlich r, eds. epidemiology: a research manual for south africa. 2nd ed. cape town: oxford university press, 2008:318-326. 22. hirsch ed. reading comprehension requires knowledge – of words and the world. am educ 2003;27(1):10-29. 23. furnham a, lane s. actual and perceived attitudes towards deafness. psychol med 1984;14(2):147-123. 24. faculty of medicine and health sciences. graduate attributes. centre for health professions education (chpe), stellenbosch university. 2013. http://www.sun.ac.za/english/faculty/healthsciences/pages/teaching---learning.aspx?termstoreid=d4aca01e-c7ae-4dc1-b7b2-54492a41081c&termsetid=e4c997b1-09db-4950-862fac7f223a7185&termid=b53b4d83-2487-46c1-a00d-ffe0e689ce2e (accessed 27 february 2018). 25. cawthon sw, winton sm, garberoglio cl, gobble me. the effects of american sign language as an assessment accommodation for students who are deaf or hard of hearing. j deaf stud deaf educ 2011;16(2):198-211. https:// doi.org/10.1093/deafed/enq053 26. qi s, mitchell re. large-scale academic achievement testing of deaf and hard-of-hearing students: past, present and future. j deaf stud deaf educ 2012;17:1-18. https://doi.org/10.1093/deafed/enr028 27. convertino c, borgna g, marschark m, durkin a. world and world knowledge among deaf learners with and without cochlear implants. j deaf stud deaf educ 2014;19(4):471-483. https://doi.org/10.1093/deafed/enu024 28. goldin-meadow s, mayberry ri. how do profoundly deaf children learn to read? learn disabil res pract 2001;16:221-228. https://doi.org/10.1002/9780470757642.refs accepted 14 september 2017. http://blogs.cdc.gov/pcd/2011/02/15/ http://blogs.cdc.gov/pcd/2011/02/15/ https://doi.org/10.1136/jech.54.1.40 https://doi.org/10.1136/jech.54.1.40 http://blogs.sun.ac.za/ukwanda/ukwanda-rural-clinical-school/why-a-rural-clinical-school/ http://blogs.sun.ac.za/ukwanda/ukwanda-rural-clinical-school/why-a-rural-clinical-school/ http://www.nid.otg.za/college/about.html http://www.nid.org.za/ https://global.oup.com/academic/product/how-deaf-children-learn-9780195389753 https://global.oup.com/academic/product/how-deaf-children-learn-9780195389753 https://doi.org/10.1179/1557069x12y.0000000010 http://www.blogs.sun.ac.za/ukwanda/ukwanda-rural-clinical-school/ http://www.blogs.sun.ac.za/ukwanda/ukwanda-rural-clinical-school/ https://doi.org/10.1097/phm.0b013e3182555ea4 https://doi.org/10.1097/phm.0b013e3182555ea4 https://doi.org/10.1177/1049732307307868 https://doi.org/10.1177/1049732307307868 http://www.groupsplus.com/pages/disabled.htm https://doi.org/10.1111/j.1525-1497.2006.00340.x https://doi.org/10 1111/j.1365-2648.2001.01657x http://www.sun.ac.za/english/faculty/healthsciences/pages/teaching----learning.aspx?termstoreid=d4aca01e-c7ae-4dc1-b7b2-54492a41081c&termsetid=e4c997b1-09db-4950-862f-ac7f223a7185&termid=b53b4d83-2487-46c1-a00d-ffe0e689ce2e http://www.sun.ac.za/english/faculty/healthsciences/pages/teaching----learning.aspx?termstoreid=d4aca01e-c7ae-4dc1-b7b2-54492a41081c&termsetid=e4c997b1-09db-4950-862f-ac7f223a7185&termid=b53b4d83-2487-46c1-a00d-ffe0e689ce2e http://www.sun.ac.za/english/faculty/healthsciences/pages/teaching----learning.aspx?termstoreid=d4aca01e-c7ae-4dc1-b7b2-54492a41081c&termsetid=e4c997b1-09db-4950-862f-ac7f223a7185&termid=b53b4d83-2487-46c1-a00d-ffe0e689ce2e https://doi.org/10.1093/deafed/enq053 https://doi.org/10.1093/deafed/enq053 scholarship of africa for africa june 2017, vol. 9 no. 2 issn 2078 5127 african journal of health professions education scholarship of africa for africa september 2018, vol. 10, no. 3 issn 2078 5127 african journal of health professions education september 2018, vol. 10, no. 3 ajhpe 153 research up to 5 15% of clinical encounters lead to diagnostic errors, i.e. delayed, incorrect or missed diagnoses.[1] the mortality, morbidity and cost of these errors are considerable;[2-5] despite 40 years of technological advances they remain largely unchanged.[6] strategies to address this major cause of patient harm must identify healthcare professionals at increased risk of making errors, characterise the errors they make and provide targeted, evidencebased intervention.[1] taxonomies of the ‘root’ causes of diagnostic errors have been developed with a view to error reduction and remediation.[1,7,8] graber et al.[1] identified three types of diagnostic errors (no-fault, system and cognitive) and reported that cognitive and system factors contributed to diagnostic errors. they clustered the root cognitive contributions to diagnostic errors (ccdes) in four categories: faulty knowledge, data-gathering errors, data synthesis difficulties and failed verification of the data used to make the diagnosis. schiff et al.[7] categorised errors according to the phase of the patient consultation process: access/presentation to healthcare, patient-practitioner encounter (history and physical examination), ordering and interpreting tests, making a diagnosis (assessment) and further consultation or referral and follow-up. retrospective studies using this taxonomy have found that practitioner-patient encounters (history and physical examination), ordering and interpreting of tests and making a diagnosis (assessment) contributed most to errors.[3,8-10] most of these studies were conducted in mixed populations of healthcare professionals[1,3,9,10] and did not focus on residents who are known to be at increased risk of making medical errors.[11] two studies of residents showed that both cognitive and system factors contributed to diagnostic errors.[12,13] these studies of malpractice claims or self-reported data are, however, >10 years old and did not focus on characterising ccdes. furthermore, their retrospective design limits the accuracy of the data owing to hindsight and outcomes biases, incomplete patient records, variable reviewer reliability and uncertainty about the final diagnoses made.[4,7,14] prospective studies characterising ccdes that residents make in patient consultations are needed to better align current training needs and remediation efforts. a central part of the diagnostic process is data gathering, i.e. taking a history and performing a physical examination of the patient. while a thoroughly conducted history and physical examination can lead to an assessment in at least 60% of cases,[6,15,16] errors related to these contribute to diagnostic errors in up to 61% of cases.[1,3,8-10] as summarised by feddock,[17] the variable clinical competence of trainees[18,19] may be ascribed to many factors, including progressive decline in bedside teaching, limited direct observation during real patient encounters, and limited feedback regarding clinical skills and performance in the workplace. knowledge of clinical skills deficits contributing to diagnostic errors that residents make in authentic clinical contexts is required to address this matter. remediation of ccdes requires a structured approach: multiple assessments to confirm the problem; an educational diagnosis (characterisation of the causes); feedback with a targeted remediation plan; and reassessment.[20-23] while experienced clinician-educators can background. experienced clinician-educators readily identify trainees making diagnostic errors, but lack pedagogic expertise to make educational diagnoses and provide feedback. simple tools are needed to address this challenge. objectives. to characterise cognitive contributions to diagnostic errors (ccdes) that trainees make in patient encounters and examiners’ perceptions of a checklist to document and provide feedback on these errors. methods. thirty examiners used a 17-item checklist to document ccdes made by medical residents failing patient encounters in a national specialist examination. a survey was used to explore examiners’ perceptions of the checklist to document and provide feedback on these errors. results. there were 98/264 failed patient encounters (37%). ninety-four completed checklists documented 691 ccdes (median of 7 per encounter). data synthesis was more problematic than data gathering, faulty knowledge or data interpretation (p<0.001 for all comparisons). the ‘top 5’ individual ccdes were failure to elicit history and/or examination findings; poor knowledge of clinical features (illness scripts); case synthesis (‘putting the case together’); and misinterpretation of clinical findings. examination-related errors were more common than history-related errors (p<0.0001). examiners found the checklist comprehensive and easy to use. they thought it could improve feedback on ccdes to unsuccessful candidates and guide remediation and training at the bedside. conclusions. a 17-item checklist identified three priority ccdes requiring remediation and training in medical residency programmes: improving clinical skills; developing adequate illness scripts; and putting a case together. examiners endorsed the use of the checklist and its potential to improve feedback and training, addressing ccdes made by trainees. afr j health professions educ 2018;10(3):153-158. doi:10.7196/ajhpe.2018.v10i3.1059 checklist of cognitive contributions to diagnostic errors: a tool for clinician-educators j m naude, mb chb, fcp (sa); v c burch, mb bch, mmed, phd, fcp (sa), frcp (lond) department of medicine, faculty of health sciences, university of cape town, south africa corresponding author: j m naude (drnaude@gmail.com) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 154 september 2018, vol. 10, no. 3 ajhpe research readily identify trainees ‘in trouble’, they often lack pedagogic expertise to make an educational diagnosis and to plan remediation.[24] this situation is aggravated by a paucity of evidence to guide remediation in medical education,[20] and few practical tools to help clinician-educators address diagnostic errors in clinical settings.[20,21] tools to assist clinician-educators to characterise ccdes residents make in practice are limited. audétat et al.[21-23] published a taxonomy of 6 common cognitive contributions to diagnostic errors, and a guide to diagnose and manage these problems in clinical training settings. one of the ongoing challenges, however, especially for clinician-educators with limited pedagogic expertise, is a reluctance to provide feedback when there is a lack of documentation of errors and limited knowledge of what to specifically document (the educational diagnosis).[25] simple tools to characterise, document and report on ccdes observed in trainee-led patient consultations are needed. using checklists to reduce or remediate diagnostic errors is gaining traction in the literature. differential diagnosis checklists successfully prompt consideration of additional diagnostic possibilities,[26,27] and limited data suggest that they can improve diagnostic accuracy in emergency departments.[27] to date, checklists have not been used to characterise and properly document ccdes observed during patient consultations. this may help clinician-educators to provide better feedback on, and remediation of, these errors observed during high-stakes examinations and at the bedside, where trainees simultaneously require clinical supervision and teaching. context of the study in south africa (sa), medical graduates complete 6 years of undergraduate training, 3 years of mandatory public service and 4 years of postgraduate training in preparation for the specialist physician licensing examinations of the colleges of medicine of sa (cmsa). the specialist examination of the college of physicians, a member college of the cmsa, assesses theoretical knowledge of the basic sciences and medicine, interpretation of diagnostic tests and clinical competence. the latter comprises three real patient encounters followed by a bedside oral presentation and discussion of each case. examiners mark candidates’ performance using a criterion-referenced scoring rubric and write a detailed description of the case presentation and ensuing discussion. the absence of a standard method of writing these notes and characterising (diagnosing) the ccdes in failed patient encounters make it challenging for examiners to provide detailed feedback to, and plan remediation for, unsuccessful candidates. checklist of cognitive contributions to diagnostic errors in 2015, these ongoing challenges prompted the college of physicians to develop a checklist for characterising (diagnosing) and documenting ccdes to provide feedback and plan remediation for unsuccessful candidates. the checklist, based on the literature,[1,7,8,21] includes 17 ccdes, grouped in four categories: knowledge gaps, data-gathering errors, data-interpretation errors and data-synthesis difficulties. the checklist was reviewed and pilot tested by a panel of examiners prior to implementation in 2015. research questions the newly implemented checklist (appendix 1) provided an opportunity to use the specialist examination setting to prospectively address two questions: • what are the priority ccdes clinician-educators need to address in training and remediation programmes for medical residents preparing for specialist examinations? • what are examiners’ perceptions of the utility of the new checklist to characterise, document and provide feedback on ccdes to unsuccessful candidates and trainees making diagnostic errors on ward rounds and during bedside teaching activities? methods research setting this study was conducted during the specialist examination of the college of physicians held at three large sa teaching hospitals in october 2015. research design this study used a prospective cross-sectional descriptive design. study population all medical residents and clinician-educators involved in the examination were invited to participate in the study. study procedure before commencing the 3-day examination proceedings, a 1-hour workshop was held to orientate examiners with regard to the purpose, structure and use of the checklist. each morning examiners were requested to complete a checklist for all failed patient encounters, i.e. use the tick boxes to record ccdes and write a short description of each. examiners completed a checklist immediately after assigning a final score to failing candidates. on the final day of the proceedings, examiners completed an anonymous 15-item closed-ended survey using a 5-point likert response scale ranging from ‘totally disagree’ to ‘totally agree’. completed surveys and anonymised checklists were collected by a member of the research team at the conclusion of the examination proceedings. diagnoses of patients included in the examination the medical illness for which a patient was included in the examination was defined as the primary diagnosis. for example, a patient with mitral stenosis was coded as primary diagnosis: valvular heart disease; discipline: cardiology. where patients had more than one diagnosis, the one accounting for most of the key clinical features (history and examination findings) was recorded as the primary diagnosis. in most of these cases the other problems were typically related to the primary diagnosis. for example, a patient with rheumatoid arthritis and pulmonary fibrosis complicated by pulmonary hypertension was coded as: primary diagnosis: rheumatoid arthritis; discipline: rheumatology. data analysis checklist and survey data were collated using microsoft excel version 15.0.4823.1004 (microsoft corp., usa) spreadsheets, and statistical analysis was performed using stata version 15 (statacorp., usa). likert-scale responses of the survey were reported in 3 categories: agree, neutral and disagree. variables were compared using the kruskal-wallis test (numerical), χ2 goodness-of-fit test (categorical) and a bonferroni correction september 2018, vol. 10, no. 3 ajhpe 155 research for multiple comparisons. a p-value <0.05 was considered significant, except for multiple comparisons, where p<0.01 was used. ethical approval institutional approval for this study was granted by the human research ethics committee, university of cape town (ref. no. hrec 733/2015). written informed consent was obtained from all participants. results patient encounters a total of 88 candidates and 30 examiners from all 8 medical schools in sa participated in the examination. there were 98/264 failed patient encounters (37%). four incomplete checklists were excluded and the remaining 94 (96%) were analysed. patient diagnoses forty-one unique diagnoses were present in 94 failed patient encounters. table 1 shows that cardiac patients (28.7%) and neurology patients (18.1%) comprised 46.8% of failed encounters, and valvular heart disease was the commonest missed/incorrect diagnosis (18.1%). failed encounters involving haematological and gastrointestinal illnesses were not reported. cognitive contributions to diagnostic errors examiners identified 691 ccdes in 94 failed patient encounters; median (range) of 7 (1 14) per encounter. only 3 candidates failed a patient encounter on the basis of 1 2 ccdes. they made multiple history and physical examination errors, which they failed to recognise during the case discussion, whereas limited time prevented further discussion of the investigation and management of the respective patients. the discipline-specific ccde rate was not significantly different (p=0.6) (fig. 1). nephrology was excluded because it included only 1 failed encounter. table 2 shows that, by category, data synthesis was more problematic than data gathering, faulty knowledge or data interpretation (35.2% v. 25.8% v. 21.9% v. 17.1%); χ2=48.2, p<0.0001; for all comparisons). ‘top 5’ cognitive contributions to diagnostic errors the top 5 ccdes comprised 44.7% of all ccdes. errors to correctly gather (38.2%) and interpret (21.7%) the history and examination findings, which collectively comprised 60% of the top 5, were more common than faulty knowledge of the clinical features of the case (23.2%) and failure to integrate and synthesise all the findings, i.e. ‘put the case together’ (16.8%) (table 3). table 1. primary missed diagnoses in 94 patient encounters, categorised by discipline discipline n cardiology (n=27) valvular heart disease 17 atrial septal defect 2 atrial fibrillation 2 hypertrophic obstructive cardiomyopathy 2 dilated cardiomyopathy 1 hypertensive heart disease 1 ischaemic heart disease 1 constrictive pericarditis 1 hepatology (n=15) portal hypertension 4 chronic liver disease 4 hepatocellular carcinoma 2 viral hepatitis 2 cryptogenic cirrhosis 1 gaucher’s disease 1 drug-induced liver injury 1 rheumatology (n=14) systemic lupus erythematosus 6 rheumatoid arthritis 3 scleroderma 2 systemic sclerosis 1 polymyositis 1 gout 1 nephrology (n=1) autosomal dominant polycystic kidney disease 1 neurology (n=17) cerebrovascular accident 7 parkinson’s disease 3 spinocerebellar ataxia 2 syringomyelia 1 myasthenia gravis 1 cerebellitis 1 neurofibromatosis 1 myeloradiculopathy 1 endocrinology (n=12) acromegaly 4 hyperthyroidism 3 diabetes mellitus 2 cushing’s syndrome 2 prader-willi syndrome 1 pulmonology (n=8) asthma 2 sarcoidosis 2 cystic fibrosis 1 kartagener’s syndrome 1 post-tuberculosis bronchiectasis 1 idiopathic pulmonary fibrosis 1 figure 1. errors (median, iqr, range) per patient encounter grouped by discipline ! " # $ % &! &" &# &$ '( )* +,,. /01 2" 3 45 6) ,-, ./ 012 &3 78 56 9( :, -,. /01 2& # ;5 <( :, -,. /01 2& = >1 *, ?)+ 1, -,. /01 2& " @6 -9 ,1 ,-, ./ 012 % pu lm on ol og y, n= 8 16 14 12 10 8 6 4 2 0 ca rd io lo gy , n =2 7 ne ur ol og y, n= 17 rh eu m at ol og y, n= 14 he pa to lo gy , n =1 5 en do cr in ol og y, n= 12 fig. 1. errors (median, interquartile range, range) per patient encounter grouped by discipline. 156 september 2018, vol. 10, no. 3 ajhpe research clinical features-related errors table 4 shows that 40% of 691 ccdes were ascribed to failure to correctly elicit and/or interpret the clinical features of the case. data gathering was more problematic than interpretation (χ2=21.96, p<0.0001). physical examination-related errors were more common than history-related errors (χ2=24.28, p<0.0001). examiners’ perceptions of the checklist all examiners completed the survey. most (n=22; 73.3%) completed the checklists, including a written description of ccdes, in <5 minutes; 8 required up to 10 minutes and 1 examiner required >10 minutes. table 5 shows that the checklist was easy to use at the bedside, efficiently identified and recorded all the ccdes previously observed and some not previously considered or identified. most examiners thought it would improve feedback and intended to use it. examiners also thought that the checklist could guide trainee teaching and feedback on ccdes at the bedside. some even felt that the checklist could improve patient care by improving diagnostic accuracy, more efficient use of investigations, reducing treatment errors and reducing length of hospital stay. discussion this study explored the use of a novel 17-item checklist to characterise (make an educational diagnosis) and document ccdes that residents made during failed real patient encounters in a specialist examination in sa. it formed part of a project to educate clinician-educators/examiners about ccdes and teach them to use a checklist to characterise and record ccdes to provide standardised, structured feedback to unsuccessful examination candidates. the use of the checklist to guide feedback to trainees about ccdes observed at the bedside during ward rounds and teaching was also explored. in this study, as elsewhere,[1,3,8-10] ccdes were multifactorial. our median error rate per patient, which was slightly higher than that in retrospective studies,[1,3,4,9] may have been due to the prospective study design. furthermore, unlike studies of mixed populations of doctors[1,3,9,10] or physicians only,[8] we focused on residents, where higher error rates were expected.[11,12] history and physical examination-related errors accounted for 60% of the top 5 ccdes identified in this study. examination-related errors were more common. in other studies the contribution of physical examination errors range from 14% to 42%,[1,3,8-10] with higher rates in studies that include more residents.[3,9,10] this is consistent with work that reports differences in clinical competence between residents and physicians.[11,12] we observed similar ccde rates in patient encounters across a broad spectrum of clinical disciplines. this is consistent with studies showing that trainees lack a broad range of physical examination skills.[19] the predominance of cardiology and neurology patients in this study is consistent with other work showing poorer physical examination competence in these disciplines.[19] faulty knowledge of clinical features contributed 23% to the top 5 ccdes. figures in published studies vary from 10%[1] to 84%,[5] suggesting that knowledge gaps may be underestimated in some retrospective studies. this examination-based study may have been better suited to identifying knowledge gaps at the bedside. as candidates in this study had already passed the theory examinations, inadequate illness scripts (knowledge of the clinical features of the illness applied in a real patient setting) rather than theoretical knowledge gaps may have been the problem.[1] further studies are needed to confirm this suggestion. as observed elsewhere, we found data gathering more problematic than data interpretation.[3,8,9] this suggests that practical clinical skills rather than knowledge of the meaning of clinical findings is the key problem. this finding may also have been influenced by the study setting, in which examiners do not pursue interpretation of missed clinical features, i.e. the examination aims to determine what candidates know rather than what they don’t know. studies in non-examination settings are needed to better understand our observation. table 2. cognitive contributions of diagnostic errors (n=691) reported in 94 failed patient encounters, expressed as a proportion (total number of errors in parentheses) category of errors proportion (n) 95% ci category 1: knowledge gaps (n=151) clinical features 0.48 (72) 0.40 0.56 investigations 0.21 (31) 0.14 0.28 basic science 0.17 (26) 0.12 0.24 treatment 0.15 (22) 0.09 0.21 category 2: data-gathering errors (n=178) missed key findings of examination 0.39 (70) 0.32 0.47 missed key findings of history 0.27 (48) 0.21 0.34 reported physical signs not present 0.24 (43) 0.18 0.31 incorrect history obtained 0.10 (17) 0.06 0.15 category 3: data-interpretation errors (n=119) inability to interpret physical signs 0.56 (67) 0.47 0.65 inability to interpret history 0.27 (32) 0.19 0.36 inability to interpret investigations 0.17 (20) 0.11 0.25 category 4: data-synthesis errors (n=243) unsatisfactory integration/synthesis 0.21 (52) 0.16 0.27 unable to identify key features 0.19 (45) 0.14 0.24 unable to make connections between data 0.18 (43) 0.13 0.23 unable to prioritise patient problems 0.16 (39) 0.12 0.21 early to focus on a diagnosis 0.13 (32) 0.09 0.18 unable to generate alternate diagnosis 0.13 (32) 0.09 0.18 ci = confidence interval. table 3. top 5 cognitive errors (n=309) made during 94 failed patient encounters, expressed as a proportion (total number of errors in parentheses) cognitive errors proportion (n) 95% ci knowledge gap of clinical features of presenting illness 0.23 (72) 0.19 0.29 failure to elicit key physical examination findings 0.23 (70) 0.18 0.28 failure to interpret physical examination findings 0.22 (67) 0.18 0.27 unsatisfactory integration and synthesis of case 0.17 (52) 0.13 0.21 failure to elicit key features of patient’s history 0.16 (48) 0.12 0.20 ci = confidence interval. september 2018, vol. 10, no. 3 ajhpe 157 research in this study, we found that clinician-educators without pedagogic expertise could use a simple checklist to systematically characterise (make an educational diagnosis), document and report on ccdes contributing to poor academic performance in a structured and standardised manner. in so doing, the checklist addresses two key issues that limit clinical supervisors’ willingness to report on poor academic performance, i.e. lack of proper documentation of errors and uncertainty about what to record (educational diagnosis).[25] study limitations in this study, patient consultation times were longer than in clinical practice. however, despite extra time, candidates made many errors. while examination-induced anxiety may have contributed to this observation, it is known that more consultation time does not routinely improve diagnostic accuracy.[11] although examiners were enthusiastic about the utility of the checklist to provide feedback on poor performance in highstakes examinations and clinical teaching, the data were self-reported and reflected anticipated rather than actual behaviour. future studies are needed to determine whether examiners adopt the checklist for feedback and remediation of ccdes in unsuccessful candidates and those preparing for the examination. study strengths although this study only included one cycle of examination data, it represented candidates and examiners from all 8 sa medical residency programmes. this prospective study of ccdes focusing on residents obviated some of the limitations of retrospective studies previously described.[4,7,14] we could not find similar studies conducted in other international medical residency programmes. so, while more data are needed to confirm the findings of this study, it is an important step in the right direction. conclusion this study has answered the two research questions it set out to address. first, we identified 3 priority ccdes that require focused training and remediation in residency training programmes in sa: inadequate clinical skills, limited quality of illness scripts (knowledge about the key features of an illness), and difficulty putting the case together. this does not require extensive reading and studying, i.e. ‘more of the same’, but rather customised remediation and table 5. examiners’ perceptions of the checklist of cognitive contributions to diagnostic errors survey item disagree, n (%) neutral, n (%) agree, n (%) 1. i provide verbal feedback to unsuccessful examination candidates 9 (30) 0 21 (70) 2. the quality of feedback i provide is comprehensive and additional information would not be useful* 17 (65.4) 5 (19.2) 4 (15.4) 3. the checklist provided an efficient means of identifying diagnostic errors 2 (6.7) 0 28 (93.3) 4. the checklist provided an efficient way of recording diagnostic errors 1 (3.3) 6 (20.0) 23 (76.7) 5. based on your experience, the checklist included all the common causes of diagnostic errors i have encountered in the past 4 (13.3) 6 (20.0) 20 (66.7) 6. compared with your current practice, the checklist could be a better way of providing structured feedback to unsuccessful candidates 1 (3.3) 0 (0) 29 (96.7) 7. this checklist listed causes of diagnostic errors you have not considered or identified previously* 7 (24.1) 10 (34.5) 12 (41.4) 8. this checklist could be a useful way of guiding bedside teaching and providing feedback for residents preparing for the examination* 1 (3.4) 1 (3.4) 27 (93.1) 9. i plan to use this checklist to provide structured feedback to unsuccessful candidates at my training centre 1 (3.3) 6 (20) 23 (76.7) 10. i would consider using the checklist to guide bedside teaching and feedback for residents 1 (3.3) 3 (10) 26 (86.7) 11. i would consider using the checklist to guide bedside teaching and feedback for undergraduate medical students 2 (6.7) 6 (20) 22 (73.3) 12. the checklist can be easily utilised at the bedside 1 (3.3) 7 (23.3) 22 (73.3) if the checklist were to be routinely used in clinical training it may contribute to improving patient care in terms of: 13. improved diagnostic accuracy 1 (3.3) 7 (23.3) 22 (73.3) 14. more efficient use of investigations 2 (6.7) 14 (46.7) 14 (46.7) 15. reduction in treatment errors 3 (10) 14 (46.7) 13 (43.3) 16. reduction in length of hospital stay 2 (6.7) 17 (56.7) 11 (36) *survey items 2, 7 and 8 do not add up to 30, as they were not answered by all participants. table 4. clinical features-related errors (n=277) made during 94 failed patient encounters, expressed as a proportion (total number of errors in parentheses) clinical features-related errors history physical examination proportion (n) 95% ci proportion (n) 95% ci total failure to elicit key clinical findings 0.17 (48) 0.13 0.22 0.25 (70) 0.20 0.31 118 findings reported incorrectly/not present 0.06 (17) 0.04 0.10 0.16 (43) 0.11 0.20 60 misinterpretation of clinical findings 0.12 (32) 0.08 0.16 0.24 (67) 0.19 0.30 99 total 0.35 (97) 0.29 0.41 0.65 (180) 0.59 0.71 277 ci = confidence interval. 158 september 2018, vol. 10, no. 3 ajhpe research faculty support, as discussed in the literature.[22,23] second, we showed that the simple checklist used in this study helped clinician-educators/examiners without pedagogic expertise to diagnose and record ccdes contributing to poor performance in high-stakes examinations. furthermore, clinicianeducators/examiners were of the opinion that this tool might help them to provide comprehensive, standardised feedback to unsuccessful examination candidates and trainees making diagnostic errors at the bedside during ward rounds and teaching. this study also suggests that clinical examinations may be a rich source of prospective data to better understand diagnostic errors trainees make and potential remediation strategies. acknowledgements. we acknowledge the contributions of the colleges of medicine of south africa and those of the examiners at the octo ber 2015 examinations. author contributions. jn: drafted the research protocol, captured data, interpreted data and wrote the first draft of the manuscript. vcb: conception, study design, data interpretation and critical review of the final manuscript. both authors approved the publication of this manuscript. funding. none. conflicts of interest. this manuscript forms part of a postgraduate dissertation of j m naude. 1. graber ml, franklin n, gordon r. diagnostic error in internal medicine. arch intern med 2005;165(13):14931499. https://doi.org/10.1001/archinte.165.13.1493  2. graber ml. the incidence of diagnostic error in medicine. bmj qual saf 2013;22(2):1-8. https://doi.org/10.1136/ bmjqs-2012-001615  3. singh h, giardina td, meyer and, forjuoh sn, reis md, thomas ej. types and origins of diagnostic errors in primary care settings. jama intern med 2013;173(6):418-425. https://doi.org/10.1001/jamainternmed.2013.2777  4. zwaan l, thijs a, wagner c, van der wal g, timmermans drm. relating faults in diagnostic reasoning with diagnostic errors and patient harm. acad med 2012;87(2):149-156. https://doi.org/10.1097/ acm.0b013e31823f71e6 5. zwaan l, de bruijne m, wagner c, et al. patient record review of the incidence, consequences, and causes of diagnostic adverse events. arch intern med 2010;170(12):1015-1021. https://doi.org/10.1001/ archinternmed.2010.146  6. kirch w, schafii c. misdiagnosis at a university hospital in 4 medical eras. medicine 1996;75(1):29-40. https:// doi.org/10.1097/00005792-199601000-00004  7. schiff gd, kim s, abrams r, et al. diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. in: henriksen k, battles jb, marks es, et al., eds. advances in patient safety: from research to implementation (volume 2: concepts and methodology). rockville, md: agency for healthcare research and quality (us), 2005:255-278. 8. schiff gd, hasan o, kim s, et al. diagnostic error in medicine. arch intern med 2009;169(20):1881-1887. https:// doi.org/10.1001/archinternmed.2009.333  9. kachalia a, gandhi tk, puopolo al, et al. missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. ann emerg med 2007;49(2):196-205. https://doi. org/10.1016/j.annemergmed.2006.06.035  10. singh h, thomas ej, khan mm, petersen la. identifying diagnostic errors in primary care using an electronic screening algorithm. arch intern med 2007;167(3):302-308. https://doi.org/10.1001/archinte.167.3.302  11. norman gr, monteiro sd, sherbino j, ilgen js, schmidt hg, mamede s. the causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. acad med 2017;92(1):23-30. https:// doi.org/10.1097/acm.0000000000001421  12. singh h, thomas ej, petersen la, studdert dm. medical errors involving trainees. arch intern med 2007;167(19):2030-2036. https://doi.org/10.1001/archinte.167.19.2030  13. jagsi r, kitch bt, weinstein df, campbell eg, hutter m, weissman js. residents report on adverse events and their causes. arch intern med 2005;165(22):2607-2613. https://doi.org/10.1001/archinte.165.22.2607  14. wears rl, nemeth cp. replacing hindsight with insight: toward better understanding of diagnostic failures. ann emerg med 2007;49(2):206-209. https://doi.org/10.1016/j.annemergmed.2006.08.027  15. peterson mc, holbrook jh, von hales d, smith nl, staker lv. contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. west j med 1992;156(2):163-165. https://doi.org/10.1097/00006254-199210000-00013  16. paley l, zornitzki t, cohen j, friedman j, kozak n, schattner a. utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. arch intern med 2011;171(15):1394-1396. https://doi.org/10.1001/archinternmed.2011.340  17. feddock ca. the lost art of clinical skills. am j med 2007;120(4):374-378. https://doi.org/10.1016/j. amjmed.2007.01.023  18. sharma s. a single-blinded, direct observational study of pgy-1 interns and pgy-2 residents in evaluating their history-taking and physical-examination skills. perm j 2011;15(4):23-29. https://doi.org/10.7812/tpp/11-106  19. ramani s, ring bn, lowe r, hunter d. a pilot study assessing knowledge of clinical signs and physical examination skills in incoming medicine residents. j grad med educ 2010;2(2):232-235. https://doi.org/10.4300/ jgme-d-09-00107.1  20. hauer ke, ciccone a, henzel tr, et al. remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. acadmed 2009;84(12):1822-1832. https://doi. org/10.1097/acm.0b013e3181bf3170  21. audétat m-c, laurin s, sanche g, et al. clinical reasoning difficulties: a taxonomy for clinical teachers. med teach 2013;35(3):984-989. https://doi.org/10.3109/0142159x.2012.733041  22. audétat m-c, laurin s, dory v, charlin b, nendaz mr. diagnosis and management of clinical reasoning difficulties: part i. clinical reasoning supervision and educational diagnosis. med teach 2017;39(8):792-796. https://doi.org/10.1080/0142159x.2017.1331033  23. audétat m-c, laurin s, dory v, charlin b, nendaz mr. diagnosis and management of clinical reasoning difficulties: part ii. clinical reasoning difficulties: management and remediation strategies. med teach 2017;39(8):797-801. https://doi.org/10.1080/0142159x.2017.1331034  24. audétat m-c, dory v, nendaz m, et al. what is so difficult about managing clinical reasoning difficulties? med educ 2012;46(2):216-227. https://doi.org/10.1111/j.1365-2923.2011.04151.x  25. dudek nl, marks mb, regehr g. failure to fail: the perspectives of clinical supervisors. acad med 2005;80(suppl):s84-s87. https://doi.org/10.1097/00001888-200510001-00023  26. graber ml, sorensen av, biswas j, et al. developing checklists to prevent diagnostic error in emergency room settings. diagnosis 2014;1(3):223-231. https://doi.org/10.1515/dx-2014-0019  27. ely jw, graber ma. checklists to prevent diagnostic errors: a pilot randomized controlled trial. diagnosis 2015;2(3):163-169. https://doi.org/10.1515/dx-2015-0008  accepted 20 february 2018. appendix 1. checklist of cognitive contributions to diagnostic errors knowledge gaps data-gathering difficulties  basic sciences  failed to identify key data during interview  clinical features of illness  obtained incorrect data during interview  investigations  failed to identify key signs on examination  treatment  found clinical signs that were not present  other, please explain below  other, please explain below data interpretation/meaning/ significance difficuly in making a diagnosis  history findings  unable to identify key features to make a dx  physical examination findings  unable to prioritise patient’s key problems  investigations  early focus on a dx, unable to change mind  other, please explain below  unable to generate alternative diagnoses  unable to make connections between data  unsatisfactory integration and synthesis  other, please explain below comments other reasons for failing the case that are not listed above https://doi.org/10.1136/bmjqs-2012-001615  https://doi.org/10.1136/bmjqs-2012-001615  https://doi.org/10.1097/acm.0b013e31823f71e6 https://doi.org/10.1097/acm.0b013e31823f71e6 https://doi.org/10.1001/archinternmed.2010.146  https://doi.org/10.1001/archinternmed.2010.146  https://doi.org/10.1097/00005792-199601000-00004  https://doi.org/10.1097/00005792-199601000-00004  https://doi.org/10.1001/archinternmed.2009.333  https://doi.org/10.1001/archinternmed.2009.333  https://doi.org/10.1016/j.annemergmed.2006.06.035  https://doi.org/10.1016/j.annemergmed.2006.06.035  https://doi.org/10.1097/acm.0000000000001421  https://doi.org/10.1097/acm.0000000000001421  https://doi.org/10.1097/00006254-199210000-00013 https://doi.org/10.1016/j.amjmed.2007.01.023  https://doi.org/10.1016/j.amjmed.2007.01.023  https://doi.org/10.7812/tpp/11-106  https://doi.org/10.4300/jgme-d-09-00107.1  https://doi.org/10.4300/jgme-d-09-00107.1  https://doi.org/10.1097/acm.0b013e3181bf3170  https://doi.org/10.1097/acm.0b013e3181bf3170  https://doi.org/10.1111/j.1365-2923.2011.04151.x https://doi.org/10.1097/00001888-200510001-00023 https://doi.org/10.1515/dx-2014-0019 https://doi.org/10.1515/dx-2015-0008 56 march 2018, vol. 10, no. 1 ajhpe research a concern of health managers who are focused on service delivery outputs is the effect of the time taken and resources used by teaching undergraduate students on service delivery. the perception exists that the deliberate teaching of students takes time away from immediate patient care, prolongs ward rounds, slows down outpatient queues and uses more medical supplies. nonetheless, students doing clinical clerkships can potentially add a pair of educated and willing hands as they learn practically by doing rather than being exclusively taught.[1] the balance between what successive groups of students bring to patient care and what they demand from it, is an ongoing tension that must be actively managed across a clinical teaching platform. international best practice and evidence show that over the long term, the health service benefits of hosting students in practices and hospitals outweigh the demands that they place on the system.[2,3] the quality of care, attitudes of staff, and long-term recruitment of practitioners have all been shown to improve health services as a result of a health facility becoming a teaching site in a developed country.[4] however, apart from one ugandan study regarding community-based education,[5] not much data exist with regard to the effect of students at district level in lowand middle-income countries, where the service pressures are more intense as a result of severely limited resources to deal with an overwhelming burden of disease. a number of significant developments in health professions education have been initiated in south africa (sa) over the past decade, in particular the decentralisation of clinical teaching to rural sites[6] and the first yearlong longitudinal placements of medical students in rural district hospitals.[7] district hospitals in sa operate as the second line of medical care in the district health system, with the first level being delivered by clinical nurse practitioners in primary care facilities. our study aimed to develop local evidence of the effect of undergraduate student involvement on the processes and outputs of district health services. what factors tip the balance in favour of service delivery, and what factors benefit the students more? is one of these factors necessarily at the expense of the other, or can they be mutually beneficial? what factors could contribute to this ideal situation? the answers to these questions have important implications for the way that undergraduate student learning on a public health service platform in resource-constrained settings is conceptualised and planned. these research questions are of equal concern to health service managers as to those in health sciences education; it is therefore difficult to find a single conceptual framework for this study. the starting point for the study could be seen from an educational perspective with implications for curriculum design, in which the theory of service-learning articulated by dewey[8] and later by kolb[9] lays equal emphasis on both the service rendered and the experiential learning of the students, with the intention of benefiting equally the provider and the recipient of the services. however, a perspective from management sciences may be more appropriate, in which human resources for health, including students, are one of the many issues that need to be planned, costed, implemented and monitored to keep health services functioning. borrowing from economics, cost-benefit analysis requires quantitative data that can be costed, but we first need to establish the major issues that have to be compared. this study therefore aimed to background. the quality of care, attitudes of staff and long-term recruitment of practitioners have been shown internationally to improve health services as a result of a health facility accepting students for teaching. this study aimed to develop further insight regarding the impact of undergraduate student involvement on district health services in south africa to understand the issues in a resource-constrained environment. objectives. to describe the effect of the placement of undergraduate students on service delivery, and to understand the health service and academic factors that influence this effect. methods. a descriptive study, using qualitative methods, was undertaken in two rural sites where undergraduate health science students had been recently introduced. potential respondents were identified to be interviewed on the basis of their positions in the health services, their degree of involvement with students and their knowledge of the health system. results. sixteen participants were interviewed, and described the effect of undergraduate students on service delivery in terms of a balance between the burden and benefit. three pivotal issues, which could tip the balance in favour of one or the other, included the length of time of student rotations, seniority of the students and number of students allocated to a particular site. overall, it would appear that the balance was marginally in favour of the benefit of student service delivery. conclusion. undergraduate students can add value to service delivery under certain conditions, but further research is needed to quantify this effect. afr j health professions educ 2018;10(1):56-60. doi:10.7196/ajhpe.2018.v10i1.959 the effect of undergraduate students on district health services delivery in the western cape province, south africa s reid,1 mb chb, mfammed, phd; h conradie,2 mb chb, mfammed; d daniels-felix,2 ma (psych) 1 primary health care directorate, faculty of health sciences, university of cape town, south africa 2 ukwanda centre for rural health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: s reid (steve.reid@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. march 2018, vol. 10, no. 1 ajhpe 57 research identify the key issues in assessing the net effect of students on service delivery at district level. methods a descriptive study was undertaken using qualitative methods to document the process of implementation of undergraduate health science student involvement in three rural sub-districts in the western cape province, sa, and the outcomes with regard to health service delivery. the objectives were to qualify and quantify the effect of undergraduate students on service delivery, and to understand the health service and academic factors that influence this effect. rural sites outside metropolitan areas, where undergraduate health science students in medicine, physiotherapy, occupational therapy or speech and language therapy had been introduced up to a year previously, or were about to be introduced into district-level services, were purposively selected after negotiation with a range of stakeholders who relate to each teaching site administered by two different faculties of health sciences. the introduction of successive groups of students into the district-level health services varied at each site, depending on the types of students, their courses and logistics, and ranged from short repeated visits over a period of time to year-long ‘longitudinal’ placements.[7,10] ten respondents in the health services were purposively identified by the researchers from each of the two faculties (n=20) to produce an adequate spread of information on the basis of their positions in the health services, their degree of involvement with students and their knowledge of the health system as determined by the researchers. potential interviewees were contacted, and after consent was obtained, face-to-face semi-structured qualitative interviews were conducted in english by trained interviewers who were not directly involved in teaching, using a standard interview guide (appendix 1). interviews were audio recorded and transcribed verbatim. additional notes taken by the interviewers were included in the data. ethical approval for the study was obtained from the university of cape town human research ethics committee (ref. no. 453/2011), and permission was obtained from the western cape government to conduct the study in its facilities. analysis of the data was carried out independently by two researchers using an inductive approach to code major and minor themes according to the framework method,[11] then debating and discussing differences of interpretation and emphasis before deciding on the final codes, as well as their inter-relationships. results during a period of 9 months in 2012, 7 participants were interviewed at one site and 9 at another site. these included 2 district managers, 2 hospital chief executive officers (ceos), 1 operational manager, 3 medical managers, 2 family physicians, 3 hospital clinicians and 3 primary healthcare managers. four potential respondents were not available at the time of the interviewers’ visits. participants talked freely and interviews lasted between 30 and 60 minutes. the experience of accommodating undergraduate students on the service platform was described in terms of two opposing forces, i.e. the burden on and the benefit to service delivery. these were contributed to respectively by a number of different factors, which are described in more detail below. three fundamental issues could tip the balance in favour of burden or benefit, as they determined the overall effect more substantially (fig. 1). these ‘fulcrum’ issues were pivotal, and included the length of time of the student rotations, the seniority of the students and the number of students allocated to a particular site. overall, taking all the data into account, the balance was assessed as marginally in favour of the benefit to service delivery of students on the platform, as directly articulated by two respondents: ‘they were also i would say more helpful than they were [a burden] or they saved us more time than they took time.’ (family physician) ‘… they help us much more than they are a drawback.’ (medical manager) fulcrum issues short v. long rotations respondents clearly favoured longer student rotations: ‘the longer period that the students are placed here permanently, obviously is more beneficial for the different departments, they become part of the team and work as part of the team, whereas the small, the 2-week and 10-day rotations, they don’t have the time to become part of the team … so i prefer, and i think my departmental heads prefer the longer rotations here.’ (district manager) ‘but i think if they stay for a good while then it will have an impact, then they become useful as you’ve orientated them.’ (family physician) ‘i think after 2 4 weeks they start adding to the service.’ (family physician) junior v. senior students senior students were preferred over juniors: ‘they are final years, so they know a lot and have practical experience. orientation and adjustment quality – students 'keep you on your toes' learning environment and sta� morale • few v. many students • short v. long rotations • junior v. senior students burden extra work to teach student attitudes students have more time to listen e�ciency – extra pair of hands benefit fig. 1. a diagrammatic representation of the major themes. 58 march 2018, vol. 10, no. 1 ajhpe research they are far progressed from the junior grades, so they are very helpful. in that sense i would say they help us much more than they are a drawback.’ (medical manager) ‘it’s been nicer with the say fifth-, sixth-year students. the fourth-year students tend to be, their knowledge is a bit less, so they tend to take more of your time to teach them, but it’s been positive so far.’ (hospital clinician) number of students a number of respondents made it clear that large numbers of students could overwhelm the clinicians, and reasonable limits need to be set on the maximum number of students at any one time at each health facility. the fewer the number of students, the more individual attention they would receive, and therefore the more responsibility they could take clinically under direct supervision. large groups are difficult to co-ordinate, and they require dedicated management: ‘i think a critical mass is important – how many students per consultant or per department, and i know the university has mentioned or has got maybe bigger plans of the numbers and i have been … approached by the head of department at the tertiary institute to say well i want to send you more students, but we don’t have space. i just had to point blankly refuse, although i love to do it. i have mentioned that the time spent with them, it won’t be the same quality of time that we have seen up to now. so there is a critical mass which we will have to protect and … i am very hesitant to say that any student … more than three at a time in a department of our size will be positively affected, i think it will kind of, that’s about the limit we can handle.’ (hospital clinician) the burden of teaching the extra work involved in teaching was described as follows: ‘… they help them and teach them but in the end it is my job to make sure they do their tasks, so that takes a lot of time.’ (family physician) ‘… you feel responsible for them, so that in a sense it’s extra work … .’ (family physician) in terms of understanding the burden of students on service delivery, there were three major themes that emerged from the interviews: the extra time involved in teaching, the orientation of new groups of students and negative student attitudes. two minor themes also became apparent: students’ different learning styles and university demands. the time for teaching it is clear that students involve extra time, as explained by numerous respondents: ‘you have to think a bit more and explain more, so i think that is the biggest impact. it obviously takes extra time because you have to speak now, you can’t think of something, but i think that is the biggest impact by far.’ (family physician) ‘it does mean you must go a bit slower because you must explain to the students, you must orientate them, you must tell them you see a patient there, i’ll see a patient here. you must go slowly around this, you must explain to them or they must present to you.’ (family physician) ‘it just takes longer to do everything if you have students with you because you can’t just expect them to follow you around and absorb things. so when you have students with you, unless you ignore them, all of your activities do take a little bit longer.’ (hospital clinician) orientation and adjustment the initial period of orientation of new groups of students takes its own time: ‘… with any new project there is an adjustment phase and i think the irony, i mean it is the same period when the junior doctors, the community-service doctors also start. so the whole team could perceive or feel the burden of having more inexperienced team members, but as the year progresses the other doctors also catch on and the students become more and more confident.’ (family physician) ‘i think the first day or two you have to show them where everything is, but once they are settled in, and that’s just a couple of days, then they are part of the team and they help a lot.’ (family physician) student attitudes some of the students were perceived to have negative attitudes, or did not show enthusiasm: ‘we’ve had many like that who are not disciplined, they duck and dive, who you have to watch because it’s one thing i definitely don’t care about students, if they’re not there, i say to them they must start at 7:30, if you’re not there i’m not looking for you, but i’m not going report then that you’re gone.’ (medical manager) ‘… not the sis [student interns], i think they were fourth years or fifth years, some of them come here with an attitude, i just want to observe like in [tertiary hospital]. i know they are not here to work but sometimes you learn more if they do the thing physically themselves, but they don’t want to, they just want to observe.’ (primary healthcare manager) students differ furthermore, students vary, and some struggle with self-directed learning styles: ‘i can just imagine if it is a student that isn’t really equipped for this kind of situation, where they need to do self-study. there is absolutely no way i will be able to supervise them and you know push them to every exam.’ (family physician) ‘some students come here with a lot of confidence, but they are more work than they save us time… .’ (primary healthcare manager) university workshops take up time the demands of the university were mentioned by one participant: ‘one of the things that i find quite difficult is that we are quite often asked to attend workshops and so on by the university and i think that they actually don’t realise how pushed we are for time to get through the clinical work and so it is the sort of peripheral activities … from the university are also a significant use of time.’ (hospital clinician) benefits the benefits to service delivery of hosting students are summarised in four major themes: efficiency, quality of care, a learning environment and thoroughness. three minor themes were also identified: teamwork, community involvement and rural career choices. efficiency – an extra pair of hands students are often regarded as part of the workforce: march 2018, vol. 10, no. 1 ajhpe 59 research ‘… but having students for me i can say it is like having an extra pair of hands.’ (operational manager) ‘… it makes the flow of patients and the work lighter because they come in the mornings, they help with ward work, see patients and then present patients.’ (medical manager) ‘they basically just have to work with us and i mean that is just a boon for us.’ (family physician) ‘so you usually don’t have to from scratch work through the patients yourself, you can just have a quick look and decide whether you’re going that way or whatever. so they save a lot of time seeing patients that you don’t have to repeat.’ (medical manager) quality of care – students ‘keep you on your toes’ the students retained the respondents’ interests in their field of expertise by challenging their thoughts: ‘you have to verbalise what you are doing and thinking, and that sometimes forces you to think a bit more because you have to explain it to a student.’ (medical manager) ‘keep you on your toes, yes, that is what they really do, they keep you on your toes.’ (medical manager) ‘the doctors they are also now more alert.’ (medical manager) ‘… it keeps me challenged; i have to organise my thoughts.’ (hospital clinician) ‘when i have to suddenly take a history and examine a patient with a student around, that, terrible to admit it, but my professionalism doubles.’ (family physician) learning environment and staff morale the teaching and learning environment had a positive effect on staff morale: ‘the clinicians have to know what they are talking about because the students ask questions and they have got to know. so i think in general it uplifts the, shall i say, the knowledge base of the clinicians working in the hospital and it is good, it stimulates a type of a learning environment.’ (district manager) ‘so you are seeing in the same system, in-service training and student teaching. it must be integrated. [they are] not separate systems, you’re talking about one health system that has a teaching/learning component that can include students, not as separate entities but as part of the same thing.’ (family physician) students have more time to listen and be thorough ‘it is more efficient and quicker because they are more thorough, they work thoroughly, because they are learning they usually do it in order as it is supposed to be done.’ (primary healthcare manager) ‘she had time to talk to this patient and she sat and she actually had a long discussion with her … if i say that quality could maybe come into it because students have more time, they’re not that pressurised to work through these patients quickly.’ (district manager) ‘… one student picked up a congenital anomaly on a baby … a newborn baby … that would have been missed if it wasn’t seen by one of the doctors.’ (family physician) teamwork ‘… it’s just one day you have to take time and show them everything and then they are part of the team, they are working with us … .’ (medical manager) ‘… so they get to be part of that clinical environment and i think also the community will then recognise them as being part of the team.’ (family physician) ‘… whereby for us as nurses or for the whole team to function or to be functional is not a one-man show, it’s a team effort. so for them being around with us, or for them being here, it makes our workload easier or lighter.’ (primary healthcare manager) community engagement students are involved in community projects that contribute to service delivery indirectly by focusing on prevention and health promotion: ‘ja, ja they are involved with the community, whereby they initiate some projects. we have a project [in the] black community around here, whereby they have initiated the support groups; they run for the chronic patients whereby really if i walk around town they will be telling me that okay things are going well in the community because of their initiatives.’ (operational manager) rural career choices the long-term goal of attracting students to rural practice after they have graduated was articulated clearly: ‘… those situations and when they realise it is actually a very fulfilling job and they might, you know, go and work rural themselves.’ (medical manager) ‘… and hopefully if it is part of the experience, they would choose to stay in the public sector, in a more rural setting.’ (family physician) discussion this study has outlined a number of key issues with regard to the effect of undergraduate students on district health services in sa. the major themes, as outlined in fig. 1, give a snapshot of the balance in favour of a positive effect, depending on certain pivotal issues. it is clear from the data that the situation differs widely between different perspectives and sites, but the overall qualitative result is more in terms of benefit than burden, which is in accordance with the literature from other countries.[3,12,13] it could be argued that the burden and the benefit are not mutually exclusive categories, as every output requires some form of input. furthermore, the factors contributing to either the burden or the benefit are not additive, as this was not a quantitative study. it would seem difficult to reduce all the major themes in these results to numbers, as the model in fig. 1 might suggest, e.g. it is difficult to quantify, let alone directly compare, the general effect on staff morale and the stimulation of a learning environment against a factor such as the variety of student attitudes to learning. it was surprising how little attention was given to the eventual career choices of students, as this is one of the key motivations for initiating rural education platforms, but most of the respondents seemed to be more concerned with the immediate pressures of services rather than longer-term problems.[14-16] nevertheless, the pivotal issues of the length of rotations, seniority of students and number of students at each site are quantifiable, and are clearly within the direct control of the faculties that send the students out; therefore, in the programme design, this balance can be actively negotiated and managed.[17] some of the factors, such as the time required for teaching, could possibly be measured directly. the question of what length of time of a student rotation in a given health facility is enough to tip the balance in favour of service delivery, is indicated by some of the following results, 60 march 2018, vol. 10, no. 1 ajhpe research e.g. one of the respondents mentioned that after the first ‘2 4’ weeks of orientation, final-year students start contributing to service delivery. this question of ‘how long is enough?’ deserves further research, preferably of a quantitative nature, as worley and kitto[18] have suggested that a hypothetical ‘turning point’ lies somewhere between 4 weeks and 5 months. while such a quantification has obvious pragmatic implications for curriculum design, it would align equally with a theoretical framing in terms of management sciences and educational theory, as it would enable student teaching to be accounted for in terms of its cost. as tertiary education generally becomes more managerial in its approach, this is an inevitable factor to consider in health professions education. study limitations the limitations of the study include the small number of sites and respondents, but the inclusion of sites run by two different faculties contributes to the validity of the findings through triangulation: the data from the two sources were remarkably similar. the researchers, as academics from the faculties involved, recognised their bias in favour of the benefit of students to service delivery, and attempted to minimise this by recursive discussion of the data itself, staying close to what the respondents said. similarly, the potential bias introduced by interviewers was counteracted by using a number of trained interviewers at different sites. conclusion undergraduate students can add benefit to health services if health professions educators plan their clinical rotations, recognising the pressures under which their clinical supervisors work to deliver services to patients. we recommend that health service managers and health professions educators collaborate closely and continually to optimise the benefit of hosting students on the district health platform for educational as well as service outcomes. acknowledgements. this project was undertaken by the collaboration for health equity through education and research (cheer). the authors thank the interviewers and all the interviewees for their contributions to the study. author contributions. sr and hc conceptualised the study together with members of cheer, and dd-f collated the data. all three authors analysed the data, and sr drafted the manuscript, which all authors reviewed. funding. the study was funded through a grant from atlantic philanthropies. conflicts of interest. none. 1. kirz hl, larsen c. costs and benefits of medical student training to a health maintenance organization. jama 1986;256(6):734-739. https://doi.org/10.1001/jama.256.6.734 2. walters l, worley p, prideaux d, lange k. do consultations in rural general practice take more time when practitioners are precepting medical students? med educ 2008;42(1):69-73. https://doi.org/10.1111/j.13652923.2007.02949.x 3. price r, spencer j, walker j. does the presence of medical students affect quality in general practice consultations? med educ 2008;42(4):374-381. https://doi.org/10.1111/j.1365-2923.2008.03016.x  4. o’flynn n, spencer j, jones r. does teaching during a general practice consultation affect patient care? br j gen pract 1999;49(438):7-9. 5. atuyambe lm, baingana rk, kibira sps, et al. undergraduate students’ contributions to health service delivery through community-based education: a qualitative study by the mesau consortium in uganda. bmc med educ 2016;16(1):123. https://doi.org/10.1186/s12909-016-0626-0  6. van schalkwyk sc, bezuidenhout j, conradie hh, et al. ‘going rural’: driving change through a rural medical education innovation. rural remote health 2014;14:2493. https://doi.org/10.3109/0142159x.2012.719652  7. voss m, coetzee jf, conradie h, van schalkwyk sc . ‘we have to flap our wings or fall to the ground’: the experiences of medical students on a longitudinal integrated clinical model.  afr j health professions educ 2015;7(suppl 1):119-124. https://doi.org/10.7196/ajhpe.507 8. kraft r. service learning. educ urban soc 1996;28(2):131-159. https://doi.org/10.1177/0013124596028002001  9. kolb da. experiential learning: experience as the source of learning and development. englewood cliffs, nj: prentice hall, 1984. 10. hudson jn, poncelet an, weston km, jushnell ja, farmer ea. longitudinal integrated clerkships. med teach 2016;39(1):7-13. https://doi.org/10.1080/0142159x.2017.1245855  11. gale nk, heath g, cameron e, rashid s, redwood s. using the framework method for the analysis of qualitative data in multi-disciplinary health research. bmc med res methodol 2013;13:117. https://doi.org/10.1186/14712288-13-117 12. walters l, prideaux d, worley p, greenhill j, rolfe h. what do general practitioners do differently when consulting with a medical student? med educ 2009;43(3):268-273. https://doi.org/10.1111/j.1365-2923.2008.03276.x  13. coleman k, murray e. patients’ views and feelings on the community-based teaching of undergraduate medical students: a qualitative study. fam pract 2002;19(2):183-188. https://doi.org/10.1093/fampra/19.2.183 14. mathers j, parry j, lewis s, greenfield s. what impact will an increased number of teaching general practices have on patients, doctors and medical students? med educ 2004;38(12):1219-1228. https://doi.org/10.1111/ j.1365-2929.2004.02014.x 15. benson  j,  quince  t,  hibble  a,  fanshawe  t,  emery  j.  impact on patients of expanded, general practice based, student teaching: observational and quantitative study.  bmj 2005;331(7508):89. https://doi.org/10.1136/ bmj.38492.599606.8f 16. blitz j, bezuidenhout j, conradie h, de villiers m, van schalkwyk s. ‘i felt colonised’: emerging clinical teachers on a new rural teaching platform. rural remote health 2014;14:2511. 17. wachter rm, katz p, showstack j, bindman a. reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. jama 1998;279(19):1560-1565. https://doi.org/10.1001/jama.279.19.1560  18. worley ps, kitto p.  a hypothetical model of the financial impact of student attachments on rural general practices. rural remote health 2001;1(1):83. accepted 15 september 2017. appendix 1. interview guide 1. please tell me about your experience of undergraduate health science students in this sub-district. 2. in your opinion, what is/will be/has been the impact of having students in this sub-district on the health services? 3. is it overall a positive effect, or a negative one? 4. why? can you explain your opinion? can you give examples? 5. what do you think is the effect of having students here on: human resources in the sub-district? quality of care in the sub-district? finances in the sub-district? morale and motivation of health personnel? 6. in your opinion, has there been any change in any of these aspects since students started coming here? (note: in second round, refer back to first-round transcripts) 7. how could any of these changes be measured and quantified? 8. what documents or statistics could be used to track such changes? https://doi.org/10.1001/jama.256.6.734 † https://doi.org/10.1111/j.1365-2923.2007.02949.x https://doi.org/10.1111/j.1365-2923.2007.02949.x https://doi.org/10.1111/j.1365-2923.2008.03016.x https://doi.org/10.1186/s12909-016-0626-0 https://doi.org/10.3109/0142159x.2012.719652 https://doi.org/10.1177/0013124596028002001 http://www.tandfonline.com/author/hudson%2c+judith+nicky http://www.tandfonline.com/author/poncelet%2c+ann+n http://www.tandfonline.com/author/weston%2c+kath+m http://www.tandfonline.com/author/bushnell%2c+john+a http://www.tandfonline.com/author/a+farmer%2c+elizabeth https://doi.org/10.1080/0142159x.2017.1245855 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1186/1471-2288-13-117 https://doi.org/10.1111/j.1365-2923.2008.03276.x https://doi.org/10.1093/fampra/19.2.183 https://doi.org/10.1111/j.1365-2929.2004.02014.x https://doi.org/10.1111/j.1365-2929.2004.02014.x https://doi.org/10.1136/bmj.38492.599606.8f https://doi.org/10.1136/bmj.38492.599606.8f https://doi.org/10.1001/jama.279.19.1560 june 2018, vol. 10, no. 2 ajhpe 114 research the contribution of discipline-independent cognitive skills to achieving success in higher education is increasingly acknowledged.[1-6] these skills are considered to be ‘important for individuals both as learners in foundation education and training, and as future employees in changing and flexible work roles’.[6] referred to as key skills,[7] generic graduate attributes[8] or generic skills that underpin lifelong learning,[9] they usually relate to six broad categories of skills: number-based skills; communication skills; information and communication technology skills; the skills required to improve one’s own learning and performance; skills for problem-solving and skills for working with others.[4,10] evidence is emerging that these underpinning generic learning skills may make an important contribution to academic performance in the first year at medical school.[11,12] students experiencing academic difficulties in their first year at medical school report problems with information handling, problem solving, critical thinking and time management.[11] academically at-risk medical students have been shown to have less practice, and confidence, in generic learning skills when compared with their peers on admission to university.[12] an academic support programme, purposefully designed to incorporate generic skills development, was found to close this ‘skills gap’ over a period of 12 months. these data suggest that generic skills proficiency may be a useful indicator of academic preparedness on entry to medical school. this may be particularly important in settings where widening participation in higher education is being pursued. a number of studies on the generic skills proficiency of medical school entrants have been based on self-reported data.[12-14] this may be considered such a significant limitation of the work as to render the findings uninformative to the broader academic community. correlations between self-assessment of discipline-specific knowledge and/or skills and external measures of performance have been shown to be widely variable in many disciplines, including medicine, education, law, engineering, sports science, behavioural science, psychology, guidance counselling, dietetics, and the workplace.[15-20] the reasons why self-assessment of both domain-specific knowledge and discipline-specific skills is unreliable are well known; high performers tend to underestimate their ability, and poor performers lack both the required expertise and insight to recognise their lack of expertise, i.e. they don’t know what they don’t know.[17,20-22] what is unknown, however, is whether self-assessment of generic learning skills, which are not discipline-specific, is subject to the same major limitations. in south africa (sa), 17 of 26 public higher education institutions currently use the national benchmark tests (nbts), alongside the national senior certificate and other high school-leaving examination results, to admit students who are likely to succeed at university.[23-29] the nbts are a set of criterion-referenced pre-university admission aptitude tests, similar to pre-admission aptitude tests written in the uk (uk clinical aptitude test),[30-32] the usa (north american medical college admission test),[33,34] australia (australian graduate medical school admissions test)[35] and background. strong generic learning skills may improve academic performance at medical school. studies evaluating the generic learning skills proficiency of medical students use self-reported data. it is not known whether self-evaluation of discipline-independent skills exhibits the same problems of widely variable accuracy as self-assessment of discipline-related skills. objective. to investigate whether the self-reported generic learning skills proficiency of medical school entrants was related to three objective measures of performance: pre-university admission aptitude-test scores, information technology (it) proficiency on entry and early academic performance at university. methods. this prospective study used a previously validated 31-item questionnaire to document the self-reported proficiency of medical school entrants (2011 2013) with regard to 6 categories of generic learning skills: information handling, technical and numeracy, computer, organisational, managing self-learning and presentation skills. the results of the questionnaire were compared with performance in pre-university admission aptitude tests, an it placement test on entry and end-of-semester 1 examinations (after 6 months at university), which are the basis for promotion to semester 2. results. a total of 640 of 648 (98.8%) students completed the questionnaire. self-reported generic learning skills proficiency was found to be significantly related to pre-university admission aptitude test scores (medium effect size), it proficiency on entry to university (large effect size) and early academic performance at university (small effect size). academically weak students did not overestimate their skills proficiency. conclusion. these findings support the opinion that self-reported generic skills proficiency can credibly contribute to determining the academic preparedness of medical school entrants. afr j health professions educ 2018;10(2):114-123. doi:10.7196/ajhpe.2018.v10i2.971 self-reported generic learning skills proficiency: another measure of medical school preparedness v c burch,1 mb bch, mmed, phd, fcp, frcp; c n t sikakana,2 bsc, phd; g d gunston,3 mb chb, mphil ed; d murdoch-eaton,4 mbbs, md, frcpch 1 department of medicine, faculty of health sciences, university of cape town, south africa 2 division of medical biochemistry, faculty of health sciences, university of cape town, south africa 3 department of human biology, faculty of health sciences, university of cape town, south africa 4 medical school, faculty of medicine, dentistry and health, university of sheffield, uk corresponding author: g d gunston (geney.gunston@uct.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 115 june 2018, vol. 10, no. 2 ajhpe research other countries such as chile, pakistan and saudi arabia.[36-38] these tests provide information about school-leavers that is supplementary to their pre-university academic achievements. as shown in tables 1 a and b, the nbts assess skills competency in three domains, namely academic literacy, quantitative literacy and mathematics.[29] the results are aggregated into three performance bands (proficient, intermediate and basic), which provide an indication of applicants’ academic preparedness and likely need for early academic support at university. the university of cape town (uct) medical school accepts applicants who fall into the first two bands. additionally, uct uses a locally designed information technology (it) placement test to identify medical school entrants who require additional intensive introductory it training prior to starting semester 1. the semester 1 academic programme at uct medical school consists of four courses: chemistry, physics, introduction to integrated health sciences (hub1006f), and becoming a professional (bp).[39] hub1006f introduces students to key physical, psychological, social and developmental concepts that shape the human life cycle from conception to death, via strategically designed problem-based learning cases. during this course, students gain an introductory overview of the human lifespan, and core disciplinespecific knowledge and skills including anatomy, physiology, psychology and sociology. bp aims to promote the conduct, knowledge, attitudes and values associated with being a professional and a professional team member. students develop a range of skills, including interpersonal, interviewing and leadership skills, in addition to critical analysis and reflection on professional conduct, diversity, health and human rights. end of semester-1 examination results comprise the results of these four courses. the purpose of this study was to determine whether the self-reported generic learning skills proficiency of medical school entrants was related to objective measures of performance, specifically: pre-university admission aptitude test scores (nbts), it proficiency on admission to university (it placement test), and academic performance after the first 6 months at university (end of semester-1 examination results, which are the basis for promotion to semester 2). demonstrating a relationship between self-reported generic learning skills proficiency and objective measures of performance would be of international interest because it would support the hypothesis that selfassessment of such skills, which are discipline-independent, may be a credible way of determining academic preparedness for university, and table 1 b. interpretation of benchmark levels in the three domain areas of the national benchmark tests (nbts)[29] benchmark performance band (level) performance band (level) descriptor proficient performance in domain areas suggests that academic performance will not be adversely affected. if admitted, students should be placed on regular programmes of study. intermediate challenges in domain areas identified such that it is predicted that academic progress will be affected. if admitted, students’ educational needs should be met in a way deemed appropriate by the institution (e.g. extended or augmented programmes, special skills provision). basic serious learning challenges identified: it is predicted that students will not cope with degree-level study without extensive and long-term support, perhaps best provided through bridging programmes or fet colleges. institutions registering students performing at this level would need to provide such support. fet = further education and training. fet colleges offer vocational and occupational courses which provide education and training with a specific range of jobs or employment possibilities. table 1 a. skills assessed in the three domain areas of the national benchmark tests (nbts)[29] academic literacy quantitative literacy mathematics making meaning from academic text understanding vocabulary related to academic study evaluating evidence used to support claims made by writers extrapolating and drawing inferences and conclusions from text differentiating main idea from supporting ideas in the overall and specific organisation of a passage identifying text differences as related to the writers’ purposes, audiences and forms of communication understanding how syntax and punctuation are used to express meaning understanding basic numerical concepts used in text applying quantitative procedures and reasoning in symbolic and non-symbolic situations applying information from a variety of tables, graphs, charts and text integrating information obtained from multiple sources performing multiple-step calculations using information presented with text, symbols and graphs identifying trends and patterns in various situations applying properties of simple geometric shapes to determine measurements interpreting quantitative information presented verbally, symbolically and graphically understanding and applying properties of the real number system, including surds and exponents recognising and using patterns, including sequences and series applying relationships such as ratios and percentages in a variety of contexts applying the results of algebraic manipulations with equations and inequalities understanding the function concept and identifying properties of functions interpreting transformations of functions represented algebraically or graphically identifying relationships between graphs and their equations, or inequalities and the regions they describe applying trigonometric identities and concepts in solving problems understanding properties and interpreting representations of 2and 3-dimensional shapes applying principles of analytic geometry interpreting various representations and measures of data using logical skills in making deductions determining the validity of given assertions june 2018, vol. 10, no. 2 ajhpe 116 research the importance of generic learning skills in achieving success in higher education.[1,5,6] methods study participants this was a prospective study of students entering year 1 of the uct mb chb programme during 2011 2013. survey instrument data were collected using a 31-item generic learning skills questionnaire previously validated in the sa context and shown to be reliable (cronbach’s α = 0.88).[14] the clustering of the skills into 6 categories (informationhandling skills, technical and numeracy skills, computer skills, organisational skills, managing self-learning skills and presentation skills) was verified using factor analysis.[40] this questionnaire reports on learning skills proficiency in terms of: (i) frequency of practice of each of the 31 skills during the 12 months preceding entry into medical school, using a 4-point scale ranging from 1 (never) to 4 (every week), and (ii) level of self-confidence in performing these skills, using a 4-point rating scale from 1 (little or no experience), 2 (basic but i sometimes need help), 3 (enough for my needs) to 4 (more than i need, i often help others). procedure on the first day of semester 1, at the end of the whole-class orientation session, all first-year medical students were fully briefed on the generic skills research project by the researcher, and given the opportunity to ask questions. consenting students completed a specially designed paper-andpencil version of the questionnaire, which was handed to the researcher prior to leaving the venue. the data from the completed self-assessment questionnaires were electronically captured using a digital scanning process, and imported into excel (microsoft, usa) spreadsheets for analysis. student data included the nbt scores, it placement test scores and end of semester-1 examination results. all student data were obtained from student records kept in the undergraduate office at uct medical school, and entered onto an excel spreadsheet for analysis. all spreadsheets were manually checked for completeness prior to commencing data analysis. data analysis comparisons were made between the generic skills proficiency of students defined in three categories, according to student performance: (i) likely academic performance at university, as defined by two nbt benchmark performance bands (table 1 b): intermediate (likely to require additional academic support), v. proficient (unlikely to need additional academic support) (ii) it proficiency, as determined by it placement test performance: <60% = not proficient (requires intensive introductory training prior to start of formal classes), v. ≥60% = proficient (introductory training not needed) (iii) early academic performance at university, as reflected by end of semester-1 examination results: <60% (poor academic performance) v. ≥60% (good academic performance). statistical analysis descriptive statistical and correlation analyses were performed using graphpad prism 6 (graphpad software inc., usa). means were compared using the unpaired t-test; where data sets showed unequal variance, the welch correction was used. a p-value <0.05 was considered significant. the effect size for the means compared was calculated using a pooled standard deviation, which took into account the difference in size of the groups compared.[41] the human research ethics committee of the faculty of health sciences, uct (ref. no. 509/2013), and the educational research ethics committee of the faculty of medicine and health, university of leeds, uk (ref. no. 0607/ dme/skills), approved the study. results a total of 640 of the 648 (98.8%) students enrolled during the study period completed the survey. fig. 1 shows the interrelationships between selfreported generic skills proficiency and the three objective measures of performance (nbt, it placement test and semester 1 examinations). the figure summarises the effect size data presented in tables 2 5. tables 2 a c compare students in the intermediate and proficient nbt performance bands for academic literacy, quantitative literacy and mathematics, with respect to performance in the it placement test and semester 1 examinations. overall, students in the proficient band performed significantly better than those in the intermediate band. eighty percent of the effect sizes (12/15) were large or very large (≥0.75), and 20% (3/15) were medium (0.45 0.74). tables 3 a c compare students in the intermediate and proficient nbt performance bands for academic literacy, quantitative literacy and mathematics with respect to frequency of practice of, and confidence in, six categories of generic learning skills. mostly, students in the proficient band reported significantly more frequent practice. the exceptions were non-significant differences between students in the two bands with respect to the frequency of practice of managing self-learning skills for all nbt components, and information handling for mathematics. while most (72%) effect sizes were small, that for academic literacy in relation to computer national benchmark tests *not relevant to the purpose of the study. semester 1 examinations la rg e (t ab le s 2 a c an d 4 a d ) n ot evaluated* very large (tables 4 a d) sm al l ( ta b le s 5 a e) generic skills pro�ciency me diu m ( tab les 3 a c ) medium (tables 5 a e) it placement test fig. 1. interrelationships between generic skills proficiency and performance prior to admission to university (nbt performance), on admission to university (it placement test) and after 6 months at university (end of semester-1 examinations). overall effect size of significant relationships and reference to the relevant data tables in the text are included. 117 june 2018, vol. 10, no. 2 ajhpe research table 2 a. comparison of assessment outcomes for academic literacy: on entry (it) and at end of semester 1 for mb chb i students in intermediate and proficient nbt performance bands assessment mean score, % (95% ci) (n=640) effect size, d* p-value†intermediate (n=108) proficient (n=532) mean difference it placement test 56.3 (51.6 60.9) 77.4 (76.2 78.6) 21.14 1.60 <0.001 chemistry examination 54.2 (52.1 56.2) 62.3 (61.1 63.4) 8.08 0.63 <0.00 physics examination 55.7 (53.6 57.9) 65.7 (64.5 66.9) 9.96 0.77 <0.001 hub1006f examination 56.7 (55.1 58.4) 67.6 (66.8 68.3) 10.83 1.19 <0.001 bp examination 68.6 (67.5 69.8) 74.0 (73.5 74.5) 5.36 0.99 <0.001 nbt = national benchmark test; hub1006f = introduction to health sciences part i; bp = becoming a professional. *effect size: <0.2 very small, ≥ 0.2 small, ≥ 0.45 medium, ≥ 0.75 large and ≥ 76 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 2 b. comparison of assessment outcomes for quantitative literacy: on entry (it) and at end of semester 1 for mb chb i students in the intermediate and proficient nbt performance bands assessment event mean score, % (95% ci) (n=640) intermediate (n=209) proficient (n=431) mean difference effect size, d* p-value† it placement test 64.3 (61.2 67.3) 78.8 (77.4 80.1) 14.50 1.06 <0.001 chemistry examination 53.8 (52.4 55.3) 64.3 (63.1 65.6) 10.53 0.87 <0.001 physics examination 55.6 (54.2 57.1) 68.1 (66.9 69.4) 12.52 1.03 <0.001 hub1006f examination 59.8 (58.6 60.9) 68.6 (67.7 69.5) 8.82 0.97 <0.001 bp examination 70.6 (69.9 71.4) 74.3 (73.8 74.8) 3.68 0.67 <0.001 nbt = national benchmark test; hub1006f = introduction to health sciences part i; bp = becoming a professional. *effect size: < 0.2 very small, ≥ 0.2 small, ≥ 0.45 medium, ≥ 0.75 large and ≥ 1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 2 c. comparison of assessment outcomes for mathematics: on entry (it) and at end of semester 1 for mb chb i students in intermediate and proficient nbt performance bands assessment mean score, % (95% ci) (n=640) effect size, d* p-value†intermediate (n=273) proficient (n=367) mean difference it placement test 66.5 (64.1 68.9) 80.3 (79.0 81.7) 13.86 1.01 <0.001 chemistry examination 53.3 (52.1 54.5) 66.5 (65.2 67.8) 13.24 1.17 <0.00 physics examination 55.5 (54.3 56.7) 70.3 (69.1 71.7) 14.91 1.32 <0.001 hub1006f examination 60.5 (59.5 61.5) 69.6 (68.7 70.6) 9.11 1.02 <0.001 bp examination 71.1 (70.5 71.7) 74.6 (74.0 75.2) 3.53 0.64 <0.001 nbt = national benchmark test; hub1006f = introduction to health sciences part i; bp = becoming a professional. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥76 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 3 a. comparison of mean generic learning skills category ratings for mb chb i students in the intermediate and proficient nbt performance bands for academic literacy mean rating of generic learning skills category (95% ci) (n=640) generic learning skills category on entry intermediate (n=108) proficient (n=532) mean difference effect size, d* p-value frequency of practice information handling 3.18 (3.07 3.30) 3.46 (3.43 3.50) 0.28 0.60 <0.001† technical and numeracy 2.92 (2.82 3.03) 3.16 (3.12 3.20) 0.24 0.48 <0.001† computer skills 2.72 (2.56 2.87) 3.24 (3.20 3.29) 0.53 0.89 <0.001† organisational skills 3.54 (3.44 3.63) 3.73 (3.69 3.77) 0.19 0.41 0.001 managing self-learning 3.43 (3.35 3.51) 3.46 (3.43 3.50) 0.03 0.07 ns presentation skills 2.67 (2.56 2.78) 2.90 (2.85 2.94) 0.22 0.43 <0.001 confidence information handling 2.74 (2.63 2.85) 3.14 (3.09 3.18) 0.40 0.76 <0.001 technical and numeracy 2.68 (2.56 2.79) 3.02 (2.98 3.07) 0.35 0.65 <0.001 computer skills 2.52 (2.37 2.67) 3.13 (3.07 3.18) 0.61 0.94 <0.001† organisational skills 3.06 (2.95 3.17) 3.29 (3.24 3.34) 0.23 0.42 <0.001 managing self-learning 3.09 (2.98 3.19) 3.21 (3.17 3.25) 0.12 0.26 <0.05† presentation skills 2.46 (2.34 2.58) 2.87 (2.82 2.92) 0.41 0.73 <0.001 nbt = national benchmark test; ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance: p-value recalculated using welch correction for unequal variance. june 2018, vol. 10, no. 2 ajhpe 118 research table 3 b. comparison of mean generic learning skills category ratings for mb chb i students in the intermediate and proficient nbt performance bands for quantitative literacy mean rating of generic learning skills category (95% ci) (n=640) generic learning skills category on entry intermediate (n=108) proficient (n=532) mean difference effect size, d* p-value† frequency of practice information handling 3.31 (3.24 3.38) 3.47 (3.43 3.51) 0.16 0.33 <0.001† technical and numeracy 2.97 (2.90 3.05) 3.19 (3.15 3.24) 0.22 0.44 <0.001† computer skills 2.88 (2.78 2.98) 3.28 (3.24 3.33) 0.41 0.68 <0.001† organisational skills 3.63 (3.56 3.70) 3.73 (3.68 3.77) 0.09 0.20 <0.05 managing self-learning 3.42 (3.36 3.48) 3.47 (3.43 3.51) 0.06 0.14 ns presentation skills 2.75 (2.67 2.82) 2.91 (2.87 2.96) 0.17 0.32 <0.001 confidence information handling 2.85 (2.77 2.92) 3.18 (3.13 3.23) 0.33 0.63 <0.001 technical and numeracy 2.74 (2.66 2.82) 3.07 (3.02 3.12) 0.33 0.63 <0.001† computer skills 2.71 (2.60 2.81) 3.18 (3.12 3.23) 0.47 0.73 <0.001† organisational skills 3.13 (3.05 3.21) 3.31 (3.26 3.36) 0.18 0.33 <0.001† managing self-learning 3.11 (3.04 3.18) 3.23 (3.18 3.27) 0.11 0.25 <0.01 presentation skills 2.60 (2.52 2.68) 2.90 (2.85 2.95) 0.30 0.52 <0.001 nbt = national benchmark test; ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance: p-value recalculated using welch correction for unequal variance. table 3 c. comparison of mean generic learning skills category ratings for mb chb i students in the intermediate and proficient nbt performance bands for mathematics mean rating of generic learning skills category (95% ci) (n=640) generic learning skills category on entry intermediate (n=108) proficient (n=532) mean difference effect size, d* p-value frequency of practice information handling 3.38 (3.32 3.44) 3.44 (3.39 3.49) 0.06 0.12 ns† technical and numeracy 3.03 (2.97 3.09) 3.19 (3.14 3.24) 0.16 0.32 <0.001 computer skills 3.00 (2.90 3.07) 3.27 (3.22 3.33) 0.28 0.47 <0.001† organisational skills 3.63 (3.57 3.69) 3.74 (3.70 3.79) 0.11 0.24 <0.05† managing self-learning 3.44 (3.39 3.50) 3.46 (3.42 3.51) 0.02 0.05 ns presentation skills 2.77 (2.71 2.84) 2.93 (2.87 2.98) 0.15 0.29 <0.001 confidence information handling 2.88 (2.82 2.90) 3.21 (3.16 3.26) 0.32 0.62 <0.001 technical and numeracy 2.77 (2.70 2.84) 3.11 (3.06 3.16) 0.33 0.64 <0.001† computer skills 2.78 (2.69 2.87) 3.21 (3.15 3.27) 0.43 0.66 <0.001† organisational skills 3.14 (3.07 3.21) 3.33 (3.28 3.39) 0.19 0.35 <0.001 managing self-learning 3.15 (3.08 3.21) 3.22 (3.18 3.26) 0.07 0.16 ns† presentation skills 2.64 (2.57 2.71) 2.92 (2.86 2.98) 0.28 0.50 <0.001 nbt = national benchmark tests; ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance: p-value recalculated using welch correction for unequal variance. table 4 a. comparison of pre-university nbt assessment outcomes v. entry it placement test and semester 1 assessment outcomes for chemistry nbt domain it placement test assessment on entry end of semester-1 assessment outcomes: chemistry examination mean percentage score (95% ci) (n=414) effect size, d* p-value mean percentage score (95% ci) (n=602) effect size, d* p-value<60% (n=58 ) ≥60% (n=356) <60% (n=282) ≥60% (n=320) academic literacy 61.6 (58.9 64.4) 74.8 (73.9 75.6) 1.58 <0.001† 70.0 (68.8 71.1) 75.9 (75.0 76.8) 0.65 <0.001† quantitative literacy 54.7 (51.3 58.1) 74.0 (72.6 75.4) 1.45 <0.001 64.8 (63.2 66.4) 77.7 (76.4 79.0) 1.00 <0.001† mathematics 51.6 (48.7 54.5) 65.2 (63.6 66.7) 0.94 <0.001† 57.0 (55.4 58.5) 72.3 (70.8 73.8) 1.16 <0.001 nbt = national benchmark tests. *effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥ 1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. 119 june 2018, vol. 10, no. 2 ajhpe research skills (6%) was large. the effect sizes for academic literacy in relation to information-handling and technical and numeracy skills, and those for quantitative literacy and mathematics in relation to computer skills (22%), were medium. in general, students in the proficient band reported significantly more confidence than those in the intermediate. the exception was the non-significant difference in confidence in managing self-learning skills between students in the two bands for mathematics. while most (55%) effect sizes were medium, those for academic literacy in relation to information-handling and computer skills (11%) were large. all effect sizes (33%) in relation to organisational skills and managing self-learning were small. tables 4 a d compare students’ results in the it placement test or semester 1 examinations with their performance in the nbts. mostly, students who achieved a good pass (≥60%) in the it placement test or semester 1 examinations had performed significantly better in the nbts. seventy-three percent of the effect sizes (11/15) were large or very large, and 27% (4/15) were medium. tables 5 a e compare students’ results in the it placement test or semester 1 examinations with their frequency of practice of, and confidence in, the six generic learning skills categories. in general, students who achieved a good pass reported significantly more frequent practice. the exceptions were the non-significant differences between strong and weak performers in the frequency of practice of managing self-learning skills for the it placement test or any semester 1 examinations, presentation skills for chemistry or hub1006f and information-handling skills for chemistry, physics or hub1006f. while most (87%) effect sizes were small, that for the it placement test in relation to computer skills (3%) was very large. the effect sizes for the it placement test in relation to technical and numeracy skills, and for hub1006f and bp in relation to computer skills (10%) were medium. in general, students who achieved a good pass reported significantly more confidence. the exceptions were the non-significant differences in confidence in managing self-learning skills between strong and weak performers in the it placement test or chemistry. most effect sizes (63%) were small, but those for the it placement test in relation to technical and numeracy skills and computer skills (7%) were large or very large. the effect sizes for the it placement test in relation to information handling, organisational and presentation skills; physics in relation to information handling, technical and numeracy, and computer skills; hub1006f in relation to computer skills; and bp in relation to information-handling and computer skills (30%) were medium. correlation analyses were also performed for all the variables presented in tables 2 5. in 87% (110/126) of comparisons, correlation coefficients table 4 b. comparison of pre-university nbt assessment outcomes v. entry it placement test and semester 1 assessment outcomes for physics nbt domain it placement test assessment on entry end of semester-1 assessment outcomes: physics examination mean percentage score (95% ci) (n=414) effect size, d* p-value mean percentage score (95% ci) (n=607) effect size, d* p-value<60% (n=58 ) ≥60% (n=356) <60% (n=235) ≥60% (n=372) academic literacy 61.6 (58.9 64.4) 74.8 (73.9 75.6) 1.58 <0.001† 69.7 (68.5 71.0) 75.3 (74.4 76.2) 0.61 <0.001 quantitative literacy 54.7 (51.3 58.1) 74.0 (72.6 75.4) 1.45 <0.001 63.1 (61.5 64.8) 77.0 (75.6 78.3) 1.08 <0.001 mathematics 51.6 (48.7 54.5) 65.2 (63.6 66.7) 0.94 <0.001† 55.3 (53.8 56.9) 71.0 (69.6 72.4) 1.19 <0.001† nbt = national benchmark tests. *effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 4 c. comparison of pre-university nbt assessment outcomes v. entry it placement test and semester 1 assessment outcomes for hub1006f nbt domain it placement test assessment on entry end of semester-1 assessment outcomes: hub1006f examination mean percentage score (95% ci) (n=414) effect size, d* p-value mean percentage score (95% ci) (n=635) effect size, d* p-value<60% (n=58 ) ≥60% (n=356) <60% (n=170) ≥60% (n=465) academic literacy 61.6 (58.9 64.4) 74.8 (73.9 75.6) 1.58 <0.001† 66.9 (65.3 68.5) 75.5 (74.8 76.2) 1.00 <0.001† quantitative literacy 54.7 (51.3 58.1) 74.0 (72.6 75.4) 1.45 <0.001 63.5 (61.2 65.7) 75.0 (73.8 76.1) 0.86 <0.001 mathematics 51.6 (48.7 54.5) 65.2 (63.6 66.7) 0.94 <0.001† 55.7 (53.8 57.7) 68.4 (67.1 69.8) 0.89 <0.001 nbt = national benchmark tests; hub1006f = introduction to health sciences part i. *effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 4 d. comparison of pre-university nbt assessment outcomes v. entry it placement test and semester 1 assessment outcomes for bp nbt domain it placement test assessment on entry end of semester-1 assessment outcomes: bp examination mean percentage score (95% ci) (n=414) effect size, d* p-value mean percentage score (95% ci) (n=455) effect size, d* p-value<60% (n=58 ) ≥60% (n=356) <60% (n=160) ≥60% (n=465) academic literacy 61.6 (58.9 64.4) 74.8 (73.9 75.6) 1.58 <0.001† 67.8 (66.0 69.5) 75.3 (74.6 76.0) 0.85 <0.001† quantitative literacy 54.7 (51.3 58.1) 74.0 (72.6 75.4) 1.45 <0.001 66.1 (63.7 68.5) 74.4 (73.5 75.6) 0.60 <0.001† mathematics 51.6 (48.7 54.5) 65.2 (63.6 66.7) 0.94 <0.001† 59.7 (57.4 62.1) 67.4 (66.1 68.8) 0.52 <0.001 nbt = national benchmark tests; bp = becoming a professional. *effect size: <0.1 is very small, ≥0.2 is small, ≥0.45 is medium, ≥0.75 is large and ≥1 is very large. †unequal variance; p-value recalculated using welch correction for unequal variance. june 2018, vol. 10, no. 2 ajhpe 120 research reflected the effect sizes as follows: small effect sizes had r-values <0.25; medium effect sizes had r-values 0.25 0.40, and large effect sizes had r-values >0.4 (data not shown). discussion this study showed that the self-reported practice of and confidence in generic learning skills proficiency of first-year medical students was related to three objective measures of performance: pre-university admission aptitude test scores, it proficiency on entry to university and early academic performance at university. since these findings are based on self-assessment data, the credibility of which is often contested in the medical education literature,[15-20] it is essential to substantiate our findings before discussing their significance. factors which are known to influence the accuracy of self-assessment data, including the nature of the self-assessment task, and the characteristics of the rating scales used,[42] are specifically addressed. regarding the nature of the task, it is essential to recognise that the students in this study were asked to self-assess their generic learning skills proficiency rather than discipline-specific skills. this is important, because the challenges that students face when self-assessing discipline-specific skills were not relevant to this task. these challenges include students’ rudimentary understanding of the knowledge required to perform discipline-specific tasks proficiently,[22] the longstanding debate about the extent (breadth and depth) of profession-specific expertise required of medical graduates, i.e. curriculum content and overload,[43,44] and the observation that experts continue to display ‘disturbing discrepancies in their judgements of how much knowledge is enough’.[45] it is not, therefore, surprising that students may struggle to have a clear idea of discipline-specific proficiency and whether they have table 5 a. comparison of mean generic learning skills category ratings v. entry it placement test results for mb chb i students generic learning skills category on entry mean rating of generic learning skills category (95% ci) (n=414) effect size, d* p-value<60% (n=58) ≥60% (n=356) frequency of practice information handling 3.30 (3.17 3.42) 3.45 (3.40 3.50) 0.34 <0.05 technical and numeracy 2.95 (2.83 3.08) 3.19 (3.15 3.24) 0.53 <0.001 computer skills 2.42 (2.22 2.62) 3.23 (3.17 3.28) 1.45 <0.001† organisational skills 3.57 (3.46 3.68) 3.75 (3.70 3.79) 0.40 <0.01 managing self-learning 3.48 (3.36 3.59) 3.45 (3.41 3.50) – 0.06 ns presentation skills 2.73 (2.59 2.87) 2.89 (2.84 2.94) 0.34 <0.05 confidence information handling 2.75 (2.59 2.90) 3.13 (3.08 3.19) 0.72 <0.001 technical and numeracy 2.65 (2.50 2.79) 3.04 (2.99 3.09) 0.78 <0.001 computer skills 2.24 (2.06 2.42) 3.11 (3.05 3.17) 1.46 <0.001 organisational skills 3.05 (2.91 3.18) 3.31 (3.26 3.37) 0.49 <0.001 managing self-learning 3.09 (2.93 3.24) 3.20 (3.15 3.25) 0.24 ns presentation skills 2.49 (2.34 2.63) 2.87 (2.82 2.93) 0.72 <0.001 ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 5 b. comparison of mean generic learning skills category ratings v. end of semester-1 examination results for chemistry generic learning skills category on entry mean rating of generic learning skills category (95% ci) (n=602) effect size, d* p-value<60% (n=282) ≥60% (n=320) frequency of practice information handling 3.36 (3.30 3.42) 3.43 (3.38 3.48) 0.14 ns† technical and numeracy 3.03 (2.97 3.09) 3.15 (3.10 3.21) 0.25 <0.01 computer skills 3.01 (2.93 3.09) 3.21 (3.15 3.27) 0.33 <0.001† organisational skills 3.62 (3.57 3.68) 3.74 (3.69 3.79) 0.25 <0.01 managing self-learning 3.43 (3.37 3.48) 3.48 (3.44 3.52) 0.13 ns presentation skills 2.81 (2.75 2.87) 2.87 (2.81 2.92) 0.11 ns confidence information handling 2.96 (2.90 3.02) 3.16 (3.10 3.22) 0.36 <0.001 technical and numeracy 2.83 (2.76 2.90) 3.05 (3.00 3.11) 0.42 <0.001 computer skills 2.86 (2.77 2.95) 3.12 (3.05 3.19) 0.38 <0.001† organisational skills 3.19 (3.12 3.25) 3.31 (3.25 3.37) 0.22 <0.01 managing self-learning 3.15 (3.09 3.21) 3.21 (3.16 3.26) 0.13 ns presentation skills 2.70 (2.64 2.77) 2.85 (2.79 2.92) 0.26 <0.01 ns = not significant. *effect size: <0.2 is very small, ≥0.2 is small, ≥0.45 is medium, ≥0.75 is large and ≥1 is very large. †unequal variance; p-value recalculated using welch correction for unequal variance. 121 june 2018, vol. 10, no. 2 ajhpe research achieved it. the same, however, is not true of discipline-independent generic learning skills. furthermore, the self-assessment process in this study reported on students’ prior experience of performing objective, well-defined, familiar activities, such as answering emails, or finding information on the internet. self-assessment of such activities has been shown to be better aligned with objective performance data.[17,20,46,47] in addition, the skills self-assessed in this study were largely ‘observable’, and, like language proficiency and sports performance, can be more accurately self-assessed than cognitive skills such as clinical reasoning.[20] this point is well illustrated in our study, where sudents who performed poorly in the it placement test appropriately rated themselves as less experienced and confident in their computer skills. this finding also suggests that poor performers may recognise their limitations if self-assessment tasks focus on familiar, observable, non-cognitive skills. a significant problem with self-assessment studies is the variable use of rating scales by participants.[42] in our study, this limitation was addressed by using rating scales that were comparative (to peers), quantitative and objectively anchored. such scales have been shown to yield more robust self-assessment data.[46,47] peer comparison probably served as an indirect source of feedback, which is known to further enhance the accuracy of self-assessment of skills.[17,46] for example, students who rated themselves as ‘know more than i need – i often assist others’ were more likely to have been approached repeatedly for help by peers who recognised their ability based on prior performance. having addressed the key potential limitation of this study, the salient findings can now be discussed. overall, they show that the relationship effect sizes for students’ self-reported confidence in their generic learning skills v. their academic results were greater than for self-reported frequency table 5 c. comparison of mean generic learning skills category ratings v. end of semester-1 examination results for physics generic learning skills category on entry mean rating of generic learning skills category (95% ci) (n=602) effect size, d* p-value<60% (n=282) ≥60% (n=320) frequency of practice information handling 3.37 (3.30 3.44) 3.42 (3.38 3.47) 0.11 ns† technical and numeracy 3.01 (2.95 3.08) 3.17 (3.12 3.22) 0.31 <0.001 computer skills 2.99 (2.90 3.08) 3.20 (3.15 3.26) 0.35 <0.001† organisational skills 3.61 (3.54 3.67) 3.74 (3.70 3.79) 0.29 <0.001† managing self-learning 3.42 (3.36 3.47) 3.47 (3.43 3.51) 0.13 ns presentation skills 2.77 (2.70 2.84) 2.89 (2.83 2.94) 0.21 <0.05 confidence information handling 2.91 (2.84 2.98) 3.17 (3.11 3.22) 0.48 <0.001 technical and numeracy 2.78 (2.71 2.86) 3.07 (3.02 3.12) 0.55 <0.001† computer skills 2.81 (2.72 2.91) 3.12 (3.06 3.18) 0.46 <0.001† organisational skills 3.14 (3.07 3.21) 3.33 (3.27 3.38) 0.34 <0.001 managing self-learning 3.13 (3.07 3.19) 3.22 (3.17 3.27) 0.19 <0.05 presentation skills 2.67 (2.59 2.74) 2.87 (2.81 2.92) 0.35 <0.001 ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. table 5 d. comparison of mean generic learning skills category ratings v. end of semester-1 examination results for hub1006f generic learning skills category on entry mean rating of generic learning skills category (95% ci) (n=635) effect size, d* p-value<60% (n=170) ≥60% (n=465) frequency of practice information handling 3.35 (3.27 3.44) 3.44 (3.40 3.48) 0.18 ns technical and numeracy 3.03 (2.94 3.11) 3.16 (3.11 3.20) 0.25 <0.01† computer skills 2.95 (2.83 3.06) 3.23 (3.18 3.27) 0.46 <0.001† organisational skills 3.59 (3.51 3.66) 3.73 (3.69 3.77) 0.31 <0.001 managing self-learning 3.43 (3.36 3.50) 3.47 (3.43 3.51) 0.09 ns presentation skills 2.81 (2.73 2.89) 2.88 (2.83 2.93) 0.13 ns confidence information handling 2.94 (2.85 3.03) 3.12 (3.07 3.17) 0.34 <0.001 technical and numeracy 2.83 (2.74 2.92) 3.01 (2.97 3.06) 0.34 <0.001 computer skills 2.79 (2.67 2.91) 3.11 (3.05 3.17) 0.48 <0.001† organisational skills 3.15 (3.07 3.23) 3.29 (3.24 3.34) 0.25 <0.01 managing self-learning 3.12 (3.05 3.20) 3.21 (3.17 3.25) 0.19 <0.05 presentation skills 2.68 (2.59 2.77) 2.85 (2.80 2.90) 0.30 <0.01 hub1006f = introduction to health sciences part i; ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. june 2018, vol. 10, no. 2 ajhpe 122 research of practice v. academic results. this makes sense, because practical skill proficiency is influenced by many factors other than frequency of practice. it is noteworthy that generally, the effect sizes were small for organisational skills, and largely insignificant for managing self-learning skills. this also makes sense, because such skills are unlikely to significantly influence aptitude test (nbts) performance or it proficiency, and the limited curriculum load in first year may not require well-developed organisational and self-learning management skills. these skills may, however, become more important in later years of study, where the large volume of work is likely to require them. this merits further exploration. internationally, there is a call for more studies aimed at determining the content and format of academic support programmes that promote sustained academic success.[48] the work presented in this article supports a focus on generic learning skills development, in addition to discipline-specific knowledge and skills learning, in such programmes.[12] the questionnaire used in the study may facilitate the conceptualisation of academic support programmes that better suit students’ needs, and direct timeous allocation of extra resources on a needs rather than ad hoc basis that may jeopardise the sustainability of such programmes. since the questionnaire is free and easy to administer, it may be particularly attractive in limited-resource settings where strategies for providing early academic support are likely to be most needed. while the findings of this study are limited to one institution, the results are encouraging, and the sample size was sufficiently large to provide meaningful data. this provides a clear mandate to conduct a multicentre study. the results also support the idea that self-assessed generic skills proficiency may be a welcome addition to university admissions and academic placement processes, to determine the academic preparedness of students from diverse backgrounds, and to further support efforts to improve the social mobility of all sectors of society.[49] acknowledgements. the authors would like to acknowledge vanessa gray from the university of leeds for her assistance with data processing. author contributions. gdg gathered the generic learning skills data provided by consenting students on a specially designed paper-and-pencil version of the questionnaire. the data were electronically captured using a digital scanning process, and imported into excel (microsoft, usa) spreadsheets for analysis (dm-e). student data (nbt scores, it placement test scores and end of semester-1 examination results) were obtained from student records kept in the undergraduate office at uct medical school, and entered onto an excel spreadsheet for analysis. all spreadsheets were manually checked for completeness prior to commencing data analysis (vb and cs). all authors contributed to the review of literature, discussion of results and writing of the article. funding. travel expenses for dm-e and some administrative and data processing in the uk were supported by dm-e’s national teaching fellowship awarded by the higher education 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2012;34(12):1033-1046. https://doi.org/10 .3109/0142159x.2012.706338 table 5 e. comparison of mean generic learning skills category ratings v. end of semester-1 examination results for bp generic learning skills category on entry mean rating of generic learning skills category (95% ci) (n=615) effect size, d* p-value<60% (n=160) ≥60% (n=465) frequency of practice information handling 3.25 (3.17 3.34) 3.46 (3.42 3.50) 0.44 <0.001† technical and numeracy 3.06 (2.97 3.14) 3.17 (3.12 3.21) 0.22 <0.05† computer skills 2.91 (2.79 3.03) 3.22 (3.17 3.27) 0.51 <0.001† organisational skills 3.54 (3.45 3.62) 3.74 (3.70 3.78) 0.44 <0.001† managing self-learning 3.40 (3.34 3.46) 3.46 (3.43 3.50) 0.15 ns presentation skills 2.77 (2.68 2.86) 2.89 (2.84 2.94) 0.23 <0.05 confidence information handling 2.90 (2.80 2.99) 3.14 (3.09 3.19) 0.45 <0.001† technical and numeracy 2.89 (2.81 2.98) 3.01 (2.96 3.06) 0.21 <0.05 computer skills 2.78 (2.66 2.91) 3.10 (3.04 3.16) 0.48 <0.001† organisational skills 3.09 (3.01 3.17) 3.30 (3.25 3.35) 0.38 <0.001 managing self-learning 3.10 (3.03 3.18) 3.21 (3.17 3.26) 0.24 <0.01 presentation skills 2.67 (2.57 2.76 2.84 (2.79 2.90) 0.30 <0.01 bp = becoming a professional; ns = not significant. *effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. †unequal variance; p-value recalculated using welch correction for unequal variance. https://doi.org/10.1007/s10459-008-9121-7 https://doi.org/10.1007/s10734-008-9189-2 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1016/s0140-6736(10)61854-5 https://doi.org/10.1111/j.1365-2923.2011.04065.x https://doi.org/10.1080/10401330903021041 https://doi.org/10.1080/10401330903021041 https://doi.org/10.3109/0142159x.2013.801551 https://doi.org/10.3109/0142159x.2013.801551 https://doi.org/10.3109/0142159x.2011.565826 https://doi.org/10.3109/0142159x.2011.565826 https://doi.org/10.3109/0142159x.2012.706338 https://doi.org/10.3109/0142159x.2012.706338 123 june 2018, 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cleland j, leggett h, sandars j, costa mj, patel r, moffat m. the remediation challenge: theoretical and methodological insights from a systematic review. med educ 2013;47(3):242-251. https://doi.org/10.1111/ medu.12052 49. milburn a. fair access to professional careers: a progress report by the independent reviewer on social mobility and child poverty. london: the national archives, 2012. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/61090/ir_fairaccess_acc2.pdf (accessed 11 june 2018). accepted 5 october 2017. https://doi.org/10.12691/ajrd-5-3-3 https://doi.org/10.1001/jama.296.9.1094 https://doi.org/10.1001/jama.296.9.1094 https://doi.org/10.1111/1467-8721.01235 https://doi.org/10.1023/b:ahse.0000038209.65714.d4 https://doi.org/10.1023/b:ahse.0000038209.65714.d4 http://www.che.ac.za/sites/default/files/publications/white_paper3.pdf http://doi.org/10.20853/30-2-619 http://www.nbt.ac.za/content/what-nbts http://www.nbt.ac.za/content/what-nbts https://doi.org/10.1136%2fbmj.327.7407.139 https://doi.org/10.1136%2fbmj.327.7407.139 https://doi.org/10.1186/1472-6920-11-98 https://doi.org/10.1186/1741-7015-11-244 https://doi.org/10.1186/1741-7015-11-244 https://doi.org/10.1097/acm.0b013e3181cece3d https://doi.org/10.1097/acm.0b013e3181cece3d https://doi.org/10.1111/j.1365-2923.2008.03154.x https://doi.org/10.1007/s10459-012-9380-1 http://www.uct.ac.za/usr/downloads/uct.ac.za/apply/handbooks/handbook8a_healthsciencesundergraduate_2016.pdf http://www.uct.ac.za/usr/downloads/uct.ac.za/apply/handbooks/handbook8a_healthsciencesundergraduate_2016.pdf http://www.psychometrica.de/effect_size.html. http://www.psychometrica.de/effect_size.html. https://doi.org/10.1016/s0140-6736(00)04134-9 https://doi.org/10.1111/medu.12052 https://doi.org/10.1111/medu.12052 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61090/ir_fairaccess_acc2.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61090/ir_fairaccess_acc2.pdf june 2018, vol. 10, no. 2 ajhpe 90 research in south africa (sa), higher education students exhibit progressively poor success rates.[1] the council on higher education (che) observed that only 35% of all first-year entrants graduate within 5 years.[1] in kwazulu-natal (kzn) province, sa, the majority of nurses are trained at a college of nursing, which has satellite campuses throughout the province.[2] there is, however, a high failure rate among these students, mostly in the first year of study. because of academic failure, 22% of students leave the training programme after the first year[3]– a precarious situation, considering the shortage of professional nurses faced by the country.[4,5] in an attempt to address this high attrition rate, the admission criteria for entry into the programme were increased, but this did not have a noticeable influence on the pass rate. students entering sa higher education institutions usually come from a wide range of cultural and social backgrounds, with resultant varying life experiences and educational opportunities, including different expectations, needs and academic potential.[6] academic success does not entirely consist of one’s application of intellectual capacity. there are many other factors that directly or indirectly affect academic success. these include the transition from secondary school to university, student motivation, study methods, teaching strategies, interaction between students, academic and social systems of the university, cultural expectations, psychosocial factors and lack of finances.[7-10] one or more of these factors could lead to stress, which could hinder academic potential by distracting students’ focus from their studies.[11] research has shown that self-concept positively affects the success of nursing students’ ability to manage anxiety and stress related to studying. specifically, if a student is confident in his/her ability and remains motivated, he/she is more likely to succeed academically, resulting in lower dropout rates. whereas the overwhelming stress associated with test anxiety has a negative relationship with academic achievements, this could lead to a decrease in the academic success of students.[12] the nursing programme also contains both intensive coursework and practical components at hospitals, which may become overwhelming and stressful with regard to a student’s ability to cope with examinations.[12] attrition rates among nursing students remain high, irrespective of attempts by institutions to provide strategies such as selection in line with quality of students, and implementing student mentoring and tutoring. it is unknown whether the stress factors that affect students attending a large university with many different faculties are different from those of students who attend smaller tertiary institutions that train them in one particular course only. in nursing, stress factors related to the clinical learning environment are well documented.[10,13,14] the increased stress of nursing students is due to the simultaneous learning in both academic and clinical areas. this adds to the growing personal stressors experienced by these students. stress negatively influences students, thus affecting their academic performance and course completion rates.[15] literature on stress that affects nursing students in small tertiary colleges in the early years of academic study is lacking. the objective of this study was to determine the stressors experienced by first-year nursing students who attended a college of nursing in sa. the study also ascertained the stress-relieving mechanisms used by these students. background. in south africa (sa), there is a high failure rate of students in the first year of nursing and many drop out after this year, a precarious situation considering the shortage of professional nurses faced by the country. academic success does not entirely comprise one’s application of intellectual capacity. other factors may affect academic success, which could lead to stress, in turn hindering students’ academic potential. objectives. to determine the stressors experienced by first-year nursing students who attended a college of nursing in sa and to ascertain the stressrelieving mechanisms used by these students. methods. student nurses (n=248) at a college of nursing in kwazulu-natal province, sa, were required to complete a quantitative questionnaire. data were collected between september and november 2013. results. long working hours, difficulty of academic work, poor study methods and family illness caused considerable stress. family pressure to pay for necessities at home was also a factor that caused stress among the students. there was insufficient money to pay for textbooks for their studies. stress-relieving mechanisms included playing with cell phones and socialising with friends. lecturers, parents and fellow nursing students’ friends were a source of support. conclusion. first-year nursing students experience a variety of stressors not directly related to their studies. stressand time-management workshops would be beneficial to these students. we also suggest that institutional support units be created to assist students in adjusting to the tertiary environment. afr j health professions educ 2018;10(2):90-95. doi:10.7196/ajhpe.2018.v10i2.993 factors causing stress among first-year students attending a nursing college in kwazulu-natal, south africa e m langtree,1,2 mtech nursing; a razak,1 phd; f haffejee,3 phd 1 department of nursing, faculty of health sciences, durban university of technology, south africa 2 port shepstone campus, kwazulu-natal college of nursing, south africa 3 department of basic medical sciences, faculty of health sciences, durban university of technology, south africa corresponding author: f haffejee (firozah@dut.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 91 june 2018, vol. 10, no. 2 ajhpe research methods a quantitative descriptive survey design was used. student nurses at a selected nursing college in kzn, who were either in the final stages of completing their first year of study or had done so in the previous semester, formed the target population (n=524) for this study. using cochrane’s formula, a minimum of 222 participants were required for the sample population to achieve significant results at a 95% confidence level. as we anticipated a response rate of ~80%, 267 students were targeted. five campuses from 8 of the 9 campuses that comprise the nursing college were chosen for the study by a ballot method. the campuses differed only with regard to geographical distribution, which allows for easy access to students from different parts of the province. the campus at which the principal investigator (eml) lectures, was excluded from the study. the criteria required for inclusion in the study were: first-year nursing students enrolled for a minimum of 7 months at the college, who understood the letter of information and signed the consent form. all students at the 5 campuses who met the inclusion criteria were invited to participate in the research study. participation was voluntary and no students were forced into entering the study. all students were provided with information about the study, both verbally and on an information sheet. students who agreed to participate after reading the information letter, signed a consent form prior to answering the self-administered questionnaire. a new questionnaire was developed, as an appropriate one was not available for the purposes of this study. the questionnaire was also used as part of a larger study. it was developed by the researcher (eml) from four common themes, in addition to a section on demographic data. the themes included: english as a second language, first-generation students, stressors experienced by students and programme orientation. there was a total of 76 questions, of which 48 were used for this part of the study. these included simple dichotomous questions for demographics, questions using rating and ranking scales and likert scale-type questions. a combination of different types of questions increases the reliability and validity of the tool.[16] participants were asked to respond to statements about factors that cause stress, by selecting 1 of 5 stress levels in response to each statement. the levels of stress were scored from 1 (not at all stressful) to 5 (very stressful). students were also asked to consider statements about factors to relieve stress and indicate their choice according to a likert scale, from 1 (strongly disagree) to 5 (strongly agree). after construction of the questionnaire, a focus group discussion was held to ensure validity of the questionnaire. the focus group discussion took place during the departmental research committee meeting, which comprised 6 academics, 5 of whom are also professional nurses and 1 who is not a nurse but a staff member at the faculty of health sciences. this group of experts in nursing and health science education and research was invited to judge each item in the questionnaire for relevance, clarity, simplicity and ambiguity. items that did not adequately meet these criteria were either removed from the questionnaire or adjusted until acceptable. the post-focus group questionnaire was then piloted for reliability with 5 students who met the inclusion criteria for the study, but who were excluded from the main study. the purpose of the pilot study was to detect flaws, establish usefulness of the questions and, if necessary, amend the questions. the pilot study population indicated that they understood the questions and did not have difficulty in answering them; therefore, no changes were made to the questionnaire. data were collected between september and november 2013. an academic not involved in the research distributed the questionnaires and was available in the classroom to answer any queries that the students might have had. the researcher was available in a nearby room to answer any queries of respondents if necessary. she was not in the classroom, in an effort to prevent students feeling obligated to participate in the study. all participants were required to sign a consent form prior to answering the questionnaire. no students were coerced into participating. data were analysed on spss version 17 (spss inc., usa) by means of frequency distribution of responses and mean scores. to test for significant trends in the data, inferential statistics were applied. these included pearson’s correlation and χ2 tests. wilcoxon signed-rank tests were used for the comparison of non-parametric data. throughout, p<0.05 was used to indicate significance. ethical approval the study was approved by the durban university of technology institutional research ethics committee (ref. no. irec 052/13). permission to conduct the study at the nursing college was obtained from the kzn department of health and the acting principal of the college. results participant demographics of the 267 questionnaires distributed, 248 were completed, giving a response rate of 92.8%. participant demographics are indicated in table 1. table 1. participant demographics demographics participants, n (%) gender female male 174 (70.2) 74 (29.8) age category, years 19 20 21 22 23 24 24 25 ≥26 41 (16.5) 42 (16.9) 48 (19.4) 41 (16.5) 75 (30.2) race black african indian coloured white 215 (86.7) 22 (8.9) 10 (4.0) 1 (0.4) home language isizulu english isixhosa afrikaans other african language 195 (78.6) 33 (13.3) 7 (2.8) 1 (0.4) 12 (4.8) area raised rural urban 152 (61.3) 96 (38.7) type of secondary school attended rural government urban government peri-urban government /township private 115 (46.4) 66 (26.6) 55 (22.2) 12 (4.8) june 2018, vol. 10, no. 2 ajhpe 92 research the majority were female (70.2%; n=174), ˂26 years of age (69.6%; n=75), of black ethnicity (86.7%; n=215) and raised in a rural area (61.3%; n=152). although 71% (n=175) were raised by their own parents, 22% were raised by extended family members, a social welfare home (4%), a child-headed household (2%) or members of the community (1%). the type of secondary school attended varied significantly between the different participants (p<0.001), with almost half having attended a rural government school (46.4%). many were the first in their family to attend a tertiary education institution (37.5%; n=93). half of the respondents indicated that they had basic necessities, such as electricity, clean water and adequate food, in their homes (52.4%; n=130), but that there was nothing extra available. only a quarter (23%; n=57) always had the basic necessities and a little extra money available. some did not have any basic necessities (18.5%; n=46) and only a few respondents (4.4%; n=11) always had everything that they wanted in their homes. for the duration of their nursing studies, all of the respondents had the opportunity to live in a nurses’ residence (100%; n=248). stressors experienced by first-year students respondents were asked to consider statements relating to factors that cause stress by selecting 1 of 5 levels in response to each statement. the overall results are presented in table 2. the levels of stress were scored from 1 (not at all stressful) to 5 (very stressful). the long working hours, financial pressures, assignments, difficulty of academic work, poor study methods, family illness and other problems at home caused considerable stress (mean >3; p<0.001). they were also required to contemplate the level of agreement to statements related to factors that may cause stress. these levels of agreement were scored from 1 (strongly disagree) to 5 (strongly agree). the overall results are presented in table 3. the majority of respondents felt that they did not have enough time for their studies, that they had to work harder than their classmates and that they experienced more stress than their classmates. they also indicated that there was family pressure to pay for necessities at home and that there was insufficient money to pay for textbooks for their studies. furthermore, stress affected their grades negatively (mean >3; p<0.001). the transition from secondary school to tertiary education was difficult (table 4). respondents felt that they did not know what was awaiting them before starting the nursing course (n=247; p<0.001). they felt that nursing was not what they had expected (n=246; p=0.038), and had anticipated the nursing programme to be more practical than theoretical (n=246; p<0.001). most respondents also expected ‘nursing to be an easy practical job’ (n=246; p<0.001). however, the choice of another course at university did not take precedence over the nursing course (n=246; p<0.001) and they were not studying nursing merely to receive a monthly salary – it was what they wanted to do (n=246; p<0.001). table 2. distribution of responses to factors that may cause stress levels of stress stress factor not at all stressful, n (%) a little stressful, n (%) stressful, n (%) rather stressful, n (%) very stressful, n (%) mean academic assignments 13 (5.3) 65 (26.4) 76 (30.9) 38 (15.5) 54 (22) 3.22 long working hours 6 (2.4) 33 (13.4) 56 (22.7) 19 (7.7) 133 (53.9) 3.97 difficulty of academic work 21 (8.7) 55 (22.7) 83 (34.3) 28 (11.6) 55 (22.7) 3.17 poor study methods 39 (16.0) 51 (20.9) 68 (27.9) 26 (10.7) 60 (24.6) 3.07 personal illness 66 (26.9) 69 (28.2) 44 (18.0) 15 (6.9) 51 (20.8) 2.66 family illness 47 (19.1) 47 (19.1) 69 (28.0) 14 (5.7) 69 (28.0) 3.04 other problems at home 31 (12.6) 60 (24.3) 57 (23.1) 32 (13.0) 67 (27.1) 3.18 living away from home 69 (28.4) 59 (24.3) 37 (15.2) 19 (7.8) 59 (24.3) 2.75 financial pressures 17 (6.9) 42 (17.0) 47 (19.0) 15 (6.1) 126 (51.0) 3.77 table 3. levels of agreement with regard to factors that cause stress statement strongly disagree, n (%) disagree, n (%) neither agree nor disagree, n (%) agree, n (%) strongly agree, n (%) mean my family does not understand the time and energy required for successful studies 81 (32.6) 81 (32.6) 13 (5.2) 49 (19.8) 24 (9.7) 2.4 i have more stressors than my classmates 20 (8.1) 74 (29.8) 44 (17.7) 78 (31.5) 32 (12.9) 3.1 i do not have enough time in the day to complete all the necessary tasks 10 (4.1) 77 (31.2) 35 (14.2) 99 (40.1) 26 (10.5) 3.2 i feel that i do not belong studying this nursing programme 96 (38.9) 100 (40.5) 23 (9.3) 19 (7.7) 9 (3.6) 2.0 stress affects my grades negatively 11 (4.5) 61 (24.7) 32 (13.0) 103 (41.7) 40 (16.2) 3.4 i have family pressure to pay for necessities at home 30 (12.1) 72 (29.0) 18 (7.3) 81 (32.7) 47 (19.0) 3.2 i don’t have enough money to pay for textbooks 17 (6.9) 55 (22.3) 26 (10.5) 84 (34.0) 65 (26.3) 3.5 in order to pass, i have to study longer hours than my classmates 9 (3.6) 47 (19.0) 38 (15.3) 91 (36.7) 63 (25.4) 3.6 93 june 2018, vol. 10, no. 2 ajhpe research stress-relieving mechanisms a significantly large proportion of respondents played with their cell phones (p<0.001) or socialised with their friends (p<0.001) to alleviate stress. eating, consumption of alcohol/partying and staying away from work were not used as stress relievers by most of the participants. the overall results for the coping mechanisms are presented in table 5. respondents were asked to use a likert rating from 1 to 5 to indicate the support that they received from specified sources, from 1 (not at all) to 5 (a great deal). a mean score was calculated. most respondents felt that their lecturers (mean 4.17 (standard deviation (sd) 1.27); n=246), parents (4.00 (1.52); n=241) and friends (fellow nursing students) (3.78 (1.44); n=246) were sources of support. to a lesser extent, respondents identified their siblings (3.22 (1.70); n=245), friends from school (3.06 (1.61); n=245) and close relatives (2.63 (1.63); n=246) as sources of support. discussion this study ascertained the factors that cause stress among first-year nursing students attending a college of nursing in sa. our findings indicate that academic commitments, family finances and illness increase the outcome of stress. it is expected that the transition from a secondary to a tertiary level of education leads to longer hours of study and having to deal with subject material of a more difficult nature. students entering tertiary institutions should be provided with mentoring workshops that help them to cope with these stressors. it is also recommended that implementation of intervention strategies is required in institutions to educate students on developing study skills to manage stress-related factors. programmes that provide academic support should include academic, self-concept and motivational factors[12] that assist in this management. mentoring by senior peers allows students to realise that this is part of the normal learning process and also offers guidance on dealing with these difficulties. studying skills can be incorporated into these mentoring workshops, as the respondents indicated that their studying skills were poor, which also caused stress. furthermore, these stressors led them to obtain poor grades. as previously pointed out, stressors related to poor college preparation and poor study skills are common.[11] most respondents found the long working hours very stressful and they did not have sufficient time to complete tasks related to their studies. other reports indicate that a lack of time contributes to students feeling stressed.[17] curriculum planning in tertiary institutions needs to ensure that academic overload does not occur and that sufficient time is provided table 4. levels of agreement with regard to orientation into tertiary education statement strongly disagree, n (%) disagree, n (%) neither agree nor disagree, n (%) agree, n (%) strongly agree, n (%) mean i knew what i was getting into before starting the nursing course 65 (26.3) 69 (27.9) 21 (8.5) 60 (24.3) 32 (13.0) 2.7 i am studying nursing to get a monthly salary 84 (34.2) 104 (42.3) 33 (13.4) 16 (6.5) 9 (3.7) 2.0 i wish i had rather studied another course at university 79 (32.1) 86 (35.0) 40 (16.3) 26 (10.6) 15 (6.1) 2.2 nursing is not what i expected it to be 37 (15.0) 49 (19.9) 23 (9.4) 100 (40.7) 37 (15.0) 3.2 i thought nursing would be more practical; i didn’t know it would be so academically difficult 18 (7.3) 28 (11.4) 18 (7.3) 104 (42.3) 78 (31.7) 3.8 i expected nursing to be an easy, practical job 20 (8.1) 46 (18.7) 25 (10.2) 94 (38.2) 61 (24.8) 3.5 at nursing college, the study culture is more difficult than in high school 5 (2.0) 30 (12.2) 15 (6.1) 122 (49.4) 75 (30.4) 3.9 at nursing college, it is more difficult to achieve well academically 6 (2.4) 57 (23.1) 34 (13.8) 117 (47.4) 33 (13.4) 3.5 at nursing college, there is a lot more work to do in a short time 1 (0.4) 7 (2.8) 9 (3.6) 103 (41.7) 127 (51.4) 4.4 at nursing college, the method of teaching is different and faster 4 (1.6) 30 (12.2) 29 (11.7) 113 (45.8) 71 (28.8) 3.9 table 5. levels of agreement with regard to stress-coping mechanisms used by students i deal with stress by … strongly disagree, n (%) disagree, n (%) neither agree nor disagree, n (%) agree, n (%) strongly agree, n (%) mean eating 65 (26.3) 79 (32.0) 26 (10.5) 58 (23.5) 19 (7.7) 2.5 playing on my cell phone 27 (10.9) 62 (25.1) 26 (10.5) 89 (36.0) 43 (17.4) 3.2 socialising with friends 27 (11.0) 34 (13.9) 19 (7.8) 113 (46.1) 52 (21.2) 3.5 keeping to myself 31 (12.6) 77 (31.3) 31 (12.6) 64 (26.0) 43 (17.5) 3.0 crying and complaining 68 (27.9) 86 (35.3) 20 (8.2) 54 (22.1) 16 (6.6) 2.4 drinking alcohol/partying 144 (58.8) 63 (25.7) 17 (6.9) 13 (5.3) 8 (3.3) 1.7 exercising 35 (14.2) 52 (21.1) 36 (14.6) 82 (33.2) 42 (17.0) 3.2 staying home from work 98 (39.7) 85 (34.4) 24 (9.7) 29 (11.7) 11 (4.5) 2.1 june 2018, vol. 10, no. 2 ajhpe 94 research for the completion of tasks. time-management workshops can alleviate such problems, particularly if these are held early in the students’ first year at college. moreover, if time is adequately managed by students, there could be an indirect improvement of their grades. recent studies indicated that group work is beneficial to students in the health sciences, with students gaining an enhanced understanding of the subject matter when working with their peers.[18,19] group work may also be beneficial in time management. brief activities or larger assignments of a collaborative nature will make learning enjoyable[19] and hence alleviate stress. despite receiving a bursary of zar3 000 (usd214) per month for the duration of their training, finances were a source of stress. while financial stress has previously been documented,[10] a novel finding of this study was that although students were living away from home, they felt that there was family pressure to pay for basic necessities at home. even though their families understood the time and energy required for their studies to be successful, there was nevertheless the expectation of payment towards household expenses, as essential items are often lacking in their homes, particularly for students from rural backgrounds and of low socioeconomic status. this would be a common dilemma faced in developing countries and would be further exacerbated for first-generation students. the students also indicated that despite receiving bursaries for their studies, there was insufficient money to purchase textbooks from these funds. it is possible that these students use part of their funds for household expenses. some students indicated that illness experienced by family members, problems at home, personal illness, and living away from home caused stress. this, yet again, demonstrates the closely-knit families from where the students come. it may also be indicative of a constant presence of illness, which may be of a serious nature. the incidence of hiv in kzn is among the highest in the world and its impact on the health of the sa workforce has a negative effect on the motivation and performance of this workforce.[20,21] thus, motivation and performance of students are also affected by hiv infection of family members. nevertheless, students do find ways of alleviating stress; one of the most important ways is socialising with friends. this concurs with reports that social support from others lessens stress.[22] such social support is also correlated with academic success.[22] however, previous reports show that first-generation students tend to isolate themselves from others, particularly academics, when stressed.[23] our finding that lecturers are a source of support, is therefore encouraging. it indicates that current students are more willing to adapt to the study environment, are trying to fit into the academic environment and are not shy to turn to their lecturers for support. the creation of a student-friendly environment is therefore beneficial for both the academic and social needs of students. as all the respondents were living in the student-nurse hostel, a family support system for coping with stress was absent and they therefore turned to academic staff when support was required. institutional support groups may provide additional aid to students who have difficulty in adjusting to the university environment. students may not understand the method of pedagogy at higher education level. teaching strategies at tertiary level are not widely understood by students, resulting in difficulty in adapting to specific programmes. therefore, institutional support that assists students to adjust to the tertiary environment is likely to improve completion rates. our findings revealed that a significant proportion of respondents redirected their attention to cell phones as a way of dealing with stress. this is another novel finding and is in contrast to reports that cell phone usage increases stress.[24] this could possibly be related to the current use of cell phones for social networking, accessing the internet, watching and sharing of videos, as well as playing video games[25] – in addition to the use of cell phones for making telephone calls and text messaging. the former uses could be beneficial, particularly regarding social networking, as social support helps to relieve stress.[22] however, such use could possibly be detrimental if it occurs during lectures, as the user will be distracted, leading to less academic information being gained. a limitation of this study is that we did not enquire about the duration of cell phone usage. notably, very few respondents reported drinking and binge eating as stress-relieving mechanisms, which is a very encouraging finding. previous reports show that first-generation students are less likely to use socialcoping strategies such as drinking and partying to manage their stress,[22] which supports our findings. mentoring programmes should reinforce these behaviours to ensure that future students do not resort to alcohol consumption. it is also promising that students used exercise as a stressrelieving mechanism. although this study was conducted at a college of nursing in kzn, the results can be generalised to universities in sa, as the majority of firstyear students at these tertiary institutions appear to come from similar backgrounds. conclusion our findings indicate that in addition to academic commitments, financial pressures and illness that affect the families of students are a major source of stress among first-year nursing students in sa. students tend to socialise with friends and play with cell phones to relieve stressful situations. in addition to friends, lecturers were a source of support. we suggest that the incorporation of stress and time management into the curriculum would be beneficial to first-year nursing students. we also propose that institutional support units should be created to assist students in adjusting to the tertiary environment. acknowledgements. we acknowledge support from the durban university of technology towards eml’s research project for the master of technology (nursing) degree. author contributions. eml collected the data and wrote the first draft of the manuscript. ar and fh supervised the project, edited the manuscript and approved the final article. funding. durban university of technology funding for masters’ students. conflicts of interest. none. 1. council on higher education. a proposal for undergraduate curriculum reform in south africa: the case for a flexible curriculum structure. pretoria: che, 2013. 2. south african nursing council. south african nursing council statistics: annual statistics. 2011. http://www. sanc.co.za/stats_an.htm (accessed 12 may 2013). 3. hopkins th. early identification of at-risk nursing students: a student support model. j nurse educ 2008;47(6):254-259. https://doi.org/10.3928/01484834-20080601-05 4. buchan j, aiken l. solving nursing shortages: a common priority. j clin nurse 2008;17(24):3262-3268. https:// doi.org/10.1111/j.1365-2702.2008.02636.x 5. mokoka e, oosthuizen mj, ehlers vj. retaining professional nurses in south africa: nurse managers’ perspectives. health sa gesondheid 2010;15(1):1-9. https://doi.org/10.4102/hsag.v15i1.484 6. chikte u, brand a. diversity in south african dental schools. j dent ass s afr 1996;51(10):641-646. 7. fraser wj, killen r. factors influencing academic success or failure of first-year and senior university students: do education students and lecturers perceive things differently? s afr j educ 2003;23(4):254-263. 8. murray m. factors affecting graduation and student dropout rates at the university of kwazulu-natal. s afr j sci 2014;110(11-12):1-6. https://doi.org/10.1590/sajs.2014/20140008 9. stephen d, welman j, jordaan w. english language proficiency as an indicator of academic performance at a tertiary institution. s afr j hum resource manage 2004;2(3):42-53. https://doi.org/10.4102/sajhrm.v2i3.48 10. timmins f, kaliszer m. aspects of nurse education programmes that frequently cause stress to nursing students – fact-finding sample survey. nurse educ today 2002;22(3):203-211. https://doi.org/10.1054/nedt.2001.0698 11. starr k. nursing education challenges: students with english as an additional language. j nurse educ 2009;48(9):478-487. https://doi.org/10.3928/01484834-20090610-01 http://www.sanc.co.za/stats_an.htm http://www.sanc.co.za/stats_an.htm https://doi.org/10.3928/01484834-20080601-05 https://doi.org/10.1111/j.1365-2702.2008.02636.x https://doi.org/10.1111/j.1365-2702.2008.02636.x https://doi.org/10.4102/hsag.v15i1.484 https://doi.org/10.1590/sajs.2014/20140008 https://doi.org/10.4102/sajhrm.v2i3.48 https://doi.org/10.1054/nedt.2001.0698 https://doi.org/10.3928/01484834-20090610-01 95 june 2018, vol. 10, no. 2 ajhpe research 12. khalaila r. the relationship between academic self-concept, intrinsic motivation, test anxiety, and academic achievement among nursing students: mediating and moderating effects. nurse educ today 2015;35(3):432-438. https://doi.org/10.1016/j.nedt.2014.11.001 13. clarke va, ruffin cl. perceived sources of stress among student nurses. contemp nurse 1992;1(1):35-36. https:// doi.org/10.1080/10376178.1992.11001462 14. lindop e. individual stress among nurses in training: why some leave while others stay. nurse educ today 1991;11(2):110-120. https://doi.org/10.1016/0260-6917(91)90146-2 15. turner k, mccarthy vl. stress and anxiety among nursing students: a review of intervention strategies in literature between 2009 and 2015. nurse educ pract 2017;22:21-29. https://doi.org/10.1016/j.nepr.2016.11.002 16. burns n, grove s. the practice of nursing research: appraisal. synthesis and generation of evidence. 6th ed. st louis: saunders elsevier, 2009. 17. watkins kd, roos v, van der walt e. an exploration of personal, relational and collective well-being in nursing students during their training at a tertiary education institution. health sa gesondheid 2011;16(1):1-10. https:// doi.org/10.4102/hsag.v16i1.552 18. van wyk j, haffejee f. benefits of group learning as a collaborative strategy in a diverse higher education. int j educ sci 2017;18(1-3):158-163. https://doi.org/10.1080/09751122.2017.1305745 19. haffejee f, van wyk j, hira v. use of role-play and community engagement to teach parasitic diseases. afr j health professions educ 2017;9(2):51-53. https://doi.org/10.7196/ajhpe.2017.v9i2.673 20. nel a, mabude z, smit j, et al. hiv incidence remains high in kwazulu-natal, south africa: evidence from three districts. plos one 2012;7(4):e35278. https://doi.org/10.1371/journal.pone.0035278 21. tawfik l, kinoti sn. the impact of hiv/aids on the health workforce in developing countries. geneva: world health organization, 2006. 22. mehta ss, newbold jj, o’rourke ma. why do first-generation students fail? coll student j 2011;45(1). 23. paulynice r. what causes many college students to fail or drop out? 2011. https://hubpages.com/education/ what-causes-college-students-to-fail-or-dropout#comment8223407 (accessed 6 august 2013). 24. thomée s, härenstam a, hagberg m. mobile phone use and stress, sleep disturbances, and symptoms of depression among young adults – a prospective cohort study. bmc public health 2011;11(1):66. https://doi. org/10.1186/1471-2458-11-66 25. lepp a, barkley je, karpinski ac. the relationship between cell phone use, academic performance, anxiety, and satisfaction with life in college students. compute hum behav 2014;31:343-350. https://doi.org/10.1016/j. chb.2013.10.049 accepted 12 october 2017. https://doi.org/10.1016/j.nedt.2014.11.001 https://doi.org/10.1080/10376178.1992.11001462 https://doi.org/10.1080/10376178.1992.11001462 https://doi.org/10.1016/0260-6917(91)90146-2 https://doi.org/10.1016/j.nepr.2016.11.002 https://doi.org/10.4102/hsag.v16i1.552 https://doi.org/10.4102/hsag.v16i1.552 https://doi.org/10.1080/09751122.2017.1305745 http://dx.doi.org/10.7196%2fajhpe.2017.v9i2.673 https://doi.org/10.1371/journal.pone.0035278 https://hubpages.com/education/what-causes-college-students-to-fail-or-dropout#comment8223407 https://hubpages.com/education/what-causes-college-students-to-fail-or-dropout#comment8223407 https://doi.org/10.1186/1471-2458-11-66 https://doi.org/10.1186/1471-2458-11-66 https://doi.org/10.1016/j.chb.2013.10.049 https://doi.org/10.1016/j.chb.2013.10.049 september 2018, vol. 10, no. 3 ajhpe 176 research the current health system in south africa (sa) struggles to meet the healthcare demands of its nation adequately, especially in kwazulu-natal (kzn) province, sa, where the quadruple disease burden of hiv/aids, tuberculosis, chronic illnesses due to unhealthy lifestyles and injuries is increasing.[1] sa has a shortage of healthcare workers, who are unequally distributed between the public and private sectors.[2] the number of public sector healthcare workers are higher in urban than rural areas.[2] kzn has a population of >10 million,[3] with only 15% of them having some medical insurance and using the private sector health services, leaving 85% of the population dependent on the public health sector for their healthcare needs.[1] many people from rural and disadvantaged communities have limited access to healthcare, including oral healthcare services. consequently, many defer treatment for their dental problems, causing long-term effects on their physical and psychological health. local communities in kzn have long since recognised the need to intervene, incorporating the government’s deficits in social services by means of the philanthropy of donors and the socially aware through non-governmental organisations (ngos), which are non-profit, nongovernmental entities.[4] they play an integral role in today’s society.[4] ngos include grass-root community-based organisations and faithbased organisations (fbos), making significant contributions across many fields, such as education and research, social services, health, culture and recreation, law, development and housing.[4] ngos attempt to supplement the public health service by increasing access to healthcare through service delivery and prevention programmes, as well as raising awareness of the improvement of health outcomes.[4] in kzn, their activities include health awareness, assessment of vital signs, examination and treatment by a medical practitioner, delivery of medication to patients, vision screening and cataract surgery. oral health services range from oral health education and promotion, dental screenings, tooth extractions for relief of pain and sepsis, restorations, scaling and polishing to specialised work such as correction of cleft palates. these services are performed by health professionals on a voluntary basis and free of charge, in underserved and underinsured communities, helping to reduce the unmet health needs of the province and relieving over-burdened public clinics. moreover, private companies become involved in service delivery by providing primary healthcare services to the community on a humanitarian basis, without any intention of making a profit. these community-driven healthcare projects, undertaken by the private sector and ngos, can also serve as a platform for active student learning by providing opportunities for experiential learning for health professional students. the pedagogy underlying experiential learning is that experiences in authentic situations and environments are transformed into learning experiences through active participation, reflection and internalisation of knowledge.[5,6] through reflective learning, a student is able to apply theory to practice by connecting classroom teaching and practice in various contexts through background. the current health system in south africa (sa) struggles to meet the healthcare demands of its nation adequately, especially in kwazulunatal (kzn) province, south africa. local communities in kzn have long since recognised the need to supplement the public health system by means of community-driven initiatives of non-governmental organisations (ngos) and the private sector. projects by these sectors can also provide a platform for experiential learning for dental therapy students. objective. to explore learning opportunities for dental therapy students through the community-driven health initiatives of ngos and the private sector in kzn. methods. this qualitative study used face-to-face interviews with key stakeholders organising community-based initiatives in the ngo and private sectors. the interviews were audio-recorded and analysed using thematic analysis. ethical clearance was obtained from the university of kwazulu-natal, durban, sa. results. according to the participants, there were many innovative service delivery modes, ranging from a mobile health bus, a container turned into a clinic, to well-established clinics that provided meaningful learning opportunities for dental students. by participating in these projects, respondents believed that students could gain real-world experiences and a greater sense of social accountability. conclusion. this study showed that there are many opportunities in the private and ngo sectors that could provide support for community-driven learning initiatives for undergraduate dental therapy students. afr j health professions educ 2018;10(3):176-182. doi:10.7196/ajhpe.2018.v10i3.1031 exploring community-based training opportunities for dental therapy students in non-governmental and private sectors in kwazulu-natal province, south africa i moodley, msc (dent); s singh, phd discipline of dentistry, school of health sciences, university of kwazulu-natal, durban, south africa corresponding author: i moodley (moodleyil@ukzn.ac.za) this open-access article is distributed under creative commons licence cc-by-nc 4.0. 177 september 2018, vol. 10, no. 3 ajhpe research critical thinking and problem-solving.[7] this type of learning differs from traditional approaches, where knowledge is merely passed down by others. karim[8] noted positive clinical, behavioural and attitudinal outcomes when health professional students participated in such projects. these included improved clinical and communication skills, a deeper understanding of the health needs and demands of local communities, enhanced social accountability, inculcation of volunteerism and a sense of moral, ethical and professional responsibility, serving the public well by providing care to all in need, and encouragement of graduates to continue with these new positive behaviours when they qualify. the discipline of dentistry is housed in the college of health sciences, university of kwazulu-natal (ukzn) and offers an undergraduate training programme in dental therapy. a dental therapist is a mid-level oral healthcare practitioner who provides basic preventive and curative dental care. in sa, the scope of dental therapy practice includes dental (oral) examinations, diagnosis of common oral diseases, scaling and polishing, placement of direct restorations and tooth extractions for child and adult patients. the dental therapist is well suited to meet the oral healthcare needs of the population in both the public and private sectors, in urban and rural communities. the objective of this study was to explore experiential learning opportunities for dental therapy students through community-driven health initiatives of ngo and private sectors in kzn so that they can benefit from all the identified positive outcomes that might be gained by such participation. methods research context clinical training of dental therapy students occurs mainly at a hospital-based setting with community-based training being undertaken in the second semester of the final year. current community-based activities include a 2-week rotation on board the phelophepa health train, which operates as a mobile healthcare clinic that provides healthcare to impoverished rural communities throughout sa.[9] the phelophepa project is a private sector initiative that offers health professional students real-world clinical experiences while training.[9] exposing students to more community settings in addition to hospital training can significantly enhance their clinical training. these settings can provide more authentic environments, which enable experiences to become knowledge[6] and can inculcate in them a deeper sense of social responsibility. research design this was a qualitative explorative study in which opportunities for community-based training for dental therapy students were explored by engaging with key stakeholders in the private and ngo sectors who are involved in organising community-based initiatives. the study was part of a larger research project conducted on community-based education in the school of health sciences, ukzn. ethical approval was obtained from the humanities and social sciences research committee, ukzn (ref. no. hss/1060/015d). participants to select interviewees, 3 ngo contacts, known to the researcher, helped to identify more participants through the snowball sampling technique. eleven different organisations were purposively selected on the basis that their community healthcare projects included the provision of dental services. of the 11 organisations selected, 9 were ngos and 2 from private enterprises. the ngos comprised 8 fbos and 1 non-profit medical organisation, while the private sector included a dental consumable company and a developmental foundation. an e-mail was sent to each organisation, requesting their participation in the study. nine responded – 8 were ngo representatives and 1 was from the private sector. participation was voluntary and participants (p1 p9) provided written informed consent. participants included medical and dental practitioners, professional nurses and experienced administrative personnel involved in organising community healthcare projects. data collection data were collected by means of face-to-face, semi-structured interviews in english, with participants from the ngos and private sector. the interviews were conducted separately in the offices of the participants – each lasting ~30 minutes. the researcher developed a set of questions to provide structure to the interviews. the schedule comprised the following questions: • what current community-based projects are being undertaken by the institution? • what motivated your institution to undertake this community-based healthcare project? • what healthcare services are being provided? • what oral health services are offered? • how do you choose the community you wish to assist? • what opportunities exist for dental therapy student participation? • what are the opportunities and barriers for other student health professionals to participate in this project in a collaborative interdisciplinary team approach? the interviews were audio-taped and a research assistant transcribed the recordings verbatim and then cleaned them. the researcher engaged the services of a research consultant to assist with the data analysis process. data coding was done independently by the researcher and research consultant to identify particular features of the data, which were then sorted, allowing themes and sub-themes to emerge from respondents’ statements, according to braun and clarke’s[10] guide to thematic analysis. the data were then compared to develop common themes. credibility is a form of internal validity in qualitative research that establishes whether the research findings are genuine and indeed a true reflection of the participants’ original views.[10] in this study, credibility was established through peer debriefing, undertaken by another member of the research team,[11,12] who reviewed the data collection methods and processes, transcripts and data analysis procedures, and provided guidance to enhance the quality of the research findings.[11] transferability, which relates to external validity in qualitative research, was facilitated by providing a thick description of the context of the enquiry and comparing the research findings with those in the current literature.[11] dependability was achieved by the use of member checks,[11] where the analysed data were sent to a few participants to evaluate the interpretations made by the researcher. dependability was further enhanced by both the researcher and the research consultant as a co-coder analysing the same data and comparing the results.[11,12] confirmability was established september 2018, vol. 10, no. 3 ajhpe 178 research through quotations of actual dialogue of the interviewees.[11] participant confidentiality and anonymity were maintained. results and discussion five main themes emerged from the data analysis process: innovative modes of health service delivery, learning opportunities for dental therapy students, support provided, creating interprofessional learning opportunities and perceived barriers. theme 1: innovative modes of health service delivery participants described innovative ways of service delivery to disadvantaged communities, ranging from the use of storage containers, schools being converted, makeshift clinics to well-established, ngo-sponsored clinics (table 1). although oral health is recognised as a basic human right, the lack of appropriate and affordable dental care is still a major challenge.[13] in sa, oral diseases are among the most common conditions affecting the population, with dental caries occurring in 90 93% and periodontal disease in 93.5%.[14] in kzn, reddy and singh[15] reported that the caries rate among 6-yearold children increased from 65% in 2002 to 73% in 2013, with almost 94% requiring dental treatment. this places a huge burden on the public health service, with its limited oral health human resources. given this context, the general public, driven to address the needs of individuals and communities, have reached out informally to assist small groups of people or have organised programmes that could benefit whole communities.[16] this is evident in this study; they used innovative ways in their attempt to strengthen the health system and assure equal healthcare to areas where it is most needed. the use of a container and a mobile health bus is especially noteworthy. mobile dental services have proven effective in several states in the usa in providing preventive and curative dental care in rural communities.[17] they also provide training opportunities for senior dental students. however, although these services answer unmet dental needs of communities by offering temporary relief, they do not provide continuous care for dental diseases that cannot be treated once only.[17] this raises an important issue of the type of dental treatment that should be offered in community initiatives. helderman and benzian[18] recommend a basic package of oral healthcare, consisting of urgent oral treatment, including extractions, affordable fluoride toothpaste and atraumatic restorative treatment, which involves the removal of soft decayed tooth tissue and replacing it with a glass ionomer cement, as a guiding framework for dental ngos. however, this one-size-fits-all solution cannot be applied to all settings; an oral healthcare package should be tailored to suit the needs of each community. in kzn, urgent treatment, i.e. tooth extractions, and more preventive oral healthcare, should be offered, including oral health education, and promotion and placement of fissure sealants for 6-year-old children. mickenautsch et al.[19] demonstrated that implementing atraumatic restorative treatment was not widely accepted in the sa context. although it provided access to restorative treatment to people who previously did not receive any care, there were several barriers to its implementation, including a large patient load, insufficient supply of materials, operators’ reluctance to adopt new techniques and patients’ preference to extracting teeth rather than restoring them. this is further supported by reddy and singh,[15] who promote preventive programmes rather than curative ones, and recommend oral health-promotion programmes at schools to instil good oral health behaviour at an early age. the mobile health bus and the container clinic can be considered suitable projects, as they offer this type of oral care package, which is simple, effective and inexpensive. this is in line with primary healthcare principles currently being adopted by the health system. theme 2: learning opportunities for dental therapy students the participants indicated that there could be several opportunities for students in their programmes. three sub-themes emerged within theme 2: participation in community initiatives, adapting to a community-based setting and developing social responsibility. participation in community initiatives respondents were keen on students joining their initiatives, offering them a chance to expand existing projects, becoming part of their team and playing a role in sustainable initiatives (table 2). table 1. modes of service delivery methods participants’ responses use of a shipping container as a mobile clinic ‘we have a shipping container, converted into a mobile clinic. it has two parts, one in which we check vital signs, assess weight, height, blood pressure, temperature and, for the actual treatment, we use the other. the container is then taken to different schools and placed there, where we work until we are finished with all the children and then it would be moved to another school.’ (p1) restructuring old premises ‘we had a school here and our school was moved to a larger place. the premises became available and the next service we thought that we could help the community with, was having a clinic.’ (p5) trust-funded clinic ‘another group of people started this clinic but handed it over to our organisation to run. about 2 years ago the charitable trust of our organisation funded us for a new clinic in this community.’ (p6) school turned into a makeshift clinic during a weekend ‘for example, if we are going to a community, we would go there and visit the place to see whether it is okay for us to use, such as the classrooms or school facilities, and closeness to a tap, as we need water to set up a dental clinic.’ (p4) mobile health bus ‘we decided to get a mobile health bus that takes healthcare to the people. we wanted to offer the types of health services that parents can’t really get to for their children. we wanted to provide a service at schools. we would park at a school for at least 1 week. a learner is taken to the optometry section and a full assessment is done there, and then move to the next section, which is primary healthcare, and then move to dentistry.’ (p9) offering healthcare packs on health awareness day ‘patients received a health pack, which included toothbrushes, toothpaste and soap. the participants were given gift bags with sanitary pads, feminine products and oral hygiene products.’ (p7) 179 september 2018, vol. 10, no. 3 ajhpe research ngos welcome students as additional team members to assist them in their endeavours. inviting students to join their projects demonstrates a need to expand the oral healthcare workforce in the ngo sector, as there are very few oral health workers who volunteer their services. this is further supported by helderman and benzian,[18] who reported that the dental ngo sector is very small, with a maximum of 500 dental ngos worldwide. involving students in such projects on an ongoing basis creates a substantial workforce. this in turn contributes towards the long-term sustainability of ngo projects in the province, leading to better oral health outcomes of communities. students can thus play an important role in enhancing the functionality of ngos and private sector teams, which ultimately shows the reciprocal nature that can be developed with this association. adapting to a community-based setting the participants believed that students could benefit by meaningful engagement with communities through real-world experiences, learning to work with available resources and a chance to develop non-technical skills (table 3). students who are engaged in community-based training gain meaningful learning experiences. in addition to improving clinical skills in community settings, they are exposed to pathological conditions that they normally do not encounter in the hospital setting. these conditions can often be observed because patients delay seeking affordable dental treatment. students also learn to adapt to work environments with limited resources. this provides them with a good learning experience, as not all work environments correspond to the ideal training site with the latest equipment and materials that they have become accustomed to. students also have opportunities to develop non-clinical skills, such as learning to treat patients with respect, compassion and care, irrespective of their background. in doing so, they attain graduate competencies of being a caring health professional who communicates well with patients of different cultures, as advocated by the institution. this type of learning is explained by the experiential learning theory that supports students being directly involved in the learning process instead of passively imbibing information from the lecturer.[20] learning is directly linked to the activity performed by the student, the context and culture in which it occurs, the interaction with peers and the community, and the reflection of this experience. in this way, learning is situated and not abstract.[20] this is further supported by a study conducted among dental students participating in ngo projects, reporting that they had opportunities of putting into practice the theory they learnt in school, improving their dental skills, observing real-life cases away from an academic setting and networking with professionals in the field.[21] table 2. participation in community initiatives learning opportunities participants’ responses opportunity to expand existing project ‘dental students can be a part of our health day initiative and screening. they have suggested that they would like to do minor procedures, such as extractions and cleaning, if provided with the equipment. there is room for the project to grow and an opportunity for them to start their own referrals to the appropriate clinics.’ (p7) ‘we run a dental clinic once in 2 weeks on a friday. this clinic is run by a dentist, who volunteers his services. this can be a good opportunity for dental students to come on board, so we can offer dental services every friday, as there is a great need for this in the community we serve.’ (p5) students viewed as potential team members ‘the oral hygienist comes only once when we are at the school, so if your students are here, it would be much better. i know we will complement each other when they come. maybe i will say this child needs an extraction, but they might say that this tooth is strong, you can still save it by cleaning and filling it. so i think it will be great, and the oral hygiene will improve.’ (p1) become role players in a sustainable project ‘dental students can be a part of our health expo on an ongoing basis. it would be nice if dental students have a mobile clinic to do simple procedures such as tooth extractions. i can arrange an afternoon only for dental procedures.’ (p2) slow integration of students into current programme ‘maybe we could get them to do the screenings from march to june and maybe scalings and, later in the year, they could join us for dental extractions when they are more competent. so they can get practical experience from beginning to end. so, you can draw up guidelines on how and where and when they can join us and as we grow, we can see how we can fit them in more.’ (p9) table 3. adapting to a community-based setting learning opportunities participants’ responses real-world experience ‘it gives them exposure to the outside world – not only being in the classroom or on campus. on campus you may be able to see all the theoretical things, and on the outside, in the field, you are seeing practical work, where you would see many diseases that you may not physically see at your place of study.’ (p4) ‘in the rural areas they have an opportunity of learning more and getting an experience with different rural communities. i did my primary healthcare at a rural area and i got that experience.’ (p1) learning to work with limited resources ‘i can improvise when i am in the community because i know that i will not be getting everything i’m used to, but to get a person healed or cured or get him some help, you need to work with what you have. so that is why i say when i am here, i come to the level of the people.’ (p1) developing non-technical skills ‘i would just like these students to be committed and dedicated to the work and to be able to follow the ethos that is there. we would like patients to be treated with absolute kindness, respect and understanding.’ (p6) september 2018, vol. 10, no. 3 ajhpe 180 research developing social responsibility through participation in community-based initiatives, participants believed that students could gain a deeper understanding of social needs and plights and hence could develop a sense of social responsibility (table 4). the world health organization (who) defines social accountability of institutions that train health professionals as an obligation to direct their education, research and service activities towards addressing priority healthcare needs of communities and nations.[22] exposing students to ngo projects in communities, allows the institution to achieve its goal of being more socially engaged. it exposes students to the realities of rural communities and the need for oral health services, which may inspire students to want to service these areas fter they have graduated. this is further supported by hood,[20] who reports that when students participate in community-based programmes, it increases the number of graduates who wish to practise in rural, underserved areas. participation in ngo projects inculcates in students a sense of giving back to the community by volunteering their services to these projects. by participating, they learn how to conduct such projects and can also inspire inhabitants to initiate this in their own communities or in those where they see a dire need for health services. this is supported by the growing consensus in the dental profession that its members have a moral responsibility to serve the public good by providing expert dental care to all in need.[8] however, it is unrealistic to expect a qualified dental professional to consciously provide care for the underserved or under-privileged if this was not given any importance in their training. therefore, providing opportunities for students to participate in ngo projects can instil values of humanitarianism and professionalism. theme 3: support provided participants reported that they could provide support, such as an enabling mentorship, transport and sustenance (table 5). participants were willing to provide orientation, training and support to assist students. while some were prepared to provide support, others regarded this as a barrier to student participation. an enabling environment is very important for active student learning. this is further supported by gordon,[23] who confers that a supportive environment is essential in building clinical competencies in students. moreover, these projects can make a real difference in communities if they are supported by local health systems, co-ordinating their programmes with that of the health system through a small ongoing partnership. in this way, there could be sharing of skills, personnel and resources, as volunteers on the ground assist public healthcare workers by reducing the daily patient load and, through sustainability, strengthen the health system.[24] theme 4: creating interprofessional learning opportunities every participant reflected on the need for students from other disciplines to join their programme (table 6). interprofessional education occurs when ≥2 health professional students learn with each other to educate and manage patients.[24] combining community-based training and interprofessional learning is ideal and a table 4. developing social responsibility learning opportunities participants’ responses addressing the community’s needs ‘oral health and oral hygiene are vital and really needed in this community. dental students can do dental screening, can go to school, do oral health education. a dental programme can be conducted during the school holidays, but you need to give advanced notice and we can advertise it so that the community is aware of it.’ (p3) ‘there is a real need for dental human resources. if we can get dental students coming in and supervised, then we can get the patients.’ (p6) ‘they can give oral hygiene education and community service. oral health education is really needed in this community. students can demonstrate to them the correct way to brush their teeth and educate them on diseases that affect the teeth.’ (p8) social accountability ‘we just want to give our people that come to our clinic service, bearing in mind humanity. so we give humane services to these people, remembering also that there can be no double standards of this care. there cannot be one care for you and your family and another one for the people coming there.’ (p6) instilling volunteerism ‘to come and see what the outside world looks like, to interact with the community and see what their needs are. when you get out into society, as a professional, you would also be able to offer that kind of compassion and service to them, maybe not because you want to earn a salary, but to have that same love to serve humanity as we do.’ (p4) table 5. support for student training support participants’ responses student safety ‘if they need our help, we will help to orientate them. if their safety is a problem, we will phone them and inform them not to go in, as there may be unrest in the community.’ (p1) transport and sustenance ‘providing transport to students to and from the health expo. provide them with a meal.’ (p2) professional support and guidance ‘we also have the professional personnel to back us up if there are complications such as breakage of a tooth. the professional will be there to extract it and relieve the issue or symptoms of the patient.’ (p4) mentorship ‘senior medical/healthcare professionals could attend the events and provide guidance and advice to students. the content comes from senior students who have attained knowledge from academic and skills training.’ (p7) enabling environment ‘we provide a platform for all healthcare students to participate in this initiative.’ (p7) 181 september 2018, vol. 10, no. 3 ajhpe research growing trend in educational institutions.[25] ngos indicating the need for services of other health professionals emphasise the need for health professionals to work together for the benefit of society. thus, ngo projects provide a platform for all student health professionals to learn to work effectively in interprofessional teams. however, these opportunities need to be created by academics from individual disciplines who have acquired humanitarian values. theme 5: perceived barriers the participants agreed that there were some barriers that could hamper student participation (table 7). in this study, it was noted that transport to the areas where ngo projects occur, is a huge barrier. these ngo projects can be beneficial for student healthcare professionals and institutions. therefore, the institution should consider providing support. orientation and training is an important aspect of the principles of experiential learning.[5] if students were to participate in these programmes, they first need to be orientated towards and informed about the project and the background of the ngo to develop a good attitude before they commence. this is in line with the principles of experiential learning: the intention of enabling experience to be transformed into knowledge with proper planning and preparedness; orientation and training; reflection through monitoring; and evaluation to ensure successful learning experiences.[5] it is important for students to realise that volunteering is sharing done with good intention, compassion and concern extended to the less privileged in a respectful manner. likewise, where ngos are not sure table 6. creating interprofessional learning opportunities opportunities participants’ responses need for rehabilitation services ‘we also need physiotherapists in the community, because we have many children that need to be rehabilitated.’ (p1) holistic patient management ‘in order to provide holistic care, i would appreciate it if other healthcare disciplines, such as optometry, physiotherapy, occupational therapy, come on board, but to get people to come out over the weekend is difficult.’ (p2) ‘we would like to collaborate with many other healthcare professionals, such as optometrists, physiotherapists, occupational therapist, to provide holistic care.’ (p7) patient screening ‘there is dire need for eye testing, so optometry students are most welcome, maybe eye and dental clinics can be conducted on the same day.’ (p3) ‘optometry students are also needed. they can come to schools and conduct eye tests and refer some patients back to the eye clinic at the hospital.’ (p1) sharing the workload ‘we are looking for pharmacists, as we have only 2 pharmacists to serve 150 -200 patients, but if we have junior pharmacists (student pharmacists) who want to volunteer their time and effort, then obviously they are welcome to do so. (p4) joining an existing programme we do have an eye clinic which is run by an optometrist who comes in every 2nd friday, so optometry students are welcome to be a part of this. we get pharmacists who come from the main hospital to dispense medication here – pharmacy students can also benefit and learn from this.’ (p5) restarting discontinued services ‘we started a programme with physiotherapy and optometry students; optometry is continuing, but with physiotherapy and occupational therapy – it could not be sustained because of lack of manpower. i would really love it if these health professional students could continue like optometry.’ (p6) ‘we also had students from the eye clinic to come to help us, service us, but unfortunately some of our projects have faded away. we want to reintroduce this eye clinic and try to make it a success, where students can get exposure to serving the communities.’ (p4) job opportunities ‘optometry, we really need the services of optometry students, there are also job opportunities for newly qualified optometrists.’ (p9) cross-cultural experience ‘there are opportunities for students from other disciplines to come to observe how it is to work in different communities.’ (p8) table 7. perceived barriers possible barriers participants’ responses transport ‘we also use one transport, we share the transport with others from the hospital and there may be no or limited space for students.’ (p1) ‘transport has been a huge barrier to participation, as it’s difficult to get a large group of people to and from the venues. the healthcare facilities are located on different campuses and have different term times, which impacts collaboration. our events are held over the weekend, which limits student availability/participation.’ (p7) ‘the funding for travelling and sustenance of these students would not be part of our funding.’ (p9) student attitude ‘the students need to be community orientated. sometimes you get students, but they do not co-operate, because in the community you have to come down to the level of the people and their working conditions are not like in the institutions.’ (p1) ‘i would not want smoking in there and i would not want people sitting there and laughing at each other or be on their cell phones and coming there to think that it is a holiday.’ (p6) ‘students must learn to treat patients with compassion and respect.’(p5) concerns about student capabilities ‘i am sceptical about allowing students to actually work on patients – doing tooth extractions. we cannot let students work on patients – we want people who are qualified to work on patients.’ (p8) september 2018, vol. 10, no. 3 ajhpe 182 research of student capabilities, they need to be orientated and informed of the scope of practice of a dental therapist. the abovementioned themes show that there are several untapped learning opportunities for health professional students outside the homogeneity of the university environment. the private sector and ngos contribute to supplementing the public health system by improving access to underserved communities through their innovative concepts of service delivery. these projects can also provide authentic learning experiences for health professional students at an interprofessional level, where knowledge is created through active participation, reflection and transformation of the experience.[6] participation in these community projects can benefit them professionally and personally. it could also inspire students to play an advocacy role in support of healthcare for all. student participation in community-based projects is mutually beneficial to ngos and private organisations, as they can significantly contribute to increasing their workforce members, demonstrating a reciprocal nature of this association. however, these learning opportunities must be conducted following the principles of experiential learning.[5] study strengths and limitations this study highlights the meaningful learning opportunities available at ngos and in the private sector for students to experience the realities of poor communities, become more socially aware, awaken their sense of social accountability and instil humanitarianism. the study findings can feed into planning and implementation of community-based education activities for dental therapy students. there is very little published work on ngos and the private sector; hence, this study provides useful data and a better understanding of the role ngos play in society. it is acknowledged that this study was conducted using only ngos and private enterprises known to the researcher and restricted to those in kzn. another limitation was that the researcher did not interview the volunteer healthcare workers directly involved in patient care in these organisations’ projects to obtain their views on volunteerism and challenges. more research is therefore required in this area. conclusion this study showed that there are many opportunities in the private and ngo sectors that could provide support for community-driven learning initiatives for undergraduate dental therapy students. acknowledgements. the authors acknowledge the participation of stakeholders from the private and ngo sectors. author contributions. im: data collection, data analysis and conceptualisation. ss: refined the methodology and oversaw the write-up. funding. none. conflicts of interest. none. 1. department of health. annual report 2013/14. pretoria: doh, 2014. 2. loots h, hertzog e, van den heever a, et al. identifying the determinants of and solutions to the shortage of doctors in south africa: is there a role for the private sector in medical education? a report commissioned by the hospital association of south africa (hasa). econex competition and applied economics 2015:1-56. 3. statistics south africa. census 2011 statistical release. pretoria: stats sa, 2011. 4. piotrowicz m, cianiara d. the role of non-governmental organisations in social and health 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